hospital_name,last_updated_on,version,location_name,hospital_address,license_number|SC,type_2_npi,"To the best of its knowledge and belief, this hospital has included all applicable standard charge information in accordance with the requirements of 45 CFR 180.50, and the information encoded is true, accurate, and complete as of the date in the file. This hospital has included all payer-specific negotiated charges in dollars that can be expressed as a dollar amount. For payer-specific negotiated charges that cannot be expressed as a dollar amount in the machine-readable file or not knowable in advance, the hospital attests that the payer-specific negotiated charge is based on a contractual algorithm, percentage or formula that precludes the provision of a dollar amount and has provided all necessary information available to the hospital for the public to be able to derive the dollar amount, including, but not limited to, the specific fee schedule or components referenced in such percentage, algorithm or formula.",attester_name
BON SECOURS ST FRANCIS XAVIER HOSPITAL INC,"4/1/2026",3.0.0,St Francis Xavier,"2095 Henry Tecklenburg Drive,Charleston,SC 29414",HTL-0750,1851361778,TRUE,Billie Jean Mounts
description,code|1,code|1|type,code|2,code|2|type,code|3,code|3|type,code|4,code|4|type,modifiers,setting,drug_unit_of_measurement,drug_type_of_measurement,standard_charge|gross,standard_charge|discounted_cash,payer_name,plan_name,standard_charge|negotiated_dollar,standard_charge|negotiated_percentage,standard_charge|negotiated_algorithm,median_amount,10th_percentile,90th_percentile,count,standard_charge|methodology,standard_charge|min,standard_charge|max,additional_generic_notes
SPLINT WRST M R THMB SPICA COT POLY FAB LTHR WRKHRD ORIG BGE,SUP-2326137,CDM,L3908,HCPCS,0272,RC,,,,both,,,73.51,47.78,,,,,,,,,,,,,
PLATE BNE STR MINI REG 2 MM 4 HOLE FOR SCR TI RIGID BLU,SUP-2461589,CDM,C1713,HCPCS,0278,RC,,,,both,,,321.79,209.16,,,,,,,,,,,,,
PILOCARPINE HCL 5 MG PO TABS,RX-12803,CDM,6370000000,HCPCS,0637,RC,00527-1313-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
EVOS TI 3.5MMX15MM LCK SCREW T15 S-T,SUP-2820423,CDM,C1713,HCPCS,0278,RC,,,,both,,,712.72,463.27,,,,,,,,,,,,,
PIN TEMP FIX L 40 MM DIA 3.5 MM LG TARGETER PROV STRL DISP,SUP-2931298,CDM,C1713,HCPCS,0278,RC,,,,both,,,1991.39,1294.40,,,,,,,,,,,,,
HEAD ULN DIA17.5 MM STEM SZ 6.5 MM COCR WR STD 1PC PART DRUJ,SUP-2933190,CDM,C1776,CPT,0278,RC,,,,both,,,20370.53,13240.84,,,,,,,,,,,,,
SPONGE BCKL 4X80MM NO504 RND SIL,SUP-2213487,CDM,L8610,HCPCS,0278,RC,,,,both,,,141.61,92.05,,,,,,,,,,,,,
CENTRALIZER MS 30 PROX/STAN SZ 10,SUP-2204700,CDM,C1776,CPT,0278,RC,,,,both,,,419.50,272.67,,,,,,,,,,,,,
FIBER LASER KIT NEURO OMNIGUIDE,SUP-2225630,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6123.00,3979.95,,,,,,,,,,,,,
TRAY KYPHOPLASTY SZ 3 BLLN L10MM DIA16MM NDL DIA016IN ADD,SUP-2293658,CDM,C1713,HCPCS,0278,RC,,,,both,,,7404.12,4812.68,,,,,,,,,,,,,
STEM RAD L30X15MM DIA8MM NK OFFSET 0MM TI ALIGN,SUP-2340145,CDM,C1713,HCPCS,0278,RC,,,,both,,,7222.00,4694.30,,,,,,,,,,,,,
CROWN DENT 4 UPPER LT,SUP-2100307,CDM,D6783,CPT,0278,RC,,,,both,,,18.37,11.94,,,,,,,,,,,,,
HOLE PIN CLAMP 2 POSTS STRAIGHT DIA 456MM,SUP-2701731,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2373.84,1543.00,,,,,,,,,,,,,
HEAD RADIAL 24 MM LT DEMO ANAT SOL 2,SUP-2657749,CDM,C1776,CPT,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
WIRE GUID GLDEWIRE STR TIP .018INX150CM 3CM,SUP-2385249,CDM,C1769,HCPCS,0272,RC,,,,both,,,169.94,110.46,,,,,,,,,,,,,
BIT DRL CINCHLOCK SS REUSE,SUP-2663979,CDM,2720000010,LOCAL,0272,RC,,,,both,,,891.26,579.32,,,,,,,,,,,,,
BIT DRL L62MM DIA2MM WRK L13MM REPOS PIN DISP FOR,SUP-2366435,CDM,2720000010,LOCAL,0272,RC,,,,both,,,501.77,326.15,,,,,,,,,,,,,
CATHETER ANGIO TORC NB ADVANTAGE BEAC TIP 125 CM 5 FR VTK,SUP-2168681,CDM,C1894,HCPCS,0272,RC,,,,both,,,81.64,53.07,,,,,,,,,,,,,
MESH SURG W8X15CM DIA5MM POLYPR RECT FLAT FOR SFT TISS REP,SUP-2219796,CDM,C1781,HCPCS,0278,RC,,,,both,,,254.34,165.32,,,,,,,,,,,,,
BASKET STONE SEGR 16MM,SUP-2141355,CDM,2720000010,LOCAL,0272,RC,,,,both,,,577.76,375.54,,,,,,,,,,,,,
COMPONENT FMRL LG TBL RTTNG PLTFRMFLXN GSB LATEX FREE ST SN,SUP-2720917,CDM,C1776,CPT,0278,RC,,,,both,,,690.80,449.02,,,,,,,,,,,,,
SET URET STENT SOFFLX L 75 CM CATH 7.2 FR GUIDEWIRE L 100 CM,SUP-2168950,CDM,C2617,HCPCS,0278,RC,,,,both,,,493.29,320.64,,,,,,,,,,,,,
PATCH CV W25XL15CM THK05MM FOR RECON ACUSEAL,SUP-2395324,CDM,C1768,CPT,0278,RC,,,,both,,,1956.22,1271.54,,,,,,,,,,,,,
SCREW BONE PED L14MM DIA4.5MM LT RT CORT PROX FEM S STL LCK,SUP-2318598,CDM,C1713,HCPCS,0278,RC,,,,both,,,900.36,585.23,,,,,,,,,,,,,
SET CV THRD PROTECTOR STRL DISP HEARTMATE 3,SUP-2895267,CDM,2720000010,LOCAL,0272,RC,,,,both,,,339.12,220.43,,,,,,,,,,,,,
MESH PTCH MK W POSIFLEX OVL 3 IN X 5 IN SM,SUP-2126069,CDM,C1781,HCPCS,0278,RC,,,,both,,,337.55,219.41,,,,,,,,,,,,,
COIL VASC I-ED COIL L 10 CM DIA 0.012 IN SECONDARY 5 MM,SUP-2865308,CDM,C1889,HCPCS,0278,RC,,,,both,,,4914.10,3194.16,,,,,,,,,,,,,
CARBOPLATIN 450 MG/45ML IV SOLN,RX-39267,CDM,J9045,HCPCS,0636,RC,61703-0262-05,NDC,,both,45,ML,55.50,36.07,,,,,,,,,,,,,
FIBER LASER CONVERGENCE OPTICIS MVDF MULT,SUP-2748375,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4556.30,2961.59,,,,,,,,,,,,,
PLATE VARIAX COMP BROAD CURVED 14HL,SUP-2705337,CDM,C1713,HCPCS,0278,RC,,,,both,,,3176.11,2064.47,,,,,,,,,,,,,
BONE GRFT M 12MM 12 DEG S BLK PRO OSTEON 500,SUP-2415015,CDM,C1713,HCPCS,0278,RC,,,,both,,,2977.03,1935.07,,,,,,,,,,,,,
XD DFS SCR15X11MM TNTNG11MM THD5MM H,SUP-2669680,CDM,C1713,HCPCS,0278,RC,,,,both,,,342.57,222.67,,,,,,,,,,,,,
KIT CATHETER L45CM OD6FR 018IN GWIRE NDL STYL SWABSTK SCIS 3,SUP-2118891,CDM,C1751,HCPCS,0278,RC,,,,both,,,671.96,436.77,,,,,,,,,,,,,
COIL VASC I-ED COIL PRIMARY L 30 CM DIA 0.010 IN SECONDARY,SUP-2865284,CDM,C1889,HCPCS,0278,RC,,,,both,,,6327.10,4112.61,,,,,,,,,,,,,
CAGE SPNL SHELL SHT 25 MM VERSION C NS FLAREHAWK 9 LTX,SUP-2877239,CDM,C1889,HCPCS,0278,RC,,,,both,,,6751.00,4388.15,,,,,,,,,,,,,
OCCLUDER OCL20US TALENT AAA 20MM,SUP-2296679,CDM,C1874,HCPCS,0278,RC,,,,both,,,8085.50,5255.57,,,,,,,,,,,,,
TUBE VENT ID1.27MM BLU FLROPLAS IMP SHEEHY,SUP-2277569,CDM,L8699,HCPCS,0278,RC,,,,both,,,51.21,33.29,,,,,,,,,,,,,
PLATE CRAN 100X20X40 MM PT SPEC IMPL PEEK,SUP-2860116,CDM,C1713,HCPCS,0278,RC,,,,both,,,23072.41,14997.07,,,,,,,,,,,,,
SCREW BNE L55MM DIA6.5MM THRD L16MM CANC TI ST SELF DRL,SUP-2190504,CDM,C1713,HCPCS,0278,RC,,,,both,,,115.43,75.03,,,,,,,,,,,,,
STIMULATOR NERVE CHECKPOINT GAURDIAN DISP,SUP-2736213,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2185.44,1420.54,,,,,,,,,,,,,
COVER BUR H L10MM W/ SHUNT PASS,SUP-2365226,CDM,C1713,HCPCS,0278,RC,,,,both,,,889.78,578.36,,,,,,,,,,,,,
BONE MATRIX CELLULAR ORIOS 10CC,SUP-2653968,CDM,C1713,HCPCS,0278,RC,,,,both,,,15072.00,9796.80,,,,,,,,,,,,,
HC Iaad Ia Shiga-Like Toxin,PX-3068742700,CDM,87427,CPT,0306,RC,,,,outpatient,,,71.00,46.15,,,,,,,,,,,,,
KIT LD L70CM SPNL CRD STIM PADDLE 32 CNTCT TIGHT COVEREDGE,SUP-2138839,CDM,C1778,HCPCS,0278,RC,,,,both,,,18526.00,12041.90,,,,,,,,,,,,,
HC Split Blood or Products,PX-3008698500,CDM,86985,CPT,0300,RC,,,,both,,,380.00,247.00,,,,,,,,,,,,,
SCREW BNE SET 4.5 MM CANN FT EXT TAB,SUP-2861022,CDM,C1713,HCPCS,0278,RC,,,,both,,,19405.20,12613.38,,,,,,,,,,,,,
SPHINCTEROTOME ENDOSCP 4.4FR TIP L5MM CUT WIRE 30MM 0.035IN,SUP-2149569,CDM,C1713,HCPCS,0278,RC,,,,both,,,673.75,437.94,,,,,,,,,,,,,
HOOK SPNL W6.5MM THRT BILAT PEDCL S STL NEUT CLOSE NAR FOR,SUP-2255716,CDM,C1713,HCPCS,0278,RC,,,,both,,,2329.88,1514.42,,,,,,,,,,,,,
BLADE RETRACTOR ABH 8X1 IN RENAL ALUM,SUP-2480945,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1443.65,938.37,,,,,,,,,,,,,
BIT DRL DIA2.7MM PERC QUIK CONN,SUP-2410870,CDM,2720000010,LOCAL,0272,RC,,,,both,,,600.27,390.18,,,,,,,,,,,,,
MESH SURG W4XL6IN STD FOR INGUINAL HERN REP PROLITE ULT,SUP-2227396,CDM,C1781,HCPCS,0278,RC,,,,both,,,141.43,91.93,,,,,,,,,,,,,
ELECTRODE ENDO MPLR DISP VPR RL DIMPLED COMPATIBLE W/ STORZ,SUP-2171428,CDM,C1713,HCPCS,0278,RC,,,,both,,,459.70,298.80,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY OCTARAY SPLINE 2CM 8FR 2-5-2MM D,SUP-2737873,CDM,C1732,HCPCS,0272,RC,,,,both,,,6810.66,4426.93,,,,,,,,,,,,,
PIN BONE FIX L60MM OD4MM LACTOSORB L15 BIOABSRB ACL,SUP-2212877,CDM,C1713,HCPCS,0278,RC,,,,both,,,1607.68,1044.99,,,,,,,,,,,,,
MANAGER PERS PAIN THER COMM HANDSET PROGRAMMABLE PROXIMITY,SUP-2284697,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3752.30,2438.99,,,,,,,,,,,,,
NITROGLYCERIN 0.2 MG/HR TD PT24,RX-27472,CDM,6370000000,HCPCS,0637,RC,00378-9104-16,NDC,,both,1,UN,3.20,2.08,,,,,,,,,,,,,
PACK NEUROSURGICAL SHTH L 50 X W 13.5 MM MYRIAD HNDPC L 13,SUP-2930202,CDM,2720000010,LOCAL,0272,RC,,,,both,,,17951.69,11668.60,,,,,,,,,,,,,
TROSPIUM CHLORIDE 20 MG PO TABS,RX-38977,CDM,6370000000,HCPCS,0637,RC,00904-7059-52,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
SCREW BNE 2X22MM CANN LO PROF CAPTURE,SUP-2243884,CDM,C1713,HCPCS,0278,RC,,,,both,,,674.66,438.53,,,,,,,,,,,,,
WEDGE SPNL 10X20MM TANGENT,SUP-2277837,CDM,C1713,HCPCS,0278,RC,,,,both,,,7206.30,4684.09,,,,,,,,,,,,,
STE NAVICULAR PLT RT SM,SUP-2588796,CDM,C1713,HCPCS,0278,RC,,,,both,,,1452.78,944.31,,,,,,,,,,,,,
BLADE SAW THK 0.38 MM CUT EDGE 10 MM THK 0.51 MM TPI 32,SUP-2898854,CDM,2720000010,LOCAL,0272,RC,,,,both,,,643.04,417.98,,,,,,,,,,,,,
WIRE FIX RND TIP 1X80 MM W/ LANCET KIRSCHNER,SUP-2224017,CDM,C1713,HCPCS,0278,RC,,,,both,,,31.40,20.41,,,,,,,,,,,,,
COMPONENT PATELLAR 45 MM KNEE RESURF GEN II,SUP-2450689,CDM,C1776,CPT,0278,RC,,,,both,,,2625.04,1706.28,,,,,,,,,,,,,
GRAFT BNE SUB 10ML HA FAST SET PTTY FILL BNE VOID CA PHSPTE,SUP-2194291,CDM,C9359,HCPCS,0278,RC,,,,both,,,9161.89,5955.23,,,,,,,,,,,,,
VALVE CSF PROGRAMMABLE IMPL DP,SUP-2666619,CDM,C1889,HCPCS,0278,RC,,,,both,,,2919.57,1897.72,,,,,,,,,,,,,
SCREW BNE L 90 MM DIA2.4 MM SS LCK T8 STARDRV AQUA HD NS V,SUP-2905776,CDM,C1713,HCPCS,0278,RC,,,,both,,,1157.25,752.21,,,,,,,,,,,,,
CONNECTOR SHUNT 1X1.9X11 MM RT ANGLE SS STRL ACCU-FLO,SUP-2666413,CDM,C1889,HCPCS,0278,RC,,,,both,,,335.07,217.80,,,,,,,,,,,,,
HEAD FEM SZ M DIA28MM FOR QUADRA HIP SYS BIOLOX DELT,SUP-2267343,CDM,C1776,CPT,0278,RC,,,,both,,,5213.53,3388.79,,,,,,,,,,,,,
PLATE BNE LNG TI ALLOY WR NAR SPANNING STRL ACU-LOC 2,SUP-2913024,CDM,C1713,HCPCS,0278,RC,,,,both,,,7422.96,4824.92,,,,,,,,,,,,,
PLATE BONE W12XL119MM 7 H SEMI TBLR ECT,SUP-2198539,CDM,C1713,HCPCS,0278,RC,,,,both,,,176.50,114.72,,,,,,,,,,,,,
BLADE SURG DIA4MM C STL HIP ARTHRO SHRP SHP DISP,SUP-2341875,CDM,2720000010,LOCAL,0272,RC,,,,both,,,643.70,418.40,,,,,,,,,,,,,
BIT DRL DIA2.5MM STP L16MM NONRADIOPAQUE REUSE,SUP-2187838,CDM,2720000010,LOCAL,0272,RC,,,,both,,,615.44,400.04,,,,,,,,,,,,,
KNIFE SRGCL LTHRP 10/25MM BLADE 8 3/4NL TNSL CRVD BNT SHPD J,SUP-2496303,CDM,2720000010,LOCAL,0272,RC,,,,both,,,310.26,201.67,,,,,,,,,,,,,
COMPONENT PAT SGL PEG RND PRI STD CEM N POR POLYETHLYENE,SUP-2390325,CDM,C1776,CPT,0278,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
BRACE THMB SPICA RT REG SPICA MOD SUPP FOAM WRP AD SM,SUP-2324380,CDM,L3931,HCPCS,0272,RC,,,,both,,,28.89,18.78,,,,,,,,,,,,,
PLATE BONE L86MM THK2MM 4 H LT LAT TIB L SHP ANG RT BTTRS,SUP-2343790,CDM,C1713,HCPCS,0278,RC,,,,both,,,2783.86,1809.51,,,,,,,,,,,,,
SPLINT THMB M L8IN LNG RT THERMOPLASTIC INSRT THERMO-FORM,SUP-2324197,CDM,L3931,HCPCS,0274,RC,,,,both,,,57.65,37.47,,,,,,,,,,,,,
DRESSING 4INX10.0YD DOME PASTE OR UNNA BOOT GELOCAST,SUP-2324582,CDM,L4387,HCPCS,0272,RC,,,,both,,,31.75,20.64,,,,,,,,,,,,,
TRAY CATH 4FR SGL LUMN MAX BARR SHERLOCK 3CG TPS STYL,SUP-2125509,CDM,C1751,HCPCS,0278,RC,,,,both,,,764.40,496.86,,,,,,,,,,,,,
PLATE BNE MAXILLOFCL 4 MESH KT NS FACE ID,SUP-2909538,CDM,C1713,HCPCS,0278,RC,,,,both,,,41703.50,27107.27,,,,,,,,,,,,,
TUBE ES DIA6MM 4 LUMN DBL BLLN ELONG SPEC MINNESOTA,SUP-2126033,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1765.94,1147.86,,,,,,,,,,,,,
HC Lipid Panel|NOT REASONABLE AND NECESSARY,PX-3018006100,CDM,80061,CPT,0301,RC,,,GZ,both,,,191.00,124.15,,,,,,,,,,,,,
SLEEVE COMPR SUSP,SUP-2388182,CDM,L2397,HCPCS,0274,RC,,,,both,,,300.78,195.51,,,,,,,,,,,,,
PLATE CRAN 200X200X40 MM PT SPEC IMPL PEEK,SUP-2860165,CDM,C1713,HCPCS,0278,RC,,,,both,,,59594.37,38736.34,,,,,,,,,,,,,
ANCHOR SUT L14MM OD4.5MM DBL ARM TWO NO 2 FIBERWIRE BIO,SUP-2121553,CDM,C1713,HCPCS,0278,RC,,,,both,,,894.90,581.68,,,,,,,,,,,,,
CATHETER ANGIOPLSTY L 40 CM BALLOON L 60 MM DIA10 MM COAT L,SUP-2909764,CDM,C1725,HCPCS,0272,RC,,,,both,,,441.80,287.17,,,,,,,,,,,,,
SCREW BNE ST 2X7 MM LP TI GLD LEIBINGER UNIV 2 5PK,SUP-2431317,CDM,C1713,HCPCS,0278,RC,,,,both,,,164.25,106.76,,,,,,,,,,,,,
"HC So RBC, Automated",PX-3058504166,CDM,85041,CPT,0305,RC,,,,both,,,34.00,22.10,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 160 MM DIA11 MM DEL SHTH,SUP-2934482,CDM,C1713,HCPCS,0278,RC,,,,both,,,13100.08,8515.05,,,,,,,,,,,,,
EXTENDER EXT FIX BNE TRNSPRT,SUP-2898543,CDM,2720000010,LOCAL,0272,RC,,,,both,,,951.42,618.42,,,,,,,,,,,,,
ALLOGRAFT HUM TISS FLUID 0.5 CC AMNIO MEMBRN PROVENDA FLO,SUP-2762321,CDM,C1762,CPT,0278,RC,,,,both,,,5375.68,3494.19,,,,,,,,,,,,,
BASEPLATE GLEN 24MM LAT +2 SHLDR MOD,SUP-2123392,CDM,C1713,HCPCS,0278,RC,,,,both,,,4553.00,2959.45,,,,,,,,,,,,,
DEFIBRILLATOR CARD W5CM 36J 2 CHMBR BPLR REMOT MON ENABLED,SUP-2357754,CDM,C1721,HCPCS,0275,RC,,,,both,,,56834.00,36942.10,,,,,,,,,,,,,
PARACENTESIS SET PIG 6 FRX12 CM SLIP LUER VLV ONESTEP,SUP-2474107,CDM,C1729,HCPCS,0272,RC,,,,both,,,185.26,120.42,,,,,,,,,,,,,
VALVE SPEAK TRACH,SUP-2138739,CDM,L8501,HCPCS,0272,RC,,,,both,,,141.30,91.84,,,,,,,,,,,,,
R-T TIB LOCK NL 13MMX36.0,SUP-2818301,CDM,C1713,HCPCS,0278,RC,,,,both,,,9594.27,6236.28,,,,,,,,,,,,,
AUGMENT ACET PART HMSPHR SZ 48 MM 10 MM THCK MULT H POR,SUP-2199308,CDM,C1776,CPT,0278,RC,,,,both,,,8251.92,5363.75,,,,,,,,,,,,,
GRAFT BONE 7.5 DEG SUB RESRB WDG POLYGRFT CA SULF OSTEOCURE,SUP-2400548,CDM,C1776,CPT,0278,RC,,,,both,,,2001.75,1301.14,,,,,,,,,,,,,
HC Strapping of Hip,PX-4502952000,CDM,29520,CPT,0450,RC,,,,both,,,214.00,139.10,,,,,,,,,,,,,
HFN RH 130 DEG 11MM X 400MM,SUP-2488052,CDM,C1713,HCPCS,0278,RC,,,,both,,,6752.38,4389.05,,,,,,,,,,,,,
CATHETER DRAINAGE INTRO 17 FRX18 CM RET FLEX BIO-MEDICUS LS,SUP-2745333,CDM,C1729,HCPCS,0272,RC,,,,both,,,1398.87,909.27,,,,,,,,,,,,,
PACK AUTOGRFT CONVENIENCE IMPL GRAFTLINK,SUP-2121384,CDM,C1776,CPT,0278,RC,,,,both,,,2135.20,1387.88,,,,,,,,,,,,,
GRAFT DERMAL MESH 4X4 CM FEN + WND MTRX MIRODERM,SUP-2431543,CDM,Q4175,HCPCS,0636,RC,,,,both,,,4019.20,2612.48,,,,,,,,,,,,,
GRAFT STENT 13 MMX10 CM 120 CM ENDOPROSTHESIS,SUP-2396584,CDM,C1874,HCPCS,0278,RC,,,,both,,,10927.20,7102.68,,,,,,,,,,,,,
SYSTEM DEL CATH L107CM OD6.7MM SHTH 16FR AORT FOR TRANSCATH,SUP-2282431,CDM,C1894,HCPCS,0272,RC,,,,both,,,6625.40,4306.51,,,,,,,,,,,,,
IMPLANT OPHTH SPNG EYE RETINAL STYL 505 G GROOVED BCKL COMP,SUP-2213499,CDM,L8610,HCPCS,0278,RC,,,,both,,,141.30,91.84,,,,,,,,,,,,,
SHEATH INTRO DRYSEAL FLX L 65 CM DIA20 FR BODY DIA 7.5 MM,SUP-2395733,CDM,C1894,HCPCS,0272,RC,,,,both,,,2160.32,1404.21,,,,,,,,,,,,,
CAGE SPNL 7 MM LORDTC TI ACIS PRO 360,SUP-2539621,CDM,C1889,HCPCS,0278,RC,,,,both,,,8726.06,5671.94,,,,,,,,,,,,,
NAIL IM L340MM OD11MM 125DEG 2MM RAD TI R IMPLANTS SET SCR,SUP-2370044,CDM,C1713,HCPCS,0278,RC,,,,both,,,6918.05,4496.73,,,,,,,,,,,,,
IMMUNE GLOBULIN (GAMMAGARD) 10%,RX-4081758,CDM,J1569,HCPCS,0636,RC,00944-2700-06,NDC,,both,200,ML,10302.00,6696.30,,,,,,,,,,,,,
PROBE COAG L2.2M DIA2.3MM FLX AR PLSM STRAIGHT FIRE CONIC BEAM,SUP-2217945,CDM,2720000010,LOCAL,0272,RC,,,,both,,,776.84,504.95,,,,,,,,,,,,,
PROSTHESIS PENILE MS PMP,SUP-2139028,CDM,C1813,HCPCS,0278,RC,,,,both,,,13360.70,8684.45,,,,,,,,,,,,,
COMPONENT ULN L3.5IN REG LT ELBW TIV PLSM INTERCHANGEABLE,SUP-2205938,CDM,C1776,CPT,0278,RC,,,,both,,,10606.92,6894.50,,,,,,,,,,,,,
STEM FEM L135MM DIA14MM EXT OFFSET HIP ZMLY CT POLISHED CEM,SUP-2203459,CDM,C1776,CPT,0278,RC,,,,both,,,9978.92,6486.30,,,,,,,,,,,,,
SET VASC NDL 15GA L15MM IO S STL WRISTBAND SHRP BLK EZ IO,SUP-2383216,CDM,2720000010,LOCAL,0272,RC,,,,both,,,428.92,278.80,,,,,,,,,,,,,
HC Mandible Mandible Min 4 Views,PX-3207011000,CDM,70110,CPT,0320,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
GRAFT EVAR L75MM DIA25MM STNT L20MM DEL SYS 19FR AORT EXT,SUP-2217571,CDM,C1768,CPT,0278,RC,,,,both,,,8776.30,5704.59,,,,,,,,,,,,,
BIT DRL SM PK ANTR CHMFR RMR TALAR KEEL MILL FOR STAR MOB,SUP-2361516,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
HC Arthrocent/Aspiration Maj Jnt|PBB CHARGE|BILATERAL PROCEDURE,PX-3612061000,CDM,20610,CPT,0361,RC,,,PBB|50,both,,,1245.00,809.25,,,,,,,,,,,,,
CATHETER PERFSN CRESCENT INSRTN L 8.9 CM DIA13 FR CONN 1/4,SUP-2745304,CDM,2720000010,LOCAL,0272,RC,,,,both,,,9106.00,5918.90,,,,,,,,,,,,,
TIP IRRIG DIA03MM ASPIR STR ULTRAFLOW,SUP-2110005,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
HC Drug Assay Carbamazepine Total,PX-3018015600,CDM,80156,CPT,0301,RC,,,,both,,,510.00,331.50,,,,,,,,,,,,,
PROCESSOR HEARING AID W65XH30MM COCHLEAR SANDY BRN CP950,SUP-2165028,CDM,L8614,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
STENT PERIPH INNOVA L 200 MM DIA 5 MM CATH L 160 CM WORKING,SUP-2146846,CDM,C1876,HCPCS,0278,RC,,,,both,,,4553.00,2959.45,,,,,,,,,,,,,
PLATE BNE CRV BROAD PEDIATRIC 3.5 MM 26 HOLE SS NS LCP,SUP-2799303,CDM,C1713,HCPCS,0278,RC,,,,both,,,3247.04,2110.58,,,,,,,,,,,,,
TAMP BNE SZ 3 L10MM BNE INFL BLLN KYPHX XPANDER,SUP-2281087,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3579.60,2326.74,,,,,,,,,,,,,
HC So Culture Aerobic Identify,PX-3008707766,CDM,87077,CPT,0300,RC,,,,both,,,109.00,70.85,,,,,,,,,,,,,
RETRACTOR NRV ROOT WIDE 5 3 4IN ENDOSCP R ANG,SUP-2292919,CDM,C1713,HCPCS,0278,RC,,,,both,,,966.52,628.24,,,,,,,,,,,,,
SPLINT CLAVICLEXSM INF W4XL52CM BCKL STRP CNTCT CLSR PD,SUP-2197367,CDM,L3650,HCPCS,0272,RC,,,,both,,,48.98,31.84,,,,,,,,,,,,,
"HC So Coombs,Direct",PX-3028688066,CDM,86880,CPT,0302,RC,,,,outpatient,,,218.00,141.70,,,,,,,,,,,,,
ROD TI LONG STRAIGHT 5.5X500,SUP-2840503,CDM,C1713,HCPCS,0278,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
CROWN DENT 4U REFIL UP CUSPID S STL PRI PRE TRIMMED PREFRM,SUP-2322230,CDM,D6783,CPT,0278,RC,,,,both,,,34.29,22.29,,,,,,,,,,,,,
SCREW BONE L80MM DIA6.5MM STD S STL CORT ST SELF DRL CANN,SUP-2343239,CDM,C1713,HCPCS,0278,RC,,,,both,,,1501.58,976.03,,,,,,,,,,,,,
HC Nonselect Debride WO Anes,PX-3619760200,CDM,97602,CPT,0361,RC,,,,both,,,253.00,164.45,,,,,,,,,,,,,
SUPPORT ORTHOT SHLDR CUST VEST TYP ABDUCTN RESTRAINER,SUP-2435755,CDM,L3675,HCPCS,0272,RC,,,,both,,,452.25,293.96,,,,,,,,,,,,,
KIT INTRO SHTH MICROEZ L 50 CM CATH 6 FR NDL L 7 CM FLEXURA,SUP-2125504,CDM,C1769,HCPCS,0272,RC,,,,both,,,120.48,78.31,,,,,,,,,,,,,
BUR SURG CYL 6.4 MM FOR XL-HD-G1/XL-HD CARBIDE,SUP-2848479,CDM,2720000010,LOCAL,0272,RC,,,,both,,,567.52,368.89,,,,,,,,,,,,,
SPACER FEM L DIA17MM DST HIP CO CHROM RNG STYL FOR SZ 6 AND,SUP-2368388,CDM,C1776,HCPCS,0278,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
TROCAR SURG TWIN FOR 2.7 MM PIN,SUP-2537826,CDM,2720000010,LOCAL,0272,RC,,,,both,,,571.29,371.34,,,,,,,,,,,,,
COMPONENT FEMORALXL RT KNEE POST STABILIZING REV PRI,SUP-2364859,CDM,C1776,CPT,0278,RC,,,,both,,,13590.42,8833.77,,,,,,,,,,,,,
SUBSTITUTE BNE GRFT PORE 500 UM 2 CC CALCIUM PHOSPHATE HA,SUP-2883829,CDM,C1713,HCPCS,0278,RC,,,,both,,,1764.68,1147.04,,,,,,,,,,,,,
GRAFT VASC GORTX L 80 CM DIA 4 MM EPTFE STR STD WALL N RING,SUP-2396415,CDM,C1768,CPT,0278,RC,,,,both,,,2125.78,1381.76,,,,,,,,,,,,,
BIT DRL L110MM DIA2MM REUSE,SUP-2167108,CDM,2720000010,LOCAL,0272,RC,,,,both,,,536.94,349.01,,,,,,,,,,,,,
GUIDEWIRE VASC REGATTA + L 195 CM DIA 0.014 IN DSTL TIP L 3,SUP-2154112,CDM,C1769,HCPCS,0272,RC,,,,both,,,225.30,146.44,,,,,,,,,,,,,
SUPPORT KNEE BASE PLT ASMBLY ALVARADO,SUP-2197867,CDM,C1776,CPT,0278,RC,,,,both,,,2459.09,1598.41,,,,,,,,,,,,,
JOINT SUBTALAR 5 SINUS TARSI ANK,SUP-2236091,CDM,C1713,HCPCS,0278,RC,,,,both,,,4961.20,3224.78,,,,,,,,,,,,,
KIT TRK KNEE PROC VIZADISC,SUP-2265694,CDM,2720000010,LOCAL,0272,RC,,,,both,,,546.20,355.03,,,,,,,,,,,,,
STAPLER INT CIR XLN MED THCK 33 MM 3/3.5/4 MM TRI-STAPLE EEA,SUP-2858017,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5173.75,3362.94,,,,,,,,,,,,,
SET URET STENT SOFFLX L 75 CM DIA 8.4 FR GUIDEWIRE L 100 CM,SUP-2168922,CDM,C2617,HCPCS,0278,RC,,,,both,,,385.40,250.51,,,,,,,,,,,,,
SCREW BONE SELF TAPPING 2.4X10 MM LOCKING TITANIUM MATRIXMAN,SUP-2837735,CDM,C1713,HCPCS,0278,RC,,,,both,,,585.11,380.32,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY PENTARAY NAV ECO 115CM 7FR4-4-4 D,SUP-2880938,CDM,C1732,HCPCS,0278,RC,,,,both,,,4279.82,2781.88,,,,,,,,,,,,,
HC Peripheral Block - Peripheral Nerve or Branch,PX-3606445000,CDM,64450,CPT,0360,RC,,,,both,,,2232.00,1450.80,,,,,,,,,,,,,
SUPPORT ORTHOT SHLDR CUST VEST TYP ABDUCTN RESTRAINER,SUP-2435755,CDM,L3675,HCPCS,0274,RC,,,,both,,,452.25,293.96,,,,,,,,,,,,,
Z DUP USE 2111355 LENS IOL SN60WF 27.5D,SUP-2111356,CDM,V2632,HCPCS,0276,RC,,,,both,,,467.86,304.11,,,,,,,,,,,,,
SCREW BNE CORTICAL 2.7X12 MM FUSION HEX DRV YEL WRST SS NS,SUP-2852108,CDM,C1713,HCPCS,0278,RC,,,,both,,,684.99,445.24,,,,,,,,,,,,,
MICROCATHETER INFUSION RENEGADE 18 150CM 20CM 0.027IN MIC 2,SUP-2361801,CDM,C1725,HCPCS,0272,RC,,,,both,,,2461.63,1600.06,,,,,,,,,,,,,
GRAFT BNE 45X11 MM OSTEOBALLAST,SUP-2644327,CDM,C1713,HCPCS,0278,RC,,,,both,,,5642.58,3667.68,,,,,,,,,,,,,
KIT OPTHACATH 3MM UNILAT,SUP-2224387,CDM,C1713,HCPCS,0278,RC,,,,both,,,894.90,581.68,,,,,,,,,,,,,
PIN GUIDE L 450 MM DIA 3.2 MM STRL DISP INTERTAN RAPID TAN,SUP-2933059,CDM,2720000010,LOCAL,0272,RC,,,,both,,,767.20,498.68,,,,,,,,,,,,,
PLATE SPNL L23MM 15DEG ANTR CERV TI CNVGNT,SUP-2280006,CDM,C1713,HCPCS,0278,RC,,,,both,,,3580.70,2327.45,,,,,,,,,,,,,
SINUS SCTN BURR ANGLD 15DGRS DMND BURR D5MM SHFT4MMX12CM 5/P,SUP-2574175,CDM,2720000010,LOCAL,0272,RC,,,,both,,,725.53,471.59,,,,,,,,,,,,,
PLATE BNE W22XL66MM STD 6X4 H NONSTERILE L DST RAD VOLAR TI,SUP-2180849,CDM,C1713,HCPCS,0278,RC,,,,both,,,2508.80,1630.72,,,,,,,,,,,,,
NAIL IM L460MM DIA10MM NK 135DEG GRN L FEM TI TROCHANTERIC,SUP-2191990,CDM,C1713,HCPCS,0278,RC,,,,both,,,5304.21,3447.74,,,,,,,,,,,,,
GRAFT BONE SUBSTITUTE 10GM VOID FILLER CALCIGEN,SUP-2470153,CDM,C1713,HCPCS,0278,RC,,,,both,,,1758.40,1142.96,,,,,,,,,,,,,
IOPAMIDOL 61 % IV SOLN,RX-27737,CDM,Q9967,HCPCS,0636,RC,00270-1315-35,NDC,,both,100,ML,25.20,16.38,,,,,,,,,,,,,
IMPLANT PENILE 5CM CYL INFL MINOCYCLINE RIFAMPIN INHIBIZONE,SUP-2140299,CDM,C1813,HCPCS,0278,RC,,,,both,,,18353.30,11929.64,,,,,,,,,,,,,
FOOTRING EXT FIX SHT TENXOR CP49360131,SUP-2530924,CDM,2720000010,LOCAL,0272,RC,,,,both,,,11301.17,7345.76,,,,,,,,,,,,,
CIRCUIT VENTILATOR 2 LIMB AD 6 FTX0.25 IN Y PORTED AIRLFE,SUP-2724361,CDM,C1713,HCPCS,0278,RC,,,,both,,,7.98,5.19,,,,,,,,,,,,,
BOOT CAST XL VELC OPN TOE FOR TOT CNTCT SYS TCC-EZ,SUP-2244449,CDM,L4370,HCPCS,0274,RC,,,,both,,,370.33,240.71,,,,,,,,,,,,,
TAP SURG DIA4.5MM PLATING SYS TUNGSTEN CARBIDE-100,SUP-2343963,CDM,2720000010,LOCAL,0272,RC,,,,both,,,944.20,613.73,,,,,,,,,,,,,
PLATE BNE LCK 2.7X26 MM 2 HOLE CNTOUR 2 COMPR SS STRL,SUP-2457983,CDM,C1713,HCPCS,0278,RC,,,,both,,,796.93,518.00,,,,,,,,,,,,,
ALLODERM SELECT 5X6 XTHIN 0.3-0.8 MESH,SUP-2827008,CDM,Q4116,HCPCS,0636,RC,,,,both,,,3240.48,2106.31,,,,,,,,,,,,,
CATHETER CV SET 025 5 FRX15 CM 3L POLYETH,SUP-2760053,CDM,C1751,HCPCS,0278,RC,,,,both,,,234.53,152.44,,,,,,,,,,,,,
KIT SHTH L22CM SM DEL CRV SPNL CLMN DORS ROOT GANG FOR LO,SUP-2357683,CDM,C1894,HCPCS,0272,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
SCREW BNE L30MM DIA4.5MM THRD L12MM S STL PARTIALLY THRDED,SUP-2184428,CDM,C1713,HCPCS,0278,RC,,,,both,,,63.46,41.25,,,,,,,,,,,,,
IMPLANT TOE L16MM 0DEG PROX INTERPHALANGEAL NIT NEUT 1 PC IM,SUP-2365954,CDM,C1713,HCPCS,0278,RC,,,,both,,,2583.12,1679.03,,,,,,,,,,,,,
KIT PENILE PROS 30CM ACCSRY CONN BLNT NDL CVD KEITHTUBING,SUP-2165368,CDM,C1713,HCPCS,0278,RC,,,,both,,,1522.90,989.88,,,,,,,,,,,,,
KIT BONE CEM MX AND DEL RADPQ VERT AUG W/ TY AVAMAX,SUP-2367083,CDM,C1713,HCPCS,0278,RC,,,,both,,,1648.50,1071.52,,,,,,,,,,,,,
PLATE BONE L200MM 16 H STRL RT LAT PROX TIB S STL FOR 3.5MM,SUP-2349728,CDM,C1713,HCPCS,0278,RC,,,,both,,,12061.37,7839.89,,,,,,,,,,,,,
ANCHOR SUT L14.7MM OD5.5MM 3 NO 2 FIBERWIRE BIOCRKSCR FT,SUP-2121552,CDM,C1713,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
SCREW BONE SELFTAPPING 1.5X6 MM CORTICAL HEXAGONAL HEAD STAI,SUP-2836702,CDM,C1713,HCPCS,0278,RC,,,,both,,,236.19,153.52,,,,,,,,,,,,,
BRACE WRST FA HND L INSTABILITY INJ 8IN IMMOB LOOP LOK,SUP-2276635,CDM,L3809,HCPCS,0274,RC,,,,both,,,21.82,14.18,,,,,,,,,,,,,
ALLOGRAFT BNE BLOCK 40X20X20 MM FD IRRADIATED CANC,SUP-2867235,CDM,C1762,CPT,0278,RC,,,,both,,,1357.27,882.23,,,,,,,,,,,,,
CATHETER URET 5FR L70CM UNIV POLYUR TAPR TIP SGL LUMN W/,SUP-2168890,CDM,C1758,HCPCS,0278,RC,,,,both,,,113.01,73.46,,,,,,,,,,,,,
GUIDEWIRE ORTH TROCAR PT 1 END 1.1X150 MM NS,SUP-2789082,CDM,C1769,HCPCS,0272,RC,,,,both,,,827.83,538.09,,,,,,,,,,,,,
PENICILLIN G BENZATHINE 1200000 UNIT/2ML IM SUSY,RX-157648,CDM,J0561,HCPCS,0636,RC,60793-0701-10,NDC,,both,2,ML,1088.70,707.65,,,,,,,,,,,,,
CAGE SPNL LORDTC 14X12X48 MM CORPECTOMY,SUP-2435229,CDM,C1889,HCPCS,0278,RC,,,,both,,,10354.15,6730.20,,,,,,,,,,,,,
BLADE SHAVER CRV 4.5X460 MM DISP 4256104463,SUP-2599801,CDM,2720000010,LOCAL,0272,RC,,,,both,,,927.74,603.03,,,,,,,,,,,,,
CATHETER GUID L 80 CM DIA16 FR HYDRPHLC STEER FOR MITRACLIP,SUP-2661363,CDM,C1887,HCPCS,0272,RC,,,,both,,,94200.00,61230.00,,,,,,,,,,,,,
CLIP INT L235CM WRK CHN DIA2.8MM OPN 11MM BRAID CATH ROT BX/10,SUP-2149429,CDM,C1889,HCPCS,0278,RC,,,,both,,,687.66,446.98,,,,,,,,,,,,,
BIT DRILL 2.6 WHITE/BLACK WITH ONE NO2 5 METRIC HI FI SUTURE,SUP-2824683,CDM,C1713,HCPCS,0278,RC,,,,both,,,1977.13,1285.13,,,,,,,,,,,,,
SCREW BONE 4.0X100 MM TIBIAXYS,SUP-2243001,CDM,C1713,HCPCS,0278,RC,,,,both,,,31.40,20.41,,,,,,,,,,,,,
SHEATH INTRO TORFLEX 45 DEG L 63 CM DIA 8 FR GUIDEWIRE L 180,SUP-2131514,CDM,C1893,HCPCS,0272,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9% BOLUS (FLUID RESUSCITATION),RX-4081440,CDM,2580000003,HCPCS,0258,RC,00264-1800-32,NDC,,both,1000,ML,229.50,149.17,,,,,,,,,,,,,
BUR SURG L7CM HD L61MM DIA64MM REV TAPR L BOR MIDAS REX,SUP-2277725,CDM,2720000010,LOCAL,0272,RC,,,,both,,,376.45,244.69,,,,,,,,,,,,,
CATHETER HD FULL SAFETY TY 035 12 FRX25 CM DRY TURBO-FLO HD,SUP-2759840,CDM,C1752,HCPCS,0278,RC,,,,both,,,447.64,290.97,,,,,,,,,,,,,
GRAFT HUM TISS SM 30X60MM <4400MM FASC LATA FRZ DRY,SUP-2264781,CDM,C1762,CPT,0278,RC,,,,both,,,2400.18,1560.12,,,,,,,,,,,,,
MONITOR CARD BIOMONITOR 2 AF PROMRI SIL HOME MONITORING MR,SUP-2138426,CDM,C1764,HCPCS,0278,RC,,,,both,,,13502.00,8776.30,,,,,,,,,,,,,
SLEEVE TIB 29MM CEM REV ATTUNE,SUP-2251460,CDM,C1776,CPT,0278,RC,,,,both,,,9334.28,6067.28,,,,,,,,,,,,,
LEVEL CMF PLATE ORTHG TLTS BSSO L SHP WTAB RGHT 10 MM BRG 2,SUP-2668656,CDM,C1713,HCPCS,0278,RC,,,,both,,,1422.99,924.94,,,,,,,,,,,,,
PLATE BNE L 2X2 H CRANIOMAXILLOFACIAL TI 3D BX LO PROF FOR,SUP-2366202,CDM,C1713,HCPCS,0278,RC,,,,both,,,885.42,575.52,,,,,,,,,,,,,
EXTRACTOR STONE 7FRX65CM CATH 4CMX6MM BAL TIP LEN 5CM HELCL,SUP-2171198,CDM,C1713,HCPCS,0278,RC,,,,both,,,777.72,505.52,,,,,,,,,,,,,
FORCEP GRASPING HK 3 MM 3 PRNG,SUP-2141711,CDM,2720000010,LOCAL,0272,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
PLATE BNE L UNIV 2.7X39 MM RT 3 HOLE 2 COMPR LCK OBLQ,SUP-2476507,CDM,C1713,HCPCS,0278,RC,,,,both,,,921.12,598.73,,,,,,,,,,,,,
VANCOMYCIN HCL 750 MG IV SOLR,RX-97281,CDM,J3373,HCPCS,0636,RC,00409-6531-02,NDC,,both,1,UN,56.60,36.79,,,,,,,,,,,,,
PPICC PROVENA SOLO 4F DL TL,SUP-2613558,CDM,C1751,HCPCS,0278,RC,,,,both,,,656.83,426.94,,,,,,,,,,,,,
SPACER SPNL 10MM BLU INDIR DCOMPR STRL SUPERION,SUP-2392699,CDM,C1821,HCPCS,0278,RC,,,,both,,,28888.00,18777.20,,,,,,,,,,,,,
CORT SCREW 115MM 3.5,SUP-2818735,CDM,C1713,HCPCS,0278,RC,,,,both,,,338.08,219.75,,,,,,,,,,,,,
SCREW BNE CANN SHT THRD 5.5X22 MM HD TI NS EXTREMIFIX LTX,SUP-2856320,CDM,C1713,HCPCS,0278,RC,,,,both,,,932.58,606.18,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9% BOLUS (FLUID RESUSCITATION),RX-4081440,CDM,J7030,HCPCS,0250,RC,00338-0049-04,NDC,,both,1000,ML,42.50,27.62,,,,,,,,,,,,,
ASSEMBLY SURG SAW SZ 15 MM IM CAM STRL DISP,SUP-2887640,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2557.53,1662.39,,,,,,,,,,,,,
SYSTEM IMPL BICEPS INCL 5.5MM PEEK SWIVELOCK FIBERLINK +,SUP-2121440,CDM,C1713,HCPCS,0278,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
SUPPORT ORTHOT ANK KNEE CUST DBL SLD STIRRUP W/O JT,SUP-2435635,CDM,L2030,HCPCS,0274,RC,,,,both,,,3066.65,1993.32,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9% BOLUS (FLUID RESUSCITATION),RX-4081440,CDM,2580000003,HCPCS,0250,RC,00264-1800-32,NDC,,both,1000,ML,229.50,149.17,,,,,,,,,,,,,
BIT DRL L230MM OD2.5MM 3 FLUT QUIK CPL REUSE,SUP-2343965,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1937.13,1259.13,,,,,,,,,,,,,
DUODENOSCOPE STRL SNGLE USE EXALT CNTRLR BX 2,SUP-2498379,CDM,C1748,HCPCS,0278,RC,,,,both,,,9200.20,5980.13,,,,,,,,,,,,,
INTRODUCER CATHETER 8FR L35IN PERI FOR CHOLGM CATHETER TAUT,SUP-2384691,CDM,C1894,HCPCS,0272,RC,,,,both,,,122.33,79.51,,,,,,,,,,,,,
HANDPIECE SURG ANGLED UNIV REPL NOSE CONE CVR SONOPET,SUP-2791043,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3254.33,2115.31,,,,,,,,,,,,,
PED CHS PLATE - 100 DEG,SUP-2818376,CDM,C1713,HCPCS,0278,RC,,,,both,,,7599.27,4939.53,,,,,,,,,,,,,
CATH BLLN SCORING 6X40MM X 137CM OTW PTA ANGIOSCULPT,SUP-2353199,CDM,C1725,HCPCS,0272,RC,,,,both,,,3367.65,2188.97,,,,,,,,,,,,,
ELECTRODE ECG MEDI-TRACE 3,SUP-2835250,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1216.66,790.83,,,,,,,,,,,,,
ENALAPRIL MALEATE 10 MG PO TABS,RX-9924,CDM,6370000000,HCPCS,0637,RC,23155-0772-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
REAMER SURG HIP GRTR DOME 52MM REFLCT,SUP-2345722,CDM,2720000010,LOCAL,0272,RC,,,,both,,,586.68,381.34,,,,,,,,,,,,,
COLLAR CERV AD H25XL19IN FIRM DENS CNTOUR HK AND LOOP CLSR,SUP-2276595,CDM,L0120,HCPCS,0274,RC,,,,both,,,8.04,5.23,,,,,,,,,,,,,
DEFIBRILLATOR CARD RESYNCHRONIZATION THER DEFIB CRT D 3,SUP-2138120,CDM,C1882,HCPCS,0275,RC,,,,both,,,64363.78,41836.46,,,,,,,,,,,,,
CATHETER VENTRICULAR RT ANGLE CLP STD 1.3X2.5 MMX23 CM ADPT,SUP-2631410,CDM,C1729,HCPCS,0272,RC,,,,both,,,487.64,316.97,,,,,,,,,,,,,
SHEET BARR W38XL50MM THK1MM ORBIT,SUP-2366488,CDM,C1713,HCPCS,0278,RC,,,,both,,,2131.18,1385.27,,,,,,,,,,,,,
VALVE SHUNT SYS ADJ DIFF PRSS 0-20CM H2O W/ GRAVITATIONAL,SUP-2108725,CDM,C1729,HCPCS,0272,RC,,,,both,,,10082.73,6553.77,,,,,,,,,,,,,
COMPONENT GLEN KEELED 44 MM TOT SHLDR OLYMPIA,SUP-2535952,CDM,C1776,CPT,0278,RC,,,,both,,,6154.40,4000.36,,,,,,,,,,,,,
ANCHOR SUT W/ ETHBND SZ 2-0 PLA GRN ROT CUF 2 LOOP,SUP-2249367,CDM,C1713,HCPCS,0278,RC,,,,both,,,1387.88,902.12,,,,,,,,,,,,,
SUPPORT ORTHOT LOWER EXTREMITY CUST THOR CTRL BND,SUP-2435691,CDM,L2660,HCPCS,0274,RC,,,,both,,,507.27,329.73,,,,,,,,,,,,,
GRAFT BNE PTTY 1 CC DBM GRFT,SUP-2294009,CDM,C1713,HCPCS,0278,RC,,,,both,,,480.42,312.27,,,,,,,,,,,,,
COLLAR EXTRIC AD 35IN FOR 11 23IN FR 1 PC FLAT LOK TAB CLS,SUP-2194415,CDM,L0120,HCPCS,0272,RC,,,,both,,,16.52,10.74,,,,,,,,,,,,,
FILLER BNE VOID 2.5 CC CORTICAL BNE SODIUM HYALURONATE,SUP-2927224,CDM,C1713,HCPCS,0278,RC,,,,both,,,1036.20,673.53,,,,,,,,,,,,,
TOTAL TM ANK,SUP-2212315,CDM,C1776,CPT,0278,RC,,,,both,,,32970.00,21430.50,,,,,,,,,,,,,
COIL NEUROVASCULAR DELTAFILL 18 L 12 CM DIA 3 MM PRIMARY DIA,SUP-2518790,CDM,C1889,HCPCS,0278,RC,,,,both,,,8906.67,5789.34,,,,,,,,,,,,,
BLADE SRGCL LMLLR STRGHT BVLD SHARP GRNDLSS SMOOTH UNDRSRFCE,SUP-2573959,CDM,2720000010,LOCAL,0272,RC,,,,both,,,51.78,33.66,,,,,,,,,,,,,
BOOT ORTHOSIS FOR 11-13IN ANK FOAM STATIC FOR POS AND PRSS,SUP-2194764,CDM,L4387,HCPCS,0272,RC,,,,both,,,138.54,90.05,,,,,,,,,,,,,
PLATE SPNL SM OCCIPITOCERVICAL LO PROF MIDLN VERTEX SEL,SUP-2289136,CDM,C1713,HCPCS,0278,RC,,,,both,,,5443.98,3538.59,,,,,,,,,,,,,
GRAFT BONE SUB SM PROCELLULAR SPNL MTRX OSTEOCEL,SUP-2310455,CDM,C1713,HCPCS,0278,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED UPLR ENDOPROSTHESIS STRYKERHUNIE] STRYKER CORP],SUP-2365981,CDM,C1776,CPT,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
CARFILZOMIB 60 MG IV SOLR,RX-117369,CDM,J9047,HCPCS,0636,RC,76075-0101-01,NDC,,both,1,UN,10187.20,6621.68,,,,,,,,,,,,,
ARCH FOOT 155MM,SUP-2488383,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5174.72,3363.57,,,,,,,,,,,,,
SHEATH URET ACC 12FR 28CML W/ DIL,SUP-2119489,CDM,C1894,HCPCS,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
TUBE GASTSTMY 20FR CONN STRL SIL EASY-FEED,SUP-2102903,CDM,2720000010,LOCAL,0272,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
PLATE BONE L33MM 6 H CRANIOFACIAL VIT STR COND FOR 1.3MM SCR,SUP-2364693,CDM,C1713,HCPCS,0278,RC,,,,both,,,527.52,342.89,,,,,,,,,,,,,
CATHETER URET 6/10FRX50CM ACC 2 LUMN STD W/ RADPQ MRK FLEXI,SUP-2168937,CDM,C1758,HCPCS,0278,RC,,,,both,,,138.47,90.01,,,,,,,,,,,,,
PROCEDURE PACK 30 CC BMAC2-30-02 BMAC,SUP-2384753,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7834.30,5092.29,,,,,,,,,,,,,
MESH HERN REP W10XL17CM ELP SYN COMP POLY ABSRB SYMBOTEX,SUP-2174764,CDM,C1781,HCPCS,0278,RC,,,,both,,,2293.83,1490.99,,,,,,,,,,,,,
CATHETER SUPP QUICK-CROSS EXTRM L 150 CM DIA 4 FR 0.018 IN,SUP-2823590,CDM,C1887,HCPCS,0272,RC,,,,both,,,624.86,406.16,,,,,,,,,,,,,
PACEMAKER CARD EVIA DR 2 CHMBR STRL,SUP-2138257,CDM,C1785,HCPCS,0275,RC,,,,both,,,15072.00,9796.80,,,,,,,,,,,,,
CATHETER CV DL AD 9 FRX90 CM TUNNELED BASIC KT INJ HICKMAN,SUP-2126551,CDM,C1751,HCPCS,0278,RC,,,,both,,,501.36,325.88,,,,,,,,,,,,,
STAPLE INT FIX W12XH10MM FT ANK NIT SUP E LO PROF NOTCH,SUP-2365478,CDM,C1713,HCPCS,0278,RC,,,,both,,,2728.91,1773.79,,,,,,,,,,,,,
PLATE BNE LCK 3.5X105 MM 8 HOLE CNTOUR 2 COMPR SS STRL,SUP-2495934,CDM,C1713,HCPCS,0278,RC,,,,both,,,972.87,632.37,,,,,,,,,,,,,
LONCASTUXIMAB TESIRINE-LPYL 10 MG IV SOLR,RX-154627,CDM,J9359,HCPCS,0636,RC,79952-0110-01,NDC,,both,1,UN,81566.60,53018.29,,,,,,,,,,,,,
ENDOPROSTHESIS VASC FLAIR L 70 MM DIA 7 MM CATH L 80 CM DIA,SUP-2126891,CDM,C1874,HCPCS,0278,RC,,,,both,,,7834.30,5092.29,,,,,,,,,,,,,
EXTRACTOR STONE 3FR L115CM BSKT DIA1CM NIT TIPLSS UNIDEX,SUP-2171307,CDM,2720000010,LOCAL,0272,RC,,,,both,,,678.24,440.86,,,,,,,,,,,,,
GUIDEWIRE VASC L190CM L155CM OD.028IN FLXIBLE REPERFUSION,SUP-2323627,CDM,C1769,HCPCS,0272,RC,,,,both,,,8164.00,5306.60,,,,,,,,,,,,,
REAMER SURG OD8MM HUM SHLDR ST ACORN MILAGRO,SUP-2249536,CDM,2720000010,LOCAL,0272,RC,,,,both,,,854.08,555.15,,,,,,,,,,,,,
PROTECTOR NRV L40MM DIA10MM PORCINE EXTRACELLULAR MTRX WRP,SUP-2124862,CDM,C1763,HCPCS,0278,RC,,,,both,,,9821.92,6384.25,,,,,,,,,,,,,
PARTIALLY THREADED SCREW 6.5 X 110MM,SUP-2586689,CDM,C1713,HCPCS,0278,RC,,,,both,,,1780.38,1157.25,,,,,,,,,,,,,
IMPLANT SPNL L40MM DIA7MM SACROILIAC JT TI POR PLSM SPR,SUP-2421209,CDM,C1776,CPT,0278,RC,,,,both,,,10440.50,6786.32,,,,,,,,,,,,,
SCREW BONE LOCKING 4.5X90 MM CORTICAL TIBIAL FEMUR SELFTAPPI,SUP-2837309,CDM,C1713,HCPCS,0278,RC,,,,both,,,1349.29,877.04,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED POROUS CKNEESNEPHPOR] SMITH AND NEPHEW ORTHOPAEDICS],SUP-2351343,CDM,C1776,CPT,0278,RC,,,,both,,,13907.06,9039.59,,,,,,,,,,,,,
SET ACCS CATH 5FR L10CM NDL 21GA L7CM GWIRE L40CM 0.018IN,SUP-2170561,CDM,C1894,HCPCS,0272,RC,,,,both,,,118.06,76.74,,,,,,,,,,,,,
GRAFT BNE W11XH10XL17MM CERV WDG FRZ DRY CANC TRICORT,SUP-2264848,CDM,C1713,HCPCS,0278,RC,,,,both,,,1941.40,1261.91,,,,,,,,,,,,,
TRANSDUCER PRSS L24IN NO STPCOCK DISP,SUP-2117231,CDM,2720000010,LOCAL,0272,RC,,,,both,,,759.88,493.92,,,,,,,,,,,,,
BUR NEUROSURGICAL L10CM DIA5MM S STL CUT RND BALL FLUT,SUP-2277615,CDM,2720000010,LOCAL,0272,RC,,,,both,,,310.48,201.81,,,,,,,,,,,,,
RETRACTOR SURG W12XH8MMXL5CM SELF RET MEDL OR LAT BLNT,SUP-2393986,CDM,C1894,HCPCS,0272,RC,,,,both,,,1868.30,1214.39,,,,,,,,,,,,,
ALLOGRAFT BNE CHIP 1-9.5 MM 15 CC FD DEMINERALIZED CANC,SUP-2717752,CDM,C1713,HCPCS,0278,RC,,,,both,,,1082.11,703.37,,,,,,,,,,,,,
SCREW SPNL MULTAXL 8.5X50 MM CANC CD HORZ TCS,SUP-2628371,CDM,C1713,HCPCS,0278,RC,,,,both,,,3355.88,2181.32,,,,,,,,,,,,,
ENDCAP ORTH L10MM FOR FEM IM NAIL SYS TRIGEN,SUP-2347070,CDM,C1776,CPT,0278,RC,,,,both,,,1200.05,780.03,,,,,,,,,,,,,
BIT DRL L215MM DIA4MM CALIB L80MM 3 FLUT QUIK CPL,SUP-2188200,CDM,2720000010,LOCAL,0272,RC,,,,both,,,748.45,486.49,,,,,,,,,,,,,
BIT DRL 1.5 MM WIRE PASS,SUP-2462176,CDM,2720000010,LOCAL,0272,RC,,,,both,,,684.52,444.94,,,,,,,,,,,,,
TOCILIZUMAB-BAVI 20 MG/ML IV SOLN (MIXTURES ONLY),RX-4083087,CDM,Q5133,HCPCS,0636,RC,64406-0023-01,NDC,,both,20,ML,6549.00,4256.85,,,,,,,,,,,,,
SIZER SURG GEL 2.5 CM PROJCT 10.3 CM 150 CC BRST SMOOTH RND,SUP-2300903,CDM,2720000010,LOCAL,0272,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
FRACTURE KIT BASE SHT 10 ML W/ PWR CRV STABILIT MX,SUP-2463110,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8010.45,5206.79,,,,,,,,,,,,,
SCREW BNE L10MM DIA1.5MM CO CHROM NONLOCKING FOR ALPS HND,SUP-2411778,CDM,C1713,HCPCS,0278,RC,,,,both,,,257.48,167.36,,,,,,,,,,,,,
"HC Plmt Nephrostomy Catheter,Perc",PX-3615043200,CDM,50432,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
PLATE BNE THK0.6MM 4X2 H L HND NONCOMPRESSION GRID FOR,SUP-2267894,CDM,C1713,HCPCS,0278,RC,,,,both,,,736.02,478.41,,,,,,,,,,,,,
SHELL BPLR OD51MM ID36MM ACET 1 PC GLADIATOR,SUP-2304608,CDM,C1776,CPT,0278,RC,,,,both,,,7143.50,4643.27,,,,,,,,,,,,,
STENT URET FLEXIMA L 22 CM DIA 6 FR TECOFLEX GLDEX 2 PIGTL,SUP-2147885,CDM,C2617,HCPCS,0278,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
ENDOPROSTHESIS VASC VIABAHN L 10CM 8MM 120CM 7FR RADIOPAQUE,SUP-2396659,CDM,C1874,HCPCS,0278,RC,,,,both,,,11093.62,7210.85,,,,,,,,,,,,,
GUIDEWIRE VASC GLIDEWIRE 180CM 0.035IN TIP 3 CM STIFF ANGLED,SUP-2385590,CDM,C1769,HCPCS,0272,RC,,,,both,,,165.82,107.78,,,,,,,,,,,,,
TAP SURG SCR THRD W O HNDL DRL SHFT BNE SPNL 35MM L10 24MM,SUP-2286804,CDM,C1713,HCPCS,0278,RC,,,,both,,,288.50,187.52,,,,,,,,,,,,,
BAND ORTHODONTIC M SZ 32 LO MAND S STL SEAMLESS CHAIRSIDE,SUP-2176641,CDM,D6783,CPT,0278,RC,,,,both,,,18.49,12.02,,,,,,,,,,,,,
IMMOBILIZER ELBW SM L7IN FOR 7-9IN BICEP 6-8IN WR COT W/O,SUP-2269055,CDM,L3650,HCPCS,0274,RC,,,,both,,,97.34,63.27,,,,,,,,,,,,,
ELECTRODE ES BPLR WIRE DISP SUPERLOOP,SUP-2313934,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1633.62,1061.85,,,,,,,,,,,,,
GRAFT HUMAN TISSUE 45X25 CM BIOLOGIC TISSUE MATRIX STERILE X,SUP-2838623,CDM,C1763,HCPCS,0278,RC,,,,both,,,104405.00,67863.25,,,,,,,,,,,,,
EMBOLIZATION KIT SPHR M100 YEL LC BEAD,SUP-2835336,CDM,C1889,HCPCS,0278,RC,,,,both,,,7300.50,4745.32,,,,,,,,,,,,,
ALLODERM SELECT 1X4 THIN 0.8-1.2,SUP-2822069,CDM,Q4116,HCPCS,0636,RC,,,,both,,,1014.22,659.24,,,,,,,,,,,,,
PUSH BLADE,SUP-2700938,CDM,2720000010,LOCAL,0272,RC,,,,both,,,525.76,341.74,,,,,,,,,,,,,
STEM FEM ROTATIONAL ENDOMODEL L 145X195,SUP-2418363,CDM,C1776,CPT,0278,RC,,,,both,,,27324.28,17760.78,,,,,,,,,,,,,
ACL REPAIR TIGHTROPE WITH INTERNALBRACE,SUP-2816616,CDM,C1713,HCPCS,0278,RC,,,,both,,,2025.30,1316.44,,,,,,,,,,,,,
CATHETER VASC 6 FR GUID JUDKINS LT 4 COR 90CM LEN W/O,SUP-2143737,CDM,C1887,HCPCS,0272,RC,,,,both,,,486.70,316.35,,,,,,,,,,,,,
UNIT SIERRA II SIERRA SER CTRL SER 6200A CONSTANT CURRENT,SUP-2152237,CDM,C1767,HCPCS,0278,RC,,,,both,,,730.05,474.53,,,,,,,,,,,,,
SHAFT SCRDRVR AO CONN TORQ LIMITING T6 DRV FOR 1.9 2.7MM,SUP-2291796,CDM,C1713,HCPCS,0278,RC,,,,both,,,16356.26,10631.57,,,,,,,,,,,,,
SCREW BNE STD 2.7X14 MM STRL HALLU SNAP-OFF,SUP-2608916,CDM,C1713,HCPCS,0278,RC,,,,both,,,762.64,495.72,,,,,,,,,,,,,
RESERVOIR SHUNT BURR HOLE 1.5 CM 0.68 CC PUDENZ CONV,SUP-2851450,CDM,C1889,HCPCS,0278,RC,,,,both,,,1343.83,873.49,,,,,,,,,,,,,
CATHETER ANGIOPLSTY SABER L 200 CM BALLOON L 20 MM DIA1.5 MM,SUP-2909781,CDM,C1725,HCPCS,0272,RC,,,,both,,,817.66,531.48,,,,,,,,,,,,,
HEAD RADIAL ANAT 26 MM LT,SUP-2107859,CDM,C1776,CPT,0278,RC,,,,both,,,9206.48,5984.21,,,,,,,,,,,,,
SCREW BONE L85MM DIA3.5MM STRL S STL LCK ST FOR SM PLATING,SUP-2349507,CDM,C1713,HCPCS,0278,RC,,,,both,,,855.87,556.32,,,,,,,,,,,,,
SOLUTION IV 1000ML 0.9% SODIUM CHLORIDE INJ USP,SUP-2900296,CDM,C1713,HCPCS,0278,RC,,,,both,,,8.13,5.28,,,,,,,,,,,,,
WEDGE TIB SZ 3-4 15MM R MED L LAT KNEE HEMI STP LEGION,SUP-2346588,CDM,C1776,CPT,0278,RC,,,,both,,,5025.57,3266.62,,,,,,,,,,,,,
KIT PROC 45DEG FIRM TIP EXT WRK CHAN CATH FOR OLY BRONCHSCP,SUP-2381763,CDM,C1887,HCPCS,0272,RC,,,,both,,,3705.20,2408.38,,,,,,,,,,,,,
GUIDEWIRE VASC GLIDEWIRE 260CM 0.035IN TIP L 1 CM ANGLED,SUP-2385108,CDM,C1769,HCPCS,0272,RC,,,,both,,,145.23,94.40,,,,,,,,,,,,,
PLATE BNE L116MM 7 H ANT ANK S STL LOK COMPR FOR ARTH,SUP-2177143,CDM,C1713,HCPCS,0278,RC,,,,both,,,4518.77,2937.20,,,,,,,,,,,,,
PLATE BONE THK1MM 4X2 H BILAT HND TRAPEZOIDAL LCK TRILOK FOR,SUP-2267932,CDM,C1713,HCPCS,0278,RC,,,,both,,,2238.82,1455.23,,,,,,,,,,,,,
INTRODUCER SHTH 0.018 IN 6 FRX23 CM 21 GAX4 CM GRN PRELUDE,SUP-2303285,CDM,C1894,HCPCS,0272,RC,,,,both,,,168.18,109.32,,,,,,,,,,,,,
PLATE X LCK 2.4/2.7MM 30X20 MED STRL,SUP-2547591,CDM,C1713,HCPCS,0278,RC,,,,both,,,2566.26,1668.07,,,,,,,,,,,,,
MATRIXNEURO EMER SCR 1.8 MM ST LEN 3 MM TI ALLOY TAN PK OF,SUP-2181597,CDM,C1713,HCPCS,0278,RC,,,,both,,,5840.40,3796.26,,,,,,,,,,,,,
BUR SURG ROUTER 1.5 MM SPRL GRN RED NS SIGN LTX,SUP-2859282,CDM,2720000010,LOCAL,0272,RC,,,,both,,,371.05,241.18,,,,,,,,,,,,,
GRAFT BNE SUB 5ML DEMIN BNE MTRX PSTE SYR FRZ DRY DBX,SUP-2306991,CDM,C1713,HCPCS,0278,RC,,,,both,,,2484.84,1615.15,,,,,,,,,,,,,
GRAFT HUM TISS L150-250MM DIA4.5MM FRZN PRESUTURED TEND,SUP-2257911,CDM,C1713,HCPCS,0278,RC,,,,both,,,4176.20,2714.53,,,,,,,,,,,,,
CATHETER IV 6 FRX60 CM 2 LUMEN POWERLINE,SUP-2217981,CDM,C1751,HCPCS,0278,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
SCREW BONE L40MM OD3.5MM FT ANK TI NONLOCKING,SUP-2321029,CDM,C1713,HCPCS,0278,RC,,,,both,,,292.02,189.81,,,,,,,,,,,,,
HYSTEROSCOPE SHTH 1 PC DSGN 5MM,SUP-2261124,CDM,C1894,HCPCS,0272,RC,,,,both,,,4666.98,3033.54,,,,,,,,,,,,,
PLATE BNE ORBIT FLR SM 1.5X35X35X0.5 MM LT SMRT TI NS,SUP-2460540,CDM,C1713,HCPCS,0278,RC,,,,both,,,3878.65,2521.12,,,,,,,,,,,,,
PLATE BNE RECON 2.7X64 MM 8 HOLE SS,SUP-2569078,CDM,C1713,HCPCS,0278,RC,,,,both,,,412.75,268.29,,,,,,,,,,,,,
GRAFT BNE 5 CC CELLULAR BNE MTRX V92 FC+,SUP-2742071,CDM,C1713,HCPCS,0278,RC,,,,both,,,8635.00,5612.75,,,,,,,,,,,,,
GRAFT HUM TISS W27-32XH11XL21-26MM POR CANC ANTR LUM INTBDY,SUP-2306951,CDM,C1713,HCPCS,0278,RC,,,,both,,,15292.08,9939.85,,,,,,,,,,,,,
GRIP CBL SM L255MM TROCHANTERIC HIP 3 CBL ACCORD,SUP-2345203,CDM,C1776,CPT,0278,RC,,,,both,,,8402.64,5461.72,,,,,,,,,,,,,
PLATE BNE W101XL182MM THK35MM 13 H BILAT TI STR RIG LOK,SUP-2191088,CDM,C1713,HCPCS,0278,RC,,,,both,,,2003.89,1302.53,,,,,,,,,,,,,
BRACE WRST L AD FOR 10 LESS THAN 11IN L1375IN R HND BLK,SUP-2196553,CDM,L3807,HCPCS,0274,RC,,,,both,,,276.01,179.41,,,,,,,,,,,,,
BRACE WRST L AD FOR 10 LESS THAN 11IN L1375IN R HND BLK,SUP-2196553,CDM,L3807,HCPCS,0272,RC,,,,both,,,276.01,179.41,,,,,,,,,,,,,
DEFIBRILLATOR IMPL LUMAX 540 DR-T 55X 66MM 13MM 40J LANDLINE,SUP-2138262,CDM,C1721,HCPCS,0275,RC,,,,both,,,67010.74,43556.98,,,,,,,,,,,,,
HC Canalith Repositioning Proc|OP PT SERVICES|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS,PX-4209599200,CDM,95992,CPT,0420,RC,,,GP|CQ,both,,,333.00,216.45,,,,,,,,,,,,,
PATCH CV HEMSHLD PLAT FINESSE L 152 X W 25 MM THK 0.36 MM,SUP-2481899,CDM,C1768,CPT,0278,RC,,,,both,,,563.32,366.16,,,,,,,,,,,,,
HC Niv Venous Duplex Bilat Study,PX-9219397000,CDM,93970,CPT,0921,RC,,,,both,,,2312.00,1502.80,,,,,,,,,,,,,
SCREW BNE CANN 4.5X44 MM SS,SUP-2183091,CDM,C1713,HCPCS,0278,RC,,,,both,,,745.31,484.45,,,,,,,,,,,,,
SYSTEM IMPL L24MM DIA5.5MM BIOCOMP INCL 2 SWIVELOCK SP FOR,SUP-2121718,CDM,C1713,HCPCS,0278,RC,,,,both,,,5589.20,3632.98,,,,,,,,,,,,,
BIT DRL L445MM DIA07MM STP 6MM L6MM ST MAXILLOFACIAL S,SUP-2187631,CDM,2720000010,LOCAL,0272,RC,,,,both,,,506.14,328.99,,,,,,,,,,,,,
TM TOTAL ANKLE RIGHT TALUS SIZE 6,SUP-2459324,CDM,C1776,CPT,0278,RC,,,,both,,,13074.11,8498.17,,,,,,,,,,,,,
HC So Lipid Panel,PX-3018006166,CDM,80061,CPT,0301,RC,,,,outpatient,,,43.00,27.95,,,,,,,,,,,,,
PLATE BNE LAT EXT RIGHT/INTERNAL LT FOR OSTEOTMY TIBIAXYS,SUP-2609012,CDM,C1713,HCPCS,0278,RC,,,,both,,,4229.93,2749.45,,,,,,,,,,,,,
HC US 3d Independent Workstation,PX-3207637700,CDM,76377,CPT,0320,RC,,,,both,,,1344.00,873.60,,,,,,,,,,,,,
COIL NEUROVASCULAR AXIUM PRIM L 15 CM SECONDARY DIA 4 MM,SUP-2458373,CDM,C1889,HCPCS,0278,RC,,,,both,,,6578.30,4275.89,,,,,,,,,,,,,
STEM EXTN L65MM DIA13MM KNEE CEMENTLESS FLUT GMK,SUP-2267623,CDM,C1776,CPT,0278,RC,,,,both,,,6554.75,4260.59,,,,,,,,,,,,,
CATHETER EMB FOGARTY L 80 CM DIA 3 FR 5MM/4.5FR 0.018 IN,SUP-2755078,CDM,C1757,HCPCS,0272,RC,,,,both,,,310.48,201.81,,,,,,,,,,,,,
HARVESTING SET 8.5 MM CHSL TAMP DRL BIT RED MOSAICPLASTY DP,SUP-2878034,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1325.39,861.50,,,,,,,,,,,,,
SET INTRO OUTER CATH 4FR L10CM NDL 21GA L4CM 0.018IN PLAT,SUP-2170547,CDM,C1894,HCPCS,0272,RC,,,,both,,,70.34,45.72,,,,,,,,,,,,,
WASHER ORTH TI FLAT FOR 7MM SCR MONSTER,SUP-2320330,CDM,C1713,HCPCS,0278,RC,,,,both,,,428.61,278.60,,,,,,,,,,,,,
CONTOURED MESH GRDNR STYLE 1.0MM STNDRD STYLE T 6L 4V,SUP-2499852,CDM,C1713,HCPCS,0278,RC,,,,both,,,8953.18,5819.57,,,,,,,,,,,,,
DEXTROSE-SODIUM CHLORIDE 5-0.2 % IV SOLN,RX-15863,CDM,J3490,HCPCS,0250,RC,00338-0077-04,NDC,,both,1000,ML,51.00,33.15,,,,,,,,,,,,,
SCREW BNE CHAMFERED 4.5X45 MM SLD COR TI ORTHOLOC 2,SUP-2539833,CDM,C1713,HCPCS,0278,RC,,,,both,,,3755.44,2441.04,,,,,,,,,,,,,
HEAD FEM POR W/ OXINIUMXLPE LNR,SUP-2347951,CDM,C1776,CPT,0278,RC,,,,both,,,14130.00,9184.50,,,,,,,,,,,,,
PIN KNOWL S STL 7.3 MM BRKOFF DIAM 10.2 CM BRKOFF LEN 18.1,SUP-2409699,CDM,C1713,HCPCS,0278,RC,,,,both,,,382.95,248.92,,,,,,,,,,,,,
HC Excis Benign Lesion 0.5 Cm,PX-4501142000,CDM,11420,CPT,0450,RC,,,,both,,,4946.00,3214.90,,,,,,,,,,,,,
CATHETER HEMO DYLS OR HD AD L50CM INSRTN L33CM DIA14.5FR,SUP-2174235,CDM,C1881,HCPCS,0278,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
CATHETER SET TRAUM CATH BA STRP,SUP-2666767,CDM,C1729,HCPCS,0272,RC,,,,both,,,394.32,256.31,,,,,,,,,,,,,
Z DISCONTINUED NO SUB IDED BREAST BIOPSY TRAY FOR US BX NDL LOC,SUP-2175843,CDM,C1819,HCPCS,0278,RC,,,,both,,,42.39,27.55,,,,,,,,,,,,,
PLATE BONE L111MM THK3.4MM 7 H BILAT S STL LCK COMPR NEUT,SUP-2348982,CDM,C1713,HCPCS,0278,RC,,,,both,,,2838.69,1845.15,,,,,,,,,,,,,
BALLOON CERV RIPENING 80ML L40CM PREINDUCTION FOR MECH DIL,SUP-2170568,CDM,C1726,HCPCS,0272,RC,,,,both,,,177.85,115.60,,,,,,,,,,,,,
CATHETER CTRL VEN OD6FR POLYUR 2 LUMN PEEL APART INTRO PWR,SUP-2127765,CDM,C1751,HCPCS,0278,RC,,,,both,,,4455.31,2895.95,,,,,,,,,,,,,
BIT DRL ARTHSCP 8 MM NS SURTAC 2000,SUP-2217552,CDM,2720000010,LOCAL,0272,RC,,,,both,,,393.16,255.55,,,,,,,,,,,,,
PLATE SPNL 4X10 MM LT MOUTH SINGLE,SUP-2708740,CDM,C1713,HCPCS,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
GUIDEWIRE TEF COAT 038INX145CM,SUP-2294351,CDM,C1769,HCPCS,0272,RC,,,,both,,,26.69,17.35,,,,,,,,,,,,,
SPLINT FNGR W325XL325IN ALUMINUM LN W FOAM PLASTALUME RADLUC,SUP-2276771,CDM,L3933,HCPCS,0272,RC,,,,both,,,3.17,2.06,,,,,,,,,,,,,
COMPONENT TIB SZ 1 RT FIX CEM GMK,SUP-2267562,CDM,C1776,CPT,0278,RC,,,,both,,,4279.07,2781.40,,,,,,,,,,,,,
STENT LACR DUCT M COLLARETTE W3MM SIL S STL TIP,SUP-2224379,CDM,C1783,HCPCS,0278,RC,,,,both,,,219.80,142.87,,,,,,,,,,,,,
PLATE BNE CLAV CS3 2.7 MM RT LAT VA LCK COMPR SS NS VA-LCP,SUP-2750790,CDM,C1713,HCPCS,0278,RC,,,,both,,,3298.26,2143.87,,,,,,,,,,,,,
PREDNISONE 5 MG/5ML PO SOLN,RX-6492,CDM,J7512,HCPCS,0637,RC,09999-9903-65,NDC,,both,5,ML,2.90,1.88,,,,,,,,,,,,,
CATHETER CV DL PEDIATRIC 7 FRX65 CM TUNNELED HICKMAN,SUP-2126154,CDM,C1751,HCPCS,0278,RC,,,,both,,,445.88,289.82,,,,,,,,,,,,,
HEAD HUM LT FRZN ALLGRFT,SUP-2335592,CDM,C1713,HCPCS,0278,RC,,,,both,,,3987.80,2592.07,,,,,,,,,,,,,
WIRE EXT FIX REDUCTION 1.5X400 MM MR SAFE,SUP-2422097,CDM,C1713,HCPCS,0278,RC,,,,both,,,668.95,434.82,,,,,,,,,,,,,
CATHETER DRAINAGE 6 FRX20 CM ALL PURP LOOP PIG PERCFLX,SUP-2147780,CDM,C1729,HCPCS,0272,RC,,,,both,,,258.92,168.30,,,,,,,,,,,,,
HC Glb Allo Stem Cell Collection,PX-9823820500,CDM,38205,CPT,0982,RC,,,,both,,,4740.00,3081.00,,,,,,,,,,,,,
ROD IM 8 MM KNEE PERSONA,SUP-2447959,CDM,C1713,HCPCS,0278,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
INSERT TIB ROTATING HINGED 6 14 MM RT-PLUS,SUP-2450897,CDM,C1776,CPT,0278,RC,,,,both,,,2097.52,1363.39,,,,,,,,,,,,,
PLATE BNE W512XL512MM THK06MM CRAN SM GRID MESH RESORB X,SUP-2263019,CDM,C1713,HCPCS,0278,RC,,,,both,,,2990.19,1943.62,,,,,,,,,,,,,
SCREW BNE L14MM DIA2.7MM CORT TI ST NONCANNULATED LOK FULL,SUP-2189716,CDM,C1713,HCPCS,0278,RC,,,,both,,,352.21,228.94,,,,,,,,,,,,,
TUNNELER SURG L 600 MM LG STD RNG MARKING STRL DISP,SUP-2929221,CDM,2720000010,LOCAL,0272,RC,,,,both,,,462.80,300.82,,,,,,,,,,,,,
VANCOMYCIN HCL 1.75 G IV SOLR,RX-168630,CDM,J3374,HCPCS,0636,RC,72078-0065-50,NDC,,both,1,UN,215.40,140.01,,,,,,,,,,,,,
SHEATH INTRO PRELUDE L 11 CM DIA 6 FR 0.025 IN 4 CM 20 GA SS,SUP-2677275,CDM,C1894,HCPCS,0272,RC,,,,both,,,67.26,43.72,,,,,,,,,,,,,
K WIRE FIX L152MM DIA0.9MM DST VOLAR RAD STD TIP GEMINUS,SUP-2340261,CDM,C1713,HCPCS,0278,RC,,,,both,,,80.07,52.05,,,,,,,,,,,,,
IMPLANT OTO W4MM W/ 9MM ABUTMENT DISP PONTO SYS,SUP-2319888,CDM,L8690,HCPCS,0278,RC,,,,both,,,9074.60,5898.49,,,,,,,,,,,,,
EVOS VOL PLATE 3H LEFT STD TI 48MM NS,SUP-2818637,CDM,C1713,HCPCS,0278,RC,,,,both,,,4568.70,2969.65,,,,,,,,,,,,,
SCREW BNE CANN SHRT THRD 4.5X20 MM 7 MM MIDFOOT HD COMPR SS,SUP-2609305,CDM,C1713,HCPCS,0278,RC,,,,both,,,1184.53,769.94,,,,,,,,,,,,,
BLADE SAW RECIPROCATOR 76X12.5X0.9 MM,SUP-2607451,CDM,2720000010,LOCAL,0272,RC,,,,both,,,99.85,64.90,,,,,,,,,,,,,
PLATE BNE T 80 MM 4 HOLE BUTTRESS TI NS,SUP-2569057,CDM,C1713,HCPCS,0278,RC,,,,both,,,1933.77,1256.95,,,,,,,,,,,,,
KIT DBS EXT TUNN STRL DISP SENSIGHT,SUP-2883079,CDM,2720000010,LOCAL,0272,RC,,,,both,,,805.41,523.52,,,,,,,,,,,,,
CATHETER THROMCTMY EXTRACTION 0.014 IN 5.5 FRX138 CM PRONTO,SUP-2605995,CDM,C1757,HCPCS,0272,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
TUBE ENDOTRACHEL AD SZ 6 OD9.7MM ID6MM HI VOL LO PRSS,SUP-2383580,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1124.12,730.68,,,,,,,,,,,,,
CATHETER NEPHSTMY 8FR L25CM FLEXIMA TEMPTIP HYDRPHLC TIP,SUP-2147906,CDM,C1729,HCPCS,0272,RC,,,,both,,,244.92,159.20,,,,,,,,,,,,,
BAR EXT FIX 11X200 MM CARBON,SUP-2749995,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1516.62,985.80,,,,,,,,,,,,,
CATHETER HD STR 15.5X20 CM LT DL STP BASIC SET HEMO-FLOW XF,SUP-2627236,CDM,C1750,HCPCS,0278,RC,,,,both,,,100.48,65.31,,,,,,,,,,,,,
SYSTEM DEL DUCT OCCL II AMPLATZER TORQVUE SHTH OD8FR TIP ANG,SUP-2355720,CDM,C1713,HCPCS,0278,RC,,,,both,,,2152.03,1398.82,,,,,,,,,,,,,
RING ACET DIA62MM HIP DYN LOK CEMENTLESS RECON DURALOC,SUP-2250741,CDM,C1776,CPT,0278,RC,,,,both,,,786.26,511.07,,,,,,,,,,,,,
IMPLANT FUS H4XL75MM IFUSE,SUP-2337742,CDM,C1713,HCPCS,0278,RC,,,,both,,,10440.50,6786.32,,,,,,,,,,,,,
LITHIUM CARBONATE 300 MG PO TABS,RX-4531,CDM,6370000000,HCPCS,0637,RC,00054-8528-25,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
NAIL INTRAMEDULLARY 3.6MM DIA 210MML TITANIUM LEFT RADIAL,SUP-2640060,CDM,C1713,HCPCS,0278,RC,,,,both,,,6433.86,4182.01,,,,,,,,,,,,,
GRAFT DERM HUM TISS HYDRATED ULT THCK ACELLULAR DERM IMPL,SUP-2307499,CDM,Q4128,HCPCS,0636,RC,,,,both,,,8891.26,5779.32,,,,,,,,,,,,,
JOINT TEMPOROMANDIBULAR UNILAT CRAN,SUP-2565227,CDM,C1776,CPT,0278,RC,,,,both,,,29830.00,19389.50,,,,,,,,,,,,,
PLATE 4.5MM 3.5MM TI LCP METAPHYSEAL 11 HOLES,SUP-2549474,CDM,C1713,HCPCS,0278,RC,,,,both,,,2320.59,1508.38,,,,,,,,,,,,,
BRACE ORTHOPEDIC PUL ON 1 XS 12-15 IN KNEE FULL CIR STRP,SUP-2150965,CDM,L1810,HCPCS,0272,RC,,,,both,,,299.09,194.41,,,,,,,,,,,,,
PLATE BNE LEFORT 11X0.6 MM LT LINDORF MOD TI,SUP-2473255,CDM,C1713,HCPCS,0278,RC,,,,both,,,836.06,543.44,,,,,,,,,,,,,
HEAD FEM 0+ MM 12/14 40 MM HIP TAPR CERM,SUP-2449612,CDM,C1776,CPT,0278,RC,,,,both,,,4846.59,3150.28,,,,,,,,,,,,,
TROCAR SURG SH ENTRY PORTAL VERSANAIL,SUP-2412760,CDM,2720000010,LOCAL,0272,RC,,,,both,,,571.48,371.46,,,,,,,,,,,,,
BLADE LARYNGOSCOPE MACINTOSH 1 FIBER OPTIC SS GRN SPEC,SUP-2149970,CDM,2720000010,LOCAL,0272,RC,,,,both,,,200.93,130.60,,,,,,,,,,,,,
SHEAR THRM LGTNG VRSTLTY W/PWR CORD CNSTNT VSBLTY CMFRT AUDB,SUP-2693695,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
HEAD RADIAL H 0.474 IN DIA 0.866 IN SZ 22S COCR ALLOY ELBW,SUP-2933572,CDM,C1776,CPT,0278,RC,,,,both,,,9512.66,6183.23,,,,,,,,,,,,,
BASKET STONE REMV L190CM DIA20MM BSKT W2.8MM 8 WIR,SUP-2313156,CDM,2720000010,LOCAL,0272,RC,,,,both,,,870.03,565.52,,,,,,,,,,,,,
HC CT Orbit/Ear/Fossa W/WO Contrast,PX-3517048200,CDM,70482,CPT,0351,RC,,,,both,,,2630.00,1709.50,,,,,,,,,,,,,
CLIP EXT FIX L1.5-1.8MM GRY WIRE DISC FOR ILIZ TAY SPAT FRME,SUP-2342994,CDM,C1769,HCPCS,0272,RC,,,,both,,,54.82,35.63,,,,,,,,,,,,,
ASSEMBLY BLADE ENDOSCP CRPL TUNN RELEASE STRL LTX DISP,SUP-2877768,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2041.00,1326.65,,,,,,,,,,,,,
BIT DRL QC 2.8X200 MM W/ SCALE 3 FLUT NS,SUP-2863396,CDM,2720000010,LOCAL,0272,RC,,,,both,,,643.79,418.46,,,,,,,,,,,,,
SYSTEM DEL CATH 14FR WRK L107CM CAP DIA6MM W/ 30CM INLINE,SUP-2419637,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6625.40,4306.51,,,,,,,,,,,,,
ANCHOR SUT OD5MM 2 3 MAXBRAID TI SCR PERM DBL LD ROT CUF,SUP-2212815,CDM,C1713,HCPCS,0278,RC,,,,both,,,1266.05,822.93,,,,,,,,,,,,,
TUBE VENT 1.02 MM 1.6 MM 2.3 MM SHEP GRMMT TAB PC SIL STRL,SUP-2535076,CDM,L8699,HCPCS,0278,RC,,,,both,,,40.41,26.27,,,,,,,,,,,,,
CATHETER LUM PERI EXT DRNGE LUER LCK CONN SUT TAB TOUHY NDL,SUP-2244312,CDM,C1729,HCPCS,0272,RC,,,,both,,,1993.30,1295.64,,,,,,,,,,,,,
SHAVERDRILL SUTURETAK DISPOSABLES KT,SUP-2419463,CDM,2720000010,LOCAL,0272,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
GUIDEWIRE ENDO L260CM DIA0.035IN HYDRPHLC ANG TIP FOR BILI,SUP-2170081,CDM,C1769,HCPCS,0272,RC,,,,both,,,310.86,202.06,,,,,,,,,,,,,
STEM FEM OD18MM 12/14 CLLRLSS STD OFFSET TAPR HIP ZIRCONIA,SUP-2222364,CDM,C1776,CPT,0278,RC,,,,both,,,14506.80,9429.42,,,,,,,,,,,,,
SUPPORT ORTHOT THOR LUMBAR SACR CUST SAGITTAL-CORONAL CTRL 2,SUP-2435549,CDM,L0491,HCPCS,0272,RC,,,,both,,,2174.29,1413.29,,,,,,,,,,,,,
BIT DRILL SHANK SHORT 3.5 MM WITH QUICK CONNECT PERILOC,SUP-2837022,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1446.76,940.39,,,,,,,,,,,,,
KIT INTRO ARROWG+ARD BLU SHTH L 10 CM DIA 8.5 FR PRB DIL,SUP-2383377,CDM,C1894,HCPCS,0272,RC,,,,both,,,265.64,172.67,,,,,,,,,,,,,
CATHETER HEMO DYLS OR HD ADMIN BASIC KT DBL LUMN SIL STR SPL,SUP-2266950,CDM,C1750,HCPCS,0278,RC,,,,both,,,1051.90,683.73,,,,,,,,,,,,,
PLATE TBL LEFT MED HLSX6 LATEX FREE MRCRY FREE PVC FREE,SUP-2588831,CDM,C1713,HCPCS,0278,RC,,,,both,,,3811.58,2477.53,,,,,,,,,,,,,
BLOCK CUT FOR CAPPED C1B CAPCONFORMISC1B] CONFORMIS INC],SUP-2165814,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
PLATE BNE COMPR FIBULAR 5 HOLE,SUP-2490400,CDM,C1713,HCPCS,0278,RC,,,,both,,,234.53,152.44,,,,,,,,,,,,,
PASSER SUTURE STR 16 MM FLUSHPORT MULTFI SCORPION,SUP-2849259,CDM,2720000010,LOCAL,0272,RC,,,,both,,,14114.30,9174.29,,,,,,,,,,,,,
HC Debride Skin at Fx Site,PX-4501101000,CDM,11010,CPT,0450,RC,,,,both,,,2188.00,1422.20,,,,,,,,,,,,,
SET INTRO L 50 CM DIA 9 FR HEMOSTATIC VLV PEELWY STRL,SUP-2138187,CDM,C1894,HCPCS,0272,RC,,,,both,,,973.40,632.71,,,,,,,,,,,,,
GRAFT HUM TISS 10.5X69 MM QUADRICEPS TEND QUADLINK,SUP-2845954,CDM,C1762,CPT,0278,RC,,,,both,,,7755.80,5041.27,,,,,,,,,,,,,
GUIDEWIRE VASC L180CM DIA0035IN TAPR L105CM FLPY PLAT TIP,SUP-2168237,CDM,C1769,HCPCS,0272,RC,,,,both,,,83.27,54.13,,,,,,,,,,,,,
PLATE BNE RECON 2-2.5X259X2.8 MM 36 HOLE ANGLED-ANGLED STRL,SUP-2479746,CDM,C1713,HCPCS,0278,RC,,,,both,,,8893.05,5780.48,,,,,,,,,,,,,
ENDCAP ORTH L0MM DIA15MM NONSTERILE FEM TI NAIL EXTN LCK HD,SUP-2192154,CDM,C1713,HCPCS,0278,RC,,,,both,,,633.78,411.96,,,,,,,,,,,,,
CEFAZOLIN SODIUM 2 G IV SOLR,RX-162906,CDM,J0688,HCPCS,0636,RC,00143-9139-01,NDC,,both,1,UN,54.10,35.16,,,,,,,,,,,,,
STENT BILI C FLX L 15 CM DIA 7 FR PLAS DBL PIGTL AD BLU STRL,SUP-2149443,CDM,C2617,HCPCS,0278,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
RING SPNL HALF CLS CRADLE END FOR RIB SUPP TI NS VEPTR,SUP-2193300,CDM,C1713,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
STENT COR OTW 2.5X8 MM 5 FRX143 CM XIENCE V,SUP-2104431,CDM,C1874,HCPCS,0278,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
SPLINT WR FRARM SM AD L11IN BLU L FOAM FOR INSTABILITY INJ,SUP-2195162,CDM,L3908,HCPCS,0274,RC,,,,both,,,28.26,18.37,,,,,,,,,,,,,
PLATE BONE STRAIGHT 1.6X0.5 MM 2 HOLE TITANIUM NON STERILE L,SUP-2838351,CDM,C1713,HCPCS,0278,RC,,,,both,,,178.98,116.34,,,,,,,,,,,,,
SCREW BNE L150MM DIA4.5MM STD CORT S STL HEX SOCK,SUP-2184421,CDM,C1713,HCPCS,0278,RC,,,,both,,,238.29,154.89,,,,,,,,,,,,,
LEVEL NEURO ST KIT CRNTMY FLAP 25 975 04 71 6 01 302 13 71 3,SUP-2677536,CDM,C1713,HCPCS,0278,RC,,,,both,,,2611.44,1697.44,,,,,,,,,,,,,
STENT URET CNTOUR VL L 22-30 CM DIA 6 FR TIP L 3 CM SENSOR,SUP-2522230,CDM,C2617,HCPCS,0278,RC,,,,both,,,550.79,358.01,,,,,,,,,,,,,
HC Chemotx Admn Prtl Cavity,PX-3319644600,CDM,96446,CPT,0331,RC,,,,inpatient,,,1444.00,938.60,,,,,,,,,,,,,
PLATE BNE L 46 MM SCREW DIA2 MM 8 H LCK NAR NS VARIAX,SUP-2900570,CDM,C1713,HCPCS,0278,RC,,,,both,,,3167.95,2059.17,,,,,,,,,,,,,
HC So Cytomegalovirus Pcr,PX-3068749666,CDM,87496,CPT,0306,RC,,,,both,,,254.00,165.10,,,,,,,,,,,,,
SCREW BNE L14MM DIA4MM CORT S STL ST NONCANNULATED LOK FULL,SUP-2185052,CDM,C1713,HCPCS,0278,RC,,,,both,,,374.85,243.65,,,,,,,,,,,,,
BARICITINIB 2 MG PO TABS,RX-142620,CDM,6370000000,HCPCS,0637,RC,00002-4182-30,NDC,,both,1,UN,415.20,269.88,,,,,,,,,,,,,
HEAD HUM H17.25MM DIA46MM STD SHLDR CO CHROM REV NECKLESS,SUP-2193859,CDM,C1776,CPT,0278,RC,,,,both,,,7987.03,5191.57,,,,,,,,,,,,,
CATHETER MAP 20 MM ACHVE,SUP-2500842,CDM,C1730,HCPCS,0272,RC,,,,both,,,2794.60,1816.49,,,,,,,,,,,,,
IMPLANT BIO TISS W10XL10CM REGEN PORCINE CLLGN SQ XENMATRIX,SUP-2125844,CDM,C1781,HCPCS,0278,RC,,,,both,,,6970.80,4531.02,,,,,,,,,,,,,
CEFTAZIDIME 1 G IJ SOLR,RX-9474,CDM,J0713,HCPCS,0636,RC,44567-0235-25,NDC,,both,1,UN,54.10,35.16,,,,,,,,,,,,,
PLATE BONE LOK 210MML HLX14 STNLSS STEEL ST LEFT LTRL DST FB,SUP-2588183,CDM,C1713,HCPCS,0278,RC,,,,both,,,2452.53,1594.14,,,,,,,,,,,,,
SET GUIDEWIRE EXCHANGE JEFFREY SHTH L 18 CM ID 6.3 FR OD 8,SUP-2168011,CDM,C1769,HCPCS,0272,RC,,,,both,,,253.34,164.67,,,,,,,,,,,,,
KIT ACP MAX COUNTER BALANCE,SUP-2867292,CDM,2720000010,LOCAL,0272,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
BIT DRILL 2.1MM BIO INSTABILITY,SUP-2828537,CDM,2720000010,LOCAL,0272,RC,,,,both,,,958.33,622.91,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED PRSS FT SHELL HD TRAB MEL CERM,SUP-2212735,CDM,C1776,CPT,0278,RC,,,,both,,,13773.61,8952.85,,,,,,,,,,,,,
MESH HERN W10XL15CM POLY POLYLACTIC ACID 70% CLLGN 30% GLYC,SUP-2174683,CDM,C1781,HCPCS,0278,RC,,,,both,,,1113.32,723.66,,,,,,,,,,,,,
PLATE BNE W13.5XL250MM THK4.2MM 14 H BILAT S STL NAR LIMIT,SUP-2185252,CDM,C1713,HCPCS,0278,RC,,,,both,,,840.80,546.52,,,,,,,,,,,,,
INSERT TIB L54MM THICKNESS 10MM POLYETH CNDYL KNEE REV MOD,SUP-2199886,CDM,C1776,CPT,0278,RC,,,,both,,,9327.37,6062.79,,,,,,,,,,,,,
SCREW BNE L10MM DIA35MM ST CORT S STL ST FULL THRD HEX DRV,SUP-2178108,CDM,C1713,HCPCS,0278,RC,,,,both,,,262.35,170.53,,,,,,,,,,,,,
PLATE BNE L121MM 4 H L PROX LAT TIB S STL LOK FOR 3.5/4MM,SUP-2372127,CDM,C1713,HCPCS,0278,RC,,,,both,,,4082.00,2653.30,,,,,,,,,,,,,
SCREW C806T CCD CL IMP 6MM PLG TI C806T,SUP-2280606,CDM,C1713,HCPCS,0278,RC,,,,both,,,536.94,349.01,,,,,,,,,,,,,
LENACAPAVIR SODIUM (SUNLENCA) 463.5 MG/1.5ML SC SOLN,RX-161039,CDM,J1961,HCPCS,0636,RC,61958-3002-01,NDC,,both,3,ML,57525.00,37391.25,,,,,,,,,,,,,
ENOXAPARIN SODIUM 120 MG/0.8ML IJ SOSY,RX-157665,CDM,J1650,HCPCS,0636,RC,63323-0609-90,NDC,,both,.8,ML,137.20,89.18,,,,,,,,,,,,,
GRAFT BNE COTTON WDG 20X6.5 MM TI,SUP-2609844,CDM,C1713,HCPCS,0278,RC,,,,both,,,8496.21,5522.54,,,,,,,,,,,,,
ALLODERM SELECT 1X1- XTHICK 2.8-4.0,SUP-2822077,CDM,Q4116,HCPCS,0636,RC,,,,both,,,241.78,157.16,,,,,,,,,,,,,
IMPLANT OP RM TUFFNEK SCR 2.7 3.5 AND,SUP-2321239,CDM,C1713,HCPCS,0278,RC,,,,both,,,341.48,221.96,,,,,,,,,,,,,
ELECTRODE LAP MNPLR OLSEN 5MM DIA SHAFT 12 12NL L HOOK WIRE,SUP-2675667,CDM,2720000010,LOCAL,0272,RC,,,,both,,,943.57,613.32,,,,,,,,,,,,,
BUR SURG 10 FLUT 9 MM RND CARBIDE UPWR,SUP-2166781,CDM,2720000010,LOCAL,0272,RC,,,,both,,,240.52,156.34,,,,,,,,,,,,,
HEAD SPNL SCREW ROD DIA 4.75/5 MM UNIAXIAL STRL CD HORZ 4PK,SUP-2928638,CDM,C1713,HCPCS,0278,RC,,,,both,,,9168.80,5959.72,,,,,,,,,,,,,
STABILIZER TISS CANSTR TBNG EVOLUTION AS OCTPS,SUP-2283007,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4945.50,3214.57,,,,,,,,,,,,,
STAPLE SPNL 4 MM SFS,SUP-2601819,CDM,C1713,HCPCS,0278,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
DIAMOND SHAVER TUBESET,SUP-2745900,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1638.04,1064.73,,,,,,,,,,,,,
GUIDE DRL L4.2MM LNG REUSE NONSTERILE RADLUC,SUP-2362676,CDM,2720000010,LOCAL,0272,RC,,,,both,,,369.08,239.90,,,,,,,,,,,,,
PLATE BNE L 28 MM SCREW DIA2.8 MM SM CP TI RT MANDIBULAR,SUP-2883703,CDM,C1713,HCPCS,0278,RC,,,,both,,,15550.22,10107.64,,,,,,,,,,,,,
INSERT TIB SZ 4 THK11MM KNEE CONVENTIONAL POLYETH CNDYL,SUP-2421265,CDM,C1776,CPT,0278,RC,,,,both,,,2238.47,1455.01,,,,,,,,,,,,,
STENT PERIPH S.M.A.R.T. CTRL L 20 MM DIA12 MM DEL SYS L 120,SUP-2158635,CDM,C1876,HCPCS,0278,RC,,,,both,,,2559.10,1663.41,,,,,,,,,,,,,
CATHETER ANGIO SOFT-VU L 100 CM 4 FR SIM2 NONBRAIDED SFT,SUP-2116696,CDM,C1725,HCPCS,0272,RC,,,,both,,,41.45,26.94,,,,,,,,,,,,,
SCREW BNE L15MM DIA2.7MM LOK FOR R3CON PLATING SYS GORILLA,SUP-2321277,CDM,C1713,HCPCS,0278,RC,,,,both,,,572.27,371.98,,,,,,,,,,,,,
HC So Antinomyces Antibody,PX-3028660266,CDM,86602,CPT,0302,RC,,,,both,,,37.00,24.05,,,,,,,,,,,,,
CONTROLLER NEUROSTIMULATOR HND HELD PRGMR WIRELESS PTM FOR,SUP-2284642,CDM,C1787,HCPCS,0278,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
KIT CATH HEMODIALYSI HEMOSPLIT XK CHRONIC STD 16FR D 5685190,SUP-2632959,CDM,C1750,HCPCS,0278,RC,,,,both,,,1496.84,972.95,,,,,,,,,,,,,
PIN BONE FIX L50MM OD4MM LACTOSORB L15 BIOABSRB ACL,SUP-2212876,CDM,C1713,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
THERA-DERM EX LOTN,RX-7831,CDM,6370000000,HCPCS,0637,RC,00904-4299-09,NDC,,both,236,ML,8.50,5.52,,,,,,,,,,,,,
CATHETER THOR 20FR L22IN PVC 4 EYELET STR ATRAUM,SUP-2227430,CDM,C1729,HCPCS,0272,RC,,,,both,,,23.24,15.11,,,,,,,,,,,,,
PLATE BNE X 1.5X1 MM 12 MM 4 HOLE OPN LOOP C-TUBE BRIDGE NS,SUP-2471280,CDM,C1713,HCPCS,0278,RC,,,,both,,,958.49,623.02,,,,,,,,,,,,,
GRAFT SFT TISS X THCK 30X30 CM RECON TISS MTRX STRATTICE,SUP-2483835,CDM,Q4130,HCPCS,0636,RC,,,,both,,,89110.06,57921.54,,,,,,,,,,,,,
DRILL SURG L1524MM DIA36MM CAPTURE,SUP-2244279,CDM,2720000010,LOCAL,0272,RC,,,,both,,,798.82,519.23,,,,,,,,,,,,,
TEMPLATE DERM W4XL10IN REGEN SZ FOR BURN RECON SURG,SUP-2243492,CDM,Q4105,HCPCS,0636,RC,,,,both,,,14315.26,9304.92,,,,,,,,,,,,,
FORCEP ELECSURG BPLR 1.5 MM 14.5 CM PRO SER SILVERGLIDE,SUP-2859593,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3775.41,2454.02,,,,,,,,,,,,,
GRAFT HUM TISS L 120 MM FIB SHFT LYOPH,SUP-2913297,CDM,C1762,CPT,0278,RC,,,,both,,,4226.44,2747.19,,,,,,,,,,,,,
GUIDEWIRE VASC APPRCH CTO L190CM 0.014IN L18CM 12GM STR SHRT,SUP-2170828,CDM,C1769,HCPCS,0272,RC,,,,both,,,401.89,261.23,,,,,,,,,,,,,
THERA-DERM EX LOTN,RX-7831,CDM,6370000000,HCPCS,0637,RC,52800-0488-26,NDC,,both,177,ML,11.20,7.28,,,,,,,,,,,,,
SCREW BNE LAG 12.7X90 MM HIP COMPR TALON,SUP-2391518,CDM,C1713,HCPCS,0278,RC,,,,both,,,1948.37,1266.44,,,,,,,,,,,,,
HC Cardiac Rehab Phase 3 - 12 Visits,PX-9900000059,CDM,9900000059,LOCAL,0990,RC,,,,both,,,60.00,39.00,,,,,,,,,,,,,
RING EXT FIX ID140MM ANK FT FULL FOR TRUELOK FRME ASSEMB,SUP-2316169,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2857.40,1857.31,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP L2700MM DIA0025IN ANG DST TIP EXCELLENT,SUP-2313168,CDM,C1769,HCPCS,0272,RC,,,,both,,,709.36,461.08,,,,,,,,,,,,,
GUIDEWIRE VASC J 15 MM 0.035 INX150 CM CRV STD FIX COR STRL,SUP-2302702,CDM,C1769,HCPCS,0272,RC,,,,both,,,21.35,13.88,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED HYBRID SHELL TRAB MEL,SUP-2212727,CDM,C1776,CPT,0278,RC,,,,both,,,13517.17,8786.16,,,,,,,,,,,,,
"HC Pt Therapeutic Exercise,Ea 15 Min|OP OCCUPATIONAL THERAPY SERV|SERVICES PROVIDED IN WHOLE OR IN PARTY BY AN OTA FOR MEDICARE PATIENTS|UNUSUAL NON-OVERLAPPING SERVICE",PX-4209711000,CDM,97110,CPT,0420,RC,,,GO|CO|XU,both,,,195.00,126.75,,,,,,,,,,,,,
POWERPORT IMPL CLEARVUE ISP 8FR,SUP-2748439,CDM,C1788,HCPCS,0278,RC,,,,both,,,812.13,527.88,,,,,,,,,,,,,
DRILL ARTHROSCOPICXL DIA1.7MM FOR SUT ANCHR SHLDR,SUP-2341892,CDM,C1713,HCPCS,0278,RC,,,,both,,,679.15,441.45,,,,,,,,,,,,,
PLATE BNE SM LT MEDL CLMN FUSION STRATUM,SUP-2497933,CDM,C1713,HCPCS,0278,RC,,,,both,,,6539.55,4250.71,,,,,,,,,,,,,
PUNCH SURG FOR 5.5MM CRKSCR FT AND 5.5MM SWIVELOCK,SUP-2121559,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
PLATE ANCHR ORTHODONTIC 12 MM 1 MM W/ FLAT 5 MM AREA CP TI,SUP-2476748,CDM,C1713,HCPCS,0278,RC,,,,both,,,534.84,347.65,,,,,,,,,,,,,
ELECTRODE ELECSURG 26FR EVAP WNG LF STRL DISP,SUP-2332860,CDM,C1713,HCPCS,0278,RC,,,,both,,,401.92,261.25,,,,,,,,,,,,,
INTRODUCER SHTH SL0 0.032 IN 10 FRX180 CM J STIFF FAST-CATH,SUP-2357207,CDM,C1893,HCPCS,0272,RC,,,,both,,,967.12,628.63,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 70 CM DIA 6MM STR TW REMOVABLE RNG,SUP-2396297,CDM,C1768,CPT,0278,RC,,,,both,,,4581.26,2977.82,,,,,,,,,,,,,
SCREW BONE SELF TAPPING 1.7X3 MM CORTICAL EMERGENCY CRICIFOR,SUP-2838190,CDM,C1713,HCPCS,0278,RC,,,,both,,,334.10,217.16,,,,,,,,,,,,,
NAIL IM CANN 125 DEG 11X380 MM RT TROCHANTERIC FIX TI GRN,SUP-2191999,CDM,C1713,HCPCS,0278,RC,,,,both,,,3984.09,2589.66,,,,,,,,,,,,,
BODY HUM TI6AL4V RVS PROX ELECTIVE ZERO OFFSET LCK SCR FOR,SUP-2265034,CDM,C1776,CPT,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
FIBER LASER 365UM 6J 80HZ 120W D F L FOR LITHO MOSES,SUP-2417490,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1314.28,854.28,,,,,,,,,,,,,
THIOTEPA 100 MG IJ SOLR,RX-138288,CDM,J9342,HCPCS,0636,RC,70121-1631-01,NDC,,both,1,UN,11700.00,7605.00,,,,,,,,,,,,,
DEFIBRILLATOR CARDIOVERTER SGL CHMBR 30 J UPLR VVIR 20 SEC,SUP-2138082,CDM,C1722,HCPCS,0275,RC,,,,both,,,37680.00,24492.00,,,,,,,,,,,,,
GUIDEWIRE .047IN DIA NON STERILE 1 1/5INL,SUP-2574078,CDM,C1769,HCPCS,0272,RC,,,,both,,,44.49,28.92,,,,,,,,,,,,,
SPLINT WRST HK LOOP CLOSURE MED 6 IN RT ELASTIC COTTON,SUP-2336321,CDM,L3809,HCPCS,0274,RC,,,,both,,,11.15,7.25,,,,,,,,,,,,,
COMPONENT THMB MOD 2+ 13 MM HD,SUP-2137781,CDM,C1776,CPT,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
COMPONENT CRANIOFACIAL CUSTOMIZED + MED COMPLX + PEEK NS LTX,SUP-2862811,CDM,C1713,HCPCS,0278,RC,,,,both,,,44820.36,29133.23,,,,,,,,,,,,,
ALLOGRAFT BNE CHIP 0.5-3 MM 15 CC FD CRUSH CORTICAL CANC,SUP-2743395,CDM,C1713,HCPCS,0278,RC,,,,both,,,1017.36,661.28,,,,,,,,,,,,,
BLADE SURG W40XL545MM THK038MM S STL SAW SAG HVY DUTY,SUP-2361911,CDM,2720000010,LOCAL,0272,RC,,,,both,,,184.51,119.93,,,,,,,,,,,,,
PLATE BNE FIBULAR 2.7X131 MM RT LAT DSTL 7 HOLE STRL VALCP,SUP-2789392,CDM,C1713,HCPCS,0278,RC,,,,both,,,3267.23,2123.70,,,,,,,,,,,,,
SEAL BONE CEM SZ 4-7 FEM DEF PRSS FIT,SUP-2375361,CDM,C1713,HCPCS,0278,RC,,,,both,,,386.22,251.04,,,,,,,,,,,,,
DEVICE EMB PIPELINE 2.50X10MM,SUP-2465674,CDM,C1889,HCPCS,0278,RC,,,,both,,,41831.08,27190.20,,,,,,,,,,,,,
PLATE BNE TALO NAVICULAR SM TI RIVAL VW,SUP-2645290,CDM,C1713,HCPCS,0278,RC,,,,both,,,5209.26,3386.02,,,,,,,,,,,,,
PLATE MESH TI CONTOURABLE 100X100MM MALLEABLE LPROF SYNTHES,SUP-2848978,CDM,C1713,HCPCS,0278,RC,,,,both,,,6556.32,4261.61,,,,,,,,,,,,,
MOSUNETUZUMAB-AXGB 1 MG/ML IV SOLN,RX-161228,CDM,J9350,HCPCS,0636,RC,50242-0159-01,NDC,,both,1,ML,1797.90,1168.63,,,,,,,,,,,,,
ERIBULIN MESYLATE 1 MG/2ML IV SOLN,RX-107177,CDM,J9179,HCPCS,0636,RC,62856-0389-01,NDC,,both,2,ML,4060.80,2639.52,,,,,,,,,,,,,
DEVICE MNSCL RPR WTH PEEK ANCHR SIZE 2 UHMWPE STRE FLXBLE ND,SUP-2858618,CDM,C1713,HCPCS,0278,RC,,,,both,,,1458.15,947.80,,,,,,,,,,,,,
COMPONENT TIB UNI RM/LL 10MM SM EIUS,SUP-2364887,CDM,C1776,CPT,0278,RC,,,,both,,,5777.60,3755.44,,,,,,,,,,,,,
MARKER BRST BX OD8GA COIL S STL BRL VACORA ATEC ENCORMR,SUP-2195589,CDM,A4648,CPT,0278,RC,,,,both,,,219.80,142.87,,,,,,,,,,,,,
KIT LTING DISP STRL LT CBL NONSTRL LT CBL ADPT ACMI,SUP-2354671,CDM,C1713,HCPCS,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
ANKLE FUSION PLATE LATERAL TTC 6H,SUP-2815311,CDM,C1713,HCPCS,0278,RC,,,,both,,,7536.00,4898.40,,,,,,,,,,,,,
DICYCLOMINE HCL 10 MG/5ML PO SOLN,RX-42119,CDM,340b,HCPCS,0637,RC,70954-0261-10,NDC,,both,5,ML,4.80,3.12,,,,,,,,,,,,,
SCREW BONE EMERGENCY 2.7X8 MM MANDIBULAR CORTICAL SELFTAPPIN,SUP-2838772,CDM,C1713,HCPCS,0278,RC,,,,both,,,397.84,258.60,,,,,,,,,,,,,
TRIAL BNE PLT 130DEG FEM DHS,SUP-2187954,CDM,C1713,HCPCS,0278,RC,,,,both,,,893.90,581.03,,,,,,,,,,,,,
INTRODUCER INCUBATING CATH 14FR L65CM DIA3MM W/ STIFFING,SUP-2168692,CDM,C1894,HCPCS,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
MESH SURG VERTESSA LITE 4X22CM STRIPS,SUP-2716339,CDM,C1781,HCPCS,0278,RC,,,,both,,,3215.36,2089.98,,,,,,,,,,,,,
GRAFT HUM TISS 4.5SQCM AMNION AND CHORION MEMBRN EPIFIX,SUP-2305745,CDM,Q4186,HCPCS,0636,RC,,,,both,,,2433.50,1581.77,,,,,,,,,,,,,
WEDGE TIB M SZ 1 THK10MM KNEE PRI PRESSFIT FULL FLAT BLK,SUP-2377113,CDM,C1776,CPT,0278,RC,,,,both,,,3244.25,2108.76,,,,,,,,,,,,,
HEAD FEM DIA32MM +0MM OFFSET 11 13 TAPR ALUMINA PRI MOD SYS,SUP-2253046,CDM,C1776,CPT,0278,RC,,,,both,,,5037.82,3274.58,,,,,,,,,,,,,
"HC N.Gonorrhea, Dna, Amp Probe",PX-3068759100,CDM,87591,CPT,0306,RC,,,,both,,,232.00,150.80,,,,,,,,,,,,,
PAD ORTHOT ABD CUST,SUP-2435590,CDM,L1270,HCPCS,0272,RC,,,,both,,,234.65,152.52,,,,,,,,,,,,,
OLANZAPINE 10 MG IM SOLR,RX-38263,CDM,J2359,HCPCS,0636,RC,00781-3159-72,NDC,,both,1,UN,161.50,104.97,,,,,,,,,,,,,
GRAFT BONE SUB 1-4MM 30ML ALLGRFT CHIP CANC DEMIN COPIOS,SUP-2205387,CDM,C1734,HCPCS,0278,RC,,,,both,,,1664.20,1081.73,,,,,,,,,,,,,
MESH SURG XL OPTIMESH,SUP-2536960,CDM,C1713,HCPCS,0278,RC,,,,both,,,14915.00,9694.75,,,,,,,,,,,,,
BRACE ANK AD H10IN STD BILAT STRP CLSR OPN HEEL AND TOE,SUP-2195182,CDM,L4397,HCPCS,0274,RC,,,,both,,,54.51,35.43,,,,,,,,,,,,,
GRAFT HUM TISS PTCH 2X2 CM UMB CRD RESTORIGIN,SUP-2321891,CDM,Q4191,HCPCS,0636,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
PLATE BONE W5MM THK0.9MM 2 H LT S STL L SHP OBLQ,SUP-2343840,CDM,C1713,HCPCS,0278,RC,,,,both,,,447.73,291.02,,,,,,,,,,,,,
CATHETER PTCA BLLN PERIPH OTW N COMPLIANT 10.0MM DIA 100MM,SUP-2117090,CDM,C1725,HCPCS,0272,RC,,,,both,,,411.34,267.37,,,,,,,,,,,,,
INFUSION PUMP KIT PAINBUSTSTER 5 INX12.5 CM 270 CC ON-Q,SUP-2236833,CDM,C1713,HCPCS,0278,RC,,,,both,,,477.28,310.23,,,,,,,,,,,,,
PROBE ENDOSCP BPLR 10 FR 2 GENRTR PLUG QUICKSILVER,SUP-2737100,CDM,2720000010,LOCAL,0272,RC,,,,both,,,722.20,469.43,,,,,,,,,,,,,
SCREW BNE ST 5X30 MM TI NS NCB MOTIONLOC,SUP-2423586,CDM,C1713,HCPCS,0278,RC,,,,both,,,558.89,363.28,,,,,,,,,,,,,
PIN NAVIGATION L150MM DIA3MM ANCHR MRK IMAG GUID ORTHOMAP,SUP-2720251,CDM,C1713,HCPCS,0278,RC,,,,both,,,34.63,22.51,,,,,,,,,,,,,
PLATE 3.5MM TI CURVED NARROW LCP 12 HOLE-STERILE,SUP-2546919,CDM,C1713,HCPCS,0278,RC,,,,both,,,2326.52,1512.24,,,,,,,,,,,,,
NYSTATIN 500000 UNITS PO TABS,RX-5752,CDM,6370000000,HCPCS,0637,RC,00093-0983-01,NDC,,both,1,UN,4.60,2.99,,,,,,,,,,,,,
SHEATH URET ACC 12FR L28CM HYDRPHLC FLX,SUP-2168991,CDM,C1894,HCPCS,0272,RC,,,,both,,,625.17,406.36,,,,,,,,,,,,,
BLADE SURG ANGLED HK STRL,SUP-2481821,CDM,2720000010,LOCAL,0272,RC,,,,both,,,420.26,273.17,,,,,,,,,,,,,
BRACE ORTH 2X UPR SLD STIR AFO,SUP-2388168,CDM,L1990,HCPCS,0274,RC,,,,both,,,1099.75,714.84,,,,,,,,,,,,,
SCREW BNE L24MM DIA2MM CORT TI ST FOR MOD HND SYS PRO-PAK,SUP-2189608,CDM,C1713,HCPCS,0278,RC,,,,both,,,97.69,63.50,,,,,,,,,,,,,
DISTRACTION INTRNL DIST MNDBLE ZRCH 2 3DX WLLMS U PLATE RGHT,SUP-2669828,CDM,C1713,HCPCS,0278,RC,,,,both,,,17933.89,11657.03,,,,,,,,,,,,,
SCREW BNE LCK 4.5X16 MM ANK FUSION CONSTRUCT,SUP-2609759,CDM,C1713,HCPCS,0278,RC,,,,both,,,1007.19,654.67,,,,,,,,,,,,,
CABLE VENTILATOR NEONATAL EDI MOD W/ TST PLUG FOR SERVO,SUP-2747016,CDM,C1713,HCPCS,0278,RC,,,,both,,,1244.95,809.22,,,,,,,,,,,,,
SCREW SKULL REF L 6 MM DIA1.5 MM BNE FIX NS DISP,SUP-2910346,CDM,2720000010,LOCAL,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
PLATE BNE RADIAL STD 22X54 MM LT VOLAR DSTL 6X3 HOLE VA,SUP-2546695,CDM,C1713,HCPCS,0278,RC,,,,both,,,4356.97,2832.03,,,,,,,,,,,,,
INSTRUMENT ORTH L7IN DRSG IN TOME,SUP-2408289,CDM,C1713,HCPCS,0278,RC,,,,both,,,561.75,365.14,,,,,,,,,,,,,
BUR SURG DIA 5 MM HUB XLI DIAMOND STRL DISP HI-LINE XS,SUP-2929057,CDM,2720000010,LOCAL,0272,RC,,,,both,,,667.78,434.06,,,,,,,,,,,,,
TIMOLOL MALEATE 0.25 % OP SOLN,RX-11561,CDM,6370000000,HCPCS,0637,RC,61314-0226-05,NDC,,both,5,ML,23.30,15.14,,,,,,,,,,,,,
SCREW BNE L 12 MM DIA2 MM TI LCK VA BLU NS PRO-PAK TRILEAP,SUP-2905566,CDM,C1713,HCPCS,0278,RC,,,,both,,,693.06,450.49,,,,,,,,,,,,,
BUNDLE CASE ORTHOGNATHIC POSTOP VSP,SUP-2862840,CDM,2720000010,LOCAL,0272,RC,,,,both,,,11952.03,7768.82,,,,,,,,,,,,,
FRACTURE KIT 2ND LNG STABILIT,SUP-2458952,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5966.00,3877.90,,,,,,,,,,,,,
CONNECTOR ROD 6.35X21.5MM SPINE TRNSVRS TI SYNERGY,SUP-2415610,CDM,C1713,HCPCS,0278,RC,,,,both,,,1387.28,901.73,,,,,,,,,,,,,
ALPHA1-PROTEINASE INHIBITOR 1000 MG IV SOLR,RX-36577,CDM,J0256,HCPCS,0636,RC,00944-2815-01,NDC,,both,1,UN,1917.50,1246.37,,,,,,,,,,,,,
CATHETER THROMCTMY INDIGO CAT PENUMBRA 140CM RX L LUMN ASPIR TBNG,SUP-2323580,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6091.60,3959.54,,,,,,,,,,,,,
RETRIEVER THROMCTMY MERCI L6 L 180 CM DIA2.7 MM DIA 4.5 MM,SUP-2367768,CDM,C1757,HCPCS,0272,RC,,,,both,,,9341.50,6071.97,,,,,,,,,,,,,
CATH DRAINAGE SET ALL-PURPOSE 6FR X 20CM,SUP-2844710,CDM,C1729,HCPCS,0272,RC,,,,both,,,245.30,159.44,,,,,,,,,,,,,
SET COLON DCOMPR CATH 8.5FR L350CM GWIRE 0.035IN MIN ACC,SUP-2169144,CDM,C1729,HCPCS,0272,RC,,,,both,,,480.42,312.27,,,,,,,,,,,,,
PLATE BNE L177MM 10 H R PROX TIB S STL VAR ANG LOK COMPR SM,SUP-2420737,CDM,C1713,HCPCS,0278,RC,,,,both,,,5921.57,3849.02,,,,,,,,,,,,,
PLATE BONE SM NONSTERILE CRAN TI ARC CNTOUR MESH MALL FOR,SUP-2190626,CDM,C1713,HCPCS,0278,RC,,,,both,,,2753.78,1789.96,,,,,,,,,,,,,
PLATE BNE L223MM 14 H ST R MED PROX TIB S STL LOK COMPR LO,SUP-2185651,CDM,C1713,HCPCS,0278,RC,,,,both,,,4408.81,2865.73,,,,,,,,,,,,,
HYSTEROSCOPE VID DIA 6.2 MM HTX60S DISP,SUP-2913697,CDM,2720000010,LOCAL,0272,RC,,,,both,,,637.95,414.67,,,,,,,,,,,,,
STEM FEM L160MM DIA12MM 12/14 TAPR HIP 5/8 POR STD NK AML,SUP-2252066,CDM,C1776,CPT,0278,RC,,,,both,,,8647.56,5620.91,,,,,,,,,,,,,
PLATE BNE L64MM THK3.3MM 5 H BILAT S STL STR LIMIT CNTCT,SUP-2185129,CDM,C1713,HCPCS,0278,RC,,,,both,,,842.09,547.36,,,,,,,,,,,,,
TUBING IRRIG INTEGRATEDCASSETTE DISP FOR FLD WST MGMT SYS,SUP-2361438,CDM,C1713,HCPCS,0278,RC,,,,both,,,397.21,258.19,,,,,,,,,,,,,
CATHETER EP 6FR L92CM 2-8-2MM SPC TIP 1MM 10 ELECTRD D CRV,SUP-2248659,CDM,C1730,HCPCS,0272,RC,,,,both,,,1447.54,940.90,,,,,,,,,,,,,
MESH HERN W10XL15CM L INGUINAL POLY ANAT PARIETEX,SUP-2174781,CDM,C1781,HCPCS,0278,RC,,,,both,,,411.47,267.46,,,,,,,,,,,,,
SCREW BONE SELFTAPPING 2.4X12 MM MANDIBULAR 20/PK TITANIUM N,SUP-2842290,CDM,C1713,HCPCS,0278,RC,,,,both,,,362.10,235.36,,,,,,,,,,,,,
OBTURATOR TROCAR CONCL SHRP 10X110 MM REUSE,SUP-2850121,CDM,2720000010,LOCAL,0272,RC,,,,both,,,344.96,224.22,,,,,,,,,,,,,
GUIDEWIRE VASC L80CM DIA0.035IN TIP L3CM NIT HYDRPHLC STIFF,SUP-2385587,CDM,C1769,HCPCS,0272,RC,,,,both,,,159.95,103.97,,,,,,,,,,,,,
ENDCAP ORTH 0 MM HIP FRAC SYS STRL CHIMAERA,SUP-2646588,CDM,C1713,HCPCS,0278,RC,,,,both,,,243.22,158.09,,,,,,,,,,,,,
BLADE LARYNGOSCOPE MACINTOSH 1 92X22 MM ENG PROF GRNLN,SUP-2381515,CDM,2720000010,LOCAL,0272,RC,,,,both,,,125.13,81.33,,,,,,,,,,,,,
MORPHINE SULFATE 1 MG/ML PCA (DISCRETE DOSING),RX-77005,CDM,J2270,HCPCS,0636,RC,70092-1519-48,NDC,,both,30,ML,57.00,37.05,,,,,,,,,,,,,
COMPONENT FEM SZ 00 UNIV POST STBL REV CEM STEM MOD UNISX,SUP-2209328,CDM,C1776,CPT,0278,RC,,,,both,,,871.66,566.58,,,,,,,,,,,,,
SCREW BNE L85MM DIA12.7MM STD S STL CANC ST LAG CANN LOK,SUP-2197702,CDM,C1713,HCPCS,0278,RC,,,,both,,,1004.80,653.12,,,,,,,,,,,,,
BLADE SAW KNEE 25.4MM CUT EDGE 90MM CUT DEPTH 1.47MM CUT THI,SUP-2605513,CDM,2720000010,LOCAL,0272,RC,,,,both,,,155.81,101.28,,,,,,,,,,,,,
KIT HEMO DYLS OR HD 13FR L12.5CM CVD EXTN LEG SH TERM 3 LUMN,SUP-2126514,CDM,C1752,HCPCS,0278,RC,,,,both,,,853.92,555.05,,,,,,,,,,,,,
DRILL SURGICAL,SUP-2633880,CDM,2720000010,LOCAL,0272,RC,,,,both,,,435.14,282.84,,,,,,,,,,,,,
BRACE KNEE POSTOP COOL PROCARE TROM ADV,SUP-2195713,CDM,L1810,HCPCS,0272,RC,,,,both,,,226.68,147.34,,,,,,,,,,,,,
LINER ACET ELEV 0 DEG 26MM ID SZ D,SUP-2205870,CDM,C1776,CPT,0278,RC,,,,both,,,4796.35,3117.63,,,,,,,,,,,,,
LOXAPINE SUCCINATE 25 MG PO CAPS,RX-4600,CDM,6370000000,HCPCS,0637,RC,00591-0371-01,NDC,,both,1,UN,5.00,3.25,,,,,,,,,,,,,
SCREWDRIVER SURG CANN ATTCH AO,SUP-2321712,CDM,2720000010,LOCAL,0272,RC,,,,both,,,868.21,564.34,,,,,,,,,,,,,
ANCHOR SUT 5 MM DIA NO 0 SUT ABSRB ANCHRLOC,SUP-2398008,CDM,C1713,HCPCS,0278,RC,,,,both,,,822.68,534.74,,,,,,,,,,,,,
HC Treat Metacarpal Fx,PX-4502660000,CDM,26600,CPT,0450,RC,,,,both,,,699.00,454.35,,,,,,,,,,,,,
HC Blood Count Reticulocytes Auto 1/> Cell Meas,PX-3058504600,CDM,85046,CPT,0305,RC,,,,both,,,21.00,13.65,,,,,,,,,,,,,
BUR SURG L48MM DIA1.5MM 150-200 GRIT DMND RND FOR OTO,SUP-2166383,CDM,2720000010,LOCAL,0272,RC,,,,both,,,327.60,212.94,,,,,,,,,,,,,
SET URET STENT SMITH L 80 CM DIA 8 FR PERCFLX PIGTL FLX TIP,SUP-2171206,CDM,C2617,HCPCS,0278,RC,,,,both,,,705.37,458.49,,,,,,,,,,,,,
PACK HARV VEIN ENDOSCP VASOVIEW,SUP-2227757,CDM,2720000010,LOCAL,0272,RC,,,,both,,,389.93,253.45,,,,,,,,,,,,,
BIT DRL DIA61MM FOR THRD HD SCR ANK COMPR NAIL SYS,SUP-2316001,CDM,2720000010,LOCAL,0272,RC,,,,both,,,916.57,595.77,,,,,,,,,,,,,
IMMOBILIZER SHLDR L STRP 43IN,SUP-2324219,CDM,L3650,HCPCS,0272,RC,,,,both,,,19.75,12.84,,,,,,,,,,,,,
MESH SURG W6XL10IN OVL SEPRA TECHNOLOGY VENTRALIGHT,SUP-2125907,CDM,C1781,HCPCS,0278,RC,,,,both,,,2807.16,1824.65,,,,,,,,,,,,,
TUBE ENTRL FEED GASTRO-JEJUNAL 18 FRX45 CM 7-10 CC FOR SURG,SUP-2764469,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1049.23,682.00,,,,,,,,,,,,,
TRAY PROVEN REV MOD TIB 2T3F,SUP-2359294,CDM,C1776,CPT,0278,RC,,,,both,,,4747.68,3085.99,,,,,,,,,,,,,
HC NM Sest. Rest Stress Single,PX-3417845100,CDM,78451,CPT,0341,RC,,,,outpatient,,,3905.00,2538.25,,,,,,,,,,,,,
PLATE BNE L306MM BLDE W48XL25MM 95DEG 18 H NONSTERILE HIP S,SUP-2186764,CDM,C1713,HCPCS,0278,RC,,,,both,,,4191.27,2724.33,,,,,,,,,,,,,
PLATE BNE LP 1 MM NEURO BNE FLAP FIX Q STYL FOR SCR TI lf,SUP-2469823,CDM,C1713,HCPCS,0278,RC,,,,both,,,1493.57,970.82,,,,,,,,,,,,,
BIT DRL CANN 6.5X330 MM QC NS,SUP-2188203,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1734.54,1127.45,,,,,,,,,,,,,
"HC So Immunofix Electphoresis,Othfld",PX-3028633566,CDM,86335,CPT,0302,RC,,,,inpatient,,,72.00,46.80,,,,,,,,,,,,,
ALLOGRAFT BNE DWL 23X22 MM FRZN THRD CTS SVC FEE MDII,SUP-2743477,CDM,C1713,HCPCS,0278,RC,,,,both,,,12098.42,7863.97,,,,,,,,,,,,,
SHUNT PERI L120CM OD25MM ID13MM REG CATHETER OPN END W WALL,SUP-2278391,CDM,C1889,HCPCS,0278,RC,,,,both,,,13586.18,8831.02,,,,,,,,,,,,,
PACEMAKER CARD PULSAR MAX II SR SINGLE CHMBR IS1 CONN UPLR,SUP-2148596,CDM,C1786,HCPCS,0275,RC,,,,both,,,14842.78,9647.81,,,,,,,,,,,,,
BLADE COAG SHR L14CM DIA5MM CVD W/ GRP AND PROTCT SL DISP,SUP-2257621,CDM,2720000010,LOCAL,0272,RC,,,,both,,,494.36,321.33,,,,,,,,,,,,,
"HC Acetone, Serum",PX-3078200900,CDM,82009,CPT,0307,RC,,,,inpatient,,,275.00,178.75,,,,,,,,,,,,,
CATHETER PTCA L130CM BLLN L40MM DIA4MM PACLITAXEL OVR THE,SUP-2280373,CDM,C2623,HCPCS,0278,RC,,,,both,,,3673.80,2387.97,,,,,,,,,,,,,
SPLINT WRST THMB L L8IN R BLK FOAM D RNG CLSR ADJ REUSE,SUP-2336030,CDM,L3809,HCPCS,0274,RC,,,,both,,,42.20,27.43,,,,,,,,,,,,,
HC So Column Chromotography Quant,PX-3018254266,CDM,82542,CPT,0301,RC,,,,both,,,202.00,131.30,,,,,,,,,,,,,
BLADE SHAVER DIA 3.5 MM 2 EDGE STRL DISP CROSSBLADE,SUP-2908772,CDM,2720000010,LOCAL,0272,RC,,,,both,,,263.76,171.44,,,,,,,,,,,,,
DISTAL RADIAL DORSAL T PLATE JIG LEFT,SUP-2723173,CDM,C1713,HCPCS,0278,RC,,,,both,,,745.18,484.37,,,,,,,,,,,,,
BOOT CAST XL L13.5IN TOE W6IN BLK CANVS NONSLIP ROCK SOLE,SUP-2196785,CDM,L4631,HCPCS,0272,RC,,,,both,,,14.85,9.65,,,,,,,,,,,,,
MATRIX PLCNTA FLOWABLE CYROPRESERVED CRYOMTRX 0.5CC,SUP-2340463,CDM,C1762,CPT,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
PLATE BNE L18MM 2X2 H L BILAT S STL T SHP RIG NEUT,SUP-2186160,CDM,C1713,HCPCS,0278,RC,,,,both,,,169.34,110.07,,,,,,,,,,,,,
CATHETER GUID GUIDELINER V3 L 150 CM DIA 7 FR RX L 25 CM,SUP-2383145,CDM,C1887,HCPCS,0272,RC,,,,both,,,1083.30,704.14,,,,,,,,,,,,,
PLATE FOOT LK CRV 6 HL,SUP-2701923,CDM,C1713,HCPCS,0278,RC,,,,both,,,2866.19,1863.02,,,,,,,,,,,,,
HC Circumcision W/Clamp/Oth Dev W/Block,PX-3615415000,CDM,54150,CPT,0361,RC,,,,inpatient,,,900.00,585.00,,,,,,,,,,,,,
SCREW BNE L8MM DIA24MM CORT CRANIOMAXILLOFACIAL TI ST,SUP-2189583,CDM,C1713,HCPCS,0278,RC,,,,both,,,279.15,181.45,,,,,,,,,,,,,
CATHETER INFUS L134CM BAL L20MM DIA2MM 0.014IN THER LOC RAP,SUP-2266025,CDM,C1751,HCPCS,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
HC Bronchoscopy W or WO Fluoro,PX-3613162200,CDM,31622,CPT,0361,RC,,,,both,,,1724.00,1120.60,,,,,,,,,,,,,
GUIDE NDL 9GA ANCIL PROD FOR EVIVA STEREOTACTIC BRST BX,SUP-2239965,CDM,C1819,HCPCS,0278,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
SPLINT WRST THMB L L8IN R BLK FOAM D RNG CLSR ADJ REUSE,SUP-2336030,CDM,L3809,HCPCS,0272,RC,,,,both,,,42.20,27.43,,,,,,,,,,,,,
GRAFT BNE PTTY 10 CC SYR DBM ACCELL EVO3,SUP-2641762,CDM,C1713,HCPCS,0278,RC,,,,both,,,5722.65,3719.72,,,,,,,,,,,,,
ALLOGRAFT DERMAL UNMESHED 4X12 CMX1-2 MM PROLAYER,SUP-2717797,CDM,C1763,HCPCS,0278,RC,,,,both,,,15233.90,9902.03,,,,,,,,,,,,,
GEMCITABINE HCL 2 GM/52.6ML IV SOLN,RX-111498,CDM,J9184,HCPCS,0636,RC,00409-0182-25,NDC,,both,52.6,ML,81.70,53.10,,,,,,,,,,,,,
CATHETER CTRL VEN 7FR POLYUR DBL LUMN INDWL RADPQ W/ BLU,SUP-2383473,CDM,C1751,HCPCS,0278,RC,,,,both,,,79.44,51.64,,,,,,,,,,,,,
PLATE BONE L38MM 3 H BILAT 1/3 TBLR NONCOMPRESSION RIG FOR,SUP-2348954,CDM,C1713,HCPCS,0278,RC,,,,both,,,526.92,342.50,,,,,,,,,,,,,
SCREW BNE L35MM DIA5MM GLEN TI NONLOCKING LO PROF BIOMOD,SUP-2404635,CDM,C1713,HCPCS,0278,RC,,,,both,,,492.98,320.44,,,,,,,,,,,,,
PLATE BNE GOTFRIED,SUP-2644725,CDM,C1713,HCPCS,0278,RC,,,,both,,,1606.68,1044.34,,,,,,,,,,,,,
Z DISCONTINUED USE 2522798 CEMENT BNE ANTIBIO HI VISC W/ GENTAMICIN SIMPLEX HV,SUP-2364373,CDM,C1713,HCPCS,0278,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
HC Gbl OP Psych Tx 60 Min,PX-9829083700,CDM,90837,CPT,0982,RC,,,,both,,,862.00,560.30,,,,,,,,,,,,,
SCREW BNE CANN 2.5X32 MM FT EVOLVE TRIAD,SUP-2423626,CDM,C1713,HCPCS,0278,RC,,,,both,,,621.72,404.12,,,,,,,,,,,,,
ANCHOR SUT SZ 2 DIA5.5MM DBL LD ABSRB LACTOSCREW MAXBRAID,SUP-2212849,CDM,C1713,HCPCS,0278,RC,,,,both,,,860.36,559.23,,,,,,,,,,,,,
SPLINT FT MED NT PLNTR FASCIITI,SUP-2195478,CDM,L4398,HCPCS,0272,RC,,,,both,,,77.18,50.17,,,,,,,,,,,,,
SCREW SPNL L25MM DIA6MM TI FIX ANG SOVEREIGN,SUP-2279888,CDM,C1713,HCPCS,0278,RC,,,,both,,,745.75,484.74,,,,,,,,,,,,,
GRAFT BNE STRP 12.5X1X0.4 CM 20 CC PLATFORM CM,SUP-2691585,CDM,C1713,HCPCS,0278,RC,,,,both,,,12462.66,8100.73,,,,,,,,,,,,,
PLATE BNE W15XL20MM TIB SHTH COVERLOC STABILIS,SUP-2399166,CDM,C1713,HCPCS,0278,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
ANCHOR SUTURE TAPE 4.5X15 MM PEEK KT STRL GRAPPLER,SUP-2749834,CDM,C1713,HCPCS,0278,RC,,,,both,,,1478.94,961.31,,,,,,,,,,,,,
TRAY CATHETER 3 LUMN W TIP SHERLOCK 6FR POWERPICC,SUP-2125517,CDM,C1751,HCPCS,0278,RC,,,,both,,,1033.06,671.49,,,,,,,,,,,,,
WIRE FIX L70MM OD0.9MM GUID TRCR TIP DISP K FIXOS,SUP-2378784,CDM,C1769,HCPCS,0272,RC,,,,both,,,72.85,47.35,,,,,,,,,,,,,
COMPONENT TALAR FLAT 1 RT TI PLASMA SPRY APEX 3D,SUP-2742156,CDM,C1776,CPT,0278,RC,,,,both,,,12756.25,8291.56,,,,,,,,,,,,,
BOOT LEG TRAC CONVOLUTED FOAM LNR W/ STAY UNIV AD BUCK,SUP-2194992,CDM,L4360,HCPCS,0274,RC,,,,both,,,31.40,20.41,,,,,,,,,,,,,
CATHETER EP CSL 2-8-2 MM 7 FRX120 CM RESPON,SUP-2464391,CDM,C1730,HCPCS,0272,RC,,,,both,,,1312.52,853.14,,,,,,,,,,,,,
COUNTERSINK SURG FOR NEXFIX NCS SYS 4.5 MM SCREW,SUP-2400526,CDM,2720000010,LOCAL,0272,RC,,,,both,,,341.63,222.06,,,,,,,,,,,,,
BIT DRL 2.9X308 MM STRL VERSANAIL,SUP-2606672,CDM,2720000010,LOCAL,0272,RC,,,,both,,,992.71,645.26,,,,,,,,,,,,,
"MEASLES, MUMPS & RUBELLA VAC IJ SOLR",RX-147433,CDM,90707,HCPCS,0636,RC,00006-4681-00,NDC,,both,1,UN,441.00,286.65,,,,,,,,,,,,,
TI LCP DISTAL FEMUR PLATE 15 HOLE/356MM RIGHT-STERILE,SUP-2546859,CDM,C1713,HCPCS,0278,RC,,,,both,,,5524.74,3591.08,,,,,,,,,,,,,
NAIL IM L360MM DIA11MM 125DEG LNG LT HIP TIM CANN LCK FOR,SUP-2211478,CDM,C1713,HCPCS,0278,RC,,,,both,,,3906.16,2539.00,,,,,,,,,,,,,
ANCHOR SUT 1MM W/ 3-0 SUT AND NDL AND DRL MINI SFT,SUP-2212961,CDM,C1713,HCPCS,0278,RC,,,,both,,,1455.23,945.90,,,,,,,,,,,,,
PLATE BNE RECON 3.5X130 MM PELV 10 HOLE LP WA SS NS,SUP-2863368,CDM,C1713,HCPCS,0278,RC,,,,both,,,1447.41,940.82,,,,,,,,,,,,,
DRILL SURG FLX 8.5 MM CANN ANAT CRUCIATED GUIDE SYS CLANCY,SUP-2849155,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3377.38,2195.30,,,,,,,,,,,,,
SCREW BNE EMGCY 1.2X10 MM CRUCFRM HD W/ FLUT TIP TI,SUP-2189164,CDM,C1713,HCPCS,0278,RC,,,,both,,,353.88,230.02,,,,,,,,,,,,,
BIT DRL L65MM DIA1.5MM ST MINI QUIK CPL NONRADIOPAQUE W/O,SUP-2187183,CDM,2720000010,LOCAL,0272,RC,,,,both,,,364.08,236.65,,,,,,,,,,,,,
STYLET SURG 45 MM INVICTUS,SUP-2553925,CDM,2720000010,LOCAL,0272,RC,,,,both,,,690.80,449.02,,,,,,,,,,,,,
KIT ABLAT PRB 17GA L20MM SGL OSTEOCOOL RF,SUP-2293684,CDM,C1886,HCPCS,0278,RC,,,,both,,,9734.00,6327.10,,,,,,,,,,,,,
BASEPLATE GLEN EXT CAGE 10+ MM SM SHLDR REVERSED EQUINOXE,SUP-2451449,CDM,C1776,CPT,0278,RC,,,,both,,,5809.00,3775.85,,,,,,,,,,,,,
BIOFOAM COTTON WEDGE 16X14X10X4.5 STERILE,SUP-2900567,CDM,C1713,HCPCS,0278,RC,,,,both,,,9245.73,6009.72,,,,,,,,,,,,,
GRAFT BONE CERV SPCR LORDTC H 11MM,SUP-2415408,CDM,C1713,HCPCS,0278,RC,,,,both,,,3626.70,2357.35,,,,,,,,,,,,,
HC Assay of Prostate Specific Antigen Total,PX-3018415300,CDM,84153,CPT,0301,RC,,,,both,,,242.00,157.30,,,,,,,,,,,,,
BLADE SHAVER SERRATED 4 MM DSTL SUCTION,SUP-2648911,CDM,2720000010,LOCAL,0272,RC,,,,both,,,535.62,348.15,,,,,,,,,,,,,
SCREW BNE L 52 MM DIA 3 MM THRD L 21 MM TI CANN COMPR HDLSS,SUP-2905726,CDM,C1713,HCPCS,0278,RC,,,,both,,,1671.61,1086.55,,,,,,,,,,,,,
PIN EXT FIX ROT CONN FOR CALCNL FRAC REAR FT FIX SIDEKCK,SUP-2400621,CDM,C1713,HCPCS,0278,RC,,,,both,,,599.74,389.83,,,,,,,,,,,,,
IMMOBILIZER KIT ABDUCTN UNIV SHLDR NYL PROCARE 45-70DEG,SUP-2196974,CDM,L3660,HCPCS,0274,RC,,,,both,,,78.88,51.27,,,,,,,,,,,,,
GRAFT BNE SPNG 50X10X7 MM DBM CANC,SUP-2641785,CDM,C1713,HCPCS,0278,RC,,,,both,,,4621.77,3004.15,,,,,,,,,,,,,
TUBE INNR EAR MYR VENT REUT BOB W/ FLNG H M 1.14 MM ID TI S,SUP-2284032,CDM,L8699,HCPCS,0278,RC,,,,both,,,71.28,46.33,,,,,,,,,,,,,
GUIDEWIRE VASC L 260 CM 0.025IN L 7CM 2.5CM SAFE-T-J FIX COR,SUP-2167593,CDM,C1769,HCPCS,0272,RC,,,,both,,,46.19,30.02,,,,,,,,,,,,,
RELOAD STPL SZ 2 H2.5MM TAN CRV TIP VASCULAR/MEDIUM,SUP-2283353,CDM,2720000010,LOCAL,0272,RC,,,,both,,,671.05,436.18,,,,,,,,,,,,,
ANCHOR SUT DIA2.8MM WHT KNOTLESS W/ PERFECT PASS MAG WIRE,SUP-2342111,CDM,C1713,HCPCS,0278,RC,,,,both,,,2025.30,1316.44,,,,,,,,,,,,,
HC So1 Drvvt,PX-3058561367,CDM,85613,CPT,0305,RC,,,,both,,,36.00,23.40,,,,,,,,,,,,,
ALLOGRAFT BNE DBM 2 CC VESUVIUS 4104K1520DC,SUP-2717992,CDM,C1713,HCPCS,0278,RC,,,,both,,,3343.19,2173.07,,,,,,,,,,,,,
GRAFT VASC GORTX L 80 CM DIA 4 MM RNG L 50 CM EPTFE STR TW,SUP-2396144,CDM,C1768,CPT,0278,RC,,,,both,,,4176.20,2714.53,,,,,,,,,,,,,
SHEATH INTRO FLX L 80 CM OD 12 FR GUIDEWIRE 0.038 IN LG,SUP-2170677,CDM,C1894,HCPCS,0272,RC,,,,both,,,146.86,95.46,,,,,,,,,,,,,
TRACKER NAVIGATION ENT INSTR FUS,SUP-2284343,CDM,2720000010,LOCAL,0272,RC,,,,both,,,496.43,322.68,,,,,,,,,,,,,
LINER ACET SZ J OD66-68MM ID26MM +4MM 20DEG XLPE ANTEVERTED,SUP-2344892,CDM,C1776,CPT,0278,RC,,,,both,,,3775.85,2454.30,,,,,,,,,,,,,
CEMENT RESTRICTOR XXS EXTRA EXTRA SMALLSZ8,SUP-2545987,CDM,C1776,CPT,0278,RC,,,,both,,,130.62,84.90,,,,,,,,,,,,,
STENT GRFT VASC TAG L 15 CM DIA28 MM SHTH 20 FR AORT,SUP-2396367,CDM,C1713,HCPCS,0278,RC,,,,both,,,40035.00,26022.75,,,,,,,,,,,,,
CATHETER ABLATN C 2-5-2 MM 4 MM 7 FRX115 CM BRAIDED CELSIUS,SUP-2248726,CDM,C1733,HCPCS,0272,RC,,,,both,,,2772.62,1802.20,,,,,,,,,,,,,
HALF PIN EXT FIX L180MM DIA4MM ANK FT THRD ELEMENTS QUIK,SUP-2316102,CDM,2720000010,LOCAL,0272,RC,,,,both,,,435.96,283.37,,,,,,,,,,,,,
Z DISCONTINUED USE 2283977 KIT HAD CATH 12FR L20CM 3 LUMN HI PRSS CRV EXTN MAHRK,SUP-2283987,CDM,C1752,HCPCS,0278,RC,,,,both,,,253.65,164.87,,,,,,,,,,,,,
PLATE BNE L263MM 16 H BROAD COMPR RIG FOR 45MM SCR L FRAG,SUP-2411431,CDM,C1713,HCPCS,0278,RC,,,,both,,,776.21,504.54,,,,,,,,,,,,,
STEM HIP SZ 8 OMFLX HA,SUP-2364206,CDM,C1776,CPT,0278,RC,,,,both,,,11429.60,7429.24,,,,,,,,,,,,,
CATHETER EP L105CM OD6FR 2-5-2MM SPC DECAPOLAR STEER BIDIR,SUP-2357020,CDM,C1730,HCPCS,0272,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
SCREW ST 50MM 2.4MM CRTX,SUP-2417892,CDM,C1713,HCPCS,0278,RC,,,,both,,,162.59,105.68,,,,,,,,,,,,,
BLADE SHAVER 3.5 MMX13 CM ULTRACUT,SUP-2765752,CDM,2720000010,LOCAL,0272,RC,,,,both,,,492.29,319.99,,,,,,,,,,,,,
GUIDEWIRE ORTH L381MM OD1.6MM SMOOTH SHRP TIP FLEX CANNFLX,SUP-2341565,CDM,C1769,HCPCS,0272,RC,,,,both,,,167.46,108.85,,,,,,,,,,,,,
CABLE CATH L 9 FT LG SPLIT HNDL CARTO 3 STRL,SUP-2737871,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3629.84,2359.40,,,,,,,,,,,,,
PLATE SPNL LCK CVR NO PROF MERID,SUP-2711068,CDM,C1713,HCPCS,0278,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
DRILL SURG ZM ATTCH FOR LG BNE PWR SYS BUSA BSPMAX II,SUP-2745861,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2185.44,1420.54,,,,,,,,,,,,,
GRAFT VASC W5XL75CM THK05MM CV PTCH GOR TX,SUP-2395326,CDM,C1768,CPT,0278,RC,,,,both,,,1111.56,722.51,,,,,,,,,,,,,
UNIT HEARING AID XPRESS,SUP-2430336,CDM,2720000010,LOCAL,0272,RC,,,,both,,,364.24,236.76,,,,,,,,,,,,,
SHEATH INTRO PRELUDE L 11 CM DIA 5 FR POLYPRO TBNG,SUP-2699690,CDM,C1894,HCPCS,0272,RC,,,,both,,,68.92,44.80,,,,,,,,,,,,,
PUMP ASPIR MAP-1000,SUP-2281164,CDM,2720000010,LOCAL,0272,RC,,,,both,,,24492.00,15919.80,,,,,,,,,,,,,
HC Main Pul Art/Rt Heart,PX-3237574600,CDM,75746,CPT,0323,RC,,,,both,,,3214.00,2089.10,,,,,,,,,,,,,
CATHETER ART L46CM OD2.2MM ID1MM BA IMPREG HAKIM,SUP-2243803,CDM,C1729,HCPCS,0272,RC,,,,both,,,505.54,328.60,,,,,,,,,,,,,
DRILL SURG 11 MM ACP,SUP-2561592,CDM,2720000010,LOCAL,0272,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
PIN FIX L 14 MM DIA2.5 MM PROV SM TARGETER SYS STRL EVOS,SUP-2933798,CDM,C1713,HCPCS,0278,RC,,,,both,,,1359.31,883.55,,,,,,,,,,,,,
STYLET NRV STIM KT 50CM W STEERING CAP,SUP-2138820,CDM,C1713,HCPCS,0278,RC,,,,both,,,414.48,269.41,,,,,,,,,,,,,
INTRODUCER SHTH 0.035 IN 4 FRX11 CM W/ GUIDEWIRE PRELUDE,SUP-2303261,CDM,C1894,HCPCS,0272,RC,,,,both,,,29.20,18.98,,,,,,,,,,,,,
GRAFT BONE SEG AO EVANS 18 X 18 X8,SUP-2854054,CDM,C1713,HCPCS,0278,RC,,,,both,,,10974.30,7133.29,,,,,,,,,,,,,
BIT DRL L102MM OD1.6MM 10-20MM STP SAG SPL SHFT END,SUP-2366425,CDM,2720000010,LOCAL,0272,RC,,,,both,,,826.10,536.96,,,,,,,,,,,,,
NAIL DIAM 13MM LEN 240MM PANTSA XL,SUP-2243621,CDM,C1713,HCPCS,0278,RC,,,,both,,,14094.71,9161.56,,,,,,,,,,,,,
DEFIBRILLATOR CRD SINGLE CHMBR LUMAX 540 VR-T,SUP-2138266,CDM,C1722,HCPCS,0275,RC,,,,both,,,47633.80,30961.97,,,,,,,,,,,,,
MESH MXLFCL PALE ADJ FOR 3DX GEAR 1.5 - 1.8 MM SS TI RED II,SUP-2482896,CDM,C1713,HCPCS,0278,RC,,,,both,,,9040.53,5876.34,,,,,,,,,,,,,
VALVE CSF STD FLAT BTM MED PRESSURE CATH GUIDE LPV II DISP,SUP-2244308,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2089.39,1358.10,,,,,,,,,,,,,
GUIDEWIRE VSCLR 0.035N DIA 150CML NTNL PRPHRL QTTRO,SUP-2492911,CDM,C1769,HCPCS,0272,RC,,,,both,,,164.66,107.03,,,,,,,,,,,,,
STRIPPER SURG 550UM HOLM LASER FBR REM FBR JKT SLM LN EZ,SUP-2141787,CDM,2720000010,LOCAL,0272,RC,,,,both,,,683.11,444.02,,,,,,,,,,,,,
COMPONENT SPNL ASMBLY 6 MM PRIMALOK SP,SUP-2319810,CDM,C1776,CPT,0278,RC,,,,both,,,19154.00,12450.10,,,,,,,,,,,,,
SCREW BNE CANN SHT THRD 4.5X24 MM HDLSS NS MONSTER,SUP-2742611,CDM,C1713,HCPCS,0278,RC,,,,both,,,1023.48,665.26,,,,,,,,,,,,,
COLLAR CERV L H3XL20IN M DENS FOAM COT STOCK LNR,SUP-2194404,CDM,L0120,HCPCS,0274,RC,,,,both,,,15.70,10.20,,,,,,,,,,,,,
CATHETER HD CRV 12.5 FRX13 CM TRPL LUMEN IC TY MAHRK ELITE,SUP-2626956,CDM,C1752,HCPCS,0278,RC,,,,both,,,297.67,193.49,,,,,,,,,,,,,
MESH SPNL W22XH90XL28MM TI OVL,SUP-2254373,CDM,C1713,HCPCS,0278,RC,,,,both,,,18858.84,12258.25,,,,,,,,,,,,,
PLATE BNE HUM 147 MM LT DSTL PL 17 HOLE STRL A.L.P.S,SUP-2462751,CDM,C1713,HCPCS,0278,RC,,,,both,,,3262.46,2120.60,,,,,,,,,,,,,
DEVICE VES SEAL FR DAVINCI ENERGY SYS SYNCHROSEAL DISP,SUP-2558676,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2274.93,1478.70,,,,,,,,,,,,,
CATHETER HD CPU 14CM 13CM PLAS STERIL PK CHNG NEW MAT,SUP-2117116,CDM,C1881,HCPCS,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
PLATE-CUTTING FORCEPS FOR 1.5MM-2.7MM PLATES,SUP-2548842,CDM,C1713,HCPCS,0278,RC,,,,both,,,4854.31,3155.30,,,,,,,,,,,,,
PROSTHESIS OSS NOTCHED 4.0MM DIA 0.8MM SHAFT 7.0MML,SUP-2902787,CDM,L8613,CPT,0278,RC,,,,both,,,1519.26,987.52,,,,,,,,,,,,,
PLATE BONE L88MM 4 HOLE STERILE PROXIMAL HUMERAL NCB,SUP-2470473,CDM,C1713,HCPCS,0278,RC,,,,both,,,3870.71,2515.96,,,,,,,,,,,,,
BASEPLATE TIB SZ 5 FLUT NXGN,SUP-2200849,CDM,C1776,CPT,0278,RC,,,,both,,,7944.20,5163.73,,,,,,,,,,,,,
VALVE AORT CRYOVALVE SZ 21 MM AORT ALLGRFT NONROTATABLE,SUP-2175207,CDM,C1889,HCPCS,0278,RC,,,,both,,,36251.30,23563.34,,,,,,,,,,,,,
SLEEVE CBL L850MM DIA2MM COCR OSTEO-CLAGE,SUP-2106615,CDM,C1713,HCPCS,0278,RC,,,,both,,,1362.76,885.79,,,,,,,,,,,,,
STENT ENDOVASC L79MM DIA6-8MM CATH L80CM INTRO SHTH 7FR,SUP-2395657,CDM,C1874,HCPCS,0278,RC,,,,both,,,9953.80,6469.97,,,,,,,,,,,,,
SET PICC 1L 4FR X 55CM W BP,SUP-2887043,CDM,C1751,HCPCS,0278,RC,,,,both,,,893.86,581.01,,,,,,,,,,,,,
PLATE BNE SGL JT FUS COMPR FOR 3.5MM SCR ALPS,SUP-2413839,CDM,C1713,HCPCS,0278,RC,,,,both,,,2255.15,1465.85,,,,,,,,,,,,,
CATHETER ANGIOPLSTY AGNT L 144 MM BALLOON L 30 MM DIA2 MM,SUP-2892813,CDM,C9610,HCPCS,0272,RC,,,,both,,,17741.00,11531.65,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY WOVEN L 105 CM DIA 7 FR SPC,SUP-2142016,CDM,C1730,HCPCS,0272,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
TACK POS TROCAR TIP CERV,SUP-2601878,CDM,C1713,HCPCS,0278,RC,,,,both,,,204.10,132.66,,,,,,,,,,,,,
SEALANT TISS FIBRIN 4 CC HUM 4 PK KT VISTASEAL,SUP-2738900,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2460.98,1599.64,,,,,,,,,,,,,
CATHETER HD DL 14.5 FRX28 CM STR SHTH INTRO HEMO-FLOW XF,SUP-2269537,CDM,C1881,HCPCS,0278,RC,,,,both,,,449.02,291.86,,,,,,,,,,,,,
BLADE SAW D64MM CUT EDGE 35MM MAT THK1.1MM SAG 2 CUT,SUP-2361900,CDM,2720000010,LOCAL,0272,RC,,,,both,,,149.81,97.38,,,,,,,,,,,,,
PLATE BNE W13.5XL142MM THK4.2MM 8 H BILAT S STL NAR LIMIT,SUP-2185239,CDM,C1713,HCPCS,0278,RC,,,,both,,,1326.27,862.08,,,,,,,,,,,,,
BLADE RETRACTOR SCOVILLE UNIV SM RNG,SUP-2480652,CDM,2720000010,LOCAL,0272,RC,,,,both,,,873.05,567.48,,,,,,,,,,,,,
TI RAISED HEAD EMERG SCREW  1.7MM  431576405,SUP-2844082,CDM,C1713,HCPCS,0278,RC,,,,both,,,604.01,392.61,,,,,,,,,,,,,
PIN BNE FIX L 40 MM DIA 3.5 MM PROV COMPR STRL EVOS,SUP-2931406,CDM,C1713,HCPCS,0278,RC,,,,both,,,731.93,475.75,,,,,,,,,,,,,
ALLOGRAFT DRML 2X12 CMX2.31 3.30 MM TSSUE MTRX ALLDRM,SUP-2498490,CDM,Q4116,HCPCS,0636,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
SPHINCTEROTOME ENDSCPC 4.5FR DIA DST TIP 7MML TIP 30MML CUT,SUP-2489149,CDM,C1769,HCPCS,0272,RC,,,,both,,,581.69,378.10,,,,,,,,,,,,,
DEVICE APPLIER CLIP F/AVM CLIPS 90MM X 3 1/2 IN,SUP-2734744,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4198.34,2728.92,,,,,,,,,,,,,
KIT INTRO ENVI L 20 CM DIA 6 FR L 65 CM DIA 0.018 CHIBA,SUP-2752502,CDM,C1894,HCPCS,0272,RC,,,,both,,,219.80,142.87,,,,,,,,,,,,,
STEM RAD L28MM DIA8MM ANT DST EL TI POR STR CEM MOD EXPLOR,SUP-2404379,CDM,C1776,CPT,0278,RC,,,,both,,,4804.20,3122.73,,,,,,,,,,,,,
BOLT SPNL L175MM DIA5MM TI FIX ANG FOR LUM INTBDY FUS BASE,SUP-2417111,CDM,C1713,HCPCS,0278,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
GRAFT BNE SPNG 16X16X16 MM DBM CANC,SUP-2641781,CDM,C1713,HCPCS,0278,RC,,,,both,,,2590.50,1683.82,,,,,,,,,,,,,
TWIST DRILL 11MM DIA X 30MM STOP DNTL LATCH SNGLE USE,SUP-2680266,CDM,2720000010,LOCAL,0272,RC,,,,both,,,446.70,290.35,,,,,,,,,,,,,
PLATE BONE L W13.5XL232MM THK4.2MM 13 H BILAT TI STR RIG,SUP-2190825,CDM,C1713,HCPCS,0278,RC,,,,both,,,926.08,601.95,,,,,,,,,,,,,
SLEEVE WIRE DIA2MM THRD DRL GUID,SUP-2187772,CDM,C1769,HCPCS,0272,RC,,,,both,,,924.98,601.24,,,,,,,,,,,,,
KIT REV ADPT SUPP SEAL GRFT EXP VASC CLMP AND SYR HERO,SUP-2302615,CDM,C1889,HCPCS,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
ACETAMINOPHEN 650 MG/20.3ML PO SOLN,RX-137415,CDM,6370000000,HCPCS,0637,RC,00904-7321-03,NDC,,both,20.3,ML,13.50,8.77,,,,,,,,,,,,,
PLATE BNE FEM 90 DEG 240 MM ARCHED MR SAFE NS,SUP-2863409,CDM,C1713,HCPCS,0278,RC,,,,both,,,3100.53,2015.34,,,,,,,,,,,,,
EXTERNAL FIXATION SET COMPLETE 4 MM ANK GALAXY FIX GEM LTX,SUP-2875649,CDM,C1713,HCPCS,0278,RC,,,,both,,,26548.70,17256.65,,,,,,,,,,,,,
CATHETER ANGIOPLSTY IMPACT L 75 CM SHFT 6 FR BALLOON L 4 CM,SUP-2124915,CDM,C1725,HCPCS,0272,RC,,,,both,,,989.89,643.43,,,,,,,,,,,,,
FEEDING TUBE KIT LP 14 FRX5 CM BLLN BUTTON MINI1,SUP-2754597,CDM,2720000010,LOCAL,0272,RC,,,,both,,,559.01,363.36,,,,,,,,,,,,,
GRAFT VASC GORTX L 40 CM DIA 4.5-6.5 MM EPTFE TAPR TW N RING,SUP-2396725,CDM,C1768,CPT,0278,RC,,,,both,,,1375.32,893.96,,,,,,,,,,,,,
CATHETER CRYOABLATION 7FR L108CM TIP L6MM CRV 60MM CARD,SUP-2281874,CDM,C1733,HCPCS,0272,RC,,,,both,,,5181.00,3367.65,,,,,,,,,,,,,
ALLOGRAFT TEND SEMITENDINOSUS W GRACILIS FRZN ASEP,SUP-2211505,CDM,C1713,HCPCS,0278,RC,,,,both,,,6280.00,4082.00,,,,,,,,,,,,,
PLATE BNE THK0.8MM 10 H LOK COMPR BILAT NEUT MAL STR FOR,SUP-2107084,CDM,C1713,HCPCS,0278,RC,,,,both,,,1497.78,973.56,,,,,,,,,,,,,
EXTENSION GUIDEWIRE VASSALLO GT L 165 CM DIA 0.014-0.018 IN,SUP-2909226,CDM,C1769,HCPCS,0272,RC,,,,both,,,73.48,47.76,,,,,,,,,,,,,
GRAFT BNE SUB W22XL60MM ILIUM BICORT STRP FRZ DRY STRUCTURAL,SUP-2307124,CDM,C1713,HCPCS,0278,RC,,,,both,,,3330.97,2165.13,,,,,,,,,,,,,
SYSTEM SURGICAL HEMOSTATIC STERILE DISPOSABLE NEXPOWDER,SUP-2934149,CDM,C1052,HCPCS,0278,RC,,,,both,,,2358.14,1532.79,,,,,,,,,,,,,
COVER BUR H DIA10MM UNIV CRANIOMAXILLOFACIAL TI MAL LO PROF,SUP-2366285,CDM,C1713,HCPCS,0278,RC,,,,both,,,883.60,574.34,,,,,,,,,,,,,
NUT SPINE LCK FIX TI FOR OMEGA 21 SYS,SUP-2414724,CDM,C1713,HCPCS,0278,RC,,,,both,,,189.91,123.44,,,,,,,,,,,,,
DRILL SURG PEG UNI TIB PART KNEE HI PERF SIG,SUP-2453109,CDM,2720000010,LOCAL,0272,RC,,,,both,,,737.90,479.63,,,,,,,,,,,,,
CANNULA DEL L120MM THK11GA 5CC END KNEE KT FOR SCP ACCUPORT,SUP-2206136,CDM,C1713,HCPCS,0278,RC,,,,both,,,11351.10,7378.21,,,,,,,,,,,,,
SCREW BNE L48MM DIA5MM HD DIA8MM TI ST ANGULAR STBL LOK,SUP-2180293,CDM,C1713,HCPCS,0278,RC,,,,both,,,613.21,398.59,,,,,,,,,,,,,
CEMENT BNE 80 GM SYS GENTA CEMEX,SUP-2222168,CDM,C1713,HCPCS,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
MESH CRAN CUSTOMIZED + LG MEDPOR PTERIONAL +,SUP-2862746,CDM,C1713,HCPCS,0278,RC,,,,both,,,57720.39,37518.25,,,,,,,,,,,,,
PACEMAKER CARD PHILOS II SR TI POLYUR SIL SINGLE CHMBR STRL,SUP-2137973,CDM,C1786,HCPCS,0275,RC,,,,both,,,11313.42,7353.72,,,,,,,,,,,,,
PIN ABSRB 1.5X40.0MM STRL F/BIOMET - 1.5X40.0MM,SUP-2136733,CDM,C1713,HCPCS,0278,RC,,,,both,,,690.80,449.02,,,,,,,,,,,,,
INTRODUCER SHTH MRK RADPQ 4FRX6CM PINN R O II,SUP-2385176,CDM,C1894,HCPCS,0272,RC,,,,both,,,76.30,49.59,,,,,,,,,,,,,
GRAFT DERMAL FEN 20X8 MM CLLGN TISS MTRX,SUP-2243674,CDM,C9360,HCPCS,0278,RC,,,,both,,,10550.40,6857.76,,,,,,,,,,,,,
HC Sel Cath Pulmonary Art,PX-3613601400,CDM,36014,CPT,0361,RC,,,,both,,,13613.00,8848.45,,,,,,,,,,,,,
GAMMATILE THERAPY DEVICE 9 PACK,SUP-2855643,CDM,C2642,HCPCS,0278,RC,,,,both,,,16397.77,10658.55,,,,,,,,,,,,,
NEXGEN ROTATING HINGE STEM TIBIAL PLATE SIZE 5,SUP-2502527,CDM,C1776,CPT,0278,RC,,,,both,,,10781.19,7007.77,,,,,,,,,,,,,
POST EXT FIX 2 H FEM FOR SIDEKCK FREE CIR FIX,SUP-2400670,CDM,C1713,HCPCS,0278,RC,,,,both,,,279.46,181.65,,,,,,,,,,,,,
ANCHOR SUTURE SS IMPL JUGGERKNOTLESS,SUP-2608584,CDM,C1713,HCPCS,0278,RC,,,,both,,,1259.71,818.81,,,,,,,,,,,,,
SYSTEM TUNN PROTCT OUTER SHTH FOR VEIN GRFT,SUP-2227395,CDM,C1713,HCPCS,0278,RC,,,,both,,,461.93,300.25,,,,,,,,,,,,,
SET INTRO VSI L 40 CM DIA 5 FR GUIDEWIRE L 60 CM DIA 0.018,SUP-2383228,CDM,C1894,HCPCS,0272,RC,,,,both,,,153.86,100.01,,,,,,,,,,,,,
TIMOLOL MALEATE 0.25 % OP SOLG,RX-24575,CDM,6370000000,HCPCS,0637,RC,43598-0747-11,NDC,,both,5,ML,874.20,568.23,,,,,,,,,,,,,
PLATE BNE L 94 MM TI EXTRATHORACIC PREBENT NS RIBFIX TITAN,SUP-2905456,CDM,C1713,HCPCS,0278,RC,,,,both,,,12019.92,7812.95,,,,,,,,,,,,,
BUR SURG FLUT 3X48 MM RND OTOTOM CARBIDE OSTEON,SUP-2166446,CDM,2720000010,LOCAL,0272,RC,,,,both,,,352.18,228.92,,,,,,,,,,,,,
GRAFT BONE SUB 15ML CRUSH DBM GRFTON,SUP-2293913,CDM,C1713,HCPCS,0278,RC,,,,both,,,3799.40,2469.61,,,,,,,,,,,,,
STENT BILI WALLFLEX L 80 MM DIA10 MM CATH L 75 CM SHTH 9 FR,SUP-2149823,CDM,C1874,HCPCS,0278,RC,,,,both,,,9231.60,6000.54,,,,,,,,,,,,,
IMPLANTABLE PULSE GENRTR,SUP-2418030,CDM,C1767,HCPCS,0278,RC,,,,both,,,78500.00,51025.00,,,,,,,,,,,,,
SCREW BNE L4MM DIA1.2MM CORT CRANIOMAXILLOFACIAL G S STL ST 5PK,SUP-2366076,CDM,C1713,HCPCS,0278,RC,,,,both,,,203.79,132.46,,,,,,,,,,,,,
SCREW TIB BASEPLT OD6MM THICKNESS 6MM UNIV STD PRI CEM IMP,SUP-2208415,CDM,C1713,HCPCS,0278,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
CATHETER KIT DL 4 FR PLCMNT POWERPICC PROVENA,SUP-2126779,CDM,C1751,HCPCS,0278,RC,,,,both,,,690.80,449.02,,,,,,,,,,,,,
GUIDEWIRE ORTHOPEDIC THRD 1.4 MM,SUP-2315873,CDM,C1769,HCPCS,0272,RC,,,,both,,,42.70,27.75,,,,,,,,,,,,,
CEMENT BNE 40 GM RADIOPAQUE FORTRESS +,SUP-2595683,CDM,C1713,HCPCS,0278,RC,,,,both,,,847.80,551.07,,,,,,,,,,,,,
VALVE AORT SZ 21MM MECH ROT POLY FLX CUF MSTR SER HP,SUP-2355087,CDM,C1889,HCPCS,0278,RC,,,,both,,,10048.00,6531.20,,,,,,,,,,,,,
PLATE BNE L65MM STD 3 H L OLECRANON EL TI LO PROF,SUP-2106999,CDM,C1713,HCPCS,0278,RC,,,,both,,,2961.02,1924.66,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH TX2 L 147 MM DIA28 MM SHTH 20 FR SS,SUP-2171024,CDM,C1874,HCPCS,0278,RC,,,,both,,,20651.78,13423.66,,,,,,,,,,,,,
SHEATH INTRO SAFSHTH L 13 CM DIA 7 FR DIL L 20 CM TEARWY,SUP-2281001,CDM,C1894,HCPCS,0272,RC,,,,both,,,146.95,95.52,,,,,,,,,,,,,
Z INACTIVE USE 2717689 FIBER LASER FLEXIVA PULSE 550,SUP-2718712,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1307.43,849.83,,,,,,,,,,,,,
WIRE FIX L150MM DIA1.6MM FOR HALLU-LOCK MTP ARTH SYS K,SUP-2242885,CDM,C1713,HCPCS,0278,RC,,,,both,,,134.93,87.70,,,,,,,,,,,,,
STRUT SPNL CNTR IMPL ENCLAVE ANTR SPNL SYS,SUP-2205466,CDM,C1713,HCPCS,0278,RC,,,,both,,,989.10,642.91,,,,,,,,,,,,,
FIBER LASER 131 FT KRA-CPAOCHXL HDMI,SUP-2798081,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1436.80,933.92,,,,,,,,,,,,,
PASSER SUT WIRE STR DISP,SUP-2120920,CDM,C1769,HCPCS,0272,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
SCREW BONE L60MM OD5.5MM PNK MIDFOOT HINDFOOT ANK CANN LNG,SUP-2320941,CDM,C1713,HCPCS,0278,RC,,,,both,,,1617.10,1051.11,,,,,,,,,,,,,
DRESSING BIO W4XL10IN BOV TEND CLLGN MESHED GLYCOSAMINOGLYCAN,SUP-2244274,CDM,C9363,HCPCS,0636,RC,,,,both,,,22684.49,14744.92,,,,,,,,,,,,,
PLATE SLOTTED 10X60MM,SUP-2469917,CDM,C1713,HCPCS,0278,RC,,,,both,,,335.85,218.30,,,,,,,,,,,,,
BUSHING FEM KNEE ARCM POLY LO FRIC INTFACE AXLE AND REINF,SUP-2405828,CDM,C1776,CPT,0278,RC,,,,both,,,522.81,339.83,,,,,,,,,,,,,
DISTRACTOR SURG WOOD 30 MM 1.5-1.8 MM 36 HOLE TI ZURICH TELE,SUP-2473748,CDM,2720000010,LOCAL,0272,RC,,,,both,,,17857.21,11607.19,,,,,,,,,,,,,
LINER ACET OD60MM ID40MM 0DEG XLPE HIP CEM REDAPT,SUP-2345567,CDM,C1776,CPT,0278,RC,,,,both,,,2844.84,1849.15,,,,,,,,,,,,,
SHELL ACET OD41MM ID28MM THK5.3MM HIP TI 3PLR FOR TOT,SUP-2404294,CDM,C1776,CPT,0278,RC,,,,both,,,2041.00,1326.65,,,,,,,,,,,,,
IMPLANT HYB HP-CEM ST/POR CUP/LGXLPE LN/ LG DELT CER HD,SUP-2212062,CDM,C1776,CPT,0278,RC,,,,both,,,13102.69,8516.75,,,,,,,,,,,,,
BONE STIM SPEC PURCH,SUP-2316213,CDM,E0749,HCPCS,0278,RC,,,,both,,,11602.30,7541.49,,,,,,,,,,,,,
ALLOGRAFT HUM TISS PTCH FD ASEP FASC LATA,SUP-2867079,CDM,C1762,CPT,0278,RC,,,,both,,,2192.51,1425.13,,,,,,,,,,,,,
DEVICE FIX 4X90 MM CLAV CRX,SUP-2431209,CDM,C1713,HCPCS,0278,RC,,,,both,,,10205.00,6633.25,,,,,,,,,,,,,
COMPONENT KNEE FOR PK 4800,SUP-2212673,CDM,C1776,CPT,0278,RC,,,,both,,,15072.00,9796.80,,,,,,,,,,,,,
SCREW BNE L48MM DIA4.5MM THRD L13MM CORT TI ST SELF DRL,SUP-2190387,CDM,C1713,HCPCS,0278,RC,,,,both,,,63.87,41.52,,,,,,,,,,,,,
KIT CATH HEMODIALYSI PWR TRIALYSI SLIM CATH ACTE 12FR DIA 15,SUP-2613258,CDM,C1752,HCPCS,0278,RC,,,,both,,,840.74,546.48,,,,,,,,,,,,,
CANNULA SCTN JRCHO 12.5NL TFLN SELF RTNNG MAL TIP W/RBBR ACR,SUP-2497863,CDM,2720000010,LOCAL,0272,RC,,,,both,,,613.18,398.57,,,,,,,,,,,,,
GUIDE SURG CUT SPEC PT FOR CAPPED C1SMITHNEPHEW] SMITH AND NEPHEW],SUP-2341216,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
BRACE THMB AD LNG POLYPR FELT LNR PERF SUEDE ALUM STAY V,SUP-2324405,CDM,L3931,HCPCS,0272,RC,,,,both,,,54.17,35.21,,,,,,,,,,,,,
BLADE TRPHNE ELLT UNVRSL HNDLE PEEK EYE SQRE RING WUNVRSL H,SUP-2668443,CDM,2720000010,LOCAL,0272,RC,,,,both,,,646.27,420.08,,,,,,,,,,,,,
JOINT TOE INTRAOSSEOUS NEUT 2.2 MM CANNULINK,SUP-2400045,CDM,C1776,CPT,0278,RC,,,,both,,,4195.04,2726.78,,,,,,,,,,,,,
CEPHALEXIN 250 MG PO CAPS,RX-9499,CDM,6370000000,HCPCS,0637,RC,60687-0152-11,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
STIMULATOR BONE SER 233284,SUP-2137325,CDM,E0749,HCPCS,0278,RC,,,,both,,,7222.00,4694.30,,,,,,,,,,,,,
BASKET SPEC RETRV STONE 65 CM BILI 3 WIR W/ SIDE ARM,SUP-2768306,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1745.40,1134.51,,,,,,,,,,,,,
"HC Est Pt, Outpt Visit Level 4|MULTIPLE OUTPATIENT HOSPITAL E/M ENCOUNTERS ON THE SAME DATE",PX-7619921400,CDM,99214,CPT,0761,RC,,,27,both,,,313.00,203.45,,,,,,,,,,,,,
STEM HUM FRAC IMPL R 9.5MM EQUINOXE,SUP-2223295,CDM,C1776,CPT,0278,RC,,,,both,,,9580.14,6227.09,,,,,,,,,,,,,
SYSTEM CLSR L SZ 1.7MM SHFT L8CM VASC TI DURA ANAS 35 CLP,SUP-2264250,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4455.66,2896.18,,,,,,,,,,,,,
ALLOGRAFT DERMAL ACELLULAR MTRX 5X10 CMX1.1-0.5 MM XENOGRAFT,SUP-2717794,CDM,C1763,HCPCS,0278,RC,,,,both,,,12874.00,8368.10,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 90 MM DIA13/10 MM DEL,SUP-2934300,CDM,C1713,HCPCS,0278,RC,,,,both,,,15886.74,10326.38,,,,,,,,,,,,,
COMPONENT FEM L200MM DIA11MM RT HIP TI POR REV BOW REACH,SUP-2406564,CDM,C1776,CPT,0278,RC,,,,both,,,19279.60,12531.74,,,,,,,,,,,,,
PACEMAKER CARD ASSURITY MRI W 50 X H 47 MM THK 6 MM 10.4 ML,SUP-2657217,CDM,C1785,HCPCS,0275,RC,,,,both,,,11618.00,7551.70,,,,,,,,,,,,,
SET DRNGE OD5FR PLEUR NEO PNEUMOPERICARDIAL FUHRMAN,SUP-2171102,CDM,C1729,HCPCS,0272,RC,,,,both,,,391.90,254.73,,,,,,,,,,,,,
PROSTHESIS OSS STAPE 0.6X0.6X4.5 MM CUP,SUP-2313686,CDM,L8613,CPT,0278,RC,,,,both,,,343.83,223.49,,,,,,,,,,,,,
RXG PLATE STR 10 HOLE T06MM,SUP-2694976,CDM,C1713,HCPCS,0278,RC,,,,both,,,863.03,560.97,,,,,,,,,,,,,
SET URET STENT UNIVERSA L 26 CM DIA 6 FR HYDRPHLC SFT,SUP-2171330,CDM,C2617,HCPCS,0278,RC,,,,both,,,523.12,340.03,,,,,,,,,,,,,
GUIDE WIRE BLUNT 1.1MM X 31CM,SUP-2574076,CDM,C1769,HCPCS,0272,RC,,,,both,,,58.25,37.86,,,,,,,,,,,,,
RING EXT FIX HALF 100 MM CARBON FIBER RINGFIX,SUP-2365273,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2829.14,1838.94,,,,,,,,,,,,,
ANCHOR SUT PILOT H SGL LD 5 FORC FBR INTELLIBRAID,SUP-2366694,CDM,C1713,HCPCS,0278,RC,,,,both,,,1381.60,898.04,,,,,,,,,,,,,
DEVICE SEAL L23CM NANO COAT MARYLAND JAW OPN DIV LIGASURE,SUP-2283563,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1480.04,962.03,,,,,,,,,,,,,
GRAFT VASC EXXCEL SFT L 50 CM DIA 6 MM EPTFE STR TW STRL,SUP-2227654,CDM,C1768,CPT,0278,RC,,,,both,,,1560.27,1014.18,,,,,,,,,,,,,
COMPONENT FEM CR 5 RT KNEE COAT,SUP-2314013,CDM,C1776,CPT,0278,RC,,,,both,,,7222.00,4694.30,,,,,,,,,,,,,
HC L-Spine Bend Only 2-3 Views,PX-3207212000,CDM,72120,CPT,0320,RC,,,,inpatient,,,628.00,408.20,,,,,,,,,,,,,
HC So Hla I Typing 1 Antigen Lr,PX-3108137466,CDM,81374,CPT,0310,RC,,,,inpatient,,,153.00,99.45,,,,,,,,,,,,,
SHEATH INTRO PEELWY L 13 CM DIA20 FR DIL 20 CM GUIDEWIRE,SUP-2168153,CDM,C1894,HCPCS,0272,RC,,,,both,,,106.73,69.37,,,,,,,,,,,,,
PLATE BNE L 300 MM SCREW DIA 4.5 MM 18 H COMPR LCK STRL EVOS,SUP-2933439,CDM,C1713,HCPCS,0278,RC,,,,both,,,3514.45,2284.39,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 18X2 CM PROC SUSPEND FASC LATA TUTOPLAST,SUP-2165385,CDM,C1762,CPT,0278,RC,,,,both,,,3595.30,2336.94,,,,,,,,,,,,,
LARGE EXTERNAL FIXATOR PELVIC FRAME KIT-STERILE,SUP-2546226,CDM,C1713,HCPCS,0278,RC,,,,both,,,14524.42,9440.87,,,,,,,,,,,,,
EPOETIN ALFA-EPBX 4000 UNIT/ML IJ SOLN,RX-142363,CDM,Q5106,HCPCS,0636,RC,00069-1307-10,NDC,,both,1,ML,130.20,84.63,,,,,,,,,,,,,
BURR HOLE COVER LOW PRFLE Q STYLE W4 HLE ARMS.4MM 21MM D11M,SUP-2676795,CDM,C1713,HCPCS,0278,RC,,,,both,,,2992.99,1945.44,,,,,,,,,,,,,
KIT PICC 5FR L55CM GWIRE L80CM CARBOTHANE S STL 2 LUMN FULL,SUP-2116960,CDM,C1751,HCPCS,0278,RC,,,,both,,,346.34,225.12,,,,,,,,,,,,,
DEVICE FIX CRV ULT FAST-FIX AB,SUP-2341777,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1164.78,757.11,,,,,,,,,,,,,
CATHETER CV DL 6 FRX55 CM PWR INJ MAX BARR NURSING KT XCELA,SUP-2734864,CDM,C1751,HCPCS,0278,RC,,,,both,,,132.51,86.13,,,,,,,,,,,,,
EXTERNAL FIXATION SET LOWER EXTREMITY WRNCH XCALIBER STRL,SUP-2646337,CDM,C1713,HCPCS,0278,RC,,,,both,,,9104.49,5917.92,,,,,,,,,,,,,
VENLAFAXINE HCL ER 150 MG PO CP24,RX-27859,CDM,6370000000,HCPCS,0637,RC,68084-0713-11,NDC,,both,1,UN,2.80,1.82,,,,,,,,,,,,,
PLATE BNE L163MM THK3.4MM 12 H BILAT S STL STR LOK COMPR,SUP-2185146,CDM,C1713,HCPCS,0278,RC,,,,both,,,1083.33,704.16,,,,,,,,,,,,,
MESH CRAN L 122 X W 122 MM THK 0.5 MM SCREW DIA1.7 MM PLLA FLX,SUP-2884160,CDM,C1713,HCPCS,0278,RC,,,,both,,,16115.67,10475.19,,,,,,,,,,,,,
PLATE BNE 100 DEG L 22.58 MM THK 0.6 MM SCREW DIA1.5 MM SZ,SUP-2935762,CDM,C1713,HCPCS,0278,RC,,,,both,,,850.94,553.11,,,,,,,,,,,,,
PLATE BNE L194MM THK3.3MM 16 H BILAT S STL RIG STR DYN,SUP-2186337,CDM,C1713,HCPCS,0278,RC,,,,both,,,2032.11,1320.87,,,,,,,,,,,,,
CATHETER CARD ABLATION EZ STEER THERMOCOOL L 115 CM F-J BLK,SUP-2248508,CDM,C1732,HCPCS,0278,RC,,,,both,,,4411.70,2867.60,,,,,,,,,,,,,
PPICC PROVENA SOLO 4F DL BASIC,SUP-2613541,CDM,C1751,HCPCS,0278,RC,,,,both,,,512.92,333.40,,,,,,,,,,,,,
KIT INTRO VSI L 10 CM DIA 5 FR NIT MANDREL TUNGSTEN TIP,SUP-2383172,CDM,C1894,HCPCS,0272,RC,,,,both,,,53.22,34.59,,,,,,,,,,,,,
SPLINT FNGR SM 4 PRNG PD,SUP-2194501,CDM,L3809,HCPCS,0272,RC,,,,both,,,3.20,2.08,,,,,,,,,,,,,
ALLOGRAFT HUM TISS W/O STRUT CRYOPRESERVED ACHILLES TEND,SUP-2867092,CDM,C1762,CPT,0278,RC,,,,both,,,3591.53,2334.49,,,,,,,,,,,,,
SLEEVE TIB 1 KNEE PLUG GRDIAN,SUP-2304398,CDM,C1776,CPT,0278,RC,,,,both,,,9891.00,6429.15,,,,,,,,,,,,,
GRAFT HUM TISS CHORION FREE THN 4X2 CM AMNIO ACTISHIELD CF,SUP-2759477,CDM,C1762,CPT,0278,RC,,,,both,,,4355.18,2830.87,,,,,,,,,,,,,
TUBE VENT ID1.27MM INNR FLNG DIA5.8MM INTERFLNG DISTANCE,SUP-2284178,CDM,L8699,HCPCS,0278,RC,,,,both,,,96.99,63.04,,,,,,,,,,,,,
SCREW BNE L29MM DIA2.4MM THRD L6MM CANC S STL SELF DRL ST,SUP-2185005,CDM,C1713,HCPCS,0278,RC,,,,both,,,987.40,641.81,,,,,,,,,,,,,
HC Inj Uretero/Pyelogr Indwell Ca,PX-3615068400,CDM,50684,CPT,0361,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
WASHER ORTH LCK CLOVER RESRB CENTRALOC RESRB TIB FIX,SUP-2212866,CDM,C1713,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
MARKER BRST BX PET DIA8GA BARBELL CLP MAMMOSTAR,SUP-2195621,CDM,A4648,CPT,0278,RC,,,,both,,,318.40,206.96,,,,,,,,,,,,,
NAIL IM FEM PEDIATRIC 5.5 MMX20 CM TI,SUP-2861971,CDM,C1713,HCPCS,0278,RC,,,,both,,,4715.46,3065.05,,,,,,,,,,,,,
CONTOURED PLATE 18 HOLE LEFT,SUP-2474531,CDM,C1713,HCPCS,0278,RC,,,,both,,,4559.28,2963.53,,,,,,,,,,,,,
KIT SUT ANCHR DIA21MM HIP SFT LO PROF FOR LABRAL REP,SUP-2136085,CDM,C1713,HCPCS,0278,RC,,,,both,,,946.02,614.91,,,,,,,,,,,,,
TRUELOK RNG FIX SYS FT PLT EXTN 7-HOLE,SUP-2316201,CDM,2720000010,LOCAL,0272,RC,,,,both,,,555.15,360.85,,,,,,,,,,,,,
GRAFT BNE FIBER 15 CC DBM CORTICAL PUREBONE,SUP-2424609,CDM,C1713,HCPCS,0278,RC,,,,both,,,5060.49,3289.32,,,,,,,,,,,,,
HC So Microsomal Antibody,PX-3028637666,CDM,86376,CPT,0302,RC,,,,both,,,237.00,154.05,,,,,,,,,,,,,
STENT CAR L20MM DIA6MM CATH L135CM SHTH DIA6FR GWIRE,SUP-2173464,CDM,C1876,HCPCS,0278,RC,,,,both,,,5966.00,3877.90,,,,,,,,,,,,,
NEEDLE ASPIR 22GA L80MM PREASSEMBLED PRESTERILIZED DISP,SUP-2313393,CDM,2720000010,LOCAL,0272,RC,,,,both,,,511.25,332.31,,,,,,,,,,,,,
PLATE BNE L220MM 9 H NONSTERILE L LAT PROX TIB TI LOK COMPR,SUP-2190716,CDM,C1713,HCPCS,0278,RC,,,,both,,,4395.50,2857.07,,,,,,,,,,,,,
ZIPRASIDONE HCL 20 MG PO CAPS,RX-29778,CDM,6370000000,HCPCS,0637,RC,60505-2528-06,NDC,,both,1,UN,6.00,3.90,,,,,,,,,,,,,
STAPLE BONE FIX W20XL20MM S STL FOREFOOT NTHRD COMPR,SUP-2397620,CDM,C1713,HCPCS,0278,RC,,,,both,,,1315.66,855.18,,,,,,,,,,,,,
CLAMP SPNL 55MM UNIV TI ALLY,SUP-2416028,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5024.00,3265.60,,,,,,,,,,,,,
CONDYLAR PLATE RIGHT 11X221MM,SUP-2818529,CDM,C1713,HCPCS,0278,RC,,,,both,,,7736.33,5028.61,,,,,,,,,,,,,
IMPLANT LARYN L10MM DIA16FR INDWL RADPQ RNG CLASS,SUP-2242367,CDM,L8509,HCPCS,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
STAPLER INT L340MM 45MM STD 12 FIRING B FRM PWR + GRIPPING,SUP-2219816,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1095.77,712.25,,,,,,,,,,,,,
CENTERPIECE SPNL EXPANDABLE B 25 MM T2 STRATOSPHERE,SUP-2730856,CDM,C1889,HCPCS,0278,RC,,,,both,,,15700.00,10205.00,,,,,,,,,,,,,
GRAFT BNE 11 MM AVITRAC MTP REV,SUP-2423330,CDM,C1713,HCPCS,0278,RC,,,,both,,,4165.21,2707.39,,,,,,,,,,,,,
DEFIBRILLATOR CARD W5.50XH5.50CM D1.20CM 40J 20SEC 6YR STD 3,SUP-2138075,CDM,C1722,HCPCS,0275,RC,,,,both,,,40502.86,26326.86,,,,,,,,,,,,,
PLATE BNE THK1MM 0DEG SM MINI TI ORAL MAXILLOFACIAL 4 H,SUP-2262736,CDM,C1713,HCPCS,0278,RC,,,,both,,,975.41,634.02,,,,,,,,,,,,,
SCREW BNE MAXILLOMANDIBULAR 2X12 MM 8 MM MAXDRIVE 250983805,SUP-2470897,CDM,C1713,HCPCS,0278,RC,,,,both,,,305.71,198.71,,,,,,,,,,,,,
NUT ORTH COMPR OLECRANON IMP STRL OD10MM,SUP-2106885,CDM,C1713,HCPCS,0278,RC,,,,both,,,769.30,500.04,,,,,,,,,,,,,
TOOL ANCHR FIX INTUITIVE DESIGN EZ TO HLD DEPLOY TACTILE,SUP-2896053,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1535.46,998.05,,,,,,,,,,,,,
TOOL SZ GASTROESOPHAGEAL NICKEL DISP FOR LINX REFLX MGMT,SUP-2388508,CDM,2720000010,LOCAL,0272,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
CABLE SURG L750MM DIA1.7MM CERCLAGE CO CHROM SMOOTH W/ CRMP,SUP-2193974,CDM,C1776,CPT,0278,RC,,,,both,,,1336.42,868.67,,,,,,,,,,,,,
PLATE BNE LCK 5X236 MM RT DSTL FEM 9 HOLE COMPR SS NS LCP,SUP-2184895,CDM,C1713,HCPCS,0278,RC,,,,both,,,4488.76,2917.69,,,,,,,,,,,,,
KIT HEMDIALYSIS L24CM BASIC ACUTE CATH 0.035INX70CM J/FLEX,SUP-2118060,CDM,C1752,HCPCS,0278,RC,,,,both,,,438.22,284.84,,,,,,,,,,,,,
IMPLANT LARYN 24GA 1ML TRNSOR CA HA FILL PERC INJ NONCORING,SUP-2303665,CDM,C1878,HCPCS,0278,RC,,,,both,,,2307.90,1500.13,,,,,,,,,,,,,
GRAFT BONE SUB 16MM CROSS SECT FEM FRZ DRY TRAD,SUP-2294085,CDM,C1713,HCPCS,0278,RC,,,,both,,,1909.12,1240.93,,,,,,,,,,,,,
CLAMP EXT FIX AD PELV PROCALLUS T FOR LIMB RECON SYS,SUP-2316282,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1413.57,918.82,,,,,,,,,,,,,
PLATE BNE L 20 MM SCREW DIA2 MM LG CP TI MANDIBULAR FULL,SUP-2883714,CDM,C1713,HCPCS,0278,RC,,,,both,,,17771.71,11551.61,,,,,,,,,,,,,
PLATE BONE LOK 132MML HLX8 STNLSS STEEL ST RIGHT LTRL DST FB,SUP-2588180,CDM,C1713,HCPCS,0278,RC,,,,both,,,2093.25,1360.61,,,,,,,,,,,,,
ROD SPNL L25MM SPINOUS PROC PIVOTING SP-FIX,SUP-2230597,CDM,C1713,HCPCS,0278,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
CATHETER GUID SKR L 135 CM SHTH 4 FR GUIDEWIRE 0.018 IN,SUP-2128482,CDM,C1887,HCPCS,0272,RC,,,,both,,,580.90,377.58,,,,,,,,,,,,,
SCREW INTFR L28MM DIA8MM FULL THRD BIO INTFR,SUP-2121167,CDM,C1713,HCPCS,0278,RC,,,,both,,,445.88,289.82,,,,,,,,,,,,,
HC So Drug or Substance Nos 1-3,PX-3018037566,CDM,G0480,CPT,0301,RC,,,,both,,,88.00,57.20,,,,,,,,,,,,,
SCREW INTRF MOD LF,SUP-2608348,CDM,C1713,HCPCS,0278,RC,,,,both,,,5.50,3.57,,,,,,,,,,,,,
SPACER SPNL W27XH12XL55MM 12DEG LORD OBLQ LAT LUM INTBDY,SUP-2284923,CDM,C1821,HCPCS,0278,RC,,,,both,,,17599.70,11439.80,,,,,,,,,,,,,
SPACER HUM W42XH5MM RVS BODY PROMOS,SUP-2351200,CDM,C1776,CPT,0278,RC,,,,both,,,5165.30,3357.44,,,,,,,,,,,,,
SPLINT WRST UNIV L11IN L CUTAWAY PERF FOAM CONSTR MAL,SUP-2194860,CDM,L3809,HCPCS,0274,RC,,,,both,,,15.51,10.08,,,,,,,,,,,,,
PLATE BNE W10.1XL82MM 7 H BILAT TI LO PROF RIG LOK COMPR,SUP-2191093,CDM,C1713,HCPCS,0278,RC,,,,both,,,1701.69,1106.10,,,,,,,,,,,,,
HC Pulmonary Arteriogram Uni,PX-3237574100,CDM,75741,CPT,0323,RC,,,,outpatient,,,3092.00,2009.80,,,,,,,,,,,,,
PLATE BNE 90 DEG L 17 MM THK 0.6 MM SCREW DIA2 MM 2X2 H REG,SUP-2936506,CDM,C1713,HCPCS,0278,RC,,,,both,,,973.40,632.71,,,,,,,,,,,,,
HEMOSTATIC KIT POLYSACCHARIDE 230 CM 2.8 MM 3 GM ENDOCLOT,SUP-2865642,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7536.00,4898.40,,,,,,,,,,,,,
MIS POR ST-NK/ POR CUP/ MET LINER/ MET HD,SUP-2212115,CDM,C1776,CPT,0278,RC,,,,both,,,17584.00,11429.60,,,,,,,,,,,,,
HC So Prothrombin Time,PX-3058561066,CDM,85610,CPT,0305,RC,,,,both,,,36.00,23.40,,,,,,,,,,,,,
GRAFT VASC IMPRA L 40 CM DIA 8 MM EPTFE STR TW N RING HEMO,SUP-2761285,CDM,C1768,CPT,0278,RC,,,,both,,,1706.94,1109.51,,,,,,,,,,,,,
DEFIBRILLATOR CARD W5.37XH8.08CM D0.99CM IS-1 DF-1 CONN,SUP-2149206,CDM,C1882,HCPCS,0275,RC,,,,both,,,52883.88,34374.52,,,,,,,,,,,,,
PLATE BNE L128MM 8 H L LAT PROX PERIARTC TIB S STL LOK COMPR,SUP-2198431,CDM,C1713,HCPCS,0278,RC,,,,both,,,3891.40,2529.41,,,,,,,,,,,,,
MATRIX WOUND THERAGENESIS MESHED 4X3CM,SUP-2738094,CDM,A2008,HCPCS,0636,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
COLLAR EXTRIC AD REG HI DENS POLYETH PD SET XTW,SUP-2194470,CDM,L0172,HCPCS,0274,RC,,,,both,,,106.76,69.39,,,,,,,,,,,,,
HOOK RETRCT GREENBERG LK BRAINPATH SHEPHARD'S SELECT-LOCK,SUP-2930216,CDM,2720000010,LOCAL,0272,RC,,,,both,,,476.18,309.52,,,,,,,,,,,,,
GRAFT BONE SUBSTITUTE FIBERGRAFT 6CC,SUP-2741934,CDM,C1713,HCPCS,0278,RC,,,,both,,,5275.20,3428.88,,,,,,,,,,,,,
HC Treat Radius Fx,PX-4502552000,CDM,25520,CPT,0450,RC,,,,both,,,1633.00,1061.45,,,,,,,,,,,,,
IMPLANT HEARING AID 4 MM PONTO BIOHELIX,SUP-2430349,CDM,L8690,HCPCS,0278,RC,,,,both,,,5162.16,3355.40,,,,,,,,,,,,,
GRAFT BNE PTTY 5 CC INJ DBM BEAST,SUP-2742043,CDM,C1713,HCPCS,0278,RC,,,,both,,,3194.95,2076.72,,,,,,,,,,,,,
BLADE SHV L11CM DIA4MM NONROTATABLE CRV SHFT RAD 40,SUP-2284145,CDM,2720000010,LOCAL,0272,RC,,,,both,,,736.52,478.74,,,,,,,,,,,,,
PLATE BNE 4X8 H TI T SHP ADPT DYN COMPR FOR 1.3MM SCR,SUP-2190693,CDM,C1713,HCPCS,0278,RC,,,,both,,,1148.46,746.50,,,,,,,,,,,,,
IMPLANT TOE JT COCR OD13.25 MM METATRSL PHLANG NP COAT,SUP-2137766,CDM,C1776,CPT,0278,RC,,,,both,,,4239.00,2755.35,,,,,,,,,,,,,
CATHETER ENDOBRONCH DIA2.6MM LOADER DEPLOYMENT HUD,SUP-2313514,CDM,C1887,HCPCS,0272,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
DRESSING BIO W4XL10IN THN CLLGN GLYCOSAMINOGLYCAN WND MTRX,SUP-2243651,CDM,Q4108,HCPCS,0636,RC,,,,both,,,27020.27,17563.18,,,,,,,,,,,,,
PIN FIX L18MM DIA1.8MM TI BTTRS FOR MOD HND SYS,SUP-2189683,CDM,C1713,HCPCS,0278,RC,,,,both,,,195.40,127.01,,,,,,,,,,,,,
PLATE BNE CONTOURABLE MESH LG 0.4 MM MASTOID TI BLU STRL,SUP-2859918,CDM,C1713,HCPCS,0278,RC,,,,both,,,3108.60,2020.59,,,,,,,,,,,,,
TUBE FEED 16FR SIL GAST DCOMPR PRT SECUR LOK RETEN RNG MIC,SUP-2124613,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1074.95,698.72,,,,,,,,,,,,,
PLATE SPNL 19X10MM 5.5 PLT TI POST FIX XLNK,SUP-2289520,CDM,C1713,HCPCS,0278,RC,,,,both,,,2386.40,1551.16,,,,,,,,,,,,,
EXTENSION STEM CEM 14X110 MM KNEE REV BKS,SUP-2434286,CDM,C1776,CPT,0278,RC,,,,both,,,2273.99,1478.09,,,,,,,,,,,,,
GUIDEWIRE SPNL K TRCR TIP 1.6X500MM NIT,SUP-2354587,CDM,C1769,HCPCS,0272,RC,,,,both,,,204.10,132.66,,,,,,,,,,,,,
SUPPORT ORTH HIP CIRC 48-60 IN LARGE/XL SZ 4 LUMSACR LP,SUP-2914959,CDM,2720000010,LOCAL,0272,RC,,,,both,,,321.00,208.65,,,,,,,,,,,,,
JOINT SHOULDER S1 EXACTECH TOTAL PLATFORM EQUINOX,SUP-2849998,CDM,C1776,CPT,0278,RC,,,,both,,,12560.00,8164.00,,,,,,,,,,,,,
COMPONENT TIB REV C RT KNEE PERSONA,SUP-2508651,CDM,C1776,CPT,0278,RC,,,,both,,,6405.60,4163.64,,,,,,,,,,,,,
HC So Tsh 3rd Generation,PX-3018444366,CDM,84443,CPT,0301,RC,,,,both,,,26.00,16.90,,,,,,,,,,,,,
CANNULA LAP ROTATABLE INSUFFLATION STOPCOCK W/O VLV ENDOTIP,SUP-2767868,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1789.17,1162.96,,,,,,,,,,,,,
TUBE JEJU 12FR PGTL TIP THRU THE PEG 3 PRT FEED ENDOVIVE,SUP-2141584,CDM,2720000010,LOCAL,0272,RC,,,,both,,,419.41,272.62,,,,,,,,,,,,,
BRACE WALKING EMBEDDED SOLE LG SHT ANK ROCKER BTM INLINE,SUP-2336133,CDM,L4361,HCPCS,0274,RC,,,,both,,,99.85,64.90,,,,,,,,,,,,,
DEXTROSE 10% IV BOLUS (PEDS),RX-4085020,CDM,2580000003,HCPCS,0258,RC,00338-0023-03,NDC,,both,500,ML,51.00,33.15,,,,,,,,,,,,,
ANCHOR SUT DIA4.5MM MULTIFIX P PEEK KNOTLESS FIX,SUP-2342074,CDM,C1776,CPT,0278,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
HC Rsf Lab Block Cases,PX-9900000122,CDM,9900000122,LOCAL,0990,RC,,,,both,,,9.00,5.85,,,,,,,,,,,,,
K-WIRE .062X4 2PT TR,SUP-2818089,CDM,C1713,HCPCS,0278,RC,,,,both,,,164.47,106.91,,,,,,,,,,,,,
PACK VITRCTMY PRB 20GA 20CC SYR CASS DRN BG ENDOILLUMINATOR,SUP-2109871,CDM,C1713,HCPCS,0278,RC,,,,both,,,1004.80,653.12,,,,,,,,,,,,,
HC Comprehensive Metabolic Panel,PX-3018005305,CDM,80053,CPT,0301,RC,,,,inpatient,,,477.00,310.05,,,,,,,,,,,,,
SCREW BONE L80MM DIA5MM FULL THRD FOR ARTH NAIL SYS PANTA 2,SUP-2244341,CDM,C1713,HCPCS,0278,RC,,,,both,,,1180.33,767.21,,,,,,,,,,,,,
SCREW BNE L14MM DIA3.5MM S STL CORT ST NONCANNULATED LOK,SUP-2348800,CDM,C1713,HCPCS,0278,RC,,,,both,,,852.82,554.33,,,,,,,,,,,,,
KIT STPL BNE FIX BRDG W8XL20MM LEG L15MM CNTR DST SPEEDTRIAD,SUP-2194271,CDM,C1713,HCPCS,0278,RC,,,,both,,,3079.43,2001.63,,,,,,,,,,,,,
COMPONENT TOT SHLDR CAPPED S4 HA,SUP-2419704,CDM,C1776,CPT,0278,RC,,,,both,,,10048.00,6531.20,,,,,,,,,,,,,
TRAY CATH HEMODIALYSI T 3 CT ACTE 15.5FR DIA 15CM STRGHT EXT,SUP-2610561,CDM,C1752,HCPCS,0278,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
PROSTHESIS ANK SZ 2 CLP LOK,SUP-2420826,CDM,C1713,HCPCS,0278,RC,,,,both,,,418.25,271.86,,,,,,,,,,,,,
SCREW SPNL FIX ANGLE 5X30 MM CANN FOR 5.5 MM ROD SHILLA,SUP-2630635,CDM,C1713,HCPCS,0278,RC,,,,both,,,4436.82,2883.93,,,,,,,,,,,,,
GRAFT BNE SUB 5CC 1GM BIOACTIVE SYN GRAN INTFACE,SUP-2138522,CDM,C1713,HCPCS,0278,RC,,,,both,,,1609.25,1046.01,,,,,,,,,,,,,
SCALPEL BONE 20MM BLUNT BLADE AND TUBESET NEXUS,SUP-2113035,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1638.04,1064.73,,,,,,,,,,,,,
BRA SURG SUPP MED 34-36 IN ZIPPER,SUP-2213722,CDM,L8000,HCPCS,0272,RC,,,,both,,,120.54,78.35,,,,,,,,,,,,,
DEFIBRILLATOR CARDIOVERTER 2 CHMBR 27 J BPLR VVED REMOT MON,SUP-2236352,CDM,C1721,HCPCS,0275,RC,,,,both,,,70964.00,46126.60,,,,,,,,,,,,,
PLATE BNE THK 0.6 MM ADV 10 MM SCREW DIA2 MM 4 H MINI CHIN,SUP-2883156,CDM,C1713,HCPCS,0278,RC,,,,both,,,1434.82,932.63,,,,,,,,,,,,,
GRAFT BONE 1.7-10MM 90ML CANC CHIP FRZ DRY,SUP-2294033,CDM,C1713,HCPCS,0278,RC,,,,both,,,3673.80,2387.97,,,,,,,,,,,,,
GRAFT MTRX DERM PTCH SFT TISS REP 5X8CM,SUP-2335647,CDM,Q4128,HCPCS,0636,RC,,,,both,,,5752.48,3739.11,,,,,,,,,,,,,
ALLOGRAFT BNE FRZN RT WHL ULNA,SUP-2740920,CDM,C1762,CPT,0278,RC,,,,both,,,10342.06,6722.34,,,,,,,,,,,,,
CLIP LIGATOR LG TI REDUC LAT SLIPPAGE COMPATIBLE KONIG ORN,SUP-2895524,CDM,C1889,HCPCS,0278,RC,,,,both,,,2.79,1.81,,,,,,,,,,,,,
CONNECTOR SPNL PARL WIDE 6.35-6.35 MM DBL SS REVERE,SUP-2594665,CDM,C1713,HCPCS,0278,RC,,,,both,,,879.20,571.48,,,,,,,,,,,,,
STENT ENDOPROS TOT CVR L150MM DIA42X38MM PROX DST CATH 25FR,SUP-2281713,CDM,C1768,CPT,0278,RC,,,,both,,,55719.30,36217.54,,,,,,,,,,,,,
GUIDEWIRE VASC L 50 CM DIA 0.018 IN CRV RAD 2 MM STR J DBL,SUP-2760068,CDM,C1769,HCPCS,0272,RC,,,,both,,,119.01,77.36,,,,,,,,,,,,,
PLATE BONE STRUT 2X4 HOLE TITANIUM NON STERILE LOW PROFILE N,SUP-2838366,CDM,C1713,HCPCS,0278,RC,,,,both,,,2225.00,1446.25,,,,,,,,,,,,,
CAP END DIA15MM 10MM EXTN LT BLU TI FOR SPRL BLDE,SUP-2192141,CDM,C1713,HCPCS,0278,RC,,,,both,,,691.65,449.57,,,,,,,,,,,,,
PLATE BNE L350MM 16 H NONSTERILE L CNDYL S STL LOK COMPR,SUP-2183118,CDM,C1713,HCPCS,0278,RC,,,,both,,,4650.06,3022.54,,,,,,,,,,,,,
COMPONENT ACET TRIFLANGED 25 MM RT HIP CUST,SUP-2137600,CDM,C1776,CPT,0278,RC,,,,both,,,34854.00,22655.10,,,,,,,,,,,,,
SCREW BNE L20MM DIA2.3MM CORT FOR WRST FIX SYS,SUP-2389724,CDM,C1713,HCPCS,0278,RC,,,,both,,,232.36,151.03,,,,,,,,,,,,,
ELECTRODE ELECSURG 3 MMX40 CM NDL INSRT,SUP-2313616,CDM,C1713,HCPCS,0278,RC,,,,both,,,989.10,642.91,,,,,,,,,,,,,
HC So Igk Rearrangeabn Clonal Pop,PX-3108126466,CDM,81264,CPT,0310,RC,,,,both,,,445.00,289.25,,,,,,,,,,,,,
PIN EXTERNAL FIXATION 5 MM FOR PROTECTIVE CAP BLACK STERILE,SUP-2836757,CDM,2720000010,LOCAL,0272,RC,,,,both,,,127.92,83.15,,,,,,,,,,,,,
DRAIN CHN 19FR L0.25IN DIA6.3MM SIL RND HUBLESS FULL FLUT,SUP-2152753,CDM,C1729,HCPCS,0272,RC,,,,both,,,44.46,28.90,,,,,,,,,,,,,
PLATE BONE LOCKING 4.5X444 MM 24 HOLE COMPRESSION,SUP-2837372,CDM,C1713,HCPCS,0278,RC,,,,both,,,12807.59,8324.93,,,,,,,,,,,,,
HC Peripheral Block - Digital,PX-3606445500,CDM,64455,CPT,0360,RC,,,,both,,,920.00,598.00,,,,,,,,,,,,,
SCREW BNE FT LG 4.5X48 MM HEX HD SS NS,SUP-2184490,CDM,C1713,HCPCS,0278,RC,,,,both,,,675.48,439.06,,,,,,,,,,,,,
DISTRACTION INTRNL ST SIZER 51 429 30 7130 MM 54 HOLE T 6L 4,SUP-2494431,CDM,C1713,HCPCS,0278,RC,,,,both,,,350.80,228.02,,,,,,,,,,,,,
ALUM CON ROD 8MMX450MM,SUP-2473149,CDM,2720000010,LOCAL,0272,RC,,,,both,,,109.90,71.43,,,,,,,,,,,,,
GRAFT BNE PTTY SYN CLLGN 15CC MOZAIK,SUP-2244490,CDM,C9359,HCPCS,0278,RC,,,,both,,,3909.30,2541.04,,,,,,,,,,,,,
DEXTROSE 5 % IV BOLUS|DISCARDED DRUG NOT ADMINISTE,RX-40840055,CDM,2580000003,HCPCS,0258,RC,00264-7510-10,NDC,JW,both,250,ML,17.00,11.05,,,,,,,,,,,,,
PASSER SUT 30DEG STR QUICKPASS LASSO,SUP-2121955,CDM,2720000010,LOCAL,0272,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
HC Simple Rep Wnd Face <2.5 Cm,PX-4501201100,CDM,12011,CPT,0450,RC,,,,outpatient,,,421.00,273.65,,,,,,,,,,,,,
STAPLER INT L45MM DIA3.5MM STD BLU TI LIN ARTC W/ 6 ROW STPL,SUP-2257580,CDM,2720000010,LOCAL,0272,RC,,,,both,,,670.42,435.77,,,,,,,,,,,,,
GRAFT TISS FRZN ALLGRFT ULNA WHL STRUCTURAL R,SUP-2307335,CDM,C1762,CPT,0278,RC,,,,both,,,8023.01,5214.96,,,,,,,,,,,,,
PROBE PERF CNTRFUG BLD PMP CORTIVA SURF AFFIN CP,SUP-2464639,CDM,2720000010,LOCAL,0272,RC,,,,both,,,788.93,512.80,,,,,,,,,,,,,
TRAY CATH PICC GROSH NXT MAXBARR 5FR 0.026IN 55CM 2 9927508D,SUP-2632714,CDM,C1751,HCPCS,0278,RC,,,,both,,,829.31,539.05,,,,,,,,,,,,,
TW DRL F/COLE RAD DRILL 4.8MM,SUP-2818201,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2052.87,1334.37,,,,,,,,,,,,,
GRAFT HUM TISS W2XL4CM AMNIO TISS MEM WRP AMNIOFIX,SUP-2305760,CDM,V2790,HCPCS,0278,RC,,,,both,,,4606.38,2994.15,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY LASSO NAV ECO L115CM 7/20FR 6MM D,SUP-2248627,CDM,C1732,HCPCS,0272,RC,,,,both,,,3990.94,2594.11,,,,,,,,,,,,,
COUPLING REPROC EXT FIX PIN TO ROD STR4920-1-020,SUP-2496949,CDM,2720000010,LOCAL,0272,RC,,,,both,,,443.18,288.07,,,,,,,,,,,,,
BLADE SURG FULL 56 MM HMSPHR EXPLANT,SUP-2202988,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
PASSER SURG L38CM CATH DISP,SUP-2284614,CDM,C1751,HCPCS,0278,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
HOOK SPNL LIP LG 6.35 MM LAM NAR BLADE SS CD HORZ LEG,SUP-2288838,CDM,C1713,HCPCS,0278,RC,,,,both,,,1193.20,775.58,,,,,,,,,,,,,
SYSTEM OCCL DEL SHTH 7FR L80CM 180DEG POLYMER PTFE REINF LO,SUP-2355730,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2152.03,1398.82,,,,,,,,,,,,,
KIT IMPL L450MM DIA2MM TIM IM AND ENDCAP THE NANCY NAIL,SUP-2253249,CDM,C1713,HCPCS,0278,RC,,,,both,,,782.17,508.41,,,,,,,,,,,,,
ELECTRODE CORTICAL 1 X 2 KT STRL DISP EVO,SUP-2934961,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1880.86,1222.56,,,,,,,,,,,,,
SPIRONOLACTONE 25 MG/5ML PO SUSP,RX-139604,CDM,6370000000,HCPCS,0637,RC,09999-9917-08,NDC,,both,5,ML,66.70,43.35,,,,,,,,,,,,,
INSTRUMENT KIT BLK PROPHECY,SUP-2304850,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
DEVICE TISS FIX L 18 X W 2.5 MM TEND THK 1.5-4 MM W 3-7 MM,SUP-2900764,CDM,C1713,HCPCS,0278,RC,,,,both,,,5714.80,3714.62,,,,,,,,,,,,,
PLATE BNE RESECT 9 MM KNEE PERSONA,SUP-2447976,CDM,C1713,HCPCS,0278,RC,,,,both,,,960.84,624.55,,,,,,,,,,,,,
SPACER CUT GUID MONOGRAM 5MM,SUP-2364869,CDM,C1776,CPT,0278,RC,,,,both,,,763.33,496.16,,,,,,,,,,,,,
GRAFT VASC GORTX L 50 CM DIA 6 MM RNG L 50 CM EPTFE STR TW,SUP-2396119,CDM,C1768,CPT,0278,RC,,,,both,,,2574.80,1673.62,,,,,,,,,,,,,
CATHETER SINUS BAL L16MM DIA6MM RELIEVA SOLO PRO,SUP-2106318,CDM,C1726,HCPCS,0272,RC,,,,both,,,2025.30,1316.44,,,,,,,,,,,,,
DEVICE PROTCT CEREB MOMA,SUP-2296569,CDM,C1884,HCPCS,0278,RC,,,,both,,,5275.20,3428.88,,,,,,,,,,,,,
COIL NEUROVASCULAR PENUMBRA COIL 400 L 6 CM DIA 5 MM STD,SUP-2323357,CDM,C1889,HCPCS,0278,RC,,,,both,,,6386.76,4151.39,,,,,,,,,,,,,
STENT BILI FLEXXUS L 8 CM DIA10 MM CATH L 190 CM DIA 7.5 FR,SUP-2166292,CDM,C1876,HCPCS,0278,RC,,,,both,,,4082.00,2653.30,,,,,,,,,,,,,
ANCHOR SUT SZ 2-0 OD2.3MM RB-1 TAPR NDL 2.0MM DRL BIT ABSRB,SUP-2249372,CDM,C1713,HCPCS,0278,RC,,,,both,,,1262.28,820.48,,,,,,,,,,,,,
CHOLANGIOGRAM KIT RX AUTOTOME UTOM XL SPHINTOM JAGWIRE 7164,SUP-2525317,CDM,C1769,HCPCS,0272,RC,,,,both,,,687.66,446.98,,,,,,,,,,,,,
HC So Lactic Acid,PX-3018360566,CDM,83605,CPT,0301,RC,,,,both,,,124.00,80.60,,,,,,,,,,,,,
CATHETER ASPIR 6FRX125CM SUPP STRL NAVIEN,SUP-2281410,CDM,C1887,HCPCS,0272,RC,,,,both,,,6421.30,4173.84,,,,,,,,,,,,,
SET VASC ACCS PED 4FR L10CM NIT PLAT ECHOGENIC TIP 0018IN,SUP-2170548,CDM,C1894,HCPCS,0272,RC,,,,both,,,81.20,52.78,,,,,,,,,,,,,
PLATE BNE L123MM 8 H ST R SUP CLAV S STL LOK COMPR FOR,SUP-2177368,CDM,C1713,HCPCS,0278,RC,,,,both,,,3088.69,2007.65,,,,,,,,,,,,,
TRILACICLIB DIHYDROCHLORIDE 300 MG IV SOLR,RX-153687,CDM,J1448,HCPCS,0636,RC,73462-0101-01,NDC,,both,1,UN,4758.50,3093.02,,,,,,,,,,,,,
STEM FEM L150MM DIA15.5MM NEUT KNEE CO CHROM POR BOW MOD,SUP-2252643,CDM,C1776,CPT,0278,RC,,,,both,,,11087.81,7207.08,,,,,,,,,,,,,
DEVICE LAPSCP UNIV FOR HND ACC GELPORT,SUP-2119621,CDM,C1788,HCPCS,0278,RC,,,,both,,,1504.06,977.64,,,,,,,,,,,,,
PROSTHESIS OSS L W2.5XH1.2XL2MM DIA1MM INCUDSTAP HA FULL,SUP-2312580,CDM,L8613,CPT,0278,RC,,,,both,,,990.17,643.61,,,,,,,,,,,,,
SET NUCLS REM L25CM 4.5MM SPINE SHV,SUP-2284309,CDM,C1713,HCPCS,0278,RC,,,,both,,,2138.65,1390.12,,,,,,,,,,,,,
GRAFT VASC GORTX L 90 CM DIA 6 MM RNG L 60 CM EPTFE STR TW,SUP-2396123,CDM,C1768,CPT,0278,RC,,,,both,,,3736.60,2428.79,,,,,,,,,,,,,
WIRE FIX L234 OD2MM W/ DRL TIP ST K,SUP-2378028,CDM,2720000010,LOCAL,0272,RC,,,,both,,,226.83,147.44,,,,,,,,,,,,,
BLADE SURG W18XL100MM,SUP-2660666,CDM,2720000010,LOCAL,0272,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
DEVICE BNE FILL NDL 13GA CRV TIP W TAMP KYPHON KURVE,SUP-2281728,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
EMTRICITABINE-TENOFOVIR AF 200-25 MG PO TABS,RX-133737,CDM,6370000000,HCPCS,0637,RC,61958-2002-01,NDC,,both,1,UN,330.40,214.76,,,,,,,,,,,,,
PROCESSOR HEARING AID CHESTNUT BRN BAHA 3 BP100,SUP-2164959,CDM,L8690,HCPCS,0278,RC,,,,both,,,10676.00,6939.40,,,,,,,,,,,,,
CATHETER URET WHSTL TIP 4 FRX70 CM SINGLE LUMEN FLEXIMA,SUP-2424629,CDM,C1758,HCPCS,0278,RC,,,,both,,,30.40,19.76,,,,,,,,,,,,,
CATHETER DRUG DEL L12.5CM 270MLX5ML/HR 2.25 DAY N NARC ON Q,SUP-2236780,CDM,C2626,HCPCS,0278,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
SYSTEM BNE FIX 18MM LC B CP LAPIDUS W PLT SCR FOR FRSH FRAC,SUP-2175174,CDM,C1713,HCPCS,0278,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
CLINDAMYCIN PHOSPHATE 1 % EX LOTN,RX-19711,CDM,6370000000,HCPCS,0637,RC,59762-3744-01,NDC,,both,60,ML,432.90,281.38,,,,,,,,,,,,,
PLATE BNE OVL SM 1.5X0.2 MM SCRN MESH JANNETTA TI NS,SUP-2481163,CDM,C1713,HCPCS,0278,RC,,,,both,,,904.54,587.95,,,,,,,,,,,,,
LINER ACET GRP 2 NEUT HIP BLU NOVATION CRWN CUP,SUP-2222028,CDM,C1776,CPT,0278,RC,,,,both,,,5581.35,3627.88,,,,,,,,,,,,,
CATHETER URETH 36 FR 5 CM BLLN W/ INFLATION DRUG OPTILUME,SUP-2863027,CDM,C1889,HCPCS,0278,RC,,,,both,,,10754.50,6990.42,,,,,,,,,,,,,
PLATE BONE CRANIOFACIAL 2X32 MM CRANIOFACIAL 6 HOLE DYNAMIC,SUP-2838376,CDM,C1713,HCPCS,0278,RC,,,,both,,,1362.76,885.79,,,,,,,,,,,,,
PLATE BNE L89MM 9 H ST ANT LAT CERV TI LOK COMPR VAR ANG FOR,SUP-2180883,CDM,C1713,HCPCS,0278,RC,,,,both,,,3369.91,2190.44,,,,,,,,,,,,,
WAND ABLAT 45DEG 3 BLK DEPTH MRK REFLX ULT 45,SUP-2342038,CDM,2720000010,LOCAL,0272,RC,,,,both,,,659.40,428.61,,,,,,,,,,,,,
PLATE BNE L87MM 4X9 H CALCNL S STL Y LOK COMPR FOR 3.5MM,SUP-2185995,CDM,C1713,HCPCS,0278,RC,,,,both,,,2908.14,1890.29,,,,,,,,,,,,,
GRAFT VASC GELWEAVE L 50 CM DIA26 MM SIDE BRANCH L 15 CM,SUP-2894702,CDM,C1768,CPT,0278,RC,,,,both,,,10990.00,7143.50,,,,,,,,,,,,,
GUIDEWIRE ORTH 2X8 MM NS,SUP-2799283,CDM,C1769,HCPCS,0272,RC,,,,both,,,470.62,305.90,,,,,,,,,,,,,
TRAY TIB SZ 9 UNIV CO CHROM UHMWPE TOT STBL CEM WFL H STEM,SUP-2378564,CDM,C1776,CPT,0278,RC,,,,both,,,6013.73,3908.92,,,,,,,,,,,,,
MESH HERN W1.8XL4.0IN POLYPR INGUINAL NONABSORBABLE,SUP-2125781,CDM,C1781,HCPCS,0278,RC,,,,both,,,173.01,112.46,,,,,,,,,,,,,
BIOTENE PBF DRY MOUTH MT LIQD,RX-82596,CDM,A9154,HCPCS,0636,RC,48582-0003-30,NDC,,both,5,ML,2.70,1.75,,,,,,,,,,,,,
KIT SHLDR SUPENSION DISP ISOTAC,SUP-2342837,CDM,C1713,HCPCS,0278,RC,,,,both,,,134.24,87.26,,,,,,,,,,,,,
BETAXOLOL HCL 0.5 % OP SOLN,RX-9268,CDM,6370000000,HCPCS,0637,RC,61314-0245-01,NDC,,both,5,ML,229.50,149.17,,,,,,,,,,,,,
PLATE BONE THK1MM 7 H MAND SLV TI STR FOR 2/2.3MM SCR SYS,SUP-2136772,CDM,C1713,HCPCS,0278,RC,,,,both,,,1453.82,944.98,,,,,,,,,,,,,
ALLOGRAFT BNE CHIPS 1-8 MM 60 CC CORTICAL CANC BIO,SUP-2632304,CDM,C1713,HCPCS,0278,RC,,,,both,,,1905.98,1238.89,,,,,,,,,,,,,
ALLOGRAFT BNE BLOCK 10X15X8 MM UNICORTICAL IL ORAGRAFT,SUP-2740829,CDM,C1713,HCPCS,0278,RC,,,,both,,,682.95,443.92,,,,,,,,,,,,,
BAR EXT FIX L200MM DIA11MM FOR XTRAFIX SYS,SUP-2199710,CDM,2720000010,LOCAL,0272,RC,,,,both,,,589.94,383.46,,,,,,,,,,,,,
SCREW INTRF L28MM DIA6MM SHLDR PLA CANN ARTHSCP FOR ANCHR,SUP-2166534,CDM,C1713,HCPCS,0278,RC,,,,both,,,686.62,446.30,,,,,,,,,,,,,
BLADE ENDOSCP SHAVER L 37 CM DIA 4 MM SPD 1200 RPM TRACH,SUP-2902052,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1605.17,1043.36,,,,,,,,,,,,,
FIBER LASER MOXY 532NM WAVELENGTH LIQUID COOLED SINGLE-USE F/GREENLIGHT XPS SYSTEM,SUP-2225585,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3014.40,1959.36,,,,,,,,,,,,,
BAG COLL 700ML REPL W/ ANTI REFLX VLV AND SAMP SITE,SUP-2244104,CDM,C1729,HCPCS,0272,RC,,,,both,,,515.18,334.87,,,,,,,,,,,,,
INSERT TIB L59MM THK20MM UNIV KNEE PRI CRUC RET NEUT LIP,SUP-2407111,CDM,C1776,CPT,0278,RC,,,,both,,,2898.22,1883.84,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9 % IV SOLN (ADD-VANTAGE),RX-4081543,CDM,J7050,HCPCS,0250,RC,00409-7101-66,NDC,,both,50,ML,38.30,24.89,,,,,,,,,,,,,
DEFIBRILLATOR IMPL ILIVIA NEO 7 VR-T PROMRI TI POLYUR SIL,SUP-2739242,CDM,C1722,HCPCS,0275,RC,,,,both,,,55590.56,36133.86,,,,,,,,,,,,,
IMPLANT HUM TISS RT DSTL HUM OSTEOARTICULAR CUST MATCHED,SUP-2932895,CDM,C1762,CPT,0278,RC,,,,both,,,21389.37,13903.09,,,,,,,,,,,,,
GRAFT EVAR L7CM DIA14.5MM FEP NIT IL EXT W/ C3 DEL SYS FOR,SUP-2395967,CDM,C1768,CPT,0278,RC,,,,both,,,9335.22,6067.89,,,,,,,,,,,,,
NAIL IM CANN 10X440 MM LT TROCHANTERIC FIX TI STRL,SUP-2192127,CDM,C1713,HCPCS,0278,RC,,,,both,,,6016.68,3910.84,,,,,,,,,,,,,
SCREW BNE L6MM DIA1MM STD CORT CRANIOMAXILLOFACIAL TI ST,SUP-2189078,CDM,C1713,HCPCS,0278,RC,,,,both,,,1685.87,1095.82,,,,,,,,,,,,,
BENDER PLT CERV,SUP-2207788,CDM,C1713,HCPCS,0278,RC,,,,both,,,2362.54,1535.65,,,,,,,,,,,,,
SPINAL SET LCK 30 MM CAP/ROD COMB NEWPORT MIS,SUP-2245597,CDM,C1713,HCPCS,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
INSERT TIB THK 15 MM SZ 00 POLYETHYL RT ANK FIX XT REV STRL,SUP-2932743,CDM,C1776,CPT,0278,RC,,,,both,,,8505.16,5528.35,,,,,,,,,,,,,
BUPIVACAINE-EPINEPHRINE (PF) 0.5% -1:200000 IJ SOLN,RX-106535,CDM,2500000003,HCPCS,0250,RC,00409-1749-71,NDC,,both,1,ML,54.10,35.16,,,,,,,,,,,,,
FOOT RING SHRT 140MM,SUP-2701803,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5950.93,3868.10,,,,,,,,,,,,,
POTASSIUM CHLORIDE IN NACL 20-0.45 MEQ/L-% IV SOLN,RX-36046,CDM,J3480,HCPCS,0636,RC,00338-0704-34,NDC,,both,1000,ML,54.10,35.16,,,,,,,,,,,,,
STEM FEM L120MM OD14MM NO CEM MOD,SUP-2265077,CDM,C1776,CPT,0278,RC,,,,both,,,6502.94,4226.91,,,,,,,,,,,,,
TITANIUM FXTN SCREW KNRLD HEAD 45MM RD II DVCE,SUP-2681269,CDM,C1713,HCPCS,0278,RC,,,,both,,,532.42,346.07,,,,,,,,,,,,,
BUR SURG L12CM DIA3MM PROX CRV 2 RIB MTCH HD MIDAS REX,SUP-2281565,CDM,C1713,HCPCS,0278,RC,,,,both,,,1129.62,734.25,,,,,,,,,,,,,
HC Hand 2 Views,PX-3207312000,CDM,73120,CPT,0320,RC,,,,both,,,348.00,226.20,,,,,,,,,,,,,
PLATE BNE L 151 MM SCREW DIA2.7/3.5 MM 12 H SS RT DSTL,SUP-2931210,CDM,C1713,HCPCS,0278,RC,,,,both,,,6015.61,3910.15,,,,,,,,,,,,,
ILLUMINATOR OPHTH DIA23GA RFID STR SMOOTH ROUNDED DSTL TIP,SUP-2109913,CDM,2720000010,LOCAL,0272,RC,,,,both,,,373.75,242.94,,,,,,,,,,,,,
HC Fna Bx W/US Gdn Ea Addl,PX-3611000600,CDM,10006,CPT,0361,RC,,,,inpatient,,,2124.00,1380.60,,,,,,,,,,,,,
CUTTER ARTHSCP 6 MM RETROCUTTER,SUP-2120847,CDM,2720000010,LOCAL,0272,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
SPLINT COLLES W FOAM L ARM PERF ALUMINIUM XR LUCENT TAN AD,SUP-2336083,CDM,L3908,HCPCS,0274,RC,,,,both,,,12.18,7.92,,,,,,,,,,,,,
GRAFT BIO TISS W20XL40CM PORCINE REGEN TISS MTRX PLIABLE,SUP-2113041,CDM,Q4130,HCPCS,0636,RC,,,,both,,,76914.30,49994.29,,,,,,,,,,,,,
K WIRE FIX L150MM DIA1.6MM SGL TRCR FOR POLYAX COMPR,SUP-2397720,CDM,C1713,HCPCS,0278,RC,,,,both,,,56.52,36.74,,,,,,,,,,,,,
SCREW BNE L18MM DIA2.5MM CO CHROM LOK SQ DRV MULTDIR PEGGED,SUP-2411663,CDM,C1713,HCPCS,0278,RC,,,,both,,,480.42,312.27,,,,,,,,,,,,,
PLATE BNE W8XL176MM THK3.3MM 22 H ST BILAT PELV S STL,SUP-2186250,CDM,C1713,HCPCS,0278,RC,,,,both,,,2488.58,1617.58,,,,,,,,,,,,,
ANCHOR SUT DIA5.5MM 1 ULTRATAPE HEALICOIL REGENESORB,SUP-2341890,CDM,C1713,HCPCS,0278,RC,,,,both,,,1104.50,717.92,,,,,,,,,,,,,
IMPLANT STAP LOOP PIST S STL 0.6MM DIA 3.5MM LEN MCGEE,SUP-2312539,CDM,L8613,CPT,0278,RC,,,,both,,,277.76,180.54,,,,,,,,,,,,,
SCREW BNE L4MM DIA2MM MAND CRANIOMAXILLOFACIAL SIL SELF DRL 5PK,SUP-2366148,CDM,C1713,HCPCS,0278,RC,,,,both,,,234.18,152.22,,,,,,,,,,,,,
PLATE BNE L89MM 3 H L PROX HUM LOK FOR 3.5MM SCR PERI-LOC,SUP-2348590,CDM,C1713,HCPCS,0278,RC,,,,both,,,12670.53,8235.84,,,,,,,,,,,,,
CATHETER HD STR 16 FRX24 CM LT SPLIT TIP SET SPLIT STRM,SUP-2267085,CDM,C1750,HCPCS,0278,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
BIT DRL DIA 5 MM CANN HALL JCBS LG SYS STRL DISP EVOS,SUP-2933342,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1649.29,1072.04,,,,,,,,,,,,,
ILLUMINATOR OPHTH RFID SAPPHIRE W ANG STRL DISP OD23GA,SUP-2109931,CDM,2720000010,LOCAL,0272,RC,,,,both,,,442.08,287.35,,,,,,,,,,,,,
KIT GWIRE SM CO CHROM T6 CANN SCRDRVR DEPTH GA COUNTSINK FOR,SUP-2225504,CDM,C1769,HCPCS,0272,RC,,,,both,,,499.89,324.93,,,,,,,,,,,,,
SLEEVE DRL DIA2.7MM MEAS FOR ALPS PROX HUM PLATING SYS,SUP-2411561,CDM,2720000010,LOCAL,0272,RC,,,,both,,,525.79,341.76,,,,,,,,,,,,,
GRAFT HUM TISS 0.5CC PLCNTA MTRX FLOWABLE IMMUNOSUPPRESSIVE,SUP-2340459,CDM,C1762,CPT,0278,RC,,,,both,,,5008.30,3255.39,,,,,,,,,,,,,
PLATE BNE STRNL 2.3X89X19 MM THOR 30 HOLE LCK LADDER LEVEL 1,SUP-2869222,CDM,C1713,HCPCS,0278,RC,,,,both,,,3083.64,2004.37,,,,,,,,,,,,,
VALVE AORT FREESTYLE H 32 MM DIA21 MM PORCINE FULL ROOT,SUP-2282937,CDM,C1889,HCPCS,0278,RC,,,,both,,,18840.00,12246.00,,,,,,,,,,,,,
SCREW CORT FT SELF TAP HEX HD 4.5MM DIA 16MML,SUP-2342647,CDM,C1713,HCPCS,0278,RC,,,,both,,,2628.18,1708.32,,,,,,,,,,,,,
GRAFT BONE SUB 1CC DBM PUTTY W/ RPM,SUP-2415792,CDM,C9359,HCPCS,0278,RC,,,,both,,,1033.06,671.49,,,,,,,,,,,,,
SYSTEM EXT FIX FOR PIP JT FLX CNTRCT AGEE DGT WIDGET,SUP-2237246,CDM,C1713,HCPCS,0278,RC,,,,both,,,5840.40,3796.26,,,,,,,,,,,,,
DEVICE ORTH TARGET FREEHAND DSTL WHT VERSANAIL,SUP-2412774,CDM,2720000010,LOCAL,0272,RC,,,,both,,,417.62,271.45,,,,,,,,,,,,,
SCREW BONE L22MM DIA1.5MM CO CHROM CORT ST NONLOCKING FULL,SUP-2411774,CDM,C1713,HCPCS,0278,RC,,,,both,,,230.60,149.89,,,,,,,,,,,,,
HC Surgery Level 5 Addtl 15min,PX-3600000015,CDM,3600000015,LOCAL,0360,RC,,,,both,,,4347.00,2825.55,,,,,,,,,,,,,
GUIDEWIRE VASC L 145 CM DIA 0.035 IN CRV RAD 5 MM SS HEPARIN,SUP-2168252,CDM,C1769,HCPCS,0272,RC,,,,both,,,164.13,106.68,,,,,,,,,,,,,
ALLOGRAFT BNE FEM 209X12X3 MM FRZN STRUT,SUP-2717896,CDM,C1762,CPT,0278,RC,,,,both,,,4619.00,3002.35,,,,,,,,,,,,,
INTRODUCER SHTH 7 FR,SUP-2355532,CDM,C1894,HCPCS,0272,RC,,,,both,,,26.69,17.35,,,,,,,,,,,,,
HC Radiologic Exam Small Int Single Contrast Study,PX-3207425000,CDM,74250,CPT,0320,RC,,,,both,,,1702.00,1106.30,,,,,,,,,,,,,
KIT BNE CEMENT MIXING SYS FEM BRKWY NOZ MED SLD PROX,SUP-2884229,CDM,C1776,CPT,0278,RC,,,,both,,,560.24,364.16,,,,,,,,,,,,,
FREELINK NOVI REMOTE CONTROL KIT,SUP-2700480,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
STENT URET STR TIP 0.038 INX150 CM 3 CM 8 FRX22 CM PERCFLX,SUP-2464970,CDM,C2617,HCPCS,0278,RC,,,,both,,,413.76,268.94,,,,,,,,,,,,,
PLATE BONE L175MM 4 H STRL LT PROX FEM S STL LO PROF LCK,SUP-2186040,CDM,C1713,HCPCS,0278,RC,,,,both,,,4170.55,2710.86,,,,,,,,,,,,,
CAST ORTH L53X54IN NO BOOT TOT CNTCT TCC EZ,SUP-2244457,CDM,C1713,HCPCS,0278,RC,,,,both,,,331.36,215.38,,,,,,,,,,,,,
CATHETER EP LG CURL 2-4-2 MM SPC 2 MM TIP,SUP-2867388,CDM,C1730,HCPCS,0272,RC,,,,both,,,2449.20,1591.98,,,,,,,,,,,,,
SPACER SPNL INTBDY FUS C RNG FOR 6.35MM ROD,SUP-2293078,CDM,C1889,HCPCS,0278,RC,,,,both,,,766.16,498.00,,,,,,,,,,,,,
DRILL TWST L 54 MM DIA1 MM STP 13.8 MM DENT SHFT NS DISP,SUP-2883327,CDM,2720000010,LOCAL,0272,RC,,,,both,,,366.47,238.21,,,,,,,,,,,,,
IFOSFAMIDE 3 G IV SOLR,RX-10249,CDM,J9208,HCPCS,0636,RC,10019-0926-02,NDC,,both,1,UN,309.80,201.37,,,,,,,,,,,,,
CATHETER ANGIO GLIDECATH L 65 CM DIA 4 FR DIA1.05 MM C1,SUP-2385505,CDM,C1887,HCPCS,0272,RC,,,,both,,,59.13,38.43,,,,,,,,,,,,,
PROBE CRYOABLATION L 17 IN OD 8 MM BALL TIP STRL DISP,SUP-2889660,CDM,C9808,HCPCS,0272,RC,,,,both,,,8164.00,5306.60,,,,,,,,,,,,,
BUR SURG MTCH HD 2.2X3.8 MM 10 CM FLUT SM BOR MIDAS REX 8,SUP-2664520,CDM,2720000010,LOCAL,0272,RC,,,,both,,,334.10,217.16,,,,,,,,,,,,,
PLATE BNE L1 2X110X0.5 MM CRANIOMAXILLOFACIAL 7 HOLE TI NS,SUP-2465043,CDM,C1713,HCPCS,0278,RC,,,,both,,,1090.84,709.05,,,,,,,,,,,,,
SOLUTION WND LAVAGE 500 ML CIT ACD SODIUM CIT SODIUM LAURYL,SUP-2900364,CDM,2720000010,LOCAL,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
NAIL IM HUM 7X255 MM LT STR CANN TI BLU STRL MULTILOC,SUP-2541271,CDM,C1713,HCPCS,0278,RC,,,,both,,,6083.66,3954.38,,,,,,,,,,,,,
SCREW BNE LG HEX STYL 4 MM HD 14.6 MM,SUP-2471318,CDM,C1713,HCPCS,0278,RC,,,,both,,,455.83,296.29,,,,,,,,,,,,,
PIN BIOABS SONICPIN 022X26MM,SUP-2700934,CDM,C1713,HCPCS,0278,RC,,,,both,,,2192.98,1425.44,,,,,,,,,,,,,
PLATE BONE L256MM BLDE W11.7XL60MM 90DEG 14 H STRL BILAT TI,SUP-2190880,CDM,C1713,HCPCS,0278,RC,,,,both,,,4736.94,3079.01,,,,,,,,,,,,,
HC MRI-Angio Neck W Contrast,PX-6157054800,CDM,70548,CPT,0615,RC,,,,both,,,3633.00,2361.45,,,,,,,,,,,,,
BASKET STONE REM SZ 16MM L120CM DIA3FR PR 6W SUR-CATCH NT,SUP-2312752,CDM,2720000010,LOCAL,0272,RC,,,,both,,,565.99,367.89,,,,,,,,,,,,,
DILATOR KIT INSUL OVL STRL SAFEOP,SUP-2800029,CDM,2720000010,LOCAL,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
HC So Dihydrotestosterone (Dht),PX-3018264266,CDM,82642,CPT,0301,RC,,,,inpatient,,,78.00,50.70,,,,,,,,,,,,,
KYPHOPLASTY PACK 10 GA 2 ML STR W/ BFD OSSEOFLEX SB OCP0212,SUP-2516670,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7222.00,4694.30,,,,,,,,,,,,,
TRAY CATH PICC RADPICC BSC 5FR 0.042N 60CM 1 LUMAN R 3165135,SUP-2632645,CDM,C1751,HCPCS,0278,RC,,,,both,,,252.14,163.89,,,,,,,,,,,,,
STEM FEM L260MM OD9MM POR RT CALCAR REV PRESSFIT IMP,SUP-2403614,CDM,C1776,CPT,0278,RC,,,,both,,,19982.96,12988.92,,,,,,,,,,,,,
CATHETER ANGIOPLSTY WORKHORSE II 75 CM 5 FR 8 MM 4 MM,SUP-2117083,CDM,C1725,HCPCS,0272,RC,,,,both,,,71.12,46.23,,,,,,,,,,,,,
GRAFT VASC VEN KT OUTFLO ADPT SUPER HERO,SUP-2302611,CDM,C1768,CPT,0278,RC,,,,both,,,12560.00,8164.00,,,,,,,,,,,,,
GRAFT BIO TISS 2X4CM THK10 20MM THCK PROLAYER,SUP-2362229,CDM,C1763,HCPCS,0278,RC,,,,both,,,2717.98,1766.69,,,,,,,,,,,,,
BLADE ARTHRO 4MM 60DEG DBL EDGE HOE TIP CRV SHRP ALL ARND S,SUP-2570496,CDM,2720000010,LOCAL,0272,RC,,,,both,,,54.04,35.13,,,,,,,,,,,,,
NEEDLE ASPIR 11 GAX11 CM STRL MAR CELLUTION 11CSTS,SUP-2743329,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3218.50,2092.02,,,,,,,,,,,,,
SPLINT WR AD SM FOR 2.5-3IN RT MCP REG FIRM OUTER FAB HND,SUP-2324879,CDM,L3809,HCPCS,0274,RC,,,,both,,,51.75,33.64,,,,,,,,,,,,,
ADAPTER STEM 4MM OFFSET W/ JAM NUT FOR SCORP SGL AXIS TOT,SUP-2376320,CDM,C1776,CPT,0278,RC,,,,both,,,2287.08,1486.60,,,,,,,,,,,,,
IMMOBILIZER SHLDR M PCH W8XL16.5IN UNIV TIETEX FOAM STRP,SUP-2195497,CDM,L3650,HCPCS,0274,RC,,,,both,,,15.39,10.00,,,,,,,,,,,,,
TUBING CNTRST DEL EXCITE L 100 CM 2.59CC NYL POLYUR AIRLESS,SUP-2302640,CDM,C1713,HCPCS,0278,RC,,,,both,,,19.28,12.53,,,,,,,,,,,,,
PLATE BNE L48MM 8 H TI DYN LOK COMPR FOR 2MM SCR MOD HND,SUP-2191481,CDM,C1713,HCPCS,0278,RC,,,,both,,,1358.62,883.10,,,,,,,,,,,,,
VALVE AORT EVOLUT PRO + DIA23 MM ANNULUS 17/18-20 MM PORCINE,SUP-2418291,CDM,C1889,HCPCS,0278,RC,,,,both,,,94200.00,61230.00,,,,,,,,,,,,,
COMPONENT FEM DSTL 5 CM RT KNEE POROUS MAK RS OSS,SUP-2449855,CDM,C1776,CPT,0278,RC,,,,both,,,16970.13,11030.58,,,,,,,,,,,,,
KIT CATH 7FR L8IN POLYUR CTRL VEN 3 LUMN ANTIMIC SURF BLU,SUP-2383390,CDM,C1751,HCPCS,0278,RC,,,,both,,,339.75,220.84,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED PATELLAR UPCHARGE MTL BK,SUP-2212688,CDM,C1776,CPT,0278,RC,,,,both,,,1171.22,761.29,,,,,,,,,,,,,
INTRODUCER SHTH SL1 0.032 IN 8.5 FRX63 CM FAST-CATH,SUP-2357168,CDM,C1893,HCPCS,0272,RC,,,,both,,,556.97,362.03,,,,,,,,,,,,,
IMPLANT FACE L 40 X W 40 MM THK 0.73 MM THK 2.5 MM LG,SUP-2883493,CDM,C1713,HCPCS,0278,RC,,,,both,,,2130.62,1384.90,,,,,,,,,,,,,
SCREW BNE FUSION LG 7.4X55 MM SS STRL G-BEAM,SUP-2646307,CDM,C1713,HCPCS,0278,RC,,,,both,,,5940.88,3861.57,,,,,,,,,,,,,
PLATE BNE L 92 MM 10 H SCREW DIA2.7 MM Y SHP NAR LCK MINI,SUP-2902292,CDM,C1713,HCPCS,0278,RC,,,,both,,,5222.45,3394.59,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 40 CM DIA 8 MM STR STD WALL REINF,SUP-2525433,CDM,C1768,CPT,0278,RC,,,,both,,,751.18,488.27,,,,,,,,,,,,,
SET LD EXTRACTION BYRD SHTH L 41/46CM 13.9FR 11.6FR SZ A YEL,SUP-2169010,CDM,C1894,HCPCS,0272,RC,,,,both,,,460.01,299.01,,,,,,,,,,,,,
PLUG SZ 5MM,SUP-2388881,CDM,C1776,CPT,0278,RC,,,,both,,,2182.30,1418.49,,,,,,,,,,,,,
KIT INTRO VSI L 12 CM DIA 4 FR GUIDEWIRE L 40 CM DIA 0.018,SUP-2763483,CDM,C1892,HCPCS,0272,RC,,,,both,,,130.62,84.90,,,,,,,,,,,,,
COUNTERSINK DENT 1.2/2/2.4MM W/ DENT SHFT PROFYLE,SUP-2419548,CDM,2720000010,LOCAL,0272,RC,,,,both,,,527.52,342.89,,,,,,,,,,,,,
CATHETER PICC DBL LUMN FULL TY NRS PWR INJ POLYUR N COAT CT,SUP-2125544,CDM,C1751,HCPCS,0278,RC,,,,both,,,601.62,391.05,,,,,,,,,,,,,
ORTHOPEDIC KIT LNG 4.5X17.5 MM ARTHRPLSTY SCREW W/ LCK CAP,SUP-2243513,CDM,C1713,HCPCS,0278,RC,,,,both,,,935.94,608.36,,,,,,,,,,,,,
WASHER ORTH LCK RESRB HALF CLOVER CENTRALOC RESRB TIB FIX SZ,SUP-2212869,CDM,C1713,HCPCS,0278,RC,,,,both,,,737.90,479.63,,,,,,,,,,,,,
PROSTHESIS OSS PISTON 0.6X3.75 MM SCHKNT SS FLROPLAS,SUP-2637745,CDM,L8613,CPT,0278,RC,,,,both,,,330.86,215.06,,,,,,,,,,,,,
"HC Blood Typing, Rh(D)",PX-3008690100,CDM,86901,CPT,0300,RC,,,,both,,,189.00,122.85,,,,,,,,,,,,,
GRAFT BONE SUB 5CC DBM PURE PUTTY,SUP-2340465,CDM,C1713,HCPCS,0278,RC,,,,both,,,2276.50,1479.72,,,,,,,,,,,,,
GRAFT SPINE AND GEN ORTH TISS FRZ DRY STRP SHAFTS ILIUM,SUP-2307131,CDM,C1713,HCPCS,0278,RC,,,,both,,,1970.48,1280.81,,,,,,,,,,,,,
GUIDEWIRE SURG L407MM DIA1.6MM S STL FLEX SMOOTH BALL TIP,SUP-2256597,CDM,C1769,HCPCS,0272,RC,,,,both,,,246.18,160.02,,,,,,,,,,,,,
GRAFT DURA W1XH3IN ULTRAPURE CLLGN ADH BARR MTRX DURAGN +,SUP-2244005,CDM,C1781,HCPCS,0278,RC,,,,both,,,1548.43,1006.48,,,,,,,,,,,,,
CATHETER GUID AXS OFFSET L 150 CM DSTL OD 0.036 IN ID 0.021,SUP-2884373,CDM,C1887,HCPCS,0272,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
SCREW BONE L4MM DIA2MM CORT CRANIOMAXILLOFACIAL TI ST,SUP-2188960,CDM,C1713,HCPCS,0278,RC,,,,both,,,177.41,115.32,,,,,,,,,,,,,
MARKER RAD 5CM DEL NDL AND REFLCT SAVI SCOUT,SUP-2164407,CDM,C1819,HCPCS,0278,RC,,,,both,,,1444.40,938.86,,,,,,,,,,,,,
GRAFT BNE SYR 1 CC DBM ACCELL CONNEXUS,SUP-2641752,CDM,C1713,HCPCS,0278,RC,,,,both,,,779.35,506.58,,,,,,,,,,,,,
GRAFT HUM TISS W3XL7CM THK.9-1.99MM ACELLULAR DERM MTRX,SUP-2402506,CDM,Q4126,HCPCS,0636,RC,,,,both,,,6123.00,3979.95,,,,,,,,,,,,,
ALLOGRAFT BNE FD ETO WHL MAND,SUP-2867075,CDM,C1762,CPT,0278,RC,,,,both,,,11544.21,7503.74,,,,,,,,,,,,,
RESTRICTOR CEM FOR 20/22MM P.F.C.,SUP-2253287,CDM,C1713,HCPCS,0278,RC,,,,both,,,489.84,318.40,,,,,,,,,,,,,
TUBE VENT PAPARELLA 1.27 MM 1 MM PHOSPHORYLCHOLINE COAT SIL,SUP-2535117,CDM,L8699,HCPCS,0278,RC,,,,both,,,38.21,24.84,,,,,,,,,,,,,
TRAY CATH PICC GROSH NXT BSC 5FR 0.026N 45CM 2 LUMAN RVS TAP,SUP-2613450,CDM,C1751,HCPCS,0278,RC,,,,both,,,451.22,293.29,,,,,,,,,,,,,
ALLOGRAFT BNE STRP 40X60 MM FRZN ASEP TRICORT IL CREST,SUP-2867193,CDM,C1762,CPT,0278,RC,,,,both,,,4402.91,2861.89,,,,,,,,,,,,,
ENOXAPARIN SODIUM 30 MG/0.3ML IJ SOSY,RX-157660,CDM,J1650,HCPCS,0636,RC,63323-0559-93,NDC,,both,0.3,ML,54.10,35.16,,,,,,,,,,,,,
SHEATH INTRO FIX CRV LVI/75-5-62-07-HO STRL,SUP-2739220,CDM,C1893,HCPCS,0272,RC,,,,both,,,1130.40,734.76,,,,,,,,,,,,,
ANCHOR SFT TISS L20MM OD6MM DISP GUN ECLIPSE,SUP-2277476,CDM,C1713,HCPCS,0278,RC,,,,both,,,2810.30,1826.69,,,,,,,,,,,,,
GRAFT HUM TISS L W80XL200MM FASC LATA FRZ DRY READIGRFT,SUP-2264778,CDM,C1762,CPT,0278,RC,,,,both,,,4319.01,2807.36,,,,,,,,,,,,,
PLATE SPNL L60MM ANT CERV BILAT TI 3 LEV INTEGR LOK,SUP-2293211,CDM,C1713,HCPCS,0278,RC,,,,both,,,2386.40,1551.16,,,,,,,,,,,,,
GRAFT DERM MTRX HUM TISS HYDRATED THCK DMND ACELLULAR DERM,SUP-2307517,CDM,Q4128,HCPCS,0636,RC,,,,both,,,55263.00,35920.95,,,,,,,,,,,,,
NITROGLYCERIN 0.4 MG/HR TD PT24,RX-27474,CDM,6370000000,HCPCS,0637,RC,00378-9112-93,NDC,,both,1,UN,3.70,2.40,,,,,,,,,,,,,
MORPHINE SULFATE 10 MG/5ML PO SOLN,RX-5176,CDM,340b,HCPCS,0637,RC,68094-0001-59,NDC,,both,1.25,ML,2.70,1.75,,,,,,,,,,,,,
BIT DRL L225MM DIA35MM ST 3 FLUT QUIK CPL NONRADIOPAQUE,SUP-2187577,CDM,2720000010,LOCAL,0272,RC,,,,both,,,500.23,325.15,,,,,,,,,,,,,
STAPLE KIT 10X15/17 MM STRL INSTAFIX LTX DISP,SUP-2857580,CDM,C1713,HCPCS,0278,RC,,,,both,,,2672.14,1736.89,,,,,,,,,,,,,
HANDLE SUT PASS SGL USE FOR MENIS REP SHRP SHOT,SUP-2362796,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1441.26,936.82,,,,,,,,,,,,,
CANNULA VENT ASST L ART SEAL OUTFLOW BEND RELF HEARTMATE III,SUP-2356019,CDM,L8670,HCPCS,0278,RC,,,,both,,,16277.76,10580.54,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE XLN 5 CC DBM FIBER INFLUENCER -RSFH,SUP-2881440,CDM,C1713,HCPCS,0278,RC,,,,both,,,6091.60,3959.54,,,,,,,,,,,,,
CLIP EXT FIX SPNG SALVATION,SUP-2401152,CDM,2720000010,LOCAL,0272,RC,,,,both,,,229.22,148.99,,,,,,,,,,,,,
GRAFT VASC HEMSHLD GLD L 100 CM DIA 6 MM POLYESTER BOV CLLGN,SUP-2265896,CDM,C1768,CPT,0278,RC,,,,both,,,1817.12,1181.13,,,,,,,,,,,,,
PLATE BNE ORBIT FLR LG 1.5X40X35X0.5 MM RT SMRT TI NS,SUP-2487018,CDM,C1713,HCPCS,0278,RC,,,,both,,,4120.21,2678.14,,,,,,,,,,,,,
PLATE BNE RECON 3.5X46 MM 4 HOLE SS,SUP-2569079,CDM,C1713,HCPCS,0278,RC,,,,both,,,326.40,212.16,,,,,,,,,,,,,
HC Insertion Picc W/Rs&I 5 Yr/>|BILATERAL PROCEDURE,PX-3613657300,CDM,36573,CPT,0361,RC,,,50,both,,,5560.00,3614.00,,,,,,,,,,,,,
KIT THERMOABLATION 6MM ENDOMET DEV NOVASURE - SEE COMMENT,SUP-2239892,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3438.30,2234.89,,,,,,,,,,,,,
COLLAR CERV SFT DENS W/ CHIN SUPP ADJ AD CNTOUR HK AND LOOP,SUP-2324378,CDM,L0120,HCPCS,0274,RC,,,,both,,,16.64,10.82,,,,,,,,,,,,,
SINCALIDE 5 MCG IJ SOLR,RX-11368,CDM,J2805,HCPCS,0636,RC,63323-0579-01,NDC,,both,1,UN,713.80,463.97,,,,,,,,,,,,,
ASSEMBLY SPNL HEADBODY STD,SUP-2175620,CDM,C1713,HCPCS,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
SCREW SPNL L100MM OD8.5MM 10DEG TI CANC PEDCL IL VAR ANG,SUP-2287188,CDM,C1713,HCPCS,0278,RC,,,,both,,,3232.94,2101.41,,,,,,,,,,,,,
SCREW BNE CANN MED THRD 5X75 MM HDLSS SHRP TIP BEAM JOUSTA,SUP-2742900,CDM,C1713,HCPCS,0278,RC,,,,both,,,3504.24,2277.76,,,,,,,,,,,,,
PLATE BNE TROCHANTERIC WIDE LT NCB,SUP-2459362,CDM,C1713,HCPCS,0278,RC,,,,both,,,3022.06,1964.34,,,,,,,,,,,,,
SCREW BNE L90MM DIA13MM STD CANC S STL LAG 1 STP RECESS FOR,SUP-2186581,CDM,C1713,HCPCS,0278,RC,,,,both,,,121.36,78.88,,,,,,,,,,,,,
BUR SURG DIA2.5 HUB II DIAMOND CUT DISK STRL REUSE HI-LINE,SUP-2928839,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1280.21,832.14,,,,,,,,,,,,,
PLATE BLADE ANGL 130 DEG 12H /90MM/200MM,SUP-2547495,CDM,C1713,HCPCS,0278,RC,,,,both,,,3176.02,2064.41,,,,,,,,,,,,,
MESH ORBIT THK0.3MM MIDFACE TI FOR 0.6MM SCR,SUP-2262594,CDM,C1713,HCPCS,0278,RC,,,,both,,,934.15,607.20,,,,,,,,,,,,,
SPLINT ORTH PNEUMATIC ANK FT CTRL,SUP-2388196,CDM,L4350,HCPCS,0274,RC,,,,both,,,246.96,160.52,,,,,,,,,,,,,
TUBE TRACH AD L110MM OD92MM ID6MM SIL CUF ADJUSTABLE NK FLNG,SUP-2352022,CDM,2720000010,LOCAL,0272,RC,,,,both,,,929.41,604.12,,,,,,,,,,,,,
INSERT HUM OD36MM THK+6MM SHLDR POLY CONSTRN AEQUALIS,SUP-2388688,CDM,C1776,CPT,0278,RC,,,,both,,,6397.75,4158.54,,,,,,,,,,,,,
HC Insert Peritoneal Venous Shunt,PX-3614942500,CDM,49425,CPT,0361,RC,,,,outpatient,,,8583.00,5578.95,,,,,,,,,,,,,
DRILL SURG STP 3.9 MM FOR 5 MM PIN SALVATION 2,SUP-2850525,CDM,2720000010,LOCAL,0272,RC,,,,both,,,474.14,308.19,,,,,,,,,,,,,
GUIDEWIRE ENDSCPC 0035N OD 260CML BLRY ANGLD TIP STIFF SHAF,SUP-2676534,CDM,C1729,HCPCS,0272,RC,,,,both,,,402.99,261.94,,,,,,,,,,,,,
BUPIVACAINE HCL (PF) 0.5 % IJ SOLN,RX-103565,CDM,J0665,HCPCS,0636,RC,55150-0170-30,NDC,,both,30,ML,54.10,35.16,,,,,,,,,,,,,
HC Extremity Venogram,PX-3613600500,CDM,36005,CPT,0361,RC,,,,outpatient,,,6875.00,4468.75,,,,,,,,,,,,,
BIT DRL L195MM DIA43 45MM FOR NCB PERIPROSTHETIC FEM SYS,SUP-2204939,CDM,2720000010,LOCAL,0272,RC,,,,both,,,455.39,296.00,,,,,,,,,,,,,
PLATE BONE L81MM 7 H STRL S STL LCK COMPR FOR 3.5MM SCR EVOS,SUP-2349630,CDM,C1713,HCPCS,0278,RC,,,,both,,,2180.79,1417.51,,,,,,,,,,,,,
SCREW BNE ST 1X6 MM CORTICAL THRD CRUCFRM RECESS TI GRN NS,SUP-2189093,CDM,C1713,HCPCS,0278,RC,,,,both,,,219.02,142.36,,,,,,,,,,,,,
BODY FEM B OD45MM HA POR PLSM SPR PROX CALCAR HIP MTPHSEAL,SUP-2408321,CDM,C1776,CPT,0278,RC,,,,both,,,16993.68,11045.89,,,,,,,,,,,,,
GUIDEWIRE VASC L 30 CM DIA 0.025 IN SS PTFE STR FIX COR STRL,SUP-2167841,CDM,C1769,HCPCS,0272,RC,,,,both,,,64.06,41.64,,,,,,,,,,,,,
ANCHOR SUT DIA5MM W/O ORTHOCORD NDL SPIRALOK,SUP-2256678,CDM,C1713,HCPCS,0278,RC,,,,both,,,847.80,551.07,,,,,,,,,,,,,
GRAFT HUM TISS INJ FLUID 2 CC AMNIO PLCNTA MEMBRN PRO3-F,SUP-2742033,CDM,C1762,CPT,0278,RC,,,,both,,,13384.25,8699.76,,,,,,,,,,,,,
WASHER ORTH ANK FIX FOR 4 MM SCREW,SUP-2389354,CDM,C1713,HCPCS,0278,RC,,,,both,,,219.80,142.87,,,,,,,,,,,,,
BUR SURG BALL 2 MM 19 CM FLUT FOR MA-19 BEAR SL,SUP-2848290,CDM,2720000010,LOCAL,0272,RC,,,,both,,,580.71,377.46,,,,,,,,,,,,,
POST EXT FIX 4 HOLE STRL TRUELOK EVO LTX,SUP-2875630,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1528.90,993.78,,,,,,,,,,,,,
BUPRENORPHINE HCL 2 MG SL SUBL,RX-34711,CDM,J0571,HCPCS,0637,RC,60687-0481-21,NDC,,both,1,UN,9.20,5.98,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED HYBRID ZHCHYBRID] ZIMMER BIOMET INC],SUP-2212724,CDM,C1776,CPT,0278,RC,,,,both,,,12732.17,8275.91,,,,,,,,,,,,,
ASPIRIN 300 MG RE SUPP,RX-693,CDM,6370000000,HCPCS,0637,RC,00574-7034-12,NDC,,both,1,UN,10.10,6.56,,,,,,,,,,,,,
HEAD FEM OD38MM +0MM M NK C CAST CO CHROM HIP PRI CONSTRN,SUP-2397308,CDM,C1776,CPT,0278,RC,,,,both,,,2983.00,1938.95,,,,,,,,,,,,,
METRONIDAZOLE 500 MG PO TABS,RX-5016,CDM,6370000000,HCPCS,0637,RC,72578-0008-05,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
LEGION FEM CONE ID 20MM L,SUP-2349186,CDM,C1776,CPT,0278,RC,,,,both,,,12560.00,8164.00,,,,,,,,,,,,,
CATHETER ANGIOPLSTY 0.035 IN 75 CM 5X120 MM MUSTANG,SUP-2432116,CDM,C1725,HCPCS,0272,RC,,,,both,,,446.19,290.02,,,,,,,,,,,,,
BAR EXT FIX L 350 MM DIA11 MM UNILAT NS DISP MAV,SUP-2931323,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2025.30,1316.44,,,,,,,,,,,,,
IMPLANT TISS FIX L 120 MM ADJ LOOP OPN W/O BTTN STRL,SUP-2908727,CDM,C1713,HCPCS,0278,RC,,,,both,,,1127.26,732.72,,,,,,,,,,,,,
NEEDLE BX 22GA EXTN 0-8CM SHTH 5.2FR US RECESS BALL TIP,SUP-2171105,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1205.76,783.74,,,,,,,,,,,,,
GRAFT BNE PTTY 10 CC DBM DBMP10] UNIVERSAL MEDICAL PRODUCTS],SUP-2391507,CDM,C9359,HCPCS,0278,RC,,,,both,,,4160.50,2704.32,,,,,,,,,,,,,
BASEPLATE GLEN SZ 8 MM REV 2 TAPR STRL ALTIVATE RVS,SUP-2904165,CDM,C1776,CPT,0278,RC,,,,both,,,4699.01,3054.36,,,,,,,,,,,,,
PACK INSTRUMENTXSM INCLUDE GUID PIN SCR DRVR THIMBLE FOR,SUP-2123611,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1252.86,814.36,,,,,,,,,,,,,
GRAFT BNE SUB 10CC TISS EXPONENT DBM,SUP-2138519,CDM,C1713,HCPCS,0278,RC,,,,both,,,2677.98,1740.69,,,,,,,,,,,,,
CATHETER PH 6FR ES SGL CHN 8 IMPED RNG DISP VERSAFLEX ZNIS,SUP-2173687,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3567.04,2318.58,,,,,,,,,,,,,
PLATE BONE ORBITAL FLOOR SMALL 1 MM CRANIOFACIAL ANATOMIC TI,SUP-2838342,CDM,C1713,HCPCS,0278,RC,,,,both,,,4705.92,3058.85,,,,,,,,,,,,,
HANDPIECE BRST BX L13CMXW20MM OD12GA ID3.7MM TOT TISS,SUP-2240017,CDM,2720000010,LOCAL,0272,RC,,,,both,,,837.60,544.44,,,,,,,,,,,,,
INTRODUCER SHTH L30CM OD12FR FOR ABD AORT ANEURYSMS,SUP-2395871,CDM,C1894,HCPCS,0272,RC,,,,both,,,266.90,173.48,,,,,,,,,,,,,
PACEMAKER CARD CONTAK RENEWAL TR W 4.50 X H 5.40 CM D 0.85,SUP-2140443,CDM,C1786,HCPCS,0275,RC,,,,both,,,21980.00,14287.00,,,,,,,,,,,,,
STAPLER SUREFORM 60 DA VINCI XI,SUP-2246800,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1747.41,1135.82,,,,,,,,,,,,,
NEEDLE BNE MAR ASPIR 6 GAX11 IN AUTOLGS CELL 60S EXTRACTOR,SUP-2138520,CDM,2720000010,LOCAL,0272,RC,,,,both,,,573.18,372.57,,,,,,,,,,,,,
PLATE BONE L169MM 8 H TI TIM RT DSTL FIBULAR LCK COMPR ANAT,SUP-2413695,CDM,C1713,HCPCS,0278,RC,,,,both,,,2969.50,1930.17,,,,,,,,,,,,,
GUIDEWIRE VASC CLOSUREFAST L 260 CM DIA 0.025 IN TIP L 1.5,SUP-2172403,CDM,C1769,HCPCS,0272,RC,,,,both,,,59.22,38.49,,,,,,,,,,,,,
TUNNELER SURG AV SHTH KT 120DEG ROD 23.5CM,SUP-2127966,CDM,C1713,HCPCS,0278,RC,,,,both,,,1091.97,709.78,,,,,,,,,,,,,
CATHETER CV SINGLE LUMEN 5 FRX60 CM SET PRO-LINE MD28035101,SUP-2626367,CDM,C1751,HCPCS,0278,RC,,,,both,,,816.40,530.66,,,,,,,,,,,,,
NALOXONE HCL 2 MG/2ML IJ SOSY,RX-135456,CDM,J2312,HCPCS,0636,RC,76329-3369-01,NDC,,both,0.4,ML,54.10,35.16,,,,,,,,,,,,,
CATHETER ABLATN D-D 1-7-4 MM 8MM 7 FRX115 CM EZ STEER LF,SUP-2248511,CDM,C1732,HCPCS,0278,RC,,,,both,,,7074.42,4598.37,,,,,,,,,,,,,
SIZER BRST IMPL EXTRA FULL PROF SIL 370 CC FILL VOL 6 CM,SUP-2113593,CDM,2720000010,LOCAL,0272,RC,,,,both,,,659.40,428.61,,,,,,,,,,,,,
KIT CRICOTHYROTOMY ADULT 14GA SPLITTING NEEDLE L6.8CM AIRWAY,SUP-2824153,CDM,2720000010,LOCAL,0272,RC,,,,both,,,418.53,272.04,,,,,,,,,,,,,
HC So Infliximab Level,PX-3018023066,CDM,80230,CPT,0301,RC,,,,inpatient,,,189.00,122.85,,,,,,,,,,,,,
HC So2 Islet Cell Antibody,PX-3028634168,CDM,86341,CPT,0302,RC,,,,outpatient,,,55.00,35.75,,,,,,,,,,,,,
GUIDEWIRE VASC L150CM DIA0.035IN STD ANG HYDRPHLC FIX COR,SUP-2302958,CDM,C1769,HCPCS,0272,RC,,,,both,,,90.56,58.86,,,,,,,,,,,,,
MARKER BRST BX L13CM OD14GA RBBN TI SENOMARK ULTRACOR,SUP-2127030,CDM,A4648,CPT,0278,RC,,,,both,,,191.89,124.73,,,,,,,,,,,,,
HC OB ER Level 3,PX-4509928301,CDM,99283,CPT,0450,RC,,,,outpatient,,,1556.00,1011.40,,,,,,,,,,,,,
HC Pacu Recovery - Addtl 15 Min,PX-7100000001,CDM,7100000001,LOCAL,0710,RC,,,,both,,,616.00,400.40,,,,,,,,,,,,,
BAR EXT FIX 11X600 MM XTRAFIX,SUP-2534563,CDM,2720000010,LOCAL,0272,RC,,,,both,,,900.43,585.28,,,,,,,,,,,,,
CAGE ACET DIA61MM L HIP TI REV PROTRUSIO RECVRY,SUP-2403960,CDM,C1776,CPT,0278,RC,,,,both,,,10638.32,6914.91,,,,,,,,,,,,,
GUAIFENESIN 100 MG/5ML PO LIQD,RX-13748,CDM,2500000003,HCPCS,0250,RC,81033-0102-05,NDC,,both,5,ML,7.90,5.13,,,,,,,,,,,,,
CANNULA INJ FOR TFNA SYS STRL TRAUMACEM V+,SUP-2382592,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1025.59,666.63,,,,,,,,,,,,,
PLATE BONE L199MM 10 H TI TIM LT FIBULAR LCK COMPR ANAT FOR,SUP-2413691,CDM,C1713,HCPCS,0278,RC,,,,both,,,3318.98,2157.34,,,,,,,,,,,,,
GRAFT BNE FIX LNG 2.5X6.5 MM PROX,SUP-2430101,CDM,C1713,HCPCS,0278,RC,,,,both,,,5730.50,3724.82,,,,,,,,,,,,,
CATHETER CARD ABLATION THERMOCOOL SMARTTOUCH 115CM 8FR D CRV,SUP-2248609,CDM,C1732,HCPCS,0272,RC,,,,both,,,9457.68,6147.49,,,,,,,,,,,,,
ADAPTER TIB TY L5MM OFFSET INTLOK FOR VANGUARD COMPLT SYS,SUP-2405430,CDM,C1776,CPT,0278,RC,,,,both,,,2637.60,1714.44,,,,,,,,,,,,,
MESH SURG L 30 X W 20 CM POLYPRO POLYLACTIC ACD GRP,SUP-2901751,CDM,C1781,HCPCS,0278,RC,,,,both,,,4258.97,2768.33,,,,,,,,,,,,,
RESERVOIR VENTRICULAR DRAINAGE WITH CATHETER 60CM CATHETER L,SUP-2826644,CDM,C1889,HCPCS,0278,RC,,,,both,,,929.03,603.87,,,,,,,,,,,,,
KIT TKR 3 FEM PREP CRUCE RET DISPOSABLE TRIATHLON PRECIS,SUP-2373669,CDM,2720000010,LOCAL,0272,RC,,,,both,,,648.10,421.26,,,,,,,,,,,,,
BIT DRILL DIAM SIZE: 2.7MM,SUP-2243131,CDM,2720000010,LOCAL,0272,RC,,,,both,,,894.90,581.68,,,,,,,,,,,,,
GUIDEWIRE VASC L 80 CM DIA 0.018 IN CRV RAD 3 MM SS PTFE,SUP-2167681,CDM,C1769,HCPCS,0272,RC,,,,both,,,161.65,105.07,,,,,,,,,,,,,
GUIDEWIRE SPNL FOR IO-FLEX DSTL HNDL,SUP-2115837,CDM,C1769,HCPCS,0272,RC,,,,both,,,295.16,191.85,,,,,,,,,,,,,
HC Strapping Hand/Finger,PX-4502928000,CDM,29280,CPT,0450,RC,,,,both,,,109.00,70.85,,,,,,,,,,,,,
POSACONAZOLE 40 MG/ML PO SUSP,RX-77371,CDM,340b,HCPCS,0637,RC,09999-9901-07,NDC,,both,2.5,ML,63.90,41.53,,,,,,,,,,,,,
MESH SURG CRANIOPLASTY XL PROS CUST,SUP-2419450,CDM,C1713,HCPCS,0278,RC,,,,both,,,53339.18,34670.47,,,,,,,,,,,,,
COMPONENT CRANIOFACIAL CUSTOMIZED XL COMPLX + PEEK NS LTX,SUP-2862813,CDM,C1713,HCPCS,0278,RC,,,,both,,,62645.64,40719.67,,,,,,,,,,,,,
GUIDEWIRE VASC ARW L 80 CM DIA 0.018 IN NIT HYDRPHLC PERIPH,SUP-2610465,CDM,C1769,HCPCS,0272,RC,,,,both,,,124.97,81.23,,,,,,,,,,,,,
ALLOGRAFT BNE ULN SHFT 51-100 MM FRZN,SUP-2717872,CDM,C1762,CPT,0278,RC,,,,both,,,2984.04,1939.63,,,,,,,,,,,,,
SCREW BNE EMGCY 2X17 MM CNTRDRV,SUP-2262657,CDM,C1713,HCPCS,0278,RC,,,,both,,,98.75,64.19,,,,,,,,,,,,,
MESH BONE 190X140MM MAXILLOFACIAL PRE-FORMED,SUP-2365220,CDM,C1781,HCPCS,0278,RC,,,,both,,,56019.33,36412.56,,,,,,,,,,,,,
GRAFT BNE PTTY 2.5 CC SYR DBM ACCELL EVO3C,SUP-2641763,CDM,C1713,HCPCS,0278,RC,,,,both,,,2034.72,1322.57,,,,,,,,,,,,,
ORTHO ANCHRGE C TUBE PLATE STRGHT 2 HOLE 6MM BRDGE T06MM CP,SUP-2676763,CDM,C1713,HCPCS,0278,RC,,,,both,,,337.30,219.24,,,,,,,,,,,,,
BUSHING ORTH L BEAR KT,SUP-2372317,CDM,C1776,CPT,0278,RC,,,,both,,,2875.61,1869.15,,,,,,,,,,,,,
HC Xray Exam of Peritoneum,PX-3207419000,CDM,74190,CPT,0320,RC,,,,both,,,908.00,590.20,,,,,,,,,,,,,
PROBE ENDOSCP 5 MMX45 CM SUCTION IRRIGATION SURGFLX,SUP-2313817,CDM,C1713,HCPCS,0278,RC,,,,both,,,659.40,428.61,,,,,,,,,,,,,
CONDUIT CV 22 MM STD BIOPROS POROSITY VLV MODEL 150 HANCOCK,SUP-2429955,CDM,C1713,HCPCS,0278,RC,,,,both,,,20410.00,13266.50,,,,,,,,,,,,,
TITANIUM MESH TRAY HEMI MANDIBLE LEFT CP TITANIUM,SUP-2489193,CDM,C1713,HCPCS,0278,RC,,,,both,,,10268.40,6674.46,,,,,,,,,,,,,
GRAFT VASC DISTAFLO L 60 CM DIA 7 MM EPTFE CARBON PERIPH,SUP-2128077,CDM,C1768,CPT,0278,RC,,,,both,,,12840.09,8346.06,,,,,,,,,,,,,
SCREW BNE ST 3.5X50 MM CRTX,SUP-2348817,CDM,C1713,HCPCS,0278,RC,,,,both,,,633.02,411.46,,,,,,,,,,,,,
SET INTRO MICROPUNCTURE CATH 10 CM 4 FR 7 CM NIT PLAT STIFF,SUP-2170555,CDM,C1894,HCPCS,0272,RC,,,,both,,,118.06,76.74,,,,,,,,,,,,,
LEAD PACE 0.5 MM SPC 40 CM BLK,SUP-2637198,CDM,C1778,HCPCS,0278,RC,,,,both,,,10688.06,6947.24,,,,,,,,,,,,,
HC So1 Tissue Level IV,PX-3128830567,CDM,88305,CPT,0312,RC,,,,both,,,103.00,66.95,,,,,,,,,,,,,
CATHETER INTVASC ULTRASOUND ATLNTS PV L 95 CM DIA 8 FR SHTH,SUP-2140560,CDM,C1753,HCPCS,0278,RC,,,,both,,,1735.57,1128.12,,,,,,,,,,,,,
KIT DIL 8/12/16/20/24FR NDL 18GA GWIRE L180CM DIA0.035IN,SUP-2352728,CDM,2720000010,LOCAL,0272,RC,,,,both,,,568.34,369.42,,,,,,,,,,,,,
VORICONAZOLE 200 MG PO TABS,RX-33009,CDM,6370000000,HCPCS,0637,RC,63739-0008-33,NDC,,both,1,UN,88.90,57.78,,,,,,,,,,,,,
BUR SURG COARSE DIAMOND 7 MM RND TPS MIDAS REX UPWR,SUP-2363383,CDM,2720000010,LOCAL,0272,RC,,,,both,,,197.82,128.58,,,,,,,,,,,,,
CANNULA SURG GRFT 100 MM GPS,SUP-2736523,CDM,2720000010,LOCAL,0272,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
RING EXT FIX SLIDING,SUP-2362804,CDM,2720000010,LOCAL,0272,RC,,,,both,,,774.80,503.62,,,,,,,,,,,,,
HC Mra Abdomen W/O Contrast,PX-6187418501,CDM,C8901,CPT,0618,RC,,,,both,,,4365.00,2837.25,,,,,,,,,,,,,
CROWN FORM DENT STRP U1 PRIMARY ANTR UPPER RT CNTRL PLAS,SUP-2322241,CDM,D6783,CPT,0278,RC,,,,both,,,40.57,26.37,,,,,,,,,,,,,
TUBE VENT 1.02 MM 1 MM 2.44/2.16 MM PAPARELLA SIL 510056,SUP-2535092,CDM,L8699,HCPCS,0278,RC,,,,both,,,32.03,20.82,,,,,,,,,,,,,
SPHERE ORBIT DIA16MM PMMA FOR RET EYE SOCK CNTOUR,SUP-2236375,CDM,L8610,HCPCS,0278,RC,,,,both,,,200.96,130.62,,,,,,,,,,,,,
SCREW BNE L20MM DIA4.75MM CORT FIX ANG NONCANNULATED,SUP-2407395,CDM,C1713,HCPCS,0278,RC,,,,both,,,402.08,261.35,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 10X6 CM SHT AMNION/CHORION AMNIOFIX,SUP-2871496,CDM,C1762,CPT,0278,RC,,,,both,,,14569.60,9470.24,,,,,,,,,,,,,
GRAFT BONE SUB 14MM CANC BLK OSTEOSPONGE,SUP-2125418,CDM,C1776,CPT,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
CATHETER ABLATN B CRV 4 MM 7 FR SFT TIP THRMCPL NAVISTAR,SUP-2248470,CDM,C1732,HCPCS,0272,RC,,,,both,,,5802.72,3771.77,,,,,,,,,,,,,
BUR SURG 6 MM 500 MM,SUP-2599992,CDM,2720000010,LOCAL,0272,RC,,,,both,,,598.01,388.71,,,,,,,,,,,,,
WIRE SMTH 1.8X400MM,SUP-2477089,CDM,C1769,HCPCS,0272,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
FIBER LASER 164 FT KRA-CPAOCHXL HDMI,SUP-2798084,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1524.22,990.74,,,,,,,,,,,,,
DILATOR SET CURET TY NS IO-FLEX LTX DISP,SUP-2855687,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4239.00,2755.35,,,,,,,,,,,,,
PLATE BONE THK1.5MM 12 H CRANIOMAXILLOFACIAL ORAL SLV TI STR,SUP-2181770,CDM,C1713,HCPCS,0278,RC,,,,both,,,3044.23,1978.75,,,,,,,,,,,,,
INVISION  TIBIAL TRAY SZ 2 4MM UNIVERSAL LNG,SUP-2477326,CDM,C1776,CPT,0278,RC,,,,both,,,18199.44,11829.64,,,,,,,,,,,,,
GRAFT BNE SUB 60CC 4 10MM PARTIC CANC FRZ DRY,SUP-2264680,CDM,C1713,HCPCS,0278,RC,,,,both,,,2072.34,1347.02,,,,,,,,,,,,,
IMPLANT SYNTH L 50 X W 25 MM THK 6 MM POLYETHYL CRANIOFACIAL,SUP-2883603,CDM,C1713,HCPCS,0278,RC,,,,both,,,2948.33,1916.41,,,,,,,,,,,,,
GRAFT BNE SUB 0.5CC DEMIN MTRX PTTY FRZ DRY JR DBX,SUP-2306993,CDM,C9359,HCPCS,0278,RC,,,,both,,,307.09,199.61,,,,,,,,,,,,,
PLATE BONE 4 H S STL T SHP BTTRS ECT,SUP-2198568,CDM,C1713,HCPCS,0278,RC,,,,both,,,600.56,390.36,,,,,,,,,,,,,
VASCULAR PROS STD WALL STAGGERED CONICA INSIDE DIAM 4MM 7MM,SUP-2395723,CDM,C1768,CPT,0278,RC,,,,both,,,2728.66,1773.63,,,,,,,,,,,,,
PLATE BONE L178MM 5X22X5 H BILAT MAND ORAL MAXILLOFACIAL TI,SUP-2191432,CDM,C1713,HCPCS,0278,RC,,,,both,,,10126.19,6582.02,,,,,,,,,,,,,
STEM FEM SZ 4 L183MM L32MM 131DEG LNG STD PROTASUL-100 HIP,SUP-2205690,CDM,C1776,CPT,0278,RC,,,,both,,,14531.92,9445.75,,,,,,,,,,,,,
EXPANDER BRST W14.6XH12.6CM P7.6CM 650CC SIL NACL SHELL RND,SUP-2300635,CDM,C1789,HCPCS,0278,RC,,,,both,,,4207.60,2734.94,,,,,,,,,,,,,
PLATE BNE LCK 2.7/3.5X237 MM RT DSTL MEDL 18 HOLE FIX ANGLE,SUP-2525036,CDM,C1713,HCPCS,0278,RC,,,,both,,,4615.86,3000.31,,,,,,,,,,,,,
WALKER BOOT HI PRESSURE MED ANK AIR TRIO,SUP-2227874,CDM,L4386,HCPCS,0274,RC,,,,both,,,187.93,122.15,,,,,,,,,,,,,
PLATE BNE LT 12 HOLE SS NS,SUP-2177459,CDM,C1713,HCPCS,0278,RC,,,,both,,,4945.53,3214.59,,,,,,,,,,,,,
SCREW BNE L 55 MM DIA 4.5 MM THRD L 22 MM TI ST SD PARTIALLY,SUP-2905555,CDM,C1713,HCPCS,0278,RC,,,,both,,,1801.45,1170.94,,,,,,,,,,,,,
SCREW BONE POLYAX PEDCL OPN TI EXT TAB ROD 5.5MM 4.5MMX25MM,SUP-2109190,CDM,C1713,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
PLATE BNE L 342 MM SCREW DIA 4.5 MM 17 H DSTL FEM STRL EVOS,SUP-2931144,CDM,C1713,HCPCS,0278,RC,,,,both,,,12771.17,8301.26,,,,,,,,,,,,,
SHAFT FIB TRAD ALLGRFT 60 MM FRZN,SUP-2294142,CDM,C1713,HCPCS,0278,RC,,,,both,,,1538.60,1000.09,,,,,,,,,,,,,
SYSTEM EXT DRNGE AND MON INTLNK W LCATH DUET,SUP-2278393,CDM,C1729,HCPCS,0272,RC,,,,both,,,1507.20,979.68,,,,,,,,,,,,,
SPLINT WRST SM R THMB SPICA COT POLY FAB LTHR WRKHRD ORIG,SUP-2326135,CDM,L3908,HCPCS,0274,RC,,,,both,,,72.06,46.84,,,,,,,,,,,,,
IPILIMUMAB 50 MG/10ML IV SOLN,RX-104773,CDM,J9228,HCPCS,0636,RC,00003-2327-11,NDC,,both,10,ML,26077.70,16950.50,,,,,,,,,,,,,
PIN FIX 26030000] SPINAL ELEMENTS INC],SUP-2353288,CDM,C1713,HCPCS,0278,RC,,,,both,,,219.80,142.87,,,,,,,,,,,,,
CONQUEST FN 2.8MMX300MM DRILL TIP GP,SUP-2820938,CDM,C1713,HCPCS,0278,RC,,,,both,,,441.64,287.07,,,,,,,,,,,,,
PLATE STR 1.5MM 6H TI STRL VAL,SUP-2546888,CDM,C1713,HCPCS,0278,RC,,,,both,,,1384.11,899.67,,,,,,,,,,,,,
"HC Debrid,Bone,1st 20sqcm or Less",PX-3611104400,CDM,11044,CPT,0361,RC,,,,both,,,4946.00,3214.90,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY L 115 CM DIA 7 FR SPC 3 MM D CRV,SUP-2248945,CDM,C1730,HCPCS,0272,RC,,,,both,,,2276.50,1479.72,,,,,,,,,,,,,
GRAFT BIO TISS W11.8XL17.7IN RECT ANTI BACT SURG PORCINE,SUP-2126235,CDM,C1781,HCPCS,0278,RC,,,,both,,,140836.54,91543.75,,,,,,,,,,,,,
POST ORTHOPEDIC 3 HOLE W/ 12MM BOLT TRUELOK,SUP-2316110,CDM,2720000010,LOCAL,0272,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
VALVE MITRL CARP EDW PERIMT MAGNA MITRL EASE DIA 31.5 MM SEW,SUP-2214314,CDM,C1889,HCPCS,0278,RC,,,,both,,,20253.00,13164.45,,,,,,,,,,,,,
VALVE VENT DRNGE IN LN W/ ANTI SIPHON DEV CERTAS +,SUP-2249016,CDM,C1729,HCPCS,0272,RC,,,,both,,,13375.90,8694.33,,,,,,,,,,,,,
UNIT NAVIGATION CLR SIMP QUIK INTFACE FOR DST FEM TIB INSTR,SUP-2314149,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
ROD IM LNG 4.5X200 MM FEM CANN OXFORD,SUP-2445146,CDM,C1713,HCPCS,0278,RC,,,,both,,,155.43,101.03,,,,,,,,,,,,,
GUIDEWIRE VASC L 260 CM 0.025IN L 7CM 2.5CM SAFE-T-J HVY DTY,SUP-2638696,CDM,C1769,HCPCS,0272,RC,,,,both,,,55.64,36.17,,,,,,,,,,,,,
SPACER SPNL ZERO-P IMPL 10MM CONVEX STERILE,SUP-2182393,CDM,C1821,HCPCS,0278,RC,,,,both,,,5416.50,3520.72,,,,,,,,,,,,,
CEMENT DENT 1LB LT YEL ZN PWD,SUP-2238331,CDM,C1713,HCPCS,0278,RC,,,,both,,,114.83,74.64,,,,,,,,,,,,,
PATCH CV HEMSHLD PLAT FINESSE L 152 X W 8 MM THK 0.36 MM,SUP-2461651,CDM,C1768,CPT,0278,RC,,,,both,,,451.59,293.53,,,,,,,,,,,,,
IRON SUCROSE 20 MG/ML IV SOLN,RX-29132,CDM,J1756,HCPCS,0636,RC,00517-2340-10,NDC,,both,2.5,ML,95.90,62.33,,,,,,,,,,,,,
SCREW BONE L20MM DIA2.5MM LCK ST T7 PERI-LOC,SUP-2350054,CDM,C1713,HCPCS,0278,RC,,,,both,,,807.14,524.64,,,,,,,,,,,,,
PLATE BONE BUR H CVR FAN BLDE STD TI 11MM TIMESH CRAN,SUP-2277538,CDM,C1713,HCPCS,0278,RC,,,,both,,,651.11,423.22,,,,,,,,,,,,,
DRESSING WND MTRX 7X20 CM MESHED STR STRL OASIS,SUP-2341253,CDM,Q4102,HCPCS,0636,RC,,,,both,,,21901.50,14235.97,,,,,,,,,,,,,
FIDUCIAL MARKER KIT SFT TISS SEED GLD,SUP-2267150,CDM,A4648,CPT,0278,RC,,,,both,,,668.82,434.73,,,,,,,,,,,,,
SYSTEM PNS 2 LD NS DISP SPRNT EXTENSA XT,SUP-2910591,CDM,C1778,HCPCS,0278,RC,,,,both,,,47100.00,30615.00,,,,,,,,,,,,,
PLATE BNE 6 H TI STR FOR 2MM SCR MOD HND SYS,SUP-2191190,CDM,C1713,HCPCS,0278,RC,,,,both,,,1334.94,867.71,,,,,,,,,,,,,
SCREW BNE CANN 8X90 MM 25 MM,SUP-2364321,CDM,C1713,HCPCS,0278,RC,,,,both,,,338.71,220.16,,,,,,,,,,,,,
GRAFT HUM TISS M W11XL20CM THK07 14MM THN ACELLULAR,SUP-2307611,CDM,Q4128,HCPCS,0636,RC,,,,both,,,13442.97,8737.93,,,,,,,,,,,,,
TROCAR LAP OD7X8MM BLDELSS CANN DIL RADIALLY EXP SL REDUC,SUP-2283299,CDM,2720000010,LOCAL,0272,RC,,,,both,,,390.90,254.08,,,,,,,,,,,,,
RAIL EXT FIX TRANSITION 5.5X495 MM CONTOURED 4D MESA,SUP-2517557,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7395.45,4807.04,,,,,,,,,,,,,
IMPLANT COSMETIC SZ 90 X 73 X 19 MM MED POLYETHYL RT,SUP-2934483,CDM,C1713,HCPCS,0278,RC,,,,both,,,6408.74,4165.68,,,,,,,,,,,,,
COLLAR CERV CAPITAL ENH,SUP-2336002,CDM,L0120,HCPCS,0274,RC,,,,both,,,84.62,55.00,,,,,,,,,,,,,
TROCAR ENDOSCP L150MM DIA5MM BLDELSS STBL SL CAM PRT W/,SUP-2218269,CDM,2720000010,LOCAL,0272,RC,,,,both,,,734.16,477.20,,,,,,,,,,,,,
BRACE ORTH 2X UPR ELBW CUF EO,SUP-2388190,CDM,L3720,HCPCS,0272,RC,,,,both,,,1683.35,1094.18,,,,,,,,,,,,,
NUT EXT FIX MRI SAFE FOR DISTR OSTEOGENESIS RNG SYS 10 PER,SUP-2179140,CDM,C1713,HCPCS,0278,RC,,,,both,,,127.30,82.74,,,,,,,,,,,,,
PLATE BNE STD SM MEDL LT CLMN FUSION SS STRL SOLE MCF LTX,SUP-2875505,CDM,C1713,HCPCS,0278,RC,,,,both,,,12799.27,8319.53,,,,,,,,,,,,,
SCREW BNE LCK 4X55 MM 6 MM CORTICAL TI STRL,SUP-2243005,CDM,C1713,HCPCS,0278,RC,,,,both,,,671.96,436.77,,,,,,,,,,,,,
LEAD NERVE STIM 70 CM 16 CONTACT KT ARTISAN,SUP-2138833,CDM,C1778,HCPCS,0278,RC,,,,both,,,11671.38,7586.40,,,,,,,,,,,,,
UNIT IPAS III BVL SPRINGLESS STRL,SUP-2310411,CDM,C1713,HCPCS,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
HC Ot Aquatic Therapeutic Exer 15 Mn,PX-4309711300,CDM,97113,CPT,0430,RC,,,,inpatient,,,150.00,97.50,,,,,,,,,,,,,
MESH HERN RECT 8X4 IN FULL RESRB FOR SFT TISS PHASIX ST,SUP-2855260,CDM,C1781,HCPCS,0278,RC,,,,both,,,10996.28,7147.58,,,,,,,,,,,,,
INTRODUCER DIAG PEEL-APART DIA 8.5 FR SLITTER L 16 CM DIA 7,SUP-2126573,CDM,C1894,HCPCS,0272,RC,,,,both,,,266.90,173.48,,,,,,,,,,,,,
HEAD FEM LFIT 0+ 40 MM HIP COCR V40,SUP-2364575,CDM,C1776,CPT,0278,RC,,,,both,,,3686.99,2396.54,,,,,,,,,,,,,
GUIDEWIRE BALL TIP L1000MM DIA2.5MM DISP,SUP-2152524,CDM,C1769,HCPCS,0272,RC,,,,both,,,162.02,105.31,,,,,,,,,,,,,
EVOS 3.5MM SUP MS CLAV PL 10H RIGHT 108MM,SUP-2819913,CDM,C1713,HCPCS,0278,RC,,,,both,,,4797.14,3118.14,,,,,,,,,,,,,
PLATE BNE L104MM 4 H BILAT S STL CLVRLF FOR 35MM SCR,SUP-2411335,CDM,C1713,HCPCS,0278,RC,,,,both,,,786.57,511.27,,,,,,,,,,,,,
MESH SURG W8XL8CM FLAT SHT BIO-A,SUP-2395750,CDM,C1781,HCPCS,0278,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
BUTORPHANOL TARTRATE 10 MG/ML NA SOLN,RX-9335,CDM,J0595,HCPCS,0637,RC,00054-3090-36,NDC,,both,2.5,ML,253.80,164.97,,,,,,,,,,,,,
SHEATH ENDO OD27.6FR WHT CONT FLO INNR RND TIP RESECTOSCOPIC,SUP-2313069,CDM,C1894,HCPCS,0272,RC,,,,both,,,4191.49,2724.47,,,,,,,,,,,,,
PIN FXTN 2.1MM DIA 5MML FLAT HEAD RSRBBLE US ACTVTN SNCWLD,SUP-2497375,CDM,C1713,HCPCS,0278,RC,,,,both,,,269.38,175.10,,,,,,,,,,,,,
PLATE BONE BOX 10X16 MM 4 HOLE TITANIUM NON STERILE LOW PROF,SUP-2838364,CDM,C1713,HCPCS,0278,RC,,,,both,,,870.41,565.77,,,,,,,,,,,,,
CATHETER CV SINGLE LUMEN 19 FRX30 CM PROC KT PWR INJ ARGY,SUP-2173948,CDM,C1751,HCPCS,0278,RC,,,,both,,,118.28,76.88,,,,,,,,,,,,,
BIT DRILL SHANK LONG 3.5 MM WITH QUICK CONNECT PERILOC,SUP-2837023,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1787.88,1162.12,,,,,,,,,,,,,
LINER KT WLK BOOT VENTURE AIR TALL M,SUP-2151042,CDM,L4386,HCPCS,0272,RC,,,,both,,,67.51,43.88,,,,,,,,,,,,,
DEVICE REPROC VES SEAL JAW SEAL 23 CM JAW LIGASURE LF,SUP-2763774,CDM,2720000010,LOCAL,0272,RC,,,,both,,,838.63,545.11,,,,,,,,,,,,,
PASSER SUTURE 155MM DIAMETER 3.5MM RIGHT RC SEAHAWK,SUP-2824492,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3753.74,2439.93,,,,,,,,,,,,,
PLATE CNDYL 6H SHFT W/GUIDES STRL TI LCP,SUP-2546745,CDM,C1713,HCPCS,0278,RC,,,,both,,,1818.88,1182.27,,,,,,,,,,,,,
MESH HERN W6XL137CM L G POLYPR SYN INGUINAL ABD FLAT,SUP-2126060,CDM,C1781,HCPCS,0278,RC,,,,both,,,239.90,155.93,,,,,,,,,,,,,
PLATE BONE L55MM THK1.4MM SHFT W6MM HD 12.3MM 2X8 H STRL T,SUP-2349669,CDM,C1713,HCPCS,0278,RC,,,,both,,,4111.83,2672.69,,,,,,,,,,,,,
PLATE BNE L37MM THK3.3MM 3 H BILAT S STL RIG STR DYN COMPR,SUP-2186327,CDM,C1713,HCPCS,0278,RC,,,,both,,,508.52,330.54,,,,,,,,,,,,,
SCREW BNE L14MM DIA3.5MM CORT S STL ST OSTEOPENIA FOR VAR,SUP-2348561,CDM,C1713,HCPCS,0278,RC,,,,both,,,192.36,125.03,,,,,,,,,,,,,
SPACER SPNL CERV 14X11X7 MM GRAFTECH,SUP-2279905,CDM,C1889,HCPCS,0278,RC,,,,both,,,2499.44,1624.64,,,,,,,,,,,,,
ELIMINATOR H APEX FOR 48-60MM PINN HIP SHELL,SUP-2250733,CDM,C1776,CPT,0278,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
CATHETER THOR 36FR L20IN DIA12MM CLR PVC THERMOSENSITIVE,SUP-2154970,CDM,C1729,HCPCS,0272,RC,,,,both,,,34.63,22.51,,,,,,,,,,,,,
HC Stab Phlebectomy 10-20,PX-3613776500,CDM,37765,CPT,0361,RC,,,,both,,,15457.00,10047.05,,,,,,,,,,,,,
MESH HERN OPTIMIZED COMP 20 CM RND SKIRTED PARIETEX,SUP-2752188,CDM,C1781,HCPCS,0278,RC,,,,both,,,4548.23,2956.35,,,,,,,,,,,,,
PIN HLD FOR 2.4/2.7MM VAR ANG LOK CALCNL PLATING SYS LCP,SUP-2179058,CDM,C1713,HCPCS,0278,RC,,,,both,,,936.76,608.89,,,,,,,,,,,,,
SURESPACE TIB SPACER MOLD SML,SUP-2540679,CDM,C1776,CPT,0278,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
PORT INFUS 8FR L45CM POLYUR ATTCH CATHETER PLAS STD PROF SGL,SUP-2126325,CDM,C1788,HCPCS,0278,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
AGBA PICC/DELTA FG: 2-L 5.5 FRX40 CM,SUP-2822088,CDM,C1751,HCPCS,0278,RC,,,,both,,,1015.26,659.92,,,,,,,,,,,,,
BIT DRL QC 2.8X135 MM 45 MM CALIB NS,SUP-2563756,CDM,2720000010,LOCAL,0272,RC,,,,both,,,349.17,226.96,,,,,,,,,,,,,
COIL EMB L26CM OD6MM 10 STRTCH RESIST FRAMING FIL FNSH,SUP-2305178,CDM,C1889,HCPCS,0278,RC,,,,both,,,5024.00,3265.60,,,,,,,,,,,,,
SET SCR SPNL FAST ANTR THORLUM TI FOR CVR PLT EPIC,SUP-2136836,CDM,C1713,HCPCS,0278,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
PIN FIX TRCR PT 1 END 0.125X9 IN RND END SS NS STEINMANN,SUP-2791376,CDM,C1713,HCPCS,0278,RC,,,,both,,,17.52,11.39,,,,,,,,,,,,,
IMMOBILIZER KNEE CUTAWAY W PAT STRP 20IN,SUP-2195122,CDM,L1830,CPT,0274,RC,,,,both,,,58.69,38.15,,,,,,,,,,,,,
PLATE OLECRANON 3.5MM 2H LT 86MM SS LCP STRL,SUP-2547481,CDM,C1713,HCPCS,0278,RC,,,,both,,,3168.61,2059.60,,,,,,,,,,,,,
HC CT Lower Ext W&W/O Cont,PX-3527370200,CDM,73702,CPT,0352,RC,,,,both,,,2769.00,1799.85,,,,,,,,,,,,,
AUGMENT TIB SM KNEE CRUCE RET REV VANGUARD 360,SUP-2408089,CDM,C1776,CPT,0278,RC,,,,both,,,1670.48,1085.81,,,,,,,,,,,,,
PLATE BONE W60XL60MM THK0.6MM TI DYN MESH FOR COMP CRAN CLSR,SUP-2243968,CDM,C1713,HCPCS,0278,RC,,,,both,,,1356.10,881.46,,,,,,,,,,,,,
TRAY VITRECTOMY DIA23 GA10000 CPM STR ENDOILLUMINATOR BVL,SUP-2914996,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2609.43,1696.13,,,,,,,,,,,,,
SCREW BONE LOCKING 3MM DIA SURFIX STERILE ALPHA,SUP-2586518,CDM,C1713,HCPCS,0278,RC,,,,both,,,460.48,299.31,,,,,,,,,,,,,
PLATE BNE L56MM THK2MM 9 H NAR R DST RAD VOLAR ANAT TI FOR,SUP-2372941,CDM,C1713,HCPCS,0278,RC,,,,both,,,4160.50,2704.32,,,,,,,,,,,,,
INTRODUCER DIAG SWARTZ L 63 CM DIA 8.5 FR DIL L 67 CM DIA,SUP-2877987,CDM,C1893,HCPCS,0272,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
DRIVER 3030002 HLD PIN DRVR,SUP-2278051,CDM,C1713,HCPCS,0278,RC,,,,both,,,1177.56,765.41,,,,,,,,,,,,,
PLATE BONE ULTRA LOW PRFLE LNG HLX2 03MM THK TTNM STRGHT W/,SUP-2676569,CDM,C1713,HCPCS,0278,RC,,,,both,,,321.03,208.67,,,,,,,,,,,,,
KIT CATH HEMODIALYSI HEMOSTAR XK CHRONIC STD 16FR DI 5885230,SUP-2632971,CDM,C1750,HCPCS,0278,RC,,,,both,,,1470.46,955.80,,,,,,,,,,,,,
PLATE BNE L72MM 5 H S STL LOK COMPR FOR 3.5MM SCR LCP,SUP-2185130,CDM,C1713,HCPCS,0278,RC,,,,both,,,788.83,512.74,,,,,,,,,,,,,
PLATE BNE L19MM THK075MM 8 H NONSTERILE R HND TI STRUT OBLQ,SUP-2180992,CDM,C1713,HCPCS,0278,RC,,,,both,,,1204.16,782.70,,,,,,,,,,,,,
PLATE BNE L 85 X W 11 MM THK 3 MM SCREW DIA2.7/3.5 MM 6 H SS 72466206,SUP-2933340,CDM,C1713,HCPCS,0278,RC,,,,both,,,4584.71,2980.06,,,,,,,,,,,,,
BIT DRL CANN 3.2X150 MM W/ WIRE STRL,SUP-2645998,CDM,2720000010,LOCAL,0272,RC,,,,both,,,491.79,319.66,,,,,,,,,,,,,
WIRE FIX L150MM DIA1.1MM S STL DBL TRCR K,SUP-2397837,CDM,C1713,HCPCS,0278,RC,,,,both,,,75.36,48.98,,,,,,,,,,,,,
PLATE BONE ANGLED 2.5 MM RIGHT 7X23 HOLE RECONSTRUCTION PREC,SUP-2837760,CDM,C1713,HCPCS,0278,RC,,,,both,,,7829.28,5089.03,,,,,,,,,,,,,
CANNULA SURG RT MIDDLE/POSTERIOR ZONENAVIGATOR SYS,SUP-2417074,CDM,2720000010,LOCAL,0272,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
GRAFT HUM TISS W2XL3CM PLCNTA MEM CRYOPRESERVED CHORION,SUP-2319166,CDM,Q4132,HCPCS,0636,RC,,,,both,,,3124.30,2030.79,,,,,,,,,,,,,
MAGNESIUM GLUCONATE 500 (27 MG) MG PO TABS,RX-123645,CDM,6370000000,HCPCS,0637,RC,60258-0172-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
APPLIER ANEURYSM CLIP L3.5IN STANDARD FINGER TIP GRIP BAYONE,SUP-2821562,CDM,C1889,HCPCS,0278,RC,,,,both,,,5364.22,3486.74,,,,,,,,,,,,,
AFFINITY CP CENTRIFUGAL NC,SUP-2722906,CDM,2720000010,LOCAL,0272,RC,,,,both,,,449.18,291.97,,,,,,,,,,,,,
MESH POLYFORM 10CMX15CM,SUP-2141770,CDM,C1763,HCPCS,0278,RC,,,,both,,,1077.02,700.06,,,,,,,,,,,,,
BLADE ARTHSCP FULL RAD SHRP TIP ERGO HNDL HIP SPEC LEN SGL,SUP-2366732,CDM,2720000010,LOCAL,0272,RC,,,,both,,,593.46,385.75,,,,,,,,,,,,,
PLATE BNE W10.2XL234MM THK2.7MM 18 H BILAT S STL STR LO,SUP-2186204,CDM,C1713,HCPCS,0278,RC,,,,both,,,2014.25,1309.26,,,,,,,,,,,,,
INTRODUCER PACE LD SCOUTPRO L 45 CM DIA 7 FR MULTPURP HK W/O,SUP-2138044,CDM,C1894,HCPCS,0272,RC,,,,both,,,668.82,434.73,,,,,,,,,,,,,
BIT DRL L130MM DIA2.7MM FOR VLP VAR ANG LOCKED PLATING SYS,SUP-2344020,CDM,2720000010,LOCAL,0272,RC,,,,both,,,560.43,364.28,,,,,,,,,,,,,
GRAFT MTRX DERM HUM TISS ACELLULAR FRZ DRY THCK 6CMX12CM,SUP-2306915,CDM,C1762,CPT,0278,RC,,,,both,,,6667.13,4333.63,,,,,,,,,,,,,
PUSHER KNOT CRV,SUP-2341940,CDM,2720000010,LOCAL,0272,RC,,,,both,,,477.28,310.23,,,,,,,,,,,,,
PLATE BNE STD 1 H ST S STL QUADRILATERAL SURF RECON LO PROF,SUP-2177158,CDM,C1713,HCPCS,0278,RC,,,,both,,,1799.50,1169.67,,,,,,,,,,,,,
GRAFT DERMAL PLIABLE THN LG 22X13 CMX0.7-1.4 MM SHP FLEXHD,SUP-2307612,CDM,Q4128,HCPCS,0636,RC,,,,both,,,16707.00,10859.55,,,,,,,,,,,,,
TUBE VENT ID1MM FLNG NO H FLROPLAS REUT BOB,SUP-2313688,CDM,L8699,HCPCS,0278,RC,,,,both,,,27.82,18.08,,,,,,,,,,,,,
KIT CATHETER REV SEG W ATTCH SUTURELESS PMP CONN 2 CLLT RUL,SUP-2280046,CDM,C1755,HCPCS,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
PLATE BNE L26MM L DORS DST RAD CONG,SUP-2107766,CDM,C1713,HCPCS,0278,RC,,,,both,,,1450.68,942.94,,,,,,,,,,,,,
BUPIVACAINE HCL 0.5 % IJ SOLN,RX-1223,CDM,J0665,HCPCS,0636,RC,00409-1163-01,NDC,,both,30,ML,54.10,35.16,,,,,,,,,,,,,
HC Gbl Office/OP Consltj New/Est Pt Mod Mdm 40 Minutes|RESIDENT/TEACHING PHYS SERV,PX-9829924401,CDM,99244,CPT,0982,RC,,,GC,outpatient,,,837.00,544.05,,,,,,,,,,,,,
CATHETER GUID WINGMAN 14 L 65 CM OD 0.035 IN TIP DIA 0.022,SUP-2227762,CDM,C1887,HCPCS,0272,RC,,,,both,,,2028.44,1318.49,,,,,,,,,,,,,
ALLOGRAFT BNE ACETABULUM,SUP-2321752,CDM,C1713,HCPCS,0278,RC,,,,both,,,5008.30,3255.39,,,,,,,,,,,,,
JOINT SACROILIAC 10.75X45 MM IFUSE,SUP-2663550,CDM,C1889,HCPCS,0278,RC,,,,both,,,9420.00,6123.00,,,,,,,,,,,,,
CARTRIDGE KYPHOPLASTY SZ 3 FULL DOSE BNE CEM RADPQ GUN AND,SUP-2293467,CDM,C1713,HCPCS,0278,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
PLATE BNE CRV 6X1 MM 6 HOLE SAG SPLIT NS MATRIXORTHOGNATHIC,SUP-2431412,CDM,C1713,HCPCS,0278,RC,,,,both,,,1455.08,945.80,,,,,,,,,,,,,
PLATE BNE 3.5X262 MM 20 HOLE SS LC-DCP,SUP-2569239,CDM,C1713,HCPCS,0278,RC,,,,both,,,454.20,295.23,,,,,,,,,,,,,
SET INTRO SUP ARW FLX SHTH L 45 CM DIA 5 FR HYDRPHLC,SUP-2383399,CDM,C1894,HCPCS,0272,RC,,,,both,,,313.50,203.77,,,,,,,,,,,,,
SCREW 3.5MM TI CONICAL SLF-TPNG FULLY THREADED 80MM,SUP-2549324,CDM,C1713,HCPCS,0278,RC,,,,both,,,408.45,265.49,,,,,,,,,,,,,
STENT BILI COTTON-HUIBREGTSE L 10 CM DIA 8.5 FR GUIDEWIRE,SUP-2169305,CDM,C2617,HCPCS,0278,RC,,,,both,,,204.10,132.66,,,,,,,,,,,,,
KIT SUTURE OPN SFT TISS REP CONVENIENCE CONTAIN HS FIBER,SUP-2906323,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1865.16,1212.35,,,,,,,,,,,,,
COLLAR CERV ADJ LP THERMOPLASTIC OSSUR MIAMI J,SUP-2388136,CDM,L0180,HCPCS,0272,RC,,,,both,,,939.80,610.87,,,,,,,,,,,,,
MESH BIOLOGIC OVINE RUMEN PERM OVITEX 20X20 CM,SUP-2383091,CDM,C1781,HCPCS,0278,RC,,,,both,,,12560.00,8164.00,,,,,,,,,,,,,
GUIDEWIRE BALL TIP ST PACKAGED INSTR 2.5MMX800MM CENTRONAIL,SUP-2316306,CDM,C1769,HCPCS,0272,RC,,,,both,,,416.36,270.63,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH ALPHA L 152 MM DIA 46 MM NIT POLYPRO,SUP-2750375,CDM,C1768,CPT,0278,RC,,,,both,,,53955.97,35071.38,,,,,,,,,,,,,
SET DRNGE FUHRMAN PLEUR STRL,SUP-2167973,CDM,C1729,HCPCS,0272,RC,,,,both,,,472.88,307.37,,,,,,,,,,,,,
LORATADINE 10 MG PO TABS,RX-10466,CDM,6370000000,HCPCS,0637,RC,68084-0248-01,NDC,,both,1,UN,2.50,1.62,,,,,,,,,,,,,
SCREW BNE CANN 5X40 MM CONCL TI NS,SUP-2190594,CDM,C1713,HCPCS,0278,RC,,,,both,,,513.55,333.81,,,,,,,,,,,,,
CANNULA ART AD 7 FR BIOLINE COATED HLS,SUP-2663451,CDM,2720000010,LOCAL,0272,RC,,,,both,,,41448.00,26941.20,,,,,,,,,,,,,
PLATE BNE L2505MM THK25MM 16 H PELV S STL STR,SUP-2362704,CDM,C1713,HCPCS,0278,RC,,,,both,,,2894.77,1881.60,,,,,,,,,,,,,
HC Pt Orthotic Fit/Train per 15 Min,PX-4209776000,CDM,97760,CPT,0420,RC,,,,both,,,206.00,133.90,,,,,,,,,,,,,
PLATE BONE W13.5XL278MM THK4.2MM 15 H BILAT S STL NAR LCK,SUP-2185254,CDM,C1713,HCPCS,0278,RC,,,,both,,,2273.36,1477.68,,,,,,,,,,,,,
HC So2 Drg Scrn Class List A,PX-3018030768,CDM,80307,CPT,0301,RC,,,,both,,,452.00,293.80,,,,,,,,,,,,,
CAGE SPNL 8MM L PEEK VBR,SUP-2211946,CDM,C1889,HCPCS,0278,RC,,,,both,,,10774.60,7003.49,,,,,,,,,,,,,
STRUT EXT FIX L75-96MM X SH STD FOR ILIZ TAY SPAT FRME EXT,SUP-2342983,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7096.71,4612.86,,,,,,,,,,,,,
COMPONENT KNEE PT SPEC INSTRUMENT MOLD,SUP-2212605,CDM,C1713,HCPCS,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
SET CHST TUBE 24 FR SMGA 17CM LEN 40CM SIDEPORTS 4/4 INCL,SUP-2170314,CDM,C1729,HCPCS,0272,RC,,,,both,,,476.78,309.91,,,,,,,,,,,,,
STENT URET FLX 0.035 IN 7 FRX22 CM 6 FR TAPR POLARIS ULTRA,SUP-2473618,CDM,C2617,HCPCS,0278,RC,,,,both,,,633.43,411.73,,,,,,,,,,,,,
CATHETER DRAINAGE SET 5 FRX8 CM FURMAN CPPDJ500WOODIMH,SUP-2759775,CDM,C1729,HCPCS,0272,RC,,,,both,,,397.90,258.63,,,,,,,,,,,,,
GRAFT BIO 8X12CM BOV PERICARD DURA SUTURABLE RESRB,SUP-2243936,CDM,C1763,HCPCS,0278,RC,,,,both,,,2604.22,1692.74,,,,,,,,,,,,,
SPLINT ORTHOGNATHIC 2 JAW W/ GUIDANCE OPS VSP,SUP-2862843,CDM,2720000010,LOCAL,0272,RC,,,,both,,,13231.96,8600.77,,,,,,,,,,,,,
STEM FNGR JT SM PROX INTERPHALANGEAL BASE IMP,SUP-2319771,CDM,L8630,HCPCS,0278,RC,,,,both,,,5862.38,3810.55,,,,,,,,,,,,,
SHEATH INTRO MORPHEUS DIA 6 FR PEELWY SPLITTABLE DIL ASMBLY,SUP-2117376,CDM,C1892,HCPCS,0272,RC,,,,both,,,7.82,5.08,,,,,,,,,,,,,
HC Mech Rem/Obst GI Tube,PX-3614946000,CDM,49460,CPT,0361,RC,,,,outpatient,,,8583.00,5578.95,,,,,,,,,,,,,
REAMER SURG 22MM MT JT CUP GEN 2,SUP-2398417,CDM,2720000010,LOCAL,0272,RC,,,,both,,,690.80,449.02,,,,,,,,,,,,,
PLATE BONE FIXATOR 1MM DIA SM WWEDGE,SUP-2669820,CDM,C1713,HCPCS,0278,RC,,,,both,,,16971.89,11031.73,,,,,,,,,,,,,
DRAWER PLATE COMPR,SUP-2474207,CDM,C1713,HCPCS,0278,RC,,,,both,,,923.16,600.05,,,,,,,,,,,,,
KIT CATHETER PICC LN 2 LUMN,SUP-2384048,CDM,C1751,HCPCS,0278,RC,,,,both,,,177.16,115.15,,,,,,,,,,,,,
SULFUR HEXAFLUORIDE MICROSPH 60.7-25 MG IJ SUSR,RX-158430,CDM,Q9950,HCPCS,0636,RC,00270-7099-16,NDC,,both,1,UN,78.20,50.83,,,,,,,,,,,,,
LEAD DEFIB 65CM IS-1 DF-1 CONN DURATA,SUP-2356246,CDM,C1895,HCPCS,0275,RC,,,,both,,,10660.30,6929.19,,,,,,,,,,,,,
PLATE BONE L LCK CRV RT 7 H TI PROX TIB PLATING SYS ALPS,SUP-2413722,CDM,C1713,HCPCS,0278,RC,,,,both,,,4043.54,2628.30,,,,,,,,,,,,,
INSERT TIB 12MM SZ 1 CONG POST STABILIZING POLYETH PROVEN,SUP-2359101,CDM,C1776,CPT,0278,RC,,,,both,,,1152.38,749.05,,,,,,,,,,,,,
CASPOFUNGIN ACETATE 50 MG IV SOLR,RX-29567,CDM,J0637,HCPCS,0636,RC,25021-0194-10,NDC,,both,1,UN,396.80,257.92,,,,,,,,,,,,,
MESH SURG ELLIP 10X8 IN W/ FEN PORCINE COLLAMEND FM,SUP-2126254,CDM,C1781,HCPCS,0278,RC,,,,both,,,14943.20,9713.08,,,,,,,,,,,,,
GRAFT HUM TISS W5XL5CM THK04 07MM DERM HUM ACELLULAR,SUP-2307044,CDM,Q4128,HCPCS,0636,RC,,,,both,,,3608.49,2345.52,,,,,,,,,,,,,
WIRE EXT FIX L 400 MM DIA1.8 MM STOPPER STRL DISP ILIZ,SUP-2933833,CDM,C1713,HCPCS,0278,RC,,,,both,,,676.51,439.73,,,,,,,,,,,,,
HC So1 Hepatitis B Core Antibody,PX-3028670467,CDM,86704,CPT,0302,RC,,,,both,,,734.00,477.10,,,,,,,,,,,,,
SHEATH INTRO 0.038 IN 50 DEG 12 FRX67 CM LG CRV BIDIR DIREX,SUP-2424659,CDM,C1766,CPT,0272,RC,,,,both,,,2747.50,1785.87,,,,,,,,,,,,,
GUIDEWIRE VASC L 150 CM DIA 0.035 IN PTFE BENT FLPY TIP STRL,SUP-2627293,CDM,C1769,HCPCS,0272,RC,,,,both,,,20.22,13.14,,,,,,,,,,,,,
PLATE BNE TIB 4.5 MM LAT PROX SET PERI-LOC,SUP-2351390,CDM,C1713,HCPCS,0278,RC,,,,both,,,5683.40,3694.21,,,,,,,,,,,,,
STEM ULN HD 4.5 LG PART MOD REPL 1ST CHOICE,SUP-2610432,CDM,C1776,CPT,0278,RC,,,,both,,,13339.88,8670.92,,,,,,,,,,,,,
MIDAZOLAM HCL (PF) 10 MG/2ML IJ SOLN,RX-147448,CDM,J2250,HCPCS,0636,RC,00409-2308-02,NDC,,both,2,ML,54.10,35.16,,,,,,,,,,,,,
COMPONENT ARTC SURF 46X52 MM GLEN TRABECULAR MTL,SUP-2199087,CDM,C1776,CPT,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
CATHETER GUID ENVOY L 90 CM OD 7 FR ID 0.078 IN MPD,SUP-2459999,CDM,C1887,HCPCS,0272,RC,,,,both,,,1781.32,1157.86,,,,,,,,,,,,,
GABAPENTIN 100 MG PO CAPS,RX-18309,CDM,6370000000,HCPCS,0637,RC,60687-0580-11,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
COMPONENT TIB SZ 1 KNEE TY ROT HNG IMP MOST OPTIONS,SUP-2208384,CDM,C1776,CPT,0278,RC,,,,both,,,12688.74,8247.68,,,,,,,,,,,,,
SCREW BNE PEDIATRIC 1 IN,SUP-2469167,CDM,C1713,HCPCS,0278,RC,,,,both,,,1528.40,993.46,,,,,,,,,,,,,
HC Pt E-Stim Stage III/IV Wound,PX-4209701401,CDM,G0281,HCPCS,0420,RC,,,,both,,,260.00,169.00,,,,,,,,,,,,,
HC Replace Picc Same Access,PX-3613658400,CDM,36584,CPT,0361,RC,,,,both,,,4973.00,3232.45,,,,,,,,,,,,,
ANCHOR SUT 23MM DIA W THRDR ULTRAFIX,SUP-2166460,CDM,C1713,HCPCS,0278,RC,,,,both,,,474.27,308.28,,,,,,,,,,,,,
CATHETER ETER CARD 6F EVALUATOR JSN CRV 5 5 5 ELECTRD SPC,SUP-2357017,CDM,C1730,HCPCS,0272,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
PLATE BONE LOK 170MML HLX13 STNLSS STEEL STRGHT RCNSTRCTN ST,SUP-2461083,CDM,C1713,HCPCS,0278,RC,,,,both,,,1759.40,1143.61,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY L 35 CM DIA 7 FR TIP L 5 MM SPC 5,SUP-2141325,CDM,C1725,HCPCS,0272,RC,,,,both,,,4027.68,2617.99,,,,,,,,,,,,,
NAIL INTRMDLLRY 13MM DIA LNG 340MML TTNM ALLOY LEFT CPHLMDLL,SUP-2588420,CDM,C1713,HCPCS,0278,RC,,,,both,,,5828.12,3788.28,,,,,,,,,,,,,
PLATE BNE SPRING 3.5 MM PELV 3 HOLE SS NS,SUP-2863439,CDM,C1713,HCPCS,0278,RC,,,,both,,,1086.31,706.10,,,,,,,,,,,,,
PIN FIX 0.157X9 IN FT NS FPS STEINMAN LTX,SUP-2856432,CDM,C1713,HCPCS,0278,RC,,,,both,,,175.84,114.30,,,,,,,,,,,,,
TRIAL BONE PLT 9 H RT LAT TIB BTTRS TC-100 L FRAG SYS,SUP-2343737,CDM,C1713,HCPCS,0278,RC,,,,both,,,6426.64,4177.32,,,,,,,,,,,,,
GRAFT BNE SM 2 CC PRO OSTEON 200R,SUP-2685763,CDM,C1713,HCPCS,0278,RC,,,,both,,,1111.56,722.51,,,,,,,,,,,,,
BLADE RTRCTR BLFR 2 1/2ND ABDMNL WIRE LTRL JARIT NON ST,SUP-2499447,CDM,2720000010,LOCAL,0272,RC,,,,both,,,346.47,225.21,,,,,,,,,,,,,
SHEATH INTRO FAST-CATH TRIO L 12 CM DIA10 FR CATH 4/5 FR,SUP-2357117,CDM,C1894,HCPCS,0272,RC,,,,both,,,21.35,13.88,,,,,,,,,,,,,
SET URET STENT SOFFLX BANDER L 75 CM DIA 6 FR 0.038 IN,SUP-2835755,CDM,C2617,HCPCS,0278,RC,,,,both,,,325.37,211.49,,,,,,,,,,,,,
MESH SURG DIA8IN CIR VENTRALIGHT,SUP-2126543,CDM,C1781,HCPCS,0278,RC,,,,both,,,2891.94,1879.76,,,,,,,,,,,,,
PROSTHESIS 5X45MM DAPAT PLATTI,SUP-2284072,CDM,L8613,CPT,0278,RC,,,,both,,,772.94,502.41,,,,,,,,,,,,,
BIT DRL DIA4MM SHT S STL FOR AG IM NAIL TRIGEN,SUP-2347047,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1099.53,714.69,,,,,,,,,,,,,
TISSUE BNE 8MMX36MM CAPSTONE,SUP-2293987,CDM,C1713,HCPCS,0278,RC,,,,both,,,17298.26,11243.87,,,,,,,,,,,,,
WASHER ORTHOPAEDIC 13 MM STAINLESS STEEL,SUP-2836677,CDM,C1713,HCPCS,0278,RC,,,,both,,,259.49,168.67,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH FLX L 111 MM DIA22 MM SHTH 18 FR RVD,SUP-2170609,CDM,C1889,HCPCS,0278,RC,,,,both,,,24021.00,15613.65,,,,,,,,,,,,,
HANDPIECE BREAST BIOPSY 9GA 14CML 3.7MML W/MR PETITE,SUP-2239992,CDM,2720000010,LOCAL,0272,RC,,,,both,,,873.23,567.60,,,,,,,,,,,,,
CRYOABLATION KIT PROST ICEPEARL 2.1 CX 10890] FORTEC MEDICAL INC],SUP-2225693,CDM,C2618,HCPCS,0272,RC,,,,both,,,12073.30,7847.64,,,,,,,,,,,,,
SCREW BNE L75MM DIA5MM CORT TI ST DBL LD THRD FOR PHOENIX,SUP-2412136,CDM,C1713,HCPCS,0278,RC,,,,both,,,733.50,476.77,,,,,,,,,,,,,
GRAFT HUMAN TISSUE BIOLOGICAL TISSUE MATRIX THICK 35X20 CM NON CROSSLINKED SCAFFOLD NATURALLY OCCURRING PORCINE STERILE GENTRIX DISPOSABLE,SUP-2106504,CDM,Q4166,HCPCS,0636,RC,,,,both,,,59510.85,38682.05,,,,,,,,,,,,,
LIDOCAINE HCL URETHRAL/MUCOSAL 2 % EX PRSY,RX-147640,CDM,6370000000,HCPCS,0637,RC,76329-3011-05,NDC,,both,5,ML,27.00,17.55,,,,,,,,,,,,,
INSTRUMENT KIT 5.5 MM ANCHR SUTURE DRL GUIDE GRAVITY DISP,SUP-2401441,CDM,2720000010,LOCAL,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
PLATE BNE H1MM 16 H MAND BLU TI MINI STR LOK LEIBINGER,SUP-2366345,CDM,C1713,HCPCS,0278,RC,,,,both,,,500.52,325.34,,,,,,,,,,,,,
GYN ESG PLASMA OVALBUTTON LNG 12 30 DEG,SUP-2727525,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1877.44,1220.34,,,,,,,,,,,,,
SUPPORT ORTHOT CUST LIFT ELEVATION MTL EXTN,SUP-2435717,CDM,L3330,HCPCS,0274,RC,,,,both,,,1602.25,1041.46,,,,,,,,,,,,,
CLIP INT USE L 50 X W 8.1 X H 11 OPENING 23.2 MM PEEK NIT,SUP-2890345,CDM,C1889,HCPCS,0278,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
CATHETER DIL 5.8FR L75CM BLLN L4CM DIA4MM 0.038IN 20ATM HI,SUP-2139189,CDM,C1726,HCPCS,0272,RC,,,,both,,,758.18,492.82,,,,,,,,,,,,,
EVOS 2.7/3.5MM PL-D HUM PL 17H L 206MM,SUP-2819862,CDM,C1713,HCPCS,0278,RC,,,,both,,,9502.90,6176.88,,,,,,,,,,,,,
CATHETER THROMCTMY EKOS + L 106 CM DIA 7.8 FR TREAT ZONE L 8,SUP-2867277,CDM,C1887,HCPCS,0272,RC,,,,both,,,12544.30,8153.79,,,,,,,,,,,,,
SPLINT FNGR M 3IN DYN KNCK BENDR RVS SGL DGT WIRE FOAM RUB,SUP-2324851,CDM,L3809,HCPCS,0274,RC,,,,both,,,41.95,27.27,,,,,,,,,,,,,
TUBE VENT 1.14 MM 0.93 MM 2.8 MM REUT BOB W/ HOLE 520181,SUP-2535144,CDM,L8699,HCPCS,0278,RC,,,,both,,,35.11,22.82,,,,,,,,,,,,,
COIL VASC AZUR CX L 24 CM DIA 8 MM MICROCATHETER 0.035 IN,SUP-2385442,CDM,C1889,HCPCS,0278,RC,,,,both,,,3821.38,2483.90,,,,,,,,,,,,,
PLATE BNE ANGLED BLADE 130 DEG SM 4.5X104 MM 80 MM 6 STRL,SUP-2653587,CDM,C1713,HCPCS,0278,RC,,,,both,,,2283.19,1484.07,,,,,,,,,,,,,
SCREW SPNL TEMP FIX LNG,SUP-2598343,CDM,C1713,HCPCS,0278,RC,,,,both,,,219.80,142.87,,,,,,,,,,,,,
SET URET STENT L 22 CM DIA 6.0 FR GUIDEWIRE L 145 CM DIA,SUP-2171280,CDM,C2617,HCPCS,0278,RC,,,,both,,,483.72,314.42,,,,,,,,,,,,,
VINCENT TOTAL 11MM 0.4MM X 11MM L HA/TI/FLUOROPLASTIC,SUP-2488899,CDM,L8613,CPT,0278,RC,,,,both,,,1346.21,875.04,,,,,,,,,,,,,
PLATE PELVIC STR 4 HOLE,SUP-2491098,CDM,C1713,HCPCS,0278,RC,,,,both,,,926.30,602.09,,,,,,,,,,,,,
K WIRE FIXATION L229MM DIA16MM STYLE 6 THREADED,SUP-2464600,CDM,C1713,HCPCS,0278,RC,,,,both,,,51.75,33.64,,,,,,,,,,,,,
SET INTRO ARROWG+ARD BLU SHTH L 10 CM DIA 8.5 FR GUIDEWIRE L,SUP-2383327,CDM,C1894,HCPCS,0272,RC,,,,both,,,169.72,110.32,,,,,,,,,,,,,
HC Beta 2 Glycoprotein I Antibody Each,PX-3028614600,CDM,86146,CPT,0302,RC,,,,both,,,138.00,89.70,,,,,,,,,,,,,
WIRE EXT FIX DIA2MM OLV FOR SALVATION EXT FIX,SUP-2401143,CDM,C1713,HCPCS,0278,RC,,,,both,,,750.46,487.80,,,,,,,,,,,,,
INSERT TIB THK 8 MM OFFSET 3.25 MM SZ 2 XLPE VIT E POST ANK,SUP-2899021,CDM,C1776,CPT,0278,RC,,,,both,,,7653.75,4974.94,,,,,,,,,,,,,
HC Clsd Tx Bimall Fx W Manip,PX-4502781000,CDM,27810,CPT,0450,RC,,,,inpatient,,,1633.00,1061.45,,,,,,,,,,,,,
TUBE TYMPANOSTOMY DIA1.14 MM MICROGEL INTERMED BLU STRL DISP,SUP-2902012,CDM,L8699,HCPCS,0278,RC,,,,both,,,80.70,52.45,,,,,,,,,,,,,
PLATE BNE L112MM 6 H ST R ANTEROMEDIAL DST TIB S STL VAR,SUP-2177671,CDM,C1713,HCPCS,0278,RC,,,,both,,,5647.42,3670.82,,,,,,,,,,,,,
LEAD PACE L40CM DIA1.27MM 1.5MM ELECTRD SPACE BLK 8 CHAN DIR,SUP-2357357,CDM,C1778,HCPCS,0278,RC,,,,both,,,17270.00,11225.50,,,,,,,,,,,,,
ALLOGRAFT BNE CUBE BLOCK 15X15X8 MM FD CANC ORAGRAFT,SUP-2740942,CDM,C1713,HCPCS,0278,RC,,,,both,,,986.43,641.18,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL PEEK SD800.553,SUP-2860234,CDM,C1713,HCPCS,0278,RC,,,,both,,,61605.54,40043.60,,,,,,,,,,,,,
IMPLANT BIO TISS W10XL20MM THK1MM BRST BOV CLLGN RECT FEN,SUP-2243671,CDM,C9360,HCPCS,0278,RC,,,,both,,,13188.00,8572.20,,,,,,,,,,,,,
PREDNISOLONE ACETATE 0.12 % OP SUSP,RX-27038,CDM,6370000000,HCPCS,0637,RC,11980-0174-05,NDC,,both,5,ML,721.80,469.17,,,,,,,,,,,,,
PLATE BONE L100MM 5 H BILAT S STL SPN LCK COMPR LO PROF RIG,SUP-2185731,CDM,C1713,HCPCS,0278,RC,,,,both,,,1080.41,702.27,,,,,,,,,,,,,
PROSTHESIS OSS CLASSIC STAP 4.5X1 MM 0.6 MM TI,SUP-2638174,CDM,L8613,CPT,0278,RC,,,,both,,,706.72,459.37,,,,,,,,,,,,,
GRAFT BONE SUB 5MMX11MMX11MM CANC CORT LORDTC CANN BLK,SUP-2278190,CDM,C1713,HCPCS,0278,RC,,,,both,,,3312.70,2153.25,,,,,,,,,,,,,
SURGICAL PROCEDURE PACK DR FUREY,SUP-2110976,CDM,C1713,HCPCS,0278,RC,,,,both,,,569.09,369.91,,,,,,,,,,,,,
CATHETER URETERAL 7FR L78CM TAMPONADE BLLN INFLATED,SUP-2119472,CDM,C1758,HCPCS,0278,RC,,,,both,,,625.80,406.77,,,,,,,,,,,,,
PSN REV TM FEM CENTRAL CONE SZ SM,SUP-2508669,CDM,C1776,CPT,0278,RC,,,,both,,,12874.00,8368.10,,,,,,,,,,,,,
LEAD NERVE STIM PADDLE SPNL,SUP-2138816,CDM,C1778,HCPCS,0278,RC,,,,both,,,163.28,106.13,,,,,,,,,,,,,
CAGE SPNL MESH 33X26X15 MM 6 LOBE,SUP-2602091,CDM,C1889,HCPCS,0278,RC,,,,both,,,11184.68,7270.04,,,,,,,,,,,,,
PLATE BNE W175XL152MM THK52MM 8 H BILAT TI RIG NEUT LOK,SUP-2190845,CDM,C1713,HCPCS,0278,RC,,,,both,,,1602.81,1041.83,,,,,,,,,,,,,
HC Mt Massage Ea 15 Min,PX-4209712401,CDM,97124,CPT,0420,RC,,,,outpatient,,,194.00,126.10,,,,,,,,,,,,,
COIL VASC AZUR L 50 CM DIA20 MM MICROCATHETER 0.035 IN LOOP,SUP-2385433,CDM,C1889,HCPCS,0278,RC,,,,both,,,4286.01,2785.91,,,,,,,,,,,,,
SCREW BNE ST 2X14 MM LCK TI SLV NS MATRIXMANDIBLE LF DISP,SUP-2181725,CDM,C1713,HCPCS,0278,RC,,,,both,,,254.97,165.73,,,,,,,,,,,,,
SPACER SPNL W26XH12MM SM PEEK THORLUM INTBDY FUS FLAT ADD,SUP-2291493,CDM,C1889,HCPCS,0278,RC,,,,both,,,8977.26,5835.22,,,,,,,,,,,,,
HEAD RADIAL MOD 20 STD ELBW,SUP-2610425,CDM,C1776,CPT,0278,RC,,,,both,,,8207.39,5334.80,,,,,,,,,,,,,
HC Tcat Perm Occls/Embolj Perq Non-Cns Head/Neck,PX-3616162600,CDM,61626,CPT,0361,RC,,,,both,,,20354.00,13230.10,,,,,,,,,,,,,
HC Ot Performnce Test Ea 15 Min,PX-4309775000,CDM,97750,CPT,0430,RC,,,,both,,,194.00,126.10,,,,,,,,,,,,,
CONNECTOR SPNL S STL THORLUM LO PROF INLINE FOR 5.5/5.5MM,SUP-2230991,CDM,C1713,HCPCS,0278,RC,,,,both,,,920.02,598.01,,,,,,,,,,,,,
CATHETER ANGIO ACCU-VU L 70 CM DIA 5 FR 0.035 IN 20 CM OMNI,SUP-2118544,CDM,C1887,HCPCS,0272,RC,,,,both,,,271.67,176.59,,,,,,,,,,,,,
SCREW BONE CANCELLOUS 6.5X65 MM TIBIAL PARTIAL THREADED LOCK,SUP-2837342,CDM,C1713,HCPCS,0278,RC,,,,both,,,301.53,195.99,,,,,,,,,,,,,
STAPLE INT BRDG W30MM LEG L30XL30MM WIRE DIA2X3MM NIT,SUP-2194230,CDM,C1713,HCPCS,0278,RC,,,,both,,,2810.30,1826.69,,,,,,,,,,,,,
CATHETER ABLAT L160CM DIA4MM BPLR ELECTRD W10XL15MM FOC,SUP-2172351,CDM,C1886,HCPCS,0278,RC,,,,both,,,6301.98,4096.29,,,,,,,,,,,,,
SHEATH INTRO PERFRMR L 13 CM DIA12 FR GUIDEWIRE 0.038 IN,SUP-2168247,CDM,C1894,HCPCS,0272,RC,,,,both,,,174.21,113.24,,,,,,,,,,,,,
LEAD PACEMKR LT VENT COR VEN SYS QUICKFLEX,SUP-2356053,CDM,C1900,HCPCS,0275,RC,,,,both,,,9420.00,6123.00,,,,,,,,,,,,,
TUBE INNR EAR MYR VENT CLLR BTTN FLNG 1.27 MM ID SIL STRL,SUP-2284034,CDM,L8699,HCPCS,0278,RC,,,,both,,,45.15,29.35,,,,,,,,,,,,,
NAIL IM L360MM OD11MM 135DEG 2MM RAD LNG FEM TI IMPLANTS,SUP-2370051,CDM,C1713,HCPCS,0278,RC,,,,both,,,6097.25,3963.21,,,,,,,,,,,,,
TI MATRIXMIDFACE  1.7MM  450398201,SUP-2844137,CDM,C1713,HCPCS,0278,RC,,,,both,,,433.82,281.98,,,,,,,,,,,,,
GRAFT BNE XL,SUP-2424566,CDM,C1713,HCPCS,0278,RC,,,,both,,,9809.36,6376.08,,,,,,,,,,,,,
SHUNT SURG MED ULTRA,SUP-2628142,CDM,C1729,HCPCS,0272,RC,,,,both,,,1406.56,914.26,,,,,,,,,,,,,
DRESSING POST OPERATIVE RIGID ANK,SUP-2388202,CDM,L5420,HCPCS,0274,RC,,,,both,,,3995.27,2596.93,,,,,,,,,,,,,
FOSAPREPITANT DIMEGLUMINE 150 MG IV SOLR,RX-107187,CDM,J1453,HCPCS,0636,RC,31722-0165-31,NDC,,both,1,UN,69.80,45.37,,,,,,,,,,,,,
CATHETER BLLN DIL FOR BRONCH THERMOPLASTY ALAIR ATS 2-5,SUP-2149864,CDM,C1886,HCPCS,0278,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
FLUPHENAZINE HCL 5 MG PO TABS,RX-3221,CDM,6370000000,HCPCS,0637,RC,00527-1790-01,NDC,,both,1,UN,14.20,9.23,,,,,,,,,,,,,
COMPONENT FEM 12X21MM TAPR POST UNICAP,SUP-2123698,CDM,C1776,CPT,0278,RC,,,,both,,,1937.38,1259.30,,,,,,,,,,,,,
SCREW 7713510 ZEVO VAR SD 3.5MM X 10MM,SUP-2289033,CDM,C1713,HCPCS,0278,RC,,,,both,,,372.88,242.37,,,,,,,,,,,,,
STEM HUM DSTL 13X130 MM SHLDR AEQUALIS FLX REVIVE PTC,SUP-2715468,CDM,C1776,CPT,0278,RC,,,,both,,,21195.00,13776.75,,,,,,,,,,,,,
SCREW INTFR L30MM DIA9MM SHTH L L30MM TIB BIOCRYL RAPIDE FOR,SUP-2256829,CDM,C1713,HCPCS,0278,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
CLIP ENDOSCP L220CM CAP D6MM DIA8.5-11MM NIT PT TEETH,SUP-2319933,CDM,C1889,HCPCS,0278,RC,,,,both,,,2006.46,1304.20,,,,,,,,,,,,,
IMPLANT LARYN L4MM DIA20FR SFT VLV ASMBLY EMBEDDED W/ SLV,SUP-2242289,CDM,L8509,HCPCS,0274,RC,,,,both,,,1224.60,795.99,,,,,,,,,,,,,
HC Esophageal Motility,PX-9209101000,CDM,91010,CPT,0750,RC,,,,both,,,1657.00,1077.05,,,,,,,,,,,,,
CURETTE SURG HOUSE 7 IN 1.3X1.1 MM STRONGLY ANGLED DBL END,SUP-2473409,CDM,2720000010,LOCAL,0272,RC,,,,both,,,581.03,377.67,,,,,,,,,,,,,
HINGE EXT FIX UNIV KNEE COMPASS,SUP-2342861,CDM,2720000010,LOCAL,0272,RC,,,,both,,,58723.02,38169.96,,,,,,,,,,,,,
GRAFT BNE 15 CC DEMINERALIZED BNE FIBER PROGRAFT,SUP-2858507,CDM,C1713,HCPCS,0278,RC,,,,both,,,3935.36,2557.98,,,,,,,,,,,,,
COMPONENT TIB AUG FLANGE 3.5 MM ANTR OSS,SUP-2441731,CDM,C1776,CPT,0278,RC,,,,both,,,2225.48,1446.56,,,,,,,,,,,,,
ALLOGRAFT BNE HEMI CONDYLE FEM FRZN,SUP-2321812,CDM,C1713,HCPCS,0278,RC,,,,both,,,30615.00,19899.75,,,,,,,,,,,,,
TRUESPAN MENIS REP SYS PLGA 12 DEG ORTHOCORD VIO BRAID COMP,SUP-2256750,CDM,C1713,HCPCS,0278,RC,,,,both,,,2254.52,1465.44,,,,,,,,,,,,,
KIT INTRO AXCESS L 11 CM DIA 7 FR GUIDEWIRE 0.035-0.038 IN,SUP-2119988,CDM,C1894,HCPCS,0272,RC,,,,both,,,43.18,28.07,,,,,,,,,,,,,
TIP LSR FBR CONCL LT TCH,SUP-2164904,CDM,2720000010,LOCAL,0272,RC,,,,both,,,753.60,489.84,,,,,,,,,,,,,
SCREW CRTX FT SELF TAP HEX HD 4.5MM DIA 46MML,SUP-2342662,CDM,C1713,HCPCS,0278,RC,,,,both,,,90.18,58.62,,,,,,,,,,,,,
SCREW BNE L6MM OD1.5MM TI ST BRNZ MATRIXMIDFACE,SUP-2181612,CDM,C1713,HCPCS,0278,RC,,,,both,,,320.91,208.59,,,,,,,,,,,,,
HEAD FEM CO CHROM W/ ALL POLY TIB INSRT JOURNEY UNI,SUP-2347997,CDM,C1776,CPT,0278,RC,,,,both,,,10676.00,6939.40,,,,,,,,,,,,,
CLAMP EXT FIX STD SINGLE STRL GALAXY FIX GEM LTX DISP,SUP-2875641,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3605.03,2343.27,,,,,,,,,,,,,
ROD EXT FIX L80MM LNG THRD SLT MR CONDITIONAL FOR DISTRCTN,SUP-2187909,CDM,2720000010,LOCAL,0272,RC,,,,both,,,189.44,123.14,,,,,,,,,,,,,
GRAFT TISS FRZN ALLGRFT FIB WHL TRAD,SUP-2294140,CDM,C1713,HCPCS,0278,RC,,,,both,,,5551.52,3608.49,,,,,,,,,,,,,
MATRIX BIO SZ 250 SQCM FISH SKIN DERMAL SLD INTACT STRL,SUP-2909210,CDM,Q4158,HCPCS,0636,RC,,,,both,,,25905.00,16838.25,,,,,,,,,,,,,
SUPPORT WR L LNG LEN RT FRARM WVN COT RUB FAB BGE FIRM W/,SUP-2324897,CDM,L3809,HCPCS,0274,RC,,,,both,,,41.01,26.66,,,,,,,,,,,,,
HC Remove Lung Catheter,PX-3613255200,CDM,32552,CPT,0361,RC,,,,outpatient,,,1289.00,837.85,,,,,,,,,,,,,
CANNULA ENDOSCP TERNAMIAN 11 MMX15 CM ENDOTIP VLV STOPCOCK,SUP-2768544,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2677.92,1740.65,,,,,,,,,,,,,
BIT DRL GRADUAL SUPLMNT,SUP-2644807,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3018.61,1962.10,,,,,,,,,,,,,
STEM FEM L127X203MM DIA11MM LNG DST KNEE TI POR BODY CRV,SUP-2364663,CDM,C1776,CPT,0278,RC,,,,both,,,12089.63,7858.26,,,,,,,,,,,,,
MESH TISS L 30 X W 23 MM TYP 1 CLLGN MTRX PLLA MICROFILAMENT,SUP-2895933,CDM,C1781,HCPCS,0278,RC,,,,both,,,9420.00,6123.00,,,,,,,,,,,,,
GUIDEWIRE VASC PIGGYBACK L 145 CM DIA 0.014 IN PERIPH WIRE,SUP-2383210,CDM,C1769,HCPCS,0272,RC,,,,both,,,22.77,14.80,,,,,,,,,,,,,
JOINT SUBTALAR 11.5 MM ANK,SUP-2318978,CDM,C1713,HCPCS,0278,RC,,,,both,,,4317.50,2806.37,,,,,,,,,,,,,
PIN DRL 2.5X125 MM LAPIDUS SYS IO FRDM DISP,SUP-2864892,CDM,2720000010,LOCAL,0272,RC,,,,both,,,320.28,208.18,,,,,,,,,,,,,
SCREW BONE L22MM DIA4.5MM CORT TI N ST N SELF DRL,SUP-2190374,CDM,C1713,HCPCS,0278,RC,,,,both,,,55.30,35.94,,,,,,,,,,,,,
KIT STBL POS SHLDR SPIDER 2 EXCEPTIONAL LIMB CTRL,SUP-2341137,CDM,L3650,HCPCS,0272,RC,,,,both,,,519.70,337.80,,,,,,,,,,,,,
CANN SCREW WASHER 13.0MM OD X 6.7MM ID,SUP-2639527,CDM,C1713,HCPCS,0278,RC,,,,both,,,386.22,251.04,,,,,,,,,,,,,
GRAFT DERMAL 7X4 CM PORCINE DERMAL CLLGN REINF MTRX STRL,SUP-2852966,CDM,C1763,HCPCS,0278,RC,,,,both,,,8511.19,5532.27,,,,,,,,,,,,,
PLATE BNE L 55 X W 55 MM THK 1.4 MM SCREW DIA2.2 MM,SUP-2909627,CDM,C1713,HCPCS,0278,RC,,,,both,,,5277.12,3430.13,,,,,,,,,,,,,
GUIDE WIRE THRDED 1.1 MMX150 MM STR,SUP-2817430,CDM,C1769,HCPCS,0272,RC,,,,both,,,81.64,53.07,,,,,,,,,,,,,
PLATE BNE L 48 MM 3 H LT VOLAR DSTL RADIAL WIDE NS VARIAX,SUP-2900628,CDM,C1713,HCPCS,0278,RC,,,,both,,,6498.01,4223.71,,,,,,,,,,,,,
MESH HERN W10XL14IN POLYPR MID WT MFIL RECTANG OVL FLAT SH,SUP-2265906,CDM,C1781,HCPCS,0278,RC,,,,both,,,281.82,183.18,,,,,,,,,,,,,
KIT CATH 1.9FR X 40CM 1-LUMEN PICC 30GA MOD INTRO 1958-1640,SUP-2874835,CDM,C1751,HCPCS,0278,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
PLATE BNE RADIAL 2.4X54 MM RT VOLAR CLMN DSTL 6X4 HOLE LCK,SUP-2177239,CDM,C1713,HCPCS,0278,RC,,,,both,,,2660.96,1729.62,,,,,,,,,,,,,
SCREW BNE CADDY COMP MOTIONLOC,SUP-2485239,CDM,C1713,HCPCS,0278,RC,,,,both,,,2413.50,1568.77,,,,,,,,,,,,,
REAMER SURG 5MM CANN ACORN,SUP-2277478,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1491.50,969.47,,,,,,,,,,,,,
PIN FIX FOR TEMP HLD PROVIDENCE,SUP-2232178,CDM,2720000010,LOCAL,0272,RC,,,,both,,,219.80,142.87,,,,,,,,,,,,,
MESH RESTRATA 12.5CM X 17.5CM,SUP-2874128,CDM,A2007,HCPCS,0636,RC,,,,both,,,30740.60,19981.39,,,,,,,,,,,,,
SCREW BNE CANN SHRT THRD 4X24 MM 10 MM MIDFOOT HD COMPR SS,SUP-2609268,CDM,C1713,HCPCS,0278,RC,,,,both,,,1138.50,740.02,,,,,,,,,,,,,
PLATE EXT FIX ID180MM DBL ROW OF H M/L REF MRK ERGO DSGN,SUP-2316196,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2854.79,1855.61,,,,,,,,,,,,,
PLATE BNE 3 H SPRING NS PRO,SUP-2902462,CDM,C1713,HCPCS,0278,RC,,,,both,,,1200.11,780.07,,,,,,,,,,,,,
PLATE BNE L262MM 16 H ST R ANTLAT DST TIB S STL VAR ANG LOK,SUP-2177691,CDM,C1713,HCPCS,0278,RC,,,,both,,,7700.91,5005.59,,,,,,,,,,,,,
SCREW BNE ZURICH 1.2X9 MM CRANIOMAXILLOFACIAL HEX TI,SUP-2540159,CDM,C1713,HCPCS,0278,RC,,,,both,,,808.33,525.41,,,,,,,,,,,,,
SET HOOK RTRCTN 68MML NROSPNE BLACK FLEXI SPINE RGGLS RDMND,SUP-2672193,CDM,2720000010,LOCAL,0272,RC,,,,both,,,680.44,442.29,,,,,,,,,,,,,
GRANISETRON HCL 4 MG/4ML IV SOLN,RX-92107,CDM,J1626,HCPCS,0636,RC,67457-0864-04,NDC,,both,4,ML,73.80,47.97,,,,,,,,,,,,,
CATHETER HD CRV EXTN 12 FRX15 CM CATH NDL DUOFLO,SUP-2627072,CDM,C1752,HCPCS,0278,RC,,,,both,,,690.80,449.02,,,,,,,,,,,,,
PLATE BNE L 115 MM SCREW DIA2.7/3.5 MM 7 H SS LT DSTL,SUP-2931412,CDM,C1713,HCPCS,0278,RC,,,,both,,,4458.80,2898.22,,,,,,,,,,,,,
SPHERE GLEN DIA36MM +6MM OFFSET CO CHROM SHLDR REV SYS,SUP-2404721,CDM,C1776,CPT,0278,RC,,,,both,,,3937.56,2559.41,,,,,,,,,,,,,
DEXTROSE 5 % IV BOLUS,RX-40840055,CDM,2580000003,HCPCS,0258,RC,00264-7510-00,NDC,,both,250,ML,8.50,5.52,,,,,,,,,,,,,
STRUT EXT FIX MED MULTAXL CORRECTION SYS HEXAPOD FULL AUTO,SUP-2905641,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6720.60,4368.39,,,,,,,,,,,,,
MENTHOL-ZINC OXIDE 0.44-20.625 % EX OINT,RX-91352,CDM,6370000000,HCPCS,0637,RC,10135-0701-04,NDC,,both,113,GR,14.80,9.62,,,,,,,,,,,,,
PLATE BNE L100MM 5 H BILAT S STL T NONCOMPRESSION LO PROF,SUP-2185754,CDM,C1713,HCPCS,0278,RC,,,,both,,,834.58,542.48,,,,,,,,,,,,,
PROBE LASER 20GA PRECIS FBR CNTR PLAS HND PC STR DISP RFID,SUP-2109917,CDM,C1713,HCPCS,0278,RC,,,,both,,,469.12,304.93,,,,,,,,,,,,,
GUIDE SURG GLEN CT AND BNE MOD L SIGN,SUP-2403463,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4239.00,2755.35,,,,,,,,,,,,,
R3 0 DEGREE +4 28MM XLPE LINER 42MM,SUP-2822957,CDM,C1713,HCPCS,0278,RC,,,,both,,,2041.00,1326.65,,,,,,,,,,,,,
PORT IMPL INFUSION SINGLE LUMEN PASV,SUP-2308260,CDM,C1788,HCPCS,0278,RC,,,,both,,,487.39,316.80,,,,,,,,,,,,,
INSERT ACET OD50MM ID22MM 0DEG HIP UHMWPE CONSTRN OMFIT II,SUP-2370343,CDM,C1776,CPT,0278,RC,,,,both,,,6817.57,4431.42,,,,,,,,,,,,,
CATHETER IV L45CM OD5FR ID0.026IN 0.34ML SIL DBL LUMN 3 W,SUP-2125618,CDM,C1751,HCPCS,0278,RC,,,,both,,,593.40,385.71,,,,,,,,,,,,,
PIN FIX L14.9CM DIA4.8MM CORT S STL SELF TAP DRL,SUP-2409694,CDM,C1713,HCPCS,0278,RC,,,,both,,,382.95,248.92,,,,,,,,,,,,,
RING EXT FIX FULL 200 MM CIR SIDEKCK,SUP-2850368,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3155.70,2051.20,,,,,,,,,,,,,
ELEVATOR SURG L11IN BLDE W32MM S STL COBB DAWSON YUHL,SUP-2160987,CDM,C1713,HCPCS,0278,RC,,,,both,,,339.81,220.88,,,,,,,,,,,,,
HC So Smear Afb,PX-3008720666,CDM,87206,CPT,0300,RC,,,,both,,,65.00,42.25,,,,,,,,,,,,,
INTRODUCER PACE LD SAFSHTH II L 23 CM DIA 8 FR GUIDEWIRE,SUP-2477457,CDM,C1892,HCPCS,0272,RC,,,,both,,,326.56,212.26,,,,,,,,,,,,,
CATHETER ABLAT 8FR L115CM TIP ELECTRD L4MM D-F CRV 1-4-1,SUP-2357505,CDM,C2630,CPT,0272,RC,,,,both,,,6594.00,4286.10,,,,,,,,,,,,,
CATHETER CV FULL SAFETY TY 7 FRX15 CM 3L RIFAMPIN SPECTRUM,SUP-2759702,CDM,C1751,HCPCS,0278,RC,,,,both,,,544.01,353.61,,,,,,,,,,,,,
ROD SPNL 5.5X110MM CVD TI CREO MIS,SUP-2417908,CDM,C1713,HCPCS,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
STEM FEM DSTL MOD W/ SLOT POR RL HARDENED OD17MM L 250MM,SUP-2404200,CDM,C1776,CPT,0278,RC,,,,both,,,10107.66,6569.98,,,,,,,,,,,,,
SCREW INTERFERENCE DIAMETER 11MM L40MM CANNULATED ABSORBABLE,SUP-2824845,CDM,C1713,HCPCS,0278,RC,,,,both,,,486.35,316.13,,,,,,,,,,,,,
PLATE BONE L85MM 7 H S STL SELF COMPR FOR 3.5MM SCR ECT,SUP-2198565,CDM,C1713,HCPCS,0278,RC,,,,both,,,341.63,222.06,,,,,,,,,,,,,
STENT PERIPH PALMAZ L 29 MM DIA IL 6-8 MM SHTH 6-7 FR SS MED,SUP-2158986,CDM,C1877,HCPCS,0278,RC,,,,both,,,3146.28,2045.08,,,,,,,,,,,,,
PIN FIX DIA3.2MM FOR GLOB AP SHLDR ARTHROPLASTY SYS,SUP-2252797,CDM,C1713,HCPCS,0278,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
COIL EMB 10 L1CM OD2MM HELCL STRTCH RESIST HYDRGEL V-TRAK,SUP-2305133,CDM,C1889,HCPCS,0278,RC,,,,both,,,3501.10,2275.71,,,,,,,,,,,,,
PLATE BNE TIB 3.5X185 MM RT PROX LAT 12 HOLE LOQTEQ,SUP-2691243,CDM,C1713,HCPCS,0278,RC,,,,both,,,5595.48,3637.06,,,,,,,,,,,,,
HC Iadna Herpes Somplx Virus Amplified Probe Tq,PX-3068752900,CDM,87529,CPT,0306,RC,,,,both,,,125.00,81.25,,,,,,,,,,,,,
DEXTROSE 5 % IV BOLUS,RX-40840055,CDM,2580000003,HCPCS,0258,RC,00990-7922-61,NDC,,both,250,ML,74.40,48.36,,,,,,,,,,,,,
CATHETER GUID L 184 CM OD 14 FR FEM CANN STRL,SUP-2214525,CDM,C1887,HCPCS,0272,RC,,,,both,,,64.31,41.80,,,,,,,,,,,,,
NEEDLE PROC AD 18GA L798CM 50DEG S STL TRANSSEPTAL POINTER,SUP-2357227,CDM,2720000010,LOCAL,0272,RC,,,,both,,,731.62,475.55,,,,,,,,,,,,,
"HC So Ag Detect Nos, Eia Multi Step",PX-3068744966,CDM,87449,CPT,0306,RC,,,,both,,,146.00,94.90,,,,,,,,,,,,,
TUBE FEED 14FR BLLN 7-10ML L45CM JEJU SIL INFL INT SECUR,SUP-2124594,CDM,2720000010,LOCAL,0272,RC,,,,both,,,426.26,277.07,,,,,,,,,,,,,
PLATE BNE RECON 3.5X130 MM 11 HOLE SS,SUP-2569086,CDM,C1713,HCPCS,0278,RC,,,,both,,,419.66,272.78,,,,,,,,,,,,,
INSERT TIB SZ 2 THK10MM LT KNEE EMPOWR 3D E +,SUP-2215901,CDM,C1776,CPT,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
CARRIER WIRE M L17MM LOOP DIA32MM ROD DIA46MM S STL RUSH SLT,SUP-2409756,CDM,C1713,HCPCS,0278,RC,,,,both,,,900.43,585.28,,,,,,,,,,,,,
HC Ot Therapeutic Activities 15 Min|OP OCCUPATIONAL THERAPY SERV|SERVICES PROVIDED IN WHOLE OR IN PARTY BY AN OTA FOR MEDICARE PATIENTS|UNUSUAL NON-OVERLAPPING SERVICE,PX-4309753000,CDM,97530,CPT,0430,RC,,,GO|CO|XU,both,,,144.00,93.60,,,,,,,,,,,,,
CONNECTOR SPNL M DORS PEDCL SCR ADJ FOR SURG TECH TSRH-3DX,SUP-2289710,CDM,C1713,HCPCS,0278,RC,,,,both,,,3081.91,2003.24,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 45 CM DIA 6 MM STR STD WALL STRL,SUP-2396279,CDM,C1768,CPT,0278,RC,,,,both,,,2932.76,1906.29,,,,,,,,,,,,,
PLATE BONE 2 H TI STR FOR CRAN CLSR SYS,SUP-2243969,CDM,C1713,HCPCS,0278,RC,,,,both,,,154.90,100.68,,,,,,,,,,,,,
BLADE RETRACTOR 80 MM CMF CRV FOR TROCAR TRANSBUCCAL LEVEL 1,SUP-2462262,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1653.78,1074.96,,,,,,,,,,,,,
INTRODUCER LD 8 FR SINGLE CHMBR PEELABLE PERQ 6208SI] MEDTRONIC USA INC],SUP-2278887,CDM,C1892,HCPCS,0272,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
ALLOGRAFT DERMAL 1X1 CMX1.26-1.75 MM DECELL DERM ORACELL,SUP-2740801,CDM,C1762,CPT,0278,RC,,,,both,,,232.86,151.36,,,,,,,,,,,,,
ANCHOR SUT W/ ORTHOCORD BIOKNOTLESS,SUP-2256603,CDM,C1713,HCPCS,0278,RC,,,,both,,,157.63,102.46,,,,,,,,,,,,,
HC Ot Manual Therapy per 15 Min.|OP PT SERVICES|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS,PX-4309714000,CDM,97140,CPT,0430,RC,,,GP|CQ,outpatient,,,194.00,126.10,,,,,,,,,,,,,
COIL EMB L10CM OD4MM 2D HELCL SFT STRTCH RESIST DETACH,SUP-2365732,CDM,C1889,HCPCS,0278,RC,,,,both,,,5814.65,3779.52,,,,,,,,,,,,,
CAGE SPNL 40X18X8 MM COROENT XLF,SUP-2567994,CDM,C1889,HCPCS,0278,RC,,,,both,,,15857.00,10307.05,,,,,,,,,,,,,
GRAFT HUM TISS L50MM DIA10MM FEM SHFT FRZN,SUP-2307345,CDM,C1713,HCPCS,0278,RC,,,,both,,,2333.81,1516.98,,,,,,,,,,,,,
KIT TKR TRABECULAR MTL FEM TIB PROLONG NXGN SURF AND STD PAT,SUP-2212237,CDM,C1776,CPT,0278,RC,,,,both,,,16682.82,10843.83,,,,,,,,,,,,,
CATHETER ETER EP ABLAT D CRV QPLR 1 7 4MM SPC 4MM TIP DEFL TEMP SENS,SUP-2248467,CDM,C1732,HCPCS,0278,RC,,,,both,,,5567.22,3618.69,,,,,,,,,,,,,
HALF RING 110MM INT DIA,SUP-2818148,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5832.71,3791.26,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 60 MM DIA 6 MM DEL SHTH,SUP-2934515,CDM,C1713,HCPCS,0278,RC,,,,both,,,8048.01,5231.21,,,,,,,,,,,,,
SYSTEM KYPHOPLASTY 15MM BALL UNIPEDICULAR ZVPLASTY,SUP-2402388,CDM,2720000010,LOCAL,0272,RC,,,,both,,,9420.00,6123.00,,,,,,,,,,,,,
KIT MINI ACCS STIFF DIL ECHO ENH S STL PLAT 7CM NDL,SUP-2303434,CDM,C1893,HCPCS,0272,RC,,,,both,,,116.18,75.52,,,,,,,,,,,,,
GRAFT BNE VIABLE 1 CC TIM MTRX FIBERCEL,SUP-2422145,CDM,C1762,CPT,0278,RC,,,,both,,,2245.10,1459.31,,,,,,,,,,,,,
PLATE BNE RADIAL NAR BABY 2.5 MM RT DSTL VOLAR FT TRILOK,SUP-2267968,CDM,C1713,HCPCS,0278,RC,,,,both,,,2722.38,1769.55,,,,,,,,,,,,,
CATHETER ETER EP ABLAT D CRV QPLR 1 7 4MM SPC 4MM TIP DEFL TEMP SENS,SUP-2248467,CDM,C1732,HCPCS,0272,RC,,,,both,,,5567.22,3618.69,,,,,,,,,,,,,
INSTRUMENT KIT SHLDR HEX PIN GPS,SUP-2451486,CDM,2720000010,LOCAL,0272,RC,,,,both,,,261.25,169.81,,,,,,,,,,,,,
GRAFT BNE SUB 10CC DBM CA SULF W/ 1-4MM CANC CHIP ALLMTRX,SUP-2399074,CDM,C9359,HCPCS,0278,RC,,,,both,,,3435.16,2232.85,,,,,,,,,,,,,
DRESSING WOUND SURGICAL MATRIX 6X15 CM PLASTIC MATRISTEM,SUP-2106491,CDM,Q4166,HCPCS,0636,RC,,,,both,,,5663.62,3681.35,,,,,,,,,,,,,
HC Clsd Tx Hum Shaft Fx Manip,PX-4502450500,CDM,24505,CPT,0450,RC,,,,both,,,1633.00,1061.45,,,,,,,,,,,,,
STENT BILI S.M.A.R.T. CTRL L 80 MM DIA14 MM DEL SYS L 80 CM,SUP-2158669,CDM,C1876,HCPCS,0278,RC,,,,both,,,3673.80,2387.97,,,,,,,,,,,,,
SPHERE EMB EMBOZENE DIA 40 UM 2 ML PREFIL SYR HYDRGEL BLK,SUP-2139483,CDM,C1889,HCPCS,0278,RC,,,,both,,,832.10,540.86,,,,,,,,,,,,,
SUTURE POLYPR SZ 2 0 NONABSORBABLE W NDL 520270,SUP-2165324,CDM,C1713,HCPCS,0278,RC,,,,both,,,1224.60,795.99,,,,,,,,,,,,,
CROWN DENT SZ LL5 LO LT 1ST PERM M S STL THCK OCCLUSAL SURF,SUP-2238806,CDM,D6783,CPT,0278,RC,,,,both,,,26.78,17.41,,,,,,,,,,,,,
SCREW BNE 1.5X7 MM 4 MM X DRV DRILL-FREE TI LEVEL 1 19700791,SUP-2462795,CDM,C1713,HCPCS,0278,RC,,,,both,,,284.61,185.00,,,,,,,,,,,,,
VALVE AORT OPN PVT DIA 31 MM CONDUIT 34 MM ORIFICE 26.8 MM,SUP-2429918,CDM,C1713,HCPCS,0278,RC,,,,both,,,10833.00,7041.45,,,,,,,,,,,,,
HC So1 Amoebic Antibodies by Iha,PX-3028675367,CDM,86753,CPT,0302,RC,,,,inpatient,,,588.00,382.20,,,,,,,,,,,,,
SPLINT KNEE L12IN UNIV WRP ARND OPN PAT WIND CLS POPLITEAL,SUP-2196739,CDM,L1830,CPT,0274,RC,,,,both,,,33.00,21.45,,,,,,,,,,,,,
BOLT IM L38MM DIA3.9MM BLU TI ALUM NIOBIUM TRCR TIP ST LOK,SUP-2192190,CDM,C1713,HCPCS,0278,RC,,,,both,,,591.51,384.48,,,,,,,,,,,,,
APPLIER CLP ENDOSCP MED LG 13 IN LIG HEMCLP +,SUP-2656752,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4396.00,2857.40,,,,,,,,,,,,,
CATHETER INFUSION ENDOVASC DEV 30 FRX135 CM US COR EKOSONIC,SUP-2214805,CDM,C1887,HCPCS,0272,RC,,,,both,,,18887.10,12276.61,,,,,,,,,,,,,
AQUAPHOR EX OINT,RX-612,CDM,6370000000,HCPCS,0637,RC,72140-0452-31,NDC,,both,50,GR,22.10,14.36,,,,,,,,,,,,,
PLATE BNE 50X20X0.1 MM MEMBRN PDLLA STRL RESORB X LF,SUP-2474269,CDM,C1713,HCPCS,0278,RC,,,,both,,,1437.37,934.29,,,,,,,,,,,,,
GRAFT HUM TISS W7XL30-59MM COSTAL CART FRZN,SUP-2417976,CDM,C1762,CPT,0278,RC,,,,both,,,1568.43,1019.48,,,,,,,,,,,,,
SCREW BNE L70MM L32MM OD75MM STD BIODUR CANC ST SELF DRL,SUP-2197560,CDM,C1713,HCPCS,0278,RC,,,,both,,,723.46,470.25,,,,,,,,,,,,,
BASEPLATE TIB SZ 5 THK11MM R POLYETH CRUCE RET CEM PRI STEM,SUP-2345922,CDM,C1776,CPT,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
HC Trluml Balo Angiop Addl Art,PX-3613724700,CDM,37247,CPT,0361,RC,,,,both,,,8583.00,5578.95,,,,,,,,,,,,,
TIP LD PULLING FOR ENDOTK RELIANCE 4-SITE NS,SUP-2481178,CDM,2720000010,LOCAL,0272,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
GRAFT SOFT TISSUE TIB 8X30 MM WITH DRIVER APERFIX II,SUP-2664012,CDM,C1713,HCPCS,0278,RC,,,,both,,,1645.86,1069.81,,,,,,,,,,,,,
APPLIER LIG CLP 5MM CONTAIN 16 TI CLP DISP ENDO CLP,SUP-2283167,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1593.55,1035.81,,,,,,,,,,,,,
PLATE BNE L57MM 6 H NONSTERILE DST DORS RAD S STL CLMN LOK,SUP-2177513,CDM,C1713,HCPCS,0278,RC,,,,both,,,1982.85,1288.85,,,,,,,,,,,,,
SUPPORT LUMBAR LP,SUP-2388156,CDM,L1220,HCPCS,0274,RC,,,,both,,,616.66,400.83,,,,,,,,,,,,,
BLADE RETRACTOR MAYO 3.5X2 IN RADLUC ALUM NS GHOSTRACT,SUP-2457893,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1326.05,861.93,,,,,,,,,,,,,
PLATE BNE 3.5X121 MM 10 HOLE SS DCP,SUP-2569142,CDM,C1713,HCPCS,0278,RC,,,,both,,,302.23,196.45,,,,,,,,,,,,,
HC So B Cell Total,PX-3028635566,CDM,86355,CPT,0302,RC,,,,both,,,64.00,41.60,,,,,,,,,,,,,
CUP ACET FULL PROF 36 MM TST,SUP-2448564,CDM,C1776,CPT,0278,RC,,,,both,,,98.91,64.29,,,,,,,,,,,,,
KIT INTRO GLIDESHEATH SLENDER L 10 CM DIA 6 FR 0.021IN PLAS,SUP-2385464,CDM,C1894,HCPCS,0272,RC,,,,both,,,294.38,191.35,,,,,,,,,,,,,
BLADE SHV L11CM DIA3.5MM STR SNUS M4 ROT LNG SHFT IRRIG,SUP-2284133,CDM,2720000010,LOCAL,0272,RC,,,,both,,,764.65,497.02,,,,,,,,,,,,,
PLATE BNE L50MM 8 H TI LAT MED REARFOOT LOK COMPR RECON RPS,SUP-2399638,CDM,C1713,HCPCS,0278,RC,,,,both,,,2738.08,1779.75,,,,,,,,,,,,,
STENT BILI L L24MM BLLN L30MM DIA10MM CATH L80CM 10ATM,SUP-2159239,CDM,C1876,HCPCS,0278,RC,,,,both,,,3598.44,2338.99,,,,,,,,,,,,,
CATHETER OPHTH PED BLLN L13MM DIA2MM LACR BILAT FOR,SUP-2330964,CDM,C1726,HCPCS,0272,RC,,,,both,,,871.35,566.38,,,,,,,,,,,,,
ANCHOR SUT TWIN LOOP DBL STRND 35MM,SUP-2366682,CDM,C1713,HCPCS,0278,RC,,,,both,,,655.85,426.30,,,,,,,,,,,,,
STEM FEM DIA13.5MM LT HIP SM STAT LNG REPLICA,SUP-2251975,CDM,C1776,CPT,0278,RC,,,,both,,,17489.80,11368.37,,,,,,,,,,,,,
HC Therapeutic Plasma Pheresis,PX-7613651400,CDM,36514,CPT,0761,RC,,,,both,,,3809.00,2475.85,,,,,,,,,,,,,
SPACER HIP 275MM LNG 54MM DIA 2.1GA XL ANTIBIO,SUP-2223684,CDM,C1776,CPT,0278,RC,,,,both,,,9388.60,6102.59,,,,,,,,,,,,,
SLEEVE FEM 30MM CEM REV ATTUNE,SUP-2251447,CDM,C1776,CPT,0278,RC,,,,both,,,7350.11,4777.57,,,,,,,,,,,,,
INSERT TIB 5 12 MM TOT ANK POLYETH PROPHECY INFIN,SUP-2462779,CDM,C1776,CPT,0278,RC,,,,both,,,6619.12,4302.43,,,,,,,,,,,,,
PLATE BONE L194MM 6X24X6 H BILAT MAND ORAL MAXILLOFACIAL TI,SUP-2191433,CDM,C1713,HCPCS,0278,RC,,,,both,,,10702.06,6956.34,,,,,,,,,,,,,
STENT ESOPH L15CM DIA18MM PROX FLARE DIA23MM CVR L12CM,SUP-2139596,CDM,C1874,HCPCS,0278,RC,,,,both,,,122.46,79.60,,,,,,,,,,,,,
AMOXICILLIN-POT CLAVULANATE 600-42.9 MG/5ML PO SUSR,RX-31177,CDM,340b,HCPCS,0637,RC,09999-9917-93,NDC,,both,5,ML,4.20,2.73,,,,,,,,,,,,,
GUIDEWIRE 8MM 0.062X15IN SURTAC,SUP-2195799,CDM,C1769,HCPCS,0272,RC,,,,both,,,15.70,10.20,,,,,,,,,,,,,
STAPLE COMPRESSION 8MMX8MM TITANIUM,SUP-2652943,CDM,C1713,HCPCS,0278,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
DRESSING BIO W2XL2CM CLLGN SH 0.1% POLYHEXMETHYLENEBIGUANIDE,SUP-2314087,CDM,Q4196,HCPCS,0636,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
PLATE BNE L90MM 4 H CRANIOMAXILLOFACIAL TI X SHP LO PROF,SUP-2191184,CDM,C1713,HCPCS,0278,RC,,,,both,,,768.67,499.64,,,,,,,,,,,,,
BRACE WLK L SHOE MAN 10 13 WOMAN 11 15 EXTRA PNEUMAT SEMI,SUP-2196363,CDM,L4361,HCPCS,0272,RC,,,,both,,,224.82,146.13,,,,,,,,,,,,,
PLATE BNE L 88 X W 10.2 MM THK 2.8 MM SCREW DIA 3.5 MM 8 H,SUP-2936316,CDM,C1713,HCPCS,0278,RC,,,,both,,,1738.93,1130.30,,,,,,,,,,,,,
ANCHOR SUT NEEDLE CRV FOR DEL MENISCI REP SYS FAST-FIX 360,SUP-2341833,CDM,C1713,HCPCS,0278,RC,,,,both,,,1534.96,997.72,,,,,,,,,,,,,
PLATE BONE L50MM CRANIOMAXILLOFACIAL MAND MOD 3 DIM MCS LUHR,SUP-2364675,CDM,C1713,HCPCS,0278,RC,,,,both,,,908.90,590.78,,,,,,,,,,,,,
SCREW BONE,SUP-2137312,CDM,C1713,HCPCS,0278,RC,,,,both,,,15684.30,10194.79,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 40 MM DIA 6 MM DEL SHTH,SUP-2934182,CDM,C1713,HCPCS,0278,RC,,,,both,,,5432.20,3530.93,,,,,,,,,,,,,
HC Fetal Eval 1st Trim @ Addl Ges,PX-4027680200,CDM,76802,CPT,0402,RC,,,,outpatient,,,793.00,515.45,,,,,,,,,,,,,
GRAFT MTRX DERM HUM TISS ACELLULAR FRZ DRY THN 2CMX4CM,SUP-2306986,CDM,C1762,CPT,0278,RC,,,,both,,,589.88,383.42,,,,,,,,,,,,,
SUPPORT LUMBAR LP,SUP-2388156,CDM,L1220,HCPCS,0272,RC,,,,both,,,616.66,400.83,,,,,,,,,,,,,
PLATE BNE W13.5XL70MM THK4.2MM 4 H BILAT S STL NAR LIMIT,SUP-2185230,CDM,C1713,HCPCS,0278,RC,,,,both,,,956.29,621.59,,,,,,,,,,,,,
SCREW BNE L26MM DIA3.5MM MINI FT ANK TI SELF DRL ST CANN AR273026H] ARTHREX INC],SUP-2121752,CDM,C1713,HCPCS,0278,RC,,,,both,,,926.30,602.09,,,,,,,,,,,,,
BUR SURG 1.4X12.8MM FLUT ROUTER FOR 5.9CM TURQ ATTCH,SUP-2176849,CDM,2720000010,LOCAL,0272,RC,,,,both,,,222.94,144.91,,,,,,,,,,,,,
ILLUMINATOR PHLEBECTOMY DEV DISP PHASTIPP,SUP-2908887,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3764.86,2447.16,,,,,,,,,,,,,
RETAINER SIDEARM,SUP-2889623,CDM,2720000010,LOCAL,0272,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
NAIL IM STD 120 DEG 11X170 MM EBA 1,SUP-2719791,CDM,C1713,HCPCS,0278,RC,,,,both,,,4615.80,3000.27,,,,,,,,,,,,,
PLATE BNE SCAPULA RT MEDL 13 HOLE BORDER,SUP-2846284,CDM,C1713,HCPCS,0278,RC,,,,both,,,4747.68,3085.99,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE 10 CC DEMINERALIZED CORT CANC BNE FIBER,SUP-2905185,CDM,C1713,HCPCS,0278,RC,,,,both,,,3088.19,2007.32,,,,,,,,,,,,,
PLATE BNE L283MM 10 H ST L PROX FEM S STL LO PROF LOK COMPR,SUP-2186046,CDM,C1713,HCPCS,0278,RC,,,,both,,,4780.30,3107.19,,,,,,,,,,,,,
CATHETER HD PRECRV 12.5 FRX28 CM LT DL STP BASIC SET HEMCATH,SUP-2627316,CDM,C1750,HCPCS,0278,RC,,,,both,,,810.12,526.58,,,,,,,,,,,,,
RING EXT FIX LNG 200 MM SET RX STRUT STRL TRUELOK EVO LTX,SUP-2875589,CDM,2720000010,LOCAL,0272,RC,,,,both,,,30265.33,19672.46,,,,,,,,,,,,,
PROSTHESIS OSS DE LA CRUZ PISTON 0.6X4.50 MM SS FLROPLAS,SUP-2638111,CDM,L8613,CPT,0278,RC,,,,both,,,313.18,203.57,,,,,,,,,,,,,
PLATE BNE T SM 1.2 MM 3X5 HOLE OBLQ NS LTX,SUP-2861952,CDM,C1713,HCPCS,0278,RC,,,,both,,,543.35,353.18,,,,,,,,,,,,,
HC So Diabetes Autoimmune Profile (First Cpt),PX-3028633767,CDM,86337,CPT,0302,RC,,,,both,,,187.00,121.55,,,,,,,,,,,,,
BRACE ORTH 30 150DEG SHLDR UNIV MOTN CTRL CHST STRP WAIST,SUP-2196399,CDM,L3650,HCPCS,0272,RC,,,,both,,,716.83,465.94,,,,,,,,,,,,,
BUR SURG DIAMOND 2.5 MM 14 CM BALL LG BOR MIDAS REX 8 LEGEND,SUP-2664553,CDM,2720000010,LOCAL,0272,RC,,,,both,,,453.67,294.89,,,,,,,,,,,,,
STENT TRACHBRONCH WSTNT L 60 MM DIA12 MM SHTH 9 FR CATH L 75,SUP-2147030,CDM,C1876,HCPCS,0278,RC,,,,both,,,3199.50,2079.67,,,,,,,,,,,,,
PLATE CRAN 30X30X20 MM PT SPEC IMPL PEEK,SUP-2860166,CDM,C1713,HCPCS,0278,RC,,,,both,,,21151.35,13748.38,,,,,,,,,,,,,
PACK NEUROSURGICAL SHTH L 60 X W 13.5 MM MYRIAD HNDPC L 13 NN-3008,SUP-2930305,CDM,2720000010,LOCAL,0272,RC,,,,both,,,22257.64,14467.47,,,,,,,,,,,,,
PLATE BNE ANGLED BLADE 130 DEG 200 MM 80 MM 12 HOLE NS DCP,SUP-2569033,CDM,C1713,HCPCS,0278,RC,,,,both,,,1891.00,1229.15,,,,,,,,,,,,,
EXPANDER BRST TISS 550CC SIL M HT SMOOTH W/ SUT TAB INTEGR,SUP-2418652,CDM,C1789,HCPCS,0278,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
STEM FEM SZ 0 L115MM DIA10MM NK L31MM 4MM OFFSET 132DEG HIP,SUP-2375322,CDM,C1776,CPT,0278,RC,,,,both,,,11581.80,7528.17,,,,,,,,,,,,,
SPLINT WR L AD W3.5-4IN BGE LT FAB GEL CRPL TUNN REG INSRT,SUP-2324880,CDM,L3809,HCPCS,0274,RC,,,,both,,,48.54,31.55,,,,,,,,,,,,,
KIT PD 5.8FT-6.3FT M STRNL BRAC PT TLSO,SUP-2123924,CDM,L0462,HCPCS,0274,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
SCREW BNE LAG 120 MM SLD SLIDING,SUP-2415891,CDM,C1713,HCPCS,0278,RC,,,,both,,,2446.06,1589.94,,,,,,,,,,,,,
PLATE SPNL 3 LEVEL WIDE 52 MM ANTR CERV ARCHON,SUP-2563408,CDM,C1713,HCPCS,0278,RC,,,,both,,,2433.50,1581.77,,,,,,,,,,,,,
PLATE BNE BROAD 3.5X237 MM 18 HOLE SS LCP,SUP-2569344,CDM,C1713,HCPCS,0278,RC,,,,both,,,592.36,385.03,,,,,,,,,,,,,
GUIDEPIN ORTH DIA3MM CANN FOR ACL RECON RETRODRILL,SUP-2120914,CDM,2720000010,LOCAL,0272,RC,,,,both,,,653.12,424.53,,,,,,,,,,,,,
PLATE BNE L 250.62 X W 48.01 MM THK 2.59 MM LG TI DBL ANGLE,SUP-2936845,CDM,C1713,HCPCS,0278,RC,,,,both,,,8405.78,5463.76,,,,,,,,,,,,,
DEWAN SUPRAPUBIC URODYNAMICS CATHETER SET,SUP-2822052,CDM,C2627,HCPCS,0272,RC,,,,both,,,246.49,160.22,,,,,,,,,,,,,
VALVE MI H17MM DIA25MM TISS ANNULUS DIA27MM PORCINE LEAFLET,SUP-2355835,CDM,C1889,HCPCS,0278,RC,,,,both,,,13816.00,8980.40,,,,,,,,,,,,,
HC So Lipoprotein-Assoc Phospholipas,PX-3018369866,CDM,83698,CPT,0301,RC,,,,both,,,79.00,51.35,,,,,,,,,,,,,
NEEDLE MAYO 1/2 CRCLE SZ 4 TAPER POINT FINE 222204,SUP-2845003,CDM,C1713,HCPCS,0278,RC,,,,both,,,19.63,12.76,,,,,,,,,,,,,
REAMER SURG 65MM IM FLX PRSS SENTNL,SUP-2198021,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1769.77,1150.35,,,,,,,,,,,,,
COMPONENT FEM L145MM DIA13MM LAT HIP CO CHROM POR CEM ANS,SUP-2406609,CDM,C1776,CPT,0278,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
PLATE BNE CRV MIC 1.5X0.5 MM NEURO GAP TI,SUP-2476123,CDM,C1713,HCPCS,0278,RC,,,,both,,,853.30,554.64,,,,,,,,,,,,,
SET URET STENT GREENE L 8-20 CM DIA 6 FR CATH L 70 CM DIA 6,SUP-2835727,CDM,C2617,HCPCS,0278,RC,,,,both,,,438.53,285.04,,,,,,,,,,,,,
KIT HAMRTOE CORR 16 28 35MM STP DRL IMPL HNDL DRVR SAW,SUP-2137579,CDM,C1713,HCPCS,0278,RC,,,,both,,,3460.53,2249.34,,,,,,,,,,,,,
PLATE BONE LOK DUAL CMPRSSN 157MML HLX12 STNLSS STEEL CNTRD,SUP-2588607,CDM,C1713,HCPCS,0278,RC,,,,both,,,1122.55,729.66,,,,,,,,,,,,,
STAPLER INT 60 MM RELD TRISTAPLE TECHNOLOGY PUR STRL SEAMGRD,SUP-2458849,CDM,2720000010,LOCAL,0272,RC,,,,both,,,656.26,426.57,,,,,,,,,,,,,
SPLINT ORTHOPEDIC COLLES SM WRST FOREARM LF,SUP-2330386,CDM,L3808,HCPCS,0274,RC,,,,both,,,18.84,12.25,,,,,,,,,,,,,
SCREW BNE L34MM DIA4.5MM TI LOK LO PROF FOR ANK FUS PLATING,SUP-2122238,CDM,C1713,HCPCS,0278,RC,,,,both,,,876.06,569.44,,,,,,,,,,,,,
PLATE BNE TIBIOTALOCALCANEAL ANTEROLATERAL AXSOS 3 630114,SUP-2613581,CDM,C1713,HCPCS,0278,RC,,,,both,,,11021.40,7163.91,,,,,,,,,,,,,
CATHETER GUID 0.035 IN 0.058 INX5 FR BARE NDL SS GRY RAILWAY,SUP-2653858,CDM,C1887,HCPCS,0272,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
SCREW 2.0X10MM CORT HEXADRIVE 6,SUP-2268100,CDM,C1713,HCPCS,0278,RC,,,,both,,,352.31,229.00,,,,,,,,,,,,,
GRAFT BNE L100MM SHFT FIB STRUCTURAL ALLGRFT FRZN,SUP-2307380,CDM,C1762,CPT,0278,RC,,,,both,,,2349.72,1527.32,,,,,,,,,,,,,
SCREW BONE L45MM DIA3.5MM CORT VOLAR S ST NONCANNULATED LCK,SUP-2348539,CDM,C1713,HCPCS,0278,RC,,,,both,,,268.38,174.45,,,,,,,,,,,,,
CONNECTOR RMR FEM ACCURIS,SUP-2344214,CDM,2720000010,LOCAL,0272,RC,,,,both,,,932.74,606.28,,,,,,,,,,,,,
SET INTRO 10GM MRI PRB VAC ASST BRST BX ENCOR,SUP-2126856,CDM,C1894,HCPCS,0272,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
SCREW BNE CORTICAL 2.7 MM UNIV LCK ULS,SUP-2861472,CDM,C1713,HCPCS,0278,RC,,,,both,,,14282.23,9283.45,,,,,,,,,,,,,
GRAFT VASC FLIXENE L 45 CM DIA 4-7 MM EPTFE GRAD WALL TAPR 3,SUP-2265953,CDM,C1768,CPT,0278,RC,,,,both,,,4075.06,2648.79,,,,,,,,,,,,,
SCREW INTFR L30MM DIA7-9MM TIB TCP/PLA BIOABSRB,SUP-2249560,CDM,C1713,HCPCS,0278,RC,,,,both,,,2157.18,1402.17,,,,,,,,,,,,,
COMPONENT PAT SZ 32MM POLYETH PATONSET PROFIX,SUP-2347041,CDM,C1776,CPT,0278,RC,,,,both,,,2102.23,1366.45,,,,,,,,,,,,,
ENDOPROBE LRIDEX 10547-120 GA 45 DEGREE,SUP-2885287,CDM,2720000010,LOCAL,0272,RC,,,,both,,,524.38,340.85,,,,,,,,,,,,,
TRIAMCINOLONE ACETONIDE 0.1 % MT PSTE,RX-8121,CDM,2500000003,HCPCS,0250,RC,51672-1267-05,NDC,,both,5,GR,290.20,188.63,,,,,,,,,,,,,
SHEARS ROBOTIC DIA5MM CRV INSRT ENDOSCP DISP FOR HARM ACE,SUP-2246590,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1350.20,877.63,,,,,,,,,,,,,
PROBE SURG MECHANOMYOGRAPHY LAT RAIL SS NS,SUP-2693684,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1161.80,755.17,,,,,,,,,,,,,
BLADE SAW OSCLLTNG 18.5MMW X28.5MML 0.4MM THK SM BNE FN TOOT,SUP-2605384,CDM,2720000010,LOCAL,0272,RC,,,,both,,,74.95,48.72,,,,,,,,,,,,,
STENT CAR ACCULINK L 40 MM DIA 6-8 MM CATH L 132 CM SHTH 6,SUP-2104587,CDM,C1876,HCPCS,0278,RC,,,,both,,,5966.00,3877.90,,,,,,,,,,,,,
ALLOGRAFT HUM TISS LG VIABLE AMNION MTRX ESSENCE,SUP-2538799,CDM,C1762,CPT,0278,RC,,,,both,,,14958.96,9723.32,,,,,,,,,,,,,
CATHETER LD DEL CPS DIR SL II L 50.7 CM AVAILABLE L 47 CM OD,SUP-2356368,CDM,C1893,HCPCS,0272,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
SCREW BONE L11MM DIA2.3MM CRANIOMAXILLOFACIAL TI CROSSDRIVE,SUP-2262619,CDM,C1713,HCPCS,0278,RC,,,,both,,,81.64,53.07,,,,,,,,,,,,,
SCREW SPNL L6MM DIA4MM CORT POST OCCIPITAL THRD VERTEX MAX,SUP-2286764,CDM,C1713,HCPCS,0278,RC,,,,both,,,951.11,618.22,,,,,,,,,,,,,
ALLOGRAFT BNE CRUSH CANC 130816034,SUP-2165601,CDM,C1889,HCPCS,0278,RC,,,,both,,,722.20,469.43,,,,,,,,,,,,,
GUIDEWIRE 1.5MM 9INX30CM STERILE ORTHOPAEDIC BLUNT,SUP-2880376,CDM,C1769,HCPCS,0272,RC,,,,both,,,158.26,102.87,,,,,,,,,,,,,
STEM HUM L75MM OD6.5MM UNIV TI SHLDR IM PROX BODY MOD REV,SUP-2403672,CDM,C1776,CPT,0278,RC,,,,both,,,8434.04,5482.13,,,,,,,,,,,,,
SCREW BNE L55MM OD6MM CORT ST NONCANNULATED NONLOCKING FULL,SUP-2377557,CDM,C1713,HCPCS,0278,RC,,,,both,,,617.95,401.67,,,,,,,,,,,,,
METAL HEMI IMPLANT TRIAL SM METAL HEMI SYSTEM,SUP-2473637,CDM,C1776,CPT,0278,RC,,,,both,,,2559.10,1663.41,,,,,,,,,,,,,
STEM HUM PRSS FT SHLDR TOT,SUP-2379211,CDM,C1776,CPT,0278,RC,,,,both,,,12874.00,8368.10,,,,,,,,,,,,,
STENT URTRL 7FR DIA 8CML TCFLX OPEN WPSH CATH LTHSTNT ST SN,SUP-2721363,CDM,C2617,HCPCS,0278,RC,,,,both,,,288.88,187.77,,,,,,,,,,,,,
SYSTEM TIGHTROPE II RT W/ DEPLOYING SUTURE,SUP-2719541,CDM,C1776,CPT,0278,RC,,,,both,,,1460.10,949.06,,,,,,,,,,,,,
CATHETER ABLATN STD 7 FRX110 CM 2.5X8 MM INTELLANAV MIFI XP,SUP-2141337,CDM,C1732,HCPCS,0272,RC,,,,both,,,8321.00,5408.65,,,,,,,,,,,,,
HUMERAL TRAY STD SHLDR TI COMPHSVE,SUP-2431691,CDM,C1776,CPT,0278,RC,,,,both,,,3925.00,2551.25,,,,,,,,,,,,,
GUIDEWIRE ORTH L12IN BLNT TIP DISP,SUP-2212566,CDM,C1769,HCPCS,0272,RC,,,,both,,,204.10,132.66,,,,,,,,,,,,,
ALLOGRAFT BNE CHIPS 1-8 MM 10 CC CANC DEMINERALIZED BNE BIO,SUP-2637036,CDM,C1713,HCPCS,0278,RC,,,,both,,,3506.09,2278.96,,,,,,,,,,,,,
GRAFT BONE 15ML CANC CHIP FRZ DRY,SUP-2165606,CDM,C1762,CPT,0278,RC,,,,both,,,659.40,428.61,,,,,,,,,,,,,
CATHETER THOR 20FR L20IN PVC STR RADPQ SENTNL LN TBNG,SUP-2154966,CDM,C1729,HCPCS,0272,RC,,,,both,,,19.06,12.39,,,,,,,,,,,,,
BUR SURG DIAMOND 2.5 MM 12 CM MTCH HD PROX MIDAS REX 8 CLRVW,SUP-2632183,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1129.62,734.25,,,,,,,,,,,,,
CONNECTOR SPNL POSTED SCREW SM VERTEX SEL,SUP-2630683,CDM,C1713,HCPCS,0278,RC,,,,both,,,1267.78,824.06,,,,,,,,,,,,,
SCREW BNE CRANIO MAXILLOFACIAL HD TI 2.3MMX11MM CENTRE DRV,SUP-2262628,CDM,C1713,HCPCS,0278,RC,,,,both,,,114.77,74.60,,,,,,,,,,,,,
EPOETIN ALFA-EPBX 4000 UNIT/ML IJ SOLN|DISCARDED DRUG NOT ADMINISTE,RX-142363,CDM,Q5106,HCPCS,0636,RC,00069-1307-10,NDC,JW,both,1,ML,130.20,84.63,,,,,,,,,,,,,
GRAFT DERMAL RECT 5.9X11.8 IN ANTIBACT XENMATRIX AB,SUP-2855242,CDM,C1781,HCPCS,0278,RC,,,,both,,,48663.72,31631.42,,,,,,,,,,,,,
HC Perq Lumbosacral Injection,PX-3612251100,CDM,22511,CPT,0361,RC,,,,both,,,10303.00,6696.95,,,,,,,,,,,,,
WIRE FIX KIRSCHNER 110118] ZIMMER SPINE],SUP-2414586,CDM,C1769,HCPCS,0272,RC,,,,both,,,131.88,85.72,,,,,,,,,,,,,
SPACER SPNL 6 DEG 60X20X10-7.9 MM TITAN TI STRL ANTERALIGN,SUP-2859352,CDM,C1889,HCPCS,0278,RC,,,,both,,,15072.00,9796.80,,,,,,,,,,,,,
PATCH CV GORTX NOM L 15 X W 2.5 CM THK 0.6 MM EPTFE CNFRM,SUP-2395300,CDM,C1768,CPT,0278,RC,,,,both,,,1416.14,920.49,,,,,,,,,,,,,
SCREW SET LAG GLOB ITST,SUP-2861293,CDM,C1713,HCPCS,0278,RC,,,,both,,,15155.46,9851.05,,,,,,,,,,,,,
CONNECTOR SPNL RT POST TI FIX MINI OFFSET SLT XLNK TRNSVRS,SUP-2256192,CDM,C1713,HCPCS,0278,RC,,,,both,,,2996.03,1947.42,,,,,,,,,,,,,
KIT INTRO VSI DE-CLOT SHTH L 4 CM DIA 6 FR GUIDEWIRE L 40 CM,SUP-2120537,CDM,C1757,HCPCS,0272,RC,,,,both,,,141.30,91.84,,,,,,,,,,,,,
PLATE BNE 16 H SS LT PELV ANTR CLMN ANAT STRL PRO,SUP-2902438,CDM,C1713,HCPCS,0278,RC,,,,both,,,7084.15,4604.70,,,,,,,,,,,,,
PROSTHESIS OSS L 9 MM SHFT DIA1 MM HD DIA 3.25 MM HA FLX H/A,SUP-2901965,CDM,L8613,CPT,0278,RC,,,,both,,,1338.90,870.28,,,,,,,,,,,,,
STEM FEM L170MM OD34MM ID9MM CALCAR HIP 1 PC H MLRY HD,SUP-2403604,CDM,C1776,CPT,0278,RC,,,,both,,,20334.64,13217.52,,,,,,,,,,,,,
CATHETER CV SINGLE LUMEN 0.018 IN 5 FRX60 CM 65 CM SIL,SUP-2168371,CDM,C1751,HCPCS,0278,RC,,,,both,,,271.55,176.51,,,,,,,,,,,,,
TROCAR SURG 4.3 MM ANK INTLOK,SUP-2457905,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2177.75,1415.54,,,,,,,,,,,,,
PLATE BNE 2 H COMPR,SUP-2321439,CDM,C1713,HCPCS,0278,RC,,,,both,,,3520.73,2288.47,,,,,,,,,,,,,
BLADE SAW 54X10 MM STRNM FOR PRIMARY,SUP-2607459,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3353.52,2179.79,,,,,,,,,,,,,
SYRINGE KIT 60 CC,SUP-2418960,CDM,2720000010,LOCAL,0272,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
PLATE BNE W10.2XL104MM THK2.7MM 8 H BILAT S STL STR LO PROF,SUP-2186195,CDM,C1713,HCPCS,0278,RC,,,,both,,,1435.55,933.11,,,,,,,,,,,,,
GUIDEWIRE VASC STYL S52ZYJD,SUP-2616264,CDM,C1769,HCPCS,0272,RC,,,,both,,,67.51,43.88,,,,,,,,,,,,,
CATHETER CARD ABLATION THERMOCOOL SF L 115 CM 8 FR B-B CRV,SUP-2727177,CDM,C2630,CPT,0272,RC,,,,both,,,4920.38,3198.25,,,,,,,,,,,,,
IMPLANT OTO L4MM PIST DIA0.6MM WELL DIA1MM FLROPLAS RICHARDS,SUP-2312589,CDM,L8613,CPT,0278,RC,,,,both,,,323.26,210.12,,,,,,,,,,,,,
GRAFT ALLGRFT TEND PAT WHL FRZN,SUP-2335546,CDM,C1713,HCPCS,0278,RC,,,,both,,,15684.30,10194.79,,,,,,,,,,,,,
PLATE BNE STR 4 HOLE LATTICE LCK,SUP-2107935,CDM,C1713,HCPCS,0278,RC,,,,both,,,5325.44,3461.54,,,,,,,,,,,,,
IMPLANT COSMETIC SZ 52 X 27 X 4 MM MED POLYETHYL LT MALAR,SUP-2934191,CDM,C1713,HCPCS,0278,RC,,,,both,,,1767.82,1149.08,,,,,,,,,,,,,
COMPONENT FEM SZ 6 R POST STBL PRI STEMLESS NP UNISX PROFIX,SUP-2347025,CDM,C1776,CPT,0278,RC,,,,both,,,10526.07,6841.95,,,,,,,,,,,,,
KIT CATH 12FR L16CM POLYUR CTRL VEN ANTIMIC 3 LUMN,SUP-2120608,CDM,C1751,HCPCS,0278,RC,,,,both,,,476.65,309.82,,,,,,,,,,,,,
MESO BIOMATRIX 4CM W X5CML X 03MM THICK,SUP-2675732,CDM,C1763,HCPCS,0278,RC,,,,both,,,1972.92,1282.40,,,,,,,,,,,,,
INTRODUCER SHTH PERC 0.035 IN 8.5 FRX10 CM KT VLV SIDE PRT,SUP-2383949,CDM,C1894,HCPCS,0272,RC,,,,both,,,91.53,59.49,,,,,,,,,,,,,
PACEMAKER CARD ADAPTA SM 2 CHMBR IS1 BIPOLAR/UNIPOLAR CONN,SUP-2282312,CDM,C1785,HCPCS,0275,RC,,,,both,,,10766.90,6998.48,,,,,,,,,,,,,
CONNECTOR ROD Y OFFSET FOR SM ROD REVERE ADDITION,SUP-2230100,CDM,C1713,HCPCS,0278,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
POST SHRT 44MM,SUP-2469399,CDM,2720000010,LOCAL,0272,RC,,,,both,,,321.54,209.00,,,,,,,,,,,,,
SCREW ARTHROERESIS SUBTALAR 8MM DIA 14MML CONIC SFT THRD TI,SUP-2388615,CDM,C1713,HCPCS,0278,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
CATHETER IV REINF TIP 18 GAX8 CM FULL TY POWERGLIDE PRO,SUP-2125668,CDM,C1751,HCPCS,0278,RC,,,,both,,,354.82,230.63,,,,,,,,,,,,,
PLATE BNE L24MM 4 H TI DYN LOK COMPR FOR 2MM SCR MOD HND,SUP-2191479,CDM,C1713,HCPCS,0278,RC,,,,both,,,1018.21,661.84,,,,,,,,,,,,,
ANCHOR SUTURE DIA 3.9 MM LOOP 1.7 MM BIOCOMP SWIVELOCK FT CC,SUP-2882180,CDM,C1713,HCPCS,0278,RC,,,,both,,,8776.30,5704.59,,,,,,,,,,,,,
PIN FIX TROCAR PT 1 END 1/8X9 IN 1 PT STYL SMOOTH PLN STRL,SUP-2150446,CDM,C1713,HCPCS,0278,RC,,,,both,,,15.98,10.39,,,,,,,,,,,,,
PLATE BNE W12XL87MM THK1MM 5 H BILAT S STL SEMI TBLR LO,SUP-2184866,CDM,C1713,HCPCS,0278,RC,,,,both,,,310.08,201.55,,,,,,,,,,,,,
HC Perq Vert Agmntj Cavity Crtj Uni/Bi Cannulj Lmbr,PX-3612251400,CDM,22514,CPT,0361,RC,,,,both,,,10303.00,6696.95,,,,,,,,,,,,,
CATHETER JEJUNOSTOMY 12 FRX72 CM 20 SP UTHANE,SUP-2168465,CDM,C1713,HCPCS,0278,RC,,,,both,,,409.24,266.01,,,,,,,,,,,,,
BIT DRL L270MM DIA3.8MM 3 FLUT QUIK CPL NONRADIOLUCENT W/O,SUP-2178939,CDM,2720000010,LOCAL,0272,RC,,,,both,,,661.41,429.92,,,,,,,,,,,,,
HC So1 Ptt|NOT REASONABLE AND NECESSARY,PX-3058573067,CDM,85730,CPT,0305,RC,,,GZ,both,,,36.00,23.40,,,,,,,,,,,,,
INSERT TIB SZ 2 THK12MM STD R KNEE POLYETH CRUCE RET PRI,SUP-2304696,CDM,C1776,CPT,0278,RC,,,,both,,,3067.78,1994.06,,,,,,,,,,,,,
GRAFT VASC HEMSHLD PLAT L 60 CM DIA20 MM POLYESTER BOV CLLGN,SUP-2227720,CDM,C1768,CPT,0278,RC,,,,both,,,2732.52,1776.14,,,,,,,,,,,,,
SUPPORT ORTHOT LOWER EXTREMITY CUST REINF SLD STIRRUP,SUP-2435656,CDM,L2260,HCPCS,0274,RC,,,,both,,,530.66,344.93,,,,,,,,,,,,,
CURETTE SURG BRUNS 0 22.9 CM 5.6X5 MM BNE STR OVL CUP SS NS,SUP-2482213,CDM,2720000010,LOCAL,0272,RC,,,,both,,,372.59,242.18,,,,,,,,,,,,,
COIL EMB L3CM OD25MM 360DEG HELI USFT STRTCH RESIST BIG,SUP-2365768,CDM,C1889,HCPCS,0278,RC,,,,both,,,6800.61,4420.40,,,,,,,,,,,,,
SEMI-TUBULAR PL 12X199MM,SUP-2818488,CDM,C1713,HCPCS,0278,RC,,,,both,,,977.70,635.50,,,,,,,,,,,,,
PLATE BONE PRECONTOURED 1.5 MM LEFT 7X23 HOLE RECONSTRUCTION,SUP-2842351,CDM,C1713,HCPCS,0278,RC,,,,both,,,6772.04,4401.83,,,,,,,,,,,,,
KIT INTRO VSI L 30 CM DIA 4 FR GUIDEWIRE L 80 CM DIA 0.018,SUP-2763441,CDM,C1894,HCPCS,0272,RC,,,,both,,,97.97,63.68,,,,,,,,,,,,,
NEEDLE KYPHOPLASTY 13GA L5IN LNG 90 HALF DOSE,SUP-2363252,CDM,C1713,HCPCS,0278,RC,,,,both,,,7536.00,4898.40,,,,,,,,,,,,,
SD BLADE XD 25 402 99 1.0MM SYSTEM,SUP-2667829,CDM,2720000010,LOCAL,0272,RC,,,,both,,,613.30,398.64,,,,,,,,,,,,,
HALF PIN FIX BOLT 4 MM,SUP-2820651,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1538.13,999.78,,,,,,,,,,,,,
OXYGENATOR PERFSN 215 ML BIOLINE COAT AD DIFFUS MEMBRN SCREW,SUP-2908605,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4632.54,3011.15,,,,,,,,,,,,,
BIT DRL L100MM DIA2.7MM,SUP-2247469,CDM,2720000010,LOCAL,0272,RC,,,,both,,,91.06,59.19,,,,,,,,,,,,,
SCREW BNE L16MM TI HND WRST ANK FT FULL THRD COMPR HDLSS,SUP-2107210,CDM,C1713,HCPCS,0278,RC,,,,both,,,596.60,387.79,,,,,,,,,,,,,
HEAD HUM L15MM DIA40MM 3.5MM OFFSET PROX SHLDR COAT FOR,SUP-2388545,CDM,C1776,CPT,0278,RC,,,,both,,,5769.75,3750.34,,,,,,,,,,,,,
DURVALUMAB 120 MG/2.4ML IV SOLN,RX-138610,CDM,J9173,HCPCS,0636,RC,00310-4500-12,NDC,,both,2.4,ML,2968.50,1929.52,,,,,,,,,,,,,
CONNECTOR CSF RT ANGLE 1X2 MM RADIOPAQUE POLYPR STRL,SUP-2851298,CDM,C1889,HCPCS,0278,RC,,,,both,,,1399.78,909.86,,,,,,,,,,,,,
LINER ACET SZ 3 ID28MM 0DEG POLY ARCM LOK RNG HI RIM RNGLOC,SUP-2403698,CDM,C1776,CPT,0278,RC,,,,both,,,2797.74,1818.53,,,,,,,,,,,,,
COIL EMB FRAME 0.010 IN 6 MMX26 CM SPHR CERECYTE PRESIDIO,SUP-2466410,CDM,C1889,HCPCS,0278,RC,,,,both,,,9650.10,6272.56,,,,,,,,,,,,,
PLATE BNE PATELLAR 2.4/2.7 MM LAT VA LCK RIM SS STRL,SUP-2750830,CDM,C1713,HCPCS,0278,RC,,,,both,,,6805.51,4423.58,,,,,,,,,,,,,
PLATE BNE L 107 MM SCREW DIA2.7 MM 12 SHFT H TI ADPT COMB,SUP-2907698,CDM,C1713,HCPCS,0278,RC,,,,both,,,3290.41,2138.77,,,,,,,,,,,,,
PLATE SPNL CERV ANT UNIV 2 LEV TI 12 H 39MM LEN STD SPIDER,SUP-2402148,CDM,C1713,HCPCS,0278,RC,,,,both,,,5286.03,3435.92,,,,,,,,,,,,,
SCREW SPNL 11X35 MM STRL FIREBIRD SI,SUP-2657863,CDM,C1713,HCPCS,0278,RC,,,,both,,,9812.50,6378.12,,,,,,,,,,,,,
PLATE SPNL 2 LEV 6 H ANTR CERV L38MM SNOWCAP,SUP-2207832,CDM,C1713,HCPCS,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
ADAPTER BASEPLT GLEN VERSA-DIAL STD 25 MM,SUP-2421377,CDM,C1776,CPT,0278,RC,,,,both,,,569.91,370.44,,,,,,,,,,,,,
SCREW PEDCL SPNL CLOSE TI 6MMDIA 35MMLGTH 4.75MM THCK,SUP-2415696,CDM,C1713,HCPCS,0278,RC,,,,both,,,2474.07,1608.15,,,,,,,,,,,,,
EXEMESTANE 25 MG PO TABS,RX-26551,CDM,6370000000,HCPCS,0637,RC,00832-0595-30,NDC,,both,1,UN,15.00,9.75,,,,,,,,,,,,,
PLATE BNE L53MM 3 H BILAT S STL T SHP LO PROF RIG NEUT,SUP-2186301,CDM,C1713,HCPCS,0278,RC,,,,both,,,1468.11,954.27,,,,,,,,,,,,,
TRAY CATH HEMODIALYSI NIAG SLIM CATH ACTE 12FR DIA 12.5CML I,SUP-2613234,CDM,C1752,HCPCS,0278,RC,,,,both,,,678.24,440.86,,,,,,,,,,,,,
MATRIX VERIT CLLGN 6X18CM,SUP-2130300,CDM,C9354,HCPCS,0278,RC,,,,both,,,9486.82,6166.43,,,,,,,,,,,,,
NAIL IM BLNT TIP 4X40 MM HUM STRL AFFIXUS NAT NAIL,SUP-2606842,CDM,C1713,HCPCS,0278,RC,,,,both,,,606.02,393.91,,,,,,,,,,,,,
AUGMENT TIB SZ 5/4+ THK5MM NP PRI CEM BLK BASE ADV,SUP-2304780,CDM,C1776,CPT,0278,RC,,,,both,,,3111.74,2022.63,,,,,,,,,,,,,
WIRE TENSIONER FOR SIDEKCK FRDM CIR FIX,SUP-2400681,CDM,2720000010,LOCAL,0272,RC,,,,both,,,763.02,495.96,,,,,,,,,,,,,
KIT SPNL H 35 MM DIA19 MM MED BLACKARMOR CARBON PEEK THORLUM,SUP-2917136,CDM,C1889,HCPCS,0278,RC,,,,both,,,11304.00,7347.60,,,,,,,,,,,,,
GRAFT BNE TISS DOWELS WDG FIBULAR THICKNESS 6MM 9 13MM,SUP-2307134,CDM,C1713,HCPCS,0278,RC,,,,both,,,1870.97,1216.13,,,,,,,,,,,,,
BRACE WALKING LP XL 14-17 IN AD M FOAM MAXTRAX AIR,SUP-2427325,CDM,L4360,HCPCS,0272,RC,,,,both,,,97.50,63.37,,,,,,,,,,,,,
BIT DRL DIA2.3MM DISP FOR ICONIX,SUP-2366697,CDM,2720000010,LOCAL,0272,RC,,,,both,,,691.68,449.59,,,,,,,,,,,,,
COMPONENT FEM SZ 5 LT OXINIUM ZIRCON POST STBL PRI STEMLESS,SUP-2347028,CDM,C1776,CPT,0278,RC,,,,both,,,10439.72,6785.82,,,,,,,,,,,,,
DEFIBRILLATOR CRD 5.23X7.14X0.99 CM 2 IS1 DF1 PERCIVA DR,SUP-2149181,CDM,C1721,HCPCS,0275,RC,,,,both,,,40192.00,26124.80,,,,,,,,,,,,,
ALLOGRAFT BNE CUBE 9X9X9 MM 0.7 CC DEMINERALIZED CONFORM,SUP-2737080,CDM,C1713,HCPCS,0278,RC,,,,both,,,1414.57,919.47,,,,,,,,,,,,,
BIT DRL L 205/110 MM DIA2.5 MM CALIB AO QC STRL DISP V,SUP-2908406,CDM,2720000010,LOCAL,0272,RC,,,,both,,,956.13,621.48,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 1-24 CM FASC,SUP-2321778,CDM,C1762,CPT,0278,RC,,,,both,,,2496.30,1622.59,,,,,,,,,,,,,
PIPERACILLIN SOD-TAZOBACTAM SO 3.375 (3-0.375) G IV SOLR,RX-18303,CDM,J2543,HCPCS,0636,RC,60505-6157-04,NDC,,both,1,UN,54.10,35.16,,,,,,,,,,,,,
CROWN DENT 7 LO LT SEC PRI M S STL GLD PREFABRICATED REPL,SUP-2322220,CDM,D6783,CPT,0278,RC,,,,both,,,25.09,16.31,,,,,,,,,,,,,
STENT BILI V SYS L 70 MM DIA10 FR CHANNEL 4.2 MM POLYETHYL,SUP-2313491,CDM,C1877,HCPCS,0278,RC,,,,both,,,134.71,87.56,,,,,,,,,,,,,
TROCAR ENDOSCP L90MM DIA5MM SHT CANN DIL W/ RADIALLY SELF,SUP-2283338,CDM,2720000010,LOCAL,0272,RC,,,,both,,,416.65,270.82,,,,,,,,,,,,,
FILIFORM URO 3FR L18IN WVN STR TIP REUSE,SUP-2128948,CDM,C1726,HCPCS,0272,RC,,,,both,,,105.66,68.68,,,,,,,,,,,,,
CATHETER ETER EP 7FR 120CM 2 15 1MM 2MM TIP UNIDIR M CRV STEER,SUP-2356883,CDM,C1730,HCPCS,0272,RC,,,,both,,,1252.86,814.36,,,,,,,,,,,,,
BIT DRL QC 2.5X135 MM 45 MM CALIB STRL,SUP-2563749,CDM,2720000010,LOCAL,0272,RC,,,,both,,,390.84,254.05,,,,,,,,,,,,,
CONNECTOR SPNL ROD 5.5X70 MM STR TI CD HORZ,SUP-2631077,CDM,C1713,HCPCS,0278,RC,,,,both,,,4713.14,3063.54,,,,,,,,,,,,,
ANCHOR SUT DIA5MM BIOZIP PLLA TWO STRND FORC FBR SEP CHN,SUP-2366665,CDM,C1713,HCPCS,0278,RC,,,,both,,,6908.00,4490.20,,,,,,,,,,,,,
SHEATH INTRO HEARTSPAN L 74 CM DIA 8.5 FR CRV L 16.4 CM,SUP-2677051,CDM,C1893,HCPCS,0272,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
LNG BRIDGE W/23MM POSTS,SUP-2908967,CDM,C1713,HCPCS,0278,RC,,,,both,,,11147.00,7245.55,,,,,,,,,,,,,
GUIDEWIRE VASC L 260 CM TIP 3 MM DIA 0.035 IN SS PTFE J FIX,SUP-2120078,CDM,C1769,HCPCS,0272,RC,,,,both,,,71.44,46.44,,,,,,,,,,,,,
HEAD HUM CEM 8 REG STD SHLDR RESURF STEM COCR MACROBOND,SUP-2403984,CDM,C1776,CPT,0278,RC,,,,both,,,9580.14,6227.09,,,,,,,,,,,,,
GRAFT HUM TISS L 220 MM DIA 8 MM POST TIBIALIS TEND FRZN,SUP-2913415,CDM,C1762,CPT,0278,RC,,,,both,,,7272.24,4726.96,,,,,,,,,,,,,
ELECTRODE ELECSURG RF 150 MM SELF GRND NITRODE,SUP-2366983,CDM,C1713,HCPCS,0278,RC,,,,both,,,9003.67,5852.39,,,,,,,,,,,,,
CATHETER HAD L36CM INSRT L19CM PALINDROME,SUP-2283914,CDM,C1750,HCPCS,0278,RC,,,,both,,,1008.38,655.45,,,,,,,,,,,,,
SPACER SPNL EXPANDABLE SM COR PROC POST FUSION AILERON-TRX,SUP-2430757,CDM,C1889,HCPCS,0278,RC,,,,both,,,10362.00,6735.30,,,,,,,,,,,,,
GRAFT BIO TISS W7XL20CM 4 LAYR PORCINE MTRX SFT TISS REINF,SUP-2168771,CDM,C1781,HCPCS,0278,RC,,,,both,,,2983.00,1938.95,,,,,,,,,,,,,
SPACER SPNL W32XH13.5MM D26MM 8DEG ANT LUM INTBDY FUS G,SUP-2182848,CDM,C1821,HCPCS,0278,RC,,,,both,,,14444.00,9388.60,,,,,,,,,,,,,
CANNULA SURG 12 MM STPLR ENDOWRIST,SUP-2246756,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4122.82,2679.83,,,,,,,,,,,,,
RAVULIZUMAB-CWVZ 1100 MG/11ML IV SOLN|DISCARDED DRUG NOT ADMINISTE,RX-152087,CDM,J1303,HCPCS,0636,RC,25682-0028-01,NDC,JW,both,11,ML,70655.40,45926.01,,,,,,,,,,,,,
ALLOGRAFT BNE CRYOPRESERVED LT TALUS,SUP-2867078,CDM,C1762,CPT,0278,RC,,,,both,,,9262.22,6020.44,,,,,,,,,,,,,
DISTRACTOR BTTRSS FOOT PLATE SHRT 3 HOLE BI DRCTNL MXLLRY DV,SUP-2681265,CDM,C1713,HCPCS,0278,RC,,,,both,,,3288.93,2137.80,,,,,,,,,,,,,
PLATE BONE SM LT CALCNL FX BTTRS SINUS TARSI APPRCH GORILLA,SUP-2321442,CDM,C1713,HCPCS,0278,RC,,,,both,,,4780.65,3107.42,,,,,,,,,,,,,
GRAFT BIO TISS W30XL30CM RECON TISS MTRX FIRM STRATTICE,SUP-2113043,CDM,Q4130,HCPCS,0636,RC,,,,both,,,86528.98,56243.84,,,,,,,,,,,,,
SCREW BNE CANN 3.5X10 MM SD FT SS,SUP-2409798,CDM,C1713,HCPCS,0278,RC,,,,both,,,542.59,352.68,,,,,,,,,,,,,
HC Iadna Streptococcus Group a Amplified Probe Tq,PX-3068765100,CDM,87651,CPT,0306,RC,,,,both,,,118.00,76.70,,,,,,,,,,,,,
BIT DRL REUSE NONSTERILE 160MM,SUP-2291551,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3347.84,2176.10,,,,,,,,,,,,,
GRAFT VASC W6XL12CM THK0.1MM PERICARD EPTFE MEM PRECL,SUP-2395368,CDM,C1768,CPT,0278,RC,,,,both,,,1271.70,826.60,,,,,,,,,,,,,
ORTHO ANCHRGE PLATE 4 HLE STRGHT 30MM BRDGE CP TTNM,SUP-2497257,CDM,C1713,HCPCS,0278,RC,,,,both,,,814.39,529.35,,,,,,,,,,,,,
GUIDEWIRE VASC L180CM DIA0.035IN S STL COR SLX STEER SFT,SUP-2157309,CDM,C1769,HCPCS,0272,RC,,,,both,,,194.05,126.13,,,,,,,,,,,,,
KIT KYPHOPLASTY L 15 MM DIA13 GA VERT AUG INFLATABLE SYS,SUP-2930269,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4777.51,3105.38,,,,,,,,,,,,,
UNIT THER COMB CRYO W/ PD KNEE W/ TUBE PWR OPERATED W/ BD,SUP-2150871,CDM,C1713,HCPCS,0278,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
KIT FTPLT SUPP MAXFRAME,SUP-2176969,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2674.31,1738.30,,,,,,,,,,,,,
SPLINT THMB AD M L BGE R MCP CMC JT PREFRM PERF FLX BASE LAM,SUP-2326183,CDM,L3908,HCPCS,0272,RC,,,,both,,,65.81,42.78,,,,,,,,,,,,,
HC Gastric/Duodenal Motility &/or Manometry Study,PX-3609015500,CDM,3609015500,LOCAL,0750,RC,,,,inpatient,,,1657.00,1077.05,,,,,,,,,,,,,
HC So Somato Medin - C,PX-3018430566,CDM,84305,CPT,0301,RC,,,,both,,,255.00,165.75,,,,,,,,,,,,,
SPLINT ARM M L85IN L ALUMINUM FOAM PD MAL COLLES,SUP-2276767,CDM,L3809,HCPCS,0274,RC,,,,both,,,14.10,9.16,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 70 CM DIA 6MM STR TW REINF SLDE GDS,SUP-2695234,CDM,C1768,CPT,0278,RC,,,,both,,,2189.21,1422.99,,,,,,,,,,,,,
PLATE BNE NAR 4.5X215 MM 13 HOLE SS DCP,SUP-2569171,CDM,C1713,HCPCS,0278,RC,,,,both,,,374.76,243.59,,,,,,,,,,,,,
PLATE BNE HS RT 8 HOLE STRATUM RS,SUP-2861980,CDM,C1713,HCPCS,0278,RC,,,,both,,,2813.75,1828.94,,,,,,,,,,,,,
SPHINCTEROTOME ENDOSCP 0.035 IN 7 FRX205 CM DOME FUSION OMNI,SUP-2737414,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1186.92,771.50,,,,,,,,,,,,,
SYSTEM MENIS REP RVS CRV ASMBLY FAST-FIX,SUP-2341589,CDM,C1713,HCPCS,0278,RC,,,,both,,,849.87,552.42,,,,,,,,,,,,,
CATHETER CV TY 7 FRX20 CM 3L CUTLMY701JABRMCUSTOM0036,SUP-2759808,CDM,C1751,HCPCS,0278,RC,,,,both,,,429.14,278.94,,,,,,,,,,,,,
GUIDEWIRE PRESSURE VERRATA + L 300 CM DIA 0.014 IN TIP L 3,SUP-2327201,CDM,C1769,HCPCS,0272,RC,,,,both,,,2279.64,1481.77,,,,,,,,,,,,,
HC 2-D-Echo-Lmt,PX-4839330800,CDM,93308,CPT,0483,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
HC Pt Therapeutic Activities 15 Min|OP OCCUPATIONAL THERAPY SERV|SERVICES PROVIDED IN WHOLE OR IN PARTY BY AN OTA FOR MEDICARE PATIENTS,PX-4209753000,CDM,97530,CPT,0420,RC,,,GO|CO,both,,,144.00,93.60,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED FEM TIB GUIDEPIN K3AARTHREX] ARTHREX INC],SUP-2123481,CDM,C1776,CPT,0278,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
DRILL SURG GLEN INVERSE ANAT SHLDR,SUP-2440739,CDM,2720000010,LOCAL,0272,RC,,,,both,,,649.98,422.49,,,,,,,,,,,,,
HC ED Clsd Tx Radial Head/Neck Fx Manip,PX-4502465500,CDM,24655,CPT,0450,RC,,,,both,,,1633.00,1061.45,,,,,,,,,,,,,
CAGE SPNL 18X41 TO 65MM EXPANDABLEXCORE,SUP-2310742,CDM,C1889,HCPCS,0278,RC,,,,both,,,12560.00,8164.00,,,,,,,,,,,,,
VALVE CSF M PRSS W/ ASD,SUP-2308212,CDM,C1889,HCPCS,0278,RC,,,,both,,,5226.22,3397.04,,,,,,,,,,,,,
IMPL SHOULDER BEARING 36MM +3,SUP-2418103,CDM,C1776,CPT,0278,RC,,,,both,,,5903.20,3837.08,,,,,,,,,,,,,
SCREW BONE L20MM OD5MM ANK CANN LAG TAPR INTOSS FIX IOFIX +,SUP-2223853,CDM,C1713,HCPCS,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
FENTANYL CITRATE (PF) 1000 MCG/20ML IJ SOLN,RX-133095,CDM,J3010,HCPCS,0636,RC,00409-9094-31,NDC,,both,0.5,ML,54.10,35.16,,,,,,,,,,,,,
LAT TIB HEAD BUTT PLT STERILIZER 7HL 149 MM LT,SUP-2820745,CDM,C1713,HCPCS,0278,RC,,,,both,,,5436.75,3533.89,,,,,,,,,,,,,
SCREW BNE CONCL 2.7X38 MM PERIARTICULAR,SUP-2457639,CDM,C1713,HCPCS,0278,RC,,,,both,,,227.71,148.01,,,,,,,,,,,,,
MICROCATHETER ETER VASC PROXIMAL DISTAL 3X24FR L155CM LUMN,SUP-2141053,CDM,C1887,HCPCS,0272,RC,,,,both,,,1868.30,1214.39,,,,,,,,,,,,,
SPONGE HEMSTAT W3XL4IN WHT CLLGN ABSRB PLIABLE NONFRIABLE,SUP-2243493,CDM,C1713,HCPCS,0278,RC,,,,both,,,771.62,501.55,,,,,,,,,,,,,
PROSTHESIS OSS CENTERED 2.00 MM BYTE PART ADJ TI,SUP-2461178,CDM,L8613,CPT,0278,RC,,,,both,,,1194.36,776.33,,,,,,,,,,,,,
HC So Nephelometry Ea Analyte Nes,PX-3018388366,CDM,83883,CPT,0301,RC,,,,both,,,53.00,34.45,,,,,,,,,,,,,
IMPLANT NSL L 55 X W 4 MM THK 4 MM PET POLYETHYL DORSUM TAPR,SUP-2883448,CDM,C1889,HCPCS,0278,RC,,,,both,,,1036.29,673.59,,,,,,,,,,,,,
HC CT Abd W&W/O Cont,PX-3527417000,CDM,74170,CPT,0352,RC,,,,both,,,1973.00,1282.45,,,,,,,,,,,,,
COMPONENT GLEN FIX METAGLENE GLOB UNITE PLATFRM SHLDR SYS,SUP-2251010,CDM,C1776,CPT,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
PLATE BNE SM W11XL103MM THK3.3MM 0DEG 7 H BILAT TI STR,SUP-2190780,CDM,C1713,HCPCS,0278,RC,,,,both,,,600.31,390.20,,,,,,,,,,,,,
VALVE AORT CRYOVALVE SZ 22 MM AORT ALLGRFT NONROTATABLE,SUP-2175205,CDM,C1889,HCPCS,0278,RC,,,,both,,,34524.30,22440.79,,,,,,,,,,,,,
PLATE BNE W102XL208MM THK27MM RAD 88MM 16 H R PELV S STL J,SUP-2186282,CDM,C1713,HCPCS,0278,RC,,,,both,,,2117.84,1376.60,,,,,,,,,,,,,
LEAD PACE STR 7 FRX46 CM ENDOCARD OPTIM INSUL ISOFLEX,SUP-2356691,CDM,C1898,HCPCS,0275,RC,,,,both,,,219.80,142.87,,,,,,,,,,,,,
PLATE L FUSION VA LCP 2.4/2.7MM STD RT TI STRL,SUP-2546992,CDM,C1713,HCPCS,0278,RC,,,,both,,,2692.55,1750.16,,,,,,,,,,,,,
HC So Antidepressant Tricyclic 1/2,PX-3018033566,CDM,G0480,CPT,0301,RC,,,,inpatient,,,380.00,247.00,,,,,,,,,,,,,
NAIL IM L320MM DIA10MM FEM TIB KNEE G TI CANN LOK AG RG,SUP-2347084,CDM,C1713,HCPCS,0278,RC,,,,both,,,5083.60,3304.34,,,,,,,,,,,,,
GRAFT BONE SUB 5ML PUTTY CA PHOS SYNTH GRAN BIOABSRB ATTRAX,SUP-2310453,CDM,C1763,HCPCS,0278,RC,,,,both,,,2241.96,1457.27,,,,,,,,,,,,,
COMPONENT GLEN FIX SM EDGE 4X6.8MM 8DEG LT POST AUG SHLDR,SUP-2223355,CDM,C1776,CPT,0278,RC,,,,both,,,3925.00,2551.25,,,,,,,,,,,,,
SUPPORT ORTHOT WRST HND CUST TURNBUCKLE W/NONTORSION JT,SUP-2435777,CDM,L3916,HCPCS,0272,RC,,,,both,,,1369.64,890.27,,,,,,,,,,,,,
APPLIER CLP M-L L55.6CM JAW L2.1CM DIA8MM 0-35DEG OPN ANG,SUP-2246686,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4396.00,2857.40,,,,,,,,,,,,,
PLATE BNE CLAV CS1 2.7 MM RT LAT VA LCK COMPR SS NS VA-LCP,SUP-2757604,CDM,C1713,HCPCS,0278,RC,,,,both,,,3347.24,2175.71,,,,,,,,,,,,,
STENT NSL L16MM DIA4MM 370UG MINI MOMETASONE FUROATE LO,SUP-2246418,CDM,C2625,HCPCS,0278,RC,,,,both,,,3406.90,2214.48,,,,,,,,,,,,,
IMPLANT TIB L30MM DIA10MM CANN DRVR FIX DEV APERFIX II,SUP-2402623,CDM,C1776,CPT,0278,RC,,,,both,,,1927.96,1253.17,,,,,,,,,,,,,
NUT SPNL PEDCL 12.7 MM SCREW LCK SILHOUETTE HEX,SUP-2414395,CDM,C1713,HCPCS,0278,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
WIRE ORTH SMOOTH SGL SHRP TIP TRCR S STL NONSTERILE 1.1MM,SUP-2304033,CDM,C1713,HCPCS,0278,RC,,,,both,,,16.39,10.65,,,,,,,,,,,,,
MESH GORE SYNECOR 35CM X 35CM RECTANGLE,SUP-2763181,CDM,C1781,HCPCS,0278,RC,,,,both,,,29713.82,19313.98,,,,,,,,,,,,,
ELECTRODE NDL W/ EXTRM LAT INTBDY FUS XLIF 90 NV MOD II,SUP-2311745,CDM,C1713,HCPCS,0278,RC,,,,both,,,2533.98,1647.09,,,,,,,,,,,,,
SCREW INTRF L20MM DIA9MM 8.6-9.4MM CANN 1.5MM KNEE POLY L,SUP-2341550,CDM,C1713,HCPCS,0278,RC,,,,both,,,751.72,488.62,,,,,,,,,,,,,
SYSTEM OCCL DEL AMPLATZER 45 DEG L 80 CM SHTH 8 FR NIT MESH,SUP-2116322,CDM,C1817,HCPCS,0278,RC,,,,both,,,1821.20,1183.78,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL PEEK SD800.534,SUP-2860215,CDM,C1713,HCPCS,0278,RC,,,,both,,,38979.33,25336.56,,,,,,,,,,,,,
RETROGRADE FEMORAL NAIL 12MMX44CM,SUP-2811095,CDM,C1713,HCPCS,0278,RC,,,,both,,,7520.30,4888.19,,,,,,,,,,,,,
GRAFT BNE SUB 15ML HA CA PHSPTE INJ DISP HYDROSET,SUP-2374939,CDM,C1713,HCPCS,0278,RC,,,,both,,,10833.00,7041.45,,,,,,,,,,,,,
BUR SURG L18.3MM OD4.7MM LNG BRL TPS,SUP-2363376,CDM,2720000010,LOCAL,0272,RC,,,,both,,,804.03,522.62,,,,,,,,,,,,,
STENT GRFT VASC RELAYPRO L 150 MM CVR L 164 MM DIA 30 MM,SUP-2894701,CDM,C1768,CPT,0278,RC,,,,both,,,59503.00,38676.95,,,,,,,,,,,,,
PLATE BNE THK0.6MM 4 H STD CRANIOMAXILLOFACIAL G TI ORBIT,SUP-2366274,CDM,C1713,HCPCS,0278,RC,,,,both,,,341.82,222.18,,,,,,,,,,,,,
KIT CATH HEMODIALYSI RELIANCE XK CHRONIC STD 16FR DIA 55CM 5,SUP-2613283,CDM,C1750,HCPCS,0278,RC,,,,both,,,1483.65,964.37,,,,,,,,,,,,,
KIT PLT CONC SYS MINI BNE MAR NDL MARROWSTIM BIOCUE,SUP-2402591,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4851.30,3153.34,,,,,,,,,,,,,
HC NM Inject for Neoprobe Study,PX-3407880800,CDM,78808,CPT,0340,RC,,,,both,,,338.00,219.70,,,,,,,,,,,,,
PLATE BONE L65MM THK0.3MM 16 H CRANIOMAXILLOFACIAL TI STR,SUP-2136519,CDM,C1713,HCPCS,0278,RC,,,,both,,,602.88,391.87,,,,,,,,,,,,,
SCREW BONE L4MM DIA2MM GLD CORT CRANIOMAXILLOFACIAL TI ST,SUP-2189659,CDM,C1713,HCPCS,0278,RC,,,,both,,,249.69,162.30,,,,,,,,,,,,,
INSTRUMENT BX 16GA L20CM PEN D22MM ACTUATOR BTTN PUR COR,SUP-2127776,CDM,C1713,HCPCS,0278,RC,,,,both,,,82.77,53.80,,,,,,,,,,,,,
BUR SURG M L64MM DIA2MM NEURO RND CUT FLUT CARB INDIGO,SUP-2284183,CDM,C1713,HCPCS,0278,RC,,,,both,,,562.94,365.91,,,,,,,,,,,,,
KIT REVISION GRAFT BONE DOWEL 16 MM,SUP-2836347,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
VANCOMYCIN HCL 1.5 G IV SOLR,RX-144490,CDM,J3373,HCPCS,0636,RC,00409-3515-01,NDC,,both,1,UN,140.10,91.06,,,,,,,,,,,,,
PLATE BNE 3.5X261 MM 20 HOLE SS LCP,SUP-2569331,CDM,C1713,HCPCS,0278,RC,,,,both,,,590.63,383.91,,,,,,,,,,,,,
CATHETER DRAINAGE 0.038 IN 14 FRX25 CM MP LCK LOOP UTHANE,SUP-2168133,CDM,C1729,HCPCS,0272,RC,,,,both,,,358.93,233.30,,,,,,,,,,,,,
CATHETER ANGIOPLSTY ATLS GLD L 80 CM BALLOON L 4 CM DIA24 MM,SUP-2127963,CDM,C1725,HCPCS,0272,RC,,,,both,,,2464.90,1602.18,,,,,,,,,,,,,
IMPLANT ORBIT W28XL40MM THK7.5MM L LT MALAR EXT ENOPHTHALMOS,SUP-2365319,CDM,C1713,HCPCS,0278,RC,,,,both,,,2003.32,1302.16,,,,,,,,,,,,,
BASEPLATE TIB SZ 1 LT KNEE NP REV CEM STEM MOD FOUNDATION,SUP-2215782,CDM,C1776,CPT,0278,RC,,,,both,,,6893.43,4480.73,,,,,,,,,,,,,
SCREW BNE 30 DEG L 45 MM DIA 3.5 MM TI LCK VA T15 DRV NS,SUP-2931494,CDM,C1713,HCPCS,0278,RC,,,,both,,,488.90,317.78,,,,,,,,,,,,,
INTRODUCER SHTH MANDREL 7 FRX7 CM BOWTIE GUIDE WIRE PRELUDE,SUP-2798460,CDM,C1894,HCPCS,0272,RC,,,,both,,,86.54,56.25,,,,,,,,,,,,,
CATHETER GUID VISTA BRT TIP L 90 CM OD 9 FR ID 0.098 IN NYL,SUP-2158086,CDM,C1887,HCPCS,0272,RC,,,,both,,,414.48,269.41,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED PRIMARY CEM STEM SUMMIT,SUP-2257248,CDM,C1776,CPT,0278,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
CATHETER ART HEP COAT L22 CM OD9.3 FR,SUP-2416141,CDM,C1751,HCPCS,0278,RC,,,,both,,,1629.28,1059.03,,,,,,,,,,,,,
KIT PERC INSRT 17GA SPNL NDL 1.1MM NIT GWIRE PORTAL DIL,SUP-2121523,CDM,2720000010,LOCAL,0272,RC,,,,both,,,690.80,449.02,,,,,,,,,,,,,
PLEDGET SUT SFT OVL 3 8X5 16IN,SUP-2384386,CDM,C1768,CPT,0278,RC,,,,both,,,76.68,49.84,,,,,,,,,,,,,
IMPLANT OP RM MINI-MONSTER 3.0 X 30MM H,SUP-2320887,CDM,C1713,HCPCS,0278,RC,,,,both,,,788.93,512.80,,,,,,,,,,,,,
STENT PERIPH L150MM DIAM 6MM CATH L120CM VASC,SUP-2396486,CDM,C1874,HCPCS,0278,RC,,,,both,,,9796.80,6367.92,,,,,,,,,,,,,
PLATE BONE 1.8MM THICKNESS STRNL LCK 6 H CP TI,SUP-2262573,CDM,C1713,HCPCS,0278,RC,,,,both,,,1828.05,1188.23,,,,,,,,,,,,,
SCREW BONE L16MM DIA3MM STRNL TI SELF DRL LCK 5 PER PK,SUP-2181536,CDM,C1713,HCPCS,0278,RC,,,,both,,,549.37,357.09,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 70 CM DIA 7 MM STR STD WALL HELIX,SUP-2525441,CDM,C1768,CPT,0278,RC,,,,both,,,1657.48,1077.36,,,,,,,,,,,,,
STEM FEM L300MM OD9MM TI POR LAT R HIP PRI CLLRD OFFSET BOW,SUP-2406597,CDM,C1776,CPT,0278,RC,,,,both,,,17847.76,11601.04,,,,,,,,,,,,,
TROCH NAIL RIGHT 12.5MMX42CMX130 DEGREE,SUP-2828988,CDM,C1713,HCPCS,0278,RC,,,,both,,,8462.30,5500.49,,,,,,,,,,,,,
ANKLE FUSION PLATE ANTERIOR TT RIGHT 4H,SUP-2815297,CDM,C1713,HCPCS,0278,RC,,,,both,,,8949.00,5816.85,,,,,,,,,,,,,
COLLAR TRACH H2 1/4IN SM PHIL,SUP-2120429,CDM,L0172,HCPCS,0272,RC,,,,both,,,56.52,36.74,,,,,,,,,,,,,
SYSTEM VITRCTMY L4MM VLV ENTRY EDGEPLUS 27+,SUP-2109960,CDM,2720000010,LOCAL,0272,RC,,,,both,,,495.99,322.39,,,,,,,,,,,,,
ANKLE FUSION PLATE LATERAL TT 4H STRL,SUP-2815341,CDM,C1713,HCPCS,0278,RC,,,,both,,,6986.50,4541.22,,,,,,,,,,,,,
TUBE FEED GASTROJEJU 14FR L22CM STOMA L1.0CM MICRO GJET,SUP-2665175,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
SCREW BONE L3MM OD1.7MM TI CORT CRANIOMAXILLOFACIAL ST LO,SUP-2363420,CDM,C1713,HCPCS,0278,RC,,,,both,,,77.56,50.41,,,,,,,,,,,,,
PLATE BONE 7 H UNIV TI HK,SUP-2319688,CDM,C1713,HCPCS,0278,RC,,,,both,,,6110.44,3971.79,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 120 MM DIA 9 MM DEL SHTH,SUP-2934469,CDM,C1713,HCPCS,0278,RC,,,,both,,,12302.52,7996.64,,,,,,,,,,,,,
SCREW BNE L52MM THRD 55MM HD 67MM S STL LNG THRD CANN,SUP-2389533,CDM,C1713,HCPCS,0278,RC,,,,both,,,2458.62,1598.10,,,,,,,,,,,,,
NAIL IM LNG 11 MMX26 CM LT PERITROCHANTERIC STRL PHOENIX LTX,SUP-2861378,CDM,C1713,HCPCS,0278,RC,,,,both,,,7373.98,4793.09,,,,,,,,,,,,,
ALLOGRAFT BNE DWL 16X30-35 MM PRESERVON XLNG CANC FLEXIGRAFT,SUP-2741077,CDM,C1713,HCPCS,0278,RC,,,,both,,,3783.32,2459.16,,,,,,,,,,,,,
NAIL IM L180MM OD11MM 130DEG S STL TROCHANTERIC LOK CANN,SUP-2371034,CDM,C1713,HCPCS,0278,RC,,,,both,,,2492.38,1620.05,,,,,,,,,,,,,
KIT FEED TB 18FR STOMA L2CM JEJU SIL LO PROF TRIM DST TIP,SUP-2236561,CDM,2720000010,LOCAL,0272,RC,,,,both,,,559.33,363.56,,,,,,,,,,,,,
ENVELOPE PACEMKR M W2.5XL2.7IN ABSRB ANTIBACT TYRX,SUP-2282347,CDM,C1889,HCPCS,0278,RC,,,,both,,,3124.30,2030.79,,,,,,,,,,,,,
ELECTRODE CORTICAL 1 X 4 T TAIL KT STRL DISP EVO,SUP-2934742,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2565.38,1667.50,,,,,,,,,,,,,
PLATE BNE L 76 MM 7 H RT VOLAR DSTL RADIAL WIDE NS VARIAX,SUP-2902168,CDM,C1713,HCPCS,0278,RC,,,,both,,,5198.40,3378.96,,,,,,,,,,,,,
HYOSCYAMINE SULFATE 0.5 MG/ML IJ SOLN,RX-10239,CDM,J1980,HCPCS,0636,RC,54288-0111-05,NDC,,both,0.5,ML,310.50,201.82,,,,,,,,,,,,,
INSTRUMENT SET 3 MM SPHR FEM GMK,SUP-2267695,CDM,C1776,CPT,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
SCREW BNE C 5X75 MM PART THRD PANTA,SUP-2539634,CDM,C1713,HCPCS,0278,RC,,,,both,,,1760.88,1144.57,,,,,,,,,,,,,
LINER ACET SZ 54-58 DIA28MM 5/15DEG MCS GXL,SUP-2221663,CDM,C1776,CPT,0278,RC,,,,both,,,7410.40,4816.76,,,,,,,,,,,,,
SHELL ACET SZ 24 OD64MM 3 H UNIV TI ALLY POR PLSM SPR,SUP-2404804,CDM,C1776,CPT,0278,RC,,,,both,,,4761.81,3095.18,,,,,,,,,,,,,
NUT FOR 4.5MM CORTEX SCW,SUP-2820891,CDM,C1713,HCPCS,0278,RC,,,,both,,,236.19,153.52,,,,,,,,,,,,,
INTRODUCER SFT ENH COAX ACC SYS 13CM STARBURSTXLL,SUP-2117221,CDM,C1894,HCPCS,0272,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
HC Clsd Tx Tibial Fracture,PX-4502753200,CDM,27532,CPT,0450,RC,,,,both,,,3319.00,2157.35,,,,,,,,,,,,,
SCREW SPNL ROD DIA 4.75/5 MM SS UNIAXIAL STRL CD HORZ 4PK,SUP-2928636,CDM,C1713,HCPCS,0278,RC,,,,both,,,10110.80,6572.02,,,,,,,,,,,,,
CATHETER DRAINAGE 14 FRX30 CM KT REG FLEXIMA VAN SONN SUMP,SUP-2147867,CDM,C1729,HCPCS,0272,RC,,,,both,,,753.60,489.84,,,,,,,,,,,,,
CONNECTOR SPNL L19MM OPN LAT RECON VERTEX,SUP-2279736,CDM,C1713,HCPCS,0278,RC,,,,both,,,447.45,290.84,,,,,,,,,,,,,
SET SCR SPNL DIA5.5MM POST CERVICOTHORACOLUMBAR TI CLS,SUP-2311750,CDM,C1713,HCPCS,0278,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
PROBE LASER CRV 23 GA ENDO OCU ILLUMINATING W/ SMA906 CONN,SUP-2713786,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5137.04,3339.08,,,,,,,,,,,,,
PROBE ENDOSCP ARTHSCP 90 DEG 3.5 MM,SUP-2314075,CDM,C1713,HCPCS,0278,RC,,,,both,,,540.08,351.05,,,,,,,,,,,,,
LENS IOL CONVEXOPLANO 10.5+ DIOPT 5.5X13.5 MM,SUP-2431933,CDM,V2630,CPT,0276,RC,,,,both,,,926.30,602.09,,,,,,,,,,,,,
GRAFT BNE CHIP 4-10 MM 30 CC CANC PUREBONE,SUP-2424604,CDM,C1713,HCPCS,0278,RC,,,,both,,,1051.90,683.73,,,,,,,,,,,,,
EXTENSION CONN THORLUM TI SM STAT FOR 6MM ROD USS II,SUP-2193436,CDM,C1713,HCPCS,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
SHEATH INTRO PRELUDE IDEAL L 11 CM DIA 6 FR NIT PD WIRE,SUP-2740597,CDM,C1892,HCPCS,0272,RC,,,,both,,,181.34,117.87,,,,,,,,,,,,,
STEM HUM 6B L109MM 132.5DEG LNG TI CEM AEQUALIS ASCEND FLX,SUP-2388754,CDM,C1776,CPT,0278,RC,,,,both,,,9553.14,6209.54,,,,,,,,,,,,,
PEG 4.0MM X 25.0MM THRD S STL S3 PROX HUM PLATING SYS,SUP-2414223,CDM,C1776,CPT,0278,RC,,,,both,,,360.44,234.29,,,,,,,,,,,,,
LENS INTOCU +27.0 DIOPT L13.5MM DIA6MM AC D5.2MM 5DEG UV,SUP-2247701,CDM,V2632,HCPCS,0276,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
TISSUE BIO MATRIDERM 21 X 29.7CM 2MM LG,SUP-2866496,CDM,A2027,HCPCS,0636,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
SPLINT ORTH AD L24IN FOR 29IN THGH UNIV KNEE FOAM,SUP-2196749,CDM,L1830,CPT,0274,RC,,,,both,,,47.19,30.67,,,,,,,,,,,,,
PROSTHESIS OSS MIC 3X1.5 MM 1 MM MONOLITHIC CENTERED TI PORP,SUP-2638166,CDM,L8613,CPT,0278,RC,,,,both,,,1056.70,686.85,,,,,,,,,,,,,
HANDPIECE LASER LAP-R FIBERLASE,SUP-2713721,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6179.52,4016.69,,,,,,,,,,,,,
SET URET STENT UTHANE L 26 CM DIA 6-9.5 FR PROX SEG L 13 CM,SUP-2835749,CDM,C2617,HCPCS,0278,RC,,,,both,,,431.09,280.21,,,,,,,,,,,,,
PROBE SURG NERVE PEDCL STR ACCS NDL,SUP-2730579,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1886.45,1226.19,,,,,,,,,,,,,
SCREW BNE L 20 MM DIA2.3 MM TI MAND ST LCK AXS NS UNIV,SUP-2909528,CDM,C1713,HCPCS,0278,RC,,,,both,,,524.98,341.24,,,,,,,,,,,,,
STIMLTR BN PHSTM LT EXTERNL,SUP-2316212,CDM,C1713,HCPCS,0278,RC,,,,both,,,9420.00,6123.00,,,,,,,,,,,,,
FLUOXETINE HCL 20 MG PO CAPS,RX-10070,CDM,6370000000,HCPCS,0637,RC,00904-7346-61,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
GRAFT VASC FLIXENE L 30 CM DIA 4-6 MM EPTFE GRAD TAPR REINF,SUP-2486972,CDM,C1768,CPT,0278,RC,,,,both,,,3111.14,2022.24,,,,,,,,,,,,,
PLATE BNE DEBURRER RIB NS LEVEL 1 LTX,SUP-2869275,CDM,C1713,HCPCS,0278,RC,,,,both,,,1313.78,853.96,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 50-100 CM FASC,SUP-2321780,CDM,C1762,CPT,0278,RC,,,,both,,,4553.00,2959.45,,,,,,,,,,,,,
CLIP ANEUR PERM MINI 4 MM CRV YASRG,SUP-2108350,CDM,C1889,HCPCS,0278,RC,,,,both,,,1008.88,655.77,,,,,,,,,,,,,
BIT DRL DIA2.7MM FOR 2.5MM PEDIFLEX ELAS STBL IM NAIL SYS,SUP-2318870,CDM,2720000010,LOCAL,0272,RC,,,,both,,,841.08,546.70,,,,,,,,,,,,,
TAPE SUTURE SZ 1.8 MM UHMWPE SMTH LP N ABSRB BLACK/WHITE,SUP-2906177,CDM,C1713,HCPCS,0278,RC,,,,both,,,370.52,240.84,,,,,,,,,,,,,
STENT URET L 24 CM DIA 7 FR PERCFLX SFT TEMP W/O DEL SYS,SUP-2141646,CDM,C2617,HCPCS,0278,RC,,,,both,,,442.11,287.37,,,,,,,,,,,,,
KIT ACCSRY SHTH 20 FR DIL DIA12/16 FR PEELWY Y ADPT 1W,SUP-2175238,CDM,C1892,HCPCS,0272,RC,,,,both,,,1796.08,1167.45,,,,,,,,,,,,,
BIT DRL 4.5 MMX9 IN FOR HDLSS SCR SYS NS LTX,SUP-2862179,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1552.42,1009.07,,,,,,,,,,,,,
CATHETER INTVENT COR CTO CROSSING CROSSBOSS,SUP-2147016,CDM,C1725,HCPCS,0272,RC,,,,both,,,5187.28,3371.73,,,,,,,,,,,,,
EXTERNAL FIXATION SET COMPLETE 6 MM ANK GALAXY FIX GEM LTX,SUP-2875648,CDM,C1713,HCPCS,0278,RC,,,,both,,,33898.50,22034.02,,,,,,,,,,,,,
SCREW INTRF L30MM DIA5MM B TRICALCIUM PHOS BIOCOMP MILAGRO,SUP-2249501,CDM,C1713,HCPCS,0278,RC,,,,both,,,1299.96,844.97,,,,,,,,,,,,,
BLOCK RETAINING SPINAL PEDICLE SCREW,SUP-2867348,CDM,C1713,HCPCS,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
SUTURE FIBERTAPE SZ 2-0 L36IN NONABSORBABLE BLU 2MM EA END AR7237,SUP-2122112,CDM,2720000010,LOCAL,0272,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
CATHETER ANGIO PERFORMA L 125 CM 5 FR 0.046 IN ULT4 1 SIDE H,SUP-2665878,CDM,C1887,HCPCS,0272,RC,,,,both,,,197.82,128.58,,,,,,,,,,,,,
GUIDE NERVE 2.3X40 MM GEM ABSORBABLE MESH SYNOVIS NEUROTUBE,SUP-2382608,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1868.30,1214.39,,,,,,,,,,,,,
HC So Aspergillus Galactomannan,PX-3068730566,CDM,87305,CPT,0306,RC,,,,both,,,356.00,231.40,,,,,,,,,,,,,
PARACENTESIS SET STR 6 FRX10 CM FIX LUER VLV ONESTEP,SUP-2460004,CDM,C1729,HCPCS,0272,RC,,,,both,,,141.30,91.84,,,,,,,,,,,,,
IMPLANT HUM TISS L 4 X W 3 CM PLCNTA MTRX MEMBRN MINIMALLY,SUP-2905518,CDM,C1762,CPT,0278,RC,,,,both,,,3391.20,2204.28,,,,,,,,,,,,,
HC Sodium Serum Plasma or Whole Blood,PX-3018429500,CDM,84295,CPT,0301,RC,,,,both,,,134.00,87.10,,,,,,,,,,,,,
GRAFT BNE SUB 3CC TISS EXPONENT DBM,SUP-2138517,CDM,C1713,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
PLATE BNE L23MM 6 H TI STR FOR 1.3MM SCR,SUP-2190687,CDM,C1713,HCPCS,0278,RC,,,,both,,,1019.68,662.79,,,,,,,,,,,,,
SET INTRO MICROPUNCTURE CATH L 10 CM 4 FR L 7 CM NIT,SUP-2633279,CDM,C1894,HCPCS,0272,RC,,,,both,,,71.22,46.29,,,,,,,,,,,,,
GRAFT TISS 7.6X15.2CM 116SQ CM THERASKIN XL,SUP-2264659,CDM,Q4121,HCPCS,0636,RC,,,,both,,,10611.00,6897.15,,,,,,,,,,,,,
SCREW INTFR L25MM DIA9MM OPN ARCHITECTURE DSGN BIOSURE,SUP-2341922,CDM,C1713,HCPCS,0278,RC,,,,both,,,1171.88,761.72,,,,,,,,,,,,,
GUIDE DRILL COMP/POLYAX 2.6MM T10,SUP-2472245,CDM,2720000010,LOCAL,0272,RC,,,,both,,,769.30,500.04,,,,,,,,,,,,,
STEM HUM L90MM 7A 127.5DEG ANG STD PTC AEQUALIS ASCEND FLX,SUP-2388742,CDM,C1776,CPT,0278,RC,,,,both,,,18840.00,12246.00,,,,,,,,,,,,,
STEM FEM SZ 3 STD SHT NK HIP HA QUADRA H,SUP-2267226,CDM,C1776,CPT,0278,RC,,,,both,,,9325.80,6061.77,,,,,,,,,,,,,
PROMETHAZINE HCL 12.5 MG RE SUPP,RX-11143,CDM,6370000000,HCPCS,0637,RC,00713-0536-12,NDC,,both,1,UN,83.90,54.53,,,,,,,,,,,,,
PLATE BNE L66MM 5 H NONSTERILE CNTOUR LOK 2 COMPR FOR 3.5MM,SUP-2411368,CDM,C1713,HCPCS,0278,RC,,,,both,,,848.68,551.64,,,,,,,,,,,,,
GRAFT BNE CRUSH 15 CC,SUP-2137585,CDM,C1734,HCPCS,0278,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
HALF PIN 5MMX90MM,SUP-2818080,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1126.95,732.52,,,,,,,,,,,,,
NAIL IM ZCKL II SUBTROCHANTERIC 17MMX350MM ROD RT,SUP-2364778,CDM,C1713,HCPCS,0278,RC,,,,both,,,4858.68,3158.14,,,,,,,,,,,,,
BIT DRL L44.5MM DIA0.76MM STP 12MM MINI QUIK CPL FOR,SUP-2187637,CDM,2720000010,LOCAL,0272,RC,,,,both,,,439.54,285.70,,,,,,,,,,,,,
BIT DRL AO CONN 1.8 MM BLU,SUP-2421747,CDM,2720000010,LOCAL,0272,RC,,,,both,,,482.99,313.94,,,,,,,,,,,,,
SCREW BNE L4MM OD1.7MM PNK TI CORT ST NONCANNULATED FT CRSS,SUP-2366100,CDM,C1713,HCPCS,0278,RC,,,,both,,,218.70,142.15,,,,,,,,,,,,,
PROCESSOR HEARING AID DMND BLK LT EAR PONTO + PWR,SUP-2319905,CDM,L8691,HCPCS,0274,RC,,,,both,,,14679.50,9541.67,,,,,,,,,,,,,
DRILL SURG BASE FEM STEM KNEE ROTATING HINGE NXGN,SUP-2437347,CDM,2720000010,LOCAL,0272,RC,,,,both,,,438.03,284.72,,,,,,,,,,,,,
SET INTRO 12FR L22CM GWIRE SAFT,SUP-2171203,CDM,C1894,HCPCS,0272,RC,,,,both,,,123.59,80.33,,,,,,,,,,,,,
SCREW BNE L12MM DIA2MM STD CORT TI NCANNULATED FULL THRD N,SUP-2189308,CDM,C1713,HCPCS,0278,RC,,,,both,,,112.85,73.35,,,,,,,,,,,,,
BUR SURG RND 0.5 MM 64 MM W/ GRD FOR DRL SYS SS POWERFORMA,SUP-2628945,CDM,2720000010,LOCAL,0272,RC,,,,both,,,168.12,109.28,,,,,,,,,,,,,
ANCHOR VERSALOOP 1.8MM DL SUTURE,SUP-2756500,CDM,C1713,HCPCS,0278,RC,,,,both,,,1670.48,1085.81,,,,,,,,,,,,,
ASSEMBLY EXT FIX PIN CLMP FOR SIDEKCK STLTH REARFOOT FIX,SUP-2400594,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1337.64,869.47,,,,,,,,,,,,,
SCREW BNE 1X9 MM CRANIOMAXILLOFACIAL TI CENTRE-DRIVE LEVEL 1,SUP-2458080,CDM,C1713,HCPCS,0278,RC,,,,both,,,222.00,144.30,,,,,,,,,,,,,
ASSEMBLY GWIRE DIA0.054IN PARA FOR MIC ACUTRK 2,SUP-2107283,CDM,C1769,HCPCS,0272,RC,,,,both,,,791.28,514.33,,,,,,,,,,,,,
STENT GRFT VASC TAG L 10 CM UNCOVERED L 6 MM PROX/DSTL,SUP-2423840,CDM,C1768,CPT,0278,RC,,,,both,,,57885.90,37625.83,,,,,,,,,,,,,
SYSTEM STENT POS 0.014X0.018 INX127 CM OSTIAL PRO,SUP-2301448,CDM,C1769,HCPCS,0272,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
HC X-Ray Exam of Femur Min 2 Views,PX-3207355200,CDM,73552,CPT,0320,RC,,,,both,,,504.00,327.60,,,,,,,,,,,,,
RELOAD STPL L45MM VASCULAR/MEDIUM TISS TAN CRV TIP ARTC,SUP-2283357,CDM,2720000010,LOCAL,0272,RC,,,,both,,,805.22,523.39,,,,,,,,,,,,,
GUIDEWIRE ORTHOPEDIC DEPTH GZ LG 3.2 MM REUSE,SUP-2223920,CDM,C1769,HCPCS,0272,RC,,,,both,,,122.46,79.60,,,,,,,,,,,,,
PLATE FOOT 140MM,SUP-2696086,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5013.32,3258.66,,,,,,,,,,,,,
PLATE BONE L157MM 12 H LT OLECRANON S STL LCK FOR 2.7/3.5MM,SUP-2348709,CDM,C1713,HCPCS,0278,RC,,,,both,,,13751.79,8938.66,,,,,,,,,,,,,
UNIT THER COMB CRYO W PD SHLDR W TB PWR OPERATED W OUT BD,SUP-2150932,CDM,C1713,HCPCS,0278,RC,,,,both,,,355.64,231.17,,,,,,,,,,,,,
KIT TKR KNEE CRUCE RET NAR CEM NP TIB INSRT VERILAST LEGION,SUP-2348042,CDM,C1776,CPT,0278,RC,,,,both,,,13031.00,8470.15,,,,,,,,,,,,,
STENT BILI SELF EXPANDABLE 0.035 IN 12X40 MM 6 FRX80 CM SMRT,SUP-2158642,CDM,C1876,HCPCS,0278,RC,,,,both,,,3579.60,2326.74,,,,,,,,,,,,,
VALGANCICLOVIR HCL 450 MG PO TABS,RX-30148,CDM,6370000000,HCPCS,0637,RC,55111-0762-60,NDC,,both,1,UN,105.50,68.57,,,,,,,,,,,,,
SCREW BNE MAXILLOMANDIBULAR 2X14 MM 10 MM SS MAXDRIVE LEVEL1,SUP-2495286,CDM,C1713,HCPCS,0278,RC,,,,both,,,313.00,203.45,,,,,,,,,,,,,
COLLAR CERV AD TALL CUSH FLX TAB OCCIPITAL SUPP STRP,SUP-2123893,CDM,L0180,HCPCS,0272,RC,,,,both,,,59.63,38.76,,,,,,,,,,,,,
COMPONENT TIB UNI LM/RL 9MM M EIUS,SUP-2364889,CDM,C1776,CPT,0278,RC,,,,both,,,3856.55,2506.76,,,,,,,,,,,,,
GRAFT VASC GORTX L 80 CM DIA 6 MM RNG L 30 CM STR TW,SUP-2396157,CDM,C1768,CPT,0278,RC,,,,both,,,3356.66,2181.83,,,,,,,,,,,,,
BAG VENT ASST L SHWR PERS SUPP,SUP-2282568,CDM,Q0501,HCPCS,0274,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 50 CM DIA 5 MM STR REINF SLDE GDS,SUP-2525457,CDM,C1768,CPT,0278,RC,,,,both,,,1488.93,967.80,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH SPIRAL-Z L 90 MM DIA11 MM SHTH 14 FR,SUP-2171072,CDM,C1874,HCPCS,0278,RC,,,,both,,,10801.60,7021.04,,,,,,,,,,,,,
PLATE BNE BROAD 4.5X119 MM 7 HOLE SS DCP,SUP-2569175,CDM,C1713,HCPCS,0278,RC,,,,both,,,369.58,240.23,,,,,,,,,,,,,
DEVICE VES SEAL L35CM OD5MM STD TIP TRIG SHFT HNDPC ENDOSCP,SUP-2257694,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6051.44,3933.44,,,,,,,,,,,,,
PLATE BNE TIB 274 MM LT LAT 13 HOLE BUTTRESS HD TI NS LC-DCP,SUP-2569064,CDM,C1713,HCPCS,0278,RC,,,,both,,,2895.52,1882.09,,,,,,,,,,,,,
PLATE BONE L14MM THK0.6MM 4 H CRANIOMAXILLOFACIAL STR FOR,SUP-2402920,CDM,C1713,HCPCS,0278,RC,,,,both,,,276.32,179.61,,,,,,,,,,,,,
WAND ABLAT DIA3.75MM 90DEG ANG INTEGR CBL SUP TURBOVAC,SUP-2342002,CDM,2720000010,LOCAL,0272,RC,,,,both,,,844.03,548.62,,,,,,,,,,,,,
GRAFT BNE CRUSH 1-10 MM 30 CC CANC,SUP-2766762,CDM,C1713,HCPCS,0278,RC,,,,both,,,1582.56,1028.66,,,,,,,,,,,,,
FIBER LASER CO2 PWR PK FIBERLASE,SUP-2713719,CDM,2720000010,LOCAL,0272,RC,,,,both,,,33158.40,21552.96,,,,,,,,,,,,,
CONTROLLER TRUVIC HOTSHOT,SUP-2855179,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
GRAFT BNE SUB 5CC CA PHSPTE DRILLABLE FAST SET PTTY NORIAN,SUP-2182829,CDM,C9359,HCPCS,0278,RC,,,,both,,,3695.50,2402.07,,,,,,,,,,,,,
BAR EXT FIX CRV 11X500 MM CARBON XTRAFIX,SUP-2534565,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1956.06,1271.44,,,,,,,,,,,,,
CAGE SPNL PARL 18X12X55 MM COUGAR LS,SUP-2256436,CDM,C1889,HCPCS,0278,RC,,,,both,,,21728.80,14123.72,,,,,,,,,,,,,
CATHETER EP JSN 5 MM SPC 6 FRX120 CM SUPREME,SUP-2458911,CDM,C1730,HCPCS,0272,RC,,,,both,,,383.08,249.00,,,,,,,,,,,,,
UNIT LITHO MECH ERCP LITHOCRUSH 22 MM,SUP-2312976,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1080.16,702.10,,,,,,,,,,,,,
NAIL IM L315MM DIA10MM NONSTERILE GRN TIB TI CANN LOK,SUP-2192798,CDM,C1713,HCPCS,0278,RC,,,,both,,,4071.61,2646.55,,,,,,,,,,,,,
HC Whfo 1 or More Custom Fit,PX-2740380601,CDM,L3806,HCPCS,0274,RC,,,,both,,,1510.00,981.50,,,,,,,,,,,,,
PLATE BNE M L52MM 0DEG 6 H ST R 1ST MTP FUS S STL VAR ANG,SUP-2178390,CDM,C1713,HCPCS,0278,RC,,,,both,,,3535.11,2297.82,,,,,,,,,,,,,
TIMOLOL MALEATE 0.5 % OP SOLN,RX-11562,CDM,6370000000,HCPCS,0637,RC,61314-0227-05,NDC,,both,5,ML,43.50,28.27,,,,,,,,,,,,,
INTRODUCER TRANSSEPTAL SHTH 8.5FR L63CM DIL L67CM 0.032IN,SUP-2357268,CDM,C1894,HCPCS,0272,RC,,,,both,,,562.06,365.34,,,,,,,,,,,,,
MESH CRAN L 119.89 X W 65.02 MM THK 0.8 MM SCREW DIA1.5 MM,SUP-2935773,CDM,C1713,HCPCS,0278,RC,,,,both,,,6908.00,4490.20,,,,,,,,,,,,,
SCREW BNE L35MM DIA4.5MM THRD L18MM HD DIA8MM MALL S STL,SUP-2184551,CDM,C1713,HCPCS,0278,RC,,,,both,,,117.18,76.17,,,,,,,,,,,,,
CATHETER DRNGE ABSC J CRV SET INCL INSRT .038IN GWIRE 2 DIL,SUP-2168139,CDM,C1729,HCPCS,0272,RC,,,,both,,,303.86,197.51,,,,,,,,,,,,,
CATHETERIZATION KIT 4 FRX50 CM SINGLE LUMEN PWR INJ,SUP-2383976,CDM,C1751,HCPCS,0278,RC,,,,both,,,522.65,339.72,,,,,,,,,,,,,
SHEATH VASC L12CM OD9FR 0.038IN GWIRE W/ LUER LCK HUB,SUP-2355398,CDM,C1894,HCPCS,0272,RC,,,,both,,,66.73,43.37,,,,,,,,,,,,,
HC Ot Ther Ex per 15 Min|OP OCCUPATIONAL THERAPY SERV|SERVICES PROVIDED IN WHOLE OR IN PARTY BY AN OTA FOR MEDICARE PATIENTS,PX-4309711000,CDM,97110,CPT,0430,RC,,,GO|CO,both,,,195.00,126.75,,,,,,,,,,,,,
GUIDE CATH VENTRICULAR STRL,SUP-2852699,CDM,C1729,HCPCS,0272,RC,,,,both,,,184.38,119.85,,,,,,,,,,,,,
HEAD SPNL POLYAX MARINER,SUP-2431111,CDM,C1713,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
TI T-BUTTRESS PLATE 5 HOLES/96MM,SUP-2549655,CDM,C1713,HCPCS,0278,RC,,,,both,,,2005.64,1303.67,,,,,,,,,,,,,
BIT DRILL OD4 MM STERILE LATEX GRIDLOCK SCREW,SUP-2880118,CDM,2720000010,LOCAL,0272,RC,,,,both,,,675.10,438.81,,,,,,,,,,,,,
GRAFT BNE PLIF SPCR RND FRZ DRY H 11MM OSTEOSTIM,SUP-2415424,CDM,C1713,HCPCS,0278,RC,,,,both,,,5020.86,3263.56,,,,,,,,,,,,,
ALLOGRAFT DERMAL 10X14X2 MM DERMAL MTRX ARTHROFLEX BIOWASHER,SUP-2741915,CDM,Q4125,HCPCS,0636,RC,,,,both,,,881.96,573.27,,,,,,,,,,,,,
PLATE BNE CRV 15X0.35 MM NEURO 3X2 HOLE LADDER W/ TAB STRL,SUP-2498705,CDM,C1713,HCPCS,0278,RC,,,,both,,,1111.69,722.60,,,,,,,,,,,,,
GRAFT BNE GEL 5 CC DBM MAROFUSE,SUP-2120698,CDM,C1713,HCPCS,0278,RC,,,,both,,,2983.00,1938.95,,,,,,,,,,,,,
MESH MIDFACIAL CUSTOMIZED PRIORITY RECON MEDPOR LTX,SUP-2862754,CDM,C1713,HCPCS,0278,RC,,,,both,,,57589.20,37432.98,,,,,,,,,,,,,
HC Blood Split Unit,PX-3900901100,CDM,P9011,HCPCS,0390,RC,,,,inpatient,,,730.00,474.50,,,,,,,,,,,,,
CATHETER VENT DRNGE L18CM STD SIL 7 FLNG DISP PORTNOY,SUP-2308215,CDM,C1713,HCPCS,0278,RC,,,,both,,,907.05,589.58,,,,,,,,,,,,,
SIZER SURG NOVEL DSGN LEN DIAM MEAS ACCURACY LO COST,SUP-2302402,CDM,2720000010,LOCAL,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
HC So Elastase Pancreatic Fecal Qt,PX-3018265366,CDM,82653,CPT,0300,RC,,,,both,,,1605.00,1043.25,,,,,,,,,,,,,
PATCH DURA W4XL4CM ELASTOMERIC INNR LAYR PRECL MVP,SUP-2395358,CDM,C1763,HCPCS,0278,RC,,,,both,,,791.28,514.33,,,,,,,,,,,,,
BLADE SAW CUT EDGE L135MM D255MM THK051MM INTRAORAL S STL,SUP-2363657,CDM,2720000010,LOCAL,0272,RC,,,,both,,,326.31,212.10,,,,,,,,,,,,,
OXYGENATOR PERFSN BIOLINE COAT PED STRL DISP QUADROX-ID,SUP-2908774,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6919.74,4497.83,,,,,,,,,,,,,
SURFACE ARTC TIB CONSTRN SZ 59 30MM I/B II CCK,SUP-2205850,CDM,C1776,CPT,0278,RC,,,,both,,,7000.63,4550.41,,,,,,,,,,,,,
CONNECTOR 2 MM 22.5 DEG BLU TI FOR IMPLATE SYS,SUP-2340249,CDM,C1713,HCPCS,0278,RC,,,,both,,,868.21,564.34,,,,,,,,,,,,,
HC OB ER Level 3|MULTIPLE OUTPATIENT HOSPITAL E/M ENCOUNTERS ON THE SAME DATE,PX-4509928301,CDM,99283,CPT,0450,RC,,,27,outpatient,,,1556.00,1011.40,,,,,,,,,,,,,
PROVENTM REV KNEE SYS DSTL FEM AUG SZ 1 THRU 5 5,SUP-2359326,CDM,C1776,CPT,0278,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
SPLINT FLX HND ADL NVY TERRY,SUP-2165484,CDM,L3807,HCPCS,0272,RC,,,,both,,,153.77,99.95,,,,,,,,,,,,,
REAMER SURG 18MM CNVX MOD FT,SUP-2400256,CDM,2720000010,LOCAL,0272,RC,,,,both,,,825.82,536.78,,,,,,,,,,,,,
GRAFT VASC GORTX L 70 CM DIA 8 MM RNG L 30 CM EPTFE STR TW,SUP-2396133,CDM,C1768,CPT,0278,RC,,,,both,,,2891.94,1879.76,,,,,,,,,,,,,
BLADE REPROC SHV ULTRACUT DUAL PURP LG HUB 4.2MM,SUP-2652969,CDM,2720000010,LOCAL,0272,RC,,,,both,,,68.04,44.23,,,,,,,,,,,,,
DRILL SURG FAR CRTX FOR FIB,SUP-2857743,CDM,2720000010,LOCAL,0272,RC,,,,both,,,367.38,238.80,,,,,,,,,,,,,
COMPONENT FEM SZ 6 R CEM HNG GMK,SUP-2267634,CDM,C1776,CPT,0278,RC,,,,both,,,25320.96,16458.62,,,,,,,,,,,,,
BIPOLAR ASSY COCR 26MM ID 56MM OD,SUP-2509100,CDM,C1713,HCPCS,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
CATHETER ANGIO SOFT-VU L 65 CM 5 FR 0.038 IN PIG NONBRAIDED,SUP-2116594,CDM,C1887,HCPCS,0272,RC,,,,both,,,96.08,62.45,,,,,,,,,,,,,
AZTREONAM 1 G IJ SOLR,RX-9185,CDM,J0457,HCPCS,0636,RC,00003-2560-16,NDC,,both,1,UN,171.00,111.15,,,,,,,,,,,,,
PROBE LITHO 1.6FR L120CM ELEC HYDRLC CALCUTRIPT,SUP-2261217,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1034.63,672.51,,,,,,,,,,,,,
PLATE BNE L 83 X W 51 MM THK 0.3 MM SCREW DIA1 MM CMF MESH,SUP-2883837,CDM,C1713,HCPCS,0278,RC,,,,both,,,3196.52,2077.74,,,,,,,,,,,,,
GRAFT VASC HEMSHLD GLD L 40 CM DIA16 X 8 MM POLYESTER BOV,SUP-2227670,CDM,C1768,CPT,0278,RC,,,,both,,,2364.67,1537.04,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED STD CEM SCREW PIN M HXLPE,SUP-2212709,CDM,C1776,CPT,0278,RC,,,,both,,,12288.77,7987.70,,,,,,,,,,,,,
DEFIBRILLATOR IMPL VIVA S DELIVERED ENERGY 36 J TI POLYUR,SUP-2282405,CDM,C1882,HCPCS,0275,RC,,,,both,,,51490.25,33468.66,,,,,,,,,,,,,
PLATE 3.5MM CURVED BROAD LCP 18H TI STRL,SUP-2546936,CDM,C1713,HCPCS,0278,RC,,,,both,,,3278.13,2130.78,,,,,,,,,,,,,
STRUT EXT FIX L70-104MM SHT ACUTE ADJ LOK UNIV HNG ON BOTH,SUP-2316066,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3256.46,2116.70,,,,,,,,,,,,,
WASHER ORTH FOR 6.5 MM CANN SCREW NS,SUP-2788658,CDM,C1713,HCPCS,0278,RC,,,,both,,,97.97,63.68,,,,,,,,,,,,,
SHUNT PERI 7FR 90CM LO REG W/O RESVR CSF ASSEMB FLO CTRL,SUP-2284549,CDM,C1729,HCPCS,0272,RC,,,,both,,,2447.66,1590.98,,,,,,,,,,,,,
PSN REV TIB FIXED KEEL CMT SZ H L,SUP-2508660,CDM,C1776,CPT,0278,RC,,,,both,,,6405.60,4163.64,,,,,,,,,,,,,
WASHER ORTH SPIK 10 MM BOLT OSS,SUP-2441747,CDM,C1713,HCPCS,0278,RC,,,,both,,,466.29,303.09,,,,,,,,,,,,,
MARKER FIDUCIAL SYS TISS GLD 18 G BIOMARC,SUP-2152634,CDM,A4648,CPT,0278,RC,,,,both,,,79.54,51.70,,,,,,,,,,,,,
PROBE LITHO US 35X400 MM OSCILLATING TIP CALCUSON DISP,SUP-2261225,CDM,C1713,HCPCS,0278,RC,,,,both,,,1006.62,654.30,,,,,,,,,,,,,
RITUXIMAB-PVVR (RUXIENCE) 10 MG/ML IV SOLN (MIXTURES ONLY),RX-4081835,CDM,Q5119,HCPCS,0636,RC,00069-0249-01,NDC,,both,50,ML,10322.00,6709.30,,,,,,,,,,,,,
BLADE SHV FULL RAD LNG STR 5.5MM 18CM DYONICS PWR EP-1,SUP-2341433,CDM,C1713,HCPCS,0278,RC,,,,both,,,743.11,483.02,,,,,,,,,,,,,
WAND ABLAT DIA4.7MM 50DEG THRMCPL TECHNOLOGY RASP DSGN RIG,SUP-2342017,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
CAFFEINE CITRATE 20 MG/ML PO SYRINGE (PED-NEO),RX-4090426,CDM,J0706,HCPCS,0636,RC,63323-0407-03,NDC,,both,3,ML,140.10,91.06,,,,,,,,,,,,,
BUR SURG M L25MM DIA0.8MM DMND HD NONFLUTED TPS,SUP-2367475,CDM,2720000010,LOCAL,0272,RC,,,,both,,,364.27,236.78,,,,,,,,,,,,,
HC Feeding Tube Plcmt W Fluoro,PX-3614375200,CDM,43752,CPT,0361,RC,,,,inpatient,,,1485.00,965.25,,,,,,,,,,,,,
PLATE BONE 11 H FIBULAR ANAT ANK FX GORILLA,SUP-2321563,CDM,C1713,HCPCS,0278,RC,,,,both,,,5044.41,3278.87,,,,,,,,,,,,,
SCREW BONE SELF TAPPING 88 MM CORTICAL CRANIOMAXILLOFACIAL E,SUP-2838217,CDM,C1713,HCPCS,0278,RC,,,,both,,,243.98,158.59,,,,,,,,,,,,,
ALBUTEROL SULFATE (2.5 MG/3ML) 0.083% IN NEBU,RX-250,CDM,J7611,HCPCS,0636,RC,00378-8270-31,NDC,,both,3,ML,2.70,1.75,,,,,,,,,,,,,
SCREW BNE CANN 6.5X85 MM 16 MM THRD AXSOS 3,SUP-2613625,CDM,C1713,HCPCS,0278,RC,,,,both,,,1937.38,1259.30,,,,,,,,,,,,,
GRAFT VASC L30CM ID6MM RING SECT L20CM STD WALLED STR GORTX,SUP-2396001,CDM,C1768,CPT,0278,RC,,,,both,,,1877.72,1220.52,,,,,,,,,,,,,
SCREW CONN FEM TI NAIL CANN FOR PERC INSRTN HNDL,SUP-2178846,CDM,C1713,HCPCS,0278,RC,,,,both,,,963.98,626.59,,,,,,,,,,,,,
PLATE BNE BROAD 3.5X146 MM 11 HOLE SS LC-DCP,SUP-2569245,CDM,C1713,HCPCS,0278,RC,,,,both,,,348.85,226.75,,,,,,,,,,,,,
PLATE BONE BROAD 4.5X303 MM 16 HOLE,SUP-2837422,CDM,C1713,HCPCS,0278,RC,,,,both,,,3121.95,2029.27,,,,,,,,,,,,,
GRAFT VASC HEMSHLD PLAT L 50 MM DIA 32 MM BRANCH SZ,SUP-2479195,CDM,C1768,CPT,0278,RC,,,,both,,,5545.30,3604.44,,,,,,,,,,,,,
IMMOBILIZER SHLDR L10.5-17IN D7IN SLNG W/ 15DEG ABD PLLW,SUP-2196388,CDM,L3650,HCPCS,0272,RC,,,,both,,,106.92,69.50,,,,,,,,,,,,,
LAPAROSCOPE RIGID L270MM OD10MM 0DEG OPERATIVE AUTOCLAVABLE,SUP-2808675,CDM,C1776,CPT,0278,RC,,,,both,,,11065.36,7192.48,,,,,,,,,,,,,
RING EXT FIX BUTTRESS 5.5 MM,SUP-2517368,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
CONDYLAR PLATE RIGHT 15X285MM,SUP-2819050,CDM,C1713,HCPCS,0278,RC,,,,both,,,8177.97,5315.68,,,,,,,,,,,,,
GRAFT BNE SUB 1CC PTTY PREHYDRATED CRUSH MIX TENSIX,SUP-2400562,CDM,C9359,HCPCS,0278,RC,,,,both,,,1748.98,1136.84,,,,,,,,,,,,,
SALVATION  BEAM 7.0 X 110MM THREAD,SUP-2459140,CDM,C1713,HCPCS,0278,RC,,,,both,,,4892.12,3179.88,,,,,,,,,,,,,
SLEEVE TROCAR L110MM DIAMETER 5MM THREADED DISPOSABLE WITH T,SUP-2803690,CDM,2720000010,LOCAL,0272,RC,,,,both,,,409.49,266.17,,,,,,,,,,,,,
ALLOGRAFT HUMAN TISS ILLIOTIBIAL BAND FZ ASP,SUP-2875983,CDM,C1762,CPT,0278,RC,,,,both,,,5387.30,3501.74,,,,,,,,,,,,,
PLUG BNE DIA28X32MM W/ DISP INSRT ALLEN,SUP-2203674,CDM,C1713,HCPCS,0278,RC,,,,both,,,273.18,177.57,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9 % IV BOLUS,RX-103555,CDM,J7030,HCPCS,0258,RC,00338-0049-04,NDC,,both,250,ML,10.70,6.95,,,,,,,,,,,,,
CATHETER GUID CS-EH ST-R 14X40 MM ACUITY CUT-AWAY,SUP-2148928,CDM,C1887,HCPCS,0272,RC,,,,both,,,1397.30,908.24,,,,,,,,,,,,,
SET INTRO V-STICK DIA 5 FR SS COAX NONECHOGENIC STIFF,SUP-2120084,CDM,C1769,HCPCS,0272,RC,,,,both,,,580.90,377.58,,,,,,,,,,,,,
PIN DISTRACTOR L14MM DSTL LORDTC STK FOR BENGAL CAGE SYS,SUP-2256855,CDM,2720000010,LOCAL,0272,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
MICROCATHETER GUID TELEPORT L 150 CM DIA PROX 2.6/2 FR,SUP-2755116,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
COLLAR CERV MED DENS UNIV 24X4 IN CNTOUR PROCARE LF,SUP-2195755,CDM,L0180,HCPCS,0272,RC,,,,both,,,7.10,4.61,,,,,,,,,,,,,
ALLOGRAFT BNE SPACER 14X11X7 MM UNICORTICAL CANC MATRIGRAFT,SUP-2264702,CDM,C1713,HCPCS,0278,RC,,,,both,,,2157.18,1402.17,,,,,,,,,,,,,
CATHETER HD CRV EXTN 11 FRX20 CM CATH NDL DUOFLO,SUP-2627070,CDM,C1752,HCPCS,0278,RC,,,,both,,,246.49,160.22,,,,,,,,,,,,,
GRAFT MTRX DERM HUM TISS ACELLULAR N MESHED NAT,SUP-2366751,CDM,Q4126,HCPCS,0636,RC,,,,both,,,3661.24,2379.81,,,,,,,,,,,,,
PLATE BNE L283MM 10 H NONSTERILE L PROX FEM S STL LO PROF,SUP-2186045,CDM,C1713,HCPCS,0278,RC,,,,both,,,4346.67,2825.34,,,,,,,,,,,,,
VIPER PRIM CFXFEN XTAB 7X55MM,SUP-2177023,CDM,C1713,HCPCS,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
ARTHROFLEX 40X70X1.0 MM,SUP-2811355,CDM,Q4125,HCPCS,0636,RC,,,,both,,,7726.28,5022.08,,,,,,,,,,,,,
LINER ACET CUP THCK PRI CEM MTL ON POLYETH STD NEUT HI WALL,SUP-2406711,CDM,C1776,CPT,0278,RC,,,,both,,,1199.48,779.66,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 6X2 CM TEND REINF MTRX PURAFORCE,SUP-2716033,CDM,C1765,HCPCS,0278,RC,,,,both,,,3925.00,2551.25,,,,,,,,,,,,,
SLEEVE ANK CLOSED HEEL 8.5-10 IN MED 1/8 IN PROCARE,SUP-2195739,CDM,L1906,HCPCS,0274,RC,,,,both,,,17.52,11.39,,,,,,,,,,,,,
NEEDLE BRST LOC BLNT 20 GAX10 CM SADOWSKY STYL STRL ACCURA,SUP-2876191,CDM,C1819,HCPCS,0278,RC,,,,both,,,142.87,92.87,,,,,,,,,,,,,
PLATE AC NRW 11 HOLE 45MM,SUP-2720916,CDM,C1713,HCPCS,0278,RC,,,,both,,,499.26,324.52,,,,,,,,,,,,,
COMPONENT ARTC 15X1.5X2.5 MM,SUP-2123535,CDM,C1776,CPT,0278,RC,,,,both,,,6280.00,4082.00,,,,,,,,,,,,,
CANNULA ARTHSCP IRRIGATION 3.2 MMX7 CM OBTURATOR 28146 QO LF,SUP-2768400,CDM,2720000010,LOCAL,0272,RC,,,,both,,,568.50,369.52,,,,,,,,,,,,,
NAIL INTRMDLLRY FMRL TTNM RT 9MM DIA 30CML VRSNL DEPUY,SUP-2587461,CDM,C1713,HCPCS,0278,RC,,,,both,,,6207.47,4034.86,,,,,,,,,,,,,
PLATE BNE 3 H L PROX TIB TIM L CRV LOK ALPS,SUP-2413713,CDM,C1713,HCPCS,0278,RC,,,,both,,,5284.62,3435.00,,,,,,,,,,,,,
DEVICE VENTRICULAR ASST INFLO CONDUIT SEAL HEARTMATE II,SUP-2356003,CDM,C1713,HCPCS,0278,RC,,,,both,,,18526.00,12041.90,,,,,,,,,,,,,
EXTENSION NERVE STIM OCTAPOLAR 20 CM 1X8 INLINE CONN LEGEND,SUP-2278214,CDM,C1883,HCPCS,0278,RC,,,,both,,,2257.66,1467.48,,,,,,,,,,,,,
GRAFT BONE 10CC DEMIN CORT OSTEOCONDUCTIVE FRZ DRY FIBEROS,SUP-2314099,CDM,C9359,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
PLATE BONE W3.8XL49MM THK0.9MM 3X9 H S STL T SHP,SUP-2343827,CDM,C1713,HCPCS,0278,RC,,,,both,,,1696.51,1102.73,,,,,,,,,,,,,
BLADE ENDO SINUS SERR CONCV ANG TIP CVD IRR 2.9MM DIA 60DEG,SUP-2312775,CDM,2720000010,LOCAL,0272,RC,,,,both,,,433.01,281.46,,,,,,,,,,,,,
CROWN DENT LR3 SEC PRI M INDIV SPACE MAINTAINER,SUP-2176709,CDM,D6783,CPT,0278,RC,,,,both,,,22.04,14.33,,,,,,,,,,,,,
FIBER LASER HOLM 150 M FOR USE W/ SMA-905 RED SMARTSYNC,SUP-2835952,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1227.87,798.12,,,,,,,,,,,,,
INSERT ACET 32X57 MM HIP METASUL,SUP-2205432,CDM,C1776,CPT,0278,RC,,,,both,,,5157.32,3352.26,,,,,,,,,,,,,
SYSTEM IMPL DRL PIN CANN SUT PASSPRT CANN GRAFTLINK,SUP-2419010,CDM,C1713,HCPCS,0278,RC,,,,both,,,2951.60,1918.54,,,,,,,,,,,,,
CATHETER CV MAXIMAL BARR TY 032 10 FRX20 CM 10 GA 5 LUMEN,SUP-2759737,CDM,C1751,HCPCS,0278,RC,,,,both,,,628.06,408.24,,,,,,,,,,,,,
DRAIN SURG W7MMXL20CM SIL FULL PERF HUBLESS FLAT RADPQ STRP,SUP-2127515,CDM,C1729,HCPCS,0272,RC,,,,both,,,14.13,9.18,,,,,,,,,,,,,
SEALER LIGASURE MARYLAND THORACIC 5MM L 30CM,SUP-2898396,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2154.20,1400.23,,,,,,,,,,,,,
PLATE BONE THK0.6MM 6 H ORBIT RIM TI CVD FOR 1.5MM SCR,SUP-2402886,CDM,C1713,HCPCS,0278,RC,,,,both,,,562.06,365.34,,,,,,,,,,,,,
PLATE BNE H1MM 90DEG REG MINI 6 H T CRANIOMAXILLOFACIAL FOR,SUP-2366325,CDM,C1713,HCPCS,0278,RC,,,,both,,,503.78,327.46,,,,,,,,,,,,,
CAGE BNE GRFT L 2.5-5 CM 96 POLYCAPROLACTONE 4 HA CALCIUM,SUP-2905646,CDM,C1713,HCPCS,0278,RC,,,,both,,,54265.32,35272.46,,,,,,,,,,,,,
BLADE SAW W0.80IN THK0.050IN FOR SYS 4 AND 2000 SAG,SUP-2367217,CDM,2720000010,LOCAL,0272,RC,,,,both,,,168.59,109.58,,,,,,,,,,,,,
PROSTHESIS OSS PISTON 0.8X3.50 MM ARMSTR STYL PLASTI PORE,SUP-2637842,CDM,L8613,CPT,0278,RC,,,,both,,,505.16,328.35,,,,,,,,,,,,,
SLEEVE PROTCT THRD LCK FOR SYNFIX EVOLUTION SYS,SUP-2255825,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
MIRTAZAPINE 15 MG PO TABS,RX-17466,CDM,6370000000,HCPCS,0637,RC,00904-6519-61,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
COLLAR CERV FIRM DENS AD 3IN 19IN L,SUP-2276591,CDM,L0120,HCPCS,0272,RC,,,,both,,,6.66,4.33,,,,,,,,,,,,,
GUIDEWIRE VASC ANGLED 35 DEG 1 CM 014X180 25 CM GLIDEWIRE,SUP-2851655,CDM,C1769,HCPCS,0272,RC,,,,both,,,1249.72,812.32,,,,,,,,,,,,,
BENDING IRON FOR 2.4MM CONDYLAR PLATE,SUP-2548472,CDM,C1713,HCPCS,0278,RC,,,,both,,,337.42,219.32,,,,,,,,,,,,,
GRAFT BONE L220-300MM OD6.5-8.5MM PERONEUS,SUP-2335255,CDM,C1713,HCPCS,0278,RC,,,,both,,,7536.00,4898.40,,,,,,,,,,,,,
DEFIBRILLATOR CARD HI ENERGY W/ TI W/ CELLULAR GSM HM LUMAX,SUP-2138416,CDM,C1722,HCPCS,0275,RC,,,,both,,,42390.00,27553.50,,,,,,,,,,,,,
KIT MIDLINE MAX BARRIER 4FR DUAL LUMEN PROVENA,SUP-2424482,CDM,C1751,HCPCS,0278,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
MESH HERN SM W8XL12CM INGUINAL OVL SELF EXP PTCH KUGEL,SUP-2125975,CDM,C1781,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
MATRIX WND CELLULAR REP GRAFIX PRIM 5 X 5CM,SUP-2319177,CDM,Q4132,HCPCS,0636,RC,,,,both,,,8321.00,5408.65,,,,,,,,,,,,,
NCB PP DF PLATE PROVISION15/18 H,SUP-2478953,CDM,C1713,HCPCS,0278,RC,,,,both,,,269.10,174.91,,,,,,,,,,,,,
SPHERE OPHTH DIA18 MM ORBIT OCULOPLASTIC POROUS,SUP-2883446,CDM,L8610,HCPCS,0278,RC,,,,both,,,1663.45,1081.24,,,,,,,,,,,,,
LEAD PACE ATTAIN STARFIX L 88 CM DIA 5.3 FR POLYUR INSUL,SUP-2278327,CDM,C1900,HCPCS,0275,RC,,,,both,,,5392.95,3505.42,,,,,,,,,,,,,
SPLINT WR AD SM UPTO W3.5IN RT MCP DLX KAY-SPLNT III,SUP-2324558,CDM,L3906,HCPCS,0272,RC,,,,both,,,75.96,49.37,,,,,,,,,,,,,
PLATE BNE T 116 MM 6 HOLE SS,SUP-2569108,CDM,C1713,HCPCS,0278,RC,,,,both,,,364.40,236.86,,,,,,,,,,,,,
DEVICE GUIDEWIRE EXCHANGE TRAPPER DIA2 FR BALLOON L 10 MM,SUP-2146907,CDM,C1725,HCPCS,0272,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
SCREW BNE ST 2.4X70 MM CRTX T8 STARDRV RECESS SS NS,SUP-2750877,CDM,C1713,HCPCS,0278,RC,,,,both,,,173.86,113.01,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 2X2 CM AMNIO WND MTRX BIOSKIN,SUP-2759485,CDM,C1762,CPT,0278,RC,,,,both,,,3100.40,2015.26,,,,,,,,,,,,,
PLEGISOL PF SOLN,RX-30272,CDM,2500000003,HCPCS,0250,RC,00409-7969-05,NDC,,both,1000,ML,488.80,317.72,,,,,,,,,,,,,
PLATE BNE L 142 X W 9 MM THK 1.1 MM SCREW DIA 3.5 MM 12 H SS,SUP-2933088,CDM,C1713,HCPCS,0278,RC,,,,both,,,365.62,237.65,,,,,,,,,,,,,
ALLOGRAFT BNE WDG 8 MM FD ILIUM TRICORT,SUP-2717912,CDM,C1713,HCPCS,0278,RC,,,,both,,,2883.74,1874.43,,,,,,,,,,,,,
KIT EXT FIX AUTO HEXAPOD ACCESSORIES MAXFRAME AUTOSTRUT,SUP-2908193,CDM,2720000010,LOCAL,0272,RC,,,,both,,,574.62,373.50,,,,,,,,,,,,,
CONFORM FLEX Q-PACK 16 MM CUBE,SUP-2547187,CDM,C1713,HCPCS,0278,RC,,,,both,,,1588.09,1032.26,,,,,,,,,,,,,
LINER ACET CUP THCK PRI CEM MTL ON POLYETH STD NEUT 39MM OD,SUP-2406717,CDM,C1776,CPT,0278,RC,,,,both,,,1199.48,779.66,,,,,,,,,,,,,
SHEATH INTRO 12FR L28CM 0.035IN GWIRE HYDRPHLC LOK,SUP-2298360,CDM,C1894,HCPCS,0272,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
GRAFT TEND GRACILIS ALLGRFT FRZ DRY 20 38CM L 3 10MM W,SUP-2307121,CDM,C1762,CPT,0278,RC,,,,both,,,3611.00,2347.15,,,,,,,,,,,,,
PPICC PROV SOLO PED 4F DL MAXDELTA,SUP-2613528,CDM,C1751,HCPCS,0278,RC,,,,both,,,1078.59,701.08,,,,,,,,,,,,,
CATHETER SET 3 LUMEN 9 FR CV KT HI FLO DEV BASIC,SUP-2214566,CDM,C1751,HCPCS,0278,RC,,,,both,,,1463.24,951.11,,,,,,,,,,,,,
GRAFT HUM TISS W4XL8CM THK18 39MM DERM ULT THCK ACELLULAR,SUP-2307492,CDM,Q4128,HCPCS,0636,RC,,,,both,,,5975.89,3884.33,,,,,,,,,,,,,
HEAD HUM ECC 40X18 MM SHLDR AFFINITI,SUP-2715308,CDM,C1776,CPT,0278,RC,,,,both,,,7603.51,4942.28,,,,,,,,,,,,,
RESERVOIR CSF 1.26ML FLSH 2.5CM STD DOME FLAT BTM W/ SM,SUP-2239246,CDM,C1889,HCPCS,0278,RC,,,,both,,,2285.92,1485.85,,,,,,,,,,,,,
SCREW SPNL 3.5X30 MM CORRIDOR,SUP-2593515,CDM,C1713,HCPCS,0278,RC,,,,both,,,1196.34,777.62,,,,,,,,,,,,,
GRAFT HUM TISS W30XL40MM THK0.5MM ACELLULAR DERM RM TEMP,SUP-2264667,CDM,Q4125,HCPCS,0636,RC,,,,both,,,2910.43,1891.78,,,,,,,,,,,,,
WIRE TEMP FIX 28 MM DIAM S STL DBL END SMOOTH DBL SHRP TIP,SUP-2342714,CDM,C1713,HCPCS,0278,RC,,,,both,,,201.02,130.66,,,,,,,,,,,,,
PLATE CRAN 100X100X40 MM PT SPEC IMPL PEEK,SUP-2860145,CDM,C1713,HCPCS,0278,RC,,,,both,,,34559.15,22463.45,,,,,,,,,,,,,
IMPLANT BEDROCK GRANITE IFUSE 10.5MM X 80MM,SUP-2858679,CDM,C1737,HCPCS,0278,RC,,,,both,,,10990.00,7143.50,,,,,,,,,,,,,
KNIFE ENDOSCP PEDIATRIC STR FOR OPT URETHROTM STRL LF,SUP-2430221,CDM,C1713,HCPCS,0278,RC,,,,both,,,916.88,595.97,,,,,,,,,,,,,
ROD IM IM BLOCK ASSY PERSONA,SUP-2449668,CDM,C1713,HCPCS,0278,RC,,,,both,,,5327.01,3462.56,,,,,,,,,,,,,
STENT PANCREATIC GEENEN L 5CM 7 FR 0.035IN NO INT FLAP,SUP-2169093,CDM,C2617,HCPCS,0278,RC,,,,both,,,204.10,132.66,,,,,,,,,,,,,
GRAFT VASC HEMGRD L 70 CM DIA 6 MM RNG L 20 CM THK 0.35 MM,SUP-2483675,CDM,C1768,CPT,0278,RC,,,,both,,,3244.09,2108.66,,,,,,,,,,,,,
GRAFT BNE SUB 15CC SZ 01 4MM CRUSH CANC CHIP FRZN,SUP-2307399,CDM,C1713,HCPCS,0278,RC,,,,both,,,1241.74,807.13,,,,,,,,,,,,,
BIT DRL L L300MM DIA17MM W/O STP CANN QUIK CPL REUSE,SUP-2188227,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2272.10,1476.86,,,,,,,,,,,,,
PLATE BNE L109MM 4 H L LAT EL TI LOK COMPR MAL FOR,SUP-2376022,CDM,C1713,HCPCS,0278,RC,,,,both,,,3469.70,2255.30,,,,,,,,,,,,,
COIL VASC TORNADO EMBOLUS L 2 CM DIA 3-2 MM 0.018IN MR,SUP-2424200,CDM,C1889,HCPCS,0278,RC,,,,both,,,361.07,234.70,,,,,,,,,,,,,
MICROCATHETER DIAG NAVVUS II L 335 CM WORKING L 150 CM DSTL,SUP-2862936,CDM,C1887,HCPCS,0272,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
IMMOBILIZER ORTHOPEDIC CUT AWAY UNIV 16 IN 14-29 IN KNEE,SUP-2428783,CDM,L1830,CPT,0274,RC,,,,both,,,28.04,18.23,,,,,,,,,,,,,
COLLAR BUTTON VT 127MM FLPL,SUP-2680288,CDM,L8699,HCPCS,0278,RC,,,,both,,,22.29,14.49,,,,,,,,,,,,,
INSERT TIB CLP FOR SYNATOMIC ULT VF COORDINATE PLT AMK,SUP-2250103,CDM,C1776,CPT,0278,RC,,,,both,,,757.37,492.29,,,,,,,,,,,,,
PLATE BNE L187MM 6 H S STL CBL NONLOCKING COMPR CBL-READY,SUP-2410268,CDM,C1713,HCPCS,0278,RC,,,,both,,,1956.06,1271.44,,,,,,,,,,,,,
SHEATH INTRO PRELUDE L 11 CM DIA 4 FR GUIDEWIRE L 40 CM NIT,SUP-2303251,CDM,C1769,HCPCS,0272,RC,,,,both,,,131.88,85.72,,,,,,,,,,,,,
ACETIC ACID 2 % OT SOLN,RX-17801,CDM,6370000000,HCPCS,0637,RC,52817-0816-15,NDC,,both,15,ML,126.10,81.96,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL PEEK SD800.507,SUP-2860189,CDM,C1713,HCPCS,0278,RC,,,,both,,,26241.92,17057.25,,,,,,,,,,,,,
RXG 3D ORB FLR RT T06MM,SUP-2681863,CDM,C1713,HCPCS,0278,RC,,,,both,,,3233.32,2101.66,,,,,,,,,,,,,
CAP HIP APEX,SUP-2165826,CDM,C1776,CPT,0278,RC,,,,both,,,78.50,51.02,,,,,,,,,,,,,
HC Imhchem/Imcytchm Ea Addl Single Antb Stain Px,PX-3128834100,CDM,88341,CPT,0312,RC,,,,both,,,371.00,241.15,,,,,,,,,,,,,
PROBE ENDSCPC BPLR 10FR DIA 350CML SNGLE PLUG HEMSTAS CXL CN,SUP-2675372,CDM,2720000010,LOCAL,0272,RC,,,,both,,,822.90,534.88,,,,,,,,,,,,,
GRAFT VASC GORTX L 60 CM DIA 6 MM EPTFE STR STD WALL N RING,SUP-2396424,CDM,C1768,CPT,0278,RC,,,,both,,,1723.86,1120.51,,,,,,,,,,,,,
CATHETER THROMCTMY LIGHTNING FLSH L 100 CM H1 TIP XTORQ,SUP-2865169,CDM,C1757,HCPCS,0272,RC,,,,both,,,30301.00,19695.65,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY OPTRELL SM D-F CRV TRUEREF,SUP-2880079,CDM,C1732,HCPCS,0272,RC,,,,both,,,9014.94,5859.71,,,,,,,,,,,,,
SCREW BNE L 36 MM DIA 4 MM LNG TI FT ST SD CANN PARTIALLY,SUP-2900638,CDM,C1713,HCPCS,0278,RC,,,,both,,,2951.60,1918.54,,,,,,,,,,,,,
SCREW SPNL 4.5X50 MM TI TSRH 3DX OSTEOGRIP,SUP-2631146,CDM,C1713,HCPCS,0278,RC,,,,both,,,1491.50,969.47,,,,,,,,,,,,,
IMETELSTAT SODIUM 31.4 MG/ML IV SOLN (MIXTURES ONLY)|DISCARDED DRUG NOT ADMINISTE,RX-4082818,CDM,J0870,HCPCS,0636,RC,82959-0111-01,NDC,JW,both,6,ML,29979.60,19486.74,,,,,,,,,,,,,
PLATE BONE L91MM 6 H STRL LT LAT PROX TIB S STL FOR 3.5MM,SUP-2341155,CDM,C1713,HCPCS,0278,RC,,,,both,,,11086.71,7206.36,,,,,,,,,,,,,
CATHETER PTCA 4FR L120CM QUADFLEX BLLN L15CM DIA5MM SHTH,SUP-2156672,CDM,C1725,HCPCS,0272,RC,,,,both,,,1186.92,771.50,,,,,,,,,,,,,
PLATE BNE L73MM 2 H ST L PROX OLECRANON S STL LO PROF VAR,SUP-2177183,CDM,C1713,HCPCS,0278,RC,,,,both,,,3168.48,2059.51,,,,,,,,,,,,,
PLATE EXT FIX L40MM ANK FT FOR TRUELOK FRME ASSEMB HEXAPOD,SUP-2316156,CDM,2720000010,LOCAL,0272,RC,,,,both,,,383.43,249.23,,,,,,,,,,,,,
SCREW BNE L16MM OD27MM ST LOK FULL THRD T8 DRV,SUP-2364744,CDM,C1713,HCPCS,0278,RC,,,,both,,,712.15,462.90,,,,,,,,,,,,,
KIT INTERNAL FIXATION WITH 2MM ORTHOSORB LS STRAIGHT PIN,SUP-2483079,CDM,C1713,HCPCS,0278,RC,,,,both,,,670.08,435.55,,,,,,,,,,,,,
BONE TNDN BONE HEMI WTH QDRCPS 10 13MM WIDTH FRZN X MSRMNT 4,SUP-2573321,CDM,C1762,CPT,0278,RC,,,,both,,,7311.08,4752.20,,,,,,,,,,,,,
SET FEED TUBE 24FR L150CM PUL METH FOR PERC ENDO PLCMNT PEG,SUP-2419560,CDM,2720000010,LOCAL,0272,RC,,,,both,,,533.80,346.97,,,,,,,,,,,,,
PLATE BNE L CNDYL TI FOR 1.5MM SCR MOD HND SYS,SUP-2191169,CDM,C1713,HCPCS,0278,RC,,,,both,,,1531.75,995.64,,,,,,,,,,,,,
CATHETER IVUS VISIONS PV .018 WORKING L 135 CM SHTH 6 FR,SUP-2898500,CDM,C1753,HCPCS,0278,RC,,,,both,,,1329.04,863.88,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH ALPHA L 109 MM DIA 30 MM SHTH 16 FR,SUP-2170230,CDM,C1874,HCPCS,0278,RC,,,,both,,,53182.18,34568.42,,,,,,,,,,,,,
GRAFT BNE FIBER 10 CC DBM CORTICAL PUREBONE,SUP-2424608,CDM,C1713,HCPCS,0278,RC,,,,both,,,3470.05,2255.53,,,,,,,,,,,,,
CATHETER BLLN DIL 7.5 FRX180 CM 15-18 MMX5.5 CM CRE RX,SUP-2417343,CDM,2720000010,LOCAL,0272,RC,,,,both,,,873.23,567.60,,,,,,,,,,,,,
BETAMETHASONE DIPROPIONATE AUG 0.05 % EX CREA,RX-9175,CDM,6370000000,HCPCS,0637,RC,51672-1310-01,NDC,,both,15,GR,95.60,62.14,,,,,,,,,,,,,
KIT CATH HEMODIALYSI EQUISTREAM CHRONIC STD 14.5FR DIA 19CM,SUP-2613298,CDM,C1750,HCPCS,0278,RC,,,,both,,,1615.53,1050.09,,,,,,,,,,,,,
MESH HERN L6XW4IN POLY SKIRTED KNIT W/ CLLGN BARR IMPL FOR,SUP-2174710,CDM,C1781,HCPCS,0278,RC,,,,both,,,1548.49,1006.52,,,,,,,,,,,,,
SOCKS PROSTHETIC SINGLE PLY FIT LF,SUP-2388228,CDM,L8470,HCPCS,0272,RC,,,,both,,,17.55,11.41,,,,,,,,,,,,,
SCREW INTRF 12X25 MM FT TI,SUP-2762233,CDM,C1713,HCPCS,0278,RC,,,,both,,,411.34,267.37,,,,,,,,,,,,,
GUIDEWIRE UROLOGICAL STR 3 CM 0.018 INX150 CM ZIPWIRE,SUP-2862341,CDM,C1769,HCPCS,0272,RC,,,,both,,,166.04,107.93,,,,,,,,,,,,,
SPACER SPNL 32X11X7 MM NANOMETALENE STRL VENTURA,SUP-2244933,CDM,C1821,HCPCS,0278,RC,,,,both,,,6908.00,4490.20,,,,,,,,,,,,,
DIPHENOXYLATE-ATROPINE 2.5-0.025 MG PO TABS,RX-2516,CDM,6370000000,HCPCS,0637,RC,00406-1236-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
HC X-Ray Bile Duct Endoscopy,PX-3207432800,CDM,74328,CPT,0320,RC,,,,both,,,859.00,558.35,,,,,,,,,,,,,
GUIDEWIRE SURG 320 MM TROCAR TIP SS IDENTITI,SUP-2544218,CDM,C1769,HCPCS,0272,RC,,,,both,,,169.56,110.21,,,,,,,,,,,,,
SCREW BNE L7MM DIA2MM CRANIOMAXILLOFACIAL TI SELF RET,SUP-2262833,CDM,C1713,HCPCS,0278,RC,,,,both,,,317.14,206.14,,,,,,,,,,,,,
HANDPIECE BRST BX 9CM ST,SUP-2239988,CDM,2720000010,LOCAL,0272,RC,,,,both,,,669.45,435.14,,,,,,,,,,,,,
SCREW BNE 28X45MM CORT G PKG 1 HEXADRIVE 7,SUP-2268292,CDM,C1713,HCPCS,0278,RC,,,,both,,,258.61,168.10,,,,,,,,,,,,,
GRAFT VASC HEMGRD L 85 CM DIA 8 MM RNG L 45 CM,SUP-2681832,CDM,C1768,CPT,0278,RC,,,,both,,,3162.92,2055.90,,,,,,,,,,,,,
KIT INFLATION DEV PTCA PRIORITY PK GA 20 ATM VLV ID 0.115 IN,SUP-2105891,CDM,C1769,HCPCS,0272,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
PROSTHESIS OSS 9.14 MM 1 MM WEHRS SINGLE NOTCH INCUS STAP HA,SUP-2464412,CDM,L8613,CPT,0278,RC,,,,both,,,1533.11,996.52,,,,,,,,,,,,,
APPLICATOR BRACHYTHERAPY SZ 5 POLYUR SPHR MAMMOSITE 2256] HOLOGIC INC],SUP-2239909,CDM,C1729,HCPCS,0272,RC,,,,both,,,8901.90,5786.23,,,,,,,,,,,,,
ALLOGRAFT BNE CRYOPRESERVED 11 MM FRSH PROCHONDRIX CR,SUP-2717803,CDM,C1762,CPT,0278,RC,,,,both,,,11628.05,7558.23,,,,,,,,,,,,,
BRACE WR ADULTXL LT INSTABILITY INJ,SUP-2198769,CDM,L3809,HCPCS,0274,RC,,,,both,,,69.39,45.10,,,,,,,,,,,,,
HC Pt Therapeutic Activities 15 Min|OP OCCUPATIONAL THERAPY SERV|DOCUMENTATION ON FILE|SERVICES PROVIDED IN WHOLE OR IN PARTY BY AN OTA FOR MEDICARE PATIENTS,PX-4209753000,CDM,97530,CPT,0420,RC,,,GO|KX|CO,both,,,144.00,93.60,,,,,,,,,,,,,
SUPPORT ORTHOT THOR LUMBAR SACR CUST FULL CORSET,SUP-2435564,CDM,L0974,HCPCS,0272,RC,,,,both,,,494.74,321.58,,,,,,,,,,,,,
MESH BIO W10XL16CM BOV PERICARD NONCROSSLINKED CLLGN MTRX,SUP-2130832,CDM,C9354,HCPCS,0278,RC,,,,both,,,12046.80,7830.42,,,,,,,,,,,,,
PLATE BNE W15XL152MM THK2MM 7 H BILAT S STL COVERLEAF RIG,SUP-2186009,CDM,C1713,HCPCS,0278,RC,,,,both,,,1611.79,1047.66,,,,,,,,,,,,,
COIL VASC HILAL MICROCOIL EMBOLUS L 1 CM CATH 0.018 IN SYNTH,SUP-2611906,CDM,C1889,HCPCS,0278,RC,,,,both,,,241.15,156.75,,,,,,,,,,,,,
PLATE BNE 3.5X61 MM 5 HOLE SS DCP,SUP-2569137,CDM,C1713,HCPCS,0278,RC,,,,both,,,231.42,150.42,,,,,,,,,,,,,
FRAME EXT FIX DIA4.2MM FIX AO FIT HOFFMANN II,SUP-2377973,CDM,C1713,HCPCS,0278,RC,,,,both,,,1642.22,1067.44,,,,,,,,,,,,,
PLATE BNE THK1.5MM 3X3 H CRANIOMAXILLOFACIAL ORAL SIL TI,SUP-2191610,CDM,C1713,HCPCS,0278,RC,,,,both,,,2510.12,1631.58,,,,,,,,,,,,,
GRAFT DERM PLIABLE FLD SUPPLE ULT THCK ACELLULAR DERM IMPL,SUP-2307565,CDM,Q4128,HCPCS,0636,RC,,,,both,,,4255.49,2766.07,,,,,,,,,,,,,
PORT INFUS 8FR L45CM POLYUR ATTACH CATH TI OPN SUT PLUG LO,SUP-2127787,CDM,C1788,HCPCS,0278,RC,,,,both,,,1036.20,673.53,,,,,,,,,,,,,
PLATE BONE LT TIB HI OSTEOTMY OSTEOTRAC,SUP-2223273,CDM,C1713,HCPCS,0278,RC,,,,both,,,4119.68,2677.79,,,,,,,,,,,,,
GRAFT BONE CRUSH FRZ DRY CANC STRL 1-10MM 15CC,SUP-2165536,CDM,C1713,HCPCS,0278,RC,,,,both,,,894.90,581.68,,,,,,,,,,,,,
CYGNUS ANTR CERV PLTE FIX PIN,SUP-2664217,CDM,C1713,HCPCS,0278,RC,,,,both,,,204.10,132.66,,,,,,,,,,,,,
HEAD PIN 2.5X100MM 10 PK KIT0758,SUP-2266535,CDM,C1713,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
COIL EMB L7CM PRI DIA0.020IN NIT J SFT FILL STRTCH RESIST,SUP-2323424,CDM,C1889,HCPCS,0278,RC,,,,both,,,6531.20,4245.28,,,,,,,,,,,,,
NAIL IM FEM 14MM DIA 28CML TI VERSANAIL DEPUY ORTHOPEDICS,SUP-2412460,CDM,C1713,HCPCS,0278,RC,,,,both,,,3956.40,2571.66,,,,,,,,,,,,,
CLAMP SURG ROD TO ROD 6.5-6.5 MM SINGLE REVERE,SUP-2584884,CDM,C1713,HCPCS,0278,RC,,,,both,,,1036.20,673.53,,,,,,,,,,,,,
BAR THRD 160MM,SUP-2316268,CDM,2720000010,LOCAL,0272,RC,,,,both,,,123.59,80.33,,,,,,,,,,,,,
SUPPORT WRST XSM L7IN FOR 55IN L HND SUEDE FLANNEL PERF LACE,SUP-2197030,CDM,L3931,HCPCS,0272,RC,,,,both,,,22.61,14.70,,,,,,,,,,,,,
SCREW LCK FOR TI TIB NAIL IMPLANTS TI GRN 5.0MM 70MM,SUP-2192345,CDM,C1713,HCPCS,0278,RC,,,,both,,,613.78,398.96,,,,,,,,,,,,,
PLATE BNE TI LT ANTR ANK FUSION STRL AXSOS 3,SUP-2902316,CDM,C1713,HCPCS,0278,RC,,,,both,,,9608.40,6245.46,,,,,,,,,,,,,
PORT VENT DRNGE 23CMX16MM STYL BTM INLET CONN BA IMPREG W,SUP-2278360,CDM,C1889,HCPCS,0278,RC,,,,both,,,931.67,605.59,,,,,,,,,,,,,
COIL VASC AZUR HYDROCOIL L 20 CM DIA 4 MM MICROCATHETER,SUP-2384881,CDM,C1889,HCPCS,0278,RC,,,,both,,,3191.81,2074.68,,,,,,,,,,,,,
GUIDEWIRE SURG L8IN DIA0.094IN LNG THRD W/ TRCR TIP DISP,SUP-2123197,CDM,C1769,HCPCS,0272,RC,,,,both,,,94.20,61.23,,,,,,,,,,,,,
SET TRCR 23GA FOR STD ALONE COMP VISN SYS CONSTELLATION,SUP-2109904,CDM,C1713,HCPCS,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
GRAFT VASC L 50 CM DIA 6 MM POLYESTER THOR ABD AORT STR TB,SUP-2227632,CDM,C1768,CPT,0278,RC,,,,both,,,1474.54,958.45,,,,,,,,,,,,,
SCREW BONE L10MM DIA2.7MM RED CORT MAXILLOMANDIBULAR TI HI,SUP-2137233,CDM,C1713,HCPCS,0278,RC,,,,both,,,141.30,91.84,,,,,,,,,,,,,
BEARING TIB STANDARD+ THK12.5MM UNIV POLYETH MENIS PRI NEUT,SUP-2250083,CDM,C1776,CPT,0278,RC,,,,both,,,3888.58,2527.58,,,,,,,,,,,,,
GRAFT HUM TISS 9/10MM TEND BNE PRESHAPED BIOCLEANSE,SUP-2335547,CDM,C1713,HCPCS,0278,RC,,,,both,,,10362.00,6735.30,,,,,,,,,,,,,
IMMOBILIZER ORTH 30-36IN M SHLDR UNIV ELAS M,SUP-2197391,CDM,L1830,CPT,0274,RC,,,,both,,,65.31,42.45,,,,,,,,,,,,,
DEVICE VENTRICULAR ASST LT KT SHWR BG HEARTMATE II,SUP-2356004,CDM,Q0501,HCPCS,0274,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
SPACER SPNL H12XL26MM PEEK POST THORLUM INTBDY FUS SET TYP,SUP-2285128,CDM,C1821,HCPCS,0278,RC,,,,both,,,7159.20,4653.48,,,,,,,,,,,,,
PLATE BNE W101XL84MM THK35MM 6 H BILAT TI STR RIG LOK COMPR,SUP-2191082,CDM,C1713,HCPCS,0278,RC,,,,both,,,1474.07,958.15,,,,,,,,,,,,,
PATCH DURA L 3.1 X W 2.4 IN SURF AREA 7.4 SQ IN BOV PERICARD,SUP-2884046,CDM,C1763,HCPCS,0278,RC,,,,both,,,2006.46,1304.20,,,,,,,,,,,,,
SCREW BNE L85MM DIA6MM ST AQUA CORT TI ST CANN LOK FULL,SUP-2191851,CDM,C1713,HCPCS,0278,RC,,,,both,,,910.38,591.75,,,,,,,,,,,,,
PLATE STRNL CLOSURE TI STR NS STERNALOCK BLU,SUP-2894549,CDM,C1713,HCPCS,0278,RC,,,,both,,,1764.68,1147.04,,,,,,,,,,,,,
DEVICE GRSP SHTH L160CM DIA2.5MM S STL 4 PRNG W/ INWARD,SUP-2391613,CDM,2720000010,LOCAL,0272,RC,,,,both,,,493.92,321.05,,,,,,,,,,,,,
KIT BNE CEM KNEE W/ L APPL MIX AND DEL SYS,SUP-2120718,CDM,2720000010,LOCAL,0272,RC,,,,both,,,769.30,500.04,,,,,,,,,,,,,
MESH CRAN L 41 X W 40 MM THK 0.3 MM SCREW DIA1.5 MM TI,SUP-2936705,CDM,C1713,HCPCS,0278,RC,,,,both,,,973.40,632.71,,,,,,,,,,,,,
SCREW BNE L28 MM L11 MM OD45 MM SHT THRD MONSTER IMPL,SUP-2320598,CDM,C1713,HCPCS,0278,RC,,,,both,,,690.64,448.92,,,,,,,,,,,,,
COMPONENT SHLDR CAPPED REVERSED TRAB MTL,SUP-2422940,CDM,C1776,CPT,0278,RC,,,,both,,,28260.00,18369.00,,,,,,,,,,,,,
GRAFT HUM TISS W2XL4CM NOM THK0.5MM LO PROF HUM DERM REGEN,SUP-2399061,CDM,Q4107,HCPCS,0636,RC,,,,both,,,2964.16,1926.70,,,,,,,,,,,,,
CATHETER EP STEER 5 MM 5 FRX110 CM 20 MM,SUP-2357450,CDM,C1730,HCPCS,0272,RC,,,,both,,,2983.00,1938.95,,,,,,,,,,,,,
KWIRE FIX L6IN DIA16MM NONSTERILE S STL 3 SIDE DBL TRCR,SUP-2150336,CDM,C1713,HCPCS,0278,RC,,,,both,,,7.44,4.84,,,,,,,,,,,,,
DRILL 15MM,SUP-2841574,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1080.16,702.10,,,,,,,,,,,,,
CODMAN SCOTT VENT CANN DISP 8FR. 1.3MM I DX2.5MM O DX80MM,SUP-2243025,CDM,C1713,HCPCS,0278,RC,,,,both,,,260.27,169.18,,,,,,,,,,,,,
GENERATOR PULSE IMPLABLE RECHRG FLEX LD CONN TO THE IMPL,SUP-2141895,CDM,C1820,HCPCS,0278,RC,,,,both,,,43449.75,28242.34,,,,,,,,,,,,,
SCREW BNE FT 4X85 MM CANC STRL PERI-LOC,SUP-2348413,CDM,C1713,HCPCS,0278,RC,,,,both,,,456.87,296.97,,,,,,,,,,,,,
PROSTHESIS TORP 084MM DIAM 4MM LEN CNTR HD HA,SUP-2313674,CDM,L8613,CPT,0278,RC,,,,both,,,1186.04,770.93,,,,,,,,,,,,,
PLATE BNE TIB 3.5X95 MM RT PROX LAT 5 HOLE NS LOQTEC,SUP-2101268,CDM,C1713,HCPCS,0278,RC,,,,both,,,4333.20,2816.58,,,,,,,,,,,,,
WAND ABLAT SHFT DIA2.5MM 60DEG DOME COBLATION,SUP-2341980,CDM,2720000010,LOCAL,0272,RC,,,,both,,,672.59,437.18,,,,,,,,,,,,,
GRAFT HUM TISS W8XL16CM THK1MM ACELLULAR DERM MTRX,SUP-2335286,CDM,C1762,CPT,0278,RC,,,,both,,,9840.76,6396.49,,,,,,,,,,,,,
COMPONENT TOT SHLDR CAPPED ADV REVERSED,SUP-2267728,CDM,C1776,CPT,0278,RC,,,,both,,,21352.00,13878.80,,,,,,,,,,,,,
PLATE BONE W38XL45MM THK0.6MM NONSTERILE GLD CRAN TI RECTANG,SUP-2190620,CDM,C1713,HCPCS,0278,RC,,,,both,,,4598.84,2989.25,,,,,,,,,,,,,
KNIFE ENDOSCP JR 3.5X4.5 MM 2300 MM 2.8 MM STRL SB KNIFE,SUP-2464540,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
PLATE BNE X 1.5X0.6 MM 6 MM 5 HOLE C PALE BRIDGE TI NS,SUP-2485735,CDM,C1713,HCPCS,0278,RC,,,,both,,,410.27,266.68,,,,,,,,,,,,,
CONTROLLER VAC ASST VEN DRNGE,SUP-2266017,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7963.04,5175.98,,,,,,,,,,,,,
GRAFT HUM TISS W4XL3CM 12SQCM UMB CRD AMNIO MEM,SUP-2116290,CDM,Q4148,HCPCS,0636,RC,,,,both,,,4694.30,3051.29,,,,,,,,,,,,,
DRESSING HEMSTAT W12XL12IN 3 PLY QUIKCLOT CONTROL+,SUP-2416087,CDM,2720000010,LOCAL,0272,RC,,,,both,,,834.99,542.74,,,,,,,,,,,,,
TROCAR ENDOSCP BLDELSS UNIV 11X100 MM STBL SL ENDOPATH BASX,SUP-2857937,CDM,2720000010,LOCAL,0272,RC,,,,both,,,399.50,259.67,,,,,,,,,,,,,
SYSTEM IO FIX 2.5MM 0DEG W/ UNIV INSRT FOR FRACTURES FUS,SUP-2175103,CDM,C1713,HCPCS,0278,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
SPLINT ARM L W25XL14IN FOR 8-21IN LIMB TRNSLUC FAB POLYSTYR,SUP-2328638,CDM,L3702,HCPCS,0274,RC,,,,both,,,31.53,20.49,,,,,,,,,,,,,
IMPLANT HUM TISS L 30 CM DIA 4-10 MM SZ 54 CM FEM ART,SUP-2932971,CDM,C1762,CPT,0278,RC,,,,both,,,38936.00,25308.40,,,,,,,,,,,,,
DILATOR BLLN CHN SZ 37MM L1950MM DST TIP L7MM DIA44FR 0035IN,SUP-2312966,CDM,C1726,HCPCS,0272,RC,,,,both,,,1569.47,1020.16,,,,,,,,,,,,,
SPRAY ENDODONTIC FORMOCRESOL 1 OZ,SUP-2322059,CDM,2720000010,LOCAL,0272,RC,,,,both,,,419.79,272.86,,,,,,,,,,,,,
TAP BNE PLT FOR 3.5MM SCR,SUP-2107127,CDM,C1713,HCPCS,0278,RC,,,,both,,,2072.40,1347.06,,,,,,,,,,,,,
PLATE BNE L31MM 4 H S STL 1 4TH TBLR W/ CLLR FOR 2.7MM SCR,SUP-2186032,CDM,C1713,HCPCS,0278,RC,,,,both,,,467.67,303.99,,,,,,,,,,,,,
SYSTEM MIC ACCS GLIDEACCESS DIA 4 FR L 40 CM SS WIRE,SUP-2385207,CDM,C1894,HCPCS,0272,RC,,,,both,,,79.29,51.54,,,,,,,,,,,,,
BIT DRILL CANN 4.5 MM ACROMIOCLAVICULAR JT MTO,SUP-2849153,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1230.88,800.07,,,,,,,,,,,,,
CLAMP SURG ROD TO ROD 18 MM ASMBLY REVERE,SUP-2584887,CDM,C1713,HCPCS,0278,RC,,,,both,,,1036.20,673.53,,,,,,,,,,,,,
KNIFE SURG CIR BLADE 2.2 MM 1 IN ARACH ULTRA THN BAYNT HNDL (MIN QTY 5),SUP-2516359,CDM,2720000010,LOCAL,0272,RC,,,,both,,,643.70,418.40,,,,,,,,,,,,,
PIN BNE FIX SHRT SHOULDERED CADENCE,SUP-2933745,CDM,C1713,HCPCS,0278,RC,,,,both,,,349.33,227.06,,,,,,,,,,,,,
WINTERGREEN OIL OIL,RX-29337,CDM,6370000000,HCPCS,0637,RC,00395-1667-92,NDC,,both,59,ML,34.60,22.49,,,,,,,,,,,,,
SPLINT ORTHOPEDIC W/ ABDUCTED MED 8 IN LT WRST FOREARM THMB,SUP-2276633,CDM,L3809,HCPCS,0272,RC,,,,both,,,22.58,14.68,,,,,,,,,,,,,
VALVE ANGIO 10IN LEN Y VLV HEMSTAT HI PRSS TBNG W INSRT TOOL,SUP-2303054,CDM,C1713,HCPCS,0278,RC,,,,both,,,80.67,52.44,,,,,,,,,,,,,
GENERATOR NERVE STIM PULSE IMPL INFIN,SUP-2637207,CDM,C1767,HCPCS,0278,RC,,,,both,,,57335.18,37267.87,,,,,,,,,,,,,
TELMISARTAN 80 MG PO TABS,RX-24336,CDM,6370000000,HCPCS,0637,RC,68462-0201-30,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
SCREW BONE L65MM OD7MM THRD L17MM PUR HINDFOOT ANK CANN SH,SUP-2320948,CDM,C1713,HCPCS,0278,RC,,,,both,,,2846.41,1850.17,,,,,,,,,,,,,
SCREW BNE 2X10 MM 8 MM DRILL-FREE STRL L1 MAXDRIVE 251980877,SUP-2460545,CDM,C1713,HCPCS,0278,RC,,,,both,,,478.57,311.07,,,,,,,,,,,,,
DEVICE BNE FILL BX 8 GA OSSEOFLEX BFD,SUP-2464015,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
PLATE BNE LCK SHT 126 MM RT DSTL MEDL HUM 7 HOLE PUR STRL,SUP-2482566,CDM,C1713,HCPCS,0278,RC,,,,both,,,2877.15,1870.15,,,,,,,,,,,,,
GRAFT VASC IMPRA L 30 CM DIA 6 MM EPTFE STR STD WALL N RING,SUP-2761262,CDM,C1768,CPT,0278,RC,,,,both,,,1357.01,882.06,,,,,,,,,,,,,
NECK FEM SZ 1 LNG CO CHROM HIP ANTEVERSION RETRO VARUS,SUP-2304838,CDM,C1776,CPT,0278,RC,,,,both,,,8572.20,5571.93,,,,,,,,,,,,,
EPOETIN ALFA 20000 UNIT/ML IJ SOLN,RX-14643,CDM,J0885,HCPCS,0636,RC,55513-0478-10,NDC,,both,1,ML,978.30,635.89,,,,,,,,,,,,,
TRAY EPIDURAL CATH DIA19 GA NDL DIA17 GA CE17TKFSN NRFIT,SUP-2936422,CDM,2720000010,LOCAL,0272,RC,,,,both,,,93.16,60.55,,,,,,,,,,,,,
COLLAR EXTRIC FR 1 3/4IN CIRC 8IN-18IN PED AQUA CERV,SUP-2194419,CDM,L0172,HCPCS,0272,RC,,,,both,,,22.67,14.74,,,,,,,,,,,,,
KNIFE FREER ANG SEPT 7IN,SUP-2162137,CDM,C1713,HCPCS,0278,RC,,,,both,,,397.02,258.06,,,,,,,,,,,,,
INTRODUCER SHTH 5FR L4CM SHT GRY HUB W S STL DBL END GWIRE,SUP-2303307,CDM,C1893,HCPCS,0272,RC,,,,both,,,81.48,52.96,,,,,,,,,,,,,
FIXATOR EXT FIX OBLQ SUPP MR SAFE,SUP-2187906,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1660.53,1079.34,,,,,,,,,,,,,
SET INTRO 5FR L13CM ID1.7MM W/ 0.018IN GWIRE NDL MICPUNC,SUP-2168724,CDM,C1894,HCPCS,0272,RC,,,,both,,,118.03,76.72,,,,,,,,,,,,,
BUR SURG MATCHSTICK SHT 3 MM FLUT FOR QD8/QD8-G1/QD8-S,SUP-2848458,CDM,2720000010,LOCAL,0272,RC,,,,both,,,404.34,262.82,,,,,,,,,,,,,
PLATE BNE L 2X20 MM LT 2 HOLE OBLQ SS,SUP-2569113,CDM,C1713,HCPCS,0278,RC,,,,both,,,131.25,85.31,,,,,,,,,,,,,
CATHETER DRNGE INCIS SET GEN PURP J TIP W/ STIFF CANN TRCR,SUP-2391575,CDM,C1729,HCPCS,0272,RC,,,,both,,,244.92,159.20,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED BPLR UPLR CEM BIOMETHBIOC] ZIMMER BIOMET INC],SUP-2137332,CDM,C1776,CPT,0278,RC,,,,both,,,5699.10,3704.41,,,,,,,,,,,,,
GUIDEWIRE VASC 0035IN DIA 150CML 3MM J TIP DBL END W STR END,SUP-2302706,CDM,C1769,HCPCS,0272,RC,,,,both,,,23.86,15.51,,,,,,,,,,,,,
BUR SURG DIAMOND LNG MED 4X69 MM RND FOR SM BNE STRL,SUP-2363285,CDM,2720000010,LOCAL,0272,RC,,,,both,,,174.27,113.28,,,,,,,,,,,,,
HC Unlisted Therapeutic Proph/Dx IV/Ia Njx/Nfs,PX-2609637900,CDM,96379,CPT,0260,RC,,,,both,,,142.00,92.30,,,,,,,,,,,,,
SPIKE CBL HIP S STL LO PROF ACCORD,SUP-2345210,CDM,C1776,CPT,0278,RC,,,,both,,,410.71,266.96,,,,,,,,,,,,,
PLATE BONE MEDIALMAX POCKETLOCK NEUT ALPHA,SUP-2400133,CDM,C1713,HCPCS,0278,RC,,,,both,,,6129.28,3984.03,,,,,,,,,,,,,
HC X-Ray Knee Standing Ap,PX-3207356500,CDM,73565,CPT,0320,RC,,,,both,,,599.00,389.35,,,,,,,,,,,,,
ALLOGRAFT BNE SPACER 23X9X14 MM PLIF CORTICAL ALLOQUENT,SUP-2736910,CDM,C1713,HCPCS,0278,RC,,,,both,,,9388.60,6102.59,,,,,,,,,,,,,
WASHER SPNL 5 MM POST TI POLARIS,SUP-2686051,CDM,C1713,HCPCS,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
BOLT EXT FIX UNIV WIRE,SUP-2197245,CDM,2720000010,LOCAL,0272,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
FIXATOR EXT NUT LK RINGFIX SYS,SUP-2495539,CDM,2720000010,LOCAL,0272,RC,,,,both,,,32.97,21.43,,,,,,,,,,,,,
TAP SRGCL SCREW CRTCL QUICK CNNCT MINI FRGMNT TTNM 2.7MM 50M,SUP-2473968,CDM,2720000010,LOCAL,0272,RC,,,,both,,,552.64,359.22,,,,,,,,,,,,,
WAND ABLAT FOR TNSLCTMY ADENOIDECTOMY COBLATION PROCISE XP,SUP-2342048,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1122.77,729.80,,,,,,,,,,,,,
PROBE PEDICLEXSM TRI TIP L40MM DIA2.5MM STR GRAD SGL PC MOD,SUP-2354603,CDM,C1776,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED FEM HIP MED DEMAND CEMNETED,SUP-2365980,CDM,C1776,CPT,0278,RC,,,,both,,,13188.00,8572.20,,,,,,,,,,,,,
SCREW INTRF KNEE EZSTART,SUP-2423002,CDM,C1713,HCPCS,0278,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
SYSTEM THREADED SEPARATOR 5MMX100MM,SUP-2119549,CDM,C1713,HCPCS,0278,RC,,,,both,,,390.05,253.53,,,,,,,,,,,,,
BOOT CAST SM FOR WMN 55 8 SQ TOE DSGN UNIV FOREFOOT CLSR,SUP-2176232,CDM,L4386,HCPCS,0274,RC,,,,both,,,27.38,17.80,,,,,,,,,,,,,
PAD ORTHOT CERV THOR LUMBAR SACR CUST KYPHOSIS FLOATING,SUP-2435572,CDM,L1025,HCPCS,0272,RC,,,,both,,,440.17,286.11,,,,,,,,,,,,,
CATHETER LITHO 4X40 MM FOR VASCULATURE CALCIFIED,SUP-2337679,CDM,C1725,HCPCS,0272,RC,,,,both,,,8635.00,5612.75,,,,,,,,,,,,,
SCREW BNE L32MM DIA3.5MM UNIV CORT S STL ST NONCANNULATED,SUP-2411075,CDM,C1713,HCPCS,0278,RC,,,,both,,,76.62,49.80,,,,,,,,,,,,,
HC Lyr Clos Nk Hnd Ft 2.6-5 Cm,PX-4501204200,CDM,12042,CPT,0450,RC,,,,both,,,1216.00,790.40,,,,,,,,,,,,,
CATHETER ATHRCTMY L135CM DIA1.75MM MAX DIA0.58IN COR BUR,SUP-2142304,CDM,C1724,HCPCS,0278,RC,,,,both,,,4851.30,3153.34,,,,,,,,,,,,,
HC Pt Contrast Baths 15min,PX-4209703400,CDM,97034,CPT,0420,RC,,,,both,,,177.00,115.05,,,,,,,,,,,,,
VALVE SHUNT MULTPURP LO PRSS W/ ANTISIPHON DEV,SUP-2244284,CDM,C1729,HCPCS,0272,RC,,,,both,,,4109.38,2671.10,,,,,,,,,,,,,
ALLOGRAFT BNE CUBE BLOCK 15X30X8 MM FD CANC ORAGRAFT,SUP-2740847,CDM,C1713,HCPCS,0278,RC,,,,both,,,1124.21,730.74,,,,,,,,,,,,,
STEM TIB 7 KNEE,SUP-2201508,CDM,C1713,HCPCS,0278,RC,,,,both,,,7586.68,4931.34,,,,,,,,,,,,,
RING ANNULPLSTY 40MM MI W/ DEL SYS PHY CARPENTIER,SUP-2214173,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7206.30,4684.09,,,,,,,,,,,,,
SCREW BNE L54MM DIA2.7MM CORT ANK FT S STL ST NONCANNULATED,SUP-2411039,CDM,C1713,HCPCS,0278,RC,,,,both,,,64.31,41.80,,,,,,,,,,,,,
COLLAR EXTRIC AD ADJUSTABLE STFFNK SEL,SUP-2120410,CDM,L0172,HCPCS,0274,RC,,,,both,,,43.96,28.57,,,,,,,,,,,,,
BLADE LARYNSCP SZ 2 G PROF MILLER,SUP-2381618,CDM,2720000010,LOCAL,0272,RC,,,,both,,,204.10,132.66,,,,,,,,,,,,,
KIT SLEEVE SURGICAL SYSTEM 10PK,SUP-2266521,CDM,C1713,HCPCS,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
CATHETER ATHRCTMY CROSSER L 146 CM DIA1.67 MM PERIPH,SUP-2126795,CDM,C1714,HCPCS,0272,RC,,,,both,,,7520.30,4888.19,,,,,,,,,,,,,
CANNULA ARTHSCP L72MM DIA6.5MM SMOOTH 3 SEAL DSGN FLEX OBT,SUP-2341062,CDM,2720000010,LOCAL,0272,RC,,,,both,,,217.70,141.50,,,,,,,,,,,,,
CABLE SPNL FLANGE W/ CRMP TI SONGER,SUP-2713124,CDM,C1713,HCPCS,0278,RC,,,,both,,,659.40,428.61,,,,,,,,,,,,,
CATHETER PICC 5FR GWIRE L70CM POLYUR NIT GWIRE,SUP-2127466,CDM,C1751,HCPCS,0278,RC,,,,both,,,396.27,257.58,,,,,,,,,,,,,
HC MRI-Upper Ext Jnt W Cont,PX-6107322200,CDM,73222,CPT,0610,RC,,,,inpatient,,,3764.00,2446.60,,,,,,,,,,,,,
LEVEL ST TWIST DRILL J NOTCH 21 MM STP15 X 50 MM QT001 EA,SUP-2677985,CDM,2720000010,LOCAL,0272,RC,,,,both,,,440.92,286.60,,,,,,,,,,,,,
WIRE PASS DRL 1.3MM S,SUP-2361699,CDM,2720000010,LOCAL,0272,RC,,,,both,,,100.07,65.05,,,,,,,,,,,,,
LEVOTHYROXINE SODIUM 50 MCG PO TABS,RX-4421,CDM,6370000000,HCPCS,0637,RC,60687-0464-11,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PLATE BNE FEM 196 MM LT DSTL 7 HOLE TI STRL LCP,SUP-2549450,CDM,C1713,HCPCS,0278,RC,,,,both,,,5273.13,3427.53,,,,,,,,,,,,,
PLATE BONE CONDYLAR MINI SHORT TITANIUM ARSENAL FOOT PLATING SYSTEM FOR 2.2/2.7/3.5MM SCREW,SUP-2878197,CDM,C1713,HCPCS,0278,RC,,,,both,,,4254.70,2765.55,,,,,,,,,,,,,
SET STENT URTRL 8FR DIA 20CML PRCFLX DBLE PGTL STRGHT TIP DU,SUP-2724130,CDM,C2617,HCPCS,0278,RC,,,,both,,,531.45,345.44,,,,,,,,,,,,,
GRAFT BONE CALCANEUS WEDGE FD,SUP-2875986,CDM,C1713,HCPCS,0278,RC,,,,both,,,2550.47,1657.81,,,,,,,,,,,,,
KIT NEUROSURGICAL ACC DIL SET MPLR PRB STIM CLP,SUP-2354672,CDM,C1713,HCPCS,0278,RC,,,,both,,,8792.00,5714.80,,,,,,,,,,,,,
ROD SPNL TI TMPLT DEFORMITY SILVERTON-D,SUP-2211158,CDM,C1713,HCPCS,0278,RC,,,,both,,,293.90,191.03,,,,,,,,,,,,,
ENDCAP DIA9.5MM EXTN 0MM GRY TI 6% ALUM 7% NIOBIUM THRD T25,SUP-2180201,CDM,C1713,HCPCS,0278,RC,,,,both,,,635.98,413.39,,,,,,,,,,,,,
SPLINT ELBOW/KNEE M L13.5IN FOR 10-12IN VLY MESH COT LINING,SUP-2324946,CDM,L3702,HCPCS,0272,RC,,,,both,,,78.44,50.99,,,,,,,,,,,,,
PLATE BNE SCREW DIA2 MM TI MANDIBULAR FULL CUSTOMIZED,SUP-2883266,CDM,C1713,HCPCS,0278,RC,,,,both,,,30253.90,19665.03,,,,,,,,,,,,,
GUIDEWIRE VASC PRELUDE L 50 CM DIA 0.035 IN TIP L 3 MM SS,SUP-2303468,CDM,C1769,HCPCS,0272,RC,,,,both,,,22.70,14.75,,,,,,,,,,,,,
PACEMAKER CARD D6MM PERM 2 CHMBR STD UNIPOLAR/BIPOLAR DDDR,SUP-2357337,CDM,C1785,HCPCS,0275,RC,,,,both,,,15857.00,10307.05,,,,,,,,,,,,,
WIRE EXT FIX 2 MM OLV SIDEKCK EZ FRAME,SUP-2850512,CDM,C1713,HCPCS,0278,RC,,,,both,,,197.82,128.58,,,,,,,,,,,,,
MINI PLATE 6 HOLE LNG RIGHT BAR TURNED 110 CP TITANIUM,SUP-2676430,CDM,C1713,HCPCS,0278,RC,,,,both,,,497.06,323.09,,,,,,,,,,,,,
PLATE BNE L237MM 14 H NONSTERILE R PROX TIB S STL VAR ANG,SUP-2177924,CDM,C1713,HCPCS,0278,RC,,,,both,,,6269.70,4075.30,,,,,,,,,,,,,
PACEMAKER CRD CONTAK RENEWAL TR 871F,SUP-2149121,CDM,C1786,HCPCS,0275,RC,,,,both,,,25434.00,16532.10,,,,,,,,,,,,,
BIT DRL JCBS 3.5 MM,SUP-2205611,CDM,2720000010,LOCAL,0272,RC,,,,both,,,579.58,376.73,,,,,,,,,,,,,
CUBE EXT FIX 4 H S STL RANCHO FOR ILIZ TAY SPAT FRME EXT,SUP-2342335,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1471.12,956.23,,,,,,,,,,,,,
EXTENSION STEM L30MM DIA20MM KNEE CEM BAL REV SYS,SUP-2315639,CDM,C1776,CPT,0278,RC,,,,both,,,2625.04,1706.28,,,,,,,,,,,,,
PLATE BNE BROAD 4.5X358 MM 20 HOLE TI NS LC-DCP,SUP-2568785,CDM,C1713,HCPCS,0278,RC,,,,both,,,4136.23,2688.55,,,,,,,,,,,,,
PLATE BNE DIA13 MM THK 0.5 MM SCREW DIA1.7 MM MAXILLOFCL,SUP-2909529,CDM,C1713,HCPCS,0278,RC,,,,both,,,2099.44,1364.64,,,,,,,,,,,,,
CATHETER GUID HEARTRAIL III L 100 CM 6 FR IL3.75 2 SIDE H,SUP-2522834,CDM,C1887,HCPCS,0272,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
GRAFT BIO TISS OASIS WND MATRIX 3X3.5CM FEN,SUP-2341251,CDM,Q4102,HCPCS,0636,RC,,,,both,,,359.81,233.88,,,,,,,,,,,,,
PROBE GUID HUM DRL SURESHOT,SUP-2340920,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1681.28,1092.83,,,,,,,,,,,,,
DRILL TWST SZ 2.5 L91MM DIA2MM STP 40MM AO QUIK CPL,SUP-2267867,CDM,2720000010,LOCAL,0272,RC,,,,both,,,467.23,303.70,,,,,,,,,,,,,
BIT DRL DIA2MM CANN FOR HDLSS SCR SYS DART-FIRE,SUP-2399825,CDM,2720000010,LOCAL,0272,RC,,,,both,,,492.98,320.44,,,,,,,,,,,,,
SET SCR SPNL L32MM DIA0.25MM IL TI LOK BRK OFF HEX CLS CDH,SUP-2287228,CDM,C1713,HCPCS,0278,RC,,,,both,,,395.95,257.37,,,,,,,,,,,,,
STENT URET STR 0.038 IN 3 CM 7 FRX22-30 CM 6 FR CNTOUR VL,SUP-2464452,CDM,C2617,HCPCS,0278,RC,,,,both,,,457.18,297.17,,,,,,,,,,,,,
PLATE BNE FEM 305 MM LT DSTL LAT CNDYL 16 HOLE BUTTRESS SS,SUP-2460588,CDM,C1713,HCPCS,0278,RC,,,,both,,,2442.48,1587.61,,,,,,,,,,,,,
LEAD KIT 28 CM SACR MRI MR CONDITIONAL INTERSTIM SURESCAN,SUP-2641994,CDM,C1778,HCPCS,0278,RC,,,,both,,,11429.60,7429.24,,,,,,,,,,,,,
GRAFT BNE 2 CC CELLULAR BNE MTRX OSSEOGEN,SUP-2858499,CDM,C1713,HCPCS,0278,RC,,,,both,,,2093.75,1360.94,,,,,,,,,,,,,
CATHETER DRAINAGE 2.1X20 MM 1 CC VENTRICULAR FLAT DOME,SUP-2277915,CDM,2720000010,LOCAL,0272,RC,,,,both,,,967.31,628.75,,,,,,,,,,,,,
GRAFT VASC IMPRA CARBOFLO L 35 CM DIA 6 MM EPTFE CARBON STR,SUP-2761266,CDM,C1768,CPT,0278,RC,,,,both,,,1472.66,957.23,,,,,,,,,,,,,
HC Assay of Ferritin,PX-3018272800,CDM,82728,CPT,0301,RC,,,,both,,,255.00,165.75,,,,,,,,,,,,,
KIT CHARGING CHRG BASE STN PWR SUPL CHRG BELT PRECIS SPECTR,SUP-2138831,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
SET COMP CNTRLZR PAT LIMB SALV LO BODY UHMWPE INCL SM 12MM,SUP-2265085,CDM,C1776,CPT,0278,RC,,,,both,,,467.86,304.11,,,,,,,,,,,,,
BIT DRL 2.3 MM 70720001] WRIGHT MEDICAL TECHNOLOGY INC],SUP-2398616,CDM,2720000010,LOCAL,0272,RC,,,,both,,,731.62,475.55,,,,,,,,,,,,,
AERO/VENT JR. KT W/ TWO TUBES HEPA FILTER,SUP-2927281,CDM,C1776,CPT,0278,RC,,,,both,,,2336.16,1518.50,,,,,,,,,,,,,
GUIDEPIN ORTH L279MM OD4MM SMOOTH SHRP TIP W/ EYELOOP GRFT,SUP-2341288,CDM,2720000010,LOCAL,0272,RC,,,,both,,,590.32,383.71,,,,,,,,,,,,,
SHEATH INTRO CHARIOT L 65 CM DIA 6 FR STR TIP XCUT LG LUMEN,SUP-2140842,CDM,C1725,HCPCS,0272,RC,,,,both,,,204.10,132.66,,,,,,,,,,,,,
DEFIBRILLATOR IMPL VENTAK MINI IV TI SINGLE CHMBR V IS1BI,SUP-2139653,CDM,C1722,HCPCS,0275,RC,,,,both,,,70650.00,45922.50,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.416,SUP-2859980,CDM,C1713,HCPCS,0278,RC,,,,both,,,35952.69,23369.25,,,,,,,,,,,,,
PENICILLIN G POTASSIUM 20000000 UNITS IJ SOLR|DISCARDED DRUG NOT ADMINISTE,RX-6085,CDM,J2540,HCPCS,0636,RC,00049-0530-28,NDC,JW,both,1,UN,292.60,190.19,,,,,,,,,,,,,
CONNECTOR SPNL 6.35X15 MM OFFSET SS REVERE,SUP-2594667,CDM,C1713,HCPCS,0278,RC,,,,both,,,791.28,514.33,,,,,,,,,,,,,
ALLOGRAFT BNE MENIS LT MEDL FRZN,SUP-2321823,CDM,C1762,CPT,0278,RC,,,,both,,,18526.00,12041.90,,,,,,,,,,,,,
CATHETER GUID 7.62FR L62CM WRK L59CM QUARTET CRV INNR,SUP-2356402,CDM,C1751,HCPCS,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
DIGOXIN 125 MCG PO TABS,RX-2444,CDM,6370000000,HCPCS,0637,RC,00904-5921-61,NDC,,both,1,UN,6.10,3.96,,,,,,,,,,,,,
MESH HERN 20X15 CM,SUP-2283400,CDM,C1781,HCPCS,0278,RC,,,,both,,,2271.48,1476.46,,,,,,,,,,,,,
COLLAR CERV RIGID SHT PD4 CH 11-16.5X2 IN HK,SUP-2246402,CDM,L0172,HCPCS,0272,RC,,,,both,,,64.56,41.96,,,,,,,,,,,,,
SCREW BNE L85MM DIA5MM TI FOR HINDFOOT FUS SYS VALOR,SUP-2397581,CDM,C1713,HCPCS,0278,RC,,,,both,,,574.62,373.50,,,,,,,,,,,,,
CATHETER VENOGRAPHY CORODYN P1 POLYUR FIX CRV VENOGRAM LD,SUP-2137966,CDM,C1893,HCPCS,0272,RC,,,,both,,,160.14,104.09,,,,,,,,,,,,,
CONNECTOR SPNL L12MM DIA45MM LAT S STL CDH LEG,SUP-2279235,CDM,C1713,HCPCS,0278,RC,,,,both,,,2361.28,1534.83,,,,,,,,,,,,,
CAGE SPNL MESH 17X13X15 MM 6 LOBE,SUP-2602080,CDM,C1889,HCPCS,0278,RC,,,,both,,,9646.08,6269.95,,,,,,,,,,,,,
INSERTER INTOSS FIX FOR 3MM IMPL CROSSTIE,SUP-2175160,CDM,2720000010,LOCAL,0272,RC,,,,both,,,777.15,505.15,,,,,,,,,,,,,
SHEATH LASER 14FR L50CM DIA4.88MM 15DEG 25-40 REPETITION RATE,SUP-2353104,CDM,C2629,CPT,0272,RC,,,,both,,,9090.30,5908.69,,,,,,,,,,,,,
GRAFT HUM TISS W20XL20CM THK08 14MM THN ACELLULAR HYDRATED,SUP-2307552,CDM,Q4128,HCPCS,0636,RC,,,,both,,,38497.66,25023.48,,,,,,,,,,,,,
BODY FEM DIA25MM +0MM OFFSET STD PROX HIP TI MOD REV CONE,SUP-2375536,CDM,C1776,CPT,0278,RC,,,,both,,,9808.10,6375.26,,,,,,,,,,,,,
MICROCATHETER DIAG RENEGADE HI FLO L 150 CM DSTL TIP L 20 CM,SUP-2139661,CDM,C1887,HCPCS,0272,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
SCREW BNE AD PED L5MM DIA12MM CORT TI ST SELF DRL,SUP-2262778,CDM,C1713,HCPCS,0278,RC,,,,both,,,227.68,147.99,,,,,,,,,,,,,
VALVE AORT L12CM DIA30MM TISS ANNULUS DIA27MM CLLGN MSTR LO,SUP-2356716,CDM,C1889,HCPCS,0278,RC,,,,both,,,21823.00,14184.95,,,,,,,,,,,,,
INTRODUCER BNE CEMENT STABILIT VP DIA10-11 GA10 CC,SUP-2421786,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2292.20,1489.93,,,,,,,,,,,,,
PLATE STRNL CLOSURE THK 1.5 MM 12 H TI STR LP NS STERNALOCK,SUP-2894522,CDM,C1713,HCPCS,0278,RC,,,,both,,,4088.28,2657.38,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 100 MM DIA 9 MM DEL SHTH,SUP-2934246,CDM,C1713,HCPCS,0278,RC,,,,both,,,15258.99,9918.34,,,,,,,,,,,,,
BLADE SCALP TRIANG (MUST BE ORDERED IN MULTIPLES OF 6 EA),SUP-2370408,CDM,2720000010,LOCAL,0272,RC,,,,both,,,738.53,480.04,,,,,,,,,,,,,
BUTTON 9X16MM 7MM FIXATION OVAL SMALL XTENDOBUTTON,SUP-2880377,CDM,C1713,HCPCS,0278,RC,,,,both,,,428.61,278.60,,,,,,,,,,,,,
PROBE KIT DECOMPRESSOR 17 GAX9 IN STR PERC,SUP-2366998,CDM,C1713,HCPCS,0278,RC,,,,both,,,5874.81,3818.63,,,,,,,,,,,,,
GRAFT HUM TISS BNE TEND BNE HEMI W/ QUADRICEPS W>13MM FRZN,SUP-2307267,CDM,C1713,HCPCS,0278,RC,,,,both,,,7311.08,4752.20,,,,,,,,,,,,,
CATHETER URET SET FIRM STAMEY OPN TIP 6FRX70CM C FLX,SUP-2139288,CDM,C1758,HCPCS,0278,RC,,,,both,,,87.54,56.90,,,,,,,,,,,,,
PLATE BONE W9.2XL49MM THK1.3MM 100DEG 4 H TI TBLR FOR 3.5MM,SUP-2412034,CDM,C1713,HCPCS,0278,RC,,,,both,,,230.79,150.01,,,,,,,,,,,,,
PLATE BNE W17.5XL106MM THK5.2MM 6 H TI BROAD LIMIT CNTCT,SUP-2190840,CDM,C1713,HCPCS,0278,RC,,,,both,,,848.15,551.30,,,,,,,,,,,,,
PROBE COAG L350CM CHN 2.8MM TIP 7FR SGL PLUG W/ COAX CONN,SUP-2313019,CDM,C1713,HCPCS,0278,RC,,,,both,,,822.90,534.88,,,,,,,,,,,,,
ALLOGRAFT BNE STRP 15X40X2 MM FD SPNG CANC READIGRAFT BLX,SUP-2740883,CDM,C1713,HCPCS,0278,RC,,,,both,,,1439.09,935.41,,,,,,,,,,,,,
SCREW BNE EMGCY 3.2X16 MM MAND SELF RET X DRV THREADLOCK TS,SUP-2540220,CDM,C1713,HCPCS,0278,RC,,,,both,,,352.90,229.38,,,,,,,,,,,,,
RITUXIMAB-ABBS 500 MG/50ML IV SOLN,RX-148010,CDM,Q5115,HCPCS,0636,RC,63459-0104-50,NDC,,both,50,ML,12176.00,7914.40,,,,,,,,,,,,,
HC Diagnostic Lumbar Puncture,PX-7616227000,CDM,62270,CPT,0761,RC,,,,both,,,2232.00,1450.80,,,,,,,,,,,,,
CHOLANGIOGRAM KIT RX AUTOTOME UTOM XL SPHINTOM JAGWIRE 7503,SUP-2496623,CDM,2720000010,LOCAL,0272,RC,,,,both,,,957.70,622.50,,,,,,,,,,,,,
RING EXT FIX DIA180MM C LO EXT OPN FOR HYBRID SYS TENXOR,SUP-2372237,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
COLLAR CERV AD H25XL22IN UNIV FIRM DENS CNTOUR HK LOOP CLSR,SUP-2276585,CDM,L0120,HCPCS,0274,RC,,,,both,,,8.07,5.25,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.539,SUP-2860056,CDM,C1713,HCPCS,0278,RC,,,,both,,,46386.59,30151.28,,,,,,,,,,,,,
REAMER CNL IM HVY DUTY TRINKLE,SUP-2362646,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2748.63,1786.61,,,,,,,,,,,,,
AB DISTRACTOR BODY END ACT 4315003,SUP-2844057,CDM,C1713,HCPCS,0278,RC,,,,both,,,16854.26,10955.27,,,,,,,,,,,,,
SNARE ENDO L230CM SHTH DIA3MM NDL 25GA L5MM OLY STYL CRD OVL,SUP-2391600,CDM,2720000010,LOCAL,0272,RC,,,,both,,,420.76,273.49,,,,,,,,,,,,,
GORE 9MMX7.5CM 8FR 120CMCATH.,SUP-2396625,CDM,C1874,HCPCS,0278,RC,,,,both,,,10748.22,6986.34,,,,,,,,,,,,,
GRAFT SFT TISS FLOWABLE 1 CC 167 MG TISS MTRX INTERFYL,SUP-2651380,CDM,Q4171,HCPCS,0636,RC,,,,both,,,6280.00,4082.00,,,,,,,,,,,,,
MICROCATHETER NAVIGATION 2.8FR L150CM GWIRE L160CM 0.021IN MCPE28151YV] TERUMO MEDICAL CORP],SUP-2385609,CDM,C1887,HCPCS,0272,RC,,,,both,,,1863.90,1211.53,,,,,,,,,,,,,
SCREW BNE L26MM OD4MM GRN FOREFOOT MIDFOOT HINDFOOT ANK,SUP-2320540,CDM,C1713,HCPCS,0278,RC,,,,both,,,620.15,403.10,,,,,,,,,,,,,
BUR SURG RND 8 MM SS TEAL UPWR,SUP-2607633,CDM,2720000010,LOCAL,0272,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
CLIP BONE SCR CRANIOMAXILLOFACIAL W/ 1.5X4MM TI SELF DRL HI,SUP-2403079,CDM,C1713,HCPCS,0278,RC,,,,both,,,778.72,506.17,,,,,,,,,,,,,
IMATINIB MESYLATE 100 MG PO TABS,RX-32979,CDM,6370000000,HCPCS,0637,RC,59651-0240-90,NDC,,both,1,UN,5.50,3.57,,,,,,,,,,,,,
RELOAD STPL L60MM DIA3.5MM UNIV ROTIC ENDO GIA,SUP-2174520,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1270.00,825.50,,,,,,,,,,,,,
CATHETER NEPHSTMY L35CM OD12FR GWIRE OD0.038IN SKATER DRNGE,SUP-2120147,CDM,C1729,HCPCS,0272,RC,,,,both,,,301.63,196.06,,,,,,,,,,,,,
STEM FEM L220MM OD15MM TI 40% POR PLSM SPR DST CALCAR MOD,SUP-2403932,CDM,C1776,CPT,0278,RC,,,,both,,,6393.04,4155.48,,,,,,,,,,,,,
TUBE VENTILIATION DIA114MM L12MM BLU T SHP SIL RICHARDS,SUP-2313721,CDM,L8699,HCPCS,0278,RC,,,,both,,,61.23,39.80,,,,,,,,,,,,,
PIN GUIDE L 300 MM DIA1.9 MM NTHRD FOR CANN SCREW BX OF 6,SUP-2933258,CDM,C1713,HCPCS,0278,RC,,,,both,,,471.66,306.58,,,,,,,,,,,,,
BIT DRL L260MM DIA4MM CALIB L60MM 3 FLUT QUIK CPL FOR TFN,SUP-2188238,CDM,2720000010,LOCAL,0272,RC,,,,both,,,591.80,384.67,,,,,,,,,,,,,
DRAINAGE KIT LL CONN 80 CM 120 CC LUMBAR GRAD CHMBR FIX TAB,SUP-2664454,CDM,C1729,HCPCS,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
CARRIER LT REPL RT LNG 180MM,SUP-2383877,CDM,2720000010,LOCAL,0272,RC,,,,both,,,927.90,603.13,,,,,,,,,,,,,
WIRE ORTHOPEDIC SMOOTH 1.4 MM OLV BABY GORILLA,SUP-2321633,CDM,C1713,HCPCS,0278,RC,,,,both,,,351.68,228.59,,,,,,,,,,,,,
HC Ot Therapeutic Activities 15 Min|OP OCCUPATIONAL THERAPY SERV|DOCUMENTATION ON FILE|SERVICES PROVIDED IN WHOLE OR IN PARTY BY AN OTA FOR MEDICARE PATIENTS,PX-4309753000,CDM,97530,CPT,0430,RC,,,GO|KX|CO,both,,,144.00,93.60,,,,,,,,,,,,,
TAMSULOSIN HCL 0.4 MG PO CAPS,RX-101727,CDM,6370000000,HCPCS,0637,RC,68084-0299-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
CANNULA VEN LNG 23 FR BIOLINE COATED HLS,SUP-2663462,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1575.37,1023.99,,,,,,,,,,,,,
GRAFT TISSUE HALO PERICARDIUM,SUP-2844927,CDM,V2785,HCPCS,0810,RC,,,,both,,,621.72,404.12,,,,,,,,,,,,,
DEVICE TISS FIX STRL FIBERTAG TIGHTROPE II,SUP-2882184,CDM,C1713,HCPCS,0278,RC,,,,both,,,1271.70,826.60,,,,,,,,,,,,,
INTRODUCER SET G2-MULTI PERC 7.5/8.5/9 MM W/ DIL BLU RHINO,SUP-2759707,CDM,C1769,HCPCS,0272,RC,,,,both,,,1804.24,1172.76,,,,,,,,,,,,,
K WIRE FIX L6IN DIA0.062IN 1600662],SUP-2304025,CDM,C1713,HCPCS,0278,RC,,,,both,,,16.20,10.53,,,,,,,,,,,,,
BIT DRL CANN 0.13X300 MM QC,SUP-2486745,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1354.13,880.18,,,,,,,,,,,,,
SCREW BNE THRD 6.5X105 MM 32 MM,SUP-2198322,CDM,C1713,HCPCS,0278,RC,,,,both,,,37.68,24.49,,,,,,,,,,,,,
PLATE BNE RECON 2-2.5X2.8 MM LT 26 HOLE ANGLED LCK TI NS,SUP-2459119,CDM,C1713,HCPCS,0278,RC,,,,both,,,7830.47,5089.81,,,,,,,,,,,,,
BUR CORTICL OPENER DIA 3.5MM AO,SUP-2459267,CDM,2720000010,LOCAL,0272,RC,,,,both,,,652.81,424.33,,,,,,,,,,,,,
PLATE BNE 2 H RT CNDYL MANDIBULAR TEMP NS,SUP-2883604,CDM,C1713,HCPCS,0278,RC,,,,both,,,3157.71,2052.51,,,,,,,,,,,,,
PLATE BNE W175XL386MM THK52MM 18 H NONSTERILE R CNDYL FEM S,SUP-2185050,CDM,C1713,HCPCS,0278,RC,,,,both,,,5807.81,3775.08,,,,,,,,,,,,,
BOOT TRACTION LOOP LCK CLOSURE LG ECON BUCK,SUP-2336329,CDM,L4398,HCPCS,0274,RC,,,,both,,,27.60,17.94,,,,,,,,,,,,,
PLATE BONE L170MM 8 H BILAT S STL COBRA HD LO PROF RIG NEUT,SUP-2185807,CDM,C1713,HCPCS,0278,RC,,,,both,,,1860.36,1209.23,,,,,,,,,,,,,
GRAFT HUMAN TSSUE W4 10XH0.009 0.13XL33MM NON MSHD DRMS TSSU,SUP-2460373,CDM,Q4116,HCPCS,0636,RC,,,,both,,,97.34,63.27,,,,,,,,,,,,,
SCREW BONE L65MM OD4MM S STL CANC CORT ST FULL THRD SELF DRL,SUP-2370612,CDM,C1713,HCPCS,0278,RC,,,,both,,,760.51,494.33,,,,,,,,,,,,,
BIT DRL HLLW CANN PERC 16MM STRL,SUP-2546209,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2945.57,1914.62,,,,,,,,,,,,,
GUIDEWIRE VASC SYNCHRO-2 L 200 CM DIA 0.014 IN SS NIT,SUP-2148473,CDM,C1769,HCPCS,0272,RC,,,,both,,,2041.00,1326.65,,,,,,,,,,,,,
BRACE THMB SPICA RT REG SPICA MOD SUPP FOAM WRP AD SM,SUP-2324380,CDM,L3931,HCPCS,0274,RC,,,,both,,,28.89,18.78,,,,,,,,,,,,,
COMPONENT FEM SMALLL LT KNEE ZNG LIBRA,SUP-2442356,CDM,C1776,CPT,0278,RC,,,,both,,,805.41,523.52,,,,,,,,,,,,,
PLATE BNE W9XL141MM THK1MM 12 H TI 1/3 TBLR W/ CLLR LOK,SUP-2190959,CDM,C1713,HCPCS,0278,RC,,,,both,,,556.47,361.71,,,,,,,,,,,,,
HC So Beta 2 Glycoprotein 1 Ab,PX-3028614666,CDM,86146,CPT,0302,RC,,,,both,,,172.00,111.80,,,,,,,,,,,,,
IMPLANT OTO L5MM HD DIA2.87MM PLASTIPORE FULL CANN PORP,SUP-2313844,CDM,L8613,CPT,0278,RC,,,,both,,,1308.97,850.83,,,,,,,,,,,,,
SYSTEM IMPL IB FIBERLINK DRL STRL DISP TIGHTROPE II RT,SUP-2882328,CDM,C1713,HCPCS,0278,RC,,,,both,,,2433.50,1581.77,,,,,,,,,,,,,
ADAPTER STEM POR TIB KNEE REV STRL IMP,SUP-2208315,CDM,C1776,CPT,0278,RC,,,,both,,,8562.78,5565.81,,,,,,,,,,,,,
STENT BILI SYM L 20 MM DIA 7 FR CATH L 75 CM DIA10 MM NIT AD,SUP-2141182,CDM,C1876,HCPCS,0278,RC,,,,both,,,3415.69,2220.20,,,,,,,,,,,,,
INTRODUCER SHTH J 9 FRX23 CM DBL DSTL W/O OBTURATOR KT,SUP-2431326,CDM,C1887,HCPCS,0272,RC,,,,both,,,1962.50,1275.62,,,,,,,,,,,,,
GUIDEWIRE VASC ANGLED 035X150 M00146151B17,SUP-2141140,CDM,C1769,HCPCS,0272,RC,,,,both,,,97.09,63.11,,,,,,,,,,,,,
KIT INTRO L 10 CM DIA 5 FR NIT SHFT GLD TIP STD DIL MIC STD,SUP-2615955,CDM,C1894,HCPCS,0272,RC,,,,both,,,92.60,60.19,,,,,,,,,,,,,
SCREW BNE L 14 MM DIA2 MM TI SNAP OFF STRL,SUP-2913555,CDM,C1713,HCPCS,0278,RC,,,,both,,,1048.45,681.49,,,,,,,,,,,,,
PLATE BONE CRANIAL 20 HOLE STRAIGHT 88.9X3.4MM TITANIUM NEUR,SUP-2827189,CDM,C1713,HCPCS,0278,RC,,,,both,,,166.42,108.17,,,,,,,,,,,,,
"HC Removal of Embedded Foreign Body, Vestible of Mouth, Simple",PX-4504080400,CDM,40804,CPT,0450,RC,,,,both,,,1056.00,686.40,,,,,,,,,,,,,
CATHETER EP JSN 1 CRV 5-10-5 MM 4 FR FIX CRV,SUP-2357395,CDM,C1730,HCPCS,0272,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
ROD ORTH FIX ALIGN N SPIK IMPL GEN II,SUP-2346872,CDM,2720000010,LOCAL,0272,RC,,,,both,,,427.10,277.61,,,,,,,,,,,,,
KIT EXP CATH DBL LUMN MULT MED 7GAX20CM DBL MULT MED CATH,SUP-2214561,CDM,C1751,HCPCS,0278,RC,,,,both,,,411.34,267.37,,,,,,,,,,,,,
KETAMINE HCL 100 MG/ML IJ SOLN,RX-4237,CDM,2500000003,HCPCS,0250,RC,00143-9509-10,NDC,,both,0.05,ML,54.10,35.16,,,,,,,,,,,,,
HC Intro Cath in Svc or Ivc,PX-3613601000,CDM,36010,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
BIT DRILL SURG 1.5MM W/ 7MM STP IQ,SUP-2136989,CDM,2720000010,LOCAL,0272,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
GRAFT BONE SUB 7GA 5ML CA PHOS SYR DISPNS GUN CANN STRUCSURE,SUP-2348205,CDM,C1713,HCPCS,0278,RC,,,,both,,,6064.44,3941.89,,,,,,,,,,,,,
PIN DRL DIA4MM ACL KNEE OPN EYELET TIGHTROPE AR1595T] ARTHREX INC],SUP-2121410,CDM,2720000010,LOCAL,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
CLAMP EXT FIX 5 H PIN FOR HOFFMANN III MOD SYS,SUP-2372221,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2147.45,1395.84,,,,,,,,,,,,,
BUR SURG L10CM DIA3MM BALL FLUT SM BOR MIDAS REX LEGEND,SUP-2277609,CDM,2720000010,LOCAL,0272,RC,,,,both,,,308.54,200.55,,,,,,,,,,,,,
JOINT TOE 1ST METATARSOPHALANGEAL SM 17 MM CANN HEMI,SUP-2609649,CDM,L8642,HCPCS,0278,RC,,,,both,,,6800.83,4420.54,,,,,,,,,,,,,
CATHETERIZATION KIT ART 025 18 GAX12 CM 25 GA 3 CC LF,SUP-2865602,CDM,C1751,HCPCS,0278,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
PIN EXTRNL FXTN L120MM D3MM THRD L20MM BROWN CNNLTD XTRFX SS,SUP-2467633,CDM,2720000010,LOCAL,0272,RC,,,,both,,,486.45,316.19,,,,,,,,,,,,,
SODIUM CHLORIDE 0.45 % IV SOLN,RX-7318,CDM,J3490,HCPCS,0250,RC,00264-7802-00,NDC,,both,1000,ML,34.00,22.10,,,,,,,,,,,,,
SCREW BONE TI HEX NUT BIPHASE SYS,SUP-2135875,CDM,C1713,HCPCS,0278,RC,,,,both,,,69.08,44.90,,,,,,,,,,,,,
PLATE BNE MESHED 126.2X11.2X2 MM SM GRID TI PDLLA STRL LF,SUP-2464804,CDM,C1713,HCPCS,0278,RC,,,,both,,,2765.34,1797.47,,,,,,,,,,,,,
NARROW PLT STERILIZER 4.5X135 MM 8 HL,SUP-2818128,CDM,C1713,HCPCS,0278,RC,,,,both,,,1251.82,813.68,,,,,,,,,,,,,
PLATE BNE 8 H ANK TI UNIV STR BILAT LOK COMPR FOR 35 4MM SCR,SUP-2398386,CDM,C1713,HCPCS,0278,RC,,,,both,,,910.60,591.89,,,,,,,,,,,,,
HC Fluoroscopy Up to 1 Hour,PX-3207600000,CDM,76000,CPT,0320,RC,,,,inpatient,,,714.00,464.10,,,,,,,,,,,,,
PLATE BNE L80MM 5 H NONSTERILE L ANTLAT DST TIB S STL LO,SUP-2185944,CDM,C1713,HCPCS,0278,RC,,,,both,,,4143.92,2693.55,,,,,,,,,,,,,
PLATE BONE SM L39MM 3 H STD BILAT COMPR CNTOUR + FOR 3.5MM,SUP-2348990,CDM,C1713,HCPCS,0278,RC,,,,both,,,1151.31,748.35,,,,,,,,,,,,,
CATHETER DIL 6FR 12CC L70CM BLLN L3.5CM DEFCT SZ 20MM,SUP-2355748,CDM,2720000010,LOCAL,0272,RC,,,,both,,,986.21,641.04,,,,,,,,,,,,,
MEMBRANE CLLGN DURA REP DURAMATRIX SUTURABLE 2IN X 2IN,SUP-2165130,CDM,C1763,HCPCS,0278,RC,,,,both,,,1638.08,1064.75,,,,,,,,,,,,,
IMPLANT BIO TISS L25CM ID5MM PERIPH NRV CLLGN CONDUIT,SUP-2378815,CDM,C9353,HCPCS,0278,RC,,,,both,,,5051.00,3283.15,,,,,,,,,,,,,
CATHETER THROMCTMY ESPERANCE L 115 CM DIA 5 FR SHFT,SUP-2892528,CDM,C1757,HCPCS,0272,RC,,,,both,,,5322.30,3459.49,,,,,,,,,,,,,
STAPLER INT MED THCK 80 MM W/ TRI-STAPLE TECHNOLOGY PUR GIA,SUP-2787699,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2336.88,1518.97,,,,,,,,,,,,,
SLING INCONT TRNS OBTURATOR TAPE ARIS,SUP-2165222,CDM,C1771,HCPCS,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
COIL NEUROVASCULAR MICRUSFRAME S 18 L 47 CM DIA14 MM PRIMARY,SUP-2249250,CDM,C1889,HCPCS,0278,RC,,,,both,,,12825.58,8336.63,,,,,,,,,,,,,
GRAFT HUM TISS L 200 MM FOLDED DIA 4.5 MM SINGLE STRND DIA 3,SUP-2913411,CDM,C1762,CPT,0278,RC,,,,both,,,5554.66,3610.53,,,,,,,,,,,,,
GUIDEWIRE VASC SENS + L 175 CM DIA 0.025 IN TIP 3 MM SS SIL,SUP-2521855,CDM,C1769,HCPCS,0272,RC,,,,both,,,124.82,81.13,,,,,,,,,,,,,
INSTRUMENT REPROC SEAL/DIVIDE LAP BLUNT TP LIGASURE NANO-COAT 5MMX37CM,SUP-2527602,CDM,2720000010,LOCAL,0272,RC,,,,both,,,797.56,518.41,,,,,,,,,,,,,
PLATE BNE L15MM THK0.3MM 2 H CRANIOMAXILLOFACIAL TI STR FOR,SUP-2402997,CDM,C1713,HCPCS,0278,RC,,,,both,,,166.42,108.17,,,,,,,,,,,,,
DISC ARTIFICIAL W15XH5XL15MM CERV CO CHROM MOLYBDENUM ALLOY,SUP-2263922,CDM,C1889,HCPCS,0278,RC,,,,both,,,13502.00,8776.30,,,,,,,,,,,,,
GUIDEWIRE VASC DURAFLO TOT LUMEN STRL,SUP-2214451,CDM,C1769,HCPCS,0272,RC,,,,both,,,125.00,81.25,,,,,,,,,,,,,
AUGMENT FEM SZ 4 THK4MM DST KNEE CO CHROM MOLYBDENUM CEM,SUP-2251999,CDM,C1776,CPT,0278,RC,,,,both,,,2763.20,1796.08,,,,,,,,,,,,,
GRAFT HUM TISS L 6 X W 2 CM AMNIO MEMBRN RESRB STRL PALINGEN,SUP-2913455,CDM,Q4173,HCPCS,0636,RC,,,,both,,,7601.94,4941.26,,,,,,,,,,,,,
CAGE SPNL H7MM 7DEG STD CERV THORLUM C FBR REINF POLYMER,SUP-2256327,CDM,C1889,HCPCS,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
"HC So Coombs,Direct",PX-3028688066,CDM,86880,CPT,0302,RC,,,,inpatient,,,218.00,141.70,,,,,,,,,,,,,
OBTURATOR ROBOTIC 8 MM 14X5.5 IN BLNT ENDOWRIST DA VINCI XI,SUP-2246720,CDM,C1713,HCPCS,0278,RC,,,,both,,,1814.92,1179.70,,,,,,,,,,,,,
GUIDEWIRE ORTH 12X100 MM SMOOTH SINGLE END TROCAR TIP,SUP-2321617,CDM,C1769,HCPCS,0272,RC,,,,both,,,87.92,57.15,,,,,,,,,,,,,
BUR SURG HD DIA3MM CARB MTCH,SUP-2367603,CDM,2720000010,LOCAL,0272,RC,,,,both,,,730.08,474.55,,,,,,,,,,,,,
GUIDEWIRE URO L145CM DIA0.035IN TIP L7CM S STL PTFE BENT,SUP-2139353,CDM,C1769,HCPCS,0272,RC,,,,both,,,88.14,57.29,,,,,,,,,,,,,
PLATE BNE L209MM 13 H ST R DST LAT FIBULAR S STL VAR ANG,SUP-2177738,CDM,C1713,HCPCS,0278,RC,,,,both,,,3442.63,2237.71,,,,,,,,,,,,,
GYN ESG PLASMABAND MED 12 30 DEG,SUP-2722603,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1615.47,1050.06,,,,,,,,,,,,,
DRILL SURGICAL BONE  MOORE,SUP-2793438,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1528.40,993.46,,,,,,,,,,,,,
HC So Tissue Culture Tumor,PX-3118823966,CDM,88239,CPT,0311,RC,,,,outpatient,,,267.00,173.55,,,,,,,,,,,,,
IMPLANT FNGR JT L15MM SCR DIAM 4MM BARB L6.8MM DIAM 5.5MM,SUP-2223971,CDM,C1776,CPT,0278,RC,,,,both,,,5231.24,3400.31,,,,,,,,,,,,,
CLAMP EXT FIX L PIN 6 POS MAG RESONANCE CONDITIONAL,SUP-2188504,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1232.10,800.86,,,,,,,,,,,,,
VALVE AORT 21 MM 19X14 MM LEAFLET FLEXFIT STENTED LP EPIC,SUP-2355830,CDM,C1713,HCPCS,0278,RC,,,,both,,,13486.30,8766.09,,,,,,,,,,,,,
DEFIBRILLATOR CARD 2 CHMBR DF1 IS1 CONN W/ RF TELMTRY,SUP-2356291,CDM,C1722,HCPCS,0275,RC,,,,both,,,36568.44,23769.49,,,,,,,,,,,,,
SCREW BONE L130MM DIA8MM STD CORT TI ST SELF DRL CANN,SUP-2343506,CDM,C1713,HCPCS,0278,RC,,,,both,,,1775.70,1154.20,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 0.25 CC INJ AMNIO FLUID STRATOGEN FLO,SUP-2777564,CDM,C1762,CPT,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
SEPARATOR THROMCTMY L175CM DST DIA0045IN COMPATIBLE W CAT5,SUP-2323710,CDM,C1757,HCPCS,0272,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
FOOTPLATE EXT FIX RAD ALUM RINGFIX 9501601,SUP-2471011,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
GRAFT DERMAL MICROPERFORATED 6X16 CMX0.6-1.05 MM DERMACELL,SUP-2777421,CDM,Q4122,HCPCS,0636,RC,,,,both,,,8305.30,5398.44,,,,,,,,,,,,,
PLATE BNE L112MM 4 H L OLECRANON S STL LOK COMPR FOR 3.5MM,SUP-2185424,CDM,C1713,HCPCS,0278,RC,,,,both,,,3005.83,1953.79,,,,,,,,,,,,,
CATHETER EMB TUFTEX L 80 CM DIA 5.5 FR BALLOON DIA12 MM,SUP-2264192,CDM,C1757,HCPCS,0272,RC,,,,both,,,257.48,167.36,,,,,,,,,,,,,
HEAD FEM +0MM DIA36MM ALUM OXIDE ZIRCONIA STRONTIUM OXIDE,SUP-2222429,CDM,C1776,CPT,0278,RC,,,,both,,,5934.60,3857.49,,,,,,,,,,,,,
SCREW BNE SET 7 MM CANN FT EXT TAB,SUP-2861033,CDM,C1713,HCPCS,0278,RC,,,,both,,,3803.42,2472.22,,,,,,,,,,,,,
STAPLE BNE FIX L 28 X W 13 X H 11 MM TI ALLOY TOE COMPR LCK,SUP-2893046,CDM,C1713,HCPCS,0278,RC,,,,both,,,10242.68,6657.74,,,,,,,,,,,,,
FORCEPS BPLR AD PED L8IN TIP DIA15MM STD NONSTICK DISPOSABLE,SUP-2364929,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1191.44,774.44,,,,,,,,,,,,,
TRAY CATH HEMODIALYSI 400XL ACUTE 14FR DIA 20CM CRV EXTN TAP,SUP-2610501,CDM,C1752,HCPCS,0278,RC,,,,both,,,449.02,291.86,,,,,,,,,,,,,
SEED BRACHYTHERAPY FOR RADIOACTIVE ADVANTAGE IOD I 125,SUP-2423883,CDM,C2638,HCPCS,0278,RC,,,,both,,,37.68,24.49,,,,,,,,,,,,,
COMPONENT CRANIOFACIAL CUSTOMIZED + LG COMPLX + PEEK NS LTX,SUP-2862812,CDM,C1713,HCPCS,0278,RC,,,,both,,,52946.81,34415.43,,,,,,,,,,,,,
GUIDEWIRE VASC L 45 CM DIA 0.018 IN NIT MARKED RADIOPAQUE,SUP-2269548,CDM,C1769,HCPCS,0272,RC,,,,both,,,78.50,51.02,,,,,,,,,,,,,
STENT GRFT VASC BIFURCATE 3 AORT LIMB EXT,SUP-2777591,CDM,C1768,CPT,0278,RC,,,,both,,,48713.96,31664.07,,,,,,,,,,,,,
"HC So Electron Microscopy, Diag",PX-3128834866,CDM,88348,CPT,0312,RC,,,,both,,,2028.00,1318.20,,,,,,,,,,,,,
PLATE BNE ULN SM 33 MM RT DSTL MEDL VOLAR 2 HOLE BUTTRESS,SUP-2477437,CDM,C1713,HCPCS,0278,RC,,,,both,,,2348.03,1526.22,,,,,,,,,,,,,
DRESSING BIO 500 MG PORCINE EXTRACELLULAR MTRX PWDR WND STRL,SUP-2911946,CDM,A2004,HCPCS,0278,RC,,,,both,,,3169.83,2060.39,,,,,,,,,,,,,
INTRODUCER DIAG PEEL-APART L 13 CM DIA15 FR PTFE PERC NO CRV,SUP-2127712,CDM,C1894,HCPCS,0272,RC,,,,both,,,265.33,172.46,,,,,,,,,,,,,
CATHETER ETER ABLAT 6FR L120CM HEXAPOLAR SPEC WIRE COR SUP,SUP-2356847,CDM,C1730,HCPCS,0272,RC,,,,both,,,985.96,640.87,,,,,,,,,,,,,
SCREW BNE L10MM DIA2.7MM LOK FOR TUFFNEK TECHNOLOGY GORILLA,SUP-2321096,CDM,C1713,HCPCS,0278,RC,,,,both,,,540.87,351.57,,,,,,,,,,,,,
CATHETER CV 1 LUMEN 8 FRX61.7 CM 14 GA 1.5 CC POWERHICKMAN,SUP-2424091,CDM,C1751,HCPCS,0278,RC,,,,both,,,2210.34,1436.72,,,,,,,,,,,,,
PLATE BNE LCK 363 MM RT PROX FEM 18 HOLE BRIDGE N CONTACT,SUP-2483555,CDM,C1713,HCPCS,0278,RC,,,,both,,,4553.75,2959.94,,,,,,,,,,,,,
NAIL IM L340MM DIA11MM 130DEG LNG LT FEM TI ALLOY CANN LCK,SUP-2362343,CDM,C1713,HCPCS,0278,RC,,,,both,,,5407.39,3514.80,,,,,,,,,,,,,
CANNULA ENDOSCP ZERO TUBE STRL DISP PARALLELPORTAL,SUP-2908750,CDM,2720000010,LOCAL,0272,RC,,,,both,,,879.20,571.48,,,,,,,,,,,,,
HC CT Guide Visc Tissue Ablation,PX-3507701300,CDM,77013,CPT,0350,RC,,,,both,,,2630.00,1709.50,,,,,,,,,,,,,
NIFEDIPINE ER OSMOTIC RELEASE 60 MG PO TB24,RX-27659,CDM,6370000000,HCPCS,0637,RC,00904-7081-06,NDC,,both,1,UN,7.60,4.94,,,,,,,,,,,,,
SCREW SPNL POLYAX 4X40 MM DEFORMITY MESA,SUP-2531600,CDM,C1713,HCPCS,0278,RC,,,,both,,,1852.60,1204.19,,,,,,,,,,,,,
IMPLANT OTO 30 X 59 MM LT EAR 2PC EXT BASE RECON POROUS TRIM,SUP-2883428,CDM,L8699,HCPCS,0278,RC,,,,both,,,3665.64,2382.67,,,,,,,,,,,,,
HANDPIECE SCIS SUP CTRL ACTUATION THRU FOOTPEDAL,SUP-2109720,CDM,2720000010,LOCAL,0272,RC,,,,both,,,320.28,208.18,,,,,,,,,,,,,
COLLAR CERV ADJ FLX THERMOPLASTIC,SUP-2388132,CDM,L0130,HCPCS,0274,RC,,,,both,,,487.64,316.97,,,,,,,,,,,,,
GUIDEWIRE VASC H2O L 150 CM DIA 0.035 IN NIT COR HYDRPHLC,SUP-2302581,CDM,C1769,HCPCS,0272,RC,,,,both,,,103.62,67.35,,,,,,,,,,,,,
BLADE REPROC SAW OSC LG BONE 1.27X13X90MM,SUP-2652873,CDM,2720000010,LOCAL,0272,RC,,,,both,,,92.88,60.37,,,,,,,,,,,,,
ACYCLOVIR 200 MG/5ML PO SUSP,RX-8970,CDM,340b,HCPCS,0637,RC,00472-0082-16,NDC,,both,5,ML,17.00,11.05,,,,,,,,,,,,,
SPACER FEM CO CHROM MOLYBDENUM ALLOY L20MM PROX STRL,SUP-2397016,CDM,C1776,CPT,0278,RC,,,,both,,,1067.60,693.94,,,,,,,,,,,,,
EXPANDER BRST 650CC W14.6XH12.6CM P7.6CM M HT CNTOUR PROF,SUP-2300698,CDM,C1789,HCPCS,0278,RC,,,,both,,,5306.60,3449.29,,,,,,,,,,,,,
MESH SURG 15CM OMEGA 3 FATTY ACID POLYPR SEE THRU CLARITY,SUP-2265961,CDM,C1781,HCPCS,0278,RC,,,,both,,,1702.79,1106.81,,,,,,,,,,,,,
TUBE VENT DIA1.14MM SIL FOR MYR PAPARELLA 2000 TYP 1,SUP-2312786,CDM,L8699,HCPCS,0278,RC,,,,both,,,50.71,32.96,,,,,,,,,,,,,
CATHETER URTRL DLTN 58FR DIA 7MM OD BLLN 21FR DIA INFLTD 75,SUP-2724143,CDM,C1726,HCPCS,0272,RC,,,,both,,,864.54,561.95,,,,,,,,,,,,,
SCREW BNE 3.5X40 MM MOTIONLOC,SUP-2606815,CDM,C1713,HCPCS,0278,RC,,,,both,,,434.70,282.55,,,,,,,,,,,,,
FASCIAL IMPL GORTX EA,SUP-2395379,CDM,C1771,HCPCS,0278,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
PLATE BNE W22XL145MM XLN STD 6X10 H ST L DST RAD VOLAR,SUP-2177309,CDM,C1713,HCPCS,0278,RC,,,,both,,,4847.28,3150.73,,,,,,,,,,,,,
CLIP BLLDG FIX APPL REMV 125MM 37CM,SUP-2108995,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6810.94,4427.11,,,,,,,,,,,,,
CATHETER INFUS L134CM BAL L20MM DIA2.5MM 0.014IN LOC THER,SUP-2266026,CDM,C1751,HCPCS,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
BOLT EXT FIX WIRE FIX STRL TRUELOK EVO LTX,SUP-2875625,CDM,2720000010,LOCAL,0272,RC,,,,both,,,333.63,216.86,,,,,,,,,,,,,
BAR EXT FIX 11X400 MM TRAFFIX,SUP-2205343,CDM,2720000010,LOCAL,0272,RC,,,,both,,,744.97,484.23,,,,,,,,,,,,,
LENS INTOCU +27.00 DIOPT L13MM DIA6MM HAPTIC REFRACTIVE,SUP-2129535,CDM,V2632,HCPCS,0276,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
NUT EXT FIX SPD,SUP-2898613,CDM,2720000010,LOCAL,0272,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
GRAFT DERM HUM TISS THCK KT BRST ACELLULAR DERM IMPL ALLGRFT,SUP-2307509,CDM,Q4128,HCPCS,0636,RC,,,,both,,,12294.26,7991.27,,,,,,,,,,,,,
SCREW INTRF CANN 8X35 MM 2 MM GUIDEWIRE BLNT THRD STD TI RCI,SUP-2878047,CDM,C1713,HCPCS,0278,RC,,,,both,,,520.93,338.60,,,,,,,,,,,,,
SPLINT WRST M L7IN AD R FA COT E SUPP INSTABILITY INJ LOOP,SUP-2276653,CDM,L3809,HCPCS,0274,RC,,,,both,,,9.80,6.37,,,,,,,,,,,,,
SHEATH INTRO PINNACLE L 10 CM 10FR GUIDEWIRE CORONARY,SUP-2385283,CDM,C1894,HCPCS,0272,RC,,,,both,,,35.58,23.13,,,,,,,,,,,,,
HC So Lactoferrin Fecal (Quant),PX-3018363166,CDM,83631,CPT,0301,RC,,,,both,,,177.00,115.05,,,,,,,,,,,,,
COMPONENT PAT L+ 3PEG RND REV ROT NP CEM WITHOUTXRAY WIRE,SUP-2252425,CDM,C1776,CPT,0278,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
PLATE CRAN 140X100X40 MM PT SPEC IMPL PEEK,SUP-2860147,CDM,C1713,HCPCS,0278,RC,,,,both,,,38882.62,25273.70,,,,,,,,,,,,,
DIPHENHYDRAMINE-ZINC ACETATE 2-0.1 % EX CREA,RX-16299,CDM,6370000000,HCPCS,0637,RC,45802-0358-03,NDC,,both,28,GR,9.80,6.37,,,,,,,,,,,,,
KIT SURG WIRE ACROMIOCLAVICULAR STRL CERCLAGE,SUP-2910464,CDM,C1713,HCPCS,0278,RC,,,,both,,,7114.93,4624.70,,,,,,,,,,,,,
LINER HUM DIA38MM +0MM OFFSET STD POLY FOR REV SHLDR SYS,SUP-2223395,CDM,C1776,CPT,0278,RC,,,,both,,,2276.50,1479.72,,,,,,,,,,,,,
ENDCAP ORTH EXTN 0MM AQUA TI ALLY STARDRV T25 RECESS MOST,SUP-2180013,CDM,C1713,HCPCS,0278,RC,,,,both,,,775.23,503.90,,,,,,,,,,,,,
SCREW CORT FT ST HEX HD 4.5MM DIA 40MML,SUP-2342659,CDM,C1713,HCPCS,0278,RC,,,,both,,,51.78,33.66,,,,,,,,,,,,,
SEALANT TISS 4ML FIBRIN PREFIL SYR PRIMA FRZN W/ 1 DUPLOJET,SUP-2130407,CDM,C1713,HCPCS,0278,RC,,,,both,,,902.25,586.46,,,,,,,,,,,,,
WASHER ORTH 7 MM FOR PROV TISS TRABECULAR MTL,SUP-2437275,CDM,C1713,HCPCS,0278,RC,,,,both,,,692.37,450.04,,,,,,,,,,,,,
HEAD HUM SHLDR CUF TEAR ARTHROPATHY,SUP-2249601,CDM,C1776,CPT,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
SHAFT BONE GRAFT ULNA SHAFT RT FZ ASP,SUP-2875972,CDM,C1762,CPT,0278,RC,,,,both,,,13563.70,8816.40,,,,,,,,,,,,,
PASSER SUT 70DEG SHT MIC NIT LOOP PERIPH ULN TRIANG,SUP-2122327,CDM,C1713,HCPCS,0278,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
HC Eval Speech Sound Lang Comprhension,PX-4449252300,CDM,92523,CPT,0444,RC,,,,both,,,484.00,314.60,,,,,,,,,,,,,
CATHETER HEMO DYLS OR HD L15CM OD14FR TAPR TIP CVD EXTN SH,SUP-2269512,CDM,C1752,HCPCS,0278,RC,,,,both,,,332.84,216.35,,,,,,,,,,,,,
HC C-Reactive Protein,PX-3028614000,CDM,86140,CPT,0302,RC,,,,both,,,205.00,133.25,,,,,,,,,,,,,
PROPOFOL BOLUS 10 MG/ML SOLN (WRAPPER),RX-430074,CDM,J2704,HCPCS,0636,RC,63323-0269-29,NDC,,both,5,ML,54.10,35.16,,,,,,,,,,,,,
IMPLANT FEM STR SHT NK HIP MOD IMPLABLE GRY ABG II V40,SUP-2372195,CDM,C1776,CPT,0278,RC,,,,both,,,1921.68,1249.09,,,,,,,,,,,,,
DEFIBRILLATOR IMPL PERCIVA W 5.23 X H 7.03 CM D 0.99 CM 28,SUP-2149183,CDM,C1721,HCPCS,0275,RC,,,,both,,,39388.16,25602.30,,,,,,,,,,,,,
HC Admin Pneumococcal Vaccine,PX-7710000900,CDM,G0009,HCPCS,0771,RC,,,,inpatient,,,85.00,55.25,,,,,,,,,,,,,
CLIP ANEURYSM OPENING W1.5MM BLADE L2MM MICRO CURVED CLOSING,SUP-2825694,CDM,C1889,HCPCS,0278,RC,,,,both,,,833.23,541.60,,,,,,,,,,,,,
PLATE BNE TALUS 2 MET LNG 1.5 MM LT CNTRL CLMN,SUP-2751049,CDM,C1713,HCPCS,0278,RC,,,,both,,,5517.77,3586.55,,,,,,,,,,,,,
PLATE BNE SCREW DIA2 MM 5 H TI LOWER EXTREMITY STR NS,SUP-2905696,CDM,C1713,HCPCS,0278,RC,,,,both,,,2403.92,1562.55,,,,,,,,,,,,,
SCREW BNE SELF DRILLING 3X12 MM CANN FIX QWIX,SUP-2434150,CDM,C1713,HCPCS,0278,RC,,,,both,,,948.03,616.22,,,,,,,,,,,,,
PROBE ARTHROSCOPIC 50DEG ENERGY WITH SUCTION,SUP-2824212,CDM,2720000010,LOCAL,0272,RC,,,,both,,,551.95,358.77,,,,,,,,,,,,,
DEVICE FEED G-JET 14F X 1.2CM X 22CM LP TRANSGASTRIC-JEJUNAL,SUP-2849683,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1909.12,1240.93,,,,,,,,,,,,,
STAPLER INT OD24MM 33MM LN 3.5MM STPL SHT GRN STD TISS CIR,SUP-2219807,CDM,C1713,HCPCS,0278,RC,,,,both,,,1164.94,757.21,,,,,,,,,,,,,
STENT PERIPH L17MM DIA25MM INTLUMN SUPP UNCONSTRAINED VES,SUP-2305192,CDM,C1876,HCPCS,0278,RC,,,,both,,,22466.70,14603.35,,,,,,,,,,,,,
KIT PICC COMPLT BD INTROSYTE INTRO W/ 26GA 1.9FRX50CM SL 1ST,SUP-2133176,CDM,C1751,HCPCS,0278,RC,,,,both,,,321.38,208.90,,,,,,,,,,,,,
LINER ACET SZ 26 OD41MM ID28MM +5MM THK10.3MM HIP UHMWPE,SUP-2404289,CDM,C1776,CPT,0278,RC,,,,both,,,5242.23,3407.45,,,,,,,,,,,,,
GRAFT BNE SUB 10CC DBM BIOCOMPOSITE OSTEOSET PTTY INJ,SUP-2399059,CDM,C9359,HCPCS,0278,RC,,,,both,,,3457.14,2247.14,,,,,,,,,,,,,
GRAFT HUM TISS L 8 X W 5 CM SZ 40 SQCM AMNION-CHORION-AMNION,SUP-2909306,CDM,Q4137,HCPCS,0636,RC,,,,both,,,19574.54,12723.45,,,,,,,,,,,,,
MIXER CEMENT M4 W/ HV BONE CEMENT,SUP-2885535,CDM,C1713,HCPCS,0278,RC,,,,both,,,3990.81,2594.03,,,,,,,,,,,,,
HC X-Ray Foot 2 Views,PX-3207362000,CDM,73620,CPT,0320,RC,,,,both,,,606.00,393.90,,,,,,,,,,,,,
MEROPENEM-SODIUM CHLORIDE 500 MG/50ML IV SOLR,RX-131653,CDM,J2184,HCPCS,0636,RC,00264-3183-11,NDC,,both,1,UN,117.90,76.63,,,,,,,,,,,,,
SUPPORT ORTHOT WRST HND CUST W/NONTORSION JT PREFABRICATED,SUP-2435776,CDM,L3915,HCPCS,0272,RC,,,,both,,,1369.64,890.27,,,,,,,,,,,,,
SYSTEM BNE BX PERF 11 GAX10 CM W/ DRL MADISON,SUP-2491183,CDM,C1894,HCPCS,0272,RC,,,,both,,,753.60,489.84,,,,,,,,,,,,,
STENT GRFT VASC ALTO L 80 MM DIA PROX 20 MM DEL SYS ID/OD,SUP-2691408,CDM,C1768,CPT,0278,RC,,,,both,,,32615.18,21199.87,,,,,,,,,,,,,
SCREW BNE LAG 60 MM HIP SUPLMNT TI STRL CHIMAERA HFS,SUP-2646677,CDM,C1713,HCPCS,0278,RC,,,,both,,,1449.49,942.17,,,,,,,,,,,,,
SCREW BNE L12MM DIA2.7MM CORT S STL ST T8 STARDRV RECESS,SUP-2183472,CDM,C1713,HCPCS,0278,RC,,,,both,,,103.59,67.33,,,,,,,,,,,,,
HC Admin Pneumococcal Vaccine,PX-7710000900,CDM,G0009,HCPCS,0771,RC,,,,outpatient,,,85.00,55.25,,,,,,,,,,,,,
STAPLE CARTRIDGE STR 20X16 MM TI,SUP-2166814,CDM,C1713,HCPCS,0278,RC,,,,both,,,433.19,281.57,,,,,,,,,,,,,
GRAFT VASC GELWEAVE L 50 CM DIA26 MM POLYESTER GEL,SUP-2385047,CDM,C1768,CPT,0278,RC,,,,both,,,3061.50,1989.97,,,,,,,,,,,,,
INSERT TIB SZ 1 THK8MM CONSTRN BAL REV SYS,SUP-2315567,CDM,C1776,CPT,0278,RC,,,,both,,,3190.24,2073.66,,,,,,,,,,,,,
PLATE BNE FIBULAR 2.7X209 MM RT LAT DSTL 13 HOLE STRL VALCP,SUP-2789779,CDM,C1713,HCPCS,0278,RC,,,,both,,,3868.10,2514.26,,,,,,,,,,,,,
CATHETER EP A CRV 2-5-2 MM 6 FRX65 CM UNIDIR,SUP-2356803,CDM,C1730,HCPCS,0272,RC,,,,both,,,813.26,528.62,,,,,,,,,,,,,
CATHETER THORACENTHESIS 9 FRX20 IN EYES TOP,SUP-2227236,CDM,C1729,HCPCS,0272,RC,,,,both,,,49.20,31.98,,,,,,,,,,,,,
SCREW BNE NLCK 3.2X10 MM VW REDUC,SUP-2645223,CDM,C1713,HCPCS,0278,RC,,,,both,,,533.33,346.66,,,,,,,,,,,,,
ANCHOR SUT 4 FBR SZ 2 SUT TI OD6.5MM INTRALINE,SUP-2421260,CDM,C1713,HCPCS,0278,RC,,,,both,,,647.59,420.93,,,,,,,,,,,,,
ANCHOR SUT NO2 DIA5.5MM PEEK FULL THRD W/ FORC FBR,SUP-2366678,CDM,C1713,HCPCS,0278,RC,,,,both,,,839.01,545.36,,,,,,,,,,,,,
TRAY BX W/ 102MM BX NDL INC. ANCIL ITEMS,SUP-2383232,CDM,C1713,HCPCS,0278,RC,,,,both,,,501.36,325.88,,,,,,,,,,,,,
INTRODUCER TRANSSEPTAL 85FRX85FR 81CMX85CM W 032IN GWIRE,SUP-2357269,CDM,C1893,HCPCS,0272,RC,,,,both,,,769.30,500.04,,,,,,,,,,,,,
HYOSCYAMINE SULFATE 0.125 MG SL SUBL,RX-17023,CDM,6370000000,HCPCS,0637,RC,62559-0424-01,NDC,,both,1,UN,3.10,2.01,,,,,,,,,,,,,
HC So Carotene,PX-3018238066,CDM,82380,CPT,0301,RC,,,,both,,,40.00,26.00,,,,,,,,,,,,,
CATHETER SAMPLING 16 FR MUSHRM TIP BALLARD MINI-BAL,SUP-2236603,CDM,C1757,HCPCS,0272,RC,,,,both,,,132.79,86.31,,,,,,,,,,,,,
PLATE BONE L100MM BRL L1IN 140DEG SH BILAT 4 SLOT KEYLESS,SUP-2342464,CDM,C1713,HCPCS,0278,RC,,,,both,,,3715.88,2415.32,,,,,,,,,,,,,
STRUT EXT FIX XSH NS DISP ACUTE QC,SUP-2933716,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4537.80,2949.57,,,,,,,,,,,,,
FIBER LASER HOLM 273 M MULTI-USE W/ SMA-905 GRN SMARTSYNC,SUP-2835958,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2201.93,1431.25,,,,,,,,,,,,,
GUIDEWIRE SUPP L300CM DIA0014IN STR TIP SAVION FLX,SUP-2140936,CDM,C1769,HCPCS,0272,RC,,,,both,,,634.28,412.28,,,,,,,,,,,,,
HC Ot Iontophoresis per 15 Min,PX-4309703300,CDM,97033,CPT,0430,RC,,,,outpatient,,,221.00,143.65,,,,,,,,,,,,,
TISSUE 16X26X26MM F TS PROGENIX +,SUP-2293924,CDM,C1713,HCPCS,0278,RC,,,,both,,,12154.94,7900.71,,,,,,,,,,,,,
COMPONENT ULNA DISCOVERY WITH BEARING E+ RIGHT 2.5X84MM,SUP-2879106,CDM,C1776,CPT,0278,RC,,,,both,,,17693.90,11501.03,,,,,,,,,,,,,
CATHETER ANGIOPLSTY SAVVY LNG L 150 CM BALLOON L 120 MM,SUP-2156637,CDM,C1725,HCPCS,0272,RC,,,,both,,,1252.29,813.99,,,,,,,,,,,,,
PROSTHESIS 16F 5MM SPEC LEN LG ESOPH FLNG INDWL VOICE,SUP-2242345,CDM,L8509,HCPCS,0274,RC,,,,both,,,979.68,636.79,,,,,,,,,,,,,
SET INTRO SUP ARW FLX SHTH L 24 CM DIA 5 FR HYDRPHLC,SUP-2383398,CDM,C1894,HCPCS,0272,RC,,,,both,,,166.42,108.17,,,,,,,,,,,,,
CEMENT BONE FULL DOSE 40 GM TWIN PK SPINPLEX STRL,SUP-2366941,CDM,C1713,HCPCS,0278,RC,,,,both,,,991.52,644.49,,,,,,,,,,,,,
INSERT TIB CR 4 12 MM KNEE BEAR TECHNOLOGY X3 TRIATHLON,SUP-2431365,CDM,C1776,CPT,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH FLX L 58 MM DIA 30 MM SHTH 20 FR SS,SUP-2750813,CDM,C1874,HCPCS,0278,RC,,,,both,,,6258.02,4067.71,,,,,,,,,,,,,
SET SUT OD5MM STD ENDOSCP,SUP-2245602,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
PLATE SPNL L42MM ANTR BILAT CERV LO PROF LEV 2 UNIPLT,SUP-2256434,CDM,C1713,HCPCS,0278,RC,,,,both,,,4804.20,3122.73,,,,,,,,,,,,,
PLATE BNE L W10.1XL98MM THK3.5MM 7 H BILAT S STL STR RIG,SUP-2186212,CDM,C1713,HCPCS,0278,RC,,,,both,,,1404.49,912.92,,,,,,,,,,,,,
HC Ot Iontophoresis per 15 Min,PX-4309703300,CDM,97033,CPT,0430,RC,,,,inpatient,,,221.00,143.65,,,,,,,,,,,,,
GRAFT BONE SUBSTITUTE SYGNACEL 5CC T90105,SUP-2929798,CDM,C1713,HCPCS,0278,RC,,,,both,,,8085.50,5255.57,,,,,,,,,,,,,
KIT INTRO ONESTIC L 5.75 CM DIA 8 FR GUIDEWIRE L 45 CM DIA,SUP-2876553,CDM,C1894,HCPCS,0272,RC,,,,both,,,210.38,136.75,,,,,,,,,,,,,
Z DISCONTINUED NO SUB IDED BUTTON SUT DIA11MM KNEE RND CONCV ABS 2 PC TIGHTROPE,SUP-2121395,CDM,C1713,HCPCS,0278,RC,,,,both,,,703.36,457.18,,,,,,,,,,,,,
ROD SPNL L90MM DIA5.5MM LORDOSED,SUP-2353319,CDM,C1713,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
TRIAL KNEE 29MM UNIV PAT RESURF GEN II,SUP-2346854,CDM,C1776,CPT,0278,RC,,,,both,,,241.78,157.16,,,,,,,,,,,,,
ANCHOR SUTURE PRE LD 2 2.9 MM W/ FORC FIBER QUATTRO GL,SUP-2608892,CDM,C1713,HCPCS,0278,RC,,,,both,,,1118.34,726.92,,,,,,,,,,,,,
BONE MARROW TRAY STD STRL T-LOK LF,SUP-2876732,CDM,2720000010,LOCAL,0272,RC,,,,both,,,338.49,220.02,,,,,,,,,,,,,
BRACE ANK LACE UP FIGURE 8 X L,SUP-2276709,CDM,L4350,HCPCS,0274,RC,,,,both,,,23.55,15.31,,,,,,,,,,,,,
IMPLANT TEND REP CONEXTIONS TR,SUP-2900742,CDM,C1713,HCPCS,0278,RC,,,,both,,,4082.00,2653.30,,,,,,,,,,,,,
PLATE BONE M W13XL101MM THK3.7MM 7 H TI STR REV FOR,SUP-2225500,CDM,C1713,HCPCS,0278,RC,,,,both,,,1358.99,883.34,,,,,,,,,,,,,
SHEATH INTRO SUPER SHTH XL L 11 CM DIA11 FR GUIDEWIRE 0.038,SUP-2147289,CDM,C1894,HCPCS,0272,RC,,,,both,,,53.38,34.70,,,,,,,,,,,,,
SCREW SPNL L16MM DIA4.2MM ANT CERV SELF DRL VAR ANG LOK ADV,SUP-2229911,CDM,C1713,HCPCS,0278,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
ALLOGRAFT BNE FRZN WHL FIB,SUP-2321808,CDM,C1713,HCPCS,0278,RC,,,,both,,,2866.82,1863.43,,,,,,,,,,,,,
ADAPTER LD 5MM UPLR,SUP-2355666,CDM,C1883,HCPCS,0278,RC,,,,both,,,816.40,530.66,,,,,,,,,,,,,
IMPLANT SYNTH L 150 X W 180 MM THK 4 MM POLYETHYL CRAN DOME,SUP-2883473,CDM,C1713,HCPCS,0278,RC,,,,both,,,15537.47,10099.36,,,,,,,,,,,,,
SCREW BNE CANN 4X38 MM CAPT SS,SUP-2848543,CDM,C1713,HCPCS,0278,RC,,,,both,,,1285.55,835.61,,,,,,,,,,,,,
GRAFT PASTE SYNTH CLLGN COPIOS BVF 5CC,SUP-2197452,CDM,C1713,HCPCS,0278,RC,,,,both,,,2468.04,1604.23,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY ORBITER ST L 95 CM DIA 7 FR SPC 2,SUP-2142353,CDM,C1731,HCPCS,0278,RC,,,,both,,,2904.50,1887.92,,,,,,,,,,,,,
BASEPLATE GLENOID HALF AUGMENT 25 DEGREE 2+ MM 28 MM OBLIQUE,SUP-2836575,CDM,C1776,CPT,0278,RC,,,,both,,,10048.00,6531.20,,,,,,,,,,,,,
DEFIBRILLATOR IMPL ITREVIA VR-T W 55 X H 65 MM D 11 MM 33 CC,SUP-2138374,CDM,C1722,HCPCS,0275,RC,,,,both,,,33707.90,21910.13,,,,,,,,,,,,,
PLATE BNE COMPR 2.7/3.5X20X25 MM PROX BILATERAL FT ANK LP SS,SUP-2397470,CDM,C1713,HCPCS,0278,RC,,,,both,,,3450.86,2243.06,,,,,,,,,,,,,
SCREW BNE L80 MM OD5.5 MM FULL THRD MONSTER IMPL,SUP-2320700,CDM,C1713,HCPCS,0278,RC,,,,both,,,1044.05,678.63,,,,,,,,,,,,,
HEAD FEM 40 MM HIP REMEDY SPECTRUM GV,SUP-2718134,CDM,C1776,CPT,0278,RC,,,,both,,,6280.00,4082.00,,,,,,,,,,,,,
MESH CRAN L 145 X W 145 MM SCREW DIA2 MM TI PANEL NS DISP,SUP-2936484,CDM,C1713,HCPCS,0278,RC,,,,both,,,4314.36,2804.33,,,,,,,,,,,,,
HC Catheter Stripping Procedure,PX-3207590100,CDM,75901,CPT,0320,RC,,,,both,,,5938.00,3859.70,,,,,,,,,,,,,
HOFFMANN LRF THUMBWHEEL TELESCOPIC STRUTS,SUP-2488273,CDM,2720000010,LOCAL,0272,RC,,,,both,,,244.92,159.20,,,,,,,,,,,,,
SCREW DENT 5.5X11.5 MM CONCL CONN WP NOBELPARALLEL,SUP-2430162,CDM,C1713,HCPCS,0278,RC,,,,both,,,1135.11,737.82,,,,,,,,,,,,,
PLATE BONE 6X17 H RT MAND HMSPHR TI RECON LEIBINGER,SUP-2363750,CDM,C1713,HCPCS,0278,RC,,,,both,,,4018.13,2611.78,,,,,,,,,,,,,
SCREW BONE L15MM DIAMETER 5MM HEX 2.5MM INTERFERENCE GUARDSM,SUP-2824110,CDM,C1713,HCPCS,0278,RC,,,,both,,,681.19,442.77,,,,,,,,,,,,,
NAIL IM L24CM DIA8MM RT ANTR POST FEM LCK CANN RG FOR,SUP-2318898,CDM,C1713,HCPCS,0278,RC,,,,both,,,11567.63,7518.96,,,,,,,,,,,,,
LACTATED RINGERS IV SOLN,RX-4318,CDM,J7120,HCPCS,0250,RC,00264-7750-00,NDC,,both,1000,ML,25.50,16.57,,,,,,,,,,,,,
MARKER BRST BX 8GA TI OPN COIL HYDROMARK,SUP-2195590,CDM,A4648,CPT,0278,RC,,,,both,,,246.49,160.22,,,,,,,,,,,,,
HC So Oxcarbazepine Metabolite,PX-3018018366,CDM,80183,CPT,0301,RC,,,,both,,,128.00,83.20,,,,,,,,,,,,,
CATHETER DIAGNOSTIC LASSOSTAR NAV OD20 MM CIRCULAR MAPPING CATHETER STERILE,SUP-2880094,CDM,C1730,HCPCS,0272,RC,,,,both,,,4662.90,3030.88,,,,,,,,,,,,,
KIT BIOPSY BONE 10GAX5IN STRL,SUP-2366855,CDM,C1713,HCPCS,0278,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
SYSTEM VLV REP MITRACLIP G4 EDGE TO EDGE BNDL SGC0701 STEER,SUP-2660820,CDM,C1725,HCPCS,0272,RC,,,,both,,,94200.00,61230.00,,,,,,,,,,,,,
PLATE BNE L235MM 15 H ST R DST LAT FIBULAR S STL VAR ANG,SUP-2177742,CDM,C1713,HCPCS,0278,RC,,,,both,,,3590.62,2333.90,,,,,,,,,,,,,
ALLOGRAFT DERMAL UNMESHED 4X4 CMX2-3.3 MM MTRX PROLAYER,SUP-2717808,CDM,C1763,HCPCS,0278,RC,,,,both,,,5275.45,3429.04,,,,,,,,,,,,,
GRAFT BNE DEMIN BNE MTRX BIO DBM,SUP-2364713,CDM,C1713,HCPCS,0278,RC,,,,both,,,3758.58,2443.08,,,,,,,,,,,,,
CATHETER PERI DLYS L120CM OD2.5MM ID1.3MM STD BA IMPREG OPN,SUP-2284393,CDM,C1750,HCPCS,0278,RC,,,,both,,,402.49,261.62,,,,,,,,,,,,,
BODY HUM L50MM R DST SHLDR SCR FOR SEG REV SYS COMPHSVE,SUP-2435912,CDM,C1776,CPT,0278,RC,,,,both,,,11176.83,7264.94,,,,,,,,,,,,,
ANCHOR SUTURE RETROGRADE 2-0 24 IN W/ NDL WHT ULTRABRAID,SUP-2848655,CDM,C1713,HCPCS,0278,RC,,,,both,,,72.53,47.14,,,,,,,,,,,,,
DOXORUBICIN HCL 50 MG IV SOLR,RX-2619,CDM,J9000,HCPCS,0636,RC,00143-9093-01,NDC,,both,1,UN,757.60,492.44,,,,,,,,,,,,,
PLATE BNE CONN 5 HOLE THRD NS,SUP-2800188,CDM,C1713,HCPCS,0278,RC,,,,both,,,353.69,229.90,,,,,,,,,,,,,
PLATE BNE W15XL168MM THK2MM 8 H BILAT S STL COVERLEAF RIG,SUP-2186010,CDM,C1713,HCPCS,0278,RC,,,,both,,,1711.96,1112.77,,,,,,,,,,,,,
CALCIUM CARB-CHOLECALCIFEROL 600-10 MG-MCG PO TABS,RX-159842,CDM,6370000000,HCPCS,0637,RC,20555-0017-00,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
INSERT TIBIAL LCS COMP VVC INS STD+ 20MM,SUP-2512984,CDM,C1776,CPT,0278,RC,,,,both,,,5851.70,3803.60,,,,,,,,,,,,,
ROD REPROC EXT FIX 11X200 MM MR CARBON FIBER NS,SUP-2188655,CDM,2720000010,LOCAL,0272,RC,,,,both,,,888.05,577.23,,,,,,,,,,,,,
SCREW BNE L44MM DIA2.7MM MTPHSEAL TAN ST LO PROF COMPR T8,SUP-2180943,CDM,C1713,HCPCS,0278,RC,,,,both,,,154.74,100.58,,,,,,,,,,,,,
SPLINT WRST M L7IN AD L FA COT E SUPP INSTABILITY INJ LOOP,SUP-2276649,CDM,L3809,HCPCS,0272,RC,,,,both,,,9.51,6.18,,,,,,,,,,,,,
CATHETER GUID STROKE FAST PK AXS CATLYST 5 L 132 CM PEBAX,SUP-2884423,CDM,C1887,HCPCS,0272,RC,,,,both,,,8478.00,5510.70,,,,,,,,,,,,,
BRACE ANK L M 115 13 WOM 13 145 L FOAM FILL SEMI RIG SHELL,SUP-2196376,CDM,L4350,HCPCS,0272,RC,,,,both,,,72.38,47.05,,,,,,,,,,,,,
INQUIRY LUMA STEER 1102 L 7 5 L,SUP-2698837,CDM,C1730,HCPCS,0272,RC,,,,both,,,2574.80,1673.62,,,,,,,,,,,,,
DRILL TWST OD5/16IN MRI,SUP-2505165,CDM,2720000010,LOCAL,0272,RC,,,,both,,,690.80,449.02,,,,,,,,,,,,,
PORT INFUS PLAS SGL LUMN W/ 9.6FR SIL CATH AIRGUARD VLV,SUP-2126328,CDM,C1788,HCPCS,0278,RC,,,,both,,,816.40,530.66,,,,,,,,,,,,,
STEM FEM SZ 4 L141MM 135DEG TI HIP CEMENTLESS BILAT STR,SUP-2304831,CDM,C1776,CPT,0278,RC,,,,both,,,9184.50,5969.92,,,,,,,,,,,,,
MESH BIO PORCINE MTRX TENDON/LIGAMENT REP 9CM LEN 6CM W,SUP-2244087,CDM,C1763,HCPCS,0278,RC,,,,both,,,9994.62,6496.50,,,,,,,,,,,,,
GUIDEWIRE VASC VSI L 40 CM DIA 0.018 IN NIT MANDREL SS TIP,SUP-2383178,CDM,C1769,HCPCS,0272,RC,,,,both,,,83.21,54.09,,,,,,,,,,,,,
CATHETER HAD ADMIN FULL KT DBL LUMN POLYUR STR SPL TIP NO,SUP-2118065,CDM,C1752,HCPCS,0278,RC,,,,both,,,613.52,398.79,,,,,,,,,,,,,
PLATE LOCKING STRAIGHT 1.3MM 12 HOLES-STERILE,SUP-2546061,CDM,C1713,HCPCS,0278,RC,,,,both,,,1353.84,880.00,,,,,,,,,,,,,
STAPLE BNE FIX W8XL8MM SUP E NIT SYS MEMOFIX,SUP-2244262,CDM,C1713,HCPCS,0278,RC,,,,both,,,3645.54,2369.60,,,,,,,,,,,,,
PLATE ADAPTER DIST LAT FEMUR RIGHT,SUP-2706389,CDM,C1713,HCPCS,0278,RC,,,,both,,,4548.29,2956.39,,,,,,,,,,,,,
BIT DRL DIA4.3MM TIB CALIB FOR NAT NAIL 18 SYS,SUP-2410909,CDM,2720000010,LOCAL,0272,RC,,,,both,,,641.69,417.10,,,,,,,,,,,,,
HC So Lipid Panel,PX-3018006166,CDM,80061,CPT,0301,RC,,,,inpatient,,,43.00,27.95,,,,,,,,,,,,,
PLATE BONE FUS STD LT,SUP-2397485,CDM,C1713,HCPCS,0278,RC,,,,both,,,3205.94,2083.86,,,,,,,,,,,,,
KIT DRL XL FOR 3MM KNOTLESS HIP SUTURETAK W STP DRL SPEAR,SUP-2121608,CDM,2720000010,LOCAL,0272,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
BIT DRL DIA3MM HD REL ADD ON,SUP-2136140,CDM,2720000010,LOCAL,0272,RC,,,,both,,,413.70,268.90,,,,,,,,,,,,,
GUIDEWIRE VASC EMERALD L 180 CM DIA 0.035 IN CRV RAD 1.5 MM,SUP-2157296,CDM,C1769,HCPCS,0272,RC,,,,both,,,69.90,45.43,,,,,,,,,,,,,
WIRE K 1.4MM DISP,SUP-2152540,CDM,C1769,HCPCS,0272,RC,,,,both,,,64.06,41.64,,,,,,,,,,,,,
MESH HERN SM 1X1.35IN INGUINAL WHT POLYPR MFIL PLUG,SUP-2125750,CDM,C1781,HCPCS,0278,RC,,,,both,,,642.13,417.38,,,,,,,,,,,,,
CATHETER GUID SIM2 AD 0.078 INX7 FRX100 CM PTFE NYL SS ENVOY,SUP-2154492,CDM,C1887,HCPCS,0272,RC,,,,both,,,1781.32,1157.86,,,,,,,,,,,,,
GRAFT BNE SUB 2.5CC SIL SOD CA PHOS OXIDE VERSATILE RESRB,SUP-2368182,CDM,C1713,HCPCS,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
PLATE BONE M THK1MM 4 H MIDFACE SLV TI STR FOR 2MM SCR,SUP-2402957,CDM,C1713,HCPCS,0278,RC,,,,both,,,514.96,334.72,,,,,,,,,,,,,
STAPLE SPNL RSTRL 23 MM CD HORZ,SUP-2278987,CDM,C1713,HCPCS,0278,RC,,,,both,,,759.88,493.92,,,,,,,,,,,,,
PROBE SPNL PEDCL NRV STIMULATING HNDPC NEUROVISION,SUP-2309802,CDM,C1713,HCPCS,0278,RC,,,,both,,,1105.28,718.43,,,,,,,,,,,,,
COMPONENT CRANIOFACIAL CUSTOMIZED MED PRIORITY + PEEK NS LTX,SUP-2862816,CDM,C1713,HCPCS,0278,RC,,,,both,,,51389.11,33402.92,,,,,,,,,,,,,
PLATE BONE 30 H STRL STRNL TI STR LO PROF NEUT LCK COMPR FOR,SUP-2192434,CDM,C1713,HCPCS,0278,RC,,,,both,,,11247.17,7310.66,,,,,,,,,,,,,
HC Cv Cath Plac W/Port Tun >5,PX-5103656100,CDM,36561,CPT,0510,RC,,,,both,,,10303.00,6696.95,,,,,,,,,,,,,
RESERVOIR VENT DRNGE ID2.5CM CONN OD1.9MM ID1.1MM SIL,SUP-2308214,CDM,C1889,HCPCS,0278,RC,,,,both,,,1615.53,1050.09,,,,,,,,,,,,,
PLUG BNE POLYPLUG MDLLRY 11MM,SUP-2197457,CDM,C1713,HCPCS,0278,RC,,,,both,,,249.63,162.26,,,,,,,,,,,,,
PLATE BNE 14 H SS RT PELV BRIM ANAT STRL PRO,SUP-2902246,CDM,C1713,HCPCS,0278,RC,,,,both,,,6351.91,4128.74,,,,,,,,,,,,,
CATHETER ABLAT 7.5FR L110CM TIP L4MM 2.5MM SPC QPLR L CRV,SUP-2141331,CDM,C2630,CPT,0272,RC,,,,both,,,5338.00,3469.70,,,,,,,,,,,,,
GENERATOR NEUROSTIMULATOR W495XH61CM THK134CM 32CC DORS,SUP-2356748,CDM,C1767,HCPCS,0278,RC,,,,both,,,61486.51,39966.23,,,,,,,,,,,,,
PIN FIX TRCR PT 1 END 0.177X9 IN RND END SS NS STEINMANN,SUP-2791273,CDM,C1713,HCPCS,0278,RC,,,,both,,,40.69,26.45,,,,,,,,,,,,,
METOLAZONE 2.5 MG PO TABS,RX-10587,CDM,6370000000,HCPCS,0637,RC,51079-0023-01,NDC,,both,1,UN,12.40,8.06,,,,,,,,,,,,,
CATHETER BLLN DIL WIRE GUID 8-9-10 MMX180 CM ELATION 5,SUP-2468604,CDM,C1726,HCPCS,0272,RC,,,,both,,,596.60,387.79,,,,,,,,,,,,,
MARKER RAD KNURLED PLCMNT NDL STRL GLDN L3MM L20CM OD.9MM,SUP-2418125,CDM,A4648,CPT,0278,RC,,,,both,,,257.48,167.36,,,,,,,,,,,,,
COMPONENT TIB SM L80MM KNEE ROT PLATFRM GMRS,SUP-2376523,CDM,C1776,CPT,0278,RC,,,,both,,,7097.50,4613.37,,,,,,,,,,,,,
PLATE BONE L61MM 2 H RT OLECRANON W/ TINES FOR 2.7/3.5MM SCR,SUP-2418064,CDM,C1713,HCPCS,0278,RC,,,,both,,,4944.87,3214.17,,,,,,,,,,,,,
OBTURATOR ENDOSCP L250MM DIA5MM FLX BLNT TIP DA VINCI,SUP-2246705,CDM,C1713,HCPCS,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
BIT DRL L330MM DIA4.2MM CALIB L100MM ST 3 FLUT QUIK CPL FOR,SUP-2178856,CDM,2720000010,LOCAL,0272,RC,,,,both,,,840.83,546.54,,,,,,,,,,,,,
NAIL IM L19.5CM DIA14MM 130DEG LT FEM HIP GRN TI CANN LCK,SUP-2347889,CDM,C1713,HCPCS,0278,RC,,,,both,,,2877.50,1870.37,,,,,,,,,,,,,
SHEATH INTRO SUREFLEX L 72 CM DIA 8.5 FR DSTL CRV DIA22 MM,SUP-2420621,CDM,C1766,CPT,0272,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
BIT DRL DIA49MM SHT CALIB FOR NAT NAIL SYS,SUP-2198667,CDM,2720000010,LOCAL,0272,RC,,,,both,,,403.65,262.37,,,,,,,,,,,,,
KIT ACC TRANSRADIAL SPR WIRE RADIALSOURCE RED 4FRX6.5CM MINI,SUP-2157406,CDM,C1894,HCPCS,0272,RC,,,,both,,,101.27,65.83,,,,,,,,,,,,,
PLATE BONE L93MM 8 H STRL S STL LCK COMPR FOR 3.5MM SCR EVOS,SUP-2349631,CDM,C1713,HCPCS,0278,RC,,,,both,,,2439.69,1585.80,,,,,,,,,,,,,
LINER TIB CEM KNEE CR XLPE PREMIER STRYK7] STRYKER ORTHOPEDICS HOWM],SUP-2379184,CDM,C1776,CPT,0278,RC,,,,both,,,11618.00,7551.70,,,,,,,,,,,,,
ENDCAP SPNL PARL 14X22X19 MM MONOLITH,SUP-2567550,CDM,C1889,HCPCS,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
"HC Concentratn ,Any, Infect Agent",PX-3008701500,CDM,87015,CPT,0300,RC,,,,both,,,79.00,51.35,,,,,,,,,,,,,
PROSTHESIS OSS 4X4X6 MM 3.67 MM RICHARDS CENTERED HA TORP,SUP-2637875,CDM,L8613,CPT,0278,RC,,,,both,,,1225.54,796.60,,,,,,,,,,,,,
PLUG HERN L W1.6XL1.9IN INGUINAL POLYPR REP PRESHAPED ONLAY,SUP-2125756,CDM,C1781,HCPCS,0278,RC,,,,both,,,653.43,424.73,,,,,,,,,,,,,
HALF PIN 5X180MM 50MM CON,SUP-2818453,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1005.11,653.32,,,,,,,,,,,,,
PROGUIDE 36CM BASIC KIT HOLES 16F PLWAY SHTH 18 G INTRDCR ND,SUP-2676389,CDM,C1894,HCPCS,0272,RC,,,,both,,,753.60,489.84,,,,,,,,,,,,,
HC So Assay of Psa Total|NOT REASONABLE AND NECESSARY,PX-3018415366,CDM,84153,CPT,0301,RC,,,GZ,outpatient,,,338.00,219.70,,,,,,,,,,,,,
PROBE BRST BX 13GA US VAC ASST MAMTOM ELITE,SUP-2195645,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1165.07,757.30,,,,,,,,,,,,,
GRAFT HUM TISS W5XL5CM PLCNTA MEM CRYOPRESERVED CHORION,SUP-2319169,CDM,Q4132,HCPCS,0636,RC,,,,both,,,8478.00,5510.70,,,,,,,,,,,,,
HEAD HUM MOD 45 MM SHLDR REMEDY,SUP-2718145,CDM,C1776,CPT,0278,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
NEEDLE TRANSSEPTAL AD 18GA L71CM 30DEG BVL BRK-1 XS CRV S,SUP-2357591,CDM,2720000010,LOCAL,0272,RC,,,,both,,,739.25,480.51,,,,,,,,,,,,,
SCREW BNE L50MM DIA8MM THRD L22MM DIA12.7MM CANC CNDYL S,SUP-2186523,CDM,C1713,HCPCS,0278,RC,,,,both,,,1027.09,667.61,,,,,,,,,,,,,
PLATE 3.5MM CURVED BROAD LCP 22H TI STRL,SUP-2546938,CDM,C1713,HCPCS,0278,RC,,,,both,,,3673.27,2387.63,,,,,,,,,,,,,
GRAFT VASC EXXCEL SFT L 45 CM DIA 4-7 MM SUPP L 10 CM EPTFE,SUP-2227651,CDM,C1768,CPT,0278,RC,,,,both,,,1722.35,1119.53,,,,,,,,,,,,,
CLAMP SPNL 6MM TI DISPOSABLE UNIV IMPL,SUP-2416029,CDM,C1713,HCPCS,0278,RC,,,,both,,,5024.00,3265.60,,,,,,,,,,,,,
ALLOGRAFT DERMAL 8X16CMX2.4/0.4 MM RDY TO USE ALLDERM,SUP-2463126,CDM,Q4116,HCPCS,0636,RC,,,,both,,,14962.10,9725.36,,,,,,,,,,,,,
ALLOGRAFT BNE 2 CC FIBER VIABLE MTRX FIBERCEL,SUP-2541276,CDM,C1713,HCPCS,0278,RC,,,,both,,,4490.20,2918.63,,,,,,,,,,,,,
PLATE BNE L W135XL260MM THK42MM 14 H BILAT TI NAR RIG NEUT,SUP-2190828,CDM,C1713,HCPCS,0278,RC,,,,both,,,2091.18,1359.27,,,,,,,,,,,,,
HC Smr Prim Src Wet Mount Nfct Agt,PX-3008721001,CDM,87210,CPT,0300,RC,,,,inpatient,,,208.00,135.20,,,,,,,,,,,,,
GRAFT BNE SUB 9 -10MM 35-45MM BTB PRESHAPED,SUP-2335537,CDM,C1776,CPT,0278,RC,,,,both,,,15700.00,10205.00,,,,,,,,,,,,,
PLATE BNE L84MM 4 H S STL T LOK COMPR FOR 4.5/5MM SCR,SUP-2185753,CDM,C1713,HCPCS,0278,RC,,,,both,,,1627.96,1058.17,,,,,,,,,,,,,
STEM FEM OD13MM +0MM SH TI HIP REV POLISHED EMPERION,SUP-2344349,CDM,C1776,CPT,0278,RC,,,,both,,,8145.16,5294.35,,,,,,,,,,,,,
FIBER LASER 70 DEG INFRATOME,SUP-2225608,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
BARRIER ADH W3XL5IN SM INCIS SEPRAFILM,SUP-2227090,CDM,C1765,HCPCS,0278,RC,,,,both,,,913.49,593.77,,,,,,,,,,,,,
PLATE BNE STR 12X0.6 MM NEURO 2 HOLE TI NS LEVEL 1 ULTRAONE,SUP-2518092,CDM,C1713,HCPCS,0278,RC,,,,both,,,262.41,170.57,,,,,,,,,,,,,
PLATE BNE MINI THK0.5MM 6 H BILAT CRANIOMAXILLOFACIAL BLU,SUP-2181680,CDM,C1713,HCPCS,0278,RC,,,,both,,,1013.28,658.63,,,,,,,,,,,,,
RESERVOIR CSF 1.31ML DIA2.5CM CONV FLAT BTM,SUP-2244287,CDM,C1729,HCPCS,0272,RC,,,,both,,,1027.44,667.84,,,,,,,,,,,,,
SCREW BNE L70MM DIA4.5MM CORT TI N ST N SELF DRL,SUP-2190370,CDM,C1713,HCPCS,0278,RC,,,,both,,,122.40,79.56,,,,,,,,,,,,,
PLATE BNE L116MM 6 H S STL T LOK COMPR FOR 4.5/5MM SCR,SUP-2185756,CDM,C1713,HCPCS,0278,RC,,,,both,,,1863.28,1211.13,,,,,,,,,,,,,
COLLAR PREMIER PRO CERV RIG 3.25INCH SM LTX FREE,SUP-2336005,CDM,L0140,HCPCS,0274,RC,,,,both,,,36.99,24.04,,,,,,,,,,,,,
SCREW BNE CORTICAL UNIV 3.5X55 MM FEM ST LCK TI ULS NCB,SUP-2466538,CDM,C1713,HCPCS,0278,RC,,,,both,,,70.40,45.76,,,,,,,,,,,,,
HC Smr Prim Src Wet Mount Nfct Agt,PX-3008721001,CDM,87210,CPT,0300,RC,,,,outpatient,,,208.00,135.20,,,,,,,,,,,,,
PLATE BNE RECON 2.7 MM 10 HOLE 2 COMPR LCK FOR SCR TI STRL,SUP-2460408,CDM,C1713,HCPCS,0278,RC,,,,both,,,1107.42,719.82,,,,,,,,,,,,,
CATHETER ANGIOPLSTY RANG L 135 CM BALLOON L 100 MM DIA 4 MM,SUP-2653303,CDM,C2623,HCPCS,0278,RC,,,,both,,,4380.30,2847.19,,,,,,,,,,,,,
SHEATH ENDO 25.6FR YEL INNR RND TIP RESECTOSCOPIC CONT FLO,SUP-2313068,CDM,C1894,HCPCS,0272,RC,,,,both,,,4191.49,2724.47,,,,,,,,,,,,,
BAND SCLER L 120 MM SZ 2.5 X 0.6 MM SIL TYP 240 SFT ELAS,SUP-2930310,CDM,C1784,HCPCS,0278,RC,,,,both,,,62.80,40.82,,,,,,,,,,,,,
HC CT Pelvis W/O Contrast,PX-3527219200,CDM,72192,CPT,0352,RC,,,,both,,,1973.00,1282.45,,,,,,,,,,,,,
CONNECTOR SPNL CROSS SM 39-46MM,SUP-2354726,CDM,C1713,HCPCS,0278,RC,,,,both,,,3642.40,2367.56,,,,,,,,,,,,,
CEFAZOLIN SODIUM 3 G SOLR (MIXTURES ONLY),RX-430080,CDM,J0688,HCPCS,0636,RC,00143-9140-01,NDC,,both,1,UN,54.10,35.16,,,,,,,,,,,,,
GRAFT HUM TISS W6XL12CM THK8 17MM DERM ACELLULAR HYDRATED,SUP-2307475,CDM,Q4128,HCPCS,0636,RC,,,,both,,,6667.13,4333.63,,,,,,,,,,,,,
SHEATH DIL L20CM ID30FR PTFE RENAL AMPLATZ,SUP-2139478,CDM,C1894,HCPCS,0272,RC,,,,both,,,130.97,85.13,,,,,,,,,,,,,
APPLIER CLP L L1.7MM DISP FOR VCS VES CLSR SYSTEMXENOSURE,SUP-2264245,CDM,C1713,HCPCS,0278,RC,,,,both,,,396.68,257.84,,,,,,,,,,,,,
BIT DRL 3 FLUT 2.7X125 MM QC SS STRL LCP,SUP-2187592,CDM,2720000010,LOCAL,0272,RC,,,,both,,,488.40,317.46,,,,,,,,,,,,,
INSERT TIBIALXL L80MM THK15MM AP51MM LT MEDL LAT ARTC CRUC,SUP-2344109,CDM,C1776,CPT,0278,RC,,,,both,,,2673.71,1737.91,,,,,,,,,,,,,
GRAFT BNE SPACER 7.54X9 MM MATRISPINE,SUP-2264621,CDM,2780000010,LOCAL,0278,RC,,,,both,,,2983.00,1938.95,,,,,,,,,,,,,
BLADE SURG HMSPHR LNG 46 MM HIP FULL EXPLANT,SUP-2206128,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
ENDOPROSTHESIS VASC VIABAHN VBX L 79 MM 8/11 MM 135 CM 7 FR,SUP-2892800,CDM,C1874,HCPCS,0278,RC,,,,both,,,11049.66,7182.28,,,,,,,,,,,,,
GRAFT VASC INTERGARD L 50 CM DIA22 X 11 MM THK 0.49 MM,SUP-2458544,CDM,C1768,CPT,0278,RC,,,,both,,,2492.44,1620.09,,,,,,,,,,,,,
PROBE ENDOSCP DISECT 90 DEG 19.7 CM SHFT FOR NEUROENDOSCOPE,SUP-2665082,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1131.66,735.58,,,,,,,,,,,,,
STIMULATOR BONE GROWTH ELEC NONINVASIVE FOR OSTEOGENESIS,SUP-2137435,CDM,E0749,HCPCS,0278,RC,,,,both,,,7842.15,5097.40,,,,,,,,,,,,,
PLATE BNE L127MM 4 H R PROX PERIARTC HUM S STL LOK COMPR,SUP-2177804,CDM,C1713,HCPCS,0278,RC,,,,both,,,4805.46,3123.55,,,,,,,,,,,,,
SCREW BONE L95MM OD3.5MM 6 CRUCFRM COARSE THRD WDRUFF,SUP-2362310,CDM,C1713,HCPCS,0278,RC,,,,both,,,28.17,18.31,,,,,,,,,,,,,
SHELL ACET DIA48MM GRP 1 UNIV TI CERAMIC PLSM COAT CLUS H,SUP-2221985,CDM,C1776,CPT,0278,RC,,,,both,,,5777.60,3755.44,,,,,,,,,,,,,
BLADE SAW SAG 4MM CUT EDGE 34MM CUT DEPTH 0.4MM THCK FLT FLF,SUP-2605394,CDM,2720000010,LOCAL,0272,RC,,,,both,,,84.06,54.64,,,,,,,,,,,,,
COLLAR PREMIER PRO CERV RIG 3.25INCH SM LTX FREE,SUP-2336005,CDM,L0140,HCPCS,0272,RC,,,,both,,,36.99,24.04,,,,,,,,,,,,,
ALLOGRAFT BNE 10X2.5 CM FD DBM GRFT FLX,SUP-2787763,CDM,C1713,HCPCS,0278,RC,,,,both,,,4132.24,2685.96,,,,,,,,,,,,,
NAIL IM L480MM DIA11MM 130DEG NONSTERILE GRN FEM TI LCK,SUP-2192578,CDM,C1713,HCPCS,0278,RC,,,,both,,,3356.22,2181.54,,,,,,,,,,,,,
CATHETER DRAINAGE TY 10 FR 8/10 FRX20 CM LCK BG MAK-NV,SUP-2467954,CDM,C1729,HCPCS,0272,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
PREGABALIN 50 MG PO CAPS,RX-42163,CDM,6370000000,HCPCS,0637,RC,60687-0484-01,NDC,,both,1,UN,6.10,3.96,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 20 CM DIA 8 MM EPTFE STR TW REINF 2,SUP-2669628,CDM,C1768,CPT,0278,RC,,,,both,,,606.37,394.14,,,,,,,,,,,,,
STEM FNGR JT 4 L49.3MM DIA7.1MM FLEXSPAN PROX NONCOATED FLX,SUP-2399928,CDM,C1776,CPT,0278,RC,,,,both,,,3212.22,2087.94,,,,,,,,,,,,,
FLUDARABINE PHOSPHATE 50 MG IV SOLR,RX-10053,CDM,J9185,HCPCS,0636,RC,45963-0609-55,NDC,,both,1,UN,272.20,176.93,,,,,,,,,,,,,
STAPLER INT CARTRIDGE MED THCK 80 MM W/ TRI-STAPLE PUR GIA,SUP-2787698,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1212.89,788.38,,,,,,,,,,,,,
SCREW BNE CAPT 135 DEG SHT BRL 100 MM HIP ANGLED TI,SUP-2469332,CDM,C1713,HCPCS,0278,RC,,,,both,,,1416.14,920.49,,,,,,,,,,,,,
CATHETER CV SET 14 GAX16 CM SINGLE LUMEN BLU FLEXTIP,SUP-2763398,CDM,C1751,HCPCS,0278,RC,,,,both,,,52.12,33.88,,,,,,,,,,,,,
SHEATH TUNN L20.5IN DIA12MM BLU POLYMER RADPQ DISP FOR 10MM,SUP-2336986,CDM,C1894,HCPCS,0272,RC,,,,both,,,216.03,140.42,,,,,,,,,,,,,
DRAIN SURG L49IN DIA1/8IN 10IN H SIL W/O TRCR END PERF,SUP-2127115,CDM,C1729,HCPCS,0272,RC,,,,both,,,13.03,8.47,,,,,,,,,,,,,
BLADE SAW 12X5X0.38 MM INT ORAL OSCILLATING SAW THN STRL LTX,SUP-2862527,CDM,2720000010,LOCAL,0272,RC,,,,both,,,322.57,209.67,,,,,,,,,,,,,
GRAFT HUM TISS L W13XL22CM THK0.7-1.4MM THN ACELLULAR,SUP-2307606,CDM,Q4128,HCPCS,0636,RC,,,,both,,,14190.29,9223.69,,,,,,,,,,,,,
TROCAR ENTRY PORTAL AFFIXUS HIP FX NAIL SYS,SUP-2412785,CDM,2720000010,LOCAL,0272,RC,,,,both,,,593.46,385.75,,,,,,,,,,,,,
HC Ot Manual Therapy per 15 Min.|DOCUMENTATION ON FILE|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS|UNUSUAL NON-OVERLAPPING SERVICE,PX-4309714000,CDM,97140,CPT,0430,RC,,,KX|CQ|XU,outpatient,,,194.00,126.10,,,,,,,,,,,,,
CATHETER DIL 10FR L200CM TAPR TIP 7.5-4FR L4CM 0.035IN GRAD,SUP-2169269,CDM,C1726,HCPCS,0272,RC,,,,both,,,210.38,136.75,,,,,,,,,,,,,
PLATE BNE L 81 X W 8 MM THK 3.5 MM SCREW DIA2.7 MM 10 H SS 72440310N,SUP-2932737,CDM,C1713,HCPCS,0278,RC,,,,both,,,1725.56,1121.61,,,,,,,,,,,,,
PIN FIX HDLSS 1/8X4 IN,SUP-2361950,CDM,2720000010,LOCAL,0272,RC,,,,both,,,185.26,120.42,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP L260CM DIA0035IN HI PERF HYDR JAGWIRE,SUP-2141528,CDM,C1769,HCPCS,0272,RC,,,,both,,,521.52,338.99,,,,,,,,,,,,,
SHEATH LD INTRO OPTISEAL L 13 CM DIA12 FR SIDEPRT STEER STRL,SUP-2459376,CDM,C1766,CPT,0272,RC,,,,both,,,226.08,146.95,,,,,,,,,,,,,
HC Asp Inj Intermediate Joint,PX-3612060500,CDM,20605,CPT,0361,RC,,,,outpatient,,,358.00,232.70,,,,,,,,,,,,,
PLATE FRAC 2MM 6H TI STRL VAL,SUP-2546917,CDM,C1713,HCPCS,0278,RC,,,,both,,,2290.60,1488.89,,,,,,,,,,,,,
SCREW BNE L55MM DIA2.7MM CORT S STL ST FULL THRD FOR SM,SUP-2183469,CDM,C1713,HCPCS,0278,RC,,,,both,,,128.77,83.70,,,,,,,,,,,,,
BLADE RTRCTR RVL LNG TOOTH 35MML BLUE F/ANTRR CRVCL FSN RMVL,SUP-2458469,CDM,2720000010,LOCAL,0272,RC,,,,both,,,483.06,313.99,,,,,,,,,,,,,
HC So Ldh,PX-3018361566,CDM,83615,CPT,0301,RC,,,,inpatient,,,25.00,16.25,,,,,,,,,,,,,
BAR ORTHOT HIP PELV THGH CUST BND SPRED,SUP-2435598,CDM,L1640,HCPCS,0274,RC,,,,both,,,1340.21,871.14,,,,,,,,,,,,,
STAPLE BNE FIX BRIDGE W 30 MM NIT METATARSOPHALANGEAL FUSION,SUP-2897012,CDM,C1713,HCPCS,0278,RC,,,,both,,,5962.86,3875.86,,,,,,,,,,,,,
KIT POWERPRT CLEARVUE ISP IMPL PRT 6FRENCH ATTCH POLYUR,SUP-2126305,CDM,C1788,HCPCS,0278,RC,,,,both,,,1152.38,749.05,,,,,,,,,,,,,
PLATE BNE TARGETING GUIDE PROX HUM B LBL SYS CASE AFFIXUS,SUP-2606196,CDM,C1713,HCPCS,0278,RC,,,,both,,,17144.40,11143.86,,,,,,,,,,,,,
ROD EXT FIX PRE BENT XL CRANIOMAXILLOFACIAL FULL MAND TI,SUP-2460030,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2455.35,1595.98,,,,,,,,,,,,,
EVOS 2.7/3.5MM EA-D HUM PL 20H RIGHT 239MM,SUP-2819911,CDM,C1713,HCPCS,0278,RC,,,,both,,,9929.31,6454.05,,,,,,,,,,,,,
PROBE NERVE STIM DIA1 MM BALL TIP INCREMENTING STRL DISP,SUP-2902011,CDM,2720000010,LOCAL,0272,RC,,,,both,,,680.60,442.39,,,,,,,,,,,,,
KIT STPL BNE FIX BRDG L20MM SPEEDTITAN BME,SUP-2194279,CDM,C1713,HCPCS,0278,RC,,,,both,,,3978.13,2585.78,,,,,,,,,,,,,
ROD SPNL CRV 3.5X200 MM PRE BENT INFIN,SUP-2421098,CDM,C1713,HCPCS,0278,RC,,,,both,,,4160.50,2704.32,,,,,,,,,,,,,
STENT GRFT VASC AFX2 BODY L 40 MM DIA22 MM LIMB 40 MM 16 MM,SUP-2846414,CDM,C1768,HCPCS,0278,RC,,,,both,,,30577.32,19875.26,,,,,,,,,,,,,
MESH HERN W30XL30CM POLY HYDRPHLC SQ KNIT HNYCMB 3D FLAT,SUP-2174806,CDM,C1781,HCPCS,0278,RC,,,,both,,,590.82,384.03,,,,,,,,,,,,,
PLATE BNE L 222 MM SCREW DIA 4.5 MM 13 H RT PROX HUM STRL,SUP-2933323,CDM,C1713,HCPCS,0278,RC,,,,both,,,10802.39,7021.55,,,,,,,,,,,,,
SCREW BONE L46MM OD5.5MM THRD L32MM STD TI CORT ST SELF DRL,SUP-2343149,CDM,C1713,HCPCS,0278,RC,,,,both,,,1937.13,1259.13,,,,,,,,,,,,,
MESH HERN OVL 8X6 IN POCKETED BIORESORBABLE PHASIX ST,SUP-2855271,CDM,C1781,HCPCS,0278,RC,,,,both,,,17348.50,11276.52,,,,,,,,,,,,,
HOOK SPNL L PEDCL S STL NEUT BILAT FOR 5.5MM ROD CDH LEG,SUP-2288176,CDM,C1713,HCPCS,0278,RC,,,,both,,,2341.03,1521.67,,,,,,,,,,,,,
PLATE BONE SM W11XL142MM THK3.3MM 0DEG 11 H BILAT TI STR RIG,SUP-2190786,CDM,C1713,HCPCS,0278,RC,,,,both,,,595.53,387.09,,,,,,,,,,,,,
TRAY CATH PICC GROSH NXT MAXBARR 4FR 0.033IN 60CM 1 LUMAN RV,SUP-2613421,CDM,C1751,HCPCS,0278,RC,,,,both,,,427.67,277.99,,,,,,,,,,,,,
SCISSORS SURG METZ DISECT STD BLNT SERR S STL CRV 9IN,SUP-2382454,CDM,2720000010,LOCAL,0272,RC,,,,both,,,62.11,40.37,,,,,,,,,,,,,
NEEDLE EPIDURAL L 6 IN STRL DISP PHARM COUD,SUP-2917193,CDM,2720000010,LOCAL,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
GUIDEWIRE VASC MAGIC TORQUE L 260 CM DIA 0.035 IN TIP 5 CM,SUP-2142699,CDM,C1769,HCPCS,0272,RC,,,,both,,,130.84,85.05,,,,,,,,,,,,,
MODULE DISPLAY LVAD,SUP-2356036,CDM,C1713,HCPCS,0278,RC,,,,both,,,8792.00,5714.80,,,,,,,,,,,,,
GUIDEWIRE VASC STBL L 300 CM DIA 0.014 IN COR DIA 0.135 IN,SUP-2157474,CDM,C1769,HCPCS,0272,RC,,,,both,,,414.48,269.41,,,,,,,,,,,,,
CHEST TUBE KIT INSRTN,SUP-2270510,CDM,2720000010,LOCAL,0272,RC,,,,both,,,678.43,440.98,,,,,,,,,,,,,
COMPONENT KNEE CMNTLS 30 MM MOD W/ FEMALE TAPR FOR 6 MM NOSE,SUP-2423134,CDM,C1776,CPT,0278,RC,,,,both,,,16883.78,10974.46,,,,,,,,,,,,,
ELECTRODE CORTICAL 1 X 6 KT STRL DISP EVO,SUP-2935141,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2376.98,1545.04,,,,,,,,,,,,,
PLATE BNE HK SHT 2.7X12 MM RT CLAV VA LCK STRL VALCP,SUP-2789387,CDM,C1713,HCPCS,0278,RC,,,,both,,,4183.23,2719.10,,,,,,,,,,,,,
PLATE BNE ACTIVE COMPR BROAD 4.5 MM 14 HOLE NS,SUP-2525138,CDM,C1713,HCPCS,0278,RC,,,,both,,,775.58,504.13,,,,,,,,,,,,,
PLATE BNE MAXILLOFCL 3 MESH NS FACE ID,SUP-2909650,CDM,C1713,HCPCS,0278,RC,,,,both,,,32381.78,21048.16,,,,,,,,,,,,,
COMPONENT TIB L65MM THK8MM TI UHMWPE MEDL LAT POST STBL AGC,SUP-2406190,CDM,C1776,CPT,0278,RC,,,,both,,,7658.46,4978.00,,,,,,,,,,,,,
CABLE CNTOUR 3.5MM SERFAS,SUP-2362166,CDM,2720000010,LOCAL,0272,RC,,,,both,,,411.03,267.17,,,,,,,,,,,,,
CATHETER ANGIOPLSTY L 135 CM BALLOON L 80 MM DIA 5 MM SHTH 6,SUP-2892911,CDM,C2623,HCPCS,0278,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
TUBING HD ACCURA DISP,SUP-2129896,CDM,2720000010,LOCAL,0272,RC,,,,both,,,352.47,229.11,,,,,,,,,,,,,
BIT DRILL LNG 4.3MM,SUP-2483730,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1262.66,820.73,,,,,,,,,,,,,
BIT DRL OD9.5MM SACROILIAC CANN SI-LOK,SUP-2232172,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
KIT INTRO MAK L 15 CM DIA 5 FR COAX DIL PR STRL,SUP-2303014,CDM,C1894,HCPCS,0272,RC,,,,both,,,64.68,42.04,,,,,,,,,,,,,
TAP SURG DIA4MM FOR CANC BONE PLATING SYS TC-100,SUP-2343960,CDM,C1713,HCPCS,0278,RC,,,,both,,,944.20,613.73,,,,,,,,,,,,,
BUR SURG DIAMOND 7.5 MM 9 CM BALL LG BOR MIDAS REX LEGEND,SUP-2631872,CDM,2720000010,LOCAL,0272,RC,,,,both,,,393.91,256.04,,,,,,,,,,,,,
SCREW BNE EMGCY 3.1X11 MM TI MAXDRIVE THREADLOCK TS LEVEL 1,SUP-2463702,CDM,C1713,HCPCS,0278,RC,,,,both,,,494.71,321.56,,,,,,,,,,,,,
CISATRACURIUM BESYLATE (PF) 200 MG/20ML IV SOLN,RX-133072,CDM,2500000003,HCPCS,0250,RC,72485-0513-01,NDC,,both,20,ML,230.00,149.50,,,,,,,,,,,,,
ALLOGRAFT HUM TISS FEN 16X6 CM SHT AMNION/CHORION AMNIOFIX,SUP-2871305,CDM,C1762,CPT,0278,RC,,,,both,,,22199.80,14429.87,,,,,,,,,,,,,
DEFIBRILLATOR CRD SINGLE CHMBR 30 J OPTIM INSUL CURRENT VR,SUP-2356049,CDM,C1722,HCPCS,0275,RC,,,,both,,,72220.00,46943.00,,,,,,,,,,,,,
BLADE ELECSURG 4.5 MM RESECT FULL RAD ELECTROBLADE,SUP-2848578,CDM,2720000010,LOCAL,0272,RC,,,,both,,,741.83,482.19,,,,,,,,,,,,,
GUIDEWIRE ORTHOPEDIC 0.8X100 MM TROCAR PT 1 END,SUP-2422315,CDM,C1769,HCPCS,0272,RC,,,,both,,,176.34,114.62,,,,,,,,,,,,,
APPLIER CLP M/L SHFT DIA5MM 15 LIG LIGAMAX 5,SUP-2218998,CDM,2720000010,LOCAL,0272,RC,,,,both,,,337.24,219.21,,,,,,,,,,,,,
COIL DETACH 10MM ID 30CM RESTRAINED NEXUS HELIX SUPERSOFT,SUP-2173641,CDM,C1889,HCPCS,0278,RC,,,,both,,,4461.94,2900.26,,,,,,,,,,,,,
KYPHOPLASTY KIT TROCAR 13 GA OSTEO INTRO BVL KYPHON V,SUP-2665005,CDM,C1713,HCPCS,0278,RC,,,,both,,,2147.76,1396.04,,,,,,,,,,,,,
SET VITALFLOW DISP W/BALANCE BIOSURFACE,SUP-2909521,CDM,2720000010,LOCAL,0272,RC,,,,both,,,30301.00,19695.65,,,,,,,,,,,,,
LINER EXT FIX LG SIDEKCK EZ FRAME,SUP-2484239,CDM,2720000010,LOCAL,0272,RC,,,,both,,,822.68,534.74,,,,,,,,,,,,,
PLATE BNE L142MM THK3.7MM 6 H NONSTERILE R DST MED TIB S,SUP-2185527,CDM,C1713,HCPCS,0278,RC,,,,both,,,3783.89,2459.53,,,,,,,,,,,,,
"HC So Surg Path, Consult, Slides",PX-3128832566,CDM,88325,CPT,0312,RC,,,,both,,,795.00,516.75,,,,,,,,,,,,,
PLATE BNE 110 DEG LNG BAR MINI RT CRANIOMAXILLOFACIAL L SHP,SUP-2883176,CDM,C1713,HCPCS,0278,RC,,,,both,,,1402.17,911.41,,,,,,,,,,,,,
INTRODUCER SHTH 8.5FR L63CM DIL 8.5FR L67CM GWIRE L180CM 407362,SUP-2357235,CDM,C1893,HCPCS,0272,RC,,,,both,,,507.74,330.03,,,,,,,,,,,,,
GUIDEWIRE ORTH L18IN DIA1.2MM FOR ACL PCL FIX SYS BIOSURE,SUP-2341765,CDM,C1769,HCPCS,0272,RC,,,,both,,,144.66,94.03,,,,,,,,,,,,,
VALVE HYDROCEPHALUS 20 A 2 PEDIATRIC WITH SHUNT ASSISTANT PR,SUP-2821856,CDM,C1889,HCPCS,0278,RC,,,,both,,,10012.96,6508.42,,,,,,,,,,,,,
CATHETER DIL L75CM BLLN L10CM DIA12FR BLLN HYDR+ HI PRSS,SUP-2139206,CDM,C1726,HCPCS,0272,RC,,,,both,,,864.54,561.95,,,,,,,,,,,,,
COMPONENT TOT HIP ONCOLOGY B-O1,SUP-2137346,CDM,C1776,CPT,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
GUIDEWIRE VASC INQWIRE L 210 CM DIA 0.035 IN TIP L 3 MM PTFE,SUP-2499040,CDM,C1769,HCPCS,0272,RC,,,,both,,,31.43,20.43,,,,,,,,,,,,,
RIVASTIGMINE 4.6 MG/24HR TD PT24,RX-82504,CDM,6370000000,HCPCS,0637,RC,00078-0501-61,NDC,,both,1,UN,102.90,66.88,,,,,,,,,,,,,
IMMUNE GLOBULIN (PRIVIGEN) 10%|DISCARDED DRUG NOT ADMINISTE,RX-4081762,CDM,J1459,HCPCS,0636,RC,44206-0437-10,NDC,JW,both,100,ML,5659.90,3678.93,,,,,,,,,,,,,
PLATE BNE L99MM 7 H BILAT MTPHSEAL S STL LOK COMPR LO PROF,SUP-2185100,CDM,C1713,HCPCS,0278,RC,,,,both,,,2437.52,1584.39,,,,,,,,,,,,,
LINER ACET HIP A-SERIES,SUP-2221814,CDM,C1776,CPT,0278,RC,,,,both,,,7.54,4.90,,,,,,,,,,,,,
PLATE BNE L336MM 16 H NONSTERILE R CNDYL S STL CRV LOK,SUP-2177863,CDM,C1713,HCPCS,0278,RC,,,,both,,,6377.34,4145.27,,,,,,,,,,,,,
INFUSION PUMP KIT PAIN 1 IN CTRL CATH PAINBUSTER ON-Q PM035] HALYARD SALES LLC FKA I-FLOW],SUP-2236843,CDM,C1713,HCPCS,0278,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
FLUOCINONIDE 0.05 % EX CREA,RX-3187,CDM,6370000000,HCPCS,0637,RC,69238-1534-05,NDC,,both,15,GR,65.70,42.70,,,,,,,,,,,,,
HC Inj Aa&/Strd Other Peripheral Nerve/Branch,PX-4506445000,CDM,64450,CPT,0450,RC,,,,both,,,2232.00,1450.80,,,,,,,,,,,,,
SALINE TEXT MAGNASITE ANATOMICIN EXP STYL 133 FILL VOL,SUP-2113320,CDM,C1789,HCPCS,0278,RC,,,,both,,,32.47,21.11,,,,,,,,,,,,,
CATHETER THORACENTESIS DRY SET 8.5 FRX6 CM 15 GA EMGCY,SUP-2759991,CDM,C1729,HCPCS,0272,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
CATHETER HEM DYLS OR HD CRV 12 FRX20 CM TRPL LUMEN,SUP-2283986,CDM,C1752,HCPCS,0278,RC,,,,both,,,304.86,198.16,,,,,,,,,,,,,
PEEK SWIVELOCK BICEPS TENO AR1662PSL710,SUP-2843734,CDM,C1713,HCPCS,0278,RC,,,,both,,,1271.70,826.60,,,,,,,,,,,,,
PLATE BNE L112MM WRST S STL STR LOK COMPR FOR FUS LCP,SUP-2177230,CDM,C1713,HCPCS,0278,RC,,,,both,,,4601.23,2990.80,,,,,,,,,,,,,
SPHERE EMB HYDROPEARL DIA 600 UM 2 ML PEG BIOCOMPATIBLE RED,SUP-2385597,CDM,C1889,HCPCS,0278,RC,,,,both,,,957.70,622.50,,,,,,,,,,,,,
CATHETER HD STR 15.5X28 CM LT DL STP BASIC SET HEMO-FLOW XF,SUP-2627239,CDM,C1750,HCPCS,0278,RC,,,,both,,,499.26,324.52,,,,,,,,,,,,,
ALLOGRAFT BNE PLUG 12 MM IRRADIATED,SUP-2867104,CDM,C1762,CPT,0278,RC,,,,both,,,1932.98,1256.44,,,,,,,,,,,,,
PROSTHESIS OSS 2-5.5 MM 1.5X2 MM 1.45 MM BOJRAB HA TI SIL,SUP-2490074,CDM,L8613,CPT,0278,RC,,,,both,,,1270.29,825.69,,,,,,,,,,,,,
SUPPORT ORTHOT ANK KNEE CUST SPRL MOLD TO PT PLAS,SUP-2435629,CDM,L1950,HCPCS,0274,RC,,,,both,,,2177.31,1415.25,,,,,,,,,,,,,
CATHETER PERFSN L 20 CM DIA 9 FR BLLN 9 MM POLYUR PRESHP,SUP-2881189,CDM,2720000010,LOCAL,0272,RC,,,,both,,,299.21,194.49,,,,,,,,,,,,,
INSERT TIB 1 2+ MM ANK TRABECULAR MTL PROLONG POLYETH,SUP-2470148,CDM,C1776,CPT,0278,RC,,,,both,,,4281.39,2782.90,,,,,,,,,,,,,
BLADE SAW NO2 W11.5XL12MM INT ORAL S STL UTTING DRL ACC,SUP-2367265,CDM,2720000010,LOCAL,0272,RC,,,,both,,,329.26,214.02,,,,,,,,,,,,,
ADAPTER ROD LNG 88MM,SUP-2704698,CDM,2720000010,LOCAL,0272,RC,,,,both,,,491.72,319.62,,,,,,,,,,,,,
SCREW BONE L9MM DIA2MM CRANIOMAXILLOFACIAL TI FOR MINI SYS,SUP-2262648,CDM,C1713,HCPCS,0278,RC,,,,both,,,109.77,71.35,,,,,,,,,,,,,
ANCHOR SUT DIA5.5MM BIOCRYL RAPIDE ABSRB 3 DYNACORD SZ 2,SUP-2256648,CDM,C1713,HCPCS,0278,RC,,,,both,,,2204.28,1432.78,,,,,,,,,,,,,
PLATE BNE HUM 88 MM LT DSTL 9 HOLE STRL LTX,SUP-2861613,CDM,C1713,HCPCS,0278,RC,,,,both,,,3318.29,2156.89,,,,,,,,,,,,,
LINER ACET C NEUT 32 MM HIP VIVACIT-E G7,SUP-2423974,CDM,C1776,CPT,0278,RC,,,,both,,,6148.12,3996.28,,,,,,,,,,,,,
PLATE BONE 2 H CRANIOMAXILLOFACIAL PURE TI STR FOR 1.3MM SCR,SUP-2190643,CDM,C1713,HCPCS,0278,RC,,,,both,,,124.34,80.82,,,,,,,,,,,,,
CATHETER BLLN 18 FR 16X34 MM TRI LOBE,SUP-2395625,CDM,C1725,HCPCS,0272,RC,,,,both,,,2050.42,1332.77,,,,,,,,,,,,,
STEM R120 MOD CEM SZ 2,SUP-2217519,CDM,C1776,CPT,0278,RC,,,,both,,,10977.44,7135.34,,,,,,,,,,,,,
BIT SURG DRL L17MM DIA2MM CANN W/ COUNTSINK FIXOS,SUP-2366052,CDM,2720000010,LOCAL,0272,RC,,,,both,,,785.63,510.66,,,,,,,,,,,,,
CATHETER PICC 5FR L55CM 17.5/17.5GA PEELABLE SHEATH/DILATOR,SUP-2118816,CDM,C1751,HCPCS,0278,RC,,,,both,,,1146.10,744.96,,,,,,,,,,,,,
COIL VASC INTERLOCK-35 L 40 CM DIA20 MM GUIDEWIRE 0.035 IN,SUP-2148129,CDM,C1889,HCPCS,0278,RC,,,,both,,,3155.70,2051.20,,,,,,,,,,,,,
WOOD ZRCH INTRRL DSTRCTR 10 15MM LFT T 6L 4V,SUP-2694290,CDM,C1713,HCPCS,0278,RC,,,,both,,,14252.11,9263.87,,,,,,,,,,,,,
SCREW BNE LCK 2.4X10 MM T7 DRVR STRL EVOS,SUP-2349399,CDM,C1713,HCPCS,0278,RC,,,,both,,,663.98,431.59,,,,,,,,,,,,,
DRILL SURG 2X95 MM,SUP-2766116,CDM,2720000010,LOCAL,0272,RC,,,,both,,,800.70,520.45,,,,,,,,,,,,,
METAL CANNULA X-LARGE HIP 5.0MM,SUP-2812750,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
COMPONENT FEM CRUC RET RT SZ 1 OXINIUM GEN II SMITH,SUP-2345845,CDM,C1776,CPT,0278,RC,,,,both,,,8209.53,5336.19,,,,,,,,,,,,,
CANNULA ENDOSCP W/O VLV 11 MMX15 CM LL W/45 STOPCOCK GRN WHT,SUP-2768024,CDM,2720000010,LOCAL,0272,RC,,,,both,,,934.62,607.50,,,,,,,,,,,,,
BIT DRL L110X85MM DIA2MM 2 FLUT MRK FOR QUIK CPL,SUP-2187312,CDM,2720000010,LOCAL,0272,RC,,,,both,,,301.91,196.24,,,,,,,,,,,,,
SCREW BONE L6MM PAN FIX LUHR,SUP-2364707,CDM,C1713,HCPCS,0278,RC,,,,both,,,132.13,85.88,,,,,,,,,,,,,
MATRIX PARTICULATE AMNIOBAND 160MG,SUP-2719487,CDM,Q4168,HCPCS,0636,RC,,,,both,,,8275.94,5379.36,,,,,,,,,,,,,
IMPLANT CRAN M CUST PEEK,SUP-2365128,CDM,C1713,HCPCS,0278,RC,,,,both,,,43306.25,28149.06,,,,,,,,,,,,,
HC NM Cardiac Muga Scan Gated Restin,PX-3417847200,CDM,78472,CPT,0341,RC,,,,outpatient,,,1924.00,1250.60,,,,,,,,,,,,,
SCREW BNE CANN 7X60 MM 16 MM THRD SS NS,SUP-2183893,CDM,C1713,HCPCS,0278,RC,,,,both,,,1102.14,716.39,,,,,,,,,,,,,
BLADE ES DIA4MM 90DEG ANG CONCAVE WIND CRV DIEGO,SUP-2313839,CDM,2720000010,LOCAL,0272,RC,,,,both,,,387.79,252.06,,,,,,,,,,,,,
PLATE BONE L86MM 4 H STRL LT LAT DSTL FIBULAR TI LCK COMPR,SUP-2177004,CDM,C1713,HCPCS,0278,RC,,,,both,,,2307.15,1499.65,,,,,,,,,,,,,
BEARING HUM DIA44-41MM +3MM OFFSET ARCOMXL FOR COMPHSVE REV,SUP-2409557,CDM,C1776,CPT,0278,RC,,,,both,,,2656.44,1726.69,,,,,,,,,,,,,
CAGE SPNL 30X25X16MM 12DEG,SUP-2353267,CDM,C1889,HCPCS,0278,RC,,,,both,,,31243.00,20307.95,,,,,,,,,,,,,
ENDOPROSTHESIS VASC VIABAHN L 2.5CM 13MM 120CM HEPARIN,SUP-2396586,CDM,C1874,HCPCS,0278,RC,,,,both,,,9715.16,6314.85,,,,,,,,,,,,,
STEM HUM INTERCALARY 30 MM ANTI-ROTATION REV SEG W/ SCREW,SUP-2442436,CDM,C1776,CPT,0278,RC,,,,both,,,17097.30,11113.24,,,,,,,,,,,,,
HC Glucose Tolerance Test,PX-3018295100,CDM,82951,CPT,0301,RC,,,,inpatient,,,445.00,289.25,,,,,,,,,,,,,
ANCHOR SUT 1.9 MM DIA NO 0 SUT ABSRB ANCHRLOC,SUP-2398002,CDM,C1713,HCPCS,0278,RC,,,,both,,,759.88,493.92,,,,,,,,,,,,,
DEVICE ARTOTMY CLOSURE MYNX ACE DIA 5/6/7 FR FEM ART GRP,SUP-2155682,CDM,C1760,HCPCS,0278,RC,,,,both,,,750.46,487.80,,,,,,,,,,,,,
STENT URET CNTOUR VL L 22-30 CM DIA 6 FR TIP L 5 CM SENSOR,SUP-2729976,CDM,C2617,HCPCS,0278,RC,,,,both,,,518.23,336.85,,,,,,,,,,,,,
SCREW BNE CANN SHT THRD 4X44 MM HD P2014044S] PARAGON 28],SUP-2320581,CDM,C1713,HCPCS,0278,RC,,,,both,,,989.10,642.91,,,,,,,,,,,,,
LINER ACET 40X27 MM SCR IN +5 RINGLOC+ MAX-ROM,SUP-2447215,CDM,C1776,CPT,0278,RC,,,,both,,,2458.62,1598.10,,,,,,,,,,,,,
NEUROSTIMULATOR EXT SM LTWT SGL BTTN H2O RESIST WIRELESS,SUP-2284422,CDM,C1897,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
SCREW BONE L40MM DIA3.5MM HD DIA6MM STD CORT TI ST SM HEX,SUP-2189860,CDM,C1713,HCPCS,0278,RC,,,,both,,,49.83,32.39,,,,,,,,,,,,,
BUR SURG L10CM DIA3MM MTCH HD FLUT SM BOR MIDAS REX LEGEND,SUP-2277620,CDM,2720000010,LOCAL,0272,RC,,,,both,,,296.89,192.98,,,,,,,,,,,,,
SCREW ACET LP 6.5X110 MM HIP SYS TI RINGLOK,SUP-2449908,CDM,C1713,HCPCS,0278,RC,,,,both,,,819.54,532.70,,,,,,,,,,,,,
TEMPLATE CLMP PEDIATRIC SANDWICH,SUP-2875762,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1783.52,1159.29,,,,,,,,,,,,,
DILATOR VASC L 12.5 CM DIA 3 FR SS STIFF STRL,SUP-2615885,CDM,C1894,HCPCS,0272,RC,,,,both,,,53.07,34.50,,,,,,,,,,,,,
CATHETER DRNGE 18GA L40CM 0.038IN HYDRPHLC 32 SIDEPRT,SUP-2168515,CDM,C1729,HCPCS,0272,RC,,,,both,,,277.51,180.38,,,,,,,,,,,,,
EXPANDER TISS 300CC P5.9CM W11XH10CM NACL STYL 133MX,SUP-2113152,CDM,C1789,HCPCS,0278,RC,,,,both,,,3548.20,2306.33,,,,,,,,,,,,,
KYPHOPLASTY TRAY 20/3 OSTEO INTRO W/ CDS KYPHOPAK XPANDER II,SUP-2632080,CDM,C1713,HCPCS,0278,RC,,,,both,,,12898.49,8384.02,,,,,,,,,,,,,
PLATE BNE 6 H LT PREBENT NS DISP TRAUMAONE CHAMPY,SUP-2934687,CDM,C1713,HCPCS,0278,RC,,,,both,,,1789.80,1163.37,,,,,,,,,,,,,
PATIENT ADMISSION KIT BRSH 3 MM PT SUPP,SUP-2356002,CDM,C1713,HCPCS,0278,RC,,,,both,,,38700.50,25155.32,,,,,,,,,,,,,
SET HAD CATH AD 14FR L30CM BASIC DBL LUMN DIL SCALP,SUP-2266999,CDM,C1751,HCPCS,0278,RC,,,,both,,,1460.10,949.06,,,,,,,,,,,,,
APPLIER CLP ENDOSCP MED 10 MMX11 IN TAKE APART HORZ MTL LIG,SUP-2656770,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3136.86,2038.96,,,,,,,,,,,,,
ESMOLOL HCL 100 MG/10ML IV SOLN,RX-82085,CDM,J1805,HCPCS,0636,RC,63323-0652-10,NDC,,both,0.5,ML,54.10,35.16,,,,,,,,,,,,,
HC Glucose Tolerance Test,PX-3018295100,CDM,82951,CPT,0301,RC,,,,outpatient,,,445.00,289.25,,,,,,,,,,,,,
GUIDEWIRE ORTH 3.2X300 MM,SUP-2646017,CDM,C1769,HCPCS,0272,RC,,,,both,,,540.08,351.05,,,,,,,,,,,,,
KIT CATH HEMODIALYSI GLIDEPATH CHRONIC EXCHANGE 14.5 5397270,SUP-2632954,CDM,C1750,HCPCS,0278,RC,,,,both,,,1341.88,872.22,,,,,,,,,,,,,
WEDGE ANK D16MM THK7.5MM COT TECH TI PORUS ANAT 3D OPN,SUP-2123094,CDM,C1713,HCPCS,0278,RC,,,,both,,,6264.30,4071.79,,,,,,,,,,,,,
KIT NEUROMODULATION NEXT GENERATION ANCHR CLIK,SUP-2138813,CDM,C1713,HCPCS,0278,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
BIT DRL DIA15/64IN PERIPH SHLDR ANTIROTATION PEG QUIK REL,SUP-2411554,CDM,2720000010,LOCAL,0272,RC,,,,both,,,550.13,357.58,,,,,,,,,,,,,
KIT CATH L11.5CM DIA9FR CTRL VEN POLYUR ANTIMIC COAT DBL,SUP-2383305,CDM,C1751,HCPCS,0278,RC,,,,both,,,416.36,270.63,,,,,,,,,,,,,
BOLT LOCKING HUMERAL ROD F/POLARUS HUMERAL ROD SYSTEM,SUP-2639961,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1058.18,687.82,,,,,,,,,,,,,
GUIDEWIRE ORTH L8IN,SUP-2137780,CDM,C1769,HCPCS,0272,RC,,,,both,,,166.42,108.17,,,,,,,,,,,,,
ALLOGRAFT BNE STRUT 15X100 MM FD TIB MATRIGRAFT,SUP-2740782,CDM,C1713,HCPCS,0278,RC,,,,both,,,1455.67,946.19,,,,,,,,,,,,,
TRAY PERCUTANEOUS INTRODUCE BL RHINO,SUP-2525924,CDM,C1769,HCPCS,0272,RC,,,,both,,,1303.10,847.01,,,,,,,,,,,,,
CABLE FBROPT SGL USE VEOA VEO,SUP-2164088,CDM,C1713,HCPCS,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
PLATE BONE 4 HOLE TITANIUM GRIDLOCK VLC PLATING SYSTEM FOR 2.4/3/4MM SCREW CUSTOM,SUP-2878334,CDM,C1713,HCPCS,0278,RC,,,,both,,,4019.20,2612.48,,,,,,,,,,,,,
HC NM Sest. Rest Stress Single,PX-3417845100,CDM,78451,CPT,0341,RC,,,,inpatient,,,3905.00,2538.25,,,,,,,,,,,,,
PROSTHESIS VOICE 12 MM LO PRESSURE KT,SUP-2246405,CDM,L8509,HCPCS,0272,RC,,,,both,,,285.74,185.73,,,,,,,,,,,,,
RING EXT FIX ID160MM ANK FT HALF FOR TRUELOK FRME ASSEMB,SUP-2316178,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1651.95,1073.77,,,,,,,,,,,,,
ADAPTER ORTH QC FOR 5 MM HALF PIN STRL,SUP-2749968,CDM,2720000010,LOCAL,0272,RC,,,,both,,,744.18,483.72,,,,,,,,,,,,,
COMPONENT FEM SZ 1 L KNEE OXINIUM POST STBL NP PRI STEMLESS,SUP-2346155,CDM,C1713,HCPCS,0278,RC,,,,both,,,10157.90,6602.63,,,,,,,,,,,,,
KNIFE SURG L188MM BAYNT FOR THOR LUM SYS,SUP-2284811,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1248.40,811.46,,,,,,,,,,,,,
DRILL TWST DIA1.7MM SPNL DISTRCTN CUT SHADOW-LINE,SUP-2161619,CDM,2720000010,LOCAL,0272,RC,,,,both,,,790.87,514.07,,,,,,,,,,,,,
KIT INTRO L 10 CM DIA 4 FR SS WIRE TUNGSTEN TIP MIC B BVL,SUP-2752618,CDM,C1894,HCPCS,0272,RC,,,,both,,,112.07,72.85,,,,,,,,,,,,,
SPACER 7771128 ELEV STD 28X11MM,SUP-2289152,CDM,C1713,HCPCS,0278,RC,,,,both,,,12089.00,7857.85,,,,,,,,,,,,,
CLIP IMPL BLADE L 7.5/6.7 MM MAXIMAL OPEN 5 MM CLS FORC FEN UP,SUP-2930704,CDM,C1889,HCPCS,0278,RC,,,,both,,,1588.15,1032.30,,,,,,,,,,,,,
GRAFT BONE SUBSTITUTE 2.5CC DEMINERALIZED BONE MATRIX PUTTY REVERSE PHASE M STIMUBLAST,SUP-2120745,CDM,C9359,HCPCS,0278,RC,,,,both,,,1243.44,808.24,,,,,,,,,,,,,
SET INSTR FOR SCR REM,SUP-2183079,CDM,C1713,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
SHEATH INTRO ARW GLIDETHRU L 7 CM DIA 5 FR DIL 5 FR POLYUR,SUP-2887199,CDM,C1894,HCPCS,0272,RC,,,,both,,,46.16,30.00,,,,,,,,,,,,,
BLADE SURG FOR ADENOTOMES WT540603,SUP-2649906,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1101.45,715.94,,,,,,,,,,,,,
GUIDEWIRE VASC L 150 CM DIA 0.035 IN TIP L 3 MM PTFE AMPLTZ,SUP-2117308,CDM,C1769,HCPCS,0272,RC,,,,both,,,45.53,29.59,,,,,,,,,,,,,
MARKER BRST BX L13CM SHP 2 SITE IDENTIFIER FOR EVIVA,SUP-2239978,CDM,A4648,CPT,0278,RC,,,,both,,,113.20,73.58,,,,,,,,,,,,,
LINER ACET ID32MM +3MM 10DEG L SER S-ROM,SUP-2253366,CDM,C1776,CPT,0278,RC,,,,both,,,4571.84,2971.70,,,,,,,,,,,,,
HC Caregiver Training Strategies&Tq 1st 30 Minutes,PX-4309755000,CDM,97550,CPT,0430,RC,,,,both,,,135.00,87.75,,,,,,,,,,,,,
K WIRE FIX L228MM DIA2MM S STL SMOOTH DBL END DBL SHRP TIP,SUP-2398088,CDM,C1713,HCPCS,0278,RC,,,,both,,,62.80,40.82,,,,,,,,,,,,,
SYRINGE MED CONE TIP 150 CC 3 RNG CTRL AUTOCLV FOR UROLOGY,SUP-2747412,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1702.79,1106.81,,,,,,,,,,,,,
CATHETER HD PRE CRV 15.5 FRX32 CM SIDE H FULL SET TITAN HD,SUP-2268418,CDM,C1881,HCPCS,0278,RC,,,,both,,,580.90,377.58,,,,,,,,,,,,,
CHOLANGIOGRAM KIT RX AUTOTOME UTOM XL SPHINTOM JAGWIRE 7532,SUP-2525328,CDM,C1769,HCPCS,0272,RC,,,,both,,,726.60,472.29,,,,,,,,,,,,,
TUBE TRACHEOSTOMY REGULAR ADULT 9.9MM SILVER FENESTRATED UNC,SUP-2793416,CDM,2720000010,LOCAL,0272,RC,,,,both,,,173.74,112.93,,,,,,,,,,,,,
COMPONENT TIB TY 6 LT TOT ANK INBONE,SUP-2850351,CDM,C1776,CPT,0278,RC,,,,both,,,3771.14,2451.24,,,,,,,,,,,,,
ALLOGRAFT BNE 80 MM FD IRRADIATED WHL RIB,SUP-2866914,CDM,C1762,CPT,0278,RC,,,,both,,,1404.99,913.24,,,,,,,,,,,,,
SCREW BNE L12MM DIA13MM GRN CORT TI ALLY ST SELF RET W T4,SUP-2180979,CDM,C1713,HCPCS,0278,RC,,,,both,,,364.96,237.22,,,,,,,,,,,,,
COMPONENT SHLDR SHT GLEN ST REVERSED 1ST XLPE COMPHSVE,SUP-2212458,CDM,C1776,CPT,0278,RC,,,,both,,,26690.00,17348.50,,,,,,,,,,,,,
Z DUP USE 2111568 LENS INTOCU +20.5 DIOPT CYL PWR +1.50 DIOPT L13MM DIA6MM,SUP-2111569,CDM,V2787,HCPCS,0276,RC,,,,both,,,390.00,253.50,,,,,,,,,,,,,
ROD ORTH THRD 150 MM PILLAR,SUP-2749919,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1620.24,1053.16,,,,,,,,,,,,,
PERI-LOC 4.5MM T25 LOCK SCREW 125MM S-T,SUP-2820251,CDM,C1713,HCPCS,0278,RC,,,,both,,,1541.17,1001.76,,,,,,,,,,,,,
RULER SURG FEM XR S2,SUP-2473062,CDM,2720000010,LOCAL,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
SCREW SPNL FIX ANGLE 4.5X13 MM ANTR CERV TI TETH,SUP-2379308,CDM,C1713,HCPCS,0278,RC,,,,both,,,866.64,563.32,,,,,,,,,,,,,
KIT CAGE SPINAL APREVO 1-LEVEL,SUP-2912822,CDM,C1889,HCPCS,0278,RC,,,,both,,,81640.00,53066.00,,,,,,,,,,,,,
SCREW BNE L10MM DIA2MM STD TI CORT MAND CRANIOMAXILLOFACIAL,SUP-2319343,CDM,C1713,HCPCS,0278,RC,,,,both,,,107.39,69.80,,,,,,,,,,,,,
FIBER LASER HOLM 365 M FOR USE W/ H-30 RED SMARTSYNC DISP,SUP-2835944,CDM,2720000010,LOCAL,0272,RC,,,,both,,,999.49,649.67,,,,,,,,,,,,,
OLECRANON TRIAL 10 HOLE/LEFT,SUP-2484761,CDM,C1713,HCPCS,0278,RC,,,,both,,,877.44,570.34,,,,,,,,,,,,,
PLATE BNE W13.5XL296MM THK4.2MM 16 H BILAT S STL NAR LOK,SUP-2185256,CDM,C1713,HCPCS,0278,RC,,,,both,,,2221.42,1443.92,,,,,,,,,,,,,
COMPONENT TOT SHLDR CAPPED AB GLEN COMPHSVE REVERSED,SUP-2212454,CDM,C1776,CPT,0278,RC,,,,both,,,9184.50,5969.92,,,,,,,,,,,,,
GUIDEWIRE VASC LAUREATE L 180 CM DIA 0.038 IN NIT ANGLED,SUP-2457657,CDM,C1769,HCPCS,0272,RC,,,,both,,,100.48,65.31,,,,,,,,,,,,,
KIT TKR CEM FEM CEM TIB VIT E SURF NO PAT PERSONA,SUP-2212226,CDM,C1776,CPT,0278,RC,,,,both,,,13542.82,8802.83,,,,,,,,,,,,,
PLATE BNE TI MIDFACE RECON 4 PLATE CUSTOMIZED FACE ID,SUP-2883691,CDM,C1713,HCPCS,0278,RC,,,,both,,,38109.18,24770.97,,,,,,,,,,,,,
APPLIER CLP FOR RAPIDLOC MENIS REP,SUP-2249478,CDM,C1713,HCPCS,0278,RC,,,,both,,,602.88,391.87,,,,,,,,,,,,,
LIDOCAINE-PRILOCAINE 2.5-2.5 % EX CREA,RX-10434,CDM,6370000000,HCPCS,0637,RC,81033-0025-50,NDC,,both,1,GR,16.20,10.53,,,,,,,,,,,,,
STEM FEM REV 145 DEG 12/14 14X385 MM HIP TAPR WAGNER SL,SUP-2206040,CDM,C1776,CPT,0278,RC,,,,both,,,19001.71,12351.11,,,,,,,,,,,,,
PLATE SPNL L6MM FULL TI STD ALONE INTBDY FUS SYS ALTA,SUP-2211549,CDM,C1713,HCPCS,0278,RC,,,,both,,,5966.00,3877.90,,,,,,,,,,,,,
HC Hip Dislocation Reduction,PX-4502725000,CDM,27250,CPT,0450,RC,,,,outpatient,,,383.00,248.95,,,,,,,,,,,,,
SCREW INTRF 8X25 MM ROUNDED EDGE FT PEEK OPTMA,SUP-2762241,CDM,C1713,HCPCS,0278,RC,,,,both,,,728.48,473.51,,,,,,,,,,,,,
EVOS VOL PLATE 5H LEFT WDE TI 83MM NS,SUP-2818938,CDM,C1713,HCPCS,0278,RC,,,,both,,,7995.23,5196.90,,,,,,,,,,,,,
HC Neg Pressure Wnd > 50 Sq Cm Disposable,PX-7619760800,CDM,97608,CPT,0761,RC,,,,both,,,813.00,528.45,,,,,,,,,,,,,
PLATE BNE L 150 X W 15 MM THK 1.4 MM SCREW DIA2.2 MM 8 H PLL,SUP-2883306,CDM,C1713,HCPCS,0278,RC,,,,both,,,35034.96,22772.72,,,,,,,,,,,,,
IMMOBILIZER KNEE AD L19IN FOR UP TO 27IN THGH UNIV FOAM NYL,SUP-2205521,CDM,L1830,CPT,0274,RC,,,,both,,,171.44,111.44,,,,,,,,,,,,,
PLATE BNE RECON 3.5 MM 8 HOLE STR STRL LTX,SUP-2861618,CDM,C1713,HCPCS,0278,RC,,,,both,,,795.61,517.15,,,,,,,,,,,,,
DRILL SURG STP 10 MM PATELLAR KNEE I/B II,SUP-2437038,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1102.14,716.39,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 70 CM DIA 8MM STR REINF SLDE GDS,SUP-2525459,CDM,C1768,CPT,0278,RC,,,,both,,,1885.76,1225.74,,,,,,,,,,,,,
BLADE SAW KNEE 12.7MM CUT EDGE 86MM CUT DEPTH 1.19MM CUT THC,SUP-2586349,CDM,2720000010,LOCAL,0272,RC,,,,both,,,212.26,137.97,,,,,,,,,,,,,
TRAY PICC 6FR POLYUR FULL TRIM LEN DBL LUMN PWR INJ PASV VLV,SUP-2126389,CDM,C1751,HCPCS,0278,RC,,,,both,,,646.97,420.53,,,,,,,,,,,,,
SYSTEM STNT INTRO CATH PUSH 9FR GUID 5.5FR L195CM 0.035IN,SUP-2170076,CDM,C1874,HCPCS,0278,RC,,,,both,,,351.68,228.59,,,,,,,,,,,,,
PLATE BNE BROAD 4.5X231 MM 14 HOLE SS DCP,SUP-2569180,CDM,C1713,HCPCS,0278,RC,,,,both,,,490.47,318.81,,,,,,,,,,,,,
PIN DRL DIA1.5MM FOR BICEPTOR TENODESIS SYS TEND SHLDR,SUP-2341815,CDM,C1769,HCPCS,0272,RC,,,,both,,,383.99,249.59,,,,,,,,,,,,,
HC Circumcision W/Clamp/Oth Dev W/Block,PX-3615415000,CDM,54150,CPT,0361,RC,,,,outpatient,,,900.00,585.00,,,,,,,,,,,,,
CATHETER URETH MEAS 4FR L50CM INFLATED BLLN 75FR 12CC,SUP-2138933,CDM,C1758,HCPCS,0278,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
IMPLANT BIO TISS M CLLGN SCFLD FOR ARTHSCP REGENETEN,SUP-2334693,CDM,C1763,HCPCS,0278,RC,,,,both,,,6970.80,4531.02,,,,,,,,,,,,,
PLATE BNE DBL Y NEURO ULTRA LO PROF W/ TAB TI LEVEL 1 LF,SUP-2457627,CDM,C1713,HCPCS,0278,RC,,,,both,,,823.59,535.33,,,,,,,,,,,,,
PLATE BNE LAPIDUS LT DORS MEDL STRATUM,SUP-2459144,CDM,C1713,HCPCS,0278,RC,,,,both,,,5627.51,3657.88,,,,,,,,,,,,,
BASKET SPEC RETRV L120CM OD12MM PTFE PULM DISPOSABLE ZEROTIP,SUP-2141361,CDM,2720000010,LOCAL,0272,RC,,,,both,,,809.24,526.01,,,,,,,,,,,,,
GUIDEWIRE VASC SPECTRE L 300 CM DIA 0.014 IN RADIOPAQUE TIP,SUP-2763459,CDM,C1769,HCPCS,0272,RC,,,,both,,,521.24,338.81,,,,,,,,,,,,,
CATHETER ETER HAD 155FR L32CM 3 LUMN STR EXTN SHT TERM T 3,SUP-2269525,CDM,C1752,HCPCS,0278,RC,,,,both,,,285.74,185.73,,,,,,,,,,,,,
STAPLE BNE FIX BRIDGE L 18 X 18 X W 4 MM MAX NIT LP NS REFLX,SUP-2896875,CDM,C1713,HCPCS,0278,RC,,,,both,,,4078.86,2651.26,,,,,,,,,,,,,
SCREW BNE L45MM DIA5.5MM FT ANK HDLSS COMPR SYS ACUTRK 2,SUP-2106630,CDM,C1713,HCPCS,0278,RC,,,,both,,,1466.38,953.15,,,,,,,,,,,,,
TRAY CATH MIDLN PROVENA MAXBARR 4FR 20CM 2 LUMAN S4254108DG,SUP-2632867,CDM,C1751,HCPCS,0278,RC,,,,both,,,524.38,340.85,,,,,,,,,,,,,
BIT DRL 3 MM LEVERAGE,SUP-2311373,CDM,2720000010,LOCAL,0272,RC,,,,both,,,800.70,520.45,,,,,,,,,,,,,
STENT GRFT VASC POWERLINK INTUITRAK L 95 MM L 75 MM 28 MM,SUP-2217581,CDM,C1768,CPT,0278,RC,,,,both,,,9718.30,6316.89,,,,,,,,,,,,,
BUR SURG 4MMDIA 8MML LNG FLUT DR FOR TPS MIDAS REX UPWR,SUP-2363366,CDM,2720000010,LOCAL,0272,RC,,,,both,,,355.23,230.90,,,,,,,,,,,,,
IMPLANT FEM 10X24MM W INSRT AFX,SUP-2402820,CDM,C1713,HCPCS,0278,RC,,,,both,,,3404.26,2212.77,,,,,,,,,,,,,
NAIL IM L320MM DIA11MM 130DEG ST GRN FEM TI LOK UNREAMED AG,SUP-2192564,CDM,C1713,HCPCS,0278,RC,,,,both,,,3888.32,2527.41,,,,,,,,,,,,,
HC Echo Exam Uterus,PX-4027683100,CDM,76831,CPT,0402,RC,,,,both,,,959.00,623.35,,,,,,,,,,,,,
KIT CTRL VEN CATH L13CM DIA12FR BLU DBL LUMN BEND FLEXTIP,SUP-2383356,CDM,C1750,HCPCS,0278,RC,,,,both,,,383.08,249.00,,,,,,,,,,,,,
PACK FIXATION LAPIPLASTY LESSER TMT,SUP-2652625,CDM,C1713,HCPCS,0278,RC,,,,both,,,5827.84,3788.10,,,,,,,,,,,,,
SCREW BNE L34MM DIA3.5MM CO CHROM ST LOK FULL THRD SQ DRV,SUP-2413771,CDM,C1713,HCPCS,0278,RC,,,,both,,,872.92,567.40,,,,,,,,,,,,,
ALLOGRAFT BNE FILL 1-8 MM 2.5 CC FD SPNG CANC READIGRAFT BLX,SUP-2740802,CDM,C1713,HCPCS,0278,RC,,,,both,,,753.63,489.86,,,,,,,,,,,,,
PLATE BONE L120.5MM 7 H LT DSTL FIB TI ANAT FOR,SUP-2225371,CDM,C1713,HCPCS,0278,RC,,,,both,,,5796.13,3767.48,,,,,,,,,,,,,
SMALL FRAGMENT WASHER,SUP-2829381,CDM,C1713,HCPCS,0278,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
SCREW CONN S STL STARDRV FOR LOK ATTCH PLT,SUP-2177788,CDM,C1713,HCPCS,0278,RC,,,,both,,,442.52,287.64,,,,,,,,,,,,,
PLATE BNE L MINI LNG 2-2.5 MM RT 3X2 HOLE LCK PEREZ TI,SUP-2464369,CDM,C1713,HCPCS,0278,RC,,,,both,,,1451.09,943.21,,,,,,,,,,,,,
GUIDEWIRE VASC IQ L 300 CM DIA 0.014 IN SIL STR TIP STRL,SUP-2140696,CDM,C1769,HCPCS,0272,RC,,,,both,,,52.12,33.88,,,,,,,,,,,,,
SCREW SPNL L 30 MM DIA 5.5 MM SHANK MDX OSTEOGRIP NS CD HORZ,SUP-2925161,CDM,C1713,HCPCS,0278,RC,,,,both,,,1444.40,938.86,,,,,,,,,,,,,
ARTICULAR SURF TIB H 18 MM SZ TIB G-H FEM 10-12 VIVACIT-E RT,SUP-2894089,CDM,C1889,HCPCS,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
HC Cytology Consult.,PX-3118810400,CDM,88104,CPT,0311,RC,,,,both,,,146.00,94.90,,,,,,,,,,,,,
CUP ACET OD53MM ID32MM LONGEVITY CEM SNAP IN SPCR PRI ZCA,SUP-2203802,CDM,C1776,CPT,0278,RC,,,,both,,,8551.79,5558.66,,,,,,,,,,,,,
TUBE TELSCP T14 ANG LEGEND,SUP-2281700,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2532.54,1646.15,,,,,,,,,,,,,
WASHER ORTH FOREFOOT MIDFOOT 2.2/2.7 MM SCR TI TOT FT SYS 2,SUP-2609139,CDM,C1713,HCPCS,0278,RC,,,,both,,,532.17,345.91,,,,,,,,,,,,,
ALLOGRAFT BNE LORDTC 7 DEG 12X14.5X9.2X7.75 MM FD VERTIGRAFT,SUP-2264912,CDM,C1713,HCPCS,0278,RC,,,,both,,,2919.89,1897.93,,,,,,,,,,,,,
DRILL SURGICAL DIA55MM CANNULATED NFORCE,SUP-2588966,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1222.72,794.77,,,,,,,,,,,,,
SCREW BNE L14MM DIA3.5MM CORT S STL ST NONCANNULATED LOK,SUP-2183575,CDM,C1713,HCPCS,0278,RC,,,,both,,,66.60,43.29,,,,,,,,,,,,,
SPREADER SURG L6 1 2IN S STL MATTE FINISH LAM INGE,SUP-2161220,CDM,2720000010,LOCAL,0272,RC,,,,both,,,502.90,326.88,,,,,,,,,,,,,
MENISCAL REPAIR SET RVS CRV INSRTR NDL BENDR FAST-FIX FLX,SUP-2835337,CDM,C1713,HCPCS,0278,RC,,,,both,,,1648.50,1071.52,,,,,,,,,,,,,
RESERVOIR PENILE PROS 75CC CLVRLF W/ LOK OUT VLV TI,SUP-2165443,CDM,C1813,HCPCS,0278,RC,,,,both,,,8895.62,5782.15,,,,,,,,,,,,,
CAGE ACET OD60MM ID57MM R TI RECON PROTRUSIO,SUP-2249681,CDM,C1776,CPT,0278,RC,,,,both,,,6174.50,4013.42,,,,,,,,,,,,,
ANCHOR SUTURE 6.5MM WITH 2 SUTURES HI-FI NEEDLE GENESYS CROS,SUP-2824355,CDM,C1713,HCPCS,0278,RC,,,,both,,,1618.92,1052.30,,,,,,,,,,,,,
SHEATH LD INTRO SAFSHTH ULTRA L 23 CM DIA 7 FR GUIDEWIRE L,SUP-2159481,CDM,C1892,HCPCS,0272,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
ALLOGRAFT HUM TISS FRZN IRRADIATED BONE-PATELLAR TENDON-BONE,SUP-2867182,CDM,C1762,CPT,0278,RC,,,,both,,,10500.16,6825.10,,,,,,,,,,,,,
BASEPLATE TIB SZ 6 RT CEM PRI STEM NP PROFIX,SUP-2347035,CDM,C1776,CPT,0278,RC,,,,both,,,5337.22,3469.19,,,,,,,,,,,,,
TUBE ENDOSCP 25 CM LEN 19.5 MM OD 16.7 MM ID W/ TAPR TIP,SUP-2416284,CDM,2720000010,LOCAL,0272,RC,,,,both,,,541.65,352.07,,,,,,,,,,,,,
RING FIX MODULAR EXTERNAL FIXATION KIT SET 1 2,SUP-2473119,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
IMPLANT SYNTH L 76 X W 50 MM THK 1.5 MM POLYETHYL,SUP-2883545,CDM,C1713,HCPCS,0278,RC,,,,both,,,1890.28,1228.68,,,,,,,,,,,,,
CONNECTOR SPNL M SZ 7 L37-45MM STD POST LUM THOR TI SCR,SUP-2254362,CDM,C1713,HCPCS,0278,RC,,,,both,,,499.26,324.52,,,,,,,,,,,,,
SCREW BNE 4.5X55 MM N LCK,SUP-2606638,CDM,C1713,HCPCS,0278,RC,,,,both,,,191.35,124.38,,,,,,,,,,,,,
TAP SURG L8MM QUIK CONN FOR SREW INTRF BIOCOMP,SUP-2121645,CDM,C1713,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
PLATE BNE LCK UNIV 2.7X49 MM 4 HOLE CONTOURED 2 COMPR,SUP-2462601,CDM,C1713,HCPCS,0278,RC,,,,both,,,786.57,511.27,,,,,,,,,,,,,
BLADE SAW W049XL295IN THK005IN CUT THK0057IN REPL SAG W,SUP-2150372,CDM,2720000010,LOCAL,0272,RC,,,,both,,,53.38,34.70,,,,,,,,,,,,,
CANNULA SUCT L165CM M STD TIP MAL,SUP-2280210,CDM,2720000010,LOCAL,0272,RC,,,,both,,,943.88,613.52,,,,,,,,,,,,,
FUROSEMIDE 20 MG PO TABS,RX-3294,CDM,6370000000,HCPCS,0637,RC,00904-7177-61,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
CATHETER CARD ABLATION BLZR PRIM HTD L 110 CM DIA 7 FR TIP 4,SUP-2141342,CDM,C1731,HCPCS,0278,RC,,,,both,,,3309.56,2151.21,,,,,,,,,,,,,
LINER ACET OD70MM ID28MM THK15.3MM 0DEG HIP POLYETH MTL MOD,SUP-2202064,CDM,C1776,CPT,0278,RC,,,,both,,,2245.10,1459.31,,,,,,,,,,,,,
SLING GYN TROCAR DIA2.8 MM INTRO 58 DEG POLYPRO BLU,SUP-2929649,CDM,C1771,HCPCS,0278,RC,,,,both,,,3874.76,2518.59,,,,,,,,,,,,,
DRIVER SURG DIA3.5MM FOR HDLSS COMPR SCR SYS REDUCT,SUP-2340186,CDM,C1713,HCPCS,0278,RC,,,,both,,,541.65,352.07,,,,,,,,,,,,,
TRANEXAMIC ACID 650 MG PO TABS,RX-103146,CDM,6370000000,HCPCS,0637,RC,00591-3720-30,NDC,,both,1,UN,18.80,12.22,,,,,,,,,,,,,
PLATE BNE LCK 3.5 MM 9 HOLE COMPR STRL ALPS LTX,SUP-2861818,CDM,C1713,HCPCS,0278,RC,,,,both,,,1009.07,655.90,,,,,,,,,,,,,
CATHETER HD TEMP 14 FRX20 CM,SUP-2217983,CDM,C1752,HCPCS,0278,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
BASKET STONE 3FR L90CM 16MM 4 WIR FLATWIRE SURLOK,SUP-2312749,CDM,2720000010,LOCAL,0272,RC,,,,both,,,420.70,273.45,,,,,,,,,,,,,
CATHETER CV MAXIMAL BARR TY 025 5 FRX12 CM 16 GA 3L SPECTRUM,SUP-2759898,CDM,C1751,HCPCS,0278,RC,,,,both,,,583.38,379.20,,,,,,,,,,,,,
IMPLANT H11MM SCR 1 5.5X30MM AND TWO 5.5X25MM INTERVERTEBRAL,SUP-2163228,CDM,C1713,HCPCS,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
SET CATH L35CM OD3.4MM ID1.9MM VENT BACTISEAL STYL CONN CAP,SUP-2243802,CDM,C1729,HCPCS,0272,RC,,,,both,,,2308.12,1500.28,,,,,,,,,,,,,
IOPAMIDOL 61 % IJ SOLN,RX-10327,CDM,Q9967,HCPCS,0636,RC,00270-1412-15,NDC,,both,15,ML,47.30,30.74,,,,,,,,,,,,,
HC Puncture Aspir Cyst-Breast,PX-3611900000,CDM,19000,CPT,0361,RC,,,,outpatient,,,3707.00,2409.55,,,,,,,,,,,,,
RELOAD STPL L45MM M THICK TISS PUR REINF ARTC INTELLIGENCE,SUP-2283374,CDM,2720000010,LOCAL,0272,RC,,,,both,,,955.09,620.81,,,,,,,,,,,,,
MESH BONE SIZE 1 06MM THK TTNM CNTRD STNDRD LATEX FREE ST B,SUP-2676601,CDM,C1713,HCPCS,0278,RC,,,,both,,,8732.43,5676.08,,,,,,,,,,,,,
TOUMA VENT TUBE W TAB 1.14MM ID SILICONE 5 PACK,SUP-2669496,CDM,L8699,HCPCS,0278,RC,,,,both,,,43.99,28.59,,,,,,,,,,,,,
BIT DRL L465MM DIA12MM CANN FLX L QUIK CPL FOR TIB NAIL,SUP-2178845,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1684.33,1094.81,,,,,,,,,,,,,
KIT LASER L45CM 0.035IN NDL 21GA GRP GLD TIP FRS FBR,SUP-2118072,CDM,C1713,HCPCS,0278,RC,,,,both,,,921.75,599.14,,,,,,,,,,,,,
INTRODUCER KYPHOPLASTY SZ 3 8GA 42MM OSTEO KYPHON ADV,SUP-2281649,CDM,C1894,HCPCS,0272,RC,,,,both,,,3061.50,1989.97,,,,,,,,,,,,,
DEVICE FIX SUT BAR DBL FOR MENIS REP SYS FAST-FIX,SUP-2341340,CDM,C1713,HCPCS,0278,RC,,,,both,,,392.34,255.02,,,,,,,,,,,,,
SCREW BNE LCK UNIV 2.7X34 MM TI STRL,SUP-2458163,CDM,C1713,HCPCS,0278,RC,,,,both,,,341.54,222.00,,,,,,,,,,,,,
PLATE BONE L156MM THK3MM 9 H TI TIM RT DSTL ANTEROLATERAL,SUP-2413680,CDM,C1713,HCPCS,0278,RC,,,,both,,,4956.49,3221.72,,,,,,,,,,,,,
PIN FXTN L229MM D48MM STNLSS STEEL 5 TRCR POINT SNGLE SHARP,SUP-2499238,CDM,C1713,HCPCS,0278,RC,,,,both,,,53.82,34.98,,,,,,,,,,,,,
HC Fresh Plasma 24hrs,PX-3900905900,CDM,P9059,HCPCS,0390,RC,,,,outpatient,,,491.00,319.15,,,,,,,,,,,,,
INTRODUCER SHTH GUID 0.038 IN 7 FRX45 CM DIL PINNACLE,SUP-2141015,CDM,C1894,HCPCS,0272,RC,,,,both,,,357.18,232.17,,,,,,,,,,,,,
NAIL IM 130 DEG L 24 CM DIA11.5 MM FEM STRL INTERTAN,SUP-2931206,CDM,C1713,HCPCS,0278,RC,,,,both,,,6848.18,4451.32,,,,,,,,,,,,,
COVER BURR H DIA20 MM THK 0.5 MM TI CRANIOFACIAL PLATE SHUNT,SUP-2883645,CDM,C1713,HCPCS,0278,RC,,,,both,,,979.43,636.63,,,,,,,,,,,,,
ANCHOR SUT 5MM DIA 2 SUT ABSRB W/ NDL TI DURABRAID TWINFIX,SUP-2341046,CDM,C1713,HCPCS,0278,RC,,,,both,,,848.99,551.84,,,,,,,,,,,,,
REAMER SURG DIA85MM CANN HD FOR AC GRAFTROPE SYS,SUP-2121243,CDM,C1713,HCPCS,0278,RC,,,,both,,,675.10,438.81,,,,,,,,,,,,,
WEDGE ENOPHTHALMOS W22XL31MM THK7MM L POLYETH REG MEDPOR,SUP-2366496,CDM,C1713,HCPCS,0278,RC,,,,both,,,1847.07,1200.60,,,,,,,,,,,,,
KIT INTRO GLIDESHEATH L 10 CM OD 5FR ID 0.074IN 0.021IN,SUP-2385317,CDM,C1894,HCPCS,0272,RC,,,,both,,,305.27,198.43,,,,,,,,,,,,,
CLAMP EXT FIX SINGLE UNIV GEM FIX NS GALAXY LTX,SUP-2875226,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2778.71,1806.16,,,,,,,,,,,,,
VINORELBINE TARTRATE 10 MG/ML IV SOLN (MIXTURES ONLY),RX-430027,CDM,J9390,HCPCS,0636,RC,25021-0204-01,NDC,,both,1,ML,72.00,46.80,,,,,,,,,,,,,
ELECTRODE VPR M LOOP FOR 30DEG TELESCOPES PLASMABUTTON,SUP-2313582,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1416.83,920.94,,,,,,,,,,,,,
SHEATH INTRO PRELUDE L 11 CM DIA 8 FR POLYPRO TBNG,SUP-2474125,CDM,C1894,HCPCS,0272,RC,,,,both,,,68.92,44.80,,,,,,,,,,,,,
MESH SURG 25X20 CM BIOMATERIAL PREPERITONEAL ENFORM,SUP-2435400,CDM,C1781,HCPCS,0278,RC,,,,both,,,20890.42,13578.77,,,,,,,,,,,,,
IMPLANT FNGR JT 20 SIL PYROCARBON TRANSFORMING EXTREMITIES,SUP-2123858,CDM,C1776,CPT,0278,RC,,,,both,,,5667.70,3684.00,,,,,,,,,,,,,
POLATUZUMAB VEDOTIN-PIIQ 30 MG IV SOLR,RX-151949,CDM,J9309,HCPCS,0636,RC,50242-0103-01,NDC,,both,1,UN,11486.00,7465.90,,,,,,,,,,,,,
CALCIUM CARBONATE ANTACID 1250 MG/5ML PO SUSP,RX-138274,CDM,340b,HCPCS,0637,RC,00121-4766-05,NDC,,both,5,ML,11.60,7.54,,,,,,,,,,,,,
ELSA SPCR 20X50MM 11-20MM 15-30 DEG,SUP-2228778,CDM,C1821,HCPCS,0278,RC,,,,both,,,29202.00,18981.30,,,,,,,,,,,,,
INJECTOR UTER AIR BUB BASE W/ H/S ELLIPTOSPHERE CATH ABBI,SUP-2756089,CDM,2720000010,LOCAL,0272,RC,,,,both,,,330.83,215.04,,,,,,,,,,,,,
PLATE BNE CORONOID EXT RT ELBW LCK TI,SUP-2518745,CDM,C1713,HCPCS,0278,RC,,,,both,,,3896.74,2532.88,,,,,,,,,,,,,
CATHETER THROMBS RETRV ERIC L 20 MM DIA 3 MM DSTL TIP L 5 MM,SUP-2898705,CDM,C1757,HCPCS,0272,RC,,,,both,,,20017.50,13011.37,,,,,,,,,,,,,
CATHETER GUID OUTBACK LTD L 120 CM SHTH 6 FR CROSSING PROF,SUP-2155728,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6594.00,4286.10,,,,,,,,,,,,,
SCREW BONE L90MM DIA6.3MM TI PARTIALLY THRD NAILING SYS,SUP-2412905,CDM,C1713,HCPCS,0278,RC,,,,both,,,678.24,440.86,,,,,,,,,,,,,
COMPONENT ULN SM L4.5IN LNG LT ELBW TIV PLSM INTERCHANGEABLE,SUP-2205940,CDM,C1776,CPT,0278,RC,,,,both,,,11153.28,7249.63,,,,,,,,,,,,,
SPLINT ORTHOPEDIC PADDED FOAM PERF ALUM,SUP-2195267,CDM,L3931,HCPCS,0272,RC,,,,both,,,27.82,18.08,,,,,,,,,,,,,
TIP CEMENT 90X6 MM OSTEO WDG TI STRL OSCAR PRO LTX,SUP-2875657,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4317.66,2806.48,,,,,,,,,,,,,
COIL EMB L8CM DIA4MM STD PUSH DSGN USE ACE TRK TECHNOLOGY,SUP-2323494,CDM,C1889,HCPCS,0278,RC,,,,both,,,5338.00,3469.70,,,,,,,,,,,,,
PIN FIX L40MM DIA2.7MM PROV FOR TARGETER PLATING SYS,SUP-2343985,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1541.17,1001.76,,,,,,,,,,,,,
THIORIDAZINE HCL 25 MG PO TABS,RX-7899,CDM,6370000000,HCPCS,0637,RC,51079-0566-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
CAGE SPNL MESH 15X12X15 MM 6 LOBE,SUP-2602074,CDM,C1889,HCPCS,0278,RC,,,,both,,,8302.16,5396.40,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE 30 CC CORTICAL FIBER,SUP-2899200,CDM,C1713,HCPCS,0278,RC,,,,both,,,15499.83,10074.89,,,,,,,,,,,,,
CLAV SUP NRW LT 10H 100MM NS,SUP-2467892,CDM,C1713,HCPCS,0278,RC,,,,both,,,4248.42,2761.47,,,,,,,,,,,,,
"HC Insert Picc Cath, 5/> Yrs",PX-3613656900,CDM,36569,CPT,0361,RC,,,,both,,,1231.00,800.15,,,,,,,,,,,,,
CATHETER IV DL 5 FR DOT KT MBP GIVA PC NG POWERMIDLINE,SUP-2626742,CDM,C1751,HCPCS,0278,RC,,,,both,,,533.80,346.97,,,,,,,,,,,,,
ALLOGRAFT DERMAL HUM TISS SM 4X1 CMX0.23-0.51 MM ALLDERM,SUP-2468452,CDM,Q4116,HCPCS,0636,RC,,,,both,,,411.34,267.37,,,,,,,,,,,,,
NEEDLE INJ BNE GRFT 11 GAX6 IN IMBIBE 20909028,SUP-2531428,CDM,2720000010,LOCAL,0272,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
GUIDEWIRE VASC L 230 MM DIA1.4 MM FOR TERRA NOVAL MI,SUP-2734732,CDM,C1769,HCPCS,0272,RC,,,,both,,,279.77,181.85,,,,,,,,,,,,,
SPLINT ORTHOPEDIC PADDED FOAM PERF ALUM,SUP-2195267,CDM,L3931,HCPCS,0274,RC,,,,both,,,27.82,18.08,,,,,,,,,,,,,
PLATE BNE X SM 2.4/2.7X24X18 MM LCK SS STRL,SUP-2863363,CDM,C1713,HCPCS,0278,RC,,,,both,,,2533.73,1646.92,,,,,,,,,,,,,
CATHETER EP 6FR L115CM 2-5-2MM SPC M CRV DECAPOLAR MAP UNI,SUP-2356858,CDM,C1730,HCPCS,0272,RC,,,,both,,,1758.40,1142.96,,,,,,,,,,,,,
SODIUM POLYSTYRENE SULFONATE 15 GM/60ML CO SUSP,RX-167835,CDM,340b,HCPCS,0637,RC,46287-0006-60,NDC,,both,60,ML,111.60,72.54,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH FLX L 58 MM DIA 32 MM SHTH 20 FR RVD,SUP-2170441,CDM,C1874,HCPCS,0278,RC,,,,both,,,5925.18,3851.37,,,,,,,,,,,,,
PLATE RAD DIST VOLAR VA LOQTEQ 2.5 BROAD 4HL,SUP-2717531,CDM,C1713,HCPCS,0278,RC,,,,both,,,4232.22,2750.94,,,,,,,,,,,,,
PLATE BONE SH THK1.8MM 4 H FOR 2.4MM SCR LORENZ,SUP-2136637,CDM,C1713,HCPCS,0278,RC,,,,both,,,580.90,377.58,,,,,,,,,,,,,
PACK NEUROSURGICAL SHTH L 50 X W 11 MM MYRIAD HNDPC L 13 CM,SUP-2930233,CDM,2720000010,LOCAL,0272,RC,,,,both,,,18059.55,11738.71,,,,,,,,,,,,,
COLLAR HUM DIA48MM ECC SUT FOR SHLDR ARTHROPLASTY SYS GLOB,SUP-2249864,CDM,C1776,CPT,0278,RC,,,,both,,,1401.70,911.10,,,,,,,,,,,,,
BIT DRL L27MM DIA1.4MM ADD ON END W/O STP FOR VARIAX HND,SUP-2374211,CDM,2720000010,LOCAL,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
LINER ACET K OD70-76MM ID22MM THK19MM 20DEG +4MM XLPE HIP,SUP-2344885,CDM,C1776,CPT,0278,RC,,,,both,,,4622.87,3004.87,,,,,,,,,,,,,
CATHETER HD TWO LUMEN 12 FRX20 CM LG BOR ARROWG+ARD BLU,SUP-2627043,CDM,C1752,HCPCS,0278,RC,,,,both,,,447.14,290.64,,,,,,,,,,,,,
SYSTEM IBV VLV INCLUDE LD TY AIRWY SZ KT W/ CALIB GA 5000,SUP-2313519,CDM,2720000010,LOCAL,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
KIT PERITONEAL DLYS TUNN TOOL PLUG STRL DISP RITUS,SUP-2882201,CDM,2720000010,LOCAL,0272,RC,,,,both,,,690.80,449.02,,,,,,,,,,,,,
CATHETER PTCA DIA10MM BLLN DIA2.75MM HYDRCOAT 2 SWAGED MRK,SUP-2103590,CDM,C1725,HCPCS,0272,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
BAR EXTERNAL FIXATION L150MM DIA11MM XTRAFIX SYSTEM,SUP-2467698,CDM,2720000010,LOCAL,0272,RC,,,,both,,,548.53,356.54,,,,,,,,,,,,,
SCREW FIX PEDCL FIX SCREW NS REUSE VADER,SUP-2917086,CDM,C1713,HCPCS,0278,RC,,,,both,,,816.40,530.66,,,,,,,,,,,,,
COMPONENT FEM A P55MM M L65MM HA POR L HIP OR KNEE CRUCE RET,SUP-2377123,CDM,C1776,CPT,0278,RC,,,,both,,,10426.06,6776.94,,,,,,,,,,,,,
SCREW BNE L50MM DIA3.7MM S STL ST SELF DRL CANN LOK FULL,SUP-2185172,CDM,C1713,HCPCS,0278,RC,,,,both,,,569.31,370.05,,,,,,,,,,,,,
CATHETER BLLN DIL WIRE GUID 6 FR 12 MMX5.5 CM ECLIPSE TTC,SUP-2737307,CDM,C1726,HCPCS,0272,RC,,,,both,,,530.66,344.93,,,,,,,,,,,,,
CATHETER EP BPLR JOSEPHSON FIX CRV POLYMER COAT DBL STRND,SUP-2142662,CDM,C1730,HCPCS,0272,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
SCREW BNE ST 1.3X14 MM CRTX W/ FLUT TIP TI MTRX GLD NS LF,SUP-2189190,CDM,C1713,HCPCS,0278,RC,,,,both,,,1611.13,1047.23,,,,,,,,,,,,,
RELOAD STPLR 60 MM FOR SIGNIA INTELLIGENT LD UNIT,SUP-2858010,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1817.46,1181.35,,,,,,,,,,,,,
GUIDEWIRE VASC INQWIRE L 180 CM 0.035 IN TIP 1.5 MM J FIX,SUP-2301896,CDM,C1769,HCPCS,0272,RC,,,,both,,,39.56,25.71,,,,,,,,,,,,,
GRAFT VASC FLX 6 MMX60 CM STD WALL N RING EPTFE CARBOFLO,SUP-2761468,CDM,C1768,CPT,0278,RC,,,,both,,,3000.05,1950.03,,,,,,,,,,,,,
PLATE BNE TBLR 6 HOLE 1/4 LCK TI STRL,SUP-2525170,CDM,C1713,HCPCS,0278,RC,,,,both,,,910.76,591.99,,,,,,,,,,,,,
STRIP SUTURE STRL DISP ZIPSEAL 16,SUP-2904104,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1799.31,1169.55,,,,,,,,,,,,,
GUIDEWIRE URO L150CM 0038IN TAPR 5CM ANG TIP STIFF SHFT BENT,SUP-2139352,CDM,C1769,HCPCS,0272,RC,,,,both,,,168.56,109.56,,,,,,,,,,,,,
SPACER SPNL 20-25MM COR DIA22MM TI FOR SELF EXP VBR,SUP-2311166,CDM,C1713,HCPCS,0278,RC,,,,both,,,12560.00,8164.00,,,,,,,,,,,,,
SCREW ADAPT LAG OMEGA,SUP-2468054,CDM,C1713,HCPCS,0278,RC,,,,both,,,1213.30,788.64,,,,,,,,,,,,,
SHEATH TUNN L12CM DIA9MM REPROC FOR SUBQ GRFT,SUP-2336990,CDM,C1894,HCPCS,0272,RC,,,,both,,,226.08,146.95,,,,,,,,,,,,,
DEVICE GLAUCOMA DRAINAGE NDL DIA23 GA AREA250 SQMM SIL TUBE,SUP-2928456,CDM,C1783,HCPCS,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
STEM FEM 60MM SH WDG HIP INTERSPACE,SUP-2223680,CDM,C1713,HCPCS,0278,RC,,,,both,,,8478.00,5510.70,,,,,,,,,,,,,
DEVICE TRAC 19-23IN SM CRWN W/ SKULL PIN FOR BREMER HALO SYS,SUP-2255771,CDM,C1713,HCPCS,0278,RC,,,,both,,,2747.50,1785.87,,,,,,,,,,,,,
SCREW SPNL ROD DIA 4.75/5 MM SS REDUCTION UNIAXIAL STRL CD,SUP-2926604,CDM,C1713,HCPCS,0278,RC,,,,both,,,2841.70,1847.10,,,,,,,,,,,,,
STRAP BITE BLOCK CLAV HVY DUTY,SUP-2148720,CDM,L3650,HCPCS,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
PACEMAKER CARD CONSULTA W 59 X H 57 MM D 6 MM 15 CC 26 GM TI,SUP-2282345,CDM,C2621,HCPCS,0275,RC,,,,both,,,19417.73,12621.52,,,,,,,,,,,,,
CATHETER VALVULOPLASTY TRUE L 110 CM BALLOON L 4.5 CM DIA21,SUP-2431942,CDM,C1725,HCPCS,0272,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
PLATE BONE COMPRESSION 2 MM MANDIBULAR 5 HOLE INTERMEDIATE L,SUP-2838407,CDM,C1713,HCPCS,0278,RC,,,,both,,,1604.54,1042.95,,,,,,,,,,,,,
BUR SURG BALL 4 MMX12 CM SYMMETRI MIDAS REX LEGEND,SUP-2627650,CDM,2720000010,LOCAL,0272,RC,,,,both,,,421.11,273.72,,,,,,,,,,,,,
PLATE BONE STRUT 0.4 MM CRANIAL 2X4 HOLE CURVED RIGID TITANI,SUP-2837705,CDM,C1713,HCPCS,0278,RC,,,,both,,,1774.73,1153.57,,,,,,,,,,,,,
HC Thrombectomy Graft Not Dialysi,PX-3613587500,CDM,35875,CPT,0361,RC,,,,both,,,15457.00,10047.05,,,,,,,,,,,,,
SPLINT KNEE L26IN CIRC 36IN UNIV AD IMMOB FIT MOST WRP ARND,SUP-2197157,CDM,L1830,CPT,0272,RC,,,,both,,,51.90,33.73,,,,,,,,,,,,,
SCREW BONE 1ST 2.5X14 MM,SUP-2137589,CDM,C1713,HCPCS,0278,RC,,,,both,,,950.85,618.05,,,,,,,,,,,,,
TRIAL HIP M LT ACET FLNG PROV RINGLOK PAR 5,SUP-2403447,CDM,C1776,CPT,0278,RC,,,,both,,,2223.12,1445.03,,,,,,,,,,,,,
HC Antigen Typing,PX-3008690500,CDM,86905,CPT,0300,RC,,,,both,,,170.00,110.50,,,,,,,,,,,,,
INSERT TIB SZ 1 THK10MM POST STBL FIX GMK,SUP-2267459,CDM,C1776,CPT,0278,RC,,,,both,,,2341.37,1521.89,,,,,,,,,,,,,
BLADE RTRCTR MCCLLCH 5CMD SPNL MSCLE MULTI TTHD BLACK FNSH U,SUP-2667617,CDM,2720000010,LOCAL,0272,RC,,,,both,,,585.04,380.28,,,,,,,,,,,,,
STEM FEM L120MM DIA11MM HIP ZMLY STD OFFSET CEM CLLRD,SUP-2203443,CDM,C1776,CPT,0278,RC,,,,both,,,8839.57,5745.72,,,,,,,,,,,,,
BAND M 31 PRIMARY UPPER,SUP-2100492,CDM,D6783,CPT,0278,RC,,,,both,,,15.42,10.02,,,,,,,,,,,,,
TROCAR SURG DBL SL 5X120 MM ASMBLY,SUP-2517248,CDM,2720000010,LOCAL,0272,RC,,,,both,,,657.83,427.59,,,,,,,,,,,,,
TR PN W/CV PT 150X50X5 HP,SUP-2818275,CDM,C1713,HCPCS,0278,RC,,,,both,,,1599.05,1039.38,,,,,,,,,,,,,
MESH HERN L20.3XW10.2CM POLYPR ABD ABSRB RECTANG SEPRAMESH,SUP-2125923,CDM,C1781,HCPCS,0278,RC,,,,both,,,1007.31,654.75,,,,,,,,,,,,,
LINER ACET OD50MM ID28MM 20DEG HIP MARTHN LAT NEUT PINN,SUP-2250516,CDM,C1776,CPT,0278,RC,,,,both,,,4664.78,3032.11,,,,,,,,,,,,,
PLATE BONE 6 H LCK SCAPHOID FOR 1.5MM SCR TRILOK,SUP-2267911,CDM,C1713,HCPCS,0278,RC,,,,both,,,2154.04,1400.13,,,,,,,,,,,,,
GUIDEWIRE ORTH 0.9 MMX6 IN,SUP-2663619,CDM,C1769,HCPCS,0272,RC,,,,both,,,44.84,29.15,,,,,,,,,,,,,
PLATE BONE L81MM 5 H STRL LT LAT DSTL FIBULAR S STL FOR,SUP-2349756,CDM,C1713,HCPCS,0278,RC,,,,both,,,4751.45,3088.44,,,,,,,,,,,,,
COIL EMB L15CM OD0.020IN NIT J STRTCH RESIST FILL SFT STBL,SUP-2323422,CDM,C1889,HCPCS,0278,RC,,,,both,,,7570.54,4920.85,,,,,,,,,,,,,
HC So Topiramate,PX-3018020166,CDM,80201,CPT,0301,RC,,,,both,,,109.00,70.85,,,,,,,,,,,,,
IMMOBILIZER SHLDR SM ENV L13IN D7IN POLY COT CLIN SLNG W/,SUP-2196915,CDM,L3650,HCPCS,0274,RC,,,,both,,,12.59,8.18,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL PEEK SD800.533,SUP-2860214,CDM,C1713,HCPCS,0278,RC,,,,both,,,36823.09,23935.01,,,,,,,,,,,,,
STABILIT FRACTURE KIT SHRT,SUP-2700643,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
GRAFT VASC HEMGRD BODY/BRANCH L 85/55 CM RNG L 45/30 CM DSTL,SUP-2474157,CDM,C1768,CPT,0278,RC,,,,both,,,5221.19,3393.77,,,,,,,,,,,,,
GUIDEWIRE VASC CRV 7 CM 0.035 INX180 CM 3 CMX3 MM AMPLATZ,SUP-2167955,CDM,C1769,HCPCS,0272,RC,,,,both,,,49.46,32.15,,,,,,,,,,,,,
BRACE KNEE M FOR 18 21IN THGH NEOPRENE PAT STBL SFT,SUP-2150848,CDM,L1810,HCPCS,0272,RC,,,,both,,,75.39,49.00,,,,,,,,,,,,,
DILATOR ENDO L180CM BAL L3CM OD6MM GWIRE OD0.035IN,SUP-2169412,CDM,C1725,HCPCS,0272,RC,,,,both,,,681.38,442.90,,,,,,,,,,,,,
CATHETER HD LT 14 FRX36 CM DBL D INT LUMEN BASIC SPLIT STRM,SUP-2627430,CDM,C1750,HCPCS,0278,RC,,,,both,,,967.12,628.63,,,,,,,,,,,,,
PLATE BNE AD BLDE L60MM THK48MM DISPLC 10MM 100DEG 4 H,SUP-2185551,CDM,C1713,HCPCS,0278,RC,,,,both,,,2764.58,1796.98,,,,,,,,,,,,,
HC Simualtion Complex,PX-3337729000,CDM,77290,CPT,0333,RC,,,,both,,,2899.00,1884.35,,,,,,,,,,,,,
SYSTEM NEUROSTIMULATOR CHARGING MINI EON,SUP-2356753,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3518.37,2286.94,,,,,,,,,,,,,
CATHETER DIAG L132CM DIA0.06IN DST ACCS AXS CATLYST 6,SUP-2368076,CDM,C1887,HCPCS,0272,RC,,,,both,,,6629.80,4309.37,,,,,,,,,,,,,
PLATE BNE THK0.6MM 3X2 H CRANIOMAXILLOFACIAL TI RECTANG 3D,SUP-2366280,CDM,C1713,HCPCS,0278,RC,,,,both,,,761.89,495.23,,,,,,,,,,,,,
CLAMP CRAN TEXT 11 MM FLAPFIX FOR EXT FIX TI NS LF,SUP-2431407,CDM,C1713,HCPCS,0278,RC,,,,both,,,1004.17,652.71,,,,,,,,,,,,,
STENT GRFT VASC AFX2 VELA L 100 MM DIA PROX/DSTL 34 MM,SUP-2217610,CDM,C1768,CPT,0278,RC,,,,both,,,14224.20,9245.73,,,,,,,,,,,,,
INTERFACE LOWER EXTREMITY SFT BK PLAS,SUP-2388186,CDM,L2820,HCPCS,0274,RC,,,,both,,,214.27,139.28,,,,,,,,,,,,,
INTRODUCER SHTH 8FR L12CM DIA0.038IN STD HEMSTAS CLOSE TOL,SUP-2355392,CDM,C1894,HCPCS,0272,RC,,,,both,,,40.82,26.53,,,,,,,,,,,,,
CATHETER ANGIOPLSTY SLEEK L 150 CM BALLOON L 40 MM DIA2 MM,SUP-2156514,CDM,C1725,HCPCS,0272,RC,,,,both,,,1224.60,795.99,,,,,,,,,,,,,
GRAFT TISS FRZ DRY ALLGRFT HEMI PAT WDG 16 18MM THICKNESS,SUP-2307176,CDM,C1713,HCPCS,0278,RC,,,,both,,,2569.84,1670.40,,,,,,,,,,,,,
ROD RM L1150MM DIA2.5MM TI W/ EXTN BALL TIP FOR IM NAIL,SUP-2188108,CDM,2720000010,LOCAL,0272,RC,,,,both,,,411.43,267.43,,,,,,,,,,,,,
SHEATH INTRO FAST-CATH L 63 CM DIL L 67 CM DIA10 FR,SUP-2357206,CDM,C1894,HCPCS,0272,RC,,,,both,,,1086.44,706.19,,,,,,,,,,,,,
KIT INTRO VSI L 10 CM DIA 5 FR GUIDEWIRE L 60CM DIA 0.018 IN,SUP-2383166,CDM,C1894,HCPCS,0272,RC,,,,both,,,103.31,67.15,,,,,,,,,,,,,
GRAFT VASC GELWEAVE L 60 CM DIA24 MM L 10/10/10CM 8/8/8MM,SUP-2894594,CDM,C1768,CPT,0278,RC,,,,both,,,13674.70,8888.55,,,,,,,,,,,,,
SCREW SPNL L25MM DIA13MM STR NONCANNULATED,SUP-2414462,CDM,C1713,HCPCS,0278,RC,,,,both,,,9881.58,6423.03,,,,,,,,,,,,,
PLATE BNE METATARSOPHALANGEAL TOE REVERSIBLE,SUP-2328039,CDM,C1713,HCPCS,0278,RC,,,,both,,,1083.30,704.14,,,,,,,,,,,,,
SYRINGE MED SHIELDED 3 CC HI DENS LD GRASS,SUP-2327795,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1193.20,775.58,,,,,,,,,,,,,
PLATE BNE L191MM 10 H S STL BROAD WAISTED LOK COMPR FOR 5MM,SUP-2372017,CDM,C1713,HCPCS,0278,RC,,,,both,,,1805.50,1173.57,,,,,,,,,,,,,
SM FRAG PLT STERILIZER 3.5X49 MM 4 HL,SUP-2820734,CDM,C1713,HCPCS,0278,RC,,,,both,,,962.47,625.61,,,,,,,,,,,,,
PACEMAKER CARD STD PERM 2 CHMBR DDDR BPLR IS-1 CONN NOT MRI,SUP-2138079,CDM,C1785,HCPCS,0275,RC,,,,both,,,16952.86,11019.36,,,,,,,,,,,,,
ALLOGRAFT BNE COR FRZN WHL PAT,SUP-2736962,CDM,C1762,CPT,0278,RC,,,,both,,,4530.96,2945.12,,,,,,,,,,,,,
COMPONENT FEM 2XL R HIP TI ALLY INTLOK PRI ASCNT,SUP-2406943,CDM,C1776,CPT,0278,RC,,,,both,,,17364.20,11286.73,,,,,,,,,,,,,
BIT DRL L195MM DIA6MM NONSTERILE JCBS CHK NONRADIOPAQUE W/O,SUP-2187322,CDM,2720000010,LOCAL,0272,RC,,,,both,,,446.95,290.52,,,,,,,,,,,,,
WASHER ORTH TIM FLAT FOR 3.5/4MM CANN SCR,SUP-2412157,CDM,C1713,HCPCS,0278,RC,,,,both,,,368.70,239.65,,,,,,,,,,,,,
STENT BILI S.M.A.R.T. CTRL L 40 MM DIA10 MM DEL SYS L 80 CM,SUP-2155369,CDM,C1876,HCPCS,0278,RC,,,,both,,,2904.25,1887.76,,,,,,,,,,,,,
PERC NGAGE NITINOL TIPLESS STONE EXTRACTOR,SUP-2827470,CDM,2720000010,LOCAL,0272,RC,,,,both,,,610.42,396.77,,,,,,,,,,,,,
COMPONENT HIP 6 MTL,SUP-2254059,CDM,C1776,CPT,0278,RC,,,,both,,,17270.00,11225.50,,,,,,,,,,,,,
SUPPORT ORTHOT KNEE CUST ADJ POS RIGID SUPP PREFABRICATED,SUP-2435610,CDM,L1833,HCPCS,0274,RC,,,,both,,,1950.10,1267.56,,,,,,,,,,,,,
SEED BRACHYTHERAPY STD STRND,SUP-2135323,CDM,C2638,HCPCS,0278,RC,,,,both,,,94.20,61.23,,,,,,,,,,,,,
CATHETER HAD L40CM L19CM OD14.5FR CHRONIC AD DBL LUMN STR,SUP-2283936,CDM,C1881,HCPCS,0278,RC,,,,both,,,1037.20,674.18,,,,,,,,,,,,,
PLATE BONE ADOL BLDE L40MM 6MM OFFSET 90DEG 4 H LT RT S STL,SUP-2318747,CDM,C1713,HCPCS,0278,RC,,,,both,,,5154.75,3350.59,,,,,,,,,,,,,
TRIAL SURG FORXPLATE FLOWERCUBE,SUP-2225464,CDM,C1713,HCPCS,0278,RC,,,,both,,,75.36,48.98,,,,,,,,,,,,,
INSERT TIB PS 3 UNIV NEUT 12 MM KNEE BEAR TECHNOLOGY COCR,SUP-2378643,CDM,C1776,CPT,0278,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
BLADE 4.5MMX20CM 1 STR AND 1 25DEG ANG SET,SUP-2284308,CDM,C1713,HCPCS,0278,RC,,,,both,,,2182.30,1418.49,,,,,,,,,,,,,
IMPLANT HUM TISS W20MMXL5CM FASC LATA FRZ DRY,SUP-2307109,CDM,C1762,CPT,0278,RC,,,,both,,,1012.27,657.98,,,,,,,,,,,,,
CATHETER INFUSION BRAIDED 3 FRX150 CM RENEGADE HYDR PASS,SUP-2147587,CDM,C1887,HCPCS,0272,RC,,,,both,,,1146.10,744.96,,,,,,,,,,,,,
CATHETER ANGIO GLIDECATH XP L 150 CM DIA 5 FR SHFT DIA1.22,SUP-2761863,CDM,C1887,HCPCS,0272,RC,,,,both,,,173.52,112.79,,,,,,,,,,,,,
BLADE BREAKER HOLDER STRAIGHT LOCK,SUP-2473494,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2347.15,1525.65,,,,,,,,,,,,,
SEALER EPI VEIN 15DEG SEAL BPLR TIP AQUAMANTYS,SUP-2281804,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2060.59,1339.38,,,,,,,,,,,,,
GUIDEWIRE VASC VASSALLO GT L 190 CM DIA 0.014 IN COIL L 12,SUP-2909257,CDM,C1769,HCPCS,0272,RC,,,,both,,,101.48,65.96,,,,,,,,,,,,,
SCREW BONE SELF TAPPING 2X8 MM MANDIBULAR SELF DRILLING LOCK,SUP-2838330,CDM,C1713,HCPCS,0278,RC,,,,both,,,545.98,354.89,,,,,,,,,,,,,
STENT URET UNIVERSA FIRM L 18 CM DIA 8 FR POLYUR AQ,SUP-2826996,CDM,C2617,HCPCS,0278,RC,,,,both,,,188.90,122.78,,,,,,,,,,,,,
CLIP ANEURYSM SUNDT-KEES 12MM FENESTRATED 90 DEG 20-1699,SUP-2849027,CDM,C1889,HCPCS,0278,RC,,,,both,,,932.36,606.03,,,,,,,,,,,,,
COMPONENT HUM 46X42MM ARTC OFFSET OVOMOTION,SUP-2123588,CDM,C1776,CPT,0278,RC,,,,both,,,18249.68,11862.29,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 4X2 CM AMNIO WND MTRX BIOSKIN,SUP-2759487,CDM,C1762,CPT,0278,RC,,,,both,,,4567.54,2968.90,,,,,,,,,,,,,
STEM EXTN L65MM DIA16MM KNEE CEMENTLESS FLUT GMK,SUP-2267626,CDM,C1776,CPT,0278,RC,,,,both,,,5708.52,3710.54,,,,,,,,,,,,,
CLIP ANEURYSM SUNDT GRAFT 2.5MM X 5MM SLIM-LINE,SUP-2849023,CDM,C1889,HCPCS,0278,RC,,,,both,,,1376.14,894.49,,,,,,,,,,,,,
HC So Chromium Serum,PX-3018249566,CDM,82495,CPT,0301,RC,,,,both,,,60.00,39.00,,,,,,,,,,,,,
DEVICE GUIDEWIRE EXCHANGE TRAPPER STR STRL,SUP-2140451,CDM,C1769,HCPCS,0272,RC,,,,both,,,266.90,173.48,,,,,,,,,,,,,
CONNECTOR SPNL OD4-4.5MM ROD PARA QUARTEX,SUP-2229083,CDM,C1713,HCPCS,0278,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
JOINT TOE INTRAOSSEOUS 2.4 MM D8 CANNULINK,SUP-2400026,CDM,C1713,HCPCS,0278,RC,,,,both,,,4543.58,2953.33,,,,,,,,,,,,,
RETRACTOR LAT VEO,SUP-2164090,CDM,C1713,HCPCS,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
HANDPIECE SURG 9 IN BEND-A-BEAM ABC,SUP-2225596,CDM,2720000010,LOCAL,0272,RC,,,,both,,,730.05,474.53,,,,,,,,,,,,,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,0258,RC,00264-7510-20,NDC,,both,250,ML,31.90,20.73,,,,,,,,,,,,,
SURFACE ARTC SZ C H26MM W/ SEG HNG POST,SUP-2200517,CDM,C1776,CPT,0278,RC,,,,both,,,5185.71,3370.71,,,,,,,,,,,,,
RAIL L230MM AD SHT COMP FOR LIMB RECON SYS,SUP-2316077,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3187.60,2071.94,,,,,,,,,,,,,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,0258,RC,00264-7510-10,NDC,,both,500,ML,34.00,22.10,,,,,,,,,,,,,
CATHETER ANGIOPLSTY 14 ATM 5 FRX139 CM 2X6 MM EMPIRA RX,SUP-2158489,CDM,C1725,HCPCS,0272,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
TISSUE T20673 FEM CORT STRUT1/3 200MM,SUP-2281652,CDM,C1713,HCPCS,0278,RC,,,,both,,,3376.29,2194.59,,,,,,,,,,,,,
PLATE BNE L233MM THK38MM 12 H L MED DST TIB S STL NEUT,SUP-2185223,CDM,C1713,HCPCS,0278,RC,,,,both,,,4639.70,3015.80,,,,,,,,,,,,,
PLATE BNE INJ RELEASE MILLER,SUP-2437006,CDM,C1713,HCPCS,0278,RC,,,,both,,,113.04,73.48,,,,,,,,,,,,,
SHEATH DIL 8 FRX15 CM 8 FR REINF W/ HEMSTAS VLV DIL,SUP-2517606,CDM,C1894,HCPCS,0272,RC,,,,both,,,120.20,78.13,,,,,,,,,,,,,
NAIL IM 10X240 MM LT TI STRL AGILE NAIL,SUP-2646469,CDM,C1713,HCPCS,0278,RC,,,,both,,,9451.40,6143.41,,,,,,,,,,,,,
FLUCONAZOLE 200 MG PO TABS,RX-10045,CDM,6370000000,HCPCS,0637,RC,50268-0339-15,NDC,,both,1,UN,11.30,7.34,,,,,,,,,,,,,
PLATE BONE L186MM 13 H LT ANTEROLATERAL MEDL DSTL TIB LCK,SUP-2348480,CDM,C1713,HCPCS,0278,RC,,,,both,,,17300.14,11245.09,,,,,,,,,,,,,
KIT NEUROSTIMULATOR L 45 CM DIA1.35 MM PERIPH TRL LD CHANNEL,SUP-2917080,CDM,2720000010,LOCAL,0272,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
RING OPHTH L24-28 MM MORCHER CAPSULAR TENS FOR CATRCT SURG,SUP-2224365,CDM,2720000010,LOCAL,0272,RC,,,,both,,,624.86,406.16,,,,,,,,,,,,,
GRAFT BNE PTTY SYR FRZ DRY DEMIN BNE MTRX CANC 1CC I C GRFT,SUP-2264797,CDM,C1713,HCPCS,0278,RC,,,,both,,,1502.65,976.72,,,,,,,,,,,,,
BIT DRILL 2.6MM FOR PRESSFT SUTURE ANCHOR,SUP-2825000,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1212.86,788.36,,,,,,,,,,,,,
LORAZEPAM 4 MG/ML IJ SOLN|DISCARDED DRUG NOT ADMINISTE,RX-10468,CDM,J2060,HCPCS,0636,RC,00641-6049-25,NDC,JW,both,0.75,ML,54.10,35.16,,,,,,,,,,,,,
SEALER TISS L45CM SHFT DIA5MM 360DEG ROT CVD JAW TAPR TIP,SUP-2219741,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1758.46,1143.00,,,,,,,,,,,,,
KIT PERC NEUROPHYSIOLOGICAL MON INTOP SCR TST W/ PEDCL PRB,SUP-2311740,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3987.80,2592.07,,,,,,,,,,,,,
BLINATUMOMAB 35 MCG IV SOLR,RX-128517,CDM,J9039,HCPCS,0636,RC,55513-0160-01,NDC,,both,1,UN,16003.50,10402.27,,,,,,,,,,,,,
GRAFT HERN REP 25X30CM POLYPR PERM POLYMER 6 LAYR OVITEX 1S,SUP-2383098,CDM,C1781,HCPCS,0278,RC,,,,both,,,32970.00,21430.50,,,,,,,,,,,,,
SCREW SPNL 2 OUTER DIAMETER 9.5-8X95 MM HD SHANK CREO 5.5,SUP-2732543,CDM,C1889,HCPCS,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
PLATE BONE REG L16MM THK0.6MM 5 H MIDFACE TI Y SHP FOR 1.5MM,SUP-2402882,CDM,C1713,HCPCS,0278,RC,,,,both,,,433.32,281.66,,,,,,,,,,,,,
CATHETER HD STR 12 FRX15 CM SHT TERM 3L TY SLIM-CATH,SUP-2424484,CDM,C1752,HCPCS,0278,RC,,,,both,,,979.96,636.97,,,,,,,,,,,,,
PROSTHESIS OSS L425MM SHFT OD05MM PLAT OR TI STAP PIST MEITI,SUP-2232478,CDM,L8613,CPT,0278,RC,,,,both,,,618.58,402.08,,,,,,,,,,,,,
TUBE TYMPANOSTOMY DIA1.27 MM INNR FLANGE DIA2.75 MM TYTAN,SUP-2901978,CDM,L8699,HCPCS,0278,RC,,,,both,,,130.56,84.86,,,,,,,,,,,,,
COIL EMB L25CM OD0.020IN NIT J STRTCH RESIST FILL SFT STBL,SUP-2323423,CDM,C1889,HCPCS,0278,RC,,,,both,,,8148.30,5296.39,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED CEM POROUS HA,SUP-2365947,CDM,C1776,CPT,0278,RC,,,,both,,,13881.94,9023.26,,,,,,,,,,,,,
SYSTEM ENTRY 23GA 4MM VLV FOR VITRCTMY EDGEPLUS,SUP-2109958,CDM,2720000010,LOCAL,0272,RC,,,,both,,,489.84,318.40,,,,,,,,,,,,,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,0258,RC,00264-1510-32,NDC,,both,100,ML,21.30,13.84,,,,,,,,,,,,,
COUPLER SURG USED EXT SVC 1 YR LG PWR,SUP-2760997,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1401.23,910.80,,,,,,,,,,,,,
CATHETER THOR 24FR L22IN PVC 4 EYELET R ANG ATRAUM,SUP-2227437,CDM,C1729,HCPCS,0272,RC,,,,both,,,36.49,23.72,,,,,,,,,,,,,
ALLOGRAFT DERMAL UNMESHED 6X12 CMX1-2 MM PRE HYDRATED DERM,SUP-2632333,CDM,C1763,HCPCS,0278,RC,,,,both,,,16249.50,10562.17,,,,,,,,,,,,,
PLATE BONE OFFSET 4MM THK0.7MM 5 H BILAT CHIN MAXILLOFACIAL,SUP-2181839,CDM,C1713,HCPCS,0278,RC,,,,both,,,1367.16,888.65,,,,,,,,,,,,,
CORTEX HEX SCREW S-T 2.7X32 MM STRL,SUP-2818130,CDM,C1713,HCPCS,0278,RC,,,,both,,,212.30,137.99,,,,,,,,,,,,,
DISTRACTION INTRNL DIST MNDBLE MICRO ZRCH 2 URATA END DRV RT,SUP-2680325,CDM,C1713,HCPCS,0278,RC,,,,both,,,20140.59,13091.38,,,,,,,,,,,,,
RING FIX DIA7MM SMER MAT FLEX INCREASED SPACE MALYUGIN 2.0,SUP-2304868,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1032.46,671.10,,,,,,,,,,,,,
PLATE BNE L W135XL332MM THK42MM 18 H BILAT TI NAR RIG NEUT,SUP-2190835,CDM,C1713,HCPCS,0278,RC,,,,both,,,2965.86,1927.81,,,,,,,,,,,,,
CATHETER EMB ARW L 40 CM DIA 5 FR SPRING GUIDEWIRE 0.035 IN,SUP-2383505,CDM,C1757,HCPCS,0272,RC,,,,both,,,204.10,132.66,,,,,,,,,,,,,
BRACE WALKING EMBEDDED SOLE LG SHT ANK ROCKER BTM INLINE,SUP-2336133,CDM,L4361,HCPCS,0272,RC,,,,both,,,99.85,64.90,,,,,,,,,,,,,
HC Venography Extremity Bilateral,PX-3207582200,CDM,75822,CPT,0320,RC,,,,both,,,1284.00,834.60,,,,,,,,,,,,,
GRAFT DERMAL 10X5 CM PORCINE DERMAL CLLGN REINF MTRX STRL,SUP-2852967,CDM,C1763,HCPCS,0278,RC,,,,both,,,9591.88,6234.72,,,,,,,,,,,,,
AUTOINJECTOR STENT GRFT OVATION PRIM PMA STRL,SUP-2217723,CDM,C1713,HCPCS,0278,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
VLP 2.7MM PERC CALC PLT X-LARGE LT 68MM STER,SUP-2820177,CDM,C1713,HCPCS,0278,RC,,,,both,,,7355.61,4781.15,,,,,,,,,,,,,
HC Comprehensive Metabolic Panel,PX-3018005300,CDM,80053,CPT,0301,RC,,,,both,,,380.00,247.00,,,,,,,,,,,,,
IMPLANT FACE L 48 X W 38 MM THK 1 MM POLYETHYL EMBEDDED TI,SUP-2883625,CDM,C1713,HCPCS,0278,RC,,,,both,,,5417.00,3521.05,,,,,,,,,,,,,
COIL AXIUM PRIME DETACHBL FRAME 5MMX10CM,SUP-2469308,CDM,C1889,HCPCS,0278,RC,,,,both,,,6264.30,4071.79,,,,,,,,,,,,,
STEM FLUTED MOB OPT TIB PLT SZ 1,SUP-2200826,CDM,C1776,CPT,0278,RC,,,,both,,,7944.20,5163.73,,,,,,,,,,,,,
PLATE BENDING PLIERS 1.0/1.5/2.0,SUP-2497455,CDM,C1713,HCPCS,0278,RC,,,,both,,,799.44,519.64,,,,,,,,,,,,,
SPLINT DORSAL AFO SPLNT M RT W STRP,SUP-2163836,CDM,L4396,HCPCS,0274,RC,,,,both,,,111.03,72.17,,,,,,,,,,,,,
GRAFT BIO TISS OMEGA3 MARIGEN 3X3.5CM,SUP-2261684,CDM,Q4158,HCPCS,0636,RC,,,,both,,,2295.34,1491.97,,,,,,,,,,,,,
STIMULATOR NERVE IMPL PULSE GENRTR W/ PT CTRL PROCLAIM + 5,SUP-2858398,CDM,C1767,HCPCS,0278,RC,,,,both,,,71205.78,46283.76,,,,,,,,,,,,,
ANCHOR SUT DIA2.3MM W/ NDL 2 STRND NO2 FORC FBR,SUP-2366690,CDM,C1713,HCPCS,0278,RC,,,,both,,,1364.68,887.04,,,,,,,,,,,,,
FILLER BNE 10ML SCFLD COLLAGE,SUP-2316224,CDM,C1713,HCPCS,0278,RC,,,,both,,,6421.30,4173.84,,,,,,,,,,,,,
PLATE BNE 11 H ST L CUBOID S STL MAL LO PROF FOR 24 27MM,SUP-2177138,CDM,C1713,HCPCS,0278,RC,,,,both,,,2508.55,1630.56,,,,,,,,,,,,,
GRAFT VASC GELSFT + L 50 CM DIA22 MM POLYESTER GEL,SUP-2384965,CDM,C1768,CPT,0278,RC,,,,both,,,1181.21,767.79,,,,,,,,,,,,,
SHEATH KIT NANONEEDLE 180 MM HIP ACCS,SUP-2849275,CDM,C1769,HCPCS,0272,RC,,,,both,,,624.86,406.16,,,,,,,,,,,,,
PLATE BNE T 3.5/4 MM RT 10 HOLE OBLQ NS FPS LTX,SUP-2856878,CDM,C1713,HCPCS,0278,RC,,,,both,,,2967.30,1928.74,,,,,,,,,,,,,
RIVAROXABAN 15 MG PO TABS,RX-111544,CDM,6370000000,HCPCS,0637,RC,50458-0578-01,NDC,,both,1,UN,89.80,58.37,,,,,,,,,,,,,
DEXMEDETOMIDINE HCL 120 MCG SL FILM,RX-158220,CDM,J1105,HCPCS,0636,RC,81092-1120-01,NDC,,both,1,UN,472.50,307.12,,,,,,,,,,,,,
MESH MAND CUSTOMIZED + STRL MEDPOR LTX,SUP-2862749,CDM,C1713,HCPCS,0278,RC,,,,both,,,27202.45,17681.59,,,,,,,,,,,,,
HC So Braf Gene,PX-3108121066,CDM,81210,CPT,0310,RC,,,,both,,,406.00,263.90,,,,,,,,,,,,,
INTRODUCER PACE LD AGILIS 85 DIA 8. 5 FR SM CURL STEER STRL,SUP-2357281,CDM,C1766,CPT,0272,RC,,,,both,,,2983.00,1938.95,,,,,,,,,,,,,
SHEATH INTRO PERFRMR L 13 CM OD 6 FR ID 2 MM DIL L 20 CM,SUP-2168223,CDM,C1894,HCPCS,0272,RC,,,,both,,,39.56,25.71,,,,,,,,,,,,,
NEEDLE BRST LOC L7CM DIA20GA WIRE L20CM BARB PIN GHIATAS 10/CA,SUP-2847881,CDM,C1819,HCPCS,0278,RC,,,,both,,,65.97,42.88,,,,,,,,,,,,,
HC X-Ray Toes Min 2 Views,PX-3207366000,CDM,73660,CPT,0320,RC,,,,both,,,414.00,269.10,,,,,,,,,,,,,
PLATE BNE L 176 X W 10.2 MM THK 2.8 MM SCREW DIA 3.5 MM 16 H,SUP-2936246,CDM,C1713,HCPCS,0278,RC,,,,both,,,3087.72,2007.02,,,,,,,,,,,,,
GRAFT DERM HUM TISS THCK KT MTRX ACELLULAR DERM IMPL ALLGRFT,SUP-2307511,CDM,Q4128,HCPCS,0636,RC,,,,both,,,21866.65,14213.32,,,,,,,,,,,,,
PROTECTOR NRV L40MM DIA3.5MM PORCINE EXTRACELLULAR MTRX WRP,SUP-2124857,CDM,C1763,HCPCS,0278,RC,,,,both,,,9627.24,6257.71,,,,,,,,,,,,,
HC Hdr Vaginal Cyl Insertion,PX-3335715600,CDM,57156,CPT,0333,RC,,,,both,,,2400.00,1560.00,,,,,,,,,,,,,
CATHETER CARD ABLATION LASSO 2515 NAV ECO L 115CM SPC2-6-2MM,SUP-2248612,CDM,C1732,HCPCS,0278,RC,,,,both,,,4939.22,3210.49,,,,,,,,,,,,,
INSERT TOE 01 2.5MM OFFSET THK3.6MM MOD TOEMOTION,SUP-2123619,CDM,C1776,CPT,0278,RC,,,,both,,,7818.60,5082.09,,,,,,,,,,,,,
STEM FEM PRSS FT HIP BPLR/UPLR CEM,SUP-2249581,CDM,C1776,CPT,0278,RC,,,,both,,,10205.00,6633.25,,,,,,,,,,,,,
CLIP ANEURYSM L9MM 90DEG STANDARD TITANIUM PERMANENT YASARGI,SUP-2821770,CDM,C1889,HCPCS,0278,RC,,,,both,,,6646.25,4320.06,,,,,,,,,,,,,
HC So Assay of Psa Complexed,PX-3018415266,CDM,84152,CPT,0301,RC,,,,both,,,98.00,63.70,,,,,,,,,,,,,
PLATE BNE RADIAL SHT MED LT VOLAR DSTL,SUP-2646869,CDM,C1713,HCPCS,0278,RC,,,,both,,,2126.78,1382.41,,,,,,,,,,,,,
BRACE WRST R INSTABILITY INJ LOOP LOK W/ STAY COCK UP E,SUP-2197948,CDM,L3931,HCPCS,0274,RC,,,,both,,,25.37,16.49,,,,,,,,,,,,,
BRACE KNEE XL L17 27IN FOR 355IN THGH UNIV POSTOP TELSCP,SUP-2151049,CDM,L1832,HCPCS,0274,RC,,,,both,,,294.69,191.55,,,,,,,,,,,,,
EXCHANGE SET FOR SV 900A/B/C/D/E SERVO 1000HR MAINT,SUP-2227271,CDM,2720000010,LOCAL,0272,RC,,,,both,,,357.96,232.67,,,,,,,,,,,,,
SET INTRO ARROW-TREROTOLA PTD SHTH L 2 IN DIA 7 FR DIL L 5,SUP-2383423,CDM,C1894,HCPCS,0272,RC,,,,both,,,150.72,97.97,,,,,,,,,,,,,
BRACE KNEE XL L17 27IN FOR 355IN THGH UNIV POSTOP TELSCP,SUP-2151049,CDM,L1832,HCPCS,0272,RC,,,,both,,,294.69,191.55,,,,,,,,,,,,,
TUBE TYMPANOSTOMY DIA1.27 MM INNR FLANGE DIA2.6 MM TI SHRT,SUP-2902094,CDM,L8699,HCPCS,0278,RC,,,,both,,,153.29,99.64,,,,,,,,,,,,,
SPLINT WRST SM L10IN L FA LN CIRCUMFERENTIAL STRP SLIP ON,SUP-2276627,CDM,L3809,HCPCS,0274,RC,,,,both,,,23.20,15.08,,,,,,,,,,,,,
BLADE SURG BRAGA-MELE 19 GA CHOP BLNT TIP OFFSET,SUP-2467236,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1259.30,818.54,,,,,,,,,,,,,
MULTIPLE VITAMINS PO TABS,RX-5225,CDM,6370000000,HCPCS,0637,RC,00904-0530-61,NDC,,both,1,UN,0.40,0.26,,,,,,,,,,,,,
GRAFT BIO TISS W2.4XL2.4IN PORCINE DERM RIFAMPIN,SUP-2125830,CDM,C1713,HCPCS,0278,RC,,,,both,,,2712.96,1763.42,,,,,,,,,,,,,
BLADE EXPLANT TRUNCATED 52MM,SUP-2202804,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1978.20,1285.83,,,,,,,,,,,,,
EVOS 2.7/3.5MM EA-D HUM PL 12H RIGHT 151MM,SUP-2819910,CDM,C1713,HCPCS,0278,RC,,,,both,,,9411.52,6117.49,,,,,,,,,,,,,
INSERT TIB 5 THK18MM KNEE BEAR SER II OMFIT,SUP-2370405,CDM,C1776,CPT,0278,RC,,,,both,,,2123.90,1380.53,,,,,,,,,,,,,
LEAD NRV STIM L90CM SPNL CRD TRL,SUP-2308600,CDM,C1897,HCPCS,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
CATHETER ANGIOPLSTY ATLS L 120 CM BALLOON L 4 CM DIA12 MM,SUP-2127917,CDM,C1725,HCPCS,0272,RC,,,,both,,,1036.20,673.53,,,,,,,,,,,,,
STENT URET RESONANCE L 24 CM CATH L 71.5 CM DIA 6 FR SHTH L,SUP-2171370,CDM,C2625,HCPCS,0278,RC,,,,both,,,4339.79,2820.86,,,,,,,,,,,,,
CUP HUM DIA36MM SHLDR NEUT SUT UNIVERS REVERS,SUP-2123345,CDM,C1776,CPT,0278,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
PATCH AMNION 2 LAYR PROTCT 4 X 6CM STERISHIELD II,SUP-2138665,CDM,C1762,CPT,0278,RC,,,,both,,,6892.30,4479.99,,,,,,,,,,,,,
SERTRALINE HCL 100 MG PO TABS,RX-11350,CDM,6370000000,HCPCS,0637,RC,68788-6835-08,NDC,,both,1,UN,12.40,8.06,,,,,,,,,,,,,
FORCEP OPHTH ASYM 23 GA STRL GRIESHABER REVOLUTION DSP DISP,SUP-2109704,CDM,C1713,HCPCS,0278,RC,,,,both,,,449.02,291.86,,,,,,,,,,,,,
PLATE BNE TIBIOTALOCALCANEAL LT 8 HOLE,SUP-2609043,CDM,C1713,HCPCS,0278,RC,,,,both,,,6492.33,4220.01,,,,,,,,,,,,,
AMPICILLIN SODIUM 500 MG IJ SOLR,RX-474,CDM,J0290,HCPCS,0636,RC,00781-3407-78,NDC,,both,1,UN,54.10,35.16,,,,,,,,,,,,,
ORTHOPEDIC KIT PIN TRACTION,SUP-2164818,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1491.50,969.47,,,,,,,,,,,,,
CATHETER CV SET 025 5 FRX8 CM 3L J TIP RIFAMPIN SPECTRUM,SUP-2759972,CDM,C1751,HCPCS,0278,RC,,,,both,,,383.11,249.02,,,,,,,,,,,,,
SET INTRO L 10 CM DIA 4 FR GUIDEWIRE L 45 CM DIA 0.018 IN,SUP-2117386,CDM,C1894,HCPCS,0272,RC,,,,both,,,84.91,55.19,,,,,,,,,,,,,
PLATE BNE T 3.5X75 MM 5 HOLE OBLQ FOR SM FRAG SS,SUP-2431715,CDM,C1713,HCPCS,0278,RC,,,,both,,,391.97,254.78,,,,,,,,,,,,,
HC So Hsv Amplified Probe,PX-3068752966,CDM,87529,CPT,0306,RC,,,,outpatient,,,498.00,323.70,,,,,,,,,,,,,
STEM FEM L130MM OD9MM 12/14 131DEG PRSS FIT STD OFFSET,SUP-2222288,CDM,C1776,CPT,0278,RC,,,,both,,,16202.40,10531.56,,,,,,,,,,,,,
ENDCAP ORTH FEM DSTL FOR NAIL TI,SUP-2564342,CDM,C1713,HCPCS,0278,RC,,,,both,,,569.88,370.42,,,,,,,,,,,,,
ANCHOR SUT HIP LEN INSRTR KNOTLESS BIORAPTOR,SUP-2341829,CDM,C1713,HCPCS,0278,RC,,,,both,,,1305.61,848.65,,,,,,,,,,,,,
GRAFT HUM TISS W10-30MMXL3-10CM THK3-20MM COSTAL CART FRZN,SUP-2307298,CDM,C1713,HCPCS,0278,RC,,,,both,,,2022.47,1314.61,,,,,,,,,,,,,
OBTURATOR STD ORNG 21FR,SUP-2313052,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2233.36,1451.68,,,,,,,,,,,,,
SCREW INTRF L16MM DIA11MM SUBTALAR FOR ARTHROEREISIS PROSTOP,SUP-2121858,CDM,C1713,HCPCS,0278,RC,,,,both,,,4694.30,3051.29,,,,,,,,,,,,,
HC Arterial Puncture Withdrawal Blood Dx,PX-3003660000,CDM,36600,CPT,0300,RC,,,,both,,,39.00,25.35,,,,,,,,,,,,,
DEFIBRILLATOR IMPL EPIC II HF THK 13 MM 36 CC 74 GM TI,SUP-2356586,CDM,C1882,HCPCS,0275,RC,,,,both,,,65940.00,42861.00,,,,,,,,,,,,,
SCREW ACET MOD TIB SPACER,SUP-2449279,CDM,C1713,HCPCS,0278,RC,,,,both,,,310.86,202.06,,,,,,,,,,,,,
CABLE ORTH L750MM DIA1MM TI SURG SMOOTH W CRMP,SUP-2193595,CDM,C1713,HCPCS,0278,RC,,,,both,,,1496.27,972.58,,,,,,,,,,,,,
PLATE 3.5MM TI LCP TM PROX TIBIA PLATE 6H 107MM RIGHT-STER,SUP-2549542,CDM,C1713,HCPCS,0278,RC,,,,both,,,3469.04,2254.88,,,,,,,,,,,,,
NYSTATIN 100000 UNIT/GM EX OINT,RX-5750,CDM,6370000000,HCPCS,0637,RC,45802-0048-35,NDC,,both,15,GR,63.00,40.95,,,,,,,,,,,,,
PLATE BNE PUBIC SYMPHYSIS PELV 4 HOLE,SUP-2518369,CDM,C1713,HCPCS,0278,RC,,,,both,,,3334.68,2167.54,,,,,,,,,,,,,
HC Repair Tun or Non Cath W/Port,PX-3613657600,CDM,36576,CPT,0361,RC,,,,outpatient,,,6875.00,4468.75,,,,,,,,,,,,,
PROBE SURG CALIB ELITE,SUP-2849110,CDM,2720000010,LOCAL,0272,RC,,,,both,,,615.44,400.04,,,,,,,,,,,,,
MESH HERN 14X6IN COMP STOMY,SUP-2752149,CDM,C1781,HCPCS,0278,RC,,,,both,,,3109.23,2021.00,,,,,,,,,,,,,
TRAY SURG PROC UMBILICAL W/3.5,SUP-2864586,CDM,2720000010,LOCAL,0272,RC,,,,both,,,406.79,264.41,,,,,,,,,,,,,
POTASSIUM BICARB-CITRIC ACID 10 MEQ PO TBEF,RX-87911,CDM,6370000000,HCPCS,0637,RC,51801-0014-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
HEAD HUM 17MM HT 41MM DIA INTEGR - 17MM HT 41MM DIAM,SUP-2408633,CDM,C1776,CPT,0278,RC,,,,both,,,3249.90,2112.43,,,,,,,,,,,,,
BIT DRL L17MM WRK L6MM OD1.6MM FOR 2/2.3MM SCR,SUP-2364188,CDM,2720000010,LOCAL,0272,RC,,,,both,,,781.99,508.29,,,,,,,,,,,,,
HC So2 Anti Striated Antibody,PX-3028625568,CDM,86255,CPT,0302,RC,,,,inpatient,,,55.00,35.75,,,,,,,,,,,,,
PLATE BNE L293MM THK3.4MM 22 H BILAT S STL STR LOK COMPR,SUP-2185159,CDM,C1713,HCPCS,0278,RC,,,,both,,,2265.82,1472.78,,,,,,,,,,,,,
SYSTEM FIX DIA9-10MM FEM HRD SCR SHTH INTRAFIX,SUP-2256826,CDM,C1776,CPT,0278,RC,,,,both,,,2204.28,1432.78,,,,,,,,,,,,,
CATHETERIZATION KIT 7 FRX8 IN CV 3 LUMEN BLU FLEXTIP,SUP-2383298,CDM,C1751,HCPCS,0278,RC,,,,both,,,102.02,66.31,,,,,,,,,,,,,
KIT INSTR DISP FOR MIC BIO SUTURETAK,SUP-2121001,CDM,2720000010,LOCAL,0272,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
SHELL ACET OD60MM LNR DML DBL MOBILITY MPACT,SUP-2267382,CDM,C1776,CPT,0278,RC,,,,both,,,8732.34,5676.02,,,,,,,,,,,,,
COIL DETACH 4MM DIA 10CM COIL OUTER DIA 0125IN VOL 792MM,SUP-2173104,CDM,C1889,HCPCS,0278,RC,,,,both,,,5947.16,3865.65,,,,,,,,,,,,,
WASHER SPNL 2 INNIE SPLIT TI NS EXPEDIUM,SUP-2590388,CDM,C1713,HCPCS,0278,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
COIL VASC AZUR HYDROCOIL L 5 CM DIA 4 MM MICROCATHETER 0.035,SUP-2385395,CDM,C1889,HCPCS,0278,RC,,,,both,,,3425.11,2226.32,,,,,,,,,,,,,
BUR SURG MATCHSTICK LNG 3 MM FLUT LESS AGGRESSIVE CARBIDE,SUP-2848157,CDM,2720000010,LOCAL,0272,RC,,,,both,,,641.00,416.65,,,,,,,,,,,,,
BIT DRL DIA2.4MM S STL LABRUM FLUT NONCANNULATED CINCHLOCK,SUP-2366747,CDM,2720000010,LOCAL,0272,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
GRAFT BNE SUB L W10XH7XL50MM COMPRESSIBLE SPNG STRP PROVIDE,SUP-2138507,CDM,C1713,HCPCS,0278,RC,,,,both,,,7322.10,4759.36,,,,,,,,,,,,,
ELECTRODE ENDO L36CM DIA5FR MPLR NDL,SUP-2218057,CDM,C1713,HCPCS,0278,RC,,,,both,,,1178.94,766.31,,,,,,,,,,,,,
BIT DRL DIA3MM CANN FOR ANK FUS PLATING SYS,SUP-2123203,CDM,2720000010,LOCAL,0272,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
RETRIEVER ENDOSCP L200CM BLLN DIA9-12MM CATH 6-7FR BILI PRO,SUP-2149619,CDM,2720000010,LOCAL,0272,RC,,,,both,,,468.96,304.82,,,,,,,,,,,,,
STAPLE INT WHT BLU G GRN BLK REINF FOR ENDOPATH ECHELON FLX,SUP-2395281,CDM,C1781,HCPCS,0278,RC,,,,both,,,523.34,340.17,,,,,,,,,,,,,
WEDGE ACF ILIUM CREST TRADITION ALLGRFT 6 MM FRZ DRY,SUP-2294061,CDM,C1713,HCPCS,0278,RC,,,,both,,,2361.28,1534.83,,,,,,,,,,,,,
BIT DRL 3.2X40 MM DURALOC,SUP-2453984,CDM,2720000010,LOCAL,0272,RC,,,,both,,,285.43,185.53,,,,,,,,,,,,,
EXTENSION STEM L205MM OD13MM HIP FEM MOD PLSM SPRY IMP,SUP-2217205,CDM,C1776,CPT,0278,RC,,,,both,,,2731.80,1775.67,,,,,,,,,,,,,
SCREW BNE FEN N FORCE 73MM X 100MM,SUP-2414077,CDM,C1713,HCPCS,0278,RC,,,,both,,,2166.60,1408.29,,,,,,,,,,,,,
BUR SURG MATCHSTICK LNG 3 MM FLUT FOR HD/HD-G1,SUP-2848171,CDM,2720000010,LOCAL,0272,RC,,,,both,,,397.96,258.67,,,,,,,,,,,,,
CATHETER CTRL VEN SGL LUMN N TUNNELED BASIC SET POLYUR N,SUP-2120633,CDM,C1751,HCPCS,0278,RC,,,,both,,,42.67,27.74,,,,,,,,,,,,,
CLIP ANEUR T BAR 45 DEG 9 MM PERM TI STRL YASRG,SUP-2108699,CDM,C1889,HCPCS,0278,RC,,,,both,,,5960.19,3874.12,,,,,,,,,,,,,
PPICC PROV SOLO PED 4F DL DELTA,SUP-2613527,CDM,C1751,HCPCS,0278,RC,,,,both,,,1015.79,660.26,,,,,,,,,,,,,
MESH HERN W6XL6IN POLYPR MFIL SQ NONABSORBABLE,SUP-2125749,CDM,C1781,HCPCS,0278,RC,,,,both,,,456.87,296.97,,,,,,,,,,,,,
TUBE GASTROSTMY 40FR L107CM CLS ROUNDED TIP SM SIDE H,SUP-2138634,CDM,2720000010,LOCAL,0272,RC,,,,both,,,750.46,487.80,,,,,,,,,,,,,
PYRIDOXINE HCL 25 MG PO TABS,RX-6746,CDM,6370000000,HCPCS,0637,RC,00536-4406-01,NDC,,both,1,UN,0.20,0.13,,,,,,,,,,,,,
PORT ACCESS GASTRIC LAPAROSCOPIC LAP-BAND AP,SUP-2119225,CDM,C1788,HCPCS,0278,RC,,,,both,,,2025.30,1316.44,,,,,,,,,,,,,
INSERT TIBIAL CRT ULTRA TIB INS SZ3 16MM,SUP-2513011,CDM,C1776,CPT,0278,RC,,,,both,,,6220.97,4043.63,,,,,,,,,,,,,
PORT INFUS 9.5FR PLAS INTMED 2 LUMN PEEL APART PERC INTRO,SUP-2127742,CDM,C1788,HCPCS,0278,RC,,,,both,,,1039.34,675.57,,,,,,,,,,,,,
HANDLE SL DRL 4 POS,SUP-2188579,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1210.63,786.91,,,,,,,,,,,,,
SET INTRO ARROWG+ARD BLU SHTH L 10 CM DIA 9 FR GUIDEWIRE L,SUP-2383328,CDM,C1894,HCPCS,0272,RC,,,,both,,,190.76,123.99,,,,,,,,,,,,,
CATHETER BLLN DIL 0.035 IN 75 CM 8-10 MMX3 CM CRE,SUP-2141508,CDM,C1726,HCPCS,0272,RC,,,,both,,,953.99,620.09,,,,,,,,,,,,,
HC Splint App Long Leg,PX-4502950500,CDM,29505,CPT,0450,RC,,,,inpatient,,,214.00,139.10,,,,,,,,,,,,,
PLATE BNE STR 0.8 MM 6 HOLE,SUP-2262685,CDM,C1713,HCPCS,0278,RC,,,,both,,,483.47,314.26,,,,,,,,,,,,,
POLYETHYLENE GLYCOL 3350 17 G PO PACK,RX-25424,CDM,6370000000,HCPCS,0637,RC,62559-0157-10,NDC,,both,1,UN,11.50,7.47,,,,,,,,,,,,,
SYSTEM EMB EMBOLIC PROTCT TARGET VASC COIL DETACH INZONE 2,SUP-2367921,CDM,2720000010,LOCAL,0272,RC,,,,both,,,816.40,530.66,,,,,,,,,,,,,
INSTRUMENT KIT HIP STR KNOTLESS FIBERTAK DISP,SUP-2423108,CDM,C1713,HCPCS,0278,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
CATHETER PACE SSPC1 C CRV STRL,SUP-2863104,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
ROD SPNL L25MM DIA5.5MM OPN OFFSET CONN CREO,SUP-2228689,CDM,C1713,HCPCS,0278,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
PLATE BNE L81MM THK3.5MM XLN R CALCNL S STL LOK COMPR FOR,SUP-2185992,CDM,C1713,HCPCS,0278,RC,,,,both,,,2179.98,1416.99,,,,,,,,,,,,,
ALLOGRAFT HUM TISS TEND 8-12.5X77-95 MM JRF GRAFTLINK XL,SUP-2264640,CDM,C1713,HCPCS,0278,RC,,,,both,,,8101.20,5265.78,,,,,,,,,,,,,
IMPLANT OP RM MINI-MONSTER 2.0X12MM H,SUP-2320867,CDM,C1713,HCPCS,0278,RC,,,,both,,,692.37,450.04,,,,,,,,,,,,,
PUNCH ENDOSCP TIP 9 DEG DIA 3.4 MM SQ UPSHAFT NS REUSE,SUP-2908582,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4895.26,3181.92,,,,,,,,,,,,,
PORT ACCESS GASTRIC LAP-BAND AP,SUP-2119224,CDM,C1788,HCPCS,0278,RC,,,,both,,,1868.30,1214.39,,,,,,,,,,,,,
PROBE NERVE STIM FLSH TIP 0.2 MM 130-270 MM SLIDESHAFT,SUP-2871474,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
GUIDEWIRE VASC L40CM DIA0018IN S STL PLAT TIP MAK NV,SUP-2302990,CDM,C1769,HCPCS,0272,RC,,,,both,,,70.96,46.12,,,,,,,,,,,,,
GRAFT BLGCL TSSUE W10XL16CM RCNSTRCTVE MTRX FIRM STRTTCE,SUP-2458367,CDM,Q4130,HCPCS,0636,RC,,,,both,,,15386.00,10000.90,,,,,,,,,,,,,
CLAMP INDEPENDENT WIRE FOR SHEFFIELD STERILISATION TY SYS,SUP-2316251,CDM,2720000010,LOCAL,0272,RC,,,,both,,,530.41,344.77,,,,,,,,,,,,,
SCREW BNE CANN 4X36 MM ASNS III,SUP-2362426,CDM,C1713,HCPCS,0278,RC,,,,both,,,562.37,365.54,,,,,,,,,,,,,
COIL EMB L10CM LOOP DIA6MM PERIPH SELF EXP HYDRGEL POLYMER,SUP-2385398,CDM,C1889,HCPCS,0278,RC,,,,both,,,3710.57,2411.87,,,,,,,,,,,,,
DRILL SURG 15MM SHT MINI QUIK CONN VLP MINI MOD,SUP-2351108,CDM,2720000010,LOCAL,0272,RC,,,,both,,,624.39,405.85,,,,,,,,,,,,,
LUTETIUM LU 177 VIPIVOTIDE TET 1000 MBQ/ML IV SOLN,RX-157859,CDM,A9607,HCPCS,0344,RC,69488-0010-61,NDC,,both,1,UN,205729.50,133724.17,,,,,,,,,,,,,
GRAFT VASC STR STD WALL N RNGD STRTCH 6MM DIA 45CM LEN,SUP-2395839,CDM,C1768,CPT,0278,RC,,,,both,,,2458.62,1598.10,,,,,,,,,,,,,
CROSSLINK SPNL L39-45MM POST THORLUM TI MSPAN PLT LO PROF,SUP-2289529,CDM,C1713,HCPCS,0278,RC,,,,both,,,1938.95,1260.32,,,,,,,,,,,,,
DEVICE SUTURING,SUP-2330450,CDM,2720000010,LOCAL,0272,RC,,,,both,,,449.02,291.86,,,,,,,,,,,,,
SHEATH INTRO FLX SHUTTLE SEL L 90 CM OD 6 FR GUIDEWIRE 0.038,SUP-2170004,CDM,C1894,HCPCS,0272,RC,,,,both,,,341.13,221.73,,,,,,,,,,,,,
LO-PRO SCRW INSTRU-MENT CS 4.5/6.7MM,SUP-2814868,CDM,C1713,HCPCS,0278,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
RING ACET SZ 23 HIP LOK REPL RNGLOC,SUP-2403338,CDM,C1776,CPT,0278,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
STEM TIB L65MM DIA11MM KNEE PRI GMK,SUP-2267618,CDM,C1776,CPT,0278,RC,,,,both,,,4309.65,2801.27,,,,,,,,,,,,,
GUIDEWIRE VASC 0.014 INX300 CM 35 CM EXCHANGE LEN SYNCHRO-14,SUP-2367845,CDM,C1769,HCPCS,0272,RC,,,,both,,,2311.04,1502.18,,,,,,,,,,,,,
GRAFT BNE 5MMX100MM CORT MTCH STK FEM FRZ DRY ALLGRFT,SUP-2264710,CDM,C1713,HCPCS,0278,RC,,,,both,,,1106.07,718.95,,,,,,,,,,,,,
PLATE BONE LOK CMPRSSN 115MML HLX6 TIMAX CRTCL BROAD PRE CNT,SUP-2588753,CDM,C1713,HCPCS,0278,RC,,,,both,,,3842.83,2497.84,,,,,,,,,,,,,
COLLAR CERV ADJ UNIV AD 13-19 IN 2 PC RIGID REPL PD VISTA TX,SUP-2196893,CDM,L0120,HCPCS,0272,RC,,,,both,,,140.48,91.31,,,,,,,,,,,,,
HC Stent Place Venous Ea Add,PX-3603723900,CDM,37239,CPT,0360,RC,,,,both,,,15457.00,10047.05,,,,,,,,,,,,,
KIT CATH HEMODIALYSI DUET CHRONIC STD 10FR DIA 19/22CMLAV IN,SUP-2613274,CDM,C1750,HCPCS,0278,RC,,,,both,,,1447.54,940.90,,,,,,,,,,,,,
COMPONENT 3.5X124MM HUMERAL ELBOW FLANGED C LEFT DISCOVERY,SUP-2879166,CDM,C1776,CPT,0278,RC,,,,both,,,16061.10,10439.71,,,,,,,,,,,,,
PLATE BNE 10 H STRNL TI X LOK FOR 3MM SCR,SUP-2192441,CDM,C1713,HCPCS,0278,RC,,,,both,,,2690.35,1748.73,,,,,,,,,,,,,
GRAFT VASC GORTX L 70 CM DIA 6 MM RNG L 20 CM EPTFE STR TW,SUP-2396153,CDM,C1768,CPT,0278,RC,,,,both,,,3246.76,2110.39,,,,,,,,,,,,,
FIBER LASER 1000UM HOLM SMRT ID SYS REUSE FOR ALL LUMENIS LASER,SUP-2141792,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3123.45,2030.24,,,,,,,,,,,,,
CLIP SM STIM DYN,SUP-2310408,CDM,C1713,HCPCS,0278,RC,,,,both,,,1299.96,844.97,,,,,,,,,,,,,
SUTURE NONABSORBABLE MONOFILAMENT CV-6 TT-09 36 IN DA 6N02B,SUP-2395546,CDM,C1713,HCPCS,0278,RC,,,,both,,,834.20,542.23,,,,,,,,,,,,,
CLIP ANEURYSM BLADE L30MM OPENING 19MM PHYNOX LONG PERMANENT,SUP-2821641,CDM,C1889,HCPCS,0278,RC,,,,both,,,1591.45,1034.44,,,,,,,,,,,,,
HC Deliver Placenta,PX-7205941400,CDM,59414,CPT,0720,RC,,,,outpatient,,,10518.00,6836.70,,,,,,,,,,,,,
COIL NEUROVASCULAR GDC-10 360 DEG L 6 CM DIA 3 MM,SUP-2362411,CDM,C1889,HCPCS,0278,RC,,,,both,,,6143.41,3993.22,,,,,,,,,,,,,
PEG BONE SBCHNDRL DST VOLAR RDS THRD 2.5X34 MM TTNM,SUP-2588902,CDM,C1713,HCPCS,0278,RC,,,,both,,,229.03,148.87,,,,,,,,,,,,,
GRAFT TISS SPCR CERV CANC FRZ DRY ALLGRFT 5MM,SUP-2307220,CDM,C1713,HCPCS,0278,RC,,,,both,,,2135.20,1387.88,,,,,,,,,,,,,
CLIP SURG SZ 1 CLS TB DISP FOR GAM 3,SUP-2368479,CDM,2720000010,LOCAL,0272,RC,,,,both,,,580.90,377.58,,,,,,,,,,,,,
CATHETER NEPHROSTOMY 8 FRX30 CM LCK PGTL GEN TOT ABSCESSION,SUP-2424173,CDM,C1729,HCPCS,0272,RC,,,,both,,,1095.86,712.31,,,,,,,,,,,,,
JACKET ORTHOT CUST POST OPERATIVE BODY,SUP-2435594,CDM,L1310,HCPCS,0272,RC,,,,both,,,5082.28,3303.48,,,,,,,,,,,,,
INSERT TIB THICKNESS 19MM L CNDYL KNEE PRI STBL NEUT UNIV,SUP-2377418,CDM,C1776,CPT,0278,RC,,,,both,,,2479.82,1611.88,,,,,,,,,,,,,
PLATE BNE THK0.6MM 16 H MAND TI STR LO PROF FOR 2MM SCR,SUP-2262931,CDM,C1713,HCPCS,0278,RC,,,,both,,,211.79,137.66,,,,,,,,,,,,,
CATHETER HD STR 7 FRX7 CM SHT TERM DL BASIC SET SOFT-LINE,SUP-2627337,CDM,C1752,HCPCS,0278,RC,,,,both,,,244.92,159.20,,,,,,,,,,,,,
GUIDEWIRE ORTHOPEDIC 1.6X220 MM TROCAR PT 1 END,SUP-2424097,CDM,C1769,HCPCS,0272,RC,,,,both,,,246.55,160.26,,,,,,,,,,,,,
NEEDLE INTRO 17GA L11.8CM BNE MAR BX OPT ECHOGENIC COAX MCXS1815BP] ARGON MEDICAL DEVICES INC],SUP-2120167,CDM,C1894,HCPCS,0272,RC,,,,both,,,62.74,40.78,,,,,,,,,,,,,
PIN HALF SD 150X30 MM 5 MM THRD,SUP-2372342,CDM,C1713,HCPCS,0278,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
CATHETER VASC GUID STR PERIPH W/ HYDRPHLC COAT AD,SUP-2139771,CDM,C1725,HCPCS,0272,RC,,,,both,,,757.21,492.19,,,,,,,,,,,,,
BIT DRL L L280MM DIA15MM TI CANN OPN MDLLRY CNL FLX QUIK,SUP-2178840,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1459.41,948.62,,,,,,,,,,,,,
CLAV SUP PLT RT 12H 125MM NS,SUP-2724399,CDM,C1713,HCPCS,0278,RC,,,,both,,,4731.98,3075.79,,,,,,,,,,,,,
ANCHOR SUTURE DIA 4.75 MM SUTURE TAPE SZ 1.8 MM PEEK W/ 2,SUP-2905878,CDM,C1713,HCPCS,0278,RC,,,,both,,,1642.22,1067.44,,,,,,,,,,,,,
PLATE BNE DBL Y MED 1.5X18X0.8 MM MIDFACE 6 HOLE W/ TAB NS,SUP-2491633,CDM,C1713,HCPCS,0278,RC,,,,both,,,884.91,575.19,,,,,,,,,,,,,
SEAT CLOSE MULTAXL VAR ANG LCK,SUP-2415639,CDM,C1713,HCPCS,0278,RC,,,,both,,,1735.54,1128.10,,,,,,,,,,,,,
BLADE SCRWDRVR F/RED II CMPLTE RIGID EXTRNL DISTR SSTM,SUP-2496051,CDM,2720000010,LOCAL,0272,RC,,,,both,,,771.84,501.70,,,,,,,,,,,,,
PACEMAKER CARD ESSENTIO DR W 4.45 X H 5.88 CM THK 0.75 CM,SUP-2149246,CDM,C1785,HCPCS,0275,RC,,,,both,,,25336.66,16468.83,,,,,,,,,,,,,
COVER BUR H 10MM W/ TAB,SUP-2365222,CDM,C1713,HCPCS,0278,RC,,,,both,,,1000.25,650.16,,,,,,,,,,,,,
PACK NEUROSURGICAL SHTH L 60 X W 11 MM MYRIAD HNDPC L 13 CM,SUP-2930210,CDM,2720000010,LOCAL,0272,RC,,,,both,,,18113.75,11773.94,,,,,,,,,,,,,
FIBER LASER 328 FT KRA-CPAOCHXL HDMI,SUP-2798106,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2709.73,1761.32,,,,,,,,,,,,,
PYRIDOXINE HCL 100 MG/ML IJ SOLN,RX-6744,CDM,J3415,HCPCS,0636,RC,63323-0180-01,NDC,,both,0.5,ML,62.50,40.62,,,,,,,,,,,,,
PROSTHESIS OSS EAR 10.2 MM INCUS-STAPE WEHRS,SUP-2342766,CDM,L8613,CPT,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
PLATE BNE L 66 MM 14 H TI REAR FT RECON NS TOT FT SYS 2,SUP-2933698,CDM,C1713,HCPCS,0278,RC,,,,both,,,4412.80,2868.32,,,,,,,,,,,,,
RETRACTOR HOSP CHLD 575IN DBL END,SUP-2244667,CDM,C1713,HCPCS,0278,RC,,,,both,,,90.02,58.51,,,,,,,,,,,,,
ROD EXT FIX L174MM DIA8MM UP L C FBR CRV SEMICIRCULAR MRI,SUP-2372442,CDM,2720000010,LOCAL,0272,RC,,,,both,,,675.10,438.81,,,,,,,,,,,,,
CATHETER SURG L24 MM OD5 FR SINUS RELIEVA SOLO,SUP-2106313,CDM,C1729,HCPCS,0272,RC,,,,both,,,2562.24,1665.46,,,,,,,,,,,,,
DEFIBRILLATOR 2 CHMBR CARDIOVERTER 36 J W/ 1 LD BPLR REMOT,SUP-2356546,CDM,C1721,HCPCS,0275,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
FORCEPS SURG L5 3 8IN CUP W1MM SATIN FINISH STR RHOT,SUP-2160870,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1013.40,658.71,,,,,,,,,,,,,
KIT BNE CEMENT SZ 40 45.3 GM PWDR 38.2 GM/0.5 GM LIQ 20 ML,SUP-2916789,CDM,C1713,HCPCS,0278,RC,,,,both,,,10917.78,7096.56,,,,,,,,,,,,,
PLATE BONE L81MM 10 H LCK RECON BILAT RIG FOR 2.7MM SCR,SUP-2348297,CDM,C1713,HCPCS,0278,RC,,,,both,,,5467.21,3553.69,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY RADIA L 95 CM DIA 7 FR SPC 2-10-2,SUP-2142362,CDM,C1731,HCPCS,0278,RC,,,,both,,,3249.90,2112.43,,,,,,,,,,,,,
HEAD STEPTECH APG 52+5MM RIGHT,SUP-2512730,CDM,C1776,CPT,0278,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
MICROCATHETER GUID TELEPORT CTRL L 135 CM DIA PROX 2.7/2.1,SUP-2159487,CDM,C1887,HCPCS,0272,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
CATHETER GASTJEJUSTMY 22/10.2 FRX7/80 CM 2 SP CAR ALZ COON,SUP-2169721,CDM,C1729,HCPCS,0272,RC,,,,both,,,310.80,202.02,,,,,,,,,,,,,
STEM FEM L170MM DIA13MM HIP CO CHROM INTLOK PRI CEM TAPR,SUP-2403348,CDM,C1776,CPT,0278,RC,,,,both,,,4584.40,2979.86,,,,,,,,,,,,,
SHEATH INTRO PERFRMR L 13 CM OD 4 FR ID 1.3 MM GUIDEWIRE,SUP-2168305,CDM,C1894,HCPCS,0272,RC,,,,both,,,54.35,35.33,,,,,,,,,,,,,
PLATE BNE 2.7X145 MM 16 HOLE SS LC-DCP,SUP-2569223,CDM,C1713,HCPCS,0278,RC,,,,both,,,416.21,270.54,,,,,,,,,,,,,
CATHETER CARD ABLATION QDOT MIC L 115 CM 8 FR 3.5 MM D-F TYP,SUP-2880099,CDM,C1732,HCPCS,0272,RC,,,,both,,,12365.32,8037.46,,,,,,,,,,,,,
ANKLE FUSION PLATE POSTERIOR TTC LEFT,SUP-2815099,CDM,C1713,HCPCS,0278,RC,,,,both,,,7143.50,4643.27,,,,,,,,,,,,,
REAMER SURG 16MM MT JT CUP GEN 2,SUP-2398414,CDM,2720000010,LOCAL,0272,RC,,,,both,,,715.92,465.35,,,,,,,,,,,,,
PLATE BNE L L114MM 2X4 H L MT TI POLYAX LOK COMPR LO PROF,SUP-2398498,CDM,C1713,HCPCS,0278,RC,,,,both,,,6955.10,4520.81,,,,,,,,,,,,,
CLIP INT LIG MED TI BLU VESOCCLUDE,SUP-2757594,CDM,C1889,HCPCS,0278,RC,,,,both,,,33.91,22.04,,,,,,,,,,,,,
TRAY HEMO DYLS OR HD CATH AD L45CM INSRTN L28CM POLYUR ADMIN,SUP-2174220,CDM,C1750,HCPCS,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
CATHETER CV MAXIMAL BARR TY 10 FRX15 CM 5 LUMEN QUINT,SUP-2759872,CDM,C1751,HCPCS,0278,RC,,,,both,,,742.64,482.72,,,,,,,,,,,,,
KIT CRUCE ACC 2.4MM DRL TIP GUID WIRE 2.7MM DRL TIP PASS,SUP-2341590,CDM,C1769,HCPCS,0272,RC,,,,both,,,815.02,529.76,,,,,,,,,,,,,
CEMENT LUTING GLS IONOMER FOR SGL UNIT KETAC-CEM APLICAP,SUP-2238639,CDM,C1713,HCPCS,0278,RC,,,,both,,,581.65,378.07,,,,,,,,,,,,,
HC US Gd Tiss Parench Ablation,PX-4027694000,CDM,76940,CPT,0402,RC,,,,both,,,1295.00,841.75,,,,,,,,,,,,,
PATCH VASC HEMAPATCH L 50 X W 25 MM THK 0.65 MM POLYESTER,SUP-2914824,CDM,C1768,CPT,0278,RC,,,,both,,,533.55,346.81,,,,,,,,,,,,,
SCREW BONE L5MM DIA2MM CRANIOMAXILLOFACIAL TI ST LCK FULL,SUP-2189379,CDM,C1713,HCPCS,0278,RC,,,,both,,,372.40,242.06,,,,,,,,,,,,,
PLATE BNE DBL ANGLED SM 2.5 MM RECON MAXILLA PT SPEC,SUP-2860098,CDM,C1713,HCPCS,0278,RC,,,,both,,,27765.14,18047.34,,,,,,,,,,,,,
CATHETER GUID 6FR L55CM BLU PTFE RDC I TRUELUMEN HYBRID,SUP-2158222,CDM,C1887,HCPCS,0272,RC,,,,both,,,244.92,159.20,,,,,,,,,,,,,
KNIFE SURG MCCABE CNL 6-1/8 IN 2.5 MM EAR CNL SHRP TIP LF,SUP-2460860,CDM,2720000010,LOCAL,0272,RC,,,,both,,,300.00,195.00,,,,,,,,,,,,,
CATHETER GUID ENVOY L 100 CM OD 6 FR ID 0.07 IN MPC,SUP-2461470,CDM,C1887,HCPCS,0272,RC,,,,both,,,1710.08,1111.55,,,,,,,,,,,,,
BRACE WALKING EMBEDDED SOLE X LG SHT ANK ROCKER BTM INLINE,SUP-2336134,CDM,L4361,HCPCS,0274,RC,,,,both,,,93.29,60.64,,,,,,,,,,,,,
OPACIFIER BONE CEM 5GM RADPQ TRACERS,SUP-2342140,CDM,C1713,HCPCS,0278,RC,,,,both,,,265.33,172.46,,,,,,,,,,,,,
KYPHOPLASTY KIT 1ST FRAC 20/3 IBT KYPHON OSTEO INTRO,SUP-2743796,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8666.40,5633.16,,,,,,,,,,,,,
PLATE BNE L73MM 3 H ST L LAT DST FIBULAR S STL LOK COMPR,SUP-2177412,CDM,C1713,HCPCS,0278,RC,,,,both,,,1866.26,1213.07,,,,,,,,,,,,,
KIT RING FIX TC 555 50PC SET,SUP-2326378,CDM,2720000010,LOCAL,0272,RC,,,,both,,,781.26,507.82,,,,,,,,,,,,,
MESH HERN 12X12IN POLY 4 HYDROXYBUTYRATE SYN SQ WVN,SUP-2126266,CDM,C1781,HCPCS,0278,RC,,,,both,,,36863.60,23961.34,,,,,,,,,,,,,
STENT URET L 26 CM DIA 8.5 FR PTFE GUIDEWIRE L 100 CM DIA,SUP-2312686,CDM,C2617,HCPCS,0278,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
CEMENT BNE 20GM PMMA TWIN PK VERTAPLEX HV,SUP-2368276,CDM,C1713,HCPCS,0278,RC,,,,both,,,1356.79,881.91,,,,,,,,,,,,,
GRAFT HUM TISS L12MM MPJ ARTH SEG FOR DEFORMITY CORR,SUP-2436366,CDM,C1713,HCPCS,0278,RC,,,,both,,,4309.65,2801.27,,,,,,,,,,,,,
COLLAR CERV L H3.25IN FOR 16-19IN PLASTAZOTE FOAM 2 PC L,SUP-2336003,CDM,L0140,HCPCS,0274,RC,,,,both,,,30.11,19.57,,,,,,,,,,,,,
SCREW BNE L10MM DIA3.5MM CANC BIODUR ALLY ST SELF DRL CANN,SUP-2409797,CDM,C1713,HCPCS,0278,RC,,,,both,,,542.59,352.68,,,,,,,,,,,,,
SPHINCTEROTOME ENDOSCP CATH 7FR 0.035IN ACC CHN 3.2MM DOME,SUP-2170082,CDM,C1769,HCPCS,0272,RC,,,,both,,,766.16,498.00,,,,,,,,,,,,,
DOXYCYCLINE HYCLATE 50 MG PO CAPS,RX-2624,CDM,6370000000,HCPCS,0637,RC,00143-9802-50,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
COMPONENT TIB SZ 5 THK7MM LT MEDL RT LAT ANTR POST KNEE ALL,SUP-2251269,CDM,C1776,CPT,0278,RC,,,,both,,,4596.96,2988.02,,,,,,,,,,,,,
CATHETER INTVENT L90CM OD6FR BAL L40MM OD7MM,SUP-2353074,CDM,C1725,HCPCS,0272,RC,,,,both,,,3.14,2.04,,,,,,,,,,,,,
SLEEVE 14MM OUTER SPNL LUM TAPR FUS DBL BRL L CAGE,SUP-2291605,CDM,C1713,HCPCS,0278,RC,,,,both,,,2169.90,1410.43,,,,,,,,,,,,,
PLATE BNE L54MM 2X8 H TI T SHP RIG NONCOMPRESSION FOR 2.4MM,SUP-2191471,CDM,C1713,HCPCS,0278,RC,,,,both,,,1912.10,1242.86,,,,,,,,,,,,,
BASEPLATE TIB SZ 4 UNIV LT MEDL RT LAT SAMP JOURNEY,SUP-2346857,CDM,C1776,CPT,0278,RC,,,,both,,,328.13,213.28,,,,,,,,,,,,,
DILATOR SURG L14CM OD1-5MM SH SGL END VASC MALL SHFT REUSE,SUP-2384418,CDM,C1713,HCPCS,0278,RC,,,,both,,,744.18,483.72,,,,,,,,,,,,,
SCREW BONE STD -5 MM DIA 50 MM LEN CANC THRD N CANN N LCK N,SUP-2417719,CDM,C1713,HCPCS,0278,RC,,,,both,,,389.36,253.08,,,,,,,,,,,,,
TREPHINE 14MM ID X 8IN,SUP-2515458,CDM,2720000010,LOCAL,0272,RC,,,,both,,,772.44,502.09,,,,,,,,,,,,,
PLATE BONE W14.9XL216MM THK1.2MM 13 H DSTL TIB S STL,SUP-2185742,CDM,C1713,HCPCS,0278,RC,,,,both,,,1469.71,955.31,,,,,,,,,,,,,
BIT OVERDRILL DIA 5.5 MM AO QC LG TARGETER SYS STRL DISP,SUP-2933095,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1543.94,1003.56,,,,,,,,,,,,,
SHUNT NEUROSURGICAL L30CM OD9FR CK VLV BLLN W/O RESVR,SUP-2214694,CDM,C1889,HCPCS,0278,RC,,,,both,,,524.63,341.01,,,,,,,,,,,,,
PLATE BONE W14.9XL152MM THK1.2MM 9 H DSTL TIB S STL,SUP-2185738,CDM,C1713,HCPCS,0278,RC,,,,both,,,1125.50,731.57,,,,,,,,,,,,,
PLATE BNE CRV BROAD PEDIATRIC 3.5 MM 22 HOLE SS NS LCP,SUP-2799224,CDM,C1713,HCPCS,0278,RC,,,,both,,,3062.07,1990.35,,,,,,,,,,,,,
ADAPTER CBL 6MM PACEMKR UPLR,SUP-2357323,CDM,C1883,HCPCS,0278,RC,,,,both,,,816.40,530.66,,,,,,,,,,,,,
ALLOGRAFT BNE FRZN WHL HUM,SUP-2321818,CDM,C1713,HCPCS,0278,RC,,,,both,,,4226.44,2747.19,,,,,,,,,,,,,
FLUOROPLASTIC VENT TUBE SHPRD GRMMT TYPE WITHOUT TAB WTH WIR,SUP-2681462,CDM,L8699,HCPCS,0278,RC,,,,both,,,26.53,17.24,,,,,,,,,,,,,
PLATE BNE W11XL208MM THK42MM 13 H MTPHSEAL S STL LOK COMPR,SUP-2185266,CDM,C1713,HCPCS,0278,RC,,,,both,,,3387.62,2201.95,,,,,,,,,,,,,
COMPONENT TOT KNEE STD W/TS STEM INSRT,SUP-2379198,CDM,C1776,CPT,0278,RC,,,,both,,,15307.50,9949.87,,,,,,,,,,,,,
GRAFT BONE RIB FROZEN DRIED,SUP-2863662,CDM,C1762,CPT,0278,RC,,,,both,,,5017.72,3261.52,,,,,,,,,,,,,
NAIL IM L300MM DIA13MM UNIV LT GRN PROX TIB TI BEND CANN,SUP-2180443,CDM,C1713,HCPCS,0278,RC,,,,both,,,4441.12,2886.73,,,,,,,,,,,,,
PIN POS 5 MM TI STRL,SUP-2563986,CDM,2720000010,LOCAL,0272,RC,,,,both,,,655.88,426.32,,,,,,,,,,,,,
CATHETER VALVULOPLASTY PED 2.5FR L65CM BAL L2CM DIA4MM INTRO,SUP-2125275,CDM,C1725,HCPCS,0272,RC,,,,both,,,1668.88,1084.77,,,,,,,,,,,,,
PACEMAKER CARD ITREVIA HF-T TI HSNG EPOXY RESIN HEADER SIL,SUP-2138467,CDM,C1882,HCPCS,0275,RC,,,,both,,,77950.50,50667.82,,,,,,,,,,,,,
SEALER TISS L37CM SHFT DIA5MM 360DEG ROT CVD JAW TAPR TIP,SUP-2219740,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4774.90,3103.68,,,,,,,,,,,,,
PLATE S PROFYLE HAND T PLT WD 1.7MM,SUP-2464985,CDM,C1713,HCPCS,0278,RC,,,,both,,,1758.40,1142.96,,,,,,,,,,,,,
SPACER SPNL 2XL W18XH7MM D15MM 7DEG ANTR CERV PEEK LORDTC,SUP-2231256,CDM,C1821,HCPCS,0278,RC,,,,both,,,2135.20,1387.88,,,,,,,,,,,,,
HC Insert Peritoneal Venous Shunt,PX-3614942500,CDM,49425,CPT,0361,RC,,,,inpatient,,,8583.00,5578.95,,,,,,,,,,,,,
PLATE BNE 2X22X1 MM 4 HOLE SS DCP,SUP-2569119,CDM,C1713,HCPCS,0278,RC,,,,both,,,259.05,168.38,,,,,,,,,,,,,
ZOLBETUXIMAB-CLZB 300 MG IV SOLR,RX-171703,CDM,J1326,HCPCS,0636,RC,00469-4425-30,NDC,,both,1,UN,13824.00,8985.60,,,,,,,,,,,,,
PLATE BNE VOLAR MED 24X62 MM LT LCK STRL DVR,SUP-2477141,CDM,C1713,HCPCS,0278,RC,,,,both,,,2986.14,1940.99,,,,,,,,,,,,,
GRAFT BIO TISS W0.8XL8CM DECELLULARIZED BOV PERICARD PTCH,SUP-2175265,CDM,C1763,HCPCS,0278,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
BOOT CAST XSM L17CM TOE W9CM BILAT BLK ETHYL VYN ACETT PRNT,SUP-2196780,CDM,L4387,HCPCS,0272,RC,,,,both,,,14.85,9.65,,,,,,,,,,,,,
GRAFT BONE SUBSTITUTE FIBERGRAFT 4CC,SUP-2741933,CDM,C1713,HCPCS,0278,RC,,,,both,,,7253.40,4714.71,,,,,,,,,,,,,
KIT IMPL DIA 9 MM ALL INSIDE STRL QUADLINK 2.0,SUP-2930401,CDM,C1713,HCPCS,0278,RC,,,,both,,,8964.70,5827.05,,,,,,,,,,,,,
FORTILINK-L TETRAFUSE 26X55X13 12L,SUP-2335272,CDM,C1713,HCPCS,0278,RC,,,,both,,,10362.00,6735.30,,,,,,,,,,,,,
MESH HERN W15XL20CM OVL PREPERI BIOMATERIAL COMP POLYPR,SUP-2395764,CDM,C1781,HCPCS,0278,RC,,,,both,,,4622.08,3004.35,,,,,,,,,,,,,
PLATE BNE L 32.49 MM THK 1 MM SCREW DIA2 MM GAP 15 MM WIDE,SUP-2936770,CDM,C1713,HCPCS,0278,RC,,,,both,,,763.02,495.96,,,,,,,,,,,,,
CATHETER EP LG CURL BI DIR IRRIG SAFIRE,SUP-2357045,CDM,C2630,CPT,0272,RC,,,,both,,,4631.50,3010.47,,,,,,,,,,,,,
SET CATH HEMODIALYSI SPLIT CATH RG CHRONIC BASIC 14FR DIA 24,SUP-2610622,CDM,C1750,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
SPLINT ORTH PNEUMATIC ANK FT CTRL,SUP-2388196,CDM,L4350,HCPCS,0272,RC,,,,both,,,246.96,160.52,,,,,,,,,,,,,
USTEKINUMAB 90 MG/ML SC SOSY,RX-127392,CDM,J3357,HCPCS,0636,RC,57894-0061-03,NDC,,both,0.5,ML,42998.50,27949.02,,,,,,,,,,,,,
BIT SURG CANN 2.4 MM MAX VPC,SUP-2459317,CDM,2720000010,LOCAL,0272,RC,,,,both,,,636.57,413.77,,,,,,,,,,,,,
AUGMENT FEM L59MM THICKNESS 5MM UNIV STD DSTL KNEE PRI CEM,SUP-2199922,CDM,C1776,CPT,0278,RC,,,,both,,,5735.21,3727.89,,,,,,,,,,,,,
GRASPER SUT 30DEG SHRP TIP LO PROF FOR RAP ACCS IN SHLDR,SUP-2249549,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1984.48,1289.91,,,,,,,,,,,,,
PARTIALLY THRD SCREW-6.5X100MM,SUP-2417724,CDM,C1713,HCPCS,0278,RC,,,,both,,,1780.38,1157.25,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY DYN TIP L 110 CM DIA 6 FR SPC 10,SUP-2142176,CDM,C1730,HCPCS,0272,RC,,,,both,,,1284.26,834.77,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 7X7 CM AMNION/CHORION MEMBRN EPIFIX,SUP-2305764,CDM,Q4186,HCPCS,0636,RC,,,,both,,,13188.00,8572.20,,,,,,,,,,,,,
TOWER SPNL REDUC ADDITION REVERE,SUP-2232140,CDM,2780000010,LOCAL,0278,RC,,,,both,,,8321.00,5408.65,,,,,,,,,,,,,
CATH ABLATION TACTIFLEX SE UNID CURVE F,SUP-2874131,CDM,C2630,CPT,0272,RC,,,,both,,,12403.00,8061.95,,,,,,,,,,,,,
SPACER SPNL W9XH7XL22MM LORDTC SELF EXP TANT MRK LO PROF,SUP-2354690,CDM,C1821,HCPCS,0278,RC,,,,both,,,17332.80,11266.32,,,,,,,,,,,,,
SHEATH INTRO MORPHEUS CT DIA 5 FR SPLITTABLE DIL ASMBLY STRL,SUP-2117209,CDM,C1894,HCPCS,0272,RC,,,,both,,,68.14,44.29,,,,,,,,,,,,,
COUNTERSINK SURG CANN REUSE FOR 4.5MM TI SCR SYS,SUP-2187348,CDM,C1713,HCPCS,0278,RC,,,,both,,,1168.05,759.23,,,,,,,,,,,,,
BLADE SHV L8MM DIA2MM PUR SM JT HOOD ABRASION BUR FRMLA,SUP-2366890,CDM,2720000010,LOCAL,0272,RC,,,,both,,,241.47,156.96,,,,,,,,,,,,,
ALLOGRAFT HUM TISS SHT 6X4 CM PLCNTA BASE MEMBRN AMNIOEFFECT,SUP-2871500,CDM,C1762,CPT,0278,RC,,,,both,,,8079.22,5251.49,,,,,,,,,,,,,
PIN EXT FIX HALF CIR FIX OD5MM L180MM L40MM THRD SIDEKCK,SUP-2400701,CDM,C1776,CPT,0278,RC,,,,both,,,335.98,218.39,,,,,,,,,,,,,
SHEET IMPL 38X50X3MM BIOMATERIAL,SUP-2366498,CDM,C1713,HCPCS,0278,RC,,,,both,,,3476.33,2259.61,,,,,,,,,,,,,
"HC Debrid,Musc/Fasc,Ea Add 20sqcm",PX-3611104600,CDM,11046,CPT,0361,RC,,,,both,,,315.00,204.75,,,,,,,,,,,,,
PLATE BNE VOLAR 2XL STD 2.7X100 MM LT DSTL RADIAL 8 HOLE,SUP-2691427,CDM,C1713,HCPCS,0278,RC,,,,both,,,5885.15,3825.35,,,,,,,,,,,,,
SLEEVE TROCAR L110MM DIAMETER 5MM THREADED DISPOSABLE WITHOU,SUP-2804209,CDM,2720000010,LOCAL,0272,RC,,,,both,,,374.51,243.43,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH FLX L 58 MM DIA22 MM SHTH 18 FR SS,SUP-2750387,CDM,C1768,CPT,0278,RC,,,,both,,,6258.02,4067.71,,,,,,,,,,,,,
CATHETER URET PIG 0.038 IN 4.8 FRX70 CM C FLX LF,SUP-2478296,CDM,C1758,HCPCS,0278,RC,,,,both,,,193.71,125.91,,,,,,,,,,,,,
NAIL IM L250MM OD13MM MULT H SUPCNDYL RG LCK CANN ANTR BEND,SUP-2343601,CDM,C1713,HCPCS,0278,RC,,,,both,,,2741.22,1781.79,,,,,,,,,,,,,
LENS INTOCU +3.0 DIOPT DIA13MM A CONSTANT 118.7 PMMA BCNVX,SUP-2129753,CDM,V2632,HCPCS,0276,RC,,,,both,,,266.90,173.48,,,,,,,,,,,,,
BIT DRL L14MM DIA2.2MM G FLAT CHK FOR ANT CERV PLT SYS,SUP-2255671,CDM,2720000010,LOCAL,0272,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
STENT URET ASCERTA L 20 CM DIA 7 FR SYNTH POLYMER FIRM STRL,SUP-2461151,CDM,C2617,HCPCS,0278,RC,,,,both,,,265.33,172.46,,,,,,,,,,,,,
SPACER SPNL H15MM ASMBLY PRIMALOK SP,SUP-2319814,CDM,C1713,HCPCS,0278,RC,,,,both,,,11932.00,7755.80,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED STD CUP HD LNR ST POROUS TRAB MTL,SUP-2212317,CDM,C1776,CPT,0278,RC,,,,both,,,15440.29,10036.19,,,,,,,,,,,,,
CAGE SPNL W11XH11XL21MM 5DEG POST THORLUM C FBR REINF,SUP-2256325,CDM,C1889,HCPCS,0278,RC,,,,both,,,7802.90,5071.88,,,,,,,,,,,,,
BIT DRILL D33MM FRHND TRGTNG TBL NAT NAIL SSTM,SUP-2467095,CDM,2720000010,LOCAL,0272,RC,,,,both,,,527.83,343.09,,,,,,,,,,,,,
BODY EXT FIX STD FEMALE FOR HIP COMP PVC FREE STRL PROCALLUS,SUP-2645896,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4693.86,3051.01,,,,,,,,,,,,,
SPLINT ARM M W18XL13IN FOR 6-17IN LIMB TRNSLUC FAB POLYSTYR,SUP-2328639,CDM,L3702,HCPCS,0272,RC,,,,both,,,34.95,22.72,,,,,,,,,,,,,
BLADE SURG STRT 58 MM FIX HNDL SHFT,SUP-2242468,CDM,2720000010,LOCAL,0272,RC,,,,both,,,737.90,479.63,,,,,,,,,,,,,
TUBE GASTROJEJU 14FR JEJU L22CM STOMA L1.2CM EN LO PROF,SUP-2119811,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1909.12,1240.93,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 90 MM DIA18/22 MM DEL 31ML,SUP-2936823,CDM,C1713,HCPCS,0278,RC,,,,both,,,17138.28,11139.88,,,,,,,,,,,,,
VALVE CSF PROGRAMMABLE 0.030 IN PLATFORM IN-LINE W/ REINF BK,SUP-2863650,CDM,C1889,HCPCS,0278,RC,,,,both,,,16875.43,10969.03,,,,,,,,,,,,,
SLEEVE IM 120DEG LT BLU TI LOK FOR SPRL BLDE 9-12MM NAIL,SUP-2191880,CDM,C1713,HCPCS,0278,RC,,,,both,,,1217.44,791.34,,,,,,,,,,,,,
WIRE OLV THRD 1.3X70MM,SUP-2321637,CDM,2720000010,LOCAL,0272,RC,,,,both,,,351.68,228.59,,,,,,,,,,,,,
CANNULA RF STR 22 GAX100 MM 2 MM SHRP ACTIVE TIP,SUP-2753127,CDM,C1887,HCPCS,0272,RC,,,,both,,,48.67,31.64,,,,,,,,,,,,,
KIT PICC CATH L 55 CM DIA 6 FR SHTH L 7 CM DIA 6 FR,SUP-2884240,CDM,C1751,HCPCS,0278,RC,,,,both,,,604.98,393.24,,,,,,,,,,,,,
BUR SURG BALL 5 MM 14 CM FLUT LG BOR MIDAS REX 8 LEGEND,SUP-2664564,CDM,2720000010,LOCAL,0272,RC,,,,both,,,443.12,288.03,,,,,,,,,,,,,
DEVICE THROMBOLYTIC 7FR L65CM SHTH 2/7FR L2IN 3000RPM PERC,SUP-2239969,CDM,C1757,HCPCS,0272,RC,,,,both,,,3532.50,2296.12,,,,,,,,,,,,,
PLATE BONE W12XL199MM THK1MM 12 H BILAT TI SEMI TBLR LO PROF,SUP-2190710,CDM,C1713,HCPCS,0278,RC,,,,both,,,385.18,250.37,,,,,,,,,,,,,
SHELL ACET SZ F DIA56MM MH OSSEOTI 2 MOBILITY G7,SUP-2403479,CDM,C1713,HCPCS,0278,RC,,,,both,,,7950.48,5167.81,,,,,,,,,,,,,
GRAFT VASC EXXCEL SFT L 45 CM DIA 4-7 MM EPTFE SHRT TAPR STD,SUP-2227652,CDM,C1768,CPT,0278,RC,,,,both,,,1475.42,959.02,,,,,,,,,,,,,
PLATE STRUT 2MM 12H TI STRL VAL,SUP-2546913,CDM,C1713,HCPCS,0278,RC,,,,both,,,2164.46,1406.90,,,,,,,,,,,,,
COIL NEUROVASCULAR CASHMERE 14 L 6 CM LOOP DIA 3 MM PRIMARY,SUP-2249263,CDM,C1889,HCPCS,0278,RC,,,,both,,,3807.25,2474.71,,,,,,,,,,,,,
GUIDEWIRE VASC PHOENIX L 300 CM DIA 0.014 IN SS COR SIL FLPY,SUP-2823718,CDM,C1769,HCPCS,0272,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
WRIST CARPAL BALL IMPLANT SM PLUS,SUP-2706713,CDM,C1713,HCPCS,0278,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
PLATE LCK HIND/MIDFOOT 2.4/2.7MM 8H 45MM,SUP-2547595,CDM,C1713,HCPCS,0278,RC,,,,both,,,2446.41,1590.17,,,,,,,,,,,,,
ALLOGRAFT HUMAN TISS AXIOFILL 250MG,SUP-2865148,CDM,C1762,CPT,0278,RC,,,,both,,,2050.42,1332.77,,,,,,,,,,,,,
KIT CATH 14.5FR L40CM INSRT L23CM POLYUR DBL LUMN STD FLO,SUP-2283941,CDM,C1881,HCPCS,0278,RC,,,,both,,,1089.05,707.88,,,,,,,,,,,,,
CATHETER CTRL VEN 0.61ML 6FR CUF POS 5CM POLYUR GRAV FLO,SUP-2127766,CDM,C1751,HCPCS,0278,RC,,,,both,,,872.92,567.40,,,,,,,,,,,,,
SHEATH INTRO PERFRMR L 30 CM DIA14 FR GUIDEWIRE 0.038 IN,SUP-2168410,CDM,C1894,HCPCS,0272,RC,,,,both,,,307.25,199.71,,,,,,,,,,,,,
BIT DRL DIA 3.7 MM SHRT QC W/ AO STRL DISP EVOS,SUP-2931295,CDM,2720000010,LOCAL,0272,RC,,,,both,,,884.22,574.74,,,,,,,,,,,,,
PLATE BNE L154MM 8 H ST L LAT PROX TIB S STL LOK COMPR LO,SUP-2185717,CDM,C1713,HCPCS,0278,RC,,,,both,,,4647.11,3020.62,,,,,,,,,,,,,
BLADE TREPHINE 17.5MM ID X 8IN,SUP-2515462,CDM,2720000010,LOCAL,0272,RC,,,,both,,,772.44,502.09,,,,,,,,,,,,,
SET CLLR SZ P1 SORBATEX EXTRA PD ANTIBACT MIAMI JR,SUP-2276576,CDM,L0120,HCPCS,0272,RC,,,,both,,,187.68,121.99,,,,,,,,,,,,,
DEFIBRILLATOR CRD SINGLE CHMBR 13 MM 33 CC 71 GM EPIC II VR V158ROPT] ST JUDE MED CARDIAC RHYM MGMT],SUP-2356510,CDM,C1722,HCPCS,0275,RC,,,,both,,,69865.00,45412.25,,,,,,,,,,,,,
SPACER SPNL W11XH8XL14MM CERV PEEK ANAT,SUP-2279108,CDM,C1889,HCPCS,0278,RC,,,,both,,,3108.60,2020.59,,,,,,,,,,,,,
COIL STONE RETRV L115CM DIA7MM SHTH 3FR NIT URO STONE CONE,SUP-2138886,CDM,2720000010,LOCAL,0272,RC,,,,both,,,820.33,533.21,,,,,,,,,,,,,
FILLER BONE VOID 10ML HA SYNTH CA PHOS PUTTY TISS IMPL CEM,SUP-2194293,CDM,C1713,HCPCS,0278,RC,,,,both,,,9161.89,5955.23,,,,,,,,,,,,,
PROBE RF COOLED 17 GAX150 MM STR COOLIEF TRANSDISCAL DISP,SUP-2859196,CDM,2720000010,LOCAL,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
PLATE BNE PNUT 1 HOLE STRATUM RS,SUP-2862033,CDM,C1713,HCPCS,0278,RC,,,,both,,,2425.65,1576.67,,,,,,,,,,,,,
INLAY ANK 1 7 MM POLYETH HINTERMANN SER H3,SUP-2751676,CDM,C1776,CPT,0278,RC,,,,both,,,8741.76,5682.14,,,,,,,,,,,,,
PLUG TIB TAPR ASCNT STEM MAXM,SUP-2405445,CDM,C1776,CPT,0278,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
GRAFT VASC HEMGRD L 40 CM DIA 7 MM POLYESTER BOV CLLGN UTHN,SUP-2763174,CDM,C1768,CPT,0278,RC,,,,both,,,1226.74,797.38,,,,,,,,,,,,,
MARKER RAD MRI FIDUCIAL PAT,SUP-2264512,CDM,A4648,CPT,0278,RC,,,,both,,,51.78,33.66,,,,,,,,,,,,,
ICP KIT PEDIATRIC PLAS DISP,SUP-2666390,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1199.70,779.80,,,,,,,,,,,,,
SHEATH INTRO FLX L 13 CM OD 9 FR ID 3.2 MM GUIDEWIRE 0.038,SUP-2168276,CDM,C1894,HCPCS,0272,RC,,,,both,,,153.83,99.99,,,,,,,,,,,,,
SCREW BNE L24MM OD3MM TI LO EXT ST SELF DRL CANN FIX STBL,SUP-2242807,CDM,C1713,HCPCS,0278,RC,,,,both,,,1027.69,668.00,,,,,,,,,,,,,
MARKER BRST BX 17 GAX 10 CM 3 MM NDL COIL ULTRACLIP II,SUP-2127913,CDM,A4648,CPT,0278,RC,,,,both,,,194.93,126.70,,,,,,,,,,,,,
PEG BNE FIX L22MM DIA2.5MM FULL THRD FOR ALPS HND FRAC SYS,SUP-2414066,CDM,C1713,HCPCS,0278,RC,,,,both,,,244.92,159.20,,,,,,,,,,,,,
ANCHOR SUTURE DIA 4.75 MM TAPE 1.4 MM PEEK 3 STRANDS W/ NDL,SUP-2906382,CDM,C1713,HCPCS,0278,RC,,,,both,,,1149.24,747.01,,,,,,,,,,,,,
PINN GRIP TF REV BUTTRESS 68R,SUP-2512742,CDM,C1776,CPT,0278,RC,,,,both,,,6146.86,3995.46,,,,,,,,,,,,,
BLADE LARYNSCP MACINTOSH AD FBR OPT SZ 3 M 135MMX15MM HEINE,SUP-2238181,CDM,2720000010,LOCAL,0272,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
DISTRACTOR EXT FIX 30 MM 1 - 1.2 MM 9 HOLE MESH END DRIVEN,SUP-2458111,CDM,C1713,HCPCS,0278,RC,,,,both,,,16631.51,10810.48,,,,,,,,,,,,,
PLATE 3.5MM TI LCP MEDIAL PROXIMAL TIBIA 10H RT 171MM-STER,SUP-2549577,CDM,C1713,HCPCS,0278,RC,,,,both,,,4701.87,3056.22,,,,,,,,,,,,,
HC I&D Finger Abscess Simple,PX-4502601000,CDM,26010,CPT,0450,RC,,,,both,,,214.00,139.10,,,,,,,,,,,,,
STIMULATOR NERVE IMPL PULSE GENRTR KT PRECIS SPECTR,SUP-2141896,CDM,C1820,HCPCS,0278,RC,,,,both,,,51182.00,33268.30,,,,,,,,,,,,,
INTRODUCER TRACH 8FR 24-28FR 0.52IN PERC TRACH CIAGLIA,SUP-2167990,CDM,C1894,HCPCS,0272,RC,,,,both,,,1399.84,909.90,,,,,,,,,,,,,
ENDCAP ORTH L15MM DIA3MM NONSTERILE HUM TI NAIL EXTN,SUP-2192719,CDM,C1713,HCPCS,0278,RC,,,,both,,,719.15,467.45,,,,,,,,,,,,,
EXPANDER TISS 700CC SMTH UHP ARTOURA PLUS,SUP-2740160,CDM,C1889,HCPCS,0278,RC,,,,both,,,5934.60,3857.49,,,,,,,,,,,,,
PLATE CRAN 160X100X40 MM PT SPEC IMPL PEEK,SUP-2860148,CDM,C1713,HCPCS,0278,RC,,,,both,,,41034.46,26672.40,,,,,,,,,,,,,
PENICILLIN G SODIUM 5000000 UNITS IJ SOLR,RX-6087,CDM,2500000003,HCPCS,0250,RC,00781-6153-94,NDC,,both,1,UN,265.00,172.25,,,,,,,,,,,,,
GRAFT BNE DRILLABLE 5 CC VOID FILL STRL LTX,SUP-2865883,CDM,C1713,HCPCS,0278,RC,,,,both,,,6604.05,4292.63,,,,,,,,,,,,,
KNIFE NDL CATH L200CM 7-5FR 0.035IN TAPR TIP 3 LUMN FOR,SUP-2169505,CDM,2720000010,LOCAL,0272,RC,,,,both,,,602.88,391.87,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 50 MM DIA 5 MM DEL SHTH,SUP-2934268,CDM,C1713,HCPCS,0278,RC,,,,both,,,5272.06,3426.84,,,,,,,,,,,,,
CROWN DENT NOELL-5 M NICKEL CHROM,SUP-2322205,CDM,D6783,CPT,0278,RC,,,,both,,,33.22,21.59,,,,,,,,,,,,,
LASER SURG HAAG-STRAIT LASERLINK,SUP-2713642,CDM,2720000010,LOCAL,0272,RC,,,,both,,,17414.44,11319.39,,,,,,,,,,,,,
GUIDEWIRE VASC SYNCHRO 2 300CM 0.014IN SEG 35CM SFT FLAT,SUP-2367904,CDM,C1769,HCPCS,0272,RC,,,,both,,,2267.71,1474.01,,,,,,,,,,,,,
FIBER LSR FLEXIVA PULSE 550,SUP-2717689,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1361.66,885.08,,,,,,,,,,,,,
STAPLE SURG 10X8MM ARCUS,SUP-2417438,CDM,C1713,HCPCS,0278,RC,,,,both,,,3263.59,2121.33,,,,,,,,,,,,,
MESH CRAN CUSTOMIZED SM KT MEDPOR PTERIONAL +,SUP-2862740,CDM,C1713,HCPCS,0278,RC,,,,both,,,38243.44,24858.24,,,,,,,,,,,,,
INFLATION KIT 15 FRX10 CM URET URETEROSCOPY DEV EZDILATE,SUP-2471739,CDM,C1726,HCPCS,0272,RC,,,,both,,,700.22,455.14,,,,,,,,,,,,,
QFIX 1.8 MINI SUT ANCHR DISP KITXL,SUP-2341147,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1979.77,1286.85,,,,,,,,,,,,,
ALLOGRAFT HUM TISS BLOCK FRZN RT MEDL MENIS FLEXIGRAFT,SUP-2740785,CDM,C1762,CPT,0278,RC,,,,both,,,13032.00,8470.80,,,,,,,,,,,,,
COMPONENT FEM CRUCE RET POR LEGION,SUP-2348063,CDM,C1776,CPT,0278,RC,,,,both,,,11618.00,7551.70,,,,,,,,,,,,,
KIT INTCRAN PRSS MON SUBDURAL CATH CAMINO,SUP-2308097,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3937.56,2559.41,,,,,,,,,,,,,
NEEDLE PROC AD 18GA L71CM 50DEG S STL TRANSSEPTAL POINTER,SUP-2357221,CDM,2720000010,LOCAL,0272,RC,,,,both,,,700.22,455.14,,,,,,,,,,,,,
BRACE WRISTXSM FOR 14.6CM LT PROTCT PD ADJ BAR D RNG CLSR,SUP-2324887,CDM,L3931,HCPCS,0274,RC,,,,both,,,41.07,26.70,,,,,,,,,,,,,
BRACE BK ASPN QUICKDRAW PRO BLK M,SUP-2123910,CDM,L0628,HCPCS,0274,RC,,,,both,,,264.67,172.04,,,,,,,,,,,,,
COUNTERSINK DRL L 205 MM DIA 5.5 MM HDLSS,SUP-2899184,CDM,2720000010,LOCAL,0272,RC,,,,both,,,682.17,443.41,,,,,,,,,,,,,
HEMO CATHETER CATHETER TRAY,SUP-2610540,CDM,C1752,HCPCS,0278,RC,,,,both,,,690.80,449.02,,,,,,,,,,,,,
STEM RADIAL MED 5.5 ULN WRST MOD COCR 1ST CHOICE,SUP-2852858,CDM,C1776,CPT,0278,RC,,,,both,,,14251.02,9263.16,,,,,,,,,,,,,
CLIP HEMSTAS 2.8 MM 155 CM 11 MM OPENING DEV STRL RESOL 360,SUP-2495512,CDM,2720000010,LOCAL,0272,RC,,,,both,,,480.61,312.40,,,,,,,,,,,,,
FORCEP ENDOSCP 4 MMX230 CM 3.2 HEMSTAS ANTI SLIP COAGRASPER,SUP-2501312,CDM,2720000010,LOCAL,0272,RC,,,,both,,,837.69,544.50,,,,,,,,,,,,,
PLATE BNE BROAD 5.5X288 MM 16 HOLE SS LCP,SUP-2569377,CDM,C1713,HCPCS,0278,RC,,,,both,,,1029.29,669.04,,,,,,,,,,,,,
PLATE BNE 6 H RT LAPIDUS FT SLOTLOCK TECHNOLOGY,SUP-2883731,CDM,C1713,HCPCS,0278,RC,,,,both,,,5692.82,3700.33,,,,,,,,,,,,,
COMPONENT FEM TROCH NEUT PROX KNEE REPL ANTIROTATION TAB TI,SUP-2252621,CDM,C1776,CPT,0278,RC,,,,both,,,13025.03,8466.27,,,,,,,,,,,,,
PREP SCORER 12X19MM,SUP-2841267,CDM,2720000010,LOCAL,0272,RC,,,,both,,,635.85,413.30,,,,,,,,,,,,,
CATHETER EP H 1-7-1 MM 7 FRX110 CM INQUIRY,SUP-2357627,CDM,C1731,HCPCS,0278,RC,,,,both,,,3070.92,1996.10,,,,,,,,,,,,,
BUR SURG DIA6MM CARB RND,SUP-2364021,CDM,2720000010,LOCAL,0272,RC,,,,both,,,864.82,562.13,,,,,,,,,,,,,
CATHETER INFUS L134CM STENT L20MM DIA1MM 0.014IN THER LOC,SUP-2266023,CDM,C1751,HCPCS,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
MODEL UPT-6 US PROC TY,SUP-2165758,CDM,C1713,HCPCS,0278,RC,,,,both,,,577.76,375.54,,,,,,,,,,,,,
SCREW SPNL MULTAXL 8.5X55 MM 6.35 MM PEDCL FOR ROD RED LEG,SUP-2289023,CDM,C1713,HCPCS,0278,RC,,,,both,,,2088.10,1357.26,,,,,,,,,,,,,
CATHETER CHOLANGIOGRAM DL 4 FRX50 CM SCOOP TIP SCOOP REDDICK,SUP-2264232,CDM,C1713,HCPCS,0278,RC,,,,both,,,507.74,330.03,,,,,,,,,,,,,
TEMPLATE BEND DIA35MM ALUMINUM FOR COMPR PLT W 7 H,SUP-2199237,CDM,C1713,HCPCS,0278,RC,,,,both,,,755.52,491.09,,,,,,,,,,,,,
ANGLE S/D BLADE 2.0/2.3MM XD SCRWS DNTL LATCH 12MM 1/2N,SUP-2498129,CDM,2720000010,LOCAL,0272,RC,,,,both,,,434.54,282.45,,,,,,,,,,,,,
GRAFT BNE STRP 25X20X7 MM COMPRESSIBLE BNE MTRX,SUP-2644320,CDM,C1713,HCPCS,0278,RC,,,,both,,,4364.29,2836.79,,,,,,,,,,,,,
GRAFT BNE L12XW12XH7MM 5DEG UNIV PEEK TI COMP SPCR ANT CERV,SUP-2317027,CDM,C1713,HCPCS,0278,RC,,,,both,,,8842.24,5747.46,,,,,,,,,,,,,
BUR SURG L64MM OD14MM NONFLUTED CARB ACORN CUT,SUP-2278089,CDM,2720000010,LOCAL,0272,RC,,,,both,,,525.51,341.58,,,,,,,,,,,,,
COUNTERSINK SURG MINI MAXLOCK EXTRM ISO,SUP-2400510,CDM,2720000010,LOCAL,0272,RC,,,,both,,,524.38,340.85,,,,,,,,,,,,,
BEAM FIX L110MM DIA8.5MM ARTH,SUP-2223962,CDM,C1776,CPT,0278,RC,,,,both,,,4568.70,2969.65,,,,,,,,,,,,,
SCREW SPNL L45MM OD7.5MM TI CANC PEDCL ST VAR ANG CANN,SUP-2211438,CDM,C1713,HCPCS,0278,RC,,,,both,,,25.91,16.84,,,,,,,,,,,,,
TRAY EPIDURAL CATH DIA20 GA NDL DIA18 GA CE18TKN ACCU BLOC,SUP-2936706,CDM,2720000010,LOCAL,0272,RC,,,,both,,,74.76,48.59,,,,,,,,,,,,,
BARIUM SULFATE 96 % PO SUSR,RX-13031,CDM,2500000003,HCPCS,0250,RC,32909-0750-03,NDC,,both,176,GR,2.80,1.82,,,,,,,,,,,,,
COUPLER SURG USED EXT SVC 1 YR SM PWR,SUP-2761004,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3379.43,2196.63,,,,,,,,,,,,,
PLATE BNE L64MM THK2MM 11 H L MED FT TIM LOK COMPR FOR,SUP-2413837,CDM,C1713,HCPCS,0278,RC,,,,both,,,2452.53,1594.14,,,,,,,,,,,,,
PLATE BNE LCK 77 MM LT DORS PROXIMAL ULNAR 3 HOLE STRL,SUP-2468301,CDM,C1713,HCPCS,0278,RC,,,,both,,,2214.80,1439.62,,,,,,,,,,,,,
BLOM-SINGER INDWL LO PRSS VOICE PROS REPL KT SER 8MM,SUP-2246404,CDM,L8509,HCPCS,0274,RC,,,,both,,,285.74,185.73,,,,,,,,,,,,,
BLADE TONGUE RUSSEL DAVIS 40MMW 92MML,SUP-2705822,CDM,2720000010,LOCAL,0272,RC,,,,both,,,317.14,206.14,,,,,,,,,,,,,
LINER ACET SZ G OD58-60MM ID32MM 10DEG ECC BEAR TECHNOLOGY,SUP-2377152,CDM,C1776,CPT,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
CATHETER ANGIOPLSTY ARMADA18 L 150 CM BALLOON L 120 MM DIA 6,SUP-2105397,CDM,C1725,HCPCS,0272,RC,,,,both,,,574.62,373.50,,,,,,,,,,,,,
HC Vasc Embolize Occlude Organ,PX-3613724300,CDM,37243,CPT,0361,RC,,,,inpatient,,,11772.00,7651.80,,,,,,,,,,,,,
HC So in Situ Hybrid per Specimen,PX-3128836866,CDM,88368,CPT,0312,RC,,,,both,,,360.00,234.00,,,,,,,,,,,,,
ROD REPROC EXT FIX ATTCH FOR LG MULTIPIN CLMP,SUP-2188491,CDM,2720000010,LOCAL,0272,RC,,,,both,,,832.10,540.86,,,,,,,,,,,,,
BRACE BK ASPN QUICKDRAW PRO BLK M,SUP-2123910,CDM,L0628,HCPCS,0272,RC,,,,both,,,264.67,172.04,,,,,,,,,,,,,
BRACE KNEE BIOSKIN Q PAT TRK M,SUP-2174970,CDM,L1820,HCPCS,0274,RC,,,,both,,,165.67,107.69,,,,,,,,,,,,,
LEAD PACE 100CM STEROID ELUTION ACT FIX IMP TENDRIL SDX,SUP-2356678,CDM,C1898,HCPCS,0275,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
BIT DRL DIA2.7MM CANN QUIK CPL,SUP-2409860,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1593.83,1035.99,,,,,,,,,,,,,
GRAFT BNE INJ 4 CC INDUCTIVE EXTREMITY PRO-STIM,SUP-2759538,CDM,C1713,HCPCS,0278,RC,,,,both,,,4741.40,3081.91,,,,,,,,,,,,,
CANNULA SURG 23GA SUTURELESS NONVALVED 1 STP DISP,SUP-2129243,CDM,2720000010,LOCAL,0272,RC,,,,both,,,453.73,294.92,,,,,,,,,,,,,
PLATE BNE STR NAR STRL NCB,SUP-2862094,CDM,C1713,HCPCS,0278,RC,,,,both,,,9159.25,5953.51,,,,,,,,,,,,,
KETOCONAZOLE 2 % EX CREA,RX-10368,CDM,6370000000,HCPCS,0637,RC,00168-0099-15,NDC,,both,15,GR,67.50,43.87,,,,,,,,,,,,,
SCREW BONE L12MM DIA2.7MM FULL THRD STP FOR OLECRANON,SUP-2177098,CDM,C1713,HCPCS,0278,RC,,,,both,,,469.87,305.42,,,,,,,,,,,,,
BUCKLE SCLER RETINAL 2.5 MM EYE TIRE STYL 220,SUP-2213514,CDM,C1784,HCPCS,0278,RC,,,,both,,,45.84,29.80,,,,,,,,,,,,,
VALVE SHUNT MR CONDITIONAL ADJ STRATA,SUP-2631432,CDM,C1889,HCPCS,0278,RC,,,,both,,,13634.29,8862.29,,,,,,,,,,,,,
MESH SURG W6XL11CM RECT PARTIALLY ABSRB FLAT FOR SFT TISS,SUP-2220107,CDM,C1781,HCPCS,0278,RC,,,,both,,,414.61,269.50,,,,,,,,,,,,,
CATHETER EMB 6FR 2ML L80CM BLLN DIA13MM INTRO 7FR ART SIL S – SEE COMMENT,SUP-2214002,CDM,C1757,HCPCS,0272,RC,,,,both,,,186.99,121.54,,,,,,,,,,,,,
SCREW BNE CEPHALIC 10.5X80 MM EBA 1,SUP-2719839,CDM,C1713,HCPCS,0278,RC,,,,both,,,1626.52,1057.24,,,,,,,,,,,,,
IMMOBILIZER KNEE PERF-VINYL FOAM MEDL LAT POST STAY LOOP LCK,SUP-2197967,CDM,L1830,CPT,0272,RC,,,,both,,,98.78,64.21,,,,,,,,,,,,,
SCREW SPNL L16MM DIA4.5MM CANC ANTR CERV TI ST LCK VAR ANG,SUP-2254603,CDM,C1713,HCPCS,0278,RC,,,,both,,,747.32,485.76,,,,,,,,,,,,,
CATHETER EP CRD 10 MM 5 FRX120 CM SUPREME,SUP-2356933,CDM,C1730,HCPCS,0272,RC,,,,both,,,568.34,369.42,,,,,,,,,,,,,
PIN FIX SINGLE DIAMOND 0.141X9 IN RND END SS NS STEINMANN,SUP-2791268,CDM,C1713,HCPCS,0278,RC,,,,both,,,31.46,20.45,,,,,,,,,,,,,
ALLOGRAFT HUM TISS MESHED 8X6 CMX0.3 MM PERITONEUM MTRX MESO,SUP-2482885,CDM,C1763,HCPCS,0278,RC,,,,both,,,3158.34,2052.92,,,,,,,,,,,,,
PLATE BNE L85MM THK1.3MM 100DEG 7 H TI TBLR FOR 3.5MM SCR,SUP-2412037,CDM,C1713,HCPCS,0278,RC,,,,both,,,292.02,189.81,,,,,,,,,,,,,
GRAFT HUM TISS L80-100CM SAPH VEIN A B AB O BLD GRP,SUP-2264307,CDM,C1762,CPT,0278,RC,,,,both,,,36891.86,23979.71,,,,,,,,,,,,,
CATHETER EMB 3FR L40CM 0.018IN THRU LUMN OVR THE WIRE RADPQ,SUP-2214015,CDM,C1757,HCPCS,0272,RC,,,,both,,,472.29,306.99,,,,,,,,,,,,,
PIN EXT FIX THRD 4X250 MM TRANSFIX APEX,SUP-2363241,CDM,C1713,HCPCS,0278,RC,,,,both,,,391.53,254.49,,,,,,,,,,,,,
HC Bladder Irrigation Simple,PX-4505170000,CDM,51700,CPT,0450,RC,,,,both,,,935.00,607.75,,,,,,,,,,,,,
BAR EXT FIX 11X400 MM CARBON XTRAFIX,SUP-2477119,CDM,2720000010,LOCAL,0272,RC,,,,both,,,755.52,491.09,,,,,,,,,,,,,
GRAFT BNE STRP 50X10X5 MM DBM FIBER,SUP-2860953,CDM,C1713,HCPCS,0278,RC,,,,both,,,3048.94,1981.81,,,,,,,,,,,,,
GRAFT SYN GRAN 30CC INQU,SUP-2247317,CDM,C1713,HCPCS,0278,RC,,,,both,,,8277.04,5380.08,,,,,,,,,,,,,
ANCHOR SUTURE DIAMETER 2.9MM STAINLESS STEEL PRETHREADED WIT,SUP-2824091,CDM,C1713,HCPCS,0278,RC,,,,both,,,692.12,449.88,,,,,,,,,,,,,
LINER CAST PADDING 6 PEDIATRIC HIP WTRPRF EPTFE SPICA SKINZ,SUP-2315939,CDM,2720000010,LOCAL,0272,RC,,,,both,,,445.88,289.82,,,,,,,,,,,,,
CONNECTOR SHUNT DIAMETER 1.9MM TITANIUM FOR HYDROCEPHALUS,SUP-2825617,CDM,C1889,HCPCS,0278,RC,,,,both,,,653.31,424.65,,,,,,,,,,,,,
BAR SPNL L15MM UNIV THORLUM TI CLS TRNSVRS SM STAT USS,SUP-2193447,CDM,C1713,HCPCS,0278,RC,,,,both,,,1705.02,1108.26,,,,,,,,,,,,,
CATHETER EP MAP 5FR L65CM 2-5-2MM SPC COR SNUS FIX CRV,SUP-2281824,CDM,C1730,HCPCS,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
PLATE BNE MINI TI MANDIBULAR PMI ORTHOGNATHIC 3D PRNT NS,SUP-2934920,CDM,C1713,HCPCS,0278,RC,,,,both,,,18434.94,11982.71,,,,,,,,,,,,,
ALLOGRAFT BNE PTTY 0.5 CC LECITHIN CARR DBM NS REGENEROSS +,SUP-2862035,CDM,C1713,HCPCS,0278,RC,,,,both,,,384.87,250.17,,,,,,,,,,,,,
SET INT FIX DIA18.5 MM TI NEURO XDRV 1 PK STRL DISP LORENZ,SUP-2935670,CDM,C1713,HCPCS,0278,RC,,,,both,,,2176.02,1414.41,,,,,,,,,,,,,
ALLOGRAFT BNE WDG 10X12 MM TRICORT IL CREST,SUP-2867122,CDM,C1762,CPT,0278,RC,,,,both,,,2282.00,1483.30,,,,,,,,,,,,,
PLATE BNE LG TI PMI LEFORT ORTHOGNATHIC 3D PRNT NS DISP,SUP-2934724,CDM,C1713,HCPCS,0278,RC,,,,both,,,26994.58,17546.48,,,,,,,,,,,,,
BIT TWST DRL L81MM DIA1.2MM STP 25MM ADD ON QUIK CPL SHFT,SUP-2267830,CDM,2720000010,LOCAL,0272,RC,,,,both,,,467.23,303.70,,,,,,,,,,,,,
PASSER SUTURE 155MM DIAMETER 3.5MM LEFT RC SEAHAWK,SUP-2828616,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3275.05,2128.78,,,,,,,,,,,,,
LEAD PACE L78CM TRNSVEN LT VENTRIC DEXMETHSON ACETT ELUT,SUP-2419407,CDM,C1900,HCPCS,0275,RC,,,,both,,,6049.40,3932.11,,,,,,,,,,,,,
GUIDE WIRE 16 MM PILOT PENNIG DYN WRST FIX,SUP-2644598,CDM,C1769,HCPCS,0272,RC,,,,both,,,231.73,150.62,,,,,,,,,,,,,
EXTRACTOR BILI RX RETRV BAL 9-12MM BELOW,SUP-2141493,CDM,2720000010,LOCAL,0272,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
RESERVOIR VENTRICULAR SM 14 MM HOLTER,SUP-2666416,CDM,C1889,HCPCS,0278,RC,,,,both,,,1271.57,826.52,,,,,,,,,,,,,
BRACE ORTHOPEDIC AFO PLAS,SUP-2388166,CDM,L1970,HCPCS,0274,RC,,,,both,,,2612.48,1698.11,,,,,,,,,,,,,
BIT DRL DIA3.2MM CANN FOR 4.5MM SCR,SUP-2179104,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1053.69,684.90,,,,,,,,,,,,,
STAPLER INT CIR MED THCK 33 MM 3/3.5/4 MM TRI-STAPLE PUR EEA,SUP-2858013,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3327.36,2162.78,,,,,,,,,,,,,
FIBER LASER LIGHT PATH ASST,SUP-2217803,CDM,2720000010,LOCAL,0272,RC,,,,both,,,929.44,604.14,,,,,,,,,,,,,
SHEATH URO L35CM ID14FR AQ PARA RAP REL FLX,SUP-2171159,CDM,C1894,HCPCS,0272,RC,,,,both,,,544.95,354.22,,,,,,,,,,,,,
STENT AXIOS ELECTROCAUTERY-ENHANCED 8MMX8MM,SUP-2855125,CDM,C2617,HCPCS,0278,RC,,,,both,,,16154.83,10500.64,,,,,,,,,,,,,
GRAFT VASC ALBOGRAFT L 40 CM DIA 6 MM POLYESTER STR KNITTED,SUP-2264284,CDM,C1768,CPT,0278,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
ALLOGRAFT BNE DBM 2.5 CC VESUVIUS 4104K0825DC,SUP-2717986,CDM,C1713,HCPCS,0278,RC,,,,both,,,1019.72,662.82,,,,,,,,,,,,,
BRACE KNEE AD UNIV FOAM POSTOP UNISX WRP ARND HNG T SCP,SUP-2150860,CDM,L1810,HCPCS,0272,RC,,,,both,,,321.54,209.00,,,,,,,,,,,,,
SHEATH LD INTRO SAFSHTH CSG WORLEY L 45 CM DIA 9 FR,SUP-2329851,CDM,C1892,HCPCS,0272,RC,,,,both,,,1648.50,1071.52,,,,,,,,,,,,,
TWIST DRILL 22MM X 50MM W/NOTCH SINGLE USE,SUP-2676751,CDM,2720000010,LOCAL,0272,RC,,,,both,,,494.17,321.21,,,,,,,,,,,,,
PLATE BNE SM MED LT MTP STRL ORTHOLOC 3DI,SUP-2900604,CDM,C1713,HCPCS,0278,RC,,,,both,,,144.44,93.89,,,,,,,,,,,,,
SCREW BNE ST 5X70 MM VA T25 SS NS,SUP-2178696,CDM,C1713,HCPCS,0278,RC,,,,both,,,631.14,410.24,,,,,,,,,,,,,
RETRACTOR SPNL L7CM DIA22MM D275IN S STL TB MED LAT DIL BLNT,SUP-2292985,CDM,C1713,HCPCS,0278,RC,,,,both,,,1167.92,759.15,,,,,,,,,,,,,
CLIP ANEURYSM SUNDTKEES 15MM RIGHT ANGLE 201629,SUP-2844592,CDM,C1889,HCPCS,0278,RC,,,,both,,,1064.46,691.90,,,,,,,,,,,,,
FOOTPLATE BNE LNG L180MM ALUMINUM MAXFRAME,SUP-2179159,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4164.61,2707.00,,,,,,,,,,,,,
INSERT TIB REG THK8.5MM POLYETH KNEE ARTC SURF NEUT UNIV PRI,SUP-2200353,CDM,C1776,CPT,0278,RC,,,,both,,,7451.22,4843.29,,,,,,,,,,,,,
MESH SURG BIOIMPLANT 9X10 CM ORTHADAPT,SUP-2323331,CDM,C1781,HCPCS,0278,RC,,,,both,,,9718.30,6316.89,,,,,,,,,,,,,
KIT PROC W/ 90DEG FIRM TIP EXT WRK CHN LOCATABLE GUID FOR,SUP-2381768,CDM,C1887,HCPCS,0272,RC,,,,both,,,5601.76,3641.14,,,,,,,,,,,,,
PLATE SPNL L35MM POST LUM INTERSPINOUS BLADED AFFIX,SUP-2311354,CDM,C1713,HCPCS,0278,RC,,,,both,,,8635.00,5612.75,,,,,,,,,,,,,
LINER ACET OD54MM ID32MM +4MM OFFSET HIP CROSSLINKED,SUP-2250552,CDM,C1776,CPT,0278,RC,,,,both,,,4069.44,2645.14,,,,,,,,,,,,,
BIT DRL L80MM OD1.9MM NONSTERILE REUSE,SUP-2242919,CDM,2720000010,LOCAL,0272,RC,,,,both,,,661.06,429.69,,,,,,,,,,,,,
PLATE BONE 8 H STR FOR SM BONES ORTHOLOC 3DI,SUP-2398062,CDM,C1713,HCPCS,0278,RC,,,,both,,,2483.74,1614.43,,,,,,,,,,,,,
DEFIBRILLATOR CRD BPLR 74X50X14 MM VENTRIC CROPT ATLAS+ VR,SUP-2356521,CDM,C1722,HCPCS,0275,RC,,,,both,,,51307.60,33349.94,,,,,,,,,,,,,
BLADE SAW 90MML X 19MMW 1.37MM THK OSCILLATING M CLASS,SUP-2586417,CDM,2720000010,LOCAL,0272,RC,,,,both,,,202.28,131.48,,,,,,,,,,,,,
PRESSURIZER BNE CEM SM PROX FEM CNL HI VAC W/O HUB DISP,SUP-2366765,CDM,C1713,HCPCS,0278,RC,,,,both,,,48.83,31.74,,,,,,,,,,,,,
PLATE BONE L14MM 4 H TI NAR HYBRID COMPR FOR 4.5MM SCR ALPS,SUP-2413741,CDM,C1713,HCPCS,0278,RC,,,,both,,,912.04,592.83,,,,,,,,,,,,,
CATHETER HEMODLYS 13FR L20CM STR SHT TERM 3 LUMN DLYS,SUP-2125590,CDM,C1752,HCPCS,0278,RC,,,,both,,,538.82,350.23,,,,,,,,,,,,,
CATHETER CV SINGLE LUMEN 7 FRX20 CM BASIC KT ARROWG+ARD,SUP-2383339,CDM,C1751,HCPCS,0278,RC,,,,both,,,177.57,115.42,,,,,,,,,,,,,
BIT DRL CANN 10X150 MM QR CALIB BUD NS POLARUS 2 DISP,SUP-2518653,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1375.32,893.96,,,,,,,,,,,,,
PLATE BNE L 113 MM 8 H SCREW DIA 3.5 MM SS LL PROX TIB SM,SUP-2931134,CDM,C1713,HCPCS,0278,RC,,,,both,,,6877.70,4470.50,,,,,,,,,,,,,
BRACE ORTH SAGITAL LUMBAR CTRL PREFABRICATED LSO,SUP-2388147,CDM,L0627,HCPCS,0272,RC,,,,both,,,1058.59,688.08,,,,,,,,,,,,,
LINEAR HIP STEM STD OFFSET SZ 5 ** SPEC ORD ONLY,SUP-2216864,CDM,C1776,CPT,0278,RC,,,,both,,,13125.20,8531.38,,,,,,,,,,,,,
TAP SURG DIA3.5MM GLD FOR CRTX BONE PLATING SYS TC-100,SUP-2343959,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1200.05,780.03,,,,,,,,,,,,,
GRAFT VASC GORTX L 20 CM DIA 7 MM EPTFE STR TW N RING STRL,SUP-2396702,CDM,C1768,CPT,0278,RC,,,,both,,,1230.88,800.07,,,,,,,,,,,,,
WASHER ORTH FOR 4.5/5.5MM SCR ANK FUS PLATING SYS ORTHOLOC,SUP-2398587,CDM,C1713,HCPCS,0278,RC,,,,both,,,182.12,118.38,,,,,,,,,,,,,
STENT BILI DYNALINK L 56 MM DIA 8 MM CATH L 120 CM GUIDEWIRE,SUP-2104147,CDM,C1876,HCPCS,0278,RC,,,,both,,,4232.72,2751.27,,,,,,,,,,,,,
BIT DRL L115MM DIA1.9MM 20MM STP DENT END FOR 2/2.3MM SCR,SUP-2366429,CDM,2720000010,LOCAL,0272,RC,,,,both,,,636.20,413.53,,,,,,,,,,,,,
SCREW BNE MENIS,SUP-2608742,CDM,C1713,HCPCS,0278,RC,,,,both,,,640.06,416.04,,,,,,,,,,,,,
GRAFT BONE SUB 1ML DEMIN MTRX GEL INJ,SUP-2307523,CDM,C1713,HCPCS,0278,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
SNARE VASC 3.2FR L175CM DIA4-8MM CATH L150CM MINI NIT LOOP,SUP-2302533,CDM,C1773,HCPCS,0272,RC,,,,both,,,1946.80,1265.42,,,,,,,,,,,,,
HC So Sgot (Ast),PX-3018445066,CDM,84450,CPT,0301,RC,,,,both,,,37.00,24.05,,,,,,,,,,,,,
"HC So Amino Acids, 6 or < Ea Spec",PX-3018213966,CDM,82139,CPT,0301,RC,,,,both,,,219.00,142.35,,,,,,,,,,,,,
COUPLER ANAS DIA1MM GRY POLYETH S STL DISP GEM,SUP-2382616,CDM,C1889,HCPCS,0278,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
COMPONENT GLEN FIX SZ 48 PEGGED AFFINITI,SUP-2396771,CDM,C1776,CPT,0278,RC,,,,both,,,5353.70,3479.90,,,,,,,,,,,,,
COLLAR CERV AD M H4.25IN FOR 13-16IN NK FOAM TRACH OPN,SUP-2195537,CDM,L0172,HCPCS,0272,RC,,,,both,,,45.28,29.43,,,,,,,,,,,,,
IMPLANT MAMM NACL ANT DIAPHM VLV RND SMOOTH 390ML - 390ML,SUP-2113258,CDM,C1789,HCPCS,0278,RC,,,,both,,,1295.25,841.91,,,,,,,,,,,,,
GRAFT CORNEA HUMAN,SUP-2738102,CDM,V2785,HCPCS,0810,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
SCREW BNE 2X13 MM,SUP-2321701,CDM,C1713,HCPCS,0278,RC,,,,both,,,628.63,408.61,,,,,,,,,,,,,
SET URET STENT SOFFLX L 75 CM CATH 6.0 FR GUIDEWIRE L 100 CM,SUP-2168924,CDM,C2617,HCPCS,0278,RC,,,,both,,,498.00,323.70,,,,,,,,,,,,,
CATHETER BLLN OCCL 2.8FR L150CM ID0.053IN BLLN L10MM DIA4MM,SUP-2368108,CDM,C2628,HCPCS,0272,RC,,,,both,,,4622.08,3004.35,,,,,,,,,,,,,
GUIDEWIRE VASC L180CM DIA0.038IN L3CM STD SM VES NIT GR3803] TERUMO MEDICAL CORP],SUP-2385578,CDM,C1769,HCPCS,0272,RC,,,,both,,,134.20,87.23,,,,,,,,,,,,,
WASHER ORTH FIX BICONCAVE TI NONSTERILE SZ 40MM,SUP-2366374,CDM,C1713,HCPCS,0278,RC,,,,both,,,120.95,78.62,,,,,,,,,,,,,
GUIDEWIRE VASC L 145 CM DIA 0.032 IN TAPR L 6 CM FLX TIP L,SUP-2167596,CDM,C1769,HCPCS,0272,RC,,,,both,,,34.67,22.54,,,,,,,,,,,,,
SHEARS ENDOSCP L9CM CRV HARM FOCS +,SUP-2219103,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1371.14,891.24,,,,,,,,,,,,,
PLATE BNE HK LG 3.5/4.5X291 MM RT FEM PROX 8 HOLE NS VA-LCP,SUP-2750913,CDM,C1713,HCPCS,0278,RC,,,,both,,,7796.49,5067.72,,,,,,,,,,,,,
PLATE BONE SM W10XL85MM THK3.4MM 7 H UNIV DSTL HUM RAD ULN,SUP-2343769,CDM,C1713,HCPCS,0278,RC,,,,both,,,1264.01,821.61,,,,,,,,,,,,,
ENDPLATE SPNL DISK H6MM 13X14MM FOOTPRINT 6DEG CO CHROM,SUP-2420862,CDM,C1713,HCPCS,0278,RC,,,,both,,,15386.00,10000.90,,,,,,,,,,,,,
DRILL TWST L53MM OD13MM STP CHK END FOR 17X12MM SCR,SUP-2366403,CDM,2720000010,LOCAL,0272,RC,,,,both,,,399.60,259.74,,,,,,,,,,,,,
COMPONENT KNEE CR PRIMARY E-POLY VANGUARD XP,SUP-2408817,CDM,C1776,CPT,0278,RC,,,,both,,,17552.60,11409.19,,,,,,,,,,,,,
ALLOGRAFT BNE IMPL 15X1 MM CRYOPRESERVED CART PROCHONDRIX CR,SUP-2361154,CDM,C1889,HCPCS,0278,RC,,,,both,,,20485.36,13315.48,,,,,,,,,,,,,
BURR SURG 4MM PUR HIP HI VISIBILITY SHTH BRL ST DYONIC,SUP-2341870,CDM,2720000010,LOCAL,0272,RC,,,,both,,,373.66,242.88,,,,,,,,,,,,,
CATHETER HEMO DYLS OR HD ADMIN FULL KT DBL LUMN SIL CVD,SUP-2174232,CDM,C1881,HCPCS,0278,RC,,,,both,,,1444.40,938.86,,,,,,,,,,,,,
DISPENSER GUIDEWIRE 1.1 MMX6 IN,SUP-2607261,CDM,C1769,HCPCS,0272,RC,,,,both,,,540.52,351.34,,,,,,,,,,,,,
GRAFT HUM TISS W5XL5CM THK04 07MM THN HYDRATED ACELLULAR,SUP-2307447,CDM,Q4128,HCPCS,0636,RC,,,,both,,,3539.09,2300.41,,,,,,,,,,,,,
TM REV ST/ TM GLENOID/ STD HD,SUP-2212304,CDM,C1776,CPT,0278,RC,,,,both,,,38260.46,24869.30,,,,,,,,,,,,,
SHEATH INTRO FAST-CATH L 30 CM DIA13 FR GUIDEWIRE 0.038 IN,SUP-2355551,CDM,C1894,HCPCS,0272,RC,,,,both,,,63.59,41.33,,,,,,,,,,,,,
KIT TRACH PERC DIL FULL COMP LOC ANES W O TB PORTEX,SUP-2351756,CDM,2720000010,LOCAL,0272,RC,,,,both,,,700.00,455.00,,,,,,,,,,,,,
AWL SURG DIA 4 MM CANN CRV GRN,SUP-2934153,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2081.82,1353.18,,,,,,,,,,,,,
GRAFT HUMAN TSSUE MTRX 2SQCM THIN SM 1CMW X 2CML 023 051MM,SUP-2675764,CDM,Q4116,HCPCS,0636,RC,,,,both,,,263.76,171.44,,,,,,,,,,,,,
"HC So Calcium,Serum",PX-3018231066,CDM,82310,CPT,0301,RC,,,,both,,,78.00,50.70,,,,,,,,,,,,,
PROSTHESIS OSS STAP 0.6X5.25 MM ECLIPSE PISTON NIT FLROPLAS,SUP-2486984,CDM,L8613,CPT,0278,RC,,,,both,,,975.35,633.98,,,,,,,,,,,,,
BOLT SPNL GRFT 8X40 MM CANN ALIF STANDALONE IDENTITI,SUP-2800082,CDM,C1713,HCPCS,0278,RC,,,,both,,,3061.50,1989.97,,,,,,,,,,,,,
HOOK SPNL L TI OFFSET FOR 5.5MM ROD CDH LEG,SUP-2287877,CDM,C1713,HCPCS,0278,RC,,,,both,,,1193.20,775.58,,,,,,,,,,,,,
TRAY TIB SZ 2 TI L MED R LAT CEM OFFSET PFC,SUP-2253955,CDM,C1776,CPT,0278,RC,,,,both,,,7167.99,4659.19,,,,,,,,,,,,,
CATHETER DRNGE PGTL MDC MAC LOC LOK LOOP MULT PURP GWIRE 5,SUP-2168158,CDM,C1729,HCPCS,0272,RC,,,,both,,,276.70,179.85,,,,,,,,,,,,,
HC Pt Aquatic Therapeutic Exer 15 Mn,PX-4209711300,CDM,97113,CPT,0420,RC,,,,both,,,165.00,107.25,,,,,,,,,,,,,
INTRODUCER REPROC STRBL AGILIS NXT 8.5FR 16.4MM,SUP-2527276,CDM,C1766,CPT,0272,RC,,,,both,,,1681.78,1093.16,,,,,,,,,,,,,
KIT VASC FILTER TRAPEASE L 90 CM DIA 6 FR CAVA DIA 30 MM NIT,SUP-2157009,CDM,C1880,HCPCS,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
BEARING TIB 20 MM OSS RS LS,SUP-2441806,CDM,C1776,CPT,0278,RC,,,,both,,,2359.71,1533.81,,,,,,,,,,,,,
HC Rmvl FB Conjunctival Sprfcl,PX-4506520500,CDM,65205,CPT,0450,RC,,,,both,,,214.00,139.10,,,,,,,,,,,,,
PLATE HLS 1MM T 3HL 215053,SUP-2247341,CDM,C1713,HCPCS,0278,RC,,,,both,,,1287.40,836.81,,,,,,,,,,,,,
PLATE 8 H 1 3RD TBLR,SUP-2243249,CDM,C1713,HCPCS,0278,RC,,,,both,,,5747.30,3735.74,,,,,,,,,,,,,
KWIRE FIX L100MM DIA11MM FOR TOT FT SYS 2,SUP-2243137,CDM,C1713,HCPCS,0278,RC,,,,both,,,112.51,73.13,,,,,,,,,,,,,
IMPLANT FEM SZ 4 LT REV PROVEN,SUP-2359377,CDM,C1776,CPT,0278,RC,,,,both,,,6738.44,4379.99,,,,,,,,,,,,,
KIT VENTRICULAR DRAINAGE COMB W/ 10110A SYS INS5010 HERM,SUP-2883636,CDM,C1729,HCPCS,0272,RC,,,,both,,,1024.11,665.67,,,,,,,,,,,,,
REAMER BLDE PAT 47MM SCORP - 47MM,SUP-2365124,CDM,2720000010,LOCAL,0272,RC,,,,both,,,850.94,553.11,,,,,,,,,,,,,
TROCAR SURG CEPHALOMEDULLARY LAG SCREW DBL BRL,SUP-2459867,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1120.98,728.64,,,,,,,,,,,,,
PATCH VASC L75MM DIA6MM HEMACAROTID ULT THN,SUP-2227501,CDM,C1768,CPT,0278,RC,,,,both,,,348.19,226.32,,,,,,,,,,,,,
PACEMAKER CARD L 38 MM DIA 6.5 MM 1.1 CU CM 2.4 GM RT,SUP-2895710,CDM,C1786,HCPCS,0275,RC,,,,both,,,34524.30,22440.79,,,,,,,,,,,,,
SCREW BNE L30MM DIA3.5MM NONLOCKING MOTOBAND CP,SUP-2175154,CDM,C1713,HCPCS,0278,RC,,,,both,,,635.85,413.30,,,,,,,,,,,,,
IMPLANT THYROPLASTY VOCAL CRD 8 M STRL MONTGOMERY,SUP-2141838,CDM,C1878,HCPCS,0278,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
HANDPIECE SURG OPN 5 MMX7 CM PRECIS CUT COAG PLASMAJET DISP,SUP-2328051,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
PLATE BONE W10XL58MM THK2.8MM 5 H S STL STR NONCOMPRESSION,SUP-2343762,CDM,C1713,HCPCS,0278,RC,,,,both,,,2735.13,1777.83,,,,,,,,,,,,,
BUPROPION HCL 75 MG PO TABS,RX-9322,CDM,6370000000,HCPCS,0637,RC,00904-6635-61,NDC,,both,1,UN,5.50,3.57,,,,,,,,,,,,,
SCREW BNE PART THRD 2.7X32 MM TI MINICAN,SUP-2458857,CDM,C1713,HCPCS,0278,RC,,,,both,,,636.57,413.77,,,,,,,,,,,,,
NAIL INTRAMEDULLARY 130 DEGREE 16 MMX44 CM LEFT FEMORAL TITA,SUP-2837106,CDM,C1713,HCPCS,0278,RC,,,,both,,,22599.84,14689.90,,,,,,,,,,,,,
PLATE BNE W9XL37MM THK1MM 3 H TI 1/3 TBLR LIMIT CNTCT DYN,SUP-2190945,CDM,C1713,HCPCS,0278,RC,,,,both,,,436.59,283.78,,,,,,,,,,,,,
BLADE SURG L19CM THK42MM WHT PREBENT HPS GREAT CONCAVE,SUP-2167160,CDM,2720000010,LOCAL,0272,RC,,,,both,,,657.83,427.59,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED CAP5100] ZIMMER BIOMET INC],SUP-2212487,CDM,C1776,CPT,0278,RC,,,,both,,,16014.00,10409.10,,,,,,,,,,,,,
GRAFT HUM TISS R LAT W HEMI PLATEAU FRZN MENIS RECON,SUP-2307291,CDM,C1713,HCPCS,0278,RC,,,,both,,,18103.83,11767.49,,,,,,,,,,,,,
NUCLEUS PROFILE PLUS W/ SLIM STRAIGHT ELECTRODE (CI622),SUP-2858188,CDM,L8614,HCPCS,0278,RC,,,,both,,,71662.65,46580.72,,,,,,,,,,,,,
CLAMP ABLAT L10CM PRB DISPOSABLE CRYOFLEX,SUP-2124490,CDM,C2618,HCPCS,0272,RC,,,,both,,,9734.00,6327.10,,,,,,,,,,,,,
PLATE BONE L238MM THK4.5MM 11 H LT LAT TIB HD BTTRS TI RIG,SUP-2190896,CDM,C1713,HCPCS,0278,RC,,,,both,,,3070.20,1995.63,,,,,,,,,,,,,
SCREW SPNL L50MM DIA5.5MM CANC PEDCL TI MULTIAXIAL SEXTANT,SUP-2288494,CDM,C1713,HCPCS,0278,RC,,,,both,,,5049.43,3282.13,,,,,,,,,,,,,
STENT VASC 4X24 MM INTCRAN W/O TIP SYS NEUROFORM ATLS,SUP-2431333,CDM,C1877,HCPCS,0278,RC,,,,both,,,23864.00,15511.60,,,,,,,,,,,,,
BIT DRILL 0.76X75 MM 14 MM J LATCH,SUP-2841945,CDM,2720000010,LOCAL,0272,RC,,,,both,,,424.21,275.74,,,,,,,,,,,,,
IMPLANT HUM TISS L 70 X W 40 MM THK 4 MM ACHILLES TEND RC,SUP-2932924,CDM,C1762,CPT,0278,RC,,,,both,,,12964.93,8427.20,,,,,,,,,,,,,
PLATE BNE TIB LT DSTL MEDL 9 HOLE LCK MERCURY-FREE PVC-FREE,SUP-2463196,CDM,C1713,HCPCS,0278,RC,,,,both,,,4389.00,2852.85,,,,,,,,,,,,,
TIP ASPIR L4.53IN ID0.05IN DISP FOR ULTRASONIC SURG ASPIR,SUP-2243960,CDM,C1713,HCPCS,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
HC Mech Rem/Obst GI Tube,PX-3614946000,CDM,49460,CPT,0361,RC,,,,inpatient,,,8583.00,5578.95,,,,,,,,,,,,,
NUT EXT FIX DIA10MM FOR SALVATION EXT FIX,SUP-2401146,CDM,C1713,HCPCS,0278,RC,,,,both,,,94.20,61.23,,,,,,,,,,,,,
IMPLANT OTO L5.5MM DIA1.14MM HA HD PLASTIPORE SHFT FULL,SUP-2313678,CDM,L8613,CPT,0278,RC,,,,both,,,1147.86,746.11,,,,,,,,,,,,,
SCREW BNE L30MM DIA3.5MM CORT ANK FT TI ST LOK FULL THRD,SUP-2371922,CDM,C1713,HCPCS,0278,RC,,,,both,,,353.25,229.61,,,,,,,,,,,,,
CANNULA ARTHSCP TERMANIAN ENDOTIP 6 MMX10.5 CM THRD BLK LF,SUP-2768019,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1899.29,1234.54,,,,,,,,,,,,,
STENT BILI QUICKPLACE V L 60 MM 10FR SCP 3.7MM DUODENAL BEND,SUP-2675681,CDM,C2617,HCPCS,0278,RC,,,,both,,,677.93,440.65,,,,,,,,,,,,,
NEEDLE ASPIR 19GA SHTH DIA1.73MM CHAN 2.8MM ADJ FLEX ENDO US,SUP-2141502,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1352.40,879.06,,,,,,,,,,,,,
TROCAR OPHTH OD23GA CANN STD ALONE PRB FOR CONSTELLATION,SUP-2109938,CDM,C1713,HCPCS,0278,RC,,,,both,,,810.12,526.58,,,,,,,,,,,,,
BIT DRL DIA10MM COUNTERBORE,SUP-2162882,CDM,2720000010,LOCAL,0272,RC,,,,both,,,546.36,355.13,,,,,,,,,,,,,
WASHER 30 MM CANNULATED SCREWS,SUP-2484531,CDM,C1713,HCPCS,0278,RC,,,,both,,,115.93,75.35,,,,,,,,,,,,,
KIT CARD PACE ARW L 110 CM DIA 5 FR BALLOON DIA 7 MM INTRO 6,SUP-2383248,CDM,C1887,HCPCS,0272,RC,,,,both,,,773.70,502.90,,,,,,,,,,,,,
HC Veeg by Tech Ea Incr 12-26 Hr Unmonitored,PX-7409571400,CDM,95714,CPT,0740,RC,,,,both,,,2592.00,1684.80,,,,,,,,,,,,,
PIN HLD PLT PREFIXATION THRD DISP TRINICA,SUP-2414371,CDM,C1713,HCPCS,0278,RC,,,,both,,,1036.20,673.53,,,,,,,,,,,,,
INTRODUCER SET BLUE RHINO G2-MULTI PDT,SUP-2718704,CDM,C1769,HCPCS,0272,RC,,,,both,,,1559.64,1013.77,,,,,,,,,,,,,
GRAFT VASC L40CM DIA28MM STR STD WALL N RING WVN VASCUTEK,SUP-2385011,CDM,L8670,HCPCS,0278,RC,,,,both,,,8383.80,5449.47,,,,,,,,,,,,,
PLATE BNE W10XL166MM THK3.6MM 14 H BILAT S STL CRV RIG CLLR,SUP-2186257,CDM,C1713,HCPCS,0278,RC,,,,both,,,2669.85,1735.40,,,,,,,,,,,,,
SCREW SPNL L35MM OD6.5MM TI PEDCL ST LO PROF POLYAX CANN IMP,SUP-2353328,CDM,C1713,HCPCS,0278,RC,,,,both,,,2533.98,1647.09,,,,,,,,,,,,,
DRIVER SURG H10 SELF RET STRL DISP MOTOBAND CP,SUP-2893267,CDM,2720000010,LOCAL,0272,RC,,,,both,,,332.84,216.35,,,,,,,,,,,,,
BUR 17MM PREC NEURO MTCH HD,SUP-2367604,CDM,C1713,HCPCS,0278,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
BAR EXT FIX L100MM STD LENGTHENING W SPCR PENNING,SUP-2316462,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1050.52,682.84,,,,,,,,,,,,,
HC So2 Nephelometry Ea Analyte Nes,PX-3018388368,CDM,83883,CPT,0301,RC,,,,both,,,84.00,54.60,,,,,,,,,,,,,
SHEATH /DILATOR GLIDETHRU 4FR X 7CM,SUP-2655673,CDM,C1894,HCPCS,0272,RC,,,,both,,,46.16,30.00,,,,,,,,,,,,,
HC Dilate Biliary Duct/Ampulla,PX-3614754200,CDM,47542,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
HALF RING W/CVD EXTR 150,SUP-2820645,CDM,2720000010,LOCAL,0272,RC,,,,both,,,11086.71,7206.36,,,,,,,,,,,,,
WIRE FIX UNIV 17.5 MM FOR BOLT SS,SUP-2162663,CDM,2720000010,LOCAL,0272,RC,,,,both,,,422.02,274.31,,,,,,,,,,,,,
HEAD HUM H15MM OD42MM CO CHROM MOLYBDENUM SHLDR STD PRI,SUP-2204829,CDM,C1776,CPT,0278,RC,,,,both,,,4333.20,2816.58,,,,,,,,,,,,,
DEVICE FIX 40MM LOOP VERSITOMIC G-LOK,SUP-2366635,CDM,C1713,HCPCS,0278,RC,,,,both,,,1232.04,800.83,,,,,,,,,,,,,
STEM FEM SEG 13 CM DPHSEAL KNEE SMOOTH OSS,SUP-2449811,CDM,C1776,CPT,0278,RC,,,,both,,,11595.08,7536.80,,,,,,,,,,,,,
IMPLANT IO 24MM M DRVR ASSEMB DISPOSABLE FOR HAMRTOE FIX SYS,SUP-2400046,CDM,C1713,HCPCS,0278,RC,,,,both,,,3689.50,2398.17,,,,,,,,,,,,,
STENT BILI AD L40MM DIA6MM CATH 6FR L135CM GWIRE 0.035IN,SUP-2420538,CDM,C1876,HCPCS,0278,RC,,,,both,,,2747.50,1785.87,,,,,,,,,,,,,
STRAP SPLNT NYL WHT 1INX14IN ROLYAN D RNG,SUP-2324779,CDM,L3908,HCPCS,0272,RC,,,,both,,,5.56,3.61,,,,,,,,,,,,,
SCREW BONE CRANIO MAXILLOFACIAL CROSS FIT ST TI 2MM DIA 14MM,SUP-2363431,CDM,C1713,HCPCS,0278,RC,,,,both,,,294.44,191.39,,,,,,,,,,,,,
GRAFT HUM TISS INJ FLUID THCK 3X2 CM AMNIO PLCNTA PRO3-C,SUP-2742029,CDM,C1762,CPT,0278,RC,,,,both,,,5517.77,3586.55,,,,,,,,,,,,,
HC Clsd Tx Bimall Fx W Manip,PX-4502781000,CDM,27810,CPT,0450,RC,,,,outpatient,,,1633.00,1061.45,,,,,,,,,,,,,
HC So Ish Ea Addl Single Probe Stain,PX-3128836966,CDM,88369,CPT,0312,RC,,,,both,,,122.00,79.30,,,,,,,,,,,,,
BASEPLATE TIB STD UNIV PRI PEG PRESSFIT POR PUR SZ A 58MM,SUP-2199508,CDM,C1776,CPT,0278,RC,,,,both,,,14001.89,9101.23,,,,,,,,,,,,,
SPLINT FNGR M 3IN DYN KNCK BENDR RVS SGL DGT WIRE FOAM RUB,SUP-2324851,CDM,L3809,HCPCS,0272,RC,,,,both,,,41.95,27.27,,,,,,,,,,,,,
HEAD HUM H21MM DIA48MM SHLDR ECC LO PROF MED FIN H FOR,SUP-2249940,CDM,C1776,CPT,0278,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
ALLOGRAFT BNE SHFT SPLIT FD FEM,SUP-2321795,CDM,C1713,HCPCS,0278,RC,,,,both,,,1899.70,1234.80,,,,,,,,,,,,,
SHEATH INTRO FLX ANSEL L 90 CM OD 5 FR ID 0.074 IN DIL L,SUP-2170360,CDM,C1894,HCPCS,0272,RC,,,,both,,,385.47,250.56,,,,,,,,,,,,,
PROSTHESIS OTO L425MM SHFT OD06MM TI MID EAR STAP FLROPLAS P,SUP-2436525,CDM,L8613,CPT,0278,RC,,,,both,,,557.76,362.54,,,,,,,,,,,,,
MESH BIO W8XL8CM BOV PERICARD NONCROSSLINKED CLLGN MTRX,SUP-2130302,CDM,C9354,HCPCS,0278,RC,,,,both,,,14513.11,9433.52,,,,,,,,,,,,,
PLATE BNE MTP STD RT MFT002SR] ORTHO HELIX SURGICAL DESIGN],SUP-2315903,CDM,C1713,HCPCS,0278,RC,,,,both,,,4122.82,2679.83,,,,,,,,,,,,,
CATHETER INFUSION UNI-FUSE L 45 CM 5FR SLT 20CM 0.035IN BALL,SUP-2117040,CDM,C1887,HCPCS,0272,RC,,,,both,,,703.36,457.18,,,,,,,,,,,,,
GUIDEWIRE VASC ARW L 14 CM DIA 0.018 IN PERIPH POS PLCMNT TB,SUP-2383493,CDM,C1769,HCPCS,0272,RC,,,,both,,,19.47,12.66,,,,,,,,,,,,,
INSERTER TACK DART DEL TISS REINF SHFT SINGLE EXIT PT STRL,SUP-2901972,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1683.04,1093.98,,,,,,,,,,,,,
BIT DRL L300MM DIA13MM CANN W/O STP CALIB QUIK CPL,SUP-2188079,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1676.29,1089.59,,,,,,,,,,,,,
CLAMP EXT FIX PIN 5 HOLE,SUP-2749992,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3381.78,2198.16,,,,,,,,,,,,,
HC Ptt|REPEAT CLINICAL DIAGNOSTIC LABORATORY TEST|NOT REASONABLE AND NECESSARY,PX-3058573000,CDM,85730,CPT,0305,RC,,,91|GZ,both,,,120.00,78.00,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY L 92 CM DIA 6 FR TIP 4 MM SPC BLU,SUP-2248666,CDM,C1733,HCPCS,0272,RC,,,,both,,,2213.70,1438.90,,,,,,,,,,,,,
SYSTEM CEREB PROTCT SENTNL FILTER SZ 15/10 MM RVD,SUP-2707488,CDM,C1884,HCPCS,0278,RC,,,,both,,,12560.00,8164.00,,,,,,,,,,,,,
CATHETER THROMCTMY SMARTCLAW L 145 CM DIA 4.95 FR BSKT DIA20,SUP-2933958,CDM,C1757,HCPCS,0272,RC,,,,both,,,12544.30,8153.79,,,,,,,,,,,,,
RISPERIDONE 1 MG/ML PO SOLN,RX-17377,CDM,340b,HCPCS,0637,RC,09999-9910-35,NDC,,both,0.25,ML,2.70,1.75,,,,,,,,,,,,,
DRILL SURG TAPR RELEASE COMPRESS,SUP-2445807,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2246.67,1460.34,,,,,,,,,,,,,
STENT URET L 22 CM DIA 6 FR PERCFLX SFT TEMP W/O DEL SYS,SUP-2141643,CDM,C2617,HCPCS,0278,RC,,,,both,,,329.64,214.27,,,,,,,,,,,,,
EXTENSION GUIDEWIRE CINCH QR L 145 CM DIA 0.014 IN STR,SUP-2157215,CDM,C1769,HCPCS,0272,RC,,,,both,,,239.74,155.83,,,,,,,,,,,,,
SCREW BONE 4.5MMDIA 16MML STD CORT FULL THRD N CANN N SELF,SUP-2198204,CDM,C1713,HCPCS,0278,RC,,,,both,,,38.97,25.33,,,,,,,,,,,,,
AUTOTRANSFUSION PACK 1 SOURC 120 MU M AUTOLOG ATLS21,SUP-2470905,CDM,2720000010,LOCAL,0272,RC,,,,both,,,316.36,205.63,,,,,,,,,,,,,
ADAPTER LD L 13 CM A1 MBP 32 MM TO IS1 CONN BPLR PACE,SUP-2137917,CDM,C1883,HCPCS,0278,RC,,,,both,,,788.14,512.29,,,,,,,,,,,,,
SCREW BONE EMERGENCY 2X9 MM WITH FLUTED TIP TITANIUM,SUP-2838218,CDM,C1713,HCPCS,0278,RC,,,,both,,,217.60,141.44,,,,,,,,,,,,,
CATHETER GUID DIA2.7 MM VER VID STRL,SUP-2165192,CDM,C1887,HCPCS,0272,RC,,,,both,,,1252.86,814.36,,,,,,,,,,,,,
CATHETER ANGIOPLSTY ATLS L 75 CM BALLOON L 4 CM DIA24 MM,SUP-2127942,CDM,C1725,HCPCS,0272,RC,,,,both,,,1805.50,1173.57,,,,,,,,,,,,,
ROD ORTH THRD 75 MM PILLAR,SUP-2749917,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1544.88,1004.17,,,,,,,,,,,,,
TUBE VENT ID1.52MM SIL NOTCH TAB TWST IN INSRT PAPARELLA,SUP-2284016,CDM,L8699,HCPCS,0278,RC,,,,both,,,73.60,47.84,,,,,,,,,,,,,
STEM HUM SZ 10 L125MM TI EPOCA PRESSFIT,SUP-2193871,CDM,C1776,CPT,0278,RC,,,,both,,,11323.31,7360.15,,,,,,,,,,,,,
BIT DRL L4MM OD4.1MM S STL WIDENING COUNTSINK DISP FOR BAHA,SUP-2164970,CDM,2720000010,LOCAL,0272,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
THYROTROPIN ALFA 0.9 MG IM SOLR,RX-155587,CDM,J3240,HCPCS,0636,RC,58468-0030-02,NDC,,both,1,UN,1103.40,717.21,,,,,,,,,,,,,
PLATE BNE W24XL45MM 8 H NONSTERILE BILAT MIDFOOT HINDFOOT TI,SUP-2191457,CDM,C1713,HCPCS,0278,RC,,,,both,,,2692.05,1749.83,,,,,,,,,,,,,
ELECTRODE ELECSURG 7 MM 18 GAX7 CM 9.9 CM MONOPOLAR RF DISP,SUP-2740360,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5495.00,3571.75,,,,,,,,,,,,,
CAGE SPNL L30MM DIA9MM CRESC INTBDY,SUP-2280121,CDM,C1889,HCPCS,0278,RC,,,,both,,,6656.80,4326.92,,,,,,,,,,,,,
BUR SURGICAL MR8 TWST DRILL 3MMX30MM0,SUP-2740421,CDM,2720000010,LOCAL,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
SCREW BONE L34MM OD4MM CANN TAPR LAG ANK INTRAOSSEUS FIX,SUP-2223797,CDM,C1713,HCPCS,0278,RC,,,,both,,,2163.46,1406.25,,,,,,,,,,,,,
HC So Factor 5,PX-3058522066,CDM,85220,CPT,0305,RC,,,,inpatient,,,280.00,182.00,,,,,,,,,,,,,
CAMPHOR-MENTHOL 0.5-0.5 % EX LOTN,RX-23063,CDM,6370000000,HCPCS,0637,RC,00536-1268-12,NDC,,both,222,ML,25.00,16.25,,,,,,,,,,,,,
PLATE BNE W10XL75MM THK1.2MM 90DEG 4X6 H BILAT S STL T SHP,SUP-2185872,CDM,C1713,HCPCS,0278,RC,,,,both,,,1297.17,843.16,,,,,,,,,,,,,
GRAFT DURA W2.63XL3.93IN BOV PERICARD ENDURA,SUP-2244039,CDM,C1763,HCPCS,0278,RC,,,,both,,,2009.60,1306.24,,,,,,,,,,,,,
PLATE BNE L104MM 6 H R LAT PROX PERIARTC TIB S STL LOK COMPR,SUP-2198429,CDM,C1713,HCPCS,0278,RC,,,,both,,,3829.29,2489.04,,,,,,,,,,,,,
DEFIBRILLATOR IMPL ACTICOR 7 HF-T QP W 75 X H 60 MM D 10 MM,SUP-2739245,CDM,C1882,HCPCS,0275,RC,,,,both,,,69529.02,45193.86,,,,,,,,,,,,,
TUBE VENT MORETZ 1.27MM 6/BXPC COAT FLROPLAS,SUP-2312795,CDM,L8699,HCPCS,0278,RC,,,,both,,,41.17,26.76,,,,,,,,,,,,,
ALLOGRAFT BNE STRP 15X30 MM PRESERVON STRUCTURAL ORAGRAFT,SUP-2741053,CDM,C1713,HCPCS,0278,RC,,,,both,,,1269.19,824.97,,,,,,,,,,,,,
MESH CS LEFT MEDIUM 8 CM X 14 CM,SUP-2655636,CDM,C1781,HCPCS,0278,RC,,,,both,,,596.60,387.79,,,,,,,,,,,,,
KETAMINE HCL 30 MG/3ML IJ SOSY,RX-143111,CDM,2500000003,HCPCS,0250,RC,69374-0982-33,NDC,,both,0.5,ML,54.10,35.16,,,,,,,,,,,,,
PLATE GLEN STD SHLDR CEM REV EQUINOXE,SUP-2223380,CDM,C1776,CPT,0278,RC,,,,both,,,4239.00,2755.35,,,,,,,,,,,,,
NAIL IM L240MM OD10MM TI DST TIB CEPHALOMEDULLARY PROX LAT,SUP-2368851,CDM,C1713,HCPCS,0278,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
PROBE RF STR 21 GAX50 MM DURABLE SS REUSE,SUP-2753307,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3173.82,2062.98,,,,,,,,,,,,,
"HC Pt Therapeutic Exercise,Ea 15 Min|DOCUMENTATION ON FILE|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS",PX-4209711000,CDM,97110,CPT,0420,RC,,,KX|CQ,both,,,195.00,126.75,,,,,,,,,,,,,
CANNULA LAP 3.9 MMX25 CM FOR 30117J VERES NDL TROCAR,SUP-2767479,CDM,2720000010,LOCAL,0272,RC,,,,both,,,500.48,325.31,,,,,,,,,,,,,
IMPLANT STRNL CLSR SM FT PLT D17MM DBL VERSION TALON,SUP-2262542,CDM,C1713,HCPCS,0278,RC,,,,both,,,4694.30,3051.29,,,,,,,,,,,,,
TUBE VENT LT,SUP-2468998,CDM,2720000010,LOCAL,0272,RC,,,,both,,,418.56,272.06,,,,,,,,,,,,,
STEM FEM L225MM OD11MM POR LT REV PRESSFIT INTEGR,SUP-2406833,CDM,C1776,CPT,0278,RC,,,,both,,,19053.52,12384.79,,,,,,,,,,,,,
PLATE BNE W22XL54MM STD 9 H R DST RAD VOLAR S STL VAR ANG,SUP-2177296,CDM,C1713,HCPCS,0278,RC,,,,both,,,2163.62,1406.35,,,,,,,,,,,,,
FORCEP ELECSURG BPLR 1.2 MM 15.5 CM PRECIS BAYNT SILVERGLIDE,SUP-2859573,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2779.78,1806.86,,,,,,,,,,,,,
MESH SURG W40XL60MM MIC LUHR,SUP-2364691,CDM,C1781,HCPCS,0278,RC,,,,both,,,2559.10,1663.41,,,,,,,,,,,,,
FEEDING TUBE KIT LP 14 FRX1.7 CM BLLN BUTTON SIL MINI 1,SUP-2754574,CDM,2720000010,LOCAL,0272,RC,,,,both,,,520.11,338.07,,,,,,,,,,,,,
PLATE BNE L131MM 7 H NONSTERILE L DST LAT FIBULAR S STL VAR,SUP-2177727,CDM,C1713,HCPCS,0278,RC,,,,both,,,2658.92,1728.30,,,,,,,,,,,,,
STRIP BONE GRAFT 22MM X 45/60MM TRICORTICAL ILIUM FD,SUP-2863675,CDM,C1713,HCPCS,0278,RC,,,,both,,,9542.46,6202.60,,,,,,,,,,,,,
NEEDLE LOC LESION BRST MOD KOP MREYE,SUP-2168710,CDM,C1819,HCPCS,0278,RC,,,,both,,,133.45,86.74,,,,,,,,,,,,,
LEAD PACE SWEET PICOTIP RX L 59 CM SIL ENDOCARD RT,SUP-2148636,CDM,C1898,HCPCS,0275,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
SUPPORT ORTHOPEDIC SM LT WRST,SUP-2330434,CDM,L3908,HCPCS,0272,RC,,,,both,,,25.12,16.33,,,,,,,,,,,,,
CATHETER NEPHSTMY L35CM DIA20FR TIP L18CM DIA8FR MCOT,SUP-2138888,CDM,C1729,HCPCS,0272,RC,,,,both,,,252.68,164.24,,,,,,,,,,,,,
CANNULA ART SHT 21 FR UNCOATED HLS,SUP-2663478,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1004.96,653.22,,,,,,,,,,,,,
TROCAR ENDOSCP L 100 MM DIA15 MM SHRT OPT FIX CANN DOLPHIN,SUP-2896220,CDM,2720000010,LOCAL,0272,RC,,,,both,,,554.05,360.13,,,,,,,,,,,,,
INSERT TIB SZ 3-4 THK9MM STD KNEE POLY POST STBL CONSTRN,SUP-2345950,CDM,C1776,CPT,0278,RC,,,,both,,,6380.48,4147.31,,,,,,,,,,,,,
CATHETER EP MAP SUPREME 6FR HEXAPOLAR W/ UPLR RCRD,SUP-2356898,CDM,C1730,HCPCS,0272,RC,,,,both,,,857.22,557.19,,,,,,,,,,,,,
IMPLANT OP RM MINI-MONSTER 2.0X38MM H,SUP-2320871,CDM,C1713,HCPCS,0278,RC,,,,both,,,859.58,558.73,,,,,,,,,,,,,
STENT URTRL 48FR DIA 22 30CML FLXMA STRGHT TIP STIFF W/003,SUP-2724821,CDM,C2617,HCPCS,0278,RC,,,,both,,,585.04,380.28,,,,,,,,,,,,,
MESH SURG W15XL12CM SEPRA TECHNOLOGY RECT PHASIX,SUP-2125883,CDM,C1781,HCPCS,0278,RC,,,,both,,,14993.50,9745.77,,,,,,,,,,,,,
KIT SCR L15MM DIA8MM W/ BICEPTOR BIOSURE,SUP-2341825,CDM,C1713,HCPCS,0278,RC,,,,both,,,1283.66,834.38,,,,,,,,,,,,,
GRAFT BIO TISS MESH 16X8 CM MIROMATRIX MIROMESH,SUP-2115023,CDM,C1781,HCPCS,0278,RC,,,,both,,,11342.18,7372.42,,,,,,,,,,,,,
PLATE BONE CALCANEUS UNIVERSAL SLIDE TITANIUM ARSENAL FOOT PLATING SYSTEM FOR 2.2/2.7/3.5MM SCREW,SUP-2878176,CDM,C1713,HCPCS,0278,RC,,,,both,,,7002.20,4551.43,,,,,,,,,,,,,
CUP ACET OD49MM ID32MM HIP LONGEVITY PRI CEM NEUT SPCR ZCA,SUP-2203741,CDM,C1776,CPT,0278,RC,,,,both,,,4000.36,2600.23,,,,,,,,,,,,,
MOULD SPACER SM R/L KNEE TEMP STRL DISP COPAL,SUP-2905409,CDM,2720000010,LOCAL,0272,RC,,,,both,,,11461.00,7449.65,,,,,,,,,,,,,
DEVICE FIX INLINE STRL TOGGLELOC ZIPLOOP,SUP-2608599,CDM,C1713,HCPCS,0278,RC,,,,both,,,341.13,221.73,,,,,,,,,,,,,
UNIT DRNGE PLEUR CAV 2 COLL WET SUCT WET SEAL REGULATED STR,SUP-2384315,CDM,C1729,HCPCS,0272,RC,,,,both,,,132.29,85.99,,,,,,,,,,,,,
HC Arthrogram Shoulder S&I,PX-3227304000,CDM,73040,CPT,0322,RC,,,,outpatient,,,1191.00,774.15,,,,,,,,,,,,,
CATHETER NSL L3.25CM DIA0.265IN SIL 2 CUF EDISTAT,SUP-2284101,CDM,2720000010,LOCAL,0272,RC,,,,both,,,382.45,248.59,,,,,,,,,,,,,
PLATE BNE L 43 MM PROF H 1.7 MM SHRT RT DSTL ULNA STR BASE,SUP-2900507,CDM,C1713,HCPCS,0278,RC,,,,both,,,3457.64,2247.47,,,,,,,,,,,,,
STEM HUM INTERCALARY 120 MM SHLDR REV SEG W/ SCREW COMPHSVE,SUP-2442427,CDM,C1776,CPT,0278,RC,,,,both,,,17634.24,11462.26,,,,,,,,,,,,,
SET NG TB 8FR L70CM 3 SIDEPRT STD STR PTFE S STL GWIRE,SUP-2168215,CDM,C1769,HCPCS,0272,RC,,,,both,,,122.46,79.60,,,,,,,,,,,,,
MESH HERN REP W15XL20CM RECT SKIRTED MFIL COMP POLY ABSRB,SUP-2173621,CDM,C1781,HCPCS,0278,RC,,,,both,,,4492.05,2919.83,,,,,,,,,,,,,
CATHETER BLLN DIL ADVANTAGE 180 CM 12X80 MM PK,SUP-2126434,CDM,C1726,HCPCS,0272,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
LENS IOL BCNVX 16+ DIOPT 6X13 MM ANTR CHMBR SIL,SUP-2112386,CDM,V2632,HCPCS,0276,RC,,,,both,,,342.26,222.47,,,,,,,,,,,,,
COMPONENT CTRL BODY EXT FIX STD PROCALLUS,SUP-2316280,CDM,C1776,CPT,0278,RC,,,,both,,,3087.19,2006.67,,,,,,,,,,,,,
TUBE JEJU 9 FRX60 CM FLO 20,SUP-2737405,CDM,C1769,HCPCS,0272,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
STRUT EXT FIX MED NS DISP ACUTE QC,SUP-2932994,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4991.56,3244.51,,,,,,,,,,,,,
HC So1 Hiv-1 Amplified Probe Tech,PX-3068753567,CDM,87535,CPT,0306,RC,,,,both,,,118.00,76.70,,,,,,,,,,,,,
TRIAL KNEE THK4MM DST FEM AUG PFC SIG SPEC 2,SUP-2253884,CDM,C1776,CPT,0278,RC,,,,both,,,279.46,181.65,,,,,,,,,,,,,
UB BLADE KELLY 1IN 3IN,SUP-2674154,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1032.02,670.81,,,,,,,,,,,,,
STENT URET L 24 CM DIA 7/10 FR SL-6 ENDOPYLTMY 2 DIAMETER,SUP-2119475,CDM,C2617,HCPCS,0278,RC,,,,both,,,358.53,233.04,,,,,,,,,,,,,
CLAMP SURG OFFSET EXTN 200 MM 6-6.5 MM LT 6.35 MM ROD,SUP-2584892,CDM,C1713,HCPCS,0278,RC,,,,both,,,8333.56,5416.81,,,,,,,,,,,,,
HC Bld Count Smear Mcrscp W/O Mnl Difrntl Wbc Count,PX-3058500800,CDM,85008,CPT,0305,RC,,,,both,,,11.00,7.15,,,,,,,,,,,,,
PERCUTANEOUS ENTRY SET,SUP-2826995,CDM,2720000010,LOCAL,0272,RC,,,,both,,,376.14,244.49,,,,,,,,,,,,,
HC Sbrt Delivery,PX-3337737300,CDM,77373,CPT,0333,RC,,,,inpatient,,,18641.00,12116.65,,,,,,,,,,,,,
GRAFT VASC STD WALL 5 MMX90 CM STR RNG REINF ADVANTA VXT,SUP-2471651,CDM,C1768,CPT,0278,RC,,,,both,,,2055.54,1336.10,,,,,,,,,,,,,
COMPONENT HIP CAPPED BPLR H31] STRYKER CORP],SUP-2365530,CDM,C1776,CPT,0278,RC,,,,both,,,7906.08,5138.95,,,,,,,,,,,,,
ELECTRODE ELECSURG FLUT VAPORTRODE,SUP-2313977,CDM,C1713,HCPCS,0278,RC,,,,both,,,3231.06,2100.19,,,,,,,,,,,,,
TRIAL SURG FOR ELONG L PLT FLOWERCUBE,SUP-2225459,CDM,C1713,HCPCS,0278,RC,,,,both,,,84.78,55.11,,,,,,,,,,,,,
FILTER VASC OPT ELITE SHTH L 100 CM DIA 5 FR CAVA DIA 30 MM,SUP-2120060,CDM,C1880,HCPCS,0278,RC,,,,both,,,6280.00,4082.00,,,,,,,,,,,,,
KIT CATH HEMODIALYSI RELIANCE XK CHRONIC STD 16FR DIA 19CM 2,SUP-2613284,CDM,C1750,HCPCS,0278,RC,,,,both,,,1483.65,964.37,,,,,,,,,,,,,
MATRIX BIO SZ 250 SQCM FISH SKIN DERMAL MESHED 21 INTACT,SUP-2909273,CDM,Q4158,HCPCS,0636,RC,,,,both,,,25041.50,16276.97,,,,,,,,,,,,,
GRAFT BONE 30ML SUB VOID FIL GRAN PLEXUR P,SUP-2293937,CDM,C1713,HCPCS,0278,RC,,,,both,,,4577.34,2975.27,,,,,,,,,,,,,
CLIP IMPL ALIGN NS DISP FATHOM,SUP-2884711,CDM,2720000010,LOCAL,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
BIT DRL QR LNG 3.5 MM SURGIBIT,SUP-2518548,CDM,2720000010,LOCAL,0272,RC,,,,both,,,326.56,212.26,,,,,,,,,,,,,
BIT DRILL T2 TRIFLAT 42 X 130MM,SUP-2701073,CDM,2720000010,LOCAL,0272,RC,,,,both,,,682.95,443.92,,,,,,,,,,,,,
PLATE BONE W16XL285MM THK5MM 15 H LT CNDYL FEM S STL BTTRS,SUP-2185796,CDM,C1713,HCPCS,0278,RC,,,,both,,,2849.27,1852.03,,,,,,,,,,,,,
GRAFT HUM TISS W14XH7MM D11MM CANC CORT LORD SPNL SPCR BLK,SUP-2293881,CDM,C1713,HCPCS,0278,RC,,,,both,,,3108.60,2020.59,,,,,,,,,,,,,
VALVULOTOME ANGIOSCOPIC L 12 IN RETROGRADE NS,SUP-2476610,CDM,2720000010,LOCAL,0272,RC,,,,both,,,331.74,215.63,,,,,,,,,,,,,
PLATE VARIAX COMP NAR STRAIGHT 4HL,SUP-2703372,CDM,C1713,HCPCS,0278,RC,,,,both,,,1371.55,891.51,,,,,,,,,,,,,
CAP ORTHOPEDIC LCK STRL NCB,SUP-2470569,CDM,C1713,HCPCS,0278,RC,,,,both,,,445.03,289.27,,,,,,,,,,,,,
PLATE BNE MESHED LG 0.6 MM MXLFCL NEURO STD PAT OUSIDE HOLE,SUP-2477844,CDM,C1713,HCPCS,0278,RC,,,,both,,,4600.85,2990.55,,,,,,,,,,,,,
DEXTROSE 5 % IV BOLUS,RX-40840055,CDM,2580000003,HCPCS,0258,RC,00264-1510-31,NDC,,both,250,ML,104.20,67.73,,,,,,,,,,,,,
PRE 20MM 035 GW STR BX20,SUP-2679397,CDM,C1769,HCPCS,0272,RC,,,,both,,,28875.44,18769.04,,,,,,,,,,,,,
SET INT FIX SCREW DIA1.5 MM 4 H TI NEURO SQ PLATE XDRV 12 PK,SUP-2935258,CDM,C1713,HCPCS,0278,RC,,,,both,,,20695.74,13452.23,,,,,,,,,,,,,
SYSTEM CLOSURE 6 FR CLINCHER KNOT TYNG,SUP-2240296,CDM,C1760,HCPCS,0278,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
INSERT TIB SZ 3 THK20MM STD L KNEE POLYETH CRUCE RET PRI,SUP-2304713,CDM,C1776,CPT,0278,RC,,,,both,,,6751.00,4388.15,,,,,,,,,,,,,
STENT PERIPH L100MM DIA10MM CATH L110CM NIT EPTFE IL,SUP-2396464,CDM,C1874,HCPCS,0278,RC,,,,both,,,8007.00,5204.55,,,,,,,,,,,,,
GRAFT HUM TISS PERONEUS LONGUS TEND >22CM FRZN (FOLDED DIAM,SUP-2307283,CDM,C1713,HCPCS,0278,RC,,,,both,,,4150.83,2698.04,,,,,,,,,,,,,
DEXTROSE-SODIUM CHLORIDE 5-0.9 % IV SOLN|DISCARDED DRUG NOT ADMINISTE,RX-15882,CDM,J7042,HCPCS,0258,RC,00338-0089-03,NDC,JW,both,500,ML,38.30,24.89,,,,,,,,,,,,,
LEAD DEFIB ENDOTK ENDUR RX L 64 CM SIL STEROID ENDOCARD,SUP-2148549,CDM,C1895,HCPCS,0275,RC,,,,both,,,21116.50,13725.72,,,,,,,,,,,,,
SENSOR PRSSRE WTRNSDCR WTH BFRCTD PRSSRE LINES WTH VAMP SST,SUP-2696594,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1103.77,717.45,,,,,,,,,,,,,
BIT DRILL CALIB 4.3MM,SUP-2491960,CDM,2720000010,LOCAL,0272,RC,,,,both,,,331.21,215.29,,,,,,,,,,,,,
CATHETER PICC L 30 CM DIA1.4 FR POLYUR SINGLE LUMEN STRL,SUP-2904957,CDM,C1751,HCPCS,0278,RC,,,,both,,,153.86,100.01,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 40 CM DIA 4-6 MM SHRT TAPR REINF,SUP-2495531,CDM,C1768,CPT,0278,RC,,,,both,,,729.11,473.92,,,,,,,,,,,,,
SCREW BNE L14MM DIA3.5MM S STL ST VAR ANG NONCANNULATED LOK,SUP-2348520,CDM,C1713,HCPCS,0278,RC,,,,both,,,1087.35,706.78,,,,,,,,,,,,,
PIN FIX L25MM DIA2MM PROV FOR EVOS SM PLATING SYS,SUP-2344053,CDM,C1713,HCPCS,0278,RC,,,,both,,,874.14,568.19,,,,,,,,,,,,,
SCREW BNE L 95 MM DIA2.4 MM 10 SHFT H SS Y SHP HD NS V,SUP-2905671,CDM,C1713,HCPCS,0278,RC,,,,both,,,2785.97,1810.88,,,,,,,,,,,,,
BIT DRL DIA2MM ULN SHORTNG GENERATION II LO PROF LOK SYS,SUP-2397325,CDM,2720000010,LOCAL,0272,RC,,,,both,,,238.64,155.12,,,,,,,,,,,,,
ENDCAP SPNL COLOSSEUM 0 DEG 14MMX16MMX3MM,SUP-2417972,CDM,C1889,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
GUIDEWIRE VASC ANGLED 45 DEG 0.035 INX350 CM STIFF GLIDEWIRE,SUP-2422176,CDM,C1769,HCPCS,0272,RC,,,,both,,,261.56,170.01,,,,,,,,,,,,,
SCREW DISTR PIN L16MM ANT CERV AGG,SUP-2417447,CDM,C1713,HCPCS,0278,RC,,,,both,,,62.86,40.86,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY ISMUS L 115 CM DIA 7 FR SPC,SUP-2248780,CDM,C1730,HCPCS,0272,RC,,,,both,,,3165.12,2057.33,,,,,,,,,,,,,
PORT LAP DIA5MM CANN OBT SFT FLX SILS,SUP-2283386,CDM,C1713,HCPCS,0278,RC,,,,both,,,1059.72,688.82,,,,,,,,,,,,,
RING ACET SZ 48 HIP LCK REPLACEMENTXRAY RNGLOC RX90,SUP-2404765,CDM,C1776,CPT,0278,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
ALLOGRAFT BNE SM 5 CC DBM FIBER OSTEOSTRAND PLUS,SUP-2731814,CDM,C1713,HCPCS,0278,RC,,,,both,,,7159.20,4653.48,,,,,,,,,,,,,
CUP ACET OD43MM ID22MM LONGEVITY HXLPE NEUT SPCR ALL POLY,SUP-2203732,CDM,C1776,CPT,0278,RC,,,,both,,,3837.08,2494.10,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9% IV BOLUS (PER WEIGHT),RX-40901010,CDM,2580000003,HCPCS,0250,RC,00264-1800-32,NDC,,both,100,ML,23.00,14.95,,,,,,,,,,,,,
STENT BILI L80MM 7FR 120CM CATH LEN 6MM DIAM AD SUPERA,SUP-2241759,CDM,C1876,HCPCS,0278,RC,,,,both,,,5322.30,3459.49,,,,,,,,,,,,,
PLATE BONE ORBITAL FLOOR 30X30X0.8 MM SMOOTH STERILE SYNPOR,SUP-2837802,CDM,C1713,HCPCS,0278,RC,,,,both,,,2068.32,1344.41,,,,,,,,,,,,,
HINGE EXT FIX ANK STRL TRUELOK PHANTOM LTX,SUP-2875237,CDM,2720000010,LOCAL,0272,RC,,,,both,,,12717.00,8266.05,,,,,,,,,,,,,
GRAFT BNE FRZ DRY PROX FEM W O HD IMPL ALLGRFT MATRIGRFT,SUP-2264783,CDM,C1713,HCPCS,0278,RC,,,,both,,,11063.10,7191.01,,,,,,,,,,,,,
PLATE BNE H06MM BAR L6MM 6 H CHIN TI ADV LEIBINGER UNIV 2,SUP-2366337,CDM,C1713,HCPCS,0278,RC,,,,both,,,797.97,518.68,,,,,,,,,,,,,
COMPONENT FEM 3X2MM OFFSET SM ARTC IMPL UNICAP,SUP-2123717,CDM,C1776,CPT,0278,RC,,,,both,,,13109.50,8521.17,,,,,,,,,,,,,
GUIDEWIRE URO L150CM DIA0.035IN TAPR 8CM STR TIP STD SHFT,SUP-2139341,CDM,C1769,HCPCS,0272,RC,,,,both,,,143.22,93.09,,,,,,,,,,,,,
CATHETER ANGIOPLSTY DIA13MM BAL DIA4.5MM HYDRCOAT RAP EXCHG,SUP-2101510,CDM,C1725,HCPCS,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
COMPONENT TIB L80MM DIA16MM STD PROX MOD GMRS,SUP-2376522,CDM,C1776,CPT,0278,RC,,,,both,,,17264.03,11221.62,,,,,,,,,,,,,
DIGOXIN 250 MCG PO TABS,RX-2445,CDM,6370000000,HCPCS,0637,RC,00904-5922-61,NDC,,both,1,UN,6.10,3.96,,,,,,,,,,,,,
ELECTRODE RESECTION ROLLER BALL 12,SUP-2848834,CDM,C1713,HCPCS,0278,RC,,,,both,,,490.63,318.91,,,,,,,,,,,,,
CATHETER HD STR 0.038 IN 16 FRX120 CM 19 CM DL HEMOSPLIT XK,SUP-2126520,CDM,C1881,HCPCS,0278,RC,,,,both,,,1486.95,966.52,,,,,,,,,,,,,
DEXRAZOXANE HCL 500 MG IV SOLR,RX-145117,CDM,J1190,HCPCS,0636,RC,72611-0716-01,NDC,,both,1,UN,548.10,356.26,,,,,,,,,,,,,
STEM FEM PRSS FIT COCR MLRY HD SZ 5/7 135MML,SUP-2403344,CDM,C1776,CPT,0278,RC,,,,both,,,8050.96,5233.12,,,,,,,,,,,,,
BRACE KNEE UNIV L22 27IN 10DEG FLX TELSCP PDDLE POSTOP FOAM,SUP-2195288,CDM,L1810,HCPCS,0272,RC,,,,both,,,220.59,143.38,,,,,,,,,,,,,
NAIL LEFT LONG 10 X 120MM,SUP-2854414,CDM,C1713,HCPCS,0278,RC,,,,both,,,8888.02,5777.21,,,,,,,,,,,,,
PATCH CV XENOSURE L 10 X W 1.5 CM BOV PERICARD BIOLOGIC UNIF,SUP-2217970,CDM,C1762,CPT,0278,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
HC Joint Survey Single View 2 or More Joints,PX-3207707700,CDM,77077,CPT,0320,RC,,,,both,,,809.00,525.85,,,,,,,,,,,,,
PLATE BNE L 120 X W 8 MM THK 3.2 MM SCREW DIA2.7 MM 15 H SS 72440115N,SUP-2933437,CDM,C1713,HCPCS,0278,RC,,,,both,,,2976.25,1934.56,,,,,,,,,,,,,
HEAD RADIAL 0+ MM 10X22 MM 7.5 MM ELBW STRL,SUP-2789482,CDM,C1776,CPT,0278,RC,,,,both,,,9249.81,6012.38,,,,,,,,,,,,,
CATHETER GUID CYB BALLOON L 55 CM DIA 8 FR POLYETHER BLOCK,SUP-2141012,CDM,C1887,HCPCS,0272,RC,,,,both,,,323.42,210.22,,,,,,,,,,,,,
BRACE KNEE UNIV L22 27IN 10DEG FLX TELSCP PDDLE POSTOP FOAM,SUP-2195288,CDM,L1810,HCPCS,0274,RC,,,,both,,,220.59,143.38,,,,,,,,,,,,,
SENSOR SLEEP STUDY SNORING SENSE EMBLA,SUP-2307707,CDM,2720000010,LOCAL,0272,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
ENTACAPONE 200 MG PO TABS,RX-26547,CDM,6370000000,HCPCS,0637,RC,60687-0188-11,NDC,,both,1,UN,18.60,12.09,,,,,,,,,,,,,
INSERTER BNE STPL PTCH DEPLOYMENT REINF SHFT 2 EXIT PT STRL,SUP-2902033,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
DEVICE CTRL MOB DGT IPOD TCH,SUP-2417135,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
IMPLANT BIO TISS W15XL20CM THK1.5MM PORCINE CLLGN FOR HERN,SUP-2174701,CDM,C9364,HCPCS,0278,RC,,,,both,,,20635.20,13412.88,,,,,,,,,,,,,
PROCEDURE PACK SHLDR HEARTWARE,SUP-2282560,CDM,Q0498,HCPCS,0274,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
PROBENECID 500 MG PO TABS,RX-6561,CDM,6370000000,HCPCS,0637,RC,00591-5347-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
CATHETER URET 11/13 FRX24 CM UROPS AS,SUP-2458910,CDM,C1758,HCPCS,0278,RC,,,,both,,,448.77,291.70,,,,,,,,,,,,,
ALLOGRAFT DERMAL PTCH THCK 10X5 CM ACELLULAR HYDRATED DERM,SUP-2321760,CDM,C1713,HCPCS,0278,RC,,,,both,,,9734.00,6327.10,,,,,,,,,,,,,
TUBE TYMPLSTY PED L1.5MM DIA0.76MM TI VENT MORETZ TAB GRMMT,SUP-2284041,CDM,L8699,HCPCS,0278,RC,,,,both,,,135.02,87.76,,,,,,,,,,,,,
CATHETER KT ABSC DRNGE CUST MTN STATES MSHA,SUP-2302881,CDM,C1729,HCPCS,0272,RC,,,,both,,,25.12,16.33,,,,,,,,,,,,,
PIN BNE FIX DIA 6 MM CANC THRD REDUCTION STRL VARIAX,SUP-2900756,CDM,C1713,HCPCS,0278,RC,,,,both,,,1281.87,833.22,,,,,,,,,,,,,
IMPLANT STAP L4.25MM DIA0.6MM PIST AND WIRE FLROPLAS S STL,SUP-2312791,CDM,L8613,CPT,0278,RC,,,,both,,,427.67,277.99,,,,,,,,,,,,,
PLATE BNE 2.7X90 MM 10 HOLE SS LCP,SUP-2569311,CDM,C1713,HCPCS,0278,RC,,,,both,,,407.57,264.92,,,,,,,,,,,,,
GRAFT VASC L80CM L30CM ID6MM THN WALLED REM RNGD,SUP-2396118,CDM,C1768,CPT,0278,RC,,,,both,,,3193.38,2075.70,,,,,,,,,,,,,
BIT DRL L110MM DIA27MM ST 3 FLUT QUIK CPL NONRADIOPAQUE,SUP-2187588,CDM,2720000010,LOCAL,0272,RC,,,,both,,,424.75,276.09,,,,,,,,,,,,,
FAMOTIDINE 20 MG PO TABS,RX-10011,CDM,6370000000,HCPCS,0637,RC,50268-0299-11,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
VALVE AORT CARP EDW PERIMT RSR 21 MM BOV PERICARD COCR REDUC,SUP-2214068,CDM,C1889,HCPCS,0278,RC,,,,both,,,18777.20,12205.18,,,,,,,,,,,,,
SPACER CEM SM SHT L94MM DIA54MM PMMA HI REL GENT IMPREG,SUP-2223674,CDM,C1776,CPT,0278,RC,,,,both,,,11649.40,7572.11,,,,,,,,,,,,,
KIT CATH 5FR L13CM CTRL VEN POLYUR DBL LUMN BLU FLEXTIP W/,SUP-2383294,CDM,C1751,HCPCS,0278,RC,,,,both,,,100.48,65.31,,,,,,,,,,,,,
BLADE SAW OSCLLTNG 29MMW X74MML 0.64MM THK 0.64MM THK CUT LG,SUP-2605583,CDM,2720000010,LOCAL,0272,RC,,,,both,,,113.86,74.01,,,,,,,,,,,,,
MESH SURG SHT 24X18 CMX2 MM AORT GRFT VASC DUALMESH,SUP-2496403,CDM,C1781,HCPCS,0278,RC,,,,both,,,6691.34,4349.37,,,,,,,,,,,,,
ALLOGRAFT BNE BLOCK 45X24 MM TRICORT,SUP-2743389,CDM,C1713,HCPCS,0278,RC,,,,both,,,7043.02,4577.96,,,,,,,,,,,,,
PLATE BNE RECON 3.5X156 MM 12 HOLE W/ WIDE ANGLE STR LP NS,SUP-2799215,CDM,C1713,HCPCS,0278,RC,,,,both,,,1607.27,1044.73,,,,,,,,,,,,,
HC OP Traction Intermittent|DOCUMENTATION ON FILE|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS,PX-4209701200,CDM,97012,CPT,0420,RC,,,KX|CQ,outpatient,,,292.00,189.80,,,,,,,,,,,,,
CEMENT BONE 5CC CA PHOS HA INJ FAST SET ISOTHERMIC RADPQ,SUP-2365155,CDM,C1713,HCPCS,0278,RC,,,,both,,,6522.97,4239.93,,,,,,,,,,,,,
Vivacit-E Art Surf Sz 1 8mm,SUP-2510951,CDM,C1776,CPT,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
KIT HAD CATH L32CM DIA15FR TIP TO CUF 27CM TWO LUMN LNG,SUP-2383443,CDM,C1750,HCPCS,0278,RC,,,,both,,,1114.70,724.55,,,,,,,,,,,,,
TUBE NG M 16FR BLLN L1.5-6IN SPEC BLAKMR DISP TO CTRL BLEED,SUP-2127132,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1030.96,670.12,,,,,,,,,,,,,
NEEDLE ENDOSCP U SHP CUETO FOR SUBQ LIG OF TROCAR INCISION,SUP-2767439,CDM,2720000010,LOCAL,0272,RC,,,,both,,,916.47,595.71,,,,,,,,,,,,,
SHUNT DRAINAGE BURR HOLE RESERVOIR PEDIATRIC 15 CM PROGAV,SUP-2108726,CDM,C1889,HCPCS,0278,RC,,,,both,,,7918.42,5146.97,,,,,,,,,,,,,
CATHETER URET 6FR L70CM OPN END FOR DRNGE RG PYELOGRAM,SUP-2171216,CDM,C1758,HCPCS,0278,RC,,,,both,,,36.33,23.61,,,,,,,,,,,,,
GRAFT BNE SPNG 10X10X10 MM BLOCK CANC DBM,SUP-2354409,CDM,C1713,HCPCS,0278,RC,,,,both,,,4587.54,2981.90,,,,,,,,,,,,,
PLATE STRNL CLOSURE THK 1.5 MM 8 H TI DBL V LP NS STERNALOCK,SUP-2894462,CDM,C1713,HCPCS,0278,RC,,,,both,,,3541.92,2302.25,,,,,,,,,,,,,
GRAFT VASC INTERGARD L 50 CM DIA12 X 6 MM THK 0.38 MM,SUP-2477864,CDM,C1768,CPT,0278,RC,,,,both,,,2244.75,1459.09,,,,,,,,,,,,,
IMPLANT HEARING 3MM TI W/ ABUTMENT ST BAHA BA300,SUP-2164961,CDM,L8614,HCPCS,0278,RC,,,,both,,,5086.80,3306.42,,,,,,,,,,,,,
KNIFE OPHTHLMC 1MM DIA UNVRSL 4 1/2NL 0.2MM THK DMND TRFCT B,SUP-2469955,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3357.45,2182.34,,,,,,,,,,,,,
SCREW BNE L90MM DIA3.5MM STD CORT S STL NONCANNULATED FULL,SUP-2183522,CDM,C1713,HCPCS,0278,RC,,,,both,,,79.91,51.94,,,,,,,,,,,,,
IMPLANT HUM TISS H 10 MM SUBTALAR PRO-SPEC WDG,SUP-2933226,CDM,C1762,CPT,0278,RC,,,,both,,,4836.20,3143.53,,,,,,,,,,,,,
FIBER LASER 365 MH N TAPR POLISHED TIP HOLM ACCUMAX,SUP-2537762,CDM,2720000010,LOCAL,0272,RC,,,,both,,,973.97,633.08,,,,,,,,,,,,,
CATHETER NEPHSTMY 8FR L25CM PERCFLX GLDEX PGTL TIP RADPQ,SUP-2147785,CDM,C1729,HCPCS,0272,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
GRAFT HUMAN TISSUE 15X6 CM MATRISTEM,SUP-2106509,CDM,Q4166,HCPCS,0636,RC,,,,both,,,7536.00,4898.40,,,,,,,,,,,,,
GRAFT HUM TISS GLEN DIA33MM 10X29MM GLENOJET,SUP-2123639,CDM,C1776,CPT,0278,RC,,,,both,,,12403.00,8061.95,,,,,,,,,,,,,
GRAFT BNE BLOCK LG 20X20 MM CANC,SUP-2766759,CDM,C1713,HCPCS,0278,RC,,,,both,,,2903.87,1887.52,,,,,,,,,,,,,
SCREW BNE SYMM PROF 3.5X14 MM LCK TI NS SURFIX,SUP-2609175,CDM,C1713,HCPCS,0278,RC,,,,both,,,1113.60,723.84,,,,,,,,,,,,,
BOLT FUSION MIDFOOT 6.5X70MM TI STRL,SUP-2546668,CDM,C1713,HCPCS,0278,RC,,,,both,,,1768.54,1149.55,,,,,,,,,,,,,
SCREW PACK,SUP-2267684,CDM,2720000010,LOCAL,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
PLATE BONE 1 MM MEDIAL WALL RIGHT TITANIUM NON STERILE,SUP-2838345,CDM,C1713,HCPCS,0278,RC,,,,both,,,4923.52,3200.29,,,,,,,,,,,,,
SPACER SPNL W14XH11XL24MM 0DEG PEEK ANT THORLUM INTBDY FUS,SUP-2286247,CDM,C1821,HCPCS,0278,RC,,,,both,,,1640.65,1066.42,,,,,,,,,,,,,
VALVE SHUNT L16MM ODSEC1.9MM IDSEC1.1MM STD LO PRSS IMP,SUP-2244290,CDM,C1729,HCPCS,0272,RC,,,,both,,,959.08,623.40,,,,,,,,,,,,,
DRILL HND L15MM SOLITAIRE C,SUP-2415026,CDM,C1713,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
GUIDEWIRE VASC STR 3 CM 035X150 STD COR HYDRPHLC CANALIZER,SUP-2120015,CDM,C1769,HCPCS,0272,RC,,,,both,,,95.46,62.05,,,,,,,,,,,,,
SHELL HUM SOCKET NEUT SHLDR TURON RSP,SUP-2634910,CDM,C1776,CPT,0278,RC,,,,both,,,5151.04,3348.18,,,,,,,,,,,,,
PROSTHESIS OSS 0.4X3.65X4.5 MM EAR,SUP-2313854,CDM,L8613,CPT,0278,RC,,,,both,,,464.09,301.66,,,,,,,,,,,,,
ALLOGRAFT BNE CHIP 1-4 MM 30 CC FD CRUSH CANC READIGRAFT,SUP-2741032,CDM,C1713,HCPCS,0278,RC,,,,both,,,1361.76,885.14,,,,,,,,,,,,,
PLATE BNE L31MM 4 H TI RIG DYN LOK COMPR FOR 2.4MM SCR MOD,SUP-2191476,CDM,C1713,HCPCS,0278,RC,,,,both,,,1636.85,1063.95,,,,,,,,,,,,,
PLATE BNE L132MM 8 H NONSTERILE POST DST TIB S STL T LOK,SUP-2177436,CDM,C1713,HCPCS,0278,RC,,,,both,,,4012.23,2607.95,,,,,,,,,,,,,
SLEEVE KNEE NEOPRENE OPN PAT BLK SM 1 8IN,SUP-2319239,CDM,L1810,HCPCS,0272,RC,,,,both,,,19.15,12.45,,,,,,,,,,,,,
BAR EXT FIX DIA 6 MM OFFSET NS DISP MAV MINI,SUP-2932789,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1483.65,964.37,,,,,,,,,,,,,
DEVICE INT FIX DIA29MM W NDL TOGGLELOC,SUP-2136123,CDM,C1713,HCPCS,0278,RC,,,,both,,,1920.17,1248.11,,,,,,,,,,,,,
CAGE SPNL E 13 MM EXPANDABLE CORPECTOMY STRL STRATOSPHERE,SUP-2423887,CDM,C1889,HCPCS,0278,RC,,,,both,,,20410.00,13266.50,,,,,,,,,,,,,
SCREW BNE L 26 MM DIA 3.7 MM LISFRANC JT SLD,SUP-2896834,CDM,C1713,HCPCS,0278,RC,,,,both,,,2665.86,1732.81,,,,,,,,,,,,,
CLIP MED 8 MM ABSORBABLE,SUP-2787681,CDM,C1889,HCPCS,0278,RC,,,,both,,,292.55,190.16,,,,,,,,,,,,,
SCREW SPNL L40MM DIA6MM PEDCL TI FULL THRD FOR 5.5MM ROD,SUP-2182693,CDM,C1713,HCPCS,0278,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
NEEDLE JAMSH BVL I-PASS III,SUP-2310419,CDM,C1713,HCPCS,0278,RC,,,,both,,,1080.16,702.10,,,,,,,,,,,,,
PLATE BNE L 234 MM SCREW DIA 4.5 MM 14 H BOW COMPR LCK STRL,SUP-2933391,CDM,C1713,HCPCS,0278,RC,,,,both,,,4472.93,2907.40,,,,,,,,,,,,,
PLATE BNE CONTOURABLE MESH LG 0.4 MM CRESCENT BLU STRL,SUP-2859904,CDM,C1713,HCPCS,0278,RC,,,,both,,,3626.70,2357.35,,,,,,,,,,,,,
PLATE BNE 95 DEG SHFT L 124 MM BLADE L 50 MM 7 H SS CNDYL,SUP-2908254,CDM,C1713,HCPCS,0278,RC,,,,both,,,3239.38,2105.60,,,,,,,,,,,,,
K WIRE FIX L70MM DIA0.6MM S STL W/ TRCR PNT,SUP-2186855,CDM,C1713,HCPCS,0278,RC,,,,both,,,213.11,138.52,,,,,,,,,,,,,
SPLINT RST PAN MIT SP M LF,SUP-2163832,CDM,L3807,HCPCS,0272,RC,,,,both,,,220.68,143.44,,,,,,,,,,,,,
IMPLANT SUBTALAR 10MM TWST,SUP-2390487,CDM,C1776,CPT,0278,RC,,,,both,,,5338.00,3469.70,,,,,,,,,,,,,
ELECTRODE ES 24X26FR DIA5MM YEL COAG BRL SHP FOR 24/28FR,SUP-2261196,CDM,2720000010,LOCAL,0272,RC,,,,both,,,429.14,278.94,,,,,,,,,,,,,
PLATE BONE SM L60MM LT CALCNL LCK FOR 3.5MM SCR PERI-LOC,SUP-2348514,CDM,C1713,HCPCS,0278,RC,,,,both,,,5056.03,3286.42,,,,,,,,,,,,,
KIT CATH 7FR L16CM CTRL VEN POLYUR 3 LUMN PRSS INJ BLU,SUP-2383382,CDM,C1751,HCPCS,0278,RC,,,,both,,,389.36,253.08,,,,,,,,,,,,,
KIT INSTRUMENT SPINAL SPINEJACK 4.2MM PREPARATION,SUP-2876925,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4359.36,2833.58,,,,,,,,,,,,,
ALLOGRAFT HUM TISS FRZN IRRADIATED PRECUT ACHILLES TEND,SUP-2867185,CDM,C1762,CPT,0278,RC,,,,both,,,6577.52,4275.39,,,,,,,,,,,,,
PLATE BNE THK0.8MM UNIV 7 H CRANIOMAXILLOFACIAL TI DBL Y,SUP-2366257,CDM,C1713,HCPCS,0278,RC,,,,both,,,936.91,608.99,,,,,,,,,,,,,
ADAPTER OTO ABUTMENT 4 MM BNE ANCHORED PONTO BHX SINGLE STG,SUP-2430258,CDM,L8690,HCPCS,0278,RC,,,,both,,,10688.56,6947.56,,,,,,,,,,,,,
STENT COR 28MM OD2.25MM BARE MTL RX S STL MULT LINK,SUP-2103678,CDM,C1876,HCPCS,0278,RC,,,,both,,,2904.50,1887.92,,,,,,,,,,,,,
NUT EXT FIX OD10MM FOR SIDEKCK FREE CIR FIX SALVATION,SUP-2400604,CDM,2720000010,LOCAL,0272,RC,,,,both,,,113.04,73.48,,,,,,,,,,,,,
SPHINCTEROTOME ENDOSCP CATH 7FR TRCE METRO DIR 0.035IN ACC,SUP-2171107,CDM,C1769,HCPCS,0272,RC,,,,both,,,1171.22,761.29,,,,,,,,,,,,,
BIT DRL L7IN OD4.5MM ID2.4MM TI CANN DISP FOR ENDOBUTTON,SUP-2340990,CDM,2720000010,LOCAL,0272,RC,,,,both,,,441.48,286.96,,,,,,,,,,,,,
COMPONENT HIP 7 MTL,SUP-2254060,CDM,C1776,CPT,0278,RC,,,,both,,,18840.00,12246.00,,,,,,,,,,,,,
INTRODUCER SHTH 0.018 IN SHT 7 FR W/ GUIDEWIRE NDL PRELUDE,SUP-2303313,CDM,C1894,HCPCS,0272,RC,,,,both,,,87.92,57.15,,,,,,,,,,,,,
TUBE LARYNCTMY BLOM SINGER VOICE PROS PT CHANGEABLE LO PRSS,SUP-2242313,CDM,L8509,HCPCS,0274,RC,,,,both,,,395.64,257.17,,,,,,,,,,,,,
DRILL SURG CTRL CEM MBT HI PERF SIG LCS,SUP-2456249,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1563.72,1016.42,,,,,,,,,,,,,
TUBE VENT 1.27 MM 1.17 MM 4.5/2.72 MM TAPR VENT SIL STRL,SUP-2535110,CDM,L8699,HCPCS,0278,RC,,,,both,,,59.60,38.74,,,,,,,,,,,,,
KIT HAD CATHETER L23CM DIA155FR STD LNG TERM POLYUR STR,SUP-2269556,CDM,C1750,HCPCS,0278,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
CATHETER EP 6FR L105CM 5MM SPC DECAPOLAR 270DEG STD CRV,SUP-2141318,CDM,C1732,HCPCS,0278,RC,,,,both,,,1931.10,1255.21,,,,,,,,,,,,,
PLATE BNE STR 1.5X100 MM 20 HOLE,SUP-2569070,CDM,C1713,HCPCS,0278,RC,,,,both,,,397.21,258.19,,,,,,,,,,,,,
CATHETER ANGIOPLSTY 18 ATM 4 FRX190 CM 2.5X100 MM SABERX,SUP-2866067,CDM,C1725,HCPCS,0272,RC,,,,both,,,1014.97,659.73,,,,,,,,,,,,,
DRILL KIT 2 MM SPD,SUP-2564465,CDM,2720000010,LOCAL,0272,RC,,,,both,,,835.49,543.07,,,,,,,,,,,,,
GRAFT OPHTH THK300-400UM W0.75XL1CM COVERING GLAUCOMA DRNGE,SUP-2135260,CDM,V2790,HCPCS,0278,RC,,,,both,,,1208.90,785.78,,,,,,,,,,,,,
FIBER LASER DBL W/ WALL PLATE,SUP-2798098,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1854.14,1205.19,,,,,,,,,,,,,
ADAPTER LD L 40 CM SIL INSUL UPLR LV1 RECEPTACLE IS1 CONN,SUP-2616254,CDM,C1883,HCPCS,0278,RC,,,,both,,,1161.80,755.17,,,,,,,,,,,,,
NAIL IM L380MM DIA14MM NK 130DEG GRN L FEM TI TROCHANTERIC,SUP-2192114,CDM,C1713,HCPCS,0278,RC,,,,both,,,5466.99,3553.54,,,,,,,,,,,,,
PLATE MED SLDE BEAV,SUP-2321505,CDM,C1713,HCPCS,0278,RC,,,,both,,,5923.61,3850.35,,,,,,,,,,,,,
PUMP PENILE PROS INFL DEFL AMS 700,SUP-2138918,CDM,C1813,HCPCS,0278,RC,,,,both,,,856.59,556.78,,,,,,,,,,,,,
GRAFT BNE PWD 1 CC DBM MAROMATCH,SUP-2120699,CDM,C1713,HCPCS,0278,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
TUBE FEED NG RADPQ POLYUR PED W OUT CO2 CONN SGL LUMN,SUP-2308298,CDM,2720000010,LOCAL,0272,RC,,,,both,,,25.06,16.29,,,,,,,,,,,,,
GRAFT DURA REP L 5 X W 5 CM THK 0.4 MM ELECTROSPUN FIBER,SUP-2904023,CDM,C1763,HCPCS,0278,RC,,,,both,,,3469.70,2255.30,,,,,,,,,,,,,
TISSUE ACHILLES TENDON PRE-SHAPED 10X260MM,SUP-2718660,CDM,C1762,CPT,0278,RC,,,,both,,,7510.19,4881.62,,,,,,,,,,,,,
RING EXT FIX ALUM ROCK FOR ILIZ TAY SPAT FRME SYS,SUP-2343002,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5695.65,3702.17,,,,,,,,,,,,,
STEM HUM 10X75 MM IM COMPHSVE SEG REV SYS MOD W/SCREW,SUP-2435450,CDM,C1776,CPT,0278,RC,,,,both,,,9184.50,5969.92,,,,,,,,,,,,,
SCREW INTRF ABSRB CANN STRL TAPR FT 11X33MM,SUP-2166526,CDM,C1713,HCPCS,0278,RC,,,,both,,,364.99,237.24,,,,,,,,,,,,,
IMPLANT HUM TISS L 4 CM AORT DIA10 MM AORTOILIAC ART ALLGRFT,SUP-2933089,CDM,C1762,CPT,0278,RC,,,,both,,,77602.37,50441.54,,,,,,,,,,,,,
DEVICE REATTACHMENT W23XL53MM SHT GREATER TROCHANTERIC TIV,SUP-2410263,CDM,C1713,HCPCS,0278,RC,,,,both,,,4512.37,2933.04,,,,,,,,,,,,,
SUPPORT ORTH XL 1 8IN NEOPRENE NYL 2 SIDE OPN PAT STBL PAT,SUP-2195472,CDM,L1851,HCPCS,0272,RC,,,,both,,,51.15,33.25,,,,,,,,,,,,,
PLATE BONE 9 H TI BROAD HYBRID COMPR FOR 4.5MM SCR ALPS,SUP-2413753,CDM,C1713,HCPCS,0278,RC,,,,both,,,1290.10,838.56,,,,,,,,,,,,,
HC So1 Delta Aminolevulinic Acid,PX-3018213567,CDM,82135,CPT,0301,RC,,,,both,,,57.00,37.05,,,,,,,,,,,,,
PAD PWR,SUP-2162146,CDM,2720000010,LOCAL,0272,RC,,,,both,,,587.40,381.81,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH L 88 MM DIA DSTL 12 MM SHTH 14 FR SS,SUP-2168731,CDM,C1768,CPT,0278,RC,,,,both,,,8732.34,5676.02,,,,,,,,,,,,,
HC Irrigation of Vad - Only,PX-7619652300,CDM,96523,CPT,0761,RC,,,,both,,,265.00,172.25,,,,,,,,,,,,,
BACITRACIN-POLYMYXIN B 500-10000 UNIT/GM OP OINT,RX-856,CDM,6370000000,HCPCS,0637,RC,24208-0555-55,NDC,,both,3.5,GR,103.20,67.08,,,,,,,,,,,,,
PROBE THERMOMETER L 65 CM OD 10 FR TECOTHANE URETHANE SHFT,SUP-2890331,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1946.80,1265.42,,,,,,,,,,,,,
BIT DRL DIA4.3MM SH 2IN1 AO FOR HALLU-LOCK MTP ARTH SYS,SUP-2242909,CDM,2720000010,LOCAL,0272,RC,,,,both,,,643.70,418.40,,,,,,,,,,,,,
HC Treat Thigh Fx,PX-4502750800,CDM,27508,CPT,0450,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
WIRE PACE MYO/WIRE II SS DBL FOR STERNOTOMY CLOSURE 4 PER,SUP-2101198,CDM,C1713,HCPCS,0278,RC,,,,both,,,79.47,51.66,,,,,,,,,,,,,
GRAFT ENDOVASC L110MM DIA13MM IL VIABAHN,SUP-2396471,CDM,C1874,HCPCS,0278,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
CANNULA VENTRICULAR 9 FR CSF DRN SYS CRANIA ELSBERG,SUP-2666333,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1359.53,883.69,,,,,,,,,,,,,
SEALANT SURG 10ML FBRN FRZN GLUE PREFIL SPRY SET ARTISS,SUP-2129854,CDM,C9250,HCPCS,0636,RC,,,,both,,,2564.60,1666.99,,,,,,,,,,,,,
SPHINCTEROTOME ENDSCPC 6FR DIA DST TIP 30MML CUT WIRE 195CML,SUP-2495294,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1116.99,726.04,,,,,,,,,,,,,
SUPPORT ORTH XL 1 8IN NEOPRENE NYL 2 SIDE OPN PAT STBL PAT,SUP-2195472,CDM,L1851,HCPCS,0274,RC,,,,both,,,51.15,33.25,,,,,,,,,,,,,
PORT INFUS PLAS SGL LUMN W 8FR CATHETER GROSH VLV OPN INTRO,SUP-2126341,CDM,C1788,HCPCS,0278,RC,,,,both,,,1384.74,900.08,,,,,,,,,,,,,
TRIAL NK 25MM 127 DEG FEM C TAPR,SUP-2375985,CDM,C1713,HCPCS,0278,RC,,,,both,,,876.06,569.44,,,,,,,,,,,,,
PLATE BNE SM TI MANDIBULAR PMI ORTHOGNATHIC 3D PRNT NS DISP,SUP-2934875,CDM,C1713,HCPCS,0278,RC,,,,both,,,18202.58,11831.68,,,,,,,,,,,,,
DEVICE TARGET STD RADLUC GUID R VOLAR DST RAD PLATING SYS,SUP-2107094,CDM,C1713,HCPCS,0278,RC,,,,both,,,4072.58,2647.18,,,,,,,,,,,,,
BONE CEMENT TRAY 20/3 IBT FRAC W/ ADV OSTEO INTRO SYS KYPHON,SUP-2293653,CDM,C1894,HCPCS,0272,RC,,,,both,,,10846.82,7050.43,,,,,,,,,,,,,
PLATE BNE L 120 X W 12 MM THK 2.4 MM SCREW DIA2.7 MM 18 H SS 72469718,SUP-2932773,CDM,C1713,HCPCS,0278,RC,,,,both,,,2852.06,1853.84,,,,,,,,,,,,,
PLATE BNE SM W38XL50MM THK0.6MM R CRANIOFACIAL TIIUM MESH,SUP-2366475,CDM,C1713,HCPCS,0278,RC,,,,both,,,3866.94,2513.51,,,,,,,,,,,,,
SCREW BONE L150MM DIA6.5MM THRD L24MM HD DIA8MM CANC S STL,SUP-2184599,CDM,C1713,HCPCS,0278,RC,,,,both,,,143.40,93.21,,,,,,,,,,,,,
SUPPORT ORTHOT HND FNGR CUST W/NONTORSION JT PREFABRICATED,SUP-2435786,CDM,L3929,HCPCS,0272,RC,,,,both,,,235.31,152.95,,,,,,,,,,,,,
SPHERE EMB ONCOZENE DIA100 UM SM 2 ML PREFIL SYR HYDRGEL WHT,SUP-2139507,CDM,C1889,HCPCS,0278,RC,,,,both,,,8949.00,5816.85,,,,,,,,,,,,,
K WIRE FIX L150MM DIA1.6MM THRD L15MM S STL TRCR PNT,SUP-2186902,CDM,C1713,HCPCS,0278,RC,,,,both,,,457.31,297.25,,,,,,,,,,,,,
KIT CATHETER ARTERIAL ARROW SAFETY 20GA 3.8CM RADIAL,SUP-2865690,CDM,C1751,HCPCS,0278,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
BIT DRL DIA3MM CLAV CANN DOG BNE,SUP-2121659,CDM,2720000010,LOCAL,0272,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
KIT INT FIX FEM ACL GUID PIN BNE PLUG GUIDWIRE DISP EZLOC,SUP-2212937,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2078.43,1350.98,,,,,,,,,,,,,
HC Irrigation of Vad - Only,PX-4509652300,CDM,96523,CPT,0450,RC,,,,both,,,265.00,172.25,,,,,,,,,,,,,
BIT DRL QC 2.5X240 MM 150 MM CALIB NS,SUP-2563752,CDM,2720000010,LOCAL,0272,RC,,,,both,,,449.74,292.33,,,,,,,,,,,,,
CLAMP PIN YELLOW,SUP-2700561,CDM,2720000010,LOCAL,0272,RC,,,,both,,,575.88,374.32,,,,,,,,,,,,,
TIBIAL COMP SINGLE COATED/US VERSION SMALL,SUP-2878755,CDM,C1776,CPT,0278,RC,,,,both,,,18197.24,11828.21,,,,,,,,,,,,,
SUPPORT ORTHOT HND FNGR CUST W/NONTORSION JT PREFABRICATED,SUP-2435786,CDM,L3929,HCPCS,0274,RC,,,,both,,,235.31,152.95,,,,,,,,,,,,,
BIT DRL SEGMENTED ADJ STP SONICWELD RX DISP,SUP-2457788,CDM,2720000010,LOCAL,0272,RC,,,,both,,,431.53,280.49,,,,,,,,,,,,,
SPLINT WRST L INSTABILITY INJ LOOP LOK W STAY FIRM SUPP,SUP-2276658,CDM,L3908,HCPCS,0274,RC,,,,both,,,16.45,10.69,,,,,,,,,,,,,
GRAFT VASC GORTX L 80 CM DIA 6 MM RNG L 60 CM EPTFE STR STD,SUP-2396096,CDM,C1768,CPT,0278,RC,,,,both,,,3171.40,2061.41,,,,,,,,,,,,,
PLATE BNE LP 1.5X0.6 MM NEURO 4X2 HOLE LADDER SQ SEG TI STRL,SUP-2472995,CDM,C1713,HCPCS,0278,RC,,,,both,,,857.06,557.09,,,,,,,,,,,,,
SCREW BNE L 155 MM DIA 6.5 MM THRD L 40 MM SS ST SD CANN RVS,SUP-2900934,CDM,C1713,HCPCS,0278,RC,,,,both,,,1302.28,846.48,,,,,,,,,,,,,
BIT DRL DIA2.5MM FOR REV SHLDR SYS,SUP-2208231,CDM,2720000010,LOCAL,0272,RC,,,,both,,,480.42,312.27,,,,,,,,,,,,,
PROBE STIM 0.5MM GRN SUBDERM MPLR BALL INSUL YINGLING,SUP-2279925,CDM,2720000010,LOCAL,0272,RC,,,,both,,,585.04,380.28,,,,,,,,,,,,,
CUP HUM DIA38MM +9MM OFFSET STD SHLDR POLYETH DELT XTEND,SUP-2251005,CDM,C1776,CPT,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
SCREW BNE L 20 MM DIA 3.5 MM TI CORTICAL WR ST T15 DRV STRL,SUP-2931733,CDM,C1713,HCPCS,0278,RC,,,,both,,,136.62,88.80,,,,,,,,,,,,,
LEAD SURG L50CM 4X8 COVEREDGE,SUP-2138840,CDM,C1778,HCPCS,0278,RC,,,,both,,,18526.00,12041.90,,,,,,,,,,,,,
COLLAR CERV SFT BABY FIRM DENS NO NK STFFNK SN6] PENNCARE],SUP-2323344,CDM,L0140,HCPCS,0274,RC,,,,both,,,36.11,23.47,,,,,,,,,,,,,
COLLAR EXT FIX CENTERING CUBE FOR 6 MM HALF PIN RANCHO,SUP-2749953,CDM,2720000010,LOCAL,0272,RC,,,,both,,,640.56,416.36,,,,,,,,,,,,,
LPS XX-SM HINGE PIN,SUP-2513219,CDM,C1776,CPT,0278,RC,,,,both,,,1483.65,964.37,,,,,,,,,,,,,
COIL VASC INTERLOCK-35 L 4.5 CM DIA 4 MM GUIDEWIRE 0.035 IN,SUP-2148130,CDM,C1889,HCPCS,0278,RC,,,,both,,,1428.70,928.65,,,,,,,,,,,,,
PLATE BONE L145MM THK3.4MM 10 H BILAT NONLOCKING COMPR FOR,SUP-2348953,CDM,C1713,HCPCS,0278,RC,,,,both,,,1611.23,1047.30,,,,,,,,,,,,,
BRACE ORTHOPEDIC SIMP 22-34 IN UNIV KNEE,SUP-2269750,CDM,2740000010,LOCAL,0272,RC,,,,both,,,351.68,228.59,,,,,,,,,,,,,
HC Glb Fna Without Imaging Guidance,PX-9821002100,CDM,10021,CPT,0982,RC,,,,both,,,1531.00,995.15,,,,,,,,,,,,,
STEM FEM SZ 9 L155MM DIA15MM HIP TI ALLY HA REV RESTR,SUP-2374175,CDM,C1776,CPT,0278,RC,,,,both,,,13795.90,8967.33,,,,,,,,,,,,,
EPICORD 3X5CM 15SQ CM,SUP-2305733,CDM,Q4187,HCPCS,0636,RC,,,,both,,,11099.90,7214.93,,,,,,,,,,,,,
PACK EYE CUST DR YOUNG,SUP-2424303,CDM,C1713,HCPCS,0278,RC,,,,both,,,400.04,260.03,,,,,,,,,,,,,
COMPONENT STEPTECH APG 44+5MM RIGHT,SUP-2512728,CDM,C1776,CPT,0278,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
COMPONENT PATELLAR 3 PEG 26X7.5 MM CEM NP RND REV PRSS FT,SUP-2251220,CDM,C1776,CPT,0278,RC,,,,both,,,3357.29,2182.24,,,,,,,,,,,,,
GRAFT HUM TISS W4XL4CM THK45UM AMNIO MEMBRN DEHYDR OMNI DIR,SUP-2340453,CDM,C1762,CPT,0278,RC,,,,both,,,13530.26,8794.67,,,,,,,,,,,,,
PROBE TRACHBRONCH AR PLSM FLX DISP FOR APC 300 SYS DIA1.5MM,SUP-2217934,CDM,2720000010,LOCAL,0272,RC,,,,both,,,626.43,407.18,,,,,,,,,,,,,
PIN EXT FIX THRD L30MM DIA5MM SHANK L110MM DIA5MM S STL,SUP-2342918,CDM,C1713,HCPCS,0278,RC,,,,both,,,1093.44,710.74,,,,,,,,,,,,,
GOUGE 8IN CRV 1 1 4IN SMITH PETERSEN,SUP-2244788,CDM,C1713,HCPCS,0278,RC,,,,both,,,249.88,162.42,,,,,,,,,,,,,
SWAN GANZ VIPOXIMETRY,SUP-2696338,CDM,2720000010,LOCAL,0272,RC,,,,both,,,644.55,418.96,,,,,,,,,,,,,
SCREW BNE L 36 MM DIA 3.5 MM FT LAG STRL ORTHOLOC 3DI,SUP-2900557,CDM,C1713,HCPCS,0278,RC,,,,both,,,1651.64,1073.57,,,,,,,,,,,,,
PACEMAKER CARD ALTRUA 40 W 42 X H 44 MM THK 8 MM 25.4 GM 2,SUP-2149275,CDM,C1785,HCPCS,0275,RC,,,,both,,,17995.34,11696.97,,,,,,,,,,,,,
MARKER BRST BX RIBBON 17 GAX10 CM FOR MRI TI ULTRACLIP II,SUP-2759097,CDM,A4648,CPT,0278,RC,,,,both,,,350.27,227.68,,,,,,,,,,,,,
ANCHOR SUT RIGIDLOOP FIXED 40MM,SUP-2749352,CDM,C1713,HCPCS,0278,RC,,,,both,,,2307.90,1500.13,,,,,,,,,,,,,
BLADE SAW RECIP 40MM CUT EDGE 9.5MM CUT DEPTH 0.4MM CUT,SUP-2136839,CDM,2720000010,LOCAL,0272,RC,,,,both,,,82.74,53.78,,,,,,,,,,,,,
PLATE BNE SEMI TBLR 39 MM 2 HOLE FOR LG FRAG SYS SS NS,SUP-2458804,CDM,C1713,HCPCS,0278,RC,,,,both,,,161.46,104.95,,,,,,,,,,,,,
KIT CATHETER PUMP INSERTION INTRACARDIAC IMPELLA CP,SUP-2652612,CDM,C1889,HCPCS,0278,RC,,,,both,,,87920.00,57148.00,,,,,,,,,,,,,
COIL EMB L48CM OD0.020IN LOOP OD13MM STD NIT COMPLX FRME,SUP-2323378,CDM,C1889,HCPCS,0278,RC,,,,both,,,7338.18,4769.82,,,,,,,,,,,,,
HOOK SPNL DIA8MM PEDCL TI CLOSE W BLDE FOR 5.5MM ROD MNRCH,SUP-2254575,CDM,C1713,HCPCS,0278,RC,,,,both,,,3001.84,1951.20,,,,,,,,,,,,,
ELECTRODE ES URLGY 24FR DIA SM 12DG ANGLD CTTNG LOOP HF RSCT,SUP-2722829,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1410.39,916.75,,,,,,,,,,,,,
CATHETER DRAINAGE 0.76X1.65 MMX46 CM LUERLOCK CONN,SUP-2308151,CDM,C1729,HCPCS,0272,RC,,,,both,,,590.54,383.85,,,,,,,,,,,,,
HC Cath Urethra Complicated,PX-4505170300,CDM,51703,CPT,0450,RC,,,,inpatient,,,214.00,139.10,,,,,,,,,,,,,
GRAFT HUM TISS 12X19MM OSTEOCHNDRL VIABLE CHONDROCYTES,SUP-2314091,CDM,C1762,CPT,0278,RC,,,,both,,,19468.00,12654.20,,,,,,,,,,,,,
CATHETER VENTRICULAR 13 CM IMPL OSV II,SUP-2666643,CDM,C1729,HCPCS,0272,RC,,,,both,,,9286.05,6035.93,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED STD UNI,SUP-2351346,CDM,C1776,CPT,0278,RC,,,,both,,,8085.50,5255.57,,,,,,,,,,,,,
CATHETER HD LT 15.5 FRX19 CM SIDE H SPRT PK W/ STYL SYMETREX,SUP-2627494,CDM,C1750,HCPCS,0278,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
ANCHOR SUT NO 2 SUT W/ NDL ABSRB POLY L LACTIDE ACID W/ DIL,SUP-2341053,CDM,C1713,HCPCS,0278,RC,,,,both,,,1158.66,753.13,,,,,,,,,,,,,
SCREW BNE L 16 MM DIA 3.5 MM TI WR ST LCK T15 DRV STRL EVOS,SUP-2931547,CDM,C1713,HCPCS,0278,RC,,,,both,,,455.55,296.11,,,,,,,,,,,,,
FEEDING TUBE KIT LP 18 FRX2 CM BLLN BUTTON SIL CLR MINI 1,SUP-2754577,CDM,2720000010,LOCAL,0272,RC,,,,both,,,599.49,389.67,,,,,,,,,,,,,
BLADE RETRACTOR HARRINGTON UNIV PEDIATRIC 2X8 IN ABD RNG,SUP-2459816,CDM,2720000010,LOCAL,0272,RC,,,,both,,,892.14,579.89,,,,,,,,,,,,,
PLATE BONE L35MM 4 H MAND TI STR ECC LIMIT CNTCT DYN COMPR,SUP-2191399,CDM,C1713,HCPCS,0278,RC,,,,both,,,2452.97,1594.43,,,,,,,,,,,,,
SAW SURG OSCLLTNG W/O HOSE FLFORTHPDC ORLORALMXLLFCL OTOLARY,SUP-2605430,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7937.35,5159.28,,,,,,,,,,,,,
ARIPIPRAZOLE 5 MG PO TABS,RX-36438,CDM,6370000000,HCPCS,0637,RC,16729-0279-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
WIRE GUID PRSS PRIMEWIRE LNG J TIP .014INX300CM PRESTIGE,SUP-2327227,CDM,C1769,HCPCS,0272,RC,,,,both,,,2182.30,1418.49,,,,,,,,,,,,,
PLATE BONE TARSALIS 2.7 1.6MM 6 H T-SHAPE LT FIX ANG LCK,SUP-2321013,CDM,C1713,HCPCS,0278,RC,,,,both,,,3055.22,1985.89,,,,,,,,,,,,,
AMLODIPINE BESYLATE 2.5 MG PO TABS,RX-9070,CDM,6370000000,HCPCS,0637,RC,69097-0126-05,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
MICROSPHERE EMB THERASPHERE 6 GBQ YTTRIUM-90 GLS DOSE VI,SUP-2135308,CDM,C1889,HCPCS,0278,RC,,,,both,,,50240.00,32656.00,,,,,,,,,,,,,
PLATE MEDL CLMN LNG TI LT NAVICULOCUNEIFORM METATRSL NS,SUP-2896788,CDM,C1713,HCPCS,0278,RC,,,,both,,,5491.86,3569.71,,,,,,,,,,,,,
ANCHOR SUT ZIP PEEK 6.5MM W/ NDL,SUP-2366668,CDM,C1713,HCPCS,0278,RC,,,,both,,,805.41,523.52,,,,,,,,,,,,,
SPLINT ARM M L85IN L ALUMINUM FOAM PD MAL COLLES,SUP-2276767,CDM,L3809,HCPCS,0272,RC,,,,both,,,14.10,9.16,,,,,,,,,,,,,
INSERTER SURG,SUP-2437813,CDM,2720000010,LOCAL,0272,RC,,,,both,,,127.17,82.66,,,,,,,,,,,,,
BLOCK RECON SM 5X10X30 MM POROUS HA,SUP-2637871,CDM,L8613,CPT,0278,RC,,,,both,,,2181.55,1418.01,,,,,,,,,,,,,
AXLE TIB SZ 3 OXIN FEM THRD STRL LEGION HK,SUP-2910083,CDM,C1776,CPT,0278,RC,,,,both,,,1500.92,975.60,,,,,,,,,,,,,
RAIL EXT FIX T HNDL SYS,SUP-2197311,CDM,2720000010,LOCAL,0272,RC,,,,both,,,989.10,642.91,,,,,,,,,,,,,
HC Wound Vac <=50 Sq Cm Dme,PX-7619760500,CDM,97605,CPT,0761,RC,,,,inpatient,,,275.00,178.75,,,,,,,,,,,,,
TRAY PICC SUBCL 2/L 5FR 55CML PU PWR INJ RADPQ PEEL 9295110,SUP-2632703,CDM,C1751,HCPCS,0278,RC,,,,both,,,558.17,362.81,,,,,,,,,,,,,
GRAFT VASC ALBOGRAFT L 15 CM DIA16 MM POLYESTER STR KNITTED,SUP-2601082,CDM,C1768,CPT,0278,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
HC So Acetone Assay,PX-3078201066,CDM,82010,CPT,0307,RC,,,,inpatient,,,116.00,75.40,,,,,,,,,,,,,
PROSTHESIS OTO L5MM OD4MM HA AND TI MID EAR OSS W/ MAL LINK,SUP-2284004,CDM,L8613,CPT,0278,RC,,,,both,,,1622.60,1054.69,,,,,,,,,,,,,
PLATE BNE L202MM 10 H ST L MED DST TIB S STL VAR ANG LOK,SUP-2177643,CDM,C1713,HCPCS,0278,RC,,,,both,,,5415.34,3519.97,,,,,,,,,,,,,
BLADE SURG 6 LT MIDLN,SUP-2631599,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1122.55,729.66,,,,,,,,,,,,,
CATHETER HAD ADMIN FULL TY SHT TERM STR 11.5FRX12CM DUO FLO,SUP-2267016,CDM,C1752,HCPCS,0278,RC,,,,both,,,219.80,142.87,,,,,,,,,,,,,
GRAFT BIO TISS W4XL4CM DERM REP SCFLD FEN PRIMATRIX,SUP-2243692,CDM,Q4110,HCPCS,0636,RC,,,,both,,,2034.72,1322.57,,,,,,,,,,,,,
PLATE BNE STD BRL 130 DEG 4.5X60 MM BILATERAL PELV 2 HOLE SS,SUP-2342573,CDM,C1713,HCPCS,0278,RC,,,,both,,,3517.90,2286.63,,,,,,,,,,,,,
CABLE SPNL TI INTEGR CRMP DBL MFIL WIRE ATLS 12PK,SUP-2289633,CDM,C1713,HCPCS,0278,RC,,,,both,,,14130.00,9184.50,,,,,,,,,,,,,
BLADE RTRCTR 40MMW X 30MML TTNM LEFT SCRL PRNGX2 LIGHT BLUE,SUP-2668042,CDM,2720000010,LOCAL,0272,RC,,,,both,,,679.53,441.69,,,,,,,,,,,,,
PLATE BNE SHRT STD TI RT ANTR TT FUSION NS,SUP-2896806,CDM,C1713,HCPCS,0278,RC,,,,both,,,6276.86,4079.96,,,,,,,,,,,,,
ALLOGRAFT DERMAL MESHED THN 25X13 CM MTRX SOMAGEN,SUP-2434142,CDM,C1762,CPT,0278,RC,,,,both,,,56909.74,36991.33,,,,,,,,,,,,,
GRAFT BONE SUB 45CC 2-5MM CORT CANC MORSELIZED FN CHIP FRZN,SUP-2307428,CDM,C1713,HCPCS,0278,RC,,,,both,,,4465.99,2902.89,,,,,,,,,,,,,
HC Pathogen Test for Platelets,PX-3020910000,CDM,P9100,CPT,0302,RC,,,,both,,,140.00,91.00,,,,,,,,,,,,,
SPLINT THMB AD L4IN UNIV R FOAM LAM INSTABILITY LOOP LOK E,SUP-2197017,CDM,L3809,HCPCS,0272,RC,,,,both,,,19.78,12.86,,,,,,,,,,,,,
DEVICE TISS FIX FIBERTAG TIGHTROPE II INTERNALBRACE ACL DRL,SUP-2910477,CDM,C1713,HCPCS,0278,RC,,,,both,,,2983.79,1939.46,,,,,,,,,,,,,
HC Insert Tunneled Perit Cath,PX-3614941800,CDM,49418,CPT,0361,RC,,,,both,,,11344.00,7373.60,,,,,,,,,,,,,
GUIDEWIRE ORTH NIT SGL PRECIS FLX RM SYS,SUP-2136105,CDM,C1769,HCPCS,0272,RC,,,,both,,,731.49,475.47,,,,,,,,,,,,,
BIT DRL CANN 4.4 MM DENS QR NS ACUTRK 4/5 LF DISP,SUP-2518468,CDM,2720000010,LOCAL,0272,RC,,,,both,,,938.86,610.26,,,,,,,,,,,,,
GRAFT HUM TISS 2X3CM 2 LAYR AMNION PTCH STERISHIELD II,SUP-2390577,CDM,C1713,HCPCS,0278,RC,,,,both,,,6044.50,3928.92,,,,,,,,,,,,,
CATHETER CV MAXIMAL BARR TY 032 10 FRX15 CM 10 GA 5 LUMEN,SUP-2759736,CDM,C1751,HCPCS,0278,RC,,,,both,,,621.72,404.12,,,,,,,,,,,,,
ANCHOR SUTURE L11MM DIAMETER 3.5MM PEEK DEPLOYED POPLOK,SUP-2825123,CDM,C1713,HCPCS,0278,RC,,,,both,,,1608.65,1045.62,,,,,,,,,,,,,
KIT ANALGESIC PMP BASIC FILTER CASETTE M LUER CONN TRNSLUC,SUP-2892643,CDM,2720000010,LOCAL,0272,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
CATHETER SHUNT L900MM OD2.5MM ID1.2MM SILICONE PERITONEAL RA,SUP-2821783,CDM,C1729,HCPCS,0272,RC,,,,both,,,801.01,520.66,,,,,,,,,,,,,
BRACE ANK L L9-10IN MAX CALF FOR 17IN BLU FT BRTH ANTIMIC,SUP-2332638,CDM,L4396,HCPCS,0274,RC,,,,both,,,272.61,177.20,,,,,,,,,,,,,
TROCAR LAPSCP 10 MM DIA 70 MM LEN BLDELSS BAL,SUP-2383785,CDM,C1788,HCPCS,0278,RC,,,,both,,,293.43,190.73,,,,,,,,,,,,,
BLOCK TIB AUG FULL FLAT 2 SM 10 MM LT KNEE PRIMARY PRSS FT,SUP-2377112,CDM,C1776,CPT,0278,RC,,,,both,,,4136.95,2689.02,,,,,,,,,,,,,
PIN BNE FIX L 5.8 MM DIA 0.062 IN SMILLIE,SUP-2933027,CDM,C1713,HCPCS,0278,RC,,,,both,,,110.18,71.62,,,,,,,,,,,,,
GRAFT BNE H14MMXL5.5CM CORT FRZ DRY WDG FOR HI TIB OSTEOTMY,SUP-2307172,CDM,C1713,HCPCS,0278,RC,,,,both,,,3314.90,2154.68,,,,,,,,,,,,,
CATHETER UMB DL PREMI INF 5 FRX15 IN SMOOTH ROUNDED ARGY,SUP-2174251,CDM,C1751,HCPCS,0278,RC,,,,both,,,90.65,58.92,,,,,,,,,,,,,
LEAD PACE AROX L 60 CM SIL INSUL PLATINIZED PLAT TIP STEROID,SUP-2137967,CDM,C1898,HCPCS,0275,RC,,,,both,,,1986.80,1291.42,,,,,,,,,,,,,
PPICC PROVENA SOLO SP 3F SLEEVE MAX TL,SUP-2613555,CDM,C1751,HCPCS,0278,RC,,,,both,,,744.12,483.68,,,,,,,,,,,,,
MOLD KNEE SPACER FEM ML DIA 70 MM TIB ML DIA 75 MM MED TEMP,SUP-2905382,CDM,2720000010,LOCAL,0272,RC,,,,both,,,11461.00,7449.65,,,,,,,,,,,,,
PLATE BNE THK0.5MM 12MM BAR 6 H 100DEG UNIV,SUP-2366248,CDM,C1713,HCPCS,0278,RC,,,,both,,,677.64,440.47,,,,,,,,,,,,,
BAR EXT FIX L 60 MM DIA 6 MM TI STRL DISP JET-X,SUP-2932947,CDM,2720000010,LOCAL,0272,RC,,,,both,,,453.57,294.82,,,,,,,,,,,,,
HC Special Doses Verification,PX-3337733100,CDM,77331,CPT,0333,RC,,,,inpatient,,,672.00,436.80,,,,,,,,,,,,,
CATHETER ANGIO SOS OMNI SEL 2 5 FRX65 CM N BRAIDED,SUP-2117141,CDM,C1725,HCPCS,0272,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
PLATE BONE ANGLED THICK 2 MM MANDIBLE PATIENT SPECIFIC ANGLE,SUP-2838604,CDM,C1713,HCPCS,0278,RC,,,,both,,,24378.02,15845.71,,,,,,,,,,,,,
DRILL TWST 90 DEG L 29.2 MM DIA1.5 MM STP 16 MM DENT SHFT NS,SUP-2883209,CDM,2720000010,LOCAL,0272,RC,,,,both,,,339.12,220.43,,,,,,,,,,,,,
PLATE BNE CHIN 1.7X12 MM 6 HOLE PRE-BENT ADV GLD NS LTX,SUP-2862770,CDM,C1713,HCPCS,0278,RC,,,,both,,,714.13,464.18,,,,,,,,,,,,,
GUAIFENESIN ER 600 MG PO TB12,RX-37651,CDM,6370000000,HCPCS,0637,RC,63824-0008-15,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PLATE BONE SM L65MM 5 H STD BILAT COMPR CNTOUR + FOR 3.5MM,SUP-2348992,CDM,C1713,HCPCS,0278,RC,,,,both,,,1279.24,831.51,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.453,SUP-2860017,CDM,C1713,HCPCS,0278,RC,,,,both,,,67483.00,43863.95,,,,,,,,,,,,,
STEM FEM L240MM OD18MM POR DSTL CALCAR MOD RL HARDENED,SUP-2403946,CDM,C1776,CPT,0278,RC,,,,both,,,9539.32,6200.56,,,,,,,,,,,,,
SCREW BNE CORTICAL 4.5X46 MM SS NS,SUP-2186998,CDM,C1713,HCPCS,0278,RC,,,,both,,,65.94,42.86,,,,,,,,,,,,,
PAD ORTHOT STRNL CUST,SUP-2435575,CDM,L1050,HCPCS,0274,RC,,,,both,,,284.08,184.65,,,,,,,,,,,,,
PPICC PROV SOLO 5F TL BASIC,SUP-2613545,CDM,C1751,HCPCS,0278,RC,,,,both,,,619.77,402.85,,,,,,,,,,,,,
FIDAXOMICIN 200 MG PO TABS,RX-108906,CDM,6370000000,HCPCS,0637,RC,52015-0080-01,NDC,,both,1,UN,1171.20,761.28,,,,,,,,,,,,,
PLATE BNE L274MM BLDE W4.8XL25MM 95DEG 16 H NONSTERILE HIP,SUP-2186762,CDM,C1713,HCPCS,0278,RC,,,,both,,,3288.49,2137.52,,,,,,,,,,,,,
BIT DRL L115MM DIA1.8MM STP 26MM FOR LORENZ MAND PLATING,SUP-2136817,CDM,2720000010,LOCAL,0272,RC,,,,both,,,477.28,310.23,,,,,,,,,,,,,
PLATE CRAN 180X160X40 MM PT SPEC IMPL PEEK,SUP-2860161,CDM,C1713,HCPCS,0278,RC,,,,both,,,49984.72,32490.07,,,,,,,,,,,,,
HC MRI-Angio Head WO Contrast,PX-6157054400,CDM,70544,CPT,0615,RC,,,,both,,,3209.00,2085.85,,,,,,,,,,,,,
GENESIS II CR HYBRID W/ CEM TIB,SUP-2347968,CDM,C1776,CPT,0278,RC,,,,both,,,11304.00,7347.60,,,,,,,,,,,,,
TWINFIX TI 5.0 (2) USP #2,SUP-2341587,CDM,C1713,HCPCS,0278,RC,,,,both,,,553.77,359.95,,,,,,,,,,,,,
VALVE SHUNT LUMBAR AD 14 GA MIN VENTRICULAR ENLARGEMENT BLU,SUP-2852675,CDM,C1889,HCPCS,0278,RC,,,,both,,,4206.12,2733.98,,,,,,,,,,,,,
PLATE BNE L85MM 7 H BILAT S STL 1/3 TBLR FOR 3.5MM SCR,SUP-2411342,CDM,C1713,HCPCS,0278,RC,,,,both,,,202.88,131.87,,,,,,,,,,,,,
GRAFT VASC HEMSHLD GLD L 40 CM DIA16 X 9 MM POLYESTER BOV,SUP-2474289,CDM,C1768,CPT,0278,RC,,,,both,,,2570.75,1670.99,,,,,,,,,,,,,
GRAFT HUM TISS W4XL7CM THK.8-1.4MM ACELLULAR DERM MTRX,SUP-2402517,CDM,Q4126,HCPCS,0636,RC,,,,both,,,5966.00,3877.90,,,,,,,,,,,,,
CATHETER INFUSION 2.4 FRX120 CM EXPANDABLE TIP SYS TRINAV,SUP-2424166,CDM,C1982,HCPCS,0278,RC,,,,both,,,24335.00,15817.75,,,,,,,,,,,,,
STENT ENDOPROS TOT CVR L200MM PROX DIA38MM DST DIA38MM CATH,SUP-2298542,CDM,C1768,CPT,0278,RC,,,,both,,,61214.30,39789.29,,,,,,,,,,,,,
KIT BONE CEMING DEL W/ NDL 13GA CANN INJ DMND AND GRN TIP,SUP-2341406,CDM,C1713,HCPCS,0278,RC,,,,both,,,6468.40,4204.46,,,,,,,,,,,,,
PLATE BNE TI L CRANIOMAXILLOFACIAL 11 H ADV NONSTERILE LE,SUP-2366350,CDM,C1713,HCPCS,0278,RC,,,,both,,,1052.87,684.37,,,,,,,,,,,,,
BIT DRL OD2.9MM INLINE REUSE ELITE PREM,SUP-2349208,CDM,2720000010,LOCAL,0272,RC,,,,both,,,597.67,388.49,,,,,,,,,,,,,
PLATE BONE FAN 44.6X0.8 MM SMOOTH REINFORCED POROUS POLYETHY,SUP-2837807,CDM,C1713,HCPCS,0278,RC,,,,both,,,4899.34,3184.57,,,,,,,,,,,,,
MESH DERM IMPL SFT TISS MTRX PORCINE 8X12CM INTEXEN LP,SUP-2140306,CDM,C1763,HCPCS,0278,RC,,,,both,,,3564.69,2317.05,,,,,,,,,,,,,
COIL EMB L30CM DIA7MM MICROCATHETER DIA0.0165IN,SUP-2305181,CDM,C1889,HCPCS,0278,RC,,,,both,,,3014.40,1959.36,,,,,,,,,,,,,
IMPLANT BRST NACL SMOOTH RND SIL SHELL ANT DIAPH VLV STYL,SUP-2113254,CDM,C1789,HCPCS,0278,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
IMPLANT RAMUS W/ INFERIOR RIDGE LT E 5,SUP-2366465,CDM,C1713,HCPCS,0278,RC,,,,both,,,1915.40,1245.01,,,,,,,,,,,,,
SPACER SPNL TRAPEZOIDAL LG 9 MM LAT TI SUSTAIN,SUP-2584074,CDM,C1821,HCPCS,0278,RC,,,,both,,,7536.00,4898.40,,,,,,,,,,,,,
REAMER SURG SPNL ADJUSTABLE POST,SUP-2286810,CDM,C1713,HCPCS,0278,RC,,,,both,,,1031.62,670.55,,,,,,,,,,,,,
CATHETER INFUS 32FR INSRTN L34CM CONN 3/8IN JUG 2 LUMN RADPQ,SUP-2279233,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
TINY TRIUNE VT SI 0.76MM,SUP-2492046,CDM,L8699,HCPCS,0278,RC,,,,both,,,51.43,33.43,,,,,,,,,,,,,
COMPONENT TIB SZ 4 RT ANK TI POR CEM AGIL,SUP-2252063,CDM,C1776,CPT,0278,RC,,,,both,,,11156.42,7251.67,,,,,,,,,,,,,
PLATE SPNL L 22 MM TI ANTR CERV LEVEL 1 NS SONOMA,SUP-2887221,CDM,C1713,HCPCS,0278,RC,,,,both,,,93.38,60.70,,,,,,,,,,,,,
SYSTEM SUT POLYPR POLYDIOXANONE SGL HND CINCHE DSGN RELD,SUP-2119259,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4003.50,2602.27,,,,,,,,,,,,,
CANNULA BIO MEDICUS 14FR,SUP-2721116,CDM,2720000010,LOCAL,0272,RC,,,,both,,,888.05,577.23,,,,,,,,,,,,,
PLATE BNE W9XL69MM THK1MM 6 H TI 1/3 TBLR W/ CLLR LOK COMPR,SUP-2420738,CDM,C1713,HCPCS,0278,RC,,,,both,,,500.23,325.15,,,,,,,,,,,,,
PACK TDC POSTERIOR 25G EVA NEXUSTM,SUP-2863707,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1156.56,751.76,,,,,,,,,,,,,
ROD SPNL 3X45 MM,SUP-2564513,CDM,C1713,HCPCS,0278,RC,,,,both,,,50.08,32.55,,,,,,,,,,,,,
BRACE KNEE 2XL FOR 255 28IN NEOPRENE OPN POPLITEAL WRP ARND,SUP-2196842,CDM,L1810,HCPCS,0274,RC,,,,both,,,65.56,42.61,,,,,,,,,,,,,
TI LOW PROFILE NEURO MACHINE,SUP-2828048,CDM,C1713,HCPCS,0278,RC,,,,both,,,301.13,195.73,,,,,,,,,,,,,
HC So Varicella Igg Igm,PX-3028678766,CDM,86787,CPT,0302,RC,,,,inpatient,,,80.00,52.00,,,,,,,,,,,,,
EPOETIN ALFA 40000 UNIT/ML IJ SOLN,RX-24513,CDM,J0885,HCPCS,0636,RC,59676-0340-00,NDC,,both,1,ML,3153.60,2049.84,,,,,,,,,,,,,
GRAFT TIMS  AFT STRAIGHT TUBE,SUP-2740169,CDM,C1713,HCPCS,0278,RC,,,,both,,,806.98,524.54,,,,,,,,,,,,,
PLATE BONE L193MM 30 H CRANIOMAXILLOFACIAL TI ADAPTATION,SUP-2191267,CDM,C1713,HCPCS,0278,RC,,,,both,,,2070.52,1345.84,,,,,,,,,,,,,
GRAFT VASC GORTX L 30 CM DIA20 MM RNG L 30 CM EPTFE STR STD,SUP-2396035,CDM,C1768,CPT,0278,RC,,,,both,,,3042.66,1977.73,,,,,,,,,,,,,
WIRE FIX L304.8MM DIA1MM S STL BEAD ISOLA,SUP-2255706,CDM,C1713,HCPCS,0278,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
PLATE SPNL 39 MM ANTR LUMBAR 4 HOLE PYRAMID +4,SUP-2631826,CDM,C1713,HCPCS,0278,RC,,,,both,,,12481.50,8112.97,,,,,,,,,,,,,
TROCAR ENDOSCP BLDELSS 12X75 MM STBL SL ENDOPATH BASX,SUP-2857942,CDM,2720000010,LOCAL,0272,RC,,,,both,,,480.58,312.38,,,,,,,,,,,,,
NAIL LAPIDUS 4HOLE RIGHT 44MM,SUP-2741750,CDM,C1713,HCPCS,0278,RC,,,,both,,,5454.18,3545.22,,,,,,,,,,,,,
STAPLER ENDOSCP L60MM DIA12MM TI THCK TISS LIN CUT 6 ROW,SUP-2219910,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1234.77,802.60,,,,,,,,,,,,,
BI MENTUM PFR CEMENTED CUP 55MM,SUP-2540599,CDM,C1776,CPT,0278,RC,,,,both,,,5351.82,3478.68,,,,,,,,,,,,,
ENDOPROSTHESIS VASC VIABAHN L 10CM 10MM 120CM 8FR HEPARIN,SUP-2610467,CDM,C1768,CPT,0278,RC,,,,both,,,10748.22,6986.34,,,,,,,,,,,,,
HEAD MOD RAD SZ 20S,SUP-2244260,CDM,C1776,CPT,0278,RC,,,,both,,,8058.03,5237.72,,,,,,,,,,,,,
SET URET STENT MARD L 24 CM DIA 6 FR PERCFLX HYDROPLUS SFT,SUP-2139582,CDM,C2617,HCPCS,0278,RC,,,,both,,,417.62,271.45,,,,,,,,,,,,,
POST EXT FIX 3 H FEM FOR SIDEKCK FREE CIR FIX,SUP-2400685,CDM,C1713,HCPCS,0278,RC,,,,both,,,292.02,189.81,,,,,,,,,,,,,
SCREW BNE L20MM DIA2.8MM HEX 1.5MM UP LO EXT TI ST CANN,SUP-2107377,CDM,C1713,HCPCS,0278,RC,,,,both,,,3221.64,2094.07,,,,,,,,,,,,,
GUIDEWIRE UROLOGICAL ANGLED 3 CM 0.035 INX150 CM GLIDEWIRE,SUP-2141742,CDM,C1769,HCPCS,0272,RC,,,,both,,,172.70,112.25,,,,,,,,,,,,,
SEALANT FBRN 2ML VALUPAK AND DUPLOJECT EZ PREP TISSEEL,SUP-2129970,CDM,C9250,HCPCS,0636,RC,,,,both,,,399.06,259.39,,,,,,,,,,,,,
PLATE BNE FIBULAR RT LAT 9-15 HOLE,SUP-2865050,CDM,C1713,HCPCS,0278,RC,,,,both,,,5096.22,3312.54,,,,,,,,,,,,,
PROBE SOUNDING FEELER CD HORZ LEG,SUP-2290334,CDM,C1713,HCPCS,0278,RC,,,,both,,,636.48,413.71,,,,,,,,,,,,,
SHEATH INTRO FLX ANSEL 55CM 5 FR 0.035 IN PTFE AQ STR,SUP-2171143,CDM,C1894,HCPCS,0272,RC,,,,both,,,167.52,108.89,,,,,,,,,,,,,
CAP NAIL HUM 0 MM AG RETROGRADE STRL AFFIXUS NAT NAIL,SUP-2606872,CDM,C1713,HCPCS,0278,RC,,,,both,,,254.34,165.32,,,,,,,,,,,,,
WASHER BONE SCR FPS 2MM,SUP-2319590,CDM,C1713,HCPCS,0278,RC,,,,both,,,191.54,124.50,,,,,,,,,,,,,
SCREW BNE L28MM DIA3.8MM 90DEG TI CORT LOK V-LOCK,SUP-2414111,CDM,C1713,HCPCS,0278,RC,,,,both,,,373.66,242.88,,,,,,,,,,,,,
CATHETER CV SET 018 5 FRX12 CM DL J TIP POLYETH,SUP-2760168,CDM,C1751,HCPCS,0278,RC,,,,both,,,234.43,152.38,,,,,,,,,,,,,
PLATE BNE L 43.2 X W 5 MM THK 1 MM 7 H GRD IV TI STR NS DISP,SUP-2937016,CDM,C1713,HCPCS,0278,RC,,,,both,,,1017.36,661.28,,,,,,,,,,,,,
BOLT EXT FIX 12 MM RR1200,SUP-2486094,CDM,2720000010,LOCAL,0272,RC,,,,both,,,119.32,77.56,,,,,,,,,,,,,
INTRODUCER SHTH SL1 0.032 IN 8 FRX63 CM DIL SWARTZ SL,SUP-2464195,CDM,C1893,HCPCS,0272,RC,,,,both,,,558.92,363.30,,,,,,,,,,,,,
SCREW BNE L 4 MM DIA2.3 MM CRANIOFACIAL CROSS PIN HD EMER 5PK,SUP-2884168,CDM,C1713,HCPCS,0278,RC,,,,both,,,1815.39,1180.00,,,,,,,,,,,,,
GRAFT VASC W12XL12CM THK0.1MM EPTFE PERICARD MEM PRECL,SUP-2395370,CDM,C1768,CPT,0278,RC,,,,both,,,2546.54,1655.25,,,,,,,,,,,,,
SCREW BNE CORTICAL 3.5X50 MM DSTL FEM ST FT HEX TI NCB,SUP-2474543,CDM,C1713,HCPCS,0278,RC,,,,both,,,289.79,188.36,,,,,,,,,,,,,
PLIER DENT TWEED 4-7/8 INX12.5 CM WIRE BEND SS LEVEL 1,SUP-2473783,CDM,2720000010,LOCAL,0272,RC,,,,both,,,648.76,421.69,,,,,,,,,,,,,
WASHER ORTHOPEDIC LCK 3.5 MM,SUP-2243054,CDM,C1713,HCPCS,0278,RC,,,,both,,,405.22,263.39,,,,,,,,,,,,,
SHELL ACET SPIK 66 MM HIP REFLECTION,SUP-2434761,CDM,C1776,CPT,0278,RC,,,,both,,,5815.28,3779.93,,,,,,,,,,,,,
HC So Tsh 3rd Generation|NOT REASONABLE AND NECESSARY,PX-3018444366,CDM,84443,CPT,0301,RC,,,GZ,both,,,26.00,16.90,,,,,,,,,,,,,
GRAFT HUM TISS L 245 MM DIA 6 MM SEMITENDINOSUS TEND FRZN,SUP-2913179,CDM,C1762,CPT,0278,RC,,,,both,,,8763.74,5696.43,,,,,,,,,,,,,
HC Surgery Level 6 Addtl 15min,PX-3600000016,CDM,3600000016,LOCAL,0360,RC,,,,inpatient,,,4961.00,3224.65,,,,,,,,,,,,,
EXTENDER SPNL BLADE NAR 26 MM SIG LTP,SUP-2800500,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
SCREW FNGR JT L10MM DIA5.5MM HEX DIA4.5MM IM DST HALLUX IPJ,SUP-2388914,CDM,C1713,HCPCS,0278,RC,,,,both,,,1039.34,675.57,,,,,,,,,,,,,
VALVE AORT L10CM DIA22MM ORIFICE DIA18.6MM TISS ANNULUS,SUP-2355099,CDM,C1889,HCPCS,0278,RC,,,,both,,,12560.00,8164.00,,,,,,,,,,,,,
IMPLANT OSS L0.5MM DIA0.8MM STAP HA DENS FTPLT PARTIALLY,SUP-2312577,CDM,L8613,CPT,0278,RC,,,,both,,,631.93,410.75,,,,,,,,,,,,,
SYSTEM DISPNS MED MAIN 2 DRAW 3500 MEDSTATION,SUP-2126362,CDM,C1781,HCPCS,0278,RC,,,,both,,,1316.60,855.79,,,,,,,,,,,,,
BUR SURG L71MM DIA25MM LNG S STL RND FN DMND NONFLUTED,SUP-2278118,CDM,2720000010,LOCAL,0272,RC,,,,both,,,473.51,307.78,,,,,,,,,,,,,
SCREW BONE L9MM DIA1.5MM MIC CRANIOMAXILLOFACIAL TI,SUP-2262597,CDM,C1713,HCPCS,0278,RC,,,,both,,,82.49,53.62,,,,,,,,,,,,,
WIRE FIX SMOOTH 1.3X70 MM OLV BABY GORILLA KIRSCHNER,SUP-2421737,CDM,C1713,HCPCS,0278,RC,,,,both,,,351.68,228.59,,,,,,,,,,,,,
PLATE BONE 3 H STD RT VOLAR WR 7 PEG FIX ANG,SUP-2389783,CDM,C1713,HCPCS,0278,RC,,,,both,,,1915.40,1245.01,,,,,,,,,,,,,
HOLDER SCR SUPLMNT W/ OUTRIG,SUP-2645903,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1889.15,1227.95,,,,,,,,,,,,,
SCREW BONE SELFTAPPING 6 MM MIDFACIAL 20/PK TITANIUM BRONZE,SUP-2842252,CDM,C1713,HCPCS,0278,RC,,,,both,,,318.84,207.25,,,,,,,,,,,,,
GUIDEWIRE VASC L200CM COIL L10CM DIA0012IN GREATER THAN,SUP-2172468,CDM,C1769,HCPCS,0272,RC,,,,both,,,1632.80,1061.32,,,,,,,,,,,,,
MICROCATHETER GUID CANTATA L 110 CM OD 2.9 FR ID 0.027 IN,SUP-2638529,CDM,C1887,HCPCS,0272,RC,,,,both,,,982.19,638.42,,,,,,,,,,,,,
GRAFT EVAR 16FR L156MM DIA16X10MM HI DENS MULTIFILAMENT,SUP-2295241,CDM,C1768,CPT,0278,RC,,,,both,,,20096.00,13062.40,,,,,,,,,,,,,
BUTTON SUTURE DIA11 MM SLT CONCV RND STRL PROCINCH,SUP-2908580,CDM,C1713,HCPCS,0278,RC,,,,both,,,938.86,610.26,,,,,,,,,,,,,
COMPONENT FEM 3 CM RT KNEE RESURF OSS RS,SUP-2441724,CDM,C1776,CPT,0278,RC,,,,both,,,17365.77,11287.75,,,,,,,,,,,,,
DEFIBRILLATOR IMPL LIVIAN TI CRT 3 CHMBR DDDR BATTERY PWR,SUP-2149052,CDM,C1882,HCPCS,0275,RC,,,,both,,,72220.00,46943.00,,,,,,,,,,,,,
TROCAR SUPRPUB CAMPBELL,SUP-2160622,CDM,C1713,HCPCS,0278,RC,,,,both,,,1944.45,1263.89,,,,,,,,,,,,,
GUIDEWIRE VASC INQWIRE L 150 CM DIA 0.038 IN PTFE PERIPH,SUP-2301912,CDM,C1769,HCPCS,0272,RC,,,,both,,,65.00,42.25,,,,,,,,,,,,,
BRACE WR L LT COT FOAM LAM INSTABILITY INJ REG EXTN D RNG W/,SUP-2326132,CDM,L3908,HCPCS,0274,RC,,,,both,,,47.57,30.92,,,,,,,,,,,,,
CATHETER PTCA L110CM DIA18MM BLLN L6CM SHTH 10FR 0.035IN,SUP-2156191,CDM,C1725,HCPCS,0272,RC,,,,both,,,835.24,542.91,,,,,,,,,,,,,
RELOAD STPL 2.5 WHT 6 ROW DISP FOR DA VINCI X AND DA VINCI,SUP-2246804,CDM,2720000010,LOCAL,0272,RC,,,,both,,,758.31,492.90,,,,,,,,,,,,,
GRAFT VASC GORTX L 20 CM DIA 7 MM EPTFE STR STD WALL N RING,SUP-2396428,CDM,C1768,CPT,0278,RC,,,,both,,,678.24,440.86,,,,,,,,,,,,,
HANDLE KNIFE BAYO CERVICAL LATEX FREE NON STERILE,SUP-2672128,CDM,2720000010,LOCAL,0272,RC,,,,both,,,432.85,281.35,,,,,,,,,,,,,
BRACE WR L LT COT FOAM LAM INSTABILITY INJ REG EXTN D RNG W/,SUP-2326132,CDM,L3908,HCPCS,0272,RC,,,,both,,,47.57,30.92,,,,,,,,,,,,,
HC Inject Trigger Point 3/> Muscle,PX-4502055300,CDM,20553,CPT,0450,RC,,,,both,,,920.00,598.00,,,,,,,,,,,,,
CEMENT BNE 10CC CA PHSPTE INJ LIQ PWD HYDROSET,SUP-2366471,CDM,C1713,HCPCS,0278,RC,,,,both,,,9024.61,5866.00,,,,,,,,,,,,,
DRILL HAND HUDSON BRACE PRECISION SNAP LOCK JARIT STERILE,SUP-2705663,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1059.59,688.73,,,,,,,,,,,,,
PISTON 08MM DIAM 45MM LEN MALL SHEA LOOP FLROPLAS SHEA,SUP-2313663,CDM,L8613,CPT,0278,RC,,,,both,,,298.68,194.14,,,,,,,,,,,,,
BAR FIX SGL SUT STR INTRO FOR MENIS REP SYS FAST-FIX,SUP-2341341,CDM,C1713,HCPCS,0278,RC,,,,both,,,405.53,263.59,,,,,,,,,,,,,
NEPHROSTOMY SET CATH 14 FR RE-ENTRY,SUP-2141726,CDM,C1729,HCPCS,0272,RC,,,,both,,,231.73,150.62,,,,,,,,,,,,,
PLATE BNE W17.5XL152MM THK5.2MM 8 H BILAT S STL BROAD LOK,SUP-2185290,CDM,C1713,HCPCS,0278,RC,,,,both,,,1456.30,946.59,,,,,,,,,,,,,
PLATE BNE C MED 2X0.7 MM 9 MM CRANIOMAXILLOFACIAL 4 LEFORT,SUP-2460649,CDM,C1713,HCPCS,0278,RC,,,,both,,,634.97,412.73,,,,,,,,,,,,,
SCREW BNE L12MM DIA27MM TI ALLY NONLOCKING CRSS DRV,SUP-2262817,CDM,C1713,HCPCS,0278,RC,,,,both,,,318.74,207.18,,,,,,,,,,,,,
KIT SPNL CEM 11CC PMMA NDLLESS HI VISC W/ RESVR MIX HYDRLC,SUP-2255658,CDM,C1713,HCPCS,0278,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
CLAMP EXT FIX FOR 10.5MM BAR 4MM PIN JET-X,SUP-2342948,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3990.00,2593.50,,,,,,,,,,,,,
SYSTEM SUT DEL SGL INCIS CVD HNDL TRIG DISP FLEXISHAFT,SUP-2165321,CDM,2720000010,LOCAL,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
HC Eeg Awake and Asleep,PX-7409581900,CDM,95819,CPT,0740,RC,,,,both,,,2577.00,1675.05,,,,,,,,,,,,,
HEAD HUM H17MM OD46MM OFFSET 3.5MM HI TI SHLDR ANAT ECC,SUP-2399869,CDM,C1776,CPT,0278,RC,,,,both,,,10792.18,7014.92,,,,,,,,,,,,,
NAIL IM L460MM DIA10MM 130DEG STRL GRN FEM TI CANN LCK AG,SUP-2192607,CDM,C1713,HCPCS,0278,RC,,,,both,,,4340.83,2821.54,,,,,,,,,,,,,
PASSER CATH LNG L55CM MAL STR UNI SHUNT KT DISP FOR,SUP-2249014,CDM,C1894,HCPCS,0272,RC,,,,both,,,388.89,252.78,,,,,,,,,,,,,
GRAFT HUM TISS W2XL2CM THK0.1-0.2MM AMNIO MEM 2 LAYR,SUP-2421268,CDM,Q4150,HCPCS,0636,RC,,,,both,,,4521.60,2939.04,,,,,,,,,,,,,
BUR SURG L9CM HD L79MM DIA5MM CYL FLUT L BOR MIDAS REX,SUP-2280237,CDM,2720000010,LOCAL,0272,RC,,,,both,,,320.19,208.12,,,,,,,,,,,,,
LEAD PACE QPLR 47 MM SPC 75 CM LT VENTRIC LG TRAD S QUARTET,SUP-2356663,CDM,C1900,HCPCS,0275,RC,,,,both,,,6280.00,4082.00,,,,,,,,,,,,,
PLATE BNE M L200MM VIT TROCHANTERIC GRP 2 2MM CBL DALL-MILE,SUP-2377572,CDM,C1713,HCPCS,0278,RC,,,,both,,,4389.72,2853.32,,,,,,,,,,,,,
HC NM 3 Phase Bone Scan,PX-3417831500,CDM,78315,CPT,0341,RC,,,,outpatient,,,3524.00,2290.60,,,,,,,,,,,,,
MESH BONE SIZE 7 TTNM STNDRD LATEX FREE PSTRR PRSGTTL CRNL,SUP-2707385,CDM,C1713,HCPCS,0278,RC,,,,both,,,1060.85,689.55,,,,,,,,,,,,,
STEM ULN L 125 MM MED TI PLASMA SPRY RT ELBW TOT ARTHPLSTY,SUP-2902180,CDM,C1776,CPT,0278,RC,,,,both,,,23073.51,14997.78,,,,,,,,,,,,,
BIT DRL CANN 3 MM STRL VERTEX SEL,SUP-2630218,CDM,2720000010,LOCAL,0272,RC,,,,both,,,901.62,586.05,,,,,,,,,,,,,
TROCAR ENDOSCP L100MM OD5-12MM PLAS BLADED BLNT TIP N THRD,SUP-2283179,CDM,2720000010,LOCAL,0272,RC,,,,both,,,422.99,274.94,,,,,,,,,,,,,
SEEDS 2.0 MCI -3.0 MCI LD IN COMS PLAQ 1-125,SUP-2247264,CDM,C2642,HCPCS,0278,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
PLATE BNE 0DEG 12 H BILAT HND S STL STR LO PROF RIG,SUP-2184849,CDM,C1713,HCPCS,0278,RC,,,,both,,,1031.55,670.51,,,,,,,,,,,,,
HC Microbe Suscept Mycobacteri,PX-3008719000,CDM,87190,CPT,0300,RC,,,,both,,,25.00,16.25,,,,,,,,,,,,,
PLATE BNE 9 H CORT WRST TI STR SM FRAG SYS FOR 2.7/3.5MM,SUP-2191037,CDM,C1713,HCPCS,0278,RC,,,,both,,,4268.14,2774.29,,,,,,,,,,,,,
GENERATOR PULSE IMP 16 CNTCT DP BRAIN STIM VERCISE GEVIA 16,SUP-2140418,CDM,C1820,HCPCS,0278,RC,,,,both,,,69080.00,44902.00,,,,,,,,,,,,,
RING EXT FIX SEG 240 MM ALUM HOFFMANN,SUP-2462724,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3494.19,2271.22,,,,,,,,,,,,,
HC Urinalysis W/ Microscopy,PX-3078100100,CDM,81001,CPT,0307,RC,,,,both,,,179.00,116.35,,,,,,,,,,,,,
SCREW BNE 1.5X4 MM DRILL-FREE TI STRL ONEDRIVE 251530476,SUP-2478592,CDM,C1713,HCPCS,0278,RC,,,,both,,,239.64,155.77,,,,,,,,,,,,,
GRAFT BNE 115X11 MM DBM BLLST,SUP-2641773,CDM,C1713,HCPCS,0278,RC,,,,both,,,13753.20,8939.58,,,,,,,,,,,,,
ALLODERM SELECT 5X10 THICK 2.0-2.8,SUP-2822076,CDM,Q4116,HCPCS,0636,RC,,,,both,,,5532.68,3596.24,,,,,,,,,,,,,
MESH BONE LATEX FREE MID FACE BODY,SUP-2676921,CDM,C1713,HCPCS,0278,RC,,,,both,,,12170.51,7910.83,,,,,,,,,,,,,
STENT CAR 7X30 MM ENROUTE,SUP-2431178,CDM,C1884,HCPCS,0278,RC,,,,both,,,7693.00,5000.45,,,,,,,,,,,,,
HC So Chimerism Anal W/Cell Select,PX-3018126866,CDM,81268,CPT,0301,RC,,,,both,,,329.00,213.85,,,,,,,,,,,,,
STEM HUM 10X130 MM SHLDR RVS NP,SUP-2436920,CDM,C1776,CPT,0278,RC,,,,both,,,13013.73,8458.92,,,,,,,,,,,,,
ROD SPNL POST CRV SMOOTH TI ALLY PREBENT 5.5MM DIA 50MM LEN,SUP-2415856,CDM,C1713,HCPCS,0278,RC,,,,both,,,1307.03,849.57,,,,,,,,,,,,,
KIT INTRO ACCS 4FR L10CM GWIRE 0018IN NDL 21GA L4CM MINI S,SUP-2302998,CDM,C1713,HCPCS,0278,RC,,,,both,,,76.46,49.70,,,,,,,,,,,,,
DISTRACTOR SURG L 35 MM MIDFACE NS,SUP-2883653,CDM,C1713,HCPCS,0278,RC,,,,both,,,12418.73,8072.17,,,,,,,,,,,,,
PLATE BONE L THK1.5MM 5X22X5 H MAND TI LCKING DBL ANG FOR,SUP-2191269,CDM,C1713,HCPCS,0278,RC,,,,both,,,8974.43,5833.38,,,,,,,,,,,,,
MICROSPHERE EMB THERASPHERE 10.5 GBQ YTTRIUM-90 GLS DOSE VI,SUP-2135280,CDM,C2616,HCPCS,0278,RC,,,,both,,,50240.00,32656.00,,,,,,,,,,,,,
TUBE VENTILATION 1.14MM ID 1.58MM FLUOROPLSTC SHANK EAR,SUP-2902751,CDM,L8699,HCPCS,0278,RC,,,,both,,,70.21,45.64,,,,,,,,,,,,,
CLAMP EXT FIX L 11 TO 5-6 MM SWVL UNILAT NS DISP MAV,SUP-2931344,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4794.78,3116.61,,,,,,,,,,,,,
INSERT TIB THK 7 MM SZ 4 UHMWPE LT ANK POST BIASED STRL,SUP-2933180,CDM,C1776,CPT,0278,RC,,,,both,,,11976.75,7784.89,,,,,,,,,,,,,
CONNECTOR SPNL U 6.35-6.35X200 MM LT REVERE,SUP-2584895,CDM,C1713,HCPCS,0278,RC,,,,both,,,8333.56,5416.81,,,,,,,,,,,,,
POST MODULAR F/AUNMENTED MGS BASEPLATE,SUP-2749343,CDM,C1776,CPT,0278,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
SCREW BONE L85MM DIA5MM FT ANK TI ALLOY CANN FT HDLSS SHRP,SUP-2321009,CDM,C1713,HCPCS,0278,RC,,,,both,,,4088.28,2657.38,,,,,,,,,,,,,
RING ANNULPLSTY HAART 300 DIA21 MM TI CVR DACRON AORT VLV,SUP-2878072,CDM,C1889,HCPCS,0278,RC,,,,both,,,19405.20,12613.38,,,,,,,,,,,,,
TRAY CATH 5FR INTRO NDL CHLOROPREP FUTURA SCALP SYR CAP,SUP-2133891,CDM,C1729,HCPCS,0272,RC,,,,both,,,150.72,97.97,,,,,,,,,,,,,
PIN FIX L5MM DIA16MM CNTR FOR REDUC JOYSTICK 27MM VAR ANG,SUP-2179087,CDM,C1713,HCPCS,0278,RC,,,,both,,,425.50,276.57,,,,,,,,,,,,,
MESH HERN ANAT XL 16X12 CM LT PRESHAPED MONOFILAMENT DEXTILE,SUP-2752176,CDM,C1781,HCPCS,0278,RC,,,,both,,,893.46,580.75,,,,,,,,,,,,,
LEAD STIM TST NRV EXT FORE BILAT PLCMNT SACR,SUP-2284414,CDM,C1897,HCPCS,0278,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
SUPPORT ORTHOT ANK KNEE THGH CALF CUST SINGLE FREE STIRRUP,SUP-2435631,CDM,L2000,HCPCS,0274,RC,,,,both,,,3167.13,2058.63,,,,,,,,,,,,,
COLLAR CERV AD TALL CUSH FLX TAB OCCIPITAL SUPP STRP,SUP-2123893,CDM,L0180,HCPCS,0274,RC,,,,both,,,59.63,38.76,,,,,,,,,,,,,
PLATE BNE 90 DEG BLADE L 50 MM DISPLC 20 MM 4 DCP H SS HIP,SUP-2907755,CDM,C1713,HCPCS,0278,RC,,,,both,,,3166.85,2058.45,,,,,,,,,,,,,
GRAFT HUM TISS 1000MG AMNIOFILL,SUP-2305716,CDM,C1762,CPT,0278,RC,,,,both,,,5809.00,3775.85,,,,,,,,,,,,,
CATHETER DRAINAGE 4 FRX10 CM 20 GA ECHOGENIC NDL TIP ACCEL,SUP-2659261,CDM,C1729,HCPCS,0272,RC,,,,both,,,66.13,42.98,,,,,,,,,,,,,
INSERT TIB 1/2 9MM L CONG NAT KNEE II,SUP-2202426,CDM,C1776,CPT,0278,RC,,,,both,,,3224.78,2096.11,,,,,,,,,,,,,
ESTRADIOL CYPIONATE 5 MG/ML IM OIL,RX-2929,CDM,J1000,HCPCS,0636,RC,00009-0271-01,NDC,,both,1,ML,221.10,143.71,,,,,,,,,,,,,
LENS INTOCU +2.0 DIOPT L13MM DIA6MM 5DEG HAPTIC ANG POST,SUP-2110621,CDM,V2632,HCPCS,0276,RC,,,,both,,,439.79,285.86,,,,,,,,,,,,,
BLOCK TIB AUG HALF 5X20 MM TAPR NXGN,SUP-2201701,CDM,C1776,CPT,0278,RC,,,,both,,,3369.22,2189.99,,,,,,,,,,,,,
CATHETER EP STD 2-8-2 MM 6 FRX105 CM POLARIS,SUP-2148487,CDM,C1730,HCPCS,0272,RC,,,,both,,,1931.10,1255.21,,,,,,,,,,,,,
FIBER LASER 200UM DUST THULIUM,SUP-2885377,CDM,2720000010,LOCAL,0272,RC,,,,both,,,938.86,610.26,,,,,,,,,,,,,
CATHETER ABLATN D-F CRV N NAVIGATIONAL EZ STEER THERMOCOOL,SUP-2257365,CDM,C1732,HCPCS,0272,RC,,,,both,,,5338.00,3469.70,,,,,,,,,,,,,
DEVICE FIX GRFT LG 16.5X3.9 MM 60 MM 12 MM BUTTON ULT GFS,SUP-2762074,CDM,C1713,HCPCS,0278,RC,,,,both,,,1224.60,795.99,,,,,,,,,,,,,
PLATE BNE 2X27X1 MM 5 HOLE SS DCP,SUP-2569120,CDM,C1713,HCPCS,0278,RC,,,,both,,,271.14,176.24,,,,,,,,,,,,,
CATHETER ETER ANGIO 14FR 12CM SCHON XL,SUP-2118061,CDM,C1752,HCPCS,0278,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
PLATE BNE 7 H R PROX TIB TIM STD CRV LOK ALPS,SUP-2413736,CDM,C1713,HCPCS,0278,RC,,,,both,,,3803.80,2472.47,,,,,,,,,,,,,
PLATE BONE L14MM THK.5MM NEURO BUR H CVR FOR 1.7MM SCR DELT,SUP-2365072,CDM,C1713,HCPCS,0278,RC,,,,both,,,2032.84,1321.35,,,,,,,,,,,,,
PLATE CRAN W15XL15CM WIRE 0.010IN TI MAL ST FOR,SUP-2243572,CDM,C1713,HCPCS,0278,RC,,,,both,,,2772.62,1802.20,,,,,,,,,,,,,
CATHETER HD IJ 20 CM DUOFLO,SUP-2217982,CDM,C1752,HCPCS,0278,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
PLATE BNE STR NAR 258 MM 18 HOLE FOR PERIPROSTHETIC FRAC NCB,SUP-2478615,CDM,C1713,HCPCS,0278,RC,,,,both,,,1800.82,1170.53,,,,,,,,,,,,,
MESH COMPOSIX LP ELP 7.2 IN X 9.2 IN W/ INTRO,SUP-2125817,CDM,C1781,HCPCS,0278,RC,,,,both,,,2891.00,1879.15,,,,,,,,,,,,,
KIT GUIDEWIRE INTRO TORQUE DEV COPILOT BLEEDBK CTRL,SUP-2103553,CDM,C1894,HCPCS,0272,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
TUBE TRACH L40MM OD5.3MM ID3.5MM FLX TEND +,SUP-2351996,CDM,2720000010,LOCAL,0272,RC,,,,both,,,452.95,294.42,,,,,,,,,,,,,
PLATE BONE L243MM 10 H LT SHFT FOR BUTTRESSING MULTIFRAGMENT,SUP-2152510,CDM,C1713,HCPCS,0278,RC,,,,both,,,4352.04,2828.83,,,,,,,,,,,,,
PORT TI DEV W 6FR ATTCH CHRONOFLEX POLYUR OPN CATHETER AND,SUP-2126308,CDM,C1788,HCPCS,0278,RC,,,,both,,,1130.40,734.76,,,,,,,,,,,,,
PLATE BONE L225MM 5 H BILAT S STL BROAD LO PROF RIG DYN,SUP-2185271,CDM,C1713,HCPCS,0278,RC,,,,both,,,977.80,635.57,,,,,,,,,,,,,
CHARCOAL ACTIVATED PO LIQD,RX-27099,CDM,6370000000,HCPCS,0637,RC,00574-0521-74,NDC,,both,120,ML,60.00,39.00,,,,,,,,,,,,,
PLATE BNE L355MM 14 H NONSTERILE L PROX FEM S STL LO PROF,SUP-2186049,CDM,C1713,HCPCS,0278,RC,,,,both,,,4971.22,3231.29,,,,,,,,,,,,,
ALLOGRAFT BNE CUBE 0.5X0.5X0.5 CM 5 CC PRESERVON READIGRAFT,SUP-2740781,CDM,C1713,HCPCS,0278,RC,,,,both,,,235.12,152.83,,,,,,,,,,,,,
SCREW BNE BICORTICAL 30 MM SELF TAPPING NO-PROFILE,SUP-2608701,CDM,C1713,HCPCS,0278,RC,,,,both,,,569.72,370.32,,,,,,,,,,,,,
BUTTON GASTROSTMY 18FR L44CM LO PROF FOR REPL GASTROSTMY TB,SUP-2141575,CDM,2720000010,LOCAL,0272,RC,,,,both,,,363.74,236.43,,,,,,,,,,,,,
PATCH CV HEMGRD L 120 X W 8 MM THK 0.41 MM POLYESTER BOV,SUP-2535435,CDM,C1768,CPT,0278,RC,,,,both,,,847.77,551.05,,,,,,,,,,,,,
SET NEPHSTMY SHTH L20CM OD4FR NDL L15CM OD21GA GWIRE L60CM,SUP-2168588,CDM,C1894,HCPCS,0272,RC,,,,both,,,266.21,173.04,,,,,,,,,,,,,
MATERIAL TRANSPLANT FECAL MICROBIOTA,SUP-2866781,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5322.30,3459.49,,,,,,,,,,,,,
SCREW KNEE ARTHROPLASTY FEM DST VIT ST DURAC 10MML,SUP-2377244,CDM,C1713,HCPCS,0278,RC,,,,both,,,186.89,121.48,,,,,,,,,,,,,
COMPONENT ARTC SURF UNI 4 11 MM KNEE UHMWPE PHYSICA ZUK,SUP-2342192,CDM,C1776,CPT,0278,RC,,,,both,,,1868.05,1214.23,,,,,,,,,,,,,
NEEDLE BX 22GA L15CM CHIBA ASPIR FN ADJ STP CLR CODE STYL,SUP-2381917,CDM,C1713,HCPCS,0278,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
ELECTRODE NERVE MONITORING SZ 2-3 MM STRL DISP APS,SUP-2901931,CDM,2720000010,LOCAL,0272,RC,,,,both,,,733.98,477.09,,,,,,,,,,,,,
SHUNT CV 4X5 MM,SUP-2633895,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2203.93,1432.55,,,,,,,,,,,,,
GENTAMICIN SULFATE 2 MG/ML SYRINGE (PED-NEO) <50 ML,RX-4090289,CDM,J1580,HCPCS,0636,RC,00338-0511-41,NDC,,both,50,ML,54.10,35.16,,,,,,,,,,,,,
"HC Gbl New Pt, E/M Level 4",PX-9829920400,CDM,99204,CPT,0982,RC,,,,inpatient,,,654.00,425.10,,,,,,,,,,,,,
HC Percutaneous Trach Insert,PX-3613160000,CDM,31600,CPT,0361,RC,,,,both,,,9617.00,6251.05,,,,,,,,,,,,,
BLADE RTRCTR BLFR STNDRD 2 5/8NW X 12NL X 1 1/2ND ABDMNL CNT,SUP-2459927,CDM,2720000010,LOCAL,0272,RC,,,,both,,,418.66,272.13,,,,,,,,,,,,,
ALLOGRAFT BNE 1.2 ML BIOACTIVE FOAM PK VITOSS BA BIMODAL,SUP-2637053,CDM,C1713,HCPCS,0278,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
STAPLER ENDO SKIN FIRING REINF W/ DRY CLLGN MTRX BOV,SUP-2130285,CDM,C9354,HCPCS,0278,RC,,,,both,,,671.90,436.73,,,,,,,,,,,,,
HC Inj Proc Shoulder Arthro,PX-3612335000,CDM,23350,CPT,0361,RC,,,,inpatient,,,3707.00,2409.55,,,,,,,,,,,,,
SUPPORT ORTHOT SHLDR ADJ CUST FIT STRP W/OUT JT FABRICATED,SUP-2435751,CDM,L3671,HCPCS,0272,RC,,,,both,,,2321.65,1509.07,,,,,,,,,,,,,
CHEEK RETRACTOR RING/THREADED,SUP-2823396,CDM,C1713,HCPCS,0278,RC,,,,both,,,1059.44,688.64,,,,,,,,,,,,,
GUIDEWIRE VASC COON L 145 CM DIA 0.035 IN TAPR L 15 CM SS,SUP-2169719,CDM,C1769,HCPCS,0272,RC,,,,both,,,38.31,24.90,,,,,,,,,,,,,
SCREW BONE L140MM DIA8MM STD CORT TI ST SELF DRL CANN,SUP-2343508,CDM,C1713,HCPCS,0278,RC,,,,both,,,2052.87,1334.37,,,,,,,,,,,,,
HC So Iron|NOT REASONABLE AND NECESSARY,PX-3018354066,CDM,83540,CPT,0301,RC,,,GZ,both,,,521.00,338.65,,,,,,,,,,,,,
SUPPORT ORTHOT HND FNGR W/O JT PREFABRICATED SFT INTFACE,SUP-2435782,CDM,L3923,HCPCS,0274,RC,,,,both,,,248.88,161.77,,,,,,,,,,,,,
BLADE SAW BONE CEM KEEL CUT OXFORD,SUP-2136845,CDM,2720000010,LOCAL,0272,RC,,,,both,,,351.68,228.59,,,,,,,,,,,,,
BOOT WALKING CUST FABRIC ANK FT,SUP-2237265,CDM,L4631,HCPCS,0274,RC,,,,both,,,4492.59,2920.18,,,,,,,,,,,,,
CATHETER CV STD SET 018 4 FRX60 CM DL PWR INJ SS TURBO-JECT,SUP-2759816,CDM,C1751,HCPCS,0278,RC,,,,both,,,367.69,239.00,,,,,,,,,,,,,
CEMENT BNE HI VISC 80 GM PALACOS R PRO,SUP-2738875,CDM,C1713,HCPCS,0278,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
PIN EXT FIX SD 4X180 MM 50 MM ST THRD SS STRL APEX,SUP-2460782,CDM,C1713,HCPCS,0278,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
PLATE BNE L242MM 10 H ST R CNDYL S STL LOK COMPR CRV FOR,SUP-2177088,CDM,C1713,HCPCS,0278,RC,,,,both,,,4814.34,3129.32,,,,,,,,,,,,,
DECOMPRESSION CANNULA,SUP-2811424,CDM,2720000010,LOCAL,0272,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
GRAFT BONE SUB 7.5CC L1-10MM CANC CRUSH FRZ DRY,SUP-2165594,CDM,C1713,HCPCS,0278,RC,,,,both,,,533.80,346.97,,,,,,,,,,,,,
KIT ORTH INCL CLLRD BRKWY AND TUBEROSITY PIN CUT BLK DISP,SUP-2121006,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1566.86,1018.46,,,,,,,,,,,,,
RELOAD STPL L60MM 3X25MM OPN 1MM CLSR WHT TI NONABSORBABLE,SUP-2283039,CDM,2720000010,LOCAL,0272,RC,,,,both,,,466.23,303.05,,,,,,,,,,,,,
GRAFT BNE SUB 15CC CA PHSPTE HYALURONIC ACID CEM VOID FILL,SUP-2378763,CDM,C1713,HCPCS,0278,RC,,,,both,,,15645.36,10169.48,,,,,,,,,,,,,
ABLATOR ARTHROSCOPIC APOLLORF H50,SUP-2744795,CDM,C1776,CPT,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
BODY EXT FIX L72MM STD PENNIG MINIFIXATOR,SUP-2316456,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2013.49,1308.77,,,,,,,,,,,,,
TRAY NERVE BLOCK CANN DIA25 GA SPNL P25BKN NRFIT STRL DISP,SUP-2936530,CDM,2720000010,LOCAL,0272,RC,,,,both,,,55.99,36.39,,,,,,,,,,,,,
PLATE BONE 17 H STR PROF TEMPLT,SUP-2365251,CDM,C1713,HCPCS,0278,RC,,,,both,,,8608.06,5595.24,,,,,,,,,,,,,
PLATE BONE LOCKING HOLEX14 RIGHT MEDIAL DISTAL TIBIAL,SUP-2458801,CDM,C1713,HCPCS,0278,RC,,,,both,,,4429.57,2879.22,,,,,,,,,,,,,
SCREW SPNL CERV FACET DISP DTRAX,SUP-2330584,CDM,C1713,HCPCS,0278,RC,,,,both,,,1962.50,1275.62,,,,,,,,,,,,,
NAIL IM 10 MM FEM RETRO AG TI STRL EXPERT,SUP-2180080,CDM,C1713,HCPCS,0278,RC,,,,both,,,5017.72,3261.52,,,,,,,,,,,,,
HC Peripheral Block - Sciatic Continuous W/Img Gdn,PX-3606444600,CDM,64446,CPT,0360,RC,,,,both,,,2895.00,1881.75,,,,,,,,,,,,,
CATHETER DRAINAGE PIG 10.2 FRX25 CM BILI SET 6 HOLE UTHANE,SUP-2168131,CDM,C1729,HCPCS,0272,RC,,,,both,,,277.42,180.32,,,,,,,,,,,,,
DEVICE COMPR FEM PMP COMPLT FEMSTP II+,SUP-2356631,CDM,C1713,HCPCS,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
PLATE BNE STR MINI MED 4 HOLE W/ BREAK-AWAY TAB TI,SUP-2459517,CDM,C1713,HCPCS,0278,RC,,,,both,,,821.68,534.09,,,,,,,,,,,,,
FRACSURE HIP STEM SOLID-CEMENTED COCR SZ 1,SUP-2207899,CDM,C1776,CPT,0278,RC,,,,both,,,3072.18,1996.92,,,,,,,,,,,,,
NALOXONE HCL 0.4 MG/ML IJ SOLN,RX-5373,CDM,J2312,HCPCS,0636,RC,67457-0292-02,NDC,,both,0.25,ML,54.10,35.16,,,,,,,,,,,,,
IMMOBILIZER SHLDR BASIC ABD SLNG SM,SUP-2150926,CDM,L3650,HCPCS,0272,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
PLATE SPNL OCPTL SM MIDLN KEEL,SUP-2630219,CDM,C1713,HCPCS,0278,RC,,,,both,,,5443.98,3538.59,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9 % IV BOLUS,RX-103555,CDM,2580000003,HCPCS,0258,RC,00338-0049-11,NDC,,both,250,ML,123.30,80.14,,,,,,,,,,,,,
PLATE BNE SM TI R CALCNL LOK,SUP-2106921,CDM,C1713,HCPCS,0278,RC,,,,both,,,281.97,183.28,,,,,,,,,,,,,
GRAFT VASC HEMSHLD GLD L 15 CM DIA18 MM POLYESTER BOV CLLGN,SUP-2488967,CDM,C1768,CPT,0278,RC,,,,both,,,1364.83,887.14,,,,,,,,,,,,,
HC Pt Elec Stim Unattended,PX-4209701400,CDM,G0283,HCPCS,0420,RC,,,,inpatient,,,206.00,133.90,,,,,,,,,,,,,
HC Assay of Urea Nitrogen Quantitative,PX-3018452000,CDM,84520,CPT,0301,RC,,,,both,,,92.00,59.80,,,,,,,,,,,,,
PROSTHESIS LARYN 10MM LO AIRFLO RESISTANCE EZ MAINT FOR,SUP-2124339,CDM,L8509,HCPCS,0274,RC,,,,both,,,932.58,606.18,,,,,,,,,,,,,
KIT STPL BRDG 18MM LEG 18MM MAX CLSR 10.4MM BME ELITE,SUP-2254041,CDM,C1713,HCPCS,0278,RC,,,,both,,,4104.51,2667.93,,,,,,,,,,,,,
KIT PROCEDURE BRONCHOSCOPY GALAXY (MUST BE PURCHASED IN INCREMENTS OF 4 EA),SUP-2881765,CDM,C1601,HCPCS,0272,RC,,,,both,,,6594.00,4286.10,,,,,,,,,,,,,
CLINDAMYCIN (CLEOCIN) 900 MG IN DEXTROSE 5% 50 ML IVPB,RX-4081153,CDM,J0736,HCPCS,0636,RC,09999-9906-20,NDC,,both,50,ML,86.00,55.90,,,,,,,,,,,,,
SCREW BNE CORTICAL STD 6 MM SHFT 6-5X200 MM 50 MM ST NS,SUP-2644426,CDM,C1713,HCPCS,0278,RC,,,,both,,,347.60,225.94,,,,,,,,,,,,,
SYSTEM URO W/ IMPL DEL DEV FOR TREAT OF URIN OUTFLO,SUP-2308351,CDM,C1889,HCPCS,0278,RC,,,,both,,,3611.00,2347.15,,,,,,,,,,,,,
BIT DRL L110MM DIA2.1MM FOR L10-36MM DIA3MM TWST CANN SM,SUP-2389433,CDM,2720000010,LOCAL,0272,RC,,,,both,,,464.72,302.07,,,,,,,,,,,,,
WIRE EXT FIX L400MM DIA1.8MM CORT TI BAYNT PT ILIZ,SUP-2342845,CDM,C1769,HCPCS,0272,RC,,,,both,,,4824.55,3135.96,,,,,,,,,,,,,
SCREW BNE L12MM DIA2MM IM FIX SELF DRL,SUP-2183326,CDM,C1713,HCPCS,0278,RC,,,,both,,,444.00,288.60,,,,,,,,,,,,,
HC Laryngoscopy Flexible Fiberoptic Diagnostic,PX-4503157500,CDM,31575,CPT,0450,RC,,,,both,,,214.00,139.10,,,,,,,,,,,,,
BOLT ORTHOPEDIC 26 MM LAT TROCHANTERIC HIP ACROS MOD REV SYS,SUP-2435440,CDM,C1776,CPT,0278,RC,,,,both,,,1381.60,898.04,,,,,,,,,,,,,
PLATE EXT FIX SHT 160 MM FT RNG CARBON FIBER NS,SUP-2799575,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2221.42,1443.92,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9 % IV BOLUS,RX-103555,CDM,J7050,HCPCS,0250,RC,00264-7800-20,NDC,,both,250,ML,23.40,15.21,,,,,,,,,,,,,
SPACER SPINE WDG TI 12DEG 18MM M ICI VANGUARD EBI SOLITAIRE,SUP-2414767,CDM,C1821,HCPCS,0278,RC,,,,both,,,15561.84,10115.20,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 70 CM DIA 4 MM STR STD WALL HELIX,SUP-2681771,CDM,C1768,CPT,0278,RC,,,,both,,,2402.10,1561.36,,,,,,,,,,,,,
LENS IO +130 DIOPT CYL PWR +300 DIOPT L13MM DIA6MM 0DEG,SUP-2111727,CDM,V2787,HCPCS,0276,RC,,,,both,,,595.00,386.75,,,,,,,,,,,,,
CATHETER INTVENT .038IN 65 GLDECATH,SUP-2141091,CDM,C1887,HCPCS,0272,RC,,,,both,,,757.21,492.19,,,,,,,,,,,,,
HC Oxygen Saturation Measurement,PX-4609476000,CDM,94760,CPT,0460,RC,,,,inpatient,,,148.00,96.20,,,,,,,,,,,,,
SHEATH INTRO D'VILL L 30 CM DIA14 FR GUIDEWIRE 0.035 IN LNG,SUP-2615936,CDM,C1894,HCPCS,0272,RC,,,,both,,,651.71,423.61,,,,,,,,,,,,,
COVER BURR HOLE CONTOURED 18X0.6 MM W/ 3.2 MM DRN LO PROF,SUP-2463299,CDM,C1713,HCPCS,0278,RC,,,,both,,,783.05,508.98,,,,,,,,,,,,,
GRAFT BNE FRZN STRUCTURAL L WHL FIB IMPL,SUP-2307385,CDM,C1713,HCPCS,0278,RC,,,,both,,,7914.40,5144.36,,,,,,,,,,,,,
WASHER ORTHOPEDIC 54X70 MM TROCH S-ROM,SUP-2455874,CDM,C1713,HCPCS,0278,RC,,,,both,,,953.30,619.64,,,,,,,,,,,,,
BLADE SCRDRIVER CRUCFRM HLD SL FOR 1MM SCR,SUP-2187564,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3504.59,2277.98,,,,,,,,,,,,,
GRAFT BNE L TRICORT BLK FOR OSTEOTMY ALLOPURE,SUP-2400551,CDM,C1762,CPT,0278,RC,,,,both,,,6369.77,4140.35,,,,,,,,,,,,,
SPLINT WRST SM L7IN AD R FA COT E SUPP INSTABILITY INJ LOOP,SUP-2276655,CDM,L3809,HCPCS,0272,RC,,,,both,,,9.36,6.08,,,,,,,,,,,,,
CATHETER ENDO BILI BAL 5FR 4MM OD 4CM 180CM WRK LEN INFL W/,SUP-2148886,CDM,C1887,HCPCS,0272,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
STEM FEM SZ 2 HIP CEM LUSTER,SUP-2251952,CDM,C1776,CPT,0278,RC,,,,both,,,11724.76,7621.09,,,,,,,,,,,,,
PREM ST/CER HD,SUP-2137302,CDM,C1776,CPT,0278,RC,,,,both,,,9052.62,5884.20,,,,,,,,,,,,,
SET SCREW OCCIPTITAL GIBRALT,SUP-2661347,CDM,C1713,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
ROD EXT FIX L300MM DIA11MM C CONN FOR HOFFMANN III MRI SYS,SUP-2372229,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1140.76,741.49,,,,,,,,,,,,,
GRAFT BNE SUB 80CC 1 8MM CANC CRUSH CHIP READIGRFT,SUP-2264811,CDM,C1713,HCPCS,0278,RC,,,,both,,,2757.80,1792.57,,,,,,,,,,,,,
SLEEVE ANK CLOSED HEEL 8.5-10 IN MED 1/8 IN PROCARE,SUP-2195739,CDM,L1906,HCPCS,0272,RC,,,,both,,,17.52,11.39,,,,,,,,,,,,,
PLATE BONE LT DBL Y MOTOBAND CP,SUP-2174976,CDM,C1713,HCPCS,0278,RC,,,,both,,,7050.87,4583.07,,,,,,,,,,,,,
CONNECTOR SPNL ROD DIA 3.5/6.35 MM POST CERV PARALLEL DBL NS,SUP-2887229,CDM,C1713,HCPCS,0278,RC,,,,both,,,111.19,72.27,,,,,,,,,,,,,
KIT DRNGE SUMP J TIP TRCR STYL .038IN GUIDWIRE CANN AIR,SUP-2147875,CDM,C1729,HCPCS,0272,RC,,,,both,,,471.47,306.46,,,,,,,,,,,,,
CLIP ANEUR MIC M CVD 9MM - 9MM,SUP-2243942,CDM,C1889,HCPCS,0278,RC,,,,both,,,1164.94,757.21,,,,,,,,,,,,,
GRAFT VASC HEMGRD L 50 CM DIA12 X 6 MM THK 0.49 MM POLYESTER,SUP-2227287,CDM,C1768,CPT,0278,RC,,,,both,,,2567.70,1669.00,,,,,,,,,,,,,
CATHETER CV SINGLE LUMEN 6.6 FRX90 CM PEEL APART INTRO BRVC,SUP-2127698,CDM,C1751,HCPCS,0278,RC,,,,both,,,607.59,394.93,,,,,,,,,,,,,
HC Biopsy Thyroid Perc Needle,PX-3616010000,CDM,60100,CPT,0361,RC,,,,outpatient,,,3707.00,2409.55,,,,,,,,,,,,,
ANCHOR SUT L17MM OD5MM HD BIOABSRB CRKSCR,SUP-2121504,CDM,C1713,HCPCS,0278,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
PLATE BONE LOK 285MML HLX12 PRTSL 64 NON CNTCT BRDGE POLYAX,SUP-2495217,CDM,C1713,HCPCS,0278,RC,,,,both,,,4098.39,2663.95,,,,,,,,,,,,,
GRAFT VASC VECTRA L 40 CM DIA 5 MM POLYUR STR STD WALL N,SUP-2126220,CDM,C1768,CPT,0278,RC,,,,both,,,3072.05,1996.83,,,,,,,,,,,,,
PIN TRACTION SKULL AD 1 PROC TI POLYMER BLK STRL DORO LUC,SUP-2887038,CDM,C1713,HCPCS,0278,RC,,,,both,,,1720.72,1118.47,,,,,,,,,,,,,
CEFAZOLIN SODIUM 1 G IJ SOLR,RX-1445,CDM,J0688,HCPCS,0636,RC,00143-9924-90,NDC,,both,1,UN,54.10,35.16,,,,,,,,,,,,,
BRACE ORTH EXTN ORTHOSIS WRST CTRL,SUP-2388193,CDM,L3908,HCPCS,0272,RC,,,,both,,,162.43,105.58,,,,,,,,,,,,,
MESH BONE LG 06MM THK TTNM LATEX FREE TMPRL MXLFCL,SUP-2707376,CDM,C1713,HCPCS,0278,RC,,,,both,,,4341.18,2821.77,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH FLX L 73 MM DIA 36 MM SHTH 20 FR RVD,SUP-2170457,CDM,C1768,CPT,0278,RC,,,,both,,,5925.18,3851.37,,,,,,,,,,,,,
PLATE BNE L98MM 6 H NONSTERILE R LAT PROX TIB LOK FOR 35MM,SUP-2348473,CDM,C1713,HCPCS,0278,RC,,,,both,,,11436.98,7434.04,,,,,,,,,,,,,
LEUPROLIDE ACETATE (6 MONTH) 45 MG IM KIT,RX-109208,CDM,J9217,HCPCS,0636,RC,00074-3473-03,NDC,,both,1,UN,3941.10,2561.71,,,,,,,,,,,,,
DRIVER SURG SM CRUCFRM UNIV SM SCR EXTR SYSTEMXTRACT ALL,SUP-2337695,CDM,2720000010,LOCAL,0272,RC,,,,both,,,659.40,428.61,,,,,,,,,,,,,
HC N Block Lumbar/Thoracic,PX-3606452000,CDM,64520,CPT,0360,RC,,,,both,,,2895.00,1881.75,,,,,,,,,,,,,
IMPLANT HUM TISS SZ 3 X 4 CM THK 2000 UM PLCNTA MEMBRN FRSH,SUP-2913444,CDM,C1762,CPT,0278,RC,,,,both,,,19741.18,12831.77,,,,,,,,,,,,,
ANGEL BLOOD PROCESSING SET US,SUP-2816344,CDM,2720000010,LOCAL,0272,RC,,,,both,,,833.67,541.89,,,,,,,,,,,,,
SCREW INTRF L23MM DIA7MM KNEE PLLA CANN BIOABSRB THRD WDG,SUP-2362043,CDM,C1713,HCPCS,0278,RC,,,,both,,,516.88,335.97,,,,,,,,,,,,,
ENDCAP SPNL RND 0 DEG 16X14 MM PARL TI X-CORE MINI,SUP-2559841,CDM,C1889,HCPCS,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
GRAFT VASC STD WALL 4-7 MMX40 CM SHT TAPR REINF ADVANTA VXT,SUP-2468444,CDM,C1768,CPT,0278,RC,,,,both,,,844.69,549.05,,,,,,,,,,,,,
KIT VENT CATH MICROSENSOR,SUP-2243822,CDM,C1729,HCPCS,0272,RC,,,,both,,,2212.48,1438.11,,,,,,,,,,,,,
STYLET PACE L52CM REACH L40MM RAD 14MM 0.016IN DEFL ENABLES,SUP-2356062,CDM,2720000010,LOCAL,0272,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
PLATE BONE L112MM 6 H S STL T SHP BTTRS LO PROF RIG,SUP-2185765,CDM,C1713,HCPCS,0278,RC,,,,both,,,1916.84,1245.95,,,,,,,,,,,,,
RALTEGRAVIR POTASSIUM 400 MG PO TABS,RX-88608,CDM,6370000000,HCPCS,0637,RC,00006-0227-61,NDC,,both,1,UN,156.30,101.59,,,,,,,,,,,,,
COLLAR CERV UNIV 13 19INCH VISTA TX,SUP-2196896,CDM,L0172,HCPCS,0274,RC,,,,both,,,128.43,83.48,,,,,,,,,,,,,
PLATE LOK STRGHT XLRG6H T10MM 1MM MARKS W/TAB CP TTNM,SUP-2694192,CDM,C1713,HCPCS,0278,RC,,,,both,,,1753.44,1139.74,,,,,,,,,,,,,
CATHETER CTRL VEN DBL LUMN N TUNNELED BASIC KT POLYUR N COAT,SUP-2383396,CDM,C1751,HCPCS,0278,RC,,,,both,,,98.34,63.92,,,,,,,,,,,,,
HEAD FEM DIA 36 MM OFFSET 0 MM COCR 12/14 TAPR STRL FRDM,SUP-2887428,CDM,C1776,CPT,0278,RC,,,,both,,,4125.96,2681.87,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY LASSO NAV ECO L 115 CM 7 FR 6MM D,SUP-2457296,CDM,C1730,HCPCS,0272,RC,,,,both,,,2583.44,1679.24,,,,,,,,,,,,,
CATHETER EP D CRV 2-5-2 MM 6 FRX120 CM FIX,SUP-2356814,CDM,C1730,HCPCS,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
SCREW BNE L90MM DIA12.7MM THRD L21MM STD IM HIP CANN LAG,SUP-2342399,CDM,C1713,HCPCS,0278,RC,,,,both,,,2308.72,1500.67,,,,,,,,,,,,,
CATHETER ABLATION L 117 CM DIA 4 FR TIP DIA19 MM GUIDE CATH,SUP-2914757,CDM,C1735,HCPCS,0272,RC,,,,both,,,49235.20,32002.88,,,,,,,,,,,,,
ALLOGRAFT BNE 200X25 MM FRZN RT PROX FEM SHFT W/ HD,SUP-2866865,CDM,C1762,CPT,0278,RC,,,,both,,,17748.85,11536.75,,,,,,,,,,,,,
STEM HUM L130MM DIA13MM UNIV DST SHLDR TI PRI REV CEM FOR,SUP-2372855,CDM,C1776,CPT,0278,RC,,,,both,,,11278.57,7331.07,,,,,,,,,,,,,
PIN EXT FIX THRD L20MM DIA3MM SHANK L65MM DIA4MM SH TI,SUP-2342890,CDM,2720000010,LOCAL,0272,RC,,,,both,,,761.45,494.94,,,,,,,,,,,,,
HC Cardiolipin Antibody Each Ig Class,PX-3028614700,CDM,86147,CPT,0302,RC,,,,both,,,138.00,89.70,,,,,,,,,,,,,
VALVE HYDROCEPHALUS 20 A WITH SHUNT ASSISTANT PEDIATRIC PREC,SUP-2821859,CDM,C1889,HCPCS,0278,RC,,,,both,,,9412.21,6117.94,,,,,,,,,,,,,
CATHETER ANGIOPLSTY BLLN L12MM DIA2MM TAKERU GWIRE 0.014IN RAP EXCHG,SUP-2418789,CDM,C1725,HCPCS,0272,RC,,,,both,,,492.98,320.44,,,,,,,,,,,,,
IMPLANT BIO L 3 X W 7 CM FISH SKIN DERMAL FEN 11 INTACT 10/BX,SUP-2909460,CDM,Q4158,HCPCS,0636,RC,,,,both,,,2763.20,1796.08,,,,,,,,,,,,,
IMPLANT OPHTH 1.8X3.75MM SIL RETIN STYL 3084 SL OVL,SUP-2263420,CDM,C1784,HCPCS,0278,RC,,,,both,,,43.96,28.57,,,,,,,,,,,,,
COLLAR CERV UNIV 13 19INCH VISTA TX,SUP-2196896,CDM,L0172,HCPCS,0272,RC,,,,both,,,128.43,83.48,,,,,,,,,,,,,
ALLOGRAFT BNE STRP 15X30 MM FD STRUCTURAL ILIUM ORAGRAFT,SUP-2741058,CDM,C1713,HCPCS,0278,RC,,,,both,,,1307.28,849.73,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.535,SUP-2860052,CDM,C1713,HCPCS,0278,RC,,,,both,,,46155.80,30001.27,,,,,,,,,,,,,
SLING ORTHOT CERV THOR LUMBAR SACR CUST AX,SUP-2435570,CDM,L1010,HCPCS,0274,RC,,,,both,,,236.88,153.97,,,,,,,,,,,,,
SLEEVE DRL OD2MM FOR 2.7MM UNIV GUID,SUP-2194068,CDM,2720000010,LOCAL,0272,RC,,,,both,,,103.31,67.15,,,,,,,,,,,,,
STENT GRFT VASC ANEURX L 165 MM DIA PROX/DSTL 26/15 MM,SUP-2281771,CDM,C1874,HCPCS,0278,RC,,,,both,,,23707.00,15409.55,,,,,,,,,,,,,
TUBE HARV L8MM BNE DWL DISPOSABLE,SUP-2212801,CDM,C1713,HCPCS,0278,RC,,,,both,,,1689.32,1098.06,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 1 CC AMNIO TISS MEMBRN AMNIFLO CRYOPRES,SUP-2423434,CDM,C1762,CPT,0278,RC,,,,both,,,6892.30,4479.99,,,,,,,,,,,,,
ANCHOR SUT W 3 NO 2 HI FI SUTS 17MM LEN 55MM CROSSFT,SUP-2167100,CDM,C1713,HCPCS,0278,RC,,,,both,,,1471.72,956.62,,,,,,,,,,,,,
SCREW BNE L 3 MM DIA1.2 MM 5PK CRANIOFACIAL SD AXS 5PK,SUP-2883346,CDM,C1713,HCPCS,0278,RC,,,,both,,,1586.96,1031.52,,,,,,,,,,,,,
SUBSTITUTE BNE GRFT 100 X 10 X 5 MM 5 CC DEMINERALIZED,SUP-2881963,CDM,C1713,HCPCS,0278,RC,,,,both,,,7002.20,4551.43,,,,,,,,,,,,,
HC Gastrostomy Tube Change W Flouro,PX-3614945000,CDM,49450,CPT,0361,RC,,,,outpatient,,,1056.00,686.40,,,,,,,,,,,,,
ROD EXT FIX THRD 115 MM SS,SUP-2162670,CDM,2720000010,LOCAL,0272,RC,,,,both,,,396.90,257.98,,,,,,,,,,,,,
KIT STRNL CLOSURE DBL CABLE PLATE STRL THORECON,SUP-2894327,CDM,C1713,HCPCS,0278,RC,,,,both,,,4945.50,3214.57,,,,,,,,,,,,,
POROUS KN SYS W/PROLONG POLY,SUP-2212149,CDM,C1776,CPT,0278,RC,,,,both,,,12894.44,8381.39,,,,,,,,,,,,,
MESH HERN COMP 40X24 CM MONOFILAMENT ELLIP X1 SYMBOTEX,SUP-2752207,CDM,C1781,HCPCS,0278,RC,,,,both,,,10400.31,6760.20,,,,,,,,,,,,,
DEFIBRILLATOR IMPL SQ-RX W 65.5 X H 78.2 MM D 15.7 MM 69.9,SUP-2148592,CDM,C1722,HCPCS,0275,RC,,,,both,,,117.53,76.39,,,,,,,,,,,,,
COIL VASC MREYE EMBOLUS L 3 CM DIA 4 MM CATH DIA 0.035 IN,SUP-2170418,CDM,C1889,HCPCS,0278,RC,,,,both,,,323.39,210.20,,,,,,,,,,,,,
SCREW BNE CANC 4X20 MM SELF TAPPING,SUP-2465094,CDM,C1713,HCPCS,0278,RC,,,,both,,,190.44,123.79,,,,,,,,,,,,,
INTRODUCER SHTH SET REINF 75FR 6IN AND DIL FOR SENS 7FR IAB,SUP-2265879,CDM,C1894,HCPCS,0272,RC,,,,both,,,157.53,102.39,,,,,,,,,,,,,
HC US Guidance for Needle Place,PX-4027694200,CDM,76942,CPT,0402,RC,,,,both,,,733.00,476.45,,,,,,,,,,,,,
STEM FEM HIP PRSS FIT REV LT 13.5MM DIA 250MM LEN PRECEDENT,SUP-2211522,CDM,C1776,CPT,0278,RC,,,,both,,,18511.87,12032.72,,,,,,,,,,,,,
WALKER PT L DIAB,SUP-2276715,CDM,L4387,HCPCS,0272,RC,,,,both,,,257.67,167.49,,,,,,,,,,,,,
PLATE BONE L202MM 10 H BILAT S STL COBRA HD LO PROF RIG NEUT,SUP-2185801,CDM,C1713,HCPCS,0278,RC,,,,both,,,2087.10,1356.61,,,,,,,,,,,,,
IMETELSTAT SODIUM 31.4 MG/ML IV SOLN (MIXTURES ONLY)|DISCARDED DRUG NOT ADMINISTE,RX-4082818,CDM,J0870,HCPCS,0636,RC,82959-0112-01,NDC,JW,both,1.5,ML,11242.40,7307.56,,,,,,,,,,,,,
PLATE BNE L27MM 2 H NONSTERILE BILAT TARSOMETATARSAL TI STR,SUP-2181253,CDM,C1713,HCPCS,0278,RC,,,,both,,,2732.93,1776.40,,,,,,,,,,,,,
COLLAR CERV MULT POST BRAC VISTA,SUP-2388138,CDM,L0190,HCPCS,0274,RC,,,,both,,,2380.12,1547.08,,,,,,,,,,,,,
SPACER TIB SM UNIV ANTIBIO REV PRESSFIT INTERSPACE,SUP-2223691,CDM,C1776,CPT,0278,RC,,,,both,,,6908.00,4490.20,,,,,,,,,,,,,
PLATE BNE LCK 5.5X311 MM LT PROX LAT TIB 18 HOLE SS STRL,SUP-2458033,CDM,C1713,HCPCS,0278,RC,,,,both,,,5381.71,3498.11,,,,,,,,,,,,,
SLING URO M SYS INTRO VENTRAL ELEVATION ALEXIS VIRTUE,SUP-2165305,CDM,C1771,HCPCS,0278,RC,,,,both,,,20479.08,13311.40,,,,,,,,,,,,,
PIN FIX 3.2 MM,SUP-2267559,CDM,C1713,HCPCS,0278,RC,,,,both,,,124.97,81.23,,,,,,,,,,,,,
CATHETER EP DBL LOOP 1 MM 7 FRX110 CM INQUIRY,SUP-2867387,CDM,C1731,HCPCS,0278,RC,,,,both,,,5548.38,3606.45,,,,,,,,,,,,,
PLATE BNE L142MM 9 H NONSTERILE R POSTEROLAT DST HUM S STL,SUP-2185905,CDM,C1713,HCPCS,0278,RC,,,,both,,,3386.18,2201.02,,,,,,,,,,,,,
DEFIBRILLATOR IMPL CONTAK RENEWAL TR TI CRT BIV BATTERY PWR,SUP-2140444,CDM,C1882,HCPCS,0275,RC,,,,both,,,77482.64,50363.72,,,,,,,,,,,,,
TRAY PICC CATHETER 6FR 2 LUMN W MICROINTRODUCER MAXIMAL BARR,SUP-2126752,CDM,C1751,HCPCS,0278,RC,,,,both,,,758.62,493.10,,,,,,,,,,,,,
COLLAR CERV 3IN 12 24IN L TRACH OPN W  CHIN SUPP ADJUSTABLE,SUP-2431856,CDM,L0174,HCPCS,0272,RC,,,,both,,,182.91,118.89,,,,,,,,,,,,,
ROD SPNL L200MM DIA35MM OCCIPITOCERVICAL UP THOR CO CHROME,SUP-2285380,CDM,C1713,HCPCS,0278,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
GUIDEWIRE VASC IMAG STR TIP 0018 IN DIA 135 CM LEN 2 CM TIP,SUP-2141241,CDM,C1769,HCPCS,0272,RC,,,,both,,,691.27,449.33,,,,,,,,,,,,,
SPLINT WRST FA AD L11IN UNIV BLU CANVS TRICOT LNR STRP ON,SUP-2194375,CDM,L3908,HCPCS,0272,RC,,,,both,,,20.79,13.51,,,,,,,,,,,,,
RETENTION PLTS RD DVCE 15MM THICK 15MM SSTM,SUP-2681289,CDM,C1713,HCPCS,0278,RC,,,,both,,,2801.82,1821.18,,,,,,,,,,,,,
BIT DRL 3.5 MM VERTELOC DISP,SUP-2431582,CDM,2720000010,LOCAL,0272,RC,,,,both,,,659.40,428.61,,,,,,,,,,,,,
CAGE SPNL 12X20MM TI ANTR LUM THRD REDUC PROF INTERFIX,SUP-2291782,CDM,C1889,HCPCS,0278,RC,,,,both,,,16356.26,10631.57,,,,,,,,,,,,,
STENT PERIPH ABRE L 150 MM DIA10 MM CATH WORKING L 90 CM,SUP-2665375,CDM,C1876,HCPCS,0278,RC,,,,both,,,5322.30,3459.49,,,,,,,,,,,,,
BIT DRL DIA3MM CANN W/O STP NONRADIOLUCENT FOR ORTHOLOC 3DI,SUP-2398329,CDM,2720000010,LOCAL,0272,RC,,,,both,,,461.58,300.03,,,,,,,,,,,,,
PIN FIX L305MM DIA3MM TEMP THRD,SUP-2198628,CDM,C1713,HCPCS,0278,RC,,,,both,,,269.10,174.91,,,,,,,,,,,,,
ROD SPNL L75MM OD5.5MM CVD CONE TIP AUXILIARY MARS,SUP-2229650,CDM,C1713,HCPCS,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
CATHETER INTVASC OCCL CODA L 100 CM DIA 9 FR BALLOON DIA 32,SUP-2167963,CDM,C2628,HCPCS,0272,RC,,,,both,,,1391.02,904.16,,,,,,,,,,,,,
COMPONENT GLEN PE SM BIOMET - SM,SUP-2408631,CDM,C1776,CPT,0278,RC,,,,both,,,6455.84,4196.30,,,,,,,,,,,,,
SCREW BNE LOK HINDFOOT S STL L35MM OD4.5MM SURFIX ADVANSYS,SUP-2243410,CDM,C1713,HCPCS,0278,RC,,,,both,,,1154.45,750.39,,,,,,,,,,,,,
GRAFT HUM TISS SEMITENDINOSUS TEND 20-26X3 CM FD IRRADIATED,SUP-2307129,CDM,C1762,CPT,0278,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
BONE SCREW 2.7MMX12MM,SUP-2841622,CDM,C1713,HCPCS,0278,RC,,,,both,,,109.90,71.43,,,,,,,,,,,,,
SPACER SPNL 10X25/28MM 6DEG SELF EXP INTBDY FUS ELITE,SUP-2354647,CDM,C1821,HCPCS,0278,RC,,,,both,,,10990.00,7143.50,,,,,,,,,,,,,
GRAFT HUM TISS W1XL1CM THK0.5MM PERICARD PTCH ALLGRFT,SUP-2308663,CDM,C1762,CPT,0278,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
SPHERE EMB BEAD BLOCK DIA100-300 UM CATH 0.010 IN 2 ML YEL,SUP-2385092,CDM,C1889,HCPCS,0278,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
ELECTRODE ENDOSCP OD24-28FR 0.35 WIRE 12DEG 30DEG MPLR W/,SUP-2312895,CDM,C1713,HCPCS,0278,RC,,,,both,,,787.57,511.92,,,,,,,,,,,,,
GRAFT EVAR L82MM DIA10X10MM CATH 14FR NIT HI DENS,SUP-2295235,CDM,C1768,CPT,0278,RC,,,,both,,,14601.00,9490.65,,,,,,,,,,,,,
HEAD FEM PRI CERAMIC ON CERAMIC ALUMINA 5 40 36MM DIA +5 NK,SUP-2364460,CDM,C1776,CPT,0278,RC,,,,both,,,3136.86,2038.96,,,,,,,,,,,,,
PLATE BNE L MIC MED 100 DEG 1.5X0.6 MM LT TI LEVEL 1,SUP-2462137,CDM,C1713,HCPCS,0278,RC,,,,both,,,597.60,388.44,,,,,,,,,,,,,
BUR SURG L14CM HD L79MM DIA6MM CYL FLUT L BOR MIDAS REX,SUP-2284381,CDM,C1713,HCPCS,0278,RC,,,,both,,,347.35,225.78,,,,,,,,,,,,,
MICROCATHETER INTRVNTNL 0.021N ID 130CML NTNL BERN ROX2 TRQB,SUP-2652829,CDM,C1887,HCPCS,0272,RC,,,,both,,,1978.20,1285.83,,,,,,,,,,,,,
GENERATOR NEUROSTIMULATOR PULSE SENZA II,SUP-2419569,CDM,C1822,CPT,0278,RC,,,,both,,,58404.00,37962.60,,,,,,,,,,,,,
HC Nephrostogram/Urography Antegrade,PX-3207442500,CDM,74425,CPT,0320,RC,,,,both,,,1485.00,965.25,,,,,,,,,,,,,
STEM FEM CMNTLS 5X145 MM HIP CLS,SUP-2205698,CDM,C1776,CPT,0278,RC,,,,both,,,14197.82,9228.58,,,,,,,,,,,,,
DEVICE PESSARY RNG 5 3 IN W/ KNOB FOLDING,SUP-2421606,CDM,A4562,HCPCS,0274,RC,,,,both,,,109.15,70.95,,,,,,,,,,,,,
INTRODUCER SHTH 0.018 IN 5 FRX13 CM 20 CM CK FLO PERFRMR,SUP-2168767,CDM,C1894,HCPCS,0272,RC,,,,both,,,108.90,70.78,,,,,,,,,,,,,
RASP SPINE SM INTBDY PYRAMETRIX,SUP-2292094,CDM,C1713,HCPCS,0278,RC,,,,both,,,2037.42,1324.32,,,,,,,,,,,,,
COLLAR CERV TRACH OPN ADJ AD 3.25IN 13-16IN M PHIL,SUP-2195170,CDM,L0172,HCPCS,0274,RC,,,,both,,,40.82,26.53,,,,,,,,,,,,,
SCREW BONE L17MM DIA2.3MM CRANIOMAXILLOFACIAL TI CROSSDRIVE,SUP-2262622,CDM,C1713,HCPCS,0278,RC,,,,both,,,89.18,57.97,,,,,,,,,,,,,
WAND IFS COBLATION TOPAZ EZ MICRODEBRIDER,SUP-2341987,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1404.99,913.24,,,,,,,,,,,,,
LEAD PACE CAPSUR L 53 CM DIA 6.6 FR SIL PLAT INSUL STEROID,SUP-2281967,CDM,C1898,HCPCS,0275,RC,,,,both,,,1024.71,666.06,,,,,,,,,,,,,
CATHETER DRAINAGE MP STYL LOOP 038 12X35 CM 16 CM MAC LCK,SUP-2638508,CDM,C1729,HCPCS,0272,RC,,,,both,,,240.96,156.62,,,,,,,,,,,,,
PROSTHESIS OSS L4.5MM OD1.65MM INCUS SGL NOTCH IMP WEHRS,SUP-2312814,CDM,L8613,CPT,0278,RC,,,,both,,,1177.12,765.13,,,,,,,,,,,,,
ANCHOR SUT 0889 MM DIA SGL ARMED S STL LTX FREE,SUP-2168713,CDM,C1713,HCPCS,0278,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
STRUT EXT FIX MED TRNSPRT NS DISP ILIZ,SUP-2933528,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6087.27,3956.73,,,,,,,,,,,,,
STEM FEM STD NK 0/1 HIP ACTIS,SUP-2452985,CDM,C1776,CPT,0278,RC,,,,both,,,615.44,400.04,,,,,,,,,,,,,
PLATE BNE L112MM HK D18MM 7 H R CLAV S STL LOK COMPR FOR,SUP-2185861,CDM,C1713,HCPCS,0278,RC,,,,both,,,3528.26,2293.37,,,,,,,,,,,,,
OMEGA PLUS LAG SCREW 85MM NS,SUP-2706059,CDM,C1713,HCPCS,0278,RC,,,,both,,,1156.31,751.60,,,,,,,,,,,,,
SCREW 4.0MMX40MM  HEADED DART-FIRE,SUP-2857926,CDM,C1713,HCPCS,0278,RC,,,,both,,,2295.34,1491.97,,,,,,,,,,,,,
ANCHOR SUT ETHBND 4-0 DRL BIT OD1.3MM NDL C-1 TAPERPOINT WHT,SUP-2256608,CDM,C1713,HCPCS,0278,RC,,,,both,,,916.88,595.97,,,,,,,,,,,,,
GRAFT BNE SUB 1ML DEMIN BNE MTRX PSTE SYR FRZ DRY DBX,SUP-2306990,CDM,C1713,HCPCS,0278,RC,,,,both,,,605.45,393.54,,,,,,,,,,,,,
ROD ORTH THRD 30 MM PILLAR,SUP-2749915,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1158.66,753.13,,,,,,,,,,,,,
GRAFT EVAR L40X70CM DIA8X8MM AXILLOBIFEMORAL FULL RNGD STD,SUP-2395787,CDM,C1768,CPT,0278,RC,,,,both,,,11680.80,7592.52,,,,,,,,,,,,,
SHEATH ENDOSCP 17 GAX12 IN,SUP-2361475,CDM,C1894,HCPCS,0272,RC,,,,both,,,25.12,16.33,,,,,,,,,,,,,
SUPPORT ORTHOT THOR LUMBAR SACR CUST FULL CORSET,SUP-2435564,CDM,L0974,HCPCS,0274,RC,,,,both,,,494.74,321.58,,,,,,,,,,,,,
GRAFT BONE CHIP FRZ DRY DEMIN CANC CORT 4MM-10MM RANG 15CC,SUP-2294042,CDM,C1713,HCPCS,0278,RC,,,,both,,,527.52,342.89,,,,,,,,,,,,,
BRACE WLK FULL SHELL WLK SM M SHOE SZ 4 7 FEM SHOE SZ 5,SUP-2336094,CDM,L4360,HCPCS,0274,RC,,,,both,,,126.10,81.96,,,,,,,,,,,,,
PLATE BNE RECON 2-2.7X3 MM RT MAND 26 HOLE ANGLED TI GLD,SUP-2480512,CDM,C1713,HCPCS,0278,RC,,,,both,,,8474.48,5508.41,,,,,,,,,,,,,
BLADE SHAVER SERRATED STD 40 DEG 4 MM N DSTL SUCTION STRL,SUP-2648979,CDM,2720000010,LOCAL,0272,RC,,,,both,,,707.63,459.96,,,,,,,,,,,,,
TOOL INSERTION FOR S-ICD ELECTRODE EMBLEM,SUP-2424812,CDM,C1713,HCPCS,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
HC So Chromogenic Ish|NOT REASONABLE AND NECESSARY,PX-3128837766,CDM,88377,CPT,0312,RC,,,GZ,outpatient,,,456.00,296.40,,,,,,,,,,,,,
MESALAMINE 4 G RE ENEM,RX-10535,CDM,6370000000,HCPCS,0637,RC,45802-0098-46,NDC,,both,60,ML,60.30,39.19,,,,,,,,,,,,,
DRILL SURG CLLRD 8 MM ARTHSCP MENIS TRANSPLANTATION,SUP-2608073,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4706.86,3059.46,,,,,,,,,,,,,
DISPOSABLE OSABLES KT FOR BIOUNI,SUP-2120770,CDM,2720000010,LOCAL,0272,RC,,,,both,,,847.80,551.07,,,,,,,,,,,,,
KIT INTRO 9FR L13CM DIA0.118IN SPLITTABLE HEMSTAT ROBUST,SUP-2302497,CDM,C1892,HCPCS,0272,RC,,,,both,,,128.74,83.68,,,,,,,,,,,,,
HC Blood Administration,PX-3913643000,CDM,36430,CPT,0391,RC,,,,both,,,1574.00,1023.10,,,,,,,,,,,,,
BLADE SHV L11CM DIA4MM 5000RPM 40DEG ROT STR SHOT CRV SHFT,SUP-2284147,CDM,2720000010,LOCAL,0272,RC,,,,both,,,763.65,496.37,,,,,,,,,,,,,
PROBE ULTRASOUND TX-BONE,SUP-2418577,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4066.30,2643.09,,,,,,,,,,,,,
CATHETER CV MAXIMAL BARR TY 018 5 FRX16 CM DL J TIP STRL,SUP-2759911,CDM,C1751,HCPCS,0278,RC,,,,both,,,442.08,287.35,,,,,,,,,,,,,
PLATE BNE VOLAR RT 9 HOLE BEAR,SUP-2389760,CDM,C1713,HCPCS,0278,RC,,,,both,,,4584.40,2979.86,,,,,,,,,,,,,
HC So Mtb Pcr,PX-3068755668,CDM,87556,CPT,0306,RC,,,,both,,,438.00,284.70,,,,,,,,,,,,,
PACEMAKER CARD OPTIMIZER SMRT SZ 47.5 X 65.4 X 11.5 MM 30.5,SUP-2639327,CDM,C2621,HCPCS,0275,RC,,,,both,,,72220.00,46943.00,,,,,,,,,,,,,
SCREW BNE CANN 3.5X32 MM HDLSS,SUP-2221505,CDM,C1713,HCPCS,0278,RC,,,,both,,,844.03,548.62,,,,,,,,,,,,,
CATHETER VENTRICULAR ANTIMICROBIAL BACTISEAL BA STRP NS0339,SUP-2666789,CDM,C1729,HCPCS,0272,RC,,,,both,,,1754.26,1140.27,,,,,,,,,,,,,
HC Wrist Min 3 Views,PX-3207311000,CDM,73110,CPT,0320,RC,,,,both,,,562.00,365.30,,,,,,,,,,,,,
GRAFT DURA W3XL3IN THK0.6MM CLLGN MEM DURAMATRIX-ONLAY +,SUP-2165126,CDM,C1763,HCPCS,0278,RC,,,,both,,,1964.54,1276.95,,,,,,,,,,,,,
ANCHOR SUTURE KNOTLESS WITH TWO STRAND OF NUMBER 0 HI FI SUT,SUP-2828610,CDM,C1713,HCPCS,0278,RC,,,,both,,,1728.48,1123.51,,,,,,,,,,,,,
KIT PROC OD44FR 20MM SPHINTOM L260CM OD0035IN GWIRE CHOLGM,SUP-2149824,CDM,C1713,HCPCS,0278,RC,,,,both,,,986.43,641.18,,,,,,,,,,,,,
CLAMP EXT FIX SM TI ALLY COMB MR CONDITIONAL CLP ON SELF,SUP-2188534,CDM,2720000010,LOCAL,0272,RC,,,,both,,,994.53,646.44,,,,,,,,,,,,,
ROD EXT FIX CARBON,SUP-2362750,CDM,C1713,HCPCS,0278,RC,,,,both,,,418.28,271.88,,,,,,,,,,,,,
COIL EMB L8CM DIA4MM 0.0115IN INTCRAN 3D MICROFILAMENT,SUP-2295052,CDM,C1889,HCPCS,0278,RC,,,,both,,,5143.32,3343.16,,,,,,,,,,,,,
STENT GI CATH 10.8FR L138CM TOT L146CM FLNG DIA24MM LUMN,SUP-2149641,CDM,C1874,HCPCS,0278,RC,,,,both,,,14230.48,9249.81,,,,,,,,,,,,,
GRAFT BNE PASTE 5 CC SYR DBM GRFT + 45005P] MEDTRONIC USA INC],SUP-2278375,CDM,C9359,HCPCS,0278,RC,,,,both,,,1782.26,1158.47,,,,,,,,,,,,,
SCREW BNE SELF DRL CANN COMPR TI L36MM L13MM OD3MM APTUS,SUP-2268358,CDM,C1713,HCPCS,0278,RC,,,,both,,,1509.08,980.90,,,,,,,,,,,,,
DEXTROSE 5% IV SOLN NEONATE,RX-40840076,CDM,2580000003,HCPCS,0250,RC,00264-1510-32,NDC,,both,100,ML,21.30,13.84,,,,,,,,,,,,,
FIBER LASER 550 MH HOLM,SUP-2225591,CDM,2720000010,LOCAL,0272,RC,,,,both,,,543.22,353.09,,,,,,,,,,,,,
DILATOR VES L17CM OD5FR 0.038IN GRY INTRO SHTH INPUT TS,SUP-2294506,CDM,C1894,HCPCS,0272,RC,,,,both,,,12.06,7.84,,,,,,,,,,,,,
ANCHOR SUT 5 MM DIA NO 2 SUT ABSRB TWINFIX,SUP-2341597,CDM,C1713,HCPCS,0278,RC,,,,both,,,788.45,512.49,,,,,,,,,,,,,
BIT DRL 2MM INTOSS FIX SYS SLD,SUP-2315897,CDM,2720000010,LOCAL,0272,RC,,,,both,,,570.22,370.64,,,,,,,,,,,,,
DEVICE SUT TEND ACHILLON SYS,SUP-2242921,CDM,C1713,HCPCS,0278,RC,,,,both,,,3747.87,2436.12,,,,,,,,,,,,,
VPAP II ST-A BI-LEVEL CPAP DEV,SUP-2331924,CDM,C1713,HCPCS,0278,RC,,,,both,,,7222.00,4694.30,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP L500CM DIA0.035IN SUP STIFF TAPR DISP FOR,SUP-2149331,CDM,C1769,HCPCS,0272,RC,,,,both,,,358.56,233.06,,,,,,,,,,,,,
SPLINT THMB L FOR 8-9IN WRST L ADJ STAY SPICA 3 DIM MOLDING,SUP-2334802,CDM,L3908,HCPCS,0272,RC,,,,both,,,74.10,48.16,,,,,,,,,,,,,
CATHETER ABLAT 7.5FR L110CM TIP L4MM 2.5MM SPC L CRV STD,SUP-2148489,CDM,C2630,CPT,0272,RC,,,,both,,,5290.90,3439.08,,,,,,,,,,,,,
DEXTROSE 5% IV SOLN NEONATE,RX-40840076,CDM,J7060,HCPCS,0250,RC,00264-7510-20,NDC,,both,250,ML,31.90,20.73,,,,,,,,,,,,,
SUPPORT ORTHOT FT CUST ABDUCTN ROT BAR W/O SHOE,SUP-2435712,CDM,L3150,HCPCS,0272,RC,,,,both,,,230.48,149.81,,,,,,,,,,,,,
GUIDEWIRE ORTH THRD 1.4X150 MM FOR CANN SCREW NS 0333301204,SUP-2789098,CDM,C1769,HCPCS,0272,RC,,,,both,,,1196.84,777.95,,,,,,,,,,,,,
CLINDAMYCIN PHOSPHATE IN D5W 900 MG/50ML IV SOLN,RX-9627,CDM,J0737,HCPCS,0636,RC,00338-3814-50,NDC,,both,50,ML,75.10,48.81,,,,,,,,,,,,,
SEED BRACHYTHERAPY I-125 IOD LOOSE VI PRECONN NDL,SUP-2129001,CDM,C2638,HCPCS,0278,RC,,,,both,,,91.06,59.19,,,,,,,,,,,,,
BENZTROPINE MESYLATE 1 MG/ML IJ SOLN,RX-9259,CDM,J0515,HCPCS,0636,RC,00143-9729-05,NDC,,both,0.5,ML,86.30,56.09,,,,,,,,,,,,,
LOOP DISTR SLDBLE F/RTNTN PLATE 51 582 51/RGD EXTRNL DISTR D,SUP-2491472,CDM,C1713,HCPCS,0278,RC,,,,both,,,550.03,357.52,,,,,,,,,,,,,
GUIDEWIRE VASC DIA.035IN L260CM TAPR COR NIT STIFF 3CM TIP,SUP-2141159,CDM,C1769,HCPCS,0272,RC,,,,both,,,165.70,107.70,,,,,,,,,,,,,
PLATE BNE 4 H LAPIDUS FT SLIM SLOTLOCK TECHNOLOGY,SUP-2883769,CDM,C1713,HCPCS,0278,RC,,,,both,,,5174.72,3363.57,,,,,,,,,,,,,
SHELL ACET CLUS H COCR ALLOY 52MM VITALOCK,SUP-2364618,CDM,C1776,CPT,0278,RC,,,,both,,,2676.85,1739.95,,,,,,,,,,,,,
HC X-Ray Exam Entire Spine 1 Vw,PX-3207208100,CDM,72081,CPT,0320,RC,,,,inpatient,,,969.00,629.85,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 80 CM DIA 5 MM STR STD WALL REINF,SUP-2462070,CDM,C1768,CPT,0278,RC,,,,both,,,1043.77,678.45,,,,,,,,,,,,,
AXLE TIB PROX KNEE MOD ROT HNG MONOGRAM,SUP-2376369,CDM,C1776,CPT,0278,RC,,,,both,,,2460.03,1599.02,,,,,,,,,,,,,
EPINEPHRINE 1 MG/ML IJ SOLN (MIXTURES ONLY),RX-430031,CDM,J0169,HCPCS,0636,RC,42023-0159-25,NDC,,both,0.1,ML,54.10,35.16,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED CMNTLS CERM ON CERM,SUP-2365524,CDM,C1776,CPT,0278,RC,,,,both,,,20738.88,13480.27,,,,,,,,,,,,,
PORT INFUS ODSEC6FR TI POLYUR SGL LUMN ATTACH OPN END,SUP-2127747,CDM,C1788,HCPCS,0278,RC,,,,both,,,678.24,440.86,,,,,,,,,,,,,
BRACE WR AD L LT INSTABILITY INJ LOOP LCK W/ STAY ELAS PUL,SUP-2197949,CDM,L3931,HCPCS,0274,RC,,,,both,,,116.18,75.52,,,,,,,,,,,,,
"HC So Phosphorus, Urine 24 Hr",PX-3018410566,CDM,84105,CPT,0301,RC,,,,both,,,27.00,17.55,,,,,,,,,,,,,
Z DISCONTINUED NO SUB IDED LOCATOR NRV 16HZ SURG STIM HD AND NK,SUP-2163797,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1466.38,953.15,,,,,,,,,,,,,
BAR EXT FIX L200MM DIA6MM C FBR FOR XTRAFIX SYS,SUP-2199718,CDM,2720000010,LOCAL,0272,RC,,,,both,,,734.82,477.63,,,,,,,,,,,,,
GRAFT VASC IMPRA L 50 CM DIA 7 MM EPTFE CENTERFLEX RING HEMO,SUP-2761403,CDM,C1768,CPT,0278,RC,,,,both,,,2282.00,1483.30,,,,,,,,,,,,,
PLATE EXT FIX 3 H SIDEKCK FREE CIR FIX,SUP-2400678,CDM,2720000010,LOCAL,0272,RC,,,,both,,,292.02,189.81,,,,,,,,,,,,,
BUTTON GASTROSTOMY 24FR DIA 2.4INL PULL STEP,SUP-2457354,CDM,2720000010,LOCAL,0272,RC,,,,both,,,544.26,353.77,,,,,,,,,,,,,
NEEDLE SURG CRV W/O CANN FOR BLLN SYS STRL AVAFLEX,SUP-2864563,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1556.37,1011.64,,,,,,,,,,,,,
SHUNT SURG 90 CM PERF LEVEL 1.0 CHMBR DELT,SUP-2628291,CDM,C1729,HCPCS,0272,RC,,,,both,,,6499.02,4224.36,,,,,,,,,,,,,
TI NARROW 8 HOLE PLATE 104MM,SUP-2695589,CDM,C1713,HCPCS,0278,RC,,,,both,,,360.47,234.31,,,,,,,,,,,,,
SPHERE EMB GEL-BEAD DIA 300-500 UM GEL BIORESORBABLE SPHR,SUP-2120485,CDM,C1889,HCPCS,0278,RC,,,,both,,,467.86,304.11,,,,,,,,,,,,,
CATHETER HD 15 FRX19 CM 39 CM HEPARIN PALINDROME PRECIS,SUP-2172341,CDM,C1750,HCPCS,0278,RC,,,,both,,,704.62,458.00,,,,,,,,,,,,,
CATHETER BAL DIL L65CM OD12FR FULL OCCL FOR AORT STENT GRFT,SUP-2395997,CDM,C2628,HCPCS,0272,RC,,,,both,,,1425.56,926.61,,,,,,,,,,,,,
DANAZOL 50 MG PO CAPS,RX-9715,CDM,6370000000,HCPCS,0637,RC,00527-1392-01,NDC,,both,1,UN,11.50,7.47,,,,,,,,,,,,,
PLATE BNE BAR 12 MM 4 H L SHP SMARTLOCK LCK NS,SUP-2883193,CDM,C1713,HCPCS,0278,RC,,,,both,,,1056.74,686.88,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 40 CM DIA 8 MM STR TW REINF,SUP-2525452,CDM,C1768,CPT,0278,RC,,,,both,,,974.84,633.65,,,,,,,,,,,,,
PLATE 95 DEG CONDYLAR 7 HOLES 40MM 124MM,SUP-2547714,CDM,C1713,HCPCS,0278,RC,,,,both,,,3322.03,2159.32,,,,,,,,,,,,,
BRACE ORTH AD XSM L6.5IN FOR 7.25-8IN HND L WRST BLK BOA LOK,SUP-2196532,CDM,L3931,HCPCS,0272,RC,,,,both,,,193.55,125.81,,,,,,,,,,,,,
PLATE POSTLAT DSTL HUM 3.5MM 9H LT 143MM LCP STRL,SUP-2547559,CDM,C1713,HCPCS,0278,RC,,,,both,,,3338.82,2170.23,,,,,,,,,,,,,
HC So Histoplasma Capsulatum,PX-3068738566,CDM,87385,CPT,0306,RC,,,,inpatient,,,315.00,204.75,,,,,,,,,,,,,
STRUT EXT FIX ANGULAR,SUP-2197287,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5934.60,3857.49,,,,,,,,,,,,,
GRAFT FISH-SKIN 7X10CM SURGICLOSE,SUP-2858155,CDM,Q4158,HCPCS,0636,RC,,,,both,,,9256.72,6016.87,,,,,,,,,,,,,
WIRE EXT FIX BUCKLES FOR USE W/ COMP RING ILIZ,SUP-2342267,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1937.13,1259.13,,,,,,,,,,,,,
PLATE BNE 16 H ST BILAT S STL NAR CRV LOK COMPR FOR 45MM SCR,SUP-2178062,CDM,C1713,HCPCS,0278,RC,,,,both,,,3210.05,2086.53,,,,,,,,,,,,,
PACEMAKER CARD SERENA CRT-P MRI SURESCAN W 46.5 X H 59 MM D,SUP-2282508,CDM,C2621,HCPCS,0275,RC,,,,both,,,15072.00,9796.80,,,,,,,,,,,,,
PAPARELLA VENT TUBE 114MM ID SILICONE 30 PACK,SUP-2682415,CDM,L8699,HCPCS,0278,RC,,,,both,,,30.77,20.00,,,,,,,,,,,,,
MESH CRAN W100XL100MM THK0.6MM PNK TI RIG CNTOUR,SUP-2181604,CDM,C1781,HCPCS,0278,RC,,,,both,,,6933.12,4506.53,,,,,,,,,,,,,
PLATE BNE LCK UNIV 3.5 MM 7 HOLE CONTOURED 2 COMPR RECON,SUP-2470716,CDM,C1713,HCPCS,0278,RC,,,,both,,,1386.84,901.45,,,,,,,,,,,,,
COMPONENT FEM SZ 3 L LAT R MED UNI KNEE POLYETH CEM HI PERF,SUP-2249751,CDM,C1776,CPT,0278,RC,,,,both,,,4317.50,2806.37,,,,,,,,,,,,,
ALLOGRAFT BNE CUBE 30 CC FRZN IRRADIATED CANC,SUP-2867098,CDM,C1762,CPT,0278,RC,,,,both,,,1342.35,872.53,,,,,,,,,,,,,
INQUIRY 7F 1120 7 2 10 XXL,SUP-2698829,CDM,C1731,HCPCS,0278,RC,,,,both,,,2829.14,1838.94,,,,,,,,,,,,,
ENDCAP ORTH TI ALLY GRN FOR CANN NAIL,SUP-2192168,CDM,C1713,HCPCS,0278,RC,,,,both,,,740.41,481.27,,,,,,,,,,,,,
DRILL SURG CRWN GAMMA3,SUP-2457416,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2329.88,1514.42,,,,,,,,,,,,,
PLATE BNE L 137 MM SHFT THK 2 MM HD 1.8 MM SCREW DIA2.7/3.5,SUP-2931248,CDM,C1713,HCPCS,0278,RC,,,,both,,,4759.77,3093.85,,,,,,,,,,,,,
NKII REV CONSTRAINED TIBIA INS LT SZ 1/2 9MM,SUP-2510385,CDM,C1776,CPT,0278,RC,,,,both,,,5576.64,3624.82,,,,,,,,,,,,,
PLATE BNE L16MM BLU QUAD FOR GUID GROWTH SYS,SUP-2316409,CDM,C1713,HCPCS,0278,RC,,,,both,,,1188.68,772.64,,,,,,,,,,,,,
GRAFT SYNTHECEL DURA MATER 2 X2 IN (5.0 CM X 5.0 CM),SUP-2719496,CDM,C1763,HCPCS,0278,RC,,,,both,,,1737.99,1129.69,,,,,,,,,,,,,
PURAPLYAM FENESTRATED 4.0X4.0 16 SQ CM,SUP-2635405,CDM,Q4196,HCPCS,0636,RC,,,,both,,,4898.40,3183.96,,,,,,,,,,,,,
HC So Alkaline Phosphatase,PX-3018407566,CDM,84075,CPT,0301,RC,,,,both,,,34.00,22.10,,,,,,,,,,,,,
NAIL INTRMDLLRY LOK CNNLTD UNVRSL 9MM DIA 300MML TTNM ALLOY,SUP-2587505,CDM,C1713,HCPCS,0278,RC,,,,both,,,4384.48,2849.91,,,,,,,,,,,,,
SET ORTHOPEDIC INSTR LISFRANC SYS STRL DISP TRUAIM,SUP-2900810,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2543.40,1653.21,,,,,,,,,,,,,
HC So Histoplasma Capsulatum,PX-3068738566,CDM,87385,CPT,0306,RC,,,,outpatient,,,315.00,204.75,,,,,,,,,,,,,
HC Inj Proc Hip|BILATERAL PROCEDURE,PX-3612709300,CDM,27093,CPT,0361,RC,,,50,outpatient,,,3707.00,2409.55,,,,,,,,,,,,,
PLATE BNE FIBULAR LT 10 HOLE LCK ANAT STRL ALPS LTX,SUP-2861808,CDM,C1713,HCPCS,0278,RC,,,,both,,,3454.13,2245.18,,,,,,,,,,,,,
SCREW BNE CANN 4X12 MM LP TI CAPTURE,SUP-2609544,CDM,C1713,HCPCS,0278,RC,,,,both,,,1006.18,654.02,,,,,,,,,,,,,
INSERT TIB SULCUS 5+ 12 MM LT RT TOT ANK POLYETH INBONE II,SUP-2850362,CDM,C1776,CPT,0278,RC,,,,both,,,3865.34,2512.47,,,,,,,,,,,,,
GRAFT HUM TISS W10MM BISECTED PAT LIG FRZN FLEXIGRFT,SUP-2264727,CDM,C1762,CPT,0278,RC,,,,both,,,7441.33,4836.86,,,,,,,,,,,,,
SHEATH INTRO FAST-CATH L 60 CM CRV DIA18 MM DIA 8.5 MM,SUP-2357205,CDM,C1894,HCPCS,0272,RC,,,,both,,,502.97,326.93,,,,,,,,,,,,,
STENT NEURO NEUROFORM ATLS L 24 MM DIA 3 MM DEL WIRE L 185,SUP-2417549,CDM,C1874,HCPCS,0278,RC,,,,both,,,20943.80,13613.47,,,,,,,,,,,,,
HC Mammo Dgx Bilateral Incl Cad if Perf,PX-4017706600,CDM,77066,CPT,0401,RC,,,,both,,,710.00,461.50,,,,,,,,,,,,,
SHEATH INTRO FLX BLKN L 45 CM OD 6 FR ID 2.2 MM GUIDEWIRE,SUP-2168593,CDM,C1894,HCPCS,0272,RC,,,,both,,,146.20,95.03,,,,,,,,,,,,,
OSS MD TAPERED OSSEOTI AUGMENT,SUP-2506339,CDM,C1776,CPT,0278,RC,,,,both,,,4822.57,3134.67,,,,,,,,,,,,,
PLATE BNE L25.9MM THK1MM 15 H TI SM T SHP FOR 1.5MM SCR,SUP-2411744,CDM,C1713,HCPCS,0278,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
SET INTRO PED 4FR L10CM GWIRE L40CM DIA0018IN NDL 21GA,SUP-2170552,CDM,C1894,HCPCS,0272,RC,,,,both,,,73.98,48.09,,,,,,,,,,,,,
STAPLE SURG W11XL8MM OSSTPL,SUP-2194213,CDM,C1713,HCPCS,0278,RC,,,,both,,,2182.30,1418.49,,,,,,,,,,,,,
STARTER KIT INJECTABLE POLYMER SYSTEM STERILE RAPIDSORB,SUP-2838538,CDM,C1713,HCPCS,0278,RC,,,,both,,,8356.80,5431.92,,,,,,,,,,,,,
INTRODUCER SHTH 7FR L11CM CLSR FAST SET,SUP-2393094,CDM,C1894,HCPCS,0272,RC,,,,both,,,95.77,62.25,,,,,,,,,,,,,
STEM FEM L9IN DIA13.5MM PLATFRM 2.25CM STD 12/14 TAPR L HIP,SUP-2252184,CDM,C1776,CPT,0278,RC,,,,both,,,20628.54,13408.55,,,,,,,,,,,,,
SPLINT WRST XSM AD L8IN FOR 5 65IN R NYL LN FOAM PUL ON,SUP-2276666,CDM,L3908,HCPCS,0274,RC,,,,both,,,18.21,11.84,,,,,,,,,,,,,
MARKER SURG TEND FOR BIOINDUCTIVE IMPL REGENETEN,SUP-2848906,CDM,2720000010,LOCAL,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
HC Bladder Irrig Simple or Continuous,PX-7615170000,CDM,51700,CPT,0761,RC,,,,both,,,935.00,607.75,,,,,,,,,,,,,
PLATE BONE LOK 145MML HLX18 STNLSS STEEL STRGHT RCNSTRCTN ST,SUP-2723637,CDM,C1713,HCPCS,0278,RC,,,,both,,,1804.68,1173.04,,,,,,,,,,,,,
PLATE BNE L221MM THK3MM 14 H BILAT S STL STR LIMIT CNTCT,SUP-2185350,CDM,C1713,HCPCS,0278,RC,,,,both,,,2324.86,1511.16,,,,,,,,,,,,,
BIT DRL DIA2MM STP L12MM QUIK CPL REUSE,SUP-2179420,CDM,2720000010,LOCAL,0272,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
STEM FEM SZ 19 L190MM 131DEG HIP CO CHROM POR STD CLLR STR,SUP-2345221,CDM,C1776,CPT,0278,RC,,,,both,,,20881.00,13572.65,,,,,,,,,,,,,
CATHETER PICC SGL LUMN MST KT INTVENT RAD N PWR INJ N COAT N,SUP-2117115,CDM,C1751,HCPCS,0278,RC,,,,both,,,362.23,235.45,,,,,,,,,,,,,
HC NM Lung Ventilation Imaging,PX-3417857900,CDM,78579,CPT,0341,RC,,,,both,,,3221.00,2093.65,,,,,,,,,,,,,
PRX HUM HI PLT RT 14H 234MM,SUP-2587058,CDM,C1713,HCPCS,0278,RC,,,,both,,,5802.72,3771.77,,,,,,,,,,,,,
FELT SURG W0.5XL4IN THK1.65MM POLY PTFE,SUP-2127687,CDM,C1768,CPT,0278,RC,,,,both,,,235.19,152.87,,,,,,,,,,,,,
STEM WAGNER SL REVISION 135 NK ANGLE 17MM X 190MM,SUP-2505398,CDM,C1776,CPT,0278,RC,,,,both,,,14130.00,9184.50,,,,,,,,,,,,,
NEXGEN ROTATING HINGE ARTICULAR SURFACE D 17MM,SUP-2502560,CDM,C1776,CPT,0278,RC,,,,both,,,4775.94,3104.36,,,,,,,,,,,,,
PLATE BNE FEM 3.5/4.5X388 MM LT PROX 12 HOLE STRL VALCP,SUP-2789624,CDM,C1713,HCPCS,0278,RC,,,,both,,,10174.79,6613.61,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA MAXBARR 4FR 55CM S9274108PD,SUP-2632876,CDM,C1751,HCPCS,0278,RC,,,,both,,,702.76,456.79,,,,,,,,,,,,,
GRAFT BONE VOID FIL CYL MTRX REGENERATIVE TISS 7MMX25MM,SUP-2293938,CDM,C1713,HCPCS,0278,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
STEM RAD DIA8MM 4MM OFFSET STD EL CO CHROM ANAT,SUP-2107873,CDM,C1776,CPT,0278,RC,,,,both,,,5692.82,3700.33,,,,,,,,,,,,,
BLADE SCRWDRVR 2MM/2.3MM DIA 94MML CROSS DRIVE RTCHTD F/2.0/,SUP-2494974,CDM,2720000010,LOCAL,0272,RC,,,,both,,,462.96,300.92,,,,,,,,,,,,,
CARTRIDGE SEED MICK CESIUM 131 DISP,SUP-2247307,CDM,C2643,HCPCS,0278,RC,,,,both,,,213.52,138.79,,,,,,,,,,,,,
PLATE BONE L92MM 5 H S STL BROAD SELF COMPR,SUP-2198604,CDM,C1713,HCPCS,0278,RC,,,,both,,,369.04,239.88,,,,,,,,,,,,,
INSERT ACET OD52MM ID28MM HIP ULTAMET LCK RNG ALTERNATIVE,SUP-2250325,CDM,C1776,CPT,0278,RC,,,,both,,,7693.00,5000.45,,,,,,,,,,,,,
PIN EXT FIX L180MM DIA5MM HALF QUIK CONN FOR RNG FIX SYS,SUP-2316103,CDM,C1713,HCPCS,0278,RC,,,,both,,,435.96,283.37,,,,,,,,,,,,,
MESH HERN RECTANGULAR 20X20 CM PREPERITONEAL ENFORM,SUP-2459009,CDM,C1781,HCPCS,0278,RC,,,,both,,,16711.08,10862.20,,,,,,,,,,,,,
DRILL TWST L 50 MM DIA 0.7 MM STP 3 MM NTC FOR 1 MM SYS NS,SUP-2934746,CDM,2720000010,LOCAL,0272,RC,,,,both,,,514.96,334.72,,,,,,,,,,,,,
TROCAR SURG L13MM DIA32MM FOR DST FEM NAIL,SUP-2188208,CDM,C1713,HCPCS,0278,RC,,,,both,,,735.55,478.11,,,,,,,,,,,,,
HC Cryptosporidium,PX-3008732866,CDM,87328,CPT,0300,RC,,,,both,,,127.00,82.55,,,,,,,,,,,,,
ELECTRODE ELECSURG LOOP W/ CABLE HF-RESECTION PLASMA BUTTON,SUP-2430209,CDM,C1713,HCPCS,0278,RC,,,,both,,,1600.83,1040.54,,,,,,,,,,,,,
SUPPORT ORTHOT KNEE LOWER EXTREMITY CUST OFFSET HVY DTY,SUP-2435667,CDM,L2395,HCPCS,0274,RC,,,,both,,,414.17,269.21,,,,,,,,,,,,,
FLOTUFOLASTAT F 18 GALLIUM 296-5846 MBQ/ML IV SOLN,RX-163890,CDM,A9608,HCPCS,0343,RC,69932-0002-01,NDC,,both,1,UN,21374.80,13893.62,,,,,,,,,,,,,
PLATE BNE L59MM THK2.4MM 18 H LOK COMPR WRST FUS SHT BEND,SUP-2267979,CDM,C1713,HCPCS,0278,RC,,,,both,,,7560.81,4914.53,,,,,,,,,,,,,
"HC So West Nile Ab, Igm",PX-3028678866,CDM,86788,CPT,0302,RC,,,,both,,,49.00,31.85,,,,,,,,,,,,,
TUBE ET ID6.5MM PVC NSL ORAL SGL LUMN LO PRSS CUF TAPR,SUP-2383844,CDM,2720000010,LOCAL,0272,RC,,,,both,,,62.80,40.82,,,,,,,,,,,,,
BIT DRL L70MM DIA2.6MM FOR CLAVICULAR LOK PLT SYS,SUP-2378012,CDM,2720000010,LOCAL,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
CATHETER EP H LG CRV 5 MM 1 MM 7 FRX110 CM,SUP-2357429,CDM,C1730,HCPCS,0272,RC,,,,both,,,1858.85,1208.25,,,,,,,,,,,,,
PLATE EXT FIX L160MM FT DBL H FOR SIDEKCK FRDM CIR FIX,SUP-2400651,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3579.60,2326.74,,,,,,,,,,,,,
TUBE VENT 1.14 MM 1.17 MM 2.54 MM PHOSPHORYLCHOLINE COAT SIL,SUP-2535105,CDM,L8699,HCPCS,0278,RC,,,,both,,,63.68,41.39,,,,,,,,,,,,,
CATHETER ANGIOPLSTY ANGIOSCULPT EVO 139CM 5FR 15MM 2.5 MM,SUP-2353215,CDM,C1725,HCPCS,0272,RC,,,,both,,,2763.20,1796.08,,,,,,,,,,,,,
POWERPICC PROVENA SOLO FT 5 FR 2 LUMAN CATH MAXBARR TY WTH S,SUP-2613531,CDM,C1751,HCPCS,0278,RC,,,,both,,,772.13,501.88,,,,,,,,,,,,,
FENTANYL CITRATE-NACL 2.5-0.9 MG/250ML-% IJ SOLN,RX-155622,CDM,J7999,HCPCS,0636,RC,69374-0523-25,NDC,,both,250,ML,198.40,128.96,,,,,,,,,,,,,
GRAFT BIO TISS W4XL8CM THK1 2MM PROLAYER,SUP-2362231,CDM,C1763,HCPCS,0278,RC,,,,both,,,8694.03,5651.12,,,,,,,,,,,,,
SCREW BNE SM BNE SYS TCP SYS,SUP-2457686,CDM,C1713,HCPCS,0278,RC,,,,both,,,2772.62,1802.20,,,,,,,,,,,,,
"HC So Selenium, Serum",PX-3018425566,CDM,84255,CPT,0301,RC,,,,both,,,744.00,483.60,,,,,,,,,,,,,
MESH SURG W8XL12CM THK1MM BIOMATERIAL OVL ANTIMIC GORE,SUP-2395339,CDM,C1781,HCPCS,0278,RC,,,,both,,,1186.92,771.50,,,,,,,,,,,,,
PATCH BIO TISS W10XL16CM BOV PERICARD CROSS LINKED,SUP-2130367,CDM,C1768,CPT,0278,RC,,,,both,,,2836.71,1843.86,,,,,,,,,,,,,
BUR SURG SHT EXTN CEBOTOME,SUP-2607450,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4341.99,2822.29,,,,,,,,,,,,,
VALVE AORT SM 21ML SUTURELESS PERCEVAL,SUP-2352660,CDM,C1889,HCPCS,0278,RC,,,,both,,,28260.00,18369.00,,,,,,,,,,,,,
ENDOPROSTHESIS VASC VIABAHN VBX 79 MM 8/16MM 135 CM 8 FR LNR,SUP-2395715,CDM,C1874,HCPCS,0278,RC,,,,both,,,11049.66,7182.28,,,,,,,,,,,,,
PLATE BNE ACTIVE COMPR BROAD 4.5 MM 7 HOLE NS,SUP-2525139,CDM,C1713,HCPCS,0278,RC,,,,both,,,568.34,369.42,,,,,,,,,,,,,
PLATE BNE STR 1.5X100 MM 20 HOLE FOR MINI FRAG SYS SS NS,SUP-2478771,CDM,C1713,HCPCS,0278,RC,,,,both,,,600.27,390.18,,,,,,,,,,,,,
USTEKINUMAB-KFCE 130 MG/26ML IV SOLN|DISCARDED DRUG NOT ADMINISTE,RX-170465,CDM,Q5100,HCPCS,0636,RC,83257-0026-11,NDC,JW,both,52,ML,2360.00,1534.00,,,,,,,,,,,,,
HC Mech Rem Fibrin via Sep Acces,PX-3613659500,CDM,36595,CPT,0361,RC,,,,inpatient,,,8583.00,5578.95,,,,,,,,,,,,,
HC Immunoglobulin Light Chains Free Each,PX-3018352100,CDM,83521,CPT,0301,RC,,,,inpatient,,,88.00,57.20,,,,,,,,,,,,,
WIRE FIX 2X150 MM TROCAR PT ON BOTH ENDS SS NS KIRSCHNER,SUP-2186879,CDM,C1713,HCPCS,0278,RC,,,,both,,,290.07,188.55,,,,,,,,,,,,,
ELECTRODE PRB HEMSTAS DSTL IRR 30CM BICAP,SUP-2312982,CDM,2720000010,LOCAL,0272,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
PLATE BNE BURR HOLE CVR 17X3X1.5 MM LP CONTOURED TI NS,SUP-2539567,CDM,C1713,HCPCS,0278,RC,,,,both,,,724.77,471.10,,,,,,,,,,,,,
PLATE BNE L122MM 4 H NONSTERILE R DST HUM EXTRA ARTC S STL,SUP-2184041,CDM,C1713,HCPCS,0278,RC,,,,both,,,3260.39,2119.25,,,,,,,,,,,,,
MESH HERN ELLIPSE 15X10 CM W/ ECHO 2 POS SYS VENTRALIGHT ST,SUP-2126502,CDM,C1781,HCPCS,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
LIGATOR ENDO L122CM DIA9.5-11.5MM 6 BND RECESS 6 SHOT SAEED,SUP-2169499,CDM,C1713,HCPCS,0278,RC,,,,both,,,731.62,475.55,,,,,,,,,,,,,
CANN SCRW THD 3.0X22MM,SUP-2586789,CDM,C1713,HCPCS,0278,RC,,,,both,,,453.01,294.46,,,,,,,,,,,,,
DEVICE TISS REMOVINGXL 17OZ L25.25IN DIA4MM ROD LENS,SUP-2239919,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4223.30,2745.14,,,,,,,,,,,,,
PLATE BNE L 100 DEG STD 1.7X5X0.55 MM RT 5 HOLE BAR MALL,SUP-2366245,CDM,C1713,HCPCS,0278,RC,,,,both,,,637.95,414.67,,,,,,,,,,,,,
PIN DRL L9.5MM KNEE GUID RG RMR FLIPCUTTER II,SUP-2120819,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
SET SCREW SPNL R 45 MM CARBON FIBER PEDCL LCK ELEMENT FOR,SUP-2883022,CDM,C1713,HCPCS,0278,RC,,,,both,,,2983.00,1938.95,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC BONE STABILIZATION SYSTEM 22/13 X 260MM,SUP-2881213,CDM,C1713,HCPCS,0278,RC,,,,both,,,16924.60,11000.99,,,,,,,,,,,,,
DEFIBRILLATOR CARD 36ML PARYLENE DF-1 IS-1 SENSE PACE CONN,SUP-2356320,CDM,C1882,HCPCS,0275,RC,,,,both,,,50240.00,32656.00,,,,,,,,,,,,,
PATELLA COMP BTTN 20MM 2.5MM X 2.5MM CE,SUP-2123674,CDM,C1776,CPT,0278,RC,,,,both,,,1857.88,1207.62,,,,,,,,,,,,,
CATHETER ABLATN D CRV 1-4-1 MM 4 MM 8 FRX115 CM FLEXABILITY,SUP-2463718,CDM,C2630,CPT,0272,RC,,,,both,,,7432.38,4831.05,,,,,,,,,,,,,
CATHETER INTVASC ULTRASOUND OPTICROSS WORKING L 135 MM,SUP-2146960,CDM,C1753,HCPCS,0278,RC,,,,both,,,2442.42,1587.57,,,,,,,,,,,,,
SET URET STENT SOFFLX BANDER L 8-12 CM DIA 3 FR POS L 25 CM,SUP-2826945,CDM,C2617,HCPCS,0278,RC,,,,both,,,398.59,259.08,,,,,,,,,,,,,
CONNECTOR ROD OFFSET,SUP-2381437,CDM,C1713,HCPCS,0278,RC,,,,both,,,989.10,642.91,,,,,,,,,,,,,
SCREW BNE ST 2X6 MM CRTX COARSE PITCH TI GLD PLUSDRIVE LF,SUP-2189327,CDM,C1713,HCPCS,0278,RC,,,,both,,,265.96,172.87,,,,,,,,,,,,,
SHEET FACE IMPL N REINF NOM THICKNESS 1MM W6 6.5X6.5,SUP-2395378,CDM,C1771,HCPCS,0278,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
ALLOGRAFT BNE FD IRRADIATED HUM SHFT,SUP-2867170,CDM,C1762,CPT,0278,RC,,,,both,,,7731.94,5025.76,,,,,,,,,,,,,
PLATE BNE T 2X18 MM 2 HOLE SS,SUP-2569097,CDM,C1713,HCPCS,0278,RC,,,,both,,,134.71,87.56,,,,,,,,,,,,,
PLATE BNE L234MM THK37MM 18 H BILAT S STL STR LO PROF RIG,SUP-2177149,CDM,C1713,HCPCS,0278,RC,,,,both,,,2899.26,1884.52,,,,,,,,,,,,,
KIT HDSET COMM SMRT PRGMR GU PROX US INTERSTIM,SUP-2281684,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5809.00,3775.85,,,,,,,,,,,,,
SCREW SPNL ROD DIA 5.5/6 MM SS REDUCTION UNIAXIAL STRL CD 2PK,SUP-2928048,CDM,C1713,HCPCS,0278,RC,,,,both,,,5683.40,3694.21,,,,,,,,,,,,,
SCREW BNE LAG 125 MM 100 MM ASMBLY NS PEAK FX,SUP-2474818,CDM,C1713,HCPCS,0278,RC,,,,both,,,1105.28,718.43,,,,,,,,,,,,,
RING EXT FIX APCL SEW CENTERING,SUP-2356025,CDM,C1713,HCPCS,0278,RC,,,,both,,,1962.47,1275.61,,,,,,,,,,,,,
NEEDLE BNE MAR RECOVERY 8 GA THRD CLOSED TIP STRL BONESYNC,SUP-2859822,CDM,2720000010,LOCAL,0272,RC,,,,both,,,635.85,413.30,,,,,,,,,,,,,
CATHETER CV DL 5 FRX50 CM MAXIMAL BARR W/ VPS STYL,SUP-2120613,CDM,C1751,HCPCS,0278,RC,,,,both,,,886.89,576.48,,,,,,,,,,,,,
ATOVAQUONE 750 MG/5ML PO SUSP,RX-14953,CDM,340b,HCPCS,0637,RC,00904-7064-41,NDC,,both,5,ML,142.80,92.82,,,,,,,,,,,,,
BLADE SHV OD4.5MM ENDO BOXED CONCV INCIS,SUP-2341410,CDM,2720000010,LOCAL,0272,RC,,,,both,,,219.80,142.87,,,,,,,,,,,,,
CATHETER DIAG 2.4X1.7FR L150CM ID0.0165IN 45DEG MIC,SUP-2367862,CDM,C1887,HCPCS,0272,RC,,,,both,,,8286.46,5386.20,,,,,,,,,,,,,
PLATE BNE L131MM 6 H NONSTERILE R PROX ULN EXTRA ARTC S STL,SUP-2177197,CDM,C1713,HCPCS,0278,RC,,,,both,,,3726.83,2422.44,,,,,,,,,,,,,
GRAFT BNE GRAN 10 CC RESRB MACR CALCIUM PHOSPHATE VITOSS,SUP-2368171,CDM,C1713,HCPCS,0278,RC,,,,both,,,14444.00,9388.60,,,,,,,,,,,,,
KIT ARTHSCP FIBROCARTILAGE REP TRIANG COMPLX GWIRE DRL BIT,SUP-2122599,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
SET INTRO SUP ARW FLX SHTH L 80 CM DIA10 FR HYDRPHLC,SUP-2894394,CDM,C1894,HCPCS,0272,RC,,,,both,,,489.84,318.40,,,,,,,,,,,,,
STAPLE BNE FIX 30X7MM BRDG 4 20MM LEG Y SHP IMPL,SUP-2194192,CDM,C1713,HCPCS,0278,RC,,,,both,,,5748.84,3736.75,,,,,,,,,,,,,
PROBLE SURG 8IN INSUL TRANSCONTINENTAL,SUP-2417903,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1023.64,665.37,,,,,,,,,,,,,
SYRINGE ASPIR 20ML BONE MAR PROCURE,SUP-2194027,CDM,C1713,HCPCS,0278,RC,,,,both,,,430.18,279.62,,,,,,,,,,,,,
PLATE BNE L50MM S STL 4 H T SHP FOR 2MM SCR MINI FRAG SYS,SUP-2199357,CDM,C1713,HCPCS,0278,RC,,,,both,,,569.22,369.99,,,,,,,,,,,,,
BUTTON SUTURE TIB STD INFIN DISP,SUP-2846787,CDM,C1713,HCPCS,0278,RC,,,,both,,,1195.71,777.21,,,,,,,,,,,,,
COLLAR CERV MED DENS 2XS PEDIATRIC 14X2 IN FRM FIT PROCARE,SUP-2195744,CDM,L0120,HCPCS,0272,RC,,,,both,,,10.83,7.04,,,,,,,,,,,,,
PLATE BNE L99MM 5 H L DST LAT FIBULAR S STL LOK COMPR FOR,SUP-2184158,CDM,C1713,HCPCS,0278,RC,,,,both,,,1672.36,1087.03,,,,,,,,,,,,,
GRAFT HUM TISS DIA15MM OSTEOCHNDRL CHONDROFIX,SUP-2200261,CDM,C1713,HCPCS,0278,RC,,,,both,,,12183.20,7919.08,,,,,,,,,,,,,
INTRODUCER FLEX URETEROSCOPY 11FRX40CM,SUP-2171263,CDM,C1894,HCPCS,0272,RC,,,,both,,,316.51,205.73,,,,,,,,,,,,,
ANTEROLATERAL PILON FUSION PLATE 9H LT,SUP-2815227,CDM,C1713,HCPCS,0278,RC,,,,both,,,11932.00,7755.80,,,,,,,,,,,,,
STRIP BONE GRAFT VIASORB 10MM X 50MM X 5MM ALLOGRAFT DBM,SUP-2893589,CDM,C1713,HCPCS,0278,RC,,,,both,,,1736.42,1128.67,,,,,,,,,,,,,
PERI-LOC 4.5MM T25 TI LCK SCREW 48MM S-T,SUP-2819594,CDM,C1713,HCPCS,0278,RC,,,,both,,,1260.96,819.62,,,,,,,,,,,,,
PLATE BASE PHLANG 2H HD 6H SHFT TI STRL VAL,SUP-2546911,CDM,C1713,HCPCS,0278,RC,,,,both,,,1843.24,1198.11,,,,,,,,,,,,,
KNIFE SURG HOUGH WHIRLYBIRD 2 LT LIGHT CRV MICROFRANCE,SUP-2461334,CDM,2720000010,LOCAL,0272,RC,,,,both,,,390.58,253.88,,,,,,,,,,,,,
SHEATH INTRO PERFRMR L 45 CM OD 7 FR ID 2.3 MM GUIDEWIRE,SUP-2168689,CDM,C1894,HCPCS,0272,RC,,,,both,,,132.70,86.25,,,,,,,,,,,,,
HC Fluoroscopy Up to 1 Hour,PX-3207600000,CDM,76000,CPT,0320,RC,,,,outpatient,,,714.00,464.10,,,,,,,,,,,,,
CARTRIDGE 37X14X8 BI CONVX LORODTIC EXP IMPL 9 WAFERS,SUP-2354684,CDM,C1713,HCPCS,0278,RC,,,,both,,,22356.80,14531.92,,,,,,,,,,,,,
BIT DRL L125MM DIA2MM S STL QUIK CPL FOR LOK COMPR PLT,SUP-2187216,CDM,2720000010,LOCAL,0272,RC,,,,both,,,387.76,252.04,,,,,,,,,,,,,
GRAFT BNE SUB SM 20CC DBM BIOCOMPOSITE OSTEOSET CANC CHIP,SUP-2399075,CDM,C9359,HCPCS,0278,RC,,,,both,,,6774.80,4403.62,,,,,,,,,,,,,
EXTENSION GUIDEWIRE L 165 CM DIA 0.014 IN STR TIP FOR PTCA,SUP-2123749,CDM,C1769,HCPCS,0272,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
BUPIVACAINE-EPINEPHRINE 0.25% -1:200000 IJ SOLN (MIXTURES ONLY),RX-430034,CDM,2500000003,HCPCS,0250,RC,63323-0468-37,NDC,,both,30,ML,69.60,45.24,,,,,,,,,,,,,
HC Assay of Sex Hormone Binding Globulin,PX-3018427000,CDM,84270,CPT,0301,RC,,,,inpatient,,,465.00,302.25,,,,,,,,,,,,,
CATHETER HD STR 11.5 FRX15 CM SHT TERM DL SET SOFT-LINE,SUP-2627330,CDM,C1752,HCPCS,0278,RC,,,,both,,,196.25,127.56,,,,,,,,,,,,,
HC So Flt3 Gene Analysis,PX-3108124666,CDM,81246,CPT,0310,RC,,,,both,,,110.00,71.50,,,,,,,,,,,,,
PROVOX VEGA VOICE PROS IS AN INDWL LO RESISTANCE VOICE PROS,SUP-2124400,CDM,L8509,HCPCS,0274,RC,,,,both,,,963.98,626.59,,,,,,,,,,,,,
GRAFT HUM TISS 2CC ACELLULAR DERM MTRX GRFTJACKET RTM,SUP-2262295,CDM,C1713,HCPCS,0278,RC,,,,both,,,6079.04,3951.38,,,,,,,,,,,,,
SYSTEM PACEMKR 23FR L105CM TRANSCATHETER MICRA,SUP-2281167,CDM,C1786,HCPCS,0275,RC,,,,both,,,60602.00,39391.30,,,,,,,,,,,,,
Z DISCONTINUED USE 2753109 KIT PRB 17GA L75MM COOLED RF NONSURGICAL MINIMALLY INVASIVE,SUP-2236751,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
VALVE PRESSURE PUDENZ 12 MM ANTISIPH DEV HI,SUP-2666753,CDM,C1889,HCPCS,0278,RC,,,,both,,,2760.09,1794.06,,,,,,,,,,,,,
TUBE MYR DIA1.14MM 0.045 BVL FLROPLAS VENT ARMSTR GRMMT,SUP-2312541,CDM,L8699,HCPCS,0278,RC,,,,both,,,58.00,37.70,,,,,,,,,,,,,
ORTHOSIS LUMSACR PREFABRICATED SAG CTRL SACROCOCCYGEAL,SUP-2237268,CDM,L0648,HCPCS,0274,RC,,,,both,,,3128.51,2033.53,,,,,,,,,,,,,
GUIDEWIRE ORTH RETICLE NEUROVISION M5 SYS,SUP-2310422,CDM,C1769,HCPCS,0272,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
STENT URIN DIV SUBQ CLS TIP 2 DIL 0.038IN STR GWIRE 8FR,SUP-2139083,CDM,C2617,HCPCS,0278,RC,,,,both,,,652.71,424.26,,,,,,,,,,,,,
PLATE BNE L25MM 4 H T POLYAX COMPR CLAW II,SUP-2397467,CDM,C1713,HCPCS,0278,RC,,,,both,,,3033.24,1971.61,,,,,,,,,,,,,
HC Inj Proc Hip,PX-3612709300,CDM,27093,CPT,0361,RC,,,,inpatient,,,3707.00,2409.55,,,,,,,,,,,,,
SODIUM CHLORIDE 0.45 % IV SOLN,RX-7318,CDM,J3490,HCPCS,0258,RC,00264-7802-00,NDC,,both,1000,ML,34.00,22.10,,,,,,,,,,,,,
STEM FEM SZ 1 L100MM NK L31MM 34MM OFFSET 132DEG HIP FORGED,SUP-2375348,CDM,C1776,CPT,0278,RC,,,,both,,,6428.21,4178.34,,,,,,,,,,,,,
MESH SURGICAL 3.8CM X 5CM MATRIX RESTRATA,SUP-2874118,CDM,A2007,HCPCS,0636,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
IMMUNE GLOBULIN (GAMMAGARD) 10%,RX-4081758,CDM,J1569,HCPCS,0636,RC,00944-2700-04,NDC,,both,50,ML,2575.50,1674.07,,,,,,,,,,,,,
BLADE RETRACTOR 7 CM MEDL LAT WIDE BLADE MAST QUAD,SUP-2631646,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1751.18,1138.27,,,,,,,,,,,,,
HYDROXYCHLOROQUINE SULFATE 200 MG PO TABS,RX-10235,CDM,6370000000,HCPCS,0637,RC,69238-1544-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
ALLOGRAFT BNE STRP 10X20X2 MM FD SPNG CANC READIGRAFT BLX,SUP-2741064,CDM,C1713,HCPCS,0278,RC,,,,both,,,1199.23,779.50,,,,,,,,,,,,,
BUPIVACAINE-EPINEPHRINE 0.25% -1:200000 IJ SOLN (MIXTURES ONLY),RX-430034,CDM,2500000003,HCPCS,0250,RC,63323-0468-17,NDC,,both,10,ML,54.10,35.16,,,,,,,,,,,,,
IMMOBILIZER KNEE L23IN UNIV AD WRP ARND OPN PAT WIND ADJ,SUP-2136226,CDM,L1830,CPT,0272,RC,,,,both,,,112.41,73.07,,,,,,,,,,,,,
ROD DISTR VRTCL 150MML CRBN F/RGD EXTRNL DISTR RED II,SUP-2489602,CDM,C1713,HCPCS,0278,RC,,,,both,,,1221.62,794.05,,,,,,,,,,,,,
STEM FEM L165MM OD11MM 100% POR PLSM SPRY DSTL CALCAR MOD,SUP-2404002,CDM,C1776,CPT,0278,RC,,,,both,,,5915.76,3845.24,,,,,,,,,,,,,
IMPLANT BIO TISS 4X7CM SM SURG TEND INTEGRA REINF MTRX,SUP-2244429,CDM,C1781,HCPCS,0278,RC,,,,both,,,7195.75,4677.24,,,,,,,,,,,,,
ALLOGRAFT BNE SPACER 16X14X7 MM PARL CC-ACS,SUP-2736995,CDM,C1713,HCPCS,0278,RC,,,,both,,,2904.50,1887.92,,,,,,,,,,,,,
PROSTHESIS OSS L 5 MM SHFT DIA1.14 MM HD DIA 4 MM HA PART,SUP-2902034,CDM,L8613,CPT,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
STENT BILI ROYAL L 19 MM DIA 6 FR CATH L 90 CM DIA 6 MM AD,SUP-2141185,CDM,C1876,HCPCS,0278,RC,,,,both,,,4066.30,2643.09,,,,,,,,,,,,,
SYSTEM VASC FILTER XS INTAORT FILTRATION STRL,SUP-2214491,CDM,C1884,HCPCS,0278,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP STR 035X480 15 CM MOVEABLE PUR TRCE HYBRID,SUP-2759262,CDM,C1769,HCPCS,0272,RC,,,,both,,,379.94,246.96,,,,,,,,,,,,,
HEAD HUM H17MM DIA48MM TI STD OFFSET PRI FOR SHLDR FX SYS,SUP-2123279,CDM,C1776,CPT,0278,RC,,,,both,,,3925.00,2551.25,,,,,,,,,,,,,
PLATE BNE STR SM LT,SUP-2398594,CDM,C1713,HCPCS,0278,RC,,,,both,,,5940.88,3861.57,,,,,,,,,,,,,
PEGFILGRASTIM-FPGK 6 MG/0.6ML SC SOSY,RX-161037,CDM,Q5127,HCPCS,0636,RC,65219-0371-10,NDC,,both,.6,ML,12685.80,8245.77,,,,,,,,,,,,,
GRAFT EVAR L18CM AORT OD28.5MM ID24-26MM IL OD12MM,SUP-2395988,CDM,C1768,CPT,0278,RC,,,,both,,,24426.06,15876.94,,,,,,,,,,,,,
GRAFT HUM TISS THN 4X4 CM AMNIO TISS MEMBRN ACTISHIELD CF,SUP-2422261,CDM,C1762,CPT,0278,RC,,,,both,,,6292.56,4090.16,,,,,,,,,,,,,
COIL NEUROVASCULAR OPTIMAX L 1 CM DIA1 MM COMPLX SUPER SFT,SUP-2743542,CDM,C1889,HCPCS,0278,RC,,,,both,,,7206.30,4684.09,,,,,,,,,,,,,
GUIDEWIRE VASC L150CM DIA0.035IN TAPR 3CM HYDRPHLC NIT STR,SUP-2148167,CDM,C1769,HCPCS,0272,RC,,,,both,,,112.41,73.07,,,,,,,,,,,,,
BLOCK CUT RT FEM TIB GUID LCK OUT KT JBCS VISIONAIRE JOURNEY,SUP-2351442,CDM,C1713,HCPCS,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
GUIDEWIRE VASC PULSE SPRY L 60 CM DIA 0.035 IN FLPY TIP L 2,SUP-2118467,CDM,C1769,HCPCS,0272,RC,,,,both,,,241.15,156.75,,,,,,,,,,,,,
INSTRUMENT SET LNG BASIC T2,SUP-2460755,CDM,C1713,HCPCS,0278,RC,,,,both,,,31413.82,20418.98,,,,,,,,,,,,,
TWIST DRILL15X115MM W/NOTCH9MM STOP,SUP-2682163,CDM,2720000010,LOCAL,0272,RC,,,,both,,,502.81,326.83,,,,,,,,,,,,,
CATHETER URET LSR 3.0FRX115CM,SUP-2171264,CDM,C1758,HCPCS,0278,RC,,,,both,,,48.07,31.25,,,,,,,,,,,,,
KIT DRN L5IN DIA1/8IN PVC TRCR CLS WND COMP EVAC HEMVAC SYS,SUP-2198689,CDM,C1729,HCPCS,0272,RC,,,,both,,,190.60,123.89,,,,,,,,,,,,,
NEEDLE SUT L2.087IN DIA0.043IN S STL REG SURG 1/2 CIR RVS,SUP-2124112,CDM,2720000010,LOCAL,0272,RC,,,,both,,,518.07,336.75,,,,,,,,,,,,,
SPLINT CLAVICLEXSM INF W4XL52CM BCKL STRP CNTCT CLSR PD,SUP-2197367,CDM,L3650,HCPCS,0274,RC,,,,both,,,48.98,31.84,,,,,,,,,,,,,
SEGMENT EXT FIX MOD RT FOR RED II ALUM 515800204,SUP-2463039,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7770.28,5050.68,,,,,,,,,,,,,
PROBE ABLAT XL 90DEG ASPIR BPLR RF 1 PC ELECTRD ERGO HNDL,SUP-2123449,CDM,2720000010,LOCAL,0272,RC,,,,both,,,596.60,387.79,,,,,,,,,,,,,
HC Ot Manual Therapy per 15 Min.|DOCUMENTATION ON FILE|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS,PX-4309714000,CDM,97140,CPT,0430,RC,,,KX|CQ,outpatient,,,194.00,126.10,,,,,,,,,,,,,
LEAD NEUROSTIMULATOR L43CM DIA2MM VAGUS NRV SIL BPLR HELI,SUP-2265173,CDM,C1778,HCPCS,0278,RC,,,,both,,,27497.29,17873.24,,,,,,,,,,,,,
STRUT EXT FIX L158 318MM LNG QUIK ADJ FOR RNG FIX SYS,SUP-2316070,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3664.00,2381.60,,,,,,,,,,,,,
BIT DRL 3 FLUT 4.2X145 MM QC NDL PT,SUP-2432345,CDM,2720000010,LOCAL,0272,RC,,,,both,,,513.39,333.70,,,,,,,,,,,,,
HC Inj Neurolytic Epi Cerv/Dor,PX-3616228100,CDM,62281,CPT,0361,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
SHEATH INTRO PEELWY L 15.5 CM DIA 8 FR GUIDEWIRE 0.035 IN,SUP-2167816,CDM,C1894,HCPCS,0272,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
OXYCODONE HCL ER 40 MG PO T12A,RX-123653,CDM,6370000000,HCPCS,0637,RC,59011-0440-20,NDC,,both,1,UN,83.50,54.27,,,,,,,,,,,,,
PIN FIX L9IN DIA24MM ST S STL 3 SIDE DBL TRCR BOTH END PNT,SUP-2150520,CDM,C1713,HCPCS,0278,RC,,,,both,,,25.72,16.72,,,,,,,,,,,,,
DISOPYRAMIDE PHOSPHATE 100 MG PO CAPS,RX-2535,CDM,6370000000,HCPCS,0637,RC,00093-3127-01,NDC,,both,1,UN,9.00,5.85,,,,,,,,,,,,,
LEVEL 1 THOR STRL PLT RIB LCK Z SHP 2.3 MM SCR 32 H T=1.5 MM,SUP-2262532,CDM,C1713,HCPCS,0278,RC,,,,both,,,4113.09,2673.51,,,,,,,,,,,,,
GRAFT VASC GORTX L 10 CM DIA 8 MM EPTFE STR STD WALL N RING,SUP-2396430,CDM,C1768,CPT,0278,RC,,,,both,,,379.94,246.96,,,,,,,,,,,,,
PLATE BONE FUSION 3.5X104 MM LEFT ANKLE HINDFOOT 5 HOLE UTIL,SUP-2837553,CDM,C1713,HCPCS,0278,RC,,,,both,,,7416.52,4820.74,,,,,,,,,,,,,
HC So2 Nuclear Antigen Antibody,PX-3028623568,CDM,86235,CPT,0302,RC,,,,both,,,672.00,436.80,,,,,,,,,,,,,
SPACER CEMENT HD TIB DIA 54 MM FEM DIA 54 MM PMMA INNR SS,SUP-2905420,CDM,C1776,CPT,0278,RC,,,,both,,,12089.00,7857.85,,,,,,,,,,,,,
STENT URET L 24 CM DIA 6 FR TIP L 3 CM STIFF SHFT ZIPWIRE,SUP-2754250,CDM,C2617,HCPCS,0278,RC,,,,both,,,566.86,368.46,,,,,,,,,,,,,
CATHETER HEMODIALYSI NIAG SLIM CATH ACTE 12FR DIA 24 5432240,SUP-2632890,CDM,C1752,HCPCS,0278,RC,,,,both,,,288.88,187.77,,,,,,,,,,,,,
TEMPLATE SZ 3 DIM LG 27X60X0.6 MM MXLFCL RT ORBIT RESORB-X,SUP-2489741,CDM,C1713,HCPCS,0278,RC,,,,both,,,2823.08,1835.00,,,,,,,,,,,,,
VALVE CSF FIXED 130 MM PRECIS CYL HI HAKIM,SUP-2666471,CDM,C1889,HCPCS,0278,RC,,,,both,,,3171.71,2061.61,,,,,,,,,,,,,
BASEPLATE TIB MOD LT REV STEM CEM NP SZ 3 FOUNDATION,SUP-2215784,CDM,C1776,CPT,0278,RC,,,,both,,,7222.00,4694.30,,,,,,,,,,,,,
HC MR Safety Implant Elec Prepj,PX-6107601800,CDM,76018,CPT,0610,RC,,,,both,,,289.00,187.85,,,,,,,,,,,,,
KIT PAINBUSTER W/ SILVERSOAK SOAK CATH 10IN 400ML X4ML PER,SUP-2420882,CDM,C9804,HCPCS,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
GRAFT VASC VENAFLO II L 10 CM DIA 6 MM EPTFE CARBON STR N,SUP-2761535,CDM,C1768,CPT,0278,RC,,,,both,,,1469.61,955.25,,,,,,,,,,,,,
PACEMAKER CRD 2 CHMBR AFFIN DR,SUP-2357334,CDM,C1785,HCPCS,0275,RC,,,,both,,,16799.00,10919.35,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC SOLO2 PLU MAXBARR 4FR 55C 1194108D3,SUP-2632631,CDM,C1751,HCPCS,0278,RC,,,,both,,,983.45,639.24,,,,,,,,,,,,,
MESH HERN CIR 4.5 IN POCKETED BIORESORBABLE PHASIX ST,SUP-2855268,CDM,C1781,HCPCS,0278,RC,,,,both,,,6876.60,4469.79,,,,,,,,,,,,,
SCREW ATTCH POLY INSRT INFIN,SUP-2397264,CDM,C1713,HCPCS,0278,RC,,,,both,,,1576.28,1024.58,,,,,,,,,,,,,
KIT ICP SKULL BOLT SPC WSHR OBT BIT DRL HEX WRNCH SCR,SUP-2243821,CDM,C1713,HCPCS,0278,RC,,,,both,,,3202.80,2081.82,,,,,,,,,,,,,
WAND ARTHSCP SHFT DIA3.75MM TIP DIA3MM 50DEG COBLATION,SUP-2342006,CDM,2720000010,LOCAL,0272,RC,,,,both,,,729.42,474.12,,,,,,,,,,,,,
PLATE BNE W10XL17MM 7 H TI HUM OVL BTTN,SUP-2418464,CDM,C1713,HCPCS,0278,RC,,,,both,,,1135.11,737.82,,,,,,,,,,,,,
COLLAR CERV ADJ FLX THERMOPLASTIC,SUP-2388132,CDM,L0130,HCPCS,0272,RC,,,,both,,,487.64,316.97,,,,,,,,,,,,,
DRILL SURG 2 MM P88802000,SUP-2751420,CDM,2720000010,LOCAL,0272,RC,,,,both,,,682.17,443.41,,,,,,,,,,,,,
PLATE BNE L 132 X W 10.2 MM THK 2.8 MM SCREW DIA 3.5 MM 12 HL,SUP-2937078,CDM,C1713,HCPCS,0278,RC,,,,both,,,1950.73,1267.97,,,,,,,,,,,,,
GUIDEWIRE ORTH L450MM OD1.2MM SMOOTH BLNT TIP NIT,SUP-2341497,CDM,C1769,HCPCS,0272,RC,,,,both,,,231.01,150.16,,,,,,,,,,,,,
CATHETER CV FULL TY 7 FRX20 CM 3L CUTLMY701JABRMCUSTOM0052,SUP-2759804,CDM,C1751,HCPCS,0278,RC,,,,both,,,554.46,360.40,,,,,,,,,,,,,
PACEMAKER CARD 23GM 12.8CC W52XH52MM THK6MM 2 CHMBR IS-1,SUP-2356462,CDM,C1785,HCPCS,0275,RC,,,,both,,,8007.00,5204.55,,,,,,,,,,,,,
MESH CRAN THK 0.2 MM SCREW DIA1/1.5 MM LG TRAP NS DISP,SUP-2936931,CDM,C1713,HCPCS,0278,RC,,,,both,,,970.26,630.67,,,,,,,,,,,,,
KIT SUTURE ANCHR DIA 4.5 MM PEEK KNOTLESS BRIDGELINE TAPE,SUP-2899051,CDM,C1713,HCPCS,0278,RC,,,,both,,,3099.97,2014.98,,,,,,,,,,,,,
CANNULA FOR USE WITH AR-8911G,SUP-2814594,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
WIRE EXT FIX REDUCTION LNG 2X400 MM MR SAFE,SUP-2176963,CDM,2720000010,LOCAL,0272,RC,,,,both,,,668.95,434.82,,,,,,,,,,,,,
ENDOPROSTHESIS VASC VIABAHN L 7.5CM 5MM 120CM 6FR RADIOPAQUE,SUP-2719624,CDM,C1768,HCPCS,0278,RC,,,,both,,,10741.94,6982.26,,,,,,,,,,,,,
IMPLANT BRST 460CC P5.9CM DIA11.4CM SFT COHESIVE SIL GEL,SUP-2113345,CDM,C1789,HCPCS,0278,RC,,,,both,,,2678.42,1740.97,,,,,,,,,,,,,
GRAFT BNE SUB 25CC 2 4MM GRAN GROWTH FACT ALLGRFT OSTEOAMP,SUP-2138501,CDM,C1713,HCPCS,0278,RC,,,,both,,,2166.60,1408.29,,,,,,,,,,,,,
GRAFT HUM TISS L 2 X W 2 CM AMNION PLCNTA MEMBRN SINGLE LAYR,SUP-2913195,CDM,C1762,CPT,0278,RC,,,,both,,,3658.10,2377.76,,,,,,,,,,,,,
BIT DRL DIA4MM 4 FLUT CANN FOR 4.5MM HDLSS COMPR SCR,SUP-2179107,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1088.10,707.26,,,,,,,,,,,,,
KIT INT FIX EL DST BICEP TEND GUID PIN MAXBRAID SUT DEV,SUP-2212944,CDM,C1713,HCPCS,0278,RC,,,,both,,,5903.20,3837.08,,,,,,,,,,,,,
GUIDEWIRE ORTH L20IN DIA2MM S STL BLNT TIP POLARUS 3,SUP-2106880,CDM,C1769,HCPCS,0272,RC,,,,both,,,351.68,228.59,,,,,,,,,,,,,
CANNULA ARTHSCP ROTATABLE 70 DEG 4X160 MM 13.7 TRUEVIEW II,SUP-2747491,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3101.19,2015.77,,,,,,,,,,,,,
POST EXT FIX CIR FEMALE 2 HOLE,SUP-2400667,CDM,2720000010,LOCAL,0272,RC,,,,both,,,380.73,247.47,,,,,,,,,,,,,
PLATE BONE L29MM THK1MM 3X4 H BILAT HND T SHP LCK TRILOK FOR,SUP-2267924,CDM,C1713,HCPCS,0278,RC,,,,both,,,2039.12,1325.43,,,,,,,,,,,,,
SCREW BONE L50MM DIA9.5MM CTRL GLEN TI ST T SHP HNDL FOR,SUP-2388787,CDM,C1713,HCPCS,0278,RC,,,,both,,,1745.84,1134.80,,,,,,,,,,,,,
PLATE BONE 7MM TI FULL,SUP-2211550,CDM,C1713,HCPCS,0278,RC,,,,both,,,5966.00,3877.90,,,,,,,,,,,,,
BUR SURG OD75MM 95MM XLN CUT ACORN N FLUT TPS,SUP-2363411,CDM,2720000010,LOCAL,0272,RC,,,,both,,,350.33,227.71,,,,,,,,,,,,,
GRAFT BNE SUB W15 18XL60MM RAD ULN SHFT FRZ DRY,SUP-2307201,CDM,C1713,HCPCS,0278,RC,,,,both,,,2113.69,1373.90,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9% BOLUS (FLUID RESUSCITATION),RX-4081440,CDM,2580000003,HCPCS,0258,RC,00338-0049-11,NDC,,both,1000,ML,493.00,320.45,,,,,,,,,,,,,
SUPPORT ORTHOT WRST HND CUST W/NONTORSION JT PREFABRICATED,SUP-2435776,CDM,L3915,HCPCS,0274,RC,,,,both,,,1369.64,890.27,,,,,,,,,,,,,
WIRE FIX 1.25 MM 80 MM TROCAR TIP SS KIRSCHNER,SUP-2653534,CDM,C1713,HCPCS,0278,RC,,,,both,,,55.52,36.09,,,,,,,,,,,,,
SHEET CRANIOFACIAL W50XL76MM THK0.85MM ULT THN BIOMATERIAL,SUP-2366461,CDM,C1713,HCPCS,0278,RC,,,,both,,,1686.18,1096.02,,,,,,,,,,,,,
SCREW BNE CORTICAL 2.7X14 MM ST STRL LTX,SUP-2861158,CDM,C1713,HCPCS,0278,RC,,,,both,,,252.27,163.98,,,,,,,,,,,,,
MARKER TISS 8GA FOR MAMTOM PRB MICROMARK II,SUP-2195631,CDM,A4648,CPT,0278,RC,,,,both,,,281.97,183.28,,,,,,,,,,,,,
SUTURE ULTRABRAID SZ 2-0 L24IN NONABSORBABLE WHT,SUP-2349217,CDM,C1713,HCPCS,0278,RC,,,,both,,,5375.84,3494.30,,,,,,,,,,,,,
WASHER ORTH DIA18MM SPIK FOR CANC SCR,SUP-2121106,CDM,C1713,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
SCREW SPNL L50MM DIA6.5MM HA CANC PEDCL MULTIAXIAL,SUP-2287274,CDM,C1713,HCPCS,0278,RC,,,,both,,,4304.47,2797.91,,,,,,,,,,,,,
CATHETER ETER DRNGE RNG 83FR L50CM BILI DUCT,SUP-2167744,CDM,C1729,HCPCS,0272,RC,,,,both,,,172.10,111.86,,,,,,,,,,,,,
BIT DRL 3.2X65 MM STP NS,SUP-2591670,CDM,2720000010,LOCAL,0272,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
TRIAMCINOLONE ACETONIDE 0.5 % EX OINT,RX-8119,CDM,6370000000,HCPCS,0637,RC,45802-0049-35,NDC,,both,15,GR,38.90,25.28,,,,,,,,,,,,,
TUBE TRACH OD12MM STD CLR SIL N ADH SMOOTH SURF 4200 SER,SUP-2138748,CDM,2720000010,LOCAL,0272,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
SYSTEM DRAINAGE RT ANGLE 32 FRX21 IN THOR SFT CATH FIRM PVC,SUP-2227085,CDM,C1729,HCPCS,0272,RC,,,,both,,,223.44,145.24,,,,,,,,,,,,,
ATTACHMENT EXTRACTOR FOR HINDFOOT TTC NAIL SYS NS DISP,SUP-2909002,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1562.15,1015.40,,,,,,,,,,,,,
DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML IJ SOLN,RX-2331,CDM,J1100,HCPCS,0636,RC,00641-0367-25,NDC,,both,0.5,ML,54.10,35.16,,,,,,,,,,,,,
PLATE CRAN 80X20X40 MM PT SPEC IMPL PEEK,SUP-2860115,CDM,C1713,HCPCS,0278,RC,,,,both,,,25204.47,16382.91,,,,,,,,,,,,,
TRIAL PLATE HK 0.8 MM AVULSION,SUP-2525711,CDM,C1713,HCPCS,0278,RC,,,,both,,,759.88,493.92,,,,,,,,,,,,,
PLATE SPNL 26 MM,SUP-2415397,CDM,C1713,HCPCS,0278,RC,,,,both,,,3271.88,2126.72,,,,,,,,,,,,,
GUIDE DRILL 3.5MM 90 DEG CANN LC-ANGLED BLADE PLATE,SUP-2548615,CDM,C1713,HCPCS,0278,RC,,,,both,,,3056.38,1986.65,,,,,,,,,,,,,
BRACE ORTH SAGITAL LUMBAR CTRL LSO,SUP-2388146,CDM,L0626,HCPCS,0274,RC,,,,both,,,200.71,130.46,,,,,,,,,,,,,
GRAFT BIO TISS OMEGA3 MARIGEN 7X7CM,SUP-2883368,CDM,Q4158,HCPCS,0636,RC,,,,both,,,5149.60,3347.24,,,,,,,,,,,,,
DYNANITE STAPLE BIT DRILL CAL 1.6,SUP-2814456,CDM,2720000010,LOCAL,0272,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
HC Closed Tx Ulnar Shaft Frac Man,PX-4502553500,CDM,25535,CPT,0450,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
COIL VASC MREYE FLIPPER EMBOLUS L 3 CM DIA 3 MM CATH DIA,SUP-2170592,CDM,C1889,HCPCS,0278,RC,,,,both,,,275.54,179.10,,,,,,,,,,,,,
GUIDEWIRE VASC HIWIRE L 220 CM 0.038 IN TAPR L 22 CM ANGLED,SUP-2170349,CDM,C1769,HCPCS,0272,RC,,,,both,,,448.20,291.33,,,,,,,,,,,,,
ALLOGRAFT BNE SPACER 25X9X8 MM FRSH IN NACL STRL TRIAD LF,SUP-2565347,CDM,C1713,HCPCS,0278,RC,,,,both,,,8164.00,5306.60,,,,,,,,,,,,,
SYSTEM IMPL 3.5 MM SHLDR ELBW RC AUG SYS TISSUETAK TEND,SUP-2910342,CDM,C1713,HCPCS,0278,RC,,,,both,,,10055.85,6536.30,,,,,,,,,,,,,
GRAFT HUM TISS D EYE AMINOGRFT,SUP-2135255,CDM,V2790,HCPCS,0274,RC,,,,both,,,2025.30,1316.44,,,,,,,,,,,,,
PLATE BONE L3MM THK0.6MM 4 H ORAL MAXILLOFACIAL TI NEUT N,SUP-2262499,CDM,C1713,HCPCS,0278,RC,,,,both,,,395.64,257.17,,,,,,,,,,,,,
SUTURE PASSER CAPFIX 45 DEG,SUP-2801014,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1390.20,903.63,,,,,,,,,,,,,
PLATE RINGFIX SYS 13 HL ALUM,SUP-2696087,CDM,2720000010,LOCAL,0272,RC,,,,both,,,802.58,521.68,,,,,,,,,,,,,
PLATE BNE L 59 MM SCREW DIA 3.5 MM 4 SHFT H SS STR VA,SUP-2907589,CDM,C1713,HCPCS,0278,RC,,,,both,,,2472.75,1607.29,,,,,,,,,,,,,
PROBE ELECSURG CHSL MIC ANGLED VULCAN,SUP-2848572,CDM,2720000010,LOCAL,0272,RC,,,,both,,,597.10,388.11,,,,,,,,,,,,,
SCREW BNE L 145 MM DIA 3.5 MM SS CORTICAL ST NS EVOS,SUP-2931838,CDM,C1713,HCPCS,0278,RC,,,,both,,,206.30,134.09,,,,,,,,,,,,,
BIT DRL L 7.4 IN DIA2.7 MM TROCR TIP AO CONN NS DISP RIBFIX,SUP-2905463,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2072.40,1347.06,,,,,,,,,,,,,
SHEATH DIL BYRD 10 FR TELSCP POLYPR,SUP-2638735,CDM,C1893,HCPCS,0272,RC,,,,both,,,692.12,449.88,,,,,,,,,,,,,
STEM TIB L115MM DIA10MM KNEE EXTN STABILIZING PRI FLUT PFC,SUP-2253316,CDM,C1713,HCPCS,0278,RC,,,,both,,,3717.76,2416.54,,,,,,,,,,,,,
SHEATH INTRO ACQGUIDE MINI-S 90 DEG L 65 CM OD 12 FR ID 8.5,SUP-2845249,CDM,C1887,HCPCS,0272,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
REAMER SURG 16 MM CUP,SUP-2319071,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
PLATE BONE THK2MM 4X20X4 H MAND TI X LCKING DBL ANG FOR 2MM,SUP-2191275,CDM,C1713,HCPCS,0278,RC,,,,both,,,8910.69,5791.95,,,,,,,,,,,,,
ANKLE JOINT ARSENAL 4.5MM 80MM TITANIUM ALLOY MALLEOLUS,SUP-2879042,CDM,C1713,HCPCS,0278,RC,,,,both,,,9341.50,6071.97,,,,,,,,,,,,,
NARROW PLATE 4.5MM 15X247MM,SUP-2818525,CDM,C1713,HCPCS,0278,RC,,,,both,,,2704.67,1758.04,,,,,,,,,,,,,
PLATE BNE W8XL192MM THK3.3MM 24 H NONSTERILE BILAT PELV S,SUP-2186251,CDM,C1713,HCPCS,0278,RC,,,,both,,,3481.63,2263.06,,,,,,,,,,,,,
PLATE SPNL L16MM UNIV CERV ANT 1 LEV TI STD REFLX,SUP-2380854,CDM,C1713,HCPCS,0278,RC,,,,both,,,5089.94,3308.46,,,,,,,,,,,,,
SCREW BONE L70MM DIA6.5MM CANC PARTIALLY THRD S STL,SUP-2348928,CDM,C1713,HCPCS,0278,RC,,,,both,,,262.25,170.46,,,,,,,,,,,,,
CUP ACET OD64MM ID22MM ALL POLYPROPYLENEXLPE CEM REFLCT,SUP-2345698,CDM,C1776,CPT,0278,RC,,,,both,,,2990.07,1943.55,,,,,,,,,,,,,
CATHETER ABLATN INTRACARDION 9 FR VIEWFLEX XTRA,SUP-2356615,CDM,C1757,HCPCS,0272,RC,,,,both,,,6908.00,4490.20,,,,,,,,,,,,,
CONNECTOR SPINE TRNSVRS ROD OMEGA 21 FIX TI,SUP-2414725,CDM,C1713,HCPCS,0278,RC,,,,both,,,536.94,349.01,,,,,,,,,,,,,
SHUNT VENTRICULAR OD2.5MM CATHETER L25CM AND L120CM 5CM WATE,SUP-2821801,CDM,C1889,HCPCS,0278,RC,,,,both,,,2601.84,1691.20,,,,,,,,,,,,,
BIT DRILL SURG DIA 4.2 MM CALIB NS DISP,SUP-2930400,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1262.28,820.48,,,,,,,,,,,,,
PLATE BNE L46MM THK3.4MM 3 H BILAT S STL STR LOK COMPR FOR,SUP-2185126,CDM,C1713,HCPCS,0278,RC,,,,both,,,731.12,475.23,,,,,,,,,,,,,
GRAFT HUM TISS L16SQCM DEHYDR AMNION CHORION MEM MESH,SUP-2305754,CDM,Q4186,HCPCS,0636,RC,,,,both,,,10299.20,6694.48,,,,,,,,,,,,,
HC Eval of Speech Production,PX-4449252200,CDM,92522,CPT,0444,RC,,,,both,,,693.00,450.45,,,,,,,,,,,,,
HC MRI-Chest W & WO Contrast,PX-6107155200,CDM,71552,CPT,0610,RC,,,,both,,,4696.00,3052.40,,,,,,,,,,,,,
HEAD HUM H13.5MM OD37MM STD OFFSET PRI NECKLESS SHLDR CO,SUP-2388624,CDM,C1776,CPT,0278,RC,,,,both,,,7091.69,4609.60,,,,,,,,,,,,,
HINGE EXT FIX M,SUP-2365313,CDM,2720000010,LOCAL,0272,RC,,,,both,,,336.29,218.59,,,,,,,,,,,,,
CATHETER US 10FR L90CM 3D SOUNDSTAR FOR SIEMENS,SUP-2248955,CDM,C1753,HCPCS,0278,RC,,,,both,,,7843.72,5098.42,,,,,,,,,,,,,
HC Biopsy of Pancreas Perc Needle,PX-3614810200,CDM,48102,CPT,0361,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
GUIDEWIRE VASC L180CM DIA0.018IN TIP L5CM S STL SIL STR LNG,SUP-2148235,CDM,C1769,HCPCS,0272,RC,,,,both,,,477.28,310.23,,,,,,,,,,,,,
DEXAMETHASONE 0.5 MG/5ML PO SOLN,RX-2320,CDM,J8540,HCPCS,0636,RC,09999-9901-04,NDC,,both,5,ML,2.70,1.75,,,,,,,,,,,,,
HC Assay of Free Thyroxine|NOT REASONABLE AND NECESSARY,PX-3018443900,CDM,84439,CPT,0301,RC,,,GZ,both,,,348.00,226.20,,,,,,,,,,,,,
DEXAMETHASONE 0.5 MG/5ML PO SOLN,RX-2320,CDM,J8540,HCPCS,0636,RC,00054-3177-63,NDC,,both,5,ML,2.70,1.75,,,,,,,,,,,,,
PLATE BONE CRANIOMAXILLOFACIAL 4 HOLE BOX CAR 10MM TITANIUM,SUP-2826365,CDM,C1713,HCPCS,0278,RC,,,,both,,,244.04,158.63,,,,,,,,,,,,,
SHEATH INTRO 9FR L40CM NDL 18GA GWIRE 0.035IN SYR 10ML COR,SUP-2282362,CDM,C1892,HCPCS,0272,RC,,,,both,,,873.08,567.50,,,,,,,,,,,,,
SHAVER BNE SONIC 1 OR 360,SUP-2305933,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1399.03,909.37,,,,,,,,,,,,,
ROUTER PWR,SUP-2304059,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1956.22,1271.54,,,,,,,,,,,,,
DEVICE ABLAT FOR EPICOR CARD ABLAT SYS ULTRAWAND LP,SUP-2355886,CDM,C1713,HCPCS,0278,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
NAIL IM CANN 125 DEG 11X440 MM LT TROCHANTERIC FIX TI GRN NS,SUP-2192025,CDM,C1713,HCPCS,0278,RC,,,,both,,,6765.07,4397.30,,,,,,,,,,,,,
INSERT INTERSPINOUS FUS UNILINK 8MM TI,SUP-2205254,CDM,C1713,HCPCS,0278,RC,,,,both,,,4082.00,2653.30,,,,,,,,,,,,,
SCREW BNE EMGCY 1.8X5 MM SELF RET DRILL-FREE TI MAXDRIVE,SUP-2460366,CDM,C1713,HCPCS,0278,RC,,,,both,,,198.23,128.85,,,,,,,,,,,,,
BLADE SAW PEDCL STRL DISP VADER,SUP-2917209,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5338.00,3469.70,,,,,,,,,,,,,
BRACE EXT FIX DRL ASMBLY 3-6 MM APEX,SUP-2479410,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1094.29,711.29,,,,,,,,,,,,,
MATRIX BIO L 7 X W 5 CM FISH SKIN DERMAL INTACT OMEGA3,SUP-2909268,CDM,Q4158,HCPCS,0636,RC,,,,both,,,3925.00,2551.25,,,,,,,,,,,,,
ANCHOR SUT DIA4.5MM PEEK OPTMA LINK SELF PUNCHING KNOTLESS,SUP-2416349,CDM,C1713,HCPCS,0278,RC,,,,both,,,1554.43,1010.38,,,,,,,,,,,,,
INSERT TIB L65MM THK10MM MEDL LAT KNEE ARTC POST STBL HI,SUP-2405945,CDM,C1776,CPT,0278,RC,,,,both,,,6477.82,4210.58,,,,,,,,,,,,,
MICROCATHETER INFUSION SUPERCROSS 90 DEG L 150 CM OD,SUP-2383137,CDM,C1887,HCPCS,0272,RC,,,,both,,,1391.02,904.16,,,,,,,,,,,,,
PIN EXT FIX L 230 MM DIA 4 MM OAL AO CONN SMTH DRL TIP NS,SUP-2899256,CDM,C1713,HCPCS,0278,RC,,,,both,,,682.17,443.41,,,,,,,,,,,,,
SCREW BNE L20MM DIA27MM DST LAT CORT PERIARTC S STL ST,SUP-2198483,CDM,C1713,HCPCS,0278,RC,,,,both,,,157.31,102.25,,,,,,,,,,,,,
RESORB XG ST MESH LG GRID 51 X 51 MM T10 MM PLLA PGA,SUP-2694979,CDM,C1713,HCPCS,0278,RC,,,,both,,,3135.51,2038.08,,,,,,,,,,,,,
GRAFT VASC GORTX L 80 CM DIA 5 MM EPTFE STR TW N RING STRL,SUP-2396689,CDM,C1768,CPT,0278,RC,,,,both,,,2468.04,1604.23,,,,,,,,,,,,,
CATHETER ANGIOPLSTY GATEWY L 90 CM BALLOON L 15 MM DIA2 MM,SUP-2361855,CDM,C1725,HCPCS,0272,RC,,,,both,,,3466.56,2253.26,,,,,,,,,,,,,
ADAPTER CANN ARTHSCP HIP FLO PRT II REUSE,SUP-2366735,CDM,C1713,HCPCS,0278,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
ENDOPROSTHESIS VASC FLUENCY + L 60 MM DIA10 MM CATH L 80 CM,SUP-2128268,CDM,C1874,HCPCS,0278,RC,,,,both,,,23747.82,15436.08,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE L 10 MM DIA12.5 MM CART ARAGONITE,SUP-2913199,CDM,C1763,HCPCS,0278,RC,,,,both,,,23550.00,15307.50,,,,,,,,,,,,,
PLATE ARSENAL ANKLE 7 HOLE ANTEROLATERAL TIBIA R,SUP-2878318,CDM,C1713,HCPCS,0278,RC,,,,both,,,7065.00,4592.25,,,,,,,,,,,,,
SPACER SPNL W12XH8XL12MM 5DEG INTBDY FUS LORDTC FOOTPRINT,SUP-2206003,CDM,C1889,HCPCS,0278,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
PIN FIX L420MM DIA3.2MM TIB THRD PRECICE UNYTE STNMN,SUP-2312266,CDM,2720000010,LOCAL,0272,RC,,,,both,,,618.58,402.08,,,,,,,,,,,,,
NUT EXT FIX WIRE SIDEKCK EZ FRAME EF1600PK,SUP-2851085,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5067.96,3294.17,,,,,,,,,,,,,
CATHETER DRAINAGE INTRO 27 FRX61 CM MULTI XL BIO-MEDICUS LS,SUP-2745341,CDM,C1729,HCPCS,0272,RC,,,,both,,,1740.82,1131.53,,,,,,,,,,,,,
PADDLE GRFT REMOVAL ASMBLY,SUP-2421819,CDM,2720000010,LOCAL,0272,RC,,,,both,,,354.82,230.63,,,,,,,,,,,,,
HC Pulse Oximetry Continuous,PX-4609476200,CDM,94762,CPT,0460,RC,,,,inpatient,,,452.00,293.80,,,,,,,,,,,,,
CATHETER HEMO DYLS OR HD L40CM ADMIN CHRONIC BASIC KT 14.5,SUP-2266984,CDM,C1750,HCPCS,0278,RC,,,,both,,,458.44,297.99,,,,,,,,,,,,,
SENSOR KT BLD GAS VIA AD,SUP-2246393,CDM,C1713,HCPCS,0278,RC,,,,both,,,1381.60,898.04,,,,,,,,,,,,,
PLATE BNE L 28 MM SCREW DIA2.8 MM LG CP TI MANDIBULAR FULL,SUP-2883715,CDM,C1713,HCPCS,0278,RC,,,,both,,,19437.79,12634.56,,,,,,,,,,,,,
DEFIBRILLATOR CARD W/ RIATA ATLS II DR,SUP-2356569,CDM,C1721,HCPCS,0275,RC,,,,both,,,71435.00,46432.75,,,,,,,,,,,,,
DISTRACTION EXTRNL HLDR RED 2 HRZNTL CROSS BAR BLACK ALMNM Q,SUP-2680464,CDM,C1713,HCPCS,0278,RC,,,,both,,,742.30,482.49,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH DIA28 MM CONTRALATERAL LIMB L 74 MM SS,SUP-2169810,CDM,C1768,CPT,0278,RC,,,,both,,,25785.68,16760.69,,,,,,,,,,,,,
BIT DRL L280MM DIA4.3MM STP W/O NONRADIOPAQUE,SUP-2188851,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1253.52,814.79,,,,,,,,,,,,,
GRAFT EVAR L124MM DIA16X16MM CATH 14FR LIMB DST DSGN C DEL,SUP-2295250,CDM,C1768,CPT,0278,RC,,,,both,,,15464.50,10051.92,,,,,,,,,,,,,
ELECTRODE ELECSURG RESECT W/ HF CABLE PLASMABUTTON SP,SUP-2430210,CDM,C1713,HCPCS,0278,RC,,,,both,,,1666.40,1083.16,,,,,,,,,,,,,
STEM FEM L250MM OD9MM TI POR LT HIP PRI BOW LNG BODY REV,SUP-2403319,CDM,C1776,CPT,0278,RC,,,,both,,,17335.94,11268.36,,,,,,,,,,,,,
BIT OVERDRILL DIA 4.5 MM AO QC LG TARGETER SYS STRL DISP,SUP-2933307,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1648.50,1071.52,,,,,,,,,,,,,
PLATE BNE LCK NAR 4.5 MM 6 HOLE COMPR STRL ALPS LTX,SUP-2861820,CDM,C1713,HCPCS,0278,RC,,,,both,,,1377.77,895.55,,,,,,,,,,,,,
MONITOR CARD ASSERT-IQ EL L 9.4 X H 49 MM THK 4.4 MM 1.2 ML,SUP-2877891,CDM,C1833,HCPCS,0278,RC,,,,both,,,16328.00,10613.20,,,,,,,,,,,,,
CATHETER DRAINAGE VLV 4 FRX10 CM 20 GA SAFETY ACCEL,SUP-2659266,CDM,C1729,HCPCS,0272,RC,,,,both,,,66.76,43.39,,,,,,,,,,,,,
COMPONENT HUM CMNTLS 42 MM SHLDR HA AEQUALIS REVERSED,SUP-2715658,CDM,C1776,CPT,0278,RC,,,,both,,,9146.82,5945.43,,,,,,,,,,,,,
PLATE BNE LCK NAR RT DSTL ANTEROLATERAL CORTICAL TIB 15 HOLE,SUP-2475112,CDM,C1713,HCPCS,0278,RC,,,,both,,,4590.02,2983.51,,,,,,,,,,,,,
RALOXIFENE HCL 60 MG PO TABS,RX-22143,CDM,6370000000,HCPCS,0637,RC,16714-0213-01,NDC,,both,1,UN,7.00,4.55,,,,,,,,,,,,,
SHEATH INTRO CHARIOT L 90 CM DIA 7 FR STR TIP XCUT LG LUMEN,SUP-2140082,CDM,C1894,HCPCS,0272,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
HANDPIECE ELECSURG ACESSA PROVU,SUP-2765141,CDM,2720000010,LOCAL,0272,RC,,,,both,,,10833.00,7041.45,,,,,,,,,,,,,
GRAFT HUM TISS L 2 X W 2 CM AMNION PLCNTA MEMBRN 2 LAYR,SUP-2913329,CDM,C1762,CPT,0278,RC,,,,both,,,3950.12,2567.58,,,,,,,,,,,,,
BLADE SCRDRVR DIA2.3MM NONCANNULATED CRSS PIN,SUP-2375073,CDM,2720000010,LOCAL,0272,RC,,,,both,,,879.20,571.48,,,,,,,,,,,,,
HC So2 Column Chromotography Quant,PX-3018254268,CDM,82542,CPT,0301,RC,,,,both,,,85.00,55.25,,,,,,,,,,,,,
MESH CRANIAL CONTOURABLE 2X50X1.2 MM RAPID RESORBABLE STERIL,SUP-2838599,CDM,C1713,HCPCS,0278,RC,,,,both,,,5769.75,3750.34,,,,,,,,,,,,,
DEXTROSE-SODIUM CHLORIDE 5-0.2 % IV SOLN,RX-15863,CDM,J3490,HCPCS,0258,RC,00338-0077-04,NDC,,both,1000,ML,51.00,33.15,,,,,,,,,,,,,
VALVE PRESSURE PROGRAMMABLE PRECIS 100 H2O MED HI RANG HAKIM,SUP-2666824,CDM,C1889,HCPCS,0278,RC,,,,both,,,5851.61,3803.55,,,,,,,,,,,,,
ELEVATOR SURG W066XL12IN S STL SATIN FINISH PERIOST CRV COBB,SUP-2161314,CDM,2720000010,LOCAL,0272,RC,,,,both,,,523.47,340.26,,,,,,,,,,,,,
CATHETER GUID AXS CATLYST 7 L 115 CM PROX/DSTL OD,SUP-2715843,CDM,C1887,HCPCS,0272,RC,,,,both,,,6349.08,4126.90,,,,,,,,,,,,,
SPLINT WRST M L7IN AD L FA COT E SUPP INSTABILITY INJ LOOP,SUP-2276649,CDM,L3809,HCPCS,0274,RC,,,,both,,,9.51,6.18,,,,,,,,,,,,,
SCREW BONE LOCKING 4.5X105 MM CORTICAL TIBIAL FEMUR SELFTAPP,SUP-2837312,CDM,C1713,HCPCS,0278,RC,,,,both,,,1419.34,922.57,,,,,,,,,,,,,
PROSTHESIS OSS 0.6X5.5 MM GRACE MALL PISTON TI,SUP-2461805,CDM,L8613,CPT,0278,RC,,,,both,,,1127.20,732.68,,,,,,,,,,,,,
SCREW SPNL LAG 25 MM CAPTURE FACET,SUP-2538839,CDM,C1713,HCPCS,0278,RC,,,,both,,,5495.00,3571.75,,,,,,,,,,,,,
BLADE SAW L 95 X W 11 MM D 12 MM THK MATERIAL 0.4 MM CUT 0.5,SUP-2929439,CDM,2720000010,LOCAL,0272,RC,,,,both,,,435.02,282.76,,,,,,,,,,,,,
PLATE BNE 24 DEG L 141 X W 8.5 MM THK 1.6 MM 10 H TI LT DSTL,SUP-2933647,CDM,C1713,HCPCS,0278,RC,,,,both,,,5853.59,3804.83,,,,,,,,,,,,,
TRAY APPL BRACHYTHERAPY SAVI 6-1 MINI,SUP-2164402,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8635.00,5612.75,,,,,,,,,,,,,
TRAY CATH MIDLN PROVENA 4FR 20CM 2 LUMAN RVS TAPR P S4254108,SUP-2632862,CDM,C1751,HCPCS,0278,RC,,,,both,,,458.44,297.99,,,,,,,,,,,,,
PLATE BNE T 12 HOLE,SUP-2205649,CDM,C1713,HCPCS,0278,RC,,,,both,,,1111.94,722.76,,,,,,,,,,,,,
ANCHOR SUT DIA6.5MM BIOCRYL RAPIDE ABSRB KNOTLESS HEALIX,SUP-2249440,CDM,C1713,HCPCS,0278,RC,,,,both,,,1441.26,936.82,,,,,,,,,,,,,
HANDPIECE SHAVER DRL DEPTH 0 DEG 4 MM POWERPICK,SUP-2845794,CDM,2720000010,LOCAL,0272,RC,,,,both,,,317.14,206.14,,,,,,,,,,,,,
SET 16CM NAR BASE CYL PMP INFPUB OTR TI,SUP-2165359,CDM,C1813,HCPCS,0278,RC,,,,both,,,22623.70,14705.40,,,,,,,,,,,,,
SCREW BNE COMPR LNG THRD 6.5X50 MM LT CANN HDLSS TI NS,SUP-2423243,CDM,C1713,HCPCS,0278,RC,,,,both,,,2008.34,1305.42,,,,,,,,,,,,,
SCREW SPNL TAPR 5X14 MM OCCIPITOCERVICAL UPPER THOR,SUP-2632011,CDM,C1713,HCPCS,0278,RC,,,,both,,,1664.20,1081.73,,,,,,,,,,,,,
PACK ARTHSCP ACL PCL PIN WIRE PAC C FOR FAST-FIX 360 MENIS,SUP-2341004,CDM,2720000010,LOCAL,0272,RC,,,,both,,,687.66,446.98,,,,,,,,,,,,,
PLATE BONE L24MM THK.3MM 5 H L TI CRAN MAXILLOFACIAL BILAT,SUP-2137626,CDM,C1713,HCPCS,0278,RC,,,,both,,,1001.66,651.08,,,,,,,,,,,,,
STENT ESOPH ALIMAXX-ES L 100 MM DIA22 MM DEL DEV L 64 MM,SUP-2461216,CDM,C1874,HCPCS,0278,RC,,,,both,,,7536.00,4898.40,,,,,,,,,,,,,
CASE GRFT ENDURANT II NIT POLYESTER 3 PC STRL,SUP-2873746,CDM,C1768,CPT,0278,RC,,,,both,,,59660.00,38779.00,,,,,,,,,,,,,
SLING INCONT TENS FRE SUPP FOR OBT SYS GYNECARE TVT,SUP-2257138,CDM,C1771,HCPCS,0278,RC,,,,both,,,7043.55,4578.31,,,,,,,,,,,,,
CATHETER SURG L16MM OD7FR SINUS RELIEVA SOLO,SUP-2106321,CDM,C1725,HCPCS,0272,RC,,,,both,,,2430.36,1579.73,,,,,,,,,,,,,
PLATE BONE L115MM RIB RIBLOC U+,SUP-2107918,CDM,C1713,HCPCS,0278,RC,,,,both,,,4722.56,3069.66,,,,,,,,,,,,,
SET INTRO SAFSHTH ULTRA L 13 CM DIA11 FR DIL L 18 CM,SUP-2159470,CDM,C1892,HCPCS,0272,RC,,,,both,,,689.29,448.04,,,,,,,,,,,,,
IMPLANT WR JT CRPL POLY INSRT SZ 1 4MM,SUP-2243505,CDM,C1776,CPT,0278,RC,,,,both,,,4275.58,2779.13,,,,,,,,,,,,,
RING ANNULPLSTY CG FUTURE ID 24 MM OD 28.9 MM STIFFENER ID,SUP-2282739,CDM,C1889,HCPCS,0278,RC,,,,both,,,5966.00,3877.90,,,,,,,,,,,,,
GUIDEWIRE VASC L 80 CM DIA 0.035 IN TAPR L 4.5 CM FLPY TIP,SUP-2167811,CDM,C1769,HCPCS,0272,RC,,,,both,,,35.04,22.78,,,,,,,,,,,,,
"HC Debrid,Subq Ea Addt'l 20sqcm",PX-3611104500,CDM,11045,CPT,0361,RC,,,,both,,,207.00,134.55,,,,,,,,,,,,,
INSERT TIB 2 8 MM RT POLYETH,SUP-2244172,CDM,C1776,CPT,0278,RC,,,,both,,,3331.54,2165.50,,,,,,,,,,,,,
NEEDLE ASPIR 22GA L80MM WRK L1400MM CHN 28MM FN ROUNDED STYL,SUP-2313400,CDM,2720000010,LOCAL,0272,RC,,,,both,,,861.58,560.03,,,,,,,,,,,,,
GRAFT BNE SUB THK10 12MM CALCANEUS CRSS SECT FRZ DRY,SUP-2307161,CDM,C1713,HCPCS,0278,RC,,,,both,,,2185.28,1420.43,,,,,,,,,,,,,
GRAFT BNE 1-2 MM 10 CC SYNTH CALCIUM PHOSPHATE ACTIFUSE ABX,SUP-2130291,CDM,C1713,HCPCS,0278,RC,,,,both,,,5495.00,3571.75,,,,,,,,,,,,,
HC CT Upper Extremity W/WO Cont,PX-3527320200,CDM,73202,CPT,0352,RC,,,,both,,,2630.00,1709.50,,,,,,,,,,,,,
IMPLANT HEARING 8.5MM ABUTMENT SNAP CPL,SUP-2164933,CDM,C1713,HCPCS,0278,RC,,,,both,,,4474.50,2908.42,,,,,,,,,,,,,
KIT TORQ WRNCH REUSE FOR NEUROSTIM,SUP-2418484,CDM,2720000010,LOCAL,0272,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
LEVETIRACETAM IN NACL 500 MG/100ML IV SOLN,RX-112651,CDM,J1953,HCPCS,0636,RC,67457-0255-10,NDC,,both,100,ML,80.50,52.32,,,,,,,,,,,,,
ECULIZUMAB 300 MG/30ML IV SOLN,RX-81696,CDM,J1299,HCPCS,0636,RC,25682-0001-01,NDC,,both,30,ML,19242.90,12507.88,,,,,,,,,,,,,
GRAFT BONE SUB 10MM CROSS SECT FEM FRZ DRY TRAD,SUP-2294079,CDM,C1713,HCPCS,0278,RC,,,,both,,,1836.90,1193.98,,,,,,,,,,,,,
GRAFT MTRX DERM PTCH SFT TISS REP 10X10CM,SUP-2335294,CDM,Q4128,HCPCS,0636,RC,,,,both,,,10362.00,6735.30,,,,,,,,,,,,,
ALLOGRAFT HUM TISS TEND FLX,SUP-2321806,CDM,C1762,CPT,0278,RC,,,,both,,,2367.56,1538.91,,,,,,,,,,,,,
ANCHOR SUT OD2.9MM TI DBL ARMED PERM PRE LD PRE THRD 2 NO 2,SUP-2341743,CDM,C1713,HCPCS,0278,RC,,,,both,,,1089.58,708.23,,,,,,,,,,,,,
SYSTEM IMPL TENODESIS SCR EYELET,SUP-2122949,CDM,C1713,HCPCS,0278,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
COMPONENT FEM L 100MM TROCHANTERIC HIP CO CHROM MOD REV,SUP-2404491,CDM,C1776,CPT,0278,RC,,,,both,,,2947.99,1916.19,,,,,,,,,,,,,
BUR SURG DIAMOND COARSE 3 MMX10 CM BALL SM BOR LEGEND,SUP-2627613,CDM,2720000010,LOCAL,0272,RC,,,,both,,,329.89,214.43,,,,,,,,,,,,,
KIT MICROINTRODUCER COAX STIFF NIT TUNGSTEN 0.018IN GWIRE,SUP-2118827,CDM,C1769,HCPCS,0272,RC,,,,both,,,87.92,57.15,,,,,,,,,,,,,
PATCH DURA W10XL12CM NONBIOLOGICAL MEMBRN FOR MINIMIZING CSF,SUP-2395375,CDM,C1713,HCPCS,0278,RC,,,,both,,,3391.20,2204.28,,,,,,,,,,,,,
SPLINT ORTHOPEDIC W/ ABDUCTED SM 8 IN RT WRST FOREARM THMB,SUP-2276639,CDM,L3809,HCPCS,0274,RC,,,,both,,,22.26,14.47,,,,,,,,,,,,,
EXPANDER BRST TISS TALL 930-1445 CC SIL SMTH SUTURE TAB,SUP-2927323,CDM,C1889,HCPCS,0278,RC,,,,both,,,6546.90,4255.48,,,,,,,,,,,,,
STENT URET CNTOUR VL L 22-30 CM DIA 6 FR CATH 6 FR GLIDEWIRE,SUP-2141662,CDM,C2617,HCPCS,0278,RC,,,,both,,,504.66,328.03,,,,,,,,,,,,,
CUP ACET DIA58MM HIP HOLED ANODIZED INSITU,SUP-2308979,CDM,C1776,CPT,0278,RC,,,,both,,,4239.00,2755.35,,,,,,,,,,,,,
PLATE BONE DUAL CMPRSSN HLX14 RCNSTRCTN F3.5MM LOK SCREW ST,SUP-2722264,CDM,C1713,HCPCS,0278,RC,,,,both,,,1940.52,1261.34,,,,,,,,,,,,,
ELECTRODE ES 035MM WIRE LOOP HF RESECT FOR 3MM 12DEG TELSCP,SUP-2313596,CDM,2720000010,LOCAL,0272,RC,,,,both,,,336.89,218.98,,,,,,,,,,,,,
PUMP INFUSION PAIN I-FLOW,SUP-2236746,CDM,E0783,HCPCS,0278,RC,,,,both,,,92.63,60.21,,,,,,,,,,,,,
CATHETER DIL PTA P3 9MM X 2CM PWRFLX,SUP-2156167,CDM,C1725,HCPCS,0272,RC,,,,both,,,797.50,518.37,,,,,,,,,,,,,
WIRE EXT FIX L400MM DIA18MM HALF PNT TIP REDUC,SUP-2179131,CDM,2720000010,LOCAL,0272,RC,,,,both,,,668.95,434.82,,,,,,,,,,,,,
HC Med Nut Therapy Ind Init 15 Min,PX-9429780200,CDM,97802,CPT,0940,RC,,,,both,,,95.00,61.75,,,,,,,,,,,,,
RING EXT FIX DIA160MM FREE CIR FULL SIDEKCK FREE CIR FIX,SUP-2400650,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2618.76,1702.19,,,,,,,,,,,,,
COMPONENT KNEE LOWER EXTREMITIES. ANCIL ZIRCONIUM NAVIO DISP,SUP-2348002,CDM,C1776,CPT,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
CATHETER URET 6FR L70CM POLYUR WHSTL TIP W/ ADPT DISP,SUP-2129007,CDM,C1758,HCPCS,0278,RC,,,,both,,,20.98,13.64,,,,,,,,,,,,,
GUIDEWIRE ORTH DIA1.6MM TIP DRL SGL PERC,SUP-2410862,CDM,C1769,HCPCS,0272,RC,,,,both,,,190.44,123.79,,,,,,,,,,,,,
PLATE BONE L195MM 11 H RT PROX HUM LCK FOR 4.5MM SCR,SUP-2348278,CDM,C1713,HCPCS,0278,RC,,,,both,,,16325.49,10611.57,,,,,,,,,,,,,
PUMP INFUSION ELASTOMERIC 400 CC 4 ML/HR FIX FLO STRL ON-Q,SUP-2424461,CDM,C9804,HCPCS,0272,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
PI PICC KIT 3-L 6 FR X 55 CM AGBA/TIPTRACKER,SUP-2565198,CDM,C1751,HCPCS,0278,RC,,,,both,,,743.02,482.96,,,,,,,,,,,,,
ANCHOR SUTURE DIA 4.75 MM PEEK DL KNOTLESS STRL CRKSCR,SUP-2930432,CDM,C1713,HCPCS,0278,RC,,,,both,,,1632.02,1060.81,,,,,,,,,,,,,
APPLIER CLP CRV MED 8 IN OPN MANUAL LOAD LCK LIG HEM-O-LOK,SUP-2656794,CDM,2720000010,LOCAL,0272,RC,,,,both,,,568.34,369.42,,,,,,,,,,,,,
GRAFT VASC FLIXENE L 30 CM DIA 8 MM EPTFE GRAD REINF 3 LAYR,SUP-2265950,CDM,C1768,CPT,0278,RC,,,,both,,,2961.02,1924.66,,,,,,,,,,,,,
CAGE SPNL 18 DEG L 22 X W 9 X H 14 MM TI ALLOY POST LUMBAR,SUP-2926401,CDM,C1889,HCPCS,0278,RC,,,,both,,,11429.60,7429.24,,,,,,,,,,,,,
ANCHOR SUT DIA13MM SGL LD 1 STRND NO2 HI FI Y KNOT,SUP-2167261,CDM,C1713,HCPCS,0278,RC,,,,both,,,2160.32,1404.21,,,,,,,,,,,,,
PLATE BNE L6MM THK0.6MM CHIN MIDFACE SIL TI FOR 2MM SCR,SUP-2402857,CDM,C1713,HCPCS,0278,RC,,,,both,,,615.44,400.04,,,,,,,,,,,,,
BLADE SAW W8XL75MM THK1MM 2.5DEG HUB RECIP SMOOTH DISP,SUP-2361584,CDM,2720000010,LOCAL,0272,RC,,,,both,,,659.40,428.61,,,,,,,,,,,,,
HC Sel Cath Plcmt Add 2/3 Brach,PX-3613621800,CDM,36218,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
BIT DRL DIA1.5MM STP D6MM MINI QUIK CPL FOR ST SCR,SUP-2188360,CDM,2720000010,LOCAL,0272,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
CUP ACET DIA64MM UNIV HIP TI POR PRESSFIT PRI CEMENTLESS MH,SUP-2250731,CDM,C1776,CPT,0278,RC,,,,both,,,4967.48,3228.86,,,,,,,,,,,,,
CLAMP MULT SCR FOR ORTHOFIX PREFIX FIX,SUP-2316289,CDM,C1713,HCPCS,0278,RC,,,,both,,,906.33,589.11,,,,,,,,,,,,,
HC Extremity Arteriogram Unilateral,PX-3237571000,CDM,75710,CPT,0323,RC,,,,outpatient,,,3608.00,2345.20,,,,,,,,,,,,,
PIN FIX L20MM FEM TRNSVRS AUXILIARY MINI COMPR,SUP-2406910,CDM,C1713,HCPCS,0278,RC,,,,both,,,171.92,111.75,,,,,,,,,,,,,
PLATE BNE BAR 14 MM 6 H SHRT CRANIOMAXILLOFACIAL SAG SPLIT,SUP-2883182,CDM,C1713,HCPCS,0278,RC,,,,both,,,1361.98,885.29,,,,,,,,,,,,,
HALF RING 160 MM INT DIAM,SUP-2818049,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8162.74,5305.78,,,,,,,,,,,,,
PLATE BNE 3.5X49 MM 4 HOLE SS DCP,SUP-2569136,CDM,C1713,HCPCS,0278,RC,,,,both,,,208.97,135.83,,,,,,,,,,,,,
CALCIUM CARBONATE ANTACID 500 MG PO CHEW,RX-9385,CDM,6370000000,HCPCS,0637,RC,66553-0004-01,NDC,,both,1,UN,0.50,0.32,,,,,,,,,,,,,
ANKLE FUSION PLATE ANTERIOR TT RIGHT 6H STRL,SUP-2815300,CDM,C1713,HCPCS,0278,RC,,,,both,,,9734.00,6327.10,,,,,,,,,,,,,
PORT INFUS CATH 9.5FR POLYUR 2 LUMN ATTCH VEN CATH X-PRT,SUP-2127755,CDM,C1788,HCPCS,0278,RC,,,,both,,,1522.90,989.88,,,,,,,,,,,,,
GRAFT BNE SUB 1.5ML VOID FILL RESRB PTTY MASTERGRFT,SUP-2288540,CDM,C9359,HCPCS,0278,RC,,,,both,,,450.56,292.86,,,,,,,,,,,,,
SCREW BNE N CANN 2 INX12 MM BOLD,SUP-2608941,CDM,C1713,HCPCS,0278,RC,,,,both,,,743.40,483.21,,,,,,,,,,,,,
CATHETER CV BEDSIDE SET 018 4 FRX60 CM SPECTRUM TURBO-JECT,SUP-2759827,CDM,C1751,HCPCS,0278,RC,,,,both,,,351.84,228.70,,,,,,,,,,,,,
COIL EMB L4CM PRI DIA0.020IN 2ND DIA4MM NIT COMPLX SFT FILL,SUP-2323392,CDM,C1889,HCPCS,0278,RC,,,,both,,,6904.86,4488.16,,,,,,,,,,,,,
SCREW BONE SELFTAPPING 2X12 MM MANDIBULAR 20/PK TITANIUM NON,SUP-2842278,CDM,C1713,HCPCS,0278,RC,,,,both,,,254.21,165.24,,,,,,,,,,,,,
GRAFT EVAR L16CM AORT OD23MM ID19-21MM IL OD12MM ID10-11MM,SUP-2395971,CDM,C1768,CPT,0278,RC,,,,both,,,23945.64,15564.67,,,,,,,,,,,,,
SCREW IM L75MM DIA105MM TI ALLY LAG NAT NAIL,SUP-2208053,CDM,C1713,HCPCS,0278,RC,,,,both,,,1614.53,1049.44,,,,,,,,,,,,,
SYSTEM KNEE NP PS FEM COMP W/ CEM TIB GEN II,SUP-2347966,CDM,C1776,CPT,0278,RC,,,,both,,,11643.12,7568.03,,,,,,,,,,,,,
COMPONENT TOE GREAT TOE METATARSAL NEUT TI SM SZ 1 SWNSN,SUP-2397899,CDM,C1776,CPT,0278,RC,,,,both,,,4537.30,2949.24,,,,,,,,,,,,,
PLATE 3.5MM TI LCP PERIARTIC PROX HUM 3 HOLE 109MM RT STRL,SUP-2546855,CDM,C1713,HCPCS,0278,RC,,,,both,,,5681.58,3693.03,,,,,,,,,,,,,
STRATOGEN MEM 4 X 4 CM,SUP-2164201,CDM,Q4139,HCPCS,0636,RC,,,,both,,,5024.00,3265.60,,,,,,,,,,,,,
DRILL HND OD1.5MM SH QUIK REL HPS,SUP-2319573,CDM,2720000010,LOCAL,0272,RC,,,,both,,,301.44,195.94,,,,,,,,,,,,,
PLATE ATTACHMENT 3.5MM TI LCKNG PL F4.5MM LCP 4H-STER,SUP-2546834,CDM,C1713,HCPCS,0278,RC,,,,both,,,1761.16,1144.75,,,,,,,,,,,,,
GRAFT BIO TISS OMEGA3 MARIGEN 3X7CM FEN,SUP-2909200,CDM,Q4158,HCPCS,0636,RC,,,,both,,,3928.14,2553.29,,,,,,,,,,,,,
KIT ORTH TENODESIS DISP FOR 3X8MM SCR SYS,SUP-2121328,CDM,C1769,HCPCS,0272,RC,,,,both,,,926.30,602.09,,,,,,,,,,,,,
SCREW BNE CORTICAL 5X38 MM FT HEX DRV SOCKET TIM AFFIXUS,SUP-2489960,CDM,C1713,HCPCS,0278,RC,,,,both,,,534.65,347.52,,,,,,,,,,,,,
DRILL SURG CANN 15 MM GLEN W/ STP GLOB UNITE,SUP-2454287,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1591.98,1034.79,,,,,,,,,,,,,
TI MATRIXMANDIBLE 3X3H ANGLE,SUP-2823040,CDM,C1713,HCPCS,0278,RC,,,,both,,,1973.80,1282.97,,,,,,,,,,,,,
GRAFT HUM TISS W2XL3CM THCK PTCH UMB CRD DERIVATIVE AMNION,SUP-2393049,CDM,Q4170,HCPCS,0636,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
PACLITAXEL 100 MG/16.7ML IV CONC,RX-31096,CDM,J9267,HCPCS,0636,RC,61703-0342-22,NDC,,both,16.7,ML,81.20,52.78,,,,,,,,,,,,,
GUIDE SURG CUT AO CUST CT DERIVED,SUP-2741997,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8007.00,5204.55,,,,,,,,,,,,,
VALVE CSF 15 CM 2PC SHUNT SYS 15 CM CATH W/ ANTECHAMBER,SUP-2666652,CDM,C1889,HCPCS,0278,RC,,,,both,,,9553.86,6210.01,,,,,,,,,,,,,
HC Blood Occult Peroxidase Actv Qual Other Sources,PX-3018227100,CDM,82271,CPT,0301,RC,,,,inpatient,,,67.00,43.55,,,,,,,,,,,,,
SYSTEM CARD ICD SYS 2 CHMBR W/ RIATA SYS FOR V-243 ATLS + DR,SUP-2356555,CDM,C1721,HCPCS,0275,RC,,,,both,,,66520.90,43238.58,,,,,,,,,,,,,
MESH HERN ELLIPSE 14X12 IN W/ ECHO2 POS SYS POLYPR PHASIX ST,SUP-2855267,CDM,C1781,HCPCS,0278,RC,,,,both,,,52595.00,34186.75,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE 2.5 CC DBM PTTY FIBER XCITE -RSFH,SUP-2881378,CDM,C1713,HCPCS,0278,RC,,,,both,,,2712.96,1763.42,,,,,,,,,,,,,
STENT ESOPH EVOLUTION L 8 CM BODY DIA20 MM FLANGE DIA25 MM,SUP-2170564,CDM,C1874,HCPCS,0278,RC,,,,both,,,5199.84,3379.90,,,,,,,,,,,,,
HC Sinuses Less Than 3 Views,PX-3207021000,CDM,70210,CPT,0320,RC,,,,both,,,433.00,281.45,,,,,,,,,,,,,
INTRODUCER HEMSTAS FAST CATH 13FRX30CM SHTH W/ L LUMN AND,SUP-2355436,CDM,C1894,HCPCS,0272,RC,,,,both,,,56.52,36.74,,,,,,,,,,,,,
SHEATH INTRO FARADRIVE TOT L 91 CM DIA13 FR L 74 CM STEER,SUP-2885431,CDM,C1766,CPT,0272,RC,,,,both,,,4082.00,2653.30,,,,,,,,,,,,,
RIGEL CERV PRNT 12MMX12MMX7MMX6 CGE TI 3D,SUP-2664102,CDM,C1889,HCPCS,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
HC Ot Vasopneumatic Device Therapy|OP PT SERVICES|DOCUMENTATION ON FILE|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS,PX-4309701600,CDM,97016,CPT,0430,RC,,,GP|KX|CQ,both,,,206.00,133.90,,,,,,,,,,,,,
BLADE RTRCTR BKWLTR KELLY MDFD STNDRD 2INW X 2 12ND,SUP-2706031,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1055.04,685.78,,,,,,,,,,,,,
PLATE BNE 8 H NONSTERILE L TI EXT H SHP LOK COMPR W SHT THRD,SUP-2180915,CDM,C1713,HCPCS,0278,RC,,,,both,,,1373.40,892.71,,,,,,,,,,,,,
CLIP ANEURYSM SUNDT TEMPORARY #7 SIDE ANGLE 10MM 201867,SUP-2844576,CDM,C1889,HCPCS,0278,RC,,,,both,,,867.27,563.73,,,,,,,,,,,,,
SET UROLOGICAL SHTH PEELWY L 9 CM DIA 5 FR GUIDEWIRE L 65 CM,SUP-2168661,CDM,C1892,HCPCS,0272,RC,,,,both,,,202.22,131.44,,,,,,,,,,,,,
PLATE BONE W35XL35MM THK0.5MM ORBIT FLR RAP RESRB FOR 1.5MM,SUP-2194079,CDM,C1713,HCPCS,0278,RC,,,,both,,,3105.77,2018.75,,,,,,,,,,,,,
PROBE SURG GUIDEWIRE 1.6 MM ACUTRK 2,SUP-2525724,CDM,2720000010,LOCAL,0272,RC,,,,both,,,675.10,438.81,,,,,,,,,,,,,
HC Asp Inj Intermediate Joint,PX-3612060500,CDM,20605,CPT,0361,RC,,,,inpatient,,,358.00,232.70,,,,,,,,,,,,,
BIT DRL L110MM WRK L20MM DIA1.6MM CLR DEPTH MRK FOR,SUP-2364186,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1293.84,841.00,,,,,,,,,,,,,
PLATE BNE 3.5X41 MM 3 HOLE SS LC-DCP,SUP-2569225,CDM,C1713,HCPCS,0278,RC,,,,both,,,191.70,124.60,,,,,,,,,,,,,
BLADE SHV L11CM DIA4MM 40DEG M4 ROT CRV SHFT TIP ROHS RAD,SUP-2284146,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1210.66,786.93,,,,,,,,,,,,,
ANCHOR SUT TWINFIX PK FT 5.5MM W/ TWO SUTS AND DISP AWL,SUP-2341094,CDM,C1713,HCPCS,0278,RC,,,,both,,,1161.80,755.17,,,,,,,,,,,,,
BIT DRL L54MM DIA1.4MM 8MM STP FOR 1.7MM SCR MID FACE,SUP-2366410,CDM,2720000010,LOCAL,0272,RC,,,,both,,,439.25,285.51,,,,,,,,,,,,,
CLAMP ORTH L FOR ORTHOFIX GALAXY FIX SYS,SUP-2316294,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1287.40,836.81,,,,,,,,,,,,,
POST EXT FIX 30DEG ANG JET-X,SUP-2342957,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1696.51,1102.73,,,,,,,,,,,,,
STEM FEM SZ 14 L165X145MM ML36MM 135DEG TI PLSM SPRAYED HIP,SUP-2304847,CDM,C1776,CPT,0278,RC,,,,both,,,9796.80,6367.92,,,,,,,,,,,,,
STENT EVAR L80MM DIA8MM DST TRNSJUG BARE MTL INTRAHEPATIC,SUP-2395924,CDM,C1874,HCPCS,0278,RC,,,,both,,,12867.72,8364.02,,,,,,,,,,,,,
PLATE BONE MAXILLOFACIAL LT W/O BRDG,SUP-2372895,CDM,C1713,HCPCS,0278,RC,,,,both,,,766.16,498.00,,,,,,,,,,,,,
HC Drug Screen Quantitative Vancomycin,PX-3018020200,CDM,80202,CPT,0301,RC,,,,both,,,170.00,110.50,,,,,,,,,,,,,
HC So Pdgfra Gene,PX-3018131466,CDM,81314,CPT,0301,RC,,,,both,,,429.00,278.85,,,,,,,,,,,,,
LEVOFLOXACIN 5 MG/ML SYRINGE (PED) <50 ML,RX-4090160,CDM,J1956,HCPCS,0636,RC,00143-9720-01,NDC,,both,50,ML,16.80,10.92,,,,,,,,,,,,,
AGENT HEMSTAT 3GM OXIDIZED REGENERATED CELOS ABSRB FOR CONT (ORDER MULTIPLES OF 5EA),SUP-2218277,CDM,2720000010,LOCAL,0272,RC,,,,both,,,454.61,295.50,,,,,,,,,,,,,
SHEATH INTRO INPUT PS L 11 CM DIA 6 FR GUIDEWIRE 0.038 IN,SUP-2277550,CDM,C1894,HCPCS,0272,RC,,,,both,,,3406.90,2214.48,,,,,,,,,,,,,
PLATE BNE T METATRSL FORE FT 6 HOLE LESSER ORTHOLOC,SUP-2398013,CDM,C1713,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC IR 4FR 55CM 1 LUMAN RVS TAP 3174335,SUP-2632654,CDM,C1751,HCPCS,0278,RC,,,,both,,,359.00,233.35,,,,,,,,,,,,,
SLIDER NDL 30DEG STAIGHT,SUP-2366705,CDM,2720000010,LOCAL,0272,RC,,,,both,,,767.79,499.06,,,,,,,,,,,,,
MESH SURG W4XL7CM THK1.1MM ACELLULAR DERM MATRIXXENOGRAFT,SUP-2362225,CDM,C1763,HCPCS,0278,RC,,,,both,,,10048.00,6531.20,,,,,,,,,,,,,
GUIDEWIRE VASC EMERALD L 260 CM DIA 0.025 IN FLX TIP L 7 CM,SUP-2157231,CDM,C1769,HCPCS,0272,RC,,,,both,,,28.26,18.37,,,,,,,,,,,,,
KIT SHUNT CATH DSTL L 120 CM VENTRICULAR L 23 CM REG,SUP-2929980,CDM,C1889,HCPCS,0278,RC,,,,both,,,17584.00,11429.60,,,,,,,,,,,,,
STEM FEM L150MM OD24MM UNIV STD TI KNEE REV CEM FLUT STR,SUP-2406977,CDM,C1776,CPT,0278,RC,,,,both,,,3331.85,2165.70,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.428,SUP-2859992,CDM,C1713,HCPCS,0278,RC,,,,both,,,38421.04,24973.68,,,,,,,,,,,,,
SET THAL QUIK CHST TUBE 28 FR CATH LEN 41CM SIDEPORTS 4 SET,SUP-2167989,CDM,C1729,HCPCS,0272,RC,,,,both,,,748.58,486.58,,,,,,,,,,,,,
SHEATH INTRO PERFRMR L 75 CM OD 5 FR ID 1.7 MM 0.035IN,SUP-2168789,CDM,C1894,HCPCS,0272,RC,,,,both,,,213.21,138.59,,,,,,,,,,,,,
CAP END STANDARD PANTA STERILE,SUP-2586600,CDM,C1889,HCPCS,0278,RC,,,,both,,,1145.28,744.43,,,,,,,,,,,,,
PEEK CANN A,SUP-2417906,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3293.86,2141.01,,,,,,,,,,,,,
BLADE SHV L11CM DIA4MM 5000RPM SNUS SERR NONROTATABLE STR,SUP-2284143,CDM,2720000010,LOCAL,0272,RC,,,,both,,,751.59,488.53,,,,,,,,,,,,,
ANCHOR SUTURE L11MM DIAMETER 3.1MM PRE THREADED WITH ONE NO,SUP-2825036,CDM,C1713,HCPCS,0278,RC,,,,both,,,1010.01,656.51,,,,,,,,,,,,,
HINGE EXT FIX 90DEG LO PROF FOR ILIZ,SUP-2342309,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1583.82,1029.48,,,,,,,,,,,,,
STENT PERIPH XPERT L 80 MM DIA 4 MM DEL SYS L 90 CM INTRO 4,SUP-2105969,CDM,C1725,HCPCS,0272,RC,,,,both,,,6594.00,4286.10,,,,,,,,,,,,,
SCREW SPNL MULTAXL 4.5X65 MM CANN EXT TAB VOYAGER 4.75,SUP-2629433,CDM,C1713,HCPCS,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
SCREW BLNT PT SCHANZ 5.0X35MM,SUP-2737900,CDM,C1713,HCPCS,0278,RC,,,,both,,,599.17,389.46,,,,,,,,,,,,,
GRAFT HUM TISS FIB SHFT BNE 200MM LEN 8 15MM W FRZN,SUP-2264756,CDM,C1713,HCPCS,0278,RC,,,,both,,,2897.75,1883.54,,,,,,,,,,,,,
STENT BILI L20MM 8FR 135CM CATH LEN 10MM DIAM AD PRECIS,SUP-2158892,CDM,C1876,HCPCS,0278,RC,,,,both,,,6085.32,3955.46,,,,,,,,,,,,,
SUMATRIPTAN SUCCINATE 25 MG PO TABS,RX-15327,CDM,6370000000,HCPCS,0637,RC,55111-0291-09,NDC,,both,1,UN,8.00,5.20,,,,,,,,,,,,,
BIOTIN 3 MG PO TABS,RX-1070,CDM,6370000000,HCPCS,0637,RC,54022-1098-01,NDC,,both,1,UN,1.20,0.78,,,,,,,,,,,,,
BLADE SAW THK0.38MM MIC LT IBO RECIP COR TPS,SUP-2363315,CDM,2720000010,LOCAL,0272,RC,,,,both,,,322.95,209.92,,,,,,,,,,,,,
OCTREOTIDE ACETATE 30 MG IM KIT,RX-24436,CDM,J2353,HCPCS,0636,RC,00078-0825-81,NDC,,both,1,UN,19908.20,12940.33,,,,,,,,,,,,,
BUR SURG L14CM DIA3MM MTCH HD FLUT L BOR MIDAS REX LEGEND,SUP-2284085,CDM,2720000010,LOCAL,0272,RC,,,,both,,,339.59,220.73,,,,,,,,,,,,,
TRAY CATHETER 4FR SGL LUMN MAXIMAL BARR GROSH,SUP-2126718,CDM,C1751,HCPCS,0278,RC,,,,both,,,697.80,453.57,,,,,,,,,,,,,
COLLAR CERV PADDED LG TALL COMFORT ADJ MIAMI J,SUP-2434343,CDM,L0174,HCPCS,0274,RC,,,,both,,,155.46,101.05,,,,,,,,,,,,,
GRAFT SFT TISS X THCK 25X15 CM RECON TISS MTRX STRATTICE,SUP-2492100,CDM,Q4130,HCPCS,0636,RC,,,,both,,,37127.36,24132.78,,,,,,,,,,,,,
ALLOGRAFT BNE SHT 3 CMX3 MM FD CIR CANC STRL ENHANCE LF DISP,SUP-2468377,CDM,C1889,HCPCS,0278,RC,,,,both,,,1513.32,983.66,,,,,,,,,,,,,
MESH HERN W3XL6IN RECTANG COMP POLYMER MACROPOROUS NAT,SUP-2219767,CDM,C1781,HCPCS,0278,RC,,,,both,,,1139.47,740.66,,,,,,,,,,,,,
TAP SURG 30MM ACUTWIST ACUTRK,SUP-2107217,CDM,2720000010,LOCAL,0272,RC,,,,both,,,395.64,257.17,,,,,,,,,,,,,
WIRE FIX L150MM DIA16MM S STL DBL TRCR K,SUP-2397838,CDM,2720000010,LOCAL,0272,RC,,,,both,,,75.36,48.98,,,,,,,,,,,,,
OCCLUDER DUCT L5MM DIA5X4MM RETEN SKRT DIA9MM SHTH 5FR,SUP-2355740,CDM,C1817,HCPCS,0278,RC,,,,both,,,14058.41,9137.97,,,,,,,,,,,,,
TRAY DIAG X LEV RADPQ W/ BONE CEM DEL AVATEX AVAMAX,SUP-2367084,CDM,C1713,HCPCS,0278,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
PLATE BNE 1.5/2X37X1.5 MM 6 HOLE SS LC-DCP,SUP-2569196,CDM,C1713,HCPCS,0278,RC,,,,both,,,264.23,171.75,,,,,,,,,,,,,
STEM TOE M METATRSL,SUP-2319769,CDM,C1776,CPT,0278,RC,,,,both,,,5275.20,3428.88,,,,,,,,,,,,,
SUBSTITUTE BONE GRFT 0.5CC PUTTY GRFTON,SUP-2307526,CDM,C9359,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
LOPERAMIDE HCL 1 MG/7.5ML PO SOLN,RX-150665,CDM,340b,HCPCS,0637,RC,68094-0129-59,NDC,,both,15,ML,54.10,35.16,,,,,,,,,,,,,
COIL EMB COMPLX 7 MMX30 CM DETACHABLE COMPLX ORBIT GALAXY,SUP-2427713,CDM,C1713,HCPCS,0278,RC,,,,both,,,6208.35,4035.43,,,,,,,,,,,,,
KIT DRL PIN L100MM DIA2MM ABSRB W/ MTL TIP K WIRE GUID SL,SUP-2121832,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
HC Ot Therapeutic Activities 15 Min|OP OCCUPATIONAL THERAPY SERV|SERVICES PROVIDED IN WHOLE OR IN PARTY BY AN OTA FOR MEDICARE PATIENTS|ADJ,PX-4309753000,CDM,97530,CPT,0430,RC,,,GO|CO|ADJ,both,,,144.00,93.60,,,,,,,,,,,,,
RING W COMPR DISTR UNIT ATTCH FOR LIMB RECON SYS DYNA,SUP-2316075,CDM,2720000010,LOCAL,0272,RC,,,,both,,,793.04,515.48,,,,,,,,,,,,,
SET HAD CATHETER 155FR L20CM 3 LUMN STR EXTN BASIC SHT TERM,SUP-2266990,CDM,C1752,HCPCS,0278,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
SEED BRACHYTHERAPY 17/18 GA CART ANCHR,SUP-2135317,CDM,C2639,HCPCS,0278,RC,,,,both,,,78.50,51.02,,,,,,,,,,,,,
PLATE BNE L193MM 8 H R DST FEM LOK FOR 4.5MM SCR PERI-LOC,SUP-2348460,CDM,C1713,HCPCS,0278,RC,,,,both,,,10568.93,6869.80,,,,,,,,,,,,,
PAD ORTHOT ABD CUST,SUP-2435590,CDM,L1270,HCPCS,0274,RC,,,,both,,,234.65,152.52,,,,,,,,,,,,,
CATHETER VALVULOPLASTY TRUE L 110 CM BALLOON L 4.5 CM DIA20,SUP-2127689,CDM,C1725,HCPCS,0272,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
BIT DRL 3.5X40 MM,SUP-2322485,CDM,2720000010,LOCAL,0272,RC,,,,both,,,848.93,551.80,,,,,,,,,,,,,
COMPONENT ARTC SURF PS 12 MM KNEE,SUP-2208666,CDM,C1776,CPT,0278,RC,,,,both,,,1965.77,1277.75,,,,,,,,,,,,,
NAIL IM L420MM DIA9MM 130DEG STRL GRN FEM TI LCK UNREAMED,SUP-2192546,CDM,C1713,HCPCS,0278,RC,,,,both,,,3463.92,2251.55,,,,,,,,,,,,,
PLATE BONE COMPR 4 H 20 MM,SUP-2243487,CDM,C1713,HCPCS,0278,RC,,,,both,,,4144.80,2694.12,,,,,,,,,,,,,
SCREW BNE L14MM DIA4MM CORT S STL ST FOR VAR ANG LCP ANK,SUP-2183683,CDM,C1713,HCPCS,0278,RC,,,,both,,,76.96,50.02,,,,,,,,,,,,,
SCREW BNE L14.5MM DIA8MM CORT TI CANN NONLOCKING COMPR FOR,SUP-2368711,CDM,C1713,HCPCS,0278,RC,,,,both,,,879.20,571.48,,,,,,,,,,,,,
PLATE BONE L246MM THK3.7MM 14 H LT DSTL MEDL TIB TI LCK,SUP-2190885,CDM,C1713,HCPCS,0278,RC,,,,both,,,4722.84,3069.85,,,,,,,,,,,,,
FOSAPREPITANT (EMEND) 150 MG IN NS 150 ML IVPB,RX-4082427,CDM,J1453,HCPCS,0636,RC,99999-9917-39,NDC,,both,150,ML,154.90,100.68,,,,,,,,,,,,,
DRESSING BIO W2XL2IN BOV TEND CLLGN MESHED GLYCOSAMINOGLYCAN,SUP-2244272,CDM,C9363,HCPCS,0636,RC,,,,both,,,10059.90,6538.93,,,,,,,,,,,,,
ROD SPNL POST SMOOTH 5.5MM DIA 30MM LEN,SUP-2289297,CDM,C1713,HCPCS,0278,RC,,,,both,,,486.70,316.35,,,,,,,,,,,,,
SCREW CANN SHRT 12.5MM OD 8.0MM ID,SUP-2457974,CDM,C1713,HCPCS,0278,RC,,,,both,,,1718.02,1116.71,,,,,,,,,,,,,
PLATE BNE W5XL23MM THK1.5MM 4 H 1ST METATARSAL FOREFOOT,SUP-2398017,CDM,C1713,HCPCS,0278,RC,,,,both,,,1208.90,785.78,,,,,,,,,,,,,
LINER ACET 24 10 DEG 32 MM FEM HIP ARCOMXL RINGLOK,SUP-2136079,CDM,C1776,CPT,0278,RC,,,,both,,,4352.04,2828.83,,,,,,,,,,,,,
PLATE SPINAL RIGHT 3X4 HOLE LOW PROFILE L OBLIQUE NEURO TITA,SUP-2838355,CDM,C1713,HCPCS,0278,RC,,,,both,,,1142.96,742.92,,,,,,,,,,,,,
WIRE ORTH THRD SGL SHRP TIP TRCR S STL NONSTERILE 1.4MM DIA,SUP-2363709,CDM,C1713,HCPCS,0278,RC,,,,both,,,29.83,19.39,,,,,,,,,,,,,
HARVESTER BNE GRFT CLOSED 4.75 MM KNEE TEND NS REUSE,SUP-2762177,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1777.24,1155.21,,,,,,,,,,,,,
PROSTHESIS OSS 6.1 MM 1.12 MM 3 MM STRASNICK TILT-TOP OTOSIL,SUP-2475021,CDM,L8613,CPT,0278,RC,,,,both,,,1159.32,753.56,,,,,,,,,,,,,
LINER ACET SNAP IN NEUT STD 28X49 MM HIP INTOP PRIMARY NS,SUP-2207586,CDM,C1776,CPT,0278,RC,,,,both,,,5265.78,3422.76,,,,,,,,,,,,,
COMPONENT TIB KNEE HNG ASMBLY ROTATIONAL STP PIN GRDIAN,SUP-2304393,CDM,C1776,CPT,0278,RC,,,,both,,,5746.20,3735.03,,,,,,,,,,,,,
ANCHOR SUT 29MM NO2 PRE DEPLOYED SUT ONLY PRE THRD W POLY,SUP-2166459,CDM,C1713,HCPCS,0278,RC,,,,both,,,666.50,433.22,,,,,,,,,,,,,
SHEATH INTRO FAST-CATH L 60 CM DIA 8.5 FR CRV DIA28 MM,SUP-2357213,CDM,C1894,HCPCS,0272,RC,,,,both,,,527.52,342.89,,,,,,,,,,,,,
CATHETER GUID 0.066 INX6 FRX100 CM CORONARY,SUP-2103094,CDM,C1887,HCPCS,0272,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
COLLAR CERV TALL AD 2 PC ATLS,SUP-2319263,CDM,L0172,HCPCS,0274,RC,,,,both,,,104.62,68.00,,,,,,,,,,,,,
PLATE BNE L161MM 8 H ST R MED DST TIB S STL LOK COMPR LO,SUP-2177447,CDM,C1713,HCPCS,0278,RC,,,,both,,,4149.82,2697.38,,,,,,,,,,,,,
MOLINA ORBTL MALAR DSTRCTR 25MM DISTR T 6L 4V SNGLE USE,SUP-2694390,CDM,C1713,HCPCS,0278,RC,,,,both,,,12775.25,8303.91,,,,,,,,,,,,,
HC So Rubella Latex Test,PX-3028676266,CDM,86762,CPT,0302,RC,,,,both,,,165.00,107.25,,,,,,,,,,,,,
GRAFT VASC IMPRA L 50 CM DIA 6 MM EPTFE FLX TW SM BEAD RING,SUP-2761456,CDM,C1768,CPT,0278,RC,,,,both,,,3033.52,1971.79,,,,,,,,,,,,,
SHEATH INTRO PINNACLE DESTINATION 45CM 6FR COAT L 5CM HS,SUP-2385270,CDM,C1894,HCPCS,0272,RC,,,,both,,,268.47,174.51,,,,,,,,,,,,,
EXPEL APDL 8.3/25 K,SUP-2652759,CDM,C1729,HCPCS,0272,RC,,,,both,,,527.52,342.89,,,,,,,,,,,,,
SHEATH INTRO PEELWY L 30 CM DIA16 FR GUIDEWIRE 0.038 IN,SUP-2167892,CDM,C1894,HCPCS,0272,RC,,,,both,,,162.84,105.85,,,,,,,,,,,,,
GUIDEWIRE MONGO18 300CM PRE US,SUP-2878242,CDM,C1769,HCPCS,0272,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
INSERT TIB THK10MM STD R MED L LAT ULT HI MOL WT POLYETH,SUP-2408378,CDM,C1776,CPT,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
BIT DRL L238MM OD31MM M LOK ST,SUP-2365051,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1046.25,680.06,,,,,,,,,,,,,
GRAFT VASC GELWEAVE L 50 CM DIA24 MM POLYESTER GEL AORT ARCH,SUP-2894579,CDM,C1768,CPT,0278,RC,,,,both,,,4210.74,2736.98,,,,,,,,,,,,,
SHEATH INTRDCR VSCLR 4FR 11CML NTNL0018N DIA 157NL GDWRE M,SUP-2699687,CDM,C1894,HCPCS,0272,RC,,,,both,,,134.55,87.46,,,,,,,,,,,,,
PLATE BONE L125MM THK3.4MM 8 H BILAT S STL LCK COMPR NEUT,SUP-2348984,CDM,C1713,HCPCS,0278,RC,,,,both,,,3259.01,2118.36,,,,,,,,,,,,,
PLATE BNE L90MM 2 H ST L OLECRANON S STL LO PROF VAR ANG,SUP-2177192,CDM,C1713,HCPCS,0278,RC,,,,both,,,3563.71,2316.41,,,,,,,,,,,,,
PLATE BNE W10XL63MM THK15MM 3X4 H R TI T SHP OBLQ LO PROF,SUP-2190918,CDM,C1713,HCPCS,0278,RC,,,,both,,,1090.74,708.98,,,,,,,,,,,,,
HC Thyroid Horm Uptk/Thyroid Hormone Binding Ratio,PX-3018447900,CDM,84479,CPT,0301,RC,,,,both,,,40.00,26.00,,,,,,,,,,,,,
STENT URETERAL STENOSTENT 24CM,SUP-2848797,CDM,C2617,HCPCS,0278,RC,,,,both,,,925.36,601.48,,,,,,,,,,,,,
METOCLOPRAMIDE HCL 5 MG/ML IJ SOLN,RX-5002,CDM,J2765,HCPCS,0636,RC,00703-4502-91,NDC,,both,1,ML,54.10,35.16,,,,,,,,,,,,,
HC Inj Methylpred Sod Succ 5mg,PX-6360291900,CDM,J2919,HCPCS,0636,RC,,,,both,,,1.00,0.65,,,,,,,,,,,,,
PLATE BONE L69MM 6 H STRL LT POSTEROLATERAL DSTL FIBULAR S,SUP-2349720,CDM,C1713,HCPCS,0278,RC,,,,both,,,3654.96,2375.72,,,,,,,,,,,,,
SET INTRO L 45 CM DIA 5 FR NIT WIRE PLAT TIP MIC SHRT B BVL,SUP-2117206,CDM,C1769,HCPCS,0272,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
SET INTRO SAFSHTH L 13 CM DIA 9 FR GUIDEWIRE 0.038 IN NDL 18,SUP-2137993,CDM,C1892,HCPCS,0272,RC,,,,both,,,204.10,132.66,,,,,,,,,,,,,
PORT IMPL INFUSION BVL 2.2X90 MM MIS SS,SUP-2419687,CDM,2720000010,LOCAL,0272,RC,,,,both,,,722.20,469.43,,,,,,,,,,,,,
PI PICC KIT: 1L 4.5FR 55CM AGBA TIPTRACK,SUP-2826699,CDM,C1751,HCPCS,0278,RC,,,,both,,,861.40,559.91,,,,,,,,,,,,,
IMPLANT COSMETIC SZ 48 X 25 MM POLYETHYL RT INFERIOR ORBIT,SUP-2935386,CDM,C1713,HCPCS,0278,RC,,,,both,,,2618.76,1702.19,,,,,,,,,,,,,
POWERPORT M.R.I. SGL LUMEN DEVICE W/ 9.6FR ATTACHABL,SUP-2844949,CDM,C1778,HCPCS,0278,RC,,,,both,,,910.60,591.89,,,,,,,,,,,,,
PLATE BNE W10XL89MM THK1.5MM 90DEG 7X4 H BILAT S STL T SHP,SUP-2185877,CDM,C1713,HCPCS,0278,RC,,,,both,,,1398.56,909.06,,,,,,,,,,,,,
PLATE BONE W14.9XL136MM THK1.2MM 8 H DSTL TIB S STL,SUP-2185737,CDM,C1713,HCPCS,0278,RC,,,,both,,,1073.60,697.84,,,,,,,,,,,,,
CATHETER INFUS L165CM OD2.7X1.5FR ID0.013IN L1.5CM 0.010IN,SUP-2284374,CDM,C1887,HCPCS,0272,RC,,,,both,,,6242.32,4057.51,,,,,,,,,,,,,
SYSTEM TRACTIONXL ADJ OPN BK HALO RNG COMPLT C GRAPHITE TI,SUP-2328134,CDM,L0810,HCPCS,0274,RC,,,,both,,,7536.00,4898.40,,,,,,,,,,,,,
KIT DRNGE 1000ML VAC BTL FOR PLEUR EFFUSIONS MALIG ASCITES,SUP-2133746,CDM,C1729,HCPCS,0272,RC,,,,both,,,172.70,112.25,,,,,,,,,,,,,
DIS HUM POSTLAT LT 25H 250MM,SUP-2499005,CDM,C1713,HCPCS,0278,RC,,,,both,,,5231.24,3400.31,,,,,,,,,,,,,
IBALANCE PFJ BLADE KIT AR60228L,SUP-2843870,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4678.60,3041.09,,,,,,,,,,,,,
THIAMINE MONONITRATE 100 MG PO TABS,RX-11538,CDM,6370000000,HCPCS,0637,RC,77333-0934-10,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PLATE BONE L168MM THK3.7MM 8 H STRL RT DSTL MEDL TIB S STL,SUP-2185530,CDM,C1713,HCPCS,0278,RC,,,,both,,,4813.43,3128.73,,,,,,,,,,,,,
GRAFT VASC INTERGARD L 70 CM DIA 7 MM RNG L 20 CM,SUP-2227612,CDM,C1768,CPT,0278,RC,,,,both,,,3244.09,2108.66,,,,,,,,,,,,,
SYSTEM TISS GLUE 5ML CONTAIN SYR PLUNG STD SYR TIP 12MM 5PKS/EA,SUP-2175219,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2935.90,1908.33,,,,,,,,,,,,,
SET TRAP SM PED UNIV FNGR S STL TRAC,SUP-2197344,CDM,2720000010,LOCAL,0272,RC,,,,both,,,996.29,647.59,,,,,,,,,,,,,
NAIL IM L170MM DIA10MM 125DEG TROCHANTERIC FEM TI CANN LOK,SUP-2370458,CDM,C1713,HCPCS,0278,RC,,,,both,,,4819.90,3132.93,,,,,,,,,,,,,
STAPLE BNE FIX SZ 28 X 17 X 14 MM ANAT QUAD RAPID COMPR STRL,SUP-2893066,CDM,C1713,HCPCS,0278,RC,,,,both,,,11771.86,7651.71,,,,,,,,,,,,,
LEAD DEFIB ENDOTK ENDUR RX L 70 CM SIL STEROID ENDOCARD,SUP-2148550,CDM,C1895,HCPCS,0275,RC,,,,both,,,11932.00,7755.80,,,,,,,,,,,,,
KNIFE 3722149 MYRINGOTOMY 90120 DEG,SUP-2667294,CDM,2720000010,LOCAL,0272,RC,,,,both,,,673.40,437.71,,,,,,,,,,,,,
SYSTEM ENDOSCOPIC 235CM PROFILE TACKING HELIX LOW XTACK,SUP-2878001,CDM,C1889,HCPCS,0278,RC,,,,both,,,5363.12,3486.03,,,,,,,,,,,,,
PACEMAKER SR SYS ACCENT,SUP-2356449,CDM,C1786,HCPCS,0275,RC,,,,both,,,13470.60,8755.89,,,,,,,,,,,,,
K WIRE FIX DIA0.90MM NTHRD,SUP-2378864,CDM,C1713,HCPCS,0278,RC,,,,both,,,101.99,66.29,,,,,,,,,,,,,
CATHETER KIT 4001] COLLINGWOOD],SUP-2165194,CDM,C1894,HCPCS,0272,RC,,,,both,,,244.92,159.20,,,,,,,,,,,,,
CATHETER PICC L55CM OD6FR GWIRE L80CM .018IN 3 LUMN N COAT,SUP-2117004,CDM,C1751,HCPCS,0278,RC,,,,both,,,236.13,153.48,,,,,,,,,,,,,
KIT TRL AXIUM INCL 2 AXIUM 50CM TRL LD KTS AND 1 CONN CBL KT,SUP-2356722,CDM,C1897,HCPCS,0278,RC,,,,both,,,8529.12,5543.93,,,,,,,,,,,,,
SUPPORT ORTHOT KNEE CUST RIGID W/O JT,SUP-2435611,CDM,L1836,HCPCS,0274,RC,,,,both,,,377.71,245.51,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 50 MM DIA 6 MM DEL SHTH,SUP-2934603,CDM,C1713,HCPCS,0278,RC,,,,both,,,5592.34,3635.02,,,,,,,,,,,,,
PLATE BNE DISTRCTN SHT 1.5-1.8 MM 2 HOLE BUTTRESS LEFORT 1,SUP-2463961,CDM,C1713,HCPCS,0278,RC,,,,both,,,3288.93,2137.80,,,,,,,,,,,,,
KIT CEM MIXING/DELIVERY 10CC RADPQ NDL 10GA L5IN W/O CEM PCD,SUP-2367026,CDM,C1713,HCPCS,0278,RC,,,,both,,,1457.84,947.60,,,,,,,,,,,,,
PLATE SPNL 17MM LAT STBL 4 H PLYMOUTH,SUP-2228575,CDM,C1713,HCPCS,0278,RC,,,,both,,,10801.60,7021.04,,,,,,,,,,,,,
MESH HERN 3 DIM PLUG SM 1.55X1.30 IN PRE FRM REP PROLOOP,SUP-2227250,CDM,C1781,HCPCS,0278,RC,,,,both,,,332.84,216.35,,,,,,,,,,,,,
BLADE SAW W70XL10MM THK1.19MM RECIP CEM FOR OXFORD KNEE,SUP-2408670,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1470.09,955.56,,,,,,,,,,,,,
CATH BLLN SCORING 4X200MM X 137CM OTW PTA ANGIOSCULPT,SUP-2353233,CDM,C1725,HCPCS,0272,RC,,,,both,,,4231.15,2750.25,,,,,,,,,,,,,
SYSTEM FIX 16X14X6 MM CERV SPINE UNISON-C,SUP-2419602,CDM,C1889,HCPCS,0278,RC,,,,both,,,5966.00,3877.90,,,,,,,,,,,,,
RING EXT FIX HALF 100 MM CARBON FIBER NS,SUP-2800122,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1275.75,829.24,,,,,,,,,,,,,
SHUNT SURG ADJ L 17 MM GRAVITATIONAL L 12 MM PRESSURE ADJ FX645T,SUP-2931040,CDM,C1729,HCPCS,0272,RC,,,,both,,,14971.05,9731.18,,,,,,,,,,,,,
MOLD CEM SPCR DIA60MM UNIV FEM SIL CRUCE SACRIFICING AGC,SUP-2408622,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3830.80,2490.02,,,,,,,,,,,,,
PLATE BNE STD LT 14 HOLE FOR ORTH FIX STRL POLARUS 3,SUP-2518199,CDM,C1713,HCPCS,0278,RC,,,,both,,,6603.42,4292.22,,,,,,,,,,,,,
SCREW BONE FULL THRD CANN SELF REINF PLLA 3.5MMX40MM,SUP-2166533,CDM,C1713,HCPCS,0278,RC,,,,both,,,938.86,610.26,,,,,,,,,,,,,
KIT PICC 5FR L50CM POLYUR DBL LUMN PRSS INJ BLU FLEXTIP T,SUP-2383371,CDM,C1751,HCPCS,0278,RC,,,,both,,,413.66,268.88,,,,,,,,,,,,,
BLADE SAW OSCLLTNG 25.4MMW X 90MML 1.37MM/1.37MM THK CUT BRZ,SUP-2586310,CDM,2720000010,LOCAL,0272,RC,,,,both,,,94.70,61.55,,,,,,,,,,,,,
PATCH EXT REF REFSTAR RMT QWIKPATCH NS,SUP-2248953,CDM,C1713,HCPCS,0278,RC,,,,both,,,1061.32,689.86,,,,,,,,,,,,,
LIFT HEEL MED 2.5 IN WDG 3 LAYR ORTHOT FT FABRIC BRN ADJLFT,SUP-2325936,CDM,L3332,HCPCS,0274,RC,,,,both,,,18.37,11.94,,,,,,,,,,,,,
GUIDE WIRE F/USE W/BOUGIES745808/9/10 745711/12/,SUP-2574269,CDM,C1769,HCPCS,0272,RC,,,,both,,,112.66,73.23,,,,,,,,,,,,,
PLATE BNE THK0.6MM 5 H CRAN TI MESH MIC RECT FOR 1.5MM SCR,SUP-2262704,CDM,C1713,HCPCS,0278,RC,,,,both,,,260.84,169.55,,,,,,,,,,,,,
MEXILETINE HCL 200 MG PO CAPS,RX-10596,CDM,6370000000,HCPCS,0637,RC,00093-8740-01,NDC,,both,1,UN,7.10,4.61,,,,,,,,,,,,,
IMPLANT TOE JT HEMI 1ST MPJ BASE OF PHALANX REPL CANN CHI TI,SUP-2392715,CDM,C1776,CPT,0278,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
NAIL IM L360MM DIA12MM ST AQUA L/R DST FEM TI LOK SLD DYN,SUP-2191785,CDM,C1713,HCPCS,0278,RC,,,,both,,,4330.06,2814.54,,,,,,,,,,,,,
SET PUMP IMPELLA LD AIC,SUP-2106267,CDM,2720000010,LOCAL,0272,RC,,,,both,,,78500.00,51025.00,,,,,,,,,,,,,
SET INTRO PERFRMR L 23 CM OD 6 FR ID 2 MM GUIDEWIRE L 80 CM,SUP-2168555,CDM,C1894,HCPCS,0272,RC,,,,both,,,109.74,71.33,,,,,,,,,,,,,
GUIDEPIN ORTH L 248 MM DIA 3.2 MM HUM THRD TIP STRL DISP,SUP-2933552,CDM,C1713,HCPCS,0278,RC,,,,both,,,374.73,243.57,,,,,,,,,,,,,
SET SCR SPNL M6 PEDCL TI ALLOY FUS FOR DYN STBL SYS DYNESYS,SUP-2414260,CDM,C1713,HCPCS,0278,RC,,,,both,,,942.63,612.71,,,,,,,,,,,,,
GRAFT HUM TISS L 1.5-2.9 X W 0.7-0.9 CM THK 3 MM SM COSTAL,SUP-2895219,CDM,C1762,CPT,0278,RC,,,,both,,,1623.07,1055.00,,,,,,,,,,,,,
PLATE BNE CRV MIC 1.5X0.6 MM NEURO 3X2 HOLE LADDER SQ SEG,SUP-2476261,CDM,C1713,HCPCS,0278,RC,,,,both,,,759.35,493.58,,,,,,,,,,,,,
BIT DRL 2.5 MM 00430004901],SUP-2199000,CDM,2720000010,LOCAL,0272,RC,,,,both,,,879.20,571.48,,,,,,,,,,,,,
GRAFT HUM TISS W/O SCLER RIM,SUP-2388444,CDM,V2785,HCPCS,0810,RC,,,,both,,,1303.10,847.01,,,,,,,,,,,,,
IMPLANT FACE W 40 X H 25 MM THK 4 MM SM POLYETHYL CHIN BTTN,SUP-2883599,CDM,C1713,HCPCS,0278,RC,,,,both,,,1300.53,845.34,,,,,,,,,,,,,
PUSHER COIL L 177 CM DIA 0.016 IN CATH 0.018 IN STRL,SUP-2142674,CDM,2720000010,LOCAL,0272,RC,,,,both,,,533.80,346.97,,,,,,,,,,,,,
SNARE VASC 1 SNR L 200 CM LOOP DIA 7 MM CATH L 175 CM,SUP-2303151,CDM,C1773,HCPCS,0272,RC,,,,both,,,1852.60,1204.19,,,,,,,,,,,,,
PLATE BONE L119MM THK3.4MM 8 H BILAT NONLOCKING COMPR FOR,SUP-2348951,CDM,C1713,HCPCS,0278,RC,,,,both,,,1559.45,1013.64,,,,,,,,,,,,,
SCREW BNE DISTRCTN 12 MM STRL,SUP-2430773,CDM,C1713,HCPCS,0278,RC,,,,both,,,150.72,97.97,,,,,,,,,,,,,
PLATE QUIKFLAP BURR 20MM SD AXS,SUP-2718053,CDM,C1713,HCPCS,0278,RC,,,,both,,,10154.76,6600.59,,,,,,,,,,,,,
GRAFT SURG 1MM PROC HUM DERM CLLGN RECTANG 8CMX12CM ALLOMAX,SUP-2126260,CDM,C1781,HCPCS,0278,RC,,,,both,,,6728.71,4373.66,,,,,,,,,,,,,
IMMOBILIZER SHLDR L STRP 43IN,SUP-2324219,CDM,L3650,HCPCS,0274,RC,,,,both,,,19.75,12.84,,,,,,,,,,,,,
DEVICE FLO CPLR OD3MM 20MHZ DOPP,SUP-2382625,CDM,C1889,HCPCS,0278,RC,,,,both,,,3444.58,2238.98,,,,,,,,,,,,,
CLIP ANEURYSM SUNDTKEES 9MM FENESTRATED 90 DEG 201719,SUP-2844604,CDM,C1889,HCPCS,0278,RC,,,,both,,,828.74,538.68,,,,,,,,,,,,,
PLATE BNE BAR L12MM 2 H CRANIOMAXILLOFACIAL TI LO PROF W/,SUP-2366199,CDM,C1713,HCPCS,0278,RC,,,,both,,,327.82,213.08,,,,,,,,,,,,,
BRACE KNEE POSTOP COOL PROCARE TROM ADV,SUP-2195713,CDM,L1810,HCPCS,0274,RC,,,,both,,,226.68,147.34,,,,,,,,,,,,,
PLATE BNE L LNG 2.4/2.7X62 MM LT 1ST MTP 2X2 HOLE VA LP LCK,SUP-2181252,CDM,C1713,HCPCS,0278,RC,,,,both,,,3306.39,2149.15,,,,,,,,,,,,,
SCREW BNE CRTX 3.5X26 MM LP ST HD HEXDRIVE TI NS,SUP-2758233,CDM,C1713,HCPCS,0278,RC,,,,both,,,95.86,62.31,,,,,,,,,,,,,
DISSECTOR ENDOSCP L RND FOR TISS PLANE SEP BLLN SPCMKR PDB,SUP-2283310,CDM,2720000010,LOCAL,0272,RC,,,,both,,,744.34,483.82,,,,,,,,,,,,,
PLATE BNE W22XL62MM THK1.6MM LNG 12 H TRILOK NAR CORR R DST,SUP-2267966,CDM,C1713,HCPCS,0278,RC,,,,both,,,3714.62,2414.50,,,,,,,,,,,,,
STAPLER INT L33MM 48MM STPL HEMORRHOIDOPEXY PROLAPSE SET DST,SUP-2787664,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1394.57,906.47,,,,,,,,,,,,,
PLATE BONE 45MML 23MM THK HLX8 TTNM 60DG ANGLD F/23MM SCRE,SUP-2680279,CDM,C1713,HCPCS,0278,RC,,,,both,,,1249.78,812.36,,,,,,,,,,,,,
CATHETER ANGIOPLSTY BLU MAX 20 L 75 CM DIA 4 FR BALLOON L 10,SUP-2140995,CDM,C1725,HCPCS,0272,RC,,,,both,,,781.86,508.21,,,,,,,,,,,,,
PIN TEMP FIX L11.5IN GUID SUBTALAR,SUP-2390490,CDM,C1776,CPT,0278,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
BIO MEDICUS 15FR,SUP-2727840,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1023.58,665.33,,,,,,,,,,,,,
PROBE RF L150MM ACT TIPL4MM OD17GA DISP COOLIEF,SUP-2237178,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1193.20,775.58,,,,,,,,,,,,,
BIT DRL 3.8 MM,SUP-2402764,CDM,2720000010,LOCAL,0272,RC,,,,both,,,734.76,477.59,,,,,,,,,,,,,
BUR DMND PEAR AUTOCLV,SUP-2227830,CDM,2720000010,LOCAL,0272,RC,,,,both,,,39.56,25.71,,,,,,,,,,,,,
GUIDE WIRE 5/1.6MM,SUP-2548457,CDM,C1769,HCPCS,0272,RC,,,,both,,,2215.52,1440.09,,,,,,,,,,,,,
MANNITOL 25 % IV SOLN,RX-4750,CDM,J2151,HCPCS,0636,RC,63323-0024-25,NDC,,both,25,ML,54.10,35.16,,,,,,,,,,,,,
SHOE ORTHOT ADDITION INSOLE RUBBER,SUP-2435738,CDM,L3510,HCPCS,0272,RC,,,,both,,,82.77,53.80,,,,,,,,,,,,,
CATHETER DRAINAGE OTW 40 CM 6 MMX4 CM GLDEX,SUP-2140998,CDM,C1725,HCPCS,0272,RC,,,,both,,,722.20,469.43,,,,,,,,,,,,,
RETRACTOR SPINE FOR MTRX SYS,SUP-2292926,CDM,C1713,HCPCS,0278,RC,,,,both,,,618.52,402.04,,,,,,,,,,,,,
PLATE BNE 1/3 TBLR 37 MM 3 HOLE NS LTX,SUP-2861939,CDM,C1713,HCPCS,0278,RC,,,,both,,,174.65,113.52,,,,,,,,,,,,,
ALLOGRAFT BNE BOAT 50X25 MM 5 CC FD DBM CORTICAL FIBER,SUP-2717786,CDM,C1713,HCPCS,0278,RC,,,,both,,,4742.15,3082.40,,,,,,,,,,,,,
BANDAGE COMPR SM MAMM COMFORTABLE HIGHLY ABSRB POST SURG,SUP-2276344,CDM,L8000,HCPCS,0272,RC,,,,both,,,119.32,77.56,,,,,,,,,,,,,
COIL EMB L6CM DIA3MM EXTRA SFT PUSH DSGN USE ACE TRK,SUP-2323529,CDM,C1889,HCPCS,0278,RC,,,,both,,,5620.60,3653.39,,,,,,,,,,,,,
GRAFT BNE SUB 90CC 1 4MM CANC CRUSH CHIP READIGRFT,SUP-2264829,CDM,C1713,HCPCS,0278,RC,,,,both,,,3354.12,2180.18,,,,,,,,,,,,,
COMPONENT PART KNEE CAPPED K1 RESURF CAPARTHROSFK1] ARTHROSURFACE],SUP-2123630,CDM,C1776,CPT,0278,RC,,,,both,,,11618.00,7551.70,,,,,,,,,,,,,
STEM FEM L160MM DIA10.5MM HIP POR L STAT STD OFFSET AML,SUP-2252043,CDM,C1776,CPT,0278,RC,,,,both,,,19888.76,12927.69,,,,,,,,,,,,,
RESERVOIR PENILE PROS 125CC CLVRLF W/ LOK OUT VLV TI,SUP-2165444,CDM,C1813,HCPCS,0278,RC,,,,both,,,8635.00,5612.75,,,,,,,,,,,,,
IMPLANT BRST GEL 5.7 CM PROJCT 12X11.1 CM 325 GM NATRELLE,SUP-2113335,CDM,C1789,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
METHYLNALTREXONE BROMIDE 12 MG/0.6ML SC SOLN (VIAL),RX-4082846,CDM,J2212,HCPCS,0636,RC,65649-0551-03,NDC,,both,0.4,ML,651.40,423.41,,,,,,,,,,,,,
DUR BANTAM 10D 22.225X38 LINER,SUP-2512907,CDM,C1776,CPT,0278,RC,,,,both,,,2136.46,1388.70,,,,,,,,,,,,,
SCREW CANC 4.5MM DIA 20MM ST FULL TI F/BIOMET - 4.5MM DIAM,SUP-2408778,CDM,C1713,HCPCS,0278,RC,,,,both,,,584.04,379.63,,,,,,,,,,,,,
HC So Viscosity,PX-3058581066,CDM,85810,CPT,0305,RC,,,,inpatient,,,376.00,244.40,,,,,,,,,,,,,
GUIDEPIN ORTHOPAEDIC 3.2X300 MM THREADED STAINLESS STEEL STE,SUP-2836890,CDM,C1713,HCPCS,0278,RC,,,,both,,,201.02,130.66,,,,,,,,,,,,,
INSERT TIB 1 9MM CONSTRN CNDYL,SUP-2221225,CDM,C1776,CPT,0278,RC,,,,both,,,5341.14,3471.74,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 6-7X170-220 MM TIBIALIS TEND FLEXIGRAFT,SUP-2740858,CDM,C1762,CPT,0278,RC,,,,both,,,5618.56,3652.06,,,,,,,,,,,,,
STAPLER INT CRV TIP 30 MM ENDOWRIST,SUP-2246773,CDM,C1713,HCPCS,0278,RC,,,,both,,,22608.00,14695.20,,,,,,,,,,,,,
STENT URET EXPEL L 24 CM DIA 6 FR FLEXITHANE HYDRPHLC 2,SUP-2652789,CDM,C2617,HCPCS,0278,RC,,,,both,,,442.74,287.78,,,,,,,,,,,,,
TRAY CATH MIDLN Q CATH INTERMED 5FR 20CM 2 LUMAN W/15GA EXCA,SUP-2613419,CDM,C1751,HCPCS,0278,RC,,,,both,,,224.51,145.93,,,,,,,,,,,,,
BOOT LEG TRAC CONVOLUTED FOAM LNR W/ STAY UNIV AD BUCK,SUP-2194992,CDM,L4360,HCPCS,0272,RC,,,,both,,,31.40,20.41,,,,,,,,,,,,,
CATHETER ETER URET 4FR WHSTL TIP WVN L DRNGE LUMN REUSE,SUP-2126129,CDM,C1758,HCPCS,0278,RC,,,,both,,,245.45,159.54,,,,,,,,,,,,,
Z DUP USE 2111319 LENS INTOCU +21.5 DIOPT CYL PWR +3.75 DIOPT 119 A CONSTANT,SUP-2111825,CDM,V2787,HCPCS,0276,RC,,,,both,,,495.00,321.75,,,,,,,,,,,,,
TUBE VENT ID1.27MM BLU SIL LUMN TAPR W/ TWIN SPN FLNG,SUP-2312835,CDM,L8699,HCPCS,0278,RC,,,,both,,,62.74,40.78,,,,,,,,,,,,,
PIPERACILLIN SOD-TAZOBACTAM SO 4.5 (4-0.5) G IV SOLR,RX-18302,CDM,J2543,HCPCS,0636,RC,55150-0121-50,NDC,,both,1,UN,54.10,35.16,,,,,,,,,,,,,
NEBULIZER AEROSOL O2 TBNG ADPT AEROGEN ULTRA AEROGEN SOLO,SUP-2777858,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2641.12,1716.73,,,,,,,,,,,,,
BUR SURG BALL LNG 3.2 MM FLUT FOR HD/HD-G1,SUP-2848162,CDM,2720000010,LOCAL,0272,RC,,,,both,,,503.47,327.26,,,,,,,,,,,,,
STENT PERIPH ELUVIA L 120 MM DIA 6 MM CATH L 130 CM DIA 6 FR,SUP-2140848,CDM,C1874,HCPCS,0278,RC,,,,both,,,9718.30,6316.89,,,,,,,,,,,,,
PIN EXT FIX L180MM DIA5MM THRD L30MM TI NITRIDE HALF FOR,SUP-2400700,CDM,2720000010,LOCAL,0272,RC,,,,both,,,335.98,218.39,,,,,,,,,,,,,
SCREW SPNL L45MM DIA7MM PEDCL TI POLYAX MNRCH,SUP-2254497,CDM,C1713,HCPCS,0278,RC,,,,both,,,3052.08,1983.85,,,,,,,,,,,,,
EVOS TI 3.5MMX11MM LCK SCREW T15 S-T,SUP-2821484,CDM,C1713,HCPCS,0278,RC,,,,both,,,673.12,437.53,,,,,,,,,,,,,
FIBER LASER FLAT TIP 1000 MH ASMBLY HOLM,SUP-2225997,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2653.30,1724.64,,,,,,,,,,,,,
DEFIBRILLATOR IMPL ATLS + HF SZ 5 CM 36 J 40 CC TI POLYUR,SUP-2357757,CDM,C1882,HCPCS,0275,RC,,,,both,,,63742.00,41432.30,,,,,,,,,,,,,
STENT 2 PIGTAIL 28CM 8FR URETERAL NITINOL HYDROPHILIC,SUP-2655872,CDM,C2625,HCPCS,0278,RC,,,,both,,,325.90,211.83,,,,,,,,,,,,,
HC So Ptt|REPEAT CLINICAL DIAGNOSTIC LABORATORY TEST|NOT REASONABLE AND NECESSARY,PX-3058573066,CDM,85730,CPT,0305,RC,,,91|GZ,both,,,47.00,30.55,,,,,,,,,,,,,
CHOLANGIOGRAM KIT RX AUTOTOME UTOM XL SPHINTOM JAGWIRE 7166,SUP-2525318,CDM,C1769,HCPCS,0272,RC,,,,both,,,708.29,460.39,,,,,,,,,,,,,
BIT DRILL NON QUICK COUPLING 3.2X165/180 MM JACOBS CHUCK END,SUP-2837047,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1184.82,770.13,,,,,,,,,,,,,
POST SURG L ANK IOFIX PLUSXPOST GRN INTOSS FIX IMPL 20MM,SUP-2223897,CDM,C1713,HCPCS,0278,RC,,,,both,,,4160.50,2704.32,,,,,,,,,,,,,
HEPATITIS B VAC RECOMBINANT 20 MCG/ML IJ SUSY,RX-159676,CDM,90740,HCPCS,0636,RC,58160-0821-43,NDC,,both,1,ML,325.10,211.31,,,,,,,,,,,,,
HEAD HUM STD 40X15 MM SHLDR AFFINITI,SUP-2715318,CDM,C1776,CPT,0278,RC,,,,both,,,7082.27,4603.48,,,,,,,,,,,,,
CATHETER PD STR AD 52 CM 6 CM 15.5 CM CLASSIC STD,SUP-2490127,CDM,C1750,HCPCS,0278,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
SYSTEM SKIN CLSR 22CM DERMBND PRINEO,SUP-2218876,CDM,2720000010,LOCAL,0272,RC,,,,both,,,274.84,178.65,,,,,,,,,,,,,
ALLOGRAFT HUMAN TISSUE DERMACELL AWM 6CM X 7CM 0.2-1MM,SUP-2909514,CDM,Q4122,HCPCS,0636,RC,,,,both,,,9215.12,5989.83,,,,,,,,,,,,,
GRAFT VASC L50CM DIA18X9MM UNIV POLY KNIT BIFUR STD WALL,SUP-2395629,CDM,C1768,CPT,0278,RC,,,,both,,,1993.90,1296.03,,,,,,,,,,,,,
OXALIPLATIN 50 MG/10ML IV SOLN,RX-98538,CDM,J9263,HCPCS,0636,RC,72266-0161-01,NDC,,both,10,ML,54.10,35.16,,,,,,,,,,,,,
SCREW EXT FIX L100MM DIA3MM SCHNZ TYP DISP,SUP-2150265,CDM,C1713,HCPCS,0278,RC,,,,both,,,87.92,57.15,,,,,,,,,,,,,
PLATE BNE 3 X 8 H MIDFACE NAR DISTRCTN,SUP-2883149,CDM,C1713,HCPCS,0278,RC,,,,both,,,4569.45,2970.14,,,,,,,,,,,,,
PLATE BONE CRANIOMAXILLOFACIAL 16 HOLE STRAIGHT 63MM TITANIU,SUP-2826363,CDM,C1713,HCPCS,0278,RC,,,,both,,,183.03,118.97,,,,,,,,,,,,,
CONNECTOR ROD TI LAT CLS L10MM OD6.35X6.35MM,SUP-2287164,CDM,C1713,HCPCS,0278,RC,,,,both,,,2314.18,1504.22,,,,,,,,,,,,,
GRAFT HUM TISS L 35-48 MM TIB BLOCK L 23 MM THK 9 MM QUAD L,SUP-2913273,CDM,C1762,CPT,0278,RC,,,,both,,,15053.16,9784.55,,,,,,,,,,,,,
ALLOGRAFT HUM TISS SHT 20X9 CM PLCNTA MEMBRN AMNIOEFFECT,SUP-2872722,CDM,C1762,CPT,0278,RC,,,,both,,,41140.28,26741.18,,,,,,,,,,,,,
SCREW BNE 7/8X30 MM STRL BIORCI-HA,SUP-2848556,CDM,C1713,HCPCS,0278,RC,,,,both,,,926.46,602.20,,,,,,,,,,,,,
PLATE BONE W12XL103MM THK4MM 6 H S STL STR NAR COMPR FOR,SUP-2343808,CDM,C1713,HCPCS,0278,RC,,,,both,,,1376.70,894.85,,,,,,,,,,,,,
TAP BLADE 27MM SCREW SYSTEM SINGLE USE,SUP-2681341,CDM,2720000010,LOCAL,0272,RC,,,,both,,,341.91,222.24,,,,,,,,,,,,,
PLATE BNE L29MM 6 H ST S STL ADPT LOK COMPR W SHT THRD DRL,SUP-2177472,CDM,C1713,HCPCS,0278,RC,,,,both,,,1374.88,893.67,,,,,,,,,,,,,
COMPONENT TIB SM L80MM DIA16MM PROX MOD GMRS,SUP-2376521,CDM,C1776,CPT,0278,RC,,,,both,,,17264.03,11221.62,,,,,,,,,,,,,
ROD SPNL 2 5.5-4.75X450 MM TI NS MONARCH,SUP-2583131,CDM,C1713,HCPCS,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
PLATE BONE L181MM THK4MM 9 H LT LAT TIB HD BTTRS FOR,SUP-2343794,CDM,C1713,HCPCS,0278,RC,,,,both,,,6396.18,4157.52,,,,,,,,,,,,,
SCREW BONE L17MM OD2.0MM CRANIO MAXILLOFACIAL HD TI MINI,SUP-2262656,CDM,C1713,HCPCS,0278,RC,,,,both,,,109.68,71.29,,,,,,,,,,,,,
MOD ARTHRO NL 1CM ELIP CNCTR,SUP-2510746,CDM,C1776,CPT,0278,RC,,,,both,,,7630.20,4959.63,,,,,,,,,,,,,
SCREW BONE L80MM DIA5MM HDLSS PA DYNANAIL,SUP-2277470,CDM,C1713,HCPCS,0278,RC,,,,both,,,2056.70,1336.85,,,,,,,,,,,,,
PACEMAKER CARD ACCOLADE MRI W 4.45 X H 5.02 CM THK 0.75 CM,SUP-2149251,CDM,C1785,HCPCS,0275,RC,,,,both,,,9036.92,5874.00,,,,,,,,,,,,,
STAPLE EXT 8X8X8 MM DYNACLIP,SUP-2537987,CDM,C1713,HCPCS,0278,RC,,,,both,,,6201.50,4030.97,,,,,,,,,,,,,
NAIL IM TROCH ENTRY 130 DEG 11 MMX46 CM LT FEM TI STRL,SUP-2412494,CDM,C1713,HCPCS,0278,RC,,,,both,,,7243.76,4708.44,,,,,,,,,,,,,
DEROTATOR TB 55MM SPNL APCL LEG INSTR CDH,SUP-2287752,CDM,C1713,HCPCS,0278,RC,,,,both,,,1838.75,1195.19,,,,,,,,,,,,,
ALLOGRAFT BNE SM 3.1-3.4X0.7-0.9 CMX 1.8-2.2 MM FD NAR PROF,SUP-2472010,CDM,C1889,HCPCS,0278,RC,,,,both,,,1694.34,1101.32,,,,,,,,,,,,,
HC Fresh Plasma 24hrs,PX-3900905900,CDM,P9059,HCPCS,0390,RC,,,,inpatient,,,491.00,319.15,,,,,,,,,,,,,
GUIDEWIRE SOLO PLUS  .038IN STIFF  STRAIGHT,SUP-2655883,CDM,C1769,HCPCS,0272,RC,,,,both,,,31.40,20.41,,,,,,,,,,,,,
CABLE EP CATH L 2.5 M 10 PIN MODEL 1910-S DIAG CONN GUID,SUP-2887273,CDM,C1732,HCPCS,0272,RC,,,,both,,,472.57,307.17,,,,,,,,,,,,,
PROCAINAMIDE HCL 100 MG/ML IJ SOLN,RX-6562,CDM,J2690,HCPCS,0636,RC,76329-3399-05,NDC,,both,10,ML,488.80,317.72,,,,,,,,,,,,,
PLATE LO PROF 4 H MINI 20 MOD TI 06MM LNG,SUP-2262930,CDM,C1713,HCPCS,0278,RC,,,,both,,,287.31,186.75,,,,,,,,,,,,,
PLATE BNE RECON 2-2.5X193X2.8 MM LT 26 HOLE ANGLED LCK STRL,SUP-2539588,CDM,C1713,HCPCS,0278,RC,,,,both,,,7636.61,4963.80,,,,,,,,,,,,,
SPHERE EYE MEDPOR POLYETH POR OD20 MM RND BIOCOMPATIBLE ST,SUP-2366440,CDM,L8610,HCPCS,0278,RC,,,,both,,,1714.44,1114.39,,,,,,,,,,,,,
IMPLANT FNGR JT M L15MM SCR OD3.4MM BARB L6.8MM OD4.5MM THRD,SUP-2223970,CDM,C1776,CPT,0278,RC,,,,both,,,5231.24,3400.31,,,,,,,,,,,,,
GUIDEWIRE ORTH L 450 MM DIA 3.2 MM SMTH W/O THRD NS DISP,SUP-2902247,CDM,C1769,HCPCS,0272,RC,,,,both,,,237.07,154.10,,,,,,,,,,,,,
SCISSORS SURG 23GA CVD,SUP-2304864,CDM,C1713,HCPCS,0278,RC,,,,both,,,327.09,212.61,,,,,,,,,,,,,
TROCAR SURG DIA3/16MM TI INSTR W/O CNTR NUT ISOLA,SUP-2255602,CDM,C1713,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
FIBER LASER RECV DDX 102 RX DVI,SUP-2748366,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5162.69,3355.75,,,,,,,,,,,,,
SPHERE EMB LC BEAD LUMI DIA 40-90 UM M0 RADIOPAQUE STRL,SUP-2664294,CDM,C1889,HCPCS,0278,RC,,,,both,,,10676.00,6939.40,,,,,,,,,,,,,
GUIDEWIRE ARTHSCP DIA1.35MM FOR PAT FRAC SYS,SUP-2121927,CDM,C1769,HCPCS,0272,RC,,,,both,,,128.74,83.68,,,,,,,,,,,,,
PLATE BNE T LT TARSALIS MID FT 5 HOLE LCK,SUP-2609121,CDM,C1713,HCPCS,0278,RC,,,,both,,,5254.63,3415.51,,,,,,,,,,,,,
SYSTEM LD CATH TIP GUIDE BACKPLATE OUTFLO ENVEO R,SUP-2281142,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1224.60,795.99,,,,,,,,,,,,,
WIRE FIX 2X450MM HYBRID CTRL OLV K,SUP-2316254,CDM,C1713,HCPCS,0278,RC,,,,both,,,442.87,287.87,,,,,,,,,,,,,
SCREW BNE 10 DEG SM TI SLD ANGLED STRL PHALINX,SUP-2900663,CDM,C1713,HCPCS,0278,RC,,,,both,,,4744.54,3083.95,,,,,,,,,,,,,
PLATE BNE L 192 X W 10 MM THK 2 MM SCREW DIA2.7/3.5 MM 14 H 72465314N,SUP-2933506,CDM,C1713,HCPCS,0278,RC,,,,both,,,5947.47,3865.86,,,,,,,,,,,,,
SLEEVE SURG DRL 1.5 MM LCK FOR TCP SYS,SUP-2319064,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
MESH HERN M W1.3XL1.6IN SYN POLY-4-HYDROXYBUTYRATE PLUG AND,SUP-2125874,CDM,C1781,HCPCS,0278,RC,,,,both,,,1380.94,897.61,,,,,,,,,,,,,
HC So1 Encephalitis St.Louis,PX-3028665367,CDM,86653,CPT,0302,RC,,,,both,,,142.00,92.30,,,,,,,,,,,,,
SET INT FIX PLATE SZ 18.5 MM SCREW DIA1.5 MM TI NEURO SHUNT,SUP-2935898,CDM,C1713,HCPCS,0278,RC,,,,both,,,24903.34,16187.17,,,,,,,,,,,,,
STENT GRFT VASC BIFURCATE 2 AORT LIMB EXT,SUP-2777590,CDM,C1768,CPT,0278,RC,,,,both,,,41127.72,26733.02,,,,,,,,,,,,,
CATHETER ANGIOPLSTY L 150 CM BALLOON L 20 MM DIA1.5 MM SHTH,SUP-2909763,CDM,C1725,HCPCS,0272,RC,,,,both,,,708.86,460.76,,,,,,,,,,,,,
DRILL SURG CANN FLX SHFT FOR 4 MM SCREW CORRIDOR,SUP-2598328,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2527.70,1643.00,,,,,,,,,,,,,
PROSTHESIS EAR BCKT HNDL 0.4X3.5 MM 2 TRANSAXIAL HOLE TI,SUP-2312847,CDM,L8613,CPT,0278,RC,,,,both,,,1174.36,763.33,,,,,,,,,,,,,
SCREW 6.5MM TI CANCELLOUS BONE WITH 4.0MM CORE DIA 60MM,SUP-2549368,CDM,C1713,HCPCS,0278,RC,,,,both,,,343.36,223.18,,,,,,,,,,,,,
PLATE BONE W14.9XL104MM THK1.2MM 6 H DSTL TIB S STL,SUP-2185735,CDM,C1713,HCPCS,0278,RC,,,,both,,,953.40,619.71,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.407,SUP-2859971,CDM,C1713,HCPCS,0278,RC,,,,both,,,32758.99,21293.34,,,,,,,,,,,,,
MARKER SFT TISS L3MM DIA0.9MM GLD FIDUCIAL W/ 18GA L20CM ETW,SUP-2164656,CDM,A4648,CPT,0278,RC,,,,both,,,244.92,159.20,,,,,,,,,,,,,
CATHETER DRAINAGE STR 8 FRX10 CM FIX LUER SELF CLS 1 STP,SUP-2430083,CDM,C1729,HCPCS,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
DEFIBRILLATOR CARD RESYNCH THER X4 CRT-D VIGILANT,SUP-2149218,CDM,C1882,HCPCS,0275,RC,,,,both,,,61638.20,40064.83,,,,,,,,,,,,,
GRAFT BNE GRAN 5 CC CLLGN HA B TRICALCIUM FORMAGRAFT,SUP-2567398,CDM,C1713,HCPCS,0278,RC,,,,both,,,1452.25,943.96,,,,,,,,,,,,,
PLATE BNE RECON 2-2.5X2.5 MM MAND 34 HOLE LCK 507603409,SUP-2539582,CDM,C1713,HCPCS,0278,RC,,,,both,,,6867.40,4463.81,,,,,,,,,,,,,
PLATE BONE M STRL UTIL FOR 2.7MM SCR VLP,SUP-2349946,CDM,C1713,HCPCS,0278,RC,,,,both,,,6228.66,4048.63,,,,,,,,,,,,,
STEM FEM SZ 3 L115MM NK L34MM 40MM OFFSET 132DEG HIP FORGED,SUP-2375350,CDM,C1776,CPT,0278,RC,,,,both,,,5775.72,3754.22,,,,,,,,,,,,,
SET PRE-DILUTE PRISMA M60,SUP-2384759,CDM,2720000010,LOCAL,0272,RC,,,,both,,,553.90,360.03,,,,,,,,,,,,,
HUMERAL TRAY +3 STD SHLDR TI COMPHSVE,SUP-2431693,CDM,C1776,CPT,0278,RC,,,,both,,,3925.00,2551.25,,,,,,,,,,,,,
GRAFT EVAR L124MM DIA16X13MM CATH 14FR LIMB DST DSGN C DEL,SUP-2295245,CDM,C1768,CPT,0278,RC,,,,both,,,15621.50,10153.97,,,,,,,,,,,,,
SHEATH INTRO SWARTZ L 81 CM DIA 8 FR TRANSSEPTAL LAMP CRV,SUP-2357234,CDM,C1893,HCPCS,0272,RC,,,,both,,,690.80,449.02,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 30 CM DIA 5 MM EPTFE STR STD WALL,SUP-2396178,CDM,C1768,CPT,0278,RC,,,,both,,,1290.54,838.85,,,,,,,,,,,,,
SCREW BONE L7MM OD2.3MM TI6AL4V LCK DRL FRE STRNL MAX DRV,SUP-2262551,CDM,C1713,HCPCS,0278,RC,,,,both,,,273.49,177.77,,,,,,,,,,,,,
SCREW BNE L 30 MM DIA2 MM SS CORTICAL T6 STARDRV SLV TUBE PK,SUP-2905750,CDM,C1713,HCPCS,0278,RC,,,,both,,,466.54,303.25,,,,,,,,,,,,,
KIT INTRO INTROFLEX L 10 CM DIA 8.5 FR HEPARIN BONDED ADJ,SUP-2214542,CDM,C1894,HCPCS,0272,RC,,,,both,,,65.63,42.66,,,,,,,,,,,,,
KIT ORTH GLEN TIGERLINK FIBERLINK SHUTTLE SUTURE CANN DRL,SUP-2882186,CDM,C1713,HCPCS,0278,RC,,,,both,,,5513.84,3584.00,,,,,,,,,,,,,
PLATE BNE L147MM 8 H NONSTERILE L PROX TIB S STL VAR ANG,SUP-2177916,CDM,C1713,HCPCS,0278,RC,,,,both,,,5322.87,3459.87,,,,,,,,,,,,,
SURGICAL PROCEDURE KIT HEMORRHOIDAL DEARTERIAL SLIDE 1,SUP-2385925,CDM,C1713,HCPCS,0278,RC,,,,both,,,1863.28,1211.13,,,,,,,,,,,,,
MATRIX TISS 2X7CM BOV SKIN SFT TISS REPAIRXENOFORM,SUP-2140341,CDM,C1713,HCPCS,0278,RC,,,,both,,,1998.23,1298.85,,,,,,,,,,,,,
PLATE TIB SZ 5 POR STEM NXGN,SUP-2201518,CDM,C1713,HCPCS,0278,RC,,,,both,,,8878.35,5770.93,,,,,,,,,,,,,
GRAFT BNE SYR 5 CC DBM ACCELL CONNEXUS,SUP-2641754,CDM,C1713,HCPCS,0278,RC,,,,both,,,2234.90,1452.68,,,,,,,,,,,,,
NEEDLE TRANSSEPTAL AD 18GA L71CM 50DEG S STL BVL BRK1 CRV,SUP-2357222,CDM,2720000010,LOCAL,0272,RC,,,,both,,,668.82,434.73,,,,,,,,,,,,,
PLATE BNE L 99 MM SCREW DIA2 MM 14 SHFT H TI STR MINI FRAG,SUP-2908088,CDM,C1713,HCPCS,0278,RC,,,,both,,,3643.19,2368.07,,,,,,,,,,,,,
"HC Debride Skin,Non-Selective",PX-4209760200,CDM,97602,CPT,0420,RC,,,,both,,,253.00,164.45,,,,,,,,,,,,,
BLADE SAW L 115 MM L 37 MM THK MATERIAL 0.4 MM CUT 0.6 MM,SUP-2929358,CDM,2720000010,LOCAL,0272,RC,,,,both,,,682.67,443.74,,,,,,,,,,,,,
HC Anterior Nose Bleed Comp,PX-4503090300,CDM,30903,CPT,0450,RC,,,,both,,,214.00,139.10,,,,,,,,,,,,,
ROD THRD 400MM,SUP-2499725,CDM,2720000010,LOCAL,0272,RC,,,,both,,,231.10,150.21,,,,,,,,,,,,,
TRIAMCINOLONE ACETONIDE 0.1 % EX CREA,RX-8113,CDM,6370000000,HCPCS,0637,RC,00168-0004-15,NDC,,both,15,GR,13.50,8.77,,,,,,,,,,,,,
CATHETER PERI DLYS AD 15FR L57CM 2 CUF SWAN NK CURL RADPQ,SUP-2283893,CDM,C1750,HCPCS,0278,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
LEAD CARD PACE PERM ATR VENT LD PACE BPLR ACT FIX IS 1 CONN,SUP-2356665,CDM,C1898,HCPCS,0275,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
IMPLANT NSL 1 SYS ABSRB LATERA,SUP-2354995,CDM,C1889,HCPCS,0278,RC,,,,both,,,5181.00,3367.65,,,,,,,,,,,,,
SHOE POSTOP SM 7-9 LO PROF FOAM/NYLON MESH M LOOP LOK CLSR,SUP-2197104,CDM,L4387,HCPCS,0274,RC,,,,both,,,15.13,9.83,,,,,,,,,,,,,
GRAFT HUM TISS W15 40 4 30XL30 40MM THK24 26MM IL CREST WDG,SUP-2307418,CDM,C1713,HCPCS,0278,RC,,,,both,,,3893.60,2530.84,,,,,,,,,,,,,
PLATE BNE L173MM THK3MM 11 H BILAT S STL STR LIMIT CNTCT DYN,SUP-2185344,CDM,C1713,HCPCS,0278,RC,,,,both,,,2030.29,1319.69,,,,,,,,,,,,,
KIT PRB 17GA L7MM RF ABLAT OSTEOCOOL,SUP-2293682,CDM,2720000010,LOCAL,0272,RC,,,,both,,,11068.50,7194.52,,,,,,,,,,,,,
CAGE SPNL L12XW12XH8MM 4 LOBE MESH L ANAT FOOTPRINT MOD IMP,SUP-2317728,CDM,C1889,HCPCS,0278,RC,,,,both,,,4179.34,2716.57,,,,,,,,,,,,,
COLLAR CERV L H3XL20IN M DENS FOAM COT STOCK LNR,SUP-2194404,CDM,L0120,HCPCS,0272,RC,,,,both,,,15.70,10.20,,,,,,,,,,,,,
BLADE US 4-9 CM HK TIP SEAL ADJ HARMONY SYNERGY,SUP-2257773,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4123.35,2680.18,,,,,,,,,,,,,
PLATE BNE SIDE 135 DEG STD BRL 38 MM HIP 4 HOLE TALON,SUP-2391522,CDM,C1713,HCPCS,0278,RC,,,,both,,,1249.12,811.93,,,,,,,,,,,,,
JOINT EXT FIX BALL NS DISP,SUP-2885054,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1552.42,1009.07,,,,,,,,,,,,,
ALLOGRAFT BNE MATCHSTICK LG FD IRRADIATED CORTICAL CANC,SUP-2867197,CDM,C1762,CPT,0278,RC,,,,both,,,481.27,312.83,,,,,,,,,,,,,
GRAFT HUM TISS 3X2 CM DBM AMNION,SUP-2431988,CDM,C1762,CPT,0278,RC,,,,both,,,4003.50,2602.27,,,,,,,,,,,,,
COIL EMB L20CM DIA5MM 3D V01 FRAMING,SUP-2280958,CDM,C1889,HCPCS,0278,RC,,,,both,,,6578.30,4275.89,,,,,,,,,,,,,
WIRE FIX L450MM OD3.2MM S STL DBL END SMOOTH DBL SHRP TIP K,SUP-2371037,CDM,C1713,HCPCS,0278,RC,,,,both,,,166.42,108.17,,,,,,,,,,,,,
HC So Zonisamide Level,PX-3018020366,CDM,80203,CPT,0301,RC,,,,both,,,92.00,59.80,,,,,,,,,,,,,
LEADWIRE NERVE STIM 70 CM SURG KT SURPS-C,SUP-2481871,CDM,C1883,HCPCS,0278,RC,,,,both,,,6280.00,4082.00,,,,,,,,,,,,,
TIP SONOPET 12CM iQ MICRO,SUP-2752127,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2835.36,1842.98,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH FLX L 111 MM DIA 32 MM SHTH 20 FR SS,SUP-2170036,CDM,C1768,CPT,0278,RC,,,,both,,,24652.14,16023.89,,,,,,,,,,,,,
STEM FEM TAPR 12/14 UNCEMENTED TI ALLOY HA/TCP SM MAYO,SUP-2210415,CDM,C1776,CPT,0278,RC,,,,both,,,15838.16,10294.80,,,,,,,,,,,,,
HC So Heparin Assoc Platelet Antibo,PX-3028602266,CDM,86022,CPT,0302,RC,,,,both,,,170.00,110.50,,,,,,,,,,,,,
GUIDE SURG L PROX TIB INSRT LISS,SUP-2187789,CDM,C1776,CPT,0278,RC,,,,both,,,10016.44,6510.69,,,,,,,,,,,,,
DIVERTED TUBE 1/2,SUP-2307039,CDM,C1713,HCPCS,0278,RC,,,,both,,,353.25,229.61,,,,,,,,,,,,,
ALLOGRAFT HUM TISS MED 60-149 MM FD FASC LATA,SUP-2792179,CDM,C1762,CPT,0278,RC,,,,both,,,2464.90,1602.18,,,,,,,,,,,,,
ALLOGRAFT BNE PLUG 14 MM FD ASEP,SUP-2867009,CDM,C1762,CPT,0278,RC,,,,both,,,1798.75,1169.19,,,,,,,,,,,,,
CONNECTOR SHUNT DIA1.9 MM TI Y SHP STRL DISP MIETHKE,SUP-2929396,CDM,C1889,HCPCS,0278,RC,,,,both,,,709.33,461.06,,,,,,,,,,,,,
"HC Transcath Stent Cerv,Carotid W/O Eps",PX-3603721600,CDM,37216,CPT,0360,RC,,,,both,,,15457.00,10047.05,,,,,,,,,,,,,
FUTURA FLX DGT IMPL ULTRASIL SIL ANAT KEYHOLE HNG RND STEM,SUP-2399889,CDM,C1776,CPT,0278,RC,,,,both,,,3008.12,1955.28,,,,,,,,,,,,,
TRAY CATH MIDLN PROVENA MAXBARR 3FR 20CM 1 LUMAN S4153108DG,SUP-2632860,CDM,C1751,HCPCS,0278,RC,,,,both,,,516.18,335.52,,,,,,,,,,,,,
STEM WR 6X15MM CAPITATE IMP MAESTRO,SUP-2136461,CDM,C1776,CPT,0278,RC,,,,both,,,2604.32,1692.81,,,,,,,,,,,,,
CATHETER NEPHROSTOMY X-FORCE N30 L 15 CM BALLOON L 8 CM DULA,SUP-2655877,CDM,C1726,HCPCS,0272,RC,,,,both,,,1384.58,899.98,,,,,,,,,,,,,
CATHETER ABLAT 7FR L115CM 1-7-4MM SPC TIP 4MM 4 ELECTRD BLU,SUP-2248512,CDM,C1732,HCPCS,0272,RC,,,,both,,,6220.34,4043.22,,,,,,,,,,,,,
GRAFT BNE SUB M SZ 14 28MM 5CC B TRICALCIUM PHSPTE SYN,SUP-2194009,CDM,C1713,HCPCS,0278,RC,,,,both,,,1076.24,699.56,,,,,,,,,,,,,
NEEDLE VENTRICULAR CONE 18 GAX3.5 IN 2 HOLE MIRROR FINISH,SUP-2868950,CDM,2720000010,LOCAL,0272,RC,,,,both,,,434.23,282.25,,,,,,,,,,,,,
SCREW BNE L 18 MM DIA 3 MM TI CANN HDLSS NS LEOS,SUP-2932615,CDM,C1713,HCPCS,0278,RC,,,,both,,,946.87,615.47,,,,,,,,,,,,,
HC Assay of Lipoprotein,PX-3018371800,CDM,83718,CPT,0301,RC,,,,both,,,216.00,140.40,,,,,,,,,,,,,
STAPLER MED 21 MM TRNSOR CIR ANVIL EEA ORVIL,SUP-2787686,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1017.83,661.59,,,,,,,,,,,,,
INTRODUCER PEEL AWAY 5FRX6CM W NDL,SUP-2357089,CDM,C1892,HCPCS,0272,RC,,,,both,,,15.70,10.20,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE 0.5 CC DEMINERALIZED CORTICAL BNE FIBER,SUP-2933253,CDM,C1762,CPT,0278,RC,,,,both,,,474.55,308.46,,,,,,,,,,,,,
PLATE CRAN W30XL30MM BILAT ORBIT FLR NONCOMPRESSION RIG,SUP-2194055,CDM,C1713,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
MICROCATHETER DIAG 45DEG L115CM ID0.025IN HI FLO FULL,SUP-2323641,CDM,C1887,HCPCS,0272,RC,,,,both,,,1852.60,1204.19,,,,,,,,,,,,,
HC Potassium Serum Plasma/Whole Blood,PX-3018413200,CDM,84132,CPT,0301,RC,,,,both,,,80.00,52.00,,,,,,,,,,,,,
SYSTEM INTRO SAFSHTH II L 23 CM DIA 7 FR DIL 28.5 CM ORN,SUP-2281630,CDM,C1892,HCPCS,0272,RC,,,,both,,,188.40,122.46,,,,,,,,,,,,,
ACTUATOR EXT FIX COMPR STD 4 CM DISTRCTN EXT TUBE PROCALLUS,SUP-2645889,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1251.35,813.38,,,,,,,,,,,,,
SCREW BNE ST 2X10 MM MAND LCK TI SLV NS MATRIXMANDIBLE LF,SUP-2181745,CDM,C1713,HCPCS,0278,RC,,,,both,,,474.77,308.60,,,,,,,,,,,,,
SPLINT ORTHOPEDIC SUPP MED 8 IN LT WRST COCK UP ELASTIC,SUP-2108132,CDM,L3809,HCPCS,0272,RC,,,,both,,,41.61,27.05,,,,,,,,,,,,,
HEAD HUM ECC 1.5 MM 39X14 MM SHLDR ANAT LOW OFFSET TI,SUP-2715720,CDM,C1776,CPT,0278,RC,,,,both,,,11779.71,7656.81,,,,,,,,,,,,,
CATHETER GUID IMA 6 FRX55 CM RENAL SET VISTA BRT TIP,SUP-2659328,CDM,C1887,HCPCS,0272,RC,,,,both,,,244.92,159.20,,,,,,,,,,,,,
SCREW BNE L12MM DIA3.5MM CORT DST VOLAR RAD TI LOK FULL,SUP-2340168,CDM,C1713,HCPCS,0278,RC,,,,both,,,239.58,155.73,,,,,,,,,,,,,
ALLOGRAFT BNE SPACER 5.5X13.5 MM DWL FD THRD FACET,SUP-2736760,CDM,C1713,HCPCS,0278,RC,,,,both,,,6661.82,4330.18,,,,,,,,,,,,,
STENT BILI COMPASS BDS L 5 CM DIA 7 FR GUIDEWIRE 0.035 IN,SUP-2863655,CDM,C2625,HCPCS,0278,RC,,,,both,,,226.08,146.95,,,,,,,,,,,,,
CAP PRICE,SUP-2212308,CDM,C1713,HCPCS,0278,RC,,,,both,,,28260.00,18369.00,,,,,,,,,,,,,
PLATE BNE L255MM 95DEG SUPCNDYL TB FREE LOK,SUP-2197720,CDM,C1713,HCPCS,0278,RC,,,,both,,,2230.66,1449.93,,,,,,,,,,,,,
EXTENSION GUIDEWIRE TRUEPATH L 160 CM DIA 0.018 IN STR STRL,SUP-2145954,CDM,C1713,HCPCS,0278,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
GRAFT BIO TISS OMEGA3 MARIGEN 16MM DISC,SUP-2261688,CDM,Q4158,HCPCS,0636,RC,,,,both,,,1626.52,1057.24,,,,,,,,,,,,,
HC So Dna/Rna Probe,PX-3068750766,CDM,87507,CPT,0306,RC,,,,both,,,434.00,282.10,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH ALPHA L 151 MM DIA 44 MM NIT POLYPRO,SUP-2750378,CDM,C1768,CPT,0278,RC,,,,both,,,33073.81,21497.98,,,,,,,,,,,,,
NUT ORTH BTTRS COMPR,SUP-2188215,CDM,C1713,HCPCS,0278,RC,,,,both,,,430.68,279.94,,,,,,,,,,,,,
SEALER VES DIA8MM EXT ENDOWRIST,SUP-2246798,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2060.88,1339.57,,,,,,,,,,,,,
SPLINT KNEE L26IN CIRC 36IN UNIV AD IMMOB FIT MOST WRP ARND,SUP-2197157,CDM,L1830,CPT,0274,RC,,,,both,,,51.90,33.73,,,,,,,,,,,,,
STEM TIB CEM 16/13X100 MM MOD W/ FEMALE TAPR FOR 6 MM NOSE,SUP-2423137,CDM,C1776,CPT,0278,RC,,,,both,,,4534.16,2947.20,,,,,,,,,,,,,
PLATE BNE W16XL299MM BLDE L70MM THK48MM 95DEG 18 H ST BILAT,SUP-2185510,CDM,C1713,HCPCS,0278,RC,,,,both,,,6221.78,4044.16,,,,,,,,,,,,,
PLATE BNE THK3MM REG 20 H TI L FOR 27MM SCR THREADLOCK,SUP-2262978,CDM,C1713,HCPCS,0278,RC,,,,both,,,4004.54,2602.95,,,,,,,,,,,,,
GRAFT DERMACELL DERMAL 16CM MATRIX X MICROPERFORATED,SUP-2777445,CDM,Q4122,HCPCS,0636,RC,,,,both,,,28888.00,18777.20,,,,,,,,,,,,,
GRAFT BONE SUB SM 5CC CA SULF RAP CURE KT SYNTHECURE,SUP-2124551,CDM,C1713,HCPCS,0278,RC,,,,both,,,2464.90,1602.18,,,,,,,,,,,,,
VALVE CSF PROGRAMMABLE BUR HOLE RT ANGLE UNITZ DSTL CATH,SUP-2666486,CDM,C1889,HCPCS,0278,RC,,,,both,,,16468.70,10704.65,,,,,,,,,,,,,
BRACE KNEE M FOR 18 21IN THGH NEOPRENE PAT STBL SFT,SUP-2150848,CDM,L1810,HCPCS,0274,RC,,,,both,,,75.39,49.00,,,,,,,,,,,,,
GUIDE CATHETER 17IN VAN BUREN,SUP-2305660,CDM,C1887,HCPCS,0272,RC,,,,both,,,54.04,35.13,,,,,,,,,,,,,
LINER CUP 28X48-50MM SZ MP5 3.15MM THCK 0 DEG ACET MTL ON,SUP-2217295,CDM,C1776,CPT,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
SCALPEL SURG SAFETY GRD LCK SZ 12 STAINLES STL LCK RTRCTBLE,SUP-2605890,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5.62,3.65,,,,,,,,,,,,,
PLATE BROAD Y 7 SHAFT HL,SUP-2702911,CDM,C1713,HCPCS,0278,RC,,,,both,,,4325.66,2811.68,,,,,,,,,,,,,
STENT PERIPH 12FR L5CM DIA13MM CATH L120CM VES DIA10.6-12MM,SUP-2396588,CDM,C1874,HCPCS,0278,RC,,,,both,,,11228.64,7298.62,,,,,,,,,,,,,
PLATE BONE 13 H LT DSTL MEDL TIB LCK W/O TAB FOR 3.5MM SCR,SUP-2349083,CDM,C1713,HCPCS,0278,RC,,,,both,,,3408.16,2215.30,,,,,,,,,,,,,
KIT EXT FIX TIB HOFFMANN II,SUP-2372210,CDM,2720000010,LOCAL,0272,RC,,,,both,,,12751.92,8288.75,,,,,,,,,,,,,
WIRE FIX TRCR PT 3.2X320 MM KIRSCHNER,SUP-2417023,CDM,2720000010,LOCAL,0272,RC,,,,both,,,424.37,275.84,,,,,,,,,,,,,
CHANNEL WORKING L 185 CM INSRTN L 160-170 CM ENDOSCP DIA,SUP-2881889,CDM,2720000010,LOCAL,0272,RC,,,,both,,,516.53,335.74,,,,,,,,,,,,,
WASHER ORTH DIA19 MM TI FOR 6.5/8 MM SCREW STRL ASNS,SUP-2902143,CDM,C1713,HCPCS,0278,RC,,,,both,,,346.19,225.02,,,,,,,,,,,,,
STEM FEM CLLRD 13 MM KNEE REV LCS COMPLETE,SUP-2453516,CDM,C1776,CPT,0278,RC,,,,both,,,951.42,618.42,,,,,,,,,,,,,
TUBE AERATION L12MM FLNG L3.5MM ID1.14MM FLROPLAS SIL STYL,SUP-2284027,CDM,L8699,HCPCS,0278,RC,,,,both,,,257.04,167.08,,,,,,,,,,,,,
HALF RNG 140MM FRDM CIR FIX,SUP-2400640,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1598.26,1038.87,,,,,,,,,,,,,
PLATE BONE TENSION BAND BROAD MINI 1 MM 3X3 HOLE MALLEABLE T,SUP-2837764,CDM,C1713,HCPCS,0278,RC,,,,both,,,1857.31,1207.25,,,,,,,,,,,,,
PLATE BNE L 20 MM SCREW DIA2 MM SM CP TI MANDIBULAR FULL,SUP-2883710,CDM,C1713,HCPCS,0278,RC,,,,both,,,16660.97,10829.63,,,,,,,,,,,,,
GUIDE SURG 10 CC CORTOSS CARTRIDGE CEM,SUP-2379533,CDM,C1713,HCPCS,0278,RC,,,,both,,,3999.73,2599.82,,,,,,,,,,,,,
MARKER ROBOTIC SYS PASS DISP FOR EXCELSIUSGPS ROBOTIC,SUP-2232050,CDM,A4648,CPT,0278,RC,,,,both,,,1789.80,1163.37,,,,,,,,,,,,,
BIT DRL QC 2.7X125 MM STRL,SUP-2563755,CDM,2720000010,LOCAL,0272,RC,,,,both,,,340.53,221.34,,,,,,,,,,,,,
SUPPORT ORTHOT KNEE LOWER EXTREMITY CUST STR,SUP-2435664,CDM,L2385,HCPCS,0274,RC,,,,both,,,416.02,270.41,,,,,,,,,,,,,
COIL NEUROVASCULAR HELIPAQ 18 CERECYTE L 8 CM DIA 3 MM,SUP-2460440,CDM,C1889,HCPCS,0278,RC,,,,both,,,5086.61,3306.30,,,,,,,,,,,,,
PLATE BNE LADDER 9X0.6 MM NEURO 2X2 HOLE TI STRL LEVEL 1,SUP-2487842,CDM,C1713,HCPCS,0278,RC,,,,both,,,856.78,556.91,,,,,,,,,,,,,
INSTRUMENT KIT 18X22X24X8 MM STRL DYNAFORCE,SUP-2427206,CDM,C1713,HCPCS,0278,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
PLATE TI BROAD LCP 4.5MM 18 HOLES 332MM,SUP-2549494,CDM,C1713,HCPCS,0278,RC,,,,both,,,3467.56,2253.91,,,,,,,,,,,,,
PLATE BNE T SM 45 MM LT DSTL DORS RADIAL 3 HOLE SS STRL,SUP-2468376,CDM,C1713,HCPCS,0278,RC,,,,both,,,1790.46,1163.80,,,,,,,,,,,,,
SLING UROLOGICAL MID-URETHRAL TRNSVAG 1 ADVANTAGE FIT ULTRA,SUP-2876040,CDM,C1771,HCPCS,0278,RC,,,,both,,,6126.14,3981.99,,,,,,,,,,,,,
DEVICE EMBOLIC COMANECI NON-OCCL 0.5-3MM 22MM BRAIDED,SUP-2854062,CDM,C1889,HCPCS,0278,RC,,,,both,,,13502.00,8776.30,,,,,,,,,,,,,
SPHERE EMB EMBOZENE DIA1300 UM 2 ML PREFIL SYR HYDRGEL,SUP-2139492,CDM,C1889,HCPCS,0278,RC,,,,both,,,769.30,500.04,,,,,,,,,,,,,
PLATE BNE CRV 2-2.5X29X1.5 MM 4 HOLE FRAC TI STRL LEVEL 1,SUP-2480937,CDM,C1713,HCPCS,0278,RC,,,,both,,,1967.40,1278.81,,,,,,,,,,,,,
BENZOIN COMPOUND EX TINC,RX-987,CDM,6370000000,HCPCS,0637,RC,00395-0243-92,NDC,,both,59,ML,40.10,26.06,,,,,,,,,,,,,
TUBE MYR DIA114MM SIL VENT TAB DONALDSON,SUP-2313714,CDM,L8699,HCPCS,0278,RC,,,,both,,,32.91,21.39,,,,,,,,,,,,,
SEED BRACHYTHERAPY VAR LOAD,SUP-2135328,CDM,C2639,HCPCS,0278,RC,,,,both,,,69.08,44.90,,,,,,,,,,,,,
CLIP INT LIG MED TI BLU NS VESOCCLUDE,SUP-2757593,CDM,C1889,HCPCS,0278,RC,,,,both,,,866.64,563.32,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 160 MM DIA 9 MM DEL SHTH,SUP-2934320,CDM,C1713,HCPCS,0278,RC,,,,both,,,16095.95,10462.37,,,,,,,,,,,,,
CUP ACET 54MM 38 N FLR M2A,SUP-2136395,CDM,C1776,CPT,0278,RC,,,,both,,,17993.46,11695.75,,,,,,,,,,,,,
GUIDEWIRE ORTH L150MM DIA1.1MM NICKEL CHROM SMOOTH SGL END,SUP-2321616,CDM,C1713,HCPCS,0278,RC,,,,both,,,76.93,50.00,,,,,,,,,,,,,
TEMPLATE SURG L45MM STR RECON PLT,SUP-2197685,CDM,C1713,HCPCS,0278,RC,,,,both,,,320.85,208.55,,,,,,,,,,,,,
GUIDEWIRE VASC TRANSEND L 190 CM DIA 0.014 IN TIP 2 CM,SUP-2148244,CDM,C1769,HCPCS,0272,RC,,,,both,,,643.70,418.40,,,,,,,,,,,,,
BLADE SHV L18CM DIA4.5MM LNG ANG RESECT CRV INCIS + ELITE,SUP-2341723,CDM,2720000010,LOCAL,0272,RC,,,,both,,,276.32,179.61,,,,,,,,,,,,,
STEM EXTN L220MM OD10MM FEM KNEE BOW PRSS FIT SYMMETRIC,SUP-2349116,CDM,C1776,CPT,0278,RC,,,,both,,,6751.00,4388.15,,,,,,,,,,,,,
CATHETER ANGIO SLIP-CATH L 150 CM DIA 3 FR GUIDEWIRE 0.025,SUP-2168705,CDM,C1751,HCPCS,0278,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
CLIP SURG MECHANOMYOGRAPHY STIM ALLIGATOR SS NS,SUP-2693682,CDM,2720000010,LOCAL,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
PLATE BONE STRAIGHT 2.8 MM 9 HOLE TITANIUM STERILE MATRIXRIB,SUP-2837691,CDM,C1713,HCPCS,0278,RC,,,,both,,,3725.61,2421.65,,,,,,,,,,,,,
SCREW BNE CANN SHT THRD 4X44 MM HD 10004044] EXACTECH INC],SUP-2221521,CDM,C1713,HCPCS,0278,RC,,,,both,,,1265.42,822.52,,,,,,,,,,,,,
PLATE 3.5MM CURVED BROAD LCP 10 HOLE-STERILE,SUP-2546100,CDM,C1713,HCPCS,0278,RC,,,,both,,,1773.00,1152.45,,,,,,,,,,,,,
ROSUVASTATIN CALCIUM 20 MG PO TABS,RX-35135,CDM,6370000000,HCPCS,0637,RC,57237-0170-90,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
TRAY CATH PICC GROSH NXT CLEARVUE BASIC 4FR 0.033N 6 7655405,SUP-2632682,CDM,C1751,HCPCS,0278,RC,,,,both,,,366.00,237.90,,,,,,,,,,,,,
PORT IMPL INFUSION PWR INJ 9.6 FR PLAS POWERPORT MRI,SUP-2427949,CDM,C1788,HCPCS,0278,RC,,,,both,,,11839.84,7695.90,,,,,,,,,,,,,
BUTTON SUT L50MM TI ACL RECON LOOP ULT ENDOBTTN,SUP-2341708,CDM,C1713,HCPCS,0278,RC,,,,both,,,985.96,640.87,,,,,,,,,,,,,
BUR SURG HOLE MAKER 12.6X10.4 MM 14 CM LG BOR MIDAS REX 8,SUP-2664603,CDM,2720000010,LOCAL,0272,RC,,,,both,,,511.69,332.60,,,,,,,,,,,,,
HC Straight Cath - Residual Urine,PX-7615170100,CDM,51701,CPT,0761,RC,,,,both,,,204.00,132.60,,,,,,,,,,,,,
SCREW SPNL L14MM DIA4MM SELF DRL VUELOCK,SUP-2415576,CDM,C1713,HCPCS,0278,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
SCREW BNE L25MM DIA5MM PARTIALLY THRD PANTSA XL,SUP-2243622,CDM,C1713,HCPCS,0278,RC,,,,both,,,1176.97,765.03,,,,,,,,,,,,,
DEVICE TORQ DIA0.018-0.038IN GRN ERGO 1 HND FOR PTFE GWIRE,SUP-2303480,CDM,C1769,HCPCS,0272,RC,,,,both,,,13.35,8.68,,,,,,,,,,,,,
SPLINT WR LT L INSTABILITY INJ 6 IN LOOP LCK W/ STAY COCK UP,SUP-2194853,CDM,L3931,HCPCS,0272,RC,,,,both,,,18.71,12.16,,,,,,,,,,,,,
MTOSCR INTF NON-CANN 9X20 STER,SUP-2341295,CDM,C1713,HCPCS,0278,RC,,,,both,,,325.74,211.73,,,,,,,,,,,,,
SHEATH INTRO FAST-CATH DUO L 75 CM DIA14 FR GUIDEWIRE 0.038,SUP-2357123,CDM,C1894,HCPCS,0272,RC,,,,both,,,690.80,449.02,,,,,,,,,,,,,
TRIPTORELIN PAMOATE 22.5 MG IM SUSR,RX-102508,CDM,J3315,HCPCS,0636,RC,74676-5906-01,NDC,,both,1,UN,15789.80,10263.37,,,,,,,,,,,,,
KNIFE SURG SCHUCKNECHT 2 ROLLER,SUP-2459172,CDM,2720000010,LOCAL,0272,RC,,,,both,,,624.23,405.75,,,,,,,,,,,,,
PROBE ELECSURG CHSL STR INTEGR VULCAN,SUP-2848574,CDM,2720000010,LOCAL,0272,RC,,,,both,,,526.83,342.44,,,,,,,,,,,,,
PLATE BNE STD UNIV TALONAVICULAR STRATUM,SUP-2607271,CDM,C1713,HCPCS,0278,RC,,,,both,,,3995.49,2597.07,,,,,,,,,,,,,
BIT DRL DIA3MM CLAV STP SCR 2 TRAK,SUP-2107141,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1664.20,1081.73,,,,,,,,,,,,,
KIT INT FIX ACL INSTR DISP,SUP-2420184,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1051.52,683.49,,,,,,,,,,,,,
DRILL SURG HI SPD COOLFLEX,SUP-2607686,CDM,2720000010,LOCAL,0272,RC,,,,both,,,17503.62,11377.35,,,,,,,,,,,,,
PROSTHESIS OSS GROTE MED 14X13X18 MM CNL WALL POROUS HA,SUP-2637869,CDM,L8613,CPT,0278,RC,,,,both,,,1416.20,920.53,,,,,,,,,,,,,
ULTRASONIC SET CRV TIP LNG 1.6 MM MIC TUBE SONASTAR,SUP-2434136,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2373.84,1543.00,,,,,,,,,,,,,
BUPIVACAINE LIPOSOME 1.3 % IJ SUSP,RX-111491,CDM,J0666,HCPCS,0636,RC,65250-0266-09,NDC,,both,5,ML,573.20,372.58,,,,,,,,,,,,,
PLATE BNE L94MM 8 H BILAT S STL STR RECON NONLOCKING,SUP-2197673,CDM,C1713,HCPCS,0278,RC,,,,both,,,1086.69,706.35,,,,,,,,,,,,,
WASHER ORTHOPEDIC FOR 4.5 MM SCR STRL EVOS,SUP-2931352,CDM,C1713,HCPCS,0278,RC,,,,both,,,159.57,103.72,,,,,,,,,,,,,
MESH CRAN W100XL100MM TEAL TI CNTOUR MAL FOR 1.5MM CRUCFRM,SUP-2191101,CDM,C1713,HCPCS,0278,RC,,,,both,,,6844.57,4448.97,,,,,,,,,,,,,
GUIDEWIRE VASC MORPHEUS L 80 CM DIA 0.018 IN PLAT TIP PERIPH,SUP-2116532,CDM,C1769,HCPCS,0272,RC,,,,both,,,138.47,90.01,,,,,,,,,,,,,
BLADE OSTEO PNEUMATIC MEDL VERSADRIVER,SUP-2877750,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2060.63,1339.41,,,,,,,,,,,,,
ATTACHMENT HNDPC L14CM DIA32MM STR L BOR MIDAS REX LEGEND,SUP-2284669,CDM,C1713,HCPCS,0278,RC,,,,both,,,3977.69,2585.50,,,,,,,,,,,,,
PLATE BNE L171MM 10 H NONSTERILE R MED PROX TIB S STL LOK,SUP-2185642,CDM,C1713,HCPCS,0278,RC,,,,both,,,3917.46,2546.35,,,,,,,,,,,,,
IMMOBILIZER KNEE PERF FOAM 12 IN T BAR ADJ MEDL BLK CUTAWAY,SUP-2336323,CDM,L1830,CPT,0272,RC,,,,both,,,43.93,28.55,,,,,,,,,,,,,
NAIL IM L160MM DIA13MM FEM GRN TI RG UNIV STR FLUT CANN LOK,SUP-2180121,CDM,C1713,HCPCS,0278,RC,,,,both,,,4778.89,3106.28,,,,,,,,,,,,,
PATELLA SUTPLT II STAR M STRL,SUP-2811474,CDM,C1713,HCPCS,0278,RC,,,,both,,,8776.30,5704.59,,,,,,,,,,,,,
PLATE BNE L241MM 8 H PROX FEM S STL HK LOK COMPR FOR 4.5MM,SUP-2186059,CDM,C1713,HCPCS,0278,RC,,,,both,,,5061.49,3289.97,,,,,,,,,,,,,
INSERT HUM DIA39MM THK+6MM B-12.5DEG SHLDR REVERSED AEQUALIS,SUP-2388717,CDM,C1776,CPT,0278,RC,,,,both,,,3524.65,2291.02,,,,,,,,,,,,,
PLATE BONE 10 H ANK S STL 3RD TBLR LCK FOR FX MGMT SYS,SUP-2123040,CDM,C1713,HCPCS,0278,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
PLATE BNE L W135XL206MM THK42MM 11 H BILAT TI NAR RIG NEUT,SUP-2190822,CDM,C1713,HCPCS,0278,RC,,,,both,,,1734.54,1127.45,,,,,,,,,,,,,
IMPLANT LARYN L10MM DIA16FR INDWL RADPQ RNG CLASS,SUP-2242367,CDM,L8509,HCPCS,0274,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
SCREW SET RIGID ASSURE,SUP-2592868,CDM,C1713,HCPCS,0278,RC,,,,both,,,31.40,20.41,,,,,,,,,,,,,
COUNTERSINK SURG DIA3-4MM FOR CANN SCR SYS,SUP-2319430,CDM,C1713,HCPCS,0278,RC,,,,both,,,1142.96,742.92,,,,,,,,,,,,,
DISTRACTION INTRNL DIST PLTL RTTRDM SNDRMC19 MM T 6L 4V QT00,SUP-2493438,CDM,C1713,HCPCS,0278,RC,,,,both,,,7262.79,4720.81,,,,,,,,,,,,,
COMPONENT FEM CO CHROM POR HD BPLR CEM TNDM KT,SUP-2347986,CDM,C1776,CPT,0278,RC,,,,both,,,9420.00,6123.00,,,,,,,,,,,,,
GRAFT BONE CRUSH FRZ DRY CANC 5CC,SUP-2120709,CDM,C1713,HCPCS,0278,RC,,,,both,,,466.29,303.09,,,,,,,,,,,,,
BONE MARROW TRAY SAFETY 11 GAX4 IN W/ BX NDL STRL T-LOK LF,SUP-2876737,CDM,2720000010,LOCAL,0272,RC,,,,both,,,364.24,236.76,,,,,,,,,,,,,
HC So Phenotype Infect Agent Drug,PX-3068790066,CDM,87900,CPT,0306,RC,,,,both,,,442.00,287.30,,,,,,,,,,,,,
KIT HEMO DYLS OR HD ADMIN CATH 2 LUMN POLYUR CHRONIC HI FLO,SUP-2174239,CDM,C1894,HCPCS,0272,RC,,,,both,,,9420.00,6123.00,,,,,,,,,,,,,
"HC Inj Proc for Myelogram/CT, Lumbar",PX-3616228400,CDM,62284,CPT,0361,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
GUIDE SURG R PT SPEC,SUP-2379229,CDM,C1713,HCPCS,0278,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
DEVICE ENDOSKELETAL SYS AK HIP ALIGNABLE SYS,SUP-2388220,CDM,L5920,HCPCS,0272,RC,,,,both,,,1394.63,906.51,,,,,,,,,,,,,
SCREW BNE CANN 10.35X70 MM TI GLD NS TFN-ADVANCED 04038070,SUP-2799596,CDM,C1713,HCPCS,0278,RC,,,,both,,,1772.91,1152.39,,,,,,,,,,,,,
IMPLANT COSMETIC SZ 45 X 44 X 7 X 3 MM POLYETHYL RT,SUP-2935970,CDM,C1713,HCPCS,0278,RC,,,,both,,,4160.50,2704.32,,,,,,,,,,,,,
KIT PMP FILL VOL 100ML FLO RATE 2ML/HR ELASTOMERIC FIX FLO,SUP-2236817,CDM,C2626,HCPCS,0278,RC,,,,both,,,197.82,128.58,,,,,,,,,,,,,
PLATE BNE NAR 4.5X295 MM 18 HOLE SS DCP,SUP-2569173,CDM,C1713,HCPCS,0278,RC,,,,both,,,468.02,304.21,,,,,,,,,,,,,
DEXTROSE 10% IV BOLUS (PEDS),RX-4085020,CDM,2580000003,HCPCS,0258,RC,63323-0824-76,NDC,,both,1000,ML,51.00,33.15,,,,,,,,,,,,,
CATHETERIZATION SET ART 021 22 GAX8 CM 20 GA INDWL LF,SUP-2865600,CDM,C1751,HCPCS,0278,RC,,,,both,,,64.68,42.04,,,,,,,,,,,,,
CATHETER ETER CTRL VEN OD12FR L16CM 035IN AD BLU 3 LUMN,SUP-2120593,CDM,C1751,HCPCS,0278,RC,,,,both,,,374.92,243.70,,,,,,,,,,,,,
SCREW BONE L100MM DIA5MM 3.5MM HEX TIBIOTALOCALCANEAL PA,SUP-2277471,CDM,C1713,HCPCS,0278,RC,,,,both,,,2056.70,1336.85,,,,,,,,,,,,,
SCREW BNE L75MM DIA73MM THRD L20MM S STL ST CANN T40 STARDRV,SUP-2178293,CDM,C1713,HCPCS,0278,RC,,,,both,,,837.66,544.48,,,,,,,,,,,,,
CLIP ANEURYSM SUNDTKEES 25MM SUPER BAYONET 201681,SUP-2848944,CDM,C1889,HCPCS,0278,RC,,,,both,,,521.24,338.81,,,,,,,,,,,,,
DISTRACTOR EXT FIX RAMUS 20 MM TRNSPRT END DRIVEN BODY ONLY,SUP-2495903,CDM,C1713,HCPCS,0278,RC,,,,both,,,16971.89,11031.73,,,,,,,,,,,,,
WIRE FIX PILOT NIT,SUP-2423034,CDM,2720000010,LOCAL,0272,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
COIL VASC AZUR HYDROCOIL L 20 CM DIA20 MM 0.035 IN,SUP-2761719,CDM,C1889,HCPCS,0278,RC,,,,both,,,4568.70,2969.65,,,,,,,,,,,,,
FOOTPLATE EXT FIX LNG 160 MM SET HEX RNG STRUT TRUELOK EVO,SUP-2875600,CDM,2720000010,LOCAL,0272,RC,,,,both,,,36721.04,23868.68,,,,,,,,,,,,,
SCREW BNE L38MM DIA4.5MM CORT TI N ST N SELF DRL,SUP-2190354,CDM,C1713,HCPCS,0278,RC,,,,both,,,55.17,35.86,,,,,,,,,,,,,
PLATE BONE HLX6 3MM THK TTNM STRGHT WBAR THRDLCK TS LATEX F,SUP-2669762,CDM,C1713,HCPCS,0278,RC,,,,both,,,2880.45,1872.29,,,,,,,,,,,,,
ENDOPROSTHESIS VASC WSTNT RP L 42 MM DIA10 MM CATH TOT L 100,SUP-2148386,CDM,C1876,HCPCS,0278,RC,,,,both,,,3244.00,2108.60,,,,,,,,,,,,,
HC Comlex Drainage Wound,PX-4501018000,CDM,10180,CPT,0450,RC,,,,both,,,8335.00,5417.75,,,,,,,,,,,,,
STEM ULN 50MM L STR PRSS FIT TI SOLAR,SUP-2372329,CDM,C1776,CPT,0278,RC,,,,both,,,12139.62,7890.75,,,,,,,,,,,,,
CATHETER THROMCTMY FOGARTY L 50 CM DIA 5 FR SPRL DIA,SUP-2214036,CDM,C1757,HCPCS,0272,RC,,,,both,,,1263.13,821.03,,,,,,,,,,,,,
CALCIUM GLUCONATE-NACL 1-0.675 GM/50ML-% IV SOLN,RX-144832,CDM,J0613,HCPCS,0636,RC,44567-0620-01,NDC,,both,50,ML,113.60,73.84,,,,,,,,,,,,,
PASSER SUT L2.75MM UP TIP 45DEG BIRDBEAK,SUP-2120793,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
KIT ACC PROLAPSE,SUP-2140329,CDM,C1713,HCPCS,0278,RC,,,,both,,,1055.04,685.78,,,,,,,,,,,,,
COMPONENT PAT STD 3PEG RND REV ROT NP CEM WITHOUTXRAY WIRE,SUP-2252418,CDM,C1776,CPT,0278,RC,,,,both,,,4066.30,2643.09,,,,,,,,,,,,,
SYSTEM OCCL DEL L60CM SHTH 6FR 45DEG CRV CBL DIL HEMSTAS,SUP-2355729,CDM,C1894,HCPCS,0272,RC,,,,both,,,2152.03,1398.82,,,,,,,,,,,,,
DRESSING WND SURG MTRX 4X12 CM THCK MATRISTEM,SUP-2106495,CDM,Q4166,HCPCS,0636,RC,,,,both,,,4080.74,2652.48,,,,,,,,,,,,,
SCREW BNE L60MM DIA3.5MM STD CORT DST TIB TI ST LOK FULL,SUP-2413586,CDM,C1713,HCPCS,0278,RC,,,,both,,,389.99,253.49,,,,,,,,,,,,,
GRAFT HUM TISS FIRM 8X8 CM RECON TISS MTRX PORCINE STRATTICE,SUP-2112977,CDM,Q4130,HCPCS,0636,RC,,,,both,,,6590.86,4284.06,,,,,,,,,,,,,
DEVICE COAG 3 CM GUID NO CANN FOR EPICARD ABLATN EPISENSE,SUP-2424446,CDM,2720000010,LOCAL,0272,RC,,,,both,,,32970.00,21430.50,,,,,,,,,,,,,
INSERT TIB SM THK26MM UNIV PLATEAU CEM PRI STEM CRUCE RET,SUP-2253231,CDM,C1713,HCPCS,0278,RC,,,,both,,,8479.26,5511.52,,,,,,,,,,,,,
BASEPLATE TIB SZ 2 OXINIUM LT KNEE FEM TAPR HNG CEM LEGION,SUP-2346245,CDM,C1776,CPT,0278,RC,,,,both,,,14337.24,9319.21,,,,,,,,,,,,,
BIT DRL DIA2.5MM CALIB DISP FOR 3.5MM LOK PROX FEM SCR,SUP-2318879,CDM,2720000010,LOCAL,0272,RC,,,,both,,,769.30,500.04,,,,,,,,,,,,,
GUIDEWIRE ORTH 11/32X222 MM FOR TI FIX NAIL LCK SET,SUP-2188219,CDM,C1769,HCPCS,0272,RC,,,,both,,,1525.85,991.80,,,,,,,,,,,,,
TUBE VENT DIA1.27MM SHEEHY TYP,SUP-2277603,CDM,L8699,HCPCS,0278,RC,,,,both,,,70.52,45.84,,,,,,,,,,,,,
HC 'hepatitis B Surface Ag - Dono,PX-3028734000,CDM,87340,CPT,0302,RC,,,,both,,,27.00,17.55,,,,,,,,,,,,,
VALVE AORT CRYOVALVE SZ 25 MM AORT ALLGRFT CONDUIT NS,SUP-2175240,CDM,C1889,HCPCS,0278,RC,,,,both,,,36251.30,23563.34,,,,,,,,,,,,,
CATHETER ARTERIAL 20 GAX12 CM ARTERIAL KIT WITH NEEDLE LOCKI,SUP-2838742,CDM,C1751,HCPCS,0278,RC,,,,both,,,353.56,229.81,,,,,,,,,,,,,
PLATE BNE L151MM THK3MM 8 H BILAT S STL STR LOK COMPR RECON,SUP-2185339,CDM,C1713,HCPCS,0278,RC,,,,both,,,1524.38,990.85,,,,,,,,,,,,,
PORT INFUS CATH DIA9.6FR TI ATTCH SIL PEEL APART INTRO SGL,SUP-2127726,CDM,C1788,HCPCS,0278,RC,,,,both,,,533.80,346.97,,,,,,,,,,,,,
MESH SURG W5.4XL7IN OMEGA 3 FATTY ACIDS NAT BIORESORBABLE,SUP-2265965,CDM,C1781,HCPCS,0278,RC,,,,both,,,1767.82,1149.08,,,,,,,,,,,,,
SET INTRO SHTH 6FR L11CM W/ INTEGR SIDE PRT HEMSTAS VLV 3 W,SUP-2383402,CDM,C1894,HCPCS,0272,RC,,,,both,,,141.30,91.84,,,,,,,,,,,,,
BUSHING EXT FIX FOR SALVATION EXT FIX,SUP-2401147,CDM,2720000010,LOCAL,0272,RC,,,,both,,,339.12,220.43,,,,,,,,,,,,,
SCREW BNE LCK 2.7X18 MM,SUP-2199257,CDM,C1713,HCPCS,0278,RC,,,,both,,,325.40,211.51,,,,,,,,,,,,,
KNIFE 3734123 JAKO MICRO LARYN SICKLE,SUP-2706869,CDM,2720000010,LOCAL,0272,RC,,,,both,,,548.46,356.50,,,,,,,,,,,,,
HC Repr Smp Nt Face 7.6-12.5cm,PX-4501200400,CDM,12004,CPT,0450,RC,,,,both,,,861.00,559.65,,,,,,,,,,,,,
PLATE BNE L62MM 2X5 H NONSTERILE T SHP FOR 27MM SCR UNIV LOK,SUP-2199365,CDM,C1713,HCPCS,0278,RC,,,,both,,,1034.94,672.71,,,,,,,,,,,,,
PLATE BNE STD EXT LG MEDL LT CLMN FUSION SS STRL SOLE MCF,SUP-2875507,CDM,C1713,HCPCS,0278,RC,,,,both,,,13260.38,8619.25,,,,,,,,,,,,,
ACTIDOSE WITH SORBITOL 25 GM/120ML PO SUSP,RX-159884,CDM,6370000000,HCPCS,0637,RC,00574-0520-74,NDC,,both,120,ML,60.00,39.00,,,,,,,,,,,,,
BLADE SHAVER SERRATED CLOSED ROTATABLE STRL DISP,SUP-2648980,CDM,2720000010,LOCAL,0272,RC,,,,both,,,673.22,437.59,,,,,,,,,,,,,
STEM HIP FEM COMP SIZE2 PREMISE,SUP-2364446,CDM,C1776,CPT,0278,RC,,,,both,,,4335.37,2817.99,,,,,,,,,,,,,
LEAD PACE FINELINE II STEROX L 58 CM DIA 5 FR SIL STEROID,SUP-2140111,CDM,C1900,HCPCS,0275,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
ROD SPNL POST R CRV SMOOTH TI ALLY PREBENT 5.5MM DIA 70MM,SUP-2415860,CDM,C1713,HCPCS,0278,RC,,,,both,,,1469.52,955.19,,,,,,,,,,,,,
PLATE BNE L68MM 7X4 H R VOLAR DST RAD S STL VAR ANG LOK,SUP-2184124,CDM,C1713,HCPCS,0278,RC,,,,both,,,2282.50,1483.62,,,,,,,,,,,,,
CLIP SUT TI W/ MT DEV,SUP-2332803,CDM,C1713,HCPCS,0278,RC,,,,both,,,321.28,208.83,,,,,,,,,,,,,
SUPPORT ORTHOPEDIC SLIP ON SM AD 7.5 IN WRST COMFORTFORM,SUP-2197051,CDM,L3931,HCPCS,0272,RC,,,,both,,,42.77,27.80,,,,,,,,,,,,,
BRACE WRST R INSTABILITY INJ LOOP LOK W/ STAY COCK UP E,SUP-2197948,CDM,L3931,HCPCS,0272,RC,,,,both,,,25.37,16.49,,,,,,,,,,,,,
ELECTRODE LAP MNPLR OLSEN 5MM DIA SHAFT 12 12NL BTTN TIP SC,SUP-2675666,CDM,2720000010,LOCAL,0272,RC,,,,both,,,982.54,638.65,,,,,,,,,,,,,
SPLINT WRST BLK XS 8 IN L,SUP-2336048,CDM,L3809,HCPCS,0272,RC,,,,both,,,18.68,12.14,,,,,,,,,,,,,
HC Pt Therapeutic Activities 15 Min|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS,PX-4209753000,CDM,97530,CPT,0420,RC,,,CQ,both,,,144.00,93.60,,,,,,,,,,,,,
FELT SURG L4IN OD1IN THICKNESS 1.65MM PTFE POLY LO POROSITY,SUP-2419778,CDM,C1768,CPT,0278,RC,,,,both,,,306.59,199.28,,,,,,,,,,,,,
SUPPORT KNEE XSM FOR 12 15IN THGH NEOPRENE,SUP-2150840,CDM,L1812,HCPCS,0272,RC,,,,both,,,32.03,20.82,,,,,,,,,,,,,
JGRLC 2.3MM SFT TIS PULL W/NDL,SUP-2589032,CDM,C1713,HCPCS,0278,RC,,,,both,,,1965.89,1277.83,,,,,,,,,,,,,
ROD EXT FIX CONN MIC 35 MM HOFFMAN,SUP-2363267,CDM,2720000010,LOCAL,0272,RC,,,,both,,,91.06,59.19,,,,,,,,,,,,,
GRAFT VASC VENAFLO II L 40 CM DIA 6 MM EPTFE CARBON STR N,SUP-2128778,CDM,C1768,CPT,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
HC Repair Tun or Non Cath W/Port,PX-3613657600,CDM,36576,CPT,0361,RC,,,,inpatient,,,6875.00,4468.75,,,,,,,,,,,,,
LENS IOL 16.0 DIOPT CYL 2.25 DIOPT L 13 MM DIA 6,SUP-2881476,CDM,V2787,HCPCS,0276,RC,,,,both,,,515.00,334.75,,,,,,,,,,,,,
ISATUXIMAB-IRFC 100 MG/5ML IV SOLN,RX-149831,CDM,J9227,HCPCS,0636,RC,00024-0654-01,NDC,,both,5,ML,2505.40,1628.51,,,,,,,,,,,,,
SHOE ORTHOT ADDITION TOE TAP STD,SUP-2435739,CDM,L3550,HCPCS,0274,RC,,,,both,,,25.31,16.45,,,,,,,,,,,,,
SEAL BNE CEM SZ 1 4 FEM PRSSURING PRSS FIT DEF,SUP-2375320,CDM,C1713,HCPCS,0278,RC,,,,both,,,147.58,95.93,,,,,,,,,,,,,
PLATE 4.5MM LCP CONDYLAR 18 HOLES 386MM RIGHT STERILE,SUP-2547446,CDM,C1713,HCPCS,0278,RC,,,,both,,,5132.93,3336.40,,,,,,,,,,,,,
MODULE FEM,SUP-2364662,CDM,C1776,CPT,0278,RC,,,,both,,,6536.70,4248.85,,,,,,,,,,,,,
SHEATH ACCS 18 FRX16 CM OPQ AMPLATZ,SUP-2835768,CDM,C1894,HCPCS,0272,RC,,,,both,,,93.73,60.92,,,,,,,,,,,,,
SHOE ORTHOT ADDITION TOE TAP STD,SUP-2435739,CDM,L3550,HCPCS,0272,RC,,,,both,,,25.31,16.45,,,,,,,,,,,,,
GRAFT URO SYR SYN INJ COAPTITE,SUP-2139476,CDM,L8606,HCPCS,0278,RC,,,,both,,,1665.77,1082.75,,,,,,,,,,,,,
GRAFT SOFT TISSUE FEM 9X24 MM WITH INSERTER AFX,SUP-2664011,CDM,C1713,HCPCS,0278,RC,,,,both,,,3404.26,2212.77,,,,,,,,,,,,,
ALLOGRAFT HUM TISS STRUT 160 MM FRZN GAM ACHILLES TEND,SUP-2866903,CDM,C1762,CPT,0278,RC,,,,both,,,3394.65,2206.52,,,,,,,,,,,,,
HC So Immunofluoresc per Spec 1st Ab,PX-3128834666,CDM,88346,CPT,0312,RC,,,,both,,,495.00,321.75,,,,,,,,,,,,,
SET SPEC RETRV L 220 CM OD 2.2 MM ID 1.9 MM CAP OD 21 MM ID,SUP-2881911,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5020.86,3263.56,,,,,,,,,,,,,
CONNECTOR ROD S STL OD55 635 MM SDLD,SUP-2279834,CDM,C1713,HCPCS,0278,RC,,,,both,,,2945.32,1914.46,,,,,,,,,,,,,
PROBE MPLR LNG,SUP-2211620,CDM,2720000010,LOCAL,0272,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
VALVE MI H19MM DIA27MM ORIFICE DIA24MM SUT RNG DIA35MM,SUP-2282629,CDM,C1889,HCPCS,0278,RC,,,,both,,,13345.00,8674.25,,,,,,,,,,,,,
MATRIX BIO L 4 X W 4 CM SZ 29 SQCM FISH SKIN DERMAL,SUP-2909208,CDM,Q4158,HCPCS,0636,RC,,,,both,,,4195.04,2726.78,,,,,,,,,,,,,
SUPPORT ORTHOT HIP CUST ABDUCTN ADJ,SUP-2435599,CDM,L1650,HCPCS,0272,RC,,,,both,,,698.18,453.82,,,,,,,,,,,,,
INSERT HUM ECC 2+ MM 12+ MM 42 MM SHLDR AEQUALIS REVERSED II,SUP-2715615,CDM,C1776,CPT,0278,RC,,,,both,,,4173.06,2712.49,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY LASSO NAV ECO L115CM 7/20FR 6MM D,SUP-2248627,CDM,C1732,HCPCS,0278,RC,,,,both,,,3990.94,2594.11,,,,,,,,,,,,,
SUPPORT ORTH HIP CIRC 48-60 IN LARGE/XL SZ 4,SUP-2915156,CDM,2720000010,LOCAL,0272,RC,,,,both,,,775.27,503.93,,,,,,,,,,,,,
CATHETER THROMCTMY AXS VECTA 71 L 115 CM ID 1.8 MM,SUP-2551060,CDM,C1757,HCPCS,0272,RC,,,,both,,,6499.80,4224.87,,,,,,,,,,,,,
SCREW BNE L3MM DIA1.7MM UNIV CORT CRANIOMAXILLOFACIAL SIL S 5PK,SUP-2366105,CDM,C1713,HCPCS,0278,RC,,,,both,,,194.65,126.52,,,,,,,,,,,,,
PROSTHESIS OSS EAR 3X4.75X1.17 MM PART PLAS POR PORP SHEEHY,SUP-2312526,CDM,L8613,CPT,0278,RC,,,,both,,,762.55,495.66,,,,,,,,,,,,,
ALLOGRAFT BNE SPNG 15 CC DBM FIBER VESUVIUS,SUP-2717979,CDM,C1713,HCPCS,0278,RC,,,,both,,,4000.36,2600.23,,,,,,,,,,,,,
FIBER LASER 550 MH SOLTIVE DISP,SUP-2540084,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1860.48,1209.31,,,,,,,,,,,,,
GRAFT HUMAN TSSUE SHEET 2CMW X 4CML ALLGRFT CNCLLS BONE RCTN,SUP-2726034,CDM,C1713,HCPCS,0278,RC,,,,both,,,1640.49,1066.32,,,,,,,,,,,,,
IMPLANT BRST SMOOTH 4.8 CM PROJCT 13.3 CM 545 CC MOD HI HSC,SUP-2264568,CDM,C1789,HCPCS,0278,RC,,,,both,,,2119.50,1377.67,,,,,,,,,,,,,
BUTTON ENEMA CECOSTOMY 14 FRX6 CM BLLN MINIACE,SUP-2119469,CDM,C1713,HCPCS,0278,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
HC CT Lower Ext W/O Cont,PX-3527370000,CDM,73700,CPT,0352,RC,,,,both,,,2077.00,1350.05,,,,,,,,,,,,,
BLADE MACINTOSH FBR OPT LARYNSCP NO 4 155MMX15MM HEINE CLASS,SUP-2238180,CDM,2720000010,LOCAL,0272,RC,,,,both,,,602.57,391.67,,,,,,,,,,,,,
DILATOR SURG URET 16FR,SUP-2141688,CDM,C1894,HCPCS,0272,RC,,,,both,,,249.76,162.34,,,,,,,,,,,,,
BIT DRL DIA2MM FOR 27MM DST LOK SCR,SUP-2121750,CDM,2720000010,LOCAL,0272,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
ALLOGRAFT BNE CHIP 1-8 MM 10 CC FD CRUSH CANC READIGRAFT,SUP-2740770,CDM,C1713,HCPCS,0278,RC,,,,both,,,550.63,357.91,,,,,,,,,,,,,
MESH CRAN L 65.02 X W 38 MM THK 0.6 MM SCREW DIA1.5 MM XL TI,SUP-2935882,CDM,C1713,HCPCS,0278,RC,,,,both,,,10478.18,6810.82,,,,,,,,,,,,,
K WIRE FIX L150MM DIA1.6MM TI TRCR PNT,SUP-2193146,CDM,C1713,HCPCS,0278,RC,,,,both,,,284.14,184.69,,,,,,,,,,,,,
BRACE KNEE 2XL POPLITEAL FAB W ADV STRTCH POLYCENTRIC HNG,SUP-2276698,CDM,L1810,HCPCS,0272,RC,,,,both,,,391.34,254.37,,,,,,,,,,,,,
"HC So Morphometric Analy, Comp Asst/Discrt Serv",PX-3128836166,CDM,88361,CPT,0312,RC,,,,inpatient,,,410.00,266.50,,,,,,,,,,,,,
CATHETER HD 14.5 FRX28 CM 45 CM STR SYMTRC TIP PALINDROME,SUP-2283944,CDM,C1750,HCPCS,0278,RC,,,,both,,,1004.36,652.83,,,,,,,,,,,,,
STENT ES L12CM DIA18MM CATH 18.5FR L120CM MTL FULL CVR SELF,SUP-2149298,CDM,C1874,HCPCS,0278,RC,,,,both,,,7661.85,4980.20,,,,,,,,,,,,,
CATHETER BILI DRNAGE 12FR L40CM POLYUR HYDRPHLC COAT SFT AND,SUP-2303562,CDM,C1729,HCPCS,0272,RC,,,,both,,,244.92,159.20,,,,,,,,,,,,,
SHEATH INTRO L 14 CM DIA10 FR GUIDEWIRE 0.038 IN PTFE X TW,SUP-2615901,CDM,C1894,HCPCS,0272,RC,,,,both,,,85.06,55.29,,,,,,,,,,,,,
KIT INTRO VSI L 10 CM DIA 4 FR NIT MANDREL TUNGSTEN TIP SMTH,SUP-2739178,CDM,C1892,HCPCS,0272,RC,,,,both,,,56.36,36.63,,,,,,,,,,,,,
RAIL EXT FIX RT WALKER,SUP-2898530,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2245.10,1459.31,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 50 CM DIA 6MM STR TW REINF SLDE GDS,SUP-2491940,CDM,C1768,CPT,0278,RC,,,,both,,,1745.56,1134.61,,,,,,,,,,,,,
HC Dilate Nephrost Ureter Urethra,PX-3207448500,CDM,74485,CPT,0320,RC,,,,both,,,1668.00,1084.20,,,,,,,,,,,,,
PLATE BONEXL THK2MM 5X22X5 H MAND TI DBL ANG LCKING FOR 2MM,SUP-2191276,CDM,C1713,HCPCS,0278,RC,,,,both,,,9416.23,6120.55,,,,,,,,,,,,,
NEEDLE ENDOSCP INJ 23 GAX5 MM 28 MMX230 CM W/CHANNEL SM BWL,SUP-2313414,CDM,2720000010,LOCAL,0272,RC,,,,both,,,86.76,56.39,,,,,,,,,,,,,
GRAFT BONE SUB 10CC DEMIN BONE MTRX PLUSXEMPLIFI,SUP-2417199,CDM,C9359,HCPCS,0278,RC,,,,both,,,3042.66,1977.73,,,,,,,,,,,,,
BIOCARTILAGE KIT,SUP-2841265,CDM,2720000010,LOCAL,0272,RC,,,,both,,,748.89,486.78,,,,,,,,,,,,,
PROPRANOLOL HCL ER 60 MG PO CP24,RX-38224,CDM,6370000000,HCPCS,0637,RC,00228-2778-11,NDC,,both,1,UN,7.60,4.94,,,,,,,,,,,,,
CRANIAL ACCESS KIT SYR NDL SOLUTION DRP TOWEL RAZOR,SUP-2666709,CDM,2720000010,LOCAL,0272,RC,,,,both,,,979.24,636.51,,,,,,,,,,,,,
CLAMP EXT FIX TRAUM CAPPED RNG DONE,SUP-2197258,CDM,2720000010,LOCAL,0272,RC,,,,both,,,53380.00,34697.00,,,,,,,,,,,,,
PLATE EXT FIX 3 H ANK FT FOR TRUELOK FRME ASSEMB HEXAPOD,SUP-2316199,CDM,2720000010,LOCAL,0272,RC,,,,both,,,643.45,418.24,,,,,,,,,,,,,
BAR EXT FIX L100MM DIA11MM FOR XTRAFIX SYS,SUP-2199708,CDM,2720000010,LOCAL,0272,RC,,,,both,,,507.14,329.64,,,,,,,,,,,,,
GRAFT STENT MAIN BODY ENDOVASC,SUP-2217643,CDM,C1768,CPT,0278,RC,,,,both,,,36361.20,23634.78,,,,,,,,,,,,,
POTASSIUM PHOSPHATE MONOBASIC 500 MG PO TABS,RX-11087,CDM,6370000000,HCPCS,0637,RC,00486-1111-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
ENDOPROSTHESIS VASC VIABAHN L 2.5 CM DIA 5 MM CATH L 75 CM,SUP-2396491,CDM,C1874,HCPCS,0278,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
NAIL IM FEM RT LCK CANN MEDIOLATERAL BEND 12MMX38CM 130DEG,SUP-2343946,CDM,C1713,HCPCS,0278,RC,,,,both,,,4932.94,3206.41,,,,,,,,,,,,,
WIRE BRST LOC BEAD BARB MR NDL 15CM 20GAX5CM GHIATAS,SUP-2126439,CDM,C1819,HCPCS,0278,RC,,,,both,,,118.79,77.21,,,,,,,,,,,,,
KIT CATH L35CM OD3.3MM ID1.9MM VENT STYL CONN SUT CLLR TRCR,SUP-2244108,CDM,C1729,HCPCS,0272,RC,,,,both,,,387.07,251.60,,,,,,,,,,,,,
DRILL TWST OD2.9MM FLUT STP FOR SUT ANCHR INLINE SYS,SUP-2341831,CDM,C1713,HCPCS,0278,RC,,,,both,,,1368.26,889.37,,,,,,,,,,,,,
TIP ASPIR SPETZLER MIC SUPER LNG UNIV 1.8X2 MMX7.9 SONOPET,SUP-2791032,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2729.95,1774.47,,,,,,,,,,,,,
PLATE BNE L 60 MM SCREW DIA2.4/2.7 MM 6 HD 3 SHFT H LT DSTL,SUP-2913507,CDM,C1713,HCPCS,0278,RC,,,,both,,,6686.32,4346.11,,,,,,,,,,,,,
HC Lung Volumes Airway Resist,PX-4609472600,CDM,94726,CPT,0460,RC,,,,both,,,584.00,379.60,,,,,,,,,,,,,
BRA SURG 2XL WHT POST SURG MAMM COMPR DSG W/ REM STRP FR HK,SUP-2276929,CDM,L8000,HCPCS,0274,RC,,,,both,,,109.90,71.43,,,,,,,,,,,,,
SPHINCTEROTOME ENDOSCP TIP 4.4FR L5MM CUT WIRE L20MM GWIRE,SUP-2149854,CDM,C1769,HCPCS,0272,RC,,,,both,,,1303.07,847.00,,,,,,,,,,,,,
GRAFT BNE SUB MINI CA SULF INJ MIIG 115,SUP-2399044,CDM,C1713,HCPCS,0278,RC,,,,both,,,2654.12,1725.18,,,,,,,,,,,,,
VALVE SHUNT HEYSCHLT HI PRESSURE MULTPURP ON-OFF FLSH,SUP-2244285,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4109.38,2671.10,,,,,,,,,,,,,
HC Splint App Long Leg,PX-4502950500,CDM,29505,CPT,0450,RC,,,,outpatient,,,214.00,139.10,,,,,,,,,,,,,
BIT DRL L12MM DIA2.3MM CERV STP W/ EPOXY RNG DISP PYRENEES,SUP-2258764,CDM,2720000010,LOCAL,0272,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
BLADE SCREWDRIVER 2MM2.3MM DIA 94MML CROSS DRIVE WSLEEVE,SUP-2707273,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1610.82,1047.03,,,,,,,,,,,,,
GRAFT HUM TISS DERMACELL POROUS 3X4CM 12SQCM,SUP-2909303,CDM,Q4122,HCPCS,0636,RC,,,,both,,,2719.24,1767.51,,,,,,,,,,,,,
SPLINT COLLES W FOAM L ARM PERF ALUMINIUM XR LUCENT TAN AD,SUP-2336083,CDM,L3908,HCPCS,0272,RC,,,,both,,,12.18,7.92,,,,,,,,,,,,,
FIBER LASER KIT 600 MIC FOR KTP,SUP-2225704,CDM,2720000010,LOCAL,0272,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
ARM EXT FIX ACTIVATION 60 MM SNAKE SS TI RESORB XG,SUP-2489183,CDM,C1713,HCPCS,0278,RC,,,,both,,,3646.61,2370.30,,,,,,,,,,,,,
BRACE ORTHOPEDIC ABDUCTN HIP,SUP-2388159,CDM,L1686,HCPCS,0272,RC,,,,both,,,4779.08,3106.40,,,,,,,,,,,,,
SEALANT TISS 10ML FIBRIN PREFIL SYR PRIMA FRZN W 1 DUPLOJET,SUP-2130408,CDM,C1713,HCPCS,0278,RC,,,,both,,,2280.49,1482.32,,,,,,,,,,,,,
CRANIAL ACCESS KIT MANUAL CRAN ROTARY HNDPC DISP HITHSP06,SUP-2666708,CDM,2720000010,LOCAL,0272,RC,,,,both,,,908.34,590.42,,,,,,,,,,,,,
SCREW BONE CNNLTD 2MM DIA 12MML TTNM COUNTSINK DEPTH GAUGE F,SUP-2586653,CDM,C1713,HCPCS,0278,RC,,,,both,,,923.10,600.01,,,,,,,,,,,,,
INTRODUCER LD L14CM OD8FR GWIRE OD0038IN PACEMKR DI LOCK DIL,SUP-2357074,CDM,C1894,HCPCS,0272,RC,,,,both,,,27.63,17.96,,,,,,,,,,,,,
CATHETER ATHRCTMY 0.058 INX135 MM 2.25 MM PRECONN ROTLNK,SUP-2143725,CDM,C1724,HCPCS,0278,RC,,,,both,,,4849.73,3152.32,,,,,,,,,,,,,
KCL IN DEXTROSE-NACL 30-5-0.45 MEQ/L-%-% IV SOLN,RX-102361,CDM,2500000003,HCPCS,0250,RC,00264-7636-00,NDC,,both,1000,ML,54.10,35.16,,,,,,,,,,,,,
PLATE BNE THK1MM 3X2 H UNIV CRANIOMAXILLOFACIAL TI 3D,SUP-2366346,CDM,C1713,HCPCS,0278,RC,,,,both,,,991.86,644.71,,,,,,,,,,,,,
SHUNT VLV SINGLE PRESSURE 9X29 CM 19 CM H2O 2 CONN PAEDIGAV,SUP-2846923,CDM,C1889,HCPCS,0278,RC,,,,both,,,5525.43,3591.53,,,,,,,,,,,,,
OSSEOFLEX SB 10 GG4ML STRGHT SSTM W OSSFLX CD H CNVNNCE PA,SUP-2701995,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7190.60,4673.89,,,,,,,,,,,,,
PROSTHESIS OSS L 8 MM SHFT DIA 0.6 MM POLYCEL SS MALL TOT,SUP-2902035,CDM,L8613,CPT,0278,RC,,,,both,,,976.67,634.84,,,,,,,,,,,,,
BOLT SPNL L45MM OD8MM TI CANC ANT THORLUM PEDCL ST FIX ANG,SUP-2292735,CDM,C1713,HCPCS,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN,RX-93931,CDM,J7620,HCPCS,0637,RC,00487-0201-01,NDC,,both,3,ML,2.70,1.75,,,,,,,,,,,,,
SCREW BONE PARTIAL THREADED 4.5X34 MM 12 MM SHAFT LARGE FRAG,SUP-2837080,CDM,C1713,HCPCS,0278,RC,,,,both,,,205.61,133.65,,,,,,,,,,,,,
SCREW SPNL MULTAXL 9.5X50 MM CANC CD HORZ TCS,SUP-2628376,CDM,C1713,HCPCS,0278,RC,,,,both,,,3355.88,2181.32,,,,,,,,,,,,,
MINI PLATE 16 HOLE REGULAR CP TITANIUM,SUP-2668087,CDM,C1713,HCPCS,0278,RC,,,,both,,,376.36,244.63,,,,,,,,,,,,,
CATHETER ABLATN LG 1 2-5-2 4 MM 1304-CP-7-25-L1-AB THER,SUP-2484445,CDM,C2630,CPT,0272,RC,,,,both,,,4527.88,2943.12,,,,,,,,,,,,,
HC Deliver Placenta,PX-7205941400,CDM,59414,CPT,0720,RC,,,,inpatient,,,10518.00,6836.70,,,,,,,,,,,,,
LINER ACET OD50MM ID28MM POLY MTL ON POLY REV NEUT OBLQ MOD,SUP-2202305,CDM,C1776,CPT,0278,RC,,,,both,,,3551.34,2308.37,,,,,,,,,,,,,
PIN FIX L102MM OD32MM TOT ANK SYS INFIN,SUP-2397265,CDM,C1713,HCPCS,0278,RC,,,,both,,,72.22,46.94,,,,,,,,,,,,,
ALLOGRAFT GRAN LESS THAN 2MM 15CC,SUP-2138493,CDM,C1713,HCPCS,0278,RC,,,,both,,,7853.14,5104.54,,,,,,,,,,,,,
GUIDEWIRE VASC KATZN L 145 CM TIP L 12 CM DIA 0.035 IN SS,SUP-2148180,CDM,C1769,HCPCS,0272,RC,,,,both,,,553.68,359.89,,,,,,,,,,,,,
KIT PROC CLR GLDE EVH,SUP-2266078,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1733.28,1126.63,,,,,,,,,,,,,
TUBE GASTROSTMY ENTRL FEED 18 FR 15 CC ENFIT CONN COMPAT,SUP-2309463,CDM,2720000010,LOCAL,0272,RC,,,,both,,,57.21,37.19,,,,,,,,,,,,,
TRAY PICC 5FR L55CM POLYUR NRS SGL LUMN FULL PWR INJ N COAT,SUP-2125636,CDM,C1751,HCPCS,0278,RC,,,,both,,,596.60,387.79,,,,,,,,,,,,,
PROCESSOR SND SYS N5SP2,SUP-2141843,CDM,L8690,HCPCS,0278,RC,,,,both,,,11147.00,7245.55,,,,,,,,,,,,,
SYSTEM EMB ONYX 18 1.5 ML EVOH DMSO VI SYR N ADH LIQ STRL,SUP-2172495,CDM,C1889,HCPCS,0278,RC,,,,both,,,9878.44,6420.99,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 40 CM DIA 6 MM STR STD WALL REINF,SUP-2494266,CDM,C1768,CPT,0278,RC,,,,both,,,673.88,438.02,,,,,,,,,,,,,
CATHETERIZATION SET ART 20 GAX4.45 CM 22 GA VEN 1 LUMEN LF,SUP-2865590,CDM,C1751,HCPCS,0278,RC,,,,both,,,16.83,10.94,,,,,,,,,,,,,
STENT UTER BALLOON L 3 X W 2.8 CM SIL FOR INTRAUTERINE SURG,SUP-2168925,CDM,C2628,HCPCS,0272,RC,,,,both,,,104.41,67.87,,,,,,,,,,,,,
CATHETER INFUSION 2.4 FRX150 CM STD FLX STR EXCELSIOR XT 17,SUP-2368069,CDM,C1887,HCPCS,0272,RC,,,,both,,,2874.36,1868.33,,,,,,,,,,,,,
ESTROGENS CONJUGATED 0.625 MG/GM VA CREA,RX-159331,CDM,6370000000,HCPCS,0637,RC,00046-0872-21,NDC,,both,30,GR,2073.90,1348.03,,,,,,,,,,,,,
PLATE BONE THK 0.75MM 8 H RESRB POLYMER TI,SUP-2364979,CDM,C1713,HCPCS,0278,RC,,,,both,,,522.09,339.36,,,,,,,,,,,,,
PLATE BONE W19.5XL55.5MM THK1.65MM 13 H TI T Y LCK LO PROF,SUP-2411748,CDM,C1713,HCPCS,0278,RC,,,,both,,,1476.59,959.78,,,,,,,,,,,,,
BLADE RTRCTR SM 24MMW X 80MML TTNM SPNL TTHX3 THIN SIL LMBRT,SUP-2466205,CDM,2720000010,LOCAL,0272,RC,,,,both,,,970.73,630.97,,,,,,,,,,,,,
FULL RING DIA120 MM CARBON,SUP-2701759,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4838.11,3144.77,,,,,,,,,,,,,
DEFIBRILLATOR IMPL EPIC DR THK 12.9 MM 33 ML 70 GM 2 CHMBR,SUP-2320138,CDM,C1721,HCPCS,0275,RC,,,,both,,,69865.00,45412.25,,,,,,,,,,,,,
HC Veeg by Tech Ea Incr 12-26 Hr Intermittent Mntr,PX-7409571500,CDM,95715,CPT,0740,RC,,,,both,,,4222.00,2744.30,,,,,,,,,,,,,
INSERTER SURG M/L 10 UNIV GEN,SUP-2349825,CDM,C1776,CPT,0278,RC,,,,both,,,1258.98,818.34,,,,,,,,,,,,,
PLATE BNE R TROCHANTERIC FEM TI ALLY PERIPROSTHETIC NCB,SUP-2411446,CDM,C1713,HCPCS,0278,RC,,,,both,,,2815.07,1829.80,,,,,,,,,,,,,
SPATULA SURG,SUP-2291544,CDM,C1713,HCPCS,0278,RC,,,,both,,,743.68,483.39,,,,,,,,,,,,,
RELOAD STPL L45MM EXTRA THCK REINF FOR SIGNIA STPLR,SUP-2283375,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2806.47,1824.21,,,,,,,,,,,,,
PUTTY BONE GRAFT FACTOR 2.5ML PEPTIDE ENHANCED W/SYRINGE,SUP-2693633,CDM,C1713,HCPCS,0278,RC,,,,both,,,3601.58,2341.03,,,,,,,,,,,,,
NEEDLE SUTURE L9.5IN BLUNT LIGATURE FOR RIGHT HAND DESCHAMPS,SUP-2802483,CDM,2720000010,LOCAL,0272,RC,,,,both,,,355.26,230.92,,,,,,,,,,,,,
SCREW BNE L30MM DIA3.5MM S STL CANN PARTIALLY THRD HD HEX,SUP-2183622,CDM,C1713,HCPCS,0278,RC,,,,both,,,440.79,286.51,,,,,,,,,,,,,
PLATE BNE BSSO MINI 2X28 MM 13 MM 14 MM DBL Y CRV FOR SCR TI,SUP-2471824,CDM,C1713,HCPCS,0278,RC,,,,both,,,1729.61,1124.25,,,,,,,,,,,,,
COIL EMB L10CM DIA6MM 0.018IN PERIPH HYDRGEL DETACH 18 SYS,SUP-2385415,CDM,C1889,HCPCS,0278,RC,,,,both,,,2847.82,1851.08,,,,,,,,,,,,,
SLEEVE CNTR L6MM FOR ANG PIN CONNECTOR/ILIZAROV TAY SPAT,SUP-2340791,CDM,2720000010,LOCAL,0272,RC,,,,both,,,874.14,568.19,,,,,,,,,,,,,
TRIAL BONE PLT 3 H T SHP OBLQ TC-100 SM FRAG SYS,SUP-2343729,CDM,C1713,HCPCS,0278,RC,,,,both,,,1952.36,1269.03,,,,,,,,,,,,,
GUIDE SURG PLN TI LP CUSTOMIZABLE BNDL RECON VSP,SUP-2883953,CDM,2720000010,LOCAL,0272,RC,,,,both,,,28189.35,18323.08,,,,,,,,,,,,,
SCREW BONE L28MM DIA5.5MM THRD L16MM STD CORT S STL ST SELF,SUP-2343633,CDM,C1713,HCPCS,0278,RC,,,,both,,,324.05,210.63,,,,,,,,,,,,,
SCREW OSTEOTOMY JACK,SUP-2811975,CDM,C1713,HCPCS,0278,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
BACITRACIN-POLYMYXIN B 500-10000 UNIT/GM EX OINT,RX-855,CDM,6370000000,HCPCS,0637,RC,58980-0012-05,NDC,,both,14.2,GR,15.80,10.27,,,,,,,,,,,,,
SUPPORT ORTHOPEDIC ADJ HIP ABDUCTN FLX EXTN CTRL,SUP-2421311,CDM,L2624,HCPCS,0274,RC,,,,both,,,1216.47,790.71,,,,,,,,,,,,,
MEDROXYPROGESTERONE ACETATE 2.5 MG PO TABS,RX-4855,CDM,6370000000,HCPCS,0637,RC,00555-0872-02,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
METHOTREXATE SODIUM (PF) 50 MG/2ML IJ SOLN,RX-117354,CDM,J9260,HCPCS,0636,RC,00143-9519-10,NDC,,both,0.5,ML,54.10,35.16,,,,,,,,,,,,,
HC Drain Pilonidal Cyst,PX-4501008100,CDM,10081,CPT,0450,RC,,,,both,,,2188.00,1422.20,,,,,,,,,,,,,
PLATE 4.5MM TI LCP TM PROX TIBIA 12H 226MM RIGHT STERILE,SUP-2549645,CDM,C1713,HCPCS,0278,RC,,,,both,,,5185.80,3370.77,,,,,,,,,,,,,
GUIDE WIRE PLUNGER,SUP-2814356,CDM,C1769,HCPCS,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
PLATE BNE L138MM 6 H NONSTERILE L OLECRANON S STL LOK COMPR,SUP-2185427,CDM,C1713,HCPCS,0278,RC,,,,both,,,3097.58,2013.43,,,,,,,,,,,,,
SCREW BNE L10MM OD2.4MM TI MAXILLOMANDIBULAR NONLOCKING HI,SUP-2403057,CDM,C1713,HCPCS,0278,RC,,,,both,,,238.64,155.12,,,,,,,,,,,,,
CATHETER VENTRICULAR H 11 CM SNAP SHUNT ENDOVENT INNERVISION,SUP-2628507,CDM,C1729,HCPCS,0272,RC,,,,both,,,633.12,411.53,,,,,,,,,,,,,
SCREW BONE L38MM DIA4.5MM HIP TI LCK FULL THRD CAPT FOR IM,SUP-2347553,CDM,C1713,HCPCS,0278,RC,,,,both,,,511.76,332.64,,,,,,,,,,,,,
BASEPLATE BONE ELBW TI ASMBLY FOR STBL SYS IJS,SUP-2340387,CDM,C1713,HCPCS,0278,RC,,,,both,,,15345.18,9974.37,,,,,,,,,,,,,
ANCHOR SUT 20 MM DIA SGL ARMED TI N ABSRB BRAID RIGIDLOOP,SUP-2431833,CDM,C1713,HCPCS,0278,RC,,,,both,,,2154.04,1400.13,,,,,,,,,,,,,
PROBE PEDCL L165MM CANN W/ MOD JAMSH NDL NO1 MOD MOD,SUP-2354606,CDM,2720000010,LOCAL,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
CATHETER HAD 11.5FR L20CM STR POLYUR DBL LUMN FULL KT,SUP-2267018,CDM,C1752,HCPCS,0278,RC,,,,both,,,271.92,176.75,,,,,,,,,,,,,
SLEEVE TROCAR L60MM DIAMETER 5MM SMOOTH WITH TAP DISPOSABLE,SUP-2804743,CDM,2720000010,LOCAL,0272,RC,,,,both,,,452.63,294.21,,,,,,,,,,,,,
GRAFT BONE MEDIOLATERAL W14.5MM H11.22X9.75MM,SUP-2264951,CDM,C1713,HCPCS,0278,RC,,,,both,,,4093.74,2660.93,,,,,,,,,,,,,
ANCHOR SUT DIA5.5MM 2 ERGO HNDL LSR BND W/O NDL DBL END HA,SUP-2366671,CDM,C1713,HCPCS,0278,RC,,,,both,,,1336.70,868.85,,,,,,,,,,,,,
HC So Dihydrotestosterone (Dht),PX-3018264266,CDM,82642,CPT,0301,RC,,,,outpatient,,,78.00,50.70,,,,,,,,,,,,,
GUIDE PIN TIP THRD 3.2X300MM,SUP-2820853,CDM,C1713,HCPCS,0278,RC,,,,both,,,328.95,213.82,,,,,,,,,,,,,
CATHETER EP 4FR L110CM 2-5-2MM SPC 1MM BND ELECTRD M CRV,SUP-2357643,CDM,C1730,HCPCS,0272,RC,,,,both,,,1695.60,1102.14,,,,,,,,,,,,,
SCREW BNE L 24 MM DIA 4 MM SHRT TI CANN HD NS LEOS,SUP-2931528,CDM,C1713,HCPCS,0278,RC,,,,both,,,961.97,625.28,,,,,,,,,,,,,
SCREW BNE L5MM DIA1.4MM CORT CRANIOMAXILLOFACIAL PUR S STL 5PK,SUP-2366086,CDM,C1713,HCPCS,0278,RC,,,,both,,,212.92,138.40,,,,,,,,,,,,,
MATRIX 1.4MM BIT DRILL W/6MM,SUP-2823023,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1483.30,964.14,,,,,,,,,,,,,
GRAFT VASC ARTEGRAFT L 45 CM DIA 5 MM CLLGN BOV CAR ART,SUP-2120664,CDM,C1768,CPT,0278,RC,,,,both,,,3953.26,2569.62,,,,,,,,,,,,,
GENTAMICIN SULFATE 2 MG/ML SYRINGE (PED-NEO) <50 ML|DISCARDED DRUG NOT ADMINISTE,RX-4090289,CDM,J1580,HCPCS,0636,RC,00338-0511-41,NDC,JW,both,50,ML,54.10,35.16,,,,,,,,,,,,,
GRAFT BONE FRZN LT TALUS IMP OSTEOCHNDRL,SUP-2307316,CDM,C1713,HCPCS,0278,RC,,,,both,,,11275.74,7329.23,,,,,,,,,,,,,
SCREW 5.0MM SELF DRILLING SCHANZ 150MM HA COATING STERILE,SUP-2547745,CDM,C1713,HCPCS,0278,RC,,,,both,,,861.33,559.86,,,,,,,,,,,,,
SUPPORT ORTHOT LOWER EXTREMITY PELV CTRL BND BELT BILATERAL,SUP-2435689,CDM,L2640,HCPCS,0272,RC,,,,both,,,889.62,578.25,,,,,,,,,,,,,
KIT MON DETACH MPLR PRB EXTN CBL BALL TIP PRB DISP,SUP-2415825,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
PERI-LOC 5.7MM CANN LCK SCREW 80MM,SUP-2819542,CDM,C1713,HCPCS,0278,RC,,,,both,,,2092.46,1360.10,,,,,,,,,,,,,
STAPLE BNE FIX 20X7MM BRDG 3 20MM LEG Y SHP IMPL,SUP-2194189,CDM,C1713,HCPCS,0278,RC,,,,both,,,5091.67,3309.59,,,,,,,,,,,,,
BLADE SHAVER RESECT 5.5X130 MM CRV CONCV SMOOTH DISP,SUP-2661227,CDM,2720000010,LOCAL,0272,RC,,,,both,,,443.05,287.98,,,,,,,,,,,,,
BIT DRL 7 MM NS GOTFRIED PCCP,SUP-2644756,CDM,2720000010,LOCAL,0272,RC,,,,both,,,700.35,455.23,,,,,,,,,,,,,
CATHETER HAD KT DIAL CHRONIC DBL LUMN 15FRX28 CANNON II,SUP-2383439,CDM,C1750,HCPCS,0278,RC,,,,both,,,1105.28,718.43,,,,,,,,,,,,,
GUIDEPIN SURG DIA1/8IN ARTHSCP SCR GUID ASNS 2,SUP-2362448,CDM,C1769,HCPCS,0272,RC,,,,both,,,160.14,104.09,,,,,,,,,,,,,
PLATE BNE L174MM 14 H L POSTEROLATERAL DST PERIARTC HUM,SUP-2198398,CDM,C1713,HCPCS,0278,RC,,,,both,,,2608.08,1695.25,,,,,,,,,,,,,
PPICC PROV SOLO PED 3F SLEEVE MAXDELTA,SUP-2613524,CDM,C1751,HCPCS,0278,RC,,,,both,,,856.15,556.50,,,,,,,,,,,,,
CATHETER IAB 0.025 IN 7 FRX26.8 IN 30 CC FLX WIRE REDIGUARD,SUP-2877610,CDM,C1894,HCPCS,0272,RC,,,,both,,,2700.40,1755.26,,,,,,,,,,,,,
BRUSH CYTO W2.1MMXL200CM CATH 8FR 0.035IN BILI DUCT MTL TB,SUP-2149564,CDM,2720000010,LOCAL,0272,RC,,,,both,,,338.55,220.06,,,,,,,,,,,,,
SPACER SPNL 8 DEG 22X8X8 MM HEDRON P,SUP-2763887,CDM,C1889,HCPCS,0278,RC,,,,both,,,8713.50,5663.77,,,,,,,,,,,,,
CATHETER NEPHSTMY 14FR L25CM FLEXIMA REG PGTL TIP RADPQ MTL,SUP-2147844,CDM,C1729,HCPCS,0272,RC,,,,both,,,248.06,161.24,,,,,,,,,,,,,
CATHETER EMB ACCUNET 2 L 141 CM DIA1.6 MM SHTH 6 FR CAR,SUP-2101770,CDM,C1757,HCPCS,0272,RC,,,,both,,,109.90,71.43,,,,,,,,,,,,,
CATHETER PULM ART 7FR L110CM INTRO 7X8FR BAL 1.5CC DIA12MM,SUP-2383250,CDM,C1751,HCPCS,0278,RC,,,,both,,,339.12,220.43,,,,,,,,,,,,,
SCREW SPNL ST 6X35 MM SOVEREIGN,SUP-2630892,CDM,C1713,HCPCS,0278,RC,,,,both,,,745.75,484.74,,,,,,,,,,,,,
BASEPLATE TIB M + STD UNIV KNEE CEM STEM PRI MOD N POR W/O,SUP-2397048,CDM,C1776,CPT,0278,RC,,,,both,,,10431.08,6780.20,,,,,,,,,,,,,
EVOS 2.7/3.5 OLCRNN PL W/TNS 13H L 179MM,SUP-2819864,CDM,C1713,HCPCS,0278,RC,,,,both,,,9853.16,6404.55,,,,,,,,,,,,,
GRAFT BONE STRUT CORT ALLGRFT SZ 2X15CM,SUP-2113894,CDM,C1713,HCPCS,0278,RC,,,,both,,,1161.80,755.17,,,,,,,,,,,,,
COMPONENT FEM CR 1 55X53 MM LT CEM ANAT DP PAT GRV POROUS,SUP-2390343,CDM,C1776,CPT,0278,RC,,,,both,,,12048.18,7831.32,,,,,,,,,,,,,
CATHETER CV MAXIMAL BARR TY 025 5 FRX8 CM 16 GA 3L SPECTRUM,SUP-2759895,CDM,C1751,HCPCS,0278,RC,,,,both,,,571.95,371.77,,,,,,,,,,,,,
TWIST DRILL ANGULUS 15 X 9MM,SUP-2679094,CDM,2720000010,LOCAL,0272,RC,,,,both,,,556.09,361.46,,,,,,,,,,,,,
DEVICE FIX L37CM PEEK SMOOTH CANN 30 ABSRB FAST FOR LAP,SUP-2125767,CDM,C1713,HCPCS,0278,RC,,,,both,,,753.60,489.84,,,,,,,,,,,,,
BRACE ORTH CIRC THGH 23.5-26.5 IN CTR 17-19 IN CALF 18-20 IN XL,SUP-2915239,CDM,2720000010,LOCAL,0272,RC,,,,both,,,368.01,239.21,,,,,,,,,,,,,
SCREW BNE EMGCY 3.1X9 MM NLCK TI MAXDRIVE LEVEL 1 258880991,SUP-2458049,CDM,C1713,HCPCS,0278,RC,,,,both,,,367.13,238.63,,,,,,,,,,,,,
BENDING TEMPLATE 5 HOLES FOR 2.7MM,SUP-2548477,CDM,C1713,HCPCS,0278,RC,,,,both,,,97.69,63.50,,,,,,,,,,,,,
IMPLANT SPHR EYE SST POLYETH W/ NOVABONE 20MM MEDPOR +,SUP-2328482,CDM,L8610,HCPCS,0278,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
LINER KT WLK BOOT VENTURE AIR TALL SM,SUP-2151041,CDM,L4386,HCPCS,0274,RC,,,,both,,,54.01,35.11,,,,,,,,,,,,,
GRAFT CORNEAL W1.5XL2CM THK50-100UM BIO TRANSPLANTATION,SUP-2135257,CDM,V2790,HCPCS,0274,RC,,,,both,,,2025.30,1316.44,,,,,,,,,,,,,
NAIL INDICATED FOR THE TREAT OF STBL AND UNSTBL PROX FEM,SUP-2152591,CDM,C1713,HCPCS,0278,RC,,,,both,,,4353.77,2829.95,,,,,,,,,,,,,
ALLOGRAFT BNE 10 CC DEMINERALIZED BNE MTRX FIBER ALLOFIBER,SUP-2759430,CDM,C1713,HCPCS,0278,RC,,,,both,,,9734.00,6327.10,,,,,,,,,,,,,
ROD SPNL L 100 DIA 6 MM CARBON FIBER PEDCL IL CREST STRL,SUP-2883099,CDM,C1713,HCPCS,0278,RC,,,,both,,,5809.00,3775.85,,,,,,,,,,,,,
MARKER BRST BX X SHP 9 GA FOR EVIVA TI SENOMARK,SUP-2759167,CDM,A4648,CPT,0278,RC,,,,both,,,188.84,122.75,,,,,,,,,,,,,
KIT SUT DEV RELD ENDOSCP FAST COMB COR-KNOT MINI,SUP-2265308,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2505.72,1628.72,,,,,,,,,,,,,
SHIM RETRACTOR SZ 51.5 MM SS SPIKE BLNT LCK NS DISP,SUP-2891844,CDM,2720000010,LOCAL,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
STAPLER INT CRV TIP 30 MM 2 MM GRY STRL SIGNIA TRI-STAPLE,SUP-2787704,CDM,2720000010,LOCAL,0272,RC,,,,both,,,832.23,540.95,,,,,,,,,,,,,
PLATE BONE W17.4XL79.8MM THK1.65MM TI LCK WEB FOR 2.5MM SCR,SUP-2411749,CDM,C1713,HCPCS,0278,RC,,,,both,,,1466.38,953.15,,,,,,,,,,,,,
SPLINT WRIST FA RIGHT 7,SUP-2136568,CDM,L3809,HCPCS,0272,RC,,,,both,,,37.40,24.31,,,,,,,,,,,,,
STE 1ST MTP FUSION PLT LT SM,SUP-2588794,CDM,C1713,HCPCS,0278,RC,,,,both,,,1921.40,1248.91,,,,,,,,,,,,,
GUIDEPIN SURG DIA1.1MM NIT FOR BIOINTERFERENCE SCR,SUP-2120909,CDM,2720000010,LOCAL,0272,RC,,,,both,,,65.94,42.86,,,,,,,,,,,,,
DILATOR ENDOSCP 6 FRX180 CM 4X40 MM BILI CATH MAXPASS DISP,SUP-2312952,CDM,C1726,HCPCS,0272,RC,,,,both,,,692.24,449.96,,,,,,,,,,,,,
SCREW BNE STR 0 DEG MED 2.5X19 MM HAMRTOE KT OSSIOFIBER,SUP-2641882,CDM,C1713,HCPCS,0278,RC,,,,both,,,4553.00,2959.45,,,,,,,,,,,,,
OSS SPLINED STEM 10X120MM,SUP-2506341,CDM,C1776,CPT,0278,RC,,,,both,,,4931.37,3205.39,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA 5FR 55CM 3 LUMAN R S9395108,SUP-2632880,CDM,C1751,HCPCS,0278,RC,,,,both,,,703.36,457.18,,,,,,,,,,,,,
COMPONENT TALAR SZ 1 L ANK CO CHROM FLAT CUT SALTO TALARIS,SUP-2244185,CDM,C1776,CPT,0278,RC,,,,both,,,33576.02,21824.41,,,,,,,,,,,,,
GRAFT BIO TISS W2XL4CM THK0.8-1.7MM ACELLULAR DERM MTRX,SUP-2307454,CDM,Q4128,HCPCS,0636,RC,,,,both,,,487.96,317.17,,,,,,,,,,,,,
SPLINT WR AD L 9IN LNG RT COT W/ STAY ELAS SUPP FOR,SUP-2324569,CDM,L3809,HCPCS,0274,RC,,,,both,,,37.68,24.49,,,,,,,,,,,,,
CATHETER IU 10FR BLLN 5ML L5CM DISP FOR FEM WORD BARTH,SUP-2384667,CDM,C1729,HCPCS,0272,RC,,,,both,,,64.90,42.18,,,,,,,,,,,,,
GRAFT HUM TISS W9XL22 30MM PAT WDG FRZ DRY,SUP-2307178,CDM,C1713,HCPCS,0278,RC,,,,both,,,3238.16,2104.80,,,,,,,,,,,,,
MESH SURG W4XL4CM THK1.1MM ACELLULAR DERM MATRIXXENOGRAFT,SUP-2362224,CDM,C1763,HCPCS,0278,RC,,,,both,,,8258.20,5367.83,,,,,,,,,,,,,
PLATE 14MM DIAM 1MM THICKNESS ATTIC DEFCT KARTUSH HA KARTUSH,SUP-2312566,CDM,C1713,HCPCS,0278,RC,,,,both,,,432.69,281.25,,,,,,,,,,,,,
HC So John Cunningham Antibody,PX-3028671166,CDM,86711,CPT,0302,RC,,,,both,,,1756.00,1141.40,,,,,,,,,,,,,
VALVE SHUNT L2.8CM OD1.9MM D.6CM VERTICAL 30CM HORIZONTAL 10,SUP-2821784,CDM,C1889,HCPCS,0278,RC,,,,both,,,6829.03,4438.87,,,,,,,,,,,,,
TUBE VENT 1.02 MM 1 MM 2.7MM BOB TI BLU STRL 500001,SUP-2535060,CDM,L8699,HCPCS,0278,RC,,,,both,,,98.60,64.09,,,,,,,,,,,,,
AUGMENT FEM THK 5 MM SZ 2 DSTL HINGE REV STRL TRIATHLON,SUP-2889784,CDM,C1776,CPT,0278,RC,,,,both,,,5000.45,3250.29,,,,,,,,,,,,,
PROSTHESIS OSS 0.6 MM 1.4X0.86X1.14 MM K-HELIX FTPLT SHOE TI,SUP-2465347,CDM,L8613,CPT,0278,RC,,,,both,,,417.59,271.43,,,,,,,,,,,,,
PLATE BNE L59MM THK3.4MM 4 H BILAT S STL STR LOK COMPR FOR,SUP-2185128,CDM,C1713,HCPCS,0278,RC,,,,both,,,765.12,497.33,,,,,,,,,,,,,
WASHER ORTH T6 FOR 2.3 MM SCREW NS VARIAX 2 MINI FRAG,SUP-2902164,CDM,C1713,HCPCS,0278,RC,,,,both,,,214.78,139.61,,,,,,,,,,,,,
BIT DRL HRD BNE CINCHLOCK FLX DISP,SUP-2663984,CDM,2720000010,LOCAL,0272,RC,,,,both,,,833.01,541.46,,,,,,,,,,,,,
PLATE BONE STRAIGHT 1.5X100X100X0.8 MM MESH RAPID RESORBABLE,SUP-2838585,CDM,C1713,HCPCS,0278,RC,,,,both,,,10921.86,7099.21,,,,,,,,,,,,,
GRAFT VASC TAPR STD WALL N RING EPTFE SM BEAD 7MM DIAX4MM,SUP-2126885,CDM,C1768,CPT,0278,RC,,,,both,,,3559.91,2313.94,,,,,,,,,,,,,
EXPANDER TISS BRST SMOOTH SURF RND,SUP-2748614,CDM,C1889,HCPCS,0278,RC,,,,both,,,2772.62,1802.20,,,,,,,,,,,,,
BIT DRL DIA 9.5 MM CANN REMOVAL NS REUSE,SUP-2905286,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2044.14,1328.69,,,,,,,,,,,,,
MESH SURG 35CM LEN 25CM W THK07MM INGUINAL SYN N ABSRB,SUP-2126051,CDM,C1781,HCPCS,0278,RC,,,,both,,,899.30,584.54,,,,,,,,,,,,,
CLIP ANEURYSM L13MM 90DEG STANDARD TITANIUM PERMANENT YASARG,SUP-2826616,CDM,C1889,HCPCS,0278,RC,,,,both,,,7451.91,4843.74,,,,,,,,,,,,,
GRAFT BNE CANC 60 CC 80-20% CORTICAL,SUP-2321771,CDM,C1762,CPT,0278,RC,,,,both,,,1639.08,1065.40,,,,,,,,,,,,,
GUIDEWIRE VASC FLPY 0.035 INX260 CM PERIPH HI TORQ VERSACORE – ORDER MULTIPLES OF 5EACH,SUP-2104848,CDM,C1769,HCPCS,0272,RC,,,,both,,,194.68,126.54,,,,,,,,,,,,,
MESH HERN XL L5XW3.8CM INGUINAL POLYPR SYN PRESHAPED LT WT,SUP-2125792,CDM,C1781,HCPCS,0278,RC,,,,both,,,565.51,367.58,,,,,,,,,,,,,
BIT DRL 10 GA STR HND COMPATIBLE OSSEOFLEX,SUP-2464598,CDM,2720000010,LOCAL,0272,RC,,,,both,,,486.70,316.35,,,,,,,,,,,,,
COMPONENT HIP H5 PREMIER HYBIRD,SUP-2351361,CDM,C1776,CPT,0278,RC,,,,both,,,10676.00,6939.40,,,,,,,,,,,,,
KIT PERICARDCENT W/ 6FR PGTL CATH DIL ANES NDL LUERLOCK SYR,SUP-2303220,CDM,C1769,HCPCS,0272,RC,,,,both,,,310.08,201.55,,,,,,,,,,,,,
PLATE BNE CRV NAR 4.5 MM 20 HOLE SS NS LCP,SUP-2178065,CDM,C1713,HCPCS,0278,RC,,,,both,,,4209.04,2735.88,,,,,,,,,,,,,
GUIDEWIRE ORTH 32X475 MM FOR NAILING SYS STRL TFN ADV,SUP-2183041,CDM,C1769,HCPCS,0272,RC,,,,both,,,341.41,221.92,,,,,,,,,,,,,
HC So Infliximab Level,PX-3018023066,CDM,80230,CPT,0301,RC,,,,outpatient,,,189.00,122.85,,,,,,,,,,,,,
PERSUADER ROD FOR SPNL FIX SYS SILVERTON,SUP-2211166,CDM,C1713,HCPCS,0278,RC,,,,both,,,3236.71,2103.86,,,,,,,,,,,,,
CURETTE SURG MIKAEEL 18 RVS STR,SUP-2484830,CDM,C1713,HCPCS,0278,RC,,,,both,,,634.34,412.32,,,,,,,,,,,,,
HC So2 Islet Cell Antibody,PX-3028634168,CDM,86341,CPT,0302,RC,,,,inpatient,,,55.00,35.75,,,,,,,,,,,,,
GUIDEWIRE REGATTA MIDWT 195CM STR,SUP-2154111,CDM,C1769,HCPCS,0272,RC,,,,both,,,244.54,158.95,,,,,,,,,,,,,
GOSERELIN ACETATE 3.6 MG SC IMPL,RX-10137,CDM,J9202,HCPCS,0636,RC,70720-0950-36,NDC,,both,1,UN,3237.00,2104.05,,,,,,,,,,,,,
APPLIER CLIP 8.25IN ANEURYSM VARIO STANDARD BAYONET SWIVEL R,SUP-2825294,CDM,C1889,HCPCS,0278,RC,,,,both,,,5839.80,3795.87,,,,,,,,,,,,,
PLATE SYNDESMOTIC L 29 MM SHFT W 10.8 MM 2 H TI PEEK ANK GRN,SUP-2894143,CDM,C1713,HCPCS,0278,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
SHEATH INTRO DRYSEAL FLX L 65 CM DIA12 FR BODY DIA 4.7 MM,SUP-2570723,CDM,C1894,HCPCS,0272,RC,,,,both,,,2716.10,1765.46,,,,,,,,,,,,,
GRAFT HUM TISS W6XL12CM BLDR TISS REGEN MTRX REPLFRM,SUP-2139393,CDM,C1762,CPT,0278,RC,,,,both,,,6613.22,4298.59,,,,,,,,,,,,,
NAIL IM L300MM DIA10MM NK ANG 130DEG LT FEM TI CANN LCK,SUP-2347145,CDM,C1713,HCPCS,0278,RC,,,,both,,,13051.25,8483.31,,,,,,,,,,,,,
INSERT TIB THK 8 MM SZ 1 POLYETHYL LT ANK FIX XT REV STRL LJV310T,SUP-2932741,CDM,C1776,CPT,0278,RC,,,,both,,,9385.46,6100.55,,,,,,,,,,,,,
PLATE BNE SUP SACROILIAC PELV 4 HOLE,SUP-2518371,CDM,C1713,HCPCS,0278,RC,,,,both,,,4430.54,2879.85,,,,,,,,,,,,,
AUGMENTED VAULTLOCK MEDIUM 25L,SUP-2815155,CDM,C1776,CPT,0278,RC,,,,both,,,9655.50,6276.07,,,,,,,,,,,,,
WIRE FIX KIRSCHNER 72090120] SMITH AND NEPHEW ENDOSCOPY],SUP-2341577,CDM,C1713,HCPCS,0278,RC,,,,both,,,685.21,445.39,,,,,,,,,,,,,
CLIP INT LIG MED LG TI VESOCCLUDE,SUP-2757595,CDM,C1889,HCPCS,0278,RC,,,,both,,,10.68,6.94,,,,,,,,,,,,,
PACK SUT PERC ACHILLES REP SYS,SUP-2122781,CDM,C1713,HCPCS,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
HC Ot Manual Therapy per 15 Min.,PX-4309714000,CDM,97140,CPT,0430,RC,,,,outpatient,,,194.00,126.10,,,,,,,,,,,,,
BIT DRL QC 2.5X240 MM 150 MM CALIB STRL,SUP-2563753,CDM,2720000010,LOCAL,0272,RC,,,,both,,,494.27,321.28,,,,,,,,,,,,,
SCREW BONE L80MM DIA5MM CO CHROM MOLYBDENUM ALLOY ST LCK,SUP-2183043,CDM,C1713,HCPCS,0278,RC,,,,both,,,1034.32,672.31,,,,,,,,,,,,,
GUIDEWIRE TROCAR TIP NIT 18 INCH INVICTUS,SUP-2114056,CDM,C1713,HCPCS,0278,RC,,,,both,,,169.56,110.21,,,,,,,,,,,,,
TUBING CATH L6FT S STL STRT UP CUST LUER W/ INTEGR AIR TRAP,SUP-2416151,CDM,C1751,HCPCS,0278,RC,,,,both,,,664.42,431.87,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 70 CM DIA 8 MM STR TW HELIX,SUP-2695230,CDM,C1768,CPT,0278,RC,,,,both,,,1785.00,1160.25,,,,,,,,,,,,,
BUR SURG GRD SHT FOR 5091 HALL SS MICROCHOICE,SUP-2846896,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1963.76,1276.44,,,,,,,,,,,,,
CATHETER EP K 5-5-5-42-5-5-5 MM 6 FRX110 CM,SUP-2461809,CDM,C1730,HCPCS,0272,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
PLATE BNE LO BEND 3.5X180 MM LT PROX TIB 12 HOLE SS NS LCP,SUP-2184311,CDM,C1713,HCPCS,0278,RC,,,,both,,,4108.38,2670.45,,,,,,,,,,,,,
PIN FIX L22MM DIA1.8MM S STL BTTRS VAR ANG LOK T8 STARDRV,SUP-2178302,CDM,C1713,HCPCS,0278,RC,,,,both,,,378.31,245.90,,,,,,,,,,,,,
PEG BNE FIX L22MM DIA2.5MM DST VOLAR RAD NONLOCKING FULL,SUP-2414180,CDM,C1713,HCPCS,0278,RC,,,,both,,,295.16,191.85,,,,,,,,,,,,,
SPHINCTEROTOME ENDOSCP L20MM TIP L5MM DIA49FR GWIRE L260CM,SUP-2149847,CDM,C1713,HCPCS,0278,RC,,,,both,,,1303.07,847.00,,,,,,,,,,,,,
KIT NEUROSTIMULATOR ANCHRING SYS W BI-WING ANCHR INJEX,SUP-2631820,CDM,2720000010,LOCAL,0272,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
BLADE RETRACTOR MAGRINA DEAVER SM 1X3.5 IN SYS BOOKWALTER,SUP-2483538,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1137.28,739.23,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 20 CM DIA 8 MM EPTFE STR TW N RING,SUP-2396351,CDM,C1768,CPT,0278,RC,,,,both,,,998.52,649.04,,,,,,,,,,,,,
TRACKER NAVIGATION EM ENT STLTH,SUP-2280208,CDM,2720000010,LOCAL,0272,RC,,,,both,,,643.70,418.40,,,,,,,,,,,,,
WIRE EXT FIX L385MM DIA1.8MM S STL DRL TIP W/ STPR FOR ILIZ,SUP-2340793,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8497.78,5523.56,,,,,,,,,,,,,
STIMULATOR NERVE IMPL 5 IPG,SUP-2637206,CDM,C1767,HCPCS,0278,RC,,,,both,,,65229.86,42399.41,,,,,,,,,,,,,
PLATE BNE COMPR 2.7X84X2.5 MM 10 HOLE,SUP-2424219,CDM,C1713,HCPCS,0278,RC,,,,both,,,610.64,396.92,,,,,,,,,,,,,
PLATE BNE LOWER RAMUS 2.3 MM LT FRAC SMRT FOR SCR TI LEVEL 1,SUP-2498565,CDM,C1713,HCPCS,0278,RC,,,,both,,,1746.84,1135.45,,,,,,,,,,,,,
ROD EXT FIX L 60 MM DIA 4 MM CARBON FIBRE CONN NS DISP,SUP-2908262,CDM,2720000010,LOCAL,0272,RC,,,,both,,,126.92,82.50,,,,,,,,,,,,,
SYSTEM PLAQ EXCISION 7/8FR L113CM TIP L9CM VES DIA3.5-7MM,SUP-2173625,CDM,C1714,HCPCS,0272,RC,,,,both,,,9577.00,6225.05,,,,,,,,,,,,,
VALVE AORT MOSAIC H 13.5 MM DIA19 MM ORIFICE 17.5 MM SUTURE,SUP-2278064,CDM,C1889,HCPCS,0278,RC,,,,both,,,13345.00,8674.25,,,,,,,,,,,,,
KIT INFUS PRT CATH L50CM DIA8FR TI SGL LUMN ATTCH GROSH VLV,SUP-2127744,CDM,C1788,HCPCS,0278,RC,,,,both,,,769.30,500.04,,,,,,,,,,,,,
BUR SURG MTL CUT 1.6X6.4 MM 14 CM LG BOR MIDAS REX 8 LEGEND,SUP-2664605,CDM,2720000010,LOCAL,0272,RC,,,,both,,,567.96,369.17,,,,,,,,,,,,,
PATCH CV HEMGRD L 150 X W 25 MM THK 0.41 MM POLYESTER BOV,SUP-2535423,CDM,C1768,CPT,0278,RC,,,,both,,,563.32,366.16,,,,,,,,,,,,,
RING TRAC L 22-24IN CERV CLOSE BK W/ 2.5IN SKULL AND POS PIN,SUP-2328118,CDM,L0810,HCPCS,0272,RC,,,,both,,,5510.70,3581.95,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 220 MM DIA17 MM DEL SHTH 51ML,SUP-2937087,CDM,C1713,HCPCS,0278,RC,,,,both,,,15282.38,9933.55,,,,,,,,,,,,,
BAG LEFT CARRY CONSLDTD F/HEARTMATE II,SUP-2356023,CDM,Q0508,HCPCS,0274,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
PLATE BONE L85MM 6 H LT POSTEROLATERAL DSTL HUM FOR,SUP-2349770,CDM,C1713,HCPCS,0278,RC,,,,both,,,7172.86,4662.36,,,,,,,,,,,,,
STENT BILI EVOLUTION L 6 CM FLANGE DIA11 MM BODY DIA10 MM,SUP-2169451,CDM,C1876,HCPCS,0278,RC,,,,both,,,6160.68,4004.44,,,,,,,,,,,,,
TAP BNE PEDCL SCR QUIK CONN 55MM DIA,SUP-2290729,CDM,C1713,HCPCS,0278,RC,,,,both,,,2035.00,1322.75,,,,,,,,,,,,,
BIT DRL DIA2.7MM CANN QUIK CONN FOR 4MM SCR,SUP-2107200,CDM,2720000010,LOCAL,0272,RC,,,,both,,,866.64,563.32,,,,,,,,,,,,,
GRAFT VASC INTERGARD L 30 CM DIA26 MM THK 0.38 MM POLYESTER,SUP-2476591,CDM,C1768,CPT,0278,RC,,,,both,,,1715.66,1115.18,,,,,,,,,,,,,
ENDCAP ORTHOPEDIC 0 MM COLECT PROT HMRX,SUP-2431228,CDM,C1889,HCPCS,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
TRAY CHST TB CATH 18FR 41CM GWIRE L80CM 3 MRK DIL 8X14X20FR,SUP-2168083,CDM,C1729,HCPCS,0272,RC,,,,both,,,750.15,487.60,,,,,,,,,,,,,
GRAFT VASC IMPRA L 70 CM DIA 7-4 MM EPTFE TAPR TW N RING,SUP-2761337,CDM,C1768,CPT,0278,RC,,,,both,,,2665.36,1732.48,,,,,,,,,,,,,
DARUNAVIR 800 MG PO TABS,RX-157646,CDM,6370000000,HCPCS,0637,RC,59676-0566-30,NDC,,both,1,UN,323.80,210.47,,,,,,,,,,,,,
DRILL SURG RETRACTABLE,SUP-2684214,CDM,2720000010,LOCAL,0272,RC,,,,both,,,866.64,563.32,,,,,,,,,,,,,
PLATE BNE L236MM 16 H ST POST DST TIB S STL T LOK COMPR FOR,SUP-2177441,CDM,C1713,HCPCS,0278,RC,,,,both,,,4880.94,3172.61,,,,,,,,,,,,,
LINER ACET SZ K OD70-76MM ID32MM THK17MM 0DEG HIPXLPE MTL ON,SUP-2344857,CDM,C1776,CPT,0278,RC,,,,both,,,4857.58,3157.43,,,,,,,,,,,,,
ALLOGRAFT BNE LAMINOPLASTY 4 MM PRESERVON CORTICAL VG1,SUP-2740851,CDM,C1713,HCPCS,0278,RC,,,,both,,,2414.00,1569.10,,,,,,,,,,,,,
BLADE RTRCTR CSPR 50MM X 23MM ILIAC BALL SNAP MED FNSTRTD F,SUP-2667359,CDM,2720000010,LOCAL,0272,RC,,,,both,,,423.87,275.52,,,,,,,,,,,,,
LINER ACET OD54MM ID40MM CO CHROM BIOFOAM HIP GRP E DYNASTY,SUP-2304540,CDM,C1776,CPT,0278,RC,,,,both,,,6735.30,4377.94,,,,,,,,,,,,,
SHEATH URET ACCS AQUAGUIDE 10 FR 12 14 FR 55 CM,SUP-2126283,CDM,C1894,HCPCS,0272,RC,,,,both,,,2684.10,1744.66,,,,,,,,,,,,,
CATHETER BLLN DIL 10 MMX15 CM NEPHROSTOMY X-FORCE N30,SUP-2126727,CDM,C1726,HCPCS,0272,RC,,,,both,,,976.54,634.75,,,,,,,,,,,,,
STAPLE BNE FIX BRDG W12MM LEG L12X15MM WIRE DIA2X2MM NIT,SUP-2194217,CDM,C1713,HCPCS,0278,RC,,,,both,,,2433.50,1581.77,,,,,,,,,,,,,
SCREW BNE LAG SHT THRD 12.7X155 MM STRL VERSAFX LTX,SUP-2861093,CDM,C1713,HCPCS,0278,RC,,,,both,,,1164.31,756.80,,,,,,,,,,,,,
SCREW BNE L30MM DIA3.5MM COR DIA2.7MM TROCHANTERIC TI LOK,SUP-2410874,CDM,C1713,HCPCS,0278,RC,,,,both,,,300.15,195.10,,,,,,,,,,,,,
CATHETER ANGIOPLSTY RX 018 5/7 FRX135 CM 7X60 MM STERLING,SUP-2142544,CDM,C1725,HCPCS,0272,RC,,,,both,,,507.74,330.03,,,,,,,,,,,,,
SCREW BNE COMPR 32 MM HIP TALON,SUP-2391511,CDM,C1713,HCPCS,0278,RC,,,,both,,,416.36,270.63,,,,,,,,,,,,,
PLATE BNE L161MM THK38MM 8 H R MED DST TIB S STL NEUT,SUP-2185218,CDM,C1713,HCPCS,0278,RC,,,,both,,,3645.16,2369.35,,,,,,,,,,,,,
CLAMP PAT-DUCTUS STR AG GLOVER,SUP-2383758,CDM,2720000010,LOCAL,0272,RC,,,,both,,,473.83,307.99,,,,,,,,,,,,,
SPLINT WRST SM L11IN L FA BLU CANVS HK AND LOOP PREMIERPRO,SUP-2336038,CDM,L3809,HCPCS,0272,RC,,,,both,,,18.65,12.12,,,,,,,,,,,,,
ALLOGRAFT BNE CUBE 30 CC FD IRRADIATED CANC,SUP-2867094,CDM,C1762,CPT,0278,RC,,,,both,,,1476.59,959.78,,,,,,,,,,,,,
HC Antihuman Globulin Indirect Each Antibody Titer,PX-3028688600,CDM,86886,CPT,0302,RC,,,,both,,,359.00,233.35,,,,,,,,,,,,,
MESH SURG L PTCH ONLAY W6XL12CM UNDERLAY 10CM HERN SYS,SUP-2220099,CDM,C1781,HCPCS,0278,RC,,,,both,,,1003.39,652.20,,,,,,,,,,,,,
BEARING TIB L63/67MM THK10MM KNEE SUP STBL POST STBL SM,SUP-2407928,CDM,C1776,CPT,0278,RC,,,,both,,,5061.68,3290.09,,,,,,,,,,,,,
HOLDER HK SPNL ANTR COLORADO 2,SUP-2290541,CDM,C1894,HCPCS,0272,RC,,,,both,,,7482.62,4863.70,,,,,,,,,,,,,
CATHETER IVUS REVOLUTION L 135 CM OUTER SHFT DIA 3.5 FR,SUP-2327234,CDM,C1753,HCPCS,0278,RC,,,,both,,,2119.50,1377.67,,,,,,,,,,,,,
HC Veno Hepatic W/O Hemo Eval S&I,PX-3207589100,CDM,75891,CPT,0320,RC,,,,inpatient,,,5468.00,3554.20,,,,,,,,,,,,,
DISTRACTOR SURG L 20 MM MIDFACE NS,SUP-2883385,CDM,C1713,HCPCS,0278,RC,,,,both,,,11446.78,7440.41,,,,,,,,,,,,,
FECAL KIT PROTECT FMS FILL PROTCT FLEXI-SEAL,SUP-2151525,CDM,2720000010,LOCAL,0272,RC,,,,both,,,369.58,240.23,,,,,,,,,,,,,
PLATE BONE L56MM LNG STRL RT ANTEROLATERAL CALCNL S STL VAR,SUP-2178429,CDM,C1713,HCPCS,0278,RC,,,,both,,,3197.09,2078.11,,,,,,,,,,,,,
MESH MIDFACIAL CUSTOMIZED + STRL MEDPOR LTX,SUP-2862748,CDM,C1713,HCPCS,0278,RC,,,,both,,,53291.17,34639.26,,,,,,,,,,,,,
VALVE VENT DRNGE PRECIS FIX INLINE W/ STR CONN INTRO,SUP-2243817,CDM,C1729,HCPCS,0272,RC,,,,both,,,2860.54,1859.35,,,,,,,,,,,,,
SPLINT WRST SM L11IN L FA BLU CANVS HK AND LOOP PREMIERPRO,SUP-2336038,CDM,L3809,HCPCS,0274,RC,,,,both,,,18.65,12.12,,,,,,,,,,,,,
CLAMP EXT FIX TWO HOLE K WIRE,SUP-2645880,CDM,2720000010,LOCAL,0272,RC,,,,both,,,563.88,366.52,,,,,,,,,,,,,
PIN EXT FIX L 160 M DIA 5 MM THRD L 35 MM SS HALF UNILAT NS,SUP-2931402,CDM,C1713,HCPCS,0278,RC,,,,both,,,906.20,589.03,,,,,,,,,,,,,
PROSTHESIS DRUMSTAPES 140059,SUP-2312529,CDM,L8613,CPT,0278,RC,,,,both,,,674.85,438.65,,,,,,,,,,,,,
CATHETER ANGIOPLSTY L 40 CM BALLOON L 2 CM DIA2 MM,SUP-2140993,CDM,C1725,HCPCS,0272,RC,,,,both,,,1441.26,936.82,,,,,,,,,,,,,
GUIDEWIRE ORTHOPEDIC 2X160 MM KT,SUP-2236759,CDM,C1769,HCPCS,0272,RC,,,,both,,,141.30,91.84,,,,,,,,,,,,,
PLATE BURR H L 14 MM THK 0.6 MM 5 H SCREW DIA1 MM TI CRAN NS,SUP-2883275,CDM,C1713,HCPCS,0278,RC,,,,both,,,844.03,548.62,,,,,,,,,,,,,
PACEMAKER CARD INGENIO W 4.45 X H 4.70 CM THK 0.75 CM 24.5,SUP-2149241,CDM,C1785,HCPCS,0275,RC,,,,both,,,11077.92,7200.65,,,,,,,,,,,,,
CATHETER ANGIOPLSTY 0.035 IN 10 FRX100 CM 18 MMX6 CM ZMED II,SUP-2309679,CDM,C1725,HCPCS,0272,RC,,,,both,,,1686.34,1096.12,,,,,,,,,,,,,
SET HAD CATH AD 11.5FR L20CM SIL PERIPH ACUTE 2 LUMN TAPR,SUP-2267078,CDM,C1752,HCPCS,0278,RC,,,,both,,,347.91,226.14,,,,,,,,,,,,,
PLATE SPNL CERV ANT UNIV 2 LEV 24MM LEN STD SPIDER,SUP-2402149,CDM,C1713,HCPCS,0278,RC,,,,both,,,4518.46,2937.00,,,,,,,,,,,,,
BUTTON FIX FOR IMPL SYS FIBERTAK,SUP-2423989,CDM,C1713,HCPCS,0278,RC,,,,both,,,2477.46,1610.35,,,,,,,,,,,,,
DRILL SURG FLIPCUTTER III,SUP-2418778,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1303.10,847.01,,,,,,,,,,,,,
STENT BILI PALMAZ GEN L 24 MM DIA 5 MM CATH L 75 CM DIA 6 FR,SUP-2159204,CDM,C1876,HCPCS,0278,RC,,,,both,,,2778.90,1806.28,,,,,,,,,,,,,
SCREWDRIVER PWR DISP FOR COMP CRAN CLSR SYS,SUP-2243987,CDM,C1713,HCPCS,0278,RC,,,,both,,,757.87,492.62,,,,,,,,,,,,,
STENT URETH ZAONTZ L 12 CM CATH L 8.0 FR FOR,SUP-2649949,CDM,C2617,HCPCS,0278,RC,,,,both,,,176.47,114.71,,,,,,,,,,,,,
DRILL HUDSON MOD TRINKLE,SUP-2362649,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3063.54,1991.30,,,,,,,,,,,,,
SYSTEM KNEE FLEX CEM GSF MIS,SUP-2212261,CDM,C1776,CPT,0278,RC,,,,both,,,15543.00,10102.95,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY L 110 CM DIA 5 FR 5 MM 10 POLE,SUP-2493971,CDM,C1730,HCPCS,0272,RC,,,,both,,,1447.54,940.90,,,,,,,,,,,,,
SPHINCTEROTOME ENDOSCP DOME 7 FR 035X480 CM TRCE METRO DIR,SUP-2737413,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1171.22,761.29,,,,,,,,,,,,,
PROSTHESIS OSS WEHRS INCUS MED 3.3X2.1X2.5 MM SINGLE NOTCH,SUP-2637873,CDM,L8613,CPT,0278,RC,,,,both,,,1195.59,777.13,,,,,,,,,,,,,
COMPONENT FEM SZ 1 L MOD BAL REV SYS,SUP-2315529,CDM,C1776,CPT,0278,RC,,,,both,,,12359.04,8033.38,,,,,,,,,,,,,
PLATE BNE W101XL308MM THK35MM 22 H BILAT TI STR RIG LOK,SUP-2191098,CDM,C1713,HCPCS,0278,RC,,,,both,,,2979.17,1936.46,,,,,,,,,,,,,
HC So Histochemical Staining,PX-3128831466,CDM,88314,CPT,0312,RC,,,,both,,,197.00,128.05,,,,,,,,,,,,,
GUIDEWIRE VASC WORKER 150CM 0.035IN 6.5CM 7.5CM AMPLTZ J CRV,SUP-2876080,CDM,C1769,HCPCS,0272,RC,,,,both,,,252.46,164.10,,,,,,,,,,,,,
ANCHOR SUTURE BIOCOMP SWIVELOCK STRL DISP FIBERTAK,SUP-2882190,CDM,C1713,HCPCS,0278,RC,,,,both,,,8713.50,5663.77,,,,,,,,,,,,,
OVITEX PRS PERMANENT RECTANGLE 16.5X20 CM,SUP-2914683,CDM,C1781,HCPCS,0278,RC,,,,both,,,18532.28,12045.98,,,,,,,,,,,,,
SCREW VPC 4.0X38MM,SUP-2587630,CDM,C1713,HCPCS,0278,RC,,,,both,,,937.26,609.22,,,,,,,,,,,,,
INSERT TIB TOT CNDYL SM/SM+/SM++ 8MM ORTHOLOC II,SUP-2397017,CDM,C1776,CPT,0278,RC,,,,both,,,5878.08,3820.75,,,,,,,,,,,,,
COLLAR CERV CAPITAL ENH,SUP-2336002,CDM,L0120,HCPCS,0272,RC,,,,both,,,84.62,55.00,,,,,,,,,,,,,
STEM FEM SZ 11 L145MM HIP TI POR STD OFFSET CEMENTLESS PRI,SUP-2344406,CDM,C1776,CPT,0278,RC,,,,both,,,5966.00,3877.90,,,,,,,,,,,,,
CATHETER HD STR EXTN 13.5 FRX30 CM DL HI FLO MAHRK ELITE,SUP-2626879,CDM,C1752,HCPCS,0278,RC,,,,both,,,155.18,100.87,,,,,,,,,,,,,
HANDPIECE ENDO L9CM OPN FN JAW THUNDERBEAT,SUP-2313546,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1601.40,1040.91,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.439,SUP-2860003,CDM,C1713,HCPCS,0278,RC,,,,both,,,42737.91,27779.64,,,,,,,,,,,,,
DILATOR SURG MINI 1-3.5 MM CERV SS LF,SUP-2735312,CDM,2720000010,LOCAL,0272,RC,,,,both,,,374.38,243.35,,,,,,,,,,,,,
ALLOGRAFT BNE PLATE LG FRZN ASEP FEM,SUP-2867060,CDM,C1762,CPT,0278,RC,,,,both,,,2469.92,1605.45,,,,,,,,,,,,,
SCR MD MICRO15X35MM FLAT TIP,SUP-2678144,CDM,C1713,HCPCS,0278,RC,,,,both,,,162.24,105.46,,,,,,,,,,,,,
SUPPORT ORTHOT WRST ELBW HND FNGR CUST W/OUT JT FABRICATED,SUP-2435764,CDM,L3765,HCPCS,0274,RC,,,,both,,,3303.85,2147.50,,,,,,,,,,,,,
CHUCK DRILL 4MM,SUP-2705307,CDM,2720000010,LOCAL,0272,RC,,,,both,,,660.66,429.43,,,,,,,,,,,,,
CATHETER ABLAT 4MM OD7.5FR STD OPN IRRIG INTELLANAV,SUP-2141345,CDM,C1732,HCPCS,0278,RC,,,,both,,,7536.00,4898.40,,,,,,,,,,,,,
PLATE STRNL CLOSURE THK 1.5 MM 12 H TI LADDER NAR LP NS,SUP-2894504,CDM,C1713,HCPCS,0278,RC,,,,both,,,3523.08,2290.00,,,,,,,,,,,,,
IMMOBILIZER KNEE PERF-VINYL FOAM MEDL LAT POST STAY LOOP LCK,SUP-2197967,CDM,L1830,CPT,0274,RC,,,,both,,,98.78,64.21,,,,,,,,,,,,,
CIPROFLOXACIN-DEXAMETHASONE 0.3-0.1 % OT SUSP,RX-36576,CDM,6370000000,HCPCS,0637,RC,16714-0628-01,NDC,,both,7.5,ML,925.30,601.44,,,,,,,,,,,,,
KIT INTRO TSX 30 DEG L 60 CM DIA 8.5 FR GUIDEWIRE L 135 CM,SUP-2148496,CDM,C1894,HCPCS,0272,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
CATHETER ABLAT 4MM OD7.5FR STD OPN IRRIG INTELLANAV,SUP-2141345,CDM,C1732,HCPCS,0272,RC,,,,both,,,7536.00,4898.40,,,,,,,,,,,,,
BRACE KNEE AD UNIV FOAM POSTOP UNISX WRP ARND HNG T SCP,SUP-2150860,CDM,L1810,HCPCS,0274,RC,,,,both,,,321.54,209.00,,,,,,,,,,,,,
PEMETREXED DISODIUM 100 MG IV SOLR,RX-89350,CDM,J9305,HCPCS,0636,RC,00002-7640-01,NDC,,both,1,UN,2328.80,1513.72,,,,,,,,,,,,,
URETERORENOSCOPE VID DIA 6.3 FR ADJ ANGLE KNOB ULTRASLIM,SUP-2934025,CDM,C1747,HCPCS,0272,RC,,,,both,,,2496.30,1622.59,,,,,,,,,,,,,
QUETIAPINE FUMARATE 400 MG PO TABS,RX-70398,CDM,6370000000,HCPCS,0637,RC,68180-0450-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
WASHER ORTH FLAT F/3 MM CANN SCREW NS,SUP-2464113,CDM,C1713,HCPCS,0278,RC,,,,both,,,167.52,108.89,,,,,,,,,,,,,
PACEMAKER CARD ELECTRD SPC 18 MM 0.8 CC VDD LEADLESS AUTO AV,SUP-2882756,CDM,C1786,HCPCS,0275,RC,,,,both,,,38370.80,24941.02,,,,,,,,,,,,,
STENT VASC 6X140 MM 125 CM DRUG ELUT ZILVER PTX,SUP-2417689,CDM,C1876,HCPCS,0278,RC,,,,both,,,5918.90,3847.28,,,,,,,,,,,,,
GUIDEWIRE VASC L 80 CM DIA 0.035 IN TAPR L 8 CM FLPY TIP L 2,SUP-2167574,CDM,C1769,HCPCS,0272,RC,,,,both,,,29.61,19.25,,,,,,,,,,,,,
PIN BONE FIX L15MM DIA3MM EXT THRD,SUP-2254087,CDM,C1713,HCPCS,0278,RC,,,,both,,,248.06,161.24,,,,,,,,,,,,,
CATHETER HD DL 14.5 FRX23 CM CHRONIC DLYS STRL VAXCEL +,SUP-2141136,CDM,C1750,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
CATHETER INT AORT BAL ULT 8 40CC,SUP-2383462,CDM,C1713,HCPCS,0278,RC,,,,both,,,2873.10,1867.51,,,,,,,,,,,,,
PLATE BONE 135DEG 14 H SUPCNDYL S STL COMPR FRELOK,SUP-2197731,CDM,C1713,HCPCS,0278,RC,,,,both,,,2266.99,1473.54,,,,,,,,,,,,,
SHOE CAST SM AD W4.25XL9.25IN W/ ROCK OPN TOE AND OPN HEEL,SUP-2203830,CDM,L4387,HCPCS,0272,RC,,,,both,,,35.33,22.96,,,,,,,,,,,,,
PLATE BONE CONTOUR MESHED 200X200X0.4 MM CRANIAL RIGID TITAN,SUP-2837706,CDM,C1713,HCPCS,0278,RC,,,,both,,,28399.42,18459.62,,,,,,,,,,,,,
PLATE BNE W11XL194MM THK3.7MM 10 H NONSTERILE R MED DST TIB,SUP-2185590,CDM,C1713,HCPCS,0278,RC,,,,both,,,4550.33,2957.71,,,,,,,,,,,,,
SUTURE ANCHOR SET 17 GAX12 CM 2 NDL ENTUIT,SUP-2170292,CDM,C1713,HCPCS,0278,RC,,,,both,,,580.90,377.58,,,,,,,,,,,,,
ORTHOPEDIC KIT HAMRTOE CCI STD W/1.25 KWIRE TI STRL,SUP-2433923,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4170.49,2710.82,,,,,,,,,,,,,
PIN ORTH 2X229MM SGL SHRP TIP STYL 5 TRCR PNT S STL ST,SUP-2207914,CDM,C1713,HCPCS,0278,RC,,,,both,,,47.60,30.94,,,,,,,,,,,,,
STEM HUM L170MM DIA12MM TRABECULAR MTL REV,SUP-2199127,CDM,C1776,CPT,0278,RC,,,,both,,,16879.07,10971.40,,,,,,,,,,,,,
CATHETER CV SET 032 7 FRX25 CM 13 GA 3L RIFAMPIN SPECTRUM,SUP-2759718,CDM,C1751,HCPCS,0278,RC,,,,both,,,357.49,232.37,,,,,,,,,,,,,
SCREW SPNL L14MM DIA4.5MM CANC ANTR CERV TI ST LCK VAR ANG,SUP-2254602,CDM,C1713,HCPCS,0278,RC,,,,both,,,1161.80,755.17,,,,,,,,,,,,,
ALLOGRAFT HUMAN TISS MAXXEUS ACHILLES PRESHAPE 10MM,SUP-2875994,CDM,C1762,CPT,0278,RC,,,,both,,,6242.32,4057.51,,,,,,,,,,,,,
CATHETER HAD L15CM OD11.5FR POLYUR ACUTE 2 LUMN STR TAPR,SUP-2267104,CDM,C1752,HCPCS,0278,RC,,,,both,,,111.53,72.49,,,,,,,,,,,,,
GRAFT HUM TISS 5X8CM THK0.4-1MM ACELLULAR DERM MTRX MESHED,SUP-2225422,CDM,Q4179,HCPCS,0636,RC,,,,both,,,11932.00,7755.80,,,,,,,,,,,,,
VALVE 15 WITH PEDIATRIC PRECHAMBER MININAV,SUP-2821802,CDM,C1889,HCPCS,0278,RC,,,,both,,,1592.77,1035.30,,,,,,,,,,,,,
SET DCOMPR CATH OD8.5FR GWIRE L480CM OD0.035IN PUR BROD,SUP-2169139,CDM,C1713,HCPCS,0278,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
OCCLUDER CV AMPLATZER PICCOLO WAIST DIA 3 MM BTWN DISC L 2,SUP-2904254,CDM,C1889,HCPCS,0278,RC,,,,both,,,28888.00,18777.20,,,,,,,,,,,,,
GRAFT VASC 4 CC AMNIO VERESHIELD,SUP-2307531,CDM,C1762,CPT,0278,RC,,,,both,,,6845.20,4449.38,,,,,,,,,,,,,
BIT DRILL FOR 22MM ALL SUTURE ANCHOR SURELOCK,SUP-2589290,CDM,2720000010,LOCAL,0272,RC,,,,both,,,615.44,400.04,,,,,,,,,,,,,
HC Strapping Knee,PX-4502953000,CDM,29530,CPT,0450,RC,,,,both,,,214.00,139.10,,,,,,,,,,,,,
BLADE SHV OD4MM 60DEG ROT SERR CLOSE DS ELITE COMPATIBLE,SUP-2313528,CDM,2720000010,LOCAL,0272,RC,,,,both,,,673.91,438.04,,,,,,,,,,,,,
CATHETER THROMCTMY ANGIOJET ULTRA ZELANTEDVT L 105 CM DIA 8,SUP-2142041,CDM,C1757,HCPCS,0272,RC,,,,both,,,19734.90,12827.68,,,,,,,,,,,,,
HC So Hla Dqb1 06:02 Genotype,PX-3108138366,CDM,81383,CPT,0310,RC,,,,both,,,276.00,179.40,,,,,,,,,,,,,
COIL NEUROVASCULAR MICROPLEX COMPASS L 3.5 CM LOOP DIA2.5 MM,SUP-2305148,CDM,C1889,HCPCS,0278,RC,,,,both,,,4270.40,2775.76,,,,,,,,,,,,,
ENDCAP SPNL DIA13MM,SUP-2415362,CDM,C1889,HCPCS,0278,RC,,,,both,,,499.26,324.52,,,,,,,,,,,,,
NEEDLE ENDO OD22GA ODSEC5.2FR TAPR BVL STYL TIP US STRL DISP,SUP-2169440,CDM,C1713,HCPCS,0278,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
STENT PERIPH VEN WSTNT L 90 MM DIA18 MM CATH L 75 CM DIA11,SUP-2558959,CDM,C1876,HCPCS,0278,RC,,,,both,,,5495.00,3571.75,,,,,,,,,,,,,
PLATE BONE W8XL44MM THK2MM 0DEG 5 H BILAT TI STR RIG DYN,SUP-2191069,CDM,C1713,HCPCS,0278,RC,,,,both,,,1207.46,784.85,,,,,,,,,,,,,
SYSTEM LOADING 23-29 MM EVOLUT FX,SUP-2854105,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1601.40,1040.91,,,,,,,,,,,,,
EAR CARVING TEMPLATE YAMADA HARADA A52 I PPSU 2PK,SUP-2682130,CDM,2720000010,LOCAL,0272,RC,,,,both,,,268.66,174.63,,,,,,,,,,,,,
SCREW CORT 5.0MMX34MM ALTA,SUP-2363416,CDM,C1713,HCPCS,0278,RC,,,,both,,,256.22,166.54,,,,,,,,,,,,,
PATCH CV HEMSHLD PLAT FINESSE L 1.2 X W 4.6 CM THK 0.635 MM,SUP-2266059,CDM,C1768,CPT,0278,RC,,,,both,,,532.23,345.95,,,,,,,,,,,,,
PLATE BONE REG L36MM THK1MM 4 H MIDFACE SLV TI STR FOR 2MM,SUP-2402947,CDM,C1713,HCPCS,0278,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
BLADE SAW D64MM CUT EDGE 34.5MM,SUP-2659188,CDM,2720000010,LOCAL,0272,RC,,,,both,,,78.50,51.02,,,,,,,,,,,,,
SCREW BONE 3.5MM X 55MM NON LOCKING HEXALOBE STR,SUP-2639373,CDM,C1713,HCPCS,0278,RC,,,,both,,,288.88,187.77,,,,,,,,,,,,,
GRAFT HUM TISS 3X5CM AMNIOCORD,SUP-2305710,CDM,Q4187,HCPCS,0636,RC,,,,both,,,6735.30,4377.94,,,,,,,,,,,,,
IMPLANT DERM W100XL150MM CLLGN SQ SHT ALLOMAX,SUP-2125858,CDM,C1781,HCPCS,0278,RC,,,,both,,,14883.60,9674.34,,,,,,,,,,,,,
INSERT HUM LAT 36X+6 MM SHLDR GLEN AEQUALIS REVERSED,SUP-2431490,CDM,C1776,CPT,0278,RC,,,,both,,,3573.32,2322.66,,,,,,,,,,,,,
IMPLANT HUM TISS L 4 X W 4 CM AMNIO MEMBRN FLX MULTLYR,SUP-2905508,CDM,C1762,CPT,0278,RC,,,,both,,,4333.20,2816.58,,,,,,,,,,,,,
DEVICE TISS CLOSURE L 195 CM OPENING W 15 CM CHANNEL 3.2 MM,SUP-2880955,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
PLATE BONE L25MM THK1.4MM SHFT W6MM 4 H STRL FLX FOR 2.4MM,SUP-2349672,CDM,C1713,HCPCS,0278,RC,,,,both,,,4218.43,2741.98,,,,,,,,,,,,,
HC Excision Up to 15 Skin Tags,PX-4501120000,CDM,11200,CPT,0450,RC,,,,both,,,633.00,411.45,,,,,,,,,,,,,
PIN FIX DBL TROCAR 0.109X9 IN SS NS STEINMANN,SUP-2791830,CDM,C1713,HCPCS,0278,RC,,,,both,,,16.67,10.84,,,,,,,,,,,,,
BLADE SAW CRESC 9.5 MM,SUP-2632409,CDM,2720000010,LOCAL,0272,RC,,,,both,,,341.95,222.27,,,,,,,,,,,,,
INDOMETHACIN 25 MG PO CAPS,RX-3897,CDM,6370000000,HCPCS,0637,RC,31722-0542-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
HC So1 Albumin Other Source Quan Ea,PX-3078204267,CDM,82042,CPT,0307,RC,,,,both,,,17.00,11.05,,,,,,,,,,,,,
GRAFT VASC GELWEAVE L 20CM 14 MM 15/15CM 10/10MM DEBRANCHING,SUP-2894550,CDM,C1768,CPT,0278,RC,,,,both,,,10205.00,6633.25,,,,,,,,,,,,,
ACTIVATION ARM RIGID CARDANIC 25MM DISTRACTOR,SUP-2493313,CDM,C1713,HCPCS,0278,RC,,,,both,,,2248.74,1461.68,,,,,,,,,,,,,
GUIDEWIRE VASC PRIMEWIRE L 185 CM 0.014 IN L 3 CM SS STR AD,SUP-2327219,CDM,C1769,HCPCS,0272,RC,,,,both,,,2166.60,1408.29,,,,,,,,,,,,,
BRACE ORTH SZ M 5 TO 7 WOM 6 TO 8 SM WLK LOEST PROF X LO,SUP-2195484,CDM,L4386,HCPCS,0272,RC,,,,both,,,221.84,144.20,,,,,,,,,,,,,
MEDROXYPROGESTERONE ACETATE 150 MG/ML IM SUSP,RX-19736,CDM,J1050,HCPCS,0636,RC,67457-0887-99,NDC,,both,1,ML,197.80,128.57,,,,,,,,,,,,,
SET BLD PMP CANN 32FR 10MM BIVENT SUPP SYS 5000 BVS VENT,SUP-2106276,CDM,2720000010,LOCAL,0272,RC,,,,both,,,56520.00,36738.00,,,,,,,,,,,,,
EXPANDER TISS BRST LO HT SILTEX CPX4T,SUP-2748632,CDM,C1889,HCPCS,0278,RC,,,,both,,,5338.00,3469.70,,,,,,,,,,,,,
SCREW BONE DART-FIRE SHORT HEADLESS 3.0MMX14MM,SUP-2854124,CDM,C1713,HCPCS,0278,RC,,,,both,,,2179.16,1416.45,,,,,,,,,,,,,
STAPLE INT W6XL20MM LIG SPIK,SUP-2120784,CDM,C1713,HCPCS,0278,RC,,,,both,,,248.06,161.24,,,,,,,,,,,,,
PIN EXTERNAL FIXATION HALF ADULT 6X200 MM 50 MM ANKLE FOOT H,SUP-2836743,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4629.62,3009.25,,,,,,,,,,,,,
TRAY EPIDURAL TUOHY NDL L 3.5 IN DIA20 GA SGL SHT LIDO NACL,SUP-2936776,CDM,2720000010,LOCAL,0272,RC,,,,both,,,49.36,32.08,,,,,,,,,,,,,
KIT NEUROSTIMULATOR 8 CHN ADPT B,SUP-2355917,CDM,C1883,HCPCS,0278,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
COLLAR CERV AD M H4.25IN FOR 13-16IN NK FOAM TRACH OPN,SUP-2195537,CDM,L0172,HCPCS,0274,RC,,,,both,,,45.28,29.43,,,,,,,,,,,,,
DEVICE FIX 3.9X50 MM W/ 14 MM NOTCH BABY GORILLA R3LEASE,SUP-2751391,CDM,C1713,HCPCS,0278,RC,,,,both,,,2157.18,1402.17,,,,,,,,,,,,,
STYLET SPNL SZ 55 MM NS DISP INVICTUS,SUP-2886458,CDM,2720000010,LOCAL,0272,RC,,,,both,,,690.80,449.02,,,,,,,,,,,,,
SOUND PROC HEARING DEV TWO PT KT RONDO 3,SUP-2905133,CDM,L8691,HCPCS,0278,RC,,,,both,,,37513.58,24383.83,,,,,,,,,,,,,
GRAFT BNE SUB 10CC CA SULF CA PHSPTE INJ REGEN PRO-DENSE,SUP-2399153,CDM,C1713,HCPCS,0278,RC,,,,both,,,10707.40,6959.81,,,,,,,,,,,,,
GRAFT HUM TISS W2XL5CM THK08 17MM DERM ACELLULAR THCK HUM,SUP-2307455,CDM,Q4128,HCPCS,0636,RC,,,,both,,,1580.05,1027.03,,,,,,,,,,,,,
COMPONENT FEM L130MM KNEE SEG IMP MOST OPTIONS,SUP-2208266,CDM,C1776,CPT,0278,RC,,,,both,,,9495.36,6171.98,,,,,,,,,,,,,
SHEATH INTRO AXCESS L 45 CM DIA 5 FR GUIDEWIRE 0.035-0.038,SUP-2876098,CDM,C1894,HCPCS,0272,RC,,,,both,,,427.04,277.58,,,,,,,,,,,,,
CONNECTOR ADJ TRNSVRS,SUP-2415594,CDM,C1713,HCPCS,0278,RC,,,,both,,,680.81,442.53,,,,,,,,,,,,,
CATHETER CTRL VEN PED 7FR 1/0.5ML RED WHT L65CM 2 LUMN,SUP-2127701,CDM,C1751,HCPCS,0278,RC,,,,both,,,1118.94,727.31,,,,,,,,,,,,,
GRAFT DURA W2XL2IN ULTRAPURE POR SUTURABLE DURAGN,SUP-2244024,CDM,C1713,HCPCS,0278,RC,,,,both,,,1684.92,1095.20,,,,,,,,,,,,,
GUIDEWIRE VASC L70CM DIA0035IN J W ADV FLX,SUP-2269533,CDM,C1769,HCPCS,0272,RC,,,,both,,,34.54,22.45,,,,,,,,,,,,,
CONNECTOR SHUNT 1.10X1.95X10.4 MM STR SS STRL,SUP-2666465,CDM,C1889,HCPCS,0278,RC,,,,both,,,274.66,178.53,,,,,,,,,,,,,
GUIDEWIRE VASC L175CM DIA0.014IN 5 SENS STR TIP PRESSUREWIRE,SUP-2331129,CDM,C1769,HCPCS,0272,RC,,,,both,,,5301.89,3446.23,,,,,,,,,,,,,
SCREW BNE LAG 12.7X130 MM CANN THRD 1 STP SS NS DHS DCS,SUP-2547618,CDM,C1713,HCPCS,0278,RC,,,,both,,,988.63,642.61,,,,,,,,,,,,,
HC So Hsv IP Stain,PX-3008725366,CDM,87253,CPT,0300,RC,,,,both,,,142.00,92.30,,,,,,,,,,,,,
SUPPORT ORTHOT WRST ELBW HND CUST ADJ FIT W/O JT FABRICATED,SUP-2435762,CDM,L3762,HCPCS,0272,RC,,,,both,,,1928.18,1253.32,,,,,,,,,,,,,
SPHERE ORBIT DIA12MM PMMA FOR RET EYE SOCK CNTOUR,SUP-2236373,CDM,L8610,HCPCS,0278,RC,,,,both,,,122.46,79.60,,,,,,,,,,,,,
BRACE WLK L 105 12MM M 115 13MM FEM STD TWO LAYR MEM FOAM,SUP-2195488,CDM,L4360,HCPCS,0272,RC,,,,both,,,82.30,53.49,,,,,,,,,,,,,
SUPPORT ORTHOT LOWER EXTREMITY CUST ABDUCTN BAR JOINTED ADJ,SUP-2435658,CDM,L2300,HCPCS,0272,RC,,,,both,,,712.75,463.29,,,,,,,,,,,,,
SNARE VASC EXPRO ELITE L 150 CM DIA10 MM GUIDEWIRE 0.035 IN,SUP-2104764,CDM,C1773,HCPCS,0272,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
GADOTERIDOL 279.3 MG/ML IV SOLN,RX-10100,CDM,A9579,HCPCS,0636,RC,00270-1111-03,NDC,,both,20,ML,18.80,12.22,,,,,,,,,,,,,
WIRE EXT FIX L360MM DIA1.8MM,SUP-2197288,CDM,2720000010,LOCAL,0272,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
PLATE BNE CLVRLF 3.5X200 MM 10 HOLE 2 COMPR FOR SCR SS NS,SUP-2471579,CDM,C1713,HCPCS,0278,RC,,,,both,,,1304.04,847.63,,,,,,,,,,,,,
CATHETER PERITONEAL DLYS COILED 63 CM LT V NK DBL X-SERIES,SUP-2269531,CDM,C1752,HCPCS,0278,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
CATHETER DLYS L62.5CM L SWAN NK 2 CUF ARGY CURL CATH,SUP-2283989,CDM,C1750,HCPCS,0278,RC,,,,both,,,560.84,364.55,,,,,,,,,,,,,
GRAFT RECON BLDR REPLFRM 2X4CM,SUP-2139387,CDM,C1762,CPT,0278,RC,,,,both,,,1754.63,1140.51,,,,,,,,,,,,,
CATHETER HD STR 15.5 FRX15 CM SHT TERM 3L T-3 CT,SUP-2627213,CDM,C1752,HCPCS,0278,RC,,,,both,,,169.56,110.21,,,,,,,,,,,,,
SHEATH INTRO PEELWY L 15.5 CM DIA15 FR DIL 20 CM GUIDEWIRE,SUP-2168165,CDM,C1892,HCPCS,0272,RC,,,,both,,,109.96,71.47,,,,,,,,,,,,,
SLEEVE ORTH SUSP ANK PELV CTRL,SUP-2388213,CDM,L5695,HCPCS,0274,RC,,,,both,,,500.23,325.15,,,,,,,,,,,,,
CARTRIDGE SUT FOR SPEEDSTITCH MINI BLK COBRAID MAG WIRE,SUP-2342095,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1569.56,1020.21,,,,,,,,,,,,,
HC Blood Culture Multiplex Pcr 2,PX-3008715400,CDM,87154,CPT,0300,RC,,,,outpatient,,,524.00,340.60,,,,,,,,,,,,,
SLEEVE ORTH SUSP ANK PELV CTRL,SUP-2388213,CDM,L5695,HCPCS,0272,RC,,,,both,,,500.23,325.15,,,,,,,,,,,,,
HC Pulmonary Arteriogram Bil,PX-3237574300,CDM,75743,CPT,0323,RC,,,,inpatient,,,7211.00,4687.15,,,,,,,,,,,,,
BASE GLEN SM COMPHSVE MOD HYBRID,SUP-2404685,CDM,C1776,CPT,0278,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
CATHETER DRNGE L35CM DIA8FR 0.038IN POLYUR SLIP COAT KINK,SUP-2120145,CDM,C1729,HCPCS,0272,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
PLATE BONE 6 H STR FOR 2MM SCR VLP MINI-MOD SM BONE SYS,SUP-2351085,CDM,C1713,HCPCS,0278,RC,,,,both,,,2479.28,1611.53,,,,,,,,,,,,,
VALVE AORT SZ 25 ID234MM GRFT L11CM DIA26MM SEW RNG DIA34MM,SUP-2175252,CDM,C1889,HCPCS,0278,RC,,,,both,,,24802.86,16121.86,,,,,,,,,,,,,
GRAFT BONE SUB 5CC 1CM DEMIN MTRX PUTTY FRZ DRY OSTEOFIL,SUP-2293736,CDM,C1713,HCPCS,0278,RC,,,,both,,,2359.40,1533.61,,,,,,,,,,,,,
KNIFE SURG 9.5 IN VERTICAL TRNSSPHND BAYNT RUGGLES-REDMOND,SUP-2486550,CDM,2720000010,LOCAL,0272,RC,,,,both,,,418.97,272.33,,,,,,,,,,,,,
PACK INSTR L INCLUDE DRL SCR DRVR THIMBLE FOR HAMRTOE CORR,SUP-2123607,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1485.22,965.39,,,,,,,,,,,,,
PLATE BONE L86MM 5 H W RT DSTL RAD VOLAR S STL LCK FOR,SUP-2348744,CDM,C1713,HCPCS,0278,RC,,,,both,,,8086.60,5256.29,,,,,,,,,,,,,
HC Inj Aa&/Strd Greater Occipital Nerve|BILATERAL PROCEDURE,PX-4506440500,CDM,64405,CPT,0450,RC,,,50,both,,,383.00,248.95,,,,,,,,,,,,,
CATHETER DIAG 2.4FR ID0.017IN L150CM HYDRPHLC COAT MICCATH,SUP-2305460,CDM,C1887,HCPCS,0272,RC,,,,both,,,2755.35,1790.98,,,,,,,,,,,,,
OVERTUBE ENDOSCP FOR OVERSTITCH SYS OVRTB,SUP-2119260,CDM,2720000010,LOCAL,0272,RC,,,,both,,,727.44,472.84,,,,,,,,,,,,,
UNIVERS II HUMERAL INSTRUMENTATION SET,SUP-2817736,CDM,C1713,HCPCS,0278,RC,,,,both,,,160140.00,104091.00,,,,,,,,,,,,,
KIT CATH VENT STR RT ANG 2.7MM DIA 15CM LEN,SUP-2308190,CDM,C1713,HCPCS,0278,RC,,,,both,,,399.31,259.55,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA MAXBARR 3FR 55CM S3173108PD,SUP-2632833,CDM,C1751,HCPCS,0278,RC,,,,both,,,675.70,439.20,,,,,,,,,,,,,
SYSTEM OCCL DEL AMPLATZER 45 DEG L 60 CM SHTH 6 FR NIT MESH,SUP-2116316,CDM,C1894,HCPCS,0272,RC,,,,both,,,1821.20,1183.78,,,,,,,,,,,,,
CATHETER LD DEL ATTAIN L 48.5 CM OD 9 FR ID 7.2 FR POLYETHER,SUP-2282153,CDM,C1887,HCPCS,0272,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
KIT SHUNT CSF LP STRATA NCS,SUP-2278371,CDM,2720000010,LOCAL,0272,RC,,,,both,,,15362.64,9985.72,,,,,,,,,,,,,
KYPHOPLASTY PACK 10 GA 2 ML W/O CEMENT DEL SYS OSSEOLFEX SB,SUP-2460443,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6389.90,4153.43,,,,,,,,,,,,,
HC So Albumin,PX-3078204066,CDM,82040,CPT,0307,RC,,,,both,,,35.00,22.75,,,,,,,,,,,,,
VALVE AORT MT DIA23MM BOV PERICARD STNT CO CHROM ALLY,SUP-2214105,CDM,C1889,HCPCS,0278,RC,,,,both,,,18212.00,11837.80,,,,,,,,,,,,,
SAW SURG JOS 7.5 INX38 MM NSL ANGL R BAYNT MICROFRANCE,SUP-2470560,CDM,2720000010,LOCAL,0272,RC,,,,both,,,687.63,446.96,,,,,,,,,,,,,
PROCESSOR HEARING AID BLONDE SND BAHA 5,SUP-2165001,CDM,L8691,HCPCS,0278,RC,,,,both,,,12403.00,8061.95,,,,,,,,,,,,,
HC Assay of Volatiles,PX-3018460000,CDM,84600,CPT,0301,RC,,,,both,,,101.00,65.65,,,,,,,,,,,,,
LEAD PACE 2.6FR L50CM UPLR TEMP ATR NONSTEROID ELUT PIN,SUP-2282230,CDM,C1786,HCPCS,0275,RC,,,,both,,,43.18,28.07,,,,,,,,,,,,,
CABLE PACE L 2 FT FOR 3105 BIOTRONIK PSA SYS,SUP-2494552,CDM,2720000010,LOCAL,0272,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
STAPLER ROBOTIC DIA30MM GRY ENDOWRIST DA VINCI XI,SUP-2246808,CDM,2720000010,LOCAL,0272,RC,,,,both,,,563.38,366.20,,,,,,,,,,,,,
HC So Assay of Estrone,PX-3018267966,CDM,82679,CPT,0301,RC,,,,both,,,139.00,90.35,,,,,,,,,,,,,
TRIPLE ANTIBIOTIC 5-400-5000 EX OINT,RX-8201,CDM,6370000000,HCPCS,0637,RC,00904-8805-67,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
CATHETER VENOGRAPHY COR SNUS BLLN (MIN 5/EA OR 1 BOX)),SUP-2356256,CDM,C1725,HCPCS,0272,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
HC Pvb Thoracic Single Inj Site,PX-3606446100,CDM,64461,CPT,0360,RC,,,,both,,,2230.00,1449.50,,,,,,,,,,,,,
LO-PRO SCRW SYS 2.0/2.3/3.0MM SET,SUP-2814795,CDM,C1713,HCPCS,0278,RC,,,,both,,,9420.00,6123.00,,,,,,,,,,,,,
CATHETER ANGIO 9 ARRY L12CM 4-7CMXL STARBURST,SUP-2117215,CDM,C1819,HCPCS,0278,RC,,,,both,,,7834.30,5092.29,,,,,,,,,,,,,
AUGMENT TIB L63/67MM THK20MM R LAT L MED KNEE UHMWPE PRI,SUP-2405781,CDM,C1776,CPT,0278,RC,,,,both,,,2783.61,1809.35,,,,,,,,,,,,,
BLADE RETRACTOR 3 IN HIP STD T BAR HNDL SELF RET,SUP-2242479,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1094.92,711.70,,,,,,,,,,,,,
STENT GRFT VASC AFX2 VELA L 95 MM DIA PROX/DSTL 25 MM,SUP-2217597,CDM,C1874,HCPCS,0278,RC,,,,both,,,14224.20,9245.73,,,,,,,,,,,,,
GUIDEWIRE ORTH L350MM DIA3.2MM ACC DISP,SUP-2152525,CDM,C1769,HCPCS,0272,RC,,,,both,,,95.46,62.05,,,,,,,,,,,,,
ALLOGRAFT BNE CHIP 4-9.5 MM 5 CC FD CANC STRL 31021405 ALLOSOURCE,SUP-2431936,CDM,C1889,HCPCS,0278,RC,,,,both,,,466.29,303.09,,,,,,,,,,,,,
SCREW COMPRESSION DART FIRE EDGE,SUP-2765151,CDM,C1713,HCPCS,0278,RC,,,,both,,,1723.86,1120.51,,,,,,,,,,,,,
ENDO FUSE  FUSION BEAM 30X10MM,SUP-2461400,CDM,C1713,HCPCS,0278,RC,,,,both,,,5601.76,3641.14,,,,,,,,,,,,,
COCHLEAR IMPL FOR OSI300 IMPL STRL OSIA,SUP-2882743,CDM,L8690,HCPCS,0278,RC,,,,both,,,14601.31,9490.85,,,,,,,,,,,,,
CATHETER DRNGE 24FR 4 WNG DISP FOR NEPHSTMY MALECOTS,SUP-2128993,CDM,C1729,HCPCS,0272,RC,,,,both,,,96.02,62.41,,,,,,,,,,,,,
WEDGE FEM L10MM POST KNEE PRI PRESSFIT LEGION,SUP-2346392,CDM,C1776,CPT,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
STENT URET STR 0.035 IN 3 CM 7 FRX26 CM DBL PGTL PERCFLX,SUP-2464159,CDM,C2617,HCPCS,0278,RC,,,,both,,,344.43,223.88,,,,,,,,,,,,,
TIP IRR DIA0.3MM 30DEG ASPIR BEND REUSE ULTRAFLOW,SUP-2110008,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1161.80,755.17,,,,,,,,,,,,,
INTRODUCER SHTH J TIP 0.038 IN 10.5 FRX25 CM HYDRPHLC COAT,SUP-2740679,CDM,C1892,HCPCS,0272,RC,,,,both,,,261.25,169.81,,,,,,,,,,,,,
JOINT TOE GREAT LG NS HEMI LTX REUSE,SUP-2857509,CDM,C1776,CPT,0278,RC,,,,both,,,5626.88,3657.47,,,,,,,,,,,,,
"HC Est Pt, E/M Level 4|RESIDENT/TEACHING PHYS SERV",PX-5109921400,CDM,99214,CPT,0510,RC,,,GC,both,,,313.00,203.45,,,,,,,,,,,,,
SET SHEATH INTRO PGTL 180 CM 45 DEG 8.5 FRX63 CM STD VERSACROSS W/CONN CBL,SUP-2516361,CDM,C1893,HCPCS,0272,RC,,,,both,,,3045.80,1979.77,,,,,,,,,,,,,
CANNULA EOPA DIL 22FR,SUP-2727091,CDM,2720000010,LOCAL,0272,RC,,,,both,,,342.29,222.49,,,,,,,,,,,,,
FIBER LASER FLEXIVA PULSE TRACTIP 242 BOX,SUP-2716208,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1502.36,976.53,,,,,,,,,,,,,
CATHETER GUID 5FR L70CM 0.038IN W/O HYDRPHLC COAT RADPQ,SUP-2117057,CDM,C1887,HCPCS,0272,RC,,,,both,,,449.02,291.86,,,,,,,,,,,,,
INTRODUCER CATH 8.5FR L71CM 8.5FR DIL L180CM DIA0.032IN W/,SUP-2357599,CDM,C1894,HCPCS,0272,RC,,,,both,,,3395.75,2207.24,,,,,,,,,,,,,
MAGIC MOUTHWASH WITH NYSTATIN SIMPLE,RX-4081628,CDM,6370000000,HCPCS,0637,RC,09999-9917-22,NDC,,both,5,ML,2.70,1.75,,,,,,,,,,,,,
DEFIBRILLATOR CRD BPLR 12 MM 39 CC 78 GM 2 CHMBR ATLS II DR V268ROPT] ST JUDE MED CARDIAC RHYM MGMT],SUP-2356571,CDM,C1721,HCPCS,0275,RC,,,,both,,,72691.00,47249.15,,,,,,,,,,,,,
STENT TRACHBRONCH L35MM DIA22MM CATH L75CM SHTH 11FR,SUP-2140091,CDM,C1876,HCPCS,0278,RC,,,,both,,,3188.89,2072.78,,,,,,,,,,,,,
CATHETER VENT DRNGE L84CM OD1.5MM ID0.7MM CSF LP BA IMPREG,SUP-2284530,CDM,C1729,HCPCS,0272,RC,,,,both,,,1653.18,1074.57,,,,,,,,,,,,,
PACK NEUROSURGICAL MYRIAD HNDPC L 13 CM DIA11 GA,SUP-2930215,CDM,2720000010,LOCAL,0272,RC,,,,both,,,46531.79,30245.66,,,,,,,,,,,,,
SET CATH HEMODIALYSI FRDM FLO CHRNC BSC 15.5FR DIA 40CM STRG,SUP-2610621,CDM,C1752,HCPCS,0278,RC,,,,both,,,832.10,540.86,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 90 CM DIA 8 MM EPTFE STR TW,SUP-2681783,CDM,C1768,CPT,0278,RC,,,,both,,,2684.04,1744.63,,,,,,,,,,,,,
STENT URET FLX 0.035 IN 3 CM 7 FRX20 CM 6 FR POLARIS ULTRA,SUP-2467805,CDM,C2617,HCPCS,0278,RC,,,,both,,,614.97,399.73,,,,,,,,,,,,,
VALVE TRACH AD OD22MM ID15MM AQUA PLAS SWALLOWING SPEAK W/,SUP-2134640,CDM,L8501,HCPCS,0274,RC,,,,both,,,294.06,191.14,,,,,,,,,,,,,
SHEATH INTRO DIREX 50 DEG L 71 CM DIA 8.5 FR SM CRV 17 MM,SUP-2424651,CDM,C1766,CPT,0272,RC,,,,both,,,2590.50,1683.82,,,,,,,,,,,,,
SYSTEM NEUROPROTECTION ENROUTE GUIDEWIRE 0.035 IN,SUP-2890430,CDM,C1884,HCPCS,0278,RC,,,,both,,,11727.90,7623.13,,,,,,,,,,,,,
PLATE BNE 9 H LAT FIB LOK FOR ANK PLATING SYS,SUP-2106975,CDM,C1713,HCPCS,0278,RC,,,,both,,,5736.78,3728.91,,,,,,,,,,,,,
VALVE TRACH AD OD22MM ID15MM AQUA PLAS SWALLOWING SPEAK W/,SUP-2134640,CDM,L8501,HCPCS,0272,RC,,,,both,,,294.06,191.14,,,,,,,,,,,,,
SPLINT WRST FA R INSTABILITY INJ LOOP LOK W STAY E SUPP COT,SUP-2276652,CDM,L3809,HCPCS,0272,RC,,,,both,,,9.55,6.21,,,,,,,,,,,,,
DRESSING WND 6 LAYR 10X15 CM MTRX CYTAL,SUP-2106533,CDM,Q4166,HCPCS,0636,RC,,,,both,,,15417.40,10021.31,,,,,,,,,,,,,
NEEDLE NERVE STIM BVL PEDCL ACCS KT INTEGRITY MONITOR PK NIM,SUP-2792154,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1886.45,1226.19,,,,,,,,,,,,,
HC Pt Manual Therapy Ea 15|OP PT SERVICES|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS,PX-4209714000,CDM,97140,CPT,0420,RC,,,GP|CQ,both,,,194.00,126.10,,,,,,,,,,,,,
DEFIBRILLATOR IMPL INCEPTA DR W 6.17 X H 6.9-7.4 CM D 0.99,SUP-2149202,CDM,C1721,HCPCS,0275,RC,,,,both,,,40926.76,26602.39,,,,,,,,,,,,,
PLATE BONE CONTOUR MESH 200X200X0.6 MM RECONSTRUCTION TITANI,SUP-2837714,CDM,C1713,HCPCS,0278,RC,,,,both,,,15821.83,10284.19,,,,,,,,,,,,,
SCREW SPNL FIX ANGLE 6.5X20 MM CANN FOR 5.5 MM ROD SHILLA,SUP-2630647,CDM,C1713,HCPCS,0278,RC,,,,both,,,4436.82,2883.93,,,,,,,,,,,,,
PISTON SMRT 6X55 MALLOUS,SUP-2313851,CDM,L8613,CPT,0278,RC,,,,both,,,1163.50,756.27,,,,,,,,,,,,,
HC Carcinoembryonic Antigen Cea,PX-3018237800,CDM,82378,CPT,0301,RC,,,,both,,,334.00,217.10,,,,,,,,,,,,,
KIT IMPL L450MM DIA2.5MM TIM IM AND ENDCAP THE NANCY NAIL,SUP-2253250,CDM,C1713,HCPCS,0278,RC,,,,both,,,637.42,414.32,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH TX2 L 154 MM DIA 36 MM SHTH 22 FR RVD,SUP-2750383,CDM,C1768,CPT,0278,RC,,,,both,,,56641.52,36816.99,,,,,,,,,,,,,
COMPONENT HUM SZ 2 SHLDR NUCLS SIMPLICITI,SUP-2388772,CDM,C1776,CPT,0278,RC,,,,both,,,15304.36,9947.83,,,,,,,,,,,,,
BUPIVACAINE 0.25% ELASTOMERIC INFUSION,RX-408722,CDM,J0665,HCPCS,0636,RC,00409-1159-10,NDC,,both,100,ML,54.10,35.16,,,,,,,,,,,,,
SCREW SPNL L30MM OD5.5MM TI CANC ANT THOR PEDCL ST,SUP-2292717,CDM,C1713,HCPCS,0278,RC,,,,both,,,970.26,630.67,,,,,,,,,,,,,
ADAPTER LD 8 CHANNEL M 10 CM,SUP-2615487,CDM,C1883,HCPCS,0278,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
CATHETER HD SHT TERM 9 FRX20 CM ADMIN BASIC SET STR DUOFLO,SUP-2267113,CDM,C1752,HCPCS,0278,RC,,,,both,,,140.42,91.27,,,,,,,,,,,,,
PATCH VASC KNIT N VEL ULT THN N TAPR END CLLGN POLY FINESSE,SUP-2227661,CDM,C1768,CPT,0278,RC,,,,both,,,398.84,259.25,,,,,,,,,,,,,
SUPPORT ORTHOT WRST ELBW HND SHLDR CUST CAP DESIGN W/O JT,SUP-2435792,CDM,L3961,HCPCS,0272,RC,,,,both,,,4329.02,2813.86,,,,,,,,,,,,,
CATHETER VASC DIAG SIM 2 PERIPH W/ HYDRPHLC COAT AD RADPQ,SUP-2141095,CDM,C1887,HCPCS,0272,RC,,,,both,,,158.10,102.76,,,,,,,,,,,,,
PLATE BNE SQ MINI 2X0.6 MM 6X4 HOLE FOR SCREW TI NS LEVEL 1,SUP-2476725,CDM,C1713,HCPCS,0278,RC,,,,both,,,942.35,612.53,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 3X2 CM BLOCKADE AMNIO PROTCT BARR,SUP-2538793,CDM,C1762,CPT,0278,RC,,,,both,,,7699.28,5004.53,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 70 CM DIA 6 MM STR STD WALL HELIX,SUP-2458479,CDM,C1768,CPT,0278,RC,,,,both,,,2455.67,1596.19,,,,,,,,,,,,,
GUIDEWIRE VASC THRUWAY L 130 CM DIA 0.018 IN SS SIL J LNG,SUP-2148319,CDM,C1769,HCPCS,0272,RC,,,,both,,,273.93,178.05,,,,,,,,,,,,,
DIAZEPAM 5 MG/ML IJ SOLN,RX-2401,CDM,J3360,HCPCS,0636,RC,00641-6244-10,NDC,,both,0.5,ML,54.10,35.16,,,,,,,,,,,,,
ELECTRODE ELECSURG RL BALL RESECTSCP CLASS SER 28 FR BLU,SUP-2312670,CDM,2720000010,LOCAL,0272,RC,,,,both,,,412.38,268.05,,,,,,,,,,,,,
PLATE BNE BROAD 5.5X324 MM 18 HOLE SS LCP,SUP-2569379,CDM,C1713,HCPCS,0278,RC,,,,both,,,1145.00,744.25,,,,,,,,,,,,,
TREPHINE SURG OD8MM COR SL DISPOSABLE,SUP-2212797,CDM,C1713,HCPCS,0278,RC,,,,both,,,1029.92,669.45,,,,,,,,,,,,,
GRAFT SFT TISS 16X10 CM PLIABLE RECON TISS MTRX STRATTICE,SUP-2467751,CDM,Q4130,HCPCS,0636,RC,,,,both,,,7344.46,4773.90,,,,,,,,,,,,,
SCREW BONE L22MM DIA2MM CORT CRANIOMAXILLOFACIAL TI ST,SUP-2189340,CDM,C1713,HCPCS,0278,RC,,,,both,,,229.91,149.44,,,,,,,,,,,,,
PIN DISTR L12MM SELF DRL CASPR,SUP-2108444,CDM,C1713,HCPCS,0278,RC,,,,both,,,98.91,64.29,,,,,,,,,,,,,
STEM FEM L70MM 15DEG 38MM OFFSET PROX KNEE TI POR FEM TAPR,SUP-2252620,CDM,C1776,CPT,0278,RC,,,,both,,,13025.03,8466.27,,,,,,,,,,,,,
BOLT EXT FIX CANN POST MT SCR SCHNZ FOR DISTRCTN,SUP-2179137,CDM,2720000010,LOCAL,0272,RC,,,,both,,,774.01,503.11,,,,,,,,,,,,,
SHEATH INTRO FLX L 80 CM OD 10 FR GUIDEWIRE 0.038 IN SM,SUP-2168816,CDM,C1894,HCPCS,0272,RC,,,,both,,,243.66,158.38,,,,,,,,,,,,,
PLATE BNE RECON 3.5X142 MM 12 HOLE SS,SUP-2569087,CDM,C1713,HCPCS,0278,RC,,,,both,,,436.93,284.00,,,,,,,,,,,,,
BIT DRL W/ CENTERING SL FOR 2.2 MM SURELOCK ALL SUTURE ANCHR,SUP-2608903,CDM,2720000010,LOCAL,0272,RC,,,,both,,,731.49,475.47,,,,,,,,,,,,,
SUPPORT ORTHOT THOR LUMBAR SACR CUST FLX TRUNK SUPP APRON,SUP-2435539,CDM,L0457,HCPCS,0274,RC,,,,both,,,2815.80,1830.27,,,,,,,,,,,,,
GRAFT DURA W1XL3IN WHT CLLGN POR MTRX ABSRB PLIABLE,SUP-2244079,CDM,C1763,HCPCS,0278,RC,,,,both,,,800.64,520.42,,,,,,,,,,,,,
ANCHOR SUT Y KNOT RC 3 LD W 3 NUMBER 2 HI FI SUTS W NDL,SUP-2418757,CDM,C1713,HCPCS,0278,RC,,,,both,,,2113.85,1374.00,,,,,,,,,,,,,
BLADE SURG TIP 09MM HK,SUP-2417747,CDM,2720000010,LOCAL,0272,RC,,,,both,,,570.85,371.05,,,,,,,,,,,,,
CLAMP SPNL UNIV THORLUM TI BODY TRNSCONN 2 COR SM STAT USS,SUP-2193593,CDM,C1713,HCPCS,0278,RC,,,,both,,,825.82,536.78,,,,,,,,,,,,,
SCREW INTRF SHT THRD 8X23 MM KNEE CRUC DRVR BIOSTEON,SUP-2366519,CDM,C1713,HCPCS,0278,RC,,,,both,,,739.00,480.35,,,,,,,,,,,,,
COMPONENT TIB ROTATIONAL NEUT LG KNEE CONN MOLYBDENUM UHMWPE,SUP-2423700,CDM,C1776,CPT,0278,RC,,,,both,,,4573.72,2972.92,,,,,,,,,,,,,
BLADE SURG 0.25-25 MM ACCUVISION DISP,SUP-2685789,CDM,2720000010,LOCAL,0272,RC,,,,both,,,901.18,585.77,,,,,,,,,,,,,
LINER ACET CONSTRN 32 MM HIP FRDM,SUP-2423252,CDM,C1776,CPT,0278,RC,,,,both,,,20221.60,13144.04,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY LASSO 2515 L115CM 7FR D DECAPOLAR,SUP-2248767,CDM,C1730,HCPCS,0272,RC,,,,both,,,4939.22,3210.49,,,,,,,,,,,,,
CANNULA SUCTION INSUL 5 MMX30 CM CRV DST ANGLED HNDL UPLR,SUP-2773025,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1905.85,1238.80,,,,,,,,,,,,,
LOW PRFLE NEURO PLATE 5X2 HOLES CRVD SQRE SGMNTS 06MM 15MM,SUP-2707407,CDM,C1713,HCPCS,0278,RC,,,,both,,,988.28,642.38,,,,,,,,,,,,,
VITAMIN A 15 MG/ML IM SOLN,RX-149965,CDM,2500000003,HCPCS,0250,RC,70199-0026-11,NDC,,both,0.2,ML,413.30,268.64,,,,,,,,,,,,,
PLATE BNE L 200 X W 11.5 MM THK 3.6 MM SCREW DIA 3.5 MM 16 H 72463116,SUP-2933390,CDM,C1713,HCPCS,0278,RC,,,,both,,,7412.76,4818.29,,,,,,,,,,,,,
SHEATH CATH INTRO 11FR L12CM HEMSTAS VLV SIDEPRT DIL DBL,SUP-2355403,CDM,C1894,HCPCS,0272,RC,,,,both,,,47.10,30.61,,,,,,,,,,,,,
LEAD PACE SIL ENDOCARD RT ATRIOVENTRICULAR ACTIVE SCREW FIX,SUP-2139480,CDM,C1898,HCPCS,0275,RC,,,,both,,,3133.72,2036.92,,,,,,,,,,,,,
DEXTROSE 5 % IV BOLUS,RX-40840055,CDM,2580000003,HCPCS,0250,RC,00264-7510-00,NDC,,both,250,ML,8.50,5.52,,,,,,,,,,,,,
PLATE BNE CONTOURABLE MESH 200X200X0.6 MM RIGID SLV NS,SUP-2859899,CDM,C1713,HCPCS,0278,RC,,,,both,,,25505.59,16578.63,,,,,,,,,,,,,
KCL-LACTATED RINGERS-D5W 20 MEQ/L IV SOLN,RX-16014,CDM,2500000003,HCPCS,0250,RC,00338-0811-04,NDC,,both,1000,ML,63.30,41.14,,,,,,,,,,,,,
SCREW BNE FT 3.5X44 MM CORTICAL SLD TI NS,SUP-2413377,CDM,C1713,HCPCS,0278,RC,,,,both,,,202.84,131.85,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 70 CM DIA 8MM L 50 CM STR STD WALL,SUP-2396275,CDM,C1768,CPT,0278,RC,,,,both,,,4028.62,2618.60,,,,,,,,,,,,,
OSTEOTOME SURG L8 1 4IN BLDE W1 4IN STR S STL SATIN FINISH,SUP-2161283,CDM,C1713,HCPCS,0278,RC,,,,both,,,309.16,200.95,,,,,,,,,,,,,
SHEATH INTRO AD 7FR L59CM DIL L67CM 0.032IN PTFE FIX CRV,SUP-2284369,CDM,C1894,HCPCS,0272,RC,,,,both,,,211.01,137.16,,,,,,,,,,,,,
GRAFT BNE 1ML DEMIN BNE MTRX GEL,SUP-2362219,CDM,C1713,HCPCS,0278,RC,,,,both,,,417.62,271.45,,,,,,,,,,,,,
STRUT EXT FIX L 126193 MM MED HEXAPOD STRL DISP MAXFRAME,SUP-2907863,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6531.20,4245.28,,,,,,,,,,,,,
ALLOGRAFT GRAFTLINK: D=8.5 L=65 MM,SUP-2815859,CDM,C1762,CPT,0278,RC,,,,both,,,7033.91,4572.04,,,,,,,,,,,,,
"HC So Quantation of Therapuetic Drug, Nes",PX-3018029966,CDM,80299,CPT,0301,RC,,,,outpatient,,,63.00,40.95,,,,,,,,,,,,,
PROSTHESIS OSS GRATE 1.15X1.78X4.7 MM MALL TO STAPE STRUT,SUP-2637861,CDM,L8613,CPT,0278,RC,,,,both,,,714.88,464.67,,,,,,,,,,,,,
PLATE BNE 12 H NONSTERILE BILAT MANUBRIUM STRNL TI LOK STAR,SUP-2192439,CDM,C1713,HCPCS,0278,RC,,,,both,,,3138.74,2040.18,,,,,,,,,,,,,
SUPPORT ORTHOT THOR LUMBAR SACR CUST FLX TRUNK SUPP APRON,SUP-2435539,CDM,L0457,HCPCS,0272,RC,,,,both,,,2815.80,1830.27,,,,,,,,,,,,,
SCREW BNE 7X14 MM BOLT TENDESIS QUATTRO,SUP-2608896,CDM,C1713,HCPCS,0278,RC,,,,both,,,1417.27,921.23,,,,,,,,,,,,,
GRAFT DURA W2XL2IN ULTRAPURE DURAGN + EA,SUP-2244006,CDM,C1763,HCPCS,0278,RC,,,,both,,,1609.41,1046.12,,,,,,,,,,,,,
IMPL SYS HIP LABRAL RECON,SUP-2814003,CDM,C1713,HCPCS,0278,RC,,,,both,,,6176.38,4014.65,,,,,,,,,,,,,
KIT CATH HEMODIALYSI BREVIA ACUTE 11FR DIA 15CML INSER 200 3,SUP-2613236,CDM,C1752,HCPCS,0278,RC,,,,both,,,400.35,260.23,,,,,,,,,,,,,
PROBE LITHO L500MM DIA1.6MM PNEUMAT HANDHELD DISP LMA,SUP-2171446,CDM,C1713,HCPCS,0278,RC,,,,both,,,625.49,406.57,,,,,,,,,,,,,
SCREW BONE L40MM OD3.2MM FULL THRD COMPR,SUP-2418850,CDM,C1713,HCPCS,0278,RC,,,,both,,,1962.50,1275.62,,,,,,,,,,,,,
GRAFT HUM TISS W14-18XL40MM FIB SHFT STRUCTURAL ALLGRFT FRZ,SUP-2307190,CDM,C1713,HCPCS,0278,RC,,,,both,,,1795.42,1167.02,,,,,,,,,,,,,
COMPONENT PAT DIA37MM THK10MM STD REV CEM SUT H BTTN W/O XR,SUP-2404199,CDM,C1713,HCPCS,0278,RC,,,,both,,,2260.80,1469.52,,,,,,,,,,,,,
BUR SURG DIA1.2 MM TWST DRL STRL DISP HI-LINE XS,SUP-2929619,CDM,2720000010,LOCAL,0272,RC,,,,both,,,267.09,173.61,,,,,,,,,,,,,
BOLT EXT FIX LNG WIRE COMB NS DISP SMRT TSF,SUP-2933200,CDM,2720000010,LOCAL,0272,RC,,,,both,,,270.04,175.53,,,,,,,,,,,,,
COMPONENT ACET AUG SM 58 MM HIP REGENEREX PT110158,SUP-2449936,CDM,C1776,CPT,0278,RC,,,,both,,,6118.29,3976.89,,,,,,,,,,,,,
PLATE BNE L62MM 3 H STD L DST RAD VOLAR S STL LOK FOR,SUP-2348737,CDM,C1713,HCPCS,0278,RC,,,,both,,,7629.73,4959.32,,,,,,,,,,,,,
BODY HUM PROXIMAGE 62 MM COMPHSVE SEG REV SYSTEML LAR,SUP-2136571,CDM,L3809,HCPCS,0272,RC,,,,both,,,11360.52,7384.34,,,,,,,,,,,,,
PLATE BNE L93MM 4X6 H S STL L DST VOLAR RAD FOR 3MM SCR,SUP-2372084,CDM,C1713,HCPCS,0278,RC,,,,both,,,2174.45,1413.39,,,,,,,,,,,,,
INSERT TIB SZ 1 THICKNESS 9MM KNEE SL IMP MOST OPTIONS,SUP-2208280,CDM,C1776,CPT,0278,RC,,,,both,,,6415.02,4169.76,,,,,,,,,,,,,
STEM FEM TAPR PRI STD OFFSET CEM CLLRD CO CHROM IMP 12/14,SUP-2344495,CDM,C1776,CPT,0278,RC,,,,both,,,11633.70,7561.90,,,,,,,,,,,,,
GRAFT BNE STRP 12 CC ISOTIS PURE,SUP-2644343,CDM,C1713,HCPCS,0278,RC,,,,both,,,6729.02,4373.86,,,,,,,,,,,,,
INDWELLING VOICE PROS LEF,SUP-2242341,CDM,L8509,HCPCS,0274,RC,,,,both,,,973.40,632.71,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.424,SUP-2859988,CDM,C1713,HCPCS,0278,RC,,,,both,,,38880.42,25272.27,,,,,,,,,,,,,
PHACOEMULSIFICATION PACK SS PREMIERE LF REUSE,SUP-2478302,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1505.32,978.46,,,,,,,,,,,,,
STEM HIP SZ 6 NK L25MM M-HA OMFLX,SUP-2364204,CDM,C1776,CPT,0278,RC,,,,both,,,13031.00,8470.15,,,,,,,,,,,,,
ALLOGRAFT HUM TISS FRZN ASEP PRECUT ACHILLES TEND,SUP-2867184,CDM,C1762,CPT,0278,RC,,,,both,,,6473.11,4207.52,,,,,,,,,,,,,
HC So Drug Assay Posaconazole,PX-3018018766,CDM,80187,CPT,0301,RC,,,,both,,,368.00,239.20,,,,,,,,,,,,,
SCREW BNE LCK 2.7 MM TOT WR STARDRV FUSION BLK NS SURFIX,SUP-2610309,CDM,C1713,HCPCS,0278,RC,,,,both,,,455.96,296.37,,,,,,,,,,,,,
GUIDEWIRE VASC L 60 CM DIA 0.035 IN STR TIP STRL,SUP-2214529,CDM,C1769,HCPCS,0272,RC,,,,both,,,30.58,19.88,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9% IV BOLUS (PER WEIGHT),RX-40901010,CDM,2580000003,HCPCS,0250,RC,00338-0049-11,NDC,,both,50,ML,24.70,16.05,,,,,,,,,,,,,
CEMENT BNE 20ML 40GM HALF DOSE PMMA W/ 0.5GM GENT HI VISC,SUP-2197462,CDM,C1713,HCPCS,0278,RC,,,,both,,,1338.68,870.14,,,,,,,,,,,,,
DEVICE SUT LAPROSCOPIC RD180 SP,SUP-2265296,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
BLADE ENDO 4MM PURP,SUP-2399180,CDM,C1713,HCPCS,0278,RC,,,,both,,,2122.64,1379.72,,,,,,,,,,,,,
GUIDEWIRE VASC L205CM TAPR L33CM OD0016IN STD S STL PLAT TIP,SUP-2257077,CDM,C1769,HCPCS,0272,RC,,,,both,,,1888.21,1227.34,,,,,,,,,,,,,
HC Gram Stain,PX-3008720500,CDM,87205,CPT,0300,RC,,,,both,,,159.00,103.35,,,,,,,,,,,,,
PROBE SUCT N CNTCT COAG TARGETED THER CLR VIS BEAMER L320CM,SUP-2166255,CDM,2720000010,LOCAL,0272,RC,,,,both,,,772.82,502.33,,,,,,,,,,,,,
BLADE ENDOSCP SHAVER L 8 CM DIA 3.5 MM SPD 5000 RPM INTNSL,SUP-2900126,CDM,2720000010,LOCAL,0272,RC,,,,both,,,430.49,279.82,,,,,,,,,,,,,
HC MRI-Upper Ext Jnt W & WO Cont,PX-6107322300,CDM,73223,CPT,0610,RC,,,,inpatient,,,4220.00,2743.00,,,,,,,,,,,,,
SUTURE PROL 7 0 L8MM NONABSORBABLE BLU BV175 7 CTRL REL 3 8 M8764,SUP-2219653,CDM,C1713,HCPCS,0278,RC,,,,both,,,250.35,162.73,,,,,,,,,,,,,
BUR SURG TAPR 1.7X15.8 MM 8 CM SM BOR MIDAS REX LEGEND,SUP-2631335,CDM,2720000010,LOCAL,0272,RC,,,,both,,,275.57,179.12,,,,,,,,,,,,,
MESH MXLFCL 26.2X26.2 MM 0.6 MM FOIL LG GRID PDLLA RESORB XG,SUP-2475635,CDM,C1713,HCPCS,0278,RC,,,,both,,,1364.46,886.90,,,,,,,,,,,,,
SCREW SPNL MULTAXL 7.5X45 MM ESSENCE KT,SUP-2631917,CDM,C1713,HCPCS,0278,RC,,,,both,,,8102.77,5266.80,,,,,,,,,,,,,
ALLOGRAFT BNE 10 MM,SUP-2736781,CDM,C1713,HCPCS,0278,RC,,,,both,,,8193.92,5326.05,,,,,,,,,,,,,
WIRE EXT FIX OLV 1.6 MM,SUP-2749722,CDM,C1713,HCPCS,0278,RC,,,,both,,,367.38,238.80,,,,,,,,,,,,,
PLATE BNE 5 H R CLOVER COMPR LISFRANC GORILLA,SUP-2321538,CDM,C1713,HCPCS,0278,RC,,,,both,,,4961.20,3224.78,,,,,,,,,,,,,
CYCLOPHOSPHAMIDE 1 GM/5ML IV SOLN,RX-151539,CDM,J9075,HCPCS,0636,RC,75907-0190-07,NDC,,both,5,ML,741.90,482.23,,,,,,,,,,,,,
NAIL IM L15CM DIA11.5MM 5DEG TROCHANTERIC BLU TI CANN LCK,SUP-2347226,CDM,C1713,HCPCS,0278,RC,,,,both,,,11574.04,7523.13,,,,,,,,,,,,,
NAIL IM SQ HD BHR,SUP-2351311,CDM,C1713,HCPCS,0278,RC,,,,both,,,901.18,585.77,,,,,,,,,,,,,
CASE STRL INSTR FOR L FRAG TI SCR SET GRPHC LCK COMPR PLT,SUP-2194001,CDM,C1713,HCPCS,0278,RC,,,,both,,,3138.81,2040.23,,,,,,,,,,,,,
PROSTHESIS VOICE SZ 3MM 7MM NSL SEPT PERF RND,SUP-2242444,CDM,C1713,HCPCS,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
WASHER ORTH FIX SM,SUP-2205628,CDM,C1713,HCPCS,0278,RC,,,,both,,,25.12,16.33,,,,,,,,,,,,,
PIN FIX SZ 2MM PROV DISP,SUP-2344037,CDM,2720000010,LOCAL,0272,RC,,,,both,,,904.60,587.99,,,,,,,,,,,,,
VINORELBINE TARTRATE 10 MG/ML IV SOLN (MIXTURES ONLY)|DISCARDED DRUG NOT ADMINISTE,RX-430027,CDM,J9390,HCPCS,0636,RC,25021-0204-01,NDC,JW,both,1,ML,72.00,46.80,,,,,,,,,,,,,
PLATE BONE L227MM 14 H RT PROX HUM LO ALPS,SUP-2418355,CDM,C1713,HCPCS,0278,RC,,,,both,,,8807.70,5725.00,,,,,,,,,,,,,
PLATE BNE L76MM BLDE W11.7XL30MM 90DEG 4 H ST BILAT S STL,SUP-2185434,CDM,C1713,HCPCS,0278,RC,,,,both,,,3363.69,2186.40,,,,,,,,,,,,,
GRAFT BNE SUB L20CM STRP MASTERGRFT,SUP-2289162,CDM,C1713,HCPCS,0278,RC,,,,both,,,9256.72,6016.87,,,,,,,,,,,,,
SPACER SPNL W10XH9-13XL31MM 15DEG THORLUM INTBDY FUS LORD,SUP-2228791,CDM,C1821,HCPCS,0278,RC,,,,both,,,16485.00,10715.25,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC SOLO2 HF 5FR 55CM 3 LUMAN 1395108Q,SUP-2632640,CDM,C1751,HCPCS,0278,RC,,,,both,,,942.66,612.73,,,,,,,,,,,,,
TI MATRIXMIDFACE SCREW  1.3MM  450395301,SUP-2844117,CDM,C1713,HCPCS,0278,RC,,,,both,,,13174.94,8563.71,,,,,,,,,,,,,
COIL VASC AZUR L 34 CM DIA14 MM MICROCATHETER 0.018 IN LOOP,SUP-2385436,CDM,C1889,HCPCS,0278,RC,,,,both,,,2893.51,1880.78,,,,,,,,,,,,,
CATHETER GUID ANGLED 0.018 IN 150 CM SUPP 3 MARKER NAVICROSS,SUP-2435371,CDM,C1887,HCPCS,0272,RC,,,,both,,,700.53,455.34,,,,,,,,,,,,,
CG+ PICC SET: THREE LUMEN 6FRX55CM W/130CM SWG,SUP-2827504,CDM,C1751,HCPCS,0278,RC,,,,both,,,590.95,384.12,,,,,,,,,,,,,
PLATE BNE L142MM BLDE W5.8XL38MM 140DEG 8 H ST BILAT PELV,SUP-2186650,CDM,C1713,HCPCS,0278,RC,,,,both,,,2307.27,1499.73,,,,,,,,,,,,,
PLATE BONE 7 H TI LCK 3RD TBLR,SUP-2419536,CDM,C1713,HCPCS,0278,RC,,,,both,,,800.70,520.45,,,,,,,,,,,,,
GRAFT BONE SUBSTITUTE 5CC DEMINERALIZED BONE MATRIX GEL REVERSE PHASE MEDIUM STIMUBLAST,SUP-2120747,CDM,C1713,HCPCS,0278,RC,,,,both,,,2260.80,1469.52,,,,,,,,,,,,,
PLATE BNE L208MM THK37MM 16 H BILAT S STL STR LO PROF RIG,SUP-2177148,CDM,C1713,HCPCS,0278,RC,,,,both,,,2817.87,1831.62,,,,,,,,,,,,,
KIT ACCS 10ML SYR CATH ALC PD PLEURX,SUP-2133744,CDM,C1729,HCPCS,0272,RC,,,,both,,,182.12,118.38,,,,,,,,,,,,,
COIL NEUROVASCULAR L 30 CM DIA 0.135 IN MICROCATHETER DIA,SUP-2896805,CDM,C1889,HCPCS,0278,RC,,,,both,,,6154.40,4000.36,,,,,,,,,,,,,
GRAFT BNE SUB 90CC 4 10MM PARTIC CANC FRZ DRY,SUP-2264682,CDM,C1713,HCPCS,0278,RC,,,,both,,,3027.40,1967.81,,,,,,,,,,,,,
KIT EXT FIX TWO RAIL W UNDERNEATH SURF CVR BY RUB FOR,SUP-2316207,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5512.58,3583.18,,,,,,,,,,,,,
CATHETER URET OPN END FLEXI-TIP,SUP-2836004,CDM,C1758,HCPCS,0278,RC,,,,both,,,167.77,109.05,,,,,,,,,,,,,
GENERATOR NEUROSTIMULATOR MODEL 2104 BAROSTIM NEO2,SUP-2881052,CDM,C1767,HCPCS,0278,RC,,,,both,,,98910.00,64291.50,,,,,,,,,,,,,
PLATE BNE L301MM 14 H NONSTERILE L CNDYL S STL CRV LOK,SUP-2177861,CDM,C1713,HCPCS,0278,RC,,,,both,,,6252.87,4064.37,,,,,,,,,,,,,
LINER ACET ELEV JJ 36X56 MM HIP POLYETH VIVACIT-E XLPE TRIL,SUP-2204092,CDM,C1776,CPT,0278,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
PLATE BONE LOK HLX3 MED CLMN RIGHT DST VOLAR RDL,SUP-2724782,CDM,C1713,HCPCS,0278,RC,,,,both,,,2716.73,1765.87,,,,,,,,,,,,,
BOOT HEEL FLOAT SYS W/ STRP 1 SZ ROCK,SUP-2319142,CDM,L4386,HCPCS,0274,RC,,,,both,,,303.01,196.96,,,,,,,,,,,,,
SHROUD CEMENT CONSTRN 28 MM LNR TRABECULAR MTL,SUP-2438927,CDM,C1776,CPT,0278,RC,,,,both,,,833.67,541.89,,,,,,,,,,,,,
SHEET SPLNT THK0.13IN STD W18XL24IN BILAT WR AND HND WHT SLD,SUP-2324794,CDM,L3730,HCPCS,0274,RC,,,,both,,,116.05,75.43,,,,,,,,,,,,,
GRAFT HUM TISS DIA24MM AMNIO MEMBRN DISK AMNIOEXCEL,SUP-2194319,CDM,Q4137,HCPCS,0636,RC,,,,both,,,2154.04,1400.13,,,,,,,,,,,,,
PLATE BNE L 270 MM SCREW DIA 4.5 MM 13 H SS LT DSTL FEM NS,SUP-2931187,CDM,C1713,HCPCS,0278,RC,,,,both,,,11916.30,7745.59,,,,,,,,,,,,,
PLATE STRNL SM 8 H TI H SHP NS MATRIXSTERNUM,SUP-2904214,CDM,C1713,HCPCS,0278,RC,,,,both,,,1938.70,1260.15,,,,,,,,,,,,,
DISTRACTION INTRNL PLATE CNSLDTN RAMUS TRNSPRT DVCE 15 MM S,SUP-2679192,CDM,C1713,HCPCS,0278,RC,,,,both,,,1837.69,1194.50,,,,,,,,,,,,,
PLATE SPINE IMPL NARROW LCK 2X34MM 6HL,SUP-2661360,CDM,C1713,HCPCS,0278,RC,,,,both,,,3519.94,2287.96,,,,,,,,,,,,,
ELECTRODE ELECSURG BPLR 0 DEG 4 MM VAPORIZING TIP VERSAPOINT,SUP-2218059,CDM,C1713,HCPCS,0278,RC,,,,both,,,1178.94,766.31,,,,,,,,,,,,,
SPLINT ANK FT XL L POST LEAF LTWT SEMI RIG ROLYAN,SUP-2326014,CDM,L4396,HCPCS,0274,RC,,,,both,,,140.08,91.05,,,,,,,,,,,,,
HC So Erythropoietin,PX-3018266866,CDM,82668,CPT,0301,RC,,,,both,,,373.00,242.45,,,,,,,,,,,,,
BIT DRL TWST 1.1X50 MM 7 MM W/ STP CYL ATTCH SS LEVEL 1 DISP,SUP-2482124,CDM,2720000010,LOCAL,0272,RC,,,,both,,,428.08,278.25,,,,,,,,,,,,,
PLATE BNE THK 0.3 MM SCREW DIA1.5 MM TI ORBIT FLR PREFRM NOE,SUP-2883818,CDM,C1713,HCPCS,0278,RC,,,,both,,,2135.20,1387.88,,,,,,,,,,,,,
BRACE ORTH 30 150DEG SHLDR UNIV MOTN CTRL CHST STRP WAIST,SUP-2196399,CDM,L3650,HCPCS,0274,RC,,,,both,,,716.83,465.94,,,,,,,,,,,,,
SET INTRO SUP ARW FLX SHTH L 35 CM DIA 7 FR HYDRPHLC,SUP-2383981,CDM,C1894,HCPCS,0272,RC,,,,both,,,935.72,608.22,,,,,,,,,,,,,
MOXIFLOXACIN HCL 0.5 % OP SOLN,RX-35699,CDM,6370000000,HCPCS,0637,RC,62332-0505-03,NDC,,both,3,ML,45.00,29.25,,,,,,,,,,,,,
ROD EXT FIX L220MM DIA8MM UNIV C FBR CONN REUSE FOR M FIX,SUP-2188740,CDM,2720000010,LOCAL,0272,RC,,,,both,,,438.09,284.76,,,,,,,,,,,,,
FIBER LASER OTO MICROLASE REUSE,SUP-2713746,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8854.80,5755.62,,,,,,,,,,,,,
KYPHOPLASTY TRAY 20/3 1 STP OSTEO INTRO CDS KYPHOPAK XPANDER,SUP-2665123,CDM,2720000010,LOCAL,0272,RC,,,,both,,,12898.49,8384.02,,,,,,,,,,,,,
BASKET SPEC RETRV HRD WIRE MEM,SUP-2759295,CDM,2720000010,LOCAL,0272,RC,,,,both,,,756.74,491.88,,,,,,,,,,,,,
PLATE BNE BAR 14 MM 6 H LNG CRANIOMAXILLOFACIAL SAG SPLIT,SUP-2883177,CDM,C1713,HCPCS,0278,RC,,,,both,,,1408.67,915.64,,,,,,,,,,,,,
SYSTEM REPAIR MENISCAL AIR+ CURVED UP,SUP-2749430,CDM,C1713,HCPCS,0278,RC,,,,both,,,2700.40,1755.26,,,,,,,,,,,,,
STEM FEM L300MM OD9MM RT HIP POR NONCOATED TYP 1 TAPR PRI,SUP-2406682,CDM,C1776,CPT,0278,RC,,,,both,,,19932.72,12956.27,,,,,,,,,,,,,
KIT NAIL INSTR CHT STICKER TENFUSE,SUP-2401377,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1193.20,775.58,,,,,,,,,,,,,
CATHETER ANGIOPLSTY MUSTANG L 75 CM BALLOON L 40 MM DIA 4 MM,SUP-2145426,CDM,C1725,HCPCS,0272,RC,,,,both,,,596.60,387.79,,,,,,,,,,,,,
KIT INTRO EXCALIBUR L 35 MM DIA 3 FR NDL 19 GA PERC ART VEN,SUP-2125566,CDM,C1894,HCPCS,0272,RC,,,,both,,,74.73,48.57,,,,,,,,,,,,,
"HC Urine,Microalbumin,Quantitativ",PX-3078204300,CDM,82043,CPT,0307,RC,,,,outpatient,,,129.00,83.85,,,,,,,,,,,,,
CATHETER DRNGE 10FR L25CM FLEXIMA GLDEX ALL PURP LOOP RADPQ,SUP-2147782,CDM,C1729,HCPCS,0272,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
CEMENT KIT CALCIUM PHOSPHATE 16 CC QUICKSET,SUP-2845380,CDM,C1713,HCPCS,0278,RC,,,,both,,,7418.25,4821.86,,,,,,,,,,,,,
PLATE CRAN THK 0.4 MM SCREW DIA1.5 MM 4 X 2 H SM TI BX LP 3D,SUP-2883642,CDM,C1713,HCPCS,0278,RC,,,,both,,,1233.14,801.54,,,,,,,,,,,,,
PLATE BNE MINI W5XL10MM THK0.5MM 4 H BILAT,SUP-2181691,CDM,C1713,HCPCS,0278,RC,,,,both,,,1114.39,724.35,,,,,,,,,,,,,
FOOTPLATE EXT FIX ROT TOT ANK INVISION,SUP-2481355,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5601.76,3641.14,,,,,,,,,,,,,
BUR ENDOSCP BRL SEMI HOOD DK GRY PNK STRL UNIDRIVE DISP,SUP-2585909,CDM,2720000010,LOCAL,0272,RC,,,,both,,,273.34,177.67,,,,,,,,,,,,,
KIT PD 5.8FT-6.3FT M STRNL BRAC PT TLSO,SUP-2123924,CDM,L0462,HCPCS,0272,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
ANCHOR SUT MIC W/ SZ 4/0 C1 TAPR PT ORTHOCORD AND DRL BIT,SUP-2256600,CDM,C1713,HCPCS,0278,RC,,,,both,,,1761.54,1145.00,,,,,,,,,,,,,
RING EXT FIX 180 MM 5/8 MR SAFE TI NS,SUP-2863455,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2307.27,1499.73,,,,,,,,,,,,,
FULLY TH CANC SCREW 6.5 145MM,SUP-2818872,CDM,C1713,HCPCS,0278,RC,,,,both,,,593.93,386.05,,,,,,,,,,,,,
GRAFT TISS FRZN SHFT TIB STRUCTURAL ALLGRFT 150MM LEN,SUP-2307367,CDM,C1713,HCPCS,0278,RC,,,,both,,,4394.43,2856.38,,,,,,,,,,,,,
PRESSURE MONITORING KIT INTCRAN VENTRICULAR CATH CAMINO,SUP-2851495,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2977.51,1935.38,,,,,,,,,,,,,
SHEATH INTRO FLX RAABE L 70 CM OD 6 FR GUIDEWIRE 0.038 IN,SUP-2168678,CDM,C1894,HCPCS,0272,RC,,,,both,,,152.29,98.99,,,,,,,,,,,,,
BLADE LARYNGOSCOPE GERMAN PROFILE STRONG CURVE EVALUEMED MAC,SUP-2828245,CDM,2720000010,LOCAL,0272,RC,,,,both,,,328.26,213.37,,,,,,,,,,,,,
SPACER SPNL EXPANDABLE 18 MM PROC POST FUSION AILERON-TRX,SUP-2430748,CDM,C1713,HCPCS,0278,RC,,,,both,,,22529.50,14644.17,,,,,,,,,,,,,
PLATE BNE W11XL12MM 4 H BILAT TI H SHP RIG NONCOMPRESSION,SUP-2191062,CDM,C1713,HCPCS,0278,RC,,,,both,,,726.72,472.37,,,,,,,,,,,,,
IMPLANT SYNTH L 106 X W 97 MM THK 6 MM POLYETHYL CRAN GRID,SUP-2883617,CDM,C1713,HCPCS,0278,RC,,,,both,,,12509.48,8131.16,,,,,,,,,,,,,
INSERT ACET 42X50X9 MM HIP HD NK MAG,SUP-2137412,CDM,C1776,CPT,0278,RC,,,,both,,,2182.30,1418.49,,,,,,,,,,,,,
ALLOGRAFT BNE FD IRRADIATED FEM SEG,SUP-2867055,CDM,C1762,CPT,0278,RC,,,,both,,,2416.23,1570.55,,,,,,,,,,,,,
COIL VASC MREYE EMBOLUS L 3 CM DIA 3 MM CATH DIA 0.035 IN,SUP-2170417,CDM,C1889,HCPCS,0278,RC,,,,both,,,313.47,203.76,,,,,,,,,,,,,
COVER SCR FOR 5MM 6MM HALF PIN STERILIZABLE,SUP-2315964,CDM,C1713,HCPCS,0278,RC,,,,both,,,6.31,4.10,,,,,,,,,,,,,
KIT INTRO L 10CM 5FR NIT WIRE TUNGSTEN TIP MIC B BVL CLR HUB,SUP-2117382,CDM,C1894,HCPCS,0272,RC,,,,both,,,78.09,50.76,,,,,,,,,,,,,
SET DIL CATH 7FR L65CM BAL L4CM DIA6MM 60PSI URET INFL PRSS,SUP-2171204,CDM,C1726,HCPCS,0272,RC,,,,both,,,845.29,549.44,,,,,,,,,,,,,
MESH SURG 18X23CM W/ POS SYS ECHO 2 VENTRALIGHT ST,SUP-2125929,CDM,C1781,HCPCS,0278,RC,,,,both,,,4129.10,2683.91,,,,,,,,,,,,,
ENDOPROSTHESIS TRACHBRONCH VIABAHN L 5 CM DIA11 MM CATH L 75,SUP-2396466,CDM,C1874,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
STAPLER INT 20X15X15 MM NIT MEMOFIX,SUP-2609680,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5736.84,3728.95,,,,,,,,,,,,,
CATHETER CV STD SET 018 3 FRX40 CM 1 LUMEN NIT TURBO-JECT,SUP-2760084,CDM,C1751,HCPCS,0278,RC,,,,both,,,410.49,266.82,,,,,,,,,,,,,
MESH CRAN THK 0.65 MM SCREW DIA1.5 MM SZ 203 X 205 MM TI,SUP-2935893,CDM,C1713,HCPCS,0278,RC,,,,both,,,20469.66,13305.28,,,,,,,,,,,,,
BUR SURG CRAN 7 MM CORNERSTONE,SUP-2363390,CDM,2720000010,LOCAL,0272,RC,,,,both,,,435.68,283.19,,,,,,,,,,,,,
HC Inj Lympho for Sentinal Node,PX-3613879200,CDM,38792,CPT,0361,RC,,,,inpatient,,,3707.00,2409.55,,,,,,,,,,,,,
CATHETER HD DL 14 FRX24 CM STR TAPR TIP SLX,SUP-2269526,CDM,C1752,HCPCS,0278,RC,,,,both,,,175.84,114.30,,,,,,,,,,,,,
BLADE SCREWDRIVER CANN MINI 3.5 MM HEX AO,SUP-2321269,CDM,2720000010,LOCAL,0272,RC,,,,both,,,769.30,500.04,,,,,,,,,,,,,
PROBE L12CM OD10GA MAMTOM REVOLVEST,SUP-2195619,CDM,2720000010,LOCAL,0272,RC,,,,both,,,803.84,522.50,,,,,,,,,,,,,
GRAFT BNE SPACER 12 MM ANTEROLATERAL FOR ALIF,SUP-2632282,CDM,C1713,HCPCS,0278,RC,,,,both,,,8504.63,5528.01,,,,,,,,,,,,,
GRAFT HUMAN TSSUE 30CM FRZE DRIED LATEX FREE ST SNGLE USE,SUP-2727658,CDM,C1762,CPT,0278,RC,,,,both,,,1474.70,958.55,,,,,,,,,,,,,
CATHETER CV 5 FRX55 CM PWR INJ MAX BARR NURSING KT XCELA,SUP-2734862,CDM,C1751,HCPCS,0278,RC,,,,both,,,126.23,82.05,,,,,,,,,,,,,
PIN FIX L32MM MINI WRST S STL LO PROF RIG FIX ANG DORS,SUP-2389360,CDM,C1713,HCPCS,0278,RC,,,,both,,,769.30,500.04,,,,,,,,,,,,,
BRACE LUMBOSACRALXL 15DEG BK HK RECV MAT SFT BRTH LNR RIG,SUP-2195547,CDM,L0625,HCPCS,0272,RC,,,,both,,,901.18,585.77,,,,,,,,,,,,,
ALLOGRAFT BNE CART 6.1X1 CM NACL COSTAL,SUP-2717802,CDM,C1762,CPT,0278,RC,,,,both,,,4722.53,3069.64,,,,,,,,,,,,,
GRAFT BNE SUB L CANC FRZN MORSELIZED W/ VIABLE CELL TRINITY,SUP-2307241,CDM,C1713,HCPCS,0278,RC,,,,both,,,10330.60,6714.89,,,,,,,,,,,,,
PLATE BNE L 1.5X23X0.6 MM MIDFACE 4X3 HOLE W/ TAB TI STRL,SUP-2518097,CDM,C1713,HCPCS,0278,RC,,,,both,,,849.68,552.29,,,,,,,,,,,,,
SHEATH DEL AMULET L 75 CM DIA14 FR LAA STEER STRL,SUP-2893216,CDM,C1766,CPT,0272,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
GUIDEWIRE PIN PRECISION TM 3.9 X 450 MM,SUP-2855151,CDM,2720000010,LOCAL,0272,RC,,,,both,,,759.03,493.37,,,,,,,,,,,,,
HEAD HUM H20MM DIA51MM 4MM OFFSET SHLDR CO CHROM HI SFT,SUP-2388770,CDM,C1776,CPT,0278,RC,,,,both,,,9817.21,6381.19,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED ADV CUP LNR G7 E1,SUP-2419008,CDM,C1776,CPT,0278,RC,,,,both,,,8364.96,5437.22,,,,,,,,,,,,,
CLINIMIX/DEXTROSE (8/14) 8 % IV SOLN,RX-151973,CDM,2500000003,HCPCS,0250,RC,00338-0184-01,NDC,,both,2000,ML,655.50,426.07,,,,,,,,,,,,,
HC So Drug Assay Clozapine,PX-3018015966,CDM,80159,CPT,0301,RC,,,,both,,,63.00,40.95,,,,,,,,,,,,,
PLATE BNE DORS MED RT MID FT,SUP-2609050,CDM,C1713,HCPCS,0278,RC,,,,both,,,5109.44,3321.14,,,,,,,,,,,,,
GRAFT OPHTH THK300-400UM W0.75XL1CM COVERING GLAUCOMA DRNGE,SUP-2135260,CDM,V2790,HCPCS,0274,RC,,,,both,,,1208.90,785.78,,,,,,,,,,,,,
PIN FIX L14MM DIA2.7MM PROV FOR LCK DRL GUID,SUP-2344007,CDM,C1713,HCPCS,0278,RC,,,,both,,,1717.83,1116.59,,,,,,,,,,,,,
PLATE SPNL W33MM CVR PILLAR SA,SUP-2317121,CDM,C1821,HCPCS,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
IMPLANT OP RM UNIV PLT TED BEAR,SUP-2321555,CDM,C1713,HCPCS,0278,RC,,,,both,,,4591.62,2984.55,,,,,,,,,,,,,
CONNECTOR SPNL L30MM STD ANT TI FIX OPN TRNSVRS BAR AX USS,SUP-2181871,CDM,C1713,HCPCS,0278,RC,,,,both,,,1701.88,1106.22,,,,,,,,,,,,,
TEMPLATE SURG XL DST RAD SZ SET LCP,SUP-2178987,CDM,2720000010,LOCAL,0272,RC,,,,both,,,592.05,384.83,,,,,,,,,,,,,
HC Drain Peri/Prevesical Space Ab,PX-3615108000,CDM,51080,CPT,0361,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
HC MRI-Myocardium WO Contrast,PX-6107555700,CDM,75557,CPT,0610,RC,,,,both,,,4146.00,2694.90,,,,,,,,,,,,,
PROBE STEREOTACTIC DIA11GA DISP MAMTOM,SUP-2195657,CDM,2720000010,LOCAL,0272,RC,,,,both,,,722.20,469.43,,,,,,,,,,,,,
HC US Guidance or Line Place W/ Permanent Image - Anes,PX-4027693701,CDM,76937,CPT,0402,RC,,,,outpatient,,,791.00,514.15,,,,,,,,,,,,,
TRAY HUM DIA44MM +10MM TI OFFSET SHLDR REV SYS COMPHSVE,SUP-2404728,CDM,C1776,CPT,0278,RC,,,,both,,,5435.34,3532.97,,,,,,,,,,,,,
PLATE STRNL SM 4 H TI SQ NS MATRIXSTERNUM,SUP-2904245,CDM,C1713,HCPCS,0278,RC,,,,both,,,1719.28,1117.53,,,,,,,,,,,,,
THYROID 60 MG PO TABS,RX-7947,CDM,6370000000,HCPCS,0637,RC,00456-0459-01,NDC,,both,1,UN,5.10,3.31,,,,,,,,,,,,,
PORTX-PORT MRI W/ 8FR CHRONOFLEX C,SUP-2127760,CDM,C1788,HCPCS,0278,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
PROSTHESIS OSS CENTERED 5.5 MM HA TI WILDCAT PRO,SUP-2457307,CDM,L8613,CPT,0278,RC,,,,both,,,1173.92,763.05,,,,,,,,,,,,,
COMPONENT FEM L65MM STD R DST HIP GMRS,SUP-2376513,CDM,C1776,CPT,0278,RC,,,,both,,,17141.10,11141.71,,,,,,,,,,,,,
HC So Suscept Macrobroth Dilution Ea,PX-3008718866,CDM,87188,CPT,0300,RC,,,,both,,,256.00,166.40,,,,,,,,,,,,,
BLADE ENDOSCP LP SHRP SCRP TIP ASMBLY BLK SMARTRELEASE ONYX,SUP-2760599,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1036.20,673.53,,,,,,,,,,,,,
STEM FEM REV PRSS FIT L BOW TI POR PLSM COAT RESTR 203MML,SUP-2375450,CDM,C1776,CPT,0278,RC,,,,both,,,17487.29,11366.74,,,,,,,,,,,,,
BIT DRL TWST 1.5X19 MM ANGULUS 2,SUP-2463344,CDM,2720000010,LOCAL,0272,RC,,,,both,,,556.09,361.46,,,,,,,,,,,,,
STAPLER INT DIA12MM 65DEG BLK 6 ROW 10 TI STPL PRELD DISPL,SUP-2752259,CDM,2720000010,LOCAL,0272,RC,,,,both,,,475.77,309.25,,,,,,,,,,,,,
SHEATH INTRO PINNACLE L 25 CM 8FR SS HYDRPHLC CORONARY,SUP-2385683,CDM,C1894,HCPCS,0272,RC,,,,both,,,72.22,46.94,,,,,,,,,,,,,
HC Debrid Wound Tis 20 Cm/<,PX-7619759700,CDM,97597,CPT,0761,RC,,,,inpatient,,,583.00,378.95,,,,,,,,,,,,,
NEEDLE PERC L2.5CM DIA20GA VASC ACCS,SUP-2169708,CDM,C1725,HCPCS,0272,RC,,,,both,,,10.61,6.90,,,,,,,,,,,,,
GRAFT IMPL HUM TISS FRZN ALLGRFT TIB CORT STRUT BONE,SUP-2294186,CDM,C1713,HCPCS,0278,RC,,,,both,,,3108.60,2020.59,,,,,,,,,,,,,
PIN FIX LCK MAK OSS,SUP-2440970,CDM,C1713,HCPCS,0278,RC,,,,both,,,2062.98,1340.94,,,,,,,,,,,,,
ALLOGRAFT BNE FIBULAR SHFT 101-159 MMX0.1 CM FD,SUP-2717857,CDM,C1762,CPT,0278,RC,,,,both,,,3565.82,2317.78,,,,,,,,,,,,,
CATHETER NEPHROSTOMY PIG 16 FRX35 CM MCOT PERCFLX,SUP-2147758,CDM,C1729,HCPCS,0272,RC,,,,both,,,202.81,131.83,,,,,,,,,,,,,
SET INTRO M.DRAIN L 20 CM SHTH 6 FR TIP L 60 CM GUIDEWIRE,SUP-2761905,CDM,C1894,HCPCS,0272,RC,,,,both,,,45.84,29.80,,,,,,,,,,,,,
PIN FIX L40MM DIA3.5MM PROV TARGETER FOR 3.5MM LAT PROX TIB,SUP-2343986,CDM,C1713,HCPCS,0278,RC,,,,both,,,1541.17,1001.76,,,,,,,,,,,,,
KIT PULSE STIMULATOR IMPL GENRTR TORQUE WRNCH VERCISE,SUP-2845261,CDM,C1820,HCPCS,0278,RC,,,,both,,,69080.00,44902.00,,,,,,,,,,,,,
INTERSPACE ATS 60/12 KNEE ATS 60/12,SUP-2810984,CDM,C1776,CPT,0278,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
GRAFT BNE SUB 15CC CELLULAR BNE MTRX OSTEOCEL +,SUP-2310451,CDM,C1713,HCPCS,0278,RC,,,,both,,,14365.50,9337.57,,,,,,,,,,,,,
SCREW DISC RET FOR RNG CUT SYS GEM,SUP-2421503,CDM,C1713,HCPCS,0278,RC,,,,both,,,62.80,40.82,,,,,,,,,,,,,
HALF PIN 6MMX70MM,SUP-2818081,CDM,2720000010,LOCAL,0272,RC,,,,both,,,670.08,435.55,,,,,,,,,,,,,
GUIDEWIRE UROLOGICAL FIX COR 15 CM 0.035 INX145 CM BENT,SUP-2835678,CDM,C1769,HCPCS,0272,RC,,,,both,,,75.67,49.19,,,,,,,,,,,,,
STIRRUP POS H10IN STD UNIV ANK AIR BLDR RIG MED LAT SHELLS,SUP-2195184,CDM,L4350,HCPCS,0272,RC,,,,both,,,41.86,27.21,,,,,,,,,,,,,
SPACER SPNL PEEK PILLAR SA 7DEG 37X32X22MM,SUP-2317184,CDM,C1821,HCPCS,0278,RC,,,,both,,,18369.00,11939.85,,,,,,,,,,,,,
SET URET STENT SOFFLX L 75 CM DIA 8.4FR GUIDEWIRE L 100CM RT,SUP-2835726,CDM,C2617,HCPCS,0278,RC,,,,both,,,221.24,143.81,,,,,,,,,,,,,
BASEPLATE GLEN FIX SHLDR RVS CNTRL SCREW 1 LCK CAP KT STRL,SUP-2908866,CDM,C1776,CPT,0278,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
STEM ENDO MODEL MOD CONICAL CMNTLSS 135X16MM,SUP-2665193,CDM,C1776,CPT,0278,RC,,,,both,,,6995.92,4547.35,,,,,,,,,,,,,
SLING URETH TRNS OBTURATOR SYS OBTRYX II,SUP-2141814,CDM,C1771,HCPCS,0278,RC,,,,both,,,3074.06,1998.14,,,,,,,,,,,,,
EXTENSION GUIDEWIRE L 145 CM DIA 0.014/0.018 IN SS POLYMER,SUP-2105889,CDM,C1769,HCPCS,0272,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
CLARIVEIN CLARIVEIN IC INFUS CATHETER 65CM,SUP-2301895,CDM,C1887,HCPCS,0272,RC,,,,both,,,3077.20,2000.18,,,,,,,,,,,,,
VALVE AORT STENT 21 MM GRAFTMASTER,SUP-2356697,CDM,C1889,HCPCS,0278,RC,,,,both,,,25025.80,16266.77,,,,,,,,,,,,,
PORT TI IMP LO PROF PRE ATTACH OPN END SIL 6.6FR SGL LUMN,SUP-2127723,CDM,C1788,HCPCS,0278,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
GRAFT HUM TISS W2XL2CM AMNIO TISS MEM WRP AMNIOFIX,SUP-2305759,CDM,V2790,HCPCS,0278,RC,,,,both,,,2581.08,1677.70,,,,,,,,,,,,,
PLATE BNE L356MM 15 H R DST FEM S STL LOK COMPR FOR 45MM SCR,SUP-2177824,CDM,C1713,HCPCS,0278,RC,,,,both,,,5024.47,3265.91,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 70 CM DIA 5 MM STR STD WALL REINF,SUP-2525437,CDM,C1768,CPT,0278,RC,,,,both,,,1343.73,873.42,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 40 MM DIA 5 MM DEL SHTH,SUP-2934465,CDM,C1713,HCPCS,0278,RC,,,,both,,,6583.29,4279.14,,,,,,,,,,,,,
SHEATH GUID 8FR L62CM ID011IN ANT CRV LO FRIC OBLQ CUT VLV,SUP-2248482,CDM,C1892,HCPCS,0272,RC,,,,both,,,442.74,287.78,,,,,,,,,,,,,
KIT CATH HEMODIALYSI DUOGLIDE ACUTE 13FR DIA 30CML INSER 400,SUP-2613240,CDM,C1752,HCPCS,0278,RC,,,,both,,,706.37,459.14,,,,,,,,,,,,,
CATHETER ENDO ACC DEL SPYSCOPE,SUP-2149612,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2491.15,1619.25,,,,,,,,,,,,,
STEM TAPER 22X235MM,SUP-2505155,CDM,C1776,CPT,0278,RC,,,,both,,,8452.88,5494.37,,,,,,,,,,,,,
FIBER LASER HPS] PURCHASE SVCS INVOICED SVCS],SUP-2330638,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2747.50,1785.87,,,,,,,,,,,,,
SURGICAL PROCEDURE PACK LAPAROSCOPIC/CHOLECYSTECTOMY ESFDA61] JNJ HEALTHCARE],SUP-2257565,CDM,2720000010,LOCAL,0272,RC,,,,both,,,537.85,349.60,,,,,,,,,,,,,
PIN FIX FLUT 3.2X150 MM KNEE FIX NS ROSA DISP,SUP-2656951,CDM,C1713,HCPCS,0278,RC,,,,both,,,149.15,96.95,,,,,,,,,,,,,
GRAFT VASC HEMGRD L 70 CM DIA 6 MM POLYESTER BOV CLLGN UTHN,SUP-2491527,CDM,C1768,CPT,0278,RC,,,,both,,,2113.94,1374.06,,,,,,,,,,,,,
PERI-LOC VLP 3.5MM S-T LOCK SCREW 42MM,SUP-2821049,CDM,C1713,HCPCS,0278,RC,,,,both,,,880.24,572.16,,,,,,,,,,,,,
PIN FIX L18MM DIA3.5MM PROV FOR TARGETER PLATING SYS,SUP-2343987,CDM,C1713,HCPCS,0278,RC,,,,both,,,1087.35,706.78,,,,,,,,,,,,,
RISEDRONATE SODIUM 35 MG PO TABS,RX-32895,CDM,6370000000,HCPCS,0637,RC,33342-0109-37,NDC,,both,1,UN,29.70,19.30,,,,,,,,,,,,,
BUR HOLE COVER KIT PRE ASSEMBLED SURETEK,SUP-2836331,CDM,C1713,HCPCS,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
WIRE PACE MYO/WIRE L 20 CM SZ 2-0 CRV NDL 28 MM SS TEMP ORN,SUP-2101197,CDM,2720000010,LOCAL,0272,RC,,,,both,,,48.92,31.80,,,,,,,,,,,,,
CATHETER HD DL 15.5 FRX36 CM LT FULL SET W/O SIDE H TITAN HD,SUP-2627358,CDM,C1750,HCPCS,0278,RC,,,,both,,,65.94,42.86,,,,,,,,,,,,,
KIT CVC L 16 CM DIA12 FR TL TEGDERM DRSG LG BOR FOR HI VOL,SUP-2909918,CDM,C1751,HCPCS,0278,RC,,,,both,,,533.17,346.56,,,,,,,,,,,,,
PLATE SPNL L26MM ANT CERV 1 LEV COMPR HELIX MINI ACP,SUP-2311444,CDM,C1713,HCPCS,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
SPHERE GLEN 40 MM,SUP-2199145,CDM,C1776,CPT,0278,RC,,,,both,,,4954.42,3220.37,,,,,,,,,,,,,
PROBE ENDO CALIB ABLAT FOR ACL RECON COOLCUT,SUP-2123444,CDM,2720000010,LOCAL,0272,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
PEAK FX PLATE 3 HOLE NS,SUP-2487949,CDM,C1713,HCPCS,0278,RC,,,,both,,,759.88,493.92,,,,,,,,,,,,,
CATHETER INFUS L20CM OD6FR 3 LUMN JACC,SUP-2120621,CDM,C1751,HCPCS,0278,RC,,,,both,,,763.96,496.57,,,,,,,,,,,,,
PLATE BONE W24XL51MM 12 HOLE RIGHT DST VOLAR RDL WRIST STNDR,SUP-2481672,CDM,C1713,HCPCS,0278,RC,,,,both,,,2571.66,1671.58,,,,,,,,,,,,,
BUPIVACAINE IN DEXTROSE 0.75-8.25 % IT SOLN,RX-9316,CDM,J0665,HCPCS,0636,RC,00409-3613-01,NDC,,both,2,ML,54.10,35.16,,,,,,,,,,,,,
BLADE RTRCTR SM 24MMW X 60MML TTNM SPNL TTHX3 THIN LMBRTRK R,SUP-2703605,CDM,2720000010,LOCAL,0272,RC,,,,both,,,888.40,577.46,,,,,,,,,,,,,
PLATE BONE L177MM 9 H S STL BROAD NONLOCKING COMPR CNTOUR,SUP-2348972,CDM,C1713,HCPCS,0278,RC,,,,both,,,2418.37,1571.94,,,,,,,,,,,,,
GRAFT AMNIOFIX AMNIOTIC MEMBRANE 20MG,SUP-2866798,CDM,C1762,CPT,0278,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
TRIAL PAT 26MM INSRT,SUP-2379227,CDM,2720000010,LOCAL,0272,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
CATHETER HD STR 22 CM BASIC KT ROBUST DURAFLO 2,SUP-2117400,CDM,C1750,HCPCS,0278,RC,,,,both,,,879.20,571.48,,,,,,,,,,,,,
DEVICE FIX 35MM AC JT FEM 2 ZIPLOOP TECHNOLOGY ZIPTIGHT,SUP-2212833,CDM,C1713,HCPCS,0278,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
OLMESARTAN MEDOXOMIL 20 MG PO TABS,RX-32762,CDM,6370000000,HCPCS,0637,RC,68462-0437-30,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PLATE BNE W10.1XL112MM THK3.5MM 8 H BILAT TI STR RIG LOK,SUP-2191083,CDM,C1713,HCPCS,0278,RC,,,,both,,,1611.67,1047.59,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED 3 PART CEM TRAB MEL,SUP-2212529,CDM,C1776,CPT,0278,RC,,,,both,,,16009.29,10406.04,,,,,,,,,,,,,
PLATE BNE STR 2 MM 6 HOLE LCK TI NS LTX,SUP-2856947,CDM,C1713,HCPCS,0278,RC,,,,both,,,2113.22,1373.59,,,,,,,,,,,,,
HC Sampling Chorionic Villus,PX-9205901500,CDM,59015,CPT,0920,RC,,,,outpatient,,,645.00,419.25,,,,,,,,,,,,,
BLADE RETRACTOR BALFOUR 4IN SPREAD 1INW X 1INL FENESTRATED,SUP-2489592,CDM,2720000010,LOCAL,0272,RC,,,,both,,,484.91,315.19,,,,,,,,,,,,,
HC Cath Urethra Complicated,PX-4505170300,CDM,51703,CPT,0450,RC,,,,outpatient,,,214.00,139.10,,,,,,,,,,,,,
PROSTHESIS OSS SCHEER PISTON SHT 0.6X3.33 MM SLIM SS,SUP-2637779,CDM,L8613,CPT,0278,RC,,,,both,,,314.53,204.44,,,,,,,,,,,,,
PROBE ABLATN NERVE BLOCK 180 DEG 8 MM BALL TIP CRYOSPHERE,SUP-2124444,CDM,C2618,HCPCS,0272,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
SCREW IM L 67.5 MM DIA 5 MM TI LCK STRL TRIGEN MAX,SUP-2931487,CDM,C1713,HCPCS,0278,RC,,,,both,,,783.74,509.43,,,,,,,,,,,,,
SHELL ACET DIA48MM HIP PORCOAT LOK PRI SECT PRESSFIT PINN,SUP-2250176,CDM,C1776,CPT,0278,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
SPACER SPNL W55XH8-15MM D20MM 6DEG ELSA,SUP-2228775,CDM,C1821,HCPCS,0278,RC,,,,both,,,29202.00,18981.30,,,,,,,,,,,,,
PLATE BNE RECON 3.5X118 MM 10 HOLE TI NS,SUP-2191078,CDM,C1713,HCPCS,0278,RC,,,,both,,,1670.89,1086.08,,,,,,,,,,,,,
PLATE BNE L70MM HK D12MM 4 H R CLAV S STL LOK COMPR FOR,SUP-2185840,CDM,C1713,HCPCS,0278,RC,,,,both,,,3146.41,2045.17,,,,,,,,,,,,,
GRAFT VASC 20 MMX9.5 CM EXCLUDER,SUP-2395968,CDM,C1768,CPT,0278,RC,,,,both,,,13502.00,8776.30,,,,,,,,,,,,,
DX KNOTLESS SWVLK PEEK 4.75 MM WITH FT,SUP-2817675,CDM,C1713,HCPCS,0278,RC,,,,both,,,1946.80,1265.42,,,,,,,,,,,,,
GUIDEWIRE ORTH DIA1.45MM BLNT THRD FOR VIPER 2 MINIMALLY,SUP-2256878,CDM,C1769,HCPCS,0272,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
BLADE LARYNGEAL SUPERFICIAL STD 2.9X22 MM STRL DISP,SUP-2638402,CDM,2720000010,LOCAL,0272,RC,,,,both,,,989.10,642.91,,,,,,,,,,,,,
SCREW BNE L 60 MM DIA 3.5 MM TI LCK T15 STARDRV NS V,SUP-2905772,CDM,C1713,HCPCS,0278,RC,,,,both,,,784.69,510.05,,,,,,,,,,,,,
HEAD SPNL SCREW ROD DIA 4.75/5 MM PEDCL REDUCTION MULTAXL,SUP-2926392,CDM,C1713,HCPCS,0278,RC,,,,both,,,2763.20,1796.08,,,,,,,,,,,,,
BOOT ORTHOT LOWER EXTREMITY CUST MOLD INNR BOOT,SUP-2435657,CDM,L4386,HCPCS,0272,RC,,,,both,,,1598.23,1038.85,,,,,,,,,,,,,
BURR SURG 4MM DIA HD XLN MIC 95MML SM BNE RND DIAMOND MICROP,SUP-2605581,CDM,2720000010,LOCAL,0272,RC,,,,both,,,90.02,58.51,,,,,,,,,,,,,
PATCH BIO W6XL8CM DECELLULARIZED BOV PERICARD RECTANG,SUP-2175266,CDM,C1763,HCPCS,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
HEAD RAD M PROS CO CHROM,SUP-2349031,CDM,C1776,CPT,0278,RC,,,,both,,,3194.89,2076.68,,,,,,,,,,,,,
SCREW BNE ST 2X4 MM CRTX T8 STARDRV RECESS TI NS,SUP-2189423,CDM,C1713,HCPCS,0278,RC,,,,both,,,902.75,586.79,,,,,,,,,,,,,
BLADE RTRCTR 1 1/2NW X 3 1/4ND STNLSS STEEL GRRTT JARIT LATE,SUP-2457803,CDM,2720000010,LOCAL,0272,RC,,,,both,,,767.26,498.72,,,,,,,,,,,,,
CATHETER INFUSION UNI-FUSE L 135 CM DIA 4 FR SLT PAT L 10 CM,SUP-2117048,CDM,C1725,HCPCS,0272,RC,,,,both,,,356.70,231.85,,,,,,,,,,,,,
CATHETER EP ABLAT C CRV QPLR 2-5-2MM SPC 4MM TIP BI DIR RF,SUP-2142282,CDM,C1733,HCPCS,0272,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
BIT DRL DIA1.4MM SHT DISP FOR SFT ANCHR SYS JUGGERKNOT,SUP-2212958,CDM,2720000010,LOCAL,0272,RC,,,,both,,,365.75,237.74,,,,,,,,,,,,,
GRAFT VASC GORTX L 5 CM DIA 3.5 MM EPTFE TW PED SHUNT STRL,SUP-2396722,CDM,C1768,CPT,0278,RC,,,,both,,,775.58,504.13,,,,,,,,,,,,,
STAR TUMOR ABLATION KIT 1015 WITH POWERCURVE SHRT,SUP-2677281,CDM,2720000010,LOCAL,0272,RC,,,,both,,,12246.00,7959.90,,,,,,,,,,,,,
KIT INFUS PRT L76CM DIA10FR PLAS ATTCH SIL 2 LUMN OPN END,SUP-2127743,CDM,C1788,HCPCS,0278,RC,,,,both,,,847.80,551.07,,,,,,,,,,,,,
STABILIZER SURG HRT OFF PMP STD PLT XPOSE 4+ ACROBAT SUV,SUP-2227772,CDM,C1713,HCPCS,0278,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
SCREW BNE SZ 4.0MMX40MM CANN,SUP-2243598,CDM,C1713,HCPCS,0278,RC,,,,both,,,1169.43,760.13,,,,,,,,,,,,,
SYSTEM BONE CEM MX UNIV SGL VAC ROTOR W/O NOZ PRSSZR RESTRIC,SUP-2199461,CDM,C1713,HCPCS,0278,RC,,,,both,,,401.92,261.25,,,,,,,,,,,,,
CATHETER INFUSION L 130 CM DIA 5 FR GUIDEWIRE 0.035 IN SEG L,SUP-2168150,CDM,C1751,HCPCS,0278,RC,,,,both,,,282.69,183.75,,,,,,,,,,,,,
HEAD HUM H24MM OD58MM ID54MM SHLDR CO CHROM MOD NECKLESS,SUP-2404507,CDM,C1776,CPT,0278,RC,,,,both,,,5705.38,3708.50,,,,,,,,,,,,,
ANCHOR SUTURE SFT LNG 1.45 MM CRV SET JUGGERKNOT DISP,SUP-2608812,CDM,C1713,HCPCS,0278,RC,,,,both,,,1033.94,672.06,,,,,,,,,,,,,
COMPONENT FEM SZ B KNEE ZMLY PC UNI HI FLX ZUK,SUP-2342157,CDM,C1776,CPT,0278,RC,,,,both,,,9511.06,6182.19,,,,,,,,,,,,,
CATHETER CV SET 018 4 FRX12 CM DL J TIP POLYETH,SUP-2760052,CDM,C1751,HCPCS,0278,RC,,,,both,,,233.08,151.50,,,,,,,,,,,,,
ALLOGRAFT HUM TISS STRUT FRZN ASEP ACHILLES TEND,SUP-2867035,CDM,C1762,CPT,0278,RC,,,,both,,,6228.50,4048.52,,,,,,,,,,,,,
CONNECTOR AX TI 50MMX55MM CDH M8,SUP-2631254,CDM,C1713,HCPCS,0278,RC,,,,both,,,3944.41,2563.87,,,,,,,,,,,,,
ERYTHROMYCIN ETHYLSUCCINATE 400 MG/5ML PO SUSR,RX-2900,CDM,340b,HCPCS,0637,RC,09999-9914-37,NDC,,both,5,ML,94.40,61.36,,,,,,,,,,,,,
PLATE SPNL POLYAX 11 MM SCREW HOLE POLYETH CNPY,SUP-2228533,CDM,C1713,HCPCS,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
COVER PLATE MOD LG LAT 1 HOLE ASMBLY TI TIMBERLINE MPF,SUP-2690202,CDM,C1713,HCPCS,0278,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
VALVE AORT PORCINE BIOPROSTHESIS STNTLSS 25MM TORONTO SPV,SUP-2357721,CDM,C1889,HCPCS,0278,RC,,,,both,,,16321.72,10609.12,,,,,,,,,,,,,
BUDESONIDE 3 MG PO CPEP,RX-31576,CDM,6370000000,HCPCS,0637,RC,00574-9855-10,NDC,,both,1,UN,4.50,2.92,,,,,,,,,,,,,
ALLOGRAFT BNE 20X15-17X15 MM FD VERTEFILL,SUP-2736761,CDM,C1713,HCPCS,0278,RC,,,,both,,,6449.25,4192.01,,,,,,,,,,,,,
BOOT ORTHOT LOWER EXTREMITY CUST MOLD INNR BOOT,SUP-2435657,CDM,L4386,HCPCS,0274,RC,,,,both,,,1598.23,1038.85,,,,,,,,,,,,,
MESH SURG W15XL19CM THK1MM EPTFE BIOMATERIAL OVL ANTIMIC,SUP-2395341,CDM,C1781,HCPCS,0278,RC,,,,both,,,2712.96,1763.42,,,,,,,,,,,,,
HC Inj Proc Wrist,PX-3612524600,CDM,25246,CPT,0361,RC,,,,outpatient,,,3707.00,2409.55,,,,,,,,,,,,,
IMMOBILIZER KNEE CUTAWAY E STRP 40IN CIRC 28IN,SUP-2194900,CDM,L1830,CPT,0272,RC,,,,both,,,115.65,75.17,,,,,,,,,,,,,
DEVICE FIX W/ 15MM TI HELI TACK PSTL GRP DISP STAT TACK,SUP-2283318,CDM,2720000010,LOCAL,0272,RC,,,,both,,,466.48,303.21,,,,,,,,,,,,,
GRAFT VASC HEMSHLD PLAT L 15 CM 18MM POLYESTER BOV CLLGN STR,SUP-2265915,CDM,C1768,CPT,0278,RC,,,,both,,,1054.66,685.53,,,,,,,,,,,,,
STENT PANCREATIC SINGLE PGTL 0.035 IN 5 FRX5 CM ADVANIX,SUP-2149519,CDM,C2617,HCPCS,0278,RC,,,,both,,,247.81,161.08,,,,,,,,,,,,,
HC Inj Proc Wrist,PX-3612524600,CDM,25246,CPT,0361,RC,,,,inpatient,,,3707.00,2409.55,,,,,,,,,,,,,
SPLINT ORTH W4IN LT HND BASE THMB SPICA ROLYAN,SUP-2324964,CDM,L3931,HCPCS,0272,RC,,,,both,,,91.91,59.74,,,,,,,,,,,,,
PIN EXT FIX HALF 4X100 MM 20 MM BLNT BLU XTRAFIX,SUP-2465629,CDM,2720000010,LOCAL,0272,RC,,,,both,,,445.03,289.27,,,,,,,,,,,,,
ENDCAP ORTH 8.2X5 MM FEM T40 STARDRV TI TAN DK PUR STRL,SUP-2546391,CDM,C1713,HCPCS,0278,RC,,,,both,,,580.15,377.10,,,,,,,,,,,,,
CATHETER PERFSN L 32 CM DIA14 FR BLLN 18 MM POLYUR,SUP-2881193,CDM,2720000010,LOCAL,0272,RC,,,,both,,,309.26,201.02,,,,,,,,,,,,,
BRACE ORTH FRAC FEM CAST MOLD KAFO L2126] TIDEWATER PROSTHETICS],SUP-2388170,CDM,L2126,HCPCS,0274,RC,,,,both,,,3243.18,2108.07,,,,,,,,,,,,,
KNIFE SURG L150MM 45MM LIBERATOR,SUP-2166550,CDM,2720000010,LOCAL,0272,RC,,,,both,,,994.31,646.30,,,,,,,,,,,,,
MESH CRAN L 90 X W 90 MM THK 0.3 MM SCREW DIA1.5/1.7 MM MED,SUP-2883430,CDM,C1713,HCPCS,0278,RC,,,,both,,,4870.86,3166.06,,,,,,,,,,,,,
PIN FIX SINGLE DIAMOND 0.156X9 IN RND END SS NS STEINMANN,SUP-2791294,CDM,C1713,HCPCS,0278,RC,,,,both,,,36.42,23.67,,,,,,,,,,,,,
KIT VERTEBROPLASTY BONE CEM DEL W/ INJ,SUP-2308557,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
KIT CRAN DRL 025IN,SUP-2244100,CDM,C1713,HCPCS,0278,RC,,,,both,,,838.41,544.97,,,,,,,,,,,,,
HC Adrenal Arteriogram Bilateral,PX-3237573300,CDM,75733,CPT,0323,RC,,,,both,,,2932.00,1905.80,,,,,,,,,,,,,
HC So Enterovirus,PX-3028665866,CDM,86658,CPT,0302,RC,,,,outpatient,,,158.00,102.70,,,,,,,,,,,,,
PLUG VASC 6FR L8MM DIA16MM CATH 8FR L100CM NIT SGL LAYR,SUP-2355747,CDM,C1713,HCPCS,0278,RC,,,,both,,,2515.14,1634.84,,,,,,,,,,,,,
HC Pt Iontophoresis per 15 Min|OP PT SERVICES|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS,PX-4209703300,CDM,97033,CPT,0420,RC,,,GP|CQ,outpatient,,,221.00,143.65,,,,,,,,,,,,,
CURVED RECON 3.5MM 12X142MM,SUP-2818804,CDM,C1713,HCPCS,0278,RC,,,,both,,,4187.98,2722.19,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC SOLO2 PLU MAXBARR 4FR 55C 1194108D4,SUP-2632632,CDM,C1751,HCPCS,0278,RC,,,,both,,,956.32,621.61,,,,,,,,,,,,,
PLATE BNE STRIKE HIP RASPING GRIPTION TF PINNACLE,SUP-2453617,CDM,C1713,HCPCS,0278,RC,,,,both,,,1843.18,1198.07,,,,,,,,,,,,,
ANCHOR SUT L17MM DIA55MM BIOCOMPOSITE FULL THRD W 3 SZ 2 0,SUP-2167095,CDM,C1713,HCPCS,0278,RC,,,,both,,,1559.95,1013.97,,,,,,,,,,,,,
PLATE BONE L162MM 14 H STRL S STL LCK COMPR FOR 3.5MM SCR,SUP-2349633,CDM,C1713,HCPCS,0278,RC,,,,both,,,4416.41,2870.67,,,,,,,,,,,,,
TAP SURG L180MM D80MM FOR 4.5MM CANN SCR,SUP-2187417,CDM,C1713,HCPCS,0278,RC,,,,both,,,2012.99,1308.44,,,,,,,,,,,,,
PLATE VOLAR DISTAL RADIUS L NRW,SUP-2466349,CDM,C1713,HCPCS,0278,RC,,,,both,,,844.66,549.03,,,,,,,,,,,,,
SET INTRO MICROPUNCTURE L 10 CM DIA 5 FR GUIDEWIRE L 40 CM,SUP-2633291,CDM,C1894,HCPCS,0272,RC,,,,both,,,59.03,38.37,,,,,,,,,,,,,
SCREW BONE SELFTAPPING 1X4 MM CORTEX CRANIOMAXILLOFACIAL WIT,SUP-2838138,CDM,C1713,HCPCS,0278,RC,,,,both,,,356.08,231.45,,,,,,,,,,,,,
RECON PLATE 18X214MM 3.5MM,SUP-2818477,CDM,C1713,HCPCS,0278,RC,,,,both,,,4979.88,3236.92,,,,,,,,,,,,,
POST EXT FIX SLT SM,SUP-2162667,CDM,2720000010,LOCAL,0272,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
SCREW BNE L20MM DIA2.7MM DST RAD LOK FULL THRD SQ DRV HD LO,SUP-2411796,CDM,C1713,HCPCS,0278,RC,,,,both,,,328.13,213.28,,,,,,,,,,,,,
BLADE SAW RECIP 12.5X73.5X0.8MM,SUP-2586294,CDM,2720000010,LOCAL,0272,RC,,,,both,,,99.73,64.82,,,,,,,,,,,,,
IMPLANT BRST MOD PROF + X SILTEX,SUP-2748665,CDM,C1789,HCPCS,0278,RC,,,,both,,,3171.40,2061.41,,,,,,,,,,,,,
STENT BILI HERCLNK + L 18 MM DIA 6 MM CATH L 80 CM GUIDEWIRE,SUP-2101563,CDM,C1876,HCPCS,0278,RC,,,,both,,,1962.50,1275.62,,,,,,,,,,,,,
BOLT FEM AUG KNEE VANGUARD,SUP-2407855,CDM,C1713,HCPCS,0278,RC,,,,both,,,514.96,334.72,,,,,,,,,,,,,
COLLAR TRACH H2 1/4IN SM PHIL,SUP-2120429,CDM,L0172,HCPCS,0274,RC,,,,both,,,56.52,36.74,,,,,,,,,,,,,
SYSTEM IMPL TEND 4.75MM SWIVELOCK BAN SUT LASSO W/ NIT WIRE,SUP-2122836,CDM,C1713,HCPCS,0278,RC,,,,both,,,3061.50,1989.97,,,,,,,,,,,,,
BIT DRL 2.2 MM,SUP-2175115,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1059.75,688.84,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE DIA 7.5 MM SZ 4 CART ARAGONITE POROUS,SUP-2913168,CDM,C1763,HCPCS,0278,RC,,,,both,,,22451.00,14593.15,,,,,,,,,,,,,
GRAFT VASC INTERGARD BODY/BRANCH L 85/55 CM RNG L 45/20 CM,SUP-2227603,CDM,C1768,CPT,0278,RC,,,,both,,,5221.19,3393.77,,,,,,,,,,,,,
CONNECTOR SPNL L13MM POST LAT OFFSET OPN MULTIAXIAL VERTEX,SUP-2286782,CDM,C1713,HCPCS,0278,RC,,,,both,,,1320.53,858.34,,,,,,,,,,,,,
PLATE BNE L L210MM THK4MM TROCH GRP VIT LO PROF W 2MM CBL,SUP-2377576,CDM,C1713,HCPCS,0278,RC,,,,both,,,5674.61,3688.50,,,,,,,,,,,,,
BIT REPROC DRL CANN 4MM W/AO CPL 2.7MM,SUP-2653174,CDM,2720000010,LOCAL,0272,RC,,,,both,,,468.33,304.41,,,,,,,,,,,,,
PROBE LITHO 12FR L3.76MM DISP SHOCKPULSE,SUP-2421174,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2247.30,1460.74,,,,,,,,,,,,,
SYSTEM DIL BLLN DIA6MM MULTISINUS,SUP-2217802,CDM,C1726,HCPCS,0272,RC,,,,both,,,5338.00,3469.70,,,,,,,,,,,,,
COUPLER ANAS VES DIA2MM TI PURE STR MALL MICROCLIP,SUP-2382618,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
HC So Gram Stain Smear,PX-3008720566,CDM,87205,CPT,0300,RC,,,,both,,,22.00,14.30,,,,,,,,,,,,,
GRAFT VASC ARTEGRAFT L 30 CM DIA 5 MM CLLGN BOV CAR ART,SUP-2120661,CDM,C1768,CPT,0278,RC,,,,both,,,3639.26,2365.52,,,,,,,,,,,,,
IMPLANT BRST RND SIL GEL HI STRENGTH COHESIVE TEXT VOL 695CC,SUP-2339908,CDM,C1789,HCPCS,0278,RC,,,,both,,,5181.00,3367.65,,,,,,,,,,,,,
MGII KNEE TIB ART SURF A/P LIP EF/ GREEN 9MM,SUP-2501956,CDM,C1776,CPT,0278,RC,,,,both,,,5526.40,3592.16,,,,,,,,,,,,,
JOINT EXT FIX UNIV,SUP-2197242,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
LINER ACETABLUAR SZ F DIA48.5MM HD OD42MM ID28MM THK6.5MM,SUP-2377721,CDM,C1776,CPT,0278,RC,,,,both,,,6914.28,4494.28,,,,,,,,,,,,,
PLATE BNE BROAD 5.5X216 MM 12 HOLE SS LCP,SUP-2569373,CDM,C1713,HCPCS,0278,RC,,,,both,,,820.33,533.21,,,,,,,,,,,,,
IMPLANT FACE L 55 X H 27 MM THK 5 MM LG POLYETHYL LT MALAR,SUP-2883370,CDM,C1713,HCPCS,0278,RC,,,,both,,,1462.39,950.55,,,,,,,,,,,,,
COIL EMB L12CM OD4MM 10 STRTCH RESIST FRAMING FIL FNSH,SUP-2305168,CDM,C1889,HCPCS,0278,RC,,,,both,,,4584.40,2979.86,,,,,,,,,,,,,
PLATE 4.5MM TI CURVED BROAD LCP TM 22 HOLES 408MM STERILE,SUP-2549500,CDM,C1713,HCPCS,0278,RC,,,,both,,,4731.48,3075.46,,,,,,,,,,,,,
BLADE SCALPEL CART MENEZES MST STRL,SUP-2481832,CDM,2720000010,LOCAL,0272,RC,,,,both,,,538.86,350.26,,,,,,,,,,,,,
GRAFT HUM TISS W2XL5CM THK08 17MM DERM HUM ACELLULAR,SUP-2307045,CDM,Q4128,HCPCS,0636,RC,,,,both,,,1633.43,1061.73,,,,,,,,,,,,,
END CAP ORTH IM NAIL STD STRL T2,SUP-2900634,CDM,C1889,HCPCS,0278,RC,,,,both,,,989.10,642.91,,,,,,,,,,,,,
SPACER SPNL 22X9X15MM LO PROF PEEK CERV CONVX TALL FOR IN,SUP-2353386,CDM,C1889,HCPCS,0278,RC,,,,both,,,22961.25,14924.81,,,,,,,,,,,,,
PUNCH SURG KNOTLESS 4.75-5.5 MM BROACHING CROSSFT DISP,SUP-2423296,CDM,C1713,HCPCS,0278,RC,,,,both,,,703.67,457.39,,,,,,,,,,,,,
BAG DRNGE C650ML H SZ 5-38 MAMM TISS EXP CNTOUR PROF NACL,SUP-2300522,CDM,C1789,HCPCS,0278,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
PAD ORTHOT STRNL CUST,SUP-2435575,CDM,L1050,HCPCS,0272,RC,,,,both,,,284.08,184.65,,,,,,,,,,,,,
FIBER LASER HOLM 940 M MULTI-USE W/ H-30 ORNG SMARTSYNC,SUP-2835946,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3082.70,2003.75,,,,,,,,,,,,,
GRAFT HUM TISS L 220 FOLDED DIA 7 MM PERONEUS LONGUS TEND,SUP-2913401,CDM,C1762,CPT,0278,RC,,,,both,,,6936.26,4508.57,,,,,,,,,,,,,
HC Glb Puncture of Shuntasp or Inj,PX-9826107000,CDM,61070,CPT,0982,RC,,,,both,,,2416.00,1570.40,,,,,,,,,,,,,
GRAFT VASC IMPRA L 10 CM DIA 7 MM EPTFE STR STD WALL N RING,SUP-2126226,CDM,C1768,CPT,0278,RC,,,,both,,,4452.52,2894.14,,,,,,,,,,,,,
BRACE ORTHOPEDIC TLSO BK W/ SHLDR SHUT,SUP-2265010,CDM,L0454,HCPCS,0272,RC,,,,both,,,1337.64,869.47,,,,,,,,,,,,,
PLATE BNE LCK NAR 4.5 MM 12 HOLE COMPR STRL ALPS LTX,SUP-2861825,CDM,C1713,HCPCS,0278,RC,,,,both,,,1649.44,1072.14,,,,,,,,,,,,,
BIT DRILL TWIST 16MM DIA 295MML STNLSS STEEL DNTL ATTCH W/,SUP-2681195,CDM,2720000010,LOCAL,0272,RC,,,,both,,,416.30,270.59,,,,,,,,,,,,,
STENT URET 035 6 FRX26 CM SET SENSOR POLARIS ULTRA,SUP-2754258,CDM,C2617,HCPCS,0278,RC,,,,both,,,516.59,335.78,,,,,,,,,,,,,
PROBE LASER 23GA 45DEG STEEPED ANG FLX TIP DISP ENDOPRB,SUP-2247216,CDM,2720000010,LOCAL,0272,RC,,,,both,,,607.06,394.59,,,,,,,,,,,,,
DISSECTOR ENDOSCP PREPERI KID SHP DISTENSION BLLN SPCMKR,SUP-2283311,CDM,C1727,CPT,0278,RC,,,,both,,,744.34,483.82,,,,,,,,,,,,,
CANNULA ENDOSCP 2 MMX22 CM CVS OPENING RT 1 LUER LCK ADPT,SUP-2773336,CDM,2720000010,LOCAL,0272,RC,,,,both,,,651.83,423.69,,,,,,,,,,,,,
PLATE BNE L37MM 3X3 H ST DST DORS RAD S STL T SHP LOK COMPR,SUP-2177504,CDM,C1713,HCPCS,0278,RC,,,,both,,,2179.60,1416.74,,,,,,,,,,,,,
COMPONENT TIB M 70MM KNEE SPCR ANTIBIO TREAT REMEDY,SUP-2319842,CDM,C1776,CPT,0278,RC,,,,both,,,8635.00,5612.75,,,,,,,,,,,,,
PLATE BNE 100 DEG L 2.28 CM THK 0.6 MM SCREW DIA1.5 MM 4X4 H,SUP-2936658,CDM,C1713,HCPCS,0278,RC,,,,both,,,759.88,493.92,,,,,,,,,,,,,
CATHETER HD STR 28 CM 23 CM SINGLE VLV VASCPAK BIOFLO,SUP-2459559,CDM,C1750,HCPCS,0278,RC,,,,both,,,916.88,595.97,,,,,,,,,,,,,
SCREW BNE SM L10MM DIA1.2MM CANC CORT HND TI ST NONLOCKING,SUP-2366388,CDM,C1713,HCPCS,0278,RC,,,,both,,,1215.18,789.87,,,,,,,,,,,,,
ALLOGRAFT BNE 1 CC DBM BONUS TRIAD,SUP-2607049,CDM,C1889,HCPCS,0278,RC,,,,both,,,1530.75,994.99,,,,,,,,,,,,,
SCREW SPNL L14MM DIA3.5MM MINI CANC POST OCCIPITAL CERV THOR,SUP-2254389,CDM,C1713,HCPCS,0278,RC,,,,both,,,2869.96,1865.47,,,,,,,,,,,,,
PLATE BONE 16 H ANTR LAT PROX FOR 4.5MM SCR,SUP-2349069,CDM,C1713,HCPCS,0278,RC,,,,both,,,1777.08,1155.10,,,,,,,,,,,,,
TITANIUM CONDYLAR HEAD,SUP-2823268,CDM,C1889,HCPCS,0278,RC,,,,both,,,10372.36,6742.03,,,,,,,,,,,,,
GRAFT BNE SUB 25CC SPNG DEMIN CORT FBR FLEXIGRFT,SUP-2264606,CDM,C1713,HCPCS,0278,RC,,,,both,,,1065.84,692.80,,,,,,,,,,,,,
SURFACE ARTC 7-10 GH THK28MM AP50MM ML82MM UNIV BLU UHMWPE,SUP-2201843,CDM,C1776,CPT,0278,RC,,,,both,,,5673.98,3688.09,,,,,,,,,,,,,
CANNULA BONE GRAFTING L150MM PRECIS,SUP-2402791,CDM,2720000010,LOCAL,0272,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
BIT DRL L150MM DIA3.2MM 3/16SQIN CONN ANK FT CANN,SUP-2321607,CDM,2720000010,LOCAL,0272,RC,,,,both,,,824.25,535.76,,,,,,,,,,,,,
KIT EEG ELECTRD L 33.5 MM 10 CONTACT RF PRB STRL DISP EVO,SUP-2936569,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3347.24,2175.71,,,,,,,,,,,,,
HC Hands Bone Age Study,PX-3207707200,CDM,77072,CPT,0320,RC,,,,outpatient,,,252.00,163.80,,,,,,,,,,,,,
PLATE BNE THK05MM 6X2 H UNIV CRANIOMAXILLOFACIAL TI 3D MAL,SUP-2366230,CDM,C1713,HCPCS,0278,RC,,,,both,,,1441.83,937.19,,,,,,,,,,,,,
BOLT IM L24MM DIA3.9MM STRL BLU CORT TI ST FULL THRD LCK,SUP-2192176,CDM,C1713,HCPCS,0278,RC,,,,both,,,723.93,470.55,,,,,,,,,,,,,
SCREW BNE L28MM DIA4.5MM S STL CORT FEM ST LOK FULL THRD,SUP-2348886,CDM,C1713,HCPCS,0278,RC,,,,both,,,1142.18,742.42,,,,,,,,,,,,,
COMPONENT FEM M PART KNEE TWIN PEGGED UNI OXFORD,SUP-2406561,CDM,C1776,CPT,0278,RC,,,,both,,,5338.00,3469.70,,,,,,,,,,,,,
SYSTEM DRNAGE 1 4IN ORTH REINFUS W PVC DRN AND 2 TROCARS,SUP-2125935,CDM,C1713,HCPCS,0278,RC,,,,both,,,560.93,364.60,,,,,,,,,,,,,
SCREW LCKING MAXFRAME HDLESS /XL25/X 5.0X26MM,SUP-2752096,CDM,C1713,HCPCS,0278,RC,,,,both,,,778.78,506.21,,,,,,,,,,,,,
BUSHING FEM DSTL HIP GMRS,SUP-2364955,CDM,C1776,CPT,0278,RC,,,,both,,,914.37,594.34,,,,,,,,,,,,,
CATHETER HD KT 15 FRX50 CM DL AG HEMOSTATIC SHTH EDGE,SUP-2763035,CDM,C1750,HCPCS,0278,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
PLATE BNE THK0.6MM 4 H MIC STR L TI NONSTERILE FOR 1.5MM,SUP-2262672,CDM,C1713,HCPCS,0278,RC,,,,both,,,255.69,166.20,,,,,,,,,,,,,
OCCLUDER CV FLO RST L 12 MM BLB DIA1.5 MM SIL RUBBER,SUP-2130325,CDM,C1760,HCPCS,0278,RC,,,,both,,,218.70,142.15,,,,,,,,,,,,,
KIT NRV BLK 270ML FOR SURG PROC W/ L INCISIONS SOAK MOD,SUP-2236748,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
CANNULA ARTHRO 3.2 MM DRNG OBTURATOR FLOW VALVE,SUP-2747512,CDM,2720000010,LOCAL,0272,RC,,,,both,,,870.69,565.95,,,,,,,,,,,,,
ALLOGRAFT BNE WDG 8X12 MM TRICORT IL CREST,SUP-2867120,CDM,C1762,CPT,0278,RC,,,,both,,,2174.61,1413.50,,,,,,,,,,,,,
BRACE ORTHOPEDIC INT FT AUG REP SYS,SUP-2121624,CDM,C1713,HCPCS,0278,RC,,,,both,,,4694.30,3051.29,,,,,,,,,,,,,
KIT SUC IRR DRAINAGE STRL DISP CLR,SUP-2914837,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1252.86,814.36,,,,,,,,,,,,,
ANCHOR SPNL L25MM ANTR LUM TI FOR INTBDY FUS,SUP-2228832,CDM,C1713,HCPCS,0278,RC,,,,both,,,2041.00,1326.65,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 20 CM DIA 6 MM RNG L 10 CM EPTFE,SUP-2396264,CDM,C1768,CPT,0278,RC,,,,both,,,1378.46,896.00,,,,,,,,,,,,,
SCREW BNE L 40 MM DIA 7 MM LNG TI CANN HD NS LEOS,SUP-2931583,CDM,C1713,HCPCS,0278,RC,,,,both,,,999.15,649.45,,,,,,,,,,,,,
IBUPROFEN 100 MG/5ML PO SUSP,RX-10246,CDM,340b,HCPCS,0637,RC,68094-0494-62,NDC,,both,10,ML,16.80,10.92,,,,,,,,,,,,,
GRAFT HUM TISS W30XH7MM D10-11MM TRANSFORAMINAL POST LUM,SUP-2306925,CDM,C1713,HCPCS,0278,RC,,,,both,,,14737.09,9579.11,,,,,,,,,,,,,
FORCEPS BX AD L195CM CHN 22MM 3MM CUP OPN STD GI FEN STATIC,SUP-2313121,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1177.53,765.39,,,,,,,,,,,,,
HC Surgery Level 6 Addtl 15min,PX-3600000016,CDM,3600000016,LOCAL,0360,RC,,,,outpatient,,,4961.00,3224.65,,,,,,,,,,,,,
MESH CRAN W200XL200MM PROF H0.6MM MIC MID FACE,SUP-2363673,CDM,C1713,HCPCS,0278,RC,,,,both,,,3902.99,2536.94,,,,,,,,,,,,,
GRAFT HUM TISS W15XL30MM THK15MM FRZ DRY ALLGRFT BLK CANC,SUP-2307112,CDM,C1713,HCPCS,0278,RC,,,,both,,,2880.13,1872.08,,,,,,,,,,,,,
RING HALF FRDM CIR FIX 160MM,SUP-2400647,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1827.48,1187.86,,,,,,,,,,,,,
PLATE BNE L81MM 4 H ST R SUP ANT CLAV TI LOK COMPR W LAT,SUP-2180861,CDM,C1713,HCPCS,0278,RC,,,,both,,,3110.92,2022.10,,,,,,,,,,,,,
GRAFT BNE GRAN 3 CC VI RESRB CERM MASTERGRAFT,SUP-2743370,CDM,C1713,HCPCS,0278,RC,,,,both,,,992.24,644.96,,,,,,,,,,,,,
SET INT FIX DIA18.5 MM TI NEURO 12 PK STRL DISP LORENZ,SUP-2935326,CDM,C1713,HCPCS,0278,RC,,,,both,,,23631.64,15360.57,,,,,,,,,,,,,
PLATE BONE COMPRESSION 2 MM MANDIBULAR 6 HOLE INTERMEDIATE L,SUP-2838408,CDM,C1713,HCPCS,0278,RC,,,,both,,,1732.02,1125.81,,,,,,,,,,,,,
SHUTTLE SUT 45DEG LT W/ CHIA IDEAL,SUP-2256802,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1155.52,751.09,,,,,,,,,,,,,
SCREW SPNL L35MM OD8MM TI CANC ANT THORLUM PEDCL ST FIX ANG,SUP-2292733,CDM,C1713,HCPCS,0278,RC,,,,both,,,5856.10,3806.46,,,,,,,,,,,,,
GUIDEWIRE VASC L 180 CM 0.035IN L7CM 2CM STR TIP HVY DTY FIX,SUP-2638692,CDM,C1769,HCPCS,0272,RC,,,,both,,,111.12,72.23,,,,,,,,,,,,,
COVER BUR H DIA22MM TI SHUNT FOR CRAN CLSR SYS,SUP-2243980,CDM,C1713,HCPCS,0278,RC,,,,both,,,455.46,296.05,,,,,,,,,,,,,
SUPPORT NEW EDGE CLAVICLEXL,SUP-2324200,CDM,L3670,HCPCS,0272,RC,,,,both,,,115.96,75.37,,,,,,,,,,,,,
GRAFT MTRX DERM HUM TISS ACELLULAR FRZN 5CMX10CM M HMTRX,SUP-2125443,CDM,Q4134,HCPCS,0636,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
CATHETER THROMCTMY L 65 CM DIA 6 FR GUIDEWIRE 0.018 IN STRL,SUP-2140133,CDM,C1757,HCPCS,0272,RC,,,,both,,,1818.06,1181.74,,,,,,,,,,,,,
DIPHENHYDRAMINE HCL 12.5 MG/5ML PO ELIX,RX-2511,CDM,6370000000,HCPCS,0637,RC,00121-0978-00,NDC,,both,2.5,ML,8.90,5.78,,,,,,,,,,,,,
PLATE BNE L57MM 6X5 H ST R DST RAD VOLAR RIM S STL LOK,SUP-2177522,CDM,C1713,HCPCS,0278,RC,,,,both,,,2953.20,1919.58,,,,,,,,,,,,,
STENT ENDOPROS TOT CVR L100MM PROX DIA38MM DST DIA38MM CATH,SUP-2298540,CDM,C1768,CPT,0278,RC,,,,both,,,53364.30,34686.79,,,,,,,,,,,,,
WASHER ORTH CONVX SPHR,SUP-2749961,CDM,2720000010,LOCAL,0272,RC,,,,both,,,367.38,238.80,,,,,,,,,,,,,
SYSTEM OPHTH IRRIGATION STRL DISP STREAMLINE,SUP-2891353,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
BLADE SURG SAFETY SZ 23 STAINLES STL BARD PARKER LTXFRDM STR,SUP-2605895,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5.81,3.78,,,,,,,,,,,,,
PORT PWR INJ 2 LUMN PLAS W/ SIL FILL SUT H ATTCH POLYUR,SUP-2118812,CDM,C1788,HCPCS,0278,RC,,,,both,,,1124.12,730.68,,,,,,,,,,,,,
HC Cath Urethral Complex,PX-7615170300,CDM,51703,CPT,0761,RC,,,,both,,,214.00,139.10,,,,,,,,,,,,,
MATRIX BIO DIA16 MM FISH SKIN DERMAL CIR INTACT OMEGA3 BX/10,SUP-2909378,CDM,Q4158,HCPCS,0636,RC,,,,both,,,1205.76,783.74,,,,,,,,,,,,,
SET CATHETER L65CM OD4FR GWIRE OD0035IN CRV TIP SHTH L55CN,SUP-2171154,CDM,C1894,HCPCS,0272,RC,,,,both,,,1310.92,852.10,,,,,,,,,,,,,
CRYOABLATION KIT PROST ICESEED,SUP-2225658,CDM,2720000010,LOCAL,0272,RC,,,,both,,,11480.63,7462.41,,,,,,,,,,,,,
GRAFT VASC STR STD WALL N RING EPTFE 6MM DIA 40CM LEN,SUP-2126766,CDM,C1768,CPT,0278,RC,,,,both,,,2263.94,1471.56,,,,,,,,,,,,,
LEAD NEUROSTIMULATOR L33CM DIA1.27MM ELECTRD SPC 1.5MM QPLR,SUP-2284491,CDM,C1778,HCPCS,0278,RC,,,,both,,,11162.70,7255.75,,,,,,,,,,,,,
PLATE BNE L405MM 20 H R CNDYL S STL CRV LOK COMPR VAR ANG,SUP-2177870,CDM,C1713,HCPCS,0278,RC,,,,both,,,8353.44,5429.74,,,,,,,,,,,,,
GUIDEWIRE HYDRPHLC STR TIP 038INX260CM ZIPWIRE,SUP-2148173,CDM,C1769,HCPCS,0272,RC,,,,both,,,131.91,85.74,,,,,,,,,,,,,
TUNNELER SURG 17 GAX12 IN,SUP-2361474,CDM,C1894,HCPCS,0272,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
BENDING TEMPLATE FOR CALCANEAL Y-PLATES 87MM,SUP-2548480,CDM,C1713,HCPCS,0278,RC,,,,both,,,112.41,73.07,,,,,,,,,,,,,
ANCHOR SUT PNCRYL 2-0 ABSRB STR NDL POLY BRAID FOR RAPIDLOC,SUP-2249490,CDM,C1713,HCPCS,0278,RC,,,,both,,,781.86,508.21,,,,,,,,,,,,,
STEM HUM L86MM 6A 127.5DEG ANG STD PTC AEQUALIS ASCEND FLX,SUP-2421317,CDM,C1776,CPT,0278,RC,,,,both,,,12632.22,8210.94,,,,,,,,,,,,,
ALLOGRAFT BNE SHT 45X20X5 MM CANC CONFORM Q-PACK,SUP-2737085,CDM,C1713,HCPCS,0278,RC,,,,both,,,5671.63,3686.56,,,,,,,,,,,,,
LEAD PACE L50CM EPICARD SIL PTCH DF-1,SUP-2282236,CDM,C1896,HCPCS,0275,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
SCREW BONE CANNULATED 6.5X105 MM PROXIMAL FEMUR LOCKING STAI,SUP-2837589,CDM,C1713,HCPCS,0278,RC,,,,both,,,2083.33,1354.16,,,,,,,,,,,,,
SYSTEM INFUSION 4 FRX90 CM 10 CM PULSESPRAY,SUP-2752579,CDM,C1751,HCPCS,0278,RC,,,,both,,,832.10,540.86,,,,,,,,,,,,,
GUIDE PIN ORTHOPEDIC 12X190 MM,SUP-2193795,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1513.48,983.76,,,,,,,,,,,,,
BIT DRL DIA4MM FOR BONE HALF PIN,SUP-2342941,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2235.62,1453.15,,,,,,,,,,,,,
DX FIBERTAK SUTURE ANCHOR #2 MTS WITH NDL,SUP-2815354,CDM,C1713,HCPCS,0278,RC,,,,both,,,1868.30,1214.39,,,,,,,,,,,,,
SCREWDRIVER SURG CANN QC COUNTSINK FOR 6.5/7/7.5 SCR NS,SUP-2486948,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1034.94,672.71,,,,,,,,,,,,,
HOOK PHLEBECTOMY RAMELET 1 3-7/8 IN RT SS,SUP-2473579,CDM,2720000010,LOCAL,0272,RC,,,,both,,,364.40,236.86,,,,,,,,,,,,,
NEEDLE BNE MAR LG 8 GA,SUP-2384767,CDM,C1713,HCPCS,0278,RC,,,,both,,,781.86,508.21,,,,,,,,,,,,,
DICLOXACILLIN SODIUM 250 MG PO CAPS,RX-2414,CDM,6370000000,HCPCS,0637,RC,00093-3123-01,NDC,,both,1,UN,3.10,2.01,,,,,,,,,,,,,
CATHETER THROMCTMY INDIGO L 150 CM PROX/DSTL DIA,SUP-2417269,CDM,C1757,HCPCS,0272,RC,,,,both,,,4364.60,2836.99,,,,,,,,,,,,,
BAG VENT ASST L SHWR PERS SUPP,SUP-2282568,CDM,Q0501,HCPCS,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
COMPONENT TOE DIA15MM 1.5X3.5MM OFFSET MT CE ARTC TOE2,SUP-2123612,CDM,C1776,CPT,0278,RC,,,,both,,,9074.60,5898.49,,,,,,,,,,,,,
GUIDEWIRE GLDEWIRE G 011IN,SUP-2305437,CDM,C1769,HCPCS,0272,RC,,,,both,,,865.07,562.30,,,,,,,,,,,,,
SCREW STRNL CLOSURE L 10 MM DIA2.7 MM TI STRL STERNALOCK XP,SUP-2895210,CDM,C1713,HCPCS,0278,RC,,,,both,,,327.09,212.61,,,,,,,,,,,,,
GUIDEWIRE ORTH SHRP FOR GRANITE IMPL NIT IFUSE BEDROCK,SUP-2864562,CDM,C1769,HCPCS,0272,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
PLATE BNE H0.5MM 20 H MID FACE BLU TI STR COND MAL,SUP-2366239,CDM,C1713,HCPCS,0278,RC,,,,both,,,1648.03,1071.22,,,,,,,,,,,,,
PERIPHERAL ROTAPRO 1.25MM,SUP-2887219,CDM,C1724,HCPCS,0278,RC,,,,both,,,7520.30,4888.19,,,,,,,,,,,,,
PACK PROC TX2 ULTRASONIC SURG ASPIR TISS REM SYS,SUP-2384733,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2653.30,1724.64,,,,,,,,,,,,,
GRAFT BNE XS 1.25 CC DBM STRND +,SUP-2641766,CDM,C1713,HCPCS,0278,RC,,,,both,,,2684.70,1745.05,,,,,,,,,,,,,
STAPLER INT 60 UNIV PUR W/ TRI-STAPLE TECHNOLOGY ULT FOR,SUP-2395286,CDM,C1781,HCPCS,0278,RC,,,,both,,,517.06,336.09,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED STD CUP HD LNR ST TRAB MTL XLPE,SUP-2212323,CDM,C1776,CPT,0278,RC,,,,both,,,17210.37,11186.74,,,,,,,,,,,,,
IMPLANT BRST 545CC P6.2CM DIA13CM COHESIVE SIL GEL SMOOTH SCX545] ALLERGAN USA INC],SUP-2113671,CDM,C1789,HCPCS,0278,RC,,,,both,,,4129.10,2683.91,,,,,,,,,,,,,
GRAFT BNE SUB 15CC CA SULF HI STRENGTH INJ RESRB MIIG X3,SUP-2399047,CDM,C1713,HCPCS,0278,RC,,,,both,,,7930.89,5155.08,,,,,,,,,,,,,
GRAFT DURA ABSRB STRL 7IN 4IN PORCINE SURGISIS BIODESIGN,SUP-2169998,CDM,C1763,HCPCS,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
ANCHOR SUT 2 DIA2.5MM BLU PLLA NONABSORBABLE ULTBRAID DBL,SUP-2341846,CDM,C1713,HCPCS,0278,RC,,,,both,,,983.67,639.39,,,,,,,,,,,,,
GRAFT STRUT FEM CORT STRUCTURAL ALLGRFT FRZN 100MM,SUP-2307363,CDM,C1713,HCPCS,0278,RC,,,,both,,,2034.12,1322.18,,,,,,,,,,,,,
COMPONENT FEM PROX TROCHANTERIC HIP NEUT MOD REPL SYS GMRS,SUP-2364666,CDM,C1776,CPT,0278,RC,,,,both,,,12003.44,7802.24,,,,,,,,,,,,,
BUTTON GAST ACCS L2.4CM DIA24FR LO PROF PUL PEG KT 1 STP,SUP-2149747,CDM,2720000010,LOCAL,0272,RC,,,,both,,,538.51,350.03,,,,,,,,,,,,,
INSERT HUM SHLDR TRABECULAR MTL REV 2 TAPR,SUP-2199138,CDM,C1776,CPT,0278,RC,,,,both,,,1281.12,832.73,,,,,,,,,,,,,
SPACER 38X2MM M LT,SUP-2209008,CDM,C1776,CPT,0278,RC,,,,both,,,11366.17,7388.01,,,,,,,,,,,,,
STEM SPLINE 15.0X115MM STRAIGHT,SUP-2505076,CDM,C1776,CPT,0278,RC,,,,both,,,8126.32,5282.11,,,,,,,,,,,,,
ENOXAPARIN SODIUM 80 MG/0.8ML IJ SOSY,RX-157663,CDM,J1650,HCPCS,0636,RC,63323-0531-90,NDC,,both,0.8,ML,91.50,59.47,,,,,,,,,,,,,
SCHON TRAY WCUT TROCAR PG,SUP-2723661,CDM,C1894,HCPCS,0272,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
CATHETER CARD ABLATION L 5 MM DIA 6 FR STD CRV QPLR STEER,SUP-2141243,CDM,C1730,HCPCS,0272,RC,,,,both,,,879.20,571.48,,,,,,,,,,,,,
NITROFURANTOIN MACROCRYSTAL 100 MG PO CAPS,RX-5593,CDM,6370000000,HCPCS,0637,RC,50268-0624-15,NDC,,both,1,UN,13.00,8.45,,,,,,,,,,,,,
HC Treat Ankle Fx,PX-4502781600,CDM,27816,CPT,0450,RC,,,,both,,,692.00,449.80,,,,,,,,,,,,,
PLATE BNE BROAD 3.5X266 MM 22 HOLE SS DCP,SUP-2569160,CDM,C1713,HCPCS,0278,RC,,,,both,,,485.29,315.44,,,,,,,,,,,,,
RECON PLATE 15X178MM 3.5MM,SUP-2818783,CDM,C1713,HCPCS,0278,RC,,,,both,,,5558.59,3613.08,,,,,,,,,,,,,
PLATE BNE L200MM HIP TI 5 CBL FOR ACCORD SYS,SUP-2345379,CDM,C1713,HCPCS,0278,RC,,,,both,,,2442.92,1587.90,,,,,,,,,,,,,
PLATE BNE W255XL47MM WIDE 7X2 H ST R DST RAD VOLAR S STL VAR,SUP-2177310,CDM,C1713,HCPCS,0278,RC,,,,both,,,2327.05,1512.58,,,,,,,,,,,,,
BIT DRL M DIA4.3MM FOR CALCNL SCR ARTH NAIL SYS PANTA,SUP-2243631,CDM,2720000010,LOCAL,0272,RC,,,,both,,,698.08,453.75,,,,,,,,,,,,,
HC Treat Ankle Fx,PX-4502778600,CDM,27786,CPT,0450,RC,,,,both,,,444.00,288.60,,,,,,,,,,,,,
CATHETER ANGIOPLSTY OTW 180 CM 6X120 MM PACIFIC+,SUP-2281322,CDM,C1725,HCPCS,0272,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
PLATE BNE L69MM 1 H SHT R LAT DST HUM S STL VAR ANG LOK,SUP-2177609,CDM,C1713,HCPCS,0278,RC,,,,both,,,3752.08,2438.85,,,,,,,,,,,,,
GUIDEWIRE VASC L 145 CM DIA 0.038 IN TAPR L 6 CM FLX TIP L,SUP-2167618,CDM,C1769,HCPCS,0272,RC,,,,both,,,28.39,18.45,,,,,,,,,,,,,
HC Whfo 1 or More Custom Fit,PX-2740380601,CDM,L3806,HCPCS,0272,RC,,,,both,,,1510.00,981.50,,,,,,,,,,,,,
FEEDING TUBE KIT LP 14 FRX1.5 CM BLLN BUTTON SIL MINI 1,SUP-2754573,CDM,2720000010,LOCAL,0272,RC,,,,both,,,511.73,332.62,,,,,,,,,,,,,
COMPONENT TIB CR 5 UNIV 12 MM NP PRIMARY CEM STEM MONOBLOCK,SUP-2378462,CDM,C1776,CPT,0278,RC,,,,both,,,2859.91,1858.94,,,,,,,,,,,,,
DEVICE BNE BX SZ 3 8GA FOR INTVENT THER KYPHON,SUP-2293564,CDM,2720000010,LOCAL,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
COMPONENT TIB AUG UNIV 55X59X10 MM KNEE OSS RS RD122061,SUP-2449994,CDM,C1776,CPT,0278,RC,,,,both,,,2444.49,1588.92,,,,,,,,,,,,,
KIT INSTR NDL 2 BVL ASSEMB PEDCL XPAK,SUP-2290651,CDM,C1713,HCPCS,0278,RC,,,,both,,,486.23,316.05,,,,,,,,,,,,,
PLATE BNE L85MM 4 H ANG L T SHP BTTRS FOR 45MM SCR L,SUP-2411388,CDM,C1713,HCPCS,0278,RC,,,,both,,,755.52,491.09,,,,,,,,,,,,,
BUTTON FIX FOR ACL RECON W/ TI AND UHMWPE TIGHTROPE,SUP-2121388,CDM,C1776,CPT,0278,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
PLATE BNE RECON 3.5 MM 20 HOLE CRV,SUP-2424069,CDM,C1713,HCPCS,0278,RC,,,,both,,,1686.97,1096.53,,,,,,,,,,,,,
BRACE ORTHOPEDIC CUST SACR LUMBAR LSO CYBERTECH,SUP-2123928,CDM,L0638,HCPCS,0274,RC,,,,both,,,4750.82,3088.03,,,,,,,,,,,,,
STEM FEM SZ 2 L124MM NK L30MM 132DEG ANG CEM ACCOLADE C,SUP-2364227,CDM,C1776,CPT,0278,RC,,,,both,,,8977.89,5835.63,,,,,,,,,,,,,
PLATE BNE MED 20 MM RT GORILLA HEVANS,SUP-2321483,CDM,C1713,HCPCS,0278,RC,,,,both,,,4686.45,3046.19,,,,,,,,,,,,,
SUPPORT ORTHOT HND FNGR W/O JT PREFABRICATED SFT INTFACE,SUP-2435782,CDM,L3923,HCPCS,0272,RC,,,,both,,,248.88,161.77,,,,,,,,,,,,,
CATHETER DRAINAGE SAFETY 4 FRX10 CM STRL SKATER LTX,SUP-2876591,CDM,C1729,HCPCS,0272,RC,,,,both,,,84.78,55.11,,,,,,,,,,,,,
GEL LIFTING SUBMUCOSAL SYR TWIN PK ORISE,SUP-2436449,CDM,2720000010,LOCAL,0272,RC,,,,both,,,533.80,346.97,,,,,,,,,,,,,
LIGATOR ENDOSCP L2.8MM DIA8.6-11.5MM MULT BND SPEEDBAND,SUP-2149561,CDM,2720000010,LOCAL,0272,RC,,,,both,,,750.52,487.84,,,,,,,,,,,,,
PLATE BNE NC FUSION LG 2.7 MM NS FPS LTX,SUP-2856864,CDM,C1713,HCPCS,0278,RC,,,,both,,,5614.32,3649.31,,,,,,,,,,,,,
LINER WLK BOOT VENTURE TALL M,SUP-2151035,CDM,L4386,HCPCS,0272,RC,,,,both,,,61.23,39.80,,,,,,,,,,,,,
SET TBNG L3.8M IRR DISP,SUP-2164957,CDM,C1713,HCPCS,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
SCREW BNE L7MM OD2MM TI CRANIOMAXILLOFACIAL SELF DRLING SELF,SUP-2262792,CDM,C1713,HCPCS,0278,RC,,,,both,,,176.44,114.69,,,,,,,,,,,,,
BUTTON SUTURE SZ 12 X 8 MM OD THK 1.6 MM TUNN SZ 4-7 MM FLAT,SUP-2906257,CDM,C1713,HCPCS,0278,RC,,,,both,,,841.52,546.99,,,,,,,,,,,,,
HC Inj Proc Shoulder Arthro,PX-3612335000,CDM,23350,CPT,0361,RC,,,,outpatient,,,3707.00,2409.55,,,,,,,,,,,,,
TUBE SZ DIA10MM FOR BONE GRFT ACUFEX ACL PCL RECON DRL GUID,SUP-2340724,CDM,2720000010,LOCAL,0272,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
BOOT WALKING CUST FABRIC ANK FT,SUP-2237265,CDM,L4631,HCPCS,0272,RC,,,,both,,,4492.59,2920.18,,,,,,,,,,,,,
SET HAD CATHETER AD 14FR L15CM BASIC DBL LUMN DIL SCALP,SUP-2266996,CDM,C1752,HCPCS,0278,RC,,,,both,,,292.02,189.81,,,,,,,,,,,,,
COMPONENT FEM L10CM KNEE TI DPHSEAL CPLR OSS,SUP-2405813,CDM,C1776,CPT,0278,RC,,,,both,,,15288.66,9937.63,,,,,,,,,,,,,
ARM EXT FIX VERTICLE ADJ 24 MM TUBE LEFORT 1 BUTTRESS,SUP-2458659,CDM,C1713,HCPCS,0278,RC,,,,both,,,6228.63,4048.61,,,,,,,,,,,,,
DEVICE SPNL INTBDY POST PLT OCTAVE 8MM,SUP-2264523,CDM,C1713,HCPCS,0278,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
GUIDEWIRE VASC L150CM DIA0.025IN TIP DIA3MM L7MM INTVASC S,SUP-2355272,CDM,C1769,HCPCS,0272,RC,,,,both,,,21.98,14.29,,,,,,,,,,,,,
ADAPTER LD L 45 CM DIA 32 MM IS1 OR 3.2 MM LP BPLR TO IS1,SUP-2148921,CDM,C1883,HCPCS,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
SHEATH INTRO L28CM DIA18FR POLYETH HYDRPHLC W/O CRV HEMSTAT,SUP-2396257,CDM,C1894,HCPCS,0272,RC,,,,both,,,800.70,520.45,,,,,,,,,,,,,
HC Renal Arteriogram Bilat,PX-3233625200,CDM,36252,CPT,0323,RC,,,,both,,,10063.00,6540.95,,,,,,,,,,,,,
PLATE BONE L86MM 7 H POST LAT S STL 1/3 TBLR LCK COMPR FOR,SUP-2349796,CDM,C1713,HCPCS,0278,RC,,,,both,,,2348.31,1526.40,,,,,,,,,,,,,
HC So Assay of Protein Other,PX-3018415766,CDM,84157,CPT,0301,RC,,,,outpatient,,,40.00,26.00,,,,,,,,,,,,,
DEVICE ARTOTMY CLOSURE STARCLOSE SE DIA 5-6 FR NIT FEM ART,SUP-2105706,CDM,C1760,HCPCS,0278,RC,,,,both,,,744.18,483.72,,,,,,,,,,,,,
GRAFT VASC GORTX L 100 CM DIA10 MM RNG L 80 CM EPTFE STR TW,SUP-2396176,CDM,C1768,CPT,0278,RC,,,,both,,,5278.34,3430.92,,,,,,,,,,,,,
BIT DRL L 205/110 MM DIA2.8 MM CALIB AO QC STRL DISP V,SUP-2907957,CDM,2720000010,LOCAL,0272,RC,,,,both,,,946.24,615.06,,,,,,,,,,,,,
GRAFT DERMAL RECT 25X20 CM REGENERATIVE CLLGN MTRX XENMATRIX,SUP-2126242,CDM,C1781,HCPCS,0278,RC,,,,both,,,32185.00,20920.25,,,,,,,,,,,,,
GLIMEPIRIDE 2 MG PO TABS,RX-16356,CDM,6370000000,HCPCS,0637,RC,68084-0326-11,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
ROD DISTR 4MM DIA 100MML CRBN FIBER F/CNSLDTN 3DX,SUP-2489176,CDM,2720000010,LOCAL,0272,RC,,,,both,,,322.13,209.38,,,,,,,,,,,,,
IMMOBILIZER SHLDR BASIC ABD SLNG SM,SUP-2150926,CDM,L3650,HCPCS,0274,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
PIN FIX DBL TROCAR 0.109X9 IN THRD SS NS STEINMANN,SUP-2791389,CDM,C1713,HCPCS,0278,RC,,,,both,,,75.11,48.82,,,,,,,,,,,,,
ASPIRIN 325 MG PO TABS,RX-681,CDM,6370000000,HCPCS,0637,RC,00536-1054-29,NDC,,both,1,UN,0.20,0.13,,,,,,,,,,,,,
ANCHOR SUT SHLDR JUGGERKNOT SZ 1 BLACK WHITE,SUP-2212951,CDM,C1713,HCPCS,0278,RC,,,,both,,,521.24,338.81,,,,,,,,,,,,,
GUIDEWIRE VASC L205CM OD0.014IN TIP L2CM HYDRPHLC,SUP-2362792,CDM,C1769,HCPCS,0272,RC,,,,both,,,1516.62,985.80,,,,,,,,,,,,,
STENT TRACHBRONCH UFLX EXP L 20 MM DIA 8 MM COMPR DIA 7 MM,SUP-2149825,CDM,C1876,HCPCS,0278,RC,,,,both,,,7875.28,5118.93,,,,,,,,,,,,,
Additional Level Access Instruments,SUP-2757213,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
MESH HERN L24XW18CM THICKNESS 1MM EPTFE INTRA-ABDOMINAL,SUP-2125801,CDM,C1781,HCPCS,0278,RC,,,,both,,,2910.78,1892.01,,,,,,,,,,,,,
STABILIZER SURG APEX SUCTION XPOSE AXIUS,SUP-2142008,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
PLATE BNE L63MM 3 H 130DEG S STL HIP COMPR LO PROF SHT BRL,SUP-2364144,CDM,C1713,HCPCS,0278,RC,,,,both,,,1841.61,1197.05,,,,,,,,,,,,,
SHUNT VLV FLSH RESERVOIR 14X14.7X600 MMX10 CM 15 CM H2O ADJ,SUP-2846931,CDM,C1889,HCPCS,0278,RC,,,,both,,,13038.60,8475.09,,,,,,,,,,,,,
SLEEVE WIRE 1.4MM SGL CHAMBER,SUP-2905212,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1482.08,963.35,,,,,,,,,,,,,
SHELL ACET DIA40MM F/M TI ALLOY POR UNIHOLED PRI REV UNIV,SUP-2202331,CDM,C1776,CPT,0278,RC,,,,both,,,4837.17,3144.16,,,,,,,,,,,,,
PACEMAKER CARD 25GM 13.7CC W52XH58MM THK6MM RESYNCH THER,SUP-2356468,CDM,C2621,HCPCS,0275,RC,,,,both,,,15072.00,9796.80,,,,,,,,,,,,,
SCREW BNE SPARE,SUP-2486613,CDM,C1713,HCPCS,0278,RC,,,,both,,,103.75,67.44,,,,,,,,,,,,,
DEFIBRILLATOR IMPL INVENTRA HF-T W 58.5 X H 65 MM D 12.5 MM,SUP-2138468,CDM,C1882,HCPCS,0275,RC,,,,both,,,86114.50,55974.42,,,,,,,,,,,,,
IMETELSTAT SODIUM 188 MG IV SOLR,RX-168241,CDM,J0870,HCPCS,0636,RC,82959-0111-01,NDC,,both,6,ML,29979.60,19486.74,,,,,,,,,,,,,
SCREW BNE L16MM DIA4MM TI MID FT POLYAX LOK LO PROF OP,SUP-2401183,CDM,C1713,HCPCS,0278,RC,,,,both,,,737.90,479.63,,,,,,,,,,,,,
CEMENT KIT 33 CC 60 GM HI ADH STRENGTH HY-BOND,SUP-2238570,CDM,C1713,HCPCS,0278,RC,,,,both,,,352.87,229.37,,,,,,,,,,,,,
BIT DRL L300X250MM DIA5MM 3 FLUT CANN CALIB FOR QUIK CPL,SUP-2178977,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1155.87,751.32,,,,,,,,,,,,,
HC Pt Ultrasound Each 15 Min,PX-4209703500,CDM,97035,CPT,0420,RC,,,,inpatient,,,194.00,126.10,,,,,,,,,,,,,
PLATE BNE RECON 3.5 MM 6 HOLE STR STRL LTX,SUP-2861617,CDM,C1713,HCPCS,0278,RC,,,,both,,,737.40,479.31,,,,,,,,,,,,,
DEVICE DEL L180CM SHTH DIA2.5MM FOR 23.5-26.5MM VID CAP,SUP-2391606,CDM,2720000010,LOCAL,0272,RC,,,,both,,,604.45,392.89,,,,,,,,,,,,,
PROSTHESIS PENILE 12CM PRECONNECT PENOSCROTAL APPRCH CX MS,SUP-2139008,CDM,C1813,HCPCS,0278,RC,,,,both,,,26058.86,16938.26,,,,,,,,,,,,,
TUBE INNR EAR MYR VENT FLNG 1.14 MM ID SIL STRL BLU GOODE,SUP-2381505,CDM,L8699,HCPCS,0278,RC,,,,both,,,155.49,101.07,,,,,,,,,,,,,
IMMOBILIZER SHLDR L10.5-17IN D7IN SLNG W/ 15DEG ABD PLLW,SUP-2196388,CDM,L3650,HCPCS,0274,RC,,,,both,,,106.92,69.50,,,,,,,,,,,,,
ALLOGRAFT BNE CUBE 15 CC FD CANC,SUP-2205398,CDM,C1889,HCPCS,0278,RC,,,,both,,,1899.70,1234.80,,,,,,,,,,,,,
GRAFT DERMAL PLIABLE THCK 20X8 CMX0.8-1.7 MM BRST KT FLEXHD,SUP-2307581,CDM,Q4128,HCPCS,0636,RC,,,,both,,,23980.97,15587.63,,,,,,,,,,,,,
STAPLE BNE FIX SM W10XL10.5MM DIA1MM S STL BARB LEG LO PROF,SUP-2122331,CDM,C1713,HCPCS,0278,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
PLATE COND CRVD VA TI 4.5 X336MM LT 16HL,SUP-2720089,CDM,C1713,HCPCS,0278,RC,,,,both,,,6444.60,4188.99,,,,,,,,,,,,,
AZITHROMYCIN 600 MG PO TABS,RX-17387,CDM,6370000000,HCPCS,0637,RC,50111-0789-10,NDC,,both,1,UN,20.80,13.52,,,,,,,,,,,,,
CABLE EP CATH WOVEN L 125 CM 4 PIN FOR FIX CRV CATH STRL,SUP-2885501,CDM,2720000010,LOCAL,0272,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
PLATE BONE L70MM 4 H STRL RT LAT PROX TIB S STL FOR 3.5MM,SUP-2349725,CDM,C1713,HCPCS,0278,RC,,,,both,,,10934.42,7107.37,,,,,,,,,,,,,
PLATE BNE 6 H R STD LO PROF NONCOMPRESSION S STL MTP FUS,SUP-2397483,CDM,C1713,HCPCS,0278,RC,,,,both,,,2967.30,1928.74,,,,,,,,,,,,,
CATHETERIZATION KIT ART 018 20 GAX4.5 CM 25 GA 3 CC LF,SUP-2865585,CDM,C1751,HCPCS,0278,RC,,,,both,,,162.65,105.72,,,,,,,,,,,,,
SYSTEM DILATOR ENDOSCOPIC XPRESS LOPROFILE 6MM BALLOON 8MM,SUP-2900183,CDM,C1726,HCPCS,0272,RC,,,,both,,,5008.30,3255.39,,,,,,,,,,,,,
HC Pt Elec Stim Unattended,PX-4209701400,CDM,G0283,HCPCS,0420,RC,,,,outpatient,,,206.00,133.90,,,,,,,,,,,,,
SCREW SPNL OD5.5MM PEDCL LUM THRD STRT H TOP CLSR,SUP-2415297,CDM,C1713,HCPCS,0278,RC,,,,both,,,496.12,322.48,,,,,,,,,,,,,
CATHETER BLLN DIL L17MM DIA6MM SPHENOID EM SKR NUVENT,SUP-2284115,CDM,C1726,HCPCS,0272,RC,,,,both,,,1309.69,851.30,,,,,,,,,,,,,
GUIDEWIRE VASC STR 2 CM 0.038 INX145 CM FIX COR SS SAFE-T-J,SUP-2167664,CDM,C1769,HCPCS,0272,RC,,,,both,,,24.74,16.08,,,,,,,,,,,,,
SM FRAG PLT STERILIZER 3.5X37 MM 3 HL,SUP-2818396,CDM,C1713,HCPCS,0278,RC,,,,both,,,944.20,613.73,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9 % IV BOLUS,RX-103555,CDM,2580000003,HCPCS,0250,RC,00338-0049-11,NDC,,both,250,ML,123.30,80.14,,,,,,,,,,,,,
COMPONENT FEM 10 MM PS FLEXED,SUP-2136960,CDM,C1776,CPT,0278,RC,,,,both,,,12246.00,7959.90,,,,,,,,,,,,,
PROSTHESIS 3MM DIAM 5.6MM LEN PORP PARTIALLY CANN HA SHEA,SUP-2312574,CDM,L8613,CPT,0278,RC,,,,both,,,722.20,469.43,,,,,,,,,,,,,
HC Oxygen Saturation Measurement,PX-4609476000,CDM,94760,CPT,0460,RC,,,,outpatient,,,148.00,96.20,,,,,,,,,,,,,
SCREW BNE S STL CONN FOR LOK ATTCH PLT STARDRV,SUP-2177789,CDM,C1713,HCPCS,0278,RC,,,,both,,,575.69,374.20,,,,,,,,,,,,,
BLADE INTREX 25X90X1.19,SUP-2166665,CDM,C1713,HCPCS,0278,RC,,,,both,,,741.04,481.68,,,,,,,,,,,,,
HEAD HUM H16MM DIA38MM 0.5MM OFFSET SH SHLDR CO CHROM,SUP-2223330,CDM,C1776,CPT,0278,RC,,,,both,,,6047.64,3930.97,,,,,,,,,,,,,
CATHETER URET L69CM DIA6FR 0.038IN POLYUR OPN TIP ADPT,SUP-2129003,CDM,C1758,HCPCS,0278,RC,,,,both,,,37.37,24.29,,,,,,,,,,,,,
HC Bone Marrow Smear Interpretation,PX-3058509700,CDM,85097,CPT,0305,RC,,,,both,,,923.00,599.95,,,,,,,,,,,,,
OXYGENATOR PERF AD W HS RESVR PRIMO2X,SUP-2265154,CDM,2720000010,LOCAL,0272,RC,,,,both,,,800.70,520.45,,,,,,,,,,,,,
FIXATOR EXT L220MM DIA2.8MM DST RAD S STL SELF DRL SCHNZ,SUP-2179166,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7469.40,4855.11,,,,,,,,,,,,,
PACK PROC BILAT HAT-TRICK MTP,SUP-2349216,CDM,C1776,CPT,0278,RC,,,,both,,,4248.89,2761.78,,,,,,,,,,,,,
STRIP INT STPL CLLGN MTRX W/ VERIT PSD 6 FIRING COMPATIBLE,SUP-2130379,CDM,C1713,HCPCS,0278,RC,,,,both,,,541.37,351.89,,,,,,,,,,,,,
RING EXT FIX 5/8 180 MM SALVATION,SUP-2459697,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3529.36,2294.08,,,,,,,,,,,,,
WASHER ORTH LAPIDUS SYS FOR 3.5 MM SCREW IO FRDM,SUP-2864919,CDM,C1713,HCPCS,0278,RC,,,,both,,,373.66,242.88,,,,,,,,,,,,,
KIT INTRO ARW THMS L 4 IN DIA 8.5 FR 0.035 IN INTEGR VLV,SUP-2383283,CDM,C1894,HCPCS,0272,RC,,,,both,,,90.90,59.08,,,,,,,,,,,,,
JOINT KNEE GLIDING SURFACE VEGA PS ALL POLY T0/0+ 14MM,SUP-2841690,CDM,C1776,CPT,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
GRAFT BNE W16XH5XL22MM FRZ DRY COT WDG FOR FLATFOOT,SUP-2307235,CDM,C1713,HCPCS,0278,RC,,,,both,,,2388.76,1552.69,,,,,,,,,,,,,
DILATOR SURG 24FR EN BLT IN PEEL AWAY SHTH FOR 20FR MIC KEY,SUP-2236744,CDM,C1894,HCPCS,0272,RC,,,,both,,,315.66,205.18,,,,,,,,,,,,,
SCREW BNE L55MM DIA7MM SHT THRD,SUP-2390530,CDM,C1713,HCPCS,0278,RC,,,,both,,,1978.20,1285.83,,,,,,,,,,,,,
KIT PEG 20FR SFTY PUSH METHD MIC,SUP-2236710,CDM,2720000010,LOCAL,0272,RC,,,,both,,,295.32,191.96,,,,,,,,,,,,,
SLING ORTHOT LUMBAR CUST,SUP-2435580,CDM,L1090,HCPCS,0274,RC,,,,both,,,284.89,185.18,,,,,,,,,,,,,
PLATE BNE LCK 3.5X104 MM LT PROX LAT TIB 6 HOLE STRL,SUP-2479491,CDM,C1713,HCPCS,0278,RC,,,,both,,,3829.29,2489.04,,,,,,,,,,,,,
STENT CORONARY RESOLUTE INTEGRITY L 22 MM DIA 3 MM CATH L,SUP-2573074,CDM,C1874,HCPCS,0278,RC,,,,both,,,2072.40,1347.06,,,,,,,,,,,,,
FIBER LT VIS TRANSCUTANEOUS XPRESS PATHASSIST,SUP-2217801,CDM,2720000010,LOCAL,0272,RC,,,,both,,,929.44,604.14,,,,,,,,,,,,,
KIT NEG PRSS W10XL30CM INCL 2 DRESSINGS 1 PMP AND PMP CLP,SUP-2351614,CDM,2720000010,LOCAL,0272,RC,,,,both,,,690.80,449.02,,,,,,,,,,,,,
GUIDEWIRE ORTH BALL NOSE HUM NS AFFIXUS,SUP-2606190,CDM,C1769,HCPCS,0272,RC,,,,both,,,857.22,557.19,,,,,,,,,,,,,
DEVICE FIX TIB 11 MM WITH PRELOADED TUNNELOC,SUP-2664002,CDM,C1713,HCPCS,0278,RC,,,,both,,,1874.45,1218.39,,,,,,,,,,,,,
PLUG VASC AMPLATZER II L 10 MM DIA14 MM DEL SYS L 135 CM,SUP-2116309,CDM,C1889,HCPCS,0278,RC,,,,both,,,2612.48,1698.11,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9 % IV BOLUS|DISCARDED DRUG NOT ADMINISTE,RX-103555,CDM,2580000003,HCPCS,0258,RC,00264-7800-10,NDC,JW,both,250,ML,14.90,9.68,,,,,,,,,,,,,
DEXAMETHASONE 6 MG PO TABS,RX-2328,CDM,6370000000,HCPCS,0637,RC,00054-8183-25,NDC,,both,1,UN,7.20,4.68,,,,,,,,,,,,,
BISMUTH SUBSALICYLATE 262 MG/15ML PO SUSP,RX-1090,CDM,340b,HCPCS,0637,RC,09999-9909-88,NDC,,both,15,ML,2.70,1.75,,,,,,,,,,,,,
KIT PMP 100ML 2ML/HR CATH L1IN ANTIMIC SIL COAT ON-Q,SUP-2236842,CDM,C9804,HCPCS,0272,RC,,,,both,,,266.90,173.48,,,,,,,,,,,,,
STAPLE BNE FIX W16XL22MM M TBL RICHARDS,SUP-2342746,CDM,C1713,HCPCS,0278,RC,,,,both,,,2259.98,1468.99,,,,,,,,,,,,,
CAUTERY ROBOTIC DIA5MM SPAT TIP DA VINCI,SUP-2246577,CDM,C1713,HCPCS,0278,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
MODEL SURG PLN CR IDENTITY IMPRNT IVIEW,SUP-2904500,CDM,2720000010,LOCAL,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
CATHETER HD SET 12 FRX25 CM ACUTE DL TURBO-FLO HD,SUP-2759834,CDM,C1752,HCPCS,0278,RC,,,,both,,,422.77,274.80,,,,,,,,,,,,,
HALF RING-SBF 90MM,SUP-2818147,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4523.01,2939.96,,,,,,,,,,,,,
HC So Total Protein,PX-3018415566,CDM,84155,CPT,0301,RC,,,,both,,,40.00,26.00,,,,,,,,,,,,,
TERCONAZOLE 80 MG VA SUPP,RX-11512,CDM,6370000000,HCPCS,0637,RC,45802-0717-08,NDC,,both,1,UN,122.50,79.62,,,,,,,,,,,,,
GRAFT DERM DECELLULARIZED RM TEMP ALLGRFT 0.75MM-1.50MM,SUP-2264719,CDM,Q4122,HCPCS,0636,RC,,,,both,,,11195.67,7277.19,,,,,,,,,,,,,
INTRO SHEATH TRANSSEPTAL 8.5FRX71CM,SUP-2357282,CDM,C1894,HCPCS,0272,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
HC Biopsy Thyroid Perc Needle,PX-3616010000,CDM,60100,CPT,0361,RC,,,,inpatient,,,3707.00,2409.55,,,,,,,,,,,,,
SCREW BNE L 21 MM DIA2 MM TI ST LCK T6 DRV NS VLP,SUP-2931579,CDM,C1713,HCPCS,0278,RC,,,,both,,,443.46,288.25,,,,,,,,,,,,,
BRACE ORTH EXTN ORTHOSIS WRST CTRL,SUP-2388193,CDM,L3908,HCPCS,0274,RC,,,,both,,,162.43,105.58,,,,,,,,,,,,,
CANNULA PERFSN L 9.5 IN EFFECTIVE L 6 IN DIA16 FR CONN 3/8,SUP-2881165,CDM,2720000010,LOCAL,0272,RC,,,,both,,,694.16,451.20,,,,,,,,,,,,,
BRACE ORTHOSIS SPNL SM M EXOS FRM II 626,SUP-2196545,CDM,L0641,HCPCS,0272,RC,,,,both,,,244.64,159.02,,,,,,,,,,,,,
CATHETER CARD ABLATION THERMOCOOL SF L 115 CM 7.5 FR B-B CRV,SUP-2248522,CDM,C1732,HCPCS,0272,RC,,,,both,,,7583.10,4929.01,,,,,,,,,,,,,
HC So 17 - Hydroxyprynenolone,PX-3018414366,CDM,84143,CPT,0301,RC,,,,both,,,74.00,48.10,,,,,,,,,,,,,
TELISOTUZUMAB VEDOTIN-TLLV 100 MG IV SOLR (MIXTURES ONLY),RX-430085,CDM,J9326,HCPCS,0636,RC,00074-1044-01,NDC,,both,1,UN,8052.50,5234.12,,,,,,,,,,,,,
PROSTHESIS PENILE RESVR 100ML FLAT INFL W/ MS PMP PRECONN,SUP-2138911,CDM,C1813,HCPCS,0278,RC,,,,both,,,9961.34,6474.87,,,,,,,,,,,,,
SUTURE SURG PRE MEASURED LOOP 2-0 12 MM 18 MM CHORD-X,SUP-2799090,CDM,C1889,HCPCS,0278,RC,,,,both,,,8474.86,5508.66,,,,,,,,,,,,,
"HC So Aldosterone, Serum",PX-3078208866,CDM,82088,CPT,0307,RC,,,,both,,,341.00,221.65,,,,,,,,,,,,,
BIT DRILL CANN 3.8MM,SUP-2470844,CDM,2720000010,LOCAL,0272,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
HC Repr Smp Not Face 20.1-30cm,PX-4501200600,CDM,12006,CPT,0450,RC,,,,both,,,1445.00,939.25,,,,,,,,,,,,,
CATHETER EP QPLR 4 MM TIP 7 FR,SUP-2356977,CDM,C1733,HCPCS,0272,RC,,,,both,,,2229.40,1449.11,,,,,,,,,,,,,
PIN SPNL TEMP FIX SHORELINE ACS,SUP-2709643,CDM,C1713,HCPCS,0278,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
ANCHOR SUTURE 1 2.8 MM W/ 2 ULTRABRAID TI TWINFIX,SUP-2848914,CDM,C1713,HCPCS,0278,RC,,,,both,,,767.38,498.80,,,,,,,,,,,,,
SHELL ACET OD58MM PRESSFIT PRI UNIV MLRY HD,SUP-2408828,CDM,C1776,CPT,0278,RC,,,,both,,,6336.52,4118.74,,,,,,,,,,,,,
SCREW SPNL LCK 4.5 MM SS SHILLA,SUP-2630595,CDM,C1713,HCPCS,0278,RC,,,,both,,,109.90,71.43,,,,,,,,,,,,,
MATRIX WOUND SM AMNIOTIC FLUID COVER NUCEL,SUP-2715851,CDM,C1765,HCPCS,0278,RC,,,,both,,,2653.30,1724.64,,,,,,,,,,,,,
PLATE BNE STR FIVE HOLE STRATUM,SUP-2607253,CDM,C1713,HCPCS,0278,RC,,,,both,,,2474.16,1608.20,,,,,,,,,,,,,
CATHETER AD COILED 1 CUF 62CM,SUP-2302488,CDM,C1750,HCPCS,0278,RC,,,,both,,,1566.86,1018.46,,,,,,,,,,,,,
PLATE BONE L48MM 6 H LCK RECON BILAT RIG FOR 2.7MM SCR,SUP-2348295,CDM,C1713,HCPCS,0278,RC,,,,both,,,4827.59,3137.93,,,,,,,,,,,,,
SYSTEM EXTR BG 6500ML RNG DIA17CM CONTAINED W/ GELPOINT MINI,SUP-2119766,CDM,C1713,HCPCS,0278,RC,,,,both,,,3501.10,2275.71,,,,,,,,,,,,,
GUIDE DRL FISHMOUTH STBL LUPINE,SUP-2249383,CDM,C1713,HCPCS,0278,RC,,,,both,,,1295.72,842.22,,,,,,,,,,,,,
SPACER SPNL SM W12XH25XL14MM 3.5/3.5DEG LORDTC THORLUM,SUP-2231168,CDM,C1821,HCPCS,0278,RC,,,,both,,,9106.00,5918.90,,,,,,,,,,,,,
FIBER LASER IMPERIUM 500 MICRON CO2,SUP-2931429,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
PROBE STIM SIDE BY SIDE INSUL TIP POLARIZED CBL HNDL KARTUSH,SUP-2279926,CDM,2720000010,LOCAL,0272,RC,,,,both,,,466.01,302.91,,,,,,,,,,,,,
BRACE ANKLE FOOT ORTHOSIS,SUP-2421821,CDM,L4396,HCPCS,0274,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
CATHETER INTRO 10.06FR UNIV OUTER SLITTABLE WIDE CRV CPS,SUP-2356382,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
WASHER ORTH FIX TI SZ 13.0MM,SUP-2412666,CDM,C1713,HCPCS,0278,RC,,,,both,,,188.40,122.46,,,,,,,,,,,,,
CATHETER ABLAT 7FR L115CM 5MM TIP 2-5-2MM SPC SM CURL QPLR,SUP-2421254,CDM,C1733,HCPCS,0272,RC,,,,both,,,2230.97,1450.13,,,,,,,,,,,,,
DEVICE ABLATN ENDOMET US NOVASURE V5,SUP-2765146,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3959.54,2573.70,,,,,,,,,,,,,
SCREW LK F/IM NAIL 5X60MM XL25 ST,SUP-2718118,CDM,C1713,HCPCS,0278,RC,,,,both,,,658.08,427.75,,,,,,,,,,,,,
SPACER SPNL W30XH9MM D24MM LAT THORLUM INTBDY FUS RADLUC,SUP-2194098,CDM,C1821,HCPCS,0278,RC,,,,both,,,13345.00,8674.25,,,,,,,,,,,,,
GUIDE WIRE CNTR SL,SUP-2290627,CDM,C1713,HCPCS,0278,RC,,,,both,,,648.85,421.75,,,,,,,,,,,,,
NEEDLE SUT PASS FOR ROT CUF LABRAL REP SUREFIRE SCORPION,SUP-2121199,CDM,2720000010,LOCAL,0272,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
PLATE BNE CONTOURABLE MESH 100X100X0.6 MM RIGID TI SLV STRL,SUP-2859898,CDM,C1713,HCPCS,0278,RC,,,,both,,,6722.11,4369.37,,,,,,,,,,,,,
TUBE TRACH CUF AD 9X12.9X140 MM SIL BIVONA TTS HYPRFLX,SUP-2352025,CDM,2720000010,LOCAL,0272,RC,,,,both,,,540.58,351.38,,,,,,,,,,,,,
CONNECTOR SPNL DOMINO 4.5-5.5 MM,SUP-2631252,CDM,C1713,HCPCS,0278,RC,,,,both,,,2176.02,1414.41,,,,,,,,,,,,,
SPEEDBRG IMP SYS W/BIO-COMP SWVLK,SUP-2812573,CDM,C1713,HCPCS,0278,RC,,,,both,,,5997.40,3898.31,,,,,,,,,,,,,
GRAFT VASC 7 MMX25/15X70 CMX0.35 MM 30 CM STR HEMGRD,SUP-2466435,CDM,C1768,CPT,0278,RC,,,,both,,,3057.26,1987.22,,,,,,,,,,,,,
ANCHOR SUT SZ 4.5MM BLU PEEK UHMWPE BRAID FLAT PERMATAPE,SUP-2417593,CDM,C1713,HCPCS,0278,RC,,,,both,,,1205.76,783.74,,,,,,,,,,,,,
MESH HERN RECTANGULAR 3 15X10 CM MONOFILAMENT VERSATEX,SUP-2752214,CDM,C1781,HCPCS,0278,RC,,,,both,,,475.40,309.01,,,,,,,,,,,,,
TIGHTROPE ABS OBLONG BUTTON,SUP-2811992,CDM,C1713,HCPCS,0278,RC,,,,both,,,631.14,410.24,,,,,,,,,,,,,
PLATE BNE THRD 1.6 MM TAK,SUP-2319690,CDM,C1713,HCPCS,0278,RC,,,,both,,,183.69,119.40,,,,,,,,,,,,,
ARCOS 12X150MM PRX TPR DIST,SUP-2505956,CDM,C1776,CPT,0278,RC,,,,both,,,7812.32,5078.01,,,,,,,,,,,,,
SPACER SPNL W10XH14XL32MM REVOLVE OPAL,SUP-2257766,CDM,C1889,HCPCS,0278,RC,,,,both,,,17310.82,11252.03,,,,,,,,,,,,,
GRAFT BONE SUB 2.5CC DEMIN BONE MTRX PRIM HD,SUP-2307262,CDM,C1713,HCPCS,0278,RC,,,,both,,,659.40,428.61,,,,,,,,,,,,,
ATTACHMENT HNDPC TELSCP MIDAS REX LEGEND,SUP-2284671,CDM,C1713,HCPCS,0278,RC,,,,both,,,4833.72,3141.92,,,,,,,,,,,,,
IMPLANT FACE L 50 X W 38 MM THK 0.25 MM POLYETHYL,SUP-2883424,CDM,C1713,HCPCS,0278,RC,,,,both,,,1425.81,926.78,,,,,,,,,,,,,
PLUG STEM TIV FLX TAPR FOR MG II ST BNE SCR NXGN,SUP-2201054,CDM,C1776,CPT,0278,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
REGADENOSON 0.4 MG/5ML IV SOLN,RX-91408,CDM,J2785,HCPCS,0636,RC,36000-0364-01,NDC,,both,5,ML,143.80,93.47,,,,,,,,,,,,,
BASEPLATE GLEN UNIV TI SHLDR PRESSFIT PROMOS +,SUP-2351199,CDM,C1776,CPT,0278,RC,,,,both,,,4898.40,3183.96,,,,,,,,,,,,,
CATHETER PTCA L120CM L10CM ODSEC3MM .035IN PERIPH OVR THE,SUP-2128652,CDM,C1725,HCPCS,0272,RC,,,,both,,,894.90,581.68,,,,,,,,,,,,,
WIRE FIX L229MM DIA1.7MM S STL PARTIALLY THRD TWO END SHRP,SUP-2409762,CDM,C1769,HCPCS,0272,RC,,,,both,,,41.39,26.90,,,,,,,,,,,,,
FIXATOR KIT SHT PVC FREE STRL PROCALLUS,SUP-2645897,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7204.29,4682.79,,,,,,,,,,,,,
INTRODUCER ENGAGE TR 4FRX12CM SHTH W/ SS STD 0.025 IN GWIRE,SUP-2355809,CDM,C1894,HCPCS,0272,RC,,,,both,,,128.74,83.68,,,,,,,,,,,,,
TIBIAL INSRT CR SZ 1 11MM,SUP-2221132,CDM,C1776,CPT,0278,RC,,,,both,,,2986.14,1940.99,,,,,,,,,,,,,
DART SURG L10MM FOR ARTHSCP MENIS REP DARTSTICK,SUP-2121765,CDM,C1713,HCPCS,0278,RC,,,,both,,,411.34,267.37,,,,,,,,,,,,,
SUPPORT ORTHOT ANK KNEE CUST SUPRAMALLEOLAR,SUP-2435625,CDM,L1907,HCPCS,0274,RC,,,,both,,,1593.11,1035.52,,,,,,,,,,,,,
COUNTERSINK IFS W/HANDLE,SUP-2400071,CDM,2720000010,LOCAL,0272,RC,,,,both,,,577.76,375.54,,,,,,,,,,,,,
CARBON FT PLT LNG 140MM FOR RNG FIX SYS,SUP-2365269,CDM,C1713,HCPCS,0278,RC,,,,both,,,2480.60,1612.39,,,,,,,,,,,,,
STEM FEM L127X203MM DIA11MM LNG DST KNEE TI W/O POR BODY,SUP-2376441,CDM,C1776,CPT,0278,RC,,,,both,,,9404.93,6113.20,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP STR 0.035 INX150 CM RADIFOCUS GLIDEWIRE,SUP-2385261,CDM,C1769,HCPCS,0272,RC,,,,both,,,118.44,76.99,,,,,,,,,,,,,
GRAFT HUM TISS M W10XL16CM THK1.6MM +/-0.4MM WHL ALLGRFT,SUP-2113183,CDM,Q4116,HCPCS,0636,RC,,,,both,,,18698.70,12154.15,,,,,,,,,,,,,
BEAM FIX 8.5X140 MM,SUP-2610033,CDM,C1713,HCPCS,0278,RC,,,,both,,,4568.70,2969.65,,,,,,,,,,,,,
PLATE BNE L271MM 12 H NONSTERILE R PERIARTC PROX HUM S STL,SUP-2177816,CDM,C1713,HCPCS,0278,RC,,,,both,,,5631.31,3660.35,,,,,,,,,,,,,
ANCHOR SUTURE 2 6.5 MM 2 ULTRABRAID TI BLU BLU TWINFIX,SUP-2849151,CDM,C1713,HCPCS,0278,RC,,,,both,,,857.22,557.19,,,,,,,,,,,,,
NAIL IM L240MM DSTL LCK POLARUS 3,SUP-2106899,CDM,C1713,HCPCS,0278,RC,,,,both,,,7529.72,4894.32,,,,,,,,,,,,,
BUR SURG DIAMOND MIC 0.38 MM FOR SALIVARY TONE,SUP-2773263,CDM,2720000010,LOCAL,0272,RC,,,,both,,,964.17,626.71,,,,,,,,,,,,,
CAGE SPNL W10XH8XL22MM 8DEG MTL POLYMER COMP LORD EXP CART,SUP-2354723,CDM,C1889,HCPCS,0278,RC,,,,both,,,15700.00,10205.00,,,,,,,,,,,,,
ELECTRODE NDL CANN L15CM ARRY DIA4CM FOR OPN AND PERC RF,SUP-2149339,CDM,C1713,HCPCS,0278,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
SET PICC 2L 5.5FR X 55CM BP,SUP-2887069,CDM,C1751,HCPCS,0278,RC,,,,both,,,1052.94,684.41,,,,,,,,,,,,,
TUBE TRACH AD L130MM OD11.7MM ID8MM SIL CUF ADJ NK FLNG,SUP-2352038,CDM,2720000010,LOCAL,0272,RC,,,,both,,,596.41,387.67,,,,,,,,,,,,,
PLATE BNE 0DEG 6 H BILAT HND S STL STR LO PROF RIG,SUP-2184848,CDM,C1713,HCPCS,0278,RC,,,,both,,,939.77,610.85,,,,,,,,,,,,,
PLATE BNE 6 H MIC TI NONSTERILE 1.5MM SCR 0.6MM,SUP-2262674,CDM,C1713,HCPCS,0278,RC,,,,both,,,321.79,209.16,,,,,,,,,,,,,
TROCAR SURG T SHP VITAL JAMSH,SUP-2693357,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
GRAFT VASC IMPRA CARBOFLO L 10 CM DIA 6 MM EPTFE CARBON FLX,SUP-2761426,CDM,C1768,CPT,0278,RC,,,,both,,,1174.45,763.39,,,,,,,,,,,,,
BUTTON CERCLAGE DIA2.5MM STRL S STL HEX STARDRV T25 USS,SUP-2187034,CDM,C1713,HCPCS,0278,RC,,,,both,,,405.06,263.29,,,,,,,,,,,,,
HC Demo/Eval Aer Neb Mdi Ippb,PX-4109466400,CDM,94664,CPT,0410,RC,,,,outpatient,,,660.00,429.00,,,,,,,,,,,,,
STENT BILI SOLUS L 7 CM DIA10 FR CATH L 210 CM 10 FR PUR,SUP-2169567,CDM,C2625,HCPCS,0278,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
CUTTER ENDO L45MM GRN TI LIN ARTC DISP,SUP-2257552,CDM,2720000010,LOCAL,0272,RC,,,,both,,,877.03,570.07,,,,,,,,,,,,,
PLATE SPNL CERV 8 DEG 24X26X12 MM GRN ZUMA,SUP-2245546,CDM,C1713,HCPCS,0278,RC,,,,both,,,20096.00,13062.40,,,,,,,,,,,,,
ROD IM ALIGN TIB LEGEND II,SUP-2454377,CDM,C1713,HCPCS,0278,RC,,,,both,,,1849.46,1202.15,,,,,,,,,,,,,
GRAFT HUM TISS M W4XL8CM ACELLULAR DERM ALLGRFT FLOWERDERM,SUP-2225420,CDM,Q4179,HCPCS,0636,RC,,,,both,,,11853.50,7704.77,,,,,,,,,,,,,
HC Reticulated Platelet Assay,PX-3058505500,CDM,85055,CPT,0305,RC,,,,both,,,122.00,79.30,,,,,,,,,,,,,
PLATE CRAN 200X100X40 MM PT SPEC IMPL PEEK,SUP-2860150,CDM,C1713,HCPCS,0278,RC,,,,both,,,45360.13,29484.08,,,,,,,,,,,,,
SOLUTION IV 500ML 0.9% SODIUM CHLORIDE INJ USP,SUP-2900295,CDM,C1713,HCPCS,0278,RC,,,,both,,,7.25,4.71,,,,,,,,,,,,,
KIT CV SHTH 10FR 30CM LEN N SPLITTABLE 18GA .038IN DIAM N,SUP-2355547,CDM,C1894,HCPCS,0272,RC,,,,both,,,58.88,38.27,,,,,,,,,,,,,
MICROCATHETER GUID CARAVEL L 135 CM SHFT OD PROX/DSTL,SUP-2123831,CDM,C1725,HCPCS,0272,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
GRAFT VASC FLIXENE L 30 CM DIA 6 MM EPTFE STD REINF 3 LAYR,SUP-2525477,CDM,C1768,CPT,0278,RC,,,,both,,,2910.75,1891.99,,,,,,,,,,,,,
CATHETER CV SET 018 4 FRX60 CM TURBO-JECT UPICDS40CT40NT1110,SUP-2759934,CDM,C1751,HCPCS,0278,RC,,,,both,,,375.51,244.08,,,,,,,,,,,,,
PLATE BONE THK1.25MM 3X3 H CRANIOMAXILLOFACIAL ORAL SLV TI,SUP-2181768,CDM,C1713,HCPCS,0278,RC,,,,both,,,1567.17,1018.66,,,,,,,,,,,,,
SCREW BNE CANN 6.5X50 MM 16 MM THRD AXSOS 3,SUP-2613620,CDM,C1713,HCPCS,0278,RC,,,,both,,,1695.60,1102.14,,,,,,,,,,,,,
GRAFT VASC GORTX L 80 CM DIA 4-7 MM OFFSET RNG L 50 CM EPTFE,SUP-2396108,CDM,C1768,CPT,0278,RC,,,,both,,,3604.72,2343.07,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 70 CM DIA 4-7 MM SHRT TAPR SLDE GDE,SUP-2525465,CDM,C1768,CPT,0278,RC,,,,both,,,2279.45,1481.64,,,,,,,,,,,,,
"HC Est Pt, Outpt Visit Level 1",PX-7619921100,CDM,99211,CPT,0761,RC,,,,inpatient,,,174.00,113.10,,,,,,,,,,,,,
GRAFT VASC VECTRA L 50 CM DIA 6 MM POLYUR STR STD WALL N,SUP-2761534,CDM,C1768,CPT,0278,RC,,,,both,,,3502.04,2276.33,,,,,,,,,,,,,
CATHETER EP LG 2-5-2 MM 5 FRX110 CM INQUIRY,SUP-2102278,CDM,C1730,HCPCS,0272,RC,,,,both,,,1287.40,836.81,,,,,,,,,,,,,
PLATE BNE 2.7X45 MM FOR SCR MULT FRAG SYS SS NS,SUP-2467227,CDM,C1713,HCPCS,0278,RC,,,,both,,,198.73,129.17,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 7X7 CM CRYOPRESERVED AMNIOX CLARIX 100,SUP-2648670,CDM,Q4156,HCPCS,0636,RC,,,,both,,,7693.00,5000.45,,,,,,,,,,,,,
MATRIX RESTRATA WOUND 2.5CM X 7.5CM,SUP-2874119,CDM,A2007,HCPCS,0636,RC,,,,both,,,7065.00,4592.25,,,,,,,,,,,,,
COMPONENT TIB BASE HNG W/ PIN,SUP-2304394,CDM,C1776,CPT,0278,RC,,,,both,,,5746.20,3735.03,,,,,,,,,,,,,
MARKER TAP L20MM DIA5MM CANN XIA 45,SUP-2381112,CDM,C1713,HCPCS,0278,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
PLATE BNE NAR 4.5X87 MM 5 HOLE SS DCP,SUP-2569163,CDM,C1713,HCPCS,0278,RC,,,,both,,,238.33,154.91,,,,,,,,,,,,,
DRESSING BIO 5 CC PORCINE URINARY BLDR MTRX 2 SYR SYS STRL,SUP-2909174,CDM,A2028,HCPCS,0636,RC,,,,both,,,8595.56,5587.11,,,,,,,,,,,,,
CAGE SPNL 15X20MM INTBDY FUS BAK,SUP-2414386,CDM,C1889,HCPCS,0278,RC,,,,both,,,18106.81,11769.43,,,,,,,,,,,,,
PATCH HERN M DIA2.5IN CIR W/ STRP SEPRA TECHNOLOGY ABSRB,SUP-2125892,CDM,C1781,HCPCS,0278,RC,,,,both,,,1316.60,855.79,,,,,,,,,,,,,
APPLICATOR TRAY GAM MINI 6-1 STRL SAVI BRACHY LF,SUP-2858444,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8635.00,5612.75,,,,,,,,,,,,,
PLATE BNE SYNDESMOSIS FOR ANK FRAC SYS ORTHOLOC 3DI,SUP-2398373,CDM,C1713,HCPCS,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
PLATE BNE CONN 4 HOLE FOR DISTRCTN OSTEOGENESIS RNG SYS,SUP-2179150,CDM,C1713,HCPCS,0278,RC,,,,both,,,291.55,189.51,,,,,,,,,,,,,
BIT DRL L DIA2MM PROX P1 ADD ON DISP FOR IM SMRT TOE II SYS,SUP-2367680,CDM,2720000010,LOCAL,0272,RC,,,,both,,,315.57,205.12,,,,,,,,,,,,,
PIN EXT FIX 6MM DIA 120MM OVERALL LEN 50MM THRD LEN,SUP-2372367,CDM,C1713,HCPCS,0278,RC,,,,both,,,372.09,241.86,,,,,,,,,,,,,
COVER IMPL IMPL 10 MM PEEK ZUMA,SUP-2245578,CDM,C1713,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
PIN FIX OD4MM THRD L50MM OD5MM TRANSFIXING PREFIX 92000 SER,SUP-2316290,CDM,C1713,HCPCS,0278,RC,,,,both,,,503.59,327.33,,,,,,,,,,,,,
GRAFT BIO TISS W10XL20CM PORCINE REGEN TISS MTRX PLIABLE,SUP-2112983,CDM,Q4130,HCPCS,0636,RC,,,,both,,,19229.36,12499.08,,,,,,,,,,,,,
ANCHOR SUTURE BRAID 2-0 5.5 MM SCR IN TI WHT BLU BLK V-LOX,SUP-2762301,CDM,C1713,HCPCS,0278,RC,,,,both,,,866.64,563.32,,,,,,,,,,,,,
ALLOGRAFT BNE CHIP 1-8 MM 15 CC PRESERVON CANC READIGRAFT,SUP-2740807,CDM,C1713,HCPCS,0278,RC,,,,both,,,822.55,534.66,,,,,,,,,,,,,
ALLOGRAFT BNE WDG 12X8 MM FD IL CREST,SUP-2860948,CDM,C1713,HCPCS,0278,RC,,,,both,,,5761.90,3745.23,,,,,,,,,,,,,
COVER BUR H DIA15MM 6 H BILAT TI NONCOMPRESSION RIG FOR,SUP-2191187,CDM,C1713,HCPCS,0278,RC,,,,both,,,854.08,555.15,,,,,,,,,,,,,
KIT INSTR W S STL STNMN PIN DRL BIT,SUP-2253297,CDM,C1713,HCPCS,0278,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
SYSTEM REP MFIL POLYPR SYNTH W/ INTEPRO LT PLIABLE FOR VAG,SUP-2140236,CDM,C1771,HCPCS,0278,RC,,,,both,,,5589.20,3632.98,,,,,,,,,,,,,
PLATE BONE DUAL CMPRSSN HLX8 TTNM CNTRD F3.5MM LOK SCREW ST,SUP-2722262,CDM,C1713,HCPCS,0278,RC,,,,both,,,1765.87,1147.82,,,,,,,,,,,,,
HC US Retroperitoneal Complete,PX-4027677000,CDM,76770,CPT,0402,RC,,,,both,,,1764.00,1146.60,,,,,,,,,,,,,
RIVASTIGMINE 9.5 MG/24HR TD PT24,RX-82505,CDM,6370000000,HCPCS,0637,RC,65162-0826-34,NDC,,both,1,UN,19.20,12.48,,,,,,,,,,,,,
DEXTROSE 5% IV SOLN NEONATE,RX-40840076,CDM,2580000003,HCPCS,0258,RC,00264-1510-31,NDC,,both,50,ML,20.90,13.58,,,,,,,,,,,,,
COMPONENT SUBTALAR SZ 12MM BILAT ANK JT PLLA NONPOLYETHYLENE,SUP-2242688,CDM,C1776,CPT,0278,RC,,,,both,,,8089.90,5258.43,,,,,,,,,,,,,
PROBE ARC STRAIGHT FIRE 23 MM OD X 220 CM 10/BX,SUP-2720130,CDM,2720000010,LOCAL,0272,RC,,,,both,,,620.31,403.20,,,,,,,,,,,,,
CAST ORTHOT ANK KNEE TIB CUST FRAC PLSTR MOLD,SUP-2435646,CDM,L2106,HCPCS,0272,RC,,,,both,,,2231.54,1450.50,,,,,,,,,,,,,
ALLOGRAFT BNE CHIP 0.1-4 MM 30 CC FD CRUSH CANC,SUP-2743394,CDM,C1713,HCPCS,0278,RC,,,,both,,,2345.58,1524.63,,,,,,,,,,,,,
ANCHOR SUT RIGIDLOOP FIXED 55MM,SUP-2749355,CDM,C1713,HCPCS,0278,RC,,,,both,,,1905.98,1238.89,,,,,,,,,,,,,
TIP EXTR FOR 2-2.5MM STRIPPED SCR HD,SUP-2337698,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1193.20,775.58,,,,,,,,,,,,,
TAP SURG NONSTERILE REUSE ORTH NEURO PROC L13MM OD4MM,SUP-2279323,CDM,2720000010,LOCAL,0272,RC,,,,both,,,386.16,251.00,,,,,,,,,,,,,
ART SURF LPS MOBILE IMPL SZ C/234 10MM,SUP-2200837,CDM,C1776,CPT,0278,RC,,,,both,,,6437.00,4184.05,,,,,,,,,,,,,
PROSTHESIS OSS PISTON 0.8X4.50 MM SCHKNT STAPE WIRE SS,SUP-2637739,CDM,L8613,CPT,0278,RC,,,,both,,,339.03,220.37,,,,,,,,,,,,,
MESH SPNL W22XH50XL28MM TI OVL,SUP-2254372,CDM,C1713,HCPCS,0278,RC,,,,both,,,13957.30,9072.24,,,,,,,,,,,,,
SCREW BNE L10MM OD2.4MM GRN TI PEEK OPTMA NONLOKING FULL,SUP-2400436,CDM,C1713,HCPCS,0278,RC,,,,both,,,84.78,55.11,,,,,,,,,,,,,
PLATE BNE RECON 3.5 MM PELV 10 HOLE,SUP-2518364,CDM,C1713,HCPCS,0278,RC,,,,both,,,3375.50,2194.07,,,,,,,,,,,,,
ALLOGRAFT DERMAL MED 4X12 CMX1.6/0.4 MM RDY TO USE ALLDERM,SUP-2492476,CDM,Q4116,HCPCS,0636,RC,,,,both,,,5306.60,3449.29,,,,,,,,,,,,,
LMA PROSEAL AIRWY PK - SZ 5,SUP-2383635,CDM,2720000010,LOCAL,0272,RC,,,,both,,,911.86,592.71,,,,,,,,,,,,,
BARIUM SULFATE 98 % PO SUSR,RX-12750,CDM,2500000003,HCPCS,0250,RC,32909-0764-01,NDC,,both,140,ML,3.70,2.40,,,,,,,,,,,,,
GRAFT VASC FLIXENE L 50 CM DIA 6 MM EPTFE STR GRAD REINF 3,SUP-2227388,CDM,C1768,CPT,0278,RC,,,,both,,,3898.25,2533.86,,,,,,,,,,,,,
DRILL SURG STEM 13 MM FEM W/ HUDSON END SPEC 2,SUP-2456532,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
BOLT FUSION MIDFOOT 6.5X115MM TI STRL,SUP-2546677,CDM,C1713,HCPCS,0278,RC,,,,both,,,1796.68,1167.84,,,,,,,,,,,,,
WASHER ORTHOPAEDIC 7 MM STAINLESS STEEL,SUP-2836676,CDM,C1713,HCPCS,0278,RC,,,,both,,,203.75,132.44,,,,,,,,,,,,,
PLATE BONE S STL FOR 5MM SCR PERIARTC SYS LCP,SUP-2177076,CDM,C1713,HCPCS,0278,RC,,,,both,,,110469.53,71805.19,,,,,,,,,,,,,
TRAY CATH HEMODIALYSI ZENYSI DL ACUTE 11FR DIA 12.5CM PCED 2,SUP-2613271,CDM,C1752,HCPCS,0278,RC,,,,both,,,859.58,558.73,,,,,,,,,,,,,
TRAB METAL FEMORAL CONE AGMT MEDIUM 50MM RIGHT,SUP-2502252,CDM,C1776,CPT,0278,RC,,,,both,,,11618.00,7551.70,,,,,,,,,,,,,
SYSTEM VENTRICULAR DRAINAGE SP0234 W/ 910121 LUMBAR CATH,SUP-2883453,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1149.11,746.92,,,,,,,,,,,,,
CEMENT BNE 20GM PMMA 30% BA SULF HALF DOSE HI VISC W/MIXER,SUP-2366942,CDM,C1713,HCPCS,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
K WIRE FIX L100MM DIA1.6MM S STL W/ THRD TIP,SUP-2186896,CDM,C1713,HCPCS,0278,RC,,,,both,,,1262.41,820.57,,,,,,,,,,,,,
LOOP OSS PISTON 5 MM RIBBON SPRING BK PLAT,SUP-2637828,CDM,L8613,CPT,0278,RC,,,,both,,,589.60,383.24,,,,,,,,,,,,,
IMMOBILIZER ORTH 30-36IN M SHLDR UNIV ELAS M,SUP-2197391,CDM,L1830,CPT,0272,RC,,,,both,,,65.31,42.45,,,,,,,,,,,,,
RESOLVE CIRQ NPHRSTMY CATH 10F CRV.MRKR BAND 0.038N 0.97 MM,SUP-2497665,CDM,C1729,HCPCS,0272,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
APPLICATOR THERMOABLATION L14CM OD1.8MM STANDARD COOLED PMTA FOR ACCULIS MICROWAVE TISSUE ABLATION SYSTEM ACCU2I,SUP-2117255,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
STEM FEM L190MM OD51MM STR REG HIP FEN ASTN MOORE,SUP-2377805,CDM,C1776,CPT,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
INTRODUCER DIAG PEEL-APART L 10.5 CM DIA 4.5 FR PTFE PERC,SUP-2127714,CDM,C1894,HCPCS,0272,RC,,,,both,,,857.22,557.19,,,,,,,,,,,,,
TRAY NERVE BLOCK CANN DIA22 GA SNB300OPM BPSK STRL LF DISP,SUP-2936665,CDM,2720000010,LOCAL,0272,RC,,,,both,,,57.09,37.11,,,,,,,,,,,,,
SCREW BNE SEMICONSTRAINED 4.5X17.5 MM WRST TI STRL FRDM,SUP-2851945,CDM,C1713,HCPCS,0278,RC,,,,both,,,947.21,615.69,,,,,,,,,,,,,
RESORB XG ST PLATE ORBTL FLR40 X 40 MM T0.6 MM PLLA PGA QT00,SUP-2498078,CDM,C1713,HCPCS,0278,RC,,,,both,,,2908.21,1890.34,,,,,,,,,,,,,
MESH HERN ELLIPSE 10X8 IN W/ ECHO2 POS SYS POLYPR PHASIX ST,SUP-2855265,CDM,C1781,HCPCS,0278,RC,,,,both,,,25371.20,16491.28,,,,,,,,,,,,,
NERVE STIMULATOR KIT IPG CHARGER KT WAVEWRITER,SUP-2141894,CDM,C1820,HCPCS,0278,RC,,,,both,,,57462.00,37350.30,,,,,,,,,,,,,
ANCHOR SUT BIOCRYL RAPIDE PUSH IN W/ 2 ETHBND GRYPHON,SUP-2249332,CDM,C1713,HCPCS,0278,RC,,,,both,,,2389.54,1553.20,,,,,,,,,,,,,
GUIDEWIRE ENDO L260CM DIA0.018IN HI PERF NOVAGOLD,SUP-2141517,CDM,C1769,HCPCS,0272,RC,,,,both,,,565.99,367.89,,,,,,,,,,,,,
HC So Drug Scrn Quan Levetiracetam,PX-3018017766,CDM,80177,CPT,0301,RC,,,,both,,,76.00,49.40,,,,,,,,,,,,,
DRESSING BIO L 3.76 X W 3.76 CM PORCINE CLLGN PHMB CROSS,SUP-2909403,CDM,Q4196,HCPCS,0636,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
SCREW BNE ST 2X6 MM CRTX COARSE PITCH TI GLD NS,SUP-2189662,CDM,C1713,HCPCS,0278,RC,,,,both,,,249.69,162.30,,,,,,,,,,,,,
SCREW BNE LAG 75 MM HIP FIX TI STRL CHIMAERA HFS,SUP-2646693,CDM,C1713,HCPCS,0278,RC,,,,both,,,2070.67,1345.94,,,,,,,,,,,,,
WIRE FIX L229MM DIA1.6MM S STL 7 DMND PNT TWO END BAYNT TIP,SUP-2412984,CDM,C1713,HCPCS,0278,RC,,,,both,,,78.66,51.13,,,,,,,,,,,,,
ALLOGRAFT DEMIN BONE PUTTY 1ML SYR,SUP-2247314,CDM,C1889,HCPCS,0278,RC,,,,both,,,430.18,279.62,,,,,,,,,,,,,
BUR SURG L72MM OD5MM LNG RND DMND NONFLUTED S STL ST,SUP-2284212,CDM,C1713,HCPCS,0278,RC,,,,both,,,473.51,307.78,,,,,,,,,,,,,
HUMERAL TRAY REVERSED 1.5 MM 12+ MM SHLDR LO OFFSET,SUP-2715761,CDM,C1776,CPT,0278,RC,,,,both,,,5666.13,3682.98,,,,,,,,,,,,,
PROBE SURG DIA8MM PIERCER DISP OSCAR3,SUP-2319122,CDM,C1713,HCPCS,0278,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
SHOE ORTHOT CALIP PLATE NEW TRANSFER,SUP-2435746,CDM,L3610,HCPCS,0274,RC,,,,both,,,284.45,184.89,,,,,,,,,,,,,
SCREW BONE L18MM DIA3.5MM MIDFOOT VAR ANG COMPR 1ST RAY,SUP-2225406,CDM,C1713,HCPCS,0278,RC,,,,both,,,499.89,324.93,,,,,,,,,,,,,
CATHETER DRAINAGE 0.038 IN 12 FRX25 CM 6 SP NDL DIL CANN SET,SUP-2168550,CDM,C1729,HCPCS,0272,RC,,,,both,,,432.13,280.88,,,,,,,,,,,,,
GRAFT HUM TISS W13-10MMXL8-14CM PAT TEND BONE HEMI SHP BLK,SUP-2307033,CDM,C1713,HCPCS,0278,RC,,,,both,,,4191.90,2724.73,,,,,,,,,,,,,
DEVICE ARTOTMY CLOSURE VASCADE DIA 5 FR CLLGN PTCH NIT DISC,SUP-2537979,CDM,C1760,HCPCS,0278,RC,,,,both,,,643.70,418.40,,,,,,,,,,,,,
PLATE BNE L63MM THK1.5MM 3X4 H BILAT S STL T SHP OBLQ ANG,SUP-2185884,CDM,C1713,HCPCS,0278,RC,,,,both,,,769.93,500.45,,,,,,,,,,,,,
PLATE BNE L112MM 4 H R MED DST TIB S STL VAR ANG LOK COMPR,SUP-2177629,CDM,C1713,HCPCS,0278,RC,,,,both,,,4769.53,3100.19,,,,,,,,,,,,,
HC Insert Cath Pleura W/ Image,PX-3613255700,CDM,32557,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
SET INTRO SUP ARW FLX SHTH L 24 CM DIA 8 FR HYDRPHLC,SUP-2383413,CDM,C1894,HCPCS,0272,RC,,,,both,,,1475.80,959.27,,,,,,,,,,,,,
LASER SURG W/ SCANNER ULTRAPULSE DUO,SUP-2713805,CDM,2720000010,LOCAL,0272,RC,,,,both,,,500045.00,325029.25,,,,,,,,,,,,,
SCREW BONE L18MM DIA2.7MM CORT S STL ST LCK FULL THRD LO,SUP-2349852,CDM,C1713,HCPCS,0278,RC,,,,both,,,801.05,520.68,,,,,,,,,,,,,
TM TIBIAL CONE LARGE 51 X 34 RIGHT,SUP-2502240,CDM,C1776,CPT,0278,RC,,,,both,,,9558.16,6212.80,,,,,,,,,,,,,
POSTERIOR PILON FUSION PLATE 12H,SUP-2817643,CDM,C1713,HCPCS,0278,RC,,,,both,,,11775.00,7653.75,,,,,,,,,,,,,
CATHETER HD DL 12 FRX16 CM CRV CONCL TIP MAHRK ELITE,SUP-2283960,CDM,C1752,HCPCS,0278,RC,,,,both,,,144.13,93.68,,,,,,,,,,,,,
PLATE BNE SCAPULA LT GLEN 4 HOLE,SUP-2846278,CDM,C1713,HCPCS,0278,RC,,,,both,,,2637.60,1714.44,,,,,,,,,,,,,
GUIDE RESECT TIB LT TRIATHLON,SUP-2364721,CDM,C1776,CPT,0278,RC,,,,both,,,618.58,402.08,,,,,,,,,,,,,
PIN EXT FIX HALF LNG 2X180 MM 25 MM THRD TIN SIDEKCK,SUP-2472329,CDM,2720000010,LOCAL,0272,RC,,,,both,,,405.06,263.29,,,,,,,,,,,,,
GRAFT BONE PASTE DEMIN BONE MTRX 8CC TREL-XC,SUP-2244468,CDM,C1713,HCPCS,0278,RC,,,,both,,,4518.46,2937.00,,,,,,,,,,,,,
PLATE BONE 135DG 14 HOLE STNLSS STEEL FMRL BLTRL STNDRD TUBE,SUP-2467104,CDM,C1713,HCPCS,0278,RC,,,,both,,,2421.79,1574.16,,,,,,,,,,,,,
COLLAR EXTRIC FR 1 3/4IN CIRC 8IN-18IN PED AQUA CERV,SUP-2194419,CDM,L0172,HCPCS,0274,RC,,,,both,,,22.67,14.74,,,,,,,,,,,,,
PLATE CRAN 180X60X40 MM PT SPEC IMPL PEEK,SUP-2860136,CDM,C1713,HCPCS,0278,RC,,,,both,,,31407.22,20414.69,,,,,,,,,,,,,
FIBER LASER DIA550UM FLEXSHIELD HOLM HI PWR POLISHED OUTPT,SUP-2139420,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1272.39,827.05,,,,,,,,,,,,,
PLATE BNE STD CNTOUR FLAT L 2ND 3RD TARSOMETATARSAL TI IMPL,SUP-2401382,CDM,C1776,CPT,0278,RC,,,,both,,,3375.50,2194.07,,,,,,,,,,,,,
SHUNT KIT NEONATAL VENTRICULOPERITONEAL HI PRESSURE ULTRA VS,SUP-2852574,CDM,C1889,HCPCS,0278,RC,,,,both,,,3890.08,2528.55,,,,,,,,,,,,,
SET INTRO 12FR L37CM SHTH L32CM UROLOGY 2 KNB PEEL AWAY,SUP-2171217,CDM,C1894,HCPCS,0272,RC,,,,both,,,176.34,114.62,,,,,,,,,,,,,
COLLAR EXTRIC AD ADJUSTABLE STFFNK SEL,SUP-2120410,CDM,L0172,HCPCS,0272,RC,,,,both,,,43.96,28.57,,,,,,,,,,,,,
SPACER SPNL L 42X30X16MM 18DEG CP SOVEREIGN,SUP-2419572,CDM,C1821,HCPCS,0278,RC,,,,both,,,13423.50,8725.27,,,,,,,,,,,,,
GRAFT BNE EVANS WDG 18X15X7 MM STRL RIPTIDE LTX,SUP-2866951,CDM,C1713,HCPCS,0278,RC,,,,both,,,6298.53,4094.04,,,,,,,,,,,,,
"HC Neuromuscular Re-Education, Ot|OP PT SERVICES|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS|UNUSUAL NON-OVERLAPPING SERVICE",PX-4309711200,CDM,97112,CPT,0430,RC,,,GP|CQ|XU,both,,,159.00,103.35,,,,,,,,,,,,,
INTRODUCER HEMSTAS FAST CATH 5FRX12CM SHTH W/ 0.038 IN GWIRE,SUP-2355476,CDM,C1894,HCPCS,0272,RC,,,,both,,,26.69,17.35,,,,,,,,,,,,,
SPLINT ELBOW/KNEE M L13.5IN FOR 10-12IN VLY MESH COT LINING,SUP-2324946,CDM,L3702,HCPCS,0274,RC,,,,both,,,78.44,50.99,,,,,,,,,,,,,
COMPONENT TOT HIP PRIMARY CERM MTL MARATHON,SUP-2249585,CDM,C1776,CPT,0278,RC,,,,both,,,15857.00,10307.05,,,,,,,,,,,,,
HC Nerve Conduction Studies 1-2 S,PX-9229590700,CDM,95907,CPT,0922,RC,,,,both,,,579.00,376.35,,,,,,,,,,,,,
NEEDLE BRST LOC KOPAN 21 GAX7.5 CM 19.4 CM SPRINGHOOK ACCURA,SUP-2876716,CDM,C1819,HCPCS,0278,RC,,,,both,,,123.09,80.01,,,,,,,,,,,,,
STRAP CLAV DLX COT L,SUP-2276604,CDM,L3650,HCPCS,0272,RC,,,,both,,,23.93,15.55,,,,,,,,,,,,,
MESH CRAN L 70 X W 80 MM SCREW DIA2 MM TI PANEL NS DISP,SUP-2936737,CDM,C1713,HCPCS,0278,RC,,,,both,,,3632.98,2361.44,,,,,,,,,,,,,
FASTRAC BONE SCREW 2.7X12MM,SUP-2841623,CDM,C1713,HCPCS,0278,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
PLATE BNE L286MM 14 H ST R MED PROX TIB S STL LOK COMPR LO,SUP-2185687,CDM,C1713,HCPCS,0278,RC,,,,both,,,4966.79,3228.41,,,,,,,,,,,,,
STEM FEM SZ 5 L130MM NK L37MM +44MM OFFSET 132DEG STD HIP,SUP-2374326,CDM,C1776,CPT,0278,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
CONNECTOR SPNL GTT ENTRY X25 6.35 MM J-HOOK CLOSED BODY,SUP-2718835,CDM,C1713,HCPCS,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
GRAFT BONE SUB 10CC CA PHOS SYNTH PUTTY FIL IMPACTION FRMLA,SUP-2319791,CDM,C1713,HCPCS,0278,RC,,,,both,,,7953.62,5169.85,,,,,,,,,,,,,
LEAD DEFIB ENDOTK ENDUR EZ L 64 CM DIA11 FR SIL PTIR STEROID,SUP-2148552,CDM,C1895,HCPCS,0275,RC,,,,both,,,56.52,36.74,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 10 CM DIA 8 MM EPTFE STR TW REINF 2,SUP-2501038,CDM,C1768,CPT,0278,RC,,,,both,,,349.98,227.49,,,,,,,,,,,,,
PLATE BNE 2X6 H ST CNDYL S STL LOK COMPR W SHT THRD DRL GUID,SUP-2177486,CDM,C1713,HCPCS,0278,RC,,,,both,,,1667.94,1084.16,,,,,,,,,,,,,
STRAP CLAV DLX COT L,SUP-2276604,CDM,L3650,HCPCS,0274,RC,,,,both,,,23.93,15.55,,,,,,,,,,,,,
PLATE BNE L MED LT 6 HOLE W/ INTERMED SPACE STRL RESORB X,SUP-2468652,CDM,C1713,HCPCS,0278,RC,,,,both,,,680.69,442.45,,,,,,,,,,,,,
DISTRACTOR SHRT BTTRSS TUBE BI DRCTNL MXLLRY DVCE T 6L 4V,SUP-2497669,CDM,C1713,HCPCS,0278,RC,,,,both,,,6228.63,4048.61,,,,,,,,,,,,,
GRAFT HUM TISS W11XH5XL14MM CANC CORT LORD SPNL SPCR,SUP-2293952,CDM,C1713,HCPCS,0278,RC,,,,both,,,3450.86,2243.06,,,,,,,,,,,,,
SCREW BONE L30MM DIA5MM TI ST FULL THRD PERIPH FOR GLEN,SUP-2388794,CDM,C1713,HCPCS,0278,RC,,,,both,,,519.67,337.79,,,,,,,,,,,,,
SNARE VASC INDY SHTH L 100 CM DIA 8 FR BSKT DIA 40 MM,SUP-2170848,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1397.17,908.16,,,,,,,,,,,,,
SCREW BNE CORTICAL 3.5 MM SS NS,SUP-2183529,CDM,C1713,HCPCS,0278,RC,,,,both,,,35.33,22.96,,,,,,,,,,,,,
NAIL IM FEM 9X300 MM RETROGRADE TI STRL DISP,SUP-2457616,CDM,C1713,HCPCS,0278,RC,,,,both,,,5818.42,3781.97,,,,,,,,,,,,,
LINER ACET HIP,SUP-2366760,CDM,C1776,CPT,0278,RC,,,,both,,,1.07,0.70,,,,,,,,,,,,,
LOW PRFLE NEURO TI MESH PANEL SML GRID 85X50MM .3MM1.5MM SYS,SUP-2500492,CDM,C1713,HCPCS,0278,RC,,,,both,,,2973.23,1932.60,,,,,,,,,,,,,
STRAP CLAV XS STD MTL TOOTH BCKL,SUP-2428779,CDM,L3650,HCPCS,0272,RC,,,,both,,,23.17,15.06,,,,,,,,,,,,,
SCREW BONE L22MM OD3.5MM CRUCFRM,SUP-2362294,CDM,C1713,HCPCS,0278,RC,,,,both,,,21.10,13.71,,,,,,,,,,,,,
EXTENSION STEM FLUT 10X80 MM KNEE REV BKS,SUP-2434300,CDM,C1776,CPT,0278,RC,,,,both,,,2327.68,1512.99,,,,,,,,,,,,,
IMPLANT ANK JT 42MM MED MALL SLED,SUP-2389600,CDM,C1713,HCPCS,0278,RC,,,,both,,,2276.50,1479.72,,,,,,,,,,,,,
ALLOGRAFT HUM TISS ACHILLES TEND FRZN PRESHAPED W/ BNE,SUP-2321838,CDM,C1762,CPT,0278,RC,,,,both,,,7520.30,4888.19,,,,,,,,,,,,,
PATCH EP CATH RHYTHMIA HDX LOCATION REF MAP NS,SUP-2744816,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2009.60,1306.24,,,,,,,,,,,,,
LO PLATE X SHAPE 8 HOLE 1.0MM 2.0 TRMA SSTM CP TTNM,SUP-2495084,CDM,C1713,HCPCS,0278,RC,,,,both,,,522.87,339.87,,,,,,,,,,,,,
MATRIX BIO L 3 X W 3 CM SZ 16 SQCM FISH SKIN DERMAL 10/BX,SUP-2909361,CDM,Q4158,HCPCS,0636,RC,,,,both,,,3617.28,2351.23,,,,,,,,,,,,,
SCREW BNE L11MM DIA1MM STD CORT CRANIOMAXILLOFACIAL TI ST,SUP-2189088,CDM,C1713,HCPCS,0278,RC,,,,both,,,336.29,218.59,,,,,,,,,,,,,
HC Ot Electricl Stim Attended 15|OP PT SERVICES|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS,PX-4309703200,CDM,97032,CPT,0430,RC,,,GP|CQ,both,,,206.00,133.90,,,,,,,,,,,,,
GRAFT VASC FLX 8 MMX70 CM STD WALL SM BEAD EPTFE CARBOFLO,SUP-2761487,CDM,C1768,CPT,0278,RC,,,,both,,,3608.58,2345.58,,,,,,,,,,,,,
CLAMP REPROC SM COMBINATION MR SAFE,SUP-2461875,CDM,2720000010,LOCAL,0272,RC,,,,both,,,356.64,231.82,,,,,,,,,,,,,
HEAD FEM MOD ANTIBIO REMEDY L 60MM,SUP-2319832,CDM,C1776,CPT,0278,RC,,,,both,,,7065.00,4592.25,,,,,,,,,,,,,
SUPPORT ORTHOT ANK PEDIATRIC KNEE CUST PLAS,SUP-2435637,CDM,L2035,HCPCS,0272,RC,,,,both,,,490.47,318.81,,,,,,,,,,,,,
BLADE SCRWDRIVER T7AOSR,SUP-2462583,CDM,2720000010,LOCAL,0272,RC,,,,both,,,879.20,571.48,,,,,,,,,,,,,
CLIP ANEURYSM L5MM 45DEG STANDARD T BAR FENESTRATED PERMANEN,SUP-2825663,CDM,C1889,HCPCS,0278,RC,,,,both,,,4291.34,2789.37,,,,,,,,,,,,,
STAPLE BONE FIX L15MM SHP MEM,SUP-2137594,CDM,C1713,HCPCS,0278,RC,,,,both,,,1125.50,731.57,,,,,,,,,,,,,
SCREW SET XCR TRAUM,SUP-2366045,CDM,C1713,HCPCS,0278,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
GRAFT VASC INTERGARD L 50 X 30 X 30 X 30 X 30 CM DIA26 X 10,SUP-2461923,CDM,C1768,CPT,0278,RC,,,,both,,,5679.48,3691.66,,,,,,,,,,,,,
WASHER ORTHPDC 65MM DIA FLAT SPDR COUNTSINK NON ST,SUP-2722546,CDM,C1713,HCPCS,0278,RC,,,,both,,,368.70,239.65,,,,,,,,,,,,,
CATHETER PICC 4FR NIT GWIRE L135CM SGL LUMN BASIC TY,SUP-2125532,CDM,C1751,HCPCS,0278,RC,,,,both,,,384.15,249.70,,,,,,,,,,,,,
COLLAR CERV RIGID SHT PD4 CH 11-16.5X2 IN HK,SUP-2246402,CDM,L0172,HCPCS,0274,RC,,,,both,,,64.56,41.96,,,,,,,,,,,,,
STAPLE BNE COMPR 2X20 MM STP,SUP-2135433,CDM,C1713,HCPCS,0278,RC,,,,both,,,4257.84,2767.60,,,,,,,,,,,,,
HC Nasal Smear for Eosinophils,PX-3008919000,CDM,89190,CPT,0300,RC,,,,both,,,223.00,144.95,,,,,,,,,,,,,
STEM FEM L7IN DIA15MM PLATFRM 1.5CM STD CALCAR HIP 12/14,SUP-2252159,CDM,C1776,CPT,0278,RC,,,,both,,,18248.42,11861.47,,,,,,,,,,,,,
DEVICE MENIS REP SEQUENT CRV 3 IMPLANTS,SUP-2167207,CDM,C1713,HCPCS,0278,RC,,,,both,,,2309.41,1501.12,,,,,,,,,,,,,
HC Cytp Fine Ndl Aspirate Immt Cytohist Std Ea Eval,PX-3118817700,CDM,88177,CPT,0311,RC,,,,both,,,177.00,115.05,,,,,,,,,,,,,
SPLINT WRST XL L8IN L BLK FOAM D RNG CLSR LO PROF MAL,SUP-2336047,CDM,L3809,HCPCS,0272,RC,,,,both,,,18.21,11.84,,,,,,,,,,,,,
PLATE BNE W175XL408MM THK52MM 22 H BILAT S STL BROAD CRV,SUP-2185325,CDM,C1713,HCPCS,0278,RC,,,,both,,,3923.40,2550.21,,,,,,,,,,,,,
SUPPORT ORTHOT CERV THOR LUMBAR SACR CUST ANTR POST LAT CTRL,SUP-2435561,CDM,L0700,HCPCS,0272,RC,,,,both,,,5636.11,3663.47,,,,,,,,,,,,,
GRAFT BNE 80 MM FD FIB SHFT,SUP-2424326,CDM,C1713,HCPCS,0278,RC,,,,both,,,1381.60,898.04,,,,,,,,,,,,,
PLATE BNE W9XL121MM THK1MM 10 H TI 1/3 TBLR LIMIT CNTCT DYN,SUP-2190957,CDM,C1713,HCPCS,0278,RC,,,,both,,,559.42,363.62,,,,,,,,,,,,,
CATHETER PTCA 4FR L170CM 0.014IN BLLN L20MM DIA2.5MM PERIPH,SUP-2170809,CDM,C1725,HCPCS,0272,RC,,,,both,,,938.26,609.87,,,,,,,,,,,,,
COUNTERSINK SURG CANN FOR 65 73MM SCR,SUP-2187344,CDM,C1713,HCPCS,0278,RC,,,,both,,,1132.50,736.12,,,,,,,,,,,,,
BURR ARTHSCP 5.5MM DIA 120MML BONE ROUND DARK GRAY ORNG F/PW,SUP-2574097,CDM,2720000010,LOCAL,0272,RC,,,,both,,,128.74,83.68,,,,,,,,,,,,,
CONNECTOR SPNL L15MM OD5.5MM S STL THORLUM LO PROF CLOSE,SUP-2230992,CDM,C1713,HCPCS,0278,RC,,,,both,,,920.02,598.01,,,,,,,,,,,,,
SUPPORT ORTHOT ANK PEDIATRIC KNEE CUST PLAS,SUP-2435637,CDM,L2035,HCPCS,0274,RC,,,,both,,,490.47,318.81,,,,,,,,,,,,,
STAPLE BONE FIXATION W14XH14XL14MM SUPERELASTIC ERGONOMIC LOW PROFILE BROAD BRIDGE DYNACLIP,SUP-2878338,CDM,C1713,HCPCS,0278,RC,,,,both,,,7394.70,4806.55,,,,,,,,,,,,,
PROBE SURG LIG PASS 4.5 MMX7.25 IN MICROSURGERY RT ANGLED TI,SUP-2458023,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1225.79,796.76,,,,,,,,,,,,,
HC Cta Heart W/WO Calcium,PX-3507557400,CDM,75574,CPT,0480,RC,,,,both,,,2388.00,1552.20,,,,,,,,,,,,,
KIT THYROPLASTY M SGL PROC MONT,SUP-2141840,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2176.02,1414.41,,,,,,,,,,,,,
SUCCINYLCHOLINE CHLORIDE 20 MG/ML IJ SOLN,RX-7536,CDM,J0330,HCPCS,0636,RC,00781-3411-95,NDC,,both,0.25,ML,54.10,35.16,,,,,,,,,,,,,
REAMER MTCRPL FOR IMPLATE SYS 3.4MM,SUP-2340242,CDM,2720000010,LOCAL,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
IMPLANT LOOP KNOTILLUS 25MM,SUP-2366686,CDM,C1713,HCPCS,0278,RC,,,,both,,,891.76,579.64,,,,,,,,,,,,,
NEEDLE BX L16CM DIA18GA DISPOSABLE CM MRK BIOPTY CUT,SUP-2127818,CDM,C1713,HCPCS,0278,RC,,,,both,,,74.42,48.37,,,,,,,,,,,,,
MATRIX DEMIN BONE 10CC STERIFUSE CRUNCH,SUP-2138661,CDM,C1713,HCPCS,0278,RC,,,,both,,,7598.80,4939.22,,,,,,,,,,,,,
PROBE NSL 20 DEG,SUP-2713684,CDM,2720000010,LOCAL,0272,RC,,,,both,,,540.14,351.09,,,,,,,,,,,,,
PLATE BNE W175XL336MM THK52MM 18 H ST BILAT S STL BROAD CRV,SUP-2185319,CDM,C1713,HCPCS,0278,RC,,,,both,,,3252.98,2114.44,,,,,,,,,,,,,
CATHETER THROMCTMY SYM L 85 CM SHTH 24 FR GUIDEWIRE 0.035 IN,SUP-2887256,CDM,C1757,HCPCS,0272,RC,,,,both,,,28244.30,18358.79,,,,,,,,,,,,,
HC So Anti-Hbs|NOT REASONABLE AND NECESSARY,PX-3028670666,CDM,86706,CPT,0302,RC,,,GZ,both,,,21.00,13.65,,,,,,,,,,,,,
PLATE OLECRANON 3.5MM 8H RT 164MM SS LCP STRL,SUP-2547485,CDM,C1713,HCPCS,0278,RC,,,,both,,,3513.47,2283.76,,,,,,,,,,,,,
SCREW 4.0MMX38MM HEADLESS,SUP-2857923,CDM,C1713,HCPCS,0278,RC,,,,both,,,2750.64,1787.92,,,,,,,,,,,,,
GRAFT BNE 166 202MM FEM SHFT FRZN BIOCLEANSE STRL,SUP-2335566,CDM,C1713,HCPCS,0278,RC,,,,both,,,8013.28,5208.63,,,,,,,,,,,,,
CATHETER OCCL BAL OCCL 26FR BAL 5FRX100CM CATH,SUP-2139720,CDM,C2628,HCPCS,0272,RC,,,,both,,,411.47,267.46,,,,,,,,,,,,,
RING ACET LCK 270 HIP RINGLOK,SUP-2441443,CDM,C1776,CPT,0278,RC,,,,both,,,296.73,192.87,,,,,,,,,,,,,
SHELL ACET OD54MM TI HA HIP CLUS H IMPL SECUR FIT XTRA,SUP-2370242,CDM,C1776,CPT,0278,RC,,,,both,,,5359.98,3483.99,,,,,,,,,,,,,
PLATE EXT FIX 2 H CIR FIX SIDEKCK FREE,SUP-2400668,CDM,2720000010,LOCAL,0272,RC,,,,both,,,270.04,175.53,,,,,,,,,,,,,
PLATE BNE NEURO MED 2 HOLE LP WIDE TI STRL LEVEL 1,SUP-2475864,CDM,C1713,HCPCS,0278,RC,,,,both,,,348.95,226.82,,,,,,,,,,,,,
POLARUS 3 SCREW CADDY 4.3 MM 48 64 MM,SUP-2639809,CDM,C1713,HCPCS,0278,RC,,,,both,,,1281.12,832.73,,,,,,,,,,,,,
PLATE STRNL CLOSURE 12 H TI Y NS STERNALOCK BLU,SUP-2894525,CDM,C1713,HCPCS,0278,RC,,,,both,,,3023.82,1965.48,,,,,,,,,,,,,
RING FIX 180 HALF IMP DNE,SUP-2197260,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2967.30,1928.74,,,,,,,,,,,,,
METATARSAL PHLANG STBL ROD 8MM,SUP-2319764,CDM,C1713,HCPCS,0278,RC,,,,both,,,1168.08,759.25,,,,,,,,,,,,,
KIT PLT BNE L54MM HD SZ 22MM 6X3 H STD R DST RAD TWO CLMN TI,SUP-2418150,CDM,C1713,HCPCS,0278,RC,,,,both,,,4356.97,2832.03,,,,,,,,,,,,,
PLATE BONE LT LAT TIBIOTALAR ANK FUS ALIGNX,SUP-2418038,CDM,C1713,HCPCS,0278,RC,,,,both,,,8007.00,5204.55,,,,,,,,,,,,,
HC Change of Ureterostomy Tube,PX-3615068800,CDM,50688,CPT,0361,RC,,,,outpatient,,,6875.00,4468.75,,,,,,,,,,,,,
STAPLER INT L90MM DIA35MM TI STPL RELD DISPOSABLE DST SER TA,SUP-2283422,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1235.84,803.30,,,,,,,,,,,,,
BLADE RETRACTOR 15 CM LT INT PIN MAST QUAD,SUP-2631629,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1728.73,1123.67,,,,,,,,,,,,,
SHEATH INTRO PERFRMR L 6 CM OD 7 FR ID 2.3 MM GUIDEWIRE,SUP-2168596,CDM,C1894,HCPCS,0272,RC,,,,both,,,60.95,39.62,,,,,,,,,,,,,
HC Automated Leukocyte Count,PX-3058504800,CDM,85048,CPT,0305,RC,,,,outpatient,,,150.00,97.50,,,,,,,,,,,,,
SPHINCTEROTOME ENDOSCP 5 MM 4.4 FRX30 MM JAGOTOME RX 7306,SUP-2480053,CDM,2720000010,LOCAL,0272,RC,,,,both,,,978.83,636.24,,,,,,,,,,,,,
GUIDE NDL BX 0 DEG 1.6 MM BOR E13C2 TRANSDUCER STRL DISP,SUP-2835414,CDM,2720000010,LOCAL,0272,RC,,,,both,,,819.54,532.70,,,,,,,,,,,,,
CATHETER CV TY 018 PEDIATRIC 5 FRX5 CM DL J TIP POLYETH,SUP-2760003,CDM,C1751,HCPCS,0278,RC,,,,both,,,287.56,186.91,,,,,,,,,,,,,
EXTRACTOR SURG SCR 4.5/5.5 MM NS EXTRIMIFIX LTX,SUP-2856029,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1403.58,912.33,,,,,,,,,,,,,
SUPPORT WR L AD RT CRPL TUNN REG FIRM SUPP CRPLGARD BLK,SUP-2324890,CDM,L3931,HCPCS,0272,RC,,,,both,,,47.51,30.88,,,,,,,,,,,,,
PIN FIX STEINMAN 9/64 IN,SUP-2150397,CDM,C1713,HCPCS,0278,RC,,,,both,,,9.42,6.12,,,,,,,,,,,,,
PLATE BNE L UNIV 2.7 MM RT 3 HOLE 2 COMPR LCK OBLQ FOR SCR,SUP-2464969,CDM,C1713,HCPCS,0278,RC,,,,both,,,890.06,578.54,,,,,,,,,,,,,
HC Lig/Trnsxj Flp Tube Abdl/Vag Appr Uni/Bi,PX-3605861100,CDM,58611,CPT,0360,RC,,,,inpatient,,,187.00,121.55,,,,,,,,,,,,,
SCREW BNE 2/PK L 4 MM DIA1.7 MM PLA GLYCOLIDE CRANIOMAXILLOFACIAL,SUP-2884150,CDM,C1713,HCPCS,0278,RC,,,,both,,,909.53,591.19,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH ALPHA L 109 MM DIA28 MM SHTH 16 FR RVD,SUP-2170227,CDM,C1874,HCPCS,0278,RC,,,,both,,,51634.16,33562.20,,,,,,,,,,,,,
GRAFT VASC EXXCEL SFT L 20 CM DIA 6 MM EPTFE STR STD WALL,SUP-2227640,CDM,C1768,CPT,0278,RC,,,,both,,,593.68,385.89,,,,,,,,,,,,,
PLATE BONE 6 H CRANIO FACE MAND FULL SEC RECON 6 + 15 + TI,SUP-2363754,CDM,C1713,HCPCS,0278,RC,,,,both,,,4242.77,2757.80,,,,,,,,,,,,,
HC Automated Leukocyte Count,PX-3058504800,CDM,85048,CPT,0305,RC,,,,inpatient,,,150.00,97.50,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE SZ 100 X 25 X 4 MM 10 CC CER GRAN,SUP-2930821,CDM,C1763,HCPCS,0278,RC,,,,both,,,8007.00,5204.55,,,,,,,,,,,,,
BIT DRL L280MM DIA4.3MM QUIK CPL W/O STP REUSE,SUP-2187276,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1115.89,725.33,,,,,,,,,,,,,
TUBE TRACHEOSTOMY FENESTRATED ADULT UNCUFFED ADAPTER STAINLE,SUP-2793417,CDM,2720000010,LOCAL,0272,RC,,,,both,,,384.68,250.04,,,,,,,,,,,,,
DEFIBRILLATOR IMPL VITALITY 2 DR W 5.9 X W 5.9 CM D 1.1 CM,SUP-2149286,CDM,C1722,HCPCS,0275,RC,,,,both,,,40506.00,26328.90,,,,,,,,,,,,,
HC Change of Ureterostomy Tube,PX-3615068800,CDM,50688,CPT,0361,RC,,,,inpatient,,,6875.00,4468.75,,,,,,,,,,,,,
SCREW SPINAL DIA45X55MM TULIP OPEN RSS LOCK RELINE,SUP-2545991,CDM,C1713,HCPCS,0278,RC,,,,both,,,188.40,122.46,,,,,,,,,,,,,
SACUBITRIL-VALSARTAN 97-103 MG PO TABS,RX-130696,CDM,6370000000,HCPCS,0637,RC,00078-0696-20,NDC,,both,1,UN,52.90,34.38,,,,,,,,,,,,,
BUTTON FIX TI UHMWPE RND GRFT SELF REINF FOR PCL RECON,SUP-2121401,CDM,C1713,HCPCS,0278,RC,,,,both,,,1095.86,712.31,,,,,,,,,,,,,
CATHETER CV QUAD LUMEN 8.5 FRX16 CM ARROWG+ARD BLU,SUP-2383385,CDM,C1751,HCPCS,0278,RC,,,,both,,,330.33,214.71,,,,,,,,,,,,,
STEM FEM SZ 3 L155MM NK L55MM 10 12 TAPR HA HIP CEM PRI STD,SUP-2253370,CDM,C1776,CPT,0278,RC,,,,both,,,9589.56,6233.21,,,,,,,,,,,,,
PPICC PROVENA SOLO SP 3F SLEEVE IR W/NIT70,SUP-2613537,CDM,C1751,HCPCS,0278,RC,,,,both,,,508.33,330.41,,,,,,,,,,,,,
SPLINT FNGR BASEBL 425IN M,SUP-2276752,CDM,L3933,HCPCS,0272,RC,,,,both,,,3.11,2.02,,,,,,,,,,,,,
TRAY CTRL VEN CATH 3FR 20GA L5CM TIP L2MM 0.018IN POLY STR J,SUP-2167946,CDM,C1751,HCPCS,0278,RC,,,,both,,,172.07,111.85,,,,,,,,,,,,,
COMPONENT TOE DIA12MM 1X1.2MM OFFSET MT CE ARTC HEMICAP,SUP-2123596,CDM,C1776,CPT,0278,RC,,,,both,,,8207.96,5335.17,,,,,,,,,,,,,
SHEATH PROTCT FOR G27 AND M3 TELESCOPES SCOPEGUARD,SUP-2313552,CDM,C1894,HCPCS,0272,RC,,,,both,,,155.59,101.13,,,,,,,,,,,,,
ROD SPNL Z 5.5X100 MM TI MARINER OUTRIG,SUP-2709841,CDM,C1713,HCPCS,0278,RC,,,,both,,,5840.40,3796.26,,,,,,,,,,,,,
GRAFT HUM TISS 40MG WHL MICRONIZED ALLGRFT AMNION CHORION,SUP-2305737,CDM,Q4186,HCPCS,0636,RC,,,,both,,,2345.61,1524.65,,,,,,,,,,,,,
PLATE BNE 40 H SCREW DIA1.5 MM TI CMF REG STR NS LORENZ,SUP-2883777,CDM,C1713,HCPCS,0278,RC,,,,both,,,1227.74,798.03,,,,,,,,,,,,,
PROSTHESIS PENILE RESERVOIR CONCEAL INFLATE,SUP-2140247,CDM,C1813,HCPCS,0278,RC,,,,both,,,7458.76,4848.19,,,,,,,,,,,,,
SET HEMO DYLS OR HD ADMIN ST150 HI PERM HEMDLYZR EXCORP CIRC,SUP-2885237,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5254.76,3415.59,,,,,,,,,,,,,
DEFIBRILLATOR IMPL ELLIPSE DR W 51 X H 70 MM THK 12 MM 36 J,SUP-2357555,CDM,C1721,HCPCS,0275,RC,,,,both,,,59660.00,38779.00,,,,,,,,,,,,,
DEVICE ULTRASONIC SHR COAG LAP W/ HND CTRL HARM,SUP-2219545,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1255.53,816.09,,,,,,,,,,,,,
BRACE KNEE OFF THE SHLF STD MED R L UNLOADER 1 +,SUP-2319283,CDM,L1844,LOCAL,0272,RC,,,,both,,,2656.44,1726.69,,,,,,,,,,,,,
ELECTRODE ENDOSCP ELECTROCAUTERY TL 175 CM EXPOSE L 11 MM,SUP-2904075,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5181.00,3367.65,,,,,,,,,,,,,
BURR SURG 4MM DIA HD LNG MIC 8MML HD SM BNE OVL DIAMOND DERM,SUP-2605571,CDM,2720000010,LOCAL,0272,RC,,,,both,,,72.09,46.86,,,,,,,,,,,,,
HC So Potassium 24hr Urine,PX-3018413366,CDM,84133,CPT,0301,RC,,,,both,,,23.00,14.95,,,,,,,,,,,,,
CHLOROTHIAZIDE 28 MG/ML IJ SOLN (PED-NEO),RX-4090152,CDM,J1205,HCPCS,0636,RC,25021-0305-66,NDC,,both,1,UN,182.20,118.43,,,,,,,,,,,,,
BLADE SAW NAR FOR STRYKR SYS 5 PROPHECY INFIN 2001381015S] WRIGHT MEDICAL TECHNOLOGY INC],SUP-2397082,CDM,2720000010,LOCAL,0272,RC,,,,both,,,533.80,346.97,,,,,,,,,,,,,
ELECTRODE KIT EMG NDL SAFEOP,SUP-2736618,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
COIL NEUROVASCULAR PENUMBRA COIL 400 L 20 CM DIA 7 MM STD,SUP-2323363,CDM,C1889,HCPCS,0278,RC,,,,both,,,6788.68,4412.64,,,,,,,,,,,,,
SHEPARD GROMMET VT 102MM FLPL,SUP-2681456,CDM,L8699,HCPCS,0278,RC,,,,both,,,24.43,15.88,,,,,,,,,,,,,
BRACE WALKING EMBEDDED SOLE MED SHT ANK ROCKER BTM INLINE,SUP-2336132,CDM,L4361,HCPCS,0274,RC,,,,both,,,79.35,51.58,,,,,,,,,,,,,
CATHETER VENTRICULAR W/ CM MRK HUNT SYS BACTISEAL,SUP-2666832,CDM,C1729,HCPCS,0272,RC,,,,both,,,1953.43,1269.73,,,,,,,,,,,,,
PLATE BNE L176MM THK3.4MM 13 H BILAT S STL STR LOK COMPR,SUP-2185148,CDM,C1713,HCPCS,0278,RC,,,,both,,,1246.11,809.97,,,,,,,,,,,,,
HC Fetal Transfusion,PX-3613646000,CDM,36460,CPT,0361,RC,,,,both,,,1377.00,895.05,,,,,,,,,,,,,
TOOL VENT ASST PMP L COR TORQ WRNCH TUNN HEX DRVR AND CVR,SUP-2282551,CDM,C1713,HCPCS,0278,RC,,,,both,,,15543.00,10102.95,,,,,,,,,,,,,
CATHETERIZATION KIT 8 FRX20 CM DL PRB ARROWG+ARD BLU +,SUP-2383109,CDM,C1751,HCPCS,0278,RC,,,,both,,,183.38,119.20,,,,,,,,,,,,,
SCREW BNE L18MM DIA3.5MM STD CORT DST TIB TI ST LOK FULL,SUP-2413564,CDM,C1713,HCPCS,0278,RC,,,,both,,,397.21,258.19,,,,,,,,,,,,,
CATHETER ANGIO JACKY RADIAL 3.5 6 FRX110 CM 2 SH OPTITORQUE,SUP-2385356,CDM,C1725,HCPCS,0272,RC,,,,both,,,109.90,71.43,,,,,,,,,,,,,
FEMORAL STEM,SUP-2364225,CDM,C1776,CPT,0278,RC,,,,both,,,8978.83,5836.24,,,,,,,,,,,,,
BLOCK EXT FIX 50MM RIG COMPRESSION/DISTRACTION STRUT,SUP-2197299,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1271.70,826.60,,,,,,,,,,,,,
ROD SPNL 5.5X30 MM LORDTC TI RELINE-O,SUP-2310170,CDM,C1713,HCPCS,0278,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
ELEVATOR ENDOSCP 7 CM NANOSCOPE,SUP-2849184,CDM,2720000010,LOCAL,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
SLEEVE COMPR SUSP,SUP-2388182,CDM,L2397,HCPCS,0272,RC,,,,both,,,300.78,195.51,,,,,,,,,,,,,
MESH SURG 16X10 CM BIOMATERIAL PREPERITONEAL ENFORM,SUP-2435399,CDM,C1781,HCPCS,0278,RC,,,,both,,,6685.06,4345.29,,,,,,,,,,,,,
ROD SPNL POST SMOOTH TI ALLOY OD4.75MM L60MM SYNERGY,SUP-2415688,CDM,C1713,HCPCS,0278,RC,,,,both,,,640.94,416.61,,,,,,,,,,,,,
DISP DRILL HIP PL SHORT HB 2.9MM,SUP-2812597,CDM,2720000010,LOCAL,0272,RC,,,,both,,,486.70,316.35,,,,,,,,,,,,,
SHUNT NEUROSURGICAL 14CM 4CM 20.5MM 900MM 8CM L VALVE SYSTEM,SUP-2826689,CDM,C1889,HCPCS,0278,RC,,,,both,,,6154.71,4000.56,,,,,,,,,,,,,
PIN HOLDING PUSH PUSH TEMP FOR ANTR CERV PLATE SYS CERVALIGN,SUP-2713497,CDM,2720000010,LOCAL,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
SCREW BNE 3.5 MM TI KREULOCK,SUP-2845747,CDM,C1713,HCPCS,0278,RC,,,,both,,,8336.70,5418.85,,,,,,,,,,,,,
ABUTMENT OTO L12MM FOR BAHA TWO STG SURG,SUP-2164987,CDM,L8614,HCPCS,0278,RC,,,,both,,,6719.60,4367.74,,,,,,,,,,,,,
KIT INTRO L 45 CM DIA 4 FR L 45 CM DIA 0.018 IN SS TUNGSTEN,SUP-2117210,CDM,C1769,HCPCS,0272,RC,,,,both,,,71.31,46.35,,,,,,,,,,,,,
SCREW BONE L80MM DIA3MM CLAV FIX TI ALLOY 2 TRAK,SUP-2106894,CDM,C1713,HCPCS,0278,RC,,,,both,,,3742.88,2432.87,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY WEBST CS L 115 CM 6 FR DECAPOLAR,SUP-2494254,CDM,C1730,HCPCS,0272,RC,,,,both,,,909.97,591.48,,,,,,,,,,,,,
CROWN POLYCARB SEC BICUSPID 53,SUP-2238347,CDM,D6783,CPT,0278,RC,,,,both,,,219.17,142.46,,,,,,,,,,,,,
K WIRE FIX L127MM DIA1.5MM DST VOLAR RAD STD TIP GEMINUS,SUP-2340262,CDM,C1713,HCPCS,0278,RC,,,,both,,,84.78,55.11,,,,,,,,,,,,,
GRAFT HUM TISS LESS THAN L5CM FIB FRZ DRY,SUP-2165544,CDM,C1713,HCPCS,0278,RC,,,,both,,,1067.60,693.94,,,,,,,,,,,,,
CATHETER SET TWO LUMEN 035 IN 12 FRX20 CM STR LG BOR PUR A+G,SUP-2627063,CDM,C1752,HCPCS,0278,RC,,,,both,,,222.59,144.68,,,,,,,,,,,,,
BUTTON SUT L12MM DIA4MM FEM SFT TISS FOR SGL INCIS BNE TO,SUP-2341291,CDM,C1713,HCPCS,0278,RC,,,,both,,,586.87,381.47,,,,,,,,,,,,,
PLATE EXT FIX L 55 MM 4 H SHRT CONN OVL SLOT NS DISP ILIZ,SUP-2933815,CDM,2720000010,LOCAL,0272,RC,,,,both,,,544.10,353.66,,,,,,,,,,,,,
STEM FEM CEM POLISHED SZ 9 125MM INTRIGUE,SUP-2406814,CDM,C1776,CPT,0278,RC,,,,both,,,9451.40,6143.41,,,,,,,,,,,,,
BLADE ARTHSCP D4.5MM GRAY SHVR ANGLD TMCT SM JOINT FRMLA,SUP-2589383,CDM,2720000010,LOCAL,0272,RC,,,,both,,,216.60,140.79,,,,,,,,,,,,,
BIT DRL QC 4.8X180 MM FOR DYN AX FIX TIN COAT NS LTX,SUP-2874957,CDM,2720000010,LOCAL,0272,RC,,,,both,,,366.75,238.39,,,,,,,,,,,,,
DEVICE LENS FRAGMENTATION MILOOP,SUP-2420828,CDM,2720000010,LOCAL,0272,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 3X3 CM CRYOPRESERVED WND NEOX 100,SUP-2648680,CDM,Q4156,HCPCS,0636,RC,,,,both,,,2119.50,1377.67,,,,,,,,,,,,,
GRAFT BNE SUB CANC CORT DEMIN 3/4 FILL DIVERTED TB AFT G2,SUP-2307037,CDM,C1889,HCPCS,0278,RC,,,,both,,,932.58,606.18,,,,,,,,,,,,,
CRANIO SCULPT CRANIAL BONE VOID FILLER3 CC QTY001 EA,SUP-2477084,CDM,C1713,HCPCS,0278,RC,,,,both,,,3803.33,2472.16,,,,,,,,,,,,,
BURR HOLE COVER CNTRD 3MM 22MM DIA 15MM SSTM CP TTNM,SUP-2678290,CDM,C1713,HCPCS,0278,RC,,,,both,,,704.74,458.08,,,,,,,,,,,,,
MILL BNE ELECTR SGL PASS CUT ACT,SUP-2363674,CDM,2720000010,LOCAL,0272,RC,,,,both,,,12560.00,8164.00,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 80 MM DIA18/22 MM DEL,SUP-2934158,CDM,C1713,HCPCS,0278,RC,,,,both,,,21289.07,13837.90,,,,,,,,,,,,,
CATHETER GUID L 100 CM OD 7 FR ID 0.078 IN PTFE LNR AR 1 SH,SUP-2910572,CDM,C1887,HCPCS,0272,RC,,,,both,,,123.53,80.29,,,,,,,,,,,,,
SUPPORT PROSTHETIC JT KNEE GTT LCK L2405] TIDEWATER PROSTHETICS],SUP-2388183,CDM,L2405,HCPCS,0274,RC,,,,both,,,224.54,145.95,,,,,,,,,,,,,
ALLOGRAFT BNE FRZN IRRADIATED LT TALUS NO CART,SUP-2867174,CDM,C1762,CPT,0278,RC,,,,both,,,8054.10,5235.16,,,,,,,,,,,,,
HC Inj Proc Hip,PX-3612709300,CDM,27093,CPT,0361,RC,,,,outpatient,,,3707.00,2409.55,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 12X2 CM PROC SUSPEND FASC LATA TUTOPLAST,SUP-2165386,CDM,C1713,HCPCS,0278,RC,,,,both,,,3482.26,2263.47,,,,,,,,,,,,,
ORTHOSIS LUMSACR PREFABRICATED SAG CTRL SACROCOCCYGEAL,SUP-2237268,CDM,L0648,HCPCS,0272,RC,,,,both,,,3128.51,2033.53,,,,,,,,,,,,,
POR ST/OSS CP/LGXL/LG HD,SUP-2212425,CDM,C1776,CPT,0278,RC,,,,both,,,17270.00,11225.50,,,,,,,,,,,,,
PASSER SUT 45DEG SLINGSHOT CHAMPION,SUP-2365419,CDM,2720000010,LOCAL,0272,RC,,,,both,,,253.21,164.59,,,,,,,,,,,,,
GUIDEWIRE 20X150MM TRCR TIP PLN,SUP-2243908,CDM,C1769,HCPCS,0272,RC,,,,both,,,140.14,91.09,,,,,,,,,,,,,
HC Blood Draw per Port,PX-7613659100,CDM,36591,CPT,0510,RC,,,,both,,,387.00,251.55,,,,,,,,,,,,,
CATHETER EP H CRV 7 FR 1X9 MM 10 INQUIRY,SUP-2102300,CDM,C1731,HCPCS,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
MESH HERN W10XL15CM THK2MM EPTFE PTCH OVL 2 SIDE FOR,SUP-2125742,CDM,C1781,HCPCS,0278,RC,,,,both,,,2514.83,1634.64,,,,,,,,,,,,,
BIT DRL TWST 2.5X76 MM W/ NOTCH LEVEL 1 DISP,SUP-2457973,CDM,2720000010,LOCAL,0272,RC,,,,both,,,358.56,233.06,,,,,,,,,,,,,
SYSTEM NEG PRSS INCIS MGMT PEEL AND PLC DISP PREVENA,SUP-2261592,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1429.96,929.47,,,,,,,,,,,,,
CATHETER GUID MRESS CRV 5 FRX110 CM LG LUMEN LAUNCHER,SUP-2429725,CDM,C1887,HCPCS,0272,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
RESERVOIR DRAINAGE 12 MM 0.6 CC BUR HOLE SIDE INLET,SUP-2277898,CDM,2720000010,LOCAL,0272,RC,,,,both,,,853.14,554.54,,,,,,,,,,,,,
SPACER SPNL 30 DEG W 34 X H 15 MM D 26 MM TI ANTR LUMBAR,SUP-2881732,CDM,C1713,HCPCS,0278,RC,,,,both,,,18840.00,12246.00,,,,,,,,,,,,,
HC Ther Ivntj Cog Funcj Cntct Ea Addl 15 Mins,PX-4409713000,CDM,97130,CPT,0440,RC,,,,outpatient,,,186.00,120.90,,,,,,,,,,,,,
PLATE BNE L 206 X W 11 MM THK 3 MM SCREW DIA2.7/3.5 MM 17 H 72466217N,SUP-2933196,CDM,C1713,HCPCS,0278,RC,,,,both,,,6074.02,3948.11,,,,,,,,,,,,,
HEAD FEM 0+ MM 10/12 36 MM TAPR OXIN,SUP-2434859,CDM,C1776,CPT,0278,RC,,,,both,,,6179.52,4016.69,,,,,,,,,,,,,
SYSTEM LD DEL ACUITY PRO,SUP-2149266,CDM,C1887,HCPCS,0272,RC,,,,both,,,1808.64,1175.62,,,,,,,,,,,,,
BOOT CAST 4IN TCC-EZ,SUP-2194354,CDM,L4386,HCPCS,0272,RC,,,,both,,,340.69,221.45,,,,,,,,,,,,,
ALLOGRAFT BNE WDG 20-22 MM FD ILIUM TRICORT,SUP-2717916,CDM,C1713,HCPCS,0278,RC,,,,both,,,5586.94,3631.51,,,,,,,,,,,,,
CATHETER DRAINAGE TY 10.2 FRX25 CM SELD PGTL FURMAN,SUP-2759779,CDM,C1729,HCPCS,0272,RC,,,,both,,,605.71,393.71,,,,,,,,,,,,,
ADAPTER LL 165MM STR,SUP-2420216,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1478.94,961.31,,,,,,,,,,,,,
PLATE BNE IM 0 DEG HI PERF LCS HP,SUP-2456396,CDM,C1713,HCPCS,0278,RC,,,,both,,,1183.78,769.46,,,,,,,,,,,,,
HC Assay of Sex Hormone Binding Globulin,PX-3018427000,CDM,84270,CPT,0301,RC,,,,outpatient,,,465.00,302.25,,,,,,,,,,,,,
HC So2 Drg Scrn Class List A|ADJ,PX-3018030768,CDM,80307,CPT,0301,RC,,,ADJ,both,,,452.00,293.80,,,,,,,,,,,,,
RING EXT FIX ID115MM TI C FBR HYBRID 3 4 FOR DST TIB FRME,SUP-2188608,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1182.49,768.62,,,,,,,,,,,,,
GRAFT DURA L 4 X W 5 IN THK 0.6 MM TYP I CLLGN BOV ACHILLES,SUP-2889754,CDM,C1763,HCPCS,0278,RC,,,,both,,,3870.30,2515.69,,,,,,,,,,,,,
GUIDEWIRE VASC INQWIRE L 260 CM DIA 0.035 IN TAPR L 7.5 CM,SUP-2665433,CDM,C1769,HCPCS,0272,RC,,,,both,,,146.95,95.52,,,,,,,,,,,,,
STAPLE BONE L SCAPHOID,SUP-2351301,CDM,C1713,HCPCS,0278,RC,,,,both,,,295.16,191.85,,,,,,,,,,,,,
SHUNT SURG ADJ L 17 MM CATH DSTL L 1200 MM VENTRICULAR L 180 FX633T,SUP-2931050,CDM,C1729,HCPCS,0272,RC,,,,both,,,12824.23,8335.75,,,,,,,,,,,,,
GUIDEWIRE UROLOGY L145CM OD0.038IN TIP L3CM S STL PTFE STR,SUP-2171181,CDM,C1769,HCPCS,0272,RC,,,,both,,,75.36,48.98,,,,,,,,,,,,,
HANDPIECE ELECSURG ANGLE 45 DEG ABC TECHNOLOGY,SUP-2225644,CDM,2720000010,LOCAL,0272,RC,,,,both,,,588.75,382.69,,,,,,,,,,,,,
PLATE BNE LAPIDUS LG 0 MM RT W/ STP TI RIVAL VW,SUP-2645192,CDM,C1713,HCPCS,0278,RC,,,,both,,,5705.38,3708.50,,,,,,,,,,,,,
KIT EXT FIX ANK HOFFMANN II,SUP-2372209,CDM,2720000010,LOCAL,0272,RC,,,,both,,,12145.27,7894.43,,,,,,,,,,,,,
MESH HERN L9CM O3FA COAT POLYPR STR KNIT CONSTRUCTION SEE,SUP-2265978,CDM,C1781,HCPCS,0278,RC,,,,both,,,807.64,524.97,,,,,,,,,,,,,
SET SCR SPNL L50MM DIA6.4MM PEDCL HA TI ALLOY FOR DYN STBL,SUP-2414276,CDM,C1713,HCPCS,0278,RC,,,,both,,,10920.92,7098.60,,,,,,,,,,,,,
TIGHTROPE XP BUTTRESS PLATE IMPLANT SYS,SUP-2830108,CDM,C1713,HCPCS,0278,RC,,,,both,,,12544.30,8153.79,,,,,,,,,,,,,
BLADE SURG SAW GRFT HARV ST S STL ACL 20MM LEN 10MM W .4MM,SUP-2236517,CDM,2720000010,LOCAL,0272,RC,,,,both,,,335.98,218.39,,,,,,,,,,,,,
BIT DRL L80MM DIA2.4MM MINI QUIK CPL,SUP-2187710,CDM,2720000010,LOCAL,0272,RC,,,,both,,,359.66,233.78,,,,,,,,,,,,,
PASSER SUT 45DEG CRV TIP FOR ARTHSCP BANKART SLAP AND ROT,SUP-2121808,CDM,2720000010,LOCAL,0272,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
WIRE ORTH 7MM 1.2MM SM THRD K,SUP-2316515,CDM,C1713,HCPCS,0278,RC,,,,both,,,89.02,57.86,,,,,,,,,,,,,
BASEPLATE GLEN DIA29MM 15MM POST PRESSFIT AEQUALIS REVERSED,SUP-2388656,CDM,C1713,HCPCS,0278,RC,,,,both,,,6398.54,4159.05,,,,,,,,,,,,,
SCREW SPNL 2PK L13MM OD4MM SELF DRL VAR ANG 2P,SUP-2418612,CDM,C1713,HCPCS,0278,RC,,,,both,,,722.20,469.43,,,,,,,,,,,,,
KIT JET7 AND PENUMBRA HI FLOW ASPIR TBNG AND 3D,SUP-2323587,CDM,2720000010,LOCAL,0272,RC,,,,both,,,28212.90,18338.38,,,,,,,,,,,,,
KIT BNE CEMENT SZ 40 44.8 GM PWDR 37.7 GM LIQ 20 ML PMMA MED,SUP-2916857,CDM,C1713,HCPCS,0278,RC,,,,both,,,6622.26,4304.47,,,,,,,,,,,,,
"HC So Porphyrins,Quantitive",PX-3018412066,CDM,84120,CPT,0301,RC,,,,both,,,1044.00,678.60,,,,,,,,,,,,,
ROD SPNL L 300 MM DIA 5.5 MM TI STR,SUP-2930633,CDM,C1889,HCPCS,0278,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
HC So Amoebic Antibodies by Iha,PX-3028675366,CDM,86753,CPT,0302,RC,,,,outpatient,,,129.00,83.85,,,,,,,,,,,,,
CATHETER ABLAT 7FR TIP L5MM 2.5MM SPC QPLR L CRV STD LEN HI,SUP-2141282,CDM,C1733,HCPCS,0272,RC,,,,both,,,2951.60,1918.54,,,,,,,,,,,,,
SCREW BNE L20MM DIA4.5MM PROX CORT TIB S STL ST LOK FULL,SUP-2184506,CDM,C1713,HCPCS,0278,RC,,,,both,,,65.12,42.33,,,,,,,,,,,,,
ATORVASTATIN CALCIUM 10 MG PO TABS,RX-19176,CDM,6370000000,HCPCS,0637,RC,00904-6290-61,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
BICTEGRAVIR-EMTRICITAB-TENOFOV 50-200-25 MG PO TABS,RX-141307,CDM,6370000000,HCPCS,0637,RC,61958-2501-01,NDC,,both,1,UN,632.50,411.12,,,,,,,,,,,,,
GUIDEWIRE VASC ARW GLIDEWHEEL L 60 CM DIA 0.032 IN NIT,SUP-2763343,CDM,C1769,HCPCS,0272,RC,,,,both,,,58.66,38.13,,,,,,,,,,,,,
SCREW CAP FOR HETTICH BUCKET,SUP-2841235,CDM,C1713,HCPCS,0278,RC,,,,both,,,70.65,45.92,,,,,,,,,,,,,
GRAFT DERMAL MESH 12X10 CM FEN CLLGN MTRX,SUP-2243699,CDM,Q4110,HCPCS,0636,RC,,,,both,,,12811.20,8327.28,,,,,,,,,,,,,
SCREW BNE ST 4.3X46 MM CANN SD PART THRD TI NS PROPELLER HD,SUP-2474003,CDM,C1713,HCPCS,0278,RC,,,,both,,,703.58,457.33,,,,,,,,,,,,,
GRAFT VASC GORTX L 30 CM DIA 6 MM EPTFE STR TW N RING STRL,SUP-2396693,CDM,C1768,CPT,0278,RC,,,,both,,,1494.64,971.52,,,,,,,,,,,,,
HYALURONIDASE BOVINE 15 UNITS/ML IJ SYRINGE,RX-40891037,CDM,J3470,HCPCS,0636,RC,09999-9917-18,NDC,,both,0.2,ML,64.20,41.73,,,,,,,,,,,,,
TRAY CATH PICC LUMENX3 6FR OD POLYURETHANE SUBCLAV MAXIMAL B,SUP-2613373,CDM,C1751,HCPCS,0278,RC,,,,both,,,784.06,509.64,,,,,,,,,,,,,
COMPONENT FEM NP HIP POST STBL CONS LEGION,SUP-2348022,CDM,C1776,CPT,0278,RC,,,,both,,,13188.00,8572.20,,,,,,,,,,,,,
MATRIX RESTRATA WOUND 7.5CM X 7.5CM,SUP-2874121,CDM,A2007,HCPCS,0636,RC,,,,both,,,10597.50,6888.37,,,,,,,,,,,,,
GRAFT BNE BLOCK MED TRICORT,SUP-2759547,CDM,C1713,HCPCS,0278,RC,,,,both,,,5907.69,3840.00,,,,,,,,,,,,,
CONNECTOR SPNL OD23MM TI MONOBLOCK MULTIAXIAL MAC LX,SUP-2379879,CDM,C1713,HCPCS,0278,RC,,,,both,,,1491.50,969.47,,,,,,,,,,,,,
STAPLE BNE 20X20X20 MM EASYCLIP,SUP-2365482,CDM,C1776,CPT,0278,RC,,,,both,,,4482.04,2913.33,,,,,,,,,,,,,
SYSTEM MICROCATHETER 2.8FR L130CM HYDRPHLC L70CM GWIRE,SUP-2385155,CDM,C1887,HCPCS,0272,RC,,,,both,,,1863.90,1211.53,,,,,,,,,,,,,
"HC Gbl New Pt, E/M Level 3",PX-9829920300,CDM,99203,CPT,0982,RC,,,,inpatient,,,498.00,323.70,,,,,,,,,,,,,
CATHETER PERITONEAL DLYS MR SAFE W/ BIOGLDE,SUP-2664551,CDM,2720000010,LOCAL,0272,RC,,,,both,,,522.84,339.85,,,,,,,,,,,,,
NUCLEUS PROFILE PLUS W/ SLIM MODIOLAR ELECTRODE (CI632),SUP-2858189,CDM,L8614,HCPCS,0278,RC,,,,both,,,75666.15,49183.00,,,,,,,,,,,,,
STEM ULN SZ 2 STD EL UHEAD,SUP-2379272,CDM,C1776,CPT,0278,RC,,,,both,,,10048.00,6531.20,,,,,,,,,,,,,
LINER ACET SZ D ID26MM STD HIP HGP II CUP ELEV RIM,SUP-2202730,CDM,C1776,CPT,0278,RC,,,,both,,,3830.80,2490.02,,,,,,,,,,,,,
HC So1 Hiv-1 Quantification,PX-3068753667,CDM,87536,CPT,0306,RC,,,,both,,,158.00,102.70,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP STR 0.035 INX450 CM STRL GLIDEWIRE LF DISP,SUP-2472758,CDM,C1769,HCPCS,0272,RC,,,,both,,,847.64,550.97,,,,,,,,,,,,,
AXLE TIB OSS AVL,SUP-2441790,CDM,C1776,CPT,0278,RC,,,,both,,,1215.18,789.87,,,,,,,,,,,,,
SPLINT ORTHOPEDIC W/ ABDUCTED XL 8 IN RT WRST FOREARM THMB,SUP-2276640,CDM,L3809,HCPCS,0274,RC,,,,both,,,23.05,14.98,,,,,,,,,,,,,
BLADE RETRACTOR 15 CMX20 MM VES THN OLIF,SUP-2627584,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2311.54,1502.50,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 70 CM DIA 6 MM 30 CM STR STD WALL,SUP-2396267,CDM,C1768,CPT,0278,RC,,,,both,,,3504.24,2277.76,,,,,,,,,,,,,
SROM NRH REPLC HINGE BRG QTY2,SUP-2515641,CDM,C1776,CPT,0278,RC,,,,both,,,1051.27,683.33,,,,,,,,,,,,,
SET HAD CATHETER 10FR L52CM SGL W CUF L22X25CM TWO FREE,SUP-2269510,CDM,C1881,HCPCS,0278,RC,,,,both,,,460.95,299.62,,,,,,,,,,,,,
PIN EXT FIX HALF M5 200 MM 30 MM SS,SUP-2162651,CDM,2720000010,LOCAL,0272,RC,,,,both,,,514.96,334.72,,,,,,,,,,,,,
PLATE BONE W24XL24MM CRAN ORBIT FLR RESRB FOR 1.5MM SCR,SUP-2194053,CDM,C1713,HCPCS,0278,RC,,,,both,,,1921.68,1249.09,,,,,,,,,,,,,
BUR SURG HD L19.1MM DIA3.1MMXLONG STR ROUTER ELITE TPS,SUP-2363412,CDM,2720000010,LOCAL,0272,RC,,,,both,,,344.24,223.76,,,,,,,,,,,,,
ALLOGRAFT BNE LORDTC 7 DEG 12 MM CERV PRESERVON VG2,SUP-2740923,CDM,C1713,HCPCS,0278,RC,,,,both,,,3435.16,2232.85,,,,,,,,,,,,,
BUNDLE CASE DISTRCTN CRAN MXLFCL 1 FULL SKULL RECON VSP,SUP-2862825,CDM,2720000010,LOCAL,0272,RC,,,,both,,,16149.59,10497.23,,,,,,,,,,,,,
GRAFT DERMAL RECT 9.8X11.8 IN ANTIBACT XENMATRIX AB,SUP-2855244,CDM,C1781,HCPCS,0278,RC,,,,both,,,78811.49,51227.47,,,,,,,,,,,,,
REAMER SURG 11 MM METATRSL MTP,SUP-2423328,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1428.70,928.65,,,,,,,,,,,,,
CATHETER DIL BAL L24MM DIA7MM SINUS RELIEVA SOLO PRO,SUP-2106328,CDM,C1729,HCPCS,0272,RC,,,,both,,,2263.94,1471.56,,,,,,,,,,,,,
COIL NEUROVASCULAR MICROPLEX L 31 CM LOOP DIA12 MM,SUP-2305215,CDM,C1889,HCPCS,0278,RC,,,,both,,,4082.00,2653.30,,,,,,,,,,,,,
DEFIBRILLATOR IMPL LUMAX 340 DR-T TI EPOXY RESIN SIL 2 CHMBR,SUP-2138119,CDM,C1721,HCPCS,0275,RC,,,,both,,,58244.39,37858.85,,,,,,,,,,,,,
APPLICATOR WAND KIT CAV WAX +,SUP-2100443,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1299.21,844.49,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP L150CM DIA0035IN S STL FLX TIP MOV COR,SUP-2313733,CDM,C1769,HCPCS,0272,RC,,,,both,,,74.39,48.35,,,,,,,,,,,,,
CATHETER ANGIOPLSTY CROSPERIO L 150 CM L 200MM DIA 2.5 MM RX,SUP-2385490,CDM,C1725,HCPCS,0272,RC,,,,both,,,678.24,440.86,,,,,,,,,,,,,
PAIN PUMP KIT 10 IN 400 CC SILVERSOAKER CATH ON-Q PAINBUSTER,SUP-2236850,CDM,C2626,HCPCS,0278,RC,,,,both,,,1130.40,734.76,,,,,,,,,,,,,
PACEMAKER CARD REOCOR D 2 CHMBR EXT TEMP NS,SUP-2138198,CDM,2720000010,LOCAL,0272,RC,,,,both,,,14130.00,9184.50,,,,,,,,,,,,,
PLATE BNE RT DSTL HUM LAT TRL,SUP-2606622,CDM,C1713,HCPCS,0278,RC,,,,both,,,907.33,589.76,,,,,,,,,,,,,
KETAMINE HCL 50 MG/ML IJ SOLN,RX-4238,CDM,2500000003,HCPCS,0250,RC,00409-2053-10,NDC,,both,10,ML,54.10,35.16,,,,,,,,,,,,,
GRAFT HUM TISS W2XL4CM THCK AMNIO BARR MEM CHORION BASE,SUP-2399182,CDM,C1762,CPT,0278,RC,,,,both,,,5604.90,3643.18,,,,,,,,,,,,,
COMPONENT FEM PS CEM HI FLX SZ 0 LT,SUP-2223180,CDM,C1776,CPT,0278,RC,,,,both,,,12760.96,8294.62,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9% BOLUS (FLUID RESUSCITATION),RX-4081440,CDM,J7040,HCPCS,0250,RC,00264-7800-10,NDC,,both,1000,ML,59.50,38.67,,,,,,,,,,,,,
HC So1 Factor VIII,PX-3058524067,CDM,85240,CPT,0305,RC,,,,inpatient,,,637.00,414.05,,,,,,,,,,,,,
CAGE SPNL L W14XH9XL16MM 4DEG CERV THORLUM C FBR POLYMER,SUP-2256206,CDM,C1889,HCPCS,0278,RC,,,,both,,,7614.50,4949.42,,,,,,,,,,,,,
ELECTRODE VPR 24FR YEL RESECTSCP,SUP-2261178,CDM,2720000010,LOCAL,0272,RC,,,,both,,,761.98,495.29,,,,,,,,,,,,,
BRACE ORTH CIRC THGH 15.5-18.5 IN CALF 12 IN SM SZ 2 TI RT,SUP-2915084,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1753.53,1139.79,,,,,,,,,,,,,
DRILL TWST L 50 MM DIA1.5 MM STP 6 MM NUT NS DISP,SUP-2936472,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1067.60,693.94,,,,,,,,,,,,,
PLATE BNE L338MM BLDE W48XL25MM 95DEG 20 H ST HIP S STL RIG,SUP-2186770,CDM,C1713,HCPCS,0278,RC,,,,both,,,4764.01,3096.61,,,,,,,,,,,,,
IMPLANT BIO L 3 X W 12 CM FISH SKIN DERMAL SLD INTACT FLAT,SUP-2909242,CDM,Q4158,HCPCS,0636,RC,,,,both,,,3617.28,2351.23,,,,,,,,,,,,,
BRACE ORTHOPEDIC SM RT WRST LTHR,SUP-2194875,CDM,L3931,HCPCS,0272,RC,,,,both,,,27.00,17.55,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED UPCHARGE CERM ON CERM UPCHGCERCER] ZIMMER BIOMET INC],SUP-2212676,CDM,C1776,CPT,0278,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
GRAFT HUM TISS L100MM FIBULAR SHFT FRZ DRY ALLGRFT MATRIGRFT,SUP-2264766,CDM,C1713,HCPCS,0278,RC,,,,both,,,1937.41,1259.32,,,,,,,,,,,,,
SCREW BNE L26MM DIA2MM PUR TI ALLY THRD AND ROUNDED CONIC HD,SUP-2181034,CDM,C1713,HCPCS,0278,RC,,,,both,,,492.79,320.31,,,,,,,,,,,,,
STRAIGHT REDUCTION CLAMP BROAD,SUP-2473831,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2030.95,1320.12,,,,,,,,,,,,,
STAPLE BNE FIX L W14.2XL23MM CO CHROM LIG SPIK,SUP-2342743,CDM,C1713,HCPCS,0278,RC,,,,both,,,1760.47,1144.31,,,,,,,,,,,,,
ROPIVACAINE HCL 10 MG/ML IJ SOLN,RX-18194,CDM,J2795,HCPCS,0636,RC,63323-0288-11,NDC,,both,15,ML,97.90,63.63,,,,,,,,,,,,,
HC So Hepatitis a Antibody (Total),PX-3028670866,CDM,86708,CPT,0302,RC,,,,inpatient,,,106.00,68.90,,,,,,,,,,,,,
SCREW BONE L45MM DIA6.5MM THRD L24MM HD DIA8MM CANC S STL ST,SUP-2184598,CDM,C1713,HCPCS,0278,RC,,,,both,,,99.38,64.60,,,,,,,,,,,,,
BIT DRL L400MM DIA25MM W O STP CALIB JCBS CHK,SUP-2188815,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1527.33,992.76,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9% BOLUS (FLUID RESUSCITATION),RX-4081440,CDM,2580000003,HCPCS,0258,RC,00990-7983-61,NDC,,both,1000,ML,297.50,193.37,,,,,,,,,,,,,
TUBE VENT DIA1MM TI REUT MIC FINISH 2 STD BOB W/ FLNG H FOR,SUP-2313689,CDM,L8699,HCPCS,0278,RC,,,,both,,,109.12,70.93,,,,,,,,,,,,,
BRACE ORTHOPEDIC SM RT WRST LTHR,SUP-2194875,CDM,L3931,HCPCS,0274,RC,,,,both,,,27.00,17.55,,,,,,,,,,,,,
RASP SURG STD SGL END CRV HANDHELD,SUP-2372588,CDM,C1713,HCPCS,0278,RC,,,,both,,,2533.85,1647.00,,,,,,,,,,,,,
Z DISCONTINUED NO SUB IDED TUBE VENT L12MM ID1.14X2.2MM EAR FLROPLAS SPL FEUERSTEIN,SUP-2381506,CDM,L8699,HCPCS,0278,RC,,,,both,,,43.96,28.57,,,,,,,,,,,,,
HC So Dna Antibody,PX-3028622566,CDM,86225,CPT,0302,RC,,,,both,,,397.00,258.05,,,,,,,,,,,,,
PROSTHESIS PENILE DSTL TIP 12 MMX3 CM DURA II,SUP-2140243,CDM,C1813,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
RING EXT FIX DIA180 MM LNG FT BLU NS DISP SMRT TSF,SUP-2932835,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5650.12,3672.58,,,,,,,,,,,,,
KYPHOPLASTY PACK 10 GA 2 ML STR W/ CD-H OSSEOFLEX SB OCP0217,SUP-2463686,CDM,2720000010,LOCAL,0272,RC,,,,both,,,10267.80,6674.07,,,,,,,,,,,,,
CATHETER CV 3L 7 FRX16 CM BASIC KT ARROWG+ARD,SUP-2383311,CDM,C1751,HCPCS,0278,RC,,,,both,,,151.10,98.21,,,,,,,,,,,,,
PLATE BNE 17 DEG THK 2.8 MM SCREW DIA2-2.3-2.7 MM 6 X 17 H,SUP-2883621,CDM,C1713,HCPCS,0278,RC,,,,both,,,4018.16,2611.80,,,,,,,,,,,,,
BUTTON GASTROSTOMY 18FR DIA 24INL PUSH STEP,SUP-2676811,CDM,2720000010,LOCAL,0272,RC,,,,both,,,544.26,353.77,,,,,,,,,,,,,
GRAFT BNE PTTY 1 CC MOLD DBM XEMPLIFI +,SUP-2423064,CDM,C9359,HCPCS,0278,RC,,,,both,,,596.60,387.79,,,,,,,,,,,,,
PLATE BONE 4X16 H RT MAND TI ANG RIG NONCOMPRESSION,SUP-2191414,CDM,C1713,HCPCS,0278,RC,,,,both,,,4995.74,3247.23,,,,,,,,,,,,,
STENT TRACHBRONCH WSTNT L 80 MM DIA20 MM SHTH 11 FR CATH L,SUP-2142678,CDM,C1876,HCPCS,0278,RC,,,,both,,,5670.09,3685.56,,,,,,,,,,,,,
STEM FEM L180MM OD19MM HA POR HIP PRI PRESSFIT MLRY HD,SUP-2408314,CDM,C1776,CPT,0278,RC,,,,both,,,16645.14,10819.34,,,,,,,,,,,,,
PLATE BONE LOK SHRT 230MML HLX15 PRPLE ST RIGHT MED DST HMRL,SUP-2588209,CDM,C1713,HCPCS,0278,RC,,,,both,,,3373.93,2193.05,,,,,,,,,,,,,
POSTOP APP NON WGT BEAR DSG,SUP-2388203,CDM,L5450,HCPCS,0274,RC,,,,both,,,715.67,465.19,,,,,,,,,,,,,
GUIDEWIRE L12IN SUBTALAR HORZ,SUP-2137795,CDM,C1769,HCPCS,0272,RC,,,,both,,,78.50,51.02,,,,,,,,,,,,,
STEM FEM L140MM DIA12MM HIP FBR MTL MIDCOAT L MTPHSEAL BODY 78411250] ZIMMER BIOMET INC],SUP-2211306,CDM,C1776,CPT,0278,RC,,,,both,,,9314.50,6054.42,,,,,,,,,,,,,
GRAFT SYNTHETIC TISSUE GRANULE 1.42.8 MM 2.5 CC BETA TRICALC,SUP-2838533,CDM,C1713,HCPCS,0278,RC,,,,both,,,1149.55,747.21,,,,,,,,,,,,,
SCREW LOW-PROF CORTICAL 03.5 X 57.5,SUP-2741992,CDM,C1713,HCPCS,0278,RC,,,,both,,,292.02,189.81,,,,,,,,,,,,,
PLATE 3.5MM TI LCP POSTEROLATERAL DISTAL HUMERUS 9H RIGHT,SUP-2549682,CDM,C1713,HCPCS,0278,RC,,,,both,,,3899.72,2534.82,,,,,,,,,,,,,
JOINT FNGR 40 MED 11.6X21.8X9.9 MM 11.8 MM PYROCARBON NUGRIP,SUP-2852867,CDM,C1776,CPT,0278,RC,,,,both,,,11986.95,7791.52,,,,,,,,,,,,,
SET CATHETER L65CM OD4FR GWIRE OD0035IN STR TIP SHTH L55CN,SUP-2171152,CDM,C1894,HCPCS,0272,RC,,,,both,,,2527.70,1643.00,,,,,,,,,,,,,
TAPESTRY RC BIOINTEGRATIVE 30X30 MM ANTR LF,SUP-2867249,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3956.40,2571.66,,,,,,,,,,,,,
PLATE BNE L 378 MM SCREW DIA 4.5 MM 19 H SS RT DSTL FEM 72574219,SUP-2933045,CDM,C1713,HCPCS,0278,RC,,,,both,,,13194.28,8576.28,,,,,,,,,,,,,
BRACE ANK LACE UP FIGURE 8 X L,SUP-2276709,CDM,L4350,HCPCS,0272,RC,,,,both,,,23.55,15.31,,,,,,,,,,,,,
STIMULATOR NERVE CHARGER GENRTR EON,SUP-2355967,CDM,C1713,HCPCS,0278,RC,,,,both,,,3124.30,2030.79,,,,,,,,,,,,,
DYNAMIZER EXT FIX RADLUC STRL TRUELOK,SUP-2875239,CDM,2720000010,LOCAL,0272,RC,,,,both,,,10424.80,6776.12,,,,,,,,,,,,,
GRAFT BIO TISS MESH 16X10 CM MIROMATRIX MIROMESH,SUP-2115025,CDM,C1781,HCPCS,0278,RC,,,,both,,,14519.36,9437.58,,,,,,,,,,,,,
PATCH DURA L 5.5 X W 3.1 IN SURF AREA17.1 SQ IN BOV PERICARD,SUP-2884058,CDM,C1763,HCPCS,0278,RC,,,,both,,,2571.66,1671.58,,,,,,,,,,,,,
PLATE SPNL L35MM SPINOUS PROC LCK SP-FIX,SUP-2230593,CDM,C1713,HCPCS,0278,RC,,,,both,,,5149.60,3347.24,,,,,,,,,,,,,
SUPPORT ORTHOT WRST HND FNGR CUST CABLE DRIVEN FABRICATED,SUP-2435770,CDM,L3901,HCPCS,0272,RC,,,,both,,,5470.16,3555.60,,,,,,,,,,,,,
POST FIX TAPR,SUP-2123530,CDM,C1776,CPT,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
IMPLANT KNEE JOINT OSTEOCHONDRAL MATRIX SYNTHETIC BONE STERILE,SUP-2913426,CDM,C1763,HCPCS,0278,RC,,,,both,,,20096.00,13062.40,,,,,,,,,,,,,
SPACER TIB MED 15 MM PROX KNEE TILASTAN,SUP-2433948,CDM,C1776,CPT,0278,RC,,,,both,,,2935.90,1908.33,,,,,,,,,,,,,
ELECTRODE ELECSURG CUT LOOP 30 DEG 24 FR 0.2 IN MONOPOLAR,SUP-2485688,CDM,2720000010,LOCAL,0272,RC,,,,both,,,377.33,245.26,,,,,,,,,,,,,
BOOT ORTHOSIS FOR 11-13IN ANK FOAM STATIC FOR POS AND PRSS,SUP-2194764,CDM,L4387,HCPCS,0274,RC,,,,both,,,138.54,90.05,,,,,,,,,,,,,
SCREW BONE CORT DIAM 2.0MM L10MM CROSS PIN LCK,SUP-2363439,CDM,C1713,HCPCS,0278,RC,,,,both,,,195.68,127.19,,,,,,,,,,,,,
ALLOGRAFT BNE CHIP 1-4 MM 15 CC PRESERVON CANC READIGRAFT,SUP-2740806,CDM,C1713,HCPCS,0278,RC,,,,both,,,847.67,550.99,,,,,,,,,,,,,
CATHETER VENT L23CM OD2.5MM ID1.3MM S STL ANTIBIO IMPREG,SUP-2284709,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1364.74,887.08,,,,,,,,,,,,,
GRAFT HUMAN TISSUE BIOLOGICAL TISSUE MATRIX THICK 30X30 CM NON CROSSLINKED SCAFFOLD NATURALLY OCCURRING PORCINE STERILE GENTRIX DISPOSABLE,SUP-2106505,CDM,Q4166,HCPCS,0636,RC,,,,both,,,76513.95,49734.07,,,,,,,,,,,,,
BURR SURG 8.5MM DIA HD LG BNE BRL FLUTEX6 CTTNG FLFRVSNS SUR,SUP-2605416,CDM,2720000010,LOCAL,0272,RC,,,,both,,,564.32,366.81,,,,,,,,,,,,,
PROBE CRYOSURGERY 18IN BALL TIP 8MM ERGO HNDL BEND DST SHFT,SUP-2124445,CDM,C2618,HCPCS,0272,RC,,,,both,,,8164.00,5306.60,,,,,,,,,,,,,
STRUT SPNL W10XL200MM THK3-12MM FEM CORT HALVED ALLGRFT,SUP-2307361,CDM,C1713,HCPCS,0278,RC,,,,both,,,3216.93,2091.00,,,,,,,,,,,,,
ANCHOR SUT DIA4.5MM KNOTLESS PEEK REELX STT,SUP-2366713,CDM,C1713,HCPCS,0278,RC,,,,both,,,1575.68,1024.19,,,,,,,,,,,,,
PLATE B1 CRANIOMAXILLOFACIAL THK1MM 12 H ORBIT TI TI LEV 1,SUP-2262688,CDM,C1713,HCPCS,0278,RC,,,,both,,,820.48,533.31,,,,,,,,,,,,,
DISC INTERVERTEBRAL ARTIFICIAL 1 6 MM CERV SIMPLIFY,SUP-2751656,CDM,C1889,HCPCS,0278,RC,,,,both,,,15662.32,10180.51,,,,,,,,,,,,,
SHEATH INTRO HEARTSPAN 120 DEG L 60 CM DIA 8.5 FR SHRT CRV,SUP-2516632,CDM,C1894,HCPCS,0272,RC,,,,both,,,486.70,316.35,,,,,,,,,,,,,
PLATE BONE L22MM 100DEG 2X3 H LT CRANIOMAXILLOFACIAL TEAL TI,SUP-2191157,CDM,C1713,HCPCS,0278,RC,,,,both,,,1028.66,668.63,,,,,,,,,,,,,
ALLOGRAFT BNE 8 CC ACTIFUSE ABX,SUP-2208430,CDM,C1889,HCPCS,0278,RC,,,,both,,,6327.10,4112.61,,,,,,,,,,,,,
SYSTEM PLATELET CONC GRAVITATIONAL SEP DBL GPS II,SUP-2424578,CDM,C1713,HCPCS,0278,RC,,,,both,,,2590.50,1683.82,,,,,,,,,,,,,
ADAPTER PACE LD NS,SUP-2137987,CDM,C1883,HCPCS,0278,RC,,,,both,,,1469.52,955.19,,,,,,,,,,,,,
LEAD PACE AD L25CM INTRO 56FR ATR VENT TI NITRIDE TIP IS 1,SUP-2356096,CDM,C1898,HCPCS,0275,RC,,,,both,,,1208.90,785.78,,,,,,,,,,,,,
STENT GRFT CVR VIABAHN 7MMX10.0X110CM,SUP-2396488,CDM,C1874,HCPCS,0278,RC,,,,both,,,8587.90,5582.13,,,,,,,,,,,,,
SKTRPN W/CV PT 60X22X3 HP,SUP-2818401,CDM,C1713,HCPCS,0278,RC,,,,both,,,1169.59,760.23,,,,,,,,,,,,,
PLATE BNE L8MM N COMPR CHIN BILAT 4 H RIG FOR 2MM SCR H DIA,SUP-2421257,CDM,C1713,HCPCS,0278,RC,,,,both,,,834.77,542.60,,,,,,,,,,,,,
STABILIZER PECTUS BAR TI NS PECTUS BLU,SUP-2895745,CDM,C1713,HCPCS,0278,RC,,,,both,,,10299.20,6694.48,,,,,,,,,,,,,
CLIP SURG MECHANOMYOGRAPHY STIM MULT STG SS NS,SUP-2693683,CDM,2720000010,LOCAL,0272,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
STENT BILI ZILVER FLX 35 L 120 MM DIA 6 MM CATH L 125 CM DIA,SUP-2170731,CDM,C1876,HCPCS,0278,RC,,,,both,,,2785.18,1810.37,,,,,,,,,,,,,
IMMOBILIZER ELBW SM L7IN FOR 7-9IN BICEP 6-8IN WR COT W/O,SUP-2269055,CDM,L3650,HCPCS,0272,RC,,,,both,,,97.34,63.27,,,,,,,,,,,,,
STENT ENDOPROS L2.5CM DIA6MM CATH 7FR L120CM 0.035IN VES,SUP-2396595,CDM,C1874,HCPCS,0278,RC,,,,both,,,9715.16,6314.85,,,,,,,,,,,,,
STEM FEM DIA13MM +10MM SHT TI HIP REV POLISHED EMPERION,SUP-2344350,CDM,C1776,CPT,0278,RC,,,,both,,,14662.23,9530.45,,,,,,,,,,,,,
SHEATH INTRO L 25 CM DIA 7 FR HEMOSTAS CLASSIC STRL,SUP-2148794,CDM,C1892,HCPCS,0272,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
BIT DRL COUNTSINK 7 MM,SUP-2315924,CDM,2720000010,LOCAL,0272,RC,,,,both,,,744.18,483.72,,,,,,,,,,,,,
TUBE VENT ARMSTR R 1.14 PHOSPHORYLCHOLINE COAT SIL 510281C,SUP-2535119,CDM,L8699,HCPCS,0278,RC,,,,both,,,49.80,32.37,,,,,,,,,,,,,
IMPLANT BIO TISS W10XL15MM THK1MM BOV CLLGN SEMI OVL FEN,SUP-2243669,CDM,C1781,HCPCS,0278,RC,,,,both,,,11304.00,7347.60,,,,,,,,,,,,,
PLATE BONE L22MM 110DEG MINI RT L LHR,SUP-2364917,CDM,C1713,HCPCS,0278,RC,,,,both,,,409.20,265.98,,,,,,,,,,,,,
BAR EXT FIX 11X400 MM CARBON,SUP-2749999,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1667.34,1083.77,,,,,,,,,,,,,
COIL NEUROVASCULAR MATRIX2 360 DEG L 15 CM DIA 7 MM,SUP-2363109,CDM,C1889,HCPCS,0278,RC,,,,both,,,8087.38,5256.80,,,,,,,,,,,,,
SCREW BNE LCK 3.5X80 MM PERIARTICULAR CANN CONCL SS,SUP-2410847,CDM,C1713,HCPCS,0278,RC,,,,both,,,351.90,228.73,,,,,,,,,,,,,
FENTANYL CITRATE-NACL 2.5-0.9 MG/250ML-% IV SOLN,RX-134085,CDM,J7999,HCPCS,0636,RC,71266-5010-01,NDC,,both,250,ML,195.50,127.07,,,,,,,,,,,,,
IMPLANT BLGCL TSSUE 15CMW X 24CML 06 17MM THK ACLLLR ALLGR,SUP-2675795,CDM,Q4128,HCPCS,0636,RC,,,,both,,,19312.98,12553.44,,,,,,,,,,,,,
HC Fluoro Exam Gtube Jtube,PX-3204946500,CDM,49465,CPT,0320,RC,,,,both,,,780.00,507.00,,,,,,,,,,,,,
WIRE BNE FIX L 150 MM DIA2 MM SS TRCR PT NS KIRSCHNER,SUP-2908310,CDM,C1713,HCPCS,0278,RC,,,,both,,,28.10,18.26,,,,,,,,,,,,,
GUIDEROD ORTH L 600 MM DIA2 MM HUM GRAD BALL TIP STRL DISP,SUP-2932892,CDM,C1713,HCPCS,0278,RC,,,,both,,,474.77,308.60,,,,,,,,,,,,,
TUBING SET CAN FOR VAC PMP,SUP-2859792,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
HEAD HUM SZ 6 HA COAT SHLDR RESURF COPELAND,SUP-2403990,CDM,C1776,CPT,0278,RC,,,,both,,,13583.64,8829.37,,,,,,,,,,,,,
BLOCK EXT FIX 150MM RIG COMPRESSION/DISTRACTION STRUT,SUP-2197296,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2119.50,1377.67,,,,,,,,,,,,,
DRILL SURG PISTON 2 MM PERC NS INION OTPS LTX REUSE,SUP-2857870,CDM,2720000010,LOCAL,0272,RC,,,,both,,,659.40,428.61,,,,,,,,,,,,,
CANNULA ARTHSCP L75MM OD8.5MM RIG DISP AQUALOC,SUP-2212793,CDM,C1713,HCPCS,0278,RC,,,,both,,,602.88,391.87,,,,,,,,,,,,,
RESERVOIR SHUNT OD14MM THK4.8MM SM TI FLSH LO PROF RADPQ,SUP-2108708,CDM,C1729,HCPCS,0272,RC,,,,both,,,887.84,577.10,,,,,,,,,,,,,
PLATE BONE L 4 H BX FOR STERNALOCK BLU SYS,SUP-2418021,CDM,C1713,HCPCS,0278,RC,,,,both,,,1519.76,987.84,,,,,,,,,,,,,
GUIDEPIN SURG OD45MM CALIB SPADE TIP TOGGLELOC,SUP-2136098,CDM,C1713,HCPCS,0278,RC,,,,both,,,569.72,370.32,,,,,,,,,,,,,
BIT DRL L115MM DIA1.5MM RED S STL TWST J NOTCH W/O STP,SUP-2262760,CDM,2720000010,LOCAL,0272,RC,,,,both,,,422.33,274.51,,,,,,,,,,,,,
LACTATED RINGERS IV SOLN,RX-4318,CDM,J7120,HCPCS,0250,RC,00338-0117-03,NDC,,both,500,ML,38.30,24.89,,,,,,,,,,,,,
GRAFT HUM TISS W4XL6CM THK45UM AMNIO MEMBRN DEHYDR OMNI DIR,SUP-2340454,CDM,C1762,CPT,0278,RC,,,,both,,,7536.00,4898.40,,,,,,,,,,,,,
GUIDEWIRE VASC GLIDEWIRE L 180 CM DIA 0.018 IN TIP L 3 CM,SUP-2148188,CDM,C1769,HCPCS,0272,RC,,,,both,,,389.36,253.08,,,,,,,,,,,,,
PLATE FOOT CRV 4 HL RT,SUP-2473511,CDM,C1713,HCPCS,0278,RC,,,,both,,,3375.50,2194.07,,,,,,,,,,,,,
MESH HERN W18XL24CM D15MM BIOMATERIAL ANTIMIC W H GORE,SUP-2395350,CDM,C1781,HCPCS,0278,RC,,,,both,,,4810.48,3126.81,,,,,,,,,,,,,
GRAFT BONE SUB 2.5CC DEMIN BONE MTRX PUTTY ALLOSYNC,SUP-2120754,CDM,C1776,CPT,0278,RC,,,,both,,,1243.44,808.24,,,,,,,,,,,,,
LEAD NERVE STIM 2X8 CONTACT 70 CM KT ARTISAN,SUP-2423219,CDM,C1778,HCPCS,0278,RC,,,,both,,,10990.00,7143.50,,,,,,,,,,,,,
COMPONENT FEM SZ 1 LT KNEE CO CHROM ROT PLATFRM FIX REF MOB,SUP-2253413,CDM,C1776,CPT,0278,RC,,,,both,,,9391.11,6104.22,,,,,,,,,,,,,
SAWBLADE STRYKER 1.27 X 19 X 100MM,SUP-2890788,CDM,C1776,CPT,0278,RC,,,,both,,,530.66,344.93,,,,,,,,,,,,,
TIP ASPIR 0.3MM STR MIC COAX INTREPID,SUP-2109919,CDM,2720000010,LOCAL,0272,RC,,,,both,,,747.32,485.76,,,,,,,,,,,,,
COLLAR CERV M PD H25IN FOR 10 20IN NK PLAS HK AND LOOP CLSR,SUP-2196887,CDM,C1874,HCPCS,0278,RC,,,,both,,,138.03,89.72,,,,,,,,,,,,,
GUIDEWIRE ORTH ANGLED PROP 3 MM FOR 3.5 MM PLATE,SUP-2644637,CDM,C1769,HCPCS,0272,RC,,,,both,,,1017.08,661.10,,,,,,,,,,,,,
RING EXT FIX LNG 160 MM SET RX STRUT STRL TRUELOK EVO LTX,SUP-2875585,CDM,2720000010,LOCAL,0272,RC,,,,both,,,29084.31,18904.80,,,,,,,,,,,,,
SPACER SHLDR HD DIA50MM 06GM GENT BASE PMMA BNE CEM MOD HUM,SUP-2319843,CDM,C1776,CPT,0278,RC,,,,both,,,11775.00,7653.75,,,,,,,,,,,,,
CATHETER DIAG L135CM DST L10CM MIC NEURO RENEGADE HI FLO,SUP-2367867,CDM,C1887,HCPCS,0272,RC,,,,both,,,2606.20,1694.03,,,,,,,,,,,,,
SCREW SPNL POLYAX MOD TULIP ADV FOR 5.5MM ROD CREO,SUP-2228673,CDM,C1713,HCPCS,0278,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
SLEEVE TROCAR L60MM DIAMETER 5MM THREADED DISPOSABLE WITHOUT,SUP-2803689,CDM,2720000010,LOCAL,0272,RC,,,,both,,,366.38,238.15,,,,,,,,,,,,,
CATHETER VALVULOPLASTY 4FR L70CM BAL L2CM DIA7MM 0.021IN MIC,SUP-2125234,CDM,C1725,HCPCS,0272,RC,,,,both,,,1684.30,1094.79,,,,,,,,,,,,,
BRACE ELBW C SHP REINF ADJ COUNTERFORCE VISCOELASTIC POLYMER,SUP-2324053,CDM,L3702,HCPCS,0274,RC,,,,both,,,137.66,89.48,,,,,,,,,,,,,
PLATE QUIKFLAP BURRHOLE  SD AXS,SUP-2718054,CDM,C1713,HCPCS,0278,RC,,,,both,,,7479.48,4861.66,,,,,,,,,,,,,
BASEPLATE GLEN HD DIA40/42MM REG BILAT UHMWPE PEGGED,SUP-2193838,CDM,C1776,CPT,0278,RC,,,,both,,,3608.71,2345.66,,,,,,,,,,,,,
HYDROCODONE-ACETAMINOPHEN 7.5-325 MG/15ML PO SOLN,RX-37848,CDM,340b,HCPCS,0637,RC,00121-2316-50,NDC,,both,5,ML,7.00,4.55,,,,,,,,,,,,,
IMPLANT IM SMRT TOE II,SUP-2365964,CDM,C1713,HCPCS,0278,RC,,,,both,,,2576.06,1674.44,,,,,,,,,,,,,
FIBER LASER 33 FT KRA-CPAOCHXL HDMI,SUP-2798088,CDM,2720000010,LOCAL,0272,RC,,,,both,,,830.40,539.76,,,,,,,,,,,,,
PLATE BNE 12 H NONSTERILE STRNL TI ANG LOK FOR 3MM SCR,SUP-2192443,CDM,C1713,HCPCS,0278,RC,,,,both,,,4120.31,2678.20,,,,,,,,,,,,,
GUIDEWIRE ORTHOPEDIC 45300015] STRYKER CORP],SUP-2362778,CDM,C1769,HCPCS,0272,RC,,,,both,,,101.42,65.92,,,,,,,,,,,,,
MARKER BRST BX TI NDL OD9GA US STEREOTACTIC GUID SHP 1 ATEC,SUP-2240069,CDM,A4648,CPT,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
PLATE BONE L216MM 12 H STD BILAT COMPR CNTOUR + BROAD FOR,SUP-2349005,CDM,C1713,HCPCS,0278,RC,,,,both,,,2591.98,1684.79,,,,,,,,,,,,,
HC N Block Paravert Thoracic 1st,PX-3606449000,CDM,64490,CPT,0360,RC,,,,both,,,4864.00,3161.60,,,,,,,,,,,,,
GRAFT BNE PTTY DEMIN BNE MTRX 3CC TREL-XC,SUP-2244467,CDM,C1713,HCPCS,0278,RC,,,,both,,,2527.70,1643.00,,,,,,,,,,,,,
MESH SURG W15XL15CM POLYPR SYN ABD NONABSORBABLE SQ 3 INDIV,SUP-2165384,CDM,C1781,HCPCS,0278,RC,,,,both,,,1360.66,884.43,,,,,,,,,,,,,
PLATE BNE 2.5X49X1.6 MM LAT DSTL RADIAL WRST 6 HOLE TI,SUP-2423733,CDM,C1713,HCPCS,0278,RC,,,,both,,,3164.18,2056.72,,,,,,,,,,,,,
SHUNT SURG L 13.4 MM CATH L DSTL 600 MM VENTRICULAR 180 MM,SUP-2929354,CDM,C1889,HCPCS,0278,RC,,,,both,,,7237.29,4704.24,,,,,,,,,,,,,
BIT DRL NANO PROF NS ACUTRK 3,SUP-2912742,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1623.38,1055.20,,,,,,,,,,,,,
COLLAR EXTRIC AD REG 2 PC TRACH OPN VELC CLSR W/ CHIN SUPP,SUP-2194469,CDM,L0180,HCPCS,0272,RC,,,,both,,,61.83,40.19,,,,,,,,,,,,,
"HC So Encephalitis, Western Equine",PX-3028665466,CDM,86654,CPT,0302,RC,,,,both,,,34.00,22.10,,,,,,,,,,,,,
VALVE CSF STD 15 CM STR CATH RADIOPAQUE LEN DOTS F8 WHT DP,SUP-2852666,CDM,C1889,HCPCS,0278,RC,,,,both,,,3560.04,2314.03,,,,,,,,,,,,,
NAIL IM L19.5CM DIA14MM 130DEG RT FEM HIP GRN TI CANN LCK,SUP-2347890,CDM,C1713,HCPCS,0278,RC,,,,both,,,2886.60,1876.29,,,,,,,,,,,,,
ELECTRODE RESECTOSCOPE UPLR 24 FRX5 MM CYL TYP,SUP-2360972,CDM,C1713,HCPCS,0278,RC,,,,both,,,641.09,416.71,,,,,,,,,,,,,
CATHETER SUPP QUICK-CROSS L 150 CM 5 FR 0.063/0.05IN 0.035IN,SUP-2823684,CDM,C1887,HCPCS,0272,RC,,,,both,,,524.38,340.85,,,,,,,,,,,,,
MESH HERN W20XL25IN POLYPR EPTFE NONABSORBABLE ELP COMPOSIX,SUP-2125808,CDM,C1781,HCPCS,0278,RC,,,,both,,,3468.13,2254.28,,,,,,,,,,,,,
GUIDE SURG KNIFE TIP 0.6 MM KNEE WIRE STRUT NOTCH END,SUP-2392436,CDM,C1769,HCPCS,0272,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
GENERATOR NEUROSTIMULATOR EON RECHRG IPG 16 CHN,SUP-2355970,CDM,C1820,HCPCS,0278,RC,,,,both,,,47100.00,30615.00,,,,,,,,,,,,,
LEAD NERVE STIM 50 CM 3-4 TRL LINEAR,SUP-2765577,CDM,C1778,HCPCS,0278,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
GUIDEWIRE ORTH THRD 2.8X300 MM,SUP-2657782,CDM,C1769,HCPCS,0272,RC,,,,both,,,182.12,118.38,,,,,,,,,,,,,
DRILL RADLUC TARGET 37MM,SUP-2371640,CDM,2720000010,LOCAL,0272,RC,,,,both,,,356.08,231.45,,,,,,,,,,,,,
IMPACTOR SURG BALL 36 MM ID LNR G7,SUP-2440304,CDM,C1776,CPT,0278,RC,,,,both,,,197.82,128.58,,,,,,,,,,,,,
COIL VASC MREYE EMBOLUS L 3 CM DIA 5 MM CATH DIA 0.035 IN,SUP-2170419,CDM,C1889,HCPCS,0278,RC,,,,both,,,211.01,137.16,,,,,,,,,,,,,
SCREW BONE OSTEOTMY CORT FULL THRD N CANN ST N LCK NSTERILE,SUP-2199955,CDM,C1713,HCPCS,0278,RC,,,,both,,,369.26,240.02,,,,,,,,,,,,,
CATHETER GUID CXI L 65 CM DIA 2.6 FR 0.018IN SS ANGLED 2 TIP,SUP-2638648,CDM,C1887,HCPCS,0272,RC,,,,both,,,638.77,415.20,,,,,,,,,,,,,
MESH C-QUR EDGEXL OBLONG OVL 14 INX14 IN,SUP-2265975,CDM,C1781,HCPCS,0278,RC,,,,both,,,7121.52,4628.99,,,,,,,,,,,,,
ROD EXT FIX L250MM DIA11MM C CONN FOR HOFFMANN III MRI SYS,SUP-2372228,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1112.19,722.92,,,,,,,,,,,,,
MESH SURG L 15 X W 15 CM POLYPRO POLYLACTIC ACD GRP,SUP-2901690,CDM,C1781,HCPCS,0278,RC,,,,both,,,2128.42,1383.47,,,,,,,,,,,,,
BASKET EXTR L4CM DIA2CM CATH L208CM SHTH 10FR ACC CHN 4.2MM,SUP-2170589,CDM,2720000010,LOCAL,0272,RC,,,,both,,,998.52,649.04,,,,,,,,,,,,,
DEFIBRILLATOR IMPL DYNAGEN MINI W 5.23 X H 6.71 CM D 0.99 CM,SUP-2149164,CDM,C1722,HCPCS,0275,RC,,,,both,,,29245.96,19009.87,,,,,,,,,,,,,
PLATE BONE 18 H ANTR BOW LAT PROX FOR 3.5 SCR,SUP-2349064,CDM,C1713,HCPCS,0278,RC,,,,both,,,1135.49,738.07,,,,,,,,,,,,,
PLATE BONE M SZ 12MM 2 H STR FOR NEURO USE LORENZ,SUP-2402909,CDM,C1713,HCPCS,0278,RC,,,,both,,,109.90,71.43,,,,,,,,,,,,,
SNARE VASC CURRY FOLDED L 150 CM SHFT L 100 CM DIA 6.3 FR,SUP-2167936,CDM,C1713,HCPCS,0278,RC,,,,both,,,797.56,518.41,,,,,,,,,,,,,
MAGNESIUM SULFATE 4000 MG/100 ML IVPB PREMIX,RX-4081077,CDM,J3475,HCPCS,0636,RC,44567-0421-24,NDC,,both,100,ML,54.10,35.16,,,,,,,,,,,,,
SCISSORS DENT L16.5CM STD SHARP/SHARP 1 SERR BLDE S STL DEAN,SUP-2238685,CDM,2720000010,LOCAL,0272,RC,,,,both,,,332.81,216.33,,,,,,,,,,,,,
CUP ACET 32X50 MM MARBURG AP,SUP-2441691,CDM,C1776,CPT,0278,RC,,,,both,,,2656.44,1726.69,,,,,,,,,,,,,
COMPONENT TIB SZ 1 IMPL TALARIS,SUP-2244136,CDM,C1776,CPT,0278,RC,,,,both,,,30172.26,19611.97,,,,,,,,,,,,,
CATHETER ETER ANGIO 27X2FR ID0019IN L150CM 0016IN HYDRPHLC STR,SUP-2422359,CDM,C1887,HCPCS,0272,RC,,,,both,,,2433.50,1581.77,,,,,,,,,,,,,
SCREW BNE L 74 MM DIA 5.5 MM SHRT TI CANN HD NS LEOS,SUP-2931442,CDM,C1713,HCPCS,0278,RC,,,,both,,,909.69,591.30,,,,,,,,,,,,,
PIN FIX 2.1X5 MM POLY-L-LACTIC ACID POLY GLYCOLIC ACID STRL,SUP-2470755,CDM,C1713,HCPCS,0278,RC,,,,both,,,287.47,186.86,,,,,,,,,,,,,
ANCHOR SUTURE HI STRENGTH 2/1/2000 W/ NDL ORTHOCORD,SUP-2176892,CDM,C1713,HCPCS,0278,RC,,,,both,,,591.45,384.44,,,,,,,,,,,,,
CATHETER INTVASC OCCL Q50 + L 65 CM L 40 MM 10-50 mm 3-60cc,SUP-2691406,CDM,C2628,HCPCS,0272,RC,,,,both,,,2125.78,1381.76,,,,,,,,,,,,,
HEAD FEM 44 MM HIP CERM SEL,SUP-2449662,CDM,C1776,CPT,0278,RC,,,,both,,,6344.37,4123.84,,,,,,,,,,,,,
DILATOR SURG 8-24FR L37CM FASCIAL POLYETH RADPQ,SUP-2171194,CDM,C1713,HCPCS,0278,RC,,,,both,,,1155.21,750.89,,,,,,,,,,,,,
SCREW ACET 6.5X30 MM CANC HIP LOGICAL 111129130],SUP-2322443,CDM,C1713,HCPCS,0278,RC,,,,both,,,235.44,153.04,,,,,,,,,,,,,
PLATE BNE TENS BND MINI NAR 1 MM 2X2 HOLE MALL TI NS,SUP-2181762,CDM,C1713,HCPCS,0278,RC,,,,both,,,1375.95,894.37,,,,,,,,,,,,,
KIT BSR-1B CONSISTING OFXXX,SUP-2139743,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2983.00,1938.95,,,,,,,,,,,,,
PLATE BONE MESHED 1X0.3 MM ORBITAL CRANIOFACIAL FLOOR TITANI,SUP-2838340,CDM,C1713,HCPCS,0278,RC,,,,both,,,4903.74,3187.43,,,,,,,,,,,,,
PIN FIX L40MM DIA2.5MM ELBW CO CHROM AXIS FOR STBL SYS IJS,SUP-2340230,CDM,C1713,HCPCS,0278,RC,,,,both,,,833.67,541.89,,,,,,,,,,,,,
GUIDEWIRE VASC L 260 CM DIA 0.032 IN TAPR L 7 CM TIP L 2.5,SUP-2638698,CDM,C1769,HCPCS,0272,RC,,,,both,,,152.70,99.25,,,,,,,,,,,,,
ANCHOR SUT DIA2.1MM W/ S STL INSRT FOR LABRAL REP,SUP-2212782,CDM,C1713,HCPCS,0278,RC,,,,both,,,1287.15,836.65,,,,,,,,,,,,,
INFINITY EVERLAST SZ 2+ 10MM TOTAL ANKLE,SUP-2822433,CDM,C1776,CPT,0278,RC,,,,both,,,7928.50,5153.52,,,,,,,,,,,,,
PLATE 4.5MM TI LCP TM STRAIGHT RECON 5 HOLES 94MM,SUP-2549505,CDM,C1713,HCPCS,0278,RC,,,,both,,,1428.17,928.31,,,,,,,,,,,,,
PLATE BNE L140MM 5 H NONSTERILE R LAT PROX TIB TI LOK COMPR,SUP-2190711,CDM,C1713,HCPCS,0278,RC,,,,both,,,3933.76,2556.94,,,,,,,,,,,,,
ALLOGRAFT BNE PLATE 150X20-30 MM FRZN IRRADIATED TIB,SUP-2866917,CDM,C1762,CPT,0278,RC,,,,both,,,1616.79,1050.91,,,,,,,,,,,,,
KIT NEG PRSS SM W15XL20CM MULTISITE DSG PIONEERING DSGN W,SUP-2351609,CDM,C1713,HCPCS,0278,RC,,,,both,,,692.40,450.06,,,,,,,,,,,,,
HC Treatment of Bone Cyst,PX-3612061500,CDM,20615,CPT,0361,RC,,,,both,,,2176.00,1414.40,,,,,,,,,,,,,
GUIDEPIN ORTH FLX FOR ACL RECON DISP VERSITOMIC,SUP-2366529,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1130.09,734.56,,,,,,,,,,,,,
SUPPORT ORTHOPEDIC TYP S HD CUSTOMIZABLE WIDE UNIFRAME SYS,SUP-2220714,CDM,2720000010,LOCAL,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
SCREW BNE L40MM DIA4.5MM PROX FEM S STL ST LOK FULL THRD,SUP-2350245,CDM,C1713,HCPCS,0278,RC,,,,both,,,1315.79,855.26,,,,,,,,,,,,,
BIOINDCTIVE IMPLNT W/ARTH DEL SYS 1 MED,SUP-2334698,CDM,C1763,HCPCS,0278,RC,,,,both,,,9420.00,6123.00,,,,,,,,,,,,,
PLATE SPNL 2 LEVEL 60 MM ANTR LUMBAR TI CITADEL,SUP-2584592,CDM,C1713,HCPCS,0278,RC,,,,both,,,10405.96,6763.87,,,,,,,,,,,,,
SCREW BNE L26MM DIA2.7MM ANK S STL ST VAR ANG LOK FULL THRD,SUP-2178355,CDM,C1713,HCPCS,0278,RC,,,,both,,,433.89,282.03,,,,,,,,,,,,,
PLATE 3.5MM TI LCP TM PROX HUMERUS LONG 12H SHAFT 268MM STER,SUP-2549719,CDM,C1713,HCPCS,0278,RC,,,,both,,,6088.59,3957.58,,,,,,,,,,,,,
STAPLE SPNL TI THOR RSTRL 2 PRNG IMPL VANTAGE,SUP-2292685,CDM,C1713,HCPCS,0278,RC,,,,both,,,3068.97,1994.83,,,,,,,,,,,,,
CASE GRFT ENDURANT II NIT POLYESTER 4 PC AORTO-UNI-ILIAC,SUP-2873752,CDM,C1768,CPT,0278,RC,,,,both,,,72220.00,46943.00,,,,,,,,,,,,,
SCREW BONE EMERGENCY 1.2X6 MM WITH PLUSDRIVE RECESS TITANIUM,SUP-2838157,CDM,C1713,HCPCS,0278,RC,,,,both,,,366.63,238.31,,,,,,,,,,,,,
HC Resuscitation,PX-4809295000,CDM,92950,CPT,0480,RC,,,,inpatient,,,424.00,275.60,,,,,,,,,,,,,
LEVEL CMF ST PLATE MDFCE T SHP WTAB 1.5 MM SCRW8 HOLE T0.6,SUP-2677544,CDM,C1713,HCPCS,0278,RC,,,,both,,,746.06,484.94,,,,,,,,,,,,,
CONNECTOR ROD OD35X55MM POST CERV PARA DBL SIERRA,SUP-2245452,CDM,C1713,HCPCS,0278,RC,,,,both,,,85.28,55.43,,,,,,,,,,,,,
HC Vertebroplasty Addl Inject,PX-3612251500,CDM,22515,CPT,0361,RC,,,,both,,,10303.00,6696.95,,,,,,,,,,,,,
TUBING IRRIGATION 0.104X0.192 IN 14.6 FR 50 FT SILAS SIL NS,SUP-2466365,CDM,2720000010,LOCAL,0272,RC,,,,both,,,561.28,364.83,,,,,,,,,,,,,
KIT SHTH DESTINO L 87 CM DIA12 FR CRV BEND L 22 MM DIL 50,SUP-2616111,CDM,C1766,CPT,0272,RC,,,,both,,,2496.30,1622.59,,,,,,,,,,,,,
GRAFT HUM TISS L 35-48 X W 10 MM TIB BLOCK L 23 X W 10 MM,SUP-2913225,CDM,C1762,CPT,0278,RC,,,,both,,,13304.18,8647.72,,,,,,,,,,,,,
PLATE BNE L147MM 7 H S STL LOK COMPR CRUCFRM FOR 27 35MM,SUP-2185747,CDM,C1713,HCPCS,0278,RC,,,,both,,,4875.01,3168.76,,,,,,,,,,,,,
PERMETHRIN 5 % EX CREA,RX-10917,CDM,6370000000,HCPCS,0637,RC,21922-0021-07,NDC,,both,60,GR,135.00,87.75,,,,,,,,,,,,,
VALVE PRESSURE PROGRAMMABLE 0.030 IN IN-LINE HAKIM NS5045,SUP-2666809,CDM,C1889,HCPCS,0278,RC,,,,both,,,16873.07,10967.50,,,,,,,,,,,,,
SUPPORT ORTHOT LOWER EXTREMITY CUST PATTEN BTM,SUP-2435662,CDM,L2370,HCPCS,0272,RC,,,,both,,,906.08,588.95,,,,,,,,,,,,,
BIT DRL OD3.5MM TTC LO EXT FOR 6.5MM SCR ADVANSYS,SUP-2243132,CDM,2720000010,LOCAL,0272,RC,,,,both,,,719.31,467.55,,,,,,,,,,,,,
HLF PN 25X120X25 BRN BLNT TIP,SUP-2722164,CDM,C1713,HCPCS,0278,RC,,,,both,,,486.45,316.19,,,,,,,,,,,,,
TOOL CV COR STRL DISP HEARTMATE 3,SUP-2895099,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1509.08,980.90,,,,,,,,,,,,,
DEVICE ELECSURG W/ DISECT PLASMABLADE X 3.0S,SUP-2633899,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
SUPPORT ORTHOT THOR LUMBAR SACR CUST SAGITTAL-CORONAL CTRL 2,SUP-2435549,CDM,L0491,HCPCS,0274,RC,,,,both,,,2174.29,1413.29,,,,,,,,,,,,,
SCREW INTRF L30MM OD7MM CANN N ABSRB TI ADVNTG,SUP-2249494,CDM,C1713,HCPCS,0278,RC,,,,both,,,499.26,324.52,,,,,,,,,,,,,
IMPLANT ORBIT THK1MM D1MM W41XL42MM L TIIUM POLYETH POR MESH,SUP-2366484,CDM,C1713,HCPCS,0278,RC,,,,both,,,3675.75,2389.24,,,,,,,,,,,,,
TIP CRYOSURGERY L 90 MM DIA1 MM GEN 2 STRL DISP IOVERA SMRT,SUP-2882200,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1481.17,962.76,,,,,,,,,,,,,
RING FIX HRT MITRL 24 MM,SUP-2214189,CDM,C1889,HCPCS,0278,RC,,,,both,,,5024.00,3265.60,,,,,,,,,,,,,
HC Repair Mouth Laceration,PX-4504083100,CDM,40831,CPT,0450,RC,,,,both,,,706.00,458.90,,,,,,,,,,,,,
PLATE SPNL 16MM 10MM H COALITION AGX,SUP-2228803,CDM,C1713,HCPCS,0278,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
BLADE LARYNSCP MACINTOSH SZ 4 FBROPT UPSHER 1019040,SUP-2301145,CDM,2720000010,LOCAL,0272,RC,,,,both,,,375.39,244.00,,,,,,,,,,,,,
HC Splint App/Short Leg,PX-4502951500,CDM,29515,CPT,0450,RC,,,,outpatient,,,497.00,323.05,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY PENTAPOLAR DEFLECTABLE STRL,SUP-2516515,CDM,C1730,HCPCS,0272,RC,,,,both,,,1036.20,673.53,,,,,,,,,,,,,
U RNG DIA180MM SPD FRME,SUP-2197265,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4239.00,2755.35,,,,,,,,,,,,,
PACK IMPL L DIA4.7MM INCLUDE PROX DSTL SCR TAPR LCK PIN,SUP-2123606,CDM,C1776,CPT,0278,RC,,,,both,,,3953.26,2569.62,,,,,,,,,,,,,
DISSECTOR SURG SPATULA LG 8 2 MM RHOTON RUGGLES-REDMOND,SUP-2484766,CDM,C1713,HCPCS,0278,RC,,,,both,,,182.75,118.79,,,,,,,,,,,,,
GUIDE WIRE OBTURATOR PERC PINNING,SUP-2816781,CDM,C1769,HCPCS,0272,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
CHLOROTHIAZIDE SODIUM 500 MG IV SOLR,RX-9526,CDM,J1205,HCPCS,0636,RC,25021-0305-66,NDC,,both,1,UN,182.20,118.43,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 6X3 CM TEND REINF MTRX PURAFORCE,SUP-2716034,CDM,C1765,HCPCS,0278,RC,,,,both,,,5495.00,3571.75,,,,,,,,,,,,,
GALLIUM GA 68 GOZETOTIDE (ILLUCCIX) 25 MCG IV KIT,RX-4083074,CDM,A9596,HCPCS,0343,RC,74725-0100-25,NDC,,both,1,UN,24189.20,15722.98,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 60 MM DIA 7 MM DEL SHTH,SUP-2934241,CDM,C1713,HCPCS,0278,RC,,,,both,,,7828.02,5088.21,,,,,,,,,,,,,
PLATE BNE THK 1 MM ADV 7 MM SCREW DIA2 MM MINI RT,SUP-2883213,CDM,C1713,HCPCS,0278,RC,,,,both,,,1815.33,1179.96,,,,,,,,,,,,,
BOLT SPNL L30MM OD8MM TI CANC ANT THORLUM PEDCL ST FIX ANG,SUP-2292732,CDM,C1713,HCPCS,0278,RC,,,,both,,,4736.69,3078.85,,,,,,,,,,,,,
NUT ORTH DIA6MM S STL RND FOR SACR BAR FIX,SUP-2187001,CDM,C1713,HCPCS,0278,RC,,,,both,,,349.29,227.04,,,,,,,,,,,,,
GRAFT AMNIOTIC MEMBRANE FLOWERAMNIOPATCH 2CM X 2CM,SUP-2866793,CDM,Q4178,HCPCS,0636,RC,,,,both,,,7261.25,4719.81,,,,,,,,,,,,,
ANCHOR KNOTLESS W/ INSRTR HNDL SPEEDSCREW,SUP-2342085,CDM,C1713,HCPCS,0278,RC,,,,both,,,1378.15,895.80,,,,,,,,,,,,,
ALLOSYNC INJECTABLE FIBERS 2.5CC,SUP-2811314,CDM,C1713,HCPCS,0278,RC,,,,both,,,1130.40,734.76,,,,,,,,,,,,,
HC Extremity Arteriogram Unilateral,PX-3237571000,CDM,75710,CPT,0323,RC,,,,inpatient,,,3608.00,2345.20,,,,,,,,,,,,,
INQUIRY AFOCUS II 1110 7 8 SM AF25,SUP-2699064,CDM,C1730,HCPCS,0272,RC,,,,both,,,3469.70,2255.30,,,,,,,,,,,,,
SCREW BNE L 40 MM DIA 7 MM SHRT TI CANN HDLSS NS LEOS,SUP-2931473,CDM,C1713,HCPCS,0278,RC,,,,both,,,1324.45,860.89,,,,,,,,,,,,,
ARTHROFLEX 40 X70X2.0 MM,SUP-2816388,CDM,Q4125,HCPCS,0636,RC,,,,both,,,10744.45,6983.89,,,,,,,,,,,,,
CANNULA PERF AD 17FR 31.8CM LENGTH FEM ART VENT BIO MEDICUS,SUP-2282866,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1150.18,747.62,,,,,,,,,,,,,
PLATE OLECRANON LCK 17 H LT,SUP-2107799,CDM,C1713,HCPCS,0278,RC,,,,both,,,3249.90,2112.43,,,,,,,,,,,,,
BIT DRL L110MM OD43MM W O STP N RADLUC CENTRONAIL,SUP-2316002,CDM,2720000010,LOCAL,0272,RC,,,,both,,,509.81,331.38,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY L 115 CM TIP 1 MM DIA 7 FR SPC 5,SUP-2248701,CDM,C1730,HCPCS,0272,RC,,,,both,,,1318.80,857.22,,,,,,,,,,,,,
TUBE EXT FIX EXT 15 MM MONOTUBE,SUP-2459669,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6256.76,4066.89,,,,,,,,,,,,,
PLATE BNE X 0.4 MM 4 HOLE TI SLV NS MATRIXMIDFACE,SUP-2181675,CDM,C1713,HCPCS,0278,RC,,,,both,,,1114.39,724.35,,,,,,,,,,,,,
PLATE SPNL L17MM ANT LUM TI LO PROF AEGIS,SUP-2255173,CDM,C1713,HCPCS,0278,RC,,,,both,,,9263.00,6020.95,,,,,,,,,,,,,
PLATE OLECRANON 3.5MM 4H RT 112MM SS LCP STRL,SUP-2547482,CDM,C1713,HCPCS,0278,RC,,,,both,,,3304.79,2148.11,,,,,,,,,,,,,
COMPONENT PAT 25MM OFFSET HEMICAP,SUP-2123680,CDM,C1776,CPT,0278,RC,,,,both,,,2314.18,1504.22,,,,,,,,,,,,,
PLATE BNE L220MM THK3.7MM 12 H NONSTERILE R DST MED TIB S,SUP-2185534,CDM,C1713,HCPCS,0278,RC,,,,both,,,3901.98,2536.29,,,,,,,,,,,,,
SEED BRACHYTHERAPY LOAD 0.7-1.0 MCI STRL ADVANTAGE 2029ALS1] ISOAID LLC],SUP-2247257,CDM,C2642,HCPCS,0278,RC,,,,both,,,266.90,173.48,,,,,,,,,,,,,
LEVOFLOXACIN 5 MG/ML SYRINGE (PED) <50 ML,RX-4090160,CDM,J1956,HCPCS,0636,RC,00143-9721-24,NDC,,both,50,ML,24.40,15.86,,,,,,,,,,,,,
SCREW BONE L36MM DIA4.5MM STD CORT S STL BLNT NONLOCKING HEX,SUP-2249403,CDM,C1713,HCPCS,0278,RC,,,,both,,,525.45,341.54,,,,,,,,,,,,,
PLATE BNE SUBCONDYLAR 2 MM NS FPS LTX,SUP-2856827,CDM,C1713,HCPCS,0278,RC,,,,both,,,2486.88,1616.47,,,,,,,,,,,,,
CATHETER THROMCTMY COR 3FR DISTAFLEX,SUP-2277427,CDM,C1757,HCPCS,0272,RC,,,,both,,,5746.20,3735.03,,,,,,,,,,,,,
COIL VASC MREYE EMBOLUS L 15 CM DIA 30 MM CATH DIA 0.038 IN,SUP-2749446,CDM,C1889,HCPCS,0278,RC,,,,both,,,211.01,137.16,,,,,,,,,,,,,
SCREW BNE L24MM DIA3.5MM CORT DST TIB TYP II ANODIZED TI ST,SUP-2411689,CDM,C1713,HCPCS,0278,RC,,,,both,,,185.26,120.42,,,,,,,,,,,,,
SET FIX PIN BI PHS BONE SCR 1 7/8IN TI,SUP-2135873,CDM,C1713,HCPCS,0278,RC,,,,both,,,866.64,563.32,,,,,,,,,,,,,
GRAFT DERM L20XW12CM CLLGN RECTANG IMPL ALLOMAX,SUP-2125866,CDM,C1781,HCPCS,0278,RC,,,,both,,,19103.76,12417.44,,,,,,,,,,,,,
RELOAD STPLR L 100 MM CLOSED STPL H 2.2 MM THCK 4 ROW LINEAR,SUP-2912267,CDM,2720000010,LOCAL,0272,RC,,,,both,,,452.41,294.07,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 70 CM DIA10 MM EPTFE STR TW N RING,SUP-2396358,CDM,C1768,CPT,0278,RC,,,,both,,,2320.46,1508.30,,,,,,,,,,,,,
HC Asp Inj Intermediate Joint,PX-4502060500,CDM,20605,CPT,0450,RC,,,,both,,,358.00,232.70,,,,,,,,,,,,,
SCREW BNE 65MMX60MM LO PROF CANC TI ALLY,SUP-2166920,CDM,C1713,HCPCS,0278,RC,,,,both,,,248.59,161.58,,,,,,,,,,,,,
GRAFT HUM TISS W13XH14XL11MM CANC CORT FRZ DRY CRNRSTN ASR,SUP-2293790,CDM,C1713,HCPCS,0278,RC,,,,both,,,2662.34,1730.52,,,,,,,,,,,,,
GRAFT BNE STRP 12.5X1X0.4 CM 10 CC PLATFORM CM,SUP-2691584,CDM,C1713,HCPCS,0278,RC,,,,both,,,6754.14,4390.19,,,,,,,,,,,,,
BRACE WLK M M 5.5-10 FEM 6.5-11 SFT NYL FOAM LNR LO PROF,SUP-2197141,CDM,L4350,HCPCS,0272,RC,,,,both,,,84.62,55.00,,,,,,,,,,,,,
LORAZEPAM 4 MG/ML IJ SOLN,RX-10468,CDM,J2060,HCPCS,0636,RC,09999-9919-62,NDC,,both,0.75,ML,54.10,35.16,,,,,,,,,,,,,
SCREW CONN 3MM W COCHLEAR W/ ABUTMENT 6MM PREMOUNTED PONTO,SUP-2319891,CDM,C1713,HCPCS,0278,RC,,,,both,,,10676.00,6939.40,,,,,,,,,,,,,
PLATE BNE CALCANEAL DSTL TIB SET PERI-LOC,SUP-2351350,CDM,C1713,HCPCS,0278,RC,,,,both,,,7379.00,4796.35,,,,,,,,,,,,,
PROSTHESIS OSSCLR TOTAL 25MM/35MM DIA HEAD 08MM DIA TROP,SUP-2680305,CDM,L8613,CPT,0278,RC,,,,both,,,1357.89,882.63,,,,,,,,,,,,,
LENS INTOCU +28.5 DIOPT L13MM DIA5.5MM D3.39MM 0.5DEG,SUP-2110854,CDM,V2630,CPT,0276,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
ELECTRODE TAB DISPOSABLE SANIBEL,SUP-2719742,CDM,2720000010,LOCAL,0272,RC,,,,both,,,229.22,148.99,,,,,,,,,,,,,
PLATE BONE CRANIOMAXILLOFACIAL 5 HOLE Y-PLATE 17MM TITANIUM,SUP-2825442,CDM,C1713,HCPCS,0278,RC,,,,both,,,162.71,105.76,,,,,,,,,,,,,
KNIFE SURG SCHKNT ROLLER 15 90 DEG 6 INX3 MM MICROFRANCE,SUP-2477075,CDM,2720000010,LOCAL,0272,RC,,,,both,,,545.76,354.74,,,,,,,,,,,,,
SODIUM HYALURONATE 60 MG/3ML IX PRSY,RX-140371,CDM,J7318,HCPCS,0636,RC,89130-2020-01,NDC,,both,3,ML,3289.30,2138.04,,,,,,,,,,,,,
DRIVER ST PK KT HEX 35MM CORETRAK,SUP-2399887,CDM,2720000010,LOCAL,0272,RC,,,,both,,,279.46,181.65,,,,,,,,,,,,,
SET URET STENT SEIDMON AG AQ L 50 CM DIA 6 FR INTRO L 32 CM,SUP-2822055,CDM,C2617,HCPCS,0278,RC,,,,both,,,311.21,202.29,,,,,,,,,,,,,
CATHETER ANGIO BUMPER 5 FRX100 CM 2 CM 1 PERFORMA ULT,SUP-2301659,CDM,C1713,HCPCS,0278,RC,,,,both,,,67.07,43.60,,,,,,,,,,,,,
CLAMP CRAN L 12 MM NEURO CRANIOTOMY LN 12 PK STRL DISP,SUP-2935348,CDM,C1713,HCPCS,0278,RC,,,,both,,,882.59,573.68,,,,,,,,,,,,,
PATCH DURA W1XL3IN REGEN CLLGN MTRX BASE SUTURABLE DURAGN,SUP-2244023,CDM,C1763,HCPCS,0278,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
SCREW BONE LAG CANC SLD PART THRD TIM,SUP-2136330,CDM,C1713,HCPCS,0278,RC,,,,both,,,135.84,88.30,,,,,,,,,,,,,
LEAD PACE L90CM ENDO LV UNI/BIPOLAR LV1 SGL ELECTRD PASS 451390] GUIDANT SALES CORP],SUP-2236354,CDM,C1779,HCPCS,0275,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
SYSTEM VES HARV ENDOSCP VASOVIEW HEMOPRO,SUP-2227299,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3443.01,2237.96,,,,,,,,,,,,,
SURGICAL PROCEDURE PACK EYE 20 GA CUST,SUP-2110949,CDM,C1713,HCPCS,0278,RC,,,,both,,,1495.05,971.78,,,,,,,,,,,,,
STEM HUM STD 6 MM SHLDR NP AFFINITI,SUP-2715297,CDM,C1776,CPT,0278,RC,,,,both,,,11143.86,7243.51,,,,,,,,,,,,,
TISSEEL VHSD 10 ML KT 1504516] BAXTER BIOSURGERY],SUP-2130320,CDM,C1713,HCPCS,0278,RC,,,,both,,,1363.48,886.26,,,,,,,,,,,,,
PLATE BNE LCK LG EXT LT CALCANEAL 2 HOLE STRL A.L.P.S,SUP-2459853,CDM,C1713,HCPCS,0278,RC,,,,both,,,3164.59,2056.98,,,,,,,,,,,,,
GRAFT BIO TISS W16XL20CM RECON TISS MTRX LAPSCP STRATTICE,SUP-2113205,CDM,Q4130,HCPCS,0636,RC,,,,both,,,30765.72,19997.72,,,,,,,,,,,,,
IMMOBILIZER ORTH 3 PANEL UNIV KNEE COTTON CANVS FOAM,SUP-2276704,CDM,L1830,CPT,0274,RC,,,,both,,,32.88,21.37,,,,,,,,,,,,,
BLADE SAW W25MM THK1.24MM D79.5MM LNG SAG CUT EDGE,SUP-2367180,CDM,2720000010,LOCAL,0272,RC,,,,both,,,84.37,54.84,,,,,,,,,,,,,
ENDOPROSTHESIS VASC VIABAHN L 15CM 9MM 120CM 8FR RADIOPAQUE,SUP-2719612,CDM,C1768,HCPCS,0278,RC,,,,both,,,10754.50,6990.42,,,,,,,,,,,,,
TUBE LARYNGECTOMY MARTIN 8 EXTN STERLING SLV LF,SUP-2489764,CDM,2720000010,LOCAL,0272,RC,,,,both,,,436.81,283.93,,,,,,,,,,,,,
GRAFT BONE SUB W20XH20XL10MM B TRICALCIUM PHOS GRAN SYNTH,SUP-2194021,CDM,C1713,HCPCS,0278,RC,,,,both,,,3048.63,1981.61,,,,,,,,,,,,,
KIT CATHETER CTRL VEN 145X23CM DOUBEL LUMN SYMMETRICAL TOP W,SUP-2283918,CDM,C1750,HCPCS,0278,RC,,,,both,,,2378.49,1546.02,,,,,,,,,,,,,
SHUNT CAR W/O RESVR N PROGRAMMABLE 10FR 31CM,SUP-2264213,CDM,C1889,HCPCS,0278,RC,,,,both,,,1190.06,773.54,,,,,,,,,,,,,
STAPLER INT L L21MM DIA5MM GI AQUA TI BARIATRIC CIR CUT 2,SUP-2283254,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4598.53,2989.04,,,,,,,,,,,,,
MESH SURG DIA4IN POLYPR PLUG MK PTCH W POSIFLEX MEM,SUP-2126067,CDM,C1781,HCPCS,0278,RC,,,,both,,,262.19,170.42,,,,,,,,,,,,,
PACK OPHTH US BASIC VISN SYS INFIN,SUP-2109873,CDM,C1713,HCPCS,0278,RC,,,,both,,,449.02,291.86,,,,,,,,,,,,,
GRAFT VASC IMPRA L 50 CM DIA 6 MM EPTFE FLX STD WALL RING,SUP-2128208,CDM,C1768,CPT,0278,RC,,,,both,,,2201.14,1430.74,,,,,,,,,,,,,
SCREW BONE SELF TAPPING 1.76X6 MM CORTICAL EMERGENCY CRICIFO,SUP-2838193,CDM,C1713,HCPCS,0278,RC,,,,both,,,333.66,216.88,,,,,,,,,,,,,
RING EXT FIX HALF 120 MM CARBON FIBER RINGFIX,SUP-2365275,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2995.56,1947.11,,,,,,,,,,,,,
HC Tiss Cul Neo Disorders Bone Marrow Blood Cells,PX-3118823700,CDM,88237,CPT,0311,RC,,,,both,,,185.00,120.25,,,,,,,,,,,,,
BIT DRL DIA35MM HI SPD,SUP-2187154,CDM,2720000010,LOCAL,0272,RC,,,,both,,,774.01,503.11,,,,,,,,,,,,,
ROD IM DIA5MM COMPR FOR ARTH NAIL SYS PANTA 2,SUP-2417301,CDM,C1713,HCPCS,0278,RC,,,,both,,,3423.98,2225.59,,,,,,,,,,,,,
CATHETER EMB FOGARTY L 120 CM DIA 3 FR BALLOON DIA,SUP-2214014,CDM,C1757,HCPCS,0272,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
HC So Citric Acid 24hr Urine,PX-3018250766,CDM,82507,CPT,0301,RC,,,,both,,,139.00,90.35,,,,,,,,,,,,,
DRILL SURG DIA4.3MM RADLUC FOR TARGET DEV,SUP-2371643,CDM,2720000010,LOCAL,0272,RC,,,,both,,,516.53,335.74,,,,,,,,,,,,,
PIN STPL LOC DIA2 MM,SUP-2898105,CDM,2720000010,LOCAL,0272,RC,,,,both,,,248.06,161.24,,,,,,,,,,,,,
"HC So1 Antidiuretic Hormone, Plasma",PX-3018458867,CDM,84588,CPT,0301,RC,,,,both,,,1003.00,651.95,,,,,,,,,,,,,
PLATE BNE SM L63MM 3X4 H BILAT TI T OBLQ LIMIT CNTCT DYN,SUP-2190942,CDM,C1713,HCPCS,0278,RC,,,,both,,,873.17,567.56,,,,,,,,,,,,,
DEVICE TORQUE MULTIGLIDECATH GUIDWIRE 0.01-0.038 IN MLTI,SUP-2140132,CDM,C1769,HCPCS,0272,RC,,,,both,,,9.99,6.49,,,,,,,,,,,,,
PLATE BONE 6 H DBL Y SHP W/ BAR LO PROF FOR 1.5MM SCR CRAN,SUP-2363636,CDM,C1713,HCPCS,0278,RC,,,,both,,,869.06,564.89,,,,,,,,,,,,,
PLUG VASC W5.3XL12MM VES 1.5-3MM PERIPH NIT PTFE MIC,SUP-2281185,CDM,C1889,HCPCS,0278,RC,,,,both,,,5495.00,3571.75,,,,,,,,,,,,,
COLLAR CERV PADDED LG TALL COMFORT ADJ MIAMI J,SUP-2434343,CDM,L0174,HCPCS,0272,RC,,,,both,,,155.46,101.05,,,,,,,,,,,,,
CATHETER SUPP NAVIEN L 105 CM OD 0.07 IN ID 0.058 IN FLX,SUP-2522807,CDM,C1887,HCPCS,0272,RC,,,,both,,,5290.90,3439.08,,,,,,,,,,,,,
CATHETER DRNGE 12FR L35CM FLEXIMA LOOP REG DUROMETER TRCR,SUP-2147864,CDM,C1729,HCPCS,0272,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
GRAFT VASC IMPRA L 50 CM DIA 4-7 MM EPTFE STP STD WALL N,SUP-2127039,CDM,C1768,CPT,0278,RC,,,,both,,,1909.12,1240.93,,,,,,,,,,,,,
NOZZLE BONE CEM REV,SUP-2216852,CDM,C1713,HCPCS,0278,RC,,,,both,,,323.42,210.22,,,,,,,,,,,,,
IMPLANT OSI200 OTOLOGIC,SUP-2858184,CDM,L8690,HCPCS,0278,RC,,,,both,,,13643.30,8868.14,,,,,,,,,,,,,
CATHETER ANGIO L49CM OD8FR PLCMNT CUT AWAY COR SNUS ACCS,SUP-2148934,CDM,C1887,HCPCS,0272,RC,,,,both,,,1397.30,908.24,,,,,,,,,,,,,
CONNECTOR TBNG OD10.5MM ID9.0MM STR,SUP-2281985,CDM,C1713,HCPCS,0278,RC,,,,both,,,367.38,238.80,,,,,,,,,,,,,
FIBERS CORT ALLOSYNC DEMINERALIZ INJ 10CC,SUP-2719764,CDM,C1713,HCPCS,0278,RC,,,,both,,,4082.00,2653.30,,,,,,,,,,,,,
HC So1 Herpes Simplex Type 1,PX-3028669567,CDM,86695,CPT,0302,RC,,,,both,,,28.00,18.20,,,,,,,,,,,,,
KIT EXT FIX L ANK FRME,SUP-2179120,CDM,C1776,CPT,0278,RC,,,,both,,,10337.57,6719.42,,,,,,,,,,,,,
CATHETER DIAG L90CM OD0.059X0.052IN TIP OD3.2FR 50MM SPC,SUP-2353138,CDM,C1887,HCPCS,0272,RC,,,,both,,,587.18,381.67,,,,,,,,,,,,,
CATHETER ABLAT 7FR L115CM 2-5-2 SPC TIP ELECTRD 3.5MM 65MM,SUP-2357692,CDM,C2630,CPT,0272,RC,,,,both,,,9106.00,5918.90,,,,,,,,,,,,,
CATHETER CNTRL VENOU LUMENX1 4.2FR 90CML SIL CLMP BRVC,SUP-2613066,CDM,C1751,HCPCS,0278,RC,,,,both,,,447.45,290.84,,,,,,,,,,,,,
FORCEP ENDOSCP DISMANTLING 6 CM NUCLS 24 CNTOUR CRV TO LT,SUP-2558686,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2618.76,1702.19,,,,,,,,,,,,,
ENDCAP ORTH DIA12MM EXTN 5MM LAT FEM GRY TI CANN T40,SUP-2188986,CDM,C1776,CPT,0278,RC,,,,both,,,638.64,415.12,,,,,,,,,,,,,
CATHETER INFUSION 35 DEG 1.9 FRX165 CM PROGREAT LAMBDA,SUP-2852402,CDM,C1887,HCPCS,0272,RC,,,,both,,,2446.06,1589.94,,,,,,,,,,,,,
KIT PICC 5FR GWIRE L70CM NIT POWERPICC SOLO,SUP-2125551,CDM,C1751,HCPCS,0278,RC,,,,both,,,385.28,250.43,,,,,,,,,,,,,
BODY EXT FIX ARTICULATED FEMALE SELF ALIGNING SUPP PROCALLUS,SUP-2645902,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4534.22,2947.24,,,,,,,,,,,,,
BEARING TIB SZ 3/4 HINGE STRL TRIATHLON,SUP-2889783,CDM,C1776,CPT,0278,RC,,,,both,,,15474.86,10058.66,,,,,,,,,,,,,
SUPPORT ORTHOT WRST HND CUST ADJ FIT STRP W/NONTORSION JT,SUP-2435772,CDM,L3905,HCPCS,0274,RC,,,,both,,,2555.14,1660.84,,,,,,,,,,,,,
ROD IM TIB N-K II,SUP-2449190,CDM,C1713,HCPCS,0278,RC,,,,both,,,2260.80,1469.52,,,,,,,,,,,,,
PLATE BNE GREATER TUBEROSITY 53 MM SHLDR SS NS ORTHOLOC SPS,SUP-2421809,CDM,C1713,HCPCS,0278,RC,,,,both,,,8123.18,5280.07,,,,,,,,,,,,,
HC Protoporphyrin RBC Screen,PX-3018420300,CDM,84203,CPT,0301,RC,,,,both,,,34.00,22.10,,,,,,,,,,,,,
EXPANDER TISS 450CC P7.1CM W14XH10.2CM BRST SIL RND TEXT,SUP-2300627,CDM,C1789,HCPCS,0278,RC,,,,both,,,4474.50,2908.42,,,,,,,,,,,,,
DEFIBRILLATOR IMPL LUMAX 740 VR-T DX 55 X 66MM 13MM BPLR GSM,SUP-2138424,CDM,C1722,HCPCS,0275,RC,,,,both,,,46158.00,30002.70,,,,,,,,,,,,,
PLATE BNE SCREW DIA2.6 MM LG TI RT CRANIOMAXILLOFACIAL STD,SUP-2936494,CDM,C1713,HCPCS,0278,RC,,,,both,,,6732.16,4375.90,,,,,,,,,,,,,
PLATE BONE W7XL39MM THK1MM 5 H S STL QTR TBLR NONCOMPRESSION,SUP-2343851,CDM,C1713,HCPCS,0278,RC,,,,both,,,624.39,405.85,,,,,,,,,,,,,
PLATE BNE L585MM THK32MM 4 H SYMPHYSIS PUBIS S STL RAD 75,SUP-2362713,CDM,C1713,HCPCS,0278,RC,,,,both,,,3692.64,2400.22,,,,,,,,,,,,,
HOOK ELECTRD L243MM BLDE L35MM L SHP PARTIALLY INSUL R ANG,SUP-2243729,CDM,2720000010,LOCAL,0272,RC,,,,both,,,622.91,404.89,,,,,,,,,,,,,
BIT DRL CALIB 2 MM W/ SL STRL STRATUM RS LTX DISP,SUP-2861973,CDM,2720000010,LOCAL,0272,RC,,,,both,,,426.91,277.49,,,,,,,,,,,,,
CEFUROXIME SODIUM 750 MG IJ SOLR,RX-1465,CDM,J0697,HCPCS,0636,RC,00143-9979-90,NDC,,both,1,UN,54.10,35.16,,,,,,,,,,,,,
PACEMAKER CARD AZURE XT DR MRI SURESCAN W 50.8 X H 46.6 MM D,SUP-2282505,CDM,C1785,HCPCS,0275,RC,,,,both,,,8478.00,5510.70,,,,,,,,,,,,,
PASSER SUTURE STRL DISP LATITUDE EV,SUP-2902539,CDM,2720000010,LOCAL,0272,RC,,,,both,,,510.25,331.66,,,,,,,,,,,,,
MESH SFT BARD PRESHAPED 2.4 IN X 5.4 IN,SUP-2125783,CDM,C1781,HCPCS,0278,RC,,,,both,,,197.51,128.38,,,,,,,,,,,,,
K WIRE FIX L4IN DIA0.045IN DBL END TRCR SMOOTH,SUP-2384027,CDM,C1713,HCPCS,0278,RC,,,,both,,,8.60,5.59,,,,,,,,,,,,,
SHUNT SURG 53 CM 5-9 CM RESERVOIR KT MED CLS UNI-SHUNT,SUP-2666559,CDM,C1889,HCPCS,0278,RC,,,,both,,,5297.81,3443.58,,,,,,,,,,,,,
CHOLANGIOGRAM KIT RX AUTOTOME UTOM XL SPHINTOM JAGWIRE 7600,SUP-2462324,CDM,C1769,HCPCS,0272,RC,,,,both,,,986.43,641.18,,,,,,,,,,,,,
GRAFT VASC DISTAFLO L 60 CM DIA 8 MM EPTFE CARBON PERIPH,SUP-2128078,CDM,C1768,CPT,0278,RC,,,,both,,,6295.70,4092.20,,,,,,,,,,,,,
MESH HERN L DIA4IN POLYPR EPTFE CIR SELF EXP PTCH FOR SFT,SUP-2125713,CDM,C1781,HCPCS,0278,RC,,,,both,,,1683.98,1094.59,,,,,,,,,,,,,
TRAY KYPHOPLASTY BLLN 4ML L15MM DIA17.7MM NDL 11GA SYR 20ML,SUP-2367077,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
HEAD FEM OD44MM +0 NK 12/14 TAPR MTL ON POLY CO CHROM PRI,SUP-2204807,CDM,C1776,CPT,0278,RC,,,,both,,,2857.40,1857.31,,,,,,,,,,,,,
PIN FIX SINGLE DIAMOND 0.078X9 IN THRD RND END NS STEINMANN,SUP-2791380,CDM,C1713,HCPCS,0278,RC,,,,both,,,67.07,43.60,,,,,,,,,,,,,
BIT DRL L190MM DIA6MM STRL TI CANN QUIK CPL W/O STP,SUP-2188288,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2073.44,1347.74,,,,,,,,,,,,,
COMPONENT FEM CR POR COAT SYMMETRICAL SZ 0,SUP-2222761,CDM,C1776,CPT,0278,RC,,,,both,,,11643.12,7568.03,,,,,,,,,,,,,
BUR SURG M L8MM DIA4MM EGG CUT FLUT ELITE TPS 51201540] STRYKER INSTRUMENT DIV],SUP-2367476,CDM,2720000010,LOCAL,0272,RC,,,,both,,,275.54,179.10,,,,,,,,,,,,,
INTRODUCER SET TRANSSEPTAL 10FRX12CM LEN AD ULTIMUM,SUP-2355595,CDM,C1894,HCPCS,0272,RC,,,,both,,,36.90,23.98,,,,,,,,,,,,,
HC Drug Screen Quantitative Digoxin Total,PX-3018016200,CDM,80162,CPT,0301,RC,,,,both,,,287.00,186.55,,,,,,,,,,,,,
STEM HUM LNG 130 DEG 12X210 MM SHLDR HA AEQUALIS,SUP-2715552,CDM,C1776,CPT,0278,RC,,,,both,,,15426.82,10027.43,,,,,,,,,,,,,
STEM FEM L160MM DIA15MM HIP L MTPHSEAL BODY STR NK TIV,SUP-2210353,CDM,C1776,CPT,0278,RC,,,,both,,,10915.71,7095.21,,,,,,,,,,,,,
COMPONENT FEM L80MM L KNEE CONN PC GMRS,SUP-2376551,CDM,C1713,HCPCS,0278,RC,,,,both,,,10436.42,6783.67,,,,,,,,,,,,,
ASSEMBLY ADPT GUIDEWIRE DIA1.5 MM AO,SUP-2934632,CDM,C1769,HCPCS,0272,RC,,,,both,,,1617.10,1051.11,,,,,,,,,,,,,
PLATE BNE W8XL96MM THK3.3MM 12 H NONSTERILE BILAT PELV S,SUP-2186239,CDM,C1713,HCPCS,0278,RC,,,,both,,,2000.93,1300.60,,,,,,,,,,,,,
RETRACTOR OPHTH NYL SMOOTH FINISH FLX HK DISP FOR MECH IRIS,SUP-2109674,CDM,2720000010,LOCAL,0272,RC,,,,both,,,328.19,213.32,,,,,,,,,,,,,
BLADE SHAVER 3.7 MMX10.5 CM 30 DEG BEND IRRIG RHINOTEC GTR,SUP-2607696,CDM,2720000010,LOCAL,0272,RC,,,,both,,,268.12,174.28,,,,,,,,,,,,,
KNIFE SURG BALLENGER SWVL 8.5 INX4 MM STR MICROFRANCE LF,SUP-2467298,CDM,2720000010,LOCAL,0272,RC,,,,both,,,678.81,441.23,,,,,,,,,,,,,
COIL DETACH 360 STD SR 13MM BIG LOOP OD 30CM INTRO GDC 10,SUP-2365679,CDM,C1889,HCPCS,0278,RC,,,,both,,,5858.93,3808.30,,,,,,,,,,,,,
TROCAR ENDOSCP BLDELSS 5X75 MM STBL SL ENDOPATH BASX,SUP-2857943,CDM,2720000010,LOCAL,0272,RC,,,,both,,,426.16,277.00,,,,,,,,,,,,,
GUIDEWIRE 2MM 15IN SCR SMOOTH BLNT TIP STRL CANNFLX,SUP-2340981,CDM,C1769,HCPCS,0272,RC,,,,both,,,135.02,87.76,,,,,,,,,,,,,
ALLOGRAFT BNE 5 CC FRZN CRYOPRESERVED BNE MTRX VIVIGEN,SUP-2741017,CDM,C1713,HCPCS,0278,RC,,,,both,,,5822.69,3784.75,,,,,,,,,,,,,
SHELL ACET SZ B DIA44MM RIM 8 H HIP TI W ARC DEPOSIT SURF,SUP-2372526,CDM,C1776,CPT,0278,RC,,,,both,,,5324.18,3460.72,,,,,,,,,,,,,
GRAFT HUM TISS BIDIR 3.5X3 CM GRID PAT AMNIO MEMBRN BIOVANCE,SUP-2651376,CDM,Q4154,HCPCS,0636,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
SCREW BONE L30MM INTERTROCHANTERIC TI COMPR TRIGEN INTERTAN,SUP-2347568,CDM,C1713,HCPCS,0278,RC,,,,both,,,2183.84,1419.50,,,,,,,,,,,,,
SHEARS ENDOSCP HARM 36CM ULTRASONIC CRV TIP UPGRD,SUP-2615608,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7364.90,4787.18,,,,,,,,,,,,,
WEDGE FEM L SZ 4 D5MM P5MM DST POST KNEE SCR ON LEGION,SUP-2346353,CDM,C1776,CPT,0278,RC,,,,both,,,5526.40,3592.16,,,,,,,,,,,,,
TI LCP PROX LATERAL TIBIA PL 9 HOLES/220MM/LEFT-STERILE,SUP-2549442,CDM,C1713,HCPCS,0278,RC,,,,both,,,4795.09,3116.81,,,,,,,,,,,,,
CANNULA SURG OD5.5 MM TAPR,SUP-2232076,CDM,2720000010,LOCAL,0272,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
PLATE BNE L 132 X W 10.2 MM THK 2.8 MM SCREW DIA 3.5 MM 12 H 72440612,SUP-2933388,CDM,C1713,HCPCS,0278,RC,,,,both,,,2641.84,1717.20,,,,,,,,,,,,,
SEMI-TUB PLT STERILIZER 119 MM LENGTH 7 HL,SUP-2818492,CDM,C1713,HCPCS,0278,RC,,,,both,,,584.79,380.11,,,,,,,,,,,,,
PLATE BONE W12XL103MM 6 H SEMI TBLR ECT,SUP-2198538,CDM,C1713,HCPCS,0278,RC,,,,both,,,165.04,107.28,,,,,,,,,,,,,
DRILL HND MYOMA 5 MMX31 CM,SUP-2850205,CDM,2720000010,LOCAL,0272,RC,,,,both,,,572.39,372.05,,,,,,,,,,,,,
PLATE DISTAL POSTERIOR LATERAL 6HL RT,SUP-2703369,CDM,C1713,HCPCS,0278,RC,,,,both,,,4354.24,2830.26,,,,,,,,,,,,,
PLATE BNE THK 0.6 MM ADV 8 MM SCREW DIA2 MM 4 H MINI CHIN,SUP-2883232,CDM,C1713,HCPCS,0278,RC,,,,both,,,1359.37,883.59,,,,,,,,,,,,,
N S BIPOLAR BAYONET FCPS 20MM TIP,SUP-2703458,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1997.20,1298.18,,,,,,,,,,,,,
LAMOTRIGINE 25 MG PO TABS,RX-13981,CDM,6370000000,HCPCS,0637,RC,00904-7007-61,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
STEM FEM 10X400 MM LT HIP META 400 BIMTRC,SUP-2449902,CDM,C1776,CPT,0278,RC,,,,both,,,16758.18,10892.82,,,,,,,,,,,,,
SHEATH INTRO PINNACLE R/O II L 10 CM DIA 7 FR 2.5 CM ETFE,SUP-2385644,CDM,C1894,HCPCS,0272,RC,,,,both,,,91.06,59.19,,,,,,,,,,,,,
GUIDEWIRE VASC COPE L 60 CM DIA 0.018 IN TAPR L 7.25 CM FLPY,SUP-2168340,CDM,C1769,HCPCS,0272,RC,,,,both,,,92.60,60.19,,,,,,,,,,,,,
PLATE BONE MESH RSRBBLE 31MMW X 106MML 1MM THK RSRB X RCTNGL,SUP-2669319,CDM,C1713,HCPCS,0278,RC,,,,both,,,4798.33,3118.91,,,,,,,,,,,,,
BIT DRL 3.6 MM STRL INCORE LAPIDUS DISP,SUP-2476184,CDM,2720000010,LOCAL,0272,RC,,,,both,,,335.04,217.78,,,,,,,,,,,,,
ROD IM 15X380MM FEM TI ALTA,SUP-2363485,CDM,C1713,HCPCS,0278,RC,,,,both,,,3272.19,2126.92,,,,,,,,,,,,,
GRAFT VASC FUSION BIOLINE L 80 CM DIA 7 MM AX COMPLIANCE,SUP-2481628,CDM,C1768,CPT,0278,RC,,,,both,,,6373.89,4143.03,,,,,,,,,,,,,
INSERT TIB SZ 2-3 THK18MM KNEE HNG ROT PLATFRM LEGION,SUP-2346658,CDM,C1776,CPT,0278,RC,,,,both,,,6123.00,3979.95,,,,,,,,,,,,,
HC Trluml Balo Angiop 1st Vein,PX-3613724800,CDM,37248,CPT,0361,RC,,,,both,,,8583.00,5578.95,,,,,,,,,,,,,
COMPONENT PAT DIA33MM STD POR PRI ASYM W O XR WIRE TI AND,SUP-2377459,CDM,C1776,CPT,0278,RC,,,,both,,,4132.24,2685.96,,,,,,,,,,,,,
HC Forearm Infant Ue Min 2 Views,PX-3207309200,CDM,73092,CPT,0320,RC,,,,both,,,276.00,179.40,,,,,,,,,,,,,
GRAFT NRV L25CM ID6MM CLLGN CONDUIT BEND 60DEG W O FORMING,SUP-2378816,CDM,C9353,HCPCS,0278,RC,,,,both,,,4830.01,3139.51,,,,,,,,,,,,,
STENT URET OPN END 6 FRX22 CM KID CURL TAPR SIL MULTI-FLEX,SUP-2313764,CDM,C2617,HCPCS,0278,RC,,,,both,,,306.21,199.04,,,,,,,,,,,,,
TRAY MAXIMAL BARR PICC CATH SGL LUMN 6 FR 55 CM LEN N COAT N,SUP-2118890,CDM,C1751,HCPCS,0278,RC,,,,both,,,690.80,449.02,,,,,,,,,,,,,
HC Caregiver Training Strategies&Tq 1st 30 Minutes,PX-4209755000,CDM,97550,CPT,0420,RC,,,,both,,,135.00,87.75,,,,,,,,,,,,,
DEVICE POS VAG PELV FLR COLPASSIST,SUP-2139402,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1671.36,1086.38,,,,,,,,,,,,,
HC Cta Head W & W/O Cont,PX-3517049600,CDM,70496,CPT,0351,RC,,,,both,,,3184.00,2069.60,,,,,,,,,,,,,
SET SHTH DESTINO TWST L 45 CM DIA 7 FR CRV BEND 22 MM DIL L,SUP-2616225,CDM,C1766,CPT,0272,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
VALVE SHUNT DIA16MM SIL FLSH INTEGR CONN M PRSS SPHR FOR,SUP-2244292,CDM,C1729,HCPCS,0272,RC,,,,both,,,2248.84,1461.75,,,,,,,,,,,,,
MESH SURG W20XL30CM PTFE RECT KNIT FLM PARTIALLY ABSRB,SUP-2395757,CDM,C1781,HCPCS,0278,RC,,,,both,,,13888.22,9027.34,,,,,,,,,,,,,
KIT THROMCTMY ACE60 HI FLO L 132 CM OD/ID PROX 6 FR/ 0.068,SUP-2323552,CDM,C1887,HCPCS,0272,RC,,,,both,,,8635.00,5612.75,,,,,,,,,,,,,
HC Caregiver Training Strategies&Tq 1st 30 Minutes,PX-4409755000,CDM,97550,CPT,0440,RC,,,,both,,,135.00,87.75,,,,,,,,,,,,,
BENZOCAINE-MENTHOL 15-2.6 MG MT LOZG,RX-110389,CDM,6370000000,HCPCS,0637,RC,09999-9918-23,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
FORCEPS OPHTH 23GA ILM DISP GRIESHABER REVOLUTION DSP,SUP-2109703,CDM,2720000010,LOCAL,0272,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
CLAMP EXT FIX PIN 8 HOLE,SUP-2749993,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3485.40,2265.51,,,,,,,,,,,,,
GUIDEWIRE VASC TAPR 035-018X145 LOC EXTN STRL TAD,SUP-2264465,CDM,C1769,HCPCS,0272,RC,,,,both,,,362.67,235.74,,,,,,,,,,,,,
HC Inf 1st Hour Hyd,PX-2609636000,CDM,96360,CPT,0260,RC,,,,both,,,370.00,240.50,,,,,,,,,,,,,
SCREW BONE 3.5MM DIA 18MML CRTCL F/TTL WRIST FSN SSTM NON ST,SUP-2586700,CDM,C1713,HCPCS,0278,RC,,,,both,,,338.30,219.89,,,,,,,,,,,,,
COLLAR CERV REG AD XTW EXT WR LF,SUP-2335999,CDM,L0120,HCPCS,0272,RC,,,,both,,,51.43,33.43,,,,,,,,,,,,,
LIFT HEEL MED 2.5 IN WDG 3 LAYR ORTHOT FT FABRIC BRN ADJLFT,SUP-2325936,CDM,L3332,HCPCS,0272,RC,,,,both,,,18.37,11.94,,,,,,,,,,,,,
GRAFT HUM TISS L 1 X W 1 CM AMNION PLCNTA MEMBRN SINGLE LAYR,SUP-2913271,CDM,C1762,CPT,0278,RC,,,,both,,,3347.24,2175.71,,,,,,,,,,,,,
SCREW BNE CORTICAL 3.5X22 MM,SUP-2343717,CDM,C1713,HCPCS,0278,RC,,,,both,,,72.22,46.94,,,,,,,,,,,,,
GRAFT EVAR L10CM DST DIA27MM FEP NIT CONTRALATERAL LEG IL,SUP-2395913,CDM,C1768,CPT,0278,RC,,,,both,,,15630.92,10160.10,,,,,,,,,,,,,
SCREW BNE TENTING STYL 1.5X5 MM MOD MAXDRIVE 503380561,SUP-2464339,CDM,C1713,HCPCS,0278,RC,,,,both,,,293.12,190.53,,,,,,,,,,,,,
GRAFT VASC INTERGARD L 40 X 35 CM DIA26 X 10 MM THK 0.38 MM,SUP-2227520,CDM,C1768,CPT,0278,RC,,,,both,,,4153.40,2699.71,,,,,,,,,,,,,
GRAFT STENT 0.035 IN 5 MMX2.5 CM 7 FRX120 CM HEPARIN VIABAHN,SUP-2396533,CDM,C1874,HCPCS,0278,RC,,,,both,,,8446.60,5490.29,,,,,,,,,,,,,
PATCH CV HEMSHLD L 3XW 0.3IN 0.76MM POLYESTER BOV NONTAPERED,SUP-2227367,CDM,C1768,CPT,0278,RC,,,,both,,,348.67,226.64,,,,,,,,,,,,,
NAIL TIBIAL ADV. 10X 345MM STERILE,SUP-2761693,CDM,C1713,HCPCS,0278,RC,,,,both,,,4336.47,2818.71,,,,,,,,,,,,,
SPLINT WRST FA R INSTABILITY INJ 10IN LOOP LOK FIRM SUPP VYN,SUP-2276624,CDM,L3809,HCPCS,0272,RC,,,,both,,,17.40,11.31,,,,,,,,,,,,,
SCREW BNE CANN 6.5X100 MM HDLSS NS EPIC,SUP-2221599,CDM,C1713,HCPCS,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
PLATE BNE L210MM 15 H NONSTERILE L ANTLAT DST TIB S STL LO,SUP-2185964,CDM,C1713,HCPCS,0278,RC,,,,both,,,4237.15,2754.15,,,,,,,,,,,,,
ANCHOR SUT L17.9MM DIA6.5MM TI W/ 2 FIBERWIRE BIO CRKSCR,SUP-2121526,CDM,C1713,HCPCS,0278,RC,,,,both,,,753.60,489.84,,,,,,,,,,,,,
ALLOGRAFT HUM TISS DISK 18 MM AMNION CHORION MEMBRN EPIFIX,SUP-2871320,CDM,Q4186,HCPCS,0636,RC,,,,both,,,2109.77,1371.35,,,,,,,,,,,,,
SHOE ORTHOT ADDITION INSOLE RUBBER,SUP-2435738,CDM,L3510,HCPCS,0274,RC,,,,both,,,82.77,53.80,,,,,,,,,,,,,
COMPONENT HNG TIB LIMB SALV LO BODY W/ ROTATIONAL STP,SUP-2314041,CDM,C1776,CPT,0278,RC,,,,both,,,10622.62,6904.70,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY DECANAV L 115 CM DIA 7 FR 10,SUP-2764134,CDM,C1732,HCPCS,0272,RC,,,,both,,,2417.49,1571.37,,,,,,,,,,,,,
SCREW SPNL L25MM DIA6.5MM ANT CANC LUM TI PYRAMID,SUP-2291653,CDM,C1713,HCPCS,0278,RC,,,,both,,,1642.09,1067.36,,,,,,,,,,,,,
CATHETER INFUSION 3X2.8 FRX130 CM 0.027 IN STR HIFLO,SUP-2141056,CDM,C1887,HCPCS,0272,RC,,,,both,,,1758.40,1142.96,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC 4FR 55CM 1 LUMAN RVS TAPR PWR INJ W,SUP-2613365,CDM,C1751,HCPCS,0278,RC,,,,both,,,721.07,468.70,,,,,,,,,,,,,
ANCHOR SUT 2-0 DIA5.5MM BLU COBRAID BLK REGENESORB PRELD,SUP-2349212,CDM,C1713,HCPCS,0278,RC,,,,both,,,1256.50,816.72,,,,,,,,,,,,,
PLATE BNE THK 0.6 MM 6 H SCREW DIA1.5 MM LNG TI MIDFACE DBL,SUP-2883781,CDM,C1713,HCPCS,0278,RC,,,,both,,,540.08,351.05,,,,,,,,,,,,,
DRESSING WND MICRONIZED PARTIC 20 MG MATRISTEM MICROMATRIX,SUP-2106467,CDM,Q4118,HCPCS,0636,RC,,,,both,,,185.89,120.83,,,,,,,,,,,,,
METHYLERGONOVINE MALEATE 0.2 MG PO TABS,RX-10572,CDM,6370000000,HCPCS,0637,RC,69238-1605-08,NDC,,both,1,UN,74.30,48.29,,,,,,,,,,,,,
PIN FIX TROCAR PT 2 END 3/16X9 IN 2 PT STYL SMOOTH PLN STRL,SUP-2150462,CDM,C1713,HCPCS,0278,RC,,,,both,,,18.81,12.23,,,,,,,,,,,,,
SHUNT NEUROSURGICAL OD18MM ADJ VLV W/O DIFF PRSS UNIT PROSA,SUP-2108729,CDM,C1889,HCPCS,0278,RC,,,,both,,,10771.02,7001.16,,,,,,,,,,,,,
GRAFT VASC GELWEAVE L 30 CM DIA16 MM POLYESTER GEL,SUP-2385016,CDM,C1768,CPT,0278,RC,,,,both,,,1156.81,751.93,,,,,,,,,,,,,
GRAFT BNE W10XL250MM THK3 12MM CORT FEM FRZN HALVED STRUT,SUP-2307351,CDM,C1713,HCPCS,0278,RC,,,,both,,,6754.77,4390.60,,,,,,,,,,,,,
BIT DRL DIA3.2MM CTRL SCR DISP FOR COMPHSVE REV SHLDR SYS,SUP-2408539,CDM,2720000010,LOCAL,0272,RC,,,,both,,,324.99,211.24,,,,,,,,,,,,,
HC Rmvl Perm Intraperitneal Cath,PX-3614942200,CDM,49422,CPT,0361,RC,,,,inpatient,,,3707.00,2409.55,,,,,,,,,,,,,
KIT INTRO VSI L 10 CM DIA 5 FR SS MANDREL TUNGSTEN TIP SIL,SUP-2763433,CDM,C1894,HCPCS,0272,RC,,,,both,,,69.08,44.90,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 45 CM DIA 6 MM STR DBL SLDE GDS,SUP-2494318,CDM,C1768,CPT,0278,RC,,,,both,,,1387.25,901.71,,,,,,,,,,,,,
SPONGE SCLER W3XL80MM SIL BCKL STYL 503,SUP-2213486,CDM,L8610,HCPCS,0278,RC,,,,both,,,146.32,95.11,,,,,,,,,,,,,
BIT DRL DIA16MM CANN FOR PROX FEM NAILING SYS TFN ADV,SUP-2178966,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2608.18,1695.32,,,,,,,,,,,,,
HC So1 Thrombin Time Plasma,PX-3058567067,CDM,85670,CPT,0305,RC,,,,both,,,36.00,23.40,,,,,,,,,,,,,
INSERT ACET SZ P4 ID32MM 15DEG HIP UHMWPE CO CHROM,SUP-2376175,CDM,C1776,CPT,0278,RC,,,,both,,,2024.67,1316.04,,,,,,,,,,,,,
PLATE BNE W10XL85MM THK15MM 3X6 H L TI T SHP OBLQ RIG NEUT,SUP-2190998,CDM,C1713,HCPCS,0278,RC,,,,both,,,1223.94,795.56,,,,,,,,,,,,,
BANDAGE COMPR SM MAMM COMFORTABLE HIGHLY ABSRB POST SURG,SUP-2276344,CDM,L8000,HCPCS,0274,RC,,,,both,,,119.32,77.56,,,,,,,,,,,,,
FEEDING TUBE KIT LP 14 FRX2 CM BLLN BUTTON SIL CLR MINI 1,SUP-2754575,CDM,2720000010,LOCAL,0272,RC,,,,both,,,702.17,456.41,,,,,,,,,,,,,
MESH HERN MED 14.2X8.6 CM W/ POCKET STRP,SUP-2858044,CDM,C1781,HCPCS,0278,RC,,,,both,,,586.11,380.97,,,,,,,,,,,,,
PLATE SPNL L19MM 2 H UNIV ANT LUM TI TRIANG PYRAMID,SUP-2291658,CDM,C1713,HCPCS,0278,RC,,,,both,,,15623.64,10155.37,,,,,,,,,,,,,
CANNULA W/ RND TIP STYL,SUP-2366997,CDM,C1713,HCPCS,0278,RC,,,,both,,,336.61,218.80,,,,,,,,,,,,,
MESH HERN W20XL20CM SYN BIOABSRB REINF BIO-A,SUP-2395753,CDM,C1781,HCPCS,0278,RC,,,,both,,,8430.90,5480.08,,,,,,,,,,,,,
STRUT EXT FIX L 57-79 MM XS BALL JT NS DISP MONK RING BONOBO,SUP-2899005,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4576.55,2974.76,,,,,,,,,,,,,
PROSTHESIS OSS 3-7 MM 4X3.25 MM 0.86X1.27 MM DORNHOFFER HA,SUP-2460430,CDM,L8613,CPT,0278,RC,,,,both,,,1425.06,926.29,,,,,,,,,,,,,
PIN FIX TRCR PT 1 END 0.109X9 IN RND END SS NS STEINMANN,SUP-2791829,CDM,C1713,HCPCS,0278,RC,,,,both,,,16.77,10.90,,,,,,,,,,,,,
SEED BRACHYTHERAPY PROST PALLADIUM-103 VI CALIB SGL,SUP-2129126,CDM,C2640,HCPCS,0278,RC,,,,both,,,204.10,132.66,,,,,,,,,,,,,
HC Ultrasound Elastography Parenchyma,PX-4027698100,CDM,76981,CPT,0402,RC,,,,both,,,1276.00,829.40,,,,,,,,,,,,,
GRAFT BNE L16MM DIA8MM CANC PLUG W CART FRZN FLEXIGRFT,SUP-2264633,CDM,C1762,CPT,0278,RC,,,,both,,,1265.58,822.63,,,,,,,,,,,,,
HC Thyroid Stimulating Hormone|NOT REASONABLE AND NECESSARY,PX-3018444300,CDM,84443,CPT,0301,RC,,,GZ,both,,,293.00,190.45,,,,,,,,,,,,,
GUIDEWIRE VASC STRT L 260 CM DIA 0.035 IN TIP L 15 CM SS,SUP-2148281,CDM,C1769,HCPCS,0272,RC,,,,both,,,49.61,32.25,,,,,,,,,,,,,
VALVE AORT ATS OPN PVT AP360 DIA18 MM ORIFICE 16.8 MM TISS,SUP-2282691,CDM,C1889,HCPCS,0278,RC,,,,both,,,9840.76,6396.49,,,,,,,,,,,,,
IMPLANT COSMETIC SZ 40 X 9 X 1.1 MM POLYETHYL NSL SHT STRL,SUP-2936094,CDM,C1713,HCPCS,0278,RC,,,,both,,,750.46,487.80,,,,,,,,,,,,,
SIZER SURG 295 CC BRST STYL SSZ FULL PROF NATRELLE INSPIRA,SUP-2753001,CDM,2720000010,LOCAL,0272,RC,,,,both,,,690.80,449.02,,,,,,,,,,,,,
GRAFT BNE INJ 15 CC INDUCTIVE PRO-STIM,SUP-2759468,CDM,C1713,HCPCS,0278,RC,,,,both,,,17621.68,11454.09,,,,,,,,,,,,,
INTRODUCER NDL DIAMOND TIP 10 GA SIDE ACCS KT STRL SYNFLATE,SUP-2758542,CDM,2720000010,LOCAL,0272,RC,,,,both,,,438.34,284.92,,,,,,,,,,,,,
GRAFT HUM TISS W18XL30MM THK18MM FRZ DRY ALLGRFT BLK CANC,SUP-2307116,CDM,C1713,HCPCS,0278,RC,,,,both,,,3052.49,1984.12,,,,,,,,,,,,,
MESH HERN W30XL36CM RECT POLYPR NONABSORBABLE PROL SFT,SUP-2219922,CDM,C1781,HCPCS,0278,RC,,,,both,,,1790.84,1164.05,,,,,,,,,,,,,
ENDCAP ORTH L5MM DIA11MM ST GRN TI NAIL EXTN TROCHANTERIC,SUP-2191918,CDM,C1776,CPT,0278,RC,,,,both,,,712.28,462.98,,,,,,,,,,,,,
DRILL TWST 3 FLUT 3.8 MM,SUP-2606637,CDM,2720000010,LOCAL,0272,RC,,,,both,,,599.61,389.75,,,,,,,,,,,,,
MESH HERN SQ 3X3 IN FULL RESRB FOR SFT TISS RECON PHASIX,SUP-2855247,CDM,C1781,HCPCS,0278,RC,,,,both,,,3623.56,2355.31,,,,,,,,,,,,,
STENT TRACHBRONCH 7X40MM STENT GRFT 80CM 8FR DEL SYS NIT,SUP-2128293,CDM,C1874,HCPCS,0278,RC,,,,both,,,6577.52,4275.39,,,,,,,,,,,,,
SCREW BNE CRTX 1.5X16 MM TI NS,SUP-2190904,CDM,C1713,HCPCS,0278,RC,,,,both,,,141.68,92.09,,,,,,,,,,,,,
MICROCATHETER INFUSION SUPERCROSS 90 DEG L 135 CM DSTL L 40,SUP-2120496,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
GRAFT BIO TISS W5.9XL7.9IN RECT XENMATRIX,SUP-2125846,CDM,C1781,HCPCS,0278,RC,,,,both,,,20934.38,13607.35,,,,,,,,,,,,,
CATHETER DIAG STEER L CRV 2 5 2MM ELECTRD SPC OCTAPOLAR,SUP-2142291,CDM,C1730,HCPCS,0272,RC,,,,both,,,1193.20,775.58,,,,,,,,,,,,,
PLATE BNE L190MM 10 H NONSTERILE L LAT PROX TIB S STL LOK,SUP-2185720,CDM,C1713,HCPCS,0278,RC,,,,both,,,4269.71,2775.31,,,,,,,,,,,,,
SEED BRACHYTHERAPY PD-103 PALLADIUM W/ SOURCELINK CONN,SUP-2129043,CDM,C2640,HCPCS,0278,RC,,,,both,,,169.56,110.21,,,,,,,,,,,,,
MIDAZOLAM 5 MG/ML SOLN (MIXTURES ONLY),RX-430000,CDM,J2250,HCPCS,0636,RC,00409-2308-01,NDC,,both,0.4,ML,54.10,35.16,,,,,,,,,,,,,
BOLT L80MM DIA65MM PROX L10MM DST L24MM FUS SALVATION,SUP-2400722,CDM,C1713,HCPCS,0278,RC,,,,both,,,5184.14,3369.69,,,,,,,,,,,,,
CAGE SPNL 14X12X10 MM ANTR CERV INTBDY FUSION PEEK MATISSE,SUP-2578103,CDM,C1889,HCPCS,0278,RC,,,,both,,,2339.30,1520.54,,,,,,,,,,,,,
SPHERE GLEN 6+ MM 40 MM VERSA-DIAL,SUP-2435438,CDM,C1776,CPT,0278,RC,,,,both,,,3611.00,2347.15,,,,,,,,,,,,,
COIL NEUROVASCULAR CASHMERE 14 L 9 CM LOOP DIA 6 MM PRIMARY,SUP-2249269,CDM,C1889,HCPCS,0278,RC,,,,both,,,3868.17,2514.31,,,,,,,,,,,,,
GRAFT 5X6CM TERMINALLY MTRX STRL TISSUEMEND,SUP-2366722,CDM,C1713,HCPCS,0278,RC,,,,both,,,13649.58,8872.23,,,,,,,,,,,,,
BIT DRL DIA11MM DISP CHONDROFIX,SUP-2200257,CDM,2720000010,LOCAL,0272,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
PLATE BONE L12MM GRN EIGHT FOR GUID GROWTH SYS,SUP-2316386,CDM,C1713,HCPCS,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
STENT PERIPHERAL L30MM DIAMETER 7MM CATHETER L80CM VASCULAR STRAIGHT ARTERIOVENOUS FLAIR,SUP-2128216,CDM,C1874,HCPCS,0278,RC,,,,both,,,6578.30,4275.89,,,,,,,,,,,,,
PLATE BONE L190MM 11 H LT PROX HUM LO ALPS,SUP-2402732,CDM,C1713,HCPCS,0278,RC,,,,both,,,8273.90,5378.03,,,,,,,,,,,,,
SCREW SPNL SHANK 5.5X30 MM POST LUMBAR INTBDY FUSION SYS MAS,SUP-2311080,CDM,C1713,HCPCS,0278,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
CATHETER IVUS VISIONS PV .035 L 90 CM COAT L 30 CM SHTH 8.5,SUP-2327233,CDM,C1753,HCPCS,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
SUGAMMADEX SODIUM 200 MG/2ML IV SOLN,RX-132570,CDM,2500000003,HCPCS,0250,RC,00006-5423-12,NDC,,both,2,ML,782.90,508.88,,,,,,,,,,,,,
UPCHARGE KNEE TRITANIUM X3 PATELLA STRYKER,SUP-2501353,CDM,C1776,CPT,0278,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
RING EXT FIX ID230MM ALUM 2/3 W/ 7 H MSTR TAB TAY SPAT FRME,SUP-2343036,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7279.46,4731.65,,,,,,,,,,,,,
ORTHOLOC SPS 3.5X38MM CORTICAL NON-LOCKING SCREW,SUP-2822324,CDM,C1713,HCPCS,0278,RC,,,,both,,,574.62,373.50,,,,,,,,,,,,,
CATHETER EP SINGLE 2-2-2MM 7FRX90CM MARINR,SUP-2281827,CDM,C1730,HCPCS,0272,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
PLATE BNE CLAV 2.7 MM RT MEDL VA LCK COMPR SS NS VA-LCP,SUP-2757613,CDM,C1713,HCPCS,0278,RC,,,,both,,,3967.70,2579.00,,,,,,,,,,,,,
CATHETER INFUSION STR 0.018 IN 160 CM 15 CMX6 CM PHENOM 21,SUP-2418136,CDM,C1887,HCPCS,0272,RC,,,,both,,,4286.10,2785.96,,,,,,,,,,,,,
GRAFT BNE PTTY LG 11 CC FIBERGRAFT BG,SUP-2330554,CDM,C1713,HCPCS,0278,RC,,,,both,,,10362.00,6735.30,,,,,,,,,,,,,
SYSTEM KNEE POD GUIDANCE IASSIST,SUP-2212348,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
GRAFT BIO TISS 14MM DISC DERM REP MESHED SCAFFOLD PRIMATRIX,SUP-2243697,CDM,Q4110,HCPCS,0636,RC,,,,both,,,1067.60,693.94,,,,,,,,,,,,,
PLATE BNE FIBULAR 2.7X157 MM RT LAT DSTL 9 HOLE STRL VALCP,SUP-2789394,CDM,C1713,HCPCS,0278,RC,,,,both,,,3425.61,2226.65,,,,,,,,,,,,,
HOOK SUT STR FOR ORIG SPECTRM,SUP-2166878,CDM,2720000010,LOCAL,0272,RC,,,,both,,,854.33,555.31,,,,,,,,,,,,,
HMRL TRAY +6 +5,SUP-2505930,CDM,C1776,CPT,0278,RC,,,,both,,,5146.46,3345.20,,,,,,,,,,,,,
GRAFT BIO TISS W8XL8CM MESHED FET BOV DERM DERM IONIC SLV,SUP-2243719,CDM,Q4110,HCPCS,0636,RC,,,,both,,,7944.20,5163.73,,,,,,,,,,,,,
TUBE EXT FIX DYN 20MM RED MONOTUBE TRIAX,SUP-2372606,CDM,C1713,HCPCS,0278,RC,,,,both,,,6382.99,4148.94,,,,,,,,,,,,,
TRAY ENDO INSTR LOCATABLE GUID OLY,SUP-2381723,CDM,C1769,HCPCS,0272,RC,,,,both,,,2621.90,1704.23,,,,,,,,,,,,,
ALLOGRAFT BNE WDG 17-19 MM FRZN ILIUM TRICORT,SUP-2717921,CDM,C1762,CPT,0278,RC,,,,both,,,5135.56,3338.11,,,,,,,,,,,,,
AMPICILLIN SODIUM 2000 MG IJ SOLR (MIXTURES ONLY),RX-430021,CDM,J0290,HCPCS,0636,RC,00781-3408-95,NDC,,both,1,UN,54.10,35.16,,,,,,,,,,,,,
SHEATH INTRO INPUT SSV L 13 CM DIA12 FR DIL L 20 CM,SUP-2294836,CDM,C1892,HCPCS,0272,RC,,,,both,,,86.35,56.13,,,,,,,,,,,,,
HC Puncture Aspir Cyst-Breast,PX-3611900000,CDM,19000,CPT,0361,RC,,,,inpatient,,,3707.00,2409.55,,,,,,,,,,,,,
VALVULOTOME ANGIOSCOPIC L 40 CM DIA2 MM SHTH TEF OTW SELF,SUP-2884029,CDM,2720000010,LOCAL,0272,RC,,,,both,,,11300.86,7345.56,,,,,,,,,,,,,
BOLT ORTH L 85 MM DIA 6.5 MM PT INTLOK,SUP-2898422,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1296.82,842.93,,,,,,,,,,,,,
CATHETER ECRP 5.5-3.5FR L200CM 0.021IN LNG TAPR TIP FOR CANN,SUP-2169268,CDM,C1757,HCPCS,0272,RC,,,,both,,,138.16,89.80,,,,,,,,,,,,,
ELECTRODE ES DIA3MM 50DEG WAND POWERFUL ANG FOR FREE,SUP-2341993,CDM,2720000010,LOCAL,0272,RC,,,,both,,,584.04,379.63,,,,,,,,,,,,,
WIRE FIX DISPNS TELLURIDE K FOR MIS SPNL FIX SYS,SUP-2211172,CDM,C1713,HCPCS,0278,RC,,,,both,,,734.76,477.59,,,,,,,,,,,,,
TUBE SUCTION T FUKUSHIMA 5 FRX3.25 IN 6.5 IN TEARDROP,SUP-2475665,CDM,2720000010,LOCAL,0272,RC,,,,both,,,372.75,242.29,,,,,,,,,,,,,
ALLOGRAFT BNE CUBE 30 CC FD CANC,SUP-2205399,CDM,C1889,HCPCS,0278,RC,,,,both,,,2935.90,1908.33,,,,,,,,,,,,,
PIN FIX HDLSS MIC 1.6X5 MM POLY-D-L-LACTIC ACID 525192504,SUP-2460985,CDM,C1713,HCPCS,0278,RC,,,,both,,,268.94,174.81,,,,,,,,,,,,,
INSERT TIB SULCUS 1+ LG 14 MM LT RT TOT ANK REV INBONE II,SUP-2850402,CDM,C1776,CPT,0278,RC,,,,both,,,5743.06,3732.99,,,,,,,,,,,,,
STAPLER INT AD L28MM DIA5MM STD GI BLU TI CIR CUT 2 ROW,SUP-2283244,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1188.68,772.64,,,,,,,,,,,,,
KNIFE ELECSURG LOWER 4.5X1.3 MM 2.8X2300 MM HOOKKNIFE DISP,SUP-2499554,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2968.09,1929.26,,,,,,,,,,,,,
GRAFT BNE PROX FIB 18 CM TISS,SUP-2165533,CDM,C1713,HCPCS,0278,RC,,,,both,,,1978.20,1285.83,,,,,,,,,,,,,
NOREPINEPHRINE BITARTRATE 1 MG/ML IV SOLN,RX-10734,CDM,2500000003,HCPCS,0250,RC,00143-9318-01,NDC,,both,4,ML,83.00,53.95,,,,,,,,,,,,,
NEEDLE BRST LOC BLNT 20 GAX3 CM STRL HAWK3 LTX,SUP-2876180,CDM,C1819,HCPCS,0278,RC,,,,both,,,176.78,114.91,,,,,,,,,,,,,
SPACER FEM SZ 0 LT MEDL CONSTRN REV CEM NP N-K II,SUP-2209254,CDM,C1776,CPT,0278,RC,,,,both,,,3592.16,2334.90,,,,,,,,,,,,,
PLATE BONE W6.3XL66MM THK1.6MM 5X5 H LT DSTL VOLAR RAD TI,SUP-2191011,CDM,C1713,HCPCS,0278,RC,,,,both,,,2033.06,1321.49,,,,,,,,,,,,,
HEMOFILTER SET EXCORP CIRC PRISMAFLEX M100,SUP-2129944,CDM,2720000010,LOCAL,0272,RC,,,,both,,,772.38,502.05,,,,,,,,,,,,,
PLATE BNE PENTAGON 1.5X0.2 MM NEURO SCRN MESH JANNETTA TI NS,SUP-2463225,CDM,C1713,HCPCS,0278,RC,,,,both,,,890.57,578.87,,,,,,,,,,,,,
PLATE BNE SCREW DIA2 MM LT BTTRS MOD NS DISP,SUP-2934877,CDM,C1713,HCPCS,0278,RC,,,,both,,,869.78,565.36,,,,,,,,,,,,,
HC Stress Echo WO Contrast,PX-4839335001,CDM,93350,CPT,0483,RC,,,,both,,,1944.00,1263.60,,,,,,,,,,,,,
POST FIX 12MM BOLT 3 H ASSEMB TRUELOK RNG,SUP-2316109,CDM,2720000010,LOCAL,0272,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
STEM FEM CALCAR HIP PLANER W/ BODY AVENIR COMPLETE,SUP-2448592,CDM,C1776,CPT,0278,RC,,,,both,,,1526.04,991.93,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 50 CM DIA 6 MM STR REINF SLDE GDS,SUP-2484260,CDM,C1768,CPT,0278,RC,,,,both,,,1557.31,1012.25,,,,,,,,,,,,,
GUIDEWIRE VASC L 40 CM DIA 0.025 IN CRV RAD 2 MM SS SAFE-T-J,SUP-2760082,CDM,C1769,HCPCS,0272,RC,,,,both,,,112.88,73.37,,,,,,,,,,,,,
BUTTON SUTURE 10X5 MM TISSUE STERILE,SUP-2836436,CDM,C1713,HCPCS,0278,RC,,,,both,,,219.80,142.87,,,,,,,,,,,,,
PIN GALAXY FIX SYS MRI ANK 80MM TRANSFIX,SUP-2316017,CDM,2720000010,LOCAL,0272,RC,,,,both,,,489.21,317.99,,,,,,,,,,,,,
PLATE BNE ADV 10 MM SCREW DIA2 MM 10 H RT,SUP-2883444,CDM,C1713,HCPCS,0278,RC,,,,both,,,1978.04,1285.73,,,,,,,,,,,,,
HC Rad Guide for Perc Drain Tube,PX-3207598900,CDM,75989,CPT,0320,RC,,,,inpatient,,,6875.00,4468.75,,,,,,,,,,,,,
INTRODUCER SHTH POLYMER COAT WIRE 0.014 IN 4 FRX6.5 CM RED,SUP-2157405,CDM,C1894,HCPCS,0272,RC,,,,both,,,101.27,65.83,,,,,,,,,,,,,
KIT FIX ANG REPLICATOR EQUINOXE,SUP-2223288,CDM,C1713,HCPCS,0278,RC,,,,both,,,3494.19,2271.22,,,,,,,,,,,,,
PLATE BONE 18 H S STL BILAT NONCOMPRESSION RIG CLLR 1/3 TBLR,SUP-2372062,CDM,C1713,HCPCS,0278,RC,,,,both,,,444.00,288.60,,,,,,,,,,,,,
SEED BRACHYTHERAPY LOOSE 7.01-8.0 MCI NS ADVANTAGE,SUP-2247280,CDM,C2643,HCPCS,0278,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
SUPPORT VAG W/ CAPIO SLIM PELV FLR MESH ASSEMB OPN ACCS DEV,SUP-2139401,CDM,C1781,HCPCS,0278,RC,,,,both,,,7244.51,4708.93,,,,,,,,,,,,,
BUTTON FIX DIA25MM BNE TO BNE ENDOBTTN CL,SUP-2341035,CDM,C1713,HCPCS,0278,RC,,,,both,,,1004.80,653.12,,,,,,,,,,,,,
REAMER SURG DIA2.5 MM LNG STRL DISP MOTOBAND CP DYNAFORCE,SUP-2893464,CDM,2720000010,LOCAL,0272,RC,,,,both,,,332.84,216.35,,,,,,,,,,,,,
OXYCODONE-ACETAMINOPHEN 7.5-325 MG PO TABS,RX-31863,CDM,6370000000,HCPCS,0637,RC,00406-0522-62,NDC,,both,1,UN,10.10,6.56,,,,,,,,,,,,,
DEVICE ARTOTMY CLOSURE MANTA DIA18 FR CLLGN FEM ART FOR VASC,SUP-2667223,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2276.50,1479.72,,,,,,,,,,,,,
KIT INTRO INTRACLUDE L 3.7 IN DIA19 FR GUIDEWIRE L 100 CM,SUP-2890128,CDM,C1894,HCPCS,0272,RC,,,,both,,,1876.84,1219.95,,,,,,,,,,,,,
GUIDEWIRE VASC L 180 CM 0.035 IN L8CM 3CM HEPARIN AMPLTZ STR,SUP-2169713,CDM,C1769,HCPCS,0272,RC,,,,both,,,75.17,48.86,,,,,,,,,,,,,
PLATE BNE TI 8 H NONCOMPRESSION ORBIT RIM BILAT 12MM SCR H,SUP-2366227,CDM,C1713,HCPCS,0278,RC,,,,both,,,659.27,428.53,,,,,,,,,,,,,
METOPROLOL TARTRATE 100 MG PO TABS,RX-5008,CDM,6370000000,HCPCS,0637,RC,62584-0267-11,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
IMPLANT HUM TISS L 3 X W 3 CM THK 1 MM 9 SQ CM SUTURABLE,SUP-2898868,CDM,C1762,CPT,0278,RC,,,,both,,,4804.20,3122.73,,,,,,,,,,,,,
BIT DRL DIA65MM CANN BITE COMPR SCR QUIK CONN,SUP-2315945,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1329.16,863.95,,,,,,,,,,,,,
THUMBWHEEL EXT FIX HEX 10 HOFFMANN LRF,SUP-2474934,CDM,2720000010,LOCAL,0272,RC,,,,both,,,237.07,154.10,,,,,,,,,,,,,
PLATE BNE L284MM THK3MM 15 H BILAT S STL STR LOK COMPR RECON,SUP-2185352,CDM,C1713,HCPCS,0278,RC,,,,both,,,2110.43,1371.78,,,,,,,,,,,,,
ALLOGRAFT BNE FEM FRZN DSTL,SUP-2321784,CDM,C1713,HCPCS,0278,RC,,,,both,,,8047.82,5231.08,,,,,,,,,,,,,
MATRIX RESTRATA WOUND 10CM X 12.5CM,SUP-2874122,CDM,A2007,HCPCS,0636,RC,,,,both,,,14130.00,9184.50,,,,,,,,,,,,,
MESH SURG W4XL4CM SCAFFOLD DERM ACELLULAR CLLGN MTRX BOV,SUP-2243716,CDM,Q4110,HCPCS,0636,RC,,,,both,,,2599.92,1689.95,,,,,,,,,,,,,
PLATE BNE L25MM 2 H TI 1 3 TBLR W CLLR SM FRAG SET SPS,SUP-2364394,CDM,C1713,HCPCS,0278,RC,,,,both,,,305.52,198.59,,,,,,,,,,,,,
PROBE ENDOSCP ELECTROCAUTERY L 2.3 M DIA2.6 MM ELECTRD L 2,SUP-2901675,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2983.00,1938.95,,,,,,,,,,,,,
TUBE ET NSL STRL NAZ-AL 7.5MM,SUP-2383858,CDM,2720000010,LOCAL,0272,RC,,,,both,,,984.11,639.67,,,,,,,,,,,,,
STRUT CORT TRAD ALLGRFT L 60X20 MM FRZ DRY,SUP-2294112,CDM,C1713,HCPCS,0278,RC,,,,both,,,2458.62,1598.10,,,,,,,,,,,,,
HYDROCORTISONE 2.5 % EX CREA,RX-3727,CDM,6370000000,HCPCS,0637,RC,00168-0080-31,NDC,,both,30,GR,14.90,9.68,,,,,,,,,,,,,
RITUXIMAB-PVVR 500 MG/50ML IV SOLN,RX-148803,CDM,Q5119,HCPCS,0636,RC,00069-0249-01,NDC,,both,50,ML,10322.00,6709.30,,,,,,,,,,,,,
MESH CRAN L 50.8 X W 50.8 MM THK 0.8 MM SCREW DIA1.5 MM SM,SUP-2935998,CDM,C1713,HCPCS,0278,RC,,,,both,,,4449.38,2892.10,,,,,,,,,,,,,
MICROFIBRILLAR COLL HEMOSTAT EX POWD,RX-10606,CDM,6370000000,HCPCS,0637,RC,53276-1010-02,NDC,,both,1,GR,390.10,253.56,,,,,,,,,,,,,
SCREW BNE L115MM DIA6.5MM THRD L32MM CANC TI ST SELF DRL,SUP-2190532,CDM,C1713,HCPCS,0278,RC,,,,both,,,156.87,101.97,,,,,,,,,,,,,
BLADE DERMTOM DISP FOR BAHA OSSCORA AND WS-75,SUP-2164929,CDM,2720000010,LOCAL,0272,RC,,,,both,,,172.70,112.25,,,,,,,,,,,,,
GRAFT BNE SPACER 14X11.5X6 MM CERV CORTICAL LORDTC CESPACE,SUP-2108960,CDM,C1889,HCPCS,0278,RC,,,,both,,,2637.60,1714.44,,,,,,,,,,,,,
DICLOFENAC SODIUM ER 100 MG PO TB24,RX-27160,CDM,6370000000,HCPCS,0637,RC,68682-0103-01,NDC,,both,1,UN,10.70,6.95,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 2X2 CM CRYOPRESERVED AMNIOX CLARIX 100,SUP-2648668,CDM,Q4156,HCPCS,0636,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
CAGE SPNL L16XW16XH70MM 4 LOBE MESH ANAT FOOTPRINT MOD IMP,SUP-2317744,CDM,C1889,HCPCS,0278,RC,,,,both,,,18613.92,12099.05,,,,,,,,,,,,,
PACEMAKER CARD AD PERM SGL CHMBR NOT MRI COMPATIBLE STD,SUP-2356708,CDM,C1786,HCPCS,0275,RC,,,,both,,,8996.10,5847.46,,,,,,,,,,,,,
IMPLANT BRST SIL 440CC SMOOTH RND NATRELLE SIL SHELL,SUP-2113265,CDM,C1789,HCPCS,0278,RC,,,,both,,,2983.00,1938.95,,,,,,,,,,,,,
SCREW SPNL ST 2.3X18 MM TI CENTREDRIVE,SUP-2459813,CDM,C1713,HCPCS,0278,RC,,,,both,,,203.22,132.09,,,,,,,,,,,,,
PLATE BNE COMPR STD 146 MM ST FOR HELIX BLADE SS NS,SUP-2186777,CDM,C1713,HCPCS,0278,RC,,,,both,,,1035.98,673.39,,,,,,,,,,,,,
CATHETER ABLAT 7FR L115CM 1-7-4MM SPC TIP 4MM 4 ELECTRD BLU,SUP-2248512,CDM,C1732,HCPCS,0278,RC,,,,both,,,6220.34,4043.22,,,,,,,,,,,,,
COMPONENT SEG DSTL TOT FEM 8CM LT SEGAL FINN,SUP-2406046,CDM,C1776,CPT,0278,RC,,,,both,,,16494.42,10721.37,,,,,,,,,,,,,
WEDGE TIB 12 DEG MED RT KNEE ANGLED DURAC,SUP-2364820,CDM,C1776,CPT,0278,RC,,,,both,,,2458.62,1598.10,,,,,,,,,,,,,
WIRE FIX THRD 2.8X200 MM 15 MM COMPR NS VA-LCP,SUP-2863399,CDM,C1713,HCPCS,0278,RC,,,,both,,,181.62,118.05,,,,,,,,,,,,,
EPICORD 2X3CM 6SQ CM,SUP-2305732,CDM,Q4187,HCPCS,0636,RC,,,,both,,,4443.10,2888.01,,,,,,,,,,,,,
CHOLANGIOGRAPHY SET 4 FRX60 CM 14 GAX7.5 CM CATH NDL PETELIN,SUP-2863652,CDM,C1894,HCPCS,0272,RC,,,,both,,,131.88,85.72,,,,,,,,,,,,,
BIT DRVR FOR 3/4MM CANN SCR,SUP-2390541,CDM,2720000010,LOCAL,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
FLUOROURACIL 2.5 GM/50ML IV SOLN,RX-82180,CDM,J9190,HCPCS,0636,RC,63323-0117-51,NDC,,both,50,ML,54.10,35.16,,,,,,,,,,,,,
TROCAR ENDOSCP L 150 MM DIA 5 MM LNG OPT BLDELSS FIX CANN,SUP-2896306,CDM,2720000010,LOCAL,0272,RC,,,,both,,,363.74,236.43,,,,,,,,,,,,,
GRAFT BONE SUB W5XL2.5CM DEMIN MTRX FLX GRFTON,SUP-2281663,CDM,C1713,HCPCS,0278,RC,,,,both,,,3384.92,2200.20,,,,,,,,,,,,,
NAIL IM L300MM DIA11MM 125DEG RAD OF CURVATURE 1.5M LNG L,SUP-2371386,CDM,C1713,HCPCS,0278,RC,,,,both,,,6594.00,4286.10,,,,,,,,,,,,,
GUIDEWIRE VASC L 145 CM DIA 0.035 IN TAPR L 8 CM TIP L 3 CM,SUP-2169795,CDM,C1769,HCPCS,0272,RC,,,,both,,,84.53,54.94,,,,,,,,,,,,,
GUIDEWIRE VASC ARISTOTLE 14 L 200 CM DIA 0.014 IN SFT,SUP-2656731,CDM,C1769,HCPCS,0272,RC,,,,both,,,1648.50,1071.52,,,,,,,,,,,,,
PI PICC KIT 2-L 5 FR X 55 CM AGBA/TIPTRACKER,SUP-2565196,CDM,C1751,HCPCS,0278,RC,,,,both,,,664.52,431.94,,,,,,,,,,,,,
GRAFT BNE SUB 6ML VOID FILL RESRB PTTY MASTERGRFT,SUP-2288542,CDM,C9359,HCPCS,0278,RC,,,,both,,,2150.90,1398.08,,,,,,,,,,,,,
STENT COR 9MM 2.25MM CO CHROM PROBIO SCP HYDRPHLC,SUP-2138133,CDM,C1876,HCPCS,0278,RC,,,,both,,,1868.30,1214.39,,,,,,,,,,,,,
SCREW BNE L 3.5 MM DIA1.8 MM CRANIOMAXILOFACIAL HI TORQUE,SUP-2935623,CDM,C1713,HCPCS,0278,RC,,,,both,,,3011.26,1957.32,,,,,,,,,,,,,
STAPLE BNE FIX W18XL15MM NIT COMPR W/ INSTR LO PROF FOR,SUP-2122351,CDM,C1776,CPT,0278,RC,,,,both,,,7206.30,4684.09,,,,,,,,,,,,,
PROBE LITHO 1.9 FRX375 CM BILI ELEC HYDRLC AUTOLITH TCH DISP,SUP-2141488,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1347.06,875.59,,,,,,,,,,,,,
SPACER CUT GUID MONOGRAM 10MM,SUP-2364870,CDM,C1776,CPT,0278,RC,,,,both,,,742.92,482.90,,,,,,,,,,,,,
ANCHOR N SUT FIX 3 MM SZ 40 MM LEN ACL TRANSFIX,SUP-2121109,CDM,C1713,HCPCS,0278,RC,,,,both,,,496.12,322.48,,,,,,,,,,,,,
CATHETER TEMP PACE L 110 CM DIA 5 FR PROX 1 CM POLYUR SS,SUP-2127113,CDM,2720000010,LOCAL,0272,RC,,,,both,,,771.34,501.37,,,,,,,,,,,,,
PLATE BNE 2 HOLE STRATUM PNUT,SUP-2464099,CDM,C1713,HCPCS,0278,RC,,,,both,,,2969.00,1929.85,,,,,,,,,,,,,
ALLOGRAFT BNE RNG 12 DEG 26X26X14 MM FRZN PRECISION-GRAFT,SUP-2787557,CDM,C1713,HCPCS,0278,RC,,,,both,,,9090.87,5909.07,,,,,,,,,,,,,
K WIRE FIX L285MM DIA3MM S STL SMOOTH DBL END SHRP TIP FOR,SUP-2368568,CDM,C1713,HCPCS,0278,RC,,,,both,,,141.30,91.84,,,,,,,,,,,,,
TRIAL FIX PIN L40MM DIA2.7MM FOR SM FRAG SYS,SUP-2343973,CDM,C1713,HCPCS,0278,RC,,,,both,,,1401.07,910.70,,,,,,,,,,,,,
PLATE BNE RECON 2.7X3 MM RT MAND 26 HOLE ANGLED TI NS,SUP-2470840,CDM,C1713,HCPCS,0278,RC,,,,both,,,6041.93,3927.25,,,,,,,,,,,,,
TACROLIMUS 5 MG PO CAPS,RX-12934,CDM,J7507,HCPCS,0636,RC,16729-0043-01,NDC,,both,1,UN,13.20,8.58,,,,,,,,,,,,,
ENDCAP ORTH L20MM DIA15MM STRL GRN FEM TI NAIL EXTN LCK HD,SUP-2192718,CDM,C1713,HCPCS,0278,RC,,,,both,,,769.93,500.45,,,,,,,,,,,,,
FORCEP ELECSURG SPETZLER MALIS 0.5 MM 20 CM 2IRRIGATING BPLR,SUP-2859775,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1370.23,890.65,,,,,,,,,,,,,
COIL DETACH SFT SR 2MM HELI COIL DIA 1CM INTRO GDC 10,SUP-2365650,CDM,C1889,HCPCS,0278,RC,,,,both,,,2128.76,1383.69,,,,,,,,,,,,,
PLATE BNE L64MM 7 H TI R LAT DST HUM LO PROF RIG ALPS,SUP-2411713,CDM,C1713,HCPCS,0278,RC,,,,both,,,4735.12,3077.83,,,,,,,,,,,,,
SCREW SPNL L20MM OD4MM MONOAX REDUC REVERE,SUP-2231808,CDM,C1713,HCPCS,0278,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
SUPPORT ORTHOT THGH LOWER EXTREMITY WT BEAR HI RL CUF,SUP-2435679,CDM,L2550,HCPCS,0272,RC,,,,both,,,963.29,626.14,,,,,,,,,,,,,
INTRODUCER SHTH 8.5FR L63CM 8.5FR DIL GWIRE L145CM,SUP-2357172,CDM,C1893,HCPCS,0272,RC,,,,both,,,527.52,342.89,,,,,,,,,,,,,
STENT COR 15MM 3MM RX MULTLNK VISN,SUP-2104207,CDM,C1876,HCPCS,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
IMPLANT HEARING AID 3 MM PONTO BIOHELIX,SUP-2430348,CDM,L8690,HCPCS,0278,RC,,,,both,,,5224.96,3396.22,,,,,,,,,,,,,
HAT EXT FIX COMPR PHOENIX,SUP-2496293,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1842.71,1197.76,,,,,,,,,,,,,
HEAD SPNL SCREW ROD DIA 4.75/5 MM PEDCL REDUCTION UNIAXIAL,SUP-2926519,CDM,C1713,HCPCS,0278,RC,,,,both,,,2920.20,1898.13,,,,,,,,,,,,,
SCREW BONE L7MM DIA1.5MM CORT CRANIOMAXILLOFACIAL TI ST FULL,SUP-2188927,CDM,C1713,HCPCS,0278,RC,,,,both,,,957.70,622.50,,,,,,,,,,,,,
HEAD FEM DIA32MM MECTACER BIOLOX OPT SYS,SUP-2267357,CDM,C1776,CPT,0278,RC,,,,both,,,6141.84,3992.20,,,,,,,,,,,,,
CATHETER ANGIO 7FR L60CM 130DEG PLCMNT CUT AWAY COR SNUS,SUP-2420680,CDM,C1887,HCPCS,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
CATHETER HD STR 15.5 FRX24 CM LT DL STP TIP SIDE H TITAN HD,SUP-2627345,CDM,C1750,HCPCS,0278,RC,,,,both,,,188.40,122.46,,,,,,,,,,,,,
GRAFT VASC STR 6 MMX40 CM TW N RING HD ACCS EPTFE CARBOFLO,SUP-2761281,CDM,C1768,CPT,0278,RC,,,,both,,,1807.35,1174.78,,,,,,,,,,,,,
HC Anoscopy Diagnostic,PX-4504660000,CDM,46600,CPT,0450,RC,,,,both,,,214.00,139.10,,,,,,,,,,,,,
TRAY CATH PICC LUMENX1 3FR DIA POLYURETHANE BASIC W/MCRZ MIC,SUP-2613427,CDM,C1751,HCPCS,0278,RC,,,,both,,,334.10,217.16,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED UPLR CHIPSTRYKUNIP] STRYKER CORP],SUP-2365435,CDM,C1776,CPT,0278,RC,,,,both,,,4082.00,2653.30,,,,,,,,,,,,,
WRENCH TORQ AUDIBLE FOR OASYS SPNL SYS,SUP-2362952,CDM,2720000010,LOCAL,0272,RC,,,,both,,,666.68,433.34,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 20 CM DIA 7 MM STR STD WALL REINF,SUP-2681082,CDM,C1768,CPT,0278,RC,,,,both,,,408.39,265.45,,,,,,,,,,,,,
PLATE BONE UNIV RT MAXLOCK EXTRM,SUP-2400154,CDM,C1713,HCPCS,0278,RC,,,,both,,,4947.38,3215.80,,,,,,,,,,,,,
CUP ACET DIA52MM UNIV HIP TI POR PRESSFIT PRI CEMENTLESS MH 124552000] JNJ DEPUY SYNTHES ORTHOPEDICS],SUP-2250720,CDM,C1776,CPT,0278,RC,,,,both,,,4509.04,2930.88,,,,,,,,,,,,,
SCREW BNE EMGCY 2X5 MM TI NS,SUP-2188963,CDM,C1713,HCPCS,0278,RC,,,,both,,,177.72,115.52,,,,,,,,,,,,,
BOLT BNE FIX L85MM DIA5MM PROX L10MM DST L22MM MIDFOOT FUS,SUP-2400719,CDM,C1713,HCPCS,0278,RC,,,,both,,,4826.18,3137.02,,,,,,,,,,,,,
CATHETER INTRAAORTIC BLLN 7.5FR 30CC L25.3IN SHTH L6IN CTRL,SUP-2383464,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3579.60,2326.74,,,,,,,,,,,,,
BOLT EXT FIX DIA2MM WIRE PREASSEMBLED FOR SALVATION EXT FIX,SUP-2401135,CDM,C1713,HCPCS,0278,RC,,,,both,,,719.06,467.39,,,,,,,,,,,,,
MATRIX BIO DIA 50 MM FISH SKIN SIL DERMAL STD CIR INTACT FEN,SUP-2909216,CDM,Q4158,HCPCS,0636,RC,,,,both,,,46346.40,30125.16,,,,,,,,,,,,,
STEM HUM L122MM DIA11MM STD CO CHROM POR PRI PRESSFIT CEM,SUP-2404593,CDM,C1776,CPT,0278,RC,,,,both,,,9909.06,6440.89,,,,,,,,,,,,,
HC Extrem Low Hip 1 Vw,PX-3207350100,CDM,73501,CPT,0320,RC,,,,both,,,460.00,299.00,,,,,,,,,,,,,
INBONE  POLY SZ 3 18MM SULCUS TOTAL ANKLE,SUP-2482081,CDM,C1776,CPT,0278,RC,,,,both,,,5743.06,3732.99,,,,,,,,,,,,,
PLATE BNE HK LG 3.5 MM PERIPROSTHETIC PROX SS NS VA-LCP,SUP-2750909,CDM,C1713,HCPCS,0278,RC,,,,both,,,5654.98,3675.74,,,,,,,,,,,,,
SCREW BNE FT 6.5X55 MM CANN STRL,SUP-2458754,CDM,C1713,HCPCS,0278,RC,,,,both,,,837.60,544.44,,,,,,,,,,,,,
BLADE SURG SAW SAG FLR ST 325MM CUT EDGE 64MM CUT DEPTH,SUP-2363584,CDM,2720000010,LOCAL,0272,RC,,,,both,,,86.66,56.33,,,,,,,,,,,,,
TETANUS IMMUNE GLOBULIN 250 UNIT/ML IM SOSY,RX-155577,CDM,J1670,HCPCS,0636,RC,13533-0634-02,NDC,,both,1,ML,1915.10,1244.81,,,,,,,,,,,,,
KIT INSRTN GUIDEWIRE L 100 CM DIA 0.038 IN SYR 10 ML PERC,SUP-2908598,CDM,C1769,HCPCS,0272,RC,,,,both,,,178.10,115.76,,,,,,,,,,,,,
PLATE BNE MAXILLOFCL 5 MESH KT NS FACE ID,SUP-2909647,CDM,C1713,HCPCS,0278,RC,,,,both,,,43967.91,28579.14,,,,,,,,,,,,,
ELECTRODE URLGY BAND TIP 26FR DIA 12DG WCLNCH ST DSPSBLE,SUP-2722577,CDM,2720000010,LOCAL,0272,RC,,,,both,,,831.06,540.19,,,,,,,,,,,,,
COMPONENT HUM SM L6IN UNIV DST EL TIV PLSM INTERCHANGEABLE,SUP-2205913,CDM,C1776,CPT,0278,RC,,,,both,,,14998.84,9749.25,,,,,,,,,,,,,
ANCHOR LD FOR SPNL CRD STIM CINCH,SUP-2356644,CDM,C1713,HCPCS,0278,RC,,,,both,,,211.95,137.77,,,,,,,,,,,,,
PROFILE CSTL CRTLGE SHEET XS 2PK L 2.5 3 CM W 1 2 CM T 1.8,SUP-2722654,CDM,C1762,CPT,0278,RC,,,,both,,,1506.42,979.17,,,,,,,,,,,,,
DRILL SURG STEM SHT TIB KNEE ROTATING HINGE N MOD NXGN,SUP-2437384,CDM,2720000010,LOCAL,0272,RC,,,,both,,,861.93,560.25,,,,,,,,,,,,,
LEAD BRAIN STIM L40CM DIA1.27MM BLK MRK BND ELECTRD L1.5MM,SUP-2357356,CDM,C1767,HCPCS,0278,RC,,,,both,,,17270.00,11225.50,,,,,,,,,,,,,
DILATOR ENDOSCP L200CM DIA3MM GWIRE 0.035IN GRAD W/O BLLN,SUP-2169260,CDM,C1726,HCPCS,0272,RC,,,,both,,,210.38,136.75,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.435,SUP-2859999,CDM,C1713,HCPCS,0278,RC,,,,both,,,42511.52,27632.49,,,,,,,,,,,,,
SCREW SPNL L12MM OD3.5MM TI CERVICOTHORACIC NONCANNULATED ST,SUP-2205770,CDM,C1713,HCPCS,0278,RC,,,,both,,,2590.50,1683.82,,,,,,,,,,,,,
ELECTRODE ELECSURG LOOP 30 DEG LG 24-28 FR HF RESECT RUNNER,SUP-2472658,CDM,2720000010,LOCAL,0272,RC,,,,both,,,703.36,457.18,,,,,,,,,,,,,
FILTER VASC ACCUNET SZ 5.5 MM CATH 8 FR SHTH 6 FR GUIDEWIRE,SUP-2104678,CDM,C1884,HCPCS,0278,RC,,,,both,,,4631.50,3010.47,,,,,,,,,,,,,
PLATE BNE L91MM THK3.7MM 7 H BILAT S STL STR LO PROF RIG,SUP-2184027,CDM,C1713,HCPCS,0278,RC,,,,both,,,2086.75,1356.39,,,,,,,,,,,,,
CABLE ELECSURG FT PEDAL ADPT NS LTX,SUP-2859254,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1034.35,672.33,,,,,,,,,,,,,
ALLOGRAFT HUM TISS LG 10 CC OSTEOCONDUCTIVE MTRX + NUCEL 12/EA,SUP-2716039,CDM,C1762,CPT,0278,RC,,,,both,,,10676.00,6939.40,,,,,,,,,,,,,
RELOAD STPL H1-2.5XL35MM VASC THN TISS WHT B FRM NAT ARTC,SUP-2220356,CDM,C1713,HCPCS,0278,RC,,,,both,,,604.36,392.83,,,,,,,,,,,,,
BIT DRL TWST LNG 1.9X105 MM TRANSBUCCAL CYL ATTCH SS LEVEL 1,SUP-2478798,CDM,2720000010,LOCAL,0272,RC,,,,both,,,405.09,263.31,,,,,,,,,,,,,
BIT DRL 0.125 INX35 MM FLX,SUP-2397076,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 3X3 CM NUSHIELD,SUP-2314109,CDM,Q4160,HCPCS,0636,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
FORCEPS ENDOSCP L240CM ODSEC5.5FR RED 3 PRNG GRSP DISP,SUP-2171354,CDM,2720000010,LOCAL,0272,RC,,,,both,,,398.78,259.21,,,,,,,,,,,,,
CUP ACET 32X62 MM FEM HIP LONGEVITY,SUP-2202577,CDM,C1776,CPT,0278,RC,,,,both,,,2024.83,1316.14,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED PRSS FT FLX POROUS GENDER SOL N-K,SUP-2212610,CDM,C1776,CPT,0278,RC,,,,both,,,15431.22,10030.29,,,,,,,,,,,,,
PROSTHESIS OSS DE LA CRUZ PISTON 0.6X4 MM SS FLROPLAS,SUP-2638110,CDM,L8613,CPT,0278,RC,,,,both,,,310.45,201.79,,,,,,,,,,,,,
SPECULUM OPHTHLMC MRDCH 24MM SPRD 57MML 14MMW BLADE STNLSS S,SUP-2484779,CDM,C1713,HCPCS,0278,RC,,,,both,,,457.18,297.17,,,,,,,,,,,,,
KIT MIXING AND DELIVERY NUMATRIX,SUP-2828504,CDM,2720000010,LOCAL,0272,RC,,,,both,,,384.34,249.82,,,,,,,,,,,,,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,0258,RC,00990-7922-61,NDC,,both,150,ML,44.70,29.05,,,,,,,,,,,,,
SCREW BNE SET 7 MM 16 MM CANN THRD EXT TAB,SUP-2861023,CDM,C1713,HCPCS,0278,RC,,,,both,,,5705.13,3708.33,,,,,,,,,,,,,
GRAFT BONE SUB 9MM LXPANSE,SUP-2294013,CDM,C1713,HCPCS,0278,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,0250,RC,00264-1510-31,NDC,,both,50,ML,20.90,13.58,,,,,,,,,,,,,
STAPLE OSTEOTMY STP 10MM OFFSET - 10MM,SUP-2212665,CDM,C1713,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
SCREW BONE L35MM OD6.5MM STD TI CANC CORT ST SELF DRL CANN,SUP-2364202,CDM,C1713,HCPCS,0278,RC,,,,both,,,1230.88,800.07,,,,,,,,,,,,,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,0250,RC,00264-7510-00,NDC,,both,1000,ML,34.00,22.10,,,,,,,,,,,,,
BIT DRL CANN 3.7 MM,SUP-2468175,CDM,2720000010,LOCAL,0272,RC,,,,both,,,372.09,241.86,,,,,,,,,,,,,
MESH CRAN L 85 X W 53 MM THK 0.6 MM SCREW DIA1.5 MM SM TI,SUP-2936498,CDM,C1713,HCPCS,0278,RC,,,,both,,,3146.28,2045.08,,,,,,,,,,,,,
SCREW BNE ST 1.9X5 MM EMGCY AXS 5PK,SUP-2421797,CDM,C1713,HCPCS,0278,RC,,,,both,,,307.53,199.89,,,,,,,,,,,,,
SPACER SPNL LIMB RECON SYS,SUP-2646834,CDM,C1889,HCPCS,0278,RC,,,,both,,,1263.79,821.46,,,,,,,,,,,,,
BASEPLATE TIB REV 2/3 14+ MM RT KNEE POROUS N-K II,SUP-2449002,CDM,C1776,CPT,0278,RC,,,,both,,,9760.06,6344.04,,,,,,,,,,,,,
SCREW BNE FT 4X70 MM CANC STRL PERI-LOC,SUP-2348410,CDM,C1713,HCPCS,0278,RC,,,,both,,,350.27,227.68,,,,,,,,,,,,,
LIGATOR ENDOSCP MULTI-BAND XL 6 SHOT SAEED,SUP-2737556,CDM,2720000010,LOCAL,0272,RC,,,,both,,,73.79,47.96,,,,,,,,,,,,,
PIN FIX ANT CERV STR TEMP 25.4MM SKYLINE,SUP-2255674,CDM,C1713,HCPCS,0278,RC,,,,both,,,219.80,142.87,,,,,,,,,,,,,
RESTRICTOR CEM DIA13MM INSERTED IN FEM MDLLRY CNL PERM DISPO,SUP-2435986,CDM,C1776,CPT,0278,RC,,,,both,,,115.40,75.01,,,,,,,,,,,,,
TRAY HEMO DYLS OR HD 12FR L20CM STR CATH VEN STYL KINK,SUP-2126525,CDM,C1752,HCPCS,0278,RC,,,,both,,,615.44,400.04,,,,,,,,,,,,,
SHEATH ENDOSCP 23FR INNR STD SH BEAK BLU,SUP-2313021,CDM,C2629,CPT,0272,RC,,,,both,,,6365.85,4137.80,,,,,,,,,,,,,
BLADE LARYNGOSCOPE 3 4 FLX TIP HEINE,SUP-2240612,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3548.20,2306.33,,,,,,,,,,,,,
PLATE BONE THK2.5MM 20 H CRANIOMAXILLOFACIAL ORAL LT BLU TI,SUP-2181775,CDM,C1713,HCPCS,0278,RC,,,,both,,,5200.47,3380.31,,,,,,,,,,,,,
STENT URET 5FR L22CM PROX PGTL POLYUR AQ SFT MFIL TETH,SUP-2169454,CDM,C2617,HCPCS,0278,RC,,,,both,,,423.24,275.11,,,,,,,,,,,,,
SCREW BNE L4MM DIA1.7MM CORT CRANIOMAXILLOFACIAL G S STL ST 5PK,SUP-2366093,CDM,C1713,HCPCS,0278,RC,,,,both,,,173.36,112.68,,,,,,,,,,,,,
SCREW BNE L50MM DIA3.5MM CALCNL TI NONLOCKING HEXALOBE,SUP-2106679,CDM,C1713,HCPCS,0278,RC,,,,both,,,263.76,171.44,,,,,,,,,,,,,
SHELL ACET MOD 66 MM HIP REDAPT,SUP-2419731,CDM,C1776,CPT,0278,RC,,,,both,,,17395.60,11307.14,,,,,,,,,,,,,
PLATE BNE Y 46X1.6 MM WRST 7 HOLE APTUS TRILOK,SUP-2423732,CDM,C1713,HCPCS,0278,RC,,,,both,,,3358.54,2183.05,,,,,,,,,,,,,
CATHETER THROMCTMY XPRESS-WAY DIA 7 FR RX,SUP-2227362,CDM,C1757,HCPCS,0272,RC,,,,both,,,926.30,602.09,,,,,,,,,,,,,
LCKNG PL STR2X816 H GRID T15MM CP TI,SUP-2694191,CDM,C1713,HCPCS,0278,RC,,,,both,,,2830.68,1839.94,,,,,,,,,,,,,
HC Rhythm Strip,PX-7309304100,CDM,93041,CPT,0730,RC,,,,both,,,106.00,68.90,,,,,,,,,,,,,
PIN EXT FIX L 150 MM DIA 4.5 MM THRD L 10 MM SHANK 6 MM HA,SUP-2932763,CDM,2720000010,LOCAL,0272,RC,,,,both,,,900.33,585.21,,,,,,,,,,,,,
PLATE BNE M W20XL30MM NONSTERILE BILAT S STL X SHP LO PROF,SUP-2186322,CDM,C1713,HCPCS,0278,RC,,,,both,,,2332.42,1516.07,,,,,,,,,,,,,
KIT PROC 600MH 4FR L24CM BRT TIP LSR FBR VARI-LASE,SUP-2120512,CDM,C1894,HCPCS,0272,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
PLATE BONE L40MM SH NONSTERILE RT ANTEROLATERAL CALCNL S STL,SUP-2178426,CDM,C1713,HCPCS,0278,RC,,,,both,,,2798.49,1819.02,,,,,,,,,,,,,
HC So Tetanus Antibodies,PX-3028677466,CDM,86774,CPT,0302,RC,,,,outpatient,,,225.00,146.25,,,,,,,,,,,,,
GRAFT VASC L 45 MM ID 7 MM CLLGN BOV CAR ART WOVEN,SUP-2880939,CDM,C1762,CPT,0278,RC,,,,both,,,8851.66,5753.58,,,,,,,,,,,,,
BASEPLATE TIB SZ 5 KNEE PERI APATITE PRI BEAD TRIATHLON,SUP-2373102,CDM,C1776,CPT,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
GUIDEWIRE VASC L 80 CM 0.018 IN L 5 CM SS MANDREL PLAT COIL,SUP-2823949,CDM,C1769,HCPCS,0272,RC,,,,both,,,123.37,80.19,,,,,,,,,,,,,
BIT DRL DIA3.5MM CLR FT PLATING SYS DISP FPS,SUP-2319605,CDM,2720000010,LOCAL,0272,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
PLATE BNE LCK REG 1.5 MM 18 HOLE TI,SUP-2462150,CDM,C1713,HCPCS,0278,RC,,,,both,,,1674.41,1088.37,,,,,,,,,,,,,
TUBE MYR ID114MM SFT SIL FLNG ST DONALDSON,SUP-2312638,CDM,L8699,HCPCS,0278,RC,,,,both,,,32.66,21.23,,,,,,,,,,,,,
PLATE OLECRANON 3.5MM 10H LT 190MM SS LCP STRL,SUP-2547488,CDM,C1713,HCPCS,0278,RC,,,,both,,,3614.08,2349.15,,,,,,,,,,,,,
BIT DRL 2 MM FOR TOT WRST FUSION DISP,SUP-2851929,CDM,2720000010,LOCAL,0272,RC,,,,both,,,838.29,544.89,,,,,,,,,,,,,
PLATE BNE THK 0.6 MM SCREW DIA2 MM 4 H XLN TI,SUP-2936171,CDM,C1713,HCPCS,0278,RC,,,,both,,,474.14,308.19,,,,,,,,,,,,,
ASSEMBLY EXT FIX STD KT SIDEKCK EZ FRAME,SUP-2469742,CDM,2720000010,LOCAL,0272,RC,,,,both,,,18262.24,11870.46,,,,,,,,,,,,,
CLINDAMYCIN HCL 150 MG PO CAPS,RX-1740,CDM,6370000000,HCPCS,0637,RC,00904-5959-61,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
SET SCR SPNL L32MM OD6.35MM S IL STL BRK OFF,SUP-2287059,CDM,C1713,HCPCS,0278,RC,,,,both,,,316.36,205.63,,,,,,,,,,,,,
CONFORM FLEX Q-PACK 20MM X 20MM X 4MM,SUP-2547190,CDM,C1713,HCPCS,0278,RC,,,,both,,,1316.01,855.41,,,,,,,,,,,,,
HC Pulmonary Arteriogram Uni,PX-3237574100,CDM,75741,CPT,0323,RC,,,,inpatient,,,3092.00,2009.80,,,,,,,,,,,,,
IMPLANT SACROILIAC JT L 170 MM DIA 8.7 MM TI 3D PRNT POROUS,SUP-2905397,CDM,C1889,HCPCS,0278,RC,,,,both,,,9734.00,6327.10,,,,,,,,,,,,,
DEXTROSE 10% IV BOLUS (PEDS),RX-4085020,CDM,2580000003,HCPCS,0250,RC,00338-0023-02,NDC,,both,250,ML,53.20,34.58,,,,,,,,,,,,,
DIST HUM LAT RT 15H 142MM STE,SUP-2588821,CDM,C1713,HCPCS,0278,RC,,,,both,,,3001.59,1951.03,,,,,,,,,,,,,
POST FIX BI-CORTICAL 4.5X40 MM KNEE,SUP-2431991,CDM,C1776,CPT,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
PLATE BNE Y 3.5X87 MM CALCANEAL FOR SCR SM FRAG SYS SS NS,SUP-2466839,CDM,C1713,HCPCS,0278,RC,,,,both,,,1272.99,827.44,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY L 110 CM DIA 5 FR TIP 2 MM SPC 2,SUP-2248854,CDM,C1730,HCPCS,0272,RC,,,,both,,,891.76,579.64,,,,,,,,,,,,,
COMPONENT TALAR FLAT CUT 1 RT ANK SALTO TALARIS,SUP-2421798,CDM,C1776,CPT,0278,RC,,,,both,,,23503.21,15277.09,,,,,,,,,,,,,
STIMULATOR NERVE 8 CHANNEL GEN,SUP-2355962,CDM,C1767,HCPCS,0278,RC,,,,both,,,33896.30,22032.59,,,,,,,,,,,,,
BIT DRL L 195 MM DIA 6 MM FOR QC NS REUSE,SUP-2908022,CDM,2720000010,LOCAL,0272,RC,,,,both,,,524.16,340.70,,,,,,,,,,,,,
MESH SURG 120X120X1 MM 3D TI STRL LEVEL 1 NEURO,SUP-2482027,CDM,C1713,HCPCS,0278,RC,,,,both,,,8660.91,5629.59,,,,,,,,,,,,,
OSSEOFLEX SN STEERABLE NEEDLE 10 G NEEDLE,SUP-2701997,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
CAGE SPINAL CERVICAL CAVUX 4MM SPINAL-X TITANIUM,SUP-2859207,CDM,C1889,HCPCS,0278,RC,,,,both,,,6123.00,3979.95,,,,,,,,,,,,,
DRILL ARTHSCP CORACOID,SUP-2418031,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2141.48,1391.96,,,,,,,,,,,,,
SCREW EXT FIX L100MM DIA4MM THRD L30MM CORT S STL SELF DRL,SUP-2186977,CDM,C1713,HCPCS,0278,RC,,,,both,,,451.41,293.42,,,,,,,,,,,,,
GRAFT BNE W7XH11X13XL23MM 8DEG LORDOSIS TRAP RAMP VERTIGRFT,SUP-2264974,CDM,C1713,HCPCS,0278,RC,,,,both,,,7046.95,4580.52,,,,,,,,,,,,,
HC Simple Rep Wnd Face <2.5 Cm,PX-4501201100,CDM,12011,CPT,0450,RC,,,,inpatient,,,421.00,273.65,,,,,,,,,,,,,
SCREW BNE 2.3X11 MM STRNL TALON,SUP-2262554,CDM,C1713,HCPCS,0278,RC,,,,both,,,125.35,81.48,,,,,,,,,,,,,
SCREW SPNL L8MM DIA35MM CANC POST CERVICOTHORACIC TI FULL,SUP-2189828,CDM,C1713,HCPCS,0278,RC,,,,both,,,232.36,151.03,,,,,,,,,,,,,
SCREW BONE L80MM D45MM THRD L24MM STNDRD CRTCL TTNM PRXML SE,SUP-2459544,CDM,C1713,HCPCS,0278,RC,,,,both,,,558.89,363.28,,,,,,,,,,,,,
ANKLE FUSION PLATE LATERAL TTC 4H,SUP-2815313,CDM,C1713,HCPCS,0278,RC,,,,both,,,7222.00,4694.30,,,,,,,,,,,,,
CATHETER EP DIAG MAP HISSER CRV QPLR 5MM SPC 1MM TIP UNI IBI81483] ST JUDE MEDICAL INC],SUP-2357638,CDM,C1730,HCPCS,0272,RC,,,,both,,,907.46,589.85,,,,,,,,,,,,,
PLATE BNE BROAD 5.5X234 MM 13 HOLE SS LCP,SUP-2569374,CDM,C1713,HCPCS,0278,RC,,,,both,,,872.14,566.89,,,,,,,,,,,,,
SPINAL KIT FACET FUSION SM NORTHSTAR,SUP-2741241,CDM,C1713,HCPCS,0278,RC,,,,both,,,7253.40,4714.71,,,,,,,,,,,,,
BIT DRL DIA 5 MM CANN LG TARGETER HALL-JACOBS STRL DISP EVOS,SUP-2931341,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2156.24,1401.56,,,,,,,,,,,,,
"HC Blood Typing, Abo",PX-3008690000,CDM,86900,CPT,0300,RC,,,,both,,,180.00,117.00,,,,,,,,,,,,,
PLATE BNE L24MM THK1MM MINI 4 H CP TI STR TLTS FOR 2 23MM,SUP-2262827,CDM,C1713,HCPCS,0278,RC,,,,both,,,965.99,627.89,,,,,,,,,,,,,
SIZER BRST IMPL 1030 CC SIL GEL ULTRA HI PROF FOR SUHE-1030,SUP-2927330,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1617.10,1051.11,,,,,,,,,,,,,
SCREW DEGENERATIVE IMPL MOD SEQUOIA PREBENT ROD CP TI 45MM,SUP-2206008,CDM,C1713,HCPCS,0278,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
STENT LACR DUCT GOLDBERG BICANALICULUS CERCLAGE,SUP-2224382,CDM,C1783,HCPCS,0278,RC,,,,both,,,167.46,108.85,,,,,,,,,,,,,
SHEATH TG0854517 85F 17MM 45CM,SUP-2298502,CDM,C1887,HCPCS,0272,RC,,,,both,,,1805.50,1173.57,,,,,,,,,,,,,
ANCHOR SUT NO 2-0 V-5 DRL BIT QUICKANCHR + MINILOK,SUP-2249373,CDM,C1713,HCPCS,0278,RC,,,,both,,,3055.22,1985.89,,,,,,,,,,,,,
GRAFT BNE SUB 15ML 100X25X6MM MTRX OSTEOCONDUCTIVE MOZAIK,SUP-2244489,CDM,C9362,HCPCS,0278,RC,,,,both,,,3909.30,2541.04,,,,,,,,,,,,,
CYTAL WOUND MATRIX 3 LAYER LAWD 16X25CM,SUP-2909172,CDM,Q4166,HCPCS,0636,RC,,,,both,,,19221.32,12493.86,,,,,,,,,,,,,
ALLOGRAFT BNE WDG 9-13 MM FRZN ILIUM TRICORT,SUP-2717919,CDM,C1762,CPT,0278,RC,,,,both,,,3570.84,2321.05,,,,,,,,,,,,,
MICROCATHETER INFUSION PROWLER SEL LP-ES L 150CM L 5CM J TIP,SUP-2460415,CDM,C1887,HCPCS,0272,RC,,,,both,,,4203.96,2732.57,,,,,,,,,,,,,
Z DUP USE 2759589 GRAFT HUM TISS 4X8CM STD ACELLULAR HUM DERM MTRX STD,SUP-2399085,CDM,Q4107,HCPCS,0636,RC,,,,both,,,8939.77,5810.85,,,,,,,,,,,,,
COLLAR HUM DIA56MM SUT FOR SHLDR ARTHROPLASTY SYS GLOB UNITE,SUP-2249867,CDM,C1713,HCPCS,0278,RC,,,,both,,,1245.95,809.87,,,,,,,,,,,,,
SPLINT WRST BLK XS 8 IN L,SUP-2336048,CDM,L3809,HCPCS,0274,RC,,,,both,,,18.68,12.14,,,,,,,,,,,,,
RING EXT FIX DIA180MM ANT ALUMINUM HALF,SUP-2242955,CDM,C1713,HCPCS,0278,RC,,,,both,,,4336.09,2818.46,,,,,,,,,,,,,
KIT RFA MULTI COOLED PROBE ADVANCED 100,SUP-2745224,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4176.20,2714.53,,,,,,,,,,,,,
SLEEVE CBL SM DIA1.6MM VIT HIP BEAD DALL-M,SUP-2377564,CDM,C1776,CPT,0278,RC,,,,both,,,790.02,513.51,,,,,,,,,,,,,
STIMULATOR NRV PERIPH W/ SENSE ELECTRD CBL HNS12 STIMUPLEX,SUP-2125190,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2916.21,1895.54,,,,,,,,,,,,,
PLATE BNE 8 H STR STERNALOCK BLU PRI CLSR SYS,SUP-2403016,CDM,C1713,HCPCS,0278,RC,,,,both,,,2307.90,1500.13,,,,,,,,,,,,,
PLATE BONE L34MM THK1.4MM SHFT W6MM 5 H STRL STR TINE FOR,SUP-2349682,CDM,C1713,HCPCS,0278,RC,,,,both,,,4446.87,2890.47,,,,,,,,,,,,,
DEVICE TISS REMOVAL MANUAL MYOSURE,SUP-2472977,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1513.48,983.76,,,,,,,,,,,,,
BONE MACH BLK 12X20MM GIC58 BICORT,SUP-2293980,CDM,C1713,HCPCS,0278,RC,,,,both,,,6361.64,4135.07,,,,,,,,,,,,,
POST EXT FIX DIA11MM STR OUTRIG MAG RESONANCE CONDITIONAL,SUP-2188506,CDM,2720000010,LOCAL,0272,RC,,,,both,,,325.74,211.73,,,,,,,,,,,,,
BLADE ARTHSCP L11CM DIA4MM 40DEG ANG PRECIS AGG SERR ESSX,SUP-2363528,CDM,2720000010,LOCAL,0272,RC,,,,both,,,447.48,290.86,,,,,,,,,,,,,
SCREW BNE L40MM DIA65MM CANC FLAT HD DOME MPACT,SUP-2267421,CDM,C1713,HCPCS,0278,RC,,,,both,,,605.45,393.54,,,,,,,,,,,,,
SPLINT WRST UNIV L11IN R CUTAWAY PERF FOAM CONSTR MAL,SUP-2194859,CDM,L3931,HCPCS,0272,RC,,,,both,,,15.51,10.08,,,,,,,,,,,,,
CATHETER IVUS VISIONS PV 8.2 L 90 CM OUTER SHFT DIA 7 FR,SUP-2327232,CDM,C1753,HCPCS,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
TRAY PICC 6FR L55CM POLYUR FULL TRIM LEN 3 LUMN NRS PWR INJ,SUP-2125555,CDM,C1751,HCPCS,0278,RC,,,,both,,,648.72,421.67,,,,,,,,,,,,,
ALLOGRAFT BNE CRUSH 1-4 MM 60 CC FD IRRADIATED CANC,SUP-2866921,CDM,C1762,CPT,0278,RC,,,,both,,,1714.44,1114.39,,,,,,,,,,,,,
CROWN DENT 3U REFIL S STL UP BICUSPID PRI PREFRM UNITEK,SUP-2322229,CDM,D6783,CPT,0278,RC,,,,both,,,27.48,17.86,,,,,,,,,,,,,
NAIL INTRMDLLRY 9MM DIA 270MML TTNM ALLOY PRXML TBL ANTGRDE,SUP-2588053,CDM,C1713,HCPCS,0278,RC,,,,both,,,4585.15,2980.35,,,,,,,,,,,,,
ORTHOPAEDIC INSTRUMENT KIT 1 PLNTR PLATE 2 DISTRACTOR STROPP,SUP-2866374,CDM,C1713,HCPCS,0278,RC,,,,both,,,2424.08,1575.65,,,,,,,,,,,,,
PACK IMPL SM DIA3.2MM INCLUDE PROX DSTL SCR TAPR LCK PIN,SUP-2123610,CDM,C1713,HCPCS,0278,RC,,,,both,,,5645.72,3669.72,,,,,,,,,,,,,
SYSTEM PAIN RELF 400ML W/ SEL A FLO 2-14ML/HR ON-Q,SUP-2236810,CDM,C9804,HCPCS,0272,RC,,,,both,,,859.70,558.80,,,,,,,,,,,,,
ALIGNER DRL TIB HI OSTEOTMY N-K,SUP-2449290,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1172.79,762.31,,,,,,,,,,,,,
SCREW EXT FIX L200MM DIA5MM THRD L80MM S STL HA SELF DRL MR,SUP-2186989,CDM,C1713,HCPCS,0278,RC,,,,both,,,861.33,559.86,,,,,,,,,,,,,
SCREW SPNL L25MM DIA5MM FACET SYS AX LIF,SUP-2389069,CDM,C1713,HCPCS,0278,RC,,,,both,,,6280.00,4082.00,,,,,,,,,,,,,
DRILL SURG ANGLED,SUP-2660234,CDM,2720000010,LOCAL,0272,RC,,,,both,,,513.23,333.60,,,,,,,,,,,,,
GRAFT BNE SUB 15ML FRZ DRY IC GRFT CHMBR,SUP-2264799,CDM,C1713,HCPCS,0278,RC,,,,both,,,4215.73,2740.22,,,,,,,,,,,,,
STENT URET POLARIS L 24 CM DIA 5 FR PERCFLX HYDROPLUS 2,SUP-2139605,CDM,C2617,HCPCS,0278,RC,,,,both,,,476.34,309.62,,,,,,,,,,,,,
KIT INTRO ONESTIC L 11 CM DIA 4 FR GUIDEWIRE L 40 CM DIA RED,SUP-2876556,CDM,C1894,HCPCS,0272,RC,,,,both,,,257.48,167.36,,,,,,,,,,,,,
CARBAMAZEPINE 200 MG PO TABS,RX-1357,CDM,6370000000,HCPCS,0637,RC,68084-0444-11,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
SYSTEM VISCOELASTIC 0.85ML PROVISC OVD 0.5ML VISCOAT OVD,SUP-2417098,CDM,2720000010,LOCAL,0272,RC,,,,both,,,317.67,206.49,,,,,,,,,,,,,
PLATE BONE CRANIAL SQUARE 14X14MM TITANIUM NEURO PLATING SYS,SUP-2825988,CDM,C1713,HCPCS,0278,RC,,,,both,,,232.99,151.44,,,,,,,,,,,,,
MESH SURG M THK0.4MM SLV TI MASTOID MALL CNTOUR LO PROF,SUP-2181585,CDM,C1781,HCPCS,0278,RC,,,,both,,,2812.81,1828.33,,,,,,,,,,,,,
GRAFT BNE PTTY 1 CC DBM TENSIX,SUP-2759548,CDM,C1713,HCPCS,0278,RC,,,,both,,,1748.98,1136.84,,,,,,,,,,,,,
SUPPORT ORTHOT HIP CUST ABDUCTN ADJ,SUP-2435599,CDM,L1650,HCPCS,0274,RC,,,,both,,,698.18,453.82,,,,,,,,,,,,,
ALLOGRAFT BNE CRYOPRESERVED LT LAT FEM CONDYLE,SUP-2867082,CDM,C1762,CPT,0278,RC,,,,both,,,10723.89,6970.53,,,,,,,,,,,,,
IMPLANT HUM TISS DIA22 MM LG ASCEND AORT CONDUIT NONVALVED,SUP-2933481,CDM,C1762,CPT,0278,RC,,,,both,,,25616.59,16650.78,,,,,,,,,,,,,
SYSTEM HEARING AID 1 STG BAHA,SUP-2165027,CDM,L8614,HCPCS,0278,RC,,,,both,,,18563.68,12066.39,,,,,,,,,,,,,
INSERT TIB L79/83MM THK10MM UNIV KNEE PRI CRUCE RET NEUT,SUP-2407124,CDM,C1776,CPT,0278,RC,,,,both,,,2486.88,1616.47,,,,,,,,,,,,,
HC IV Inf Thera Concurrent,PX-2609636800,CDM,96368,CPT,0260,RC,,,,both,,,83.00,53.95,,,,,,,,,,,,,
LINER ACET SZ B OD42MM ID22MM 20DEGXLPE CONSTRN PRI REFLCT,SUP-2348090,CDM,C1776,CPT,0278,RC,,,,both,,,2816.58,1830.78,,,,,,,,,,,,,
BUR SURG RND 3 MM 75 MM CARBIDE,SUP-2629001,CDM,2720000010,LOCAL,0272,RC,,,,both,,,561.46,364.95,,,,,,,,,,,,,
COMPONENT HIP PRSS FT HI DEMAND BIPOLAR/UNIPOLAR,SUP-2351417,CDM,C1776,CPT,0278,RC,,,,both,,,9734.00,6327.10,,,,,,,,,,,,,
KIT PICC 5FR L55CM POLYUR NRS SGL LUMN BASIC PWR INJ N COAT,SUP-2126704,CDM,C1751,HCPCS,0278,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
TRAY CATH HEMODIALYSI HEM CATH CHRONIC 12.5FR DIA LNG 32CM S,SUP-2610598,CDM,C1750,HCPCS,0278,RC,,,,both,,,690.80,449.02,,,,,,,,,,,,,
INSERT ACET TAPR HIP M2A-MAGNUM,SUP-2137413,CDM,C1776,CPT,0278,RC,,,,both,,,1940.52,1261.34,,,,,,,,,,,,,
INSERT TIB AP40MM /ML58MM THICKNESS 9MM AB PUR UHMWPE KNEE,SUP-2199501,CDM,C1776,CPT,0278,RC,,,,both,,,5653.57,3674.82,,,,,,,,,,,,,
CATHETER GUID DAC L 125 CM OD 3.9 FR ID 0.038 IN SS LNR PTFE,SUP-2367781,CDM,C1887,HCPCS,0272,RC,,,,both,,,3391.39,2204.40,,,,,,,,,,,,,
GRAFT VASC L10CM ID6MM PTFE STD WALLED NONRINGED STRTCH,SUP-2395777,CDM,C1768,CPT,0278,RC,,,,both,,,1014.22,659.24,,,,,,,,,,,,,
BRACE ORTH CIRC THGH 18.5-21 IN CTR 14-15 IN CALF 14-16 IN SPCR,SUP-2916973,CDM,2720000010,LOCAL,0272,RC,,,,both,,,366.50,238.22,,,,,,,,,,,,,
TUBE VENT 7 MM 0.9 MM 2.3 MM STR FLROPLAS STRL 520061,SUP-2535133,CDM,L8699,HCPCS,0278,RC,,,,both,,,21.23,13.80,,,,,,,,,,,,,
SET PNEUMOTHRAX CATH 10.2FR L30CM NDL 18GA L20CM 18,SUP-2168504,CDM,C1729,HCPCS,0272,RC,,,,both,,,311.90,202.73,,,,,,,,,,,,,
IMPLANT SPNL H26-36MM 0DEG LUM W/ L ENDPLATE RATCH MECHANISM,SUP-2194240,CDM,C1889,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
PLATE SPNL CERV 20 MM ANTR INVIZIA,SUP-2414396,CDM,C1713,HCPCS,0278,RC,,,,both,,,4777.35,3105.28,,,,,,,,,,,,,
HC Chemo Extend IV Infus W/Pump Cost,PX-2800049800,CDM,G0498,HCPCS,0280,RC,,,,outpatient,,,1112.00,722.80,,,,,,,,,,,,,
PLATE BNE L 1.2 CM THK 0.5 MM SCREW DIA1.5 MM 2 H SHRT,SUP-2936843,CDM,C1713,HCPCS,0278,RC,,,,both,,,175.84,114.30,,,,,,,,,,,,,
BIT DRL L15MM DIA3.2MM ACET SCR FLEX REFLCT,SUP-2345714,CDM,2720000010,LOCAL,0272,RC,,,,both,,,609.16,395.95,,,,,,,,,,,,,
HC Cystogram Routine Min 3 Views,PX-3207443000,CDM,74430,CPT,0320,RC,,,,both,,,900.00,585.00,,,,,,,,,,,,,
SUPPORT ORTHOT LOWER EXTREMITY CUST ANTR SWNG BND,SUP-2435660,CDM,L2335,HCPCS,0272,RC,,,,both,,,795.86,517.31,,,,,,,,,,,,,
KIT MAC 2-LUMEN 9 FR 11.5CM,SUP-2660675,CDM,C1894,HCPCS,0272,RC,,,,both,,,529.22,343.99,,,,,,,,,,,,,
CATHETER CV DL 6 FRX135 CM TY IRRIGATION POWERPICC SOLO 2,SUP-2126391,CDM,C1751,HCPCS,0278,RC,,,,both,,,589.82,383.38,,,,,,,,,,,,,
GUIDEWIRE VASC L190CM DIA0.014IN FULL COAT STR TIP HI TORQ,SUP-2105270,CDM,C1876,HCPCS,0278,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
DEFIBRILLATOR IMPL DYNAGEN X4 W 5.37 X H 8.08 CM D 0.99 CM,SUP-2149215,CDM,C1882,HCPCS,0275,RC,,,,both,,,47925.82,31151.78,,,,,,,,,,,,,
SCREW BNE SLD 3.5X14 MM GUID GROWTH PLATE SYS + TI,SUP-2646859,CDM,C1713,HCPCS,0278,RC,,,,both,,,777.15,505.15,,,,,,,,,,,,,
PUTTY IS INDICATED FOR USE AS A BNE VOID FILL FOR VOIDS OR,SUP-2125446,CDM,C9359,HCPCS,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
GRAFT WND BURN 7X10 CM FEN EXTRACELLULAR MTRX MATRISTEM,SUP-2106463,CDM,Q4166,HCPCS,0636,RC,,,,both,,,3689.50,2398.17,,,,,,,,,,,,,
CATHETER ETER IRRIG SNUS RELIEVA VORT 2,SUP-2106374,CDM,C1729,HCPCS,0272,RC,,,,both,,,486.70,316.35,,,,,,,,,,,,,
PLATE BNE LCK LG LT FT CALCANEUS ALPS,SUP-2607127,CDM,C1713,HCPCS,0278,RC,,,,both,,,2480.60,1612.39,,,,,,,,,,,,,
SCREW BNE L 11 MM DIA 3.5 MM TI CORTICAL WR ST T15 DRV STRL,SUP-2931621,CDM,C1713,HCPCS,0278,RC,,,,both,,,135.62,88.15,,,,,,,,,,,,,
HC Removal FB Skin,PX-3611012000,CDM,10120,CPT,0361,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
CATHETER DRNGE PERI DSTL BA OPN END,SUP-2243794,CDM,C1729,HCPCS,0272,RC,,,,both,,,834.99,542.74,,,,,,,,,,,,,
EXTRACTOR SURG SZ 2.6 MM SCREW DIA2.3-6 MM STRL DISP OPERACE,SUP-2913608,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2060.63,1339.41,,,,,,,,,,,,,
GRAFT BIO TISS W20XL30CM PORCINE REGEN TISS MTRX PLIABLE,SUP-2113039,CDM,Q4130,HCPCS,0636,RC,,,,both,,,57684.94,37495.21,,,,,,,,,,,,,
GRAFT VASC STD WALL 8 MMX50 CM STR TWO LAYR ADVANTA VXT,SUP-2468368,CDM,C1768,CPT,0278,RC,,,,both,,,1511.66,982.58,,,,,,,,,,,,,
KIT IRRIG ALL CHN W 30ML SYR,SUP-2313030,CDM,2720000010,LOCAL,0272,RC,,,,both,,,728.48,473.51,,,,,,,,,,,,,
ALLOGRAFT BNE LG FRZN ASEP TIB SHFT,SUP-2867007,CDM,C1762,CPT,0278,RC,,,,both,,,5611.02,3647.16,,,,,,,,,,,,,
HC Mod Sed Oth Phys/Qhp 5/>Yrs Initial 15 Min,PX-3729915600,CDM,99156,CPT,0372,RC,,,,both,,,306.00,198.90,,,,,,,,,,,,,
NAIL IM SHT 130 DEG 10 MM HIP FRAC SYS STRL CHIMAERA,SUP-2646593,CDM,C1713,HCPCS,0278,RC,,,,both,,,5353.48,3479.76,,,,,,,,,,,,,
BIT DRL SLD 3.5 MM ALIGNX,SUP-2433775,CDM,2720000010,LOCAL,0272,RC,,,,both,,,464.72,302.07,,,,,,,,,,,,,
NEXGEN ROTATING HINGE FEMORAL F-RT,SUP-2502540,CDM,C1776,CPT,0278,RC,,,,both,,,21746.07,14134.95,,,,,,,,,,,,,
HC Removal FB Skin,PX-4501012000,CDM,10120,CPT,0450,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
KIT WARMING GALIL URETHRAL FPRPR4003,SUP-2885468,CDM,C2618,HCPCS,0272,RC,,,,both,,,1846.32,1200.11,,,,,,,,,,,,,
VALVE AORT AVALUS H 18 MM DIA29 MM ORIFICE 27.5 MM RNG DIA,SUP-2429902,CDM,C1713,HCPCS,0278,RC,,,,both,,,17270.00,11225.50,,,,,,,,,,,,,
SLEEVE LD SZ 5-6 MM,SUP-2137906,CDM,C1883,HCPCS,0278,RC,,,,both,,,147.58,95.93,,,,,,,,,,,,,
SET SCR GUID,SUP-2211150,CDM,2720000010,LOCAL,0272,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
GRAFT EVAR MAIN BODY L90MM DIA28MM LIMB L30MM DIA20MM IL,SUP-2217661,CDM,C1768,CPT,0278,RC,,,,both,,,34524.30,22440.79,,,,,,,,,,,,,
PROMETHAZINE HCL 25 MG/ML IJ SOLN,RX-6618,CDM,J2550,HCPCS,0636,RC,00641-0928-21,NDC,,both,0.25,ML,54.10,35.16,,,,,,,,,,,,,
GUIDEWIRE ORTH CRV SM 230 MM ERGO HNDL NS SQ LN REUSE,SUP-2846802,CDM,C1769,HCPCS,0272,RC,,,,both,,,632.40,411.06,,,,,,,,,,,,,
MINOCYCLINE HCL 50 MG PO CAPS,RX-5111,CDM,6370000000,HCPCS,0637,RC,68382-0316-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
GRAFT BNE H11XL21MM PARA PLIF FRZN TEXT VERTIGRFT VG 2,SUP-2264963,CDM,C1713,HCPCS,0278,RC,,,,both,,,8164.79,5307.11,,,,,,,,,,,,,
BRACE ORTHOPEDIC ABDUCTN HIP,SUP-2388159,CDM,L1686,HCPCS,0274,RC,,,,both,,,4779.08,3106.40,,,,,,,,,,,,,
BIT DRL L145MM DIA3.2MM ST HUM 3 FLUT QUIK CPL NDL PNT FOR,SUP-2178875,CDM,2720000010,LOCAL,0272,RC,,,,both,,,689.54,448.20,,,,,,,,,,,,,
CASPIAN OCCIPITAL FIXATION ANCHOR 7 MM,SUP-2867345,CDM,C1713,HCPCS,0278,RC,,,,both,,,4553.00,2959.45,,,,,,,,,,,,,
CATHETER CV SET 025 5 FRX8 CM 3L POLYETH,SUP-2760048,CDM,C1751,HCPCS,0278,RC,,,,both,,,235.25,152.91,,,,,,,,,,,,,
LCCK 0D SZ4 5MM 46X34 CPL,SUP-2502174,CDM,C1776,CPT,0278,RC,,,,both,,,12095.28,7861.93,,,,,,,,,,,,,
SPACER KNEE 3-10 16 MM DSTL SYS REV GUIDE ATTUNE,SUP-2454501,CDM,C1776,CPT,0278,RC,,,,both,,,1827.48,1187.86,,,,,,,,,,,,,
COLLAR CERV ADJ UNIV AD 13-19 IN 2 PC RIGID REPL PD VISTA TX,SUP-2196893,CDM,L0120,HCPCS,0274,RC,,,,both,,,140.48,91.31,,,,,,,,,,,,,
SPLINT WRST FA W ABDUCTED THMB L XSM,SUP-2276636,CDM,L3809,HCPCS,0274,RC,,,,both,,,22.70,14.75,,,,,,,,,,,,,
SCREW BNE MIC 1X3 MM DRILL-FREE TI CENTRE-DRIVE,SUP-2462156,CDM,C1713,HCPCS,0278,RC,,,,both,,,207.18,134.67,,,,,,,,,,,,,
ACETAMINOPHEN-CODEINE 300-30 MG PO TABS,RX-8949,CDM,6370000000,HCPCS,0637,RC,00406-0484-23,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
DOXAZOSIN MESYLATE 1 MG PO TABS,RX-9894,CDM,6370000000,HCPCS,0637,RC,00904-5522-61,NDC,,both,1,UN,3.90,2.53,,,,,,,,,,,,,
SHUNT SURG L 8.9 MM VENTRICULAR CATH L 180 MM PRESSURE 10 CM FV694T,SUP-2929006,CDM,C1889,HCPCS,0278,RC,,,,both,,,4178.74,2716.18,,,,,,,,,,,,,
PLATE SPNL 24 H THOR PRE CNTOUR RIBFIX BLU,SUP-2137003,CDM,C1713,HCPCS,0278,RC,,,,both,,,7680.44,4992.29,,,,,,,,,,,,,
HC Fna Bx W/US Gdn Ea Addl,PX-3611000600,CDM,10006,CPT,0361,RC,,,,outpatient,,,2124.00,1380.60,,,,,,,,,,,,,
SCREW BNE L64MM DIA4.5MM HD DIA8MM CORT S STL FULL THRD HEX,SUP-2184402,CDM,C1713,HCPCS,0278,RC,,,,both,,,119.89,77.93,,,,,,,,,,,,,
TROCAR SURG CALCANEUS,SUP-2468313,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
GUIDEPIN ORTHOPAEDIC 3.2X230 MM DRILL TIP,SUP-2837052,CDM,2720000010,LOCAL,0272,RC,,,,both,,,371.59,241.53,,,,,,,,,,,,,
PUTTY W/ CHIP 5.0CC DBM W/ RPM,SUP-2415803,CDM,C9359,HCPCS,0278,RC,,,,both,,,1846.32,1200.11,,,,,,,,,,,,,
FIBER LASER 200 MH N TAPR POLISHED TIP HOLM ACCUMAX,SUP-2465399,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1088.39,707.45,,,,,,,,,,,,,
CATHETER ANGIOPLSTY DIA8MM BAL DIA3.5MM HYDRCOAT RAP EXCHG 2,SUP-2101496,CDM,C1725,HCPCS,0272,RC,,,,both,,,533.80,346.97,,,,,,,,,,,,,
GRAFT VASC IMPRA L 60 CM DIA 7-4 MM EPTFE SHRT TAPR STD WALL,SUP-2761311,CDM,C1768,CPT,0278,RC,,,,both,,,2184.62,1420.00,,,,,,,,,,,,,
TUBE TYMPANOSTOMY DIA1.02 MM INNR FLANGE DIA2.40 MM FLROPLAS,SUP-2902027,CDM,L8699,HCPCS,0278,RC,,,,both,,,42.04,27.33,,,,,,,,,,,,,
BAND STRUT ACUTE QC STRL DISP,SUP-2933784,CDM,2720000010,LOCAL,0272,RC,,,,both,,,186.77,121.40,,,,,,,,,,,,,
IMPLANT STAP L45MM STD PIST DIA06MM STD WELL DIA09MM CLASS,SUP-2313855,CDM,L8613,CPT,0278,RC,,,,both,,,647.15,420.65,,,,,,,,,,,,,
SCREW BNE L 4 MM DIA1.7 MM CRANIOMAXILLOFACIAL ST LCK NS AXS 5PK,SUP-2884114,CDM,C1713,HCPCS,0278,RC,,,,both,,,1658.55,1078.06,,,,,,,,,,,,,
GUIDEWIRE ORTH L 220 MM DIA2.8 MM SCREW DIA 6.5/7.5 MM,SUP-2908344,CDM,C1769,HCPCS,0272,RC,,,,both,,,449.40,292.11,,,,,,,,,,,,,
TUBE ENDOTRACH WIRE REINF 7MM ID,SUP-2525905,CDM,2720000010,LOCAL,0272,RC,,,,both,,,62.49,40.62,,,,,,,,,,,,,
HC So Jak2 Gene Trget Seq Analysis,PX-3108127966,CDM,81279,CPT,0310,RC,,,,both,,,441.00,286.65,,,,,,,,,,,,,
SHEATH ENDO PROTCT STRL DISP ENF-P4 ENF-GP ENT 3.6FR FOR OLY,SUP-2277925,CDM,C1894,HCPCS,0272,RC,,,,both,,,54.48,35.41,,,,,,,,,,,,,
SHUNT VENTRICULOPERI CSF L SNAP ASMBLY CNTOUR REG FLO CTRL,SUP-2277928,CDM,C1889,HCPCS,0278,RC,,,,both,,,3391.20,2204.28,,,,,,,,,,,,,
HC Sel Cath Abd/Pelvic/Le 1st Ord,PX-3613624500,CDM,36245,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9 % IV SOLN (ADD-VANTAGE),RX-4081543,CDM,J7050,HCPCS,0258,RC,00409-7101-66,NDC,,both,50,ML,38.30,24.89,,,,,,,,,,,,,
SCREW BONE L50MM DIA13MM THRD L22MM CANC S STL ST CANN LAG,SUP-2186522,CDM,C1713,HCPCS,0278,RC,,,,both,,,2022.16,1314.40,,,,,,,,,,,,,
MESH 1X4IN PROL SFT POLYPR SYN ABD NONABSORBABLE RECT SFT,SUP-2219921,CDM,C1781,HCPCS,0278,RC,,,,both,,,3485.49,2265.57,,,,,,,,,,,,,
PLATE BNE L60MM 7 H S STL COMPR FOR 27MM SCR MINI FRAG SYS,SUP-2199361,CDM,C1713,HCPCS,0278,RC,,,,both,,,486.45,316.19,,,,,,,,,,,,,
GRAFT DURA ABSRB STRL 3.93IN 2.75IN PORCINE SURGISIS,SUP-2169999,CDM,C1763,HCPCS,0278,RC,,,,both,,,2543.40,1653.21,,,,,,,,,,,,,
PROSTHESIS OSS WEHRS INCUS LNG 4.5X3.3X2.5 MM SINGLE NOTCH,SUP-2637874,CDM,L8613,CPT,0278,RC,,,,both,,,1220.11,793.07,,,,,,,,,,,,,
PLATE BNE W10XL101MM THK1.2MM 90DEG 4X8 H BILAT S STL T SHP,SUP-2185878,CDM,C1713,HCPCS,0278,RC,,,,both,,,1937.19,1259.17,,,,,,,,,,,,,
PLATE 3.5MM TI LCP EXTRA-ARTICLR DSTL HUM 14H/LT 302MM-STER,SUP-2546627,CDM,C1713,HCPCS,0278,RC,,,,both,,,6326.88,4112.47,,,,,,,,,,,,,
INTRODUCER SHTH 0.035 IN 4 FRX11 CM W/O GUIDEWIRE SUPER SHTH,SUP-2464025,CDM,C1894,HCPCS,0272,RC,,,,both,,,29.83,19.39,,,,,,,,,,,,,
ALPRAZOLAM 0.5 MG PO TABS,RX-325,CDM,6370000000,HCPCS,0637,RC,00228-2029-10,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
INSERT TIB SZ 4 THK14MM POST STBL FIX GMK,SUP-2267511,CDM,C1776,CPT,0278,RC,,,,both,,,2452.65,1594.22,,,,,,,,,,,,,
GRAFT BONE ASEP MTRX DEMIN GRFTON,SUP-2307032,CDM,C9359,HCPCS,0278,RC,,,,both,,,2139.91,1390.94,,,,,,,,,,,,,
DEVICE INFLATION BALLOON L 3 CM DIA24/18 FR PACLITAXEL COAT,SUP-2881841,CDM,C1889,HCPCS,0278,RC,,,,both,,,10676.00,6939.40,,,,,,,,,,,,,
PLUG RMR DIA14MM SPNL LUM TAPR FUS L CAGE,SUP-2291607,CDM,C1713,HCPCS,0278,RC,,,,both,,,895.81,582.28,,,,,,,,,,,,,
PLATE ANAT REPLICATOR 15MM FOR PRI REV TOT SHLDR,SUP-2223284,CDM,C1713,HCPCS,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
RING EXT FIX HALF 180 MM,SUP-2197284,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2967.30,1928.74,,,,,,,,,,,,,
CANNULA 25GA ANTERIOR CHAMBER STORZ HESLIN,SUP-2462221,CDM,2720000010,LOCAL,0272,RC,,,,both,,,346.97,225.53,,,,,,,,,,,,,
EXTENSION FEM KNEE L 25 MM DIA15 MM STRL EMPOWR,SUP-2890694,CDM,C1776,CPT,0278,RC,,,,both,,,8164.00,5306.60,,,,,,,,,,,,,
WAND ABLAT VULCAN TACS,SUP-2314077,CDM,C1713,HCPCS,0278,RC,,,,both,,,926.30,602.09,,,,,,,,,,,,,
PLATE BNE BURR HOLE CVR 22 MM 6 HOLE LP CONTOURED TI NS,SUP-2499636,CDM,C1713,HCPCS,0278,RC,,,,both,,,899.04,584.38,,,,,,,,,,,,,
CLAMP CRAN TEXT SM 13 MM FLAPFIX FOR EXT FIX TI NS LF,SUP-2431404,CDM,C1713,HCPCS,0278,RC,,,,both,,,1062.58,690.68,,,,,,,,,,,,,
BIT DRL CANN 2X120MM,SUP-2321601,CDM,2720000010,LOCAL,0272,RC,,,,both,,,428.61,278.60,,,,,,,,,,,,,
GUIDEWIRE MOVABLE COR DSGN 0.038 INX150CM W/ J TIP 3MM,SUP-2355316,CDM,C1769,HCPCS,0272,RC,,,,both,,,37.68,24.49,,,,,,,,,,,,,
PLATE BNE 3.5X235 MM 18 HOLE SS LCP,SUP-2569330,CDM,C1713,HCPCS,0278,RC,,,,both,,,561.28,364.83,,,,,,,,,,,,,
BLADE L SERR SONICONE,SUP-2305950,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1472.66,957.23,,,,,,,,,,,,,
SNARE SURG SAGE 25 GAX9 IN TONSIL SS NS,SUP-2496822,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1278.39,830.95,,,,,,,,,,,,,
FLEXIBLE DRILL FIBERTAK 1.9MM,SUP-2812671,CDM,2720000010,LOCAL,0272,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
SCREW BNE L4MM DIA1.5MM CORT CRANIOMAXILLOFACIAL TI SELF,SUP-2188934,CDM,C1713,HCPCS,0278,RC,,,,both,,,278.71,181.16,,,,,,,,,,,,,
CRANIAL ACCESS KIT 5.31 MM W/O PREP SOL BIT,SUP-2666738,CDM,2720000010,LOCAL,0272,RC,,,,both,,,790.71,513.96,,,,,,,,,,,,,
POST ANG HOFFMANN II SS EXT FIXATION 30D,SUP-2701726,CDM,2720000010,LOCAL,0272,RC,,,,both,,,500.20,325.13,,,,,,,,,,,,,
MIS CALC PLT LG RT STE,SUP-2587005,CDM,C1713,HCPCS,0278,RC,,,,both,,,2233.83,1451.99,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 40 CM DIA 6 MM EPTFE STR STD WALL,SUP-2396186,CDM,C1768,CPT,0278,RC,,,,both,,,1739.56,1130.71,,,,,,,,,,,,,
TRIAL BONE PLT 10 H 1/3 TBLR W/ CLLR FOR 3.5MM SCR TC-100 SM,SUP-2343725,CDM,C1713,HCPCS,0278,RC,,,,both,,,831.50,540.47,,,,,,,,,,,,,
VALVE VENTRICULAR 5/35CM WATER WITHOUT RESERVOIR NON PROGRAM,SUP-2825652,CDM,C1889,HCPCS,0278,RC,,,,both,,,5900.03,3835.02,,,,,,,,,,,,,
GRAFT VASC GRAD WALL 8 MMX80 CM STR REINF GRAD WALL FLIXENE,SUP-2468087,CDM,C1768,CPT,0278,RC,,,,both,,,4945.50,3214.57,,,,,,,,,,,,,
STEM FEM STD C/D 0-5 CM MOD MECH,SUP-2861076,CDM,C1776,CPT,0278,RC,,,,both,,,698.59,454.08,,,,,,,,,,,,,
PUSHER KNOT 3.5 MMX31 CM EXCORP,SUP-2850204,CDM,2720000010,LOCAL,0272,RC,,,,both,,,953.93,620.05,,,,,,,,,,,,,
KIT EXT FIX DYNAMIZATION STRL DISP SMRT TSF,SUP-2933448,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2340.84,1521.55,,,,,,,,,,,,,
SUPPORT ORTHOPEDIC ADJ HIP ABDUCTN FLX EXTN CTRL,SUP-2421311,CDM,L2624,HCPCS,0272,RC,,,,both,,,1216.47,790.71,,,,,,,,,,,,,
FONDAPARINUX SODIUM 10 MG/0.8ML SC SOLN,RX-104345,CDM,J1652,HCPCS,0636,RC,55150-0233-00,NDC,,both,0.8,ML,115.60,75.14,,,,,,,,,,,,,
BIT DRL DIA4MM DSTL RAD ULN CANN,SUP-2119910,CDM,2720000010,LOCAL,0272,RC,,,,both,,,383.08,249.00,,,,,,,,,,,,,
KNIFE SURG TABB PICK 6.25 INX3 MM CRV LF,SUP-2489023,CDM,2720000010,LOCAL,0272,RC,,,,both,,,333.06,216.49,,,,,,,,,,,,,
DHHS HELIX BLADE 100MM-STERILE,SUP-2547631,CDM,C1713,HCPCS,0278,RC,,,,both,,,1185.44,770.54,,,,,,,,,,,,,
REDAPT SLVLS MONO STEM 240MM SZ 12 SO,SUP-2345577,CDM,C1776,CPT,0278,RC,,,,both,,,18136.64,11788.82,,,,,,,,,,,,,
EXTRACTOR SURG EASYOUT 2.5 MM QR ACUTRK,SUP-2857692,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1026.78,667.41,,,,,,,,,,,,,
HYDROMORPHONE HCL PF 2 MG/ML IJ SOLN,RX-118038,CDM,J1171,HCPCS,0636,RC,63323-0853-03,NDC,,both,0.5,ML,54.10,35.16,,,,,,,,,,,,,
PLATE BONE LNG DOGBONE NAR OMNI,SUP-2224008,CDM,C1713,HCPCS,0278,RC,,,,both,,,3758.58,2443.08,,,,,,,,,,,,,
HC Reticulocyte,PX-3058504500,CDM,85045,CPT,0305,RC,,,,both,,,142.00,92.30,,,,,,,,,,,,,
SCREW BNE BLNT PT 6X30 MM 175 MM THRD VAR LEN SCHNZ SS NS,SUP-2750874,CDM,C1713,HCPCS,0278,RC,,,,both,,,419.57,272.72,,,,,,,,,,,,,
GRAFT VASC STR 6 MMX20 CM TW N RING HD ACCS EPTFE CARBOFLO,SUP-2761254,CDM,C1768,CPT,0278,RC,,,,both,,,1089.27,708.03,,,,,,,,,,,,,
STEM FEM REV CEM STR LT NAT HIP SZ 2,SUP-2210702,CDM,C1776,CPT,0278,RC,,,,both,,,15307.50,9949.87,,,,,,,,,,,,,
EXTENSION STEM L80MM OD11MM REG TI KNEE PRI PRESSFIT FLUT,SUP-2376325,CDM,C1776,CPT,0278,RC,,,,both,,,2412.56,1568.16,,,,,,,,,,,,,
HC Aspirate Pleura W/ Imaging,PX-3503255500,CDM,32555,CPT,0350,RC,,,,both,,,3598.00,2338.70,,,,,,,,,,,,,
DEVICE PESSARY SZ 6 83MM RNG W KNOB AND SUPP GEHRUNG,SUP-2417157,CDM,A4562,HCPCS,0272,RC,,,,both,,,112.66,73.23,,,,,,,,,,,,,
STEM HUM L 90 MM SZ 7S SHRT PLASMA SPRY POROUS TI SHLDR,SUP-2912616,CDM,C1776,CPT,0278,RC,,,,both,,,24021.00,15613.65,,,,,,,,,,,,,
PIN EXT FIX CONCL SET CONN ELEMENT STRL TRUELOK EVO LTX,SUP-2875605,CDM,C1713,HCPCS,0278,RC,,,,both,,,18446.28,11990.08,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY INQUIRY AFOCUS II L 110 CM DIA 5,SUP-2491785,CDM,C1730,HCPCS,0272,RC,,,,both,,,734.41,477.37,,,,,,,,,,,,,
PIN FIX L40MM DIA2.5MM PROV FOR EVOS SM PLATING SYS,SUP-2344057,CDM,C1713,HCPCS,0278,RC,,,,both,,,1163.50,756.27,,,,,,,,,,,,,
SET DIL 8/10FR PTFE GRADUAL TAPR SMOOTH TRANSITION SFTY,SUP-2139236,CDM,C1894,HCPCS,0272,RC,,,,both,,,147.23,95.70,,,,,,,,,,,,,
PLATE BNE L 172.82 MM THK 1.6 MM LG WIDE TI ANGLED NS DISP,SUP-2936414,CDM,C1713,HCPCS,0278,RC,,,,both,,,3893.60,2530.84,,,,,,,,,,,,,
PLATE SPNL W16XL53MM THK1.9MM 6 H LEV 2 ANTR CERV TI SNOWCAP,SUP-2207836,CDM,C1713,HCPCS,0278,RC,,,,both,,,4035.53,2623.09,,,,,,,,,,,,,
DISTRACTOR MLNA MNDBLR BDRCTNL LG RGHT 76 X 40 MM,SUP-2669819,CDM,C1713,HCPCS,0278,RC,,,,both,,,16063.93,10441.55,,,,,,,,,,,,,
GRAFT 4MM 10MM RANG 90CC CHIP CRUSH CANC FRZN ALLGRFT,SUP-2264742,CDM,C1713,HCPCS,0278,RC,,,,both,,,3105.08,2018.30,,,,,,,,,,,,,
TRIPTORELIN PAMOATE 11.25 MG IM SUSR,RX-31708,CDM,J3315,HCPCS,0636,RC,74676-5904-01,NDC,,both,1,UN,7894.90,5131.68,,,,,,,,,,,,,
DRESSING BIO L 8 X W 16 CM PORCINE CLLGN PHMB CROSS LINKED,SUP-2909415,CDM,C1763,HCPCS,0278,RC,,,,both,,,24115.20,15674.88,,,,,,,,,,,,,
HC Cell Count Misc Body Fluids W/Differential Count,PX-3008905100,CDM,89051,CPT,0300,RC,,,,both,,,340.00,221.00,,,,,,,,,,,,,
PLATE BNE L 1.5X0.6 MM 4 MM MIDFACE 2X2 HOLE BRIDGE TI NS,SUP-2518099,CDM,C1713,HCPCS,0278,RC,,,,both,,,876.28,569.58,,,,,,,,,,,,,
CAGE SPNL 25X15X13 MM SABER,SUP-2256339,CDM,C1889,HCPCS,0278,RC,,,,both,,,10468.76,6804.69,,,,,,,,,,,,,
SHEATH INTRO SAFSHTH DIA 9.5 FR STRL,SUP-2458215,CDM,C1894,HCPCS,0272,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
ALLOGRAFT HUM TISS FRZN ASEP SEMITENDINOSUS 920780,SUP-2867085,CDM,C1762,CPT,0278,RC,,,,both,,,4581.89,2978.23,,,,,,,,,,,,,
SCREW CRTX ST TI STRL 4.5MM DIA 26MML,SUP-2343931,CDM,C1713,HCPCS,0278,RC,,,,both,,,191.57,124.52,,,,,,,,,,,,,
GUIDEWIRE VASC PROTRACK L 175 CM DIA 0.025 IN COIL L 13 CM,SUP-2131511,CDM,C1769,HCPCS,0272,RC,,,,both,,,675.10,438.81,,,,,,,,,,,,,
SET INTRO DIA12 FR CATH 14 GA NDL 21 GA1 CC/20 CC TRNSJUG,SUP-2117071,CDM,C1713,HCPCS,0278,RC,,,,both,,,1067.60,693.94,,,,,,,,,,,,,
SCREW BNE L10MM DIA23MM LOK T6 VARIAX,SUP-2364896,CDM,C1713,HCPCS,0278,RC,,,,both,,,512.13,332.88,,,,,,,,,,,,,
CATHETER ATHRCTMY L130CM DIA2MM VES DIA3MM GUID CATH DIA8FR,SUP-2353050,CDM,C1724,HCPCS,0278,RC,,,,both,,,10344.73,6724.07,,,,,,,,,,,,,
STEM SEG LIMB SALV LO BODY CEM STR FLUT ELEOS 32MM,SUP-2314047,CDM,C1776,CPT,0278,RC,,,,both,,,14459.70,9398.80,,,,,,,,,,,,,
BIOPSY KIT BNE LESION 11 GAX10 CM 12 GAX14.8 CM TREK,SUP-2754746,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1114.70,724.55,,,,,,,,,,,,,
NAPROXEN 250 MG PO TABS,RX-5391,CDM,6370000000,HCPCS,0637,RC,70010-0137-01,NDC,,both,1,UN,0.40,0.26,,,,,,,,,,,,,
TUBE ENTRL FEED PUSH METHOD 035 20 FRX4.47 MM PHAR FLO 20,SUP-2737403,CDM,C1769,HCPCS,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
PLATE BONE DUAL CMPRSSN HLX11 TTNM RCNSTRCTN F/3.5MM SCREW U,SUP-2492990,CDM,C1713,HCPCS,0278,RC,,,,both,,,1573.14,1022.54,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 70 CM DIA 6 MM EPTFE STR STD WALL,SUP-2396189,CDM,C1768,CPT,0278,RC,,,,both,,,2847.98,1851.19,,,,,,,,,,,,,
KIT BONE MAR ASPIR,SUP-2415886,CDM,C1713,HCPCS,0278,RC,,,,both,,,1831.56,1190.51,,,,,,,,,,,,,
HC Therapeutic Prophylactic/Dx Njx Intra-Arterial,PX-2609637300,CDM,96373,CPT,0260,RC,,,,both,,,267.00,173.55,,,,,,,,,,,,,
BASKET STONE STR 3 FR 12 MMX70 CM 4 WIR W/O TIP NIT STRL,SUP-2767533,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1189.12,772.93,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH RENU L 116 MM PROX/DSTL L 52/64,SUP-2170459,CDM,C1874,HCPCS,0278,RC,,,,both,,,20453.96,13295.07,,,,,,,,,,,,,
COIL VASC MREYE EMBOLUS L 15 CM DIA25 MM CATH DIA 0.038 IN,SUP-2638537,CDM,C1889,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
ENDCAP ORTH VN 2 HOLE IMPING STRL LTX,SUP-2861518,CDM,C1889,HCPCS,0278,RC,,,,both,,,717.99,466.69,,,,,,,,,,,,,
BOOT CAST XSM L17CM TOE W9CM BILAT BLK ETHYL VYN ACETT PRNT,SUP-2196780,CDM,L4387,HCPCS,0274,RC,,,,both,,,14.85,9.65,,,,,,,,,,,,,
IMPLANT OP RM MINI-MONSTER 4.0 X 44MM HD CANN SHT THRD SCR,SUP-2320565,CDM,C1713,HCPCS,0278,RC,,,,both,,,868.21,564.34,,,,,,,,,,,,,
CONNECTOR SPNL TI SLT TRNSVRS ASMBLY FOR 5.5MM ROD MOSS,SUP-2254452,CDM,C1713,HCPCS,0278,RC,,,,both,,,2480.60,1612.39,,,,,,,,,,,,,
MESH CRANIAL STRAIGHT 1.5X75X75X0.8 MM RAPID RESORBABLE STER,SUP-2838586,CDM,C1713,HCPCS,0278,RC,,,,both,,,7064.37,4591.84,,,,,,,,,,,,,
LOOP TISS FIX L 120 MM ADJ OPN BTTN STRL PROCINCH,SUP-2906386,CDM,C1713,HCPCS,0278,RC,,,,both,,,1676.76,1089.89,,,,,,,,,,,,,
DRESSING BIO W8XL10IN MESHED BILAYER WND MTRX,SUP-2244275,CDM,C9363,HCPCS,0636,RC,,,,both,,,34906.00,22688.90,,,,,,,,,,,,,
STENT GRFT VASC TAG L 10 CM DIA 45/45 MM THOR AORT,SUP-2719572,CDM,C1768,HCPCS,0278,RC,,,,both,,,57885.90,37625.83,,,,,,,,,,,,,
VALVE PRESSURE PROGRAMMABLE 120 CM,SUP-2666784,CDM,C1889,HCPCS,0278,RC,,,,both,,,11315.78,7355.26,,,,,,,,,,,,,
HC Extracranial Bilat Study,PX-9219388000,CDM,93880,CPT,0921,RC,,,,both,,,1104.00,717.60,,,,,,,,,,,,,
CELECOXIB 400 MG PO CAPS,RX-33653,CDM,6370000000,HCPCS,0637,RC,65862-0910-60,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
HC Diabetes Indiv/30min,PX-9420010800,CDM,G0108,HCPCS,0942,RC,,,,inpatient,,,160.00,104.00,,,,,,,,,,,,,
GATIFLOXACIN 0.5 % OP SOLN,RX-103346,CDM,6370000000,HCPCS,0637,RC,61314-0672-25,NDC,,both,2.5,ML,212.80,138.32,,,,,,,,,,,,,
PLATE BNE W11XL190MM THK33MM 14 H BILAT MTPHSEAL TI LOK,SUP-2190767,CDM,C1713,HCPCS,0278,RC,,,,both,,,3806.50,2474.22,,,,,,,,,,,,,
SCREW ACET PLR PROV LCK LNR,SUP-2438404,CDM,C1713,HCPCS,0278,RC,,,,both,,,197.82,128.58,,,,,,,,,,,,,
PROSTHESIS TESTICULAR M W2.7XL4CM NACL FIL,SUP-2300764,CDM,C1894,HCPCS,0272,RC,,,,both,,,6267.44,4073.84,,,,,,,,,,,,,
PLATE BONE 8 H LT MEDL DSTL TIB S STL,SUP-2123160,CDM,C1713,HCPCS,0278,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
CATHETER HEMO DYLS OR HD GLIDEPATH L 36 CM INSRTN L 31 CM,SUP-2613290,CDM,C1750,HCPCS,0278,RC,,,,both,,,1309.38,851.10,,,,,,,,,,,,,
BOLT IM L50MM DIA4.9MM 3.5MM TI ST LOK HEX RECESS GRN,SUP-2192395,CDM,C1713,HCPCS,0278,RC,,,,both,,,515.46,335.05,,,,,,,,,,,,,
SYSTEM TISS CLOSURE ENDOSCP STD PDLOK CLP,SUP-2736730,CDM,C1889,HCPCS,0278,RC,,,,both,,,1468.20,954.33,,,,,,,,,,,,,
CROSSLINK SPNL RVS 29-34 MM,SUP-2232299,CDM,C1713,HCPCS,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
GRAFT STENT BIFUR 12-13.5X14.5 MMX7 CM 12 FR AAA IL EXT,SUP-2395918,CDM,C1768,CPT,0278,RC,,,,both,,,9432.56,6131.16,,,,,,,,,,,,,
SCREW SPNL L14MM DIA3.5MM POST CERVICOTHORACIC TI ST,SUP-2286842,CDM,C1713,HCPCS,0278,RC,,,,both,,,1664.20,1081.73,,,,,,,,,,,,,
SIMILAC HUMAN MILK FORTIFIER PO CONC,RX-121133,CDM,2500000003,HCPCS,0250,RC,70074-0630-11,NDC,,both,5,ML,54.10,35.16,,,,,,,,,,,,,
PLATE BNE STR MINI MED 2X1 MM 4 HOLE FOR SCR TI NS LEVEL 1,SUP-2476756,CDM,C1713,HCPCS,0278,RC,,,,both,,,255.69,166.20,,,,,,,,,,,,,
PLATE BNE MINI RT CRANIOMAXILLOFACIAL L-Y SHP PREBENT,SUP-2883169,CDM,C1713,HCPCS,0278,RC,,,,both,,,1257.73,817.52,,,,,,,,,,,,,
PLATE BNE L LT 5 HOLE,SUP-2864960,CDM,C1713,HCPCS,0278,RC,,,,both,,,4534.16,2947.20,,,,,,,,,,,,,
SCREW STRNL CLOSURE L 10 MM TI LCK MINT NS STERNALOCK EZ,SUP-2894455,CDM,C1713,HCPCS,0278,RC,,,,both,,,200.96,130.62,,,,,,,,,,,,,
POSITIONER PT ACC MAINTAINS HEMODYNAMICSXPOSE4,SUP-2266083,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2667.02,1733.56,,,,,,,,,,,,,
VENETOCLAX 100 MG PO TABS,RX-133767,CDM,J8999,HCPCS,0636,RC,00074-0576-11,NDC,,both,1,UN,585.70,380.70,,,,,,,,,,,,,
SHEATH UROLOGICAL AMPLTZ L 16 CM DIL L 30 CM DIA24 FR RENAL,SUP-2835769,CDM,C1894,HCPCS,0272,RC,,,,both,,,106.98,69.54,,,,,,,,,,,,,
STEM RADIAL STD 8X10 MM ELBW,SUP-2107884,CDM,C1776,CPT,0278,RC,,,,both,,,3925.00,2551.25,,,,,,,,,,,,,
PLATE BONE L70MM THK1.2MM DISTANCE BTWN H 10.5MM CALCNL TI,SUP-2190979,CDM,C1713,HCPCS,0278,RC,,,,both,,,1781.13,1157.73,,,,,,,,,,,,,
MICROCATHETER INFUSION MAESTRO 150CM 2.9/2.9FR SWAN TIP,SUP-2301446,CDM,C1887,HCPCS,0272,RC,,,,both,,,857.06,557.09,,,,,,,,,,,,,
PLATE BONE 4 H VOLAR WR S STL HK,SUP-2389791,CDM,C1713,HCPCS,0278,RC,,,,both,,,1962.50,1275.62,,,,,,,,,,,,,
GRAFT HUM TISS W12XL12CM THK.9-1.99MM ACELLULAR DERM MTRX,SUP-2402515,CDM,Q4126,HCPCS,0636,RC,,,,both,,,40820.00,26533.00,,,,,,,,,,,,,
HC Layer Clos Face 2.6-5.0 Cm,PX-4501205200,CDM,12052,CPT,0450,RC,,,,outpatient,,,1216.00,790.40,,,,,,,,,,,,,
GRAFT VASC PROPATEN L 15 CM DIA 6 MM EPTFE CBAS HEPARIN TW,SUP-2655628,CDM,C1768,CPT,0278,RC,,,,both,,,3475.98,2259.39,,,,,,,,,,,,,
GII C/R DEEP TIB SZ5 11MM LF,SUP-2822559,CDM,C1776,CPT,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
CATHETER DRAINAGE PUDENZ,SUP-2666771,CDM,C1729,HCPCS,0272,RC,,,,both,,,449.81,292.38,,,,,,,,,,,,,
BIT DRL DIA4X45MM CANN BITE COMPR SCR QUIK CONN,SUP-2315943,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1232.95,801.42,,,,,,,,,,,,,
PORT INFUS 9.5FR ATTCH CHRONOFLEX POLYUR CATH SIL FILL SUT,SUP-2127805,CDM,C1788,HCPCS,0278,RC,,,,both,,,1507.20,979.68,,,,,,,,,,,,,
IMPLANT SPNG SIL OBLONG,SUP-2213503,CDM,L8610,HCPCS,0278,RC,,,,both,,,170.19,110.62,,,,,,,,,,,,,
REAMER SURG DIA4MM CANN HD,SUP-2120846,CDM,2720000010,LOCAL,0272,RC,,,,both,,,634.28,412.28,,,,,,,,,,,,,
COMPONENT PAT RESURF IMP GEN II,SUP-2349043,CDM,C1776,CPT,0278,RC,,,,both,,,1861.77,1210.15,,,,,,,,,,,,,
PLATE BNE L170MM WRST STR SPANNING LO PROF FOR 2.4MM CORT,SUP-2194239,CDM,C1713,HCPCS,0278,RC,,,,both,,,4897.36,3183.28,,,,,,,,,,,,,
SPACER SPNL L58-84MM 0DEG ANTR THORLUM TI CTRL BODY NONSCREW,SUP-2182820,CDM,C1821,HCPCS,0278,RC,,,,both,,,20273.72,13177.92,,,,,,,,,,,,,
FIXER XR FOR RAPID REDI-CHEM HSI SOLUTION AUTO,SUP-2238458,CDM,2720000010,LOCAL,0272,RC,,,,both,,,36.11,23.47,,,,,,,,,,,,,
TITANIUM CABLE CRIMP-STERILE,SUP-2549743,CDM,C1713,HCPCS,0278,RC,,,,both,,,99.13,64.43,,,,,,,,,,,,,
HC Exc Tr-Ext B9+Marg 0.5 Cm<,PX-4501140000,CDM,11400,CPT,0450,RC,,,,both,,,2188.00,1422.20,,,,,,,,,,,,,
SCREW TAP BIO-CORE INTERFERENCE 7MM,SUP-2633081,CDM,C1713,HCPCS,0278,RC,,,,both,,,1737.30,1129.24,,,,,,,,,,,,,
RIFABUTIN 150 MG PO CAPS,RX-11290,CDM,6370000000,HCPCS,0637,RC,59762-1350-01,NDC,,both,1,UN,63.00,40.95,,,,,,,,,,,,,
CATHETER EP DIAG MAPPINGXLARGE CRV DECAPOLAR 2-8-2MM SPC,SUP-2356929,CDM,C1730,HCPCS,0272,RC,,,,both,,,1987.62,1291.95,,,,,,,,,,,,,
INTRODUCER PACE LD FLOWGUARD DIA 9 FR ART VLV PEELABLE STRL,SUP-2281860,CDM,C1894,HCPCS,0272,RC,,,,both,,,196.53,127.74,,,,,,,,,,,,,
PROBE ULTRASONIC ASPIR W HATCH WND DEB DISP FOR SONICONE OR,SUP-2305956,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1309.85,851.40,,,,,,,,,,,,,
CLAMP EXT FIX RNG TENXOR,SUP-2372244,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1805.50,1173.57,,,,,,,,,,,,,
GALLIUM GA 68 GOZETOTIDE (GOZELLIX) 25 MCG IV KIT,RX-157520,CDM,A9616,HCPCS,0343,RC,84552-0500-25,NDC,,both,1,UN,171275.00,111328.75,,,,,,,,,,,,,
VANTEX KT 3 LUMN 7 F 20 CM W/ HPRN,SUP-2214382,CDM,C1751,HCPCS,0278,RC,,,,both,,,204.10,132.66,,,,,,,,,,,,,
BELLADONNA ALKALOIDS-OPIUM 16.2-30 MG RE SUPP,RX-9219,CDM,6370000000,HCPCS,0637,RC,00574-7045-12,NDC,,both,1,UN,99.10,64.41,,,,,,,,,,,,,
PLATE BNE SM 11 H ANT TIB TI DELT LOK COMPR FOR 3.5/4MM SCR,SUP-2398401,CDM,C1713,HCPCS,0278,RC,,,,both,,,1507.20,979.68,,,,,,,,,,,,,
GRAFT VASC BIFUR 16X9 MMX50 CMX0.49 MM RVS LOCKNIT HEMGRD,SUP-2464396,CDM,C1768,CPT,0278,RC,,,,both,,,2492.44,1620.09,,,,,,,,,,,,,
DISOPYRAMIDE PHOSPHATE 150 MG PO CAPS,RX-2536,CDM,6370000000,HCPCS,0637,RC,00093-3129-01,NDC,,both,1,UN,10.20,6.63,,,,,,,,,,,,,
STARTER PLUG/NUT FOR M8 MULTAXL SCR SPNL SYS CD HORZ,SUP-2290033,CDM,C1713,HCPCS,0278,RC,,,,both,,,2490.02,1618.51,,,,,,,,,,,,,
SLING UROLOGICAL MID-URETHRAL SUPRAPUBIC 2 DEL LYNX ULTRA,SUP-2876041,CDM,C1771,HCPCS,0278,RC,,,,both,,,5251.96,3413.77,,,,,,,,,,,,,
ELECTRODE ELECSURG OD5MM YEL STRL DISP FOR 24/26FR RESECTSCP,SUP-2261199,CDM,2720000010,LOCAL,0272,RC,,,,both,,,551.07,358.20,,,,,,,,,,,,,
PROSTHESIS PENILE 22 CM SCROT PMP SET NAR BASE TITAN ESZ922] COLOPLAST CORP],SUP-2165451,CDM,C1813,HCPCS,0278,RC,,,,both,,,29795.46,19367.05,,,,,,,,,,,,,
LOOP OPHTH 25+GA FLX RETRCT TIP FOR POST SEG SURG DISP,SUP-2109656,CDM,2720000010,LOCAL,0272,RC,,,,both,,,436.46,283.70,,,,,,,,,,,,,
IMPACTOR SURG ANG FOR GRFT PYRAMETRIX,SUP-2292626,CDM,C1713,HCPCS,0278,RC,,,,both,,,1382.98,898.94,,,,,,,,,,,,,
SCREW INTRF 10MM 35MM 1MM CANN KNEE ABSRB POLY-L LACTIC ACID,SUP-2366629,CDM,C1713,HCPCS,0278,RC,,,,both,,,636.79,413.91,,,,,,,,,,,,,
MESH HERN W3.2XL3.2IN UMB EPIGASTRIC OMEGA 3 FATTY ACID,SUP-2227401,CDM,C1781,HCPCS,0278,RC,,,,both,,,1799.22,1169.49,,,,,,,,,,,,,
BAG LEFT CARRY CONSLDTD F/HEARTMATE II,SUP-2356023,CDM,Q0508,HCPCS,0272,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
MORPHINE SULFATE ER 15 MG PO TBCR,RX-120979,CDM,6370000000,HCPCS,0637,RC,00406-8315-23,NDC,,both,1,UN,4.10,2.66,,,,,,,,,,,,,
PREDNISOLONE ACETATE 1 % OP SUSP,RX-6487,CDM,6370000000,HCPCS,0637,RC,60758-0119-05,NDC,,both,5,ML,198.00,128.70,,,,,,,,,,,,,
SCREW SQ FIT 1.7X6MM,SUP-2363521,CDM,C1713,HCPCS,0278,RC,,,,both,,,100.42,65.27,,,,,,,,,,,,,
TRAY KYPHOPLASTY SZ 3 BLLN L15MM ADD FRAC IBT KYPHON,SUP-2293660,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5966.00,3877.90,,,,,,,,,,,,,
IMPLANT ANK JT FIX INSRT L UHMWPE SALTO TALARIS SZ 1 8 MM,SUP-2244149,CDM,C1776,CPT,0278,RC,,,,both,,,7740.10,5031.06,,,,,,,,,,,,,
PLATE BNE L MIC XLN 100 DEG 1.5 MM LT 3X3 HOLE TI NS,SUP-2482046,CDM,C1713,HCPCS,0278,RC,,,,both,,,649.29,422.04,,,,,,,,,,,,,
HC Sclerotx Fluid Collection,PX-3614918500,CDM,49185,CPT,0361,RC,,,,inpatient,,,3707.00,2409.55,,,,,,,,,,,,,
SHEATH PEELAWAY INTRODUCER 14 FR 5-PACK,SUP-2854425,CDM,C1894,HCPCS,0272,RC,,,,both,,,1285.52,835.59,,,,,,,,,,,,,
CATHETER DRNAGE 14FR L40CM POLYUR HYDRPHLC BILI W/ LCK PGTL,SUP-2419069,CDM,C1729,HCPCS,0272,RC,,,,both,,,244.92,159.20,,,,,,,,,,,,,
BUR SURG L 10 MM DIA 3 MM DIAMOND X COARSE STRL DISP ELAN 4,SUP-2929035,CDM,2720000010,LOCAL,0272,RC,,,,both,,,524.16,340.70,,,,,,,,,,,,,
HC Extractable Nuclear Antigen Antibody Any Method,PX-3028623500,CDM,86235,CPT,0302,RC,,,,both,,,98.00,63.70,,,,,,,,,,,,,
CATHETER ETER ABLAT 4MM N NAVIGATIONAL,SUP-2248494,CDM,C1733,HCPCS,0272,RC,,,,both,,,2392.68,1555.24,,,,,,,,,,,,,
DISTRACTOR SURG L70MM TELSCP LNR TRUELOK,SUP-2316072,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1318.39,856.95,,,,,,,,,,,,,
THERASKIN LG 39SQ CM 5.1X7.6CM,SUP-2264658,CDM,Q4121,HCPCS,0636,RC,,,,both,,,3969.90,2580.43,,,,,,,,,,,,,
PLATE BONE L41MM 10 H ORBIT RIM CRANIOMAXILLOFACIAL TI FOR,SUP-2191139,CDM,C1713,HCPCS,0278,RC,,,,both,,,1294.62,841.50,,,,,,,,,,,,,
GRAFT BONE SUB L9MM CORT FIBULAR WDG FRZ DRY CORNERSTONE SEL,SUP-2293786,CDM,C1713,HCPCS,0278,RC,,,,both,,,1805.50,1173.57,,,,,,,,,,,,,
NITROFURANTOIN MACROCRYSTAL 25 MG PO CAPS,RX-5594,CDM,6370000000,HCPCS,0637,RC,62332-0389-31,NDC,,both,1,UN,9.00,5.85,,,,,,,,,,,,,
HC Nutrition Class,PX-9420947200,CDM,S9472,CPT,0942,RC,,,,both,,,106.00,68.90,,,,,,,,,,,,,
DILATOR ENDO SZ 54FR POLYVI OVR THE WIRE TAPR MRK SPR TIP,SUP-2166174,CDM,C1713,HCPCS,0278,RC,,,,both,,,722.20,469.43,,,,,,,,,,,,,
BIT DRL L195MM DIA2.5MM S STL QUIK CONN NONRADIOLUCENT W/O,SUP-2411441,CDM,2720000010,LOCAL,0272,RC,,,,both,,,786.57,511.27,,,,,,,,,,,,,
CATHETER ANGIOPLSTY L75CM BAL L40MM OD5MM GWIRE OD0.035IN,SUP-2266001,CDM,C1725,HCPCS,0272,RC,,,,both,,,543.22,353.09,,,,,,,,,,,,,
CUBE EXT FIX 120 MM UBER,SUP-2898471,CDM,2720000010,LOCAL,0272,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
GRAFT VASC IMPRA L 45 CM DIA 4-7 MM EPTFE STP STD WALL N,SUP-2127036,CDM,C1768,CPT,0278,RC,,,,both,,,1723.86,1120.51,,,,,,,,,,,,,
NAIL IM 4.5X450 MM SS STRL MJ-FLEX,SUP-2646280,CDM,C1713,HCPCS,0278,RC,,,,both,,,1617.54,1051.40,,,,,,,,,,,,,
IMPLANT STBL SYS AXIALIF 2L +,SUP-2389072,CDM,C1889,HCPCS,0278,RC,,,,both,,,46456.30,30196.59,,,,,,,,,,,,,
FEMORAL VG CEM POR TIB/ARC/PAT,SUP-2137307,CDM,C1713,HCPCS,0278,RC,,,,both,,,13542.82,8802.83,,,,,,,,,,,,,
PLATE BONE W17.5XL282MM THK5.2MM 15 H STRL BILAT S STL BROAD,SUP-2185308,CDM,C1713,HCPCS,0278,RC,,,,both,,,2603.28,1692.13,,,,,,,,,,,,,
SPHINCTEROTOME ENDOSCP 3 LUMEN GUIDEWIRE CLEVERCUT DISP,SUP-2313226,CDM,C1713,HCPCS,0278,RC,,,,both,,,587.18,381.67,,,,,,,,,,,,,
AMINOPHYLLINE 25 MG/ML IV SOLN,RX-407,CDM,J0280,HCPCS,0636,RC,00409-5921-01,NDC,,both,2,ML,54.10,35.16,,,,,,,,,,,,,
PLATE BNE RECON 3.5 MM PELV 4 HOLE,SUP-2518361,CDM,C1713,HCPCS,0278,RC,,,,both,,,2901.36,1885.88,,,,,,,,,,,,,
PLATE BNE L W135XL152MM THK42MM 8 H BILAT TI NAR RIG NEUT,SUP-2190816,CDM,C1713,HCPCS,0278,RC,,,,both,,,1417.84,921.60,,,,,,,,,,,,,
ALLOGRAFT BNE DURA MATER 8-30 SC PTCH ETO,SUP-2867076,CDM,C1763,HCPCS,0278,RC,,,,both,,,1291.64,839.57,,,,,,,,,,,,,
SET CBL GRP L DIA1.6MM VIT FOR HOWMEDICA OSTEONICS DALL-M,SUP-2377562,CDM,C1713,HCPCS,0278,RC,,,,both,,,2157.81,1402.58,,,,,,,,,,,,,
SLEEVE FEM NK L 3MM UPLR HIP 10 12 TAPR EXT ADPT ULT,SUP-2253259,CDM,C1776,CPT,0278,RC,,,,both,,,649.98,422.49,,,,,,,,,,,,,
BENDING TEMPLATE FOR LOCKING CALCANEAL PLATE-MINI,SUP-2548481,CDM,C1713,HCPCS,0278,RC,,,,both,,,238.29,154.89,,,,,,,,,,,,,
SCREW BNE L110MM DIA6.5MM THRD L30MM ST LAT FEM HIP G TI ST,SUP-2179685,CDM,C1713,HCPCS,0278,RC,,,,both,,,668.10,434.26,,,,,,,,,,,,,
ALLOGRAFT BNE WHL RIB 4 CM FRZN,SUP-2717948,CDM,C1762,CPT,0278,RC,,,,both,,,3077.20,2000.18,,,,,,,,,,,,,
STEM HUM L6MM SHT PRESERVE EQUINOXE,SUP-2435975,CDM,C1776,CPT,0278,RC,,,,both,,,5966.00,3877.90,,,,,,,,,,,,,
CUP ACET POLYETH CEMENTEDCOMPONENTS I.D. INSIDE DIAM O.D.,SUP-2221684,CDM,C1776,CPT,0278,RC,,,,both,,,3014.40,1959.36,,,,,,,,,,,,,
FLIPCUTTER II SHORT 11.5MM,SUP-2811332,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
PLATE HOLDING WAND 20MM SYSTEM 18CM,SUP-2707264,CDM,C1713,HCPCS,0278,RC,,,,both,,,961.72,625.12,,,,,,,,,,,,,
IMPLANT GYN L 16 X W 6 CM ALLGRFT DERM PROC OMNI DIR STRL,SUP-2896112,CDM,C1762,CPT,0278,RC,,,,both,,,10120.22,6578.14,,,,,,,,,,,,,
CATHETER CV TY 025 5 FRX12 CM 3L POLYETH,SUP-2760002,CDM,C1751,HCPCS,0278,RC,,,,both,,,312.43,203.08,,,,,,,,,,,,,
PLATE BNE L57MM THK34MM 4 H BILAT PUBIC S STL LO PROF RIG,SUP-2177137,CDM,C1713,HCPCS,0278,RC,,,,both,,,2261.40,1469.91,,,,,,,,,,,,,
PLATE BNE THK1.8MM 8 H STRNL TI X SHP LOK,SUP-2262576,CDM,C1713,HCPCS,0278,RC,,,,both,,,1397.55,908.41,,,,,,,,,,,,,
CAPSULE ENDOSCP INGESTIBLE CAM FOR SM BWL NS DISP PILLCAM SB,SUP-2905445,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1870.81,1216.03,,,,,,,,,,,,,
MESH HERN DIA6IN CIR W/ ECHO PS POS SYS VENTRALIGHT ST,SUP-2125915,CDM,C1781,HCPCS,0278,RC,,,,both,,,2336.16,1518.50,,,,,,,,,,,,,
CHOLANGIOGRAM KIT RX AUTOTOME UTOM XL SPHINTOM JAGWIRE 7553,SUP-2525335,CDM,C1769,HCPCS,0272,RC,,,,both,,,715.48,465.06,,,,,,,,,,,,,
CATHETER THROMCTMY ANGIOJET ULTRA SPIROFLEX VG L 135 CM DIA,SUP-2142036,CDM,C1757,HCPCS,0272,RC,,,,both,,,6123.00,3979.95,,,,,,,,,,,,,
SPLINT IM M W4MM TI ALLOY MATRIXRIB,SUP-2181513,CDM,C1713,HCPCS,0278,RC,,,,both,,,2220.77,1443.50,,,,,,,,,,,,,
SET INTRO OD7GA VISILOC FOR ENCOR MRI PRB,SUP-2126857,CDM,C1894,HCPCS,0272,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
SHEATH INTRO FLX RAABE L 55 CM OD 4 FR GUIDEWIRE 0.035 IN,SUP-2633282,CDM,C1894,HCPCS,0272,RC,,,,both,,,125.47,81.56,,,,,,,,,,,,,
ALLOGRAFT BNE PTTY + 10 CC DBM,SUP-2632267,CDM,C1713,HCPCS,0278,RC,,,,both,,,3925.00,2551.25,,,,,,,,,,,,,
HC Cltx Medial Ankle Fx,PX-4502776000,CDM,27760,CPT,0450,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
ELECTRODE SUBDERM NDL L 12.5 MM 4 CHANNEL PRASS PR SM HUB,SUP-2901947,CDM,2720000010,LOCAL,0272,RC,,,,both,,,610.13,396.58,,,,,,,,,,,,,
TAP SURG L16MM CANN DIL BIO-COMPRESSION,SUP-2121894,CDM,2720000010,LOCAL,0272,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
HOOK MRK L FOR M8 SPNL SYS CDH,SUP-2293464,CDM,A4648,CPT,0278,RC,,,,both,,,427.17,277.66,,,,,,,,,,,,,
GUIDEWIRE ORTH L46CM DIA3.2MM S STL DISP,SUP-2412675,CDM,C1769,HCPCS,0272,RC,,,,both,,,351.68,228.59,,,,,,,,,,,,,
PLATE SPNL L8-14MM 4 H LAT FULL CVR FOR MOD FIX SYS,SUP-2415816,CDM,C1713,HCPCS,0278,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY L 80 CM DIA 5 FR SPC 2-5-2 MM A,SUP-2248647,CDM,C1730,HCPCS,0272,RC,,,,both,,,2157.18,1402.17,,,,,,,,,,,,,
HC Veeg by Tech 2-12 Hr Cont R-T Monitoring,PX-7409571300,CDM,95713,CPT,0740,RC,,,,outpatient,,,4222.00,2744.30,,,,,,,,,,,,,
INTRODUCER ENDOSCP KIT 20 FR MIC-KEY G,SUP-2236585,CDM,2720000010,LOCAL,0272,RC,,,,both,,,758.59,493.08,,,,,,,,,,,,,
BUR SURG DIA22 MM HUB I DIAMOND CUT DISK STRL DISP HI-LINE,SUP-2929561,CDM,2720000010,LOCAL,0272,RC,,,,both,,,979.65,636.77,,,,,,,,,,,,,
GRAFT BNE 20 CC CRUSH FD CANC,SUP-2684089,CDM,C1713,HCPCS,0278,RC,,,,both,,,3249.90,2112.43,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 15 CM DIA 6 MM EPTFE STR TW N RING,SUP-2396337,CDM,C1768,CPT,0278,RC,,,,both,,,1218.32,791.91,,,,,,,,,,,,,
PLATE STRNL CLOSURE 8 H TI X WIDE NS STERNALOCK BLU,SUP-2894439,CDM,C1713,HCPCS,0278,RC,,,,both,,,1971.92,1281.75,,,,,,,,,,,,,
COMPONENT ARTC BUTTON 30X7 MM PATELLAR,SUP-2123681,CDM,C1776,CPT,0278,RC,,,,both,,,2160.32,1404.21,,,,,,,,,,,,,
HC Inj Anes/Steroid C/D Facet Sg,PX-3616449000,CDM,64490,CPT,0361,RC,,,,outpatient,,,4864.00,3161.60,,,,,,,,,,,,,
DISSECTOR ENDOSCP L21CM TIP CURVATURE 40DEG FN CRV JAW VES,SUP-2172419,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1599.45,1039.64,,,,,,,,,,,,,
IMPLANT PENILE 18CM CYL INFL MINOCYCLINE RIFAMPIN INHIBIZONE,SUP-2140280,CDM,C1813,HCPCS,0278,RC,,,,both,,,15527.30,10092.74,,,,,,,,,,,,,
GRAFT BNE SUB 10CC 4-7MM CONT DBM PTTY CANC CHIP CUST,SUP-2399141,CDM,C9359,HCPCS,0278,RC,,,,both,,,5341.77,3472.15,,,,,,,,,,,,,
SHEATH UROLOGICAL 1 STP TROCAR L 20 CM L 17 CM CATH 14 FR,SUP-2835964,CDM,C1894,HCPCS,0272,RC,,,,both,,,390.93,254.10,,,,,,,,,,,,,
RAIL INT FIX COMP SPANNING TEMPFIX,SUP-2487359,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7285.55,4735.61,,,,,,,,,,,,,
HC Ot Aquatic Therapeutic Exer 15 Mn,PX-4309711300,CDM,97113,CPT,0430,RC,,,,outpatient,,,150.00,97.50,,,,,,,,,,,,,
PLATE BNE W10XL58MM THK3.3MM HK D15MM 6 H R CLAV S STL LOK,SUP-2185830,CDM,C1713,HCPCS,0278,RC,,,,both,,,2353.49,1529.77,,,,,,,,,,,,,
PLATE BNE H1MM BAR L8MM 6 H MAND BLU TI MINI STR LOK,SUP-2366343,CDM,C1713,HCPCS,0278,RC,,,,both,,,717.18,466.17,,,,,,,,,,,,,
SYSTEM REPAIR MENISCAL AIR+ CURVED DOWN,SUP-2749431,CDM,C1713,HCPCS,0278,RC,,,,both,,,1361.19,884.77,,,,,,,,,,,,,
LINER KT WLK BOOT VENTURE AIR TALL M,SUP-2151042,CDM,L4386,HCPCS,0274,RC,,,,both,,,67.51,43.88,,,,,,,,,,,,,
CALCITONIN (SALMON) 200 UNIT/ACT NA SOLN,RX-15738,CDM,6370000000,HCPCS,0637,RC,60505-0823-06,NDC,,both,3.7,ML,430.50,279.82,,,,,,,,,,,,,
PLATE BNE L 242 X W 10.2 MM THK 2.8 MM SCREW DIA 3.5 MM 22 HL,SUP-2936834,CDM,C1713,HCPCS,0278,RC,,,,both,,,3923.74,2550.43,,,,,,,,,,,,,
CABLE RIB GUIDE NS ADVANTAGERIB,SUP-2908964,CDM,C1713,HCPCS,0278,RC,,,,both,,,722.20,469.43,,,,,,,,,,,,,
STAPLER INT BRTRC REINF LN FOR PROX TCT 75 TLC 55 BIODESIGN,SUP-2863654,CDM,C1763,HCPCS,0278,RC,,,,both,,,540.71,351.46,,,,,,,,,,,,,
SONICPIN RX 21 X 9MM 2/CTG,SUP-2669329,CDM,C1713,HCPCS,0278,RC,,,,both,,,268.94,174.81,,,,,,,,,,,,,
CARBON FT PLT LNG 180MM FOR RNG FIX SYS,SUP-2365271,CDM,C1713,HCPCS,0278,RC,,,,both,,,2515.14,1634.84,,,,,,,,,,,,,
GRAFT VASC IMPRA L 80 CM DIA 6 MM EPTFE CENTERFLEX RING HEMO,SUP-2761406,CDM,C1768,CPT,0278,RC,,,,both,,,3480.82,2262.53,,,,,,,,,,,,,
PLATE BONE SHFT L428MM BLDE L60MM THK4.8MM 95DEG 26 H BILAT,SUP-2185471,CDM,C1713,HCPCS,0278,RC,,,,both,,,3939.26,2560.52,,,,,,,,,,,,,
GRAFT BONE SUB 3ML DEMIN BONE MTRX PUTTY GRFTON,SUP-2281669,CDM,C9359,HCPCS,0278,RC,,,,both,,,1868.93,1214.80,,,,,,,,,,,,,
STEMLESS HUMERAL COMP INTEGRIP CAGE SIZE 1,SUP-2512429,CDM,C1776,CPT,0278,RC,,,,both,,,11932.00,7755.80,,,,,,,,,,,,,
SUTURE FIBERSNARE 2 L26IN NONABSORBABLE GRN L12IN FIBERWIRE AR7209SN,SUP-2122084,CDM,C1713,HCPCS,0278,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
MESH HERN SM DIA4.3CM VENTRAL POLYPR EPTFE CIR SELF EXP,SUP-2125719,CDM,C1781,HCPCS,0278,RC,,,,both,,,1501.86,976.21,,,,,,,,,,,,,
INTRODUCER SHTH MARKER TIP 6 FRX23 CM GRN PRELUDE,SUP-2467843,CDM,C1894,HCPCS,0272,RC,,,,both,,,81.48,52.96,,,,,,,,,,,,,
MATRIXNEURO EMER SCR 1.8 MM ST LEN 5 MM TI ALLOY TAN PK OF,SUP-2181602,CDM,C1713,HCPCS,0278,RC,,,,both,,,34.35,22.33,,,,,,,,,,,,,
GUIDE WIRE SLEEVE PERC PINNING 1.6MM,SUP-2841337,CDM,C1769,HCPCS,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
CATHETER GUID FUBUKI L 120 CM DIA 0.043 IN COAT L 105 CM,SUP-2858325,CDM,C1887,HCPCS,0272,RC,,,,both,,,6280.00,4082.00,,,,,,,,,,,,,
COMPONENT ARTC SURF 5-6 17 MM KNEE NXGN LEG,SUP-2201195,CDM,C1776,CPT,0278,RC,,,,both,,,2476.99,1610.04,,,,,,,,,,,,,
BRACE ORTH 2X UPR ELBW CUF EO,SUP-2388190,CDM,L3720,HCPCS,0274,RC,,,,both,,,1683.35,1094.18,,,,,,,,,,,,,
CONNECTOR SPINE 5.5/6.35MM L30MM ANT IL S STL ASSEMB FIX,SUP-2286992,CDM,C1713,HCPCS,0278,RC,,,,both,,,2343.07,1523.00,,,,,,,,,,,,,
CATHETER OCCL 12FR 50ML BLLN AORT S STL STYL DBL LUMN,SUP-2264227,CDM,C2628,HCPCS,0272,RC,,,,both,,,907.46,589.85,,,,,,,,,,,,,
PLATE BNE W175XL247MM THK52MM 13 H ST BILAT S STL BROAD CRV,SUP-2185302,CDM,C1713,HCPCS,0278,RC,,,,both,,,2233.29,1451.64,,,,,,,,,,,,,
CATHETER NEPHROSTOMY SET 12 FRX19.5 CM COPE LOOP,SUP-2835683,CDM,C1729,HCPCS,0272,RC,,,,both,,,571.98,371.79,,,,,,,,,,,,,
KIT INT FIX DIA29MM INCL DRL GUID AND GUID PIN DISPOSABLE,SUP-2136137,CDM,2720000010,LOCAL,0272,RC,,,,both,,,685.78,445.76,,,,,,,,,,,,,
ANCHOR SUT RIGIDLOOP FIXED 35MM,SUP-2749351,CDM,C1713,HCPCS,0278,RC,,,,both,,,2307.90,1500.13,,,,,,,,,,,,,
ALLOGRAFT HUMAN TISS AXIOFILL 1000MG,SUP-2865150,CDM,C1762,CPT,0278,RC,,,,both,,,8192.26,5324.97,,,,,,,,,,,,,
VALVE CSF PROGRAMMABLE SM IN-LINE UNITZ BACTISEAL CERTAS +,SUP-2666579,CDM,C1889,HCPCS,0278,RC,,,,both,,,14067.80,9144.07,,,,,,,,,,,,,
CLASSIC COILED 3 CM DISTANCE CUFFS 42 CM INFANT,SUP-2700449,CDM,C1750,HCPCS,0278,RC,,,,both,,,687.66,446.98,,,,,,,,,,,,,
BUR SURG LNG WAVED SPRL FOR CRANIOTOME HNDPC STRL DISP,SUP-2937208,CDM,2720000010,LOCAL,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
BUR SURG SYMTRC 6 MM 7.5 CM FOR DISECT TOOL MIDAS REX LEGEND,SUP-2630552,CDM,2720000010,LOCAL,0272,RC,,,,both,,,464.56,301.96,,,,,,,,,,,,,
PLATE BNE RECON LG 2-2.3X2.8 MM RT PRESHAPED SMRT TI NS,SUP-2481226,CDM,C1713,HCPCS,0278,RC,,,,both,,,10230.87,6650.07,,,,,,,,,,,,,
KIT FIX ANK STRL,SUP-2316326,CDM,C1713,HCPCS,0278,RC,,,,both,,,12101.56,7866.01,,,,,,,,,,,,,
GRAFT HUM TISS ACHILLES TEND 160 MM W/ STRUT FRZN ASEP,SUP-2264580,CDM,C1713,HCPCS,0278,RC,,,,both,,,7222.00,4694.30,,,,,,,,,,,,,
WIRE FIX OLV 2.4 MM THRD STRL STRATUM RS LTX DISP,SUP-2862182,CDM,2720000010,LOCAL,0272,RC,,,,both,,,329.89,214.43,,,,,,,,,,,,,
IMPLANT HUMAN TSSUE W96XH104 228XL193MM ACLLLR DRML TSSUE,SUP-2680187,CDM,Q4116,HCPCS,0636,RC,,,,both,,,14732.88,9576.37,,,,,,,,,,,,,
MESH SURG POLYPR VENTRAL CIR 12.5CM 12.5CM 11.4CM,SUP-2265974,CDM,C1781,HCPCS,0278,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
IMPLANT HUM TISS L 3 X W 2 CM AMNIO MEMBRN FLX MULTLYR,SUP-2905526,CDM,C1762,CPT,0278,RC,,,,both,,,3972.10,2581.86,,,,,,,,,,,,,
BRACE ORTH SAGITAL LUMBAR CTRL PREFABRICATED LSO,SUP-2388147,CDM,L0627,HCPCS,0274,RC,,,,both,,,1058.59,688.08,,,,,,,,,,,,,
BAR EXT FIX 128 X 210 MM CARBON KICKSTAND NS DISP MONK BARS,SUP-2909119,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4136.17,2688.51,,,,,,,,,,,,,
IMPLANT ANTIREFLX 16 BEAD GASTROESOPHAGEAL TI MAG LINX,SUP-2388510,CDM,C1889,HCPCS,0278,RC,,,,both,,,17270.00,11225.50,,,,,,,,,,,,,
SLEEVE DRL L200MM DIA8/5MM FOR LAT ENTRY FEM NAIL RECON-EX,SUP-2178860,CDM,2720000010,LOCAL,0272,RC,,,,both,,,861.33,559.86,,,,,,,,,,,,,
POST EXT FIX CIR FEMALE 3 HOLE,SUP-2400677,CDM,2720000010,LOCAL,0272,RC,,,,both,,,395.95,257.37,,,,,,,,,,,,,
COIL EMB L5CM PRI DIA0.02IN 2ND DIA3MM COMPLX STD FRME L,SUP-2323652,CDM,C1889,HCPCS,0278,RC,,,,both,,,2480.60,1612.39,,,,,,,,,,,,,
PENICILLIN V POTASSIUM 250 MG/5ML PO SOLR,RX-6091,CDM,340b,HCPCS,0637,RC,09999-9914-33,NDC,,both,5,ML,2.70,1.75,,,,,,,,,,,,,
INSULIN LISPRO 100 UNIT/ML IJ SOLN,RX-157657,CDM,J1815,HCPCS,0637,RC,00002-7510-01,NDC,,both,10,ML,53.20,34.58,,,,,,,,,,,,,
BIT DRL DIA22MM REUSE LINDERMANN,SUP-2367598,CDM,2720000010,LOCAL,0272,RC,,,,both,,,415.17,269.86,,,,,,,,,,,,,
INTRODUCER IV CATH NEOMAGIC CATH 1.9/2 FR VEN BRKWY NDL,SUP-2874176,CDM,C1894,HCPCS,0272,RC,,,,both,,,108.33,70.41,,,,,,,,,,,,,
STENT URET 45FR L22CM POLYMER HYDRPHLC OPN TIP RADPQ MRK,SUP-2313776,CDM,C2617,HCPCS,0278,RC,,,,both,,,376.42,244.67,,,,,,,,,,,,,
CAFFEINE CITRATE 20 MG/ML SYRINGE (PED-NEO),RX-4090401,CDM,J0706,HCPCS,0636,RC,63323-0407-03,NDC,,both,3,ML,179.10,116.41,,,,,,,,,,,,,
CATHETER PICC DIA 4 FR MAX POLY DUAL LUM PICC,SUP-2913462,CDM,C1751,HCPCS,0278,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
ROD SPNL L50MM DIA5.5MM THORACOLUMBOSACRAL TI PREBENT CDH,SUP-2290741,CDM,C1713,HCPCS,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
GRAFT VSCLR L W51XL152CM KNTTD DBLE VLR FBRC HMSHLD,SUP-2467001,CDM,C1768,CPT,0278,RC,,,,both,,,1077.30,700.24,,,,,,,,,,,,,
SCREW BONE SELF TPPNG 2.7X58 MM CRTCL SM HEX STNLSS STEEL,SUP-2491101,CDM,C1713,HCPCS,0278,RC,,,,both,,,66.25,43.06,,,,,,,,,,,,,
ESTROGENS CONJUGATED 0.625 MG PO TABS,RX-9974,CDM,6370000000,HCPCS,0637,RC,00046-1102-81,NDC,,both,1,UN,31.90,20.73,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 50 CM DIA 7 MM STR STD WALL REINF,SUP-2525435,CDM,C1768,CPT,0278,RC,,,,both,,,866.99,563.54,,,,,,,,,,,,,
HC So Tiss Trnsgltmnase Ea Ig Clas,PX-3028636400,CDM,86364,CPT,0302,RC,,,,both,,,62.00,40.30,,,,,,,,,,,,,
CLAMP REPROC ROD ROD HII MRI 8X8MM,SUP-2678696,CDM,2720000010,LOCAL,0272,RC,,,,both,,,623.16,405.05,,,,,,,,,,,,,
TEMPLATE SURG SM W6XL16MM 0DEG IM CHT FIX SYS ANG SZ NIT,SUP-2194206,CDM,C1776,CPT,0278,RC,,,,both,,,3799.40,2469.61,,,,,,,,,,,,,
GUIDEWIRE VASC KATZN L 180 CM TIP L 12 CM DIA 0.035 IN SS,SUP-2148181,CDM,C1769,HCPCS,0272,RC,,,,both,,,370.65,240.92,,,,,,,,,,,,,
ANCHOR SFT TISS FIBERWIRE SZ 2-0 SUTURE POLYESTER STR RC NS,SUP-2882258,CDM,C1713,HCPCS,0278,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
SIZER VLV SZ 31/33/35 MM LG AORT 2 KT DISP AVNEO,SUP-2895324,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3749.16,2436.95,,,,,,,,,,,,,
KIT HARV VES VASOVIEW HEMOPRO 2 W VASOSHIELD PRSS,SUP-2227761,CDM,C1713,HCPCS,0278,RC,,,,both,,,4021.15,2613.75,,,,,,,,,,,,,
SYSTEM BONE REPL 5G QUICKSET MIMIX,SUP-2402960,CDM,C1713,HCPCS,0278,RC,,,,both,,,2047.28,1330.73,,,,,,,,,,,,,
SUPPORT ORTHOT HIP CUST ABDUCTN FLX FREJKA CVR ONLY,SUP-2435596,CDM,L1610,HCPCS,0274,RC,,,,both,,,154.96,100.72,,,,,,,,,,,,,
KIT HAD CATHETER 12FR L20CM 2 LUMN ACUTE STR EXTN 2 SEAL CAP,SUP-2283957,CDM,C1752,HCPCS,0278,RC,,,,both,,,161.33,104.86,,,,,,,,,,,,,
BRACE ORTH SZ M 5 TO 7 WOM 6 TO 8 SM WLK LOEST PROF X LO,SUP-2195484,CDM,L4386,HCPCS,0274,RC,,,,both,,,221.84,144.20,,,,,,,,,,,,,
PLATE BNE L21MM THK0.4MM 20 H CRANIOMAXILLOFACIAL BILAT BLU,SUP-2181565,CDM,C1713,HCPCS,0278,RC,,,,both,,,1710.67,1111.94,,,,,,,,,,,,,
HC Ther Speech Genrating Device Prgrmg&Modification,PX-4409260900,CDM,92609,CPT,0440,RC,,,,both,,,410.00,266.50,,,,,,,,,,,,,
PLATE CRAN SM TI PT SPEC NS DISP ACCUSHAPE,SUP-2936590,CDM,C1713,HCPCS,0278,RC,,,,both,,,56648.74,36821.68,,,,,,,,,,,,,
COIL EMB COMPLX 2 MMX6 CM ORBIT GALAXY XTRASOFT,SUP-2427736,CDM,C1713,HCPCS,0278,RC,,,,both,,,5700.26,3705.17,,,,,,,,,,,,,
CABLE ORTH DIA2MM HIP CO CHROM FOR GRP PLT ACCORD,SUP-2345212,CDM,C1776,CPT,0278,RC,,,,both,,,743.55,483.31,,,,,,,,,,,,,
GENERATOR NEUROSTIMULATOR 386CUCM H198XL263IN THK053IN,SUP-2356747,CDM,C1767,HCPCS,0278,RC,,,,both,,,50240.00,32656.00,,,,,,,,,,,,,
CATHETER PERITONEAL DLYS STD 13X25 MMX90CM BA IMPREG TRNSLUC,SUP-2277946,CDM,C1729,HCPCS,0272,RC,,,,both,,,394.26,256.27,,,,,,,,,,,,,
SUPPORT ORTHOT HIP CUST ABDUCTN CTRL SEMI FLX,SUP-2435597,CDM,L1630,HCPCS,0272,RC,,,,both,,,598.11,388.77,,,,,,,,,,,,,
TUBE TYMPANOSTOMY DIA1.02 MM INNR FLANGE DIA2.5 MM MICROGEL,SUP-2901932,CDM,L8699,HCPCS,0278,RC,,,,both,,,79.35,51.58,,,,,,,,,,,,,
SET SHTH DESTINO REACH L 75 CM DIA12 FR CRV BEND 22 MM DIL,SUP-2616170,CDM,C1766,CPT,0272,RC,,,,both,,,2433.50,1581.77,,,,,,,,,,,,,
ADAPTER UPLR FEM 12 14 TAPR +0MM OFFSET SOLITUDE,SUP-2314488,CDM,C1776,CPT,0278,RC,,,,both,,,238.64,155.12,,,,,,,,,,,,,
STEM FEM SZ 20 L190MM 131DEG HIP CO CHROM POR STD CLLR STR,SUP-2345222,CDM,C1776,CPT,0278,RC,,,,both,,,19389.50,12603.17,,,,,,,,,,,,,
STAPLE BNE FIX 08X10X10MM NITINEX,SUP-2392910,CDM,C1713,HCPCS,0278,RC,,,,both,,,8352.40,5429.06,,,,,,,,,,,,,
CATHETER VENTRICULAR STYL 15 CM W/ CM MRK HOLTER,SUP-2666803,CDM,C1729,HCPCS,0272,RC,,,,both,,,513.58,333.83,,,,,,,,,,,,,
SCREW BONE L140MM OD6.5MM THRD L32MM STD S STL CANC ST,SUP-2371170,CDM,C1713,HCPCS,0278,RC,,,,both,,,127.48,82.86,,,,,,,,,,,,,
GRAFT HUM TISS NONBONE SEMITENDINOSUS TEND SGL STRND FRZN,SUP-2165607,CDM,C1762,CPT,0278,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
GRAFT BONE SUB W7XH35XL25MM 7DEG B TRICALCIUM PHOS GRAN,SUP-2194024,CDM,C1713,HCPCS,0278,RC,,,,both,,,3639.89,2365.93,,,,,,,,,,,,,
PLATE BNE THK1.5MM 4 H CRANIOMAXILLOFACIAL G FRAC ANG W/,SUP-2366367,CDM,C1713,HCPCS,0278,RC,,,,both,,,1193.33,775.66,,,,,,,,,,,,,
SPACER TIB CONCV 14 MM UNI M/G,SUP-2437230,CDM,C1776,CPT,0278,RC,,,,both,,,1215.18,789.87,,,,,,,,,,,,,
IMPLANT HUM TISS W2XL4CM PROC DERM CLLGN RECTANG ALLOMAX,SUP-2125851,CDM,C1781,HCPCS,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
CATHETER PERITONEAL DLYS 15 FRX64 CM UPPER ABD SET X-SERIES,SUP-2267007,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1318.80,857.22,,,,,,,,,,,,,
CATHETER BILI L40CM DIA5FR 0.4ML BLLN PRB FGRTY ORDER MULT OF 5 EA,SUP-2214137,CDM,C1726,HCPCS,0272,RC,,,,both,,,270.86,176.06,,,,,,,,,,,,,
PLATE BNE L 51 X W 19.94 MM THK 0.6 MM SCREW DIA1.5 MM SM TI,SUP-2936520,CDM,C1713,HCPCS,0278,RC,,,,both,,,2609.34,1696.07,,,,,,,,,,,,,
HC Capsule Endoscopy,PX-3609019000,CDM,3609019000,LOCAL,0750,RC,,,,both,,,3214.00,2089.10,,,,,,,,,,,,,
GRAFT DWL PRECIS MACHINED ALLGRFT MAJ DIAM 5.5MM,SUP-2309708,CDM,C1713,HCPCS,0278,RC,,,,both,,,6672.50,4337.12,,,,,,,,,,,,,
SEED BRACHYTHERAPY STRND,SUP-2247310,CDM,C2642,HCPCS,0278,RC,,,,both,,,226.08,146.95,,,,,,,,,,,,,
DISTRACTOR EXT FIX 25 MM 1-1.2 MM 9 HOLE MID DRIVEN RATCH,SUP-2467477,CDM,C1713,HCPCS,0278,RC,,,,both,,,18129.67,11784.29,,,,,,,,,,,,,
DEVICE DCOMPR SM EXP POST FUS COR AILERON,SUP-2264536,CDM,2780000010,LOCAL,0278,RC,,,,both,,,9420.00,6123.00,,,,,,,,,,,,,
SCREW BONE L100MM DIA9.5MM THRD L12.7MM S STL INTERMED LAG,SUP-2343609,CDM,C1713,HCPCS,0278,RC,,,,both,,,691.40,449.41,,,,,,,,,,,,,
STEM FEM L140MM OD8MM CO CHROM HIP TAPR NEUT PRI CEM INTLOK,SUP-2136440,CDM,C1776,CPT,0278,RC,,,,both,,,5582.92,3628.90,,,,,,,,,,,,,
TUBE INNR EAR MYR VENT REUT BOB W/O FLNG H 1.14 MM ID,SUP-2312591,CDM,L8699,HCPCS,0278,RC,,,,both,,,21.95,14.27,,,,,,,,,,,,,
CORD ELECSURG BPLR RESECT NS FORCETRIAD LTX,SUP-2862411,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1281.12,832.73,,,,,,,,,,,,,
BRACE KNEE RT L ORTHOPRO HYPEREX,SUP-2324014,CDM,L1810,HCPCS,0274,RC,,,,both,,,277.04,180.08,,,,,,,,,,,,,
ANCHOR SUTURE DIA 5.5 MM TAPE 1.4 MM BIOCOMP 3 STRND XBRAID,SUP-2908777,CDM,C1713,HCPCS,0278,RC,,,,both,,,1375.32,893.96,,,,,,,,,,,,,
AUGMENTED CAGE LEFT LARGE,SUP-2512450,CDM,C1776,CPT,0278,RC,,,,both,,,5913.25,3843.61,,,,,,,,,,,,,
BAG COLL 700ML REPL W/ ANTI REFLX VLV FOR ACCU DRN EXT CSF,SUP-2898725,CDM,C1729,HCPCS,0272,RC,,,,both,,,101.20,65.78,,,,,,,,,,,,,
VALVE HEMOSTAS DBL PLAY LUMEN DIA 9 FR POLYCARB TORQUE DEV,SUP-2303046,CDM,C1713,HCPCS,0278,RC,,,,both,,,57.71,37.51,,,,,,,,,,,,,
CUP SUCT ACET STR HNDL DISP TRIL IT,SUP-2204133,CDM,C1776,CPT,0278,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
PIN SELF DRILL HALF DIA 6MM 150X40MM,SUP-2703127,CDM,C1713,HCPCS,0278,RC,,,,both,,,794.11,516.17,,,,,,,,,,,,,
GRAFT VASC STR 6 MMX20 CM STD WALL N RING EPTFE CARBOFLO,SUP-2761252,CDM,C1768,CPT,0278,RC,,,,both,,,903.66,587.38,,,,,,,,,,,,,
PROBE DOPPLER INTOP FLO CPLR,SUP-2900198,CDM,2720000010,LOCAL,0272,RC,,,,both,,,675.10,438.81,,,,,,,,,,,,,
SCREW BNE 2.1X5 MM PDLLA STRL RESORB RX 520242504,SUP-2497382,CDM,C1713,HCPCS,0278,RC,,,,both,,,217.29,141.24,,,,,,,,,,,,,
SCREW BONE L10MM DIA1.5MM STD CORT TI NCANNULATED N ST N,SUP-2188915,CDM,C1713,HCPCS,0278,RC,,,,both,,,94.92,61.70,,,,,,,,,,,,,
SHEATH INTRO SOLOPATH WORKING L 35 CM EXPANDABLE L 30CM 21FR,SUP-2385699,CDM,C1894,HCPCS,0272,RC,,,,both,,,2119.50,1377.67,,,,,,,,,,,,,
SPHERE EMB VI ACRYL GEL 500-700 MIC 2ML 5ML SYR N,SUP-2303495,CDM,C1889,HCPCS,0278,RC,,,,both,,,759.25,493.51,,,,,,,,,,,,,
ENDOPROSTHESIS VASC VIABAHN VBX L 15 MM 5/8 MM 80 CM 7 FR,SUP-2395634,CDM,C1874,HCPCS,0278,RC,,,,both,,,7601.94,4941.26,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA PLU MAXBARR 4FR S1274108D3,SUP-2632801,CDM,C1751,HCPCS,0278,RC,,,,both,,,1059.75,688.84,,,,,,,,,,,,,
FIBER LASER 200 MH HOLM SU200TRUE] FORTEC MEDICAL INC],SUP-2225719,CDM,2720000010,LOCAL,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
HC So1 Fta-Abs,PX-3028678067,CDM,86780,CPT,0302,RC,,,,both,,,72.00,46.80,,,,,,,,,,,,,
KIT HAD 14.5FR CATH L29CM INSRT L24CM LNG TERM ALPHACURVE,SUP-2127866,CDM,C1750,HCPCS,0278,RC,,,,both,,,1470.46,955.80,,,,,,,,,,,,,
PIN EXTERNAL FIXATION HALF 6X20 MM ARROW STAINLESS STEEL JET,SUP-2836754,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1766.56,1148.26,,,,,,,,,,,,,
HC Cbc,PX-3058502500,CDM,85025,CPT,0305,RC,,,,both,,,180.00,117.00,,,,,,,,,,,,,
VALVE SHUNT ADJ W/ BURR HOLE RESERVOIR POLARIS SPVA] KIRWAN SURGICAL PRODUCTS],SUP-2262474,CDM,C1889,HCPCS,0278,RC,,,,both,,,7284.80,4735.12,,,,,,,,,,,,,
SCREW ORTH FOR POLY LNR REMOVAL STRL DISP G7,SUP-2887697,CDM,2720000010,LOCAL,0272,RC,,,,both,,,649.98,422.49,,,,,,,,,,,,,
CATHETER HD 14 FRX24 CM ASH SPLIT CATH,SUP-2269497,CDM,C1750,HCPCS,0278,RC,,,,both,,,1193.20,775.58,,,,,,,,,,,,,
SLEEVE CBL M VIT FOR USE W/ 2MM CBL DALL-M,SUP-2377578,CDM,C1776,CPT,0278,RC,,,,both,,,453.42,294.72,,,,,,,,,,,,,
ANCHOR SUTURE DIA 4.75 MM TAPE 1.8/1.4 MM PEEK NONSLIDING,SUP-2882659,CDM,C1713,HCPCS,0278,RC,,,,both,,,2785.18,1810.37,,,,,,,,,,,,,
PLATE BNE L151MM THK3.8MM 9 H BILAT S STL NAR DYN COMPR FOR,SUP-2185209,CDM,C1713,HCPCS,0278,RC,,,,both,,,1507.01,979.56,,,,,,,,,,,,,
SCREW BNE NLCK 4.5X30 MM DBL STRT THRD STRL JPS LTX,SUP-2875290,CDM,C1713,HCPCS,0278,RC,,,,both,,,1411.27,917.33,,,,,,,,,,,,,
GRAFT CORNEAL PROC FEE,SUP-2164746,CDM,V2785,HCPCS,0278,RC,,,,both,,,10048.00,6531.20,,,,,,,,,,,,,
INSERT TIB ULT CONG L 22MM SZ A NAT KNEE,SUP-2209475,CDM,C1776,CPT,0278,RC,,,,both,,,5903.20,3837.08,,,,,,,,,,,,,
GRAFT HUM TISS 7X14X11MM CANC SPCR BLK BNE MECH GIC58,SUP-2293807,CDM,C1713,HCPCS,0278,RC,,,,both,,,2496.30,1622.59,,,,,,,,,,,,,
CATHETER EP DIAG VIK DAMATO CRV 2MM QPLR POLES 6FR 115CM,SUP-2142574,CDM,C1730,HCPCS,0272,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
CATHETER CV SET 018 4 FRX12 CM DL J TIP RIFAMPIN SPECTRUM,SUP-2759852,CDM,C1751,HCPCS,0278,RC,,,,both,,,333.66,216.88,,,,,,,,,,,,,
HC So Q Fever Antibody,PX-3028663866,CDM,86638,CPT,0302,RC,,,,both,,,423.00,274.95,,,,,,,,,,,,,
KIT ART LN DIA20GA W/ SHRP SFTY,SUP-2383455,CDM,C1751,HCPCS,0278,RC,,,,both,,,183.38,119.20,,,,,,,,,,,,,
ALLOGRAFT BNE GEL 1 CC DBM BIO,SUP-2637041,CDM,C1713,HCPCS,0278,RC,,,,both,,,930.19,604.62,,,,,,,,,,,,,
CATHETER ABLATN LG 2-5-2 8 MM 7 FRX110 1304-7-25-L-TE8 THER,SUP-2538006,CDM,C1733,HCPCS,0272,RC,,,,both,,,2245.10,1459.31,,,,,,,,,,,,,
PLATE CRAN L 40.2 X W 24.8 MM THK 0.3 MM SCREW DIA1.5 MM TI,SUP-2937002,CDM,C1713,HCPCS,0278,RC,,,,both,,,2084.96,1355.22,,,,,,,,,,,,,
BOOT WLK L TALL VECTRA,SUP-2151014,CDM,L4360,HCPCS,0272,RC,,,,both,,,95.14,61.84,,,,,,,,,,,,,
SCREW SPNL RET DIA3.5MM THRD L16MM FOR TOT DISC REPL SYS 3820104] JNJ HEALTHCARE],SUP-2256931,CDM,C1713,HCPCS,0278,RC,,,,both,,,480.42,312.27,,,,,,,,,,,,,
CATHETER CV SINGLE LUMEN AD 4 FRX55 CM PWR INJ POWERPICC,SUP-2126703,CDM,C1751,HCPCS,0278,RC,,,,both,,,603.63,392.36,,,,,,,,,,,,,
PLATE BNE W17.5XL386MM THK5.2MM 18 H NONSTERILE L CNDYL FEM,SUP-2185051,CDM,C1713,HCPCS,0278,RC,,,,both,,,5101.37,3315.89,,,,,,,,,,,,,
GRAFT STRGHT STNDRD WALL NON RNGD PLSTR KNTTD RDLLY 6MM DIA,SUP-2466495,CDM,C1768,CPT,0278,RC,,,,both,,,2798.18,1818.82,,,,,,,,,,,,,
IMPLANT HUM TISS L 6 X W 2 CM PLCNTA MTRX MEMBRN DEHYDR ASEP,SUP-2905495,CDM,Q4184,HCPCS,0636,RC,,,,both,,,9420.00,6123.00,,,,,,,,,,,,,
BONE FEN PERF,SUP-2419192,CDM,2720000010,LOCAL,0272,RC,,,,both,,,648.41,421.47,,,,,,,,,,,,,
ANCHOR SUTURE 5.5 MM KNOTLESS HEALICOIL,SUP-2516501,CDM,C1713,HCPCS,0278,RC,,,,both,,,1532.85,996.35,,,,,,,,,,,,,
TUBE DCOMPR L48IN DIA16FR RADIOPQ OPQ RUB FUN END LEVIN,SUP-2127563,CDM,2720000010,LOCAL,0272,RC,,,,both,,,59.28,38.53,,,,,,,,,,,,,
STENT CORONARY SYNERGY L 8 MM DIA2.25 MM CATH L 144 CM DIA,SUP-2146136,CDM,C1874,HCPCS,0278,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
PLATE BNE L94MM 5 H ST R SUP ANT CLAV TI LOK COMPR W LAT,SUP-2180865,CDM,C1713,HCPCS,0278,RC,,,,both,,,3165.65,2057.67,,,,,,,,,,,,,
ANCHOR SUTURE 1-0 SHT 1.4X1 MM SINGLE LD BLK WHT JUGGERKNOT,SUP-2745511,CDM,C1776,CPT,0278,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
SCREW BNE L8MM DIA2MM CORT HND S STL ST NONLOCKING LO PROF,SUP-2183285,CDM,C1713,HCPCS,0278,RC,,,,both,,,111.00,72.15,,,,,,,,,,,,,
SCREW BNE L44MM OD45MM STD S STL CORT N ST NCANNULATED,SUP-2362351,CDM,C1713,HCPCS,0278,RC,,,,both,,,116.49,75.72,,,,,,,,,,,,,
BOOT WLK L TALL VECTRA,SUP-2151014,CDM,L4360,HCPCS,0274,RC,,,,both,,,95.14,61.84,,,,,,,,,,,,,
KIT BNE CEM ENH TOT HIP W/ CNL BRSH SUCT ABSORBER PRSSZR,SUP-2711612,CDM,C1776,CPT,0278,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
ANCHOR SUTURE 1.4 MM KT STRL GRAPPLER,SUP-2749836,CDM,C1713,HCPCS,0278,RC,,,,both,,,1591.98,1034.79,,,,,,,,,,,,,
SHEATH INTRO FLX RAABE L 55 CM OD 7 FR GUIDEWIRE 0.038 IN,SUP-2168675,CDM,C1894,HCPCS,0272,RC,,,,both,,,121.83,79.19,,,,,,,,,,,,,
GUIDEWIRE ORTH L3IN OD0.035IN,SUP-2319793,CDM,C1769,HCPCS,0272,RC,,,,both,,,62.80,40.82,,,,,,,,,,,,,
LIDOCAINE HCL URETHRAL/MUCOSAL 2 % EX PRSY,RX-147640,CDM,6370000000,HCPCS,0637,RC,25021-0673-77,NDC,,both,11,ML,28.60,18.59,,,,,,,,,,,,,
CONNECTOR SPNL PARA 6.5MM TO 6.5MM,SUP-2228083,CDM,C1713,HCPCS,0278,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
PLATE BNE FIBULAR RT LAT ANK 6 HOLE NS,SUP-2518402,CDM,C1713,HCPCS,0278,RC,,,,both,,,5388.24,3502.36,,,,,,,,,,,,,
BIT SURG DRL FOR POLY LNR REMOVAL STRL DISP G7,SUP-2887667,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1215.18,789.87,,,,,,,,,,,,,
DRILL SURG PILOT FOR NAVIGATED SI FUSION SYS RIALTO,SUP-2632154,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1646.77,1070.40,,,,,,,,,,,,,
CATHETER CV SET 018 4 FRX15 CM DL J TIP RIFAMPIN SPECTRUM,SUP-2759966,CDM,C1751,HCPCS,0278,RC,,,,both,,,348.48,226.51,,,,,,,,,,,,,
ROD SPNL DIA4.5MM 90MM ACTUATOR STD FOR BRACING AND,SUP-2312244,CDM,C1713,HCPCS,0278,RC,,,,both,,,54950.00,35717.50,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED INCRD MOTN ADD ON 1,SUP-2212531,CDM,C1776,CPT,0278,RC,,,,both,,,646.84,420.45,,,,,,,,,,,,,
DEXAMETHASONE 4 MG/ML IJ SOLN (MIXTURES ONLY),RX-4081237,CDM,J1100,HCPCS,0636,RC,63323-0165-01,NDC,,both,.5,ML,54.10,35.16,,,,,,,,,,,,,
PLATE FRACTURE 4H CRVD W/BAR 2MM,SUP-2740125,CDM,C1713,HCPCS,0278,RC,,,,both,,,1850.90,1203.08,,,,,,,,,,,,,
PLATE BNE L 201 MM SCREW DIA 4.5 MM 12 H COMPR LCK STRL EVOS,SUP-2933446,CDM,C1713,HCPCS,0278,RC,,,,both,,,3194.95,2076.72,,,,,,,,,,,,,
PROPRANOLOL HCL 1 MG/ML IV SOLN,RX-29335,CDM,J1800,HCPCS,0636,RC,63323-0604-01,NDC,,both,1,ML,66.10,42.96,,,,,,,,,,,,,
ALLOGRAFT BNE DWL 18X15+ MM PRESERVON MATRIGRAFT,SUP-2740899,CDM,C1762,CPT,0278,RC,,,,both,,,1712.59,1113.18,,,,,,,,,,,,,
CATHETER CV 1 LUMEN 0.018 IN 5 FRX60 CM 150 CM TURBO FLO,SUP-2170006,CDM,C1751,HCPCS,0278,RC,,,,both,,,320.75,208.49,,,,,,,,,,,,,
GRAFT STENT BIFUR 23X16X166 MM AAA ENDURANT II,SUP-2295202,CDM,C1768,CPT,0278,RC,,,,both,,,31321.50,20358.97,,,,,,,,,,,,,
CHOLECALCIFEROL 10 MCG (400 UNIT) PO TABS,RX-24559,CDM,6370000000,HCPCS,0637,RC,00904-5823-60,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
CATHETER CV KT 8.5 FRX20 CM 4 LUMEN PRESSURE INJ ARROWG+ARD,SUP-2763388,CDM,C1751,HCPCS,0278,RC,,,,both,,,526.89,342.48,,,,,,,,,,,,,
PROBE SUCT DIA2MM 60DEG BLK VULCAN ABLATOR-S DYONICS,SUP-2341618,CDM,C1713,HCPCS,0278,RC,,,,both,,,553.90,360.03,,,,,,,,,,,,,
PIN SELF DRILLING TIP 3.0X25X60MM,SUP-2480996,CDM,C1713,HCPCS,0278,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
HC Gerd Test W/Electrode (Bravo),PX-3604323500,CDM,3604323500,LOCAL,0750,RC,,,,both,,,2447.00,1590.55,,,,,,,,,,,,,
COIL EMB L10CM LOOP DIA5MM 0.035IN PLAT HYDRGEL POLYMER,SUP-2385373,CDM,C1889,HCPCS,0278,RC,,,,both,,,1083.30,704.14,,,,,,,,,,,,,
GRAFT VASC STD WALL 5 MMX70 CM STR RNG REINF ADVANTA VXT,SUP-2466490,CDM,C1768,CPT,0278,RC,,,,both,,,1705.52,1108.59,,,,,,,,,,,,,
STEM ULN HD 6.5 SM PART MOD REPL 1ST CHOICE,SUP-2610440,CDM,C1776,CPT,0278,RC,,,,both,,,11662.87,7580.87,,,,,,,,,,,,,
PLATE BONE LOK 79MML HLX6 STNLSS STEEL STRGHT RCNSTRCTN ST,SUP-2588598,CDM,C1713,HCPCS,0278,RC,,,,both,,,1364.33,886.81,,,,,,,,,,,,,
IMPLANT FACE W 57 X H 38 MM THK 9 MM PROJCT LG POLYETHYL,SUP-2883417,CDM,C1889,HCPCS,0278,RC,,,,both,,,1447.92,941.15,,,,,,,,,,,,,
ALLOGRAFT BNE FRZN ASEP RT PROX FEM W/ LIGMNT,SUP-2867031,CDM,C1762,CPT,0278,RC,,,,both,,,15437.03,10034.07,,,,,,,,,,,,,
BIT DRILL OD4MM CANNULATED,SUP-2878352,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1491.50,969.47,,,,,,,,,,,,,
INTRODUCER TUBE SET 80 FR PERC ADV SET CIAGLIA BLU RHINO,SUP-2759757,CDM,C1769,HCPCS,0272,RC,,,,both,,,1299.96,844.97,,,,,,,,,,,,,
SPLINT WRST L INSTABILITY INJ 8IN LOOP LOK W STAY FIRM SUPP,SUP-2276657,CDM,L3808,HCPCS,0274,RC,,,,both,,,16.23,10.55,,,,,,,,,,,,,
SCREW BNE L9MM DIA2.3MM CORT HND TI HEXALOBE MULTISCR,SUP-2106772,CDM,C1713,HCPCS,0278,RC,,,,both,,,367.38,238.80,,,,,,,,,,,,,
PLATE XR IMAGING 14X17 IN,SUP-2303642,CDM,C1713,HCPCS,0278,RC,,,,both,,,2072.40,1347.06,,,,,,,,,,,,,
PROBE NERVE STIM DIA1 MM MONOPOLAR BALL TIP STRL DISP,SUP-2901933,CDM,2720000010,LOCAL,0272,RC,,,,both,,,391.56,254.51,,,,,,,,,,,,,
DEXAMETHASONE 4 MG/ML IJ SOLN (MIXTURES ONLY),RX-4081237,CDM,J1100,HCPCS,0636,RC,63323-0165-30,NDC,,both,0.5,ML,54.10,35.16,,,,,,,,,,,,,
TRAY CATH HEMODIALYSI ZENYSI DL ACUTE 11FR DIA 24CM STRGHT 2,SUP-2613266,CDM,C1752,HCPCS,0278,RC,,,,both,,,814.05,529.13,,,,,,,,,,,,,
SCREW BNE FT 4X24 MM CANN STRL,SUP-2457840,CDM,C1713,HCPCS,0278,RC,,,,both,,,484.28,314.78,,,,,,,,,,,,,
BIT DRL DIA3.2MM PROX HUM CALIB DISP,SUP-2411559,CDM,2720000010,LOCAL,0272,RC,,,,both,,,678.24,440.86,,,,,,,,,,,,,
VLP TI 3.5MMX28MM LCK SCREW T15 S-T,SUP-2820373,CDM,C1713,HCPCS,0278,RC,,,,both,,,624.39,405.85,,,,,,,,,,,,,
CERTOLIZUMAB PEGOL 200 MG/ML SC PSKT,RX-167342,CDM,J0717,HCPCS,0636,RC,50474-0710-79,NDC,,both,1,UN,17698.40,11503.96,,,,,,,,,,,,,
WEDGE TIB SZ 3-4 10MM KNEE REV FULL STP LEGION,SUP-2346592,CDM,C1776,CPT,0278,RC,,,,both,,,4603.24,2992.11,,,,,,,,,,,,,
HC Antibody Rubella,PX-3028676200,CDM,86762,CPT,0302,RC,,,,both,,,137.00,89.05,,,,,,,,,,,,,
CATHETER CV DL 8 FRX16 CM FULL KT ARROWG+ARD BLU +,SUP-2383383,CDM,C1751,HCPCS,0278,RC,,,,both,,,239.90,155.93,,,,,,,,,,,,,
KIT SCR TORQ DEFINING,SUP-2223286,CDM,C1713,HCPCS,0278,RC,,,,both,,,1469.52,955.19,,,,,,,,,,,,,
PLATE BNE L90MM 4 H R POSTEROLATERAL DST FIBULAR S STL LOK,SUP-2177383,CDM,C1713,HCPCS,0278,RC,,,,both,,,1706.40,1109.16,,,,,,,,,,,,,
PLATE BONE L98MM 6 H RT ANTEROLATERAL MEDL DSTL TIB LCK FOR,SUP-2348481,CDM,C1713,HCPCS,0278,RC,,,,both,,,16888.96,10977.82,,,,,,,,,,,,,
HINGE COUPLING,SUP-2484255,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1153.01,749.46,,,,,,,,,,,,,
STENT COLON 0.035 IN 22-27X120 MM 10 FRX135 CM NIT WALLFLEX,SUP-2458673,CDM,C2617,HCPCS,0278,RC,,,,both,,,7968.44,5179.49,,,,,,,,,,,,,
CANNULA SRGCL 48MML TRNSBCCL STNDRD SMOOTH FTRCR SSTM,SUP-2680126,CDM,2720000010,LOCAL,0272,RC,,,,both,,,404.93,263.20,,,,,,,,,,,,,
GUIDEWIRE VASC L 260 CM DIA 0.014 IN ENDOVASC ANEUR REP TEDV,SUP-2217587,CDM,C1769,HCPCS,0272,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
CANNULA SURG PERC FOR 3/4MM SCREW,SUP-2483349,CDM,2720000010,LOCAL,0272,RC,,,,both,,,994.75,646.59,,,,,,,,,,,,,
SET THORCENT CATH 10.2FR L29CM 20 SIDEPRT TRCR WIRE GUID TO,SUP-2171160,CDM,C1729,HCPCS,0272,RC,,,,both,,,1173.70,762.90,,,,,,,,,,,,,
BUSHING FEM SM FOR DST FEM GMRS,SUP-2376514,CDM,C1776,CPT,0278,RC,,,,both,,,740.41,481.27,,,,,,,,,,,,,
PROBE ULTRASONIC LITHO 3.5X370MM RIG URETRON,SUP-2332894,CDM,C1713,HCPCS,0278,RC,,,,both,,,2227.36,1447.78,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL PEEK SD800.524,SUP-2860205,CDM,C1713,HCPCS,0278,RC,,,,both,,,33422.79,21724.81,,,,,,,,,,,,,
HC Inj Proc Elbow Arthrography,PX-3612422000,CDM,24220,CPT,0361,RC,,,,outpatient,,,3707.00,2409.55,,,,,,,,,,,,,
ELECTRODE KIT RF 2.5X10 CM COOL TIP,SUP-2174637,CDM,C1733,HCPCS,0272,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
PROFYLE/BONE SCREW 2.3X38MM S/T,SUP-2489044,CDM,C1713,HCPCS,0278,RC,,,,both,,,109.90,71.43,,,,,,,,,,,,,
PLATE BNE L59MM 12 H TI STR MOD HND SYS FOR 1.5MM SCR,SUP-2191108,CDM,C1713,HCPCS,0278,RC,,,,both,,,1109.99,721.49,,,,,,,,,,,,,
PLATE BNE 3.5X73 MM 6 HOLE SS DCP,SUP-2569138,CDM,C1713,HCPCS,0278,RC,,,,both,,,243.51,158.28,,,,,,,,,,,,,
PLATE BNE RECON 3.5X169 MM 13 HOLE W/ WIDE ANGLE STR LP NS,SUP-2799193,CDM,C1713,HCPCS,0278,RC,,,,both,,,1688.63,1097.61,,,,,,,,,,,,,
PLATE BNE STR 1.5X0.6 MM MIDFACE 24 HOLE W/ TAB TI STRL,SUP-2486413,CDM,C1713,HCPCS,0278,RC,,,,both,,,1141.70,742.10,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 3X200 MM FRZN GAM GRACILIS TEND,SUP-2866908,CDM,C1762,CPT,0278,RC,,,,both,,,1959.36,1273.58,,,,,,,,,,,,,
PLATE BONEXL THK2MM 6X24X6 H MAND TI DBL ANG LCKING FOR 2MM,SUP-2191277,CDM,C1713,HCPCS,0278,RC,,,,both,,,9912.98,6443.44,,,,,,,,,,,,,
STENT BILI PRECIS L 20 MM DIA 8 MM CATH L 135 CM DIA 6 FR,SUP-2158922,CDM,C1876,HCPCS,0278,RC,,,,both,,,5598.49,3639.02,,,,,,,,,,,,,
SHEATH DIL BYRD 10.4 FR TELSCP SS,SUP-2638738,CDM,C1893,HCPCS,0272,RC,,,,both,,,1095.29,711.94,,,,,,,,,,,,,
SCREW LK F/IM NAIL 5X30MM XL25,SUP-2718107,CDM,C1713,HCPCS,0278,RC,,,,both,,,543.13,353.03,,,,,,,,,,,,,
PLATE BONE L183MM THK3.4MM 12 H BILAT S STL LCK COMPR NEUT,SUP-2348988,CDM,C1713,HCPCS,0278,RC,,,,both,,,3837.71,2494.51,,,,,,,,,,,,,
BLADE SAW THK1.27 MM 8 MM D70 MM CUT EDGE STERILE LATEX FREE DISPOSABLE,SUP-2880143,CDM,2720000010,LOCAL,0272,RC,,,,both,,,741.83,482.19,,,,,,,,,,,,,
PIN FIX L230MM DIA2MM TRCR PNT PLN STNMN,SUP-2371628,CDM,C1713,HCPCS,0278,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
CANNULA SURG TALL ENTRY,SUP-2463629,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2080.25,1352.16,,,,,,,,,,,,,
DRAINAGE KIT CATH 180 DEG 25 CM FOR CYST PUNC TAPR EXAFLOW,SUP-2666677,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1378.68,896.14,,,,,,,,,,,,,
STYLUS NSL BREATHING RHINAER,SUP-2739151,CDM,C1889,HCPCS,0278,RC,,,,both,,,6280.00,4082.00,,,,,,,,,,,,,
HANDSET INCEPTIV W/COMMUNICATOR KIT,SUP-2891619,CDM,C1787,HCPCS,0278,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
GRAFT BNE 10X20X2MM DEMIN CANC SPNG STRP FLEXIGRFT,SUP-2264612,CDM,C9362,HCPCS,0278,RC,,,,both,,,1343.48,873.26,,,,,,,,,,,,,
SNARE ENDOSCP HELCL LOOP 0.014 INX180 CM 4 MM MIC ELITE,SUP-2606013,CDM,C1773,HCPCS,0272,RC,,,,both,,,6179.52,4016.69,,,,,,,,,,,,,
GRAFT DERMAL FEN 12X8 CM CLLGN TISS MTRX,SUP-2243695,CDM,Q4110,HCPCS,0636,RC,,,,both,,,10248.96,6661.82,,,,,,,,,,,,,
IMPLANT EAR 1.27 MM TUBE VENT PAPARELLA TYP 2INNR FLANGE SIL,SUP-2312832,CDM,L8699,HCPCS,0278,RC,,,,both,,,40.88,26.57,,,,,,,,,,,,,
AMILORIDE HCL 5 MG PO TABS,RX-391,CDM,6370000000,HCPCS,0637,RC,00574-0292-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
HEAD FEMORAL UNIPOLAR 12/14 50MM,SUP-2504171,CDM,C1776,CPT,0278,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
PLATE BNE L 400 MM SCREW DIA 3.5/4.5 MM 20 H SS RT PROX FEM 72582220,SUP-2933062,CDM,C1713,HCPCS,0278,RC,,,,both,,,20853.53,13554.79,,,,,,,,,,,,,
HEAD RAD H16.5MM DIA22MM +4MM OFFSET BILAT ELBW CO CHROM,SUP-2183051,CDM,C1776,CPT,0278,RC,,,,both,,,6074.61,3948.50,,,,,,,,,,,,,
PIN FIX SINGLE DIAMOND 0.078X9 IN 3 SHANK END NS STEINMANN,SUP-2791279,CDM,C1713,HCPCS,0278,RC,,,,both,,,15.57,10.12,,,,,,,,,,,,,
SYSTEM AUTOGRFT TRNSF 6MM SM JT OSTEOCHNDRL DISP,SUP-2123216,CDM,C1776,CPT,0278,RC,,,,both,,,1398.87,909.27,,,,,,,,,,,,,
DEXTROSE 5 % IV BOLUS,RX-40840055,CDM,2580000003,HCPCS,0250,RC,00264-1510-31,NDC,,both,250,ML,104.20,67.73,,,,,,,,,,,,,
LEAD NEUROSTIMULATOR L70CM PERC PRELD ENH STYL,SUP-2138785,CDM,C1778,HCPCS,0278,RC,,,,both,,,5338.00,3469.70,,,,,,,,,,,,,
COMPONENT PAT L STD TI POLYETH 3 PEG RND REV PRESSFIT POR,SUP-2250831,CDM,C1776,CPT,0278,RC,,,,both,,,1848.52,1201.54,,,,,,,,,,,,,
VLP 4.0MM P-T OST SCREW 28MM STER,SUP-2820006,CDM,C1713,HCPCS,0278,RC,,,,both,,,432.50,281.12,,,,,,,,,,,,,
STENT TRACHBRONCH WSTNT L 40 MM DIA12 MM SHTH 9 FR CATH L,SUP-2147050,CDM,C1876,HCPCS,0278,RC,,,,both,,,3713.74,2413.93,,,,,,,,,,,,,
LENS INTRAOCULAR 9.5 DIOPT CYL PWR 2.25 DIOPT L 13 MM DIA,SUP-2885275,CDM,V2632,HCPCS,0276,RC,,,,both,,,1617.10,1051.11,,,,,,,,,,,,,
DEVICE ERECTILE RESTR FOR PENILE PROSTHESIS,SUP-2138945,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1547.39,1005.80,,,,,,,,,,,,,
GUIDEWIRE ORTH BALL NOSE 2X800 MM STRL,SUP-2766031,CDM,C1769,HCPCS,0272,RC,,,,both,,,1208.90,785.78,,,,,,,,,,,,,
IMPLANT INTERPHALANGEAL JT DIA2.75MM 0DEG CANN HAMMERTUBE,SUP-2321071,CDM,C1776,CPT,0278,RC,,,,both,,,5092.30,3309.99,,,,,,,,,,,,,
HC So Lactate Dehydrogenase (Ld) Isoenzymes,PX-3018362567,CDM,83625,CPT,0301,RC,,,,both,,,25.00,16.25,,,,,,,,,,,,,
CATHETER THROMCTMY LIGHTNING BOLT INDIGO L 130 CM SHTH 7 FR,SUP-2880239,CDM,C1757,HCPCS,0272,RC,,,,both,,,25999.20,16899.48,,,,,,,,,,,,,
HC Aspirate/Inj Ganglion Cys,PX-4502061200,CDM,20612,CPT,0450,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
HC So Antibody Screen,PX-3028685066,CDM,86850,CPT,0302,RC,,,,both,,,358.00,232.70,,,,,,,,,,,,,
SLEEVE DECOMPRESSION DIA 32 FR SHRT GASTRECTOMY 3D CALIB SYS,SUP-2883407,CDM,C1889,HCPCS,0278,RC,,,,both,,,3064.64,1992.02,,,,,,,,,,,,,
GRAFT VASC STR 4 MMX10 CM STD WALL N RING EPTFE CARBOFLO,SUP-2761231,CDM,C1768,CPT,0278,RC,,,,both,,,450.31,292.70,,,,,,,,,,,,,
COUNTERSINK SURG HD DISP FOR 4MM MINI MONSTER HD SCR,SUP-2320964,CDM,2720000010,LOCAL,0272,RC,,,,both,,,494.55,321.46,,,,,,,,,,,,,
CATHETER HD SET 15 FRX42 CM DL AG ACCS CENTER VECTORFLOW,SUP-2762980,CDM,C1750,HCPCS,0278,RC,,,,both,,,580.90,377.58,,,,,,,,,,,,,
PLATE BONE 3X2 H LCK BILAT GRID TRAPEOID HND DISP FOR 2MM,SUP-2267929,CDM,C1713,HCPCS,0278,RC,,,,both,,,1343.92,873.55,,,,,,,,,,,,,
ANCHOR FIX 60 MM AERO-LL,SUP-2732358,CDM,C1713,HCPCS,0278,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
BODY FEM SZ A W21XH60MM DIA18.5MM PROX HIP TI PPS STD,SUP-2404446,CDM,C1776,CPT,0278,RC,,,,both,,,14330.96,9315.12,,,,,,,,,,,,,
CATHETER OCCL 2.8FR L150CM ID0.053IN BLLN L30MM DIA4MM,SUP-2368111,CDM,C2628,HCPCS,0272,RC,,,,both,,,4622.08,3004.35,,,,,,,,,,,,,
PLATE BNE L172MM 8 H ST L DST MED TIB S STL VAR ANG LOK,SUP-2177640,CDM,C1713,HCPCS,0278,RC,,,,both,,,5361.52,3484.99,,,,,,,,,,,,,
CATHETER CHOLGM 4FR L50CM NDL INTRO REDDICK SCOOP TIP,SUP-2264235,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
SCREW SPNL CANN 4X32 MM CORRIDOR,SUP-2423406,CDM,C1713,HCPCS,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
RELOAD STPL L45MM H15 35MM REG TISS BLU 6 ROW B FRM NAT,SUP-2218985,CDM,2720000010,LOCAL,0272,RC,,,,both,,,476.53,309.74,,,,,,,,,,,,,
PLATE BNE THK 0.3 MM SCREW DIA1.5 MM XS RETRO NS DISP,SUP-2936975,CDM,C1713,HCPCS,0278,RC,,,,both,,,2785.18,1810.37,,,,,,,,,,,,,
KIT BONE GRAFT HARVESTING 20 MM STRL,SUP-2563899,CDM,2720000010,LOCAL,0272,RC,,,,both,,,10129.89,6584.43,,,,,,,,,,,,,
PLATE BNE L230MM 10 H NONSTERILE R CNDYL S STL CRV LOK,SUP-2177852,CDM,C1713,HCPCS,0278,RC,,,,both,,,5741.62,3732.05,,,,,,,,,,,,,
ENDCAP ORTH ST BLU TI FOR SLD TIB IM NAIL,SUP-2192163,CDM,C1713,HCPCS,0278,RC,,,,both,,,560.24,364.16,,,,,,,,,,,,,
SET INTRO SUP ARW FLX SHTH L 65 CM DIA 9 FR HYDRPHLC,SUP-2383419,CDM,C1894,HCPCS,0272,RC,,,,both,,,263.13,171.03,,,,,,,,,,,,,
CENTRALIZER STEM 16 MM POST HIP SPECTRN EF COBRA,SUP-2434607,CDM,C1776,CPT,0278,RC,,,,both,,,192.17,124.91,,,,,,,,,,,,,
DEXTROSE 5 % IV BOLUS,RX-40840055,CDM,2580000003,HCPCS,0250,RC,00990-7922-61,NDC,,both,250,ML,74.40,48.36,,,,,,,,,,,,,
PLATE BNE SM W11XL100MM THK15MM 90DEG 4X8 H TI T SHP R ANG,SUP-2190940,CDM,C1713,HCPCS,0278,RC,,,,both,,,1842.55,1197.66,,,,,,,,,,,,,
WAND ABLAT 50DEG DIA3MM TRI 50 ICW,SUP-2342005,CDM,2720000010,LOCAL,0272,RC,,,,both,,,580.90,377.58,,,,,,,,,,,,,
PLATE BNE STR 2-2.5X2.8 MM 20 HOLE RECON LCK FOR SCR TI NS,SUP-2484089,CDM,C1713,HCPCS,0278,RC,,,,both,,,4443.63,2888.36,,,,,,,,,,,,,
KIT MIDLN 20GA L10CM FLO RATE 5ML/SEC MIDLN PWR INJ FULL TY,SUP-2125666,CDM,C1751,HCPCS,0278,RC,,,,both,,,292.02,189.81,,,,,,,,,,,,,
CATHETER EP QPLR 2-5-2 MM 7 FRX115 CM TC,SUP-2356974,CDM,C1733,HCPCS,0272,RC,,,,both,,,2229.40,1449.11,,,,,,,,,,,,,
MATRIX BIO L 25 X W 20 CM FET BOV DERM IONIC SLV DERMAL SLD,SUP-2909307,CDM,Q4110,HCPCS,0636,RC,,,,both,,,27624.15,17955.70,,,,,,,,,,,,,
ESUCTION ESOPH 3/BOX,SUP-2419431,CDM,2720000010,LOCAL,0272,RC,,,,both,,,681.41,442.92,,,,,,,,,,,,,
DISC NEUROSURGICAL N PROGRAMMABLE SET W/O RESERVOIR PROGAV,SUP-2846929,CDM,C1889,HCPCS,0278,RC,,,,both,,,3099.05,2014.38,,,,,,,,,,,,,
BASKET DISP FLOWER ROT 8W 20MM W/ BULL TIP ROT 2.8MMX1950MM,SUP-2313153,CDM,C1713,HCPCS,0278,RC,,,,both,,,825.07,536.30,,,,,,,,,,,,,
SCREW BONE LOCKING 2.4X10 MM MANDIBULAR SELFTAPPING 20/PK TI,SUP-2842337,CDM,C1713,HCPCS,0278,RC,,,,both,,,585.55,380.61,,,,,,,,,,,,,
SCREW BNE CANN SHT THRD 4X36 MM HDLSS NS MINI-MONSTER,SUP-2742596,CDM,C1713,HCPCS,0278,RC,,,,both,,,757.21,492.19,,,,,,,,,,,,,
SYSTEM EMB EMBOSHIELD NAV6 DIA 7.2 MM WIRE L 190 CM SHTH 5,SUP-2105920,CDM,C1884,HCPCS,0278,RC,,,,both,,,5096.22,3312.54,,,,,,,,,,,,,
ALLOGRAFT BNE FRZN ASEP LT WHL TIB SHFT,SUP-2867032,CDM,C1762,CPT,0278,RC,,,,both,,,5011.44,3257.44,,,,,,,,,,,,,
GRAFT BNE 451559,SUP-2684152,CDM,C1713,HCPCS,0278,RC,,,,both,,,4455.66,2896.18,,,,,,,,,,,,,
ALLOGRAFT HUMAN TISSUE DERMACELL AWM 5CM X 7CM 0.2-1MM,SUP-2909512,CDM,Q4122,HCPCS,0636,RC,,,,both,,,7665.53,4982.59,,,,,,,,,,,,,
PROCEDURE PACK SHLDR HEARTWARE,SUP-2282560,CDM,Q0498,HCPCS,0272,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
TUBE VENT 1.0MM REUT BOB,SUP-2312592,CDM,L8699,HCPCS,0278,RC,,,,both,,,128.74,83.68,,,,,,,,,,,,,
CATHETER CV MAXIMAL BARR TY 032 10 FRX20 CM 5 LUMEN STRL,SUP-2759924,CDM,C1751,HCPCS,0278,RC,,,,both,,,587.53,381.89,,,,,,,,,,,,,
HC So1 Amoebic Antibodies by Iha,PX-3028675367,CDM,86753,CPT,0302,RC,,,,outpatient,,,588.00,382.20,,,,,,,,,,,,,
CATHETERIZATION SET ART 021 22 GAX12 CM 22 GA INDWL LF,SUP-2865603,CDM,C1751,HCPCS,0278,RC,,,,both,,,71.28,46.33,,,,,,,,,,,,,
GRAFT BNE SUB 4CC DBM PRO-DENSE INJ INDUCTIVE PRO-STIM,SUP-2399130,CDM,C1713,HCPCS,0278,RC,,,,both,,,4669.18,3034.97,,,,,,,,,,,,,
KIT PI PICC 2-L 5.5 FR X 55 CM WITH CHG AND VPS,SUP-2565197,CDM,C1751,HCPCS,0278,RC,,,,both,,,772.44,502.09,,,,,,,,,,,,,
STAPLER INT 48MM W21MMXL22CM AQUA STD CUT EDGE TECHNOLOGY,SUP-2283240,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1132.06,735.84,,,,,,,,,,,,,
BIT DRL DIA25MM STP 12MM SHT VECTRA,SUP-2179381,CDM,2720000010,LOCAL,0272,RC,,,,both,,,602.88,391.87,,,,,,,,,,,,,
SPLINT KNEE L12IN UNIV WRP ARND OPN PAT WIND CLS POPLITEAL,SUP-2196739,CDM,L1830,CPT,0272,RC,,,,both,,,33.00,21.45,,,,,,,,,,,,,
GUIDEWIRE VASC RDRUN PC THE FIRM L 145 CM DIA 0.038 IN TAPR,SUP-2168189,CDM,C1769,HCPCS,0272,RC,,,,both,,,75.99,49.39,,,,,,,,,,,,,
PLATE BNE L104MM THK3.7MM 8 H BILAT S STL STR LO PROF RIG,SUP-2184028,CDM,C1713,HCPCS,0278,RC,,,,both,,,2168.17,1409.31,,,,,,,,,,,,,
CLAMP SURG CENTERING W/ 2 MM DRL NS LTX,SUP-2856602,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4239.00,2755.35,,,,,,,,,,,,,
IMPLANT BRST 125CC DIA8.9CM P2.8CM SIL GEL SMOOTH RND MOD +,SUP-2300233,CDM,C1789,HCPCS,0278,RC,,,,both,,,3092.90,2010.38,,,,,,,,,,,,,
COVER BURR H BASE SUPPORT CLP STRL DISP SENSIGHT,SUP-2883057,CDM,C1713,HCPCS,0278,RC,,,,both,,,1491.50,969.47,,,,,,,,,,,,,
PLATE 3.5MM CURVED BROAD LCP 20H TI STRL,SUP-2546937,CDM,C1713,HCPCS,0278,RC,,,,both,,,3489.80,2268.37,,,,,,,,,,,,,
GENERATOR NEUROSTIMULATOR PULSE SENZA OMNIA,SUP-2719958,CDM,C1822,CPT,0278,RC,,,,both,,,60251.58,39163.53,,,,,,,,,,,,,
PLATE BONE L132MM 10 H LT OLECRANON S STL LCK FOR 2.7/3.5MM,SUP-2348708,CDM,C1713,HCPCS,0278,RC,,,,both,,,13584.27,8829.78,,,,,,,,,,,,,
HC Pt Therapeutic Activities 15 Min,PX-4209753000,CDM,97530,CPT,0420,RC,,,,both,,,144.00,93.60,,,,,,,,,,,,,
COMPONENT TOT SHLDR CAPPED XL AB GLEN COMPHSVE REVERSED,SUP-2417334,CDM,C1776,CPT,0278,RC,,,,both,,,26206.44,17034.19,,,,,,,,,,,,,
MONTELUKAST SODIUM 4 MG PO PACK,RX-36023,CDM,6370000000,HCPCS,0637,RC,27241-0015-31,NDC,,both,30,UN,427.50,277.87,,,,,,,,,,,,,
CATHETER DRAINAGE 0.035 IN 10 FRX30 CM LCK RESOLV +,SUP-2303334,CDM,C1729,HCPCS,0272,RC,,,,both,,,210.25,136.66,,,,,,,,,,,,,
PLATE BNE W17.5XL196MM THK5.2MM 11 H BILAT S STL BROAD,SUP-2185295,CDM,C1713,HCPCS,0278,RC,,,,both,,,1736.11,1128.47,,,,,,,,,,,,,
GRAFT HUM TISS CART VIABLE CARTIMAX,SUP-2307231,CDM,C1762,CPT,0278,RC,,,,both,,,14444.00,9388.60,,,,,,,,,,,,,
PLATE BONE LNG RT LAT CLAVICULAR,SUP-2399401,CDM,C1713,HCPCS,0278,RC,,,,both,,,5799.58,3769.73,,,,,,,,,,,,,
BLADE SCREWDRVR W2.4MM PRI CLSR SYS PWR DRVR STERNALOCK BLU,SUP-2420206,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1296.82,842.93,,,,,,,,,,,,,
KNIFE SURG TABB 15.5 CM MUCOUS SS,SUP-2474747,CDM,2720000010,LOCAL,0272,RC,,,,both,,,372.31,242.00,,,,,,,,,,,,,
CLIP HEARING AID CONN,SUP-2430305,CDM,2720000010,LOCAL,0272,RC,,,,both,,,499.89,324.93,,,,,,,,,,,,,
KIT SUTURE SZ 1 X 4 MM STRL DISP SPEEDBUTTON,SUP-2893328,CDM,C1713,HCPCS,0278,RC,,,,both,,,1664.20,1081.73,,,,,,,,,,,,,
CALCIUM CARB-CHOLECALCIFEROL 250-3.125 MG-MCG PO TABS,RX-160060,CDM,6370000000,HCPCS,0637,RC,20555-0025-00,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
GRAFT SYNTH TISS 10MM 4ML 40MM LEN 10MM THICKNESS BLK IMPL,SUP-2413073,CDM,C1713,HCPCS,0278,RC,,,,both,,,3457.14,2247.14,,,,,,,,,,,,,
PLATE BNE L 203 MM SCREW DIA 4.5 MM 11 H NAR COMPR NLCK NS,SUP-2933315,CDM,C1713,HCPCS,0278,RC,,,,both,,,1902.34,1236.52,,,,,,,,,,,,,
HC L-Spine Comp Inc Bend Min 6 Views,PX-3207211400,CDM,72114,CPT,0320,RC,,,,inpatient,,,1420.00,923.00,,,,,,,,,,,,,
PIN FIX L25MM DIA2.7MM PROV FOR VAR ANG PLATING SYS,SUP-2343968,CDM,C1713,HCPCS,0278,RC,,,,both,,,1331.01,865.16,,,,,,,,,,,,,
DISTRACTOR SURG CLVRLF 25 MM END DRV 4 PLATE TI ZURICH II,SUP-2473793,CDM,2720000010,LOCAL,0272,RC,,,,both,,,15859.67,10308.79,,,,,,,,,,,,,
CLIP SURG DIL STRL,SUP-2710541,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
SCREW BNE HUM SHLDR INTERCALARY STEM ASSEMB MRS,SUP-2376487,CDM,C1713,HCPCS,0278,RC,,,,both,,,1080.95,702.62,,,,,,,,,,,,,
PIN FIX 2 MM STRL INION OTPS LTX DISP,SUP-2857902,CDM,C1713,HCPCS,0278,RC,,,,both,,,1127.26,732.72,,,,,,,,,,,,,
PTERIONAL RT SMOOTH MEDPOR,SUP-2365256,CDM,C1889,HCPCS,0278,RC,,,,both,,,5570.36,3620.73,,,,,,,,,,,,,
BRACE KNEE HNG WRP 2X L,SUP-2276699,CDM,L1820,HCPCS,0272,RC,,,,both,,,55.08,35.80,,,,,,,,,,,,,
HC Blood Count Red Blood Cell Automated,PX-3058504100,CDM,85041,CPT,0305,RC,,,,both,,,112.00,72.80,,,,,,,,,,,,,
BOOT HEEL FLOAT SYS W/ STRP 1 SZ ROCK,SUP-2319142,CDM,L4386,HCPCS,0272,RC,,,,both,,,303.01,196.96,,,,,,,,,,,,,
PLATE BONE 12 H BILAT TI MALL LCK COMPR MAND DBL ROW FOR 2MM,SUP-2191248,CDM,C1713,HCPCS,0278,RC,,,,both,,,1745.21,1134.39,,,,,,,,,,,,,
BUTTON FIX DIA20MM BNE TO BNE ENDOBTTN CL,SUP-2341034,CDM,C1713,HCPCS,0278,RC,,,,both,,,1004.80,653.12,,,,,,,,,,,,,
TENSIONER SURG STRNL FOR CABLE STRL DISP STERNALOCK XP,SUP-2894320,CDM,2720000010,LOCAL,0272,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
CATHETER INTVASC ULTRASOUND ACUNAV DIA10 FR POLYMER CORONARY,SUP-2535567,CDM,C1759,HCPCS,0272,RC,,,,both,,,2348.41,1526.47,,,,,,,,,,,,,
KIT CRAN ACCS RAZ SYR NDL FEN DRP W BARR WHT ABSRB TWL GZ,SUP-2244099,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1736.42,1128.67,,,,,,,,,,,,,
STIMULATOR BONE GROWTH 60UA CATHODE WAVE SPF + MINI,SUP-2414471,CDM,C1713,HCPCS,0278,RC,,,,both,,,21328.45,13863.49,,,,,,,,,,,,,
IMPLANT HUM TISS L 175-260 MM DIA 9-11 MM TEND FRZN,SUP-2881955,CDM,C1762,CPT,0278,RC,,,,both,,,7573.24,4922.61,,,,,,,,,,,,,
TISLELIZUMAB-JSGR 100 MG/10ML IV SOLN,RX-168837,CDM,J9329,HCPCS,0636,RC,72579-0121-01,NDC,,both,10,ML,16053.20,10434.58,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL PEEK SD800.525,SUP-2860206,CDM,C1713,HCPCS,0278,RC,,,,both,,,34697.63,22553.46,,,,,,,,,,,,,
DRESSING WOUND SURGICAL MATRIX 10X15 CM PLASTIC MATRISTEM,SUP-2106494,CDM,Q4166,HCPCS,0636,RC,,,,both,,,10435.82,6783.28,,,,,,,,,,,,,
STEM HUM SZ 9 DIA9MM PROX SHLDR TI HYDROXYAPETITE REUNION,SUP-2379011,CDM,C1776,CPT,0278,RC,,,,both,,,17237.34,11204.27,,,,,,,,,,,,,
CLAMP SURG MULT SCR FOR ORTHOFIX GALAXY FIX SYS,SUP-2316295,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2059.84,1338.90,,,,,,,,,,,,,
PLATE BONE 2X8 H TI T SHP FOR 1.5MM SCR VLP MINI-MOD SM BONE,SUP-2351070,CDM,C1713,HCPCS,0278,RC,,,,both,,,3548.36,2306.43,,,,,,,,,,,,,
KIT BAL DIL 16X40MM RELIEVA TRACT,SUP-2417596,CDM,C1726,HCPCS,0272,RC,,,,both,,,2182.30,1418.49,,,,,,,,,,,,,
TWIST DRILL MRRSNKLS MRTN1.5MMX105MM WNTCH SGTTL SPLIT LEV,SUP-2676882,CDM,2720000010,LOCAL,0272,RC,,,,both,,,476.93,310.00,,,,,,,,,,,,,
BLADE 110DEG CVD DIEGO,SUP-2312776,CDM,2720000010,LOCAL,0272,RC,,,,both,,,374.29,243.29,,,,,,,,,,,,,
WIRE BRST LESION L10.7CM DIA20GA LOC DUALOK,SUP-2550496,CDM,C1819,HCPCS,0278,RC,,,,both,,,48.48,31.51,,,,,,,,,,,,,
BUR SURG CARB DMND RND N FLUT STRL 3.0MM 39MML,SUP-2361984,CDM,2720000010,LOCAL,0272,RC,,,,both,,,61.23,39.80,,,,,,,,,,,,,
PLATE BNE L157MM 8 H ST POST MED PROX TIB S STL LOK COMPR,SUP-2177799,CDM,C1713,HCPCS,0278,RC,,,,both,,,3588.93,2332.80,,,,,,,,,,,,,
CROWN DENT D3 PEDIATRIC 1ST PRIMARY M UPPER LT SS,SUP-2240509,CDM,D6783,CPT,0278,RC,,,,both,,,23.24,15.11,,,,,,,,,,,,,
SCREW BNE L 4 MM DIA1.2 MM CRANIOMAXILLOFACIAL ST NS AXS 5PK,SUP-2884111,CDM,C1713,HCPCS,0278,RC,,,,both,,,1431.84,930.70,,,,,,,,,,,,,
CATHETER INFUS L150CM OD2.1 1.7FR ID.017IN L2.5MM .014IN,SUP-2172497,CDM,C1887,HCPCS,0272,RC,,,,both,,,2675.28,1738.93,,,,,,,,,,,,,
TAP SURG SCR CANN CANC BNE SPNL THOR 40MM TAPMAS,SUP-2286834,CDM,C1713,HCPCS,0278,RC,,,,both,,,451.28,293.33,,,,,,,,,,,,,
BIT DRL L25IN TEND GRFT DISPOSABLE,SUP-2166848,CDM,2720000010,LOCAL,0272,RC,,,,both,,,807.04,524.58,,,,,,,,,,,,,
VALVE SPEAK SZ 6 SIL CANN MONT,SUP-2138745,CDM,L8501,HCPCS,0272,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
INTRODUCER NEUROSTIMULATOR REACTIV8 PERC STRL,SUP-2877972,CDM,C1730,HCPCS,0272,RC,,,,both,,,141.30,91.84,,,,,,,,,,,,,
NAIL INTRMDLLRY CNNLTD 35MM DIA 150MML FBLR SST ST,SUP-2721290,CDM,C1713,HCPCS,0278,RC,,,,both,,,2951.60,1918.54,,,,,,,,,,,,,
KIT DBS CONN PLUG STRL DISP SENSIGHT,SUP-2883136,CDM,2720000010,LOCAL,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
ANCHOR SUT L36IN SZ 2 ETHBND POLY L LACTIDE 2 ABSRB GRN WHT,SUP-2184247,CDM,C1713,HCPCS,0278,RC,,,,both,,,488.90,317.78,,,,,,,,,,,,,
PLATE BNE L12MM GRN GUID GROWTH EIGHT PLT,SUP-2316387,CDM,C1713,HCPCS,0278,RC,,,,both,,,902.94,586.91,,,,,,,,,,,,,
MOLD FEM SPCR SM AP37MM ML60MM PMMA URETHANE GENT KASM,SUP-2315774,CDM,C1776,CPT,0278,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
TITANIUM 3D MESH 80MM X 80MM 1MM THICK 15MM SYSTEM,SUP-2707392,CDM,C1713,HCPCS,0278,RC,,,,both,,,4888.38,3177.45,,,,,,,,,,,,,
GRAFT BONE CHIP FRZN CRUSH CANC 1.7MM-10MM RANG 90CC,SUP-2307401,CDM,C1713,HCPCS,0278,RC,,,,both,,,5311.15,3452.25,,,,,,,,,,,,,
AZATHIOPRINE 50 MG PO TABS,RX-9183,CDM,J7500,HCPCS,0636,RC,68084-0229-01,NDC,,both,1,UN,3.10,2.01,,,,,,,,,,,,,
CATHETER HD STR 8 FRX24 CM LT DL STP BASIC SET SIL HEMCATH,SUP-2627311,CDM,C1750,HCPCS,0278,RC,,,,both,,,794.42,516.37,,,,,,,,,,,,,
SCREW BNE CANN 2.7X18 MM TI CAPTURE QUICKSNAP,SUP-2609590,CDM,C1713,HCPCS,0278,RC,,,,both,,,1234.74,802.58,,,,,,,,,,,,,
OSS 9CM OSSEOTI PROX TIB SLV,SUP-2506335,CDM,C1776,CPT,0278,RC,,,,both,,,14917.04,9696.08,,,,,,,,,,,,,
ALLOGRAFT BNE PTTY 2 CC LECITHIN CARR DBM NS REGENEROSS +,SUP-2862037,CDM,C1713,HCPCS,0278,RC,,,,both,,,1335.72,868.22,,,,,,,,,,,,,
ALLOGRAFT BNE 100-15 MM FRZN IRRADIATED HUM SHFT,SUP-2866869,CDM,C1762,CPT,0278,RC,,,,both,,,6001.80,3901.17,,,,,,,,,,,,,
GRAFT BONE LT HUM WHL W/ CUF TRAD FRZN,SUP-2294177,CDM,C1713,HCPCS,0278,RC,,,,both,,,11445.30,7439.44,,,,,,,,,,,,,
COUNTERSINK SURG DIA3.5/4MM,SUP-2123101,CDM,C1713,HCPCS,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
PLATE EXT FIX 4 H THRD CONN MRI CONDITIONAL FOR DISTR,SUP-2179152,CDM,2720000010,LOCAL,0272,RC,,,,both,,,293.02,190.46,,,,,,,,,,,,,
BIT DRL DIA2MM DISP FOR PLT CLAW,SUP-2397355,CDM,2720000010,LOCAL,0272,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
BRACE LUMBOSACRALXL 15DEG BK HK RECV MAT SFT BRTH LNR RIG,SUP-2195547,CDM,L0625,HCPCS,0274,RC,,,,both,,,901.18,585.77,,,,,,,,,,,,,
STENT ENDOPROS L15CM DIA5MM CATH 7FR L120CM BAL DIA5MM,SUP-2396494,CDM,C1874,HCPCS,0278,RC,,,,both,,,10864.40,7061.86,,,,,,,,,,,,,
TUBE INNR EAR MYR VENT FLNG 1.14 MM ID STRL DONALDSON,SUP-2277593,CDM,L8699,HCPCS,0278,RC,,,,both,,,21.10,13.71,,,,,,,,,,,,,
IMPLANT FNGR JT SM PIP FUSION,SUP-2897385,CDM,C1713,HCPCS,0278,RC,,,,both,,,2979.86,1936.91,,,,,,,,,,,,,
GRAFT BNE PTTY 1 CC SYR DBM ACCELL EVO3,SUP-2641759,CDM,C1713,HCPCS,0278,RC,,,,both,,,1391.02,904.16,,,,,,,,,,,,,
COMPONENT FEM MOD LG 65X72.5 MM LT KNEE ENDO-MODEL SL,SUP-2423699,CDM,C1776,CPT,0278,RC,,,,both,,,21644.15,14068.70,,,,,,,,,,,,,
MESH SURG 25X36 CM FLX PHYSIOMESH DISP,SUP-2219749,CDM,C1781,HCPCS,0278,RC,,,,both,,,7440.54,4836.35,,,,,,,,,,,,,
PLATE BNE L 170 X W 10.9 MM THK 3.4 MM SCREW DIA 3.5 MM 13 H 72463813,SUP-2933023,CDM,C1713,HCPCS,0278,RC,,,,both,,,5885.62,3825.65,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL PEEK SD800.550,SUP-2860231,CDM,C1713,HCPCS,0278,RC,,,,both,,,53919.14,35047.44,,,,,,,,,,,,,
MESH CRANIAL CONTOURABLE 200X200X0.6 MM PRECONTOURED TITANIU,SUP-2842246,CDM,C1713,HCPCS,0278,RC,,,,both,,,26545.56,17254.61,,,,,,,,,,,,,
CATHETER INFUSION 0.038 IN 5 FRX65 CM 15 CM 20 SH MEWISSEN,SUP-2141168,CDM,C1887,HCPCS,0272,RC,,,,both,,,236.44,153.69,,,,,,,,,,,,,
PROSTHESIS OSS STAP 4 MM 0.4 MM GRACE BCKT HNDL NOTCH TI NIT,SUP-2462825,CDM,L8613,CPT,0278,RC,,,,both,,,852.70,554.25,,,,,,,,,,,,,
CATHETER VENTRICULAR RT ANGLE 9 BA ACCU-FLO,SUP-2666405,CDM,C1729,HCPCS,0272,RC,,,,both,,,804.69,523.05,,,,,,,,,,,,,
STENT BILI ST-2 SOEH TANNENBAUM L 15 CM DIA10 FR ENDOSCP,SUP-2738113,CDM,C2625,HCPCS,0278,RC,,,,both,,,401.92,261.25,,,,,,,,,,,,,
SCREW BNE 6.5X120 MM FIX BEAM FOR CHARCOT FIX SYS AXIS,SUP-2433773,CDM,C1713,HCPCS,0278,RC,,,,both,,,4239.00,2755.35,,,,,,,,,,,,,
SPLINT A SPA BALL SP S LF,SUP-2163829,CDM,L3807,HCPCS,0272,RC,,,,both,,,108.33,70.41,,,,,,,,,,,,,
STIRRUP POS H10IN STD UNIV ANK AIR BLDR RIG MED LAT SHELLS,SUP-2195184,CDM,L4350,HCPCS,0274,RC,,,,both,,,41.86,27.21,,,,,,,,,,,,,
COMPONENT PATELLAR PS 38X10 MM KNEE RND PEG CEM,SUP-2359099,CDM,C1776,CPT,0278,RC,,,,both,,,6939.40,4510.61,,,,,,,,,,,,,
PRODENSE 15CC BONE GRFT SUB,SUP-2400572,CDM,C1713,HCPCS,0278,RC,,,,both,,,12230.30,7949.69,,,,,,,,,,,,,
CONNECTOR SPNL EXT LAT TI ADJ FOR 6.35MM ROD,SUP-2415612,CDM,C1713,HCPCS,0278,RC,,,,both,,,1851.60,1203.54,,,,,,,,,,,,,
ANCHOR SUT 3.5MM NO 0 TI DBL STRND NDL FORC FBR INSITE FT,SUP-2388905,CDM,C1713,HCPCS,0278,RC,,,,both,,,1424.30,925.79,,,,,,,,,,,,,
CAP BNE CEM COMPR FEM,SUP-2368422,CDM,L8690,HCPCS,0278,RC,,,,both,,,303.95,197.57,,,,,,,,,,,,,
PLATE BONE 4 H S STL LT L SHP BTTRS,SUP-2198569,CDM,C1713,HCPCS,0278,RC,,,,both,,,540.96,351.62,,,,,,,,,,,,,
CONNECTOR EXT FIX OBLQ AD ILIZ,SUP-2340732,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5436.75,3533.89,,,,,,,,,,,,,
IMPLANT BREAST 625ML HIGH PROFILE SALINE SMOOTH ROUND,SUP-2745924,CDM,C1789,HCPCS,0278,RC,,,,both,,,2983.00,1938.95,,,,,,,,,,,,,
GRAFT BONE ALIF SPCR ANTR APPRCH FRZ DRY H 11MM,SUP-2306897,CDM,C1713,HCPCS,0278,RC,,,,both,,,14184.95,9220.22,,,,,,,,,,,,,
SET BILI STENT COTTON-HUIBREGTSE L 9 CM DIA 7 FR PUSH L 170,SUP-2169187,CDM,C2625,HCPCS,0278,RC,,,,both,,,405.06,263.29,,,,,,,,,,,,,
JOINT GREAT TOE PHLANG 40 MOV,SUP-2609670,CDM,L8642,HCPCS,0278,RC,,,,both,,,7768.64,5049.62,,,,,,,,,,,,,
RX TEMPLATE125 X 125LARGE GRID MALLEABLE T0.6MM,SUP-2488345,CDM,2720000010,LOCAL,0272,RC,,,,both,,,191.45,124.44,,,,,,,,,,,,,
TRASTUZUMAB-DKST 420 MG IV SOLR,RX-148007,CDM,Q5114,HCPCS,0636,RC,67457-0847-44,NDC,,both,1,UN,7560.20,4914.13,,,,,,,,,,,,,
PLATE CRANIAL UN3 2 H W /TAB DOGBONE LOW-PROFILE,SUP-2363622,CDM,C1713,HCPCS,0278,RC,,,,both,,,419.91,272.94,,,,,,,,,,,,,
SHUNT NEUROSURGICAL L30CM OD11FR CK VLV BAL W/O RESVR,SUP-2214696,CDM,C1713,HCPCS,0278,RC,,,,both,,,532.29,345.99,,,,,,,,,,,,,
SET INTRO PERFRMR L 35 CM DIA 5 FR TIP 3 MM GUIDEWIRE 0.035,SUP-2169704,CDM,C1894,HCPCS,0272,RC,,,,both,,,93.26,60.62,,,,,,,,,,,,,
CATHETER VALVULOPLASTY TYSHAK L 100 CM DIA 5.5 FR 2 CM 6 MM,SUP-2659383,CDM,C1725,HCPCS,0272,RC,,,,both,,,2431.18,1580.27,,,,,,,,,,,,,
GRAFT DURAL 4IN X 5IN ULTRPRE CLLGN ONLAY STRLSS CLSRE ENHNC,SUP-2491974,CDM,C1763,HCPCS,0278,RC,,,,both,,,4534.38,2947.35,,,,,,,,,,,,,
HC So Comparative Analysis Using Str,PX-3108126566,CDM,81265,CPT,0310,RC,,,,both,,,306.00,198.90,,,,,,,,,,,,,
BIT DRL TWST 3.8 MM CALIB,SUP-2862209,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1067.29,693.74,,,,,,,,,,,,,
MESH SURG W10XL15CM THK1MM EPTFE CORDUROY SURF CNFRM TEXT,SUP-2395330,CDM,C1781,HCPCS,0278,RC,,,,both,,,1504.06,977.64,,,,,,,,,,,,,
STEM HUM CEM STD UNIV 6X70 MM REV W/ ALIGN HOLE TI PLASMA,SUP-2431684,CDM,C1776,CPT,0278,RC,,,,both,,,8481.14,5512.74,,,,,,,,,,,,,
HALOPERIDOL 2 MG PO TABS,RX-3581,CDM,6370000000,HCPCS,0637,RC,51079-0735-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PLATE BONE W14.9XL264MM THK1.2MM 16 H DSTL TIB S STL,SUP-2185745,CDM,C1713,HCPCS,0278,RC,,,,both,,,1740.16,1131.10,,,,,,,,,,,,,
CAGE SPNL H14MM INTBDY FUS OCTAVE POST PLT,SUP-2264529,CDM,C1889,HCPCS,0278,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
BLADE SURG 11 LT MIDLN MAST MIDLF,SUP-2631593,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2132.85,1386.35,,,,,,,,,,,,,
CATHETER THROMCTMY L 80 MM BALLOON L 10 MM DIA 8 MM PTFE,SUP-2227485,CDM,C1725,HCPCS,0272,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
STIMULATOR NERVE REMOTE CONTROL,SUP-2568749,CDM,C1787,HCPCS,0278,RC,,,,both,,,2590.50,1683.82,,,,,,,,,,,,,
SPACER HUM SM HD DIA4.1MM 0.4GM GNTMYCN BASE PREFRM TWO STG,SUP-2223701,CDM,C1776,CPT,0278,RC,,,,both,,,12246.00,7959.90,,,,,,,,,,,,,
GUIDEWIRE VASC SAFESEPT L 135 CM DIA 0.014 IN NIT,SUP-2159466,CDM,C1769,HCPCS,0272,RC,,,,both,,,692.68,450.24,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PLU MAXBARR 4FR 55CM 1 LU 1174108D1,SUP-2632625,CDM,C1751,HCPCS,0278,RC,,,,both,,,947.84,616.10,,,,,,,,,,,,,
HC So1 Ptt|REPEAT CLINICAL DIAGNOSTIC LABORATORY TEST|NOT REASONABLE AND NECESSARY,PX-3058573067,CDM,85730,CPT,0305,RC,,,91|GZ,both,,,36.00,23.40,,,,,,,,,,,,,
INSERTER SURG GUIDEPIN INLINE NS FLAREHAWK 7 LTX,SUP-2871312,CDM,C1889,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
CATHETER HD STR 11.5 FRX24 CM SHT TERM DL SET SOFT-LINE,SUP-2627336,CDM,C1752,HCPCS,0278,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
CORTEX HEX SCREW S-T 3.5X22 MM STRL,SUP-2818133,CDM,C1713,HCPCS,0278,RC,,,,both,,,230.57,149.87,,,,,,,,,,,,,
PROSTHESIS PENILE DSTL TIP 12 MMX4 CM DURA II,SUP-2140240,CDM,C1813,HCPCS,0278,RC,,,,both,,,1241.09,806.71,,,,,,,,,,,,,
BASEPLATE KNEE MG II PC PEG TIB E/GREEN,SUP-2199603,CDM,C1776,CPT,0278,RC,,,,both,,,11354.24,7380.26,,,,,,,,,,,,,
COMPONENT TIB TY DSTL PLATE NS OPTILOCK LTX,SUP-2861373,CDM,C1776,CPT,0278,RC,,,,both,,,12302.90,7996.88,,,,,,,,,,,,,
METHYLPREDNISOLONE SODIUM SUCC 125 MG IJ SOLR (MIXTURES ONLY),RX-430072,CDM,J2919,HCPCS,0636,RC,00009-0047-25,NDC,,both,1,UN,60.00,39.00,,,,,,,,,,,,,
FORCEPS ENDOSCP SPEC RETRV 3.3FR L115CM PTFE S STL ALGTR,SUP-2171258,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1089.20,707.98,,,,,,,,,,,,,
KIT INTRO MAK-NV L 20 CM DIA 6 FR DIL 4 FR GUIDEWIRE L 60 CM,SUP-2303019,CDM,C1894,HCPCS,0272,RC,,,,both,,,192.73,125.27,,,,,,,,,,,,,
PIN SURG DRL TRNSVRS XLN 68 MM COMPRESS,SUP-2441835,CDM,C1713,HCPCS,0278,RC,,,,both,,,197.82,128.58,,,,,,,,,,,,,
SCREW ABSRBBLE 40MM DIA 54MML LOW PRFLE DRCT DRIVE ARTHRTK,SUP-2724044,CDM,C1725,HCPCS,0272,RC,,,,both,,,803.84,522.50,,,,,,,,,,,,,
HC Cv Cath Plac WO Port>5yr (Tun),PX-3613655800,CDM,36558,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
SPATULA SURG L32CM FOR SUCT IRRIG,SUP-2361198,CDM,2720000010,LOCAL,0272,RC,,,,both,,,465.94,302.86,,,,,,,,,,,,,
KIT CATH 14.5FR L36CM INSRT L19CM POLYUR DBL LUMN STD FLO,SUP-2283940,CDM,C1881,HCPCS,0278,RC,,,,both,,,805.76,523.74,,,,,,,,,,,,,
SCREW BNE L38MM DIA35MM NONLOCKING FOR TUFFNEK TECHNOLOGY,SUP-2321207,CDM,C1713,HCPCS,0278,RC,,,,both,,,545.89,354.83,,,,,,,,,,,,,
BUR SURG DIA 3 MM DIAMOND COARSE 1 RNG STRL DISP ELAN 4 GP165SU,SUP-2928924,CDM,2720000010,LOCAL,0272,RC,,,,both,,,449.27,292.03,,,,,,,,,,,,,
BONE MARROW TRAY ECON 11 GAX4 IN 16 GAX2.688 IN ASPIR T-LOK,SUP-2876723,CDM,2720000010,LOCAL,0272,RC,,,,both,,,332.84,216.35,,,,,,,,,,,,,
MESH HERN W3.1XL5.3IN M POLYPR L INGUINAL NONABSORBABLE LT,SUP-2125793,CDM,C1781,HCPCS,0278,RC,,,,both,,,564.89,367.18,,,,,,,,,,,,,
SCREW BNE ST 1.5X4 MM CRTX W/ T4 STARDRV RECESS SS NS,SUP-2178443,CDM,C1713,HCPCS,0278,RC,,,,both,,,127.30,82.74,,,,,,,,,,,,,
OVERDRILL SURG DIA3.5MM SH W/ AO QUIK CONN DISP FOR SM,SUP-2344048,CDM,2720000010,LOCAL,0272,RC,,,,both,,,825.41,536.52,,,,,,,,,,,,,
PLATE BONE THK10MM 10DEG SUPCNDYL N COMPR SUP AUG,SUP-2223381,CDM,C1776,CPT,0278,RC,,,,both,,,5809.00,3775.85,,,,,,,,,,,,,
GRAFT HUM TISS W6XL16CM THK07 14MM THN ACELLULAR HYDRATED,SUP-2436519,CDM,Q4128,HCPCS,0636,RC,,,,both,,,7316.83,4755.94,,,,,,,,,,,,,
PROBE ABLATN,SUP-2225695,CDM,C2618,HCPCS,0272,RC,,,,both,,,4129.10,2683.91,,,,,,,,,,,,,
COVER BURR HOLE CONTOURED 18X0.3 MM 5 HOLE TI LEVEL 1 NEURO,SUP-2493732,CDM,C1713,HCPCS,0278,RC,,,,both,,,801.20,520.78,,,,,,,,,,,,,
FIXATOR BNE PLT ORTH AO FIT TEMP,SUP-2378029,CDM,2720000010,LOCAL,0272,RC,,,,both,,,803.84,522.50,,,,,,,,,,,,,
INTRODUCER HEMSTAS ULTIMUM 4FRX23CM SHTH W/ .038IN GWIRE,SUP-2355646,CDM,C1894,HCPCS,0272,RC,,,,both,,,69.08,44.90,,,,,,,,,,,,,
ENDPLATE SPNL 3 DEG LG SUP PRODISC-L,SUP-2741245,CDM,C1889,HCPCS,0278,RC,,,,both,,,13816.00,8980.40,,,,,,,,,,,,,
TUBE VENT 1.14 MM 1 MM RUBE TAB MYRINGOTOMY SIL STRL 510183,SUP-2535111,CDM,L8699,HCPCS,0278,RC,,,,both,,,42.11,27.37,,,,,,,,,,,,,
RING ACET MUELLER ROOF REINF RNG 36MM,SUP-2212042,CDM,C1776,CPT,0278,RC,,,,both,,,4370.88,2841.07,,,,,,,,,,,,,
CABLE CATH EP 16 24 POL150 CML E FIXED STEERABLE,SUP-2676241,CDM,2720000010,LOCAL,0272,RC,,,,both,,,643.70,418.40,,,,,,,,,,,,,
HC Path Consltj Surg Ea Addl Blk Frozen Section,PX-3128833200,CDM,88332,CPT,0312,RC,,,,both,,,182.00,118.30,,,,,,,,,,,,,
PLATE BNE L L PROX HUM POLARUS,SUP-2107824,CDM,C1713,HCPCS,0278,RC,,,,both,,,6666.22,4333.04,,,,,,,,,,,,,
SCREW BNE EMGCY 2.5X9 MM SELF RET TI CENTRE-DRIVE,SUP-2495884,CDM,C1713,HCPCS,0278,RC,,,,both,,,206.61,134.30,,,,,,,,,,,,,
ALLOGRAFT HUM TISS GRAFIX PRIME 3X4CM CYROPRESERVED,SUP-2319163,CDM,Q4133,HCPCS,0636,RC,,,,both,,,3815.10,2479.81,,,,,,,,,,,,,
GUIDEWIRE VASC DIA0.9MM ITS,SUP-2247390,CDM,C1769,HCPCS,0272,RC,,,,both,,,172.70,112.25,,,,,,,,,,,,,
BIT DRILL 2.3MM TWIST L180,SUP-2858200,CDM,2720000010,LOCAL,0272,RC,,,,both,,,439.51,285.68,,,,,,,,,,,,,
HINGE OUTBOARD FOR TRUELOK FIX SYS,SUP-2316081,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1935.59,1258.13,,,,,,,,,,,,,
PLATE BNE L163MM 6 H NONSTERILE L PERIARTC PROX HUM S STL,SUP-2177808,CDM,C1713,HCPCS,0278,RC,,,,both,,,5067.43,3293.83,,,,,,,,,,,,,
CATHETER EP CSL 2-8-2 MM 5 FRX120 MM SUPREME,SUP-2355231,CDM,C1730,HCPCS,0272,RC,,,,both,,,1414.35,919.33,,,,,,,,,,,,,
SCREW ACET LP UNIV 6.5X45 MM HIP DOMED 2 MOBILITY STRL G7,SUP-2403205,CDM,C1713,HCPCS,0278,RC,,,,both,,,109.90,71.43,,,,,,,,,,,,,
FIBER LASER SINGLE 200 MH FLEXIVA ID,SUP-2458969,CDM,C1713,HCPCS,0278,RC,,,,both,,,1088.39,707.45,,,,,,,,,,,,,
HC Iadna Nos Amplified Probe Tq Each Organism,PX-3068779800,CDM,87798,CPT,0306,RC,,,,both,,,135.00,87.75,,,,,,,,,,,,,
SROM*STMXXL36+21+4L 16X11X300L,SUP-2540378,CDM,C1776,CPT,0278,RC,,,,both,,,19359.98,12583.99,,,,,,,,,,,,,
HC I&D Simple,PX-7611006000,CDM,10060,CPT,0761,RC,,,,both,,,632.00,410.80,,,,,,,,,,,,,
PLATE BNE COMPR NAR 5X97 MM 5 HOLE LCK NS AXSOS,SUP-2424238,CDM,C1713,HCPCS,0278,RC,,,,both,,,6213.75,4038.94,,,,,,,,,,,,,
SCREW STRNL CLOSURE L 10 MM DIA2.7 MM STRL STERNALOCK XP,SUP-2894391,CDM,C1713,HCPCS,0278,RC,,,,both,,,98.13,63.78,,,,,,,,,,,,,
PACK PHACO GAMMA STER 0.9MM 45DEG BAL FMS IRR ASPIR CENTURION,SUP-2916666,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1035.26,672.92,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC HF BSC 5FR 55CM 3 LUMAN RV 3385118Q,SUP-2632680,CDM,C1751,HCPCS,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
NEEDLE KYPHOPLASTY 13GA L5IN MTCH GRND BVL TIP INTRO N,SUP-2367334,CDM,C1713,HCPCS,0278,RC,,,,both,,,130.84,85.05,,,,,,,,,,,,,
CATHETER ATHRCTMY JETSTREAM G3 SF TIP DIA1.85 MM PERIPH STRL,SUP-2139500,CDM,C1724,HCPCS,0278,RC,,,,both,,,10048.00,6531.20,,,,,,,,,,,,,
SET ENDO L40CM OD8FR 0.038IN BILI DRNGE 6 H KINK RESIST LCK,SUP-2117064,CDM,C1729,HCPCS,0272,RC,,,,both,,,1130.40,734.76,,,,,,,,,,,,,
CATHETERIZATION KIT 0.025 IN 7 FRX6 IN CV ARROWG+ARD,SUP-2383310,CDM,C1751,HCPCS,0278,RC,,,,both,,,140.58,91.38,,,,,,,,,,,,,
NEEDLE BRST LOC 20 GAX5 CM,SUP-2174902,CDM,C1819,HCPCS,0278,RC,,,,both,,,93.89,61.03,,,,,,,,,,,,,
ALLOGRAFT BNE BLOCK TRICORT 800131,SUP-2743375,CDM,C1713,HCPCS,0278,RC,,,,both,,,2581.08,1677.70,,,,,,,,,,,,,
ABATACEPT 250 MG IV SOLR,RX-70287,CDM,J0129,HCPCS,0636,RC,00003-2187-13,NDC,,both,1,UN,4572.50,2972.12,,,,,,,,,,,,,
TUBE SURG FLR EXCHG FOR IM NAIL EXTR,SUP-2410278,CDM,2720000010,LOCAL,0272,RC,,,,both,,,496.78,322.91,,,,,,,,,,,,,
CATHETER NERVE BLOCK 19 GAX60 CM 17 GAX8 CM CPNB KT,SUP-2383238,CDM,C1755,HCPCS,0278,RC,,,,both,,,272.52,177.14,,,,,,,,,,,,,
HC So Microsatellite Instability,PX-3108130166,CDM,81301,CPT,0310,RC,,,,both,,,506.00,328.90,,,,,,,,,,,,,
AUG PAT 3-PEG ROT POR 177975000] JNJ DEPUY SYNTHES ORTHOPEDICS],SUP-2252416,CDM,C1776,CPT,0278,RC,,,,both,,,4019.20,2612.48,,,,,,,,,,,,,
TAP SURG OD4MM CANN QUIK CONN FOR PERI-LOC SM FRAG PLATING,SUP-2344009,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2582.84,1678.85,,,,,,,,,,,,,
CEFAZOLIN 3000 MG IN NS 100 ML IVPB,RX-4081571,CDM,J0690,HCPCS,0636,RC,09999-9912-52,NDC,,both,100,ML,54.10,35.16,,,,,,,,,,,,,
PLATE SPNL MOD 14 MM LAT 1 HOLE TLH STRL ENDOSKELETON TL,SUP-2730526,CDM,C1713,HCPCS,0278,RC,,,,both,,,10982.15,7138.40,,,,,,,,,,,,,
SPLINT THMB AD L4IN UNIV R FOAM LAM INSTABILITY LOOP LOK E,SUP-2197017,CDM,L3809,HCPCS,0274,RC,,,,both,,,19.78,12.86,,,,,,,,,,,,,
PLATE BONE L97MM 12 H LCK RECON BILAT RIG FOR 2.7MM SCR,SUP-2348298,CDM,C1713,HCPCS,0278,RC,,,,both,,,5924.08,3850.65,,,,,,,,,,,,,
FEMORAL KNEE CEM W/ MTL BASEPLT AND STD POLY INSRT USED IN,SUP-2351385,CDM,C1776,CPT,0278,RC,,,,both,,,10048.00,6531.20,,,,,,,,,,,,,
"HC So Protein C, Activity",PX-3058530366,CDM,85303,CPT,0305,RC,,,,both,,,492.00,319.80,,,,,,,,,,,,,
PLATE BNE L39MM THK3.7MM 3 H BILAT S STL STR LO PROF RIG,SUP-2184023,CDM,C1713,HCPCS,0278,RC,,,,both,,,1759.66,1143.78,,,,,,,,,,,,,
STAPLER INT L60MM STD TISS BLU 7/8 FIRING W/ 3.5MM 21 TI,SUP-2283418,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1155.33,750.96,,,,,,,,,,,,,
SCREW BONE L15MM OD6.5MM MTL ON POLYETH CANC HIP RESTORIS Z,SUP-2371460,CDM,C1713,HCPCS,0278,RC,,,,both,,,589.60,383.24,,,,,,,,,,,,,
CAPLACIZUMAB-YHDP 11 MG IJ KIT,RX-145241,CDM,C9047,HCPCS,0636,RC,58468-0225-01,NDC,,both,1,UN,25286.50,16436.22,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.544,SUP-2860061,CDM,C1713,HCPCS,0278,RC,,,,both,,,48841.76,31747.14,,,,,,,,,,,,,
BAR REDUCER EXTN SHT STRL OSCAR 3 LTX DISP,SUP-2875733,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1145.79,744.76,,,,,,,,,,,,,
COMPONENT FEM SZ 5 R KNEE POST STBL CEM SIG,SUP-2252517,CDM,C1776,CPT,0278,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
DRILL SURG CALIB 2.5X95 MM AO STYL,SUP-2766122,CDM,2720000010,LOCAL,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
PROBE NEUROMONITORING 4MM STERILE,SUP-2538830,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3014.40,1959.36,,,,,,,,,,,,,
GRAFT HUM TISS L 6 X W 4 CM XL AMNIO MEMBRN RESRB AIR DRY,SUP-2913443,CDM,Q4173,HCPCS,0636,RC,,,,both,,,9790.52,6363.84,,,,,,,,,,,,,
HEAD HUM .44-16IN ARW CO CHROM CNTR,SUP-2224501,CDM,C1776,CPT,0278,RC,,,,both,,,6280.00,4082.00,,,,,,,,,,,,,
FORCEPS OPHTH 23GA CRV DISP GRIESHABER REVOLUTION DSP,SUP-2109706,CDM,2720000010,LOCAL,0272,RC,,,,both,,,545.20,354.38,,,,,,,,,,,,,
EXTRACTOR SURG FOR FEM NK SCR TI TROCHANTERIC FIX NAIL SYS,SUP-2188254,CDM,C1713,HCPCS,0278,RC,,,,both,,,2785.31,1810.45,,,,,,,,,,,,,
SET DIL L 45 CM DIA16 FR/18 FR GUIDEWIRE 0.035 IN HYDRPHLC,SUP-2170999,CDM,2720000010,LOCAL,0272,RC,,,,both,,,941.97,612.28,,,,,,,,,,,,,
TRACKER NAVIGATION ENT ELECTROMAGNETIC STRL DISP,SUP-2902102,CDM,2720000010,LOCAL,0272,RC,,,,both,,,532.98,346.44,,,,,,,,,,,,,
OXALIPLATIN DESENSITIZATION SIMPLE RECORD,RX-159643,CDM,J9263,HCPCS,0636,RC,09999-9917-40,NDC,,both,1,UN,0.10,0.06,,,,,,,,,,,,,
NAIL LOCKING BOLT FIBULAR NAIL,SUP-2811063,CDM,C1713,HCPCS,0278,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
VALVE SHUNT INLINE PROGRAMMABLE,SUP-2243811,CDM,C1729,HCPCS,0272,RC,,,,both,,,14668.20,9534.33,,,,,,,,,,,,,
DISSECTOR SURG US 48 CM CRV JAW CRDLSS STRL SONICISION 7 LF,SUP-2863485,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1447.67,940.99,,,,,,,,,,,,,
SHEATH DIL SM 12FR L43CM OD0.215IN ID0.168IN STR TORQ DEL,SUP-2353109,CDM,C1894,HCPCS,0272,RC,,,,both,,,910.60,591.89,,,,,,,,,,,,,
PLATE BNE TIBIOTALOCALCANEAL LNG RT LAT STRADDLE,SUP-2751254,CDM,C1713,HCPCS,0278,RC,,,,both,,,6899.37,4484.59,,,,,,,,,,,,,
ALLOGRAFT DERMAL PTCH THCK 5X4 CM ACELLULAR HYDRATED DERM,SUP-2321761,CDM,C1713,HCPCS,0278,RC,,,,both,,,3893.60,2530.84,,,,,,,,,,,,,
PROSTHESIS OSS WEHRS II SHT 5.3X4.1X1.6X3.5 MM 0.9 MM HA,SUP-2638126,CDM,L8613,CPT,0278,RC,,,,both,,,1258.23,817.85,,,,,,,,,,,,,
PLATE BNE 2 MM 20 HOLE PT SPEC TI MATRIXMANDIBLE,SUP-2860073,CDM,C1713,HCPCS,0278,RC,,,,both,,,10719.65,6967.77,,,,,,,,,,,,,
HC Veeg by Tech 2-12 Hr Intmt Monitoring,PX-7409571200,CDM,95712,CPT,0740,RC,,,,inpatient,,,2592.00,1684.80,,,,,,,,,,,,,
FEE PROC ARTIX THROMCTMY SYS,SUP-2905442,CDM,C1757,HCPCS,0272,RC,,,,both,,,23550.00,15307.50,,,,,,,,,,,,,
GUIDE CORONARY SINUS WORLEY ADV CSG SHTH L 50 CM OD 0.157 IN,SUP-2303505,CDM,C1892,HCPCS,0272,RC,,,,both,,,1142.96,742.92,,,,,,,,,,,,,
ANCHOR SUT L20MM DIA2.8MM FOR ROT CUF REP Q-FIX,SUP-2341380,CDM,C1776,CPT,0278,RC,,,,both,,,1235.40,803.01,,,,,,,,,,,,,
BIT DRL QC 40-44 MM CTRL GLOB APG+,SUP-2453896,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1397.30,908.24,,,,,,,,,,,,,
NITROGLYCERIN 0.3 MG SL SUBL,RX-5603,CDM,6370000000,HCPCS,0637,RC,00071-0417-24,NDC,,both,1,UN,3.40,2.21,,,,,,,,,,,,,
SHEATH INTRO CEREBASE DA L 90 CM OD 8 FR ID 0.090 IN PTFE SS,SUP-2655902,CDM,C1894,HCPCS,0272,RC,,,,both,,,1870.40,1215.76,,,,,,,,,,,,,
PLATE BONE 8 H NONSTERILE STRNL TI STR LCK FOR 3MM SCR,SUP-2192446,CDM,C1713,HCPCS,0278,RC,,,,both,,,2937.16,1909.15,,,,,,,,,,,,,
SCREW BNE L95MM DIA5MM S STL ST VAR ANG FULL THRD CANN LOK,SUP-2178740,CDM,C1713,HCPCS,0278,RC,,,,both,,,906.49,589.22,,,,,,,,,,,,,
SET INT FIX SCREW DIA1.5 MM 6 H LNG TI NEURO STR PLT 12 PK,SUP-2935696,CDM,C1713,HCPCS,0278,RC,,,,both,,,21072.54,13697.15,,,,,,,,,,,,,
PLATE BNE HK SM 3.5/4.5X354 MM RT FEM PROX 10 HOLE NS VA-LCP,SUP-2750914,CDM,C1713,HCPCS,0278,RC,,,,both,,,8429.93,5479.45,,,,,,,,,,,,,
LEAD PACE PROTEGO S L 65 CM PTIR FRACTAL COAT DXA STEROID,SUP-2138291,CDM,C1777,HCPCS,0275,RC,,,,both,,,8792.00,5714.80,,,,,,,,,,,,,
IMMOBILIZER KNEE CUTAWAY E STRP 40IN CIRC 28IN,SUP-2194900,CDM,L1830,CPT,0274,RC,,,,both,,,115.65,75.17,,,,,,,,,,,,,
PLATE BNE SINGLE LISFRANC 2 HOLE STRATUM,SUP-2606571,CDM,C1713,HCPCS,0278,RC,,,,both,,,3675.21,2388.89,,,,,,,,,,,,,
GUIDEWIRE NOSE BALL 100CM,SUP-2478134,CDM,C1769,HCPCS,0272,RC,,,,both,,,6685.75,4345.74,,,,,,,,,,,,,
ALLOGRAFT BNE BLOCK FD IRRADIATED CANC,SUP-2867101,CDM,C1762,CPT,0278,RC,,,,both,,,1783.83,1159.49,,,,,,,,,,,,,
HC Cast Short Leg,PX-4502940500,CDM,29405,CPT,0450,RC,,,,both,,,848.00,551.20,,,,,,,,,,,,,
RESERVOIR VENT DRNGE 6MM BUR H CATHETER CONN STR SHAL,SUP-2278367,CDM,C1889,HCPCS,0278,RC,,,,both,,,390.11,253.57,,,,,,,,,,,,,
STENT GI AXIOS SADL L 10 MM LUMEN DIA20 MM CATH L 138 CM,SUP-2141523,CDM,C1874,HCPCS,0278,RC,,,,both,,,16154.83,10500.64,,,,,,,,,,,,,
HC So Theophylline,PX-3018019866,CDM,80198,CPT,0301,RC,,,,inpatient,,,437.00,284.05,,,,,,,,,,,,,
PROSTHESIS OSS 1 CENTERED DUO ALTO TOT,SUP-2479517,CDM,L8613,CPT,0278,RC,,,,both,,,1279.05,831.38,,,,,,,,,,,,,
PLATE BONE L67MM THK3.4MM 4 H BILAT S STL LCK COMPR NEUT RIG,SUP-2348980,CDM,C1713,HCPCS,0278,RC,,,,both,,,2628.53,1708.54,,,,,,,,,,,,,
INTRODUCER SHTH SL1 0.032 IN 8.5 FRX63 CM BRAIDED SWARTZ SL,SUP-2457832,CDM,C1893,HCPCS,0272,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
HC So Enterovirus,PX-3028665866,CDM,86658,CPT,0302,RC,,,,inpatient,,,158.00,102.70,,,,,,,,,,,,,
PLATE BNE L71MM 4 H L DST LAT FIBULAR VAR ANG LOK FOR 35MM,SUP-2349827,CDM,C1713,HCPCS,0278,RC,,,,both,,,5543.36,3603.18,,,,,,,,,,,,,
PLATE CRAN 160X120X40 MM PT SPEC IMPL PEEK,SUP-2860153,CDM,C1713,HCPCS,0278,RC,,,,both,,,43632.50,28361.12,,,,,,,,,,,,,
PIN FIX L3.5IN DIA1/8IN S STL FLUT HDLSS SQ END,SUP-2150349,CDM,C1713,HCPCS,0278,RC,,,,both,,,218.39,141.95,,,,,,,,,,,,,
ANCHOR SUT OD1MM NDL 2 0 MINI SFT JUGGERKNOT,SUP-2137229,CDM,C1713,HCPCS,0278,RC,,,,both,,,1427.79,928.06,,,,,,,,,,,,,
LEVOTHYROXINE SODIUM 88 MCG PO TABS,RX-10403,CDM,6370000000,HCPCS,0637,RC,42292-0038-20,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
KIT INTRO MAK-NV L 20 CM DIA 6 FR DIL 4 FR NONVASCULAR,SUP-2677151,CDM,C1894,HCPCS,0272,RC,,,,both,,,114.61,74.50,,,,,,,,,,,,,
CATHETER INTVASC OCCL CODA L 100 CM DIA10 FR BALLOON DIA 32,SUP-2750738,CDM,C2628,HCPCS,0272,RC,,,,both,,,1349.29,877.04,,,,,,,,,,,,,
GRAFT BONE MAR M + CONC,SUP-2163083,CDM,2720000010,LOCAL,0272,RC,,,,both,,,10676.00,6939.40,,,,,,,,,,,,,
ALLOGRAFT BNE PROX TIB DSTL HUM FRZN LT W/ PAT QUADRICEP,SUP-2717964,CDM,C1762,CPT,0278,RC,,,,both,,,25386.90,16501.48,,,,,,,,,,,,,
LINER ACET CUP 28 MM ID 0 DEG MTL AND POLY ON POLY SZ P5,SUP-2364629,CDM,C1776,CPT,0278,RC,,,,both,,,6572.30,4271.99,,,,,,,,,,,,,
INSERT TIBIAL CR IDENTITY ITOTAL 10MM,SUP-2719733,CDM,C1776,CPT,0278,RC,,,,both,,,775.58,504.13,,,,,,,,,,,,,
KIT CHOLANGIOGM SPHINTOM BILI EXT STR 44FR 20MM 0035IN,SUP-2149815,CDM,C1713,HCPCS,0278,RC,,,,both,,,876.06,569.44,,,,,,,,,,,,,
GRAFT BONE 100X20MM FEM CORT STRUT,SUP-2281642,CDM,C1713,HCPCS,0278,RC,,,,both,,,3747.28,2435.73,,,,,,,,,,,,,
TRACKER PT NAVIGATE SPINPERC VPAD,SUP-2392604,CDM,C1713,HCPCS,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
BUR SURG DIA 8 MM HUB I ROSEN STRL REUSE HI-LINE,SUP-2929616,CDM,2720000010,LOCAL,0272,RC,,,,both,,,261.41,169.92,,,,,,,,,,,,,
GRAFT BONE FEM HEMI CONDYLE RT MEDL FRSH STORED,SUP-2335224,CDM,C1713,HCPCS,0278,RC,,,,both,,,34524.30,22440.79,,,,,,,,,,,,,
SHAFT FIB TRAD ALLGRFT 40X14 - 18 MM FRZ DRY,SUP-2294103,CDM,C1713,HCPCS,0278,RC,,,,both,,,1764.68,1147.04,,,,,,,,,,,,,
GRAFT BNE SUB L 50X20X7MM DEMIN CANC N IRRADIATED DBMFORM,SUP-2354400,CDM,C1713,HCPCS,0278,RC,,,,both,,,2747.50,1785.87,,,,,,,,,,,,,
PIN FIX L100MM SPNL PERC DISP O ARM,SUP-2280201,CDM,2720000010,LOCAL,0272,RC,,,,both,,,963.98,626.59,,,,,,,,,,,,,
HC Iaad Ia Severe Aqt Respir Synd Coronavirus,PX-3068742600,CDM,87426,CPT,0306,RC,,,,inpatient,,,71.00,46.15,,,,,,,,,,,,,
IMPLANT NSL MID TURB ST MEDIENT,SUP-2123501,CDM,L8613,CPT,0278,RC,,,,both,,,420.76,273.49,,,,,,,,,,,,,
BASEPLATE TIB STD UNIV REV STEM CEM SZ 2 AMK,SUP-2251228,CDM,C1776,CPT,0278,RC,,,,both,,,7840.58,5096.38,,,,,,,,,,,,,
PLATE BNE FEM 3.5/4.5X285 MM LT PROX 9 HOLE NS VA-LCP,SUP-2757663,CDM,C1713,HCPCS,0278,RC,,,,both,,,7426.51,4827.23,,,,,,,,,,,,,
MARKER RADIOGRAPHIC L10MM DIA0.018IN PLAT CONSTRUCTION,SUP-2420155,CDM,A4648,CPT,0278,RC,,,,both,,,537.94,349.66,,,,,,,,,,,,,
PLATE BNE W8XL60MM THK2MM 0DEG 7 H BILAT S STL STR RIG DYN,SUP-2186179,CDM,C1713,HCPCS,0278,RC,,,,both,,,693.03,450.47,,,,,,,,,,,,,
DEFIBRILLATOR IMPL PROF MD TI POLYUR SIL SINGLE CHMBR IS1,SUP-2357744,CDM,C1722,HCPCS,0275,RC,,,,both,,,76616.00,49800.40,,,,,,,,,,,,,
HOOK ENDOSCP L4-9CM TIP FOR SEAL AND DISECT HARM,SUP-2219115,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1672.74,1087.28,,,,,,,,,,,,,
COMPONENT TIB KNEE LOK BAR COMPLT SYS VANGUARD,SUP-2405365,CDM,C1776,CPT,0278,RC,,,,both,,,301.44,195.94,,,,,,,,,,,,,
SCREW BNE COMPR HUM C LBL AG RETROGRADE AFFIXUS NAT NAIL,SUP-2606205,CDM,C1713,HCPCS,0278,RC,,,,both,,,1927.96,1253.17,,,,,,,,,,,,,
GRAFT VASC RESTOREFLOW SZ 18 MM PA COMPETENT VLV STRL,SUP-2884025,CDM,C1768,CPT,0278,RC,,,,both,,,73001.86,47451.21,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE DIA 7.5 MM SZ 3 CART ARAGONITE POROUS,SUP-2913149,CDM,C1763,HCPCS,0278,RC,,,,both,,,21666.00,14082.90,,,,,,,,,,,,,
BENDAMUSTINE HCL (UNBRANDED) 100 MG/4ML IV SOLN,RX-132213,CDM,J9036,HCPCS,0636,RC,10019-0079-01,NDC,,both,4,ML,6739.20,4380.48,,,,,,,,,,,,,
BLADE RETRCT W2XL7CM NAR MUSC MCCULLOCH,SUP-2161019,CDM,C1713,HCPCS,0278,RC,,,,both,,,606.96,394.52,,,,,,,,,,,,,
GRAFT BNE 450556,SUP-2838801,CDM,C1713,HCPCS,0278,RC,,,,both,,,2022.16,1314.40,,,,,,,,,,,,,
COMPONENT FEM KNEE POST STABILIZING UNISX REV PRESSFIT STEM,SUP-2199742,CDM,C1776,CPT,0278,RC,,,,both,,,23821.30,15483.84,,,,,,,,,,,,,
SCREW SPNL POST THORLUM TI CLS LOK ARMDA,SUP-2311943,CDM,C1713,HCPCS,0278,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
PLATE BNE L53MM THK1.2MM 2X8 H T SHP FOR 2MM SCR PRO-PAK,SUP-2186300,CDM,C1713,HCPCS,0278,RC,,,,both,,,1046.34,680.12,,,,,,,,,,,,,
ALLOGRAFT BNE FEM 209X13X3 MM FD STRUT,SUP-2717898,CDM,C1762,CPT,0278,RC,,,,both,,,3315.06,2154.79,,,,,,,,,,,,,
BIT DRL CANN 1.6X100 MM QC,SUP-2221710,CDM,2720000010,LOCAL,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
PROBE ELECTROTHERAPY DENERVATION SIMPLICITY,SUP-2357697,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
LINER ACET OD54MM ID28MM 10DEG MARATHON HIP REV DURALOC,SUP-2250508,CDM,C1776,CPT,0278,RC,,,,both,,,4848.16,3151.30,,,,,,,,,,,,,
SCREW BNE L16MM DIA5MM S STL ST VAR ANG LOK FULL THRD T25,SUP-2178698,CDM,C1713,HCPCS,0278,RC,,,,both,,,573.49,372.77,,,,,,,,,,,,,
HC So Hiv-2 Pcr,PX-3068753866,CDM,87538,CPT,0306,RC,,,,both,,,293.00,190.45,,,,,,,,,,,,,
PLATE BNE L24MM THK0.4MM 4 H CRANIOMAXILLOFACIAL BILAT BLU,SUP-2181556,CDM,C1713,HCPCS,0278,RC,,,,both,,,239.27,155.53,,,,,,,,,,,,,
BENZOCAINE-MENTHOL 20-0.5 % EX AERO,RX-28048,CDM,6370000000,HCPCS,0637,RC,51409-0007-22,NDC,,both,78,GR,26.70,17.35,,,,,,,,,,,,,
INSERT TIB SZ 3-4 THK15MM STD LT POST STBL PRI NEUT RENASYS,SUP-2350489,CDM,C1776,CPT,0278,RC,,,,both,,,3358.42,2182.97,,,,,,,,,,,,,
PARICALCITOL 1 MCG PO CAPS,RX-41497,CDM,6370000000,HCPCS,0637,RC,49483-0687-03,NDC,,both,1,UN,4.50,2.92,,,,,,,,,,,,,
CATHETER GUID 16FR L62CM DEFLECTED TIP REACH 28MM NK,SUP-2119937,CDM,C1894,HCPCS,0272,RC,,,,both,,,5529.54,3594.20,,,,,,,,,,,,,
POSITIONER PT LEG FOR SALVATION EXT FIX,SUP-2401156,CDM,2720000010,LOCAL,0272,RC,,,,both,,,894.90,581.68,,,,,,,,,,,,,
CORN STARCH-ZINC OXIDE 81-15 % EX POWD,RX-134174,CDM,6370000000,HCPCS,0637,RC,63736-0111-51,NDC,,both,142,GR,14.70,9.55,,,,,,,,,,,,,
KIT INSTR 3.5X8.5MM DISP FOR SL ANCHR THMB COLLATERAL LIGMNT,SUP-2419624,CDM,2720000010,LOCAL,0272,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
PLATE BNE SM TI MEDL MALL PEG NS UNITE,SUP-2897724,CDM,C1713,HCPCS,0278,RC,,,,both,,,4392.86,2855.36,,,,,,,,,,,,,
GRAFT BNE PAT TISS,SUP-2391739,CDM,C1713,HCPCS,0278,RC,,,,both,,,9143.68,5943.39,,,,,,,,,,,,,
PLATE BNE CLAV CS2 2.7 MM RT VA LCK COMPR TI STRL VALCP,SUP-2789618,CDM,C1713,HCPCS,0278,RC,,,,both,,,3737.48,2429.36,,,,,,,,,,,,,
STEM FEM SZ 6 CO CHROM CEM LD FX NAT HIP,SUP-2210730,CDM,C1776,CPT,0278,RC,,,,both,,,4104.61,2668.00,,,,,,,,,,,,,
GRAFT BONE SUB 30CC CANC CUBE,SUP-2212020,CDM,C1713,HCPCS,0278,RC,,,,both,,,1485.22,965.39,,,,,,,,,,,,,
PLATE BONE 80MMW X 80MML 06MM THK CP TTNM 3D F/15MM SCREW,SUP-2681435,CDM,C1713,HCPCS,0278,RC,,,,both,,,4919.06,3197.39,,,,,,,,,,,,,
TIP ASPIR L4.5IN OD1.92MM ID1.5MM SFT TISS SPETZLER,SUP-2367532,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1966.61,1278.30,,,,,,,,,,,,,
BIT DRL L330MM DIA3.2MM CALIB L100MM ST 3 FLUT QUIK CPL FOR,SUP-2178853,CDM,2720000010,LOCAL,0272,RC,,,,both,,,903.75,587.44,,,,,,,,,,,,,
PLATE CRAN W200XL200MM NONSTERILE TI RECTANG RIG CNTOUR MESH,SUP-2190623,CDM,C1713,HCPCS,0278,RC,,,,both,,,28608.54,18595.55,,,,,,,,,,,,,
TRIAL CBL MULTILD FOR DIR LD INFIN IPG,SUP-2101969,CDM,C1883,HCPCS,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
CATHETER SUPP NAVIEN L 130 CM OD 0.07 IN ID 0.058 IN FLX,SUP-2522809,CDM,C1887,HCPCS,0272,RC,,,,both,,,5290.90,3439.08,,,,,,,,,,,,,
STEM FEM OD19MM 12/14 131DEG PRSS FIT TAPR STD OFFSET,SUP-2222218,CDM,C1776,CPT,0278,RC,,,,both,,,14318.40,9306.96,,,,,,,,,,,,,
IMPLANT BIO PROXICOR PERICARDIAL CLOSURE 7X15CM,SUP-2172035,CDM,C1768,CPT,0278,RC,,,,both,,,4505.90,2928.83,,,,,,,,,,,,,
BEVACIZUMAB-BVZR 400 MG/16ML IV SOLN,RX-148791,CDM,Q5118,HCPCS,0636,RC,00069-0342-01,NDC,,both,16,ML,7066.40,4593.16,,,,,,,,,,,,,
K WIRE FIX L6IN DIA1.6MM NONSTERILE S STL 2 SIDE DBL DMND,SUP-2150659,CDM,C1713,HCPCS,0278,RC,,,,both,,,45.09,29.31,,,,,,,,,,,,,
CITRELOCK XPRESS IMPL SYS 5MM X 10MM,SUP-2900673,CDM,C1713,HCPCS,0278,RC,,,,both,,,5127.62,3332.95,,,,,,,,,,,,,
RING EXT FIX HALF 150 MM MR SAFE TI,SUP-2422193,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1357.11,882.12,,,,,,,,,,,,,
BRACE ORTHPDC ADLT M 6 6.5N RIGHT THUMB NPRN WRAP HOOK LOOP,SUP-2472988,CDM,L3931,HCPCS,0274,RC,,,,both,,,53.57,34.82,,,,,,,,,,,,,
PLATE BONE L130MM 11 HOLE BLTRL STNLSS STEEL STRGHT RCNSTRCT,SUP-2474985,CDM,C1713,HCPCS,0278,RC,,,,both,,,1179.86,766.91,,,,,,,,,,,,,
DISTRACTION INTRNL DIST MNDBLE ZRCH 2 TLTS TRANS STR 15 18,SUP-2681414,CDM,C1713,HCPCS,0278,RC,,,,both,,,17738.58,11530.08,,,,,,,,,,,,,
HC Anterior Epitaxis Simple,PX-4503090100,CDM,30901,CPT,0450,RC,,,,inpatient,,,214.00,139.10,,,,,,,,,,,,,
BRACE ORTHPDC ADLT M 6 6.5N RIGHT THUMB NPRN WRAP HOOK LOOP,SUP-2472988,CDM,L3931,HCPCS,0272,RC,,,,both,,,53.57,34.82,,,,,,,,,,,,,
COUNTERSINK SURG 3.5MM W/ AO QUIK CPL EVOS,SUP-2344050,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1234.02,802.11,,,,,,,,,,,,,
SYSTEM EMBOLIC PROTCT FILTERWIRE EZ L 300 CM RVD 2.25-3.5 MM,SUP-2145069,CDM,C1769,HCPCS,0272,RC,,,,both,,,4286.10,2785.96,,,,,,,,,,,,,
BIT DRL L333MM DIA4MM LNG ADD ON PILOT DISP FOR TRIGEN,SUP-2347048,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1519.85,987.90,,,,,,,,,,,,,
SPACER SPNL CORPECTOMY MED LG 0 DEG 30X25X3946 MM XPANDR,SUP-2740411,CDM,C1889,HCPCS,0278,RC,,,,both,,,18526.00,12041.90,,,,,,,,,,,,,
ALLOGRAFT BNE FIBULAR SHFT 51-100 MMX0.1 CM FD,SUP-2717856,CDM,C1762,CPT,0278,RC,,,,both,,,3049.25,1982.01,,,,,,,,,,,,,
COMPONENT FIX DF P HEMICAPDF P,SUP-2123623,CDM,C1776,CPT,0278,RC,,,,both,,,3997.22,2598.19,,,,,,,,,,,,,
HC N Block Paravert Thoracic 1st|BILATERAL PROCEDURE,PX-3606449000,CDM,64490,CPT,0360,RC,,,50,both,,,4864.00,3161.60,,,,,,,,,,,,,
CATHETER URETH L29CM DIA7FR BLLN L18CM DIA8.7MM PTFE S STL,SUP-2171310,CDM,C1726,HCPCS,0272,RC,,,,both,,,640.56,416.36,,,,,,,,,,,,,
METOPROLOL SUCCINATE ER 50 MG PO TB24,RX-30070,CDM,6370000000,HCPCS,0637,RC,55111-0467-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
MESH T SLNG 1CM W,SUP-2152280,CDM,C1771,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
CATHETER ATHRCTMY SILVERHAWK L 135 CM EFFECTIVE L 129 CM TIP,SUP-2173083,CDM,C1714,HCPCS,0272,RC,,,,both,,,8619.30,5602.54,,,,,,,,,,,,,
STENT TRACHBRONCH L95CM EXP L60MM DIA14MM TIP DIA4MM CVR,SUP-2141613,CDM,C1874,HCPCS,0278,RC,,,,both,,,9702.60,6306.69,,,,,,,,,,,,,
GRAFT HUM TISS PERICARD SM 40 MMX4 CM FD,SUP-2307104,CDM,C1713,HCPCS,0278,RC,,,,both,,,946.14,614.99,,,,,,,,,,,,,
TI MATRIXMANDIBLE 2X2 HOLE,SUP-2823041,CDM,C1713,HCPCS,0278,RC,,,,both,,,2582.65,1678.72,,,,,,,,,,,,,
STEM HUM PRSS FT 125 DEG 7X115 MM SHLDR AEQUALIS,SUP-2715567,CDM,C1776,CPT,0278,RC,,,,both,,,10622.62,6904.70,,,,,,,,,,,,,
GUIDEWIRE ORTH L 150 MM DIA1.1 MM SCREW DIA2.5/3 MM THRD FOR,SUP-2907642,CDM,C1769,HCPCS,0272,RC,,,,both,,,389.58,253.23,,,,,,,,,,,,,
KIT PROCEDURE ISSUMISITE CATHETER 45,SUP-2741798,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5413.36,3518.68,,,,,,,,,,,,,
PLATE BNE CONN 90 DEG 2 HOLE OFFSET NS,SUP-2799518,CDM,C1713,HCPCS,0278,RC,,,,both,,,306.34,199.12,,,,,,,,,,,,,
SYSTEM INJECT ISTENT TRABECULAR MICRO-BYPASS,SUP-2854046,CDM,C1783,HCPCS,0278,RC,,,,both,,,4867.00,3163.55,,,,,,,,,,,,,
VEST TRAC L98CM DIA72MM SYNTH LNR SH VERSATILE VAC FRM TOOL,SUP-2255763,CDM,L0810,HCPCS,0272,RC,,,,both,,,5165.30,3357.44,,,,,,,,,,,,,
KIT CATH HEMODIALYSI GLIDEPATH CHRONIC EXCHANGE 14.5 5397190 - ORDER UOM CA,SUP-2632952,CDM,C1750,HCPCS,0278,RC,,,,both,,,1277.98,830.69,,,,,,,,,,,,,
CATHETER ANGIOPLSTY RX 3X15 MM VOYAGER,SUP-2424269,CDM,C1725,HCPCS,0272,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
CATHETER APPL DL 17 CM 25 CM DUPLOCATH,SUP-2129874,CDM,C1751,HCPCS,0278,RC,,,,both,,,54.95,35.72,,,,,,,,,,,,,
MESH HERN RECTANGULAR 1 45X30 CM MONOFILAMENT VERSATEX,SUP-2752220,CDM,C1781,HCPCS,0278,RC,,,,both,,,1278.77,831.20,,,,,,,,,,,,,
BLADE SAW L 60 X W 16 MM D 12 MM THK MATERIAL 0.5 MM CUT 0.5,SUP-2929166,CDM,2720000010,LOCAL,0272,RC,,,,both,,,404.49,262.92,,,,,,,,,,,,,
ENDCAP ORTH L10MM DIA3.5MM STRL TI NAIL SPRL BLDE EXTN HUM,SUP-2192479,CDM,C1713,HCPCS,0278,RC,,,,both,,,759.44,493.64,,,,,,,,,,,,,
CATHETER PERI DLYS DBL CUF AD LT STR RADPQ STRP 15FR 43CM,SUP-2174275,CDM,C1752,HCPCS,0278,RC,,,,both,,,403.33,262.16,,,,,,,,,,,,,
SCREW BNE 22MM DIA 6MM EMGCY ABSRB LEIBINGER DELT SYS 10PK,SUP-2364997,CDM,C1713,HCPCS,0278,RC,,,,both,,,1869.43,1215.13,,,,,,,,,,,,,
BIT DRL L155MM DIA3.5MM SHT SHANK DISP FOR PERI LOC 4.5MM,SUP-2343998,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1105.63,718.66,,,,,,,,,,,,,
HC ED Clsd Tx Prox Hum Fx Manip,PX-4502360500,CDM,23605,CPT,0450,RC,,,,both,,,1633.00,1061.45,,,,,,,,,,,,,
KIT GJ TB 16FR BLLN 3-5ML JEJU L25.4CM SIL GASTROENT INT,SUP-2124600,CDM,2720000010,LOCAL,0272,RC,,,,both,,,559.33,363.56,,,,,,,,,,,,,
PROBE SURG BEYER 8X143 MM PGTL CRV BLNT RND KNURLED HNDL,SUP-2461814,CDM,2720000010,LOCAL,0272,RC,,,,both,,,351.05,228.18,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED STEJK4A] STRYKER CORP],SUP-2365946,CDM,C1776,CPT,0278,RC,,,,both,,,12230.30,7949.69,,,,,,,,,,,,,
GRAFT HUM TISS W4XL7CM THK04 08MM ACELLULAR DERM MTRX,SUP-2307444,CDM,Q4128,HCPCS,0636,RC,,,,both,,,1689.70,1098.30,,,,,,,,,,,,,
ANCHOR SUTURE BIOCOMP SWIVELOCK FIBERTAPE LOOP STRL,SUP-2882187,CDM,C1713,HCPCS,0278,RC,,,,both,,,8148.30,5296.39,,,,,,,,,,,,,
SURGICAL PROCEDURE PACK EYE DR LAKHANI,SUP-2110954,CDM,C1713,HCPCS,0278,RC,,,,both,,,788.23,512.35,,,,,,,,,,,,,
SNARE VASC OPTEASE L 80 CM DIA10 FR NIT FEM LP LNG SIDE,SUP-2153947,CDM,2720000010,LOCAL,0272,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
HC Trigger Point 3 or More,PX-5102055300,CDM,20553,CPT,0510,RC,,,,inpatient,,,775.00,503.75,,,,,,,,,,,,,
SCREW BNE LCK 2.5X13 MM CRANIOMAXILLOFACIAL TI MAXDRIVE,SUP-2468299,CDM,C1713,HCPCS,0278,RC,,,,both,,,466.01,302.91,,,,,,,,,,,,,
CATHETER VASC GUID CLS CRV 3.75 COR W/O HYDRPHLC COAT AD,SUP-2139824,CDM,C1887,HCPCS,0272,RC,,,,both,,,147.58,95.93,,,,,,,,,,,,,
RING EXT FIX UNIV LAM THOR TI FRONTAL HALF HK USS,SUP-2193624,CDM,C1713,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
BUR SURG DIA 6 MM HUB III ROSEN STRL DISP HI-LINE XS,SUP-2929270,CDM,2720000010,LOCAL,0272,RC,,,,both,,,374.95,243.72,,,,,,,,,,,,,
GRAFT HUM TISS XSM W9XL15CM THK07 14MM THN ACELLULAR,SUP-2307600,CDM,Q4128,HCPCS,0636,RC,,,,both,,,15751.97,10238.78,,,,,,,,,,,,,
CANNULA VEN LNG 21 FR UNCOATED HLS,SUP-2663480,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1369.70,890.30,,,,,,,,,,,,,
BRACE KNEE LG W/ FAN STBL,SUP-2337058,CDM,L1810,HCPCS,0274,RC,,,,both,,,133.48,86.76,,,,,,,,,,,,,
SCREW BNE L13MM OD27MM TI LOK TAPR THREADLOCK TS,SUP-2262839,CDM,C1713,HCPCS,0278,RC,,,,both,,,453.73,294.92,,,,,,,,,,,,,
HC NM Liver Image With Flow,PX-3417820200,CDM,78202,CPT,0341,RC,,,,both,,,2641.00,1716.65,,,,,,,,,,,,,
AXLE TIB SM ROT HNG KINEMATIC,SUP-2376474,CDM,C1776,CPT,0278,RC,,,,both,,,2530.68,1644.94,,,,,,,,,,,,,
IMPLANT BIO W 7 X H 4 CM THK 2P PORCINE SM INTEST SUBMUCOSA,SUP-2884036,CDM,C1768,CPT,0278,RC,,,,both,,,4380.30,2847.19,,,,,,,,,,,,,
PLATE BONE W16XL190MM THK5MM 9 H LT CNDYL FEM S STL BTTRS,SUP-2185804,CDM,C1713,HCPCS,0278,RC,,,,both,,,2499.60,1624.74,,,,,,,,,,,,,
SCREW SPNL L50MM DIA6.5MM CANC PEDCL THORLUM TI NTHRD LOK,SUP-2229413,CDM,C1713,HCPCS,0278,RC,,,,both,,,1899.70,1234.80,,,,,,,,,,,,,
HC Joint Bursa Inj Med Arm,PX-7612060500,CDM,20605,CPT,0761,RC,,,,both,,,358.00,232.70,,,,,,,,,,,,,
GRAFT VASC L 45 MM ID 5 MM CLLGN BOV CAR ART WOVEN,SUP-2880946,CDM,C1768,CPT,0278,RC,,,,both,,,13593.06,8835.49,,,,,,,,,,,,,
IMPLANT NSL DESIGN A LG 8X66 MM DORSUM SHP MEDPOR LF,SUP-2366464,CDM,C1889,HCPCS,0278,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
DILTIAZEM HCL-SODIUM CHLORIDE 125-0.7 MG/125ML-% IV SOLN,RX-148148,CDM,2500000003,HCPCS,0250,RC,69374-0997-15,NDC,,both,125,ML,82.70,53.75,,,,,,,,,,,,,
RAIL EXT FIX MINI 4 IN SYS RX-FIX,SUP-2517152,CDM,2720000010,LOCAL,0272,RC,,,,both,,,9360.34,6084.22,,,,,,,,,,,,,
SCREW BNE L11MM OD2MM S STL IMPL FRAC CORRECTIVE OSTEOTMY,SUP-2361633,CDM,C1713,HCPCS,0278,RC,,,,both,,,763.33,496.16,,,,,,,,,,,,,
GRAFT BNE 30ML CANC MIC MORSL B-TCP VITOSS,SUP-2368166,CDM,C1713,HCPCS,0278,RC,,,,both,,,4524.74,2941.08,,,,,,,,,,,,,
SCREW BNE L 160 MM DIA 8 MM TI ST SD CANN FULL THRD RVS CUT,SUP-2901010,CDM,C1713,HCPCS,0278,RC,,,,both,,,1297.32,843.26,,,,,,,,,,,,,
GRAFT BONE SUB 20ML VOID FIL GRAN PLEXUR +,SUP-2293936,CDM,C1713,HCPCS,0278,RC,,,,both,,,4640.92,3016.60,,,,,,,,,,,,,
HC L-Spine 2-3 Views,PX-3207210000,CDM,72100,CPT,0320,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
CATHETER EP 6FR L110CM 1MM TIP 2-5-2MM SPC M CRV DECAPOLAR,SUP-2357621,CDM,C1730,HCPCS,0272,RC,,,,both,,,1428.70,928.65,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 70 CM DIA 8 MM RNG L 30 CM EPTFE,SUP-2396302,CDM,C1768,CPT,0278,RC,,,,both,,,3293.86,2141.01,,,,,,,,,,,,,
ANCHOR SUT OD2.3MM 2 WHT ULTRABRAID OSTEORAPTOR,SUP-2341113,CDM,C1713,HCPCS,0278,RC,,,,both,,,1026.78,667.41,,,,,,,,,,,,,
PLATE BNE L 209 MM SCREW DIA 4.5 MM 11 H LT PROX LAT TIB NS,SUP-2932989,CDM,C1713,HCPCS,0278,RC,,,,both,,,10223.84,6645.50,,,,,,,,,,,,,
PLATE BONE FAN 44.6X1.5 MM REINFORCED POROUS POLYETHYLENE TI,SUP-2837805,CDM,C1713,HCPCS,0278,RC,,,,both,,,4804.83,3123.14,,,,,,,,,,,,,
GUIDEWIRE ORTH 3.2 MM W/ STP STRL,SUP-2789606,CDM,C1769,HCPCS,0272,RC,,,,both,,,538.82,350.23,,,,,,,,,,,,,
CENTRALIZER STEM DIA11MM UNIV DST HIP,SUP-2210693,CDM,C1776,CPT,0278,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
RESERVOIR 20MM 15 WITH UND SHUNT ASSISTANT HYDRO SPRUNG PROG,SUP-2821839,CDM,C1889,HCPCS,0278,RC,,,,both,,,8912.76,5793.29,,,,,,,,,,,,,
INSERT REDUC SCR BLK,SUP-2289268,CDM,C1713,HCPCS,0278,RC,,,,both,,,828.96,538.82,,,,,,,,,,,,,
ALBUTEROL SULFATE 4 MG PO TABS,RX-254,CDM,6370000000,HCPCS,0637,RC,69238-1345-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
DEFIBRILLATOR IMPL COGNIS W 6.17 X H 7.95 CM D 0.99 CM 72 GM,SUP-2149260,CDM,C1882,HCPCS,0275,RC,,,,both,,,62800.00,40820.00,,,,,,,,,,,,,
ALLOGRAFT BNE PASTE 3 CC DEMINERALIZED BNE MTRX + CANC,SUP-2717766,CDM,C1713,HCPCS,0278,RC,,,,both,,,2472.31,1607.00,,,,,,,,,,,,,
WIRE FIX TROCAR PT 1 END 0.062X12 IN RND END SS NS KIRSCHNER,SUP-2791265,CDM,C1713,HCPCS,0278,RC,,,,both,,,8.85,5.75,,,,,,,,,,,,,
BIT DRILL QUICK COUPLING MINI 0.76X19 MM 5 MM WITH STOP NON,SUP-2837981,CDM,2720000010,LOCAL,0272,RC,,,,both,,,569.28,370.03,,,,,,,,,,,,,
SHEATH INTRO FAST-CATH CSTA L 60 CM DIA 8 FR GUIDEWIRE L 145,SUP-2357180,CDM,C1894,HCPCS,0272,RC,,,,both,,,530.66,344.93,,,,,,,,,,,,,
"HC Culture, Fungus Blood",PX-3008710300,CDM,87103,CPT,0300,RC,,,,outpatient,,,454.00,295.10,,,,,,,,,,,,,
CATHETER INTVENT 2X2.5FR L156CM ID0.021IN TIP DIA0.021IN,SUP-2305466,CDM,C1887,HCPCS,0272,RC,,,,both,,,3202.80,2081.82,,,,,,,,,,,,,
DRIVER SURG OD15MM M HEX FOR EVOLUTION C CERV IMPL REM SYS,SUP-2293604,CDM,C1713,HCPCS,0278,RC,,,,both,,,159.42,103.62,,,,,,,,,,,,,
IBAL TKA FEM IMP PS CEMENTED SZ 4 LFT,SUP-2813065,CDM,C1776,CPT,0278,RC,,,,both,,,4396.00,2857.40,,,,,,,,,,,,,
HC Perq Dev Soft Tiss Add Imag,PX-3611003600,CDM,10036,CPT,0361,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
GRAFT VASC HEMGRD L 40 CM DIA10 MM POLYESTER BOV CLLGN STR,SUP-2227539,CDM,C1768,CPT,0278,RC,,,,both,,,1737.61,1129.45,,,,,,,,,,,,,
IMPLANT K-WIRE 9X.035 IN,SUP-2363583,CDM,C1713,HCPCS,0278,RC,,,,both,,,24.18,15.72,,,,,,,,,,,,,
ETRAVIRINE 100 MG PO TABS,RX-89432,CDM,6370000000,HCPCS,0637,RC,59676-0570-01,NDC,,both,1,UN,56.20,36.53,,,,,,,,,,,,,
POSTERIOR PILON FUSION PLATE 7H,SUP-2815015,CDM,C1713,HCPCS,0278,RC,,,,both,,,10205.00,6633.25,,,,,,,,,,,,,
NEEDLE BRST LOC 20GAX5CM REPOSITIONAL MRK SYS BARB DISP HAWK,SUP-2120048,CDM,C1819,HCPCS,0278,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
CATHETER INTERMED REVIVE IC L 115 CM OD 5 FR ID 0.056 IN,SUP-2460546,CDM,C1887,HCPCS,0272,RC,,,,both,,,4509.54,2931.20,,,,,,,,,,,,,
CATHETER GUID MP OUTER CPS DIR SL,SUP-2357293,CDM,C1887,HCPCS,0272,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
ANCHOR SUT TI UP EXT ST W/ CIR TAPR NDL 2 STRANDS FULL THRD,SUP-2366679,CDM,C1713,HCPCS,0278,RC,,,,both,,,872.57,567.17,,,,,,,,,,,,,
GRAFT BNE KT 5 CC W/ BEAD MOLD TY GENEX,SUP-2867001,CDM,C1713,HCPCS,0278,RC,,,,both,,,6418.16,4171.80,,,,,,,,,,,,,
STENT TRACHBRONCH WSTNT L 40 MM DIA16 MM SHTH 10 FR CATH L,SUP-2142677,CDM,C1876,HCPCS,0278,RC,,,,both,,,3221.48,2093.96,,,,,,,,,,,,,
PROSTATE SEEDING SET 18 GAX20 CM RIGID ETW STRL LTX,SUP-2876583,CDM,2720000010,LOCAL,0272,RC,,,,both,,,38.31,24.90,,,,,,,,,,,,,
PLATE SPNL L45-47MM POST THORLUM TI LO PROF FOR 5.5MM ROD,SUP-2289530,CDM,C1713,HCPCS,0278,RC,,,,both,,,1938.95,1260.32,,,,,,,,,,,,,
PACEMAKER CARD CYLOS DR-T TI POLYUR SIL 2 CHMBR IS1 CONN,SUP-2138080,CDM,C1785,HCPCS,0275,RC,,,,both,,,20378.60,13246.09,,,,,,,,,,,,,
PLATE BNE L133MM 10 H TI FIBULAR COMP LOK COMPR FOR,SUP-2413684,CDM,C1713,HCPCS,0278,RC,,,,both,,,886.33,576.11,,,,,,,,,,,,,
PATCH REP 2X9 CM DURA-GUARD,SUP-2129885,CDM,C1763,HCPCS,0278,RC,,,,both,,,966.49,628.22,,,,,,,,,,,,,
HC Diffusing Capacity,PX-4609472900,CDM,94729,CPT,0460,RC,,,,both,,,509.00,330.85,,,,,,,,,,,,,
BRONCHOSCOPE GS BFLEX 2 LARGE 5.8 SU,SUP-2864558,CDM,2720000010,LOCAL,0272,RC,,,,both,,,939.49,610.67,,,,,,,,,,,,,
GRAFT HUM TISS DERMACELL POROUS 5X5CM 25SQCM,SUP-2909334,CDM,Q4122,HCPCS,0636,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
PATCH VASC HEMAPATCH L 100 X W 25 MM THK 0.65 MM POLYESTER,SUP-2525490,CDM,C1768,CPT,0278,RC,,,,both,,,430.21,279.64,,,,,,,,,,,,,
SPLINT CLAV XSM 20 24IN WHT HVY PD FELT FOAM CNTCT CLSR,SUP-2196987,CDM,L3650,HCPCS,0272,RC,,,,both,,,17.40,11.31,,,,,,,,,,,,,
KIT MICROSNARE 2.3-3FR L175CM LOOP DIA4MM CATH L150CM G PLT,SUP-2173553,CDM,C1773,HCPCS,0272,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
CATHETER HAD L15CM OD15FR SIL POLYUR ACUTE 2 LUMN TIP CLP,SUP-2118062,CDM,C1752,HCPCS,0278,RC,,,,both,,,333.06,216.49,,,,,,,,,,,,,
CATHETER THROMCTMY L 180 CM DIA 0.014 IN HELCL STRL,SUP-2365834,CDM,C1757,HCPCS,0272,RC,,,,both,,,10660.30,6929.19,,,,,,,,,,,,,
ADAPTER EXT L 20 CM FOR BSX NEVRO LD STRL DISP,SUP-2882921,CDM,C1883,HCPCS,0278,RC,,,,both,,,3202.80,2081.82,,,,,,,,,,,,,
LEAD PERC MRI AVISTA 8 CONTACT 56CM,SUP-2138798,CDM,C1778,HCPCS,0278,RC,,,,both,,,10519.00,6837.35,,,,,,,,,,,,,
STEM FEM SZ 0 TRABECULAR MTL CEM NP NATURAL-HIP,SUP-2210708,CDM,C1776,CPT,0278,RC,,,,both,,,16453.60,10694.84,,,,,,,,,,,,,
CATHETER ANGIOPLSTY 5FR L130CM BAL L120CM DIA7MM DRUG COAT,SUP-2128376,CDM,C2623,HCPCS,0278,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
COMPONENT TIB CR 2XS UNIV PEDIATRIC 11 MM STEM NP MONOBLOCK,SUP-2376416,CDM,C1776,CPT,0278,RC,,,,both,,,3898.00,2533.70,,,,,,,,,,,,,
PLATE BONE LOK HLX12 LTRL CLMN RIGHT DST VOLAR RDL,SUP-2721390,CDM,C1713,HCPCS,0278,RC,,,,both,,,3376.50,2194.72,,,,,,,,,,,,,
SCREW BONE L30MM DIA6MM STRL CORT TI ST CANN LCK FULL THRD,SUP-2191859,CDM,C1713,HCPCS,0278,RC,,,,both,,,781.29,507.84,,,,,,,,,,,,,
INSTRUMENT REPROC SEAL/DIVIDE LIGASURE SM JAW CRV TIP 7.4IN,SUP-2527601,CDM,2720000010,LOCAL,0272,RC,,,,both,,,880.93,572.60,,,,,,,,,,,,,
SCREW BNE L4MM DIA1.5MM TI SELF DRL FULL THRD CRSS PIN COR,SUP-2366090,CDM,C1713,HCPCS,0278,RC,,,,both,,,223.07,145.00,,,,,,,,,,,,,
HC So Ammonia,PX-3018214066,CDM,82140,CPT,0301,RC,,,,both,,,72.00,46.80,,,,,,,,,,,,,
PLATE BNE W135XL404MM THK42MM 22 H BILAT S STL NAR LOK,SUP-2185260,CDM,C1713,HCPCS,0278,RC,,,,both,,,3741.37,2431.89,,,,,,,,,,,,,
BONE REDUCTION CLAMP BLUNT LAG SCREW SYSTEM,SUP-2473871,CDM,2720000010,LOCAL,0272,RC,,,,both,,,770.81,501.03,,,,,,,,,,,,,
COMPONENT BPLR OD54MM ID26MM FEM CO CHROM ASSEMB,SUP-2207812,CDM,C1776,CPT,0278,RC,,,,both,,,4219.75,2742.84,,,,,,,,,,,,,
EXPANDER TISS SELF TIGHT CONT EXT DERMACLOSE,SUP-2396767,CDM,C1789,HCPCS,0278,RC,,,,both,,,3136.86,2038.96,,,,,,,,,,,,,
DISTRACTOR ANGULAR 100MM FOR TRUELOK FIX SYS,SUP-2316082,CDM,C1713,HCPCS,0278,RC,,,,both,,,3246.01,2109.91,,,,,,,,,,,,,
CATHETER PICC 5FR L55CM 2 LUMN MAX BARR W/ SHERLOCK 3CG TPS,SUP-2125512,CDM,C1751,HCPCS,0278,RC,,,,both,,,662.82,430.83,,,,,,,,,,,,,
SCREW SPNL MULTAXL XS 3X22 MM OCCIPITOCERVICAL UPPER THOR,SUP-2631944,CDM,C1713,HCPCS,0278,RC,,,,both,,,1789.80,1163.37,,,,,,,,,,,,,
BASKET SPEC RETRV STONE 4.5 FRX85 CM W/O HNDL FLX CYSTOSCOPE,SUP-2772965,CDM,2720000010,LOCAL,0272,RC,,,,both,,,409.64,266.27,,,,,,,,,,,,,
PLEDGET CV L 9.5 X W 4.8 MM THK 0.65 MM PTFE FELT RECT SHP,SUP-2761354,CDM,C1768,CPT,0278,RC,,,,both,,,31.40,20.41,,,,,,,,,,,,,
INSERT TIB REV KNEE RP BX CUT ATTUNE,SUP-2454416,CDM,C1776,CPT,0278,RC,,,,both,,,3322.12,2159.38,,,,,,,,,,,,,
SET INT FIX SCREW DIA1.5 MM 2 H TI NEURO WIDE PLATE 12 PK,SUP-2935261,CDM,C1713,HCPCS,0278,RC,,,,both,,,9134.26,5937.27,,,,,,,,,,,,,
CLAMP EXT FIX OPT FASTFRAME,SUP-2498315,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
HC Blood Split Unit,PX-3900901100,CDM,P9011,HCPCS,0390,RC,,,,outpatient,,,730.00,474.50,,,,,,,,,,,,,
GRAFT BNE SUB W7XL30MM WDG FOR OSTEOTMY OSFERION,SUP-2121046,CDM,C1713,HCPCS,0278,RC,,,,both,,,1398.87,909.27,,,,,,,,,,,,,
CATHETER CV TY 7 FRX15 CM 3L CUTLMY701JABRMCUSTOM0014,SUP-2759904,CDM,C1751,HCPCS,0278,RC,,,,both,,,510.31,331.70,,,,,,,,,,,,,
PLATE BNE W22XL51MM 12 H R DST VOLAR RAD WRST NAR LOK,SUP-2411815,CDM,C1713,HCPCS,0278,RC,,,,both,,,3171.40,2061.41,,,,,,,,,,,,,
GUIDEWIRE ORTH 3.2 MM W/ STP NS,SUP-2757692,CDM,C1769,HCPCS,0272,RC,,,,both,,,489.97,318.48,,,,,,,,,,,,,
HC Pt Ultrasound Each 15 Min,PX-4209703500,CDM,97035,CPT,0420,RC,,,,outpatient,,,194.00,126.10,,,,,,,,,,,,,
CHEEK RETRACTOR RING,SUP-2827971,CDM,C1713,HCPCS,0278,RC,,,,both,,,934.15,607.20,,,,,,,,,,,,,
PROSTHESIS OSS VENT TUBE 1.27X0.050X1.65 MM BUTTON FLROPLAS,SUP-2312804,CDM,L8699,HCPCS,0278,RC,,,,both,,,19.81,12.88,,,,,,,,,,,,,
KNEE VNGD TI FEM PS 60MM RT,SUP-2510720,CDM,C1713,HCPCS,0278,RC,,,,both,,,5966.00,3877.90,,,,,,,,,,,,,
BELT RIB XL 6 IN M ELASTIC VELCRO CLOSURE,SUP-2194761,CDM,L0220,HCPCS,0272,RC,,,,both,,,22.95,14.92,,,,,,,,,,,,,
CONFORM FLEX Q-PACK 6 MM CUBE 3 PACK,SUP-2547191,CDM,C1713,HCPCS,0278,RC,,,,both,,,1040.47,676.31,,,,,,,,,,,,,
GRAFT DERMAL MESH 16X8 CM SM CRV RECON TISS MTRX STRATTICE,SUP-2422960,CDM,C1781,HCPCS,0278,RC,,,,both,,,7344.46,4773.90,,,,,,,,,,,,,
BIT DRL DIA5MM FOR SALVATION SYS,SUP-2400808,CDM,2720000010,LOCAL,0272,RC,,,,both,,,985.96,640.87,,,,,,,,,,,,,
CATHETER HD DL 14 FRX12 CM ADMIN BASIC KT DURAFLO,SUP-2266958,CDM,C1750,HCPCS,0278,RC,,,,both,,,185.26,120.42,,,,,,,,,,,,,
FAMOTIDINE 40 MG/5ML PO SUSR,RX-10010,CDM,340b,HCPCS,0637,RC,31722-0063-31,NDC,,both,1.25,ML,2.70,1.75,,,,,,,,,,,,,
TRAY NERVE BLOCK CANN DIA25 GA S25BKN NRFIT STRL DISP,SUP-2936465,CDM,2720000010,LOCAL,0272,RC,,,,both,,,48.54,31.55,,,,,,,,,,,,,
PLATE BUR H L18.5MM CRAN W/ SLOT THINFLAP,SUP-2137622,CDM,C1713,HCPCS,0278,RC,,,,both,,,744.18,483.72,,,,,,,,,,,,,
SOUND PROC HEARING DEV TWO PT KT SONNET 2,SUP-2905156,CDM,L8619,HCPCS,0278,RC,,,,both,,,37513.58,24383.83,,,,,,,,,,,,,
GRAFT BNE SUB 90CC SZ 05 5MM CORT CANC GRAN FRZ DRY,SUP-2307058,CDM,C1713,HCPCS,0278,RC,,,,both,,,3135.01,2037.76,,,,,,,,,,,,,
CATHETER ETER CARD 6FR 2 5 2MM ABLAT CSL CRV ELECTRD SPC 65CM LEN,SUP-2356836,CDM,C1730,HCPCS,0272,RC,,,,both,,,1208.90,785.78,,,,,,,,,,,,,
PLATE BONE 12X3 H MESH FOR 2.4MM SCR VLP MINI-MOD SM BONE,SUP-2351099,CDM,C1713,HCPCS,0278,RC,,,,both,,,6198.20,4028.83,,,,,,,,,,,,,
SLEEVE CNTR DIA9MM SHLDR PMMA BIOMOD,SUP-2404625,CDM,C1776,CPT,0278,RC,,,,both,,,797.56,518.41,,,,,,,,,,,,,
PLATE BNE THK0.6MM 2X5 H BILAT HND T SHP NONCOMPRESSION,SUP-2267878,CDM,C1713,HCPCS,0278,RC,,,,both,,,693.31,450.65,,,,,,,,,,,,,
RESERVOIR DRNGE 6MM BUR H W/ NYL BASE SALM,SUP-2243787,CDM,C1729,HCPCS,0272,RC,,,,both,,,1378.46,896.00,,,,,,,,,,,,,
EELECTRODE COAG 0.35 24/26 FR POINTED,SUP-2585817,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1298.14,843.79,,,,,,,,,,,,,
PLATE BNE STR WRST FUSION BEND SS NS LCP,SUP-2183196,CDM,C1713,HCPCS,0278,RC,,,,both,,,4935.08,3207.80,,,,,,,,,,,,,
PLATE BNE CONTOURABLE MESH 100X0.6 MM RIGID TI SLV NS,SUP-2859915,CDM,C1713,HCPCS,0278,RC,,,,both,,,6249.23,4062.00,,,,,,,,,,,,,
COMPONENT HIP FOR PK 4500,SUP-2212672,CDM,C1776,CPT,0278,RC,,,,both,,,14130.00,9184.50,,,,,,,,,,,,,
GRAFT BNE ANTR TIBIALIS 10.5X350 MM ASEP,SUP-2264572,CDM,C1713,HCPCS,0278,RC,,,,both,,,6914.28,4494.28,,,,,,,,,,,,,
WASHER ORTH STRL FOR 3.5MM SCR EVOS SM PLATING SYS,SUP-2349664,CDM,C1776,CPT,0278,RC,,,,both,,,220.68,143.44,,,,,,,,,,,,,
PLATE BONE ANTR BOW LAT PROX 20 H FOR 3.5 SCR,SUP-2349065,CDM,C1713,HCPCS,0278,RC,,,,both,,,1218.57,792.07,,,,,,,,,,,,,
COMPONENT FEM SZ 1 CO CHROM LT KNEE REV STEMLESS POST STBL,SUP-2346122,CDM,C1776,CPT,0278,RC,,,,both,,,19848.73,12901.67,,,,,,,,,,,,,
CATHETER CV SET 032 7 FRX20 CM 3L RIFAMPIN SPECTRUM,SUP-2759978,CDM,C1751,HCPCS,0278,RC,,,,both,,,255.88,166.32,,,,,,,,,,,,,
FIBER LSWER SINGLE USE 200U SLIMLINE SIS EZ,SUP-2724146,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1295.25,841.91,,,,,,,,,,,,,
INSERT TIB RP FEM KNEE CEM,SUP-2249577,CDM,C1776,CPT,0278,RC,,,,both,,,14130.00,9184.50,,,,,,,,,,,,,
FIBER LASER 400 MH REUSE,SUP-2479649,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2131.21,1385.29,,,,,,,,,,,,,
STENT TRACHBRONCH COOK-Z GIANTURCO-ROSCH L 5 CM DIA15 MM,SUP-2693656,CDM,C1877,HCPCS,0278,RC,,,,both,,,2888.80,1877.72,,,,,,,,,,,,,
STABILIZER SHLDR SM UNIV HARN ARM BND FOR FOOTBALL PLAYER,SUP-2150933,CDM,L3660,HCPCS,0272,RC,,,,both,,,325.93,211.85,,,,,,,,,,,,,
PATCH VASC HEMAPATCH L 100 X W 100 MM THK 0.65 MM POLYESTER,SUP-2227506,CDM,C1781,HCPCS,0278,RC,,,,both,,,790.34,513.72,,,,,,,,,,,,,
PLATE SHIFT CLAVICLE SHAFT 3.5 RT 7 HL L 88 R,SUP-2719491,CDM,C1713,HCPCS,0278,RC,,,,both,,,4301.39,2795.90,,,,,,,,,,,,,
RING EXT FIX FULL 140 MM CARBON FIBER NS,SUP-2800124,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2859.28,1858.53,,,,,,,,,,,,,
PLATE BNE CRV 4.5X230 MM RT CNDYL 10 HOLE VA LCK STRL VALCP,SUP-2789389,CDM,C1713,HCPCS,0278,RC,,,,both,,,6384.06,4149.64,,,,,,,,,,,,,
RITUXIMAB-PVVR (RUXIENCE) 10 MG/ML IV SOLN (MIXTURES ONLY),RX-4081835,CDM,Q5119,HCPCS,0636,RC,00069-0238-01,NDC,,both,10,ML,2064.40,1341.86,,,,,,,,,,,,,
STENT BILI HERCLNK + L 12 MM DIA 6 MM CATH L 80 CM GUIDEWIRE,SUP-2101562,CDM,C1876,HCPCS,0278,RC,,,,both,,,1962.50,1275.62,,,,,,,,,,,,,
PLATE BONE THK0.3MM NONSTERILE LT MEDL WALL TI FOR 1MM SCR,SUP-2190578,CDM,C1713,HCPCS,0278,RC,,,,both,,,4705.92,3058.85,,,,,,,,,,,,,
DESMOPRESSIN ACETATE PF 4 MCG/ML IJ SOLN,RX-153915,CDM,J2597,HCPCS,0636,RC,69918-0899-10,NDC,,both,0.25,ML,54.70,35.55,,,,,,,,,,,,,
COLLAR CERV FIRM 3X21IN XL,SUP-2276594,CDM,L0120,HCPCS,0272,RC,,,,both,,,6.69,4.35,,,,,,,,,,,,,
BUTTON GAST ACCS L44CM DIA24FR LO PROF PUL PEG KT 1 STP,SUP-2149749,CDM,C1733,HCPCS,0272,RC,,,,both,,,538.51,350.03,,,,,,,,,,,,,
GRAFT VASC GELSFT L 45 CM DIA12 MM BRANCH DIA 6 MM POLYESTER,SUP-2384919,CDM,C1768,CPT,0278,RC,,,,both,,,3815.10,2479.81,,,,,,,,,,,,,
DILTIAZEM HCL ER 120 MG PO CP12,RX-11892,CDM,6370000000,HCPCS,0637,RC,00378-6120-01,NDC,,both,1,UN,17.10,11.11,,,,,,,,,,,,,
SCREW SPNL HEX 1.2X9 MM 7 MM THRD MAXDRIVE ZURICH 503480909,SUP-2460177,CDM,C1713,HCPCS,0278,RC,,,,both,,,509.50,331.17,,,,,,,,,,,,,
ROD THRD 120MM FOR RINGFIX SYS,SUP-2378779,CDM,C1713,HCPCS,0278,RC,,,,both,,,109.90,71.43,,,,,,,,,,,,,
EXTRACTOR SURG L675IN 24MM TIB PIN DRVR RUSH,SUP-2409753,CDM,C1713,HCPCS,0278,RC,,,,both,,,1314.40,854.36,,,,,,,,,,,,,
MANNITOL 20 % IV SOLN,RX-4749,CDM,2500000003,HCPCS,0250,RC,00264-7578-10,NDC,,both,125,ML,71.90,46.73,,,,,,,,,,,,,
STAPLE BONE FIX W12XL25MM CO CHROM LAT LIGMNT 2 PRNG N THRD,SUP-2342730,CDM,C1713,HCPCS,0278,RC,,,,both,,,2954.43,1920.38,,,,,,,,,,,,,
SYSTEM CONC WHL BLD INPUT 30ML PLT RICH POOR PLSM OUTPT,SUP-2402588,CDM,C1713,HCPCS,0278,RC,,,,both,,,3571.75,2321.64,,,,,,,,,,,,,
CATHETER CARD ABLATION RF MARINR L 80 CM DIA 5 FR TIP L 65,SUP-2749546,CDM,C1732,HCPCS,0272,RC,,,,both,,,1491.50,969.47,,,,,,,,,,,,,
BLADE RTRCTR MCCLLCH 20MMW X 80MML SPNL MSCLE NRRW RGGLS RDM,SUP-2670370,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1606.49,1044.22,,,,,,,,,,,,,
GRAFT HUM TISS W4XL6CM EPIFIX,SUP-2305755,CDM,Q4186,HCPCS,0636,RC,,,,both,,,15072.00,9796.80,,,,,,,,,,,,,
HC Phase II Recovery - First 15 Min,PX-7100000010,CDM,7100000010,LOCAL,0710,RC,,,,both,,,1013.00,658.45,,,,,,,,,,,,,
SCREW BNE LAG 2.3X32 MM CRANIOMAXILLOFACIAL TI STRL LEVEL 1,SUP-2458251,CDM,C1713,HCPCS,0278,RC,,,,both,,,268.97,174.83,,,,,,,,,,,,,
PLATE FT 130MM FOR TRUELOK FIX SYS,SUP-2316187,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1426.09,926.96,,,,,,,,,,,,,
BIT DRILL QUICK COUPLING 2.5X205/230 MM 3 FLUTED STERILE TC1,SUP-2837038,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2031.55,1320.51,,,,,,,,,,,,,
SCREW BNE HEX HD SM 4X35 MM CANC,SUP-2199301,CDM,C1713,HCPCS,0278,RC,,,,both,,,13.09,8.51,,,,,,,,,,,,,
COIL EMB L30CM DIA0.034IN LOOP DIA15MM DETACH 18 AZUR,SUP-2385427,CDM,C1889,HCPCS,0278,RC,,,,both,,,3328.40,2163.46,,,,,,,,,,,,,
STENT BILI 0.035 IN 6X150 MM 6 FRX80 CM LIFESTENT,SUP-2126871,CDM,C1876,HCPCS,0278,RC,,,,both,,,7222.00,4694.30,,,,,,,,,,,,,
SCREW ATTCH TIB STEM EXACTECH,SUP-2222987,CDM,C1713,HCPCS,0278,RC,,,,both,,,138.47,90.01,,,,,,,,,,,,,
DISTRACTOR SURG LG STD SET ACCS FEE,SUP-2432346,CDM,2720000010,LOCAL,0272,RC,,,,both,,,513.39,333.70,,,,,,,,,,,,,
GUIDEWIRE VASC COON L 145 CM DIA 0.038 IN TAPR L 15 CM FLPY,SUP-2167848,CDM,C1769,HCPCS,0272,RC,,,,both,,,93.26,60.62,,,,,,,,,,,,,
GRAFT BIO TISS W3.9XL5.9IN RECT XENMATRIX,SUP-2125845,CDM,C1781,HCPCS,0278,RC,,,,both,,,10465.62,6802.65,,,,,,,,,,,,,
BLADE IM L42MM ST G TI SPRL FOR HUM NAIL,SUP-2192461,CDM,C1713,HCPCS,0278,RC,,,,both,,,1645.52,1069.59,,,,,,,,,,,,,
LINER ACET OD47MM ID28MMXLPE HIP BPLR SHELL TNDM,SUP-2344654,CDM,C1776,CPT,0278,RC,,,,both,,,3692.64,2400.22,,,,,,,,,,,,,
KIT ENDOSCP 2MM TIGERTAPE LOOP 3MM CANN DRL SUTLASS SD WIRE,SUP-2121672,CDM,C1713,HCPCS,0278,RC,,,,both,,,3532.50,2296.12,,,,,,,,,,,,,
HC X-Ray Tibia/Fibula 2 Views,PX-3207359000,CDM,73590,CPT,0320,RC,,,,both,,,613.00,398.45,,,,,,,,,,,,,
KIT TB RETEN SYS OD12FR NG CORGRIP,SUP-2236652,CDM,2720000010,LOCAL,0272,RC,,,,both,,,260.21,169.14,,,,,,,,,,,,,
WASHER ORTH SM,SUP-2466763,CDM,C1713,HCPCS,0278,RC,,,,both,,,124.22,80.74,,,,,,,,,,,,,
SCREW CANN COUNTERSINC,SUP-2319442,CDM,C1713,HCPCS,0278,RC,,,,both,,,1375.32,893.96,,,,,,,,,,,,,
INSERT TIB THICKNESS 11MM UNIV STD POLYETH PRI NEUT IMPL,SUP-2200354,CDM,C1776,CPT,0278,RC,,,,both,,,6714.89,4364.68,,,,,,,,,,,,,
BRACE ORTHOSIS SPNL SM M EXOS FRM II 626,SUP-2196545,CDM,L0641,HCPCS,0274,RC,,,,both,,,244.64,159.02,,,,,,,,,,,,,
BRACE ANK SM H875IN L SEMI RIG ANATOMICALLY DESIGNED SHELL,SUP-2196369,CDM,L4350,HCPCS,0272,RC,,,,both,,,61.80,40.17,,,,,,,,,,,,,
DRESSING BIO CORNEAL BNDG PROKERA SLIM,SUP-2135267,CDM,V2790,HCPCS,0274,RC,,,,both,,,2979.86,1936.91,,,,,,,,,,,,,
AIRWAY LARYNGEAL 2,SUP-2312344,CDM,2720000010,LOCAL,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
SPACER SPNL 30X11X13 MM BIO AVS TL,SUP-2850810,CDM,C1889,HCPCS,0278,RC,,,,both,,,8504.63,5528.01,,,,,,,,,,,,,
ACET RECONSTRUCTION CAGE 58MM OD X54MM ID LT,SUP-2504592,CDM,C1776,CPT,0278,RC,,,,both,,,6983.36,4539.18,,,,,,,,,,,,,
KIT DISPOSABLE 9MM,SUP-2200253,CDM,C1713,HCPCS,0278,RC,,,,both,,,1849.46,1202.15,,,,,,,,,,,,,
ROD EXT FIX L300MM LNG THRD MR CONDITIONAL FOR DISTR,SUP-2187912,CDM,2720000010,LOCAL,0272,RC,,,,both,,,239.77,155.85,,,,,,,,,,,,,
SCREW BONE L5MM DIA2MM CRANIOMAXILLOFACIAL LACTOSORB PUSH,SUP-2137234,CDM,C1713,HCPCS,0278,RC,,,,both,,,271.61,176.55,,,,,,,,,,,,,
SCREW BONE L10MM LCK TALAR,SUP-2365933,CDM,C1713,HCPCS,0278,RC,,,,both,,,4694.30,3051.29,,,,,,,,,,,,,
BUR SURG HD L12MM OD1.5MM ROUTER TAPR D-57 DURAGUARD,SUP-2363357,CDM,2720000010,LOCAL,0272,RC,,,,both,,,262.35,170.53,,,,,,,,,,,,,
IMPL HAMMERTOE NEXTRA 4.5/3.2MM ST,SUP-2500329,CDM,C1713,HCPCS,0278,RC,,,,both,,,2342.22,1522.44,,,,,,,,,,,,,
RESORB X TWIST DRILL 21MM X 50MM 8MM STOP CLNDRCL 24MM SCR,SUP-2694404,CDM,2720000010,LOCAL,0272,RC,,,,both,,,446.70,290.35,,,,,,,,,,,,,
SPLINT ORTHOPEDIC SLIP ON XL 7 IN LT WRST ELASTIC LTX,SUP-2276651,CDM,L3809,HCPCS,0274,RC,,,,both,,,10.77,7.00,,,,,,,,,,,,,
SHELL ACET LIMIT H 23 54 MM HIP LCK MECHANISM TI RINGLOC+,SUP-2409128,CDM,C1776,CPT,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
GUIDEWIRE VASC L 45 CM DIA 0.018 IN NIT TUNGSTEN TIP PERIPH,SUP-2752623,CDM,C1769,HCPCS,0272,RC,,,,both,,,64.31,41.80,,,,,,,,,,,,,
MESH HERN L W6XL12CM ULTRAPRO SYS,SUP-2220100,CDM,C1781,HCPCS,0278,RC,,,,both,,,984.30,639.79,,,,,,,,,,,,,
SHEATH INTRO TISS STBL 11 FRX11.2 CM 16.2X19.4 FR EVOLUTION,SUP-2638746,CDM,C1893,HCPCS,0272,RC,,,,both,,,779.47,506.66,,,,,,,,,,,,,
PLATE BNE ORBIT FLR 1.5X0.2 MM MESHED BOWLE SHP TI GLD NS,SUP-2494182,CDM,C1713,HCPCS,0278,RC,,,,both,,,1070.74,695.98,,,,,,,,,,,,,
SPLINT WR AD SM UPTO W3.5IN RT MCP DLX KAY-SPLNT III,SUP-2324558,CDM,L3906,HCPCS,0274,RC,,,,both,,,75.96,49.37,,,,,,,,,,,,,
CUTTER SURG LT MEDL RT LAT FEM ACCURIS STRL,SUP-2344212,CDM,C1713,HCPCS,0278,RC,,,,both,,,963.35,626.18,,,,,,,,,,,,,
ELECTRODE ENDOSCP HF-RESECTION 12-30 DEG PLASMABAND DISP,SUP-2459184,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1600.83,1040.54,,,,,,,,,,,,,
KIT INT FIX MED COLLATERAL LIG FOR KNEE LIG AUG REP,SUP-2121947,CDM,C1713,HCPCS,0278,RC,,,,both,,,3752.30,2438.99,,,,,,,,,,,,,
CROWN FORM DENT STRP U1 PRIMARY ANTR UPPER LT CNTRL PLAS,SUP-2322237,CDM,D6783,CPT,0278,RC,,,,both,,,13.03,8.47,,,,,,,,,,,,,
GRAFT VASC HEMSHLD PLAT L 50 CM DIA 30 MM BRANCH SZ,SUP-2695456,CDM,C1768,CPT,0278,RC,,,,both,,,6437.44,4184.34,,,,,,,,,,,,,
GRAFT HUM TISS PAT TEND BIOCLEANSE,SUP-2361833,CDM,C1713,HCPCS,0278,RC,,,,both,,,8964.70,5827.05,,,,,,,,,,,,,
SPLINT ORTHOGNATHIC 2 JAW W/ GENIOPLASTY OPS VSP,SUP-2862844,CDM,2720000010,LOCAL,0272,RC,,,,both,,,15693.72,10200.92,,,,,,,,,,,,,
BASEPLATE TIB SZ 4+ UNIV TI ALLOY NP REV CEM STEM MOD SCR H,SUP-2304815,CDM,C1776,CPT,0278,RC,,,,both,,,7485.76,4865.74,,,,,,,,,,,,,
OXYGENATOR PERF ART FILTER BAL AFFIN FUSION,SUP-2496214,CDM,2720000010,LOCAL,0272,RC,,,,both,,,973.40,632.71,,,,,,,,,,,,,
SET ART PRSS MON RAD 2.5FR 2.5CM GWIRE INTRO NDL SYR,SUP-2167880,CDM,C1751,HCPCS,0278,RC,,,,both,,,281.12,182.73,,,,,,,,,,,,,
STAPLER INT AD L33MM DIA5MM STD GI YEL TI CIR CUT 2 ROW,SUP-2283246,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2245.51,1459.58,,,,,,,,,,,,,
DRILL SURG CANN 2.7 MM MANUAL NS LTX,SUP-2855973,CDM,2720000010,LOCAL,0272,RC,,,,both,,,536.94,349.01,,,,,,,,,,,,,
PLATE BONE CONDYLAR 2 MM RIGHT 6 HOLE STAINLESS STEEL STERIL,SUP-2836693,CDM,C1713,HCPCS,0278,RC,,,,both,,,2065.05,1342.28,,,,,,,,,,,,,
RAMUCIRUMAB 100 MG/10ML IV SOLN,RX-125954,CDM,J9308,HCPCS,0636,RC,00002-7669-01,NDC,,both,10,ML,4322.30,2809.49,,,,,,,,,,,,,
ANCHOR SUT FOR PERCANNULA SYS,SUP-2256655,CDM,C1713,HCPCS,0278,RC,,,,both,,,687.66,446.98,,,,,,,,,,,,,
MATRIX WOUND THERAGENESIS MESHED 8.2X12CM,SUP-2740183,CDM,A2008,HCPCS,0636,RC,,,,both,,,10751.36,6988.38,,,,,,,,,,,,,
EXTENSION LD DBS L 95 CM STRL DISP SENSIGHT,SUP-2883016,CDM,C1883,HCPCS,0278,RC,,,,both,,,2965.10,1927.31,,,,,,,,,,,,,
PLATE BONE HOLEX8 TITANIUM BLUE CRANIOMAXILLOFACIAL,SUP-2694730,CDM,C1713,HCPCS,0278,RC,,,,both,,,393.60,255.84,,,,,,,,,,,,,
STEM FEM 34-B MAG NK W/ TRUNNION SIRIUS,SUP-2442945,CDM,C1776,CPT,0278,RC,,,,both,,,946.71,615.36,,,,,,,,,,,,,
BALLOON ENDOSCP EUS CUF US FOR GFUM20 JFUM20 GFUM130Q130 (Order by Box),SUP-2313284,CDM,C1753,HCPCS,0278,RC,,,,both,,,88.99,57.84,,,,,,,,,,,,,
BUR SURG RND MED 4 MM 68 MM FLUT FOR DRL SYS SS,SUP-2628953,CDM,2720000010,LOCAL,0272,RC,,,,both,,,202.97,131.93,,,,,,,,,,,,,
CATHETER ANGIOPLSTY POLARCATH L 150 CM BALLOON L 40 MM DIA 4,SUP-2148537,CDM,C1725,HCPCS,0272,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
STENT URET 0.038 IN 5 FRX28 CM 6 FR DBL PGTL PERCFLX POLARIS,SUP-2482049,CDM,C2617,HCPCS,0278,RC,,,,both,,,485.41,315.52,,,,,,,,,,,,,
SCREW BNE L36MM CORT S STL ST NONCANNULATED NONLOCKING FULL,SUP-2186582,CDM,C1713,HCPCS,0278,RC,,,,both,,,256.04,166.43,,,,,,,,,,,,,
GUIDE PIN SL SHT 30 MM FOR AG FEM NAT NAIL SYS,SUP-2198663,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1097.05,713.08,,,,,,,,,,,,,
KIT DISECT BLNT TIP TRCR W/ OVL BLLN SPCMKR PRO,SUP-2283391,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1275.03,828.77,,,,,,,,,,,,,
PLATE BNE W33XL225MM 16 H R DST MED TIB S STL LOK COMPR NEUT,SUP-2185119,CDM,C1713,HCPCS,0278,RC,,,,both,,,5472.93,3557.40,,,,,,,,,,,,,
SUBSTITUTE BONE GRFT 10ML PUTTY TRANZGRFT,SUP-2353941,CDM,C1713,HCPCS,0278,RC,,,,both,,,6123.00,3979.95,,,,,,,,,,,,,
BIT DRL CALIB LNG 1.8X110 MM QC,SUP-2653739,CDM,2720000010,LOCAL,0272,RC,,,,both,,,835.11,542.82,,,,,,,,,,,,,
BIT DRL AO CONN 2X105 MM SCALED,SUP-2422313,CDM,2720000010,LOCAL,0272,RC,,,,both,,,607.72,395.02,,,,,,,,,,,,,
STENT TRACHBRONCH UFLX L 12 MM DIA 4 MM CATH L 95 CM DIA16,SUP-2141591,CDM,C1874,HCPCS,0278,RC,,,,both,,,5589.20,3632.98,,,,,,,,,,,,,
ALLOGRAFT BNE PLUG 13 MM FD IRRADIATED,SUP-2867043,CDM,C1762,CPT,0278,RC,,,,both,,,1927.02,1252.56,,,,,,,,,,,,,
SCREW BNE STD 2.7X16 MM STRL HALLU SNAP-OFF,SUP-2608917,CDM,C1713,HCPCS,0278,RC,,,,both,,,564.70,367.05,,,,,,,,,,,,,
FOOTPLATE SHOE W109XH114XL140MM ID08MM TI DORNHOFFER,SUP-2232503,CDM,L8613,CPT,0278,RC,,,,both,,,417.59,271.43,,,,,,,,,,,,,
CATHETER EP JSN 2-5-2 MM 6 FRX120 CM RESPON,SUP-2356802,CDM,C1730,HCPCS,0272,RC,,,,both,,,879.20,571.48,,,,,,,,,,,,,
BASEPLATE TIB SZ 6 REV STRL TRIATHLON,SUP-2889780,CDM,C1776,CPT,0278,RC,,,,both,,,14086.98,9156.54,,,,,,,,,,,,,
CLAMP SURG T CONN LT PROTEX CT,SUP-2584528,CDM,C1713,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
SUPPORT ORTHOT ANK KNEE CUST SUPRAMALLEOLAR,SUP-2435625,CDM,L1907,HCPCS,0272,RC,,,,both,,,1593.11,1035.52,,,,,,,,,,,,,
WALKER PT L DIAB,SUP-2276715,CDM,L4387,HCPCS,0274,RC,,,,both,,,257.67,167.49,,,,,,,,,,,,,
PLATE BONE L130MM 6 H LT LAT PROX TIB S STL LCK FOR 4.5MM,SUP-2348222,CDM,C1713,HCPCS,0278,RC,,,,both,,,12640.07,8216.05,,,,,,,,,,,,,
COMPONENT PATELLAR KNEE POLYETH PERSONA,SUP-2207897,CDM,C1776,CPT,0278,RC,,,,both,,,2735.60,1778.14,,,,,,,,,,,,,
TRACKER NAVIGATION PT ELECTROMAGNETIC NONINVASIVE AXIEM,SUP-2284344,CDM,2720000010,LOCAL,0272,RC,,,,both,,,600.53,390.34,,,,,,,,,,,,,
SURFACE ARTC SZ 1-2 AB THK11MM LT KNEE HIGHLY CROSSLINKED,SUP-2206698,CDM,C1776,CPT,0278,RC,,,,both,,,11618.00,7551.70,,,,,,,,,,,,,
KIT DRL BIT DIA2.65MM CORRESPONDING INCL DRL GUID HNDL LOC,SUP-2194164,CDM,2720000010,LOCAL,0272,RC,,,,both,,,786.35,511.13,,,,,,,,,,,,,
GUIDEWIRE VASC L80CM DIA0.035IN TIP L3MM PTFE J TIP FIX COR,SUP-2302726,CDM,C1769,HCPCS,0272,RC,,,,both,,,21.35,13.88,,,,,,,,,,,,,
SCREW BNE COMRESSION 2.7X16 MM STRL RE+LINE,SUP-2458038,CDM,C1713,HCPCS,0278,RC,,,,both,,,450.78,293.01,,,,,,,,,,,,,
PLATE BONE THK0.6MM ORAL MAXILLOFACIAL N COMPR STR BILAT 20,SUP-2262703,CDM,C1713,HCPCS,0278,RC,,,,both,,,423.43,275.23,,,,,,,,,,,,,
COMPONENT FEM UNI LM/RL X SM EIUS,SUP-2364875,CDM,C1776,CPT,0278,RC,,,,both,,,3856.55,2506.76,,,,,,,,,,,,,
SHEATH INTRO 30 DEG 8.5 FRX60 CM HEARTSPAN,SUP-2464534,CDM,C1894,HCPCS,0272,RC,,,,both,,,486.70,316.35,,,,,,,,,,,,,
SPLINT ORTHOPEDIC SLIP ON LG 8 IN RT WRST PLUSH FOAM LNR NYL,SUP-2276662,CDM,L3908,HCPCS,0272,RC,,,,both,,,16.64,10.82,,,,,,,,,,,,,
IMPLANT BIO TISS W4XL7CM BOV PERICARD CLLGN MTRX MESH SGL,SUP-2130298,CDM,C9354,HCPCS,0278,RC,,,,both,,,2225.13,1446.33,,,,,,,,,,,,,
HC CT Pelvis W/ Contrast,PX-3527219300,CDM,72193,CPT,0352,RC,,,,both,,,2630.00,1709.50,,,,,,,,,,,,,
PLUG ANCHR OD10MM STD COMPR,SUP-2406886,CDM,C1713,HCPCS,0278,RC,,,,both,,,2863.68,1861.39,,,,,,,,,,,,,
T-PLATE 5 HOLEX100MM,SUP-2819049,CDM,C1713,HCPCS,0278,RC,,,,both,,,2256.94,1467.01,,,,,,,,,,,,,
BIT CANNULATED DRIVER,SUP-2878748,CDM,2720000010,LOCAL,0272,RC,,,,both,,,675.10,438.81,,,,,,,,,,,,,
CEMENT BNE L VOID FILL,SUP-2293454,CDM,C1713,HCPCS,0278,RC,,,,both,,,8741.76,5682.14,,,,,,,,,,,,,
PLATE BNE MESHED 104X29X1 MM LG GRID PLLA-PGA STRL RESORB XG,SUP-2476307,CDM,C1713,HCPCS,0278,RC,,,,both,,,5298.62,3444.10,,,,,,,,,,,,,
VALVE SPEAK PMV 2000,SUP-2433847,CDM,L8501,HCPCS,0274,RC,,,,both,,,324.08,210.65,,,,,,,,,,,,,
GRASPER ENDOSCP JAW RANG 130 DEG L 220 CM DIA2.8 MM STRL LF,SUP-2881767,CDM,2720000010,LOCAL,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
CATHETER ANGIO MARINER L 150 CM 4 FR 0.035 IN BERN BRAIDED,SUP-2116915,CDM,C1887,HCPCS,0272,RC,,,,both,,,312.87,203.37,,,,,,,,,,,,,
SCREW BNE L 24 MM DIA 4.5 MM CORTICAL ST STRL EVOS,SUP-2931126,CDM,C1713,HCPCS,0278,RC,,,,both,,,131.94,85.76,,,,,,,,,,,,,
TRAY EPIDURAL CATH DIA19 GA TOUPHY NDL DIA17 GA CE17TKFCN,SUP-2936703,CDM,2720000010,LOCAL,0272,RC,,,,both,,,91.25,59.31,,,,,,,,,,,,,
BRACE WLK FULL SHELL WLK SM M SHOE SZ 4 7 FEM SHOE SZ 5,SUP-2336094,CDM,L4360,HCPCS,0272,RC,,,,both,,,126.10,81.96,,,,,,,,,,,,,
BUR SURG 20MM DRL WIRE PASS BIT REUSE FOR ELITE,SUP-2367597,CDM,2720000010,LOCAL,0272,RC,,,,both,,,408.45,265.49,,,,,,,,,,,,,
BIT DRL TRI FLAT STRL DISP CENTERPIECE,SUP-2926468,CDM,2720000010,LOCAL,0272,RC,,,,both,,,365.81,237.78,,,,,,,,,,,,,
STENT BILI WSTNT L 21 MM DIA 8 MM CATH L 155 CM SHTH 5 FR,SUP-2140233,CDM,C1876,HCPCS,0278,RC,,,,both,,,4898.40,3183.96,,,,,,,,,,,,,
CUP ACET PROFORM POR BEAD ACET CUP NO H 56,SUP-2359087,CDM,C1776,CPT,0278,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
PLATE BONE L144MM 7 H RT PROX HUM LCK FOR 4.5MM SCR PERI-LOC,SUP-2348276,CDM,C1713,HCPCS,0278,RC,,,,both,,,15274.69,9928.55,,,,,,,,,,,,,
FORCEPS 25GA TIP SGL USE MAXGRIP ADV DSP,SUP-2109721,CDM,C1713,HCPCS,0278,RC,,,,both,,,492.07,319.85,,,,,,,,,,,,,
DRIVER SURG ENDCAP LCK SCREWX-CORE 2,SUP-2311088,CDM,C1713,HCPCS,0278,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
SUPPORT ORTHOT HIP CUST ABDUCTN FLX FREJKA TYP W/CVR,SUP-2435595,CDM,L1600,HCPCS,0272,RC,,,,both,,,364.81,237.13,,,,,,,,,,,,,
BIT DRL CANN 4.8X155 MM TRAPEZIUM NS,SUP-2863449,CDM,2720000010,LOCAL,0272,RC,,,,both,,,889.34,578.07,,,,,,,,,,,,,
PLATE BONE L56MM 4 H RT ANG T SHP PERI-LOC SM FRAG SYS,SUP-2348448,CDM,C1713,HCPCS,0278,RC,,,,both,,,1157.40,752.31,,,,,,,,,,,,,
HC Rsf Lab Bmh - Case / Block,PX-9900000123,CDM,9900000123,LOCAL,0990,RC,,,,both,,,12.00,7.80,,,,,,,,,,,,,
PLATE BNE W23XL51MM THK18MM 13 H L VOLAR TI WIDE LNG TRILOK,SUP-2423734,CDM,C1713,HCPCS,0278,RC,,,,both,,,5608.35,3645.43,,,,,,,,,,,,,
COMPONENT TIB 6 RT ANK HINTERMANN SER H3,SUP-2751707,CDM,C1776,CPT,0278,RC,,,,both,,,18212.00,11837.80,,,,,,,,,,,,,
HC CT Abdomen W/ Cont,PX-3527416000,CDM,74160,CPT,0352,RC,,,,both,,,1973.00,1282.45,,,,,,,,,,,,,
BUTTON CERCLAGE CANN 4 MM HEX TI STRL,SUP-2547009,CDM,C1713,HCPCS,0278,RC,,,,both,,,503.19,327.07,,,,,,,,,,,,,
FLUPHENAZINE HCL 2.5 MG/ML IJ SOLN,RX-3216,CDM,J2680,HCPCS,0636,RC,63323-0281-10,NDC,,both,0.5,ML,55.30,35.94,,,,,,,,,,,,,
PLATE BONE TUBULAR 98 MM 8 HOLE 1/3 STERILE PERILOC,SUP-2837394,CDM,C1713,HCPCS,0278,RC,,,,both,,,648.76,421.69,,,,,,,,,,,,,
BLADE SAW KEEL RECIP CEM FOR LINVATEC HALL POWERPRO SYS,SUP-2136842,CDM,2720000010,LOCAL,0272,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED CEM SCREW PIN GENDER SPEC FLX ZCKPINGSF] ZIMMER BIOMET INC],SUP-2212713,CDM,C1776,CPT,0278,RC,,,,both,,,13858.77,9008.20,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 30-50X10 MM 10X25 MM FRZN PATELLAR TEND,SUP-2866895,CDM,C1762,CPT,0278,RC,,,,both,,,8478.00,5510.70,,,,,,,,,,,,,
BIT DRL ENDOSCP UNIV FOR JT PRESERVATION MICROFX OCD DISP,SUP-2366638,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1740.41,1131.27,,,,,,,,,,,,,
DEVICE VENTRICULAR ASST LT KT SHWR BG HEARTMATE II,SUP-2356004,CDM,Q0501,HCPCS,0272,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
ALLOGRAFT BNE 250-1000 MH 0.5 CC FD MINERALIZED ORAGRAFT,SUP-2740794,CDM,C1713,HCPCS,0278,RC,,,,both,,,148.11,96.27,,,,,,,,,,,,,
SCREW BNE L35MM DIA5MM THRD LOK FOR HIP FRAC SYS CHIMAERA,SUP-2316359,CDM,C1713,HCPCS,0278,RC,,,,both,,,571.89,371.73,,,,,,,,,,,,,
ELECTRODE CORTICAL 2 X 4 T TAIL KT STRL DISP EVO,SUP-2935047,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3061.50,1989.97,,,,,,,,,,,,,
PLATE BNE L45MM STD 3X2 H NONSTERILE BILAT 1ST MTP FUS TI,SUP-2181242,CDM,C1713,HCPCS,0278,RC,,,,both,,,3136.55,2038.76,,,,,,,,,,,,,
CLAMP REPROC PIN 4 HOLE MR SAFE,SUP-2483971,CDM,2720000010,LOCAL,0272,RC,,,,both,,,417.78,271.56,,,,,,,,,,,,,
MESH SURG L 5 X W 10 CM D 1.5 MM PORCINE DERMAL CLLGN ABD,SUP-2901711,CDM,C9364,HCPCS,0278,RC,,,,both,,,3275.43,2129.03,,,,,,,,,,,,,
IMMUNE GLOBULIN (HUMAN) 5 GM/50ML IJ SOLN,RX-107299,CDM,J1561,HCPCS,0636,RC,13533-0800-20,NDC,,both,50,ML,2194.00,1426.10,,,,,,,,,,,,,
SCREW BNE L10MM DIA5MM S STL ST LOK FULL THRD T25 STARDRV,SUP-2184875,CDM,C1713,HCPCS,0278,RC,,,,both,,,578.67,376.14,,,,,,,,,,,,,
STEM 12 CONQ BPLR 46,SUP-2347985,CDM,C1776,CPT,0278,RC,,,,both,,,9420.00,6123.00,,,,,,,,,,,,,
GRAFT GRAN PRO OSTEON 500 15CC,SUP-2413079,CDM,C1713,HCPCS,0278,RC,,,,both,,,3130.58,2034.88,,,,,,,,,,,,,
HEAD PAT MED LARGE+ MEDL LCS MILESTONE,SUP-2454058,CDM,C1776,CPT,0278,RC,,,,both,,,1698.74,1104.18,,,,,,,,,,,,,
BASKET STONE RETRV L120CM SHTH 1.3FR NIT THMB WHL DSGN RACK,SUP-2139283,CDM,2720000010,LOCAL,0272,RC,,,,both,,,764.72,497.07,,,,,,,,,,,,,
BUPROPION HCL ER (SR) 150 MG PO TB12,RX-18386,CDM,6370000000,HCPCS,0637,RC,00591-3541-60,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
INSERT TIB SZ 9 THK18MM UNIV CO CHROM UHMWPE KNEE REV NEUT,SUP-2378391,CDM,C1776,CPT,0278,RC,,,,both,,,3597.75,2338.54,,,,,,,,,,,,,
MODULE EMG STRL DISP KT MAXCESS,SUP-2311772,CDM,C1713,HCPCS,0278,RC,,,,both,,,6553.18,4259.57,,,,,,,,,,,,,
STENT BILI 6FR L40MM DIA10MM USABLE L120CM NIT OVR THE WIRE,SUP-2173493,CDM,C1876,HCPCS,0278,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
BLADE SAW W16.5XL34.5MM THK0.38MM CUT THK0.43MM REPL SAG,SUP-2150716,CDM,2720000010,LOCAL,0272,RC,,,,both,,,27.19,17.67,,,,,,,,,,,,,
PLATE BNE DORS VOLAR FRAG Y SHP DVR YFP] ZIMMER BIOMET INC],SUP-2137707,CDM,C1713,HCPCS,0278,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
HC CT Chest W/WO Contrast,PX-3527127000,CDM,71270,CPT,0352,RC,,,,outpatient,,,2630.00,1709.50,,,,,,,,,,,,,
K WIRE FIX L4IN DIA0.045IN DBL TRCR,SUP-2319460,CDM,C1713,HCPCS,0278,RC,,,,both,,,78.50,51.02,,,,,,,,,,,,,
ADAPTER HRT ALRM CTRL,SUP-2282559,CDM,Q0508,HCPCS,0272,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
COMPONENT FEM TY PROX DSTL PERIARTICULAR PLATE NS OPTILOCK,SUP-2861372,CDM,C1776,CPT,0278,RC,,,,both,,,7917.32,5146.26,,,,,,,,,,,,,
STENT BILI S.M.A.R.T. L 120 MM DIA 6 MM CATH L 135 CM,SUP-2158904,CDM,C1876,HCPCS,0278,RC,,,,both,,,5796.44,3767.69,,,,,,,,,,,,,
GRAFT BONE LT PROX TIB TRAD FRZN,SUP-2294147,CDM,C1713,HCPCS,0278,RC,,,,both,,,11586.60,7531.29,,,,,,,,,,,,,
NARROW PLATE 4.5MM 14X231MM,SUP-2818811,CDM,C1713,HCPCS,0278,RC,,,,both,,,2558.47,1663.01,,,,,,,,,,,,,
DILATOR SURG FOR CD HORZ SEXTANT ROD INSRTN SYS POLYMER BLU,SUP-2279981,CDM,2720000010,LOCAL,0272,RC,,,,both,,,582.60,378.69,,,,,,,,,,,,,
BIT DRL CANN 3 MM RESRB,SUP-2608845,CDM,2720000010,LOCAL,0272,RC,,,,both,,,989.10,642.91,,,,,,,,,,,,,
MOLINA UNDRCTNL MNDBLR DISTR LNGTH 43MM T 6L 4V SNGLE USE,SUP-2669818,CDM,C1713,HCPCS,0278,RC,,,,both,,,10791.33,7014.36,,,,,,,,,,,,,
RING ACET DIA48MM FOR MOD CUP REPL LCK,SUP-2209081,CDM,C1776,CPT,0278,RC,,,,both,,,364.24,236.76,,,,,,,,,,,,,
SCREW INTRF L23MM DIA8MM NONABSORBABLE ADV PEEK MILAGRO,SUP-2419571,CDM,C1713,HCPCS,0278,RC,,,,both,,,1601.40,1040.91,,,,,,,,,,,,,
PROBE LITHO 1.5X440 MM TRIL KT SWISS LITHOCLAST DISP,SUP-2520664,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2806.78,1824.41,,,,,,,,,,,,,
SCISSOR SURG METZ 5.75 IN DISECT CRV DEL SHRP/SHRP NS VITAL,SUP-2872581,CDM,C1889,HCPCS,0278,RC,,,,both,,,198.48,129.01,,,,,,,,,,,,,
SCREW BNE CANN 4X10 MM CANC LAG STRL ALPS LTX,SUP-2861636,CDM,C1713,HCPCS,0278,RC,,,,both,,,562.75,365.79,,,,,,,,,,,,,
LEVOFLOXACIN IN D5W 500 MG/100ML IV SOLN,RX-104434,CDM,J1956,HCPCS,0636,RC,25021-0132-82,NDC,,both,100,ML,54.10,35.16,,,,,,,,,,,,,
GUIDEWIRE VASC LUNDERQUIST L 120 CM DIA 0.038 IN PTFE PERIPH,SUP-2169790,CDM,C1769,HCPCS,0272,RC,,,,both,,,176.63,114.81,,,,,,,,,,,,,
STEM HUM 5X100 MM RT SHLDR DISCOVERY,SUP-2136216,CDM,C1776,CPT,0278,RC,,,,both,,,12550.58,8157.88,,,,,,,,,,,,,
PLATE BNE 1.5/2X69X1.5 MM 10 HOLE SS LCP,SUP-2569292,CDM,C1713,HCPCS,0278,RC,,,,both,,,376.49,244.72,,,,,,,,,,,,,
HC Assay of Lipase,PX-3018369000,CDM,83690,CPT,0301,RC,,,,both,,,264.00,171.60,,,,,,,,,,,,,
BRACE WR AD L LT INSTABILITY INJ LOOP LCK W/ STAY ELAS PUL,SUP-2197949,CDM,L3931,HCPCS,0272,RC,,,,both,,,116.18,75.52,,,,,,,,,,,,,
GUIDEWIRE VASC RDRUN L 480 CM DIA 0.018 IN NIT PLAT PTFE,SUP-2759287,CDM,C1769,HCPCS,0272,RC,,,,both,,,379.94,246.96,,,,,,,,,,,,,
CONNECTOR SPNL XLNK ASSEMB FIX POST ST360 6.35MM ROD 15MM,SUP-2289999,CDM,C1713,HCPCS,0278,RC,,,,both,,,2875.77,1869.25,,,,,,,,,,,,,
PLATE BONE TUBULAR NARROW 4.5 MM 7 HOLE PROVISIONAL FIXATION,SUP-2836973,CDM,C1713,HCPCS,0278,RC,,,,both,,,1602.09,1041.36,,,,,,,,,,,,,
VENLAFAXINE HCL ER 37.5 MG PO CP24,RX-27857,CDM,6370000000,HCPCS,0637,RC,65862-0527-30,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
STENT URET INLAY L 16 CM DIA 4.7 FR POLYUR HYDRPHLC,SUP-2126619,CDM,C2617,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
GRAFT TISS FRZ DRY ALLGRFT STRUT CORT TRAD 120X20MM,SUP-2294116,CDM,C1713,HCPCS,0278,RC,,,,both,,,1651.64,1073.57,,,,,,,,,,,,,
CATHETER DRAINAGE NO VLV 4 FRX10 CM 1 STP,SUP-2303153,CDM,C1729,HCPCS,0272,RC,,,,both,,,49.64,32.27,,,,,,,,,,,,,
CATHETER INTVASC OCCL FOGARTY L 40 CM DIA 4 FR BALLOON DIA,SUP-2214268,CDM,C2628,HCPCS,0272,RC,,,,both,,,393.54,255.80,,,,,,,,,,,,,
CATHETER PERFSN PRUITT L 24 CM DIA12 FR BALLOON DIA20 MM,SUP-2884050,CDM,C2628,HCPCS,0272,RC,,,,both,,,1566.86,1018.46,,,,,,,,,,,,,
PROBE ABLATN 40 MM FLX VASC,SUP-2427439,CDM,C1713,HCPCS,0278,RC,,,,both,,,8635.00,5612.75,,,,,,,,,,,,,
SCREW BNE CORTICAL 3.5X12 MM FUSION HEX DRV YEL WRST SS NS,SUP-2851926,CDM,C1713,HCPCS,0278,RC,,,,both,,,776.99,505.04,,,,,,,,,,,,,
HANDPIECE LASER THER MNL FBR STEER SOLOGRIP III,SUP-2175247,CDM,C2618,HCPCS,0272,RC,,,,both,,,18698.70,12154.15,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL PEEK SD800.504,SUP-2860186,CDM,C1713,HCPCS,0278,RC,,,,both,,,28182.76,18318.79,,,,,,,,,,,,,
PLATE BNE 1ST METATARSOPHALANGEAL SM RT FT STRL A.L.P.S,SUP-2481927,CDM,C1713,HCPCS,0278,RC,,,,both,,,2278.26,1480.87,,,,,,,,,,,,,
HC X-Ray Exam Entire Spine 1 Vw,PX-3207208100,CDM,72081,CPT,0320,RC,,,,outpatient,,,969.00,629.85,,,,,,,,,,,,,
PROX ULNAR LOCKING PLT JIG LT,SUP-2723794,CDM,C1713,HCPCS,0278,RC,,,,both,,,1386.84,901.45,,,,,,,,,,,,,
PLATE BNE SPRING 3.5 MM PELV 2 HOLE SS NS,SUP-2863369,CDM,C1713,HCPCS,0278,RC,,,,both,,,990.10,643.56,,,,,,,,,,,,,
GUIDEWIRE VASCULAR 0.018INX80CM STRAIGHT PLATINUM TIP NITINO,SUP-2823948,CDM,C1769,HCPCS,0272,RC,,,,both,,,129.21,83.99,,,,,,,,,,,,,
CATHETER CRICOTHYROTOMY SET UNIV 5 FRX9 CM EMGCY CUF MELK,SUP-2759814,CDM,C1769,HCPCS,0272,RC,,,,both,,,1599.83,1039.89,,,,,,,,,,,,,
BUTTON GASTROTOMY BLLN 12 FRX1 CM SAFETY PLUG MINIONE,SUP-2431941,CDM,C1889,HCPCS,0278,RC,,,,both,,,331.27,215.33,,,,,,,,,,,,,
GRAFT BNE STRP 50X20X5 MM COMPRESSIBLE BNE MTRX,SUP-2644323,CDM,C1713,HCPCS,0278,RC,,,,both,,,5922.04,3849.33,,,,,,,,,,,,,
PLATE BNE STR 3.5 MM 6 HOLE RECON FOR SM FRAG SYS TI NS,SUP-2466155,CDM,C1713,HCPCS,0278,RC,,,,both,,,853.83,554.99,,,,,,,,,,,,,
MAGNESIUM SULFATE 50 % IJ SOLN,RX-4720,CDM,J3475,HCPCS,0636,RC,63323-0064-01,NDC,,both,2,ML,54.10,35.16,,,,,,,,,,,,,
BIT DRL OD13MM DISK FOR UDRV 3 ULTRASONIC REV SYS,SUP-2136773,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1428.70,928.65,,,,,,,,,,,,,
GRAFT HUM TISS 2CC LIQ FLOWABLE AMNION,SUP-2120776,CDM,C1776,CPT,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
WIRE FIX BLNT TIP CORRIDOR L500MM OD1.05MM K,SUP-2232177,CDM,C1713,HCPCS,0278,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
CATHETER VENTRICULAR STYL 6 CM 14 CM STYL RT ANGLE BACTISEAL,SUP-2666815,CDM,C1729,HCPCS,0272,RC,,,,both,,,1498.41,973.97,,,,,,,,,,,,,
CAGE SPNL 15 DEG 40X30X15X8 MM ALIF CASCADIA,SUP-2732271,CDM,C1889,HCPCS,0278,RC,,,,both,,,12999.60,8449.74,,,,,,,,,,,,,
SCREW BNE L 26 MM DIA 4.7 MM SS FT LCK OSTEOPENIA STRL EVOS,SUP-2931486,CDM,C1713,HCPCS,0278,RC,,,,both,,,599.61,389.75,,,,,,,,,,,,,
SYSTEM VENTRICULAR DRAINAGE W/ CATH ACCUDRAIN,SUP-2883455,CDM,C1729,HCPCS,0272,RC,,,,both,,,629.73,409.32,,,,,,,,,,,,,
BLADE RTRCTR 60MMW X 70MML TTNM SPNL WIDE PRNGX6 DARK BLUE L,SUP-2457651,CDM,2720000010,LOCAL,0272,RC,,,,both,,,873.71,567.91,,,,,,,,,,,,,
PLATE QUIKFLAP BURR 14MM SD AXS,SUP-2718052,CDM,C1713,HCPCS,0278,RC,,,,both,,,10051.14,6533.24,,,,,,,,,,,,,
HC Assay of Troponin Quantitative,PX-3018448400,CDM,84484,CPT,0301,RC,,,,both,,,214.00,139.10,,,,,,,,,,,,,
GUIDEWIRE VASC RDRUN PC THE FIRM LT L 260 CM DIA 0.035 IN,SUP-2638706,CDM,C1769,HCPCS,0272,RC,,,,both,,,114.04,74.13,,,,,,,,,,,,,
CATHETER VALVULOPLASTY ZMED L 100 CM DIA 6 FR 3 CM 11 MM,SUP-2659421,CDM,C1725,HCPCS,0272,RC,,,,both,,,2219.60,1442.74,,,,,,,,,,,,,
MESH HERN BIOMATERIAL 15X10 CMX2 MM 2 SURF EPTFE DUALMESH,SUP-2395328,CDM,C1781,HCPCS,0278,RC,,,,both,,,3224.78,2096.11,,,,,,,,,,,,,
GRAFT VASC L45CM DIA6MM RAD L5CM PTFE HEP STD WALLED INTEGR,SUP-2395834,CDM,C1768,CPT,0278,RC,,,,both,,,4078.86,2651.26,,,,,,,,,,,,,
BIT DRL CANN 5 MM KNEE TRANSTIBIAL,SUP-2422800,CDM,2720000010,LOCAL,0272,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
HALOPERIDOL 5 MG PO TABS,RX-3583,CDM,6370000000,HCPCS,0637,RC,51079-0736-01,NDC,,both,1,UN,4.10,2.66,,,,,,,,,,,,,
MESH HERN M W11XL14CM INGUINAL OVL SELF EXP PTCH KUGEL,SUP-2125979,CDM,C1781,HCPCS,0278,RC,,,,both,,,373.19,242.57,,,,,,,,,,,,,
SET INSTR IMPL SCR DIA4.5MM ORTH CANN,SUP-2183053,CDM,C1713,HCPCS,0278,RC,,,,both,,,43488.03,28267.22,,,,,,,,,,,,,
STENT BILI LIFESTENT NT L 30 MM DIA 6 MM CATH L 120 CM DIA 6,SUP-2214605,CDM,C1876,HCPCS,0278,RC,,,,both,,,4396.00,2857.40,,,,,,,,,,,,,
CAGE SPNL H12-17MM OD14MM 0DEG SM TI ANT THORLUM INTBDY FUS,SUP-2390792,CDM,C1889,HCPCS,0278,RC,,,,both,,,12520.75,8138.49,,,,,,,,,,,,,
SHEATH INTRO FLX L 30 CM OD 6 FR GUIDEWIRE 0.038 IN SM CKFLO,SUP-2168401,CDM,C1894,HCPCS,0272,RC,,,,both,,,143.15,93.05,,,,,,,,,,,,,
SCREW BONE CORTICAL 1.5X14 MM SELFTAPPING PLUSDRIVE RECESS T,SUP-2838126,CDM,C1713,HCPCS,0278,RC,,,,both,,,235.19,152.87,,,,,,,,,,,,,
PIN FIX DBL DIAMOND 0.125X9 IN SS NS STEINMANN,SUP-2791821,CDM,C1713,HCPCS,0278,RC,,,,both,,,27.88,18.12,,,,,,,,,,,,,
GRAFT VASC STD WALL 5-8 MMX70 CM LNG TAPR REINF ADVANTA VXT,SUP-2470202,CDM,C1768,CPT,0278,RC,,,,both,,,1056.39,686.65,,,,,,,,,,,,,
PLATE BNE N COMPR Y BILAT 5 H RIG FOR 2MM SCR H DIA,SUP-2366326,CDM,C1713,HCPCS,0278,RC,,,,both,,,606.46,394.20,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 50 CM DIA 8 MM EPTFE STR TW,SUP-2525454,CDM,C1768,CPT,0278,RC,,,,both,,,1340.81,871.53,,,,,,,,,,,,,
PLUG HERN M DIA7CM POLYPR TILENE INGUNIAL ONLAY PTCH LT,SUP-2402566,CDM,C1781,HCPCS,0278,RC,,,,both,,,659.40,428.61,,,,,,,,,,,,,
CATHETER ETER EP MAP DIAG 5FR 110CM LEN M CRV OCTAPOLAR 2MM SPC 1MM,SUP-2357653,CDM,C1730,HCPCS,0272,RC,,,,both,,,1117.84,726.60,,,,,,,,,,,,,
TRAY THORCENT L4.75IN DIA8FR SFTY COMP PRECIS TURKEL,SUP-2154964,CDM,C1729,HCPCS,0272,RC,,,,both,,,258.27,167.88,,,,,,,,,,,,,
CATHETER NEPHSTMY 22FR L30CM POLYUR PERC W/ RADPQ STRP MCOT,SUP-2171231,CDM,C1729,HCPCS,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
GUIDEWIRE SUBTALAR TRUARCH 16 X 2286 MM,SUP-2586665,CDM,C1769,HCPCS,0272,RC,,,,both,,,163.91,106.54,,,,,,,,,,,,,
ROD SPNL L300MM DIA5.5MM R ANT TI ALLY SMOOTH MOSS MIAMI,SUP-2254456,CDM,C1713,HCPCS,0278,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
MICRO PLATE 3 X 2 HOLES RCTNGLR SGMNTS 10MM 15MM SSTM CP T,SUP-2681101,CDM,C1713,HCPCS,0278,RC,,,,both,,,594.72,386.57,,,,,,,,,,,,,
SCREW BNE CRTX 3.5X40 MM LP ST HD T15 STARDRV RECESS TI NS,SUP-2758268,CDM,C1713,HCPCS,0278,RC,,,,both,,,121.08,78.70,,,,,,,,,,,,,
CANNULA ENDOSCP TROCAR 2.5 MMX3.5 CM,SUP-2767309,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1372.31,892.00,,,,,,,,,,,,,
VALVE AORT H16MM OD23MM ID23MM PROTRUSION 13MM PORCINE,SUP-2357530,CDM,C1889,HCPCS,0278,RC,,,,both,,,15072.00,9796.80,,,,,,,,,,,,,
STAPLE STR ASSEMB 25MM X 20MM,SUP-2321574,CDM,C1713,HCPCS,0278,RC,,,,both,,,4318.60,2807.09,,,,,,,,,,,,,
PLATE 3.5MM TI LCP TM CLAVICLE 6H RT-18MM HOOK DEPTH-STER,SUP-2549670,CDM,C1713,HCPCS,0278,RC,,,,both,,,3723.60,2420.34,,,,,,,,,,,,,
CATHETER INFUSION DIA 4 FR STRL,SUP-2117143,CDM,C1725,HCPCS,0272,RC,,,,both,,,712.78,463.31,,,,,,,,,,,,,
SCREW BONE L16MM DIA3.5MM STD CORT S STL ST FULL THRD HEX HD,SUP-2343890,CDM,C1713,HCPCS,0278,RC,,,,both,,,254.18,165.22,,,,,,,,,,,,,
ROD EXT FIX L360MM DIA8MM C FBR CONN REUSE,SUP-2188750,CDM,2720000010,LOCAL,0272,RC,,,,both,,,479.51,311.68,,,,,,,,,,,,,
HC So Insulin Antibodies,PX-3028633766,CDM,86337,CPT,0302,RC,,,,inpatient,,,815.00,529.75,,,,,,,,,,,,,
HC MRI-Upper Ext Jnt W Cont,PX-6107322200,CDM,73222,CPT,0610,RC,,,,outpatient,,,3764.00,2446.60,,,,,,,,,,,,,
SCREW BNE L16MM DIA3.5MM CORT DST RAD VOLAR TI NONLOCKING,SUP-2340292,CDM,C1713,HCPCS,0278,RC,,,,both,,,357.96,232.67,,,,,,,,,,,,,
CHLORPROMAZINE HCL 25 MG/ML IJ SOLN,RX-1649,CDM,J3230,HCPCS,0636,RC,00641-1397-31,NDC,,both,0.4,ML,66.50,43.22,,,,,,,,,,,,,
ENDCAP ORTH DIA11MM 5MM EXTN GRN TI FOR TROCHANTERIC FIX,SUP-2191917,CDM,C1713,HCPCS,0278,RC,,,,both,,,539.58,350.73,,,,,,,,,,,,,
SUPPORT OBESITY BARIATRIC L FOR 65-75IN HIP W/ LUM SHLDR,SUP-2324542,CDM,L0642,HCPCS,0274,RC,,,,both,,,215.94,140.36,,,,,,,,,,,,,
STEM FEM CMNTLS 14X240 MM KNEE MOD IMPL,SUP-2433945,CDM,C1776,CPT,0278,RC,,,,both,,,7768.36,5049.43,,,,,,,,,,,,,
LEAD PACE L90CM ENDO LV UNI/BIPOLAR IS-1 SGL ELECTRD PASS,SUP-2148689,CDM,C1786,HCPCS,0275,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
SHEATH GUID HALO 1 L 70 CM DIA 5 FR DIL L 77.5 CM GUIDEWIRE,SUP-2890321,CDM,C1887,HCPCS,0272,RC,,,,both,,,973.40,632.71,,,,,,,,,,,,,
FIBER LASER DVDF DVI-SC W/ WALL PLATE,SUP-2798107,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2234.42,1452.37,,,,,,,,,,,,,
HEAD FEM OD28MM +0MM 12/14 TAPR LO WR FRAC TOUGH PLT TYP,SUP-2222420,CDM,C1776,CPT,0278,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
GUIDEWIRE VASC L 80 CM DIA 0.035 IN TAPR L 15 CM FLPY TIP L,SUP-2167810,CDM,C1769,HCPCS,0272,RC,,,,both,,,47.41,30.82,,,,,,,,,,,,,
MOLD CEM SPCR HD DIA48MM HIP SIL S STL FOR MAKING TEMP HEMI,SUP-2408601,CDM,C1776,CPT,0278,RC,,,,both,,,2298.48,1494.01,,,,,,,,,,,,,
COIL EMB L1CM OD0.010IN LOOP OD2MM PLAT TUNGSTEN HELCL,SUP-2249136,CDM,C1889,HCPCS,0278,RC,,,,both,,,3076.26,1999.57,,,,,,,,,,,,,
BIT DRILL 3.8MM DIA 127MML STAINLESS STEEL CALIBRATED,SUP-2588762,CDM,2720000010,LOCAL,0272,RC,,,,both,,,343.86,223.51,,,,,,,,,,,,,
WEDGE TIB SZ 3-4 10MM R MED L LAT KNEE HEMI STP LEGION,SUP-2346580,CDM,C1776,CPT,0278,RC,,,,both,,,4226.44,2747.19,,,,,,,,,,,,,
SIL TMPTUBE PAPARELLA XTAB 102 ID 5,SUP-2680277,CDM,L8699,HCPCS,0278,RC,,,,both,,,23.36,15.18,,,,,,,,,,,,,
LOW PROFILE SCREW CASE TRAY INSERT 3,SUP-2815084,CDM,C1713,HCPCS,0278,RC,,,,both,,,2182.30,1418.49,,,,,,,,,,,,,
KIT PACE STYL L 85 CM STR STD WIDE NAR J CLP ON/IMPLANT TOOL,SUP-2356350,CDM,C1713,HCPCS,0278,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
NKII REV NP FEMORAL SPACER LT SIZE 4 4MM LAT,SUP-2509619,CDM,C1776,CPT,0278,RC,,,,both,,,3215.36,2089.98,,,,,,,,,,,,,
ADAPTER SPNL ANGLED RT OCT MULTIPOINT SYM,SUP-2718799,CDM,C1713,HCPCS,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
CATHETER THRMDIL 7FR L110CM TORQ CTRL INFUS PRT HND OFF 5,SUP-2383926,CDM,C1751,HCPCS,0278,RC,,,,both,,,438.34,284.92,,,,,,,,,,,,,
NEEDLE ASPIR WITH SYRINGE 22GA L700MM US GUID TREAT DST END FOR,SUP-2313404,CDM,2720000010,LOCAL,0272,RC,,,,both,,,717.80,466.57,,,,,,,,,,,,,
SCREW BONE L10MM DIA1.85MM TI COARSE PITCH ST,SUP-2181790,CDM,C1713,HCPCS,0278,RC,,,,both,,,315.63,205.16,,,,,,,,,,,,,
ALLOGRAFT BNE FRZN ASEP FEM HD,SUP-2867013,CDM,C1762,CPT,0278,RC,,,,both,,,3624.35,2355.83,,,,,,,,,,,,,
SEEKER BALLOON L 17 MM DIA 5 MM SPHND FOR ENT,SUP-2902051,CDM,C1726,HCPCS,0272,RC,,,,both,,,1309.69,851.30,,,,,,,,,,,,,
HC Special Med Physics Consult,PX-3337737000,CDM,77370,CPT,0333,RC,,,,both,,,1443.00,937.95,,,,,,,,,,,,,
PACK NEUROSURGICAL SHTH L 75 X W 11 MM MYRIAD HNDPC L 13 CM NN-2002,SUP-2930266,CDM,2720000010,LOCAL,0272,RC,,,,both,,,18168.07,11809.25,,,,,,,,,,,,,
HC So1 Hla I Typing Complete Hr,PX-3108137967,CDM,81379,CPT,0310,RC,,,,both,,,380.00,247.00,,,,,,,,,,,,,
K WIRE FIX L270MM DIA2.5MM THRD FOR ANK FUS PLATING SYS,SUP-2398611,CDM,C1713,HCPCS,0278,RC,,,,both,,,69.08,44.90,,,,,,,,,,,,,
SLEEVE SURG DRL 2.5-3.5X130 MM DBL,SUP-2319110,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1428.70,928.65,,,,,,,,,,,,,
CLAMP SURG 4.5-6 MM ASMBLY RAIL G2 NILE,SUP-2734571,CDM,C1713,HCPCS,0278,RC,,,,both,,,2386.40,1551.16,,,,,,,,,,,,,
BIT DRILL SURG 3.5 MM ALPS DISP,SUP-2607156,CDM,2720000010,LOCAL,0272,RC,,,,both,,,550.47,357.81,,,,,,,,,,,,,
CATHETER ABLAT L160CM DIA4MM BPLR ELECTRD W13XL20MM FOC,SUP-2172349,CDM,C1888,HCPCS,0272,RC,,,,both,,,4851.30,3153.34,,,,,,,,,,,,,
ANCHOR SUT LABRUM KNOTLESS LABRALOCK W/INSERTER HNDL,SUP-2342080,CDM,C1776,CPT,0278,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
"HC Parananeoplastic Ab Panel, Voltage-Gtd Ca Chnl Antb Ea",PX-3028659667,CDM,86596,CPT,0302,RC,,,,both,,,71.00,46.15,,,,,,,,,,,,,
SNARE ENDO L350CM DIA2.4MM STD OVL POLYP DISP SH THROW,SUP-2360309,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
CLAMP EXT FIX DBL PIN W/ BALL JT JET-X MINI,SUP-2342867,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4964.65,3227.02,,,,,,,,,,,,,
ANCHOR SUT DIA5MM ABSRB HNDL INSRT CRV FAST-FIX AB,SUP-2341594,CDM,C1713,HCPCS,0278,RC,,,,both,,,927.12,602.63,,,,,,,,,,,,,
SCREW BNE L55MM DIA75MM THRD L16MM CALCNL ANK TI CANN HD,SUP-2399014,CDM,C1713,HCPCS,0278,RC,,,,both,,,675.10,438.81,,,,,,,,,,,,,
PIN EXTERNAL FIXATION HALF 5X40 MM TITANIUM NITRIDE STERILE,SUP-2836781,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1559.45,1013.64,,,,,,,,,,,,,
PLATE FT 170MM FOR TRUELOK FIX SYS,SUP-2316193,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
CATHETER DRAINAGE OPN TIP 14 GAX8.8 CM 0.7X1.5 MM ADPT HERM,SUP-2244105,CDM,C1729,HCPCS,0272,RC,,,,both,,,424.06,275.64,,,,,,,,,,,,,
CATHETER CV SET 032 10 FRX20 CM 11 GA 5 LUMEN QUINT,SUP-2759730,CDM,C1751,HCPCS,0278,RC,,,,both,,,421.58,274.03,,,,,,,,,,,,,
WASHER ORTH FOR 6.2 MM BNE SCR VIT STRL LTX,SUP-2869884,CDM,C1713,HCPCS,0278,RC,,,,both,,,261.25,169.81,,,,,,,,,,,,,
GRAFT VASC RESTOREFLOW SZ 70-74 CM SAPH VEIN BLD TYP A B AB,SUP-2264306,CDM,C1768,CPT,0278,RC,,,,both,,,31239.86,20305.91,,,,,,,,,,,,,
HC Lyr Clos Sc Tk Ext 12.6-20,PX-4501203500,CDM,12035,CPT,0450,RC,,,,both,,,1674.00,1088.10,,,,,,,,,,,,,
INTRODUCER NDL BX 7 FR 18 GAX60 CM SET LIV ACCS,SUP-2432217,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1701.88,1106.22,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 50 CM DIA 8 MM RNG L 40 CM EPTFE,SUP-2396303,CDM,C1768,CPT,0278,RC,,,,both,,,3406.90,2214.48,,,,,,,,,,,,,
COMPONENT HUM FLNG 4X100 MM LT SHLDR BOND COAT MOSAIC STRL,SUP-2215487,CDM,C1776,CPT,0278,RC,,,,both,,,10902.08,7086.35,,,,,,,,,,,,,
PEMBROLIZUMAB 100 MG/4ML IV SOLN,RX-128829,CDM,J9271,HCPCS,0636,RC,00006-3026-02,NDC,,both,4,ML,17325.20,11261.38,,,,,,,,,,,,,
PLATE NSL W40XL50MM THK0.15MM POLYDIOXANONE FLX ABSRB DISP,SUP-2301043,CDM,C1713,HCPCS,0278,RC,,,,both,,,1669.44,1085.14,,,,,,,,,,,,,
HC Mech Rem Fibrin via Sep Acces,PX-3613659500,CDM,36595,CPT,0361,RC,,,,outpatient,,,8583.00,5578.95,,,,,,,,,,,,,
DRESSING WOUND SURGICAL MATRIX XSMALL 8X16 CM PLASTIC MATRISTEM,SUP-2106511,CDM,Q4166,HCPCS,0636,RC,,,,both,,,10761.41,6994.92,,,,,,,,,,,,,
HC Treat Tail Bone Fx,PX-4502720000,CDM,27200,CPT,0450,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
SLING ORTH ADJ STRP UNIV 5.4X5 IN 19X13 IN SHLDR DLX,SUP-2195027,CDM,L3660,HCPCS,0272,RC,,,,both,,,31.43,20.43,,,,,,,,,,,,,
SCREW BNE L 17 MM DIA2.4 MM SS LCK T8 STARDRV AQUA HD TUBE,SUP-2905730,CDM,C1713,HCPCS,0278,RC,,,,both,,,848.99,551.84,,,,,,,,,,,,,
GUIDEWIRE VASC L 70 CM DIA 0.038 IN TIP L 3 MM DEPTH MARKING,SUP-2117325,CDM,C1769,HCPCS,0272,RC,,,,both,,,52.75,34.29,,,,,,,,,,,,,
PLATE BONE L52MM 4 H STRL S STL COMPR FOR 3.5MM SCR EVOS,SUP-2349636,CDM,C1713,HCPCS,0278,RC,,,,both,,,953.34,619.67,,,,,,,,,,,,,
DRAINAGE SET PGTL 0.25 INX15 CM 5 FRX6 MM CATH NDL,SUP-2638579,CDM,C1729,HCPCS,0272,RC,,,,both,,,152.23,98.95,,,,,,,,,,,,,
GUIDEWIRE VASC HIWIRE L 180 CM 0.035 IN TAPR L 22 CM ANGLED,SUP-2170347,CDM,C1769,HCPCS,0272,RC,,,,both,,,116.21,75.54,,,,,,,,,,,,,
WASHER ORTH 9 H RECON PLT LISFRANC CHARLOTTE,SUP-2397630,CDM,C1713,HCPCS,0278,RC,,,,both,,,144.44,93.89,,,,,,,,,,,,,
CLAMP EXT FIX DIA8/11MM COMB CLP ON SELF HLD,SUP-2188531,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1780.41,1157.27,,,,,,,,,,,,,
DEVICE TARGETING DIAM 2.8MM LEN 195MM SIDEWNDR RADLUC,SUP-2371637,CDM,C1713,HCPCS,0278,RC,,,,both,,,516.53,335.74,,,,,,,,,,,,,
ANAGRELIDE HCL 0.5 MG PO CAPS,RX-20446,CDM,6370000000,HCPCS,0637,RC,13668-0453-01,NDC,,both,1,UN,3.80,2.47,,,,,,,,,,,,,
PLATE BNE L355MM 14 H ST L PROX FEM S STL LO PROF LOK COMPR,SUP-2186050,CDM,C1713,HCPCS,0278,RC,,,,both,,,5468.47,3554.51,,,,,,,,,,,,,
HC So Factor VIII,PX-3058524066,CDM,85240,CPT,0305,RC,,,,both,,,191.00,124.15,,,,,,,,,,,,,
"HC Gbl Est Pt, E/M Level 4|ADJ|SIGNIFICANT, SEPARATELY IDENTIFIABLE EVALUATION AND MANAGEMENT SERVICE BY THE SAME PHYSICIAN ON THE SAME DAY OF THE PROCEDURE OR OTHER SERVICE",PX-9829921400,CDM,99214,CPT,0982,RC,,,ADJ|25,outpatient,,,522.00,339.30,,,,,,,,,,,,,
GRAFT MTRX DERM HUM TISS ACELLULAR THCK FRZ DRY 8CMX16CM,SUP-2306917,CDM,C1762,CPT,0278,RC,,,,both,,,12516.95,8136.02,,,,,,,,,,,,,
PLATE BNE SM R CALCNL LOK,SUP-2413700,CDM,C1713,HCPCS,0278,RC,,,,both,,,2248.87,1461.77,,,,,,,,,,,,,
NAIL IM L320MM DIA11MM 125DEG L LNG FOR HIP FRAC SYS,SUP-2316363,CDM,C1713,HCPCS,0278,RC,,,,both,,,5370.62,3490.90,,,,,,,,,,,,,
STEM FEM SZ 16 STD HIP CLLR MOD ENTRADA,SUP-2315497,CDM,C1713,HCPCS,0278,RC,,,,both,,,10465.62,6802.65,,,,,,,,,,,,,
HC Immunoglobulin Light Chains Free Each,PX-3018352100,CDM,83521,CPT,0301,RC,,,,outpatient,,,88.00,57.20,,,,,,,,,,,,,
CATHETER HEMO DYLS OR HD AD 14FR L32CM SIL ADMIN FULL KT DBL,SUP-2269572,CDM,C1751,HCPCS,0278,RC,,,,both,,,750.46,487.80,,,,,,,,,,,,,
SET INTRO PEELWY L 32 CM DIA 9 FR DIL L 37 CM STRL,SUP-2835672,CDM,C1894,HCPCS,0272,RC,,,,both,,,157.19,102.17,,,,,,,,,,,,,
STENT COR RX 0.014 IN 3.5X16 MM 144 CM TAXUS LIBERTE,SUP-2140599,CDM,C1874,HCPCS,0278,RC,,,,both,,,5495.00,3571.75,,,,,,,,,,,,,
VALVE MITRL CARP EDW PERIMT MAGNA DIA 25/27/29/31/33 MM,SUP-2214301,CDM,C1889,HCPCS,0278,RC,,,,both,,,29516.00,19185.40,,,,,,,,,,,,,
CUTTER SURG OD15MM BLK CUT ST DISP FOR ROTOCUT G1 MORSLZR,SUP-2261064,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2136.46,1388.70,,,,,,,,,,,,,
SCREW BONE L76MM OD7MM THRD L21MM PUR HINDFOOT ANK CANN M,SUP-2320952,CDM,C1713,HCPCS,0278,RC,,,,both,,,2187.01,1421.56,,,,,,,,,,,,,
PLATE BNE 18 H ST BILAT S STL NAR CRV LOK COMPR FOR 35MM SCR,SUP-2178050,CDM,C1713,HCPCS,0278,RC,,,,both,,,3002.84,1951.85,,,,,,,,,,,,,
NEEDLE BRST LOC NON-REPOSITIONABLE 20 GAX12.5 CM WIRE HAWK3,SUP-2874185,CDM,C1819,HCPCS,0278,RC,,,,both,,,102.05,66.33,,,,,,,,,,,,,
GRAFT HUM TISS L 4 X W 4 CM LG AMNIO MEMBRN RESRB AIR DRY,SUP-2913441,CDM,Q4173,HCPCS,0636,RC,,,,both,,,8810.84,5727.05,,,,,,,,,,,,,
CATHETER ETER CARD 7FR 2 5 2MM ELECTRD SPC 115CM ABLAT L CRV QPLR,SUP-2357035,CDM,C1733,HCPCS,0272,RC,,,,both,,,2276.50,1479.72,,,,,,,,,,,,,
PLATE BNE L80MM 4 H L LAT DST PERIARTC FIBULAR S STL LOK,SUP-2410715,CDM,C1713,HCPCS,0278,RC,,,,both,,,1935.37,1257.99,,,,,,,,,,,,,
HC Transesophageal Echo W/Ctrst,PX-4809331201,CDM,C8925,HCPCS,0480,RC,,,,both,,,3039.00,1975.35,,,,,,,,,,,,,
GRAFT HD FEM BONE W/O CART FRZN ALLGRFT,SUP-2165539,CDM,C1713,HCPCS,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
PLATE BNE NC FUSION SM 2.7 MM NS FPS LTX,SUP-2856865,CDM,C1713,HCPCS,0278,RC,,,,both,,,4298.66,2794.13,,,,,,,,,,,,,
PROCESSOR SND MAG STRENGTH 2 NS BAHA LTX,SUP-2858107,CDM,L8690,HCPCS,0278,RC,,,,both,,,412.38,268.05,,,,,,,,,,,,,
SET AUTOTRNS PROC 125ML BOWL PASXTRA,SUP-2352719,CDM,2720000010,LOCAL,0272,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
BRACE KNEE OFF THE SHLF STD MED R L UNLOADER 1 +,SUP-2319283,CDM,L1844,LOCAL,0274,RC,,,,both,,,2656.44,1726.69,,,,,,,,,,,,,
TUBE HARV L7MM BNE DWL DISPOSABLE,SUP-2212800,CDM,C1713,HCPCS,0278,RC,,,,both,,,1303.10,847.01,,,,,,,,,,,,,
DISPOSABLES KIT 2.4MM PUSHLOCK,SUP-2812587,CDM,2720000010,LOCAL,0272,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
OBTURATOR ENDO OD5.5MM STD,SUP-2340734,CDM,2720000010,LOCAL,0272,RC,,,,both,,,505.54,328.60,,,,,,,,,,,,,
CATHETER BAL DIL L160CM THROMBOSIS MICCATH INTIME,SUP-2141043,CDM,C1751,HCPCS,0278,RC,,,,both,,,1789.80,1163.37,,,,,,,,,,,,,
PROCESSOR SND CHESTNUT BRN PWR BAHA 3 BP110,SUP-2164976,CDM,L8690,HCPCS,0278,RC,,,,both,,,11304.00,7347.60,,,,,,,,,,,,,
IMPLANT EAR RT BRN BONE ANCHORED AD UNILAT W/ SLEEPER BAHA,SUP-2165009,CDM,L8614,HCPCS,0278,RC,,,,both,,,14428.30,9378.39,,,,,,,,,,,,,
CAGE SPNL CONVX 17X14X12 MM TI X-CORE MINI,SUP-2559854,CDM,C1889,HCPCS,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
PLATE BNE TIB LT ANTEROLATERAL DSTL 19 HOLE,SUP-2751187,CDM,C1713,HCPCS,0278,RC,,,,both,,,5633.16,3661.55,,,,,,,,,,,,,
GRAFT BNE CHIP CRUSH FRZ DRY CANC 1MM 4MM RANG 20CC,SUP-2264675,CDM,C1713,HCPCS,0278,RC,,,,both,,,939.08,610.40,,,,,,,,,,,,,
BASKET HELCL STONE 3FR SHTH L110CM 4W DISP,SUP-2261077,CDM,2720000010,LOCAL,0272,RC,,,,both,,,690.80,449.02,,,,,,,,,,,,,
KIT SURG PWR MINIMALLY INVASIVE PROC OPN STRL LF DISP,SUP-2881103,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7253.40,4714.71,,,,,,,,,,,,,
ELECTRODE ELECSURG CYL 12-30 DEG HF RESECT W/ SPIKE STRL,SUP-2430223,CDM,2720000010,LOCAL,0272,RC,,,,both,,,405.91,263.84,,,,,,,,,,,,,
COMPONENT HIP CEM BPLR HA LD/FX,SUP-2212769,CDM,C1776,CPT,0278,RC,,,,both,,,5338.00,3469.70,,,,,,,,,,,,,
KIT TKR HYBRID CEM FEM TRABECULAR MTL TIB PROLONG SURF AND,SUP-2402812,CDM,C1776,CPT,0278,RC,,,,both,,,13542.82,8802.83,,,,,,,,,,,,,
KIT SUT SZ 0 L7MM DIA2.2MM W/ SUT ANCHR FIBERWIRE NDL V TAK,SUP-2122459,CDM,C1713,HCPCS,0278,RC,,,,both,,,496.12,322.48,,,,,,,,,,,,,
PLATE BNE HUM 3.5X266 MM RT DSTL 12 HOLE LCK LP RIGID STRL,SUP-2177171,CDM,C1713,HCPCS,0278,RC,,,,both,,,5265.75,3422.74,,,,,,,,,,,,,
PLATE BNE L114MM 6 H R LAT PROX PERIARTC HUM LOK COMPR,SUP-2410727,CDM,C1713,HCPCS,0278,RC,,,,both,,,4305.38,2798.50,,,,,,,,,,,,,
PASSER SUT DIA2.3MM BAN SUTLASSO,SUP-2121807,CDM,2720000010,LOCAL,0272,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
PLATE BONE CRANIAL SQUARE 12X12MM TITANIUM NEURO PLATING SYS,SUP-2827186,CDM,C1713,HCPCS,0278,RC,,,,both,,,209.75,136.34,,,,,,,,,,,,,
SCREW BNE ST STD 7X40 MM CANC CANN NLCK HEX HD SS,SUP-2183954,CDM,C1713,HCPCS,0278,RC,,,,both,,,826.07,536.95,,,,,,,,,,,,,
BLADE IM L100MM DIA11MM STRL GLD TI HNDL HELCL FOR,SUP-2192550,CDM,C1713,HCPCS,0278,RC,,,,both,,,3899.88,2534.92,,,,,,,,,,,,,
PLATE BNE LADDER 23X0.6 MM NEURO 3X2 HOLE CRV TI NS LEVEL 1,SUP-2477039,CDM,C1713,HCPCS,0278,RC,,,,both,,,1010.61,656.90,,,,,,,,,,,,,
TAPESTRY RC BIOINTEGRATIVE 30X20 MM LAT LF,SUP-2867246,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3611.00,2347.15,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY OCTARAY SPLINE 2CM 8FR 2-5-2MM D,SUP-2737873,CDM,C1732,HCPCS,0278,RC,,,,both,,,6810.66,4426.93,,,,,,,,,,,,,
PLATE BONE W8XL76MM THK2MM 0DEG 9 H BILAT TI STR RIG DYN,SUP-2191073,CDM,C1713,HCPCS,0278,RC,,,,both,,,1644.54,1068.95,,,,,,,,,,,,,
CATHETER INTRO KT 14F DIAM,SUP-2327257,CDM,C1894,HCPCS,0272,RC,,,,both,,,354.82,230.63,,,,,,,,,,,,,
SHEATH INTRO PINNACLE R/O II L 6 CM DIA 6 FR 2.5 CM ETFE,SUP-2385639,CDM,C1894,HCPCS,0272,RC,,,,both,,,83.21,54.09,,,,,,,,,,,,,
LEVEL NEURO PLATE ULTRNE LDDR NEURO SCRW4 X 2 HOLES 30 MM T0,SUP-2707417,CDM,C1713,HCPCS,0278,RC,,,,both,,,1043.27,678.13,,,,,,,,,,,,,
PLATE BONE DOUBLE BEND 1.5X4 MM CHIN 6 HOLE ADVANCEMENT TITA,SUP-2838382,CDM,C1713,HCPCS,0278,RC,,,,both,,,1290.23,838.65,,,,,,,,,,,,,
SCREW BNE 3X16 MM SNAP-OFF,SUP-2608926,CDM,C1713,HCPCS,0278,RC,,,,both,,,1249.41,812.12,,,,,,,,,,,,,
AIRWAY ENDOTRACHEAL ADULT 70-100KG MAX CUFF 40ML LG,SUP-2824582,CDM,2720000010,LOCAL,0272,RC,,,,both,,,138.16,89.80,,,,,,,,,,,,,
PLATE BNE LCK FT ANAT LAT CLMN W/ SM WDG TIM A.L.P.S,SUP-2463473,CDM,C1713,HCPCS,0278,RC,,,,both,,,2244.75,1459.09,,,,,,,,,,,,,
BIT DRL 3.8 MMX6 IN STRL DISP,SUP-2606666,CDM,2720000010,LOCAL,0272,RC,,,,both,,,965.36,627.48,,,,,,,,,,,,,
BIT DRL OD1.5MM DENT FGS,SUP-2365168,CDM,2720000010,LOCAL,0272,RC,,,,both,,,326.56,212.26,,,,,,,,,,,,,
DEFIBRILLATOR IMPL VISIA AF MRI VR SURESCAN W 51 X H 64 MM D,SUP-2282425,CDM,C1722,HCPCS,0275,RC,,,,both,,,32046.84,20830.45,,,,,,,,,,,,,
SCREW BONE 1.8X3MM STERILE EMERGENCY CROSS DRIVE SELF TAPPIN,SUP-2825714,CDM,C1713,HCPCS,0278,RC,,,,both,,,83.30,54.14,,,,,,,,,,,,,
SPACER TIB 8-16 MM VANGUARD XP,SUP-2446831,CDM,C1776,CPT,0278,RC,,,,both,,,2373.84,1543.00,,,,,,,,,,,,,
HC So Cytogen Micro Array Copy No&Snp,PX-3108122966,CDM,81229,CPT,0310,RC,,,,both,,,1699.00,1104.35,,,,,,,,,,,,,
COMPONENT SHLDR CAPPED HUM REVERSED STEM CEM TRAB MTL,SUP-2212296,CDM,C1776,CPT,0278,RC,,,,both,,,26690.00,17348.50,,,,,,,,,,,,,
MESH HERN RECTANGULAR 8X16 CM INTRAPERITONEAL ENFORM,SUP-2539547,CDM,C1781,HCPCS,0278,RC,,,,both,,,7432.38,4831.05,,,,,,,,,,,,,
HC Ther Ivntj Cog Funcj Cntct Ea Addl 15 Mins,PX-4409713000,CDM,97130,CPT,0440,RC,,,,inpatient,,,186.00,120.90,,,,,,,,,,,,,
SUMMIT SZ6/7 STD NECK SEGMENT,SUP-2515371,CDM,C1776,CPT,0278,RC,,,,both,,,1865.16,1212.35,,,,,,,,,,,,,
PEG BONE FXTN 2.5MM DIA 30MML CBLT CHRMM DST RDL VOLAR PRTLL,SUP-2589000,CDM,C1713,HCPCS,0278,RC,,,,both,,,259.05,168.38,,,,,,,,,,,,,
BIT DRL DIA35MM NONSTERILE FOR MULT AX CORR SYS MAXFRAME,SUP-2176978,CDM,2720000010,LOCAL,0272,RC,,,,both,,,541.65,352.07,,,,,,,,,,,,,
GRAFT BNE SUB 05CC REHYDRATED PTTY OSTEOAMP,SUP-2138513,CDM,C1713,HCPCS,0278,RC,,,,both,,,854.08,555.15,,,,,,,,,,,,,
"HC Pain Mgt,Inj, Intra-Arterial",PX-7619637300,CDM,96373,CPT,0761,RC,,,,both,,,267.00,173.55,,,,,,,,,,,,,
CAP NAIL L4.7MM FEM HEX SET SCR META-NAIL TRIGEN,SUP-2347544,CDM,C1713,HCPCS,0278,RC,,,,both,,,1175.68,764.19,,,,,,,,,,,,,
MARKER TISS PLCMNT NDL 18GA ETWX12CM W/ 0.9X3MM GLD,SUP-2164655,CDM,A4648,CPT,0278,RC,,,,both,,,257.48,167.36,,,,,,,,,,,,,
TAP SURG DIA17MM SELF DRL HEX FOR 3 4MM,SUP-2365069,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1147.07,745.60,,,,,,,,,,,,,
SCREW BONE L76MM DIA4.5MM S STL CORT FEM ST NONLCK FULL THRD,SUP-2348873,CDM,C1713,HCPCS,0278,RC,,,,both,,,319.81,207.88,,,,,,,,,,,,,
PLATE BONE LT KNEE TI L SHP FOR HI OSTEOTMY SYS N-K,SUP-2210171,CDM,C1713,HCPCS,0278,RC,,,,both,,,3039.52,1975.69,,,,,,,,,,,,,
TRAY THORCENT CATH 8FR 3ML CHLORAPREP NDL STRW FLTR FN TIP,SUP-2133920,CDM,C1729,HCPCS,0272,RC,,,,both,,,222.94,144.91,,,,,,,,,,,,,
PLATE BNE STR 15X0.6 MM NEURO 2 HOLE TI NS LEVEL 1 251521209,SUP-2518094,CDM,C1713,HCPCS,0278,RC,,,,both,,,340.63,221.41,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 20 CM DIA 6 MM EPTFE STR TW REINF 2,SUP-2479774,CDM,C1768,CPT,0278,RC,,,,both,,,460.14,299.09,,,,,,,,,,,,,
BIT DRILL SURG DIA 4.5 MM LNG FLUT FOR 6 MM PIN NS MAV,SUP-2931209,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2025.30,1316.44,,,,,,,,,,,,,
KIT SEP W/ BLD DRAW TB SYR NDL TRNQT PD,SUP-2402596,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2041.00,1326.65,,,,,,,,,,,,,
BLADES HOOK 25 DEGREE STR,SUP-2705990,CDM,C1713,HCPCS,0278,RC,,,,both,,,525.76,341.74,,,,,,,,,,,,,
GRAFT NERVE REP 2X2 CM SFT TISS MEMBRN AVIVE,SUP-2423444,CDM,C1762,CPT,0278,RC,,,,both,,,4474.50,2908.42,,,,,,,,,,,,,
HC So Glucose 6 Phos Dehydro Quant,PX-3018295566,CDM,82955,CPT,0301,RC,,,,both,,,111.00,72.15,,,,,,,,,,,,,
BASKET STONE RTRVL 24FR L120CM D11MM 3 WIRE O TIP PRD HELI,SUP-2730107,CDM,C1889,HCPCS,0278,RC,,,,both,,,634.00,412.10,,,,,,,,,,,,,
HC Surgery Level 4 Addtl 15min,PX-3600000014,CDM,3600000014,LOCAL,0360,RC,,,,both,,,3551.00,2308.15,,,,,,,,,,,,,
PORT INFUS CATH 6.6FR TI LO PROF W/ PREATTACH OPN END SIL,SUP-2127724,CDM,C1788,HCPCS,0278,RC,,,,both,,,558.92,363.30,,,,,,,,,,,,,
ALLOGRAFT BNE FILL 1-8 MM 10 CC FD SPNG CANC READIGRAFT BLX,SUP-2740972,CDM,C1713,HCPCS,0278,RC,,,,both,,,2550.78,1658.01,,,,,,,,,,,,,
ALLOGRAFT BNE 5 CC FIBER KORE,SUP-2736956,CDM,C1713,HCPCS,0278,RC,,,,both,,,3508.95,2280.82,,,,,,,,,,,,,
PLATE BNE VA NEUT 2.7/3.5X232 MM RT DSTL TIB 14 HOLE LCK LP,SUP-2177686,CDM,C1713,HCPCS,0278,RC,,,,both,,,6632.97,4311.43,,,,,,,,,,,,,
GRAFT EVAR L49MM DIA23X23MM CATH 18FR AORT EXTN W/ FREE FLO,SUP-2295230,CDM,C1768,CPT,0278,RC,,,,both,,,13109.50,8521.17,,,,,,,,,,,,,
SPACER ORTH SUBTALAR 6.5 MM,SUP-2482068,CDM,C1713,HCPCS,0278,RC,,,,both,,,4317.50,2806.37,,,,,,,,,,,,,
"HC Gbl Est Pt, E/M Level 4",PX-9829921400,CDM,99214,CPT,0982,RC,,,,inpatient,,,522.00,339.30,,,,,,,,,,,,,
CATHETER EP DAO CRV 10 MM 6 FRX120 CM SUPREME,SUP-2356852,CDM,C1730,HCPCS,0272,RC,,,,both,,,427.04,277.58,,,,,,,,,,,,,
PLATE BNE L92MM 7 H BILAT FIBULAR TIM LOK COMPR FOR,SUP-2413682,CDM,C1713,HCPCS,0278,RC,,,,both,,,785.82,510.78,,,,,,,,,,,,,
PLATE BONE LOK LNG HLX6 1MM THK CP TTNM LATEX FREE,SUP-2668742,CDM,C1713,HCPCS,0278,RC,,,,both,,,1124.09,730.66,,,,,,,,,,,,,
POST EXT FIX 1 H SPEEDWIRE M,SUP-2898444,CDM,C1713,HCPCS,0278,RC,,,,both,,,690.80,449.02,,,,,,,,,,,,,
RING EXT FIX ROCKER,SUP-2342855,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3925.00,2551.25,,,,,,,,,,,,,
PLATE BONE DUAL CMPRSSN HLX5 L SHPD OBLQUE LEFT F/2.7MM SCRE,SUP-2495295,CDM,C1713,HCPCS,0278,RC,,,,both,,,931.45,605.44,,,,,,,,,,,,,
SCREW INTFR L23MM OD6MM BIOSTEON WDG SHP ROUNDED THRD CRUCE,SUP-2366618,CDM,C1713,HCPCS,0278,RC,,,,both,,,705.15,458.35,,,,,,,,,,,,,
CATHETERIZATION KIT 13-1/8 IN 6 FRX50 CM 3L BLU FLEXTIP,SUP-2383372,CDM,C1751,HCPCS,0278,RC,,,,both,,,524.47,340.91,,,,,,,,,,,,,
PLATE BONE 3D PRNT LG MIDFACE MAND TI TRUMATCH,SUP-2860369,CDM,C1713,HCPCS,0278,RC,,,,both,,,49048.37,31881.44,,,,,,,,,,,,,
IMPLANT PECTUS BAR L10IN S STL ROUNDED END BLNT EDGE FOR,SUP-2402854,CDM,C1713,HCPCS,0278,RC,,,,both,,,5623.74,3655.43,,,,,,,,,,,,,
BIT DRL CALIB 4.2X145 MM 3 FLUT QC NDL PT TFNA ADV,SUP-2178878,CDM,2720000010,LOCAL,0272,RC,,,,both,,,527.02,342.56,,,,,,,,,,,,,
CATHETER THORACENTESIS SET 14 FRX30 CM PNEUMOTHORAX SIMP,SUP-2760075,CDM,C1729,HCPCS,0272,RC,,,,both,,,304.58,197.98,,,,,,,,,,,,,
DIST MED HUM PLT PROV,SUP-2725825,CDM,C1713,HCPCS,0278,RC,,,,both,,,1666.27,1083.08,,,,,,,,,,,,,
PLATE BONE FACIAL ID TITANIUM 3D RECONST CUSTOM,SUP-2883354,CDM,C1713,HCPCS,0278,RC,,,,both,,,26743.63,17383.36,,,,,,,,,,,,,
ALLOGRAFT BNE SPACER 9/11X26X11 MM FD T-PLIF,SUP-2736785,CDM,C1713,HCPCS,0278,RC,,,,both,,,13903.17,9037.06,,,,,,,,,,,,,
STENT NEURO NEUROFORM EZ L 20 MM DIA 4.5 MM MICROCATHETER,SUP-2368089,CDM,C1876,HCPCS,0278,RC,,,,both,,,20943.80,13613.47,,,,,,,,,,,,,
COIL EMB L2CM 2ND DIA1MM HELI SFT NEUROVASC SMRT WAVE,SUP-2323454,CDM,C1889,HCPCS,0278,RC,,,,both,,,3548.20,2306.33,,,,,,,,,,,,,
LEAD PACE L90CM 2X8 SPEC SURESCAN MRI,SUP-2284651,CDM,C1778,HCPCS,0278,RC,,,,both,,,15700.00,10205.00,,,,,,,,,,,,,
GUIDEPIN ORTH DIA2.5MM PROX LOK DISP FOR ATN TROCHANTERIC,SUP-2413925,CDM,2720000010,LOCAL,0272,RC,,,,both,,,395.64,257.17,,,,,,,,,,,,,
TRAY VERT AUG SYS BAL L10MM W/ 13GA NDL IVAS,SUP-2361540,CDM,C1726,HCPCS,0272,RC,,,,both,,,4777.51,3105.38,,,,,,,,,,,,,
PLATE BONE W8XL52MM 6 H TI DYN COMPR FOR 2.7MM SCR,SUP-2191070,CDM,C1713,HCPCS,0278,RC,,,,both,,,1294.87,841.67,,,,,,,,,,,,,
SCREW SPNL L25MM DIA4.2MM CANC POST PEDCL THORLUM TI SIDE,SUP-2193512,CDM,C1713,HCPCS,0278,RC,,,,both,,,2209.93,1436.45,,,,,,,,,,,,,
EXPANDER BRST W11.7XH10CM P6.6CM 350CC SIL NACL SHELL RND M,SUP-2300632,CDM,C1789,HCPCS,0278,RC,,,,both,,,4317.50,2806.37,,,,,,,,,,,,,
PIN FIX BUTTRESS 24/14 MM SFC COMBINATION,SUP-2389691,CDM,2720000010,LOCAL,0272,RC,,,,both,,,973.40,632.71,,,,,,,,,,,,,
PLATE BONE SM 5 H PROX RAD TI LCK COMPR FOR 2.5MM SCR ALPS,SUP-2411725,CDM,C1713,HCPCS,0278,RC,,,,both,,,2647.02,1720.56,,,,,,,,,,,,,
HC Iron Binding Capacity,PX-3018355000,CDM,83550,CPT,0301,RC,,,,both,,,128.00,83.20,,,,,,,,,,,,,
PLATE BNE DBL ANGLED LG 2.5 MM RECON PT SPEC,SUP-2860103,CDM,C1713,HCPCS,0278,RC,,,,both,,,29866.42,19413.17,,,,,,,,,,,,,
GUIDEPIN ORTH DIA2MM FOR HEMI CAP IMPL,SUP-2123522,CDM,C1769,HCPCS,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
BIT DRL DIA8MM ACL CANN TRANSTIBIAL,SUP-2120876,CDM,2720000010,LOCAL,0272,RC,,,,both,,,527.52,342.89,,,,,,,,,,,,,
SYSTEM BONE MAR ASPIR 60ML CONC ACCELERATE,SUP-2223566,CDM,C1713,HCPCS,0278,RC,,,,both,,,5542.10,3602.36,,,,,,,,,,,,,
GUIDE SURG TI VSP,SUP-2883357,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8949.00,5816.85,,,,,,,,,,,,,
GRAFT VASC FLIXENE 60 DEG L 90 CM DIA 8 MM BRANCH L 50 CM,SUP-2681858,CDM,C1768,CPT,0278,RC,,,,both,,,6637.93,4314.65,,,,,,,,,,,,,
NAIL IM L460MM DIA11MM UNIV L R DST FEM TI CANN LOK RG DYN,SUP-2191763,CDM,C1713,HCPCS,0278,RC,,,,both,,,7534.12,4897.18,,,,,,,,,,,,,
CATHETER EMB NOVASIL L 80 CM DIA 4 FR BALLOON DIA 9 MM 0.60,SUP-2264197,CDM,C1757,HCPCS,0272,RC,,,,both,,,499.26,324.52,,,,,,,,,,,,,
PIN FIX L120MM DIA35MM S STL SGL END SMOOTH SHRP TIP FOR,SUP-2186908,CDM,C1713,HCPCS,0278,RC,,,,both,,,112.00,72.80,,,,,,,,,,,,,
SLING URETH PRECIS MINIARC 443378,SUP-2140110,CDM,C1771,HCPCS,0278,RC,,,,both,,,4025.35,2616.48,,,,,,,,,,,,,
ROD EXT FIX HOFF CARBON FIBER 6MMX120MM,SUP-2463769,CDM,2720000010,LOCAL,0272,RC,,,,both,,,205.98,133.89,,,,,,,,,,,,,
STEM FEM HI OFFSET A MAG NK W/ TRUNNION ARCOS,SUP-2443221,CDM,C1776,CPT,0278,RC,,,,both,,,1978.20,1285.83,,,,,,,,,,,,,
ANCHOR SUT MORPHIX USP NO 2 SUTS 3.5X8 MM,SUP-2277448,CDM,C1713,HCPCS,0278,RC,,,,both,,,1767.82,1149.08,,,,,,,,,,,,,
"HC Gbl New Pt, E/M Level 3",PX-9829920300,CDM,99203,CPT,0982,RC,,,,outpatient,,,498.00,323.70,,,,,,,,,,,,,
DRILL SURG 70 MM FOR 3.5MM SCR SPEEDGUIDE,SUP-2480443,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1314.40,854.36,,,,,,,,,,,,,
SHUNT SURG SM 120 CM PERF LEVEL 1.0 SNAP DELT,SUP-2628308,CDM,C1729,HCPCS,0272,RC,,,,both,,,4612.72,2998.27,,,,,,,,,,,,,
PROBE ABLAT L130MM TIP DIA3MM 90DEG CERAMIC ASPIR MPLR LO,SUP-2123445,CDM,C1713,HCPCS,0278,RC,,,,both,,,478.85,311.25,,,,,,,,,,,,,
SPLINT WRST M L7IN AD R FA COT E SUPP INSTABILITY INJ LOOP,SUP-2276653,CDM,L3809,HCPCS,0272,RC,,,,both,,,9.80,6.37,,,,,,,,,,,,,
CATHETER CV KT AD 7 FRX20 CM 3L PRESSURE INJ N TUNNELED,SUP-2763383,CDM,C1751,HCPCS,0278,RC,,,,both,,,339.75,220.84,,,,,,,,,,,,,
TUBE TRACHEOSTOMY FENEST CUFFLESS BLUSELECT,SUP-2915315,CDM,2720000010,LOCAL,0272,RC,,,,both,,,94.26,61.27,,,,,,,,,,,,,
ALLOGRAFT BNE FRZN W/ GROWTH PLATE RT WHL FEM,SUP-2740873,CDM,C1713,HCPCS,0278,RC,,,,both,,,32818.97,21332.33,,,,,,,,,,,,,
CATHETER ETER URETH 5FR L30CM SIL HYSTEROSALPINGOGRAPHY BLLN,SUP-2168929,CDM,C2628,HCPCS,0272,RC,,,,both,,,255.50,166.07,,,,,,,,,,,,,
IMMOBILIZER KNEE SM L19IN FOR 14 16IN BLU CANVS T BAR STAY,SUP-2336065,CDM,L1830,CPT,0274,RC,,,,both,,,40.07,26.05,,,,,,,,,,,,,
BOOT CAST XL VELC OPN TOE FOR TOT CNTCT SYS TCC-EZ,SUP-2244449,CDM,L4370,HCPCS,0272,RC,,,,both,,,370.33,240.71,,,,,,,,,,,,,
SCREW BNE L6MM DIA1.3MM HND 316L S STL ST LOK T4 STARDRV,SUP-2177969,CDM,C1713,HCPCS,0278,RC,,,,both,,,331.33,215.36,,,,,,,,,,,,,
COMPONENT TOT ANK NEUT 4 18 MM POLYETH VIT E APEX 3D,SUP-2742203,CDM,C1776,CPT,0278,RC,,,,both,,,6594.00,4286.10,,,,,,,,,,,,,
SET EXPLORATION COMMON BILE DUCT W/ GWIRE INTRO BLLN CATH,SUP-2169659,CDM,C1726,HCPCS,0272,RC,,,,both,,,2904.50,1887.92,,,,,,,,,,,,,
STRIP INT STPL DRY VERIT BOV PERICARD PSD-V TISS CLLGN MTRX,SUP-2130378,CDM,C9354,HCPCS,0278,RC,,,,both,,,739.60,480.74,,,,,,,,,,,,,
BLADE SHAVER BPLR STD STR SERRATED CLOSED STRL DISP,SUP-2648960,CDM,2720000010,LOCAL,0272,RC,,,,both,,,501.14,325.74,,,,,,,,,,,,,
PIN DISTRACTOR 14 MM TI NS,SUP-2591705,CDM,C1713,HCPCS,0278,RC,,,,both,,,219.80,142.87,,,,,,,,,,,,,
COIL NEUROVASCULAR TARGET 360 DEG L 4 CM DIA2 MM STD,SUP-2368017,CDM,C1889,HCPCS,0278,RC,,,,both,,,6271.99,4076.79,,,,,,,,,,,,,
HC So Immunoassayanalytenos,PX-3018352066,CDM,83520,CPT,0301,RC,,,,both,,,170.00,110.50,,,,,,,,,,,,,
"HC Total Protein, Other Source",PX-3018415700,CDM,84157,CPT,0301,RC,,,,both,,,206.00,133.90,,,,,,,,,,,,,
PACEMAKER CARD 2 CHMBR PULSE GENRTR DDDR UPLR IS 1 TEMP W/,SUP-2278428,CDM,C1785,HCPCS,0275,RC,,,,both,,,11391.92,7404.75,,,,,,,,,,,,,
EYELET ORTH LP VUEPOINT II,SUP-2563645,CDM,C1713,HCPCS,0278,RC,,,,both,,,1491.50,969.47,,,,,,,,,,,,,
HC Blood Count Manual Difrntl Wbc Count Buffy Coat,PX-3058500900,CDM,85009,CPT,0305,RC,,,,both,,,17.00,11.05,,,,,,,,,,,,,
ALLOGRAFT BNE REFRIGERATED RT FEM HD,SUP-2740783,CDM,C1762,CPT,0278,RC,,,,both,,,24572.51,15972.13,,,,,,,,,,,,,
PLATE BNE L 192 X W 10 MM THK 2 MM SCREW DIA2.7/3.5 MM 14 H,SUP-2936263,CDM,C1713,HCPCS,0278,RC,,,,both,,,5707.26,3709.72,,,,,,,,,,,,,
INSERT TIB CR T1/1+ 12 MM KNEE GLIDING SURF DP DSH POLYETH,SUP-2422121,CDM,C1776,CPT,0278,RC,,,,both,,,1648.50,1071.52,,,,,,,,,,,,,
GRAFT VASC SEALPTFE L 50 CM DIA 6 MM GEL SEAL EPTFE STD WALL,SUP-2392561,CDM,C1768,CPT,0278,RC,,,,both,,,1805.50,1173.57,,,,,,,,,,,,,
SCREW ACET LP UNIV 6.5X70 MM HIP DOMED 2 MOBILITY STRL G7,SUP-2403208,CDM,C1713,HCPCS,0278,RC,,,,both,,,109.90,71.43,,,,,,,,,,,,,
CATHETER ANGIOPLSTY MR L 75 CM DIA 5.2 FR BALLOON L 2 CM DIA,SUP-2139652,CDM,C1725,HCPCS,0272,RC,,,,both,,,736.80,478.92,,,,,,,,,,,,,
PROBE DISCECTOMY L3IN DIA19GA PERC STR INTRO CANN BLNT STYL,SUP-2367004,CDM,C1713,HCPCS,0278,RC,,,,both,,,5874.81,3818.63,,,,,,,,,,,,,
PLATE BONE SM W10XL53MM THK1.5MM 3X3 H S STL DSTL OBLQ T SHP,SUP-2343784,CDM,C1713,HCPCS,0278,RC,,,,both,,,1888.40,1227.46,,,,,,,,,,,,,
TROCAR SURG SINUS 4 MM 180 MM 90 MM W/ CANN,SUP-2476423,CDM,2720000010,LOCAL,0272,RC,,,,both,,,583.10,379.01,,,,,,,,,,,,,
GRAFT SFT TISS 4 MMX26 CM ACTIVE TEND HUNTER,SUP-2517187,CDM,C1763,HCPCS,0278,RC,,,,both,,,4267.26,2773.72,,,,,,,,,,,,,
"HC So Zinc, Serum",PX-3018463066,CDM,84630,CPT,0301,RC,,,,both,,,295.00,191.75,,,,,,,,,,,,,
WIRE LIG BLNT 0.5X160 MM 24 GA THRD N ABSRB SS UNIV 2 10/EA,SUP-2361095,CDM,C1713,HCPCS,0278,RC,,,,both,,,36.36,23.63,,,,,,,,,,,,,
PROSTHESIS OSS SHEEHY 0.13X5.5 MM INCUS REPL STRUT SS,SUP-2637815,CDM,L8613,CPT,0278,RC,,,,both,,,281.85,183.20,,,,,,,,,,,,,
IMPLANT HAMMERTUBE 3.50MM 0 DEG CANN,SUP-2419715,CDM,C1713,HCPCS,0278,RC,,,,both,,,3867.70,2514.00,,,,,,,,,,,,,
PLEDGET CV L 6 X W 6 MM THK 1.65 MM PTFE FELT SQ FOR SEPTAL,SUP-2761355,CDM,C1768,CPT,0278,RC,,,,both,,,37.99,24.69,,,,,,,,,,,,,
NAIL OSSIOFIBER CANNULATED TRIMMABLE FIXATION IMPLANT 4.0 X 100MM,SUP-2904886,CDM,C1713,HCPCS,0278,RC,,,,both,,,5485.58,3565.63,,,,,,,,,,,,,
DEVICE INTVASC OCCL TRUEPATH CTO L 165 CM GUIDEWIRE 0.018 IN,SUP-2145955,CDM,C1769,HCPCS,0272,RC,,,,both,,,8820.26,5733.17,,,,,,,,,,,,,
SYSTEM CHARGING FOR DP BAIN STIM VERCISE,SUP-2140424,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
STEM HUM DIA12MM SHLDR CO CHROM NP COMPHSVE,SUP-2403970,CDM,C1776,CPT,0278,RC,,,,both,,,9905.13,6438.33,,,,,,,,,,,,,
ALLOGRAFT HUM TISS GRAFIX PRIME 2X3CM CYROPRESERVED,SUP-2319162,CDM,Q4133,HCPCS,0636,RC,,,,both,,,3124.30,2030.79,,,,,,,,,,,,,
HEAD HUM H18MM DIA44MM PRI STD OFFSET GLOB AP,SUP-2249983,CDM,C1776,CPT,0278,RC,,,,both,,,5972.28,3881.98,,,,,,,,,,,,,
GUIDEWIRE ORTH L 300 MM DIA2.8 MM THRD FOR CANN SYS STRL,SUP-2908091,CDM,C1769,HCPCS,0272,RC,,,,both,,,814.23,529.25,,,,,,,,,,,,,
OBTURATOR ENDOSCP SPEAR TRCR TIP FOR 3.7MM SUTURETAK AND,SUP-2121487,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
PLATE BNE SCREW DIA2 MM 6 H TI LOWER EXTREMITY Y SHP NS,SUP-2905676,CDM,C1713,HCPCS,0278,RC,,,,both,,,2680.18,1742.12,,,,,,,,,,,,,
LINER ACET 20 DEG 36X54 MM HIP XLPE R3,SUP-2345001,CDM,C1776,CPT,0278,RC,,,,both,,,2041.00,1326.65,,,,,,,,,,,,,
GRAFT TISS FRZN ALLGRFT TEND ACHILLES W/ STRUT 200MML,SUP-2137245,CDM,C1776,CPT,0278,RC,,,,both,,,4802.63,3121.71,,,,,,,,,,,,,
COMPONENT FEM 8X2MM OFFSET UNICAP,SUP-2123703,CDM,C1776,CPT,0278,RC,,,,both,,,16271.48,10576.46,,,,,,,,,,,,,
CONNECTOR SPNL TI FOR VAR AXIS SCR AND ROD,SUP-2193307,CDM,C1713,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
HC Peripheral Block - Femoral Single or Saphenous W/Img Gdn,PX-3606444700,CDM,64447,CPT,0360,RC,,,,both,,,2230.00,1449.50,,,,,,,,,,,,,
REAMER SURG 520 MM KIT TBNG ROD SEAL STRL RIA 2,SUP-2432237,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8046.44,5230.19,,,,,,,,,,,,,
HC So Hla II Typing 1 Locus Lr,PX-3108137666,CDM,81376,CPT,0310,RC,,,,both,,,143.00,92.95,,,,,,,,,,,,,
SCREW BNE CANN MED THRD 7X46 MM HDLSS NS MONSTER,SUP-2742679,CDM,C1713,HCPCS,0278,RC,,,,both,,,2155.14,1400.84,,,,,,,,,,,,,
CROWN DENT STRP L2 PEDIATRIC LOWER CUSPID,SUP-2119363,CDM,D6783,CPT,0278,RC,,,,both,,,12.53,8.14,,,,,,,,,,,,,
TRAY CATH HEMODIALYSI SLXACUTE 14FR DIA 24CM STRGHT TAPR TIP,SUP-2610565,CDM,C1752,HCPCS,0278,RC,,,,both,,,577.76,375.54,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9% BOLUS (FLUID RESUSCITATION),RX-4081440,CDM,J7030,HCPCS,0258,RC,00338-0049-04,NDC,,both,1000,ML,42.50,27.62,,,,,,,,,,,,,
PLATE BNE L 114 MM SCREW DIA2.7/3.5 MM 8 H SS RT OLECRANON,SUP-2931273,CDM,C1713,HCPCS,0278,RC,,,,both,,,5801.46,3770.95,,,,,,,,,,,,,
DENOSUMAB-BMWO 120 MG/1.7ML SC SOLN,RX-172325,CDM,Q5157,HCPCS,0636,RC,72606-0038-01,NDC,,both,1.7,ML,9667.90,6284.13,,,,,,,,,,,,,
GRAFT VASC TW 6 MMX80 CM STR SFT WRP TUNN ATTCH ADVANTA VXT,SUP-2464366,CDM,C1768,CPT,0278,RC,,,,both,,,1061.29,689.84,,,,,,,,,,,,,
CANNULA SUCTION CURVED RUGGLES REDMOND,SUP-2702224,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4491.20,2919.28,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED RESURF H20] STRYKER CORP],SUP-2365526,CDM,C1776,CPT,0278,RC,,,,both,,,30772.00,20001.80,,,,,,,,,,,,,
NAIL IM 5.5 MM DSTL DRL GAMMA,SUP-2538267,CDM,C1713,HCPCS,0278,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
NAIL IM L380MM DIA8MM ST DK BLU TIB TI LOK UNREAMED SLD W/,SUP-2192763,CDM,C1713,HCPCS,0278,RC,,,,both,,,5558.74,3613.18,,,,,,,,,,,,,
GRAFT NRV L70MM DIA2-3MM PERIPH NAT CONN CBL PROC FOR RECON,SUP-2124851,CDM,C1762,CPT,0278,RC,,,,both,,,26859.56,17458.71,,,,,,,,,,,,,
SCREW 1.7X4MM,SUP-2363744,CDM,C1713,HCPCS,0278,RC,,,,both,,,164.32,106.81,,,,,,,,,,,,,
STENT PERIPH L60MM DIA7MM CATH L120CM SHTH 6FR 0.035IN NIT,SUP-2395886,CDM,C1874,HCPCS,0278,RC,,,,both,,,4461.94,2900.26,,,,,,,,,,,,,
HC Hepatitis C Antibody,PX-3028680300,CDM,86803,CPT,0302,RC,,,,both,,,37.00,24.05,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9% BOLUS (FLUID RESUSCITATION),RX-4081440,CDM,J7050,HCPCS,0258,RC,00264-7800-20,NDC,,both,1000,ML,93.50,60.77,,,,,,,,,,,,,
HC Mod Sed Same Phys/Qhp Ea,PX-3729915300,CDM,99153,CPT,0372,RC,,,,inpatient,,,297.00,193.05,,,,,,,,,,,,,
HC So Immunoglob G Subclasses Each,PX-3018278766,CDM,82787,CPT,0301,RC,,,,both,,,232.00,150.80,,,,,,,,,,,,,
SCREW BNE NLCK 5X65 MM OSTEOPENIA PARTIALLY THRD NS PERI-LOC,SUP-2348508,CDM,C1713,HCPCS,0278,RC,,,,both,,,251.36,163.38,,,,,,,,,,,,,
HEAD FEM C TAPR 0+ MM 36 MM OFFSET PRIMARY ALUMINA CERM,SUP-2368527,CDM,C1776,CPT,0278,RC,,,,both,,,4410.44,2866.79,,,,,,,,,,,,,
CATHETER DRNGE 10.2FR L50CM DIA0.038IN HYDRPHLC RADPQ BND,SUP-2168696,CDM,C1729,HCPCS,0272,RC,,,,both,,,250.76,162.99,,,,,,,,,,,,,
PLATE BONE L90MM NONCOMPRESSION FRAG,SUP-2364908,CDM,C1713,HCPCS,0278,RC,,,,both,,,478.07,310.75,,,,,,,,,,,,,
BRACE KNEE OFF THE SHLF W ACCUTRAC TECHNOLOGY STD PCL MOD L,SUP-2319280,CDM,L1810,HCPCS,0274,RC,,,,both,,,1125.94,731.86,,,,,,,,,,,,,
CATHETER DIAG 6FR L95CM DST L6CM 0.035/0.038IN S STL MP,SUP-2323595,CDM,C1887,HCPCS,0272,RC,,,,both,,,2056.70,1336.85,,,,,,,,,,,,,
IMMOBILIZER ORTH XSM SHLDR,SUP-2196914,CDM,L3660,HCPCS,0274,RC,,,,both,,,12.59,8.18,,,,,,,,,,,,,
SODIUM THIOSULFATE 250 MG/ML IV SOLN|DISCARDED DRUG NOT ADMINISTE,RX-156090,CDM,J0209,HCPCS,0636,RC,60267-0705-50,NDC,JW,both,1,ML,54.10,35.16,,,,,,,,,,,,,
IMPLANT CRANIALXL CUST DEFORMITY PEEK,SUP-2365130,CDM,C1713,HCPCS,0278,RC,,,,both,,,61739.03,40130.37,,,,,,,,,,,,,
COMPONENT TOT SHLDR CAPPED ADV REV,SUP-2197232,CDM,C1776,CPT,0278,RC,,,,both,,,21823.00,14184.95,,,,,,,,,,,,,
GRAFT EVAR L13CM AORT DIA31MM IL DIA14.5MM IPSILATERAL LEG,SUP-2396062,CDM,C1768,CPT,0278,RC,,,,both,,,33010.82,21457.03,,,,,,,,,,,,,
CATHETER ATHRCTMY DIAMONDBACK 360 L 135 CM DIA1.25 MM SHTH 6,SUP-2159495,CDM,C1724,HCPCS,0278,RC,,,,both,,,11916.30,7745.59,,,,,,,,,,,,,
GRASPER SURG 3 PRNG 3.2 FRX115 CM CAPT,SUP-2835967,CDM,2720000010,LOCAL,0272,RC,,,,both,,,602.79,391.81,,,,,,,,,,,,,
SCREW HAND EMERG CRSS PIN 12X9MM,SUP-2695503,CDM,C1713,HCPCS,0278,RC,,,,both,,,202.53,131.64,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 90 MM DIA13/10 MM DEL 9ML,SUP-2936839,CDM,C1713,HCPCS,0278,RC,,,,both,,,12142.38,7892.55,,,,,,,,,,,,,
ALLOGRAFT BNE WDG 20-22 MM FRZN ILIUM TRICORT,SUP-2717922,CDM,C1762,CPT,0278,RC,,,,both,,,5466.58,3553.28,,,,,,,,,,,,,
BONE MARROW KIT SM BIO ART BMC,SUP-2163086,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5997.40,3898.31,,,,,,,,,,,,,
TI LCP DIA-META VOLAR DISTAL RADIUS PL 11H SHAFT/LT-STERILE,SUP-2546646,CDM,C1713,HCPCS,0278,RC,,,,both,,,5548.41,3606.47,,,,,,,,,,,,,
PLATE CRAN 100X60X40 MM PT SPEC IMPL PEEK,SUP-2860132,CDM,C1713,HCPCS,0278,RC,,,,both,,,30240.08,19656.05,,,,,,,,,,,,,
ELRANATAMAB-BCMM 76 MG/1.9ML SC SOLN,RX-165065,CDM,J1323,HCPCS,0636,RC,00069-4494-01,NDC,,both,0.3,ML,6496.50,4222.72,,,,,,,,,,,,,
PLATE BNE W10XL90MM THK1.2MM 90DEG 4X6 H BILAT S STL T SHP,SUP-2185875,CDM,C1713,HCPCS,0278,RC,,,,both,,,853.45,554.74,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 80 CM DIA 8MM STR STD WALL SLDE GDS,SUP-2681786,CDM,C1768,CPT,0278,RC,,,,both,,,2372.77,1542.30,,,,,,,,,,,,,
STENT NEURO NEUROFORM ATLS L 21 MM DIA 4.5 MM DEL WIRE L 185,SUP-2431334,CDM,C1877,HCPCS,0278,RC,,,,both,,,25748.00,16736.20,,,,,,,,,,,,,
PLATE BNE NAR 4.5X71 MM 4 HOLE SS DCP,SUP-2569162,CDM,C1713,HCPCS,0278,RC,,,,both,,,219.33,142.56,,,,,,,,,,,,,
PROSTHESIS 16F 5MM SPEC LEN LG ESOPH FLNG INDWL VOICE,SUP-2242345,CDM,L8509,HCPCS,0272,RC,,,,both,,,979.68,636.79,,,,,,,,,,,,,
KIT CEM 12ML 33GM GLS IONOMER CEM LUTING RADPQ,SUP-2238633,CDM,C1713,HCPCS,0278,RC,,,,both,,,617.92,401.65,,,,,,,,,,,,,
GRAFT HUM TISS D EYE AMINOGRFT,SUP-2135255,CDM,V2790,HCPCS,0278,RC,,,,both,,,2025.30,1316.44,,,,,,,,,,,,,
PLATE BNE MESHED 11.2X248.7X1 MM SM GRID OFFSET PDLLA STRL,SUP-2486480,CDM,C1713,HCPCS,0278,RC,,,,both,,,5907.47,3839.86,,,,,,,,,,,,,
DEFIBRILLATOR CRD SINGLE CHMBR 13 MM 33 CC 71 GM EPIC II VR V158RST] ST JUDE MED CARDIAC RHYM MGMT],SUP-2356512,CDM,C1722,HCPCS,0275,RC,,,,both,,,55578.00,36125.70,,,,,,,,,,,,,
PROGRAMMER NEUROSTIMULATOR PT ITREL III,SUP-2284581,CDM,C1787,HCPCS,0278,RC,,,,both,,,3124.30,2030.79,,,,,,,,,,,,,
CAP NAIL RET SHFT FOR RG FEM NAT NAIL,SUP-2198680,CDM,C1713,HCPCS,0278,RC,,,,both,,,869.37,565.09,,,,,,,,,,,,,
WIRE FIX NIT K,SUP-2353339,CDM,C1713,HCPCS,0278,RC,,,,both,,,163.28,106.13,,,,,,,,,,,,,
UNIT COMPR DISTR CLICKER STD EXT TO 4CM,SUP-2316061,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1429.01,928.86,,,,,,,,,,,,,
SCREW SQ FIT 2.0X12MM,SUP-2363524,CDM,C1713,HCPCS,0278,RC,,,,both,,,94.20,61.23,,,,,,,,,,,,,
GUIDEWIRE ANGIO COR CANALIZ 0.035X150CM,SUP-2120024,CDM,C1769,HCPCS,0272,RC,,,,both,,,145.70,94.70,,,,,,,,,,,,,
PLATE BNE L63MM THK1.3MM 2X8 H L MTCRPL TI L SHP COMPR FOR,SUP-2267920,CDM,C1713,HCPCS,0278,RC,,,,both,,,909.34,591.07,,,,,,,,,,,,,
HEAD FEM DIA28MM +0MM M NK CO CHROM HIP SLOT TAPR N,SUP-2304436,CDM,C1776,CPT,0278,RC,,,,both,,,3775.85,2454.30,,,,,,,,,,,,,
KNIFE SONOPET 12CM IQ STANDARD,SUP-2719780,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2721.69,1769.10,,,,,,,,,,,,,
COLLAR CERV H3XL22IN UNIV COT M DENS FOAM BRTH ADJ,SUP-2335994,CDM,L0120,HCPCS,0272,RC,,,,both,,,15.51,10.08,,,,,,,,,,,,,
GRAFT VASC HEMSHLD PLAT L 30 CM DIA28 MM POLYESTER BOV CLLGN,SUP-2265924,CDM,C1768,CPT,0278,RC,,,,both,,,1921.30,1248.84,,,,,,,,,,,,,
BIT DRL SHT 2.8 MM POLARUS 3,SUP-2431926,CDM,2720000010,LOCAL,0272,RC,,,,both,,,386.22,251.04,,,,,,,,,,,,,
VALVE ENDOSCP EMPHYSEMA 9 MM SPIRATION,SUP-2457293,CDM,C1889,HCPCS,0278,RC,,,,both,,,8792.00,5714.80,,,,,,,,,,,,,
ALLOGRAFT BNE STRP 50-80X9X15 MM FD IRRADIATED IL CREST,SUP-2866877,CDM,C1762,CPT,0278,RC,,,,both,,,4164.27,2706.78,,,,,,,,,,,,,
HC Lyr Clos Sc Tk Ext 2.6-7 Cm,PX-4501203200,CDM,12032,CPT,0450,RC,,,,both,,,1216.00,790.40,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 50 CM DIA 8 MM EPTFE STR STD WALL,SUP-2396199,CDM,C1768,CPT,0278,RC,,,,both,,,1868.30,1214.39,,,,,,,,,,,,,
FIBER LASER HOLM 200 M FOR USE W/ SMA-905 RED SMARTSYNC,SUP-2835953,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1108.83,720.74,,,,,,,,,,,,,
BLADE LARYNSCP SZ 4 STD GRN S STL FBR OPT MACINTOSH,SUP-2394599,CDM,2720000010,LOCAL,0272,RC,,,,both,,,332.53,216.14,,,,,,,,,,,,,
CANNULA ENDOSCP ENDOTIP 11 MMX10.5 CM W/O VLV THRD,SUP-2767350,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1899.29,1234.54,,,,,,,,,,,,,
BOLT EEG ELECTRD L 25 MM OD 2.4 MM ID 0.9 MM ANCHR BLU STRL,SUP-2936470,CDM,C1713,HCPCS,0278,RC,,,,both,,,524.38,340.85,,,,,,,,,,,,,
IMPLANT GYN Y MESH 27X5 CM UTER PELV SACROCOLPOPEXY ARTISYN,SUP-2717350,CDM,C1781,HCPCS,0278,RC,,,,both,,,2363.70,1536.40,,,,,,,,,,,,,
INTRODUCER SHTH 16FR L37CM SHTH L32CM 2 KNOB GWIRE PEEL AWAY,SUP-2171218,CDM,C1892,HCPCS,0272,RC,,,,both,,,176.34,114.62,,,,,,,,,,,,,
HC So Adamts-13 Activity,PX-3058539766,CDM,85397,CPT,0305,RC,,,,outpatient,,,196.00,127.40,,,,,,,,,,,,,
IMPLANT FACE L 96 X W 61 MM THK 1.5 MM POLYETHYL EMBEDDED TI,SUP-2883594,CDM,C1713,HCPCS,0278,RC,,,,both,,,9400.00,6110.00,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.514,SUP-2860031,CDM,C1713,HCPCS,0278,RC,,,,both,,,37126.42,24132.17,,,,,,,,,,,,,
CATHETER VALVULOPLASTY L 90 CM MODEL VB STRL,SUP-2141044,CDM,C1725,HCPCS,0272,RC,,,,both,,,993.94,646.06,,,,,,,,,,,,,
LEAD PACE AD L52CM PERM ATR BPLR J+TINES FIX IS 1 CONN,SUP-2356085,CDM,C1898,HCPCS,0275,RC,,,,both,,,1648.50,1071.52,,,,,,,,,,,,,
CATHETER ANGIOPLSTY OPTA LP L 80 CM BALLOON L 20 MM DIA 7 MM,SUP-2156112,CDM,C1725,HCPCS,0272,RC,,,,both,,,496.12,322.48,,,,,,,,,,,,,
PEG KIT FEED 16 FR TUBE RNG PUL N ENFIT LIDO CORFLO,SUP-2764876,CDM,2720000010,LOCAL,0272,RC,,,,both,,,377.37,245.29,,,,,,,,,,,,,
GRAFT BNE W14XL24MM THK6X2.5MM CANC COT WDG FOR OSTEOTMY,SUP-2399090,CDM,C1713,HCPCS,0278,RC,,,,both,,,4807.34,3124.77,,,,,,,,,,,,,
KIT INTRO VSI DE-CLOT SHTH L 4 CM DIA 5 FR GUIDEWIRE L 40 CM,SUP-2763460,CDM,C1769,HCPCS,0272,RC,,,,both,,,169.56,110.21,,,,,,,,,,,,,
PLATE BNE 2 COMPR 3.5X217X1.1 MM 18 HOLE FOR SCR SM FRAG SYS,SUP-2457213,CDM,C1713,HCPCS,0278,RC,,,,both,,,1128.11,733.27,,,,,,,,,,,,,
SPACER HUM L9MM TRABECULAR MTL,SUP-2199140,CDM,C1776,CPT,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
GRAFT DURA W3XL3IN CLLGN BASE CSF LEAK RESISTANCE DURAFORM,SUP-2243766,CDM,2780000010,LOCAL,0278,RC,,,,both,,,2983.00,1938.95,,,,,,,,,,,,,
PLATE BONE L104MM 5 H ANTR PRI COMPR SLOT RT ANK FUS L FRAG,SUP-2349835,CDM,C1713,HCPCS,0278,RC,,,,both,,,7416.52,4820.74,,,,,,,,,,,,,
TUBE ABLATN SHT 1.1 MM SET W/ PRECIS TIP SONASTAR,SUP-2539638,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2373.84,1543.00,,,,,,,,,,,,,
SET INT FIX SCREW DIA1.5 MM TI NEURO Y DBL PLATE 12 PK STRL,SUP-2935455,CDM,C1713,HCPCS,0278,RC,,,,both,,,24950.44,16217.79,,,,,,,,,,,,,
LNT IMP SYSTEM 4.75 PEEK KL SWIVELOCK,SUP-2812244,CDM,C1713,HCPCS,0278,RC,,,,both,,,2621.90,1704.23,,,,,,,,,,,,,
REAMER SURG HLLW COMPLT FOR 4.5MM SCR,SUP-2187148,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1170.65,760.92,,,,,,,,,,,,,
HALF RING WITH CVD EXT120,SUP-2818048,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8650.07,5622.55,,,,,,,,,,,,,
PLATE SPNL L45MM CEPHALIC TO CAUD 37MM 8 H GLD ANTR BILAT,SUP-2193039,CDM,C1713,HCPCS,0278,RC,,,,both,,,1664.20,1081.73,,,,,,,,,,,,,
RADICAL PIN PLT,SUP-2389685,CDM,C1713,HCPCS,0278,RC,,,,both,,,1648.50,1071.52,,,,,,,,,,,,,
FORCEP SURG RANEY SCALP CLP,SUP-2863555,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1270.82,826.03,,,,,,,,,,,,,
HC Path Consltj Surg 1st Blk Frozen Sctj 1st Spec,PX-3128833100,CDM,88331,CPT,0312,RC,,,,both,,,330.00,214.50,,,,,,,,,,,,,
HC Pulse Oximetry Continuous,PX-4609476200,CDM,94762,CPT,0460,RC,,,,outpatient,,,452.00,293.80,,,,,,,,,,,,,
KIT SUT DEV L31CM DIA5MM PUR TARGET WIRE W/ SNR CRV HNDL,SUP-2265300,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
STENT BILI 5.5FR L18MM DIA8MM CATH L80CM 0.035IN OVR THE,SUP-2101605,CDM,C1876,HCPCS,0278,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
CAP END DIA12MM EXTN 0MM TI CANN LOK HD FOR 9-12MM FEM NAIL,SUP-2192362,CDM,C1713,HCPCS,0278,RC,,,,both,,,918.45,596.99,,,,,,,,,,,,,
HC So Adamts-13 Activity,PX-3058539766,CDM,85397,CPT,0305,RC,,,,inpatient,,,196.00,127.40,,,,,,,,,,,,,
PROSTHESIS VOICE 20 FRX8 MM INDWL ESOPH FLANGE BLOM-SINGER,SUP-2242399,CDM,L8509,HCPCS,0274,RC,,,,both,,,973.40,632.71,,,,,,,,,,,,,
ALLOGRAFT HUMAN TISSUE DERMACELL AWM 4CM X 8CM 0.2-1MM,SUP-2909513,CDM,Q4122,HCPCS,0636,RC,,,,both,,,7006.13,4553.98,,,,,,,,,,,,,
DRILL SURG 24X33MM PROX SL,SUP-2400089,CDM,2720000010,LOCAL,0272,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
BUR SURG DIA 4.5 MM HUB II DIAMOND EXCEPT LG STRL REUSE,SUP-2929541,CDM,2720000010,LOCAL,0272,RC,,,,both,,,403.84,262.50,,,,,,,,,,,,,
BIT DRL DIA4.5MM DISP FOR TOGGLELOC FEM FIX DEV,SUP-2212826,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1005.80,653.77,,,,,,,,,,,,,
DEFIBRILLATOR CRD BPLR 67X50X14 MM 38 CC 78 GM ATLS + DR V243RST] ST JUDE MED CARDIAC RHYM MGMT],SUP-2356554,CDM,C1721,HCPCS,0275,RC,,,,both,,,70022.00,45514.30,,,,,,,,,,,,,
SCREW BONE L50MM OD4MM ANK CANN LAG TAPR INTOSS FIX IOFIX +,SUP-2223803,CDM,C1713,HCPCS,0278,RC,,,,both,,,2041.00,1326.65,,,,,,,,,,,,,
SPLINT ANK FT L R POST LEAF LTWT SEMI RIG ROLYAN,SUP-2324822,CDM,L4397,HCPCS,0274,RC,,,,both,,,98.56,64.06,,,,,,,,,,,,,
HC Extracranial Uni/Ltd Study,PX-9219388200,CDM,93882,CPT,0921,RC,,,,both,,,596.00,387.40,,,,,,,,,,,,,
INSERT TIB SZ 1 THK10MM LT ANK FIX BEAR VANTAGE,SUP-2223499,CDM,C1776,CPT,0278,RC,,,,both,,,3689.50,2398.17,,,,,,,,,,,,,
IMMOBILIZER KNEE CLOSE PATTELLA FOAM VELC LOOP STRP LT OR RT,SUP-2330405,CDM,L1830,CPT,0272,RC,,,,both,,,80.64,52.42,,,,,,,,,,,,,
DRESSING BIO 1000 MG TYP I/III BOV CLLGN MTRX FIBRILLAR SHLF,SUP-2905499,CDM,C1763,HCPCS,0278,RC,,,,both,,,5181.00,3367.65,,,,,,,,,,,,,
PLATE BNE 8 H BILAT WRST S STL SHT BEND FUS LO PROF LOK,SUP-2186123,CDM,C1713,HCPCS,0278,RC,,,,both,,,4415.59,2870.13,,,,,,,,,,,,,
PLATE BNE LCK 51 MM LT RADIAL 5 HOLE STYLOID 00235802805,SUP-2457581,CDM,C1713,HCPCS,0278,RC,,,,both,,,1676.63,1089.81,,,,,,,,,,,,,
PLATE BONE PRECONTOURED 2X3 HOLE TITANIUM LIGHT GREEN MATRIX,SUP-2842242,CDM,C1713,HCPCS,0278,RC,,,,both,,,1445.03,939.27,,,,,,,,,,,,,
WEDGE TIB SZ 1-2 5MM L MED R LAT KNEE HEMI STP SCR ON,SUP-2346177,CDM,C1776,CPT,0278,RC,,,,both,,,4257.84,2767.60,,,,,,,,,,,,,
ALLOGRAFT BNE FRZN ASEP RT PROX TIB W/ PATELLAR,SUP-2867049,CDM,C1762,CPT,0278,RC,,,,both,,,15786.04,10260.93,,,,,,,,,,,,,
HC Pt Adl Training 15mn|OP PT SERVICES|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS,PX-4209753500,CDM,97535,CPT,0420,RC,,,GP|CQ,outpatient,,,174.00,113.10,,,,,,,,,,,,,
GRAFT BNE SUB 10CC CA PHSPTE HYALURONIC ACID CEM VOID FILL,SUP-2378762,CDM,C1713,HCPCS,0278,RC,,,,both,,,8600.46,5590.30,,,,,,,,,,,,,
BRACE ANK L M 115 13 WOM 13 145 L FOAM FILL SEMI RIG SHELL,SUP-2196376,CDM,L4350,HCPCS,0274,RC,,,,both,,,72.38,47.05,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY SUPREME L 120 CM DIA 5 FR CSL,SUP-2480684,CDM,C1730,HCPCS,0272,RC,,,,both,,,186.05,120.93,,,,,,,,,,,,,
STEM HUM CEM 132.5 DEG 200 MM LEN PRI LT 7 MM DIAM FX TI,SUP-2223297,CDM,C1776,CPT,0278,RC,,,,both,,,16786.44,10911.19,,,,,,,,,,,,,
BIT DRL L30MM OD2MM ADD ON FIT SPEEDGUIDE,SUP-2378001,CDM,2720000010,LOCAL,0272,RC,,,,both,,,769.30,500.04,,,,,,,,,,,,,
SHEATH INTRO PERFRMR L 25 CM OD 5 FR ID 1.7 FR GUIDEWIRE,SUP-2168274,CDM,C1894,HCPCS,0272,RC,,,,both,,,89.14,57.94,,,,,,,,,,,,,
PLATE BNE 8 H CRANIOMAXILLOFACIAL TI LO PROF STR FOR UNIV,SUP-2366212,CDM,C1713,HCPCS,0278,RC,,,,both,,,519.73,337.82,,,,,,,,,,,,,
HC So Plasminogen,PX-3058542066,CDM,85420,CPT,0305,RC,,,,both,,,515.00,334.75,,,,,,,,,,,,,
LAMIVUDINE 150 MG PO TABS,RX-15880,CDM,6370000000,HCPCS,0637,RC,64380-0710-03,NDC,,both,1,UN,3.10,2.01,,,,,,,,,,,,,
HEAD RAD M THK15MM WRST CO CHROM SOLAR,SUP-2377863,CDM,C1776,CPT,0278,RC,,,,both,,,11759.30,7643.54,,,,,,,,,,,,,
HC ED Clsd Tx Prox Ulnar Fx Manip,PX-4502467500,CDM,24675,CPT,0450,RC,,,,both,,,1633.00,1061.45,,,,,,,,,,,,,
NICARDIPINE HCL IN NACL 20-0.9 MG/200ML-% IV SOLN,RX-150326,CDM,J2404,HCPCS,0636,RC,69097-0007-45,NDC,,both,200,ML,287.50,186.87,,,,,,,,,,,,,
ADAPTER FEM SL +5MM OFFSET MTPHSEAL TI PORCOAT FOR PRESSFIT,SUP-2252608,CDM,C1776,CPT,0278,RC,,,,both,,,1544.41,1003.87,,,,,,,,,,,,,
GUIDEROD ORTH L600MM DIA3MM SMOOTH BALL TIP,SUP-2347567,CDM,2720000010,LOCAL,0272,RC,,,,both,,,422.52,274.64,,,,,,,,,,,,,
IMMOBILIZER KNEE CLOSE PATTELLA FOAM VELC LOOP STRP LT OR RT,SUP-2330405,CDM,L1830,CPT,0274,RC,,,,both,,,80.64,52.42,,,,,,,,,,,,,
CRANIAL ACCESS KIT W/ DRUG 2 DRL BIT RAZOR,SUP-2852690,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1701.88,1106.22,,,,,,,,,,,,,
SHUNT SURG ADJ L 17 MM CATH DSTL L 1200/200 MM VENTRICULAR L,SUP-2928860,CDM,C1889,HCPCS,0278,RC,,,,both,,,12824.23,8335.75,,,,,,,,,,,,,
CATHETER THORACENTESIS STR 20 FRX20 IN THROMBO RESIST ARGY,SUP-2428068,CDM,C1729,HCPCS,0272,RC,,,,both,,,55.26,35.92,,,,,,,,,,,,,
GRAFT HUM TISS SEMITENDINOSUS TEND 16-19.9X3 CM FRZN,SUP-2423852,CDM,C1762,CPT,0278,RC,,,,both,,,5338.00,3469.70,,,,,,,,,,,,,
GRAFT HUM TISS 15ML VIABLE CELL MORSELIZED IMPL TRINITY,SUP-2307246,CDM,C1713,HCPCS,0278,RC,,,,both,,,18007.90,11705.13,,,,,,,,,,,,,
METHYLPREDNISOLONE NA SUC (PF) 125 MG IJ SOLR,RX-162820,CDM,J2919,HCPCS,0636,RC,00009-0047-25,NDC,,both,1,UN,60.00,39.00,,,,,,,,,,,,,
TISSUETAK TENDON ANCHOR,SUP-2812415,CDM,C1713,HCPCS,0278,RC,,,,both,,,2747.50,1785.87,,,,,,,,,,,,,
PROSTHESIS VOICE 20 FRX8 MM INDWL ESOPH FLANGE BLOM-SINGER,SUP-2242399,CDM,L8509,HCPCS,0272,RC,,,,both,,,973.40,632.71,,,,,,,,,,,,,
MONTELUKAST SODIUM 4 MG PO CHEW,RX-27234,CDM,6370000000,HCPCS,0637,RC,50268-0573-11,NDC,,both,1,UN,4.80,3.12,,,,,,,,,,,,,
CATHETER GUID CXI L 135 CM DIA 2.3FR 0.014IN SS ANGLED 2 TIP,SUP-2638646,CDM,C1887,HCPCS,0272,RC,,,,both,,,609.38,396.10,,,,,,,,,,,,,
APPLIER CLP SHFT L33CM W/ 20 M L SUP INTLOK TI CLP PSTL GRP,SUP-2283165,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1088.36,707.43,,,,,,,,,,,,,
PLATE BNE L35MM THK1.3MM 6 H NONSTERILE HND S STL STR LOK,SUP-2178033,CDM,C1713,HCPCS,0278,RC,,,,both,,,1553.95,1010.07,,,,,,,,,,,,,
CATHETER GUID VIPERCATH XC 30 DEG L 200 CM DIA 5 FR,SUP-2417482,CDM,C1887,HCPCS,0272,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
ORTHOLINK 2-HOLE 4MM WEDGE,SUP-2830214,CDM,C1713,HCPCS,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
PEDIATRIC LAG SCREW - 25MM,SUP-2818377,CDM,C1713,HCPCS,0278,RC,,,,both,,,4477.33,2910.26,,,,,,,,,,,,,
DRILL TWST L83MM DIA1MM STRYKR END PROFYLE,SUP-2364171,CDM,2720000010,LOCAL,0272,RC,,,,both,,,390.93,254.10,,,,,,,,,,,,,
SET ENDOSCP RETRV L 220 CM OD 16.9 MM ID 2.3 MM ENDOSCP DIA,SUP-2881873,CDM,2720000010,LOCAL,0272,RC,,,,both,,,516.53,335.74,,,,,,,,,,,,,
PLATE BNE STR 1 MM 6 MM LT 4 HOLE C-TUBE HK BRIDGE TI NS,SUP-2518095,CDM,C1713,HCPCS,0278,RC,,,,both,,,1261.12,819.73,,,,,,,,,,,,,
SYSTEM VLV SHUNT GRAVITATIONAL UNIT L10CM TI ADJ,SUP-2108720,CDM,C1729,HCPCS,0272,RC,,,,both,,,8946.96,5815.52,,,,,,,,,,,,,
PLATE BNE THK0.6MM 8 H STD CRANIOMAXILLOFACIAL G STR UNIV 2,SUP-2366289,CDM,C1713,HCPCS,0278,RC,,,,both,,,793.48,515.76,,,,,,,,,,,,,
SPLINT FNGR W325XL325IN ALUMINUM LN W FOAM PLASTALUME RADLUC,SUP-2276771,CDM,L3933,HCPCS,0274,RC,,,,both,,,3.17,2.06,,,,,,,,,,,,,
SCREW SPNL L50MM DIA4MM CORT PEDCL TI CANN DISCVR,SUP-2256187,CDM,C1713,HCPCS,0278,RC,,,,both,,,2388.57,1552.57,,,,,,,,,,,,,
GRAFT HUM TISS W7.3XL14.7CM CNTOUR ALLDERM,SUP-2113060,CDM,Q4116,HCPCS,0636,RC,,,,both,,,8342.98,5422.94,,,,,,,,,,,,,
DISTRACTION INTRNL DIST CRNL MICRO ZRCH 2 ARND END DRV 20 2,SUP-2681381,CDM,C1713,HCPCS,0278,RC,,,,both,,,12475.16,8108.85,,,,,,,,,,,,,
CATHETER EP D 2-5-2 MM SPC 7 FRX95 CM RADIA,SUP-2142360,CDM,C1731,HCPCS,0278,RC,,,,both,,,2436.64,1583.82,,,,,,,,,,,,,
GRAFT VASC GELSFT L 60 CM DIA 8 MM POLYESTER GEL ABD PERIPH,SUP-2384966,CDM,C1768,CPT,0278,RC,,,,both,,,1451.31,943.35,,,,,,,,,,,,,
LEAD PACEMKR VENT UPLR STEROID ELUT CAPSUR SP,SUP-2281902,CDM,C1898,HCPCS,0275,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
UB BLADE KELLY 2 1/2IN X 3IN,SUP-2676580,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1004.89,653.18,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC SOLO2 PLU MAXBARR 4FR 55C 1194108D2,SUP-2632630,CDM,C1751,HCPCS,0278,RC,,,,both,,,949.54,617.20,,,,,,,,,,,,,
TRIAL SPNL L17MM ANTR PLT,SUP-2291671,CDM,C1713,HCPCS,0278,RC,,,,both,,,2731.80,1775.67,,,,,,,,,,,,,
CEMENT BONE 70GM FULL DOSE POLYMETHYLMETHACRYLATE W/O,SUP-2222197,CDM,C1713,HCPCS,0278,RC,,,,both,,,1318.80,857.22,,,,,,,,,,,,,
CATHETER HD STR 14 FRX32 CM LT BASIC SET SPLIT CATH III,SUP-2627121,CDM,C1750,HCPCS,0278,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
RING ANNULPLSTY CARP EDW PHY 26MM 30.7MM 24.9MM 325SQMM FLX2,SUP-2214157,CDM,C1889,HCPCS,0278,RC,,,,both,,,7614.50,4949.42,,,,,,,,,,,,,
TUBE TYMPANOSTOMY VENT,SUP-2312869,CDM,L8699,HCPCS,0278,RC,,,,both,,,142.56,92.66,,,,,,,,,,,,,
SCREW BNE ST 2X22 MM CRTX FT W/ FLUT TIP TI NS,SUP-2189377,CDM,C1713,HCPCS,0278,RC,,,,both,,,207.05,134.58,,,,,,,,,,,,,
COMPONENT FEM 9X3X1.5MM KNEE UNI OFFSET,SUP-2123706,CDM,C1776,CPT,0278,RC,,,,both,,,11869.20,7714.98,,,,,,,,,,,,,
TAMOXIFEN CITRATE 10 MG PO TABS,RX-7711,CDM,6370000000,HCPCS,0637,RC,00378-0144-91,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
VALVE PULM SPIRATION CARTRIDGE 5MM BRONCHIAL 1-WAY PRELOADED F/POSTOP AIR LEAK CONTROL,SUP-2313515,CDM,C1889,HCPCS,0278,RC,,,,both,,,8321.00,5408.65,,,,,,,,,,,,,
PLATE BNE L262MM 14 H NONSTERILE R LAT PROX TIB S STL LOK,SUP-2185726,CDM,C1713,HCPCS,0278,RC,,,,both,,,4364.44,2836.89,,,,,,,,,,,,,
KETOCONAZOLE 200 MG PO TABS,RX-10369,CDM,6370000000,HCPCS,0637,RC,64380-0827-06,NDC,,both,1,UN,4.80,3.12,,,,,,,,,,,,,
ENDCAP ORTH L0MM DIA11MM ST GRN TI NAIL EXTN TROCHANTERIC,SUP-2191916,CDM,C1713,HCPCS,0278,RC,,,,both,,,712.28,462.98,,,,,,,,,,,,,
CATHETER EP 6FR L65CM 2-5-2MM SPC STABILENE DECAPOLAR,SUP-2141259,CDM,C1730,HCPCS,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
BIT DRL 4.8X280 MM,SUP-2644555,CDM,2720000010,LOCAL,0272,RC,,,,both,,,267.78,174.06,,,,,,,,,,,,,
PLATE BNE SM L58MM NONSTERILE L CALCNL S STL VAR ANG LOK FOR,SUP-2178420,CDM,C1713,HCPCS,0278,RC,,,,both,,,3013.77,1958.95,,,,,,,,,,,,,
CATHETER ANGIO SOFT-VU L 100 CM 4 FR OMNI NONBRAIDED SFT,SUP-2116674,CDM,C1725,HCPCS,0272,RC,,,,both,,,49.67,32.29,,,,,,,,,,,,,
SUPPORT ORTHOT LOWER EXTREMITY CUST PATTEN BTM,SUP-2435662,CDM,L2370,HCPCS,0274,RC,,,,both,,,906.08,588.95,,,,,,,,,,,,,
PLATE BONE L56MM STD 4 H LT DSTL VOLAR RAD S STL LO PROF,SUP-2341162,CDM,C1713,HCPCS,0278,RC,,,,both,,,2730.80,1775.02,,,,,,,,,,,,,
BOBBIN VT 1.14MM FLPL,SUP-2488688,CDM,L8699,HCPCS,0278,RC,,,,both,,,22.04,14.33,,,,,,,,,,,,,
ANCHOR SUTURE TWST 3.2 MM DRAW TIGHT TWO PEEK WHT BLU,SUP-2761982,CDM,C1713,HCPCS,0278,RC,,,,both,,,882.34,573.52,,,,,,,,,,,,,
HC Repair Mouth Laceration,PX-4504083000,CDM,40830,CPT,0450,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
PLATE BNE 130 DEG PEDIATRIC 2.7X46 MM 12/8 MM HIP 2 HOLE LCP,SUP-2799232,CDM,C1713,HCPCS,0278,RC,,,,both,,,2271.76,1476.64,,,,,,,,,,,,,
CLAMP EXT FIX HLD FOR 1.6MM K WIRE MINI FIX,SUP-2188693,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2052.71,1334.26,,,,,,,,,,,,,
TUBE VENT 1.14 MM CLLR BUTTON SIL 510536,SUP-2478220,CDM,L8699,HCPCS,0278,RC,,,,both,,,1775.48,1154.06,,,,,,,,,,,,,
ELECTRODE ELECSURG VPR 27 FRX1.2 MM 2 STEM CUT LOOP BRN,SUP-2261203,CDM,2720000010,LOCAL,0272,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
BIT DRL OD45MM FIX VANTAGE,SUP-2292756,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1185.41,770.52,,,,,,,,,,,,,
SCREW BNE L 4 MM DIA1.5 MM TI SD PRELD NEURO MOD NS,SUP-2883431,CDM,C1713,HCPCS,0278,RC,,,,both,,,17342.25,11272.46,,,,,,,,,,,,,
PRBE COAG L2.2MD2.3MM FLX AR PLSM CRFRTL BM-ORDR MULTI 10 EA,SUP-2217948,CDM,C1886,HCPCS,0278,RC,,,,both,,,820.48,533.31,,,,,,,,,,,,,
BLADE SAW DISP OXFORD,SUP-2408667,CDM,2720000010,LOCAL,0272,RC,,,,both,,,693.94,451.06,,,,,,,,,,,,,
SPACER CERV SPNL GRFT CANC FRZ DRY 5MM ALLOFUSE,SUP-2113928,CDM,C1713,HCPCS,0278,RC,,,,both,,,2229.40,1449.11,,,,,,,,,,,,,
STENT URET L 20 CM DIA 6 FR GUIDEWIRE 0.038 IN SIL FILIFORM,SUP-2836025,CDM,C2617,HCPCS,0278,RC,,,,both,,,594.40,386.36,,,,,,,,,,,,,
HC Pt Vasopneumatic Device Therapy|DOCUMENTATION ON FILE|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS,PX-4209701600,CDM,97016,CPT,0420,RC,,,KX|CQ,outpatient,,,206.00,133.90,,,,,,,,,,,,,
SCREW SPNL L20MM DIA3.5MM CANC POST CERVICOTHORACIC TI FIX,SUP-2254385,CDM,C1713,HCPCS,0278,RC,,,,both,,,483.56,314.31,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY L 92 CM DIA 6 FR DIAG QPLR D-TYPE,SUP-2495465,CDM,C1730,HCPCS,0272,RC,,,,both,,,379.06,246.39,,,,,,,,,,,,,
REAMER SURG OD36MM S STL ACET SPHR CUTTINGEDGE,SUP-2361866,CDM,2720000010,LOCAL,0272,RC,,,,both,,,661.28,429.83,,,,,,,,,,,,,
SCREW BNE CANN CONN INSRT TFN-ADVANCED,SUP-2178962,CDM,C1713,HCPCS,0278,RC,,,,both,,,1735.20,1127.88,,,,,,,,,,,,,
PLATE BONE 13 HOLE 2X65 MM STATIC ZYDAPTION TITANIUM,SUP-2838390,CDM,C1713,HCPCS,0278,RC,,,,both,,,1316.60,855.79,,,,,,,,,,,,,
CLAMP SURG DIA20MM TI CRAN CRANIOFIX 2,SUP-2108415,CDM,C1713,HCPCS,0278,RC,,,,both,,,583.88,379.52,,,,,,,,,,,,,
HC Resuscitation,PX-4809295000,CDM,92950,CPT,0480,RC,,,,outpatient,,,424.00,275.60,,,,,,,,,,,,,
TIRE SIL 12.5MM CONCV GROOVE2.5MM,SUP-2213513,CDM,L8610,HCPCS,0278,RC,,,,both,,,55.26,35.92,,,,,,,,,,,,,
ALLOGRAFT BNE RAD DSTL,SUP-2321879,CDM,C1713,HCPCS,0278,RC,,,,both,,,3234.20,2102.23,,,,,,,,,,,,,
POST GLEN 15.6X32 MM 2 MM TAPR W/ SHT PIN GUIDEWIRE CLN OVO,SUP-2776723,CDM,C1713,HCPCS,0278,RC,,,,both,,,1792.94,1165.41,,,,,,,,,,,,,
COIL EMB L15CM DIA8MM 3D NEUROVASC DETACH FRME PRIM,SUP-2280961,CDM,C1889,HCPCS,0278,RC,,,,both,,,6578.30,4275.89,,,,,,,,,,,,,
INSTRUMENT KIT,SUP-2119914,CDM,C1776,CPT,0278,RC,,,,both,,,643.70,418.40,,,,,,,,,,,,,
SEED BRACHYTHERAPY CESIUM LD IN NDL,SUP-2247308,CDM,C2643,HCPCS,0278,RC,,,,both,,,226.08,146.95,,,,,,,,,,,,,
BRACE ORTHOPEDIC PUL ON 1 XS 12-15 IN KNEE FULL CIR STRP,SUP-2150965,CDM,L1810,HCPCS,0274,RC,,,,both,,,299.09,194.41,,,,,,,,,,,,,
NEEDLE SET 0.038 IN 20 GA 5 FRX15 CM MP PIG CATH 8 SP,SUP-2167985,CDM,C1729,HCPCS,0272,RC,,,,both,,,204.89,133.18,,,,,,,,,,,,,
SEGMENTAL TM COLLAR FOR 9-16MM 25MM,SUP-2502454,CDM,C1776,CPT,0278,RC,,,,both,,,6231.33,4050.36,,,,,,,,,,,,,
SUTURE ANCHOR KIT 4.5 MM PEEK STRL LTX,SUP-2857592,CDM,C1713,HCPCS,0278,RC,,,,both,,,1777.24,1155.21,,,,,,,,,,,,,
PLATE BNE M L64MM ST R CALCNL S STL VAR ANG LOK FOR 27MM SCR,SUP-2178422,CDM,C1713,HCPCS,0278,RC,,,,both,,,3338.35,2169.93,,,,,,,,,,,,,
ELECTRODE EMG L 25 MM TIP 3 MM WIRE L 1 M SIL COAT TIP GRN,SUP-2901976,CDM,2720000010,LOCAL,0272,RC,,,,both,,,416.36,270.63,,,,,,,,,,,,,
CAP SCR SHLDR LCK AEQUALIS FLX REVIVE,SUP-2417740,CDM,C1776,CPT,0278,RC,,,,both,,,1259.14,818.44,,,,,,,,,,,,,
BUR SURG DIAMOND LNG 8 MM BALL FOR QD14-S/QD14-G1/QD14,SUP-2848151,CDM,2720000010,LOCAL,0272,RC,,,,both,,,392.31,255.00,,,,,,,,,,,,,
CATHETER ANGIOPLSTY ATLS GLD L 80 CM BALLOON L 4 CM DIA12 MM,SUP-2127947,CDM,C1725,HCPCS,0272,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
COMPONENT KNEE INLAY 11 UNI,SUP-2378876,CDM,C1776,CPT,0278,RC,,,,both,,,10799.97,7019.98,,,,,,,,,,,,,
CANNULA SPNL CVD 1.5 MM,SUP-2366996,CDM,C1713,HCPCS,0278,RC,,,,both,,,336.61,218.80,,,,,,,,,,,,,
CROWN DENT SZ LL2 LO LT 1ST PERM M S STL THCK OCCLUSAL SURF,SUP-2238798,CDM,D6783,CPT,0278,RC,,,,both,,,109.87,71.42,,,,,,,,,,,,,
UPCHARGE KNEE TRITANIUM TIBIAL COMPONET STRYKER,SUP-2501354,CDM,C1776,CPT,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
INTRODUCER PACE LD SAFSHTH II L 13 CM DIA 9.5 FR GUIDEWIRE L,SUP-2418816,CDM,C1892,HCPCS,0272,RC,,,,both,,,226.08,146.95,,,,,,,,,,,,,
FIBER LASER HOLM 273 M FOR USE W/ SMA-905 RED SMARTSYNC,SUP-2835954,CDM,2720000010,LOCAL,0272,RC,,,,both,,,910.82,592.03,,,,,,,,,,,,,
COMPONENT FEM C- KNEE FEMALE NXGN LPS-FLEX GENDER SOL 00592401351] ZIMMER BIOMET INC],SUP-2200806,CDM,C1776,CPT,0278,RC,,,,both,,,16554.08,10760.15,,,,,,,,,,,,,
GRAFT BNE FIBER 2.5 CC DBM CORTICAL PUREBONE,SUP-2424607,CDM,C1713,HCPCS,0278,RC,,,,both,,,1233.77,801.95,,,,,,,,,,,,,
PIN ORTH SPARE CNTR FOR HLLW RMR EXT FIX 309.035,SUP-2187147,CDM,2720000010,LOCAL,0272,RC,,,,both,,,356.67,231.84,,,,,,,,,,,,,
FEMORAL L RT CO CHROM MOLYBDENUM NP PRI UNI OXFORD,SUP-2136402,CDM,C1776,CPT,0278,RC,,,,both,,,11118.74,7227.18,,,,,,,,,,,,,
HC NM Bone Limited,PX-3417830000,CDM,78300,CPT,0341,RC,,,,outpatient,,,1898.00,1233.70,,,,,,,,,,,,,
GALILEOTROCHNAIL RIGHT 10MMX39CMX125 DEGREE,SUP-2828776,CDM,C1713,HCPCS,0278,RC,,,,both,,,8148.30,5296.39,,,,,,,,,,,,,
NAIL INTRMDLLRY L42CM D93MM RGHT GRTR TRCHNTR FMRL GREEN TTN,SUP-2487065,CDM,C1713,HCPCS,0278,RC,,,,both,,,5112.64,3323.22,,,,,,,,,,,,,
SCREW BNE L3MM DIA1.5MM SIL TI SELF DRL FULL THRD 0450310320] DEPUY SYNTHES USA],SUP-2181589,CDM,C1713,HCPCS,0278,RC,,,,both,,,258.67,168.14,,,,,,,,,,,,,
GUIDEWIRE VASC LAUREATE L 80 CM DIA 0.018 IN NIT COR,SUP-2459599,CDM,C1769,HCPCS,0272,RC,,,,both,,,141.30,91.84,,,,,,,,,,,,,
CLIP LIG CVD UP JAW FILSHIE 10 PER BX,SUP-2716342,CDM,2720000010,LOCAL,0272,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
HC NM Bone Limited,PX-3417830000,CDM,78300,CPT,0341,RC,,,,inpatient,,,1898.00,1233.70,,,,,,,,,,,,,
KIT THORCENT 8FR L5IN POLYUR W/ 18/22/25GA NDL 3 W STPCOCK,SUP-2383254,CDM,C1729,HCPCS,0272,RC,,,,both,,,109.27,71.03,,,,,,,,,,,,,
PUTTY 10.0CC DBM W/ RPM,SUP-2415795,CDM,C9359,HCPCS,0278,RC,,,,both,,,6515.50,4235.07,,,,,,,,,,,,,
PROSTHESIS OSS PISTON 0.8X4.5 MM MCGEE SS,SUP-2637756,CDM,L8613,CPT,0278,RC,,,,both,,,275.06,178.79,,,,,,,,,,,,,
MESH HERN OPTIMIZED COMP 30X20 CM RND POLYESTER PARIETEX,SUP-2752187,CDM,C1781,HCPCS,0278,RC,,,,both,,,7627.85,4958.10,,,,,,,,,,,,,
PLATE BNE THK16MM 7 H MAND TI STR FOR 2 23MM SCR TRAUMAONE,SUP-2136791,CDM,C1713,HCPCS,0278,RC,,,,both,,,1730.14,1124.59,,,,,,,,,,,,,
CATHETER ANGIO GLIDECATH L 65 CM DIA 4 FR DIA1.05 MM ANGLED,SUP-2385512,CDM,C1887,HCPCS,0272,RC,,,,both,,,177.41,115.32,,,,,,,,,,,,,
LEVEL NEURO SCREWDRIVER BLADE ULTRAONE58 MM QTY001 EA,SUP-2677979,CDM,2720000010,LOCAL,0272,RC,,,,both,,,692.06,449.84,,,,,,,,,,,,,
STEM FEM LAT 15-21 126.5 DEG PROX HIP W/ TRUNION REDUC PROF,SUP-2450451,CDM,C1776,CPT,0278,RC,,,,both,,,621.72,404.12,,,,,,,,,,,,,
BUR SURG X COARSE DIAMOND 6 MM 9 CM BALL FLUT LG BOR,SUP-2631870,CDM,2720000010,LOCAL,0272,RC,,,,both,,,392.00,254.80,,,,,,,,,,,,,
HOOK SUT L25MM DIA6MM LARE CRV CRESC SPECTRM,SUP-2167030,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
SPHERE GLEN DIA36MM STD REVERSED AEQUALIS PERFORM,SUP-2388775,CDM,C1776,CPT,0278,RC,,,,both,,,9843.90,6398.53,,,,,,,,,,,,,
CATHETER ANGIOPLSTY CHARGER L 135 CM BALLOON L 60 MM DIA 5,SUP-2140812,CDM,C1725,HCPCS,0272,RC,,,,both,,,276.95,180.02,,,,,,,,,,,,,
BIT DRL DIA2.4MM TRIFLAT ADJ FOR ATLNTS ANT CERV PLT SYS,SUP-2291125,CDM,2720000010,LOCAL,0272,RC,,,,both,,,681.69,443.10,,,,,,,,,,,,,
COMPONENT KNEE FEMORAL PERSONA CEMENTED UNICOMPARTMENTAL CONSTRAINED,SUP-2212240,CDM,C1776,CPT,0278,RC,,,,both,,,10676.00,6939.40,,,,,,,,,,,,,
TAP SURG L11MM OD4MM THRD,SUP-2293253,CDM,C1713,HCPCS,0278,RC,,,,both,,,469.24,305.01,,,,,,,,,,,,,
INQUIRY 6F STEER OCT 1108 6 25 L1 BD TE2BE1SOFT,SUP-2698831,CDM,C1730,HCPCS,0272,RC,,,,both,,,1576.28,1024.58,,,,,,,,,,,,,
GRAFT BNE FIBER 1 CC OSTEOAMP SEL,SUP-2424597,CDM,C1713,HCPCS,0278,RC,,,,both,,,1507.20,979.68,,,,,,,,,,,,,
COIL NEUROVASCULAR GDC-10 360 DEG L 20 CM DIA10 MM,SUP-2362409,CDM,C1889,HCPCS,0278,RC,,,,both,,,6013.73,3908.92,,,,,,,,,,,,,
MARKER FIDUCIAL VISICOIL 12CM,SUP-2844926,CDM,A4648,CPT,0278,RC,,,,both,,,497.44,323.34,,,,,,,,,,,,,
LINER TIB KNEE HYBIRD XLPE PREMIER STRYK3] STRYKER ORTHOPEDICS HOWM],SUP-2379180,CDM,C1776,CPT,0278,RC,,,,both,,,20410.00,13266.50,,,,,,,,,,,,,
SPLINT WR FRARM SM AD L11IN BLU L FOAM FOR INSTABILITY INJ,SUP-2195162,CDM,L3908,HCPCS,0272,RC,,,,both,,,28.26,18.37,,,,,,,,,,,,,
KIT BNE CEMENT MIXING SYS MIS FEM BRKWY NOZ ADV FEM CNL,SUP-2884228,CDM,2720000010,LOCAL,0272,RC,,,,both,,,406.44,264.19,,,,,,,,,,,,,
LORAZEPAM 4 MG/ML IJ SOLN,RX-10468,CDM,J2060,HCPCS,0636,RC,00641-6047-10,NDC,,both,0.75,ML,54.10,35.16,,,,,,,,,,,,,
KIT AUTOTRANSFUSION FILTER 150 UM 225 ML COLLCTN RESERVOIR 3,SUP-2905512,CDM,2720000010,LOCAL,0272,RC,,,,both,,,927.65,602.97,,,,,,,,,,,,,
STYLET ABLAT 6FR L12CM 0.035IN ENDOVENOUS RF COMPATIBLE W/,SUP-2393095,CDM,2720000010,LOCAL,0272,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
PLATE HOCKEY 8H LT RS,SUP-2653979,CDM,C1713,HCPCS,0278,RC,,,,both,,,2504.15,1627.70,,,,,,,,,,,,,
SUPPORT EXT FIX FT LEG ALIGN STRL TRUELOK LTX,SUP-2875383,CDM,2720000010,LOCAL,0272,RC,,,,both,,,410.30,266.69,,,,,,,,,,,,,
PIN DRL QUIK HI PERF FOR SIG SYS,SUP-2253438,CDM,2720000010,LOCAL,0272,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
HC Bx Breast 1st Les MR Image|RIGHT SIDE|REDUCED SERVICES,PX-3611908500,CDM,19085,CPT,0361,RC,,,RT|52,outpatient,,,6672.00,4336.80,,,,,,,,,,,,,
KIT PICC PI 1-L 4FR X 55 CM TIPTRACKER,SUP-2855517,CDM,C1751,HCPCS,0278,RC,,,,both,,,598.96,389.32,,,,,,,,,,,,,
SYSTEM PLATE BONE 206MML HOLEX7 STAINLESS STEEL BMP HIP,SUP-2721323,CDM,C1713,HCPCS,0278,RC,,,,both,,,9498.50,6174.02,,,,,,,,,,,,,
PLATE BNE TIB ANTR DSTL 15 HOLE,SUP-2751182,CDM,C1713,HCPCS,0278,RC,,,,both,,,4304.94,2798.21,,,,,,,,,,,,,
ALLOGRAFT BNE FEM SHFT 51-150 MMX0.3 CM FD,SUP-2717848,CDM,C1762,CPT,0278,RC,,,,both,,,4644.09,3018.66,,,,,,,,,,,,,
STEM FEM HI OFFSET 10 SHT HIP TAPR POROUS,SUP-2450684,CDM,C1776,CPT,0278,RC,,,,both,,,14883.60,9674.34,,,,,,,,,,,,,
PROBE ABLATOR VULCAN 90 DEG HP,SUP-2850058,CDM,2720000010,LOCAL,0272,RC,,,,both,,,526.83,342.44,,,,,,,,,,,,,
MESH MXLFCL 126.2X11.2 MM 2 MM SM GRID PDLLA STRL RESORB X,SUP-2476653,CDM,C1713,HCPCS,0278,RC,,,,both,,,2583.00,1678.95,,,,,,,,,,,,,
TUBE VENT FEUERSTEIN SPLIT 1.02X9 MM FLROPLAS,SUP-2637787,CDM,L8699,HCPCS,0278,RC,,,,both,,,49.30,32.04,,,,,,,,,,,,,
BLADE RETRACTOR LNG TEETH 45X15 MM RED FLEXI-SPINE,SUP-2459643,CDM,2720000010,LOCAL,0272,RC,,,,both,,,754.60,490.49,,,,,,,,,,,,,
PLATE DSTL RAD VLR RIM 2.4MM 7H HD 5H SHFT LT TI VA LCP STRL,SUP-2546769,CDM,C1713,HCPCS,0278,RC,,,,both,,,3222.30,2094.49,,,,,,,,,,,,,
SYSTEM DRAINAGE BURET SAMPLING NEEDLELESS,SUP-2666769,CDM,2720000010,LOCAL,0272,RC,,,,both,,,484.78,315.11,,,,,,,,,,,,,
CLIP HEMOSTATIC REPOSITIONABLE 235 CMX11 MM DURACLIP,SUP-2428103,CDM,C1713,HCPCS,0278,RC,,,,both,,,682.45,443.59,,,,,,,,,,,,,
BLADE SHAVER SUCTION 40 DEG 3 MMX12 CM DBL SERRATED YEL STRL,SUP-2602792,CDM,2720000010,LOCAL,0272,RC,,,,both,,,597.92,388.65,,,,,,,,,,,,,
TI DSTL FEM LISS PLT 11 HOLES/276MM-RIGHT,SUP-2190743,CDM,C1713,HCPCS,0278,RC,,,,both,,,5454.18,3545.22,,,,,,,,,,,,,
SEED BRACHYTHERAPY STD LOAD,SUP-2135322,CDM,C2638,HCPCS,0278,RC,,,,both,,,69.08,44.90,,,,,,,,,,,,,
SHAFT FEM TRAD ALLGRFT 150 MM FRZN,SUP-2294169,CDM,C1713,HCPCS,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
HC Stent Place Initial Venous Ang,PX-3603723800,CDM,37238,CPT,0360,RC,,,,both,,,11772.00,7651.80,,,,,,,,,,,,,
PLATE BNE L132MM 8 H L LAT DST PERIARTC FIBULAR S STL LOK,SUP-2410717,CDM,C1713,HCPCS,0278,RC,,,,both,,,2235.49,1453.07,,,,,,,,,,,,,
BLADE RETRACTOR ABH 6X1 IN RENAL ALUM,SUP-2483688,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1303.51,847.28,,,,,,,,,,,,,
CATHETER ELECHEMSTAS 7FR L350CM WRK CHN 2.8MM G PRB STD,SUP-2149702,CDM,2720000010,LOCAL,0272,RC,,,,both,,,504.54,327.95,,,,,,,,,,,,,
RONGEUR SURG KERRISON 1 MM SHRP THN FTPLT DISP,SUP-2481830,CDM,2720000010,LOCAL,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
SCREW BONE L5MM OD1.8MM MAG TI CRANIOMAXILLOFACIAL ST,SUP-2403082,CDM,C1713,HCPCS,0278,RC,,,,both,,,1877.72,1220.52,,,,,,,,,,,,,
HC So Osteocalcin,PX-3018393766,CDM,83937,CPT,0301,RC,,,,both,,,469.00,304.85,,,,,,,,,,,,,
PLATE BNE L132MM THK3MM 7 H BILAT S STL STR LOK COMPR RECON,SUP-2185337,CDM,C1713,HCPCS,0278,RC,,,,both,,,1451.84,943.70,,,,,,,,,,,,,
FERROUS SULFATE ER 45 MG PO TBCR,RX-167216,CDM,6370000000,HCPCS,0637,RC,10006-0730-13,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
INSERT TIB SZ 3 THK10MM RT ARTC CRUC RET CNFRM NEUT PRI,SUP-2347009,CDM,C1776,CPT,0278,RC,,,,both,,,3132.94,2036.41,,,,,,,,,,,,,
INTRODUCER NERVE STIM 8 FRX67 CM TRANSSEPTAL GUIDE,SUP-2355064,CDM,C1893,HCPCS,0272,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
HEAD FEM DIA40MM A CLASS HIP BACKFILLED BFH TECHNOLOGY,SUP-2304509,CDM,C1776,CPT,0278,RC,,,,both,,,10713.68,6963.89,,,,,,,,,,,,,
STAPLER INT MEDIUM THICK 60 MM W/ TRI-STAPLE PUR GIA,SUP-2787695,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1500.73,975.47,,,,,,,,,,,,,
WASHER ORTH DIA16MM SFT SPIK RND FOR ARTHROTEK WSHRLOC,SUP-2212894,CDM,C1713,HCPCS,0278,RC,,,,both,,,1920.17,1248.11,,,,,,,,,,,,,
PIN EXT FIX THRD 4X80 MM 7 MM MXLFCL LF,SUP-2481897,CDM,2720000010,LOCAL,0272,RC,,,,both,,,662.45,430.59,,,,,,,,,,,,,
PLATE BNE L 279 MM SCREW DIA 3.5/4.5 MM 12 H UTIL NS EVOS,SUP-2933281,CDM,C1713,HCPCS,0278,RC,,,,both,,,17019.59,11062.73,,,,,,,,,,,,,
ALLOGRACT HUM TISS AMNIOBAND MEMBRANE 10MM DISK,SUP-2905500,CDM,Q4151,HCPCS,0636,RC,,,,both,,,457.78,297.56,,,,,,,,,,,,,
SEALER TISS L45CM DIA5MM ARTC ADV BPLR STR TIP LAP APPRCH,SUP-2219737,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8587.90,5582.13,,,,,,,,,,,,,
HC So Ld Isoenzyme Referred,PX-3018362566,CDM,83625,CPT,0301,RC,,,,inpatient,,,374.00,243.10,,,,,,,,,,,,,
PLATE BONE POST SPNL FUS EXP STATIC AILERON M,SUP-2264539,CDM,C1713,HCPCS,0278,RC,,,,both,,,4082.00,2653.30,,,,,,,,,,,,,
GRAFT VASC HEMGRD L 70 CM DIA 8 MM POLYESTER BOV CLLGN UTHN,SUP-2681834,CDM,C1768,CPT,0278,RC,,,,both,,,2113.94,1374.06,,,,,,,,,,,,,
CATHETER CV SET 018 4 FRX8 CM DL J TIP RIFAMPIN SPECTRUM,SUP-2759965,CDM,C1751,HCPCS,0278,RC,,,,both,,,348.04,226.23,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH TX2 L 77 MM DIA 36 MM SHTH 22 FR SS,SUP-2171023,CDM,C1874,HCPCS,0278,RC,,,,both,,,16321.72,10609.12,,,,,,,,,,,,,
PLATE BONE W9XL37MM AUG 6MM CO CHROM RIG FOR MAESTRO TOT WR,SUP-2407329,CDM,C1713,HCPCS,0278,RC,,,,both,,,4772.80,3102.32,,,,,,,,,,,,,
LEAD PACE BPLR 6 FRX52 CM TENDRIL ST,SUP-2356688,CDM,C1898,HCPCS,0275,RC,,,,both,,,2590.50,1683.82,,,,,,,,,,,,,
PLATE BNE THK2.3MM SHT CRV NONCOMPRESSION FRAC,SUP-2263002,CDM,C1713,HCPCS,0278,RC,,,,both,,,489.84,318.40,,,,,,,,,,,,,
HC Isodose Plan-Simple,PX-3337730600,CDM,77306,CPT,0333,RC,,,,both,,,2451.00,1593.15,,,,,,,,,,,,,
HC So Ld Isoenzyme Referred,PX-3018362566,CDM,83625,CPT,0301,RC,,,,outpatient,,,374.00,243.10,,,,,,,,,,,,,
BEARING TIB KNEE COMP KINEMATIC,SUP-2376287,CDM,C1776,CPT,0278,RC,,,,both,,,6834.68,4442.54,,,,,,,,,,,,,
BLEOMYCIN SULFATE 15 UNITS IJ SOLR,RX-9289,CDM,J9040,HCPCS,0636,RC,71288-0106-10,NDC,,both,1,UN,88.40,57.46,,,,,,,,,,,,,
FEARON MODIFIED UPPER RED II,SUP-2669814,CDM,C1713,HCPCS,0278,RC,,,,both,,,3990.00,2593.50,,,,,,,,,,,,,
ADAPTER FEM L-4MM UPLR NEUT NK,SUP-2207893,CDM,C1776,CPT,0278,RC,,,,both,,,640.56,416.36,,,,,,,,,,,,,
DRAINAGE SET 5 FRX80 CM NEEDLE-FREE LDS LUMBAR DRAINAGE CLMP,SUP-2666661,CDM,C1729,HCPCS,0272,RC,,,,both,,,832.16,540.90,,,,,,,,,,,,,
SYSTEM ENDOSCP ULTRASOUND DEL 19 GA PRE LD NDL BEAC DSF1901] MEDTRONIC COVIDIEN GIVEN IMAGING],SUP-2173691,CDM,A4648,CPT,0278,RC,,,,both,,,2166.60,1408.29,,,,,,,,,,,,,
CLAMP EXT FIX ADJ WIRE PIN,SUP-2188591,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2316.16,1505.50,,,,,,,,,,,,,
WEDGE TIB SZ 5-6 10MM KNEE REV FULL STP LEGION,SUP-2346593,CDM,C1776,CPT,0278,RC,,,,both,,,4603.24,2992.11,,,,,,,,,,,,,
HC Intraosseous Needle Placement (ED),PX-4503668000,CDM,36680,CPT,0450,RC,,,,both,,,954.00,620.10,,,,,,,,,,,,,
FIBER LASER 600 MICRON SINGLE USE WITH FLAT TIP,SUP-2883717,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
GUIDEWIRE .035INDIA STERILE 13INL BLUNT F/SHOULDER,SUP-2574087,CDM,C1769,HCPCS,0272,RC,,,,both,,,58.25,37.86,,,,,,,,,,,,,
INVOTEC TYMPANOSTOMY TUBE SHEEHY GROMMET ID 1.27MM FLPL,SUP-2930250,CDM,L8699,HCPCS,0278,RC,,,,both,,,29.20,18.98,,,,,,,,,,,,,
SCREW BONE L4MM DIA2MM CORT CRANIOMAXILLOFACIAL TI EMER W/,SUP-2189253,CDM,C1713,HCPCS,0278,RC,,,,both,,,243.98,158.59,,,,,,,,,,,,,
LITTLE REMEDIES SALINE NA SOLN,RX-159138,CDM,6370000000,HCPCS,0637,RC,56184-0120-11,NDC,,both,30,ML,10.80,7.02,,,,,,,,,,,,,
PLATE BNE OSTEOTMY 2.4/2.7 MM LCK VA OPENING WDG W/O SPACER,SUP-2184805,CDM,C1713,HCPCS,0278,RC,,,,both,,,3079.37,2001.59,,,,,,,,,,,,,
PLATE BNE L18MM THK03MM 6 H CRANIOMAXILLOFACIAL TI DBL Y FOR,SUP-2136524,CDM,C1713,HCPCS,0278,RC,,,,both,,,577.76,375.54,,,,,,,,,,,,,
CATHETER ANGIOPLSTY L 60 CM DIA 3 FR BALLOON DIA 3 MM SIL,SUP-2168563,CDM,C1725,HCPCS,0272,RC,,,,both,,,640.37,416.24,,,,,,,,,,,,,
MORETZ VENT TUBE WTAB 1.27MM ID BLUE TITANIUM 10 PACK,SUP-2695100,CDM,L8699,HCPCS,0278,RC,,,,both,,,66.57,43.27,,,,,,,,,,,,,
LINER ACET HI RIM RINGLOK 0 DEG 22MM ID SZ 20,SUP-2403374,CDM,C1776,CPT,0278,RC,,,,both,,,2756.92,1792.00,,,,,,,,,,,,,
COMPONENT FEM SM L PROX KNEE POLYETH MOD ROT HNG CEM REV,SUP-2376349,CDM,C1776,CPT,0278,RC,,,,both,,,12961.45,8424.94,,,,,,,,,,,,,
SUPPORT ORTHOT ANK KNEE CUST SPRL MOLD TO PT PLAS,SUP-2435629,CDM,L1950,HCPCS,0272,RC,,,,both,,,2177.31,1415.25,,,,,,,,,,,,,
GRASPER SUT 60DEG SHRP TIP LO PROF FOR RAP ACCS IN SHLDR,SUP-2249551,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1984.48,1289.91,,,,,,,,,,,,,
FIXATOR EXT HING RINGFIX SYS 90DEG STD,SUP-2696090,CDM,2720000010,LOCAL,0272,RC,,,,both,,,765.85,497.80,,,,,,,,,,,,,
PLATE BNE L W13.5XL142MM THK4.2MM 8 H BILAT TI STR RIG,SUP-2190815,CDM,C1713,HCPCS,0278,RC,,,,both,,,1363.29,886.14,,,,,,,,,,,,,
CAGE ACET CUP DIA52MM THK2MM LT COMMERCIALLY PURE TI MOD,SUP-2405114,CDM,C1776,CPT,0278,RC,,,,both,,,13564.80,8817.12,,,,,,,,,,,,,
KIT FILL 14ML FOR STNT GRFT SYS STNT OVATION PRIM,SUP-2217724,CDM,C1768,CPT,0278,RC,,,,both,,,2326.74,1512.38,,,,,,,,,,,,,
NEPHRON FA PO TABS,RX-5497,CDM,6370000000,HCPCS,0637,RC,59528-4456-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
SINUS SUCTION BURR STERILE,SUP-2574170,CDM,2720000010,LOCAL,0272,RC,,,,both,,,645.71,419.71,,,,,,,,,,,,,
GRAFT SFT TISS FASC LATA SLNG L3CMXW2CM TUTOPLAST,SUP-2247187,CDM,C1762,CPT,0278,RC,,,,both,,,1365.90,887.83,,,,,,,,,,,,,
SYSTEM TOE JT GREAT HEMI TOT PROX MOV W 183 HT 132 STEM LEN,SUP-2244253,CDM,L8659,HCPCS,0278,RC,,,,both,,,7768.64,5049.62,,,,,,,,,,,,,
CATHETER INTVASC 9.3FR L38CM POLYUR APPLAUSE HEAT EXCHG FLX,SUP-2416149,CDM,C1751,HCPCS,0278,RC,,,,both,,,2998.57,1949.07,,,,,,,,,,,,,
CATHETER KIT 1 LUMEN 4 FR W/ PASV PWR INJ XCELA,SUP-2117187,CDM,C1751,HCPCS,0278,RC,,,,both,,,373.66,242.88,,,,,,,,,,,,,
PROBE TEMP CTRL BLU SENS MALL SHFT TACS,SUP-2341021,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1015.48,660.06,,,,,,,,,,,,,
SET INTRO NEFF SHTH L 18 CM OD 6 FR ID 4 FR 15 CM 21 GA,SUP-2168589,CDM,C1894,HCPCS,0272,RC,,,,both,,,224.07,145.65,,,,,,,,,,,,,
KIT EEG ELECTRD L 26.5 MM 8 CONTACT RF PRB STRL DISP EVO,SUP-2936689,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3161.98,2055.29,,,,,,,,,,,,,
HC Parathyrd Planar W/WO Subtrj,PX-3417807100,CDM,78071,CPT,0341,RC,,,,inpatient,,,8208.00,5335.20,,,,,,,,,,,,,
GRAFT BNE 11 MM CUBE Q-PACK CONFORM,SUP-2264596,CDM,C1713,HCPCS,0278,RC,,,,both,,,2091.24,1359.31,,,,,,,,,,,,,
CATHETER DRAINAGE 13X25 MMX120 CM ANTIBIO IMPREG ARES,SUP-2280104,CDM,C1729,HCPCS,0278,RC,,,,both,,,1336.23,868.55,,,,,,,,,,,,,
RXG FOIL52X52MM T06MM SM HOLES,SUP-2669331,CDM,C1713,HCPCS,0278,RC,,,,both,,,3591.91,2334.74,,,,,,,,,,,,,
KYPHOPLASTY KIT TROCAR 11 GA OSTEO INTRO BVL KYPHON V,SUP-2632234,CDM,C1713,HCPCS,0278,RC,,,,both,,,2147.76,1396.04,,,,,,,,,,,,,
MARKER BRST BX L12CM 18GA NIT VISN SHP INTRO FREE HND TUMARK,SUP-2239916,CDM,A4648,CPT,0278,RC,,,,both,,,365.50,237.57,,,,,,,,,,,,,
CATHETER BLLN DIL 24 FRX15 CM NEPHROLITHOTOMY EZDILATE,SUP-2464490,CDM,C1758,HCPCS,0278,RC,,,,both,,,806.20,524.03,,,,,,,,,,,,,
SCREW BONE L5MM DIA1.5MM CRANIOMAXILLOFACIAL TI SELF DRL FOR,SUP-2181593,CDM,C1713,HCPCS,0278,RC,,,,both,,,259.99,168.99,,,,,,,,,,,,,
DRESSING WND MICRONIZED PARTIC 100 MG MATRISTEM MICROMATRIX,SUP-2106472,CDM,Q4118,HCPCS,0636,RC,,,,both,,,1065.53,692.59,,,,,,,,,,,,,
BAG 200 L CAP TISS RETRV,SUP-2330507,CDM,2720000010,LOCAL,0272,RC,,,,both,,,680.34,442.22,,,,,,,,,,,,,
BASKET STONE HELCL 2.5 FR 16 MMX120 CM 4 WIR W/ TIP NIT STRL,SUP-2769751,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1039.12,675.43,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 180 MM DIA15 MM DEL SHTH 33ML,SUP-2937082,CDM,C1713,HCPCS,0278,RC,,,,both,,,14462.84,9400.85,,,,,,,,,,,,,
ATTACHMENT HNDPC ANG TELSCP TUBE T12 MIDAS REX LEGEND,SUP-2284705,CDM,C1713,HCPCS,0278,RC,,,,both,,,2616.69,1700.85,,,,,,,,,,,,,
PLATE LK COMPRSS 18 HOLE,SUP-2704416,CDM,C1713,HCPCS,0278,RC,,,,both,,,1650.38,1072.75,,,,,,,,,,,,,
CATHETER HD SET 16 FRX28 CM 23 CM 2 TRINIFLEX SPLIT CATH III,SUP-2863689,CDM,C1750,HCPCS,0278,RC,,,,both,,,750.46,487.80,,,,,,,,,,,,,
GRAFT VASC HEMGRD L 100 CM DIA 6 MM POLYESTER BOV CLLGN STR,SUP-2227525,CDM,C1768,CPT,0278,RC,,,,both,,,1927.11,1252.62,,,,,,,,,,,,,
BIT DRL L270MM DIA12MM ST LNG CANN L QUIK CPL FOR,SUP-2178907,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1512.95,983.42,,,,,,,,,,,,,
BRACE ORTH 2X UPR SLD STIR AFO,SUP-2388168,CDM,L1990,HCPCS,0272,RC,,,,both,,,1099.75,714.84,,,,,,,,,,,,,
HC NM Cardiac Muga Scan Gated Restin,PX-3417847200,CDM,78472,CPT,0341,RC,,,,inpatient,,,1924.00,1250.60,,,,,,,,,,,,,
METHOHEXITAL SODIUM 0.5 G IJ SOLR,RX-70545,CDM,2500000003,HCPCS,0250,RC,42023-0105-01,NDC,,both,1,UN,641.30,416.84,,,,,,,,,,,,,
MESH HERN DIA4.5IN CIR W/ ECHO PS POS SYS VENTRALIGHT ST,SUP-2125913,CDM,C1781,HCPCS,0278,RC,,,,both,,,1538.60,1000.09,,,,,,,,,,,,,
CAGE SPNL INTBDY 7 DEG 16X14X12 MM NS SHORELINE ACS,SUP-2245752,CDM,C1889,HCPCS,0278,RC,,,,both,,,2151.21,1398.29,,,,,,,,,,,,,
BLADE SAW OSCLLTNG 25.4MMW X90MML 0.8MM THK 0.9MM THK CUT ME,SUP-2605470,CDM,2720000010,LOCAL,0272,RC,,,,both,,,94.70,61.55,,,,,,,,,,,,,
HC Bladder Scan|UNUSUAL NON-OVERLAPPING SERVICE,PX-4505179800,CDM,51798,CPT,0450,RC,,,XU,outpatient,,,191.00,124.15,,,,,,,,,,,,,
PLATE BNE W5XL50MM THK1-1.2MM 3X9 H BILAT TI T SHP RIG,SUP-2191057,CDM,C1713,HCPCS,0278,RC,,,,both,,,798.75,519.19,,,,,,,,,,,,,
KIT ACCESS PORT 010CC RAPIDPORT EZ,SUP-2430924,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2794.60,1816.49,,,,,,,,,,,,,
KIT INSRTN CATH OD8FR 25ML FIDELITY,SUP-2227322,CDM,C1713,HCPCS,0278,RC,,,,both,,,332.84,216.35,,,,,,,,,,,,,
FORCEP ENDOSCP BX 5 FRX105 CM 1.5 MM STR FRMBL SS JAWZ LTX,SUP-2876093,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1507.20,979.68,,,,,,,,,,,,,
STEM FEM SZ 5 LAT HIP HA AMISTEM-H,SUP-2267272,CDM,C1776,CPT,0278,RC,,,,both,,,9574.49,6223.42,,,,,,,,,,,,,
CLIP INT DIA21 MM THRD L 165 CM ENDOSCP DIA11.5-14 MM POINTED,SUP-2881855,CDM,C1889,HCPCS,0278,RC,,,,both,,,2163.46,1406.25,,,,,,,,,,,,,
PLATE BNE THK0.6MM 2X3 H L HND L SHP NONCOMPRESSION GRID,SUP-2267882,CDM,C1713,HCPCS,0278,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
SYSTEM CAST 3IN W/ 1 REG BOOT TCC-EZ 5 CAST,SUP-2244453,CDM,2720000010,LOCAL,0272,RC,,,,both,,,530.66,344.93,,,,,,,,,,,,,
PROSTHESIS VOICE 12 MM LO PRESSURE KT,SUP-2246405,CDM,L8509,HCPCS,0274,RC,,,,both,,,285.74,185.73,,,,,,,,,,,,,
HC So Drug Assay Itraconazole,PX-3018018966,CDM,80189,CPT,0301,RC,,,,both,,,399.00,259.35,,,,,,,,,,,,,
HEAD RAD H14MM OD20MM UNIV CO CHROM ANT DST EL STR MOD,SUP-2404361,CDM,C1776,CPT,0278,RC,,,,both,,,6280.00,4082.00,,,,,,,,,,,,,
HC Inj Trigger Pt 1-2 Musc Grps,PX-5102055200,CDM,20552,CPT,0510,RC,,,,outpatient,,,613.00,398.45,,,,,,,,,,,,,
KIT SUT PASS W/ SZ 2 TIGERLOOP SZ 2 FIBERLOOP CRV MIC,SUP-2122152,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2182.30,1418.49,,,,,,,,,,,,,
SIDEPLATE SHRT BARL 150 DEG 3H STRL LCP DHHS,SUP-2547710,CDM,C1713,HCPCS,0278,RC,,,,both,,,1578.16,1025.80,,,,,,,,,,,,,
PLATE BNE L28MM THK1MM 6 H NONSTERILE HND S STL STR LOK VAR,SUP-2178005,CDM,C1713,HCPCS,0278,RC,,,,both,,,1333.68,866.89,,,,,,,,,,,,,
TUBE MYR 102MM DIAM VENT TAB SIL PAPARELLA,SUP-2313720,CDM,L8699,HCPCS,0278,RC,,,,both,,,43.74,28.43,,,,,,,,,,,,,
EXTRACTOR STONE BSKT 0.6 MM 4 WIR HNDL SCP STRL DISP,SUP-2773234,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1135.83,738.29,,,,,,,,,,,,,
PLATE BONE W24XL24MM THK0.5MM CRAN ORBIT FLR RAP RESRB,SUP-2194077,CDM,C1713,HCPCS,0278,RC,,,,both,,,2868.39,1864.45,,,,,,,,,,,,,
GRAFT VASC PTCH 10X5 CMX1 MM SFT TISS MESH TRIM GORTX,SUP-2458148,CDM,C1768,CPT,0278,RC,,,,both,,,615.44,400.04,,,,,,,,,,,,,
GRAFT BNE SUB L W5XH23XL16MM COMPRESSIBLE SPNG PROVIDE,SUP-2138504,CDM,C1713,HCPCS,0278,RC,,,,both,,,5385.10,3500.31,,,,,,,,,,,,,
LEVEL CMF ST PLATE ORBTL FLOOR SMART LEFT 15 MM SCRW40 X 35,SUP-2676707,CDM,C1713,HCPCS,0278,RC,,,,both,,,4579.34,2976.57,,,,,,,,,,,,,
COMPONENT PATELLAR 0 7 MM KNEE DURASUL N-K II,SUP-2209588,CDM,C1776,CPT,0278,RC,,,,both,,,3143.14,2043.04,,,,,,,,,,,,,
PLATE BNE LCK LG RT CALCANEAL ALPS,SUP-2413701,CDM,C1713,HCPCS,0278,RC,,,,both,,,2646.80,1720.42,,,,,,,,,,,,,
CATHETER BLLN DIL SET 2 MMX100 CM ESOPH SAVARY-GILLIARD,SUP-2759281,CDM,C1769,HCPCS,0272,RC,,,,both,,,12864.58,8361.98,,,,,,,,,,,,,
HC So1 Alpha Fetoprotein,PX-3018210567,CDM,82105,CPT,0301,RC,,,,outpatient,,,107.00,69.55,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC FT MAXBARR 5FR 55CM 2 LUM 3275108FD,SUP-2632668,CDM,C1751,HCPCS,0278,RC,,,,both,,,489.84,318.40,,,,,,,,,,,,,
CATHETER INFSN 4FR DIA 90CML 5CML PEBAX OCCLDNG WIRE HEMSTAS,SUP-2677058,CDM,C1751,HCPCS,0278,RC,,,,both,,,372.09,241.86,,,,,,,,,,,,,
CAP ORTH,SUP-2388584,CDM,C1776,CPT,0278,RC,,,,both,,,9420.00,6123.00,,,,,,,,,,,,,
PLATE BONE L171MM 6 H NONSTERILE RT MEDL DSTL TIB LCK FOR,SUP-2348487,CDM,C1713,HCPCS,0278,RC,,,,both,,,12990.34,8443.72,,,,,,,,,,,,,
KIT PAIN PMP 270ML 5ML/HR NONNARCOTIC ELASTOMERIC ACUTE AMB,SUP-2236834,CDM,C9804,HCPCS,0272,RC,,,,both,,,373.66,242.88,,,,,,,,,,,,,
IRBESARTAN 150 MG PO TABS,RX-21848,CDM,6370000000,HCPCS,0637,RC,31722-0730-90,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
FORCEPS OPHTH 23GA BLNT DST END MICROTEXTURED BROAD GRSP,SUP-2109700,CDM,2720000010,LOCAL,0272,RC,,,,both,,,477.75,310.54,,,,,,,,,,,,,
PLATE BNE 1ST MTP/MPJ 2.7 MM RT PRIMARY NS FPS LTX,SUP-2856860,CDM,C1713,HCPCS,0278,RC,,,,both,,,5115.06,3324.79,,,,,,,,,,,,,
PLATE BNE L 311 MM SCREW DIA 3.5/4.5 MM 12 H LT,SUP-2931217,CDM,C1713,HCPCS,0278,RC,,,,both,,,21708.39,14110.45,,,,,,,,,,,,,
CATHETER DRAINAGE OTW 40 CM 6 MMX2 CM GLDEX,SUP-2140997,CDM,C1725,HCPCS,0272,RC,,,,both,,,737.90,479.63,,,,,,,,,,,,,
ROD EXT FIX 90 MM FOR SM BNE SHFT FIX CARBON FIBER,SUP-2525825,CDM,2720000010,LOCAL,0272,RC,,,,both,,,511.82,332.68,,,,,,,,,,,,,
BENZONATATE 100 MG PO CAPS,RX-988,CDM,6370000000,HCPCS,0637,RC,00904-7153-61,NDC,,both,1,UN,4.30,2.79,,,,,,,,,,,,,
SCREW BNE LCK 2.5X5 MM TI MAXDRIVE 258850591,SUP-2460110,CDM,C1713,HCPCS,0278,RC,,,,both,,,474.23,308.25,,,,,,,,,,,,,
FIBER LASER SINGLE W/ WALL PLATE,SUP-2798103,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1041.98,677.29,,,,,,,,,,,,,
RETRIEVER VASC 035 8 FRX55 CM 4 LOOP SNR INDY OTW,SUP-2750812,CDM,C1773,HCPCS,0272,RC,,,,both,,,1397.17,908.16,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY D OCTAPOLAR DEFLECTABLE REPROC,SUP-2535612,CDM,C1730,HCPCS,0272,RC,,,,both,,,347.88,226.12,,,,,,,,,,,,,
SUPPORT ORTHOT LOWER EXTREMITY CUST THOR CTRL LAT SUPP UPR,SUP-2435693,CDM,L2680,HCPCS,0272,RC,,,,both,,,414.26,269.27,,,,,,,,,,,,,
BAND GAST CRV ADJ DISECT REALIZE ENDO-SURGERY,SUP-2219869,CDM,C1889,HCPCS,0278,RC,,,,both,,,9071.46,5896.45,,,,,,,,,,,,,
GRAFT BNE SUB W6XH24XL14MM FT ANK PRESHAPED ALLGRFT FOR COT,SUP-2370448,CDM,C1713,HCPCS,0278,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
VALVE CSF MINI 15 CM TWO PC SYS ANTECHAMBER VENTRICULAR CATH,SUP-2666633,CDM,C1889,HCPCS,0278,RC,,,,both,,,9770.24,6350.66,,,,,,,,,,,,,
PLATE BONE NONSTERILE LT VOLAR RIM CROSSLOCK DVR,SUP-2136268,CDM,C1713,HCPCS,0278,RC,,,,both,,,2711.39,1762.40,,,,,,,,,,,,,
KNEE VNGD TI FEM SSK 65MM RT,SUP-2510698,CDM,C1776,CPT,0278,RC,,,,both,,,17671.92,11486.75,,,,,,,,,,,,,
THUMB SCREW FOR WIRE GUIDE/,SUP-2828031,CDM,C1713,HCPCS,0278,RC,,,,both,,,661.60,430.04,,,,,,,,,,,,,
PLATE BNE FOR SCREW STRL LEVEL 1,SUP-2499890,CDM,C1713,HCPCS,0278,RC,,,,both,,,1680.03,1092.02,,,,,,,,,,,,,
SCREW BNE CANN 4X26 MM FT TIM NS,SUP-2460927,CDM,C1713,HCPCS,0278,RC,,,,both,,,484.28,314.78,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.513,SUP-2860030,CDM,C1713,HCPCS,0278,RC,,,,both,,,36330.74,23614.98,,,,,,,,,,,,,
WIRE FIX L150MM DIA1.2MM S STL TRCR TIP K APTUS,SUP-2267988,CDM,C1713,HCPCS,0278,RC,,,,both,,,127.17,82.66,,,,,,,,,,,,,
CROWN DENT SZ UR1 UP RT CTRL PRI M S STL THCK OCCLUSAL SURF,SUP-2238825,CDM,D6783,CPT,0278,RC,,,,both,,,110.34,71.72,,,,,,,,,,,,,
STAPLER INT STR 3.5X45 MM RELD BIOABSORBABLE BLU WHT SEAMGRD,SUP-2485773,CDM,2720000010,LOCAL,0272,RC,,,,both,,,514.43,334.38,,,,,,,,,,,,,
PLATE BONE W6XL33MM 12 H VIT LADDER STRUT FOR 1.3MM SCR,SUP-2364703,CDM,C1713,HCPCS,0278,RC,,,,both,,,405.06,263.29,,,,,,,,,,,,,
SCREW BNE L60MM DIA5MM PROX FEM S STL ST SELF DRL CANN,SUP-2184743,CDM,C1713,HCPCS,0278,RC,,,,both,,,464.69,302.05,,,,,,,,,,,,,
ROD SPNL L200MM DIA3MM POST BILAT TI SMOOTH SYNERGY SUMMIT,SUP-2254416,CDM,C1713,HCPCS,0278,RC,,,,both,,,1174.36,763.33,,,,,,,,,,,,,
SHUNT CV SM CAR ART NL8505400,SUP-2633897,CDM,2720000010,LOCAL,0272,RC,,,,both,,,743.24,483.11,,,,,,,,,,,,,
SHEATH GUID L 10 CM DIA 5 FR GUIDEWIRE 0.035 IN SS HYDRPHLC,SUP-2890403,CDM,C1887,HCPCS,0272,RC,,,,both,,,266.90,173.48,,,,,,,,,,,,,
ALLOGRAFT BNE CHIP 1-8 MM 5 CC FD CRUSH CANC READIGRAFT,SUP-2740843,CDM,C1713,HCPCS,0278,RC,,,,both,,,411.28,267.33,,,,,,,,,,,,,
DOUBLE DRILL GUIDE 35/25MM,SUP-2696009,CDM,C1713,HCPCS,0278,RC,,,,both,,,2797.61,1818.45,,,,,,,,,,,,,
MESH SURG MXLFCL 85X50X0.3 MM SM GRID FOR 1.5 MM SCREW TI,SUP-2485036,CDM,C1713,HCPCS,0278,RC,,,,both,,,2864.47,1861.91,,,,,,,,,,,,,
SCREW BONE L30MM DIA2.5MM CRTX ST T7 PERI-LOC,SUP-2350070,CDM,C1713,HCPCS,0278,RC,,,,both,,,178.48,116.01,,,,,,,,,,,,,
CAP ORAL SYR LT BLU EXACTAMED,SUP-2130331,CDM,C1760,HCPCS,0278,RC,,,,both,,,138.16,89.80,,,,,,,,,,,,,
CATHETER DRNGE VSC LOOP FIRM DUROMETER 12FRX35CM FLEXIMA VS,SUP-2147871,CDM,C1729,HCPCS,0272,RC,,,,both,,,329.98,214.49,,,,,,,,,,,,,
"HC Acetone, Serum",PX-3078200900,CDM,82009,CPT,0307,RC,,,,outpatient,,,275.00,178.75,,,,,,,,,,,,,
HC Repr Smp Not Face 2.6-7.5cm,PX-4501200200,CDM,12002,CPT,0450,RC,,,,outpatient,,,632.00,410.80,,,,,,,,,,,,,
CEMENT KIT CALCIUM PHOSPHATE 5 CC QUICKSET,SUP-2845378,CDM,C1713,HCPCS,0278,RC,,,,both,,,3857.49,2507.37,,,,,,,,,,,,,
SPACER SPNL LORDTC 360 DEG STD 14X13X8 MM STRL ACIS PROTI,SUP-2590288,CDM,C1889,HCPCS,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
PLATE BNE L226MM 12 H NONSTERILE R LAT PROX TIB S STL LOK,SUP-2185722,CDM,C1713,HCPCS,0278,RC,,,,both,,,4320.04,2808.03,,,,,,,,,,,,,
TAP SURG DIA2.3 MM CRANIOMAXILLOFACIAL NS DISP LORENZ,SUP-2936869,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1588.84,1032.75,,,,,,,,,,,,,
GRAFT HUM TISS 3.5X3.5CM ALLGRFT MEMBRN AMNIO AMNIOEXC,SUP-2194320,CDM,Q4137,HCPCS,0636,RC,,,,both,,,3000.27,1950.18,,,,,,,,,,,,,
PIN FIX TIBIAL SZR TEMPLATE 2PK,SUP-2890804,CDM,C1776,CPT,0278,RC,,,,both,,,582.47,378.61,,,,,,,,,,,,,
GUIDEPIN BNE FIX DIA 6 MM CANC REDUCTION THRD NS VARIAX,SUP-2902189,CDM,C1713,HCPCS,0278,RC,,,,both,,,1627.78,1058.06,,,,,,,,,,,,,
GRAFT VASC HEMSHLD GLD L 30 CM DIA12 MM BRANCH SZ 8 MM,SUP-2694338,CDM,C1768,CPT,0278,RC,,,,both,,,4260.79,2769.51,,,,,,,,,,,,,
SCREW BNE EMGCY 12 MM TI NS MATRIXMIDFACE,SUP-2191595,CDM,C1713,HCPCS,0278,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
STENT PERIPH SMRT RADIANZ L 150 MM DIA 7 MM DEL SYS L 190 CM,SUP-2866204,CDM,C1725,HCPCS,0272,RC,,,,both,,,5704.81,3708.13,,,,,,,,,,,,,
CATHETER NEPHSTMY 22FR BAL 5CC SIL SH TIP COUNCL STYL BAL,SUP-2129042,CDM,C1729,HCPCS,0272,RC,,,,both,,,172.70,112.25,,,,,,,,,,,,,
KIT SUTURE ANCHR L 20 MM DIA 4.75 MM DYN KNOTLESS PRELD PASS,SUP-2899199,CDM,C1713,HCPCS,0278,RC,,,,both,,,1640.65,1066.42,,,,,,,,,,,,,
CATHETER AORT L65CM ENDOCLAMP,SUP-2214466,CDM,2720000010,LOCAL,0272,RC,,,,both,,,9467.10,6153.61,,,,,,,,,,,,,
IMMOBILIZER KNEE AD L19IN FOR UP TO 27IN THGH UNIV FOAM NYL,SUP-2205521,CDM,L1830,CPT,0272,RC,,,,both,,,171.44,111.44,,,,,,,,,,,,,
PACEMAKER CARD DISCOVERY II SINGLE CHMBR IS1 CONN UPLR BPLR,SUP-2148597,CDM,C1786,HCPCS,0275,RC,,,,both,,,12798.64,8319.12,,,,,,,,,,,,,
NEEDLE BX 19GA L137.5-141.5CM CHN 2.8MM SHTH DIA1.73MM US,SUP-2149651,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1681.78,1093.16,,,,,,,,,,,,,
CANNULA PERF 17FR L17CM FEM ART W/ 12FR INTRO TANDEMHEART,SUP-2152641,CDM,C1889,HCPCS,0278,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
MESH SURG SZ 20 X 25 IN POLYDIOXANONE MACROPOROUS MONOFILAME,SUP-2881031,CDM,C1781,HCPCS,0278,RC,,,,both,,,17584.00,11429.60,,,,,,,,,,,,,
IMPLANT HUM TISS W6XL16CM THK1MM PROC DERM CLLGN RECTANG,SUP-2125863,CDM,C1781,HCPCS,0278,RC,,,,both,,,10676.00,6939.40,,,,,,,,,,,,,
ANCHOR SUT MINILOK QUIK ANCHR W/ NO 0 ORTHOCORD OS-2 NDL AND,SUP-2256606,CDM,C1713,HCPCS,0278,RC,,,,both,,,1438.12,934.78,,,,,,,,,,,,,
GUIDEWIRE ORTH L 450 MM DIA2.8 MM FLUT TIP FOR CANN COMPR,SUP-2907626,CDM,C1769,HCPCS,0272,RC,,,,both,,,624.04,405.63,,,,,,,,,,,,,
PLATE BONE SM L54MM 4 HOLE LEFT DST VOLAR PRRTCLR RDL,SUP-2470134,CDM,C1713,HCPCS,0278,RC,,,,both,,,1852.57,1204.17,,,,,,,,,,,,,
PLATE BNE CLAV CS1 2.7 MM LT LAT VA LCK COMPR TI NS VA-LCP,SUP-2758159,CDM,C1713,HCPCS,0278,RC,,,,both,,,3681.96,2393.27,,,,,,,,,,,,,
CATHETER MAP 4 MM 8 FRX120 CM 48 MM 64 ELECTRD CONSTELLATION,SUP-2424696,CDM,C1732,HCPCS,0272,RC,,,,both,,,14626.12,9506.98,,,,,,,,,,,,,
PLATE BNE 100 DEG L 40.51 MM THK 0.6 MM SCREW DIA1.5 MM 5 X,SUP-2935916,CDM,C1713,HCPCS,0278,RC,,,,both,,,1752.12,1138.88,,,,,,,,,,,,,
FORCEP ENDOSCP RUBBER TIP 4.8X1900 MM 2 MM GRASPING CHANNEL,SUP-2865648,CDM,2720000010,LOCAL,0272,RC,,,,both,,,596.00,387.40,,,,,,,,,,,,,
TRASTUZUMAB-PKRB 150 MG IV SOLR|DISCARDED DRUG NOT ADMINISTE,RX-149777,CDM,Q5113,HCPCS,0636,RC,63459-0303-43,NDC,JW,both,1,UN,3163.40,2056.21,,,,,,,,,,,,,
STEM FEM L250MM DIA13.5MM BEAD 10IN 35MM OFFSET LT HIP CO,SUP-2203192,CDM,C1776,CPT,0278,RC,,,,both,,,22022.39,14314.55,,,,,,,,,,,,,
PLATE BONE 2 CARPAL WRIST FREEDOM,SUP-2586701,CDM,C1713,HCPCS,0278,RC,,,,both,,,12898.96,8384.32,,,,,,,,,,,,,
CROSSBAR SPNL FIX 3 MM SET SCR REPL OZAT DAYTONA,SUP-2709431,CDM,C1713,HCPCS,0278,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
WASHER ORTH L DIA13MM S STL FLAT RND FOR 4.5-6.5MM SCR,SUP-2411299,CDM,C1713,HCPCS,0278,RC,,,,both,,,99.38,64.60,,,,,,,,,,,,,
HEAD FEM 3.5+ MM 12/14 32 MM HIP TAPR CERM,SUP-2449605,CDM,C1776,CPT,0278,RC,,,,both,,,4140.09,2691.06,,,,,,,,,,,,,
CANNULA KYPHOPLASTY NDL 11GA SPNL W/ CEM INFL VERT AUG SYS,SUP-2366875,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4152.21,2698.94,,,,,,,,,,,,,
COIL EMB L6CM DIA3MM EXTRA SFT 3D DETACH AXIUM PRIM,SUP-2295045,CDM,C1889,HCPCS,0278,RC,,,,both,,,6123.00,3979.95,,,,,,,,,,,,,
SYSTEM OCCL DEL AMPLATZER 45 DEG L 60 CM OD 2.44 MM ID 3.05,SUP-2116318,CDM,C1817,HCPCS,0278,RC,,,,both,,,1821.20,1183.78,,,,,,,,,,,,,
HC So Thrombin Clotting Level,PX-3058567066,CDM,85670,CPT,0305,RC,,,,both,,,122.00,79.30,,,,,,,,,,,,,
GUIDEWIRE VASC ARW L 33 CM DIA 0.025 IN SS PERIPH,SUP-2383970,CDM,C1769,HCPCS,0272,RC,,,,both,,,28.39,18.45,,,,,,,,,,,,,
DEVICE PESSARY L 55 MM SZ 1 SIL SUPP WHT NS LF GEHRUNG,SUP-2895812,CDM,A4562,HCPCS,0272,RC,,,,both,,,108.27,70.38,,,,,,,,,,,,,
BRACE BK M FOR 35 40IN WAIST BLK ALUMINUM NYL STRNL BAR POLY,SUP-2196478,CDM,L0464,HCPCS,0272,RC,,,,both,,,599.83,389.89,,,,,,,,,,,,,
SCREW BNE L 110 MM DIA 4.7 MM PARTIALLY THRD OSTEOPENIA NS,SUP-2931472,CDM,C1713,HCPCS,0278,RC,,,,both,,,299.81,194.88,,,,,,,,,,,,,
ALLOGRAFT DERMAL MESHED THN 15X10 CM MTRX SOMAGEN,SUP-2434141,CDM,C1762,CPT,0278,RC,,,,both,,,32676.79,21239.91,,,,,,,,,,,,,
COMPONENT TALAR SINGLE COATED/US VERS LARGE RIGHT,SUP-2878211,CDM,C1776,CPT,0278,RC,,,,both,,,20158.96,13103.32,,,,,,,,,,,,,
VITAMIN B-12 100 MCG PO TABS,RX-8653,CDM,6370000000,HCPCS,0637,RC,50268-0852-15,NDC,,both,1,UN,1.60,1.04,,,,,,,,,,,,,
ANCHOR SUT DIA4.5MM TAP IN DSGN FOR SFT TISS FIX FOOTPRINT,SUP-2341861,CDM,C1713,HCPCS,0278,RC,,,,both,,,1164.78,757.11,,,,,,,,,,,,,
CATHETER VENT DRNGE L15CM OD3.1MM ID1.5MM S STL SIL BA,SUP-2243792,CDM,C1729,HCPCS,0272,RC,,,,both,,,143.12,93.03,,,,,,,,,,,,,
NAIL IM L420MM DIA8MM ST DK BLU TIB TI LOK UNREAMED SLD W/,SUP-2192767,CDM,C1713,HCPCS,0278,RC,,,,both,,,5705.69,3708.70,,,,,,,,,,,,,
TAP MAND LCK BONE SCR FIX MOD NONSTERILE REUSE LEIBINGER,SUP-2364415,CDM,2720000010,LOCAL,0272,RC,,,,both,,,541.02,351.66,,,,,,,,,,,,,
BIT DRILL CANNULATED AO 20X80MM,SUP-2723518,CDM,2720000010,LOCAL,0272,RC,,,,both,,,268.03,174.22,,,,,,,,,,,,,
PLATE BNE METATARSAL PHYLANGEAL FUS FOR 35MM SCR,SUP-2243231,CDM,C1713,HCPCS,0278,RC,,,,both,,,4050.60,2632.89,,,,,,,,,,,,,
CATHETER MAP 4 MM 8 FRX120 CM 48 MM 64 ELECTRD CONSTELLATION,SUP-2424696,CDM,C1732,HCPCS,0278,RC,,,,both,,,14626.12,9506.98,,,,,,,,,,,,,
IMPLANT ANK JT SZ 2 TIB COMP CO CHROM SALTO TALARIS,SUP-2244137,CDM,C1776,CPT,0278,RC,,,,both,,,18775.32,12203.96,,,,,,,,,,,,,
"HC So Hiv-1, Amplified Probe Tech",PX-3068753566,CDM,87535,CPT,0306,RC,,,,both,,,293.00,190.45,,,,,,,,,,,,,
ALLOGRAFT BNE STRUT 45.1-50 MM BONE-PATELLAR TENDON-BONE,SUP-2866884,CDM,C1762,CPT,0278,RC,,,,both,,,6681.92,4343.25,,,,,,,,,,,,,
GRAFT BONE SUB 10ML DEMIN BONE MTRX ACCELL CONNEXUS,SUP-2242682,CDM,C1713,HCPCS,0278,RC,,,,both,,,4177.96,2715.67,,,,,,,,,,,,,
FELODIPINE ER 2.5 MG PO TB24,RX-27489,CDM,6370000000,HCPCS,0637,RC,68462-0233-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
WIRE FIX SM KIRSCHNER,SUP-2418530,CDM,C1713,HCPCS,0278,RC,,,,both,,,499.89,324.93,,,,,,,,,,,,,
BAR XTRAFIX 11MM CRBN 600,SUP-2720467,CDM,2720000010,LOCAL,0272,RC,,,,both,,,900.43,585.28,,,,,,,,,,,,,
MATRIX BIO DIA15 MM FISH SKIN SIL DERMAL ADH CIR FEN INTACT,SUP-2909289,CDM,Q4158,HCPCS,0636,RC,,,,both,,,2829.14,1838.94,,,,,,,,,,,,,
DEGARELIX ACETATE(240 MG DOSE) 120 MG/VIAL SC SOLR,RX-149780,CDM,J9155,HCPCS,0636,RC,55566-8403-01,NDC,,both,1,UN,2194.90,1426.68,,,,,,,,,,,,,
KIT HEMO DYLS OR HD CATH 15.5FR L24CM STD CHRONIC PEEL AWAY,SUP-2120052,CDM,C1751,HCPCS,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
PLATE BNE W17.5XL170MM THK5.2MM 9 H BILAT S STL BROAD LOK,SUP-2185292,CDM,C1713,HCPCS,0278,RC,,,,both,,,1576.19,1024.52,,,,,,,,,,,,,
PLATE BNE L116MM 4 H NONSTERILE R MED DST TIB S STL LOK,SUP-2185578,CDM,C1713,HCPCS,0278,RC,,,,both,,,4081.78,2653.16,,,,,,,,,,,,,
SET INT FIX SCREW DIA1.5 MM TI NEURO 3 Y SHP XLN PLATE 12 PK,SUP-2936715,CDM,C1713,HCPCS,0278,RC,,,,both,,,53916.94,35046.01,,,,,,,,,,,,,
JOINT SHOULDER HUMERAL FIXATION RING EQUINOXE 18.5MM,SUP-2855528,CDM,C1776,CPT,0278,RC,,,,both,,,3500.32,2275.21,,,,,,,,,,,,,
CATHETER HD KT 15 FRX23 CM DL LNG TERM ACCS CANNON II +,SUP-2763010,CDM,C1750,HCPCS,0278,RC,,,,both,,,178.98,116.34,,,,,,,,,,,,,
PLATE BNE H0.5MM 24 H UP FACE BLU TI STR COND MAL LEIBINGER,SUP-2366238,CDM,C1713,HCPCS,0278,RC,,,,both,,,1669.35,1085.08,,,,,,,,,,,,,
INTRODUCER PACE LD L 14 CM DIA14 FR DI-LOCK DIL L 19 CM,SUP-2357071,CDM,C1892,HCPCS,0272,RC,,,,both,,,25.12,16.33,,,,,,,,,,,,,
PLATE BNE L288MM 21 H R ANTLAT DST TIB TI LOK COMPR FOR 35MM,SUP-2190976,CDM,C1713,HCPCS,0278,RC,,,,both,,,4949.02,3216.86,,,,,,,,,,,,,
PLATE BONE CRANIAL 4 HOLE STRAIGHT 21.4X3.4MM TITANIUM NEURO,SUP-2827188,CDM,C1713,HCPCS,0278,RC,,,,both,,,89.80,58.37,,,,,,,,,,,,,
PLATE BONE L61MM 5 H STRL LT LAT DSTL FIBULAR S STL FOR,SUP-2349735,CDM,C1713,HCPCS,0278,RC,,,,both,,,3594.04,2336.13,,,,,,,,,,,,,
MAGGOT MED,SUP-2306595,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1083.30,704.14,,,,,,,,,,,,,
GRAFT BIO TISS W8XL12CM THK08 17MM THCK STRUCTURAL,SUP-2307478,CDM,Q4128,HCPCS,0636,RC,,,,both,,,9281.59,6033.03,,,,,,,,,,,,,
GUIDE SURG PT SPEC W/ PLN,SUP-2860269,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6972.06,4531.84,,,,,,,,,,,,,
PLUG VASC L10MM DIA4MM CATH L125CM 0.038IN NIT MULT LAYR,SUP-2355703,CDM,C1889,HCPCS,0278,RC,,,,both,,,2983.00,1938.95,,,,,,,,,,,,,
PLATE BNE 5 H TI X FOR 1MM PLUSDRIVE SCR,SUP-2190615,CDM,C1713,HCPCS,0278,RC,,,,both,,,894.59,581.48,,,,,,,,,,,,,
MICRODEBRIDER ABLAT TOPAZ ARTHCARE,SUP-2341971,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
GRAFT TEND ANTR TIBIALIS HUM TISS 8.5MMX250ML,SUP-2257909,CDM,C1762,CPT,0278,RC,,,,both,,,6123.00,3979.95,,,,,,,,,,,,,
SYSTEM 7FR 90CM ULT SM CSF SNAP SHUNT ASSEMB FLOW CTRL VLV,SUP-2278382,CDM,C1729,HCPCS,0272,RC,,,,both,,,2901.83,1886.19,,,,,,,,,,,,,
PLATE BNE CRV 4.5X370 MM LT CNDYL 18 HOLE VA LCK NS VA-LCP,SUP-2758218,CDM,C1713,HCPCS,0278,RC,,,,both,,,6863.38,4461.20,,,,,,,,,,,,,
SCREW BNE 5512003] STRYKER CORP],SUP-2363726,CDM,C1713,HCPCS,0278,RC,,,,both,,,133.64,86.87,,,,,,,,,,,,,
CANNULA INJ BENJAMIN 2 MMX13.5 CM F/POS PRESSURE ASST VENT,SUP-2774794,CDM,2720000010,LOCAL,0272,RC,,,,both,,,838.51,545.03,,,,,,,,,,,,,
CYCLOPENTOLATE HCL 2 % OP SOLN,RX-9700,CDM,6370000000,HCPCS,0637,RC,00065-0397-02,NDC,,both,2,ML,208.70,135.65,,,,,,,,,,,,,
CALCIPOTRIENE 0.005 % EX CREA,RX-16034,CDM,6370000000,HCPCS,0637,RC,66993-0877-61,NDC,,both,60,GR,945.30,614.44,,,,,,,,,,,,,
HC Bilirubin Total Transcutaneous,PX-3018872000,CDM,88720,CPT,0301,RC,,,,outpatient,,,24.00,15.60,,,,,,,,,,,,,
CATHETER THOR 20FR L15.75IN PVC SHRP TRCR TIP RADPQ SENTNL,SUP-2154956,CDM,C1729,HCPCS,0272,RC,,,,both,,,103.62,67.35,,,,,,,,,,,,,
PLATE BNE LP 1.5X0.6 MM NEURO 3X2 HOLE LADDER SQ SEG STRL,SUP-2475785,CDM,C1713,HCPCS,0278,RC,,,,both,,,739.82,480.88,,,,,,,,,,,,,
CAGE SPNL L14XW14XH50MM SPNL 4 LOBE IMP NGAGE,SUP-2317740,CDM,C1889,HCPCS,0278,RC,,,,both,,,15712.56,10213.16,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 280 MM DIA17 MM DEL SHTH,SUP-2934598,CDM,C1713,HCPCS,0278,RC,,,,both,,,20857.32,13557.26,,,,,,,,,,,,,
PLATE BNE MINI CRANIOMAXILLOFACIAL STR DBL STRP,SUP-2883254,CDM,C1713,HCPCS,0278,RC,,,,both,,,5353.01,3479.46,,,,,,,,,,,,,
GRAFT HUM TISS L 2.75 X W 1.5 CM PLCNTA MEMBRN ALLGRFT 3D,SUP-2909395,CDM,Q4194,HCPCS,0636,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
CONNECTOR LASER FIBER LITHO SUREFLEX 200,SUP-2263900,CDM,2720000010,LOCAL,0272,RC,,,,both,,,725.34,471.47,,,,,,,,,,,,,
SCREW CP LAG 4.1X48 MM T10,SUP-2703201,CDM,C1713,HCPCS,0278,RC,,,,both,,,1138.88,740.27,,,,,,,,,,,,,
ADAPTER DRL BIT CIR FOR VERTEX MAX,SUP-2286731,CDM,C1713,HCPCS,0278,RC,,,,both,,,2321.43,1508.93,,,,,,,,,,,,,
SCREW BONE L65MM DIA5MM PARTIALLY THRD OSTEOPENIA PERI-LOC,SUP-2348507,CDM,C1713,HCPCS,0278,RC,,,,both,,,630.48,409.81,,,,,,,,,,,,,
BIT DRL 5X24 MM NCB,SUP-2862214,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3454.13,2245.18,,,,,,,,,,,,,
TI SPHERICAL WASHER LRG ROUND FOR 6.5/7.3MM CANN SCREW-STER,SUP-2549384,CDM,C1713,HCPCS,0278,RC,,,,both,,,449.68,292.29,,,,,,,,,,,,,
LEVEL CMF PLATE FRAC TLTS CVD 20 25 MM SCRW6 HOLE 31 MM T1,SUP-2694190,CDM,C1713,HCPCS,0278,RC,,,,both,,,1778.50,1156.02,,,,,,,,,,,,,
GRAFT VASC IMPRA L 80 CM DIA10 MM EPTFE STR TW N RING HEMO,SUP-2761372,CDM,C1768,CPT,0278,RC,,,,both,,,3015.28,1959.93,,,,,,,,,,,,,
BIT DRL L254MM DIA8MM FOR DH-DC 3 RMR,SUP-2187942,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1617.60,1051.44,,,,,,,,,,,,,
APPLIER CLP 8.75IN ANEUR VARIO STD BAYNT SWVL REUSE,SUP-2108607,CDM,C1889,HCPCS,0278,RC,,,,both,,,6032.41,3921.07,,,,,,,,,,,,,
PLATE 95 DEG CONDYLAR 9 HOLES 40MM 156MM,SUP-2547716,CDM,C1713,HCPCS,0278,RC,,,,both,,,3559.13,2313.43,,,,,,,,,,,,,
CATHETER HD PRECRV 14 FRX12 CM SHT TERM SET DUOFLO 400XL,SUP-2627165,CDM,C1752,HCPCS,0278,RC,,,,both,,,260.62,169.40,,,,,,,,,,,,,
NEEDLE SPNL LASER 25 CM SIDEFIRE ORTH HOLM,SUP-2225668,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1295.25,841.91,,,,,,,,,,,,,
SUPPORT ORTHOT HEEL CUST COUNT REINF PLAS,SUP-2435729,CDM,L3430,HCPCS,0272,RC,,,,both,,,453.70,294.90,,,,,,,,,,,,,
MARKER BRST BX TI SHP 2 TOP HAT FOR CELERO 12 DEV SECURMARK,SUP-2240048,CDM,A4648,CPT,0278,RC,,,,both,,,258.89,168.28,,,,,,,,,,,,,
KIT DISP NEUROVISION,SUP-2310413,CDM,C1713,HCPCS,0278,RC,,,,both,,,1770.96,1151.12,,,,,,,,,,,,,
HC C-Reactive Protein High Sensitivity,PX-3028614100,CDM,86141,CPT,0302,RC,,,,both,,,192.00,124.80,,,,,,,,,,,,,
GRAFT HUM TISS W6XL16CM ACELLULAR DERM CLLGN RECTANG,SUP-2125862,CDM,C1781,HCPCS,0278,RC,,,,both,,,9545.60,6204.64,,,,,,,,,,,,,
SPLINT ANKLE FOOT ORTHOSIS MALE 8-10 RT LG,SUP-2326060,CDM,L4350,HCPCS,0274,RC,,,,both,,,98.56,64.06,,,,,,,,,,,,,
HC Rt Bronch Dx W/Biopsy(S),PX-3613162500,CDM,31625,CPT,0361,RC,,,,both,,,5261.00,3419.65,,,,,,,,,,,,,
PLATE BNE L 120 MM TI EXTRATHORACIC PREBENT NS RIBFIX TITAN,SUP-2905464,CDM,C1713,HCPCS,0278,RC,,,,both,,,15624.64,10156.02,,,,,,,,,,,,,
STENT GRFT VASC AFX BODY L 110 MM DIA25 MM LIMB 30 MM 16 MM,SUP-2217629,CDM,C1874,HCPCS,0278,RC,,,,both,,,36361.20,23634.78,,,,,,,,,,,,,
K WIRE FIX L5IN DIA1MM S STL SMOOTH BLNT TIP FOR PEDCL SCR,SUP-2289237,CDM,C1769,HCPCS,0272,RC,,,,both,,,366.19,238.02,,,,,,,,,,,,,
GUIDE SURG 3IN HUM CNL FINDER,SUP-2372566,CDM,C1713,HCPCS,0278,RC,,,,both,,,1492.88,970.37,,,,,,,,,,,,,
ALLOGRAFT PUROS 250-1000MIC 1ML SCAFFOLD CANC CERVICAL,SUP-2863676,CDM,C1713,HCPCS,0278,RC,,,,both,,,369.26,240.02,,,,,,,,,,,,,
CATHETERIZATION KIT 7 FRX20 CM 3L,SUP-2383967,CDM,C1751,HCPCS,0278,RC,,,,both,,,440.01,286.01,,,,,,,,,,,,,
GRAFT VASC W1XL3IN THK0.36MM CLLGN ULT THN KNIT PTCH N TAPR,SUP-2227662,CDM,C1768,CPT,0278,RC,,,,both,,,465.22,302.39,,,,,,,,,,,,,
INTRODUCER VASC AD 7FRX14CM,SUP-2357077,CDM,C1892,HCPCS,0272,RC,,,,both,,,109.90,71.43,,,,,,,,,,,,,
PLATE BNE FIBULAR 2.7/3.5X116 MM LT POSTEROLATERAL DSTL 6,SUP-2424163,CDM,C1713,HCPCS,0278,RC,,,,both,,,2020.15,1313.10,,,,,,,,,,,,,
CATHETER URET 13/15 FRX24 CM UROPS AS,SUP-2465467,CDM,C1758,HCPCS,0278,RC,,,,both,,,327.16,212.65,,,,,,,,,,,,,
PLATE BNE L63MM THK1.5MM 4 H R S STL T OBLQ ANG LOK COMPR,SUP-2185825,CDM,C1713,HCPCS,0278,RC,,,,both,,,993.06,645.49,,,,,,,,,,,,,
CLIP SURG 1.4MM M TI ANAS VES CLSR ST DISP ANASTOCLP VCS,SUP-2264238,CDM,2720000010,LOCAL,0272,RC,,,,both,,,832.10,540.86,,,,,,,,,,,,,
GRAFT VASC UNIV 6 MM DIAM 700 MM LEN THN WALL N TAPR N RING,SUP-2265858,CDM,C1768,CPT,0278,RC,,,,both,,,2549.68,1657.29,,,,,,,,,,,,,
KIT ACCS PRT 0 10ML GAST LO PROF APS AVG BND LAP BND,SUP-2119226,CDM,C1889,HCPCS,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
SYSTEM NEUROSTIMULATOR ENTERRA II,SUP-2930513,CDM,C1767,HCPCS,0278,RC,,,,both,,,52595.00,34186.75,,,,,,,,,,,,,
CONFORM FLEX Q-PACK 40MM X 20MM X 5MM,SUP-2547188,CDM,C1713,HCPCS,0278,RC,,,,both,,,3347.30,2175.74,,,,,,,,,,,,,
KIT INTRO ARW THMS DIA 8.5 FR GUIDEWIRE 0.035 IN POLYUR PERC,SUP-2383287,CDM,C1894,HCPCS,0272,RC,,,,both,,,95.36,61.98,,,,,,,,,,,,,
HC So Ceruloplasmin,PX-3018239066,CDM,82390,CPT,0301,RC,,,,both,,,114.00,74.10,,,,,,,,,,,,,
REAMER SURG DIA 4.2 MM CANN AO QC STRL DISP FLEX-THREAD,SUP-2900375,CDM,C1713,HCPCS,0278,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
BIT DRL QC 2.8X170 MM 80 MM CALIB STRL,SUP-2563759,CDM,2720000010,LOCAL,0272,RC,,,,both,,,456.93,297.00,,,,,,,,,,,,,
PLATE BONE W38XL42MM 4X4MM H SPC CRAN TI MESH FOR 1MM SCR,SUP-2190567,CDM,C1713,HCPCS,0278,RC,,,,both,,,4622.39,3004.55,,,,,,,,,,,,,
LINER ACET SZ MP5 ID28MM HIP CONSTRN FMP,SUP-2217141,CDM,C1776,CPT,0278,RC,,,,both,,,4588.33,2982.41,,,,,,,,,,,,,
SYSTEM IMPL DST BICEPS REP DEL W/ BICEPS BTTN 7X10MM PEEK,SUP-2121661,CDM,C1713,HCPCS,0278,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
PLATE BNE EVANS W/ 10 MM SPACER TI RIVAL VW REDUC,SUP-2645297,CDM,C1713,HCPCS,0278,RC,,,,both,,,5333.29,3466.64,,,,,,,,,,,,,
STEM FEM SZ 5 L125MM NK L37MM 47MM OFFSET 132DEG HIP FORGED,SUP-2375352,CDM,C1776,CPT,0278,RC,,,,both,,,6133.55,3986.81,,,,,,,,,,,,,
SODIUM POLYSTYRENE SULFONATE PO POWD,RX-7356,CDM,6370000000,HCPCS,0637,RC,10702-0036-15,NDC,,both,15,GR,56.30,36.59,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP 0.1MM DIA TIP 3.2MML TIP STRGHT TIP SHFT R,SUP-2637603,CDM,C1769,HCPCS,0272,RC,,,,both,,,320.12,208.08,,,,,,,,,,,,,
HEMIN 350 MG IV SOLR,RX-139180,CDM,J1640,HCPCS,0636,RC,55292-0702-55,NDC,,both,1,UN,33016.80,21460.92,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED CERM ON CERM CHIPSNEPHCERCER] SMITH AND NEPHEW ORTHOPAEDICS],SUP-2351335,CDM,C1776,CPT,0278,RC,,,,both,,,20052.04,13033.83,,,,,,,,,,,,,
STEM HUM L125MM OD15.5MM TI POR IMP BI-ANGULAR,SUP-2404703,CDM,C1776,CPT,0278,RC,,,,both,,,11690.22,7598.64,,,,,,,,,,,,,
ALLOGRAFT BNE WDG FRZN ASEP IL CREST,SUP-2867034,CDM,C1762,CPT,0278,RC,,,,both,,,2362.54,1535.65,,,,,,,,,,,,,
KIT CTRL VEN CATH AD L20CM DIA12FR BLU FLX TIP POLYUR,SUP-2383318,CDM,C1752,HCPCS,0278,RC,,,,both,,,363.61,236.35,,,,,,,,,,,,,
ANCHOR SUTURE DIA 3.9 MM PEEK CC FIBERTAK ACHILLES,SUP-2910468,CDM,C1713,HCPCS,0278,RC,,,,both,,,9066.75,5893.39,,,,,,,,,,,,,
SYSTEM ANNULPLSTY OD38MM SYS FOR MITRL TRICSP POSITIONS,SUP-2214209,CDM,C1889,HCPCS,0278,RC,,,,both,,,6280.00,4082.00,,,,,,,,,,,,,
DARATUMUMAB 100 MG/5ML IV SOLN,RX-131895,CDM,J9145,HCPCS,0636,RC,57894-0505-05,NDC,,both,5,ML,2233.90,1452.03,,,,,,,,,,,,,
PLATE BNE T 3.5X67 MM 3X5 HOLE RT ANGLED SS LCP,SUP-2569405,CDM,C1713,HCPCS,0278,RC,,,,both,,,511.19,332.27,,,,,,,,,,,,,
STAPLE COMPRESSION 25MMX20MM TITANIUM,SUP-2652948,CDM,C1713,HCPCS,0278,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
GRAFT HUM TISS W12-13XL100MM FRZ DRY ALLGRFT FIB SHFT BNE,SUP-2307198,CDM,C1762,CPT,0278,RC,,,,both,,,2201.20,1430.78,,,,,,,,,,,,,
PLATE ILLIOSACRAL POST STD LEN RT 30MM,SUP-2290618,CDM,C1713,HCPCS,0278,RC,,,,both,,,9398.02,6108.71,,,,,,,,,,,,,
PLATE BNE L184MM 11 H ST L DST RAD VOLAR DPHSEAL MTPHSEAL S,SUP-2177224,CDM,C1713,HCPCS,0278,RC,,,,both,,,5086.67,3306.34,,,,,,,,,,,,,
CATHETER PTCA BLLN L10MM DIA2.25MM COR OVR THE WIRE SCORED,SUP-2142793,CDM,C1725,HCPCS,0272,RC,,,,both,,,2697.26,1753.22,,,,,,,,,,,,,
BIT DRL OD2MM CANN FOR MULTIUSE COMPR CHARLOTTE SCR,SUP-2397718,CDM,2720000010,LOCAL,0272,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
SUPPORT KNEE HALF RND,SUP-2324295,CDM,L1810,HCPCS,0272,RC,,,,both,,,113.20,73.58,,,,,,,,,,,,,
COVER HOLE BURR MEDPORE 29MM X 7MM X 14MM (3/PK),SUP-2848972,CDM,C1713,HCPCS,0278,RC,,,,both,,,1811.78,1177.66,,,,,,,,,,,,,
CATHETER IV DL 5 FR MAX BARR TY POWERMIDLINE,SUP-2126992,CDM,C1751,HCPCS,0278,RC,,,,both,,,561.75,365.14,,,,,,,,,,,,,
"HC Aortography, Thoracic WO Serialography, S&I",PX-3237560000,CDM,75600,CPT,0323,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
COMPONENT ULN XSM L3IN L EL TIV PLSM CRV INTERCHANGEABLE,SUP-2205932,CDM,C1776,CPT,0278,RC,,,,both,,,14543.91,9453.54,,,,,,,,,,,,,
PLATE BNE CALCANEAL 4X96 MM REG LT LAT SS STRL,SUP-2495463,CDM,C1713,HCPCS,0278,RC,,,,both,,,1428.23,928.35,,,,,,,,,,,,,
SHEATH INTRO PERFRMR L 45 CM OD 5 FR ID 1.7 MM GUIDEWIRE,SUP-2168666,CDM,C1894,HCPCS,0272,RC,,,,both,,,234.53,152.44,,,,,,,,,,,,,
PLATE BONE L189MM 14 H NONSTERILE RT PROX TIB S STL LO PROF,SUP-2185819,CDM,C1713,HCPCS,0278,RC,,,,both,,,3746.90,2435.48,,,,,,,,,,,,,
PLATE BONE L15MM THK0.9MM 3MM OFFSET 0DEG 4 H BILAT CHIN,SUP-2191214,CDM,C1713,HCPCS,0278,RC,,,,both,,,797.56,518.41,,,,,,,,,,,,,
GRAFT VASC EXXCEL SFT L 20 CM DIA 8 MM EPTFE STR TW ULTRA,SUP-2266065,CDM,C1768,CPT,0278,RC,,,,both,,,914.24,594.26,,,,,,,,,,,,,
SHUNT SURG REG ASMBLY VENTRICULOSTOMY RESERVOIR STRATA NSC,SUP-2628620,CDM,C1729,HCPCS,0272,RC,,,,both,,,15162.59,9855.68,,,,,,,,,,,,,
CATHETER ANGIOPLSTY L 135 CM BALLOON L 100 MM DIA10 MM,SUP-2140536,CDM,C1725,HCPCS,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
ALLOGRAFT BNE STRP LG FD ASEP IL CREST,SUP-2867020,CDM,C1762,CPT,0278,RC,,,,both,,,2684.70,1745.05,,,,,,,,,,,,,
KIT CATH HEMODIALYSI RELIANCE XK CHRONIC STD 16FR DIA 28CM 2,SUP-2613278,CDM,C1750,HCPCS,0278,RC,,,,both,,,7418.25,4821.86,,,,,,,,,,,,,
BENRALIZUMAB 30 MG/ML SC SOSY|DISCARDED DRUG NOT ADMINISTE,RX-140433,CDM,J0517,HCPCS,0636,RC,00310-1730-30,NDC,JW,both,1,ML,17248.80,11211.72,,,,,,,,,,,,,
OCCLUDER CV FLO RST L 12 MM BLB DIA1.25 MM SIL RUBBER,SUP-2130324,CDM,C1760,HCPCS,0278,RC,,,,both,,,229.66,149.28,,,,,,,,,,,,,
PLATE BNE W8XL48MM THK3.3MM 6 H NONSTERILE BILAT PELV S STL,SUP-2186231,CDM,C1713,HCPCS,0278,RC,,,,both,,,1515.49,985.07,,,,,,,,,,,,,
MARKER CLP ULTRACOR FOR 14GA S STL,SUP-2126904,CDM,A4648,CPT,0278,RC,,,,both,,,204.10,132.66,,,,,,,,,,,,,
TUBE TYMPANOSTOMY DIA1.27MM GRN SIL VENT CLLR BTTN SHEEHY,SUP-2284029,CDM,L8699,HCPCS,0278,RC,,,,both,,,61.04,39.68,,,,,,,,,,,,,
HC So2 Thrombin Time Plasma,PX-3058567068,CDM,85670,CPT,0305,RC,,,,both,,,8.00,5.20,,,,,,,,,,,,,
KIT VEIN HARV VASOVIEW UNIPORT + W/ BPLR BISECTOR,SUP-2227754,CDM,2720000010,LOCAL,0272,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
ROD SPNL STR 5.5X25 MM TI NS CD HORZ MODULEX,SUP-2854493,CDM,C1713,HCPCS,0278,RC,,,,both,,,1381.60,898.04,,,,,,,,,,,,,
INSTRUMENT ENDOSCP CRPL TUNN RELEASE SX-ONE MICROKNIFE DISP,SUP-2874141,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3293.86,2141.01,,,,,,,,,,,,,
PATCH BIO W7XL10CM PORCINE 4 PLY FOR INTCARD REP,SUP-2172037,CDM,C1768,CPT,0278,RC,,,,both,,,3199.03,2079.37,,,,,,,,,,,,,
HC ED Closed Tx Tmj Dislocation,PX-4502148000,CDM,21480,CPT,0450,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
CETIRIZINE HCL 10 MG PO TABS,RX-9506,CDM,6370000000,HCPCS,0637,RC,00904-7510-61,NDC,,both,1,UN,1.20,0.78,,,,,,,,,,,,,
KIT REV ULN EL BEAR DISCVR,SUP-2215462,CDM,C1776,CPT,0278,RC,,,,both,,,10252.10,6663.86,,,,,,,,,,,,,
KIT URO STENT L24CM DIA6FR DBL PGTL RADPQ THRD HYDRPHLC FLEX,SUP-2171443,CDM,C2617,HCPCS,0278,RC,,,,both,,,372.88,242.37,,,,,,,,,,,,,
IMPLANT SYNTH L 70 X W 70 MM THK 10 MM SM POLYETHYL TEMPORAL,SUP-2883391,CDM,C1713,HCPCS,0278,RC,,,,both,,,4812.11,3127.87,,,,,,,,,,,,,
COIL L10CM OD5MM HELCL DETACH 18D SYS AZUR,SUP-2385414,CDM,C1889,HCPCS,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
GRAFT BNE SM CYL 5 BETA-TRICALCIUM PHOSPHATE STRL CHRONOS L,SUP-2194032,CDM,C1713,HCPCS,0278,RC,,,,both,,,1151.60,748.54,,,,,,,,,,,,,
CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % EX CREA,RX-29424,CDM,6370000000,HCPCS,0637,RC,00168-0258-15,NDC,,both,15,GR,75.90,49.33,,,,,,,,,,,,,
PLATE BNE L310MM 14X5 H S STL R DST LAT PERIARTC FEM LOK FOR,SUP-2362735,CDM,C1713,HCPCS,0278,RC,,,,both,,,7396.27,4807.58,,,,,,,,,,,,,
PLATE BNE W8XL112MM THK3.3MM 14 H NONSTERILE BILAT PELV S,SUP-2186241,CDM,C1713,HCPCS,0278,RC,,,,both,,,2128.20,1383.33,,,,,,,,,,,,,
PIN FIX L9IN DIA48MM ST S STL 3 SIDE SGL TRCR 1 END PNT,SUP-2150504,CDM,C1713,HCPCS,0278,RC,,,,both,,,26.34,17.12,,,,,,,,,,,,,
BUR SURG MATCHSTICK LNG 3 MM FLUT FOR QD14-S/QD14-G1/QD14,SUP-2848156,CDM,2720000010,LOCAL,0272,RC,,,,both,,,415.20,269.88,,,,,,,,,,,,,
FISH OIL TRIPLE STRENGTH 1400 MG PO CAPS,RX-104121,CDM,6370000000,HCPCS,0637,RC,74312-0194-04,NDC,,both,1,UN,1.70,1.10,,,,,,,,,,,,,
MICROCATHETER INFUSION PROWLER 27 L 150 CM OD 3/2.6 FR ID,SUP-2257682,CDM,C1887,HCPCS,0272,RC,,,,both,,,3172.59,2062.18,,,,,,,,,,,,,
ENDOPROSTHESIS VASC EXCLUDER L 12CM AORTIC/ILIAC 28.5/14.5MM,SUP-2738005,CDM,C1768,CPT,0278,RC,,,,both,,,36279.56,23581.71,,,,,,,,,,,,,
GRAFT BONE SUB 10CC HA INJ HYDROSET,SUP-2364372,CDM,C1713,HCPCS,0278,RC,,,,both,,,7536.00,4898.40,,,,,,,,,,,,,
MATRIX BIO L 7 X W 10 CM FISH SKIN DERMAL SLD INTACT STRL 10/BX,SUP-2909440,CDM,Q4158,HCPCS,0636,RC,,,,both,,,7363.30,4786.14,,,,,,,,,,,,,
IMMOBILIZER SHLDR SM ENV L13IN D7IN POLY COT CLIN SLNG W/,SUP-2196915,CDM,L3650,HCPCS,0272,RC,,,,both,,,12.59,8.18,,,,,,,,,,,,,
COIL EMB 3 DIM 4 MMX8 CM TARGET 3D,SUP-2368051,CDM,C1889,HCPCS,0278,RC,,,,both,,,5533.47,3596.76,,,,,,,,,,,,,
GRAFT VASC STR STD WALL N RING 6MM DIA 50CM LEN 8CM GORTX,SUP-2395999,CDM,C1768,CPT,0278,RC,,,,both,,,2411.52,1567.49,,,,,,,,,,,,,
INSERT TIB SZ 9 THICKNESS 8MM CRUC RET NEUT UNIV PRI SCORP,SUP-2365097,CDM,C1776,CPT,0278,RC,,,,both,,,2027.66,1317.98,,,,,,,,,,,,,
PLATE BNE ULNA UNILAT CROSSLOCK DVR,SUP-2411824,CDM,C1713,HCPCS,0278,RC,,,,both,,,2468.04,1604.23,,,,,,,,,,,,,
SPACER SPNL W11XH10XL28MM PEEK OPTMA LUM OBLQ LO PROF RADLUC,SUP-2211919,CDM,C1821,HCPCS,0278,RC,,,,both,,,9420.00,6123.00,,,,,,,,,,,,,
DAKINS (1/4 STRENGTH) 0.125 % EX SOLN,RX-76724,CDM,6370000000,HCPCS,0637,RC,00436-0672-16,NDC,,both,473,ML,51.10,33.21,,,,,,,,,,,,,
DISTRACTION INTRNL PLATE TLCK TRANS 1 HOLE 27 32 MM SCREW,SUP-2679288,CDM,C1713,HCPCS,0278,RC,,,,both,,,3008.53,1955.54,,,,,,,,,,,,,
GRAFT HUM TISS 4X12CM THK0.8-1.8MM DERM NEOFORM,SUP-2300709,CDM,C1762,CPT,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
VERAPAMIL HCL ER 180 MG PO TBCR,RX-14626,CDM,6370000000,HCPCS,0637,RC,75834-0158-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
CATHETER CV QUAD LUMEN 8.5 FRX20 CM ARROWG+ARD BLU,SUP-2383394,CDM,C1751,HCPCS,0278,RC,,,,both,,,369.17,239.96,,,,,,,,,,,,,
PLATE BNE H 3.5/4 MM 15 HOLE NS FPS LTX,SUP-2856880,CDM,C1713,HCPCS,0278,RC,,,,both,,,2662.72,1730.77,,,,,,,,,,,,,
TUBE TYMPANOSTOMY DIA 0.76 MM INNR FLANGE DIA1 MM FLROPLAS,SUP-2901953,CDM,L8699,HCPCS,0278,RC,,,,both,,,71.91,46.74,,,,,,,,,,,,,
TUBE JEJUSTMY 26FR BLLN 7 10ML JEJU L579CM SIL INFL GAST,SUP-2236871,CDM,C1713,HCPCS,0278,RC,,,,both,,,559.33,363.56,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP 0.035 INX150 CM TRCE HYBRID,SUP-2759288,CDM,C1769,HCPCS,0272,RC,,,,both,,,562.06,365.34,,,,,,,,,,,,,
PLATE BONE DUAL CMPRSSN HLX14 TTNM CNTRD F3.5MM LOK SCREW S,SUP-2724128,CDM,C1713,HCPCS,0278,RC,,,,both,,,1959.93,1273.95,,,,,,,,,,,,,
PLATE BNE L260MM 11 H NONSTERILE R LAT PROX TIB TI LOK COMPR,SUP-2190717,CDM,C1713,HCPCS,0278,RC,,,,both,,,4479.87,2911.92,,,,,,,,,,,,,
COMPONENT HIP UNIPOLAR/BIPOLAR H4 HEMI,SUP-2431151,CDM,C1776,CPT,0278,RC,,,,both,,,4396.00,2857.40,,,,,,,,,,,,,
BRACE ORTH CIRC THGH 26.5-29.5 IN CTR 19-21 IN CALF 20-22 IN,SUP-2914906,CDM,2720000010,LOCAL,0272,RC,,,,both,,,879.45,571.64,,,,,,,,,,,,,
RACEPINEPHRINE HCL 2.25 % IN NEBU,RX-114658,CDM,6370000000,HCPCS,0637,RC,00487-5901-99,NDC,,both,1,UN,54.10,35.16,,,,,,,,,,,,,
SCREW BNE DIA 4.5 MM SS LCK H INSRT STRL EVOS,SUP-2932215,CDM,C1713,HCPCS,0278,RC,,,,both,,,638.99,415.34,,,,,,,,,,,,,
PIN EXT FIX HALF 6X25 MM HA STRL SALVATION,SUP-2468860,CDM,2720000010,LOCAL,0272,RC,,,,both,,,901.18,585.77,,,,,,,,,,,,,
TALQUETAMAB-TGVS 40 MG/ML SC SOLN,RX-165051,CDM,J3055,HCPCS,0636,RC,57894-0470-01,NDC,,both,1,ML,33272.80,21627.32,,,,,,,,,,,,,
GRAFT HUMAN TISSUE THICK 25X20 CM HYDRATED BIOLOGIC TISSUE M,SUP-2838618,CDM,C1763,HCPCS,0278,RC,,,,both,,,46401.98,30161.29,,,,,,,,,,,,,
HC L-Spine Bend Only 2-3 Views,PX-3207212000,CDM,72120,CPT,0320,RC,,,,outpatient,,,628.00,408.20,,,,,,,,,,,,,
SHOULDER IMMOB VELPEAU ELAS XLG,SUP-2194409,CDM,L3650,HCPCS,0274,RC,,,,both,,,19.66,12.78,,,,,,,,,,,,,
SCREW BONE L3.5MM OD1.5MM GRN TI CRANIOMAXILLOFACIAL SELF,SUP-2403083,CDM,C1713,HCPCS,0278,RC,,,,both,,,218.54,142.05,,,,,,,,,,,,,
ESTROGENS CONJUGATED 25 MG IJ SOLR,RX-9972,CDM,J1410,HCPCS,0636,RC,00046-0749-05,NDC,,both,1,UN,2167.10,1408.61,,,,,,,,,,,,,
HC X-Ray Exam Abdomen 1 View,PX-3207401800,CDM,74018,CPT,0320,RC,,,,both,,,674.00,438.10,,,,,,,,,,,,,
CATHETER STEER LIVEWIRE 7FR QPLR 2-5-2MM ELECTRD SPC SM SWP,SUP-2356859,CDM,C1730,HCPCS,0272,RC,,,,both,,,1044.05,678.63,,,,,,,,,,,,,
PLATE BONE L25MM 6 H TI GAP FOR CRAN CLSR SYS,SUP-2243974,CDM,C1713,HCPCS,0278,RC,,,,both,,,355.89,231.33,,,,,,,,,,,,,
DEFIBRILLATOR IMPL CONTAK RENEWAL TR W 4.50 X H 5.40 CM D,SUP-2149119,CDM,C1882,HCPCS,0275,RC,,,,both,,,25434.00,16532.10,,,,,,,,,,,,,
FIBER LASER 365 MH SOLTIVE DISP,SUP-2540083,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1193.42,775.72,,,,,,,,,,,,,
GUIDEWIRE VASC STR 10 CM 0.035 INX150 CM BENT FIX INQWIRE,SUP-2302701,CDM,C1769,HCPCS,0272,RC,,,,both,,,33.47,21.76,,,,,,,,,,,,,
PEG BNE FIX 15MM HD LOK REFLCT,SUP-2344766,CDM,C1776,CPT,0278,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
CATHETER CV FULL TY 032 10 FRX20 CM 10 GA 5 LUMEN SPECTRUM,SUP-2759735,CDM,C1751,HCPCS,0278,RC,,,,both,,,617.70,401.50,,,,,,,,,,,,,
HC So Nk Cell Total,PX-3028635766,CDM,86357,CPT,0302,RC,,,,both,,,64.00,41.60,,,,,,,,,,,,,
RIZATRIPTAN BENZOATE 10 MG PO TABS,RX-23377,CDM,6370000000,HCPCS,0637,RC,00093-7472-19,NDC,,both,1,UN,6.80,4.42,,,,,,,,,,,,,
CATHETER TRAY SINGLE LUMEN 4 FR MAXIMAL BARR PRB POWERPICC,SUP-2125508,CDM,C1751,HCPCS,0278,RC,,,,both,,,1015.66,660.18,,,,,,,,,,,,,
HC So Hla I Typing 1 Antigen Lr,PX-3108137466,CDM,81374,CPT,0310,RC,,,,outpatient,,,153.00,99.45,,,,,,,,,,,,,
DRAIN CHN 24FR L8MM SIL RND HUBLESS FULL FLUT DEPTH MRK,SUP-2127338,CDM,C1729,HCPCS,0272,RC,,,,both,,,43.93,28.55,,,,,,,,,,,,,
BUTTON SEPT SILIC1 1 PC STYL,SUP-2313941,CDM,C1889,HCPCS,0278,RC,,,,both,,,250.54,162.85,,,,,,,,,,,,,
DRILL SURG 1.8MM FLEX DISP FOR Q-FIX ALL-SUTURE ANCHR,SUP-2341146,CDM,2720000010,LOCAL,0272,RC,,,,both,,,566.83,368.44,,,,,,,,,,,,,
INSULIN LISPRO PROT & LISPRO (75-25) 100 UNIT/ML SC SUSP,RX-70693,CDM,J1815,HCPCS,0637,RC,00002-7511-01,NDC,,both,10,ML,68.40,44.46,,,,,,,,,,,,,
INSTRUMENT KIT ORTHOPEDIC KNEE NAVITRACK,SUP-2422962,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
INSTRUMENT KIT PLN PT SPEC MIDFACE RECON SD900056,SUP-2860262,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8712.87,5663.37,,,,,,,,,,,,,
CATHETER CARD ABLATION EZ STEER THERMOCOOL L 115 CM F-J BLK,SUP-2248508,CDM,C1732,HCPCS,0272,RC,,,,both,,,4411.70,2867.60,,,,,,,,,,,,,
"HC So Cytomegalovirus,Igm Antibody",PX-3028664566,CDM,86645,CPT,0302,RC,,,,both,,,179.00,116.35,,,,,,,,,,,,,
ALLOGRAFT BNE PASTE 8 CC DEMINERALIZED BNE MTRX + CANC,SUP-2717767,CDM,C1713,HCPCS,0278,RC,,,,both,,,4979.44,3236.64,,,,,,,,,,,,,
PLATE BNE 0MM SPCR STD TI REARFOOT LAT CLMN LENGTHENING PIA,SUP-2399632,CDM,C1713,HCPCS,0278,RC,,,,both,,,3086.62,2006.30,,,,,,,,,,,,,
SCREW BNE 35MM LOK SCR SURFIT TOT WRST FUS SYS,SUP-2243055,CDM,C1713,HCPCS,0278,RC,,,,both,,,412.78,268.31,,,,,,,,,,,,,
SCREW BNE AD PED L32MM DIA2MM TI ALLY DGT FUS CANC PARTIALLY,SUP-2243897,CDM,C1713,HCPCS,0278,RC,,,,both,,,1214.43,789.38,,,,,,,,,,,,,
DIVALPROEX SODIUM ER 250 MG PO TB24,RX-34418,CDM,6370000000,HCPCS,0637,RC,65862-0594-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PIN FIX L14IN DIA0.094IN SMOOTH W/ EYELET BEATH FOR ANT,SUP-2249397,CDM,2720000010,LOCAL,0272,RC,,,,both,,,700.22,455.14,,,,,,,,,,,,,
HEAD FEM DIA36MM +9MM OFFSET HIP CO CHROM TYP 12/14 TAPR,SUP-2405363,CDM,C1776,CPT,0278,RC,,,,both,,,3315.84,2155.30,,,,,,,,,,,,,
KIT INTRODUCER GASTROSTOMY FEEDING TUBE 16FR,SUP-2124619,CDM,C1894,HCPCS,0272,RC,,,,both,,,766.19,498.02,,,,,,,,,,,,,
FIBER LASER RFID 200 MH REUSE,SUP-2474911,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3842.23,2497.45,,,,,,,,,,,,,
K WIRE FIX L150MM DIA1.25MM S STL TRCR PNT,SUP-2186859,CDM,C1713,HCPCS,0278,RC,,,,both,,,24.55,15.96,,,,,,,,,,,,,
SET INTRO SHTH 6FR L2IN PERC POLYUR W/ INTEGR HAEMOSTASIS,SUP-2383421,CDM,C1894,HCPCS,0272,RC,,,,both,,,54.73,35.57,,,,,,,,,,,,,
EXTENSION STEM 12X135 MM KNEE REV PERSONA,SUP-2435463,CDM,C1776,CPT,0278,RC,,,,both,,,4333.20,2816.58,,,,,,,,,,,,,
CANNULA VEN SHT 25 FR UNCOATED HLS,SUP-2663487,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1255.31,815.95,,,,,,,,,,,,,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,0258,RC,00264-7510-00,NDC,,both,1000,ML,34.00,22.10,,,,,,,,,,,,,
IMMOBILIZER ORTH OPN PAT MED 19 IN 16-18 IN CANVS BLU,SUP-2194399,CDM,L1830,CPT,0272,RC,,,,both,,,50.24,32.66,,,,,,,,,,,,,
BRACE ORTHOPEDIC FIG 8 SHLDR,SUP-2417064,CDM,L3660,HCPCS,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
KIT JEJUSTMY TB 18FR BLLN 5ML STOMA L45CM SIL SECURELOK R,SUP-2124608,CDM,2720000010,LOCAL,0272,RC,,,,both,,,535.24,347.91,,,,,,,,,,,,,
GRAFT BNE 1MM 4MM RANG 15CC CHIP CRUSH FRZN CANC ALLGRFT,SUP-2264732,CDM,C1713,HCPCS,0278,RC,,,,both,,,838.54,545.05,,,,,,,,,,,,,
EXTENSION POST 10+ MM TI HUMELOCK II,SUP-2741763,CDM,2720000010,LOCAL,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
TUBE SUCTION T FUKUSHIMA 10 FRX4 IN 7 IN TEARDROP TAPR MALL,SUP-2496259,CDM,2720000010,LOCAL,0272,RC,,,,both,,,358.87,233.27,,,,,,,,,,,,,
ALLOGRAFT DRML EXTRA THICK 20X16 CM READY USE TSSUE MTRX ALL,SUP-2474052,CDM,Q4116,HCPCS,0636,RC,,,,both,,,37406.82,24314.43,,,,,,,,,,,,,
COIL VASC MREYE EMBOLUS L 5 CM 5 MM 0.035 IN SUPERALLOY,SUP-2167555,CDM,C1889,HCPCS,0278,RC,,,,both,,,109.90,71.43,,,,,,,,,,,,,
SCREW BNE CONN CANN FOR STD INSRTN HNDL NS,SUP-2863434,CDM,C1713,HCPCS,0278,RC,,,,both,,,1528.83,993.74,,,,,,,,,,,,,
CATHETER ENDO DIA15MM MICROVASIVE RAP EXCHG 3 LUMN RETRV BAL,SUP-2140119,CDM,2720000010,LOCAL,0272,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
PLATE BNE W10XL50MM THK1.2MM 90DEG 3X3 H BILAT S STL T SHP,SUP-2185863,CDM,C1713,HCPCS,0278,RC,,,,both,,,980.56,637.36,,,,,,,,,,,,,
PLATE 4.5MM TI LCP TM STRAIGHT RECON 8 HOLES 151MM,SUP-2549508,CDM,C1713,HCPCS,0278,RC,,,,both,,,1678.30,1090.89,,,,,,,,,,,,,
BLADE SURG 26 MM LIF-PTP,SUP-2736616,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
RELOAD STPLR 20 CMX5 MM JUSTRIGHT,SUP-2427768,CDM,C1713,HCPCS,0278,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
OXYGENATOR PERF 0.5-5LPM 4000ML HLLW FBR HARDSHELL RESVR,SUP-2384843,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
CANNULA ORTH L 110 MM DIA11 GA ACCESS/DELIVERY OPN TIP,SUP-2893108,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
STEM FEM VERSYS ADVOCATE CEMENTED STEM 14X135 STANDARD,SUP-2504398,CDM,C1776,CPT,0278,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
COMPONENT TOT SHLDR CAPPED STD ANAT,SUP-2267727,CDM,C1776,CPT,0278,RC,,,,both,,,14130.00,9184.50,,,,,,,,,,,,,
CANNULA IRRIGATION 7X85 MM HEX-FLEX,SUP-2167092,CDM,2720000010,LOCAL,0272,RC,,,,both,,,84.78,55.11,,,,,,,,,,,,,
PIN FIX L61MM DIA10MM PROV SH THRD TC-100,SUP-2343744,CDM,C1713,HCPCS,0278,RC,,,,both,,,752.31,489.00,,,,,,,,,,,,,
PLATE BNE H0.6MM 10X10 H UP FACE G TI 3D LEIBINGER UNIV 2,SUP-2366271,CDM,C1713,HCPCS,0278,RC,,,,both,,,3885.03,2525.27,,,,,,,,,,,,,
MICROCATHETER DIAG 2.8FR L130CM 900PSI HYDRPHLC HEMSTAT VLV,SUP-2385149,CDM,C1887,HCPCS,0272,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
REAMER SURG DIA 3.2 MM STRL DISP DYNAFORCE,SUP-2893421,CDM,2720000010,LOCAL,0272,RC,,,,both,,,775.58,504.13,,,,,,,,,,,,,
IMPLANT THYROPLASTY VOCAL CRD 12 M STRL MONTGOMERY,SUP-2141839,CDM,L8509,HCPCS,0274,RC,,,,both,,,2176.02,1414.41,,,,,,,,,,,,,
COLLAR EXTRIC AD REG HI DENS POLYETH PD SET XTW,SUP-2194470,CDM,L0172,HCPCS,0272,RC,,,,both,,,106.76,69.39,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 40 MM DIA 6 MM DEL SHTH 2.1ML,SUP-2936808,CDM,C1713,HCPCS,0278,RC,,,,both,,,7106.39,4619.15,,,,,,,,,,,,,
GRAFT DERMAL PLIABLE PRE THN XL 26X23 CMX0.7-1.4 MM FLEXHD,SUP-2430131,CDM,Q4128,HCPCS,0636,RC,,,,both,,,42564.02,27666.61,,,,,,,,,,,,,
IMPLANT TOE JT 2.7 MM METATRSL LESSER SHORTNG SLOT STRL,SUP-2898968,CDM,C1776,CPT,0278,RC,,,,both,,,1874.58,1218.48,,,,,,,,,,,,,
ELECTRODE 3MM THERM VAPOUR FOR THERM MOD SUCT SL 2,SUP-2256726,CDM,C1894,HCPCS,0272,RC,,,,both,,,54.48,35.41,,,,,,,,,,,,,
CURETTE SURG SIMS 6 10.25 IN UTER SHRP 1 PC CONSTRUCTION,SUP-2484829,CDM,C1713,HCPCS,0278,RC,,,,both,,,102.55,66.66,,,,,,,,,,,,,
PREDNISONE 10 MG PO TABS,RX-6494,CDM,J7512,HCPCS,0637,RC,00054-0017-20,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PATCH VASC HEMAPATCH L 140 X W 20 MM THK 0.65 MM POLYESTER,SUP-2914839,CDM,C1768,CPT,0278,RC,,,,both,,,538.10,349.76,,,,,,,,,,,,,
BASKET SPEC RETRV 3 FRX120X11 MM WOVEN NET SUR-CATCH,SUP-2312751,CDM,2720000010,LOCAL,0272,RC,,,,both,,,514.33,334.31,,,,,,,,,,,,,
GRAFT HUM TISS W4XL4CM THN AMNIO PLCNTAL MEM PRO3 PLCNTA,SUP-2320321,CDM,C1713,HCPCS,0278,RC,,,,both,,,5000.45,3250.29,,,,,,,,,,,,,
BIT DRILL TWIST 2 MM FOR DISTAL RADIUS SYSTEM STERILE LATEXF,SUP-2836739,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1955.40,1271.01,,,,,,,,,,,,,
PLATE BNE L 43.18 X W 5.08 MM THK 1 MM 7 H GRD III TI STR NS,SUP-2937039,CDM,C1713,HCPCS,0278,RC,,,,both,,,948.28,616.38,,,,,,,,,,,,,
WIRE GUIDE.BALL END 3FR PKG 10,SUP-2574027,CDM,C1769,HCPCS,0272,RC,,,,both,,,241.84,157.20,,,,,,,,,,,,,
CATHETER EP H 2-7-1 MM 7 FRX110 CM INQUIRY,SUP-2357628,CDM,C1730,HCPCS,0272,RC,,,,both,,,4239.00,2755.35,,,,,,,,,,,,,
RING 5/8 180MM FOR TRUELOK FIX SYS,SUP-2316185,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2056.39,1336.65,,,,,,,,,,,,,
COLLAR CERV MED DENS X LG 24X4.5 IN FRM FIT COTTON PROCARE,SUP-2195746,CDM,L0120,HCPCS,0274,RC,,,,both,,,9.86,6.41,,,,,,,,,,,,,
CATHETER EP 7FR 2-10-2MM SPC DUODECAPOLAR BIDIR SUP L CRV,SUP-2141250,CDM,C1731,HCPCS,0278,RC,,,,both,,,3925.00,2551.25,,,,,,,,,,,,,
HC Treat Radius Fx,PX-4502465000,CDM,24650,CPT,0450,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
BUR SURG 2 MM ROT,SUP-2140973,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2810.30,1826.69,,,,,,,,,,,,,
REAMER CRANTOM DISPOSABLE HI LN XS,SUP-2108780,CDM,C1713,HCPCS,0278,RC,,,,both,,,351.68,228.59,,,,,,,,,,,,,
PLATE BNE L 170 X W 11.4 MM THK 3.4 MM SCREW DIA 3.5 MM 13 H 72463313,SUP-2932750,CDM,C1713,HCPCS,0278,RC,,,,both,,,5651.53,3673.49,,,,,,,,,,,,,
SCREW BONE SUBTROCHANTERIC SET ZCKL II,SUP-2364779,CDM,C1713,HCPCS,0278,RC,,,,both,,,736.96,479.02,,,,,,,,,,,,,
DEVICE WND CLSR V-LOC 3-0 CV-23 90,SUP-2174853,CDM,C1760,HCPCS,0278,RC,,,,both,,,70.78,46.01,,,,,,,,,,,,,
DEVICE ENDOSKELETAL SYS AK HIP ALIGNABLE SYS,SUP-2388220,CDM,L5920,HCPCS,0274,RC,,,,both,,,1394.63,906.51,,,,,,,,,,,,,
GRAFT BNE SUB 30CC 17 10MM CANC CRUSH CHIP READIGRFT,SUP-2264821,CDM,C1713,HCPCS,0278,RC,,,,both,,,1064.27,691.78,,,,,,,,,,,,,
PROBE LSR ANG ILLUMINATING STP OPTIMAL BRIGHTNESS 20DEG,SUP-2247217,CDM,2720000010,LOCAL,0272,RC,,,,both,,,862.46,560.60,,,,,,,,,,,,,
GRAFT BNE H100MM ANT POST DIA23 27MM FEM SHFT FRZ DRY TEXT,SUP-2264865,CDM,C1713,HCPCS,0278,RC,,,,both,,,4534.41,2947.37,,,,,,,,,,,,,
LEAD DEFIB 7FR L52/58/65CM SIL SGL COIL TRUE BPLR ACT,SUP-2357378,CDM,C1777,HCPCS,0275,RC,,,,both,,,17270.00,11225.50,,,,,,,,,,,,,
DEXTROSE 10% IV BOLUS (PEDS),RX-4085020,CDM,2580000003,HCPCS,0258,RC,00338-0023-02,NDC,,both,250,ML,53.20,34.58,,,,,,,,,,,,,
HC Fibrin Dgradj Products D-Dimer Quantitative,PX-3058537900,CDM,85379,CPT,0305,RC,,,,both,,,340.00,221.00,,,,,,,,,,,,,
COLLAR CERV MED DENS X LG 24X4.5 IN FRM FIT COTTON PROCARE,SUP-2195746,CDM,L0120,HCPCS,0272,RC,,,,both,,,9.86,6.41,,,,,,,,,,,,,
COMPONENT FEM 7 LT KNEE OXINIUM PRI CEM BICOMPARTMENTAL,SUP-2346428,CDM,C1776,CPT,0278,RC,,,,both,,,13470.60,8755.89,,,,,,,,,,,,,
PEDIATRIC LCP CONDYLAR PLATE 3.5MM/90/5 HOLES-STERILE,SUP-2546041,CDM,C1713,HCPCS,0278,RC,,,,both,,,2742.38,1782.55,,,,,,,,,,,,,
ORTHOSIS ANK FT SM SZ M 6-7.5 WOM 7.5-9 LT CLOSE HEEL DLX,SUP-2195193,CDM,L1930,HCPCS,0274,RC,,,,both,,,104.72,68.07,,,,,,,,,,,,,
GRAFT VASC FLIXENE L 10 CM DIA 7 MM EPTFE STR STD WALL REINF,SUP-2669709,CDM,C1768,CPT,0278,RC,,,,both,,,1199.48,779.66,,,,,,,,,,,,,
COIL EMB L15CM OD4MM 0.018IN HYDRGEL PERIPH DETACH 18 SYS,SUP-2385412,CDM,C1889,HCPCS,0278,RC,,,,both,,,2857.40,1857.31,,,,,,,,,,,,,
BLADE SCRWDRVR 2MM2.3MM DIA STNLSS STEEL CNTRE DRIVE,SUP-2694256,CDM,2720000010,LOCAL,0272,RC,,,,both,,,340.38,221.25,,,,,,,,,,,,,
PLATE SPNL W10XL30.5MM 4 H LAT FULL PROF FOR MOD FIX SYS,SUP-2137112,CDM,C1713,HCPCS,0278,RC,,,,both,,,5259.50,3418.67,,,,,,,,,,,,,
SPACER SPNL 0 DEG 21X9X11 MM POST LUMBAR INTBDY VALEO II,SUP-2577867,CDM,C1889,HCPCS,0278,RC,,,,both,,,6672.50,4337.12,,,,,,,,,,,,,
SET SHTH DESTINO L 87 CM L 67 CM DIA12 FR CRV BEND 22 MM,SUP-2616186,CDM,C1766,CPT,0272,RC,,,,both,,,2402.10,1561.36,,,,,,,,,,,,,
SHELL HUM DIA44MM SHLDR CO CHROM BPLR ABS,SUP-2404520,CDM,C1776,CPT,0278,RC,,,,both,,,5878.08,3820.75,,,,,,,,,,,,,
FLUCONAZOLE (DIFLUCAN) IVPB,RX-4081084,CDM,J1450,HCPCS,0636,RC,25021-0184-82,NDC,,both,50,ML,54.10,35.16,,,,,,,,,,,,,
SCREW BNE L26MM DIA5MM S STL ST LOK FULL THRD T25 STARDRV,SUP-2184260,CDM,C1713,HCPCS,0278,RC,,,,both,,,392.19,254.92,,,,,,,,,,,,,
RASP SURG PWR RECIP 14.0X7MM L TEAR XCUT,SUP-2363297,CDM,2720000010,LOCAL,0272,RC,,,,both,,,329.57,214.22,,,,,,,,,,,,,
SCREW BNE 1.5X3.5 MM DRILL-FREE STRL LEVEL 1 NEURO ONEDRIVE,SUP-2495298,CDM,C1713,HCPCS,0278,RC,,,,both,,,223.35,145.18,,,,,,,,,,,,,
EXPLORATION SET STRANGE 7.5 FRX40 CM BILE DUCT STONE,SUP-2737154,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1679.90,1091.93,,,,,,,,,,,,,
MESH HERN 50X20 CMX1.5 MM HYDRATED PORCINE CLLGN PERMACOL,SUP-2174704,CDM,C1781,HCPCS,0278,RC,,,,both,,,75662.38,49180.55,,,,,,,,,,,,,
DRILL TWST RM 5/16 IN LNG,SUP-2436179,CDM,2720000010,LOCAL,0272,RC,,,,both,,,819.54,532.70,,,,,,,,,,,,,
BLADE SHAVER RESECT 3.5X130 MM SMOOTH DISP,SUP-2661215,CDM,2720000010,LOCAL,0272,RC,,,,both,,,357.30,232.24,,,,,,,,,,,,,
LISINOPRIL 5 MG PO TABS,RX-10451,CDM,6370000000,HCPCS,0637,RC,00904-6797-61,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
HEAD CASS 12MM DISP FOR VBR EXP ADDPLUS,SUP-2390800,CDM,2720000010,LOCAL,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
HANDPIECE HYDROSURGERY TIP L14MM 45DEG EXACT DISP FOR MAX,SUP-2351651,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1909.12,1240.93,,,,,,,,,,,,,
BUR SURG OD3MM WHT SPRL ROUTER CUT SIGN,SUP-2367529,CDM,C1713,HCPCS,0278,RC,,,,both,,,376.45,244.69,,,,,,,,,,,,,
KNIFE ENDOSCP 0.7 MMX195 CM 2 MM FLAT ERCP LF DISP,SUP-2497990,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1117.37,726.29,,,,,,,,,,,,,
SET CENTESIS 1 STP CATH L 10 CM DIA 4 FR INTRO NDL 20 GA NO,SUP-2484924,CDM,C1729,HCPCS,0272,RC,,,,both,,,49.64,32.27,,,,,,,,,,,,,
BUSHING FEM UNIV KNEE PLOY MOD CEM STEM ROT HNG REV,SUP-2376368,CDM,C1776,CPT,0278,RC,,,,both,,,719.22,467.49,,,,,,,,,,,,,
IMPLANT MAXILLOFACIAL 79X32X10X4X10X5MM RT ES ANG,SUP-2328481,CDM,L8610,HCPCS,0278,RC,,,,both,,,989.10,642.91,,,,,,,,,,,,,
NAIL IM L285MM DIA13MM UNIV LT GRN PROX TIB TI BEND CANN,SUP-2180442,CDM,C1713,HCPCS,0278,RC,,,,both,,,4576.36,2974.63,,,,,,,,,,,,,
MESH HERN W10XL15CM VENTRAL OVL COMPOSIX E/X,SUP-2125805,CDM,C1781,HCPCS,0278,RC,,,,both,,,992.87,645.37,,,,,,,,,,,,,
KIT INTRO VSI L 10CM 4FR NIT MANDREL TUNGSTEN TIP SIL ANGLED,SUP-2763490,CDM,C1892,HCPCS,0272,RC,,,,both,,,73.79,47.96,,,,,,,,,,,,,
GRAFT DISC BIOFIBER BIOLOGIC SCAFFOLD BIOFIBER 8MM,SUP-2388568,CDM,C1781,HCPCS,0278,RC,,,,both,,,353.25,229.61,,,,,,,,,,,,,
ALLOGRAFT BNE CRUSH 1-4 MM 90 CC FD IRRADIATED CANC,SUP-2866922,CDM,C1762,CPT,0278,RC,,,,both,,,2637.60,1714.44,,,,,,,,,,,,,
PLATE BONE 6 H STRL MANUBRIUM STRNL TI STAR SHP LCK FOR 3MM,SUP-2192438,CDM,C1713,HCPCS,0278,RC,,,,both,,,3182.70,2068.75,,,,,,,,,,,,,
PROBE ELECTROSURG PERCUTANEOUS COOLED RF COOLIEF,SUP-2736734,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
ANCHOR SUTURE STRL TILINK-P,SUP-2937212,CDM,C1713,HCPCS,0278,RC,,,,both,,,9812.50,6378.12,,,,,,,,,,,,,
SPHERE GLEN DIA36MM CNTR CO CHROM FOR 29MM GLEN BASEPLT,SUP-2388677,CDM,C1776,CPT,0278,RC,,,,both,,,9344.64,6074.02,,,,,,,,,,,,,
DRILL SURG CANN STD 3.7 MM AO QR NS LTX,SUP-2856021,CDM,2720000010,LOCAL,0272,RC,,,,both,,,624.86,406.16,,,,,,,,,,,,,
VALVE AORT ORIFICE DIA21.4MM TISS ANNULUS DIA23MM 85DEG,SUP-2355104,CDM,C1889,HCPCS,0278,RC,,,,both,,,13062.40,8490.56,,,,,,,,,,,,,
NKII R/C FEMUR NP REV ADAPTER SPCR RT SIZE 0 LAT,SUP-2509751,CDM,C1776,CPT,0278,RC,,,,both,,,3265.60,2122.64,,,,,,,,,,,,,
KIT SPRY COAX 2 TIP PLT CONC SYS,SUP-2402582,CDM,C1713,HCPCS,0278,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
SCREW BNE L70MM DIA5.5MM S STL CORT PERIARTC ST CANN LOK,SUP-2410841,CDM,C1713,HCPCS,0278,RC,,,,both,,,538.20,349.83,,,,,,,,,,,,,
GUIDEWIRE VASC THRUWAY L 130 CM DIA 0.014 IN SS SIL STR LNG,SUP-2148329,CDM,C1769,HCPCS,0272,RC,,,,both,,,301.44,195.94,,,,,,,,,,,,,
BUR SURG L 95 MM DIA2.35 MM HD DIA 7 MM BRL NS REUSE,SUP-2929114,CDM,2720000010,LOCAL,0272,RC,,,,both,,,353.60,229.84,,,,,,,,,,,,,
CATHETER DRAINAGE 8.5 FRX40 CM BILI STD LCK LOOP UTHANE,SUP-2168120,CDM,C1729,HCPCS,0272,RC,,,,both,,,305.33,198.46,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED FEM COMP TRAB MEL PERSONA FEMZIMCOMPNTS] ZIMMER BIOMET INC],SUP-2212568,CDM,C1776,CPT,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
GRAFT BONE SUBSTITUTEXL 20ML CORT RESRB MOLD MINERALIZED,SUP-2293950,CDM,C1713,HCPCS,0278,RC,,,,both,,,11260.83,7319.54,,,,,,,,,,,,,
NAIL IM 16 MMX40 CM FEM M/DN,SUP-2198168,CDM,C1713,HCPCS,0278,RC,,,,both,,,1906.61,1239.30,,,,,,,,,,,,,
WIRE BNE FIX DIA2.75 MM METATRSL SHORTNG PILOT H STRL,SUP-2898942,CDM,C1713,HCPCS,0278,RC,,,,both,,,320.28,208.18,,,,,,,,,,,,,
PESSARY UTER DSH 3 65 MM SFT PLIABLE W/O SUPP SIL WHT LF,SUP-2794444,CDM,A4562,HCPCS,0272,RC,,,,both,,,103.62,67.35,,,,,,,,,,,,,
INTRODUCER CEMENT COMPLT FRAC SHT 10 GA STABILIT POWERCURVE,SUP-2421785,CDM,2720000010,LOCAL,0272,RC,,,,both,,,9420.00,6123.00,,,,,,,,,,,,,
PLATE EXT FIX 120 DEG 240 MM FEM ARCH CARBON FIBER NS,SUP-2799528,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2763.07,1796.00,,,,,,,,,,,,,
CATHETER NEPHSTMY 26FR MALECOTS DRNGE 4 WNG DISP,SUP-2129076,CDM,C2627,HCPCS,0272,RC,,,,both,,,83.08,54.00,,,,,,,,,,,,,
SCREW BONE L44MM OD5.5MM PNK MIDFOOT HINDFOOT ANK CANN SH,SUP-2320939,CDM,C1713,HCPCS,0278,RC,,,,both,,,1747.41,1135.82,,,,,,,,,,,,,
CLORAZEPATE DIPOTASSIUM 3.75 MG PO TABS,RX-1759,CDM,6370000000,HCPCS,0637,RC,51672-4042-01,NDC,,both,1,UN,4.50,2.92,,,,,,,,,,,,,
SPACER SPNL H5MM INTBDY LORDTC A-CIFT SOLOFUSE,SUP-2353558,CDM,C1713,HCPCS,0278,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
SUPPORT ORTHOT KNEE CUST ADJACENT W/AIR CHMBR,SUP-2435615,CDM,L1847,HCPCS,0274,RC,,,,both,,,1628.40,1058.46,,,,,,,,,,,,,
PUMP PENILE PROS STANDALONE ELONGATED NK HI PROF DEFLATION,SUP-2930715,CDM,C1813,HCPCS,0278,RC,,,,both,,,30104.91,19568.19,,,,,,,,,,,,,
GUIDEWIRE VASC STR 3 CM 0.014 INX300 CM MOD RAIL SUPP CHOICE,SUP-2143060,CDM,C1769,HCPCS,0272,RC,,,,both,,,210.38,136.75,,,,,,,,,,,,,
DRILL CANN 4MM,SUP-2417468,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
HC Insert Ivc Filter,PX-3613719100,CDM,37191,CPT,0361,RC,,,,inpatient,,,16763.00,10895.95,,,,,,,,,,,,,
DRILL SURG PEGGED 1/8 IN KNEE TRIATHLON,SUP-2663081,CDM,2720000010,LOCAL,0272,RC,,,,both,,,683.89,444.53,,,,,,,,,,,,,
FIBER LASER 550 MH 0.58 MM SIDE FIRING HOLM SLM LN EZ DISP,SUP-2141789,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3811.71,2477.61,,,,,,,,,,,,,
GRAFT DURA ABSRB CLLGN BASE ST 2IN 2IN DURAMATRIX,SUP-2165120,CDM,C1763,HCPCS,0278,RC,,,,both,,,1643.26,1068.12,,,,,,,,,,,,,
TUBE TRACH SZ 14 L118MM DIA14X11MM SIL CLR N ADH THOR 5200,SUP-2138751,CDM,C1713,HCPCS,0278,RC,,,,both,,,574.62,373.50,,,,,,,,,,,,,
DEVICE FIX QUAD ADJ STRL ULTRABUTTON LTX,SUP-2880213,CDM,C1713,HCPCS,0278,RC,,,,both,,,1522.90,989.88,,,,,,,,,,,,,
PLATE BNE TEMPORAL SM 1.5X32X18X0.6 MM MESHED JANNETTA TI NS,SUP-2487803,CDM,C1713,HCPCS,0278,RC,,,,both,,,974.31,633.30,,,,,,,,,,,,,
PLATE BONE THK1.7MM 14 H STR RESRB STRL DELT SYS,SUP-2364973,CDM,C1713,HCPCS,0278,RC,,,,both,,,565.36,367.48,,,,,,,,,,,,,
CONNECTOR SPNL TI AX FOR 5.5-5.5MM ROD CDH LEG,SUP-2290020,CDM,C1713,HCPCS,0278,RC,,,,both,,,3331.54,2165.50,,,,,,,,,,,,,
HC So1 Trichomonas Vaginalis Amplif,PX-3068766167,CDM,87661,CPT,0306,RC,,,,both,,,44.00,28.60,,,,,,,,,,,,,
HANDLE DETACH FOR EMB COIL RUBY,SUP-2323706,CDM,2720000010,LOCAL,0272,RC,,,,both,,,747.32,485.76,,,,,,,,,,,,,
SCREW BNE L50MM DIA6.5MM THRD L32MM TAN CANN SELF DRL HDLSS,SUP-2177013,CDM,C1889,HCPCS,0278,RC,,,,both,,,954.87,620.67,,,,,,,,,,,,,
SCREW BNE LAG 80 MM SLD FIX STRL PHOENIX LTX DISP,SUP-2861385,CDM,C1713,HCPCS,0278,RC,,,,both,,,1804.68,1173.04,,,,,,,,,,,,,
SET LD INTRO EVOLUTION RL L 40.6 CM OD 21 FR ID 13 FR CTRL,SUP-2169471,CDM,C1773,HCPCS,0272,RC,,,,both,,,6908.00,4490.20,,,,,,,,,,,,,
CLAMP EXT FIX SZ 6-4 MM SWVL NS DISP MAV MINI,SUP-2932874,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2219.98,1442.99,,,,,,,,,,,,,
PLATE BONE W10XL75MM THK1.5MM 3X5 H NEUT BILAT S STL,SUP-2185889,CDM,C1713,HCPCS,0278,RC,,,,both,,,863.81,561.48,,,,,,,,,,,,,
IMPLANT BRST SIL GEL LO HT MOD + PROF ANAT MEMORYSHAPE,SUP-2748608,CDM,C1789,HCPCS,0278,RC,,,,both,,,4034.90,2622.68,,,,,,,,,,,,,
SET INT FIX SCREW DIA1.5 MM 4 H TI NEURO SQ PLATE 12 PK STRL,SUP-2935684,CDM,C1713,HCPCS,0278,RC,,,,both,,,18730.10,12174.56,,,,,,,,,,,,,
DIST CRANIAL15 LG SPDL50MM END DRVN,SUP-2694398,CDM,C1713,HCPCS,0278,RC,,,,both,,,19439.39,12635.60,,,,,,,,,,,,,
HEAD FEM ENDOPROSTHESIS 12-14 56 MM HIP,SUP-2203057,CDM,C1776,CPT,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
RETRACTOR SURG L 50/30 X W 15/20 MM CRDLS INTEGR MULTILED,SUP-2914857,CDM,2720000010,LOCAL,0272,RC,,,,both,,,855.65,556.17,,,,,,,,,,,,,
CATHETER CTRL VEN 6FR 2 LUMN POLYUR BASIC PROC TY POWERHOHN,SUP-2125478,CDM,C1751,HCPCS,0278,RC,,,,both,,,840.45,546.29,,,,,,,,,,,,,
EVOS 2.7/3.5MM EA-D HUM PL 25H L 294MM,SUP-2820165,CDM,C1713,HCPCS,0278,RC,,,,both,,,11299.92,7344.95,,,,,,,,,,,,,
BUR DENT 3X70 MM CARBIDE STRL PM2 80K,SUP-2134828,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1632.80,1061.32,,,,,,,,,,,,,
PLATE VOLAR DISTL RADL SMARTLOCK,SUP-2702960,CDM,C1713,HCPCS,0278,RC,,,,both,,,3112.05,2022.83,,,,,,,,,,,,,
KIT LD TRL 8 CNTRCT 50CM,SUP-2138793,CDM,C1778,HCPCS,0278,RC,,,,both,,,2088.10,1357.26,,,,,,,,,,,,,
PLATE BONE THK1.8MM 9 H STRNL TI Y SHP LCK,SUP-2262583,CDM,C1713,HCPCS,0278,RC,,,,both,,,1559.36,1013.58,,,,,,,,,,,,,
SHEATH INTRO ACCEL L 20 CM DIA 6 FR L 60 CM DIA 21 GA SS,SUP-2659243,CDM,C1894,HCPCS,0272,RC,,,,both,,,226.52,147.24,,,,,,,,,,,,,
EPINEPHRINE (ANAPHYLAXIS) 30 MG/30ML IJ SOLN,RX-140394,CDM,J0169,HCPCS,0636,RC,42023-0168-01,NDC,,both,0.1,ML,54.10,35.16,,,,,,,,,,,,,
COMPONENT ULN SM L3IN L EL TIV PLSM INTERCHANGEABLE CEM,SUP-2205934,CDM,C1776,CPT,0278,RC,,,,both,,,15386.00,10000.90,,,,,,,,,,,,,
GRAFT HUM TISS 2X4CM PLCNTA MEMBRN BIODFENCE G3,SUP-2243998,CDM,Q4140,HCPCS,0636,RC,,,,both,,,6934.69,4507.55,,,,,,,,,,,,,
BIT DRILL 2.6MM AO SHANK,SUP-2858751,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1083.30,704.14,,,,,,,,,,,,,
KIT SUTURE STRP WND CLOSURE DEV ZIP PRELOC 2,SUP-2904097,CDM,2720000010,LOCAL,0272,RC,,,,both,,,859.01,558.36,,,,,,,,,,,,,
COMPONENT FEM L3CM RT KNEE RESURF REDUC SZ OSS,SUP-2406467,CDM,C1776,CPT,0278,RC,,,,both,,,17351.64,11278.57,,,,,,,,,,,,,
PLATE BONEXL THK2MM 12 H MAND TI STR FOR 2MM PLUSDRIVE SCR,SUP-2191271,CDM,C1713,HCPCS,0278,RC,,,,both,,,3521.20,2288.78,,,,,,,,,,,,,
UNIT ELECSURG 10 CM RIGID ANT 1,SUP-2105410,CDM,C1713,HCPCS,0278,RC,,,,both,,,13345.00,8674.25,,,,,,,,,,,,,
TERBUTALINE SULFATE 1 MG/ML IJ SOLN,RX-11507,CDM,J3105,HCPCS,0636,RC,63323-0665-01,NDC,,both,0.25,ML,54.10,35.16,,,,,,,,,,,,,
MATRIX PARTICULATE AMNIOBAND 80MG,SUP-2719486,CDM,Q4168,HCPCS,0636,RC,,,,both,,,6085.32,3955.46,,,,,,,,,,,,,
GRAFT HUM TISS HUM SHFT STRUCTURAL FRZ DRY,SUP-2165582,CDM,C1713,HCPCS,0278,RC,,,,both,,,1946.80,1265.42,,,,,,,,,,,,,
BIT DRL 3 MM LF,SUP-2608415,CDM,2720000010,LOCAL,0272,RC,,,,both,,,320.91,208.59,,,,,,,,,,,,,
SCREW BNE 3X50 MM MICA MIS,SUP-2417204,CDM,C1713,HCPCS,0278,RC,,,,both,,,1997.04,1298.08,,,,,,,,,,,,,
DEVICE ARTOTMY CLOSURE STARCLOSE DIA 8 FR FEM ART INTVASC,SUP-2105645,CDM,C1760,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
COMPONENT KNEE CEM STD FEM TIB PATELLAR OPT PROLONG LPS-FLEX,SUP-2212329,CDM,C1776,CPT,0278,RC,,,,both,,,9891.00,6429.15,,,,,,,,,,,,,
PLATE BNE 6 H NONSTERILE BILAT MIDFOOT TALUS S STL MAL LO,SUP-2177140,CDM,C1713,HCPCS,0278,RC,,,,both,,,2253.99,1465.09,,,,,,,,,,,,,
CATHETER HD KT 0.035 IN 12 FRX25 CM 3L INTRO NDL SHRP SAFETY,SUP-2762983,CDM,C1752,HCPCS,0278,RC,,,,both,,,331.58,215.53,,,,,,,,,,,,,
HC Endo Level 3 Addl 15 Min,PX-3600007513,CDM,3600007513,LOCAL,0360,RC,,,,both,,,2331.00,1515.15,,,,,,,,,,,,,
SCREW BNE L 160 MM DIA 7.5 MM THRD L 16 MM TI CANN SHRT THRD,SUP-2905747,CDM,C1713,HCPCS,0278,RC,,,,both,,,1341.94,872.26,,,,,,,,,,,,,
HEAD FEM CO CHROM CEM POLY CUP,SUP-2347940,CDM,C1776,CPT,0278,RC,,,,both,,,13816.00,8980.40,,,,,,,,,,,,,
IMPLANT HUM TISS L 230-330 MM DIA 4-8.5 MM TIBIALIS TEND,SUP-2881937,CDM,C1762,CPT,0278,RC,,,,both,,,4014.40,2609.36,,,,,,,,,,,,,
STENT URET L22-28CM DIA4.5FR HYDRPHLC QUADRA COIL TECOFLEX,SUP-2313748,CDM,C2617,HCPCS,0278,RC,,,,both,,,252.27,163.98,,,,,,,,,,,,,
SCREW SPNL 2PK ST 3.5X15 MM MINIP DIVERGENCE,SUP-2632042,CDM,C1713,HCPCS,0278,RC,,,,both,,,828.96,538.82,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY LASSO L 115 CM DIA 7 FR D CRV,SUP-2880105,CDM,C1732,HCPCS,0272,RC,,,,both,,,4282.96,2783.92,,,,,,,,,,,,,
REAMER MDI RMR TAPR FOR SZ 3 AND 4,SUP-2400145,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1359.62,883.75,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9 % IV SOLN (ADD-VANTAGE),RX-4081543,CDM,J7050,HCPCS,0250,RC,00409-7101-02,NDC,,both,250,ML,48.90,31.78,,,,,,,,,,,,,
SCREW SPNL L45MM OD6MM CORT FIX TI POLYAX FEN EXT TAB MIS,SUP-2255030,CDM,C1713,HCPCS,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
HC Counseling Visit for Ldct-Pbb|PBB CHARGE,PX-5100029600,CDM,G0296,CPT,0510,RC,,,PBB,outpatient,,,254.00,165.10,,,,,,,,,,,,,
OSS RS 9CM PROX TIB MOD COCR,SUP-2510703,CDM,C1776,CPT,0278,RC,,,,both,,,17945.10,11664.31,,,,,,,,,,,,,
CATHETER ARTERIAL 20 GAX12 CM WITH NEEDLE LOCKING DISPOSAL C,SUP-2838741,CDM,C1751,HCPCS,0278,RC,,,,both,,,197.19,128.17,,,,,,,,,,,,,
HANDLE HEAT THRM W AA BTTRY FOR PIST SMRT,SUP-2313821,CDM,C1713,HCPCS,0278,RC,,,,both,,,333.03,216.47,,,,,,,,,,,,,
COLLAR CERV M FIRM DENS AD CNTOUR HK AND LOOP CLSR W COT CVR,SUP-2276592,CDM,L0120,HCPCS,0272,RC,,,,both,,,6.63,4.31,,,,,,,,,,,,,
OCTREOTIDE ACETATE 500 MCG/ML IJ SOLN,RX-91281,CDM,J2354,HCPCS,0636,RC,00641-6176-10,NDC,,both,0.2,ML,54.10,35.16,,,,,,,,,,,,,
BRACE THMB AD SM FOR 3.875-9.5IN IP TO WR CREASE LNG LT CMC,SUP-2324971,CDM,L3931,HCPCS,0272,RC,,,,both,,,62.58,40.68,,,,,,,,,,,,,
FILLER BNE VOID 0.5 CC CORTICAL BNE SODIUM HYALURONATE,SUP-2927232,CDM,C1713,HCPCS,0278,RC,,,,both,,,260.62,169.40,,,,,,,,,,,,,
BIT DRL DIA2.7MM FOR ANTR CERV PLT SYS,SUP-2108490,CDM,2720000010,LOCAL,0272,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
PLATE BNE THK0.6MM 12MM BAR 6 H 100DEG UNIV,SUP-2366310,CDM,C1713,HCPCS,0278,RC,,,,both,,,683.67,444.39,,,,,,,,,,,,,
BIT DRILL ARTHSCP RETROCUTTER 10.5MM,SUP-2120854,CDM,2720000010,LOCAL,0272,RC,,,,both,,,876.06,569.44,,,,,,,,,,,,,
BRACE THMB AD SM FOR 3.875-9.5IN IP TO WR CREASE LNG LT CMC,SUP-2324971,CDM,L3931,HCPCS,0274,RC,,,,both,,,62.58,40.68,,,,,,,,,,,,,
HC Inj N Block Hypogas Plxs,PX-3616451700,CDM,64517,CPT,0361,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
PIN BONE FIX L3IN HDLSS W/O FLUT TRIATHLON,SUP-2364725,CDM,C1713,HCPCS,0278,RC,,,,both,,,1147.36,745.78,,,,,,,,,,,,,
SCREW BNE L16MM DIA3MM SHT THRD L4MM CANC TI CANN ST SELF,SUP-2181306,CDM,C1713,HCPCS,0278,RC,,,,both,,,879.36,571.58,,,,,,,,,,,,,
PLATE BONE 1 MM 20 HOLE ADAPTION TITANIUM MATRIXMANDIBLE,SUP-2837747,CDM,C1713,HCPCS,0278,RC,,,,both,,,2696.95,1753.02,,,,,,,,,,,,,
KIT CATH HEMODIALYSI RETRO CHRONIC STD 16FR DIA 32CM 27CML I,SUP-2613316,CDM,C1750,HCPCS,0278,RC,,,,both,,,1318.80,857.22,,,,,,,,,,,,,
JACKET ORTHOT CUST POST OPERATIVE BODY,SUP-2435594,CDM,L1310,HCPCS,0274,RC,,,,both,,,5082.28,3303.48,,,,,,,,,,,,,
GUIDEWIRE ORTH 2.3X200 MM SS,SUP-2646005,CDM,C1769,HCPCS,0272,RC,,,,both,,,85.16,55.35,,,,,,,,,,,,,
SCREW BNE LCK 5X30 MM SLD,SUP-2433777,CDM,C1713,HCPCS,0278,RC,,,,both,,,684.52,444.94,,,,,,,,,,,,,
INSERT SCIS SZ 5MM L36CM FOR HK SGL ACT JAW NOT CROSSING,SUP-2261301,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1604.60,1042.99,,,,,,,,,,,,,
GRASPER HYSTEROSCOPIC L 33 CM DIA 3 MM HND ACTUATED STRL,SUP-2913667,CDM,2720000010,LOCAL,0272,RC,,,,both,,,580.90,377.58,,,,,,,,,,,,,
SPLINT THMB M+ LT CARPOMETACARPAL JT RESTRICT ELAS SUPP,SUP-2324211,CDM,L3931,HCPCS,0274,RC,,,,both,,,64.24,41.76,,,,,,,,,,,,,
PANTOPRAZOLE SODIUM 40 MG PO PACK,RX-89791,CDM,6370000000,HCPCS,0637,RC,00008-0844-01,NDC,,both,1,UN,64.90,42.18,,,,,,,,,,,,,
ROD SPNL L75MM DIA4.75MM THORACOLUMBOSACRAL CO CHROM CDH,SUP-2284745,CDM,C1713,HCPCS,0278,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
PLATE BNE CONN 1 HOLE FOR CARBON FIBER RNG NS,SUP-2799519,CDM,C1713,HCPCS,0278,RC,,,,both,,,258.99,168.34,,,,,,,,,,,,,
CATHETER GUID HEARTRAIL III L 100 CM DIA 6 FR 700 PSI IL4.5,SUP-2384864,CDM,C1887,HCPCS,0272,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
COVER DOPP SHTH W/ 20ML US GEL STRL 3 1/2INX12IN,SUP-2308232,CDM,C1894,HCPCS,0272,RC,,,,both,,,656.26,426.57,,,,,,,,,,,,,
COIL NEUROVASCULAR AXIUM MICROFX L 20 CM SECONDARY DIA 7 MM,SUP-2430041,CDM,C1713,HCPCS,0278,RC,,,,both,,,5947.16,3865.65,,,,,,,,,,,,,
COUNTERSINK SURG AO SCREW QC FOR FIBULAR NAIL NS DISP,SUP-2909072,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1295.25,841.91,,,,,,,,,,,,,
HC MRI-Spine Cervical W & WO Cont,PX-6127215600,CDM,72156,CPT,0612,RC,,,,both,,,3486.00,2265.90,,,,,,,,,,,,,
CANNULA KYPHOPLASTY BVL W/ INTRO ULT AFFIRM,SUP-2232190,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1758.40,1142.96,,,,,,,,,,,,,
INTRODUCER SHTH 12FR L28CM ID4.1MM HYDRPHLC DRYSEAL,SUP-2395740,CDM,C1894,HCPCS,0272,RC,,,,both,,,885.48,575.56,,,,,,,,,,,,,
CATHETER ETER ABLAT M 7FR L115CM SPC 2 5 2MM SWP QPLR BI DIR STEER,SUP-2357031,CDM,C1733,HCPCS,0272,RC,,,,both,,,2647.02,1720.56,,,,,,,,,,,,,
DRILL 6.5MM CANNULATED,SUP-2811645,CDM,2720000010,LOCAL,0272,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
COMPONENT CRANIOFACIAL CUSTOMIZED SM PRIORITY + PEEK NS LTX,SUP-2862815,CDM,C1713,HCPCS,0278,RC,,,,both,,,44685.65,29045.67,,,,,,,,,,,,,
SHAFT HUM TRAD ALLGRFT FRZN,SUP-2294183,CDM,C1713,HCPCS,0278,RC,,,,both,,,4549.86,2957.41,,,,,,,,,,,,,
PLATE BONE SM STRL UTIL FOR 2.7MM SCR VLP,SUP-2349945,CDM,C1713,HCPCS,0278,RC,,,,both,,,5680.42,3692.27,,,,,,,,,,,,,
GUIDEWIRE ORTHOPEDIC BLNT TIP 9 IN STRL CANNFLX LTX,SUP-2879294,CDM,C1769,HCPCS,0272,RC,,,,both,,,187.93,122.15,,,,,,,,,,,,,
PLATE BNE LCK 3.5 MM 4 HOLE ATTCH VA LCK COMPR NS VA-LCP,SUP-2757676,CDM,C1713,HCPCS,0278,RC,,,,both,,,2021.63,1314.06,,,,,,,,,,,,,
SPLINT KNEE L20IN FOR 32IN THGH UNIV FOAM 3 PC DSGN TRIMMED,SUP-2196754,CDM,L1830,CPT,0274,RC,,,,both,,,39.19,25.47,,,,,,,,,,,,,
SCREW BNE CAPT 135 DEG SHT BRL 130 MM HIP ANGLED TI,SUP-2472228,CDM,C1713,HCPCS,0278,RC,,,,both,,,1466.38,953.15,,,,,,,,,,,,,
STEM FEM L150MM OD10.5MM TI POR IM STR CEM LNG BODY MOD,SUP-2405799,CDM,C1776,CPT,0278,RC,,,,both,,,4790.07,3113.55,,,,,,,,,,,,,
STENT BILI OTW 0.035 IN 6X30 MM 6 FRX135 CM LIFESTAR,SUP-2472542,CDM,C1876,HCPCS,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
STEM TIB DIA16MM BILAT ANK PLSM BASE CEM PROPHECY INBONE,SUP-2397063,CDM,C1776,CPT,0278,RC,,,,both,,,1456.96,947.02,,,,,,,,,,,,,
CROWN FORM DENT STRP U1 PRIMARY ANTR UPPER RT LAT PLAS,SUP-2322249,CDM,D6783,CPT,0278,RC,,,,both,,,16.92,11.00,,,,,,,,,,,,,
BIT DRILL CALIBRATED SHORT 3.5 MMX5.1 IN WITH QUICK CONNECT,SUP-2837019,CDM,2720000010,LOCAL,0272,RC,,,,both,,,615.25,399.91,,,,,,,,,,,,,
PLATE 3.5MM CURVED BROAD LCP 20 HOLE-STERILE,SUP-2546105,CDM,C1713,HCPCS,0278,RC,,,,both,,,3196.74,2077.88,,,,,,,,,,,,,
DRILL SH COUNTSINK COMB 3-4MM,SUP-2319462,CDM,2720000010,LOCAL,0272,RC,,,,both,,,841.52,546.99,,,,,,,,,,,,,
PURAPLYAM (Fenestrated 3.0x4.0) 12 sq. cm,SUP-2635404,CDM,Q4196,HCPCS,0636,RC,,,,both,,,4144.80,2694.12,,,,,,,,,,,,,
PLATE BNE W14XL118MM THK3.8MM 90DEG 5 H L TIB S STL L SHP,SUP-2185789,CDM,C1713,HCPCS,0278,RC,,,,both,,,4020.11,2613.07,,,,,,,,,,,,,
PIN FIX ANTR CERV THRD SMOOTH TEMP EAGLE + SWIFT +,SUP-2252862,CDM,C1713,HCPCS,0278,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
GRAFT BNE SUB M CANC FRZN MORSELIZED W/ VIABLE CELL TRINITY,SUP-2307240,CDM,C1713,HCPCS,0278,RC,,,,both,,,5658.28,3677.88,,,,,,,,,,,,,
GUIDEWIRE VASC L40CM DIA0018IN NDL 21GA L7CM Z S STL MAK,SUP-2302986,CDM,C1769,HCPCS,0272,RC,,,,both,,,61.54,40.00,,,,,,,,,,,,,
DEVICE TISS SEAL L45CM BPLR CRV TIP ENSEAL TRIO,SUP-2257601,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
ALLOGRAFT HUM TISS FRZN ASEP BONE-PATELLAR TENDON-BONE,SUP-2867144,CDM,C1762,CPT,0278,RC,,,,both,,,9187.64,5971.97,,,,,,,,,,,,,
STENT ESOPH EVOLUTION L 10 CM BODY DIA20 MM FLANGE DIA25 MM,SUP-2170565,CDM,C1874,HCPCS,0278,RC,,,,both,,,5460.46,3549.30,,,,,,,,,,,,,
HC So Glucose CSF,PX-3018294568,CDM,82945,CPT,0301,RC,,,,both,,,33.00,21.45,,,,,,,,,,,,,
DRILL SLEEVE DOUBLE 2.7/2.0MM F/KMEDIC,SUP-2466477,CDM,2720000010,LOCAL,0272,RC,,,,both,,,683.08,444.00,,,,,,,,,,,,,
CLAMP ABLAT JAW L53MM L CRV 2 ELECTRD BPLR,SUP-2124465,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8478.00,5510.70,,,,,,,,,,,,,
HC Ptt|NOT REASONABLE AND NECESSARY,PX-3058573000,CDM,85730,CPT,0305,RC,,,GZ,both,,,120.00,78.00,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.525,SUP-2860042,CDM,C1713,HCPCS,0278,RC,,,,both,,,43647.88,28371.12,,,,,,,,,,,,,
SHAFT FEM TRAD ALLGRFT 100 MM FRZN,SUP-2294168,CDM,C1713,HCPCS,0278,RC,,,,both,,,2474.32,1608.31,,,,,,,,,,,,,
HEAD HUM M DIA52MM ECC FOR TOT SHLDR ARTHROPLASTY GLOB,SUP-2250028,CDM,C1776,CPT,0278,RC,,,,both,,,4955.55,3221.11,,,,,,,,,,,,,
GRAFT BIO TISS 5X8CM 1MM 1:1 MESHED PROLAYER,SUP-2370455,CDM,C1763,HCPCS,0278,RC,,,,both,,,9831.97,6390.78,,,,,,,,,,,,,
SCREW STEM SIDE LCK MAK OSS,SUP-2449822,CDM,C1713,HCPCS,0278,RC,,,,both,,,805.41,523.52,,,,,,,,,,,,,
WIRE OLV SMOOTH 1.6MM COMP/DIST,SUP-2321640,CDM,C1769,HCPCS,0272,RC,,,,both,,,351.68,228.59,,,,,,,,,,,,,
INTRODUCER SHTH 9FR L13CM NDL 18GA GWIRE 0.035IN SYR VLV,SUP-2281846,CDM,C1892,HCPCS,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
PLATE BNE MESHED 126X126X1 MM LG GRID PLLA-PGA STRL,SUP-2458840,CDM,C1713,HCPCS,0278,RC,,,,both,,,10456.33,6796.61,,,,,,,,,,,,,
COUNTERSINK SURG DIA3/2.4MM CANN SCR,SUP-2390540,CDM,2720000010,LOCAL,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
DEVICE PESSARY SZ 6 83MM RNG W KNOB AND SUPP GEHRUNG,SUP-2417157,CDM,A4562,HCPCS,0274,RC,,,,both,,,112.66,73.23,,,,,,,,,,,,,
COIL NEUROVASCULAR AXIUM MICROFX L 40 CM SECONDARY DIA12 MM,SUP-2459512,CDM,C1889,HCPCS,0278,RC,,,,both,,,5918.90,3847.28,,,,,,,,,,,,,
FEE PROC LIMFLOW SYS,SUP-2902910,CDM,C1757,HCPCS,0272,RC,,,,both,,,78500.00,51025.00,,,,,,,,,,,,,
SCREW BONE L60MM DIA4.5MM CORT LCK FULL THRD RECON FOR,SUP-2318958,CDM,C1713,HCPCS,0278,RC,,,,both,,,859.10,558.41,,,,,,,,,,,,,
DABIGATRAN ETEXILATE MESYLATE 75 MG PO CAPS,RX-103560,CDM,6370000000,HCPCS,0637,RC,00597-0355-56,NDC,,both,1,UN,14.90,9.68,,,,,,,,,,,,,
K WIRE FIX L9IN DIA0.062IN DMND PNT RND END THRD,SUP-2342672,CDM,C1713,HCPCS,0278,RC,,,,both,,,347.22,225.69,,,,,,,,,,,,,
CATHETER INTRO 10.06FR UNIV OUTER SLITTABLE RT CRV CPS DIR,SUP-2356377,CDM,C1893,HCPCS,0272,RC,,,,both,,,554.84,360.65,,,,,,,,,,,,,
ROD IM FOREARM TARGETING BASE,SUP-2525750,CDM,C1713,HCPCS,0278,RC,,,,both,,,4496.48,2922.71,,,,,,,,,,,,,
PLATE BONE LCK L CRV LT 13 H TI PROX TIB PLATING SYS ALPS,SUP-2413718,CDM,C1713,HCPCS,0278,RC,,,,both,,,4163.64,2706.37,,,,,,,,,,,,,
KIT CATH AD L36CM DIA12FR ADMIN BASIC 2 LUMN STR STAGGERED,SUP-2283903,CDM,C1750,HCPCS,0278,RC,,,,both,,,518.73,337.17,,,,,,,,,,,,,
GUIDEWIRE VASC L 40 CM DIA 0.025 IN TIP CRV RAD 2 MM HVY DBL,SUP-2759995,CDM,C1769,HCPCS,0272,RC,,,,both,,,136.78,88.91,,,,,,,,,,,,,
DILATOR SURG STRL DISP,SUP-2536958,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2260.80,1469.52,,,,,,,,,,,,,
ROD EXTR DIA7 8MM STD CONIC FOR UNIV NAIL DEV,SUP-2368583,CDM,C1713,HCPCS,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
COIL DET AXIUM 4X10 HELIX,SUP-2490177,CDM,C1889,HCPCS,0278,RC,,,,both,,,3422.60,2224.69,,,,,,,,,,,,,
PATCH DURAL SUB 10X12.5CM ONLAY LYCOPLANT,SUP-2717537,CDM,C1763,HCPCS,0278,RC,,,,both,,,3113.69,2023.90,,,,,,,,,,,,,
SPLINT WR AD SM FOR 2.5-3IN RT MCP REG FIRM OUTER FAB HND,SUP-2324879,CDM,L3809,HCPCS,0272,RC,,,,both,,,51.75,33.64,,,,,,,,,,,,,
MARKER BRST BX 17GA L10CM NIT RNG SHP ULTRACOR TWIRL,SUP-2128631,CDM,A4648,CPT,0278,RC,,,,both,,,204.07,132.65,,,,,,,,,,,,,
ROD SPNL EXTN TENOR,SUP-2289259,CDM,C1713,HCPCS,0278,RC,,,,both,,,3300.14,2145.09,,,,,,,,,,,,,
DRILL SURG RESECT TOT ANK,SUP-2742330,CDM,2720000010,LOCAL,0272,RC,,,,both,,,584.04,379.63,,,,,,,,,,,,,
BRACE WALKING EMBEDDED SOLE X LG SHT ANK ROCKER BTM INLINE,SUP-2336134,CDM,L4361,HCPCS,0272,RC,,,,both,,,93.29,60.64,,,,,,,,,,,,,
CATHETER DRAINAGE VLV 5 FRX15 CM 20 GA ECHOGENIC NDL ACCEL,SUP-2659252,CDM,C1729,HCPCS,0272,RC,,,,both,,,68.33,44.41,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE 10 CC CORTICAL FIBER,SUP-2899230,CDM,C1713,HCPCS,0278,RC,,,,both,,,5569.58,3620.23,,,,,,,,,,,,,
SPLINT HND AD SM L5.75IN LT HEADLINER CVR FIVE STRP CLSR ADJ,SUP-2324297,CDM,L3807,HCPCS,0274,RC,,,,both,,,180.93,117.60,,,,,,,,,,,,,
CUFF TRNQT 8IN CIRC 1 PRT 1 BLDR PED NONSTERILE PNEUMAT,SUP-2208886,CDM,C1713,HCPCS,0278,RC,,,,both,,,404.75,263.09,,,,,,,,,,,,,
REPAIR KIT KNOTLESS AC IMPL STRL LTX,SUP-2859826,CDM,C1713,HCPCS,0278,RC,,,,both,,,4936.08,3208.45,,,,,,,,,,,,,
CLIP ANEUR BLDE L5MM 7.8MM OD3.5MM 5.8MM OPN 110GM CLS FORC,SUP-2108528,CDM,C1889,HCPCS,0278,RC,,,,both,,,1361.79,885.16,,,,,,,,,,,,,
COLLAR CERV L H3.25IN FOR 16-19IN PLASTAZOTE FOAM 2 PC L,SUP-2336003,CDM,L0140,HCPCS,0272,RC,,,,both,,,30.11,19.57,,,,,,,,,,,,,
SCREW BNE L36MM DIA3.5MM CORT S STL ST FULL THRD LOK T15,SUP-2184691,CDM,C1713,HCPCS,0278,RC,,,,both,,,68.08,44.25,,,,,,,,,,,,,
AMOXICILLIN-POT CLAVULANATE 200-28.5 MG/5ML PO SUSR,RX-33229,CDM,340b,HCPCS,0637,RC,16714-0292-01,NDC,,both,5,ML,3.90,2.53,,,,,,,,,,,,,
BLADE PUSH DISP ST,SUP-2370238,CDM,2720000010,LOCAL,0272,RC,,,,both,,,725.34,471.47,,,,,,,,,,,,,
SPLINT WRIST FA RIGHT 7,SUP-2136568,CDM,L3809,HCPCS,0274,RC,,,,both,,,37.40,24.31,,,,,,,,,,,,,
TUBE JEJUSTMY ENTAKE PUSH GW 9FR 35IN,SUP-2166297,CDM,C1713,HCPCS,0278,RC,,,,both,,,630.70,409.95,,,,,,,,,,,,,
MARKER IDENTIFIER BX SITE MAMMOSTAR 14 G BARBELL SHP,SUP-2195625,CDM,A4648,CPT,0278,RC,,,,both,,,232.36,151.03,,,,,,,,,,,,,
PLATE BNE MTP MED 0 DEG RT FUSION,SUP-2397256,CDM,C1713,HCPCS,0278,RC,,,,both,,,4016.06,2610.44,,,,,,,,,,,,,
HC US Scrotum & Contents,PX-4027687000,CDM,76870,CPT,0402,RC,,,,both,,,1745.00,1134.25,,,,,,,,,,,,,
CATHETER GUID BRANCHOR L 90 CM DIA 9 FR SHFT OD 3 MM COAT L,SUP-2879945,CDM,C2628,HCPCS,0272,RC,,,,both,,,5322.30,3459.49,,,,,,,,,,,,,
PIN FIX L150MM DIA4.5MM S STL SGL END SHRP TIP CTRL THRD,SUP-2186929,CDM,C1713,HCPCS,0278,RC,,,,both,,,301.13,195.73,,,,,,,,,,,,,
LITHOTRIPTER SURG FIBER SUREFLEX REUSE RLLF550] LASER VENTURES],SUP-2263898,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
PLATE BNE VA 90- DEG 2.4X41 MM DSTL RADIAL DORS 3X2 HOLE,SUP-2190204,CDM,C1713,HCPCS,0278,RC,,,,both,,,2272.10,1476.86,,,,,,,,,,,,,
SIZER SURG 27MM NEUT IMPL TRL,SUP-2400078,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1482.08,963.35,,,,,,,,,,,,,
BLADE SURG 62MM ACET REV SYS EZOUT,SUP-2365141,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
SPLINT WR AD L 9IN LNG RT COT W/ STAY ELAS SUPP FOR,SUP-2324569,CDM,L3809,HCPCS,0272,RC,,,,both,,,37.68,24.49,,,,,,,,,,,,,
SHEATH INTRO SUPER SHTH XL L 25 CM DIA10 FR GUIDEWIRE 0.038,SUP-2147297,CDM,C1894,HCPCS,0272,RC,,,,both,,,62.80,40.82,,,,,,,,,,,,,
HC So Cystic Fibrosis Gene Analysis,PX-3108122066,CDM,81220,CPT,0310,RC,,,,both,,,1485.00,965.25,,,,,,,,,,,,,
EXPANDER TISS 11.6 CM PROJCT 14.9X16 CM 1445 CC TALL HT CPX4,SUP-2758788,CDM,C1889,HCPCS,0278,RC,,,,both,,,5306.60,3449.29,,,,,,,,,,,,,
GRAFT BNE SYNTH 50X10X2 MM 2 CC CLLGN COMP FOAM BI OSTETIC,SUP-2134723,CDM,C1713,HCPCS,0278,RC,,,,both,,,3179.25,2066.51,,,,,,,,,,,,,
GRAFT HUMAN TISSUE THICK 16X6 CM HYDRATED BIOLOGIC TISSUE MA,SUP-2838609,CDM,C1763,HCPCS,0278,RC,,,,both,,,8908.49,5790.52,,,,,,,,,,,,,
BLADE ENDOSCP SHAVER 360 DEG L 13 CM DIA 4 MM SPD 7500 RPM,SUP-2902043,CDM,2720000010,LOCAL,0272,RC,,,,both,,,739.03,480.37,,,,,,,,,,,,,
PIN GUIDE 2.4X230 MM,SUP-2391523,CDM,C1713,HCPCS,0278,RC,,,,both,,,374.13,243.18,,,,,,,,,,,,,
MIXER BNE CEM 40GM SGL MIX OPTVAC VAC SYS,SUP-2216855,CDM,C1713,HCPCS,0278,RC,,,,both,,,558.92,363.30,,,,,,,,,,,,,
INTRODUCER SHTH 8.5FR L63CM DIL 8.5FR L67CM GWIRE L180CM,SUP-2357169,CDM,C1893,HCPCS,0272,RC,,,,both,,,476.97,310.03,,,,,,,,,,,,,
SCREW ACET CANC 6.5X15 MM HIP,SUP-2390373,CDM,C1713,HCPCS,0278,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
EXPANDER BRST 450CC W12.7XH10.8CM P7CM M HT CNTOUR PROF W/,SUP-2300696,CDM,C1789,HCPCS,0278,RC,,,,both,,,5306.60,3449.29,,,,,,,,,,,,,
SCREW BNE L45MM OD45MM TI CANC GLEN ST NONLOCKING COMPR,SUP-2401414,CDM,C1713,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
BIT DRL DIA 4.8 MM LG CANN AO QR NS DISP,SUP-2913217,CDM,2720000010,LOCAL,0272,RC,,,,both,,,819.54,532.70,,,,,,,,,,,,,
PLATE HLDR,SUP-2207866,CDM,C1713,HCPCS,0278,RC,,,,both,,,1769.08,1149.90,,,,,,,,,,,,,
KIT INSRT REV TAPR SGL LUMN 4FR,SUP-2116995,CDM,C1751,HCPCS,0278,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
LINER ACET 38X26 MM SCR IN +5 HI WALL RINGLOC+,SUP-2447219,CDM,C1776,CPT,0278,RC,,,,both,,,2486.88,1616.47,,,,,,,,,,,,,
DEVICE OCCL CLP L50MM 60DEG HD ARTC DEPLOYMENT LAA EXCLUSION,SUP-2124470,CDM,C1713,HCPCS,0278,RC,,,,both,,,11618.00,7551.70,,,,,,,,,,,,,
GRAFT DURA W2XL2IN CLLGN SUTURELESS HIGHLY CNFRM RESTR,SUP-2165125,CDM,C1763,HCPCS,0278,RC,,,,both,,,1667.56,1083.91,,,,,,,,,,,,,
HC So Plasma Cryofibrinogen,PX-3018258566,CDM,82585,CPT,0301,RC,,,,both,,,255.00,165.75,,,,,,,,,,,,,
CATHETER ABLATN D-D 1-7-4 MM 8MM 7 FRX115 CM EZ STEER LF,SUP-2248511,CDM,C1732,HCPCS,0272,RC,,,,both,,,7074.42,4598.37,,,,,,,,,,,,,
PACEMAKER IMP CRT-P QUADRA ALLURE MP RF CRT-P MRI MERLINPKG,SUP-2356476,CDM,C2621,HCPCS,0275,RC,,,,both,,,21352.00,13878.80,,,,,,,,,,,,,
BIT DRL CANN 5.5X150 MM,SUP-2606630,CDM,2720000010,LOCAL,0272,RC,,,,both,,,794.42,516.37,,,,,,,,,,,,,
CATHETER GUID BNCHMRK 071 L 115 CM OD 6 FR 0.071 IN MP,SUP-2716391,CDM,C1887,HCPCS,0272,RC,,,,both,,,2998.70,1949.15,,,,,,,,,,,,,
SHELL ACET SZ D DIA50MM 3 H OSSEOTI LIMIT H 2 MOBILITY G7,SUP-2403468,CDM,C1776,CPT,0278,RC,,,,both,,,5181.00,3367.65,,,,,,,,,,,,,
APPLICATOR TRAY SPHR 5-6 CM MAMMOSITE,SUP-2239832,CDM,C1728,HCPCS,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
PORT INFUS 10FR PLAS VLV OPN INTRO 2 LUMN INTERMED,SUP-2127753,CDM,C1788,HCPCS,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
HC Syphilis Test Quantitative,PX-3028659300,CDM,86593,CPT,0302,RC,,,,both,,,99.00,64.35,,,,,,,,,,,,,
TUBE TRACH PED L41MM OD6MM ID4MM SIL CUF STR NK FLNG FLX W,SUP-2352326,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1142.33,742.51,,,,,,,,,,,,,
SEALANT FIBRIN 10 CC FRZN PRE FILLED SYR TISSEEL,SUP-2130315,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1967.18,1278.67,,,,,,,,,,,,,
MATRIX RESTRATA WOUND 2.5CM X 2.5CM,SUP-2874116,CDM,A2007,HCPCS,0636,RC,,,,both,,,3070.92,1996.10,,,,,,,,,,,,,
SUBSTITUTE BONE GRFT L12XW12XH12MM IRRADIATED SCAFFOLD BLK,SUP-2125417,CDM,C1713,HCPCS,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
PLATE SPNL 1 LEVEL 14 MM ANTR CERV TETH,SUP-2379299,CDM,C1713,HCPCS,0278,RC,,,,both,,,4813.62,3128.85,,,,,,,,,,,,,
SLEEVE PROTCT LNG TISS REUSE,SUP-2362053,CDM,2720000010,LOCAL,0272,RC,,,,both,,,786.00,510.90,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED FEM TIB PATELLAR MONOBLOCK,SUP-2402813,CDM,C1776,CPT,0278,RC,,,,both,,,22746.16,14785.00,,,,,,,,,,,,,
PLATE BONE L16MM 5 H TI NAR HYBRID COMPR FOR 4.5MM SCR ALPS,SUP-2413742,CDM,C1713,HCPCS,0278,RC,,,,both,,,749.74,487.33,,,,,,,,,,,,,
ELECTRODE ELECSURG VPR 24 FR 2 STEM BALL SHP YEL HALF MOON,SUP-2423435,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1316.45,855.69,,,,,,,,,,,,,
BUR REPROC SHV 4MMX18CM ABRAD HI VISIBILITY,SUP-2652940,CDM,2720000010,LOCAL,0272,RC,,,,both,,,74.67,48.54,,,,,,,,,,,,,
DICLOFENAC SODIUM 0.1 % OP SOLN,RX-19714,CDM,6370000000,HCPCS,0637,RC,61314-0014-05,NDC,,both,5,ML,63.00,40.95,,,,,,,,,,,,,
PLATE CRAN 200X120X40 MM PT SPEC IMPL PEEK,SUP-2860155,CDM,C1713,HCPCS,0278,RC,,,,both,,,44217.17,28741.16,,,,,,,,,,,,,
CATHETER CV SET 032 10 FRX20 CM 10 GA 5 LUMEN QUINT SPECTRUM,SUP-2759732,CDM,C1751,HCPCS,0278,RC,,,,both,,,423.08,275.00,,,,,,,,,,,,,
SCREW BNE SELF DRILLING 1.2X5 MM,SUP-2435296,CDM,C1713,HCPCS,0278,RC,,,,both,,,216.19,140.52,,,,,,,,,,,,,
SCREW BONE L15MM DIA2.3MM CRANIOMAXILLOFACIAL TI CROSSDRIVE,SUP-2262621,CDM,C1713,HCPCS,0278,RC,,,,both,,,84.72,55.07,,,,,,,,,,,,,
ALLOGRAFT DERMAL UNMESHED 4X16 CMX1-2 MM PROLAYER,SUP-2717798,CDM,C1763,HCPCS,0278,RC,,,,both,,,18086.40,11756.16,,,,,,,,,,,,,
SET PNEUMOTHOR CATH 9FR L29CM NDL 18GA L20CM 20 SIDEPRT,SUP-2167923,CDM,C1729,HCPCS,0272,RC,,,,both,,,780.92,507.60,,,,,,,,,,,,,
PROSTHESIS OSS WEHRS II SHT 5.3X4.1X2.5 MM SINGLE NOTCH HA,SUP-2638122,CDM,L8613,CPT,0278,RC,,,,both,,,1176.53,764.74,,,,,,,,,,,,,
ROD EXT FIX L200MM DIA8MM DSTL RAD ELBW C FBR REUSE FOR,SUP-2188739,CDM,2720000010,LOCAL,0272,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
BASKET RETRV MEM HRD WIRE 4W 1.5 CMX3.5 CM BSKT,SUP-2169082,CDM,C1713,HCPCS,0278,RC,,,,both,,,791.28,514.33,,,,,,,,,,,,,
SPACER SPNL W9XH7XL22MM TI CONVX LO PROF EXP 8 WAF,SUP-2354692,CDM,C1821,HCPCS,0278,RC,,,,both,,,19066.08,12392.95,,,,,,,,,,,,,
ALLOGRAFT BNE SHFT 11 CM FD FEM,SUP-2321793,CDM,C1713,HCPCS,0278,RC,,,,both,,,2625.04,1706.28,,,,,,,,,,,,,
TRAY CATH HEMODIALYSI DUOGLIDE ACUTE 13FR DIA 30CML INSER 40,SUP-2613242,CDM,C1752,HCPCS,0278,RC,,,,both,,,838.47,545.01,,,,,,,,,,,,,
TRIAL HIP BPLR 26MMX51 CENTRAX,SUP-2364942,CDM,C1776,CPT,0278,RC,,,,both,,,417.62,271.45,,,,,,,,,,,,,
JOINT WRST 1 TIE-INTM,SUP-2535948,CDM,C1776,CPT,0278,RC,,,,both,,,4804.20,3122.73,,,,,,,,,,,,,
CATHETER DRNGE 8.5FR L25CM 0.038IN 8 H POLYUR HYDRPHLC BLU,SUP-2303364,CDM,C1729,HCPCS,0272,RC,,,,both,,,187.93,122.15,,,,,,,,,,,,,
GRAFT BNE GEL 0.5 CC INJ DBM GRFT 41110A] MEDTRONIC USA INC],SUP-2278316,CDM,C1713,HCPCS,0278,RC,,,,both,,,236.13,153.48,,,,,,,,,,,,,
SHEATH INTRO SILHOUETTE PEELWY L 30 CM DIA 9 FR GUIDEWIRE,SUP-2168315,CDM,C1892,HCPCS,0272,RC,,,,both,,,156.97,102.03,,,,,,,,,,,,,
GRAFT VASC ARTEGRAFT L 40 CM DIA 6 MM CLLGN BOV CAR ART,SUP-2120669,CDM,C1768,CPT,0278,RC,,,,both,,,8098.06,5263.74,,,,,,,,,,,,,
SCREW INTFR L25MM DIA7MM CANN 1.5MM BIOABSRB PLLA RND THRD,SUP-2341553,CDM,C1713,HCPCS,0278,RC,,,,both,,,692.78,450.31,,,,,,,,,,,,,
SYSTEM PLATELET CONC 30 CC,SUP-2431545,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
REAMER SURG 10 20 METATARSAL GREAT TOE SYS SURF MOV,SUP-2244270,CDM,2720000010,LOCAL,0272,RC,,,,both,,,778.09,505.76,,,,,,,,,,,,,
GRAFT VASC GORTX L 60 CM DIA 6 MM RNG L 30 CM EPTFE STR TW,SUP-2396116,CDM,C1768,CPT,0278,RC,,,,both,,,2678.42,1740.97,,,,,,,,,,,,,
DEXTROSE 5 % AND 0.45 % NACL IV BOLUS,RX-40840056,CDM,J3490,HCPCS,0250,RC,00338-0085-04,NDC,,both,250,ML,12.80,8.32,,,,,,,,,,,,,
CLIP ASSURANCE 13MM,SUP-2862313,CDM,C1889,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
BIT DRILL SURG DIA 3.5 MM MINI PK FOOTPRINT,SUP-2883117,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1299.96,844.97,,,,,,,,,,,,,
INTRODUCER STEER 2 REACH 22.4MM CURL BI DIR W/ .032 GWIRE,SUP-2357598,CDM,C1894,HCPCS,0272,RC,,,,both,,,2656.13,1726.48,,,,,,,,,,,,,
PLATE BNE CONTOURED 1.5X26X0.3 MM BURR HOLE CVR MOD TI,SUP-2479956,CDM,C1713,HCPCS,0278,RC,,,,both,,,655.44,426.04,,,,,,,,,,,,,
STRIP INT STPL CLLGN MTRX W/ VERIT REINF 6 FIRING COMPATIBLE,SUP-2130375,CDM,C1713,HCPCS,0278,RC,,,,both,,,541.40,351.91,,,,,,,,,,,,,
RING TRAC L 22-24IN CERV CLOSE BK W/ 2.5IN SKULL AND POS PIN,SUP-2328118,CDM,L0810,HCPCS,0274,RC,,,,both,,,5510.70,3581.95,,,,,,,,,,,,,
PLATE BONE L67MM 8 H STRL S STL COMPR FOR 2.7MM SCR EVOS,SUP-2349623,CDM,C1713,HCPCS,0278,RC,,,,both,,,1663.01,1080.96,,,,,,,,,,,,,
NECK FEM H+10MM CO CHROM HI OFFSET MOD REDAPT,SUP-2345461,CDM,C1776,CPT,0278,RC,,,,both,,,2858.66,1858.13,,,,,,,,,,,,,
VALVE MITRL OPN PVT AP360 DIA22 MM ORIFICE 20.8 MM TISS,SUP-2429923,CDM,C1713,HCPCS,0278,RC,,,,both,,,9840.76,6396.49,,,,,,,,,,,,,
SCREW BNE L65MM DIA14MM THRD L22MM ST CANC S STL ST CANN LAG,SUP-2186554,CDM,C1713,HCPCS,0278,RC,,,,both,,,1192.85,775.35,,,,,,,,,,,,,
HC Sclerotx Fluid Collection,PX-3614918500,CDM,49185,CPT,0361,RC,,,,outpatient,,,3707.00,2409.55,,,,,,,,,,,,,
CEMENT BNE 2 VISC FULL DOSE LOWER POROSITY SIMPLEX P,SUP-2365914,CDM,C1713,HCPCS,0278,RC,,,,both,,,195.94,127.36,,,,,,,,,,,,,
INTRODUCER SHTH SET 0.18 IN 6 FRX20 CM HYDRPHLC COAT M DRN,SUP-2303568,CDM,C1894,HCPCS,0272,RC,,,,both,,,229.22,148.99,,,,,,,,,,,,,
FIBER LSR FLEXIVA PULSE 365,SUP-2717688,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1033.00,671.45,,,,,,,,,,,,,
PLATE BONE L142MM 12 H STRL BILAT S STL NONCOMPRESSION RECON,SUP-2348447,CDM,C1713,HCPCS,0278,RC,,,,both,,,4264.12,2771.68,,,,,,,,,,,,,
CATHETER CV KT 8 FRX20 CM DL PRESSURE INJ GUIDEWIRE DIL,SUP-2763386,CDM,C1751,HCPCS,0278,RC,,,,both,,,438.97,285.33,,,,,,,,,,,,,
CATHETER HD RAULERSON 13 FRX20 CM IJ SHT TERM DUO-SPLIT,SUP-2627188,CDM,C1752,HCPCS,0278,RC,,,,both,,,191.54,124.50,,,,,,,,,,,,,
TOBRAMYCIN SULFATE 1.2 GM/30ML IJ SOLN,RX-97699,CDM,J3260,HCPCS,0636,RC,09999-9919-73,NDC,,both,2,ML,54.10,35.16,,,,,,,,,,,,,
CLAMP EXT FIX OD25MM RED PIN FOR MONOTUBE TRIAX SYS,SUP-2372623,CDM,C1713,HCPCS,0278,RC,,,,both,,,1805.50,1173.57,,,,,,,,,,,,,
MESH CRAN KASSAM REG 0.3 MM SCRN PANEL NEURO SCREW CP TI,SUP-2472595,CDM,C1713,HCPCS,0278,RC,,,,both,,,812.41,528.07,,,,,,,,,,,,,
BRACE WR CIRC 7 1/4IN TO 8IN L RT REG IMMOB LOOP LCK W/ STAY,SUP-2324900,CDM,L3931,HCPCS,0272,RC,,,,both,,,30.27,19.68,,,,,,,,,,,,,
PLATE BNE 110 DEG BAR 10 MM MINI RT CRANIOMAXILLOFACIAL L,SUP-2883280,CDM,C1713,HCPCS,0278,RC,,,,both,,,1249.59,812.23,,,,,,,,,,,,,
"HC So Infectious Agent,Nos",PX-3068789966,CDM,87899,CPT,0306,RC,,,,both,,,141.00,91.65,,,,,,,,,,,,,
BOWL BONE CEM MX W/ SPAT SUMMIT,SUP-2304362,CDM,C1713,HCPCS,0278,RC,,,,both,,,364.24,236.76,,,,,,,,,,,,,
SCREW 5.0MM TI DUAL CORE LCKNG T25 STRDRV 62MM F IM NAIL STE,SUP-2546350,CDM,C1713,HCPCS,0278,RC,,,,both,,,714.98,464.74,,,,,,,,,,,,,
SHEATH ROT CF INNR G 25.6FR,SUP-2313077,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5082.22,3303.44,,,,,,,,,,,,,
CATHETER ETER PICC AD 5FR L55CM 2 LUMN NRS PWR INJ N COAT CT,SUP-2126708,CDM,C1751,HCPCS,0278,RC,,,,both,,,623.98,405.59,,,,,,,,,,,,,
PROSTHESIS OSS EAR INCUS-STAPE WEHRS,SUP-2342764,CDM,L8613,CPT,0278,RC,,,,both,,,825.82,536.78,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.532,SUP-2860049,CDM,C1713,HCPCS,0278,RC,,,,both,,,47180.07,30667.05,,,,,,,,,,,,,
HC So1 Prothrombin Time,PX-3058561067,CDM,85610,CPT,0305,RC,,,,both,,,7.00,4.55,,,,,,,,,,,,,
BONE GRFT SUB L 12.5CC BIOACTIVE GLS MTRX,SUP-2419733,CDM,C9359,HCPCS,0278,RC,,,,both,,,11869.20,7714.98,,,,,,,,,,,,,
INTRODUCER SHTH L81CM L85CM OD8.5FR 3MM TIP .032IN SL0,SUP-2357265,CDM,C1894,HCPCS,0272,RC,,,,both,,,769.30,500.04,,,,,,,,,,,,,
GRAFT BNE SUB 5CC CANC CORT DEMIN CHIP OPTECURE,SUP-2223579,CDM,C1713,HCPCS,0278,RC,,,,both,,,3702.06,2406.34,,,,,,,,,,,,,
CATHETER GUID ZIPLINE ID 0.070 IN HYDRPHLC 1 LUMEN VAR,SUP-2929968,CDM,C1887,HCPCS,0272,RC,,,,both,,,6908.00,4490.20,,,,,,,,,,,,,
PLATE BNE 16 H SCR H DIA1.2MM L N COMPR CRV,SUP-2267876,CDM,C1713,HCPCS,0278,RC,,,,both,,,788.77,512.70,,,,,,,,,,,,,
VALVE HYDROCEPHALUS WITH PEDIATRIC PRECHAMBER PROGAV 2.0,SUP-2826976,CDM,C1889,HCPCS,0278,RC,,,,both,,,8115.05,5274.78,,,,,,,,,,,,,
GRAFT BONE SUB 2ML HUM CORT DEMIN FBR STAGRFT,SUP-2136830,CDM,C1763,HCPCS,0278,RC,,,,both,,,1228.05,798.23,,,,,,,,,,,,,
SHEATH INTRO ACCEL L 20 CM DIA 6 FR L 60/145 CM DIA 21 GA SS,SUP-2659241,CDM,C1894,HCPCS,0272,RC,,,,both,,,253.71,164.91,,,,,,,,,,,,,
CYSTOSCOPE FLX UP 210 DEG DN 120 DEG L 15 2/5 IN DIA 5.4 MM,SUP-2882870,CDM,2720000010,LOCAL,0272,RC,,,,both,,,737.90,479.63,,,,,,,,,,,,,
VALPROATE SODIUM 250 MG/5ML PO SOLN,RX-137331,CDM,340b,HCPCS,0637,RC,09999-9903-62,NDC,,both,5,ML,14.20,9.23,,,,,,,,,,,,,
SCREW CRAN 5PK L 4 MM DIA1.5 MM NEURO SURG SD CROSS PIN HD NS,SUP-2883996,CDM,C1713,HCPCS,0278,RC,,,,both,,,161.49,104.97,,,,,,,,,,,,,
CATHETER BILI 5FR L23CM BAL FOR CHOLANGIOGRAPHY SYNTEL,SUP-2119458,CDM,C1726,HCPCS,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
MICROCATHETER DIAG L160CM OD2.95/2.6IN ID0.025IN MIC NIT,SUP-2323716,CDM,C1887,HCPCS,0272,RC,,,,both,,,3253.04,2114.48,,,,,,,,,,,,,
SCREW BNE L30MM DIA4.75MM CORT FIX ANG NONCANNULATED,SUP-2407397,CDM,C1713,HCPCS,0278,RC,,,,both,,,562.06,365.34,,,,,,,,,,,,,
PLATE BONE L134MM 6 H LT MEDL DSTL TIB LCK FOR 3.5MM SCR,SUP-2348244,CDM,C1713,HCPCS,0278,RC,,,,both,,,16630.07,10809.55,,,,,,,,,,,,,
PLATE BNE ORBIT MED GLD,SUP-2135898,CDM,C1713,HCPCS,0278,RC,,,,both,,,2112.72,1373.27,,,,,,,,,,,,,
BIT DRL L150MM WRK L50MM DIA2MM 3 FLUTEREPLACEMENT S STL,SUP-2150426,CDM,2720000010,LOCAL,0272,RC,,,,both,,,493.33,320.66,,,,,,,,,,,,,
TUBE TRACHEOSTOMY FENESTRATED ADULT 10.6MM UNCUFFED ADAPTER,SUP-2793423,CDM,2720000010,LOCAL,0272,RC,,,,both,,,406.76,264.39,,,,,,,,,,,,,
HARD BONE ACCESS NEEDLE WITH DRILL 11 G 6.5 CM,SUP-2462215,CDM,2720000010,LOCAL,0272,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
INSERT TIB THK 11 MM SZ 3 HINGE REV STRL TRIATHLON,SUP-2889771,CDM,C1776,CPT,0278,RC,,,,both,,,7986.43,5191.18,,,,,,,,,,,,,
CATHETER BLLN DIL FIX WIRE 6-7-8 MMX7.5 FRX180 CM ELATION,SUP-2473228,CDM,C1726,HCPCS,0272,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
BLOM-SINGER INDWL LO PRSS VOICE PROS REPL KT SER 8MM,SUP-2246404,CDM,L8509,HCPCS,0272,RC,,,,both,,,285.74,185.73,,,,,,,,,,,,,
BLADE SHV 4.5MM DIA ENDO ANG CVD DBL SERR ULT SER DISP,SUP-2341007,CDM,2720000010,LOCAL,0272,RC,,,,both,,,326.03,211.92,,,,,,,,,,,,,
STENT PERIPH PALMAZ GEN L 15 MM DIA 4 MM CATH L 80 CM,SUP-2159105,CDM,C1877,HCPCS,0278,RC,,,,both,,,2370.70,1540.95,,,,,,,,,,,,,
FORCEPS SURG SUT TISS 4.75 IN REUSE NONSTERILE AD ADSN,SUP-2412590,CDM,C1713,HCPCS,0278,RC,,,,both,,,806.98,524.54,,,,,,,,,,,,,
CEFAZOLIN SODIUM 10 G IJ SOLR,RX-1446,CDM,J0690,HCPCS,0636,RC,00143-9261-10,NDC,,both,1,UN,54.10,35.16,,,,,,,,,,,,,
THYROID 15 MG PO TABS,RX-7940,CDM,6370000000,HCPCS,0637,RC,00456-0457-01,NDC,,both,1,UN,3.90,2.53,,,,,,,,,,,,,
CATHETER DIL UROMX ULTRA L 75 CM DIA21 FR BALLOON L 4 CM DIA,SUP-2139199,CDM,C1726,HCPCS,0272,RC,,,,both,,,864.54,561.95,,,,,,,,,,,,,
DILATOR FILFRM SPRL TIP 4FR HEYMAN,SUP-2126290,CDM,C1758,HCPCS,0278,RC,,,,both,,,26.38,17.15,,,,,,,,,,,,,
BIT DRL PED DIA3.2MM SH PEDINAIL,SUP-2318888,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1016.42,660.67,,,,,,,,,,,,,
PACEMAKER CARD EVIA DR-T TI HOME MONITORING MOB STRL,SUP-2138285,CDM,C1785,HCPCS,0275,RC,,,,both,,,12089.00,7857.85,,,,,,,,,,,,,
BEAM FIX L100MM DIA8.5MM ARTH,SUP-2223961,CDM,C1713,HCPCS,0278,RC,,,,both,,,4568.70,2969.65,,,,,,,,,,,,,
PLATE BNE HUM 3.5X127 MM LT PERIARTICULAR PROX 4 HOLE LCK LP,SUP-2255803,CDM,C1713,HCPCS,0278,RC,,,,both,,,5286.44,3436.19,,,,,,,,,,,,,
MATERIAL REINF STPL LN BIOABSRB FOR ENDOPATH ETS45 SEAMGRD,SUP-2395282,CDM,C1781,HCPCS,0278,RC,,,,both,,,514.43,334.38,,,,,,,,,,,,,
SIZER INSTR 7 20MM 7 PC DISPOSABLE PROCHONDRIX,SUP-2363973,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1248.02,811.21,,,,,,,,,,,,,
STENT CORONARY VERIFLEX MR L 20 MM DIA 4.5 MM SS RX,SUP-2144502,CDM,C1876,HCPCS,0278,RC,,,,both,,,1852.60,1204.19,,,,,,,,,,,,,
K WIRE FIX L285MM DIA2MM S STL FOR AXSOS SYS,SUP-2377976,CDM,C1713,HCPCS,0278,RC,,,,both,,,382.45,248.59,,,,,,,,,,,,,
SCREW BNE L 28 MM DIA 4 MM FT CHMFR MIS HV,SUP-2896781,CDM,C1713,HCPCS,0278,RC,,,,both,,,2590.50,1683.82,,,,,,,,,,,,,
SCREW SPNL L 30 MM DIA 5 MM FIX ANGLE STRL CD HORZ MODULEX,SUP-2926389,CDM,C1713,HCPCS,0278,RC,,,,both,,,2292.20,1489.93,,,,,,,,,,,,,
URETEROSCOPE FLX FLD OF VW 100 DEG SHFT L 670 MM DSTL TIP,SUP-2909606,CDM,C1747,HCPCS,0272,RC,,,,both,,,3689.50,2398.17,,,,,,,,,,,,,
SCREW BONE L10XOD2MM TI CORT CRANIOMAXILLOFACIAL CROSS PIN,SUP-2363434,CDM,C1713,HCPCS,0278,RC,,,,both,,,105.57,68.62,,,,,,,,,,,,,
FORCEP ENDOSCP ALLIGATOR CUP 2.4X1800 MM W/ SPIKE STRL DISP,SUP-2791292,CDM,C1769,HCPCS,0272,RC,,,,both,,,25.43,16.53,,,,,,,,,,,,,
METHYLPREDNISOLONE 16 MG PO TABS,RX-4992,CDM,J7509,HCPCS,0636,RC,59762-0050-01,NDC,,both,1,UN,12.80,8.32,,,,,,,,,,,,,
ENDOPROSTHESIS VASC VIABAHN L 15CM 6MM 120CM 6FR HEPARIN,SUP-2396649,CDM,C1874,HCPCS,0278,RC,,,,both,,,12616.52,8200.74,,,,,,,,,,,,,
HC Splint - Long Arm,PX-7612910500,CDM,29105,CPT,0761,RC,,,,both,,,867.00,563.55,,,,,,,,,,,,,
BIT DRL DIA4MM CARB DISP FOR 3.5/5MM SCR,SUP-2187124,CDM,2720000010,LOCAL,0272,RC,,,,both,,,812.51,528.13,,,,,,,,,,,,,
BLADE DRIVER T8,SUP-2704916,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1017.67,661.49,,,,,,,,,,,,,
PLATE BNE L236MM 17 H L ANTLAT DST TIB TI LOK COMPR FOR,SUP-2190973,CDM,C1713,HCPCS,0278,RC,,,,both,,,4863.20,3161.08,,,,,,,,,,,,,
TRIANGLETIPJ UPPER LENGTH 1 UNIT EA,SUP-2677728,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4802.32,3121.51,,,,,,,,,,,,,
STENT URET STR 0.035 IN 3 CM 7 FRX22 CM 6 FR DBL PGTL CNTOUR,SUP-2490283,CDM,C2617,HCPCS,0278,RC,,,,both,,,415.08,269.80,,,,,,,,,,,,,
GRAFT BONE 1ML DEMIN BONE MTRX SYR POLOXAMER RVS PHASE M,SUP-2247312,CDM,C9359,HCPCS,0278,RC,,,,both,,,832.10,540.86,,,,,,,,,,,,,
SHUNT KIT OPN END LUMPERITON 2 VLV STRATA NSC,SUP-2629180,CDM,C1729,HCPCS,0272,RC,,,,both,,,13716.18,8915.52,,,,,,,,,,,,,
GRAFT BNE SUB 10CC CANC MORSELIZED W/ VIABLE CELL FRZN,SUP-2307245,CDM,C1713,HCPCS,0278,RC,,,,both,,,14396.90,9357.98,,,,,,,,,,,,,
PLATE BONE COMPRESSION BROAD 198 MM PELVIC 11 HOLE CONTOURED,SUP-2837530,CDM,C1713,HCPCS,0278,RC,,,,both,,,3039.71,1975.81,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 80 CM DIA 5 MM RNG L 30 CM EPTFE,SUP-2396284,CDM,C1768,CPT,0278,RC,,,,both,,,3658.10,2377.76,,,,,,,,,,,,,
PLATE BNE 1 H PELV ACET POST RIM BROAD STRL PRO,SUP-2902162,CDM,C1713,HCPCS,0278,RC,,,,both,,,2441.98,1587.29,,,,,,,,,,,,,
CONNECTOR SHUNT 0.78X1.35 MM TYP C SS HOLTER,SUP-2666818,CDM,C1889,HCPCS,0278,RC,,,,both,,,1136.08,738.45,,,,,,,,,,,,,
CATHETER PA L 75 CM DIA 4 FR INTRO DIA 5 FR BALLOON DIA 8 MM,SUP-2894093,CDM,2720000010,LOCAL,0272,RC,,,,both,,,489.84,318.40,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY LASSO L 115 CM 7 FR 35MM 1-1 MM D,SUP-2248480,CDM,C1731,HCPCS,0278,RC,,,,both,,,3541.92,2302.25,,,,,,,,,,,,,
GRAFT HUM TISS W2XL4CM THK45UM AMNIO MEMBRN DEHYDR OMNI DIR,SUP-2340452,CDM,C1762,CPT,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
BALLOON DIL 30-33-36FR L8CM INFLATED DIA10-11-12MM 2-4-6ATM,SUP-2170091,CDM,C1726,HCPCS,0272,RC,,,,both,,,618.58,402.08,,,,,,,,,,,,,
GRAFT BNE 10 CC CELLULAR BNE MTRX V92,SUP-2742072,CDM,C1713,HCPCS,0278,RC,,,,both,,,16406.50,10664.22,,,,,,,,,,,,,
JETD REPERFUSION CATHETER,SUP-2500569,CDM,C1887,HCPCS,0272,RC,,,,both,,,7504.60,4877.99,,,,,,,,,,,,,
PLATE BNE RECON 2.5 MM 20 HOLE RECON PT SPEC,SUP-2860089,CDM,C1713,HCPCS,0278,RC,,,,both,,,18162.07,11805.35,,,,,,,,,,,,,
CATHETER INFUSION 018IN 29FRX150CM 5CM MULTIPLE SH MICROMEWI,SUP-2172533,CDM,C1751,HCPCS,0278,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
LGN POR HA TIB BASE WITHOUT HOLES SZ 4 RT,SUP-2822665,CDM,C1776,CPT,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
COMPONENT CRANIOFACIAL PRIORITY + PEEK,SUP-2862819,CDM,C1713,HCPCS,0278,RC,,,,both,,,51056.02,33186.41,,,,,,,,,,,,,
TUBE VENT SHEEHY 1.27 MM PHOSPHORYLCHOLINE COAT SIL 510136C,SUP-2535104,CDM,L8699,HCPCS,0278,RC,,,,both,,,37.40,24.31,,,,,,,,,,,,,
PERFORATOR SURG 9X6MM CRAN SHRP HUDSON END DISP,SUP-2243195,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1252.86,814.36,,,,,,,,,,,,,
SHELL ACET 60 MM HIP 9 HOLE REFLECTION FSO,SUP-2434637,CDM,C1776,CPT,0278,RC,,,,both,,,5005.16,3253.35,,,,,,,,,,,,,
VALVE AORT ON-X TISS ANNULUS 19 MM ORIFICE 17.4 MM FLARE,SUP-2175254,CDM,C1889,HCPCS,0278,RC,,,,both,,,15696.86,10202.96,,,,,,,,,,,,,
TUNNELER SURG L 600 MM LG RIGID NO RNG MARKING STRL DISP 10/PK,SUP-2928804,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4628.14,3008.29,,,,,,,,,,,,,
GRAFT BONE 1ML DEMIN BONE MTRX PASTE INTERGRO,SUP-2414008,CDM,C1713,HCPCS,0278,RC,,,,both,,,737.90,479.63,,,,,,,,,,,,,
SOUND PROCESSOR MAGNET STRENGTH 4,SUP-2858180,CDM,L8690,HCPCS,0278,RC,,,,both,,,412.38,268.05,,,,,,,,,,,,,
COIL EMB L4CM OD3MM .020IN NIT NEUROVASC COMPLX SFT FILL,SUP-2323389,CDM,C1889,HCPCS,0278,RC,,,,both,,,7391.56,4804.51,,,,,,,,,,,,,
TRAY HAD CATH 12FR L13CM 2 LUMN ACUTE STR EXTN MAHRK ELITE,SUP-2172336,CDM,C1752,HCPCS,0278,RC,,,,both,,,238.73,155.17,,,,,,,,,,,,,
ELECTRODE ELECSURG MONOPOLAR 5X400 MM FLAT J HK HI FREQ DISP,SUP-2797662,CDM,2720000010,LOCAL,0272,RC,,,,both,,,748.80,486.72,,,,,,,,,,,,,
STENT GRFT VASC AFX L 100 MM UNCOVERED L 20 MM DIA 34 MM,SUP-2217607,CDM,C1768,CPT,0278,RC,,,,both,,,16532.10,10745.86,,,,,,,,,,,,,
INSTRUMENT EXT FIX REARFOOT SUBTALAR ARTH FOR SIDEKCK FIX,SUP-2400592,CDM,2720000010,LOCAL,0272,RC,,,,both,,,9357.20,6082.18,,,,,,,,,,,,,
CAP ORTH COMPR,SUP-2406885,CDM,C1776,CPT,0278,RC,,,,both,,,279.46,181.65,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.412,SUP-2859976,CDM,C1713,HCPCS,0278,RC,,,,both,,,32134.76,20887.59,,,,,,,,,,,,,
SPACER 38X3MM M LT,SUP-2209009,CDM,C1776,CPT,0278,RC,,,,both,,,11366.17,7388.01,,,,,,,,,,,,,
GUIDEWIRE ORTH L100CM DIA3MM S STL BALL NOSE,SUP-2412710,CDM,C1769,HCPCS,0272,RC,,,,both,,,414.48,269.41,,,,,,,,,,,,,
BLADE LARYNSCP L135MM DSTL W15MM MAC 3 FBROPT CLASS,SUP-2238179,CDM,2720000010,LOCAL,0272,RC,,,,both,,,668.82,434.73,,,,,,,,,,,,,
EXPANDER BRST W15.6XH13.3CM P8CM 800CC W/ SUT TAB M HT STYL,SUP-2300657,CDM,C1789,HCPCS,0278,RC,,,,both,,,5008.30,3255.39,,,,,,,,,,,,,
TUNNELER SURG 17GA L8IN DISP FOR ABD APPRCH UNIV TUNN,SUP-2236791,CDM,C1894,HCPCS,0272,RC,,,,both,,,65.94,42.86,,,,,,,,,,,,,
PLATE BONE THK0.6MM 8 H ORBIT RIM SLV FOR 2MM SCR LORENZ,SUP-2402931,CDM,C1713,HCPCS,0278,RC,,,,both,,,499.26,324.52,,,,,,,,,,,,,
GUIDEPIN ORTH L343MM DIA3.2MM FULL THRD BLNT TIP DISP,SUP-2347570,CDM,2720000010,LOCAL,0272,RC,,,,both,,,822.37,534.54,,,,,,,,,,,,,
GRAFT BNE VOID FILL MIXING DEL SYS MG,SUP-2742078,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2072.40,1347.06,,,,,,,,,,,,,
HANDPIECE ELECSURG L140MM SHFT L100MM ELECTRD DIA1.1MM CONCL,SUP-2313606,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1029.92,669.45,,,,,,,,,,,,,
ANCHOR SUTURE FIBER 5.5/6 MM FOR SCR THERAFUZE DBF,SUP-2744195,CDM,C1776,CPT,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
LEUCOVORIN CALCIUM 200 MG IJ SOLR,RX-15426,CDM,J0640,HCPCS,0636,RC,67457-0529-20,NDC,,both,1,UN,118.00,76.70,,,,,,,,,,,,,
GRAFT BNE SUB 5CC CA PHSPTE HA PTTY INJ HYDROSET,SUP-2371662,CDM,C1713,HCPCS,0278,RC,,,,both,,,6219.56,4042.71,,,,,,,,,,,,,
HC So Genotype Dna/Rna Hiv,PX-3068790666,CDM,87906,CPT,0306,RC,,,,both,,,362.00,235.30,,,,,,,,,,,,,
MESH SURG DIA86CM POLY PGLA CLLGN FLM RIG ABSRB EXP SEMI,SUP-2283995,CDM,C1781,HCPCS,0278,RC,,,,both,,,1649.94,1072.46,,,,,,,,,,,,,
HC Proc Xr Fluoro Unlistd,PX-3207649600,CDM,76496,CPT,0320,RC,,,,both,,,96.00,62.40,,,,,,,,,,,,,
MATRIX BIO L 6 X W 6 CM FET BOV DERM IONIC SLV DERMAL SLD,SUP-2909265,CDM,Q4110,HCPCS,0636,RC,,,,both,,,4874.85,3168.65,,,,,,,,,,,,,
DELIVERY NEEDLE 8GX11CM OPEN TIP,SUP-2816333,CDM,2720000010,LOCAL,0272,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
SCREW INTFR L8MM DIA5.5MM EL PEEK BIO-TENODESIS,SUP-2121426,CDM,C1713,HCPCS,0278,RC,,,,both,,,894.90,581.68,,,,,,,,,,,,,
RADIOGRAPHIC RULER FOR SMALL FRAGMENT PLATES 360MM,SUP-2548115,CDM,C1713,HCPCS,0278,RC,,,,both,,,936.10,608.46,,,,,,,,,,,,,
TUBE MYRINGOTOMY 1.27 MM 1 MM RUBE TAB SIL STRL,SUP-2535113,CDM,L8699,HCPCS,0278,RC,,,,both,,,42.04,27.33,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL PEEK SD800.512,SUP-2860194,CDM,C1713,HCPCS,0278,RC,,,,both,,,30349.98,19727.49,,,,,,,,,,,,,
COLLAR VENTRICULAR ASST DEV SEAL OUTFLO GRFT BEND REL STRL,SUP-2894740,CDM,C1889,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
GRAFT BNE SUB 60ML 05 5MM CORT CANC GRAN MORSELIZED FRZ DRY,SUP-2307057,CDM,C1713,HCPCS,0278,RC,,,,both,,,2450.27,1592.68,,,,,,,,,,,,,
SUPPORT ORTHOT KNEE LCK W/INTEGR RELEASE MECHANISM,SUP-2435668,CDM,L2415,HCPCS,0274,RC,,,,both,,,343.96,223.57,,,,,,,,,,,,,
SET INTRO L 30 CM DIA 9 FR GUIDEWIRE 0.038 IN PTFE TEARWY,SUP-2226014,CDM,C1892,HCPCS,0272,RC,,,,both,,,166.42,108.17,,,,,,,,,,,,,
HC External Version,PX-7205941200,CDM,59412,CPT,0720,RC,,,,inpatient,,,1981.00,1287.65,,,,,,,,,,,,,
COMPONENT FEM UNI XS KNEE COCR GEN,SUP-2349775,CDM,C1776,CPT,0278,RC,,,,both,,,9011.02,5857.16,,,,,,,,,,,,,
SCREW BNE CRTX 1.5X10 MM,SUP-2569460,CDM,C1713,HCPCS,0278,RC,,,,both,,,32.81,21.33,,,,,,,,,,,,,
TAP SURG L4.9IN QUIK CONN FOR 4.5MM SCR,SUP-2410965,CDM,C1713,HCPCS,0278,RC,,,,both,,,279.46,181.65,,,,,,,,,,,,,
TISSUE FRZ DRY IL CREST WDG 10-12MM THCK 6-9MMW 14-20MML,SUP-2307520,CDM,C1713,HCPCS,0278,RC,,,,both,,,2084.96,1355.22,,,,,,,,,,,,,
BAG BLD TRNSFUS CONSOLIDATED VENTRICULAR ASST DEV BLK,SUP-2356005,CDM,Q0508,HCPCS,0272,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
ALLOGRAFT DERMAL 4X5 CMX2.5-3.5 MM DERMAL MTRX ARTHROFLEX,SUP-2741012,CDM,Q4125,HCPCS,0636,RC,,,,both,,,9133.63,5936.86,,,,,,,,,,,,,
SCREW SPNL MULTAXL 7.5X60 MM 6.35 MM FOR ROD RED CD HORZ,SUP-2288753,CDM,C1713,HCPCS,0278,RC,,,,both,,,2088.10,1357.26,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 70 CM DIA 6 MM STR TW REINF,SUP-2763163,CDM,C1768,CPT,0278,RC,,,,both,,,1268.34,824.42,,,,,,,,,,,,,
GRAFT BNE SCAFFOLD 0.5 CC OSTEOINDUCTIVE DBM EXPONENT,SUP-2424595,CDM,C1889,HCPCS,0278,RC,,,,both,,,208.81,135.73,,,,,,,,,,,,,
POST EXT FIX L35 MM OD9.5 MM 60 DEG MAGENTAX-POST INTOSS,SUP-2223911,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5322.30,3459.49,,,,,,,,,,,,,
GUIDEWIRE FLUT,SUP-2362517,CDM,C1769,HCPCS,0272,RC,,,,both,,,451.06,293.19,,,,,,,,,,,,,
BIT DRL 4.5 MM ACTIFLIP,SUP-2762116,CDM,2720000010,LOCAL,0272,RC,,,,both,,,684.52,444.94,,,,,,,,,,,,,
GRAFT BNE H12XL25MM TRICORT PAT WDG FRZ DRY MATRIGRFT,SUP-2264808,CDM,C1713,HCPCS,0278,RC,,,,both,,,2075.98,1349.39,,,,,,,,,,,,,
HC So Clot Factor XIII Fibrin Scrn,PX-3058529166,CDM,85291,CPT,0305,RC,,,,both,,,456.00,296.40,,,,,,,,,,,,,
K WIRE FIX L150MM DIA1MM S STL TRCR PNT,SUP-2186857,CDM,C1713,HCPCS,0278,RC,,,,both,,,245.67,159.69,,,,,,,,,,,,,
STIMULATOR NERVE REMOT CTRL PRGMR KT FREELINK,SUP-2139754,CDM,C1787,HCPCS,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
SPRONE OBLONG 3.5X7.5X80MM,SUP-2213497,CDM,C1784,HCPCS,0278,RC,,,,both,,,156.37,101.64,,,,,,,,,,,,,
PROBE SURG DEPTH 0.035 IN,SUP-2535242,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1045.62,679.65,,,,,,,,,,,,,
TUBE TYMPANOSTOMY ID1.27MM FL9.5MM L3MM INNR EAR MYR VENT,SUP-2277939,CDM,L8699,HCPCS,0278,RC,,,,both,,,135.65,88.17,,,,,,,,,,,,,
COMBO KT CONSISTS OF 10 150 INS 5010,SUP-2242729,CDM,C1713,HCPCS,0278,RC,,,,both,,,661.60,430.04,,,,,,,,,,,,,
PLATE 4.5MM 3.5MM TI LCP METAPHYSEAL 9 HOLES,SUP-2549472,CDM,C1713,HCPCS,0278,RC,,,,both,,,2246.61,1460.30,,,,,,,,,,,,,
HC Allo Stem Cell Collection,PX-8153820500,CDM,38205,CPT,0815,RC,,,,both,,,4740.00,3081.00,,,,,,,,,,,,,
BLADE LARYNGOSCOPE MACINTOSH 0 PREMI NEONATAL FIBEROPTIC MRI,SUP-2309344,CDM,2720000010,LOCAL,0272,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
SET CATH HEMODIALYSI 400XL ACUTE BSC 14FR DIA 24CM CRVD EXTN,SUP-2610502,CDM,C1752,HCPCS,0278,RC,,,,both,,,285.74,185.73,,,,,,,,,,,,,
SPHINCTEROTOME ENDOSCP 5 MM 4.4 FRX20 MM TRUTOME 8310,SUP-2500225,CDM,2720000010,LOCAL,0272,RC,,,,both,,,917.16,596.15,,,,,,,,,,,,,
PLATE BNE VOLAR HK FOR DST RAD SYS GEMINUS,SUP-2340194,CDM,C1713,HCPCS,0278,RC,,,,both,,,1088.01,707.21,,,,,,,,,,,,,
DRESSING BIO 38 SQ CM INTACT FISH SKIN MIC STRL KERECIS,SUP-2883566,CDM,Q4158,HCPCS,0636,RC,,,,both,,,6280.00,4082.00,,,,,,,,,,,,,
ISOSORBIDE MONONITRATE ER 60 MG PO TB24,RX-24268,CDM,6370000000,HCPCS,0637,RC,00904-6450-61,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
NEEDLE BRST LOC L10CM OD20GA HAWK II 252100,SUP-2269618,CDM,C1819,HCPCS,0278,RC,,,,both,,,141.36,91.88,,,,,,,,,,,,,
SCREW BONE CORTICAL 1.5X18 MM SELFTAPPING PLUSDRIVE RECESS T,SUP-2838128,CDM,C1713,HCPCS,0278,RC,,,,both,,,215.40,140.01,,,,,,,,,,,,,
SET ENDOBRONCH BLK AD L78CM BAL 9FR W/ SPHR MULTPURP ADPT,SUP-2168834,CDM,2720000010,LOCAL,0272,RC,,,,both,,,634.41,412.37,,,,,,,,,,,,,
ST REPL BLADE/STRYKER 5071-201 19.5X86X1.27M,SUP-2199481,CDM,C1713,HCPCS,0278,RC,,,,both,,,489.84,318.40,,,,,,,,,,,,,
SUPPORT ORTHOT LOWER EXTREMITY CUST ABDUCTN BAR JOINTED ADJ,SUP-2435658,CDM,L2300,HCPCS,0274,RC,,,,both,,,712.75,463.29,,,,,,,,,,,,,
LEVEL NEURO PLATE ULTRNE LDDR CVD NEURO SCRW5 X 2 HOLES 43 M,SUP-2676747,CDM,C1713,HCPCS,0278,RC,,,,both,,,1108.58,720.58,,,,,,,,,,,,,
STIMULATOR PACEMKR SINGLE CHMBR EXT,SUP-2138027,CDM,C1786,HCPCS,0275,RC,,,,both,,,5871.80,3816.67,,,,,,,,,,,,,
LEGION TIBIAL WEDGE LUG 10MM,SUP-2822935,CDM,C1776,CPT,0278,RC,,,,both,,,636.79,413.91,,,,,,,,,,,,,
CLIP MULTI-STAGE  STRL SINGLE-USE,SUP-2114096,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
MESH CRAN CHIARI MIDLN NS DISP,SUP-2936971,CDM,C1713,HCPCS,0278,RC,,,,both,,,5397.66,3508.48,,,,,,,,,,,,,
GRAFT BNE SUB 15CC PARTIC 4-9.5MM CANC FRZ DRY CHIP,SUP-2113907,CDM,C1713,HCPCS,0278,RC,,,,both,,,894.12,581.18,,,,,,,,,,,,,
PLATE BNE L298MM 16 H ST L LAT PROX TIB S STL LOK COMPR LO,SUP-2185730,CDM,C1713,HCPCS,0278,RC,,,,both,,,4679.67,3041.79,,,,,,,,,,,,,
KIT HAD CATHETER 12FR L16CM STR EXTN 2 LUMN MAHRK ELITE,SUP-2283958,CDM,C1752,HCPCS,0278,RC,,,,both,,,227.40,147.81,,,,,,,,,,,,,
CATHETER PERITONEAL DLYS TENCK INF 39.25 CM 1 CUF CURL QUINT,SUP-2754740,CDM,C1752,HCPCS,0278,RC,,,,both,,,407.89,265.13,,,,,,,,,,,,,
GRAFT DURA PTCH 12X12 CM DURAMATER,SUP-2321735,CDM,C1713,HCPCS,0278,RC,,,,both,,,8462.30,5500.49,,,,,,,,,,,,,
PATCH CV IMPRA L 150 X W 50 MM THK 0.6 MM EPTFE RECTANGULAR,SUP-2761294,CDM,C1768,CPT,0278,RC,,,,both,,,1728.22,1123.34,,,,,,,,,,,,,
LASER SURG 532NM/577/659NM W/ SMA CONN VISION 1 LIO KEELER,SUP-2713800,CDM,2720000010,LOCAL,0272,RC,,,,both,,,30696.64,19952.82,,,,,,,,,,,,,
GRAFT HUM TISS L45MM FEM HD FRZN ALLGRFT TRAD,SUP-2294154,CDM,C1713,HCPCS,0278,RC,,,,both,,,3322.12,2159.38,,,,,,,,,,,,,
SCREW BNE CANC 6.5X95 MM,SUP-2205621,CDM,C1713,HCPCS,0278,RC,,,,both,,,86.00,55.90,,,,,,,,,,,,,
"HC Mono Spot Test,Agglutination",PX-3028630800,CDM,86308,CPT,0302,RC,,,,both,,,363.00,235.95,,,,,,,,,,,,,
SCREW IM L 42.5 MM DIA 5 MM TI CORTICAL NS CARBOFIX,SUP-2930829,CDM,C1713,HCPCS,0278,RC,,,,both,,,387.41,251.82,,,,,,,,,,,,,
SCREW COMPR 1.5X14MM HEADLESS TI STRL,SUP-2547164,CDM,C1713,HCPCS,0278,RC,,,,both,,,699.50,454.67,,,,,,,,,,,,,
GRAFT BNE L200MM SHFT FEM FEM FRZN MATRIGRFT,SUP-2264758,CDM,C1713,HCPCS,0278,RC,,,,both,,,3182.04,2068.33,,,,,,,,,,,,,
STENT CORONARY MULTLNK TRI L 13 MM DIA 3.5 MM GUIDE CATH,SUP-2101463,CDM,C1876,HCPCS,0278,RC,,,,both,,,4553.00,2959.45,,,,,,,,,,,,,
KIT COR DCOMPR 15CC FOR INJ REGEN GRFT PRO DENSE,SUP-2399156,CDM,C1713,HCPCS,0278,RC,,,,both,,,15944.92,10364.20,,,,,,,,,,,,,
BLADE SAW THK0.015IN CUT EDGE L0.8IN D1.6IN MIC OSC AND SAG,SUP-2363669,CDM,2720000010,LOCAL,0272,RC,,,,both,,,155.40,101.01,,,,,,,,,,,,,
PURAPLY AM 6X9 CM 54SQ CM,SUP-2314119,CDM,Q4196,HCPCS,0636,RC,,,,both,,,16108.20,10470.33,,,,,,,,,,,,,
SET APPLICATOR LOCALIZER-S 20 5 CM,SUP-2657246,CDM,A4648,CPT,0278,RC,,,,both,,,17741.00,11531.65,,,,,,,,,,,,,
HC So Sickling of RBC,PX-3058566066,CDM,85660,CPT,0305,RC,,,,both,,,55.00,35.75,,,,,,,,,,,,,
HC Spleenoportography S&I,PX-3207581000,CDM,75810,CPT,0320,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
COMPONENT TIB PS 7 UNIV 15 MM NP PRIMARY CEM STEM MONOBLOCK,SUP-2378478,CDM,C1776,CPT,0278,RC,,,,both,,,3085.99,2005.89,,,,,,,,,,,,,
CATHETER DIAG L150CM OD2.9X2.7FR ID0.027IN DST L18CM,SUP-2368150,CDM,C1887,HCPCS,0272,RC,,,,both,,,3163.24,2056.11,,,,,,,,,,,,,
HC Iron Binding Capacity|NOT REASONABLE AND NECESSARY,PX-3018355000,CDM,83550,CPT,0301,RC,,,GZ,both,,,128.00,83.20,,,,,,,,,,,,,
GRAFT BNE 2.5 CC OSTEOSURGE 300,SUP-2641800,CDM,C1713,HCPCS,0278,RC,,,,both,,,1780.38,1157.25,,,,,,,,,,,,,
CATHETER HD 14.5 FRX28 CM TUNN PLAS VAXCEL,SUP-2308265,CDM,C1881,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
STRUT FIX XSH QUIK ADJ MAXFRAME,SUP-2179160,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3399.49,2209.67,,,,,,,,,,,,,
INSTRUMENT TRAY 3X15 MM 11 GA INFLATABLE TAMP KYPHON XPANDER,SUP-2293648,CDM,C1894,HCPCS,0272,RC,,,,both,,,10846.82,7050.43,,,,,,,,,,,,,
RETAINER NSL L 19 X W 26 MM DIA 9 MM SZ 4 SIL NOSTRIL ARCH,SUP-2883404,CDM,2720000010,LOCAL,0272,RC,,,,both,,,536.06,348.44,,,,,,,,,,,,,
PLATE BNE HK ANK 8 HOLE,SUP-2389479,CDM,C1713,HCPCS,0278,RC,,,,both,,,2402.10,1561.36,,,,,,,,,,,,,
GRAFT TEND ACHILLES W CALCANEUS ALLGRFT FRZ DRY 195 38CM L,SUP-2307083,CDM,C1762,CPT,0278,RC,,,,both,,,6446.04,4189.93,,,,,,,,,,,,,
CATHETER ETER DLYS 135FR 16CM IC STR EXTN MAHRK ELITE,SUP-2613219,CDM,C1752,HCPCS,0278,RC,,,,both,,,283.51,184.28,,,,,,,,,,,,,
PLATE BNE METATARSOPHALANGEAL MED TI RIVAL VW,SUP-2645185,CDM,C1713,HCPCS,0278,RC,,,,both,,,5457.32,3547.26,,,,,,,,,,,,,
BRACE KNEE RT L ORTHOPRO HYPEREX,SUP-2324014,CDM,L1810,HCPCS,0272,RC,,,,both,,,277.04,180.08,,,,,,,,,,,,,
STIMULATOR KIT SPINE ACCSRY CRD,SUP-2356681,CDM,C1822,CPT,0278,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
ELECTRODE MONOPOLAR COAG 24 FRX3 MM BALL,SUP-2360971,CDM,C1713,HCPCS,0278,RC,,,,both,,,420.76,273.49,,,,,,,,,,,,,
SCREW BNE SCHNZ 4X125 MM DISP,SUP-2605953,CDM,C1713,HCPCS,0278,RC,,,,both,,,306.15,199.00,,,,,,,,,,,,,
GRAFT VASC ARTEGRAFT L 35 CM DIA 5 MM CLLGN BOV CAR ART,SUP-2120662,CDM,C1768,CPT,0278,RC,,,,both,,,3984.66,2590.03,,,,,,,,,,,,,
CATHETER VALVULOPLASTY ZMED L 85 CM DIA 6 FR 3 CM 10 MM,SUP-2659352,CDM,C1725,HCPCS,0272,RC,,,,both,,,1252.64,814.22,,,,,,,,,,,,,
SPLINT RST PAN MIT SP S LF,SUP-2163830,CDM,L3807,HCPCS,0274,RC,,,,both,,,81.29,52.84,,,,,,,,,,,,,
BIT DRL DIA 4.8 MM SHRT FOR HALF PIN NS DISP,SUP-2933111,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1585.76,1030.74,,,,,,,,,,,,,
PLATE BNE 45MM R NONBIOABSORBABLE DISPOSABLE TCP,SUP-2396861,CDM,C1713,HCPCS,0278,RC,,,,both,,,3406.90,2214.48,,,,,,,,,,,,,
CATHETER HD ALPHACURVE 14.5 FRX28 CM CHRONIC KT GLIDEPATH,SUP-2126480,CDM,C1881,HCPCS,0278,RC,,,,both,,,1374.85,893.65,,,,,,,,,,,,,
CANNULA LAP W/O VLV 6 MMX8.5 CM W/ INSUFFLATION STOPCOCK BLK,SUP-2767864,CDM,2720000010,LOCAL,0272,RC,,,,both,,,934.72,607.57,,,,,,,,,,,,,
HC Ot Apply Finger Splint Dynamic,PX-7612913100,CDM,29131,CPT,0761,RC,,,,both,,,606.00,393.90,,,,,,,,,,,,,
PLATE BNE L 90 DEG 6X0.5 MM 2X2 HOLE REVERSIBLE TI BLU NS LF,SUP-2431401,CDM,C1713,HCPCS,0278,RC,,,,both,,,1008.88,655.77,,,,,,,,,,,,,
PIN STBL 170MM ENDORING,SUP-2291689,CDM,C1713,HCPCS,0278,RC,,,,both,,,208.81,135.73,,,,,,,,,,,,,
HALOPERIDOL DECANOATE 50 MG/ML IM SOLN,RX-10163,CDM,J1631,HCPCS,0636,RC,71288-0502-02,NDC,,both,0.5,ML,57.50,37.37,,,,,,,,,,,,,
GRFT CRUSH CANC 1-4MM 60CC PUROS,SUP-2693927,CDM,C1713,HCPCS,0278,RC,,,,both,,,5554.66,3610.53,,,,,,,,,,,,,
LINER ACET NEUT I 5+ MM 28 MM PROV G7,SUP-2441113,CDM,C1776,CPT,0278,RC,,,,both,,,211.95,137.77,,,,,,,,,,,,,
HC So Lamotrigine,PX-3018017566,CDM,80175,CPT,0301,RC,,,,both,,,96.00,62.40,,,,,,,,,,,,,
NAIL IM L33CM OD10MM TIB CANN LCK DELT RUSS TAY,SUP-2342518,CDM,C1713,HCPCS,0278,RC,,,,both,,,1735.16,1127.85,,,,,,,,,,,,,
CUTTER ENDOSCP 15 MMX125 CM ROTOCUT G1 ADIPOSE MORCELLATOR,SUP-2261065,CDM,C1713,HCPCS,0278,RC,,,,both,,,1750.68,1137.94,,,,,,,,,,,,,
KIT MICROINTRODUCER 21GA L7CM 4FR 0.018IN GWIRE COAX STD S,SUP-2308254,CDM,C1894,HCPCS,0272,RC,,,,both,,,116.02,75.41,,,,,,,,,,,,,
RING EXT FIX DIA105 MM FULL RED NS DISP SMRT TSF,SUP-2933002,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4377.32,2845.26,,,,,,,,,,,,,
TUBE CHST 16FR L9 8 10IN OPN TIP STR FIRM RADPQ POLYVI CHL,SUP-2174292,CDM,C1729,HCPCS,0272,RC,,,,both,,,37.62,24.45,,,,,,,,,,,,,
SHELL HUM DIA40MM SHLDR CO CHROM BPLR ABS,SUP-2404519,CDM,C1776,CPT,0278,RC,,,,both,,,3808.82,2475.73,,,,,,,,,,,,,
DEVICE EXTR BLLN OD85MM 115 15MM DST TIP OD45FR ERCP MULT,SUP-2312989,CDM,2720000010,LOCAL,0272,RC,,,,both,,,499.61,324.75,,,,,,,,,,,,,
CATHETER ANGIOPLSTY STERLING MR L 135 CM BALLOON L 4 MM DIA2,SUP-2140052,CDM,C1725,HCPCS,0272,RC,,,,both,,,1197.28,778.23,,,,,,,,,,,,,
SHUNT SURG REG SNAP ASMBLY STRATA II,SUP-2628615,CDM,C1729,HCPCS,0272,RC,,,,both,,,14397.18,9358.17,,,,,,,,,,,,,
CATHETER ANGIOPLSTY POLARCATH L 135 CM BALLOON L 20 MM DIA 4,SUP-2141985,CDM,C1725,HCPCS,0272,RC,,,,both,,,2387.91,1552.14,,,,,,,,,,,,,
SET NEPHROSTOMY STENT L 7 CM DIA 4.7 FR CATH L 15 CM DIA 8.2,SUP-2835700,CDM,C1729,HCPCS,0272,RC,,,,both,,,219.89,142.93,,,,,,,,,,,,,
CANNULA ENDOSCP L 100 MM IN/OUTFLOW DRN SHRP TROCAR,SUP-2908669,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1786.66,1161.33,,,,,,,,,,,,,
HC Drain Cyst/Absces Dentoaveolar,PX-4504180000,CDM,41800,CPT,0450,RC,,,,both,,,214.00,139.10,,,,,,,,,,,,,
HC So Neuro CSF Prion Prtn Qual,PX-3100035066,CDM,0035U,CPT,0310,RC,,,,both,,,630.00,409.50,,,,,,,,,,,,,
BUR SURG DIA 6 MM HUB XLI ROSEN STRL REUSE HI-LINE,SUP-2928876,CDM,2720000010,LOCAL,0272,RC,,,,both,,,615.13,399.83,,,,,,,,,,,,,
DRESSING WND MULTLYR CLLGN MTRX 7X10 CM SHT MATRISTEM,SUP-2106526,CDM,Q4166,HCPCS,0636,RC,,,,both,,,3855.92,2506.35,,,,,,,,,,,,,
CATHETER IVUS VERISIGHT PRO DEFLECTION 120 DEG L 90 CM DIA 9,SUP-2904261,CDM,C1753,HCPCS,0278,RC,,,,both,,,10676.00,6939.40,,,,,,,,,,,,,
CATHETER CV TY 018 5 FRX60 CM 1 LUMEN TURBO-FLO,SUP-2759990,CDM,C1751,HCPCS,0278,RC,,,,both,,,366.41,238.17,,,,,,,,,,,,,
GUIDEWIRE ENDOSCOPIC 1.6 MM JETX,SUP-2836760,CDM,C1769,HCPCS,0272,RC,,,,both,,,7355.61,4781.15,,,,,,,,,,,,,
PLATE BNE STR SHT NEURO ULTRA LO PROF W/ TAB FOR SCR TI,SUP-2483895,CDM,C1713,HCPCS,0278,RC,,,,both,,,262.41,170.57,,,,,,,,,,,,,
MINI PLATE 20 3 ROUND HOLES L 17,SUP-2704952,CDM,C1713,HCPCS,0278,RC,,,,both,,,237.38,154.30,,,,,,,,,,,,,
ENDCAP ORTH L5MM FOR FEM IM NAIL SYS TRIGEN,SUP-2347069,CDM,C1713,HCPCS,0278,RC,,,,both,,,1200.05,780.03,,,,,,,,,,,,,
DEXAMETHASONE 4 MG/ML IJ SOLN (MIXTURES ONLY),RX-4081237,CDM,J1100,HCPCS,0636,RC,67457-0422-54,NDC,,both,0.5,ML,54.10,35.16,,,,,,,,,,,,,
WIRE PACE MYO/WIRE L 61 CM SZ 2-0 CRV 26 MM STR 89 MM SS WHT,SUP-2101191,CDM,2720000010,LOCAL,0272,RC,,,,both,,,39.25,25.51,,,,,,,,,,,,,
REAMER SURG DIA9MM PAT FLEX INTERCHANGEABLE HD W/ END CUT,SUP-2343580,CDM,2720000010,LOCAL,0272,RC,,,,both,,,841.39,546.90,,,,,,,,,,,,,
CATHETER ETER PICC 19FR 2 LUMN ARGY,SUP-2173951,CDM,C1751,HCPCS,0278,RC,,,,both,,,334.57,217.47,,,,,,,,,,,,,
STRAP SELF ADH BGE 1X18IN D RNG,SUP-2324798,CDM,L3908,HCPCS,0274,RC,,,,both,,,10.86,7.06,,,,,,,,,,,,,
THIOTEPA 15 MG IJ SOLR,RX-7901,CDM,J9342,HCPCS,0636,RC,00143-9565-01,NDC,,both,1,UN,2160.00,1404.00,,,,,,,,,,,,,
SURGICAL PROCEDURE PACK HEMORRHOID TRANSANAL,SUP-2385924,CDM,C1713,HCPCS,0278,RC,,,,both,,,1347.06,875.59,,,,,,,,,,,,,
FILTER VASC TRAPEASE L 90 CM DIA 6 FR CAVA DIA 30 MM NIT AC,SUP-2157010,CDM,C1880,HCPCS,0278,RC,,,,both,,,3560.76,2314.49,,,,,,,,,,,,,
PROSTHESIS OSSCLR DRNHFFR 09MM DIA SHAFT TTNM STPS SHOE FTP,SUP-2669514,CDM,L8613,CPT,0278,RC,,,,both,,,405.91,263.84,,,,,,,,,,,,,
SCREW BNE CRANIOFACIAL RESRB 17MMX6MM DELT SYS 4/EA,SUP-2364994,CDM,C1713,HCPCS,0278,RC,,,,both,,,647.12,420.63,,,,,,,,,,,,,
TAP SURG DIA6.5MM QUIK CONN FOR PLATING SYS PERI-LOC,SUP-2344003,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2558.47,1663.01,,,,,,,,,,,,,
RITUXIMAB-PVVR 100 MG/10ML IV SOLN,RX-148801,CDM,Q5119,HCPCS,0636,RC,00069-0238-01,NDC,,both,10,ML,2064.40,1341.86,,,,,,,,,,,,,
TUBE MYR OD1.14MM VENT BVL SIL ARMSTR,SUP-2313719,CDM,L8699,HCPCS,0278,RC,,,,both,,,50.46,32.80,,,,,,,,,,,,,
TRAZODONE HCL 150 MG PO TABS,RX-8084,CDM,6370000000,HCPCS,0637,RC,50268-0776-11,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
BUTTON SUT ADJUSTABLE FOR SFT TISS FIX ULTRABTTN,SUP-2341144,CDM,C1713,HCPCS,0278,RC,,,,both,,,1417.05,921.08,,,,,,,,,,,,,
SET PANCREATIC STENT ZMMN L 2 CM 5 FR 0.035 IN 2MM POLYETHYL,SUP-2169211,CDM,C2625,HCPCS,0278,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
FIXATION STPL 19X18X18MM,SUP-2401354,CDM,C1713,HCPCS,0278,RC,,,,both,,,4000.36,2600.23,,,,,,,,,,,,,
SAFETY PRCNTSS TRAY WTH ONSTP CATH 8F 7CM LOK LUER,SUP-2487936,CDM,C1729,HCPCS,0272,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
GRAFT NRV L5CM DIA12MM NEURO CONDUIT CLLGN WRP,SUP-2378818,CDM,C9353,HCPCS,0278,RC,,,,both,,,4179.34,2716.57,,,,,,,,,,,,,
HC So Factor 5,PX-3058522066,CDM,85220,CPT,0305,RC,,,,outpatient,,,280.00,182.00,,,,,,,,,,,,,
COIL EMB L8CM OD3MM 0.01IN 2D HELCL DETACH GDC-10,SUP-2365655,CDM,C1889,HCPCS,0278,RC,,,,both,,,1520.07,988.05,,,,,,,,,,,,,
DRESSING POST OPERATIVE RIGID ANK,SUP-2388202,CDM,L5420,HCPCS,0272,RC,,,,both,,,3995.27,2596.93,,,,,,,,,,,,,
SPLINT WRST L INSTABILITY INJ 8IN LOOP LOK W STAY FIRM SUPP,SUP-2276657,CDM,L3808,HCPCS,0272,RC,,,,both,,,16.23,10.55,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY LIVEWIRE L 110 CM DIA 7 FR SPC,SUP-2356887,CDM,C1730,HCPCS,0272,RC,,,,both,,,1648.50,1071.52,,,,,,,,,,,,,
SCREW CONN MTPHSEAL HUM ADPT STEM UNION FOR REVERSED II FX,SUP-2399857,CDM,C1713,HCPCS,0278,RC,,,,both,,,1328.22,863.34,,,,,,,,,,,,,
HOLDER NDL 4 1/2IN SMOOTH TUNGSTEN CARB WEBST,SUP-2129710,CDM,2720000010,LOCAL,0272,RC,,,,both,,,464.72,302.07,,,,,,,,,,,,,
HC So RBC Pretreatment Serum,PX-3028697866,CDM,86978,CPT,0302,RC,,,,both,,,351.00,228.15,,,,,,,,,,,,,
CONNECTOR SPNL L SZ 10 L51-59MM STD POST LUM THOR TI SCR,SUP-2254365,CDM,C1713,HCPCS,0278,RC,,,,both,,,4223.30,2745.14,,,,,,,,,,,,,
GRAFT VASC GELWEAVE L 50 CM DIA 34 MM SIDE BRANCH L 15 CM,SUP-2894590,CDM,C1768,CPT,0278,RC,,,,both,,,7319.34,4757.57,,,,,,,,,,,,,
GRAFT PLCNTA MEMBRN 14MM DISC ECM GRAFIX,SUP-2319159,CDM,Q4133,HCPCS,0636,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
HOOP EXT FIX 1/4 MED,SUP-2459039,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1000.09,650.06,,,,,,,,,,,,,
GUIDEWIRE VASC L 40 CM 0.018 IN L 5 CM NIT MANDREL SS COIL,SUP-2823946,CDM,C1769,HCPCS,0272,RC,,,,both,,,64.84,42.15,,,,,,,,,,,,,
HC Inj Cvad W/Fluoro,PX-3613659800,CDM,36598,CPT,0361,RC,,,,outpatient,,,3707.00,2409.55,,,,,,,,,,,,,
STEM HUM SZ 4B L78MM 132.5DEG STD SHLDR TI PRESSFIT,SUP-2388550,CDM,C1776,CPT,0278,RC,,,,both,,,12117.26,7876.22,,,,,,,,,,,,,
CAGE SPNL ANGLED 0 DEG 12X10-13 MM TI SM VBR,SUP-2431555,CDM,C1889,HCPCS,0278,RC,,,,both,,,23393.00,15205.45,,,,,,,,,,,,,
BRACE ORTHOPEDIC SM 8 IN RT WRST CNTOUR,SUP-2124889,CDM,L3931,HCPCS,0274,RC,,,,both,,,45.53,29.59,,,,,,,,,,,,,
GRAFT BIO TISS OMEGA3 MARIGEN 3.5X3CM FEN,SUP-2909163,CDM,Q4158,HCPCS,0636,RC,,,,both,,,2461.76,1600.14,,,,,,,,,,,,,
GRAFT HUM TISS ACHILLES TEND CALCANEOUS,SUP-2281656,CDM,C1713,HCPCS,0278,RC,,,,both,,,7426.10,4826.96,,,,,,,,,,,,,
CATHETER HEMODIALYSIS 27X22X9 CM 165 CC SET WITH HF1000 HEMO,SUP-2838669,CDM,2720000010,LOCAL,0272,RC,,,,both,,,888.24,577.36,,,,,,,,,,,,,
PLATE BNE L 62 MM SCREW DIA2.7 MM 8 SHFT H TI STR COMPACT,SUP-2907766,CDM,C1713,HCPCS,0278,RC,,,,both,,,5266.97,3423.53,,,,,,,,,,,,,
ORTHOSES THERMOPLASTIC WRST HND COCKUP,SUP-2319134,CDM,L3908,HCPCS,0274,RC,,,,both,,,188.40,122.46,,,,,,,,,,,,,
GRAFT VASC INTERGARD L 40 CM DIA 7 MM THK 0.35 MM POLYESTER,SUP-2227610,CDM,C1768,CPT,0278,RC,,,,both,,,1566.36,1018.13,,,,,,,,,,,,,
SHEATH INTRO FLX ANSEL L 55 CM OD 7 FR GUIDEWIRE 0.018/0.038,SUP-2169823,CDM,C1894,HCPCS,0272,RC,,,,both,,,181.68,118.09,,,,,,,,,,,,,
CAGE SPNL W18XH10XL45MM 15DEG C FBR REINF POLYMER,SUP-2418473,CDM,C1889,HCPCS,0278,RC,,,,both,,,334.88,217.67,,,,,,,,,,,,,
RING EXT FIX HALF 80 MM CARBON FIBER RINGFIX,SUP-2365281,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2662.72,1730.77,,,,,,,,,,,,,
SET INT FIX SCREW DIA1.5 MM CRANIOMAXILOFACIAL 3 LNG DOG BNE 15-7378X-12,SUP-2936397,CDM,C1713,HCPCS,0278,RC,,,,both,,,24190.56,15723.86,,,,,,,,,,,,,
SPACER SPNL 10X26MM H11 TO 15MM CALIB,SUP-2230719,CDM,C1821,HCPCS,0278,RC,,,,both,,,13188.00,8572.20,,,,,,,,,,,,,
GUIDEWIRE VASC ARW L 35 CM DIA 0.021 IN SS PERIPH,SUP-2383969,CDM,C1769,HCPCS,0272,RC,,,,both,,,26.38,17.15,,,,,,,,,,,,,
HEMOSTATIC KIT POLYSACCHARIDE 230 CM 2.8 MM 5 GM ENDOCLOT,SUP-2865644,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8478.00,5510.70,,,,,,,,,,,,,
SCREWDRIVER BLADE 2 MM RT ANGLED W/ DENT LATCH SS MAXDRIVE,SUP-2461284,CDM,2720000010,LOCAL,0272,RC,,,,both,,,416.30,270.59,,,,,,,,,,,,,
PLATE BNE L301MM 14 H ST R CNDYL S STL CRV LOK COMPR VAR,SUP-2177860,CDM,C1713,HCPCS,0278,RC,,,,both,,,6878.48,4471.01,,,,,,,,,,,,,
CEMENT BNE 40GM W/ GENT HI VISC RADPQ FOR REV SURG,SUP-2403494,CDM,C1713,HCPCS,0278,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
WIRE FIX SH L150MM FOR BRISTOW LATARJET INSTABILITY SHLDR,SUP-2256873,CDM,C1713,HCPCS,0278,RC,,,,both,,,386.22,251.04,,,,,,,,,,,,,
AB DISTRACTOR BODY END ACT  4315054,SUP-2844067,CDM,C1713,HCPCS,0278,RC,,,,both,,,17779.62,11556.75,,,,,,,,,,,,,
GUIDE TARGETING STD LT 2 VDR ACU LOC,SUP-2107132,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3912.44,2543.09,,,,,,,,,,,,,
COVER BUR H DIA14MM STD CRAN TI FAN BLDE TIMESH,SUP-2277539,CDM,C1713,HCPCS,0278,RC,,,,both,,,633.02,411.46,,,,,,,,,,,,,
DRESSING NSL L3.15IN 100% SYNTH PROPRIETARY POLYMER,SUP-2363655,CDM,2720000010,LOCAL,0272,RC,,,,both,,,778.72,506.17,,,,,,,,,,,,,
PLATE 4.5MM TI LCP TM STRAIGHT RECON 14 HOLES 265MM,SUP-2549514,CDM,C1713,HCPCS,0278,RC,,,,both,,,1704.93,1108.20,,,,,,,,,,,,,
COIL VASC NEST EMBOLUS L 7 CM DIA 6 MM STD SFT HELCL,SUP-2604642,CDM,C1889,HCPCS,0278,RC,,,,both,,,333.34,216.67,,,,,,,,,,,,,
HC So2 Porphobilinogenurine Quant,PX-3018411068,CDM,84110,CPT,0301,RC,,,,both,,,76.00,49.40,,,,,,,,,,,,,
BOOT WALKING CAM,SUP-2390668,CDM,L4387,HCPCS,0274,RC,,,,both,,,998.52,649.04,,,,,,,,,,,,,
PLATE BNE ANGLED BLADE 130 DEG 60 MM 60 MM 4 HOLE TI NS DCP,SUP-2569036,CDM,C1713,HCPCS,0278,RC,,,,both,,,1396.42,907.67,,,,,,,,,,,,,
TRAY TIBIALXL SZ 0 SALTO TALARIS,SUP-2244190,CDM,C1776,CPT,0278,RC,,,,both,,,19527.03,12692.57,,,,,,,,,,,,,
SHEATH ENH INSRT TS 8FRX11CM,SUP-2294565,CDM,C1894,HCPCS,0272,RC,,,,both,,,28.95,18.82,,,,,,,,,,,,,
PIN FIX L9IN DIA24MM ST S STL 3 SIDE SGL TRCR 1 END PNT,SUP-2150506,CDM,C1713,HCPCS,0278,RC,,,,both,,,25.94,16.86,,,,,,,,,,,,,
BLADE REPROC SHV 4.5MM FULL RAD BONECUTTER PLAT,SUP-2653220,CDM,2720000010,LOCAL,0272,RC,,,,both,,,77.84,50.60,,,,,,,,,,,,,
PLATE BNE 12 H TI STR FOR 2MM SCR MOD HND SYS,SUP-2191191,CDM,C1713,HCPCS,0278,RC,,,,both,,,1099.63,714.76,,,,,,,,,,,,,
GUIDEWIRE URO L150CM DIA0.035IN STR FLOP BENSTON TYP,SUP-2140200,CDM,C1769,HCPCS,0272,RC,,,,both,,,133.89,87.03,,,,,,,,,,,,,
PACEMAKER CARD INSIGNIA I ULTRA W 4.45 X H 5.88 CM THK 0.75,SUP-2148598,CDM,C1786,HCPCS,0275,RC,,,,both,,,17128.70,11133.65,,,,,,,,,,,,,
SET ENDOSCP BIOCOMPOSITE ACL TIGHTROPE FOR MED,SUP-2121123,CDM,C1776,CPT,0278,RC,,,,both,,,5297.18,3443.17,,,,,,,,,,,,,
MESH HERN W8XL12CM THK1MM EPTFE RECTANG 2 SIDE,SUP-2125740,CDM,C1781,HCPCS,0278,RC,,,,both,,,1104.65,718.02,,,,,,,,,,,,,
MESH SURG ELLIP 7X9 IN W/ FEN PORCINE COLLAMEND FM,SUP-2126253,CDM,C1763,HCPCS,0278,RC,,,,both,,,14217.61,9241.45,,,,,,,,,,,,,
CATHETER CTRL VEN L55CM L60CM OD5FR PWR INJ 2 LUMN GWIRE,SUP-2118962,CDM,C1751,HCPCS,0278,RC,,,,both,,,401.92,261.25,,,,,,,,,,,,,
IO FIX TRIO PLATE 10,SUP-2586666,CDM,C1713,HCPCS,0278,RC,,,,both,,,4766.52,3098.24,,,,,,,,,,,,,
COUNTERSINK BNE L37MM DIA3.5MM FOR 2.0/2.3 LAG SCR,SUP-2267854,CDM,C1713,HCPCS,0278,RC,,,,both,,,499.26,324.52,,,,,,,,,,,,,
PLATE BNE Z CRANIOFACIAL 4 HOLE REVERSIBLE TI GRY NS UNIV II,SUP-2422996,CDM,C1713,HCPCS,0278,RC,,,,both,,,857.57,557.42,,,,,,,,,,,,,
BIT DRILL DIA3.5MM CANNULATED 5MM SCREW,SUP-2465630,CDM,2720000010,LOCAL,0272,RC,,,,both,,,904.32,587.81,,,,,,,,,,,,,
PLATE BNE L386MM 18 H ST R CNDYL S STL LOK COMPR CRV FOR,SUP-2177092,CDM,C1713,HCPCS,0278,RC,,,,both,,,5398.92,3509.30,,,,,,,,,,,,,
GUIDEWIRE UROLOGICAL FIX COR 3 MM 0.038 INX80 CM SAFE-T-J,SUP-2835663,CDM,C1769,HCPCS,0272,RC,,,,both,,,116.97,76.03,,,,,,,,,,,,,
DEXTROSE 20 % IV SOLN,RX-2359,CDM,2580000003,HCPCS,0258,RC,00990-7935-19,NDC,,both,500,ML,123.30,80.14,,,,,,,,,,,,,
HC Remove Lung Catheter,PX-3613255200,CDM,32552,CPT,0361,RC,,,,inpatient,,,1289.00,837.85,,,,,,,,,,,,,
"HC Est Pt, Outpt Visit Level 5|RESIDENT/TEACHING PHYS SERV",PX-7619921500,CDM,99215,CPT,0761,RC,,,GC,both,,,369.00,239.85,,,,,,,,,,,,,
ROD EXT FIX L860MM DIA8MM SPAN L540MM 180DEG C FBR CVD,SUP-2188724,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1559.95,1013.97,,,,,,,,,,,,,
SLING ARM M FOR 11-13IN UNIV PREM QUAL BRTH EXTRA PD FAB,SUP-2196420,CDM,L3660,HCPCS,0274,RC,,,,both,,,164.38,106.85,,,,,,,,,,,,,
SET IM NAIL L 50 MM DIA 3 MM K WIRE CANN DRL BIT DEPTH GA,SUP-2904307,CDM,C1713,HCPCS,0278,RC,,,,both,,,4976.90,3234.98,,,,,,,,,,,,,
SCREW BNE LCK 3.5X24 MM 311351] DEPUY SYNTHES USA],SUP-2187399,CDM,C1713,HCPCS,0278,RC,,,,both,,,1435.61,933.15,,,,,,,,,,,,,
BASKET STONE RETRV L3.2MM DIA2.5CM GWIRE 0.035IN BILI DUCT,SUP-2149356,CDM,2720000010,LOCAL,0272,RC,,,,both,,,852.79,554.31,,,,,,,,,,,,,
SCREW BONE SELF TAPPING 2.4X6 MM CORTICAL CRUCIFORM RECESS S,SUP-2837810,CDM,C1713,HCPCS,0278,RC,,,,both,,,127.48,82.86,,,,,,,,,,,,,
HC 2d Echo Without Contrast - With Dop/Color Flow,PX-4839330601,CDM,93306,CPT,0483,RC,,,,both,,,3365.00,2187.25,,,,,,,,,,,,,
BLADE SAW L 13X70MM LAT MALL PROTECTED W/ RBBN RETRCT SALTO,SUP-2388889,CDM,2720000010,LOCAL,0272,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
PROSTHESIS OSS CAUSSE BCKT HNDL 0.4X5 MM 1.32 MM FLROPLAS,SUP-2638169,CDM,L8613,CPT,0278,RC,,,,both,,,450.72,292.97,,,,,,,,,,,,,
ALLOGRAFT BNE CUBE 8X8X8 MM FD DEMINERALIZED CANC LIFEFLEX,SUP-2866836,CDM,C1762,CPT,0278,RC,,,,both,,,781.55,508.01,,,,,,,,,,,,,
COVER BUR H DIA17MM 6 H CRANIOMAXILLOFACIAL BLU TI,SUP-2181546,CDM,C1713,HCPCS,0278,RC,,,,both,,,796.93,518.00,,,,,,,,,,,,,
TRAY HUM THK+0MM 0MM OFFSET CNTR REVERSED AEQUALIS ASCEND,SUP-2388720,CDM,C1776,CPT,0278,RC,,,,both,,,4661.33,3029.86,,,,,,,,,,,,,
HC Puncture/Aspiration Hematoma,PX-3611016000,CDM,10160,CPT,0361,RC,,,,both,,,1386.00,900.90,,,,,,,,,,,,,
PLEDGET SURGICAL W3/8XL0.374IN THK1.5MM PTFE RECTANGLE,SUP-2425486,CDM,C1768,CPT,0278,RC,,,,both,,,92.66,60.23,,,,,,,,,,,,,
GRAFT BNE SUB 5CC DBM PTTY INJ BIOCOMPOSITE ALLMTRX,SUP-2399057,CDM,C9359,HCPCS,0278,RC,,,,both,,,2141.48,1391.96,,,,,,,,,,,,,
ELECTRODE LOOP 24FR 90DEG 0.012IN CUT,SUP-2361448,CDM,2720000010,LOCAL,0272,RC,,,,both,,,331.52,215.49,,,,,,,,,,,,,
BIT DRL QC 2X110 MM 30 MM CALIB NS,SUP-2757822,CDM,2720000010,LOCAL,0272,RC,,,,both,,,395.14,256.84,,,,,,,,,,,,,
GRAFT VASC HEMSHLD GLD L 30 CM DIA 8 MM POLYESTER BOV CLLGN,SUP-2484046,CDM,C1768,CPT,0278,RC,,,,both,,,1737.61,1129.45,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 7X7 CM AMNIO MEMBRN MTRX NEOX,SUP-2135263,CDM,Q4148,HCPCS,0636,RC,,,,both,,,9404.30,6112.79,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 50 MM DIA 7 MM DEL SHTH 2.9ML,SUP-2936810,CDM,C1713,HCPCS,0278,RC,,,,both,,,8571.10,5571.21,,,,,,,,,,,,,
PLATE BNE ORTHOGNATHIC STRP STD 2 MM 3X10 HOLE MESHED TI NS,SUP-2467959,CDM,C1713,HCPCS,0278,RC,,,,both,,,758.50,493.02,,,,,,,,,,,,,
MESH HERN W10XL15CM FLAT MACRO X3 STD DISPOSABLE PARIETENE,SUP-2174737,CDM,C1781,HCPCS,0278,RC,,,,both,,,227.74,148.03,,,,,,,,,,,,,
BUR SURG SUCTION 35 MMX30 CM INTEGR IRRIGATION STR SHFT,SUP-2775985,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3096.42,2012.67,,,,,,,,,,,,,
KNIFE SURG BALLENGER SWVL 8 IN 3 MM STR,SUP-2474030,CDM,2720000010,LOCAL,0272,RC,,,,both,,,492.70,320.25,,,,,,,,,,,,,
GRAFT BONE 8ML CORT CANC DEMIN CONT G2 PRECIS,SUP-2307036,CDM,C1713,HCPCS,0278,RC,,,,both,,,3849.64,2502.27,,,,,,,,,,,,,
SET BLADE RTRCTR SHRT TEETH SPNL RGGLS RDMND FLEXI SPINE,SUP-2672161,CDM,2720000010,LOCAL,0272,RC,,,,both,,,9609.84,6246.40,,,,,,,,,,,,,
PLATE BONE L140MM 7 H RT PROX HUM LCK FOR 3.5MM SCR PERI-LOC,SUP-2348554,CDM,C1713,HCPCS,0278,RC,,,,both,,,13447.21,8740.69,,,,,,,,,,,,,
STEM RADIAL ELBW KATALYST,SUP-2610316,CDM,C1776,CPT,0278,RC,,,,both,,,9239.61,6005.75,,,,,,,,,,,,,
BUR DIAMOND RND 2.5MM,SUP-2736214,CDM,2720000010,LOCAL,0272,RC,,,,both,,,897.63,583.46,,,,,,,,,,,,,
PLATE BNE SM TI PMI LEFORT ORTHOGNATHIC 3D PRNT NS DISP,SUP-2934960,CDM,C1713,HCPCS,0278,RC,,,,both,,,20890.42,13578.77,,,,,,,,,,,,,
HC So Cardiolipin Antibody,PX-3028614766,CDM,86147,CPT,0302,RC,,,,both,,,434.00,282.10,,,,,,,,,,,,,
PLATE BNE FEM 3.5/4.5X251 MM LT PROX 8 HOLE NS VA-LCP,SUP-2757661,CDM,C1713,HCPCS,0278,RC,,,,both,,,7003.20,4552.08,,,,,,,,,,,,,
INSERTER LCK CAP,SUP-2207862,CDM,2780000010,LOCAL,0278,RC,,,,both,,,1563.72,1016.42,,,,,,,,,,,,,
VALVE CSF STD SM RICKHAM-STYLE RESERVOIR HI ULTRAVS,SUP-2666749,CDM,C1889,HCPCS,0278,RC,,,,both,,,3032.49,1971.12,,,,,,,,,,,,,
KYPHOPLASTY TRAY 15/3 OSTEO INTRO CDS SYS KYPHOPAK XPANDER,SUP-2665114,CDM,2720000010,LOCAL,0272,RC,,,,both,,,11617.00,7551.05,,,,,,,,,,,,,
BLADESTERILEABRADER BURR,SUP-2574153,CDM,2720000010,LOCAL,0272,RC,,,,both,,,302.92,196.90,,,,,,,,,,,,,
DEFIBRILLATOR CRD BPLR 74X50X14 MM VENTRIC ATLAS+ VR,SUP-2356530,CDM,C1722,HCPCS,0275,RC,,,,both,,,66568.00,43269.20,,,,,,,,,,,,,
CONTROLLER VENT ASST W EMGCY BK BTTRY HEARTMATE 3,SUP-2356029,CDM,C1713,HCPCS,0278,RC,,,,both,,,18651.60,12123.54,,,,,,,,,,,,,
SIDEPLATE STD BARL 130 DEG 14H STRL LCP DHHS,SUP-2547648,CDM,C1713,HCPCS,0278,RC,,,,both,,,3087.25,2006.71,,,,,,,,,,,,,
HC Ot Sensory Integrate 15 Min,PX-4309753300,CDM,97533,CPT,0430,RC,,,,both,,,149.00,96.85,,,,,,,,,,,,,
HC Sbrt Delivery,PX-3337737300,CDM,77373,CPT,0333,RC,,,,outpatient,,,18641.00,12116.65,,,,,,,,,,,,,
GUIDEWIRE VASC NEUROSCOUT 14 L 300 CM DSTL TIP L 43 CM DIA,SUP-2699306,CDM,C1769,HCPCS,0272,RC,,,,both,,,2850.15,1852.60,,,,,,,,,,,,,
COIL EMB 10 L6CM OD4MM COMPLX STRTCH RESIST FNSH V-TRAK SFT,SUP-2305161,CDM,C1889,HCPCS,0278,RC,,,,both,,,3171.40,2061.41,,,,,,,,,,,,,
ALLOGRAFT BNE CORTICAL 110-240X20 MM FRZN STRUT,SUP-2717910,CDM,C1762,CPT,0278,RC,,,,both,,,4699.26,3054.52,,,,,,,,,,,,,
GRAFT HUM TISS W5XL10CM THK.8-1.4MM ACELLULAR DERM MTRX,SUP-2402519,CDM,Q4126,HCPCS,0636,RC,,,,both,,,8022.70,5214.75,,,,,,,,,,,,,
GRAFT VASC GELSFT L 20 MM DIA12 MM POLYESTER GEL ABD PERIPH,SUP-2384940,CDM,C1768,CPT,0278,RC,,,,both,,,1688.88,1097.77,,,,,,,,,,,,,
PLATE BNE W135XL332MM THK42MM 18 H BILAT S STL NAR LOK,SUP-2185257,CDM,C1713,HCPCS,0278,RC,,,,both,,,2696.51,1752.73,,,,,,,,,,,,,
PLATE BNE W9XL73MM THK1MM 6 H TI 1/3 TBLR LIMIT CNTCT DYN,SUP-2190950,CDM,C1713,HCPCS,0278,RC,,,,both,,,517.97,336.68,,,,,,,,,,,,,
MARKER BRST BX XR 8 GA MAMTOM IDENTIFIER PRB TISS MICROMARK,SUP-2195655,CDM,A4648,CPT,0278,RC,,,,both,,,341.10,221.71,,,,,,,,,,,,,
CLAMP REPROC FIX EXT MULTI PIN 6 POS LG,SUP-2471393,CDM,2720000010,LOCAL,0272,RC,,,,both,,,550.66,357.93,,,,,,,,,,,,,
NEEDLE BX INTRO DISP 18GA 12CM,SUP-2139372,CDM,C1894,HCPCS,0272,RC,,,,both,,,104.28,67.78,,,,,,,,,,,,,
LOW PRFLE NEURO PLATE STRGHT 2 HOLE MED CP TTNM,SUP-2680998,CDM,C1713,HCPCS,0278,RC,,,,both,,,321.03,208.67,,,,,,,,,,,,,
POST EXT FIX 5.9 MMX28 MM LT TI INCORE LAPIDUS,SUP-2485803,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7303.83,4747.49,,,,,,,,,,,,,
GRAFT HUM TISS 25X30MM DECELLULARIZED DERM W/MATRACELL,SUP-2718701,CDM,Q4125,HCPCS,0636,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
KWIRE 3X285MM,SUP-2701537,CDM,2720000010,LOCAL,0272,RC,,,,both,,,540.71,351.46,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9% IV BOLUS (PER WEIGHT),RX-40901010,CDM,J7030,HCPCS,0250,RC,00338-0049-04,NDC,,both,1000,ML,42.50,27.62,,,,,,,,,,,,,
DRILL HND OD4MM BONE CANN OVR QUIK REL,SUP-2319582,CDM,2720000010,LOCAL,0272,RC,,,,both,,,580.90,377.58,,,,,,,,,,,,,
PREDNISONE 1 MG PO TABS,RX-6493,CDM,J7512,HCPCS,0637,RC,00054-8739-25,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
SCREW BNE LAG 12.7X105 MM,SUP-2314153,CDM,C1713,HCPCS,0278,RC,,,,both,,,2001.75,1301.14,,,,,,,,,,,,,
TUBING ASPIR PUMP/CANISTER,SUP-2748589,CDM,2720000010,LOCAL,0272,RC,,,,both,,,438.82,285.23,,,,,,,,,,,,,
SPLINT FT AD SM SZ 3-6 UNISX LT PREFABRICATED POST LEAF,SUP-2325044,CDM,L4398,HCPCS,0272,RC,,,,both,,,82.08,53.35,,,,,,,,,,,,,
GRAFT HUM TISS L 10ML BONE MTRX CELLULAR OSTEOCEL PRO,SUP-2310457,CDM,C1713,HCPCS,0278,RC,,,,both,,,9734.00,6327.10,,,,,,,,,,,,,
INTRODUCER TRANSSEPTAL 85FRX60CM TM,SUP-2357191,CDM,C1893,HCPCS,0272,RC,,,,both,,,320.28,208.18,,,,,,,,,,,,,
DIREXION/SINGLE/021/J/1RO/105,SUP-2652824,CDM,C1887,HCPCS,0272,RC,,,,both,,,1868.30,1214.39,,,,,,,,,,,,,
ALLOGRAFT BNE FIBULAR SHFT 160 MMX0.1 CM FRZN,SUP-2717862,CDM,C1762,CPT,0278,RC,,,,both,,,4814.59,3129.48,,,,,,,,,,,,,
HC X-Ray Foot Min 3 Views Complete,PX-3207363000,CDM,73630,CPT,0320,RC,,,,both,,,680.00,442.00,,,,,,,,,,,,,
STENT URET 7FR L28CM UROPS OBSTRUCTION,SUP-2312715,CDM,C2617,HCPCS,0278,RC,,,,both,,,659.40,428.61,,,,,,,,,,,,,
GRAFT VASC FLIXENE L 35 CM DIA 4-7 MM EPTFE TRMPT GRAD WALL,SUP-2227244,CDM,C1768,CPT,0278,RC,,,,both,,,4239.00,2755.35,,,,,,,,,,,,,
CATHETER HD LT 15 FRX19 CM NEXTSTEP RETROGRADE,SUP-2383435,CDM,C1750,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
RESUSCITATION KIT DL 41 FR 20 CC 140 CC ESOPH COMBITUBE,SUP-2240633,CDM,C1713,HCPCS,0278,RC,,,,both,,,414.48,269.41,,,,,,,,,,,,,
SNARE ENDOSCP POLYP BARB LOOP ASMBLY SHTH WIRE COLONSCP,SUP-2462427,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1469.52,955.19,,,,,,,,,,,,,
SUBSTITUTE BONE GRFT 90CC CORT CANC CHIP MORSELIZED BONE,SUP-2307053,CDM,C1713,HCPCS,0278,RC,,,,both,,,4292.69,2790.25,,,,,,,,,,,,,
HC Quant Diff Pulm Prfusion & Ventlaj W/WO Imaging,PX-3417859800,CDM,78598,CPT,0341,RC,,,,both,,,4641.00,3016.65,,,,,,,,,,,,,
SCREW BONE CANN SELF-COMPRESSIVE 2.6MMX24MM,SUP-2224026,CDM,C1713,HCPCS,0278,RC,,,,both,,,1369.04,889.88,,,,,,,,,,,,,
MIXER BNE CEM MINI SMARTMIX,SUP-2253059,CDM,2720000010,LOCAL,0272,RC,,,,both,,,232.36,151.03,,,,,,,,,,,,,
ARM EXTN 5MM VAR ANG W/ 4MM BLIND SCR AXSOS 3,SUP-2365358,CDM,C1713,HCPCS,0278,RC,,,,both,,,1429.96,929.47,,,,,,,,,,,,,
GRAFT SFT TISS X THCK 40X20 CM RECON TISS MTRX STRATTICE,SUP-2496346,CDM,Q4130,HCPCS,0636,RC,,,,both,,,79203.36,51482.18,,,,,,,,,,,,,
GRAFT HUM TISS W2XL3CM THK100UM AMNIO MEMBRN AMBIO5,SUP-2247196,CDM,V2790,HCPCS,0278,RC,,,,both,,,1648.50,1071.52,,,,,,,,,,,,,
PLATE BNE 6 H S STL LOK STR FOR ANK FRAC MGMT,SUP-2123027,CDM,C1713,HCPCS,0278,RC,,,,both,,,1491.50,969.47,,,,,,,,,,,,,
GUIDE SURG SZ 03-02 MOD SET FOR TOT KNEE ARTHROPLASTY SIGN,SUP-2136775,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
SHEATH INTRO CHARIOT L 65 CM DIA 7 FR STR TIP XCUT LG LUMEN,SUP-2140079,CDM,C1894,HCPCS,0272,RC,,,,both,,,204.10,132.66,,,,,,,,,,,,,
PLATE BONE L62MM 5 H 1/3 TBLR BILAT NONCOMPRESSION RIG FOR,SUP-2348956,CDM,C1713,HCPCS,0278,RC,,,,both,,,615.25,399.91,,,,,,,,,,,,,
COMPONENT TIB L MOD NEUT ROTATIONAL KNEE ENDO MOD,SUP-2265074,CDM,C1776,CPT,0278,RC,,,,both,,,9539.32,6200.56,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9% IV BOLUS (PER WEIGHT),RX-40901010,CDM,J7040,HCPCS,0250,RC,00264-7800-10,NDC,,both,500,ML,29.80,19.37,,,,,,,,,,,,,
PERI-LOC 3.5MM S-T LOCK SCREW 16MM,SUP-2819136,CDM,C1713,HCPCS,0278,RC,,,,both,,,1023.39,665.20,,,,,,,,,,,,,
PLATE BONE W5XL32MM THK1MM 6 H BILAT TI STR RIG NEUT DYN,SUP-2191043,CDM,C1713,HCPCS,0278,RC,,,,both,,,860.52,559.34,,,,,,,,,,,,,
HEAD HUM DIA54MM THK23MM SHLDR CO CHROM REPL PROS AEQUALIS,SUP-2388634,CDM,C1776,CPT,0278,RC,,,,both,,,7917.51,5146.38,,,,,,,,,,,,,
PLATE BNE L120MM 7 H ST R SUP CLAV S STL LOK COMPR W/ LAT,SUP-2177374,CDM,C1713,HCPCS,0278,RC,,,,both,,,3010.26,1956.67,,,,,,,,,,,,,
SPLINT FT AD SM SZ 3-6 UNISX LT PREFABRICATED POST LEAF,SUP-2325044,CDM,L4398,HCPCS,0274,RC,,,,both,,,82.08,53.35,,,,,,,,,,,,,
CATHETER URET 4FR L70CM 0.025IN OPN END FOR DRNGE RG,SUP-2171215,CDM,C1758,HCPCS,0278,RC,,,,both,,,50.15,32.60,,,,,,,,,,,,,
HEAD FEM DIA36MM +0MM OFFSET ZIRCONIUM UNIV TAPR STD OFFSET 65190136] STRYKER CORP],SUP-2364698,CDM,C1776,CPT,0278,RC,,,,both,,,527.52,342.89,,,,,,,,,,,,,
SCREW BNE 1.5X18MM CORT HEXADRIVE 4,SUP-2268057,CDM,C1713,HCPCS,0278,RC,,,,both,,,243.66,158.38,,,,,,,,,,,,,
SHELL ACET DIA36MM TI ALLOY POR HA CALCICOAT CERAMIC MH PRI,SUP-2210210,CDM,C1776,CPT,0278,RC,,,,both,,,6592.43,4285.08,,,,,,,,,,,,,
CATHETER KT BIO-STABLE NON-VALVED,SUP-2118833,CDM,C1751,HCPCS,0278,RC,,,,both,,,310.86,202.06,,,,,,,,,,,,,
PLATE BONE CMPRSSN 25MML HLX2 1.1MM THK STNLSS STEEL F/3.5MM,SUP-2494112,CDM,C1713,HCPCS,0278,RC,,,,both,,,320.85,208.55,,,,,,,,,,,,,
PIN FIX L16.8CM DIA4.8MM CORT S STL SELF TAP DRL,SUP-2409697,CDM,C1713,HCPCS,0278,RC,,,,both,,,382.95,248.92,,,,,,,,,,,,,
VEST TRAC L112CM DIA76MM SYNTH LNR TALL COMPATIBLE ADV,SUP-2255764,CDM,L0810,HCPCS,0274,RC,,,,both,,,4505.90,2928.83,,,,,,,,,,,,,
SET HAD CATH AD 14FR L15CM POLYUR ADMIN BASIC DBL LUMN STR,SUP-2266964,CDM,C1752,HCPCS,0278,RC,,,,both,,,237.38,154.30,,,,,,,,,,,,,
HC Perq Replacement Gtube Req Revj Gstrst Trc,PX-3614376300,CDM,43763,CPT,0361,RC,,,,both,,,935.00,607.75,,,,,,,,,,,,,
HC So2enzyme Activitycells/Tissue,PX-3018265768,CDM,82657,CPT,0301,RC,,,,both,,,85.00,55.25,,,,,,,,,,,,,
OBTURATOR SHTH FAST-CATH SWARTZ SR L 15 CM DIA 6 FR W/ HUB,SUP-2355497,CDM,C1893,HCPCS,0272,RC,,,,both,,,19.63,12.76,,,,,,,,,,,,,
IMPLANT COCHLEAR CNTOUR ADV ELECTRD NUCLS,SUP-2165046,CDM,L8614,HCPCS,0278,RC,,,,both,,,48670.00,31635.50,,,,,,,,,,,,,
SHEATH INTRO CHARIOT L 90 CM DIA 8 FR STR TIP XCUT LG LUMEN,SUP-2140081,CDM,C1894,HCPCS,0272,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
MICROSPHERE EMB 700-900UM GRN TRISACRYL IN 2ML PREFIL SYR,SUP-2303422,CDM,C1889,HCPCS,0278,RC,,,,both,,,778.72,506.17,,,,,,,,,,,,,
HC So Aluminum,PX-3018210866,CDM,82108,CPT,0301,RC,,,,both,,,497.00,323.05,,,,,,,,,,,,,
BIT DRL L485MM DIA4.5/6.5MM TI STP L QUIK CPL FOR INFERIOR 03010078] DEPUY SYNTHES USA],SUP-2178865,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1583.91,1029.54,,,,,,,,,,,,,
CATHETER ANGIOPLSTY OTW 5 FRX130 CM 4X150 MM LUTONIX BSLX3513041505F] BARD PERIPHERAL VASCULAR],SUP-2127969,CDM,C2623,HCPCS,0278,RC,,,,both,,,4867.00,3163.55,,,,,,,,,,,,,
DILATOR URETH OD26FR BAL L180XOD8.7MM SHFT L30CMXOD7FR COUDE,SUP-2141678,CDM,C1726,HCPCS,0272,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
BLADE OSTEOTOM W10XL140MM S STL FLEX THN,SUP-2342367,CDM,2720000010,LOCAL,0272,RC,,,,both,,,571.48,371.46,,,,,,,,,,,,,
INSTRUMENT TRAY 3X15 MM INFLATABLE BNE TAMP KYPHON XPANDER,SUP-2293650,CDM,C1894,HCPCS,0272,RC,,,,both,,,7065.00,4592.25,,,,,,,,,,,,,
RESERVOIR SHUNT LG LUMPERITON CSF 2 MTL CONN SPETZLER,SUP-2851455,CDM,C1889,HCPCS,0278,RC,,,,both,,,1109.55,721.21,,,,,,,,,,,,,
GRAFT DURA L 1 X W 1 IN THK 0.6 MM TYP I CLLGN BOV ACHILLES,SUP-2889758,CDM,C1763,HCPCS,0278,RC,,,,both,,,957.39,622.30,,,,,,,,,,,,,
HC Cysto Bladder W/Ureteral Catheterization,PX-4505200500,CDM,52005,CPT,0450,RC,,,,both,,,2099.00,1364.35,,,,,,,,,,,,,
GRAFT ALLGRFT AMNIO MEMBRN 1.5CMX2CM AMBIODRY,SUP-2247195,CDM,V2790,HCPCS,0274,RC,,,,both,,,1805.50,1173.57,,,,,,,,,,,,,
COMPONENT GLEN FIX 44 HAP CONVX MTL BK BASE ARW,SUP-2224545,CDM,C1776,CPT,0278,RC,,,,both,,,6280.00,4082.00,,,,,,,,,,,,,
ENDCAP SPNL 5,SUP-2361819,CDM,C1889,HCPCS,0278,RC,,,,both,,,438.50,285.02,,,,,,,,,,,,,
INSERT TIB SZ 2 THK12MM POST STBL FIX GMK,SUP-2267477,CDM,C1776,CPT,0278,RC,,,,both,,,3415.66,2220.18,,,,,,,,,,,,,
PLATE BNE SCREW DIA 3/3.5/4 MM LG TI ALLOY LT 1ST SEC,SUP-2907560,CDM,C1713,HCPCS,0278,RC,,,,both,,,6804.60,4422.99,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED BPLR FIX CEM,SUP-2212515,CDM,C1776,CPT,0278,RC,,,,both,,,5983.27,3889.13,,,,,,,,,,,,,
PLATE BNE L118MM 9 H RECON FOR 35MM SCR UNIV LOK SYS,SUP-2199389,CDM,C1713,HCPCS,0278,RC,,,,both,,,1542.09,1002.36,,,,,,,,,,,,,
SET SUPRPUB CATH 10FR L30CM NDL 18GA INCL MCOT LOK CONN TB,SUP-2171108,CDM,C2627,HCPCS,0272,RC,,,,both,,,252.14,163.89,,,,,,,,,,,,,
GUIDEWIRE VASC MORPHEUS L 130 CM DIA 0.018 IN PLAT TIP,SUP-2117374,CDM,C1769,HCPCS,0272,RC,,,,both,,,182.43,118.58,,,,,,,,,,,,,
PLATE BNE L172MM 8 H L ANTEROMEDIAL DST TIB S STL VAR ANG,SUP-2177661,CDM,C1713,HCPCS,0278,RC,,,,both,,,5625.59,3656.63,,,,,,,,,,,,,
ELECTRODE LOOP L WITH CABLE 30DEG TELESCOPE,SUP-2721001,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1600.83,1040.54,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP L150CM OD0.025IN OD14FR INTRO 3CM ANG TIP,SUP-2139344,CDM,C1769,HCPCS,0272,RC,,,,both,,,163.03,105.97,,,,,,,,,,,,,
BLADE REAMER 38 MM PATELLAR FOR RM SYS,SUP-2201494,CDM,2720000010,LOCAL,0272,RC,,,,both,,,602.88,391.87,,,,,,,,,,,,,
CATHETER INFUSION PMP 4 ML/HR 2X5 IN 275 CC,SUP-2365200,CDM,C2626,HCPCS,0278,RC,,,,both,,,546.36,355.13,,,,,,,,,,,,,
COIL VASC I-ED COIL PRIMARY L 15 CM DIA 0.010 IN SECONDARY,SUP-2865282,CDM,C1889,HCPCS,0278,RC,,,,both,,,5871.80,3816.67,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 40 CM DIA 8 MM RNG L 20 CM EPTFE,SUP-2396273,CDM,C1768,CPT,0278,RC,,,,both,,,2436.64,1583.82,,,,,,,,,,,,,
PLATE BNE ACROMION RT SCAPULA 7 HOLE,SUP-2106427,CDM,C1713,HCPCS,0278,RC,,,,both,,,10208.14,6635.29,,,,,,,,,,,,,
THORACENTESIS TRAY PGTL 6 FRX16 CM LIDO SAFE-T-CENTESIS LF,SUP-2428006,CDM,C1729,HCPCS,0272,RC,,,,both,,,168.99,109.84,,,,,,,,,,,,,
NAIL IM TRIM 2.4X30 MM 2 IMPL BIO INTEGRATIVE OSSIOFIBER,SUP-2641886,CDM,C1713,HCPCS,0278,RC,,,,both,,,5488.72,3567.67,,,,,,,,,,,,,
CATHETER SPNL FOR USE W/ INTRO NDL SPINECATH,SUP-2341606,CDM,C1754,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
PROGRAMMER NEUROSTIMULATOR W73XH14CM THK20CM 02KG SCRN 35IN,SUP-2357680,CDM,C1787,HCPCS,0278,RC,,,,both,,,4827.94,3138.16,,,,,,,,,,,,,
GUIDEWIRE VASC L145CM OD0035IN 3MM TIP CRV RAD PTFE MOVABLE,SUP-2167917,CDM,C1769,HCPCS,0272,RC,,,,both,,,54.17,35.21,,,,,,,,,,,,,
BIT DRL QC 2 MM,SUP-2646723,CDM,2720000010,LOCAL,0272,RC,,,,both,,,285.80,185.77,,,,,,,,,,,,,
CATHETER ANGIOPLSTY ATLS L 75 CM BALLOON L 4 CM DIA18 MM,SUP-2127936,CDM,C1725,HCPCS,0272,RC,,,,both,,,1130.40,734.76,,,,,,,,,,,,,
FIBER LASER N CONTACT SUBMERSIBLE FLAT,SUP-2227278,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1491.50,969.47,,,,,,,,,,,,,
PLATE BNE CALCANEAL RT 2 HOLE LCK SM EXTN ALPS MIS,SUP-2423261,CDM,C1713,HCPCS,0278,RC,,,,both,,,2869.33,1865.06,,,,,,,,,,,,,
KIT SOFT TISSUE FIXATION TACTILE ACCESS AND EZ SAWITCH PORTA,SUP-2824688,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5369.40,3490.11,,,,,,,,,,,,,
PLATE BONE SHFT L366MM BLDE L60MM THK4.8MM 95DEG 22 H BILAT,SUP-2185462,CDM,C1713,HCPCS,0278,RC,,,,both,,,3567.67,2318.99,,,,,,,,,,,,,
HC Drain/Inj Joint/Bursa W/US|BILATERAL PROCEDURE,PX-3612061100,CDM,20611,CPT,0361,RC,,,50,both,,,3707.00,2409.55,,,,,,,,,,,,,
HC Closed Tx of Ankle Dislocation,PX-4502784000,CDM,27840,CPT,0450,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
AUGMENT FEM L72.5MM THICKNESS 5MM LT MEDL RT LAT KNEE,SUP-2407760,CDM,C1776,CPT,0278,RC,,,,both,,,2917.06,1896.09,,,,,,,,,,,,,
EXPANDER TISS BRST TEXT SURF + LO POLE FULL HT 600-720CC FIL,SUP-2353025,CDM,C1789,HCPCS,0278,RC,,,,both,,,3611.00,2347.15,,,,,,,,,,,,,
ANCHOR SUTURE KNOTLESS 4.5/5.5 MM FOR 10314 10315,SUP-2762151,CDM,C1713,HCPCS,0278,RC,,,,both,,,295.16,191.85,,,,,,,,,,,,,
SCREW BONE LOCKING 5.7X110 MM CORTICAL SELFDRILLING SELFTAPP,SUP-2837336,CDM,C1713,HCPCS,0278,RC,,,,both,,,2400.09,1560.06,,,,,,,,,,,,,
COMPONENT FEM SZ 3 RT KNEE OXINIUM CEM ASMBLY HNG LEGION,SUP-2346251,CDM,C1776,CPT,0278,RC,,,,both,,,28674.48,18638.41,,,,,,,,,,,,,
BUR SURG CANN 6 MM FLX SHFT,SUP-2598325,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2527.70,1643.00,,,,,,,,,,,,,
MESH HERN FLAT SHT 6X6 IN SQ RND FLX KNITTED PROLITE ULTRA,SUP-2227247,CDM,C1781,HCPCS,0278,RC,,,,both,,,112.79,73.31,,,,,,,,,,,,,
PLATE BNE L 201 X W 10.9 MM THK 3.4 MM SCREW DIA 3.5 MM 16 H 72463716,SUP-2933029,CDM,C1713,HCPCS,0278,RC,,,,both,,,6063.97,3941.58,,,,,,,,,,,,,
CATHETER TRAY 10 FRX90 CM CV PASV 2,SUP-2308259,CDM,C1751,HCPCS,0278,RC,,,,both,,,1018.77,662.20,,,,,,,,,,,,,
SLEEVE KNEE NEOPRENE OPN PAT BLK SM 1 8IN,SUP-2319239,CDM,L1810,HCPCS,0274,RC,,,,both,,,19.15,12.45,,,,,,,,,,,,,
TBO-FILGRASTIM 300 MCG/0.5ML SC SOSY,RX-124231,CDM,J1447,HCPCS,0636,RC,63459-0910-11,NDC,,both,0.5,ML,737.10,479.11,,,,,,,,,,,,,
STENT URET STR 0.035 IN 3 CM 8 FRX22 CM 6 FR PERCFLX POLARIS,SUP-2457662,CDM,C2617,HCPCS,0278,RC,,,,both,,,490.53,318.84,,,,,,,,,,,,,
GRAFT BNE L60MM FIBULAR SHFT SEG FRZ DRY MATRIGRFT,SUP-2264769,CDM,C1713,HCPCS,0278,RC,,,,both,,,1628.18,1058.32,,,,,,,,,,,,,
GUIDEWIRE VASC HYDR JAGWIRE L 260 CM DIA 0.035 IN SS NIT,SUP-2436462,CDM,C1769,HCPCS,0272,RC,,,,both,,,551.38,358.40,,,,,,,,,,,,,
PLATE BNE L84MM 0DEG 7 H ANK TI BILAT 1 3 TBLR STR LOK COMPR,SUP-2398344,CDM,C1713,HCPCS,0278,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
PLATE BONE L65MM 8 H S STL QTR TBLR ECT,SUP-2198594,CDM,C1713,HCPCS,0278,RC,,,,both,,,171.92,111.75,,,,,,,,,,,,,
CAGE SPNL CORPECTOMY 0 DEG 28X36X82-106 MM EXT HSNG CAPRI,SUP-2519629,CDM,C1889,HCPCS,0278,RC,,,,both,,,6499.80,4224.87,,,,,,,,,,,,,
GUIDEWIRE ORTH L1000MM DIA2.4MM SMOOTH BLNT TIP S STL,SUP-2413016,CDM,C1769,HCPCS,0272,RC,,,,both,,,289.79,188.36,,,,,,,,,,,,,
COIL EMB L2CM DIA0.02IN LOOP DIA2MM COMPLX EXTRA SFT FILL,SUP-2323425,CDM,C1889,HCPCS,0278,RC,,,,both,,,5548.38,3606.45,,,,,,,,,,,,,
IMMOBILIZER ORTH CUTAWAY MED 20 IN KNEE ADJ PERF FOAM,SUP-2194893,CDM,L1830,CPT,0274,RC,,,,both,,,53.38,34.70,,,,,,,,,,,,,
STENT BILI S.M.A.R.T. L 60 MM DIA 8 MM GUIDEWIRE 0.018 IN,SUP-2158926,CDM,C1876,HCPCS,0278,RC,,,,both,,,3755.44,2441.04,,,,,,,,,,,,,
BUTTON SUT L12MM LOOP L15MM TI RETROBTTN,SUP-2121373,CDM,C1713,HCPCS,0278,RC,,,,both,,,737.90,479.63,,,,,,,,,,,,,
HC Inject Epidural Blood/Clot Patch,PX-3616227300,CDM,62273,CPT,0361,RC,,,,both,,,1586.00,1030.90,,,,,,,,,,,,,
MESH SURG W5XL10CM THK1MM BIOMATERIAL MYCROMESH,SUP-2395359,CDM,C1781,HCPCS,0278,RC,,,,both,,,317.14,206.14,,,,,,,,,,,,,
CONNECTOR SPNL SM SZ 1 L17-18MM STD POST LUM THOR TI SCR,SUP-2254356,CDM,C1713,HCPCS,0278,RC,,,,both,,,3680.08,2392.05,,,,,,,,,,,,,
MICROCATHETER VASC RENEGADE 18 L 150 CM PROX/DSTL,SUP-2367822,CDM,C1887,HCPCS,0272,RC,,,,both,,,2527.70,1643.00,,,,,,,,,,,,,
GRAFT DERMAL STRUCTURAL ULTRA THCK 24X12 CMX1.8-4 MM FLEXHD,SUP-2307487,CDM,Q4128,HCPCS,0636,RC,,,,both,,,27286.82,17736.43,,,,,,,,,,,,,
HEMOSTASIS VALVE PACK ADVANTAGE+ WATCHDOG,SUP-2798392,CDM,2720000010,LOCAL,0272,RC,,,,both,,,585.92,380.85,,,,,,,,,,,,,
CATHETER CV TY 7 FRX15 CM 3L CUTLMY701JABRMCUSTOM0001,SUP-2759793,CDM,C1751,HCPCS,0278,RC,,,,both,,,449.65,292.27,,,,,,,,,,,,,
TUBING IRRIG HI FLO RIO SYS ANSPACH EMAX 2,SUP-2368423,CDM,2720000010,LOCAL,0272,RC,,,,both,,,153.86,100.01,,,,,,,,,,,,,
BLADE LARYNGOSCOPE SIZE 4 L207MM M GREENLINE MILLER FIBEROPT,SUP-2828246,CDM,2720000010,LOCAL,0272,RC,,,,both,,,328.26,213.37,,,,,,,,,,,,,
BLADE REPROC SHV TRICUT STR SHAFT 11CM W/O TUBE 4MM,SUP-2653216,CDM,2720000010,LOCAL,0272,RC,,,,both,,,218.32,141.91,,,,,,,,,,,,,
GENERATOR PACEMKR CYLOS DR 2 CHMBR ADV DDDR IS1 BPLR CONN,SUP-2138178,CDM,C1785,HCPCS,0275,RC,,,,both,,,17552.60,11409.19,,,,,,,,,,,,,
TROCAR LAP TIP L12MM BLNT DISP SPCMKR,SUP-2283315,CDM,2720000010,LOCAL,0272,RC,,,,both,,,541.24,351.81,,,,,,,,,,,,,
SAW GUIDE FOR CHILD/ADOLESCENT OSTEOTOMY PLATES,SUP-2548628,CDM,C1713,HCPCS,0278,RC,,,,both,,,2077.86,1350.61,,,,,,,,,,,,,
WIRE FIX L285MM DIA2MM TI TRCR PNT SMOOTH DBL SHRP TIP K,SUP-2193150,CDM,C1713,HCPCS,0278,RC,,,,both,,,338.90,220.28,,,,,,,,,,,,,
HOOK LENS SINSKEY II 90 DEG 4-5/8 IN BLNT FLAT HNDL ANGLED,SUP-2871892,CDM,2720000010,LOCAL,0272,RC,,,,both,,,346.91,225.49,,,,,,,,,,,,,
ZINC 50 MG PO TABS,RX-8863,CDM,6370000000,HCPCS,0637,RC,74312-0020-60,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
BIT DRL QC 2.4X100 MM FOR VAR ANGLE NS LCP,SUP-2424151,CDM,2720000010,LOCAL,0272,RC,,,,both,,,374.76,243.59,,,,,,,,,,,,,
ALTEPLASE (ACTIVASE) 100 MG VIAL IV INFUSION,RX-4081202,CDM,J2997,HCPCS,0636,RC,50242-0085-27,NDC,,both,1,UN,50602.10,32891.36,,,,,,,,,,,,,
PLATE BNE Y MIC XLN 1.5 MM TI LEVEL 1,SUP-2461681,CDM,C1713,HCPCS,0278,RC,,,,both,,,565.99,367.89,,,,,,,,,,,,,
HC Fluoro Guidance Spine,PX-3207700300,CDM,77003,CPT,0320,RC,,,,both,,,987.00,641.55,,,,,,,,,,,,,
PUMP INFUSION PAIN SINGLE AUTO,SUP-2361461,CDM,C2626,HCPCS,0278,RC,,,,both,,,1711.30,1112.34,,,,,,,,,,,,,
C WIRE FIX L5IN DIA0.062IN DBL END SPADE TIP,SUP-2166344,CDM,C1713,HCPCS,0278,RC,,,,both,,,21.89,14.23,,,,,,,,,,,,,
SET INTRO S-MAK L 10 CM DIA 4 FR L 40 CM SS STIFF DIL MINI,SUP-2889705,CDM,C1894,HCPCS,0272,RC,,,,both,,,98.66,64.13,,,,,,,,,,,,,
STENT NEURO LVIS EVO UNDEPLOYED L 44 MM LABELED L 24 MM DIA,SUP-2905256,CDM,C1876,HCPCS,0278,RC,,,,both,,,22466.70,14603.35,,,,,,,,,,,,,
ALLOGRAFT BNE STRP 50X10X5 MM,SUP-2225966,CDM,C1889,HCPCS,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
HC US Guidance or Line Place W/ Permanent Image - Anes,PX-4027693701,CDM,76937,CPT,0402,RC,,,,inpatient,,,791.00,514.15,,,,,,,,,,,,,
CATHETER PICC AD 5FR L55CM 2 LUMN NRS PWR INJ N COAT CT,SUP-2125548,CDM,C1751,HCPCS,0278,RC,,,,both,,,507.52,329.89,,,,,,,,,,,,,
SPHERE GLEN DIA 40 MM OFFSET 4 MM SHLDR RETAINING SCREW,SUP-2904146,CDM,C1776,CPT,0278,RC,,,,both,,,6488.81,4217.73,,,,,,,,,,,,,
STEM FEM L200MMXOD14MM LIMB SALV LO BODY CYL CEMENTLESS,SUP-2265079,CDM,C1776,CPT,0278,RC,,,,both,,,8179.89,5316.93,,,,,,,,,,,,,
GRAFT HUM TISS FRZN COSTAL CART IMPL ALLGRFT L15XW10 TO 30MM,SUP-2307299,CDM,C1762,CPT,0278,RC,,,,both,,,1181.27,767.83,,,,,,,,,,,,,
ENDPLATE CAGE W 18 MM D 18 MM DIA16 MM FOOTPRINT DIA18 MM VA,SUP-2928057,CDM,C1889,HCPCS,0278,RC,,,,both,,,5024.00,3265.60,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY LIVEWIRE L 115 CM DIA 6 FR POLYUR,SUP-2462422,CDM,C1730,HCPCS,0272,RC,,,,both,,,383.61,249.35,,,,,,,,,,,,,
GUIDEWIRE VASC BACK-UP MEIER L 300 CM DIA 0.035 IN TIP L 10,SUP-2147055,CDM,C1769,HCPCS,0272,RC,,,,both,,,257.48,167.36,,,,,,,,,,,,,
CORTEX HEX SCREW S-T 3.5X85 MM STRL,SUP-2818137,CDM,C1713,HCPCS,0278,RC,,,,both,,,278.55,181.06,,,,,,,,,,,,,
GUIDEWIRE ORTH THRD 2.8X300 MM FOR CANN SCREW NS 0333301504,SUP-2789106,CDM,C1769,HCPCS,0272,RC,,,,both,,,461.27,299.83,,,,,,,,,,,,,
SCREW BONE L125MM DIA10.5MM TROCHANTERIC NAIL LAG ATN,SUP-2413939,CDM,C1713,HCPCS,0278,RC,,,,both,,,1909.12,1240.93,,,,,,,,,,,,,
COMPONENT PAT M 3 PEG MTL BK CEM RND REV W/O XR WIRE,SUP-2250822,CDM,C1776,CPT,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
MILL BNE MANUAL DISP,SUP-2430784,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1083.30,704.14,,,,,,,,,,,,,
GRAFT BNE SUB 5CC TRICALCIUM PHSPTE FOAM FLO INJ VITOSS,SUP-2368179,CDM,C1713,HCPCS,0278,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
DRESSING WND 6 LAYR 5X5 CM MTRX CYTAL,SUP-2106531,CDM,Q4166,HCPCS,0636,RC,,,,both,,,3984.66,2590.03,,,,,,,,,,,,,
GAUGE DEPTH FIX SZR 14 CM RIB NS LEVEL 1 LTX,SUP-2869176,CDM,C1763,HCPCS,0278,RC,,,,both,,,1916.66,1245.83,,,,,,,,,,,,,
SPLINT ORTH PLASTALUME 6.25X6.25 IN FNGR W/ BLB RADLUC,SUP-2276775,CDM,L3933,HCPCS,0274,RC,,,,both,,,5.78,3.76,,,,,,,,,,,,,
DRESSING WND MICRONIZED PARTIC 20 MG MICROMATRIX,SUP-2106465,CDM,Q4118,HCPCS,0636,RC,,,,both,,,305.84,198.80,,,,,,,,,,,,,
GUIDEWIRE VASC MIRACLEBROS 4.5 L 300 CM DIA 0.014 IN,SUP-2123728,CDM,C1769,HCPCS,0272,RC,,,,both,,,94.20,61.23,,,,,,,,,,,,,
SUTURE V-LOC 180 3-0 L18IN ABSRB GRN V-20 L26MM 1/2 CIR VLOCL0624,SUP-2174830,CDM,C1760,HCPCS,0278,RC,,,,both,,,81.99,53.29,,,,,,,,,,,,,
NEEDLE PROC L56CM OD19-22GA TRANSSEPTAL PERC STYL PED L HRT,SUP-2167853,CDM,2720000010,LOCAL,0272,RC,,,,both,,,339.12,220.43,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE 5 CC CER GRAN TYPE-I BOV CLLGN RPM CARR,SUP-2930803,CDM,C1763,HCPCS,0278,RC,,,,both,,,4239.00,2755.35,,,,,,,,,,,,,
ONDANSETRON HCL 4 MG/5ML PO SOLN,RX-18877,CDM,Q0162,HCPCS,0637,RC,09999-9903-78,NDC,,both,5,ML,9.90,6.43,,,,,,,,,,,,,
DRESSING WND MICRONIZED PARTIC 500 MG MATRISTEM MICROMATRIX,SUP-2106478,CDM,Q4118,HCPCS,0636,RC,,,,both,,,4549.86,2957.41,,,,,,,,,,,,,
TUBE VENT INTERFLNG DISTANCE 117MM FLNG OD450X272MM LUMN,SUP-2232493,CDM,L8699,HCPCS,0278,RC,,,,both,,,68.70,44.65,,,,,,,,,,,,,
ORTHOLOC SPS 105MM POSTERIOR4 HOLE PLATE-LEFT,SUP-2827742,CDM,C1713,HCPCS,0278,RC,,,,both,,,8839.10,5745.41,,,,,,,,,,,,,
SCREW SPNL OCT 6 MM POST ASCNT,SUP-2589729,CDM,C1713,HCPCS,0278,RC,,,,both,,,445.88,289.82,,,,,,,,,,,,,
PLATE CRAN 120X40X40 MM PT SPEC IMPL PEEK,SUP-2860125,CDM,C1713,HCPCS,0278,RC,,,,both,,,28804.79,18723.11,,,,,,,,,,,,,
STENT BILI L11MM CATH 6FR L80CM BLLN L15MM DIA7MM 0.018IN,SUP-2159000,CDM,C1876,HCPCS,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
CAGE SPNL MESH 33X26X70 MM 6 LOBE,SUP-2602092,CDM,C1889,HCPCS,0278,RC,,,,both,,,20133.68,13086.89,,,,,,,,,,,,,
BURR CUTTING ACORN FLUTED 6MM SHD6ACG1,SUP-2843320,CDM,2720000010,LOCAL,0272,RC,,,,both,,,441.74,287.13,,,,,,,,,,,,,
GUIDEPIN SURG L16IN OD3/32IN PK INSRT,SUP-2212926,CDM,C1713,HCPCS,0278,RC,,,,both,,,640.56,416.36,,,,,,,,,,,,,
STENT URET SILHOUETTE COMFORT L 24 CM DIA 4.6 FR NIT SYNTH,SUP-2119483,CDM,C2617,HCPCS,0278,RC,,,,both,,,580.90,377.58,,,,,,,,,,,,,
ACETYLCYSTEINE 10 % IN SOLN,RX-122,CDM,J7608,HCPCS,0636,RC,00409-3307-03,NDC,,both,30,ML,90.50,58.82,,,,,,,,,,,,,
BIT DRL OD3.2MM HUM AO ADPT SURESHOT,SUP-2347933,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1163.50,756.27,,,,,,,,,,,,,
CANNULA SUCTION SIMMEN 3.5 MMX12 CM NOSE EPISTAXIS ANGULAR,SUP-2776831,CDM,2720000010,LOCAL,0272,RC,,,,both,,,715.83,465.29,,,,,,,,,,,,,
PLATE BNE 3X8 H NONSTERILE S STL Y SHP LOK COMPR W/ SHT,SUP-2177483,CDM,C1713,HCPCS,0278,RC,,,,both,,,1247.62,810.95,,,,,,,,,,,,,
WASHER ORTH 4.5-8 MM 430290,SUP-2609253,CDM,C1713,HCPCS,0278,RC,,,,both,,,434.80,282.62,,,,,,,,,,,,,
GRAFT ENDOVASC L12CM AORT IL DIA28.5X14.5MM TRUNK,SUP-2396084,CDM,C1768,CPT,0278,RC,,,,both,,,32970.00,21430.50,,,,,,,,,,,,,
SUPPORT ORTHOT LOWER EXTREMITY CUST REINF SLD STIRRUP,SUP-2435656,CDM,L2260,HCPCS,0272,RC,,,,both,,,530.66,344.93,,,,,,,,,,,,,
CONNECTOR SHUNT OD1.9MM TITANIUM L HYDROCEPHALUS MIETHKE,SUP-2825886,CDM,C1889,HCPCS,0278,RC,,,,both,,,771.72,501.62,,,,,,,,,,,,,
MATRIX HUM TISS L 3 X W 3 CM THK 0.2-1 MM ACELLULAR DERMAL,SUP-2909223,CDM,Q4122,HCPCS,0636,RC,,,,both,,,3124.30,2030.79,,,,,,,,,,,,,
RELOAD STPL SZ 2 PUR RAD MEDIUM/THICK TRI-STPL,SUP-2283369,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1705.99,1108.89,,,,,,,,,,,,,
HC So Crp,PX-3028614066,CDM,86140,CPT,0302,RC,,,,both,,,17.00,11.05,,,,,,,,,,,,,
BRACE THMB UNIV LT SPICA,SUP-2319328,CDM,L3906,HCPCS,0272,RC,,,,both,,,25.28,16.43,,,,,,,,,,,,,
BRACE ORTHOPEDIC SIMP 22-34 IN UNIV KNEE,SUP-2269750,CDM,2740000010,LOCAL,0274,RC,,,,both,,,351.68,228.59,,,,,,,,,,,,,
STEM HUM L115MM OD15MM TI IMP BIOMOD,SUP-2404603,CDM,C1776,CPT,0278,RC,,,,both,,,2041.00,1326.65,,,,,,,,,,,,,
GRAFT BNE SUB 5CC DEMIN BNE MTRX GEL DBL SYR SYS ALLOSYNC,SUP-2120756,CDM,C1776,CPT,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
CATHETER REPROC RPRCSS EP INQRY STRBLE DECAP LG CRV 4FRX110CM SP 2 5 2M,SUP-2473227,CDM,C1730,HCPCS,0272,RC,,,,both,,,727.16,472.65,,,,,,,,,,,,,
SCREW BNE CYL 4 MM SHFT 3X100 MM 20 MM XCALIBER,SUP-2645993,CDM,C1713,HCPCS,0278,RC,,,,both,,,437.72,284.52,,,,,,,,,,,,,
SCREW BNE LAG 85 MM SS NS DH-DC,SUP-2186453,CDM,C1713,HCPCS,0278,RC,,,,both,,,960.40,624.26,,,,,,,,,,,,,
BLADE RTRCTR LNG TEETH 15MMW X 75MML SPNL BLACK FLEXI SPINE,SUP-2669144,CDM,2720000010,LOCAL,0272,RC,,,,both,,,754.60,490.49,,,,,,,,,,,,,
BIT DRL TWST 1.6X75 MM SEGMENTED STP BOS ATTCH SONICWELD RX,SUP-2463875,CDM,2720000010,LOCAL,0272,RC,,,,both,,,431.53,280.49,,,,,,,,,,,,,
GRAFT BNE SUB 1CC 1 4MM DEMIN CANC SPNG CHIP FLEXIGRFT,SUP-2264609,CDM,C1713,HCPCS,0278,RC,,,,both,,,438.50,285.02,,,,,,,,,,,,,
HC Endovenous Rf Vein Add-On,PX-3613647600,CDM,36476,CPT,0361,RC,,,,both,,,10314.00,6704.10,,,,,,,,,,,,,
GRAFT BONE SUB 10ML DBM GRFTON,SUP-2281668,CDM,C1713,HCPCS,0278,RC,,,,both,,,2949.72,1917.32,,,,,,,,,,,,,
NEEDLE PUNC 21 MMX213 CM,SUP-2768432,CDM,2720000010,LOCAL,0272,RC,,,,both,,,421.70,274.10,,,,,,,,,,,,,
CLADRIBINE 10 MG/10ML IV SOLN,RX-133071,CDM,J9065,HCPCS,0636,RC,63323-0140-10,NDC,,both,10,ML,400.60,260.39,,,,,,,,,,,,,
LEAD PACE SIL MYOCARDIAL RT VENTRICULAR SCREW FIX IS1 UPLR,SUP-2148632,CDM,C1898,HCPCS,0275,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
GUIDE SURGICAL VSP NYLON F/ORTHOGNATHIC,SUP-2883356,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5593.13,3635.53,,,,,,,,,,,,,
BLADE RTRCTR BLFR 3 14NW X 10 34NL X 2 38ND SPRPBC CNTR J,SUP-2703311,CDM,2720000010,LOCAL,0272,RC,,,,both,,,439.47,285.66,,,,,,,,,,,,,
PLATE BNE W10.1XL180MM THK3.5MM 16 H S STL CRV LOK COMPR,SUP-2186266,CDM,C1713,HCPCS,0278,RC,,,,both,,,2743.64,1783.37,,,,,,,,,,,,,
COLLAR TRACHEOTOMY M H3.25IN FOR 13-16IN NK POLY FOAM TWO,SUP-2196876,CDM,L0120,HCPCS,0274,RC,,,,both,,,28.39,18.45,,,,,,,,,,,,,
COVER BURR H DIA 7 MM THK 0.5 MM SCREW DIA1.7 MM CRAN STRL,SUP-2909602,CDM,C1713,HCPCS,0278,RC,,,,both,,,1659.80,1078.87,,,,,,,,,,,,,
SHEATH TRANSSEPTAL 90 DEG L 63 CM DIA 8.5 FR SS BRAIDED NYL,SUP-2913238,CDM,C1893,HCPCS,0272,RC,,,,both,,,690.80,449.02,,,,,,,,,,,,,
SUPPORT ORTHOT HEEL CUST THMS EXT TO BALL,SUP-2435735,CDM,L3470,HCPCS,0274,RC,,,,both,,,176.41,114.67,,,,,,,,,,,,,
GRAFT TISS DEHYDR TUTOPLAST PERICARD PTCH ST 1.5X1.5CM,SUP-2247188,CDM,C1762,CPT,0278,RC,,,,both,,,1001.66,651.08,,,,,,,,,,,,,
CATHETER THOR 24FR L15.75IN PVC SHRP TRCR TIP RADPQ SENTNL,SUP-2154957,CDM,C1729,HCPCS,0272,RC,,,,both,,,37.62,24.45,,,,,,,,,,,,,
SCISSORS 5MM 32CML LAPSCP CVD MPLR STD NU TIP REUSE HNDL,SUP-2171742,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1252.86,814.36,,,,,,,,,,,,,
PLATE BNE L180MM BRL L15IN 130DEG PELVIS BILAT S STL STD 8,SUP-2342434,CDM,C1713,HCPCS,0278,RC,,,,both,,,4781.91,3108.24,,,,,,,,,,,,,
SUPPORT ORTHOT HEEL CUST THMS EXT TO BALL,SUP-2435735,CDM,L3470,HCPCS,0272,RC,,,,both,,,176.41,114.67,,,,,,,,,,,,,
HEAD FEM LG 60 MM HIP REMEDY SPECTRM GV,SUP-2424211,CDM,C1776,CPT,0278,RC,,,,both,,,9184.50,5969.92,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE L 40 X W 15 X H 3 MM MED DBM STRP SPNG,SUP-2904100,CDM,C1713,HCPCS,0278,RC,,,,both,,,4474.50,2908.42,,,,,,,,,,,,,
ALLOGRAFT BNE 200X25 MM FRZN LT DSTL FEM CONDYLE SHFT,SUP-2866854,CDM,C1762,CPT,0278,RC,,,,both,,,11649.40,7572.11,,,,,,,,,,,,,
PLATE RINGFIX SYS 3 HL ALUM,SUP-2704792,CDM,2720000010,LOCAL,0272,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
COMPONENT COMPR PED 0 62CM FOR LIMB RECON SYS DISTR UNIT EXT,SUP-2316144,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1202.43,781.58,,,,,,,,,,,,,
WASHER ORTH 3.5 MM FOR 4MM SCR,SUP-2559086,CDM,C1713,HCPCS,0278,RC,,,,both,,,91.06,59.19,,,,,,,,,,,,,
PLATE BONE SZ 6+ GLD 3 SCR CONSTRUCT TAPR LCK TECHNOLOGY,SUP-2223766,CDM,C1713,HCPCS,0278,RC,,,,both,,,4389.72,2853.32,,,,,,,,,,,,,
POWDER SURG CELLERATE RX 1 GM HYDROL COLLEGEN,SUP-2737594,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
PROSTHESIS OSS GROTE INCUS 1.5X1.5X6 MM 0.83 MM STAIR STP HA,SUP-2637867,CDM,L8613,CPT,0278,RC,,,,both,,,1304.54,847.95,,,,,,,,,,,,,
ROD ORTH THRD 300 MM,SUP-2749914,CDM,2720000010,LOCAL,0272,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
ALLOGRAFT BNE PLATE MED FD ASEP FEM,SUP-2867021,CDM,C1762,CPT,0278,RC,,,,both,,,2389.38,1553.10,,,,,,,,,,,,,
HC Hgb/Rbcs Fetal Fetomaternal Hemrrg Rosette,PX-3058546100,CDM,85461,CPT,0305,RC,,,,outpatient,,,254.00,165.10,,,,,,,,,,,,,
BIT DRL L465MM DIA13MM ST CANN FLX L QUIK CPL FOR NAIL,SUP-2178843,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2195.80,1427.27,,,,,,,,,,,,,
INBONE  TIBIAL TRAY RIGHT SIZE 6 RIGHT,SUP-2462502,CDM,C1776,CPT,0278,RC,,,,both,,,3771.14,2451.24,,,,,,,,,,,,,
PROSTHESIS VOICE RAPID EXCHANGE 16 FRX6 MM BLOM-SINGER,SUP-2238266,CDM,L8507,HCPCS,0274,RC,,,,both,,,266.90,173.48,,,,,,,,,,,,,
BASKET STONE RETRV 1.5 FRX90 CMX12 MM TIPLSS NIT,SUP-2336363,CDM,2720000010,LOCAL,0272,RC,,,,both,,,617.32,401.26,,,,,,,,,,,,,
SCREW SPNL MULTAXL 8.5X60 MM REDUCTION CD HORZ SOLERA 5.5/6,SUP-2629916,CDM,C1713,HCPCS,0278,RC,,,,both,,,2496.30,1622.59,,,,,,,,,,,,,
PLATE BONE L154MM 12 HOLE RIGHT LTRL PRXML PRRTCLR TBL STNLS,SUP-2457771,CDM,C1713,HCPCS,0278,RC,,,,both,,,2401.10,1560.71,,,,,,,,,,,,,
SCREW BNE ST 1.9X5 MM EMGCY PROFYLE,SUP-2364075,CDM,C1713,HCPCS,0278,RC,,,,both,,,175.09,113.81,,,,,,,,,,,,,
EXTRACTOR STONE 1.7FR L115CM NIT PATENTED DSGN NGAGE,SUP-2171430,CDM,2720000010,LOCAL,0272,RC,,,,both,,,761.92,495.25,,,,,,,,,,,,,
CLAMP CRAN TEXT SM 13 MM FLAPFIX FOR EXT FIX TI STRL,SUP-2431408,CDM,C1713,HCPCS,0278,RC,,,,both,,,1232.14,800.89,,,,,,,,,,,,,
ERYTHROMYCIN ETHYLSUCCINATE 400 MG/5ML PO SUSR,RX-2900,CDM,340b,HCPCS,0637,RC,75834-0294-01,NDC,,both,5,ML,66.00,42.90,,,,,,,,,,,,,
KIT CATH 20FR L10IN PVC CHST THORACOSTOMY THOR TRCR STR,SUP-2154961,CDM,C1729,HCPCS,0272,RC,,,,both,,,84.94,55.21,,,,,,,,,,,,,
IMPLANT WR JT L60MM OD4.5MM FX MAESTRO,SUP-2407383,CDM,C1776,CPT,0278,RC,,,,both,,,4760.24,3094.16,,,,,,,,,,,,,
PLATE BNE 2/2.7X300 MM 50 HOLE CUT-TO-LENGTH,SUP-2569076,CDM,C1713,HCPCS,0278,RC,,,,both,,,402.39,261.55,,,,,,,,,,,,,
DRILL SURG 5/32 IN JCBS STR CHK W/ KEY ATTCH BUSA BSPMAX II,SUP-2745859,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1639.08,1065.40,,,,,,,,,,,,,
HC Gastric/Duodenal Motility &/or Manometry Study,PX-3609015500,CDM,3609015500,LOCAL,0750,RC,,,,outpatient,,,1657.00,1077.05,,,,,,,,,,,,,
PIN SECUR 6X2MM TWO H K WIRE FOR SHEFFIELD FIX,SUP-2316249,CDM,C1713,HCPCS,0278,RC,,,,both,,,530.41,344.77,,,,,,,,,,,,,
BRIMONIDINE TARTRATE-TIMOLOL 0.2-0.5 % OP SOLN,RX-87834,CDM,6370000000,HCPCS,0637,RC,00832-1425-05,NDC,,both,5,ML,576.00,374.40,,,,,,,,,,,,,
ANCHOR SUTURE 5.5X15 MM PEEK KT STRL GRAPPLER,SUP-2749833,CDM,C1713,HCPCS,0278,RC,,,,both,,,1403.58,912.33,,,,,,,,,,,,,
SPLINT THMB AD M L BGE R MCP CMC JT PREFRM PERF FLX BASE LAM,SUP-2326183,CDM,L3908,HCPCS,0274,RC,,,,both,,,65.81,42.78,,,,,,,,,,,,,
BLADE SURG SERRATED 20 MM UNILAT TUBESET NEXUS BONESCALPEL,SUP-2745898,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1638.04,1064.73,,,,,,,,,,,,,
LEAD DEFIB 59 CM ENDOCARD 2 COIL PASS FIX RELIANCE ENDOTK,SUP-2148612,CDM,C1895,HCPCS,0275,RC,,,,both,,,8691.52,5649.49,,,,,,,,,,,,,
HEAD HUM H19MM OD48MM SHLDR CHOICE SHLDR SYS IMPL BIO MOD,SUP-2404656,CDM,C1776,CPT,0278,RC,,,,both,,,6754.14,4390.19,,,,,,,,,,,,,
CEMENT BNE 3 CC STRL FORTERA LTX,SUP-2855701,CDM,C1713,HCPCS,0278,RC,,,,both,,,5598.62,3639.10,,,,,,,,,,,,,
TROCAR EXT FIX GRN,SUP-2534567,CDM,2720000010,LOCAL,0272,RC,,,,both,,,362.23,235.45,,,,,,,,,,,,,
MESH BONE SIZE 11 0.6MM THK TTNM CNTRD STNDRD LATEX FREE RIG,SUP-2500946,CDM,C1713,HCPCS,0278,RC,,,,both,,,16574.52,10773.44,,,,,,,,,,,,,
WASHER ORTH 4.5MM DIA2.2MM S STL RND FIX,SUP-2184678,CDM,C1713,HCPCS,0278,RC,,,,both,,,62.14,40.39,,,,,,,,,,,,,
GRAFT DURA CLLGN MTRX 2X2 IN ABSORBABLE,SUP-2383006,CDM,C1763,HCPCS,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
PLATE MESH TI CONTOURABLE 38X45MM RIGID LPROF SYNTHES,SUP-2848979,CDM,C1713,HCPCS,0278,RC,,,,both,,,4214.51,2739.43,,,,,,,,,,,,,
SCREW TI METAPHYSEAL 2.7MM SLF-TPNG/T8 STRDRV 75MM - STER,SUP-2546830,CDM,C1713,HCPCS,0278,RC,,,,both,,,274.15,178.20,,,,,,,,,,,,,
MARKER TISS W4XL4CM RADIOGRAPHIC HAS BIOABSRB SPCR BIOZORB,SUP-2225564,CDM,A4648,CPT,0278,RC,,,,both,,,3124.30,2030.79,,,,,,,,,,,,,
K WIRE FIX L150MM DIA2MM S STL SGL END SMOOTH SGL SHRP TIP (MUST BE ORDERED IN MULTIPLES OF 10 EACH),SUP-2371660,CDM,C1713,HCPCS,0278,RC,,,,both,,,90.75,58.99,,,,,,,,,,,,,
CATHETER INTVASC ULTRASOUND EAGLE EYE PLAT ST L 150 CM DIA 5,SUP-2900263,CDM,C1753,HCPCS,0278,RC,,,,both,,,1360.81,884.53,,,,,,,,,,,,,
MAXFRAME QA Strut Long,SUP-2548604,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3399.49,2209.67,,,,,,,,,,,,,
PLATE BNE LEFORT 2X7X1 MM LT MOD SUNDHEIMER TI,SUP-2460357,CDM,C1713,HCPCS,0278,RC,,,,both,,,804.44,522.89,,,,,,,,,,,,,
LENS IOL 3 PC 2.5+ DIOPT 6X13 MM POST CHMBR SOFLEX,SUP-2391943,CDM,V2632,HCPCS,0276,RC,,,,both,,,431.75,280.64,,,,,,,,,,,,,
STENT TRACHBRONCH WGRFT L 30 MM DIA 7 MM CATH TOT L 116 CM,SUP-2141191,CDM,C1874,HCPCS,0278,RC,,,,both,,,7083.84,4604.50,,,,,,,,,,,,,
NAIL IM L200MM DIA2.75MM ANK FT LSR MRK MEAS W/ GUIDEPIN,SUP-2321050,CDM,C1713,HCPCS,0278,RC,,,,both,,,648.41,421.47,,,,,,,,,,,,,
HC Onc Sol Tum Cfdna&Rna Ngs IR Gm CHIP Tum-Drv Snv,PX-3100485066,CDM,0485U,CPT,0310,RC,,,,both,,,3831.00,2490.15,,,,,,,,,,,,,
CATHETER CV STD SET 018 3 FRX40 CM 1 LUMEN SS TURBO-JECT,SUP-2760083,CDM,C1751,HCPCS,0278,RC,,,,both,,,400.76,260.49,,,,,,,,,,,,,
GUIDEWIRE ORTH L 100 MM DIA 0.8 MM SCREW DIA2 MM TROCAR TIP,SUP-2908181,CDM,C1769,HCPCS,0272,RC,,,,both,,,242.60,157.69,,,,,,,,,,,,,
PLATE BONE W8XL192MM THK3.3MM 24 H STRL BILAT PELV S STL,SUP-2186252,CDM,C1713,HCPCS,0278,RC,,,,both,,,2827.41,1837.82,,,,,,,,,,,,,
HC Abd Aortogram With Runoffs,PX-3237563000,CDM,75630,CPT,0323,RC,,,,both,,,6621.00,4303.65,,,,,,,,,,,,,
CATHETER HD KT 15 FRX27 CM DL RETROGRADE SHTH CANNON II +,SUP-2763032,CDM,C1750,HCPCS,0278,RC,,,,both,,,524.38,340.85,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.523,SUP-2860040,CDM,C1713,HCPCS,0278,RC,,,,both,,,41065.23,26692.40,,,,,,,,,,,,,
SET INTRO L 5 CM DIA 5.5 FR GUIDEWIRE L 45 CM DIA 0.018 IN,SUP-2267052,CDM,C1894,HCPCS,0272,RC,,,,both,,,109.90,71.43,,,,,,,,,,,,,
GRAFT BNE SUB 1CC DEMIN BNE MTRX PTTY OSTEOINDUCTIVE INJ,SUP-2306994,CDM,C9359,HCPCS,0278,RC,,,,both,,,536.94,349.01,,,,,,,,,,,,,
DEVICE SEAL BLNT TIP NANO COAT HND AND FT ACT LIGASURE,SUP-2283559,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1355.57,881.12,,,,,,,,,,,,,
ANCHOR SFT TISS L10MM DIA11MM KNEE COPOLYMER SGL SELF REINF,SUP-2166728,CDM,C1776,CPT,0278,RC,,,,both,,,391.56,254.51,,,,,,,,,,,,,
SHEATH INTRO PINNACLE DESTINATION 90CM 7FR COAT L 15CM XCUT,SUP-2385652,CDM,C1894,HCPCS,0272,RC,,,,both,,,405.06,263.29,,,,,,,,,,,,,
COVER BUR H DIA13MM 5 H TI BENT W/O TAB NONCOMPRESSION LO,SUP-2402999,CDM,C1713,HCPCS,0278,RC,,,,both,,,791.28,514.33,,,,,,,,,,,,,
COLLAR CERV LG MED 4.5X24 IN POLY CVR FOAM,SUP-2194442,CDM,L0120,HCPCS,0274,RC,,,,both,,,10.93,7.10,,,,,,,,,,,,,
CANNULA ROBOTIC DIA85MM BLNT E REUSE DA VINCI SGL SITE,SUP-2246589,CDM,C1713,HCPCS,0278,RC,,,,both,,,4082.00,2653.30,,,,,,,,,,,,,
PLATE BONE L231MM 14 H BILAT S STL BROAD LO PROF RIG DYN,SUP-2185279,CDM,C1713,HCPCS,0278,RC,,,,both,,,928.81,603.73,,,,,,,,,,,,,
BISOPROLOL-HYDROCHLOROTHIAZIDE 2.5-6.25 MG PO TABS,RX-18291,CDM,6370000000,HCPCS,0637,RC,29300-0187-13,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
CATHETER FOR ASCITES SHUNT 15.5FR VEN 60CM,SUP-2133691,CDM,C1729,HCPCS,0272,RC,,,,both,,,537.35,349.28,,,,,,,,,,,,,
ES TROCH NAIL LEFT 12.5X33CMX125 GOLD,SUP-2811011,CDM,C1713,HCPCS,0278,RC,,,,both,,,9404.30,6112.79,,,,,,,,,,,,,
PLATE BONE TIBIAL 2.7X32 MM MEDIAL DISTAL 3 HOLE STRAIGHT LO,SUP-2836533,CDM,C1713,HCPCS,0278,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
PLATE BONE L59MM 3 H LT DSTL LAT FIBULAR VAR ANG LCK FOR,SUP-2349826,CDM,C1713,HCPCS,0278,RC,,,,both,,,5223.55,3395.31,,,,,,,,,,,,,
ANCHOR SUT 1.4MM W/ FLX INSRT HI STRENGTH FLXIBLE DEL FOR,SUP-2366741,CDM,C1713,HCPCS,0278,RC,,,,both,,,3136.86,2038.96,,,,,,,,,,,,,
PLATE BNE 24 DEG L 174 X W 8.5 MM THK 1.6 MM 13 H SS RT DSTL,SUP-2933532,CDM,C1713,HCPCS,0278,RC,,,,both,,,6031.16,3920.25,,,,,,,,,,,,,
COLLAR CERV LG MED 4.5X24 IN POLY CVR FOAM,SUP-2194442,CDM,L0120,HCPCS,0272,RC,,,,both,,,10.93,7.10,,,,,,,,,,,,,
NEEDLE ENDO 22GA US FOR SAMP GI LESIONS DISP ECHO-TIP,SUP-2169550,CDM,C1713,HCPCS,0278,RC,,,,both,,,621.72,404.12,,,,,,,,,,,,,
GRAFT BNE FRZN TIB SEG IMPL ALLGRFT L200MM MATRIGRFT,SUP-2264790,CDM,C1713,HCPCS,0278,RC,,,,both,,,3332.54,2166.15,,,,,,,,,,,,,
CATHETER CV SINGLE LUMEN 3 FRX20 CM 19 GA SIL PER-Q-CATH,SUP-2125573,CDM,C1751,HCPCS,0278,RC,,,,both,,,198.13,128.78,,,,,,,,,,,,,
BRACE ORTH FRAC FEM CAST MOLD KAFO L2126] TIDEWATER PROSTHETICS],SUP-2388170,CDM,L2126,HCPCS,0272,RC,,,,both,,,3243.18,2108.07,,,,,,,,,,,,,
POST EXT FIX 2 H S STL M SUPP FOR ILIZ TAY SPAT FRME SYS,SUP-2342286,CDM,2720000010,LOCAL,0272,RC,,,,both,,,874.14,568.19,,,,,,,,,,,,,
CATHETER EP 6FR L115CM 2.5-2.5-2.5 2.5-247.5MM SPC TIP 1MM,SUP-2248459,CDM,C1730,HCPCS,0272,RC,,,,both,,,543.22,353.09,,,,,,,,,,,,,
CANNULA ENDOSCP TERNAMIAN ENDOTIP 13 MMX15 CM VLV STOPCOCK,SUP-2768737,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2838.59,1845.08,,,,,,,,,,,,,
GRAFT EVAR L11.5CM DIA20MM IL LIMB EXCLUDER,SUP-2395956,CDM,C1768,CPT,0278,RC,,,,both,,,12497.20,8123.18,,,,,,,,,,,,,
CATHETER DRAINAGE 0.035 IN 14 FRX30 CM LCK RESOLV +,SUP-2303342,CDM,C1729,HCPCS,0272,RC,,,,both,,,210.25,136.66,,,,,,,,,,,,,
DRSG BIO PRCN MTRX RS STRL DISP REINF STW MATRISTEM 15X10CM,SUP-2106517,CDM,Q4166,HCPCS,0636,RC,,,,both,,,7065.00,4592.25,,,,,,,,,,,,,
SPACER SPNL 16-22MM COR DIA16MM TI FOR SELF EXP VBR SYS,SUP-2311131,CDM,C1821,HCPCS,0278,RC,,,,both,,,12560.00,8164.00,,,,,,,,,,,,,
SCREW BNE L 18 MM DIA 3 MM HD,SUP-2909472,CDM,C1713,HCPCS,0278,RC,,,,both,,,991.86,644.71,,,,,,,,,,,,,
SYSTEM  EUSTACHIAN TUBE DILATION,SUP-2749727,CDM,C1726,HCPCS,0272,RC,,,,both,,,5809.00,3775.85,,,,,,,,,,,,,
FIXATOR EXT HING RINGFIX SYS F,SUP-2474967,CDM,2720000010,LOCAL,0272,RC,,,,both,,,334.10,217.16,,,,,,,,,,,,,
HC Tissue Homogenization,PX-3008717600,CDM,87176,CPT,0300,RC,,,,both,,,41.00,26.65,,,,,,,,,,,,,
CAGE SPNL XL 12X22X55 MM COROENT,SUP-2310950,CDM,C1889,HCPCS,0278,RC,,,,both,,,14444.00,9388.60,,,,,,,,,,,,,
SHELL TRI + SHELL CLUS 46MM,SUP-2267696,CDM,C1776,CPT,0278,RC,,,,both,,,3170.77,2061.00,,,,,,,,,,,,,
PIN EXTERNAL FIXATION HALF 4X35 MM TITANIUM NITRIDE STERILE,SUP-2836772,CDM,2720000010,LOCAL,0272,RC,,,,both,,,904.60,587.99,,,,,,,,,,,,,
BLADE SHV L L13CM DIA42MM 15DEG FULL RAD RESECT PREBENT,SUP-2167049,CDM,C1713,HCPCS,0278,RC,,,,both,,,229.79,149.36,,,,,,,,,,,,,
SPHINCTEROTOME ENDO L480CM 0.021IN DOME TIP DBL LUMN HOWELL,SUP-2169580,CDM,C1769,HCPCS,0272,RC,,,,both,,,750.46,487.80,,,,,,,,,,,,,
NEEDLE PHACOEMULSIFICATION 19GA 30DEG STERILE LATEX FREE,SUP-2493028,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1241.27,806.83,,,,,,,,,,,,,
SCREW BNE L 30 MM DIA2.5 MM TI CANN HD NS LEOS,SUP-2932602,CDM,C1713,HCPCS,0278,RC,,,,both,,,802.80,521.82,,,,,,,,,,,,,
TRAY HEMO DYLS OR HD CATH AD 14.5FR L36CM INSRTN L16CM,SUP-2174213,CDM,C1751,HCPCS,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
SPACER SPNL L W30XH20XL24MM 8DEG ANG PEEK PERIMETER,SUP-2285369,CDM,C1713,HCPCS,0278,RC,,,,both,,,7457.50,4847.37,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC BSC 5FR 55CM 1 LUMAN RVS TA 9175118,SUP-2632696,CDM,C1751,HCPCS,0278,RC,,,,both,,,434.32,282.31,,,,,,,,,,,,,
DEVICE TORQ 0009 0018IN GRN PTFE GWIRE ANGIO COAT PIN VISE,SUP-2303056,CDM,C1769,HCPCS,0272,RC,,,,both,,,11.59,7.53,,,,,,,,,,,,,
MATRIX PLCNTA FLOWABLE CYROPRESERVED CRYOMTRX 1.0CC,SUP-2340460,CDM,C1762,CPT,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
IMPLANT WR SPCR CMC I,SUP-2361943,CDM,C1776,CPT,0278,RC,,,,both,,,5181.00,3367.65,,,,,,,,,,,,,
HC So Varicella Igg Igm,PX-3028678766,CDM,86787,CPT,0302,RC,,,,outpatient,,,80.00,52.00,,,,,,,,,,,,,
CLIP INT LIG SM WIDE TI NS VESOCCLUDE,SUP-2757590,CDM,C1889,HCPCS,0278,RC,,,,both,,,778.72,506.17,,,,,,,,,,,,,
STAPLE INT L13XW11MM S STL COMPR INTERAXIS NONSTERILE IMPL,SUP-2243118,CDM,C1776,CPT,0278,RC,,,,both,,,2983.57,1939.32,,,,,,,,,,,,,
PACEMAKER DR SYS ACCENT,SUP-2356459,CDM,C1785,HCPCS,0275,RC,,,,both,,,16579.20,10776.48,,,,,,,,,,,,,
CATHETER DRAINAGE 5 FRX15 CM 51IN SAFETY SPIN-LOCK ACCEL,SUP-2659273,CDM,C1729,HCPCS,0272,RC,,,,both,,,104.09,67.66,,,,,,,,,,,,,
STEM FEM L150MM STD OFFSET L HIP CO CHROM PROSTALAC,SUP-2251990,CDM,C1776,CPT,0278,RC,,,,both,,,9377.30,6095.24,,,,,,,,,,,,,
CABLE CONN THER 2 8,SUP-2357459,CDM,2720000010,LOCAL,0272,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
DEFIBRILLATOR CRD BPLR ATR VENTRIC 2 CHMBR ROPT EPIC DR,SUP-2356538,CDM,C1721,HCPCS,0275,RC,,,,both,,,53270.10,34625.56,,,,,,,,,,,,,
SET INTRO MICROPUNCTURE SHTH L 7 CM DIA 4 FR GUIDEWIRE L 40,SUP-2167895,CDM,C1894,HCPCS,0272,RC,,,,both,,,119.23,77.50,,,,,,,,,,,,,
HC Cbc (Hemogram)|NOT REASONABLE AND NECESSARY,PX-3058502700,CDM,85027,CPT,0305,RC,,,GZ,both,,,116.00,75.40,,,,,,,,,,,,,
PROSTHESIS OSS 3-7 MM 3 MM 0.8 MM LT ALTO TOT W/ BND HA TI,SUP-2470841,CDM,L8613,CPT,0278,RC,,,,both,,,1314.09,854.16,,,,,,,,,,,,,
PLATE BNE LCK 5.5X189 MM LT PROX LAT TIB 10 HOLE COMPR SS,SUP-2198439,CDM,C1713,HCPCS,0278,RC,,,,both,,,3974.20,2583.23,,,,,,,,,,,,,
PLUG BNE POLY PLUG MDLLRY 13MM,SUP-2205393,CDM,C1713,HCPCS,0278,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
ANCHOR SUT SZ 2 L93CM WHT N ABSRB BRAID POLYETH RAPPEL LINE,SUP-2399081,CDM,C1713,HCPCS,0278,RC,,,,both,,,835.24,542.91,,,,,,,,,,,,,
BRACE ORTHOPEDIC TLSO BK W/ SHLDR SHUT,SUP-2265010,CDM,L0454,HCPCS,0274,RC,,,,both,,,1337.64,869.47,,,,,,,,,,,,,
MINERIN CREME EX CREA,RX-70759,CDM,6370000000,HCPCS,0637,RC,80681-0155-00,NDC,,both,113,GR,12.30,7.99,,,,,,,,,,,,,
PLATE BNE 5 DEG SM RT METATARSOPHALANGEAL REV NS LEOS,SUP-2931335,CDM,C1713,HCPCS,0278,RC,,,,both,,,4498.05,2923.73,,,,,,,,,,,,,
CATHETER BLLN DIL SET 5 FRX65 CM 5 MMX4 CM URET,SUP-2835669,CDM,C1758,HCPCS,0278,RC,,,,both,,,474.77,308.60,,,,,,,,,,,,,
STIMULATOR COCHLEAR BILATERAL AD SLEEPER BAHA,SUP-2165012,CDM,L8614,HCPCS,0278,RC,,,,both,,,39250.00,25512.50,,,,,,,,,,,,,
TUBE TRACHEOSTOMY STERLING ADULT L69MM OD12MM ID9.2MM STERLI,SUP-2793421,CDM,2720000010,LOCAL,0272,RC,,,,both,,,435.14,282.84,,,,,,,,,,,,,
INTRODUCER LAT VEIN L62CM OD5.5FR ADV TELSCP SYS RENAL,SUP-2303515,CDM,C1894,HCPCS,0272,RC,,,,both,,,1205.54,783.60,,,,,,,,,,,,,
SET INTRO PEELWY L 24 CM OD 7 FR DIL 34 IN GUIDEWIRE 0.038,SUP-2638745,CDM,C1894,HCPCS,0272,RC,,,,both,,,409.90,266.43,,,,,,,,,,,,,
CATHETER NEPHSTMY L25CM DIA14FR BLLN L15CM DIA12MM TAMP FOR,SUP-2171207,CDM,C1729,HCPCS,0272,RC,,,,both,,,579.49,376.67,,,,,,,,,,,,,
ALLOGRAFT BNE CHIP 1-8 MM 15 CC FRZN CANC READIGRAFT,SUP-2741038,CDM,C1713,HCPCS,0278,RC,,,,both,,,831.66,540.58,,,,,,,,,,,,,
POST REPROC EXT FIX OUTRIG STR,SUP-2468581,CDM,2720000010,LOCAL,0272,RC,,,,both,,,127.36,82.78,,,,,,,,,,,,,
SHEATH INTRO FAST-CATH L 90 CM DIA 7.5 FR GUIDEWIRE 0.038 IN,SUP-2355528,CDM,C1894,HCPCS,0272,RC,,,,both,,,80.07,52.05,,,,,,,,,,,,,
PILLAR EXT FIX L 300 MM THRD MONK RING,SUP-2899088,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1701.10,1105.71,,,,,,,,,,,,,
IMPLANT HUM TISS L 30 X W 20 MM THK 3 MM ACHILLES TEND RC,SUP-2933146,CDM,C1762,CPT,0278,RC,,,,both,,,3241.23,2106.80,,,,,,,,,,,,,
BASEPLATE TIB 2 R MED L LAT PC UNI HI FLX NXGN,SUP-2342146,CDM,C1776,CPT,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
BUR SURG LINDE 1.6X31 MM FOR OTO SPINE NEURO STRL,SUP-2607649,CDM,2720000010,LOCAL,0272,RC,,,,both,,,649.60,422.24,,,,,,,,,,,,,
GUIDEWIRE VASC L260CM DIA0035IN TIP L23CM PTFE BENT STR FIX,SUP-2302721,CDM,C1769,HCPCS,0272,RC,,,,both,,,36.90,23.98,,,,,,,,,,,,,
DART SURG L18MM FOR ARTHSCP MENIS KNEE REP SYS,SUP-2121788,CDM,C1713,HCPCS,0278,RC,,,,both,,,379.94,246.96,,,,,,,,,,,,,
SYSTEM DELIVERY 23-29 MM  EVOLUT FX,SUP-2854099,CDM,2720000010,LOCAL,0272,RC,,,,both,,,15605.80,10143.77,,,,,,,,,,,,,
PACEMAKER CARD PULSAR MAX SR TI SINGLE CHMBR IS1 COMPATIBLE,SUP-2148593,CDM,C1786,HCPCS,0275,RC,,,,both,,,13866.24,9013.06,,,,,,,,,,,,,
CANNULA ENDOSCP EVAC 180 MM LL 1 STP COCK,SUP-2768386,CDM,2720000010,LOCAL,0272,RC,,,,both,,,591.80,384.67,,,,,,,,,,,,,
GRAFT DERMAL FEN 5X5 CM CLLGN TISS MTRX,SUP-2243693,CDM,Q4110,HCPCS,0636,RC,,,,both,,,3124.30,2030.79,,,,,,,,,,,,,
NECK FEM SHT CO CHROM HIP NEUT MOD PROFEMUR,SUP-2304837,CDM,C1776,CPT,0278,RC,,,,both,,,8368.10,5439.26,,,,,,,,,,,,,
TI END CAP FOR TROCHANTERIC FIXATION NAILS 0MM EXT,SUP-2549732,CDM,C1889,HCPCS,0278,RC,,,,both,,,539.58,350.73,,,,,,,,,,,,,
HC Hands Bone Age Study,PX-3207707200,CDM,77072,CPT,0320,RC,,,,inpatient,,,252.00,163.80,,,,,,,,,,,,,
TAP SURG CANN 3.5 MM STRL,SUP-2194152,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1180.64,767.42,,,,,,,,,,,,,
PLATE BONE L107MM 6 H DSTL ANTR TIB VAR ANG LCK FOR 3.5MM,SUP-2349814,CDM,C1713,HCPCS,0278,RC,,,,both,,,9244.00,6008.60,,,,,,,,,,,,,
HC Cta Abd & Pelvis W & W/O Cont,PX-3527417400,CDM,74174,CPT,0352,RC,,,,both,,,2760.00,1794.00,,,,,,,,,,,,,
KIT INTRO L 14 CM DIA 6 FR GUIDEWIRE L 50 CM DIA 0.038 IN,SUP-2615890,CDM,C1894,HCPCS,0272,RC,,,,both,,,103.34,67.17,,,,,,,,,,,,,
COMPONENT HUM SHLDR RESURF TITAN,SUP-2244435,CDM,C1776,CPT,0278,RC,,,,both,,,810.12,526.58,,,,,,,,,,,,,
MICROSPHERE EMB 120-240UM ORNG VYN ACETT METH ACRYLATE VI,SUP-2303490,CDM,C1889,HCPCS,0278,RC,,,,both,,,4082.00,2653.30,,,,,,,,,,,,,
BLADE SHAVER RESECT 2X45 MM SERRATED DISP,SUP-2661212,CDM,2720000010,LOCAL,0272,RC,,,,both,,,365.18,237.37,,,,,,,,,,,,,
LIGATOR HEMORRHOID VARICEAL NAT RUB TAMP MULT BND UNIV,SUP-2170088,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1026.78,667.41,,,,,,,,,,,,,
ALLOGRAFT BNE PARL MED 14X13X6X6 MM CANC VERTIGRAFT VG2,SUP-2740763,CDM,C1713,HCPCS,0278,RC,,,,both,,,2721.38,1768.90,,,,,,,,,,,,,
BUR SURG MED 6.7 MM COR TOOL FOR HD-G1,SUP-2848301,CDM,2720000010,LOCAL,0272,RC,,,,both,,,985.77,640.75,,,,,,,,,,,,,
PLATE BNE FEM 3.5/4.5X285 MM RT PROX 9 HOLE STRL VALCP,SUP-2789284,CDM,C1713,HCPCS,0278,RC,,,,both,,,8169.43,5310.13,,,,,,,,,,,,,
SHELL ACET TOT HIP PRI PRESSFIT COCR ALLOY CLUS H UNIV 48MM,SUP-2364616,CDM,C1776,CPT,0278,RC,,,,both,,,3756.07,2441.45,,,,,,,,,,,,,
KIT VASC SNR ATRIEVE 90 DEG TIP 15 DEG L 120 CM DIA 6-10 MM,SUP-2120068,CDM,C1773,HCPCS,0272,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
COMPONENT FEM KNEE POST STABILIZING LT UNISX PRI N POR CEM,SUP-2201894,CDM,C1776,CPT,0278,RC,,,,both,,,10289.78,6688.36,,,,,,,,,,,,,
PLATE BNE L 221 X W 11.5 MM THK 3.6 MM SCREW DIA 3.5 MM 18 H,SUP-2936269,CDM,C1713,HCPCS,0278,RC,,,,both,,,7579.96,4926.97,,,,,,,,,,,,,
REAMER SURG 10.5MM W/ FLEX GUID PIN,SUP-2121210,CDM,C1713,HCPCS,0278,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
SYSTEM CLSR M SZ 1.1MM SHFT L8CM VASC DURA ANAS TI 35 CLP,SUP-2264249,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4455.66,2896.18,,,,,,,,,,,,,
GRAFT HUM TISS W25XL30MM THK25MM FRZ DRY ALLGRFT BLK CANC,SUP-2307115,CDM,C1713,HCPCS,0278,RC,,,,both,,,3437.04,2234.08,,,,,,,,,,,,,
STEM FEM L27MM OD14MM UNIV CSTI POR KNEE PRI CEM FLUT IMP,SUP-2208274,CDM,C1776,CPT,0278,RC,,,,both,,,13621.32,8853.86,,,,,,,,,,,,,
PLATE BNE LCK UNIV 3.5X131 MM 10 HOLE CONTOURED 2 COMPR,SUP-2476460,CDM,C1713,HCPCS,0278,RC,,,,both,,,1034.94,672.71,,,,,,,,,,,,,
COMPONENT TIB PS MOLD ON MTL BK 11MM SZ 1,SUP-2222989,CDM,C1776,CPT,0278,RC,,,,both,,,9545.60,6204.64,,,,,,,,,,,,,
SET ACCS CATH 4FR L10CM NDL 21GA L7CM GWIRE L40CM,SUP-2170544,CDM,C1894,HCPCS,0272,RC,,,,both,,,74.58,48.48,,,,,,,,,,,,,
BIT DRILL STRYKER J LATCH 1.25X125 MM CRANIOMAXILLOFACIAL 2,SUP-2837626,CDM,2720000010,LOCAL,0272,RC,,,,both,,,670.39,435.75,,,,,,,,,,,,,
COMPONENT FEM 5 CM LT KNEE RESURF OSS RS,SUP-2441727,CDM,C1776,CPT,0278,RC,,,,both,,,17747.28,11535.73,,,,,,,,,,,,,
FRACTURE PLATE 8 HOLES 55MM 23MM SYSTEM TI 6AL 4V,SUP-2679142,CDM,C1713,HCPCS,0278,RC,,,,both,,,1074.54,698.45,,,,,,,,,,,,,
CATHETER UROLOGICAL MTL TIP SM 4.5-6 FR RAMROD,SUP-2312762,CDM,C1726,HCPCS,0272,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
CANNULA SURG CEPHALOMEDULLARY LAG SCREW,SUP-2488398,CDM,2720000010,LOCAL,0272,RC,,,,both,,,967.12,628.63,,,,,,,,,,,,,
PLATE FOOT LK T PLT OBLQ LT,SUP-2701924,CDM,C1713,HCPCS,0278,RC,,,,both,,,2388.91,1552.79,,,,,,,,,,,,,
CATHETER VALVULOPLASTY TYSHAK-X L 100 CM DIA 6 FR 2 CM 8 MM,SUP-2659818,CDM,C1725,HCPCS,0272,RC,,,,both,,,1841.77,1197.15,,,,,,,,,,,,,
ALUM SULFATE-CA ACETATE EX PACK,RX-9020,CDM,6370000000,HCPCS,0637,RC,16864-0240-01,NDC,,both,1,UN,3.00,1.95,,,,,,,,,,,,,
BOLT ATTCH TARGETING DEV FOR PEDINAIL PED FEM NAIL,SUP-2318963,CDM,C1776,CPT,0278,RC,,,,both,,,2649.22,1721.99,,,,,,,,,,,,,
PLATE BNE 2.4X96X2 MM 12 HOLE SS LCP,SUP-2569303,CDM,C1713,HCPCS,0278,RC,,,,both,,,459.38,298.60,,,,,,,,,,,,,
ALLOGRAFT DERMAL PERF THN 20X12 CMX0.7-1.4 MM FLEXHD PLIABLE,SUP-2457809,CDM,Q4128,HCPCS,0636,RC,,,,both,,,19688.40,12797.46,,,,,,,,,,,,,
CARBIDOPA-LEVODOPA 25-100 MG PO TABS,RX-9407,CDM,6370000000,HCPCS,0637,RC,00904-7501-61,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
ROD SPNL L40MM DIA5.5MM R POST TI PRECUT CNTOUR SMOOTH CRV,SUP-2289823,CDM,C1713,HCPCS,0278,RC,,,,both,,,1026.62,667.30,,,,,,,,,,,,,
CUP HUM DIA42MM NEUT OFFSET SHLDR COAT UNIVERS REVERS,SUP-2123342,CDM,C1776,CPT,0278,RC,,,,both,,,4596.02,2987.41,,,,,,,,,,,,,
CARRIER FBR OPT LT L50CM FOR ESOPHAGOSCOPES,SUP-2261091,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1824.15,1185.70,,,,,,,,,,,,,
SET INTRO PERFRMR L 45 CM OD 5 MM ID 1.7 MM TIP 3 MM,SUP-2169774,CDM,C1894,HCPCS,0272,RC,,,,both,,,61.20,39.78,,,,,,,,,,,,,
HC Pt Re-Eval Est Plan Care,PX-4249716400,CDM,97164,CPT,0424,RC,,,,both,,,153.00,99.45,,,,,,,,,,,,,
SCREW BONE L20MM DIA6.5MM FOR NOVATION CRWN CUP ACET SHELL,SUP-2222487,CDM,C1713,HCPCS,0278,RC,,,,both,,,337.55,219.41,,,,,,,,,,,,,
PLATE BNE 24.5 CM THOR WAND HOLDING STERNOTOMY HEMI NS LTX,SUP-2869209,CDM,C1713,HCPCS,0278,RC,,,,both,,,4747.93,3086.15,,,,,,,,,,,,,
PROBE ABLAT XL L180MM DIA3.5MM MAX CUT LEV 11 90-S RF AGG,SUP-2366563,CDM,2720000010,LOCAL,0272,RC,,,,both,,,634.28,412.28,,,,,,,,,,,,,
GRAFT PERICARD PROC TUTOPLAST 2X7CM,SUP-2300762,CDM,C1762,CPT,0278,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
GRAFT BONE 2.5ML DEMIN BONE MTRX PUTTY ACCELL CONNEXUS,SUP-2242681,CDM,C9359,HCPCS,0278,RC,,,,both,,,1218.57,792.07,,,,,,,,,,,,,
PLATE BNE HUM 3.5X199 MM LT PERIARTICULAR PROX 8 HOLE LCK LP,SUP-2177813,CDM,C1713,HCPCS,0278,RC,,,,both,,,5785.20,3760.38,,,,,,,,,,,,,
HC Radiation Treatment Delivery Level 3,PX-3337741200,CDM,77412,CPT,0333,RC,,,,both,,,3090.00,2008.50,,,,,,,,,,,,,
SUPPORT NEW EDGE CLAVICLEXL,SUP-2324200,CDM,L3670,HCPCS,0274,RC,,,,both,,,115.96,75.37,,,,,,,,,,,,,
CATHETER THROMCTMY 5MAX L 132 CM PROX/DSTL OD 6/5.75,SUP-2323547,CDM,C1725,HCPCS,0272,RC,,,,both,,,7504.60,4877.99,,,,,,,,,,,,,
CONFORMER OPHTH M W21XL24MM BILAT CLR VENT ACRYL CUP,SUP-2366502,CDM,L8610,HCPCS,0278,RC,,,,both,,,157.50,102.37,,,,,,,,,,,,,
BLADE SHAVER 4.2 MM PREBENT ULTRACUT,SUP-2765853,CDM,2720000010,LOCAL,0272,RC,,,,both,,,524.25,340.76,,,,,,,,,,,,,
NAIL IM DSTL TIB GRY 10MMX32CM,SUP-2347129,CDM,C1713,HCPCS,0278,RC,,,,both,,,2973.55,1932.81,,,,,,,,,,,,,
CAP NAIL DIA 0 MM STRL TRIGEN MAX,SUP-2933053,CDM,C1713,HCPCS,0278,RC,,,,both,,,670.70,435.95,,,,,,,,,,,,,
NEEDLE TRANSSEPTAL AD 18 GAX89 CM CRV BRK1 STYL BRK SS,SUP-2357595,CDM,C1713,HCPCS,0278,RC,,,,both,,,697.08,453.10,,,,,,,,,,,,,
PARTICLE EMB SZ 150 250UM POLYVI ALC N RADIOACTIVE CNTOUR 5,SUP-2148438,CDM,C1713,HCPCS,0278,RC,,,,both,,,398.78,259.21,,,,,,,,,,,,,
TUBE SUCTION TEARDROP 6 FRX5.75 IN 8.25 IN TAPR SUPER MALL,SUP-2473491,CDM,2720000010,LOCAL,0272,RC,,,,both,,,266.05,172.93,,,,,,,,,,,,,
GRAFT HUMAN TSSUE SGMNT 8MML MPJ ARTHRDSS FRZN IRRDTD ENHNCE,SUP-2727664,CDM,C1713,HCPCS,0278,RC,,,,both,,,4021.40,2613.91,,,,,,,,,,,,,
DRILL SET HUDSON CRAN BRAC COMPLETE,SUP-2470555,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1795.17,1166.86,,,,,,,,,,,,,
GUIDEWIRE VASC .012 .014IN DIA 175CM LEN STR TIP SUPERSOFT,SUP-2157200,CDM,C1769,HCPCS,0272,RC,,,,both,,,185.26,120.42,,,,,,,,,,,,,
PROSTHESIS OSS VENT TUBE 1.02X0.040X1 MM W/ TAB SHEA PARASOL,SUP-2312829,CDM,L8699,HCPCS,0278,RC,,,,both,,,46.85,30.45,,,,,,,,,,,,,
PROSTHESIS OSS L 8 MM SHFT DIA1 MM HD DIA 3.25 MM TI HA FLX,SUP-2902106,CDM,L8613,CPT,0278,RC,,,,both,,,1685.87,1095.82,,,,,,,,,,,,,
CATHETER EP D 6 MM 20 MMX7 FRX115 CM CARTO,SUP-2467701,CDM,C1732,HCPCS,0278,RC,,,,both,,,7262.82,4720.83,,,,,,,,,,,,,
DRAINAGE SET ABSC 038 14 FRX41 CM 18 GAX15 CM J THAL QUIK,SUP-2168352,CDM,C1729,HCPCS,0272,RC,,,,both,,,303.86,197.51,,,,,,,,,,,,,
PLATE BONE 4 H AUX 1 CBL TRITIUM SCP,SUP-2335607,CDM,C1713,HCPCS,0278,RC,,,,both,,,1868.30,1214.39,,,,,,,,,,,,,
PAD TRACH STOMA 1 35X30 MM INNOVATIVE CUSH SIL.FLEX,SUP-2352874,CDM,C1713,HCPCS,0278,RC,,,,both,,,486.70,316.35,,,,,,,,,,,,,
IMPLANT BIO TISS W7XL17CM THK1MM RECT ACELLULAR CLLGN MTRX,SUP-2243670,CDM,C9360,HCPCS,0278,RC,,,,both,,,7846.86,5100.46,,,,,,,,,,,,,
ALLOGRAFT BNE INJ MINI 4 CC IGNITE PWR MIX,SUP-2759447,CDM,C1713,HCPCS,0278,RC,,,,both,,,4705.20,3058.38,,,,,,,,,,,,,
CATHETER PERITONEAL DLYS TENCK PEDIATRIC 37.5 CM LT SIL ARGY,SUP-2754733,CDM,C1752,HCPCS,0278,RC,,,,both,,,434.42,282.37,,,,,,,,,,,,,
COUNTERSINK SURG OD4.5MM HDLSS SGL USE MONSTER,SUP-2320973,CDM,2720000010,LOCAL,0272,RC,,,,both,,,520.93,338.60,,,,,,,,,,,,,
PIN EXT FIX L 60 MM DIA 5 MM LNG TI HALF STRL DISP JET-X,SUP-2933205,CDM,2720000010,LOCAL,0272,RC,,,,both,,,518.01,336.71,,,,,,,,,,,,,
DEFIBRILLATOR IMPL EVERA MRI S DR SURESCAN W 51 X H 66 MM D,SUP-2282400,CDM,C1721,HCPCS,0275,RC,,,,both,,,42514.44,27634.39,,,,,,,,,,,,,
SYSTEM INTRO 8FR L13CM STD BLU CAP HEMSTAT SPLITTABLE,SUP-2302495,CDM,C1894,HCPCS,0272,RC,,,,both,,,86.07,55.95,,,,,,,,,,,,,
MICROCATHETER DIAG SWIFTNINJA L 125 CM DIA PROX/DSTL,SUP-2303080,CDM,C1887,HCPCS,0272,RC,,,,both,,,7536.00,4898.40,,,,,,,,,,,,,
PLATE BONE STRAIGHT 2 MM 20 HOLE STAINLESS STEEL STERILE TC1,SUP-2836686,CDM,C1713,HCPCS,0278,RC,,,,both,,,1730.01,1124.51,,,,,,,,,,,,,
ELECTRODE ENDO MPLR KNF DISP 27FR,SUP-2261171,CDM,2720000010,LOCAL,0272,RC,,,,both,,,443.71,288.41,,,,,,,,,,,,,
DEFIBRILLATOR CRD 69X51X12 MM 31 CC 71 GM SYS DF4 GALLANT DR,SUP-2876021,CDM,C1721,HCPCS,0275,RC,,,,both,,,55245.16,35909.35,,,,,,,,,,,,,
BLADE SURG NO64 S STL SATIN FINISH MINIATURE EDGE ROUNDED,SUP-2161434,CDM,2720000010,LOCAL,0272,RC,,,,both,,,27.51,17.88,,,,,,,,,,,,,
BIT DRL TWST 1.9X115 MM 11 MM W/ STP NOTCH LEVEL 1 DISP,SUP-2473660,CDM,2720000010,LOCAL,0272,RC,,,,both,,,476.93,310.00,,,,,,,,,,,,,
RING EXT FIX 5/8 210 MM ALUM MAXFRAME,SUP-2432234,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3378.80,2196.22,,,,,,,,,,,,,
HC OP Traction Intermittent|OP PT SERVICES|DOCUMENTATION ON FILE|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS,PX-4209701200,CDM,97012,CPT,0420,RC,,,GP|KX|CQ,outpatient,,,292.00,189.80,,,,,,,,,,,,,
HC So Clot Inhibit Protein S Total,PX-3058530566,CDM,85305,CPT,0305,RC,,,,both,,,112.00,72.80,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 40 CM DIA 5 MM STR STD WALL REINF,SUP-2525432,CDM,C1768,CPT,0278,RC,,,,both,,,209.72,136.32,,,,,,,,,,,,,
STAPLE BNE FIX BRIDGE L 8 X 8 X W 1.5 MM MINI NIT LP NS,SUP-2897019,CDM,C1713,HCPCS,0278,RC,,,,both,,,2508.86,1630.76,,,,,,,,,,,,,
PLATE BNE THK 1 MM BAR 4 MM SCREW DIA2 MM 6 H MINI CRV,SUP-2883221,CDM,C1713,HCPCS,0278,RC,,,,both,,,923.69,600.40,,,,,,,,,,,,,
SCREW BONE L4MM DIA1MM CORT CRANIOMAXILLOFACIAL GLD TI ST,SUP-2189035,CDM,C1713,HCPCS,0278,RC,,,,both,,,346.40,225.16,,,,,,,,,,,,,
DEVICE 12 WATCHPAT ONE,SUP-2848789,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3391.20,2204.28,,,,,,,,,,,,,
PLATE BNE L LG 100 DEG 1.5X24X1 MM MIDFACE 7 W/ TAB STRL,SUP-2461633,CDM,C1713,HCPCS,0278,RC,,,,both,,,855.34,555.97,,,,,,,,,,,,,
MEMBRANE AMNIO AMNIOFIX ALLGRFT 4.0X4.0CM,SUP-2305730,CDM,V2790,HCPCS,0278,RC,,,,both,,,5950.30,3867.69,,,,,,,,,,,,,
IMPLANT TAILORS BUNION MEDIUM,SUP-2662918,CDM,C1713,HCPCS,0278,RC,,,,both,,,3705.20,2408.38,,,,,,,,,,,,,
SCREW BNE L16MM OD2MM THRD L12MM TI BRK OFF MONSTER BITE,SUP-2320998,CDM,C1713,HCPCS,0278,RC,,,,both,,,1000.88,650.57,,,,,,,,,,,,,
JOINT TOE 10 DEG 2.4 MM NS EXTREMIFUSE LTX,SUP-2856276,CDM,C1776,CPT,0278,RC,,,,both,,,4270.40,2775.76,,,,,,,,,,,,,
ASPIRIN-DIPYRIDAMOLE ER 25-200 MG PO CP12,RX-27644,CDM,6370000000,HCPCS,0637,RC,65162-0596-06,NDC,,both,1,UN,4.60,2.99,,,,,,,,,,,,,
BIT DRL L16MM OD8MM BIOABSRB SURTAC,SUP-2341293,CDM,2720000010,LOCAL,0272,RC,,,,both,,,844.03,548.62,,,,,,,,,,,,,
CATHETER ABLATN D-F CRV N NAVIGATIONAL EZ STEER THERMOCOOL,SUP-2257365,CDM,C1732,HCPCS,0278,RC,,,,both,,,5338.00,3469.70,,,,,,,,,,,,,
LINER ACET HIP IPOLYSE GRP D 36MM +0 FC,SUP-2165913,CDM,C1776,CPT,0278,RC,,,,both,,,2612.48,1698.11,,,,,,,,,,,,,
CAGE SPNL 22X9X45MM 0DEG PARA LAT INTBDY FUS VEO,SUP-2164083,CDM,C1889,HCPCS,0278,RC,,,,both,,,21352.00,13878.80,,,,,,,,,,,,,
GRAFT ENDOVASC L15CM DIA5MM CATH L120CM BAL DIA5MM 0.035IN,SUP-2396543,CDM,C1874,HCPCS,0278,RC,,,,both,,,11523.80,7490.47,,,,,,,,,,,,,
GRAFT EVAR L13.5CM DIA18MM CONTRALATERAL LEG ENDOPROS USED,SUP-2395954,CDM,C1768,CPT,0278,RC,,,,both,,,11837.80,7694.57,,,,,,,,,,,,,
SCREW BNE PED L18MM DIA3.5MM L R CORT PROX FEM TIB S STL ST,SUP-2318506,CDM,C1713,HCPCS,0278,RC,,,,both,,,175.84,114.30,,,,,,,,,,,,,
CATHETER DIAG 2.1-1.6FR L156CM ID0.0165IN STR 2 MRK TIP,SUP-2305458,CDM,C1887,HCPCS,0272,RC,,,,both,,,2869.18,1864.97,,,,,,,,,,,,,
FIXATOR EXT FIX 40 MM SIDEKCK CORETRAK,SUP-2464291,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5677.12,3690.13,,,,,,,,,,,,,
SCREW BNE CANN 7X115 MM FT SS NS,SUP-2183895,CDM,C1713,HCPCS,0278,RC,,,,both,,,6.28,4.08,,,,,,,,,,,,,
VALVE SHUNT L 13.4 MM PRESSURE SUPINE 10 CM H2O UPR 30 CM,SUP-2928867,CDM,C1889,HCPCS,0278,RC,,,,both,,,6204.42,4032.87,,,,,,,,,,,,,
ALLOGRAFT BNE 1 CRYOPRESERVED RT MTCRPL PHLANG,SUP-2867044,CDM,C1762,CPT,0278,RC,,,,both,,,5074.08,3298.15,,,,,,,,,,,,,
HC Repair Wounds 20.1cm to 30.0cm,PX-4501205600,CDM,12056,CPT,0450,RC,,,,both,,,2133.00,1386.45,,,,,,,,,,,,,
SCREW BONE CRANIO MAXILLOFACIAL HI TORQ CROSS DRV ST MIDFACE,SUP-2403040,CDM,C1713,HCPCS,0278,RC,,,,both,,,116.18,75.52,,,,,,,,,,,,,
DEROTATOR SURG 12MM 35DEG SPNL APCL DANEK,SUP-2292677,CDM,C1713,HCPCS,0278,RC,,,,both,,,1452.60,944.19,,,,,,,,,,,,,
PACEMAKER CARD EDORA SR-T W 40 X H 48 MM D 6.5 MM 10 CC 21,SUP-2138477,CDM,C1786,HCPCS,0275,RC,,,,both,,,13423.50,8725.27,,,,,,,,,,,,,
PLATE BNE L119MM 6 H NONSTERILE R MED PROX TIB S STL LOK,SUP-2185634,CDM,C1713,HCPCS,0278,RC,,,,both,,,3827.22,2487.69,,,,,,,,,,,,,
SCREW BONE L17MM OD2MM SLV TI CORT CRANIOMAXILLOFACIAL,SUP-2403116,CDM,C1713,HCPCS,0278,RC,,,,both,,,100.48,65.31,,,,,,,,,,,,,
GUIDEWIRE VASC VASSALLO GT L 190 CM DIA 0.014 IN TIP LOAD 3,SUP-2909314,CDM,C1769,HCPCS,0272,RC,,,,both,,,94.48,61.41,,,,,,,,,,,,,
LINER ACET OD68MM ID32MM HIP MARATHON NEUT SNAP IN REV PINN,SUP-2250409,CDM,C1776,CPT,0278,RC,,,,both,,,4370.88,2841.07,,,,,,,,,,,,,
TAP SURG SILVERTON OD4.5MM,SUP-2211141,CDM,2720000010,LOCAL,0272,RC,,,,both,,,204.10,132.66,,,,,,,,,,,,,
HANDPIECE ELECSURG L20CM 9MM JAW OPN EXT FR ACTUATED GRP,SUP-2313550,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1460.73,949.47,,,,,,,,,,,,,
EXTERNAL FIXATION SET COMPLETE QUADRILATERAL GALAXY FIX GEM,SUP-2875651,CDM,C1713,HCPCS,0278,RC,,,,both,,,21605.02,14043.26,,,,,,,,,,,,,
PLATE BNE GRIFFIN MOD LINDORF 7 MM CHIN FOR 2.0 MM SYS CP TI,SUP-2458596,CDM,C1713,HCPCS,0278,RC,,,,both,,,614.84,399.65,,,,,,,,,,,,,
PLATE BNE FIBULAR 2.7X118 MM LT LAT DSTL 6 HOLE STRL VALCP,SUP-2789397,CDM,C1713,HCPCS,0278,RC,,,,both,,,3110.48,2021.81,,,,,,,,,,,,,
CATHETER GUID AR1 7 FRX100 CM SH CONCIERGE,SUP-2302491,CDM,C1887,HCPCS,0272,RC,,,,both,,,179.61,116.75,,,,,,,,,,,,,
SCREW BNE CANN 3.2X33 MM TWINFIX,SUP-2364038,CDM,C1713,HCPCS,0278,RC,,,,both,,,896.78,582.91,,,,,,,,,,,,,
PIN 5X160X35MM YL,SUP-2483733,CDM,C1713,HCPCS,0278,RC,,,,both,,,445.03,289.27,,,,,,,,,,,,,
IMPLANT OP RM MINI-MONSTER 4.0 X 20MM HD CANN SHT THRD SCR,SUP-2320534,CDM,C1713,HCPCS,0278,RC,,,,both,,,642.92,417.90,,,,,,,,,,,,,
SYSTEM INFUS MATCHING OCCL WIRE CK RELF VLV PASS HEMSTAS VLV,SUP-2302564,CDM,C1751,HCPCS,0278,RC,,,,both,,,379.63,246.76,,,,,,,,,,,,,
GRAFT NRV REP L4CM DIA3MM TYP 1 CLLGN ABSRB SEMIPERMEABLE,SUP-2244317,CDM,C9352,HCPCS,0278,RC,,,,both,,,4642.84,3017.85,,,,,,,,,,,,,
ALLOGRAFT BNE STRP 10X20X8 MM FD SPNG CANC READIGRAFT BLX,SUP-2740889,CDM,C1713,HCPCS,0278,RC,,,,both,,,2030.20,1319.63,,,,,,,,,,,,,
IMPLANT OSS L4.5MM PIST DIA0.6MM STAP PLAT S STL RBBN LOOP,SUP-2312547,CDM,L8613,CPT,0278,RC,,,,both,,,429.30,279.04,,,,,,,,,,,,,
SUPPORT ORTHOT SHLDR ADJ CUST FIT STRP W/OUT JT FABRICATED,SUP-2435751,CDM,L3671,HCPCS,0274,RC,,,,both,,,2321.65,1509.07,,,,,,,,,,,,,
LINER ACET 23 10 DEG 32 MM FEM HIP ARCOMXL RINGLOK,SUP-2136078,CDM,C1776,CPT,0278,RC,,,,both,,,4483.92,2914.55,,,,,,,,,,,,,
"HC Transluminal Peripheral Atherectomy, Brachiocephal and Branches, Ea",PX-3610237000,CDM,0237T,HCPCS,0361,RC,,,,both,,,10136.00,6588.40,,,,,,,,,,,,,
COUNTERSINK SURG DIA 4 MM CANN FT AO QC MIS,SUP-2898209,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1127.26,732.72,,,,,,,,,,,,,
NAIL IM TROCHANTERIC 9X265 MM STRL FITBONE,SUP-2875397,CDM,C1713,HCPCS,0278,RC,,,,both,,,105538.07,68599.75,,,,,,,,,,,,,
GRAFT BNE 10 CC DEMINERALIZED BNE FIBER PROGRAFT,SUP-2858506,CDM,C1713,HCPCS,0278,RC,,,,both,,,3282.24,2133.46,,,,,,,,,,,,,
PLATE BNE ADV 7 MM RT CRANIOMAXILLOFACIAL LEFORT I,SUP-2883175,CDM,C1713,HCPCS,0278,RC,,,,both,,,1956.00,1271.40,,,,,,,,,,,,,
BIT DRILL/MINI QC/50MM 1.0MM,SUP-2842394,CDM,2720000010,LOCAL,0272,RC,,,,both,,,805.76,523.74,,,,,,,,,,,,,
HC Feeding Tube Plcmt W Fluoro,PX-3614375200,CDM,43752,CPT,0361,RC,,,,outpatient,,,1485.00,965.25,,,,,,,,,,,,,
BRACE KNEE POSTOP 1 SZ FITS MOST SH UNIV UNISX FASTEN ON HNG,SUP-2150852,CDM,L1832,HCPCS,0272,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
CORTEX SCREW 2.0MMX24MM,SUP-2818645,CDM,C1713,HCPCS,0278,RC,,,,both,,,226.77,147.40,,,,,,,,,,,,,
JIG SURG KNEE PS REPL STRL ITOTAL IDENTITY,SUP-2904460,CDM,2720000010,LOCAL,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
PLATE BONE SM L91MM 7 H STD BILAT COMPR CNTOUR + FOR 3.5MM,SUP-2348994,CDM,C1713,HCPCS,0278,RC,,,,both,,,1391.93,904.75,,,,,,,,,,,,,
CENTRALIZER KNEE L DIA16MM UHMWPE CEM ENDO-MODEL-M,SUP-2265086,CDM,C1776,CPT,0278,RC,,,,both,,,464.72,302.07,,,,,,,,,,,,,
VALVE MITRL CARP EDW PERIMT THEON DIA25 MM SEW RNG DIA 34 MM,SUP-2214296,CDM,C1889,HCPCS,0278,RC,,,,both,,,19452.30,12643.99,,,,,,,,,,,,,
FORCEP SPEC RETRV GRASPING 3 FRX65 CM 14 MM,SUP-2835679,CDM,2720000010,LOCAL,0272,RC,,,,both,,,913.74,593.93,,,,,,,,,,,,,
NAIL IM L180MM DIA11MM TIB MAG PHOENIX,SUP-2412147,CDM,C1713,HCPCS,0278,RC,,,,both,,,8653.84,5625.00,,,,,,,,,,,,,
PLATE BNE THK 1 MM SCREW DIA2/2.3 MM 10 H GRD II TI SLV,SUP-2936080,CDM,C1713,HCPCS,0278,RC,,,,both,,,1557.44,1012.34,,,,,,,,,,,,,
NEEDLE INTRO EXCALIBUR L 35 MM NDL 19 GA PERC ART VEN ACCS,SUP-2125565,CDM,C1894,HCPCS,0272,RC,,,,both,,,42.08,27.35,,,,,,,,,,,,,
GUIDEWIRE EXT FIX L350MM DIA18MM FOR ANK COMPR NAILING SYS,SUP-2316009,CDM,C1769,HCPCS,0272,RC,,,,both,,,342.89,222.88,,,,,,,,,,,,,
COMPONENT FEM SZ 1 KNEE POST STBL SYMMETRICAL POR COAT,SUP-2223008,CDM,C1776,CPT,0278,RC,,,,both,,,12371.60,8041.54,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED CEM GENDER SPEC M HXLPE,SUP-2212705,CDM,C1776,CPT,0278,RC,,,,both,,,12933.69,8406.90,,,,,,,,,,,,,
FLEXI-TIP URETERAL CATHETER,SUP-2826939,CDM,C1758,HCPCS,0278,RC,,,,both,,,37.71,24.51,,,,,,,,,,,,,
HC MRI-Angio Neck WO & W Contra,PX-6157054900,CDM,70549,CPT,0615,RC,,,,inpatient,,,4932.00,3205.80,,,,,,,,,,,,,
CANNULATED HIP PIN 30MM,SUP-2818073,CDM,C1713,HCPCS,0278,RC,,,,both,,,2631.57,1710.52,,,,,,,,,,,,,
PLATE BNE SM RT CALCANEAL PERIMETER NS,SUP-2896942,CDM,C1713,HCPCS,0278,RC,,,,both,,,2822.86,1834.86,,,,,,,,,,,,,
WASHER ORTH 2.5MM SPIK CRTX SCR,SUP-2184670,CDM,C1713,HCPCS,0278,RC,,,,both,,,332.21,215.94,,,,,,,,,,,,,
RXG BURR HOLE COVER SLIGHT CONTOURED 1MM 17MM DIA,SUP-2679390,CDM,C1713,HCPCS,0278,RC,,,,both,,,1142.61,742.70,,,,,,,,,,,,,
BEAM FIX 7.5X155 MM CHARCOAT FIX SYS AXIS,SUP-2610030,CDM,C1713,HCPCS,0278,RC,,,,both,,,4380.30,2847.19,,,,,,,,,,,,,
GUIDEWIRE ORTH LNG SALVATION,SUP-2850526,CDM,C1769,HCPCS,0272,RC,,,,both,,,2373.84,1543.00,,,,,,,,,,,,,
SHEATH INTRO AXS INFIN LS L 70 CM OD 8 FR ID 0.088 IN SS LNR,SUP-2367810,CDM,C1894,HCPCS,0272,RC,,,,both,,,1429.96,929.47,,,,,,,,,,,,,
SCREW BNE MULT DIR 2.4X18 MM STRL STRATUM RS,SUP-2862012,CDM,C1713,HCPCS,0278,RC,,,,both,,,630.67,409.94,,,,,,,,,,,,,
WASHER ORTH DIA6.0MM,SUP-2343054,CDM,C1713,HCPCS,0278,RC,,,,both,,,12.97,8.43,,,,,,,,,,,,,
GRAFT BNE SUB 3ML CA PHSPTE FAST SET PTTY DRILLABLE NORIAN,SUP-2420786,CDM,C1713,HCPCS,0278,RC,,,,both,,,2252.51,1464.13,,,,,,,,,,,,,
GROMMET VENT ID1.14MM INNR FLNG OD2.4MM INTERFLNG DISTANCE,SUP-2284033,CDM,L8699,HCPCS,0278,RC,,,,both,,,126.95,82.52,,,,,,,,,,,,,
IMPLANT HUM TISS DIA22 MM MONO CUSP PTCH SINGLE LEAFLET,SUP-2933362,CDM,C1762,CPT,0278,RC,,,,both,,,22293.87,14491.02,,,,,,,,,,,,,
CATHETER VALVULOPLASTY TYSHAK MINI L 65 CM 2.5 FR 1 CM 6 MM,SUP-2659647,CDM,C1725,HCPCS,0272,RC,,,,both,,,2352.86,1529.36,,,,,,,,,,,,,
BELT ORTHOT RIB THOR CUST FABRICATED,SUP-2435536,CDM,L0220,HCPCS,0274,RC,,,,both,,,365.75,237.74,,,,,,,,,,,,,
MESH SURG 26X4X3CM POLYPR Y FOR SACROCOLPOPEXY VERTESSA LT,SUP-2152281,CDM,C1781,HCPCS,0278,RC,,,,both,,,2964.16,1926.70,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9 % IV BOLUS,RX-103555,CDM,2580000003,HCPCS,0250,RC,00264-1800-32,NDC,,both,250,ML,57.40,37.31,,,,,,,,,,,,,
SHEATH INTRO FLX BLKN L 40 CM OD 6 FR GUIDEWIRE 0.038 IN,SUP-2170113,CDM,C1894,HCPCS,0272,RC,,,,both,,,146.20,95.03,,,,,,,,,,,,,
PIN SYS SCHNZ 4MM,SUP-2399234,CDM,C1713,HCPCS,0278,RC,,,,both,,,204.10,132.66,,,,,,,,,,,,,
ANCHOR SUT RIGIDLOOP FIXED 50MM,SUP-2749354,CDM,C1713,HCPCS,0278,RC,,,,both,,,2216.84,1440.95,,,,,,,,,,,,,
HC MRI-Angio Neck WO & W Contra,PX-6157054900,CDM,70549,CPT,0615,RC,,,,outpatient,,,4932.00,3205.80,,,,,,,,,,,,,
PLATE BNE 2.7X129 MM 16 HOLE,SUP-2199265,CDM,C1713,HCPCS,0278,RC,,,,both,,,1396.67,907.84,,,,,,,,,,,,,
PLATE BNE 3.5X85 MM 7 HOLE SS DCP,SUP-2569139,CDM,C1713,HCPCS,0278,RC,,,,both,,,262.50,170.62,,,,,,,,,,,,,
STEM FEM L160MM OD10MM TIB KNEE UNCEMENTED SPLINED STR IMP,SUP-2405468,CDM,C1776,CPT,0278,RC,,,,both,,,4298.66,2794.13,,,,,,,,,,,,,
CATHETER EP 7FR L115CM TIP 15-25MM 2-6-2MM SPC 20 ELECTRD D,SUP-2248774,CDM,C1731,HCPCS,0278,RC,,,,both,,,4939.22,3210.49,,,,,,,,,,,,,
BUTTON GAST ACC AD 28FR L1.5CM NONBLLN NONOBTRUSIVE,SUP-2125949,CDM,2720000010,LOCAL,0272,RC,,,,both,,,411.34,267.37,,,,,,,,,,,,,
CATHETER CV KT AD 9 FRX11.5 CM DL N TUNNELED 7.5-8 FR MAC,SUP-2763351,CDM,C1751,HCPCS,0278,RC,,,,both,,,378.68,246.14,,,,,,,,,,,,,
FIBER LASER W/ 200 EXCALIBUR,SUP-2225718,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1146.10,744.96,,,,,,,,,,,,,
PLATE STRNL CLOSURE THK 1.5 MM 8 H TI V LP NS STERNALOCK EZ,SUP-2894512,CDM,C1713,HCPCS,0278,RC,,,,both,,,3579.60,2326.74,,,,,,,,,,,,,
PLATE BNE L99MM 5 H ST L LAT DST FIBULAR S STL LOK COMPR,SUP-2177417,CDM,C1713,HCPCS,0278,RC,,,,both,,,1923.97,1250.58,,,,,,,,,,,,,
GUIDEWIRE ORTH 1.4 MM TAPR,SUP-2535943,CDM,C1769,HCPCS,0272,RC,,,,both,,,69.08,44.90,,,,,,,,,,,,,
TUBE ET AD DIA6MM 6ML MAX INFL VOL PHYCON UNIVENT,SUP-2115123,CDM,2720000010,LOCAL,0272,RC,,,,both,,,578.92,376.30,,,,,,,,,,,,,
PLATE BNE CLAV CS1 2.7 MM RT VA LCK COMPR TI STRL VALCP,SUP-2789607,CDM,C1713,HCPCS,0278,RC,,,,both,,,3853.41,2504.72,,,,,,,,,,,,,
SWAN GANZ PACEPORT OXIMETRY TD,SUP-2696592,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1095.11,711.82,,,,,,,,,,,,,
DISTRACTOR LIN 150MM FOR TRUELOK FIX SYS,SUP-2316065,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1651.95,1073.77,,,,,,,,,,,,,
GRAFT STENT 0.035 IN 9 MMX15 CM 9 FRX120 CM HEPARIN VIABAHN,SUP-2396521,CDM,C1874,HCPCS,0278,RC,,,,both,,,10952.32,7119.01,,,,,,,,,,,,,
PLATE BNE STR NAR 4.5X215 MM 13 HOLE 2 COMPR FOR SCR SS NS,SUP-2479158,CDM,C1713,HCPCS,0278,RC,,,,both,,,631.33,410.36,,,,,,,,,,,,,
PLATE SPNL 1 LEVEL 16 MM ANTR CERV TETH,SUP-2379300,CDM,C1713,HCPCS,0278,RC,,,,both,,,5305.34,3448.47,,,,,,,,,,,,,
GRAFT BIO TISS W10XL12CM FET BOV SLV MESHED ANTIMIC,SUP-2243714,CDM,Q4110,HCPCS,0636,RC,,,,both,,,15888.40,10327.46,,,,,,,,,,,,,
IMP SYS T-ROPE RIGHT W/8.0MM FLIPCUTR II,SUP-2812195,CDM,C1713,HCPCS,0278,RC,,,,both,,,2119.50,1377.67,,,,,,,,,,,,,
PLATE 3.5MM TI LCP MEDIAL PROXIMAL TIBIA 4H RT 93MM-STER,SUP-2549565,CDM,C1713,HCPCS,0278,RC,,,,both,,,4531.68,2945.59,,,,,,,,,,,,,
CATHETER EP THER COOL PATH,SUP-2463047,CDM,C2630,CPT,0272,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
CATHETER HAD AD 13FR L24CM POLYUR STR TAPR TIP NO CUF,SUP-2125595,CDM,C1752,HCPCS,0278,RC,,,,both,,,947.62,615.95,,,,,,,,,,,,,
CATHETER UMB SINGLE LUMEN PEDIATRIC 3.5/5 FRX15 IN VEN ARGY,SUP-2174249,CDM,C1751,HCPCS,0278,RC,,,,both,,,469.90,305.43,,,,,,,,,,,,,
CATHETER DRAINAGE LCK PIG 16 FR,SUP-2381893,CDM,C1729,HCPCS,0272,RC,,,,both,,,57.15,37.15,,,,,,,,,,,,,
SET URET STENT L 55 CM DIA 4 FR KID INT SPLNT FOR,SUP-2171260,CDM,C2625,HCPCS,0278,RC,,,,both,,,302.95,196.92,,,,,,,,,,,,,
PLATE BNE L70MM THK1.2MM BILAT CALCNL S STL LOK COMPR FOR,SUP-2185987,CDM,C1713,HCPCS,0278,RC,,,,both,,,2885.94,1875.86,,,,,,,,,,,,,
GRAFT HUMAN TISSUE THICK 7X4 CM HYDRATED BIOLOGIC TISSUE MAT,SUP-2838607,CDM,C1763,HCPCS,0278,RC,,,,both,,,2598.04,1688.73,,,,,,,,,,,,,
SET INTRO SUP ARW FLX SHTH L 65 CM DIA 6 FR HYDRPHLC,SUP-2383405,CDM,C1894,HCPCS,0272,RC,,,,both,,,307.88,200.12,,,,,,,,,,,,,
CATHETER CV DL 7 FRX20 CM KT BLU FLEXTIP,SUP-2383472,CDM,C1751,HCPCS,0278,RC,,,,both,,,81.64,53.07,,,,,,,,,,,,,
KIT HAD L45CM CATH SYMMETRIC TIP 2 LUMN CATH SFTY SHTH TISS,SUP-2283924,CDM,C1881,HCPCS,0278,RC,,,,both,,,746.06,484.94,,,,,,,,,,,,,
CONNECTOR SPNL OD5.5X5.5MM TI THORLUM SACR PARA DOMINO FOR,SUP-2205439,CDM,C1713,HCPCS,0278,RC,,,,both,,,1648.50,1071.52,,,,,,,,,,,,,
LINER ACET PRSS FT HIP POROUS MTL CERM,SUP-2304817,CDM,C1776,CPT,0278,RC,,,,both,,,17584.00,11429.60,,,,,,,,,,,,,
PLATE BNE SET FOR LG LOWER EXTREMITY PERI-LOC,SUP-2351391,CDM,C1713,HCPCS,0278,RC,,,,both,,,5730.50,3724.82,,,,,,,,,,,,,
PLATE PROX LATERAL TIB 3.5 RT 9H,SUP-2854931,CDM,C1713,HCPCS,0278,RC,,,,both,,,7186.77,4671.40,,,,,,,,,,,,,
INSTRUMENT EXT FIX REARFOOT 3 ARTH FOR SIDEKCK FIX,SUP-2400591,CDM,C1894,HCPCS,0272,RC,,,,both,,,16541.52,10751.99,,,,,,,,,,,,,
PLATE BNE W24XL43MM 12 H L DST RAD TI LOK COMPR LO PROF NAR,SUP-2411821,CDM,C1713,HCPCS,0278,RC,,,,both,,,3397.48,2208.36,,,,,,,,,,,,,
BUR SURG RND STD 3.5 MM 57 MM TOOL STL POWERFORMA,SUP-2629014,CDM,2720000010,LOCAL,0272,RC,,,,both,,,237.82,154.58,,,,,,,,,,,,,
SHELL HMSPHR SHELL 44 MM,SUP-2217267,CDM,C1776,CPT,0278,RC,,,,both,,,15511.60,10082.54,,,,,,,,,,,,,
BIT DRL L66MM DIA2.35MM STP 10MM TWST QUIK NONRADIOLUCENT,SUP-2267851,CDM,2720000010,LOCAL,0272,RC,,,,both,,,263.76,171.44,,,,,,,,,,,,,
STEM FEM 19.5 MM HIP MOCK ZMR,SUP-2439593,CDM,C1776,CPT,0278,RC,,,,both,,,2204.28,1432.78,,,,,,,,,,,,,
PASSOR SUTURE MEDIUM,SUP-2749339,CDM,2720000010,LOCAL,0272,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
PLATE BONE 8MM ADV MINI TI CHIN CRANIOMAXILLOFACIAL FOR 2MM,SUP-2319367,CDM,C1713,HCPCS,0278,RC,,,,both,,,511.82,332.68,,,,,,,,,,,,,
TI LOW PROFILE NEURO,SUP-2823424,CDM,C1713,HCPCS,0278,RC,,,,both,,,2225.00,1446.25,,,,,,,,,,,,,
CATHETER CENTESIS 5FR L7CM 1 STP,SUP-2303193,CDM,C1729,HCPCS,0272,RC,,,,both,,,62.80,40.82,,,,,,,,,,,,,
SCREW BONE CNNLTD CMPRSSN 5.5MM DIA 35MML TTNM ALLOY FLLY TH,SUP-2586464,CDM,C1713,HCPCS,0278,RC,,,,both,,,1485.03,965.27,,,,,,,,,,,,,
UNIVERSAL GLENOID - INLAY LARGE PLUS,SUP-2817692,CDM,C1713,HCPCS,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
INSERT ACET 28X61 MM HIP PIERCED POLYETH,SUP-2494897,CDM,C1776,CPT,0278,RC,,,,both,,,579.58,376.73,,,,,,,,,,,,,
PLATE BNE L139MM 2 H ST R PROX FEM S STL LO PROF LOK COMPR,SUP-2186131,CDM,C1713,HCPCS,0278,RC,,,,both,,,4092.11,2659.87,,,,,,,,,,,,,
PLATE CNDYL 2MM 2H HD 6H SHFT TI STRL VAL,SUP-2546912,CDM,C1713,HCPCS,0278,RC,,,,both,,,2110.65,1371.92,,,,,,,,,,,,,
SYRINGE MED CONE TIP 100 CC 3 RNG CTRL AUTOCLV FOR UROLOGY,SUP-2747410,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1286.18,836.02,,,,,,,,,,,,,
COMPONENT FEM LIP 59X60 MM LT MEDL LAT CNDYL CONSTRN COCR,SUP-2199878,CDM,C1776,CPT,0278,RC,,,,both,,,30737.46,19979.35,,,,,,,,,,,,,
SET SCR SPNL OD4MM TI BRK OFF VERTEX XLNK,SUP-2286943,CDM,C1713,HCPCS,0278,RC,,,,both,,,43.96,28.57,,,,,,,,,,,,,
STAPLER INT INSTRUMENT 45 MM ENDOWRIST XI SUREFORM DISP,SUP-2246799,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1516.62,985.80,,,,,,,,,,,,,
GUIDEWIRE VASC AD L195CM DIA0.014IN TIP 3CM FLPY J TIP,SUP-2158057,CDM,C1769,HCPCS,0272,RC,,,,both,,,204.10,132.66,,,,,,,,,,,,,
VALVE VENT DRNGE PRECIS FIX INLINE W/ STR CONN INTRO PRIMING,SUP-2243816,CDM,C1729,HCPCS,0272,RC,,,,both,,,3035.12,1972.83,,,,,,,,,,,,,
PIN FIX L140MM DIA4MM BNE,SUP-2368427,CDM,2720000010,LOCAL,0272,RC,,,,both,,,326.56,212.26,,,,,,,,,,,,,
HC Perc Transhep Port W/Hemo Eval,PX-3207588500,CDM,75885,CPT,0320,RC,,,,both,,,7130.00,4634.50,,,,,,,,,,,,,
IMPLANT TOE XSM 10DEG ANG PHALINX,SUP-2397783,CDM,C1776,CPT,0278,RC,,,,both,,,1438.12,934.78,,,,,,,,,,,,,
CRADLE BUTTON CORTICAL FEMORAL ADJUSTABLE GRAFTMAX,SUP-2824645,CDM,C1713,HCPCS,0278,RC,,,,both,,,574.43,373.38,,,,,,,,,,,,,
GRAFT DERMACELL DERMAL 4X12CM X 1.25-2MM UNMESHED MATRIX,SUP-2878003,CDM,Q4122,HCPCS,0636,RC,,,,both,,,4264.12,2771.68,,,,,,,,,,,,,
SET INT FIX SCREW DIA1.5 MM 4 H LNG TI NEURO STR PLT XDRV 12,SUP-2935190,CDM,C1713,HCPCS,0278,RC,,,,both,,,17125.56,11131.61,,,,,,,,,,,,,
LINK TYPE: FEM SIZE: 52MM,SUP-2397006,CDM,C1776,CPT,0278,RC,,,,both,,,10770.20,7000.63,,,,,,,,,,,,,
CELLECT CATRIDGE EMP,SUP-2255623,CDM,C1713,HCPCS,0278,RC,,,,both,,,1742.70,1132.75,,,,,,,,,,,,,
DRILL SURG 1.6 MMX6 IN,SUP-2607263,CDM,2720000010,LOCAL,0272,RC,,,,both,,,492.76,320.29,,,,,,,,,,,,,
GRAFT HUM TISS W5XL5CM NOM THK1.5MM MAXFORC HUM DERM REGEN,SUP-2399110,CDM,Q4107,HCPCS,0636,RC,,,,both,,,7209.44,4686.14,,,,,,,,,,,,,
GRAFT HUM TISS FIRM 25X20 CM RECON TISS MTRX STRATTICE,SUP-2113038,CDM,Q4130,HCPCS,0636,RC,,,,both,,,49508.38,32180.45,,,,,,,,,,,,,
BALL TIP NRV STIM PRB 160MM,SUP-2415717,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
IMPLANT STAPE PISTON WIRE SCHKNT 0.8MM PISTON 6.25MML SSSFLR,SUP-2638215,CDM,2720000010,LOCAL,0272,RC,,,,both,,,328.26,213.37,,,,,,,,,,,,,
HC Debride Skin Sub Musc Bone,PX-4501104400,CDM,11044,CPT,0450,RC,,,,both,,,1677.00,1090.05,,,,,,,,,,,,,
SCREW BNE L34MM OD43MM TI LO EXT ST SELF DRL CANN FIX STBL,SUP-2242827,CDM,C1713,HCPCS,0278,RC,,,,both,,,1169.21,759.99,,,,,,,,,,,,,
PLATE BNE M ST L CALCNL FOR 35MM SCR VLP,SUP-2349962,CDM,C1713,HCPCS,0278,RC,,,,both,,,6289.58,4088.23,,,,,,,,,,,,,
SYSTEM ES CUP DIA4CM PNEUMO OCCL BLLN DISP FOR CLIN POS,SUP-2171721,CDM,2720000010,LOCAL,0272,RC,,,,both,,,304.58,197.98,,,,,,,,,,,,,
"HC So Aldosterone, Serum",PX-3018208866,CDM,82088,CPT,0301,RC,,,,both,,,341.00,221.65,,,,,,,,,,,,,
BIT DRL L52MM DIA1MM STP 20MM TWST DENT NONRADIOLUCENT DISP,SUP-2267818,CDM,2720000010,LOCAL,0272,RC,,,,both,,,378.34,245.92,,,,,,,,,,,,,
BLADE IM L90MM DIA11MM TI HELI FOR TROCHANTERIC NAIL FIX,SUP-2191899,CDM,C1713,HCPCS,0278,RC,,,,both,,,1727.13,1122.63,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED 2 MOBILITY RESURF H6ZIMMER] ZIMMER BIOMET INC],SUP-2212581,CDM,C1776,CPT,0278,RC,,,,both,,,21980.00,14287.00,,,,,,,,,,,,,
CANNULA RF 100MM 20GA VENOM,SUP-2366962,CDM,2720000010,LOCAL,0272,RC,,,,both,,,229.35,149.08,,,,,,,,,,,,,
TRAY DRAINAGE CATH DIA15.5 FR NDL DIA25 GA SIL CUF POLYESTER,SUP-2881432,CDM,C1729,HCPCS,0272,RC,,,,both,,,2599.92,1689.95,,,,,,,,,,,,,
HUNTER ACTIVE TENDON IMPLANT PC 4MMX22CM,SUP-2822403,CDM,C1763,HCPCS,0278,RC,,,,both,,,4267.26,2773.72,,,,,,,,,,,,,
IMPLANT BIO TISS CLLGN TEND WRP TENOMEND,SUP-2223610,CDM,C1713,HCPCS,0278,RC,,,,both,,,2888.80,1877.72,,,,,,,,,,,,,
CEFAZOLIN SODIUM 2 G IJ SOLR,RX-157632,CDM,J0690,HCPCS,0636,RC,60505-6231-00,NDC,,both,1,UN,54.10,35.16,,,,,,,,,,,,,
CATHETER VENTRICULAR PUDENZ STD 18 CM 1.3X2.5 MM BA STRIPE,SUP-2244289,CDM,C1729,HCPCS,0272,RC,,,,both,,,352.75,229.29,,,,,,,,,,,,,
GRFT CHIPS CORT CANC 1-4MM 4.59MM 30CC PUROS,SUP-2693920,CDM,C1713,HCPCS,0278,RC,,,,both,,,3152.56,2049.16,,,,,,,,,,,,,
BIT DRL CEM 15.7 MM TIB PERSONA,SUP-2448191,CDM,2720000010,LOCAL,0272,RC,,,,both,,,805.41,523.52,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED 3 PART ADD ON,SUP-2212530,CDM,C1776,CPT,0278,RC,,,,both,,,1617.10,1051.11,,,,,,,,,,,,,
WIRE FIX BLNT SS STRL KIRSCHNER,SUP-2207918,CDM,C1713,HCPCS,0278,RC,,,,both,,,112.00,72.80,,,,,,,,,,,,,
SCREW BNE L 7 MM DIA1.5 MM FT CANN LAG STRL NANOPHIX,SUP-2912795,CDM,C1713,HCPCS,0278,RC,,,,both,,,2618.76,1702.19,,,,,,,,,,,,,
DRESSING BIO CORNEAL BNDG PROKERA SLIM,SUP-2135267,CDM,V2790,HCPCS,0278,RC,,,,both,,,2979.86,1936.91,,,,,,,,,,,,,
CATHETER BLLN DIL 200 CM 5-20 MMX70 CM SAVARY-GILLIARD,SUP-2759272,CDM,C1769,HCPCS,0272,RC,,,,both,,,11329.12,7363.93,,,,,,,,,,,,,
NEEDLE PHACO 30 DEG 20/21 GA ANGLED VORT STRL LF DISP,SUP-2464271,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1277.16,830.15,,,,,,,,,,,,,
SPLINT WRST WRP ARND UNIV 8 IN FOREARM RT COOL BLU,SUP-2336238,CDM,L3908,HCPCS,0274,RC,,,,both,,,15.57,10.12,,,,,,,,,,,,,
GRAFT HUM TISS W5XL5CM THK08 17MM DERM HUM ACELLULAR,SUP-2307047,CDM,Q4128,HCPCS,0636,RC,,,,both,,,4329.12,2813.93,,,,,,,,,,,,,
SCREW BONE L3MM DIA1.5MM CRANIOMAXILLOFACIAL TI SELF DRL,SUP-2181588,CDM,C1713,HCPCS,0278,RC,,,,both,,,258.86,168.26,,,,,,,,,,,,,
GRAFT BONE TIBIA DISTAL TALUS RIGHT,SUP-2858710,CDM,C1762,CPT,0278,RC,,,,both,,,21509.00,13980.85,,,,,,,,,,,,,
INBONE EVERLAST SZ 3+ 20MM TOTAL ANKLE,SUP-2822312,CDM,C1776,CPT,0278,RC,,,,both,,,6892.30,4479.99,,,,,,,,,,,,,
PLATE BONE THK1.25MM 2X2 H CRANIOMAXILLOFACIAL ORAL SLV TI,SUP-2181766,CDM,C1713,HCPCS,0278,RC,,,,both,,,1336.38,868.65,,,,,,,,,,,,,
PISTON OTOLARYN L4.5MM OD.6MM S STL FLROPLAS INCUS PIST WIRE,SUP-2312537,CDM,L8613,CPT,0278,RC,,,,both,,,328.16,213.30,,,,,,,,,,,,,
PLATE CRAN 180X180X40 MM PT SPEC IMPL PEEK,SUP-2860163,CDM,C1713,HCPCS,0278,RC,,,,both,,,53824.62,34986.00,,,,,,,,,,,,,
STENT GRFT VASC TAG L 10 CM DIA PROX/DSTL 31/31 MM,SUP-2396388,CDM,C1768,CPT,0278,RC,,,,both,,,47778.24,31055.86,,,,,,,,,,,,,
SPHERE GLEN DIA41MM +3MM OFFSET CO CHROM SHLDR REV SYS,SUP-2404723,CDM,C1776,CPT,0278,RC,,,,both,,,3397.48,2208.36,,,,,,,,,,,,,
PLATE 14HL 2.7X113,SUP-2471359,CDM,C1713,HCPCS,0278,RC,,,,both,,,1376.48,894.71,,,,,,,,,,,,,
LENGTHENER EXT FIX VERTICAL AXIS MINIRAIL,SUP-2316440,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3259.70,2118.80,,,,,,,,,,,,,
PLATE BNE 4 H R T SLNT COMPR FOR LISFRANC INJ GORILLA,SUP-2321527,CDM,C1713,HCPCS,0278,RC,,,,both,,,3814.63,2479.51,,,,,,,,,,,,,
PLATE BONE SM 116MML HLX10 STNLSS STEEL BTTRSS ST RIGHT DST,SUP-2471023,CDM,C1713,HCPCS,0278,RC,,,,both,,,2111.30,1372.34,,,,,,,,,,,,,
FORCEPS BPLR L7IN TIP 1MM STD DISPOSABLE SPETZLER MALIS,SUP-2364925,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1191.44,774.44,,,,,,,,,,,,,
STENT BILI SENTINOL L 40 MM DIA 8 MM CATH L 135 CM NIT SELF,SUP-2144563,CDM,C1876,HCPCS,0278,RC,,,,both,,,3990.16,2593.60,,,,,,,,,,,,,
NEEDLE TRANSSEPTAL HEARTSPAN DIA18 GA STRL,SUP-2457165,CDM,2720000010,LOCAL,0272,RC,,,,both,,,480.42,312.27,,,,,,,,,,,,,
SET APPLICATOR LOCALIZER-S 20 10 CM HOLOGIC,SUP-2874144,CDM,A4648,CPT,0278,RC,,,,both,,,887.05,576.58,,,,,,,,,,,,,
CONDYLAR PLATE RIGHT 13X253MM,SUP-2820887,CDM,C1713,HCPCS,0278,RC,,,,both,,,7934.31,5157.30,,,,,,,,,,,,,
DEVICE FIX TWIN TAIL TECH TIGHTROPE,SUP-2121666,CDM,C1776,CPT,0278,RC,,,,both,,,1805.50,1173.57,,,,,,,,,,,,,
PLATE BNE FIBULAR 2.7X157 MM RT LAT DSTL 9 HOLE NS VA-LCP,SUP-2758201,CDM,C1713,HCPCS,0278,RC,,,,both,,,3120.28,2028.18,,,,,,,,,,,,,
TRIMETHOPRIM 100 MG PO TABS,RX-8182,CDM,6370000000,HCPCS,0637,RC,75907-0043-01,NDC,,both,1,UN,8.40,5.46,,,,,,,,,,,,,
KIT CONVENIENCE HND WRST INTERNALBRACE LIG AUG IMPL REP SYS,SUP-2123211,CDM,C1776,CPT,0278,RC,,,,both,,,4694.30,3051.29,,,,,,,,,,,,,
CATHETER INTVASC ULTRASOUND OPTICROSS 35 L 105 CM DIA 8 FR,SUP-2738597,CDM,C1753,HCPCS,0278,RC,,,,both,,,2731.80,1775.67,,,,,,,,,,,,,
DRESSING WND REP 15X7.5 IN GRAPHIX,SUP-2391509,CDM,Q4133,HCPCS,0636,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
IMPLANT SACROILIAC JT FUS L65MM DIA7MM TI POR PLSM SPRY,SUP-2337790,CDM,C1713,HCPCS,0278,RC,,,,both,,,10440.50,6786.32,,,,,,,,,,,,,
TUBE VENT ID127MM SIL BLU FOR MYR CLLR BTTN,SUP-2313713,CDM,L8699,HCPCS,0278,RC,,,,both,,,38.65,25.12,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED TIB UPCHARGE BASEPLT TRAB MEL,SUP-2212694,CDM,C1776,CPT,0278,RC,,,,both,,,3249.90,2112.43,,,,,,,,,,,,,
SCREW BONE 3.5MM DIA 10MML CORTICAL,SUP-2588529,CDM,C1713,HCPCS,0278,RC,,,,both,,,84.87,55.17,,,,,,,,,,,,,
KIT VASC SNR ATRIEVE 90 DEG TIP 15 DEG L 175 CM DIA 4-8 MM,SUP-2120067,CDM,C1773,HCPCS,0272,RC,,,,both,,,2260.80,1469.52,,,,,,,,,,,,,
REAMER EXTRACTION SZ 5.8 MM SCREW DIA 4.7-5.8 MM STRL DISP,SUP-2913564,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3160.19,2054.12,,,,,,,,,,,,,
MOMETASONE FUROATE 0.1 % EX CREA,RX-10646,CDM,6370000000,HCPCS,0637,RC,00713-0634-15,NDC,,both,15,GR,78.80,51.22,,,,,,,,,,,,,
PATCH VASC HEMGRD L 150 X W 50 MM THK 0.65 MM POLYESTER BOV,SUP-2535428,CDM,C1768,CPT,0278,RC,,,,both,,,1109.83,721.39,,,,,,,,,,,,,
CATHETER HD STR 9 FRX12 CM CATH INTRO NDL DUOFLO,SUP-2627100,CDM,C1752,HCPCS,0278,RC,,,,both,,,188.40,122.46,,,,,,,,,,,,,
PLATE BNE FIBULAR 2.7X235 MM LT LAT DSTL 15 HOLE NS VA-LCP,SUP-2758208,CDM,C1713,HCPCS,0278,RC,,,,both,,,3677.07,2390.10,,,,,,,,,,,,,
CATHETERIZATION KIT 9 FRX115 CM CV DL ARROWG+ARD +,SUP-2383375,CDM,C1751,HCPCS,0278,RC,,,,both,,,467.23,303.70,,,,,,,,,,,,,
STAPLER INT POWDERED 33 MM ECHELON CIR,SUP-2218875,CDM,C1889,HCPCS,0278,RC,,,,both,,,1165.44,757.54,,,,,,,,,,,,,
DISSECTOR SURG US 26 CM CRV JAW CRDLSS STRL SONICISION 7 LF,SUP-2863484,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1224.60,795.99,,,,,,,,,,,,,
SCREW SPNL L45MM DIA8.5MM CANC PEDCL S STL NO CUT ISOLA VSP,SUP-2255688,CDM,C1713,HCPCS,0278,RC,,,,both,,,1551.16,1008.25,,,,,,,,,,,,,
HC Antistreptolysin O Screen,PX-3028606300,CDM,86063,CPT,0302,RC,,,,both,,,339.00,220.35,,,,,,,,,,,,,
PLATE BONE L114MM 6 H LT DSTL FIBULAR FOR PICCOLO COMP PLT,SUP-2152519,CDM,C1713,HCPCS,0278,RC,,,,both,,,2804.81,1823.13,,,,,,,,,,,,,
GRAFT HUM TISS W12XL16CM THK18 4MM ACELLULAR DERM MTRX,SUP-2307485,CDM,Q4128,HCPCS,0636,RC,,,,both,,,18390.32,11953.71,,,,,,,,,,,,,
SYSTEM MONITOR HEARTMATE II,SUP-2356045,CDM,C1713,HCPCS,0278,RC,,,,both,,,29830.00,19389.50,,,,,,,,,,,,,
SCREW INTRF L20MM DIA9MM UNIV TI CANN BLNT NONABSORBABLE,SUP-2362042,CDM,C1713,HCPCS,0278,RC,,,,both,,,322.70,209.75,,,,,,,,,,,,,
PLATE BONE FIXATION 2 MM CONDYLAR TITANIUM,SUP-2837684,CDM,C1713,HCPCS,0278,RC,,,,both,,,1191.32,774.36,,,,,,,,,,,,,
PLATE BNE 100 DEG L 2.48 CM THK 1 MM SCREW DIA2 MM 2X2 H LNG,SUP-2936779,CDM,C1713,HCPCS,0278,RC,,,,both,,,430.18,279.62,,,,,,,,,,,,,
PLATE BNE RECON 2-2.5X2 MM MAND 34 HOLE FULL MAND TI NS,SUP-2472861,CDM,C1713,HCPCS,0278,RC,,,,both,,,6481.02,4212.66,,,,,,,,,,,,,
MESH GYN W4XL27CM Y PRESHAPED UNIDIR POLYPR FOR,SUP-2165309,CDM,C1781,HCPCS,0278,RC,,,,both,,,3438.30,2234.89,,,,,,,,,,,,,
HC Air Contrast Barium Enema,PX-3207428000,CDM,74280,CPT,0320,RC,,,,both,,,1815.00,1179.75,,,,,,,,,,,,,
PLATE BNE CONTOURABLE MESH LG 0.6 MM CRESCENT SLV NS,SUP-2859907,CDM,C1713,HCPCS,0278,RC,,,,both,,,3779.30,2456.54,,,,,,,,,,,,,
CLAMP REPROC PIN ROD HII MRI 4TO5X8MM,SUP-2700533,CDM,2720000010,LOCAL,0272,RC,,,,both,,,471.91,306.74,,,,,,,,,,,,,
CATHETER CV 5 FRX45 CM SHERLOCK STYL BARR KT GROSH,SUP-2126721,CDM,C1751,HCPCS,0278,RC,,,,both,,,785.31,510.45,,,,,,,,,,,,,
GUIDEWIRE VASC GLIDEWIRE L 180 CM DIA 0.018 IN NIT HYDRPHLC,SUP-2141152,CDM,C1769,HCPCS,0272,RC,,,,both,,,216.66,140.83,,,,,,,,,,,,,
GRAFT BNE 2.5 CC OSTEOCURRENT,SUP-2644332,CDM,C1713,HCPCS,0278,RC,,,,both,,,3485.40,2265.51,,,,,,,,,,,,,
COUPLER SURG PWR SM NEW EXT SVC 1YR,SUP-2760773,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2967.30,1928.74,,,,,,,,,,,,,
METHYLPREDNISOLONE ACETATE 40 MG/ML IJ SUSP,RX-4995,CDM,J1010,HCPCS,0636,RC,00009-3073-03,NDC,,both,0.25,ML,54.10,35.16,,,,,,,,,,,,,
VALVE AORT CARP EDW PERIMT MAGNA SZ 19 SEW RNG DIA24 MM PROF,SUP-2214088,CDM,C1889,HCPCS,0278,RC,,,,both,,,15700.00,10205.00,,,,,,,,,,,,,
PLATE BNE W10XL94MM THK3.6MM 8 H BILAT S STL CRV RIG CLLR,SUP-2186254,CDM,C1713,HCPCS,0278,RC,,,,both,,,2169.65,1410.27,,,,,,,,,,,,,
GUIDEROD ORTH L600MM DIA2MM GRAD BALL TIP TRIGEN,SUP-2348121,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1163.50,756.27,,,,,,,,,,,,,
TUBING ASPIR FOR REPERFUSION CATH PMP CANSTR MAX PTS3,SUP-2849700,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1130.40,734.76,,,,,,,,,,,,,
GRAFT SKIN L 20 X W 8 CM THK 1.25-2 MM HUM ACELLULAR DERMAL,SUP-2890354,CDM,Q4122,HCPCS,0636,RC,,,,both,,,14221.09,9243.71,,,,,,,,,,,,,
PATCH VASC VASCU-GUARD L 6 X W 1 CM BOV PERICARD FOR CARTOID,SUP-2130382,CDM,C1768,CPT,0278,RC,,,,both,,,469.74,305.33,,,,,,,,,,,,,
CATHETER ANGIO GLIDECATH XP L 100 CM DIA 5 FR 1.22 MM ANGLED,SUP-2385165,CDM,C1887,HCPCS,0272,RC,,,,both,,,173.52,112.79,,,,,,,,,,,,,
KIT THR TRABECULAR MTL POR STEM CUP VIT E LNR AND STD HD,SUP-2212131,CDM,C1776,CPT,0278,RC,,,,both,,,18683.00,12143.95,,,,,,,,,,,,,
CANNULA ARTHSCP L2CM DIA8MM PASSPRT BTTN,SUP-2122040,CDM,C1713,HCPCS,0278,RC,,,,both,,,100.48,65.31,,,,,,,,,,,,,
"HC Est Pt, Outpt Visit Level 1",PX-7619921100,CDM,99211,CPT,0761,RC,,,,outpatient,,,174.00,113.10,,,,,,,,,,,,,
PLATE BONE 5 H LT LAPIDUS OMNI,SUP-2224013,CDM,C1713,HCPCS,0278,RC,,,,both,,,4399.14,2859.44,,,,,,,,,,,,,
FIBER LASER 550 MH SMOOTH TIP LUMENIS HOLM SLM LN 200 DFL,SUP-2478182,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1194.02,776.11,,,,,,,,,,,,,
DEVICE PESSARY RNG 5 3 IN W/ KNOB FOLDING,SUP-2421606,CDM,A4562,HCPCS,0272,RC,,,,both,,,109.15,70.95,,,,,,,,,,,,,
HC Eye 1-3 Vws for Foreign Body,PX-3207003000,CDM,70030,CPT,0320,RC,,,,both,,,1197.00,778.05,,,,,,,,,,,,,
ELECTRODE NDL CANN L15CM ARRY DIA3.5CM FOR OPN AND PERC RF,SUP-2149299,CDM,C1713,HCPCS,0278,RC,,,,both,,,6003.68,3902.39,,,,,,,,,,,,,
HEAD HUM DIA40MM THK18MM SHLDR CO CHROM PRI STD OFFSET NK 53504018] STRYKER ORTHOPEDICS HOWM],SUP-2372833,CDM,C1776,CPT,0278,RC,,,,both,,,7418.25,4821.86,,,,,,,,,,,,,
BRACE KNEE T SCP POSTOP MEAS TAKEN 6IN ABV MID PAT 27-35IN,SUP-2150859,CDM,L1810,HCPCS,0274,RC,,,,both,,,303.95,197.57,,,,,,,,,,,,,
PROSTHESIS OSS 0.6X6 MM MID EAR MALL PISTON FLROPLAS SMRT,SUP-2313852,CDM,L8613,CPT,0278,RC,,,,both,,,1054.82,685.63,,,,,,,,,,,,,
GUIDEWIRE ORTHOPEDIC THRD 1.4X150 MM,SUP-2377914,CDM,C1769,HCPCS,0272,RC,,,,both,,,257.17,167.16,,,,,,,,,,,,,
STAPLE CAUD TI 19MM SM CD HORZ,SUP-2290268,CDM,C1713,HCPCS,0278,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
KIT REP FOR 10FR CATHETER ETERS BRVC HCKMN AND LNRD,SUP-2126563,CDM,C1751,HCPCS,0278,RC,,,,both,,,656.26,426.57,,,,,,,,,,,,,
Z DUP USE 2305332 COIL EMB 0.010 IN 8 MMX25 CM V-TRAK ADV DEL SYS COSMOS 10,SUP-2530390,CDM,C1889,HCPCS,0278,RC,,,,both,,,5071.10,3296.21,,,,,,,,,,,,,
DRESSING PURAPLY ANTIMICROB WND MATRIX 3.02X3.02CM,SUP-2719558,CDM,Q4196,HCPCS,0636,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
TRAY CATH PICC POLY Q CATH 5FR 0.042N 60CM 1 LUMAN RVRSE TAP,SUP-2613428,CDM,C1751,HCPCS,0278,RC,,,,both,,,429.55,279.21,,,,,,,,,,,,,
LEAD DEFIB BPLR 58 CM ACTIVE FIX DURATA,SUP-2357374,CDM,C1895,HCPCS,0275,RC,,,,both,,,13797.95,8968.67,,,,,,,,,,,,,
REPAIR KIT SYNDESMOSIS TI NS FIBULINK,SUP-2790021,CDM,C1713,HCPCS,0278,RC,,,,both,,,3678.38,2390.95,,,,,,,,,,,,,
GRAFT HUM TISS 15X15MM PERICARD FRZ DRY READIGRFT,SUP-2264831,CDM,C1768,CPT,0278,RC,,,,both,,,312.78,203.31,,,,,,,,,,,,,
TROCAR SURG FOR 2 MM PIN,SUP-2537825,CDM,2720000010,LOCAL,0272,RC,,,,both,,,452.79,294.31,,,,,,,,,,,,,
IMPLANT OP RM UNIV PLT 10MM DOGB,SUP-2321540,CDM,C1713,HCPCS,0278,RC,,,,both,,,3758.58,2443.08,,,,,,,,,,,,,
CHRONOS(TM) BETA-TCP WEDGE 10 DEG/RECTANGULAR-STERILE,SUP-2550432,CDM,C1713,HCPCS,0278,RC,,,,both,,,1846.98,1200.54,,,,,,,,,,,,,
BEARING TIB THK16MM KNEE UHMWPE ORTH SALV SYS,SUP-2405763,CDM,C1776,CPT,0278,RC,,,,both,,,2811.87,1827.72,,,,,,,,,,,,,
PATCH CV HEMGRD L 75 X W 10 MM THK 0.41 MM POLYESTER BOV,SUP-2535417,CDM,C1768,CPT,0278,RC,,,,both,,,454.01,295.11,,,,,,,,,,,,,
IMPLANT ANK JT SM GAITWAY,SUP-2397257,CDM,C1776,CPT,0278,RC,,,,both,,,4003.50,2602.27,,,,,,,,,,,,,
COMPONENT FEM SZ 8 CO CHROM RT KNEE REV STEMLESS POST STBL,SUP-2346137,CDM,C1776,CPT,0278,RC,,,,both,,,19427.78,12628.06,,,,,,,,,,,,,
SPLINT ORTHOPEDIC CLAV UNIV CONTACT CLOSURE NYL PROCARE,SUP-2196992,CDM,L3650,HCPCS,0274,RC,,,,both,,,21.76,14.14,,,,,,,,,,,,,
LEVEL NEURO ST PLATE ULTRNE LDDR CVD NEURO SCRW3 X 2 HOLES 2,SUP-2707443,CDM,C1713,HCPCS,0278,RC,,,,both,,,1111.69,722.60,,,,,,,,,,,,,
CATHETER ANGIO ACCU-VU L 70 CM DIA 5 FR 0.038 IN 2 CM OMNI,SUP-2117050,CDM,C1725,HCPCS,0272,RC,,,,both,,,747.01,485.56,,,,,,,,,,,,,
DEXTROSE 5% IV SOLN NEONATE,RX-40840076,CDM,J7060,HCPCS,0258,RC,00264-7510-10,NDC,,both,500,ML,34.00,22.10,,,,,,,,,,,,,
SYSTEM BRST LOC 75CM DEL NDL SAVI SCOUT,SUP-2164411,CDM,C1819,HCPCS,0278,RC,,,,both,,,1444.40,938.86,,,,,,,,,,,,,
PACEMAKER CARD ENTOVIS PROMRI SR-T SINGLE CHMBR CELLULAR HM,SUP-2138453,CDM,C1786,HCPCS,0275,RC,,,,both,,,11461.00,7449.65,,,,,,,,,,,,,
DRILL TWST 1.8MM DS FOR 4MM SCR,SUP-2365070,CDM,2720000010,LOCAL,0272,RC,,,,both,,,317.67,206.49,,,,,,,,,,,,,
PROBE PRESSURE MONITOR MIC FOR O2 LICOX,SUP-2883662,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1088.20,707.33,,,,,,,,,,,,,
GUIDEWIRE ORTH L190CM DIA1.6MM TIB PARTIALLY THRD SHRP TIP,SUP-2204945,CDM,C1769,HCPCS,0272,RC,,,,both,,,62.11,40.37,,,,,,,,,,,,,
SCREW CNCLLS LOK 5.3MM DIA 20MML FLLY THRDD TTNM ST ACMD,SUP-2639948,CDM,C1713,HCPCS,0278,RC,,,,both,,,1400.44,910.29,,,,,,,,,,,,,
SPECULUM 3714691 BECKMAN NASAL SZ2 MED,SUP-2494947,CDM,2720000010,LOCAL,0272,RC,,,,both,,,750.87,488.07,,,,,,,,,,,,,
HC US Pelvis Limited,PX-4027685700,CDM,76857,CPT,0402,RC,,,,both,,,1220.00,793.00,,,,,,,,,,,,,
HOLDER PIN 16X11CM M TRAC BOHLER STNMN,SUP-2197324,CDM,C1713,HCPCS,0278,RC,,,,both,,,493.92,321.05,,,,,,,,,,,,,
DEXTROSE 5% IV SOLN NEONATE,RX-40840076,CDM,2580000003,HCPCS,0250,RC,00990-7922-61,NDC,,both,150,ML,44.70,29.05,,,,,,,,,,,,,
SCREW INTRF L20MM DIA11MM KNEE PLLA RND HD CANN ABSRB,SUP-2166524,CDM,C1713,HCPCS,0278,RC,,,,both,,,580.90,377.58,,,,,,,,,,,,,
NAIL IM L190MM DIA7.5MM 120DEG STRL BLU L/R HUM TI CANN LCK,SUP-2192483,CDM,C1713,HCPCS,0278,RC,,,,both,,,5665.75,3682.74,,,,,,,,,,,,,
GUIDEWIRE VASC STR 0.038 INX145 CM X STIFF TAPR SS AMPLATZ,SUP-2167903,CDM,C1769,HCPCS,0272,RC,,,,both,,,54.51,35.43,,,,,,,,,,,,,
CATHETER HD SET 14 FRX15 CM DL INDWL CRV N COAT BLU FLEXTIP,SUP-2762994,CDM,C1752,HCPCS,0278,RC,,,,both,,,216.66,140.83,,,,,,,,,,,,,
NAIL IM L270MM DIA9MM TIB DK BLU TI SLD LOK BEND,SUP-2192771,CDM,C1713,HCPCS,0278,RC,,,,both,,,4215.70,2740.20,,,,,,,,,,,,,
LUSPATERCEPT-AAMT 75 MG SC SOLR,RX-148222,CDM,J0896,HCPCS,0636,RC,59572-0775-01,NDC,,both,1,UN,35537.40,23099.31,,,,,,,,,,,,,
HC Implantable Pump - Refill/Main,PX-3359652200,CDM,96522,CPT,0335,RC,,,,both,,,477.00,310.05,,,,,,,,,,,,,
SPLINT ORTHOPEDIC CLAV UNIV CONTACT CLOSURE NYL PROCARE,SUP-2196992,CDM,L3650,HCPCS,0272,RC,,,,both,,,21.76,14.14,,,,,,,,,,,,,
DEXTROSE 5% IV SOLN NEONATE,RX-40840076,CDM,J7060,HCPCS,0258,RC,00264-7510-20,NDC,,both,250,ML,31.90,20.73,,,,,,,,,,,,,
DEXTROSE 5% IV SOLN NEONATE,RX-40840076,CDM,J7060,HCPCS,0250,RC,00264-7510-10,NDC,,both,500,ML,34.00,22.10,,,,,,,,,,,,,
GRAFT BNE 13 MM CUBE Q-PACK CONFORM,SUP-2264597,CDM,C1713,HCPCS,0278,RC,,,,both,,,2255.15,1465.85,,,,,,,,,,,,,
ELECTRODE ENDOSCP MPLR DISPOSABLE  NDL 37CM MCCARTHY,SUP-2436272,CDM,2720000010,LOCAL,0272,RC,,,,both,,,733.50,476.77,,,,,,,,,,,,,
BIT DRL OD7MM CANN COUNTSINK,SUP-2315876,CDM,2720000010,LOCAL,0272,RC,,,,both,,,693.94,451.06,,,,,,,,,,,,,
TIBIAL NAIL D10XL345,SUP-2701446,CDM,C1713,HCPCS,0278,RC,,,,both,,,8206.70,5334.35,,,,,,,,,,,,,
SIZER SURG NACL 13.3-13.2 CM 350-370 CC 68LP NATRELLE,SUP-2493745,CDM,2720000010,LOCAL,0272,RC,,,,both,,,131.88,85.72,,,,,,,,,,,,,
CATHETER DIAG L150CM ID0.0175IN SHTH OD5FR 0.014IN STD S,SUP-2173631,CDM,C1887,HCPCS,0272,RC,,,,both,,,4396.00,2857.40,,,,,,,,,,,,,
PLATE BONE L191MM 11 H LT PROX HUM LCK FOR 3.5MM SCR,SUP-2348594,CDM,C1713,HCPCS,0278,RC,,,,both,,,14345.72,9324.72,,,,,,,,,,,,,
PLATE BNE L183MM 10 H ST POST MED PROX TIB S STL LOK COMPR,SUP-2177801,CDM,C1713,HCPCS,0278,RC,,,,both,,,3625.92,2356.85,,,,,,,,,,,,,
STENT PERIPH EVERFLEX L 20 MM DIA 6 MM CATH L 80 CM SHTH 5,SUP-2172884,CDM,C1725,HCPCS,0272,RC,,,,both,,,2041.00,1326.65,,,,,,,,,,,,,
PLATE BONE 3 MM STP THK1.6 MM TI IMP F 3.5 MM SCR LAPIDUS,SUP-2321011,CDM,C1713,HCPCS,0278,RC,,,,both,,,5224.96,3396.22,,,,,,,,,,,,,
PLATE BNE BROAD 3.5X158 MM 13 HOLE SS DCP,SUP-2569155,CDM,C1713,HCPCS,0278,RC,,,,both,,,366.12,237.98,,,,,,,,,,,,,
PLATE SPNL ANCHR 37 MM OCPTL ASCNT POCT,SUP-2601971,CDM,C1713,HCPCS,0278,RC,,,,both,,,3114.88,2024.67,,,,,,,,,,,,,
SCREW SPNL L35MM OD7.5MM FOR 5.5MM ROD VAR ANG N CANN THRD,SUP-2230086,CDM,C1713,HCPCS,0278,RC,,,,both,,,2276.50,1479.72,,,,,,,,,,,,,
SHOE ORTHOT CUST DENNIS BRN SPLNT,SUP-2435749,CDM,L3640,HCPCS,0274,RC,,,,both,,,122.49,79.62,,,,,,,,,,,,,
PLATE BNE TALONAVICULAR SM LT STRATUM,SUP-2474525,CDM,C1713,HCPCS,0278,RC,,,,both,,,5220.00,3393.00,,,,,,,,,,,,,
PLATE BNE L 1.6 MM RT LCK NS LTX,SUP-2856935,CDM,C1713,HCPCS,0278,RC,,,,both,,,828.96,538.82,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 55 CM DIA 4-7 MM EPTFE TAPR STD,SUP-2396216,CDM,C1768,CPT,0278,RC,,,,both,,,2398.96,1559.32,,,,,,,,,,,,,
KIT INTRO PEELPRO L 14 CM DIA 7 FR PTFE TEARWY STD,SUP-2118930,CDM,C1894,HCPCS,0272,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
FIBER LASER OMNIGUIDE ELEV ELITE,SUP-2225690,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4251.56,2763.51,,,,,,,,,,,,,
GRAFT BNE SUB L30MM THK1MM STRP COMPRESSIBLE SPNG SM GROWTH,SUP-2138505,CDM,C1713,HCPCS,0278,RC,,,,both,,,4505.90,2928.83,,,,,,,,,,,,,
HC Peripheral Block - Brachial Plexus Continuous W/Img Gdn,PX-3606441600,CDM,64416,CPT,0360,RC,,,,both,,,2895.00,1881.75,,,,,,,,,,,,,
RELOAD STPL M L60MM THCK TISS GRN W/ GRIPPING SURF,SUP-2283359,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1394.88,906.67,,,,,,,,,,,,,
BASKET SPEC RETRV 5 FRX60 CM FLX SHTH,SUP-2767787,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1695.22,1101.89,,,,,,,,,,,,,
BODY FEM SZ 16.5 STD L DST TEXT APR,SUP-2210919,CDM,C1776,CPT,0278,RC,,,,both,,,28228.60,18348.59,,,,,,,,,,,,,
CATHETER ANGIOPLSTY L 200 CM BALLOON L 100 MM DIA 7 MM SHTH,SUP-2890556,CDM,C1725,HCPCS,0272,RC,,,,both,,,1193.20,775.58,,,,,,,,,,,,,
SP PLASMANEEDLE LNG RIGHT ANGLED,SUP-2722602,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1598.10,1038.76,,,,,,,,,,,,,
SCREW ABSORBABLE CANNULATED 40MM DIA 34MML ARTHROTEK,SUP-2724045,CDM,C1725,HCPCS,0272,RC,,,,both,,,860.36,559.23,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL PEEK SD800.557,SUP-2860238,CDM,C1713,HCPCS,0278,RC,,,,both,,,25085.77,16305.75,,,,,,,,,,,,,
PLATE BONE SM 6 H GAP LO PROF FOR 1.5MM SCR CRAN FIX SYS,SUP-2363637,CDM,C1713,HCPCS,0278,RC,,,,both,,,1071.12,696.23,,,,,,,,,,,,,
SAW SURG 105X20X1.27MM WIDE OSC TIP W/ CART FOR BNE CUT,SUP-2367672,CDM,2720000010,LOCAL,0272,RC,,,,both,,,989.10,642.91,,,,,,,,,,,,,
PIN IMPL POS N THRD NS BB-TAK,SUP-2930402,CDM,C1713,HCPCS,0278,RC,,,,both,,,280.25,182.16,,,,,,,,,,,,,
CATHETER OCCL BLLN L11MM DIA4MM DST TIP L5MM EXTRA,SUP-2305410,CDM,C2628,HCPCS,0272,RC,,,,both,,,5524.83,3591.14,,,,,,,,,,,,,
IMMOBILIZER ORTH 3 PNL 2XL 22 IN KNEE BRTRC ADJ FOAM,SUP-2194906,CDM,L1830,CPT,0274,RC,,,,both,,,57.46,37.35,,,,,,,,,,,,,
ANCHOR SUT DIA4.5MM BIOCRYL RAPIDE ABSRB 2 DYNACORD SZ 2,SUP-2256645,CDM,C1713,HCPCS,0278,RC,,,,both,,,1978.20,1285.83,,,,,,,,,,,,,
ALLOGRAFT BNE REFRIGERATED LT FEM TROCHLEA,SUP-2740868,CDM,C1713,HCPCS,0278,RC,,,,both,,,36594.06,23786.14,,,,,,,,,,,,,
SYSTEM FIX ACL KNEE ADJ 4 PT LCK W/ 9MM FLIPCUTTER II,SUP-2121389,CDM,C1713,HCPCS,0278,RC,,,,both,,,2119.50,1377.67,,,,,,,,,,,,,
SPLINT ORTHOPEDIC W/ ABDUCTED MED 8 IN LT WRST FOREARM THMB,SUP-2276633,CDM,L3809,HCPCS,0274,RC,,,,both,,,22.58,14.68,,,,,,,,,,,,,
RHS SHORT RADIAMETERL STEM DIAMETER 6MM NECK 13MM,SUP-2830222,CDM,C1776,CPT,0278,RC,,,,both,,,8939.58,5810.73,,,,,,,,,,,,,
GRAFT VASC STR 32 MMX30 CMX0.038 MM AORT CV BOV INTERGARD,SUP-2472279,CDM,C1768,CPT,0278,RC,,,,both,,,1429.01,928.86,,,,,,,,,,,,,
NAIL IM L300MM DIA8.5MM TIB KNEE GRY TI CANN LOK RG BENT,SUP-2347448,CDM,C1713,HCPCS,0278,RC,,,,both,,,11741.56,7632.01,,,,,,,,,,,,,
SLING GYN L 12 X W 1.1 CM POLYPRO MONOFILAMENT SHRT,SUP-2929641,CDM,C1771,HCPCS,0278,RC,,,,both,,,3874.76,2518.59,,,,,,,,,,,,,
HC Ot Ultrasound 15 Min|OP PT SERVICES|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS,PX-4309703500,CDM,97035,CPT,0430,RC,,,GP|CQ,outpatient,,,194.00,126.10,,,,,,,,,,,,,
BUR SURG DIAMOND 4 MM COARSE BALL FOR MIA16-G1/MIA16,SUP-2848317,CDM,2720000010,LOCAL,0272,RC,,,,both,,,463.90,301.53,,,,,,,,,,,,,
PATCH CV W1XL9CM THK0.5MM SQ TIP,SUP-2395321,CDM,C1768,CPT,0278,RC,,,,both,,,637.42,414.32,,,,,,,,,,,,,
CUTTER ENDOSCP DIA9MM USED TO ELIMINATE TRANSOSSEOUS TUNN,SUP-2120853,CDM,2720000010,LOCAL,0272,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
STEM FEM L155MM DIA17MM DST HIP TI HA STR CONIC CEM MOD REV,SUP-2375812,CDM,C1776,CPT,0278,RC,,,,both,,,7027.32,4567.76,,,,,,,,,,,,,
KIT K WIRE SM T6 SCRDRVR PLATING DEPTH GA FOR 1.5/2/2.4MM,SUP-2225515,CDM,C1713,HCPCS,0278,RC,,,,both,,,499.89,324.93,,,,,,,,,,,,,
TIP SUCTION FRAZIER 4 FRX9 CM 4 FR ESSAR W/ REL HOLE,SUP-2473037,CDM,2720000010,LOCAL,0272,RC,,,,both,,,776.55,504.76,,,,,,,,,,,,,
IMMUNE GLOBULIN (OCTAGAM) 10%|DISCARDED DRUG NOT ADMINISTE,RX-4081765,CDM,J1568,HCPCS,0636,RC,68982-0850-02,NDC,JW,both,50,ML,2865.20,1862.38,,,,,,,,,,,,,
VALVE MITRL CARP EDW TISS ANNULUS 25 MM SEW RNG DIA 34 MM,SUP-2214272,CDM,C1889,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
PLATE BNE W21.6XL48.9MM SHT NAR ANAT FAST GUID TECHNOLOGY,SUP-2414022,CDM,C1713,HCPCS,0278,RC,,,,both,,,2709.82,1761.38,,,,,,,,,,,,,
CAGE SPNL 16X23MM THRD INTBODY FUS INT FIX,SUP-2291441,CDM,C1889,HCPCS,0278,RC,,,,both,,,13685.00,8895.25,,,,,,,,,,,,,
SEED BRACHYTHERAPY LOAD 1.01-2.0 MCI STRL ADVANTAGE,SUP-2247261,CDM,C2642,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
KIT SND PROC FOR OSI300 IMPL NS OSIA2I,SUP-2882744,CDM,L8691,HCPCS,0278,RC,,,,both,,,13647.38,8870.80,,,,,,,,,,,,,
LEAD PACE POLYUR ENDOCARD RT ATR J+ EXT RETRACTABLE SCREW,SUP-2140090,CDM,C1883,HCPCS,0278,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
NAIL IM L380MM DIA10MM FEM TIB KNEE G TI CANN LOK AG RG,SUP-2347087,CDM,C1713,HCPCS,0278,RC,,,,both,,,3990.16,2593.60,,,,,,,,,,,,,
CALCIUM GLUCONATE (ANTIDOTE) 2.5 % EX GEL,RX-87801,CDM,6370000000,HCPCS,0637,RC,77683-0063-06,NDC,,both,25,GR,171.00,111.15,,,,,,,,,,,,,
WIRE FIX OLV 1.6 MM KIRSCHNER,SUP-2267997,CDM,C1713,HCPCS,0278,RC,,,,both,,,676.98,440.04,,,,,,,,,,,,,
RETRACTOR SPNL L6CM DIA22MM D2.36IN S STL TB MED LAT DIL,SUP-2292984,CDM,2720000010,LOCAL,0272,RC,,,,both,,,660.97,429.63,,,,,,,,,,,,,
ROMOSOZUMAB-AQQG 105 MG/1.17ML SC SOSY,RX-145946,CDM,J3111,HCPCS,0636,RC,55513-0998-02,NDC,,both,2.34,ML,7755.40,5041.01,,,,,,,,,,,,,
GRAFT VASC ADVANTA AFT L 30 CM DIA 6 MM EPTFE STR STD WALL,SUP-2493251,CDM,C1768,CPT,0278,RC,,,,both,,,992.87,645.37,,,,,,,,,,,,,
CATHETER GUID LUMAX L 80 CM DIA 8 FR GUIDEWIRE 0.038 IN,SUP-2638618,CDM,C1887,HCPCS,0272,RC,,,,both,,,1058.97,688.33,,,,,,,,,,,,,
URETERAL URETERAL DILATOR,SUP-2822050,CDM,C2627,HCPCS,0272,RC,,,,both,,,844.13,548.68,,,,,,,,,,,,,
HANDPIECE 430 SER AND SOLARA SER HIGH-SPEED LUBEFREE CERAMIC,SUP-2322265,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1196.34,777.62,,,,,,,,,,,,,
PAD ORTHOT CERV THOR LUMBAR SACR CUST KYPHOSIS FLOATING,SUP-2435572,CDM,L1025,HCPCS,0274,RC,,,,both,,,440.17,286.11,,,,,,,,,,,,,
FOOTPLATE EXT FIX 140 MM ALUM,SUP-2162657,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5144.58,3343.98,,,,,,,,,,,,,
HC So Urine Cult/Colony Count,PX-3008708666,CDM,87086,CPT,0300,RC,,,,both,,,101.00,65.65,,,,,,,,,,,,,
HC Insert Ureteral Tube,PX-3615069300,CDM,50693,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
DEVICE EMBOLIC 0.36MM WIRE DIA 190CM 5FR INTRO 7MM TEMP NIT S,SUP-2173566,CDM,C1884,HCPCS,0278,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
EXTENSION GUIDEWIRE STRTCH L 150 CM DIA 0.014 IN STRL,SUP-2664346,CDM,C1769,HCPCS,0272,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
BRACE ORTH AD XSM L6.5IN FOR 7.25-8IN HND L WRST BLK BOA LOK,SUP-2196532,CDM,L3931,HCPCS,0274,RC,,,,both,,,193.55,125.81,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED STD CEM POLYETH,SUP-2212716,CDM,C1776,CPT,0278,RC,,,,both,,,11049.69,7182.30,,,,,,,,,,,,,
STENT URET MARD L 24-30 CM DIA 6 FR PERCFLX HYDROPLUS SFT,SUP-2141625,CDM,C2617,HCPCS,0278,RC,,,,both,,,402.71,261.76,,,,,,,,,,,,,
POST EXT FIX FEMALE 1 H W/O THRD ATTACH NS DISP MONK RING,SUP-2899261,CDM,C1713,HCPCS,0278,RC,,,,both,,,604.45,392.89,,,,,,,,,,,,,
ROD TI PREBENT 5.5X25,SUP-2840371,CDM,C1713,HCPCS,0278,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
SITAGLIPTIN PHOSPHATE 25 MG PO TABS,RX-77615,CDM,6370000000,HCPCS,0637,RC,00006-0221-31,NDC,,both,1,UN,49.50,32.17,,,,,,,,,,,,,
GRAFT TISS 1X2 ENT REP BIODESIGN,SUP-2170295,CDM,C1763,HCPCS,0278,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
PROBE SURG SCRP 8X180 MM NS OSCAR 3 LTX,SUP-2875737,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1365.90,887.83,,,,,,,,,,,,,
BIT DRL DIA2.6MM PILOT H CANN FOR 4MM SCR FLOWERCUBE,SUP-2225308,CDM,2720000010,LOCAL,0272,RC,,,,both,,,675.23,438.90,,,,,,,,,,,,,
SUPPORT OBESITY BARIATRIC L FOR 65-75IN HIP W/ LUM SHLDR,SUP-2324542,CDM,L0642,HCPCS,0272,RC,,,,both,,,215.94,140.36,,,,,,,,,,,,,
HC Chloride Bld,PX-3018243500,CDM,82435,CPT,0301,RC,,,,both,,,112.00,72.80,,,,,,,,,,,,,
PLATE BNE THK0.8MM UNIV 6X2 H CRANIOMAXILLOFACIAL TI 3D LOK,SUP-2366256,CDM,C1713,HCPCS,0278,RC,,,,both,,,1883.00,1223.95,,,,,,,,,,,,,
SET SCR HEXALOBE 25 ARRY SYS,SUP-2415866,CDM,C1713,HCPCS,0278,RC,,,,both,,,211.01,137.16,,,,,,,,,,,,,
PROMETHAZINE HCL 25 MG PO TABS,RX-6622,CDM,Q0169,HCPCS,0637,RC,00904-7304-61,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
SYSTEM CRAN FIX SM 12 MM STRL LOOP,SUP-2430763,CDM,C1713,HCPCS,0278,RC,,,,both,,,1428.70,928.65,,,,,,,,,,,,,
ATTACHMENT SH O STR,SUP-2367373,CDM,C1713,HCPCS,0278,RC,,,,both,,,2455.51,1596.08,,,,,,,,,,,,,
SPLINT WRST XSM AD L8IN FOR 5 65IN R NYL LN FOAM PUL ON,SUP-2276666,CDM,L3908,HCPCS,0272,RC,,,,both,,,18.21,11.84,,,,,,,,,,,,,
SLEEVE TIBIAL ML 40MM AP 28MM BALANCED KNEE REVISION SYSTEM,SUP-2603528,CDM,C1776,CPT,0278,RC,,,,both,,,6104.16,3967.70,,,,,,,,,,,,,
KIT INTRO AXCESS L 23 CM DIA 6 FR GUIDEWIRE 0.035-0.038 IN,SUP-2877842,CDM,C1894,HCPCS,0272,RC,,,,both,,,285.74,185.73,,,,,,,,,,,,,
KIT FIX GRFT PASS PIN DRL PNT K WIRE NIT GWIRE ACL BNE PLUG,SUP-2212935,CDM,C1713,HCPCS,0278,RC,,,,both,,,1737.30,1129.24,,,,,,,,,,,,,
PACK FIX CL SZ CALC W/ CANN ENDO DRL BIT GWIRE PASS PIN CANN,SUP-2341042,CDM,C1713,HCPCS,0278,RC,,,,both,,,1011.08,657.20,,,,,,,,,,,,,
SCREW BONE L110MM DIA10.5MM HIP LAG FOR AFFIXUS FX NAIL SYS,SUP-2137050,CDM,C1713,HCPCS,0278,RC,,,,both,,,1863.24,1211.11,,,,,,,,,,,,,
GRAFT HUMAN TISSUE PELVIC FLOOR MATRIX 15X10 CM MATRISTEM,SUP-2106488,CDM,C1763,HCPCS,0278,RC,,,,both,,,14836.50,9643.72,,,,,,,,,,,,,
BRACE KNEE WOM AD SM 6IN ABV MID PAT 15-18IN 6IN BELOW,SUP-2151050,CDM,L3660,HCPCS,0274,RC,,,,both,,,891.57,579.52,,,,,,,,,,,,,
ELECTRODE ELECSURG NDL 45 DEG TURIS CABLE PLASMA BUTTON,SUP-2313584,CDM,C1713,HCPCS,0278,RC,,,,both,,,1596.88,1037.97,,,,,,,,,,,,,
IMPLANT HUM TISS L 30 CM OD 4-10 MM FEM ART CRYOPRESERVED,SUP-2931247,CDM,C1762,CPT,0278,RC,,,,both,,,22949.10,14916.91,,,,,,,,,,,,,
BIT DRL CANN QUIK COUPLE COUNTSINK FOR 4.5/5.5 MM SCREW NS,SUP-2197517,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1034.94,672.71,,,,,,,,,,,,,
NUT ORTH CORT S STL FOR 4.5MM SCR,SUP-2411298,CDM,C1713,HCPCS,0278,RC,,,,both,,,173.89,113.03,,,,,,,,,,,,,
AZITHROMYCIN 200 MG/5ML PO SUSR,RX-15797,CDM,340b,HCPCS,0637,RC,09999-9903-76,NDC,,both,5,ML,39.30,25.54,,,,,,,,,,,,,
BRACE ORTH CUST FABRICATED RIGID W/O INTFACE LNR PLAS,SUP-2388142,CDM,L0482,HCPCS,0272,RC,,,,both,,,4080.59,2652.38,,,,,,,,,,,,,
CATHETER VALVULOPLASTY TYSHAK MINI L 65 CM 2.5 FR 2 CM 8 MM,SUP-2659640,CDM,C1725,HCPCS,0272,RC,,,,both,,,1668.88,1084.77,,,,,,,,,,,,,
SCREW SPNL LOK FOR 6.25MM ROD SPHERX PPS,SUP-2311510,CDM,C1713,HCPCS,0278,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
FIBER LASER HOLM 11046] FORTEC MEDICAL INC],SUP-2418108,CDM,2720000010,LOCAL,0272,RC,,,,both,,,690.80,449.02,,,,,,,,,,,,,
PROBE SUCT L5.5MM OD3.75MM 90DEG ARTHSCP ABLAT BPLR GRATED,SUP-2341116,CDM,2720000010,LOCAL,0272,RC,,,,both,,,609.16,395.95,,,,,,,,,,,,,
PLATE BONE W13.6XL222MM THK3.3MM 12 H S STL RT PERIARTC TIB,SUP-2362733,CDM,C1713,HCPCS,0278,RC,,,,both,,,2839.82,1845.88,,,,,,,,,,,,,
BIT DRL DIA 4 MM LAG DBL BANDED MAG NS DISP LEOS,SUP-2933395,CDM,2720000010,LOCAL,0272,RC,,,,both,,,413.54,268.80,,,,,,,,,,,,,
STEM FEM PRSS FT 4 HIP PRIMARY CEM UPLR/BPLR LNR POLYETH,SUP-2267798,CDM,C1776,CPT,0278,RC,,,,both,,,10990.00,7143.50,,,,,,,,,,,,,
POR ST/G7 CP/LGXL/LG HD,SUP-2212369,CDM,C1776,CPT,0278,RC,,,,both,,,13545.96,8804.87,,,,,,,,,,,,,
KIT RESIN AND CEM CUST,SUP-2341408,CDM,C1713,HCPCS,0278,RC,,,,both,,,687.66,446.98,,,,,,,,,,,,,
VALVE 40019 AORT MMX U30 1Y,SUP-2278288,CDM,C1889,HCPCS,0278,RC,,,,both,,,17270.00,11225.50,,,,,,,,,,,,,
GUIDEPIN ORTH DIA2.5MM BRK AWAY FOR ANCHR PEG GLEN GLOB,SUP-2252720,CDM,2720000010,LOCAL,0272,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
BLADE SURG 6 RT MIDLN 9563186,SUP-2631616,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1122.55,729.66,,,,,,,,,,,,,
PLATE BNE L 110 X W 10.2 MM THK 2.8 MM SCREW DIA 3.5 MM 10 H,SUP-2936286,CDM,C1713,HCPCS,0278,RC,,,,both,,,2463.49,1601.27,,,,,,,,,,,,,
CHLORPROMAZINE HCL 10 MG PO TABS,RX-1653,CDM,6370000000,HCPCS,0637,RC,50268-0162-15,NDC,,both,1,UN,6.60,4.29,,,,,,,,,,,,,
HC Inf Ea Add'l Hour Hyd,PX-2609636100,CDM,96361,CPT,0260,RC,,,,both,,,87.00,56.55,,,,,,,,,,,,,
COMPONENT FEM L200MM CSTI POR KNEE TOT SEG IMP MOST OPTIONS,SUP-2208269,CDM,C1776,CPT,0278,RC,,,,both,,,14299.56,9294.71,,,,,,,,,,,,,
GRAFT VASC IMPRA CARBOFLO L 30 CM DIA 6 MM EPTFE CARBON STR,SUP-2761263,CDM,C1768,CPT,0278,RC,,,,both,,,1448.29,941.39,,,,,,,,,,,,,
CATHETER REPROC EP 5FR 5MM 4 POLE CRD2,SUP-2270125,CDM,C1730,HCPCS,0272,RC,,,,both,,,102.33,66.51,,,,,,,,,,,,,
COMPONENT FEM SZ 9 L POST KNEE NP PRI BICRUCIATE CEM STBL,SUP-2350310,CDM,C1776,CPT,0278,RC,,,,both,,,14411.82,9367.68,,,,,,,,,,,,,
CLAMP PIN 2-BAR 45MMXTRAFIX,SUP-2205436,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3867.70,2514.00,,,,,,,,,,,,,
CATHETER ANGIOPLSTY POLARCATH L 80 CM BALLOON L 60 MM DIA 4,SUP-2141203,CDM,C1725,HCPCS,0272,RC,,,,both,,,1790.93,1164.10,,,,,,,,,,,,,
COLLAR CERV AD H25XL22IN UNIV FIRM DENS CNTOUR HK LOOP CLSR,SUP-2276585,CDM,L0120,HCPCS,0272,RC,,,,both,,,8.07,5.25,,,,,,,,,,,,,
SCREW BNE LCK 3.5X12 MM DBL STRT THRD STRL JPS LTX,SUP-2875331,CDM,C1713,HCPCS,0278,RC,,,,both,,,1383.33,899.16,,,,,,,,,,,,,
BLADE SHV DIA4MM ENT MICRODEBRIDER AGG SERR,SUP-2366837,CDM,2720000010,LOCAL,0272,RC,,,,both,,,326.18,212.02,,,,,,,,,,,,,
BIT DRL L 70 MM DIA1.5 MM STP 22 MM OC NS DISP,SUP-2936678,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1117.84,726.60,,,,,,,,,,,,,
ROD EXT FIX FOR MR CONDITIONAL L MULTIPIN CLMP,SUP-2188489,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1108.67,720.64,,,,,,,,,,,,,
CATHETER ABLAT 7FR L115CM 1-7-4MM SPC TIP 8MM 4 ELECTRD FJ,SUP-2248501,CDM,C1733,HCPCS,0272,RC,,,,both,,,3746.02,2434.91,,,,,,,,,,,,,
PACK BOWL CELL SAVR BASIC HI SPD,SUP-2236450,CDM,2720000010,LOCAL,0272,RC,,,,both,,,318.71,207.16,,,,,,,,,,,,,
PLATE BNE HUM 3.5X302 MM RT DSTL 14 HOLE LCK LP RIGID STRL,SUP-2177172,CDM,C1713,HCPCS,0278,RC,,,,both,,,5798.54,3769.05,,,,,,,,,,,,,
GUIDEWIRE ORTH TROCAR PT 1 END 2.8X220 MM NS,SUP-2789097,CDM,C1769,HCPCS,0272,RC,,,,both,,,1374.82,893.63,,,,,,,,,,,,,
GRAFT BONE SUB 30CC 0.5-3MM DEMIN CANC CORT CRUSH FRZ DRY,SUP-2294040,CDM,C1713,HCPCS,0278,RC,,,,both,,,879.20,571.48,,,,,,,,,,,,,
HOOK SPNL SIDE LD SM LAM PEDCL LT TALL BODY SM STAT TI USS,SUP-2193438,CDM,C1713,HCPCS,0278,RC,,,,both,,,2022.16,1314.40,,,,,,,,,,,,,
KIT HEMODLYS REP CATHETER EXTN FOR DLYS SPL,SUP-2269564,CDM,C1769,HCPCS,0272,RC,,,,both,,,194.68,126.54,,,,,,,,,,,,,
KNIFE SURG FOR MINI CRPL TUNN REL SFGRD,SUP-2242702,CDM,2720000010,LOCAL,0272,RC,,,,both,,,904.32,587.81,,,,,,,,,,,,,
SYSTEM THR NP UPLR PART CAPITATED,SUP-2347956,CDM,C1776,CPT,0278,RC,,,,both,,,5495.00,3571.75,,,,,,,,,,,,,
SUPPORT WR L AD RT CRPL TUNN REG FIRM SUPP CRPLGARD BLK,SUP-2324890,CDM,L3931,HCPCS,0274,RC,,,,both,,,47.51,30.88,,,,,,,,,,,,,
CANNULA ENDOSCP SUCTION 4.5 MMX12 CM SIMMEN INSUL ANGULAR,SUP-2774731,CDM,2720000010,LOCAL,0272,RC,,,,both,,,715.83,465.29,,,,,,,,,,,,,
STEM HUM L200MM DIA9MM LNG UNIV DSTL SHLDR TI PRI REV CEM,SUP-2372860,CDM,C1776,CPT,0278,RC,,,,both,,,11991.66,7794.58,,,,,,,,,,,,,
EXTRACTOR ENDOSCP SM 11X35 MM VAG BALL SPHR AUTO CLICKLINE,SUP-2776255,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2439.00,1585.35,,,,,,,,,,,,,
INSERT TIB ARTC SURF NEUT UNIV PRI CONSTRN POLYETH MOLD CRUC,SUP-2201340,CDM,C1776,CPT,0278,RC,,,,both,,,3682.59,2393.68,,,,,,,,,,,,,
BLADE IM NAIL HELCL 90X11 MM IMPL TI,SUP-2191875,CDM,C1713,HCPCS,0278,RC,,,,both,,,2216.09,1440.46,,,,,,,,,,,,,
HC Lig/Trnsxj Flp Tube Abdl/Vag Appr Uni/Bi,PX-3605861100,CDM,58611,CPT,0360,RC,,,,outpatient,,,187.00,121.55,,,,,,,,,,,,,
MESH ULTRAPRO ADVANCED 6CM 12CM,SUP-2740092,CDM,C1781,HCPCS,0278,RC,,,,both,,,394.79,256.61,,,,,,,,,,,,,
CATHETER CV DL 8 FRX16 CM PRESSURE INJ BLU FLEXTIP,SUP-2383384,CDM,C1751,HCPCS,0278,RC,,,,both,,,324.05,210.63,,,,,,,,,,,,,
STENT PERIPH SMRT RADIANZ L 80 MM DIA 8 MM DEL SYS L 150 CM,SUP-2866175,CDM,C1876,HCPCS,0278,RC,,,,both,,,3949.49,2567.17,,,,,,,,,,,,,
IMPLANT CRAN SM CUST PEEK,SUP-2365127,CDM,C1713,HCPCS,0278,RC,,,,both,,,36270.64,23575.92,,,,,,,,,,,,,
HC Treat Ulna Fx,PX-4502553000,CDM,25530,CPT,0450,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
BRACE WALKING EMBEDDED SOLE MED SHT ANK ROCKER BTM INLINE,SUP-2336132,CDM,L4361,HCPCS,0272,RC,,,,both,,,79.35,51.58,,,,,,,,,,,,,
IMMOBILIZER PREMIER PRO KNEE CUTAWAY CNTOUR 22INCH COOL BLU,SUP-2336081,CDM,L1830,CPT,0274,RC,,,,both,,,81.73,53.12,,,,,,,,,,,,,
HC Layer Closure Face <2.5 Cm,PX-4501205100,CDM,12051,CPT,0450,RC,,,,outpatient,,,810.00,526.50,,,,,,,,,,,,,
CATHETER HD STR 14 FRX20 CM SHT TERM 400 XL PRE CRV TAPR TIP,SUP-2266966,CDM,C1752,HCPCS,0278,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
KNIFE 3724293 STAPEDECTOMY 45 DEG,SUP-2667370,CDM,2720000010,LOCAL,0272,RC,,,,both,,,644.96,419.22,,,,,,,,,,,,,
TRAY PICC 5FR L55CM 2 LUMN CATH FULL NRS POWERPICC SV,SUP-2125539,CDM,C1751,HCPCS,0278,RC,,,,both,,,448.24,291.36,,,,,,,,,,,,,
DARBEPOETIN ALFA 100 MCG/0.5ML IJ SOSY,RX-131228,CDM,J0881,HCPCS,0636,RC,55513-0025-04,NDC,,both,0.5,ML,2283.30,1484.14,,,,,,,,,,,,,
IMPLANT FEM L29MM DIA9MM INSRT APERFIX AM,SUP-2402620,CDM,C1713,HCPCS,0278,RC,,,,both,,,3175.67,2064.19,,,,,,,,,,,,,
ARTHROFLEX 30X40X0.5 MM,SUP-2811253,CDM,Q4125,HCPCS,0636,RC,,,,both,,,3583.37,2329.19,,,,,,,,,,,,,
SCREW BNE L20MM DIA5MM CNDYL S STL ST VAR ANG CANN LOK FULL,SUP-2178725,CDM,C1713,HCPCS,0278,RC,,,,both,,,750.08,487.55,,,,,,,,,,,,,
HC Iaad Ia Shiga-Like Toxin,PX-3068742700,CDM,87427,CPT,0306,RC,,,,inpatient,,,71.00,46.15,,,,,,,,,,,,,
CARDIOVASCULAR PROC KT CUST 41 MYOCARDIAL SET,SUP-2384963,CDM,C1768,CPT,0278,RC,,,,both,,,377.59,245.43,,,,,,,,,,,,,
CAPITATED KNEE UNI GENS ON-LAYCAPITATED PRICING,SUP-2347980,CDM,C1776,CPT,0278,RC,,,,both,,,9106.00,5918.90,,,,,,,,,,,,,
INSERT TIB SZ C KNEE POLYETH SEG,SUP-2200504,CDM,C1776,CPT,0278,RC,,,,both,,,847.80,551.07,,,,,,,,,,,,,
GRAFT HUM TISS W16XL20CM THK0.7-1.4MM THN ACELLULAR,SUP-2307574,CDM,Q4128,HCPCS,0636,RC,,,,both,,,26250.56,17062.86,,,,,,,,,,,,,
CATHETER DRAINAGE 14 FRX35 CM KT REG FLEXIMA VAN SONN SUMP,SUP-2147869,CDM,C1729,HCPCS,0272,RC,,,,both,,,753.60,489.84,,,,,,,,,,,,,
HEAD FEM V40 TAPR LFIT ION IMP CO CHROM 26MM + 16MM TRIDENT,SUP-2364461,CDM,C1776,CPT,0278,RC,,,,both,,,1809.27,1176.03,,,,,,,,,,,,,
PROGRAMMER NEUROSTIMULATOR PT FOR URIN CTRL INTERSTIM ICON,SUP-2284411,CDM,C1787,HCPCS,0278,RC,,,,both,,,3549.77,2307.35,,,,,,,,,,,,,
SPLINT THMB M L8IN LNG RT THERMOPLASTIC INSRT THERMO-FORM,SUP-2324197,CDM,L3931,HCPCS,0272,RC,,,,both,,,57.65,37.47,,,,,,,,,,,,,
TUBE FEEDING 8FR 36 IRIS ENFIT,SUP-2878013,CDM,2720000010,LOCAL,0272,RC,,,,both,,,648.03,421.22,,,,,,,,,,,,,
PLATE BNE L100MM STD 7 H L OLECRANON EL TI LO PROF FOR,SUP-2107003,CDM,C1713,HCPCS,0278,RC,,,,both,,,4295.52,2792.09,,,,,,,,,,,,,
IMMOBILIZER PREMIER PRO KNEE CUTAWAY CNTOUR 22INCH COOL BLU,SUP-2336081,CDM,L1830,CPT,0272,RC,,,,both,,,81.73,53.12,,,,,,,,,,,,,
SCREW BNE L18MM DIA3.2MM ULN ANK S STL CORT LOK THRD HEX LO,SUP-2389562,CDM,C1713,HCPCS,0278,RC,,,,both,,,3332.98,2166.44,,,,,,,,,,,,,
GRAFT TISSUE HALO PERICARDIUM,SUP-2844927,CDM,V2785,HCPCS,0278,RC,,,,both,,,621.72,404.12,,,,,,,,,,,,,
GUIDEWIRE VASC GLIDEWIRE ADVANTAGE L 260 CM DIA 0.035 IN TIP,SUP-2385544,CDM,C1769,HCPCS,0272,RC,,,,both,,,731.62,475.55,,,,,,,,,,,,,
DEVICE BNE FILL BX 10 GA OSSEOFLEX BFD,SUP-2496250,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1009.29,656.04,,,,,,,,,,,,,
SCREW BONE LOK 3.5MM DIA 34MML STNLSS STEEL SRFX STE ST,SUP-2586536,CDM,C1713,HCPCS,0278,RC,,,,both,,,1025.27,666.43,,,,,,,,,,,,,
HC Russell Viper Venom Time Diluted,PX-3058561300,CDM,85613,CPT,0305,RC,,,,both,,,116.00,75.40,,,,,,,,,,,,,
MESH SURG W6XL13.7CM DIA5MM POLYPR L PRESHAPED H FLAT FOR,SUP-2219798,CDM,C1781,HCPCS,0278,RC,,,,both,,,342.07,222.35,,,,,,,,,,,,,
STEM HUM CEM STD UNIV 6X115 MM REV W/ ALIGN HOLE TI PLASMA,SUP-2431672,CDM,C1776,CPT,0278,RC,,,,both,,,12195.76,7927.24,,,,,,,,,,,,,
FUSION WCARMEDA 26L,SUP-2725865,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1295.25,841.91,,,,,,,,,,,,,
BIT DRL L136MM OD2MM PILOT W/O STP J LATCH N RADLUC REUSE,SUP-2319401,CDM,2720000010,LOCAL,0272,RC,,,,both,,,405.06,263.29,,,,,,,,,,,,,
HC Perq Dev Soft Tiss 1st Imag,PX-3611003500,CDM,10035,CPT,0361,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
CATHETER THROMCTMY ANGIOJET XPEEDIOR L 120 CM DIA 6 FR,SUP-2277420,CDM,C1757,HCPCS,0272,RC,,,,both,,,3234.20,2102.23,,,,,,,,,,,,,
DRILL SURG 5MM J SLOT PILOT PAN FIX LUHR,SUP-2364711,CDM,2720000010,LOCAL,0272,RC,,,,both,,,233.02,151.46,,,,,,,,,,,,,
SCREW BNE L6MM DIA2.4MM TEAL TI ST EMGCY BLU,SUP-2189409,CDM,C1713,HCPCS,0278,RC,,,,both,,,247.06,160.59,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY INQUIRY L 110 CM 5 FR 5 DECAPOLAR,SUP-2480413,CDM,C1730,HCPCS,0272,RC,,,,both,,,578.80,376.22,,,,,,,,,,,,,
PLATE BNE 5 H TI ALLOY Y SHP ALPHA NS LEOS,SUP-2932910,CDM,C1713,HCPCS,0278,RC,,,,both,,,3325.26,2161.42,,,,,,,,,,,,,
ROD SPNL L150MM N HANCE,SUP-2181851,CDM,C1713,HCPCS,0278,RC,,,,both,,,19478.99,12661.34,,,,,,,,,,,,,
CATHETER DIAG ID.0170IN MIC STR COURIER,SUP-2249257,CDM,C1889,HCPCS,0278,RC,,,,both,,,2040.69,1326.45,,,,,,,,,,,,,
BIT DRL CHK END 12 MM TIB FOR ACL COMBINATION,SUP-2608126,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1042.70,677.75,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 80 MM DIA 8 MM DEL SHTH 5ML,SUP-2936835,CDM,C1713,HCPCS,0278,RC,,,,both,,,11184.68,7270.04,,,,,,,,,,,,,
KIT ELECTRD 17GA TIP 3CM RAD FREQ ABLAT COOL-TIP,SUP-2172360,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6604.99,4293.24,,,,,,,,,,,,,
ROD SPNL S STL STR L125MM L125MM OD5.5MM REVERE,SUP-2185222,CDM,C1713,HCPCS,0278,RC,,,,both,,,4639.70,3015.80,,,,,,,,,,,,,
GRAFT HUMAN TSSUE CLLGN SPCR MNSCS FRZN IRRDTD WO TBL PLTEA,SUP-2727097,CDM,C1762,CPT,0278,RC,,,,both,,,4842.63,3147.71,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 45 CM DIA 4-7 MM SHRT TAPR DBL SLDE,SUP-2669697,CDM,C1768,CPT,0278,RC,,,,both,,,1766.82,1148.43,,,,,,,,,,,,,
SHAFT DRVR L50MM DIA15MM NONCANNULATED HEX QUIK CONN,SUP-2199219,CDM,2720000010,LOCAL,0272,RC,,,,both,,,890.06,578.54,,,,,,,,,,,,,
RETRACTOR LAPSCP RNG DIA100MM W/ ALEXIS DEV GELPORT,SUP-2119623,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1425.56,926.61,,,,,,,,,,,,,
AUGMENT FEM STD THCK UNIV DST PRI PRESSFIT SZ 2 5MM,SUP-2223054,CDM,C1776,CPT,0278,RC,,,,both,,,3419.46,2222.65,,,,,,,,,,,,,
CATHETER ETER IV THER L8CM OD18GA REINF TIP BASIC BIOPATCH,SUP-2125667,CDM,C1751,HCPCS,0278,RC,,,,both,,,251.58,163.53,,,,,,,,,,,,,
HC Blood Draw per Port,PX-7613659100,CDM,36591,CPT,0761,RC,,,,both,,,387.00,251.55,,,,,,,,,,,,,
NAIL FIX L 100 MM DIA 4 MM CANN TRIM HEX TAPR END DIR BARB,SUP-2904325,CDM,C1713,HCPCS,0278,RC,,,,both,,,7683.58,4994.33,,,,,,,,,,,,,
CATHETER URET SET 038 5 FRX70 CM LT PGTL,SUP-2835660,CDM,C1758,HCPCS,0278,RC,,,,both,,,145.07,94.30,,,,,,,,,,,,,
NEEDLE BX L25CM S STL 2 CANN DISP FOR CRW SYS NASHOLD,SUP-2244276,CDM,C1713,HCPCS,0278,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
CATHETER ASPIR PRIORITYONE AC L 140 CM TIP L 6 MM GUIDE CATH,SUP-2384837,CDM,C1757,HCPCS,0272,RC,,,,both,,,1642.22,1067.44,,,,,,,,,,,,,
ANCHOR SUTURE 1 2.3 MM 38 IN 2 ULTRABRAID NDL BLU BIORAPTOR,SUP-2848916,CDM,C1713,HCPCS,0278,RC,,,,both,,,823.75,535.44,,,,,,,,,,,,,
GRAFT HUM TISS H6MM CANC PLUG CORT RNG CERV SPCR FIBULAR WDG,SUP-2293797,CDM,C1713,HCPCS,0278,RC,,,,both,,,3045.80,1979.77,,,,,,,,,,,,,
GRAFT VASC TAPR 7-4 MMX70 CM STD WALL N RING EPTFE CARBOFLO,SUP-2761336,CDM,C1768,CPT,0278,RC,,,,both,,,3511.24,2282.31,,,,,,,,,,,,,
RESTRICTOR CEM ELBW W/ NOZ COONRAD/MORREY,SUP-2205931,CDM,C1776,CPT,0278,RC,,,,both,,,881.71,573.11,,,,,,,,,,,,,
IMMUNE GLOBULIN (GAMMAGARD) 10%,RX-4081758,CDM,J1561,HCPCS,0636,RC,13533-0800-15,NDC,,both,25,ML,1316.40,855.66,,,,,,,,,,,,,
ANCHOR SUTURE 2 4.5 MM TI WHT BLU STRL TWINFIX ULTRA,SUP-2848954,CDM,C1713,HCPCS,0278,RC,,,,both,,,892.67,580.24,,,,,,,,,,,,,
TRAY TIB SZ 74 AP60MM ML81MM KNEE IB2,SUP-2199757,CDM,C1776,CPT,0278,RC,,,,both,,,10388.69,6752.65,,,,,,,,,,,,,
HC NM I 131 Thyroid Treatment,PX-3427900500,CDM,79005,CPT,0342,RC,,,,both,,,1313.00,853.45,,,,,,,,,,,,,
CUP ACET DIA56MM 5 H DP PROF GRIPTION REV PINN,SUP-2250150,CDM,C1776,CPT,0278,RC,,,,both,,,9546.86,6205.46,,,,,,,,,,,,,
SCREW PEDCL PIROUETTE TIMED POLYAX TI 5.5MM DIA 55MML,SUP-2205099,CDM,C1713,HCPCS,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
DRESSING WOUND SURGICAL MATRIX 7X15 CM PLASTIC MATRISTEM,SUP-2106493,CDM,Q4166,HCPCS,0636,RC,,,,both,,,4063.16,2641.05,,,,,,,,,,,,,
KIT CATH AD L40CM DIA14.5FR 1.9ML SIL DBL LUMN CVD SYMMETRIC,SUP-2174231,CDM,C1750,HCPCS,0278,RC,,,,both,,,1444.40,938.86,,,,,,,,,,,,,
DRILL SURG HUDSON LUG PATHWY,SUP-2453507,CDM,2720000010,LOCAL,0272,RC,,,,both,,,938.86,610.26,,,,,,,,,,,,,
PIN EXT FIX L80MM OD25MM THRD L15MM HALF FOR CORETRAK FIX,SUP-2400675,CDM,C1713,HCPCS,0278,RC,,,,both,,,169.56,110.21,,,,,,,,,,,,,
NAIL FLEX PRECURVED 175X300MM,SUP-2700541,CDM,C1713,HCPCS,0278,RC,,,,both,,,906.68,589.34,,,,,,,,,,,,,
GRAFT VASC GORTX L 10 CM DIA 8 MM EPTFE STR TW N RING STRL,SUP-2396708,CDM,C1768,CPT,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
COMPONENT BEAR TIB DSTL FEM KNEE MRH,SUP-2452041,CDM,C1776,CPT,0278,RC,,,,both,,,6498.39,4223.95,,,,,,,,,,,,,
GRAFT VASC PERIPH BYPS STR STD WALL N RING EPTFE 6MM DIA,SUP-2126225,CDM,C1768,CPT,0278,RC,,,,both,,,453.35,294.68,,,,,,,,,,,,,
PLATE BONE L33MM 4 H SEMI COMPR,SUP-2319390,CDM,C1713,HCPCS,0278,RC,,,,both,,,697.08,453.10,,,,,,,,,,,,,
GRAFT VASC GELWEAVE L 60 CM DIA16 MM POLYESTER GEL,SUP-2894631,CDM,C1889,HCPCS,0278,RC,,,,both,,,3532.50,2296.12,,,,,,,,,,,,,
"HC Gbl Est Pt, E/M Level 4",PX-9829921400,CDM,99214,CPT,0982,RC,,,,outpatient,,,522.00,339.30,,,,,,,,,,,,,
"HC Albumin Other Source, Quan Ea",PX-3078204200,CDM,82042,CPT,0307,RC,,,,both,,,154.00,100.10,,,,,,,,,,,,,
ALLOGRAFT BNE STRP 5X2.5 CM DBM FIBERFUSE,SUP-2736952,CDM,C1713,HCPCS,0278,RC,,,,both,,,6499.80,4224.87,,,,,,,,,,,,,
KIT RF 4MM ACT TIP 17GA 75MM MULT PRB PROC COMPONENTS MULT,SUP-2236771,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6908.00,4490.20,,,,,,,,,,,,,
CATHETER ETER DRNGE 12FR L25CM 0038IN MCOT SFT SHFT,SUP-2168854,CDM,C1729,HCPCS,0272,RC,,,,both,,,204.16,132.70,,,,,,,,,,,,,
SCREW EMER ABSRB 2.5MMDIA 4MML,SUP-2364995,CDM,C1713,HCPCS,0278,RC,,,,both,,,178.13,115.78,,,,,,,,,,,,,
ROD EXT FIX L499MM DIA11MM 135DEG UNIV C FBR SEMI CIR CRV,SUP-2188645,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1871.03,1216.17,,,,,,,,,,,,,
PROBE BX BRST L105MM DIA10GA SYS ULT FINESSE,SUP-2126874,CDM,2720000010,LOCAL,0272,RC,,,,both,,,833.67,541.89,,,,,,,,,,,,,
CLAMP EXT FIX ANK JET-X FRDM,SUP-2342879,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8284.58,5384.98,,,,,,,,,,,,,
ANCHOR SUTURE 5MM WITH 3 NO 2 SUTURES HI-FI DISPOSABLE DRIVE,SUP-2824809,CDM,C1713,HCPCS,0278,RC,,,,both,,,774.61,503.50,,,,,,,,,,,,,
CLIP ANEUR BLDE L5X49MM FEN DIA35MM OPN 49MM CLS FORC,SUP-2108333,CDM,C1713,HCPCS,0278,RC,,,,both,,,1273.05,827.48,,,,,,,,,,,,,
INTRODUCER RF L100MM OD17GA COOLED,SUP-2237170,CDM,2720000010,LOCAL,0272,RC,,,,both,,,354.98,230.74,,,,,,,,,,,,,
SPHINCTEROTOME 49 30MM TRUETOME,SUP-2149856,CDM,C1713,HCPCS,0278,RC,,,,both,,,501.30,325.84,,,,,,,,,,,,,
PLATE BNE LCK LG EXT LT CALCANEAL 3 HOLE NS A.L.P.S,SUP-2480150,CDM,C1713,HCPCS,0278,RC,,,,both,,,3198.09,2078.76,,,,,,,,,,,,,
RING EXT FIX MOD 3/8 D 160 MM RX STRL TRUELOK EVO LTX,SUP-2875609,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4995.99,3247.39,,,,,,,,,,,,,
SCREW BNE FT 20 5 MM PANTA,SUP-2421866,CDM,C1713,HCPCS,0278,RC,,,,both,,,1180.33,767.21,,,,,,,,,,,,,
COIL EMB 10 L15CM OD6MM COMPLX STRTCH RESIST FNSH V TRAK,SUP-2305175,CDM,C1889,HCPCS,0278,RC,,,,both,,,3042.66,1977.73,,,,,,,,,,,,,
HC Trach Removal,PX-3600000037,CDM,3600000037,LOCAL,0360,RC,,,,both,,,192.00,124.80,,,,,,,,,,,,,
PROSTHESIS OSS EAR 1.17X5.6 MM PROP GOLDENBERG MALL,SUP-2312826,CDM,L8613,CPT,0278,RC,,,,both,,,1290.60,838.89,,,,,,,,,,,,,
ANCHOR SUT L14.7MM DIA5.5MM BIOCOMPOSITE W/ 3 SZ 2,SUP-2121541,CDM,C1713,HCPCS,0278,RC,,,,both,,,1067.60,693.94,,,,,,,,,,,,,
BIT DRL DIA2MM SHT CALIB W/ AO QUIK CONN PERI-LOC,SUP-2344005,CDM,2720000010,LOCAL,0272,RC,,,,both,,,858.92,558.30,,,,,,,,,,,,,
HC Ot Ther Ex per 15 Min|DOCUMENTATION ON FILE|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS,PX-4309711000,CDM,97110,CPT,0430,RC,,,KX|CQ,both,,,195.00,126.75,,,,,,,,,,,,,
PLATE CRAN L 23.62 X W 18.5 MM SCREW DIA1.5 MM TI,SUP-2935842,CDM,C1713,HCPCS,0278,RC,,,,both,,,781.86,508.21,,,,,,,,,,,,,
GUIDE DISTRCTN LAPIDUS SYS IO FRDM,SUP-2865097,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1218.32,791.91,,,,,,,,,,,,,
STENT NEURO LVIS L 19 MM DIA 3.5 MM MICROCATHETER 0.021 IN,SUP-2305225,CDM,C1876,HCPCS,0278,RC,,,,both,,,20205.90,13133.83,,,,,,,,,,,,,
PLATE BNE TBLR 55 MM 4 HOLE 1/3 LCK SS STRL,SUP-2480564,CDM,C1713,HCPCS,0278,RC,,,,both,,,476.09,309.46,,,,,,,,,,,,,
WIRE 1.8MM W/OLIVE DIA PT,SUP-2497301,CDM,C1713,HCPCS,0278,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
BIT DRILL NON QUICK COUPLING 1.1X45 MM JACOBS CHUCK END STER,SUP-2837041,CDM,2720000010,LOCAL,0272,RC,,,,both,,,785.82,510.78,,,,,,,,,,,,,
CLAMP EXTERNAL FIXATION MULTI VECTOR DISTRACTOR FOR CARBON F,SUP-2838086,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2835.42,1843.02,,,,,,,,,,,,,
ETHAMBUTOL HCL 400 MG PO TABS,RX-9983,CDM,6370000000,HCPCS,0637,RC,68084-0280-01,NDC,,both,1,UN,4.90,3.18,,,,,,,,,,,,,
KIT INTRO BILI STNT PUSH CATH 7FR,SUP-2149475,CDM,C2625,HCPCS,0278,RC,,,,both,,,230.19,149.62,,,,,,,,,,,,,
SCREW BNE L18MM DIA4.2MM NONLOCKING COMPR FOR TUFFNEK,SUP-2321248,CDM,C1713,HCPCS,0278,RC,,,,both,,,560.49,364.32,,,,,,,,,,,,,
PLATE BONE L396MM 18 H RT PROX FEM LCK FOR 4.5MM SCR,SUP-2351132,CDM,C1713,HCPCS,0278,RC,,,,both,,,15746.79,10235.41,,,,,,,,,,,,,
CATHETER SYS DRNGE UNIV CRV AQ HYDRPHLC COAT,SUP-2168612,CDM,C1729,HCPCS,0272,RC,,,,both,,,225.42,146.52,,,,,,,,,,,,,
BLADE SHAVER SUPERFICIAL 18 DEG 4X270 MM LARYNGEAL DBL BEND,SUP-2638097,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1020.06,663.04,,,,,,,,,,,,,
PLATE BNE T 2.7 MM 6 HOLE NS FPS LTX,SUP-2856837,CDM,C1713,HCPCS,0278,RC,,,,both,,,2323.60,1510.34,,,,,,,,,,,,,
PUMP PAIN FILL VOL 400ML FLO RATE 1-7ML/HR 5ML BOL,SUP-2236811,CDM,C9804,HCPCS,0272,RC,,,,both,,,675.10,438.81,,,,,,,,,,,,,
PLATE BNE L 77 MM 7 H RT DSTL VOLAR RADIAL NAR EXT STRL,SUP-2902421,CDM,C1713,HCPCS,0278,RC,,,,both,,,6498.01,4223.71,,,,,,,,,,,,,
LINER ACET OD56MM ID36MM CERAMIC PRI SNAP IN US BIOLOX FORTE,SUP-2345187,CDM,C1776,CPT,0278,RC,,,,both,,,5571.93,3621.75,,,,,,,,,,,,,
GRAFT HUM TISS W4XL8CM THK08 17MM DERM ACELLULAR THCK HUM,SUP-2307468,CDM,Q4128,HCPCS,0636,RC,,,,both,,,4969.68,3230.29,,,,,,,,,,,,,
COMPONENT TIB G KNEE PERSONA,SUP-2207896,CDM,C1776,CPT,0278,RC,,,,both,,,5887.53,3826.89,,,,,,,,,,,,,
CANNULA VEN 24FR 60CM W/ 21FR INTRO CARDPULM PROTEKSOLO,SUP-2152642,CDM,C1889,HCPCS,0278,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
SET CATH 5FR L10CM NDL 21GA L7CM GWIRE L40CM DIA0.018IN NIT,SUP-2170559,CDM,C1894,HCPCS,0272,RC,,,,both,,,79.60,51.74,,,,,,,,,,,,,
K WIRE FIX L150MM DIA1.6MM S STL THRD TRCR PNT,SUP-2186897,CDM,C1713,HCPCS,0278,RC,,,,both,,,45.72,29.72,,,,,,,,,,,,,
GUIDEWIRE VASC APPRCH CTO L135CM 0.014IN L18CM 12GM STR SHRT,SUP-2638729,CDM,C1769,HCPCS,0272,RC,,,,both,,,395.95,257.37,,,,,,,,,,,,,
MESH SURG W20XL25CM OVL FOR TISS SEPARATING AND HERN FIX,SUP-2219762,CDM,C1781,HCPCS,0278,RC,,,,both,,,4868.51,3164.53,,,,,,,,,,,,,
SUPPORT EL NEOPRENE11 13IN L,SUP-2276611,CDM,L3702,HCPCS,0274,RC,,,,both,,,10.61,6.90,,,,,,,,,,,,,
SYSTEM LD INTRO SELECTRA L 55 CM DIA 7 FR HK CRV PEELWY,SUP-2418818,CDM,C1893,HCPCS,0272,RC,,,,both,,,668.82,434.73,,,,,,,,,,,,,
SCREW BONE L60MM DIA6.5MM STD CONCL PARTIALLY THRD CANN LCK,SUP-2351137,CDM,C1713,HCPCS,0278,RC,,,,both,,,1793.98,1166.09,,,,,,,,,,,,,
HC Strapping Ankle/Foot,PX-4502954000,CDM,29540,CPT,0450,RC,,,,both,,,497.00,323.05,,,,,,,,,,,,,
ANCHOR SUTURE 2.6 WITH TWO NO 1 4M HIFI 1 WHITE BLACK AND 1,SUP-2824684,CDM,C1713,HCPCS,0278,RC,,,,both,,,1744.52,1133.94,,,,,,,,,,,,,
RESERVOIR SHUNT L 14 MM DSTL CATH L 600 MM TI CTRL,SUP-2929195,CDM,C1889,HCPCS,0278,RC,,,,both,,,1936.44,1258.69,,,,,,,,,,,,,
GRAFT BNE SUB M SZ 14 28MM 10CC B TRICALCIUM PHSPTE SYN,SUP-2194010,CDM,C1713,HCPCS,0278,RC,,,,both,,,1860.32,1209.21,,,,,,,,,,,,,
HC Njx Noncmpnd Sclrsnt 1 Vein,PX-3613646500,CDM,36465,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
HEAD HUM RESURF MACROBOND SZ 6 COPELAND EAS,SUP-2403998,CDM,C1776,CPT,0278,RC,,,,both,,,10880.10,7072.06,,,,,,,,,,,,,
BIT DRL DIA24MM NAVIGATION FOR VERTEX RECON SYS,SUP-2281198,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1803.24,1172.11,,,,,,,,,,,,,
SCREW CP LAG 36X32MM,SUP-2695664,CDM,C1713,HCPCS,0278,RC,,,,both,,,952.36,619.03,,,,,,,,,,,,,
STEM FEM L127MM OD11MM STR FLUT TI ALLY HA DST HIP REV MOD,SUP-2375713,CDM,C1776,CPT,0278,RC,,,,both,,,6045.13,3929.33,,,,,,,,,,,,,
GRAFT VASC TW 7 MMX50 CM RNG SFT WRP TUNN ATTCH ADVANTA VXT,SUP-2464993,CDM,C1768,CPT,0278,RC,,,,both,,,1445.56,939.61,,,,,,,,,,,,,
HC CT for Limited or Localized St,PX-3507638000,CDM,76380,CPT,0350,RC,,,,both,,,2769.00,1799.85,,,,,,,,,,,,,
CATHETER ANGIO IMPRESS L 100 CM 4 FR 0.04 IN L 40 CM SIM2,SUP-2301493,CDM,C1713,HCPCS,0278,RC,,,,both,,,94.20,61.23,,,,,,,,,,,,,
SPLINT WRST FA L INSTABILITY INJ W STAY COCK UP FIRM SUPP,SUP-2276617,CDM,L3809,HCPCS,0272,RC,,,,both,,,15.95,10.37,,,,,,,,,,,,,
PLATE FT 200MM FOR TRUELOK FIX SYS,SUP-2316197,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1951.35,1268.38,,,,,,,,,,,,,
SEALER REPROC VES 37 CM MARYLAND JAW LIGASURE,SUP-2418777,CDM,2720000010,LOCAL,0272,RC,,,,both,,,915.03,594.77,,,,,,,,,,,,,
GUIDEPIN FIX DIA3MM THRD ITST,SUP-2410483,CDM,2720000010,LOCAL,0272,RC,,,,both,,,434.70,282.55,,,,,,,,,,,,,
CATHETER DRNGE L25CM OD7FR ACC GB PERC SH TERM LCK PGTL,SUP-2141077,CDM,C1729,HCPCS,0272,RC,,,,both,,,234.31,152.30,,,,,,,,,,,,,
GRAFT BONE SUB 4-10MM 15CC CANC CHIP FIL OSTEOSPONGE,SUP-2125411,CDM,C1713,HCPCS,0278,RC,,,,both,,,3603.15,2342.05,,,,,,,,,,,,,
WASHER CLAVICLE,SUP-2812278,CDM,C1713,HCPCS,0278,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
SCREW BNE L42MM DIA4.5MM CORT HIP S STL ST NONCANNULATED,SUP-2343711,CDM,C1713,HCPCS,0278,RC,,,,both,,,28.61,18.60,,,,,,,,,,,,,
PLUG BONE CEM 5X18MM GRN GRFT SYNTH CANC COMP RESRB TRUFIT,SUP-2341080,CDM,C1713,HCPCS,0278,RC,,,,both,,,2000.18,1300.12,,,,,,,,,,,,,
DILATOR SURG L24MM OD7MM INTVENT SNUS BLLN DIL CATH SYS,SUP-2106325,CDM,C1726,HCPCS,0272,RC,,,,both,,,3265.60,2122.64,,,,,,,,,,,,,
"HC Hla a,B,C,Dr1,3,4,5, Dq Intermediate Resolution",PX-3108137066,CDM,81370,CPT,0310,RC,,,,both,,,477.00,310.05,,,,,,,,,,,,,
PLATE BNE L85MM THK1.5MM 3X6 H L S STL OBLQ T SHP LOK COMPR,SUP-2186028,CDM,C1713,HCPCS,0278,RC,,,,both,,,1112.94,723.41,,,,,,,,,,,,,
STENT BILI PRECIS L 30 MM DIA 9 MM CATH L 135 CM DIA 8 FR,SUP-2158970,CDM,C1876,HCPCS,0278,RC,,,,both,,,6594.00,4286.10,,,,,,,,,,,,,
PLATE BONE L22MM MINI T SHP,SUP-2364915,CDM,C1713,HCPCS,0278,RC,,,,both,,,292.24,189.96,,,,,,,,,,,,,
HC Mod Sed Same Phys/Qhp Ea,PX-3729915300,CDM,99153,CPT,0372,RC,,,,outpatient,,,297.00,193.05,,,,,,,,,,,,,
PLATE BONE SM RT MEDL CLMN LO PROF FOR 3.5MM SCR,SUP-2123111,CDM,C1713,HCPCS,0278,RC,,,,both,,,4553.00,2959.45,,,,,,,,,,,,,
GRAFT ENDOVASC L16CM AORT DIA26MM IL DIA14.5MM ABD EXCLUDER,SUP-2396079,CDM,C1768,CPT,0278,RC,,,,both,,,31384.30,20399.79,,,,,,,,,,,,,
SCREW BNE L85MM DIA6.5MM THRD L32MM HD DIA8MM CANC S STL ST,SUP-2184612,CDM,C1713,HCPCS,0278,RC,,,,both,,,113.98,74.09,,,,,,,,,,,,,
PLUG VASC SM 5 MM AZUR,SUP-2853095,CDM,C1889,HCPCS,0278,RC,,,,both,,,6124.57,3980.97,,,,,,,,,,,,,
IMPLANT PROX INTERPHALANGEAL SZ 4 SIL NONCOATED CEMENTLESS,SUP-2250681,CDM,L8630,HCPCS,0278,RC,,,,both,,,2441.04,1586.68,,,,,,,,,,,,,
CABLE NEUROSTIMULATOR W45XL57MM 50GM MULT LD TRIALING,SUP-2284448,CDM,C1778,HCPCS,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
VALVE SHUNT OD 2.5 MM ID 1.14 MM CATH 120/14 CM PRESSURE 40,SUP-2883449,CDM,C1729,HCPCS,0272,RC,,,,both,,,3171.71,2061.61,,,,,,,,,,,,,
PLATE-SBF LONG 5 HOLE,SUP-2818118,CDM,C1713,HCPCS,0278,RC,,,,both,,,1766.56,1148.26,,,,,,,,,,,,,
SODIUM BICARBONATE 4.2 % IV SOLN,RX-7306,CDM,2500000003,HCPCS,0250,RC,51754-5012-01,NDC,,both,10,ML,54.10,35.16,,,,,,,,,,,,,
HYDRALAZINE HCL 20 MG/ML IJ SOLN,RX-3697,CDM,J0360,HCPCS,0636,RC,63323-0614-00,NDC,,both,0.25,ML,54.10,35.16,,,,,,,,,,,,,
REPAIR KIT CATH 9 FR DL TISS INGROWTH CUF HICKMAN,SUP-2126561,CDM,C1751,HCPCS,0278,RC,,,,both,,,593.46,385.75,,,,,,,,,,,,,
CARTRIDGE PMP FOR ERBEJET 2 STRL DISP,SUP-2901809,CDM,2720000010,LOCAL,0272,RC,,,,both,,,467.86,304.11,,,,,,,,,,,,,
PLATE BNE Y MIC 1.5X1 MM CRANIOMAXILLOFACIAL 5 HOLE TI NS,SUP-2466997,CDM,C1713,HCPCS,0278,RC,,,,both,,,666.53,433.24,,,,,,,,,,,,,
BLADE SURG BLACKLINE 40 MM BLNT TIP SS TI BLK LF,SUP-2763862,CDM,2720000010,LOCAL,0272,RC,,,,both,,,445.10,289.31,,,,,,,,,,,,,
SHELL ACET HIP,SUP-2205431,CDM,C1776,CPT,0278,RC,,,,both,,,3784.96,2460.22,,,,,,,,,,,,,
BIT DRL 4.2MM DSTL SH,SUP-2316018,CDM,2720000010,LOCAL,0272,RC,,,,both,,,800.45,520.29,,,,,,,,,,,,,
KIT INTRO S-MAK L 10 CM DIA 5 FR GUIDEWIRE L 40 CM PLAT TIP,SUP-2740507,CDM,C1894,HCPCS,0272,RC,,,,both,,,59.35,38.58,,,,,,,,,,,,,
KIT THROMCTMY BOBBY SOFIA + L 131 CM DIA 6 FR GUIDE CATH L,SUP-2915895,CDM,C1757,HCPCS,0272,RC,,,,both,,,13833.27,8991.63,,,,,,,,,,,,,
BRACE ORTH SAGITAL LUMBAR CTRL LSO,SUP-2388146,CDM,L0626,HCPCS,0272,RC,,,,both,,,200.71,130.46,,,,,,,,,,,,,
BUR SURG SHANNON STYL 3 MM BNE STRL BABY GORILLA,SUP-2751458,CDM,2720000010,LOCAL,0272,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
PLATE BNE TBLR 3.5X185 MM 14 HOLE 1/3 2 COMPR LCK FOR SCR TI,SUP-2467640,CDM,C1713,HCPCS,0278,RC,,,,both,,,1138.44,739.99,,,,,,,,,,,,,
CONNECTOR SPNL PARL WIDE 6.35-6.35 MM SS REVERE,SUP-2594662,CDM,C1713,HCPCS,0278,RC,,,,both,,,879.20,571.48,,,,,,,,,,,,,
GRAFT HUM TISS SZ A 2.5X2CM THK50-100UM OPHTH AMNIO MEM STK,SUP-2135258,CDM,V2790,HCPCS,0274,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
STEM FEM SM L46MM NK L25MM LNG CEMEX GENT HI REL IMPREG,SUP-2223682,CDM,C1776,CPT,0278,RC,,,,both,,,11994.80,7796.62,,,,,,,,,,,,,
KIT INTRO VSI L 15 CM DIA 4 FR NIT TUNGSTEN TIP SIL STIFFEN,SUP-2763487,CDM,C1892,HCPCS,0272,RC,,,,both,,,199.70,129.80,,,,,,,,,,,,,
COIL VASC AZUR CX L 28 CM DIA 9 MM MICROCATHETER 0.018 IN,SUP-2385238,CDM,C1889,HCPCS,0278,RC,,,,both,,,1412.22,917.94,,,,,,,,,,,,,
SCREW BONE L10MM DIA1.5MM EMER PAN FIX LUHR,SUP-2364710,CDM,C1713,HCPCS,0278,RC,,,,both,,,111.47,72.46,,,,,,,,,,,,,
PLATE BNE GENIOPLASTY 2X0.6 MM 4 MM GRIFFIN W/ MIDLN TI,SUP-2459394,CDM,C1713,HCPCS,0278,RC,,,,both,,,608.28,395.38,,,,,,,,,,,,,
COIL EMB L14CM LOOP DIA10MM 0.035IN PLAT HYDRGEL POLYMER,SUP-2385377,CDM,C1889,HCPCS,0278,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
HC MRI Lower Ext Jnt W&W/O Cont,PX-6107372300,CDM,73723,CPT,0610,RC,,,,both,,,4220.00,2743.00,,,,,,,,,,,,,
PLATE SPNL L39MM LEV 1 ANTR BILAT CERV TI LCK LO PROF,SUP-2254585,CDM,C1713,HCPCS,0278,RC,,,,both,,,3592.16,2334.90,,,,,,,,,,,,,
BLADE SHV L11CM DIA4MM 5000RPM M4 360DEG ROT 60DEG CRV SHFT,SUP-2277873,CDM,2720000010,LOCAL,0272,RC,,,,both,,,766.66,498.33,,,,,,,,,,,,,
PLATE BNE L103MM THK3.4MM 8 H BILAT S STL STR LIMIT CNTCT,SUP-2185136,CDM,C1713,HCPCS,0278,RC,,,,both,,,979.74,636.83,,,,,,,,,,,,,
NEPHROMAX CLEAR 10 12755,SUP-2726023,CDM,C1726,HCPCS,0272,RC,,,,both,,,965.52,627.59,,,,,,,,,,,,,
NEEDLE ASPIR 19GA FLX L2.8MM SHTH DIA1.73MM FN ENDO ULT SND,SUP-2141503,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1340.34,871.22,,,,,,,,,,,,,
PLATE BNE C 1 40 MM RT METATARSOPHALANGEAL 4 HOLE TI GRN,SUP-2608933,CDM,C1713,HCPCS,0278,RC,,,,both,,,2179.54,1416.70,,,,,,,,,,,,,
BUR SURG DIAMOND 4 MM 10 CM BALL SM BOR MIDAS REX 8 LEGEND,SUP-2664489,CDM,2720000010,LOCAL,0272,RC,,,,both,,,413.22,268.59,,,,,,,,,,,,,
SPACER ALLGRFT 7 DEG L 11 X W 14 X H 5 MM CORT CANC BNE CERV,SUP-2916804,CDM,C1713,HCPCS,0278,RC,,,,both,,,2433.50,1581.77,,,,,,,,,,,,,
SPACER 56301010 12W 30MM X 10MM 10 DG TI,SUP-2417156,CDM,C1889,HCPCS,0278,RC,,,,both,,,15660.75,10179.49,,,,,,,,,,,,,
LENS IOL BCNVX 7.5+ DIOPT POST CHMBR ACRYL AKREOS,SUP-2129300,CDM,V2632,HCPCS,0276,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
WAVE CALCANEAL FRACTURE PLATE GUIDE PIN MODEL 1.6X130MM,SUP-2830336,CDM,C1713,HCPCS,0278,RC,,,,both,,,69.08,44.90,,,,,,,,,,,,,
MEPERIDINE HCL 25 MG/ML IJ SOLN,RX-4903,CDM,J2175,HCPCS,0636,RC,00409-1176-30,NDC,,both,0.5,ML,54.10,35.16,,,,,,,,,,,,,
ENVELOPE CV DEV M W6.5XL6.9CM PORCINE DERIVED EXTRACELLULAR,SUP-2172040,CDM,C1889,HCPCS,0278,RC,,,,both,,,3092.90,2010.38,,,,,,,,,,,,,
BIT DRL L150MM DIA7.4MM GLEN SCR W/O STP NONRADIOPAQUE,SUP-2194186,CDM,2720000010,LOCAL,0272,RC,,,,both,,,510.85,332.05,,,,,,,,,,,,,
COMPONENT PAT SM DUR KNEE KINEMATIC,SUP-2376390,CDM,C1776,CPT,0278,RC,,,,both,,,1979.61,1286.75,,,,,,,,,,,,,
EXTENSION DBS LD L 50 CM 8 CHANNEL FLX MR UNSAFE FOR MED,SUP-2637200,CDM,C1883,HCPCS,0278,RC,,,,both,,,3113.94,2024.06,,,,,,,,,,,,,
K-WIRE THR DMD PT .045X9,SUP-2818085,CDM,C1713,HCPCS,0278,RC,,,,both,,,347.22,225.69,,,,,,,,,,,,,
STENT CORONARY JOSTENT GRAFTMASTER L 26 MM DIA 5 MM,SUP-2105688,CDM,C1874,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
AXOGUARD NERVE CAP 6MMX20MM,SUP-2885543,CDM,C1763,HCPCS,0278,RC,,,,both,,,7507.74,4880.03,,,,,,,,,,,,,
MESH 16X12 L ANAT,SUP-2172954,CDM,C1781,HCPCS,0278,RC,,,,both,,,1490.50,968.82,,,,,,,,,,,,,
COLLAR EXTRIC AD 35IN FOR 11 23IN FR 1 PC FLAT LOK TAB CLS,SUP-2194415,CDM,L0120,HCPCS,0274,RC,,,,both,,,16.52,10.74,,,,,,,,,,,,,
INSERT TIB SZ 1 1+ H10MM ANK POLYETH INFIN,SUP-2397283,CDM,C1776,CPT,0278,RC,,,,both,,,6619.12,4302.43,,,,,,,,,,,,,
INTRODUCER TRANSSEPTAL AD 7FRX60CM,SUP-2357196,CDM,C1894,HCPCS,0272,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
STRM PEANUT PLATE 1 HOLE,SUP-2478558,CDM,C1713,HCPCS,0278,RC,,,,both,,,2891.37,1879.39,,,,,,,,,,,,,
HC MRI-Abdomen WO Contrast,PX-6107418100,CDM,74181,CPT,0610,RC,,,,both,,,3764.00,2446.60,,,,,,,,,,,,,
SUPPORT ORTHOT LOWER EXTREMITY CUST THOR CTRL BND,SUP-2435691,CDM,L2660,HCPCS,0272,RC,,,,both,,,507.27,329.73,,,,,,,,,,,,,
WIRE FIX L150MM OD1.4MM NICKEL CHROM SMOOTH SGL END TRCR,SUP-2321619,CDM,C1713,HCPCS,0278,RC,,,,both,,,65.94,42.86,,,,,,,,,,,,,
VALVULOTOME ANGIOSCOPIC DIA2.5 MM STRL,SUP-2264158,CDM,C1713,HCPCS,0278,RC,,,,both,,,1036.20,673.53,,,,,,,,,,,,,
PLATE BNE CRESCENT BROAD 2 MM 3X3 HOLE TI NS MATRIXMANDIBLE,SUP-2181772,CDM,C1713,HCPCS,0278,RC,,,,both,,,2776.07,1804.45,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP L260CM DIA0.025IN BILI STD HYDRPHLC HI,SUP-2149310,CDM,C1769,HCPCS,0272,RC,,,,both,,,314.38,204.35,,,,,,,,,,,,,
LEAD DEFIB TRANSVENE L 52 CM DIA 7.5 FR SIL POLYUR TRNSVEN,SUP-2282253,CDM,C1896,HCPCS,0275,RC,,,,both,,,1856.87,1206.97,,,,,,,,,,,,,
DEFIBRILLATOR IMPL VIVA XT DELIVERED ENERGY 36 J 35 CC 80 GM,SUP-2282401,CDM,C1882,HCPCS,0275,RC,,,,both,,,46972.80,30532.32,,,,,,,,,,,,,
PLATE BNE MED TI RL FIBULAR NS UNITE,SUP-2896969,CDM,C1713,HCPCS,0278,RC,,,,both,,,2665.86,1732.81,,,,,,,,,,,,,
BLADE RETRACTOR THERAPON CLAY COLLEY 40X100 MM SET ULTRA,SUP-2464698,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2161.86,1405.21,,,,,,,,,,,,,
BRACE KNEE OFF THE SHLF W ACCUTRAC TECHNOLOGY STD PCL MOD L,SUP-2319280,CDM,L1810,HCPCS,0272,RC,,,,both,,,1125.94,731.86,,,,,,,,,,,,,
COMPONENT TIB POR FIN 1F/1T 2F/1T,SUP-2222768,CDM,C1776,CPT,0278,RC,,,,both,,,7674.16,4988.20,,,,,,,,,,,,,
PROBE SURG PEDCL SCREW STRL PHANTOM XL DISP,SUP-2731890,CDM,2720000010,LOCAL,0272,RC,,,,both,,,901.49,585.97,,,,,,,,,,,,,
BUR SURG FLUT 11.1 MM ROUTER FOR ATTCH ORNG,SUP-2848327,CDM,2720000010,LOCAL,0272,RC,,,,both,,,526.08,341.95,,,,,,,,,,,,,
ACCESSORY NEUROSTIMULATOR 2XL PERIPH HORIZONTAL FOR WEARABLE,SUP-2917123,CDM,2720000010,LOCAL,0272,RC,,,,both,,,467.86,304.11,,,,,,,,,,,,,
SCREW BNE L14MM DIA2.4MM DST RAD VOLAR S STL ST VAR ANG LOK,SUP-2178312,CDM,C1713,HCPCS,0278,RC,,,,both,,,415.42,270.02,,,,,,,,,,,,,
PLATE BNE X 35 MM TCP,SUP-2535867,CDM,C1713,HCPCS,0278,RC,,,,both,,,4125.96,2681.87,,,,,,,,,,,,,
NEEDLE BX REUSE FRANK SILVERMAN 18GA 15CM,SUP-2161880,CDM,2720000010,LOCAL,0272,RC,,,,both,,,424.40,275.86,,,,,,,,,,,,,
CEMENT BNE 40 GM RADIOPAQUE CONCORD,SUP-2595682,CDM,C1713,HCPCS,0278,RC,,,,both,,,602.88,391.87,,,,,,,,,,,,,
LACTATED RINGERS IV SOLN,RX-4318,CDM,J7120,HCPCS,0258,RC,00338-0117-03,NDC,,both,500,ML,38.30,24.89,,,,,,,,,,,,,
BURR CARBIDE BALL FLUTED 7.0MM 14 FLUTES,SUP-2801009,CDM,2720000010,LOCAL,0272,RC,,,,both,,,693.16,450.55,,,,,,,,,,,,,
KIT BNE PIN L 50 MM DIA1.5 MM K WIRE DIA1.5 MM,SUP-2913324,CDM,C1713,HCPCS,0278,RC,,,,both,,,1262.28,820.48,,,,,,,,,,,,,
DEVICE EXTR CATH 7-5FR L200CM GWIRE 0.035IN BAL 12MM 2.8MM,SUP-2169382,CDM,2720000010,LOCAL,0272,RC,,,,both,,,401.92,261.25,,,,,,,,,,,,,
GAUGE DEPTH FOR 27X35X4MM SCR TO 60MM,SUP-2199215,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1045.31,679.45,,,,,,,,,,,,,
SHEATH ENDOSCP CATH 7FR L90CM DEFLECTION L9MM 2.3MM 180DEG,SUP-2298501,CDM,C1887,HCPCS,0272,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
SUTR ANCH AR1902SF1,SUP-2843743,CDM,C1713,HCPCS,0278,RC,,,,both,,,690.80,449.02,,,,,,,,,,,,,
INQUIRY H CURVE STEER DEC 110 6 291 H,SUP-2676235,CDM,C1731,HCPCS,0278,RC,,,,both,,,2025.30,1316.44,,,,,,,,,,,,,
CATHETER ETER THROMB 8FR 80CM 19MM,SUP-2214113,CDM,C1757,HCPCS,0272,RC,,,,both,,,199.11,129.42,,,,,,,,,,,,,
GRAFT VASC HYBRID L 50 CM DIA 6 MM REINF SECT L 5 CM DIA 6,SUP-2395254,CDM,C1768,CPT,0278,RC,,,,both,,,7884.54,5124.95,,,,,,,,,,,,,
PLATE BNE W10.2XL52MM THK2.7MM 4 H BILAT S STL STR LO PROF,SUP-2186191,CDM,C1713,HCPCS,0278,RC,,,,both,,,1136.62,738.80,,,,,,,,,,,,,
BRACE KNEE HNG LAT L L OA ADJ 3,SUP-2196482,CDM,L1852,HCPCS,0274,RC,,,,both,,,1314.40,854.36,,,,,,,,,,,,,
KIT BONE CEM DEL 11GM W/ BOWL CANN INJ DMND STYL AND GRN TIP,SUP-2342068,CDM,C1713,HCPCS,0278,RC,,,,both,,,1318.80,857.22,,,,,,,,,,,,,
MESH HERN XL W4XL5CM INGUINAL POLYPR SYN PRESHAPED LT WT,SUP-2125789,CDM,C1781,HCPCS,0278,RC,,,,both,,,573.05,372.48,,,,,,,,,,,,,
SHEATH ENDOSCP DIA4MM 30DEG LENS CLN DISP ENDO-SCRUB 2,SUP-2284170,CDM,C1894,HCPCS,0272,RC,,,,both,,,161.58,105.03,,,,,,,,,,,,,
STENT URET 4.5FR L24CM OPN END LUB FLX,SUP-2313777,CDM,C2617,HCPCS,0278,RC,,,,both,,,214.31,139.30,,,,,,,,,,,,,
PLATE BNE L 89 MM 5 H SCREW DIA2.7/3.5 MM SS LT SUP DSTL,SUP-2931287,CDM,C1713,HCPCS,0278,RC,,,,both,,,3134.35,2037.33,,,,,,,,,,,,,
SHUNT VENTRICULAR L1.5CM DIAMETER 2.5MM CATHETER L18CM DISTA,SUP-2825682,CDM,C1889,HCPCS,0278,RC,,,,both,,,2517.90,1636.63,,,,,,,,,,,,,
ENDOPROSTHESIS VASC VIABAHN L 25CM 7MM 120CM 7FR RADIOPAQUE,SUP-2396655,CDM,C1874,HCPCS,0278,RC,,,,both,,,20052.04,13033.83,,,,,,,,,,,,,
PLATE 4.5MM TI LCP MEDIAL PROXIMAL TIBIA 10H LT 214MM STER,SUP-2549615,CDM,C1713,HCPCS,0278,RC,,,,both,,,3544.53,2303.94,,,,,,,,,,,,,
PLATE BONE LNG DSTL VOLAR RAD CROSSLOCK LT STRL,SUP-2137041,CDM,C1713,HCPCS,0278,RC,,,,both,,,6966.47,4528.21,,,,,,,,,,,,,
SPACER SPNL 12 DEG 55X22X17 MM INTBDY SKYHAWK,SUP-2658122,CDM,C1748,HCPCS,0278,RC,,,,both,,,10362.00,6735.30,,,,,,,,,,,,,
LINE GAS SAMP L10FT 0.05MM LUER TO M LUER UNFILTERED,SUP-2882145,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2.45,1.59,,,,,,,,,,,,,
DILATOR SURG INSUL 8/13/18 MM STRL,SUP-2710542,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2920.20,1898.13,,,,,,,,,,,,,
PLATE BNE 59 MM,SUP-2136811,CDM,C1713,HCPCS,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
HC So Assay Myeloperoxidase,PX-3018387666,CDM,83876,CPT,0301,RC,,,,both,,,84.00,54.60,,,,,,,,,,,,,
IMMOBILIZER ORTH CUTAWAY UNIV 18 IN KNEE ADJ PERF FOAM,SUP-2194899,CDM,L1830,CPT,0272,RC,,,,both,,,62.80,40.82,,,,,,,,,,,,,
CATHETER HD SHT TERM 11.5 FRX24 CM STR TRI-FLOW,SUP-2627432,CDM,C1752,HCPCS,0278,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
ENDCAP ORTH L0MM DIA8MM ST FEM TI NAIL EXTN,SUP-2191864,CDM,C1713,HCPCS,0278,RC,,,,both,,,527.52,342.89,,,,,,,,,,,,,
LP PLATE 4 X 4 HOLES SQRE SGMNTS 6MM 20MM SSTM CP TTNM,SUP-2681102,CDM,C1713,HCPCS,0278,RC,,,,both,,,910.79,592.01,,,,,,,,,,,,,
STEM SEG LIMB SALV LO BODY CEM STR FLUT ELEOS 25MM,SUP-2314046,CDM,C1776,CPT,0278,RC,,,,both,,,12073.30,7847.64,,,,,,,,,,,,,
VITAMIN C 250 MG PO TABS,RX-8679,CDM,6370000000,HCPCS,0637,RC,50268-0860-11,NDC,,both,1,UN,1.90,1.23,,,,,,,,,,,,,
BLADE DERMTOM W25MM,SUP-2319878,CDM,C1713,HCPCS,0278,RC,,,,both,,,753.60,489.84,,,,,,,,,,,,,
GRAFT VASC BYPS 6 MMX60 CM STD WALL MINI CUF EPTFE DISTAFLO,SUP-2761424,CDM,C1768,CPT,0278,RC,,,,both,,,12667.07,8233.60,,,,,,,,,,,,,
HC Iaad Ia Hepatitis B Surface Antigen,PX-3068734000,CDM,87340,CPT,0306,RC,,,,both,,,554.00,360.10,,,,,,,,,,,,,
GRAFT BONE 0 DEGREE 6X11X11 MM ASSEMBLED PUROS-S,SUP-2414403,CDM,C1762,CPT,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
"HC So Cortisol,Serum",PX-3018253366,CDM,82533,CPT,0301,RC,,,,outpatient,,,212.00,137.80,,,,,,,,,,,,,
COMPONENT TIB SZ 2 THK7MM RT MEDL LT LAT ANTR POST KNEE ALL,SUP-2251255,CDM,C1776,CPT,0278,RC,,,,both,,,4596.96,2988.02,,,,,,,,,,,,,
SCREW BNE L 3 MM DIA1.4 MM CRANIOMAXILLOFACIAL EMER ST 5PK,SUP-2884112,CDM,C1713,HCPCS,0278,RC,,,,both,,,1479.57,961.72,,,,,,,,,,,,,
PLATE BONE L58MM 3 H LT PROX MEDL TIB TI FOR 3.5MM SCR,SUP-2418113,CDM,C1713,HCPCS,0278,RC,,,,both,,,4320.64,2808.42,,,,,,,,,,,,,
GRAFT STENT PROX COMP 32X94 MM 20 FR AAA FEN ZENITH AAA,SUP-2423972,CDM,C1768,CPT,0278,RC,,,,both,,,32910.34,21391.72,,,,,,,,,,,,,
AUGMENT TIBIAL KNEE EMPOWR HALF BLK 6BU 5MM,SUP-2891099,CDM,C1776,CPT,0278,RC,,,,both,,,8275.47,5379.06,,,,,,,,,,,,,
SCREW BNE CANC LG 6.5X150 MM 16 MM HEX NS LTX,SUP-2861492,CDM,C1713,HCPCS,0278,RC,,,,both,,,213.46,138.75,,,,,,,,,,,,,
DEVICE EXTR BLLN 12MM 200CM CLR CONN PUR DEV EXTR DBL LUMN,SUP-2169100,CDM,2720000010,LOCAL,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
CATHETER ANGIOPLSTY L 60 CM DIA 3 FR SIL MINI COMPR 2 STRL,SUP-2168564,CDM,C2628,HCPCS,0272,RC,,,,both,,,640.37,416.24,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE 15 CC CANC CRUSH,SUP-2898985,CDM,C1713,HCPCS,0278,RC,,,,both,,,2357.36,1532.28,,,,,,,,,,,,,
SUPPORT ORTHOT CUST MILWAUKEE TYP SUPERSTRUCTURE,SUP-2435586,CDM,L1230,HCPCS,0272,RC,,,,both,,,1888.71,1227.66,,,,,,,,,,,,,
LEVEL CMF ST PLATE MDFCE T SHP WTAB 1.5 MM SCRW8 HOLE 27 MM,SUP-2676828,CDM,C1713,HCPCS,0278,RC,,,,both,,,757.37,492.29,,,,,,,,,,,,,
KIT INTRO ARROWG+ARD BLU SHTH L 10 CM DIA 9 FR SIDEPRT,SUP-2763368,CDM,C1892,HCPCS,0272,RC,,,,both,,,381.20,247.78,,,,,,,,,,,,,
KIT LD INTRO SAFSHTH L 13 CM DIA11 FR NDL 18 GA10 ML,SUP-2148863,CDM,C1894,HCPCS,0272,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
HOOK RETRCT STRL DISP SECUREHOLD,SUP-2930232,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1301.03,845.67,,,,,,,,,,,,,
PLUG FEN HIP STEM NO 3,SUP-2377824,CDM,C1776,CPT,0278,RC,,,,both,,,241.78,157.16,,,,,,,,,,,,,
VALVE HEMOSTAS DBL PLAY LUMEN DIA 9 FR POLYCARB SIL Y LG BOR,SUP-2303044,CDM,C1713,HCPCS,0278,RC,,,,both,,,49.64,32.27,,,,,,,,,,,,,
GUIDEWIRE VASC L 260 CM 0.021 IN L 7 CM 2CM STR TIP FIX COR,SUP-2167647,CDM,C1769,HCPCS,0272,RC,,,,both,,,73.73,47.92,,,,,,,,,,,,,
MATRIX BIO L 3.2 X W 2.4 IN SZ 49.2 SQCM PORCINE TEND,SUP-2909311,CDM,A2008,HCPCS,0636,RC,,,,both,,,7385.28,4800.43,,,,,,,,,,,,,
ANCHOR SUT SZ 2 3MM HI STRENGTH BIOABSRB XCEL,SUP-2362556,CDM,C1713,HCPCS,0278,RC,,,,both,,,989.10,642.91,,,,,,,,,,,,,
NAVIGATION SET CRAN PASS BX NAVIGUS,SUP-2432049,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4374.65,2843.52,,,,,,,,,,,,,
SUPPORT ORTHOT CUST MILWAUKEE TYP SUPERSTRUCTURE,SUP-2435586,CDM,L1230,HCPCS,0274,RC,,,,both,,,1888.71,1227.66,,,,,,,,,,,,,
DRILL SURG 1.1MM QUIK CONN VLP MINI MOD,SUP-2351106,CDM,2720000010,LOCAL,0272,RC,,,,both,,,688.35,447.43,,,,,,,,,,,,,
TIP SUCT EXT YANK BLB FOR LT IRRIG GYN PLAS SURG VIT VUE,SUP-2172324,CDM,2720000010,LOCAL,0272,RC,,,,both,,,520.77,338.50,,,,,,,,,,,,,
COVER SPNL LCK 14 MM ZUMA,SUP-2245580,CDM,C1713,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
LOOP N TACK 3.9 TENODESIS SYS,SUP-2737931,CDM,C1776,CPT,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
SCREW BNE ABSORBABLE 5X40 MM LP PART THRD REUNITE,SUP-2466225,CDM,C1713,HCPCS,0278,RC,,,,both,,,803.84,522.50,,,,,,,,,,,,,
PLATE BONE L124MM 6 H S STL NAR NONLOCKING COMPR CNTOUR FOR,SUP-2348962,CDM,C1713,HCPCS,0278,RC,,,,both,,,1455.89,946.33,,,,,,,,,,,,,
WIRE FIX 2 SHRP TIP K S STL L150MM OD1.6MM,SUP-2242887,CDM,C1713,HCPCS,0278,RC,,,,both,,,131.19,85.27,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.536,SUP-2860053,CDM,C1713,HCPCS,0278,RC,,,,both,,,46674.53,30338.44,,,,,,,,,,,,,
KIT PI PICC 1-L 4.5 FR X 55 CM WITH CHG AND VPS,SUP-2565195,CDM,C1751,HCPCS,0278,RC,,,,both,,,778.09,505.76,,,,,,,,,,,,,
CHRONOS(TM) BETA-TCP BLOCK 20MM X 20MM X 10MM-STERILE,SUP-2550431,CDM,C1713,HCPCS,0278,RC,,,,both,,,1827.76,1188.04,,,,,,,,,,,,,
GRAFT BIO TISS W4XL16CM THK08 17MM THCK STRUCTURAL,SUP-2307470,CDM,Q4128,HCPCS,0636,RC,,,,both,,,5776.44,3754.69,,,,,,,,,,,,,
ENVELOPE PACEMKR L W2.9XL3.3IN ABSRB ANTIBACT TYRX,SUP-2282348,CDM,C1889,HCPCS,0278,RC,,,,both,,,2810.30,1826.69,,,,,,,,,,,,,
FORCEPS GRSP L700MM DIA8MM CHN 2MM SHARK TOOTH RAT REUSE FOR,SUP-2313149,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2645.89,1719.83,,,,,,,,,,,,,
SCREW BNE L14MM DIA3.5MM STD CORT DST TIB TI ST LOK FULL,SUP-2413562,CDM,C1713,HCPCS,0278,RC,,,,both,,,378.68,246.14,,,,,,,,,,,,,
PLATE BNE NAR 3.5X215 MM 12 HOLE SS LCP,SUP-2569356,CDM,C1713,HCPCS,0278,RC,,,,both,,,607.90,395.13,,,,,,,,,,,,,
SIMVASTATIN 20 MG PO TABS,RX-11365,CDM,6370000000,HCPCS,0637,RC,68084-0512-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
BUR SURG RND XL 4 MM TORNADO + STRL FMS VUE DISP,SUP-2624804,CDM,2720000010,LOCAL,0272,RC,,,,both,,,320.28,208.18,,,,,,,,,,,,,
LEAD PACING UFM W 26MM HCIR 64MM KN,SUP-2850071,CDM,C1898,HCPCS,0275,RC,,,,both,,,42.77,27.80,,,,,,,,,,,,,
TUBE ET OD11.8MM ID8MM EVAC ORAL MURPHY EYE TAPERGUARD CUF,SUP-2172243,CDM,2720000010,LOCAL,0272,RC,,,,both,,,75.71,49.21,,,,,,,,,,,,,
HC Iadna Respiratry Probe & Rev Trnscr 12-25 Target|NOT REASONABLE AND NECESSARY,PX-3068763300,CDM,87633,CPT,0306,RC,,,GZ,both,,,683.00,443.95,,,,,,,,,,,,,
PLATE BNE TIB 238 MM LAT 11 HOLE BUTTRESS HD TI NS LC-DCP,SUP-2569061,CDM,C1713,HCPCS,0278,RC,,,,both,,,2780.88,1807.57,,,,,,,,,,,,,
AMPICILLIN SODIUM 1 G IV SOLR,RX-27280,CDM,J0290,HCPCS,0636,RC,00781-3412-15,NDC,,both,1,UN,75.40,49.01,,,,,,,,,,,,,
SURFACE ARTC 1-2 AB THK10MM AP40MM ML58MM UNIV PUR UHMWPE,SUP-2201438,CDM,C1776,CPT,0278,RC,,,,both,,,3469.70,2255.30,,,,,,,,,,,,,
HC Bone Marrow Biopsy-CT,PX-3613822100,CDM,38221,CPT,0361,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
MESH CRAN DIA23MM PROF 06MM CRANIOMAXILLOFACIAL RESORB X,SUP-2263014,CDM,C1713,HCPCS,0278,RC,,,,both,,,2215.30,1439.94,,,,,,,,,,,,,
RIFAMPIN 600 MG IV SOLR,RX-11291,CDM,J2804,HCPCS,0636,RC,00068-0597-01,NDC,,both,1,UN,1026.80,667.42,,,,,,,,,,,,,
PLATE BURR H DIA20.1 MM THK 0.3 MM SCREW DIA1.5 MM SZ 20 MM,SUP-2935957,CDM,C1713,HCPCS,0278,RC,,,,both,,,185.26,120.42,,,,,,,,,,,,,
PLATE BNE LADDER 43X0.6 MM NEURO 5X2 HOLE CRV STRL LEVEL 1,SUP-2486606,CDM,C1713,HCPCS,0278,RC,,,,both,,,1219.45,792.64,,,,,,,,,,,,,
MESH CRAN L 102.12 X W 39.22 MM THK 0.3 MM SCREW DIA1.5 MM,SUP-2936540,CDM,C1713,HCPCS,0278,RC,,,,both,,,4618.94,3002.31,,,,,,,,,,,,,
SCREW BNE CANC 6.5X140 MM FT HEX HD SS NS,SUP-2457545,CDM,C1713,HCPCS,0278,RC,,,,both,,,132.48,86.11,,,,,,,,,,,,,
GRAFT HUM TISS PTCH 3X3 CM UMB CRD RESTORIGIN,SUP-2321892,CDM,Q4191,HCPCS,0636,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
ELECTRODE ES WIRE 0.35IN ANG 12DEG MPLR HF RESECT,SUP-2312903,CDM,2720000010,LOCAL,0272,RC,,,,both,,,498.51,324.03,,,,,,,,,,,,,
SEGMENT FEM COMP L SZ 1 W75XH20MM RT MEDL TILASTAN-S,SUP-2418364,CDM,C1776,CPT,0278,RC,,,,both,,,2555.96,1661.37,,,,,,,,,,,,,
GRAFT VASC GORTX L 40 CM DIA 8 MM RNG L 20 CM EPTFE STR TW,SUP-2396164,CDM,C1768,CPT,0278,RC,,,,both,,,2185.44,1420.54,,,,,,,,,,,,,
CONTOURED MESH 10 XL LEFT FRNTTMPRPRTL APPRCH 0.6MM,SUP-2492074,CDM,C1713,HCPCS,0278,RC,,,,both,,,17154.54,11150.45,,,,,,,,,,,,,
HC Complement Antigen Each Component,PX-3028616000,CDM,86160,CPT,0302,RC,,,,both,,,32.00,20.80,,,,,,,,,,,,,
HC Sclerotx Fluid Collection|BILATERAL PROCEDURE,PX-3614918500,CDM,49185,CPT,0361,RC,,,50,outpatient,,,3707.00,2409.55,,,,,,,,,,,,,
STENT TRACHBRONCH WSTNT L 40 MM DIA14 MM SHTH 10 FR CATH L,SUP-2142676,CDM,C1876,HCPCS,0278,RC,,,,both,,,3207.73,2085.02,,,,,,,,,,,,,
CATHETER STONE REM OD5FR ANTI RETROPULSION CLR GEL LITHO,SUP-2149868,CDM,C1713,HCPCS,0278,RC,,,,both,,,1186.92,771.50,,,,,,,,,,,,,
CATHETER ABLATN ASYM 4 7 FRX110 CM 2.5 MM INTELLATIP MIFI XP,SUP-2148495,CDM,C1733,HCPCS,0272,RC,,,,both,,,6123.00,3979.95,,,,,,,,,,,,,
CATHETER DRAINAGE 90 CM PERITONEAL PUDENZ HI PRESSURE RATE,SUP-2550574,CDM,C1729,HCPCS,0272,RC,,,,both,,,608.53,395.54,,,,,,,,,,,,,
SCREW BNE L30MM DIA6.5MM CANC LO PROF,SUP-2121115,CDM,C1713,HCPCS,0278,RC,,,,both,,,279.46,181.65,,,,,,,,,,,,,
CATHETER ETER INFUS L130CM OD084X61MM ID053X046MM DST L40CM,SUP-2417577,CDM,C1887,HCPCS,0272,RC,,,,both,,,1161.80,755.17,,,,,,,,,,,,,
PLATE BONE L102MM 3 H PROX HUM FOR PICCOLO COMP PLT SYS,SUP-2152595,CDM,C1713,HCPCS,0278,RC,,,,both,,,3054.03,1985.12,,,,,,,,,,,,,
SPLINT ORTHOPEDIC W/ ABDUCTED SM 8 IN RT WRST FOREARM THMB,SUP-2276639,CDM,L3809,HCPCS,0272,RC,,,,both,,,22.26,14.47,,,,,,,,,,,,,
GRAFT BNE PLUG 12 MM CLOWARD DWL FD ASEP,SUP-2693956,CDM,C1713,HCPCS,0278,RC,,,,both,,,5193.56,3375.81,,,,,,,,,,,,,
NEEDLE BRST LOC 20 GAX12.5 CM HAWKINS II,SUP-2120051,CDM,C1819,HCPCS,0278,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
ALPHA1-PROTEINASE INHIBITOR 1000 MG/20ML IV SOLN,RX-140878,CDM,J0256,HCPCS,0636,RC,13533-0705-01,NDC,,both,1,UN,1770.00,1150.50,,,,,,,,,,,,,
HC Sacroplasty Bilat,PX-3610201000,CDM,0201T,CPT,0361,RC,,,,both,,,15457.00,10047.05,,,,,,,,,,,,,
CATHETER ART THERMODILUTION 0.025 IN 7 FRX110 CM STD 4 LUMEN,SUP-2662684,CDM,C1751,HCPCS,0278,RC,,,,both,,,351.68,228.59,,,,,,,,,,,,,
LINER ACET NEUT G 5+ MM 32 MM PROV G7,SUP-2441119,CDM,C1776,CPT,0278,RC,,,,both,,,183.69,119.40,,,,,,,,,,,,,
FIBER LASER KIT PROC,SUP-2225707,CDM,2720000010,LOCAL,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
KNOWLES PIN 5.32X3 1.2,SUP-2818102,CDM,C1713,HCPCS,0278,RC,,,,both,,,1288.37,837.44,,,,,,,,,,,,,
SAW SURG OSCILLATING DISP,SUP-2391436,CDM,2720000010,LOCAL,0272,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
COMPONENT SUBTALAR L4MM SZ 8MM BILAT ANK JT PLLA,SUP-2242684,CDM,C1713,HCPCS,0278,RC,,,,both,,,8089.90,5258.43,,,,,,,,,,,,,
CLONIDINE HCL 0.1 MG PO TABS,RX-1755,CDM,6370000000,HCPCS,0637,RC,60687-0113-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
BIT DRL 2X130 MM PENNIG DYN WRST FIX,SUP-2644602,CDM,2720000010,LOCAL,0272,RC,,,,both,,,272.93,177.40,,,,,,,,,,,,,
BLADE RTRCTR HIBBS 2INW X 3INL PRONG F/HMI LMNCTMY RGGLS RDM,SUP-2501131,CDM,2720000010,LOCAL,0272,RC,,,,both,,,340.72,221.47,,,,,,,,,,,,,
BAR EXT FIX DIA6MM V JET-X,SUP-2342914,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1602.09,1041.36,,,,,,,,,,,,,
HC Neg Pressure Wnd <= 50 Sq Cm Disposable,PX-7619760700,CDM,97607,CPT,0761,RC,,,,outpatient,,,813.00,528.45,,,,,,,,,,,,,
CAGE SPNL L16XW16XH50MM SPNL 4 LOBE IMP NGAGE,SUP-2317743,CDM,C1889,HCPCS,0278,RC,,,,both,,,16337.42,10619.32,,,,,,,,,,,,,
SET SPEC RETRV CATH 6.3FR L80CM 11FR SHTH L60CM VENA CAVA,SUP-2168835,CDM,C1880,HCPCS,0278,RC,,,,both,,,846.64,550.32,,,,,,,,,,,,,
KIT THR R 3 TIB 4 FEM KNEE RESECT GUID SPEC 2 TRUMATCH,SUP-2252932,CDM,C1713,HCPCS,0278,RC,,,,both,,,4052.48,2634.11,,,,,,,,,,,,,
IMPL SPNE SN VG-VLAG-0051,SUP-2431581,CDM,C1889,HCPCS,0278,RC,,,,both,,,8478.00,5510.70,,,,,,,,,,,,,
DEVICE BRST IMPL TISS EXP W/ 7.7CM PROJCT,SUP-2300523,CDM,C1789,HCPCS,0278,RC,,,,both,,,4160.50,2704.32,,,,,,,,,,,,,
PLATE BNE TBLR UNIV 3.5 MM 6 HOLE 1/3 2 COMPR LCK FOR SCR TI,SUP-2468115,CDM,C1713,HCPCS,0278,RC,,,,both,,,455.39,296.00,,,,,,,,,,,,,
GRAFT VASC IMPRA L 90 CM DIA 8 MM EPTFE STR STD WALL N RING,SUP-2761375,CDM,C1768,CPT,0278,RC,,,,both,,,2905.76,1888.74,,,,,,,,,,,,,
BLADE SHAVER BONECUTTER PLATINUM 3.5MM,SUP-2740122,CDM,2720000010,LOCAL,0272,RC,,,,both,,,544.66,354.03,,,,,,,,,,,,,
PLATE BNE L61MM THK1.3MM 100DEG 5 H TI TBLR FOR 3.5MM SCR,SUP-2412035,CDM,C1713,HCPCS,0278,RC,,,,both,,,257.48,167.36,,,,,,,,,,,,,
PIN FIX DIA32MM THRD FOR CEPHALOMEDULLARY SM NAT NAIL SYS,SUP-2198687,CDM,2720000010,LOCAL,0272,RC,,,,both,,,538.20,349.83,,,,,,,,,,,,,
PLATE BONE L103MM 11 H STRL LT LAT DSTL FIBULAR S STL FOR,SUP-2349737,CDM,C1713,HCPCS,0278,RC,,,,both,,,4462.10,2900.36,,,,,,,,,,,,,
PLATE BNE L 10 H L CLAV LOK,SUP-2107747,CDM,C1713,HCPCS,0278,RC,,,,both,,,2339.30,1520.54,,,,,,,,,,,,,
RETRACTOR PED OP OPN 3 1 2 89CM BALF,SUP-2162002,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1179.35,766.58,,,,,,,,,,,,,
BIT DRL QC 2.8X135 MM 45 MM CALIB STRL,SUP-2563757,CDM,2720000010,LOCAL,0272,RC,,,,both,,,383.65,249.37,,,,,,,,,,,,,
SCREW BNE THMB SHT REPL TRABECULAR MTL BIGLIANI/FLATOW,SUP-2436703,CDM,C1713,HCPCS,0278,RC,,,,both,,,211.95,137.77,,,,,,,,,,,,,
NEOSTIGMINE METHYLSULFATE 10 MG/10ML IV SOLN,RX-122343,CDM,J2710,HCPCS,0636,RC,00641-6149-01,NDC,,both,0.5,ML,54.10,35.16,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA PLU MAXBARR 4FR S1274108D1,SUP-2632799,CDM,C1751,HCPCS,0278,RC,,,,both,,,790.50,513.82,,,,,,,,,,,,,
CATHETER REPROC DIAG EP MAPPING 5FRX10MMX120CM,SUP-2467425,CDM,C1730,HCPCS,0272,RC,,,,both,,,221.68,144.09,,,,,,,,,,,,,
COIL EMB COMPLX 2 MMX4 CM ORBIT GALAXY XTRASOFT,SUP-2427735,CDM,C1713,HCPCS,0278,RC,,,,both,,,4994.30,3246.29,,,,,,,,,,,,,
HC So Carbohydrate Antigen 19-9,PX-3028630166,CDM,86301,CPT,0302,RC,,,,both,,,306.00,198.90,,,,,,,,,,,,,
ALTEPLASE 50 MG IV SOLR,RX-9003,CDM,J2997,HCPCS,0636,RC,50242-0044-13,NDC,,both,1,UN,25301.10,16445.71,,,,,,,,,,,,,
HC Echo Exam of Fetal Heart Complete,PX-4027682700,CDM,76827,CPT,0402,RC,,,,both,,,372.00,241.80,,,,,,,,,,,,,
GUIDEWIRE VASC L 40 CM 0.018 IN L 5 CM NIT MANDREL PLAT COIL,SUP-2823945,CDM,C1769,HCPCS,0272,RC,,,,both,,,113.98,74.09,,,,,,,,,,,,,
HC So Arsenic,PX-3018217566,CDM,82175,CPT,0301,RC,,,,both,,,125.00,81.25,,,,,,,,,,,,,
HC Pt Neuro Facilitation Ea 15 Min|OP OCCUPATIONAL THERAPY SERV|SERVICES PROVIDED IN WHOLE OR IN PARTY BY AN OTA FOR MEDICARE PATIENTS,PX-4209711200,CDM,97112,CPT,0420,RC,,,GO|CO,both,,,159.00,103.35,,,,,,,,,,,,,
FIBER LASER HOLM 940 M FOR USE W/ H-30 RED SMARTSYNC DISP,SUP-2835951,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2180.86,1417.56,,,,,,,,,,,,,
GRAFT HUM TISS 6 10MM 30CC CANC CUBE,SUP-2293752,CDM,C1713,HCPCS,0278,RC,,,,both,,,2245.10,1459.31,,,,,,,,,,,,,
IMPLANT SUBTALAR 9MM TI HORZ,SUP-2137778,CDM,2780000010,LOCAL,0278,RC,,,,both,,,3925.00,2551.25,,,,,,,,,,,,,
SCREW BNE L 14 MM DIA2.7 MM NLCK NS LEOS,SUP-2931322,CDM,C1713,HCPCS,0278,RC,,,,both,,,342.89,222.88,,,,,,,,,,,,,
SCREW BNE SLD 6.5X10 MM PEDCL THRESHOLD,SUP-2435244,CDM,C1713,HCPCS,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
IMPLANT FINGER JOINT SIZE 1 PROXIMAL INTERPHALANGEAL COBALT CHROME TITANIUM POLYETHYLENE SEMI CONSTRAINED SR PIP,SUP-2879157,CDM,C1776,CPT,0278,RC,,,,both,,,6396.18,4157.52,,,,,,,,,,,,,
PLATE BNE LCK 3.5X53 MM 4 HOLE CNTOUR 2 COMPR SS STRL,SUP-2476210,CDM,C1713,HCPCS,0278,RC,,,,both,,,807.26,524.72,,,,,,,,,,,,,
IMPLANT STPE PSTN SM 6MM WRE FLROPLAS,SUP-2650109,CDM,L8613,CPT,0278,RC,,,,both,,,363.99,236.59,,,,,,,,,,,,,
CATHETER DRNGE 10FR RNG BILI DUCT,SUP-2169777,CDM,C1729,HCPCS,0272,RC,,,,both,,,119.32,77.56,,,,,,,,,,,,,
ENDOPROSTHESIS VASC VIABAHN L 10 MM DIA 9 MM CATH L 120 CM,SUP-2558723,CDM,C1768,CPT,0278,RC,,,,both,,,10748.22,6986.34,,,,,,,,,,,,,
STEM FEM HI OFFSET 15-18 MM CLLR MAG NK W/ TRUNNION ARCOS,SUP-2441349,CDM,C1776,CPT,0278,RC,,,,both,,,974.97,633.73,,,,,,,,,,,,,
NAIL IM PROX 7X160 MM RT HUM AFFIXUS NAT NAIL,SUP-2606944,CDM,C1713,HCPCS,0278,RC,,,,both,,,5969.14,3879.94,,,,,,,,,,,,,
CLIP SURG L8MM M L POLYGLY ACID POLYGLY LAP ABSRB RAD,SUP-2172325,CDM,2720000010,LOCAL,0272,RC,,,,both,,,543.41,353.22,,,,,,,,,,,,,
PLATE BONE L290MM 10 H TI CVD CBL SUPERCBL,SUP-2262263,CDM,C1713,HCPCS,0278,RC,,,,both,,,6751.00,4388.15,,,,,,,,,,,,,
NAIL IM FEM LT CANN TI ALLOY STRL 10.3MMX34CM SIRUS,SUP-2204957,CDM,C1713,HCPCS,0278,RC,,,,both,,,3908.20,2540.33,,,,,,,,,,,,,
PROSTHESIS OSS 4X3.25 MM 1.45X2 MM DSTL END TI HA DORNHOFFER,SUP-2232510,CDM,L8613,CPT,0278,RC,,,,both,,,1262.28,820.48,,,,,,,,,,,,,
LINER ACET CONSTRN NEUT TI POLYETH LOK RNG HIP IMPL + 4MM,SUP-2250294,CDM,C1776,CPT,0278,RC,,,,both,,,11388.78,7402.71,,,,,,,,,,,,,
VALVE CSF PROGRAMMABLE W/ SIPHONGUARD UNITZ CERTAS +,SUP-2666585,CDM,C1889,HCPCS,0278,RC,,,,both,,,13375.90,8694.33,,,,,,,,,,,,,
SCREW BONE L20MM OD3.5MM CORT,SUP-2412506,CDM,C1713,HCPCS,0278,RC,,,,both,,,90.53,58.84,,,,,,,,,,,,,
PLATE BNE L175MM 4 H NONSTERILE L PROX FEM S STL LO PROF,SUP-2186039,CDM,C1713,HCPCS,0278,RC,,,,both,,,3793.15,2465.55,,,,,,,,,,,,,
STENT GRFT VASC RELAYPRO L 200 MM CVR L 190 MM DIA 24 MM,SUP-2894581,CDM,C1768,CPT,0278,RC,,,,both,,,62643.00,40717.95,,,,,,,,,,,,,
POST SURG INTOSS FIX GRN L30MM OD6.6MM 60DEG ANK IOFIX,SUP-2223899,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3925.00,2551.25,,,,,,,,,,,,,
STEM FEM L150MM OD11MM BOW CLLRD TI IM OSS,SUP-2405837,CDM,C1776,CPT,0278,RC,,,,both,,,5171.58,3361.53,,,,,,,,,,,,,
MESH 45IN PTCH MK W POSIFLEX CIR W STRP AND PRESHAPED,SUP-2126068,CDM,C1781,HCPCS,0278,RC,,,,both,,,315.57,205.12,,,,,,,,,,,,,
COLLAR CERV FIRM DENS W CHIN SUPP AD CNTOUR W COT CVR SERP,SUP-2276598,CDM,L0120,HCPCS,0274,RC,,,,both,,,10.30,6.69,,,,,,,,,,,,,
STENT URET L 22 CM DIA 6 FR PERCFLX 2 PIGTL FIRM DUROMETER,SUP-2138866,CDM,C2617,HCPCS,0278,RC,,,,both,,,268.69,174.65,,,,,,,,,,,,,
CARTRIDGE IOD LD MICK STRL K,SUP-2127062,CDM,C2639,HCPCS,0278,RC,,,,both,,,36.11,23.47,,,,,,,,,,,,,
PLATE BNE CRV 4.5X405 MM RT CNDYL 20 HOLE VA LCK STRL VALCP,SUP-2789785,CDM,C1713,HCPCS,0278,RC,,,,both,,,8442.55,5487.66,,,,,,,,,,,,,
PROSTHESIS OSS MIC 3X3 MM 1 MM MONOLITHIC CENTERED TI PORP,SUP-2638135,CDM,L8613,CPT,0278,RC,,,,both,,,1078.50,701.02,,,,,,,,,,,,,
"HC New Pt, E/M Level 5",PX-5109920500,CDM,99205,CPT,0510,RC,,,,both,,,387.00,251.55,,,,,,,,,,,,,
SYSTEM INTRO SHTH 9FR L13CM BLK HUB W O SIDEPRT SPLITTABLE,SUP-2303230,CDM,C1892,HCPCS,0272,RC,,,,both,,,97.34,63.27,,,,,,,,,,,,,
BASEPLATE TIB STD STEM CEM LT MEDL RT LAT PRI MOD REPICCI II,SUP-2136600,CDM,C1713,HCPCS,0278,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
NAIL IM LCK 9X300 MM ANK STRL PHOENIX LTX DISP,SUP-2861152,CDM,C1713,HCPCS,0278,RC,,,,both,,,9702.60,6306.69,,,,,,,,,,,,,
LEVOFLOXACIN 5 MG/ML SYRINGE (PED) <50 ML,RX-4090160,CDM,J1956,HCPCS,0636,RC,25021-0132-81,NDC,,both,50,ML,33.60,21.84,,,,,,,,,,,,,
KNIFE SURG VON GRAEFE 4 5 IN CATRCT,SUP-2464951,CDM,2720000010,LOCAL,0272,RC,,,,both,,,373.66,242.88,,,,,,,,,,,,,
HOOK ARTHSCP CRV BLNT TIP CROCHET,SUP-2121870,CDM,C1713,HCPCS,0278,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
ENDOPROSTHESIS VASC VIABAHN L 25CM 8MM 120CM 7FR RADIOPAQUE,SUP-2396661,CDM,C1874,HCPCS,0278,RC,,,,both,,,20658.06,13427.74,,,,,,,,,,,,,
LOCK SMOOTH PEG 2.2X14MM STER,SUP-2477512,CDM,C1713,HCPCS,0278,RC,,,,both,,,292.02,189.81,,,,,,,,,,,,,
BUR SURG DIA 6 MM HUB I ROSEN STRL REUSE HI-LINE,SUP-2928935,CDM,2720000010,LOCAL,0272,RC,,,,both,,,577.76,375.54,,,,,,,,,,,,,
ABUTMENT HEALING 17 DEG 3.5 MM CONCL REG PLATFORM MULTI-UNIT,SUP-2430164,CDM,C1713,HCPCS,0278,RC,,,,both,,,581.69,378.10,,,,,,,,,,,,,
BRACE ORTH L 16.5 IN WAIST CIRC 55 IN SHRT HIP UNIV ADV ROM,SUP-2914999,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1111.18,722.27,,,,,,,,,,,,,
BIT DRL DIA4MM CANN W/ CALIB DEPTH MRK FOR STD TWO INCIS,SUP-2120844,CDM,2720000010,LOCAL,0272,RC,,,,both,,,577.76,375.54,,,,,,,,,,,,,
NAIL IM L380MM DIA12MM TI ALLY RG CORELOCK TECHNOLOGY,SUP-2405540,CDM,C1713,HCPCS,0278,RC,,,,both,,,6757.28,4392.23,,,,,,,,,,,,,
TUBE INNR EAR MYR VENT FLNG BVL 1.14 MM ID FLROPLAS ARMSTR,SUP-2312595,CDM,L8613,CPT,0278,RC,,,,both,,,30.40,19.76,,,,,,,,,,,,,
BIT DRL L230MM DIA3.2MM ST 3 FLUT QUIK CPL NONRADIOPAQUE,SUP-2187619,CDM,2720000010,LOCAL,0272,RC,,,,both,,,828.77,538.70,,,,,,,,,,,,,
PUMP VENT ASST BLD L PERICARD MINIATURIZED FULL OUTPT LESS,SUP-2282536,CDM,C1713,HCPCS,0278,RC,,,,both,,,234401.00,152360.65,,,,,,,,,,,,,
SCREW WRIST 30MM,SUP-2706178,CDM,C1776,CPT,0278,RC,,,,both,,,751.72,488.62,,,,,,,,,,,,,
INTRODUCER SHTH 0.035 IN 4 FRX23 CM GUIDEWIRE PRELUDE,SUP-2303263,CDM,C1894,HCPCS,0272,RC,,,,both,,,41.64,27.07,,,,,,,,,,,,,
THERA-DERM EX LOTN,RX-7831,CDM,6370000000,HCPCS,0637,RC,00299-3918-08,NDC,,both,237,ML,23.50,15.27,,,,,,,,,,,,,
PLATE BNE TIBIOTALAR RT LAT ANK FUSION ALIGNX,SUP-2610039,CDM,C1713,HCPCS,0278,RC,,,,both,,,8007.00,5204.55,,,,,,,,,,,,,
DEVICE FIX 5 MM HELCL 30 MESH ASSEMBLED HERN REP TCKR,SUP-2283317,CDM,2720000010,LOCAL,0272,RC,,,,both,,,957.20,622.18,,,,,,,,,,,,,
SCREW BONE L85MM DIA6.5MM THRD L32MM STD CANC S STL LAG HEX,SUP-2344198,CDM,C1713,HCPCS,0278,RC,,,,both,,,481.24,312.81,,,,,,,,,,,,,
NEXGEN TRAB METAL TIB AGMT BLK 30MM RLAT/LMED SZ3,SUP-2502194,CDM,C1776,CPT,0278,RC,,,,both,,,5501.28,3575.83,,,,,,,,,,,,,
PLATE BNE SHT BRL 130 DEG 4.5X126 MM 25 MM 6 HOLE LCK STRL,SUP-2186825,CDM,C1713,HCPCS,0278,RC,,,,both,,,1882.68,1223.74,,,,,,,,,,,,,
GUIDEWIRE URO L150CM DIA0.025IN STD NIT HYDRPHLC STR TIP,SUP-2139329,CDM,C1769,HCPCS,0272,RC,,,,both,,,126.67,82.34,,,,,,,,,,,,,
COVER BURR H L 31.3 X W 24 MM SCREW DIA1.5 MM LG TI OBLNG,SUP-2936764,CDM,C1713,HCPCS,0278,RC,,,,both,,,703.36,457.18,,,,,,,,,,,,,
CATHETER CV PRESSURE MONITORING TY 018 3 FRX8 CM J TIP,SUP-2760124,CDM,C1751,HCPCS,0278,RC,,,,both,,,189.00,122.85,,,,,,,,,,,,,
MESH SURG DIA8CM POLY MFIL POLYLACTIC ACID KNIT PARTIALLY,SUP-2752164,CDM,C1781,HCPCS,0278,RC,,,,both,,,599.77,389.85,,,,,,,,,,,,,
FORCEPS ELECSURG L190MM BPLR STR BAYNT TRANSCONTINENTAL,SUP-2232205,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
ALLOGRAFT HUM TISS FRZN ASEP PERONEUS LONGUS TEND,SUP-2867232,CDM,C1762,CPT,0278,RC,,,,both,,,5262.01,3420.31,,,,,,,,,,,,,
PLATE BNE L324MM 13 H L DST FEM TI LOK COMPR NCB,SUP-2205039,CDM,C1713,HCPCS,0278,RC,,,,both,,,4139.78,2690.86,,,,,,,,,,,,,
GRAFT VASC GORTX L 80 CM DIA 4 MM EPTFE STR TW N RING STRL,SUP-2396684,CDM,C1768,CPT,0278,RC,,,,both,,,2596.78,1687.91,,,,,,,,,,,,,
SET INT FIX SCREW DIA1.5 MM TI NEURO Y PLT 1 PK STRL DISP,SUP-2935673,CDM,C1713,HCPCS,0278,RC,,,,both,,,1997.04,1298.08,,,,,,,,,,,,,
CUP ACET OD50MM ID36MM 0DEG HIP UHMWPE CONSTRN STD FACE,SUP-2403893,CDM,C1776,CPT,0278,RC,,,,both,,,5400.80,3510.52,,,,,,,,,,,,,
TUBE VENT 1.14 MM 1.1 MM 2.6X2.6 MM POPE POLYETH STRL 530003,SUP-2483781,CDM,L8699,HCPCS,0278,RC,,,,both,,,43.27,28.13,,,,,,,,,,,,,
PLATE SPNL L70MM TI ANT CERV LOK LO PROF ATLNTS VISN,SUP-2293173,CDM,C1713,HCPCS,0278,RC,,,,both,,,2873.57,1867.82,,,,,,,,,,,,,
ASSEMBLY SL HLD REVERE,SUP-2232137,CDM,2780000010,LOCAL,0278,RC,,,,both,,,2681.56,1743.01,,,,,,,,,,,,,
VARIABLE ANGLE LOCK SCRWWSHR ST TTNM D2.7 L22MM,SUP-2586566,CDM,C1713,HCPCS,0278,RC,,,,both,,,1040.34,676.22,,,,,,,,,,,,,
GRAFT SFT TISS CRV LG 10X22 CM RECON TISS MTRX STRATTICE,SUP-2460257,CDM,Q4130,HCPCS,0636,RC,,,,both,,,8098.06,5263.74,,,,,,,,,,,,,
STENT URET DBL PGTL 0.035 IN 6 FRX26 CM 6 FR PERCFLX + DISP,SUP-2139106,CDM,C2617,HCPCS,0278,RC,,,,both,,,441.14,286.74,,,,,,,,,,,,,
NARROW PLATE 4.5MM 24X390MM,SUP-2818526,CDM,C1713,HCPCS,0278,RC,,,,both,,,5086.49,3306.22,,,,,,,,,,,,,
STENT ESOPH NITI-S L 6 CM 16 MM 70 CM 16 FR FULL CVR,SUP-2737333,CDM,C1874,HCPCS,0278,RC,,,,both,,,7222.00,4694.30,,,,,,,,,,,,,
KIT ACC 10GA 3ML SYR BVL TIP END OPN RADPQ W/O CEM SYNFLATE,SUP-2255820,CDM,2720000010,LOCAL,0272,RC,,,,both,,,631.14,410.24,,,,,,,,,,,,,
CEFUROXIME AXETIL 250 MG PO TABS,RX-9495,CDM,6370000000,HCPCS,0637,RC,65862-0699-20,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
GUIDEWIRE SURG,SUP-2644722,CDM,C1769,HCPCS,0272,RC,,,,both,,,494.36,321.33,,,,,,,,,,,,,
SCREW BNE L16MM DIA2.7MM LNG CORT FT ANK S STL ST,SUP-2411018,CDM,C1713,HCPCS,0278,RC,,,,both,,,66.25,43.06,,,,,,,,,,,,,
PLATE BNE BROAD 4.5X323 MM 17 HOLE SS LCP,SUP-2569370,CDM,C1713,HCPCS,0278,RC,,,,both,,,904.95,588.22,,,,,,,,,,,,,
HC Removal FB Foot Subcutaneous,PX-4502819000,CDM,28190,CPT,0450,RC,,,,both,,,730.00,474.50,,,,,,,,,,,,,
GUIDEWIRE VASC 145CM 0.035IN TAPR 10CM FLPY TIP 3CM RAD7.5MM,SUP-2167631,CDM,C1769,HCPCS,0272,RC,,,,both,,,41.86,27.21,,,,,,,,,,,,,
TROCAR ARTHSCP 5MM CANN SPEED-LOCK,SUP-2361387,CDM,2720000010,LOCAL,0272,RC,,,,both,,,468.02,304.21,,,,,,,,,,,,,
PLATE BONE CONTOUR MESH 70X0.6 MM RECONSTRUCTION TITANIUM GO,SUP-2837715,CDM,C1713,HCPCS,0278,RC,,,,both,,,6064.60,3941.99,,,,,,,,,,,,,
CATHETERIZATION KIT 7 FRX16 CM 3L,SUP-2383966,CDM,C1751,HCPCS,0278,RC,,,,both,,,448.02,291.21,,,,,,,,,,,,,
BODY HUM SZ 90MM SHLDR INTERCALARY PROX LAT SEG REV W/ SCR,SUP-2402756,CDM,C1776,CPT,0278,RC,,,,both,,,17450.55,11342.86,,,,,,,,,,,,,
PLATE BNE L SHT 0.6 MM RT,SUP-2262734,CDM,C1713,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
TUBE T SUP SFT SIL 12MM,SUP-2381504,CDM,L8699,HCPCS,0278,RC,,,,both,,,153.29,99.64,,,,,,,,,,,,,
STEM FEM STD OFFSET 0 12/14 105 MM HIP PROS TAPR COCR CPT,SUP-2439514,CDM,C1776,CPT,0278,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
HC Njx Aa&/Strd Ntrcost Nrv 1|RIGHT SIDE,PX-3616442000,CDM,64420,CPT,0361,RC,,,RT,both,,,2230.00,1449.50,,,,,,,,,,,,,
WIRE FIX 1.45-1.75+ MM 40-150 MM PERCUFIX KIRSCHNER,SUP-2483740,CDM,C1713,HCPCS,0278,RC,,,,both,,,31.40,20.41,,,,,,,,,,,,,
KIT ARTHSCP DEL APPL TIP,SUP-2402579,CDM,C1713,HCPCS,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
SLING GYN MESH ASSEMB HALO NDL GUID TB HNDL TRANSOBTURATOR,SUP-2139450,CDM,C1771,HCPCS,0278,RC,,,,both,,,5251.96,3413.77,,,,,,,,,,,,,
SCREW BNE CORTICAL 2X12 MM ST HEX HD MINI SS NS,SUP-2469222,CDM,C1713,HCPCS,0278,RC,,,,both,,,72.47,47.11,,,,,,,,,,,,,
CANNULA VEN LNG 25 FR UNCOATED HLS,SUP-2663482,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1369.67,890.29,,,,,,,,,,,,,
CUP ACET CMNTLS FEM HIP PREMIER STEM POROUS,SUP-2379161,CDM,C1776,CPT,0278,RC,,,,both,,,14444.00,9388.60,,,,,,,,,,,,,
FIXATOR EXT HING RINGFIX SYS M,SUP-2496821,CDM,2720000010,LOCAL,0272,RC,,,,both,,,334.10,217.16,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED PRSS FT STEM SHELL EPOCH TRAB MEL,SUP-2212733,CDM,C1776,CPT,0278,RC,,,,both,,,15814.61,10279.50,,,,,,,,,,,,,
IMPLANT OSS L7.9MM HD DIA3X4MM SHFT DIA0.8MM 1.17MM HA HD,SUP-2312820,CDM,L8613,CPT,0278,RC,,,,both,,,1167.08,758.60,,,,,,,,,,,,,
HC Central Ven Cath 5+ Yrs|UNUSUAL NON-OVERLAPPING SERVICE,PX-4503655600,CDM,36556,CPT,0450,RC,,,XU,outpatient,,,9955.00,6470.75,,,,,,,,,,,,,
DICYCLOMINE HCL 10 MG/5ML PO SOLN,RX-42119,CDM,340b,HCPCS,0637,RC,09999-9902-16,NDC,,both,5,ML,2.70,1.75,,,,,,,,,,,,,
PLATE BNE L12MM 4 H MIDFOOT REARFOOT TI BILAT LOK,SUP-2399623,CDM,C1713,HCPCS,0278,RC,,,,both,,,2596.78,1687.91,,,,,,,,,,,,,
PLATE BNE L44MM THK13MM 2X6 H NONSTERILE CNDYL HND TI LOK,SUP-2181040,CDM,C1713,HCPCS,0278,RC,,,,both,,,1935.75,1258.24,,,,,,,,,,,,,
NEBIVOLOL HCL 10 MG PO TABS,RX-89286,CDM,6370000000,HCPCS,0637,RC,00904-7499-04,NDC,,both,1,UN,15.80,10.27,,,,,,,,,,,,,
CATHETER BLLN 6X12 MM SINUS ACELLA,SUP-2106316,CDM,C1726,HCPCS,0272,RC,,,,both,,,11225.50,7296.57,,,,,,,,,,,,,
PUMP SET INFLATABLE 10 CM INFPUB NAR BASE CYL TITAN OTR,SUP-2165402,CDM,C1813,HCPCS,0278,RC,,,,both,,,21552.96,14009.42,,,,,,,,,,,,,
ANCHOR SFT TISS FIX L116MM DIA8MM 18DEG BIOABSRB ANG HD FOR,SUP-2341628,CDM,C1713,HCPCS,0278,RC,,,,both,,,959.43,623.63,,,,,,,,,,,,,
COMPONENT TALAR W30MM D31MMXSM RT ANK STAR CO CHROM TI IMP,SUP-2362580,CDM,C1776,CPT,0278,RC,,,,both,,,13834.21,8992.24,,,,,,,,,,,,,
DILTIAZEM HCL ER COATED BEADS 120 MG PO CP24,RX-29270,CDM,6370000000,HCPCS,0637,RC,00904-7217-61,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
KIT INTRO PK L 10 CM DIA 4 FR 7 CM 21 GA 7 CM 21 GA HYDRPHLC,SUP-2703689,CDM,C1894,HCPCS,0272,RC,,,,both,,,222.94,144.91,,,,,,,,,,,,,
LP PLATE STRAIGHT 2 HOLE MED 06MM CP TITANIUM,SUP-2694753,CDM,C1713,HCPCS,0278,RC,,,,both,,,117.78,76.56,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 45 CM DIA 4-6 MM SHRT TAPR REINF,SUP-2525446,CDM,C1768,CPT,0278,RC,,,,both,,,797.28,518.23,,,,,,,,,,,,,
FIBER LASER DIA550UM FLEXSHIELD COAT HOLM HI PWR POLISHED,SUP-2139421,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1258.83,818.24,,,,,,,,,,,,,
SUPPORT ORTHOT KNEE CUST RIGID W/O JT,SUP-2435611,CDM,L1836,HCPCS,0272,RC,,,,both,,,377.71,245.51,,,,,,,,,,,,,
CATHETER EMB FOGARTY L 80 CM DIA 6 FR 13MM/7FR 0.035IN,SUP-2214022,CDM,C1757,HCPCS,0272,RC,,,,both,,,381.26,247.82,,,,,,,,,,,,,
NERVE STIMULATOR CARD 51X68 MM 61 G 2 CHMBR PERCEPT PC,SUP-2516490,CDM,C1767,HCPCS,0278,RC,,,,both,,,6908.00,4490.20,,,,,,,,,,,,,
PLATE BNE L233MM 14 H BILAT S STL STR NONCOMPRESSION RECON,SUP-2410185,CDM,C1713,HCPCS,0278,RC,,,,both,,,1479.98,961.99,,,,,,,,,,,,,
SCREW 5.0MM PERIPR VA LCKNG SLF TPNG STRDRV 8MM STER,SUP-2546195,CDM,C1713,HCPCS,0278,RC,,,,both,,,950.23,617.65,,,,,,,,,,,,,
STEM HUM L125MM DIA10MM UNIV SHLDR CO CHROM REV CEM ANAT,SUP-2193876,CDM,C1776,CPT,0278,RC,,,,both,,,9946.48,6465.21,,,,,,,,,,,,,
LINER ACET DUR 0 DEG 28MM ID 50-52MM OD,SUP-2376137,CDM,C1776,CPT,0278,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
CORE 13MM E+ SLIDING STAR TOTAL ANKLE,SUP-2878205,CDM,C1776,CPT,0278,RC,,,,both,,,8304.33,5397.81,,,,,,,,,,,,,
MESH BIO BOV TISS FEN MTRX WND 4CM LEN 4CM W PRIMTRX,SUP-2366724,CDM,C9359,HCPCS,0278,RC,,,,both,,,2619.86,1702.91,,,,,,,,,,,,,
GRAFT DURA REP L 5 X W 5 CM THK 0.4 MM ELECTROSPUN FIBER ART5506,SUP-2904066,CDM,C1763,HCPCS,0278,RC,,,,both,,,3122.73,2029.77,,,,,,,,,,,,,
AUGMENT FEM SZ 5 THK5MM L DST KNEE CO CHROM TOT STBL FULL,SUP-2373487,CDM,C1776,CPT,0278,RC,,,,both,,,1821.92,1184.25,,,,,,,,,,,,,
HC Immunofixj Electrophoresis Other Fluids,PX-3028633500,CDM,86335,CPT,0302,RC,,,,both,,,214.00,139.10,,,,,,,,,,,,,
PLATE BONE L98MM 6 H STRL RT POST DSTL TIB S STL FOR 3.5MM,SUP-2349734,CDM,C1713,HCPCS,0278,RC,,,,both,,,5147.40,3345.81,,,,,,,,,,,,,
PROBE COAG 60DEG BLK MPLR MIC ABLAT SUCT,SUP-2341613,CDM,C1713,HCPCS,0278,RC,,,,both,,,568.34,369.42,,,,,,,,,,,,,
SUPPORT ORTH H 9.5 IN UNIV ANK AD DPLX AIRCELL TECHNOLOGY,SUP-2915216,CDM,2720000010,LOCAL,0272,RC,,,,both,,,47.92,31.15,,,,,,,,,,,,,
GUIDEWIRE VASC L 60 CM DIA 0.025 IN TIP CRV RAD 3 MM HVY DBL,SUP-2759996,CDM,C1769,HCPCS,0272,RC,,,,both,,,85.91,55.84,,,,,,,,,,,,,
CONNECTOR SPNL PARL 5.5-5.5X10 MM CREO,SUP-2584321,CDM,C1713,HCPCS,0278,RC,,,,both,,,2166.60,1408.29,,,,,,,,,,,,,
BIT DRL L8IN DIA3.8MM DISP FOR TIB NAILING SYS VERSANAIL,SUP-2412809,CDM,2720000010,LOCAL,0272,RC,,,,both,,,499.26,324.52,,,,,,,,,,,,,
GUIDEWIRE VASC L150CM DIA0.035IN FLX TIP L7CM PTFE STR FIX,SUP-2157259,CDM,C1769,HCPCS,0272,RC,,,,both,,,30.62,19.90,,,,,,,,,,,,,
CATHETER HD 12 FRX16 CM DL FLEXTIP KT ARROWG+ARD BLU,SUP-2383376,CDM,C1752,HCPCS,0278,RC,,,,both,,,402.55,261.66,,,,,,,,,,,,,
PLATE SPNL L21MM ANT LUM TI LO PROF AEGIS,SUP-2255174,CDM,C1713,HCPCS,0278,RC,,,,both,,,8478.00,5510.70,,,,,,,,,,,,,
STAPLER SKIN AUTOSUT,SUP-2155526,CDM,C1889,HCPCS,0278,RC,,,,both,,,1280.59,832.38,,,,,,,,,,,,,
MODEL ANAT MAXILLOMANDIBULAR OSTEOVIEW,SUP-2883673,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5121.28,3328.83,,,,,,,,,,,,,
HC So Giardia Antigen,PX-3068732966,CDM,87329,CPT,0306,RC,,,,both,,,423.00,274.95,,,,,,,,,,,,,
BAG TISS CLSR DIA5CM TRNSPAR SIL SILO SPR LD PROX OPN SFT,SUP-2134673,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1271.70,826.60,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA 4FR 55CM 2 LUMAN R S3274108,SUP-2632840,CDM,C1751,HCPCS,0278,RC,,,,both,,,494.52,321.44,,,,,,,,,,,,,
CATHETER DIL BAL L24MM DIA5MM FOR INTRASINUS IRR RELIEVA,SUP-2106314,CDM,C1729,HCPCS,0272,RC,,,,both,,,517.47,336.36,,,,,,,,,,,,,
PLATE BONE CMPRSSN 8.7MM ID 12.19MM OD TUBE 246MML HLX14 38.,SUP-2492487,CDM,C1713,HCPCS,0278,RC,,,,both,,,2421.79,1574.16,,,,,,,,,,,,,
GLUTH ALTO TOTAL,SUP-2669516,CDM,L8613,CPT,0278,RC,,,,both,,,1176.84,764.95,,,,,,,,,,,,,
CONTROLLER DETACH V-GRIP FOR V-TRAK DEL SYS STRL,SUP-2305470,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2904.50,1887.92,,,,,,,,,,,,,
PLATE BNE L 25.17 X W 25.22 MM THK 0.6 MM ADV 6 MM SCREW,SUP-2935752,CDM,C1713,HCPCS,0278,RC,,,,both,,,781.86,508.21,,,,,,,,,,,,,
WASHER ORTHOPEDIC 3.5 MM FOR 4 MM SCREW,SUP-2398284,CDM,C1713,HCPCS,0278,RC,,,,both,,,84.78,55.11,,,,,,,,,,,,,
GRAFT HUM TISS L 250 MM DIA 7 MM PERONEUS LONGUS TEND FRZN,SUP-2913198,CDM,C1762,CPT,0278,RC,,,,both,,,6575.16,4273.85,,,,,,,,,,,,,
PLATE BNE 3 H PELV ACET SPRING STRL PRO,SUP-2902627,CDM,C1713,HCPCS,0278,RC,,,,both,,,1320.53,858.34,,,,,,,,,,,,,
PLATE BNE L39MM 5 H S STL 1/4 TBLR CLLRD FOR 2.7MM SCR,SUP-2411323,CDM,C1713,HCPCS,0278,RC,,,,both,,,238.04,154.73,,,,,,,,,,,,,
COMPONENT HUM ELBW CONN PC M TO M TAPR MRS L35MM,SUP-2364664,CDM,C1776,CPT,0278,RC,,,,both,,,10418.52,6772.04,,,,,,,,,,,,,
BRACE ORTH CIRC THGH 15.5-18.5 IN CTR 13-14 IN CALF 12-14 IN 11-3504,SUP-2916999,CDM,2720000010,LOCAL,0272,RC,,,,both,,,430.93,280.10,,,,,,,,,,,,,
GRAFT VASC INTERGARD L 40 CM DIA14 MM THK 0.49 MM POLYESTER,SUP-2227585,CDM,C1768,CPT,0278,RC,,,,both,,,1737.61,1129.45,,,,,,,,,,,,,
ANCHOR SUT BIOABSRB IMPL W/ ORTHOCORD LUPINE BR,SUP-2249329,CDM,C1713,HCPCS,0278,RC,,,,both,,,1164.94,757.21,,,,,,,,,,,,,
ANCHOR SUT OD2.8MM TI PRELD TWO SZ 2-0 DURABRAID NDL TWINFIX,SUP-2341047,CDM,C1713,HCPCS,0278,RC,,,,both,,,1022.07,664.35,,,,,,,,,,,,,
LIDOCAINE (CARDIAC) 100 MG/5ML IV SOLN (MIXTURES ONLY),RX-430054,CDM,J2003,HCPCS,0636,RC,63323-0208-05,NDC,,both,1,ML,54.10,35.16,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL PEEK SD800.542,SUP-2860223,CDM,C1713,HCPCS,0278,RC,,,,both,,,49061.56,31890.01,,,,,,,,,,,,,
COMPONENT PAT L RESURFACE POR GEN,SUP-2344077,CDM,C1776,CPT,0278,RC,,,,both,,,2081.82,1353.18,,,,,,,,,,,,,
CLAMP SURG L0.25IN SPINE BND MNRCH,SUP-2256195,CDM,C1713,HCPCS,0278,RC,,,,both,,,3338.07,2169.75,,,,,,,,,,,,,
SUPPORT ORTHOT LOWER EXTREMITY CUST THOR CTRL LAT SUPP UPR,SUP-2435693,CDM,L2680,HCPCS,0274,RC,,,,both,,,414.26,269.27,,,,,,,,,,,,,
PLATE BONE MEDIAL COLUMN LEFT SHORT TITANIUM ARSENAL FOOT PLATING SYSTEM FOR 2.2/2.7/3.5MM SCREW,SUP-2878229,CDM,C1713,HCPCS,0278,RC,,,,both,,,7755.80,5041.27,,,,,,,,,,,,,
SPLINT WRST FA R INSTABILITY INJ 10IN LOOP LOK FIRM SUPP VYN,SUP-2276624,CDM,L3809,HCPCS,0274,RC,,,,both,,,17.40,11.31,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC SOLO2 FT IR 5FR 55CM 2 LUM 3295335F,SUP-2632677,CDM,C1751,HCPCS,0278,RC,,,,both,,,323.29,210.14,,,,,,,,,,,,,
SEGMENT FEM OD21MM 5DEG SM TRAPEZOIDAL FLARE COMP SCR FORGED,SUP-2222171,CDM,C1776,CPT,0278,RC,,,,both,,,6004.94,3903.21,,,,,,,,,,,,,
ARTHROSCOPE VID L 125 MM PASSPRT CANN L 4 CM DIA 8 MM,SUP-2930492,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1730.93,1125.10,,,,,,,,,,,,,
SHEATH INTRO 20FR L30CM,SUP-2395873,CDM,C1894,HCPCS,0272,RC,,,,both,,,741.04,481.68,,,,,,,,,,,,,
WAND 55-ENT ARTHWAND REFLX ULT,SUP-2342029,CDM,2720000010,LOCAL,0272,RC,,,,both,,,643.70,418.40,,,,,,,,,,,,,
GUIDEWIRE ENDO L400CM DIA0.035IN STD FIX COR STR TIP,SUP-2168864,CDM,C1769,HCPCS,0272,RC,,,,both,,,232.36,151.03,,,,,,,,,,,,,
DILATOR VASC L30CM OD20 24FR .035IN HYDRPHLC IL LNG TAPR TIP,SUP-2168829,CDM,2720000010,LOCAL,0272,RC,,,,both,,,580.90,377.58,,,,,,,,,,,,,
PLATE BNE L36MM 7 H R CNDYL TI STR FOR 1.5MM SCR FIX MOD,SUP-2191170,CDM,C1713,HCPCS,0278,RC,,,,both,,,1472.85,957.35,,,,,,,,,,,,,
HC Smr Prim Src Wet Mount Nfct Agt|UNUSUAL NON-OVERLAPPING SERVICE,PX-3008721001,CDM,87210,CPT,0300,RC,,,XU,outpatient,,,208.00,135.20,,,,,,,,,,,,,
PLATE BNE L105MM 4 H TI L POST LAT EL LOK VARIAX,SUP-2376028,CDM,C1713,HCPCS,0278,RC,,,,both,,,3359.80,2183.87,,,,,,,,,,,,,
PIN EXT FIX AXIS 2.5X55 MM ELBW IJS-E,SUP-2340386,CDM,C1713,HCPCS,0278,RC,,,,both,,,833.67,541.89,,,,,,,,,,,,,
STENT BILI ABS L 100 MM UNCONSTRAINED DIA 6 MM CATH L 135 CM,SUP-2101747,CDM,C1876,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
PLATE BONE L87MM THK1.2MM CALCNL BEND W/ TEMPLT FOR 3.5/4MM,SUP-2343825,CDM,C1713,HCPCS,0278,RC,,,,both,,,5254.01,3415.11,,,,,,,,,,,,,
PACEMAKER LEADLESS VR PM 19.5F 38.5MM RV,SUP-2880906,CDM,C1786,HCPCS,0275,RC,,,,both,,,25748.00,16736.20,,,,,,,,,,,,,
PASSER SUT L162MM CANN DIA6MM BITE D18MM MINI SELF CAPTURE 224038] SMITH AND NEPHEW ENDOSCOPY],SUP-2341371,CDM,2720000010,LOCAL,0272,RC,,,,both,,,815.71,530.21,,,,,,,,,,,,,
ENDOPROSTHESIS VASC ICAST L 22 MM DIA 5 MM CATH L 80 CM,SUP-2884885,CDM,C1874,HCPCS,0278,RC,,,,both,,,7917.35,5146.28,,,,,,,,,,,,,
GRAFT BONE SUB W14XH7XL14MM CORT INTBDY FUS FRZ DRY BLK SPCR,SUP-2277891,CDM,C1889,HCPCS,0278,RC,,,,both,,,2650.16,1722.60,,,,,,,,,,,,,
SET IMPL PELVIC PRO STRYKER,SUP-2496129,CDM,C1713,HCPCS,0278,RC,,,,both,,,113400.97,73710.63,,,,,,,,,,,,,
CAGE SPNL 12X22 MM COR MONOLITH,SUP-2559968,CDM,C1889,HCPCS,0278,RC,,,,both,,,12560.00,8164.00,,,,,,,,,,,,,
KYPHOPLASTY TRAY 10/3 ADV OSTEO INTRO SYS KYPHOPAK XPANDERII,SUP-2665119,CDM,2720000010,LOCAL,0272,RC,,,,both,,,11340.17,7371.11,,,,,,,,,,,,,
COLLAR CERV SFT 375X15IN SM,SUP-2276590,CDM,L0120,HCPCS,0274,RC,,,,both,,,6.12,3.98,,,,,,,,,,,,,
HC Sacrum and Coccyx Min 2 Views,PX-3207222000,CDM,72220,CPT,0320,RC,,,,both,,,665.00,432.25,,,,,,,,,,,,,
NEEDLE PROC 86 DEG 18 GAX71 CM TRANSSEPTAL ANGLED HEARTSPAN,SUP-2550595,CDM,2720000010,LOCAL,0272,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
DEVICE EMBOLIC PROTCT SPIDERFX WIRE L 190 CM DIA 0.014 IN,SUP-2173562,CDM,C1884,HCPCS,0278,RC,,,,both,,,2983.00,1938.95,,,,,,,,,,,,,
RADIAL STYLOID LK PL 5H R,SUP-2726464,CDM,C1713,HCPCS,0278,RC,,,,both,,,1940.52,1261.34,,,,,,,,,,,,,
PLATE BNE L 48 MM SCREW DIA2.7 MM 6 H LCK RECON STRL EVOS,SUP-2931393,CDM,C1713,HCPCS,0278,RC,,,,both,,,2211.56,1437.51,,,,,,,,,,,,,
STAPLER INT EXTRA THICK 80 MM W/ TRI-STAPLE BLK GIA,SUP-2787701,CDM,2720000010,LOCAL,0272,RC,,,,both,,,624.64,406.02,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY DECANAV L 115 CM DIA 7 FR 10,SUP-2764134,CDM,C1732,HCPCS,0278,RC,,,,both,,,2417.49,1571.37,,,,,,,,,,,,,
PROSTHESIS OSS 3 MM 0.8X37 MM INTEGR SHOE TI CENTERED ALTO,SUP-2232496,CDM,L8613,CPT,0278,RC,,,,both,,,1218.60,792.09,,,,,,,,,,,,,
SCREW BNE STATIC 4X30 MM PECA BUNION,SUP-2758562,CDM,C1713,HCPCS,0278,RC,,,,both,,,2194.86,1426.66,,,,,,,,,,,,,
SCREW BNE CRANIOMAXILLOFACIAL 2X17 MM MAXDRIVE THREADLOCK TS,SUP-2458986,CDM,C1713,HCPCS,0278,RC,,,,both,,,374.70,243.55,,,,,,,,,,,,,
GRAFT BNE CRUSH 1-10 MM 60 CC CANC,SUP-2766763,CDM,C1713,HCPCS,0278,RC,,,,both,,,2987.08,1941.60,,,,,,,,,,,,,
COMPONENT TIB STEM OPT NXGN SZ 6+,SUP-2201538,CDM,C1776,CPT,0278,RC,,,,both,,,8289.60,5388.24,,,,,,,,,,,,,
PLATE BNE L97MM 8 H BILAT S STL 1/3 TBLR FOR 3.5MM SCR,SUP-2411345,CDM,C1713,HCPCS,0278,RC,,,,both,,,217.35,141.28,,,,,,,,,,,,,
BLADE SAW THK0.38MM CUT EDGE 11.5MM CUT D7MM INTRAORAL THN,SUP-2363668,CDM,2720000010,LOCAL,0272,RC,,,,both,,,384.34,249.82,,,,,,,,,,,,,
PACEMAKER CARD DISCOVERY DR TI 2 CHMBR IS1 COMPATIBLE CONN,SUP-2139584,CDM,C1785,HCPCS,0275,RC,,,,both,,,17270.00,11225.50,,,,,,,,,,,,,
SCREW BNE L4MM DIA1.8MM CORT CRANIOMAXILLOFACIAL NONLOCKING,SUP-2403077,CDM,C1713,HCPCS,0278,RC,,,,both,,,153.86,100.01,,,,,,,,,,,,,
CATHETER DRAINAGE 80CM CEREBROSPINAL FLUID NDL LUERLOCK CONN,SUP-2284545,CDM,C1713,HCPCS,0278,RC,,,,both,,,575.84,374.30,,,,,,,,,,,,,
PLATE BNE SM 3 HOLE GLD,SUP-2328038,CDM,C1713,HCPCS,0278,RC,,,,both,,,521.24,338.81,,,,,,,,,,,,,
PLATE BNE 4 H CRANIOMAXILLOFACIAL TI X SHP FOR 1.3MM SCR,SUP-2190671,CDM,C1713,HCPCS,0278,RC,,,,both,,,649.98,422.49,,,,,,,,,,,,,
PLATE X LCK 2.4/2.7MM MED 30X20MM TI STRL,SUP-2549727,CDM,C1713,HCPCS,0278,RC,,,,both,,,2319.11,1507.42,,,,,,,,,,,,,
PLATE BNE LCK 172 MM RT LAT PROX TIB 7 HOLE BRIDGE N CONTACT,SUP-2468693,CDM,C1713,HCPCS,0278,RC,,,,both,,,4036.28,2623.58,,,,,,,,,,,,,
SPLINT FT MED NT PLNTR FASCIITI,SUP-2195478,CDM,L4398,HCPCS,0274,RC,,,,both,,,77.18,50.17,,,,,,,,,,,,,
BLADE RTRCTR MCCLLCH 8CMD STNLSS STEEL SPNL MSCLE WIDE ULTRA,SUP-2674041,CDM,2720000010,LOCAL,0272,RC,,,,both,,,407.89,265.13,,,,,,,,,,,,,
PLATE BONE TIBIAL 214X14X4 MM TIBIAL HEAD 11 HOLE BUTTRESS S,SUP-2836989,CDM,C1713,HCPCS,0278,RC,,,,both,,,8406.41,5464.17,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY WOVEN L 125 CM DIA 6 FR DECAPOLAR,SUP-2535572,CDM,C1730,HCPCS,0272,RC,,,,both,,,305.68,198.69,,,,,,,,,,,,,
PLATE BNE CALCANEOCUBOID SM RT STRATUM,SUP-2474069,CDM,C1713,HCPCS,0278,RC,,,,both,,,4430.54,2879.85,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC FT 5FR 55CM 2 LUMAN RVS TA 9275108F,SUP-2632700,CDM,C1751,HCPCS,0278,RC,,,,both,,,551.29,358.34,,,,,,,,,,,,,
NAIL IM TIB 7.5X240 MM PHOENIX,SUP-2534688,CDM,C1713,HCPCS,0278,RC,,,,both,,,339.12,220.43,,,,,,,,,,,,,
BLADE SAW KNEE 13MM CUT EDGE 2039710] EXACTECH INC],SUP-2222814,CDM,C1713,HCPCS,0278,RC,,,,both,,,414.48,269.41,,,,,,,,,,,,,
SET URET STENT PROX L 30 CM DIA24 FR DSTL L 20 CM DIA12-7 FR,SUP-2171266,CDM,C2617,HCPCS,0278,RC,,,,both,,,327.50,212.87,,,,,,,,,,,,,
GRAFT BONE H10.75MM ANTEROPOSTERIOR DIA23-27MM MEDIOLATERAL,SUP-2264888,CDM,C1713,HCPCS,0278,RC,,,,both,,,9592.89,6235.38,,,,,,,,,,,,,
BIT DRL L 152 MM DIA2 MM AO NS DISP LEOS,SUP-2933573,CDM,2720000010,LOCAL,0272,RC,,,,both,,,699.40,454.61,,,,,,,,,,,,,
DEVICE FIX ARTICULATING RELD W/ 8 DP PURCH RELIATACK,SUP-2752199,CDM,C1713,HCPCS,0278,RC,,,,both,,,443.93,288.55,,,,,,,,,,,,,
SUTURE PACK 2 2P NDL ASMBLY UHMWPE BLK STRL EASYWHIP DISP,SUP-2875931,CDM,2720000010,LOCAL,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
LEVEL CMF ST PLATE RECON TLTS SMART RGHT20 25 MM SCREW 22,SUP-2679032,CDM,C1713,HCPCS,0278,RC,,,,both,,,9806.41,6374.17,,,,,,,,,,,,,
PLATE BONE 3D PRNT SM MIDFACE MAND TI TRUMATCH SD980.107,SUP-2860371,CDM,C1713,HCPCS,0278,RC,,,,both,,,32187.51,20921.88,,,,,,,,,,,,,
BRACE BK M FOR 35 40IN WAIST BLK ALUMINUM NYL STRNL BAR POLY,SUP-2196478,CDM,L0464,HCPCS,0274,RC,,,,both,,,599.83,389.89,,,,,,,,,,,,,
COMPONENT STERILE LATEX TALAR XXSMALL RIGHT VERSION STAR,SUP-2879208,CDM,C1776,CPT,0278,RC,,,,both,,,20158.96,13103.32,,,,,,,,,,,,,
BLADE REPROC SHV GREAT WHITE LG HUB 4.8MM,SUP-2652963,CDM,2720000010,LOCAL,0272,RC,,,,both,,,104.44,67.89,,,,,,,,,,,,,
MESH SURG W10XL15CM GYN NONABSORBABLE PROL,SUP-2219079,CDM,C1781,HCPCS,0278,RC,,,,both,,,1624.92,1056.20,,,,,,,,,,,,,
ALLOGRAFT FRZN MENISCI RT MEDL,SUP-2175248,CDM,C1762,CPT,0278,RC,,,,both,,,20410.00,13266.50,,,,,,,,,,,,,
HC Abd Paracentesis W Guide|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE PRIOR TO THE ADMINISTRATION OF ANESTHESIA,PX-3614908300,CDM,49083,CPT,0361,RC,,,73,both,,,3707.00,2409.55,,,,,,,,,,,,,
PLATE BONE LOK DUAL CMPRSSN 131MML HLX10 STNLSS STEEL CNTRD,SUP-2588605,CDM,C1713,HCPCS,0278,RC,,,,both,,,1018.93,662.30,,,,,,,,,,,,,
TUBE ENDOTRACHEAL L 34 CM OD 7.9 MM ID 5 MM SIL DUALCUFF BLU,SUP-2891630,CDM,2720000010,LOCAL,0272,RC,,,,both,,,796.84,517.95,,,,,,,,,,,,,
GRAFT DERMAL N FEN 4X4 CMX2.2-3.5 MM DERMAL MTRX PARADERM,SUP-2742065,CDM,C1763,HCPCS,0278,RC,,,,both,,,5863.17,3811.06,,,,,,,,,,,,,
WIRE FIX 3X160 MM KIRSCHNER,SUP-2451413,CDM,C1713,HCPCS,0278,RC,,,,both,,,141.30,91.84,,,,,,,,,,,,,
ADAPTER TIB TY OFFSET SCR BAL REV SYS,SUP-2315557,CDM,C1776,CPT,0278,RC,,,,both,,,238.64,155.12,,,,,,,,,,,,,
IMMOBILIZER KIT ABDUCTN UNIV SHLDR NYL PROCARE 45-70DEG,SUP-2196974,CDM,L3660,HCPCS,0272,RC,,,,both,,,78.88,51.27,,,,,,,,,,,,,
SCREW BNE L9MM DIA24MM SHT THRD L4MM ST CANC S STL ST SELF,SUP-2178490,CDM,C1713,HCPCS,0278,RC,,,,both,,,912.67,593.24,,,,,,,,,,,,,
CLAMP CONN FOR 5MM SUSP ROD TI ANTR CERV,SUP-2290604,CDM,C1713,HCPCS,0278,RC,,,,both,,,1300.75,845.49,,,,,,,,,,,,,
SCREW BNE L 3 MM DIA1.9 MM CRANIOMAXILLOFACIAL EMER ST NS 5PK,SUP-2884116,CDM,C1713,HCPCS,0278,RC,,,,both,,,1407.98,915.19,,,,,,,,,,,,,
STENT BILI E-LUMINEXX L 40 MM DIA10 MM CATH L 135 CM DIA 6,SUP-2128910,CDM,C1876,HCPCS,0278,RC,,,,both,,,4553.00,2959.45,,,,,,,,,,,,,
KIT PRESSURE MONITOR HNDL TUOHY BORST ADPT W/ SKULL BOLT SPC,SUP-2883589,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2393.90,1556.03,,,,,,,,,,,,,
FLUOCINONIDE 0.05 % EX OINT,RX-3189,CDM,6370000000,HCPCS,0637,RC,51672-1264-01,NDC,,both,15,GR,83.30,54.14,,,,,,,,,,,,,
PLATE BNE THK 2 MM SCREW DIA2/2.3 MM MED GRD IV TI,SUP-2935991,CDM,C1713,HCPCS,0278,RC,,,,both,,,6085.32,3955.46,,,,,,,,,,,,,
TRIAL PLATE T 1.3 MM,SUP-2525717,CDM,C1713,HCPCS,0278,RC,,,,both,,,737.90,479.63,,,,,,,,,,,,,
HC Treat Lower Leg Fx,PX-4502782500,CDM,27825,CPT,0450,RC,,,,both,,,1633.00,1061.45,,,,,,,,,,,,,
CPS SHRT CENTERING SLEEVE 26MM,SUP-2506438,CDM,C1776,CPT,0278,RC,,,,both,,,932.58,606.18,,,,,,,,,,,,,
DEFIBRILLATOR IMPL EVERA XT DR 34 CC 71.4 GM TI POLYUR SIL,SUP-2282396,CDM,C1721,HCPCS,0275,RC,,,,both,,,40348.31,26226.40,,,,,,,,,,,,,
STIMULATOR NERVE PT PRGMR PRODIGY MRI,SUP-2615546,CDM,C1787,HCPCS,0278,RC,,,,both,,,2933.39,1906.70,,,,,,,,,,,,,
SCREW FIX BUNION CORRECTION SYS 15X6 MM KT STRL RE+LN,SUP-2457367,CDM,C1713,HCPCS,0278,RC,,,,both,,,2116.83,1375.94,,,,,,,,,,,,,
CATHETER HD SYMMETRICAL 14.5 FRX23 CM SLV PALINDROMIC HSI,SUP-2283945,CDM,C1750,HCPCS,0278,RC,,,,both,,,1478.97,961.33,,,,,,,,,,,,,
PLATE 4.5MM TI LCP TM STRAIGHT RECON 7 HOLES 132MM,SUP-2549507,CDM,C1713,HCPCS,0278,RC,,,,both,,,1598.39,1038.95,,,,,,,,,,,,,
STEM FEM L330MM OD18X11.5MM 9 TI HX COAT HIP CEMENTLESS 03,SUP-2397015,CDM,C1776,CPT,0278,RC,,,,both,,,19342.40,12572.56,,,,,,,,,,,,,
ALLOGRAFT BNE SPACER 5 DEG 8X22X10 MM LORDTC PLIF,SUP-2632323,CDM,C1713,HCPCS,0278,RC,,,,both,,,6829.50,4439.17,,,,,,,,,,,,,
PROBE QUIK CONN SPNL LUM CDH SEXTANT,SUP-2290626,CDM,C1713,HCPCS,0278,RC,,,,both,,,1312.27,852.98,,,,,,,,,,,,,
PLATE BONE MAND HEMI PRI RECON RT 5 + 17 H,SUP-2363733,CDM,C1713,HCPCS,0278,RC,,,,both,,,3469.83,2255.39,,,,,,,,,,,,,
GRAFT VASC IMPRA L 70 CM DIA10 MM EPTFE FLX STD WALL SM BEAD,SUP-2761491,CDM,C1768,CPT,0278,RC,,,,both,,,3118.74,2027.18,,,,,,,,,,,,,
SPACER SHLDR 11X20 MM AEQUALIS FLX REVIVE,SUP-2421705,CDM,C1776,CPT,0278,RC,,,,both,,,8093.35,5260.68,,,,,,,,,,,,,
PLATE BNE TIB NEUT 4.5X82 MM LT LAT PROX 4 HOLE LCK LP STRL,SUP-2185711,CDM,C1713,HCPCS,0278,RC,,,,both,,,4539.06,2950.39,,,,,,,,,,,,,
BLADE SCREWDRIVER LG 1.5X80 MM CROSS DRV LEVEL 1,SUP-2467370,CDM,2720000010,LOCAL,0272,RC,,,,both,,,506.83,329.44,,,,,,,,,,,,,
BASKET STONE 22 MM 2Q MECH LITHO,SUP-2475444,CDM,2720000010,LOCAL,0272,RC,,,,both,,,544.41,353.87,,,,,,,,,,,,,
STAPLE BNE 26 DEG 10 MM FOR LOWER EXTREMITY NS SOLUSTAPLE,SUP-2608914,CDM,C1713,HCPCS,0278,RC,,,,both,,,596.95,388.02,,,,,,,,,,,,,
PROBE SPNL L PEDCL STR NRV STIM DISP,SUP-2310402,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1299.96,844.97,,,,,,,,,,,,,
KIT INSTRUMENT SPINAL SPINEJACK 5.8MM PREPARATION,SUP-2876927,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4358.73,2833.17,,,,,,,,,,,,,
PLATE SPNL L13MM THK1.75-2.3MM BILAT ANT CERV 1 LEV,SUP-2255543,CDM,C1713,HCPCS,0278,RC,,,,both,,,2009.60,1306.24,,,,,,,,,,,,,
GRAFT VASC VENAFLO II L 50 CM DIA 6 MM EPTFE CARBON STR STD,SUP-2127047,CDM,C1768,CPT,0278,RC,,,,both,,,2540.26,1651.17,,,,,,,,,,,,,
RING EXT FIX HALF 80 MM ALUM RINGFIX,SUP-2365295,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2763.20,1796.08,,,,,,,,,,,,,
SCREW BONE L24MM DIA5.5MM CANC BLNT ARW,SUP-2224548,CDM,C1713,HCPCS,0278,RC,,,,both,,,6280.00,4082.00,,,,,,,,,,,,,
PLATE BNE L207MM 12 H NONSTERILE R PROX TIB S STL VAR ANG,SUP-2177920,CDM,C1713,HCPCS,0278,RC,,,,both,,,6005.66,3903.68,,,,,,,,,,,,,
STEM FEM SM 0-3 CM M LT NS LTX,SUP-2861253,CDM,C1776,CPT,0278,RC,,,,both,,,1280.74,832.48,,,,,,,,,,,,,
PLATE LO PROF 4 H MINI 20 MOD TI 06MM REG,SUP-2262929,CDM,C1713,HCPCS,0278,RC,,,,both,,,272.93,177.40,,,,,,,,,,,,,
MESH BIOLOGIC OVINE RUMEN RESRB OVITEX 1S 16X20 CM,SUP-2383105,CDM,C1781,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
CATHETER HAD L40CM INSRT L23CM 2 LUMN PERMCATH,SUP-2283904,CDM,C1750,HCPCS,0278,RC,,,,both,,,539.45,350.64,,,,,,,,,,,,,
CATHETER IV 22 GAX1.25 IN ECHOGENIC GUIDEWIRE ACCUCATH,SUP-2125657,CDM,C1751,HCPCS,0278,RC,,,,both,,,69.08,44.90,,,,,,,,,,,,,
PLATE BONE W200XL200MM THK1.5MM NONSTERILE TI RECTANG CNTOUR,SUP-2191103,CDM,C1713,HCPCS,0278,RC,,,,both,,,21757.06,14142.09,,,,,,,,,,,,,
HANDLE SURG INSTR DSTL IO-FLEX,SUP-2115827,CDM,C1713,HCPCS,0278,RC,,,,both,,,741.04,481.68,,,,,,,,,,,,,
PLATE BNE L90MM THK3.3MM 7 H BILAT S STL STR LIMIT CNTCT,SUP-2185134,CDM,C1713,HCPCS,0278,RC,,,,both,,,932.39,606.05,,,,,,,,,,,,,
HC So Cea,PX-3018237866,CDM,82378,CPT,0301,RC,,,,both,,,67.00,43.55,,,,,,,,,,,,,
BIT DRL L110MM DIA2MM STD RMR ADD ON DISP,SUP-2366053,CDM,2720000010,LOCAL,0272,RC,,,,both,,,516.22,335.54,,,,,,,,,,,,,
GRAFT HUM TISS W16XL20CM PROC DERM CLLGN RECTANG ALLOMAX,SUP-2126264,CDM,C1781,HCPCS,0278,RC,,,,both,,,19936.49,12958.72,,,,,,,,,,,,,
IMPLANT BIA300 3 MM W ABUTMENT 6 MM,SUP-2858175,CDM,L8690,HCPCS,0278,RC,,,,both,,,8315.94,5405.36,,,,,,,,,,,,,
"HC Est Pt, E/M Level 1",PX-5109921100,CDM,99211,CPT,0510,RC,,,,inpatient,,,174.00,113.10,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 240 MM DIA22/13 MM DEL 58ML,SUP-2937089,CDM,C1713,HCPCS,0278,RC,,,,both,,,16761.32,10894.86,,,,,,,,,,,,,
SCREW BNE ST 2X5 MM CRTX MAND TI GLD NS PLUSDRIVE,SUP-2189324,CDM,C1713,HCPCS,0278,RC,,,,both,,,264.64,172.02,,,,,,,,,,,,,
KIT STPL SZ 15 X 15 X 15 MM NIT TIB FIBULAR STR PRELD RIGID,SUP-2880922,CDM,C1713,HCPCS,0278,RC,,,,both,,,4318.60,2807.09,,,,,,,,,,,,,
MESH PTCH SYN ABD N ABSRB RECT EXP POLYTETRAFLUROETHYLENE,SUP-2395289,CDM,C1781,HCPCS,0278,RC,,,,both,,,1651.64,1073.57,,,,,,,,,,,,,
LEAD DEFIB 59 CM ENDOCARD 2 COIL DF4-LLHH ENDOTK RELIANCE G,SUP-2148578,CDM,C1895,HCPCS,0275,RC,,,,both,,,8691.52,5649.49,,,,,,,,,,,,,
PLATE BNE VOLAR XLN 24X125 MM LT LCK STRL DVR,SUP-2481183,CDM,C1713,HCPCS,0278,RC,,,,both,,,3884.18,2524.72,,,,,,,,,,,,,
CATHETER EP STD 2-5 MM 8 FRX110 CM STR BLZR,SUP-2424664,CDM,C1733,HCPCS,0272,RC,,,,both,,,5495.00,3571.75,,,,,,,,,,,,,
RING EXT FIX PART 5/8 200 MM SLT SALVATION,SUP-2458987,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
GRAFT DURAL SUBSTITUTE CRANIAL TUMOR TRAUMA NON ABSORBABLE P,SUP-2825291,CDM,C1763,HCPCS,0278,RC,,,,both,,,641.25,416.81,,,,,,,,,,,,,
DRESSING WND THERAGENESIS MESHED BILYR MATRIX 20X24CM,SUP-2737951,CDM,A2008,HCPCS,0636,RC,,,,both,,,30618.14,19901.79,,,,,,,,,,,,,
GUIDE L 70MM SPD FOR 35MM T10,SUP-2378000,CDM,C1713,HCPCS,0278,RC,,,,both,,,938.86,610.26,,,,,,,,,,,,,
CATHETER HD STR 11.5 FRX12 CM SHT TERM DL SET SOFT-LINE,SUP-2627326,CDM,C1752,HCPCS,0278,RC,,,,both,,,17.52,11.39,,,,,,,,,,,,,
HEX DRIVER SHRT 2MM 6,SUP-2473819,CDM,2720000010,LOCAL,0272,RC,,,,both,,,665.68,432.69,,,,,,,,,,,,,
GRAFT SYNTH TISS 10MMX20MMX50MM BLK BONE IMPL CA PHOS HA PRO,SUP-2413075,CDM,C1713,HCPCS,0278,RC,,,,both,,,5878.08,3820.75,,,,,,,,,,,,,
CUP ACET HIP TRITANIUM,SUP-2366003,CDM,C1776,CPT,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
PUSHER ROD,SUP-2232113,CDM,C1713,HCPCS,0278,RC,,,,both,,,3783.70,2459.40,,,,,,,,,,,,,
BIPOLAR SHELL 43MM OD,SUP-2501841,CDM,C1776,CPT,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
SCREW BNE STD L14MM DIA4MM ANTLAT DST CANC TIB S STL FULL,SUP-2348826,CDM,C1713,HCPCS,0278,RC,,,,both,,,206.52,134.24,,,,,,,,,,,,,
BIT DRL 24902008] WRIGHT MEDICAL TECHNOLOGY INC],SUP-2397215,CDM,2720000010,LOCAL,0272,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
TRAY INTRO DIA 6 FR NDL 18/22/25 GA TUOHY BORST STRL,SUP-2877844,CDM,C1894,HCPCS,0272,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
GRAFT BNE 10 CC OSTEOSURGE 300,SUP-2641802,CDM,C1713,HCPCS,0278,RC,,,,both,,,5722.65,3719.72,,,,,,,,,,,,,
HEAD HUM ECC 3.5 MM 39X14 MM SHLDR ANAT HI OFFSET TI,SUP-2715729,CDM,C1776,CPT,0278,RC,,,,both,,,12373.17,8042.56,,,,,,,,,,,,,
BUR SURG HUB I CRANIOTOME CUT STR STRL DISP HI-LINE XS,SUP-2928998,CDM,2720000010,LOCAL,0272,RC,,,,both,,,351.68,228.59,,,,,,,,,,,,,
PLATE SPNL SH POST LUM TI 1 H MNRCH,SUP-2254512,CDM,C1713,HCPCS,0278,RC,,,,both,,,4132.24,2685.96,,,,,,,,,,,,,
STYLET RETRV INOUE-BALLOON L 80 CM DIA 0.038 IN SS PERC,SUP-2388519,CDM,2720000010,LOCAL,0272,RC,,,,both,,,417.62,271.45,,,,,,,,,,,,,
CLIP ANEUR BLDE L12/17MM MAX OPN 9.6MM 180GM TI PERM STD,SUP-2108622,CDM,C1889,HCPCS,0278,RC,,,,both,,,1361.79,885.16,,,,,,,,,,,,,
MESH HERNIAXL W8XL12IN OBLONG OVL ABD O3FA COAT POLYPR STR,SUP-2265989,CDM,C1781,HCPCS,0278,RC,,,,both,,,3611.00,2347.15,,,,,,,,,,,,,
CANCELLOUS SCREW STERILIZER 4.0X24 MM F-T,SUP-2818172,CDM,C1713,HCPCS,0278,RC,,,,both,,,173.61,112.85,,,,,,,,,,,,,
PLATE BNE SM THK1.6MM 4 H L L COMPR MED WALL SPANNING,SUP-2321486,CDM,C1713,HCPCS,0278,RC,,,,both,,,5703.81,3707.48,,,,,,,,,,,,,
VINORELBINE TARTRATE 10 MG/ML IV SOLN (MIXTURES ONLY),RX-430027,CDM,J9390,HCPCS,0636,RC,45963-0607-56,NDC,,both,5,ML,259.20,168.48,,,,,,,,,,,,,
METHOTREXATE SODIUM PF 25 MG/ML IJ SOLN (MIXTURES ONLY)|DISCARDED DRUG NOT ADMINISTE,RX-1150418,CDM,J9260,HCPCS,0636,RC,61703-0408-41,NDC,JW,both,0.5,ML,54.10,35.16,,,,,,,,,,,,,
ADAPTER EXT FIX DRV W/ QUIK CPL FOR 5MM SCHNZ SCR,SUP-2188584,CDM,2720000010,LOCAL,0272,RC,,,,both,,,950.13,617.58,,,,,,,,,,,,,
PLATE BONE L112MM PROX HUM LCK FOR ORTH FIX SYS,SUP-2167418,CDM,C1713,HCPCS,0278,RC,,,,both,,,3384.92,2200.20,,,,,,,,,,,,,
SLEEVE FEM L SZ 18D UNIV PROX HIP ZTT MOD CONE SPOUT PRI,SUP-2253119,CDM,C1776,CPT,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
SHEATH INTRO SAFSHTH L 13 CM DIA 7 FR STR VLV ACCS HEMOSTAS,SUP-2148970,CDM,C1894,HCPCS,0272,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
DRILL SURG DISCOVERY,SUP-2256729,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1381.60,898.04,,,,,,,,,,,,,
VANCOMYCIN HCL 10 G IV SOLR,RX-11627,CDM,J3373,HCPCS,0636,RC,00409-1319-01,NDC,,both,1,UN,1249.10,811.91,,,,,,,,,,,,,
PLATE BNE FIBULAR 3.5X59 MM LT LAT DSTL 3 HOLE EVOS,SUP-2349741,CDM,C1713,HCPCS,0278,RC,,,,both,,,3898.62,2534.10,,,,,,,,,,,,,
NORTRIPTYLINE HCL 10 MG PO CAPS,RX-5674,CDM,6370000000,HCPCS,0637,RC,51672-4001-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
ROD SPNL L450MM DIA6.35MM POST BILAT S STL SMOOTH STR,SUP-2255704,CDM,C1713,HCPCS,0278,RC,,,,both,,,1693.46,1100.75,,,,,,,,,,,,,
VALVE DRAINAGE 110 CM 3 PC SHUNT SYS SLD BA OSCV II LO PRO,SUP-2243848,CDM,C1729,HCPCS,0272,RC,,,,both,,,9378.40,6095.96,,,,,,,,,,,,,
TRIUNE VENT TUBE 135MM ID X 5MM LENGTH 80 DUROMETER 5 PACK,SUP-2669495,CDM,L8699,HCPCS,0278,RC,,,,both,,,49.46,32.15,,,,,,,,,,,,,
PLEDGET CV SAUVAGE L 15.2 X W 1 CM THK 0.61 MM POLYESTER,SUP-2761349,CDM,C1768,CPT,0278,RC,,,,both,,,511.16,332.25,,,,,,,,,,,,,
APPLICATOR TISS GLUE L15CM SIL EXT TIP DURA SEAL,SUP-2243106,CDM,C1713,HCPCS,0278,RC,,,,both,,,452.69,294.25,,,,,,,,,,,,,
"HC So Cmv, Congenital,Qaul Pcr, Saliva",PX-3068749667,CDM,87496,CPT,0306,RC,,,,inpatient,,,393.00,255.45,,,,,,,,,,,,,
CATHETER EMB SYNTEL L 40 CM DIA 4 FR INFLATED DIA 9 MM 0.75,SUP-2119456,CDM,C1757,HCPCS,0272,RC,,,,both,,,162.97,105.93,,,,,,,,,,,,,
JOINT WRST 1 LT RADIAL COCR MOLYBDENUM FRDM,SUP-2851944,CDM,C1776,CPT,0278,RC,,,,both,,,25281.62,16433.05,,,,,,,,,,,,,
SPACER KNEE M GENT IMPREG CEMEX PMMA CLASS PREFRM ARTC PART,SUP-2223693,CDM,C1776,CPT,0278,RC,,,,both,,,6908.00,4490.20,,,,,,,,,,,,,
TAPE FIBER CARCLAGE W/ TIGER LINK (ORDER MUTLIPLES OF 5 EACH),SUP-2749337,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1491.50,969.47,,,,,,,,,,,,,
VALVE CSF PROGRAMMABLE REG RT ANGLE W/O SIPHONGUARD HAKIM,SUP-2666512,CDM,C1889,HCPCS,0278,RC,,,,both,,,14668.20,9534.33,,,,,,,,,,,,,
PUNCH ARTHSCP OD34MM 90DEG L STR SHFT ROTARY TIP SER 1,SUP-2120932,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3124.30,2030.79,,,,,,,,,,,,,
HC So Hemoglobin,PX-3058501866,CDM,85018,CPT,0305,RC,,,,both,,,34.00,22.10,,,,,,,,,,,,,
SUPPORT ORTHOT WRST ELBW HND SHLDR ADJ AIRPLANE DESIGN,SUP-2435791,CDM,L3960,HCPCS,0274,RC,,,,both,,,2055.04,1335.78,,,,,,,,,,,,,
DEVICE ENDOSKELETAL SYS PROSTHETIC BK FORK STRP,SUP-2388211,CDM,L5684,HCPCS,0274,RC,,,,both,,,126.48,82.21,,,,,,,,,,,,,
CANN DRL BIT W/18MM DEPTH MARK 3.5MM,SUP-2816612,CDM,2720000010,LOCAL,0272,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
HC Arthrogram Hip S&I,PX-3227352500,CDM,73525,CPT,0322,RC,,,,outpatient,,,1013.00,658.45,,,,,,,,,,,,,
SPACER SPNL W28XH10XL33MM 8DEG PEEK ANT LUM INTBDY FUS LORD,SUP-2380526,CDM,C1889,HCPCS,0278,RC,,,,both,,,7159.20,4653.48,,,,,,,,,,,,,
CATHETER CV 3L 7 FRX20 CM KT STR J TIP,SUP-2383338,CDM,C1751,HCPCS,0278,RC,,,,both,,,278.05,180.73,,,,,,,,,,,,,
FIBER LASER W/ LITHO HOLM,SUP-2225710,CDM,2720000010,LOCAL,0272,RC,,,,both,,,496.12,322.48,,,,,,,,,,,,,
SYSTEM FIX DIA8-8.5MM FEM HRD SCR SHTH INTRAFIX,SUP-2256825,CDM,C1713,HCPCS,0278,RC,,,,both,,,2028.44,1318.49,,,,,,,,,,,,,
ASPIRATION NEEDLE 8GX23CM CLOSED TIP,SUP-2818024,CDM,2720000010,LOCAL,0272,RC,,,,both,,,918.45,596.99,,,,,,,,,,,,,
STEM HUM SZ 6C L86MM 137.5DEG ANG SH STD SHLDR PTC PRESSFIT,SUP-2388553,CDM,C1776,CPT,0278,RC,,,,both,,,11539.50,7500.67,,,,,,,,,,,,,
CATHETER CV SET 025 5 FRX12 CM 3L J TIP RIFAMPIN SPECTRUM,SUP-2759971,CDM,C1751,HCPCS,0278,RC,,,,both,,,370.08,240.55,,,,,,,,,,,,,
CUTTER TDC HIGH SPEED 25G DISP,SUP-2863701,CDM,2720000010,LOCAL,0272,RC,,,,both,,,730.93,475.10,,,,,,,,,,,,,
HC So Assay of Mercury Quantitative,PX-3018382566,CDM,83825,CPT,0301,RC,,,,both,,,135.00,87.75,,,,,,,,,,,,,
PLATE BNE VOLAR NAR SHT LT 3 HOLE ANAT STRL DVR,SUP-2462388,CDM,C1713,HCPCS,0278,RC,,,,both,,,2141.48,1391.96,,,,,,,,,,,,,
IMPLANT SPNL L65MM DIA7MM POR TI PLSM SPR SACROILIAC TRIANG,SUP-2337789,CDM,C1713,HCPCS,0278,RC,,,,both,,,9420.00,6123.00,,,,,,,,,,,,,
CATHETER DRNGE L40CM DIA22FR 0.038IN COAX L BOR CRV FOR,SUP-2168763,CDM,C1729,HCPCS,0272,RC,,,,both,,,221.24,143.81,,,,,,,,,,,,,
SEATING CHISEL FOR TODDLER OSTEOTOMY PLATES,SUP-2548624,CDM,C1713,HCPCS,0278,RC,,,,both,,,1286.08,835.95,,,,,,,,,,,,,
SYSTEM MENIS REP SUQUENT CRV NDL 4 IMPLANTS,SUP-2167208,CDM,C1713,HCPCS,0278,RC,,,,both,,,3638.57,2365.07,,,,,,,,,,,,,
HOLDER NDLE MAYO HEGAR 7NL STRGHT STBBY JAW LATEX FREE,SUP-2484870,CDM,C1713,HCPCS,0278,RC,,,,both,,,150.00,97.50,,,,,,,,,,,,,
CATHETER MAP 3 MM 7 FRX110 CM 15 MM INQUIRY AFOCUS II EB,SUP-2516512,CDM,C1731,HCPCS,0278,RC,,,,both,,,3227.92,2098.15,,,,,,,,,,,,,
CROWN DENT PED SZ DUR2 RT UP 1ST PRI M S STL REPL PRETRIMMED,SUP-2238870,CDM,D6783,CPT,0278,RC,,,,both,,,18.84,12.25,,,,,,,,,,,,,
IMPLANT UROLOGICAL 8 CM SCREW INSRT,SUP-2140252,CDM,C1713,HCPCS,0278,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
ACETAZOLAMIDE ER 500 MG PO CP12,RX-8962,CDM,6370000000,HCPCS,0637,RC,16729-0331-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
ALLOGRAFT BNE BLOCK 6.25X2X0.8 CM 10 CC CRBNT APATITE VENADO,SUP-2718021,CDM,C1713,HCPCS,0278,RC,,,,both,,,2563.56,1666.31,,,,,,,,,,,,,
FIBERTAK SHAVERDRILL 2.6MM,SUP-2812925,CDM,2720000010,LOCAL,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
PLATE BNE TBLR 2.7X57 MM 7 HOLE 1/4 TI,SUP-2536110,CDM,C1713,HCPCS,0278,RC,,,,both,,,435.20,282.88,,,,,,,,,,,,,
GRAFT BNE SPNL SPCR PARA CERV IMPL ALLGRFT L12XW145XH10MM,SUP-2264900,CDM,C1713,HCPCS,0278,RC,,,,both,,,2474.63,1608.51,,,,,,,,,,,,,
DOFETILIDE 125 MCG PO CAPS,RX-26965,CDM,6370000000,HCPCS,0637,RC,72205-0039-60,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
ANCHOR SUTURE KNOTLESS 2.9 MM PEEK OPTMA LINK CLEAT EYELET,SUP-2431668,CDM,C1713,HCPCS,0278,RC,,,,both,,,1491.50,969.47,,,,,,,,,,,,,
CAGE SPNL EXPANDABLE LG 0 DEG 30X10X12-18 MM,SUP-2737675,CDM,C1713,HCPCS,0278,RC,,,,both,,,15857.00,10307.05,,,,,,,,,,,,,
STEM FEM L150MM DIA11MM NEUT KNEE CO CHROM BOW CEM MOD SALV,SUP-2252628,CDM,C1776,CPT,0278,RC,,,,both,,,10386.96,6751.52,,,,,,,,,,,,,
SCREW BNE ST 2X7 MM LCK,SUP-2569629,CDM,C1713,HCPCS,0278,RC,,,,both,,,75.99,49.39,,,,,,,,,,,,,
BRACE THMB AD LNG POLYPR FELT LNR PERF SUEDE ALUM STAY V,SUP-2324405,CDM,L3931,HCPCS,0274,RC,,,,both,,,54.17,35.21,,,,,,,,,,,,,
COMPONENT KNEE RJP POROUS ATTUNE,SUP-2427743,CDM,C1776,CPT,0278,RC,,,,both,,,14731.81,9575.68,,,,,,,,,,,,,
SPONGE SCLER DIA5MM SIL RND BULK STYL 505,SUP-2213494,CDM,L8610,HCPCS,0278,RC,,,,both,,,166.42,108.17,,,,,,,,,,,,,
ACTIVATOR MRI HANDHELD RAD WAVE COMM,SUP-2356409,CDM,C1713,HCPCS,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
COMPONENT FEM SZ 6 NP RT KNEE PRI CRUC RET CEM STEMLESS,SUP-2349035,CDM,C1776,CPT,0278,RC,,,,both,,,8728.57,5673.57,,,,,,,,,,,,,
HC Pelvis Min 3 Views,PX-3207219000,CDM,72190,CPT,0320,RC,,,,both,,,513.00,333.45,,,,,,,,,,,,,
LEVEL CMF TMPLTE 50 799 28 XX ALMNM QT001 EA,SUP-2680247,CDM,C1713,HCPCS,0278,RC,,,,both,,,244.92,159.20,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP L125CM OD0035IN INTRO OD14FR STR TIP,SUP-2169710,CDM,C1769,HCPCS,0272,RC,,,,both,,,89.87,58.42,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.414,SUP-2859978,CDM,C1713,HCPCS,0278,RC,,,,both,,,33673.36,21887.68,,,,,,,,,,,,,
TUBE MYR 1.14MM DIAM VENT PAPARELLA,SUP-2313843,CDM,L8699,HCPCS,0278,RC,,,,both,,,51.62,33.55,,,,,,,,,,,,,
BAR EXTERNAL FIXATION L300MM DIA11MM XTRAFIX SYSTEM,SUP-2476763,CDM,2720000010,LOCAL,0272,RC,,,,both,,,672.71,437.26,,,,,,,,,,,,,
PLATE SPNL L27MM ANT CERV TI ALLY CNVGNT ATLNTS,SUP-2291073,CDM,C1713,HCPCS,0278,RC,,,,both,,,2768.73,1799.67,,,,,,,,,,,,,
SHEATH LASER L50CM OD12FR LD OD7.5FR TIP OD12.5FR ID8.3FR,SUP-2353106,CDM,C2629,CPT,0272,RC,,,,both,,,10440.50,6786.32,,,,,,,,,,,,,
SCREW SPNL L10MM DIA4MM MINI CANC POST OCCIPITAL CERV THOR,SUP-2256184,CDM,C1713,HCPCS,0278,RC,,,,both,,,3344.10,2173.66,,,,,,,,,,,,,
CATHETER DRAINAGE PIG 0.038 IN 8.5 FRX25 CM 7 HOLE UTHANE,SUP-2168244,CDM,C1729,HCPCS,0272,RC,,,,both,,,593.49,385.77,,,,,,,,,,,,,
SPLINT ORTH M HND THMS SUSP,SUP-2112602,CDM,L3807,HCPCS,0272,RC,,,,both,,,96.96,63.02,,,,,,,,,,,,,
CATHETER CV DL 6 FR PASV VLV MAX BARR NURSING KT BIOFLO,SUP-2734868,CDM,C1751,HCPCS,0278,RC,,,,both,,,162.02,105.31,,,,,,,,,,,,,
IMPLANT TOE SM DIA22MM WIRE DIA08MM FOR IO FIX SYS CANNULINK,SUP-2400043,CDM,C1776,CPT,0278,RC,,,,both,,,3689.50,2398.17,,,,,,,,,,,,,
INSERT TIB SZ 4 THK12MM RT FLX GMK SPHR,SUP-2267672,CDM,C1776,CPT,0278,RC,,,,both,,,1890.59,1228.88,,,,,,,,,,,,,
GRAFT STRUT CORT FEM STRUCTURAL ALLGRFT FRZ DRY 100MM LX20MM,SUP-2307185,CDM,C1713,HCPCS,0278,RC,,,,both,,,1702.60,1106.69,,,,,,,,,,,,,
ASCENSION RADFX PROX RAD FIX SYS 02 STD STEM,SUP-2244258,CDM,C1776,CPT,0278,RC,,,,both,,,10699.36,6954.58,,,,,,,,,,,,,
GUIDEWIRE ORTH L9IN DIA0.062IN SGL TRCR THRD S STL ACUTRK +,SUP-2107901,CDM,C1769,HCPCS,0272,RC,,,,both,,,185.26,120.42,,,,,,,,,,,,,
SHOULDER IMMOB VELPEAU ELAS XLG,SUP-2194409,CDM,L3650,HCPCS,0272,RC,,,,both,,,19.66,12.78,,,,,,,,,,,,,
CATHETER THROMCTMY PRODIGY TWST L 154 CM SHTH 5 FR STRL,SUP-2864592,CDM,C1757,HCPCS,0272,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
DRILL SURG DIA1.5MM MNL NONRADIOLUCENT W/O STP HPS,SUP-2319570,CDM,2720000010,LOCAL,0272,RC,,,,both,,,301.44,195.94,,,,,,,,,,,,,
PLATE BNE L98MM 6 H NONSTERILE L LAT PROX TIB LOK FOR 3.5MM,SUP-2348470,CDM,C1713,HCPCS,0278,RC,,,,both,,,9944.54,6463.95,,,,,,,,,,,,,
SUPPORT ORTHOT KNEE CUST ADJ POS RIGID SUPP PREFABRICATED,SUP-2435610,CDM,L1833,HCPCS,0272,RC,,,,both,,,1950.10,1267.56,,,,,,,,,,,,,
LINER ACET ID28MM E 0DEG HIP CONSTRN FOR A-SERIES ACUMATCH,SUP-2222086,CDM,C1776,CPT,0278,RC,,,,both,,,5934.60,3857.49,,,,,,,,,,,,,
SULFAMETHOXAZOLE-TRIMETHOPRIM 800-160 MG PO TABS,RX-11599,CDM,6370000000,HCPCS,0637,RC,57237-0233-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PLATE PROX TIB 3.5MM 6H RT STRL,SUP-2547547,CDM,C1713,HCPCS,0278,RC,,,,both,,,4238.62,2755.10,,,,,,,,,,,,,
PLATE BNE L MINI REG 1 MM RT W/O SPACE BTWN HOLE TI,SUP-2458089,CDM,C1713,HCPCS,0278,RC,,,,both,,,597.60,388.44,,,,,,,,,,,,,
NAIL IM L440MM DIA11MM 135DEG LNG LT FEM TI ALLOY CANN LCK,SUP-2371021,CDM,C1713,HCPCS,0278,RC,,,,both,,,5013.64,3258.87,,,,,,,,,,,,,
SCREW BNE CORT ANK FUS 4.0MMX46MM 6.0MM HD TIBIAXYS,SUP-2243003,CDM,C1713,HCPCS,0278,RC,,,,both,,,739.88,480.92,,,,,,,,,,,,,
PLATE BNE L 94 MM TI INTRATHORACIC PREBENT NS RIBFIX TITAN,SUP-2905460,CDM,C1713,HCPCS,0278,RC,,,,both,,,12710.72,8261.97,,,,,,,,,,,,,
COMPONENT TIB M THK8MM RT MEDL LT LAT KNEE UNI NONBEADED CEM,SUP-2364890,CDM,C1776,CPT,0278,RC,,,,both,,,4459.59,2898.73,,,,,,,,,,,,,
STAPLE INT STR 12X12 MM ASMBLY,SUP-2751333,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3652.92,2374.40,,,,,,,,,,,,,
GRAFT HUM TISS BIDIR 4X4 CM GRID PAT AMNIO MEMBRN BIOVANCE,SUP-2651377,CDM,Q4154,HCPCS,0636,RC,,,,both,,,6287.85,4087.10,,,,,,,,,,,,,
PROCESSOR HEARING AID SFT BLK FULL PROGRAMMABLE BP100 BAHA 3,SUP-2164958,CDM,L8691,HCPCS,0278,RC,,,,both,,,10676.00,6939.40,,,,,,,,,,,,,
CEMENT BONE 40GM FULL DOSE POLYMETHYLMETHACRYLATE W/O,SUP-2253082,CDM,C1713,HCPCS,0278,RC,,,,both,,,1134.17,737.21,,,,,,,,,,,,,
SET INSTR IMPL SCR DIA3MM CANN GRPHC CASES INSTR EXTR DEV,SUP-2183058,CDM,C1713,HCPCS,0278,RC,,,,both,,,74912.11,48692.87,,,,,,,,,,,,,
KIT PENILE PROS STD ASSEMB TI,SUP-2165367,CDM,C1813,HCPCS,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
CHLORPROMAZINE HCL 50 MG/2ML IJ SOLN,RX-131208,CDM,J3230,HCPCS,0250,RC,00641-1398-35,NDC,,both,0.4,ML,54.10,35.16,,,,,,,,,,,,,
CALIPER SURG SPNL CROSS CONN REVERE,SUP-2232146,CDM,C1713,HCPCS,0278,RC,,,,both,,,2446.06,1589.94,,,,,,,,,,,,,
WEDGE TIB SZ 2.5 THK16MM 10DEG MOD CEM FULL REV STP PFC SIG,SUP-2253295,CDM,C1776,CPT,0278,RC,,,,both,,,5199.84,3379.90,,,,,,,,,,,,,
SCREW BONE SHLDR ASMBLY AEQUALIS FLX REVIVE,SUP-2417739,CDM,C1713,HCPCS,0278,RC,,,,both,,,2697.26,1753.22,,,,,,,,,,,,,
TRAY CHST TUBE 32 FR TRCR TIP STR SFT 10.7 MM DIA 4,SUP-2168202,CDM,C1729,HCPCS,0272,RC,,,,both,,,634.28,412.28,,,,,,,,,,,,,
TUBE VENT SHEP GRMMT 1.02 MM 1.6 MM 2.3 MM W/ TAB FLROPLAS,SUP-2535128,CDM,L8699,HCPCS,0278,RC,,,,both,,,24.30,15.79,,,,,,,,,,,,,
STENT COR 23MM 3MM DEL SYS 145CM 0.014IN CO CHROM,SUP-2105455,CDM,C1874,HCPCS,0278,RC,,,,both,,,2225.26,1446.42,,,,,,,,,,,,,
SET PICC L 20CM DIA 5FR SHTH L 7CM DIA 5FR PR-32052-BAS,SUP-2887214,CDM,C1751,HCPCS,0278,RC,,,,both,,,308.35,200.43,,,,,,,,,,,,,
KIT ANCHOR SUTURE MINI 1.8 MM Q-FIX DISP,SUP-2341946,CDM,C1713,HCPCS,0278,RC,,,,both,,,545.01,354.26,,,,,,,,,,,,,
WEDGE TOE IMPL W20XH10XL20MM FT TI PEEK FOR EVANS OSTEOTMY,SUP-2417148,CDM,C1713,HCPCS,0278,RC,,,,both,,,5986.82,3891.43,,,,,,,,,,,,,
SUPPORT HD SECT FOR SPNL SURG JACK,SUP-2257072,CDM,C1713,HCPCS,0278,RC,,,,both,,,769.30,500.04,,,,,,,,,,,,,
INSERT ACET SZ P2 OD46-48MM ID28MM THK5MM 10DEG X FRE CO,SUP-2376204,CDM,C1776,CPT,0278,RC,,,,both,,,1166.98,758.54,,,,,,,,,,,,,
DRILL SRGCL TWIST HAND 11MM DIA 85MML F/BTTRY OPRTD SCRWDRV,SUP-2668855,CDM,2720000010,LOCAL,0272,RC,,,,both,,,775.74,504.23,,,,,,,,,,,,,
STEM FEM 12X220MM BOW LEGION,SUP-2349118,CDM,C1776,CPT,0278,RC,,,,both,,,6751.00,4388.15,,,,,,,,,,,,,
PLATE BNE L36MM THK1MM 2X6 H NONSTERILE CNDYL HND TI LOK VAR,SUP-2181007,CDM,C1713,HCPCS,0278,RC,,,,both,,,1648.15,1071.30,,,,,,,,,,,,,
PIN STEINMANN 2.8 MM,SUP-2817723,CDM,C1713,HCPCS,0278,RC,,,,both,,,109.90,71.43,,,,,,,,,,,,,
GRAFT VASC VENAFLO II L 30 CM DIA 7 MM EPTFE CARBON STR N,SUP-2761539,CDM,C1768,CPT,0278,RC,,,,both,,,1971.64,1281.57,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 8X3 CM TERMINALLY STRL WND NEOX CRD RT,SUP-2648700,CDM,Q4148,HCPCS,0636,RC,,,,both,,,7536.00,4898.40,,,,,,,,,,,,,
PLATE STRNL SM 10 H TI LADDER NS MATRIXSTERNUM,SUP-2904249,CDM,C1713,HCPCS,0278,RC,,,,both,,,2740.15,1781.10,,,,,,,,,,,,,
IMPLANT HUM TISS W61-150MMXL6-15CM PERICARD FRZ DRY,SUP-2307107,CDM,C1762,CPT,0278,RC,,,,both,,,2037.26,1324.22,,,,,,,,,,,,,
WIRE BNE FIX DIA1.6 MM SMTH NS LEOS KIRSCHNER,SUP-2931299,CDM,C1713,HCPCS,0278,RC,,,,both,,,117.75,76.54,,,,,,,,,,,,,
SCREW BONE L10MM OD2.5MM MIC TI ST SELF DRL CANN COMPR HDLSS,SUP-2321405,CDM,C1713,HCPCS,0278,RC,,,,both,,,700.06,455.04,,,,,,,,,,,,,
HEAD HUM H18.75MM DIA50MM CO CHROM ALLY BPLR STD OFFSET REV,SUP-2193861,CDM,C1776,CPT,0278,RC,,,,both,,,8962.82,5825.83,,,,,,,,,,,,,
NEXGEN LCCK FEMORAL SIZE E-LT,SUP-2503327,CDM,C1776,CPT,0278,RC,,,,both,,,15448.80,10041.72,,,,,,,,,,,,,
PLATE FEM DIST LAT 20 HL 414MM RT,SUP-2705053,CDM,C1713,HCPCS,0278,RC,,,,both,,,10104.52,6567.94,,,,,,,,,,,,,
GUIDEWIRE VASC L 180 CM DIA 0.035 IN PTFE,SUP-2147061,CDM,C1769,HCPCS,0272,RC,,,,both,,,45.91,29.84,,,,,,,,,,,,,
SLING GYN L 45 X W 1.1 CM POLYPRO MONOFILAMENT WRP,SUP-2929631,CDM,C1771,HCPCS,0278,RC,,,,both,,,3215.36,2089.98,,,,,,,,,,,,,
ALLOGRAFT BNE CHIP 1-4 MM 15 CC CRUSH CANC,SUP-2435351,CDM,C1889,HCPCS,0278,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
LG OATS HARVSTR 14,SUP-2812478,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1410.17,916.61,,,,,,,,,,,,,
LEAD NEUROSTIMULATOR REACTIV8 L 45 CM SUTURE SLV STRL,SUP-2877967,CDM,C1730,HCPCS,0272,RC,,,,both,,,8656.98,5627.04,,,,,,,,,,,,,
NAIL IM L340MM DIA10MM THK1.5MM 1.5M CURVATURE RAD UNIV FEM,SUP-2186405,CDM,C1713,HCPCS,0278,RC,,,,both,,,3674.27,2388.28,,,,,,,,,,,,,
MESH BIOLOGIC OVINE RUMEN PERM OVITEX 1S 20X20CM,SUP-2383097,CDM,C1781,HCPCS,0278,RC,,,,both,,,22608.00,14695.20,,,,,,,,,,,,,
SHEATH INTRO 30 DEG L 60 CM DIA 9.5 FR CRV,SUP-2141303,CDM,C1894,HCPCS,0272,RC,,,,both,,,675.10,438.81,,,,,,,,,,,,,
BASKET SPEC RETRV 7 FR 1.5X3.5 CM FOR REMOVAL BILI STONE MEM,SUP-2422798,CDM,2720000010,LOCAL,0272,RC,,,,both,,,838.38,544.95,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 280 MM DIA15 MM DEL SHTH,SUP-2934434,CDM,C1713,HCPCS,0278,RC,,,,both,,,20211.65,13137.57,,,,,,,,,,,,,
SLEEVE IM RESRB FOR 5MM ANGULAR STBL LOK SCR,SUP-2182837,CDM,C1713,HCPCS,0278,RC,,,,both,,,563.66,366.38,,,,,,,,,,,,,
TIP SUCT L45CM OD5MM J TIP REPOSABLE STRYKEPROBE,SUP-2361205,CDM,2720000010,LOCAL,0272,RC,,,,both,,,864.94,562.21,,,,,,,,,,,,,
STABILIT MX FRACTURE KIT WITH POWERCURVE SHRT,SUP-2701994,CDM,2720000010,LOCAL,0272,RC,,,,both,,,9548.58,6206.58,,,,,,,,,,,,,
COUPLER MULTDIR SPNL TI OMEGA 21,SUP-2414707,CDM,C1713,HCPCS,0278,RC,,,,both,,,1909.62,1241.25,,,,,,,,,,,,,
PATCH HERN L DIA4.5IN UNCOATED MFIL PROPYLENE CIR ABSRB,SUP-2125895,CDM,C1781,HCPCS,0278,RC,,,,both,,,1791.06,1164.19,,,,,,,,,,,,,
PLATE BNE RECTANGULAR 1.5X38X45X0.6 MM MESH RIGID TI NS,SUP-2191100,CDM,C1713,HCPCS,0278,RC,,,,both,,,4384.07,2849.65,,,,,,,,,,,,,
RELOAD STPL 3.5MM L60MM 0DEG UNIV TISS PUR TI 6 ROW LIN,SUP-2283264,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1238.13,804.78,,,,,,,,,,,,,
SCREW INTRF L20MM DIA7MM TI CANN SOFTSILK FOR 1MM GWIRE,SUP-2340726,CDM,C1713,HCPCS,0278,RC,,,,both,,,638.42,414.97,,,,,,,,,,,,,
WIRE FIX 1.6X150 MM W/STP KIRSCHNER VARIAX,SUP-2435340,CDM,2720000010,LOCAL,0272,RC,,,,both,,,396.27,257.58,,,,,,,,,,,,,
CATHETER TRROMBECTORY TRUVIC PRODIGY 6F,SUP-2855181,CDM,C1751,HCPCS,0278,RC,,,,both,,,10048.00,6531.20,,,,,,,,,,,,,
JIG SURG RT TIB KNEE AREF ROT PT SPEC DISP PERSONA,SUP-2205589,CDM,2720000010,LOCAL,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
PROSTHESIS OSSCLR TOTAL 2MM/2.5MM DIA HEAD 0.8MM DIA DST END,SUP-2493782,CDM,L8613,CPT,0278,RC,,,,both,,,1191.44,774.44,,,,,,,,,,,,,
SPHERE EMB ONCOZENE DIA 75 UM 3 ML HYDRGEL POLYZENE MIC WHT,SUP-2139506,CDM,C1889,HCPCS,0278,RC,,,,both,,,13188.00,8572.20,,,,,,,,,,,,,
SUTURE ULTRATAPE SZ 2 NONABSORBABLE BLU 72203896,SUP-2341898,CDM,C1713,HCPCS,0278,RC,,,,both,,,210.73,136.97,,,,,,,,,,,,,
DEXTROSE 10% IV BOLUS (PEDS),RX-4085020,CDM,2580000003,HCPCS,0250,RC,63323-0824-76,NDC,,both,1000,ML,51.00,33.15,,,,,,,,,,,,,
STENT BILI S.M.A.R.T. L 20 MM DIA10 MM CATH L 120 CM NIT,SUP-2158890,CDM,C1876,HCPCS,0278,RC,,,,both,,,3231.06,2100.19,,,,,,,,,,,,,
LENS IOL TORIC MX60ETE125 20.0D,SUP-2423521,CDM,V2632,HCPCS,0276,RC,,,,both,,,1491.50,969.47,,,,,,,,,,,,,
PLATE BNE FEM 3.5/4.5X320 MM RT PROX 10 HOLE NS VA-LCP,SUP-2757664,CDM,C1713,HCPCS,0278,RC,,,,both,,,7849.75,5102.34,,,,,,,,,,,,,
SAW SURG STRGHT OSCLLTNG REMOVABLE LEVER FLFSMLL BNE MICROPO,SUP-2605589,CDM,2720000010,LOCAL,0272,RC,,,,both,,,9083.05,5903.98,,,,,,,,,,,,,
CATHETER GUID CROSSCATH L 150 MM DIA PROX/DSTL 4.8/3.7,SUP-2170841,CDM,C1887,HCPCS,0272,RC,,,,both,,,441.39,286.90,,,,,,,,,,,,,
GUIDEWIRE ENDO L145CM 0.038IN INJ LUMENATOR,SUP-2141748,CDM,C1769,HCPCS,0272,RC,,,,both,,,177.19,115.17,,,,,,,,,,,,,
PLATE 3.5MM TI LCP PROXIMAL TIBIA LOW BEND 16H 232MM RT STER,SUP-2546876,CDM,C1713,HCPCS,0278,RC,,,,both,,,5197.67,3378.49,,,,,,,,,,,,,
SYSTEM DRNGE W/ INTLNK NDLLSS INJ SITE DUET,SUP-2284564,CDM,2720000010,LOCAL,0272,RC,,,,both,,,420.38,273.25,,,,,,,,,,,,,
COIL NEUROVASCULAR TARGET XL L 50 CM DIA12 MM,SUP-2368039,CDM,C1889,HCPCS,0278,RC,,,,both,,,5829.41,3789.12,,,,,,,,,,,,,
BUMPER KNEE REV HINGE NEUT STRL TRIATHLON,SUP-2890083,CDM,C1776,CPT,0278,RC,,,,both,,,2959.45,1923.64,,,,,,,,,,,,,
PREDNISOLONE SODIUM PHOSPHATE 1 % OP SOLN,RX-6489,CDM,6370000000,HCPCS,0637,RC,24208-0715-10,NDC,,both,0.05,ML,2.70,1.75,,,,,,,,,,,,,
PLATE BNE TI MIDFACE RECON 2 PLATE CUSTOMIZED FACE ID,SUP-2883365,CDM,C1713,HCPCS,0278,RC,,,,both,,,34299.38,22294.60,,,,,,,,,,,,,
SYSTEM ABLAT CARD SURG BPLR TRANSMURALITY PEN CARDIOBLATE,SUP-2278865,CDM,2720000010,LOCAL,0272,RC,,,,both,,,10974.30,7133.29,,,,,,,,,,,,,
BLADE BNE MILL L3.2MM SPNL FN,SUP-2367527,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
MARKER BRST BX XR SITE CLP,SUP-2128487,CDM,A4648,CPT,0278,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
GUIDEWIRE VASC ARW L 68 CM DIA 0.035 IN SS PERIPH SFT,SUP-2383363,CDM,C1769,HCPCS,0272,RC,,,,both,,,31.53,20.49,,,,,,,,,,,,,
SCREW BNE L12MM DIA3.5MM STD CORT DST TIB TI ST LOK FULL,SUP-2413561,CDM,C1713,HCPCS,0278,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
SPACER THMB CMC 20MMX14MMX14MM L ARTELON,SUP-2361862,CDM,C1776,CPT,0278,RC,,,,both,,,5642.58,3667.68,,,,,,,,,,,,,
INSERT TIB CR 67X10 MM KNEE PRIMARY BEAR MAXM VI,SUP-2404013,CDM,C1776,CPT,0278,RC,,,,both,,,2332.39,1516.05,,,,,,,,,,,,,
X-CLIP FIX L20MM DIA5.5MM ARTH FOR CHARCOT DEFORMITY AXIS,SUP-2223943,CDM,C1713,HCPCS,0278,RC,,,,both,,,4239.00,2755.35,,,,,,,,,,,,,
CHP TITAN 135 LNGTH 16 THD,SUP-2818366,CDM,C1713,HCPCS,0278,RC,,,,both,,,2567.61,1668.95,,,,,,,,,,,,,
MATRIX HUM TISS L 6 X W 7 CM THK 0.2-1 MM ACELLULAR DERMAL,SUP-2909281,CDM,Q4122,HCPCS,0636,RC,,,,both,,,9198.63,5979.11,,,,,,,,,,,,,
CATHETER THROMCTMY 4.5 MM REVIVE PV,SUP-2530214,CDM,C1757,HCPCS,0272,RC,,,,both,,,6609.70,4296.30,,,,,,,,,,,,,
NAIL IM 12X170 MM SUPCNDYL FEM T2,SUP-2361803,CDM,C1713,HCPCS,0278,RC,,,,both,,,9026.56,5867.26,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL PEEK SD800.513,SUP-2860195,CDM,C1713,HCPCS,0278,RC,,,,both,,,27657.43,17977.33,,,,,,,,,,,,,
AUGMENT FEM L54MM THICKNESS 5MM UNIV STD DSTL KNEE PRI CEM,SUP-2199916,CDM,C1776,CPT,0278,RC,,,,both,,,5935.86,3858.31,,,,,,,,,,,,,
CLAMP PIN 105MMXTRAFIX,SUP-2205435,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2030.80,1320.02,,,,,,,,,,,,,
TROCAR ENDOPATH BASX BLDELSS W STBL SL 12MMX100MM DISPOSABLE,SUP-2220020,CDM,2720000010,LOCAL,0272,RC,,,,both,,,440.10,286.06,,,,,,,,,,,,,
MIXER BNE CEM 40GM MAX CAP SGL MIX OPTVAC VAC SYS,SUP-2216857,CDM,C1713,HCPCS,0278,RC,,,,both,,,432.69,281.25,,,,,,,,,,,,,
IMPLANT TOE JT L16MM DIA4MM BLDE W5XL7.85IN 0DEG S STL THRD,SUP-2397823,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1080.16,702.10,,,,,,,,,,,,,
PACEMAKER CARD MERID SR 10.5 CC TI POLYUR SINGLE CHMBR IS1,SUP-2148595,CDM,C1786,HCPCS,0275,RC,,,,both,,,8148.30,5296.39,,,,,,,,,,,,,
STRUT FEM CORT TRAD ALLGRFT 60 MM 4 EA FRZ DRY,SUP-2294113,CDM,C1713,HCPCS,0278,RC,,,,both,,,6430.72,4179.97,,,,,,,,,,,,,
BAND ANNULPLSTY COSGROVE-EDWARDS SZ 38 MM L 83.1 MM OD 45.6,SUP-2214203,CDM,C1713,HCPCS,0278,RC,,,,both,,,8446.60,5490.29,,,,,,,,,,,,,
SCREW EXT FIX L14MM FOR DISTRCTN,SUP-2359062,CDM,C1713,HCPCS,0278,RC,,,,both,,,113.04,73.48,,,,,,,,,,,,,
SYSTEM ANCHOR 4.75 BC LOOP N TRACK,SUP-2717578,CDM,C1776,CPT,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
PLATE BNE L141MM 12 H BILAT S STL STR RECON NONLOCKING,SUP-2197677,CDM,C1713,HCPCS,0278,RC,,,,both,,,1231.60,800.54,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH ALPHA L 117 MM DIA 38 MM SHTH 18 FR,SUP-2170242,CDM,C1874,HCPCS,0278,RC,,,,both,,,49612.00,32247.80,,,,,,,,,,,,,
SCREW BNE 2X11 MM SELF COMPRESSIVE DYNAFIT,SUP-2610274,CDM,C1713,HCPCS,0278,RC,,,,both,,,1070.74,695.98,,,,,,,,,,,,,
RING ID190MM 2 3 RADLUC,SUP-2316273,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2770.48,1800.81,,,,,,,,,,,,,
SET INSTR W/ GWIRE DRL BIT COUNTSINK SL SCRDRIVER SHFT MEAS,SUP-2183057,CDM,C1713,HCPCS,0278,RC,,,,both,,,39611.01,25747.16,,,,,,,,,,,,,
PLATE BONE L165MM 8 H LT LAT PROX TIB S STL LCK FOR 4.5MM,SUP-2348223,CDM,C1713,HCPCS,0278,RC,,,,both,,,12777.13,8305.13,,,,,,,,,,,,,
MODIFIED MAXDRIVE SCREW TENTING STYLE 15 X 5MM 5/PKG,SUP-2669679,CDM,C1713,HCPCS,0278,RC,,,,both,,,287.56,186.91,,,,,,,,,,,,,
PIN FIX APEX HALF STD 5X150MM,SUP-2363229,CDM,2720000010,LOCAL,0272,RC,,,,both,,,361.76,235.14,,,,,,,,,,,,,
SUPPORT ORTHOPEDIC SLIP ON SM AD 7.5 IN WRST COMFORTFORM,SUP-2197051,CDM,L3931,HCPCS,0274,RC,,,,both,,,42.77,27.80,,,,,,,,,,,,,
SCREW BONE L6MM DIA2MM MAND SLV NONLOCKINGXDRIVE FOR LORENZ,SUP-2136746,CDM,C1713,HCPCS,0278,RC,,,,both,,,166.42,108.17,,,,,,,,,,,,,
DRILL SURG FOR KNOTLESS SUTURETAK VERY HRD BONE,SUP-2121609,CDM,C1776,CPT,0278,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
CATHETER CARD ABLATION LASSO 2515 NAV ECO L 115CM SPC2-6-2MM,SUP-2248612,CDM,C1732,HCPCS,0272,RC,,,,both,,,4939.22,3210.49,,,,,,,,,,,,,
IMPLANT COSMETIC SZ 110 X 97.5 X 5.25 MM POLYETHYL CRAN WFL,SUP-2936211,CDM,C1713,HCPCS,0278,RC,,,,both,,,15552.42,10109.07,,,,,,,,,,,,,
NAIL IM L34CM OD10MM 130DEG S STL HIP R LOK CANN,SUP-2343923,CDM,C1713,HCPCS,0278,RC,,,,both,,,5830.98,3790.14,,,,,,,,,,,,,
BIT DRL L33MM LNG G FOR 32MM HDLSS COMPR SCR DARCO,SUP-2400360,CDM,2720000010,LOCAL,0272,RC,,,,both,,,452.16,293.90,,,,,,,,,,,,,
CATHETER ELECHEMSTAS 10FR L300CM WRK CHN 3.7MM STD PLUG,SUP-2149700,CDM,2720000010,LOCAL,0272,RC,,,,both,,,394.38,256.35,,,,,,,,,,,,,
GRAFT VASC EXXCEL SFT L 40 CM DIA 6 MM EPTFE STR TW STRL,SUP-2227653,CDM,C1768,CPT,0278,RC,,,,both,,,1251.04,813.18,,,,,,,,,,,,,
HC Allo Cryo Infusion,PX-3623824001,CDM,38240,CPT,0362,RC,,,,both,,,1411.00,917.15,,,,,,,,,,,,,
PLATE BNE MESH PANEL 1/1.5X85X54X0.2 MM SCRN TI NS LEVEL 1,SUP-2496233,CDM,C1713,HCPCS,0278,RC,,,,both,,,1649.94,1072.46,,,,,,,,,,,,,
SCREW CORT NON-LOCKING 90 DEG 3.8 MMX38.0 MM S3 PROX HUM,SUP-2137573,CDM,C1713,HCPCS,0278,RC,,,,both,,,6.34,4.12,,,,,,,,,,,,,
SCREW BNE COMPR 3X32 MM MULT USE,SUP-2397494,CDM,C1713,HCPCS,0278,RC,,,,both,,,800.70,520.45,,,,,,,,,,,,,
PLATE BNE RECON 3.5X130 MM 10 HOLE LCK LP SS NS,SUP-2184030,CDM,C1713,HCPCS,0278,RC,,,,both,,,2329.47,1514.16,,,,,,,,,,,,,
BRACE ORTHOPEDIC PADDED UNIV ANK STIRRUP,SUP-2306212,CDM,L4350,HCPCS,0272,RC,,,,both,,,75.05,48.78,,,,,,,,,,,,,
HANDPIECE ENDO L35CM DIA5MM THUNDERBEAT FR ACTUATED GRP,SUP-2313548,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1350.20,877.63,,,,,,,,,,,,,
CATHETER PTCA 3.7FR L80CM DURALYN BLLN L2CM DIA6MM GUID 6FR,SUP-2156712,CDM,C1725,HCPCS,0272,RC,,,,both,,,1111.56,722.51,,,,,,,,,,,,,
CIPROFLOXACIN HCL 0.3 % OP SOLN,RX-9610,CDM,6370000000,HCPCS,0637,RC,61314-0656-25,NDC,,both,2.5,ML,47.30,30.74,,,,,,,,,,,,,
ALLOGRAFT BNE 90XX22X5 MM,SUP-2138662,CDM,C1889,HCPCS,0278,RC,,,,both,,,8164.00,5306.60,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH L 124 MM DIA26 MM SHTH 20 FR RVD 21-22,SUP-2170126,CDM,C1768,CPT,0278,RC,,,,both,,,32910.34,21391.72,,,,,,,,,,,,,
INSERTER SURGICAL 30X10X10MM 4 LEG INLINE PRELOADED DYNACLIP,SUP-2878201,CDM,C1713,HCPCS,0278,RC,,,,both,,,10440.50,6786.32,,,,,,,,,,,,,
PFC*MOD PL TB WDG STP-10MM SZ5,SUP-2515663,CDM,C1776,CPT,0278,RC,,,,both,,,3759.21,2443.49,,,,,,,,,,,,,
HEAD FEM PRI MTL ON MTL CO CHROM 28MM DIA +3 NK LEN,SUP-2404247,CDM,C1776,CPT,0278,RC,,,,both,,,3538.78,2300.21,,,,,,,,,,,,,
CATHETER ATHRCTMY JETSTREAM SC L 145 CM DIA 7 FR TIP DIA1.6,SUP-2148528,CDM,C1724,HCPCS,0278,RC,,,,both,,,16808.42,10925.47,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 8X240 MM FRZN ASEP POST TIBIALIS TEND,SUP-2866982,CDM,C1762,CPT,0278,RC,,,,both,,,4509.04,2930.88,,,,,,,,,,,,,
RING FIX 21-24IN CIRC M OPN BK BAIL HALO,SUP-2328127,CDM,L0859,HCPCS,0274,RC,,,,both,,,4408.56,2865.56,,,,,,,,,,,,,
PROBE SURG KARLIN 9.5 IN LUMBAR SQ HNDL M-DISC,SUP-2475655,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1071.18,696.27,,,,,,,,,,,,,
ANCHOR SUTURE 4MM KNOTLESS BIOCOMPOSITE WITH ONE 2MM HI FI B,SUP-2824390,CDM,C1713,HCPCS,0278,RC,,,,both,,,2144.93,1394.20,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 50 CM DIA 6 MM HELIX SLDE GDS,SUP-2525461,CDM,C1768,CPT,0278,RC,,,,both,,,1968.43,1279.48,,,,,,,,,,,,,
GUIDEWIRE ORTH DIA1.4MM S STL DISP PK FOR MINIMAL INVASIVE,SUP-2259523,CDM,C1769,HCPCS,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
KIT INTRO L 14 CM DIA10 FR GUIDEWIRE L 50 CM DIA 0.038 IN,SUP-2125278,CDM,C1894,HCPCS,0272,RC,,,,both,,,103.34,67.17,,,,,,,,,,,,,
SCREW BNE HD 5X22.5 MM CORTICAL DYNANAIL,SUP-2277460,CDM,C1713,HCPCS,0278,RC,,,,both,,,1774.10,1153.16,,,,,,,,,,,,,
SYSTEM SEAL 5ML SPINE DURA FOR CRAN SURG DURASEAL,SUP-2243096,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2553.57,1659.82,,,,,,,,,,,,,
LEAD DEFIB SPRNT QUATTRO SECUR S MRI SURESCAN L 72 CM DIA,SUP-2282267,CDM,C1895,HCPCS,0275,RC,,,,both,,,8258.20,5367.83,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA IR 3FR 55CM 1 LUMA S3173355,SUP-2632835,CDM,C1751,HCPCS,0278,RC,,,,both,,,382.73,248.77,,,,,,,,,,,,,
PLATE BNE L49MM THK3.3MM 4 H BILAT S STL RIG STR DYN COMPR,SUP-2186328,CDM,C1713,HCPCS,0278,RC,,,,both,,,853.83,554.99,,,,,,,,,,,,,
ROD EXT FIX L 100 MM DIA11 MM LG CARBON FIBRE MR CONDITIONAL,SUP-2908429,CDM,2720000010,LOCAL,0272,RC,,,,both,,,749.05,486.88,,,,,,,,,,,,,
TAP SURG SCR CANN JONES FIX INSTR 65MM,SUP-2398107,CDM,C1713,HCPCS,0278,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
BRACE KNEE 2XL POPLITEAL FAB W ADV STRTCH POLYCENTRIC HNG,SUP-2276698,CDM,L1810,HCPCS,0274,RC,,,,both,,,391.34,254.37,,,,,,,,,,,,,
ALLOGRAFT BNE STRUT SEG FD RAD,SUP-2321898,CDM,C1713,HCPCS,0278,RC,,,,both,,,1836.90,1193.98,,,,,,,,,,,,,
LEVEL CMF ST PLATE MDFCE STR WTAB 1.5 MM SCRW24 HOLE 108 MM,SUP-2677639,CDM,C1713,HCPCS,0278,RC,,,,both,,,1111.56,722.51,,,,,,,,,,,,,
ROD EXT FIX 250X9.5 MM ALUM VISION,SUP-2517870,CDM,2720000010,LOCAL,0272,RC,,,,both,,,621.72,404.12,,,,,,,,,,,,,
HC So Culture Virus,PX-3068725566,CDM,87255,CPT,0306,RC,,,,both,,,84.00,54.60,,,,,,,,,,,,,
PLATE BNE SCREW DIA2.7 MM PATELLAR STAGGERED STRL EVOS,SUP-2932873,CDM,C1713,HCPCS,0278,RC,,,,both,,,8835.96,5743.37,,,,,,,,,,,,,
MESH HERN W4XL6IN ELLIPSE W/ ECHO PS POS SYS VENTRALIGHT ST,SUP-2125914,CDM,C1781,HCPCS,0278,RC,,,,both,,,1397.30,908.24,,,,,,,,,,,,,
ANCHOR SUT DIA3.5MM SZ 2 ETHBND PANALOK ABSRB,SUP-2249321,CDM,C1713,HCPCS,0278,RC,,,,both,,,995.38,647.00,,,,,,,,,,,,,
CATHETER CRICO L7.5CM DIA6MM UNCUF AIRWY RADPQ ACCS,SUP-2168034,CDM,C1769,HCPCS,0272,RC,,,,both,,,777.46,505.35,,,,,,,,,,,,,
PLATE BNE 3D PRNT SM MIDFACE MAND TI TRUMATCH,SUP-2860366,CDM,C1713,HCPCS,0278,RC,,,,both,,,19313.83,12553.99,,,,,,,,,,,,,
SEGMENT FEM COMP M SZ 3 W65XH50MM LT DSTL TILASTAN,SUP-2265083,CDM,C1776,CPT,0278,RC,,,,both,,,4788.50,3112.52,,,,,,,,,,,,,
STRIPS ILIUM TRICORT TRAD ALLGRFT 22X55 MM FRZ DRY,SUP-2294073,CDM,C1713,HCPCS,0278,RC,,,,both,,,5890.64,3828.92,,,,,,,,,,,,,
TRIAL SPACER LG FEM MOLD SURESPACE,SUP-2433927,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
HC So Hsv Amplified Probe,PX-3068752966,CDM,87529,CPT,0306,RC,,,,inpatient,,,498.00,323.70,,,,,,,,,,,,,
SCREW BONE L80MM OD6.5MM STD CANC NONCANNULATED NONLOCKING,SUP-2343750,CDM,C1713,HCPCS,0278,RC,,,,both,,,58.91,38.29,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED POROUS STEJH2] STRYKER CORP],SUP-2365935,CDM,C1776,CPT,0278,RC,,,,both,,,14211.64,9237.57,,,,,,,,,,,,,
BALL CARPAL WRIST MED NEUT,SUP-2696157,CDM,C1776,CPT,0278,RC,,,,both,,,3346.93,2175.50,,,,,,,,,,,,,
SUPPORT ORTHOT KNEE CUST ADJACENT W/AIR CHMBR,SUP-2435615,CDM,L1847,HCPCS,0272,RC,,,,both,,,1628.40,1058.46,,,,,,,,,,,,,
PRISMASATE BGK 4/0/1.2 DIALYSIS SOLUTION,RX-40850037,CDM,2500000003,HCPCS,0250,RC,09999-9907-68,NDC,,both,5000,ML,103.50,67.27,,,,,,,,,,,,,
SCREW SPNL EMGCY 3.1X13 MM LCK MAXDRIVE,SUP-2470622,CDM,C1713,HCPCS,0278,RC,,,,both,,,488.27,317.38,,,,,,,,,,,,,
MESH HERNIAXL W8XL10IN INTRAABDOMINAL POLYPR OBLONG OVL,SUP-2265988,CDM,C1781,HCPCS,0278,RC,,,,both,,,3548.20,2306.33,,,,,,,,,,,,,
INSERT TOE 01 25MM OFFSET THK36MM MOD HEMICAPDF P,SUP-2123620,CDM,C1776,CPT,0278,RC,,,,both,,,9633.52,6261.79,,,,,,,,,,,,,
GRAFT BLK CERV CORT ALLGRFT 6MMX14MMX11MM,SUP-2289234,CDM,C1713,HCPCS,0278,RC,,,,both,,,2815.80,1830.27,,,,,,,,,,,,,
AGENT HEMSTAT W6XL9IN OXIDIZED REGENERATED CELOS ABSRB FOR,SUP-2218187,CDM,2720000010,LOCAL,0272,RC,,,,both,,,400.95,260.62,,,,,,,,,,,,,
SCREW SPNL MULTAXL 5X20 MM 6.35 MM PEDCL FOR ROD RED LEG,SUP-2288979,CDM,C1713,HCPCS,0278,RC,,,,both,,,2088.10,1357.26,,,,,,,,,,,,,
MESH SURG W26XL34CM THK1MM EPTFE CORDUROY SURF CNFRM TEXT,SUP-2395336,CDM,C1781,HCPCS,0278,RC,,,,both,,,6314.54,4104.45,,,,,,,,,,,,,
HAMMERTOE IMPL SZ 2,SUP-2397609,CDM,C1776,CPT,0278,RC,,,,both,,,2031.58,1320.53,,,,,,,,,,,,,
GRAFT HUM TISS W20XL100MM CORT BONE FEM STRP FRZ DRY,SUP-2115984,CDM,C1776,CPT,0278,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
BIT DRL TWST 40 MM 2.2X85 MM 35 MM FLUT W/ STP NOTCH LEVEL 1,SUP-2485268,CDM,2720000010,LOCAL,0272,RC,,,,both,,,632.96,411.42,,,,,,,,,,,,,
GRAFT VASC HEMSHLD GLD L 15 CM DIA 8 MM POLYESTER BOV CLLGN,SUP-2476065,CDM,C1768,CPT,0278,RC,,,,both,,,1182.37,768.54,,,,,,,,,,,,,
COLLAR PREMIER PRO CERV UNIV ADJ CLS CELL FOAM LNR L TRACH,SUP-2336010,CDM,L0140,HCPCS,0274,RC,,,,both,,,14.10,9.16,,,,,,,,,,,,,
VALVE PRESSURE PROGRAMMABLE 100MM H2O + OR MINUS 10MM H2O,SUP-2666798,CDM,C1889,HCPCS,0278,RC,,,,both,,,3386.08,2200.95,,,,,,,,,,,,,
MOLD CEM SPCR DIA70MM UNIV TIB SIL CRUCE SACRIFICING AGC,SUP-2408627,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1777.24,1155.21,,,,,,,,,,,,,
HANDPIECE BX INTRO 9GA NDL L14CM APER L20MM FOR MRI GUID,SUP-2239994,CDM,2720000010,LOCAL,0272,RC,,,,both,,,873.23,567.60,,,,,,,,,,,,,
HC So2 Anti Striated Antibody,PX-3028625568,CDM,86255,CPT,0302,RC,,,,outpatient,,,55.00,35.75,,,,,,,,,,,,,
SCREW BNE L10MM OD4MM STD TI CANC CORT ST SELF DRL CANN,SUP-2374501,CDM,C1713,HCPCS,0278,RC,,,,both,,,811.38,527.40,,,,,,,,,,,,,
PEG FIX LCK 2.5X12 MM PART THRD STRL,SUP-2457660,CDM,C1713,HCPCS,0278,RC,,,,both,,,276.32,179.61,,,,,,,,,,,,,
GUIDEWIRE ORTH L6IN DIA0.054IN S STL SGL TRCR FOR ACU-LOC 2,SUP-2107894,CDM,C1769,HCPCS,0272,RC,,,,both,,,8.04,5.23,,,,,,,,,,,,,
ANCHOR SUT OD5MM PLLA ABSRB TWO SZ 2 PRELD DURABRAID NDL,SUP-2341653,CDM,C1713,HCPCS,0278,RC,,,,both,,,1134.17,737.21,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY L 115 CM DIA 7 FR TIP 4 MM SPC 2,SUP-2248699,CDM,C1730,HCPCS,0272,RC,,,,both,,,2157.18,1402.17,,,,,,,,,,,,,
SEALANT TISS 10 ML FIBRIN VISTASEAL,SUP-2423173,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1562.65,1015.72,,,,,,,,,,,,,
SCREW BNE CANN 3X20 MM TC-SERIES LP TI TI6,SUP-2609870,CDM,C1713,HCPCS,0278,RC,,,,both,,,1020.85,663.55,,,,,,,,,,,,,
GUIDEPIN SURG L11IN OD2.4MM TRCR TIP PASS W/ EYELET FOR,SUP-2341318,CDM,2720000010,LOCAL,0272,RC,,,,both,,,393.91,256.04,,,,,,,,,,,,,
GUIDEWIRE VASC L 180 CM DIA 0.021 IN TAPR L 7 CM FLPY TIP L,SUP-2167769,CDM,C1769,HCPCS,0272,RC,,,,both,,,53.29,34.64,,,,,,,,,,,,,
NAPROXEN SODIUM 550 MG PO TABS,RX-5395,CDM,6370000000,HCPCS,0637,RC,43598-0495-01,NDC,,both,1,UN,3.40,2.21,,,,,,,,,,,,,
COUPLER EXT FIX ROD TO TB COMPR DISTR COMP SYS HOFFMANN II,SUP-2372254,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
BLADE RTRCTR MCCLLCH 7CMD SPNL MSCLE MULTI TTHD BLACK FNSH U,SUP-2672371,CDM,2720000010,LOCAL,0272,RC,,,,both,,,585.36,380.48,,,,,,,,,,,,,
SCREW BONE L26MM DIA3MM CANC ST CANN NONLOCKING LAG,SUP-2319423,CDM,C1713,HCPCS,0278,RC,,,,both,,,367.38,238.80,,,,,,,,,,,,,
SEED BRACHYTHERAPY IODINE-125 NS ADVANTAGE,SUP-2247255,CDM,C2638,HCPCS,0278,RC,,,,both,,,40.82,26.53,,,,,,,,,,,,,
STEM ULN 55MM R STR PRSS FIT TI SOLAR,SUP-2372332,CDM,C1713,HCPCS,0278,RC,,,,both,,,14086.98,9156.54,,,,,,,,,,,,,
PSN REV STRAIGHT SMOOTH STEM EXT 12X175MM,SUP-2508769,CDM,C1776,CPT,0278,RC,,,,both,,,4044.32,2628.81,,,,,,,,,,,,,
COIL VASC NEST EMBOLUS L 5 CM DIA 5 MM CATH DIA 0.018 IN,SUP-2638547,CDM,C1889,HCPCS,0278,RC,,,,both,,,326.53,212.24,,,,,,,,,,,,,
STIMULATOR BNE DISP,SUP-2316220,CDM,2720000010,LOCAL,0272,RC,,,,both,,,11775.00,7653.75,,,,,,,,,,,,,
ACTIVATION ARM RIGID CRDNC 50MM DSTRCTR CLPBLE,SUP-2488786,CDM,C1713,HCPCS,0278,RC,,,,both,,,2248.74,1461.68,,,,,,,,,,,,,
CAGE SPNL W17XH8XL22MM ANT CERV THORLUM TI OBLONG,SUP-2193227,CDM,C1889,HCPCS,0278,RC,,,,both,,,8242.50,5357.62,,,,,,,,,,,,,
PLATE BONE L113MM 6 H RT OLECRANON,SUP-2364578,CDM,C1713,HCPCS,0278,RC,,,,both,,,3557.78,2312.56,,,,,,,,,,,,,
GUIDEWIRE ORTH THRD 1.1X150 MM FOR CANN SCREW NS 03333011,SUP-2789094,CDM,C1769,HCPCS,0272,RC,,,,both,,,257.98,167.69,,,,,,,,,,,,,
DEVICE FIX SM TAILORS BUNION PROSTEP,SUP-2846073,CDM,C1713,HCPCS,0278,RC,,,,both,,,3705.20,2408.38,,,,,,,,,,,,,
DA VINCI TIBIAL NAIL 8MMX31.5CM,SUP-2828905,CDM,C1713,HCPCS,0278,RC,,,,both,,,6264.30,4071.79,,,,,,,,,,,,,
PERFORATOR CRAN AD PED 11/7MM MINI DISP FOR THK1MM AREA DGR,SUP-2106554,CDM,2720000010,LOCAL,0272,RC,,,,both,,,876.06,569.44,,,,,,,,,,,,,
SCREW BNE L20MM DIA2.7MM DST VOLAR RAD MULTDIR FULL THRD SQ,SUP-2411813,CDM,C1713,HCPCS,0278,RC,,,,both,,,546.36,355.13,,,,,,,,,,,,,
WIRE FIX DIA1.8MM LNG PROV,SUP-2351116,CDM,C1713,HCPCS,0278,RC,,,,both,,,560.43,364.28,,,,,,,,,,,,,
CROWN DENT UR3 PED REFIL UP RT CTRL STRP FRM THN,SUP-2322243,CDM,D6783,CPT,0278,RC,,,,both,,,40.38,26.25,,,,,,,,,,,,,
STENT EVAR L50MM DIA8MM CATH 9FR L80CM 0.035IN EPTFE GRFT,SUP-2128230,CDM,C1874,HCPCS,0278,RC,,,,both,,,7520.30,4888.19,,,,,,,,,,,,,
CONNECTOR SPNL OPN CBL VERTEX SEL,SUP-2279730,CDM,C1713,HCPCS,0278,RC,,,,both,,,1067.60,693.94,,,,,,,,,,,,,
CATHETER GUID SUPP 035 65 CM CORONARY 45 DEG QUIK CROSS SEL,SUP-2353137,CDM,C1887,HCPCS,0272,RC,,,,both,,,533.80,346.97,,,,,,,,,,,,,
GRAFT HUM TISS XL W15XL24CM THK0.7-1.4MM THN ACELLULAR,SUP-2307608,CDM,Q4128,HCPCS,0636,RC,,,,both,,,18996.37,12347.64,,,,,,,,,,,,,
ANCHOR SUT VERSALOK ORTHOCORD,SUP-2256593,CDM,C1713,HCPCS,0278,RC,,,,both,,,1296.82,842.93,,,,,,,,,,,,,
RING EXT FIX LNG 180 MM SET HEX RX STRUT TRUELOK EVO LTX,SUP-2875595,CDM,2720000010,LOCAL,0272,RC,,,,both,,,30964.17,20126.71,,,,,,,,,,,,,
CATHETER BILI DRN CATH SET CONTENTS CATH PROX LOOP 2 INTRO,SUP-2168183,CDM,C1729,HCPCS,0272,RC,,,,both,,,412.34,268.02,,,,,,,,,,,,,
SET CATH HEMODIALYSI BIOFLXTESIO CHRONIC BSC 10FR DIA 70CM 4,SUP-2610496,CDM,C1750,HCPCS,0278,RC,,,,both,,,945.14,614.34,,,,,,,,,,,,,
SYSTEM DEL 1 CLP MITRACLP,SUP-2106212,CDM,C1889,HCPCS,0278,RC,,,,both,,,94200.00,61230.00,,,,,,,,,,,,,
ROD EXT FIX L80MM THRD,SUP-2197305,CDM,2720000010,LOCAL,0272,RC,,,,both,,,141.30,91.84,,,,,,,,,,,,,
STENT URTRL 45FR DIA 20CML TCFLX OPEN END FLXBLE LUBRI FLEX,SUP-2721958,CDM,C2617,HCPCS,0278,RC,,,,both,,,214.31,139.30,,,,,,,,,,,,,
MARKER FIDUCIAL STERIL GOLD W/DEL NEEDLES 1.2MM X 3MM (PK/3),SUP-2874150,CDM,A4648,CPT,0278,RC,,,,both,,,791.28,514.33,,,,,,,,,,,,,
GUIDEWIRE VASC WISEWIRE L 180 CM DIA 0.035 IN STR TIP DEV,SUP-2148142,CDM,C1769,HCPCS,0272,RC,,,,both,,,1579.01,1026.36,,,,,,,,,,,,,
PIN FIX TROCAR PT 2 END 5/64X9 IN 2 PT STYL SMOOTH PLN STRL,SUP-2150468,CDM,C1713,HCPCS,0278,RC,,,,both,,,13.72,8.92,,,,,,,,,,,,,
SCREW BONE L65MM DIA7MM THRD L16MM S STL CANN,SUP-2183894,CDM,C1713,HCPCS,0278,RC,,,,both,,,949.07,616.90,,,,,,,,,,,,,
ROD SPNL L35MM OD4.75MM CO CHROM NONSTERILE IMPL CDH,SUP-2284737,CDM,C1713,HCPCS,0278,RC,,,,both,,,1044.05,678.63,,,,,,,,,,,,,
GRAFT HUM TISS W4XL7CM THK18 4MM ULT THCK ACELLULAR,SUP-2307491,CDM,Q4128,HCPCS,0636,RC,,,,both,,,2701.03,1755.67,,,,,,,,,,,,,
CATHETER VENTRICULAR RT ANGLE 1.5X3.1 MMX4 CM HOLTER,SUP-2666425,CDM,C1729,HCPCS,0272,RC,,,,both,,,488.87,317.77,,,,,,,,,,,,,
STENT TRACHBRONCH WGRFT L 50 MM DIA14 MM CATH TOT L 116 CM,SUP-2140226,CDM,C1874,HCPCS,0278,RC,,,,both,,,7065.00,4592.25,,,,,,,,,,,,,
CATHETER ATHRCTMY FRONTRUNNER XP L 140 CM DIA 3.1 FR SHTH 6,SUP-2158727,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3573.32,2322.66,,,,,,,,,,,,,
SCREW BNE 2X7 MM CNTRDRV,SUP-2262661,CDM,C1713,HCPCS,0278,RC,,,,both,,,118.44,76.99,,,,,,,,,,,,,
PUMP BLD CENTRIMAG,SUP-2355998,CDM,C1713,HCPCS,0278,RC,,,,both,,,37680.00,24492.00,,,,,,,,,,,,,
K WIRE FIX L5.5IN DIA0.045IN SMOOTH DBL TRCR,SUP-2304014,CDM,C1713,HCPCS,0278,RC,,,,both,,,19.66,12.78,,,,,,,,,,,,,
GRAFT HUM TISS 10.5X71 MM QUADRICEPS TEND QUADLINK,SUP-2845956,CDM,C1762,CPT,0278,RC,,,,both,,,7347.60,4775.94,,,,,,,,,,,,,
BRACE THMB W ADJUSTABLE STRP UNIV,SUP-2276642,CDM,L3931,HCPCS,0274,RC,,,,both,,,12.21,7.94,,,,,,,,,,,,,
HOOK SPNL TRNSVRS PEDCL CONN FOR 3MM ROD SUMMIT FIX SYS,SUP-2254418,CDM,C1713,HCPCS,0278,RC,,,,both,,,1077.02,700.06,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY INQUIRY L 60 CM DIA 4 FR SPC,SUP-2357647,CDM,C1730,HCPCS,0272,RC,,,,both,,,1601.40,1040.91,,,,,,,,,,,,,
CURETTE SURG 7X5 MM CUP JT PREP LAPIDUS SYS IO FRDM,SUP-2865099,CDM,2720000010,LOCAL,0272,RC,,,,both,,,995.38,647.00,,,,,,,,,,,,,
BIT DRL 11 MM NS 7080610,SUP-2730588,CDM,2720000010,LOCAL,0272,RC,,,,both,,,741.26,481.82,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY LASSO L 115 CM DIA 7 FR D CRV,SUP-2880105,CDM,C1732,HCPCS,0278,RC,,,,both,,,4282.96,2783.92,,,,,,,,,,,,,
PLATE BNE L139MM 9 H NONSTERILE R LAT DST PERIARTC HUM LOK,SUP-2198469,CDM,C1713,HCPCS,0278,RC,,,,both,,,2835.77,1843.25,,,,,,,,,,,,,
PHENOL 1.4 % MT LIQD,RX-36976,CDM,340b,HCPCS,0637,RC,78112-0011-04,NDC,,both,177,ML,20.00,13.00,,,,,,,,,,,,,
STEM FEM SZ 3 L250MM 12 14 TAPR R HIP BOW REV CEM ENDUR,SUP-2251948,CDM,C1776,CPT,0278,RC,,,,both,,,12472.08,8106.85,,,,,,,,,,,,,
GUIDE PIN ORTHOPEDIC KNEE,SUP-2123460,CDM,C1713,HCPCS,0278,RC,,,,both,,,2637.60,1714.44,,,,,,,,,,,,,
BIT DRL FOR SHT 5MM HALF PIN JET-X,SUP-2342943,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2235.62,1453.15,,,,,,,,,,,,,
BLADE RETRACTOR YOUNG 7/16X2 IN 210 MM PROST LAT NOTCH ANTR,SUP-2459083,CDM,2720000010,LOCAL,0272,RC,,,,both,,,490.78,319.01,,,,,,,,,,,,,
CATHETER EP LG CRV 2-5-2 MM 6 FRX110 CM QPLR STJ81104] ST JUDE MEDICAL INC],SUP-2357724,CDM,C1730,HCPCS,0272,RC,,,,both,,,509.90,331.43,,,,,,,,,,,,,
HEAD HUM SZ 5 HA COAT SHLDR RESURF COPELAND,SUP-2403989,CDM,C1776,CPT,0278,RC,,,,both,,,13583.64,8829.37,,,,,,,,,,,,,
GRAFT TISS ACELLULAR PORCINE CROSSLINKED FEN ACELLULAR,SUP-2126251,CDM,C1781,HCPCS,0278,RC,,,,both,,,6037.28,3924.23,,,,,,,,,,,,,
FERROUS SULFATE 75 (15 FE) MG/ML PO SOLN,RX-95693,CDM,340b,HCPCS,0637,RC,09999-9905-53,NDC,,both,1,ML,2.70,1.75,,,,,,,,,,,,,
DEVICE TISS REM L32CM DIA3MM S STL ULT HRD HI WR RESISTANCE,SUP-2436359,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3039.52,1975.69,,,,,,,,,,,,,
DILATOR ENDO BAL L4CM DIA10MM CATH L230CM PYL COLON PET DISP,SUP-2166057,CDM,C1726,HCPCS,0272,RC,,,,both,,,248.06,161.24,,,,,,,,,,,,,
CATHETER INTVASC ULTRASOUND SONICATH ULTRA L 95 CM DIA 6 FR,SUP-2139882,CDM,C1753,HCPCS,0278,RC,,,,both,,,982.04,638.33,,,,,,,,,,,,,
STEM HUM 14X170 MM SHLDR RVS TRABECULAR MTL,SUP-2436913,CDM,C1776,CPT,0278,RC,,,,both,,,18533.85,12047.00,,,,,,,,,,,,,
TRACH EXCHANGE SET WEINMANN-MULTI,SUP-2718703,CDM,C1769,HCPCS,0272,RC,,,,both,,,668.35,434.43,,,,,,,,,,,,,
CATHETER DIAG L90CM OD0.044X0.03IN TIP OD1.8FR 15MM SPC,SUP-2353125,CDM,C1887,HCPCS,0272,RC,,,,both,,,501.52,325.99,,,,,,,,,,,,,
GRAFT BNE H25MM IL CREST WDG FRZ DRY MATRIGRFT,SUP-2264802,CDM,C1713,HCPCS,0278,RC,,,,both,,,2571.69,1671.60,,,,,,,,,,,,,
CONNECTOR VENTILATOR SW ALRM OUTPT SERVO-I,SUP-2747001,CDM,C1713,HCPCS,0278,RC,,,,both,,,564.63,367.01,,,,,,,,,,,,,
STENT PERIPH L150MM DIA10MM CATH L120CM DIA11FR 0.035IN NIT,SUP-2396578,CDM,C1874,HCPCS,0278,RC,,,,both,,,12261.70,7970.10,,,,,,,,,,,,,
PIN FIX SMOOTH TIP 2.5X200 MM STRL AEQUALIS PERFORM DISP,SUP-2715617,CDM,2720000010,LOCAL,0272,RC,,,,both,,,372.09,241.86,,,,,,,,,,,,,
LOW PRFLE NEURO PLATE DBLE Y SHAPE LNG CP TTNM ST,SUP-2677803,CDM,C1713,HCPCS,0278,RC,,,,both,,,695.13,451.83,,,,,,,,,,,,,
CATHETER ANGIOPLSTY OTW 6 FRX150 CM 2X120 MM COYOTE,SUP-2140810,CDM,C1725,HCPCS,0272,RC,,,,both,,,600.05,390.03,,,,,,,,,,,,,
GRAFT BNE SUB 2.5ML PTTY DEMIN BNE MTRX JR GRFTON,SUP-2294015,CDM,C9359,HCPCS,0278,RC,,,,both,,,1427.13,927.63,,,,,,,,,,,,,
SHUNT CAR W/O RESVR N PROGRAMMABLE 9FR 15CM,SUP-2264205,CDM,C1713,HCPCS,0278,RC,,,,both,,,1362.76,885.79,,,,,,,,,,,,,
BUTTON GASTRIC KIT 24 FRX35 CM ADJ APPLE SHP BLLN MINIONE,SUP-2119902,CDM,2720000010,LOCAL,0272,RC,,,,both,,,510.12,331.58,,,,,,,,,,,,,
SODIUM BICARBONATE 650 MG PO TABS,RX-7313,CDM,6370000000,HCPCS,0637,RC,66553-0008-01,NDC,,both,1,UN,0.50,0.32,,,,,,,,,,,,,
PLATE BNE L112MM 4 H R ANTEROMEDIAL DST TIB S STL VAR ANG LO,SUP-2177656,CDM,C1713,HCPCS,0278,RC,,,,both,,,5516.26,3585.57,,,,,,,,,,,,,
SET INTRO SHTH 12FR L22CM OBT 7FR L26CM CATH 5FR L50CM,SUP-2171199,CDM,C1769,HCPCS,0272,RC,,,,both,,,185.39,120.50,,,,,,,,,,,,,
BLADE SAW L8IN AMP CHARRIERE,SUP-2161343,CDM,C1713,HCPCS,0278,RC,,,,both,,,783.12,509.03,,,,,,,,,,,,,
HC Midline Placement 3yr or >,PX-3613641000,CDM,36410,CPT,0361,RC,,,,both,,,1195.00,776.75,,,,,,,,,,,,,
KIT TKR KNEE REPL BUSHING MOST OPTIONS,SUP-2208279,CDM,C1776,CPT,0278,RC,,,,both,,,17266.86,11223.46,,,,,,,,,,,,,
COIL NEUROVASCULAR L 20 CM DIA 6 MM PLAT TUNGSTEN DETACHABLE,SUP-2884372,CDM,C1889,HCPCS,0278,RC,,,,both,,,9420.00,6123.00,,,,,,,,,,,,,
GLYCOPYRROLATE 1 MG PO TABS,RX-10130,CDM,6370000000,HCPCS,0637,RC,60687-0458-11,NDC,,both,1,UN,5.00,3.25,,,,,,,,,,,,,
SYSTEM MENIS REP PEEK W/ 24DEG NDL TRUESPAN,SUP-2249486,CDM,C1713,HCPCS,0278,RC,,,,both,,,3023.82,1965.48,,,,,,,,,,,,,
SCREW BONE L65MM THRD DIA3MM HD DIA3.7MM COR DIA1.6MM PITCH,SUP-2349533,CDM,C1713,HCPCS,0278,RC,,,,both,,,502.56,326.66,,,,,,,,,,,,,
SCREW FIX INF ULT SLNG SYS,SUP-2140330,CDM,C1771,HCPCS,0278,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
KIT CVC 7FR POLYURETHAN CTRL VEN CATHETERS EXP,SUP-2214562,CDM,C1751,HCPCS,0278,RC,,,,both,,,83.21,54.09,,,,,,,,,,,,,
BLADE SHAVER CRV 4.5 MMX11.5 CM 45 DEG PRE BENT STRL ROUTER,SUP-2607704,CDM,2720000010,LOCAL,0272,RC,,,,both,,,859.83,558.89,,,,,,,,,,,,,
PLATE BONE L116MM 6 H T SHP FOR 4.5MM CORTEX/MALLEOLAR/SHAFT,SUP-2343817,CDM,C1713,HCPCS,0278,RC,,,,both,,,2494.51,1621.43,,,,,,,,,,,,,
CATHETER CARD ABLATION QDOT MIC L 115 CM 8 FR 3.5 MM D-F TYP,SUP-2880099,CDM,C1732,HCPCS,0278,RC,,,,both,,,12365.32,8037.46,,,,,,,,,,,,,
PLATE BNE M THK0.3MM STD G UP FACE TI ORBIT FLR BASIC FOR,SUP-2366222,CDM,C1713,HCPCS,0278,RC,,,,both,,,2577.72,1675.52,,,,,,,,,,,,,
GUIDEWIRE ORTH L150MM DIA1.1MM S STL NTHRD FOR 3MM CANN SCR,SUP-2186885,CDM,C1769,HCPCS,0272,RC,,,,both,,,68.83,44.74,,,,,,,,,,,,,
PROTHROMBIN COMPLEX CONC HUMAN 1000 UNITS IV KIT,RX-125560,CDM,J7168,HCPCS,0636,RC,63833-0387-02,NDC,,both,1,UN,8791.00,5714.15,,,,,,,,,,,,,
STENT PERIPH S.M.A.R.T. L 80 MM DIA10 MM CATH L 80 CM DIA10,SUP-2158632,CDM,C1876,HCPCS,0278,RC,,,,both,,,4961.20,3224.78,,,,,,,,,,,,,
SHANK SPNL SCREW L 30 MM DIA 5 MM OSTEOGRIP STRL CD HORZ 2PK,SUP-2928379,CDM,C1713,HCPCS,0278,RC,,,,both,,,2888.80,1877.72,,,,,,,,,,,,,
CATHETER HD KT 12 FRX25 CM 3L PRESSURE INJ HI VOL INFUSION,SUP-2762988,CDM,C1752,HCPCS,0278,RC,,,,both,,,401.01,260.66,,,,,,,,,,,,,
STEM TIB L150MM OD18MM TI KNEE PRI IMP GEN II,SUP-2346012,CDM,C1776,CPT,0278,RC,,,,both,,,3275.81,2129.28,,,,,,,,,,,,,
CATHETER HD STR 14.5 FRX24 CM 19 CM STD LT KT STYL GLIDEPATH - ORDER UOM CA,SUP-2126473,CDM,C1750,HCPCS,0278,RC,,,,both,,,800.70,520.45,,,,,,,,,,,,,
GRAFT CORNEAL W1.5XL2CM THK50-100UM BIO TRANSPLANTATION,SUP-2135257,CDM,V2790,HCPCS,0278,RC,,,,both,,,2025.30,1316.44,,,,,,,,,,,,,
SCREW SHT TRCR FOR AG FEM NAT NAIL SYS 80MM,SUP-2198682,CDM,2720000010,LOCAL,0272,RC,,,,both,,,869.37,565.09,,,,,,,,,,,,,
HC Thoracentesis WO Imaging,PX-7613255400,CDM,32554,CPT,0761,RC,,,,both,,,1901.00,1235.65,,,,,,,,,,,,,
PLATE BNE L 111 MM 14 H SCREW DIA2.4 MM TI ALLOY MINI FRAG,SUP-2902398,CDM,C1713,HCPCS,0278,RC,,,,both,,,3180.91,2067.59,,,,,,,,,,,,,
PLATE BONE L96MM 12 H MAND TI STR LCK COMPR RECON FOR 2.4MM,SUP-2191425,CDM,C1713,HCPCS,0278,RC,,,,both,,,3984.97,2590.23,,,,,,,,,,,,,
FIXATOR 5/8 RNG 180MM FRDM CIR,SUP-2400657,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1827.48,1187.86,,,,,,,,,,,,,
HC Mammo Screening Incl Cad if Perf,PX-4037706700,CDM,77067,CPT,0403,RC,,,,outpatient,,,480.00,312.00,,,,,,,,,,,,,
SCREW BONE L12MM DIA2.7MM CORT DSTL RAD LCK FULL THRD SQ DRV,SUP-2136254,CDM,C1713,HCPCS,0278,RC,,,,both,,,687.66,446.98,,,,,,,,,,,,,
PLATE BONE L21MM THK2MM 6X21 H RT MAND ORAL MAXILLOFACIAL TI,SUP-2191273,CDM,C1713,HCPCS,0278,RC,,,,both,,,8033.69,5221.90,,,,,,,,,,,,,
SUPPORT ORTHOT LOWER EXTREMITY PELV CTRL BND BELT BILATERAL,SUP-2435689,CDM,L2640,HCPCS,0274,RC,,,,both,,,889.62,578.25,,,,,,,,,,,,,
BUR SURG L14CM HD L38MM DIA3MM MTCH HD DMND TELSCP MIDAS,SUP-2281647,CDM,2720000010,LOCAL,0272,RC,,,,both,,,405.56,263.61,,,,,,,,,,,,,
ADJUSTABLE CONNECT ROD 5MM,SUP-2695692,CDM,2720000010,LOCAL,0272,RC,,,,both,,,848.43,551.48,,,,,,,,,,,,,
GRAFT BNE L40MM OD2MM CORT FRZ DRY PIN IMPL ALLOFIX,SUP-2307226,CDM,C1713,HCPCS,0278,RC,,,,both,,,803.37,522.19,,,,,,,,,,,,,
PACK NEUROSURGICAL SHTH L 75 X W 13.5 MM MYRIAD HNDPC L 13 NN-2005,SUP-2930268,CDM,2720000010,LOCAL,0272,RC,,,,both,,,18005.55,11703.61,,,,,,,,,,,,,
PIN FIX EXCHANGE 500 MM SI-LUTION,SUP-2872547,CDM,2720000010,LOCAL,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
ALLOGRAFT BNE ULN SHFT 26-50 MM FRZN,SUP-2717871,CDM,C1762,CPT,0278,RC,,,,both,,,2337.10,1519.11,,,,,,,,,,,,,
GUIDEWIRE VASC L260CM DIA0.035IN L1.5MM STD SM VES NIT,SUP-2385576,CDM,C1769,HCPCS,0272,RC,,,,both,,,157.44,102.34,,,,,,,,,,,,,
NEEDLE BRST LOC REPOSITIONAL DISP 20GA 3CM KOP,SUP-2331830,CDM,C1819,HCPCS,0278,RC,,,,both,,,54.07,35.15,,,,,,,,,,,,,
DEVICE FIX 5 MMX39 CM CANN ABSORBABLE FAST OBTIFIX,SUP-2125765,CDM,C1713,HCPCS,0278,RC,,,,both,,,6860.90,4459.58,,,,,,,,,,,,,
GUIDEWIRE ORTH 1.1 MMX6 IN,SUP-2663620,CDM,C1769,HCPCS,0272,RC,,,,both,,,45.28,29.43,,,,,,,,,,,,,
PLATE BNE RADIAL SM 116 MM LT DSTL VOLAR PERIARTICULAR 10,SUP-2472488,CDM,C1713,HCPCS,0278,RC,,,,both,,,2111.30,1372.34,,,,,,,,,,,,,
TIP ASPIR L11CM APEX KNF FOR SURG HNDPC SONOPET IQ,SUP-2419488,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3256.87,2116.97,,,,,,,,,,,,,
MESH SURG L 8 X W 3 CM D 1 MM PORCINE DERMAL CLLGN ABD HERN,SUP-2901722,CDM,C9364,HCPCS,0278,RC,,,,both,,,1965.26,1277.42,,,,,,,,,,,,,
SPACER TEND NO5 W5XH2.5XL24MM SIL SWNSN HUNTER,SUP-2397188,CDM,C1776,CPT,0278,RC,,,,both,,,3133.72,2036.92,,,,,,,,,,,,,
BURR SURG 8.5MM DIA HD LG BNE CONTOURED FLUTEX8 FLFRVSNS SUR,SUP-2605420,CDM,2720000010,LOCAL,0272,RC,,,,both,,,400.70,260.45,,,,,,,,,,,,,
EXTERNAL FIXATION SET ANCIL SUBFIX,SUP-2467210,CDM,2720000010,LOCAL,0272,RC,,,,both,,,10413.81,6768.98,,,,,,,,,,,,,
GRAFT TISS FRZN ALLGRFT HUM WHL R W/ CUF,SUP-2307340,CDM,C1776,CPT,0278,RC,,,,both,,,26498.46,17224.00,,,,,,,,,,,,,
VALVE CSF PROGRAMMABLE MED PEDIATRIC IMPL YEL DP,SUP-2666617,CDM,C1889,HCPCS,0278,RC,,,,both,,,2367.12,1538.63,,,,,,,,,,,,,
BLADE RETRACTOR CASPAR 23MMW X 50MMD LATERAL TOOTHED ULTRA,SUP-2676423,CDM,2720000010,LOCAL,0272,RC,,,,both,,,565.14,367.34,,,,,,,,,,,,,
SHEET WND 130X200X0.02 MM BIORESORBABLE PROTCT POLYLACTIDE,SUP-2175201,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1252.86,814.36,,,,,,,,,,,,,
TRAY CATH HEMODIALYSI DUOGLIDE ACUTE 13FR DIA 24CML 5626240,SUP-2632919,CDM,C1752,HCPCS,0278,RC,,,,both,,,885.35,575.48,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 80 CM DIA 6 MM L 50CM STR STD WALL,SUP-2396269,CDM,C1768,CPT,0278,RC,,,,both,,,3981.52,2587.99,,,,,,,,,,,,,
DRILL SURG L11MM BUD REUSE,SUP-2107586,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1092.72,710.27,,,,,,,,,,,,,
CATHETER HD LT 15.5 FRX19 CM SET W/ SIDE H STYL SYMETREX,SUP-2627447,CDM,C1750,HCPCS,0278,RC,,,,both,,,737.90,479.63,,,,,,,,,,,,,
DEFIBRILLATOR CARD W/ RIATA EPIC II DR,SUP-2356559,CDM,C1721,HCPCS,0275,RC,,,,both,,,71121.00,46228.65,,,,,,,,,,,,,
MESH BONE PTTSBRGH SM 03MM THK TTNM LATEX FREE MXLFCL,SUP-2676688,CDM,C1713,HCPCS,0278,RC,,,,both,,,1443.33,938.16,,,,,,,,,,,,,
PLATE BNE THK0.6MM 2X2 H STD CRANIOMAXILLOFACIAL G TI 3D SQ,SUP-2366268,CDM,C1713,HCPCS,0278,RC,,,,both,,,674.47,438.41,,,,,,,,,,,,,
SCREW BNE LCK 2.7 MM TOT WR STARDRV FUSION BLK STRL SURFIX,SUP-2610310,CDM,C1713,HCPCS,0278,RC,,,,both,,,456.96,297.02,,,,,,,,,,,,,
K WIRE FIX L15IN DIA1.5MM,SUP-2167176,CDM,C1713,HCPCS,0278,RC,,,,both,,,86.19,56.02,,,,,,,,,,,,,
DRILL TWST L 115 MM DIA1.5 MM STP 37 MM SCREW DIA2 MM J-NT,SUP-2883860,CDM,2720000010,LOCAL,0272,RC,,,,both,,,348.54,226.55,,,,,,,,,,,,,
MGII KNEE TIB ART SURF A/P LIP GHJK/ BLU 9MM,SUP-2501963,CDM,C1776,CPT,0278,RC,,,,both,,,5526.40,3592.16,,,,,,,,,,,,,
PLATE BNE RECON MAND 8 HOLE TI LEVEL 1 THREADLOCK,SUP-2497967,CDM,C1713,HCPCS,0278,RC,,,,both,,,1949.56,1267.21,,,,,,,,,,,,,
GUIDEWIRE VASC INQWIRE L 180 CM DIA 0.018 IN PTFE PERIPH STR,SUP-2301902,CDM,C1769,HCPCS,0272,RC,,,,both,,,39.25,25.51,,,,,,,,,,,,,
KNIFE 3722008 SICKLE 3MM CVD BLADE,SUP-2705724,CDM,2720000010,LOCAL,0272,RC,,,,both,,,390.96,254.12,,,,,,,,,,,,,
ENDCAP ORTH 0MM EXTN TI W/ T25 STARDRV FOR HUM NAIL-EX SPRL,SUP-2188943,CDM,C1713,HCPCS,0278,RC,,,,both,,,392.31,255.00,,,,,,,,,,,,,
CATHETER URETH STR 6 FRX80 CM OPN W/O EYE OLYCATH,SUP-2798127,CDM,C1758,HCPCS,0278,RC,,,,both,,,53.91,35.04,,,,,,,,,,,,,
GUIDEWIRE VASC L 50 CM DIA 0.015 IN STR FLX SFT TIP FIX COR,SUP-2167845,CDM,C1769,HCPCS,0272,RC,,,,both,,,87.92,57.15,,,,,,,,,,,,,
PLATE BONE 14 H TI BROAD HYBRID COMPR FOR 4.5MM SCR ALPS,SUP-2413756,CDM,C1713,HCPCS,0278,RC,,,,both,,,1589.97,1033.48,,,,,,,,,,,,,
CUTTER VITRECTOMY 23 GA POST STAND ALONE WIDE FLD HI SPD,SUP-2490264,CDM,2720000010,LOCAL,0272,RC,,,,both,,,593.46,385.75,,,,,,,,,,,,,
ARCHBAR ORTHODONTIC PREFRM FOR MAXILLOMANDIBULAR FIX SYS,SUP-2135878,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
CABLE ELECTRD ENH BLU MAIN 14 TO 14 PIN STARBURSTXLL,SUP-2117216,CDM,C1819,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
STAPLER INT STR UNIV 45 MM REINF LINEAR GRN STRL ENDO GIA,SUP-2395287,CDM,C1713,HCPCS,0278,RC,,,,both,,,514.43,334.38,,,,,,,,,,,,,
PLATE BNE L91MM 6 H L POSTEROLATERAL DST PERIARTC HUM,SUP-2410658,CDM,C1713,HCPCS,0278,RC,,,,both,,,2276.88,1479.97,,,,,,,,,,,,,
HYDROCERIN EX CREA,RX-20102,CDM,6370000000,HCPCS,0637,RC,72140-0000-22,NDC,,both,113,GR,33.10,21.51,,,,,,,,,,,,,
BIT OVERDRILL L 229 MM DIA 7 MM LG AO NS DISP LEOS,SUP-2932999,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1312.83,853.34,,,,,,,,,,,,,
LIGATOR ENDOSCP TRIG CRD L122CM SCP DIA9.5-13MM ACC CHN,SUP-2169392,CDM,2720000010,LOCAL,0272,RC,,,,both,,,709.64,461.27,,,,,,,,,,,,,
FIBER LSR UROLOGICALXPS GREENLIGHT,SUP-2225712,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3337.82,2169.58,,,,,,,,,,,,,
BACLOFEN 10 MG PO TABS,RX-860,CDM,6370000000,HCPCS,0637,RC,00527-1330-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
KIT EEG ELECTRD L 80 MM 16 CONTACT STRL DISP EVO,SUP-2936489,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3567.04,2318.58,,,,,,,,,,,,,
NEEDLE BRST LOC REPOSITIONABLE 20GA X 10CM HOMER,SUP-2120046,CDM,C1819,HCPCS,0278,RC,,,,both,,,105.19,68.37,,,,,,,,,,,,,
PLATE BNE FEM 90 5 DEG 5 MM DSTL 4 HOLE FLARE SS STRL JPS,SUP-2645619,CDM,C1713,HCPCS,0278,RC,,,,both,,,16755.04,10890.78,,,,,,,,,,,,,
PLATE LOK 10MM THCK PEREZ MINI T SHP EXT BASE LNG WIDE BAR,SUP-2262971,CDM,C1713,HCPCS,0278,RC,,,,both,,,1552.26,1008.97,,,,,,,,,,,,,
NICARDIPINE HCL 2.5 MG/ML IV SOLN,RX-12370,CDM,J2404,HCPCS,0636,RC,00143-9689-01,NDC,,both,10,ML,146.80,95.42,,,,,,,,,,,,,
SPLINT ORTH D RNG CLOSURE UNIV 8 IN WRST FOREARM LT,SUP-2336337,CDM,L3809,HCPCS,0274,RC,,,,both,,,24.55,15.96,,,,,,,,,,,,,
NAIL IM L210MM OD14MM 130DEG STD CANN LCK COMPR,SUP-2351368,CDM,C1713,HCPCS,0278,RC,,,,both,,,1931.10,1255.21,,,,,,,,,,,,,
TAP SHORT MODULAR INTERFERENCE SCREW 9-10MM GENESYS MATRYX,SUP-2842818,CDM,C1713,HCPCS,0278,RC,,,,both,,,1226.14,796.99,,,,,,,,,,,,,
PATCH ABSRB CLLGN WND DRSG PLUG FOR ORAL WND PROTCT HEALING,SUP-2204810,CDM,C1713,HCPCS,0278,RC,,,,both,,,27.69,18.00,,,,,,,,,,,,,
PROBE SURG PEDCL STR SGL END W O EYE VERTEX SEL,SUP-2286790,CDM,C1713,HCPCS,0278,RC,,,,both,,,1408.79,915.71,,,,,,,,,,,,,
STEM FEM L185MM OD21MM 135DEG STD TI PRESSFIT POR HIP PRI,SUP-2409380,CDM,C1776,CPT,0278,RC,,,,both,,,28731.00,18675.15,,,,,,,,,,,,,
DEVICE UTER MANIP CERV CUP FORNISEE DISP,SUP-2427798,CDM,C1713,HCPCS,0278,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
PLATE BONE DOUBLE ANGLE THICK 2.5 MM MANDIBLE PATIENT SPECIF,SUP-2838602,CDM,C1713,HCPCS,0278,RC,,,,both,,,32062.23,20840.45,,,,,,,,,,,,,
DEVICE EMB PIPELINE 3.00X35MM,SUP-2466480,CDM,C1889,HCPCS,0278,RC,,,,both,,,44745.00,29084.25,,,,,,,,,,,,,
PLATE BNE L253MM 16 H R DST ANTLAT TIB S STL LOK FOR 35 4MM,SUP-2362749,CDM,C1713,HCPCS,0278,RC,,,,both,,,6440.14,4186.09,,,,,,,,,,,,,
PLATE BNE L W12XL87MM THK1MM 5 H BILAT TI SEMI TBLR LO PROF,SUP-2190703,CDM,C1713,HCPCS,0278,RC,,,,both,,,317.52,206.39,,,,,,,,,,,,,
PLATE SPNL L14MM ASMBLY SPINOUS PROC ASPN,SUP-2209278,CDM,C1713,HCPCS,0278,RC,,,,both,,,18055.00,11735.75,,,,,,,,,,,,,
TI MATRIXMIDFACE SCREW  1.3MM  450395805,SUP-2844126,CDM,C1713,HCPCS,0278,RC,,,,both,,,2169.11,1409.92,,,,,,,,,,,,,
MARKER 1.2MM 1 MRK PER NDL 30CM 17GA FIDUCIAL GLD SFT TISS 4,SUP-2164651,CDM,A4648,CPT,0278,RC,,,,both,,,885.48,575.56,,,,,,,,,,,,,
PLUG MESH M ANCHR 4CM RIM 5CM SYN POLYPR POLIGLECAPRONE 25,SUP-2220112,CDM,C1781,HCPCS,0278,RC,,,,both,,,613.09,398.51,,,,,,,,,,,,,
DEVICE THROMCTMY ARROW-TREROTOLA PTD DIA 7 FR PWR 3000 RPM,SUP-2384058,CDM,C1757,HCPCS,0272,RC,,,,both,,,753.60,489.84,,,,,,,,,,,,,
STAPLE BNE FIX DIA1 MM STD OBLQ NS VARISATION,SUP-2885080,CDM,C1713,HCPCS,0278,RC,,,,both,,,465.72,302.72,,,,,,,,,,,,,
SEGMENTAL BWD FLUTED STEM 15X250MM,SUP-2502482,CDM,C1776,CPT,0278,RC,,,,both,,,9919.26,6447.52,,,,,,,,,,,,,
PLATE BNE L 80 MM SCREW DIA2 MM 5 HD 10 SHFT H SS Y SHP VA NS,SUP-2909161,CDM,C1713,HCPCS,0278,RC,,,,both,,,2830.49,1839.82,,,,,,,,,,,,,
BOOT TRACTION LOOP LCK CLOSURE UNIV ECON BUCK,SUP-2336324,CDM,L4398,HCPCS,0272,RC,,,,both,,,93.38,60.70,,,,,,,,,,,,,
CAGE FUSION SPINAL MODULUS ALIF 8X34X24MM 10 DEG,SUP-2719500,CDM,C1889,HCPCS,0278,RC,,,,both,,,16642.00,10817.30,,,,,,,,,,,,,
FORCEP ELECSURG BPLR 1.2 MM 22 CM IRRIGATING SILVERGLIDE,SUP-2859627,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3600.20,2340.13,,,,,,,,,,,,,
RING ANNULPLSTY 28MM MEMO 3D,SUP-2352688,CDM,C1889,HCPCS,0278,RC,,,,both,,,5887.50,3826.87,,,,,,,,,,,,,
PIN HALF THRD 5X120 MM 35 MM SELF DRILLING APEX,SUP-2363228,CDM,C1713,HCPCS,0278,RC,,,,both,,,201.24,130.81,,,,,,,,,,,,,
CATHETER HEMO DYLS OR HD OVERALL L40CM L24CM DIA14.5FR,SUP-2174238,CDM,C1750,HCPCS,0278,RC,,,,both,,,1306.08,848.95,,,,,,,,,,,,,
NAIL IM L360MM DIA11MM 130DEG LNG TROCHANTERIC FEM HIP TI,SUP-2253395,CDM,C1713,HCPCS,0278,RC,,,,both,,,4352.04,2828.83,,,,,,,,,,,,,
CATHETER BLLN DIL URET,SUP-2835668,CDM,C1758,HCPCS,0278,RC,,,,both,,,445.10,289.31,,,,,,,,,,,,,
PROSTHESIS PENILE INFLATABLE 13 MMX18 CM AMS AMBICOR,SUP-2140275,CDM,C1813,HCPCS,0278,RC,,,,both,,,14130.00,9184.50,,,,,,,,,,,,,
COMPONENT FEM L25MM OD12MM CSTI POR KNEE STEM SEGMENTED HEX,SUP-2208270,CDM,C1776,CPT,0278,RC,,,,both,,,11530.08,7494.55,,,,,,,,,,,,,
SET URET STENT C FLX L 8 CM DIA 5 FR GUIDEWIRE 0.038 IN SM,SUP-2171208,CDM,C2617,HCPCS,0278,RC,,,,both,,,300.03,195.02,,,,,,,,,,,,,
DEVICE LD SZ EZ L65CM DIA0.38-0.58MM LOK CLR STYL LO PROF,SUP-2353133,CDM,C1773,HCPCS,0272,RC,,,,both,,,1983.44,1289.24,,,,,,,,,,,,,
HC Fibrinogen Activity,PX-3058538400,CDM,85384,CPT,0305,RC,,,,both,,,272.00,176.80,,,,,,,,,,,,,
CEMENT BNE 3 CC DEMINERALIZED BONE MATRIX STRL TRABEXUS LTX,SUP-2855698,CDM,C1713,HCPCS,0278,RC,,,,both,,,11093.62,7210.85,,,,,,,,,,,,,
HC I&D Abscess Scrotal Wall,PX-4505510000,CDM,55100,CPT,0450,RC,,,,both,,,1649.00,1071.85,,,,,,,,,,,,,
GRAFT BNE FEN 15X150 MM DEMINERALIZED CORTICAL FENFLEX,SUP-2742007,CDM,C1713,HCPCS,0278,RC,,,,both,,,4058.45,2637.99,,,,,,,,,,,,,
GRAFT BONE ALLGRFT TEND SEMITENDINOSUS N GAM FRZN MAXXEUS,SUP-2165610,CDM,C1713,HCPCS,0278,RC,,,,both,,,6123.00,3979.95,,,,,,,,,,,,,
HC So Coccidioides,PX-3028663566,CDM,86635,CPT,0302,RC,,,,both,,,98.00,63.70,,,,,,,,,,,,,
KIT ANGIO XCELA DIA 4 FR STRL,SUP-2117195,CDM,C1751,HCPCS,0278,RC,,,,both,,,519.61,337.75,,,,,,,,,,,,,
CASSETTE IRR SUCT SONOPET IQ,SUP-2419516,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1504.44,977.89,,,,,,,,,,,,,
ROD RM 3X950 MM W/ BALL TIP SS STRL,SUP-2188114,CDM,2720000010,LOCAL,0272,RC,,,,both,,,515.02,334.76,,,,,,,,,,,,,
PIN FIX DIA1.2MM FOR SM BNE PLATING SYS ORTHOLOC 3DI,SUP-2399749,CDM,C1713,HCPCS,0278,RC,,,,both,,,113.04,73.48,,,,,,,,,,,,,
CATHETER CARD ABLATION THERMOCOOL SMARTTOUCH 115CM 8FR D CRV,SUP-2248609,CDM,C1732,HCPCS,0278,RC,,,,both,,,9457.68,6147.49,,,,,,,,,,,,,
PLATE BNE ORTHODONTIC TRAUM CRSS DRV W WIRE ANCHR TI,SUP-2262927,CDM,C1713,HCPCS,0278,RC,,,,both,,,342.57,222.67,,,,,,,,,,,,,
GRAFT VASC FLIXENE L 50 CM DIA 8 MM EPTFE STR STD WALL REINF,SUP-2474614,CDM,C1768,CPT,0278,RC,,,,both,,,3298.51,2144.03,,,,,,,,,,,,,
BLADE SURG 4MM DETACH STR W/ HNDL CAPSULECUT,SUP-2121993,CDM,C1713,HCPCS,0278,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
PROTECTOR NERVE L 6 X W 3 CM PORCINE SODIUM HYALURONATE,SUP-2890394,CDM,C1763,HCPCS,0278,RC,,,,both,,,11731.04,7625.18,,,,,,,,,,,,,
SNARE VASC CLOVER SNR L 90 CM DIA 6 FR SHTH OUTER L 80 CM,SUP-2171012,CDM,C1773,HCPCS,0272,RC,,,,both,,,1957.44,1272.34,,,,,,,,,,,,,
GRAFT HUMAN TISSUE THICK 16X8 CM HYDRATED BIOLOGIC TISSUE MA,SUP-2838611,CDM,C1763,HCPCS,0278,RC,,,,both,,,11877.99,7720.69,,,,,,,,,,,,,
TROCAR SURG MULT HOLE T2 RECON,SUP-2467457,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4790.07,3113.55,,,,,,,,,,,,,
POTASSIUM CHLORIDE CRYS ER 20 MEQ PO TBCR,RX-35943,CDM,6370000000,HCPCS,0637,RC,00245-5319-89,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
CANNULA SURG W/ STOPCOCK 70 MM 4.5 MM IRRIGATION OBTUTATOR,SUP-2794072,CDM,2720000010,LOCAL,0272,RC,,,,both,,,584.57,379.97,,,,,,,,,,,,,
CLIP ANEURYSM L5MM 2.3MM OPENING PHYNOX VASCULAR CURVED AVM,SUP-2825391,CDM,C1889,HCPCS,0278,RC,,,,both,,,745.62,484.65,,,,,,,,,,,,,
HC So1 Ptt / Thromboplastin Subs,PX-3058573267,CDM,85732,CPT,0305,RC,,,,both,,,36.00,23.40,,,,,,,,,,,,,
CLOVERLEAF PL 9H 184MM,SUP-2818806,CDM,C1713,HCPCS,0278,RC,,,,both,,,4599.16,2989.45,,,,,,,,,,,,,
INJECTOR IO LENS FOR LENS MNRCH III IOL DEL SYS,SUP-2110042,CDM,2720000010,LOCAL,0272,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
HC OB ER Level 3,PX-4509928301,CDM,99283,CPT,0450,RC,,,,inpatient,,,1556.00,1011.40,,,,,,,,,,,,,
BODY FEM SZ 10.5 STD LT DST TEXT APR,SUP-2210915,CDM,C1776,CPT,0278,RC,,,,both,,,16266.77,10573.40,,,,,,,,,,,,,
PIN FIX L3IN W HNDL STNMN PFC,SUP-2253359,CDM,C1713,HCPCS,0278,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
INSERT ACET OD48MM ID32MM THK5.9MM 20DEGXLPE MTL ON POLY,SUP-2371337,CDM,C1776,CPT,0278,RC,,,,both,,,7034.26,4572.27,,,,,,,,,,,,,
HC Nutrition Class,PX-9420947200,CDM,S9472,CPT,0940,RC,,,,both,,,106.00,68.90,,,,,,,,,,,,,
DEXTROSE 5 % AND 0.45 % NACL IV BOLUS,RX-40840056,CDM,J3490,HCPCS,0258,RC,00338-0085-04,NDC,,both,250,ML,12.80,8.32,,,,,,,,,,,,,
ALLOGRAFT BNE 250-1000 MH 0.70 CC FD CORTICAL PWD ORAGRAFT,SUP-2741047,CDM,C1713,HCPCS,0278,RC,,,,both,,,198.57,129.07,,,,,,,,,,,,,
CODMAN HAKIM PROGRAMMABLE VLV IN-LINE VLV W/ SIPHONGUARD,SUP-2243810,CDM,C1729,HCPCS,0272,RC,,,,both,,,16468.70,10704.65,,,,,,,,,,,,,
WIRE FIX 1X70 MM DBL END TRCR PT STRL KIRSCHNER,SUP-2860990,CDM,C1713,HCPCS,0278,RC,,,,both,,,368.70,239.65,,,,,,,,,,,,,
IMPL WRIST HEAD STEM 6MM COLLAR SZ 2,SUP-2703130,CDM,C1776,CPT,0278,RC,,,,both,,,9679.84,6291.90,,,,,,,,,,,,,
CATHETER VENTRICULAR ANTIMICROBIAL BACTISEAL BA STRP NS0340,SUP-2666790,CDM,C1729,HCPCS,0272,RC,,,,both,,,3088.41,2007.47,,,,,,,,,,,,,
PLATE BNE FIBULAR 61 MM EXT DSTL ANK 5 HOLE TI,SUP-2525763,CDM,C1713,HCPCS,0278,RC,,,,both,,,3777.42,2455.32,,,,,,,,,,,,,
PLATE BNE W11XL220MM THK3.7MM 12 H L MED DST TIB S STL LOK,SUP-2185596,CDM,C1713,HCPCS,0278,RC,,,,both,,,4598.25,2988.86,,,,,,,,,,,,,
SHELL ACET MOD 74 MM HIP REDAPT,SUP-2434873,CDM,C1776,CPT,0278,RC,,,,both,,,7807.30,5074.74,,,,,,,,,,,,,
SYNPOR SMOOTH FAN PLATE,SUP-2827982,CDM,C1713,HCPCS,0278,RC,,,,both,,,2457.36,1597.28,,,,,,,,,,,,,
PLATE BNE RECON 2.8 MM 20 HOLE PT SPEC TI,SUP-2860107,CDM,C1713,HCPCS,0278,RC,,,,both,,,15728.89,10223.78,,,,,,,,,,,,,
PLATE BNE FIBULAR 86 MM LT LAT DSTL 4 HOLE TI NS,SUP-2180876,CDM,C1713,HCPCS,0278,RC,,,,both,,,2523.62,1640.35,,,,,,,,,,,,,
PLATE BNE SCREW DIA 3.5 MM LG SS LT INTRAPELVIC ACET EXT,SUP-2905610,CDM,C1713,HCPCS,0278,RC,,,,both,,,9033.56,5871.81,,,,,,,,,,,,,
SHUNT CV L10CM DIA3.5X5MM SIL STR FULL SPR REINF SUNDT,SUP-2308221,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1890.31,1228.70,,,,,,,,,,,,,
SUPPORT ORTHOT SHLDR AIRPLANE DESIGN W/W O NONTORSION JT,SUP-2435754,CDM,L3674,HCPCS,0274,RC,,,,both,,,3045.61,1979.65,,,,,,,,,,,,,
BRACE KNEE BIOSKIN Q PAT TRK M,SUP-2174970,CDM,L1820,HCPCS,0272,RC,,,,both,,,165.67,107.69,,,,,,,,,,,,,
GRAFT BNE W22XL20MM THK75X12MM BICORT EVANS WDG FOR,SUP-2399096,CDM,C1734,HCPCS,0278,RC,,,,both,,,6204.64,4033.02,,,,,,,,,,,,,
CATHETER ART LN 5.5FR L15CM 2 LUMN MIDLN PRSS INJ ARROWG+ARD,SUP-2120617,CDM,C1751,HCPCS,0278,RC,,,,both,,,514.33,334.31,,,,,,,,,,,,,
SET SCR SPNL DIA5.5MM POST THORLUM TI BRK OFF FOR,SUP-2289459,CDM,C1713,HCPCS,0278,RC,,,,both,,,451.06,293.19,,,,,,,,,,,,,
STENT PERIPH PALMAZ GEN L 19 MM BALLOON L 17 MM DIA10 MM,SUP-2159189,CDM,C1877,HCPCS,0278,RC,,,,both,,,3749.16,2436.95,,,,,,,,,,,,,
CATHETER ABLATN B CRV 4 MM 7 FR SFT TIP THRMCPL NAVISTAR,SUP-2248470,CDM,C1732,HCPCS,0278,RC,,,,both,,,5802.72,3771.77,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED BPLR PRSS FT CHIPBIOBIPPRS] ZIMMER BIOMET INC],SUP-2137371,CDM,C1776,CPT,0278,RC,,,,both,,,11325.98,7361.89,,,,,,,,,,,,,
ALLOGRAFT BNE CUBE 15 CC FD ASEP CANC,SUP-2867066,CDM,C1762,CPT,0278,RC,,,,both,,,805.41,523.52,,,,,,,,,,,,,
CAP NAIL FEM RETRGRD,SUP-2467182,CDM,C1889,HCPCS,0278,RC,,,,both,,,589.94,383.46,,,,,,,,,,,,,
HEAD RADL SZ2 LAT STEM,SUP-2705945,CDM,C1776,CPT,0278,RC,,,,both,,,6869.85,4465.40,,,,,,,,,,,,,
GRAFT SYN H7.5XL20MM WDG BIOFOAM,SUP-2397880,CDM,C1713,HCPCS,0278,RC,,,,both,,,5099.36,3314.58,,,,,,,,,,,,,
GRAFT EVAR L120MM DIA25MM PROX 16MM DST AAA INTUITRAK,SUP-2217564,CDM,C1768,CPT,0278,RC,,,,both,,,33896.30,22032.59,,,,,,,,,,,,,
WASHER SCRW 17MM,SUP-2695514,CDM,C1713,HCPCS,0278,RC,,,,both,,,154.80,100.62,,,,,,,,,,,,,
GUIDEWIRE VASC HI TORQ COMMND ES L 300 CM DIA 0.014 IN TIP L,SUP-2105881,CDM,C1769,HCPCS,0272,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
SPACER SPNL XL W16XH6MM D14MM 7DEG ANT CERV PEEK LORD SELF,SUP-2231287,CDM,C1821,HCPCS,0278,RC,,,,both,,,2135.20,1387.88,,,,,,,,,,,,,
CANDESARTAN CILEXETIL 16 MG PO TABS,RX-23231,CDM,6370000000,HCPCS,0637,RC,33342-0116-07,NDC,,both,1,UN,4.70,3.05,,,,,,,,,,,,,
NAIL IM L150MM DIA13MM R HINDFOOT TI CANN LOK LAT BEND FLUT,SUP-2176983,CDM,C1713,HCPCS,0278,RC,,,,both,,,5611.31,3647.35,,,,,,,,,,,,,
HEAD FEM OD46MM ID28MM UNIV CO CHROM COMPHSVE SZ ARRY FOR,SUP-2379240,CDM,C1776,CPT,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
SHUNT CV SUNDT L 30 CM DSTL TBNG OD 3 MM ID 2 MM PROX TBNG,SUP-2308224,CDM,C1889,HCPCS,0278,RC,,,,both,,,2093.53,1360.79,,,,,,,,,,,,,
PLATE BNE L 265 X W 11.5 MM THK 3.6 MM SCREW DIA 3.5 MM 22 H 72463122,SUP-2933433,CDM,C1713,HCPCS,0278,RC,,,,both,,,8092.72,5260.27,,,,,,,,,,,,,
SCREW INTRF BIOSURE REGENESORB 9MMX35MM,SUP-2341924,CDM,C1713,HCPCS,0278,RC,,,,both,,,1019.90,662.93,,,,,,,,,,,,,
SUPPORT ORTHOT SHLDR AIRPLANE DESIGN W/W O NONTORSION JT,SUP-2435754,CDM,L3674,HCPCS,0272,RC,,,,both,,,3045.61,1979.65,,,,,,,,,,,,,
DRILL TWST FOR 13MM 5MM AND 6MM SCR,SUP-2365066,CDM,2720000010,LOCAL,0272,RC,,,,both,,,275.91,179.34,,,,,,,,,,,,,
SHELL ACET OD48MM UNIV TI HA POR CLUS H PRESSFIT PRI IMPL,SUP-2370239,CDM,C1776,CPT,0278,RC,,,,both,,,5359.98,3483.99,,,,,,,,,,,,,
IMPLANT BNE CONDUCTION KT BCI 602 STRL BONEBRIDGE,SUP-2905142,CDM,L8690,HCPCS,0278,RC,,,,both,,,17491.06,11369.19,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 70 CM DIA 7MM STR TW REINF SLDE GDS,SUP-2681201,CDM,C1768,CPT,0278,RC,,,,both,,,2189.21,1422.99,,,,,,,,,,,,,
BLADE GROSSMAN RETRACTOR WIDE REPLACEMENT,SUP-2707288,CDM,2720000010,LOCAL,0272,RC,,,,both,,,337.99,219.69,,,,,,,,,,,,,
BOTTLE DRNGE 500ML ACT VAC TECHNOLOGY W/ DRNGE LN PLEURX,SUP-2133739,CDM,C1729,HCPCS,0272,RC,,,,both,,,97.34,63.27,,,,,,,,,,,,,
HC NM Thyroid Uptake Sgl/Multi,PX-3417801400,CDM,78014,CPT,0341,RC,,,,both,,,4685.00,3045.25,,,,,,,,,,,,,
PLATE BNE 3.5X109 MM 9 HOLE SS DCP,SUP-2569141,CDM,C1713,HCPCS,0278,RC,,,,both,,,286.68,186.34,,,,,,,,,,,,,
SYSTEM BX ASPIR TRANSPERINEAL PRECISIONPOINT,SUP-2884258,CDM,2720000010,LOCAL,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
VALVE HYDROCEPHALUS 10 WITH SHUNT ASSISTANT PROGAV 2.0,SUP-2821861,CDM,C1889,HCPCS,0278,RC,,,,both,,,9344.33,6073.81,,,,,,,,,,,,,
GUIDEWIRE VASC L 50 CM DIA 0.018 IN SS PTFE SAFE-T-J STR FIX,SUP-2760058,CDM,C1769,HCPCS,0272,RC,,,,both,,,85.50,55.57,,,,,,,,,,,,,
ANCHOR SUT DIA6.5MM KNOTLESS MULTIFLEX S-ULTRA,SUP-2341942,CDM,C1713,HCPCS,0278,RC,,,,both,,,1120.98,728.64,,,,,,,,,,,,,
CATHETER TRAY PWR INJ 7 FRX20 CM CV 3L,SUP-2120603,CDM,C1751,HCPCS,0278,RC,,,,both,,,544.48,353.91,,,,,,,,,,,,,
SCREW BNE L45MM DIA4X5MM CORT CANN HDLSS TAPR PROF ACUTRK,SUP-2107222,CDM,C1713,HCPCS,0278,RC,,,,both,,,1190.06,773.54,,,,,,,,,,,,,
HANDLE BLDE FOR PLNTR FASCTMY ENDOTRAC,SUP-2362194,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1729.83,1124.39,,,,,,,,,,,,,
PLATE ADAPT 1.5MM 6H W/GUIDES STRL TI LCP,SUP-2546737,CDM,C1713,HCPCS,0278,RC,,,,both,,,1330.51,864.83,,,,,,,,,,,,,
TAP SURG DIA1.5MM FOR PLATING SYS TC-100,SUP-2343954,CDM,2720000010,LOCAL,0272,RC,,,,both,,,913.74,593.93,,,,,,,,,,,,,
KIT INTRO MAK L 15 CM DIA 5 FR GUIDEWIRE L 60 CM DIA 0.018,SUP-2303006,CDM,C1894,HCPCS,0272,RC,,,,both,,,110.69,71.95,,,,,,,,,,,,,
SHEARS ENDOSCP CRV FOR DA VINCI S HARM,SUP-2246580,CDM,C1713,HCPCS,0278,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
STABILIT MX FRACTURE KIT BASE LNG,SUP-2702592,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7309.92,4751.45,,,,,,,,,,,,,
SCREW BNE CANN 6.5 X 30 MM TI NS,SUP-2530787,CDM,C1713,HCPCS,0278,RC,,,,both,,,1162.74,755.78,,,,,,,,,,,,,
PLATE BNE L W10.1XL154MM THK3.5MM 11 H BILAT S STL STR RIG,SUP-2186218,CDM,C1713,HCPCS,0278,RC,,,,both,,,1647.21,1070.69,,,,,,,,,,,,,
ABUTMENT COCHLEAR 9MM BA300 BAHA,SUP-2823401,CDM,L8690,HCPCS,0278,RC,,,,both,,,6060.20,3939.13,,,,,,,,,,,,,
NEEDLE LOC 19GA 1CM MRK ZONE SPINPERC,SUP-2392620,CDM,C1713,HCPCS,0278,RC,,,,both,,,2358.77,1533.20,,,,,,,,,,,,,
PROSTHESIS OSS PISTON 0.4X4.75 MM RICHARD SPRING BK FLROPLAS,SUP-2637901,CDM,L8613,CPT,0278,RC,,,,both,,,529.69,344.30,,,,,,,,,,,,,
PLATE BNE T 119 MM RT DSTL DORS RADIAL 10 HOLE LCK SS,SUP-2410738,CDM,C1713,HCPCS,0278,RC,,,,both,,,2794.35,1816.33,,,,,,,,,,,,,
HC Clsd Tx Navicular Fx Manip,PX-4502562400,CDM,25624,CPT,0450,RC,,,,both,,,1633.00,1061.45,,,,,,,,,,,,,
CARTRIDGE BONE CEMENT MANIFOLD 8GA VERTEPORT X4,SUP-2876049,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1192.54,775.15,,,,,,,,,,,,,
DEVICE CSF FLO CTRL SIPHONGUARD,SUP-2243808,CDM,C1729,HCPCS,0272,RC,,,,both,,,2394.50,1556.42,,,,,,,,,,,,,
INTRODUCER SHTH 0.032 IN 5 FRX12 CM VEN PERC CATHER,SUP-2355247,CDM,C1894,HCPCS,0272,RC,,,,both,,,33.76,21.94,,,,,,,,,,,,,
SPACER SPNL W20XH8XL60MM M TRANSCONTINENTAL,SUP-2231326,CDM,C1821,HCPCS,0278,RC,,,,both,,,18526.00,12041.90,,,,,,,,,,,,,
MESH 3IN PTCH MK W POSIFLEX CIR W STRP AND PRESHAPED,SUP-2126066,CDM,C1781,HCPCS,0278,RC,,,,both,,,246.33,160.11,,,,,,,,,,,,,
PLATE BONE SM W11XL233MM THK3.3MM 0DEG 18 H BILAT TI STR RIG,SUP-2190798,CDM,C1713,HCPCS,0278,RC,,,,both,,,1518.88,987.27,,,,,,,,,,,,,
ONDANSETRON 4 MG PO TBDP,RX-27697,CDM,Q0162,HCPCS,0637,RC,16714-0200-10,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
HC Ultraviolet,PX-4209702800,CDM,97028,CPT,0420,RC,,,,both,,,194.00,126.10,,,,,,,,,,,,,
PROBE LITHO 9FR L120CM EHL,SUP-2313968,CDM,2720000010,LOCAL,0272,RC,,,,both,,,948.69,616.65,,,,,,,,,,,,,
STEM HUM 14MM MINI SHLDR CO CHROM COMPHSVE REV PRI CEM,SUP-2404567,CDM,C1776,CPT,0278,RC,,,,both,,,16010.86,10407.06,,,,,,,,,,,,,
BIT DRL OCCIPITOCERVICAL UP THOR NAVIGATED INFIN,SUP-2421075,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1609.03,1045.87,,,,,,,,,,,,,
RITONAVIR 100 MG PO TABS,RX-101897,CDM,6370000000,HCPCS,0637,RC,65862-0687-30,NDC,,both,1,UN,12.10,7.86,,,,,,,,,,,,,
HC Balloon Dilate Urtrl Strx,PX-3615070600,CDM,50706,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
CATHETER RENAL ACC 6FR L65CM TORC W/ INNR S STL BRAID COBRA,SUP-2171213,CDM,C1758,HCPCS,0278,RC,,,,both,,,113.67,73.89,,,,,,,,,,,,,
SCREW KIT TRAD EQUINOXE,SUP-2451372,CDM,C1713,HCPCS,0278,RC,,,,both,,,816.40,530.66,,,,,,,,,,,,,
SHORT CALCNL DRL 4.1MM,SUP-2244336,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1210.69,786.95,,,,,,,,,,,,,
IMPLANT OP RM MINI-MONSTER 2.0 X 12MM H,SUP-2320339,CDM,C1713,HCPCS,0278,RC,,,,both,,,671.18,436.27,,,,,,,,,,,,,
PLATE BNE STR 2-2.5X33X1.25 MM 4 HOLE FRAC TI LEVEL 1,SUP-2457057,CDM,C1713,HCPCS,0278,RC,,,,both,,,1836.30,1193.59,,,,,,,,,,,,,
PACEMAKER CARD W42.9XH40.2MM D7.5MM GENRTR SGL CHMBR ADAPTA,SUP-2282314,CDM,C1786,HCPCS,0275,RC,,,,both,,,9518.13,6186.78,,,,,,,,,,,,,
HC Bx Breast Add Lesion Strtctc,PX-3611908200,CDM,19082,CPT,0361,RC,,,,outpatient,,,3707.00,2409.55,,,,,,,,,,,,,
ANCHOR SUT GLOK XL,SUP-2589313,CDM,C1713,HCPCS,0278,RC,,,,both,,,666.72,433.37,,,,,,,,,,,,,
ENDCAP SPINAL 12MM X 5MM OFFSET,SUP-2587319,CDM,C1713,HCPCS,0278,RC,,,,both,,,454.70,295.55,,,,,,,,,,,,,
DRESSING WND MICRONIZED PARTIC 30 MG PWD MICROMATRIX,SUP-2106468,CDM,Q4118,HCPCS,0636,RC,,,,both,,,360.10,234.06,,,,,,,,,,,,,
MESH HERN L15XW15CM POLY OVL W O HYDRGEL BARR IMPL PARIETEX,SUP-2174804,CDM,C1781,HCPCS,0278,RC,,,,both,,,652.34,424.02,,,,,,,,,,,,,
SCREW BONE L65MM THRD DIA2.7MM HD DIA4.5MM COR DIA2MM PITCH,SUP-2349327,CDM,C1713,HCPCS,0278,RC,,,,both,,,290.89,189.08,,,,,,,,,,,,,
CANNULA ARTHSCP OBTURATOR SFT TISS STRL DISP INTEGRITY,SUP-2901938,CDM,2720000010,LOCAL,0272,RC,,,,both,,,540.08,351.05,,,,,,,,,,,,,
HC Skeletal Survey Large Bone,PX-3207707400,CDM,77074,CPT,0320,RC,,,,both,,,128.00,83.20,,,,,,,,,,,,,
RETRACTOR SPNL L4CM DIA22MM D1.57IN S STL TB MED LAT DIL,SUP-2292982,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1167.92,759.15,,,,,,,,,,,,,
GRAFT HUM TISS 220 300MM 65 85MM TIBIALIS POST,SUP-2335541,CDM,C1762,CPT,0278,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
HC So Tiss Trnsgltmnase Ea Ig Clas,PX-3028636466,CDM,86364,CPT,0302,RC,,,,both,,,36.00,23.40,,,,,,,,,,,,,
BLADE SAW PROPHECY INFIN,SUP-2397078,CDM,2720000010,LOCAL,0272,RC,,,,both,,,486.70,316.35,,,,,,,,,,,,,
SHEATH UROLOGY OD21FR ORNG CYSTOURETHROSCOPE USA ELITE SYS,SUP-2313053,CDM,C1894,HCPCS,0272,RC,,,,both,,,2331.51,1515.48,,,,,,,,,,,,,
COIL VASC AZUR HYDROCOIL L 10 CM DIA 5 MM 0.018 IN HELCL,SUP-2385387,CDM,C1889,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
STENT TRACHBRONCH WGRFT L 50 MM DIA10 MM CATH TOT L 116 CM,SUP-2148350,CDM,C1874,HCPCS,0278,RC,,,,both,,,5495.00,3571.75,,,,,,,,,,,,,
LGN EXT FLUTE PRESSFIT STEM 20MMX160MM,SUP-2822667,CDM,C1776,CPT,0278,RC,,,,both,,,4100.84,2665.55,,,,,,,,,,,,,
TUBE VENT ARMSTR R 1.14 MM 1 MM 2.7 MM FLROPLAS BLU 525502,SUP-2535157,CDM,L8699,HCPCS,0278,RC,,,,both,,,39.60,25.74,,,,,,,,,,,,,
PLATE BONE CRANIAL MESH 40.2X25.2X0.3MM TITANIUM NEURO PLATI,SUP-2826280,CDM,C1713,HCPCS,0278,RC,,,,both,,,1394.47,906.41,,,,,,,,,,,,,
SHOE CAST SM AD W4.25XL9.25IN W/ ROCK OPN TOE AND OPN HEEL,SUP-2203830,CDM,L4387,HCPCS,0274,RC,,,,both,,,35.33,22.96,,,,,,,,,,,,,
ALLOGRAFT BNE 10X10X16 MM BIOEXPAND,SUP-2637002,CDM,C1713,HCPCS,0278,RC,,,,both,,,3825.65,2486.67,,,,,,,,,,,,,
ALLOGRAFT BNE GRAN STRP 1 CC HA/TCP CLLGN VENADO 4815T5011,SUP-2718006,CDM,C1713,HCPCS,0278,RC,,,,both,,,803.24,522.11,,,,,,,,,,,,,
SCREW BNE 1.5X4 MM DRL FREE,SUP-2262613,CDM,C1713,HCPCS,0278,RC,,,,both,,,130.00,84.50,,,,,,,,,,,,,
IMMOBILIZER KNEE CUTAWAY W PAT STRP 20IN,SUP-2195122,CDM,L1830,CPT,0272,RC,,,,both,,,58.69,38.15,,,,,,,,,,,,,
WIRE FIX L600MM DIA1MM CERCLAGE S STL PRECUT SMOOTH W/,SUP-2186838,CDM,2720000010,LOCAL,0272,RC,,,,both,,,341.88,222.22,,,,,,,,,,,,,
KIT ISOLATED ACUSINCH,SUP-2106901,CDM,C1713,HCPCS,0278,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
GRAFT DURA XS 3X1 IN REGEN MTRX DURAGN,SUP-2624231,CDM,C1763,HCPCS,0278,RC,,,,both,,,2695.94,1752.36,,,,,,,,,,,,,
MIXER BNE CEM 120GM 3 MIX OPTVAC VAC SYS 60050120] ENCORE MEDICAL - DJO SURGICAL],SUP-2217405,CDM,C1713,HCPCS,0278,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
CATHETER ANGIOPLSTY CROSPERIO L 150 CM L 80MM DIA 4 MM OTW,SUP-2761745,CDM,C1725,HCPCS,0272,RC,,,,both,,,838.38,544.95,,,,,,,,,,,,,
DEFIBRILLATOR CARD W5.5CM 20SEC 3 CHMBR CARD,SUP-2138071,CDM,C1882,HCPCS,0275,RC,,,,both,,,55753.84,36240.00,,,,,,,,,,,,,
PLATE BNE LOK COMPR FOR 3.5MM SCR SYS,SUP-2413709,CDM,C1713,HCPCS,0278,RC,,,,both,,,942.16,612.40,,,,,,,,,,,,,
PLATE BNE L 2.19 IN MED TI ALLOY RT 2ND/3RD DORS FT LP,SUP-2912926,CDM,C1713,HCPCS,0278,RC,,,,both,,,7856.28,5106.58,,,,,,,,,,,,,
AGENT HEMSTAT W2XL4IN FIBRIN SEAL PTCH DSG EVARREST,SUP-2257603,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2433.50,1581.77,,,,,,,,,,,,,
IMPLANT OTO L4.25MM PIST DIA0.5MM NIT FLROPLAS SMRT,SUP-2313863,CDM,2780000010,LOCAL,0278,RC,,,,both,,,831.06,540.19,,,,,,,,,,,,,
HYDROCODONE-ACETAMINOPHEN 10-325 MG PO TABS,RX-28384,CDM,6370000000,HCPCS,0637,RC,00406-0125-23,NDC,,both,1,UN,3.20,2.08,,,,,,,,,,,,,
PLATE BONE L104MM 7 H STRL RT POSTEROMEDIAL PROX TIB S STL T,SUP-2349730,CDM,C1713,HCPCS,0278,RC,,,,both,,,8634.84,5612.65,,,,,,,,,,,,,
ANCHOR SUT NO 2 SUT TI KT SHLDR FIX QUIK T KNOT PUSH SUT CUT,SUP-2341071,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1102.14,716.39,,,,,,,,,,,,,
CATHETER ANGIOPLSTY SLOM L 135 CM DIA 3.7 FR BALLOON L 20 MM,SUP-2153854,CDM,C1725,HCPCS,0272,RC,,,,both,,,787.51,511.88,,,,,,,,,,,,,
MESH CRAN W90XL90MM THK0.6MM CRANIOMAXILLOFACIAL G TI DYN,SUP-2366219,CDM,C1713,HCPCS,0278,RC,,,,both,,,4798.45,3118.99,,,,,,,,,,,,,
AGENT VISCOELASTIC 0.85 CC COHESIVE HEALON GV PRO,SUP-2753859,CDM,C1814,HCPCS,0278,RC,,,,both,,,109.90,71.43,,,,,,,,,,,,,
SUPPORT ORTHOT HIP CUST ABDUCTN FLX FREJKA CVR ONLY,SUP-2435596,CDM,L1610,HCPCS,0272,RC,,,,both,,,154.96,100.72,,,,,,,,,,,,,
CATHETER ANGIOPLSTY MARSH L 75 CM BALLOON L 40 MM DIA 9 MM,SUP-2141029,CDM,C1725,HCPCS,0272,RC,,,,both,,,660.66,429.43,,,,,,,,,,,,,
PLATE BNE L276MM 11 H NONSTERILE R DST FEM TI LOK COMPR FOR,SUP-2190727,CDM,C1713,HCPCS,0278,RC,,,,both,,,5031.91,3270.74,,,,,,,,,,,,,
CATHETER GUID WINGMAN 35 L 65 CM OD 0.06 IN TIP DIA 0.050 IN,SUP-2227768,CDM,C1887,HCPCS,0272,RC,,,,both,,,2028.44,1318.49,,,,,,,,,,,,,
PLATE BNE 6 H CRANIOMAXILLOFACIAL TI LO PROF DBL Y W/ BAR,SUP-2366208,CDM,C1713,HCPCS,0278,RC,,,,both,,,560.80,364.52,,,,,,,,,,,,,
STYLET GUID PRECALIBRATED INCORPORATED PASS MRK PLT DISP,SUP-2150267,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1679.90,1091.93,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED PERSONA,SUP-2212184,CDM,C1776,CPT,0278,RC,,,,both,,,16485.00,10715.25,,,,,,,,,,,,,
BOOT CAST L W525XL125IN M SHOE SZ 12 155 CANVS THCK ROCK,SUP-2276729,CDM,L4387,HCPCS,0272,RC,,,,both,,,18.40,11.96,,,,,,,,,,,,,
BIT DRL L260MM DIA11MM CANN FOR IM LIMB LENGTHENING SYS,SUP-2312223,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1748.98,1136.84,,,,,,,,,,,,,
BLADE SAW KNEE 18.5MM CUT EDGE 90MM CUT DEPTH 1.26MM CUT THI,SUP-2605517,CDM,2720000010,LOCAL,0272,RC,,,,both,,,240.05,156.03,,,,,,,,,,,,,
HC So1 Immunofluoresc per Spec 1st Ab,PX-3128834667,CDM,88346,CPT,0312,RC,,,,both,,,12.00,7.80,,,,,,,,,,,,,
BLADE SURG SAW SAG 90 MM LEN 1.2 MM BLDE THICKNESS 25.4 MM W,SUP-2166684,CDM,2720000010,LOCAL,0272,RC,,,,both,,,118.06,76.74,,,,,,,,,,,,,
PLATE BONE SM LT ANTEROLATERAL,SUP-2398500,CDM,C1713,HCPCS,0278,RC,,,,both,,,7457.50,4847.37,,,,,,,,,,,,,
KIT DIL PRB K WIRE DISP FOR EXTRM LUM INTBDY FUS,SUP-2310420,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2778.90,1806.28,,,,,,,,,,,,,
PLATE BNE THK05MM 2X2 H UNIV CRANIOMAXILLOFACIAL TI 3D MAL,SUP-2366229,CDM,C1713,HCPCS,0278,RC,,,,both,,,564.60,366.99,,,,,,,,,,,,,
ELECTRODE ELECSURG MONOPOLAR 5X400 MM FLAT HI FREQ LNG HK,SUP-2797664,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1069.70,695.30,,,,,,,,,,,,,
TUBE GASTROSTMY 24FR 34 CM,SUP-2149750,CDM,C1713,HCPCS,0278,RC,,,,both,,,538.51,350.03,,,,,,,,,,,,,
SET PD SM SURF COOL STX,SUP-2416135,CDM,C1713,HCPCS,0278,RC,,,,both,,,2009.10,1305.91,,,,,,,,,,,,,
DEVICE ARTOTMY CLOSURE MYNXGRIP DIA 6/7 FR 10 ML FEM ART ADV,SUP-2155681,CDM,C1760,HCPCS,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
PACEMAKER CARD EVIA SR SINGLE CHMBR W/ CLS AUTO RESPON STRL,SUP-2138258,CDM,C1786,HCPCS,0275,RC,,,,both,,,12246.00,7959.90,,,,,,,,,,,,,
BUR SURG DIAMOND SUPER LNG 60 K 3 MM HI SPD UNIDRIVE DISP,SUP-2599302,CDM,2720000010,LOCAL,0272,RC,,,,both,,,472.19,306.92,,,,,,,,,,,,,
BOOT CAST L W525XL125IN M SHOE SZ 12 155 CANVS THCK ROCK,SUP-2276729,CDM,L4387,HCPCS,0274,RC,,,,both,,,18.40,11.96,,,,,,,,,,,,,
IMPLANT FACE 38 X 50 MM THK 0.85 MM POLYETHYL CRANIOFACIAL,SUP-2883226,CDM,C1713,HCPCS,0278,RC,,,,both,,,1374.19,893.22,,,,,,,,,,,,,
PI PICC KIT: 2L 5.5FR 55CM AGBA TIPTRACK,SUP-2827053,CDM,C1751,HCPCS,0278,RC,,,,both,,,799.66,519.78,,,,,,,,,,,,,
WIRE FIX THRD 2.5 MM OLV DISP,SUP-2417726,CDM,2720000010,LOCAL,0272,RC,,,,both,,,458.44,297.99,,,,,,,,,,,,,
MESH SURG 34CM LEN 26CM W THK2MM SYN ABD N ABSRB RECT EXP,SUP-2125810,CDM,C1781,HCPCS,0278,RC,,,,both,,,12560.00,8164.00,,,,,,,,,,,,,
CROWN DENT NODUL-7 1ST PRI M UP L S STL,SUP-2322214,CDM,D6783,CPT,0278,RC,,,,both,,,156.65,101.82,,,,,,,,,,,,,
ATAZANAVIR SULFATE 150 MG PO CAPS,RX-36149,CDM,6370000000,HCPCS,0637,RC,42385-0920-60,NDC,,both,1,UN,13.40,8.71,,,,,,,,,,,,,
CUP ACET CONSTRN STD 32X48 MM HIP SNAP IN ALL POLYETH ZCA,SUP-2203662,CDM,C1776,CPT,0278,RC,,,,both,,,5044.10,3278.66,,,,,,,,,,,,,
RING PESSARY RNG 5 KNOB SIL,SUP-2171733,CDM,A4562,HCPCS,0274,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
ANCHOR SUT L14.5MM DIA3MM W/ SZ 2 FIBERWIRE BIO-SUTTAK(ORDER MULTIPLES OF 5EA),SUP-2121590,CDM,C1713,HCPCS,0278,RC,,,,both,,,769.30,500.04,,,,,,,,,,,,,
HC So1 Ptt,PX-3058573067,CDM,85730,CPT,0305,RC,,,,both,,,36.00,23.40,,,,,,,,,,,,,
STEM FEM L135MM OD11MM STR MOD SEG FORGED HIP TI ACUMATCH,SUP-2222137,CDM,C1776,CPT,0278,RC,,,,both,,,4314.67,2804.54,,,,,,,,,,,,,
TUBE VENT L12MM ID1.14MM SIL GOODE T,SUP-2284010,CDM,L8699,HCPCS,0278,RC,,,,both,,,109.21,70.99,,,,,,,,,,,,,
RESERVOIR VENTRICULAR DRAINAGE 18CM CATHETER LENGTH 20MM DIA,SUP-2830489,CDM,C1729,HCPCS,0272,RC,,,,both,,,1681.94,1093.26,,,,,,,,,,,,,
HC Cystourethroscopy (Separate Procedure),PX-4505200000,CDM,52000,CPT,0450,RC,,,,both,,,706.00,458.90,,,,,,,,,,,,,
RING FIX SM FOR 16-21IN OPN BK BAIL HALO,SUP-2328128,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4408.56,2865.56,,,,,,,,,,,,,
SUPPORT ORTHOT HIP CUST ABDUCTN CTRL SEMI FLX,SUP-2435597,CDM,L1630,HCPCS,0274,RC,,,,both,,,598.11,388.77,,,,,,,,,,,,,
PACEMAKER CARD 10.4ML W50XH47MM THK6MM IS-1 CONN 2 CHMBR,SUP-2356464,CDM,C1785,HCPCS,0275,RC,,,,both,,,10990.00,7143.50,,,,,,,,,,,,,
RING EXT FIX DIA210MM LNG FT C FBR FOR HOFF LRF SYS,SUP-2363178,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6694.79,4351.61,,,,,,,,,,,,,
PLATE BNE TIB 36 MM POST 5 HOLE Y SHP,SUP-2865069,CDM,C1713,HCPCS,0278,RC,,,,both,,,4311.22,2802.29,,,,,,,,,,,,,
BLADE LUM 27X80MM TURQ MCCULLOCH,SUP-2161659,CDM,2720000010,LOCAL,0272,RC,,,,both,,,693.94,451.06,,,,,,,,,,,,,
PLATE BONE LNG L27MM THK0.6MM 6 H MIDFACE SLV TI STR FOR,SUP-2402874,CDM,C1713,HCPCS,0278,RC,,,,both,,,332.84,216.35,,,,,,,,,,,,,
LEUPROLIDE ACETATE (3 MONTH) 22.5 MG SC KIT,RX-33669,CDM,J9217,HCPCS,0636,RC,62935-0223-05,NDC,,both,1,UN,1512.00,982.80,,,,,,,,,,,,,
KIT ASMBLY TI PENILE IMPL,SUP-2165316,CDM,C1713,HCPCS,0278,RC,,,,both,,,1485.22,965.39,,,,,,,,,,,,,
CLAMP THRCSCPC DUVAL 10MM/11MM DIA 13 1/2NL TRNGLR RING LEFT,SUP-2484902,CDM,C1713,HCPCS,0278,RC,,,,both,,,2407.81,1565.08,,,,,,,,,,,,,
Z INACTIVATING USE 2718717 LASER FIBER FLEXIVA PULSE ID 365,SUP-2718716,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1000.78,650.51,,,,,,,,,,,,,
PLATE BNE 4 H L SLNT STR COMPR LISFRANC GORILLA,SUP-2321514,CDM,C1713,HCPCS,0278,RC,,,,both,,,4945.50,3214.57,,,,,,,,,,,,,
ANCHOR SUT DIA5.5MM PEEK ZIP W/ NDL (ORDER MUTLIPLES OF 5 EACH),SUP-2366666,CDM,C1713,HCPCS,0278,RC,,,,both,,,736.71,478.86,,,,,,,,,,,,,
INTRODUCER PACE LD L 60 CM DIA 7 FR PEELABLE FOR TRNSVEN,SUP-2282101,CDM,C1894,HCPCS,0272,RC,,,,both,,,183.69,119.40,,,,,,,,,,,,,
CONE TIB AUG MED 25 MM KNEE REGENEREX POROUS TI,SUP-2441909,CDM,C1776,CPT,0278,RC,,,,both,,,2501.01,1625.66,,,,,,,,,,,,,
HC Brain Imaging Pet,PX-4047860800,CDM,78608,CPT,0404,RC,,,,inpatient,,,5713.00,3713.45,,,,,,,,,,,,,
GRAFT BNE SUB W25XH8XL100MM 20ML SIL SOD CA PHOS OXIDE FOAM,SUP-2368188,CDM,C1713,HCPCS,0278,RC,,,,both,,,8160.08,5304.05,,,,,,,,,,,,,
HEAD FEM 12/14 TAPR ZIRCONIA 28MM +0 NOVATION ELEMENT,SUP-2222106,CDM,C1776,CPT,0278,RC,,,,both,,,4772.80,3102.32,,,,,,,,,,,,,
PROBESAPHYRE ALBLATION-S 60DE,SUP-2341622,CDM,2720000010,LOCAL,0272,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
CONNECTOR SPNL DIA5.5X5.5MM TI OPN SIDE LD ROD TO ROD ARMDA,SUP-2311885,CDM,C1713,HCPCS,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
PLATE BNE M L14MM ID4.2MM 0DEG NONLOCKING COMPR FOR L MT,SUP-2321448,CDM,C1713,HCPCS,0278,RC,,,,both,,,5198.27,3378.88,,,,,,,,,,,,,
CATHETER HD 14 FRX28 CM ASH SPLIT CATH,SUP-2269571,CDM,C1751,HCPCS,0278,RC,,,,both,,,750.46,487.80,,,,,,,,,,,,,
SPHINCTEROTOME ENDO L20MM OD6-5FR 2 LUMN GWIRE BRAID,SUP-2169135,CDM,C1713,HCPCS,0278,RC,,,,both,,,342.26,222.47,,,,,,,,,,,,,
HC Blood Culture Multiplex Pcr 2,PX-3008715400,CDM,87154,CPT,0300,RC,,,,inpatient,,,524.00,340.60,,,,,,,,,,,,,
ALLOGRAFT BNE PLATE LG FRZN ASEP TIB,SUP-2867059,CDM,C1762,CPT,0278,RC,,,,both,,,2523.62,1640.35,,,,,,,,,,,,,
PLATE TI LOCKING 1.3MM 3H HEAD 5H SHAFT STERILE,SUP-2546880,CDM,C1713,HCPCS,0278,RC,,,,both,,,1538.85,1000.25,,,,,,,,,,,,,
ALLOGRAFT DERMAL 1X1 CMX0.76-1.25 MM DECELL DERM ORACELL,SUP-2741063,CDM,C1713,HCPCS,0278,RC,,,,both,,,232.86,151.36,,,,,,,,,,,,,
BRACE WLK L 105 12MM M 115 13MM FEM STD TWO LAYR MEM FOAM,SUP-2195488,CDM,L4360,HCPCS,0274,RC,,,,both,,,82.30,53.49,,,,,,,,,,,,,
KIT CATH HEMODIALYSI SFT CELL CHRONIC STD 12.5FR DIA 27CM 12,SUP-2613293,CDM,C1750,HCPCS,0278,RC,,,,both,,,629.73,409.32,,,,,,,,,,,,,
SET INT FIX SCREW DIA1.5 MM 4 H LNG TI NEURO STR PLT 1 PK,SUP-2935613,CDM,C1713,HCPCS,0278,RC,,,,both,,,1265.42,822.52,,,,,,,,,,,,,
STENT ESOPH HANAROSTENT L 100 MM DIA22 MM DEL SYS L 700 MM,SUP-2498307,CDM,C1874,HCPCS,0278,RC,,,,both,,,6860.90,4459.58,,,,,,,,,,,,,
RELOAD STPLR L45MM GRN ENDOWRIST,SUP-2246811,CDM,2720000010,LOCAL,0272,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
HC Pulmonary Arteriogram Bil,PX-3237574300,CDM,75743,CPT,0323,RC,,,,outpatient,,,7211.00,4687.15,,,,,,,,,,,,,
SHEATH INTRO SILHOUETTE PEELWY L 30 CM DIA16 FR GUIDEWIRE,SUP-2168321,CDM,C1894,HCPCS,0272,RC,,,,both,,,154.65,100.52,,,,,,,,,,,,,
COIL VASC HILAL MICROCOIL EMBOLUS L 6 CM DIA 7 MM CATH DIA,SUP-2168196,CDM,C1889,HCPCS,0278,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
SET PROC AUTO 3 SENS TECHNOLOGY FOR APPL TO ORTH PRP SITE,SUP-2120729,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
RETRACTOR SURG SM 6CM SFT TISS GREATER TEAR RESISTANCE LO,SUP-2214621,CDM,2720000010,LOCAL,0272,RC,,,,both,,,879.20,571.48,,,,,,,,,,,,,
HC So1 Factor IX,PX-3058525067,CDM,85250,CPT,0305,RC,,,,both,,,53.00,34.45,,,,,,,,,,,,,
Z DISCONTINUED NO SUB IDED STAPLER INT DIA33MM STPL L4MM KNF DIA24.4MM 2 ROW,SUP-2219808,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1248.15,811.30,,,,,,,,,,,,,
FILTER VASC DENALI SHTH L 55 CM VENA CAVA KT EMB FEM DEL ADV,SUP-2126818,CDM,C1880,HCPCS,0278,RC,,,,both,,,5259.50,3418.67,,,,,,,,,,,,,
FIBER LASER 200 MICRON 3/PKG STERILE INCLUDES 1,SUP-2574061,CDM,2720000010,LOCAL,0272,RC,,,,both,,,902.12,586.38,,,,,,,,,,,,,
"HC So Sodium, Other Source",PX-3018430266,CDM,84302,CPT,0301,RC,,,,both,,,32.00,20.80,,,,,,,,,,,,,
SUPPORT ORTHOT CUST LIFT ELEVATION MTL EXTN,SUP-2435717,CDM,L3330,HCPCS,0272,RC,,,,both,,,1602.25,1041.46,,,,,,,,,,,,,
CATHETER URET 3FR L70CM 0.018IN PVC OPN END FOR DRNGE RG,SUP-2171250,CDM,C1758,HCPCS,0278,RC,,,,both,,,42.86,27.86,,,,,,,,,,,,,
SCREW BNE L18MM DIA2.7MM LOK FOR R3CON TECHNOLOGY GORILLA,SUP-2321280,CDM,C1713,HCPCS,0278,RC,,,,both,,,527.52,342.89,,,,,,,,,,,,,
ALLODERM SELECT RESTORE EXTRA LARGE - THICK 2.4 0.4MM,SUP-2826665,CDM,Q4116,HCPCS,0636,RC,,,,both,,,44182.94,28718.91,,,,,,,,,,,,,
BLADE SAW SAG 9.5MMW X7.5MML 0.4MM THK 0.6MM THK CUT SM BNE,SUP-2605377,CDM,2720000010,LOCAL,0272,RC,,,,both,,,83.93,54.55,,,,,,,,,,,,,
PLATE BNE W12XL135MM THK1MM 8 H BILAT TI SEMI TBLR LO PROF,SUP-2190706,CDM,C1713,HCPCS,0278,RC,,,,both,,,316.10,205.46,,,,,,,,,,,,,
PLATE BNE T 4 HOLE FLAT,SUP-2315927,CDM,C1713,HCPCS,0278,RC,,,,both,,,2672.14,1736.89,,,,,,,,,,,,,
PORT IMPL INFUSION ILLUMINATED 20 GA MIC FORCEP,SUP-2213471,CDM,C1788,HCPCS,0278,RC,,,,both,,,269.51,175.18,,,,,,,,,,,,,
DEVICE ENDOSKELETAL SYS PROSTHETIC BK TOT CONTACT,SUP-2388207,CDM,L5637,HCPCS,0274,RC,,,,both,,,894.59,581.48,,,,,,,,,,,,,
PLATE BONE L77MM 6 H STRL S STL COMPR FOR 3.5MM SCR EVOS,SUP-2349637,CDM,C1713,HCPCS,0278,RC,,,,both,,,1066.03,692.92,,,,,,,,,,,,,
BIT DRL L120MM DIA2MM JCBS CHK END,SUP-2399751,CDM,2720000010,LOCAL,0272,RC,,,,both,,,449.02,291.86,,,,,,,,,,,,,
BROACH SURG STD HUM,SUP-2372571,CDM,C1776,CPT,0278,RC,,,,both,,,3173.91,2063.04,,,,,,,,,,,,,
CROWN DENT LR6 SEC PRI M INDIV SPACE MAINTAINER,SUP-2176712,CDM,D6783,CPT,0278,RC,,,,both,,,20.35,13.23,,,,,,,,,,,,,
HEMI TOE IMPL K2 SZ 1,SUP-2243069,CDM,C1776,CPT,0278,RC,,,,both,,,4681.74,3043.13,,,,,,,,,,,,,
IMPLANT SYS DX KL SLEEVE BC 4.75 MM CC FT,SUP-2815108,CDM,C1713,HCPCS,0278,RC,,,,both,,,3124.30,2030.79,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED STD HD LNR COCR POLYETH,SUP-2267787,CDM,C1776,CPT,0278,RC,,,,both,,,13542.82,8802.83,,,,,,,,,,,,,
GRAFT BONE SUB 5CC VOID FIL OSTEOCRETE,SUP-2138671,CDM,C1713,HCPCS,0278,RC,,,,both,,,4631.50,3010.47,,,,,,,,,,,,,
DEVICE ENDOSKELETAL SYS PROSTHETIC BK TOT CONTACT,SUP-2388207,CDM,L5637,HCPCS,0272,RC,,,,both,,,894.59,581.48,,,,,,,,,,,,,
CATHETER HEMO DYLS OR HD L24CM OD14.5FR POLYUR 2 LUMN SPL,SUP-2126523,CDM,C1750,HCPCS,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
ALLOGRAFT BNE CRYOPRESERVED 13 MM FRSH PROCHONDRIX CR,SUP-2717804,CDM,C1762,CPT,0278,RC,,,,both,,,13184.86,8570.16,,,,,,,,,,,,,
CATHETER CV DL 4 FRX13 CM BASIC KT ARROWG+ARD,SUP-2383314,CDM,C1751,HCPCS,0278,RC,,,,both,,,154.17,100.21,,,,,,,,,,,,,
CLIP HEMSTAT TI CHEVRON SHP INTLOK ATRAUM TEETH MICROCLP,SUP-2382613,CDM,C1760,HCPCS,0278,RC,,,,both,,,32.44,21.09,,,,,,,,,,,,,
BATTALION LAT INTDISC SHIM STRL,SUP-2114089,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1036.20,673.53,,,,,,,,,,,,,
SHUNT CAR L30CM TBNG OD4X5MM ID2X3MM EAE SUNDT,SUP-2308227,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2585.04,1680.28,,,,,,,,,,,,,
KIT PICC CATH AD 5FR L55CM GWIRE L13 1/8IN 0.018IN POLYUR,SUP-2383477,CDM,C1751,HCPCS,0278,RC,,,,both,,,175.97,114.38,,,,,,,,,,,,,
COMPONENT FEM SZ 5 L KNEE TOT STBL TRIATHLON,SUP-2372989,CDM,C1776,CPT,0278,RC,,,,both,,,14927.56,9702.91,,,,,,,,,,,,,
PLATE BNE BROAD 3.5X289 MM 22 HOLE SS LCP,SUP-2569346,CDM,C1713,HCPCS,0278,RC,,,,both,,,633.81,411.98,,,,,,,,,,,,,
RING EXT FIX OPEN ALUMINIUM DIA180 MM,SUP-2472823,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3762.98,2445.94,,,,,,,,,,,,,
BUR SURG CYL 7.6 MMX14 CM FLUT LG BOR MIDAS REX LEGEND,SUP-2627698,CDM,2720000010,LOCAL,0272,RC,,,,both,,,403.62,262.35,,,,,,,,,,,,,
NAIL IM L240MM DIA9MM UNIV HUM BLU TI CANN LOK RND CRSS,SUP-2179637,CDM,C1713,HCPCS,0278,RC,,,,both,,,4877.61,3170.45,,,,,,,,,,,,,
BIT DRL SURG 1.6MM SURG W/ 26MM STP IQ SER,SUP-2136986,CDM,2720000010,LOCAL,0272,RC,,,,both,,,440.29,286.19,,,,,,,,,,,,,
DRILL SURG 1.8 MM 2.8 MM FOR ANCHR TI TWINFIX,SUP-2849117,CDM,2720000010,LOCAL,0272,RC,,,,both,,,379.72,246.82,,,,,,,,,,,,,
SET CBL SL SM DIA2MM VIT FOR RECON AND TRAUM SYS DALL-M,SUP-2377565,CDM,C1776,CPT,0278,RC,,,,both,,,738.53,480.04,,,,,,,,,,,,,
GRAFT HUM TISS L 115 X W 11 MM PLGA DBM RESRB STRL,SUP-2928389,CDM,Q4118,HCPCS,0636,RC,,,,both,,,13753.20,8939.58,,,,,,,,,,,,,
POTASSIUM CITRATE ER 10 MEQ (1080 MG) PO TBCR,RX-11083,CDM,6370000000,HCPCS,0637,RC,31722-0130-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
KIT VOID FILL STIMULAN RAP CURE 20CC,SUP-2135335,CDM,C1713,HCPCS,0278,RC,,,,both,,,8007.00,5204.55,,,,,,,,,,,,,
PLATE BONE M THK0.6MM 2 H MIDFACE SLV TI STR FOR 2MM SCR,SUP-2402932,CDM,C1713,HCPCS,0278,RC,,,,both,,,213.52,138.79,,,,,,,,,,,,,
HC Inj Cvad W/Fluoro,PX-3613659800,CDM,36598,CPT,0361,RC,,,,inpatient,,,3707.00,2409.55,,,,,,,,,,,,,
PIN DISTR AD AND PED L12MM ANT CERV R OR L,SUP-2290991,CDM,C1713,HCPCS,0278,RC,,,,both,,,360.66,234.43,,,,,,,,,,,,,
GRAFT BNE L160 180MM DIA4 6MM SEMITENDINOSUS TEND HAMSTRING,SUP-2264639,CDM,C1713,HCPCS,0278,RC,,,,both,,,2525.78,1641.76,,,,,,,,,,,,,
SCREW BONE CORT ST,SUP-2184533,CDM,C1713,HCPCS,0278,RC,,,,both,,,67.95,44.17,,,,,,,,,,,,,
BLADE SHV L13CM DIA4MM 360DEG STR SHFT ROT DISP FOR,SUP-2284160,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1210.66,786.93,,,,,,,,,,,,,
EXPANDER TISS NACL 5.3 CM PROJCT 12X12.5 CM 400 CC 133FV,SUP-2113117,CDM,C1789,HCPCS,0278,RC,,,,both,,,4239.00,2755.35,,,,,,,,,,,,,
PLATE BNE W14XL149MM THK3.8MM 7 H R LAT TIB HD BTTRS S STL,SUP-2185777,CDM,C1713,HCPCS,0278,RC,,,,both,,,4101.22,2665.79,,,,,,,,,,,,,
SCREW BNE PART THRD 2.7X26 MM LCK,SUP-2363947,CDM,C1713,HCPCS,0278,RC,,,,both,,,229.16,148.95,,,,,,,,,,,,,
PROSTHESIS PENILE 65ML INFL RESVR ULTREX AMS 700,SUP-2140279,CDM,C1813,HCPCS,0278,RC,,,,both,,,2904.50,1887.92,,,,,,,,,,,,,
COIL VASC 3D SFT 6MM DIA 12CM LEN .010IN GWIRE STRTCH,SUP-2173668,CDM,C1889,HCPCS,0278,RC,,,,both,,,3432.02,2230.81,,,,,,,,,,,,,
WIRE FIX 0.7X127 MM SS KIRSCHNER,SUP-2412972,CDM,C1713,HCPCS,0278,RC,,,,both,,,35.61,23.15,,,,,,,,,,,,,
LEAD NEUROSTIMULATOR L43CM DIA3MM SGL PIN SIL INSUL VNS,SUP-2175909,CDM,C1778,HCPCS,0278,RC,,,,both,,,9809.36,6376.08,,,,,,,,,,,,,
CATHETER GUID JARIT L 18 IN WORKING L 340 MM DIA 4 FR TIP W,SUP-2488570,CDM,C1769,HCPCS,0272,RC,,,,both,,,44.62,29.00,,,,,,,,,,,,,
CLIP INT LIG MED TI BLU,SUP-2757592,CDM,C1889,HCPCS,0278,RC,,,,both,,,8.07,5.25,,,,,,,,,,,,,
HC So Prolactin,PX-3018414666,CDM,84146,CPT,0301,RC,,,,both,,,64.00,41.60,,,,,,,,,,,,,
GUIDEWIRE SURG L1000MM DIA3MM S STL IM SMOOTH TIP,SUP-2362246,CDM,C1769,HCPCS,0272,RC,,,,both,,,667.25,433.71,,,,,,,,,,,,,
PLATE BNE L182MM THK37MM 14 H BILAT S STL STR LO PROF RIG,SUP-2177146,CDM,C1713,HCPCS,0278,RC,,,,both,,,2656.53,1726.74,,,,,,,,,,,,,
VUTRISIRAN SODIUM 25 MG/0.5ML SC SOSY,RX-158762,CDM,J0225,HCPCS,0636,RC,71336-1003-01,NDC,,both,0.5,ML,176044.10,114428.66,,,,,,,,,,,,,
PLATE BNE W24.4XL175.3MM STD EXTRA EXT ANAT R GUID DVR,SUP-2414031,CDM,C1713,HCPCS,0278,RC,,,,both,,,5250.08,3412.55,,,,,,,,,,,,,
RASBURICASE 1.5 MG IV SOLR,RX-33591,CDM,J2783,HCPCS,0636,RC,00024-5150-10,NDC,,both,1,UN,3265.70,2122.70,,,,,,,,,,,,,
RETRACTOR FAN 15IN 5 FINGER 10MM,SUP-2243665,CDM,C1713,HCPCS,0278,RC,,,,both,,,3254.80,2115.62,,,,,,,,,,,,,
ANALYZER COAG 2 TUBE 2 PLT RICH FBRN MTRX AUTOLGS PLT SYS,SUP-2307547,CDM,C1713,HCPCS,0278,RC,,,,both,,,1582.56,1028.66,,,,,,,,,,,,,
BLADE SAW W10XL70MM THK1.19MM RECIP CEM PK FOR SYNTHES PWR,SUP-2136840,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1214.40,789.36,,,,,,,,,,,,,
RAIL EXT FIX TRANSITION 5.5X495 MM CONTOURED 4D TI MESA,SUP-2517549,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6987.38,4541.80,,,,,,,,,,,,,
MESH SURG W200XL200MM THK1.5MMXCM ABD WALL BIOLOGIC PORCINE,SUP-2194312,CDM,C1763,HCPCS,0278,RC,,,,both,,,37122.02,24129.31,,,,,,,,,,,,,
KIT CATHETER ARTERIAL 20GA 4.45CM RADIAL,SUP-2865692,CDM,C1751,HCPCS,0278,RC,,,,both,,,158.88,103.27,,,,,,,,,,,,,
CATHETER HD SHT TERM 11.5 FRX15 CM DL TAPR SET SIL HEMCATH,SUP-2627305,CDM,C1752,HCPCS,0278,RC,,,,both,,,30.58,19.88,,,,,,,,,,,,,
ALLOGRAFT HUM TISS PTCH 2X2 CM 2 LAYR AMNION STERISHIELD II,SUP-2138663,CDM,C1713,HCPCS,0278,RC,,,,both,,,4945.50,3214.57,,,,,,,,,,,,,
HC Exam & Select Archive Tissue Molecular Analysi,PX-3108836300,CDM,88363,CPT,0310,RC,,,,both,,,51.00,33.15,,,,,,,,,,,,,
SCREW BONE L4MM DIA2MM CORT CRANIOMAXILLOFACIAL TI COARSE,SUP-2189660,CDM,C1713,HCPCS,0278,RC,,,,both,,,248.37,161.44,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP L 45 CM DIA1.2 MM NIT STRL,SUP-2754756,CDM,C1769,HCPCS,0272,RC,,,,both,,,141.30,91.84,,,,,,,,,,,,,
STEM FEM L300MM OD17MM TI 60% POR PLSM SPR DST CALCAR MOD,SUP-2403918,CDM,C1776,CPT,0278,RC,,,,both,,,8716.64,5665.82,,,,,,,,,,,,,
BASEPLATE TIB 00 POR PRI LT STEM N-K LL,SUP-2209282,CDM,C1776,CPT,0278,RC,,,,both,,,7429.24,4829.01,,,,,,,,,,,,,
SCREW BNE L45MM DIA3.5MM CALCNL TI NONLOCKING HEXALOBE,SUP-2106678,CDM,C1713,HCPCS,0278,RC,,,,both,,,213.52,138.79,,,,,,,,,,,,,
CATHETER GUID EASYTRAK L 54 CM OD 8 FR ID 0.87 IN CORONARY,SUP-2148999,CDM,C1887,HCPCS,0272,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
WASHER ORTH DIA10MM DBL FOR 2MM SCR,SUP-2349665,CDM,C1713,HCPCS,0278,RC,,,,both,,,389.86,253.41,,,,,,,,,,,,,
SLEEVE TIB H40MM AP31MM ML53MM MTPHSEAL KNEE TI PORCOAT POR,SUP-2250950,CDM,C1776,CPT,0278,RC,,,,both,,,6886.65,4476.32,,,,,,,,,,,,,
END BONE TRANSPORT STRUT,SUP-2494142,CDM,2720000010,LOCAL,0272,RC,,,,both,,,69.08,44.90,,,,,,,,,,,,,
SCREW SPNL L12MM DIA4.5MM CANC ANTR CERV TI ST LCK VAR ANG,SUP-2254600,CDM,C1713,HCPCS,0278,RC,,,,both,,,816.40,530.66,,,,,,,,,,,,,
CLAMP SURG OFFSET CONN 6.35X100 MM REVERE,SUP-2584684,CDM,C1713,HCPCS,0278,RC,,,,both,,,910.60,591.89,,,,,,,,,,,,,
PLATE BNE FRAC WRST COLLES STRL LTX,SUP-2861191,CDM,C1713,HCPCS,0278,RC,,,,both,,,1668.85,1084.75,,,,,,,,,,,,,
PLATE BNE L27MM 2 H NONSTERILE BILAT TARSOMETATARSAL S STL,SUP-2184840,CDM,C1713,HCPCS,0278,RC,,,,both,,,2485.69,1615.70,,,,,,,,,,,,,
GRAFT VASC GELWEAVE L 50 CM DIA 30 MM L 15CM 8 MM ANTE FLO,SUP-2385477,CDM,C1768,CPT,0278,RC,,,,both,,,3696.53,2402.74,,,,,,,,,,,,,
LEAD PACE L46CM DIA5.6FR VENT BPLR TI NITRIDE HELIX TIP SIL,SUP-2357747,CDM,C1722,HCPCS,0275,RC,,,,both,,,65940.00,42861.00,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 50 CM DIA 4-7 MM EPTFE SHRT TAPR,SUP-2487439,CDM,C1768,CPT,0278,RC,,,,both,,,1144.18,743.72,,,,,,,,,,,,,
BRACE ORTHOPEDIC SM 8 IN RT WRST CNTOUR,SUP-2124889,CDM,L3931,HCPCS,0272,RC,,,,both,,,45.53,29.59,,,,,,,,,,,,,
LENS IOL CNA0T0.205,SUP-2876998,CDM,V2632,HCPCS,0276,RC,,,,both,,,527.52,342.89,,,,,,,,,,,,,
IMPLANT BRST DIA5.4CM 800ML P16.5CM NACL SIL SHELL TEXT RND,SUP-2300231,CDM,C1789,HCPCS,0278,RC,,,,both,,,6280.00,4082.00,,,,,,,,,,,,,
BOWL BNE CEM MIX UNIV W/ SPAT SGL VAC ROTOR W/OUT NOZ,SUP-2199458,CDM,C1763,HCPCS,0278,RC,,,,both,,,273.49,177.77,,,,,,,,,,,,,
PLATE BONE ADAPTION 2 MM 8 HOLE RAPID RESORBABLE STERILE RAP,SUP-2838589,CDM,C1713,HCPCS,0278,RC,,,,both,,,824.25,535.76,,,,,,,,,,,,,
HC ER Level 2,PX-4509928200,CDM,99282,CPT,0450,RC,,,,both,,,987.00,641.55,,,,,,,,,,,,,
SCREW SPNL L50MM DIA5.5MM CANC PEDCL TI FIX ANG,SUP-2287931,CDM,C1713,HCPCS,0278,RC,,,,both,,,2579.82,1676.88,,,,,,,,,,,,,
ROD IM 25 CM FEM OSS ARCOS,SUP-2441767,CDM,C1713,HCPCS,0278,RC,,,,both,,,7714.98,5014.74,,,,,,,,,,,,,
GRAFT BIO TISS W16XL20CM THK18 4MM ACELLULAR DERM MTRX ULT,SUP-2307500,CDM,Q4128,HCPCS,0636,RC,,,,both,,,29660.25,19279.16,,,,,,,,,,,,,
PORT IMP TI SIL CATH 8FR W/ 8 INTRO SHTH VAXCEL,SUP-2308262,CDM,C1788,HCPCS,0278,RC,,,,both,,,1553.30,1009.64,,,,,,,,,,,,,
HOLE PIN CLAMP 1 POST STRAIGHT DIA 456MM,SUP-2704574,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2323.29,1510.14,,,,,,,,,,,,,
RING ANNULPLSTY SIMULUS L 30 X W 23.1 MM ORIFICE L 24 X W,SUP-2282790,CDM,C1889,HCPCS,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
VLP MINIMOD 2.4 TALUS PLT MDL T RIGHT ST,SUP-2820413,CDM,C1713,HCPCS,0278,RC,,,,both,,,4096.60,2662.79,,,,,,,,,,,,,
NAIL HELCL 50MM BIOTRAK,SUP-2106906,CDM,C1713,HCPCS,0278,RC,,,,both,,,1400.44,910.29,,,,,,,,,,,,,
PLATE BNE L 312 MM SCREW DIA 3.5/4.5 MM 14 H UTIL NS EVOS,SUP-2932827,CDM,C1713,HCPCS,0278,RC,,,,both,,,17347.72,11276.02,,,,,,,,,,,,,
SLING GYN POLYPR MESH SUBURETHRAL TAPE FEM,SUP-2220078,CDM,C1771,HCPCS,0278,RC,,,,both,,,4584.40,2979.86,,,,,,,,,,,,,
SLING ARM M FOR 11-13IN UNIV PREM QUAL BRTH EXTRA PD FAB,SUP-2196420,CDM,L3660,HCPCS,0272,RC,,,,both,,,164.38,106.85,,,,,,,,,,,,,
COUPLER EXT FIX INVRT PIN TO ROD DELT FOR HOFFMANN III SYS,SUP-2372220,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2046.34,1330.12,,,,,,,,,,,,,
COLLAR CERV SFT 375X17IN M,SUP-2276589,CDM,L0120,HCPCS,0274,RC,,,,both,,,5.97,3.88,,,,,,,,,,,,,
INSERT TIB KNEE BUMPER MOD ROT HNG NEUT MONOGRAM,SUP-2376370,CDM,C1776,CPT,0278,RC,,,,both,,,1476.59,959.78,,,,,,,,,,,,,
PLATE BNE OLECRANON SM 79 MM 10 HOLE STRL A.L.P.S,SUP-2472849,CDM,C1713,HCPCS,0278,RC,,,,both,,,2778.90,1806.28,,,,,,,,,,,,,
ENDOBRONCHIAL KIT BX FORCEP GUIDE SLDE FOR 2MM CHANNEL STRL,SUP-2479442,CDM,2720000010,LOCAL,0272,RC,,,,both,,,420.60,273.39,,,,,,,,,,,,,
HC Inj Proc Elbow Arthrography,PX-3612422000,CDM,24220,CPT,0361,RC,,,,inpatient,,,3707.00,2409.55,,,,,,,,,,,,,
LEAD DEFIB LT HRT POLYUR SIL STEROID UPLR S CRV QUICKSITE,SUP-2356618,CDM,C1900,HCPCS,0275,RC,,,,both,,,6280.00,4082.00,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH L 80 MM DIA 46 MM SHTH 16 FR RVD 31-38,SUP-2750386,CDM,C1768,CPT,0278,RC,,,,both,,,48234.48,31352.41,,,,,,,,,,,,,
PATCH CV FLUOROPASSIV L 50 X W 10 MM POLYESTER FLUOROPOLYMER,SUP-2385074,CDM,C1768,CPT,0278,RC,,,,both,,,305.11,198.32,,,,,,,,,,,,,
TUNNELER SURG L 700 MM XL RIGID NO RNG MARKING STRL DISP,SUP-2928844,CDM,2720000010,LOCAL,0272,RC,,,,both,,,497.09,323.11,,,,,,,,,,,,,
MOLD FEM STEM L155MM DIA15MM HIP SIL W/ S STL REINF,SUP-2408612,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2876.24,1869.56,,,,,,,,,,,,,
RING EXT FIX ID180MM ALUM FULL W/ 7 H MSTR TAB FOR ILIZ TAY,SUP-2342965,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7629.73,4959.32,,,,,,,,,,,,,
HC Arthrogram Shoulder S&I,PX-3227304000,CDM,73040,CPT,0322,RC,,,,inpatient,,,1191.00,774.15,,,,,,,,,,,,,
KIT GUID NDL C95,SUP-2164587,CDM,2720000010,LOCAL,0272,RC,,,,both,,,499.26,324.52,,,,,,,,,,,,,
GUIDEWIRE VASC L 180 CM 0.035 IN L 6 CM SAFE-T-J CRV FIX COR,SUP-2638697,CDM,C1769,HCPCS,0272,RC,,,,both,,,33.57,21.82,,,,,,,,,,,,,
SHELL ACET OD56MM ID24MM +5MM TI POR UNIV HIP FULL HMSPHR,SUP-2403300,CDM,C1776,CPT,0278,RC,,,,both,,,6154.40,4000.36,,,,,,,,,,,,,
CANNULA ENDOSCP W/O VLV 11 MMX15 CM GRN RED,SUP-2768547,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1006.50,654.22,,,,,,,,,,,,,
IMPLANT HUM TISS L 8 X W 4 CM PLCNTA MTRX MEMBRN DEHYDR ASEP,SUP-2905488,CDM,Q4184,HCPCS,0636,RC,,,,both,,,25120.00,16328.00,,,,,,,,,,,,,
CLIP ANEURYSM SUNDTKEES 20MM STRAIGHT 201605,SUP-2844586,CDM,C1889,HCPCS,0278,RC,,,,both,,,820.48,533.31,,,,,,,,,,,,,
STENT GRFT VASC AFX L 75 MM DIA PROX/DSTL 28 MM COCR,SUP-2217599,CDM,C1768,CPT,0278,RC,,,,both,,,10785.90,7010.83,,,,,,,,,,,,,
BUR SURG DIA0.6MM BLK DRL TIP OTO-FLEX SKEETER,SUP-2284272,CDM,2720000010,LOCAL,0272,RC,,,,both,,,697.39,453.30,,,,,,,,,,,,,
BIT DRL L125MM DIA2MM STRYKR SHFT END OVR FOR 2X50MM,SUP-2366436,CDM,2720000010,LOCAL,0272,RC,,,,both,,,591.58,384.53,,,,,,,,,,,,,
ORTHO ANCHRGE C TUBE PLATE CROSS SHPD 17MM BRDGE 10MM THICK,SUP-2707481,CDM,C1713,HCPCS,0278,RC,,,,both,,,632.05,410.83,,,,,,,,,,,,,
"HC So Quantation of Therapuetic Drug, Nes",PX-3018029966,CDM,80299,CPT,0301,RC,,,,inpatient,,,63.00,40.95,,,,,,,,,,,,,
ALLOGRAFT DERMAL 16X20 CMX2.4/0.4 MM RDY TO USE ALLDERM,SUP-2488336,CDM,Q4116,HCPCS,0636,RC,,,,both,,,37406.82,24314.43,,,,,,,,,,,,,
PORT INFUS CATH 8FR TI ATTACH OPN END SGL LUMN CHRONOFLEX,SUP-2127756,CDM,C1788,HCPCS,0278,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
PLATE BNE STRNL 2.3X1.5 MM THOR 10 HOLE LCK BODY NS LEVEL 1,SUP-2869267,CDM,C1713,HCPCS,0278,RC,,,,both,,,1828.05,1188.23,,,,,,,,,,,,,
WASHER ORTH OD13MM ID6.6MM S STL RND BONE FIX,SUP-2343820,CDM,C1713,HCPCS,0278,RC,,,,both,,,287.84,187.10,,,,,,,,,,,,,
SCREW SPNL CANN 9.5X70 MM MULTAXL COCR CD HORZ SOLERA 5.5/6,SUP-2629689,CDM,C1713,HCPCS,0278,RC,,,,both,,,2684.70,1745.05,,,,,,,,,,,,,
MENTHOL-ZINC OXIDE 0.44-20.6 % EX OINT,RX-128035,CDM,6370000000,HCPCS,0637,RC,00799-0001-02,NDC,,both,71,GR,17.60,11.44,,,,,,,,,,,,,
TROCAR THOR 10IN 12FR PLEUR EVAC,SUP-2384359,CDM,C1729,HCPCS,0272,RC,,,,both,,,42.08,27.35,,,,,,,,,,,,,
HC Syphilis Test Non-Treponemal Antibody Qual,PX-3028659200,CDM,86592,CPT,0302,RC,,,,both,,,72.00,46.80,,,,,,,,,,,,,
GUIDEWIRE VASC 025X180 GLIDEWIRE,SUP-2148189,CDM,C1769,HCPCS,0272,RC,,,,both,,,405.06,263.29,,,,,,,,,,,,,
CONNECTOR SPNL FRONT LD 3X5.5 MM SIDE BY SIDE FOR ROD SFS,SUP-2589734,CDM,C1713,HCPCS,0278,RC,,,,both,,,2891.94,1879.76,,,,,,,,,,,,,
COMPONENT GLEN INLAY UNIV MED SHLDR,SUP-2422329,CDM,C1776,CPT,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
PLATE BNE 12 H WIDE LADDER STERNALOCK BLU PRI CLSR SYS,SUP-2403027,CDM,C1713,HCPCS,0278,RC,,,,both,,,1384.74,900.08,,,,,,,,,,,,,
PLATE BNE FOR ORTHOPEDIC BRIDGE,SUP-2423029,CDM,C1713,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
PLATE BNE THK 0.4 MM SCREW DIA1.5 MM LG RT MIDFACE ANAT SHP,SUP-2934897,CDM,C1713,HCPCS,0278,RC,,,,both,,,4854.44,3155.39,,,,,,,,,,,,,
PLATE BNE SM L190MM 16 H BILAT S STL LO PROF RIG LIMIT,SUP-2186210,CDM,C1713,HCPCS,0278,RC,,,,both,,,2049.76,1332.34,,,,,,,,,,,,,
PLATE BNE MINI CRV,SUP-2883198,CDM,C1713,HCPCS,0278,RC,,,,both,,,1069.42,695.12,,,,,,,,,,,,,
PIN GUIDE L 300 MM DIA 3.2 MM DRL TIP LG SYS STRL DISP EVOS,SUP-2933361,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1735.64,1128.17,,,,,,,,,,,,,
GRAFT BNE PAT TISS FULL EXTENSOR,SUP-2165600,CDM,2780000010,LOCAL,0278,RC,,,,both,,,6908.00,4490.20,,,,,,,,,,,,,
SCREW BONE L9MM OD1.5MM LCK TI T4 S-T VLP MINI MOD,SUP-2341191,CDM,C1713,HCPCS,0278,RC,,,,both,,,575.66,374.18,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP L150CM DIA0.038IN TIP L3CM STD PTFE ANG,SUP-2385262,CDM,C1769,HCPCS,0272,RC,,,,both,,,118.44,76.99,,,,,,,,,,,,,
ANCHOR SUTURE SUPER WITH 5MM HI-FI SUTURE REVO,SUP-2828534,CDM,C1713,HCPCS,0278,RC,,,,both,,,789.62,513.25,,,,,,,,,,,,,
DEXTROSE 5 % IV BOLUS,RX-40840055,CDM,J7060,HCPCS,0258,RC,00264-7510-20,NDC,,both,250,ML,31.90,20.73,,,,,,,,,,,,,
GRAFT DURA L 1 X W 1 IN TYP I CLLGN BOV ACHILLES TEND RESRB,SUP-2889750,CDM,C1763,HCPCS,0278,RC,,,,both,,,882.53,573.64,,,,,,,,,,,,,
SCREW BNE LCK 4X14 MM VA FOR MEDL CLMN FUSION PLATE SOLE LTX,SUP-2875515,CDM,C1713,HCPCS,0278,RC,,,,both,,,1453.19,944.57,,,,,,,,,,,,,
SCREW BNE L95MM DIA5MM S STL ST VAR ANG LOK FULL THRD T25,SUP-2178723,CDM,C1713,HCPCS,0278,RC,,,,both,,,709.70,461.30,,,,,,,,,,,,,
EXPANDER BRST 475CC W13XH13CM P6.8CM SIL TEXT HI PROF,SUP-2301033,CDM,C1789,HCPCS,0278,RC,,,,both,,,6248.60,4061.59,,,,,,,,,,,,,
BOLT EXT FIX WIRE SIDEKCK EZ FRAME EF001500,SUP-2850507,CDM,2720000010,LOCAL,0272,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
CLAMP CRAN TEXT 11 MM FLAPFIX FOR EXT FIX TI STRL LF,SUP-2431411,CDM,C1713,HCPCS,0278,RC,,,,both,,,1175.62,764.15,,,,,,,,,,,,,
HC Culture Typing Gas/High Pres Liq Chromatography,PX-3068714300,CDM,87143,CPT,0306,RC,,,,both,,,69.00,44.85,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9% IV BOLUS (PER WEIGHT),RX-40901010,CDM,J7050,HCPCS,0250,RC,00264-7800-20,NDC,,both,250,ML,23.40,15.21,,,,,,,,,,,,,
PLATE BNE L 1.5X24X22X0.6 MM RT CRANIOMAXILLOFACIAL 9 NS,SUP-2462863,CDM,C1713,HCPCS,0278,RC,,,,both,,,1010.39,656.75,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9% IV BOLUS (PER WEIGHT),RX-40901010,CDM,2580000003,HCPCS,0258,RC,00338-0049-11,NDC,,both,50,ML,24.70,16.05,,,,,,,,,,,,,
GRAFT BONE SUB 1CC DEMIN BONE MTRX PUTTY INJ SYR PUROS,SUP-2205385,CDM,C1713,HCPCS,0278,RC,,,,both,,,1004.80,653.12,,,,,,,,,,,,,
GRAFT DERM L10XW5CM THCKNESS 8 17MM ACELLULAR DERM HYDRATED,SUP-2307472,CDM,Q4128,HCPCS,0636,RC,,,,both,,,4484.92,2915.20,,,,,,,,,,,,,
SET TARGETING 11GA 3.1MM L115MM SH UNIV MR,SUP-2195614,CDM,2720000010,LOCAL,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
GRAFT 10MM TEND ACHILLES ALLGRFT W/ BONE PRE SHP MACHINED,SUP-2165609,CDM,C1713,HCPCS,0278,RC,,,,both,,,9106.00,5918.90,,,,,,,,,,,,,
NEEDLE KIT 45 MM SET MANUAL DISP,SUP-2759199,CDM,2720000010,LOCAL,0272,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
PLATE BONE L40MM 3 HOLE RCNSTRCTN 35MM SCREW UNVRSL LOK SSTM,SUP-2498369,CDM,C1713,HCPCS,0278,RC,,,,both,,,1159.16,753.45,,,,,,,,,,,,,
STAPLE 20MM X 20MM X 20MM STPLS,SUP-2401355,CDM,C1713,HCPCS,0278,RC,,,,both,,,5058.54,3288.05,,,,,,,,,,,,,
GUIDEWIRE VASC KATZN L 145 CM TIP L 3 CM DIA 0.035 IN SS,SUP-2148174,CDM,C1769,HCPCS,0272,RC,,,,both,,,481.39,312.90,,,,,,,,,,,,,
CATHETER GUID FL6 MOD SIDE H MOD WG 8FR 100CM .086IN,SUP-2140493,CDM,C1887,HCPCS,0272,RC,,,,both,,,664.42,431.87,,,,,,,,,,,,,
DRILL SURG CANN 7.5X25 MM TRABECULAR MTL RVS +,SUP-2436962,CDM,2720000010,LOCAL,0272,RC,,,,both,,,904.32,587.81,,,,,,,,,,,,,
IMMUNE GLOBULIN (GAMMAGARD) 10%|DISCARDED DRUG NOT ADMINISTE,RX-4081758,CDM,J1569,HCPCS,0636,RC,00944-2700-06,NDC,JW,both,200,ML,10302.00,6696.30,,,,,,,,,,,,,
CATHETER CV SET AD 12 FRX16 CM 3L N TUNNELED BASIC KT UNCUF,SUP-2763393,CDM,C1751,HCPCS,0278,RC,,,,both,,,256.22,166.54,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 45 CM DIA 4-7 MM EPTFE TAPR STD,SUP-2396214,CDM,C1768,CPT,0278,RC,,,,both,,,2034.72,1322.57,,,,,,,,,,,,,
CATHETER SPEC RETRV 035 7-5 FRX200 CM 12 MM BELOW TRI-EX,SUP-2738197,CDM,2720000010,LOCAL,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
SCREW BNE L 14 MM DIA 3.5 MM CORTICAL LO PROF STRL ORTHOLOC,SUP-2900508,CDM,C1713,HCPCS,0278,RC,,,,both,,,646.84,420.45,,,,,,,,,,,,,
BURR SURG SWNSN REAMER 2MM DIA HD MED MIC 62MML STL SM BNE F,SUP-2605555,CDM,2720000010,LOCAL,0272,RC,,,,both,,,143.72,93.42,,,,,,,,,,,,,
PLATE BNE L164MM 8 H NONSTERILE R OLECRANON S STL LOK COMPR,SUP-2185428,CDM,C1713,HCPCS,0278,RC,,,,both,,,3193.79,2075.96,,,,,,,,,,,,,
BOOT WALKING HI TOP SM FT ANK LIFESTRIDE,SUP-2108144,CDM,L4386,HCPCS,0274,RC,,,,both,,,109.59,71.23,,,,,,,,,,,,,
CATHETER CV 3L 6 FRX135 CM TY IRRIGATION POWERPICC SOLO 2,SUP-2126405,CDM,C1751,HCPCS,0278,RC,,,,both,,,743.24,483.11,,,,,,,,,,,,,
MESH CRANIOMAXILLOFACIAL STANDARDXL W200XL200MM THK0.6MM,SUP-2419462,CDM,C1713,HCPCS,0278,RC,,,,both,,,21055.40,13686.01,,,,,,,,,,,,,
HC MRI-Upper Ext Jnt W & WO Cont,PX-6107322300,CDM,73223,CPT,0610,RC,,,,outpatient,,,4220.00,2743.00,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9% IV BOLUS (PER WEIGHT),RX-40901010,CDM,2580000003,HCPCS,0250,RC,00990-7983-61,NDC,,both,150,ML,44.70,29.05,,,,,,,,,,,,,
"HC Est Pt, Outpt Visit Level 3|RESIDENT/TEACHING PHYS SERV",PX-7619921300,CDM,99213,CPT,0761,RC,,,GC,both,,,257.00,167.05,,,,,,,,,,,,,
COMPONENT HUM DSTL MRS L45MM,SUP-2364665,CDM,C1776,CPT,0278,RC,,,,both,,,14506.80,9429.42,,,,,,,,,,,,,
LEAD DEFIB RELIANCE SG L 64 CM SIL EPTFE STEROID ENDOCARD RT,SUP-2459476,CDM,C1777,HCPCS,0275,RC,,,,both,,,8691.52,5649.49,,,,,,,,,,,,,
GUIDEWIRE VASC L145CM DIA0.035IN TIP L4CM PTFE S STL SHT,SUP-2148227,CDM,C1769,HCPCS,0272,RC,,,,both,,,99.22,64.49,,,,,,,,,,,,,
PLATE BONE W7XL23MM THK1MM 3 H BILAT TI 1/4 TBLR RIG,SUP-2191001,CDM,C1713,HCPCS,0278,RC,,,,both,,,259.52,168.69,,,,,,,,,,,,,
COVID-19 MRNA VAC-TRIS(PFIZER) 30 MCG/0.3ML IM SUSY,RX-165477,CDM,91320,HCPCS,0250,RC,00069-2528-01,NDC,,both,.3,ML,849.30,552.04,,,,,,,,,,,,,
SYSTEM PLT PREP AUTOLGS CASCADE,SUP-2307546,CDM,C1713,HCPCS,0278,RC,,,,both,,,527.52,342.89,,,,,,,,,,,,,
TRAY CATH MIDLN POWERGLIDE PRO BASIC 22GA 8CM WNG 1 F322087T,SUP-2632774,CDM,C1751,HCPCS,0278,RC,,,,both,,,251.58,163.53,,,,,,,,,,,,,
SCREW DYNA PIP IMPLANT W/14MM BENT,SUP-2665177,CDM,C1776,CPT,0278,RC,,,,both,,,5950.30,3867.69,,,,,,,,,,,,,
MESH HERN 4X6 IN O3FA COAT POLYPR C-QUR TACSHIELD,SUP-2227256,CDM,C1781,HCPCS,0278,RC,,,,both,,,1491.50,969.47,,,,,,,,,,,,,
SET VENT EXT DRNGE HERM KT 2.7MM DIA 35CM CATH W/ STYL CRV,SUP-2244102,CDM,2720000010,LOCAL,0272,RC,,,,both,,,367.19,238.67,,,,,,,,,,,,,
MESH SURG 40X25 CM BIOMATERIAL INTRAPERITONEAL ENFORM,SUP-2435398,CDM,C1781,HCPCS,0278,RC,,,,both,,,58068.02,37744.21,,,,,,,,,,,,,
SCREW BONE L44MM OD4MM GRN FOREFOOT MIDFOOT HINDFOOT ANK,SUP-2320931,CDM,C1713,HCPCS,0278,RC,,,,both,,,1000.09,650.06,,,,,,,,,,,,,
METHYLPREDNISOLONE ACETATE 80 MG/ML IJ SUSP,RX-4996,CDM,J1010,HCPCS,0636,RC,70121-1574-05,NDC,,both,1,ML,93.90,61.03,,,,,,,,,,,,,
RABIES IMMUNE GLOBULIN 300 UNIT/2ML IJ SOLN,RX-141161,CDM,90377,HCPCS,0636,RC,76125-0150-02,NDC,,both,2,ML,2199.60,1429.74,,,,,,,,,,,,,
BRACE WLK L SHOE MAN 10 13 WOMAN 11 15 EXTRA PNEUMAT SEMI,SUP-2196363,CDM,L4361,HCPCS,0274,RC,,,,both,,,224.82,146.13,,,,,,,,,,,,,
DISTRACTION INTRNL MESH MESH MDFC8 X 8 HOLE T07 MM CP TTNM,SUP-2707282,CDM,C1713,HCPCS,0278,RC,,,,both,,,4127.78,2683.06,,,,,,,,,,,,,
GRAFT BIO TISS W3.9XL3.9IN PORCINE DERM RIFAMPIN,SUP-2125834,CDM,C1781,HCPCS,0278,RC,,,,both,,,10716.19,6965.52,,,,,,,,,,,,,
STEM FEM L125MM OD17MM STD CO CHROM STR CLLRD DST CAP,SUP-2406296,CDM,C1776,CPT,0278,RC,,,,both,,,13721.80,8919.17,,,,,,,,,,,,,
PLATE BNE 3 H 7 PEG STD R VOLAR S STL BEAR,SUP-2389753,CDM,C1713,HCPCS,0278,RC,,,,both,,,2920.20,1898.13,,,,,,,,,,,,,
FIXATOR EXT PEDIATRIC,SUP-2874976,CDM,C1713,HCPCS,0278,RC,,,,both,,,6000.54,3900.35,,,,,,,,,,,,,
CATHETER DIAG PERCFLX GUIDEWIRE L 30 CM DIA 0.014 IN SS,SUP-2147725,CDM,C1729,HCPCS,0272,RC,,,,both,,,323.45,210.24,,,,,,,,,,,,,
DEFIBRILLATOR IMPL CONTAK RENEWAL III W 5.94 X H 7.75 CM D,SUP-2149224,CDM,C1895,HCPCS,0275,RC,,,,both,,,82977.64,53935.47,,,,,,,,,,,,,
PLATE BNE L 118 SCREW DIA 3.5 MM 10 H TI RECON NS,SUP-2908832,CDM,C1713,HCPCS,0278,RC,,,,both,,,1781.10,1157.71,,,,,,,,,,,,,
PLATE BNE 24 DEG L 209 X W 8.5 MM THK 1.6 MM 16 H SS RT DSTL,SUP-2932864,CDM,C1713,HCPCS,0278,RC,,,,both,,,8253.80,5364.97,,,,,,,,,,,,,
ENFIT BUTTON G TUBE 182.4,SUP-2674508,CDM,2720000010,LOCAL,0272,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
ATENOLOL 50 MG PO TABS,RX-718,CDM,6370000000,HCPCS,0637,RC,64980-0438-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
STEM FEM L150MM OD18MM UNIV STD TI KNEE REV CEM FLUT STR,SUP-2406974,CDM,C1776,CPT,0278,RC,,,,both,,,4468.22,2904.34,,,,,,,,,,,,,
ANCHOR SUTURE 5MM WITH 2 NO 2 SUTURES AND WITHOUT NEEDLE SUP,SUP-2824874,CDM,C1713,HCPCS,0278,RC,,,,both,,,1378.46,896.00,,,,,,,,,,,,,
GRAFT BNE SUB 1 8MM 20ML CANC CORT CHIP FRZ DRY READIGRFT,SUP-2264694,CDM,C1713,HCPCS,0278,RC,,,,both,,,705.43,458.53,,,,,,,,,,,,,
VEST TRAC L112CM DIA76MM SYNTH LNR TALL COMPATIBLE ADV,SUP-2255764,CDM,L0810,HCPCS,0272,RC,,,,both,,,4505.90,2928.83,,,,,,,,,,,,,
KIT ENDOSCP FLUID MGMT IN-FLOPAK OUT-FLOPAK TISS TRAP WSTE,SUP-2913560,CDM,2720000010,LOCAL,0272,RC,,,,both,,,849.68,552.29,,,,,,,,,,,,,
BLADE ENDOSCP CAPSLTMY 4 MM CRV HNDL CAPSULECUT DISP,SUP-2121994,CDM,C1713,HCPCS,0278,RC,,,,both,,,675.10,438.81,,,,,,,,,,,,,
PLATE BNE BROAD 3.5X263 MM 20 HOLE SS LCP,SUP-2569345,CDM,C1713,HCPCS,0278,RC,,,,both,,,625.17,406.36,,,,,,,,,,,,,
INTRODUCER SUPRPUB SHTH 18FR L17CM TRCR STYL L20CM REM DISP,SUP-2169600,CDM,C1725,HCPCS,0272,RC,,,,both,,,379.31,246.55,,,,,,,,,,,,,
PLATE BNE L65MM THK385MM 5 H BILAT S STL STR WIDE ANG LO,SUP-2177152,CDM,C1713,HCPCS,0278,RC,,,,both,,,1188.43,772.48,,,,,,,,,,,,,
CATHETER ANGIOPLSTY VASCUTRAK L 80 CM BALLOON L 8 CM DIA 7,SUP-2128769,CDM,C1725,HCPCS,0272,RC,,,,both,,,2496.30,1622.59,,,,,,,,,,,,,
TUBE CONN INNR END TELLURIDE FOR MIS SPNL FIX SYS,SUP-2211190,CDM,2780000010,LOCAL,0278,RC,,,,both,,,2468.04,1604.23,,,,,,,,,,,,,
SPHINCTEROTOME ENDSCPC 49 5FR OD DST TIP 20MML CUT WIRE BLR,SUP-2676818,CDM,2720000010,LOCAL,0272,RC,,,,both,,,847.80,551.07,,,,,,,,,,,,,
SCREW SPNL L17MM DIA4MM FIX ANG ANT CERV CANC TI ST,SUP-2293231,CDM,C1713,HCPCS,0278,RC,,,,both,,,1326.27,862.08,,,,,,,,,,,,,
PIN FIX L STR BILAT AXLE,SUP-2372339,CDM,C1713,HCPCS,0278,RC,,,,both,,,6975.45,4534.04,,,,,,,,,,,,,
KWIRE FIX XSM SM L102MM DIA09MM FOR HAMRTOE FIX SYS,SUP-2397787,CDM,C1713,HCPCS,0278,RC,,,,both,,,31.40,20.41,,,,,,,,,,,,,
BIT DRL CANN 13.5 MM ENTRY,SUP-2476955,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1312.52,853.14,,,,,,,,,,,,,
SHEATH URO L30CM DIA30FR NEPHSTMY TRACT CONT FLO OPQ AMPLTZ,SUP-2168948,CDM,C1894,HCPCS,0272,RC,,,,both,,,112.54,73.15,,,,,,,,,,,,,
PIN TEMP FIX 268530000] JNJ HEALTHCARE],SUP-2256845,CDM,2720000010,LOCAL,0272,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
FIBER LASER 550UM DUST THULIUM,SUP-2885424,CDM,2720000010,LOCAL,0272,RC,,,,both,,,697.08,453.10,,,,,,,,,,,,,
BRACE ORTH WAIST CIRC 53 IN BELT L 18 IN HIP HINGE ROM HT,SUP-2914920,CDM,2720000010,LOCAL,0272,RC,,,,both,,,842.68,547.74,,,,,,,,,,,,,
BIT DRL L14MM OD2MM W/O STP NONRADIOLUCENT,SUP-2353296,CDM,2720000010,LOCAL,0272,RC,,,,both,,,872.92,567.40,,,,,,,,,,,,,
STAPLE KIT 8X8 MM INDIV ASMBLY STRL ARCUS,SUP-2482189,CDM,C1713,HCPCS,0278,RC,,,,both,,,2384.86,1550.16,,,,,,,,,,,,,
PUMP INFUSION NACL FOR DIAMONDBACK 360 ORBIT ATHRCTMY SYS NS,SUP-2892841,CDM,C1724,HCPCS,0278,RC,,,,both,,,6264.30,4071.79,,,,,,,,,,,,,
CANNULA ART SHT 13 FR UNCOATED HLS,SUP-2663474,CDM,2720000010,LOCAL,0272,RC,,,,both,,,970.10,630.56,,,,,,,,,,,,,
UPCHARGE KNEE ATTUNE REVISION TRAY DEPUY SYNTHES,SUP-2501360,CDM,C1776,CPT,0278,RC,,,,both,,,2992.42,1945.07,,,,,,,,,,,,,
ALLOGRAFT BNE PLUG 11 MM OSTEOCHNDRL,SUP-2866831,CDM,C1762,CPT,0278,RC,,,,both,,,12140.81,7891.53,,,,,,,,,,,,,
HC Hemoglobin Glycosylated A1c|NOT REASONABLE AND NECESSARY,PX-3018303600,CDM,83036,CPT,0301,RC,,,GZ,both,,,141.00,91.65,,,,,,,,,,,,,
BIT DRL OD3.4MM CANN ANK FOR IOFIX + SYS,SUP-2223749,CDM,2720000010,LOCAL,0272,RC,,,,both,,,467.86,304.11,,,,,,,,,,,,,
HC Glb Allo Fresh Infusion,PX-9823824000,CDM,38240,CPT,0982,RC,,,,both,,,1464.00,951.60,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY POLARIS X 270 DEG L 106 CM DIA 6,SUP-2652866,CDM,C1732,HCPCS,0272,RC,,,,both,,,1074.16,698.20,,,,,,,,,,,,,
BIT DRL L135MM DIA25MM AO FIT FOR TOT FT SYS,SUP-2244016,CDM,2720000010,LOCAL,0272,RC,,,,both,,,580.81,377.53,,,,,,,,,,,,,
CATHETER ANGIOPLSTY L90CM BAL L20MM OD5MM DIL RX MRAIL,SUP-2140567,CDM,C1725,HCPCS,0272,RC,,,,both,,,1014.22,659.24,,,,,,,,,,,,,
CATHETER CV KT 0.018 IN PEDIATRIC 4 FRX13 CM DL INTRO NDL,SUP-2763322,CDM,C1751,HCPCS,0278,RC,,,,both,,,131.25,85.31,,,,,,,,,,,,,
GRAFT VASC L200MM W15MM THK01MM PTCH PERICARD MEM UNIV STR,SUP-2395371,CDM,C1781,HCPCS,0278,RC,,,,both,,,4973.76,3232.94,,,,,,,,,,,,,
PLATE BONE L189MM 14 HOLE RIGHT LTRL DST PRRTCLR TBL STNLSS,SUP-2479174,CDM,C1713,HCPCS,0278,RC,,,,both,,,4491.68,2919.59,,,,,,,,,,,,,
PLATE BNE 95 DEG SHFT L 156 MM BLADE L 50 MM SCREW DIA 4.5,SUP-2908361,CDM,C1713,HCPCS,0278,RC,,,,both,,,4447.31,2890.75,,,,,,,,,,,,,
TUBE VENT PAPARELLA 1.27 PHOSPHORYLCHOLINE COAT SIL 510212C,SUP-2535116,CDM,L8699,HCPCS,0278,RC,,,,both,,,40.00,26.00,,,,,,,,,,,,,
CATHETER HD STR 13.5 FRX24 CM SHT TERM 3L MAX BARR TRIO-CT,SUP-2627088,CDM,C1752,HCPCS,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
COIL EMB L 6 CM DIA1.5 MM PLAT TUNGSTEN NEUROVASCULAR LG VOL,SUP-2934022,CDM,C1889,HCPCS,0278,RC,,,,both,,,9404.30,6112.79,,,,,,,,,,,,,
WASHER ORTH TIB,SUP-2449671,CDM,C1713,HCPCS,0278,RC,,,,both,,,28.26,18.37,,,,,,,,,,,,,
COMPONENT TIB CEM FIN 1F/1T 2F/1T,SUP-2222592,CDM,C1776,CPT,0278,RC,,,,both,,,6367.92,4139.15,,,,,,,,,,,,,
PUMP INFUSION ELASTOMERIC 400 CC 6 ML/HR TRPL FIX FLO ON-Q,SUP-2424462,CDM,C1713,HCPCS,0278,RC,,,,both,,,197.82,128.58,,,,,,,,,,,,,
ANCHOR SUT NO2 DIA3MM GLEN SFT TISS TI WDG NDL PRELD W 1,SUP-2362549,CDM,C1713,HCPCS,0278,RC,,,,both,,,590.79,384.01,,,,,,,,,,,,,
HC MRI Breast W Cont Unilat,PX-6107704801,CDM,77048,CPT,0610,RC,,,,inpatient,,,568.00,369.20,,,,,,,,,,,,,
MESH SURG PORCINE COLLGN MTRX W/ PHMB 0.1% PURAPLYAM,SUP-2423145,CDM,Q4195,HCPCS,0636,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
STEM FEM CEM 12 125 MM HIP PROS EXT OFFSET VERSYS ADVOCATE,SUP-2439206,CDM,C1776,CPT,0278,RC,,,,both,,,16799.00,10919.35,,,,,,,,,,,,,
PLATE BNE STRNL 2.3X66X23X1.8 MM THOR 26 HOLE LADDER LEVEL 1,SUP-2869246,CDM,C1713,HCPCS,0278,RC,,,,both,,,2517.75,1636.54,,,,,,,,,,,,,
ELECTRODE MPLR 22FR 30DEG 0.014IN CUT LOOP RESECTOSCOPIC,SUP-2361454,CDM,2720000010,LOCAL,0272,RC,,,,both,,,411.75,267.64,,,,,,,,,,,,,
STEM FEM VERSYS 10 IN BEADED FC +10CALCAR 18.0X240MM BWD RT,SUP-2504288,CDM,C1776,CPT,0278,RC,,,,both,,,15599.52,10139.69,,,,,,,,,,,,,
REDUCER SCREW 4 IN BIRD ZYG,SUP-2492875,CDM,2720000010,LOCAL,0272,RC,,,,both,,,499.39,324.60,,,,,,,,,,,,,
PLATE LCP 2.7MM 16HL /148MM ST,SUP-2761692,CDM,C1713,HCPCS,0278,RC,,,,both,,,1385.15,900.35,,,,,,,,,,,,,
"HC Gbl Office/OP Consltj New/Est Pt High Mdm 55 Minutes|SIGNIFICANT, SEPARATELY IDENTIFIABLE EVALUATION AND MANAGEMENT SERVICE BY THE SAME PHYSICIAN ON THE SAME DAY OF THE PROCEDURE OR OTHER SERVICE",PX-9829924501,CDM,99245,CPT,0982,RC,,,25,outpatient,,,1137.00,739.05,,,,,,,,,,,,,
CATHETER CV KT PEDIATRIC 2 FRX9 CM 24 GA SINGLE LUMEN,SUP-2763318,CDM,C1751,HCPCS,0278,RC,,,,both,,,56.52,36.74,,,,,,,,,,,,,
GUIDEWIRE VASC L 30 CM TIP L 2 MM DIA 0.018 IN STR CRV DBL,SUP-2760170,CDM,C1769,HCPCS,0272,RC,,,,both,,,133.51,86.78,,,,,,,,,,,,,
SCREW BONE L30MM DIA5MM TAPR LCK FOR INTOSS FIX IOFIX 2.0,SUP-2223857,CDM,C1713,HCPCS,0278,RC,,,,both,,,1808.64,1175.62,,,,,,,,,,,,,
SUPPORT ORTHOT HIP CUST ABDUCTN STATIC PLAS,SUP-2435601,CDM,L1660,HCPCS,0272,RC,,,,both,,,511.63,332.56,,,,,,,,,,,,,
HEAD HUM H18MM DIA48MM SHLDR CO CHROM STD OFFSET PRI FOR,SUP-2249953,CDM,C1776,CPT,0278,RC,,,,both,,,5893.78,3830.96,,,,,,,,,,,,,
HC CT Rf Ablation Pulm Tumor(S),PX-3613299800,CDM,32998,CPT,0361,RC,,,,both,,,10314.00,6704.10,,,,,,,,,,,,,
RIFAXIMIN 200 MG PO TABS,RX-39063,CDM,6370000000,HCPCS,0637,RC,65649-0301-03,NDC,,both,1,UN,50.60,32.89,,,,,,,,,,,,,
GRAFT HUM TISS VEIN 3MM OD 61 70CML SAPHENOU CRYOPRESERVED A,SUP-2607339,CDM,C1762,CPT,0278,RC,,,,both,,,29069.65,18895.27,,,,,,,,,,,,,
LOW PRFLE NEURO PLATE SQRE .6MM 1.5MM SYS CP TTNM ST,SUP-2497791,CDM,C1713,HCPCS,0278,RC,,,,both,,,639.30,415.54,,,,,,,,,,,,,
ALLOGRAFT BNE 30X10 MM FRZN IRRADIATED COSTAL CART,SUP-2866969,CDM,C1762,CPT,0278,RC,,,,both,,,1224.60,795.99,,,,,,,,,,,,,
NEEDLE SPNL DMND SPRINGLESS BVL TIP ST I-PAS III,SUP-2310405,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
ROD SPNL 2 MM W/ SPACER SZR GRN ORTHOFLEX,SUP-2319095,CDM,C1713,HCPCS,0278,RC,,,,both,,,1208.90,785.78,,,,,,,,,,,,,
TRAY CATH HEMODIALYSI 400XL ACTE 14FR DIA 20CM STRGHT TAPR T,SUP-2610526,CDM,C1752,HCPCS,0278,RC,,,,both,,,335.29,217.94,,,,,,,,,,,,,
IMPLANT OPHTH 125MM RETIN STRP SCLER BCKL STYL 42 SIL,SUP-2129437,CDM,C1784,HCPCS,0278,RC,,,,both,,,144.13,93.68,,,,,,,,,,,,,
EASYFUSE INSTRUMENT PACK MID / HINDFOOT,SUP-2830243,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
SPLINT A SPA BALL SP S LF,SUP-2163829,CDM,L3807,HCPCS,0274,RC,,,,both,,,108.33,70.41,,,,,,,,,,,,,
PUMP ONLY KT SEL A FLOW 270ML X1 THRU 7ML PER HR ON Q,SUP-2236853,CDM,C9804,HCPCS,0272,RC,,,,both,,,65.94,42.86,,,,,,,,,,,,,
PI PICC 1-LUMEN: 4FRX50CM WITH 80CM SS S,SUP-2826701,CDM,C1751,HCPCS,0278,RC,,,,both,,,330.33,214.71,,,,,,,,,,,,,
CATHETER INTRAAORTIC BAL L174MM OD8FR BAL OD14.7MM 25ML N,SUP-2265880,CDM,C1725,HCPCS,0272,RC,,,,both,,,3925.00,2551.25,,,,,,,,,,,,,
EXTERNAL FIXATION SET MINI CALCANEAL FIX FIX SYS CALCFIX +,SUP-2875652,CDM,C1713,HCPCS,0278,RC,,,,both,,,800.45,520.29,,,,,,,,,,,,,
TRIAL KNEE SZ 2 AP56MM ML60MM R FEM HI PERF CRUCE RET FOR PR,SUP-2436185,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2358.14,1532.79,,,,,,,,,,,,,
FOOTPLATE BNE L180MM DBL ROW ST TL HEX,SUP-2316310,CDM,C1713,HCPCS,0278,RC,,,,both,,,6764.31,4396.80,,,,,,,,,,,,,
TAP BNE DIA 375MM PEDCL SCR SLD QUIK CONN,SUP-2290724,CDM,C1713,HCPCS,0278,RC,,,,both,,,1171.94,761.76,,,,,,,,,,,,,
SPLINT ORTHOPEDIC COLLES SM WRST FOREARM LF,SUP-2330386,CDM,L3808,HCPCS,0272,RC,,,,both,,,18.84,12.25,,,,,,,,,,,,,
SCREW BONE L90MM DIA4.5MM THRD L40MM MALL S STL ST SELF DRL,SUP-2184561,CDM,C1713,HCPCS,0278,RC,,,,both,,,101.11,65.72,,,,,,,,,,,,,
PROTECTOR TISS SHTH L 14 CM INCISION 2.5-8 CM SM ORTH RIGID,SUP-2929746,CDM,2720000010,LOCAL,0272,RC,,,,both,,,533.80,346.97,,,,,,,,,,,,,
PLATE BNE SM LT DBL LISFRANC STRATUM,SUP-2458796,CDM,C1713,HCPCS,0278,RC,,,,both,,,6044.50,3928.92,,,,,,,,,,,,,
CATHETER ABLATN STD 7 FRX110 CM 2.5X8 MM INTELLANAV MIFI XP,SUP-2141337,CDM,C1732,HCPCS,0278,RC,,,,both,,,8321.00,5408.65,,,,,,,,,,,,,
PLATE BONE W8XL44MM THK2MM 0DEG 5 H BILAT S STL STR RIG DYN,SUP-2186176,CDM,C1713,HCPCS,0278,RC,,,,both,,,499.92,324.95,,,,,,,,,,,,,
BRACE WRST AND FA R CIRC LESS THAN 13IN LEN 10IN SZ UNIV,SUP-2197069,CDM,L3931,HCPCS,0272,RC,,,,both,,,25.28,16.43,,,,,,,,,,,,,
STENT CORONARY VERIFLEX MR L 12 MM DIA 4 MM SS RX BALLOON,SUP-2142461,CDM,C1876,HCPCS,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
HC So Hcg Quantitative,PX-3018470266,CDM,84702,CPT,0301,RC,,,,both,,,64.00,41.60,,,,,,,,,,,,,
TRAY PICC ARROW TAPERFREE MAX BARRIER MIDLINE 4FR 20CM 1-LUM,SUP-2887105,CDM,C1751,HCPCS,0278,RC,,,,both,,,425.16,276.35,,,,,,,,,,,,,
TUBE LARYNCTMY BLOM SINGER VOICE PROS PT CHANGEABLE LO PRSS,SUP-2242313,CDM,L8509,HCPCS,0272,RC,,,,both,,,395.64,257.17,,,,,,,,,,,,,
BEARING TIB L63/67MM THK14MM KNEE SUP STBL POST STBL CNDYL 183824] ZIMMER BIOMET ORTHOPEDICS],SUP-2407708,CDM,C1776,CPT,0278,RC,,,,both,,,7350.74,4777.98,,,,,,,,,,,,,
CATHETER INTVASC ULTRASOUND ACUSON ACUNAV L 110 CM DIA 8 FR,SUP-2481874,CDM,C1753,HCPCS,0278,RC,,,,both,,,2348.41,1526.47,,,,,,,,,,,,,
ANCHOR SUT L12.5MM DIA2.9MM SHT PEEK KNOTLESS REVISABLE,SUP-2121762,CDM,C1713,HCPCS,0278,RC,,,,both,,,1130.40,734.76,,,,,,,,,,,,,
CATHETER ANGIOPLSTY BAL L10MM OD2.5MM OVR THE WIRE CUT MRAIL,SUP-2140406,CDM,C1725,HCPCS,0272,RC,,,,both,,,2904.50,1887.92,,,,,,,,,,,,,
DEFIBRILLATOR IMPL CONTAK RENEWAL III RF W 6.6 X H 8.26 CM D,SUP-2149228,CDM,C1882,HCPCS,0275,RC,,,,both,,,85408.00,55515.20,,,,,,,,,,,,,
SHOE ROCKER SHRT MED PR,SUP-2459606,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5150.57,3347.87,,,,,,,,,,,,,
BUTTON NSL SEPTAL DIA 3 MM SZ 11 X 13 MM OVL 2PC,SUP-2889375,CDM,C1889,HCPCS,0278,RC,,,,both,,,1036.20,673.53,,,,,,,,,,,,,
Z INACTIVE USE 2305833 HANDPIECE ELECSURG THERM ABLATN DISP,SUP-2305832,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3124.30,2030.79,,,,,,,,,,,,,
BRACE WRST AND FA R CIRC LESS THAN 13IN LEN 10IN SZ UNIV,SUP-2197069,CDM,L3931,HCPCS,0274,RC,,,,both,,,25.28,16.43,,,,,,,,,,,,,
SET NEPHROSTOMY NEFF D AGOSTINO MOD STRL,SUP-2638485,CDM,C1769,HCPCS,0272,RC,,,,both,,,431.69,280.60,,,,,,,,,,,,,
GRAFT VASC RESTOREFLOW SZ 10 CM FEM VEIN BLD TYP A B AB O,SUP-2884018,CDM,C1768,CPT,0278,RC,,,,both,,,17047.06,11080.59,,,,,,,,,,,,,
CATHETER DRNGE 10FR L11CM WRK L40CM 17 H BILI LOK ATRAUM,SUP-2303327,CDM,C1729,HCPCS,0272,RC,,,,both,,,204.10,132.66,,,,,,,,,,,,,
GUIDEWIRE VASC VICTORY 14 L 300 CM DIA 0.014 IN TIP L 2.5 CM,SUP-2146038,CDM,C1769,HCPCS,0272,RC,,,,both,,,602.88,391.87,,,,,,,,,,,,,
LOCKING MNDBLR ANGLE PLATE 3X3 NON CMPRSSN 20MM THICK T 6L,SUP-2694218,CDM,C1713,HCPCS,0278,RC,,,,both,,,1630.48,1059.81,,,,,,,,,,,,,
CATHETER EP CIR 1-4-5-1 MM 7 FRX110 CM OPTMA,SUP-2102280,CDM,C1731,HCPCS,0278,RC,,,,both,,,4819.90,3132.93,,,,,,,,,,,,,
CATHETER ENDOSCP FOR URETHROTM,SUP-2747469,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3222.21,2094.44,,,,,,,,,,,,,
KIT BNE CEMENT KNEE MIXING SYS CANC NOZ TIB PRESSURIZER TIP,SUP-2884226,CDM,2720000010,LOCAL,0272,RC,,,,both,,,331.99,215.79,,,,,,,,,,,,,
SCREW BNE LNG THRD 5.5X55 MM,SUP-2315911,CDM,C1713,HCPCS,0278,RC,,,,both,,,763.02,495.96,,,,,,,,,,,,,
PLATE BNE FUSION 2 HOLE SINGLE LISFRANC STRATUM RS,SUP-2861193,CDM,C1713,HCPCS,0278,RC,,,,both,,,3881.04,2522.68,,,,,,,,,,,,,
I/B II KNEE TIBIAL WEDGESIZE 59 20 DEG 22MM,SUP-2502057,CDM,C1776,CPT,0278,RC,,,,both,,,7096.40,4612.66,,,,,,,,,,,,,
HC Debrid Wound Tis 20 Cm/<,PX-4209759700,CDM,97597,CPT,0420,RC,,,,both,,,583.00,378.95,,,,,,,,,,,,,
GRAFT BNE CRUSH 90 CC,SUP-2321772,CDM,C1762,CPT,0278,RC,,,,both,,,2458.62,1598.10,,,,,,,,,,,,,
KIT JEJUSTMY TB 22FR L45CM SIL INFL SECUR-LOK TAPR DST TIP,SUP-2124612,CDM,2720000010,LOCAL,0272,RC,,,,both,,,741.04,481.68,,,,,,,,,,,,,
ANCHOR ORTH HUM LG UNCEMENTED,SUP-2440776,CDM,C1776,CPT,0278,RC,,,,both,,,14327.82,9313.08,,,,,,,,,,,,,
PUTTY T50101 GRFT DBF 1CC,SUP-2417486,CDM,C9359,HCPCS,0278,RC,,,,both,,,1002.29,651.49,,,,,,,,,,,,,
SCREW BNE SELF RET MIC 1.5X3.5 MM MXLFCL X DRV DRILL-FREE TI,SUP-2497000,CDM,C1713,HCPCS,0278,RC,,,,both,,,179.86,116.91,,,,,,,,,,,,,
BENDER ROD RT CORONAL PLANE,SUP-2232094,CDM,2780000010,LOCAL,0278,RC,,,,both,,,3702.06,2406.34,,,,,,,,,,,,,
VALVE AORTIC TRANSCATH SYS NAVITOR RDPQ MRKRS 27MM,SUP-2929880,CDM,C1889,HCPCS,0278,RC,,,,both,,,81640.00,53066.00,,,,,,,,,,,,,
HC Gonadotropin Luteinizing Hormone,PX-3018300200,CDM,83002,CPT,0301,RC,,,,both,,,443.00,287.95,,,,,,,,,,,,,
GENERATOR NEUROSTIMULATOR 27GM VAGUS NRV POLYUR 2 PIN LI C,SUP-2175904,CDM,C1767,HCPCS,0278,RC,,,,both,,,52805.38,34323.50,,,,,,,,,,,,,
SHEATH KIT NANONEEDLE 180 MM HI FLO OPERATIVE,SUP-2849274,CDM,2720000010,LOCAL,0272,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
TROCAR SURG OD5.5 MM SCR LCK VERSANAIL,SUP-2412770,CDM,2720000010,LOCAL,0272,RC,,,,both,,,351.68,228.59,,,,,,,,,,,,,
INTRODUCER SHTH 8FR L63CM DIL 8FR L67CM 0.032IN TRANSSEPTAL,SUP-2357159,CDM,C1893,HCPCS,0272,RC,,,,both,,,521.24,338.81,,,,,,,,,,,,,
PLUG ORTH DIA4MM LOK SM FRAG CBL AXSOS,SUP-2371466,CDM,C1713,HCPCS,0278,RC,,,,both,,,353.25,229.61,,,,,,,,,,,,,
CATHETER ANGIOPLSTY ULTRAVERSE L 120 CM BALLOON L 4 CM DIA 3,SUP-2128654,CDM,C1725,HCPCS,0272,RC,,,,both,,,982.82,638.83,,,,,,,,,,,,,
SCREW BONE SELFTAPPING 4.5X40 MM CORTICAL HIP HEXAGONAL HEAD,SUP-2836646,CDM,C1713,HCPCS,0278,RC,,,,both,,,161.27,104.83,,,,,,,,,,,,,
GRAFT VASC STR 4 MMX10 CM TW N RING HD ACCS EPTFE CARBOFLO,SUP-2761233,CDM,C1768,CPT,0278,RC,,,,both,,,1974.68,1283.54,,,,,,,,,,,,,
SCREW BNE SM L25MM AQUA FOR IO FIX X-POST IOFIX 2.0,SUP-2223904,CDM,C1713,HCPCS,0278,RC,,,,both,,,5002.02,3251.31,,,,,,,,,,,,,
EXTERNAL FIXATION SET ARTICULATED ANK PVC FREE STRL XCALIBER,SUP-2646340,CDM,C1713,HCPCS,0278,RC,,,,both,,,11344.57,7373.97,,,,,,,,,,,,,
EXPANDER TISS GEL 7.1 CM PROJCT 14X13 CM 600 CC MOD HT X,SUP-2418551,CDM,C1789,HCPCS,0278,RC,,,,both,,,5099.36,3314.58,,,,,,,,,,,,,
QUARTEX OCCIPITAL PLT SM,SUP-2229108,CDM,C1713,HCPCS,0278,RC,,,,both,,,5730.50,3724.82,,,,,,,,,,,,,
DEVICE FIX DIA7-8MM LNG FEM ANCHR SFT TISS FOR 35-50MM TUNN,SUP-2212829,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2240.20,1456.13,,,,,,,,,,,,,
PLATE BONE INF BLDE L42MM DISPLC 12MM 90DEG 3 H NONSTERILE,SUP-2185417,CDM,C1713,HCPCS,0278,RC,,,,both,,,1409.61,916.25,,,,,,,,,,,,,
COLLAR CERV FOAM PADDING REG PEDIATRIC INF 1.25 IN PROCARE,SUP-2195748,CDM,L0180,HCPCS,0274,RC,,,,both,,,80.01,52.01,,,,,,,,,,,,,
COIL DETACH 3MM DIA 4CM 1.2MM THER DIA NXT HELIX SFT 10,SUP-2173006,CDM,C1889,HCPCS,0278,RC,,,,both,,,1786.66,1161.33,,,,,,,,,,,,,
SET CIRC BRTH AD L180CM COAX FLOW EXPIRATORY VLV PRESSEMBLED,SUP-2237224,CDM,C1713,HCPCS,0278,RC,,,,both,,,141.36,91.88,,,,,,,,,,,,,
NEEDLE NRV STIM INSRT NDL 65IN PAIN MGMT,SUP-2138808,CDM,2720000010,LOCAL,0272,RC,,,,both,,,514.33,334.31,,,,,,,,,,,,,
SIZER MAMM IMPL NACL STRL 275CC,SUP-2300471,CDM,2720000010,LOCAL,0272,RC,,,,both,,,141.30,91.84,,,,,,,,,,,,,
COIL NEUROVASCULAR PENUMBRA COIL 400 L 30 CM PRIMARY DIA,SUP-2323366,CDM,C1889,HCPCS,0278,RC,,,,both,,,7077.56,4600.41,,,,,,,,,,,,,
PLATE DISTR 90MML 15MM THK CP TTNM RTNTN F/RGD EXTRNL DISTR,SUP-2694382,CDM,C1713,HCPCS,0278,RC,,,,both,,,3066.18,1993.02,,,,,,,,,,,,,
HOLDER INSTRUMENT HK FORCEP STYL CERTEX,SUP-2401548,CDM,C1713,HCPCS,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
IMPLANT BIO L 7 X W 10 CM FISH SKIN DERMAL FEN 11 INTACT,SUP-2909299,CDM,Q4158,HCPCS,0636,RC,,,,both,,,9815.64,6380.17,,,,,,,,,,,,,
CUTTER OPHTH 19GA IOL PACKER CHANG,SUP-2304862,CDM,C1713,HCPCS,0278,RC,,,,both,,,2590.50,1683.82,,,,,,,,,,,,,
CATHETER CARD ABLATION THERMOCOOL SF 115CM 8FR BD NAVIGATION,SUP-2248525,CDM,C1732,HCPCS,0278,RC,,,,both,,,8336.70,5418.85,,,,,,,,,,,,,
ENDCAP ORTH 12 MM 15 MM EXTN XL40 RECESS FOR FEM NAIL TI GRN,SUP-2789367,CDM,C1889,HCPCS,0278,RC,,,,both,,,599.17,389.46,,,,,,,,,,,,,
CATHETER CARD ABLATION THERMOCOOL SF 115CM 8FR BD NAVIGATION,SUP-2248525,CDM,C1732,HCPCS,0272,RC,,,,both,,,8336.70,5418.85,,,,,,,,,,,,,
GRAFT BNE SUB 20CC DBM PRO-DENSE INJ INDUCTIVE PRO-STIM,SUP-2399132,CDM,C1713,HCPCS,0278,RC,,,,both,,,14685.78,9545.76,,,,,,,,,,,,,
PRE-LOADED APPLICATORS 5MM DIAMETER - 42CM LENGTH 50MMX5MMX1,SUP-2826788,CDM,C1763,HCPCS,0278,RC,,,,both,,,231.73,150.62,,,,,,,,,,,,,
BRACE ORTHOSIS SPNL S M EXOS FRM II 637,SUP-2196548,CDM,L0641,HCPCS,0272,RC,,,,both,,,488.40,317.46,,,,,,,,,,,,,
BUSHING ULN LG POLYETHYL LT ELBW TOT ARTHPLSTY STRL LATITUDE,SUP-2902294,CDM,C1776,CPT,0278,RC,,,,both,,,2857.40,1857.31,,,,,,,,,,,,,
GRAFT VASC IMPRA L 20 CM DIA 6 MM EPTFE STR STD WALL N RING,SUP-2761251,CDM,C1768,CPT,0278,RC,,,,both,,,861.08,559.70,,,,,,,,,,,,,
PLATE BNE SM W11XL85MM THK3.4MM 6 H BILAT TI RIG NEUT LOK,SUP-2420763,CDM,C1713,HCPCS,0278,RC,,,,both,,,923.51,600.28,,,,,,,,,,,,,
ADAPTER STEM 8MM OFFSET KNEE JAM NUT EXTN TOT STABILIZING,SUP-2376322,CDM,C1776,CPT,0278,RC,,,,both,,,2287.08,1486.60,,,,,,,,,,,,,
ARTHROFLEX 40X40X1.0 MM,SUP-2816389,CDM,Q4125,HCPCS,0636,RC,,,,both,,,6335.89,4118.33,,,,,,,,,,,,,
NUT LCK SPNL F ZM 8MM 8MM,SUP-2205109,CDM,C1713,HCPCS,0278,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
STEM HUM L 77 MM MED STD TI PLASMA SPRY LT ELBW SQ TOT,SUP-2902154,CDM,C1776,CPT,0278,RC,,,,both,,,25843.14,16798.04,,,,,,,,,,,,,
PROSTHESIS OSS PISTON 0.6X4.75 MM ARMSTR STYL PLASTI PORE,SUP-2637840,CDM,L8613,CPT,0278,RC,,,,both,,,509.28,331.03,,,,,,,,,,,,,
IMPLANT COSMETIC SZ 31 X 22 X 6.5 MM POLYETHYL LT REG,SUP-2935890,CDM,C1713,HCPCS,0278,RC,,,,both,,,2298.48,1494.01,,,,,,,,,,,,,
KIT HAD CATHETER 12FR L24CM STR EXTN 2 LUMN MAHRK ELITE,SUP-2283959,CDM,C1750,HCPCS,0278,RC,,,,both,,,227.40,147.81,,,,,,,,,,,,,
MATRIX TISS REGEN GRFTJKT NOW THCK 4CM X 8CM,SUP-2399087,CDM,Q4107,HCPCS,0636,RC,,,,both,,,10107.60,6569.94,,,,,,,,,,,,,
PROTECTOR TISS 2X2 IN 1 CC FLAT DRY SHT TRNSLUC VERSAWRAP,SUP-2740208,CDM,C1889,HCPCS,0278,RC,,,,both,,,7222.00,4694.30,,,,,,,,,,,,,
HC Arthrocent/Aspiration Maj Jnt|BILATERAL PROCEDURE,PX-3612061000,CDM,20610,CPT,0361,RC,,,50,both,,,1245.00,809.25,,,,,,,,,,,,,
GRAFT VASC GORTX L 10 CM DIA 6 MM RNG L 10 CM EPTFE STR TW,SUP-2396112,CDM,C1768,CPT,0278,RC,,,,both,,,750.46,487.80,,,,,,,,,,,,,
CATHETER PERIPH 1820GA MULT LUMN RADPQ RND WALL NDL TWIN,SUP-2570504,CDM,C1751,HCPCS,0278,RC,,,,both,,,13.85,9.00,,,,,,,,,,,,,
GENII CONST ART ISRT SZ5-6 9MM,SUP-2822847,CDM,C1776,CPT,0278,RC,,,,both,,,2599.92,1689.95,,,,,,,,,,,,,
BUR SURG L9CM DIA3MM MTCH HD DMND L BOR MIDAS REX LEGEND,SUP-2284665,CDM,2720000010,LOCAL,0272,RC,,,,both,,,378.40,245.96,,,,,,,,,,,,,
SCREW BNE L135MM DIA6.5MM THRD L32MM CANC TI ST SELF DRL,SUP-2190536,CDM,C1713,HCPCS,0278,RC,,,,both,,,124.31,80.80,,,,,,,,,,,,,
SCREW SPINE BONE IMPL T6 2X18MM,SUP-2661362,CDM,C1713,HCPCS,0278,RC,,,,both,,,602.88,391.87,,,,,,,,,,,,,
GRAFT 21 23CM WX295 31 LX08 17MM THCK L DMND FLEXHD,SUP-2307516,CDM,Q4128,HCPCS,0636,RC,,,,both,,,48125.65,31281.67,,,,,,,,,,,,,
PLATE BONE ADAPTION 2 MM 20 HOLE RAPID RESORBABLE STERILE RA,SUP-2838590,CDM,C1713,HCPCS,0278,RC,,,,both,,,1202.31,781.50,,,,,,,,,,,,,
LOOP PIST .5MMX4.25 MCGEE MOD,SUP-2277635,CDM,L8613,CPT,0278,RC,,,,both,,,213.52,138.79,,,,,,,,,,,,,
MESH HERN W15XL10CM TEXTILE MFIL POLYETH TEREPHTHALATE,SUP-2174685,CDM,C1781,HCPCS,0278,RC,,,,both,,,1330.79,865.01,,,,,,,,,,,,,
PROSTHESIS PENILE 20CM CYL MALL MINOCYCLINE RIFAMPIN,SUP-2140254,CDM,C1813,HCPCS,0278,RC,,,,both,,,5636.30,3663.59,,,,,,,,,,,,,
PLATE BNE T 84 MM 4 HOLE SS,SUP-2569106,CDM,C1713,HCPCS,0278,RC,,,,both,,,335.04,217.78,,,,,,,,,,,,,
SPONGE GRV SIL 3.0MMX5.0MMX80MM,SUP-2213496,CDM,L8610,HCPCS,0278,RC,,,,both,,,178.98,116.34,,,,,,,,,,,,,
BIT DRILL SURG DIA2.5 MM LNG AO QC ATTACH STRL DISP EVOS,SUP-2931401,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1062.95,690.92,,,,,,,,,,,,,
RESTRICTOR FEM CNL SZ 4 DIA15.75MM POLYETH NONRESORBABLE,SUP-2253089,CDM,C1776,CPT,0278,RC,,,,both,,,141.30,91.84,,,,,,,,,,,,,
RESTRICTOR CEM DIA12-18MM FEM W/ DISP HNDL CEMEX,SUP-2223702,CDM,C1713,HCPCS,0278,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
PLATE BNE MESHED 11X126X1 MM 2 HOLE SM GRID STR PDLLA STRL,SUP-2464434,CDM,C1713,HCPCS,0278,RC,,,,both,,,1844.56,1198.96,,,,,,,,,,,,,
HC So Acetone Assay,PX-3078201066,CDM,82010,CPT,0307,RC,,,,outpatient,,,116.00,75.40,,,,,,,,,,,,,
HC Wound Vac <=50 Sq Cm Dme,PX-7619760500,CDM,97605,CPT,0761,RC,,,,outpatient,,,275.00,178.75,,,,,,,,,,,,,
FIBER LASER 200UM 2J 80HZ 60W D F L FOR LITHO MOSES,SUP-2417489,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1646.99,1070.54,,,,,,,,,,,,,
SCREW BONE 7X30MM INTRF BIOABSRB 1.5MM CANN TI LTX STRL,SUP-2341646,CDM,C1713,HCPCS,0278,RC,,,,both,,,596.76,387.89,,,,,,,,,,,,,
STRUT FIX 2XSHORT STD MAXFRAME,SUP-2176975,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3303.28,2147.13,,,,,,,,,,,,,
SCREW SPNL CANC 6.5X50 MM LUMBAR SD FIX THRD TI SPINELINK,SUP-2468598,CDM,C1713,HCPCS,0278,RC,,,,both,,,202.88,131.87,,,,,,,,,,,,,
ALLOGRAFT DERMAL SHP THCK LG 22X13 CMX1.5-2.2 MM FLEXHD,SUP-2463664,CDM,Q4128,HCPCS,0636,RC,,,,both,,,14426.79,9377.41,,,,,,,,,,,,,
KIT BX 14GA L10CM DISP MPTY,SUP-2127775,CDM,C1713,HCPCS,0278,RC,,,,both,,,82.43,53.58,,,,,,,,,,,,,
SHEATH INTRO PEELWY L 15.5 CM DIA 5 FR DIL 20 CM GUIDEWIRE,SUP-2168169,CDM,C1894,HCPCS,0272,RC,,,,both,,,111.63,72.56,,,,,,,,,,,,,
NEEDLE ENDOSCP SPARE 5 MMX31 CM FHF REPL FOR 30675ND MANHES,SUP-2767121,CDM,2720000010,LOCAL,0272,RC,,,,both,,,435.68,283.19,,,,,,,,,,,,,
NAIL IM L420MM OD11.5MM 130DEG ANG LIME LOK CANN TI L FEM,SUP-2347982,CDM,C1713,HCPCS,0278,RC,,,,both,,,10048.00,6531.20,,,,,,,,,,,,,
PATCH DURAL 1.5X3CM NEURO PATCH,SUP-2826140,CDM,C1763,HCPCS,0278,RC,,,,both,,,210.95,137.12,,,,,,,,,,,,,
BURR SURG 2.1MM DIA HD LNG MIC 4.9MML HD SM BNE DIAMOND CROS,SUP-2605574,CDM,2720000010,LOCAL,0272,RC,,,,both,,,119.38,77.60,,,,,,,,,,,,,
FLEET ENEMA RE ENEM,RX-156779,CDM,6370000000,HCPCS,0637,RC,00132-0201-40,NDC,,both,133,ML,4.80,3.12,,,,,,,,,,,,,
BRACE ORTHOPEDIC SM LT WRST LTHR,SUP-2194370,CDM,L3809,HCPCS,0272,RC,,,,both,,,25.94,16.86,,,,,,,,,,,,,
MASTOID MESH 06MM THICK LOW PROFILE STYLE CP TITANIUM,SUP-2707276,CDM,C1713,HCPCS,0278,RC,,,,both,,,2536.90,1648.98,,,,,,,,,,,,,
SHELL ACET OD62MM TI-COAT HIP RESTORIS Z KLASSIC HD,SUP-2371083,CDM,C1776,CPT,0278,RC,,,,both,,,8037.74,5224.53,,,,,,,,,,,,,
ANCHOR SUT L15.5MM DIA5MM W/ TWO SZ 2 FIBERWIRE CRKSCR II,SUP-2121501,CDM,C1713,HCPCS,0278,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
CATHETER THROMCTMY ANGIOJET XMI L 135 CM DIA 4 FR INTRO 4 FR,SUP-2142032,CDM,C1757,HCPCS,0272,RC,,,,both,,,6185.80,4020.77,,,,,,,,,,,,,
SCREW AX MULT 3603536 35 X 36MM,SUP-2285460,CDM,C1713,HCPCS,0278,RC,,,,both,,,4176.20,2714.53,,,,,,,,,,,,,
RING EXT FIX DIA180 MM SPEEDWIRE FULL,SUP-2898417,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3799.40,2469.61,,,,,,,,,,,,,
MATRIX TISS PELV FLR REP BOV 4CMX7CM XENFORM,SUP-2139395,CDM,C1763,HCPCS,0278,RC,,,,both,,,2466.85,1603.45,,,,,,,,,,,,,
IMPLANT TOE JT DIA19MM THK8MM MT LENGTHENING DISC,SUP-2321675,CDM,C1776,CPT,0278,RC,,,,both,,,7473.20,4857.58,,,,,,,,,,,,,
BIT DRL OD2.9MM STBL NONSTERILE REUSE FOR COMPHSVE DEL SYS,SUP-2249337,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1077.02,700.06,,,,,,,,,,,,,
COIL EMB L6CM DIA3MM DETACH TARGET 3D,SUP-2368049,CDM,C1889,HCPCS,0278,RC,,,,both,,,6286.28,4086.08,,,,,,,,,,,,,
BEARING TIB MED 3 MM RT KNEE,SUP-2136405,CDM,C1776,CPT,0278,RC,,,,both,,,4763.38,3096.20,,,,,,,,,,,,,
PLATE BNE RECON 3.5X58 MM 5 HOLE SS,SUP-2569080,CDM,C1713,HCPCS,0278,RC,,,,both,,,338.49,220.02,,,,,,,,,,,,,
HC Repair Forearm Tendon/Muscle Prim 1 Ea Tdn,PX-4502527000,CDM,25270,CPT,0450,RC,,,,both,,,3319.00,2157.35,,,,,,,,,,,,,
SCREW BONE CANN POLYAX THRESHOLD PEDICULAR FIX 5.5 MMX50 MM,SUP-2354664,CDM,C1713,HCPCS,0278,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
CATHETER EP HISSER 5 MM SPC 5 FRX110 CM STEER,SUP-2357440,CDM,C1730,HCPCS,0272,RC,,,,both,,,1491.50,969.47,,,,,,,,,,,,,
BIT DRILL 1X75 MM 12 MM J LATCH,SUP-2841946,CDM,2720000010,LOCAL,0272,RC,,,,both,,,430.81,280.03,,,,,,,,,,,,,
ANCHOR SUT DIA4.5MM HA TWO NO2 WHT COBRAID BLU TWINFIX ULT,SUP-2341840,CDM,C1713,HCPCS,0278,RC,,,,both,,,988.13,642.28,,,,,,,,,,,,,
KIT CA 5.8MM SPINEJACK,SUP-2417100,CDM,C1062,HCPCS,0278,RC,,,,both,,,13078.10,8500.76,,,,,,,,,,,,,
ENDOPROSTHESIS VASC FLUENCY + L 40 MM DIA 7 MM CATH L 80 CM,SUP-2128256,CDM,C1874,HCPCS,0278,RC,,,,both,,,5809.00,3775.85,,,,,,,,,,,,,
ARCOS CAL SZ D +0 HI 60MM,SUP-2506013,CDM,C1776,CPT,0278,RC,,,,both,,,15159.92,9853.95,,,,,,,,,,,,,
KIT BNE GRFT SUB 5CC MINI BEAD RESRB OSTEOSET,SUP-2399041,CDM,C1713,HCPCS,0278,RC,,,,both,,,1940.52,1261.34,,,,,,,,,,,,,
HC Dysphagia/Swallowing Study,PX-3207423000,CDM,74230,CPT,0320,RC,,,,both,,,857.00,557.05,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL PEEK SD800.503,SUP-2860185,CDM,C1713,HCPCS,0278,RC,,,,both,,,27470.60,17855.89,,,,,,,,,,,,,
NAIL IM L320MM DIA15MM AQUA FEM TI CANN LOK RG AG BEND FLUT,SUP-2180147,CDM,C1713,HCPCS,0278,RC,,,,both,,,4636.62,3013.80,,,,,,,,,,,,,
SCREW BNE L25MM DIA6.28MM S STL CANC CANN LOK FULL THRD,SUP-2370998,CDM,C1713,HCPCS,0278,RC,,,,both,,,310.23,201.65,,,,,,,,,,,,,
HC Veeg by Tech 2-12 Hr Intmt Monitoring,PX-7409571200,CDM,95712,CPT,0740,RC,,,,outpatient,,,2592.00,1684.80,,,,,,,,,,,,,
HC Puncture Ea Add Breast Cyst,PX-3611900100,CDM,19001,CPT,0361,RC,,,,outpatient,,,3707.00,2409.55,,,,,,,,,,,,,
SEVELAMER CARBONATE 0.8 G PO PACK,RX-98615,CDM,J0602,HCPCS,0637,RC,65862-0930-08,NDC,,both,1,UN,8.60,5.59,,,,,,,,,,,,,
MESH SURG L 40 X W 30 CM POLYPRO POLYLACTIC ACD GRP,SUP-2901811,CDM,C1781,HCPCS,0278,RC,,,,both,,,7594.09,4936.16,,,,,,,,,,,,,
NAIL IM TIB 7.5X360 MM PROX AG TARGETING ARM CLR CODE TI,SUP-2460210,CDM,C1713,HCPCS,0278,RC,,,,both,,,1871.44,1216.44,,,,,,,,,,,,,
IMPLANT FACE L 42 X W 41 MM THK 0.6 MM SCREW DIA 0.5 MM,SUP-2883459,CDM,C1713,HCPCS,0278,RC,,,,both,,,3778.42,2455.97,,,,,,,,,,,,,
PLATE BONE L62MM 5 H LT POSTEROLATERAL DSTL FIBULAR VAR ANG,SUP-2349819,CDM,C1713,HCPCS,0278,RC,,,,both,,,4477.33,2910.26,,,,,,,,,,,,,
HC Wound Cautery-Chemical,PX-3611725000,CDM,17250,CPT,0361,RC,,,,both,,,280.00,182.00,,,,,,,,,,,,,
PLATE BONE THK0.8MM 4 H HND STR TRILOK FOR 1.5MM SCR APTUS,SUP-2267903,CDM,C1713,HCPCS,0278,RC,,,,both,,,1594.99,1036.74,,,,,,,,,,,,,
CATHETER NEPHSTMY L 6FR L20CM HYDRPHLC MULTPURP ABSC TAPR,SUP-2303529,CDM,C1729,HCPCS,0272,RC,,,,both,,,244.92,159.20,,,,,,,,,,,,,
NERVE STIMULATOR KIT CHARGER LUMBAR ACCESSORIES,SUP-2858401,CDM,2720000010,LOCAL,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
BIT DRL QC 2.5X135 MM 45 MM CALIB NS,SUP-2422951,CDM,2720000010,LOCAL,0272,RC,,,,both,,,354.91,230.69,,,,,,,,,,,,,
PEG BNE FIX L18MM DIA2.5MM STD VOLAR NONLOCKING FULL THRD,SUP-2414178,CDM,C1713,HCPCS,0278,RC,,,,both,,,285.74,185.73,,,,,,,,,,,,,
CATHETER HD DL 11.5 FRX15 CM FULL KT STR DUOFLO,SUP-2267017,CDM,C1750,HCPCS,0278,RC,,,,both,,,271.92,176.75,,,,,,,,,,,,,
NEEDLE FN NDL BX 25GA ENDOBRONCH US,SUP-2418160,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1148.14,746.29,,,,,,,,,,,,,
BASEPLATE TIB CLLRD STD KNEE ASMBLY BIMTRC,SUP-2448786,CDM,C1776,CPT,0278,RC,,,,both,,,1780.38,1157.25,,,,,,,,,,,,,
RETRACTOR SURG CHARNLEY 2 INX5.1 CM STD BLADE,SUP-2242478,CDM,2720000010,LOCAL,0272,RC,,,,both,,,983.39,639.20,,,,,,,,,,,,,
NEEDLE BRACHYTHERAPY L20CM OD18GA PROST STABILIZING,SUP-2134785,CDM,C1713,HCPCS,0278,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
GRAFT VASC INTERGARD L 60 CM DIA28 MM THK 0.38 MM POLYESTER,SUP-2476757,CDM,C1768,CPT,0278,RC,,,,both,,,1991.58,1294.53,,,,,,,,,,,,,
MESH HERN W15.9XL21CM VENTRAL POLYPR EPTFE OVL,SUP-2125816,CDM,C1781,HCPCS,0278,RC,,,,both,,,2181.36,1417.88,,,,,,,,,,,,,
GUIDEWIRE ORTHOPEDIC 1.5MM X 4IN STT,SUP-2640113,CDM,C1769,HCPCS,0272,RC,,,,both,,,128.74,83.68,,,,,,,,,,,,,
JOINT FNGR BASIL THMB 2 TI SWNSN,SUP-2538166,CDM,C1776,CPT,0278,RC,,,,both,,,6995.92,4547.35,,,,,,,,,,,,,
PLATE BNE 2 X 32 H MINI MIDFACE DBL STRP MALL,SUP-2883291,CDM,C1713,HCPCS,0278,RC,,,,both,,,5012.98,3258.44,,,,,,,,,,,,,
"HC Est Pt, Outpt Visit Level 4",PX-7619921400,CDM,99214,CPT,0761,RC,,,,both,,,313.00,203.45,,,,,,,,,,,,,
STENT URET CNTOUR VL L 22-30 CM DIA 4.8 FR CATH 6 FR,SUP-2139128,CDM,C2617,HCPCS,0278,RC,,,,both,,,581.90,378.23,,,,,,,,,,,,,
MARKER BRST BX 15GA TI OPN COIL RIG NDL W/ RADPQ CLP W/IN,SUP-2195597,CDM,A4648,CPT,0278,RC,,,,both,,,246.18,160.02,,,,,,,,,,,,,
BLADE SHV L13CM DIA4.3MM STR LNG SHFT IRRIG TBNG FOR,SUP-2284161,CDM,2720000010,LOCAL,0272,RC,,,,both,,,801.83,521.19,,,,,,,,,,,,,
ALLOGRAFT HUM TISS SEMITENDINOSUS TEND N SUTURED DBL STRND,SUP-2418411,CDM,C1762,CPT,0278,RC,,,,both,,,6311.40,4102.41,,,,,,,,,,,,,
HC Puncture Ea Add Breast Cyst,PX-3611900100,CDM,19001,CPT,0361,RC,,,,inpatient,,,3707.00,2409.55,,,,,,,,,,,,,
IMMUNE GLOBULIN (HUMAN) 5 GM/100ML IV SOLN,RX-104391,CDM,J1568,HCPCS,0636,RC,68982-0840-03,NDC,,both,100,ML,2865.40,1862.51,,,,,,,,,,,,,
HC X-Ray Clavicle,PX-3207300000,CDM,73000,CPT,0320,RC,,,,both,,,1049.00,681.85,,,,,,,,,,,,,
CLAMP EXT FIX DBL MULTIPIN MED STRL GALAXY FIX GEM LTX,SUP-2875645,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6315.80,4105.27,,,,,,,,,,,,,
PLATE BONE 18MM SPINOUS,SUP-2209280,CDM,C1713,HCPCS,0278,RC,,,,both,,,18055.00,11735.75,,,,,,,,,,,,,
MESH SURG 40X20 CM BIOMATERIAL PREPERITONEAL ENFORM,SUP-2435401,CDM,C1781,HCPCS,0278,RC,,,,both,,,33422.16,21724.40,,,,,,,,,,,,,
PLATE BONE 86MM PROX HUM LCK,SUP-2167417,CDM,C1713,HCPCS,0278,RC,,,,both,,,2819.72,1832.82,,,,,,,,,,,,,
KIT INTRO GLIDESHEATH SLENDER L 10 CM DIA 6 FR 0.021IN NIT,SUP-2384887,CDM,C1894,HCPCS,0272,RC,,,,both,,,261.84,170.20,,,,,,,,,,,,,
SCREW SPNL MULT ANGLE 90 DEG 6.75X40 MM SPRL ROD,SUP-2381435,CDM,C1713,HCPCS,0278,RC,,,,both,,,4330.06,2814.54,,,,,,,,,,,,,
TUNNELER SURG PLAS FOR HCKMN BRVC LNRD CATH,SUP-2127721,CDM,C1894,HCPCS,0272,RC,,,,both,,,505.54,328.60,,,,,,,,,,,,,
KYPHOPLASTY KIT BLLN 11 GAX30 MM FRAC 2ND,SUP-2864568,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4164.83,2707.14,,,,,,,,,,,,,
CATHETER PICC 3FR L50CM AND 3.5FR L7CM GWIRE 0.018IN S STL,SUP-2168435,CDM,C1751,HCPCS,0278,RC,,,,both,,,194.68,126.54,,,,,,,,,,,,,
BAYONET BPLR FRCP N STK IRRIG TIP 05MM LENGTH: 8IN 203CM,SUP-2160425,CDM,2720000010,LOCAL,0272,RC,,,,both,,,423.59,275.33,,,,,,,,,,,,,
BRACE ANK H85IN SM AD BILAT STRP CLSR OPN HEEL TOE RIG W,SUP-2195185,CDM,L4350,HCPCS,0274,RC,,,,both,,,71.72,46.62,,,,,,,,,,,,,
GRAFT DURA L 5 X W 4 IN TYP I CLLGN BOV ACHILLES TEND RESRB,SUP-2889755,CDM,C1763,HCPCS,0278,RC,,,,both,,,3602.58,2341.68,,,,,,,,,,,,,
BURR SURG 64X5.0MM RND CUT NEURO L NONFLUTED CARB ST,SUP-2284255,CDM,2720000010,LOCAL,0272,RC,,,,both,,,614.06,399.14,,,,,,,,,,,,,
COMPONENT FEM SZ 1 L KNEE TRITANIUM PERI APATITE POST STBL 5516F101] STRYKER ORTHOPEDICS HOWM],SUP-2373044,CDM,C1776,CPT,0278,RC,,,,both,,,13331.18,8665.27,,,,,,,,,,,,,
MESH HERN DIA8IN CIR W/ PRE ATTCH LO PROF BLLN AND ECHO PS,SUP-2125919,CDM,C1781,HCPCS,0278,RC,,,,both,,,3937.56,2559.41,,,,,,,,,,,,,
SCREW BNE COMPR LNG THRD 3.2X10 MM,SUP-2399955,CDM,C1713,HCPCS,0278,RC,,,,both,,,844.66,549.03,,,,,,,,,,,,,
PLATE BONE L35MM AQUA LT TOT COMPR L,SUP-2396854,CDM,C1713,HCPCS,0278,RC,,,,both,,,3133.72,2036.92,,,,,,,,,,,,,
"PANCRELIPASE (LIP-PROT-AMYL) 15000-47000-63,000 UNITS PO CPEP",RX-142325,CDM,6370000000,HCPCS,0637,RC,73562-0111-01,NDC,,both,1,UN,27.40,17.81,,,,,,,,,,,,,
SCREW BONE L12XOD2.7MM TI CORT ST EMER NONLOCKING HEX HD,SUP-2363469,CDM,C1713,HCPCS,0278,RC,,,,both,,,148.05,96.23,,,,,,,,,,,,,
CATHETER UMB 3L 5 FRX15 IN ATRAUM TIP ROUNDED VES ARGY,SUP-2174252,CDM,C1751,HCPCS,0278,RC,,,,both,,,111.91,72.74,,,,,,,,,,,,,
HC Cntrl Orophary Hmrhg W Srg Int,PX-4504296200,CDM,42962,CPT,0450,RC,,,,both,,,3206.00,2083.90,,,,,,,,,,,,,
GRAFT BNE SUB 10CC SACROILIAC PTTY DEMIN MTRX JR FOR RIALTO,SUP-2294017,CDM,C9359,HCPCS,0278,RC,,,,both,,,4468.22,2904.34,,,,,,,,,,,,,
HC Inj Anes/Steroid C/D Facet Sg|BILATERAL PROCEDURE,PX-3616449000,CDM,64490,CPT,0361,RC,,,50,outpatient,,,4864.00,3161.60,,,,,,,,,,,,,
KIT EXT FIX AUTO HEXAPOD CTRL MAXFRAME AUTOSTRUT,SUP-2908466,CDM,C1713,HCPCS,0278,RC,,,,both,,,22969.10,14929.91,,,,,,,,,,,,,
HYDROCORTISONE VALERATE 0.2 % EX OINT,RX-10219,CDM,6370000000,HCPCS,0637,RC,51672-1292-01,NDC,,both,15,GR,354.30,230.29,,,,,,,,,,,,,
GUIDEWIRE ORTH L 450 MM DIA2.8 MM TROCAR FLUT TIP FOR CANN,SUP-2908265,CDM,C1769,HCPCS,0272,RC,,,,both,,,622.66,404.73,,,,,,,,,,,,,
ADENOSINE 6 MG/2ML IV SOLN,RX-38703,CDM,J0153,HCPCS,0636,RC,67457-0855-02,NDC,,both,1,ML,54.10,35.16,,,,,,,,,,,,,
SAW SURG OSCILLATING HALL TITAN PRO9350B,SUP-2607719,CDM,2720000010,LOCAL,0272,RC,,,,both,,,29037.15,18874.15,,,,,,,,,,,,,
PLATE BONE DUAL CMPRSSN HLX5 TTNM RCNSTRCTN F3.5MM LOK SCRE,SUP-2720931,CDM,C1713,HCPCS,0278,RC,,,,both,,,1300.15,845.10,,,,,,,,,,,,,
FIBER LASER 1000UM DUST THULIUM,SUP-2885327,CDM,2720000010,LOCAL,0272,RC,,,,both,,,923.16,600.05,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED TIB PATELLAR COMP PERSONA TIBZIMCOMPNTS] ZIMMER BIOMET INC],SUP-2212670,CDM,C1776,CPT,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
GRAFT BONE L50-100MM SHFT FRZN,SUP-2335280,CDM,C1762,CPT,0278,RC,,,,both,,,3218.50,2092.02,,,,,,,,,,,,,
PLATE BNE 8 H L DST MED TIB LOK W/O TAB FOR 3.5MM SCR,SUP-2349081,CDM,C1713,HCPCS,0278,RC,,,,both,,,5020.86,3263.56,,,,,,,,,,,,,
INTRODUCER LD 9 FRX50 CM SET CRD STD CS ACCS SAFSHTH WORLEY,SUP-2138101,CDM,C1893,HCPCS,0272,RC,,,,both,,,1318.80,857.22,,,,,,,,,,,,,
PLATE 8H,SUP-2247339,CDM,C1713,HCPCS,0278,RC,,,,both,,,1639.08,1065.40,,,,,,,,,,,,,
PATCH CV VASCU-GUARD L 9 X W 2 CM BOV PERICARD PERIPH STRL,SUP-2129977,CDM,C1768,CPT,0278,RC,,,,both,,,752.85,489.35,,,,,,,,,,,,,
DEVICE CAPT NDL,SUP-2876934,CDM,2720000010,LOCAL,0272,RC,,,,both,,,557.19,362.17,,,,,,,,,,,,,
PROSTHESIS 4MM DIAM 7MM LEN TORP FLROPLAS SHEA,SUP-2313655,CDM,L8613,CPT,0278,RC,,,,both,,,694.51,451.43,,,,,,,,,,,,,
BRACE ORTH L 11.5 X W 3 X H 18.5 IN THORACOLUMBOSACRAL MODEL,SUP-2902070,CDM,L0456,HCPCS,0274,RC,,,,both,,,219.80,142.87,,,,,,,,,,,,,
LENS BILL IOL 60005,SUP-2881901,CDM,V2787,HCPCS,0276,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
DEVICE FIX 35MM AC JT FEM 1 ZIPLOOP TECHNOLOGY ZIPTIGHT,SUP-2137182,CDM,C1713,HCPCS,0278,RC,,,,both,,,2631.32,1710.36,,,,,,,,,,,,,
"HC Culture, Afb",PX-3008711600,CDM,87116,CPT,0300,RC,,,,both,,,358.00,232.70,,,,,,,,,,,,,
SLEEVE LAPSCP 6MM DEPTH,SUP-2232028,CDM,2720000010,LOCAL,0272,RC,,,,both,,,775.58,504.13,,,,,,,,,,,,,
STIMULATOR NRV SPNL CRD NEUROMODULATION PRECIS,SUP-2141950,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6896.70,4482.85,,,,,,,,,,,,,
CATHETER HEMODIALYSI HEM FLO CHRONIC 14.5FR DIA 40CM 35CML C,SUP-2610555,CDM,C1750,HCPCS,0278,RC,,,,both,,,270.04,175.53,,,,,,,,,,,,,
SUPPORT ORTHOT LUMBAR SACR CUST SAGITTAL-CORONAL FRAME,SUP-2435559,CDM,L0650,HCPCS,0274,RC,,,,both,,,3667.77,2384.05,,,,,,,,,,,,,
CATHETER DIL PTA P3 8MM X 2CM PWRFLX,SUP-2156155,CDM,C1725,HCPCS,0272,RC,,,,both,,,586.11,380.97,,,,,,,,,,,,,
SHUNT VENTRICULOPERTIONEAL 6FR 90CM M SM W SNAP RESVR CSF,SUP-2278381,CDM,C1889,HCPCS,0278,RC,,,,both,,,3784.64,2460.02,,,,,,,,,,,,,
OXAZEPAM 15 MG PO CAPS,RX-5931,CDM,6370000000,HCPCS,0637,RC,62584-0813-11,NDC,,both,1,UN,11.80,7.67,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 120 MM DIA 8 MM DEL SHTH,SUP-2934286,CDM,C1713,HCPCS,0278,RC,,,,both,,,11822.10,7684.36,,,,,,,,,,,,,
PLATE BNE INTRAPELVIC RT 5 HOLE,SUP-2518357,CDM,C1713,HCPCS,0278,RC,,,,both,,,4556.14,2961.49,,,,,,,,,,,,,
DRILL FOR 2.4MM PL HIP HARD BONE,SUP-2812340,CDM,2720000010,LOCAL,0272,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
ELECTRODE ENDOSCP 24-28FR 12DEG AND 30DEG HI FREQ RESECT,SUP-2314006,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1954.65,1270.52,,,,,,,,,,,,,
COMPONENT TIB CR 00 9 MM LT KNEE PRIMARY STEM CEM NP UCONG,SUP-2209389,CDM,C1776,CPT,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
SHEATH PROSTHETIC BK,SUP-2388223,CDM,L8400,HCPCS,0272,RC,,,,both,,,45.66,29.68,,,,,,,,,,,,,
GUN BNE CEM INJ 2 SPD,SUP-2366768,CDM,C1713,HCPCS,0278,RC,,,,both,,,1987.62,1291.95,,,,,,,,,,,,,
PLATE BONE RECONSTRUCTION 3.5X166 MM 14 HOLE FOR SCREW STERI,SUP-2836657,CDM,C1713,HCPCS,0278,RC,,,,both,,,4203.20,2732.08,,,,,,,,,,,,,
GRAFT HUM TISS W6-20X9-21XL14-25MM THK16-18MM IL CREST WDG,SUP-2307144,CDM,C1762,CPT,0278,RC,,,,both,,,2518.28,1636.88,,,,,,,,,,,,,
TUBE VENT OD1.27MM 3.1IFD WHT SHEEHY TYP BTTN FLPL ST,SUP-2284044,CDM,L8699,HCPCS,0278,RC,,,,both,,,40.85,26.55,,,,,,,,,,,,,
SCREWDRIVER SURG N CANN STD 25 MM HEX ATLNTS REUSE,SUP-2279318,CDM,2720000010,LOCAL,0272,RC,,,,both,,,312.08,202.85,,,,,,,,,,,,,
ARCH EXT FIX BOW SHT 90 MM NS TRUELOK LTX,SUP-2875042,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1700.15,1105.10,,,,,,,,,,,,,
CATHETER SOLEX 7 HEPARIN USA,SUP-2570572,CDM,C1751,HCPCS,0278,RC,,,,both,,,3316.34,2155.62,,,,,,,,,,,,,
CUP ACET DIA48MM RT HIP POR PRI PRESSFIT ASR,SUP-2254021,CDM,C1776,CPT,0278,RC,,,,both,,,15247.84,9911.10,,,,,,,,,,,,,
CATHETER ANGIOPLSTY POLARCATH L 135 CM BALLOON L 60 MM DIA 3,SUP-2141231,CDM,C1725,HCPCS,0272,RC,,,,both,,,2574.80,1673.62,,,,,,,,,,,,,
BENDER ROD 5.5MM REVERE,SUP-2232131,CDM,C1713,HCPCS,0278,RC,,,,both,,,2527.70,1643.00,,,,,,,,,,,,,
GRAFT BNE L22 30XW9MM THICKNESS 13 15MM PAT FRZ DRY WDG IMPL,SUP-2307177,CDM,C1713,HCPCS,0278,RC,,,,both,,,2962.34,1925.52,,,,,,,,,,,,,
ALLOGRAFT BNE BLOCK FD IRRADIATED IL CREST,SUP-2867054,CDM,C1762,CPT,0278,RC,,,,both,,,2308.84,1500.75,,,,,,,,,,,,,
DEVICE GUID DBL JT TYP 2 MM 115 CM ROTATABLE STRL LF DISP,SUP-2865624,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1491.50,969.47,,,,,,,,,,,,,
AMOXAPINE 25 MG PO TABS,RX-448,CDM,6370000000,HCPCS,0637,RC,00591-5713-01,NDC,,both,1,UN,2.80,1.82,,,,,,,,,,,,,
SHEATH GLD OPER VERSASCOPE,SUP-2257610,CDM,C1894,HCPCS,0272,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
SPHINCTEROTOME ENDO 5.5FR L200CM EXPOSED CUT WIRE VAR SOEH,SUP-2169149,CDM,2720000010,LOCAL,0272,RC,,,,both,,,467.86,304.11,,,,,,,,,,,,,
SHEATH PROSTHETIC BK,SUP-2388223,CDM,L8400,HCPCS,0274,RC,,,,both,,,45.66,29.68,,,,,,,,,,,,,
DEFIBRILLATOR IMPL TELIGEN VR TI SINGLE CHMBR RF HI ENERGY,SUP-2149135,CDM,C1722,HCPCS,0275,RC,,,,both,,,51025.00,33166.25,,,,,,,,,,,,,
HEAD FEM REV +8 MM 26 MM HIP PRIMARY INCREASED TAPR COCR,SUP-2375218,CDM,C1776,CPT,0278,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
ALLOGRAFT HUM TISS GRACILIS TEND FRZN COLL-E-STRONG,SUP-2321811,CDM,C1762,CPT,0278,RC,,,,both,,,4239.00,2755.35,,,,,,,,,,,,,
MESH HERN VENTRAL SM 1.7X1.7 IN O3FA POLYPR C-QUR V-PATCH,SUP-2227251,CDM,C1781,HCPCS,0278,RC,,,,both,,,1092.72,710.27,,,,,,,,,,,,,
GRAFT NRV REP L3CM DIA2MM TYP 1 CLLGN ABSRB SEMIPERMEABLE,SUP-2244349,CDM,C9352,HCPCS,0278,RC,,,,both,,,4600.26,2990.17,,,,,,,,,,,,,
PORT VASC ACC 10.5FRXCELA POWERPRT,SUP-2116580,CDM,C1892,HCPCS,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
PI PICC KIT 2-L 5 FR X 55 CM TIPTRACKER,SUP-2565191,CDM,C1751,HCPCS,0278,RC,,,,both,,,570.44,370.79,,,,,,,,,,,,,
CATHETER THROMCTMY LIGHTNING FLSH L 115 CM BER TIP HTORQ,SUP-2865163,CDM,C1757,HCPCS,0272,RC,,,,both,,,30677.80,19940.57,,,,,,,,,,,,,
PLATE BONE ORBITAL FLOOR 30X30X1.5 MM POROUS POLYETHYLENE ST,SUP-2837798,CDM,C1713,HCPCS,0278,RC,,,,both,,,1940.83,1261.54,,,,,,,,,,,,,
PLATE BNE ORBIT FLR 1.5X0.3 MM CONTOURED FOR SCREW TI NS LF,SUP-2476448,CDM,C1713,HCPCS,0278,RC,,,,both,,,3059.84,1988.90,,,,,,,,,,,,,
SAW SURG RECIP W/O HOSE FLFORTHPDC ORLORALMXLLFCL OTOLARYN S,SUP-2605428,CDM,2720000010,LOCAL,0272,RC,,,,both,,,11110.51,7221.83,,,,,,,,,,,,,
INSERT TIB M THK11MM UNIV DUR TOT STBL REV NEUT DURAC,SUP-2377484,CDM,C1776,CPT,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
PLATE SPNL L5CM STD ANT THORLUM TI VANTAGE,SUP-2292691,CDM,C1713,HCPCS,0278,RC,,,,both,,,12481.50,8112.97,,,,,,,,,,,,,
GRAFT SKIN 2X3 IN PURAPLY AM,SUP-2314116,CDM,Q4196,HCPCS,0636,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
VALVE MITRL MSTR SER CUF DIA20 MM TISS ANNULUS DIA15 MM,SUP-2894019,CDM,C1889,HCPCS,0278,RC,,,,both,,,29651.02,19273.16,,,,,,,,,,,,,
RELOAD STPL 45MM THCK TISS GRN W/ GRIPPING SURF TECHNOLOGY,SUP-2283261,CDM,2720000010,LOCAL,0272,RC,,,,both,,,718.18,466.82,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 40 CM DIA 8 MM STR TW SLDE GDS,SUP-2669694,CDM,C1768,CPT,0278,RC,,,,both,,,1886.70,1226.35,,,,,,,,,,,,,
BLADE SCREWDRIVER 2/2.3X140 MM CENTRE DRV LEVEL 1,SUP-2471285,CDM,2720000010,LOCAL,0272,RC,,,,both,,,799.44,519.64,,,,,,,,,,,,,
SAW SURG JOS 7.5 INX38 MM NSL STR MICROFRANCE,SUP-2464445,CDM,2720000010,LOCAL,0272,RC,,,,both,,,602.79,391.81,,,,,,,,,,,,,
BONESYNC PUTTY 15CC,SUP-2811423,CDM,C1713,HCPCS,0278,RC,,,,both,,,4945.50,3214.57,,,,,,,,,,,,,
PLATE BONE L64MM 7 HOLE LEFT LTRL DST HMRL TTNM LOW PRFLE RI,SUP-2487661,CDM,C1713,HCPCS,0278,RC,,,,both,,,3020.68,1963.44,,,,,,,,,,,,,
PLATE BNE BUTTRESS 30 MM ATLS,SUP-2391495,CDM,C1713,HCPCS,0278,RC,,,,both,,,8785.41,5710.52,,,,,,,,,,,,,
BLADE ARTHSCP SHV L8CM DIA2.5MM AGG SERR,SUP-2363530,CDM,2720000010,LOCAL,0272,RC,,,,both,,,401.89,261.23,,,,,,,,,,,,,
ENDCAP ORTHOPEDIC PANTA,SUP-2423079,CDM,C1713,HCPCS,0278,RC,,,,both,,,3105.37,2018.49,,,,,,,,,,,,,
CATHETER DLYS L40CM L23CM OD13.5FR 2 LUMN VITACUF ANTIMIC,SUP-2127708,CDM,C1881,HCPCS,0278,RC,,,,both,,,1045.15,679.35,,,,,,,,,,,,,
KIT SPNL CRD STIM TRL LD 1 INTELLIS,SUP-2882918,CDM,C1897,HCPCS,0278,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
HC Trigger Point 3 or More,PX-5102055300,CDM,20553,CPT,0510,RC,,,,outpatient,,,775.00,503.75,,,,,,,,,,,,,
PLATE EXT FIX 90 DEG 240 MM FEM ARCH CARBON FIBER NS,SUP-2799527,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2609.18,1695.97,,,,,,,,,,,,,
SCREW BNE L70MM OD4MM THRD L20MM CORT OSTEOTITE HA COAT,SUP-2316320,CDM,C1713,HCPCS,0278,RC,,,,both,,,409.39,266.10,,,,,,,,,,,,,
KIT BONE MAR ASPIR CONC SYS BOS,SUP-2137031,CDM,2720000010,LOCAL,0272,RC,,,,both,,,816.40,530.66,,,,,,,,,,,,,
WIRE BNE FIX L 228.6 MM DIA1.6 MM TROCAR END NS KIRSCHNER,SUP-2885112,CDM,C1713,HCPCS,0278,RC,,,,both,,,329.89,214.43,,,,,,,,,,,,,
COVER BUR H 5 H TI LO PROF FOR 2MM SCR,SUP-2363681,CDM,C1713,HCPCS,0278,RC,,,,both,,,584.48,379.91,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.427,SUP-2859991,CDM,C1713,HCPCS,0278,RC,,,,both,,,36930.80,24005.02,,,,,,,,,,,,,
GUIDEWIRE VASC L80CM OD0.018IN TIP L2CM NIT COR TUNGSTEN,SUP-2172967,CDM,C1769,HCPCS,0272,RC,,,,both,,,486.70,316.35,,,,,,,,,,,,,
PROBE LTHTRPSY DSPSBLE 19FR PNMTC F/UTRSCPY AUTLTH IEHL,SUP-2722575,CDM,2720000010,LOCAL,0272,RC,,,,both,,,970.26,630.67,,,,,,,,,,,,,
ENDOPROSTHESIS VASC VIABAHN VBX L 29 MM 9/13 MM 135 CM 8 FR,SUP-2395681,CDM,C1874,HCPCS,0278,RC,,,,both,,,9862.74,6410.78,,,,,,,,,,,,,
PLATE BNE NAR 130 MM 10 HOLE TI,SUP-2459103,CDM,C1713,HCPCS,0278,RC,,,,both,,,389.05,252.88,,,,,,,,,,,,,
CLAMP EXT FIX DBL UNIV MULT PIN GEM FIX NS GALAXY LTX,SUP-2875227,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4975.83,3234.29,,,,,,,,,,,,,
STENT PERIPH L25CM DIA8MM CATH 7FR L120CM BAL DIA8MM,SUP-2396638,CDM,C1874,HCPCS,0278,RC,,,,both,,,20080.30,13052.19,,,,,,,,,,,,,
PREM ST/RGX CP/LGXL/LG HD,SUP-2212378,CDM,C1776,CPT,0278,RC,,,,both,,,17270.00,11225.50,,,,,,,,,,,,,
PLATE BNE TIB TUBEROSITY ADV 2.4/2.7X53 MM RT 2 HOLE LCP,SUP-2569433,CDM,C1713,HCPCS,0278,RC,,,,both,,,113.98,74.09,,,,,,,,,,,,,
TUBING SUCT L244CM L61CM DIR CTRL HD DISP FOR OLY FUJINON,SUP-2360654,CDM,C1713,HCPCS,0278,RC,,,,both,,,431.75,280.64,,,,,,,,,,,,,
SCREW BRAKE OFF SOLERA G5 4.75MM TI NS,SUP-2285819,CDM,C1713,HCPCS,0278,RC,,,,both,,,174.74,113.58,,,,,,,,,,,,,
BRACE KNEE LG W/ FAN STBL,SUP-2337058,CDM,L1810,HCPCS,0272,RC,,,,both,,,133.48,86.76,,,,,,,,,,,,,
COMPONENT FEM SZ C LT KNEE POST STBL COMPATIBLE W/ LPS-FLEX,SUP-2201145,CDM,C1776,CPT,0278,RC,,,,both,,,14801.96,9621.27,,,,,,,,,,,,,
STEM FEM MOD E HIP FOR KINECTIV TECHNOLOGY NK IMPL,SUP-2439200,CDM,C1776,CPT,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
IMIPRAMINE HCL 50 MG PO TABS,RX-3862,CDM,6370000000,HCPCS,0637,RC,64380-0171-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
GUIDEWIRE ORTH MED,SUP-2400567,CDM,C1769,HCPCS,0272,RC,,,,both,,,200.96,130.62,,,,,,,,,,,,,
GRAFT VASC GELWEAVE L 30 CM DIA10 MM SIDE BRANCH L 10/10/10,SUP-2894597,CDM,C1768,CPT,0278,RC,,,,both,,,7768.36,5049.43,,,,,,,,,,,,,
SET PLEURAL PNEUMOPERICARDIAL DRAINAGE FUHRMAN,SUP-2759700,CDM,C1729,HCPCS,0272,RC,,,,both,,,462.84,300.85,,,,,,,,,,,,,
ENDPLATE SPNL VA 12X13 MM UPPER W/ FOOTPRINT FORTIFY,SUP-2732982,CDM,C1889,HCPCS,0278,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
PLATE BNE 2X9 MM TI,SUP-2262918,CDM,C1713,HCPCS,0278,RC,,,,both,,,364.24,236.76,,,,,,,,,,,,,
HC Doppler Velocimetry Fetal Umb,PX-4027682000,CDM,76820,CPT,0402,RC,,,,both,,,607.00,394.55,,,,,,,,,,,,,
SCREW BNE EXTRACTION FOR HUM NAILING SYS NS MULTILOC,SUP-2799297,CDM,C1713,HCPCS,0278,RC,,,,both,,,1767.35,1148.78,,,,,,,,,,,,,
SHUNT VENTRICULAR PUMP CHAMBER 5/30CM WATER WITHOUT RESERVOI,SUP-2821796,CDM,C1889,HCPCS,0278,RC,,,,both,,,7008.83,4555.74,,,,,,,,,,,,,
SENNOSIDES 8.8 MG/5ML PO SYRP,RX-15168,CDM,340b,HCPCS,0637,RC,48433-0219-40,NDC,,both,5,ML,9.00,5.85,,,,,,,,,,,,,
COMPONENT PAT DIA35MM DST KNEE POLY OVL DOME 3 PEG NP CEM,SUP-2253503,CDM,C1776,CPT,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
FEEDING TUBE KIT LP 14 FRX0.8 CM BLLN BUTTON SIL MINI 1,SUP-2754571,CDM,2720000010,LOCAL,0272,RC,,,,both,,,680.94,442.61,,,,,,,,,,,,,
BUR SURG DIAMOND SUPER LNG 60 K 2 MM HI SPD UNIDRIVE DISP,SUP-2599301,CDM,2720000010,LOCAL,0272,RC,,,,both,,,571.17,371.26,,,,,,,,,,,,,
CUP ACET OD54MM ID24MM HIP UHMWPE TPLR REV FOR TOT,SUP-2404276,CDM,C1776,CPT,0278,RC,,,,both,,,6468.40,4204.46,,,,,,,,,,,,,
CATHETER HD INT ACCS JUG,SUP-2269565,CDM,C1750,HCPCS,0278,RC,,,,both,,,131.88,85.72,,,,,,,,,,,,,
PLATE BONE 2X2 HOLE 90 DEGREE 2X17 MM LEFT L TYPE LOW PROFIL,SUP-2838400,CDM,C1713,HCPCS,0278,RC,,,,both,,,841.83,547.19,,,,,,,,,,,,,
COIL FIL COMPLX SFT .020IN W DIA 13MM SEC DIA 48CM PENUMBRA,SUP-2323417,CDM,C1889,HCPCS,0278,RC,,,,both,,,8176.56,5314.76,,,,,,,,,,,,,
NAIL IM 11X300 MM TIB TI LIGHT GRN NS,SUP-2179844,CDM,C1713,HCPCS,0278,RC,,,,both,,,4935.08,3207.80,,,,,,,,,,,,,
SCREW BNE L28MM DIA5.5MM PERIPH LOK FOR MOD GLEN SYS,SUP-2123412,CDM,C1713,HCPCS,0278,RC,,,,both,,,307.72,200.02,,,,,,,,,,,,,
HC NM 3 Phase Bone Scan,PX-3417831500,CDM,78315,CPT,0341,RC,,,,inpatient,,,3524.00,2290.60,,,,,,,,,,,,,
PLATE BNE L73MM 3 H L PROX HUM LO ALPS,SUP-2411632,CDM,C1713,HCPCS,0278,RC,,,,both,,,5871.80,3816.67,,,,,,,,,,,,,
COMPONENT FEM SEG 55 MM M FEMALE KNEE,SUP-2437248,CDM,C1776,CPT,0278,RC,,,,both,,,9269.28,6025.03,,,,,,,,,,,,,
ENDOSCOPIC SET FOR AUTOGRFT TRANSFER SYS DISP,SUP-2121639,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1469.52,955.19,,,,,,,,,,,,,
MEMBRANE AMNIO AMNIOFIX ALLGRFT 4.0X4.0CM,SUP-2305730,CDM,V2790,HCPCS,0274,RC,,,,both,,,5950.30,3867.69,,,,,,,,,,,,,
NAIL COMPR L200MM DIA10MM ANK TI CANN,SUP-2316330,CDM,C1713,HCPCS,0278,RC,,,,both,,,8330.61,5414.90,,,,,,,,,,,,,
MESH SURG L9MM OD16MM MET RND MP PYRAMESH,SUP-2292070,CDM,C1713,HCPCS,0278,RC,,,,both,,,3176.30,2064.59,,,,,,,,,,,,,
GUIDEWIRE VASC L155CM DIA0035IN EXTN SYS WHLY,SUP-2281741,CDM,C1769,HCPCS,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
KIT TEND COMPR BRDG FIBERTAPE,SUP-2122140,CDM,C1713,HCPCS,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
LEAD PACE ACUITY SPRL L 90 CM DIA 6 FR SIL POLYUR ETFE PTIR,SUP-2148699,CDM,C1900,HCPCS,0275,RC,,,,both,,,3617.28,2351.23,,,,,,,,,,,,,
IMPLANT SYNTH TISS L 122 X W 122 MM THK 0.5 MM 1.7 MM PLLA,SUP-2883135,CDM,C1713,HCPCS,0278,RC,,,,both,,,13360.64,8684.42,,,,,,,,,,,,,
STRAP ORTHOT HIP KNEE ANK CUST TORSON UNILAT ROT,SUP-2435643,CDM,L2070,HCPCS,0272,RC,,,,both,,,439.41,285.62,,,,,,,,,,,,,
LEAD PACE FLXTND L 59 CM SIL STEROID ENDOCARD RT,SUP-2140096,CDM,C1779,HCPCS,0275,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
PLATE COMPRSS VARIAX BRD CRV 16H,SUP-2705338,CDM,C1713,HCPCS,0278,RC,,,,both,,,4267.73,2774.02,,,,,,,,,,,,,
SHEATH THROMCTMY CATH INTHRILL L 6 CM DIA 8 FR STRL,SUP-2862338,CDM,C1894,HCPCS,0272,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
ORTHOSIS ADDITION TO LO EXT VARUS VALGUS CORR PLAS MOD,SUP-2237271,CDM,L2275,HCPCS,0274,RC,,,,both,,,420.76,273.49,,,,,,,,,,,,,
BIT DRL L75MM DIA2MM STRL J LATCH NONRADIOPAQUE W/O STP,SUP-2187208,CDM,2720000010,LOCAL,0272,RC,,,,both,,,393.38,255.70,,,,,,,,,,,,,
CATHETER ANGIOPLSTY LP 0.018 IN 100 CM 5X150 MM LUTONIX 018,SUP-2128354,CDM,C2623,HCPCS,0278,RC,,,,both,,,6908.00,4490.20,,,,,,,,,,,,,
SCREW SPNL L4MM DIA2MM CORT TI SELF DRL FULL THRD STARDRV,SUP-2189353,CDM,C1713,HCPCS,0278,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
BRUSH CYTO CHN SZ 1.2MM L115CM DIA2MM BRIST DIA0.064MM THCK,SUP-2312963,CDM,2720000010,LOCAL,0272,RC,,,,both,,,110.97,72.13,,,,,,,,,,,,,
SHELL ACET CLUS H COCR ALLOY 62MM VITALOCK,SUP-2364623,CDM,C1776,CPT,0278,RC,,,,both,,,2892.73,1880.27,,,,,,,,,,,,,
FONDAPARINUX SODIUM 5 MG/0.4ML SC SOLN,RX-104343,CDM,J1652,HCPCS,0636,RC,67457-0583-04,NDC,,both,0.4,ML,336.40,218.66,,,,,,,,,,,,,
BUR SURG 5MM D14X11MM CUT FOR CRNRSTN,SUP-2290949,CDM,2720000010,LOCAL,0272,RC,,,,both,,,640.87,416.57,,,,,,,,,,,,,
PLATE BONE SM L85MM 7 HOLE RIGHT DST VOLAR PRRTCLR RDL ULNAR,SUP-2720786,CDM,C1713,HCPCS,0278,RC,,,,both,,,2503.27,1627.13,,,,,,,,,,,,,
SET INTRO SUP ARW FLX SHTH L 65 CM DIA 7 FR HYDRPHLC,SUP-2383409,CDM,C1894,HCPCS,0272,RC,,,,both,,,254.97,165.73,,,,,,,,,,,,,
AGENT BONDING 5ML UNIV LT CURE NAT ELEGANCE,SUP-2238467,CDM,C1713,HCPCS,0278,RC,,,,both,,,156.97,102.03,,,,,,,,,,,,,
OXYGENATOR PERF CARDOTMY RESERVOIR PMP MT AFFIN NT,SUP-2463204,CDM,2720000010,LOCAL,0272,RC,,,,both,,,855.78,556.26,,,,,,,,,,,,,
HC So1 Complement C-3/C-4,PX-3028616067,CDM,86160,CPT,0302,RC,,,,inpatient,,,315.00,204.75,,,,,,,,,,,,,
SP PLASMA OVALBUTTON LNG,SUP-2722877,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1843.97,1198.58,,,,,,,,,,,,,
ANCHOR SUTURE 4.5 MM ACHILLES REP KT CSL FOOTPRINT ULTRA PK,SUP-2848637,CDM,C1713,HCPCS,0278,RC,,,,both,,,3626.70,2357.35,,,,,,,,,,,,,
SCREW EXT FIX L12MM FOR DISTRCTN,SUP-2359061,CDM,C1713,HCPCS,0278,RC,,,,both,,,113.04,73.48,,,,,,,,,,,,,
PLATE LCK 2.4/2.7MM 2H STRL,SUP-2547593,CDM,C1713,HCPCS,0278,RC,,,,both,,,1269.82,825.38,,,,,,,,,,,,,
MICRO PLATE STRAIGHT 2 HOLE LNG RIGID BLUE TI 6AL 4V,SUP-2680997,CDM,C1713,HCPCS,0278,RC,,,,both,,,186.77,121.40,,,,,,,,,,,,,
SPLINT FLX HND ADL NVY TERRY,SUP-2165484,CDM,L3807,HCPCS,0274,RC,,,,both,,,153.77,99.95,,,,,,,,,,,,,
MESH HERN W10XL15.2CM POLY 4 HYDROXYBUTYRATE SYN RECTANG,SUP-2125869,CDM,C1781,HCPCS,0278,RC,,,,both,,,5966.00,3877.90,,,,,,,,,,,,,
MESH SURG 20X25CM W/ POS SYS ECHO 2 VENTRALIGHT ST,SUP-2125930,CDM,C1781,HCPCS,0278,RC,,,,both,,,5008.30,3255.39,,,,,,,,,,,,,
SHELL ACET BPLR 22X64 MM HIP COCR UHMWPE TNDM,SUP-2344596,CDM,C1776,CPT,0278,RC,,,,both,,,2912.35,1893.03,,,,,,,,,,,,,
LEUPROLIDE ACETATE 3.75 MG IM KIT,RX-13691,CDM,J1950,HCPCS,0636,RC,00074-3641-03,NDC,,both,1,UN,5187.20,3371.68,,,,,,,,,,,,,
LINER WLK BOOT VENTURE TALL M,SUP-2151035,CDM,L4386,HCPCS,0274,RC,,,,both,,,61.23,39.80,,,,,,,,,,,,,
PLATE BNE L L57MM 5DEG 7 H NONSTERILE L 1ST MTP FUS TI VAR,SUP-2181236,CDM,C1713,HCPCS,0278,RC,,,,both,,,4021.15,2613.75,,,,,,,,,,,,,
WIRE FIX SMOOTH 1.1X102 MM TRCR PT KIRSCHNER,SUP-2247471,CDM,C1769,HCPCS,0272,RC,,,,both,,,25.12,16.33,,,,,,,,,,,,,
GRAFT BONE SUB 15CC CANC CUBE FRZ DRY,SUP-2115981,CDM,C1713,HCPCS,0278,RC,,,,both,,,690.80,449.02,,,,,,,,,,,,,
BIT DRL DIA 4.5 MM CANN AO QC LG SYS STRL DISP EVOS,SUP-2933913,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1448.95,941.82,,,,,,,,,,,,,
SHEATH INTRO PERFRMR L 43 CM DIA 7 FR GUIDEWIRE 0.038 IN,SUP-2168450,CDM,C1894,HCPCS,0272,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
GRAFT DURA L 1 X W 3 IN THK 0.3 MM TYP I CLLGN BOV ACHILLES,SUP-2889753,CDM,C1763,HCPCS,0278,RC,,,,both,,,1373.72,892.92,,,,,,,,,,,,,
GRAFT AORT VLV 33MM WVN DBL VEL HEMSHLD COAT,SUP-2356744,CDM,C1889,HCPCS,0278,RC,,,,both,,,25025.80,16266.77,,,,,,,,,,,,,
PLATE BNE T 210 MM 12 HOLE SS,SUP-2569110,CDM,C1713,HCPCS,0278,RC,,,,both,,,457.66,297.48,,,,,,,,,,,,,
POST EXT FIX 3 H M,SUP-2898632,CDM,C1713,HCPCS,0278,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
SCREW BNE LOK 35MMX18MM CONTOURS LPS LAPIDUS PLATING SYS,SUP-2316495,CDM,C1713,HCPCS,0278,RC,,,,both,,,440.01,286.01,,,,,,,,,,,,,
DISTRACTION INTRNL DIST SMPHSS ZRCH 1 RTTRDM 20 23 MM SCRW,SUP-2680370,CDM,C1713,HCPCS,0278,RC,,,,both,,,9424.90,6126.18,,,,,,,,,,,,,
PIN FIX TRCR PT 1 END 0.078X9 IN 3 SHANK END SS NS STEINMANN,SUP-2791828,CDM,C1713,HCPCS,0278,RC,,,,both,,,31.84,20.70,,,,,,,,,,,,,
CEMENT BONE 13.8GM FULL DOSE M VISC RADPQ LNG SET TIME PMMA,SUP-2155334,CDM,C1713,HCPCS,0278,RC,,,,both,,,368.32,239.41,,,,,,,,,,,,,
SLEEVE DRL SPEC BLADE GUIDE FOR TROCHANTERIC FIX NAIL,SUP-2188248,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4392.55,2855.16,,,,,,,,,,,,,
EXTENSION STEM L100MM DST FEM MOD PC GMRS,SUP-2376561,CDM,C1776,CPT,0278,RC,,,,both,,,7254.34,4715.32,,,,,,,,,,,,,
DEFIBRILLATOR CARD V-196 W/ RIATA ST OPTIM EPIC VR,SUP-2356532,CDM,C1721,HCPCS,0275,RC,,,,both,,,66586.84,43281.45,,,,,,,,,,,,,
CATHETER CV MAXIMAL BARR TY 032 9 FRX20 CM 3L STRL,SUP-2759923,CDM,C1751,HCPCS,0278,RC,,,,both,,,470.12,305.58,,,,,,,,,,,,,
GRAFT HUM TISS L50MM WDG FIBULAR STRUT,SUP-2293970,CDM,C1713,HCPCS,0278,RC,,,,both,,,2433.50,1581.77,,,,,,,,,,,,,
KIT CATHETERIZATION ARROWG+ARD BLUE HEMODIALYSIS 2-L 14 FR X 15 CM,SUP-2930754,CDM,C1752,HCPCS,0278,RC,,,,both,,,582.78,378.81,,,,,,,,,,,,,
SHEET ORBIT W4XL4CM THK0.3MM NYL SMOOTH SQ FOR PLAS SURG,SUP-2335971,CDM,C1765,HCPCS,0278,RC,,,,both,,,14.92,9.70,,,,,,,,,,,,,
STENT URET POLARIS L 26 CM DIA 5 FR SENSOR GUIDEWIRE L 150,SUP-2537597,CDM,C2617,HCPCS,0278,RC,,,,both,,,497.25,323.21,,,,,,,,,,,,,
COMPONENT TALAR FLAT CUT 0 RT ANK DOMED SALTO TALARIS,SUP-2423987,CDM,C1776,CPT,0278,RC,,,,both,,,24408.79,15865.71,,,,,,,,,,,,,
SCREW BNE L26 MM OD55 MM FULL THRD MONSTER IMPL,SUP-2320644,CDM,C1713,HCPCS,0278,RC,,,,both,,,915.31,594.95,,,,,,,,,,,,,
PLATE BNE NAR 4.5X151 MM 9 HOLE SS DCP,SUP-2569167,CDM,C1713,HCPCS,0278,RC,,,,both,,,303.95,197.57,,,,,,,,,,,,,
ALLOGRAFT BNE FD ASEP WHL RIB,SUP-2867057,CDM,C1762,CPT,0278,RC,,,,both,,,1825.60,1186.64,,,,,,,,,,,,,
JOINT SACROILIAC 7X55 MM IFUSE-3D,SUP-2337786,CDM,C1713,HCPCS,0278,RC,,,,both,,,10440.50,6786.32,,,,,,,,,,,,,
SCREWDRIVER SURG OD15MM NONCANNULATED DRL FREE CENTRE DRV,SUP-2262791,CDM,C1713,HCPCS,0278,RC,,,,both,,,176.44,114.69,,,,,,,,,,,,,
BUR SURG DIA 4.5 MM FRONT CUT FLX,SUP-2934309,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1774.10,1153.16,,,,,,,,,,,,,
ENDCAP ORTH L15MM DIA11MM ST BLU TI EXTN FOR SLD TIB IM,SUP-2192165,CDM,C1713,HCPCS,0278,RC,,,,both,,,942.06,612.34,,,,,,,,,,,,,
PLATE BNE L338MM BLDE W48XL25MM 95DEG 20 H NONSTERILE HIP S,SUP-2186769,CDM,C1713,HCPCS,0278,RC,,,,both,,,4330.37,2814.74,,,,,,,,,,,,,
HC Gbl Psychotherapy - Individual,PX-9829083401,CDM,90834,CPT,0982,RC,,,,both,,,754.00,490.10,,,,,,,,,,,,,
ROD SPNL PREBENT 5.5X600 MM TI NS MONARCH,SUP-2583128,CDM,C1713,HCPCS,0278,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
SCREW BNE L18MM DIA4MM ST BLU CORT TI ST NONCANNULATED LOK,SUP-2192240,CDM,C1713,HCPCS,0278,RC,,,,both,,,735.48,478.06,,,,,,,,,,,,,
KIT INTRO ONESTIC DIA 6 FR PERC MIC ACCS STRL,SUP-2876563,CDM,C1894,HCPCS,0272,RC,,,,both,,,244.92,159.20,,,,,,,,,,,,,
TROCAR SURG L75MM OD5MM BLDELSS XCEL,SUP-2218268,CDM,2720000010,LOCAL,0272,RC,,,,both,,,635.35,412.98,,,,,,,,,,,,,
REAMER SURG OD41MM S STL ACET SPHR CUTTINGEDGE,SUP-2361869,CDM,2720000010,LOCAL,0272,RC,,,,both,,,677.61,440.45,,,,,,,,,,,,,
NAIL 12MMX210MM,SUP-2244339,CDM,C1713,HCPCS,0278,RC,,,,both,,,16396.99,10658.04,,,,,,,,,,,,,
CATHETER IABP AD 8FR L174MM DIA14.7MM 25ML NONFIBEROPTIC,SUP-2227415,CDM,C1725,HCPCS,0272,RC,,,,both,,,2983.00,1938.95,,,,,,,,,,,,,
GUIDEWIRE ORTHOPEDIC 117290] ORTHOFIX INC],SUP-2315988,CDM,C1769,HCPCS,0272,RC,,,,both,,,441.48,286.96,,,,,,,,,,,,,
HC Gases Blood Ph Only,PX-3018280000,CDM,82800,CPT,0301,RC,,,,both,,,246.00,159.90,,,,,,,,,,,,,
HC Attendace at Delivery,PX-7229946400,CDM,99464,CPT,0722,RC,,,,outpatient,,,227.00,147.55,,,,,,,,,,,,,
GUIDEPIN ORTH L300MM OD3.2MM NTHRD,SUP-2340962,CDM,2720000010,LOCAL,0272,RC,,,,both,,,662.54,430.65,,,,,,,,,,,,,
SCREW BONE L65MM OD4.5MM BLU MIDFOOT HINDFOOT ANK CANN SH,SUP-2320934,CDM,C1713,HCPCS,0278,RC,,,,both,,,1351.77,878.65,,,,,,,,,,,,,
PLATE BNE L91MM THK385MM 7 H BILAT S STL STR WIDE ANG LO,SUP-2177154,CDM,C1713,HCPCS,0278,RC,,,,both,,,1292.02,839.81,,,,,,,,,,,,,
CLAMP REPROC MULTI PIN 4 POS MR SAFE LG,SUP-2457728,CDM,2720000010,LOCAL,0272,RC,,,,both,,,550.66,357.93,,,,,,,,,,,,,
PROSTHESIS LARYN 10MM LO AIRFLO RESISTANCE EZ MAINT FOR,SUP-2124339,CDM,L8509,HCPCS,0272,RC,,,,both,,,932.58,606.18,,,,,,,,,,,,,
CATHETER BLLN DIL 3 FRX150 CM 4 MMX4 CM 4 CM PASSPRT,SUP-2139183,CDM,C1726,HCPCS,0272,RC,,,,both,,,815.71,530.21,,,,,,,,,,,,,
K WIRE FIX L100MM DIA0.9MM S STL,SUP-2389798,CDM,C1713,HCPCS,0278,RC,,,,both,,,43.96,28.57,,,,,,,,,,,,,
AMLODIPINE BESYLATE 5 MG PO TABS,RX-9071,CDM,6370000000,HCPCS,0637,RC,00904-6370-61,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
BIT DRL TWST 1.5 MM,SUP-2389416,CDM,2720000010,LOCAL,0272,RC,,,,both,,,357.96,232.67,,,,,,,,,,,,,
RESIN VERTEBROPLASTY ACRYL SECOUR,SUP-2342138,CDM,C1713,HCPCS,0278,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
PLATELET CONCENTRATION KIT ERYTHROCYTE MAR STRL DISP,SUP-2417287,CDM,C1713,HCPCS,0278,RC,,,,both,,,5338.00,3469.70,,,,,,,,,,,,,
GRAFT BONE SUB 2.5CC ALLOSYNC PURE,SUP-2120753,CDM,C1713,HCPCS,0278,RC,,,,both,,,1695.60,1102.14,,,,,,,,,,,,,
"HC Est Pt, Outpt Visit Level 2",PX-7619921200,CDM,99212,CPT,0761,RC,,,,both,,,302.00,196.30,,,,,,,,,,,,,
SHAFT SCRDRVR SELF RET AO QC T8 STRL DISP FLEX-THREAD,SUP-2900417,CDM,2720000010,LOCAL,0272,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
CATHETER THOR 12FR 25CM VAN SONN,SUP-2141068,CDM,C1729,HCPCS,0272,RC,,,,both,,,205.83,133.79,,,,,,,,,,,,,
COMPONENT TOT SHLDR CAPPED STD S3 MOD TURON,SUP-2197233,CDM,C1776,CPT,0278,RC,,,,both,,,14601.00,9490.65,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9 % IV BOLUS,RX-103555,CDM,J7040,HCPCS,0250,RC,00264-7800-10,NDC,,both,250,ML,14.90,9.68,,,,,,,,,,,,,
PLATE BONE TUBULAR BROAD 4.5 MM 6 HOLE PROVISIONAL FIXATION,SUP-2836962,CDM,C1713,HCPCS,0278,RC,,,,both,,,2144.24,1393.76,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 1.5X1.5 CM AMNIOX CLARIX CRD 1K,SUP-2648671,CDM,Q4148,HCPCS,0636,RC,,,,both,,,1588.84,1032.75,,,,,,,,,,,,,
SHUNT CEREBROSPINAL FLD L80CM TUOHY NDL L3.5IN LUM PERI KT,SUP-2308229,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1861.71,1210.11,,,,,,,,,,,,,
SLING ORTHOT LUMBAR CUST,SUP-2435580,CDM,L1090,HCPCS,0272,RC,,,,both,,,284.89,185.18,,,,,,,,,,,,,
PLATE BNE SCREW DIA2 MM 6 H TI ALLOY T SHP NS TRILEAP,SUP-2907914,CDM,C1713,HCPCS,0278,RC,,,,both,,,2521.86,1639.21,,,,,,,,,,,,,
BUR SURGICAL DIAMETER 22MM SPHERICAL FOR SKULL OPENING NEURO,SUP-2804671,CDM,2720000010,LOCAL,0272,RC,,,,both,,,406.69,264.35,,,,,,,,,,,,,
PLATE BNE L125MM 7 H ST L DST RAD VOLAR DPHSEAL MTPHSEAL S,SUP-2177222,CDM,C1713,HCPCS,0278,RC,,,,both,,,4682.62,3043.70,,,,,,,,,,,,,
Gender PFJ FEMORAL COMP CEMENTED SIZE 4-LT,SUP-2502683,CDM,C1776,CPT,0278,RC,,,,both,,,6594.00,4286.10,,,,,,,,,,,,,
CATHETER PERI STD L91CM OD2.3MM ID1.1MM SIL ELASTMR OPN END,SUP-2243863,CDM,C1752,HCPCS,0278,RC,,,,both,,,375.10,243.81,,,,,,,,,,,,,
LENS INTOCU +6.0 DIOPT L13.5MM DIA6MM AC D5.2MM 5DEG UV BLK,SUP-2247662,CDM,V2632,HCPCS,0276,RC,,,,both,,,405.06,263.29,,,,,,,,,,,,,
HC So1 Lipid Panel,PX-3018006167,CDM,80061,CPT,0301,RC,,,,both,,,55.00,35.75,,,,,,,,,,,,,
GUIDEWIRE ORTH DIA1.4MM FOR MAXTORQUE CANN SCR SYS,SUP-2399450,CDM,C1769,HCPCS,0272,RC,,,,both,,,37.68,24.49,,,,,,,,,,,,,
CATHETER ETER CTRL VEN PED 42FR L71CM SGL LUMN TISS INGROWTH,SUP-2126553,CDM,C1751,HCPCS,0278,RC,,,,both,,,841.30,546.84,,,,,,,,,,,,,
GAMMATILE THERAPY DEVICE 8 PACK,SUP-2855642,CDM,C2642,HCPCS,0278,RC,,,,both,,,16485.00,10715.25,,,,,,,,,,,,,
ALLOGRAFT BNE CHIP 4-10 MM 15 CC CANC,SUP-2641777,CDM,C1713,HCPCS,0278,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
SEALER ENDOSCP BPLR VATS STRL AQUAMANTYS ENDO VS 8.7R LF,SUP-2865744,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1960.68,1274.44,,,,,,,,,,,,,
COLLAR CERV FIRM DENS AD 3IN 19IN L,SUP-2276591,CDM,L0120,HCPCS,0274,RC,,,,both,,,6.66,4.33,,,,,,,,,,,,,
DEVICE FIX HERN STATTACK,SUP-2165306,CDM,C1713,HCPCS,0278,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
CURETTE SURG 11IN NO 6 STR ST COBB DAWSON YUHL,SUP-2160983,CDM,C1713,HCPCS,0278,RC,,,,both,,,341.91,222.24,,,,,,,,,,,,,
SCREW BNE SEMICONSTRAINED 4.5X20 MM WRST TI STRL FRDM,SUP-2851949,CDM,C1713,HCPCS,0278,RC,,,,both,,,802.49,521.62,,,,,,,,,,,,,
COLLAR CERV L20XW4IN L CNTOUR COT STOCK M DENS STOUT AD FOR,SUP-2196871,CDM,L0120,HCPCS,0272,RC,,,,both,,,12.75,8.29,,,,,,,,,,,,,
KIT INTRO GLIDESHEATH SLENDER L 10 CM DIA 5FR 0.021IN SS,SUP-2385480,CDM,C1894,HCPCS,0272,RC,,,,both,,,207.24,134.71,,,,,,,,,,,,,
STENT URET 7FR L90CM SIL PTFE J SGL URIN DIV,SUP-2313760,CDM,C2617,HCPCS,0278,RC,,,,both,,,1144.37,743.84,,,,,,,,,,,,,
SCREW INTFR L28MM DIA10MM KNEE PLLA CANN ABSRB THRD WDG,SUP-2366624,CDM,C1713,HCPCS,0278,RC,,,,both,,,753.60,489.84,,,,,,,,,,,,,
GRAFT DERMAL THCK 16X4 CMX0.8-1.7 MM BRST KT ACELLULAR DERM,SUP-2307008,CDM,C1762,CPT,0278,RC,,,,both,,,10649.09,6921.91,,,,,,,,,,,,,
BIT DRL DIA7MM CANN DISP FOR IFUSE IMPL SYS,SUP-2337731,CDM,2720000010,LOCAL,0272,RC,,,,both,,,778.72,506.17,,,,,,,,,,,,,
SCREW SPNL ROD DIA 4.75/5 MM SS MULTAXL STRL CD HORZ MODULEX 559200015,SUP-2927811,CDM,C1713,HCPCS,0278,RC,,,,both,,,1.88,1.22,,,,,,,,,,,,,
ALLOGRAFT BNE CUBE 8X8X8 MM FD SPNG CANC READIGRAFT BLX,SUP-2740981,CDM,C1713,HCPCS,0278,RC,,,,both,,,1134.51,737.43,,,,,,,,,,,,,
CATHETER EP MED LG 2-8-2 5 FRX110 INQUIRY,SUP-2467795,CDM,C1730,HCPCS,0272,RC,,,,both,,,1566.86,1018.46,,,,,,,,,,,,,
GRAFT BNE BLOCK SM 13X13 MM CANC,SUP-2766758,CDM,C1713,HCPCS,0278,RC,,,,both,,,2655.66,1726.18,,,,,,,,,,,,,
SHAFT FEM TRAD ALLGRFT 200 MM FRZN,SUP-2294170,CDM,C1713,HCPCS,0278,RC,,,,both,,,3108.60,2020.59,,,,,,,,,,,,,
KIT PRSS MON L84IN DBL VAMP +,SUP-2214664,CDM,C1713,HCPCS,0278,RC,,,,both,,,146.95,95.52,,,,,,,,,,,,,
PLATE BNE L 221 MM SCREW DIA 4.5 MM 12 H SS NAR COMPR NLCK,SUP-2933812,CDM,C1713,HCPCS,0278,RC,,,,both,,,2244.13,1458.68,,,,,,,,,,,,,
SPLINT WRST SM L7IN AD R FA COT E SUPP INSTABILITY INJ LOOP,SUP-2276655,CDM,L3809,HCPCS,0274,RC,,,,both,,,9.36,6.08,,,,,,,,,,,,,
PLATE BNE U FT 4 H INTERAXIS COMPR UNIV CP FOR FIX OF BNE,SUP-2243478,CDM,C1713,HCPCS,0278,RC,,,,both,,,12098.42,7863.97,,,,,,,,,,,,,
SHEATH INTRO 16GA L12IN TUNN DISP ON-Q,SUP-2236804,CDM,C1894,HCPCS,0272,RC,,,,both,,,85.09,55.31,,,,,,,,,,,,,
MESH SURG DIA4.5IN CIR W/ ECHO 2 POS SYS VENTRALIGHT,SUP-2125926,CDM,C1781,HCPCS,0278,RC,,,,both,,,1679.90,1091.93,,,,,,,,,,,,,
STAPLER INT L100MM THK48MM TI RELD TWO DBL STAGGERED ROW,SUP-2283277,CDM,2720000010,LOCAL,0272,RC,,,,both,,,658.80,428.22,,,,,,,,,,,,,
CAUTERY ELECSURG BATTERY OPERATED,SUP-2106405,CDM,C1713,HCPCS,0278,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
PLATE BNE W17.5XL124MM THK5.2MM 7 H BILAT S STL BROAD LIMIT,SUP-2185287,CDM,C1713,HCPCS,0278,RC,,,,both,,,1146.98,745.54,,,,,,,,,,,,,
GRAFT BNE DRILLABLE 3 CC VOID FILL STRL LTX,SUP-2865882,CDM,C1713,HCPCS,0278,RC,,,,both,,,3961.74,2575.13,,,,,,,,,,,,,
COMPONENT FEM MOD REV POR COAT CO CHROM SZ 5 75MM PROVEN,SUP-2359208,CDM,C1776,CPT,0278,RC,,,,both,,,17898.00,11633.70,,,,,,,,,,,,,
SPLINT ORTHOPEDIC SLIP ON XL 7 IN LT WRST ELASTIC LTX,SUP-2276651,CDM,L3809,HCPCS,0272,RC,,,,both,,,10.77,7.00,,,,,,,,,,,,,
PLATE BNE LAT 70 MM LT 8 HOLE EVOLVE EPS ORTHOLOC,SUP-2535915,CDM,C1713,HCPCS,0278,RC,,,,both,,,3303.28,2147.13,,,,,,,,,,,,,
PLATE BNE L235MM 15 H NONSTERILE R DST LAT FIBULAR S STL VAR,SUP-2177741,CDM,C1713,HCPCS,0278,RC,,,,both,,,3271.10,2126.21,,,,,,,,,,,,,
PIN FIX SM 22 MM REINF EMPOWR VVC,SUP-2634253,CDM,C1776,CPT,0278,RC,,,,both,,,2681.65,1743.07,,,,,,,,,,,,,
SCRAPER OPHTH 23GA DMND DUSTED MEM TANO DDMS,SUP-2382593,CDM,C1713,HCPCS,0278,RC,,,,both,,,314.53,204.44,,,,,,,,,,,,,
SCREW W CABLE LLIF STRL LT TIP,SUP-2114090,CDM,C1713,HCPCS,0278,RC,,,,both,,,1899.70,1234.80,,,,,,,,,,,,,
IMPLANT BIO L 6 X W 4 CM OMEGA 3 21 PRE-MESHED FISH STRL,SUP-2909171,CDM,Q4158,HCPCS,0636,RC,,,,both,,,4885.84,3175.80,,,,,,,,,,,,,
COMPONENT HUM DIA25MM 3.5X3.5MM OFFSET ARTC HEMICAP,SUP-2123540,CDM,C1776,CPT,0278,RC,,,,both,,,12695.02,8251.76,,,,,,,,,,,,,
GUIDEWIRE VASC L18CM L15CM OD8FR ID64FR 0018IN 0038IN S,SUP-2167887,CDM,C1769,HCPCS,0272,RC,,,,both,,,268.34,174.42,,,,,,,,,,,,,
SHEATH INTRO L 90 CM DIA 6 FR GUIDEWIRE 0.035 IN SIL,SUP-2913543,CDM,C1894,HCPCS,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
STAPLER INT 75MM CUT LN L73MM STPL LN L77MM LNAR B-FORM,SUP-2220029,CDM,2720000010,LOCAL,0272,RC,,,,both,,,466.01,302.91,,,,,,,,,,,,,
KIT IMPL HUM CONDYLE HEXALOBULAR ELBW SYS DISCVR,SUP-2196663,CDM,C1776,CPT,0278,RC,,,,both,,,6041.36,3926.88,,,,,,,,,,,,,
GUIDEWIRE TORQUABLE ANG TIP STD .035INX450CM FX WIRE,SUP-2166275,CDM,C1769,HCPCS,0272,RC,,,,both,,,370.52,240.84,,,,,,,,,,,,,
GRAFT VASC GORTX L 90 CM DIA 6-8 MM EPTFE TAPR TW N RING,SUP-2396733,CDM,C1768,CPT,0278,RC,,,,both,,,1591.98,1034.79,,,,,,,,,,,,,
SYSTEM LOADING ENVEO R 34MM,SUP-2501426,CDM,C1889,HCPCS,0278,RC,,,,both,,,1224.60,795.99,,,,,,,,,,,,,
HC Ot Paraffin Bath,PX-4309701800,CDM,97018,CPT,0430,RC,,,,both,,,144.00,93.60,,,,,,,,,,,,,
SCREW L20MM TRAC MINI JT DISTRACTOR,SUP-2123104,CDM,C1713,HCPCS,0278,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
PLATE BNE BROAD 4.5X161 MM 9 HOLE SS LCP,SUP-2569362,CDM,C1713,HCPCS,0278,RC,,,,both,,,611.36,397.38,,,,,,,,,,,,,
SET ORTH INSTR SZ 3.5 MM OSSIFIED BIOINTEGRATIVE COMPR SCREW,SUP-2904308,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1805.50,1173.57,,,,,,,,,,,,,
PUMP INFUS 275ML 4ML/HR W/ 5IN 2ML CATH PAINPMP,SUP-2361465,CDM,C2626,HCPCS,0278,RC,,,,both,,,521.24,338.81,,,,,,,,,,,,,
BIT DRL L200MM DIA4.3MM CANN QUIK CPL W/O STP REUSE FOR 5MM,SUP-2187329,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1035.98,673.39,,,,,,,,,,,,,
BLADE SAW L 93 X W 5 MM L 10 MM RECIP RASP DOWNWARD ANGLE,SUP-2929470,CDM,2720000010,LOCAL,0272,RC,,,,both,,,595.28,386.93,,,,,,,,,,,,,
SCREW BNE L10MM OD35MM CANC ACET HIP ST SELF DRL X CHANGE,SUP-2368348,CDM,C1713,HCPCS,0278,RC,,,,both,,,96.77,62.90,,,,,,,,,,,,,
ALUMINUM & MAGNESIUM HYDROXIDE 200-200 MG/5ML PO SUSP,RX-37605,CDM,6370000000,HCPCS,0637,RC,00121-1760-30,NDC,,both,30,ML,40.60,26.39,,,,,,,,,,,,,
HC So Receptor Assay Nonendocrine,PX-3018423866,CDM,84238,CPT,0301,RC,,,,inpatient,,,213.00,138.45,,,,,,,,,,,,,
SHELL ACET OD54MM STD UNIV GRP 2 CERAMIC MTL POLYETH POR,SUP-2304460,CDM,C1776,CPT,0278,RC,,,,both,,,7449.65,4842.27,,,,,,,,,,,,,
PLATE BONE SM W11XL90MM THK3.3MM 0DEG 7 H BILAT TI STR LIMIT,SUP-2190779,CDM,C1713,HCPCS,0278,RC,,,,both,,,508.11,330.27,,,,,,,,,,,,,
CATHETER EP X LG CRV 7 FR BRAIDED COOL PATH,SUP-2357458,CDM,C2630,CPT,0272,RC,,,,both,,,4317.50,2806.37,,,,,,,,,,,,,
CATHETER HD ASH SPLIT 14 FRX40 CM,SUP-2269501,CDM,C1750,HCPCS,0278,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
CLIP ANEUR DIA7MM 5MM FEN 90DEG MIC,SUP-2243950,CDM,C1889,HCPCS,0278,RC,,,,both,,,1019.75,662.84,,,,,,,,,,,,,
LINER ACET OD52MM ID40MM 0DEG HIP CO CHROM PRI SNAP IN,SUP-2345308,CDM,C1776,CPT,0278,RC,,,,both,,,11960.26,7774.17,,,,,,,,,,,,,
SLING ORTHOT CERV THOR LUMBAR SACR CUST AX,SUP-2435570,CDM,L1010,HCPCS,0272,RC,,,,both,,,236.88,153.97,,,,,,,,,,,,,
SCREW BNE CANN 4X50 MM,SUP-2221524,CDM,C1713,HCPCS,0278,RC,,,,both,,,1224.60,795.99,,,,,,,,,,,,,
HEAD FEM 12/14 TAPR PRI MTL ON POLY CO CHROM 22MM DIA +0 NK,SUP-2198944,CDM,C1776,CPT,0278,RC,,,,both,,,2265.51,1472.58,,,,,,,,,,,,,
GRAFT HUM TISS L 100 MM DIA10 MM FIB SHFT LYOPH STRL,SUP-2913150,CDM,C1762,CPT,0278,RC,,,,both,,,3598.44,2338.99,,,,,,,,,,,,,
WIRE FIX UNIV 23 MM FOR BOLT SS,SUP-2162664,CDM,2720000010,LOCAL,0272,RC,,,,both,,,449.65,292.27,,,,,,,,,,,,,
JOINT FNGR X-TYPE 0 DEG LG UNIV 22.5X7 MM PRIMARY PRSS FT,SUP-2431397,CDM,C1776,CPT,0278,RC,,,,both,,,2983.00,1938.95,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 40 CM DIA 6 MM EPTFE STR TW,SUP-2481324,CDM,C1768,CPT,0278,RC,,,,both,,,1119.22,727.49,,,,,,,,,,,,,
BASEPLATE GLEN 10 DEG SHLDR CNTRL SCREW SUP AUG STRL,SUP-2908903,CDM,C1776,CPT,0278,RC,,,,both,,,5809.00,3775.85,,,,,,,,,,,,,
KIT TKR CEM FEM TIB STD SURF AND VIT E PAT PERSONA 98000240120] ZIMMER BIOMET INC],SUP-2212218,CDM,C1776,CPT,0278,RC,,,,both,,,14601.00,9490.65,,,,,,,,,,,,,
KIT PAIN PMP 100ML 1ML/HR CATH L1IN W/ SOAK CATH ON-Q,SUP-2420883,CDM,C9804,HCPCS,0272,RC,,,,both,,,260.62,169.40,,,,,,,,,,,,,
GUIDEWIRE EXT FIX L400MM DIA3.2MM ENTRY FOR ANK COMPR,SUP-2316007,CDM,C1769,HCPCS,0272,RC,,,,both,,,509.81,331.38,,,,,,,,,,,,,
CUP ACET DIA62MM UNIV HIP PORCOAT MH STD PROF REV PINN,SUP-2250122,CDM,C1776,CPT,0278,RC,,,,both,,,5042.84,3277.85,,,,,,,,,,,,,
SCREW BNE 4.5X55 MM 5TH METATRSL JONES UNION SYS,SUP-2610083,CDM,C1713,HCPCS,0278,RC,,,,both,,,3758.58,2443.08,,,,,,,,,,,,,
BRIDGE RIB FIX POST L 23 MM SHRT LCK NS ADVANTAGERIB,SUP-2908966,CDM,C1713,HCPCS,0278,RC,,,,both,,,10048.00,6531.20,,,,,,,,,,,,,
GRAFT VASC STD WALL 4-7 MMX45 CM STR SHT TAPR ADVANTA VXT,SUP-2471230,CDM,C1768,CPT,0278,RC,,,,both,,,2009.57,1306.22,,,,,,,,,,,,,
CANNULA SUCTION MONOPOLAR 3 MMX30 CM COAG W/ TRMPT VLV,SUP-2767732,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1745.40,1134.51,,,,,,,,,,,,,
ETOMIDATE 2 MG/ML IV SOLN,RX-20472,CDM,2500000003,HCPCS,0250,RC,00143-9506-10,NDC,,both,5,ML,54.10,35.16,,,,,,,,,,,,,
PLATE CRAN L 48 X W 45 MM THK 0.3 MM SCREW DIA1.5 MM MED TI,SUP-2936500,CDM,C1713,HCPCS,0278,RC,,,,both,,,2414.66,1569.53,,,,,,,,,,,,,
COMPONENT FEM STANDARD+ R KNEE CRUCE RET CEM REV NP NONBEADE,SUP-2436145,CDM,C1776,CPT,0278,RC,,,,both,,,12938.06,8409.74,,,,,,,,,,,,,
HC Ot Manual Therapy per 15 Min.|OP PT SERVICES|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS|UNUSUAL NON-OVERLAPPING SERVICE,PX-4309714000,CDM,97140,CPT,0430,RC,,,GP|CQ|XU,outpatient,,,194.00,126.10,,,,,,,,,,,,,
FLUDROCORTISONE ACETATE 0.1 MG PO TABS,RX-10054,CDM,6370000000,HCPCS,0637,RC,68084-0288-11,NDC,,both,1,UN,3.80,2.47,,,,,,,,,,,,,
PLATE BNE L142MM 6 H ST R MED PROX TIB S STL LOK COMPR LO,SUP-2185671,CDM,C1713,HCPCS,0278,RC,,,,both,,,4592.34,2985.02,,,,,,,,,,,,,
ANCHOR SUTURE BLU MICRORAPTOR REGENESORB,SUP-2879933,CDM,C1713,HCPCS,0278,RC,,,,both,,,1153.95,750.07,,,,,,,,,,,,,
LEVEL NEURO ST MESH 3D ULTRNE NEURO SCRW125 MM DIA T10 MM C,SUP-2677439,CDM,C1713,HCPCS,0278,RC,,,,both,,,9426.75,6127.39,,,,,,,,,,,,,
SLING LIFT PCH W13XL19IN SWTH W5XL54IN UNIV PERF FOAM ADJ,SUP-2194775,CDM,L3650,HCPCS,0274,RC,,,,both,,,21.70,14.10,,,,,,,,,,,,,
PLATE BNE CERV SM 2.7X52 MM 6 HOLE SS,SUP-2536115,CDM,C1713,HCPCS,0278,RC,,,,both,,,369.26,240.02,,,,,,,,,,,,,
INTRODUCER SHTH 10 FR KT,SUP-2470168,CDM,C1894,HCPCS,0272,RC,,,,both,,,204.10,132.66,,,,,,,,,,,,,
BEARING TIB CR 63X14 MM KNEE INSRT LCK VANGUARD MONO-LOCK,SUP-2408141,CDM,C1776,CPT,0278,RC,,,,both,,,4239.00,2755.35,,,,,,,,,,,,,
SCREW BNE LCK 2.7X12 MM WRST COMPR FUSION SS NS SURFIX,SUP-2852054,CDM,C1713,HCPCS,0278,RC,,,,both,,,989.19,642.97,,,,,,,,,,,,,
SCREW SPNL L45MM DIA5.5MM ANTR THORLUM FOR TRAVERSEXLP + SYS,SUP-2311617,CDM,C1713,HCPCS,0278,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
SCREW BNE L30MM OD6.5MM TI BICORT ACL PCL POST ST CANN,SUP-2121132,CDM,C1713,HCPCS,0278,RC,,,,both,,,659.40,428.61,,,,,,,,,,,,,
PLATE BNE 9 HOLE 0.5 MM ORBIT 1.3 MM SCR TI NS MATRIXMIDFACE,SUP-2776726,CDM,C1713,HCPCS,0278,RC,,,,both,,,1909.37,1241.09,,,,,,,,,,,,,
CATHETER GUID NAVICROSS L 150 CM DIA 1.39 MM L 40 CM ANGLED,SUP-2385616,CDM,C1887,HCPCS,0272,RC,,,,both,,,717.49,466.37,,,,,,,,,,,,,
SET INTRO FLX L 38.5 CM OD 10 FR GUIDEWIRE 0.035 IN CKFLO,SUP-2168822,CDM,C1894,HCPCS,0272,RC,,,,both,,,284.14,184.69,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY OPTRELL SM D-F CRV TRUEREF,SUP-2880079,CDM,C1732,HCPCS,0278,RC,,,,both,,,9014.94,5859.71,,,,,,,,,,,,,
MATRIX BIO L 10 X W 8 IN BOV TEND CLLGN GLYCOSAMINOGLYCAN,SUP-2909320,CDM,Q4105,HCPCS,0636,RC,,,,both,,,42631.75,27710.64,,,,,,,,,,,,,
SURGICAL PROCEDURE PACK MAMMOGRAPHIC LOC MAMMO LOC PK,SUP-2495484,CDM,A4648,CPT,0278,RC,,,,both,,,58.72,38.17,,,,,,,,,,,,,
BUR SURG RND CUT 3.0 MM DIAM FLUT,SUP-2367535,CDM,C1713,HCPCS,0278,RC,,,,both,,,383.36,249.18,,,,,,,,,,,,,
TRAY CATH PICC LUMENX2 5FR DIA 60CML POLYURETHANE 0.55ML PRI,SUP-2613391,CDM,C1751,HCPCS,0278,RC,,,,both,,,227.02,147.56,,,,,,,,,,,,,
TAP 7-8MM FIXED FOR GENESYS MATRYX INTERFERENCE SCREW,SUP-2842816,CDM,C1713,HCPCS,0278,RC,,,,both,,,1993.08,1295.50,,,,,,,,,,,,,
CANNULATED HIP PIN 115MM,SUP-2818076,CDM,C1713,HCPCS,0278,RC,,,,both,,,2421.41,1573.92,,,,,,,,,,,,,
SCREW BONE L5MM OD1.8MM ORAL MAXILLOFACIAL TI EMER MIC,SUP-2262606,CDM,C1713,HCPCS,0278,RC,,,,both,,,114.74,74.58,,,,,,,,,,,,,
BIT DRL ATTCH REUSE FOR CBL TENSIONER,SUP-2188555,CDM,2720000010,LOCAL,0272,RC,,,,both,,,532.80,346.32,,,,,,,,,,,,,
SHEATH INTRO 6FR L45CM NYL PTFE S STL HYDROPHILLIC STR CRSS,SUP-2385263,CDM,C1894,HCPCS,0272,RC,,,,both,,,332.84,216.35,,,,,,,,,,,,,
SHUNT SURG DENV DBL VLV,SUP-2153836,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2766.34,1798.12,,,,,,,,,,,,,
SET ART LN CATH 4FR L12CM 0.021IN POLY STR NDL HUB W/,SUP-2167819,CDM,C1751,HCPCS,0278,RC,,,,both,,,126.76,82.39,,,,,,,,,,,,,
ANCHOR SFT TISS L 10 MM DIA 5 MM CITREGEN BIOMIMETIC RESRB,SUP-2902209,CDM,C1713,HCPCS,0278,RC,,,,both,,,2565.38,1667.50,,,,,,,,,,,,,
PLATE BNE HUM 4.5/6.5X107 MM RT PROX LAT 4 HOLE BUTTRESS,SUP-2464138,CDM,C1713,HCPCS,0278,RC,,,,both,,,2256.18,1466.52,,,,,,,,,,,,,
PROTECTOR NAV2017 SOLERA TISS SM,SUP-2281196,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2245.10,1459.31,,,,,,,,,,,,,
TRIAL HD 32MM -4MM OFFSET SH FEM TAPR LFIT HMSPHR V40,SUP-2364471,CDM,C1776,CPT,0278,RC,,,,both,,,295.95,192.37,,,,,,,,,,,,,
CATHETER EP CRD 10 MM 6 FRX120 CM BPLR RESPON,SUP-2356821,CDM,C1730,HCPCS,0272,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
KIT CATH NEPHRO STENT,SUP-2312713,CDM,C2617,HCPCS,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
PLATE BNE ANAT RT HND 7 HOLE EXT NS DVR,SUP-2414029,CDM,C1713,HCPCS,0278,RC,,,,both,,,2295.34,1491.97,,,,,,,,,,,,,
APPLICATOR ELECSURG 5X350 MM RIGID PLASMA COAG FILTER NDL AR,SUP-2762600,CDM,2720000010,LOCAL,0272,RC,,,,both,,,646.68,420.34,,,,,,,,,,,,,
SET DRNGE CATH 14FR L29CM SIDEPRT 19 NDL L9CM CONN TUBE,SUP-2171162,CDM,C1729,HCPCS,0272,RC,,,,both,,,815.77,530.25,,,,,,,,,,,,,
SCREW BNE POLYAX 6.5X44 MM XIA,SUP-2319334,CDM,C1713,HCPCS,0278,RC,,,,both,,,2954.74,1920.58,,,,,,,,,,,,,
IMPLANT NEUROSTIMULATOR ECOIN TIBIAL -  RSFH ONLY,SUP-2862632,CDM,C1767,HCPCS,0278,RC,,,,both,,,54950.00,35717.50,,,,,,,,,,,,,
AMOXICILLIN 400 MG/5ML PO SUSR,RX-25246,CDM,340b,HCPCS,0637,RC,00781-6157-46,NDC,,both,5,ML,2.70,1.75,,,,,,,,,,,,,
STEM FEM SZ 8 L205MM OD12MM 5MM OFFSET HA DST HIP STR,SUP-2379097,CDM,C1776,CPT,0278,RC,,,,both,,,16781.73,10908.12,,,,,,,,,,,,,
HC Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/O Img Gdn,PX-3606232200,CDM,62322,CPT,0360,RC,,,,both,,,2230.00,1449.50,,,,,,,,,,,,,
GRAFT BNE 5 CC DEMINERALIZED BNE FIBER PROGRAFT,SUP-2858505,CDM,C1713,HCPCS,0278,RC,,,,both,,,1929.53,1254.19,,,,,,,,,,,,,
HYDROCORTISONE 1 % EX CREA,RX-3726,CDM,6370000000,HCPCS,0637,RC,45802-0438-03,NDC,,both,28,GR,9.50,6.17,,,,,,,,,,,,,
SCREW BONE LOK 5MM DIA 20MML TTNM ALLOY CRTCL FLLY THRDD PAN,SUP-2586613,CDM,C1713,HCPCS,0278,RC,,,,both,,,1144.62,744.00,,,,,,,,,,,,,
SCREW BONE 1.5X8MM CORT HEXADRIVE 4,SUP-2268037,CDM,C1713,HCPCS,0278,RC,,,,both,,,335.67,218.19,,,,,,,,,,,,,
OXYCODONE-ACETAMINOPHEN 10-325 MG PO TABS,RX-31864,CDM,6370000000,HCPCS,0637,RC,00904-7095-61,NDC,,both,1,UN,5.40,3.51,,,,,,,,,,,,,
STEM HUM 13 5X70 MM SHLDR,SUP-2123329,CDM,C1776,CPT,0278,RC,,,,both,,,7032.03,4570.82,,,,,,,,,,,,,
JIG SURG MIS 3.5 MM RT PROX LAT,SUP-2517802,CDM,C1713,HCPCS,0278,RC,,,,both,,,25221.61,16394.05,,,,,,,,,,,,,
STEM FEM L205MM DIA14X9MM NK L36MM LNG STD NEUT HIP 11 13,SUP-2253038,CDM,C1776,CPT,0278,RC,,,,both,,,11707.18,7609.67,,,,,,,,,,,,,
ALLOGRAFT HUM TISS SQ 80X80 MM FRZN IRRADIATED FASC LATA,SUP-2866850,CDM,C1762,CPT,0278,RC,,,,both,,,1431.84,930.70,,,,,,,,,,,,,
INTRODUCER PACE LD SOLO-TRAK KR XLN KINK RESIST STRL,SUP-2282097,CDM,C1894,HCPCS,0272,RC,,,,both,,,232.27,150.98,,,,,,,,,,,,,
GRAFT EVAR L13.5CM DIA16MM IL LIMB EXCLUDER,SUP-2395951,CDM,C1768,CPT,0278,RC,,,,both,,,10578.66,6876.13,,,,,,,,,,,,,
SCREW BNE LAG SHT 12.7X130 MM 17 MM THRD FREE LOK,SUP-2205402,CDM,C1713,HCPCS,0278,RC,,,,both,,,313.22,203.59,,,,,,,,,,,,,
TUBE DCOMPR 12FR CATH L35IN GAST PUSH JEJU FEED,SUP-2127677,CDM,C1769,HCPCS,0272,RC,,,,both,,,547.58,355.93,,,,,,,,,,,,,
BIT DRL L195MM DIA4.5MM ST TI QUIK CPL NONRADIOPAQUE W/O,SUP-2187289,CDM,2720000010,LOCAL,0272,RC,,,,both,,,497.28,323.23,,,,,,,,,,,,,
MATRIX BIO L 7 X W 8 CM SZ 101 SQCM FISH SKIN DERMAL,SUP-2909202,CDM,Q4158,HCPCS,0636,RC,,,,both,,,6521.15,4238.75,,,,,,,,,,,,,
HC So Urinary Stone Analysis,PX-3018236566,CDM,82365,CPT,0301,RC,,,,both,,,181.00,117.65,,,,,,,,,,,,,
CARTRIDGE GRFT PREP HEALOS CELLECT,SUP-2255624,CDM,C1713,HCPCS,0278,RC,,,,both,,,339.12,220.43,,,,,,,,,,,,,
HC Cltx Gr Hmrl Tbrs Fx WO Mnpj,PX-4502362000,CDM,23620,CPT,0450,RC,,,,both,,,630.00,409.50,,,,,,,,,,,,,
SCREW BNE NLCK 2.7X24 MM SQ DRVR DVR,SUP-2470347,CDM,C1713,HCPCS,0278,RC,,,,both,,,379.94,246.96,,,,,,,,,,,,,
SCREW BNE L110MM OD3.5MM S STL CORT ST NONLOK FULL THRD LO,SUP-2348357,CDM,C1713,HCPCS,0278,RC,,,,both,,,292.55,190.16,,,,,,,,,,,,,
CATHETER BLLN OCCL 2.8X2.2FR L150MM BLLN L15MM DIA4MM TIP,SUP-2172470,CDM,C2628,HCPCS,0272,RC,,,,both,,,4747.68,3085.99,,,,,,,,,,,,,
CATHETER CV SINGLE LUMEN 0.018 IN 4 FRX60 CM 65 CM TURBO FLO,SUP-2168788,CDM,C1751,HCPCS,0278,RC,,,,both,,,293.46,190.75,,,,,,,,,,,,,
SPLINT ORTHOPEDIC SLIP ON LG 8 IN RT WRST PLUSH FOAM LNR NYL,SUP-2276662,CDM,L3908,HCPCS,0274,RC,,,,both,,,16.64,10.82,,,,,,,,,,,,,
DRILL TWST 1.7X10 MM FOR DISTRACTION SCREW,SUP-2732065,CDM,2720000010,LOCAL,0272,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
SHUNT CAR ENDART 3X4 MM STR SUNDT,SUP-2308219,CDM,C1713,HCPCS,0278,RC,,,,both,,,2424.33,1575.81,,,,,,,,,,,,,
PLATE BNE TOD BLDE L44MM DISPLC 4MM 100DEG NONSTERILE S STL,SUP-2185408,CDM,C1713,HCPCS,0278,RC,,,,both,,,2151.87,1398.72,,,,,,,,,,,,,
PUMP PAIN 400ML 2 PART,SUP-2236774,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1036.20,673.53,,,,,,,,,,,,,
HC Inject Peritoneal Cavity,PX-3614940000,CDM,49400,CPT,0361,RC,,,,both,,,455.00,295.75,,,,,,,,,,,,,
KIT BNE MAR CONC MINI W/O ACDA BIOCUE,SUP-2884250,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4122.82,2679.83,,,,,,,,,,,,,
RING EXT FIX SEG 120 MM CARBON HOFFMANN,SUP-2470768,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4300.54,2795.35,,,,,,,,,,,,,
BRACE KNEE T SCP POSTOP MEAS TAKEN 6IN ABV MID PAT 27-35IN,SUP-2150859,CDM,L1810,HCPCS,0272,RC,,,,both,,,303.95,197.57,,,,,,,,,,,,,
PLATE FIXATION STERNAL HEX 6 HOLES,SUP-2849060,CDM,C1713,HCPCS,0278,RC,,,,both,,,1381.73,898.12,,,,,,,,,,,,,
SCREW BONE L75MM DIA5MM PARTIALLY THRD FOR ARTH NAIL SYS,SUP-2417303,CDM,C1713,HCPCS,0278,RC,,,,both,,,2072.65,1347.22,,,,,,,,,,,,,
ANCHOR SUT DIA3.5MM 2 BLK WHT KNOTLESS FORC FBR COBRAIDED,SUP-2388894,CDM,C1713,HCPCS,0278,RC,,,,both,,,1507.20,979.68,,,,,,,,,,,,,
PLATE BNE SET FOR SM FRAG PERI-LOC,SUP-2351407,CDM,C1713,HCPCS,0278,RC,,,,both,,,63600.70,41340.45,,,,,,,,,,,,,
SET PICC 3L 6FR X 55CM W TEGADERM,SUP-2887057,CDM,C1751,HCPCS,0278,RC,,,,both,,,2314.18,1504.22,,,,,,,,,,,,,
MESH CRANIOMAXILLOFACIAL STD M W90XL90MM THK0.6MM UPGRADED,SUP-2419458,CDM,C1713,HCPCS,0278,RC,,,,both,,,5556.10,3611.46,,,,,,,,,,,,,
PLATE BNE STRIKE,SUP-2589504,CDM,C1713,HCPCS,0278,RC,,,,both,,,516.53,335.74,,,,,,,,,,,,,
BLADE CAST CUT CRD HEX 115 V 1.5 A 5060 HZ 10 FTX2.5 IN DRV,SUP-2599495,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3166.22,2058.04,,,,,,,,,,,,,
PLATE RAD INTMD CLMN 2.4MM +90DEG 2H HD 4H SHFT TI STRL,SUP-2546764,CDM,C1713,HCPCS,0278,RC,,,,both,,,2569.78,1670.36,,,,,,,,,,,,,
PLATE BONE HLX16 TTNM STRGHT PRPLE FNRO SSTM CRNFCL,SUP-2676832,CDM,C1713,HCPCS,0278,RC,,,,both,,,661.63,430.06,,,,,,,,,,,,,
DEXTROSE 5% IV SOLN NEONATE,RX-40840076,CDM,2580000003,HCPCS,0250,RC,00264-1510-31,NDC,,both,50,ML,20.90,13.58,,,,,,,,,,,,,
POST SURG 5.9X28 MM RT LAPIDUS INCORE,SUP-2435483,CDM,C1713,HCPCS,0278,RC,,,,both,,,7303.83,4747.49,,,,,,,,,,,,,
VALPROATE SODIUM 100 MG/ML IV SOLN,RX-20887,CDM,J3379,HCPCS,0636,RC,00143-9785-01,NDC,,both,5,ML,54.10,35.16,,,,,,,,,,,,,
SPACER TIB SZ 1 THK4MM UNIV MEDL PRI ASYM CEM N-K II,SUP-2209339,CDM,C1776,CPT,0278,RC,,,,both,,,2675.28,1738.93,,,,,,,,,,,,,
PIN EXT FIX SZ 4 X 80 X 15 MM HALF NS DISP MAV MINI,SUP-2933100,CDM,2720000010,LOCAL,0272,RC,,,,both,,,504.44,327.89,,,,,,,,,,,,,
KIT PENILE PROS PT RECORD LBL ASMBLY TOOL STRL DISP TITAN,SUP-2905153,CDM,C1813,HCPCS,0278,RC,,,,both,,,2587.36,1681.78,,,,,,,,,,,,,
KINECTIV MODULAR NECK G1,SUP-2504379,CDM,C1776,CPT,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
STENT CORONARY MULTLNK TRI L 23 MM DIA 3.5 MM GUIDE CATH,SUP-2101465,CDM,C1876,HCPCS,0278,RC,,,,both,,,6138.70,3990.15,,,,,,,,,,,,,
SCREW BNE LAG 12.7X50 MM 1 STP THRD SS STRL DH-DC,SUP-2186524,CDM,C1713,HCPCS,0278,RC,,,,both,,,1161.77,755.15,,,,,,,,,,,,,
AMNION THICK 3X3,SUP-2811249,CDM,C1762,CPT,0278,RC,,,,both,,,5769.75,3750.34,,,,,,,,,,,,,
PLATE BNE W17.5XL142MM THK5.2MM 8 H TI BROAD LIMIT CNTCT,SUP-2190844,CDM,C1713,HCPCS,0278,RC,,,,both,,,1052.31,684.00,,,,,,,,,,,,,
CAST ORTHOT ANK KNEE TIB CUST FRAC PLSTR MOLD,SUP-2435646,CDM,L2106,HCPCS,0274,RC,,,,both,,,2231.54,1450.50,,,,,,,,,,,,,
ALLOGRAFT BNE XS 2.5-3X0.7-0.9 CMX 1.8-2.2 MM FD NAR PROF,SUP-2482550,CDM,C1889,HCPCS,0278,RC,,,,both,,,1357.27,882.23,,,,,,,,,,,,,
GRAFT HUM TISS W10-20MMXL16-19.4CM ACHILLES TEND W/O,SUP-2307293,CDM,C1713,HCPCS,0278,RC,,,,both,,,6226.24,4047.06,,,,,,,,,,,,,
SCREW BONE CNNLTD 5MM DIA 32MML TIMAX PRTLLY THRDD NON ST,SUP-2586811,CDM,C1713,HCPCS,0278,RC,,,,both,,,484.25,314.76,,,,,,,,,,,,,
SCREW BNE 2X2 MM,SUP-2262854,CDM,C1713,HCPCS,0278,RC,,,,both,,,148.55,96.56,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 40 MM DIA 4 MM DEL SHTH,SUP-2934391,CDM,C1713,HCPCS,0278,RC,,,,both,,,6374.07,4143.15,,,,,,,,,,,,,
TRAY BONE LESION BX NDL 11GA L10CM ACC L6CM PWR ONCONTROL,SUP-2383235,CDM,C1713,HCPCS,0278,RC,,,,both,,,1325.08,861.30,,,,,,,,,,,,,
IMPLANT NASAL LATERA 24MM,SUP-2739008,CDM,C1889,HCPCS,0278,RC,,,,both,,,6144.98,3994.24,,,,,,,,,,,,,
PLATE BNE R ANT TIBIOTALAR ANK FUS,SUP-2123207,CDM,C1713,HCPCS,0278,RC,,,,both,,,6515.50,4235.07,,,,,,,,,,,,,
STENT URET INLAY L 16 CM DIA 6 FR POLYUR HYDRPHLC LUBRICIOUS,SUP-2126624,CDM,C2625,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
PLATE BNE L157MM 8 H NONSTERILE POST MED PROX TIB S STL LOK,SUP-2177798,CDM,C1713,HCPCS,0278,RC,,,,both,,,3261.83,2120.19,,,,,,,,,,,,,
COMPONENT FEM KNEE OXINIUM LAT TROCHLEAR GRV,SUP-2347981,CDM,C1776,CPT,0278,RC,,,,both,,,13502.00,8776.30,,,,,,,,,,,,,
GUIDEWIRE VASC SENS L 55 CM DIA 0.035 IN TIP 3 MM SS SIL,SUP-2521857,CDM,C1769,HCPCS,0272,RC,,,,both,,,161.58,105.03,,,,,,,,,,,,,
PLATE BNE RT PELV QUADRILATERAL SURF,SUP-2518355,CDM,C1713,HCPCS,0278,RC,,,,both,,,3890.46,2528.80,,,,,,,,,,,,,
PLATE BONE CRANIAL LONG 6 HOLE GAP 48.8X16.2X0.4MM TITANIUM,SUP-2826278,CDM,C1713,HCPCS,0278,RC,,,,both,,,628.94,408.81,,,,,,,,,,,,,
SET IMPL L FRAG LCP W/ 4.5MM BROAD NAR T PLT,SUP-2183081,CDM,C1713,HCPCS,0278,RC,,,,both,,,65377.94,42495.66,,,,,,,,,,,,,
HC Dysphagia Therapy,PX-4409252600,CDM,92526,CPT,0440,RC,,,,both,,,347.00,225.55,,,,,,,,,,,,,
ENDCAP SPNL L10XW10MM 0DEG TI 4 LOBE SURG MESH LORDTC DMND,SUP-2317745,CDM,C1713,HCPCS,0278,RC,,,,both,,,1526.04,991.93,,,,,,,,,,,,,
KIT CATH HEMODIALYSI PWR TRIALYSI ACUTE 13FR DIA 20CML INSER,SUP-2613245,CDM,C1752,HCPCS,0278,RC,,,,both,,,896.78,582.91,,,,,,,,,,,,,
GRAFT BNE SUB 5ML 1.7-10MM CANC CHIP MORSELIZED FRZ DRY,SUP-2307076,CDM,C1713,HCPCS,0278,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
IMMOBILIZER ORTH 3 PNL 2XL 22 IN KNEE BRTRC ADJ FOAM,SUP-2194906,CDM,L1830,CPT,0272,RC,,,,both,,,57.46,37.35,,,,,,,,,,,,,
BLADE ENDOSCP SHAVER 15 DEG L 22.5 CM DIA2.9 MM TIP 6 MM SPD,SUP-2902074,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1635.31,1062.95,,,,,,,,,,,,,
ALLOGRAFT GRAFTLINK: D=9.5 L=79 MM,SUP-2815865,CDM,C1762,CPT,0278,RC,,,,both,,,6895.44,4482.04,,,,,,,,,,,,,
ROD EXT FIX L400MM S STL THRD TELSCP ORIG CIR FOR TAY SPAT,SUP-2342308,CDM,2720000010,LOCAL,0272,RC,,,,both,,,502.56,326.66,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 3X2 CM TERMINALLY STRL WND NEOX CRD RT,SUP-2648696,CDM,Q4148,HCPCS,0636,RC,,,,both,,,2166.60,1408.29,,,,,,,,,,,,,
ALLOGRAFT BNE 20X50X4 MM MOLD SCAFFOLD DBM FUSIONFLEX,SUP-2759531,CDM,C1713,HCPCS,0278,RC,,,,both,,,9370.55,6090.86,,,,,,,,,,,,,
KIT CHOLGM 4.4FR L30MM 5FR 0.035IN CATH L260CM SPHINTOM,SUP-2149002,CDM,C1887,HCPCS,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
CANNULA SUCTION HASSON 5 MM AUTO-VALVE,SUP-2484301,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2016.82,1310.93,,,,,,,,,,,,,
CATHETER EP CSL 2-2-2 MM 7 FRX120 CM RESPON,SUP-2356770,CDM,C1730,HCPCS,0272,RC,,,,both,,,1347.06,875.59,,,,,,,,,,,,,
GRAFT BNE SYR 2.5 CC DBM ACCELL CONNEXUS,SUP-2641753,CDM,C1713,HCPCS,0278,RC,,,,both,,,1203.41,782.22,,,,,,,,,,,,,
CLINIMIX/DEXTROSE (4.25/5) 4.25 % IV SOLN,RX-25749,CDM,2500000003,HCPCS,0250,RC,00338-1133-03,NDC,,both,1000,ML,224.30,145.79,,,,,,,,,,,,,
IMPLANT COCHLEAR PK STRL MI1250 SYNCHRONY 2 FLEX26,SUP-2905158,CDM,L8614,HCPCS,0278,RC,,,,both,,,53851.00,35003.15,,,,,,,,,,,,,
SODIUM NITROPRUSSIDE 25 MG/ML IV SOLN,RX-152053,CDM,2500000003,HCPCS,0250,RC,70436-0028-80,NDC,,both,2,ML,115.00,74.75,,,,,,,,,,,,,
PLATE BONE L159MM 20 H BILAT MAND ORAL MAXILLOFACIAL TI LO,SUP-2191462,CDM,C1713,HCPCS,0278,RC,,,,both,,,4402.28,2861.48,,,,,,,,,,,,,
SET BONE BX NDL PNCL PT 12GX6.5CM ACKERMANN,SUP-2167931,CDM,2720000010,LOCAL,0272,RC,,,,both,,,970.07,630.55,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP L450CM DIA0.035IN STD BILI HYDRPHLC TRIM,SUP-2149669,CDM,C1769,HCPCS,0272,RC,,,,both,,,361.57,235.02,,,,,,,,,,,,,
TIP TRANSILLUMINATION SYS DIA40FR FBR OPT BLNT HURST DETACH,SUP-2277401,CDM,C1713,HCPCS,0278,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
GRAFT VASC STR STD WALL RING 6MM DIA 80CM LEN 70CM GORTX,SUP-2396010,CDM,C1768,CPT,0278,RC,,,,both,,,4097.70,2663.50,,,,,,,,,,,,,
GRAFT BNE L12CMXW2CM REGEN MTRX 2 REPLFRM,SUP-2139391,CDM,C1762,CPT,0278,RC,,,,both,,,2956.62,1921.80,,,,,,,,,,,,,
SHOE ORTHOT CALIP PLATE NEW TRANSFER,SUP-2435746,CDM,L3610,HCPCS,0272,RC,,,,both,,,284.45,184.89,,,,,,,,,,,,,
BLADE SAW RECIP,SUP-2418566,CDM,2720000010,LOCAL,0272,RC,,,,both,,,514.33,334.31,,,,,,,,,,,,,
PLATE BNE TI ORTHOGNATHIC 7 PLATE CUSTOMIZED FACE ID,SUP-2883699,CDM,C1713,HCPCS,0278,RC,,,,both,,,34382.69,22348.75,,,,,,,,,,,,,
GRAFT BONE 11CM FEM SHFT FRZ DRY,SUP-2165571,CDM,C1713,HCPCS,0278,RC,,,,both,,,2245.10,1459.31,,,,,,,,,,,,,
SET URET STENT L 20 CM DIA 8.5 FR GUIDEWIRE 0.035 IN UTHANE,SUP-2168517,CDM,C2625,HCPCS,0278,RC,,,,both,,,347.16,225.65,,,,,,,,,,,,,
STEM TIB SMOOTH MID 16 MM TOT ANK COAT INBONE II,SUP-2468750,CDM,C1776,CPT,0278,RC,,,,both,,,1428.70,928.65,,,,,,,,,,,,,
GUIDEWIRE VASC ARW L 25 CM DIA 0.018 IN SS PERIPH,SUP-2383358,CDM,C1769,HCPCS,0272,RC,,,,both,,,29.01,18.86,,,,,,,,,,,,,
BASKET STONE RETRV L70CM DIA4.5FR SEGR,SUP-2141083,CDM,2720000010,LOCAL,0272,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
PLATE BNE DBL HK 1.5 MM 18 MM RT STELNICKI/MARCHETTO TI NS,SUP-2471608,CDM,C1713,HCPCS,0278,RC,,,,both,,,2583.00,1678.95,,,,,,,,,,,,,
SCRAPER MEMBRN 27 CVD DISP GRIESHABER VITREOUS,SUP-2109657,CDM,2720000010,LOCAL,0272,RC,,,,both,,,530.66,344.93,,,,,,,,,,,,,
COVER BUR H DIA14MM STD UNIV CRANIOMAXILLOFACIAL TI LO PROF,SUP-2366281,CDM,C1713,HCPCS,0278,RC,,,,both,,,790.81,514.03,,,,,,,,,,,,,
INTRODUCER SHTH L14CM DIA6FR GWIRE L50CM DIA0.38IN NDL,SUP-2357059,CDM,C1892,HCPCS,0272,RC,,,,both,,,25.12,16.33,,,,,,,,,,,,,
STENT GRFT VASC AFX BODY L 70 MM DIA25 MM LIMB L 30 MM DIA16,SUP-2217634,CDM,C1768,CPT,0278,RC,,,,both,,,35152.30,22848.99,,,,,,,,,,,,,
GRAFT ADIPOSE MATRIX 1.5CC LENEVA,SUP-2857969,CDM,C1762,CPT,0278,RC,,,,both,,,3692.64,2400.22,,,,,,,,,,,,,
VALVE CSF ULTRAVS NL8501129,SUP-2666750,CDM,C1889,HCPCS,0278,RC,,,,both,,,3037.48,1974.36,,,,,,,,,,,,,
PLATE BNE W13.5XL286MM THK4.2MM 16 H BILAT S STL NAR LIMIT,SUP-2185255,CDM,C1713,HCPCS,0278,RC,,,,both,,,2285.42,1485.52,,,,,,,,,,,,,
SCREW BNE FT 3.2X30 MM SELF COMPR,SUP-2433779,CDM,C1713,HCPCS,0278,RC,,,,both,,,1620.24,1053.16,,,,,,,,,,,,,
HC CT Abd/Pelvis W/O Contrast,PX-3527417600,CDM,74176,CPT,0352,RC,,,,both,,,4901.00,3185.65,,,,,,,,,,,,,
PLATE BONE PRECONTOURED 1.5X300 MM STERNAL 30 HOLE TITANIUM,SUP-2842223,CDM,C1713,HCPCS,0278,RC,,,,both,,,7863.35,5111.18,,,,,,,,,,,,,
ELECTRODE ES 24FR YEL KNF MPLR DISP,SUP-2313985,CDM,2720000010,LOCAL,0272,RC,,,,both,,,443.09,288.01,,,,,,,,,,,,,
STRAP CLAV XS STD MTL TOOTH BCKL,SUP-2428779,CDM,L3650,HCPCS,0274,RC,,,,both,,,23.17,15.06,,,,,,,,,,,,,
SUPPORT ORTHOT WRST HND FNGR CUST DYN FLX HINGE FABRICATED,SUP-2435769,CDM,L3900,HCPCS,0272,RC,,,,both,,,4173.94,2713.06,,,,,,,,,,,,,
NEEDLE BX MENG LIV 3.5 MMX30 CM 16 MM,SUP-2766981,CDM,2720000010,LOCAL,0272,RC,,,,both,,,750.99,488.14,,,,,,,,,,,,,
HC So Free Valproic Acid,PX-3018016566,CDM,80165,CPT,0301,RC,,,,both,,,125.00,81.25,,,,,,,,,,,,,
APPLICATOR ELECSURG 35 MM RIGID PLASMA COAG FILTER NDL AR,SUP-2762596,CDM,2720000010,LOCAL,0272,RC,,,,both,,,577.60,375.44,,,,,,,,,,,,,
IRRIGATOR SUCTION STRL DISP CLR,SUP-2914829,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1064.46,691.90,,,,,,,,,,,,,
STENT ESOPH HANAROSTENT L 60MM 18MM L 1800MM 0.035/0.038IN,SUP-2865626,CDM,C1874,HCPCS,0278,RC,,,,both,,,9843.90,6398.53,,,,,,,,,,,,,
CROWN DENT LL5 SEC PRI M INDIV SPACE MAINTAINER,SUP-2176704,CDM,D6783,CPT,0278,RC,,,,both,,,26.53,17.24,,,,,,,,,,,,,
ANCHOR SUT ROT CUF EZ BRAID POLY W/ CP 2 NDL INSRTR ETHBND,SUP-2249356,CDM,C1713,HCPCS,0278,RC,,,,both,,,999.15,649.45,,,,,,,,,,,,,
INSERT TIB SZ 1 THK7MM UCONG BAL SYS,SUP-2314848,CDM,C1776,CPT,0278,RC,,,,both,,,3001.84,1951.20,,,,,,,,,,,,,
SPACER 7770823 ELEV STD 23X8MM,SUP-2289142,CDM,C1821,HCPCS,0278,RC,,,,both,,,12089.00,7857.85,,,,,,,,,,,,,
SCREW BNE L34MM DIA4MM PERIARTC S STL ST LOK FULL THRD FOR,SUP-2184954,CDM,C1713,HCPCS,0278,RC,,,,both,,,430.18,279.62,,,,,,,,,,,,,
SET PUNC L12.5MM DIA20FR PHARYNX PROTCT NDL GWIRE DIL DISP,SUP-2124377,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1260.68,819.44,,,,,,,,,,,,,
SCREW INTFR 5X10MM IORT TEND TENSIONING SUP FIX STRENGTH,SUP-2399118,CDM,C1713,HCPCS,0278,RC,,,,both,,,1491.50,969.47,,,,,,,,,,,,,
CLAMP EXT FIX RNG TO ROD,SUP-2188590,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2594.39,1686.35,,,,,,,,,,,,,
GRAFT VASC IMPRA L 20 CM DIA 8 MM EPTFE STR TW N RING HEMO,SUP-2761258,CDM,C1768,CPT,0278,RC,,,,both,,,1004.08,652.65,,,,,,,,,,,,,
CONNECTOR SPNL STD POST S STL FIX SLT ANG XLNK FOR 6.35MM,SUP-2255708,CDM,C1713,HCPCS,0278,RC,,,,both,,,2342.44,1522.59,,,,,,,,,,,,,
SET PICC L 40 CM DIA 6 FR SHTH L 7 CM DIA 6 FR,SUP-2887028,CDM,C1751,HCPCS,0278,RC,,,,both,,,714.04,464.13,,,,,,,,,,,,,
GRAFT BNE STRP 12.5X1X0.4 CM 5 CC PLATFORM CM,SUP-2691583,CDM,C1713,HCPCS,0278,RC,,,,both,,,4823.04,3134.98,,,,,,,,,,,,,
CANNULA SUCTION INSUL 3.5 MMX30 CM COAG W/ STYL,SUP-2773549,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1625.70,1056.70,,,,,,,,,,,,,
BRACE ORTH L 30 CM CIRC THGH 15.5-18.5 IN CTR 13-14 IN CALF,SUP-2914947,CDM,2720000010,LOCAL,0272,RC,,,,both,,,841.02,546.66,,,,,,,,,,,,,
PLATE BNE COMPR 0.8 MM HND 6 HOLE STRL,SUP-2518383,CDM,C1713,HCPCS,0278,RC,,,,both,,,1325.08,861.30,,,,,,,,,,,,,
KIT INTRO MINI STK II L 7 CM DIA 4 FR GUIDEWIRE L 45 CM DIA,SUP-2734845,CDM,C1894,HCPCS,0272,RC,,,,both,,,21.98,14.29,,,,,,,,,,,,,
BLADE RETRCT W2.5XL5 5/8IN HARR BKWALT,SUP-2382390,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1393.75,905.94,,,,,,,,,,,,,
PLATE BONE 37MML HLX7 1.5MM STNLSS STEEL F/2MM SCREW MINI FR,SUP-2493892,CDM,C1713,HCPCS,0278,RC,,,,both,,,496.78,322.91,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 8X240 MM FRZN GAM ANTR TIBIALIS TEND,SUP-2866911,CDM,C1762,CPT,0278,RC,,,,both,,,3624.35,2355.83,,,,,,,,,,,,,
GRAFT DURA REP L7 X W 7 CM THK 0.4 MM ELECTROSPUN FIBER ART7706,SUP-2904067,CDM,C1763,HCPCS,0278,RC,,,,both,,,4592.25,2984.96,,,,,,,,,,,,,
CATHETER SUPRPUB 16FR L25CM 10ML BAL ORNG PVC 3 FACET TRCR,SUP-2384291,CDM,C2627,HCPCS,0272,RC,,,,both,,,108.46,70.50,,,,,,,,,,,,,
SEGMENTAL FEMORAL HINGE SERVICE KIT SIZE B,SUP-2502431,CDM,C1776,CPT,0278,RC,,,,both,,,5666.13,3682.98,,,,,,,,,,,,,
BLADE SHAVER ARTHSCP 3X120 MM STR FULL RAD DRILLCUTX RED,SUP-2602787,CDM,2720000010,LOCAL,0272,RC,,,,both,,,525.42,341.52,,,,,,,,,,,,,
PLATE BONE W14.9XL88MM THK1.2MM 5 H DSTL TIB S STL SCALLOPED,SUP-2185734,CDM,C1713,HCPCS,0278,RC,,,,both,,,898.76,584.19,,,,,,,,,,,,,
WIRE FIX THRD SMOOTH CAPTURE 1MM OD 70MM LEN K,SUP-2243922,CDM,C1713,HCPCS,0278,RC,,,,both,,,112.13,72.88,,,,,,,,,,,,,
TETANUS-DIPHTHERIA TOXOIDS TD 5-2 LF/0.5ML IM SUSP,RX-173416,CDM,90714,HCPCS,0636,RC,49281-0215-15,NDC,,both,.5,ML,190.20,123.63,,,,,,,,,,,,,
SYSTEM BNE BX MINI 13 GAX6 CM MADISON,SUP-2466658,CDM,2720000010,LOCAL,0272,RC,,,,both,,,596.60,387.79,,,,,,,,,,,,,
PIN DRL STR SUT BTTN FIX ON CORT BNE RETROBTTN,SUP-2121408,CDM,C1713,HCPCS,0278,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
BRACE KNEE WOM AD SM 6IN ABV MID PAT 15-18IN 6IN BELOW,SUP-2151050,CDM,L3660,HCPCS,0272,RC,,,,both,,,891.57,579.52,,,,,,,,,,,,,
CATHETER BLLN OCCL 4MM TIP 2.2FRX150MM 3X15MM HYPERGLIDE,SUP-2172475,CDM,C2628,HCPCS,0272,RC,,,,both,,,4521.60,2939.04,,,,,,,,,,,,,
GRAFT HUM TISS W3XL2CM THK1MM CRYOPRESERVED UMB CRD AMNIO,SUP-2116288,CDM,Q4148,HCPCS,0636,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
BAND MOLAR LOWER SZ30+ NARROW GEN PURP,SUP-2100462,CDM,D6783,CPT,0278,RC,,,,both,,,13.78,8.96,,,,,,,,,,,,,
DRILL TWST L85MM DIA1.9MM WRK L20MM FOR 2/2.3MM SCR,SUP-2366431,CDM,2720000010,LOCAL,0272,RC,,,,both,,,411.94,267.76,,,,,,,,,,,,,
STENT URET 7 FRX28 CM W/O GUIDEWIRE LUB FLX,SUP-2313790,CDM,C2617,HCPCS,0278,RC,,,,both,,,275.28,178.93,,,,,,,,,,,,,
SET CATH 8.5FR L25CM DIL 9FR GWIRE 0.038IN 6 SIDEPRT NIT,SUP-2168531,CDM,C1729,HCPCS,0272,RC,,,,both,,,432.13,280.88,,,,,,,,,,,,,
CANNULA SUC IRR 5X350 MM 2 TRMPT VLV LASER GUIDE SEAL SS,SUP-2490633,CDM,2720000010,LOCAL,0272,RC,,,,both,,,808.36,525.43,,,,,,,,,,,,,
TRIAL HIP OD43MM ID28MM ACET SHELL FOR MOD ENDO HD SELF CNTR,SUP-2252704,CDM,C1776,CPT,0278,RC,,,,both,,,1488.36,967.43,,,,,,,,,,,,,
SPLINT WRST XL L8IN L BLK FOAM D RNG CLSR LO PROF MAL,SUP-2336047,CDM,L3809,HCPCS,0274,RC,,,,both,,,18.21,11.84,,,,,,,,,,,,,
PLATE BNE L300MM BRL L15IN 135DEG PELVIS BILAT S STL STD 14,SUP-2342445,CDM,C1713,HCPCS,0278,RC,,,,both,,,7462.21,4850.44,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY LASSO L 115CM 7FR 25MM 3FR D CRV,SUP-2248769,CDM,C1730,HCPCS,0272,RC,,,,both,,,1456.96,947.02,,,,,,,,,,,,,
SHEATH DESTIN SL 6FR R2P 105CM,SUP-2633196,CDM,C1894,HCPCS,0272,RC,,,,both,,,1003.23,652.10,,,,,,,,,,,,,
TRAY APPL BLLN 3.5-5CM TARGETED BRST RAD THER TRCR INTRO,SUP-2239889,CDM,C1751,HCPCS,0278,RC,,,,both,,,8954.65,5820.52,,,,,,,,,,,,,
CATHETER CECOSTOMY 10.2FR TRACT L0-6CM 3 SIDE PRT PERC,SUP-2168674,CDM,C1729,HCPCS,0272,RC,,,,both,,,646.84,420.45,,,,,,,,,,,,,
SCREW BNE L 22 MM DIA 3.5 MM TI CANN HDLSS NS LEOS,SUP-2932592,CDM,C1713,HCPCS,0278,RC,,,,both,,,1010.77,657.00,,,,,,,,,,,,,
SCREW BNE L65MM DIA6.5MM THRD L16MM STD CANC S STL,SUP-2373835,CDM,C1713,HCPCS,0278,RC,,,,both,,,73.79,47.96,,,,,,,,,,,,,
SET SCR SPNL L50MM DIA6.5MM THORLUM TI THRD MULTAXL 30,SUP-2137297,CDM,C1713,HCPCS,0278,RC,,,,both,,,232.86,151.36,,,,,,,,,,,,,
NCB PP DF PLATE PROVISION 912H,SUP-2720671,CDM,C1713,HCPCS,0278,RC,,,,both,,,269.10,174.91,,,,,,,,,,,,,
HC Inj Anes/Steroid L/S Facet Sg|BILATERAL PROCEDURE,PX-3616449300,CDM,64493,CPT,0361,RC,,,50,both,,,4864.00,3161.60,,,,,,,,,,,,,
PIN EXT FIX L300MM DIA5/6MM THRD L40MM TRANSFIXING APEX,SUP-2372504,CDM,C1713,HCPCS,0278,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
KIT ENDO INSTR CATH MEDL FIRM TIP EXT WRK CHAN LOCATABLE,SUP-2281539,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4892.12,3179.88,,,,,,,,,,,,,
PLATE BONE L154MM 7 H TI LT DSTL DORSOLATERAL HUM FOR 3.5MM,SUP-2101271,CDM,C1713,HCPCS,0278,RC,,,,both,,,2758.18,1792.82,,,,,,,,,,,,,
PLATE STRNL LG 8 H TI X SHP NS MATRIXSTERNUM,SUP-2904220,CDM,C1713,HCPCS,0278,RC,,,,both,,,2129.52,1384.19,,,,,,,,,,,,,
DRESSING BIO SZ 8 X 15 CM OVINE MTRX 3 LAYR CNTOUR LT RESRB,SUP-2914594,CDM,C1781,HCPCS,0278,RC,,,,both,,,6327.10,4112.61,,,,,,,,,,,,,
BUR ENDOSCP BRL 6.5X120 MM FINISH DK BLK PUR UNIDRIVE,SUP-2585889,CDM,2720000010,LOCAL,0272,RC,,,,both,,,121.68,79.09,,,,,,,,,,,,,
POTASSIUM CHLORIDE 20 MEQ/50ML IV SOLN,RX-11077,CDM,J3480,HCPCS,0636,RC,00338-0703-41,NDC,,both,50,ML,54.10,35.16,,,,,,,,,,,,,
CATHETER PICC L55CM OD4FR SGL LUMN N COAT N CT COMPATIBLE N,SUP-2118829,CDM,C1751,HCPCS,0278,RC,,,,both,,,339.12,220.43,,,,,,,,,,,,,
SCREW BONE 4.5X20MM ACET CANC TI SELF TAP HGP II,SUP-2202665,CDM,C1713,HCPCS,0278,RC,,,,both,,,424.53,275.94,,,,,,,,,,,,,
PLATE BONE L292MM 22 H LCK COMPR WAISTED FOR 4MM SCR,SUP-2371970,CDM,C1713,HCPCS,0278,RC,,,,both,,,1017.67,661.49,,,,,,,,,,,,,
GRAFT VASC IMPRA L 40 CM DIA 3 MM EPTFE STR TW N RING HEMO,SUP-2761274,CDM,C1768,CPT,0278,RC,,,,both,,,1801.26,1170.82,,,,,,,,,,,,,
ELECTRODE ES 14GA L25CM TALON SEMI FLX RF FOR TISS ABLAT,SUP-2118721,CDM,C1819,HCPCS,0278,RC,,,,both,,,7253.40,4714.71,,,,,,,,,,,,,
PLATE BNE L THK0.8MM 2X3 H L BILAT CRANIOMAXILLOFACIAL G TI,SUP-2181704,CDM,C1713,HCPCS,0278,RC,,,,both,,,1131.97,735.78,,,,,,,,,,,,,
HC Clip Placement Node Biops,PX-3613899900,CDM,38999,CPT,0361,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
GRAFT VASC VLV 31 MM AORT ROTATABLE STENT MSTR SER,SUP-2355156,CDM,C1768,CPT,0278,RC,,,,both,,,20045.76,13029.74,,,,,,,,,,,,,
SHEATH URO 12/14FR L36CM SGL TAPR FLX DIL TIP NAVIGATOR HD,SUP-2139225,CDM,C1894,HCPCS,0272,RC,,,,both,,,420.23,273.15,,,,,,,,,,,,,
PYRAZINAMIDE 500 MG PO TABS,RX-6738,CDM,6370000000,HCPCS,0637,RC,70954-0484-10,NDC,,both,1,UN,20.50,13.32,,,,,,,,,,,,,
GRAFT BNE 2.5 CC ACTIFUSE ABX,SUP-2208431,CDM,C1713,HCPCS,0278,RC,,,,both,,,2449.20,1591.98,,,,,,,,,,,,,
SODIUM CHLORIDE BACTERIOSTATIC 0.9% IJ (MIXTURES ONLY),RX-430053,CDM,2500000003,HCPCS,0250,RC,00409-1966-07,NDC,,both,30,ML,54.10,35.16,,,,,,,,,,,,,
SPLINT FNGR BASEBL 425IN M,SUP-2276752,CDM,L3933,HCPCS,0274,RC,,,,both,,,3.11,2.02,,,,,,,,,,,,,
BUR SURG L115MM DIA1MM S STL RND CUT FLUT CRV VISAO,SUP-2284228,CDM,C1713,HCPCS,0278,RC,,,,both,,,806.60,524.29,,,,,,,,,,,,,
TUBE ENTRL FEED GAST-JEJU 16 FRX1.5X30 CM LP G-JET BUTTON,SUP-2754594,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2786.97,1811.53,,,,,,,,,,,,,
DRESSING BIO W4XL5IN BOV TEND CLLGN MESHED GLYCOSAMINOGLYCAN,SUP-2244273,CDM,C9363,HCPCS,0636,RC,,,,both,,,16944.23,11013.75,,,,,,,,,,,,,
BUR SURG 3MM COARSE DMND MTCH HD,SUP-2365196,CDM,2720000010,LOCAL,0272,RC,,,,both,,,639.15,415.45,,,,,,,,,,,,,
TETRACAINE HCL 0.5 % OP SOLN,RX-7795,CDM,6370000000,HCPCS,0637,RC,00065-0741-14,NDC,,both,4,ML,62.50,40.62,,,,,,,,,,,,,
PLATE BNE L32MM 2X3 H R S STL L LO PROF LOK COMPR FOR 2.7MM,SUP-2186357,CDM,C1713,HCPCS,0278,RC,,,,both,,,1053.75,684.94,,,,,,,,,,,,,
BIT DRL DIA4MM OSTEOCHNDRL DEFCT FOR COR CART REP,SUP-2249553,CDM,2720000010,LOCAL,0272,RC,,,,both,,,816.40,530.66,,,,,,,,,,,,,
FIBER LASER 400UM HOLM LT GUID,SUP-2313981,CDM,C1713,HCPCS,0278,RC,,,,both,,,1346.53,875.24,,,,,,,,,,,,,
COUPLING REPROC EXT FIX ROD TO ROD STR4941-1-010,SUP-2516728,CDM,2720000010,LOCAL,0272,RC,,,,both,,,325.02,211.26,,,,,,,,,,,,,
GUIDE PIN ORTHOPEDIC 2 MM,SUP-2242698,CDM,2720000010,LOCAL,0272,RC,,,,both,,,92.63,60.21,,,,,,,,,,,,,
COMPONENT FEM CR 1 55X53 MM LT KNEE CEM ANAT DP PAT GRV TI,SUP-2390327,CDM,C1776,CPT,0278,RC,,,,both,,,15150.50,9847.82,,,,,,,,,,,,,
PLATE CRAN 80X80X40 MM PT SPEC IMPL PEEK,SUP-2860138,CDM,C1713,HCPCS,0278,RC,,,,both,,,30967.62,20128.95,,,,,,,,,,,,,
IMPLANT HUMAN TSSUE W4XL7CM THICK SKIN RGNRTVE MTRX FRZE DRI,SUP-2458846,CDM,Q4116,HCPCS,0636,RC,,,,both,,,2835.42,1843.02,,,,,,,,,,,,,
RXG PLATE STR 4 HLE 40MM 24MM BRG RDCD HOLE SPCNG T1.0MM,SUP-2488145,CDM,C1713,HCPCS,0278,RC,,,,both,,,2658.98,1728.34,,,,,,,,,,,,,
GRAFT VASC 13 CM EXCLUDER AAA,SUP-2395633,CDM,C1768,CPT,0278,RC,,,,both,,,31384.30,20399.79,,,,,,,,,,,,,
NAIL INTRMDLLRY 2MM DIA 440MML TTNM FLXBLE UNVRSL SOLID GREE,SUP-2734263,CDM,C1713,HCPCS,0278,RC,,,,both,,,759.88,493.92,,,,,,,,,,,,,
GRAFT TENDON SEMITENDINOSUS SGL STRAND,SUP-2855505,CDM,C1762,CPT,0278,RC,,,,both,,,3642.40,2367.56,,,,,,,,,,,,,
COIL NEUROVASCULAR HELIPAQ 10 L 6 CM DIA2 MM WORKING L 190,SUP-2457847,CDM,C1889,HCPCS,0278,RC,,,,both,,,3486.47,2266.21,,,,,,,,,,,,,
TREPHINE SURG 55IN DIA17MM,SUP-2252781,CDM,C1713,HCPCS,0278,RC,,,,both,,,1679.12,1091.43,,,,,,,,,,,,,
K WIRE FIX L150MM DIA1.25MM TI TRCR PNT,SUP-2193144,CDM,C1776,CPT,0278,RC,,,,both,,,284.14,184.69,,,,,,,,,,,,,
SCREW BNE ZURICH 1.2X7 MM 9 MM DRILL-FREE 2 MM STRL LEVEL 1,SUP-2540290,CDM,C1713,HCPCS,0278,RC,,,,both,,,553.46,359.75,,,,,,,,,,,,,
CAGE SPNL 20 DEG 35X27X16 MM 3D 3 HOLE NO PROF,SUP-2750689,CDM,C1889,HCPCS,0278,RC,,,,both,,,18604.50,12092.92,,,,,,,,,,,,,
TAP SURG L175X140MM CALIB FOR 4.5MM CORT SCR,SUP-2187415,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1277.20,830.18,,,,,,,,,,,,,
PACEMAKER CRD 2 CHAMBERED SYM DR,SUP-2265199,CDM,C1785,HCPCS,0275,RC,,,,both,,,15700.00,10205.00,,,,,,,,,,,,,
PIN 3.0X355MM,SUP-2500376,CDM,C1713,HCPCS,0278,RC,,,,both,,,331.21,215.29,,,,,,,,,,,,,
DRESSING 4INX10.0YD DOME PASTE OR UNNA BOOT GELOCAST,SUP-2324582,CDM,L4387,HCPCS,0274,RC,,,,both,,,31.75,20.64,,,,,,,,,,,,,
BOOT TRACTION LOOP LCK CLOSURE LG ECON BUCK,SUP-2336329,CDM,L4398,HCPCS,0272,RC,,,,both,,,27.60,17.94,,,,,,,,,,,,,
STAPLE BNE COMPR 3X2 MM,SUP-2223645,CDM,C1713,HCPCS,0278,RC,,,,both,,,1083.30,704.14,,,,,,,,,,,,,
MARKER RAD NDL L20CM OD18GA PROC SFT TISS FIDUCIAL KT,SUP-2164653,CDM,A4648,CPT,0278,RC,,,,both,,,675.10,438.81,,,,,,,,,,,,,
GUIDEWIRE VASC ASAHI FIELDER L 180 CM TIP L 3 CM DIA 0.014,SUP-2102218,CDM,C1769,HCPCS,0272,RC,,,,both,,,65.94,42.86,,,,,,,,,,,,,
SYSTEM CARD ICD SYS 2 CHMBR W/ RIATA ST OPTIM SYS FOR V-265,SUP-2356567,CDM,C1721,HCPCS,0275,RC,,,,both,,,72220.00,46943.00,,,,,,,,,,,,,
PIN EXT FIX L9IN DIA3/32IN S STL DMND PNT W/ SMOOTH SHFT,SUP-2342709,CDM,C1713,HCPCS,0278,RC,,,,both,,,402.05,261.33,,,,,,,,,,,,,
ANCHOR SUT DIA4.5MM TWO ULTRABRAID FOR ROT CUF SFT TISS FIX,SUP-2341877,CDM,C1713,HCPCS,0278,RC,,,,both,,,1235.40,803.01,,,,,,,,,,,,,
PLATE BNE L123MM 8 H NONSTERILE R LAT PROX TIB LOK FOR 35MM,SUP-2348475,CDM,C1713,HCPCS,0278,RC,,,,both,,,11589.27,7533.03,,,,,,,,,,,,,
HC Layer Closure Face <2.5 Cm,PX-4501205100,CDM,12051,CPT,0450,RC,,,,inpatient,,,810.00,526.50,,,,,,,,,,,,,
COMPONENT GLEN L 40MM STD SHLDR UHMWPE COFIELD2,SUP-2344311,CDM,C1776,CPT,0278,RC,,,,both,,,3037.95,1974.67,,,,,,,,,,,,,
PLATE BNE W10XL142MM THK3.6MM 12 H BILAT S STL CRV RIG CLLR,SUP-2186256,CDM,C1713,HCPCS,0278,RC,,,,both,,,2378.30,1545.89,,,,,,,,,,,,,
KIT LAPSCP L100MM L5MM PRT CANN OBT ADPT TAUT,SUP-2383783,CDM,C1788,HCPCS,0278,RC,,,,both,,,94.01,61.11,,,,,,,,,,,,,
PLATE BNE L314MM 14 H NONSTERILE L CNDYL S STL LOK COMPR,SUP-2183117,CDM,C1713,HCPCS,0278,RC,,,,both,,,4562.77,2965.80,,,,,,,,,,,,,
BOX JUNCTION OFFSET 5 DEG FEM BKRS,SUP-2434214,CDM,C1776,CPT,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
ARGATROBAN 250 MG/2.5ML IV SOLN,RX-28947,CDM,J0883,HCPCS,0636,RC,67457-0212-02,NDC,,both,2.5,ML,1529.50,994.17,,,,,,,,,,,,,
DRILL SURG CEM 4-6 FBT HI PERF SIG,SUP-2456272,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1733.28,1126.63,,,,,,,,,,,,,
SCREW BNE L32MM DIA5MM TAN ST FULL THRD BLNT TIP T25,SUP-2420772,CDM,C1713,HCPCS,0278,RC,,,,both,,,613.21,398.59,,,,,,,,,,,,,
CEMENT FLX FEM/CEM TIB/PRLNGSURF/NO PAT,SUP-2212154,CDM,C1776,CPT,0278,RC,,,,both,,,11252.35,7314.03,,,,,,,,,,,,,
BRACE ORTH CARBON FIBER FRME RT KNEE COMBINED INSTABILITY,SUP-2914917,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1031.30,670.34,,,,,,,,,,,,,
SCREW BNE L16MM DIA3.2MM S STL ST SELF DRL CANN NONLOCKING,SUP-2397537,CDM,C1713,HCPCS,0278,RC,,,,both,,,310.86,202.06,,,,,,,,,,,,,
DEVICE SUCT TBNG L244CM IRRIG LN L61CM DIR OLY FUJINON,SUP-2360653,CDM,C1713,HCPCS,0278,RC,,,,both,,,347.25,225.71,,,,,,,,,,,,,
SHEATH INTRO FLX L 40 CM OD 12 FR GUIDEWIRE 0.038 IN LG,SUP-2170116,CDM,C1894,HCPCS,0272,RC,,,,both,,,176.66,114.83,,,,,,,,,,,,,
HC Blood Draw per Port,PX-5103659100,CDM,36591,CPT,0510,RC,,,,both,,,387.00,251.55,,,,,,,,,,,,,
SCREW BNE ST 1X10 MM CRUCFRM HD TI NS,SUP-2189086,CDM,C1713,HCPCS,0278,RC,,,,both,,,336.29,218.59,,,,,,,,,,,,,
IMMOBILIZER KNEE L23IN UNIV AD WRP ARND OPN PAT WIND ADJ,SUP-2136226,CDM,L1830,CPT,0274,RC,,,,both,,,112.41,73.07,,,,,,,,,,,,,
GUIDEWIRE ORTH MINI 1.4MM MTP POCKETLOCK MAXLOCK EXTRM,SUP-2400513,CDM,C1769,HCPCS,0272,RC,,,,both,,,600.37,390.24,,,,,,,,,,,,,
STRUT EXT FIX L163 300MM LNG ACUTE ADJ LOK UNIV HNG ON BOTH,SUP-2316068,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2908.43,1890.48,,,,,,,,,,,,,
LEVETIRACETAM 500 MG PO TABS,RX-26817,CDM,6370000000,HCPCS,0637,RC,68180-0113-16,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
STEM HUM 5MM MINI SHLDR CO CHROM COMPHSVE REV PRI CEM,SUP-2404558,CDM,C1776,CPT,0278,RC,,,,both,,,15389.14,10002.94,,,,,,,,,,,,,
SCREW BNE L 95 MM DIA 3.5 MM SS CORTICAL ST NS EVOS,SUP-2931848,CDM,C1713,HCPCS,0278,RC,,,,both,,,109.84,71.40,,,,,,,,,,,,,
CAGE SPNL MESH 33X26X90 MM 6 LOBE,SUP-2602093,CDM,C1889,HCPCS,0278,RC,,,,both,,,21317.46,13856.35,,,,,,,,,,,,,
LEAD DEFIB L59CM ENDOCARD SGL COIL ACT NO CHRG RELIANCE S,SUP-2148546,CDM,C1896,HCPCS,0275,RC,,,,both,,,8691.52,5649.49,,,,,,,,,,,,,
ANCHOR SUT SZ 2 DIA5MM ABSRB ETHBND MINI FASTIN RC,SUP-2249446,CDM,C1713,HCPCS,0278,RC,,,,both,,,1011.08,657.20,,,,,,,,,,,,,
PROVOX VEGA VOICE PROS IS AN INDWL LO RESISTANCE VOICE PROS,SUP-2124400,CDM,L8509,HCPCS,0272,RC,,,,both,,,963.98,626.59,,,,,,,,,,,,,
BLADE SURG W/O HNDL STR ATRAUM CAPSLTMY STRL DISP SAFECUT,SUP-2910463,CDM,2720000010,LOCAL,0272,RC,,,,both,,,593.46,385.75,,,,,,,,,,,,,
VALVE SPEAK TRACH,SUP-2138739,CDM,L8501,HCPCS,0274,RC,,,,both,,,141.30,91.84,,,,,,,,,,,,,
TRAY CATH PICC GROSH NXT 5FR 0.026N 55CM 2 LUMAN RVS 9927508,SUP-2632713,CDM,C1751,HCPCS,0278,RC,,,,both,,,584.89,380.18,,,,,,,,,,,,,
GRAFT HUM TISS W16XL20CM THK0.75-1.5MM DECELLULARIZED DERM,SUP-2264623,CDM,Q4122,HCPCS,0636,RC,,,,both,,,27989.18,18192.97,,,,,,,,,,,,,
ENDCAP ORTH DIA1 MM THRD T8 STRL FLEX-THREAD,SUP-2900420,CDM,C1889,HCPCS,0278,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
PLATE BONE L118MM THK2.8MM 10 H BILAT S STL NONCOMPRESSION,SUP-2348978,CDM,C1713,HCPCS,0278,RC,,,,both,,,3929.08,2553.90,,,,,,,,,,,,,
PLATE BNE W13.5XL98MM THK4.2MM 5 H BILAT S STL NAR LOK,SUP-2185234,CDM,C1713,HCPCS,0278,RC,,,,both,,,994.53,646.44,,,,,,,,,,,,,
ENDCAP SPNL W/ LCK SCR TI X-CORE MINI,SUP-2567546,CDM,C1889,HCPCS,0278,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
PIN FIX DBL TROCAR 0.093X9 IN SS NS STEINMANN,SUP-2791606,CDM,C1713,HCPCS,0278,RC,,,,both,,,12.06,7.84,,,,,,,,,,,,,
STENT GRFT VASC AFX BODY L 90 MM DIA22 MM LIMB 30 MM 20 MM,SUP-2217624,CDM,C1874,HCPCS,0278,RC,,,,both,,,36110.00,23471.50,,,,,,,,,,,,,
SCREW BONE L85MM DIA3.5MM S STL ST VAR ANG NONCANNULATED LCK,SUP-2348261,CDM,C1713,HCPCS,0278,RC,,,,both,,,1157.40,752.31,,,,,,,,,,,,,
BOOT CAST 4IN TCC-EZ,SUP-2194354,CDM,L4386,HCPCS,0274,RC,,,,both,,,340.69,221.45,,,,,,,,,,,,,
PLATE BNE THK 0.6 MM DIA1 MM 2 H BAR 8 MM SCREW DIA2 MM TI,SUP-2883196,CDM,C1713,HCPCS,0278,RC,,,,both,,,280.59,182.38,,,,,,,,,,,,,
HC So Vitamin B12 Binding Capacity,PX-3018260866,CDM,82608,CPT,0301,RC,,,,both,,,48.00,31.20,,,,,,,,,,,,,
ALLOGRAFT BNE PTTY 5 CC DBM FIBER NEVOS,SUP-2762317,CDM,C1713,HCPCS,0278,RC,,,,both,,,1771.90,1151.73,,,,,,,,,,,,,
PIN FIX L9IN DIA48MM S STL 3 SIDE SGL TRCR 1 END PNT STYL,SUP-2150447,CDM,C1713,HCPCS,0278,RC,,,,both,,,82.11,53.37,,,,,,,,,,,,,
STENT NEURO FRED L 28/22 MM WORKING L 22/14 MM DIA 5.5 MM,SUP-2738105,CDM,C1876,HCPCS,0278,RC,,,,both,,,39901.55,25936.01,,,,,,,,,,,,,
WRX DISTAL RADIUS NAIL 5X70MM STERILE,SUP-2816191,CDM,C1713,HCPCS,0278,RC,,,,both,,,10048.00,6531.20,,,,,,,,,,,,,
PLATE BNE CLAV 2.7 MM LT SHFT VA LCK COMPR TI STRL VALCP,SUP-2789383,CDM,C1713,HCPCS,0278,RC,,,,both,,,3869.74,2515.33,,,,,,,,,,,,,
TOBRAMYCIN 300 MG/5ML IN NEBU,RX-22240,CDM,J7682,HCPCS,0636,RC,09999-9918-02,NDC,,both,5,ML,132.50,86.12,,,,,,,,,,,,,
HC Iaad Ia Hiv-1 Ag W/Hiv-1 & Hiv-2 Antbdy Single,PX-3068738900,CDM,87389,CPT,0306,RC,,,,both,,,482.00,313.30,,,,,,,,,,,,,
GUIDE PIN ORTH DBL TROCAR 1.5X250 MM,SUP-2766036,CDM,2720000010,LOCAL,0272,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
SPLINT WR AD L 9IN LNG LT COT W/ STAY ELAS SUPP FOR,SUP-2324570,CDM,L3809,HCPCS,0274,RC,,,,both,,,36.86,23.96,,,,,,,,,,,,,
BIT DRL OD3MM JCBS CHK END FOR CHARLOTTE COMPR STPL,SUP-2397623,CDM,2720000010,LOCAL,0272,RC,,,,both,,,467.86,304.11,,,,,,,,,,,,,
IMPLANT WR JT CRPL POLY INSRT SZ 1 STD,SUP-2243503,CDM,C1776,CPT,0278,RC,,,,both,,,3617.78,2351.56,,,,,,,,,,,,,
HC So Chlamydia Antibody,PX-3028663166,CDM,86631,CPT,0302,RC,,,,both,,,236.00,153.40,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY PENTARAY NAV ECO 115CM 7FR4-4-4 D,SUP-2880938,CDM,C1732,HCPCS,0272,RC,,,,both,,,4279.82,2781.88,,,,,,,,,,,,,
MICROCATHETER GUID CORSAIR PRO L 150 CM DIA GUIDEWIRE 0.014,SUP-2123834,CDM,C1887,HCPCS,0272,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
BUR ENDOSCP RND SITELINE STRL UNIDRIVE DISP,SUP-2585908,CDM,2720000010,LOCAL,0272,RC,,,,both,,,254.62,165.50,,,,,,,,,,,,,
MESH HERN W10XL14IN POLYPR MFIL RECTANG,SUP-2125745,CDM,C1781,HCPCS,0278,RC,,,,both,,,244.92,159.20,,,,,,,,,,,,,
STENT BILI AD 85FR L50MM MIN WRK CHN 32MM ETHYLENE VYN,SUP-2313490,CDM,C2617,HCPCS,0278,RC,,,,both,,,182.40,118.56,,,,,,,,,,,,,
POST FIX L30MM OD4.5MM TI KNEE SUT STRL FOR ACL PCL FIX SYS,SUP-2342261,CDM,C1713,HCPCS,0278,RC,,,,both,,,277.04,180.08,,,,,,,,,,,,,
PLATE BNE L 118 MM SCREW DIA 4.5 MM 5 H RT PROX HUM STRL,SUP-2932775,CDM,C1713,HCPCS,0278,RC,,,,both,,,9317.17,6056.16,,,,,,,,,,,,,
BLADE SURG FULL SM 52 MM EXTRACTOR EXPLANT,SUP-2204475,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1978.20,1285.83,,,,,,,,,,,,,
SCREW VAL SCREOPTILINK SLF TAP SD 5.0X95MM ST,SUP-2752105,CDM,C1713,HCPCS,0278,RC,,,,both,,,728.23,473.35,,,,,,,,,,,,,
TRABECULAR METAL REVISION SHELL 56MM,SUP-2503824,CDM,C1776,CPT,0278,RC,,,,both,,,7510.88,4882.07,,,,,,,,,,,,,
CAGE SPNL L10XW10XH9MM 4 LOBE MESH ANAT FOOTPRINT MOD IMP,SUP-2317724,CDM,C1889,HCPCS,0278,RC,,,,both,,,4311.22,2802.29,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE MED 5.4 CC CORTICOCANCELLOUS VIABLE 002,SUP-2936804,CDM,C1762,CPT,0278,RC,,,,both,,,6837.00,4444.05,,,,,,,,,,,,,
REVOWAVE 0035 450CM ANG ULT HRD,SUP-2418531,CDM,C1769,HCPCS,0272,RC,,,,both,,,514.93,334.70,,,,,,,,,,,,,
BLADE GRFT HARV W165MM THK04MM CUT THK9MM 20MM DEPTH STP,SUP-2166091,CDM,C1713,HCPCS,0278,RC,,,,both,,,341.51,221.98,,,,,,,,,,,,,
SCREW BNE CANN 5.7X75 MM CRTX ST LCK PERI-LOC,SUP-2340940,CDM,C1713,HCPCS,0278,RC,,,,both,,,125.13,81.33,,,,,,,,,,,,,
BIT DRL 2.4 MM CERV FOR 3.5 MM SCREW S4,SUP-2108734,CDM,2720000010,LOCAL,0272,RC,,,,both,,,758.31,492.90,,,,,,,,,,,,,
PLATE BNE L12MM THK0.4MM 2 H CRANIOMAXILLOFACIAL BILAT BLU,SUP-2181555,CDM,C1713,HCPCS,0278,RC,,,,both,,,211.01,137.16,,,,,,,,,,,,,
PLATE BNE L12MM 4 H BILAT S STL H SHP LO PROF RIG NEUT,SUP-2186161,CDM,C1713,HCPCS,0278,RC,,,,both,,,550.85,358.05,,,,,,,,,,,,,
CATHETER MAP DF CRV 1-4-1 MM SPC 8 FRX117 CM CIR ADVISOR VL,SUP-2867392,CDM,C1730,HCPCS,0272,RC,,,,both,,,5777.60,3755.44,,,,,,,,,,,,,
SEED BRACHYTHERAPY I-125 IMPL STRANDS LD RND HUB NDL,SUP-2247256,CDM,C2638,HCPCS,0278,RC,,,,both,,,87.92,57.15,,,,,,,,,,,,,
CATHETER ANGIO MARINER L 90 CM 4 FR 0.038 IN STR NONBRAIDED,SUP-2118165,CDM,C1887,HCPCS,0272,RC,,,,both,,,108.68,70.64,,,,,,,,,,,,,
PACEMAKER 2 CHMBR MRI SAFE ACCENT DR,SUP-2357691,CDM,C1785,HCPCS,0275,RC,,,,both,,,18526.00,12041.90,,,,,,,,,,,,,
GUIDEWIRE VASC L 260 CM 0.035 IN L 3 MM SS PTFE J UNIFORMITY,SUP-2763689,CDM,C1769,HCPCS,0272,RC,,,,both,,,25.78,16.76,,,,,,,,,,,,,
SPACER SPNL 7 DEGREEX25LX7 MM ZYSTON TRANSFORM,SUP-2137077,CDM,C1821,HCPCS,0278,RC,,,,both,,,18840.00,12246.00,,,,,,,,,,,,,
BLADE BPLR OD4MM STD STR SERR ELITE COMPATIBLE DS DIEGO,SUP-2312959,CDM,C1713,HCPCS,0278,RC,,,,both,,,516.81,335.93,,,,,,,,,,,,,
BOOT TRAC FT FOAM INSRT VELC STRP AD,SUP-2360615,CDM,L4387,HCPCS,0274,RC,,,,both,,,595.50,387.07,,,,,,,,,,,,,
BOOT TRAC FT FOAM INSRT VELC STRP AD,SUP-2360615,CDM,L4387,HCPCS,0272,RC,,,,both,,,595.50,387.07,,,,,,,,,,,,,
NAIL IM L165MM DIA3.175MM FEM HIP S STL CANN NONLOCKING,SUP-2371422,CDM,C1713,HCPCS,0278,RC,,,,both,,,1204.50,782.92,,,,,,,,,,,,,
ALLODERM SELECT 1X2 MEDIUM 1.2-2.0,SUP-2822071,CDM,Q4116,HCPCS,0636,RC,,,,both,,,606.02,393.91,,,,,,,,,,,,,
SCALPEL SURG LCK STRL T2 ALPHA GAMMA4,SUP-2900711,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1901.21,1235.79,,,,,,,,,,,,,
SET PANCREATIC STENT ZMMN L 4 CM 5 FR 0.035 IN POLYETHYL,SUP-2169294,CDM,C2625,HCPCS,0278,RC,,,,both,,,405.06,263.29,,,,,,,,,,,,,
DEVICE FIX OVL HD RAP DEL SYS STRL DISP SURTAC III,SUP-2341627,CDM,C1713,HCPCS,0278,RC,,,,both,,,913.27,593.63,,,,,,,,,,,,,
TUBE INNR EAR MYR VENT FLNG 1.14 MM ID SIL STRL BLU,SUP-2381503,CDM,L8699,HCPCS,0278,RC,,,,both,,,145.07,94.30,,,,,,,,,,,,,
COIL DETACH 3MM DIA 12CM 4MM THER DIA NXT HELIX STD 10,SUP-2173001,CDM,C1889,HCPCS,0278,RC,,,,both,,,2678.42,1740.97,,,,,,,,,,,,,
PLATE BONE 18 H STRNL LCK LADDER FOR 1.5MM SCR,SUP-2262570,CDM,C1713,HCPCS,0278,RC,,,,both,,,2097.52,1363.39,,,,,,,,,,,,,
IMPLANT HUM TISS L 30-80 X W 25-50 MM PA PTCH TRUNK THCK,SUP-2932767,CDM,C1762,CPT,0278,RC,,,,both,,,21457.10,13947.11,,,,,,,,,,,,,
STEM FEM REV PRSS FIT L BOW TI POR PLSM COAT RESTR 254MML,SUP-2375433,CDM,C1776,CPT,0278,RC,,,,both,,,18097.70,11763.50,,,,,,,,,,,,,
SHEATH INTRO ARW L 10 CM DIA 6 FR GUIDEWIRE 0.018 IN PTFE,SUP-2120536,CDM,C1892,HCPCS,0272,RC,,,,both,,,65.94,42.86,,,,,,,,,,,,,
CABLE ORTH 2X900 MM ASMBLY 2 LEADER STRL,SUP-2563690,CDM,C1713,HCPCS,0278,RC,,,,both,,,1474.07,958.15,,,,,,,,,,,,,
SUPPORT EL NEOPRENE11 13IN L,SUP-2276611,CDM,L3702,HCPCS,0272,RC,,,,both,,,10.61,6.90,,,,,,,,,,,,,
GAMMATILE THERAPY DEVICE 7 PACK,SUP-2855641,CDM,C2642,HCPCS,0278,RC,,,,both,,,16597.13,10788.13,,,,,,,,,,,,,
GRAFT BNE SUB M SZ 14 28MM 5ML B TRICALCIUM PHSPTE SYN,SUP-2194008,CDM,C1713,HCPCS,0278,RC,,,,both,,,964.95,627.22,,,,,,,,,,,,,
KIT CEM MIXING/DELIVERY 10CC HALF DOSE,SUP-2367023,CDM,C1713,HCPCS,0278,RC,,,,both,,,1722.79,1119.81,,,,,,,,,,,,,
HC Assay of Prostate Specific Antigen Total|NOT REASONABLE AND NECESSARY,PX-3018415300,CDM,84153,CPT,0301,RC,,,GZ,both,,,242.00,157.30,,,,,,,,,,,,,
CATHETER ABLATN MED CURL 7 FR QPLR LIVEWIRE TC,SUP-2356991,CDM,C1733,HCPCS,0272,RC,,,,both,,,2084.96,1355.22,,,,,,,,,,,,,
GRAFT BONE SUB 10CC INJ KT BETA-BSM,SUP-2218020,CDM,C1713,HCPCS,0278,RC,,,,both,,,8231.35,5350.38,,,,,,,,,,,,,
PLATE BNE CLAV CS1 2.7 MM LT LAT VA LCK COMPR TI STRL VALCP,SUP-2789772,CDM,C1713,HCPCS,0278,RC,,,,both,,,4050.98,2633.14,,,,,,,,,,,,,
GUIDEWIRE URO TAPR RADPQ STR STIFF TIP POLYUR TUNGSTEN NIT,SUP-2385259,CDM,C1769,HCPCS,0272,RC,,,,both,,,614.81,399.63,,,,,,,,,,,,,
TRAY PICC CATH 5FR POLYUR FULL TRIM LEN SGL LUMN NRS PWR INJ,SUP-2126377,CDM,C1751,HCPCS,0278,RC,,,,both,,,493.29,320.64,,,,,,,,,,,,,
PLATE BNE 24 DEG L 141 X W 8.5 MM THK 1.6 MM 10 H TI RT DSTL,SUP-2932928,CDM,C1713,HCPCS,0278,RC,,,,both,,,5918.27,3846.88,,,,,,,,,,,,,
PIN FIX L9IN DIA2MM ST S STL 3 SIDE SGL TRCR 1 END PNT STYL,SUP-2150454,CDM,C1713,HCPCS,0278,RC,,,,both,,,13.69,8.90,,,,,,,,,,,,,
BIT DRL S STL W/ STP CANN DISP,SUP-2208225,CDM,2720000010,LOCAL,0272,RC,,,,both,,,659.40,428.61,,,,,,,,,,,,,
KIT ABLATION RF MULTI-COOLED 17GA 5CM ADV,SUP-2719768,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4082.00,2653.30,,,,,,,,,,,,,
PLATE BNE HK UNIV 5 HOLE NS LTX,SUP-2857096,CDM,C1713,HCPCS,0278,RC,,,,both,,,6110.44,3971.79,,,,,,,,,,,,,
CATHETER EP 6FR L120CM 2-5-2 SPC 1MM BND DECAPOLAR TORQ,SUP-2356813,CDM,C1730,HCPCS,0272,RC,,,,both,,,844.66,549.03,,,,,,,,,,,,,
PLATE BONE L216MM 13 H RT PROX HUM LCK FOR 3.5MM SCR,SUP-2348560,CDM,C1713,HCPCS,0278,RC,,,,both,,,14741.67,9582.09,,,,,,,,,,,,,
SPLINT ORTHOPEDIC W/ ABDUCTED XL 8 IN RT WRST FOREARM THMB,SUP-2276640,CDM,L3809,HCPCS,0272,RC,,,,both,,,23.05,14.98,,,,,,,,,,,,,
CATHETER DRAINAGE 6 FRX70 CM ANGLED TIP W/ GUIDEWIRE FLEXIMA,SUP-2141722,CDM,C1758,HCPCS,0278,RC,,,,both,,,86.51,56.23,,,,,,,,,,,,,
INSERT TIB THK6MM S STL UHMWPE KNEE PRI MOB SLDE COR STAR,SUP-2362575,CDM,C1776,CPT,0278,RC,,,,both,,,5821.56,3784.01,,,,,,,,,,,,,
WASHER ORTH OD7MM OLV WIRE S STL,SUP-2343821,CDM,C1713,HCPCS,0278,RC,,,,both,,,1425.43,926.53,,,,,,,,,,,,,
SCREW BONE L105MM DIA6.5MM THRD L20MM CANN GUID ASNS 2,SUP-2362442,CDM,C1713,HCPCS,0278,RC,,,,both,,,971.52,631.49,,,,,,,,,,,,,
MEPOLIZUMAB 100 MG/ML SC SOAJ,RX-146589,CDM,J2182,HCPCS,0636,RC,00173-0892-01,NDC,,both,1,ML,11320.60,7358.39,,,,,,,,,,,,,
STEM FEM SLT 13.5X220 MM HIP BOW MOD TIV POROUS PLASMA SPRY,SUP-2204348,CDM,C1776,CPT,0278,RC,,,,both,,,12572.56,8172.16,,,,,,,,,,,,,
COLLAR CERV AD H25XL19IN FIRM DENS CNTOUR HK AND LOOP CLSR,SUP-2276595,CDM,L0120,HCPCS,0272,RC,,,,both,,,8.04,5.23,,,,,,,,,,,,,
COLLAR CERV ADJ BAR FLX THERMOPLASTIC,SUP-2388137,CDM,L0190,HCPCS,0272,RC,,,,both,,,1222.12,794.38,,,,,,,,,,,,,
GRAFT BNE SUB L SZ 28 56MM 10CC B TRICALCIUM PHSPTE SYN,SUP-2194017,CDM,C1713,HCPCS,0278,RC,,,,both,,,2077.11,1350.12,,,,,,,,,,,,,
PLATE BNE L 208 MM SCREW DIA 3.5 MM 18 H SS HUM FEM TIB,SUP-2931234,CDM,C1713,HCPCS,0278,RC,,,,both,,,3277.22,2130.19,,,,,,,,,,,,,
CATHETER PTCA 5FR L130CM BLLN L100MM DIA4MM GWIRE 0.035IN,SUP-2128356,CDM,C2623,HCPCS,0278,RC,,,,both,,,5181.00,3367.65,,,,,,,,,,,,,
ALLOGRAFT BNE HD FD HUM,SUP-2321813,CDM,C1713,HCPCS,0278,RC,,,,both,,,2204.28,1432.78,,,,,,,,,,,,,
SYSTEM DEL 11 GA W/ NDL,SUP-2308558,CDM,C1713,HCPCS,0278,RC,,,,both,,,1632.80,1061.32,,,,,,,,,,,,,
CLIP HEMSTAS 135 DEG 4 MM LNG ARM ROTATABLE SHT TAIL EZ CLP,SUP-2865653,CDM,C1889,HCPCS,0278,RC,,,,both,,,648.98,421.84,,,,,,,,,,,,,
HC So Hepatitis a Antibody (Total),PX-3028670866,CDM,86708,CPT,0302,RC,,,,outpatient,,,106.00,68.90,,,,,,,,,,,,,
PROBE VITRCTMY 25GA L27MM 10000CPM CONSTELLATION ULTRAVIT,SUP-2109976,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4445.30,2889.44,,,,,,,,,,,,,
PLATE BNE L62MM 3 H S STL LOK COMPR HK FOR 3.5MM SCR LCP,SUP-2177457,CDM,C1713,HCPCS,0278,RC,,,,both,,,1962.44,1275.59,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9% BOLUS (FLUID RESUSCITATION),RX-4081440,CDM,J7050,HCPCS,0250,RC,00264-7800-20,NDC,,both,1000,ML,93.50,60.77,,,,,,,,,,,,,
TESTOSTERONE CYPIONATE 200 MG/ML IM SOLN,RX-127408,CDM,J1071,HCPCS,0636,RC,00574-0827-01,NDC,,both,0.25,ML,54.10,35.16,,,,,,,,,,,,,
ALLOGRAFT BNE SPACER 5 DEG 8X22X14 MM LORDTC PLIF,SUP-2632325,CDM,C1713,HCPCS,0278,RC,,,,both,,,7928.50,5153.52,,,,,,,,,,,,,
COLLAR CERV ADJ BAR FLX THERMOPLASTIC,SUP-2388137,CDM,L0190,HCPCS,0274,RC,,,,both,,,1222.12,794.38,,,,,,,,,,,,,
DEFIBRILLATOR IMPL VITALITY 2 DR TI 2 CHMBR STD 2 LD BPLR,SUP-2149080,CDM,C1721,HCPCS,0275,RC,,,,both,,,53223.00,34594.95,,,,,,,,,,,,,
HC Inj Thrombin for Aneurysm,PX-3613600200,CDM,36002,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
STEM FEM 12/14 5 STD OFFSET TAPR LPI PRIM,SUP-2222349,CDM,C1776,CPT,0278,RC,,,,both,,,24492.00,15919.80,,,,,,,,,,,,,
PLATE BONE MINI STERNALOCK BLU SYS,SUP-2137636,CDM,C1713,HCPCS,0278,RC,,,,both,,,2700.40,1755.26,,,,,,,,,,,,,
GRAFT HUM TISS L 3.2 X W 3.2 CM PLCNTA MEMBRN ALLGRFT,SUP-2909401,CDM,Q4160,HCPCS,0636,RC,,,,both,,,2291.57,1489.52,,,,,,,,,,,,,
NAIL IM L400MM OD13MM 125DEG LNG TIM RT HIP AG CANN LCK,SUP-2402793,CDM,C1776,CPT,0278,RC,,,,both,,,4954.92,3220.70,,,,,,,,,,,,,
PATCH CV IVENA L 30 X W 20 MM PTFE PLLW SHP,SUP-2763170,CDM,C1768,CPT,0278,RC,,,,both,,,853.11,554.52,,,,,,,,,,,,,
CATHETERIZATION KIT ART 021 22 GAX5 CM 25 GA 3 CC LF,SUP-2865596,CDM,C1751,HCPCS,0278,RC,,,,both,,,156.37,101.64,,,,,,,,,,,,,
ALLOGRAFT HUM TISS SPACER 11X13 MM PLIF TRAP VERTIGRAFT VG2,SUP-2264968,CDM,C1713,HCPCS,0278,RC,,,,both,,,8164.79,5307.11,,,,,,,,,,,,,
HC So1 Factor VIII,PX-3058524067,CDM,85240,CPT,0305,RC,,,,outpatient,,,637.00,414.05,,,,,,,,,,,,,
GUIDEWIRE VASC COON L 180 CM DIA 0.035 IN TAPR L 15 CM FLPY,SUP-2167871,CDM,C1769,HCPCS,0272,RC,,,,both,,,89.36,58.08,,,,,,,,,,,,,
SET PICC 2L 5FR X 55CM W BP,SUP-2887054,CDM,C1751,HCPCS,0278,RC,,,,both,,,945.14,614.34,,,,,,,,,,,,,
SCREW BONE L36MM DIA4.5MM CORT S STL ST NONCANNULATED,SUP-2363883,CDM,C1713,HCPCS,0278,RC,,,,both,,,72.16,46.90,,,,,,,,,,,,,
STENT PERIPH EXPRESS LD L 17 MM DIA 7 MM CATH L 75 CM DIA 6,SUP-2144310,CDM,C1876,HCPCS,0278,RC,,,,both,,,3532.50,2296.12,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9% BOLUS (FLUID RESUSCITATION),RX-4081440,CDM,2580000003,HCPCS,0250,RC,00338-0049-11,NDC,,both,1000,ML,493.00,320.45,,,,,,,,,,,,,
RETRACTOR SPNL 125INW 3IN DEPTH SHRP TAY MED LAT HND HELD,SUP-2409708,CDM,C1713,HCPCS,0278,RC,,,,both,,,393.29,255.64,,,,,,,,,,,,,
PEDIATRIC LCP(TM) HIP PLATE 5.0MM 110-STERILE,SUP-2546028,CDM,C1713,HCPCS,0278,RC,,,,both,,,2706.87,1759.47,,,,,,,,,,,,,
CATHETER INFUSION 85 CM ROTATING WIRE TIP INTRO CLARIVEIN IC,SUP-2466562,CDM,C1751,HCPCS,0278,RC,,,,both,,,1711.30,1112.34,,,,,,,,,,,,,
MESALAMINE 400 MG PO CPDR,RX-120377,CDM,6370000000,HCPCS,0637,RC,00093-5907-86,NDC,,both,1,UN,15.10,9.81,,,,,,,,,,,,,
SPHINCTEROTOME BILI 3 LUMN WIRE GUID LNG NOSE 20MM UTOM XL,SUP-2149505,CDM,2720000010,LOCAL,0272,RC,,,,both,,,387.29,251.74,,,,,,,,,,,,,
ALLOGRAFT DERMAL 2X4 CMX1.26-1.75 MM DECELL DERM ORACELL,SUP-2740797,CDM,C1762,CPT,0278,RC,,,,both,,,569.22,369.99,,,,,,,,,,,,,
GUIDE DRL AND 2MM PIN GLENOJET,SUP-2123641,CDM,2720000010,LOCAL,0272,RC,,,,both,,,624.86,406.16,,,,,,,,,,,,,
PLATE BNE UNIV 4 H STR MAXLOCK EXTRM,SUP-2400385,CDM,C1713,HCPCS,0278,RC,,,,both,,,3403.76,2212.44,,,,,,,,,,,,,
AIRWAY LARYN MASK AD SZ 4 CUF 30ML SIL SFT INFL PILOT BAL LN,SUP-2383543,CDM,2720000010,LOCAL,0272,RC,,,,both,,,708.07,460.25,,,,,,,,,,,,,
HEAD RADIAL MOD 22 LNG ELBW,SUP-2610426,CDM,C1776,CPT,0278,RC,,,,both,,,9236.25,6003.56,,,,,,,,,,,,,
SROM MILLER SHELL SZ 25,SUP-2515426,CDM,C1776,CPT,0278,RC,,,,both,,,4634.64,3012.52,,,,,,,,,,,,,
HC 3d Rendering Requiring Sep Wor,PX-3507637700,CDM,76377,CPT,0350,RC,,,,both,,,1344.00,873.60,,,,,,,,,,,,,
FEEDING TUBE KIT LP 16 FRX4 CM BLLN BUTTON MINI1,SUP-2754598,CDM,2720000010,LOCAL,0272,RC,,,,both,,,651.61,423.55,,,,,,,,,,,,,
DRILL SURG DIA2.8MM TWST CAPTURE,SUP-2244278,CDM,2720000010,LOCAL,0272,RC,,,,both,,,770.81,501.03,,,,,,,,,,,,,
SPACER SPNL W26XH10XL50MM 0DEG NONSTANDARD PEEK OPTMA LAT,SUP-2402802,CDM,C1889,HCPCS,0278,RC,,,,both,,,10362.00,6735.30,,,,,,,,,,,,,
SHEATH LENS CLN SYS 4MM 30DEG FOR STRYKR 502-477-031,SUP-2277883,CDM,C1894,HCPCS,0272,RC,,,,both,,,160.30,104.19,,,,,,,,,,,,,
DILATOR UROLOGICAL 0.038 IN 14 FR URETH PROC SHTH SET PTFE,SUP-2141687,CDM,C1726,HCPCS,0272,RC,,,,both,,,611.73,397.62,,,,,,,,,,,,,
WEDGE TIB SZ 5-6 7DEG STD FULL PRI GEN II,SUP-2345775,CDM,C1776,CPT,0278,RC,,,,both,,,2949.25,1917.01,,,,,,,,,,,,,
INFINITY POLY SZ 5 6MM TOTAL ANKLE,SUP-2827698,CDM,C1776,CPT,0278,RC,,,,both,,,4898.40,3183.96,,,,,,,,,,,,,
INSERT TIB THK9MM S STL UHMWPE PRI MOB SLDE COR STAR PGT,SUP-2362578,CDM,C1776,CPT,0278,RC,,,,both,,,3664.38,2381.85,,,,,,,,,,,,,
RONGEUR SURG LEMPERT 6.5 IN 10X2 MM LIGHT MODEL SLENDER JAW,SUP-2159922,CDM,2720000010,LOCAL,0272,RC,,,,both,,,446.16,290.00,,,,,,,,,,,,,
SYSTEM RETRV RECOVERY CONE CATH L 75 CM INTRO 10 FR VENA,SUP-2128233,CDM,C1773,HCPCS,0272,RC,,,,both,,,1868.30,1214.39,,,,,,,,,,,,,
KIT SCR L90-95MM LAG COMPR INTEGR META-TAN,SUP-2340869,CDM,C1713,HCPCS,0278,RC,,,,both,,,4096.60,2662.79,,,,,,,,,,,,,
PLATE BNE STR 2-2.5X28X1.5 MM 4 HOLE FRAC TI STRL LEVEL 1,SUP-2491647,CDM,C1713,HCPCS,0278,RC,,,,both,,,1438.87,935.27,,,,,,,,,,,,,
CATHETER HD SHT TERM 11.5 FRX18 CM FULL KINK RESIST HEMCATH,SUP-2627418,CDM,C1752,HCPCS,0278,RC,,,,both,,,732.88,476.37,,,,,,,,,,,,,
EXPANDER TISS BRST 5.7 CM PROJCT 12X11 CM 340 CC MOD HT ACX,SUP-2340086,CDM,C1789,HCPCS,0278,RC,,,,both,,,3752.30,2438.99,,,,,,,,,,,,,
TUBE VENT ARMSTR R 1.14 MM 1 MM 2.7 MM FLROPLAS STRL 520503,SUP-2535146,CDM,L8699,HCPCS,0278,RC,,,,both,,,39.72,25.82,,,,,,,,,,,,,
WIRE EXT FIX HALF 1.8X400 MM SMOOTH,SUP-2749888,CDM,C1713,HCPCS,0278,RC,,,,both,,,461.58,300.03,,,,,,,,,,,,,
ELECTRODE SUCT HIP CHSL TIP VAPR ARCTIC,SUP-2176894,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1843.18,1198.07,,,,,,,,,,,,,
PLATE BNE L106MM 4 H NONSTERILE R MED PROX TIB S STL LOK,SUP-2185666,CDM,C1713,HCPCS,0278,RC,,,,both,,,4123.20,2680.08,,,,,,,,,,,,,
DRILL SURG DIA3.2MM CORACOID STP FOR BRISTOW LATARJET,SUP-2256872,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2000.18,1300.12,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 2X1 CM TERMINALLY STRL WND NEOX CRD RT,SUP-2648694,CDM,Q4148,HCPCS,0636,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
BEAM FIX L70MM DIA6.5MM ARTH FOR CHARCOT DEFORMITY AXIS,SUP-2223944,CDM,C1776,CPT,0278,RC,,,,both,,,4239.00,2755.35,,,,,,,,,,,,,
CATHETER PACE ARW L 110 CM DIA 5 FR BALLOON DIA 7 MM INTRO 6,SUP-2383249,CDM,C1713,HCPCS,0278,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
LANREOTIDE ACETATE 120 MG/0.5ML SC SOLN,RX-87861,CDM,J1930,HCPCS,0636,RC,15054-1120-04,NDC,,both,0.5,ML,28207.90,18335.13,,,,,,,,,,,,,
SYSTEM PROX SEAL DEL DEV AND LOADER HEARTSTRING II,SUP-2266053,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1527.99,993.19,,,,,,,,,,,,,
DURACON ALL POLY TIB L1 13MM,SUP-2364903,CDM,C1776,CPT,0278,RC,,,,both,,,3782.88,2458.87,,,,,,,,,,,,,
INTRODUCER HEMSTAS MAXIMUMXTRA 5.5FRX12CM SHTH W/ 0.038 IN,SUP-2355575,CDM,C1894,HCPCS,0272,RC,,,,both,,,26.69,17.35,,,,,,,,,,,,,
PURAPLY 2X4CM 8SQ CM,SUP-2314121,CDM,Q4195,HCPCS,0636,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
IMMOBILIZER ORTH XSM SHLDR,SUP-2196914,CDM,L3660,HCPCS,0272,RC,,,,both,,,12.59,8.18,,,,,,,,,,,,,
BOOT TRACTION LOOP LCK CLOSURE MED ECON BUCK,SUP-2336328,CDM,L4398,HCPCS,0274,RC,,,,both,,,28.29,18.39,,,,,,,,,,,,,
PLATE BNE 6X2 H LOK BILAT GRID TRAPEOID HND DISP FOR 2MM,SUP-2267933,CDM,C1713,HCPCS,0278,RC,,,,both,,,1479.57,961.72,,,,,,,,,,,,,
CATHETER ELECHEMSTAS 7FR L300CM CHN 2.8MM STD CONN DISP G,SUP-2149699,CDM,2720000010,LOCAL,0272,RC,,,,both,,,394.42,256.37,,,,,,,,,,,,,
CATHETER IRRIGATION L 80 CM DIA 4 FR FOR VASC CLOT MGMT STRL,SUP-2119768,CDM,C1757,HCPCS,0272,RC,,,,both,,,81.48,52.96,,,,,,,,,,,,,
LINER ACET OD68MM ID28MM HIP MARATHON LIP SNAP IN REV PINN,SUP-2250381,CDM,C1776,CPT,0278,RC,,,,both,,,3850.90,2503.08,,,,,,,,,,,,,
SET AUTOTRNS 10L 120UM ATF FAST COLLCTN RESVR SUCT LN W/,SUP-2385070,CDM,C1713,HCPCS,0278,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
PLATE BNE L 79.8 X W 17.4 MM THK 1.65 MM SCREW DIA2.5 MM TIM,SUP-2885133,CDM,C1713,HCPCS,0278,RC,,,,both,,,2115.17,1374.86,,,,,,,,,,,,,
TUBE ENTRL FEED GASTRO-JEJUNAL 16 FRX30 CM 1.5 CM 3-5 CC,SUP-2764494,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1055.20,685.88,,,,,,,,,,,,,
PLATE BONE 130DEG 6 H PROX FEM LCK FOR 3.5MM SCR PEDILOC,SUP-2318558,CDM,C1713,HCPCS,0278,RC,,,,both,,,7899.61,5134.75,,,,,,,,,,,,,
PIN HALF THRD 5X180 MM,SUP-2197301,CDM,2720000010,LOCAL,0272,RC,,,,both,,,678.24,440.86,,,,,,,,,,,,,
PLATELET CONCENTRATION KIT ARTERIOCYTE SEP MAGELLAN PRP,SUP-2120696,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED CEM TRIATHLON K15] STRYKER CORP],SUP-2365626,CDM,C1776,CPT,0278,RC,,,,both,,,15438.44,10034.99,,,,,,,,,,,,,
SCREW BNE LCK 2.7X28 MM CORTICAL NS,SUP-2423259,CDM,C1713,HCPCS,0278,RC,,,,both,,,350.42,227.77,,,,,,,,,,,,,
PARTICLE EMB SZ 250-500UM POLYVI ALC N RADIOACTIVE CNTOUR 2,SUP-2148441,CDM,C1889,HCPCS,0278,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
GRAFT VASC FLIXENE L 45 CM DIA 5-8 MM EPTFE TAPR REINF 3,SUP-2681857,CDM,C1768,CPT,0278,RC,,,,both,,,3111.39,2022.40,,,,,,,,,,,,,
GRAFT BNE PTTY 2.5 CC OSTEOSURGE 300C,SUP-2644324,CDM,C1713,HCPCS,0278,RC,,,,both,,,2034.72,1322.57,,,,,,,,,,,,,
TRIAL KNEE SZ 2 THK8MM DST FEM AUG REV WDG FOR MOB BEAR TIB,SUP-2436186,CDM,2720000010,LOCAL,0272,RC,,,,both,,,637.42,414.32,,,,,,,,,,,,,
ANCHOR SUTURE DIA 4.75 MM SUTURE TAPE W 1.4 MM BIOCOMP 2,SUP-2907016,CDM,C1713,HCPCS,0278,RC,,,,both,,,1394.16,906.20,,,,,,,,,,,,,
IMPLANT COSMETIC SZ 25 X 50 X 6 MM POLYETHYL BLOCK STRL DISP,SUP-2935699,CDM,C1713,HCPCS,0278,RC,,,,both,,,2201.14,1430.74,,,,,,,,,,,,,
SHEATH CLEARPETRA NEPHROSTOMY 18/20FR 21CM,SUP-2874892,CDM,2720000010,LOCAL,0272,RC,,,,both,,,810.12,526.58,,,,,,,,,,,,,
SEED BRACHYTHERAPY LOAD 4.01-5.0 MCI STRL ADVANTAGE 2029ELS2] ISOAID LLC],SUP-2247270,CDM,C2642,HCPCS,0278,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
PLATE BNE CNDYL MINI 1.5 MM LT 6 HOLE,SUP-2346879,CDM,C1713,HCPCS,0278,RC,,,,both,,,424.53,275.94,,,,,,,,,,,,,
MESH SURG W6.4XL6.4CM CIR VENTRAL PTCH FOR TISS SEPARATING,SUP-2219820,CDM,C1781,HCPCS,0278,RC,,,,both,,,1586.99,1031.54,,,,,,,,,,,,,
HC Prealbumin,PX-3018413400,CDM,84134,CPT,0301,RC,,,,both,,,379.00,246.35,,,,,,,,,,,,,
DRESSING BIO 500 MG TYP I/III BOV CLLGN MTRX FIBRILLAR SHLF,SUP-2905505,CDM,C1763,HCPCS,0278,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
PLATE BONE FEMORAL 4.5X234 MM LEFT PROXIMAL 9 HOLE LOCKING F,SUP-2837598,CDM,C1713,HCPCS,0278,RC,,,,both,,,11726.33,7622.11,,,,,,,,,,,,,
LACTATED RINGERS IV SOLN,RX-4318,CDM,J7120,HCPCS,0258,RC,00264-7750-00,NDC,,both,1000,ML,25.50,16.57,,,,,,,,,,,,,
CATHETER DEL CARR L 152 CM SM HYDRPHLC 1 LUMEN COMP VAR PK 1,SUP-2912477,CDM,C1887,HCPCS,0272,RC,,,,both,,,6892.30,4479.99,,,,,,,,,,,,,
PLATE BNE DBL ANGLED SM 2 MM RECON MAXILLA PT SPEC,SUP-2860081,CDM,C1713,HCPCS,0278,RC,,,,both,,,26314.46,17104.40,,,,,,,,,,,,,
PLATE EXT FIX DIA160MM ANK FT DBL ROW TL HEX,SUP-2417463,CDM,C1713,HCPCS,0278,RC,,,,both,,,6764.31,4396.80,,,,,,,,,,,,,
COMPONENT FEM W11XL21.5MM TAPR POST DISP FOR RESURF SYS,SUP-2123692,CDM,C1776,CPT,0278,RC,,,,both,,,1852.60,1204.19,,,,,,,,,,,,,
FENTANYL AND BUPIVACAINE (OB) EPIDURAL 100 ML,RX-4081586,CDM,2500000003,HCPCS,0250,RC,09999-9912-76,NDC,,both,100,ML,54.10,35.16,,,,,,,,,,,,,
GRAFT BIO TISS 20X20CM LAPSCP STRATTICE,SUP-2113220,CDM,Q4130,HCPCS,0636,RC,,,,both,,,38458.72,24998.17,,,,,,,,,,,,,
"HC So Dna Quantification, Each",PX-3068779966,CDM,87799,CPT,0306,RC,,,,both,,,267.00,173.55,,,,,,,,,,,,,
STAPLE BNE FIX BRDG W25MM LEG L22X22MM NIT NONBIOABSORBABLE,SUP-2194229,CDM,C1713,HCPCS,0278,RC,,,,both,,,4600.10,2990.06,,,,,,,,,,,,,
DRILL SURG 3.4X160 MM FOR 5 MM HALF PIN,SUP-2749965,CDM,2720000010,LOCAL,0272,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
CATHETER CV FULL SAFETY TY 032 7 FRX25 CM 13 GA 3L SPECTRUM,SUP-2759869,CDM,C1751,HCPCS,0278,RC,,,,both,,,474.64,308.52,,,,,,,,,,,,,
STENT URET SOF-CURL 360 DEG L 30 CM DIA 7 FR TECOFLEX NYL,SUP-2460737,CDM,C2617,HCPCS,0278,RC,,,,both,,,211.17,137.26,,,,,,,,,,,,,
BUR SURG 45MMX19CM PREBENT SPHR HIP PRESERVATION SYS,SUP-2167162,CDM,2720000010,LOCAL,0272,RC,,,,both,,,774.01,503.11,,,,,,,,,,,,,
BRACE KNEE HNG LAT L L OA ADJ 3,SUP-2196482,CDM,L1852,HCPCS,0272,RC,,,,both,,,1314.40,854.36,,,,,,,,,,,,,
SPACER SPNL W27XH16XL37MM 12DEG TI ANT LUM INTBDY FUS SCR,SUP-2289229,CDM,C1713,HCPCS,0278,RC,,,,both,,,13423.50,8725.27,,,,,,,,,,,,,
BRIVARACETAM 50 MG/5ML IV SOLN,RX-133987,CDM,2500000003,HCPCS,0250,RC,50474-0970-75,NDC,,both,2.5,ML,181.50,117.97,,,,,,,,,,,,,
CROWN DENT 5 S STL SEC PRI M LO RT ANTR CUSPID PREFABRICATED,SUP-2238830,CDM,D6783,CPT,0278,RC,,,,both,,,27.82,18.08,,,,,,,,,,,,,
MATRIX BNE EXTRACELLULAR REP STEM CELL OVATION 0.3ML,SUP-2319180,CDM,C1713,HCPCS,0278,RC,,,,both,,,5325.44,3461.54,,,,,,,,,,,,,
SLEEVE SURG PERC 2.7 MM UNIV LCK SYS,SUP-2534561,CDM,C1713,HCPCS,0278,RC,,,,both,,,413.98,269.09,,,,,,,,,,,,,
HC Fresh Frozen Plasma Thawing,PX-3008692700,CDM,86927,CPT,0300,RC,,,,inpatient,,,247.00,160.55,,,,,,,,,,,,,
CATHETER CTRL VEN AD 5FR L16CM POLYUR SGL LUMN N TUNNELED,SUP-2120605,CDM,C1751,HCPCS,0278,RC,,,,both,,,42.39,27.55,,,,,,,,,,,,,
PLATE BONE L100MM 5 H BILAT TI SPN LCK COMPR LO PROF RIG FOR,SUP-2190887,CDM,C1713,HCPCS,0278,RC,,,,both,,,1092.25,709.96,,,,,,,,,,,,,
SCREW INTRF L12MM DIA6MM BIOCRYL RAPIDE ABSRB MILAGRO,SUP-2256772,CDM,C1713,HCPCS,0278,RC,,,,both,,,1563.72,1016.42,,,,,,,,,,,,,
RETRIEVER SNR CATH L 152 CM DIA 3 FR VASC MULTIUSE STRL,SUP-2368064,CDM,C1773,HCPCS,0272,RC,,,,both,,,11209.80,7286.37,,,,,,,,,,,,,
GRAFT BONE L15XW12XH8MM 5DEG UNIV PEEK TI COMP SPCR ANTR,SUP-2317061,CDM,C1713,HCPCS,0278,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
GRAFT DERM L6.3XW3.1IN ACELLULAR HUM DERM NONCROSSLINKED ST,SUP-2125865,CDM,C1781,HCPCS,0278,RC,,,,both,,,20817.26,13531.22,,,,,,,,,,,,,
HC So1 Creatine Kinase (CK) Mb,PX-3018255367,CDM,82553,CPT,0301,RC,,,,both,,,41.00,26.65,,,,,,,,,,,,,
CATHETER CV FULL SAFETY TY 032 8 FRX15 CM 3L SPECTRUM,SUP-2759803,CDM,C1751,HCPCS,0278,RC,,,,both,,,489.90,318.43,,,,,,,,,,,,,
PLATE BNE L68MM 5 H 1 3RD TBLR LOK FOR 3.5MM SCR UNIV LOK,SUP-2411367,CDM,C1713,HCPCS,0278,RC,,,,both,,,455.39,296.00,,,,,,,,,,,,,
SCREW BNE SNAP OFF 2X13 MM,SUP-2175087,CDM,C1713,HCPCS,0278,RC,,,,both,,,1059.75,688.84,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 260 MM DIA15 MM DEL SHTH,SUP-2934499,CDM,C1713,HCPCS,0278,RC,,,,both,,,19350.72,12577.97,,,,,,,,,,,,,
STEM HIP PATIENT SPEC,SUP-2165897,CDM,C1776,CPT,0278,RC,,,,both,,,7818.60,5082.09,,,,,,,,,,,,,
CAGE SPNL C 20 MM EXPANDABLE CORPECTOMY T2 STRATOSPHERE,SUP-2423275,CDM,C1889,HCPCS,0278,RC,,,,both,,,20410.00,13266.50,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY SPC 5 MM SM ANAT DIAG STRL,SUP-2248648,CDM,C1730,HCPCS,0272,RC,,,,both,,,1384.74,900.08,,,,,,,,,,,,,
KIT INSRT 40ML INT AORT CATH OD9.5FR 650MM 90 SER EXT,SUP-2227307,CDM,C1713,HCPCS,0278,RC,,,,both,,,2056.70,1336.85,,,,,,,,,,,,,
HC Cv Cath Plac W/Port Tun >5,PX-3613656100,CDM,36561,CPT,0361,RC,,,,both,,,10303.00,6696.95,,,,,,,,,,,,,
CATHETER EP LG CURL 4 MM TIP SAFIRE TX,SUP-2357027,CDM,C1733,HCPCS,0272,RC,,,,both,,,2072.40,1347.06,,,,,,,,,,,,,
CATHETER HD PRECRV 15.5 FRX32 CM LT DL FULL SET TITAN HD,SUP-2627363,CDM,C1750,HCPCS,0278,RC,,,,both,,,78.50,51.02,,,,,,,,,,,,,
PORT INFUS ODSEC66FR PLAS NONPOWERED SGL LUMN NONFILLED SUT,SUP-2127729,CDM,C1788,HCPCS,0278,RC,,,,both,,,609.16,395.95,,,,,,,,,,,,,
COMPONENT TOT HIP 1 PRIMARY,SUP-2378853,CDM,C1776,CPT,0278,RC,,,,both,,,16642.00,10817.30,,,,,,,,,,,,,
BIT DRL DIA4.0MM LNG HUM AO DISP SURESHOT,SUP-2340921,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1324.92,861.20,,,,,,,,,,,,,
ALLOGRAFT BNE MACHINED 10MMX3IN PLIF PUROS,SUP-2684813,CDM,C1713,HCPCS,0278,RC,,,,both,,,10343.16,6723.05,,,,,,,,,,,,,
DRILL SURG 1.8 MM HRD BNE STRL MICRORAPTOR LTX,SUP-2879944,CDM,2720000010,LOCAL,0272,RC,,,,both,,,631.14,410.24,,,,,,,,,,,,,
UPCHARGE KNEE PRIMARY ATTUNE AOX INSERT DEPUY SYNTHES,SUP-2501359,CDM,C1776,CPT,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
HC N Block Paravert Thoracic 2nd,PX-3606449100,CDM,64491,CPT,0360,RC,,,,both,,,3892.00,2529.80,,,,,,,,,,,,,
IMPULSE TIG45 SGL,SUP-2664316,CDM,C1887,HCPCS,0272,RC,,,,both,,,31.40,20.41,,,,,,,,,,,,,
SCREW SPNL MONOAX 5.5X40 MM 4.5 MM SS,SUP-2630570,CDM,C1713,HCPCS,0278,RC,,,,both,,,4436.82,2883.93,,,,,,,,,,,,,
CABLE SPNL DIA12MM ST S STL SGL LOOP W BAR CRMP SONGER,SUP-2255760,CDM,C1713,HCPCS,0278,RC,,,,both,,,62.80,40.82,,,,,,,,,,,,,
BIT DRL CHK END BNE ACL PLUG SUTURE JCBS STRL DISP,SUP-2608081,CDM,2720000010,LOCAL,0272,RC,,,,both,,,314.75,204.59,,,,,,,,,,,,,
PATCH BIO TISS W60XL80MM BOV PERICARD GLUTARHYD CROSS LINKED,SUP-2130365,CDM,C1768,CPT,0278,RC,,,,both,,,1806.85,1174.45,,,,,,,,,,,,,
SPACER SPNL SM H12MM 24X32MM FOOTPRINT 7DEG ANTR LUM PEEK,SUP-2415807,CDM,C1713,HCPCS,0278,RC,,,,both,,,8164.00,5306.60,,,,,,,,,,,,,
TIP ULTRASONIC L280MM TIP L12.8MM OD1.95MM ID1.50MM REPL,SUP-2243012,CDM,C1713,HCPCS,0278,RC,,,,both,,,2927.11,1902.62,,,,,,,,,,,,,
SCREW INTFR L16MM DIA8MM BOLT TENODESIS FOR PROX BICEPS REP,SUP-2417350,CDM,C1713,HCPCS,0278,RC,,,,both,,,1417.27,921.23,,,,,,,,,,,,,
LINER ACET 15 DEG STD POLYETH 36MM SZ H ACUMATCH,SUP-2221921,CDM,C1776,CPT,0278,RC,,,,both,,,3265.60,2122.64,,,,,,,,,,,,,
PIN FIX DOCKING 3.3X20 MM,SUP-2232044,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
STEM XL TAPER 18X185MM,SUP-2505009,CDM,C1776,CPT,0278,RC,,,,both,,,8025.84,5216.80,,,,,,,,,,,,,
PLATE BNE STRNL 2.3X1.8 MM THOR 4 HOLE LCK ANGLE NS LEVEL 1,SUP-2869248,CDM,C1713,HCPCS,0278,RC,,,,both,,,461.05,299.68,,,,,,,,,,,,,
GUIDEWIRE VASC CONFIANZA PRO 9 L 300 CM DIA 0.014 IN,SUP-2123737,CDM,C1769,HCPCS,0272,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
TITANIUM FXTN SCREW KNRLD HEAD 55MM RD II DVCE,SUP-2676923,CDM,C1713,HCPCS,0278,RC,,,,both,,,532.42,346.07,,,,,,,,,,,,,
HC Malaria Prep,PX-3008720700,CDM,87207,CPT,0300,RC,,,,both,,,229.00,148.85,,,,,,,,,,,,,
HC So Sugars Qual,PX-3018437766,CDM,84377,CPT,0301,RC,,,,both,,,81.00,52.65,,,,,,,,,,,,,
Z DUP USE 2111325 LENS INTOCU +20.0 DIOPT L13MM DIA6MM 0DEG HAPTIC ANG A,SUP-2111326,CDM,V2632,HCPCS,0276,RC,,,,both,,,442.74,287.78,,,,,,,,,,,,,
TRAY GASTSTMY L17CM L12CM OD14FR SIL RADPQ STRL DISP PERC,SUP-2168068,CDM,C1713,HCPCS,0278,RC,,,,both,,,753.60,489.84,,,,,,,,,,,,,
NAIL IM L38CM DIA12MM 130DEG LT FEM HIP GRN TI CANN LCK AG,SUP-2347903,CDM,C1713,HCPCS,0278,RC,,,,both,,,5764.10,3746.66,,,,,,,,,,,,,
HEAD SPNL SCREW ROD DIA 4.75/5 MM REDUCTION UNIAXIAL STRL CD 2PK,SUP-2928052,CDM,C1713,HCPCS,0278,RC,,,,both,,,5212.40,3388.06,,,,,,,,,,,,,
PLATE BNE FEM 3.5/4.5X354 MM RT PROX 11 HOLE NS VA-LCP,SUP-2757666,CDM,C1713,HCPCS,0278,RC,,,,both,,,8271.55,5376.51,,,,,,,,,,,,,
BUR SURG L75CM DIA5MM DMND LEGEND MIDAS REX,SUP-2279702,CDM,2720000010,LOCAL,0272,RC,,,,both,,,403.11,262.02,,,,,,,,,,,,,
PLATE BONE L150MM 90DEG 2 H SUPCNDYL TUBE FRELOK,SUP-2197716,CDM,C1713,HCPCS,0278,RC,,,,both,,,1771.87,1151.72,,,,,,,,,,,,,
NEXGEN STRAIGHT STEM EXT 15MM DIA X 200MM(155MM),SUP-2503202,CDM,C1776,CPT,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
GRAFT VASCULAR PATCH 1X14CM TAPERED,SUP-2713906,CDM,C1768,CPT,0278,RC,,,,both,,,1409.86,916.41,,,,,,,,,,,,,
ALLOGRAFT HUM TISS ALLOPATCH PLIABLE 2X2CM,SUP-2307618,CDM,Q4128,HCPCS,0636,RC,,,,both,,,979.68,636.79,,,,,,,,,,,,,
KIT KNEE IMPL CAPPED K3 HYBRID K3ZIMMERBIOMET,SUP-2431895,CDM,C1776,CPT,0278,RC,,,,both,,,11147.00,7245.55,,,,,,,,,,,,,
INSERT TIB THICKNESS 11MM SM CNDYL KNEE PRI STBL NEUT UNIV,SUP-2377405,CDM,C1776,CPT,0278,RC,,,,both,,,2403.98,1562.59,,,,,,,,,,,,,
LEAD DEFIB RELIANCE SG ACTIVE FIX STRL,SUP-2139725,CDM,C1777,HCPCS,0275,RC,,,,both,,,8691.52,5649.49,,,,,,,,,,,,,
KIT DISP W/ SPEAR DRL AND TENSIONER CUT FOR KNOTLESS,SUP-2121610,CDM,2720000010,LOCAL,0272,RC,,,,both,,,926.30,602.09,,,,,,,,,,,,,
STEM FEM L160MM DIA20MM PRESSFIT BILAT PRI STD OFFSET STR,SUP-2210351,CDM,C1776,CPT,0278,RC,,,,both,,,18411.39,11967.40,,,,,,,,,,,,,
CATH REPROC EP INQUIRY STRBL DECAPLR 2-5-2MM LG CRV 6FR 110CM,SUP-2526274,CDM,C1730,HCPCS,0272,RC,,,,both,,,958.05,622.73,,,,,,,,,,,,,
BIT DRL L125MM DIA2.7MM QUIK CPL 3 FLUT,SUP-2187589,CDM,2720000010,LOCAL,0272,RC,,,,both,,,318.21,206.84,,,,,,,,,,,,,
GRAFT RECT XENMATRIX 4 IN X 8 IN,SUP-2126240,CDM,C1781,HCPCS,0278,RC,,,,both,,,19889.07,12927.90,,,,,,,,,,,,,
TUBE IRRIGATION HI FLO ANSPACH EMAX2,SUP-2265795,CDM,2720000010,LOCAL,0272,RC,,,,both,,,377.59,245.43,,,,,,,,,,,,,
HC Assay of Magnesium|NOT REASONABLE AND NECESSARY,PX-3018373500,CDM,83735,CPT,0301,RC,,,GZ,both,,,122.00,79.30,,,,,,,,,,,,,
RETRACTOR OMNI-TRACT POST LUM COMPLT,SUP-2305866,CDM,C1713,HCPCS,0278,RC,,,,both,,,39727.28,25822.73,,,,,,,,,,,,,
SHELL ACET 46 MM FEM HIP MTL,SUP-2202535,CDM,C1776,CPT,0278,RC,,,,both,,,8314.72,5404.57,,,,,,,,,,,,,
VALVE HYDROCEPHALUS PEDIATRIC WITH BURR HOLE RESERVOIR PROGA,SUP-2826123,CDM,C1889,HCPCS,0278,RC,,,,both,,,7946.46,5165.20,,,,,,,,,,,,,
CAPSULE ENDO IMAG SM BWL SB3,SUP-2227942,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8829.68,5739.29,,,,,,,,,,,,,
CATHETER THROMCTMY LATIS L 80 CM DIA 4 FR PEBAX PTFE GRFT,SUP-2119468,CDM,C1757,HCPCS,0272,RC,,,,both,,,391.12,254.23,,,,,,,,,,,,,
PLATE BNE 12.5 DEG RT STRL AXI+LINE LTX,SUP-2861969,CDM,C1713,HCPCS,0278,RC,,,,both,,,3492.94,2270.41,,,,,,,,,,,,,
FEM OPENG WEDG OSTEOTOME PLT 9MM,SUP-2811471,CDM,C1713,HCPCS,0278,RC,,,,both,,,2606.20,1694.03,,,,,,,,,,,,,
"HC So Encephalitis, St.Louis",PX-3028665366,CDM,86653,CPT,0302,RC,,,,both,,,34.00,22.10,,,,,,,,,,,,,
STEM FEM 17 MM LT KNEE ANAT,SUP-2204193,CDM,C1776,CPT,0278,RC,,,,both,,,5463.60,3551.34,,,,,,,,,,,,,
SCREW BNE L5MM DIA15MM TI SELF DRL FULL THRD CRSS PIN COR,SUP-2366091,CDM,C1713,HCPCS,0278,RC,,,,both,,,209.19,135.97,,,,,,,,,,,,,
PLATE BNE THK2MM 32 H MAND TI ANG LOK RECON FOR 23MM SCR,SUP-2262974,CDM,C1713,HCPCS,0278,RC,,,,both,,,6214.91,4039.69,,,,,,,,,,,,,
VALVE ENDOSCP ASPIR FOR BRONCHOSCOPES OES 20,SUP-2313339,CDM,2720000010,LOCAL,0272,RC,,,,both,,,454.95,295.72,,,,,,,,,,,,,
STENT BILI S.M.A.R.T. CTRL L 80 MM DIA10 MM DEL SYS L 80 CM,SUP-2158631,CDM,C1876,HCPCS,0278,RC,,,,both,,,2731.80,1775.67,,,,,,,,,,,,,
SET URET STENT MARD L 22 CM DIA 6 FR PERCFLX HYDROPLUS TEMP,SUP-2141627,CDM,C1876,HCPCS,0278,RC,,,,both,,,417.62,271.45,,,,,,,,,,,,,
BLADE SAW L 31 X W 9 MM THK 0.51 MM ORTHOCIRCLE STRL DISP,SUP-2881142,CDM,2720000010,LOCAL,0272,RC,,,,both,,,354.04,230.13,,,,,,,,,,,,,
COMPONENT FEM L11MM KNEE HNG BOLT W/ SL LEGION,SUP-2346259,CDM,C1776,CPT,0278,RC,,,,both,,,3303.28,2147.13,,,,,,,,,,,,,
CLOBETASOL PROPIONATE 0.05 % EX GEL,RX-13203,CDM,6370000000,HCPCS,0637,RC,51672-1294-01,NDC,,both,15,GR,161.20,104.78,,,,,,,,,,,,,
HC Splint App/Short Leg,PX-4502951500,CDM,29515,CPT,0450,RC,,,,inpatient,,,497.00,323.05,,,,,,,,,,,,,
EPINEPHRINE-NACL 5-0.9 MG/250ML-% IV SOLN,RX-151011,CDM,J0163,HCPCS,0636,RC,42023-0434-10,NDC,,both,250,ML,287.50,186.87,,,,,,,,,,,,,
ANCHOR SUT DIA5.5MM PEEK KNOTLESS HEALIX ADV,SUP-2249441,CDM,C1713,HCPCS,0278,RC,,,,both,,,1356.48,881.71,,,,,,,,,,,,,
PLATE FT CARBONLONG FOR RNG FIX SYS 160MM,SUP-2365270,CDM,C1713,HCPCS,0278,RC,,,,both,,,2496.30,1622.59,,,,,,,,,,,,,
CHOLANGIOGRAM KIT 450 CM AUTOTOME RX 44 SPHINTOM JAGWIRE,SUP-2525312,CDM,C1769,HCPCS,0272,RC,,,,both,,,876.06,569.44,,,,,,,,,,,,,
PLATE BNE L230MM 10 H L DST LAT FEM S STL LOK FOR 4.5MM SCR,SUP-2348211,CDM,C1713,HCPCS,0278,RC,,,,both,,,13934.54,9057.45,,,,,,,,,,,,,
PLATE BONE L160MM 8 H LT MEDL DSTL TIB LCK FOR 3.5MM SCR,SUP-2348245,CDM,C1713,HCPCS,0278,RC,,,,both,,,16782.36,10908.53,,,,,,,,,,,,,
HEAD FEM 5 MM HIP ALUMINIUM,SUP-2364874,CDM,C1776,CPT,0278,RC,,,,both,,,3956.40,2571.66,,,,,,,,,,,,,
MESH HERN W10XL12IN RECT FULL RESRB SCFLD MFIL ABSRB - ORDER BY CASE,SUP-2126271,CDM,C1781,HCPCS,0278,RC,,,,both,,,35168.00,22859.20,,,,,,,,,,,,,
ELECTRODE SUCTION SPATULA 5 MMX45 CM W/ VLV,SUP-2850571,CDM,2720000010,LOCAL,0272,RC,,,,both,,,934.78,607.61,,,,,,,,,,,,,
HC Drain Rectal Abscess,PX-4504500500,CDM,45005,CPT,0450,RC,,,,both,,,1217.00,791.05,,,,,,,,,,,,,
STENT TRACHBRONCH WSTNT L 20 MM DIA12 MM SHTH 9 FR CATH L,SUP-2147049,CDM,C1876,HCPCS,0278,RC,,,,both,,,5181.00,3367.65,,,,,,,,,,,,,
SET INTUB W/ RAPI-FIT ADPT FOR REPL OF ET TUBE CATH 6FR,SUP-2168499,CDM,2720000010,LOCAL,0272,RC,,,,both,,,642.82,417.83,,,,,,,,,,,,,
PLATE BNE L240MM ALUMINUM BRDG FOR 5 8 RNG MAXFRAME,SUP-2176973,CDM,C1713,HCPCS,0278,RC,,,,both,,,4903.14,3187.04,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED CEM SCREW PIN HI FLX HXLPE TI,SUP-2212710,CDM,C1776,CPT,0278,RC,,,,both,,,27240.66,17706.43,,,,,,,,,,,,,
ALLOGRAFT HUMAN TISSUE SALERA 2CM X 2CM DEHYDRATED,SUP-2907552,CDM,C1762,CPT,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
PROSTHESIS OSS EAR 3.2 MM TORP W/ CRDL,SUP-2312770,CDM,L8613,CPT,0278,RC,,,,both,,,975.25,633.91,,,,,,,,,,,,,
PLATE BONE W10XL94MM THK2.8MM 8 H S STL STR NONCOMPRESSION,SUP-2343765,CDM,C1713,HCPCS,0278,RC,,,,both,,,3761.56,2445.01,,,,,,,,,,,,,
PLATE BONE CRANIAL 4 HOLE STRAIGHT 24.4X3.4MM TITANIUM NEURO,SUP-2827190,CDM,C1713,HCPCS,0278,RC,,,,both,,,99.85,64.90,,,,,,,,,,,,,
PIN BOLT APEX 3 6MM,SUP-2499937,CDM,2720000010,LOCAL,0272,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
HC Neg Pressure Wnd <= 50 Sq Cm Disposable,PX-7619760700,CDM,97607,CPT,0761,RC,,,,inpatient,,,813.00,528.45,,,,,,,,,,,,,
BUR SURG 3500-5000RPM COARSE GRIT HYDROBRADER,SUP-2284174,CDM,C1713,HCPCS,0278,RC,,,,both,,,831.47,540.46,,,,,,,,,,,,,
KIT EXT REAR TIP NAR BASE TI,SUP-2165317,CDM,C1813,HCPCS,0278,RC,,,,both,,,1403.58,912.33,,,,,,,,,,,,,
CABLE EP L150CM BLK 24K GLD PLT PINS EXTN CONN DUO DECAPOLAR,SUP-2356880,CDM,C1730,HCPCS,0272,RC,,,,both,,,527.52,342.89,,,,,,,,,,,,,
NAIL IM RETROGRADE 5 DEG 12X280 MM FEM TI STRL RFNADVANCED,SUP-2789410,CDM,C1713,HCPCS,0278,RC,,,,both,,,5404.03,3512.62,,,,,,,,,,,,,
GRAFT BNE STRP LG 100X25X6 MM 30 CC SCAFFOLD ATTRAX,SUP-2736498,CDM,C1713,HCPCS,0278,RC,,,,both,,,11775.00,7653.75,,,,,,,,,,,,,
WEDGE TIB SZ 1-2 MEDL LAT PRI GEN II,SUP-2346050,CDM,C1776,CPT,0278,RC,,,,both,,,2530.84,1645.05,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED PRSS FT STEM HD SHELL TRAB MEL CERM,SUP-2212728,CDM,C1776,CPT,0278,RC,,,,both,,,16128.61,10483.60,,,,,,,,,,,,,
PLATE BNE 2.7X44 MM 5 HOLE SS DCP,SUP-2569127,CDM,C1713,HCPCS,0278,RC,,,,both,,,257.32,167.26,,,,,,,,,,,,,
PLATE BNE W10.3XL111.6MM THK3.7MM 8 H TI LOK COMPR LO PROF,SUP-2413708,CDM,C1713,HCPCS,0278,RC,,,,both,,,885.48,575.56,,,,,,,,,,,,,
HC Urea Breath Test C-14 Isotopic Acquisj Analysis,PX-3417826700,CDM,78267,CPT,0341,RC,,,,both,,,1160.00,754.00,,,,,,,,,,,,,
DRESSING WND W8XL10IN CROSSLINKED BOV TEND CLLGN,SUP-2243935,CDM,Q4104,HCPCS,0636,RC,,,,both,,,35084.60,22804.99,,,,,,,,,,,,,
SCREW BNE CONN CANN W/ INT THRD FOR PERC INSRTN HNDL NS,SUP-2799750,CDM,C1713,HCPCS,0278,RC,,,,both,,,1420.76,923.49,,,,,,,,,,,,,
CATHETER ANGIOPLSTY OTW 14 ATM 4/6 FRX150 CM 3X220 MM COYOTE,SUP-2145622,CDM,C1725,HCPCS,0272,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
APPLIER TKR SYS W/ MAL GRFT RETRCT FOR OMNISPAN MENISCI REP,SUP-2252748,CDM,C1769,HCPCS,0272,RC,,,,both,,,687.66,446.98,,,,,,,,,,,,,
FORM CRWN 30 UP 18UP LAT AND 12 STRP OFF,SUP-2238329,CDM,D6783,CPT,0278,RC,,,,both,,,4.11,2.67,,,,,,,,,,,,,
PIN FIX TRCR PT 1 END 0.156X9 IN RND END SS NS STEINMANN,SUP-2791817,CDM,C1713,HCPCS,0278,RC,,,,both,,,38.94,25.31,,,,,,,,,,,,,
GRAFT BNE WDG 8 DEG 8 MM LAPIDUS,SUP-2321726,CDM,C1713,HCPCS,0278,RC,,,,both,,,5418.95,3522.32,,,,,,,,,,,,,
WIRE EXT FIX L360MM DIA2MM OLV,SUP-2197298,CDM,2720000010,LOCAL,0272,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
PLATE BNE 0.8 MM HND OFFSET STRL,SUP-2518382,CDM,C1713,HCPCS,0278,RC,,,,both,,,1381.60,898.04,,,,,,,,,,,,,
BRACE WLK M M 5.5-10 FEM 6.5-11 SFT NYL FOAM LNR LO PROF,SUP-2197141,CDM,L4350,HCPCS,0274,RC,,,,both,,,84.62,55.00,,,,,,,,,,,,,
SCREW BONE L90MM DIA3.5MM S STL CORT ST VAR ANG,SUP-2348269,CDM,C1713,HCPCS,0278,RC,,,,both,,,250.35,162.73,,,,,,,,,,,,,
NEEDLE NERVE BLOCK ASPIRATION 13 GA INTRAOSSEOUS BIOPLASTY,SUP-2836588,CDM,2720000010,LOCAL,0272,RC,,,,both,,,664.11,431.67,,,,,,,,,,,,,
SMALL SQC CANN COUNTERSINK CANNULATED SCREW SYSTEM,SUP-2487743,CDM,2720000010,LOCAL,0272,RC,,,,both,,,967.12,628.63,,,,,,,,,,,,,
HC So Ldh,PX-3018361566,CDM,83615,CPT,0301,RC,,,,outpatient,,,25.00,16.25,,,,,,,,,,,,,
ASSEMBLY BLDE DISP FOR SMARTREL ENDOSCP CRPL TUNN REL SYS 6,SUP-2303824,CDM,2720000010,LOCAL,0272,RC,,,,both,,,795.46,517.05,,,,,,,,,,,,,
BAR ORTHOT HIP PELV THGH CUST BND SPRED,SUP-2435598,CDM,L1640,HCPCS,0272,RC,,,,both,,,1340.21,871.14,,,,,,,,,,,,,
STEM HUM M L116MM OD12.6X10.5MM MOD FOR REMEDY SHLDR SYS,SUP-2319844,CDM,C1776,CPT,0278,RC,,,,both,,,11775.00,7653.75,,,,,,,,,,,,,
LORAZEPAM 4 MG/ML IJ SOLN,RX-10468,CDM,J2060,HCPCS,0636,RC,00641-6049-25,NDC,,both,0.75,ML,54.10,35.16,,,,,,,,,,,,,
CABLE ASSY CERCLAGE SST 18MM X 914MM,SUP-2721369,CDM,C1713,HCPCS,0278,RC,,,,both,,,1262.66,820.73,,,,,,,,,,,,,
PLATE BNE H0.6MM BAR L5MM 100DEG 5 H R MID FACE G TI L,SUP-2366298,CDM,C1713,HCPCS,0278,RC,,,,both,,,459.79,298.86,,,,,,,,,,,,,
HC Rh Immune Globulin,PX-6360279000,CDM,J2790,CPT,0636,RC,,,,both,,,543.00,352.95,,,,,,,,,,,,,
STENT URET LUBRICIOUS COAT,SUP-2126177,CDM,C2617,HCPCS,0278,RC,,,,both,,,324.99,211.24,,,,,,,,,,,,,
MESH SPNL H30XL10MM TI RND,SUP-2254463,CDM,C1713,HCPCS,0278,RC,,,,both,,,8748.04,5686.23,,,,,,,,,,,,,
TROCAR ENDOSCP L 100 MM DIA 8 MM STD BLDELSS FIX CANN,SUP-2896251,CDM,2720000010,LOCAL,0272,RC,,,,both,,,328.26,213.37,,,,,,,,,,,,,
CATHETER CTRL VEN 0.62ML 5FR CUF POS 5CM POLYUR GRAV FLO,SUP-2127764,CDM,C1887,HCPCS,0272,RC,,,,both,,,725.34,471.47,,,,,,,,,,,,,
PLATE BNE BROAD 4.5X250 MM 14 HOLE SS LC-DCP,SUP-2569272,CDM,C1713,HCPCS,0278,RC,,,,both,,,488.74,317.68,,,,,,,,,,,,,
IMPLANT SYNTH TISS L 46 X W 43 MM THK 6 MM LT PERITONEAL,SUP-2883132,CDM,C1713,HCPCS,0278,RC,,,,both,,,3659.04,2378.38,,,,,,,,,,,,,
COMPONENT ARTC SURF PS 5-6 EF UNIV 15 MM CNDYL FIX CONSTRN,SUP-2201186,CDM,C1776,CPT,0278,RC,,,,both,,,3956.40,2571.66,,,,,,,,,,,,,
KIT CVC L 20 CM DIA12 FR TL TEGDERM DRSG LG BOR FOR HI VOL,SUP-2909914,CDM,C1751,HCPCS,0278,RC,,,,both,,,555.78,361.26,,,,,,,,,,,,,
PLATE BNE TBLR 85 MM 7-HOLE 1/3,SUP-2518440,CDM,C1713,HCPCS,0278,RC,,,,both,,,1868.30,1214.39,,,,,,,,,,,,,
POSACONAZOLE 100 MG PO TBEC,RX-124366,CDM,6370000000,HCPCS,0637,RC,70748-0258-07,NDC,,both,1,UN,33.80,21.97,,,,,,,,,,,,,
SCREW BONE SELFDRILLING 2X8 MM MANDIBULAR 5/PK TITANIUM NONS,SUP-2842312,CDM,C1713,HCPCS,0278,RC,,,,both,,,280.46,182.30,,,,,,,,,,,,,
STEM HUM UNIV SHLDR TI PORCOAT BALL TAPR ADJ NK ASSEMB GLOB,SUP-2249959,CDM,C1776,CPT,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
SYSTEM UROLIFT2 W/ IMPL DEL DEV FOR TREAT OF URIN OUTFLO,SUP-2743298,CDM,C1889,HCPCS,0278,RC,,,,both,,,3218.50,2092.02,,,,,,,,,,,,,
GRAFT BNE PAT TEND TISS HEMI ALLGRFT,SUP-2335536,CDM,C1762,CPT,0278,RC,,,,both,,,10362.00,6735.30,,,,,,,,,,,,,
RELOAD STPL L60MM H1-2.6MM MESENTERY THN TISS WHT 6 ROW,SUP-2219090,CDM,2720000010,LOCAL,0272,RC,,,,both,,,639.93,415.95,,,,,,,,,,,,,
BIT DRL L11MM TIB FOR GEN II SYS,SUP-2346859,CDM,2720000010,LOCAL,0272,RC,,,,both,,,546.99,355.54,,,,,,,,,,,,,
EXTRACTOR SCR CENTRONAIL FEM GEN INSTRMT BX LCK,SUP-2315999,CDM,C1713,HCPCS,0278,RC,,,,both,,,213.71,138.91,,,,,,,,,,,,,
SPACER SPNL ANGLED 4 DEG 23X14X10 MM SLT RECTANGULAR PARL,SUP-2416074,CDM,C1889,HCPCS,0278,RC,,,,both,,,11037.10,7174.11,,,,,,,,,,,,,
PLATE BONE L127MM 15 H STRL S STL COMPR FOR 2.7MM SCR EVOS,SUP-2349625,CDM,C1713,HCPCS,0278,RC,,,,both,,,2537.15,1649.15,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY REFLEXION SPRL L 99 CM 7FR 1-4-1,SUP-2496760,CDM,C1730,HCPCS,0272,RC,,,,both,,,746.91,485.49,,,,,,,,,,,,,
GUIDEWIRE VASC STR 182 FLPY CHOICE,SUP-2139580,CDM,C1769,HCPCS,0272,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
BURR DIAMOND BALL 3.0MM S3DG1,SUP-2843311,CDM,2720000010,LOCAL,0272,RC,,,,both,,,356.52,231.74,,,,,,,,,,,,,
CATHETER GUID L100CM OD5FR ID0.056IN S STL NYL PTFE AL3 AL1,SUP-2159373,CDM,C1887,HCPCS,0272,RC,,,,both,,,144.44,93.89,,,,,,,,,,,,,
IMPLANT SET TOT HIP,SUP-2347960,CDM,C1776,CPT,0278,RC,,,,both,,,7536.00,4898.40,,,,,,,,,,,,,
SCREW BNE SD 2X4 MM CRTX MAND TI SLV NS PLUSDRIVE,SUP-2189343,CDM,C1713,HCPCS,0278,RC,,,,both,,,282.66,183.73,,,,,,,,,,,,,
SET SPRUNG RESVR W/ DSTL CATH,SUP-2108710,CDM,C1729,HCPCS,0272,RC,,,,both,,,1940.49,1261.32,,,,,,,,,,,,,
IMPLANT OPHTH MERIDIONAL 10.5 MM RETINAL STYL 106,SUP-2263421,CDM,L8610,HCPCS,0278,RC,,,,both,,,61.86,40.21,,,,,,,,,,,,,
COMPONENT FEM L7CM L PROX HIP TI MOD FINN STYL ORTH SALV,SUP-2405809,CDM,C1776,CPT,0278,RC,,,,both,,,18369.00,11939.85,,,,,,,,,,,,,
IMMOBILIZER ORTH 3 PANEL UNIV KNEE COTTON CANVS FOAM,SUP-2276704,CDM,L1830,CPT,0272,RC,,,,both,,,32.88,21.37,,,,,,,,,,,,,
KIT INTRO MAK-NV NDL L 15 CM DIA21 GA NONVASCULAR CHIBA STYL,SUP-2653964,CDM,C1894,HCPCS,0272,RC,,,,both,,,30.62,19.90,,,,,,,,,,,,,
CLIP ANEURYSM SUNDT TEMPORARY #6 SLIGHT CURVE 6MM 201860,SUP-2844637,CDM,C1889,HCPCS,0278,RC,,,,both,,,867.46,563.85,,,,,,,,,,,,,
NEEDLE CYTO 21GA L137MM DIA1.9MM PULM BRAID TAPR SHTH OPT 5PK,SUP-2281030,CDM,2720000010,LOCAL,0272,RC,,,,both,,,747.32,485.76,,,,,,,,,,,,,
PLATE BNE W5XL37MM THK1.5MM 0DEG 7 H BILAT S STL STR RIG,SUP-2186165,CDM,C1713,HCPCS,0278,RC,,,,both,,,629.07,408.90,,,,,,,,,,,,,
FOLIC ACID 400 MCG PO TABS,RX-3234,CDM,6370000000,HCPCS,0637,RC,50268-0346-11,NDC,,both,1,UN,1.80,1.17,,,,,,,,,,,,,
BARRIER ADH L 4 X W 2 CM AMNIO MEMBRN DBL SIDE LAYR PROTCT,SUP-2904080,CDM,C1762,CPT,0278,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
BLADE SAW OSCLLTNG 19.5MMW X80MML 0.9MM THK 0.9MM THK CUT LG,SUP-2605477,CDM,2720000010,LOCAL,0272,RC,,,,both,,,81.45,52.94,,,,,,,,,,,,,
SCREW BONE 4.5X100MM MALLEOLUS ARSENAL,SUP-2878254,CDM,C1713,HCPCS,0278,RC,,,,both,,,9341.50,6071.97,,,,,,,,,,,,,
GRAFT HUM TISS W2XL4CM AMNIO MEMBRN TRNSLUC GRID PAT SGL,SUP-2113885,CDM,Q4154,HCPCS,0636,RC,,,,both,,,3956.40,2571.66,,,,,,,,,,,,,
ANCHOR BONE BTB TIGHTROPE 2,SUP-2741981,CDM,C1776,CPT,0278,RC,,,,both,,,1711.30,1112.34,,,,,,,,,,,,,
DEVICE VES SEAL OD 15 FR ID 10-12 FR PERC FEM VEN ACCS SITE,SUP-2927663,CDM,C1760,HCPCS,0278,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
PIN EXTERNAL FIXATION HALF 6X50 MM ARROW STAINLESS STEEL JET,SUP-2836755,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1873.17,1217.56,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 40 CM DIA22 MM EPTFE STR STD WALL,SUP-2396232,CDM,C1768,CPT,0278,RC,,,,both,,,2920.20,1898.13,,,,,,,,,,,,,
ANCHOR SUT OD3.7MM NONABSORBABLE TAG WDG,SUP-2341289,CDM,C1713,HCPCS,0278,RC,,,,both,,,530.82,345.03,,,,,,,,,,,,,
GUIDE SURG PLN TI LP CUSTOMIZABLE JAW IN A DAY RECON VSP,SUP-2883955,CDM,2720000010,LOCAL,0272,RC,,,,both,,,35080.08,22802.05,,,,,,,,,,,,,
STENT VASC L150MM DIA7MM CATH L130CM SHTH 6FR DRUG ELUT,SUP-2853969,CDM,C1874,HCPCS,0278,RC,,,,both,,,9090.30,5908.69,,,,,,,,,,,,,
STEM HUM L125MM OD13MM 140DEG NK ANG UNIV CO CHROME SHLDR,SUP-2399848,CDM,C1776,CPT,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
PROBE NSL 20 DEG W/ SMK EVAC,SUP-2713685,CDM,2720000010,LOCAL,0272,RC,,,,both,,,749.99,487.49,,,,,,,,,,,,,
DEVICE COAG GUIDED EPI-SENSE ST W/ 30MM CANNULA,SUP-2858422,CDM,2720000010,LOCAL,0272,RC,,,,both,,,42390.00,27553.50,,,,,,,,,,,,,
PLATE BNE SM W11XL72MM THK34MM 5 H BILAT TI RIG NEUT LOK,SUP-2190777,CDM,C1713,HCPCS,0278,RC,,,,both,,,865.76,562.74,,,,,,,,,,,,,
GUIDEWIRE VASC GLIDEWIRE L 260 CM DIA 0.035 IN NIT HYDRPHLC,SUP-2141144,CDM,C1769,HCPCS,0272,RC,,,,both,,,187.62,121.95,,,,,,,,,,,,,
SEALANT HEMSTATIC HUM 4 CC KT FIBRIN VISTASEAL,SUP-2432427,CDM,2720000010,LOCAL,0272,RC,,,,both,,,615.25,399.91,,,,,,,,,,,,,
FORCEPS SURG 23GA FN TIP ECKARDT INT LIMITING MEMBRN PINN,SUP-2129183,CDM,2720000010,LOCAL,0272,RC,,,,both,,,424.53,275.94,,,,,,,,,,,,,
CAGE SPNL INTBDY 7 DEG 14X13X12 MM NS SHORELINE ACS,SUP-2245736,CDM,C1889,HCPCS,0278,RC,,,,both,,,2048.85,1331.75,,,,,,,,,,,,,
PLATE BNE OSTEOTMY 5 MM MEDL 2 HOLE WEDGED MAXLOCK EXTRM,SUP-2388614,CDM,C1713,HCPCS,0278,RC,,,,both,,,3354.15,2180.20,,,,,,,,,,,,,
WIRE FIX DIA2.4MM S STL DRL PNT FOR CRUCE RECON K,SUP-2212936,CDM,C1713,HCPCS,0278,RC,,,,both,,,594.34,386.32,,,,,,,,,,,,,
DARIFENACIN HYDROBROMIDE ER 7.5 MG PO TB24,RX-40402,CDM,6370000000,HCPCS,0637,RC,13668-0202-30,NDC,,both,1,UN,4.50,2.92,,,,,,,,,,,,,
ENDCAP ORTH UNIV FLSH FOR VERSANAIL TIB NAILING SYS,SUP-2412386,CDM,C1713,HCPCS,0278,RC,,,,both,,,552.64,359.22,,,,,,,,,,,,,
LENS INTOCU +15.0 DIOPT L13MM DIA6MM 0DEG HAPTIC ANG A,SUP-2111015,CDM,V2632,HCPCS,0276,RC,,,,both,,,420.76,273.49,,,,,,,,,,,,,
SLEEVE TROCAR L60MM DIAMETER 5MM THREADED WITH TAP DISPOSABL,SUP-2803688,CDM,2720000010,LOCAL,0272,RC,,,,both,,,468.77,304.70,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 80 CM DIA 6 MM STR STD WALL HELIX,SUP-2525443,CDM,C1768,CPT,0278,RC,,,,both,,,2416.23,1570.55,,,,,,,,,,,,,
PROSTHESIS PENILE 18X12 CM PMP PRECONNECT INFLATABLE AMS 700,SUP-2140300,CDM,C1813,HCPCS,0278,RC,,,,both,,,18353.30,11929.64,,,,,,,,,,,,,
GUIDEWIRE ORTH L300MM DIA2.8MM S STL TRCR TIP FOR MIDFOOT,SUP-2185083,CDM,C1769,HCPCS,0272,RC,,,,both,,,99.91,64.94,,,,,,,,,,,,,
ERYTHROMYCIN LACTOBIONATE 500 MG IV SOLR,RX-2903,CDM,J1364,HCPCS,0636,RC,00409-6482-11,NDC,,both,1,UN,631.10,410.21,,,,,,,,,,,,,
GUIDEWIRE ENDO L360CM S STL PROG FLEX TIP TO INTRODUCE DIL,SUP-2169232,CDM,C1769,HCPCS,0272,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
NAIL IM L28CM DIA8.5MM TIB KNEE GRY TI CANN LCK RG BEND,SUP-2347074,CDM,C1713,HCPCS,0278,RC,,,,both,,,9533.35,6196.68,,,,,,,,,,,,,
BIT DRL OD2.7MM CANN,SUP-2319794,CDM,2720000010,LOCAL,0272,RC,,,,both,,,558.92,363.30,,,,,,,,,,,,,
COLLAR CERV TALL AD 2 PC ATLS,SUP-2319263,CDM,L0172,HCPCS,0272,RC,,,,both,,,104.62,68.00,,,,,,,,,,,,,
IMPLANT SPNL H31 46MM 0DEG LUM W L ENDPLATE RATCH MECHANISM,SUP-2193200,CDM,C1889,HCPCS,0278,RC,,,,both,,,20724.00,13470.60,,,,,,,,,,,,,
SPLINT WRST HK LOOP CLOSURE MED 6 IN RT ELASTIC COTTON,SUP-2336321,CDM,L3809,HCPCS,0272,RC,,,,both,,,11.15,7.25,,,,,,,,,,,,,
SPACER SPNL H18XL20MM TI INTBDY FUS VLIFT,SUP-2380363,CDM,C1713,HCPCS,0278,RC,,,,both,,,11304.00,7347.60,,,,,,,,,,,,,
ROD EXT FIX L200MM LNG THRD MR CONDITIONAL FOR DISTR,SUP-2179147,CDM,2720000010,LOCAL,0272,RC,,,,both,,,207.21,134.69,,,,,,,,,,,,,
NEEDLE EPIDRL COUDE RX AND INTRODUCERS TW 16GAX3.5IN,SUP-2217821,CDM,C1713,HCPCS,0278,RC,,,,both,,,57.62,37.45,,,,,,,,,,,,,
SUPPORT ORTHOT WRST HND CUST ADJ FIT STRP W/NONTORSION JT,SUP-2435772,CDM,L3905,HCPCS,0272,RC,,,,both,,,2555.14,1660.84,,,,,,,,,,,,,
PACK PROC 3.5MM W/ DRL GUID AND BIT DISP MORPHIX,SUP-2277454,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1318.80,857.22,,,,,,,,,,,,,
GUIDEWIRE ORTH L800MM DIA2.2MM S STL SMOOTH TIP FOR T2 HUM,SUP-2368577,CDM,C1769,HCPCS,0272,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
ALLOGRAFT BNE 2 CC,SUP-2264599,CDM,C1889,HCPCS,0278,RC,,,,both,,,1789.80,1163.37,,,,,,,,,,,,,
SPHINCTEROTOME ENDOSCP CANN 3.9 FRX20 MM 0.025 IN TRUETOME,SUP-2141617,CDM,C1769,HCPCS,0272,RC,,,,both,,,917.16,596.15,,,,,,,,,,,,,
IMPLANT OP RM MINI-MONSTER 3.0 X 26MM H,SUP-2320885,CDM,C1713,HCPCS,0278,RC,,,,both,,,736.33,478.61,,,,,,,,,,,,,
GRAFT L SEG AND RECON TISS FRZN TIB TIB DST L,SUP-2307314,CDM,C1713,HCPCS,0278,RC,,,,both,,,7699.28,5004.53,,,,,,,,,,,,,
PLATE BNE L187MM 10 H ST R MED DST TIB S STL LOK COMPR LO,SUP-2177449,CDM,C1713,HCPCS,0278,RC,,,,both,,,4194.22,2726.24,,,,,,,,,,,,,
LEVOTHYROXINE SODIUM 125 MCG PO TABS,RX-4424,CDM,6370000000,HCPCS,0637,RC,51079-0443-01,NDC,,both,1,UN,3.00,1.95,,,,,,,,,,,,,
ECLIPSE TRUNION 41 MM TPS CTD,SUP-2830121,CDM,C1776,CPT,0278,RC,,,,both,,,3611.00,2347.15,,,,,,,,,,,,,
BIT DRL GRAD 10-12 MM 177651] ORTHOFIX INC],SUP-2316012,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
NAIL INTRMDLLRY LOK CNNLTD UNVRSL 8MM DIA 345MML TTNM ALLOY,SUP-2587452,CDM,C1713,HCPCS,0278,RC,,,,both,,,3716.94,2416.01,,,,,,,,,,,,,
MESH CRANIOMAXILLOFACIAL SM W40XL40MM THK0.3MM MALL,SUP-2419457,CDM,C1713,HCPCS,0278,RC,,,,both,,,3740.18,2431.12,,,,,,,,,,,,,
KIT IMAGING SYS RIGID W/SNGL USE KITX6 FLUORESCENT F/ENDOSCOPE PINPOINT DISP SPY-MIS PACK,SUP-2424109,CDM,2720000010,LOCAL,0272,RC,,,,both,,,638.96,415.32,,,,,,,,,,,,,
SUCTION TUBE 8 UPMC GARDNER STYLE,SUP-2495017,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1741.16,1131.75,,,,,,,,,,,,,
LEVEL NEURO PLATE ULTRNE X SHP WTAB NEURO SCRW4 HOLE 14 MM,SUP-2676749,CDM,C1713,HCPCS,0278,RC,,,,both,,,823.59,535.33,,,,,,,,,,,,,
KIT IMPL KNEE CUST EXACTECHGPS,SUP-2223587,CDM,C1713,HCPCS,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
ANCHOR SFT TISS BICEPS FIBERTAK,SUP-2419689,CDM,C1713,HCPCS,0278,RC,,,,both,,,2804.02,1822.61,,,,,,,,,,,,,
SCREW BNE L30MM DIA4MM PERIARTC S STL ST LOK FULL THRD FOR,SUP-2184953,CDM,C1713,HCPCS,0278,RC,,,,both,,,342.26,222.47,,,,,,,,,,,,,
STENT URET OPN END 7 FRX28 CM KID CURL TAPR SIL MULTI-FLEX,SUP-2313771,CDM,C2617,HCPCS,0278,RC,,,,both,,,388.10,252.26,,,,,,,,,,,,,
STENT URET ENDOPYLTMY 14/7 FRX22 CM HYDROPLUS COAT RETROMX +,SUP-2141648,CDM,C2617,HCPCS,0278,RC,,,,both,,,622.88,404.87,,,,,,,,,,,,,
SHEATH INTRO OPTISEAL L 25 CM OD 12 FR ID 4.1 MM DIL DIA 4.2,SUP-2281856,CDM,C1892,HCPCS,0272,RC,,,,both,,,202.12,131.38,,,,,,,,,,,,,
BENDAMUSTINE HCL (BENDEKA) 100 MG/4 ML IV SOLN,RX-4082824,CDM,J9034,HCPCS,0636,RC,63459-0348-04,NDC,,both,4,ML,7124.60,4630.99,,,,,,,,,,,,,
HC Skin Test Tuberculosis Intradermal,PX-3028658000,CDM,86580,CPT,0302,RC,,,,both,,,48.00,31.20,,,,,,,,,,,,,
LIGATOR ENDOSCP MULTI-BAND ESOPH 6 SHOT SAEED,SUP-2737554,CDM,2720000010,LOCAL,0272,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
BARRIER ADH ABSRB GYNECARE INTCEED ST L6XW5IN,SUP-2218344,CDM,C1765,HCPCS,0278,RC,,,,both,,,1142.55,742.66,,,,,,,,,,,,,
NEEDLE BRST LOC L7.5CM OD20GA N REPOSITIONABLE W/ FLEXSTRAND,SUP-2269620,CDM,C1819,HCPCS,0278,RC,,,,both,,,1036.20,673.53,,,,,,,,,,,,,
CATHETER VASC GUID N 5 PERIPH W/ HYDRPHLC COAT AD RADPQ,SUP-2116878,CDM,C1887,HCPCS,0272,RC,,,,both,,,119.32,77.56,,,,,,,,,,,,,
KIT IM NAIL SM L150MM DIA10MM R HINDFOOT FUS VALOR,SUP-2397553,CDM,C1713,HCPCS,0278,RC,,,,both,,,5909.48,3841.16,,,,,,,,,,,,,
MICROSPHERE EMB CNTOUR SE DIA 300-500 UM 2 ML PVA PREFIL SYR,SUP-2148448,CDM,C1889,HCPCS,0278,RC,,,,both,,,750.96,488.12,,,,,,,,,,,,,
PLATE BNE MIC THK06MM 100DEG 6 H LNG L CRANIOMAXILLOFACIAL,SUP-2262721,CDM,C1713,HCPCS,0278,RC,,,,both,,,597.60,388.44,,,,,,,,,,,,,
CATHETER IV NEOMAGIC L 40 CM DIA1.9 FR SIL PICC 1 LUMEN STRL,SUP-2874157,CDM,C1751,HCPCS,0278,RC,,,,both,,,113.04,73.48,,,,,,,,,,,,,
CATHETER ABLATN SM 2-5-2 4 MM 7 FRX110 CM 1304-7-25-S THER,SUP-2491363,CDM,C1733,HCPCS,0272,RC,,,,both,,,1899.70,1234.80,,,,,,,,,,,,,
SCREW BONE CORTICAL 1.3X18 MM SELFTAPPING PLUSDRIVE RECESS T,SUP-2838153,CDM,C1713,HCPCS,0278,RC,,,,both,,,287.94,187.16,,,,,,,,,,,,,
SUPPORT ANKLE HAMMER SPLINT BREMER HALO SYSTEM,SUP-2431399,CDM,2720000010,LOCAL,0272,RC,,,,both,,,210.63,136.91,,,,,,,,,,,,,
EYELET ORTH FOR 2 MM CABLE STRL,SUP-2563693,CDM,C1713,HCPCS,0278,RC,,,,both,,,495.77,322.25,,,,,,,,,,,,,
PATCH CV GORTX NOM L 7.5 X W 5 CM THK 0.6 MM EPTFE CNFRM,SUP-2395301,CDM,C1768,CPT,0278,RC,,,,both,,,1460.10,949.06,,,,,,,,,,,,,
PLATE BONE 1X3 H CRANIOMAXILLOFACIAL TI Y SHP MALL FOR 1.5MM,SUP-2191689,CDM,C1713,HCPCS,0278,RC,,,,both,,,844.66,549.03,,,,,,,,,,,,,
GRAFT BONE CHIP FRZ DRY DEMIN CANC CORT 4MM-10MM RANG 60CC,SUP-2294044,CDM,C1713,HCPCS,0278,RC,,,,both,,,2191.72,1424.62,,,,,,,,,,,,,
GRAFT BNE SUB 10ML HA SYN TISS CLLGN MTRX STRP RESRB HEALOS,SUP-2255627,CDM,C9362,HCPCS,0278,RC,,,,both,,,3108.60,2020.59,,,,,,,,,,,,,
TUBE MYR 127MM DIAM VENT SIL FLNG TAB PAPARELLA ULTRASIL,SUP-2312837,CDM,L8699,HCPCS,0278,RC,,,,both,,,56.08,36.45,,,,,,,,,,,,,
TREPHINE SURG OD10MM CRWN DRL,SUP-2368637,CDM,C1713,HCPCS,0278,RC,,,,both,,,2014.31,1309.30,,,,,,,,,,,,,
PLATE BONE ORAL MAXILLOFACIAL SMITH GENIOPLASTY DIAM 2.0MM,SUP-2262915,CDM,C1713,HCPCS,0278,RC,,,,both,,,364.24,236.76,,,,,,,,,,,,,
BUR SURG MTCH HD 3 MM 12 CM DSTL BEND MIDAS REX 8 CLRVW,SUP-2632177,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1129.62,734.25,,,,,,,,,,,,,
DISTRACTOR SURG L 20 MM 2 X 2 H LT MANDIBULAR PED NS,SUP-2883526,CDM,C1713,HCPCS,0278,RC,,,,both,,,22137.00,14389.05,,,,,,,,,,,,,
BUR SURG DIA 3.1 MM HUB II ROSEN STRL REUSE HI-LINE,SUP-2929219,CDM,2720000010,LOCAL,0272,RC,,,,both,,,386.91,251.49,,,,,,,,,,,,,
CLIP ANEUR BLDE W3MM DIA4MM OPN S STL GRFT SLIM-LINE,SUP-2243075,CDM,C1713,HCPCS,0278,RC,,,,both,,,3545.06,2304.29,,,,,,,,,,,,,
STAPLER INT HERN 65 DEG 12 MM TI ENDO UNIV DISP,SUP-2752171,CDM,2720000010,LOCAL,0272,RC,,,,both,,,485.29,315.44,,,,,,,,,,,,,
PLATE BNE STR 127 MM R/L 13 HOLE EVOLVE EPS ORTHOLOC,SUP-2535934,CDM,C1713,HCPCS,0278,RC,,,,both,,,2794.60,1816.49,,,,,,,,,,,,,
DRILL SURGICAL PERFORATING  FLAT CUSHING,SUP-2793113,CDM,2720000010,LOCAL,0272,RC,,,,both,,,356.30,231.59,,,,,,,,,,,,,
SURGICAL PROCEDURE KIT 400 MH PERF,SUP-2752490,CDM,C1888,HCPCS,0272,RC,,,,both,,,889.41,578.12,,,,,,,,,,,,,
SHEARS ENDO L20CM DIA10MM HARM SCALP HNDPC ULTRASONIC UCIS,SUP-2257412,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1093.22,710.59,,,,,,,,,,,,,
PLATE BNE RECON LNG LT NON-CROSS,SUP-2399292,CDM,C1713,HCPCS,0278,RC,,,,both,,,5846.68,3800.34,,,,,,,,,,,,,
VALVE 10 WITH MCLANAHAN RESERVOIR MININAV,SUP-2825729,CDM,C1889,HCPCS,0278,RC,,,,both,,,2055.04,1335.78,,,,,,,,,,,,,
LINER FEM OD46MM ID32MM BPLR CENTRAX,SUP-2364425,CDM,C1776,CPT,0278,RC,,,,both,,,1892.67,1230.24,,,,,,,,,,,,,
CLAMP SURG L9IN S STL MATTE FINISH ANG NONCRUSHING GLSMN,SUP-2162099,CDM,2720000010,LOCAL,0272,RC,,,,both,,,452.76,294.29,,,,,,,,,,,,,
SYSTEM BRACHYTHERAPY DEL W THE PALLADIUM 103 SEED READYLINK,SUP-2129128,CDM,C2640,HCPCS,0278,RC,,,,both,,,178.98,116.34,,,,,,,,,,,,,
GUIDEWIRE NDL FRE TRANSSEPTAL SAFESEPT,SUP-2329875,CDM,C1769,HCPCS,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
GRAFT BONE 5ML MTRX,SUP-2136829,CDM,C1713,HCPCS,0278,RC,,,,both,,,4622.08,3004.35,,,,,,,,,,,,,
GRAFT IMPL HUM TISS FRZN ALLGRFT FEM L MED STRUT BNE 250MM,SUP-2307419,CDM,C1713,HCPCS,0278,RC,,,,both,,,2795.26,1816.92,,,,,,,,,,,,,
PLATE BNE L 184 MM SCREW DIA2.7 MM 18 SHFT H SS STR VA SLV,SUP-2907595,CDM,C1713,HCPCS,0278,RC,,,,both,,,4935.61,3208.15,,,,,,,,,,,,,
CUBE EXTERNAL FIXATION 3 HOLE STAINLESS STEEL,SUP-2586502,CDM,2720000010,LOCAL,0272,RC,,,,both,,,724.05,470.63,,,,,,,,,,,,,
STEM FEM 3 240 MM LT MOLD PROSTALAC,SUP-2454731,CDM,C1776,CPT,0278,RC,,,,both,,,33180.38,21567.25,,,,,,,,,,,,,
KIT INFUS MULTIRATE 2 4 6,SUP-2210564,CDM,C1713,HCPCS,0278,RC,,,,both,,,486.70,316.35,,,,,,,,,,,,,
CATHETER STONE REMV 6FR L23CM 1.25ML BILI BLLN PRB ATRAUM,SUP-2214136,CDM,C1726,HCPCS,0272,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
BLADE RETRCT D6IN FOR CHARNLEY TYP FRME,SUP-2242484,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1022.70,664.75,,,,,,,,,,,,,
COLLAR CERV REG AD XTW EXT WR LF,SUP-2335999,CDM,L0120,HCPCS,0274,RC,,,,both,,,51.43,33.43,,,,,,,,,,,,,
ALLOGRAFT HUM TISS ASEP SEMITENDINOSUS W/ GRACILIS,SUP-2867086,CDM,C1762,CPT,0278,RC,,,,both,,,4772.80,3102.32,,,,,,,,,,,,,
APPLIER CLP L12.99IN TI CLP GRY PSTL GRP DISP ENDO CLP II,SUP-2283176,CDM,2720000010,LOCAL,0272,RC,,,,both,,,962.63,625.71,,,,,,,,,,,,,
ALLOGRAFT BNE SPACER 14X11X6 MM UNICORTICAL CANC LIFEGRAFT,SUP-2309677,CDM,C1713,HCPCS,0278,RC,,,,both,,,3202.80,2081.82,,,,,,,,,,,,,
ROD TI MIS PREBENT 5.5X65,SUP-2840517,CDM,C1713,HCPCS,0278,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
SCREW BNE SET 3.5 MM CANN FT EXT TAB,SUP-2861020,CDM,C1713,HCPCS,0278,RC,,,,both,,,15795.83,10267.29,,,,,,,,,,,,,
SEED BRACHYTHERAPY LOOSE 5.01-6.0 MCI NS ADVANTAGE,SUP-2247274,CDM,C2643,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
"HC So Culture, Afb",PX-3008711666,CDM,87116,CPT,0300,RC,,,,both,,,155.00,100.75,,,,,,,,,,,,,
HC Shoulder 1 View,PX-3207302000,CDM,73020,CPT,0320,RC,,,,both,,,238.00,154.70,,,,,,,,,,,,,
ALLOGRAFT BNE CHIP 1-4 MM 60 CC PRESERVON CANC READIGRAFT,SUP-2740982,CDM,C1713,HCPCS,0278,RC,,,,both,,,2147.73,1396.02,,,,,,,,,,,,,
HC So1 Alpha Fetoprotein,PX-3018210567,CDM,82105,CPT,0301,RC,,,,inpatient,,,107.00,69.55,,,,,,,,,,,,,
CATHETER DIAG STEER L CRV 5MM ELECTRD SPC QPLR POLES 6FR,SUP-2142287,CDM,C1730,HCPCS,0272,RC,,,,both,,,1130.40,734.76,,,,,,,,,,,,,
HC Bx Breast Percut W/O Image,PX-5101910000,CDM,19100,CPT,0510,RC,,,,both,,,5012.00,3257.80,,,,,,,,,,,,,
GRAFT HUM TISS W/O SCLER RIM,SUP-2388444,CDM,V2785,HCPCS,0278,RC,,,,both,,,1303.10,847.01,,,,,,,,,,,,,
PLATE BNE PROF THK 1 MM 2 X 4 H SCREW DIA2 MM TI MIDFACE,SUP-2883876,CDM,C1713,HCPCS,0278,RC,,,,both,,,1048.76,681.69,,,,,,,,,,,,,
STAPLE INT L3.85XH3MM OD.24MM 60MM CUT LEN BLU TI RELD 2,SUP-2283065,CDM,2720000010,LOCAL,0272,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
PACEMAKER CARD ALTURA20 TI 2 CHMBR 1 LD BATTERY PWR EXT,SUP-2149114,CDM,C1882,HCPCS,0275,RC,,,,both,,,13816.00,8980.40,,,,,,,,,,,,,
SPHERE GLEN CENTERED 39 MM 25 MM SHLDR COCR AEQUALIS,SUP-2715793,CDM,C1776,CPT,0278,RC,,,,both,,,9160.95,5954.62,,,,,,,,,,,,,
CATHETER ANGIOPLSTY FLSH L 135 CM BALLOON L 12 MM DIA 5 MM,SUP-2319857,CDM,C1725,HCPCS,0272,RC,,,,both,,,3921.86,2549.21,,,,,,,,,,,,,
STEM FEM LAT 9/13 MAG NK W/ TRUNNION GENERATION 4,SUP-2443999,CDM,C1776,CPT,0278,RC,,,,both,,,918.45,596.99,,,,,,,,,,,,,
ALLOGRAFT DERMAL MED 6X18 CMX1.6/0.4 MM RDY TO USE ALLDERM,SUP-2465996,CDM,Q4116,HCPCS,0636,RC,,,,both,,,12622.80,8204.82,,,,,,,,,,,,,
STEM HUM DIA9MM 132.5DEG STD SHLDR PROX BODY AEQUALIS FLX,SUP-2417741,CDM,C1776,CPT,0278,RC,,,,both,,,13489.44,8768.14,,,,,,,,,,,,,
HC Glb CSF Shunt Reprogram,PX-9826225200,CDM,62252,CPT,0982,RC,,,,both,,,1179.00,766.35,,,,,,,,,,,,,
CANNULATED FULLY THREADED COMPRESSION SCREW 2.6MM X 36MM.,SUP-2883432,CDM,C1713,HCPCS,0278,RC,,,,both,,,1460.10,949.06,,,,,,,,,,,,,
Z DISCONTINUED NO SUB IDED CATHETER GUID VENTURE L 144.5 CM SHFT OD 4.1 FR ID 0.015 IN,SUP-2383161,CDM,C1887,HCPCS,0272,RC,,,,both,,,2041.00,1326.65,,,,,,,,,,,,,
CATHETER ETER PICC AD 6FR L55CM 3 LUMN NRS PWR INJ N COAT CT,SUP-2126715,CDM,C1751,HCPCS,0278,RC,,,,both,,,885.48,575.56,,,,,,,,,,,,,
COLLECTOR TISS AUTOLGS,SUP-2418776,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1208.90,785.78,,,,,,,,,,,,,
BLADE IM L85MM DIA12.5MM FEM G TI CANN SPRL FR CUT EDGE FOR,SUP-2189404,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1557.13,1012.13,,,,,,,,,,,,,
DRILL SURG MOD AO DETACHABLE FIT,SUP-2449172,CDM,2720000010,LOCAL,0272,RC,,,,both,,,664.11,431.67,,,,,,,,,,,,,
HC Cardiac Rehab Phase 3 - 1 Visit,PX-9900000065,CDM,9900000065,LOCAL,0990,RC,,,,both,,,75.00,48.75,,,,,,,,,,,,,
KIT HAD CATH AD 15.5FR L28CM BASIC PRECRV STK TIP DBL LUMN,SUP-2116544,CDM,C1750,HCPCS,0278,RC,,,,both,,,938.86,610.26,,,,,,,,,,,,,
NEEDLE SPNL 1 BVL TRCR TIP CDH SEXTANT DISP,SUP-2290630,CDM,2720000010,LOCAL,0272,RC,,,,both,,,772.60,502.19,,,,,,,,,,,,,
PROSTHESIS OSS CLASSIC STAP 4X0.9 MM 0.4 MM TI,SUP-2638171,CDM,L8613,CPT,0278,RC,,,,both,,,701.26,455.82,,,,,,,,,,,,,
KIT FIX FNGR JT PROX INTERPHALANGEAL UNIV RADLUC PLAS,SUP-2342291,CDM,C1713,HCPCS,0278,RC,,,,both,,,14482.78,9413.81,,,,,,,,,,,,,
CATHETER ETER MIDLN FULL NRS TY 2 LUMN 5FRX20 CM,SUP-2267039,CDM,C1751,HCPCS,0278,RC,,,,both,,,65.31,42.45,,,,,,,,,,,,,
HC Repr Smp Not Face 2.6-7.5cm,PX-4501200200,CDM,12002,CPT,0450,RC,,,,inpatient,,,632.00,410.80,,,,,,,,,,,,,
ISOSORB DINITRATE-HYDRALAZINE 20-37.5 MG PO TABS,RX-41893,CDM,6370000000,HCPCS,0637,RC,52536-0006-09,NDC,,both,1,UN,5.00,3.25,,,,,,,,,,,,,
BIOCOMP SWVLK BICEPS TENO 9X23 KIT,SUP-2811898,CDM,C1713,HCPCS,0278,RC,,,,both,,,2257.66,1467.48,,,,,,,,,,,,,
STEM FEM VERSYS 8 INCH BEADED FC REV 15.0X200MM BWD LT,SUP-2504261,CDM,C1776,CPT,0278,RC,,,,both,,,14557.04,9462.08,,,,,,,,,,,,,
CATHETER SUPP NAVIEN L 125 CM OD 0.084 IN ID 0.072 IN FLX,SUP-2522812,CDM,C1887,HCPCS,0272,RC,,,,both,,,6735.30,4377.94,,,,,,,,,,,,,
SCREW VA LCK ST 2X30MM SS W/T6 STARDRV RECESS VAL,SUP-2546090,CDM,C1713,HCPCS,0278,RC,,,,both,,,484.35,314.83,,,,,,,,,,,,,
BRACE WRST LEN 7 3 4IN CIRC OVR 8 3 4IN XL R REG D RNG W,SUP-2326029,CDM,L3908,HCPCS,0272,RC,,,,both,,,80.35,52.23,,,,,,,,,,,,,
SPACER SPNL LG 12 DEG 42X30X20 MM SOVEREIGN,SUP-2630956,CDM,C1889,HCPCS,0278,RC,,,,both,,,13423.50,8725.27,,,,,,,,,,,,,
PLATE BNE CONTOURABLE MESH 100X100X0.6 MM RIGID SLV NS,SUP-2859897,CDM,C1713,HCPCS,0278,RC,,,,both,,,6556.32,4261.61,,,,,,,,,,,,,
BLADE SAW LG 70X13X1.24 MM STRYKR SALTO TALARIS,SUP-2365910,CDM,2720000010,LOCAL,0272,RC,,,,both,,,483.56,314.31,,,,,,,,,,,,,
SET ART LN CATH 3FR L5CM RAD ART SGL LUMN W/ SCALP NDL OINT,SUP-2167832,CDM,C1751,HCPCS,0278,RC,,,,both,,,172.70,112.25,,,,,,,,,,,,,
CONNECTOR SPNL CLOSE 2 FOR 6.35MM ROD ISOLA,SUP-2255601,CDM,C1713,HCPCS,0278,RC,,,,both,,,3152.56,2049.16,,,,,,,,,,,,,
COIL EMB DETACHABLE 0.010 IN 2 MMX2 CM FILL PLAT DELTAPAQ 10,SUP-2249030,CDM,C1889,HCPCS,0278,RC,,,,both,,,3259.01,2118.36,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE 3 CC CORTICOCANCELLOUS CELLULAR BNE,SUP-2933286,CDM,C1762,CPT,0278,RC,,,,both,,,5623.36,3655.18,,,,,,,,,,,,,
PLATE SPNL FACE 18 MM 2 HOLE NO-PROFILE INTBDY MERID,SUP-2711060,CDM,C1713,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
CATHETER HD STR 12.5 FRX24 CM LT DL STP BASIC SET HEMCATH,SUP-2627219,CDM,C1750,HCPCS,0278,RC,,,,both,,,112.16,72.90,,,,,,,,,,,,,
PUMP PROS PENILE TCH ASMBLY TI,SUP-2165315,CDM,C1813,HCPCS,0278,RC,,,,both,,,18840.00,12246.00,,,,,,,,,,,,,
DELIVERY SYR SCP 5-PACK,SUP-2205791,CDM,C1713,HCPCS,0278,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
CUTTER ENDOSCP 10 MM STRL FLIPCUTTER AR1204F] ARTHREX INC],SUP-2120832,CDM,2720000010,LOCAL,0272,RC,,,,both,,,894.90,581.68,,,,,,,,,,,,,
CATHETER URODYN BLLN 7.4 FRX30 CM,SUP-2835714,CDM,C1726,HCPCS,0272,RC,,,,both,,,131.28,85.33,,,,,,,,,,,,,
CATHETER CARD ABLATION EZ STEER THERMOCOOL L 115CM 7.5FR D-F,SUP-2248506,CDM,C1732,HCPCS,0272,RC,,,,both,,,4301.80,2796.17,,,,,,,,,,,,,
CHUCK SURG DRL KEYLESS 5 MM AO CONN RM QUIK RELEASE APEX,SUP-2363255,CDM,2720000010,LOCAL,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
BIT DRL L 120/50 MM DIA1.5 MM SCREW NS DIA2 MM CALIB AO QC CLR,SUP-2913757,CDM,2720000010,LOCAL,0272,RC,,,,both,,,664.36,431.83,,,,,,,,,,,,,
SCREW BNE FIX SM 7X30 MM W/ 30MM SHTH SS NS,SUP-2249570,CDM,C1713,HCPCS,0278,RC,,,,both,,,2829.14,1838.94,,,,,,,,,,,,,
BIT DRL 3.5X24 MM,SUP-2608416,CDM,2720000010,LOCAL,0272,RC,,,,both,,,320.91,208.59,,,,,,,,,,,,,
CATHETER BLLN 7.5FR 25ML LIN INT AORT DATASCP SYS D68400047801] GETINGE USA MAQUET MED SYS],SUP-2227496,CDM,C1725,HCPCS,0272,RC,,,,both,,,2644.98,1719.24,,,,,,,,,,,,,
WASHER EXT FIX 2.5 MM,SUP-2457738,CDM,2720000010,LOCAL,0272,RC,,,,both,,,113.04,73.48,,,,,,,,,,,,,
STEM FEM SZ 12 R IMAG,SUP-2344438,CDM,C1776,CPT,0278,RC,,,,both,,,15409.55,10016.21,,,,,,,,,,,,,
GUIDEWIRE PTFE COAT FIX COR STIFF BODIED 0038INX150CM J TIP,SUP-2139320,CDM,C1769,HCPCS,0272,RC,,,,both,,,42.67,27.74,,,,,,,,,,,,,
STENT GRFT VASC OVATION IX L 140 MM 185 MM 14/14 MM 10/12 FR,SUP-2217744,CDM,C1876,HCPCS,0278,RC,,,,both,,,13275.92,8629.35,,,,,,,,,,,,,
BLADE SAW OSCLLTNG 16.5MMW X20MML 0.4MM THK X11MM THK CUT AN,SUP-2605459,CDM,2720000010,LOCAL,0272,RC,,,,both,,,352.43,229.08,,,,,,,,,,,,,
DEVICE PESSARY L 55 MM SZ 1 SIL SUPP WHT NS LF GEHRUNG,SUP-2895812,CDM,A4562,HCPCS,0274,RC,,,,both,,,108.27,70.38,,,,,,,,,,,,,
PLATE BNE LCK 155 MM RT DORS PROXIMAL ULNAR 9 HOLE STRL,SUP-2462364,CDM,C1713,HCPCS,0278,RC,,,,both,,,2504.59,1627.98,,,,,,,,,,,,,
PIN EXT FIX THRD L25MM DIA3MM SHANK L65MM DIA4MM SH TI,SUP-2342891,CDM,C1713,HCPCS,0278,RC,,,,both,,,761.45,494.94,,,,,,,,,,,,,
MESH SYN 10X15CM HERN RECT PARIETEX,SUP-2174803,CDM,C1781,HCPCS,0278,RC,,,,both,,,617.45,401.34,,,,,,,,,,,,,
GUIDEWIRE ORTH TAPERED TIP 3X330 MM LATERAL ACCESS DISP,SUP-2731938,CDM,C1769,HCPCS,0272,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
IMPLANT PAT RND PRI 9 MM THCK CEM N POR STD WITHOUTXRAY WIRE,SUP-2200482,CDM,C1776,CPT,0278,RC,,,,both,,,1554.68,1010.54,,,,,,,,,,,,,
SCREW BONE L4MM DIA2MM CORT TI ST PLUSDRIVE RECESS,SUP-2189322,CDM,C1713,HCPCS,0278,RC,,,,both,,,264.64,172.02,,,,,,,,,,,,,
KIT TKR 3 STD TIB PREP CRUCE RET DISPOSABLE TRIATHLON PRECIS,SUP-2373668,CDM,2720000010,LOCAL,0272,RC,,,,both,,,346.66,225.33,,,,,,,,,,,,,
WASHER ORTH MONSTER FOR 5.5MM SCR FLAT,SUP-2320328,CDM,C1713,HCPCS,0278,RC,,,,both,,,494.55,321.46,,,,,,,,,,,,,
MESH BONE 126MMW X 126MML 1MM THK RSRB X GRDN STYLE LATEX FR,SUP-2681140,CDM,C1713,HCPCS,0278,RC,,,,both,,,11274.04,7328.13,,,,,,,,,,,,,
REGULATOR SUCT CONT INTMIT PED,SUP-2113856,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1522.90,989.88,,,,,,,,,,,,,
SCREW BNE ASMBLY 165 MM SHLDR ADJ REVERSED AEQUALIS,SUP-2715376,CDM,C1713,HCPCS,0278,RC,,,,both,,,2700.40,1755.26,,,,,,,,,,,,,
CATHETER THORACENTESIS RT ANGLED 32 FR,SUP-2431310,CDM,C1729,HCPCS,0272,RC,,,,both,,,50.24,32.66,,,,,,,,,,,,,
SCREW BONE L3MM DIA1.6MM CORT CRANIOMAXILLOFACIAL TI SELF,SUP-2189296,CDM,C1713,HCPCS,0278,RC,,,,both,,,237.38,154.30,,,,,,,,,,,,,
CAP ORTH FOR LOK HUM ROD POLARUS +,SUP-2107687,CDM,C1713,HCPCS,0278,RC,,,,both,,,1190.06,773.54,,,,,,,,,,,,,
CATHETER INTRAAORTIC 8FR BAL 30CC POLYUR NYL CARDIOTHANE II,SUP-2383459,CDM,C1713,HCPCS,0278,RC,,,,both,,,4254.70,2765.55,,,,,,,,,,,,,
SCREW SPNL L11MM DIA4MM ANT CERV SELF DRL FOR STD ALONE,SUP-2293584,CDM,C1713,HCPCS,0278,RC,,,,both,,,414.48,269.41,,,,,,,,,,,,,
PIN FIX POLY LOK OSS,SUP-2405829,CDM,C1776,CPT,0278,RC,,,,both,,,551.07,358.20,,,,,,,,,,,,,
SIZER BRST 500CC DIA13.6CM P5.5CM COHESIVE I SIL GEL SMOOTH,SUP-2300888,CDM,2720000010,LOCAL,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
GUIDEWIRE VASC L 70 CM DIA 0.038 IN J FLX ADV STRL,SUP-2269534,CDM,C1769,HCPCS,0272,RC,,,,both,,,30.58,19.88,,,,,,,,,,,,,
AMNION THIN 7X7,SUP-2811236,CDM,C1762,CPT,0278,RC,,,,both,,,11598.38,7538.95,,,,,,,,,,,,,
SCREW BNE ST 5 MM LCK TI NS,SUP-2190373,CDM,C1713,HCPCS,0278,RC,,,,both,,,49.55,32.21,,,,,,,,,,,,,
BUR SURG DIAMOND 2 MM 12 CM BALL TELSCP MIDAS REX LEGEND,SUP-2632195,CDM,2720000010,LOCAL,0272,RC,,,,both,,,428.86,278.76,,,,,,,,,,,,,
GRAFT BNE SUB 10CC DBM GEL FRZ DRY OPTIUM,SUP-2264858,CDM,C1713,HCPCS,0278,RC,,,,both,,,2749.82,1787.38,,,,,,,,,,,,,
BIT DRL HEXA 3.5 MM POWERBIT TRINKLE END OMEGA +,SUP-2457452,CDM,2720000010,LOCAL,0272,RC,,,,both,,,873.92,568.05,,,,,,,,,,,,,
BIT DRILL CANN 3.3MMD QUICK COUPLING,SUP-2482353,CDM,2720000010,LOCAL,0272,RC,,,,both,,,931.45,605.44,,,,,,,,,,,,,
MATRIX BIO SZ 300 SQCM FISH SKIN DERMAL SLD INTACT STRL SINGLE,SUP-2909456,CDM,Q4158,HCPCS,0636,RC,,,,both,,,31086.00,20205.90,,,,,,,,,,,,,
PLATE BONE W12XL167MM THK4MM 10 H S STL STR NAR COMPR FOR,SUP-2343812,CDM,C1713,HCPCS,0278,RC,,,,both,,,1809.21,1175.99,,,,,,,,,,,,,
SHEATH INTRO PINNACLE L 25 CM 5FR SS HYDRPHLC CORONARY,SUP-2385666,CDM,C1894,HCPCS,0272,RC,,,,both,,,74.76,48.59,,,,,,,,,,,,,
SCREW BONE L20MM DIA2MM STD CORT TI NCANNULATED FULL THRD N,SUP-2189312,CDM,C1713,HCPCS,0278,RC,,,,both,,,93.54,60.80,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA PLU MAXBARR 4FR S1294108D3,SUP-2632811,CDM,C1751,HCPCS,0278,RC,,,,both,,,1127.57,732.92,,,,,,,,,,,,,
GUIDEWIRE URO L150CM DIA0.018IN TAPR L3CM NIT HYDRPHLC STR,SUP-2139328,CDM,C1769,HCPCS,0272,RC,,,,both,,,181.77,118.15,,,,,,,,,,,,,
HC CT Brain W/O Contrast,PX-3517045000,CDM,70450,CPT,0351,RC,,,,both,,,2762.00,1795.30,,,,,,,,,,,,,
INSERTER SURG STR IN SCP HANDLE.,SUP-2140251,CDM,C2631,HCPCS,0278,RC,,,,both,,,1171.22,761.29,,,,,,,,,,,,,
METHYLPREDNISOLONE SODIUM SUCC 40 MG IJ SOLR (MIXTURES ONLY),RX-430071,CDM,J2919,HCPCS,0636,RC,00009-0039-33,NDC,,both,1,UN,54.10,35.16,,,,,,,,,,,,,
ALFUZOSIN HCL ER 10 MG PO TB24,RX-36982,CDM,6370000000,HCPCS,0637,RC,47335-0956-88,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
KIT INTRO L 10 CM DIA 5 FR SS SHFT GLD TIP STD DIL MIC,SUP-2615952,CDM,C1894,HCPCS,0272,RC,,,,both,,,90.81,59.03,,,,,,,,,,,,,
SEED BRACHYTHERAPY LOOSE 3.01-4.0 MCI NS ADVANTAGE,SUP-2247268,CDM,C2643,HCPCS,0278,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
PLATE SPNL L42MM CEPHALIC TO CAUD 34MM 8 H GLD ANTR BILAT,SUP-2193038,CDM,C1713,HCPCS,0278,RC,,,,both,,,1739.56,1130.71,,,,,,,,,,,,,
HC Bilirubin Total Transcutaneous,PX-3018872000,CDM,88720,CPT,0301,RC,,,,inpatient,,,24.00,15.60,,,,,,,,,,,,,
GRAFT VASC ARTEGRAFT L 15 CM DIA 6 MM CLLGN BOV CAR ART,SUP-2120666,CDM,C1768,CPT,0278,RC,,,,both,,,6433.86,4182.01,,,,,,,,,,,,,
ELECTRODE ENDSCPC URLGY 24FR DIA 12DG CTTNG LOOP HF RSCTN LA,SUP-2730095,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1011.02,657.16,,,,,,,,,,,,,
TUBING ASPIR RIPTIDE,SUP-2280540,CDM,2720000010,LOCAL,0272,RC,,,,both,,,879.20,571.48,,,,,,,,,,,,,
COOLCUT 50 ASP ABLATOR,SUP-2815766,CDM,2720000010,LOCAL,0272,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
CATH ANGIO BLN EVERCROSS PTA 8 X 20MM  80CM,SUP-2172912,CDM,C1725,HCPCS,0272,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
COMPONENT PATELLAR AUG KNEE,SUP-2201425,CDM,C1776,CPT,0278,RC,,,,both,,,11705.92,7608.85,,,,,,,,,,,,,
CATHETER INFUS 5FR 30CM INFUS LEN 90CM LEN - 5FR 30CM INFUS,SUP-2117008,CDM,C1757,HCPCS,0272,RC,,,,both,,,273.18,177.57,,,,,,,,,,,,,
MESH SURG 43CM LEN 15CM W SYN ABD N ABSRB OVL,SUP-2126075,CDM,C1781,HCPCS,0278,RC,,,,both,,,146.32,95.11,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY INQUIRY DIA 6 FR SPC 2-5-2 MM JSN,SUP-2538000,CDM,C1730,HCPCS,0272,RC,,,,both,,,692.37,450.04,,,,,,,,,,,,,
CATHETER ETER EP L115CM OD7FR 2 5 2MM SPC TIP L4MM 2 CRV DIAG MAP L,SUP-2356992,CDM,C1733,HCPCS,0272,RC,,,,both,,,2084.96,1355.22,,,,,,,,,,,,,
STAPLER INT L L25MM DIA5MM GI WHT TI BARIATRIC CIR CUT 2,SUP-2283255,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3857.62,2507.45,,,,,,,,,,,,,
BIT DRL CANN 4.7X215 MM POLYPR CLR EPIC,SUP-2420821,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
PLATE BONE 17DEG 6X17 H LT MAND SEC HMSPHR TI RECON,SUP-2363752,CDM,C1713,HCPCS,0278,RC,,,,both,,,3661.43,2379.93,,,,,,,,,,,,,
GRAFT BONE LT PROX HUM W/ CUF TRAD FRZN,SUP-2294178,CDM,C1713,HCPCS,0278,RC,,,,both,,,11021.40,7163.91,,,,,,,,,,,,,
PLATE BNE 18MM UNIV FOREFOOT,SUP-2243215,CDM,C1776,CPT,0278,RC,,,,both,,,3976.78,2584.91,,,,,,,,,,,,,
CABLE EP CATH L 2.5 M 10 PIN MODEL 1910-S DIAG CONN GUID,SUP-2887273,CDM,C1732,HCPCS,0278,RC,,,,both,,,472.57,307.17,,,,,,,,,,,,,
EXTERNAL FIXATION KIT A FLD STRL HOFFMANN 3,SUP-2431371,CDM,2720000010,LOCAL,0272,RC,,,,both,,,14579.33,9476.56,,,,,,,,,,,,,
STAPLE BNE BLNT SET,SUP-2478384,CDM,C1713,HCPCS,0278,RC,,,,both,,,1668.91,1084.79,,,,,,,,,,,,,
BRACE ORTH LNR 3 SHELL TLSO,SUP-2388140,CDM,L0462,HCPCS,0274,RC,,,,both,,,3215.55,2090.11,,,,,,,,,,,,,
STENT PERIPH L5CM DIA6MM CATH L120CM 0.035IN HEP BIOACTIVE,SUP-2396597,CDM,C1874,HCPCS,0278,RC,,,,both,,,9391.74,6104.63,,,,,,,,,,,,,
ALLOGRAFT BNE FRZN ASEP FEM SHFT,SUP-2867012,CDM,C1762,CPT,0278,RC,,,,both,,,5100.93,3315.60,,,,,,,,,,,,,
SLING GYN POST PELV FLR RECON MESH GYNECARE PROLIFT+M,SUP-2219784,CDM,C1771,HCPCS,0278,RC,,,,both,,,4537.30,2949.24,,,,,,,,,,,,,
PLATE BNE L189.6MM THK3.7MM 0DEG 14 H TI TIM THN LOK COMPR,SUP-2413712,CDM,C1713,HCPCS,0278,RC,,,,both,,,1225.07,796.30,,,,,,,,,,,,,
PATCH HERN M W4.3XL5.5IN UNCOATED MFIL PROPYLENE OVL SELF,SUP-2125897,CDM,C1781,HCPCS,0278,RC,,,,both,,,2358.14,1532.79,,,,,,,,,,,,,
MESH CRAN CUSTOMIZED SM PRIORITY STRL MEDPOR,SUP-2862750,CDM,C1713,HCPCS,0278,RC,,,,both,,,44597.29,28988.24,,,,,,,,,,,,,
MESH SURG H16MM DIA12MM SPNL TI SGL LEV RND,SUP-2254375,CDM,C1781,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
BASKET RETRV 7 FRX65 CM URETHRA,SUP-2139588,CDM,C1713,HCPCS,0278,RC,,,,both,,,593.46,385.75,,,,,,,,,,,,,
IMPLANT BRST W11.5XH10.8CM 295ML P4.9CM SIL GEL MOD +,SUP-2300200,CDM,C1789,HCPCS,0278,RC,,,,both,,,4553.00,2959.45,,,,,,,,,,,,,
GRAFT BNE PARTICULATE 250-1000 M UM 0.5 CC CANC PUROS,SUP-2860956,CDM,C1713,HCPCS,0278,RC,,,,both,,,261.25,169.81,,,,,,,,,,,,,
STEM FEM CEM -5 MM 8/14 205 MM LT HIP BOW REV REDUC NK,SUP-2376570,CDM,C1776,CPT,0278,RC,,,,both,,,16882.52,10973.64,,,,,,,,,,,,,
IRINOTECAN HCL 40 MG/2ML IV SOLN,RX-91055,CDM,J9206,HCPCS,0636,RC,63323-0193-52,NDC,,both,2,ML,54.10,35.16,,,,,,,,,,,,,
PROPOFOL 1000 MG/100ML IV EMUL,RX-133092,CDM,J2704,HCPCS,0636,RC,00409-4699-24,NDC,,both,100,ML,124.20,80.73,,,,,,,,,,,,,
CATHETER HD STR 9 FRX20 CM CATH INTRO NDL DUOFLO,SUP-2627102,CDM,C1752,HCPCS,0278,RC,,,,both,,,6.75,4.39,,,,,,,,,,,,,
HC Ot Re-Eval Est Plan Care,PX-4349716800,CDM,97168,CPT,0434,RC,,,,both,,,161.00,104.65,,,,,,,,,,,,,
HC Rad Guide for Perc Drain Tube,PX-3207598900,CDM,75989,CPT,0320,RC,,,,outpatient,,,6875.00,4468.75,,,,,,,,,,,,,
GUIDEWIRE VASC L 150 CM DIA 0.038 IN SS PTFE STR FIX COR N,SUP-2116518,CDM,C1769,HCPCS,0272,RC,,,,both,,,29.83,19.39,,,,,,,,,,,,,
SPACER SPNL M H13MM 8DEG ANTR LUM INTBDY FUS MONUMENT,SUP-2231099,CDM,C1821,HCPCS,0278,RC,,,,both,,,20410.00,13266.50,,,,,,,,,,,,,
BIT DRL DIA32MM CANN FOR GUID GROWTH EIGHT PLATE SYS,SUP-2316400,CDM,2720000010,LOCAL,0272,RC,,,,both,,,605.77,393.75,,,,,,,,,,,,,
PLATE BNE W11XL164MM THK33MM 12 H BILAT MTPHSEAL TI LOK,SUP-2190766,CDM,C1713,HCPCS,0278,RC,,,,both,,,3689.56,2398.21,,,,,,,,,,,,,
TROCAR ENDOPATH XCEL W/OPTIVIEW TECH DILATING TIP 5MM 75MM,SUP-2855494,CDM,2720000010,LOCAL,0272,RC,,,,both,,,635.35,412.98,,,,,,,,,,,,,
PLATE BNE THK1.5MM TI ORAL MAXILLOFACIAL MAND 3X3 H,SUP-2263007,CDM,C1713,HCPCS,0278,RC,,,,both,,,691.11,449.22,,,,,,,,,,,,,
WEDGE TIB SZ 3-4 5MM R MED L LAT KNEE HEMI STP SCR ON,SUP-2346182,CDM,C1776,CPT,0278,RC,,,,both,,,5068.75,3294.69,,,,,,,,,,,,,
GUIDEWIRE VASC N L 190 CM DIA 0.035 IN LLT TAPR CRV STRL,SUP-2170313,CDM,C1769,HCPCS,0272,RC,,,,both,,,116.18,75.52,,,,,,,,,,,,,
NAIL IM L255MM DIA8MM UNIV DK BLU PROX TIB TI BEND CANN LOK,SUP-2180381,CDM,C1713,HCPCS,0278,RC,,,,both,,,4592.41,2985.07,,,,,,,,,,,,,
HC So1 Alpha Fetoprotein|NOT REASONABLE AND NECESSARY,PX-3018210567,CDM,82105,CPT,0301,RC,,,GZ,outpatient,,,107.00,69.55,,,,,,,,,,,,,
RESERVOIR VENTRICULAR 6 MM CSF SHUNT,SUP-2278366,CDM,C1889,HCPCS,0278,RC,,,,both,,,390.11,253.57,,,,,,,,,,,,,
PLATE BNE L216MM 16 H BILAT MTPHSEAL S STL LOK COMPR LO,SUP-2185107,CDM,C1713,HCPCS,0278,RC,,,,both,,,3534.16,2297.20,,,,,,,,,,,,,
ALLOGRAFT DERMAL SM THCK PERF CNTOUR TISS MTRX ALLDERM,SUP-2113061,CDM,Q4116,HCPCS,0636,RC,,,,both,,,8594.18,5586.22,,,,,,,,,,,,,
DEVICE BNE ACCS SZ 3 8GA L18MM DIA42MM INTRO FOR VERTPLSTY,SUP-2280279,CDM,C1894,HCPCS,0272,RC,,,,both,,,1160.54,754.35,,,,,,,,,,,,,
TRIAL HIP OD54MM ID36MM 0DEG CROSSLINKED POLYETH LNR DISP R3,SUP-2345756,CDM,C1776,CPT,0278,RC,,,,both,,,519.70,337.80,,,,,,,,,,,,,
COMPONENT FEM H LT KNEE OPT NXGN LPS-FLEX,SUP-2201161,CDM,C1776,CPT,0278,RC,,,,both,,,17596.56,11437.76,,,,,,,,,,,,,
SPLINT ANKLE FOOT ORTHOSIS MALE 8-10 RT LG,SUP-2326060,CDM,L4350,HCPCS,0272,RC,,,,both,,,98.56,64.06,,,,,,,,,,,,,
DEVICE COAG 3 CM GUID 6130 EPISENSE (only avail by Each),SUP-2424447,CDM,2720000010,LOCAL,0272,RC,,,,both,,,36110.00,23471.50,,,,,,,,,,,,,
GRAFT BONE POSTEROLATERAL 2.5CMX5CM MAGNIFUSE,SUP-2293967,CDM,C1713,HCPCS,0278,RC,,,,both,,,9784.24,6359.76,,,,,,,,,,,,,
KIT INTRO DIL DIA16 FR ENDOSCP OR RADIOLOGIC FOR GASTMY FEED,SUP-2764590,CDM,2720000010,LOCAL,0272,RC,,,,both,,,690.71,448.96,,,,,,,,,,,,,
PLATE BNE W195XL72MM NAR 6X5 H ST R DST RAD VOLAR TI VAR ANG,SUP-2180842,CDM,C1713,HCPCS,0278,RC,,,,both,,,2841.39,1846.90,,,,,,,,,,,,,
TUBE INNR EAR MYR VENT REUT BOB W/ FLNG H 1.14 MM ID,SUP-2277564,CDM,L8699,HCPCS,0278,RC,,,,both,,,41.39,26.90,,,,,,,,,,,,,
SUPPORT ORTHOT LOWER EXTREMITY CUST GTT LCK RETAINER,SUP-2435697,CDM,L2785,HCPCS,0274,RC,,,,both,,,83.90,54.53,,,,,,,,,,,,,
CAGE SPNL L12XW12XH10MM 4 LOBE MESH L ANAT FOOTPRINT MOD,SUP-2317730,CDM,C1889,HCPCS,0278,RC,,,,both,,,5614.32,3649.31,,,,,,,,,,,,,
DEVICE ENDOSKELETAL SYS PROSTHETIC BK FORK STRP,SUP-2388211,CDM,L5684,HCPCS,0272,RC,,,,both,,,126.48,82.21,,,,,,,,,,,,,
PLATE BONE WITHOUT ANGLE THICK 2 MM MANDIBLE PATIENT SPECIFI,SUP-2838606,CDM,C1713,HCPCS,0278,RC,,,,both,,,16463.02,10700.96,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED PRSS FT CHIPBIOPRES] ZIMMER BIOMET INC],SUP-2137375,CDM,C1776,CPT,0278,RC,,,,both,,,17719.02,11517.36,,,,,,,,,,,,,
CATHETER EP F CRV 5-5-5MM SPC 6FRX110CM TORQR,SUP-2281819,CDM,C1730,HCPCS,0272,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
GUIDEPIN ORTHOPAEDIC 2.8 MM NON STERILE LATEXFREE REUSABLE,SUP-2836578,CDM,C1769,HCPCS,0272,RC,,,,both,,,135.02,87.76,,,,,,,,,,,,,
SUPPORT KNEE HALF RND,SUP-2324295,CDM,L1810,HCPCS,0274,RC,,,,both,,,113.20,73.58,,,,,,,,,,,,,
MESH SYN Y SHP FLAT SUT SURF MULTDIR POS FOR VAG COLPASSIST,SUP-2139037,CDM,C1781,HCPCS,0278,RC,,,,both,,,4361.65,2835.07,,,,,,,,,,,,,
IMPLANT BRST DIA14.3CM P4.4CM 475-570CC NACL RND SMOOTH,SUP-2300244,CDM,C1789,HCPCS,0278,RC,,,,both,,,3344.10,2173.66,,,,,,,,,,,,,
KNIFE OPHTH 0.5MM STR DISECT USHRP GRIESHABER,SUP-2109684,CDM,2720000010,LOCAL,0272,RC,,,,both,,,428.42,278.47,,,,,,,,,,,,,
BUR SURG HUDSON BRAC 16 MM MCKENZ ENLARGING,SUP-2476367,CDM,2720000010,LOCAL,0272,RC,,,,both,,,354.82,230.63,,,,,,,,,,,,,
SUPPORT ORTHOT ANK KNEE TIB CUST FRAC SEMI RIGID,SUP-2435649,CDM,L4396,HCPCS,0274,RC,,,,both,,,1789.02,1162.86,,,,,,,,,,,,,
HC So Bcr/Abl1 Translocation Anal,PX-3108120666,CDM,81206,CPT,0310,RC,,,,both,,,211.00,137.15,,,,,,,,,,,,,
LOCKING PLATE SGTTL 8 HOLE CRVD LNG 10MM THICK CP TTNM,SUP-2676885,CDM,C1713,HCPCS,0278,RC,,,,both,,,1150.43,747.78,,,,,,,,,,,,,
GRAFT BNE SUB 5CC SYN TISS TRICALCIUM PHSPTE RESRB MORSL,SUP-2368163,CDM,C1713,HCPCS,0278,RC,,,,both,,,1613.02,1048.46,,,,,,,,,,,,,
COUNTERSINK SURG SCREW DIA 6.5/7.5 MM LG CANN HD QC STRL,SUP-2905604,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2315.28,1504.93,,,,,,,,,,,,,
SPACER SPNL W12XH18XL14MM 0DEG PEEK OPTMA INTERVERTEBRAL LUM,SUP-2211873,CDM,C1821,HCPCS,0278,RC,,,,both,,,12560.00,8164.00,,,,,,,,,,,,,
GRAFT VASC GORTX L 20 CM DIA20 MM RNG L 20 CM EPTFE STR STD,SUP-2396034,CDM,C1768,CPT,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
HC Inject Tendon Origin/Insert|RIGHT SIDE,PX-3612055100,CDM,20551,CPT,0361,RC,,,RT,outpatient,,,1485.00,965.25,,,,,,,,,,,,,
ALLOGRAFT BNE CRUSH 5 CC FD IRRADIATED CANC,SUP-2867154,CDM,C1762,CPT,0278,RC,,,,both,,,563.79,366.46,,,,,,,,,,,,,
PIN FIX L4MM DIA21MM CRANIOMAXILLOFACIAL SELF RET,SUP-2263016,CDM,C1713,HCPCS,0278,RC,,,,both,,,1151.94,748.76,,,,,,,,,,,,,
SCREW BONE 6.4MMX90MM CAPT RECON SCR TI TRIGEN,SUP-2347067,CDM,C1713,HCPCS,0278,RC,,,,both,,,963.98,626.59,,,,,,,,,,,,,
TROCAR ENDOSCP L 100 MM DIA12 MM STD LAPSCP BLADED SMTH CANN,SUP-2896405,CDM,2720000010,LOCAL,0272,RC,,,,both,,,393.38,255.70,,,,,,,,,,,,,
SYSTEM BX 25GA FN NDL SIX DST CUT EDG SHARKCORE,SUP-2174357,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1623.38,1055.20,,,,,,,,,,,,,
PLATE BNE T 1.5X50 MM 4X9 HOLE SS,SUP-2569096,CDM,C1713,HCPCS,0278,RC,,,,both,,,336.77,218.90,,,,,,,,,,,,,
ANCHOR SUT DIA5.5MM PEEK KNOTLESS FOR SFT TISS FIX MULTIFIX,SUP-2342077,CDM,C1713,HCPCS,0278,RC,,,,both,,,3751.48,2438.46,,,,,,,,,,,,,
GRAFT DERMAL 10X10 CMX1 MM PORCINE DERMAL CLLGN PERMACOL,SUP-2174695,CDM,C9364,HCPCS,0278,RC,,,,both,,,6878.42,4470.97,,,,,,,,,,,,,
HEAD FEM FD 40 MM TIMS CRFT,SUP-2423183,CDM,C1776,CPT,0278,RC,,,,both,,,5290.90,3439.08,,,,,,,,,,,,,
SCREW BNE L32MM DIA3.5MM STD CORT TIM ST CANN NONLOCKING,SUP-2413371,CDM,C1713,HCPCS,0278,RC,,,,both,,,91.06,59.19,,,,,,,,,,,,,
CATHETER CV FULL TY 018 4 FRX5 CM DL J TIP STR NDL SPECTRUM,SUP-2759854,CDM,C1751,HCPCS,0278,RC,,,,both,,,512.89,333.38,,,,,,,,,,,,,
SCREW BNE L24MM DIA3.5MM S STL SELF DRL NONCANNULATED LOK,SUP-2397385,CDM,C1713,HCPCS,0278,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
THERASKIN SM 2.5X5.1CM 13SQ CM,SUP-2264657,CDM,Q4121,HCPCS,0636,RC,,,,both,,,3399.05,2209.38,,,,,,,,,,,,,
GRAFT VASC ARTEGRAFT L 35 CM DIA 6 MM CLLGN BOV CAR ART,SUP-2120668,CDM,C1768,CPT,0278,RC,,,,both,,,7878.26,5120.87,,,,,,,,,,,,,
TRAY CATH CNTRL VENOU LUMENX2 7FR DIA 36CML SIL 0.2/0.3ML PR,SUP-2613072,CDM,C1751,HCPCS,0278,RC,,,,both,,,497.69,323.50,,,,,,,,,,,,,
TAP VITALITY 7.5MM IL,SUP-2402707,CDM,2720000010,LOCAL,0272,RC,,,,both,,,659.40,428.61,,,,,,,,,,,,,
SCREW BNE L 14 MM DAI 3.5 MM COCR ELBW LCK HEXALOBE,SUP-2912775,CDM,C1713,HCPCS,0278,RC,,,,both,,,433.32,281.66,,,,,,,,,,,,,
KIT PEG 20FR STD NONSAFETY PUL PLCMNT TECH PONSKY,SUP-2127663,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2611.29,1697.34,,,,,,,,,,,,,
STEM FEM SEG LG 3 CM DPHSEAL KNEE ELLIP OSS,SUP-2445716,CDM,C1776,CPT,0278,RC,,,,both,,,2359.71,1533.81,,,,,,,,,,,,,
IMPLANT TOE JT L13MM DIA2MM BLDE W4XL635IN 10DEG S STL THRD,SUP-2397816,CDM,C1776,CPT,0278,RC,,,,both,,,1080.16,702.10,,,,,,,,,,,,,
PLATE BNE STR 3.5X49.2 MM 4 HOLE RECON FOR SM FRAG SYS TI NS,SUP-2475381,CDM,C1713,HCPCS,0278,RC,,,,both,,,834.42,542.37,,,,,,,,,,,,,
WEDGE OSTEOTMY L6CM W3CM H1.75CM ASEP FRZ DRY,SUP-2320325,CDM,C1776,CPT,0278,RC,,,,both,,,4678.60,3041.09,,,,,,,,,,,,,
BUR SURG DIAMOND 4 MM 15 CM BALL FOR MA-15 BEAR SL,SUP-2848284,CDM,2720000010,LOCAL,0272,RC,,,,both,,,548.68,356.64,,,,,,,,,,,,,
CATHETER THROMCTMY CLOTTRIEVER L 115 CM DIA11 FR COR ELEMENT,SUP-2740186,CDM,C1757,HCPCS,0272,RC,,,,both,,,20410.00,13266.50,,,,,,,,,,,,,
INSERT TIB SZ 1 THK7MM E VITALIZE POST STBL HI FLX,SUP-2314968,CDM,C1776,CPT,0278,RC,,,,both,,,4232.72,2751.27,,,,,,,,,,,,,
BLADE SAW OSCILLATING 9.5MMW X18.5MML FLUORIDEFSTRYKER MICRO,SUP-2605446,CDM,2720000010,LOCAL,0272,RC,,,,both,,,63.62,41.35,,,,,,,,,,,,,
KIT PAIN PMP 270ML 4ML/HR ELASTOMERIC NONNARCOTIC 2 ON-Q,SUP-2236816,CDM,C9804,HCPCS,0272,RC,,,,both,,,413.44,268.74,,,,,,,,,,,,,
GUIDEWIRE VASC SYNCHRO 300CM 0.014IN SEG 35CM EXCHANGE STD,SUP-2717705,CDM,C1769,HCPCS,0272,RC,,,,both,,,2716.10,1765.46,,,,,,,,,,,,,
PLATE BNE W9XL145MM THK1MM 12 H TI 1/3 TBLR W/ CLLR LIMIT,SUP-2190958,CDM,C1713,HCPCS,0278,RC,,,,both,,,584.57,379.97,,,,,,,,,,,,,
BIT DRL OD90MM TIB CANN TOGGLELOC,SUP-2212946,CDM,2720000010,LOCAL,0272,RC,,,,both,,,985.96,640.87,,,,,,,,,,,,,
RAIL INT FIX NEW AD 150 MM,SUP-2517842,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3366.08,2187.95,,,,,,,,,,,,,
IMPLANT BIO TISS W16XL20CM REINF BIOSCAFFOLDS PERM OVITEX 1S,SUP-2383095,CDM,C1781,HCPCS,0278,RC,,,,both,,,18086.40,11756.16,,,,,,,,,,,,,
POST EXT FIX 90 DEG UNILAT NS MAV,SUP-2931139,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1384.74,900.08,,,,,,,,,,,,,
SCREW BONE L130MM DIA12MM HIP NAIL LAG FOR TRAUM GAM,SUP-2370996,CDM,C1713,HCPCS,0278,RC,,,,both,,,1358.36,882.93,,,,,,,,,,,,,
STENT BILI L20MM DIA7MM CATH L80CM LIFESTNT,SUP-2420396,CDM,C1876,HCPCS,0278,RC,,,,both,,,3124.30,2030.79,,,,,,,,,,,,,
BIT DRL AO SHFT 4.5 MM OVR SCR NS DISP,SUP-2489681,CDM,2720000010,LOCAL,0272,RC,,,,both,,,926.68,602.34,,,,,,,,,,,,,
STAPLER INT STPL SZ 35MM L21MM DIA5MM TI CIR CUT ECHELON,SUP-2283241,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3758.39,2442.95,,,,,,,,,,,,,
SPLINT ORTH M HND THMS SUSP,SUP-2112602,CDM,L3807,HCPCS,0274,RC,,,,both,,,96.96,63.02,,,,,,,,,,,,,
SPHINCTEROTOME ENDOSCP STR TIP 0.035 INX30 MM DSTL VISIGLIDE,SUP-2465029,CDM,2720000010,LOCAL,0272,RC,,,,both,,,11423.38,7425.20,,,,,,,,,,,,,
CAP PROTCT FOR FIX PIN W/ 4.5 MM,SUP-2188623,CDM,C1713,HCPCS,0278,RC,,,,both,,,4571.68,2971.59,,,,,,,,,,,,,
SCREW STEREOTACTIC SYS LNG HD RNG DISP,SUP-2244000,CDM,C1713,HCPCS,0278,RC,,,,both,,,676.98,440.04,,,,,,,,,,,,,
STOCKING COMPR TIB SOCK LEN,SUP-2237272,CDM,2720000010,LOCAL,0272,RC,,,,both,,,394.32,256.31,,,,,,,,,,,,,
PLATE BNE W16XL92MM BLDE L80MM THK4.8MM 95DEG 5 H,SUP-2185489,CDM,C1713,HCPCS,0278,RC,,,,both,,,2683.19,1744.07,,,,,,,,,,,,,
SYRINGE TB 27 GAX1/2 IN 1 CC SAFETY,SUP-2693958,CDM,2720000010,LOCAL,0272,RC,,,,both,,,14795.68,9617.19,,,,,,,,,,,,,
VALVE HYDROCEPHALUS W/ DSTL CATH PROGAV 2.0,SUP-2108743,CDM,C1729,HCPCS,0272,RC,,,,both,,,8274.50,5378.42,,,,,,,,,,,,,
K WIRE FIXATION L400MM STAINLESS STEEL SMOOTH,SUP-2586483,CDM,C1713,HCPCS,0278,RC,,,,both,,,635.38,413.00,,,,,,,,,,,,,
LINER ACET F HIP DBL MOBILITY CONV FOR DME MPACT,SUP-2420198,CDM,C1776,CPT,0278,RC,,,,both,,,5375.68,3494.19,,,,,,,,,,,,,
PLATE BNE LCK 5.5X189 MM RT PROX LAT TIB 10 HOLE SS STRL,SUP-2478081,CDM,C1713,HCPCS,0278,RC,,,,both,,,3974.20,2583.23,,,,,,,,,,,,,
DEVICE COAG 3CM GUID 6130 FOR EPICARD ABLAT EPI-SENSE,SUP-2124438,CDM,2720000010,LOCAL,0272,RC,,,,both,,,36110.00,23471.50,,,,,,,,,,,,,
CATHETER ART DL 0.018 IN 6 FRX110 CM PULM HEPCOAT LTX,SUP-2662681,CDM,C1751,HCPCS,0278,RC,,,,both,,,86.38,56.15,,,,,,,,,,,,,
COMPONENT SHLDR REVERSED RSP,SUP-2217517,CDM,C1776,CPT,0278,RC,,,,both,,,25905.00,16838.25,,,,,,,,,,,,,
HEAD HUM H19MM DIA48MM SHLDR CO CHROM PRI BIO MOD STD NK,SUP-2404618,CDM,C1776,CPT,0278,RC,,,,both,,,3001.84,1951.20,,,,,,,,,,,,,
UNIT THER COMB CRYO W/ PD SHLDR W/ TUBE PWR OPERATED W/ BD,SUP-2150877,CDM,C1713,HCPCS,0278,RC,,,,both,,,492.98,320.44,,,,,,,,,,,,,
PLATE BNE L21MM THK0.6MM 8MM OFFSET 5 H BILAT CHIN ORAL,SUP-2191219,CDM,C1713,HCPCS,0278,RC,,,,both,,,1213.30,788.64,,,,,,,,,,,,,
SURGICAL PROCEDURE PACK UNIV STRL,SUP-2418088,CDM,2720000010,LOCAL,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
SHUNT SURG REG 60 CM ASMBLY STRATA II BIOGLDE,SUP-2628594,CDM,C1729,HCPCS,0272,RC,,,,both,,,13928.95,9053.82,,,,,,,,,,,,,
CATHETER EP A 5-5-5-175-175 MM 5 FRX120 CM,SUP-2356899,CDM,C1730,HCPCS,0272,RC,,,,both,,,775.58,504.13,,,,,,,,,,,,,
GUIDEWIRE SMOOTH 2.0X150MM,SUP-2720114,CDM,C1769,HCPCS,0272,RC,,,,both,,,129.68,84.29,,,,,,,,,,,,,
PROBE OPHTH LASER FIX FBR MOV SHFT ST DIR 20GA,SUP-2382598,CDM,2720000010,LOCAL,0272,RC,,,,both,,,499.26,324.52,,,,,,,,,,,,,
PLATE BNE LCK 3.5X104 MM RT DSTL MEDL HUM 5 HOLE FIX ANGLE,SUP-2500304,CDM,C1713,HCPCS,0278,RC,,,,both,,,2587.36,1681.78,,,,,,,,,,,,,
HOOK PED GIC52 5.5 RHT THOR HK TI88905532,SUP-2291328,CDM,C1713,HCPCS,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
SPHINCTEROTOME RAP EXCHG CANN WIRE STD 20MM 5MM,SUP-2149565,CDM,C1713,HCPCS,0278,RC,,,,both,,,547.74,356.03,,,,,,,,,,,,,
ANCHOR SUTURE STRL CITREFIX XPRESS,SUP-2883465,CDM,C1713,HCPCS,0278,RC,,,,both,,,4264.12,2771.68,,,,,,,,,,,,,
MESH HERN DIA20CM POLY SYN CLLGN COAT RND OPTIMIZED COMP,SUP-2174717,CDM,C1781,HCPCS,0278,RC,,,,both,,,2345.36,1524.48,,,,,,,,,,,,,
HC Ot Vasopneumatic Device Therapy,PX-4309701600,CDM,97016,CPT,0430,RC,,,,both,,,206.00,133.90,,,,,,,,,,,,,
PLATE BNE L 10 H R CLAV LOK,SUP-2107748,CDM,C1713,HCPCS,0278,RC,,,,both,,,2367.56,1538.91,,,,,,,,,,,,,
PLATE BONE LOCKING 4.5X408 MM 22 HOLE COMPRESSION,SUP-2837371,CDM,C1713,HCPCS,0278,RC,,,,both,,,12046.14,7829.99,,,,,,,,,,,,,
CATHETER MAP 8.5 FR 50 MMX128 CM FIRMAP,SUP-2473916,CDM,C1730,HCPCS,0272,RC,,,,both,,,14758.00,9592.70,,,,,,,,,,,,,
ELECTRODE CORTICAL 4 X 4 KT STRL DISP EVO,SUP-2934685,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4160.50,2704.32,,,,,,,,,,,,,
STEM FEM L230MM DIA14MM RT HIP CVD REV CLLRLSS U2,SUP-2391365,CDM,C1776,CPT,0278,RC,,,,both,,,19946.85,12965.45,,,,,,,,,,,,,
HEAD FEM SKIRTED 15+ MM 14/16 32 MM OFFSET TAPR STD STYL,SUP-2249720,CDM,C1776,CPT,0278,RC,,,,both,,,2013.37,1308.69,,,,,,,,,,,,,
PLATE BNE L 28.8 X W 5.1 MM THK 1 MM SCREW DIA2/2.3 MM 4 H,SUP-2936179,CDM,C1713,HCPCS,0278,RC,,,,both,,,1924.82,1251.13,,,,,,,,,,,,,
BIT DRL L 125 MM DIA2 MM SCREW DIA2 MM AO QC NS REUSE V,SUP-2908197,CDM,2720000010,LOCAL,0272,RC,,,,both,,,717.11,466.12,,,,,,,,,,,,,
BLADE SHV 2MM TYP A BPLR STR DISPOSABLE,SUP-2312958,CDM,C1713,HCPCS,0278,RC,,,,both,,,547.68,355.99,,,,,,,,,,,,,
CLAMP EXT FIX M 6 POS MULTIPIN,SUP-2188529,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2039.40,1325.61,,,,,,,,,,,,,
PLATE BNE L54MM BLDE W9.2XL30MM 90DEG 4 H BILAT S STL LOK,SUP-2185359,CDM,C1713,HCPCS,0278,RC,,,,both,,,3175.17,2063.86,,,,,,,,,,,,,
SPACER AUG SZ 10 STD TAPR CEM PRI,SUP-2251031,CDM,C1776,CPT,0278,RC,,,,both,,,616.07,400.45,,,,,,,,,,,,,
CETUXIMAB 200 MG/100ML IV SOLN,RX-104381,CDM,J9055,HCPCS,0636,RC,66733-0958-23,NDC,,both,100,ML,4818.30,3131.89,,,,,,,,,,,,,
GRAFT HUM TISS FRZN ALLGRFT FEM WHL STRUCTURAL L,SUP-2307312,CDM,C1713,HCPCS,0278,RC,,,,both,,,29046.66,18880.33,,,,,,,,,,,,,
STAPLE BNE 25X20X20 MM SUPER ELASTIC NIT MEMOFIX,SUP-2423401,CDM,C1713,HCPCS,0278,RC,,,,both,,,5736.84,3728.95,,,,,,,,,,,,,
PLATE BNE MAXILLOFCL 1 MESH KT NS FACE ID,SUP-2909638,CDM,C1713,HCPCS,0278,RC,,,,both,,,34573.57,22472.82,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED STD FEM TIB PATELLAR CEM SURF TIV,SUP-2212332,CDM,C1776,CPT,0278,RC,,,,both,,,12850.07,8352.55,,,,,,,,,,,,,
ALLOPATCH HD MESHED THIN 04 07MM 2CM X 5CM HYDRATED,SUP-2727151,CDM,Q4128,HCPCS,0636,RC,,,,both,,,1975.06,1283.79,,,,,,,,,,,,,
CARBOXYMETHYLCELLULOSE SOD PF 1 % OP GEL,RX-138278,CDM,6370000000,HCPCS,0637,RC,00023-4554-30,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
SCREW INTRF 7X25 MM NS SOFTSILK,SUP-2877782,CDM,C1713,HCPCS,0278,RC,,,,both,,,128.58,83.58,,,,,,,,,,,,,
GRAFT BNE BLOCK 7 MM ILLIUM TRICORT,SUP-2162595,CDM,C1713,HCPCS,0278,RC,,,,both,,,7206.30,4684.09,,,,,,,,,,,,,
VALVE CSF PROGRAMMABLE SM IN-LINE SEPARABLE CATH CERTAS +,SUP-2666578,CDM,C1889,HCPCS,0278,RC,,,,both,,,11914.89,7744.68,,,,,,,,,,,,,
STAPLE KIT 20X20 MM STRL INSTAFIX LTX DISP,SUP-2857583,CDM,C1713,HCPCS,0278,RC,,,,both,,,4625.22,3006.39,,,,,,,,,,,,,
GUIDEWIRE ORTH L 450 MM DIA 3.2 MM SMTH W/O THRD STRL ASNS,SUP-2902286,CDM,C1769,HCPCS,0272,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
GRAFT DURA L 2 X W 2 IN TYP I CLLGN BOV ACHILLES TEND RESRB,SUP-2889749,CDM,C1763,HCPCS,0278,RC,,,,both,,,1478.03,960.72,,,,,,,,,,,,,
BIT DRL CANN 90-120 MM 85-100 MM FT SCREW YEL ACUTRK 6/7,SUP-2107242,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2964.16,1926.70,,,,,,,,,,,,,
PACK AUTOLOG AUTOTRANSUFION,SUP-2280541,CDM,2720000010,LOCAL,0272,RC,,,,both,,,364.24,236.76,,,,,,,,,,,,,
MESH HERN OPTIMIZED COMP 15X10 CM RND POLYESTER PARIETEX,SUP-2752181,CDM,C1781,HCPCS,0278,RC,,,,both,,,2354.56,1530.46,,,,,,,,,,,,,
PLATE BNE MESHED 1 MM MXLFCL 8 HOLE LF,SUP-2461932,CDM,C1713,HCPCS,0278,RC,,,,both,,,3886.66,2526.33,,,,,,,,,,,,,
STIMULATOR NERVE QPLR 60X55X11.4 MM 28 CC 45 GM ENTERRA II,SUP-2866565,CDM,C1767,HCPCS,0278,RC,,,,both,,,40820.00,26533.00,,,,,,,,,,,,,
BEARING TIB L67MM THK24MM KNEE ANTR STBL VANGUARD,SUP-2408110,CDM,C1776,CPT,0278,RC,,,,both,,,7168.62,4659.60,,,,,,,,,,,,,
GRAFT HUM TISS DIA19MM THK20MM MT RESTORING DISC,SUP-2321678,CDM,C1776,CPT,0278,RC,,,,both,,,10142.20,6592.43,,,,,,,,,,,,,
SET SCR SPNL L225MM DIA14MM ANTR PEDCL S STL BRK OFF FOR 2,SUP-2279972,CDM,C1713,HCPCS,0278,RC,,,,both,,,223.73,145.42,,,,,,,,,,,,,
GRAFT DURA W3XL3IN THK0.6MM PURIFIED TYP 1 CLLGN HIGHLY,SUP-2365423,CDM,C1763,HCPCS,0278,RC,,,,both,,,2468.79,1604.71,,,,,,,,,,,,,
EXTENSION STEM L45MM GTT DN FOR TIB PLT NXGN MIS,SUP-2200893,CDM,C1713,HCPCS,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
CUTTER LINEAR PWR LNG 45 MM ARTICULATING ENDOSCP ECHELON,SUP-2851474,CDM,2720000010,LOCAL,0272,RC,,,,both,,,959.33,623.56,,,,,,,,,,,,,
PLATE RIM RAD HD LNG,SUP-2361552,CDM,C1713,HCPCS,0278,RC,,,,both,,,3275.33,2128.96,,,,,,,,,,,,,
CONNECTOR SPNL TI ROD STR SLT FOR 6.35MM ROD MNRCH,SUP-2254509,CDM,C1713,HCPCS,0278,RC,,,,both,,,2317.32,1506.26,,,,,,,,,,,,,
SCREW INTRF L25MM DIA8MM STD CORT NONLOCKING SMARTSCR ACL,SUP-2166539,CDM,C1713,HCPCS,0278,RC,,,,both,,,430.75,279.99,,,,,,,,,,,,,
CUTTER PYRAMESH LOT NUMBER RS06M004,SUP-2280089,CDM,2720000010,LOCAL,0272,RC,,,,both,,,820.33,533.21,,,,,,,,,,,,,
SCREW BNE L55MM DIA4.5MM THRD L26MM HD DIA8MM MALL S STL,SUP-2184555,CDM,C1713,HCPCS,0278,RC,,,,both,,,129.12,83.93,,,,,,,,,,,,,
PIN TRANSFIXING L275MM DIA5MM THRD L6MM S STL EXTRAFIX,SUP-2205303,CDM,C1713,HCPCS,0278,RC,,,,both,,,540.87,351.57,,,,,,,,,,,,,
SCREW IM NAIL DIA 5 MM SZ 60 PARTIALLY THRD C NS PANTA2,SUP-2931277,CDM,C1713,HCPCS,0278,RC,,,,both,,,1760.88,1144.57,,,,,,,,,,,,,
PLATE BONE L57MM 4 H BILAT 1/3 TBLR LCK COMPR RIG FOR 3.5MM,SUP-2343753,CDM,C1713,HCPCS,0278,RC,,,,both,,,267.18,173.67,,,,,,,,,,,,,
COMPONENT HUM DIA48MM STD SUT CLLR GLOB UNITE,SUP-2249863,CDM,C1776,CPT,0278,RC,,,,both,,,1245.95,809.87,,,,,,,,,,,,,
PLATE SPINAL 38X45X0.4 MM CONTOURABLE MESH MALLEABLE LOW PRO,SUP-2838370,CDM,C1713,HCPCS,0278,RC,,,,both,,,4214.51,2739.43,,,,,,,,,,,,,
CATHETER HD SET 035 12 FRX15 CM 60 CM ACUTE DL TURBO-FLO HD,SUP-2759833,CDM,C1752,HCPCS,0278,RC,,,,both,,,435.30,282.94,,,,,,,,,,,,,
SYSTEM MIXING AND DELIVERY BONE CEMENT MEDIUM VISCOSITY,SUP-2766615,CDM,C1713,HCPCS,0278,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
CONNECTOR SPNL CLOSED 30 MM AX MARINER OUTRIG,SUP-2709766,CDM,C1713,HCPCS,0278,RC,,,,both,,,5840.40,3796.26,,,,,,,,,,,,,
SCREW BNE SELF RET MINI 2X6 MM MAND X DRV TI,SUP-2466032,CDM,C1713,HCPCS,0278,RC,,,,both,,,155.40,101.01,,,,,,,,,,,,,
SPLINT WRST UNIV L11IN L CUTAWAY PERF FOAM CONSTR MAL,SUP-2194860,CDM,L3809,HCPCS,0272,RC,,,,both,,,15.51,10.08,,,,,,,,,,,,,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,0250,RC,00990-7922-61,NDC,,both,150,ML,44.70,29.05,,,,,,,,,,,,,
GUIDEWIRE ORTH L5.75IN DIA0.035IN TI SGL TRCR THRD FOR MAYO,SUP-2107906,CDM,C1769,HCPCS,0272,RC,,,,both,,,144.44,93.89,,,,,,,,,,,,,
LOOP SURG 2-0 INFIN W/ NDL THRDR WHT BLU ACTIFLIP SB,SUP-2761966,CDM,C1713,HCPCS,0278,RC,,,,both,,,1777.24,1155.21,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 10 CM DIA 5 MM STR STD WALL REINF,SUP-2488337,CDM,C1768,CPT,0278,RC,,,,both,,,356.30,231.59,,,,,,,,,,,,,
PIN EXT FIX L150MM DIA5MM THRD L40MM TI ST SELF DRL U SHP,SUP-2372357,CDM,2720000010,LOCAL,0272,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
GRAFT BNE FIBER XS 1.25 CC SYR DBM,SUP-2431095,CDM,C1889,HCPCS,0278,RC,,,,both,,,1460.10,949.06,,,,,,,,,,,,,
KIT BARIATRIC SIGNIA TRISTAPLE 1,SUP-2716331,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5430.25,3529.66,,,,,,,,,,,,,
BUR SURG DIA15MM TAPR ROUTER CUT ACC,SUP-2363689,CDM,2720000010,LOCAL,0272,RC,,,,both,,,362.70,235.75,,,,,,,,,,,,,
IMPLANT BIO 250 SQ CM OMEGA 3 21 PRE-MESHED FISH STRL DISP,SUP-2909178,CDM,Q4158,HCPCS,0636,RC,,,,both,,,29792.32,19365.01,,,,,,,,,,,,,
MIDLINE CATHETERIZATION KIT: 3 FRX8,SUP-2827494,CDM,C1751,HCPCS,0278,RC,,,,both,,,322.16,209.40,,,,,,,,,,,,,
GRAFT VASC SEALPTFE L 40 CM DIA 6 MM EPTFE GEL STD WALL STR,SUP-2385216,CDM,C1768,CPT,0278,RC,,,,both,,,1519.04,987.38,,,,,,,,,,,,,
STENT GRFT VASC OVATION IX L 100 MM 145 MM 14/10 MM 10/12 FR,SUP-2217732,CDM,C1768,CPT,0278,RC,,,,both,,,14126.86,9182.46,,,,,,,,,,,,,
KIT CARD POS 0035IN W NDL SYR CPS,SUP-2357315,CDM,C1769,HCPCS,0272,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
SLEEVE REDUC PUSH PUL FOR 3.5MM LCP PLT,SUP-2187792,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1216.53,790.74,,,,,,,,,,,,,
PLATE BNE L73MM 4 H NONSTERILE L PROX TIB S STL,SUP-2185697,CDM,C1713,HCPCS,0278,RC,,,,both,,,3647.27,2370.73,,,,,,,,,,,,,
MESH CRAN W120XL120MM PROF H0.6MM MIC MID FACE,SUP-2363672,CDM,C1713,HCPCS,0278,RC,,,,both,,,7994.94,5196.71,,,,,,,,,,,,,
GRAFT VASC L15CM BOR 24MM MAX SKRT L24MM DIA32MM PROX CLLR,SUP-2384984,CDM,C1768,CPT,0278,RC,,,,both,,,8917.60,5796.44,,,,,,,,,,,,,
CATHETER PICC 5FR L20CM MIDLN W/ STYL INTMED TY PER-Q-CATH,SUP-2125575,CDM,C1894,HCPCS,0272,RC,,,,both,,,198.13,128.78,,,,,,,,,,,,,
DARBEPOETIN ALFA 300 MCG/0.6ML IJ SOSY,RX-131233,CDM,J0881,HCPCS,0636,RC,55513-0111-01,NDC,,both,0.6,ML,6849.90,4452.43,,,,,,,,,,,,,
Z DISCONTINUED CATHETER IABP 7FR 40CC SHTH LAIN FBROPT DATASCP SYS,SUP-2227313,CDM,C1725,HCPCS,0272,RC,,,,both,,,2976.06,1934.44,,,,,,,,,,,,,
CATHETER ATHRCTMY OCELOT MVRX L 110 CM DIA 6 FR GUIDEWIRE,SUP-2124794,CDM,C2628,HCPCS,0272,RC,,,,both,,,7834.30,5092.29,,,,,,,,,,,,,
HC Ot Manual Therapy per 15 Min.|OP PT SERVICES|DOCUMENTATION ON FILE|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS|UNUSUAL NON-OVERLAPPING SERVICE,PX-4309714000,CDM,97140,CPT,0430,RC,,,GP|KX|CQ|XU,outpatient,,,194.00,126.10,,,,,,,,,,,,,
SUPPORT ORTHOT WRST HND CUST ADJ FIT STRP W/O JT FABRICATED,SUP-2435773,CDM,L3906,HCPCS,0272,RC,,,,both,,,1305.74,848.73,,,,,,,,,,,,,
CATHETER EMB 2.2-2.2FR L150CM BLLN L10MM DIA4MM OCCL,SUP-2172471,CDM,C2628,HCPCS,0272,RC,,,,both,,,4747.68,3085.99,,,,,,,,,,,,,
PIN FIX L65MM THRD HDLSS FOR TIB AND DSTL FEM NAVIGATION,SUP-2314150,CDM,C1713,HCPCS,0278,RC,,,,both,,,188.40,122.46,,,,,,,,,,,,,
SCREW BNE L60MM DIA3MM THRD L20MM CORT SELF DRL,SUP-2316449,CDM,C1713,HCPCS,0278,RC,,,,both,,,288.88,187.77,,,,,,,,,,,,,
GUIDEWIRE VASC L 145 CM DIA 0.035 IN PTFE STR TIP,SUP-2147057,CDM,C1769,HCPCS,0272,RC,,,,both,,,29.08,18.90,,,,,,,,,,,,,
BIT DRL CANN MINI 4 MM BLU,SUP-2543593,CDM,2720000010,LOCAL,0272,RC,,,,both,,,782.49,508.62,,,,,,,,,,,,,
BUDESONIDE-FORMOTEROL FUMARATE 80-4.5 MCG/ACT IN AERO,RX-81453,CDM,6370000000,HCPCS,0637,RC,00186-0372-28,NDC,,both,6.9,GR,622.90,404.88,,,,,,,,,,,,,
TIP ASPIR L4.5IN OD1.92MM ID1.5MM SFT TISS STR FOR SONOPET,SUP-2367531,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1700.94,1105.61,,,,,,,,,,,,,
PLATE STRNL CLOSURE THK 1.5 MM 12 H TI O JUNCTION LP NS,SUP-2894535,CDM,C1713,HCPCS,0278,RC,,,,both,,,3353.52,2179.79,,,,,,,,,,,,,
HC Treat Radius Fx,PX-4502550000,CDM,25500,CPT,0450,RC,,,,both,,,692.00,449.80,,,,,,,,,,,,,
GRAFT BONE 15GM 15ML PARTICULATE SYNTH OSTEOCONDUCTIVE CLLGN,SUP-2288537,CDM,C1713,HCPCS,0278,RC,,,,both,,,2267.90,1474.13,,,,,,,,,,,,,
GRAFT HUM TISS W4XL4CM THK0.1-.2MM AMNIO MEM 2 LAYR,SUP-2370451,CDM,Q4150,HCPCS,0636,RC,,,,both,,,8314.72,5404.57,,,,,,,,,,,,,
SPACER SPNL LG 25 DEG 39X29X19 MM 5.3 CC ALIF INDEPENDENCE,SUP-2733342,CDM,C1889,HCPCS,0278,RC,,,,both,,,19468.00,12654.20,,,,,,,,,,,,,
DRILL TWST DIA4MM G FOR COLE RADLUC,SUP-2342346,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2052.87,1334.37,,,,,,,,,,,,,
CONNECTOR PACE LD SELECTSECURE MRI SURESCAN L 3.66 M,SUP-2937136,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1007.94,655.16,,,,,,,,,,,,,
PLATE BNE L 369 MM SCREW DIA 3.5/4.5 MM 18 H RT DSTL FEM,SUP-2931416,CDM,C1713,HCPCS,0278,RC,,,,both,,,20844.89,13549.18,,,,,,,,,,,,,
ALLOGRAFT HUM TISS FEN 10X4 CM SHT AMNION/CHORION AMNIOFIX,SUP-2871304,CDM,C1762,CPT,0278,RC,,,,both,,,9250.44,6012.79,,,,,,,,,,,,,
PLATE BNE LCK 118 MM RT DSTL RADIAL VOLAR 10 HOLE LAT CLMN,SUP-2459511,CDM,C1713,HCPCS,0278,RC,,,,both,,,2690.85,1749.05,,,,,,,,,,,,,
DRILL SURG UNIV SHFT COMPHSVE,SUP-2443504,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4041.18,2626.77,,,,,,,,,,,,,
STRUT EXT FIX LNG TRNSPRT NS DISP ILIZ,SUP-2933872,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6696.02,4352.41,,,,,,,,,,,,,
COMPONENT FEM SZ 6 R KNEE OXINIUM BI CRUCE STBL JOURNEY II,SUP-2350341,CDM,C1776,CPT,0278,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
SCREW INTRF N CANN 12X25 MM,SUP-2662018,CDM,C1713,HCPCS,0278,RC,,,,both,,,696.33,452.61,,,,,,,,,,,,,
ORTHOSIS ANK FT SM SZ M 6-7.5 WOM 7.5-9 LT CLOSE HEEL DLX,SUP-2195193,CDM,L1930,HCPCS,0272,RC,,,,both,,,104.72,68.07,,,,,,,,,,,,,
IMPLANT BRST GEL 4.9 CM PROJCT 11.1 CM 320-340 CC NATRELLE SZHP63320] ALLERGAN USA INC],SUP-2113784,CDM,C1789,HCPCS,0278,RC,,,,both,,,141.30,91.84,,,,,,,,,,,,,
SPLINT WRST SM L10IN L FA LN CIRCUMFERENTIAL STRP SLIP ON,SUP-2276627,CDM,L3809,HCPCS,0272,RC,,,,both,,,23.20,15.08,,,,,,,,,,,,,
TUBE VENT JAHN 1X9.5 MM BIOCOMPATIBLE DENS LT HA,SUP-2637886,CDM,L8699,HCPCS,0278,RC,,,,both,,,571.92,371.75,,,,,,,,,,,,,
CATHETER EP LG 5 MM 1 MM 5 FRX110 INQUIRY,SUP-2483880,CDM,C1730,HCPCS,0272,RC,,,,both,,,1405.90,913.83,,,,,,,,,,,,,
BIT DRL RETROGRADE 6 MM CANN W/ SUTURE RETRV ACUFEX TRUNAV,SUP-2848647,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1236.38,803.65,,,,,,,,,,,,,
DIST TIB ANTLAT PLATE LEFT NARROW 12H,SUP-2588758,CDM,C1713,HCPCS,0278,RC,,,,both,,,3920.92,2548.60,,,,,,,,,,,,,
PLATE BNE L 49 X W 8 MM THK 3.5 MM SCREW DIA2.7 MM 6 H SS 72440306N,SUP-2932862,CDM,C1713,HCPCS,0278,RC,,,,both,,,1431.06,930.19,,,,,,,,,,,,,
CLAMP SURG ADJ FOR SCHNZ SCREW NS,SUP-2863404,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1315.69,855.20,,,,,,,,,,,,,
GUIDEWIRE VASC GLIDEWIRE L 180 CM DIA 0.038 IN NIT HYDRPHLC,SUP-2141145,CDM,C1769,HCPCS,0272,RC,,,,both,,,132.88,86.37,,,,,,,,,,,,,
PROSTHESIS OSS STD 0.6X0.9X4.25 MM CLASSIC STAP TI,SUP-2638175,CDM,L8613,CPT,0278,RC,,,,both,,,706.72,459.37,,,,,,,,,,,,,
PLATE TI VA-LCKNG CALCANEAL W/TABS LG 2.7MM 64MM RGHT-STER,SUP-2547005,CDM,C1713,HCPCS,0278,RC,,,,both,,,3373.65,2192.87,,,,,,,,,,,,,
SCREW BNE SD 2X8 MM LCK TI SLV NS MATRIXMANDIBLE LF,SUP-2423439,CDM,C1713,HCPCS,0278,RC,,,,both,,,281.34,182.87,,,,,,,,,,,,,
NEEDLE SPNL Y 300 MM ES2 LT,SUP-2532844,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1522.08,989.35,,,,,,,,,,,,,
PLATE BNE L142MM 8 H ST R ANTEROMEDIAL DST TIB S STL VAR ANG,SUP-2177675,CDM,C1713,HCPCS,0278,RC,,,,both,,,5707.99,3710.19,,,,,,,,,,,,,
BRA SURG SUPP MED 34-36 IN ZIPPER,SUP-2213722,CDM,L8000,HCPCS,0274,RC,,,,both,,,120.54,78.35,,,,,,,,,,,,,
SCREW BNE L 110 MM DIA 3.5 MM ST LCK NS EVOS,SUP-2931890,CDM,C1713,HCPCS,0278,RC,,,,both,,,547.05,355.58,,,,,,,,,,,,,
BIT DRL DIA5MM CANN FOR 6.5MM L SCR SYS,SUP-2344064,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3182.86,2068.86,,,,,,,,,,,,,
CATHETER CV MAXIMAL BARR TY 032 7 FRX25 IN 13 GA 3L SPECTRUM,SUP-2759722,CDM,C1751,HCPCS,0278,RC,,,,both,,,494.55,321.46,,,,,,,,,,,,,
SPLINT WRST UNIV L11IN R CUTAWAY PERF FOAM CONSTR MAL,SUP-2194859,CDM,L3931,HCPCS,0274,RC,,,,both,,,15.51,10.08,,,,,,,,,,,,,
CATHETER EP SM 2-5-2 MM 8 FR110 CM BPLR STEER,SUP-2357036,CDM,C1733,HCPCS,0272,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
PLATE BNE W17.5XL260MM THK5.2MM 14 H BILAT S STL BROAD LOK,SUP-2185304,CDM,C1713,HCPCS,0278,RC,,,,both,,,2131.15,1385.25,,,,,,,,,,,,,
GRAFT AMNIO MEMBRN W2XL3CM DEHYDR AMNIOEXCEL,SUP-2194318,CDM,Q4137,HCPCS,0636,RC,,,,both,,,4408.56,2865.56,,,,,,,,,,,,,
BLADE IM L100MM DIA1035MM PROX FEM G TI CANN HELI TFN ADV,SUP-2180757,CDM,C1713,HCPCS,0278,RC,,,,both,,,2023.07,1315.00,,,,,,,,,,,,,
MIRTAZAPINE 15 MG PO TBDP,RX-29531,CDM,6370000000,HCPCS,0637,RC,65862-0021-06,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
BLADE CHSL SM W10XL60MM THK1MM RIG SGL END STR DISP FOR KNEE,SUP-2351289,CDM,2720000010,LOCAL,0272,RC,,,,both,,,452.16,293.90,,,,,,,,,,,,,
SIZER SURG SURG ID MANDIBULAR PLATE RECON NS DISP,SUP-2884163,CDM,2720000010,LOCAL,0272,RC,,,,both,,,555.37,360.99,,,,,,,,,,,,,
ENDPLATE INTERVERTEBRAL THORACO LUM MTL ON MTL TI SPIK 3DEG,SUP-2205505,CDM,C1889,HCPCS,0278,RC,,,,both,,,5259.50,3418.67,,,,,,,,,,,,,
SEGMENT FEM COMP M SZ 3 W65XH50MM RT DSTL TILASTAN,SUP-2419629,CDM,C1776,CPT,0278,RC,,,,both,,,4311.22,2802.29,,,,,,,,,,,,,
TUBE VENT 1.02 MM 1 MM 2.7MM BOB TI BLU STRL 500002,SUP-2535061,CDM,L8699,HCPCS,0278,RC,,,,both,,,70.62,45.90,,,,,,,,,,,,,
PACEMAKER CARD ADVANTIO W 4.45 X H 4.70 CM THK 0.75 CM 24.5,SUP-2149239,CDM,C1785,HCPCS,0275,RC,,,,both,,,10462.48,6800.61,,,,,,,,,,,,,
SHAVER SURG SIL SLV MACR HK STRL DISP BONESCALPEL,SUP-2887851,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1280.62,832.40,,,,,,,,,,,,,
INTRODUCER SHTH SLR3 0.032 IN 8 FRX63 CM 8 FRX67 CM SWARTZ,SUP-2357258,CDM,C1893,HCPCS,0272,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
SUPPORT KNEE XSM FOR 12 15IN THGH NEOPRENE,SUP-2150840,CDM,L1812,HCPCS,0274,RC,,,,both,,,32.03,20.82,,,,,,,,,,,,,
PLATE BNE L 62.7 X W 17.3 MM THK 0.6 MM SCREW DIA1.65 MM 18,SUP-2936419,CDM,C1713,HCPCS,0278,RC,,,,both,,,1221.46,793.95,,,,,,,,,,,,,
NAIL IM 10X320 MM ANK ARTH PHOENIX,SUP-2416998,CDM,C1713,HCPCS,0278,RC,,,,both,,,25120.00,16328.00,,,,,,,,,,,,,
CANNULA ENDOSCP W/O VLV 3.5 MMX6 CM W/ INSUFFLATION STOPCOCK,SUP-2767480,CDM,2720000010,LOCAL,0272,RC,,,,both,,,654.53,425.44,,,,,,,,,,,,,
PLATE BNE W7XL39MM THK1MM 5 H BILAT TI 1/4 TBLR RIG,SUP-2191003,CDM,C1713,HCPCS,0278,RC,,,,both,,,329.92,214.45,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.502,SUP-2860019,CDM,C1713,HCPCS,0278,RC,,,,both,,,33471.14,21756.24,,,,,,,,,,,,,
LEAD DEFIB PERM TRNSVEN LD PACE BPLR PASS FIX IS 1 CONN 53CM,SUP-2137969,CDM,C1898,HCPCS,0275,RC,,,,both,,,1986.80,1291.42,,,,,,,,,,,,,
PLATE BNE L42MM STD 2X2 H NONSTERILE BILAT 1ST MTP FUS S,SUP-2184832,CDM,C1713,HCPCS,0278,RC,,,,both,,,2852.31,1854.00,,,,,,,,,,,,,
DEVICE INT FIX 50 MM POLYURETHANE ENDOBUTTON CL,SUP-2341709,CDM,C1713,HCPCS,0278,RC,,,,both,,,985.96,640.87,,,,,,,,,,,,,
PESSARY UTER DSH 3 65 MM SFT PLIABLE W/O SUPP SIL WHT LF,SUP-2794444,CDM,A4562,HCPCS,0274,RC,,,,both,,,103.62,67.35,,,,,,,,,,,,,
PLATE BNE VOLAR RT 12 HOLE ANAT X EXT STRL DVR,SUP-2476728,CDM,C1713,HCPCS,0278,RC,,,,both,,,4110.26,2671.67,,,,,,,,,,,,,
BOLT ORTHOPEDIC FUSION 6.5X90 MM MIDFOOT SS NS,SUP-2184093,CDM,C1713,HCPCS,0278,RC,,,,both,,,1491.81,969.68,,,,,,,,,,,,,
DRAWER TAG 70 MM IMPLANTS 60X28X4MM,SUP-2696076,CDM,C1713,HCPCS,0278,RC,,,,both,,,93.20,60.58,,,,,,,,,,,,,
SENSOR SPO2 AD FNGR PULSE DURA SENS REUSE,SUP-2394647,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1073.88,698.02,,,,,,,,,,,,,
ALLOGRAFT BNE STRP 25X50-80 MM FD 1/3 SHFT ILIUM,SUP-2717843,CDM,C1762,CPT,0278,RC,,,,both,,,10010.35,6506.73,,,,,,,,,,,,,
PLATE BONE MESHED 1.5X100X100X0.25 MM CRANIOFACIAL ORBITAL C,SUP-2838565,CDM,C1713,HCPCS,0278,RC,,,,both,,,10948.24,7116.36,,,,,,,,,,,,,
SIZER SURG WIRE MINI ACUTRK,SUP-2525731,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
"HC So Morphometric Analy, Comp Asst/Discrt Serv",PX-3128836166,CDM,88361,CPT,0312,RC,,,,outpatient,,,410.00,266.50,,,,,,,,,,,,,
KYPHOPLASTY TRAY 15/3 1 STP OSTEO INTRO CDS KYPHOPAK XPANDER,SUP-2632077,CDM,C1713,HCPCS,0278,RC,,,,both,,,12898.49,8384.02,,,,,,,,,,,,,
PATCH DURAL 6X8CM POLYESTER URETHANE SYNTHETIC SUBSTITUTE NO,SUP-2826138,CDM,C1763,HCPCS,0278,RC,,,,both,,,1737.83,1129.59,,,,,,,,,,,,,
CONNECTOR NRV L10MM DIA3MM PORCINE EXTRACELLULAR MTRX,SUP-2124865,CDM,C1763,HCPCS,0278,RC,,,,both,,,4477.64,2910.47,,,,,,,,,,,,,
CATHETER ETER EP 6FR L115CM 2MM SPC A CRV POLE 8 FIX,SUP-2248893,CDM,C1730,HCPCS,0272,RC,,,,both,,,640.56,416.36,,,,,,,,,,,,,
SCREW INTRF KNEE CANN N ABSRB TI 9MM 20MM,SUP-2256755,CDM,C1713,HCPCS,0278,RC,,,,both,,,719.06,467.39,,,,,,,,,,,,,
DRILL SURG BUSHING 10.7 MM IMPLEX,SUP-2437389,CDM,2720000010,LOCAL,0272,RC,,,,both,,,621.72,404.12,,,,,,,,,,,,,
GUIDEWIRE VASC RDRUN L 180 CM DIA 0.018 IN TAPR L 7 CM FLPY,SUP-2168240,CDM,C1769,HCPCS,0272,RC,,,,both,,,272.05,176.83,,,,,,,,,,,,,
PLATE BONE SM 4X4 H T SHP,SUP-2198580,CDM,C1713,HCPCS,0278,RC,,,,both,,,153.86,100.01,,,,,,,,,,,,,
SEALANT TISS FIBRIN 1 CC HUM W/ AIRLESS SPRY ACCSRY EVICEL,SUP-2738903,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3321.34,2158.87,,,,,,,,,,,,,
CATHETER GUID TIG3.5 6 FRX100 CM SM ATRAUM SFT CONVEY,SUP-2146313,CDM,C1887,HCPCS,0272,RC,,,,both,,,150.72,97.97,,,,,,,,,,,,,
NEEDLE SUTURE L8.25IN BLUNT LIGATURE FOR LEFT HAND DESCHAMPS,SUP-2802481,CDM,2720000010,LOCAL,0272,RC,,,,both,,,314.31,204.30,,,,,,,,,,,,,
OSSEOFLEX SN STRBLE NDLE 8 G INCL CNNLSSTLTSBPSY NDLE,SUP-2677171,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
CATHETER ASPIR 6FR L140CM GWIRE 0.014IN OPTIMIZED TIP DSGN,SUP-2295344,CDM,C1757,HCPCS,0272,RC,,,,both,,,1114.70,724.55,,,,,,,,,,,,,
GRAFT VASC L60CM DIA8MM STD L60CM THN WALLED INTEGR RNG,SUP-2395861,CDM,C1768,CPT,0278,RC,,,,both,,,6942.54,4512.65,,,,,,,,,,,,,
CARRIER LT TYP 30R,SUP-2383873,CDM,2720000010,LOCAL,0272,RC,,,,both,,,935.44,608.04,,,,,,,,,,,,,
GRAFT BNE SUTURABLE 6X8 CM BOV PERICARD,SUP-2624227,CDM,C1763,HCPCS,0278,RC,,,,both,,,1578.79,1026.21,,,,,,,,,,,,,
COIL NEUROVASCULAR CEREPAK UNIF XL L 12.2 CM DIA 6 MM SLV,SUP-2865189,CDM,C1889,HCPCS,0278,RC,,,,both,,,8497.69,5523.50,,,,,,,,,,,,,
NAIL IM RETROGRADE 13X180 MM TI NS,SUP-2417495,CDM,C1713,HCPCS,0278,RC,,,,both,,,5074.02,3298.11,,,,,,,,,,,,,
SHEATH INTRO AVNT + DIA 5 FR CANN L 11 CM GUIDEWIRE 0.035 IN,SUP-2156063,CDM,C1894,HCPCS,0272,RC,,,,both,,,31.46,20.45,,,,,,,,,,,,,
DISTRACTOR EXT FIX FEARON MOD MATTHEWS-TESSIER 40 MM 1 MM,SUP-2458296,CDM,C1713,HCPCS,0278,RC,,,,both,,,16816.87,10930.97,,,,,,,,,,,,,
GRAFT HUM TISS W2XL4CM AMNIO TISS MEM WRP AMNIOFIX,SUP-2305760,CDM,V2790,HCPCS,0274,RC,,,,both,,,4606.38,2994.15,,,,,,,,,,,,,
HC Treat Vaginal Bleeding,PX-4505718000,CDM,57180,CPT,0450,RC,,,,both,,,214.00,139.10,,,,,,,,,,,,,
FLUOROURACIL 500 MG/10ML IV SOLN,RX-82200,CDM,J9190,HCPCS,0636,RC,63323-0117-10,NDC,,both,10,ML,54.10,35.16,,,,,,,,,,,,,
SHEATH INTRO COMPASS L 90 CM OD 6 FR ID 2.25 MM GUIDEWIRE,SUP-2846726,CDM,C1894,HCPCS,0272,RC,,,,both,,,298.33,193.91,,,,,,,,,,,,,
IMPLANT WRST JT THK1.7X1.5MM L18MM L12-13MM QUADRIPODAL 4,SUP-2378989,CDM,C1713,HCPCS,0278,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
CABLE SPNL TI DBL LOOP W/ 2 INTEGR CRMP,SUP-2206117,CDM,C1713,HCPCS,0278,RC,,,,both,,,2103.80,1367.47,,,,,,,,,,,,,
SUPPORT ORTHOT LOWER EXTREMITY CUST ANTR SWNG BND,SUP-2435660,CDM,L2335,HCPCS,0274,RC,,,,both,,,795.86,517.31,,,,,,,,,,,,,
ELECTRODE ELECTROTHERAPY L10CM RF REUSE,SUP-2357706,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.413,SUP-2859977,CDM,C1713,HCPCS,0278,RC,,,,both,,,32879.88,21371.92,,,,,,,,,,,,,
GUIDEWIRE VASC ARW L 100 CM DIA 0.035 IN PTFE PERIPH J,SUP-2383973,CDM,C1769,HCPCS,0272,RC,,,,both,,,58.91,38.29,,,,,,,,,,,,,
HC Chemo Extend IV Infus W/Pump Cost,PX-2800049800,CDM,G0498,HCPCS,0280,RC,,,,inpatient,,,1112.00,722.80,,,,,,,,,,,,,
GRAFT DURA W1XL3IN BOV ABSRB POR DURAGN,SUP-2244080,CDM,C1713,HCPCS,0278,RC,,,,both,,,724.40,470.86,,,,,,,,,,,,,
CYLINDER PENILE PROS L20CM 0DEG SCROT PMP SET TI TCH,SUP-2165446,CDM,C1813,HCPCS,0278,RC,,,,both,,,37680.00,24492.00,,,,,,,,,,,,,
PLATE BNE GRP LG 160 MM TROCHANTERIC SS DALL-M,SUP-2451638,CDM,C1713,HCPCS,0278,RC,,,,both,,,3919.98,2547.99,,,,,,,,,,,,,
GUIDEPIN SURG TRANSTIBIAL SUT EYE RETRODRILL,SUP-2120916,CDM,2720000010,LOCAL,0272,RC,,,,both,,,420.76,273.49,,,,,,,,,,,,,
NICOTINE 14 MG/24HR TD PT24,RX-27862,CDM,6370000000,HCPCS,0637,RC,43598-0447-71,NDC,,both,1,UN,14.80,9.62,,,,,,,,,,,,,
BIT DRL CANN SHT 2.5 MM,SUP-2693944,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4835.60,3143.14,,,,,,,,,,,,,
HC Thrombolytic Art Therapy,PX-3613721100,CDM,37211,CPT,0361,RC,,,,both,,,16763.00,10895.95,,,,,,,,,,,,,
HC Ult Guide Perc Drain Abscess,PX-4027598900,CDM,75989,CPT,0402,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
STENT CORONARY RESOLUTE ONYX L 8 MM DIA2.25 MM CATH L 140 CM,SUP-2517067,CDM,C1874,HCPCS,0278,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
SPACER FEM SZ 0 THK4MM LT LAT CONSTRN REV CEM NP N-K II,SUP-2209189,CDM,C1776,CPT,0278,RC,,,,both,,,3224.78,2096.11,,,,,,,,,,,,,
KNIFE SCKL STR BLNT TIP,SUP-2261344,CDM,2720000010,LOCAL,0272,RC,,,,both,,,530.75,344.99,,,,,,,,,,,,,
KIT RF MULT COOLED INCL PRB INTRO BURET DISP COOLIEF ADV,SUP-2719766,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4176.20,2714.53,,,,,,,,,,,,,
ERYTHROMYCIN BASE 250 MG PO TBEC,RX-2891,CDM,6370000000,HCPCS,0637,RC,13668-0586-30,NDC,,both,1,UN,22.50,14.62,,,,,,,,,,,,,
SCREW BNE BLNT PT 6X250 MM 40 MM THRD SCHNZ TI STRL,SUP-2789434,CDM,C1713,HCPCS,0278,RC,,,,both,,,514.39,334.35,,,,,,,,,,,,,
GUIDEWIRE VASC THRUWAY L 190 CM DIA 0.014 IN SS SIL STR LNG,SUP-2148333,CDM,C1769,HCPCS,0272,RC,,,,both,,,332.75,216.29,,,,,,,,,,,,,
ROD REPROC EXT FIX HYBRID CARBN 11X450MM,SUP-2736202,CDM,2720000010,LOCAL,0272,RC,,,,both,,,405.03,263.27,,,,,,,,,,,,,
PLATE BNE Z MINI 2-2.5X11X1 MM RT 4 HOLE TI LEVEL 1,SUP-2479524,CDM,C1713,HCPCS,0278,RC,,,,both,,,1192.76,775.29,,,,,,,,,,,,,
KIT CVC 7FR FOR 2 LUMN CATHETER HCKMN,SUP-2126564,CDM,C1894,HCPCS,0272,RC,,,,both,,,332.84,216.35,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA FT PLU MAXBARR S1275108FD3,SUP-2632806,CDM,C1751,HCPCS,0278,RC,,,,both,,,1008.88,655.77,,,,,,,,,,,,,
STEM FEM L150MM DIA115MM NEUT KNEE CO CHROME POR BOW MOD,SUP-2252639,CDM,C1776,CPT,0278,RC,,,,both,,,10508.48,6830.51,,,,,,,,,,,,,
SCREW BONE L14MM OD1.3MM CO CHROM CORT ST NONLOCKING FULL,SUP-2411756,CDM,C1713,HCPCS,0278,RC,,,,both,,,193.90,126.03,,,,,,,,,,,,,
HC Pt Manual Therapy Ea 15|OP PT SERVICES|DOCUMENTATION ON FILE|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS|UNUSUAL NON-OVERLAPPING SERVICE,PX-4209714000,CDM,97140,CPT,0420,RC,,,GP|KX|CQ|XU,both,,,194.00,126.10,,,,,,,,,,,,,
CATHETER ANGIOPLSTY STELLAREX L 135 CM DIA 6 FR BALLOON L,SUP-2420208,CDM,C2623,HCPCS,0278,RC,,,,both,,,6437.00,4184.05,,,,,,,,,,,,,
SPACER SPNL 11X11X11 MM CERV CORNERSTONE PSR,SUP-2279533,CDM,C1821,HCPCS,0278,RC,,,,both,,,1789.80,1163.37,,,,,,,,,,,,,
CATHETER GUID L100CM COR S STL PTFE IR 2 FLX SHFT L LUMN HI,SUP-2384868,CDM,C1887,HCPCS,0272,RC,,,,both,,,296.73,192.87,,,,,,,,,,,,,
BIT PERF L14/11MM CRAN DISP ZYPHR,SUP-2367385,CDM,2720000010,LOCAL,0272,RC,,,,both,,,549.91,357.44,,,,,,,,,,,,,
CLIP LIG L235CM RESOL 360 BX/20,SUP-2149430,CDM,C1889,HCPCS,0278,RC,,,,both,,,624.86,406.16,,,,,,,,,,,,,
RING 58 RINGFIX SYS ALUM 180MM,SUP-2696085,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3362.94,2185.91,,,,,,,,,,,,,
INTRODUCER ENDO OD3.07MM ID2.48MM S STL SGL USE,SUP-2239408,CDM,C1894,HCPCS,0272,RC,,,,both,,,87.92,57.15,,,,,,,,,,,,,
BIT DRL 7 MM SHLDR FOR SILK FIX SCR NS DISP,SUP-2762096,CDM,2720000010,LOCAL,0272,RC,,,,both,,,898.04,583.73,,,,,,,,,,,,,
STEM HUM 13X17 MM DSTL SHLDR,SUP-2363645,CDM,C1776,CPT,0278,RC,,,,both,,,9529.27,6194.03,,,,,,,,,,,,,
SPHINCTEROTOME ENDO OD5.5FR 0.021IN DOME TIP BLK CONN DASH,SUP-2169612,CDM,2720000010,LOCAL,0272,RC,,,,both,,,540.08,351.05,,,,,,,,,,,,,
GRAFT HUM TISS W16XL20CM THK0.4-2.4MM REGEN TISS MTRX PERF,SUP-2113012,CDM,Q4116,HCPCS,0636,RC,,,,both,,,38524.66,25041.03,,,,,,,,,,,,,
COMPONENT FEM SZ 2 L NP CRUCE RET BKS TRIMAX,SUP-2314952,CDM,C1776,CPT,0278,RC,,,,both,,,7372.72,4792.27,,,,,,,,,,,,,
CUTTER SURG L8CM OD4MM AGG MICRODEBRIDER ESSX,SUP-2363535,CDM,2720000010,LOCAL,0272,RC,,,,both,,,402.52,261.64,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9 % IV SOLN (ADD-VANTAGE),RX-4081543,CDM,J7050,HCPCS,0258,RC,00409-7101-67,NDC,,both,100,ML,37.40,24.31,,,,,,,,,,,,,
MARKER FIDUCIAL VISICOIL 20CM,SUP-2844757,CDM,A4648,CPT,0278,RC,,,,both,,,536.59,348.78,,,,,,,,,,,,,
HC Puncture Shunt/Reservoir,PX-3616107000,CDM,61070,CPT,0361,RC,,,,both,,,1818.00,1181.70,,,,,,,,,,,,,
KIT SHTH CONVOY 55 DEG L 79.4 CM DIA 8.5 FR SFT TIP ADV DEL,SUP-2141300,CDM,C1894,HCPCS,0272,RC,,,,both,,,675.10,438.81,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9 % IV SOLN (ADD-VANTAGE),RX-4081543,CDM,J7050,HCPCS,0258,RC,00409-7101-02,NDC,,both,250,ML,48.90,31.78,,,,,,,,,,,,,
KIT MIDLN 18GA L8CM FLO RATE 7ML/SEC MIDLN PWR INJ FULL TY,SUP-2125660,CDM,C1751,HCPCS,0278,RC,,,,both,,,370.52,240.84,,,,,,,,,,,,,
BRACE THMB W ADJUSTABLE STRP UNIV,SUP-2276642,CDM,L3931,HCPCS,0272,RC,,,,both,,,12.21,7.94,,,,,,,,,,,,,
BURR ROUTER FLUTED 2.5MM X 25.4MM LCRNG1,SUP-2843298,CDM,2720000010,LOCAL,0272,RC,,,,both,,,413.48,268.76,,,,,,,,,,,,,
CANNULA IRRIGATION SIMCOE RVS DOUBLE-BARRELED UNIT ULTRA LF,SUP-2467846,CDM,2720000010,LOCAL,0272,RC,,,,both,,,359.03,233.37,,,,,,,,,,,,,
STAPLE INT BIOABSORABLE LN REINF 29 PROX 29 ETHICON SEAMGRD,SUP-2395312,CDM,2720000010,LOCAL,0272,RC,,,,both,,,923.16,600.05,,,,,,,,,,,,,
KIT LUM DRNGE CEREBROSPINAL FLD VERSION II,SUP-2308152,CDM,C1729,HCPCS,0272,RC,,,,both,,,709.39,461.10,,,,,,,,,,,,,
GUIDEWIRE VASC L 260 CM DIA 0.038 IN TAPR L 9.5 CM FLPY TIP,SUP-2167915,CDM,C1769,HCPCS,0272,RC,,,,both,,,85.16,55.35,,,,,,,,,,,,,
INJECTOR PELLET 3 MM 1.25 CC OSTEOSET,SUP-2468000,CDM,C1713,HCPCS,0278,RC,,,,both,,,1438.37,934.94,,,,,,,,,,,,,
ROD SPNL 5X210 MM,SUP-2564523,CDM,C1713,HCPCS,0278,RC,,,,both,,,70.81,46.03,,,,,,,,,,,,,
CONE FEM SZ D H60MM PROX HIP TI PPS STD OFFSET MOD REV,SUP-2404451,CDM,C1776,CPT,0278,RC,,,,both,,,15159.92,9853.95,,,,,,,,,,,,,
PLATE BNE L246MM THK3MM 13 H BILAT S STL STR LOK COMPR RECON,SUP-2185349,CDM,C1713,HCPCS,0278,RC,,,,both,,,1971.32,1281.36,,,,,,,,,,,,,
SPINDLE ORTH XS 30 MM 400 LB ANTI ROT W/ PIN COMPRESS,SUP-2441810,CDM,C1776,CPT,0278,RC,,,,both,,,9311.67,6052.59,,,,,,,,,,,,,
SHEATH INTRO PRELUDE L 11 CM DIA 5 FR 0.035 IN 7 CM 18 GA SS,SUP-2700276,CDM,C1894,HCPCS,0272,RC,,,,both,,,38.37,24.94,,,,,,,,,,,,,
STEM FEM HIP CEM REV NEUT CALCAR 10.5MM DIA 175MM LEN,SUP-2211495,CDM,C1776,CPT,0278,RC,,,,both,,,17613.83,11448.99,,,,,,,,,,,,,
SPLINT THMB M+ LT CARPOMETACARPAL JT RESTRICT ELAS SUPP,SUP-2324211,CDM,L3931,HCPCS,0272,RC,,,,both,,,64.24,41.76,,,,,,,,,,,,,
RESERVOIR CSF EXT MINI 1.5X2.7 MM 1.2X2.2 MM 0.023 CC,SUP-2852565,CDM,C1889,HCPCS,0278,RC,,,,both,,,1635.59,1063.13,,,,,,,,,,,,,
CONFORMER EYE SM AD BILAT OCU METHYLMETHACRYLATE M W/O H,SUP-2391939,CDM,L8610,HCPCS,0278,RC,,,,both,,,53.38,34.70,,,,,,,,,,,,,
CROMOLYN SODIUM 4 % OP SOLN,RX-9691,CDM,6370000000,HCPCS,0637,RC,61314-0237-10,NDC,,both,10,ML,101.30,65.84,,,,,,,,,,,,,
SEALER ENDOSCP L37CM NANO COAT BLNT TIP LAP DIV,SUP-2283560,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1036.20,673.53,,,,,,,,,,,,,
ALLOGRAFT BNE STRP 22X50 MM PRESERVON TRICORT MATRIGRAFT,SUP-2740870,CDM,C1713,HCPCS,0278,RC,,,,both,,,5765.48,3747.56,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP ACROBAT 2 L 450 CM DIA 0.025 IN RADIOPAQUE,SUP-2170531,CDM,C1769,HCPCS,0272,RC,,,,both,,,656.26,426.57,,,,,,,,,,,,,
HC NM Bone Scan Whole Body,PX-3417830600,CDM,78306,CPT,0341,RC,,,,both,,,2813.00,1828.45,,,,,,,,,,,,,
GUIDEWIRE VASC GLIDEWIRE ADVANTAGE L 300 CM DIA 0.018 IN TIP,SUP-2385542,CDM,C1769,HCPCS,0272,RC,,,,both,,,974.97,633.73,,,,,,,,,,,,,
STENT PERIPH LIFESTENT L 170 MM DIA 5 MM CATH L 80 CM DIA 5,SUP-2541393,CDM,C1876,HCPCS,0278,RC,,,,both,,,10660.30,6929.19,,,,,,,,,,,,,
COIL NEUROVASCULAR PENUMBRA COIL 400 L 15 CM DIA 8 MM STD,SUP-2323364,CDM,C1889,HCPCS,0278,RC,,,,both,,,7115.24,4624.91,,,,,,,,,,,,,
NEEDLE BRAIN BX DIM A 8MM DIMINLIN 24C,SUP-2107928,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1874.58,1218.48,,,,,,,,,,,,,
HC Assay of Phenylalanine Blood,PX-3018403000,CDM,84030,CPT,0301,RC,,,,outpatient,,,609.00,395.85,,,,,,,,,,,,,
ROD EXT FIX L 550 MM DIA11 MM LG CARBON FIBRE MR CONDITIONAL,SUP-2908139,CDM,2720000010,LOCAL,0272,RC,,,,both,,,952.21,618.94,,,,,,,,,,,,,
KNIFE SURGICAL APFELBAUM DURA LG 8 34INL LATEX FREE,SUP-2671894,CDM,2720000010,LOCAL,0272,RC,,,,both,,,527.90,343.13,,,,,,,,,,,,,
REAMER SURG OD6MM ANT CERV SPNL,SUP-2286460,CDM,C1713,HCPCS,0278,RC,,,,both,,,1136.02,738.41,,,,,,,,,,,,,
GRAFT VASC GELSFT ERS L 40 CM SUPP L 20 CM DIA 8 MM,SUP-2384972,CDM,C1768,CPT,0278,RC,,,,both,,,1407.72,915.02,,,,,,,,,,,,,
BIT DRL OD3MM UNIV GUID NONSTERILE REUSE STEALTHSTATION,SUP-2253540,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4907.19,3189.67,,,,,,,,,,,,,
CATHETER CTRL VEN 6FR L60CM 2 LUMN BASIC NONTUNNELED,SUP-2267059,CDM,C1751,HCPCS,0278,RC,,,,both,,,690.80,449.02,,,,,,,,,,,,,
GUIDEWIRE VASC MCNAM 90 DEG L 180 CM DIA 0.018 IN TAPR L 3,SUP-2168643,CDM,C1769,HCPCS,0272,RC,,,,both,,,267.34,173.77,,,,,,,,,,,,,
BLADE SAW OSCLLTNG CLSSC 19MMW X90MML 1.19MM THK INNVTVE TOO,SUP-2605823,CDM,2720000010,LOCAL,0272,RC,,,,both,,,82.11,53.37,,,,,,,,,,,,,
IMPLANT ANKLE JOINT 3 TIBIAL IMPLANTABLE,SUP-2490913,CDM,C1776,CPT,0278,RC,,,,both,,,9831.34,6390.37,,,,,,,,,,,,,
SCREW BNE 36 MM LATARJET SS NS,SUP-2256866,CDM,C1713,HCPCS,0278,RC,,,,both,,,1155.52,751.09,,,,,,,,,,,,,
COMPONENT FEM SZ C L POST STBL NXGN,SUP-2201883,CDM,C1776,CPT,0278,RC,,,,both,,,7853.45,5104.74,,,,,,,,,,,,,
PLATE BONE LOK 77MML HLX3/6 HD/SHFT STNLSS STEEL T SHPD NON,SUP-2499014,CDM,C1713,HCPCS,0278,RC,,,,both,,,2566.67,1668.34,,,,,,,,,,,,,
PLATE BONE L84.5MM 4 H RT DSTL FIB TI ANAT FOR 2.7/3/3.5/4MM,SUP-2225372,CDM,C1713,HCPCS,0278,RC,,,,both,,,4415.47,2870.06,,,,,,,,,,,,,
VALVE AORT CARP EDW PERIMT RSR 25 MM BOV PERICARD COCR REDUC,SUP-2214072,CDM,C1889,HCPCS,0278,RC,,,,both,,,24492.00,15919.80,,,,,,,,,,,,,
LEAD DEFIB LINOX SD L 65 CM DIA2.6 MM TIP DISTANCE 16 CM SIL,SUP-2138041,CDM,C1895,HCPCS,0275,RC,,,,both,,,11618.00,7551.70,,,,,,,,,,,,,
COMPONENT TOT SHLDR CAPPED BIOMET5500] ZIMMER BIOMET INC],SUP-2137328,CDM,C1776,CPT,0278,RC,,,,both,,,17270.00,11225.50,,,,,,,,,,,,,
TUBE SUCTION FRAZIER 7 FRX4 IN 7.5 IN ANGLED SS STRL,SUP-2498054,CDM,C1713,HCPCS,0278,RC,,,,both,,,65.16,42.35,,,,,,,,,,,,,
SYSTEM EXT DRNGE LSR ACCURACY L RED CAP YEL TAG MRI SAFE W O,SUP-2308154,CDM,C1729,HCPCS,0272,RC,,,,both,,,683.89,444.53,,,,,,,,,,,,,
ENDPLATE SPNL LOWER L12MM 15X18MM FOOTPRINT 7DEG VERT BODY,SUP-2229978,CDM,C1713,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
SCREW BONE L30MM OD3.5MM TI CORT T15 ST,SUP-2101289,CDM,C1713,HCPCS,0278,RC,,,,both,,,80.38,52.25,,,,,,,,,,,,,
PLATE BONE 253MML HLX20 STNLSS STEEL BTTRSS F/3.5MM/4MM CRTC,SUP-2499035,CDM,C1713,HCPCS,0278,RC,,,,both,,,2525.28,1641.43,,,,,,,,,,,,,
LENS IOL TECNIS SYNERGY TORIC II DFW150U180,SUP-2853109,CDM,V2788,HCPCS,0276,RC,,,,both,,,1095.00,711.75,,,,,,,,,,,,,
SPLINT KNEE L20IN FOR 32IN THGH UNIV FOAM 3 PC DSGN TRIMMED,SUP-2196754,CDM,L1830,CPT,0272,RC,,,,both,,,39.19,25.47,,,,,,,,,,,,,
GRAFT HUM TISS 1000 MG PURAPLY MZ,SUP-2849178,CDM,C1763,HCPCS,0278,RC,,,,both,,,7269.10,4724.91,,,,,,,,,,,,,
HC Mammo Screening Incl Cad if Perf,PX-4037706700,CDM,77067,CPT,0403,RC,,,,inpatient,,,480.00,312.00,,,,,,,,,,,,,
SPINAL KIT STANDARD 4 MM STANDARD TITANIUM STERILE MATRIXNEU,SUP-2837710,CDM,C1713,HCPCS,0278,RC,,,,both,,,2104.43,1367.88,,,,,,,,,,,,,
GUIDE PIN FIX 12X225MM SMOOTH SHRP TIP BRKWY,SUP-2208446,CDM,2720000010,LOCAL,0272,RC,,,,both,,,175.84,114.30,,,,,,,,,,,,,
FORCEPS OPHTH 25+GA ILM DISP GRIESHABER REVOLUTION DSP,SUP-2109695,CDM,2720000010,LOCAL,0272,RC,,,,both,,,372.28,241.98,,,,,,,,,,,,,
GRAFT BNE SUB THK16-18MM CALCANEUS CRSS SECT FRZ DRY,SUP-2307163,CDM,C1713,HCPCS,0278,RC,,,,both,,,2423.95,1575.57,,,,,,,,,,,,,
IMPLANT IM L 130 MM DIA 9.5 MM BODY DIA 8 MM SS THRD ST,SUP-2905261,CDM,C1713,HCPCS,0278,RC,,,,both,,,9922.40,6449.56,,,,,,,,,,,,,
BLADE RTRCTR SM 24MMW X 70MML TTNM SPNL TTHX3 THIN LMBRTRK R,SUP-2479895,CDM,2720000010,LOCAL,0272,RC,,,,both,,,776.55,504.76,,,,,,,,,,,,,
GUIDEWIRE VASC RDRUN PC THE FIRM L 260 CM 0.035IN 3CM ANGLED,SUP-2168416,CDM,C1769,HCPCS,0272,RC,,,,both,,,117.22,76.19,,,,,,,,,,,,,
PLATE BNE L94MM 6 H ST L SUP ANT CLAV S STL LOK COMPR FOR,SUP-2177340,CDM,C1713,HCPCS,0278,RC,,,,both,,,2934.80,1907.62,,,,,,,,,,,,,
NAIL IM L480MM DIA10MM 130DEG ST GRN FEM TI CANN LOK AG RG,SUP-2192609,CDM,C1713,HCPCS,0278,RC,,,,both,,,4428.53,2878.54,,,,,,,,,,,,,
GRAFT ALLODERM SELECT REGENERATIVE TISSUE MATRIX 2X4,SUP-2665173,CDM,Q4116,HCPCS,0636,RC,,,,both,,,1764.68,1147.04,,,,,,,,,,,,,
LIDOCAINE-EPINEPHRINE 2 %-1:100000 IJ SOLN,RX-10430,CDM,J2004,HCPCS,0636,RC,63323-0483-03,NDC,,both,1.7,ML,54.10,35.16,,,,,,,,,,,,,
BUR SURG OD6MM CRNRSTN,SUP-2363337,CDM,2720000010,LOCAL,0272,RC,,,,both,,,684.46,444.90,,,,,,,,,,,,,
ASSEMBLY CRKSCR LAT L,SUP-2293413,CDM,C1713,HCPCS,0278,RC,,,,both,,,7438.66,4835.13,,,,,,,,,,,,,
PLATE BNE 12 H STRNL TI STR LO PROF NEUT LOK COMPR FOR 3MM,SUP-2192430,CDM,C1713,HCPCS,0278,RC,,,,both,,,5123.54,3330.30,,,,,,,,,,,,,
PROBE BRST BX DIA12GA VERTICAL ENCOR,SUP-2715833,CDM,2720000010,LOCAL,0272,RC,,,,both,,,517.79,336.56,,,,,,,,,,,,,
LEAD PACE EMBLEM Q-TRAK W 83.1 X H 69.1 MM D 12.7 MM SIL,SUP-2421444,CDM,C1896,HCPCS,0275,RC,,,,both,,,14130.00,9184.50,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 10X4 CM SHT AMNION/CHORION AMNIOFIX,SUP-2871495,CDM,C1762,CPT,0278,RC,,,,both,,,9712.02,6312.81,,,,,,,,,,,,,
K WIRE FIX L150MM DIA1MM S STL TRCR PT FOR SM BONE PLATING,SUP-2343914,CDM,C1769,HCPCS,0272,RC,,,,both,,,109.65,71.27,,,,,,,,,,,,,
STENT TRACH POLYFLEX L 40 MM DIA14 MM DEL SYS DIA 9 MM,SUP-2436473,CDM,C1874,HCPCS,0278,RC,,,,both,,,6001.11,3900.72,,,,,,,,,,,,,
KIT NEUROSTIMULATOR L 45 CM DIA1.35 MM PERIPH PERM 4 CONTACT,SUP-2917095,CDM,C1816,LOCAL,0278,RC,,,,both,,,53380.00,34697.00,,,,,,,,,,,,,
SCREW BNE LCK 3.2X18 MM VW REDUC,SUP-2645273,CDM,C1713,HCPCS,0278,RC,,,,both,,,781.39,507.90,,,,,,,,,,,,,
IOPAMIDOL 41 % IJ SOLN,RX-10325,CDM,Q9966,HCPCS,0636,RC,00270-1411-11,NDC,,both,10,ML,35.60,23.14,,,,,,,,,,,,,
PLATE BNE 3X3 H 2 23X365MM LOK GRID TRILOK,SUP-2267952,CDM,C1713,HCPCS,0278,RC,,,,both,,,2801.63,1821.06,,,,,,,,,,,,,
PI PICC KIT 2-L 5 FR X 55 CM VPS G4 PRELOADED,SUP-2565192,CDM,C1751,HCPCS,0278,RC,,,,both,,,678.37,440.94,,,,,,,,,,,,,
HC Thoracentesis WO Imaging,PX-4503255400,CDM,32554,CPT,0450,RC,,,,both,,,1901.00,1235.65,,,,,,,,,,,,,
LINER KT WLK BOOT VENTURE AIR TALL SM,SUP-2151041,CDM,L4386,HCPCS,0272,RC,,,,both,,,54.01,35.11,,,,,,,,,,,,,
PORT IMPL INFUSION SINGLE LUMEN 6 FR ATTCH POLYURETHANE MRI,SUP-2126178,CDM,C1788,HCPCS,0278,RC,,,,both,,,775.58,504.13,,,,,,,,,,,,,
TRAY NERVE BLOCK CANN DIA20 GA BPSK SNB400OPM STRL LF DISP,SUP-2936628,CDM,2720000010,LOCAL,0272,RC,,,,both,,,57.34,37.27,,,,,,,,,,,,,
ROD EXT FIX THRD 200 MM,SUP-2197272,CDM,C1713,HCPCS,0278,RC,,,,both,,,326.56,212.26,,,,,,,,,,,,,
STEM RADIAL STR 6X24 MM ELBW TI STRL,SUP-2564336,CDM,C1713,HCPCS,0278,RC,,,,both,,,4861.82,3160.18,,,,,,,,,,,,,
IMMOBILIZER SHLDR M PCH W8XL16.5IN UNIV TIETEX FOAM STRP,SUP-2195497,CDM,L3650,HCPCS,0272,RC,,,,both,,,15.39,10.00,,,,,,,,,,,,,
DRILL SURG DIA6MM 0.5CC FOR BNE GRFT HARV,SUP-2107381,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5394.52,3506.44,,,,,,,,,,,,,
HC Aspirate Pleura W/ Imaging,PX-3203255500,CDM,32555,CPT,0320,RC,,,,both,,,3598.00,2338.70,,,,,,,,,,,,,
WIRE FIX OD1.8MM END L6MM PLT SZ 2.4MM SH PROV,SUP-2351115,CDM,C1713,HCPCS,0278,RC,,,,both,,,529.97,344.48,,,,,,,,,,,,,
GUIDE RM BNE AND IMPL MOD COMPHSVE VRS,SUP-2402733,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2486.88,1616.47,,,,,,,,,,,,,
ALLOGRAFT BNE 2.5X5 CM DBM GRFT,SUP-2743371,CDM,C1713,HCPCS,0278,RC,,,,both,,,6283.14,4084.04,,,,,,,,,,,,,
SHEATH INTRO HIPOINT 88 TENZING 8 HYBRID 088 ACCS SYS STRL,SUP-2878100,CDM,C1887,HCPCS,0272,RC,,,,both,,,15857.00,10307.05,,,,,,,,,,,,,
TRASTUZUMAB-ANNS 420 MG IV SOLR,RX-146642,CDM,Q5117,HCPCS,0636,RC,55513-0132-01,NDC,,both,1,UN,10967.60,7128.94,,,,,,,,,,,,,
INTRODUCER HEMSTAS TEAR AWAY 9.5FR,SUP-2148789,CDM,C1894,HCPCS,0272,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE 1.25 CC CER GRAN TYPE-I BOV CLLGN RPM,SUP-2930798,CDM,C1763,HCPCS,0278,RC,,,,both,,,1522.90,989.88,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE 10 CC DEMINERALIZED CORTICAL BNE FIBER,SUP-2932784,CDM,C1762,CPT,0278,RC,,,,both,,,5086.11,3305.97,,,,,,,,,,,,,
CLIP OCCL ATRICLIP FLEX-V L 45 MM TI POLYETHYL TEREPHTHALATE,SUP-2424444,CDM,C1889,HCPCS,0278,RC,,,,both,,,5809.00,3775.85,,,,,,,,,,,,,
PLUG BNE CEM SM POLYETH FOR 8-10MM IM CNL,SUP-2405150,CDM,C1713,HCPCS,0278,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
BLADE RETRACTOR GELPI UNIV ABD RNG,SUP-2465675,CDM,2720000010,LOCAL,0272,RC,,,,both,,,963.63,626.36,,,,,,,,,,,,,
PLATE BNE LCK UNIV 2X2.3X1.5 MM 4 HOLE BAR SCREW TI GLD NS,SUP-2366363,CDM,C1713,HCPCS,0278,RC,,,,both,,,1153.60,749.84,,,,,,,,,,,,,
WRENCH TORQUE REACTIV8,SUP-2877971,CDM,C1730,HCPCS,0272,RC,,,,both,,,279.46,181.65,,,,,,,,,,,,,
PLATE BONE PREBENT 10MM STP LT MAX 1.6MM SCR OSA SYS,SUP-2319387,CDM,C1713,HCPCS,0278,RC,,,,both,,,920.02,598.01,,,,,,,,,,,,,
CATHETER ETER NEPHSTMY 14FR L35CM INCL C FLX RE ENTRY MCOT C,SUP-2436250,CDM,C1729,HCPCS,0272,RC,,,,both,,,231.73,150.62,,,,,,,,,,,,,
COMPONENT TALAR SZ 1 DOME TOT ANK SYS INFIN,SUP-2397268,CDM,C1776,CPT,0278,RC,,,,both,,,14836.50,9643.72,,,,,,,,,,,,,
WIRE FIX TROCAR TIP 1.6 MM A.L.P.S KIRSCHNER,SUP-2461813,CDM,C1713,HCPCS,0278,RC,,,,both,,,69.08,44.90,,,,,,,,,,,,,
PLATE BNE L350MM 16 H ST R CNDYL S STL LOK COMPR CRV FOR,SUP-2177091,CDM,C1713,HCPCS,0278,RC,,,,both,,,5113.30,3323.64,,,,,,,,,,,,,
IMPLANT BIO L 7 X W 10 CM FISH SKIN DERMAL SLD INTACT FLAT,SUP-2909240,CDM,Q4158,HCPCS,0636,RC,,,,both,,,7363.30,4786.14,,,,,,,,,,,,,
BLADE SHV DIA4MM STR AGG DISECT FOR DIEGO SYS,SUP-2313840,CDM,2720000010,LOCAL,0272,RC,,,,both,,,360.53,234.34,,,,,,,,,,,,,
KIT STIMULATOR NERVE LD L65CM 565 SPC MRI COMPATIBLE,SUP-2631822,CDM,C1767,HCPCS,0278,RC,,,,both,,,19954.70,12970.55,,,,,,,,,,,,,
SCREW BNE NLCK 2X15 MM TI NS BABY GORILLA,SUP-2750072,CDM,C1713,HCPCS,0278,RC,,,,both,,,459.70,298.80,,,,,,,,,,,,,
CATHETER GLDE ANG 4FRX65CM,SUP-2141097,CDM,C1887,HCPCS,0272,RC,,,,both,,,151.44,98.44,,,,,,,,,,,,,
SCREW CONN FOR DSTL FEM TI NAIL,SUP-2188205,CDM,C1713,HCPCS,0278,RC,,,,both,,,1539.17,1000.46,,,,,,,,,,,,,
COLLAR CERV COT DIAL HT ADJ XL PT ACCS WIND VISTA,SUP-2123900,CDM,L0190,HCPCS,0274,RC,,,,both,,,102.71,66.76,,,,,,,,,,,,,
GUIDEWIRE VASC HIWIRE L 180 CM 0.038 IN TAPR L 22 CM ANGLED,SUP-2170351,CDM,C1769,HCPCS,0272,RC,,,,both,,,580.99,377.64,,,,,,,,,,,,,
GRAFT BNE PTTY SM 4 CC BIOACTIVE FIBERGRAFT BG GPS,SUP-2736518,CDM,C1713,HCPCS,0278,RC,,,,both,,,4082.00,2653.30,,,,,,,,,,,,,
CAGE SPNL 10X27X10MM LUM PARA PEEK VISTA P,SUP-2414321,CDM,C1889,HCPCS,0278,RC,,,,both,,,9923.97,6450.58,,,,,,,,,,,,,
CAGE HUM STEMLESS 1 EQUINOXE,SUP-2606121,CDM,C1889,HCPCS,0278,RC,,,,both,,,11932.00,7755.80,,,,,,,,,,,,,
SUPPORT ORTHOT METATRSL CUST BAR WDG BTWN SOLE,SUP-2435727,CDM,L3410,HCPCS,0274,RC,,,,both,,,262.82,170.83,,,,,,,,,,,,,
SPLINT ORTH D RNG CLOSURE UNIV 8 IN WRST FOREARM LT,SUP-2336337,CDM,L3809,HCPCS,0272,RC,,,,both,,,24.55,15.96,,,,,,,,,,,,,
PLANER SURG LAT,SUP-2418046,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2072.40,1347.06,,,,,,,,,,,,,
PLATE BNE CLVRLF 3.5X120 MM 5 HOLE 2 COMPR FOR SCR SS NS,SUP-2473208,CDM,C1713,HCPCS,0278,RC,,,,both,,,983.20,639.08,,,,,,,,,,,,,
RING EXT FIX HALF 110 MM TI NS,SUP-2800189,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1075.95,699.37,,,,,,,,,,,,,
PLATE BNE SCREW DIA 3/3.5/4 MM MED TI ALLOY TALONAVICULAR,SUP-2907925,CDM,C1713,HCPCS,0278,RC,,,,both,,,6486.36,4216.13,,,,,,,,,,,,,
EPINEPHRINE 1 MG/10ML IV SOSY,RX-153347,CDM,J0169,HCPCS,0636,RC,76329-3318-01,NDC,,both,10,ML,79.10,51.41,,,,,,,,,,,,,
PUTTY BONE GRAFT FACTOR 5ML PEPTIDE ENHANCED W/SYRINGE,SUP-2693634,CDM,C1713,HCPCS,0278,RC,,,,both,,,5604.90,3643.18,,,,,,,,,,,,,
SYSTEM OCCL DEL SHTH 7FR L60CM 45DEG SEPT S STL PTFE,SUP-2355731,CDM,C1894,HCPCS,0272,RC,,,,both,,,2152.03,1398.82,,,,,,,,,,,,,
HC Ligation of Hemorrhoid(S),PX-4504622100,CDM,46221,CPT,0450,RC,,,,both,,,1056.00,686.40,,,,,,,,,,,,,
SET CANN SM AD BIOLINE COAT HLS ADV 5,SUP-2266040,CDM,2720000010,LOCAL,0272,RC,,,,both,,,42583.24,27679.11,,,,,,,,,,,,,
BIT DRL STR STRL PILLAR,SUP-2316058,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2188.58,1422.58,,,,,,,,,,,,,
DEVICE URETER COMPR,SUP-2129159,CDM,C1713,HCPCS,0278,RC,,,,both,,,675.10,438.81,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED SIGN VANGUARD,SUP-2137381,CDM,C1776,CPT,0278,RC,,,,both,,,18840.00,12246.00,,,,,,,,,,,,,
GUIDEWIRE VASC L 50 CM DIA 0.035 IN CRV RAD 3 MM STR FIX COR,SUP-2167844,CDM,C1769,HCPCS,0272,RC,,,,both,,,86.44,56.19,,,,,,,,,,,,,
BASKET RETRV 20MM SEGR,SUP-2141356,CDM,2720000010,LOCAL,0272,RC,,,,both,,,599.74,389.83,,,,,,,,,,,,,
PLATE BNE L 71 MM SCREW DIA 3.5 MM 4 H SS RT PROX,SUP-2931194,CDM,C1713,HCPCS,0278,RC,,,,both,,,4213.57,2738.82,,,,,,,,,,,,,
ROD SPNL L300MM DIA5.5MM THORLUM CO CHROM HEX END CREO,SUP-2420851,CDM,C1713,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
CATHETER GUID LUMAX L 90 CM DIA 7 FR GUIDEWIRE 0.038 IN,SUP-2638654,CDM,C1887,HCPCS,0272,RC,,,,both,,,1058.97,688.33,,,,,,,,,,,,,
PIN FIX L30MM OD2MM NONLOCKING RESRB SELF REINF PLLA ST,SUP-2166476,CDM,2720000010,LOCAL,0272,RC,,,,both,,,466.38,303.15,,,,,,,,,,,,,
PIN FIX L20MM OD1.5MM LACTOSORB COPOLYMER ABSRB SGL USE,SUP-2212967,CDM,C1713,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
PLATE BONE L56MM 4 H LT OLECRANON S STL LCK FOR 2.7/3.5MM,SUP-2348705,CDM,C1713,HCPCS,0278,RC,,,,both,,,11162.86,7255.86,,,,,,,,,,,,,
BENDING TEMPLATE FOR 3.5MM LCP(TM) PILON PLATES,SUP-2548485,CDM,C1713,HCPCS,0278,RC,,,,both,,,449.90,292.43,,,,,,,,,,,,,
DRILL SURG DIA27MM STD CANN PERIARTC,SUP-2410859,CDM,C1713,HCPCS,0278,RC,,,,both,,,538.20,349.83,,,,,,,,,,,,,
SPLINT ARM M W18XL13IN FOR 6-17IN LIMB TRNSLUC FAB POLYSTYR,SUP-2328639,CDM,L3702,HCPCS,0274,RC,,,,both,,,34.95,22.72,,,,,,,,,,,,,
KIT ENDOSCP DRL DRL GUID OBT DISP FOR 1.8MM Q-FIX,SUP-2341379,CDM,C1713,HCPCS,0278,RC,,,,both,,,1827.48,1187.86,,,,,,,,,,,,,
BIT DRILL LG 3 MM POWEREASE,SUP-2660005,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1248.40,811.46,,,,,,,,,,,,,
IMPL HAMMERTOE MED 10 DEG,SUP-2704889,CDM,C1713,HCPCS,0278,RC,,,,both,,,4181.44,2717.94,,,,,,,,,,,,,
TISSEEL VHSD 2 ML KT,SUP-2130318,CDM,C1713,HCPCS,0278,RC,,,,both,,,327.09,212.61,,,,,,,,,,,,,
GUIDEPIN SURG L17.5IN DIA3.2MM THRD FOR AFFIXUS HIP FRAC,SUP-2413924,CDM,2720000010,LOCAL,0272,RC,,,,both,,,430.18,279.62,,,,,,,,,,,,,
BLOCK FEM AUG L70MM THK5MM R LAT L MED DST KNEE REV,SUP-2408052,CDM,C1776,CPT,0278,RC,,,,both,,,2964.16,1926.70,,,,,,,,,,,,,
MESH SURG L 5 X W 2 CM D 1 MM PORCINE DERMAL CLLGN ABD HERN,SUP-2901774,CDM,C9364,HCPCS,0278,RC,,,,both,,,818.85,532.25,,,,,,,,,,,,,
CONNECTOR SUT PASS INTEGR GRSP DISP SMARTSTITCH,SUP-2342089,CDM,2720000010,LOCAL,0272,RC,,,,both,,,980.75,637.49,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 20 CM DIA 5 MM EPTFE STR STD WALL,SUP-2496964,CDM,C1768,CPT,0278,RC,,,,both,,,466.48,303.21,,,,,,,,,,,,,
ADAPTER FEM DIA6MM KNEE TOT STBL OFFSET REV TRIATHLON,SUP-2373735,CDM,C1776,CPT,0278,RC,,,,both,,,2684.04,1744.63,,,,,,,,,,,,,
HC So Bile Acids Total,PX-3018223966,CDM,82239,CPT,0301,RC,,,,both,,,65.00,42.25,,,,,,,,,,,,,
BOOT TRACTION LOOP LCK CLOSURE UNIV ECON BUCK,SUP-2336324,CDM,L4398,HCPCS,0274,RC,,,,both,,,93.38,60.70,,,,,,,,,,,,,
CORE OSTEOCHONDRAL FS/A 15MM,SUP-2876043,CDM,C1762,CPT,0278,RC,,,,both,,,16328.00,10613.20,,,,,,,,,,,,,
STENT PERIPH L20MM OD4MM CATH L135CM OD3.5FR GWIRE L300CM,SUP-2368140,CDM,C1876,HCPCS,0278,RC,,,,both,,,21073.80,13697.97,,,,,,,,,,,,,
GUIDEWIRE UROLOGY STR 0.035 INX145 CM 3 CM STD BODY RDRUN PC,SUP-2835779,CDM,C1769,HCPCS,0272,RC,,,,both,,,152.76,99.29,,,,,,,,,,,,,
DILATOR ENDOSCP THRD 5 MM SUTURE ANCHR STRL TWINFIX AB LTX,SUP-2879123,CDM,2720000010,LOCAL,0272,RC,,,,both,,,411.34,267.37,,,,,,,,,,,,,
PLATE BONE L21MM 4 H CRANIOFACIAL VIT STR COND FOR 1.3MM SCR,SUP-2364692,CDM,C1713,HCPCS,0278,RC,,,,both,,,178.98,116.34,,,,,,,,,,,,,
PLATE BNE SIDE 145 DEG STD BRL 6 SLOT OMEGA +,SUP-2464268,CDM,C1713,HCPCS,0278,RC,,,,both,,,2241.96,1457.27,,,,,,,,,,,,,
NAIL RG SH 10MMX140MM,SUP-2316242,CDM,C1713,HCPCS,0278,RC,,,,both,,,3728.75,2423.69,,,,,,,,,,,,,
IMMOBILIZER KNEE AD L22IN FOR UP TO 27IN THGH UNIV FOAM NYL,SUP-2197966,CDM,L1830,CPT,0272,RC,,,,both,,,179.61,116.75,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH FLX L 80 MM PROX/DSTL 24/12 MM,SUP-2171045,CDM,C1874,HCPCS,0278,RC,,,,both,,,7743.24,5033.11,,,,,,,,,,,,,
PLATE BNE SQ 1.5X0.6 MM CRANIOFACIAL NEURO 4 HOLE LADDER NS,SUP-2485041,CDM,C1713,HCPCS,0278,RC,,,,both,,,614.18,399.22,,,,,,,,,,,,,
CATHETER TY PERIPHERALLY INSERTED CTRL VEN 5FR LEN 60CM TWIN,SUP-2168844,CDM,C1751,HCPCS,0278,RC,,,,both,,,312.93,203.40,,,,,,,,,,,,,
SHAFT RMR L470MM DIA5MM FLX,SUP-2188123,CDM,C1776,CPT,0278,RC,,,,both,,,7075.74,4599.23,,,,,,,,,,,,,
CUBE EXT FIX 1 HOLE SS,SUP-2162665,CDM,2720000010,LOCAL,0272,RC,,,,both,,,527.52,342.89,,,,,,,,,,,,,
ALLOGRAFT DRML LG THICK CNTR PRFRTD READY USE ALLDRM,SUP-2466700,CDM,Q4116,HCPCS,0636,RC,,,,both,,,17769.26,11550.02,,,,,,,,,,,,,
GRAFT BNE SUB 90CC 1 8MM CANC CRUSH CHIP READIGRFT,SUP-2264828,CDM,C1713,HCPCS,0278,RC,,,,both,,,3089.10,2007.91,,,,,,,,,,,,,
CATHETER EP DAO 5 MM 6 FRX120 CM SUPREME,SUP-2458303,CDM,C1730,HCPCS,0272,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
ANCHOR SUT GRN SGL SUT CP 2 NDL PANALOK QUICKANCHR,SUP-2184245,CDM,C1713,HCPCS,0278,RC,,,,both,,,338.90,220.28,,,,,,,,,,,,,
PLATE BONE W8XL160MM THK3.3MM 20 H STRL BILAT PELV S STL,SUP-2186248,CDM,C1713,HCPCS,0278,RC,,,,both,,,2193.64,1425.87,,,,,,,,,,,,,
RING ANAS 2 MM 31 MM GAP VALTRAC,SUP-2174532,CDM,C1889,HCPCS,0278,RC,,,,both,,,1321.03,858.67,,,,,,,,,,,,,
SCREW BNE L50MM DIA6.5MM THRD L16MM CALCNL TI CANN HD COMPR,SUP-2398985,CDM,C1713,HCPCS,0278,RC,,,,both,,,857.22,557.19,,,,,,,,,,,,,
HC Iadna Mycobacteria Tuberculosis Amp Prb,PX-3068755600,CDM,87556,CPT,0306,RC,,,,both,,,151.00,98.15,,,,,,,,,,,,,
CATHETER DRAINAGE VLV 6 FRX10 CM 18 GA SAFETY ACCEL,SUP-2659270,CDM,C1729,HCPCS,0272,RC,,,,both,,,70.18,45.62,,,,,,,,,,,,,
GUIDEWIRE VASC L 15 CM DIA 0.025 IN SS SAFE-T-J STR FIX COR,SUP-2760069,CDM,C1769,HCPCS,0272,RC,,,,both,,,45.37,29.49,,,,,,,,,,,,,
GRAFT ENDOPROS LN L5CM UNLN L2CM ID8-10MM SHTH 10FR 0.035IN,SUP-2395933,CDM,C1874,HCPCS,0278,RC,,,,both,,,16642.00,10817.30,,,,,,,,,,,,,
PLATE BNE MED MALL,SUP-2399842,CDM,C1713,HCPCS,0278,RC,,,,both,,,3708.34,2410.42,,,,,,,,,,,,,
ALLOGRAFT BNE SHT 45X20X7 MM DBM CONFORM Q-PACK,SUP-2737086,CDM,C1713,HCPCS,0278,RC,,,,both,,,6899.37,4484.59,,,,,,,,,,,,,
HC Add 2nd/3rd Order Abd/Le,PX-3613624800,CDM,36248,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
IMPLANT BRST GEL 4.9 CM PROJCT 11.6 CM 350-380 CC NATRELLE,SUP-2113257,CDM,C1789,HCPCS,0278,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
KIT INTRO ARROWG+ARD BLU SHTH L 10 CM DIA 9 FR ANTIMICROBIAL,SUP-2763369,CDM,C1892,HCPCS,0272,RC,,,,both,,,447.14,290.64,,,,,,,,,,,,,
PACEMAKER CARD REOCOR S SINGLE CHMBR EXT TEMP NS,SUP-2138197,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6280.00,4082.00,,,,,,,,,,,,,
ELECTRODE ES 36CM LAP STR SPAT COAT DISPOSABLE CLEANCOAT,SUP-2283544,CDM,C1713,HCPCS,0278,RC,,,,both,,,116.37,75.64,,,,,,,,,,,,,
BASEPLATE TIB SZ 3 KNEE CO CHROM MOLYBDENUM TI ALLY ROT,SUP-2251421,CDM,C1776,CPT,0278,RC,,,,both,,,11278.88,7331.27,,,,,,,,,,,,,
ALLOGRAFT HUM TISS PERICARD 7X2 CM M THN PROC TUTOPLAST,SUP-2847987,CDM,C1762,CPT,0278,RC,,,,both,,,3491.68,2269.59,,,,,,,,,,,,,
OCCLUDER SEPT L3MM DIA4MM 45DEG CRV SHTH 6FR WAIST NIT,SUP-2355672,CDM,C1817,HCPCS,0278,RC,,,,both,,,20027.92,13018.15,,,,,,,,,,,,,
SPHINCTEROTOME WRK CHN 37MM DST TIP DIA44FR GWIRE DIA0035IN,SUP-2313229,CDM,2720000010,LOCAL,0272,RC,,,,both,,,864.35,561.83,,,,,,,,,,,,,
ALLOGRAFT BNE 6.5-8.5X220 MM POST TIBIALIS,SUP-2866881,CDM,C1762,CPT,0278,RC,,,,both,,,3654.18,2375.22,,,,,,,,,,,,,
STEM FEM SEG 3 CM DPHSEAL KNEE SMOOTH OSS,SUP-2449806,CDM,C1776,CPT,0278,RC,,,,both,,,10557.94,6862.66,,,,,,,,,,,,,
BONE CEMENT SURG PMMA GENTAMICIN VANCO STD SET HI VISC,SUP-2905405,CDM,C1713,HCPCS,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
MATRIX BIO SZ 300-540 SQCM FISH SKIN DERMAL MESHED 21,SUP-2909213,CDM,Q4158,HCPCS,0636,RC,,,,both,,,25434.00,16532.10,,,,,,,,,,,,,
BIT DRILL 2.1MM,SUP-2468680,CDM,2720000010,LOCAL,0272,RC,,,,both,,,717.43,466.33,,,,,,,,,,,,,
BRACE KNEE SM FOR 15-18IN LT PAT PREFABRICATED AIRTECH FRME,SUP-2151021,CDM,L3660,HCPCS,0272,RC,,,,both,,,931.29,605.34,,,,,,,,,,,,,
DRILL SURG 12 MM FOR ANCHORAGE HOLE,SUP-2449524,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1186.92,771.50,,,,,,,,,,,,,
PATCH CV FOR CARD PED 05MM NOM THICKNESSX3CM NOM WIDTHX3CM,SUP-2395327,CDM,C1768,CPT,0278,RC,,,,both,,,486.70,316.35,,,,,,,,,,,,,
SET CATH HEMODIALYSI BIOFLXTESIO CHRNC SNGLE 10FR DIA 52CM 2,SUP-2610497,CDM,C1750,HCPCS,0278,RC,,,,both,,,162.78,105.81,,,,,,,,,,,,,
TOBRAMYCIN SULFATE 1.2 GM/30ML IJ SOLN,RX-97699,CDM,J3260,HCPCS,0636,RC,67457-0428-30,NDC,,both,2,ML,54.10,35.16,,,,,,,,,,,,,
HC So Drug or Substance Nos 7 or Mor,PX-3018037766,CDM,G0480,CPT,0301,RC,,,,both,,,144.00,93.60,,,,,,,,,,,,,
HC Carbon Dioxide Bicarbonate,PX-3018237400,CDM,82374,CPT,0301,RC,,,,both,,,121.00,78.65,,,,,,,,,,,,,
KIT CAGE SPINAL APREVO 4-LEVEL,SUP-2912825,CDM,C1889,HCPCS,0278,RC,,,,both,,,138160.00,89804.00,,,,,,,,,,,,,
PLATE BNE ACET PELV 3 HOLE SPRING,SUP-2518349,CDM,C1713,HCPCS,0278,RC,,,,both,,,2599.92,1689.95,,,,,,,,,,,,,
ALLOGRAFT BNE CRUNCH 15 CC FD DBM GRFT,SUP-2787766,CDM,C1713,HCPCS,0278,RC,,,,both,,,5066.70,3293.35,,,,,,,,,,,,,
ALLOGRAFT GRAFTON DBF 6CC W/DELIVERY TUBE,SUP-2738997,CDM,C1713,HCPCS,0278,RC,,,,both,,,5463.60,3551.34,,,,,,,,,,,,,
MESH SURG W15XL20CM PTFE OVL KNIT FLM PARTIALLY ABSRB,SUP-2395759,CDM,C1781,HCPCS,0278,RC,,,,both,,,4688.02,3047.21,,,,,,,,,,,,,
TAMP BNE SZ 3 BLLN L20MM INFL FRAC REDUC SYS KYPHON XPANDER,SUP-2281106,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
RESTRICTOR CEM DIA5-8MM HUM ELBW REVERSED AEQUALIS,SUP-2399877,CDM,C1713,HCPCS,0278,RC,,,,both,,,626.43,407.18,,,,,,,,,,,,,
CANNULA ENDOSCP TERMANIAN ENDOTIP 11 MMX4 CM THRD,SUP-2775615,CDM,2720000010,LOCAL,0272,RC,,,,both,,,878.35,570.93,,,,,,,,,,,,,
PLATE BNE L130MM 11 H BILAT TI RIG LO PROF NONCOMPRESSION,SUP-2191079,CDM,C1713,HCPCS,0278,RC,,,,both,,,1929.91,1254.44,,,,,,,,,,,,,
PROBE LITHO RENAL BLDR DISP,SUP-2313962,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1877.72,1220.52,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL PEEK SD800.554,SUP-2860235,CDM,C1713,HCPCS,0278,RC,,,,both,,,23166.92,15058.50,,,,,,,,,,,,,
HC Veno Hepatic W/O Hemo Eval S&I,PX-3207589100,CDM,75891,CPT,0320,RC,,,,outpatient,,,5468.00,3554.20,,,,,,,,,,,,,
SPHINCTEROTOME ENDOSCP CATH 6FR L480CM 0.025IN DOME TIP FOR,SUP-2169530,CDM,2720000010,LOCAL,0272,RC,,,,both,,,750.46,487.80,,,,,,,,,,,,,
BASKET STONE 1.8 FR POLYMER SHTH WIRE ULTRA-CATCH NT,SUP-2457150,CDM,2720000010,LOCAL,0272,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
PACK PROC 120ML BX ASPIR CONC NDL FLTR BMAC SMARTPREP 2,SUP-2384780,CDM,C1713,HCPCS,0278,RC,,,,both,,,9090.30,5908.69,,,,,,,,,,,,,
COMPONENT TIB BASEPLT M/L 63MM A/P 41MM PROVEN GEN-FLEX,SUP-2390299,CDM,C1776,CPT,0278,RC,,,,both,,,4154.22,2700.24,,,,,,,,,,,,,
BENRALIZUMAB 30 MG/ML SC SOSY,RX-140433,CDM,J0517,HCPCS,0636,RC,00310-1730-30,NDC,,both,1,ML,17248.80,11211.72,,,,,,,,,,,,,
ALLOGRAFT HUM TISS HEMI BTB FRZN COLL-E-STRONG,SUP-2321769,CDM,C1762,CPT,0278,RC,,,,both,,,8635.00,5612.75,,,,,,,,,,,,,
FRACTURE KIT FULL SHT 10 ML STABILIT MX,SUP-2485944,CDM,2720000010,LOCAL,0272,RC,,,,both,,,9061.26,5889.82,,,,,,,,,,,,,
GUIDEWIRE VASCULAR L95CM DIA0.014IN ENROUTE,SUP-2431163,CDM,C1769,HCPCS,0272,RC,,,,both,,,499.26,324.52,,,,,,,,,,,,,
TOOL INSRTN TRANSVALVULAR,SUP-2139581,CDM,C1725,HCPCS,0272,RC,,,,both,,,18824.30,12235.79,,,,,,,,,,,,,
ANCHOR SUT DIA5.5MM TWO ULTRABRAID SUT FOR ROT CUF SFT TISS,SUP-2341134,CDM,C1713,HCPCS,0278,RC,,,,both,,,1136.68,738.84,,,,,,,,,,,,,
SCREW PIN PROV FIX 23MMDIA 61MMLENGTH LNG THRD,SUP-2343746,CDM,C1713,HCPCS,0278,RC,,,,both,,,785.82,510.78,,,,,,,,,,,,,
GRAFT PERICARDIAL PERI-GUARD 8CM X 14CM REPAIR PATCH,SUP-2845105,CDM,C1781,HCPCS,0278,RC,,,,both,,,2373.40,1542.71,,,,,,,,,,,,,
HC Vasc Embolize Occlude Organ,PX-3613724300,CDM,37243,CPT,0361,RC,,,,outpatient,,,11772.00,7651.80,,,,,,,,,,,,,
ANCHOR SUT DIA3.7MM BIOABSRB TAG WDG,SUP-2341290,CDM,C1713,HCPCS,0278,RC,,,,both,,,926.46,602.20,,,,,,,,,,,,,
PROBE OPHTH VITRECTOMY 20 GA CRV ENDOPROBE,SUP-2225655,CDM,2720000010,LOCAL,0272,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
GRAFT VASC STD WALLED INTEGR RNG IMPL L20CM L5CM ID6MM,SUP-2395833,CDM,C1768,CPT,0278,RC,,,,both,,,2050.42,1332.77,,,,,,,,,,,,,
COMPONENT FEM A ZMLY LT KNEE PRI CEM PRESSFIT CRUC RET,SUP-2201252,CDM,C1776,CPT,0278,RC,,,,both,,,9082.45,5903.59,,,,,,,,,,,,,
PIN FIX DBL TROCAR 0.156X9 IN SS NS STEINMANN,SUP-2791600,CDM,C1713,HCPCS,0278,RC,,,,both,,,36.55,23.76,,,,,,,,,,,,,
WEDGE TRIAL 6MM,SUP-2465287,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3516.80,2285.92,,,,,,,,,,,,,
BASEPLATE GLEN SM POROUS,SUP-2535492,CDM,C1713,HCPCS,0278,RC,,,,both,,,5385.10,3500.31,,,,,,,,,,,,,
PLATE BNE L 242 X W 10.2 MM THK 2.8 MM SCREW DIA 3.5 MM 22 H 72440622N,SUP-2932785,CDM,C1713,HCPCS,0278,RC,,,,both,,,4078.55,2651.06,,,,,,,,,,,,,
SPACER SPNL 13-16 MM TI ACCULIF,SUP-2381479,CDM,C1713,HCPCS,0278,RC,,,,both,,,15072.00,9796.80,,,,,,,,,,,,,
GUIDEWIRE THRD CALIB 32X300,SUP-2695784,CDM,C1769,HCPCS,0272,RC,,,,both,,,268.16,174.30,,,,,,,,,,,,,
ROD 3600100 OC ADJUSTABLE TI 35 X 100,SUP-2285375,CDM,C1713,HCPCS,0278,RC,,,,both,,,1267.78,824.06,,,,,,,,,,,,,
CATHETER HEMO DYLS OR HD ADMIN BASIC INSRTN KT DBL LUMN,SUP-2126482,CDM,C1752,HCPCS,0278,RC,,,,both,,,405.06,263.29,,,,,,,,,,,,,
GEMCITABINE HCL 1 G IV SOLR,RX-17122,CDM,J9201,HCPCS,0636,RC,25021-0235-50,NDC,,both,1,UN,143.00,92.95,,,,,,,,,,,,,
PROSTHESIS OSS 0.6X4.5 MM MAZZAWI PISTON TAB PLAT RIBBON TI,SUP-2482389,CDM,L8613,CPT,0278,RC,,,,both,,,604.48,392.91,,,,,,,,,,,,,
GANCICLOVIR SODIUM 500 MG IV SOLR,RX-10101,CDM,J1570,HCPCS,0636,RC,70436-0089-55,NDC,,both,1,UN,253.00,164.45,,,,,,,,,,,,,
TUBE PEG L17CM OD18FR LO PROF PUSH KT ENDOVIVE 1 STP BTTN,SUP-2149752,CDM,C1713,HCPCS,0278,RC,,,,both,,,538.51,350.03,,,,,,,,,,,,,
IMPLANT OTO L5.13MM DIA0.76MM SH HA INCUS STAPE KARTUSH,SUP-2312560,CDM,L8613,CPT,0278,RC,,,,both,,,927.15,602.65,,,,,,,,,,,,,
RETRIEVER SURG 0.015 IN 3X32 MM TREVO NXT PROVUE,SUP-2551050,CDM,C1757,HCPCS,0272,RC,,,,both,,,22518.20,14636.83,,,,,,,,,,,,,
PATCH BIO L 4 X W 4 CM BOV PERICARD STRL XENOSURE,SUP-2884021,CDM,C1768,CPT,0278,RC,,,,both,,,1535.46,998.05,,,,,,,,,,,,,
MINOXIDIL 2.5 MG PO TABS,RX-5115,CDM,6370000000,HCPCS,0637,RC,68084-0204-11,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
CATHETER CTRL VEN L20CM OD12FR 3 LUMN N TUNNELED FULL KT,SUP-2120611,CDM,C1751,HCPCS,0278,RC,,,,both,,,545.73,354.72,,,,,,,,,,,,,
SCREW INTFR L23MM DIA10MM BIOCRYL RAPIDE ABSRB MILAGRO ADV,SUP-2249511,CDM,C1713,HCPCS,0278,RC,,,,both,,,1482.08,963.35,,,,,,,,,,,,,
RING EXT FIX HALF 160 MM DORS EZ FRAME,SUP-2490034,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2395.82,1557.28,,,,,,,,,,,,,
PLATE BONE 2 H STR STD GRD 1/3 COMMERCIALLY PURE TI CRAN,SUP-2277531,CDM,C1713,HCPCS,0278,RC,,,,both,,,141.30,91.84,,,,,,,,,,,,,
HC So Morph Analy Insitu Dist Serv,PX-3128836766,CDM,88367,CPT,0312,RC,,,,both,,,110.00,71.50,,,,,,,,,,,,,
CATHETER W/ OLIGON 7F VANTEX CTRL VEN W/ OLIGON,SUP-2214383,CDM,C1751,HCPCS,0278,RC,,,,both,,,169.81,110.38,,,,,,,,,,,,,
CAGE SPNL 5.5X14MM TAPR CERV STALIF C,SUP-2163186,CDM,C1889,HCPCS,0278,RC,,,,both,,,5887.50,3826.87,,,,,,,,,,,,,
BLADE ENDOSCP SHAVER 12 DEG L 11 CM DIA 4 MM SPD 7500 RPM,SUP-2902114,CDM,2720000010,LOCAL,0272,RC,,,,both,,,752.60,489.19,,,,,,,,,,,,,
GRAFT BNE SUB 1CC REHYDRATED PTTY OSTEOAMP,SUP-2138510,CDM,C1713,HCPCS,0278,RC,,,,both,,,1365.90,887.83,,,,,,,,,,,,,
SCREW BNE L7MM OD2.0MM EMGCY TI CENTRE DRV,SUP-2262624,CDM,C1713,HCPCS,0278,RC,,,,both,,,200.96,130.62,,,,,,,,,,,,,
SUPPORT ORTHOT WRST ELBW HND FNGR CUST W/OUT JT FABRICATED,SUP-2435764,CDM,L3765,HCPCS,0272,RC,,,,both,,,3303.85,2147.50,,,,,,,,,,,,,
EVOS WASHER - 3.5MM SCREWS,SUP-2819677,CDM,C1713,HCPCS,0278,RC,,,,both,,,220.68,143.44,,,,,,,,,,,,,
KIT BNE CEM PREP UNIV W/ RESTRIC INSRT 2 CEM SCULP FEM CNL,SUP-2366770,CDM,2720000010,LOCAL,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
HANDLE SURG T DRVR NONCANNULATED FOR IM NAIL TRIGEN,SUP-2347052,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1601.40,1040.91,,,,,,,,,,,,,
FORCEPS STONE RETRV L120CM DIA8MM SHTH 2.6FR NIT 2 PRNG,SUP-2139240,CDM,2720000010,LOCAL,0272,RC,,,,both,,,635.66,413.18,,,,,,,,,,,,,
DISPOSABLES KIT ACL ALL INSIDE,SUP-2811845,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1485.22,965.39,,,,,,,,,,,,,
BAR INSTR BARMESH ARCH 14.5CM,SUP-2135881,CDM,2720000010,LOCAL,0272,RC,,,,both,,,112.00,72.80,,,,,,,,,,,,,
PACEMAKER CARD ADVANTIO W 4.45 X H 4.57 CM THK 0.75 CM 23.5,SUP-2149238,CDM,C1786,HCPCS,0275,RC,,,,both,,,9354.06,6080.14,,,,,,,,,,,,,
BLADE MONOPOLAR SERRATED STD 4 MM STR SUCTION EDGE FRM MALL,SUP-2638409,CDM,2720000010,LOCAL,0272,RC,,,,both,,,501.14,325.74,,,,,,,,,,,,,
TRAY HUM ADPT +5MM OFFSET STD POLY FOR REV SHLDR SYS,SUP-2223377,CDM,C1776,CPT,0278,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
TRAY CATH HEMODIALYSI SLXACUTE 14FR DIA LG 15CM STRGHT TAPR,SUP-2610563,CDM,C1752,HCPCS,0278,RC,,,,both,,,577.76,375.54,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC FT MAXBARR 5FR 55CM 2 LUM 1275108FD,SUP-2632636,CDM,C1751,HCPCS,0278,RC,,,,both,,,813.17,528.56,,,,,,,,,,,,,
SPACER HUM +8MM MONOBLOCK W RET SCR RSP,SUP-2217386,CDM,C1776,CPT,0278,RC,,,,both,,,4252.69,2764.25,,,,,,,,,,,,,
PLATE BNE H0.6MM 8 H STD UP FACE G TI STR LEIBINGER UNIV 2,SUP-2366266,CDM,C1713,HCPCS,0278,RC,,,,both,,,835.68,543.19,,,,,,,,,,,,,
STAPLER CUT L 100 MM CLOSED STPL H 1.5/2.2 MM 4 ROW LINEAR,SUP-2912269,CDM,2720000010,LOCAL,0272,RC,,,,both,,,344.74,224.08,,,,,,,,,,,,,
SUPPORT ORTHOT ANK KNEE CUST W/O JT MULT AXIS PLAS,SUP-2435639,CDM,L2308,HCPCS,0274,RC,,,,both,,,5155.88,3351.32,,,,,,,,,,,,,
INTRODUCER TUBE 21/24/27 FR ADV SET DIL CIAGLIA BLU RHINO G2,SUP-2759772,CDM,C1769,HCPCS,0272,RC,,,,both,,,1077.02,700.06,,,,,,,,,,,,,
SCREW BNE LCK 2.4X10 MM T8 DRV FT STRL VARIAX,SUP-2485634,CDM,C1713,HCPCS,0278,RC,,,,both,,,793.48,515.76,,,,,,,,,,,,,
GRAFT HUM TISS W25MMXW10CM FASC LATA FRZ DRY TUTOPLAST,SUP-2307100,CDM,C1762,CPT,0278,RC,,,,both,,,714.70,464.55,,,,,,,,,,,,,
SCREW BNE L80MM DIA15.8MM LAG FREE LOK L THRD,SUP-2197713,CDM,C1713,HCPCS,0278,RC,,,,both,,,1105.28,718.43,,,,,,,,,,,,,
FRAG LOC COMPRESSION SCREW LNG,SUP-2639435,CDM,C1776,CPT,0278,RC,,,,both,,,976.54,634.75,,,,,,,,,,,,,
CATHETER CTRL VEN QUAD LUMN N TUNNELED FULL KT POLYUR CDC42854PIA] ARROW INTERNATIONAL],SUP-2120622,CDM,C1751,HCPCS,0278,RC,,,,both,,,364.24,236.76,,,,,,,,,,,,,
CATHETER THOR L21IN DIA32FR R ANG HYDRAGLIDE SFT RADPQ STRP,SUP-2227334,CDM,C1729,HCPCS,0272,RC,,,,both,,,50.55,32.86,,,,,,,,,,,,,
PLATE EXT FIX SHT REAR FT BRAC ARTH SIDEKCK,SUP-2400636,CDM,2720000010,LOCAL,0272,RC,,,,both,,,222.94,144.91,,,,,,,,,,,,,
STENT BILI ZILVER L 4 CM DIA 6 MM INTRO L 208 CM DIA 7 FR,SUP-2169572,CDM,C1876,HCPCS,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
STEM FEM SZ 17 L190MM 131DEG HIP CO CHROM POR STD CLLR STR,SUP-2345219,CDM,C1776,CPT,0278,RC,,,,both,,,16930.88,11005.07,,,,,,,,,,,,,
BUR SURGICAL DIAMETER 9MM FOR SKULL OPENING NEUROSURGERY HUD,SUP-2805594,CDM,2720000010,LOCAL,0272,RC,,,,both,,,522.94,339.91,,,,,,,,,,,,,
PLATE BNE STD 14 MM,SUP-2243117,CDM,C1713,HCPCS,0278,RC,,,,both,,,4804.20,3122.73,,,,,,,,,,,,,
ALLOGRAFT BNE MACHINED 7 DEG 14X11X5 MM PUROS S2,SUP-2415682,CDM,C1889,HCPCS,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
LIGATOR ENDOSCP MULTI-BAND 9.5-13 MMX142 CM BND 6 SHOT SAEED,SUP-2737553,CDM,2720000010,LOCAL,0272,RC,,,,both,,,945.14,614.34,,,,,,,,,,,,,
PLATE HLS STR 1.5 4HL 215044,SUP-2247336,CDM,C1713,HCPCS,0278,RC,,,,both,,,1299.96,844.97,,,,,,,,,,,,,
DISSECTOR ENDOSCP RND BLLN SHRP TIP SPCMKR +,SUP-2283395,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2013.05,1308.48,,,,,,,,,,,,,
KIT NRV STIM BLUETOOTH INTERSTIM,SUP-2281689,CDM,C1897,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
PIN FIX L229MM DIA2.8MM S STL 6 DMND PNT STYL UNTHREADED,SUP-2409676,CDM,C1713,HCPCS,0278,RC,,,,both,,,53.47,34.76,,,,,,,,,,,,,
LEAD STIMULATION UPPER AIRWAY INSPIRE,SUP-2664096,CDM,C1778,HCPCS,0278,RC,,,,both,,,6308.26,4100.37,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE 5 CC CALCIUM SULF CALCIUM PHOSPHATE LO,SUP-2890267,CDM,C1713,HCPCS,0278,RC,,,,both,,,11872.34,7717.02,,,,,,,,,,,,,
HEAD HUM SZ 7 HA COAT SHLDR RESURF COPELAND,SUP-2403991,CDM,C1776,CPT,0278,RC,,,,both,,,13976.14,9084.49,,,,,,,,,,,,,
HC External Version,PX-7205941200,CDM,59412,CPT,0720,RC,,,,outpatient,,,1981.00,1287.65,,,,,,,,,,,,,
CATHETER COR L20.25IN OD3.45MM ID1.73MM CUF DIA13/32IN SIL,SUP-2384406,CDM,C1751,HCPCS,0278,RC,,,,both,,,381.86,248.21,,,,,,,,,,,,,
STENT BILI L 10 CM DIA 7 FR GUIDEWIRE 0.035 IN PLAS RX,SUP-2149576,CDM,C2625,HCPCS,0278,RC,,,,both,,,330.58,214.88,,,,,,,,,,,,,
BRACE THMB XSM AD FOR 725 LESS THAN 8IN L9IN R WRST BLK,SUP-2196550,CDM,L3931,HCPCS,0274,RC,,,,both,,,279.18,181.47,,,,,,,,,,,,,
FA-PYRIDOXINE-CYANOCOBALAMIN 2.5-25-2 MG PO TABS,RX-91043,CDM,6370000000,HCPCS,0637,RC,51991-0384-90,NDC,,both,1,UN,3.50,2.27,,,,,,,,,,,,,
HC Cpap/Bipap Daily,PX-4109466000,CDM,94660,CPT,0410,RC,,,,both,,,831.00,540.15,,,,,,,,,,,,,
PLATE BNE VA 2.7X211 MM ARTC PROX 12 HOLE SS NS VA-LCP,SUP-2184187,CDM,C1713,HCPCS,0278,RC,,,,both,,,4015.49,2610.07,,,,,,,,,,,,,
ALLOGRAFT BNE 1 CC DEMINERALIZED BNE MTRX FIBER ALLOFIBER,SUP-2759528,CDM,C1713,HCPCS,0278,RC,,,,both,,,1373.50,892.77,,,,,,,,,,,,,
HC So1 Thyroxine Total,PX-3018443667,CDM,84436,CPT,0301,RC,,,,both,,,26.00,16.90,,,,,,,,,,,,,
RING PESSARY RNG 5 KNOB SIL,SUP-2171733,CDM,A4562,HCPCS,0272,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
PLATE BNE T 25 MM TCP,SUP-2535852,CDM,C1713,HCPCS,0278,RC,,,,both,,,3950.12,2567.58,,,,,,,,,,,,,
PIN EXT FIX TRANSFIXATION 5X325 MM CENTRALLY THRD,SUP-2749989,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1375.32,893.96,,,,,,,,,,,,,
NEEDLE BX L210MM DIA25MM DISPOSABLE SEDAN,SUP-2364149,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1534.83,997.64,,,,,,,,,,,,,
GRAFT CORNEA HUMAN,SUP-2738102,CDM,V2785,HCPCS,0278,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
WASHER SUT 3.5MM 5 H,SUP-2167395,CDM,C1713,HCPCS,0278,RC,,,,both,,,219.80,142.87,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP STR 0.025 INX150 CM EZGLIDER,SUP-2540063,CDM,C1769,HCPCS,0272,RC,,,,both,,,114.92,74.70,,,,,,,,,,,,,
SHUNT NEUROSURGICAL 5CM H2O 30CM H2O VALVE SYSTEM SPRUNG RES,SUP-2825936,CDM,C1889,HCPCS,0278,RC,,,,both,,,8188.84,5322.75,,,,,,,,,,,,,
ANCHOR SUT W/ ORTHOCORD W/ NDL 6.5MM HEALIX BRAID,SUP-2249426,CDM,C1713,HCPCS,0278,RC,,,,both,,,1312.52,853.14,,,,,,,,,,,,,
CAGE SPNL L10XW10XH7MM 4 LOBE MESH ANAT FOOTPRINT MOD IMP,SUP-2317722,CDM,C1889,HCPCS,0278,RC,,,,both,,,3859.06,2508.39,,,,,,,,,,,,,
GUIDEWIRE VASC L260 DIA0035IN TAPR 105CM TIP L3CM 2MM CRV,SUP-2168683,CDM,C1769,HCPCS,0272,RC,,,,both,,,117.15,76.15,,,,,,,,,,,,,
GRAFT BIO TISS W20XL25CM PORCINE REGEN TISS MTRX PLIABLE,SUP-2113037,CDM,Q4130,HCPCS,0636,RC,,,,both,,,48070.26,31245.67,,,,,,,,,,,,,
DRILL SURG BUSHING 2.5 MM TRABECULAR MTL BIGLIANI/FLATOW,SUP-2436806,CDM,2720000010,LOCAL,0272,RC,,,,both,,,890.19,578.62,,,,,,,,,,,,,
GRAFT EVAR L49MM DIA32X32MM EXTN FREE FLO CLS WEB FOR ABD,SUP-2295233,CDM,C1768,CPT,0278,RC,,,,both,,,14365.50,9337.57,,,,,,,,,,,,,
PROBE SURG SCR PEDCL DISP,SUP-2852927,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
CATHETER ETER DLYS 28CM PALINDROME,SUP-2283923,CDM,C1750,HCPCS,0278,RC,,,,both,,,746.06,484.94,,,,,,,,,,,,,
TUBE VENT 1.27 MM 1.3 MM 2.75 MM SHEEHY CLLR BUTTON SIL,SUP-2473009,CDM,L8699,HCPCS,0278,RC,,,,both,,,38.94,25.31,,,,,,,,,,,,,
PLATE BNE ADPT NEUT 2X81 MM 12 HOLE LP RIGID LCK COMPR TI,SUP-2191259,CDM,C1713,HCPCS,0278,RC,,,,both,,,1222.43,794.58,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE SM 1.3 CC CORTICOCANCELLOUS VIABLE 4PK,SUP-2936803,CDM,C1762,CPT,0278,RC,,,,both,,,6154.40,4000.36,,,,,,,,,,,,,
STENT GRFT VASC DETOUR CAP FOR ANY NUMBER OF TORUS/ENDOCROSS,SUP-2898716,CDM,C1604,HCPCS,0278,RC,,,,both,,,78500.00,51025.00,,,,,,,,,,,,,
IRRIGATOR SURG DIA8MM SUCT ENDOWRIST,SUP-2246796,CDM,2720000010,LOCAL,0272,RC,,,,both,,,873.96,568.07,,,,,,,,,,,,,
SUBSTITUTE BNE GRFT PORE 500 UM 5 CC CALCIUM PHOSPHATE HA,SUP-2883749,CDM,C1713,HCPCS,0278,RC,,,,both,,,2882.52,1873.64,,,,,,,,,,,,,
KIT CATH NPHRSTMY PRCTNS W/STNT 0.038N 150CML GDWRE STPCCK S,SUP-2468752,CDM,C1769,HCPCS,0272,RC,,,,both,,,477.25,310.21,,,,,,,,,,,,,
PEG SAFETY ENFIT 20FR ENTRSTAR,SUP-2719889,CDM,2720000010,LOCAL,0272,RC,,,,both,,,353.25,229.61,,,,,,,,,,,,,
CLAMP REPROC ADJUSTABLE WIRE/PIN CLAMP REPROC HYBRID FIXATOR,SUP-2464999,CDM,2720000010,LOCAL,0272,RC,,,,both,,,479.82,311.88,,,,,,,,,,,,,
SHEAR SURG RIB 12 IN RT CORYLLOS-BETHUNE,SUP-2484900,CDM,C1713,HCPCS,0278,RC,,,,both,,,1423.61,925.35,,,,,,,,,,,,,
VALVE MITRL OPN PVT DIA 33 MM ORIFICE 26.8 MM TISS ANNULUS,SUP-2282658,CDM,C1889,HCPCS,0278,RC,,,,both,,,8478.00,5510.70,,,,,,,,,,,,,
ENDOPROSTHESIS VASC VIABAHN L 5 CM DIA 6 MM CATH L 75 CM NIT,SUP-2396475,CDM,C1876,HCPCS,0278,RC,,,,both,,,6437.00,4184.05,,,,,,,,,,,,,
HC Pt Eval High Complex,PX-4249716300,CDM,97163,CPT,0424,RC,,,,both,,,326.00,211.90,,,,,,,,,,,,,
RING ANNULPLSTY EDW MC3 26MM TI ALLOY POLYESTER SIL RUBBER,SUP-2214214,CDM,C1889,HCPCS,0278,RC,,,,both,,,6908.00,4490.20,,,,,,,,,,,,,
BENDAMUSTINE HCL (TREANDA) 100 MG IV SOLR,RX-91300,CDM,J9033,HCPCS,0636,RC,71288-0103-20,NDC,,both,1,UN,1008.00,655.20,,,,,,,,,,,,,
CATHETER GUID L100CM OD7FR GEOMETRIC L 4.5 W/O HYDRPHLC,SUP-2103127,CDM,C1887,HCPCS,0272,RC,,,,both,,,172.70,112.25,,,,,,,,,,,,,
PLATE BNE H0.8MM 8 H CRANIOMAXILLOFACIAL GRY TI CRV LOK,SUP-2366260,CDM,C1713,HCPCS,0278,RC,,,,both,,,576.82,374.93,,,,,,,,,,,,,
GADOTERIDOL 279.3 MG/ML IV SOLN,RX-10100,CDM,A9579,HCPCS,0636,RC,00270-1111-02,NDC,,both,15,ML,14.10,9.16,,,,,,,,,,,,,
KIT INTRO MAK-NV L 20 CM DIA 6FR 0.018IN CHIBA NDL 15CM SS,SUP-2477486,CDM,C1894,HCPCS,0272,RC,,,,both,,,205.67,133.69,,,,,,,,,,,,,
FEM OPENG WEDG OSTEOTOME PLT 12.5MM,SUP-2811662,CDM,C1713,HCPCS,0278,RC,,,,both,,,2606.20,1694.03,,,,,,,,,,,,,
HC Ot Ther Ex per 15 Min|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS,PX-4309711000,CDM,97110,CPT,0430,RC,,,CQ,both,,,195.00,126.75,,,,,,,,,,,,,
COAGULATOR ELECSURG MONOPOLAR 5 MMX33 CM J HK FLAT TIP,SUP-2478460,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1338.21,869.84,,,,,,,,,,,,,
SCREW BNE L36MM DIA4.5MM TI ALUM NIOBIUM ALLY FULL THRD,SUP-2180222,CDM,C1713,HCPCS,0278,RC,,,,both,,,736.39,478.65,,,,,,,,,,,,,
PLATE BNE COMPR SM 2.7X76 MM 9 HOLE DYN NS DCP LTX,SUP-2861902,CDM,C1713,HCPCS,0278,RC,,,,both,,,446.32,290.11,,,,,,,,,,,,,
HC Assay of Folic Acid Serum,PX-3018274600,CDM,82746,CPT,0301,RC,,,,both,,,210.00,136.50,,,,,,,,,,,,,
MESH SYNTH SM H1.3IN D1.1IN W/ KEYHOLE SLT ONLAY PLUG,SUP-2265957,CDM,C1781,HCPCS,0278,RC,,,,both,,,431.75,280.64,,,,,,,,,,,,,
CATHETER THROMCTMY PRONTO V4 L 138 CM 5.5FR 5FR 0.014IN 30CC,SUP-2120488,CDM,C1757,HCPCS,0272,RC,,,,both,,,763.02,495.96,,,,,,,,,,,,,
SCREW ILIOSACRAL TI 7.0MMDIA 50MML,SUP-2290579,CDM,C1713,HCPCS,0278,RC,,,,both,,,3686.36,2396.13,,,,,,,,,,,,,
GRAFT BNE 30CC 1 8MM CANC CRUSH CHIP READIGRFT,SUP-2264819,CDM,C1713,HCPCS,0278,RC,,,,both,,,1067.51,693.88,,,,,,,,,,,,,
PROVEN REV MOD FEM SZ 1,SUP-2359348,CDM,C1776,CPT,0278,RC,,,,both,,,13973.00,9082.45,,,,,,,,,,,,,
HC Amniocentesis Any Method,PX-3615900000,CDM,59000,CPT,0361,RC,,,,outpatient,,,924.00,600.60,,,,,,,,,,,,,
ANCHOR SUTURE ZIP 5.5 MM COBRAID STRANDS PEEK WHT BLU,SUP-2608440,CDM,C1713,HCPCS,0278,RC,,,,both,,,664.11,431.67,,,,,,,,,,,,,
BASEPLATE TIB SCR FIX LCK FLX MOD NXGN LEG,SUP-2201053,CDM,C1713,HCPCS,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
CATHETER CV FULL TY 032 10 FRX25 CM 10 GA 5 LUMEN SPECTRUM,SUP-2759734,CDM,C1751,HCPCS,0278,RC,,,,both,,,617.58,401.43,,,,,,,,,,,,,
RETRACTOR BLDE TOP OBLQ SPRD SPNL CATLYST SURG MED LAT SELF,SUP-2285278,CDM,C1713,HCPCS,0278,RC,,,,both,,,799.26,519.52,,,,,,,,,,,,,
CATHETER ANGIOPLSTY L145CM BAL L12MM DIA1.5MM GWIRE 0.014IN,SUP-2418141,CDM,C1725,HCPCS,0272,RC,,,,both,,,492.98,320.44,,,,,,,,,,,,,
SHEATH INTRO PINNACLE TIF TIP L 10 CM DIA 6 FR 0.038 IN,SUP-2384799,CDM,C1894,HCPCS,0272,RC,,,,both,,,56.52,36.74,,,,,,,,,,,,,
GREAT TOE METATRSL MED 15 DEG NP BIOPRO,SUP-2137798,CDM,C1776,CPT,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
IMPLANT LARYN L8MM DIA16FR INDWL RADPQ RNG CLASS BLOM-SINGER,SUP-2242359,CDM,L8509,HCPCS,0274,RC,,,,both,,,910.60,591.89,,,,,,,,,,,,,
BAR EXTERNAL FIXATION L250MM DIA11MM XTRAFIX SYSTEM,SUP-2459552,CDM,2720000010,LOCAL,0272,RC,,,,both,,,652.02,423.81,,,,,,,,,,,,,
SPLINT RST PAN MIT SP S LF,SUP-2163830,CDM,L3807,HCPCS,0272,RC,,,,both,,,81.29,52.84,,,,,,,,,,,,,
BEAD MAT ORTH SIL FOR MAG BVF MIXING DEL SYS,SUP-2899246,CDM,2720000010,LOCAL,0272,RC,,,,both,,,777.15,505.15,,,,,,,,,,,,,
BANDAGE SUPP ANK AK PELV,SUP-2388214,CDM,L5697,HCPCS,0274,RC,,,,both,,,222.03,144.32,,,,,,,,,,,,,
EXTERNAL FIXATION KIT MILITARY LG STRL,SUP-2546227,CDM,C1713,HCPCS,0278,RC,,,,both,,,11817.55,7681.41,,,,,,,,,,,,,
DEVICE GRAFT DELIVERY WITH CUSTOM CANNULA,SUP-2731950,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
PLATE BONE L23MM 100DEG 7 H RT CRANIOMAXILLOFACIAL TI L FOR,SUP-2136527,CDM,C1713,HCPCS,0278,RC,,,,both,,,631.14,410.24,,,,,,,,,,,,,
MESH CRANIAL CONTOURABLE 1.5X30X40X0.25 MM RAPID RESORBABLE,SUP-2838570,CDM,C1713,HCPCS,0278,RC,,,,both,,,1556.18,1011.52,,,,,,,,,,,,,
ROCKER EXT FIX SHRT FT NS DISP MONK RING,SUP-2899189,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4308.87,2800.77,,,,,,,,,,,,,
CATHETER HD SYMMETRICAL 14.5 FRX19 CM SLV PALINDROMIC HSI,SUP-2283948,CDM,C1750,HCPCS,0278,RC,,,,both,,,1046.34,680.12,,,,,,,,,,,,,
PLATE CNDLR CMMRCLLY PURE TTNM FRAC 3D LOK RHMBS LATEX FREE,SUP-2676762,CDM,C1713,HCPCS,0278,RC,,,,both,,,1194.33,776.31,,,,,,,,,,,,,
KIT STEREOTACTIC CKPT,SUP-2368431,CDM,2720000010,LOCAL,0272,RC,,,,both,,,227.65,147.97,,,,,,,,,,,,,
GRAFT VASC INTERGARD L 40 X 35 CM DIA24 X 10 MM THK 0.38 MM,SUP-2227519,CDM,C1768,CPT,0278,RC,,,,both,,,4011.32,2607.36,,,,,,,,,,,,,
SLING GYN ANT PELV FLR RECON MESH GYNECARE PROLIFT+M,SUP-2219782,CDM,C1771,HCPCS,0278,RC,,,,both,,,4945.50,3214.57,,,,,,,,,,,,,
COMPONENT HUM DIA40MM SHLDR SUT CLLR FOR PLATFRM,SUP-2249859,CDM,C1776,CPT,0278,RC,,,,both,,,1245.95,809.87,,,,,,,,,,,,,
BLADE SURG L110MM S STL HELIX FOR LCP DHHS SYS,SUP-2186786,CDM,C1713,HCPCS,0278,RC,,,,both,,,1050.77,683.00,,,,,,,,,,,,,
BIT DRL CANN LG 13X465 MM QC FLX TI NS EXPERT,SUP-2863378,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2051.17,1333.26,,,,,,,,,,,,,
NAIL IM L200MM DIA12MM UNIV FEM BENT RG LCK CANN,SUP-2412884,CDM,C1713,HCPCS,0278,RC,,,,both,,,4264.12,2771.68,,,,,,,,,,,,,
DILATOR ES 60FR 20MM OVR THE GWIRE FLX SAFEGUIDE,SUP-2277393,CDM,2720000010,LOCAL,0272,RC,,,,both,,,773.70,502.90,,,,,,,,,,,,,
INSERT TIB SZ 6-7 THK11MM RT KNEE HNG GUID MOTN LEGION,SUP-2346691,CDM,C1776,CPT,0278,RC,,,,both,,,6663.08,4331.00,,,,,,,,,,,,,
CATHETER URET 10FR L54CM 2 TORQUEABLE,SUP-2139305,CDM,C1758,HCPCS,0278,RC,,,,both,,,234.12,152.18,,,,,,,,,,,,,
GUIDEWIRE SURG L240MM DIA2MM S STL TRCR TIP FOR HUM NAIL,SUP-2178839,CDM,C1769,HCPCS,0272,RC,,,,both,,,99.07,64.40,,,,,,,,,,,,,
TRAY MIDLN BASIC POWERGLIDE ST 20G X 8CM ST020080,SUP-2125704,CDM,C1751,HCPCS,0278,RC,,,,both,,,340.56,221.36,,,,,,,,,,,,,
SPACER CORT ADCF 8MM,SUP-2137562,CDM,C1821,HCPCS,0278,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
INSERT TIB SM SZ 1-2 THK9MM RT KNEE POLYETH PRI NEUT,SUP-2350388,CDM,C1776,CPT,0278,RC,,,,both,,,3925.00,2551.25,,,,,,,,,,,,,
PEG BNE FIX L16MM DIA2.5MM DST VOLAR CORT RAD CO CHROM,SUP-2411662,CDM,C1713,HCPCS,0278,RC,,,,both,,,404.90,263.18,,,,,,,,,,,,,
ASCENT DST AUG MED 16MM LM/RL,SUP-2408818,CDM,C1776,CPT,0278,RC,,,,both,,,2568.52,1669.54,,,,,,,,,,,,,
HUMERAL TRAY REVERSED +10 MM 49 MM SHLDR,SUP-2431686,CDM,C1776,CPT,0278,RC,,,,both,,,4352.04,2828.83,,,,,,,,,,,,,
KIT INTRO L 10 CM DIA 4 FR NIT WIRE TUNGSTEN TIP MIC STIFF,SUP-2752609,CDM,C1894,HCPCS,0272,RC,,,,both,,,84.91,55.19,,,,,,,,,,,,,
ELECTRODE ELECSURG GRN MAIN CBL 9 TO 14 PIN STARBURSTXL,SUP-2117213,CDM,C1819,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE DIA 7.5 MM SZ 5 CART ARAGONITE POROUS,SUP-2913309,CDM,C1763,HCPCS,0278,RC,,,,both,,,23079.00,15001.35,,,,,,,,,,,,,
PLATE BONE 8 H TI BROAD HYBRID COMPR FOR 4.5MM SCR ALPS,SUP-2413752,CDM,C1713,HCPCS,0278,RC,,,,both,,,1199.54,779.70,,,,,,,,,,,,,
GUIDEPIN SURG DIA3MM NONCANNULATED RETRODRILL,SUP-2120915,CDM,2720000010,LOCAL,0272,RC,,,,both,,,401.92,261.25,,,,,,,,,,,,,
HEAD HUM MOD STD PRI STD NK 38MM OD 15MM HT,SUP-2408632,CDM,C1776,CPT,0278,RC,,,,both,,,5859.24,3808.51,,,,,,,,,,,,,
COIL EMB 3D 1 MMX3 CM V-TRAK ADV DEL SYS HYPERSOFT,SUP-2530419,CDM,C1889,HCPCS,0278,RC,,,,both,,,5204.55,3382.96,,,,,,,,,,,,,
PLATE BONE L15MM THK1.5MM 2X2 H MINI BLU TI,SUP-2319369,CDM,C1713,HCPCS,0278,RC,,,,both,,,304.58,197.98,,,,,,,,,,,,,
PLATE BNE L82MM 7 H BILAT S STL STR RECON NONLOCKING,SUP-2197672,CDM,C1713,HCPCS,0278,RC,,,,both,,,1055.67,686.19,,,,,,,,,,,,,
INSERT TIB CR 67X14 MM KNEE PRIMARY BEAR MAXM VI,SUP-2404015,CDM,C1776,CPT,0278,RC,,,,both,,,2424.08,1575.65,,,,,,,,,,,,,
HEAD FEM TYP 1 3- MM 36 MM HIP CERM,SUP-2449631,CDM,C1776,CPT,0278,RC,,,,both,,,6090.03,3958.52,,,,,,,,,,,,,
SHUNT SURG VENTRICULAR CATH L 180 MM PRESSURE DIFF 5 CM H2O,SUP-2931100,CDM,C1729,HCPCS,0272,RC,,,,both,,,16930.91,11005.09,,,,,,,,,,,,,
LENS SFTY WRP ARND LO PROF,SUP-2366927,CDM,V2632,HCPCS,0276,RC,,,,both,,,41.32,26.86,,,,,,,,,,,,,
SHELL ACET SZ 25 OD60MM HIP LIMIT H LOK RNG RANAWAT,SUP-2403853,CDM,C1776,CPT,0278,RC,,,,both,,,4535.73,2948.22,,,,,,,,,,,,,
TRAY KYPHOPLASTY BLLN 4ML L20MM DIA19.2MM NDL 10GA SYR 20ML,SUP-2367081,CDM,C1894,HCPCS,0272,RC,,,,both,,,8087.07,5256.60,,,,,,,,,,,,,
WAND ABLAT FOR ADENOTONSILLECTOMY EVAC 70XTRA HP COBLATION,SUP-2342043,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1167.14,758.64,,,,,,,,,,,,,
STEM FEM 13.5X170 MM HIP,SUP-2204191,CDM,C1776,CPT,0278,RC,,,,both,,,10423.01,6774.96,,,,,,,,,,,,,
KIT REP BRDG TECH FOR TRANSTEND REP OF PART ARTC SIDE,SUP-2121601,CDM,C1713,HCPCS,0278,RC,,,,both,,,3720.90,2418.58,,,,,,,,,,,,,
CATHETER GUID LT HRT ATTAIN COMMND SUREVALVE,SUP-2282221,CDM,C1887,HCPCS,0272,RC,,,,both,,,980.62,637.40,,,,,,,,,,,,,
SCREW BONE L26MM DIA4.7MM STRL S STL PARTIALLY THRD FOR,SUP-2349592,CDM,C1713,HCPCS,0278,RC,,,,both,,,405.09,263.31,,,,,,,,,,,,,
PLATE BNE L87MM 4 H NONSTERILE L PROX TIB S STL VAR ANG LOK 02127211],SUP-2177908,CDM,C1713,HCPCS,0278,RC,,,,both,,,4626.60,3007.29,,,,,,,,,,,,,
WAND ELECTROSURG IRONMAN,SUP-2342012,CDM,2720000010,LOCAL,0272,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
CATHETER DRNGE 8FR L30CM UNIV NIT LOK PGTL NAVARRE,SUP-2128423,CDM,C1729,HCPCS,0272,RC,,,,both,,,247.18,160.67,,,,,,,,,,,,,
SET LD INTRO PEELWY L 24 CM ID 10 FR GUIDEWIRE 0.038 IN NDL,SUP-2169807,CDM,C1892,HCPCS,0272,RC,,,,both,,,186.52,121.24,,,,,,,,,,,,,
BURR SURG 1.7MM DIA HD LNG MIC 70MML 12MML HD CARBIDE SM BNE,SUP-2605562,CDM,2720000010,LOCAL,0272,RC,,,,both,,,69.74,45.33,,,,,,,,,,,,,
GUIDE SURG K WIRE DEPTH,SUP-2232163,CDM,C1713,HCPCS,0278,RC,,,,both,,,204.10,132.66,,,,,,,,,,,,,
GUIDEWIRE VASC VSI TRU-TORQUE L 260 CM DIA 0.035 IN PTFE MOD,SUP-2763464,CDM,C1769,HCPCS,0272,RC,,,,both,,,241.78,157.16,,,,,,,,,,,,,
CANNULA SUCTION L245MM DIAMETER 3MM DEBAKEY TIP,SUP-2806702,CDM,2720000010,LOCAL,0272,RC,,,,both,,,382.48,248.61,,,,,,,,,,,,,
BLADE SAW 62.5X11.5 MM 0.64 MM 25 MM 8.7 CM LG SECT SS,SUP-2632335,CDM,2720000010,LOCAL,0272,RC,,,,both,,,365.94,237.86,,,,,,,,,,,,,
HC Lactate Dehydrogenase Isoenzymes Sep&Quan,PX-3018362500,CDM,83625,CPT,0301,RC,,,,both,,,385.00,250.25,,,,,,,,,,,,,
HC Inject Trigger Point 1/2 Muscle,PX-3612055200,CDM,20552,CPT,0361,RC,,,,both,,,613.00,398.45,,,,,,,,,,,,,
GRAFT VASC EXXCEL SFT L 80 CM SUPP L 80 CM DIA 6 MM EPTFE,SUP-2227659,CDM,C1768,CPT,0278,RC,,,,both,,,3097.99,2013.69,,,,,,,,,,,,,
STENT BILI FLEXXUS L 4 CM DIA10 MM CATH L 190 CM DIA 7.5 FR,SUP-2166290,CDM,C1876,HCPCS,0278,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
GUIDEWIRE VASC L 150 CM DIA 0.035 IN TIP L 3 MM PTFE J STR,SUP-2301941,CDM,C1769,HCPCS,0272,RC,,,,both,,,25.43,16.53,,,,,,,,,,,,,
PLATE BNE WIRE DORS WRST 3 HOLE,SUP-2389787,CDM,C1713,HCPCS,0278,RC,,,,both,,,1146.10,744.96,,,,,,,,,,,,,
GRAFT BONE 40X15MM 10DEG WDG MTRX REGENERATIVE TISS BONE,SUP-2293941,CDM,C1713,HCPCS,0278,RC,,,,both,,,2323.60,1510.34,,,,,,,,,,,,,
IMPLANT FACE W38XL50MM THK085MM CHN BARR SHT MEDPOR,SUP-2366495,CDM,C1713,HCPCS,0278,RC,,,,both,,,2913.98,1894.09,,,,,,,,,,,,,
PLATE BNE HK 0.8 MM HND AVULSION STRL,SUP-2518380,CDM,C1713,HCPCS,0278,RC,,,,both,,,778.72,506.17,,,,,,,,,,,,,
LINER ACET OD56MM ID32MM 10DEG MARATHON CEMENTLESS RECON,SUP-2250545,CDM,C1776,CPT,0278,RC,,,,both,,,3673.80,2387.97,,,,,,,,,,,,,
DRILL TWST L 9 MM DIA1.1 MM STP 7 MM HALL FOR 1.5 SYS NS,SUP-2935115,CDM,2720000010,LOCAL,0272,RC,,,,both,,,449.02,291.86,,,,,,,,,,,,,
STRUT FX MAXIFRAME STANDOFF 80MM,SUP-2737905,CDM,2720000010,LOCAL,0272,RC,,,,both,,,359.22,233.49,,,,,,,,,,,,,
ATROPINE SULFATE 0.4 MG/ML IV SOLN,RX-153338,CDM,J0462,HCPCS,0636,RC,00517-1004-25,NDC,,both,0.5,ML,54.10,35.16,,,,,,,,,,,,,
PENICILLIN G POTASSIUM 5000000 UNITS IJ SOLR,RX-6086,CDM,J2540,HCPCS,0636,RC,00049-0520-22,NDC,,both,1,UN,54.10,35.16,,,,,,,,,,,,,
HC Mt Massage Ea 15 Min,PX-4209712401,CDM,97124,CPT,0420,RC,,,,inpatient,,,194.00,126.10,,,,,,,,,,,,,
KIT PRB 17GA L100MM MULTI-3 COOLED RF W/ 4MM ACT TIP,SUP-2236769,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6908.00,4490.20,,,,,,,,,,,,,
BIT DRILL 1.5X90 MM FOR MINI QUICK COUPLING NON STERILE,SUP-2837639,CDM,2720000010,LOCAL,0272,RC,,,,both,,,639.62,415.75,,,,,,,,,,,,,
CATHETER PA L 110 CM DIA 6 FR 4 LUMEN 1.5 CC POLYUR,SUP-2893601,CDM,2720000010,LOCAL,0272,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
STRAP SELF ADH BGE 1X18IN D RNG,SUP-2324798,CDM,L3908,HCPCS,0272,RC,,,,both,,,10.86,7.06,,,,,,,,,,,,,
PLATE BONE L100MM 4X8 HOLE T SHAPED 35MM SCREW,SUP-2471047,CDM,C1713,HCPCS,0278,RC,,,,both,,,589.94,383.46,,,,,,,,,,,,,
CYCLOBENZAPRINE HCL 10 MG PO TABS,RX-2017,CDM,6370000000,HCPCS,0637,RC,60687-0558-11,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PLATE BNE L206MM 14 H ST R PROX BILAT TIB S STL NEUT LOK,SUP-2177840,CDM,C1713,HCPCS,0278,RC,,,,both,,,4567.19,2968.67,,,,,,,,,,,,,
FIBER LASER AURA ACCUSTAT 125UM 5W SINGLE-MODE,SUP-2885320,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2678.42,1740.97,,,,,,,,,,,,,
GRAFT TISS FRZN ALLGRFT TIB WHL L W BTB,SUP-2307302,CDM,C1713,HCPCS,0278,RC,,,,both,,,30481.68,19813.09,,,,,,,,,,,,,
HC Monitoring Cst Fetal,PX-7215902000,CDM,59020,CPT,0721,RC,,,,both,,,1010.00,656.50,,,,,,,,,,,,,
BLADE SAW 25X2-86 MM MICS ATTCH STRL,SUP-2869283,CDM,2720000010,LOCAL,0272,RC,,,,both,,,717.80,466.57,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE SZ 50 X 20 X 7 MM DBM CANC SPNG STRP,SUP-2913397,CDM,C1713,HCPCS,0278,RC,,,,both,,,12267.98,7974.19,,,,,,,,,,,,,
SYSTEM CARD PACEMKR SGL CHMBR MICRONY II SR PULSE RATE,SUP-2356133,CDM,C1786,HCPCS,0275,RC,,,,both,,,11410.76,7416.99,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH TX2 L 162 MM DIA 42 MM SHTH 22 FR RVD,SUP-2171022,CDM,C1713,HCPCS,0278,RC,,,,both,,,37975.16,24683.85,,,,,,,,,,,,,
PLATE BONE THK1MM 2X2 H RT BILAT CRANIOMAXILLOFACIAL ORAL TI,SUP-2181779,CDM,C1713,HCPCS,0278,RC,,,,both,,,1472.66,957.23,,,,,,,,,,,,,
ROMIPLOSTIM 250 MCG SC SOLR,RX-93566,CDM,J2802,HCPCS,0636,RC,55513-0221-01,NDC,,both,1,UN,8121.50,5278.97,,,,,,,,,,,,,
SHEATH DIL OD16.3FR ID14.1FR CXL WHT POLYPR LD EXTR TELSCP,SUP-2169008,CDM,C1893,HCPCS,0272,RC,,,,both,,,307.72,200.02,,,,,,,,,,,,,
PACEMAKER CRD SINGLE CHMBR LD CABLE INTRO,SUP-2357726,CDM,C1786,HCPCS,0275,RC,,,,both,,,12560.00,8164.00,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.550,SUP-2860067,CDM,C1713,HCPCS,0278,RC,,,,both,,,62697.95,40753.67,,,,,,,,,,,,,
IMPLANT LARYN L4MM DIA20FR SFT VLV ASMBLY EMBEDDED W/ SLV,SUP-2242289,CDM,L8509,HCPCS,0272,RC,,,,both,,,1224.60,795.99,,,,,,,,,,,,,
STEM FEM CLLRD 11X220 MM LT HIP BIMTRC,SUP-2449882,CDM,C1776,CPT,0278,RC,,,,both,,,12183.20,7919.08,,,,,,,,,,,,,
SPLINT WRST FA R INSTABILITY INJ LOOP LOK W STAY E SUPP COT,SUP-2276652,CDM,L3809,HCPCS,0274,RC,,,,both,,,9.55,6.21,,,,,,,,,,,,,
IMPLANT FOSSA MED UHMWPE LT TEMPOROMANDIBULAR JT STRL DISP,SUP-2934203,CDM,C1713,HCPCS,0278,RC,,,,both,,,17304.54,11247.95,,,,,,,,,,,,,
SUPPORT ORTHOT WRST ELBW HND SHLDR CUST CAP DESIGN W/O JT,SUP-2435792,CDM,L3961,HCPCS,0274,RC,,,,both,,,4329.02,2813.86,,,,,,,,,,,,,
PACK PROC S AND N PART SHLDR H COFLD,SUP-2347983,CDM,C1776,CPT,0278,RC,,,,both,,,8478.00,5510.70,,,,,,,,,,,,,
BLADE SHAVER RESECT 5.5X130 MM SMOOTH DISP,SUP-2661217,CDM,2720000010,LOCAL,0272,RC,,,,both,,,394.04,256.13,,,,,,,,,,,,,
SCREW BNE NLCK 2.7X18 MM LP STRL STRATUM,SUP-2423343,CDM,C1713,HCPCS,0278,RC,,,,both,,,465.72,302.72,,,,,,,,,,,,,
HC Intro Needle/Cath Ext Art,PX-3613614000,CDM,36140,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
PLATE BNE GAP 1.5/0.5X50 MM NEURO,SUP-2403039,CDM,C1713,HCPCS,0278,RC,,,,both,,,530.66,344.93,,,,,,,,,,,,,
BIT DRILL T2 TRIFLAT 42 X 260MM,SUP-2704166,CDM,2720000010,LOCAL,0272,RC,,,,both,,,697.08,453.10,,,,,,,,,,,,,
BUR SURG DIA5MM CARB RND,SUP-2364020,CDM,2720000010,LOCAL,0272,RC,,,,both,,,735.36,477.98,,,,,,,,,,,,,
KIT STBL POS SHLDR SPIDER 2 EXCEPTIONAL LIMB CTRL,SUP-2341137,CDM,L3650,HCPCS,0274,RC,,,,both,,,519.70,337.80,,,,,,,,,,,,,
SUPPORT WR L LNG LEN RT FRARM WVN COT RUB FAB BGE FIRM W/,SUP-2324897,CDM,L3809,HCPCS,0272,RC,,,,both,,,41.01,26.66,,,,,,,,,,,,,
ANCHOR SUTURE BRAID 2-0 4.5 MM TWST SCR IN WHT BLU GRN,SUP-2762183,CDM,C1713,HCPCS,0278,RC,,,,both,,,703.36,457.18,,,,,,,,,,,,,
GRAFT ALLGRFT TEND TIBIALIS ANT FRZN AESEPTIC 920332] ZIMMER BIOMET INC],SUP-2137246,CDM,C1762,CPT,0278,RC,,,,both,,,5273.94,3428.06,,,,,,,,,,,,,
HC So Bordetella,PX-3028661566,CDM,86615,CPT,0302,RC,,,,both,,,24.00,15.60,,,,,,,,,,,,,
COLLAR CERV SFT 375X17IN M,SUP-2276589,CDM,L0120,HCPCS,0272,RC,,,,both,,,5.97,3.88,,,,,,,,,,,,,
TAP BNE SPNL ANT CERV,SUP-2286471,CDM,C1713,HCPCS,0278,RC,,,,both,,,505.16,328.35,,,,,,,,,,,,,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-103564,CDM,J0665,HCPCS,0636,RC,55150-0167-10,NDC,,both,30,ML,54.10,35.16,,,,,,,,,,,,,
MATRIX DERM BOV TISS FEN PRIMTRX 6CM X 6CM,SUP-2366725,CDM,C9359,HCPCS,0278,RC,,,,both,,,5831.29,3790.34,,,,,,,,,,,,,
GRAFT HUM TISS W30MMXL15CM FASC LATA FRZ DRY,SUP-2307099,CDM,C1762,CPT,0278,RC,,,,both,,,946.14,614.99,,,,,,,,,,,,,
GRAFT BONE PRO DENS 2CC,SUP-2399145,CDM,C1713,HCPCS,0278,RC,,,,both,,,2284.73,1485.07,,,,,,,,,,,,,
BLADE SAW RECIP KEEL FOR STRYKR SYS,SUP-2408500,CDM,C1713,HCPCS,0278,RC,,,,both,,,753.60,489.84,,,,,,,,,,,,,
PLATE STRNL CLOSURE THK 1.5 MM 14 H TI DBL T LP NS,SUP-2894433,CDM,C1713,HCPCS,0278,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
FRAME EXT FIX UNIV SPD JT,SUP-2197310,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1695.60,1102.14,,,,,,,,,,,,,
PLATE BONE MESHED 109X78 MM CRANIAL PREFORMED FRONTAL RIGID,SUP-2837721,CDM,C1713,HCPCS,0278,RC,,,,both,,,14781.86,9608.21,,,,,,,,,,,,,
SCREW BNE L 5 MM DIA2.7 MM MANDIBULAR UNIV AXS ST EMER NS,SUP-2909471,CDM,C1713,HCPCS,0278,RC,,,,both,,,363.61,236.35,,,,,,,,,,,,,
CATHETER CTRL VEN 7FR POLYUR MULTILUMEN INDWL RADPQ W/ BLU,SUP-2120637,CDM,C1751,HCPCS,0278,RC,,,,both,,,102.36,66.53,,,,,,,,,,,,,
POST FIX PLATE COMPR 25 MM SYS IMPL INSTRUMENT AXIS,SUP-2610265,CDM,C1713,HCPCS,0278,RC,,,,both,,,4144.80,2694.12,,,,,,,,,,,,,
DONALDSON VT PC SI 114MM,SUP-2669490,CDM,L8699,HCPCS,0278,RC,,,,both,,,36.33,23.61,,,,,,,,,,,,,
BUR SURG OD2MM SM CYL LEADER PNT,SUP-2398606,CDM,C1713,HCPCS,0278,RC,,,,both,,,599.74,389.83,,,,,,,,,,,,,
APPLIER CLP XL 10 MMX45 CM MANUAL LOAD HEM-O-LOK ENDO10,SUP-2656815,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3764.86,2447.16,,,,,,,,,,,,,
BOLT ORTHOPEDIC LCK 3.9X52 MM TI NS,SUP-2192160,CDM,C1713,HCPCS,0278,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
GRAFT 6CMWX16CMLX18 25MM ULT THCK DERM PLIABLE BIL BRST KT,SUP-2307592,CDM,Q4128,HCPCS,0636,RC,,,,both,,,15794.99,10266.74,,,,,,,,,,,,,
STENT PERIPH ZILVER VENA L 100 MM DIA10 MM CATH L 120 CM,SUP-2647182,CDM,C1876,HCPCS,0278,RC,,,,both,,,4706.86,3059.46,,,,,,,,,,,,,
KIT INTRO L 45 CM DIA 5 FR GCI STRL,SUP-2876512,CDM,C1894,HCPCS,0272,RC,,,,both,,,160.14,104.09,,,,,,,,,,,,,
CAP ORTH SM LT ULN ELBW LATITUDE,SUP-2399817,CDM,C1776,CPT,0278,RC,,,,both,,,6132.42,3986.07,,,,,,,,,,,,,
GRAFT 0.5CC BONE PUTTY DBM PUROS,SUP-2335222,CDM,C9359,HCPCS,0278,RC,,,,both,,,607.59,394.93,,,,,,,,,,,,,
PLATE BNE TI MIDFACE RECON 1 PLATE CUSTOMIZED FACE ID,SUP-2883364,CDM,C1713,HCPCS,0278,RC,,,,both,,,32394.47,21056.41,,,,,,,,,,,,,
CATHETER PRB GLD DIR 10FR,SUP-2141559,CDM,2720000010,LOCAL,0272,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
SHEATH INTRO HEARTSPAN 90 DEG L 81 CM DIA 8.5 FR NDL L 89 CM,SUP-2460734,CDM,C1893,HCPCS,0272,RC,,,,both,,,448.39,291.45,,,,,,,,,,,,,
CANNULA INJ F/POS PRESSURE ASST VENT 8588 A/B/BV,SUP-2776890,CDM,2720000010,LOCAL,0272,RC,,,,both,,,548.59,356.58,,,,,,,,,,,,,
DEXTROSE 5 % IV BOLUS,RX-40840055,CDM,J7060,HCPCS,0250,RC,00264-7510-20,NDC,,both,250,ML,31.90,20.73,,,,,,,,,,,,,
HC OP Traction Intermittent|OP PT SERVICES|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS|UNUSUAL NON-OVERLAPPING SERVICE,PX-4209701200,CDM,97012,CPT,0420,RC,,,GP|CQ|XU,outpatient,,,292.00,189.80,,,,,,,,,,,,,
CATHETER HD TRPL LUMEN 12 FRX24 CM HI PRESSURE CRV EXT MAHRK,SUP-2283988,CDM,C1750,HCPCS,0278,RC,,,,both,,,1293.68,840.89,,,,,,,,,,,,,
COMPONENT FEM SZ B L KNEE SEG,SUP-2200498,CDM,C1776,CPT,0278,RC,,,,both,,,22480.83,14612.54,,,,,,,,,,,,,
SEALER VES BPLR FOR DA VINCI XI ENDOWRIST,SUP-2246797,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1868.30,1214.39,,,,,,,,,,,,,
CATHETER ATHRCTMY WILDCAT L 110 CM OD 6 FR ID 0.038 JUICEBOX,SUP-2124797,CDM,C1769,HCPCS,0272,RC,,,,both,,,4694.30,3051.29,,,,,,,,,,,,,
KIT PERICARDCENT PERIVAC STR CATH W/ CLP STRL,SUP-2885610,CDM,C1729,HCPCS,0272,RC,,,,both,,,487.74,317.03,,,,,,,,,,,,,
SCREW BNE MAXILLOMANDIBULAR 2X16 MM 12 MM MAXDRIVE 250984261,SUP-2469866,CDM,C1713,HCPCS,0278,RC,,,,both,,,309.98,201.49,,,,,,,,,,,,,
HC Change G to Gj Tube,PX-3614944600,CDM,49446,CPT,0361,RC,,,,inpatient,,,8583.00,5578.95,,,,,,,,,,,,,
PLATE BONE L108MM 4 H RT MEDL DSTL TIB LCK FOR 3.5MM SCR,SUP-2348249,CDM,C1713,HCPCS,0278,RC,,,,both,,,16493.01,10720.46,,,,,,,,,,,,,
CAGE SPNL MESH 15X12X14 MM 6 LOBE,SUP-2602073,CDM,C1889,HCPCS,0278,RC,,,,both,,,8233.08,5351.50,,,,,,,,,,,,,
DEFIBRILLATOR CRD 69X51X12 MM 31 CC 71 GM SYS DF4 ENTRANT DR,SUP-2876020,CDM,C1721,HCPCS,0275,RC,,,,both,,,53725.40,34921.51,,,,,,,,,,,,,
PROSTHESIS OSS MIC 3X3 MM 1 MM MONOLITHIC OFF CENTERED TI,SUP-2638138,CDM,L8613,CPT,0278,RC,,,,both,,,1067.60,693.94,,,,,,,,,,,,,
GRAFT VASC GORTX L 70 CM DIA 6-8 MM EPTFE TAPR TW N RING,SUP-2396731,CDM,C1768,CPT,0278,RC,,,,both,,,2612.48,1698.11,,,,,,,,,,,,,
NAIL IM L 225 MM DIA10.5 MM ARTH OSTEOSYN NITINAIL,SUP-2898595,CDM,C1713,HCPCS,0278,RC,,,,both,,,32813.00,21328.45,,,,,,,,,,,,,
SCREWDRIVER BLADE 7 1.5 MM SCR HD SOCKET CENTRE DRV,SUP-2459619,CDM,2720000010,LOCAL,0272,RC,,,,both,,,423.59,275.33,,,,,,,,,,,,,
TOCILIZUMAB-AAZG 80 MG/4ML IV SOLN,RX-167520,CDM,Q5135,HCPCS,0636,RC,65219-0590-04,NDC,,both,4,ML,1155.50,751.07,,,,,,,,,,,,,
SYSTEM PRESSURE MEAS NDL L 8 CM DIA25 GA SHTH 5.2 FR CONN,SUP-2881797,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6170.10,4010.56,,,,,,,,,,,,,
GRAFT HUM TISS 4X4CM THCK THK2-3.3MM REGENERATIVE TISS MTRX,SUP-2399086,CDM,Q4107,HCPCS,0636,RC,,,,both,,,7272.05,4726.83,,,,,,,,,,,,,
GRAFT BNE 0.5-1 MM POROUS GRAN HA,SUP-2651599,CDM,C1713,HCPCS,0278,RC,,,,both,,,473.79,307.96,,,,,,,,,,,,,
CATHETER EP ABLAT THER 2 8 7FR QPLR 1304-7-25-S-TE8TC2,SUP-2357456,CDM,C1733,HCPCS,0272,RC,,,,both,,,3061.50,1989.97,,,,,,,,,,,,,
INTRODUCER GUID 85FRX63CM,SUP-2357214,CDM,C1893,HCPCS,0272,RC,,,,both,,,584.04,379.63,,,,,,,,,,,,,
BLADE SAW 10X31MM ANG CONSIGNED BUR BLDE RASP MIC OSC DISP,SUP-2361966,CDM,2720000010,LOCAL,0272,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
GRAFT BNE PTTY DEMINERLIZED BNE MTRX 5CC ALLOFUSE,SUP-2113946,CDM,C1713,HCPCS,0278,RC,,,,both,,,2182.30,1418.49,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA PLU MAXBARR 5FR S1385108D2,SUP-2632821,CDM,C1751,HCPCS,0278,RC,,,,both,,,878.26,570.87,,,,,,,,,,,,,
STEM FEM SZ 1 135DEG STD HIP CEMENTLESS RESTORIS METAFIX,SUP-2265769,CDM,C1776,CPT,0278,RC,,,,both,,,4553.00,2959.45,,,,,,,,,,,,,
CONNECTOR TBNG NYL FOR DENV SHUNT REV SYS,SUP-2133694,CDM,2720000010,LOCAL,0272,RC,,,,both,,,188.40,122.46,,,,,,,,,,,,,
DEXTROSE 5 % IV BOLUS,RX-40840055,CDM,2580000003,HCPCS,0250,RC,00264-1510-32,NDC,,both,250,ML,53.20,34.58,,,,,,,,,,,,,
KIT BNE MAR ASPIR 60ML 15GA SYR,SUP-2163070,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
FIXATOR EXT MINI CALCNL,SUP-2316441,CDM,C1713,HCPCS,0278,RC,,,,both,,,9749.45,6337.14,,,,,,,,,,,,,
CATHETER INT THCL 0.5X12 MMX13.97 CM CLOSED TIP PMP ASCENDA,SUP-2280044,CDM,C1755,HCPCS,0278,RC,,,,both,,,3519.94,2287.96,,,,,,,,,,,,,
COUNTERSINK SURG M DISP FOR INTOSS FIXATIONX-POST IOFIX 2.0,SUP-2223764,CDM,2720000010,LOCAL,0272,RC,,,,both,,,781.86,508.21,,,,,,,,,,,,,
GUIDEWIRE VASC ARW L 80 CM DIA 0.018 IN SS HYDRPHLC PERIPH,SUP-2844901,CDM,C1769,HCPCS,0272,RC,,,,both,,,109.27,71.03,,,,,,,,,,,,,
MATRIX RESTRATA WOUND 2.5CM X 5.0CM,SUP-2874117,CDM,A2007,HCPCS,0636,RC,,,,both,,,4301.80,2796.17,,,,,,,,,,,,,
NAIL IM TIB 8X330 MM STRL T2 ALPHA,SUP-2461254,CDM,C1713,HCPCS,0278,RC,,,,both,,,8091.53,5259.49,,,,,,,,,,,,,
ALLOGRAFT BNE EVANS WDG 22X22X16 MM FD STRL LF DISP,SUP-2489620,CDM,C1889,HCPCS,0278,RC,,,,both,,,2922.56,1899.66,,,,,,,,,,,,,
IMMOBILIZER SHOULDER SLING SWATHE DLX,SUP-2196951,CDM,L3660,HCPCS,0274,RC,,,,both,,,22.98,14.94,,,,,,,,,,,,,
PARTICLE EMB SZ 250 355UM POLYVI ALC N RADIOACTIVE CNTOUR 2,SUP-2148439,CDM,C1713,HCPCS,0278,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
OCCLUDER CV L12MM BLB DIA3.5MM SIL RUB COR VES RADPQ DISP,SUP-2129864,CDM,C1760,HCPCS,0278,RC,,,,both,,,138.16,89.80,,,,,,,,,,,,,
COMPONENT TROCHLEAR SZ 1 RT PATELLOFEMORAL CEM IBALANCE,SUP-2121884,CDM,C1776,CPT,0278,RC,,,,both,,,10676.00,6939.40,,,,,,,,,,,,,
PLATE BNE SZ 2.8 MM TI MANDIBULAR STR NS DISP ACCUPLATE,SUP-2934743,CDM,C1713,HCPCS,0278,RC,,,,both,,,40110.36,26071.73,,,,,,,,,,,,,
PLUG ACET DOME H PLUG CONVERGE,SUP-2207429,CDM,C1776,CPT,0278,RC,,,,both,,,753.60,489.84,,,,,,,,,,,,,
SET VASC ACCS 4FR L10CM S STL PLAT TIP 0.018IN NDL 21GA,SUP-2170543,CDM,C1894,HCPCS,0272,RC,,,,both,,,68.36,44.43,,,,,,,,,,,,,
HC So H Pylori Breath Test,PX-3018301366,CDM,83013,CPT,0301,RC,,,,both,,,638.00,414.70,,,,,,,,,,,,,
BIT DRL OD5MM TRIFLAT LO PROF,SUP-2290256,CDM,2720000010,LOCAL,0272,RC,,,,both,,,416.14,270.49,,,,,,,,,,,,,
SCREW BONE L4MM DIA1.5MM CORT RAP RESRB FOR 1.5MM PLT RECON,SUP-2194051,CDM,C1713,HCPCS,0278,RC,,,,both,,,317.61,206.45,,,,,,,,,,,,,
INFINITY ADAPTIS TIB SZ4LNG INFINITY ADAPTIS,SUP-2822271,CDM,C1776,CPT,0278,RC,,,,both,,,14823.94,9635.56,,,,,,,,,,,,,
SCREW BNE L14MM DIA3.5MM EL TI ST LOK MULTDIR FOR ALPS,SUP-2413761,CDM,C1713,HCPCS,0278,RC,,,,both,,,519.01,337.36,,,,,,,,,,,,,
EXTERNAL FIXATION KIT SET FT SUPP COMPLETE GALAXY FIX GEM,SUP-2875640,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7043.71,4578.41,,,,,,,,,,,,,
DRESSING BIOLOGICAL L4XW2CM PORCINE EXTRACELLULAR MATRIX SHEET STERILE DISPOSABLE FOR SOFT TISSUE REINFORCEMENT MATRISTEM RS,SUP-2106514,CDM,Q4166,HCPCS,0636,RC,,,,both,,,504.44,327.89,,,,,,,,,,,,,
KIT EMR L1650MM HRD STR DST CAP DIA139MM W RIM FOR UP GI,SUP-2313207,CDM,C1713,HCPCS,0278,RC,,,,both,,,658.05,427.73,,,,,,,,,,,,,
S-T CRTX SCRW 18MM 3.5MM,SUP-2844053,CDM,C1713,HCPCS,0278,RC,,,,both,,,233.30,151.64,,,,,,,,,,,,,
GRAFT HUM TISS W6XL3CM 12SQCM UMB CRD AMNIO MEM,SUP-2116291,CDM,Q4148,HCPCS,0636,RC,,,,both,,,6264.30,4071.79,,,,,,,,,,,,,
EEA CIR STPLR W TRISTAPLE TECHNOLOGY 28MM M THICK,SUP-2172449,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1366.97,888.53,,,,,,,,,,,,,
SYSTEM GASTRIC BANDING L ADJUSTABLE WITH OMNIFORM DESIGN ACCESS PORT I INFLATABLE KINK RESISTANT TUBING END PLUG SEAL FOR MORBID OBESITY LAP-BAND AP,SUP-2119247,CDM,C1889,HCPCS,0278,RC,,,,both,,,10880.10,7072.06,,,,,,,,,,,,,
RING EXT FIX FULL 160 MM SINGLE ROW,SUP-2749869,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4135.38,2688.00,,,,,,,,,,,,,
CROWN DENT 2U ANTR UPPER CUSPID PRIMARY REFILL SS UNITEK,SUP-2322228,CDM,D6783,CPT,0278,RC,,,,both,,,26.34,17.12,,,,,,,,,,,,,
ARM TARGET DEV DSTL 2 MM RT,SUP-2484798,CDM,C1713,HCPCS,0278,RC,,,,both,,,8389.33,5453.06,,,,,,,,,,,,,
ALLOGRAFT BNE 8-15X40 MM FIBULAR SHFT STRL BIO LF DISP,SUP-2632314,CDM,C1762,CPT,0278,RC,,,,both,,,3026.96,1967.52,,,,,,,,,,,,,
HC Puncture Drainage of Lesion,PX-4501016000,CDM,10160,CPT,0450,RC,,,,both,,,1386.00,900.90,,,,,,,,,,,,,
TUBE VENT ID1.27MM FLROPLAS SHEEHY CLLR BTTN,SUP-2313870,CDM,L8699,HCPCS,0278,RC,,,,both,,,83.96,54.57,,,,,,,,,,,,,
COMPONENT HUM SM L8IN UNIV DSTL ELBW TIV PLSM,SUP-2205914,CDM,C1776,CPT,0278,RC,,,,both,,,11511.24,7482.31,,,,,,,,,,,,,
KIT ANCHR SWIVELOCK W/ NO2 FIBERTAPE SUT GWIRE TRCR TIP DRL,SUP-2121451,CDM,C1713,HCPCS,0278,RC,,,,both,,,3375.50,2194.07,,,,,,,,,,,,,
SCREW BONE L50MM DIA4.8MM CANC FOR VERSANAIL UNIV HUM,SUP-2412558,CDM,C1713,HCPCS,0278,RC,,,,both,,,421.55,274.01,,,,,,,,,,,,,
DEFIBRILLATOR IMPL LUMAX 340 HF-T TI EPOXY RESIN SIL,SUP-2138122,CDM,C1882,HCPCS,0275,RC,,,,both,,,76582.72,49778.77,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9% IV BOLUS (PER WEIGHT),RX-40901010,CDM,J7030,HCPCS,0258,RC,00338-0049-04,NDC,,both,1000,ML,42.50,27.62,,,,,,,,,,,,,
TROCAR SURG RETROGRADE 8 MM FEM TRI FLUT,SUP-2495675,CDM,2720000010,LOCAL,0272,RC,,,,both,,,838.32,544.91,,,,,,,,,,,,,
PIN FIX L229MM DIA3.2MM S STL STYL 6 STNMN,SUP-2409662,CDM,C1713,HCPCS,0278,RC,,,,both,,,28.98,18.84,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9% IV BOLUS (PER WEIGHT),RX-40901010,CDM,2580000003,HCPCS,0258,RC,00264-1800-32,NDC,,both,100,ML,23.00,14.95,,,,,,,,,,,,,
GRAFT HUM TISS W2XL3CM THK100UM AMNIO MEMBRN AMBIO5,SUP-2247196,CDM,V2790,HCPCS,0274,RC,,,,both,,,1648.50,1071.52,,,,,,,,,,,,,
BEVACIZUMAB-AWWB 400 MG/16ML IV SOLN,RX-146510,CDM,Q5107,HCPCS,0636,RC,55513-0207-01,NDC,,both,16,ML,8037.80,5224.57,,,,,,,,,,,,,
GRAFT BONE L26XW26XH14MM CORT RNG MACHINED FRZ DRY,SUP-2293911,CDM,C1713,HCPCS,0278,RC,,,,both,,,12154.94,7900.71,,,,,,,,,,,,,
INTRODUCER PEEL AWAY 9FRX45CM,SUP-2357106,CDM,C1892,HCPCS,0272,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
CATHETER DRAINAGE VLV 5 FRX15 CM 20 GA SAFETY ACCEL,SUP-2659269,CDM,C1729,HCPCS,0272,RC,,,,both,,,71.59,46.53,,,,,,,,,,,,,
COMPONENT FEM KNEE SEMI CONSTRN CEM MTL POLYMER,SUP-2684575,CDM,C1776,CPT,0278,RC,,,,both,,,1378.46,896.00,,,,,,,,,,,,,
AMK UNIV STEM 10X50MM,SUP-2251243,CDM,C1776,CPT,0278,RC,,,,both,,,2254.52,1465.44,,,,,,,,,,,,,
PROPARACAINE HCL 0.5 % OP SOLN,RX-6644,CDM,2500000003,HCPCS,0250,RC,24208-0730-06,NDC,,both,15,ML,157.90,102.63,,,,,,,,,,,,,
SHEATH INTRO PRELUDEEASE 11CM 4FR 40 CM NDL 4 CM SS WIRE,SUP-2491270,CDM,C1894,HCPCS,0272,RC,,,,both,,,126.60,82.29,,,,,,,,,,,,,
SET INTRO SCOUTPRO L 45 CM DIA 7 FR GUIDEWIRE 0.038 IN NDL,SUP-2138045,CDM,C1894,HCPCS,0272,RC,,,,both,,,2003.32,1302.16,,,,,,,,,,,,,
KIT SHTH CONVOY 90 DEG L 79.4 CM DIA 8.5 FR SFT TIP ADV DEL,SUP-2141298,CDM,C1894,HCPCS,0272,RC,,,,both,,,675.10,438.81,,,,,,,,,,,,,
WASHER ORTH L1MM FOR SIDEKCK EZ FRME EXT FIX,SUP-2400673,CDM,2720000010,LOCAL,0272,RC,,,,both,,,109.90,71.43,,,,,,,,,,,,,
PLATE 3.5MM CURVED BROAD LCP 22 HOLE-STERILE,SUP-2546106,CDM,C1713,HCPCS,0278,RC,,,,both,,,3368.40,2189.46,,,,,,,,,,,,,
COMPONENT FEM SZ 3 LT KNEE POR PRI NAR ADV STAT,SUP-2304648,CDM,C1776,CPT,0278,RC,,,,both,,,19471.14,12656.24,,,,,,,,,,,,,
SET INTRO MICROPUNCTURE L 13 CM DIL L 20 CM OD 6 FR ID 2 FR,SUP-2168723,CDM,C1894,HCPCS,0272,RC,,,,both,,,118.19,76.82,,,,,,,,,,,,,
BUR OVAL FLUSHCUT RETR 8 FLUT 5.0MMX13C,SUP-2814158,CDM,2720000010,LOCAL,0272,RC,,,,both,,,317.14,206.14,,,,,,,,,,,,,
SCREW BNE L 70 MM DIA 5.7 MM SS CANN LCK NS EVOS,SUP-2931203,CDM,C1713,HCPCS,0278,RC,,,,both,,,1170.91,761.09,,,,,,,,,,,,,
CATHETER URET 5/10FR L50CM INJ LUMN DIA0.05IN AQ 2 LUMN,SUP-2168943,CDM,C1758,HCPCS,0278,RC,,,,both,,,153.04,99.48,,,,,,,,,,,,,
SCREW INTRF L23MM DIA8MM KNEE PLLA CANN BIOABSRB THRD WDG,SUP-2362044,CDM,C1713,HCPCS,0278,RC,,,,both,,,611.36,397.38,,,,,,,,,,,,,
CATHETER HD KT 12 FRX20 CM DL INTRO INJ NDL TISS DIL SUTURE,SUP-2762985,CDM,C1752,HCPCS,0278,RC,,,,both,,,253.08,164.50,,,,,,,,,,,,,
BRACE KNEE HNG WRP 2X L,SUP-2276699,CDM,L1820,HCPCS,0274,RC,,,,both,,,55.08,35.80,,,,,,,,,,,,,
BIT DRL CANN 2.9X140 MM STRL,SUP-2607154,CDM,2720000010,LOCAL,0272,RC,,,,both,,,656.29,426.59,,,,,,,,,,,,,
GRAFT HUM TISS 6-10MM 15CC CANC CUBE,SUP-2293751,CDM,C1713,HCPCS,0278,RC,,,,both,,,1366.40,888.16,,,,,,,,,,,,,
HC Fetal Eval 1st Trim @ Addl Ges,PX-4027680200,CDM,76802,CPT,0402,RC,,,,inpatient,,,793.00,515.45,,,,,,,,,,,,,
GRAFT ALLGRFT AMNIO MEMBRN 1.5CMX2CM AMBIODRY,SUP-2247195,CDM,V2790,HCPCS,0278,RC,,,,both,,,1805.50,1173.57,,,,,,,,,,,,,
INFLUENZA VAC SPLIT HIGH-DOSE 0.5 ML IM SUSY,RX-106520,CDM,90662,HCPCS,0636,RC,49281-0125-88,NDC,,both,.5,ML,388.10,252.26,,,,,,,,,,,,,
BUR MED RND 31MM,SUP-2398604,CDM,C1713,HCPCS,0278,RC,,,,both,,,480.42,312.27,,,,,,,,,,,,,
GUIDEWIRE ORTH L161MM DIA17/3.2MM FOR TI TROCHANTERIC NAIL,SUP-2188225,CDM,C1769,HCPCS,0272,RC,,,,both,,,1237.29,804.24,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA MAXBARR 4FR 55CM S3274108PD,SUP-2632842,CDM,C1751,HCPCS,0278,RC,,,,both,,,693.50,450.77,,,,,,,,,,,,,
CATHETER EP L120CM OD6FR 2-5-2MM SPC CRD QPLR ELECTRD,SUP-2355183,CDM,C1730,HCPCS,0272,RC,,,,both,,,401.70,261.10,,,,,,,,,,,,,
SCREW BNE L90MM DIA7.3MM CORT S STL ST CANN LOK FULL THRD,SUP-2184942,CDM,C1713,HCPCS,0278,RC,,,,both,,,709.64,461.27,,,,,,,,,,,,,
ELECTRODE RT ANG 3.0MMX90DEG ARTHWAND,SUP-2341955,CDM,2720000010,LOCAL,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
HC So Immunodiffusion Nes,PX-3028632966,CDM,86329,CPT,0302,RC,,,,both,,,330.00,214.50,,,,,,,,,,,,,
SCREW BONE CONDYLE FASTENING F/TEMP ADJ DEV LEIBINGER UNIV 2PK,SUP-2363870,CDM,C1713,HCPCS,0278,RC,,,,both,,,409.33,266.06,,,,,,,,,,,,,
CLAMP BAR-TO-BARXTRAFIX,SUP-2205433,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1724.65,1121.02,,,,,,,,,,,,,
LEAD DEFIB PLEXA PROMRI SD L 60 CM SIL SIL-GLYDE SURF 2,SUP-2739227,CDM,C1777,HCPCS,0275,RC,,,,both,,,9627.24,6257.71,,,,,,,,,,,,,
PLUG TIB 12MM AS COLUMBUS,SUP-2108985,CDM,C1713,HCPCS,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
SHEET SPLNT THK0.13IN STD W18XL24IN BILAT WR AND HND WHT SLD,SUP-2324794,CDM,L3730,HCPCS,0272,RC,,,,both,,,116.05,75.43,,,,,,,,,,,,,
CATHETER HD RAULERSON 11.5 FRX15 CM IJ DL TAPR TIP DUOFLO,SUP-2627384,CDM,C1752,HCPCS,0278,RC,,,,both,,,141.68,92.09,,,,,,,,,,,,,
HC MRI Breast W Cont Unilat,PX-6107704801,CDM,77048,CPT,0610,RC,,,,outpatient,,,568.00,369.20,,,,,,,,,,,,,
MANIFOLD 200PSI 2 PORTS R ORIENTATION AND ROT LUER SIDE OFF,SUP-2301351,CDM,C1713,HCPCS,0278,RC,,,,both,,,13.22,8.59,,,,,,,,,,,,,
PLATE BNE L423MM 26 H BROAD COMPR RIG FOR 45MM SCR L FRAG,SUP-2411436,CDM,C1713,HCPCS,0278,RC,,,,both,,,1469.65,955.27,,,,,,,,,,,,,
CARDIOPLEGIA DEL NIDO FORMULA PF SOLN,RX-148227,CDM,2500000003,HCPCS,0250,RC,71285-0202-01,NDC,,both,1052.8,ML,865.90,562.83,,,,,,,,,,,,,
PLATE BNE L122MM 4 H ST R DST HUM EXTRA ARTC S STL LOK,SUP-2177167,CDM,C1713,HCPCS,0278,RC,,,,both,,,3587.45,2331.84,,,,,,,,,,,,,
GRAFT HUMAN TSSUE W12XL12CM THK1.04 2.28MM THICK RGNRTVE TSS,SUP-2466201,CDM,Q4116,HCPCS,0636,RC,,,,both,,,15360.88,9984.57,,,,,,,,,,,,,
SPLINT WR L AD W3.5-4IN BGE LT FAB GEL CRPL TUNN REG INSRT,SUP-2324880,CDM,L3809,HCPCS,0272,RC,,,,both,,,48.54,31.55,,,,,,,,,,,,,
SCREW PED GIC52 4.5-6.35MM CLS LAT CON 30MM SS 7021230,SUP-2286989,CDM,C1713,HCPCS,0278,RC,,,,both,,,1267.78,824.06,,,,,,,,,,,,,
PLATE TI VA-LOCKING CALCANEALMED 2.7MM 64MM LEFT STRL,SUP-2547002,CDM,C1713,HCPCS,0278,RC,,,,both,,,3642.75,2367.79,,,,,,,,,,,,,
ALLOGRAFT BNE 15 CC FIBERCEL,SUP-2787759,CDM,C1713,HCPCS,0278,RC,,,,both,,,12235.45,7953.04,,,,,,,,,,,,,
PLATE BONE L250MM 25 H HUM LNG DSTL POST LAT LCK RT,SUP-2136233,CDM,C1713,HCPCS,0278,RC,,,,both,,,7609.32,4946.06,,,,,,,,,,,,,
PUSHER ENDOSCP KNOT 5 MMX45 CM,SUP-2171745,CDM,2720000010,LOCAL,0272,RC,,,,both,,,954.18,620.22,,,,,,,,,,,,,
ALLOGRAFT BNE 20 MM PRESERVON FIBULAR SHFT MATRIGRAFT,SUP-2740989,CDM,C1762,CPT,0278,RC,,,,both,,,1491.12,969.23,,,,,,,,,,,,,
PLATE BONE 25MM 6 H N COMPR BUR H CVR BILAT RIG TI FOR 1.5MM,SUP-2402907,CDM,C1713,HCPCS,0278,RC,,,,both,,,750.46,487.80,,,,,,,,,,,,,
CATHETER CV 3L 5.5 FRX8 CM BASIC KT ARROWG+ARD,SUP-2383321,CDM,C1751,HCPCS,0278,RC,,,,both,,,243.66,158.38,,,,,,,,,,,,,
CATHETER THROMCTMY ZOOM 71 L 137 CM DIA 6 FR DSTL OD/ID 6,SUP-2739213,CDM,C1757,HCPCS,0272,RC,,,,both,,,7802.90,5071.88,,,,,,,,,,,,,
HC Rmvl FB Cornea WO Slit Lamp,PX-4506522000,CDM,65220,CPT,0450,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
GRAFT VASC IMPRA L 50 CM DIA 6 MM EPTFE FLX STD WALL SM BEAD,SUP-2761453,CDM,C1768,CPT,0278,RC,,,,both,,,2297.22,1493.19,,,,,,,,,,,,,
STEM FEM L140MM OD7MM CO CHROM INTLOK HIP PRI CEM TAPR NEUT,SUP-2403345,CDM,C1776,CPT,0278,RC,,,,both,,,9551.88,6208.72,,,,,,,,,,,,,
PROSTHESIS PENILE PLUG INFL TRUE-LOCK,SUP-2165392,CDM,C1813,HCPCS,0278,RC,,,,both,,,436.46,283.70,,,,,,,,,,,,,
BIT DRILL OD2.6MM FLUTED NONCANNULATED PRESSFT,SUP-2824999,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1146.38,745.15,,,,,,,,,,,,,
SHEATH INTRO PED 6FR L44CM DIL L52CM 0025IN PTFE FIX CRV,SUP-2294358,CDM,C1893,HCPCS,0272,RC,,,,both,,,219.80,142.87,,,,,,,,,,,,,
TRAY CATHETER SILICONE URINE METER 12 FR 10ML,SUP-2526981,CDM,C1776,CPT,0278,RC,,,,both,,,55.74,36.23,,,,,,,,,,,,,
TWIST DRILL 0.7MM DIA X 18MM 5MM STOP DNTL LATCH SNGLE USE,SUP-2488431,CDM,2720000010,LOCAL,0272,RC,,,,both,,,390.74,253.98,,,,,,,,,,,,,
K WIRE FIX L9IN DIA1.1MM NS S STL 2 SIDE SGL DMND 6PK,SUP-2150680,CDM,C1713,HCPCS,0278,RC,,,,both,,,121.08,78.70,,,,,,,,,,,,,
SCREW BNE COMPR 7.5X55 MM 15 MM HDLSS BITE,SUP-2644947,CDM,C1713,HCPCS,0278,RC,,,,both,,,2232.54,1451.15,,,,,,,,,,,,,
CAP PROTCT OD4MM PIN BAR EXT FIX SYS JETX,SUP-2342868,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1425.43,926.53,,,,,,,,,,,,,
ALLOGRAFT BNE PARTICULATE 250-1000 MH 2 CC CANC ORAGRAFT,SUP-2741030,CDM,C1713,HCPCS,0278,RC,,,,both,,,432.10,280.86,,,,,,,,,,,,,
PLATE BONE W17.5XL322MM THK5.2MM 18 H BILAT S STL BROAD,SUP-2185316,CDM,C1713,HCPCS,0278,RC,,,,both,,,1303.07,847.00,,,,,,,,,,,,,
KIT ABLATION ACESSA LAPAROSCOPIC RADIOFREQUENCY,SUP-2665165,CDM,2720000010,LOCAL,0272,RC,,,,both,,,10173.60,6612.84,,,,,,,,,,,,,
ELECTRODE ELECSURG NDL 90 DEG PEDIATRIC 10 FR HF RESECT STRL,SUP-2464387,CDM,2720000010,LOCAL,0272,RC,,,,both,,,733.50,476.77,,,,,,,,,,,,,
STENT ESOPH ALIMAXX-ES L 70 MM DIA18 MM DEL SYS L 67 MM,SUP-2700428,CDM,C1874,HCPCS,0278,RC,,,,both,,,7536.00,4898.40,,,,,,,,,,,,,
LINER ACET +5 MM NEUT 36 MM HIP E1 G7,SUP-2422197,CDM,C1776,CPT,0278,RC,,,,both,,,5681.83,3693.19,,,,,,,,,,,,,
CATHETER EP DIAG VIK JOSEPHSON CRV 2MM HEXAPOLAR POLES 6FR,SUP-2142583,CDM,C1730,HCPCS,0272,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
BIT DRL L150MM DIA39X42MM 3 FLUT QUIK CPL FOR 5MM SCR,SUP-2178951,CDM,2720000010,LOCAL,0272,RC,,,,both,,,582.41,378.57,,,,,,,,,,,,,
HC Clsed Tx Radial W Manipulation,PX-4502550500,CDM,25505,CPT,0450,RC,,,,both,,,1633.00,1061.45,,,,,,,,,,,,,
PLEDGET CV L 5/16 X W 5/16 IN PTFE STRL,SUP-2761293,CDM,C1768,CPT,0278,RC,,,,both,,,3.14,2.04,,,,,,,,,,,,,
TUBE VENT L7MM ID0.89MM WHT FLROPLAS PLN STR SHANK,SUP-2284046,CDM,L8699,HCPCS,0278,RC,,,,both,,,31.40,20.41,,,,,,,,,,,,,
NUT ORTH SCR 5 MM FOR PERIARTICULAR PLATING SYS TI,SUP-2563978,CDM,C1713,HCPCS,0278,RC,,,,both,,,479.51,311.68,,,,,,,,,,,,,
HARVESTER MORSELIZING BONE GRAFT AO 6MM,SUP-2740174,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2187.01,1421.56,,,,,,,,,,,,,
AUTOINJECTOR STENT GRFT ALTO 2 CUSTOMSEAL KT SYR PLUNG AAA,SUP-2691413,CDM,C1768,CPT,0278,RC,,,,both,,,1161.80,755.17,,,,,,,,,,,,,
STEM RAD L33X17MM DIA9MM NK OFFSET 2MM TI ALIGN,SUP-2340151,CDM,C1776,CPT,0278,RC,,,,both,,,5887.50,3826.87,,,,,,,,,,,,,
PLATE BONE W8XL144MM THK3.3MM 18 H STRL BILAT PELV S STL,SUP-2186246,CDM,C1713,HCPCS,0278,RC,,,,both,,,2057.05,1337.08,,,,,,,,,,,,,
CATHETER IABP AD 7.5FR L230MM 30CC POLYUR S STL FBROPT,SUP-2383463,CDM,C1713,HCPCS,0278,RC,,,,both,,,2496.30,1622.59,,,,,,,,,,,,,
DISC BNE SCREW DIA 4.5 MM NIT DYN REFLX,SUP-2897520,CDM,C1713,HCPCS,0278,RC,,,,both,,,4078.86,2651.26,,,,,,,,,,,,,
GRAFT HUM TISS DIA20MM DISC VIABLE OSTEOCHNDRL ALLGRFT,SUP-2120738,CDM,C1713,HCPCS,0278,RC,,,,both,,,26690.00,17348.50,,,,,,,,,,,,,
HC Inj Lympho for Sentinal Node,PX-3613879200,CDM,38792,CPT,0361,RC,,,,outpatient,,,3707.00,2409.55,,,,,,,,,,,,,
GUIDEPIN ORTH L14IN OD3.6MM CNL PREP DISP,SUP-2412706,CDM,C1713,HCPCS,0278,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
HC Inj/Asp Maj Jnt or Bursa|PBB CHARGE|BILATERAL PROCEDURE,PX-7612061000,CDM,20610,CPT,0761,RC,,,PBB|50,outpatient,,,1092.00,709.80,,,,,,,,,,,,,
PLATE BNE ANGLED BLADE 130 DEG 104 MM 50 MM 6 HOLE TI NS DCP,SUP-2569046,CDM,C1713,HCPCS,0278,RC,,,,both,,,1493.98,971.09,,,,,,,,,,,,,
AMK TIB TY SZ 2,SUP-2251227,CDM,C1776,CPT,0278,RC,,,,both,,,7240.84,4706.55,,,,,,,,,,,,,
SUPPORT ORTHOT HIP CUST ABDUCTN STATIC PLAS,SUP-2435601,CDM,L1660,HCPCS,0274,RC,,,,both,,,511.63,332.56,,,,,,,,,,,,,
LUG FEM PRI GEN II,SUP-2346154,CDM,C1776,CPT,0278,RC,,,,both,,,117.75,76.54,,,,,,,,,,,,,
BIT DRILL AO  SHORT  3.8MM,SUP-2750030,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1836.90,1193.98,,,,,,,,,,,,,
PLATE BNE L66MM THK1.25MM 3X10 H BILAT S STL T SHP ST LO,SUP-2186373,CDM,C1713,HCPCS,0278,RC,,,,both,,,1157.34,752.27,,,,,,,,,,,,,
PLATE BONE THICKNESS1.8MM STRNL LCK PLT 10 H STR,SUP-2262582,CDM,C1713,HCPCS,0278,RC,,,,both,,,2656.44,1726.69,,,,,,,,,,,,,
GRAFT VASC BIFUR 20 MMX40 CM 1 LAYR POLYESTER WOVEN HEMSHLD,SUP-2473904,CDM,C1768,CPT,0278,RC,,,,both,,,1778.81,1156.23,,,,,,,,,,,,,
DEVICE SUTURING ABSORBABLE 3-0 6 IN RELD GRN ENDOSTCH,SUP-2787725,CDM,2720000010,LOCAL,0272,RC,,,,both,,,384.71,250.06,,,,,,,,,,,,,
PLATE BNE CRANIOMAXILLOFACIAL THK08MM 12 H ORBIT MIDFACE TI,SUP-2262686,CDM,C1713,HCPCS,0278,RC,,,,both,,,853.30,554.64,,,,,,,,,,,,,
HC Pbb Carpal Tunnel Inj Pmc,PX-5102052600,CDM,20526,CPT,0510,RC,,,,outpatient,,,775.00,503.75,,,,,,,,,,,,,
HEAD HUM H16.5MM DIA44MM STD SHLDR CO CHROM REV NECKLESS,SUP-2193858,CDM,C1776,CPT,0278,RC,,,,both,,,8527.17,5542.66,,,,,,,,,,,,,
PLATE RAD HD RIM 2.4MM 3H LT TI LCP,SUP-2549709,CDM,C1713,HCPCS,0278,RC,,,,both,,,1983.16,1289.05,,,,,,,,,,,,,
PLATE CRPL 9X43MM 14MM AUG TAPR MAESTRO,SUP-2407334,CDM,C1776,CPT,0278,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
KIT VASC SNR ATRIEVE 90 DEG TIP 15 DEG L 120 CM DIA 9-15 MM,SUP-2120069,CDM,C1773,HCPCS,0272,RC,,,,both,,,989.10,642.91,,,,,,,,,,,,,
"HC Urinalysis, Auto, W/O Scope",PX-3078100300,CDM,81003,CPT,0307,RC,,,,both,,,96.00,62.40,,,,,,,,,,,,,
CATHETER GUID NAVICROSS L 65 CM DIA 1.39 MM L 40 CM ANGLED,SUP-2385618,CDM,C1887,HCPCS,0272,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
NEEDLE SUTURE L7.75IN SLIGHTLY CURVED REVERDIN,SUP-2802447,CDM,2720000010,LOCAL,0272,RC,,,,both,,,677.30,440.24,,,,,,,,,,,,,
GUIDEWIRE VASC HIWIRE L 150 CM 0.035 IN TAPR L 15 CM STR,SUP-2170340,CDM,C1769,HCPCS,0272,RC,,,,both,,,106.23,69.05,,,,,,,,,,,,,
PLATE BNE RECON 2.8 MM 20 HOLE PT SPEC,SUP-2860106,CDM,C1713,HCPCS,0278,RC,,,,both,,,20157.86,13102.61,,,,,,,,,,,,,
CATHETER CNTSS 5FR DIA 19GA INTRDCR NDLE 7CML TPRD TIP LOW P,SUP-2473617,CDM,C1729,HCPCS,0272,RC,,,,both,,,54.17,35.21,,,,,,,,,,,,,
SCREW BNE L24MM DIA3MM LOK PLATING SYS MOTOBAND CP,SUP-2175142,CDM,C1713,HCPCS,0278,RC,,,,both,,,833.67,541.89,,,,,,,,,,,,,
CATHETER ANGIO 5FR L125CM DIA0.047IN FEM L 3.5 IMPLS,SUP-2142085,CDM,2720000010,LOCAL,0272,RC,,,,both,,,29.52,19.19,,,,,,,,,,,,,
GRAFT ENDOVASC L108MM PROX L37MM DSTL L71MM DIA24X12MM SHTH,SUP-2170308,CDM,C1874,HCPCS,0278,RC,,,,both,,,19860.50,12909.32,,,,,,,,,,,,,
SCREW BNE L 12 MM DIA 3.5 MM TI CORTICAL WR ST T15 DRV STRL,SUP-2931471,CDM,C1713,HCPCS,0278,RC,,,,both,,,135.74,88.23,,,,,,,,,,,,,
HEAD FEM DIA36MM NK L+7MM 12/14 TAPR HIP CO CHROM CEM PRI 80183604] ZIMMER BIOMET ETEX CORP],SUP-2402792,CDM,C1776,CPT,0278,RC,,,,both,,,2670.35,1735.73,,,,,,,,,,,,,
BLADE SAW OSCLLTNG 19.5MMW X95MML 1.27MM THK CUT BRAZOL CTD,SUP-2605461,CDM,2720000010,LOCAL,0272,RC,,,,both,,,86.41,56.17,,,,,,,,,,,,,
RITUXIMAB-ARRX 100 MG/10ML IV SOLN,RX-153027,CDM,Q5123,HCPCS,0636,RC,55513-0224-01,NDC,,both,10,ML,2064.40,1341.86,,,,,,,,,,,,,
CURETTE BONE RVS ANG SZ 0 MTRX,SUP-2292916,CDM,C1713,HCPCS,0278,RC,,,,both,,,2546.54,1655.25,,,,,,,,,,,,,
CATHETER NEPHSTMY 16FR 4 WNG MCOT DISP,SUP-2128991,CDM,C1729,HCPCS,0272,RC,,,,both,,,37.02,24.06,,,,,,,,,,,,,
KIT NPHRSTMY MLCT 14FR DIA CATH PRCTNS WC FLXBLE GDWRE .038,SUP-2721823,CDM,C1729,HCPCS,0272,RC,,,,both,,,312.05,202.83,,,,,,,,,,,,,
PLATE BONE CRANIOMAXILLOFACIAL 6 HOLE DOUBLE Y-PLATE 15MM TI,SUP-2825443,CDM,C1713,HCPCS,0278,RC,,,,both,,,172.92,112.40,,,,,,,,,,,,,
NAIL FEMORAL RETROGRADE 105MM 380MM,SUP-2587158,CDM,C1713,HCPCS,0278,RC,,,,both,,,5446.74,3540.38,,,,,,,,,,,,,
FIBER LASER 600UM HOLM LT GUID,SUP-2313982,CDM,C1713,HCPCS,0278,RC,,,,both,,,1305.52,848.59,,,,,,,,,,,,,
DEVICE TNSLCTMY OPN SEAL DIV BIZACT,SUP-2172364,CDM,2720000010,LOCAL,0272,RC,,,,both,,,926.30,602.09,,,,,,,,,,,,,
PLATE DISTL ANTERO TIB RT 8HL 153MM,SUP-2702943,CDM,C1713,HCPCS,0278,RC,,,,both,,,7018.21,4561.84,,,,,,,,,,,,,
BIT DRL L100MM DIA1.7MM CANN QUIK CPL NONRADIOLUCENT W/O,SUP-2187212,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1106.98,719.54,,,,,,,,,,,,,
COIL NEUROVASCULAR ULTIPAQ 10 CERECYTE L 8 CM DIA 4 MM,SUP-2458404,CDM,C1889,HCPCS,0278,RC,,,,both,,,4434.25,2882.26,,,,,,,,,,,,,
PLATE BNE L 332 MM SCREW DIA 4.5 MM 20 H BOW COMPR LCK NS,SUP-2933182,CDM,C1713,HCPCS,0278,RC,,,,both,,,5431.42,3530.42,,,,,,,,,,,,,
HC Apply Hand/Wrist Cast,PX-4502908500,CDM,29085,CPT,0450,RC,,,,both,,,320.00,208.00,,,,,,,,,,,,,
"HC So Heavy Metals,Quant Ea",PX-3018301866,CDM,83018,CPT,0301,RC,,,,both,,,70.00,45.50,,,,,,,,,,,,,
SYSTEM VAC MX 3 CLEARMIX,SUP-2206138,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
TAP SURG L110MM QUIK CONN FOR 4MM SCR,SUP-2410964,CDM,C1713,HCPCS,0278,RC,,,,both,,,269.10,174.91,,,,,,,,,,,,,
GUIDEWIRE VASC L 100 CM DIA 0.038 IN TAPR L 9.5 CM FLPY TIP,SUP-2638699,CDM,C1769,HCPCS,0272,RC,,,,both,,,66.57,43.27,,,,,,,,,,,,,
SCREW BNE PARTIALLY THRD 5X110 MM PANTA PAN10101710NS,SUP-2434157,CDM,C1713,HCPCS,0278,RC,,,,both,,,2135.55,1388.11,,,,,,,,,,,,,
SHEATH INTRO PRELUDE ROADSTER L 65 CM DIA 6 FR COAT L 35 CM,SUP-2900369,CDM,C1894,HCPCS,0272,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
TIP ASPIR CLAW MIC 1.6X2 MM 18 CM APEX SONOPET IQ,SUP-2791057,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3557.46,2312.35,,,,,,,,,,,,,
BIT DRL L190MM OD3MM TIBIO TALO CALCNL LO EXT FOR 4.5MM SCR,SUP-2243130,CDM,2720000010,LOCAL,0272,RC,,,,both,,,828.96,538.82,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 3X140-200 MM TEND FLEXIGRAFT CONN EXT,SUP-2740961,CDM,C1762,CPT,0278,RC,,,,both,,,3348.94,2176.81,,,,,,,,,,,,,
GRAFT HUM TISS W2XL2CM AMNIO TISS MEM WRP AMNIOFIX,SUP-2305759,CDM,V2790,HCPCS,0274,RC,,,,both,,,2581.08,1677.70,,,,,,,,,,,,,
SCREW BNE L 8 MM DIA2 MM MAXILLOMANDIBULAR LCK SD NS HYBRID,SUP-2909486,CDM,C1713,HCPCS,0278,RC,,,,both,,,532.54,346.15,,,,,,,,,,,,,
STABILIZER SURG RIGID STD BLADE ULT,SUP-2102336,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4066.30,2643.09,,,,,,,,,,,,,
DEVICE SUT CAPT W ALIGN INDIC NDL DRVR BTTN SUT FOR OPN RAD,SUP-2139406,CDM,C2631,HCPCS,0278,RC,,,,both,,,778.63,506.11,,,,,,,,,,,,,
INSERT TIB SZ 2 THK10MM POST STBL FIX GMK,SUP-2267474,CDM,C1776,CPT,0278,RC,,,,both,,,2974.93,1933.70,,,,,,,,,,,,,
PACEMAKER CARD EVIA HF-T RESYNCHRONIZATION BIV LANDLINE HM,SUP-2138362,CDM,C2621,HCPCS,0275,RC,,,,both,,,25245.60,16409.64,,,,,,,,,,,,,
SET CLMP INSRT L33MM HYDRA/TRACTION JAW DISP FGRTY,SUP-2214535,CDM,C1894,HCPCS,0272,RC,,,,both,,,93.60,60.84,,,,,,,,,,,,,
ANCHOR SUT NO2 DIA2.9MM MAXBRAID DBL LD SFT W/ TAPR NDL,SUP-2212781,CDM,C1713,HCPCS,0278,RC,,,,both,,,1444.40,938.86,,,,,,,,,,,,,
PLATE BNE W22XL41MM 12 H L DST RAD TI LOK COMPR LO PROF NAR,SUP-2411819,CDM,C1713,HCPCS,0278,RC,,,,both,,,2873.10,1867.51,,,,,,,,,,,,,
PIN FIX L15IN DIA2.7MM PASS DRL TIP,SUP-2341327,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2360.09,1534.06,,,,,,,,,,,,,
GRAFT VASC IMPRA L 50 CM DIA 8 MM EPTFE STR STD WALL N RING,SUP-2761305,CDM,C1768,CPT,0278,RC,,,,both,,,1773.88,1153.02,,,,,,,,,,,,,
DRESSING BIO 1000 MG PORCINE EXTRACELLULAR MTRX PWDR WND,SUP-2911929,CDM,A2004,HCPCS,0278,RC,,,,both,,,6323.96,4110.57,,,,,,,,,,,,,
STOCKING COMPR ARM BUTLER APPL AID DEV W/ STD LEN,SUP-2724359,CDM,C1713,HCPCS,0278,RC,,,,both,,,114.58,74.48,,,,,,,,,,,,,
HC Pt Therapeutic Activities 15 Min|OP OCCUPATIONAL THERAPY SERV|SERVICES PROVIDED IN WHOLE OR IN PARTY BY AN OTA FOR MEDICARE PATIENTS|ADJ,PX-4209753000,CDM,97530,CPT,0420,RC,,,GO|CO|ADJ,both,,,144.00,93.60,,,,,,,,,,,,,
KIT ACC 10GA 3ML SYR BVL TIP SIDE OPN RADPQ W/O CEM SYNFLATE,SUP-2255821,CDM,2720000010,LOCAL,0272,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
KIT INSTR PLT STRL DISP MOTOBAND CP DYNAFORCE,SUP-2893439,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1522.90,989.88,,,,,,,,,,,,,
PLATE BNE THK0.6MM 8MM BAR 6 H 100DEG UNIV,SUP-2366308,CDM,C1713,HCPCS,0278,RC,,,,both,,,668.41,434.47,,,,,,,,,,,,,
HC Debrid Wound Tis 20 Cm/<,PX-7619759700,CDM,97597,CPT,0761,RC,,,,outpatient,,,583.00,378.95,,,,,,,,,,,,,
COLLAR CERV FOAM PADDING REG PEDIATRIC INF 1.25 IN PROCARE,SUP-2195748,CDM,L0180,HCPCS,0272,RC,,,,both,,,80.01,52.01,,,,,,,,,,,,,
SOCKS PROSTHETIC MULT PLY BK,SUP-2314055,CDM,L8420,HCPCS,0274,RC,,,,both,,,98.63,64.11,,,,,,,,,,,,,
PLATE BNE W13.5XL170MM THK4.2MM 9 H BILAT S STL NAR LOK,SUP-2185242,CDM,C1713,HCPCS,0278,RC,,,,both,,,1348.25,876.36,,,,,,,,,,,,,
ALLOGRAFT BNE BLOCK 14X11X6 MM LORDTC DENS CANC,SUP-2743372,CDM,C1713,HCPCS,0278,RC,,,,both,,,3868.48,2514.51,,,,,,,,,,,,,
HEAD FEM DIA28 MM CERAMYS CHOICE HIP REV STRL,SUP-2929704,CDM,C1776,CPT,0278,RC,,,,both,,,6247.47,4060.86,,,,,,,,,,,,,
SCREW BONE L ACET LNR MULT H VIT E,SUP-2212341,CDM,C1713,HCPCS,0278,RC,,,,both,,,7693.00,5000.45,,,,,,,,,,,,,
STAPLE BNE 15X15X15MM HND FT NIT SUP E FOR OSTEOTMY ARTH,SUP-2175097,CDM,C1713,HCPCS,0278,RC,,,,both,,,5636.30,3663.59,,,,,,,,,,,,,
GUIDEWIRE VASC ANGLED 0.035 INX220 CM STD HYDRPHLC LAUREATE,SUP-2472876,CDM,C1769,HCPCS,0272,RC,,,,both,,,103.49,67.27,,,,,,,,,,,,,
HC Peritoneal Lavage W/WO Imaging Guidance,PX-4504908400,CDM,49084,CPT,0450,RC,,,,both,,,1056.00,686.40,,,,,,,,,,,,,
NUT ORTH 5 MM CORTICAL SCR HEX SOCKET NS LCP,SUP-2184944,CDM,C1713,HCPCS,0278,RC,,,,both,,,433.63,281.86,,,,,,,,,,,,,
CANNULA SUCTION COAG 3 MMX30 CM INSUL,SUP-2776947,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1139.54,740.70,,,,,,,,,,,,,
SUPPORT ORTHOT ELBW CUST ADJ W/POS LCK JT PREFABRICATED,SUP-2435760,CDM,L3761,HCPCS,0274,RC,,,,both,,,1288.59,837.58,,,,,,,,,,,,,
PLATE BONE SPNL ASPN M 8 MM,SUP-2136958,CDM,C1713,HCPCS,0278,RC,,,,both,,,10676.00,6939.40,,,,,,,,,,,,,
HC Atomic Absrpj Spectroscopy Ea Analyte,PX-3008219066,CDM,82190,CPT,0300,RC,,,,both,,,526.00,341.90,,,,,,,,,,,,,
SHUNT CV OD11.5FR DBL VLV RETAINS NUTRIENTS DIURESIS DENV,SUP-2133688,CDM,C1889,HCPCS,0278,RC,,,,both,,,6045.91,3929.84,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY WOVEN L 110 CM DIA 6 FR SPC 2-4-2,SUP-2142305,CDM,C1731,HCPCS,0278,RC,,,,both,,,1962.50,1275.62,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY INQUIRY L 110 CM 7FR DUODECAPOLAR,SUP-2538101,CDM,C1731,HCPCS,0278,RC,,,,both,,,1617.73,1051.52,,,,,,,,,,,,,
PHENYLEPHRINE HCL-NACL 50-0.9 MG/250ML-% IV SOLN,RX-137288,CDM,J7999,HCPCS,0636,RC,71266-5250-01,NDC,,both,250,ML,209.90,136.43,,,,,,,,,,,,,
COLLAR CERV SFT BABY FIRM DENS NO NK STFFNK SN6] PENNCARE],SUP-2323344,CDM,L0140,HCPCS,0272,RC,,,,both,,,36.11,23.47,,,,,,,,,,,,,
GRAFT BNE SUB 15CC CANC 1 4MM CRUSH CHIP READIGRFT,SUP-2264816,CDM,C1713,HCPCS,0278,RC,,,,both,,,769.99,500.49,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 90 X 40 CM DIA 8 X 8 MM EPTFE,SUP-2396237,CDM,C1768,CPT,0278,RC,,,,both,,,7601.94,4941.26,,,,,,,,,,,,,
BANDAGE SUPP ANK AK SILESIAN,SUP-2388215,CDM,L5698,HCPCS,0272,RC,,,,both,,,276.13,179.48,,,,,,,,,,,,,
BLADE EXTR 58MM FULL HMSPHR FOR ACET SHELL REM SYS EXPLANT,SUP-2202794,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
SCREW BONE L25MM OD28MM LCTSRB CPLMR SHLDR SOLID FLLY THRDD,SUP-2724201,CDM,C1713,HCPCS,0278,RC,,,,both,,,649.98,422.49,,,,,,,,,,,,,
CATHETER KIT 3 LUMEN 6 FR W/ PASV PWR INJ XCELA,SUP-2117188,CDM,C1751,HCPCS,0278,RC,,,,both,,,562.06,365.34,,,,,,,,,,,,,
LINER ACET OD46-48MM ID28MM +4MM 20DEG XLPE REFLCT,SUP-2344757,CDM,C1776,CPT,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
SCREW BNE L16MM DIA3.5MM EL TI LOK MULTDIR FOR ALPS FRAC,SUP-2413762,CDM,C1713,HCPCS,0278,RC,,,,both,,,779.35,506.58,,,,,,,,,,,,,
FENTANYL 75 MCG/HR TD PT72,RX-27907,CDM,6370000000,HCPCS,0637,RC,47781-0427-11,NDC,,both,1,UN,90.10,58.56,,,,,,,,,,,,,
HC Sampling Chorionic Villus,PX-9205901500,CDM,59015,CPT,0920,RC,,,,inpatient,,,645.00,419.25,,,,,,,,,,,,,
BRACE WALKING LP XL 14-17 IN AD M FOAM MAXTRAX AIR,SUP-2427325,CDM,L4360,HCPCS,0274,RC,,,,both,,,97.50,63.37,,,,,,,,,,,,,
BANDAGE SUPP ANK AK SILESIAN,SUP-2388215,CDM,L5698,HCPCS,0274,RC,,,,both,,,276.13,179.48,,,,,,,,,,,,,
BRACE ORTHOSIS SPNL S M EXOS FRM II 637,SUP-2196548,CDM,L0641,HCPCS,0274,RC,,,,both,,,488.40,317.46,,,,,,,,,,,,,
PLATE BONE L96MM 6 H RT FEM CNTOUR LCK COMPR FOR 4.5MM SCR,SUP-2318706,CDM,C1713,HCPCS,0278,RC,,,,both,,,12927.44,8402.84,,,,,,,,,,,,,
BLADE SHV 3.5MM L11CM SINUS TAPR TIP CVD SHFT NONROTATABLE,SUP-2277865,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1050.86,683.06,,,,,,,,,,,,,
KIT STRNL CLOSURE SS BX CABLE PLATE SCREW STRL THORECON,SUP-2894495,CDM,C1713,HCPCS,0278,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
KIT SCOPE NANO 1.9MM DISP,SUP-2713884,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2069.26,1345.02,,,,,,,,,,,,,
CATHETER ANGIO MARINER L 100 CM DIA 4 FR 0.038 IN JB2 SEL,SUP-2116864,CDM,C1887,HCPCS,0272,RC,,,,both,,,138.79,90.21,,,,,,,,,,,,,
PLATE BNE BROAD 4.5X167 MM 10 HOLE SS DCP,SUP-2569178,CDM,C1713,HCPCS,0278,RC,,,,both,,,423.12,275.03,,,,,,,,,,,,,
HC 2-D-Echo-Lmt - MRI,PX-6100893400,CDM,C8934,CPT,0610,RC,,,,both,,,4365.00,2837.25,,,,,,,,,,,,,
VALVE VENT SM L36MM DIA13MM THK6MM PERF LEV 1.5 DELT,SUP-2284514,CDM,C1889,HCPCS,0278,RC,,,,both,,,3441.44,2236.94,,,,,,,,,,,,,
LORATADINE-PSEUDOEPHEDRINE ER 10-240 MG PO TB24,RX-27521,CDM,6370000000,HCPCS,0637,RC,00904-5833-48,NDC,,both,1,UN,3.20,2.08,,,,,,,,,,,,,
CATHETER PERI DLYS L60CM DIA7FR PERC PACE INTRO LD AXIA RSN,SUP-2283892,CDM,C1750,HCPCS,0278,RC,,,,both,,,249.69,162.30,,,,,,,,,,,,,
GRAFT 5ML PUTTY NOVABONE,SUP-2307533,CDM,C9359,HCPCS,0278,RC,,,,both,,,2392.68,1555.24,,,,,,,,,,,,,
NEEDLE NAVIGATION SPINE TRCR TIP K WIRE INSRT CANNUALTED,SUP-2364162,CDM,2720000010,LOCAL,0272,RC,,,,both,,,960.46,624.30,,,,,,,,,,,,,
FIBER LASER L3050MM COR DIA750UM GRN LT MOXY,SUP-2139479,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4974.67,3233.54,,,,,,,,,,,,,
ELECTRODE ENDOSCP HF-RESECTION LNG CABLE ANGLED PLASMALOOP,SUP-2470110,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1593.55,1035.81,,,,,,,,,,,,,
STEM FEM L200MM OD15MM 3DEG TI POR PLSM SPR HIP REV,SUP-2405029,CDM,C1776,CPT,0278,RC,,,,both,,,19279.60,12531.74,,,,,,,,,,,,,
WIRE BNE FIX L 255 MM DIA2 MM DRL TIP STRL KIRSCHNER,SUP-2933808,CDM,C1713,HCPCS,0278,RC,,,,both,,,2480.66,1612.43,,,,,,,,,,,,,
INSERT TIB PROX KNEE IMP MOST OPTIONS,SUP-2208304,CDM,C1776,CPT,0278,RC,,,,both,,,29136.06,18938.44,,,,,,,,,,,,,
PAROXETINE HCL 10 MG/5ML PO SUSP,RX-22959,CDM,340b,HCPCS,0637,RC,09999-9905-91,NDC,,both,5,ML,20.90,13.58,,,,,,,,,,,,,
SPACER SPNL W26XH10MM SM PEEK THORLUM INTBDY FUS CNTR STK,SUP-2291507,CDM,C1889,HCPCS,0278,RC,,,,both,,,4421.12,2873.73,,,,,,,,,,,,,
LIP-GUARD EX OINT,RX-82160,CDM,6370000000,HCPCS,0637,RC,04138-8210-21,NDC,,both,7,GR,2.70,1.75,,,,,,,,,,,,,
ALLOGRAFT BNE SYRINGE LG 8 CC DBM FIBER OSTEOSTRAND PLUS,SUP-2731819,CDM,C1713,HCPCS,0278,RC,,,,both,,,13282.20,8633.43,,,,,,,,,,,,,
SCREW BNE CANN 11X30 MM 7 MM RCI STRL,SUP-2849113,CDM,C1713,HCPCS,0278,RC,,,,both,,,451.69,293.60,,,,,,,,,,,,,
COIL EMB L2CM DIA2MM 0.01IN MICROCOIL SFT FINISH HELCL,SUP-2249137,CDM,C1889,HCPCS,0278,RC,,,,both,,,3106.72,2019.37,,,,,,,,,,,,,
PLATE 4.5MM TI LCP TM STRAIGHT RECON 9 HOLES 170MM,SUP-2549509,CDM,C1713,HCPCS,0278,RC,,,,both,,,1796.68,1167.84,,,,,,,,,,,,,
PLATE BONE TI 8 HOLEXSHAPED FOR 2.4MM SCR RIG STRNL SYS,SUP-2136977,CDM,C1713,HCPCS,0278,RC,,,,both,,,1601.40,1040.91,,,,,,,,,,,,,
BUR SURG RND XLN 1.5 MM 77 MM ENT FLUT CARBIDE,SUP-2628881,CDM,2720000010,LOCAL,0272,RC,,,,both,,,569.91,370.44,,,,,,,,,,,,,
NEEDLE ENDOSCP STR JAW 5X250 MM W/O SUTURE FOR FACE CLOSURE,SUP-2797597,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1188.21,772.34,,,,,,,,,,,,,
BLADE SHAVER SUPERFICIAL 18 DEG 2.9X270 MM LARYNGEAL DBL,SUP-2648908,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1061.60,690.04,,,,,,,,,,,,,
CATHETER EMB FOGARTY L 60 CM DIA2 FR BALLOON DIA,SUP-2213998,CDM,C1757,HCPCS,0272,RC,,,,both,,,75.58,49.13,,,,,,,,,,,,,
STENT BILI HANAROSTENT L 80 MM DIA 8 MM L 1800 MM LNG WIRE,SUP-2679934,CDM,C1874,HCPCS,0278,RC,,,,both,,,4474.50,2908.42,,,,,,,,,,,,,
CLIP ASSURANCE 16MM,SUP-2862314,CDM,C1889,HCPCS,0278,RC,,,,both,,,278.36,180.93,,,,,,,,,,,,,
RING EXT FIX DIA105 MM ACCSRY SINGLE ROW 2/3 NS DISP TSF,SUP-2932865,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4858.77,3158.20,,,,,,,,,,,,,
PLATE BONE L146MM 6 H RT MEDL DSTL TIB LCK W/O TAB FOR 3.5MM,SUP-2349084,CDM,C1713,HCPCS,0278,RC,,,,both,,,3313.49,2153.77,,,,,,,,,,,,,
MULTI DIR THREADED PEG 30MM,SUP-2587091,CDM,C1713,HCPCS,0278,RC,,,,both,,,406.16,264.00,,,,,,,,,,,,,
PLATE BNE STR 2X23 MM 4 HOLE,SUP-2569071,CDM,C1713,HCPCS,0278,RC,,,,both,,,143.34,93.17,,,,,,,,,,,,,
ALLOGRAFT BNE CHIP 1-9.5 MM 50 CC FRZN IRRADIATED CANC,SUP-2717937,CDM,C1713,HCPCS,0278,RC,,,,both,,,3336.25,2168.56,,,,,,,,,,,,,
HC So Theophylline,PX-3018019866,CDM,80198,CPT,0301,RC,,,,outpatient,,,437.00,284.05,,,,,,,,,,,,,
DRILL SURG FLX 10.5 MM CANN ANAT CRUCIATED GUIDE SYS CLANCY,SUP-2849156,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2945.32,1914.46,,,,,,,,,,,,,
PORT INFUS CATH DIA8FR PLAS POLYUR PEEL APART PERC INTRO,SUP-2127738,CDM,C1788,HCPCS,0278,RC,,,,both,,,722.20,469.43,,,,,,,,,,,,,
KIT EEG ELECTRD L 16 MM 5 CONTACT RF PRB STRL DISP EVO,SUP-2936747,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3017.54,1961.40,,,,,,,,,,,,,
GUIDEWIRE VASC ANGLED 0.038 INX260 CM STD EXCHANGE LAUREATE,SUP-2463109,CDM,C1769,HCPCS,0272,RC,,,,both,,,106.76,69.39,,,,,,,,,,,,,
CATHETER HD STR 15.5 FRX24 CM SHT TERM 3L T-3 CT,SUP-2627215,CDM,C1752,HCPCS,0278,RC,,,,both,,,112.16,72.90,,,,,,,,,,,,,
RING EXT FIX DIA155 MM LNG FT 2/3 BLU NS DISP SMRT TSF,SUP-2933202,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4167.03,2708.57,,,,,,,,,,,,,
MESH CRAN L 40 X W 40 MM THK 0.6 MM SCREW DIA1.5/1.7 MM SM,SUP-2883495,CDM,C1713,HCPCS,0278,RC,,,,both,,,4114.28,2674.28,,,,,,,,,,,,,
COIL EMB L35CM PRI DIA0.020IN 2ND DIA11MM NIT COMPLX SFT,SUP-2323412,CDM,C1889,HCPCS,0278,RC,,,,both,,,7799.76,5069.84,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED PRSS FT SHELL TRAB MEL,SUP-2212734,CDM,C1776,CPT,0278,RC,,,,both,,,13459.61,8748.75,,,,,,,,,,,,,
PLATE BNE STR METATARSOPHALANGEAL LATTICE LCK,SUP-2107934,CDM,C1713,HCPCS,0278,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
GRAFT STENT 0.035 IN 10X13X39 MM 8 FRX135 CM VIABAHN VBX,SUP-2395692,CDM,C1874,HCPCS,0278,RC,,,,both,,,9715.16,6314.85,,,,,,,,,,,,,
MESH SURG DIA12CM WHT POLY CLLGN FLM RND MFIL BIOABSRB,SUP-2283397,CDM,C1781,HCPCS,0278,RC,,,,both,,,1340.31,871.20,,,,,,,,,,,,,
SET PUMP VENTRICULAR ASSIST 2.5FR DIA IMPELLA,SUP-2652613,CDM,C1889,HCPCS,0278,RC,,,,both,,,62800.00,40820.00,,,,,,,,,,,,,
STENT BILI LIFESTENT NT L 40 MM DIA 6 MM CATH L 120 CM,SUP-2214606,CDM,C1876,HCPCS,0278,RC,,,,both,,,4992.60,3245.19,,,,,,,,,,,,,
PLATE CRAN 140X20X40 MM PT SPEC IMPL PEEK,SUP-2860118,CDM,C1713,HCPCS,0278,RC,,,,both,,,23843.90,15498.53,,,,,,,,,,,,,
PLATE SPNL 12 H THOR PRE CNTOUR RIBFIX BLU,SUP-2137001,CDM,C1713,HCPCS,0278,RC,,,,both,,,4088.28,2657.38,,,,,,,,,,,,,
CLAMP CLP SCR FOR ORTHOFIX PREFIX FIX,SUP-2316287,CDM,2720000010,LOCAL,0272,RC,,,,both,,,679.75,441.84,,,,,,,,,,,,,
PLATE BNE L19MM THK0.6MM LNG 4 H SIL TI STR FOR 1.5MM SCR,SUP-2402872,CDM,C1713,HCPCS,0278,RC,,,,both,,,222.94,144.91,,,,,,,,,,,,,
HEAD HUM H18MM DIA56MM DUOFIX HA RESURF GLOB CAP,SUP-2250672,CDM,C1776,CPT,0278,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
GRAFT STENT 7X2.5 MM 75 CM SUPERFICIAL FEM ART W/O HEPARIN,SUP-2396502,CDM,C1874,HCPCS,0278,RC,,,,both,,,7017.90,4561.63,,,,,,,,,,,,,
PATCH CV HEMGRD L 75 X W 8 MM THK 0.41 MM POLYESTER BOV,SUP-2266052,CDM,C1768,CPT,0278,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
PLATE BNE STR 3.5X183 MM 14 HOLE RECON LCK SS STRL,SUP-2490201,CDM,C1713,HCPCS,0278,RC,,,,both,,,1821.51,1183.98,,,,,,,,,,,,,
STABILIZER SURG FOR BEAT HRT SURG URCHIN EVO,SUP-2282944,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
KCL IN DEXTROSE-NACL 10-5-0.45 MEQ/L-%-% IV SOLN,RX-102355,CDM,2500000003,HCPCS,0250,RC,00264-7634-00,NDC,,both,1000,ML,57.50,37.37,,,,,,,,,,,,,
SET SCR THRESHOLD PEDICULAR FIX,SUP-2354658,CDM,C1713,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
PLATE BNE BROAD 3.5X133 MM 10 HOLE SS LCP,SUP-2569336,CDM,C1713,HCPCS,0278,RC,,,,both,,,469.74,305.33,,,,,,,,,,,,,
GRAFT VASC EXXCEL SFT L 70 CM DIA 6 MM EPTFE STR STD WALL,SUP-2227646,CDM,C1768,CPT,0278,RC,,,,both,,,1744.93,1134.20,,,,,,,,,,,,,
SCREW BONE LOK 27MM DIA UNVRSL 14MML TTNM ST,SUP-2720367,CDM,C1713,HCPCS,0278,RC,,,,both,,,388.10,252.26,,,,,,,,,,,,,
CATHETER GUID SPEX 35 L 50 CM OD 0.035 IN ID 0.063 IN,SUP-2227749,CDM,C1887,HCPCS,0272,RC,,,,both,,,508.68,330.64,,,,,,,,,,,,,
INTRODUCER CATHETER 10FR L8IN FOR CHOLGM CATHETER TAUT,SUP-2384042,CDM,C1894,HCPCS,0272,RC,,,,both,,,115.68,75.19,,,,,,,,,,,,,
SCREW BNE L30MM OD6.5MM TIV KNEE ST MG II NXGN,SUP-2199568,CDM,C1713,HCPCS,0278,RC,,,,both,,,508.52,330.54,,,,,,,,,,,,,
ULS 20MM STANDARD CANNULA,SUP-2722403,CDM,2720000010,LOCAL,0272,RC,,,,both,,,351.90,228.73,,,,,,,,,,,,,
SCREW BNE L26MM OD3MM HDLSS,SUP-2365592,CDM,C1713,HCPCS,0278,RC,,,,both,,,816.40,530.66,,,,,,,,,,,,,
MELATONIN 3 MG PO TABS,RX-16830,CDM,6370000000,HCPCS,0637,RC,77333-0516-25,NDC,,both,1,UN,1.80,1.17,,,,,,,,,,,,,
TUBE JEJUNOSTOMY FEED 14 FRX45 CM 5 CM STOMA LP AMT G-JET,SUP-2424369,CDM,C1713,HCPCS,0278,RC,,,,both,,,1527.61,992.95,,,,,,,,,,,,,
COMPONENT RADIAL IM XL DSTL WRST MICRONAIL,SUP-2538186,CDM,C1776,CPT,0278,RC,,,,both,,,7231.42,4700.42,,,,,,,,,,,,,
PLUG VASC UNCONSTRAINED L18MM DIA22MM CATH 9FR L100CM NIT,SUP-2355718,CDM,C1889,HCPCS,0278,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
TUBE TRACH AD SZ 6 SPECIALIZED CUF SHILEY,SUP-2172420,CDM,2720000010,LOCAL,0272,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
HC Iaad Ia Severe Aqt Respir Synd Coronavirus,PX-3068742600,CDM,87426,CPT,0306,RC,,,,outpatient,,,71.00,46.15,,,,,,,,,,,,,
GRAFT CELLR BNE MATRX INFLUX SPARC 5CC,SUP-2615609,CDM,C1713,HCPCS,0278,RC,,,,both,,,10864.40,7061.86,,,,,,,,,,,,,
KIT NEUROSTIMULATOR L 45 CM DIA1.35 MM PERIPH TRL 8 CONTACT,SUP-2917077,CDM,C1816,LOCAL,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
PLATE BNE W17.5XL250MM THK5.2MM 14 H BILAT S STL BROAD,SUP-2185303,CDM,C1713,HCPCS,0278,RC,,,,both,,,2049.20,1331.98,,,,,,,,,,,,,
REMOVER SCR FOR ORTH FIX SYS,SUP-2319565,CDM,C1713,HCPCS,0278,RC,,,,both,,,675.10,438.81,,,,,,,,,,,,,
ROD EXT FIX L125MM DIA11MM C FBR MR CONDITIONAL FOR LNG,SUP-2188650,CDM,2720000010,LOCAL,0272,RC,,,,both,,,452.16,293.90,,,,,,,,,,,,,
ROD RMR L650MM DIA2.5MM W/ EXTN BALL TIP,SUP-2188109,CDM,2720000010,LOCAL,0272,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
FILGRASTIM-AAFI 480 MCG/1.6ML IJ SOLN,RX-145106,CDM,Q5110,HCPCS,0636,RC,00069-0294-10,NDC,,both,1.6,ML,2014.80,1309.62,,,,,,,,,,,,,
"HC Insert Picc Cath, <5 Yrs",PX-3613656800,CDM,36568,CPT,0361,RC,,,,both,,,4942.00,3212.30,,,,,,,,,,,,,
SEALER BPLR 5MM H1.59XL12.75IN SHTH W/ 2 ELECTRD TIP,SUP-2281806,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1910.38,1241.75,,,,,,,,,,,,,
XXL VOLAR DR TRIAL NARROW RIGHT 8 HOLE,SUP-2695485,CDM,C1713,HCPCS,0278,RC,,,,both,,,219.80,142.87,,,,,,,,,,,,,
WEDGE FEM L SZ 3 DST CO CHROME POR STACKED GEN II,SUP-2346026,CDM,C1776,CPT,0278,RC,,,,both,,,1764.68,1147.04,,,,,,,,,,,,,
COIL NEUROVASCULAR PRESIDIO 18 CERECYTE L 50 CM LOOP DIA20,SUP-2249259,CDM,C1889,HCPCS,0278,RC,,,,both,,,9518.13,6186.78,,,,,,,,,,,,,
GRAFT DURA 1X1 IN CLLGN MTRX DURAGN CLASSIC,SUP-2243067,CDM,C1713,HCPCS,0278,RC,,,,both,,,913.46,593.75,,,,,,,,,,,,,
HC So Bilirubin Total,PX-3018224766,CDM,82247,CPT,0301,RC,,,,both,,,38.00,24.70,,,,,,,,,,,,,
SET TRNSF INSEM INTRAMURAL ECHOSIGHT JANSEN-ANDERSON,SUP-2171311,CDM,2720000010,LOCAL,0272,RC,,,,both,,,321.54,209.00,,,,,,,,,,,,,
BIT DRL TWST 1.5X9 MM ANGLED SCREWDRIVER STRL ANGULUS 2,SUP-2457824,CDM,2720000010,LOCAL,0272,RC,,,,both,,,562.37,365.54,,,,,,,,,,,,,
SCREW BNE STYLOID 2X28 MM ST HI ANGLE T5 DRV,SUP-2466651,CDM,C1713,HCPCS,0278,RC,,,,both,,,156.59,101.78,,,,,,,,,,,,,
BRACE ANK H85IN SM AD BILAT STRP CLSR OPN HEEL TOE RIG W,SUP-2195185,CDM,L4350,HCPCS,0272,RC,,,,both,,,71.72,46.62,,,,,,,,,,,,,
TWNFX TI 2.8 HS 2 USP NO 2-0,SUP-2341010,CDM,C1713,HCPCS,0278,RC,,,,both,,,719.66,467.78,,,,,,,,,,,,,
STEM HUM SLT 14X125 MM SHLDR OLYMPIA,SUP-2535972,CDM,C1776,CPT,0278,RC,,,,both,,,11197.24,7278.21,,,,,,,,,,,,,
CATHETER CV SET 018 PEDIATRIC 3 FRX5 CM 1 LUMEN J TIP,SUP-2760148,CDM,C1751,HCPCS,0278,RC,,,,both,,,144.91,94.19,,,,,,,,,,,,,
ALLOGRAFT FASC RESRB MEMBRN NAT BARR 2.0CMX3.0CM MAXXEUS,SUP-2165616,CDM,C1713,HCPCS,0278,RC,,,,both,,,241.78,157.16,,,,,,,,,,,,,
HC N Block Paravert Lumbar 1st|BILATERAL PROCEDURE,PX-3606449300,CDM,64493,CPT,0360,RC,,,50,both,,,4864.00,3161.60,,,,,,,,,,,,,
ANCHOR SUT ARTHSCP HNDL INSRT NO 2 SUT TI DURABRAID 2.8MM,SUP-2341741,CDM,C1713,HCPCS,0278,RC,,,,both,,,741.83,482.19,,,,,,,,,,,,,
GRAFT BONE SUB 43ML W2XL36MM B TRICALCIUM PHOS CLLGN HA RECT,SUP-2289163,CDM,C1713,HCPCS,0278,RC,,,,both,,,13539.68,8800.79,,,,,,,,,,,,,
BOLT BNE FIX L80MM DIA5MM PROX L10MM DST L22MM MIDFOOT FUS,SUP-2400718,CDM,C1713,HCPCS,0278,RC,,,,both,,,4826.18,3137.02,,,,,,,,,,,,,
SEALER BPLR L5.74MM DIA3.48MM SPC 6MM 30DEG MAL W/ LT BLK,SUP-2281805,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2392.68,1555.24,,,,,,,,,,,,,
SHEATH INNR W STPCOCK PRSS SENS FOR 87K FLD MGMT SYS,SUP-2166833,CDM,C1894,HCPCS,0272,RC,,,,both,,,3073.87,1998.02,,,,,,,,,,,,,
PROBE VITRCTMY ANT ATIOP LEG EVEREST,SUP-2109630,CDM,2720000010,LOCAL,0272,RC,,,,both,,,468.49,304.52,,,,,,,,,,,,,
GRAFT HUM TISS W4XL7CM THK2-3.5MM ACELLULAR DERM MTRX,SUP-2402521,CDM,Q4126,HCPCS,0636,RC,,,,both,,,7410.40,4816.76,,,,,,,,,,,,,
PLATE BNE L274MM BLDE W48XL25MM 95DEG 16 H ST HIP S STL RIG,SUP-2186763,CDM,C1713,HCPCS,0278,RC,,,,both,,,3618.50,2352.02,,,,,,,,,,,,,
IMMOBILIZER SLNG LOOP CLOSURE UNIV UNISX SHLDR PROCARE,SUP-2196933,CDM,L3660,HCPCS,0272,RC,,,,both,,,21.26,13.82,,,,,,,,,,,,,
BLADE SHAVER SERRATED STD 2.9 MM STR DSTL SUCTION STRL DISP,SUP-2638418,CDM,2720000010,LOCAL,0272,RC,,,,both,,,395.64,257.17,,,,,,,,,,,,,
HALF PIN EXT FIX L110MM DIA5MM THRD L35MM DIA5MM SH TI,SUP-2342925,CDM,C1713,HCPCS,0278,RC,,,,both,,,1206.14,783.99,,,,,,,,,,,,,
CABLE SURG L750MM DIA1MM S STL SMOOTH W/ CRMP,SUP-2187028,CDM,C1776,CPT,0278,RC,,,,both,,,1334.94,867.71,,,,,,,,,,,,,
GRAFT BNE L80MM FIBULAR SHFT SEG FRZ DRY MATRIGRFT,SUP-2264770,CDM,C1713,HCPCS,0278,RC,,,,both,,,1774.98,1153.74,,,,,,,,,,,,,
SCREW INTRF L30MM DIA10MM PEEK FOR INTRAFIX ADV TIB FAST SYS,SUP-2256833,CDM,C1713,HCPCS,0278,RC,,,,both,,,1199.48,779.66,,,,,,,,,,,,,
COLLAR CERV 3 1/4X10-12IN SM TRACH OPN ADJ PHIL,SUP-2195259,CDM,L0120,HCPCS,0272,RC,,,,both,,,39.56,25.71,,,,,,,,,,,,,
CANNULA SURG ID15MM SACROILIAC SPNL MINIMAL ACC RETRCT SYS,SUP-2232174,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1736.42,1128.67,,,,,,,,,,,,,
ALLOGRAFT BNE GRAN STRP 2 CC HA/TCP CLLGN VENADO 4815T5022,SUP-2718007,CDM,C1713,HCPCS,0278,RC,,,,both,,,1595.12,1036.83,,,,,,,,,,,,,
SUPPORT ORTHOT LUMBAR SACR CUST SAGITTAL-CORONAL FRAME,SUP-2435559,CDM,L0650,HCPCS,0272,RC,,,,both,,,3667.77,2384.05,,,,,,,,,,,,,
CANNULA GRFT DEL SYS X3 PREFILLED,SUP-2740841,CDM,C1713,HCPCS,0278,RC,,,,both,,,5735.84,3728.30,,,,,,,,,,,,,
CATHETER THROMCTMY ESPERANCE L 115 CM DIA 6 FR SHFT,SUP-2892525,CDM,C1757,HCPCS,0272,RC,,,,both,,,6264.30,4071.79,,,,,,,,,,,,,
IMPLANT FRESH CORNEA LEFT,SUP-2855178,CDM,V2785,HCPCS,0278,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA IR 4FR 55CM 2 LUMA S3294335,SUP-2632847,CDM,C1751,HCPCS,0278,RC,,,,both,,,466.98,303.54,,,,,,,,,,,,,
KIT HAD AD L33CM OD14.5FR STD BASIC SGL LUMN POLYUR PRECRV,SUP-2127854,CDM,C1750,HCPCS,0278,RC,,,,both,,,1529.81,994.38,,,,,,,,,,,,,
SHUNT SURG REG 16 GA SNAP ASMBLY BLNT NDL BIOGLDE STRATA II,SUP-2628598,CDM,C1729,HCPCS,0272,RC,,,,both,,,15834.02,10292.11,,,,,,,,,,,,,
CATHETER DRNGE SUMP LOOP PERCFLX MAT N COAT W/ TEMPTIP,SUP-2147745,CDM,C1729,HCPCS,0272,RC,,,,both,,,323.45,210.24,,,,,,,,,,,,,
TUBE VENT 1.14 MM 12 MM 9.8 MM T TUBE SIL STRL 510101,SUP-2535097,CDM,L8699,HCPCS,0278,RC,,,,both,,,55.11,35.82,,,,,,,,,,,,,
CATHETER THROMCTMY 4MAX L 139 CM PROX/DSTL OD 6,SUP-2323544,CDM,C1725,HCPCS,0272,RC,,,,both,,,4553.00,2959.45,,,,,,,,,,,,,
GRAFT MTRX DEMIN DEMIN BONE PUTTY ALLGRFT ALLOGENIX 10CC,SUP-2402967,CDM,C1713,HCPCS,0278,RC,,,,both,,,4085.14,2655.34,,,,,,,,,,,,,
BONESYNC PUTTY 5.0CC,SUP-2811322,CDM,C1713,HCPCS,0278,RC,,,,both,,,1695.60,1102.14,,,,,,,,,,,,,
PLATE BONE 8 H S STL 1/3 TBLR ECT,SUP-2198534,CDM,C1713,HCPCS,0278,RC,,,,both,,,139.82,90.88,,,,,,,,,,,,,
HC Anterior Epitaxis Simple,PX-4503090100,CDM,30901,CPT,0450,RC,,,,outpatient,,,214.00,139.10,,,,,,,,,,,,,
PLATE BNE CLAV SET PERI-LOC,SUP-2351348,CDM,C1713,HCPCS,0278,RC,,,,both,,,26187.60,17021.94,,,,,,,,,,,,,
TUNNELER SURG L 8 IN DIA11 GA STRL DISP ON-Q,SUP-2917152,CDM,2720000010,LOCAL,0272,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
DEFIBRILLATOR IMPL VITALITY EL TI RELIANCE PASS FIX EXT,SUP-2149068,CDM,C1722,HCPCS,0275,RC,,,,both,,,52438.00,34084.70,,,,,,,,,,,,,
CANNULA ENDOSCP FLX W/ NDL INJ,SUP-2747281,CDM,2720000010,LOCAL,0272,RC,,,,both,,,915.62,595.15,,,,,,,,,,,,,
BIT DRL L320MM DIA4.3MM CALIB FOR PHOENIX SYS,SUP-2412960,CDM,2720000010,LOCAL,0272,RC,,,,both,,,478.54,311.05,,,,,,,,,,,,,
GRAFT HUMAN TISSUE PELVIC FLOOR MATRIX 12X4 CM MATRISTEM,SUP-2106484,CDM,C1763,HCPCS,0278,RC,,,,both,,,4747.68,3085.99,,,,,,,,,,,,,
TRAY CATH MIDLN POWERGLIDE STRL SELD MAXBARR 20GA 10CM 1 LUM,SUP-2613569,CDM,C1751,HCPCS,0278,RC,,,,both,,,487.74,317.03,,,,,,,,,,,,,
DRESSING BIO L 10 X W 7 CM SZ 200 UM PORCINE SM INTEST,SUP-2905515,CDM,Q4103,HCPCS,0636,RC,,,,both,,,2706.30,1759.09,,,,,,,,,,,,,
BOLT IM L56MM DIA3.9MM HD DIA8MM TI ST LOK HEX RECESS TRCR,SUP-2192212,CDM,C1713,HCPCS,0278,RC,,,,both,,,599.02,389.36,,,,,,,,,,,,,
CATHETER ANGIOPLSTY RANG L 150 CM BALLOON L 150 MM DIA 4 MM,SUP-2653305,CDM,C2623,HCPCS,0278,RC,,,,both,,,5322.30,3459.49,,,,,,,,,,,,,
IPRATROPIUM BROMIDE 0.03 % NA SOLN,RX-16070,CDM,6370000000,HCPCS,0637,RC,00054-0045-44,NDC,,both,30,ML,162.00,105.30,,,,,,,,,,,,,
DARATUMUMAB-HYALURONIDASE-FIHJ 1800-30000 MG-UT/15ML SC SOLN,RX-150615,CDM,J9144,HCPCS,0636,RC,57894-0503-01,NDC,,both,15,ML,30447.00,19790.55,,,,,,,,,,,,,
NAIL IM L420MM DIA12MM 130DEG NONSTERILE GRN HIP TI CANN,SUP-2192643,CDM,C1713,HCPCS,0278,RC,,,,both,,,4217.65,2741.47,,,,,,,,,,,,,
TUBE VENT W9.8XL12MM DIA1.14MM SIL RICHARD T,SUP-2312833,CDM,L8699,HCPCS,0278,RC,,,,both,,,70.56,45.86,,,,,,,,,,,,,
PLATE BONE W7XL63MM THK1MM 8 H S STL QTR TBLR NONCOMPRESSION,SUP-2343853,CDM,C1713,HCPCS,0278,RC,,,,both,,,767.54,498.90,,,,,,,,,,,,,
BIT DRL QC 2X140 MM 60 MM CALIB STRL,SUP-2563748,CDM,2720000010,LOCAL,0272,RC,,,,both,,,482.78,313.81,,,,,,,,,,,,,
CANNULA THERMOCAN 7FT CASE OF 50,SUP-2307711,CDM,C1713,HCPCS,0278,RC,,,,both,,,643.70,418.40,,,,,,,,,,,,,
PLATE BONE MINI L29MM 4 H STR ECT,SUP-2198560,CDM,C1713,HCPCS,0278,RC,,,,both,,,121.49,78.97,,,,,,,,,,,,,
COMPONENT TIB BASE CEM LT/RT 63MM MEDL LAT FINN - L/R 63MM,SUP-2406092,CDM,C1776,CPT,0278,RC,,,,both,,,8556.50,5561.72,,,,,,,,,,,,,
GUIDEWIRE VASC L260CM DIA0.035IN TAPR L7CM FLPY TIP L3CM,SUP-2167947,CDM,C1769,HCPCS,0272,RC,,,,both,,,54.64,35.52,,,,,,,,,,,,,
FILGRASTIM 300 MCG/ML IJ SOLN,RX-10036,CDM,J1442,HCPCS,0636,RC,55513-0530-10,NDC,,both,1,ML,928.80,603.72,,,,,,,,,,,,,
PIN EXT FIX L150MM DIA6MM THRD L60MM S STL HA HALF FOR ILIZ,SUP-2343021,CDM,C1713,HCPCS,0278,RC,,,,both,,,1260.96,819.62,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED INCRD MOTN ADD ON,SUP-2365442,CDM,C1776,CPT,0278,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
PLATE BNE L74MM 4 H R POSTEROLATERAL DST PERIARTC FIBULAR S,SUP-2410554,CDM,C1713,HCPCS,0278,RC,,,,both,,,1293.68,840.89,,,,,,,,,,,,,
TAP SURG L 43 MM DIA2.2 MM SCREW DIA 8/10 MM SD HEX NS DISP,SUP-2909588,CDM,C1713,HCPCS,0278,RC,,,,both,,,1249.63,812.26,,,,,,,,,,,,,
MATRIX RESTRATA WOUND 5.0CM X 5.0CM,SUP-2874120,CDM,A2007,HCPCS,0636,RC,,,,both,,,8792.00,5714.80,,,,,,,,,,,,,
BLADE SHV 4.0MM DIA MICROENDOSCOPY SHRP EDGE FRMLA FOR,SUP-2361331,CDM,2720000010,LOCAL,0272,RC,,,,both,,,369.33,240.06,,,,,,,,,,,,,
BIT DRL LNG 2X5.5 MM PROF FOR 4.5MM SCREW NS ACUTRK 2,SUP-2518457,CDM,2720000010,LOCAL,0272,RC,,,,both,,,879.20,571.48,,,,,,,,,,,,,
SCREW SPNL STR RAIL 4.5X500 MM DEFORMITY COCR MESA RAIL 4D,SUP-2538577,CDM,C1713,HCPCS,0278,RC,,,,both,,,6343.05,4122.98,,,,,,,,,,,,,
KNIFE SURG MALTZ CART 50 DEG 6.75 INX10 MM MICROFRANCE,SUP-2464267,CDM,2720000010,LOCAL,0272,RC,,,,both,,,752.06,488.84,,,,,,,,,,,,,
SET THROMCTMY ANGIOJET XPEEDIOR L 120 CM DIA 6 FR SHTH 6 FR,SUP-2142031,CDM,C1757,HCPCS,0272,RC,,,,both,,,3940.70,2561.45,,,,,,,,,,,,,
PACEMAKER CARD ADAPTA SR W 42.9 X H 43.3 MM D 7.5 MM 11 CC,SUP-2282316,CDM,C1786,HCPCS,0275,RC,,,,both,,,7268.63,4724.61,,,,,,,,,,,,,
FRACTURE STEM SYS W MPLR CUP,SUP-2212072,CDM,C1776,CPT,0278,RC,,,,both,,,6157.54,4002.40,,,,,,,,,,,,,
HC ED Cltx Distal Radial Fx Manip,PX-4502560500,CDM,25605,CPT,0450,RC,,,,both,,,1633.00,1061.45,,,,,,,,,,,,,
BLADE ENDOSCP SHAVER L 18 CM DIA2.9 MM SPD 500-1500 RPM ENT,SUP-2902046,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1439.38,935.60,,,,,,,,,,,,,
SYSTEM NEUROSTIMULATOR IMPL HEX IQ PORT PLUG,SUP-2900853,CDM,C1822,CPT,0278,RC,,,,both,,,75360.00,48984.00,,,,,,,,,,,,,
VEST TRAC L98CM DIA72MM SYNTH LNR SH VERSATILE VAC FRM TOOL,SUP-2255763,CDM,L0810,HCPCS,0274,RC,,,,both,,,5165.30,3357.44,,,,,,,,,,,,,
GRAFT SYN H6XL17MM MIDFOOT WDG BIOFOAM,SUP-2397871,CDM,C1713,HCPCS,0278,RC,,,,both,,,5356.84,3481.95,,,,,,,,,,,,,
STEM FEM PRSS FT HIP CERM ON POLYETH OXIN R3,SUP-2351410,CDM,C1776,CPT,0278,RC,,,,both,,,15072.00,9796.80,,,,,,,,,,,,,
PLATE BNE 24 H MIC TI NONSTERILE 15MM SCR 06MM,SUP-2262719,CDM,C1713,HCPCS,0278,RC,,,,both,,,838.95,545.32,,,,,,,,,,,,,
IVABRADINE HCL 5 MG PO TABS,RX-129773,CDM,6370000000,HCPCS,0637,RC,55513-0800-60,NDC,,both,1,UN,47.00,30.55,,,,,,,,,,,,,
"HC Insert Picc Cath, 5/> Yrs - Anes|REDUCED SERVICES",PX-3613656901,CDM,36569,CPT,0361,RC,,,52,both,,,4942.00,3212.30,,,,,,,,,,,,,
CATHETER EP D 6 MM 20 MMX7 FRX115 CM CARTO,SUP-2467701,CDM,C1732,HCPCS,0272,RC,,,,both,,,7262.82,4720.83,,,,,,,,,,,,,
SYSTEM REP KNOTLESS AC,SUP-2121712,CDM,C1713,HCPCS,0278,RC,,,,both,,,5372.54,3492.15,,,,,,,,,,,,,
CAGE SPNL 17X14X5MM 5 DEG CERV LORDOSIS ZEUS,SUP-2115255,CDM,C1889,HCPCS,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
NAIL IM PROX LNG 7X220 MM RT HUM AFFIXUS NAT NAIL,SUP-2606956,CDM,C1713,HCPCS,0278,RC,,,,both,,,6044.50,3928.92,,,,,,,,,,,,,
COMPONENT PAT STD + 3PEG RND REV ROT CEM NP LCS,SUP-2252420,CDM,C1776,CPT,0278,RC,,,,both,,,2951.60,1918.54,,,,,,,,,,,,,
TUBE MYR DIA1MM S STL REUT BOB,SUP-2313690,CDM,L8699,HCPCS,0278,RC,,,,both,,,110.18,71.62,,,,,,,,,,,,,
PLATE SPNL FIX 4.5X28 MM SS CROSSLINK,SUP-2630565,CDM,C1713,HCPCS,0278,RC,,,,both,,,5071.10,3296.21,,,,,,,,,,,,,
WASHER 2.5X17MM RND SFT TISS FIX SPIK POST HT LO PROF TI ST,SUP-2166926,CDM,C1713,HCPCS,0278,RC,,,,both,,,612.49,398.12,,,,,,,,,,,,,
PLATE BNE ST 2.4/2.7X90 MM VA LCK COMPR TI VA-LCP,SUP-2758286,CDM,C1713,HCPCS,0278,RC,,,,both,,,199.74,129.83,,,,,,,,,,,,,
NAIL IM FEM N LCK LT RECON STRL FOR VECT SYS 11MM 320MM,SUP-2136668,CDM,C1713,HCPCS,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
KIT 4.75MM LOOP N TAK BICEP,SUP-2781309,CDM,C1713,HCPCS,0278,RC,,,,both,,,2700.40,1755.26,,,,,,,,,,,,,
STRAP ORTHOT HIP KNEE ANK CUST TORSON UNILAT ROT,SUP-2435643,CDM,L2070,HCPCS,0274,RC,,,,both,,,439.41,285.62,,,,,,,,,,,,,
BIT DRL L 175/90 MM DIA1.8 MM SCREW DIA2.4 MM CALIB AO QC,SUP-2907684,CDM,2720000010,LOCAL,0272,RC,,,,both,,,906.68,589.34,,,,,,,,,,,,,
PLATE BNE L239MM 14 H ST R MED DST TIB S STL LOK COMPR LO,SUP-2177455,CDM,C1713,HCPCS,0278,RC,,,,both,,,4294.89,2791.68,,,,,,,,,,,,,
SCREW BONE SELFDRILLING 1.85X8 MM MAXILLOMANDIBULAR 5/PK TIT,SUP-2842357,CDM,C1713,HCPCS,0278,RC,,,,both,,,469.49,305.17,,,,,,,,,,,,,
CAGE SPNL MESH 22X17X15 MM 6 LOBE,SUP-2602083,CDM,C1889,HCPCS,0278,RC,,,,both,,,10066.84,6543.45,,,,,,,,,,,,,
"HC Culture, Fungus Blood",PX-3008710300,CDM,87103,CPT,0300,RC,,,,inpatient,,,454.00,295.10,,,,,,,,,,,,,
PLATE BNE L109MM 6 H NONSTERILE R PROX TIB S STL,SUP-2185698,CDM,C1713,HCPCS,0278,RC,,,,both,,,3692.80,2400.32,,,,,,,,,,,,,
SPACER SPNL H7MM STD ANTR CERV PEEK OPTMA TI PLT INTBDY FUS,SUP-2182388,CDM,C1821,HCPCS,0278,RC,,,,both,,,11461.00,7449.65,,,,,,,,,,,,,
CAGE SPNL L H6MM 7DEG CERV THORLUM C FBR INTBDY FUS REINF,SUP-2256333,CDM,C1889,HCPCS,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 160 MM FRZN GAM PRESHAPED ACHILLES TEND,SUP-2866902,CDM,C1762,CPT,0278,RC,,,,both,,,5086.02,3305.91,,,,,,,,,,,,,
PLATE BONE THK0.8MM 4 H HND DBL ROW TRILOK FOR 1.5MM SCR,SUP-2267906,CDM,C1713,HCPCS,0278,RC,,,,both,,,1762.73,1145.77,,,,,,,,,,,,,
SCREW BNE MINI FOR BASE PLT TI 20MMX7MM MAXDRIVE,SUP-2262844,CDM,C1713,HCPCS,0278,RC,,,,both,,,811.22,527.29,,,,,,,,,,,,,
PLEDGET SURG W3/16XL0.25IN THK1.65MM PTFE OVL FELT FOR THE,SUP-2127904,CDM,C1781,HCPCS,0278,RC,,,,both,,,23.71,15.41,,,,,,,,,,,,,
EPIFIX DISK 14MM,SUP-2305746,CDM,Q4186,HCPCS,0636,RC,,,,both,,,1114.70,724.55,,,,,,,,,,,,,
RING ADPT BOLT STLTH REARFOOT FIX,SUP-2400664,CDM,2720000010,LOCAL,0272,RC,,,,both,,,609.16,395.95,,,,,,,,,,,,,
FILTER IVC BIOCONVERTIBLE FOR SENTRY SYS,SUP-2416859,CDM,C1880,HCPCS,0278,RC,,,,both,,,3925.00,2551.25,,,,,,,,,,,,,
ROD ORTH THRD 100 MM PILLAR,SUP-2749918,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1582.56,1028.66,,,,,,,,,,,,,
STENT PERIPH L60MM DIA6MM DEL SYS L125CM SHTH 6FR 0.035IN,SUP-2170397,CDM,C1874,HCPCS,0278,RC,,,,both,,,4694.30,3051.29,,,,,,,,,,,,,
EXTENSION EXT FIX 20 MM RIGID FOR ACTIVATION ARM TI,SUP-2461285,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2087.66,1356.98,,,,,,,,,,,,,
PUMP ANALGESIC FLO RATE 8 ML/HR 400 ML ELASTOMERIC FIX SOAK,SUP-2892658,CDM,C9804,HCPCS,0272,RC,,,,both,,,109.90,71.43,,,,,,,,,,,,,
BIT DRL 3X220 MM TORNIER,SUP-2388668,CDM,2720000010,LOCAL,0272,RC,,,,both,,,797.56,518.41,,,,,,,,,,,,,
SCULPT FLOW DELIVERY SYSTEM,SUP-2682265,CDM,C1713,HCPCS,0278,RC,,,,both,,,400.35,260.23,,,,,,,,,,,,,
STYLET NERVE STIM ENHANCED 30 CM KT W/ STEERING CAP STIFF,SUP-2464114,CDM,2720000010,LOCAL,0272,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
PACEMAKER CARD INVIVE W 44.5 X H 61 MM THK 7.5 MM CRT-P 3,SUP-2149291,CDM,C2621,HCPCS,0275,RC,,,,both,,,21540.40,14001.26,,,,,,,,,,,,,
Elite H Continuous Compression Implant 25x25x13mm 4 Legs,SUP-2550449,CDM,C1713,HCPCS,0278,RC,,,,both,,,6775.05,4403.78,,,,,,,,,,,,,
COMPONENT TOT KNEE CEM FIX BEAR RP XLINKED,SUP-2249590,CDM,C1776,CPT,0278,RC,,,,both,,,12717.00,8266.05,,,,,,,,,,,,,
DETECTOR CARBON DIOX PEDIATRIC EZ CAP II DISP,SUP-2264516,CDM,2720000010,LOCAL,0272,RC,,,,both,,,678.24,440.86,,,,,,,,,,,,,
SYSTEM RETROPUBIC TENS FREE SUPP DISP FOR INCONT GYNECARE,SUP-2218516,CDM,C1771,HCPCS,0278,RC,,,,both,,,5906.15,3839.00,,,,,,,,,,,,,
DISTRACTION INTRNL EXTN RIGID ACT ARM20 MM T 6L 4V QT001 EA,SUP-2679178,CDM,C1713,HCPCS,0278,RC,,,,both,,,2965.48,1927.56,,,,,,,,,,,,,
PLATE BONE LEFORT 1.5X6 MM MIDFACE ADVANCEMENT FOR SCREW TITANIUM,SUP-2754965,CDM,C1713,HCPCS,0278,RC,,,,both,,,731.62,475.55,,,,,,,,,,,,,
CATHETER CTRL VEN L28CM OD12FR TIP L23CM POLYUR 3 LUMN HCKMN,SUP-2127762,CDM,C1751,HCPCS,0278,RC,,,,both,,,1824.34,1185.82,,,,,,,,,,,,,
PORT ACCS BVL 26 MM,SUP-2433828,CDM,2720000010,LOCAL,0272,RC,,,,both,,,722.20,469.43,,,,,,,,,,,,,
PLATE BNE Y LNG 1.5 MM NEURO LP FOR SCREW TI NS LEVEL 1 LF,SUP-2470292,CDM,C1713,HCPCS,0278,RC,,,,both,,,644.89,419.18,,,,,,,,,,,,,
"HC Gbl New Pt, E/M Level 4",PX-9829920400,CDM,99204,CPT,0982,RC,,,,outpatient,,,654.00,425.10,,,,,,,,,,,,,
PLATE BONE MESH SCREEN 1.3X20X30X0.2 MM TITANIUM,SUP-2838349,CDM,C1713,HCPCS,0278,RC,,,,both,,,740.73,481.47,,,,,,,,,,,,,
TWIST DRILL 2.2MM DIA X 70MM CYLINDRICAL,SUP-2491655,CDM,2720000010,LOCAL,0272,RC,,,,both,,,405.09,263.31,,,,,,,,,,,,,
ALLOGRAFT BNE 10 CC BONEPLAST,SUP-2424581,CDM,C1713,HCPCS,0278,RC,,,,both,,,2546.54,1655.25,,,,,,,,,,,,,
PLATE BNE DBL T MINI 2X1 MM CRANIOMAXILLOFACIAL 8 HOLE TI NS,SUP-2493421,CDM,C1713,HCPCS,0278,RC,,,,both,,,524.38,340.85,,,,,,,,,,,,,
PLATE BNE THK15MM REG 6 H LOK ANG FOR 27MM SCR THREADLOCK,SUP-2262969,CDM,C1713,HCPCS,0278,RC,,,,both,,,2578.94,1676.31,,,,,,,,,,,,,
GRAFT L SEG RECON TISS FRZN PELV ILIUM WHL L,SUP-2307411,CDM,C1713,HCPCS,0278,RC,,,,both,,,21021.64,13664.07,,,,,,,,,,,,,
COIL NEUROVASCULAR HYDROSOFT L 2 CM LOOP DIA1.5 MM,SUP-2305281,CDM,C1889,HCPCS,0278,RC,,,,both,,,5275.20,3428.88,,,,,,,,,,,,,
SPHINCTEROTOME ENDOSCP CANN 5 MM 4.4 FRX20 MM TRUETOME 44,SUP-2141621,CDM,2720000010,LOCAL,0272,RC,,,,both,,,693.06,450.49,,,,,,,,,,,,,
CAGE SPNL STAND ALONE C 3D PRNT TECHNOLOGY SCR INTEGR DESIGN,SUP-2935294,CDM,C1713,HCPCS,0278,RC,,,,both,,,7222.00,4694.30,,,,,,,,,,,,,
SPLINT WRST FA L INSTABILITY INJ 8IN IMMOB LOOP LOK ABDUCTED,SUP-2276632,CDM,L3809,HCPCS,0274,RC,,,,both,,,22.33,14.51,,,,,,,,,,,,,
DEFIBRILLATOR CARD 30.5CC W6.17XH6.90CM D0.99CM VR CONN DF4,SUP-2149196,CDM,C1722,HCPCS,0275,RC,,,,both,,,37234.12,24202.18,,,,,,,,,,,,,
CATHETER BAL DIL L17MM DIA7MM 70DEG ELECTROMAGNETIC FRONTAL,SUP-2284117,CDM,C1713,HCPCS,0278,RC,,,,both,,,3389.00,2202.85,,,,,,,,,,,,,
PHENYLEPHRINE HCL 10 % OP SOLN,RX-19636,CDM,6370000000,HCPCS,0637,RC,70756-0614-30,NDC,,both,5,ML,180.00,117.00,,,,,,,,,,,,,
PLATE CRAN XL PEEK NS DISP ACCUSHAPE,SUP-2936894,CDM,C1713,HCPCS,0278,RC,,,,both,,,30772.00,20001.80,,,,,,,,,,,,,
GRAFT BNE FRSH STORED REFRIGERATED L LAT FEM HEMICONDYLE,SUP-2335302,CDM,C1713,HCPCS,0278,RC,,,,both,,,24649.00,16021.85,,,,,,,,,,,,,
CEMENT BNE SLO CURING RADIOPAQUE GENTAMICIN PALACOS,SUP-2602137,CDM,C1713,HCPCS,0278,RC,,,,both,,,2041.00,1326.65,,,,,,,,,,,,,
ARM EXT FIX LNG ARTC 3 ARTH FOR SIDEKCK STLTH REARFOOT FIX,SUP-2400634,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2226.26,1447.07,,,,,,,,,,,,,
IMPLANT TISSUE CONNECTIVE PASTE MED,SUP-2880205,CDM,C1762,CPT,0278,RC,,,,both,,,11285.16,7335.35,,,,,,,,,,,,,
GRAFT VASC IMPRA L 40 CM DIA 6-4 MM EPTFE SHRT TAPR,SUP-2126767,CDM,C1768,CPT,0278,RC,,,,both,,,2214.39,1439.35,,,,,,,,,,,,,
COIL EMB L1CM DIA2MM 0010IN NYL DETACH 3D SFT STRTCH,SUP-2173062,CDM,C1889,HCPCS,0278,RC,,,,both,,,4618.94,3002.31,,,,,,,,,,,,,
INSTRUMENT KIT PLN PT SPEC MAND RECON,SUP-2860252,CDM,2720000010,LOCAL,0272,RC,,,,both,,,13922.13,9049.38,,,,,,,,,,,,,
SCREW BNE CANN 6.5X90 MM COMPR FT TI STRL 04355790S,SUP-2787799,CDM,C1713,HCPCS,0278,RC,,,,both,,,1136.68,738.84,,,,,,,,,,,,,
DILATOR SURG DISP FOR ERECTILE REST 4 PK,SUP-2138905,CDM,C1713,HCPCS,0278,RC,,,,both,,,800.70,520.45,,,,,,,,,,,,,
CATHETER EP CSL 2-8-2 MM 6 FRX65 CM RESPON,SUP-2356827,CDM,C1730,HCPCS,0272,RC,,,,both,,,1227.74,798.03,,,,,,,,,,,,,
NEEDLE BRACHYTHERAPY L20CM OD18GA APPL BRACHYSTAR,SUP-2129080,CDM,C1715,HCPCS,0272,RC,,,,both,,,351.68,228.59,,,,,,,,,,,,,
PLATE BNE L 138 X W 10.9 MM THK 3.4 MM SCREW DIA 3.5 MM 10 H 72463810N,SUP-2933425,CDM,C1713,HCPCS,0278,RC,,,,both,,,5584.65,3630.02,,,,,,,,,,,,,
PLATE BNE L 146 MM 12 H SS RADIAL SHFT STRL EVOS,SUP-2933112,CDM,C1713,HCPCS,0278,RC,,,,both,,,3290.09,2138.56,,,,,,,,,,,,,
GUIDEWIRE ORTH L100MM DIA0.8MM S STL FOR 2.4MM CANN SCR SYS,SUP-2186881,CDM,C1769,HCPCS,0272,RC,,,,both,,,367.51,238.88,,,,,,,,,,,,,
REAMER SURG OD9.5MM FULL FLUT,SUP-2256781,CDM,2720000010,LOCAL,0272,RC,,,,both,,,587.18,381.67,,,,,,,,,,,,,
COLLAR HUM DIA40MM ECC SUT FOR SHLDR ARTHROPLASTY SYS GLOB,SUP-2249860,CDM,C1713,HCPCS,0278,RC,,,,both,,,1401.70,911.10,,,,,,,,,,,,,
CATHETER HD SWAN NK 62.5 CM MONCRIEF-POPOVICH CURL CATH ARGY,SUP-2626975,CDM,C1750,HCPCS,0278,RC,,,,both,,,578.58,376.08,,,,,,,,,,,,,
PLATE BONE RECONSTRUCTION 3.5X82 MM 7 HOLE FOR SCREW STERILE,SUP-2836652,CDM,C1713,HCPCS,0278,RC,,,,both,,,2966.61,1928.30,,,,,,,,,,,,,
CATHETER ETER URET TORQUEABLE C2 TIP 5FRX65CM IMAGER II,SUP-2139302,CDM,C1758,HCPCS,0278,RC,,,,both,,,54.38,35.35,,,,,,,,,,,,,
ELECTRODE KIT EMG SSEP NDL SAFEOP,SUP-2736620,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
HINGE EXT FIX LCK,SUP-2749935,CDM,2720000010,LOCAL,0272,RC,,,,both,,,932.58,606.18,,,,,,,,,,,,,
TUBE TRACHEOSTOMY STAINLES ADULT RIGID ORIGINAL NECK FLANGE,SUP-2793422,CDM,2720000010,LOCAL,0272,RC,,,,both,,,251.64,163.57,,,,,,,,,,,,,
PLATE BNE MINI 15 MM MIDFOOT 4 HOLE MOTOBAND CP SCP,SUP-2866408,CDM,C1713,HCPCS,0278,RC,,,,both,,,3312.70,2153.25,,,,,,,,,,,,,
SCREW SPNL L12MM DIA4MM MINI CANC POST OCCIPITAL CERV THOR,SUP-2254393,CDM,C1713,HCPCS,0278,RC,,,,both,,,2923.34,1900.17,,,,,,,,,,,,,
OCCLUDER CV WATCHMAN NIT POLYETHYL TEREPHTHALATE PTFE PEBAX,SUP-2142003,CDM,C1894,HCPCS,0272,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9 % IV BOLUS,RX-103555,CDM,J7030,HCPCS,0250,RC,00338-0049-04,NDC,,both,250,ML,10.70,6.95,,,,,,,,,,,,,
FOLLOWER URETH 12FR L35.5CM DIL W/O SIDEPRT PHILIPS,SUP-2171273,CDM,2720000010,LOCAL,0272,RC,,,,both,,,106.70,69.35,,,,,,,,,,,,,
GUN BONE CEM REVOLUTION,SUP-2361483,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2272.42,1477.07,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9 % IV BOLUS,RX-103555,CDM,2580000003,HCPCS,0258,RC,00264-1800-32,NDC,,both,250,ML,57.40,37.31,,,,,,,,,,,,,
SCREW BNE L22MM DIA2.3MM CORT NONTOGGLING FOR VOLAR DST RAD,SUP-2107556,CDM,C1713,HCPCS,0278,RC,,,,both,,,276.32,179.61,,,,,,,,,,,,,
MATRIX BIO L 20 X W 7 CM FISH SKIN DERMAL INTACT MARIGEN 10/BX,SUP-2909388,CDM,Q4158,HCPCS,0636,RC,,,,both,,,21983.14,14289.04,,,,,,,,,,,,,
SHUTTLE SUT 90DEG UP CHIA IDEAL,SUP-2256804,CDM,2720000010,LOCAL,0272,RC,,,,both,,,960.84,624.55,,,,,,,,,,,,,
WIRE SMOOTH 0.62X9IN K,SUP-2303780,CDM,C1713,HCPCS,0278,RC,,,,both,,,17.84,11.60,,,,,,,,,,,,,
SET LD INTRO PEELWY L 30 CM OD 14 FR GUIDEWIRE 0.038 IN,SUP-2167898,CDM,C1892,HCPCS,0272,RC,,,,both,,,194.68,126.54,,,,,,,,,,,,,
MODEL ANAT RECON VIRTUAL PLN NO GUIDE VSP,SUP-2883528,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7536.00,4898.40,,,,,,,,,,,,,
SHEATH INTRO 22FR L28CM ID 7.5MM GORE DRYSEAL,SUP-2396259,CDM,C1894,HCPCS,0272,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
BASKET RETRIEVAL HELICAL PLYP 3X6CM,SUP-2736180,CDM,2720000010,LOCAL,0272,RC,,,,both,,,948.28,616.38,,,,,,,,,,,,,
GUIDEWIRE VASC L180CM DIA0.035IN TAPR L7CM FLPY TIP L3CM,SUP-2167925,CDM,C1769,HCPCS,0272,RC,,,,both,,,76.02,49.41,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9 % IV BOLUS,RX-103555,CDM,J7040,HCPCS,0258,RC,00264-7800-10,NDC,,both,250,ML,14.90,9.68,,,,,,,,,,,,,
MESH SURG W6XL10IN OVL W/ ECHO PS POS SYS FOR LAP VENTRAL,SUP-2125916,CDM,C1781,HCPCS,0278,RC,,,,both,,,3881.04,2522.68,,,,,,,,,,,,,
PASSER SURG L 36 CM DISP,SUP-2883600,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1850.59,1202.88,,,,,,,,,,,,,
BELT ORTHOT RIB THOR CUST FABRICATED,SUP-2435536,CDM,L0220,HCPCS,0272,RC,,,,both,,,365.75,237.74,,,,,,,,,,,,,
PLATE BONE L194MM 20 H MAND TI STR LCK COMPR RECON FOR 2.4MM,SUP-2191428,CDM,C1713,HCPCS,0278,RC,,,,both,,,5508.19,3580.32,,,,,,,,,,,,,
GUIDEWIRE ORTH ANGLED PROP FOR 3.5/5 MM PLATE,SUP-2644636,CDM,C1769,HCPCS,0272,RC,,,,both,,,1214.55,789.46,,,,,,,,,,,,,
STABILIZER SHLDR SM UNIV HARN ARM BND FOR FOOTBALL PLAYER,SUP-2150933,CDM,L3660,HCPCS,0274,RC,,,,both,,,325.93,211.85,,,,,,,,,,,,,
SCREW BONE L60MM DIA6.7MM THRD L18MM FT ANK TI CANN LO PROF,SUP-2123175,CDM,C1713,HCPCS,0278,RC,,,,both,,,1124.12,730.68,,,,,,,,,,,,,
IMPLANT NSL 17 X 13 X 3 MM OVL PERF 2PC MAGNETICALLY COUPLED,SUP-2887847,CDM,C1889,HCPCS,0278,RC,,,,both,,,910.60,591.89,,,,,,,,,,,,,
STEM FEM L200MM CO CHROM MOLYBDENUM POREX CEM MOD ENDO MOD,SUP-2265095,CDM,C1776,CPT,0278,RC,,,,both,,,19986.10,12990.96,,,,,,,,,,,,,
STEM MOD REMEDY LNG SM 227MM,SUP-2319836,CDM,C1776,CPT,0278,RC,,,,both,,,5495.00,3571.75,,,,,,,,,,,,,
ELECTRODE SUBDERM NDL L 18 MM CABLE L 2 M 4 CHANNEL PRASS PR,SUP-2902062,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1030.23,669.65,,,,,,,,,,,,,
PROSTHESIS 9MM PENILE MAL GEN,SUP-2165394,CDM,C1813,HCPCS,0278,RC,,,,both,,,22438.44,14584.99,,,,,,,,,,,,,
PLATE BONE 3D PRNT MIDFACE MAND TI TRUMATCH,SUP-2860374,CDM,C1713,HCPCS,0278,RC,,,,both,,,36785.73,23910.72,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9 % IV BOLUS,RX-103555,CDM,J7050,HCPCS,0258,RC,00264-7800-20,NDC,,both,250,ML,23.40,15.21,,,,,,,,,,,,,
BIT DRL CANN 5X150 MM,SUP-2606631,CDM,2720000010,LOCAL,0272,RC,,,,both,,,604.45,392.89,,,,,,,,,,,,,
SHUNT PERI SM DST CATH L120CM INCL STRATA II VLV,SUP-2284561,CDM,2720000010,LOCAL,0272,RC,,,,both,,,12562.89,8165.88,,,,,,,,,,,,,
PATCH HERN L DIA3.2IN CIR W/ STRP SEPRA TECHNOLOGY ABSRB,SUP-2125893,CDM,C1781,HCPCS,0278,RC,,,,both,,,1683.98,1094.59,,,,,,,,,,,,,
BLADE RETRACTOR KARLIN 4 IN 0.75 IN CRANK,SUP-2864706,CDM,2720000010,LOCAL,0272,RC,,,,both,,,885.57,575.62,,,,,,,,,,,,,
JOINT TOE 1ST MTP 16 MM HA COAT ENCOMPASS LTX,SUP-2857529,CDM,C1776,CPT,0278,RC,,,,both,,,9407.44,6114.84,,,,,,,,,,,,,
HC Attendace at Delivery,PX-7229946400,CDM,99464,CPT,0722,RC,,,,inpatient,,,227.00,147.55,,,,,,,,,,,,,
OMEPRAZOLE 2 MG/ML PO SUSP,RX-4081109,CDM,6370000000,HCPCS,0637,RC,09999-9904-27,NDC,,both,5,ML,5.70,3.70,,,,,,,,,,,,,
PIN FIX TROCAR PT 1 END 3/32X9 IN 1 PT STYL SMOOTH PLN STRL,SUP-2150450,CDM,C1713,HCPCS,0278,RC,,,,both,,,13.35,8.68,,,,,,,,,,,,,
BONE MARROW KIT MED BIO ART BMC,SUP-2163082,CDM,C1830,HCPCS,0278,RC,,,,both,,,10833.00,7041.45,,,,,,,,,,,,,
CATHETER CARD ABLATION RF MARINR L 80 CM DIA 5 FR TIP L 65,SUP-2749546,CDM,C1732,HCPCS,0278,RC,,,,both,,,1491.50,969.47,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9 % IV BOLUS|DISCARDED DRUG NOT ADMINISTE,RX-103555,CDM,2580000003,HCPCS,0258,RC,00338-0049-04,NDC,JW,both,250,ML,10.70,6.95,,,,,,,,,,,,,
FORCEPS BPLR BAYNT 7IN IRR NONSTICK COHEN,SUP-2858213,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
BIT DRL DIA2.7MM TWST FOR INTMED OSTEOTMY SYS,SUP-2343752,CDM,2720000010,LOCAL,0272,RC,,,,both,,,303.51,197.28,,,,,,,,,,,,,
RIVASTIGMINE TARTRATE 1.5 MG PO CAPS,RX-28278,CDM,6370000000,HCPCS,0637,RC,33342-0089-09,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
HC Blood Type Antigen Donor Ea,PX-3008690200,CDM,86902,CPT,0300,RC,,,,both,,,153.00,99.45,,,,,,,,,,,,,
FOOTRING EXT FIX SHT TENXOR CP49360128,SUP-2530922,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6800.61,4420.40,,,,,,,,,,,,,
MESH BONE 126MMW X 126MML 1MM THK RSRB XG SM GRID LATEX FREE,SUP-2487541,CDM,C1713,HCPCS,0278,RC,,,,both,,,8438.81,5485.23,,,,,,,,,,,,,
SIZER SURG BRST SMOOTH HI PROF X SILTEX MEMORYGEL,SUP-2748644,CDM,2720000010,LOCAL,0272,RC,,,,both,,,769.30,500.04,,,,,,,,,,,,,
STAPLER INT L45IN S STL AUTO PLCMNT 2-0 SUT SURGDAC DISP,SUP-2283035,CDM,2720000010,LOCAL,0272,RC,,,,both,,,375.51,244.08,,,,,,,,,,,,,
MARKER BRST BX IDENTIFIER SITE COMPATIBLE FOR STEREOTACTIC,SUP-2240033,CDM,A4648,CPT,0278,RC,,,,both,,,200.18,130.12,,,,,,,,,,,,,
SCREW BNE L 105 MM DIA 3.5 MM SS CORTICAL ST STRL EVOS,SUP-2931880,CDM,C1713,HCPCS,0278,RC,,,,both,,,118.94,77.31,,,,,,,,,,,,,
DEFIBRILLATOR IMPL ALTRUA 60 TI SINGLE CHMBR BATTERY PWR,SUP-2149104,CDM,C1786,HCPCS,0275,RC,,,,both,,,12246.00,7959.90,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE LG 11 CC CORTICOCANCELLOUS VIABLE 003,SUP-2936805,CDM,C1762,CPT,0278,RC,,,,both,,,11321.90,7359.23,,,,,,,,,,,,,
SCREW BNE L40MM DIA4MM CORT TIB TALAR FUS TIBIAXYS,SUP-2243002,CDM,C1713,HCPCS,0278,RC,,,,both,,,900.96,585.62,,,,,,,,,,,,,
BLADE REPROC M4 TURBINATE INFERIOR,SUP-2526000,CDM,2720000010,LOCAL,0272,RC,,,,both,,,442.27,287.48,,,,,,,,,,,,,
PLATE SPNL L24MM ANT CERV TI LEV 2 REFLX,SUP-2380858,CDM,C1713,HCPCS,0278,RC,,,,both,,,2794.60,1816.49,,,,,,,,,,,,,
POST STR OUTRIG 11MM,SUP-2188507,CDM,2720000010,LOCAL,0272,RC,,,,both,,,260.62,169.40,,,,,,,,,,,,,
WEDGE TIB SZ 2.5 THK10MM KNEE STP CEM MOD + PFC,SUP-2253294,CDM,C1776,CPT,0278,RC,,,,both,,,3759.21,2443.49,,,,,,,,,,,,,
SCREW TENODESIS BICEP BICEPTOR BIOSURE PK 9MM X 15MM,SUP-2341823,CDM,C1713,HCPCS,0278,RC,,,,both,,,816.40,530.66,,,,,,,,,,,,,
IMPLANT OP RM TISS 12 X 6MM CALCANEO CUBOID JT WDG,SUP-2321657,CDM,C1776,CPT,0278,RC,,,,both,,,8792.00,5714.80,,,,,,,,,,,,,
BRACE ANK SM H875IN L SEMI RIG ANATOMICALLY DESIGNED SHELL,SUP-2196369,CDM,L4350,HCPCS,0274,RC,,,,both,,,61.80,40.17,,,,,,,,,,,,,
IMPLANT OPHTH RND 7.5X80 MM SPNG SIL,SUP-2263416,CDM,L8610,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
GRAFT BONE SUB 5CC CA PHOS SYNTH PUTTY FIL IMPACTION FRMLA,SUP-2319790,CDM,C1713,HCPCS,0278,RC,,,,both,,,4011.51,2607.48,,,,,,,,,,,,,
SCREW ACET EXTRACT REMOVAL 8 MM,SUP-2453035,CDM,C1713,HCPCS,0278,RC,,,,both,,,1491.50,969.47,,,,,,,,,,,,,
PLATE BNE BROAD 4.5X251 MM 14 HOLE SS LCP,SUP-2569367,CDM,C1713,HCPCS,0278,RC,,,,both,,,778.88,506.27,,,,,,,,,,,,,
STEM FEM L210MM OD22.5MM 005 TI HX COAT HIP CEMENTLESS 03,SUP-2397013,CDM,C1776,CPT,0278,RC,,,,both,,,14287.00,9286.55,,,,,,,,,,,,,
CATHETER DRAINAGE 8.5 FRX40 CM BILI MAC LOC LOOP UTHANE,SUP-2168530,CDM,C1729,HCPCS,0272,RC,,,,both,,,523.60,340.34,,,,,,,,,,,,,
PLATE BNE THK 0.3 MM SCREW DIA1.5 MM XS TRNS NS DISP,SUP-2936892,CDM,C1713,HCPCS,0278,RC,,,,both,,,3457.14,2247.14,,,,,,,,,,,,,
HC So Ferritin|NOT REASONABLE AND NECESSARY,PX-3018272866,CDM,82728,CPT,0301,RC,,,GZ,both,,,79.00,51.35,,,,,,,,,,,,,
WIRE BRST LOC L15CM NDL 20GA L5CM N REPOSITIONAL BARB STIFF,SUP-2126457,CDM,C1819,HCPCS,0278,RC,,,,both,,,51.78,33.66,,,,,,,,,,,,,
BISOPROLOL FUMARATE 5 MG PO TABS,RX-18288,CDM,6370000000,HCPCS,0637,RC,29300-0126-13,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PLATE BNE LG LAT LEN NS,SUP-2534747,CDM,C1713,HCPCS,0278,RC,,,,both,,,2244.75,1459.09,,,,,,,,,,,,,
PLATE BONE L208MM 12 H S STL T SHP BTTRS LO PROF RIG,SUP-2185762,CDM,C1713,HCPCS,0278,RC,,,,both,,,2091.49,1359.47,,,,,,,,,,,,,
PLATE BONE LNG PROX HUM S STL FOR 3.5MM SCR SM FRAG SYS LCP,SUP-2177063,CDM,C1713,HCPCS,0278,RC,,,,both,,,23769.89,15450.43,,,,,,,,,,,,,
BAG EXT DRNGE ANTIREFLX VLV NDL FREE SAMP SITE HYDROPHOBIC,SUP-2244107,CDM,C1729,HCPCS,0272,RC,,,,both,,,666.59,433.28,,,,,,,,,,,,,
FIBER LASER 600UM DISP FLAT TIP HOLM 10X SINGLEFLEX,SUP-2213048,CDM,C1713,HCPCS,0278,RC,,,,both,,,1061.32,689.86,,,,,,,,,,,,,
TR-28 HIP PROTRUSIO RNG 58MM,SUP-2203819,CDM,C1776,CPT,0278,RC,,,,both,,,1318.80,857.22,,,,,,,,,,,,,
KIT CBL AD PUSHBUTTON HD FOR LO LIMB PAIN NEUROSTIM AXIUM,SUP-2357681,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1419.56,922.71,,,,,,,,,,,,,
PLATE BNE L226MM 12 H ST R LAT PROX TIB S STL LOK COMPR LO,SUP-2185723,CDM,C1713,HCPCS,0278,RC,,,,both,,,4752.20,3088.93,,,,,,,,,,,,,
PIN FIX L9IN DIA32MM NONSTERILE S STL 3 SIDE SGL TRCR 1,SUP-2150445,CDM,C1713,HCPCS,0278,RC,,,,both,,,64.87,42.17,,,,,,,,,,,,,
COMPONENT FEM L80MM R KNEE CONN PC GMRS,SUP-2376553,CDM,C1713,HCPCS,0278,RC,,,,both,,,10533.92,6847.05,,,,,,,,,,,,,
MESH HERNIAXL W7XL9IN OBLONG OVL ABD O3FA COAT POLYPR STR,SUP-2265987,CDM,C1781,HCPCS,0278,RC,,,,both,,,2791.46,1814.45,,,,,,,,,,,,,
HC Assay of Haptoglobin Quantitative,PX-3018301000,CDM,83010,CPT,0301,RC,,,,both,,,339.00,220.35,,,,,,,,,,,,,
KIT OSIA 2 SOUND PROCESSOR,SUP-2858185,CDM,L8690,HCPCS,0278,RC,,,,both,,,12983.90,8439.53,,,,,,,,,,,,,
KIT GUIDEPIN DIA2MM DISP FOR TEMP FIX,SUP-2123520,CDM,2720000010,LOCAL,0272,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
PLATE BNE RECON 3.5X98 MM 7 HOLE SS LCP,SUP-2569391,CDM,C1713,HCPCS,0278,RC,,,,both,,,404.12,262.68,,,,,,,,,,,,,
PLATE SPNL EXPANDABLE SM PROC AILERON-TRX,SUP-2430758,CDM,C1713,HCPCS,0278,RC,,,,both,,,8792.00,5714.80,,,,,,,,,,,,,
RADIAL HD INSRT KIT; CONTENTS: CO CHROM TRL HD STEM INSTR,SUP-2397254,CDM,C1776,CPT,0278,RC,,,,both,,,11633.70,7561.90,,,,,,,,,,,,,
HC Gastrostomy Tube Change W Flouro,PX-3614945000,CDM,49450,CPT,0361,RC,,,,inpatient,,,1056.00,686.40,,,,,,,,,,,,,
ROD GUIDE ALIGN SET PROPHECY,SUP-2304848,CDM,C1776,CPT,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
NAIL IM L28CM DIA7MM L MED LAT FEM LOK CANN RG FOR SUPCNDYL,SUP-2318915,CDM,C1713,HCPCS,0278,RC,,,,both,,,7279.78,4731.86,,,,,,,,,,,,,
SCREW BNE L70MM DIA65MM THRD L15MM LO PROF HD COMPR,SUP-2315947,CDM,C1713,HCPCS,0278,RC,,,,both,,,1116.27,725.58,,,,,,,,,,,,,
IMMOBILIZER ORTHOPEDIC CUT AWAY UNIV 16 IN 14-29 IN KNEE,SUP-2428783,CDM,L1830,CPT,0272,RC,,,,both,,,28.04,18.23,,,,,,,,,,,,,
HC So Vitamin Nos,PX-3018459166,CDM,84591,CPT,0301,RC,,,,both,,,116.00,75.40,,,,,,,,,,,,,
PLATE BNE L210MM BLDE W4.8XL25MM 95DEG 12 H ST HIP S STL,SUP-2186757,CDM,C1713,HCPCS,0278,RC,,,,both,,,3392.08,2204.85,,,,,,,,,,,,,
BIT DRL 25X60 MM FOR SALVATION 3DI PLATING SYS DISP,SUP-2401182,CDM,2720000010,LOCAL,0272,RC,,,,both,,,530.66,344.93,,,,,,,,,,,,,
BUSHING TIB STD AXLE STD ASMBLY PK STRL TRIATHLON,SUP-2889782,CDM,C1776,CPT,0278,RC,,,,both,,,7719.06,5017.39,,,,,,,,,,,,,
DRILL TWST DIA1.8 MM STP 6 MM SCREW DIA 5-6 MM CHK NS DISP,SUP-2883220,CDM,2720000010,LOCAL,0272,RC,,,,both,,,322.16,209.40,,,,,,,,,,,,,
FORCEPS ES AD PED L9IN DIA15MM 2 IRRIG BPLR NONCORDED,SUP-2364932,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1191.44,774.44,,,,,,,,,,,,,
FORCEP SPEC RETRV STONE 3 FRX120 CM RETRACTING PRNG TRICEP,SUP-2473736,CDM,2720000010,LOCAL,0272,RC,,,,both,,,538.86,350.26,,,,,,,,,,,,,
SCREW INTFR L30MM DIA8MM KNEE FULL THRD RND HD FOR ACL FIX,SUP-2136090,CDM,C1713,HCPCS,0278,RC,,,,both,,,1244.95,809.22,,,,,,,,,,,,,
K WIRE FXTN L95MM D0.9MM CBLT CHRME MAX VPC SCREW SSTM,SUP-2467869,CDM,C1713,HCPCS,0278,RC,,,,both,,,82.24,53.46,,,,,,,,,,,,,
DILATOR ENDO 36FR L180CM BAL L8CM ESOPH PET DISP ELIM,SUP-2166034,CDM,C1726,HCPCS,0272,RC,,,,both,,,279.46,181.65,,,,,,,,,,,,,
GRAFT BIO TISS W8XL12CM MESHED FET BOV ACELLULAR DERM MTRX,SUP-2243706,CDM,Q4110,HCPCS,0636,RC,,,,both,,,10048.00,6531.20,,,,,,,,,,,,,
PLATE BNE W10XL67MM THK1.2MM 90DEG 3X5 H BILAT S STL T SHP,SUP-2185869,CDM,C1713,HCPCS,0278,RC,,,,both,,,1112.35,723.03,,,,,,,,,,,,,
IMPLANT SPNL 35X27MM NM 14MM 10 DEG,SUP-2245145,CDM,C1713,HCPCS,0278,RC,,,,both,,,18902.80,12286.82,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 120 MM DIA22 MM DEL SHTH,SUP-2934230,CDM,C1713,HCPCS,0278,RC,,,,both,,,17975.24,11683.91,,,,,,,,,,,,,
ELECTRODE ELECSURG HK 5 MX33 CM MONOPOLAR PARTIALLY INSUL,SUP-2496707,CDM,2720000010,LOCAL,0272,RC,,,,both,,,582.60,378.69,,,,,,,,,,,,,
TM SHIM 5 DEGREE,SUP-2501805,CDM,C1776,CPT,0278,RC,,,,both,,,2059.84,1338.90,,,,,,,,,,,,,
HC Clsd Tx MC Fx Manipulation,PX-4502660500,CDM,26605,CPT,0450,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
GRAFT HUM TISS W2XL4CM THK0.1-0.2MM AMNIO MEM 2 LAYR,SUP-2370450,CDM,Q4150,HCPCS,0636,RC,,,,both,,,4747.68,3085.99,,,,,,,,,,,,,
BIT DRL 2X200 MM K WIRE VARIAX,SUP-2537991,CDM,2720000010,LOCAL,0272,RC,,,,both,,,686.03,445.92,,,,,,,,,,,,,
CARVEDILOL 12.5 MG PO TABS,RX-15749,CDM,6370000000,HCPCS,0637,RC,00904-7307-61,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
GRAFT BIO W25XL13CM THK2MM NONDENATURED BOV CLLGN RECTANG,SUP-2243683,CDM,C9360,HCPCS,0278,RC,,,,both,,,18369.00,11939.85,,,,,,,,,,,,,
PLATE BONE L80MM THK3.4MM 5 H BILAT NONLOCKING COMPR FOR,SUP-2348948,CDM,C1713,HCPCS,0278,RC,,,,both,,,1367.56,888.91,,,,,,,,,,,,,
SCREW BNE L30MM DIA3.5MM HD 2.7MM S STL CORT PERIARTC ST,SUP-2410681,CDM,C1713,HCPCS,0278,RC,,,,both,,,107.64,69.97,,,,,,,,,,,,,
TIP ULTRASONIC EXT MACR CVD CUSA 23KHZ,SUP-2243957,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2339.30,1520.54,,,,,,,,,,,,,
PIN FIX DBL TROCAR 0.177X9 IN SS NS STEINMANN,SUP-2791346,CDM,C1713,HCPCS,0278,RC,,,,both,,,38.12,24.78,,,,,,,,,,,,,
PLATE VA-LOCKING CALCANEAL 2.7MM SMALL 58MM LEFT-STERILE,SUP-2546124,CDM,C1713,HCPCS,0278,RC,,,,both,,,3313.11,2153.52,,,,,,,,,,,,,
COMPONENT CRANIOFACIAL COMPLX + PEEK,SUP-2862814,CDM,C1713,HCPCS,0278,RC,,,,both,,,48883.58,31774.33,,,,,,,,,,,,,
IMPLANT TISS FIX ADJ LOOP BTTN STRL PROCINCH QUADCINCH,SUP-2908646,CDM,C1713,HCPCS,0278,RC,,,,both,,,1544.88,1004.17,,,,,,,,,,,,,
PLATE BNE L 257 MM SCREW DIA 4.5 MM 14 H NAR COMPR NLCK NS,SUP-2933676,CDM,C1713,HCPCS,0278,RC,,,,both,,,2689.10,1747.91,,,,,,,,,,,,,
HEAD FEM DISASSEMBLY HIP ATTCH PLAS,SUP-2440396,CDM,C1776,CPT,0278,RC,,,,both,,,692.37,450.04,,,,,,,,,,,,,
PLATE BONE LOK HLX26 25MM THK TTNM ANGLD RCNSTRCTN NON BRDG,SUP-2679035,CDM,C1713,HCPCS,0278,RC,,,,both,,,8295.94,5392.36,,,,,,,,,,,,,
PLATE BNE LINDORF LEFORT MIC 1.5X3X1 MM LT TI LEVEL 1,SUP-2262906,CDM,C1713,HCPCS,0278,RC,,,,both,,,907.90,590.13,,,,,,,,,,,,,
LEAD DEFIB PROTEGO SD L 65 CM TIP DISTANCE 16 CM PTIR,SUP-2138428,CDM,C1896,HCPCS,0275,RC,,,,both,,,8792.00,5714.80,,,,,,,,,,,,,
ANCHOR SUT DIA5.5MM NO2 TWINFIX PK FT W/ 3 WHT COBRAID BLU,SUP-2341785,CDM,C1713,HCPCS,0278,RC,,,,both,,,1092.72,710.27,,,,,,,,,,,,,
SPHERE OPHTH DIA21MM BIOCOMPATIBLE W/ INSRT MEDPOR,SUP-2366489,CDM,C1713,HCPCS,0278,RC,,,,both,,,1714.44,1114.39,,,,,,,,,,,,,
MARKER SURG FOR ATEC SECURMARK,SUP-2240034,CDM,A4648,CPT,0278,RC,,,,both,,,222.94,144.91,,,,,,,,,,,,,
SUPPORT EXT FIX U 200 MM TRAUM STRL TRUELOK LTX,SUP-2875380,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3852.65,2504.22,,,,,,,,,,,,,
UPCHARGE BLUEPRINT GUIDE GLEN,SUP-2388597,CDM,C1776,CPT,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
WASHER ORTH SPIK 8 MM BOLT OSS,SUP-2441746,CDM,C1713,HCPCS,0278,RC,,,,both,,,408.36,265.43,,,,,,,,,,,,,
STEM HUM L160MM DIA6MM UNIV SHLDR CO CHROME NONCOATED CEM,SUP-2249918,CDM,C1776,CPT,0278,RC,,,,both,,,13794.02,8966.11,,,,,,,,,,,,,
SPACER SPNL 10X26MM 8 TO 12MM 8DEG ALTERA,SUP-2228780,CDM,C1821,HCPCS,0278,RC,,,,both,,,16485.00,10715.25,,,,,,,,,,,,,
SPLINT WRST FA AD L11IN UNIV BLU CANVS TRICOT LNR STRP ON,SUP-2194375,CDM,L3908,HCPCS,0274,RC,,,,both,,,20.79,13.51,,,,,,,,,,,,,
BUR SURG ACROMIONIZER 3.5X130 MM W/ LAT PROTCT VIO STRL DISP,SUP-2599845,CDM,2720000010,LOCAL,0272,RC,,,,both,,,443.05,287.98,,,,,,,,,,,,,
KIT VENTCULSTMY LUERLOCK HUB APPL DRP GZ SPNG FCPS MRK PEN,SUP-2243738,CDM,C1713,HCPCS,0278,RC,,,,both,,,2358.14,1532.79,,,,,,,,,,,,,
GRAFT VASC ACUSEAL L 10 CM DIA 6 MM EPTFE CBAS HEPARIN 3,SUP-2655618,CDM,C1768,CPT,0278,RC,,,,both,,,1224.60,795.99,,,,,,,,,,,,,
ANCHOR SUT 5.5MM IMPL W/ ORTHOCORD HEALIX ADV BR,SUP-2249434,CDM,C1713,HCPCS,0278,RC,,,,both,,,1560.58,1014.38,,,,,,,,,,,,,
BIT DRILL STOP 90 DEGREE 1.1X13 MM 6 MM FOR SCREWDRIVER NON,SUP-2842079,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1068.23,694.35,,,,,,,,,,,,,
STAPLER INT MULTFI 30-V3 MM DST SER TA,SUP-2174498,CDM,C1713,HCPCS,0278,RC,,,,both,,,2424.08,1575.65,,,,,,,,,,,,,
WIRE GUID TRANSRADIAL HYDRPHLC REG STIFFNESS SHT TAPR STR,SUP-2158672,CDM,C1769,HCPCS,0272,RC,,,,both,,,130.00,84.50,,,,,,,,,,,,,
ALLOGRAFT BNE FIBER SM CORTICAL INCITE,SUP-2538794,CDM,C1889,HCPCS,0278,RC,,,,both,,,2062.98,1340.94,,,,,,,,,,,,,
DARBEPOETIN ALFA 60 MCG/0.3ML IJ SOSY,RX-131225,CDM,J0881,HCPCS,0636,RC,55513-0023-04,NDC,,both,0.3,ML,1370.00,890.50,,,,,,,,,,,,,
SMRT KNE-PSN IQ STM W/HBS,SUP-2879113,CDM,C1776,CPT,0278,RC,,,,both,,,4945.50,3214.57,,,,,,,,,,,,,
AZTREONAM 2 G IJ SOLR,RX-9186,CDM,J0457,HCPCS,0636,RC,00409-0830-11,NDC,,both,1,UN,385.00,250.25,,,,,,,,,,,,,
MICRUSFRAME C 14 STRTCH RESIST COIL CONTENTS 1 DETACH COIL,SUP-2249230,CDM,C1889,HCPCS,0278,RC,,,,both,,,4090.23,2658.65,,,,,,,,,,,,,
PROBE SURG L175MM BALL TIP,SUP-2280152,CDM,2720000010,LOCAL,0272,RC,,,,both,,,610.32,396.71,,,,,,,,,,,,,
VALVE SPEAK PMV 2000,SUP-2433847,CDM,L8501,HCPCS,0272,RC,,,,both,,,324.08,210.65,,,,,,,,,,,,,
PROXILOCK HA TI STEM 9MM 01-220-09241,SUP-2198953,CDM,C1776,CPT,0278,RC,,,,both,,,17326.21,11262.04,,,,,,,,,,,,,
HC Iaad Ia Clostridium Difficile Toxin,PX-3068732400,CDM,87324,CPT,0306,RC,,,,both,,,65.00,42.25,,,,,,,,,,,,,
PLATE BNE COMPR SM 3.5X97 MM 8 HOLE DYN NS DCP LTX,SUP-2861908,CDM,C1713,HCPCS,0278,RC,,,,both,,,407.51,264.88,,,,,,,,,,,,,
MATRIX 1.1MM BIT DRILL/HXC,SUP-2823018,CDM,2720000010,LOCAL,0272,RC,,,,both,,,833.23,541.60,,,,,,,,,,,,,
HC Pt Gait Training Ea 15 Min|OP PT SERVICES|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS,PX-4209711600,CDM,97116,CPT,0420,RC,,,GP|CQ,both,,,164.00,106.60,,,,,,,,,,,,,
PLATE BNE 6 H ANODIZATION TYP II CALCANEAL FLAT LP UNIV ANAT,SUP-2902262,CDM,C1713,HCPCS,0278,RC,,,,both,,,5968.51,3879.53,,,,,,,,,,,,,
COLLAR CERV TRACH OPN ADJ AD 3.25IN 13-16IN M PHIL,SUP-2195170,CDM,L0172,HCPCS,0272,RC,,,,both,,,40.82,26.53,,,,,,,,,,,,,
CATHETER THRMDLTN VLMTRC 75FR LMNX7 110CML CNTNS CRDC OUTPT,SUP-2696591,CDM,2720000010,LOCAL,0272,RC,,,,both,,,815.14,529.84,,,,,,,,,,,,,
SUPPORT ORTHOT HIP CUST ABDUCTN FLX FREJKA TYP W/CVR,SUP-2435595,CDM,L1600,HCPCS,0274,RC,,,,both,,,364.81,237.13,,,,,,,,,,,,,
STEM FEM L150MM DIA12.5MM IM TI POR STR LNG BODY MOD NEUT,SUP-2405800,CDM,C1776,CPT,0278,RC,,,,both,,,4790.07,3113.55,,,,,,,,,,,,,
DILTIAZEM HCL 100 MG IV SOLR,RX-22156,CDM,J1163,HCPCS,0636,RC,00409-4350-13,NDC,,both,1,UN,65.70,42.70,,,,,,,,,,,,,
STENT BILI ABS L 40 MM UNCONSTRAINED DIA10 MM CATH L 80 CM,SUP-2101743,CDM,C1876,HCPCS,0278,RC,,,,both,,,4000.36,2600.23,,,,,,,,,,,,,
GUIDEWIRE VASC GLIDEWIRE GT L 180CM 0.018IN 90 DEG ANGLED,SUP-2385630,CDM,C1769,HCPCS,0272,RC,,,,both,,,619.08,402.40,,,,,,,,,,,,,
BLADE RETRACTOR KOROS 1.25 IN SELF RET,SUP-2444062,CDM,2720000010,LOCAL,0272,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
HC Hepatitis B Surf Antibody Hbsab|NOT REASONABLE AND NECESSARY,PX-3028670600,CDM,86706,CPT,0302,RC,,,GZ,both,,,551.00,358.15,,,,,,,,,,,,,
BIT DRL L 150 MM DIA 3.5 MM AO QC NS REUSE V,SUP-2907760,CDM,2720000010,LOCAL,0272,RC,,,,both,,,718.75,467.19,,,,,,,,,,,,,
SUPPORT WRST XSM L7IN FOR 55IN L HND SUEDE FLANNEL PERF LACE,SUP-2197030,CDM,L3931,HCPCS,0274,RC,,,,both,,,22.61,14.70,,,,,,,,,,,,,
COMPONENT HIP FOR PK 5400,SUP-2212668,CDM,C1776,CPT,0278,RC,,,,both,,,16956.00,11021.40,,,,,,,,,,,,,
PLATE BNE L 148.08 MM THK 1 MM 20 H TI STR NS DISP TRAUMAONE,SUP-2936645,CDM,C1713,HCPCS,0278,RC,,,,both,,,2524.56,1640.96,,,,,,,,,,,,,
BRACE W/ STRNL PD KT COMPLT BLK M CNTOUR TLSO,SUP-2123919,CDM,L0462,HCPCS,0272,RC,,,,both,,,1020.19,663.12,,,,,,,,,,,,,
EXTERNAL FIXATION SET BAR PIN CLMP ASMBLY TEMPFIX,SUP-2484777,CDM,C1713,HCPCS,0278,RC,,,,both,,,268.03,174.22,,,,,,,,,,,,,
HC Pt Orthotic Fit/Train Subsq per 15 Min,PX-4209776300,CDM,97763,CPT,0420,RC,,,,both,,,160.00,104.00,,,,,,,,,,,,,
INTRODUCER SHTH 0.038 IN 6 FRX14 CM DILOCK DIL PEELWY,SUP-2357092,CDM,C1892,HCPCS,0272,RC,,,,both,,,16.96,11.02,,,,,,,,,,,,,
GRAFT BONE SUB 10ML PUTTY BIOLOGIC SPINE SURG BIOACTIVE,SUP-2232313,CDM,C9359,HCPCS,0278,RC,,,,both,,,4490.20,2918.63,,,,,,,,,,,,,
DATOPOTAMAB DERUXTECAN-DLNK 100 MG IV SOLR,RX-170631,CDM,J9011,HCPCS,0636,RC,65597-0801-01,NDC,,both,1,UN,14086.30,9156.09,,,,,,,,,,,,,
CLIP ANEUR BLDE L5MM OPN 4MM CLS FORC 70GM MINI TI CRV TEMP,SUP-2108363,CDM,C1713,HCPCS,0278,RC,,,,both,,,1273.05,827.48,,,,,,,,,,,,,
OBTURATOR ENDO T25,SUP-2287777,CDM,C1713,HCPCS,0278,RC,,,,both,,,975.50,634.07,,,,,,,,,,,,,
HC Cltx Hip Dislocation Traumatic Req Anesthesia,PX-4502725200,CDM,27252,CPT,0450,RC,,,,both,,,4754.00,3090.10,,,,,,,,,,,,,
SCREW ANCHR ORTHODONTIC 2X8 MM 15 MM EXT HK HD TI,SUP-2481001,CDM,C1713,HCPCS,0278,RC,,,,both,,,504.44,327.89,,,,,,,,,,,,,
ESTRADIOL 0.01 % VA CREA,RX-173615,CDM,6370000000,HCPCS,0637,RC,66993-0002-10,NDC,,both,42.5,GR,324.00,210.60,,,,,,,,,,,,,
PIN FIX BUTTRESS 10X24 MM SFC COMBINATION,SUP-2389690,CDM,C1713,HCPCS,0278,RC,,,,both,,,973.40,632.71,,,,,,,,,,,,,
DEXTROSE 5% IV SOLN NEONATE,RX-40840076,CDM,2580000003,HCPCS,0258,RC,00264-1510-32,NDC,,both,100,ML,21.30,13.84,,,,,,,,,,,,,
STAPLER SKIN S STL RELD STPL DISP,SUP-2283075,CDM,2720000010,LOCAL,0272,RC,,,,both,,,337.52,219.39,,,,,,,,,,,,,
CYCLOSPORINE MODIFIED 100 MG/ML PO SOLN,RX-28844,CDM,J7502,HCPCS,0636,RC,00172-7313-20,NDC,,both,1,ML,21.30,13.84,,,,,,,,,,,,,
DEVICE SUT L53IN DIA5MM THE RUNNING DEV RD 180,SUP-2265295,CDM,2720000010,LOCAL,0272,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
UNIVERSAL RING RETRACTOR BLADE MALLEABLE 4X12,SUP-2672838,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1809.17,1175.96,,,,,,,,,,,,,
DEXTROSE 5% IV SOLN NEONATE,RX-40840076,CDM,2580000003,HCPCS,0250,RC,00264-7510-00,NDC,,both,1000,ML,34.00,22.10,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED HIPCAP3000] STRYKER CORP],SUP-2365534,CDM,C1776,CPT,0278,RC,,,,both,,,9420.00,6123.00,,,,,,,,,,,,,
HC OB ER Level 5,PX-4509928501,CDM,99285,CPT,0450,RC,,,,outpatient,,,3911.00,2542.15,,,,,,,,,,,,,
TITANIUM MESH PANEL REG GRID 85MM X 55MM 6MM 20MM SYS CP T,SUP-2707374,CDM,C1713,HCPCS,0278,RC,,,,both,,,2195.05,1426.78,,,,,,,,,,,,,
FIBER LASER SURG FIBER 365 MH HOLM SMARTSCOPE DISP,SUP-2337026,CDM,2720000010,LOCAL,0272,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
KIT CATH HEMODIALYSI HEMOSTAR CHRONIC STD 14.5FR DIA LG LUMA,SUP-2613297,CDM,C1750,HCPCS,0278,RC,,,,both,,,1470.46,955.80,,,,,,,,,,,,,
SPACER KNEE 10MM L-2XL DSTL POST DURAC,SUP-2364868,CDM,C1776,CPT,0278,RC,,,,both,,,947.02,615.56,,,,,,,,,,,,,
PIN FIX OLV 1.6 MM,SUP-2223127,CDM,C1713,HCPCS,0278,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
TUBE VENT 1.14 MM 0.7 MM 2.54X3.81 MM ARMSTR R TAB SIL STRL,SUP-2535118,CDM,L8699,HCPCS,0278,RC,,,,both,,,42.86,27.86,,,,,,,,,,,,,
DEXTROSE 5% IV SOLN NEONATE,RX-40840076,CDM,2580000003,HCPCS,0258,RC,00990-7922-61,NDC,,both,150,ML,44.70,29.05,,,,,,,,,,,,,
GRAFT BIO TISS W5.9XL9.8IN PORCINE DERM RIFAMPIN,SUP-2125839,CDM,C1781,HCPCS,0278,RC,,,,both,,,35949.86,23367.41,,,,,,,,,,,,,
BLADE ULTRSNC ASPIR WORKING L 140 MM L 1.8 X W 1.3 MM MINI,SUP-2889547,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1798.09,1168.76,,,,,,,,,,,,,
BIT DRILL JLATCH 1.7 MM 4 MM WITH STOP FOR RAPIDSORB IPS STE,SUP-2837905,CDM,2720000010,LOCAL,0272,RC,,,,both,,,685.78,445.76,,,,,,,,,,,,,
SET URET STENT L 90 CM DIA 7.2 FR GUIDEWIRE 0.038 IN SIL,SUP-2835745,CDM,C2617,HCPCS,0278,RC,,,,both,,,523.41,340.22,,,,,,,,,,,,,
CEMENT BNE 15CC CA PHSPTE INJ LIQ PWD HYDROSET,SUP-2366473,CDM,C1713,HCPCS,0278,RC,,,,both,,,12950.58,8417.88,,,,,,,,,,,,,
ANCHOR SUT PRELD SMOOTH ENLD LO PROF STITCHPAK ST DISPOSABLE,SUP-2166458,CDM,C1713,HCPCS,0278,RC,,,,both,,,630.48,409.81,,,,,,,,,,,,,
STENT BILI S.M.A.R.T. CTRL L 30 MM DIA 9 MM DEL SYS L 120 CM,SUP-2155366,CDM,C1876,HCPCS,0278,RC,,,,both,,,4183.89,2719.53,,,,,,,,,,,,,
PORT IMPL INFUS LO PROF SGL CHMBR TI DEV OPN SUT PLG ATTCH,SUP-2126175,CDM,C1788,HCPCS,0278,RC,,,,both,,,615.44,400.04,,,,,,,,,,,,,
ROD SPNL CVD MULT ANG PERC IMP L30MM OD5.5MM SNIPER,SUP-2354845,CDM,C1713,HCPCS,0278,RC,,,,both,,,2499.44,1624.64,,,,,,,,,,,,,
INSERT TIB RP 5 10 MM KNEE CRUC RETAINING STBL REV ATTUNE,SUP-2136396,CDM,C1776,CPT,0278,RC,,,,both,,,9256.72,6016.87,,,,,,,,,,,,,
TESTOSTERONE ENANTHATE 200 MG/ML IM SOLN,RX-127409,CDM,J3121,HCPCS,0636,RC,00143-9750-01,NDC,,both,0.25,ML,54.10,35.16,,,,,,,,,,,,,
GRAFT BNE SUB 30CC 0.1-4MM CRUSH CANC CHIP MORSELIZED FRZ,SUP-2307065,CDM,C1713,HCPCS,0278,RC,,,,both,,,1405.15,913.35,,,,,,,,,,,,,
NAIL IM L320MM OD13MM UNIV TI FEM CANN LCK VERSANAIL,SUP-2412450,CDM,C1713,HCPCS,0278,RC,,,,both,,,5024.00,3265.60,,,,,,,,,,,,,
GUIDEWIRE ORTH L 16 IN DIA2 MM LG TROCAR TIP STRL DISP,SUP-2934484,CDM,C1769,HCPCS,0272,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
PLATE BNE STR 2-2.5X1 MM 6 HOLE FRAC LCK TI LEVEL 1,SUP-2484699,CDM,C1713,HCPCS,0278,RC,,,,both,,,875.24,568.91,,,,,,,,,,,,,
LEVEL CMF ST PLATE RECON TLTS STR 20 25 MM SCRW20 HOLE 158,SUP-2669748,CDM,C1713,HCPCS,0278,RC,,,,both,,,3896.68,2532.84,,,,,,,,,,,,,
GRAFT HUM TISS M 30X150MM FASC LATA FRZ DRY READIGRFT,SUP-2264780,CDM,C1762,CPT,0278,RC,,,,both,,,3003.57,1952.32,,,,,,,,,,,,,
ALLOGRAFT BNE 2.5 CC FIBER PLIAFX PRIM,SUP-2741025,CDM,C1713,HCPCS,0278,RC,,,,both,,,1193.04,775.48,,,,,,,,,,,,,
PACEMAKER CARD 67X259 MM 0.8 CC SINGLE CHMBR,SUP-2281166,CDM,C1786,HCPCS,0275,RC,,,,both,,,27475.00,17858.75,,,,,,,,,,,,,
BIT DRL STP STRT PFC ULT,SUP-2456005,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1375.32,893.96,,,,,,,,,,,,,
CATHETER EP DAO CRV 5 MM 6 FRX120 CM RESPON,SUP-2356798,CDM,C1730,HCPCS,0272,RC,,,,both,,,351.68,228.59,,,,,,,,,,,,,
"HC So Epstein-Barr Virus,Ebna",PX-3028666466,CDM,86664,CPT,0302,RC,,,,both,,,118.00,76.70,,,,,,,,,,,,,
PLATE BNE L 2.35 X W 0.36 CM THK 0.5 MM SCREW DIA1.5 MM 6 H,SUP-2936497,CDM,C1713,HCPCS,0278,RC,,,,both,,,653.12,424.53,,,,,,,,,,,,,
BLADE SHVR ARTHSCP 3MM DIA 120MML 65DG CRVD RCTNGLR WNDW RDS,SUP-2574166,CDM,2720000010,LOCAL,0272,RC,,,,both,,,814.52,529.44,,,,,,,,,,,,,
DIAZEPAM 5 MG PO TABS,RX-2405,CDM,6370000000,HCPCS,0637,RC,51079-0285-20,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
COMPONENT FEM CEM C MACR LT KNEE,SUP-2201885,CDM,C1776,CPT,0278,RC,,,,both,,,5604.90,3643.18,,,,,,,,,,,,,
DISTRACTION PIN LRGE 3.2X62MM7MM CTTNG SHAFT PK2T 6L 4V SN,SUP-2681380,CDM,C1713,HCPCS,0278,RC,,,,both,,,510.53,331.84,,,,,,,,,,,,,
SCREW BNE ST 2X8 MM LCK T8 TI NS,SUP-2189382,CDM,C1713,HCPCS,0278,RC,,,,both,,,339.12,220.43,,,,,,,,,,,,,
MESH HERN L DIA45IN POLYPR MFIL DBL LAYR CIR NONABSORBABLE,SUP-2125978,CDM,C1781,HCPCS,0278,RC,,,,both,,,401.92,261.25,,,,,,,,,,,,,
PLATE BNE THK 0.75 MM SCREW DIA1.7 MM 3 X 21 H PLL,SUP-2883171,CDM,C1713,HCPCS,0278,RC,,,,both,,,14565.52,9467.59,,,,,,,,,,,,,
OPTIMIZER SMART MINI IPG 10-B501-2-XX,SUP-2854408,CDM,C1824,HCPCS,0278,RC,,,,both,,,81640.00,53066.00,,,,,,,,,,,,,
DILATOR SURG L21.5CM TEF SMOOTH MALL FOR INTRACERVICAL DIL,SUP-2421469,CDM,C1713,HCPCS,0278,RC,,,,both,,,11.40,7.41,,,,,,,,,,,,,
CATHETER ABLATN LG 2-5-2 MM 8 MM TIP 8 FRX110 CM THER 2 8,SUP-2102286,CDM,C1733,HCPCS,0272,RC,,,,both,,,2844.84,1849.15,,,,,,,,,,,,,
RING ANNULPLSTY CARP EDW PHY DIA26 MM TI ALLOY POLYESTER SIL,SUP-2214261,CDM,C1889,HCPCS,0278,RC,,,,both,,,7677.30,4990.24,,,,,,,,,,,,,
BLADE SCREWDRIVER 1.7MM DIA CROSS-FIT,SUP-2695622,CDM,2720000010,LOCAL,0272,RC,,,,both,,,914.37,594.34,,,,,,,,,,,,,
PLATE SPNL AFFIX III 50 MM POST SIDE,SUP-2561438,CDM,C1713,HCPCS,0278,RC,,,,both,,,8949.00,5816.85,,,,,,,,,,,,,
ANCHOR SUTURE 2.9MM DIAMETER NO 2 ABSORBABLE POLYESTER ULTRA,SUP-2824089,CDM,C1713,HCPCS,0278,RC,,,,both,,,843.03,547.97,,,,,,,,,,,,,
SYSTEM PACE ANALYZER 2 CHMBR 4 CHANNEL RCRD BLT IN PRNT PT,SUP-2137946,CDM,C1713,HCPCS,0278,RC,,,,both,,,50711.00,32962.15,,,,,,,,,,,,,
CATHETER GUID WALRUS L 95 CM DIA 8 FR BALLOON DIA11.1 MM,SUP-2719537,CDM,C1887,HCPCS,0272,RC,,,,both,,,5495.00,3571.75,,,,,,,,,,,,,
COVER BUR H DIA15MM BILAT TI CNTOUR RIG NONCOMPRESSION LO,SUP-2190698,CDM,C1713,HCPCS,0278,RC,,,,both,,,779.98,506.99,,,,,,,,,,,,,
GRAFT VASC 6MM DIA 20CM LEN 10CM STR STRTCH STD WALL N RNGD,SUP-2395840,CDM,C1768,CPT,0278,RC,,,,both,,,1268.56,824.56,,,,,,,,,,,,,
GRAFT DERMAL MESH 2X3 CM FEN WND MTRX MIRODERM,SUP-2431547,CDM,Q4175,HCPCS,0636,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
MORPHINE SULFATE (PF) 4 MG/ML IJ SOLN,RX-142448,CDM,J2272,HCPCS,0636,RC,63323-0454-00,NDC,,both,0.5,ML,54.10,35.16,,,,,,,,,,,,,
GRAFT DERMAL N FEN 8X4 CMX1-2 MM DERMAL MTRX PARADERM,SUP-2742064,CDM,C1763,HCPCS,0278,RC,,,,both,,,7037.53,4574.39,,,,,,,,,,,,,
PEN ISOLATOR ELECTRD L7MM BPLR PEN 33CM LNG TRANSPOLAR,SUP-2124460,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5809.00,3775.85,,,,,,,,,,,,,
SCREW BNE 1.5X4 MM CRANIOMAXILLOFACIAL F3 MAXDRIVE 258580491,SUP-2463374,CDM,C1713,HCPCS,0278,RC,,,,both,,,187.02,121.56,,,,,,,,,,,,,
PLATE STRNL CLOSURE THK 1.5 MM 7 H TI T LP NS STERNALOCK EZ,SUP-2894464,CDM,C1713,HCPCS,0278,RC,,,,both,,,2995.56,1947.11,,,,,,,,,,,,,
ICE ROD KIT,SUP-2314035,CDM,2720000010,LOCAL,0272,RC,,,,both,,,10.68,6.94,,,,,,,,,,,,,
PLATE BONE RECONSTRUCTION MEDIUM 2 MM DOUBLE ANGLE TITANIUM,SUP-2837757,CDM,C1713,HCPCS,0278,RC,,,,both,,,8895.31,5781.95,,,,,,,,,,,,,
TAP SURG L196MM QUIK CONN FOR 6.5MM SCR,SUP-2410966,CDM,2720000010,LOCAL,0272,RC,,,,both,,,507.14,329.64,,,,,,,,,,,,,
PLATE BNE L205MM 6 H PROX FEM S STL HK LOK COMPR LO PROF,SUP-2186056,CDM,C1713,HCPCS,0278,RC,,,,both,,,4436.95,2884.02,,,,,,,,,,,,,
BLADE SCREWDRIVER 1MM DIA 61MML CENTRE DRIVE,SUP-2676783,CDM,2720000010,LOCAL,0272,RC,,,,both,,,393.76,255.94,,,,,,,,,,,,,
PEG BNE FIX DST FEM KNEE CO CHROM MOLYBDENUM ALLY VANGUARD,SUP-2407475,CDM,C1776,CPT,0278,RC,,,,both,,,697.08,453.10,,,,,,,,,,,,,
BOLT GUIDE VOLAR DST RDL LOK F/GDE PLTNG SSTM ACU LOC 2,SUP-2639632,CDM,2720000010,LOCAL,0272,RC,,,,both,,,700.22,455.14,,,,,,,,,,,,,
IMPLANT LARYN 1ML GEL INJ VOCAL CRD MEDIALIZATION PROLARYN,SUP-2303664,CDM,L8607,HCPCS,0274,RC,,,,both,,,2307.90,1500.13,,,,,,,,,,,,,
PLATE BNE R DST VOLAR RAD ANAT FAST GUID DNP,SUP-2414017,CDM,C1713,HCPCS,0278,RC,,,,both,,,2681.56,1743.01,,,,,,,,,,,,,
PLATE BONE 12MM OFFSET 90DEG 3 H PROX FEM LCK FOR 3.5MM SCR,SUP-2318552,CDM,C1713,HCPCS,0278,RC,,,,both,,,7045.69,4579.70,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED UPCHARGE HD CERM,SUP-2212677,CDM,C1776,CPT,0278,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
CLAMP SURG ROD TO ROD 7.5 MM 4.75 TO 5.5-6.5 MM CREO,SUP-2584159,CDM,C1713,HCPCS,0278,RC,,,,both,,,1975.06,1283.79,,,,,,,,,,,,,
INFLIXIMAB-DYYB 100 MG IV SOLR,RX-135985,CDM,Q5103,HCPCS,0636,RC,00069-0809-01,NDC,,both,1,UN,2791.60,1814.54,,,,,,,,,,,,,
ANCHOR SUTURE DIAMETER 1.8MM WITH TWO SIZE 2 BLUE AND WHITE/,SUP-2828693,CDM,C1713,HCPCS,0278,RC,,,,both,,,1482.08,963.35,,,,,,,,,,,,,
HC Stool Culture Add Pathogens,PX-3008704600,CDM,87046,CPT,0300,RC,,,,both,,,65.00,42.25,,,,,,,,,,,,,
SET INTRO INSUL CANN SFT TISS BX FOR RF 3000 GENRTR,SUP-2139748,CDM,C1894,HCPCS,0272,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
CATHETER REPERFUSION L190CM WRK L155CM DIA0.022IN SEP FLX,SUP-2323626,CDM,C1757,HCPCS,0272,RC,,,,both,,,8164.00,5306.60,,,,,,,,,,,,,
RING REPROC HALF,SUP-2488432,CDM,2720000010,LOCAL,0272,RC,,,,both,,,961.91,625.24,,,,,,,,,,,,,
GUIDEWIRE VASC ANGLED 0.035 INX260 CM STIFF SHFT ZIPWIRE,SUP-2148203,CDM,C1769,HCPCS,0272,RC,,,,both,,,134.08,87.15,,,,,,,,,,,,,
PLATE BONE SM W10XL73MM THK1.5MM 3X5 H S STL DSTL OBLQ T SHP,SUP-2343785,CDM,C1713,HCPCS,0278,RC,,,,both,,,2046.78,1330.41,,,,,,,,,,,,,
COMPONENT SHLDR LT SHLDR TOT GUIDE BNE MODEL COMPHSVE,SUP-2424042,CDM,C1713,HCPCS,0278,RC,,,,both,,,4239.00,2755.35,,,,,,,,,,,,,
CATHETER EP DIAG MAP L CRV QPLR 2-5-2MM SPC 5MM TIP BI DIR,SUP-2357032,CDM,C1733,HCPCS,0272,RC,,,,both,,,2647.02,1720.56,,,,,,,,,,,,,
SHUNT SURG REG 16 GA SNAP ASMBLY BLNT NDL STRATA NSC,SUP-2628579,CDM,C1729,HCPCS,0272,RC,,,,both,,,13667.29,8883.74,,,,,,,,,,,,,
BIT DRILL DIA3.2MM BLU CALIB DISP FOR FEM NAIL PEDINAIL,SUP-2318889,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1040.91,676.59,,,,,,,,,,,,,
COMPONENT CRANIOFACIAL CUSTOMIZED + SM COMPLX + PEEK NS LTX,SUP-2862810,CDM,C1713,HCPCS,0278,RC,,,,both,,,38021.38,24713.90,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.552,SUP-2860069,CDM,C1713,HCPCS,0278,RC,,,,both,,,66788.43,43412.48,,,,,,,,,,,,,
BOOT CAST SM FOR WMN 55 8 SQ TOE DSGN UNIV FOREFOOT CLSR,SUP-2176232,CDM,L4386,HCPCS,0272,RC,,,,both,,,27.38,17.80,,,,,,,,,,,,,
GUIDEWIRE VASC COON L 100 CM DIA 0.038 IN TAPR L 15 CM FLPY,SUP-2167859,CDM,C1769,HCPCS,0272,RC,,,,both,,,65.41,42.52,,,,,,,,,,,,,
OSSEOFLEX 10GA4ML SB CONVENIENCE PACK,SUP-2702606,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7186.68,4671.34,,,,,,,,,,,,,
INDOMETHACIN 50 MG RE SUPP,RX-3901,CDM,6370000000,HCPCS,0637,RC,70710-1852-07,NDC,,both,1,UN,1547.20,1005.68,,,,,,,,,,,,,
ELECTRODE ELECSURG OD22FR KNF COLLINGS,SUP-2361457,CDM,2720000010,LOCAL,0272,RC,,,,both,,,491.54,319.50,,,,,,,,,,,,,
PLATE BONE RECONSTRUCTION 3.5X70 MM 6 HOLE FOR SCREW STERILE,SUP-2836651,CDM,C1713,HCPCS,0278,RC,,,,both,,,3115.85,2025.30,,,,,,,,,,,,,
SYSTEM LD CATH TIP CAPSULE GUIDE TUBE VLV ENVEO R PRO,SUP-2281141,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1224.60,795.99,,,,,,,,,,,,,
GRAFT SYN TISS W15XL20CM THK2MM EPTFE SFT PTCH RECTANG FOR,SUP-2395291,CDM,C1781,HCPCS,0278,RC,,,,both,,,6057.06,3937.09,,,,,,,,,,,,,
SET URET STENT UNIVERSA L 18 CM DIA 5 FR HYDRPHLC SFT,SUP-2169452,CDM,C2617,HCPCS,0278,RC,,,,both,,,207.55,134.91,,,,,,,,,,,,,
SUPPORT ORTHOT WRST HND FNGR CUST DYN FLX HINGE FABRICATED,SUP-2435769,CDM,L3900,HCPCS,0274,RC,,,,both,,,4173.94,2713.06,,,,,,,,,,,,,
LEAD DEFIB SIL ENDOCARD ICD SGL COIL RIATA,SUP-2356671,CDM,C1777,HCPCS,0275,RC,,,,both,,,13345.00,8674.25,,,,,,,,,,,,,
HEAD FEM DIA36MM OFFSET +5MM 12 14 TAPR HIP ASPHERE M SPEC,SUP-2251145,CDM,C1776,CPT,0278,RC,,,,both,,,5130.13,3334.58,,,,,,,,,,,,,
SCREW BNE LCK 5X75 MM COR 2 W/ STARDRV TI NS,SUP-2181843,CDM,C1713,HCPCS,0278,RC,,,,both,,,640.56,416.36,,,,,,,,,,,,,
ACTIVATOR PATIENT REACTIV8,SUP-2877969,CDM,C1730,HCPCS,0272,RC,,,,both,,,2157.18,1402.17,,,,,,,,,,,,,
HC Elec Alys Implt Cplx Cn Npgt Prgrmg,PX-9209597700,CDM,95977,CPT,0920,RC,,,,both,,,298.00,193.70,,,,,,,,,,,,,
LABETALOL HCL 20 MG/4ML IV SOSY,RX-141251,CDM,J1920,HCPCS,0636,RC,71506-0046-45,NDC,,both,1,ML,54.10,35.16,,,,,,,,,,,,,
WAND ABLAT 50DEG DIA3MM RAD FREQ SUCT,SUP-2341996,CDM,2720000010,LOCAL,0272,RC,,,,both,,,709.64,461.27,,,,,,,,,,,,,
PLATE BNE L73MM 2 H L PROX OLECRANON S STL VAR ANG LOK,SUP-2177182,CDM,C1713,HCPCS,0278,RC,,,,both,,,2880.92,1872.60,,,,,,,,,,,,,
BIT DRL DIA2.2MM CROSSLOCK MOD TY DVR ANAT VOLAR PLATING,SUP-2412639,CDM,2720000010,LOCAL,0272,RC,,,,both,,,248.41,161.47,,,,,,,,,,,,,
DEVICE FIX 5MM TI HELI 5 MESH ASSEMB DISP FOR HERN REP TCKR,SUP-2283316,CDM,2720000010,LOCAL,0272,RC,,,,both,,,861.49,559.97,,,,,,,,,,,,,
COMPONENT FEM MOD BX 55 MM LT KNEE VANGUARD 360,SUP-2444786,CDM,C1776,CPT,0278,RC,,,,both,,,1540.17,1001.11,,,,,,,,,,,,,
DRILL SURG L495MM OD105MM LAG SCR STP W O STP NONRADIOLUCENT,SUP-2361614,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5234.76,3402.59,,,,,,,,,,,,,
GRAFT VASC HEMSHLD GLD L 30 CM 14 MM POLYESTER BOV CLLGN STR,SUP-2265892,CDM,C1768,CPT,0278,RC,,,,both,,,1490.24,968.66,,,,,,,,,,,,,
TROCAR DLYS STYL PERI TUNN FALLER ARGY,SUP-2172340,CDM,2720000010,LOCAL,0272,RC,,,,both,,,625.17,406.36,,,,,,,,,,,,,
LINER ACET ID32MM 0DEG HIP UHMWPE CONSTRN W/ RNG L SER,SUP-2420916,CDM,C1776,CPT,0278,RC,,,,both,,,6060.20,3939.13,,,,,,,,,,,,,
HANDPIECE MORCELLATION L 21.5 CM DIA19 GA FOR AESCULAP,SUP-2930235,CDM,2720000010,LOCAL,0272,RC,,,,both,,,13672.60,8887.19,,,,,,,,,,,,,
BASEPLATE GLEN DIA36MM +5MM STD TI SHLDR PROMOS +,SUP-2351195,CDM,C1776,CPT,0278,RC,,,,both,,,4898.40,3183.96,,,,,,,,,,,,,
FOLIC ACID 5 MG/ML IJ SOLN,RX-3232,CDM,J1808,HCPCS,0636,RC,63323-0184-10,NDC,,both,0.2,ML,54.10,35.16,,,,,,,,,,,,,
CADDY SCR 4.5X16 MM OCPTL VIRAGE,SUP-2684915,CDM,C1713,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
SUPPORT ORTHOT CERV THOR LUMBAR SACR CUST ANTR POST LAT CTRL,SUP-2435561,CDM,L0700,HCPCS,0274,RC,,,,both,,,5636.11,3663.47,,,,,,,,,,,,,
CATHETER DRAINAGE 12 FRX30 CM REG FLEXIMA,SUP-2147862,CDM,C1729,HCPCS,0272,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
CATHETER NEPHSTMY 18FR 4 WNG MCOT DISP,SUP-2129074,CDM,C2627,HCPCS,0272,RC,,,,both,,,76.74,49.88,,,,,,,,,,,,,
BLADE SHAVER STR 4 MM DOUBLE SERRATED DISP,SUP-2720013,CDM,2720000010,LOCAL,0272,RC,,,,both,,,879.20,571.48,,,,,,,,,,,,,
"HC Est Pt, Outpt Visit Level 5",PX-7619921500,CDM,99215,CPT,0761,RC,,,,both,,,369.00,239.85,,,,,,,,,,,,,
RING BPLR DIA53-57MM HIP REPL RNGLOC,SUP-2404324,CDM,C1776,CPT,0278,RC,,,,both,,,150.72,97.97,,,,,,,,,,,,,
TRAY CATH PICC GROSH NXT INTERMED 5FR 0.026IN 45CM 2 LUMAN R,SUP-2613423,CDM,C1751,HCPCS,0278,RC,,,,both,,,390.93,254.10,,,,,,,,,,,,,
JOINT EXT FIX UNIV SS,SUP-2162676,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1979.46,1286.65,,,,,,,,,,,,,
CONNECTOR NEUROSTIMULATOR L35CM M1 PRECIS,SUP-2138844,CDM,C1883,HCPCS,0278,RC,,,,both,,,2621.90,1704.23,,,,,,,,,,,,,
COMPONENT TOT KNEE HYBRID FIX BEAR RP POROUS,SUP-2249595,CDM,C1776,CPT,0278,RC,,,,both,,,13345.00,8674.25,,,,,,,,,,,,,
DRESSING BIO L 5 X W 5 CM PORCINE CLLGN SINGLE LAYR FEN SHT,SUP-2909417,CDM,Q4195,HCPCS,0636,RC,,,,both,,,7222.00,4694.30,,,,,,,,,,,,,
PEG BNE FIX L18MM DIA2MM DST VOLAR RAD LOK SMOOTH FOR ANAT,SUP-2414131,CDM,C1776,CPT,0278,RC,,,,both,,,359.78,233.86,,,,,,,,,,,,,
STENT BILI SYM L 22 MM DIA 7 FR CATH L 75 CM DIA 6 MM NIT AD,SUP-2141179,CDM,C1876,HCPCS,0278,RC,,,,both,,,3808.82,2475.73,,,,,,,,,,,,,
REUSABLE NS SINGLE-ANGLE BRKT W/ ACCUSITE NDL GUID 5,SUP-2164637,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
NAIL IM L270MM DIA7.5MM 120DEG STRL BLU L/R HUM TI CANN LCK,SUP-2192494,CDM,C1713,HCPCS,0278,RC,,,,both,,,5991.37,3894.39,,,,,,,,,,,,,
PLATE BNE W175XL116MM THK52MM 6 H BILAT TI RIG NEUT LOK,SUP-2190841,CDM,C1713,HCPCS,0278,RC,,,,both,,,1235.78,803.26,,,,,,,,,,,,,
MESH PARIETEX COMP RND 8CM SKIRTED,SUP-2174725,CDM,C1781,HCPCS,0278,RC,,,,both,,,1157.53,752.39,,,,,,,,,,,,,
SCREW ANCHR ORTHODONTIC 2X8 MM 13 MM BRACKET HD TI,SUP-2493034,CDM,C1713,HCPCS,0278,RC,,,,both,,,364.65,237.02,,,,,,,,,,,,,
SHEATH INTRO DRYSEAL FLX L 33 CM DIA12 FR BODY DIA 4.7 MM,SUP-2395726,CDM,C1894,HCPCS,0272,RC,,,,both,,,1645.36,1069.48,,,,,,,,,,,,,
HC Peripheral Block - Caudal,PX-3606444900,CDM,64449,CPT,0360,RC,,,,both,,,2895.00,1881.75,,,,,,,,,,,,,
METOPROLOL TARTRATE 5 MG/5ML IV SOLN,RX-92079,CDM,J0616,HCPCS,0636,RC,00409-1778-05,NDC,,both,2.5,ML,54.10,35.16,,,,,,,,,,,,,
BOOT WALKING DISTRACTOR BLOCK ALUM,SUP-2391502,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
MESH HERN L W1.6XL1.9IN INGUINAL WHT POLYPR MFIL PLUG PTCH,SUP-2125752,CDM,C1781,HCPCS,0278,RC,,,,both,,,661.28,429.83,,,,,,,,,,,,,
SPLINT WRST M R THMB SPICA COT POLY FAB LTHR WRKHRD ORIG BGE,SUP-2326137,CDM,L3908,HCPCS,0274,RC,,,,both,,,73.51,47.78,,,,,,,,,,,,,
SCREW BNE 2.3X27 MM CRANIOMAXILLOFACIAL TI MAXDRIVE LEVEL 1,SUP-2457088,CDM,C1713,HCPCS,0278,RC,,,,both,,,204.92,133.20,,,,,,,,,,,,,
SCREW BONE L2MM DIA1MM GLD CORT CRANIOMAXILLOFACIAL TI ST,SUP-2189033,CDM,C1713,HCPCS,0278,RC,,,,both,,,354.32,230.31,,,,,,,,,,,,,
SCREW 4.X32MM CANN COMPR HDLSS 2 THRD TI,SUP-2392778,CDM,C1713,HCPCS,0278,RC,,,,both,,,469.43,305.13,,,,,,,,,,,,,
SUPPORT ORTHOT KNEE LOWER EXTREMITY CUST OFFSET HVY DTY,SUP-2435667,CDM,L2395,HCPCS,0272,RC,,,,both,,,414.17,269.21,,,,,,,,,,,,,
LENS INTOCU +6.5 DIOPT L13MM DIA6MM A CONSTANT 118.4 10DEG,SUP-2110484,CDM,V2632,HCPCS,0276,RC,,,,both,,,260.87,169.57,,,,,,,,,,,,,
STENT BILI ZILVER L 4 CM DIA 8 MM INTRO L 208 CM DIA 7 FR,SUP-2169573,CDM,C1876,HCPCS,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
CLIP SURG JAW L25MM 350GM CLS FORC ENDO VES SHORT STRAIGHT,SUP-2108996,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2098.62,1364.10,,,,,,,,,,,,,
ALLOGRAFT BNE DEMINERALIZED CORTICAL 125-710 MIC 5 CC FD,SUP-2717748,CDM,C1713,HCPCS,0278,RC,,,,both,,,1139.82,740.88,,,,,,,,,,,,,
ANCHOR SUT OD5MM L36IN 2 VIO BLU MO-7 NDL TI SFT TISS BRAID,SUP-2256683,CDM,C1713,HCPCS,0278,RC,,,,both,,,948.28,616.38,,,,,,,,,,,,,
GRAFT SKIN 1.6 CM ANTIMICROBIAL DISC PURAPLY,SUP-2314114,CDM,Q4196,HCPCS,0636,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
PEG FIX LCK 1.8X28 MM PERIARTICULAR STRL,SUP-2525164,CDM,C1713,HCPCS,0278,RC,,,,both,,,186.30,121.09,,,,,,,,,,,,,
SLEEVE REDUC DIA 55MM L14MM SPNL CDH,SUP-2287806,CDM,C1713,HCPCS,0278,RC,,,,both,,,756.61,491.80,,,,,,,,,,,,,
ANCHOR SUT DIA5MM ROTATORY CUF W/ SZ 2 GRN WHT STRND ETHBND,SUP-2249445,CDM,C1713,HCPCS,0278,RC,,,,both,,,897.41,583.32,,,,,,,,,,,,,
WEDGE TIB SZ 1-2 15MM R MED L LAT KNEE HEMI STP LEGION,SUP-2346587,CDM,C1776,CPT,0278,RC,,,,both,,,5025.57,3266.62,,,,,,,,,,,,,
CONNECTOR SPNL LCK BRK OFF AX IMP OD5.5X5.5MM COLORADO 2,SUP-2290610,CDM,C1713,HCPCS,0278,RC,,,,both,,,5363.12,3486.03,,,,,,,,,,,,,
TIP ASPIR L UNIV MIC CLAW DISP 25KHZ FOR ORTH SURG SONOPET,SUP-2363704,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2072.40,1347.06,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC SOLO2 PLU MAXBARR 4FR 55C 1194108D1,SUP-2632629,CDM,C1751,HCPCS,0278,RC,,,,both,,,735.39,478.00,,,,,,,,,,,,,
NUT EXT FIX WIRE SIDEKCK EZ FRAME EF001600,SUP-2851070,CDM,2720000010,LOCAL,0272,RC,,,,both,,,511.82,332.68,,,,,,,,,,,,,
CATHETER ANGIO DIA 5 FR PIG NONBRAIDED MEM TIP STRL,SUP-2117138,CDM,C1713,HCPCS,0278,RC,,,,both,,,923.16,600.05,,,,,,,,,,,,,
PROSTHESIS OSS 0.5X6.50 MM EAR PISTON NIT FLROPLAS ECLIPSE,SUP-2232528,CDM,L8613,CPT,0278,RC,,,,both,,,989.10,642.91,,,,,,,,,,,,,
NAIL IM L420MM DIA8MM UNIV DK BLU PROX TIB TI BEND CANN LOK,SUP-2180392,CDM,C1713,HCPCS,0278,RC,,,,both,,,4731.67,3075.59,,,,,,,,,,,,,
TITLE CAP SCR EXTR TIP,SUP-2212567,CDM,C1713,HCPCS,0278,RC,,,,both,,,838.38,544.95,,,,,,,,,,,,,
PLATE BNE M 12 H SIL TI MESH CNTOUR MAL FOR 1.5MM SCR,SUP-2181553,CDM,C1713,HCPCS,0278,RC,,,,both,,,2566.01,1667.91,,,,,,,,,,,,,
ALLOGRAFT NERVE 2-3X15 MM PROC STRL AVANCE LTX,SUP-2753344,CDM,C1762,CPT,0278,RC,,,,both,,,8499.98,5524.99,,,,,,,,,,,,,
GRAFT HUM TISS FEM HD W/O CART FRZN ALLGRFT,SUP-2113900,CDM,C1776,CPT,0278,RC,,,,both,,,3940.70,2561.45,,,,,,,,,,,,,
DRILL TWST L 70 MM DIA2.2 MM STP 12 MM TEMPOROMANDIBULAR JT,SUP-2934179,CDM,2720000010,LOCAL,0272,RC,,,,both,,,580.90,377.58,,,,,,,,,,,,,
STENT ESOPH AGILE L 97 MM DIA18 MM PROX/DSTL FLARE,SUP-2745387,CDM,C1874,HCPCS,0278,RC,,,,both,,,9106.00,5918.90,,,,,,,,,,,,,
PLATE BNE L42MM THK1.3MM 5X2 H LOK COMPR GRID TRAP BILAT,SUP-2267949,CDM,C1713,HCPCS,0278,RC,,,,both,,,1969.41,1280.12,,,,,,,,,,,,,
PLATE BNE T MINI,SUP-2206143,CDM,C1713,HCPCS,0278,RC,,,,both,,,106.76,69.39,,,,,,,,,,,,,
SET INTRO PERFRMR L 13 CM DIA 4 FR GUIDEWIRE 0.018 IN CKFLO,SUP-2168783,CDM,C1894,HCPCS,0272,RC,,,,both,,,118.66,77.13,,,,,,,,,,,,,
HC Intro Cath Dialysis Circuit,PX-3613690100,CDM,36901,CPT,0361,RC,,,,both,,,10303.00,6696.95,,,,,,,,,,,,,
ACYCLOVIR 200 MG PO CAPS,RX-8969,CDM,6370000000,HCPCS,0637,RC,72578-0002-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
THUMBWHEEL EXT FIX XTRAFIX,SUP-2517828,CDM,2720000010,LOCAL,0272,RC,,,,both,,,610.64,396.92,,,,,,,,,,,,,
ALLOGRAFT BNE FIBULAR SHFT 26-50 MMX0.1 CM FRZN,SUP-2717859,CDM,C1762,CPT,0278,RC,,,,both,,,2342.09,1522.36,,,,,,,,,,,,,
COLLAR CERV MED DENS 2XS PEDIATRIC 14X2 IN FRM FIT PROCARE,SUP-2195744,CDM,L0120,HCPCS,0274,RC,,,,both,,,10.83,7.04,,,,,,,,,,,,,
SET URET STENT CNTOUR L 30 CM DIA 7 FR SENSOR GUIDEWIRE,SUP-2724944,CDM,C2617,HCPCS,0278,RC,,,,both,,,473.86,308.01,,,,,,,,,,,,,
PLATE BNE 4 H FIB RAREFT FOR TOT FT SYS 2,SUP-2243246,CDM,C1713,HCPCS,0278,RC,,,,both,,,6568.31,4269.40,,,,,,,,,,,,,
GUIDEWIRE VASC L150CM DIA0.035IN HYDRPHLC STIFF SHFT,SUP-2141154,CDM,C1769,HCPCS,0272,RC,,,,both,,,144.44,93.89,,,,,,,,,,,,,
OSTEOTOME SURG L9 1 2IN BLDE W1 4IN CRV HIBBS,SUP-2161306,CDM,2720000010,LOCAL,0272,RC,,,,both,,,358.84,233.25,,,,,,,,,,,,,
Z DISCONTINUED NO SUB IDED TUBE JEJUSTMY L66CM DIA12FR GWIRE L200CM 0.035IN JEJU PEG,SUP-2169407,CDM,2720000010,LOCAL,0272,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
CATHETER DRNGE 12FR L25CM 0.038IN 9 H POLYUR HYDRPHLC YEL,SUP-2303337,CDM,C1729,HCPCS,0272,RC,,,,both,,,189.81,123.38,,,,,,,,,,,,,
GUIDEWIRE ORTH DIA 3 MM BALL TIP,SUP-2898625,CDM,C1769,HCPCS,0272,RC,,,,both,,,778.72,506.17,,,,,,,,,,,,,
PUMP PAIN 100ML 2ML/HR FIX INCIS FOR MED DEL ON-Q,SUP-2236773,CDM,C9804,HCPCS,0272,RC,,,,both,,,207.24,134.71,,,,,,,,,,,,,
NEEDLE BRST LOC 7GA ENCOR,SUP-2126866,CDM,C1819,HCPCS,0278,RC,,,,both,,,486.70,316.35,,,,,,,,,,,,,
CONNECTOR SPINE DEV CLS,SUP-2289281,CDM,C1713,HCPCS,0278,RC,,,,both,,,1457.78,947.56,,,,,,,,,,,,,
GRAFT HUM TISS BIDIR 6X6 CM GRID PAT AMNIO MEMBRN BIOVANCE,SUP-2651379,CDM,Q4154,HCPCS,0636,RC,,,,both,,,11147.00,7245.55,,,,,,,,,,,,,
PLATE BNE HUM XLN LT PROX TI NS POLARUS,SUP-2525800,CDM,C1713,HCPCS,0278,RC,,,,both,,,8176.56,5314.76,,,,,,,,,,,,,
GRAFT BNE INJ 20 CC PRO-DENSE,SUP-2759541,CDM,C1713,HCPCS,0278,RC,,,,both,,,15427.01,10027.56,,,,,,,,,,,,,
COMPONENT TIB TY 5 ANK INFIN,SUP-2397011,CDM,C1776,CPT,0278,RC,,,,both,,,17147.54,11145.90,,,,,,,,,,,,,
INSERT TIB THK10MM STD UNIV MENIS POLYETH PRI NEUT ROT,SUP-2250758,CDM,C1776,CPT,0278,RC,,,,both,,,4726.33,3072.11,,,,,,,,,,,,,
SPACER FEM IBII CCK AUG 74X2.5X5 POST,SUP-2199944,CDM,C1776,CPT,0278,RC,,,,both,,,5935.86,3858.31,,,,,,,,,,,,,
GUIDEWIRE VASC J 1.5 MM 0.035 INX400 CM STIFF SHFT GLIDEWIRE,SUP-2421820,CDM,C1769,HCPCS,0272,RC,,,,both,,,298.93,194.30,,,,,,,,,,,,,
MESH HERN W45XL10CM POLYPR PRESHAPED HERN ABD G STD MFIL,SUP-2126050,CDM,C1781,HCPCS,0278,RC,,,,both,,,209.44,136.14,,,,,,,,,,,,,
STEM FEM CEM -5 MM 5 9X145 MM 25 MM HIP CRV REDUC NK TAPR,SUP-2376609,CDM,C1776,CPT,0278,RC,,,,both,,,14962.73,9725.77,,,,,,,,,,,,,
PRIMAQUINE PHOSPHATE 26.3 (15 BASE) MG PO TABS,RX-155114,CDM,6370000000,HCPCS,0637,RC,00024-1596-01,NDC,,both,1,UN,9.30,6.04,,,,,,,,,,,,,
PATCH DURA L 6.3 X W 3.9 IN SURF AREA24.6 SQ IN BOV PERICARD,SUP-2884057,CDM,C1763,HCPCS,0278,RC,,,,both,,,2791.46,1814.45,,,,,,,,,,,,,
ANCHOR SUTURE DIA 3.9 MM BIOCOMP KNOTLESS DX CC STRL MIS,SUP-2882191,CDM,C1713,HCPCS,0278,RC,,,,both,,,10032.30,6520.99,,,,,,,,,,,,,
GRAFT HUM TISS SEMITENDINOSUS 3X200 MM FRZN GRACILIS TEND,SUP-2264583,CDM,C1713,HCPCS,0278,RC,,,,both,,,3265.60,2122.64,,,,,,,,,,,,,
SCREW 12MM 22MM PLT LOK,SUP-2243262,CDM,C1713,HCPCS,0278,RC,,,,both,,,903.13,587.03,,,,,,,,,,,,,
SCREW BNE L28MM DIA3.5MM PROX HUM NONLOCKING T15 LO PROF,SUP-2411566,CDM,C1713,HCPCS,0278,RC,,,,both,,,221.53,143.99,,,,,,,,,,,,,
CATHETER HD LT 15.5 FRX32 CM 27 CM STR W/ SH,SUP-2267101,CDM,C1750,HCPCS,0278,RC,,,,both,,,357.96,232.67,,,,,,,,,,,,,
GUIDEWIRE ORTH L350MM DIA1.6MM SHT TRCR TIP,SUP-2290628,CDM,C1769,HCPCS,0272,RC,,,,both,,,105.57,68.62,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE L 10 MM DIA 7.5 MM SZ 3 CART ARAGONITE,SUP-2913299,CDM,C1763,HCPCS,0278,RC,,,,both,,,24806.00,16123.90,,,,,,,,,,,,,
GRAFT VASC VENAFLO II L 30 CM DIA 4-7 MM EPTFE CARBON STP N,SUP-2128784,CDM,L8670,HCPCS,0278,RC,,,,both,,,5625.62,3656.65,,,,,,,,,,,,,
KIT CATH DRNGE 155FR DIA 15CML SLCNE HYDRO GLIDE CTD STLT 1,SUP-2676360,CDM,C1729,HCPCS,0272,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
SCREW WR INTEGRA FRDM ARTHROPLASTY CRPL PLT IS USED IN AN,SUP-2243494,CDM,C1713,HCPCS,0278,RC,,,,both,,,12018.57,7812.07,,,,,,,,,,,,,
INSERT TIB SZ 6 THK17MM STD FIX GMK,SUP-2267548,CDM,C1776,CPT,0278,RC,,,,both,,,2179.91,1416.94,,,,,,,,,,,,,
SPLINT WR AD L 9IN LNG LT COT W/ STAY ELAS SUPP FOR,SUP-2324570,CDM,L3809,HCPCS,0272,RC,,,,both,,,36.86,23.96,,,,,,,,,,,,,
SCREW CORTCL 27X12MM SELF TAP,SUP-2695478,CDM,C1713,HCPCS,0278,RC,,,,both,,,421.70,274.10,,,,,,,,,,,,,
HC So Flt3 Gene Analysis,PX-3108124566,CDM,81245,CPT,0310,RC,,,,both,,,209.00,135.85,,,,,,,,,,,,,
PLATE BNE L86MM 6 H BILAT MTPHSEAL S STL LOK COMPR LO PROF,SUP-2185099,CDM,C1713,HCPCS,0278,RC,,,,both,,,2390.17,1553.61,,,,,,,,,,,,,
PLATE STRNL LG 4 H TI SQ NS MATRIXSTERNUM,SUP-2904226,CDM,C1713,HCPCS,0278,RC,,,,both,,,1812.78,1178.31,,,,,,,,,,,,,
SHEARS SEAL L20CM DIA5MM ULTRASONIC CRV TIP HARM HD 1000I,SUP-2219111,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1864.72,1212.07,,,,,,,,,,,,,
COIL EMB L12MM DIA2.5MM NEUROVASC BRAID DSGN FLXIBLE,SUP-2296687,CDM,C1889,HCPCS,0278,RC,,,,both,,,43925.46,28551.55,,,,,,,,,,,,,
PLATE BNE L 105 X W 8 MM THK 2.4 MM SCREW DIA2.7 MM 6 H SS,SUP-2933934,CDM,C1713,HCPCS,0278,RC,,,,both,,,2783.92,1809.55,,,,,,,,,,,,,
TEMPLATE DERM REGEN IMPANT BIO TISS CLLGN MTRX ST 25CM LEN,SUP-2243548,CDM,Q4105,HCPCS,0636,RC,,,,both,,,30066.38,19543.15,,,,,,,,,,,,,
SCREW INTRF BIOSURE REGENESORB 8MMX25MM,SUP-2341918,CDM,C1713,HCPCS,0278,RC,,,,both,,,1126.63,732.31,,,,,,,,,,,,,
DEFIBRILLATOR IMPL LUMAX 540 DR-T W 59 X H 66 MM D 13 MM 40,SUP-2138130,CDM,C1882,HCPCS,0275,RC,,,,both,,,33912.00,22042.80,,,,,,,,,,,,,
BLOCK LARYN NETTERVILLE PHONOFORM LT SIL,SUP-2243733,CDM,C1878,HCPCS,0278,RC,,,,both,,,1014.22,659.24,,,,,,,,,,,,,
PROBE LSR 25GA PICK RFID ILLUMINATED MEMBRN PUREPOINT,SUP-2109948,CDM,C1713,HCPCS,0278,RC,,,,both,,,476.78,309.91,,,,,,,,,,,,,
BLADE SAW THK.93 MM L43 MM X W8 MM RECIPROCATE STERILE LATEX FREE DISPOSABLE,SUP-2880173,CDM,2720000010,LOCAL,0272,RC,,,,both,,,741.83,482.19,,,,,,,,,,,,,
SCREW BNE FIX 32 MM LIBRA,SUP-2442377,CDM,C1713,HCPCS,0278,RC,,,,both,,,98.91,64.29,,,,,,,,,,,,,
PLATE BNE L322MM 16 H NONSTERILE R MED PROX TIB S STL LOK,SUP-2185690,CDM,C1713,HCPCS,0278,RC,,,,both,,,4559.78,2963.86,,,,,,,,,,,,,
"HC So Mituberculosis,Dna,Amp.Probe",PX-3068755666,CDM,87556,CPT,0306,RC,,,,both,,,438.00,284.70,,,,,,,,,,,,,
OSS 5CM OSSEOTI PROX TIB SLV,SUP-2506333,CDM,C1776,CPT,0278,RC,,,,both,,,9311.67,6052.59,,,,,,,,,,,,,
SET CATH HEMODIALYSI ACUTE 12FR DIA 20CM 2LM INDWL BLU FLEXT,SUP-2613328,CDM,C1752,HCPCS,0278,RC,,,,both,,,270.04,175.53,,,,,,,,,,,,,
CATHETER THROMCTMY SOCRATES 38 L 156 CM DIA 4 FR COAT L 90,SUP-2909581,CDM,C1757,HCPCS,0272,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
SCREW BNE CANN 7.3X105 MM PERI ARTC LCK SS NS LCP,SUP-2184763,CDM,C1713,HCPCS,0278,RC,,,,both,,,783.08,509.00,,,,,,,,,,,,,
RETRACTOR SURG SCREW KT REDDICK SAYE,SUP-2264236,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1332.74,866.28,,,,,,,,,,,,,
GRAFT BIO TISS MESH 8X8 CM MIROMATRIX MIROMESH,SUP-2115022,CDM,C1781,HCPCS,0278,RC,,,,both,,,5805.86,3773.81,,,,,,,,,,,,,
IMMUNE GLOBULIN (GAMMAGARD) 10%,RX-4081758,CDM,J1569,HCPCS,0636,RC,00944-2700-05,NDC,,both,100,ML,5151.00,3348.15,,,,,,,,,,,,,
TRIAL SURG 20X75MM BIOFOAM,SUP-2397848,CDM,2720000010,LOCAL,0272,RC,,,,both,,,621.72,404.12,,,,,,,,,,,,,
ANTEROLATERAL PILON FUSION PLATE 12H LT,SUP-2814968,CDM,C1713,HCPCS,0278,RC,,,,both,,,12560.00,8164.00,,,,,,,,,,,,,
ASPIRIN 1 MG/ML PO SUSP (FOR DESENSITIZATION),RX-4081557,CDM,6370000000,HCPCS,0637,RC,09999-9909-92,NDC,,both,10,ML,2.70,1.75,,,,,,,,,,,,,
CATHETER VENTRICULAR 1.5X3.1X15.7X3X6 MM STRL HOLTER,SUP-2666418,CDM,C1729,HCPCS,0272,RC,,,,both,,,1548.96,1006.82,,,,,,,,,,,,,
CATHETER PICC ARROWG+ARD BLUE ADVANCE 4.5FR 55CM 1-LUMEN,SUP-2887064,CDM,C1751,HCPCS,0278,RC,,,,both,,,645.80,419.77,,,,,,,,,,,,,
KIT IM NAIL L150MM DIA10MM PROX HUM LCK,SUP-2412505,CDM,C1713,HCPCS,0278,RC,,,,both,,,4939.22,3210.49,,,,,,,,,,,,,
PLATE BONE SM 44MML HLX1 STNLSS STEEL DELTA BTTRSS ST RIGHT,SUP-2720785,CDM,C1713,HCPCS,0278,RC,,,,both,,,2309.22,1500.99,,,,,,,,,,,,,
PROSTHESIS PENILE 65ML INFL PMP INHIBIZONE IMP AMS 700,SUP-2140255,CDM,C1813,HCPCS,0278,RC,,,,both,,,3121.16,2028.75,,,,,,,,,,,,,
HC ER Level 3|MULTIPLE OUTPATIENT HOSPITAL E/M ENCOUNTERS ON THE SAME DATE,PX-4509928300,CDM,99283,CPT,0450,RC,,,27,outpatient,,,1556.00,1011.40,,,,,,,,,,,,,
SCREW SPNL L40MM OD4MM TI MULTAXL NONCANNULATED FOR 5.5MM,SUP-2415137,CDM,C1713,HCPCS,0278,RC,,,,both,,,1752.12,1138.88,,,,,,,,,,,,,
BIT DRL L 295 MM DIA 7.5 MM LG LNG CANN AO QC FOR CSS NS,SUP-2907919,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3643.31,2368.15,,,,,,,,,,,,,
GRAFT VASC FLIXENE L 10 CM DIA 8 MM EPTFE STR STD WALL REINF,SUP-2500396,CDM,C1768,CPT,0278,RC,,,,both,,,852.54,554.15,,,,,,,,,,,,,
TIP ELECSURG 5MM STD 14CM ENSEAL,SUP-2257686,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1101.70,716.10,,,,,,,,,,,,,
HC Diskography Cerv/Thorac S&I,PX-3207228500,CDM,72285,CPT,0320,RC,,,,both,,,3509.00,2280.85,,,,,,,,,,,,,
NAIL IM TIBIOTALOCALCANEL 11MMX15CM REV,SUP-2343699,CDM,C1713,HCPCS,0278,RC,,,,both,,,6019.38,3912.60,,,,,,,,,,,,,
INTRODUCER TUBE SET 6.5/7/7.5/8 MM MULTI PERC W/O TRACH TUBE,SUP-2759705,CDM,C1769,HCPCS,0272,RC,,,,both,,,1014.22,659.24,,,,,,,,,,,,,
SYSTEM EMB L 190 CM RVD 5-6 MM CAR STENTING FLX TIP PEELWY,SUP-2101765,CDM,C1876,HCPCS,0278,RC,,,,both,,,4867.00,3163.55,,,,,,,,,,,,,
PLATE BNE L50.5MM 12 H R DST RAD VOLAR S STL LOK COMPR CLMN,SUP-2184073,CDM,C1713,HCPCS,0278,RC,,,,both,,,2345.74,1524.73,,,,,,,,,,,,,
LINER ACET OD52MM ID28MM 0DEG +4MM HIP MARTHN LAT NEUT PINN,SUP-2250527,CDM,C1776,CPT,0278,RC,,,,both,,,5124.48,3330.91,,,,,,,,,,,,,
SCREW BNE 002360904035] ZIMMER BIOMET INC],SUP-2198528,CDM,C1713,HCPCS,0278,RC,,,,both,,,291.39,189.40,,,,,,,,,,,,,
SUTURE NOVOSTITCH PRO SZ 0 FOR MENIS REP DISP CTXA004,SUP-2419747,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1829.84,1189.40,,,,,,,,,,,,,
KYPHOPLASTY KIT BLLN 10 GAX15 MM FRAC IVAS ELITE DISP,SUP-2422838,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7536.00,4898.40,,,,,,,,,,,,,
INTRODUCER SHTH 7 FRX18 CM PERC SMOOTH TRANSITION SS ORNG LF,SUP-2473518,CDM,C1894,HCPCS,0272,RC,,,,both,,,86.66,56.33,,,,,,,,,,,,,
SNARE SURG HEX 3 MMX230 CM ISNARE,SUP-2736642,CDM,2720000010,LOCAL,0272,RC,,,,both,,,370.52,240.84,,,,,,,,,,,,,
FORCEPS BPLR FOR GRD I AND II INT HEMORRHOID HET,SUP-2172227,CDM,C1713,HCPCS,0278,RC,,,,both,,,2144.62,1394.00,,,,,,,,,,,,,
HC So Amoebic Antibodies by Iha,PX-3028675366,CDM,86753,CPT,0302,RC,,,,inpatient,,,129.00,83.85,,,,,,,,,,,,,
CATHETER DRNGE 10.2FR L50CM 0.038IN UNIV 6 SIDE PRT AMPLATZ,SUP-2168697,CDM,C1729,HCPCS,0272,RC,,,,both,,,198.23,128.85,,,,,,,,,,,,,
CATHETER INTVASC OCCL ER-REBOA L 72 CM DIA 32 MM BALLOON,SUP-2417425,CDM,C2628,HCPCS,0272,RC,,,,both,,,6264.30,4071.79,,,,,,,,,,,,,
WASHER 55MM 75MM CANN SCREWS 12MM THICK,SUP-2720255,CDM,C1713,HCPCS,0278,RC,,,,both,,,213.46,138.75,,,,,,,,,,,,,
SCREW SPNL MULTAXL 6.5X50 MM CANN PEEK CD HORZ LEG,SUP-2279494,CDM,C1713,HCPCS,0278,RC,,,,both,,,2684.70,1745.05,,,,,,,,,,,,,
PROBE UTER SOUNDING DEV NOVASURE/SURESOUND,SUP-2239967,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4183.52,2719.29,,,,,,,,,,,,,
VALVE AORT CARP EDW PERIMT RSR THEON DIA27 MM SEW RNG DIA 35,SUP-2488176,CDM,2720000010,LOCAL,0272,RC,,,,both,,,13863.10,9011.01,,,,,,,,,,,,,
GRAFT PROC FASC LATA SCLER TUTOPLAST ALLGRFT 0.6X1.0CM,SUP-2247192,CDM,L8610,HCPCS,0278,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
GRAFT BNE BLOCK FULL ACHILLES TEND,SUP-2335254,CDM,C1713,HCPCS,0278,RC,,,,both,,,9278.70,6031.15,,,,,,,,,,,,,
HC Dress or Debride Burn Medium,PX-4501602500,CDM,16025,CPT,0450,RC,,,,both,,,632.00,410.80,,,,,,,,,,,,,
ALLOGRAFT BNE IRRADIATED HUM HD,SUP-2867158,CDM,C1762,CPT,0278,RC,,,,both,,,3490.11,2268.57,,,,,,,,,,,,,
SCREW SPNL ROD DIA 5.5/6 MM SS UNIAXIAL STRL CD HORZ MODULEX,SUP-2926483,CDM,C1713,HCPCS,0278,RC,,,,both,,,2527.70,1643.00,,,,,,,,,,,,,
STEM HUM L140MM DIA8.5MM 132.5DEG R SHLDR TI ALLY CEM PRI,SUP-2223304,CDM,C1776,CPT,0278,RC,,,,both,,,7862.56,5110.66,,,,,,,,,,,,,
CERAMIC BALL HD 12/14 28 IN3.5 S,SUP-2267743,CDM,C1776,CPT,0278,RC,,,,both,,,2875.46,1869.05,,,,,,,,,,,,,
HYALURONIDASE BOVINE 15 UNITS/ML IJ SYRINGE,RX-40891037,CDM,J3470,HCPCS,0636,RC,09999-9917-17,NDC,,both,0.2,ML,64.20,41.73,,,,,,,,,,,,,
PLATE BNE CHAMPY 2/2.5X41X9X1 MM LT 6 HOLE SMART3D TRAUM NS,SUP-2484068,CDM,C1713,HCPCS,0278,RC,,,,both,,,1258.89,818.28,,,,,,,,,,,,,
CEMENT BNE VOID 2 GM,SUP-2402962,CDM,C1713,HCPCS,0278,RC,,,,both,,,781.86,508.21,,,,,,,,,,,,,
CUP ACET 66 MM FEM HIP,SUP-2202536,CDM,C1776,CPT,0278,RC,,,,both,,,9216.53,5990.74,,,,,,,,,,,,,
KIT DOLPHIX STARTER,SUP-2854265,CDM,C1713,HCPCS,0278,RC,,,,both,,,25120.00,16328.00,,,,,,,,,,,,,
PLATE BNE W102XL78MM THK27MM RAD 108MM 6 H BILAT PELV S STL,SUP-2186269,CDM,C1713,HCPCS,0278,RC,,,,both,,,1997.95,1298.67,,,,,,,,,,,,,
BLADE RTRCTR BLFR HRGN 2INW X 15 3/4NL X 6 1/2ND ABDMNL CNTR,SUP-2476917,CDM,2720000010,LOCAL,0272,RC,,,,both,,,500.39,325.25,,,,,,,,,,,,,
RESERVOIR VENTRICULAR RT ANGLE STD 5 CM 0.1 CC CSF IMPREG BA,SUP-2631387,CDM,C1729,HCPCS,0272,RC,,,,both,,,1016.70,660.85,,,,,,,,,,,,,
PROBE NERVE STIM MONOPOLAR STD PRASS FLSH TIP STRL DISP,SUP-2901969,CDM,2720000010,LOCAL,0272,RC,,,,both,,,366.19,238.02,,,,,,,,,,,,,
DRILL 5.0MM DEV TARGETING RADLUC,SUP-2371644,CDM,2720000010,LOCAL,0272,RC,,,,both,,,516.53,335.74,,,,,,,,,,,,,
BLADE SHAVER 4.2 MMX10.5 CM 45 DEG BEND RHINOTEC CUDA,SUP-2607643,CDM,2720000010,LOCAL,0272,RC,,,,both,,,169.87,110.42,,,,,,,,,,,,,
CATHETER THROMCTMY FOGARTY L 80 CM DIA 5 FR MEMBRN DIA,SUP-2214031,CDM,C1757,HCPCS,0272,RC,,,,both,,,813.23,528.60,,,,,,,,,,,,,
BRACE WRST FA HND L INSTABILITY INJ 8IN IMMOB LOOP LOK,SUP-2276635,CDM,L3809,HCPCS,0272,RC,,,,both,,,21.82,14.18,,,,,,,,,,,,,
ULTRATHANE SUPRAPUBIC CATHETER SET,SUP-2822057,CDM,C2627,HCPCS,0272,RC,,,,both,,,234.72,152.57,,,,,,,,,,,,,
IMPLANT COSMETIC SZ 38 X 50 X 1.5 MM POLYETHYL ORBIT FLR SHT,SUP-2935201,CDM,C1713,HCPCS,0278,RC,,,,both,,,1183.78,769.46,,,,,,,,,,,,,
BIT DRL L500MM DIA6X9MM CANN STP L QUIK CPL FOR DH DC TFN,SUP-2178964,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1590.60,1033.89,,,,,,,,,,,,,
PLATE BNE L74MM 6 H BILAT 1/3 TBLR NONCOMPRESSION RIG FOR,SUP-2348957,CDM,C1713,HCPCS,0278,RC,,,,both,,,630.48,409.81,,,,,,,,,,,,,
BIT DRL TWST 1.8X36.5 MM 2.75 IN,SUP-2136230,CDM,2720000010,LOCAL,0272,RC,,,,both,,,389.36,253.08,,,,,,,,,,,,,
SPLINT WRST FA L INSTABILITY INJ W STAY COCK UP FIRM SUPP,SUP-2276617,CDM,L3809,HCPCS,0274,RC,,,,both,,,15.95,10.37,,,,,,,,,,,,,
OCCLUDER UTER DISP COLPO-PNEUMO,SUP-2171682,CDM,2720000010,LOCAL,0272,RC,,,,both,,,327.09,212.61,,,,,,,,,,,,,
COMPONENT FEM SZ 1 L POST STBL NP BAL SYS,SUP-2314595,CDM,C1776,CPT,0278,RC,,,,both,,,6958.24,4522.86,,,,,,,,,,,,,
STEM VNGD CR HOUSING 75 LEFT,SUP-2506443,CDM,C1776,CPT,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
PLATE BONE SM W10XL50MM THK1.2MM 3X3 H RT DSTL S STL T SHP,SUP-2343782,CDM,C1713,HCPCS,0278,RC,,,,both,,,1056.89,686.98,,,,,,,,,,,,,
SCREW BNE CRTX 3.5X32 MM LP ST HD HEXDRIVE TI NS,SUP-2758236,CDM,C1713,HCPCS,0278,RC,,,,both,,,100.92,65.60,,,,,,,,,,,,,
SUPPORT ORTHOT ANK KNEE CUST DBL SLD STIRRUP W/O JT,SUP-2435635,CDM,L2030,HCPCS,0272,RC,,,,both,,,3066.65,1993.32,,,,,,,,,,,,,
SYSTEM TOT KNEE,SUP-2212227,CDM,C1776,CPT,0278,RC,,,,both,,,14484.82,9415.13,,,,,,,,,,,,,
ALLOGRAFT FRZ DRY FASC LATA IRRADIATED 60-120MM N WT BEAR,SUP-2115976,CDM,C1762,CPT,0278,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
COIL FIL COMPLX SFT .020IN W DIA 15MM SEC DIA 45CM PENUMBRA,SUP-2323419,CDM,C1889,HCPCS,0278,RC,,,,both,,,8233.08,5351.50,,,,,,,,,,,,,
KIT CATH 7FR L30CM CTRL VEN POLYUR 3 LUMN ARWGRD + BLU,SUP-2120596,CDM,C1751,HCPCS,0278,RC,,,,both,,,184.00,119.60,,,,,,,,,,,,,
COMPONENT TIB MONOBLOCK UNI UNIV PRI STEM CEM NP POLYETH SZ,SUP-2215732,CDM,C1776,CPT,0278,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
PLATE BONE L100MM THK2MM 5 H SPN FOR 4.5MM SCR TC-100 L FRAG,SUP-2343814,CDM,C1713,HCPCS,0278,RC,,,,both,,,2911.78,1892.66,,,,,,,,,,,,,
CATHETER GUID Q4 6 FRX110 CM VASC RUNWAY DISP,SUP-2423584,CDM,C1887,HCPCS,0272,RC,,,,both,,,364.24,236.76,,,,,,,,,,,,,
TAP FOR 2.3MM MAND SCR,SUP-2364419,CDM,C1713,HCPCS,0278,RC,,,,both,,,881.68,573.09,,,,,,,,,,,,,
SCREW BONE L85MM LAG OMEGA + SUP,SUP-2370966,CDM,C1713,HCPCS,0278,RC,,,,both,,,969.98,630.49,,,,,,,,,,,,,
POTASSIUM CHLORIDE ER 10 MEQ PO CPCR,RX-13644,CDM,6370000000,HCPCS,0637,RC,60687-0653-11,NDC,,both,1,UN,3.90,2.53,,,,,,,,,,,,,
CATHETER CARD ABLATION PULSESELECT PFA170 DEG TOT L 145 CM,SUP-2882558,CDM,C1733,HCPCS,0272,RC,,,,both,,,20096.00,13062.40,,,,,,,,,,,,,
INSERT TIB 1 8 MM CONSTRN REV BKS,SUP-2434222,CDM,C1776,CPT,0278,RC,,,,both,,,2763.83,1796.49,,,,,,,,,,,,,
BARRIER ADH TISS SM 3X5 IN INCISION ABSORBABLE SEPRAFILM,SUP-2336787,CDM,C1765,HCPCS,0278,RC,,,,both,,,855.56,556.11,,,,,,,,,,,,,
DISTRACTOR SURG L150MM EXT FIX LIMB RECON ANGULAR TRUELOK,SUP-2316083,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3238.22,2104.84,,,,,,,,,,,,,
PLATE BNE H08MM 30 H TI STR REG LEIBINGER UNIV 2,SUP-2366330,CDM,C1713,HCPCS,0278,RC,,,,both,,,1594.81,1036.63,,,,,,,,,,,,,
SCREW HIP CMPNNT CNNLTD LAG 10.5MM DIA 75MML TIMAX PRXML FMR,SUP-2588695,CDM,C1713,HCPCS,0278,RC,,,,both,,,1863.24,1211.11,,,,,,,,,,,,,
SCREW CANNULATED 6.5X140MM SS FULL THRD,SUP-2547260,CDM,C1713,HCPCS,0278,RC,,,,both,,,636.20,413.53,,,,,,,,,,,,,
IMPL TOE SMART 16MM,SUP-2476622,CDM,C1776,CPT,0278,RC,,,,both,,,2583.12,1679.03,,,,,,,,,,,,,
KIT INTRO VSI L 12 CM DIA 6 FR NIT MANDREL SS TIP HYDRPHLC,SUP-2763486,CDM,C1892,HCPCS,0272,RC,,,,both,,,119.32,77.56,,,,,,,,,,,,,
COVER BUR H DIA24MM LO PROF W/ TAB FOR 1.5MM SCR CRAN FIX,SUP-2363635,CDM,C1713,HCPCS,0278,RC,,,,both,,,952.17,618.91,,,,,,,,,,,,,
CLINDAMYCIN PHOSPHATE 2 % VA CREA,RX-9624,CDM,6370000000,HCPCS,0637,RC,00168-0277-40,NDC,,both,40,GR,469.30,305.04,,,,,,,,,,,,,
FIBER LASER FLEXIVA PULSE 910,SUP-2718713,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2303.69,1497.40,,,,,,,,,,,,,
URSODIOL 250 MG PO TABS,RX-22660,CDM,6370000000,HCPCS,0637,RC,64380-0918-06,NDC,,both,1,UN,3.40,2.21,,,,,,,,,,,,,
IMPLANT OSS L5.9MM HD 4.25MM THK2.3MM 1.12MM INCUS STAP HA,SUP-2312818,CDM,L8613,CPT,0278,RC,,,,both,,,1368.38,889.45,,,,,,,,,,,,,
PLATE BNE XS RL FIBULAR NS PENDING,SUP-2896972,CDM,C1713,HCPCS,0278,RC,,,,both,,,2351.86,1528.71,,,,,,,,,,,,,
BIT DRL CANN 2X145 MM QC FOR 2.5-3 MM SCREW PUR YEL NS,SUP-2422318,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1273.58,827.83,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9% BOLUS (FLUID RESUSCITATION),RX-4081440,CDM,J7040,HCPCS,0258,RC,00264-7800-10,NDC,,both,1000,ML,59.50,38.67,,,,,,,,,,,,,
NEEDLE LOC L5CM DIA21GA BRST LESION MOD NONPALPABLE DISP QK,SUP-2167885,CDM,C1819,HCPCS,0278,RC,,,,both,,,93.51,60.78,,,,,,,,,,,,,
RAMIPRIL 1.25 MG PO CAPS,RX-11258,CDM,6370000000,HCPCS,0637,RC,68382-0144-06,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
DEVICE BRST BX 9 GAX13 CM 12 MM FOR STEREOTACTIC HNDPC PRB,SUP-2427468,CDM,2720000010,LOCAL,0272,RC,,,,both,,,837.60,544.44,,,,,,,,,,,,,
HC Direct Ldl Cholesterol,PX-3018372100,CDM,83721,CPT,0301,RC,,,,both,,,81.00,52.65,,,,,,,,,,,,,
SCREW INTRF L25MM OD7MM TI ACL CANN BLNT THRD NONABSORBABLE,SUP-2362041,CDM,C1713,HCPCS,0278,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
CATHETER EP 5FR L110CM ELECTRD TIP L1MM SPC 2-5-2MM M CRV,SUP-2357630,CDM,C1730,HCPCS,0272,RC,,,,both,,,1161.80,755.17,,,,,,,,,,,,,
BIT DRL DIA2.4MM FOR JT STBL AND TEND INJ REP GLL QANCHR,SUP-2249340,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1276.72,829.87,,,,,,,,,,,,,
CEFUROXIME 1.5 G IV SOLN (MIXTURES ONLY),RX-430023,CDM,J0697,HCPCS,0636,RC,00143-9977-22,NDC,,both,1,UN,54.10,35.16,,,,,,,,,,,,,
GRAFT VASC RESTOREFLOW AORTOILIAC ART BLD TYP A B AB O STRL,SUP-2884049,CDM,C1768,CPT,0278,RC,,,,both,,,74195.06,48226.79,,,,,,,,,,,,,
DRESSING BIO W4XL5IN THN CLLGN GLYCOSAMINOGLYCAN WND MTRX,SUP-2243650,CDM,Q4108,HCPCS,0636,RC,,,,both,,,17272.98,11227.44,,,,,,,,,,,,,
CATHETER DASH ERCP TIP 4.5FR RECOMMENDED WIRE GUID .025IN,SUP-2169553,CDM,C1713,HCPCS,0278,RC,,,,both,,,204.10,132.66,,,,,,,,,,,,,
SCREW BNE 2X8 MM 6 MM DRILL-FREE TI L1 MAXDRIVE,SUP-2468792,CDM,C1713,HCPCS,0278,RC,,,,both,,,435.05,282.78,,,,,,,,,,,,,
PLATE BONE L103MM 7 H RT MEDL DSTL HUM LCK FOR 2.7/3.5MM SCR,SUP-2348597,CDM,C1713,HCPCS,0278,RC,,,,both,,,11239.00,7305.35,,,,,,,,,,,,,
SHEATH INTRO ARW GLIDETHRU L 19.5 CM DIA 5 FR DIL 5 FR,SUP-2384049,CDM,C1894,HCPCS,0272,RC,,,,both,,,619.30,402.54,,,,,,,,,,,,,
BIT DRL 9.5X229 MM SENTNL,SUP-2765832,CDM,2720000010,LOCAL,0272,RC,,,,both,,,688.13,447.28,,,,,,,,,,,,,
PLATE BNE L90MM 6 H NONSTERILE L POSTEROLATERAL DST TIB S,SUP-2177704,CDM,C1713,HCPCS,0278,RC,,,,both,,,2906.13,1888.98,,,,,,,,,,,,,
STENT URET STR 0.035 IN 3 CM 4.8 FRX22-30 CM FLX STRTCH VL,SUP-2486689,CDM,C2617,HCPCS,0278,RC,,,,both,,,427.79,278.06,,,,,,,,,,,,,
SUPPORT ORTHOT ANK KNEE ANTR TIB CUST PREFABRICATED RIGID,SUP-2435628,CDM,L1932,HCPCS,0274,RC,,,,both,,,2526.32,1642.11,,,,,,,,,,,,,
IMPL ANKLE SUBFIX 9MM,SUP-2706710,CDM,C1776,CPT,0278,RC,,,,both,,,4396.00,2857.40,,,,,,,,,,,,,
STIMULATOR NERVE PT PRGMR EXT GENRTR,SUP-2355979,CDM,C1787,HCPCS,0278,RC,,,,both,,,3752.30,2438.99,,,,,,,,,,,,,
AUGMENT FEM L65MM THK5MM R LAT L MED DST KNEE TI INTLOK,SUP-2407757,CDM,C1776,CPT,0278,RC,,,,both,,,2549.68,1657.29,,,,,,,,,,,,,
LEAD DEFIB TRUE BPLR 21 CM ACTIVE FIX OPTIM INSUL RIATA ST,SUP-2357370,CDM,C1895,HCPCS,0275,RC,,,,both,,,14915.00,9694.75,,,,,,,,,,,,,
CATHETER RF ENDOVENOUS ABLAT CLOSUREFAST 60CM,SUP-2120510,CDM,C1760,HCPCS,0278,RC,,,,both,,,1130.40,734.76,,,,,,,,,,,,,
HC Biopsy Soft Tissue Thigh/Knee Area Superficial,PX-3612732300,CDM,27323,CPT,0361,RC,,,,both,,,5104.00,3317.60,,,,,,,,,,,,,
ALLOGRAFT BNE RNG FD ULNA,SUP-2321918,CDM,C1713,HCPCS,0278,RC,,,,both,,,1664.20,1081.73,,,,,,,,,,,,,
MATRIX BIO L 7 X W 3 CM FISH SKIN DERMAL INTACT OMEGA3 10/BX,SUP-2909380,CDM,Q4158,HCPCS,0636,RC,,,,both,,,3592.16,2334.90,,,,,,,,,,,,,
GRAFT VASC DYNAFLO L 50 CM DIA 8 MM EPTFE CARBON PERIPH STR,SUP-2126821,CDM,C1768,CPT,0278,RC,,,,both,,,4552.91,2959.39,,,,,,,,,,,,,
SPLINT ORTHOPEDIC ANTIMICROBIAL WHFO LG RT HND,SUP-2325146,CDM,L3809,HCPCS,0272,RC,,,,both,,,142.65,92.72,,,,,,,,,,,,,
ALLOGRAFT HUM TISS PERICARD 30X40 MM PUROS,SUP-2335277,CDM,C1762,CPT,0278,RC,,,,both,,,1114.70,724.55,,,,,,,,,,,,,
BOOT TRACTION LOOP LCK CLOSURE MED ECON BUCK,SUP-2336328,CDM,L4398,HCPCS,0272,RC,,,,both,,,28.29,18.39,,,,,,,,,,,,,
LEAD NERVE STIM 16 60 CM LAMITRODE TRIPOLE,SUP-2615510,CDM,C1778,HCPCS,0278,RC,,,,both,,,14130.00,9184.50,,,,,,,,,,,,,
SPLINT ORTHOPEDIC ANTIMICROBIAL WHFO LG RT HND,SUP-2325146,CDM,L3809,HCPCS,0274,RC,,,,both,,,142.65,92.72,,,,,,,,,,,,,
PLATE BONE L96.5MM 5 H LT DSTL FIB TI ANAT FOR 2.7/3/3.5/4MM,SUP-2225370,CDM,C1713,HCPCS,0278,RC,,,,both,,,4416.10,2870.46,,,,,,,,,,,,,
SHEATH INTRO 24FR L28CM ID8.2MM DRYSEAL,SUP-2396260,CDM,C1894,HCPCS,0272,RC,,,,both,,,1083.30,704.14,,,,,,,,,,,,,
CATHETER NEPHROSTOMY PIG TIP 12 FRX25 CM SFT FLEXIMA,SUP-2147846,CDM,C1729,HCPCS,0272,RC,,,,both,,,238.64,155.12,,,,,,,,,,,,,
MORCELLATOR ENDO 15MM OBT DISPOSABLEXCISE,SUP-2265061,CDM,C1782,HCPCS,0272,RC,,,,both,,,2351.86,1528.71,,,,,,,,,,,,,
PLATE BNE 16 H R DST CLAV LOK FOR 2.3MM SCR,SUP-2106963,CDM,C1713,HCPCS,0278,RC,,,,both,,,3720.90,2418.58,,,,,,,,,,,,,
GRAFT HUMAN TISSUE THICK 16X25 CM HYDRATED BIOLOGIC TISSUE M,SUP-2838617,CDM,C1763,HCPCS,0278,RC,,,,both,,,37122.02,24129.31,,,,,,,,,,,,,
GRAFT VASC VLV 19 MM AORT ROTATABLE STENT MSTR SER,SUP-2356695,CDM,C1889,HCPCS,0278,RC,,,,both,,,11304.00,7347.60,,,,,,,,,,,,,
ALLOGRAFT BNE RAD SHFT 101-159X2 MM FRZN,SUP-2717879,CDM,C1762,CPT,0278,RC,,,,both,,,3846.50,2500.22,,,,,,,,,,,,,
LINER ACET OD68MM ID32MM THK12.4MM 10DEG LONGEVITY,SUP-2202590,CDM,C1776,CPT,0278,RC,,,,both,,,2139.28,1390.53,,,,,,,,,,,,,
GRAFT VASC FLIXENE L 80 CM DIA 8 MM EPTFE TRMPT GRAD WALL,SUP-2525474,CDM,C1768,CPT,0278,RC,,,,both,,,3906.82,2539.43,,,,,,,,,,,,,
COLLAR CERV H3XL22IN UNIV COT M DENS FOAM BRTH ADJ,SUP-2335994,CDM,L0120,HCPCS,0274,RC,,,,both,,,15.51,10.08,,,,,,,,,,,,,
COIL NEUROVASCULAR CASHMERE 14 L 3 CM LOOP DIA 3 MM PRIMARY,SUP-2249261,CDM,C1889,HCPCS,0278,RC,,,,both,,,3776.79,2454.91,,,,,,,,,,,,,
BOLT EXT FIX HALF PIN FIX STRL TRUELOK EVO LTX,SUP-2875631,CDM,2720000010,LOCAL,0272,RC,,,,both,,,288.69,187.65,,,,,,,,,,,,,
ANCHOR SPNL 13 MM COALITION MIS,SUP-2733248,CDM,C1889,HCPCS,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
SCREW BONE LOK 6.5MM DIA 45MML TIMAX CNCLLS HXGNL HEAD 22MML,SUP-2588747,CDM,C1713,HCPCS,0278,RC,,,,both,,,135.52,88.09,,,,,,,,,,,,,
CATHETER PICC L50CM OD5FR DBL LUMN BASIC,SUP-2383963,CDM,C1751,HCPCS,0278,RC,,,,both,,,1515.30,984.94,,,,,,,,,,,,,
PLATE BNE L333MM BLDE W5.8XL38MM 135DEG 20 H ST BILAT PELV,SUP-2186592,CDM,C1713,HCPCS,0278,RC,,,,both,,,3152.34,2049.02,,,,,,,,,,,,,
BLADE SURG 6 MF6 INSRT TIP,SUP-2423795,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
PROBE NRV STIM BALL TIP DISP M5,SUP-2310417,CDM,C1713,HCPCS,0278,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
HC Xray Cystogram Voiding,PX-3207445500,CDM,74455,CPT,0320,RC,,,,both,,,950.00,617.50,,,,,,,,,,,,,
PLATE BNE LCK 5X196 MM RT DSTL FEM 7 HOLE COMPR SS NS LCP,SUP-2184891,CDM,C1713,HCPCS,0278,RC,,,,both,,,4392.55,2855.16,,,,,,,,,,,,,
CROSSLINK SPNL TITLE 2 IMP T LINK 50MM GLDN GATE,SUP-2205496,CDM,C1713,HCPCS,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
IMPLANT OTO L4MM PIST DIA0.5MM NIT FLROPLAS SMRT,SUP-2313862,CDM,2780000010,LOCAL,0278,RC,,,,both,,,950.48,617.81,,,,,,,,,,,,,
ES TROCH NAIL LEFT 10MMX39CM X125 DEGREE,SUP-2828767,CDM,C1713,HCPCS,0278,RC,,,,both,,,9090.30,5908.69,,,,,,,,,,,,,
CATHETER SUPP NAVIEN L 105 CM OD 0.084 IN ID 0.072 IN FLX,SUP-2522810,CDM,C1887,HCPCS,0272,RC,,,,both,,,3846.50,2500.22,,,,,,,,,,,,,
INSERT TIB PRIMARY 25 MM PCA,SUP-2451596,CDM,C1776,CPT,0278,RC,,,,both,,,2129.67,1384.29,,,,,,,,,,,,,
SCREW BNE EMGCY 2X10 MM STARDRV RECESS TI NS,SUP-2188968,CDM,C1713,HCPCS,0278,RC,,,,both,,,887.05,576.58,,,,,,,,,,,,,
STAPLER INT CIR XL MED THCK 31 MM 3-4 MM PUR EEA,SUP-2787720,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5078.86,3301.26,,,,,,,,,,,,,
KNIFE SURG ROSEN 45-90 DEG 7-5/8 INX193 MM CART DBL END LF,SUP-2498652,CDM,2720000010,LOCAL,0272,RC,,,,both,,,358.68,233.14,,,,,,,,,,,,,
HANDPIECE ELECSURG SONICFUSION,SUP-2484828,CDM,C1713,HCPCS,0278,RC,,,,both,,,19342.40,12572.56,,,,,,,,,,,,,
LINER ACET 2 MOBILITY H 50 MM PROV G7,SUP-2441322,CDM,C1776,CPT,0278,RC,,,,both,,,621.72,404.12,,,,,,,,,,,,,
COMPONENT FEM KNEE POST STABILIZING UNISX REV CEM STEM LT RT,SUP-2199737,CDM,C1776,CPT,0278,RC,,,,both,,,17226.04,11196.93,,,,,,,,,,,,,
LEUPROLIDE ACETATE 7.5 MG IM KIT,RX-10392,CDM,J9217,HCPCS,0636,RC,00074-3642-03,NDC,,both,1,UN,656.90,426.98,,,,,,,,,,,,,
CATHETER CV JACC 5.5 FRX30 CM DL PRESSURE INJ ADV LF,SUP-2763378,CDM,C1751,HCPCS,0278,RC,,,,both,,,814.30,529.29,,,,,,,,,,,,,
CENTRALIZER STEM DIA13MM DST FEM HIP NP CEM PFC SIG,SUP-2253266,CDM,C1713,HCPCS,0278,RC,,,,both,,,422.02,274.31,,,,,,,,,,,,,
BUR SURG CYL 5 MMX14 CM LG BOR MIDAS REX LEGEND,SUP-2627693,CDM,2720000010,LOCAL,0272,RC,,,,both,,,428.86,278.76,,,,,,,,,,,,,
METOCLOPRAMIDE HCL 10 MG PO TABS,RX-5005,CDM,6370000000,HCPCS,0637,RC,60687-0631-11,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
ETODOLAC 200 MG PO CAPS,RX-9997,CDM,6370000000,HCPCS,0637,RC,62559-0250-01,NDC,,both,1,UN,5.00,3.25,,,,,,,,,,,,,
BURR DIAMOND DISK 25.4MM MHD25DDG1,SUP-2843307,CDM,2720000010,LOCAL,0272,RC,,,,both,,,786.07,510.95,,,,,,,,,,,,,
GRAFT TISS FRZ DRY ALLGRFT STRUT CORT TRAD 60X5MM SM,SUP-2294111,CDM,C1713,HCPCS,0278,RC,,,,both,,,2147.76,1396.04,,,,,,,,,,,,,
WAND ARTHSCP 90DEG ABLAT HK COOLCUT,SUP-2123443,CDM,C1713,HCPCS,0278,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
HC Pt Manual Therapy Ea 15|OP PT SERVICES|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS|UNUSUAL NON-OVERLAPPING SERVICE,PX-4209714000,CDM,97140,CPT,0420,RC,,,GP|CQ|XU,both,,,194.00,126.10,,,,,,,,,,,,,
PROSTHESIS OSS 4X51 MM CENTERED HD FULL RICHARDS PORP HA,SUP-2312572,CDM,L8613,CPT,0278,RC,,,,both,,,1069.42,695.12,,,,,,,,,,,,,
PROBE COAG L350CM CHN 28MM TIP 7FR 2 PLUG W FIX PIN CONN,SUP-2313020,CDM,2720000010,LOCAL,0272,RC,,,,both,,,822.90,534.88,,,,,,,,,,,,,
GRAFT VASC BEND 4 IN SEAL OUTFLO HEARTMATE II,SUP-2356000,CDM,L8670,HCPCS,0278,RC,,,,both,,,15072.00,9796.80,,,,,,,,,,,,,
GRAFT DERMAL PLIABLE PRE THN LG 24X21 CMX0.7-1.4 MM FLEXHD,SUP-2422950,CDM,Q4128,HCPCS,0636,RC,,,,both,,,41499.06,26974.39,,,,,,,,,,,,,
CATHETER EP MED CRV 5 MM SPACING 6 FR INQUIRY,SUP-2102279,CDM,C1730,HCPCS,0272,RC,,,,both,,,1438.12,934.78,,,,,,,,,,,,,
COLLAR EXTRIC AD REG 2 PC TRACH OPN VELC CLSR W/ CHIN SUPP,SUP-2194469,CDM,L0180,HCPCS,0274,RC,,,,both,,,61.83,40.19,,,,,,,,,,,,,
IMMOBILIZER ORTH CUTAWAY UNIV 18 IN KNEE ADJ PERF FOAM,SUP-2194899,CDM,L1830,CPT,0274,RC,,,,both,,,62.80,40.82,,,,,,,,,,,,,
"HC So Cortisol,Serum",PX-3018253366,CDM,82533,CPT,0301,RC,,,,inpatient,,,212.00,137.80,,,,,,,,,,,,,
BELT STBL SM 100759] ST JUDE MED THORATEC],SUP-2355989,CDM,C1713,HCPCS,0278,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
SCREW INTRF L25MM DIA9MM 1 TI CANN FLX NONABSORBABLE TAPR HD,SUP-2342264,CDM,C1713,HCPCS,0278,RC,,,,both,,,342.26,222.47,,,,,,,,,,,,,
PLATE BONE L109MM 9 H S STL SELF COMPR FOR 3.5MM SCR ECT,SUP-2198566,CDM,C1713,HCPCS,0278,RC,,,,both,,,293.40,190.71,,,,,,,,,,,,,
CLIP HEMSTAS L2300MM DIA275MM OPNING 11MM OPN CLOSE,SUP-2313203,CDM,2720000010,LOCAL,0272,RC,,,,both,,,648.98,421.84,,,,,,,,,,,,,
FORCEP TISS ROSANO,SUP-2245978,CDM,2720000010,LOCAL,0272,RC,,,,both,,,476.37,309.64,,,,,,,,,,,,,
CANNULA ENDOSCP HEINKELSEMM DIL SET FOR 9916,SUP-2766870,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1371.08,891.20,,,,,,,,,,,,,
COMPONENT FEM SZ 4 LT KNEE NP PRI CRUC STABILIZING CRUC RET,SUP-2304562,CDM,C1776,CPT,0278,RC,,,,both,,,6280.00,4082.00,,,,,,,,,,,,,
GRAFT DURA REP L7 X W 7 CM THK 0.4 MM ELECTROSPUN FIBER,SUP-2904024,CDM,C1763,HCPCS,0278,RC,,,,both,,,5102.50,3316.62,,,,,,,,,,,,,
ALLOGRAFT HUM TISS ALLOPATCH PLIABLE MESHED 4X8CM,SUP-2905509,CDM,Q4128,HCPCS,0636,RC,,,,both,,,5181.00,3367.65,,,,,,,,,,,,,
PLATE BNE THK 0.5 MM SCREW DIA1.7 MM 3 X 21 H PLL STRUT,SUP-2883358,CDM,C1713,HCPCS,0278,RC,,,,both,,,16060.85,10439.55,,,,,,,,,,,,,
PEGINTERFERON ALFA-2A 180 MCG/ML SC SOLN,RX-34034,CDM,J3590,HCPCS,0636,RC,82154-0449-01,NDC,,both,1,ML,3284.60,2134.99,,,,,,,,,,,,,
COMPONENT FEM L65MM L KNEE POR ANAT PRI MAXM,SUP-2405270,CDM,C1776,CPT,0278,RC,,,,both,,,5966.00,3877.90,,,,,,,,,,,,,
GRAFT SURG REGEN PORCINE CLLGN XENMATRIX RECT 10CM X 28CM,SUP-2126241,CDM,C1781,HCPCS,0278,RC,,,,both,,,26844.80,17449.12,,,,,,,,,,,,,
PLATE BONE L35MM THK0.8MM ORBIT FLR POLYETH TI REINF SYNPOR,SUP-2182842,CDM,C1713,HCPCS,0278,RC,,,,both,,,2035.35,1322.98,,,,,,,,,,,,,
CATHETER HD CRV EXTN 11 FRX12 CM CATH NDL DUOFLO,SUP-2627068,CDM,C1752,HCPCS,0278,RC,,,,both,,,593.46,385.75,,,,,,,,,,,,,
RING EXT FIX HALF 210 MM 6 TAB ALUM RINGFIX,SUP-2530905,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4510.30,2931.69,,,,,,,,,,,,,
DRILL TWST L 105 MM DIA1.1 MM STP 18 MM SCREW DIA1.5 MM NS,SUP-2883836,CDM,2720000010,LOCAL,0272,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
SPLINT ANK FT L R POST LEAF LTWT SEMI RIG ROLYAN,SUP-2324822,CDM,L4397,HCPCS,0272,RC,,,,both,,,98.56,64.06,,,,,,,,,,,,,
CATHETER URETH SPRL FILIFORM TIP 5 FRX70 CM WOVEN BLASUCCI,SUP-2126133,CDM,C1758,HCPCS,0278,RC,,,,both,,,266.27,173.08,,,,,,,,,,,,,
COMPONENT TIB KNEE TY CRUC RET POR STEM MEDL LEFT/LAT RT,SUP-2199626,CDM,C1776,CPT,0278,RC,,,,both,,,15659.81,10178.88,,,,,,,,,,,,,
STENT BILI EPIC L 100 MM DIA10 MM CATH L 220 CM DIA 6 FR,SUP-2436475,CDM,C1876,HCPCS,0278,RC,,,,both,,,4835.13,3142.83,,,,,,,,,,,,,
PLATE BONE L91MM 6 H STRL RT LAT PROX TIB S STL PART ARTC,SUP-2349712,CDM,C1713,HCPCS,0278,RC,,,,both,,,7142.40,4642.56,,,,,,,,,,,,,
EXPANDER BRST W14.6XH12.6CM P7.6CM 650CC W/ SUT TAB M HT,SUP-2300656,CDM,C1789,HCPCS,0278,RC,,,,both,,,4443.10,2888.01,,,,,,,,,,,,,
CROWN FORM DENT STRP U2 PRIMARY ANTR UPPER LT LAT PLAS,SUP-2322246,CDM,D6783,CPT,0278,RC,,,,both,,,43.30,28.14,,,,,,,,,,,,,
HEAD UPLR DIA38MM FEM SOLITUDE,SUP-2314465,CDM,C1776,CPT,0278,RC,,,,both,,,954.56,620.46,,,,,,,,,,,,,
CATHETER VENTRICULAR DRAINAGE L600MM SILICONE PERITONEAL BAR,SUP-2830497,CDM,C1729,HCPCS,0272,RC,,,,both,,,393.38,255.70,,,,,,,,,,,,,
GRAFT DURAGEN W3XL3IN REABSORBABLE MTRX EACH=5 UNITS,SUP-2922516,CDM,C1763,HCPCS,0278,RC,,,,both,,,1464.03,951.62,,,,,,,,,,,,,
HC Canalith Repositioning Proc|OP PT SERVICES,PX-4209599200,CDM,95992,CPT,0420,RC,,,GP,both,,,333.00,216.45,,,,,,,,,,,,,
PLATE B1 THK1.8MM 6 H STRNL THOR CP TI STR LCK LEV 1 FOR,SUP-2262580,CDM,C1713,HCPCS,0278,RC,,,,both,,,1415.20,919.88,,,,,,,,,,,,,
PEG FIX L24MM DIA2.7MM CORT TI THRD NONLOCKING FOR DSTL,SUP-2340280,CDM,C1713,HCPCS,0278,RC,,,,both,,,979.68,636.79,,,,,,,,,,,,,
PLATE BNE CERV SM 2.7X60 MM 7 HOLE SS,SUP-2473099,CDM,C1713,HCPCS,0278,RC,,,,both,,,389.05,252.88,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC SV MAXBARR 4FR 55CM 2 LUMAN RVS TAP,SUP-2613435,CDM,C1751,HCPCS,0278,RC,,,,both,,,734.19,477.22,,,,,,,,,,,,,
BRACE ELBW C SHP REINF ADJ COUNTERFORCE VISCOELASTIC POLYMER,SUP-2324053,CDM,L3702,HCPCS,0272,RC,,,,both,,,137.66,89.48,,,,,,,,,,,,,
TIP SUCT L3.13IN DIA0.1IN 23KHZ FLUE CUSA EXCEL MACROTIP,SUP-2243956,CDM,C1713,HCPCS,0278,RC,,,,both,,,508.68,330.64,,,,,,,,,,,,,
NUCLEUS PROFILE PLUS W/ SLIM 20 ELECTRODE (CI624),SUP-2858186,CDM,L8614,HCPCS,0278,RC,,,,both,,,75666.15,49183.00,,,,,,,,,,,,,
SET INTRO MICROPUNCTURE CATH L 15 CM DIA 5 FR SS PLAT,SUP-2635415,CDM,C1894,HCPCS,0272,RC,,,,both,,,76.74,49.88,,,,,,,,,,,,,
LOCK SCREW SQUARE 3.5X8MM STERILE,SUP-2587138,CDM,C1713,HCPCS,0278,RC,,,,both,,,302.10,196.36,,,,,,,,,,,,,
PROSTHESIS PENILE 18CM N PRECONN SNAP FIT RT LGX,SUP-2139018,CDM,C1813,HCPCS,0278,RC,,,,both,,,24466.88,15903.47,,,,,,,,,,,,,
CATHETER GUID L57CM OD7.1FR 90DEG PEBA POLYAMIDE 12 CRV FOR,SUP-2282183,CDM,C1887,HCPCS,0272,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
GUN DEPLOYMENT ANCHR AND INSTR VERSA-LOK,SUP-2249391,CDM,C1713,HCPCS,0278,RC,,,,both,,,2668.84,1734.75,,,,,,,,,,,,,
AML/TL ENDR REP LINER 32X44SP,SUP-2513025,CDM,C1776,CPT,0278,RC,,,,both,,,4588.17,2982.31,,,,,,,,,,,,,
HC So Testosterone Total|NOT REASONABLE AND NECESSARY,PX-3018440366,CDM,84403,CPT,0301,RC,,,GZ,both,,,118.00,76.70,,,,,,,,,,,,,
PLATE SPNL L57MM ANT BILAT THORLUM TI LOK,SUP-2193093,CDM,C1713,HCPCS,0278,RC,,,,both,,,7174.90,4663.68,,,,,,,,,,,,,
PLATE BONE NON LOCKING SMALL 3.5X41 MM CORTICAL 2 HOLE COMPR,SUP-2837373,CDM,C1713,HCPCS,0278,RC,,,,both,,,1175.68,764.19,,,,,,,,,,,,,
BLADE ENDOSCP SHAVER 12 DEG L 11 CM DIA 3.5 MM SPD 5000 RPM,SUP-2902021,CDM,2720000010,LOCAL,0272,RC,,,,both,,,630.51,409.83,,,,,,,,,,,,,
HC Med Nut Therapy Ind Init 15 Min,PX-9429780200,CDM,97802,CPT,0942,RC,,,,both,,,95.00,61.75,,,,,,,,,,,,,
PLATE BONE NC FUS 1.5MM THICKNESS LT SM,SUP-2321508,CDM,C1713,HCPCS,0278,RC,,,,both,,,6143.41,3993.22,,,,,,,,,,,,,
SET URET STENT CNTOUR L 24 CM DIA 4.8 FR PTFE GUIDEWIRE SLV,SUP-2462210,CDM,C2617,HCPCS,0278,RC,,,,both,,,465.41,302.52,,,,,,,,,,,,,
CARD DATA SYS MONITOR FOR COLLECTING LOG FILE INFO,SUP-2355991,CDM,C1713,HCPCS,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
AUGMENT TIB STD SZ 11 COMPLT 5 DEG CEM UNIV WDG SCORP,SUP-2378538,CDM,C1776,CPT,0278,RC,,,,both,,,4495.22,2921.89,,,,,,,,,,,,,
PLATE BONE LOCKING HOLEX10 LEFT MEDIAL DISTAL TIBIAL,SUP-2499627,CDM,C1713,HCPCS,0278,RC,,,,both,,,4305.38,2798.50,,,,,,,,,,,,,
BUR SURG HD L18.3MM DIA3MM CARB MTL CUT LEGEND,SUP-2284690,CDM,2720000010,LOCAL,0272,RC,,,,both,,,580.05,377.03,,,,,,,,,,,,,
MATRIX BIO L 10 X W 4 IN BOV CLLGN CHONDROITIN-6-SULFATE,SUP-2909211,CDM,Q4108,HCPCS,0636,RC,,,,both,,,22995.04,14946.78,,,,,,,,,,,,,
HMRS ROT HINGE TIBIAL ROTATING COMPONENT,SUP-2512643,CDM,C1776,CPT,0278,RC,,,,both,,,13383.94,8699.56,,,,,,,,,,,,,
BIT DRL CANLT W/AO 2.0MM INTOSS FXTN SYS,SUP-2400074,CDM,2720000010,LOCAL,0272,RC,,,,both,,,590.32,383.71,,,,,,,,,,,,,
BIT DRL L233MM DIA4.5MM CANN FOR LC ANG BLDE PLT,SUP-2187341,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1111.40,722.41,,,,,,,,,,,,,
HC Assay of Parathormone,PX-3018397000,CDM,83970,CPT,0301,RC,,,,both,,,308.00,200.20,,,,,,,,,,,,,
CLASSIC CHS PL 10 SLOT 145 DEG,SUP-2818262,CDM,C1713,HCPCS,0278,RC,,,,both,,,5741.33,3731.86,,,,,,,,,,,,,
MICROCATHETER ETER VASC DST 25FR PROX 28FR L154CM TIP,SUP-2418600,CDM,C1887,HCPCS,0272,RC,,,,both,,,4136.95,2689.02,,,,,,,,,,,,,
PLATE BONE RECONSTRUCTION 4.5X221 MM 14 HOLE FOR SCREW STERI,SUP-2836649,CDM,C1713,HCPCS,0278,RC,,,,both,,,4340.27,2821.18,,,,,,,,,,,,,
SCREW BNE L5MM DIA2MM CORT CRANIOMAXILLOFACIAL G TI ST 5PK,SUP-2366116,CDM,C1713,HCPCS,0278,RC,,,,both,,,164.25,106.76,,,,,,,,,,,,,
ROD SPNL ANTR RT SMOOTH 5.0MM DIA 600MM LEN,SUP-2290521,CDM,C1713,HCPCS,0278,RC,,,,both,,,2411.52,1567.49,,,,,,,,,,,,,
CAGE SPNL L W10XH10XL30MM 5DEG ANT CERV INTBDY FUS PEEK,SUP-2310886,CDM,C1889,HCPCS,0278,RC,,,,both,,,7614.50,4949.42,,,,,,,,,,,,,
BUR SURG SPRL 2.3X16.4 MM 8 CM TAPR FOOTED SM BOR MIDAS REX,SUP-2631920,CDM,2720000010,LOCAL,0272,RC,,,,both,,,279.43,181.63,,,,,,,,,,,,,
CURETTE SURG 000 9 IN CERV AX CUT BKWRD ANGLED DN STRL ULTRA,SUP-2473466,CDM,2720000010,LOCAL,0272,RC,,,,both,,,593.30,385.64,,,,,,,,,,,,,
PLATE 3.5MM CURVED BROAD LCP 12H TI STRL,SUP-2546933,CDM,C1713,HCPCS,0278,RC,,,,both,,,2511.50,1632.47,,,,,,,,,,,,,
MESH SURG L 22 X W 10 CM POLYPRO SHT,SUP-2929632,CDM,C1781,HCPCS,0278,RC,,,,both,,,2804.02,1822.61,,,,,,,,,,,,,
STEM TIB L75MM DIA10MM KNEE EXTN STABILIZING PRI FLUT,SUP-2253311,CDM,C1713,HCPCS,0278,RC,,,,both,,,3639.26,2365.52,,,,,,,,,,,,,
STENT URETH FIRLIT-KLUGE L 31 CM DIA 8 FR SIL BALL/TUBING,SUP-2826947,CDM,C2617,HCPCS,0278,RC,,,,both,,,105.76,68.74,,,,,,,,,,,,,
MESH HERN W2XL4IN VENTRAL INGUINAL POLYPR REP MFIL,SUP-2125744,CDM,C1781,HCPCS,0278,RC,,,,both,,,121.46,78.95,,,,,,,,,,,,,
ALLOGRAFT BNE CUBE 12X12X12 MM DEMINERALIZED CANC LIFEFLEX,SUP-2866838,CDM,C1762,CPT,0278,RC,,,,both,,,1407.98,915.19,,,,,,,,,,,,,
ROD SPNL L31CM DIA635MM QTR UNIT,SUP-2289676,CDM,C1713,HCPCS,0278,RC,,,,both,,,3881.04,2522.68,,,,,,,,,,,,,
HC Smr Prim Src Wet Mount Nfct Agt,PX-3008721000,CDM,87210,CPT,0300,RC,,,,both,,,207.00,134.55,,,,,,,,,,,,,
PLATE 4.5MM 3.5MM TI LCP METAPHYSEAL 12 HOLES,SUP-2549475,CDM,C1713,HCPCS,0278,RC,,,,both,,,2995.47,1947.06,,,,,,,,,,,,,
MESH CRAN W40XL40MM THK0.3MM CRANIOFACIAL TI DYN MAL FOR,SUP-2366216,CDM,C1713,HCPCS,0278,RC,,,,both,,,4173.66,2712.88,,,,,,,,,,,,,
PLATE BONE COMPRESSION 3.5 MM 7 HOLE SMALL FRAGMENT SET FOR,SUP-2836958,CDM,C1713,HCPCS,0278,RC,,,,both,,,1312.74,853.28,,,,,,,,,,,,,
COMPONENT TOE L18MM DIA9.5MM MT CE TAPR POST HEMICAP,SUP-2123594,CDM,C1776,CPT,0278,RC,,,,both,,,2000.18,1300.12,,,,,,,,,,,,,
NITROGLYCERIN 0.1 MG/HR TD PT24,RX-27471,CDM,6370000000,HCPCS,0637,RC,00378-9102-16,NDC,,both,1,UN,2.80,1.82,,,,,,,,,,,,,
GRAFT VASC STR STD WALL N RING EPTFE 6MM DIA 80CM LEN,SUP-2126679,CDM,C1768,CPT,0278,RC,,,,both,,,2850.96,1853.12,,,,,,,,,,,,,
DEVICE CLSR 10/12MM XL PRT SYS SUT PASS ST DISP CARTER,SUP-2171695,CDM,2720000010,LOCAL,0272,RC,,,,both,,,617.54,401.40,,,,,,,,,,,,,
HC MRI-Brain W Contrast,PX-6117055200,CDM,70552,CPT,0611,RC,,,,both,,,4146.00,2694.90,,,,,,,,,,,,,
CEFDINIR 300 MG PO CAPS,RX-22289,CDM,6370000000,HCPCS,0637,RC,65862-0177-60,NDC,,both,1,UN,3.80,2.47,,,,,,,,,,,,,
SHEATH INTRO PRELUDE SNAP L 13 CM DIA 10 FR L 50/80 CM,SUP-2739252,CDM,C1892,HCPCS,0272,RC,,,,both,,,326.56,212.26,,,,,,,,,,,,,
RING EXT FIX DIA220 MM 1/2 CIR,SUP-2898403,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3108.60,2020.59,,,,,,,,,,,,,
HC Vertebroplasty Addl Inject,PX-3612251200,CDM,22512,CPT,0361,RC,,,,both,,,10303.00,6696.95,,,,,,,,,,,,,
PLATE BNE CRV SHT 1.5 MM FRAC LCK MOD TI,SUP-2489763,CDM,C1713,HCPCS,0278,RC,,,,both,,,1873.48,1217.76,,,,,,,,,,,,,
PREGABALIN 150 MG PO CAPS,RX-42166,CDM,6370000000,HCPCS,0637,RC,62332-0123-90,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PROSTHESIS OSS EAR 3X0.5 MM FRISBEE MYRINGOPEXY STAPE TI,SUP-2232497,CDM,L8613,CPT,0278,RC,,,,both,,,832.10,540.86,,,,,,,,,,,,,
HC MRI Lower Ext W/O Cont,PX-6107371800,CDM,73718,CPT,0610,RC,,,,both,,,3764.00,2446.60,,,,,,,,,,,,,
SCREW BNE L 80 MM DIA 6.5 MM CANN STRL EVOS,SUP-2931302,CDM,C1713,HCPCS,0278,RC,,,,both,,,1364.33,886.81,,,,,,,,,,,,,
"HC Debridement, Skin, Sub-Q Tissue,Each Add 20 Sq Cm",PX-4501104500,CDM,11045,CPT,0450,RC,,,,both,,,207.00,134.55,,,,,,,,,,,,,
BUTTON FIXATION 4.5X14MM CORTICAL FEMORAL ADJUSTABLE BTB GRA,SUP-2825173,CDM,C1713,HCPCS,0278,RC,,,,both,,,1119.98,727.99,,,,,,,,,,,,,
BLADE SURG SAFETY SZ 21 STAINLES STL BARD PARKER LTXFRDM STR,SUP-2605893,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2.79,1.81,,,,,,,,,,,,,
GRAFT BNE PLNTR WDG CANC COT 7MMX14MMX10MMX25MM,SUP-2321718,CDM,C1713,HCPCS,0278,RC,,,,both,,,4097.70,2663.50,,,,,,,,,,,,,
STEM FEM L200MM OD9MM RT HIP POR NONCOATED TYP 1 TAPR PRI,SUP-2406644,CDM,C1776,CPT,0278,RC,,,,both,,,17885.44,11625.54,,,,,,,,,,,,,
PEG BONE FXTN L20MM D2.2MM DST VOLAR RDL SMOOTH LOK CRSSLCK,SUP-2478013,CDM,C1713,HCPCS,0278,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
STENT URET UNIVERSA FIRM L 26 CM DIA 6 FR POLYUR AQ BRAIDED,SUP-2170688,CDM,C2617,HCPCS,0278,RC,,,,both,,,498.95,324.32,,,,,,,,,,,,,
PROBE RF MPLR LIGMNT CHSL HK MIC ABLAT VULCAN,SUP-2341614,CDM,C1713,HCPCS,0278,RC,,,,both,,,567.08,368.60,,,,,,,,,,,,,
HEAD FEM DIA44MM OFFSET +15MM 12 14 TAPR HIP ASPHERE M SPEC,SUP-2251154,CDM,C1776,CPT,0278,RC,,,,both,,,8370.61,5440.90,,,,,,,,,,,,,
SET GJ CATHETER L7CM DIA22X102FR DBL LUMN 2 SIDEPRT NDL ADPT,SUP-2168098,CDM,C1713,HCPCS,0278,RC,,,,both,,,1110.62,721.90,,,,,,,,,,,,,
SMALL PLATE 14X169MM 3.5MM,SUP-2818478,CDM,C1713,HCPCS,0278,RC,,,,both,,,2990.98,1944.14,,,,,,,,,,,,,
RING EXT FIX FOOT LNG HOFF ALUM 180MM,SUP-2496206,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5174.72,3363.57,,,,,,,,,,,,,
SET ORTH L13.5MM DIA3.5MM W/ DRL GUID DRL BIT TAP FOR DX,SUP-2123214,CDM,C1713,HCPCS,0278,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
BIT DRL K WIRE 1.6X200 MM 2 MM FOR SCR VARIAX,SUP-2613646,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1051.90,683.73,,,,,,,,,,,,,
BLADE SHV L11CM DIA2MM 3000RPM LNG STR SNUS M4 ROT INFERIOR,SUP-2284123,CDM,2720000010,LOCAL,0272,RC,,,,both,,,927.93,603.15,,,,,,,,,,,,,
PLATE BONE L84MM 4 H BILAT TI T SHP LIMIT CNTCT DYN LCK,SUP-2190890,CDM,C1713,HCPCS,0278,RC,,,,both,,,934.28,607.28,,,,,,,,,,,,,
NEEDLE SPNL TIG 3.7X20-45 MM PEDCL ACCS LT,SUP-2538789,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1841.99,1197.29,,,,,,,,,,,,,
SCREW BNE EMGCY 1.2X7 MM MAND X DRV TI,SUP-2470631,CDM,C1713,HCPCS,0278,RC,,,,both,,,220.27,143.18,,,,,,,,,,,,,
SCREW BONE L28MM DIA4MM CORT SLD,SUP-2123643,CDM,C1713,HCPCS,0278,RC,,,,both,,,938.86,610.26,,,,,,,,,,,,,
CATHETER ANGIO SOFT-VU L 80 CM 5 FR 0.035 IN SOS OMNI2 SFT,SUP-2116772,CDM,C1887,HCPCS,0272,RC,,,,both,,,59.03,38.37,,,,,,,,,,,,,
PLATE BNE R MT CX CROSSCHECK,SUP-2399298,CDM,C1713,HCPCS,0278,RC,,,,both,,,6543.76,4253.44,,,,,,,,,,,,,
STAPLER INT REINF 60 MM BRTRC BIODESIGN ECHELON 60 CSLRASC60,SUP-2737229,CDM,2720000010,LOCAL,0272,RC,,,,both,,,540.71,351.46,,,,,,,,,,,,,
CARBOPLATIN 50 MG/5ML IV SOLN,RX-39265,CDM,J9045,HCPCS,0636,RC,00703-4244-01,NDC,,both,5,ML,54.10,35.16,,,,,,,,,,,,,
GRAFT BONE TRICORT BLK FRZ DRY,SUP-2165604,CDM,C1713,HCPCS,0278,RC,,,,both,,,4239.00,2755.35,,,,,,,,,,,,,
STEM XL POROUS 18.0X260MM BOWED,SUP-2504984,CDM,C1776,CPT,0278,RC,,,,both,,,9520.48,6188.31,,,,,,,,,,,,,
DEVICE FIX 55 MM CL ULTRA ENDOBUTTON,SUP-2848587,CDM,C1713,HCPCS,0278,RC,,,,both,,,959.43,623.63,,,,,,,,,,,,,
CATHETER THOR 28FR STR SFT PLEUR-EVAC,SUP-2384355,CDM,C1729,HCPCS,0272,RC,,,,both,,,21.26,13.82,,,,,,,,,,,,,
PLATE BNE L313MM 12 H ST PROX FEM S STL HK LO PROF LOK,SUP-2186063,CDM,C1713,HCPCS,0278,RC,,,,both,,,5493.65,3570.87,,,,,,,,,,,,,
IMPLANT FACE W38XL50MM THK1.6MM R MAND ANG MEDPOR,SUP-2366494,CDM,C1713,HCPCS,0278,RC,,,,both,,,1004.80,653.12,,,,,,,,,,,,,
HC Blood Occult Peroxidase Actv Qual Other Sources,PX-3018227100,CDM,82271,CPT,0301,RC,,,,outpatient,,,67.00,43.55,,,,,,,,,,,,,
PLATE BNE W16XL299MM BLDE L70MM THK48MM 95DEG 18 H,SUP-2185509,CDM,C1713,HCPCS,0278,RC,,,,both,,,5656.46,3676.70,,,,,,,,,,,,,
GRAFT HUM TISS L 2 X W 1.5 CM AMNION-CHORION-AMNION LAYR,SUP-2909287,CDM,Q4140,HCPCS,0636,RC,,,,both,,,5047.42,3280.82,,,,,,,,,,,,,
TRIMMER MESH SPNL PYRAMESH,SUP-2280084,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2841.48,1846.96,,,,,,,,,,,,,
SYSTEM CATHETER 16FR L107CM W INTEGR HNDL FOR 23 26 29MM,SUP-2280901,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6625.40,4306.51,,,,,,,,,,,,,
BUR SURG TAPR 1.1X6.4 MM 7 CM SM BOR MIDAS REX 8 LEGEND,SUP-2664805,CDM,2720000010,LOCAL,0272,RC,,,,both,,,293.65,190.87,,,,,,,,,,,,,
HC Removal of FB,PX-4502052500,CDM,20525,CPT,0450,RC,,,,both,,,8301.00,5395.65,,,,,,,,,,,,,
CLAMP EXT FIX PENNING MINIFIX FOR 3MM SCR FIX SYS,SUP-2316504,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2265.82,1472.78,,,,,,,,,,,,,
CATHETER GUID L100CM OD7FR ID0.081IN NYL COR EXTRA BK UP,SUP-2296064,CDM,C1887,HCPCS,0272,RC,,,,both,,,141.30,91.84,,,,,,,,,,,,,
PLATE BNE FUSION RT ANTR ANK 7 HOLE CONSTRUCT,SUP-2609568,CDM,C1713,HCPCS,0278,RC,,,,both,,,6595.19,4286.87,,,,,,,,,,,,,
LINER ACET SZ DMD OD48MM ID28MM YEL HIP HIGHCROSS DBL,SUP-2267317,CDM,C1776,CPT,0278,RC,,,,both,,,5465.80,3552.77,,,,,,,,,,,,,
SNARE ENDOSCP MUCOSECTOMY XL 1.5X2.5 CM 7 FR 11-14 MM DUETTE,SUP-2737290,CDM,2720000010,LOCAL,0272,RC,,,,both,,,920.02,598.01,,,,,,,,,,,,,
THORACIC AND LUM CD HORION LEG PEEK ROD SYS CA SCR MOD,SUP-2279435,CDM,C1713,HCPCS,0278,RC,,,,both,,,753.60,489.84,,,,,,,,,,,,,
COLLAR CERV FIRM DENS W CHIN SUPP AD CNTOUR W COT CVR SERP,SUP-2276598,CDM,L0120,HCPCS,0272,RC,,,,both,,,10.30,6.69,,,,,,,,,,,,,
ROD SPNL L480MM DIA5.5MM POST THORLUM CO CHROM SMOOTH STR,SUP-2256567,CDM,C1713,HCPCS,0278,RC,,,,both,,,1491.50,969.47,,,,,,,,,,,,,
CONNECTOR SPNL 10MM LAT OFFSET CLS END RECON SYS VERTEX,SUP-2289130,CDM,C1713,HCPCS,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
STEM FEM SZ 11 L145MM CEM POLISHED INTRIGUE,SUP-2406816,CDM,C1776,CPT,0278,RC,,,,both,,,7504.60,4877.99,,,,,,,,,,,,,
BUTALBITAL-ASA-CAFF-CODEINE 50-325-40-30 MG PO CAPS,RX-18214,CDM,6370000000,HCPCS,0637,RC,69238-1993-01,NDC,,both,1,UN,9.90,6.43,,,,,,,,,,,,,
STEM HUM SZ 14 L153MM STD SHLDR PORCOAT FOR ARTHROPLASTY,SUP-2250054,CDM,C1776,CPT,0278,RC,,,,both,,,7536.00,4898.40,,,,,,,,,,,,,
LINER ACET SZ F OD54-56MM ID28MM 20DEG XLPE CONSTRN PRI LOK,SUP-2348109,CDM,C1776,CPT,0278,RC,,,,both,,,2673.71,1737.91,,,,,,,,,,,,,
HEAD FEM TYP 1 3+ MM 44 MM HIP CERM,SUP-2449641,CDM,C1776,CPT,0278,RC,,,,both,,,6966.09,4527.96,,,,,,,,,,,,,
NEEDLE BX CHIBA 22 GAX9 CM,SUP-2120158,CDM,2720000010,LOCAL,0272,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
COMPONENT PAT SZ 2 L FEM CO CHROM RESTORIS MCK,SUP-2368537,CDM,C1776,CPT,0278,RC,,,,both,,,5024.00,3265.60,,,,,,,,,,,,,
PLATE BNE L32MM 6 H ZYG TI STR DYN COMPR FOR 2MM CRUCFRM,SUP-2191061,CDM,C1713,HCPCS,0278,RC,,,,both,,,1112.19,722.92,,,,,,,,,,,,,
GUIDEWIRE VASC INQWIRE L 150 CM 0.035 IN BENT CRV STR,SUP-2665403,CDM,C1769,HCPCS,0272,RC,,,,both,,,38.94,25.31,,,,,,,,,,,,,
CONE TIB SM H20MM CNTR 3DMETAL,SUP-2267615,CDM,C1776,CPT,0278,RC,,,,both,,,12385.73,8050.72,,,,,,,,,,,,,
ALLOGRAFT BNE FRSH W/ MENIS OSTEOCHNDRL RT TIB PLATEAU,SUP-2740828,CDM,C1762,CPT,0278,RC,,,,both,,,40519.09,26337.41,,,,,,,,,,,,,
BIT DRL L32MM 2IN1 CANN AO DISP FOR HALLU-LOCK MTP ARTH SYS,SUP-2243021,CDM,2720000010,LOCAL,0272,RC,,,,both,,,743.40,483.21,,,,,,,,,,,,,
GUIDEWIRE SURG L220MM DIA1.6MM NTHRD TRCR TIP S STL SMOOTH,SUP-2184963,CDM,C1769,HCPCS,0272,RC,,,,both,,,88.83,57.74,,,,,,,,,,,,,
HC So Histoplasm,PX-3028669866,CDM,86698,CPT,0302,RC,,,,both,,,96.00,62.40,,,,,,,,,,,,,
PLATE BNE LCK 234 MM RT DSTL MEDL HUM 15 HOLE GRN STRL,SUP-2470412,CDM,C1713,HCPCS,0278,RC,,,,both,,,3415.32,2219.96,,,,,,,,,,,,,
NAIL IM L360MM DIA10MM 130DEG NONSTERILE GRN FEM TI CANN,SUP-2192596,CDM,C1713,HCPCS,0278,RC,,,,both,,,3974.99,2583.74,,,,,,,,,,,,,
GRAFT BNE L210MM SHFT FEM FEM FRZN BISECTED MATRIGRFT,SUP-2264726,CDM,C1713,HCPCS,0278,RC,,,,both,,,2883.43,1874.23,,,,,,,,,,,,,
GRAFT STENT IL 0.035 IN 10 MMX2.5 CM 11 FRX120 CM VIABAHN,SUP-2396573,CDM,C1874,HCPCS,0278,RC,,,,both,,,9200.20,5980.13,,,,,,,,,,,,,
CATHETER URET 5FR L70CM 0.038IN OPN END FOR DRNGE RG,SUP-2171200,CDM,C1758,HCPCS,0278,RC,,,,both,,,75.08,48.80,,,,,,,,,,,,,
FORCEPS BPLR L33CM L5MM TWO TIER SERR FN ROUNDED TIP TAPR,SUP-2312660,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1199.48,779.66,,,,,,,,,,,,,
ADAPTER SEAL PEELABLE INNR CATH SFSHTH CPS DIR,SUP-2355663,CDM,C1894,HCPCS,0272,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
KIT STRNL CLOSURE FIBERTAPE L 36 IN DIA2 MM SUTURE X6 BLU,SUP-2930487,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4368.53,2839.54,,,,,,,,,,,,,
BIT DRL OD2MM,SUP-2366046,CDM,2720000010,LOCAL,0272,RC,,,,both,,,665.68,432.69,,,,,,,,,,,,,
MAGNESIUM SULFATE 2 GM/50ML IV SOLN,RX-131192,CDM,J3475,HCPCS,0636,RC,47335-0992-01,NDC,,both,50,ML,72.50,47.12,,,,,,,,,,,,,
KIT BNE VOID FILL IMPACT DEL CALLOS,SUP-2106913,CDM,C1713,HCPCS,0278,RC,,,,both,,,323.42,210.22,,,,,,,,,,,,,
BUR SURG STR 2.9X13 MM,SUP-2432007,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
CAP END LOK LO EXT PANTA TI ST XL,SUP-2243618,CDM,C1713,HCPCS,0278,RC,,,,both,,,1145.28,744.43,,,,,,,,,,,,,
GUIDEWIRE VASC L 180 CM DIA 0.032 IN TAPR L 6 CM FLPY TIP L,SUP-2167850,CDM,C1769,HCPCS,0272,RC,,,,both,,,43.05,27.98,,,,,,,,,,,,,
PLATE BNE L155MM THK3MM 6 H MAND TI FOR RECON SYS,SUP-2262976,CDM,C1713,HCPCS,0278,RC,,,,both,,,2313.83,1503.99,,,,,,,,,,,,,
GRAFT BONE SUB 10ML CANC CORT DEMIN BONE MTRX FRZ DRY,SUP-2212980,CDM,C1713,HCPCS,0278,RC,,,,both,,,14158.26,9202.87,,,,,,,,,,,,,
SCREW BNE CANC FULL THRD N CANN N LOK 4.0MM DIA 20MM LEN,SUP-2198337,CDM,C1713,HCPCS,0278,RC,,,,both,,,48.23,31.35,,,,,,,,,,,,,
GRAFT BNE L PROX TIB BNE TEND BNE FRZN IMPL,SUP-2307300,CDM,C1713,HCPCS,0278,RC,,,,both,,,17772.87,11552.37,,,,,,,,,,,,,
DILATOR ENDOSCP L240CM BLLN L5.5CM DIA10X11X12MM CATH 7.5FR,SUP-2141551,CDM,C1726,HCPCS,0272,RC,,,,both,,,690.39,448.75,,,,,,,,,,,,,
PROBE ABLAT DIA2MM 60DEG BLK MPLR PWR PKT ELECTRD HI FLO,SUP-2341023,CDM,2720000010,LOCAL,0272,RC,,,,both,,,526.83,342.44,,,,,,,,,,,,,
SCREW BNE CANN FOR NAIL EXTRACTION,SUP-2653750,CDM,C1713,HCPCS,0278,RC,,,,both,,,2481.39,1612.90,,,,,,,,,,,,,
BRACE ANK AD H10IN STD BILAT STRP CLSR OPN HEEL AND TOE,SUP-2195182,CDM,L4397,HCPCS,0272,RC,,,,both,,,54.51,35.43,,,,,,,,,,,,,
VALVE VENT L32MM DIA18MM THK7.5MM LO PRSS CNTOUR REG FOR,SUP-2284509,CDM,C1889,HCPCS,0278,RC,,,,both,,,2083.30,1354.14,,,,,,,,,,,,,
BASEPLATE TIB UNIV SZ 0F/1T CO CHROM MOLYBDENUM CEM PRI REV,SUP-2221010,CDM,C1776,CPT,0278,RC,,,,both,,,6782.40,4408.56,,,,,,,,,,,,,
VALVE TRICSP EVOQUE SZ 44 MM NIT SELF EXPANDABLE THERMAFIX,SUP-2930358,CDM,C1889,HCPCS,0278,RC,,,,both,,,135020.00,87763.00,,,,,,,,,,,,,
GRAFT VASC GORTX L 20 CM DIA 8 MM EPTFE STR TW N RING STRL,SUP-2396709,CDM,C1768,CPT,0278,RC,,,,both,,,794.42,516.37,,,,,,,,,,,,,
SCREW BNE L32MM DIA4MM TIB BLU TI ST CANN LOK FULL THRD T25,SUP-2179893,CDM,C1713,HCPCS,0278,RC,,,,both,,,500.74,325.48,,,,,,,,,,,,,
DEXAMETHASONE 0.2 MG/ML IJ SOLN (PED-NEO),RX-4090129,CDM,J1100,HCPCS,0636,RC,09999-9906-51,NDC,,both,1,UN,54.10,35.16,,,,,,,,,,,,,
DEFIBRILLATOR IMPL ALTRUA 40 TI SINGLE CHMBR BATTERY PWR,SUP-2149105,CDM,C1722,HCPCS,0275,RC,,,,both,,,11932.00,7755.80,,,,,,,,,,,,,
SCREW ACET DOME PLUG PK HIP IMP TRABECULAR MTL TI ALLOY,SUP-2203896,CDM,C1713,HCPCS,0278,RC,,,,both,,,428.61,278.60,,,,,,,,,,,,,
SET INTRO MICROPUNCTURE CATH L 30 CM DIA 5 FR GUIDEWIRE L 80,SUP-2633286,CDM,C1894,HCPCS,0272,RC,,,,both,,,118.44,76.99,,,,,,,,,,,,,
TRUNION KIT FOR UNIVERS II,SUP-2817691,CDM,C1776,CPT,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED STD K1 HA CEM,SUP-2419694,CDM,C1776,CPT,0278,RC,,,,both,,,9734.00,6327.10,,,,,,,,,,,,,
BIT REPROC DRL PILOT LNG AO FIT 4MM,SUP-2653028,CDM,2720000010,LOCAL,0272,RC,,,,both,,,394.13,256.18,,,,,,,,,,,,,
SET INTRO L 7 CM DIA 5 FR MIC ACCS PEELWY STRL,SUP-2117377,CDM,C1892,HCPCS,0272,RC,,,,both,,,93.89,61.03,,,,,,,,,,,,,
BLADE SCRWDRVR 40MML STNLSS STEEL WIDE ULTRA LOW PRFLE FBOS,SUP-2682156,CDM,2720000010,LOCAL,0272,RC,,,,both,,,665.81,432.78,,,,,,,,,,,,,
WIRE ORTH SMOOTH S STL 1.6MM DIA 150MM,SUP-2397719,CDM,C1713,HCPCS,0278,RC,,,,both,,,879.20,571.48,,,,,,,,,,,,,
SCREW SPNL MULTAXL 3.5X36 MM PART THRD INFIN,SUP-2631995,CDM,C1713,HCPCS,0278,RC,,,,both,,,1789.80,1163.37,,,,,,,,,,,,,
NEEDLE CRYOABLATION 90 DEG ICEEDGE,SUP-2225666,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4698.23,3053.85,,,,,,,,,,,,,
CATHETERIZATION KIT 13-1/8 IN 5 FRX55 CM DL BLU FLEXTIP,SUP-2383374,CDM,C1751,HCPCS,0278,RC,,,,both,,,463.21,301.09,,,,,,,,,,,,,
LEAD NERVE STIM 50 CM W/ PLANTLOCK ARTISAN,SUP-2765588,CDM,C1883,HCPCS,0278,RC,,,,both,,,10990.00,7143.50,,,,,,,,,,,,,
SCREW IM LCK DSTL 6.28MM 20MM FT STRL F/HOWMEDICA OSTEONICS,SUP-2370997,CDM,C1713,HCPCS,0278,RC,,,,both,,,617.64,401.47,,,,,,,,,,,,,
LINER HUM DIA 42 MM OFFSET 2.5 MM SHLDR RVS STRL EQUINOXE,SUP-2889618,CDM,C1776,CPT,0278,RC,,,,both,,,2276.50,1479.72,,,,,,,,,,,,,
SPACER SPNL 8X23X10MM INTBDY POST LUM PEEK 0 DEG CYL VISTA P,SUP-2414312,CDM,C1713,HCPCS,0278,RC,,,,both,,,8121.61,5279.05,,,,,,,,,,,,,
HC So Cadmium,PX-3018230066,CDM,82300,CPT,0301,RC,,,,both,,,142.00,92.30,,,,,,,,,,,,,
CATHETER ATHRCTMY 8FR L110CM TIP L2.5MM 0.018IN OVR THE WIRE,SUP-2353081,CDM,C1714,HCPCS,0272,RC,,,,both,,,5887.50,3826.87,,,,,,,,,,,,,
SYSTEM FAT TRANSFER LIPOASPIRATE WSH STRL VIALITY LTX,SUP-2869230,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1852.60,1204.19,,,,,,,,,,,,,
TUBE MYR DIA127MM VENT TAB SIL ST ULTRASIL PAPARELLA,SUP-2312836,CDM,L8699,HCPCS,0278,RC,,,,both,,,53.19,34.57,,,,,,,,,,,,,
SET INTRO 4FR L10CM NDL 21GA L7CM 0.018IN NIT COR PLAT TIP,SUP-2303432,CDM,C1894,HCPCS,0272,RC,,,,both,,,81.64,53.07,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC SOLO2 FT 5FR 55CM 2 LUMAN 3295108F,SUP-2632675,CDM,C1751,HCPCS,0278,RC,,,,both,,,526.04,341.93,,,,,,,,,,,,,
MATRIX BIO L 2.5 X W 2.5 CM BOV CLLGN CHONDROITIN-6-SULFATE,SUP-2909266,CDM,Q4105,HCPCS,0636,RC,,,,both,,,2698.05,1753.73,,,,,,,,,,,,,
GUIDE RESECT TIB MOD CAPTURE RT TRIATHLON,SUP-2364722,CDM,C1776,CPT,0278,RC,,,,both,,,2706.37,1759.14,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED CUP TRAB MEL,SUP-2212524,CDM,C1776,CPT,0278,RC,,,,both,,,18111.52,11772.49,,,,,,,,,,,,,
STENT GRFT VASC AFX BODY L 70 MM DIA22 MM LIMB L 30 MM DIA20,SUP-2217621,CDM,C1874,HCPCS,0278,RC,,,,both,,,36361.20,23634.78,,,,,,,,,,,,,
ENDPLATE SPNL 14MM UP 15X18MM FOOTPRINT 7DEG PEEK INTEGR TI,SUP-2231208,CDM,C1713,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
NITROGLYCERIN 5 MG/ML IV SOLN,RX-5599,CDM,J2305,HCPCS,0636,RC,00517-4810-25,NDC,,both,10,ML,89.50,58.17,,,,,,,,,,,,,
CATHETER IVUS VISIONS PV .035 WORKING L 90 CM SHTH 8.5 FR,SUP-2898458,CDM,C1753,HCPCS,0278,RC,,,,both,,,1783.36,1159.18,,,,,,,,,,,,,
BLOCK TIB AUG 4 10 MM,SUP-2201702,CDM,C1776,CPT,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
SCREW SPNL 6.5X50 MM EXPEDIUM VERSE,SUP-2256230,CDM,C1713,HCPCS,0278,RC,,,,both,,,2904.50,1887.92,,,,,,,,,,,,,
GRAFT HUMAN TISSUE THICK 20X12 CM HYDRATED BIOLOGIC TISSUE M,SUP-2838615,CDM,C1763,HCPCS,0278,RC,,,,both,,,22274.53,14478.44,,,,,,,,,,,,,
BOLT SET 6.5MM MIDFOOT FUS,SUP-2177068,CDM,C1713,HCPCS,0278,RC,,,,both,,,86307.74,56100.03,,,,,,,,,,,,,
GRAFT BNE SUB 90CC 4 10MM CORT CANC CHIP COARSE FRZN,SUP-2307431,CDM,C1713,HCPCS,0278,RC,,,,both,,,6862.78,4460.81,,,,,,,,,,,,,
PLATE BNE L87MM 4 H L PROX TIB S STL VAR ANG LOK COMPR SM,SUP-2177909,CDM,C1713,HCPCS,0278,RC,,,,both,,,5090.79,3309.01,,,,,,,,,,,,,
CATHETER THRMDIL 7FR L110CM STD PULM ART 4 INFUS LUMN SWN,SUP-2214026,CDM,C1751,HCPCS,0278,RC,,,,both,,,489.21,317.99,,,,,,,,,,,,,
DEVICE FIX TIB SM ADJ STRL ULTRABUTTON LTX,SUP-2880219,CDM,C1713,HCPCS,0278,RC,,,,both,,,1632.80,1061.32,,,,,,,,,,,,,
HC Ot Electricl Stim Attended 15,PX-4309703200,CDM,97032,CPT,0430,RC,,,,both,,,206.00,133.90,,,,,,,,,,,,,
HEAD RMR REPL WRST FUS HUB CAP,SUP-2107839,CDM,C1713,HCPCS,0278,RC,,,,both,,,1312.52,853.14,,,,,,,,,,,,,
NAIL IM L275MM DIA12.5MM STROKE 80MM 10DEG TROCHANTERIC FEM,SUP-2312261,CDM,C1713,HCPCS,0278,RC,,,,both,,,59628.60,38758.59,,,,,,,,,,,,,
DRAIN PACK,SUP-2302898,CDM,C1894,HCPCS,0272,RC,,,,both,,,282.51,183.63,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 30 CM DIA 8MM STR TW REMOVABLE RNG,SUP-2396300,CDM,C1768,CPT,0278,RC,,,,both,,,1912.26,1242.97,,,,,,,,,,,,,
CATHETER HEMO DYLS ULTRASTREAM L 32 CM DIA15.5 FR,SUP-2120057,CDM,C1881,HCPCS,0278,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
PLATE BNE COMPR 2.7X161 MM 20 HOLE ADPT LCK TI STRL LCP,SUP-2789465,CDM,C1713,HCPCS,0278,RC,,,,both,,,1821.95,1184.27,,,,,,,,,,,,,
GRAFT VASC HERO L 50 CM DIA 6 MM SIL NIT ART CO STRL,SUP-2874108,CDM,C1768,CPT,0278,RC,,,,both,,,3592.16,2334.90,,,,,,,,,,,,,
GRAFT VASC FLIXENE L 45 CM DIA 5-8 MM EPTFE TRMPT GRAD WALL,SUP-2681849,CDM,C1768,CPT,0278,RC,,,,both,,,3166.50,2058.22,,,,,,,,,,,,,
HANDLE PRB CANN DETACH FOR GRP MOD MOD PEDIGUARD,SUP-2354605,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5020.86,3263.56,,,,,,,,,,,,,
SET URET STENT L 22 CM DIA 4.8 FR CATH 6 FR PTFE GUIDEWIRE,SUP-2139090,CDM,C2617,HCPCS,0278,RC,,,,both,,,406.82,264.43,,,,,,,,,,,,,
IMPLANT PENILE 18 CM CYL 21 MM INFL HYDROPHILLIC TI,SUP-2300755,CDM,C1813,HCPCS,0278,RC,,,,both,,,21552.96,14009.42,,,,,,,,,,,,,
LEAD KIT STIM TST INTERSTIM,SUP-2640134,CDM,C1897,HCPCS,0278,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
PLATE BONE L20MM UNICOMPRESSION INTERAXIS UNI-CLIP,SUP-2243462,CDM,C1713,HCPCS,0278,RC,,,,both,,,1959.36,1273.58,,,,,,,,,,,,,
PLATE BNE 130 DEG PEDIATRIC 5X175X23 MM HIP 9 HOLE SS STRL,SUP-2546039,CDM,C1713,HCPCS,0278,RC,,,,both,,,3264.82,2122.13,,,,,,,,,,,,,
SET SCR SPNL L85MM OD10.5MM TI HIP U BLDE LAG FOR GAMMA3,SUP-2362204,CDM,C1713,HCPCS,0278,RC,,,,both,,,3035.60,1973.14,,,,,,,,,,,,,
PROBE CYL TIP DEB TI SONIC 1,SUP-2305953,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1287.40,836.81,,,,,,,,,,,,,
BALLOON PRSS REG 71-80CM H20 M FOR AMS 800 URIN CTRL SYS,SUP-2138915,CDM,C1815,HCPCS,0278,RC,,,,both,,,6751.00,4388.15,,,,,,,,,,,,,
PLATE BNE X 8 HOLE STERNALOCK,SUP-2423213,CDM,C1713,HCPCS,0278,RC,,,,both,,,1158.66,753.13,,,,,,,,,,,,,
STEM HUM L90MM DIA13MM DSTL SHLDR PTC AEQUALIS FLX REVIVE,SUP-2419076,CDM,C1776,CPT,0278,RC,,,,both,,,10926.73,7102.37,,,,,,,,,,,,,
COOLCUT 90 ABLATOR MENISCECTOM,SUP-2816011,CDM,2720000010,LOCAL,0272,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
SYSTEM BNE CEM MIX VAC 3 DOSE COMP,SUP-2199465,CDM,2720000010,LOCAL,0272,RC,,,,both,,,461.58,300.03,,,,,,,,,,,,,
ZOLPIDEM TARTRATE 5 MG PO TABS,RX-11701,CDM,6370000000,HCPCS,0637,RC,13668-0007-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
OCCLUDER CV WATCHMAN DIA21 MM SHTH L 75 CM DIA14 FR DEL SYS,SUP-2141820,CDM,C1889,HCPCS,0278,RC,,,,both,,,53380.00,34697.00,,,,,,,,,,,,,
AXICABTAGENE CILOLEUCEL 200000000 CELLS IV SUSP,RX-155561,CDM,Q2041,HCPCS,0891,RC,71287-0119-01,NDC,,both,1,UN,3525060.00,2291289.00,,,,,,,,,,,,,
ROD IM TIB MILLING NXGN,SUP-2438143,CDM,C1713,HCPCS,0278,RC,,,,both,,,367.38,238.80,,,,,,,,,,,,,
AMIODARONE HCL IN DEXTROSE 360-4.14 MG/200ML-% IV SOLN,RX-108516,CDM,2500000003,HCPCS,0250,RC,43066-0360-20,NDC,,both,200,ML,265.70,172.70,,,,,,,,,,,,,
BSS PLUS IO SOLN,RX-834,CDM,2500000003,HCPCS,0250,RC,00065-0795-15,NDC,,both,15,ML,57.00,37.05,,,,,,,,,,,,,
HC Fine Needle Aspiration Bx W/O Img Gdn 1st Lesion,PX-5101002100,CDM,10021,CPT,0510,RC,,,,both,,,1531.00,995.15,,,,,,,,,,,,,
SLING GYN SUPRPUB 5 DEL DEV 5 MESH ASMBLY LYNX,SUP-2141795,CDM,C1771,HCPCS,0278,RC,,,,both,,,2292.04,1489.83,,,,,,,,,,,,,
SNARE ENDOSCP POLYP 2.8 MMX230 CM HEX ASMBLY SNAREMASTER +,SUP-2463704,CDM,2720000010,LOCAL,0272,RC,,,,both,,,581.87,378.22,,,,,,,,,,,,,
PLATE BONE 4 H S STL ANK HK PLT,SUP-2389477,CDM,C1713,HCPCS,0278,RC,,,,both,,,2119.50,1377.67,,,,,,,,,,,,,
"HC So Immunofix Electphoresis,Othfld",PX-3028633566,CDM,86335,CPT,0302,RC,,,,outpatient,,,72.00,46.80,,,,,,,,,,,,,
LEAD KT STD TRL 8 ELECTRD CONTACTS 30MM SPC 4MM L60CM,SUP-2278240,CDM,C1897,HCPCS,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
DISC INTERVERT PLT VERT BODY REPL RT END PC SZ B 0DEG,SUP-2390786,CDM,C1889,HCPCS,0278,RC,,,,both,,,6123.00,3979.95,,,,,,,,,,,,,
DEFIBRILLATOR CRD LUMAX 340 HF-T,SUP-2138072,CDM,C1882,HCPCS,0275,RC,,,,both,,,58687.17,38146.66,,,,,,,,,,,,,
KIT PICC IMTERMEDIATE SAFT MST 4FR SGL LUMN W/45CM WIRE,SUP-2117119,CDM,C1751,HCPCS,0278,RC,,,,both,,,407.51,264.88,,,,,,,,,,,,,
CATHETER EP JSN 2-5-2MM SPC 5FRX110CM TORQR,SUP-2281820,CDM,C1730,HCPCS,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
CLAMP REPROC ADJ OPEN DYNAMIZATION MRI SAFE EXT,SUP-2482943,CDM,2720000010,LOCAL,0272,RC,,,,both,,,541.68,352.09,,,,,,,,,,,,,
ASSEMBLY SHUNT CATH DSTL L 120 CM REG STRL STRATAMR II,SUP-2929975,CDM,C1889,HCPCS,0278,RC,,,,both,,,17270.00,11225.50,,,,,,,,,,,,,
SET URET STENT SOFFLX L 10 CM DIA 3.0 FR GUIDEWIRE L 60 CM,SUP-2707492,CDM,C2617,HCPCS,0278,RC,,,,both,,,556.09,361.46,,,,,,,,,,,,,
SYSTEM RADAR LOC DEL 15 GAX12.3 CM REFLCT STRL SCOUT BX LTX,SUP-2864535,CDM,C1819,HCPCS,0278,RC,,,,both,,,1450.68,942.94,,,,,,,,,,,,,
PLATE BNE 95 DEG L ANT TALAR HI NK,SUP-2399163,CDM,C1713,HCPCS,0278,RC,,,,both,,,4116.54,2675.75,,,,,,,,,,,,,
ALLOGRAFT BNE BLOCK TRICORT 800125,SUP-2743366,CDM,C1713,HCPCS,0278,RC,,,,both,,,3972.10,2581.86,,,,,,,,,,,,,
CEFAZOLIN SODIUM 500 MG IJ SOLR,RX-1448,CDM,J0688,HCPCS,0636,RC,00143-9923-90,NDC,,both,1,UN,54.10,35.16,,,,,,,,,,,,,
CEMENT 40.8ML 12 SYR CD 3 SZ LIQ DURELON,SUP-2238645,CDM,C1713,HCPCS,0278,RC,,,,both,,,367.79,239.06,,,,,,,,,,,,,
EVOS 3.5MM LCK COMP PL 10H 116MM,SUP-2931191,CDM,C1713,HCPCS,0278,RC,,,,both,,,1589.56,1033.21,,,,,,,,,,,,,
POLYETHYLENE GLYCOL 3350 17 GM/SCOOP PO POWD,RX-24984,CDM,6370000000,HCPCS,0637,RC,00536-1052-24,NDC,,both,17,GR,2.70,1.75,,,,,,,,,,,,,
KIT CARD PACE ARW CATH L 110 CM DIA 5 FR INTRO 6 FR ELECTRD,SUP-2904194,CDM,C1730,HCPCS,0272,RC,,,,both,,,1111.56,722.51,,,,,,,,,,,,,
VALVE CSF PROGRAMMABLE IN-LINE W/ SIPHONGUARD CATH CERTAS +,SUP-2666574,CDM,C1889,HCPCS,0278,RC,,,,both,,,13375.90,8694.33,,,,,,,,,,,,,
SYSTEM GASTRIC BANDING STANDARD ADJUSTABLE RAPIDPORT EZ LAP-BAND AP,SUP-2119256,CDM,C1889,HCPCS,0278,RC,,,,both,,,14412.60,9368.19,,,,,,,,,,,,,
PLATE BNE CRV 4.5X230 MM RT CNDYL 10 HOLE VA LCK NS VA-LCP,SUP-2758213,CDM,C1713,HCPCS,0278,RC,,,,both,,,5803.85,3772.50,,,,,,,,,,,,,
HC So Viscosity,PX-3058581066,CDM,85810,CPT,0305,RC,,,,outpatient,,,376.00,244.40,,,,,,,,,,,,,
BIT DRL 10 MM LUER,SUP-2364442,CDM,2720000010,LOCAL,0272,RC,,,,both,,,315.95,205.37,,,,,,,,,,,,,
GRAFT VASC GELWEAVE L 25 CM DIA18 MM POLYESTER GEL,SUP-2385007,CDM,C1768,CPT,0278,RC,,,,both,,,1156.78,751.91,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 100 CM DIA 6 MM EPTFE STR TW,SUP-2525472,CDM,C1768,CPT,0278,RC,,,,both,,,3821.22,2483.79,,,,,,,,,,,,,
CATHETER PICC 4FR SIL SGL LUMN W/ EXCALIBUR INTRO FLSH THRU,SUP-2125572,CDM,C1751,HCPCS,0278,RC,,,,both,,,161.40,104.91,,,,,,,,,,,,,
ROD SPNL L70MM DIA5.5MM POST BILAT PEEK S STL PRECRV SMOOTH,SUP-2256305,CDM,C1713,HCPCS,0278,RC,,,,both,,,2229.31,1449.05,,,,,,,,,,,,,
GUIDEWIRE SURG L300MM DIA2.8MM S STL CALIB FOR 6.5/7.3MM,SUP-2186894,CDM,C1769,HCPCS,0272,RC,,,,both,,,352.12,228.88,,,,,,,,,,,,,
RELOAD STPLR X THN 60 MM REINF FOR SIGNIA LD TRI-STAPLE 2.0,SUP-2858006,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1530.09,994.56,,,,,,,,,,,,,
CATHETER INFUSION SPEEDLYSER L 15 CM DIA 5 FR SLT PAT L 10,SUP-2118522,CDM,C1757,HCPCS,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
GRAFT VASC GORTX L 90 CM DIA 8 MM RNG L 80 CM EPTFE STR TW,SUP-2396140,CDM,C1768,CPT,0278,RC,,,,both,,,4047.46,2630.85,,,,,,,,,,,,,
SCREW BNE CORTICAL 3.5X22 MM FUSION HEX DRV YEL WRST SS NS,SUP-2852005,CDM,C1713,HCPCS,0278,RC,,,,both,,,693.59,450.83,,,,,,,,,,,,,
BIT DRL ADJ DEPTH,SUP-2598578,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1120.98,728.64,,,,,,,,,,,,,
COLLAR CERV SFT 375X15IN SM,SUP-2276590,CDM,L0120,HCPCS,0272,RC,,,,both,,,6.12,3.98,,,,,,,,,,,,,
HC Inject Sinus Tract Diagnostic,PX-3612050100,CDM,20501,CPT,0361,RC,,,,both,,,1485.00,965.25,,,,,,,,,,,,,
BRACE WRST LEN 7 3 4IN CIRC OVR 8 3 4IN XL R REG D RNG W,SUP-2326029,CDM,L3908,HCPCS,0274,RC,,,,both,,,80.35,52.23,,,,,,,,,,,,,
TOLVAPTAN 15 MG PO TABS,RX-97802,CDM,6370000000,HCPCS,0637,RC,59148-0020-50,NDC,,both,1,UN,2340.90,1521.58,,,,,,,,,,,,,
ELECTRODE NDL CANN L25CM ARRY DIA2CM FOR OPN AND PERC RF,SUP-2139750,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4163.64,2706.37,,,,,,,,,,,,,
GENERATOR NEUROSTIMULATOR 28ML W55XL60MM THK11MM 45GM SGL,SUP-2284466,CDM,C1767,HCPCS,0278,RC,,,,both,,,30018.40,19511.96,,,,,,,,,,,,,
KIT PERICARDCENT PROC HI FLO PGTL CATH CE MRK 6FR,SUP-2303219,CDM,C1729,HCPCS,0272,RC,,,,both,,,332.84,216.35,,,,,,,,,,,,,
"HC Smear,Afb",PX-3008720600,CDM,87206,CPT,0300,RC,,,,both,,,228.00,148.20,,,,,,,,,,,,,
CATHETER URET 5FR L70CM POLYUR CONE FLX TIP KINK RESIST W/,SUP-2129014,CDM,C1758,HCPCS,0278,RC,,,,both,,,26.00,16.90,,,,,,,,,,,,,
STEM FEM DIA15MM LT HIP L STAT LNG REPLICA,SUP-2251984,CDM,C1776,CPT,0278,RC,,,,both,,,21863.82,14211.48,,,,,,,,,,,,,
HC Rmvl Perm Intraperitneal Cath,PX-3614942200,CDM,49422,CPT,0361,RC,,,,outpatient,,,3707.00,2409.55,,,,,,,,,,,,,
GUIDE SURG ANT CERV FIX ANG VENTURE,SUP-2293245,CDM,C1713,HCPCS,0278,RC,,,,both,,,1274.09,828.16,,,,,,,,,,,,,
STAPLER INT REG RELD LD UNIT SM DISP,SUP-2787673,CDM,2720000010,LOCAL,0272,RC,,,,both,,,325.24,211.41,,,,,,,,,,,,,
PLATE BNE RECTANGULAR LG 1.5X0.2 MM SCRN MESH JANNETTA TI NS,SUP-2466981,CDM,C1713,HCPCS,0278,RC,,,,both,,,1044.11,678.67,,,,,,,,,,,,,
GUIDEWIRE UROLOGICAL STR 0.035 IN X150 CM MOVABLE COR FLX,SUP-2469005,CDM,C1769,HCPCS,0272,RC,,,,both,,,100.54,65.35,,,,,,,,,,,,,
GRAFT BNE SUB W15 18XL40MM RAD ULN SHFT FRZ DRY,SUP-2307200,CDM,C1713,HCPCS,0278,RC,,,,both,,,1957.19,1272.17,,,,,,,,,,,,,
SUPPORT WR M AD LT CRPL TUNN REG FIRM SUPP CRPLGARD BLK,SUP-2324891,CDM,L3931,HCPCS,0274,RC,,,,both,,,48.92,31.80,,,,,,,,,,,,,
COMPONENT TOT SHLDR CAPPED S4 REVERSED CAPBIOMETS4] ZIMMER BIOMET INC],SUP-2137369,CDM,C1776,CPT,0278,RC,,,,both,,,24492.00,15919.80,,,,,,,,,,,,,
KIT PICC 4FR CATH L20CM SGL LUMN MIDLN MAX BARR TWO NIT,SUP-2118842,CDM,C1751,HCPCS,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
ELECTRODE SUBDERM NDL L 25 MM CABLE L 1 M PRASS PR 2 CHANNEL,SUP-2902120,CDM,2720000010,LOCAL,0272,RC,,,,both,,,456.93,297.00,,,,,,,,,,,,,
SCREW BONE CANNULATED 6.5X105 MM ANKLE PROXIMAL FEMORAL PART,SUP-2837562,CDM,C1713,HCPCS,0278,RC,,,,both,,,1382.79,898.81,,,,,,,,,,,,,
UPCHARGE KNEE X3 PATELLA STRYKER,SUP-2501352,CDM,C1776,CPT,0278,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
GUIDEWIRE ORTH SUPER STIFF 3X200 MM SHLDR MARKER AEQUALIS,SUP-2715409,CDM,C1769,HCPCS,0272,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
TRIAL PLATE 1.3 MM ROTATIONAL CORRECTION,SUP-2525719,CDM,C1713,HCPCS,0278,RC,,,,both,,,2493.16,1620.55,,,,,,,,,,,,,
KIT H CVR UNIV UHMWPE FOR REV ACET SYS REDAPT,SUP-2345484,CDM,C1776,CPT,0278,RC,,,,both,,,219.80,142.87,,,,,,,,,,,,,
OSTEOTOME SURG 6MM PROX SL,SUP-2400080,CDM,2720000010,LOCAL,0272,RC,,,,both,,,734.76,477.59,,,,,,,,,,,,,
PLATE 3.5MM TI LCP PERIARTIC PROX HUM 10H 235MM LT STRL,SUP-2546850,CDM,C1713,HCPCS,0278,RC,,,,both,,,6548.88,4256.77,,,,,,,,,,,,,
ELECTRODE SUCTION BLNT 5 MMX33 CM W/ VLV,SUP-2850585,CDM,2720000010,LOCAL,0272,RC,,,,both,,,952.68,619.24,,,,,,,,,,,,,
HC Unlisted Chemistry Procedure,PX-3018499900,CDM,84999,CPT,0301,RC,,,,both,,,213.00,138.45,,,,,,,,,,,,,
DEVICE FEED G-JET 16F X 2.0CM X 22CM LP TRANSGASTRIC-JEJUNAL,SUP-2849687,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1730.14,1124.59,,,,,,,,,,,,,
KIT PLATELET CONCENTRATION CARDIAMP 60ML F/CELL SEPARATOR,SUP-2866981,CDM,2720000010,LOCAL,0272,RC,,,,both,,,733.82,476.98,,,,,,,,,,,,,
KIT CATH 1.9FR X 25CM 1-LUMEN POLYURETH PICC 30GA MOD INTRO,SUP-2874172,CDM,C1751,HCPCS,0278,RC,,,,both,,,543.22,353.09,,,,,,,,,,,,,
ENDOPROSTHESIS VASC WSTNT RP L 24 MM DIA 6 MM CATH TOT L 160,SUP-2142749,CDM,C1876,HCPCS,0278,RC,,,,both,,,3972.10,2581.86,,,,,,,,,,,,,
PLATE BNE W14XL101MM THK3.8MM 90DEG 5 H R TIB L BTTRS L ANG,SUP-2185767,CDM,C1713,HCPCS,0278,RC,,,,both,,,1783.21,1159.09,,,,,,,,,,,,,
CATHETER GUID TURNPIKE L 150 CM SHFT DIA PROX/DSTL,SUP-2383151,CDM,C1887,HCPCS,0272,RC,,,,both,,,2606.20,1694.03,,,,,,,,,,,,,
GRAFT BNE SUB 07ML W9XH9XL9MM DEMIN CANC CUBOID CNFRM,SUP-2306902,CDM,C1713,HCPCS,0278,RC,,,,both,,,1632.30,1060.99,,,,,,,,,,,,,
STEM FEM L190MM DIA16MM STD CO CHROME POR + HA HIP REV,SUP-2345322,CDM,C1776,CPT,0278,RC,,,,both,,,17703.32,11507.16,,,,,,,,,,,,,
IMPLANT KINEMATCH PAT FEM REPL,SUP-2262255,CDM,C1776,CPT,0278,RC,,,,both,,,16485.00,10715.25,,,,,,,,,,,,,
BURR SURG OD4.7MM 127MM LEN M CUT DR FLUT ST EIUS SYS,SUP-2367441,CDM,2720000010,LOCAL,0272,RC,,,,both,,,562.94,365.91,,,,,,,,,,,,,
BLADE SHV L11CM DIA2.9MM STR NONROTATABLE SHFT IRRIG TBNG,SUP-2284127,CDM,2720000010,LOCAL,0272,RC,,,,both,,,749.08,486.90,,,,,,,,,,,,,
NERVE BLOCK SET 19 GAX60 CM 17 GAX9 CM CATH STIMUCATH,SUP-2383923,CDM,C1755,HCPCS,0278,RC,,,,both,,,186.39,121.15,,,,,,,,,,,,,
GUIDEWIRE VASC 0.9,SUP-2174975,CDM,C1769,HCPCS,0272,RC,,,,both,,,70.65,45.92,,,,,,,,,,,,,
IMPLANT NSL L 37 X W 22 MM THK 0.5 MM POLYETHYL TIP TOP FLAT,SUP-2883515,CDM,C1889,HCPCS,0278,RC,,,,both,,,1356.32,881.61,,,,,,,,,,,,,
CATHETER THORACENTESIS STR 12 FRX20 IN CLR DRN PVC STRL ARGY,SUP-2428081,CDM,C1729,HCPCS,0272,RC,,,,both,,,26.19,17.02,,,,,,,,,,,,,
TISSEEL VHSD 10 ML KT 1501238] BAXTER],SUP-2129974,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1726.62,1122.30,,,,,,,,,,,,,
INSERT TIBIALXS-SM THK8MM UNI UNI GEN,SUP-2344271,CDM,C1776,CPT,0278,RC,,,,both,,,2720.03,1768.02,,,,,,,,,,,,,
SCREW BNE CORTICAL 3.5 MM UNIV LCK,SUP-2861482,CDM,C1713,HCPCS,0278,RC,,,,both,,,23053.38,14984.70,,,,,,,,,,,,,
GRAFT VASC GORTX L 30 CM DIA 6 MM RNG L 20 CM EPTFE STR TW,SUP-2396113,CDM,C1768,CPT,0278,RC,,,,both,,,1777.24,1155.21,,,,,,,,,,,,,
TAMP KYPHOPLASTY SZ 3 BLLN L10MM INFL BNE KYPHON XPANDER II,SUP-2293665,CDM,C1713,HCPCS,0278,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
COMPONENT FEM PS 1 LT KNEE,SUP-2391440,CDM,C1776,CPT,0278,RC,,,,both,,,7652.18,4973.92,,,,,,,,,,,,,
IMPLANT OP RM MINI-MONSTER 3.0 X 10MM H,SUP-2320440,CDM,C1713,HCPCS,0278,RC,,,,both,,,602.10,391.36,,,,,,,,,,,,,
EPIDURAL TRAY CATH THERACATH,SUP-2383961,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
BIT DRL STP 6.5 MM STRL VERSANAIL,SUP-2606670,CDM,2720000010,LOCAL,0272,RC,,,,both,,,684.02,444.61,,,,,,,,,,,,,
COIL EMB L30CM OD10MM 360DEG STD STRTCH RESIST BIG LOOP,SUP-2365749,CDM,C1889,HCPCS,0278,RC,,,,both,,,8515.05,5534.78,,,,,,,,,,,,,
RELOAD STPL 3.8MM L90MM S STL SGL USE LD UNIT GIA 90 PREM,SUP-2283066,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1482.52,963.64,,,,,,,,,,,,,
PACK PROCEDURE SURGICAL 20GA VLV CPM 10K,SUP-2717577,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1918.26,1246.87,,,,,,,,,,,,,
BLADE SHV L13CM DIA43MM AUTO EM TRK FUS ROT QUADCUT,SUP-2277876,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1205.57,783.62,,,,,,,,,,,,,
NAIL IM L440MM DIA3.5MM PROX TIB BLU TI ALLY,SUP-2192731,CDM,C1713,HCPCS,0278,RC,,,,both,,,920.55,598.36,,,,,,,,,,,,,
GRAFT HUMAN TISSUE THICK 20X8 CM HYDRATED BIOLOGIC TISSUE MA,SUP-2838612,CDM,C1763,HCPCS,0278,RC,,,,both,,,14849.69,9652.30,,,,,,,,,,,,,
CATHETER PULM ART 8FR L110CM THRMDIL 3 LUMN W/ EXTRA INFUS 4121701] ICU MEDICAL INC],SUP-2241227,CDM,C1751,HCPCS,0278,RC,,,,both,,,186.74,121.38,,,,,,,,,,,,,
GRAFT BONE SUB 0.5CC PUTTY,SUP-2307522,CDM,C1713,HCPCS,0278,RC,,,,both,,,335.98,218.39,,,,,,,,,,,,,
TI LCP DIA-META VOLAR DISTAL RADIUS PL 15H SHAFT/RT-STERILE,SUP-2546642,CDM,C1713,HCPCS,0278,RC,,,,both,,,5258.34,3417.92,,,,,,,,,,,,,
GUIDEWIRE VASC L 70 CM DIA 0.035 IN SPRING STRL,SUP-2627228,CDM,C1769,HCPCS,0272,RC,,,,both,,,35.86,23.31,,,,,,,,,,,,,
PLATE BNE L 77 MM SCREW DIA2.4/2.7 MM 6 HD 5 SHFT H LT DSTL,SUP-2913602,CDM,C1713,HCPCS,0278,RC,,,,both,,,6429.15,4178.95,,,,,,,,,,,,,
CUP ACET DIA48MM HIP GRIPTION PRI PINN,SUP-2250219,CDM,C1776,CPT,0278,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
NI CB STERILE,SUP-2720575,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1868.30,1214.39,,,,,,,,,,,,,
BRACE ORTH LNR 3 SHELL TLSO,SUP-2388140,CDM,L0462,HCPCS,0272,RC,,,,both,,,3215.55,2090.11,,,,,,,,,,,,,
HC Quan MRI Alys Brain With Diagnostic MRI,PX-6110866000,CDM,0866T,CPT,0611,RC,,,,both,,,1344.00,873.60,,,,,,,,,,,,,
CUP ACET FLNG E LT HIP,SUP-2419769,CDM,C1776,CPT,0278,RC,,,,both,,,31400.00,20410.00,,,,,,,,,,,,,
PATCH VASC W1XL9CM THK0.5MM FLUOROPOLYMER ACCUSEAL,SUP-2395322,CDM,C1768,CPT,0278,RC,,,,both,,,894.90,581.68,,,,,,,,,,,,,
GRAFT BIO W8XL12CM SFT REGEN TISS MTRX PELV FLR REP BOV,SUP-2139397,CDM,C1763,HCPCS,0278,RC,,,,both,,,5353.57,3479.82,,,,,,,,,,,,,
CATHETER ANGIOPLSTY ATLS L 120 CM BALLOON L 4 CM DIA20 MM,SUP-2127925,CDM,C1725,HCPCS,0272,RC,,,,both,,,1271.70,826.60,,,,,,,,,,,,,
PLATE BNE STD L DORS FIX ANG LOK K WIRE JOYSTICK H ACU-LOC,SUP-2106932,CDM,C1713,HCPCS,0278,RC,,,,both,,,3039.52,1975.69,,,,,,,,,,,,,
GRAFT HUM TISS W6XL12CM THK1.04-2.28MM THCK REGEN TISS MTRX,SUP-2112995,CDM,Q4116,HCPCS,0636,RC,,,,both,,,7818.60,5082.09,,,,,,,,,,,,,
SCREW INTFR BIOSURE REGENESORB 11MM X 25MM,SUP-2341929,CDM,C1713,HCPCS,0278,RC,,,,both,,,1120.07,728.05,,,,,,,,,,,,,
TRAY SUPRPUB CATH 12FR INTRO 14FR NDL INTRO COUNCL CATH,SUP-2129018,CDM,C1729,HCPCS,0272,RC,,,,both,,,619.21,402.49,,,,,,,,,,,,,
IMPLANT OP RM MINI-MONSTER 2.5 X 10MM HD CANN SHT THRD SCR,SUP-2320388,CDM,C1713,HCPCS,0278,RC,,,,both,,,682.95,443.92,,,,,,,,,,,,,
"HC Est Pt, E/M Level 1",PX-5109921100,CDM,99211,CPT,0510,RC,,,,outpatient,,,174.00,113.10,,,,,,,,,,,,,
CATHETER US INT CARD ECHOCARDIOGRAPHY VIEWFLEX +,SUP-2356603,CDM,C1759,HCPCS,0272,RC,,,,both,,,6908.00,4490.20,,,,,,,,,,,,,
KIT BLD PMP 17FR ART CANN 62CM VEN TANDEMHEART,SUP-2152645,CDM,C1889,HCPCS,0278,RC,,,,both,,,61230.00,39799.50,,,,,,,,,,,,,
SCREW FIX FASTENING THREADLOCK TAPR CROSS DRV 50-174-03-75,SUP-2493744,CDM,C1889,HCPCS,0278,RC,,,,both,,,267.56,173.91,,,,,,,,,,,,,
VALVE CSF FLO BURR HOLE 12 MM CTRL VENTRICULOSTOMY DELT,SUP-2629162,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2084.65,1355.02,,,,,,,,,,,,,
GAMMATILE THERAPY DEVICE 4 PACK,SUP-2855638,CDM,C2642,HCPCS,0278,RC,,,,both,,,20410.00,13266.50,,,,,,,,,,,,,
SCREW BNE L20MM DIA1.5MM THRD L6MM NONSTERILE CORT S STL ST,SUP-2178688,CDM,C1713,HCPCS,0278,RC,,,,both,,,634.00,412.10,,,,,,,,,,,,,
DRILL SURG STP 2X2.5 MM PIN,SUP-2464811,CDM,2720000010,LOCAL,0272,RC,,,,both,,,393.29,255.64,,,,,,,,,,,,,
PLATE BNE L 20 MM SCREW DIA2 MM SM CP TI RT MANDIBULAR HEMI,SUP-2883702,CDM,C1713,HCPCS,0278,RC,,,,both,,,13884.14,9024.69,,,,,,,,,,,,,
KIT CATH PLEUR CHLORAPREP FEN DRP FLTR STRW FOAM CATH PD,SUP-2133738,CDM,C1729,HCPCS,0272,RC,,,,both,,,1915.40,1245.01,,,,,,,,,,,,,
BLADE SHV OD4MM 60DEG STD SERR CLOSE DS ELITE COMPATIBLE,SUP-2313529,CDM,2720000010,LOCAL,0272,RC,,,,both,,,431.31,280.35,,,,,,,,,,,,,
SCREW BONE L100MM OD5MM FLLY THRDD CNNLTD TTNM NNSTRLE,SUP-2488455,CDM,C1713,HCPCS,0278,RC,,,,both,,,536.06,348.44,,,,,,,,,,,,,
ANCHOR SUTURE KT ULTRABRACE,SUP-2882976,CDM,C1713,HCPCS,0278,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
GLYCOPYRROLATE 0.2 MG/ML IJ SOLN,RX-3497,CDM,J1596,HCPCS,0636,RC,00143-9682-25,NDC,,both,0.5,ML,54.10,35.16,,,,,,,,,,,,,
KIT DRL BIT DIA2MM DRL GUID HNDL TMPLT LOC PIN TAMP,SUP-2194162,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1037.71,674.51,,,,,,,,,,,,,
CONFORMER OPHTH W/ HOLE MED 23X20 MM,SUP-2261402,CDM,L8610,HCPCS,0278,RC,,,,both,,,62.80,40.82,,,,,,,,,,,,,
IMPLANT ANK JT 3 LT TALUS IMPLABLE,SUP-2199170,CDM,C1776,CPT,0278,RC,,,,both,,,13074.11,8498.17,,,,,,,,,,,,,
SCREW BONE CNNLTD 6.5MM DIA 45MML TIMAX 16MML THRDD NON ST,SUP-2586826,CDM,C1713,HCPCS,0278,RC,,,,both,,,734.19,477.22,,,,,,,,,,,,,
RECORDER CARD MON REVEAL LINQ MYCARELINK LNQSYS] MEDTRONIC USA INC],SUP-2281139,CDM,C1764,HCPCS,0278,RC,,,,both,,,14130.00,9184.50,,,,,,,,,,,,,
SHELL ACET OD48MM TI HA W O DOME H IMPL SECUR FIT XTRA,SUP-2370256,CDM,C1776,CPT,0278,RC,,,,both,,,5659.54,3678.70,,,,,,,,,,,,,
BIT DRL 3.2 MM 5 MM FOR HALF PIN,SUP-2162652,CDM,2720000010,LOCAL,0272,RC,,,,both,,,660.66,429.43,,,,,,,,,,,,,
SCREW BNE L 7 MM DIA2 MM TI MAND ST LCK AXS NS UNIV,SUP-2909600,CDM,C1713,HCPCS,0278,RC,,,,both,,,476.78,309.91,,,,,,,,,,,,,
PLATE BNE L W135XL170MM THK42MM 9 H BILAT TI NAR RIG NEUT,SUP-2190818,CDM,C1713,HCPCS,0278,RC,,,,both,,,1484.40,964.86,,,,,,,,,,,,,
ADAPTER NEUROSTIM PKT FOR DP BRAIN STIM,SUP-2284579,CDM,2780000010,LOCAL,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
SUPPORT ORTHOT HEEL CUST COUNT REINF PLAS,SUP-2435729,CDM,L3430,HCPCS,0274,RC,,,,both,,,453.70,294.90,,,,,,,,,,,,,
SCREW BNE L16MM DIA4.5MM STD CORT TI ST LOK LO PROF AXSOS,SUP-2704436,CDM,C1713,HCPCS,0278,RC,,,,both,,,156.06,101.44,,,,,,,,,,,,,
BIT DRL L110MM DIA4MM OVR CANN ADD ON,SUP-2321610,CDM,2720000010,LOCAL,0272,RC,,,,both,,,459.23,298.50,,,,,,,,,,,,,
LEAD PACE CAPSUR L 50 CM SIL INSUL STEROID EPICARD BPLR STRL,SUP-2278400,CDM,C1898,HCPCS,0275,RC,,,,both,,,2863.68,1861.39,,,,,,,,,,,,,
CATHETER ASPIR 6FR L140CM DIA0.07IN EXPORT ADV,SUP-2294991,CDM,C1757,HCPCS,0272,RC,,,,both,,,1114.70,724.55,,,,,,,,,,,,,
DEVICE THROMBOLYTIC ARROW-TREROTOLA PTD L 65 CM DIA 5 FR,SUP-2383482,CDM,C1894,HCPCS,0272,RC,,,,both,,,3265.60,2122.64,,,,,,,,,,,,,
CATHETER ANGIOPLSTY SABER L 150 CM BALLOON L 80 MM DIA 6 MM,SUP-2909667,CDM,C1725,HCPCS,0272,RC,,,,both,,,744.31,483.80,,,,,,,,,,,,,
TUBE VENT 1.27 MM 3 MM BAXTER BVL BOB TAPR FLROPLAS,SUP-2535149,CDM,L8699,HCPCS,0278,RC,,,,both,,,40.47,26.31,,,,,,,,,,,,,
SYSTEM KYPHOPLASTY INTRO OSTEO KYPHON XPANDER II,SUP-2281648,CDM,C1894,HCPCS,0272,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
SCREW SPNL TRANS FACET INT FIXATION SYSTEM MARINER CAP SP,SUP-2708144,CDM,C1821,HCPCS,0278,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
SHOE POSTOP SM 7-9 LO PROF FOAM/NYLON MESH M LOOP LOK CLSR,SUP-2197104,CDM,L4387,HCPCS,0272,RC,,,,both,,,15.13,9.83,,,,,,,,,,,,,
SCREW BONE L83MM OD3.5MM 6 CRUCFRM COARSE THRD WDRUFF,SUP-2362308,CDM,C1713,HCPCS,0278,RC,,,,both,,,28.26,18.37,,,,,,,,,,,,,
SHEATH INTRO CHARIOT L 45 CM DIA 5 FR STR TIP XCUT LG LUMEN,SUP-2140841,CDM,C1725,HCPCS,0272,RC,,,,both,,,204.10,132.66,,,,,,,,,,,,,
PLATE BNE L250MM 12 H NONSTERILE R MED PROX TIB S STL LOK,SUP-2185682,CDM,C1713,HCPCS,0278,RC,,,,both,,,4468.03,2904.22,,,,,,,,,,,,,
EXCHANGER PERF CRDPLGIA 6LPM FLOW RATE 135ML CPCTY W38N CN,SUP-2722919,CDM,2720000010,LOCAL,0272,RC,,,,both,,,844.69,549.05,,,,,,,,,,,,,
TUBE JEJUNOSTOMY FEED 18 FR 7-10 CC SECUR-LOK EXT ENFIT MIC,SUP-2764436,CDM,2720000010,LOCAL,0272,RC,,,,both,,,428.55,278.56,,,,,,,,,,,,,
PIN BONE FIX L50MM CROSS CANN L15 AXL,SUP-2137196,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1736.42,1128.67,,,,,,,,,,,,,
PLATE BNE L37MM +90DEG 2X3 H ST DST DORS RAD S STL L SHP,SUP-2177488,CDM,C1713,HCPCS,0278,RC,,,,both,,,2108.95,1370.82,,,,,,,,,,,,,
ADAPTER TIB TY NEUT OFFSET KNEE INTLOK VANGUARD COMPLT SYS,SUP-2405428,CDM,C1776,CPT,0278,RC,,,,both,,,1783.52,1159.29,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY LIVEWIRE BDB L 95 CM DIA 7 FR SPC,SUP-2356918,CDM,C1731,HCPCS,0278,RC,,,,both,,,3981.52,2587.99,,,,,,,,,,,,,
SPACER FEM UNI SIG HP,SUP-2453114,CDM,C1776,CPT,0278,RC,,,,both,,,1067.60,693.94,,,,,,,,,,,,,
SPACER TIB LIMB SALV LO BODY POLY ELEOS 12MM,SUP-2314040,CDM,C1776,CPT,0278,RC,,,,both,,,8851.66,5753.58,,,,,,,,,,,,,
BIT DRL DIA2.4MM CANN W/ DEPTH STP TWINFIX,SUP-2368330,CDM,2720000010,LOCAL,0272,RC,,,,both,,,753.60,489.84,,,,,,,,,,,,,
CATHETER CV 3L AD 6 FRX55 CM PWR INJ N COAT POWERPICC,SUP-2125554,CDM,C1751,HCPCS,0278,RC,,,,both,,,575.56,374.11,,,,,,,,,,,,,
STAPLE BONE FIX 18X18X18MM NIT SUPERELASTIC OSTEOTMY FIX AND,SUP-2175183,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2983.00,1938.95,,,,,,,,,,,,,
SUPPORT ORTHOT WRST ELBW HND SHLDR ADJ AIRPLANE DESIGN,SUP-2435791,CDM,L3960,HCPCS,0272,RC,,,,both,,,2055.04,1335.78,,,,,,,,,,,,,
MITOMYCIN 40 MG IV SOLR,RX-10631,CDM,J9280,HCPCS,0636,RC,71288-0139-51,NDC,,both,1,UN,1728.00,1123.20,,,,,,,,,,,,,
MICROSPHERE EMB EMBOSPHERE DIA 40-120 UM 2 CC 20 CC SYR ORN,SUP-2303394,CDM,C1889,HCPCS,0278,RC,,,,both,,,753.60,489.84,,,,,,,,,,,,,
BIT DRL L215MM DIA3.2MM CALIB L82MM STRL 3 FLUT QUIK CPL,SUP-2188198,CDM,2720000010,LOCAL,0272,RC,,,,both,,,808.61,525.60,,,,,,,,,,,,,
MESH HERN W10XL15CM THK1MM EPTFE ABD VENTRAL NONABSORBABLE,SUP-2125741,CDM,C1781,HCPCS,0278,RC,,,,both,,,1004.80,653.12,,,,,,,,,,,,,
BUR SURG DIA 4.5 MM HUB III DIAMOND X COARSE STRL REUSE,SUP-2928850,CDM,2720000010,LOCAL,0272,RC,,,,both,,,408.77,265.70,,,,,,,,,,,,,
KIT GASTSTMY TUBE 20FR STD NONSAFETY PUSH GWIRE PLCMNT TECH,SUP-2127664,CDM,C1769,HCPCS,0272,RC,,,,both,,,277.76,180.54,,,,,,,,,,,,,
SCREW BNE CORTICAL 5X84 MM DBL LD TI STRL PHOENIX LTX DISP,SUP-2861149,CDM,C1713,HCPCS,0278,RC,,,,both,,,698.59,454.08,,,,,,,,,,,,,
SET ORTH MOD W/ DRL GUID STARDRV SCR DRVR X ARTC PLT LCK,SUP-2177066,CDM,C1713,HCPCS,0278,RC,,,,both,,,85853.19,55804.57,,,,,,,,,,,,,
RETRACTOR W17MM H11MM L5CM TUBE D.4IN OD12MM SELF RET MEDL,SUP-2393989,CDM,C1894,HCPCS,0272,RC,,,,both,,,2182.30,1418.49,,,,,,,,,,,,,
PLATE BNE L 441 MM SCREW DIA 3.5/4.5 MM 22 H SS LT DSTL FEM 72585122,SUP-2933084,CDM,C1713,HCPCS,0278,RC,,,,both,,,22986.37,14941.14,,,,,,,,,,,,,
TWIST DRILL 22MM DIA X 34MM 27MM STOP DNTL LATCH SNGLE USE,SUP-2681260,CDM,2720000010,LOCAL,0272,RC,,,,both,,,413.29,268.64,,,,,,,,,,,,,
GUIDEWIRE ORTH L1000MM DIA3.2MM S STL FULL THRD TIP FOR,SUP-2347060,CDM,C1769,HCPCS,0272,RC,,,,both,,,679.21,441.49,,,,,,,,,,,,,
GUIDEWIRE VASC L 145 CM 0.035 IN TIP L 3 MM PTFE HEPARIN J,SUP-2118918,CDM,C1769,HCPCS,0272,RC,,,,both,,,23.08,15.00,,,,,,,,,,,,,
SCREW BNE L36MM DIA3.5MM STD CORT TIM ST CANN NONLOCKING,SUP-2413373,CDM,C1713,HCPCS,0278,RC,,,,both,,,150.72,97.97,,,,,,,,,,,,,
EVOS SMALL TGTR 2.5MM DRILL,SUP-2931349,CDM,C1713,HCPCS,0278,RC,,,,both,,,1316.45,855.69,,,,,,,,,,,,,
TUNNELER SURGICAL PLUG BNE CEM CANN DISP FOR 7-12MM TUNN,SUP-2905129,CDM,C1713,HCPCS,0278,RC,,,,both,,,129.05,83.88,,,,,,,,,,,,,
TRASTUZUMAB-ANNS 150 MG IV SOLR,RX-148188,CDM,Q5117,HCPCS,0636,RC,55513-0141-01,NDC,,both,1,UN,3917.10,2546.11,,,,,,,,,,,,,
SCREW BNE 5.5X120 MM FIX BEAM FOR CHARCOT FIX SYS AXIS,SUP-2433772,CDM,C1713,HCPCS,0278,RC,,,,both,,,4050.60,2632.89,,,,,,,,,,,,,
PLATE BONE FRDM WR IMPL CRPL SIZE2,SUP-2243495,CDM,C1713,HCPCS,0278,RC,,,,both,,,14189.25,9223.01,,,,,,,,,,,,,
FENOFIBRATE 145 MG PO TABS,RX-40010,CDM,6370000000,HCPCS,0637,RC,60687-0629-21,NDC,,both,1,UN,10.50,6.82,,,,,,,,,,,,,
PIN KIT EXTN BND 1.5X20 MM SS,SUP-2107848,CDM,C1713,HCPCS,0278,RC,,,,both,,,1617.10,1051.11,,,,,,,,,,,,,
ACTIVATION NUT FOR,SUP-2823437,CDM,C1713,HCPCS,0278,RC,,,,both,,,393.44,255.74,,,,,,,,,,,,,
"HC So Cyclic Citrullinated Peptd,Ab",PX-3028620066,CDM,86200,CPT,0302,RC,,,,both,,,207.00,134.55,,,,,,,,,,,,,
HC Angio Int Mammary S&I,PX-3217575600,CDM,75756,CPT,0321,RC,,,,both,,,6654.00,4325.10,,,,,,,,,,,,,
"HC So Cmv, Congenital,Qaul Pcr, Saliva",PX-3068749667,CDM,87496,CPT,0306,RC,,,,outpatient,,,393.00,255.45,,,,,,,,,,,,,
WIRE BNE FIX L 20 CM DIA1.22 MM LOOP NS LUQ,SUP-2882138,CDM,C1713,HCPCS,0278,RC,,,,both,,,116.93,76.00,,,,,,,,,,,,,
ORTHOPEDIC KIT 8X240 MM HUM NAIL HMRX,SUP-2431227,CDM,C1713,HCPCS,0278,RC,,,,both,,,9734.00,6327.10,,,,,,,,,,,,,
ANCHOR SUT L135MM DIA35MM FOR LISFRANC INTERNALBRACE LIG,SUP-2123215,CDM,C1776,CPT,0278,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
BASEPLATE TIB HINGED BEAR XS 21 MM KNEE S-ROM NOILES,SUP-2455912,CDM,C1713,HCPCS,0278,RC,,,,both,,,8479.26,5511.52,,,,,,,,,,,,,
COIL NEUROVASCULAR L 50 CM DIA16 MM PLATINUM/TUNGSTEN SFT,SUP-2895555,CDM,C1889,HCPCS,0278,RC,,,,both,,,8148.30,5296.39,,,,,,,,,,,,,
CAFFEINE CITRATE 20 MG/ML SYRINGE (PED-NEO)|DISCARDED DRUG NOT ADMINISTE,RX-4090401,CDM,J0706,HCPCS,0636,RC,63323-0407-03,NDC,JW,both,3,ML,179.10,116.41,,,,,,,,,,,,,
PASSER SUT NDL CAPTURE 1ST PASS,SUP-2341370,CDM,2720000010,LOCAL,0272,RC,,,,both,,,503.97,327.58,,,,,,,,,,,,,
LITHIUM CARBONATE ER 450 MG PO TBCR,RX-10455,CDM,6370000000,HCPCS,0637,RC,68084-0655-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
HC So Iron,PX-3018354066,CDM,83540,CPT,0301,RC,,,,both,,,521.00,338.65,,,,,,,,,,,,,
HC Perq Vert Agmntj Cavity Crtj Uni/Bi Cannulation,PX-3612251300,CDM,22513,CPT,0361,RC,,,,both,,,10303.00,6696.95,,,,,,,,,,,,,
SET FLAP REP OSTEOCHNDRL SGL SHOT W/ SHTH DRL DART INSRT,SUP-2121789,CDM,2720000010,LOCAL,0272,RC,,,,both,,,643.70,418.40,,,,,,,,,,,,,
CANNULA INJ 8.5 CM F/POS PRESSURE VENT LARYNGOSCOPE 8590KC,SUP-2774910,CDM,2720000010,LOCAL,0272,RC,,,,both,,,568.65,369.62,,,,,,,,,,,,,
GRAFT SYNTH TISS 5MMX12MMX40MM BLK BONE IMPL CA PHOS HA PRO,SUP-2413072,CDM,C1713,HCPCS,0278,RC,,,,both,,,1673.46,1087.75,,,,,,,,,,,,,
PLATE BNE L33MM THK3.4MM 2 H BILAT S STL STR LOK COMPR FOR,SUP-2185124,CDM,C1713,HCPCS,0278,RC,,,,both,,,704.46,457.90,,,,,,,,,,,,,
KIT REPL FOR CHARGE PAK BTTRY CHRG 2 SET ELECTRD LFEPK CR +,SUP-2327704,CDM,2720000010,LOCAL,0272,RC,,,,both,,,733.25,476.61,,,,,,,,,,,,,
GRAFT BONE H10MM PARA NAR CERV PRESERVON VERTIGRFT VG 2,SUP-2264954,CDM,C1713,HCPCS,0278,RC,,,,both,,,3624.97,2356.23,,,,,,,,,,,,,
PASSER SUT REUSE VIPER,SUP-2121177,CDM,2720000010,LOCAL,0272,RC,,,,both,,,9404.30,6112.79,,,,,,,,,,,,,
CATHETER CTRL VEN L70CM OD5X6FR IDSEC15.5GA 55CM NIT WIRE,SUP-2118835,CDM,C1751,HCPCS,0278,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
INTRODUCER ENGAGE TR 4FRX12CM SHTH W/ COAT CANN 0.025 IN,SUP-2355815,CDM,C1894,HCPCS,0272,RC,,,,both,,,135.02,87.76,,,,,,,,,,,,,
SPLINT ORTHOPEDIC SUPP MED 8 IN LT WRST COCK UP ELASTIC,SUP-2108132,CDM,L3809,HCPCS,0274,RC,,,,both,,,41.61,27.05,,,,,,,,,,,,,
CATHETER PICC 4FR SGL LUMN MAX BARR TY W/ TPS STYL,SUP-2125507,CDM,C1751,HCPCS,0278,RC,,,,both,,,641.91,417.24,,,,,,,,,,,,,
SHAVER BLADE SIGNATURE SERIES 4.2 MM HPS FRR PREBENT CONVEX,SUP-2824497,CDM,2720000010,LOCAL,0272,RC,,,,both,,,522.03,339.32,,,,,,,,,,,,,
SET URET STENT SOFFLX L 16 CM CATH 4.7 FR POS DIA 4.7 FR,SUP-2168898,CDM,C2617,HCPCS,0278,RC,,,,both,,,383.14,249.04,,,,,,,,,,,,,
SET INT FIX SCREW DIA1.5 MM 4 H TI NEURO SQ PLATE 1 PK STRL,SUP-2935608,CDM,C1713,HCPCS,0278,RC,,,,both,,,1563.72,1016.42,,,,,,,,,,,,,
SHEATH INTRO POWERLINK DIA12.5 FR TEARWY,SUP-2217701,CDM,C1892,HCPCS,0272,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
GUIDEWIRE VASC L145CM OD0035IN 3MM TIP CRV RAD S STL PTFE J,SUP-2167581,CDM,C1769,HCPCS,0272,RC,,,,both,,,38.09,24.76,,,,,,,,,,,,,
PLATE 3.5MM TI LCP EXTRA-ARTICLR DSTL HUM 6H/RT 158MM-STER,SUP-2546619,CDM,C1713,HCPCS,0278,RC,,,,both,,,4475.44,2909.04,,,,,,,,,,,,,
SCREW BONE 4.5X12MM SPNL VAR ANG ST,SUP-2353301,CDM,C1713,HCPCS,0278,RC,,,,both,,,464.72,302.07,,,,,,,,,,,,,
PLATE BNE L 213 MM 15 H SS LT PROX HUM CRV STRL EVOS,SUP-2931174,CDM,C1713,HCPCS,0278,RC,,,,both,,,6331.50,4115.47,,,,,,,,,,,,,
COMPONENT FEM L70MM LT KNEE POR ANAT PRI MAXM,SUP-2405272,CDM,C1776,CPT,0278,RC,,,,both,,,21176.16,13764.50,,,,,,,,,,,,,
AGENT HEMSTAT 1GM CLLGN MICFIB ACT ABSRB FLOUR AVIT,SUP-2125824,CDM,2720000010,LOCAL,0272,RC,,,,both,,,411.97,267.78,,,,,,,,,,,,,
SUPPORT ORTHOT THGH LOWER EXTREMITY WT BEAR HI RL CUF,SUP-2435679,CDM,L2550,HCPCS,0274,RC,,,,both,,,963.29,626.14,,,,,,,,,,,,,
SET ORTH GRPHC CA W/ BILAT GUID FOR 4.5MM CVD CNDYL PLT,SUP-2177059,CDM,C1713,HCPCS,0278,RC,,,,both,,,62181.36,40417.88,,,,,,,,,,,,,
SPLINT WR ADULTXL LT THMB NEOPRNE TRIOXON LNR FIRM STRP ON,SUP-2326120,CDM,L3908,HCPCS,0274,RC,,,,both,,,138.00,89.70,,,,,,,,,,,,,
STENT URET 6FR L22CM HYDR+ DBL PGTL THRD TAPR TIP RADPQ,SUP-2139649,CDM,C2617,HCPCS,0278,RC,,,,both,,,357.96,232.67,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.542,SUP-2860059,CDM,C1713,HCPCS,0278,RC,,,,both,,,52173.93,33913.05,,,,,,,,,,,,,
ALLOGRAFT BNE DEMINERALIZED CORTICAL 125-710 MIC 10 CC FD,SUP-2717749,CDM,C1713,HCPCS,0278,RC,,,,both,,,1823.96,1185.57,,,,,,,,,,,,,
GUIDEWIRE VASC SENS L 145 CM DIA 0.018 IN TIP 3 MM SS SIL,SUP-2227414,CDM,C1769,HCPCS,0272,RC,,,,both,,,130.03,84.52,,,,,,,,,,,,,
GRAFT DERMAL RECT 2.4X3.1 IN ANTIBACT XENMATRIX AB,SUP-2855240,CDM,C1781,HCPCS,0278,RC,,,,both,,,5120.71,3328.46,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA 5FR 55CM 3 LUMAN R S3395108,SUP-2632852,CDM,C1751,HCPCS,0278,RC,,,,both,,,682.76,443.79,,,,,,,,,,,,,
PIN HALF THRD 6X200 MM 25 MM EXT FIX SS HA,SUP-2343011,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1260.96,819.62,,,,,,,,,,,,,
MESH SURG L6XW6IN 6MM THICKNESS POLY RIG KNIT RND CORNERS,SUP-2174778,CDM,C1781,HCPCS,0278,RC,,,,both,,,209.44,136.14,,,,,,,,,,,,,
SUTURE ENDOSCP L165CM DIA2.8MM TISS HELIX F/ OVERSTITCH 6/BX,SUP-2119262,CDM,C1768,CPT,0278,RC,,,,both,,,677.71,440.51,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY EPSTAR L 65 CM DIA 6 FR SPC 2-8-2,SUP-2641909,CDM,C1730,HCPCS,0272,RC,,,,both,,,2041.00,1326.65,,,,,,,,,,,,,
DEVICE MENIS REP 25 CRV INFIN AIM,SUP-2846785,CDM,C1713,HCPCS,0278,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
HC CT Brain W/ Contrast,PX-3517046000,CDM,70460,CPT,0351,RC,,,,both,,,2630.00,1709.50,,,,,,,,,,,,,
HC GI Endoscopic US S&I,PX-4027697500,CDM,76975,CPT,0402,RC,,,,both,,,269.00,174.85,,,,,,,,,,,,,
COMPONENT FEM 2XSM R DST KNEE CO CHROME ALLY POST STBL PRI C,SUP-2436158,CDM,C1776,CPT,0278,RC,,,,both,,,23761.01,15444.66,,,,,,,,,,,,,
BHANSALI ALTO TOTAL DYNAMIC,SUP-2680308,CDM,L8613,CPT,0278,RC,,,,both,,,1343.29,873.14,,,,,,,,,,,,,
SUPPORT ORTHOT KNEE LOWER EXTREMITY CUST STR,SUP-2435664,CDM,L2385,HCPCS,0272,RC,,,,both,,,416.02,270.41,,,,,,,,,,,,,
BIT DRL TWST 1X40 MM 5 MM HEX W/ STP STRL SONICWELD RX DISP,SUP-2483084,CDM,2720000010,LOCAL,0272,RC,,,,both,,,559.14,363.44,,,,,,,,,,,,,
STEM FEM L240MM OD13.5MM 10IN BEAD L MTPHSEAL BODY CO CHROM,SUP-2203201,CDM,C1776,CPT,0278,RC,,,,both,,,21838.70,14195.15,,,,,,,,,,,,,
IMPLANT OPHTH EYE BNK,SUP-2309110,CDM,C1713,HCPCS,0278,RC,,,,both,,,8792.00,5714.80,,,,,,,,,,,,,
SPLINT FNGR SM 4 PRNG PD,SUP-2194501,CDM,L3809,HCPCS,0274,RC,,,,both,,,3.20,2.08,,,,,,,,,,,,,
GUIDEWIRE VASC L 260 CM DIA 0.035 IN TAPR L 4.5 CM FLX TIP L,SUP-2167749,CDM,C1769,HCPCS,0272,RC,,,,both,,,70.68,45.94,,,,,,,,,,,,,
LEAD DEFIB ENDOTK ENDUR EZ L 70 CM SIL PTIR STEROID ENDOCARD,SUP-2148553,CDM,C1899,HCPCS,0275,RC,,,,both,,,21116.50,13725.72,,,,,,,,,,,,,
SCREW BONE L20MM DIA4.5MM CORT STRNL S STL CANN NONLOCKING,SUP-2184374,CDM,C1713,HCPCS,0278,RC,,,,both,,,296.73,192.87,,,,,,,,,,,,,
ELECTRODE ENDOSCP 24FR MPLR DISP BALL UROLOGY COAG 1 STEM,SUP-2261112,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
BIT DRL QC 2.8X200 MM 110 MM CALIB NS,SUP-2563760,CDM,2720000010,LOCAL,0272,RC,,,,both,,,444.00,288.60,,,,,,,,,,,,,
CATHETER ETER MEDSTN 9MM EYE ON SIDE HYDRAGLIDE COAT SIL,SUP-2265912,CDM,C1729,HCPCS,0272,RC,,,,both,,,48.20,31.33,,,,,,,,,,,,,
PLATE BNE FEM DSTL SET PERI-LOC,SUP-2351349,CDM,C1713,HCPCS,0278,RC,,,,both,,,6719.60,4367.74,,,,,,,,,,,,,
ALLOGRAFT BNE WDG LG FRZN IRRADIATED IL CREST,SUP-2867217,CDM,C1762,CPT,0278,RC,,,,both,,,3946.51,2565.23,,,,,,,,,,,,,
CUP ACET DIA68MM THK2MM LT COMMERCIALLY PURE TI MOD,SUP-2405116,CDM,C1776,CPT,0278,RC,,,,both,,,13564.80,8817.12,,,,,,,,,,,,,
STENT ENDOPROS L10CM DIA8MM CATH 8FR L120CM BLLN DIA8MM,SUP-2396566,CDM,C1874,HCPCS,0278,RC,,,,both,,,10927.20,7102.68,,,,,,,,,,,,,
GRAFT BNE SUB 10CC DEMIN BNE MTRX PTTY,SUP-2306997,CDM,C9359,HCPCS,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
ELEVATOR SURG L11IN TIP W19MM S STL SATIN FINISH COBB,SUP-2160985,CDM,2720000010,LOCAL,0272,RC,,,,both,,,325.27,211.43,,,,,,,,,,,,,
SHEATH INTRO NEURON MAX L 90 CM 6 FR 0.088 IN STR TIP XCUT,SUP-2323606,CDM,C1887,HCPCS,0272,RC,,,,both,,,1522.90,989.88,,,,,,,,,,,,,
IMMOBILIZER ORTH OPN PAT MED 19 IN 16-18 IN CANVS BLU,SUP-2194399,CDM,L1830,CPT,0274,RC,,,,both,,,50.24,32.66,,,,,,,,,,,,,
TUBE NASOPHARYNGEAL W/ BLLN CATH,SUP-2106339,CDM,C1726,HCPCS,0272,RC,,,,both,,,6311.40,4102.41,,,,,,,,,,,,,
PLATE BONE W17.5XL178MM THK5.2MM 10 H TI BROAD LIMIT CNTCT,SUP-2190848,CDM,C1713,HCPCS,0278,RC,,,,both,,,999.84,649.90,,,,,,,,,,,,,
STENT GRFT VASC AFX L 55 MM DIA PROX/DSTL 28 MM COCR,SUP-2217598,CDM,C1768,CPT,0278,RC,,,,both,,,16638.86,10815.26,,,,,,,,,,,,,
"HC OB ER Level 3|SIGNIFICANT, SEPARATELY IDENTIFIABLE EVALUATION AND MANAGEMENT SERVICE BY THE SAME PHYSICIAN ON THE SAME DAY OF THE PROCEDURE OR OTHER SERVICE",PX-4509928301,CDM,99283,CPT,0450,RC,,,25,outpatient,,,1556.00,1011.40,,,,,,,,,,,,,
SPLINT WR LT L INSTABILITY INJ 6 IN LOOP LCK W/ STAY COCK UP,SUP-2194853,CDM,L3931,HCPCS,0274,RC,,,,both,,,18.71,12.16,,,,,,,,,,,,,
MESH HERN SZ 5.12IN OMEGA 3 FATTY ACID COAT POLYPR RND,SUP-2265979,CDM,C1781,HCPCS,0278,RC,,,,both,,,1117.24,726.21,,,,,,,,,,,,,
ALLOGRAFT HUM TISS SHT 16X6 CM PLCNTA MEMBRN AMNIOEFFECT,SUP-2871501,CDM,C1762,CPT,0278,RC,,,,both,,,26925.50,17501.57,,,,,,,,,,,,,
HOLDER PLT DIA2X2.4MM THRD FOR HND PLATING SYS TAK,SUP-2319569,CDM,C1713,HCPCS,0278,RC,,,,both,,,116.18,75.52,,,,,,,,,,,,,
BURR SURG 4MM DIA HD MED MIC 48MML 10MML HD SM BNE DIAMOND D,SUP-2605559,CDM,2720000010,LOCAL,0272,RC,,,,both,,,69.39,45.10,,,,,,,,,,,,,
DEFIBRILLATOR CARD 80GM 41CC W50XH74MM THK14MM DF1 IS1 CONN,SUP-2356283,CDM,C1721,HCPCS,0275,RC,,,,both,,,36568.44,23769.49,,,,,,,,,,,,,
HC Transcatheter Biopsy S&I,PX-3207597000,CDM,75970,CPT,0320,RC,,,,both,,,1637.00,1064.05,,,,,,,,,,,,,
SEED BRACHYTHERAPY LOOSE 0.7-1.0 MCI NS ADVANTAGE,SUP-2247259,CDM,C2643,HCPCS,0278,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
CATHETER LD DEL ATTAIN L 45 CM OD 9 FR ID 7.2 FR POLYETHER,SUP-2282152,CDM,C1887,HCPCS,0272,RC,,,,both,,,537.29,349.24,,,,,,,,,,,,,
VALVE AORT MITROFLOW H 11 MM OD 18.6 MM ID 15.4 MM SEW RNG W,SUP-2265194,CDM,C1889,HCPCS,0278,RC,,,,both,,,16817.84,10931.60,,,,,,,,,,,,,
BIT DRL DIA 3.2/1.8 MM LNG CANN FOR HALF PIN NS DISP,SUP-2933050,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1825.60,1186.64,,,,,,,,,,,,,
PLATE BONE W17.5XL250MM THK5.2MM 14 H TI BROAD LIMIT CNTCT,SUP-2190854,CDM,C1713,HCPCS,0278,RC,,,,both,,,1076.33,699.61,,,,,,,,,,,,,
GRAFT HUM TISS W1XL2CM AMNIO MEMBRN TRNSLUC GRID PAT SGL,SUP-2113882,CDM,Q4154,HCPCS,0636,RC,,,,both,,,1342.35,872.53,,,,,,,,,,,,,
VALVE MI 25MM T6 ANTICALCIFICATION TREAT RADPQ ANNULUS RNG,SUP-2282997,CDM,C1889,HCPCS,0278,RC,,,,both,,,9420.00,6123.00,,,,,,,,,,,,,
SHUNT CSF CONNECTOR 1.9MM VALVE 4MM CATHETER 1.2MM 2.5MM VAL,SUP-2821793,CDM,C1889,HCPCS,0278,RC,,,,both,,,6315.83,4105.29,,,,,,,,,,,,,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,0250,RC,00264-7510-10,NDC,,both,500,ML,34.00,22.10,,,,,,,,,,,,,
PLATE BNE L112MM 6 H NONSTERILE R ANTEROMEDIAL DST TIB S,SUP-2177670,CDM,C1713,HCPCS,0278,RC,,,,both,,,5134.50,3337.42,,,,,,,,,,,,,
BIT DRL PROF FOR MIC COMPR FULL THRD SCR,SUP-2122479,CDM,2720000010,LOCAL,0272,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
BRACE ORTHOPEDIC FIG 8 SHLDR,SUP-2417064,CDM,L3660,HCPCS,0274,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
PLATE BNE RIGID 4.5X138 MM BILATERAL 4X6 HOLE NC STBL STRL,SUP-2186750,CDM,C1713,HCPCS,0278,RC,,,,both,,,2453.82,1594.98,,,,,,,,,,,,,
SCREW BNE L 52 MM DIA 4 MM SHRT TI CANN HDLSS NS LEOS,SUP-2931484,CDM,C1713,HCPCS,0278,RC,,,,both,,,1076.99,700.04,,,,,,,,,,,,,
CRICOTHYROTOMY KIT 4 MM AD QUICKTRACH,SUP-2384062,CDM,2720000010,LOCAL,0272,RC,,,,both,,,854.08,555.15,,,,,,,,,,,,,
PLATE BNE THK0.6MM BAR L2MM 100DEG 5 H L,SUP-2366295,CDM,C1713,HCPCS,0278,RC,,,,both,,,553.93,360.05,,,,,,,,,,,,,
SHEATH INTRO SAFSHTH ULTRA LT L 13 CM DIA 8.5 FR DIL L 18 CM,SUP-2118987,CDM,C1894,HCPCS,0272,RC,,,,both,,,131.25,85.31,,,,,,,,,,,,,
PLATE BNE SM L238MM 20 H BILAT S STL LO PROF RIG LIMIT,SUP-2186216,CDM,C1713,HCPCS,0278,RC,,,,both,,,2606.23,1694.05,,,,,,,,,,,,,
SCREWDRIVER SURG 3X4MM OVR DRL CANN TI,SUP-2244047,CDM,2720000010,LOCAL,0272,RC,,,,both,,,737.21,479.19,,,,,,,,,,,,,
WASHER ORTH 4.5-8 MM 430290SINGLE,SUP-2609254,CDM,C1713,HCPCS,0278,RC,,,,both,,,438.44,284.99,,,,,,,,,,,,,
TREPHINE BONE BX ORTH DISECT SZ 4.5 MM,SUP-2205288,CDM,C1713,HCPCS,0278,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
NUT ORTH ACROSS FLAT 11 MM,SUP-2719396,CDM,C1713,HCPCS,0278,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
LENACAPAVIR SODIUM 300 MG PO TABS,RX-171583,CDM,J0752,HCPCS,0636,RC,61958-3401-01,NDC,,both,1,UN,2645.50,1719.57,,,,,,,,,,,,,
FIBER SURG LASER DIA1000 UM STD RFID BLU BUFF FOR HOLM,SUP-2937401,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1208.90,785.78,,,,,,,,,,,,,
MATRIX BIO L 6 X W 4 CM FISH SKIN DERMAL INTACT STRL OMEGA3 10/BX,SUP-2909454,CDM,Q4158,HCPCS,0636,RC,,,,both,,,3843.36,2498.18,,,,,,,,,,,,,
QUICKSET ACE GRATER HEAD 39MM,SUP-2514445,CDM,C1776,CPT,0278,RC,,,,both,,,1532.32,996.01,,,,,,,,,,,,,
CATHETER THROMCTMY SYM L 117 CM SHTH 16 FR GUIDEWIRE 0.035,SUP-2887255,CDM,C1757,HCPCS,0272,RC,,,,both,,,22592.30,14684.99,,,,,,,,,,,,,
INSTRUMENT SET AM GASTROC EXPRESS,SUP-2473423,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2851.12,1853.23,,,,,,,,,,,,,
DEVICE VBR SZ 16A H17MM DIA16MM THORLUM TI CO CHROM NIT,SUP-2292779,CDM,C1889,HCPCS,0278,RC,,,,both,,,21477.60,13960.44,,,,,,,,,,,,,
PLATE TISS MEND 4CMX4CM PTCH,SUP-2364668,CDM,Q4109,HCPCS,0636,RC,,,,both,,,7065.00,4592.25,,,,,,,,,,,,,
MOLD CEM SPCR NK L+6MM HIP SIL S STL ADPT FOR MAKING TEMP,SUP-2408607,CDM,C1776,CPT,0278,RC,,,,both,,,577.76,375.54,,,,,,,,,,,,,
MODULE NEUROSURGICAL MAXCESS III,SUP-2311771,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2394.25,1556.26,,,,,,,,,,,,,
CATHETER GUID 3DRC 0.078 INX7 FRX100 CM 2 SH,SUP-2155866,CDM,C1887,HCPCS,0272,RC,,,,both,,,474.77,308.60,,,,,,,,,,,,,
HC Comprehensive Metabolic Panel,PX-3018005305,CDM,80053,CPT,0301,RC,,,,outpatient,,,477.00,310.05,,,,,,,,,,,,,
MAGNESIUM SULFATE (LAXATIVE) PO GRAN,RX-27322,CDM,6370000000,HCPCS,0637,RC,10939-0872-44,NDC,,both,454,GR,4.10,2.66,,,,,,,,,,,,,
GRAFT BNE STRP SM 50X25X6 MM 15 CC SCAFFOLD ATTRAX,SUP-2736497,CDM,C1713,HCPCS,0278,RC,,,,both,,,6358.50,4133.02,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 80 CM DIA 6 MM L 50 CM STR TW,SUP-2396315,CDM,C1768,CPT,0278,RC,,,,both,,,4458.80,2898.22,,,,,,,,,,,,,
KIT NEUROSTIMULATOR EPI ANCHR LD FOR N300,SUP-2308582,CDM,C1889,HCPCS,0278,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
WARFARIN SODIUM 2.5 MG PO TABS,RX-8750,CDM,6370000000,HCPCS,0637,RC,68084-0027-11,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PLATE STRNL CLOSURE 16 H TI LADDER NAR NS STERNALOCK BLU,SUP-2894505,CDM,C1713,HCPCS,0278,RC,,,,both,,,3052.08,1983.85,,,,,,,,,,,,,
ALLOGRAFT BNE FIBULAR 15 MMX0.2 CM FD CROSS SECT,SUP-2717832,CDM,C1762,CPT,0278,RC,,,,both,,,2449.20,1591.98,,,,,,,,,,,,,
BUR SURG L8MM DIA2MM MICA PROSTEP,SUP-2398171,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1073.88,698.02,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED UPCHARGE STEM PREMIER,SUP-2212691,CDM,C1776,CPT,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
COMPONENT TIB M THK11MM DST KNEE POLY KINEMATIC ROT HNG GMRS,SUP-2376400,CDM,C1776,CPT,0278,RC,,,,both,,,3642.71,2367.76,,,,,,,,,,,,,
HC So Immunofluor per Spec Ea Add Ab,PX-3128835066,CDM,88350,CPT,0312,RC,,,,both,,,358.00,232.70,,,,,,,,,,,,,
KIT ACL ANT CRUCE LIG CANN RUL PEN DRL PIN GWIRE RETRCT,SUP-2249535,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2885.66,1875.68,,,,,,,,,,,,,
SCREW BNE CANC 6.5 MM DIAM 20 MM LEN FULL THRD PEEK BLNT,SUP-2121077,CDM,C1713,HCPCS,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP FOR CANN,SUP-2585858,CDM,C1769,HCPCS,0272,RC,,,,both,,,263.60,171.34,,,,,,,,,,,,,
PLATE BNE L 108 MM SCREW DIA2 MM 20 SHFT H SS ADPT VA SLV,SUP-2908336,CDM,C1713,HCPCS,0278,RC,,,,both,,,3944.84,2564.15,,,,,,,,,,,,,
SHUNT COR L16CM DIA1MM NONPROGRAMMABLE GUIDANT W/O RESVR,SUP-2582813,CDM,2720000010,LOCAL,0272,RC,,,,both,,,318.33,206.91,,,,,,,,,,,,,
CATH REPROC EP STRBL QUADRPLR LG CRV 6FR 5MM 110CM,SUP-2526277,CDM,C1730,HCPCS,0272,RC,,,,both,,,662.16,430.40,,,,,,,,,,,,,
CATHETER CV SET 018 4 FRX60 CM DL OTW SS SPECTRUM TURBO-JECT,SUP-2759826,CDM,C1751,HCPCS,0278,RC,,,,both,,,430.40,279.76,,,,,,,,,,,,,
IMPLANT THYROPLASTY VOCAL CRD 12 M STRL MONTGOMERY,SUP-2141839,CDM,L8509,HCPCS,0272,RC,,,,both,,,2176.02,1414.41,,,,,,,,,,,,,
BOOT TRAC AD UNIV LEG FELT CONVOLUTED FOAM LNR FULL FT OPN,SUP-2194994,CDM,L4398,HCPCS,0274,RC,,,,both,,,59.25,38.51,,,,,,,,,,,,,
NECK FEM L30MM 8DEG YEL MOD HIP REJUVENATE,SUP-2378895,CDM,C1776,CPT,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
BLADE ENDO SHV DIA4MM 30DEG ANG SINUS CVD SERR CONCV WIND,SUP-2312774,CDM,2720000010,LOCAL,0272,RC,,,,both,,,347.79,226.06,,,,,,,,,,,,,
SCREW EXT FIX L100MM DIA4X3MM THRD L20MM CORT TI SELF DRL,SUP-2193158,CDM,C1713,HCPCS,0278,RC,,,,both,,,503.19,327.07,,,,,,,,,,,,,
BROACH SURG LESSER ENCOMPASS,SUP-2319783,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1318.80,857.22,,,,,,,,,,,,,
PLATE BONE ADAPTION 1.6X0.5 MM 20 HOLE STRAIGHT FOR SCREW LO,SUP-2838363,CDM,C1713,HCPCS,0278,RC,,,,both,,,1998.92,1299.30,,,,,,,,,,,,,
CAGE SPNL LORDTC 17X14X6 MM MP DIVERGENCE,SUP-2603526,CDM,C1889,HCPCS,0278,RC,,,,both,,,2433.50,1581.77,,,,,,,,,,,,,
NEEDLE SUTURE L7.75IN HEAVY CURVED REVERDIN,SUP-2802449,CDM,2720000010,LOCAL,0272,RC,,,,both,,,720.25,468.16,,,,,,,,,,,,,
NEEDLE BX 19 GAX155 MM ALWAYS-ON TIP TRACKED,SUP-2797899,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2246.67,1460.34,,,,,,,,,,,,,
ALLOGRAFT BNE WHL HUM 10 CM FRZN W/ ROT CUF LT,SUP-2717944,CDM,C1762,CPT,0278,RC,,,,both,,,23198.32,15078.91,,,,,,,,,,,,,
SUPPORT ORTHOT WRST HND CUST ADJ FIT STRP W/O JT FABRICATED,SUP-2435773,CDM,L3906,HCPCS,0274,RC,,,,both,,,1305.74,848.73,,,,,,,,,,,,,
BOOT TRAC AD UNIV LEG FELT CONVOLUTED FOAM LNR FULL FT OPN,SUP-2194994,CDM,L4398,HCPCS,0272,RC,,,,both,,,59.25,38.51,,,,,,,,,,,,,
HC So Tetanus Antibodies,PX-3028677466,CDM,86774,CPT,0302,RC,,,,inpatient,,,225.00,146.25,,,,,,,,,,,,,
PLATE BNE DBL ANGLED LG 2.5 MM RECON MAXILLA PT SPEC,SUP-2860104,CDM,C1713,HCPCS,0278,RC,,,,both,,,31583.06,20528.99,,,,,,,,,,,,,
DEXTROSE 10% IV BOLUS (PEDS),RX-4085020,CDM,2580000003,HCPCS,0250,RC,00338-0023-03,NDC,,both,500,ML,51.00,33.15,,,,,,,,,,,,,
GRAFT BONE SUB 18CC CA SULF HA INJ BIPHASIC OSTEOCONDUCTIVE,SUP-2402600,CDM,C1713,HCPCS,0278,RC,,,,both,,,16676.54,10839.75,,,,,,,,,,,,,
INTRODUCER SHTH KT PERC BONDED ADJ VLV 6FRX10CM INTRO FLX,SUP-2272869,CDM,C1894,HCPCS,0272,RC,,,,both,,,160.55,104.36,,,,,,,,,,,,,
SCREW BNE L75MM DIA27MM MTPHSEAL S STL ST STARDRV RECESS,SUP-2177779,CDM,C1713,HCPCS,0278,RC,,,,both,,,292.62,190.20,,,,,,,,,,,,,
GRAFT BNE FIBER 1 CC DBM CORTICAL PUREBONE,SUP-2424606,CDM,C1713,HCPCS,0278,RC,,,,both,,,674.75,438.59,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC FT IR 5FR 55CM 2 LUMAN RVS 3275355F,SUP-2632671,CDM,C1751,HCPCS,0278,RC,,,,both,,,351.93,228.75,,,,,,,,,,,,,
GUIDEWIRE STRL DISP STD WIRE STR TIP NO TORQ VISE,SUP-2166276,CDM,C1769,HCPCS,0272,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
INSTRUMENT OPHTH OD20 GA BACKFLUSH BLNT NDL NONSTERILE,SUP-2213455,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2904.50,1887.92,,,,,,,,,,,,,
CATHETER HD CRV 12.5 FRX13 CM  TRPL LUMEN PASS MAHRK ELITE,SUP-2626957,CDM,C1752,HCPCS,0278,RC,,,,both,,,462.55,300.66,,,,,,,,,,,,,
DEXTROSE 5 % IV BOLUS|DISCARDED DRUG NOT ADMINISTE,RX-40840055,CDM,2580000003,HCPCS,0258,RC,00264-7510-20,NDC,JW,both,250,ML,31.90,20.73,,,,,,,,,,,,,
HC Ablation 1/> Liver Tumor Perq Cryoablation,PX-3614738300,CDM,47383,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
OSS STRAIGHT STEM 9 X 225,SUP-2506328,CDM,C1776,CPT,0278,RC,,,,both,,,4578.12,2975.78,,,,,,,,,,,,,
CATHETER ANGIOPLSTY CROSPERIO L 150 CM L40MM 3.5MM INFLATION,SUP-2384785,CDM,C1725,HCPCS,0272,RC,,,,both,,,728.48,473.51,,,,,,,,,,,,,
SCREW BNE L6MM DIA1.85MM TI SELF DRL FOR MMF SYS MATRIXWAVE,SUP-2181784,CDM,C1713,HCPCS,0278,RC,,,,both,,,470.37,305.74,,,,,,,,,,,,,
CATHETER NEPHROSTOMY PIG 038 IN 8.3 FRX25 CM REPL KT JINRO,SUP-2520662,CDM,C1729,HCPCS,0272,RC,,,,both,,,58.44,37.99,,,,,,,,,,,,,
COMPONENT FEMORALXSM RT KNEE PRI CEM STEMLESS POST,SUP-2406873,CDM,C1776,CPT,0278,RC,,,,both,,,14566.46,9468.20,,,,,,,,,,,,,
PLATE SPNL L72-79.5MM THORLUM COMPR TRUSS,SUP-2230329,CDM,C1713,HCPCS,0278,RC,,,,both,,,10801.60,7021.04,,,,,,,,,,,,,
CIPROFLOXACIN HCL 500 MG PO TABS,RX-25119,CDM,6370000000,HCPCS,0637,RC,60687-0860-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
TRANSFIX SCREW 3X50MM,SUP-2811821,CDM,C1713,HCPCS,0278,RC,,,,both,,,577.76,375.54,,,,,,,,,,,,,
GRAFT BNE 1 CC OSTEOSURGE 100,SUP-2641796,CDM,C1713,HCPCS,0278,RC,,,,both,,,779.35,506.58,,,,,,,,,,,,,
STENT CORONARY L 8 MM DIA2.5 MM EVEROLIMUS RX DRUG ELUT,SUP-2101778,CDM,C1876,HCPCS,0278,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
LIGATOR ENDOSCP MULTI-BAND 9.5-13 MM 122 CM 6 SHOT SAEED,SUP-2737555,CDM,2720000010,LOCAL,0272,RC,,,,both,,,653.12,424.53,,,,,,,,,,,,,
SPACER NSL FRONTAL SINUS 14MM CATH W/ PRECIS FRM MICPOR,SUP-2106332,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2496.30,1622.59,,,,,,,,,,,,,
GRAFT VASC EXXCEL SFT L 20 CM DIA 8 MM EPTFE STR TW USFT,SUP-2266005,CDM,C1768,CPT,0278,RC,,,,both,,,1171.22,761.29,,,,,,,,,,,,,
ROD MEAS ALIGN OPN WDG OSTEOTMY SYS SET,SUP-2121037,CDM,C1713,HCPCS,0278,RC,,,,both,,,1155.52,751.09,,,,,,,,,,,,,
KIT DRNGE STRT PERI INSRT TY W CATHETER DSG KT ASPIRA,SUP-2126465,CDM,C1729,HCPCS,0272,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
BRACE ORTHOPEDIC PADDED UNIV ANK STIRRUP,SUP-2306212,CDM,L4350,HCPCS,0274,RC,,,,both,,,75.05,48.78,,,,,,,,,,,,,
SCREW SPNL MULTAXL 6.5X40 MM STRL CD HORZ ESSENTIALS,SUP-2660150,CDM,C1713,HCPCS,0278,RC,,,,both,,,3596.24,2337.56,,,,,,,,,,,,,
ALLOGRAFT BNE CHIP 4-10 MM 30 CC CANC,SUP-2641778,CDM,C1713,HCPCS,0278,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED CEM STEJH1] STRYKER CORP],SUP-2365934,CDM,C1776,CPT,0278,RC,,,,both,,,11897.46,7733.35,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 20X10X4 MM FUSIONFLEX,SUP-2759530,CDM,C1713,HCPCS,0278,RC,,,,both,,,2873.10,1867.51,,,,,,,,,,,,,
SCREW BONE OD2MM 2ND MOD PLT,SUP-2413270,CDM,C1713,HCPCS,0278,RC,,,,both,,,1281.12,832.73,,,,,,,,,,,,,
IMPLANT MP SZ 20 30DEG SIL ELASTMR PREFLEXED FLX HNG PROS,SUP-2244438,CDM,L8630,HCPCS,0278,RC,,,,both,,,3136.86,2038.96,,,,,,,,,,,,,
CATHETER THROMCTMY INDIGO LIGHTNING BOLT 12 L 100 CM DIA12,SUP-2930522,CDM,C1757,HCPCS,0272,RC,,,,both,,,30520.80,19838.52,,,,,,,,,,,,,
GRAFT BNE L150 250MM L PROX FEM W HD FRZN,SUP-2335567,CDM,C1713,HCPCS,0278,RC,,,,both,,,10801.60,7021.04,,,,,,,,,,,,,
KIT PRSS TRNSDUC TBNG L48X12IN STD TWO FLSH DEV BIFUR IV,SUP-2214624,CDM,C1713,HCPCS,0278,RC,,,,both,,,41.17,26.76,,,,,,,,,,,,,
CATHETER HAD L28CM OD14.5FR POLYUR 2 LUMN SPL TIP CUF 5685230] BARD PERIPHERAL VASCULAR],SUP-2127838,CDM,C1750,HCPCS,0278,RC,,,,both,,,1496.84,972.95,,,,,,,,,,,,,
PLATE BONE W9XL37MM CRPL FOR MAESTRO WR RECON SYS,SUP-2136459,CDM,C1713,HCPCS,0278,RC,,,,both,,,4908.61,3190.60,,,,,,,,,,,,,
SCREW BONE L4MM NEURO TI SELF DRL LO PROF,SUP-2189298,CDM,C1713,HCPCS,0278,RC,,,,both,,,291.08,189.20,,,,,,,,,,,,,
CATHETER ETER URET 4FR L70CM POLYUR OPN TIP W ADPT,SUP-2129002,CDM,C1758,HCPCS,0278,RC,,,,both,,,31.40,20.41,,,,,,,,,,,,,
GRAFT HUM TISS 20X25MM DISC CRYOPRESERVED VIABLE OSTEOCHNDRL,SUP-2120740,CDM,C1713,HCPCS,0278,RC,,,,both,,,31086.00,20205.90,,,,,,,,,,,,,
GUIDEWIRE VASC L180CM DIA0.035IN TIP L3CM STIFF NIT,SUP-2385585,CDM,C1769,HCPCS,0272,RC,,,,both,,,164.76,107.09,,,,,,,,,,,,,
SCREW INT HEX CAPT 5.0MMX32.5MM,SUP-2349089,CDM,C1713,HCPCS,0278,RC,,,,both,,,524.32,340.81,,,,,,,,,,,,,
BIT DRL 4.3 MM CALIB NAT NAIL,SUP-2862256,CDM,2720000010,LOCAL,0272,RC,,,,both,,,368.70,239.65,,,,,,,,,,,,,
COTTON OSTEOTOMY WEDGE TI/PEEK 16MMX4.5MM STERILE,SUP-2547172,CDM,C1713,HCPCS,0278,RC,,,,both,,,5583.36,3629.18,,,,,,,,,,,,,
SCREW BONE L85MM DIA6.5MM THRD L20MM CANN GUID ASNS 2,SUP-2362438,CDM,C1713,HCPCS,0278,RC,,,,both,,,588.75,382.69,,,,,,,,,,,,,
TRIATHLON CR X3 TIBIAL INSERT,SUP-2431349,CDM,C1776,CPT,0278,RC,,,,both,,,6317.37,4106.29,,,,,,,,,,,,,
MESH HERN RECT 6.3X3 IN FULL RESRB FOR SFT TISS PHASIX,SUP-2855248,CDM,C1781,HCPCS,0278,RC,,,,both,,,7247.12,4710.63,,,,,,,,,,,,,
COLLAR PREMIER PRO CERV UNIV ADJ CLS CELL FOAM LNR L TRACH,SUP-2336010,CDM,L0140,HCPCS,0272,RC,,,,both,,,14.10,9.16,,,,,,,,,,,,,
COIL VASC NEST EMBOLUS L 14 CM DIA 4 MM CATH DIA 0.018 IN,SUP-2169678,CDM,C1889,HCPCS,0278,RC,,,,both,,,244.92,159.20,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.530,SUP-2860047,CDM,C1713,HCPCS,0278,RC,,,,both,,,43775.37,28453.99,,,,,,,,,,,,,
PLATE STRNL CLOSURE THK 1.5 MM 4 H TI BRIDGE BX LP BLU NS,SUP-2894448,CDM,C1713,HCPCS,0278,RC,,,,both,,,2260.80,1469.52,,,,,,,,,,,,,
HC Cv Cath Plac Nontun <5yr,PX-3613655500,CDM,36555,CPT,0361,RC,,,,both,,,10064.00,6541.60,,,,,,,,,,,,,
MANIFOLD ANGIO 200PSI ANGIO 4 VLV M PRSS ON HNDL PRT REG RT,SUP-2118875,CDM,C1713,HCPCS,0278,RC,,,,both,,,810.12,526.58,,,,,,,,,,,,,
ALLOGRAFT HUM TISS BLOCK ASEP ACHILLES TEND,SUP-2257908,CDM,C1762,CPT,0278,RC,,,,both,,,6908.00,4490.20,,,,,,,,,,,,,
PLATE BONE 5 H STR MOTOBAND CP,SUP-2174980,CDM,C1713,HCPCS,0278,RC,,,,both,,,6485.67,4215.69,,,,,,,,,,,,,
PIN FIX L240MM DIA4MM S STL TRCR SMOOTH SHRP TIP,SUP-2341351,CDM,C1713,HCPCS,0278,RC,,,,both,,,1099.53,714.69,,,,,,,,,,,,,
KIT INFLATION DEV PRIORITY PK INFLATED 20 ATM VLV ID 0.096,SUP-2103551,CDM,C1894,HCPCS,0272,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
CANNULA ART LNG 21 FR UNCOATED HLS,SUP-2663472,CDM,2720000010,LOCAL,0272,RC,,,,both,,,945.23,614.40,,,,,,,,,,,,,
BAG DRNGE 1000ML DISP FOR ASPIRA SYS,SUP-2301570,CDM,C1729,HCPCS,0272,RC,,,,both,,,84.78,55.11,,,,,,,,,,,,,
PLATE BNE STD 15 H L OLECRANON,SUP-2107007,CDM,C1713,HCPCS,0278,RC,,,,both,,,4782.22,3108.44,,,,,,,,,,,,,
TUBE FEED 18FR L45CM SIL TRANSGASTRIC JEJU EXT RETEN RNG,SUP-2124610,CDM,2720000010,LOCAL,0272,RC,,,,both,,,733.69,476.90,,,,,,,,,,,,,
ROD IM BAL ATTUNE,SUP-2454770,CDM,C1713,HCPCS,0278,RC,,,,both,,,646.84,420.45,,,,,,,,,,,,,
GRAFT BNE SUB 20CC 2 4MM GRAN GROWTH FACT ALLGRFT OSTEOAMP,SUP-2138500,CDM,C1713,HCPCS,0278,RC,,,,both,,,8741.45,5681.94,,,,,,,,,,,,,
DEVICE LASER DEL LNG ENT ANGLED OTOPROBE 10775] FORTEC MEDICAL INC],SUP-2225683,CDM,2720000010,LOCAL,0272,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
SCREW BONE L90MM DIA11MM CANC SUBTROCHANTERIC TI CANN LAG,SUP-2347861,CDM,C1713,HCPCS,0278,RC,,,,both,,,3792.02,2464.81,,,,,,,,,,,,,
SCREW BNE CANC 4X22 MM PERIARTICULAR FT HEX HD STRL,SUP-2459346,CDM,C1713,HCPCS,0278,RC,,,,both,,,89.02,57.86,,,,,,,,,,,,,
HC Insert Ivc Filter,PX-3613719100,CDM,37191,CPT,0361,RC,,,,outpatient,,,16763.00,10895.95,,,,,,,,,,,,,
GRAFT DURA W5XL7IN ULTRAPURE REGEN CLLGN MTRX ABSRB DURAGN,SUP-2244009,CDM,C1763,HCPCS,0278,RC,,,,both,,,6950.45,4517.79,,,,,,,,,,,,,
COMPONENT TIB SZ 3 THK9.5MM RT MEDL LT LAT ANTR POST KNEE,SUP-2251258,CDM,C1776,CPT,0278,RC,,,,both,,,4970.62,3230.90,,,,,,,,,,,,,
HANDPIECE ENDO L33CM 10MM VES SEAL STR SCIS DISP PK,SUP-2312644,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1651.64,1073.57,,,,,,,,,,,,,
CEMENT BNE HI VISC 80 GM GENTAMICIN PALACOS R+G PRO,SUP-2738877,CDM,C1713,HCPCS,0278,RC,,,,both,,,1428.70,928.65,,,,,,,,,,,,,
SHEATH INTRO CLOTTRIEVER L 15 CM DIA13 FR DEPLOYED FUNNEL,SUP-2417093,CDM,C1894,HCPCS,0272,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
HC Bx Breast 1st Les MR Image|LEFT SIDE|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE PRIOR TO THE ADMINISTRATION OF ANESTHESIA,PX-3611908500,CDM,19085,CPT,0361,RC,,,LT|73,outpatient,,,6672.00,4336.80,,,,,,,,,,,,,
SPHINCTEROTOME ENDOSCP XL 7.5FR MIC NONCOATED BILI NDL KNF,SUP-2149455,CDM,2720000010,LOCAL,0272,RC,,,,both,,,449.55,292.21,,,,,,,,,,,,,
ROD COUPLER 30  HOFFMANN3 11MM,SUP-2704573,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1417.71,921.51,,,,,,,,,,,,,
PLATE BNE COBRA HD LG 4.5X186 MM 9 HOLE FOR SCR SS NS,SUP-2460108,CDM,C1713,HCPCS,0278,RC,,,,both,,,1376.48,894.71,,,,,,,,,,,,,
PLATE BNE THK075MM 3X5 H HND 316L S STL T SHP LOK FOR 13MM,SUP-2177983,CDM,C1713,HCPCS,0278,RC,,,,both,,,1301.69,846.10,,,,,,,,,,,,,
BRA SURG 2XL WHT POST SURG MAMM COMPR DSG W/ REM STRP FR HK,SUP-2276929,CDM,L8000,HCPCS,0272,RC,,,,both,,,109.90,71.43,,,,,,,,,,,,,
PLATE BNE W16XL10MM THK0.4MM 4 H CRANIOMAXILLOFACIAL BILAT,SUP-2181566,CDM,C1713,HCPCS,0278,RC,,,,both,,,736.64,478.82,,,,,,,,,,,,,
GRAFT HERN PORCINE CLLGN PERMACOL 1.5MM THICKNESS 5CMX10CM,SUP-2388447,CDM,C9364,HCPCS,0278,RC,,,,both,,,8704.08,5657.65,,,,,,,,,,,,,
ROD SPINE BENT TI 6.35 X 80MM,SUP-2293090,CDM,C1713,HCPCS,0278,RC,,,,both,,,1002.13,651.38,,,,,,,,,,,,,
HC So Ferritin,PX-3018272866,CDM,82728,CPT,0301,RC,,,,both,,,79.00,51.35,,,,,,,,,,,,,
NUSHIELD 3X4CM 12SQ CM,SUP-2314110,CDM,Q4160,HCPCS,0636,RC,,,,both,,,3661.24,2379.81,,,,,,,,,,,,,
PLATE BNE COMPR NAR 14 HOLE,SUP-2205651,CDM,C1713,HCPCS,0278,RC,,,,both,,,545.67,354.69,,,,,,,,,,,,,
BIT DRL DIA11MM TRIFLAT FOR ZEPHIR ANT CERV PLT SYS,SUP-2291211,CDM,2720000010,LOCAL,0272,RC,,,,both,,,483.56,314.31,,,,,,,,,,,,,
CATHETER HEMODIALYSI NIAG SLIM CATH ACTE 12FR DIA 24 5551240,SUP-2632900,CDM,C1752,HCPCS,0278,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
CATHETER HD STR 14 FRX24 CM SHT TERM 400 XL FULL TY TAPR TIP,SUP-2266971,CDM,C1752,HCPCS,0278,RC,,,,both,,,293.90,191.03,,,,,,,,,,,,,
K WIRE FIX L200MM DIA2.5MM THRD L15MM TRCR PNT FOR TOMOFIX,SUP-2186905,CDM,C1713,HCPCS,0278,RC,,,,both,,,523.91,340.54,,,,,,,,,,,,,
NEEDLE FIST 16GA L1IN ANTISTICK FIX WNG CLMP DISP BKEYE,SUP-2305492,CDM,C1713,HCPCS,0278,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
HC Surgery Ohs Base,PX-3600000008,CDM,3600000008,LOCAL,0360,RC,,,,both,,,9658.00,6277.70,,,,,,,,,,,,,
GRAFT BNE SUB 5CC VI DIA3MM CA SULF PELLET RESRB PRELD,SUP-2399037,CDM,C1713,HCPCS,0278,RC,,,,both,,,1458.12,947.78,,,,,,,,,,,,,
SCREW BNE L90MM DIA4MM TI ALLY LOK FULL THRD T15 DRV AXSOS 3,SUP-2706304,CDM,C1713,HCPCS,0278,RC,,,,both,,,665.99,432.89,,,,,,,,,,,,,
HC So Immunoperoxidase Stain,PX-3128834266,CDM,88342,CPT,0312,RC,,,,both,,,792.00,514.80,,,,,,,,,,,,,
HC So Tissue Culture Placenta,PX-3118823566,CDM,88235,CPT,0311,RC,,,,both,,,329.00,213.85,,,,,,,,,,,,,
PLATE BNE L277MM 10 H ST PROX FEM S STL HK LO PROF LOK,SUP-2177029,CDM,C1713,HCPCS,0278,RC,,,,both,,,5319.00,3457.35,,,,,,,,,,,,,
JOINT TOE 14 MM STR KT DYNANITE PIP,SUP-2432009,CDM,C1713,HCPCS,0278,RC,,,,both,,,5950.30,3867.69,,,,,,,,,,,,,
SHEATH INTRO TORFLEX 55 DEG L 63 CM DIA 8.5 FR GUIDEWIRE L,SUP-2131518,CDM,C1893,HCPCS,0272,RC,,,,both,,,675.10,438.81,,,,,,,,,,,,,
TRIAL BONE PLT 4 H T SHP TC-100 L FRAG SYS,SUP-2343747,CDM,C1713,HCPCS,0278,RC,,,,both,,,1136.08,738.45,,,,,,,,,,,,,
DRSG BIO L 7 X W 20 CM DECELL INTACT FISH SKIN SKIN MESHED 2,SUP-2909179,CDM,Q4158,HCPCS,0636,RC,,,,both,,,22501.24,14625.81,,,,,,,,,,,,,
PLATE BNE RECON UNIV 2.7 MM 8 HOLE 2 COMPR LCK FOR SCR TI NS,SUP-2478271,CDM,C1713,HCPCS,0278,RC,,,,both,,,1086.69,706.35,,,,,,,,,,,,,
PLATE BNE TBLR 49 MM 4 HOLE 1/3 STRL,SUP-2518435,CDM,C1713,HCPCS,0278,RC,,,,both,,,1956.22,1271.54,,,,,,,,,,,,,
IMPLANT GAIT M,SUP-2397258,CDM,C1776,CPT,0278,RC,,,,both,,,4003.50,2602.27,,,,,,,,,,,,,
HYDROMORPHONE HCL 1 MG/ML IJ SOLN,RX-3757,CDM,J1171,HCPCS,0636,RC,76045-0009-06,NDC,,both,0.5,ML,54.10,35.16,,,,,,,,,,,,,
COVER BURR H DIA13 MM PROF THK 0.6 MM THK 0.5 MM SCREW DIA2,SUP-2883873,CDM,C1713,HCPCS,0278,RC,,,,both,,,687.66,446.98,,,,,,,,,,,,,
SLING GYN W1XL60CM MIDURETHRAL SYN PERM LO ELASTICITY,SUP-2165381,CDM,C1771,HCPCS,0278,RC,,,,both,,,3161.98,2055.29,,,,,,,,,,,,,
PLATE LK COMPRSS 12 HOLE,SUP-2704415,CDM,C1713,HCPCS,0278,RC,,,,both,,,1223.66,795.38,,,,,,,,,,,,,
PRIMAGEN 1CC,SUP-2137604,CDM,C1734,HCPCS,0278,RC,,,,both,,,1168.08,759.25,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.408,SUP-2859972,CDM,C1713,HCPCS,0278,RC,,,,both,,,33304.10,21647.66,,,,,,,,,,,,,
MESH SURG W10XH11XL10MM OD10-14MM TI OVOID THORLUM INTBDY,SUP-2292059,CDM,C1713,HCPCS,0278,RC,,,,both,,,6452.61,4194.20,,,,,,,,,,,,,
POST EXT FIX DIA11MM 30DEG ANG FOR HOFFMANN III MOD SYS,SUP-2372222,CDM,2720000010,LOCAL,0272,RC,,,,both,,,375.86,244.31,,,,,,,,,,,,,
SET INSTR FOR 8MM SM JT OATS,SUP-2123217,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1398.87,909.27,,,,,,,,,,,,,
LINER ACET ELEV TRIDENT X3 ECC 0 DEG 32MM OD SZ E,SUP-2376079,CDM,C1776,CPT,0278,RC,,,,both,,,2462.39,1600.55,,,,,,,,,,,,,
SCREW BNE L 10 MM DIA2.3 MM TI MAND ST EMER AXS NS UNIV 2.0,SUP-2909554,CDM,C1713,HCPCS,0278,RC,,,,both,,,342.32,222.51,,,,,,,,,,,,,
CONNECTOR CSF T 1.2X1.8 MM FOR NEUROSURGERY SS STRL,SUP-2851467,CDM,C1889,HCPCS,0278,RC,,,,both,,,3246.85,2110.45,,,,,,,,,,,,,
TIMOLOL MALEATE 0.5 % OP SOLG,RX-24576,CDM,6370000000,HCPCS,0637,RC,61314-0225-05,NDC,,both,5,ML,782.20,508.43,,,,,,,,,,,,,
HC ED Clsd Tx Finger Fx W Manip,PX-4502672500,CDM,26725,CPT,0450,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
GUIDEWIRE SURG STRL AFFIRM,SUP-2598527,CDM,C1769,HCPCS,0272,RC,,,,both,,,169.56,110.21,,,,,,,,,,,,,
CALCITRIOL 1 MCG/ML IV SOLN,RX-9348,CDM,J0636,HCPCS,0636,RC,72266-0251-10,NDC,,both,0.5,ML,54.10,35.16,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9 % IV SOLN (ADD-VANTAGE),RX-4081543,CDM,J7050,HCPCS,0250,RC,00409-7101-67,NDC,,both,100,ML,37.40,24.31,,,,,,,,,,,,,
MESH CRNL 50MMW X 85MML TTNM MXLFCL LATEX FREE,SUP-2707373,CDM,C1713,HCPCS,0278,RC,,,,both,,,3062.57,1990.67,,,,,,,,,,,,,
JGRKNT LNG 1 2 BLUE MB 10 PK,SUP-2589016,CDM,C1713,HCPCS,0278,RC,,,,both,,,1122.55,729.66,,,,,,,,,,,,,
SPLINT WRST FA W ABDUCTED THMB L XSM,SUP-2276636,CDM,L3809,HCPCS,0272,RC,,,,both,,,22.70,14.75,,,,,,,,,,,,,
IMPLANT PENILE 13CM CYIINDER 12MM INFL DURA II,SUP-2140239,CDM,C1813,HCPCS,0278,RC,,,,both,,,12387.30,8051.74,,,,,,,,,,,,,
ASSEMBLY INSTRUMENT SHUNT REG W/ BIOGLDE STRATA,SUP-2631758,CDM,C1729,HCPCS,0272,RC,,,,both,,,13084.44,8504.89,,,,,,,,,,,,,
SCREW BNE LCK 3.5X38 MM CRTX NS PERI-LOC,SUP-2348576,CDM,C1713,HCPCS,0278,RC,,,,both,,,78.19,50.82,,,,,,,,,,,,,
GRAFT BONE SUB 0.25MM-1.0MM 1.0MM CORTICOCANCELLOUS,SUP-2165617,CDM,C1713,HCPCS,0278,RC,,,,both,,,185.26,120.42,,,,,,,,,,,,,
DRILL HND BUNNELL 5/32 IN CANN LIGHTWEIGHT GEAR JCBS CHK KEY,SUP-2872463,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2340.15,1521.10,,,,,,,,,,,,,
PLATE BNE RECON 2-2.5X2 MM MAND 32 HOLE ANGLED-ANGLED NS,SUP-2486910,CDM,C1713,HCPCS,0278,RC,,,,both,,,6141.46,3991.95,,,,,,,,,,,,,
PLATE BNE STR LCK,SUP-2477810,CDM,C1713,HCPCS,0278,RC,,,,both,,,828.43,538.48,,,,,,,,,,,,,
CATHETER ART DL 0.025 IN 7 FRX110 CM PULM HEPCOAT LTX,SUP-2662680,CDM,C1751,HCPCS,0278,RC,,,,both,,,118.69,77.15,,,,,,,,,,,,,
CATHETER ATRSEPTSTMY Z-5 TIP 35 DEG L 50 CM DIA 4 FR BALLOON,SUP-2125232,CDM,C1725,HCPCS,0272,RC,,,,both,,,994.85,646.65,,,,,,,,,,,,,
BUR SURG HD L19.1MM DIA3.1MM LNG STR ROUTER ELITE TPS,SUP-2363374,CDM,2720000010,LOCAL,0272,RC,,,,both,,,317.61,206.45,,,,,,,,,,,,,
CLAMP SURG PED STR CTRL FOR LIMB RECON SYS,SUP-2316145,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1277.10,830.11,,,,,,,,,,,,,
FIBER LASER HPS/XPS,SUP-2225586,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
COLLAR CERV M FIRM DENS AD CNTOUR HK AND LOOP CLSR W COT CVR,SUP-2276592,CDM,L0120,HCPCS,0274,RC,,,,both,,,6.63,4.31,,,,,,,,,,,,,
HEAD FEM OD38MM NK L-6MM CO CHROM MOLYBDENUM ALLY MOD 12/14,SUP-2408805,CDM,C1776,CPT,0278,RC,,,,both,,,8509.40,5531.11,,,,,,,,,,,,,
SCREW BNE 2.7X10 MM THORECON,SUP-2720003,CDM,C1713,HCPCS,0278,RC,,,,both,,,98.13,63.78,,,,,,,,,,,,,
POST FIX DIA75MM TAPR CAPITATE,SUP-2123591,CDM,C1776,CPT,0278,RC,,,,both,,,2496.30,1622.59,,,,,,,,,,,,,
PLATE BNE W8XL176MM THK3.3MM 22 H NONSTERILE BILAT PELV S,SUP-2186249,CDM,C1713,HCPCS,0278,RC,,,,both,,,3094.47,2011.41,,,,,,,,,,,,,
NEXGEN FEMORAL AUGMENT SCREW,SUP-2503254,CDM,C1776,CPT,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
PLATE BNE 3 H TI ALLOY STR NS LEOS,SUP-2933587,CDM,C1713,HCPCS,0278,RC,,,,both,,,3127.44,2032.84,,,,,,,,,,,,,
GRAFT VASC L90CM RNGD L70CM ID5MM EPTFE CBAS HEP SURF THN,SUP-2395808,CDM,C1768,CPT,0278,RC,,,,both,,,9313.24,6053.61,,,,,,,,,,,,,
PLATE BNE L269MM THK38MM 14 H R MED DST TIB S STL NEUT,SUP-2185224,CDM,C1713,HCPCS,0278,RC,,,,both,,,5175.44,3364.04,,,,,,,,,,,,,
SHEATH FEM ACCS WRK L35CM EXP L30CM OD23FR ID19FR INSRT,SUP-2385217,CDM,C1894,HCPCS,0272,RC,,,,both,,,2417.80,1571.57,,,,,,,,,,,,,
BIT DRL DIA2MM QUIK REL SURGIBIT,SUP-2107099,CDM,2720000010,LOCAL,0272,RC,,,,both,,,339.12,220.43,,,,,,,,,,,,,
BOLT EXP L41MM SH CO CHROM MOLYBDENUM ALLOY FOR RECON PROS,SUP-2265099,CDM,C1713,HCPCS,0278,RC,,,,both,,,828.96,538.82,,,,,,,,,,,,,
SHEATH INTRO HEARTSPAN L 60 CM DIA 8.5 FR NDL L 71 CM MP28,SUP-2516626,CDM,C1893,HCPCS,0272,RC,,,,both,,,92.32,60.01,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP ANGLED 0.025 INX260 CM RND STIFF JAGWIRE,SUP-2457436,CDM,C1729,HCPCS,0272,RC,,,,both,,,314.38,204.35,,,,,,,,,,,,,
STEM HUM SZ 10 DIA10MM PROX SHLDR TI HYDROXYAPETITE REUNION,SUP-2379012,CDM,C1776,CPT,0278,RC,,,,both,,,11869.20,7714.98,,,,,,,,,,,,,
KIT JEJUSTMY TB 22FR BLLN 7-10ML JEJU L45CM TRANSGASTRIC,SUP-2124614,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1074.95,698.72,,,,,,,,,,,,,
RING ANNULPLSTY CARP EDW CLASSIC 36MM OD 41.2MM MITRL,SUP-2214147,CDM,C1889,HCPCS,0278,RC,,,,both,,,4867.00,3163.55,,,,,,,,,,,,,
NEEDLE BNE MAR SET 11 GAX152 MM BX SYS ONCONTROL,SUP-2766673,CDM,2720000010,LOCAL,0272,RC,,,,both,,,417.09,271.11,,,,,,,,,,,,,
CATHETER LD DEL CPS AIM SL L 65 CM DIA 7.62 FR SS PEBAX,SUP-2421250,CDM,C1887,HCPCS,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
"HC So1 Herpes Simplex, Type 2",PX-3028669667,CDM,86696,CPT,0302,RC,,,,both,,,35.00,22.75,,,,,,,,,,,,,
PLATE BNE W17.5XL160MM THK5.2MM 9 H TI BROAD LIMIT CNTCT,SUP-2190846,CDM,C1713,HCPCS,0278,RC,,,,both,,,1427.32,927.76,,,,,,,,,,,,,
SCREW BONE L16MM OD2.5MM S STL ELBW CANN FULL THRD EVOLVE,SUP-2397950,CDM,C1713,HCPCS,0278,RC,,,,both,,,621.72,404.12,,,,,,,,,,,,,
CATHETER CV INFUSE 7 FR 1 LUMEN,SUP-2214538,CDM,C1751,HCPCS,0278,RC,,,,both,,,45.40,29.51,,,,,,,,,,,,,
PLATE BNE 5 X 7 H CRANIOMAXILLOFACIAL REG DISTRCTN NS,SUP-2883235,CDM,C1713,HCPCS,0278,RC,,,,both,,,5484.61,3565.00,,,,,,,,,,,,,
GRAFT VASC GORTX L 110 CM DIA 6-8 MM EPTFE TAPR STD WALL N,SUP-2396457,CDM,C1768,CPT,0278,RC,,,,both,,,3290.72,2138.97,,,,,,,,,,,,,
KIT ABLAT PRB 17GA L10MM SGL OSTEOCOOL RF,SUP-2293683,CDM,C1886,HCPCS,0278,RC,,,,both,,,11068.50,7194.52,,,,,,,,,,,,,
SET IMPL SCR DISK SELF DRL 1.5MM DIA 4MML,SUP-2362178,CDM,C1713,HCPCS,0278,RC,,,,both,,,1709.73,1111.32,,,,,,,,,,,,,
BIT DRL L260.4MM DIA3.5MM S STL GRAD ADD ON CONN FOR BAR,SUP-2342881,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1839.66,1195.78,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP L480CM 0.018IN TIP L3CM PLAT SPR COIL TIP,SUP-2169364,CDM,C1769,HCPCS,0272,RC,,,,both,,,458.44,297.99,,,,,,,,,,,,,
TROCAR EXT FIX LNG ORNG,SUP-2465961,CDM,2720000010,LOCAL,0272,RC,,,,both,,,362.23,235.45,,,,,,,,,,,,,
SCREW BONE L100MM DIA5MM CANC TIM CANN ANTIROTATION,SUP-2137177,CDM,C1713,HCPCS,0278,RC,,,,both,,,795.61,517.15,,,,,,,,,,,,,
CUP ACET 2 HOLE 46 MM HIP I-HIP,SUP-2240792,CDM,C1776,CPT,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
BOLT BONE L80MM DIA10MM GLD TI ALLOY FOR FEM NK SYS,SUP-2181052,CDM,C1713,HCPCS,0278,RC,,,,both,,,1109.99,721.49,,,,,,,,,,,,,
TUBE VENT SHEP GRMMT 1.14 MM 1.6 MM 2.3 MM FLROPLAS 520121,SUP-2535139,CDM,L8699,HCPCS,0278,RC,,,,both,,,24.49,15.92,,,,,,,,,,,,,
NAIL IM L360MM DIA11MM UNIV FEM S STL,SUP-2186417,CDM,C1713,HCPCS,0278,RC,,,,both,,,3537.68,2299.49,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED LG CEM HD CUP LNR ST TRAB MTL CERM,SUP-2212106,CDM,C1776,CPT,0278,RC,,,,both,,,15186.77,9871.40,,,,,,,,,,,,,
BIT DRL 3.5 MM W/ K-WIRE CONTOURSLPS,SUP-2646743,CDM,2720000010,LOCAL,0272,RC,,,,both,,,623.29,405.14,,,,,,,,,,,,,
PLATE BNE 5 DEG SM LT METATARSOPHALANGEAL FUSION NS ORTHOLOC,SUP-2900669,CDM,C1713,HCPCS,0278,RC,,,,both,,,8594.18,5586.22,,,,,,,,,,,,,
SCREW BNE L 75 MM DIA 3.5 MM THRD L 19 MM TI CANN COMPR,SUP-2906100,CDM,C1713,HCPCS,0278,RC,,,,both,,,1673.15,1087.55,,,,,,,,,,,,,
HEMOSTAT SURG LG TEND PASS,SUP-2474134,CDM,C1713,HCPCS,0278,RC,,,,both,,,1149.24,747.01,,,,,,,,,,,,,
DEVICE REATTACHMENT W23XL121MM LNG GREATER TROCHANTERIC,SUP-2410264,CDM,C1713,HCPCS,0278,RC,,,,both,,,7182.53,4668.64,,,,,,,,,,,,,
CATHETER PERITONEAL DIALYSI V SER 15FR DIA 43CM S MC20VS43RC,SUP-2633015,CDM,C1752,HCPCS,0278,RC,,,,both,,,543.22,353.09,,,,,,,,,,,,,
SPLINT HND AD SM L5.75IN LT HEADLINER CVR FIVE STRP CLSR ADJ,SUP-2324297,CDM,L3807,HCPCS,0272,RC,,,,both,,,180.93,117.60,,,,,,,,,,,,,
TUBE VENT POPE 1.14 MM 1 MM 2.5 PHOSPHORYLCHOLINE COAT SIL,SUP-2535108,CDM,L8699,HCPCS,0278,RC,,,,both,,,50.21,32.64,,,,,,,,,,,,,
NAIL IM L26CM OD10MM GLD FEM TIB KNEE LCK CANN BENT RG AG,SUP-2347081,CDM,C1713,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
ALENDRONATE SODIUM 70 MG PO TABS,RX-29048,CDM,6370000000,HCPCS,0637,RC,16714-0633-01,NDC,,both,1,UN,5.10,3.31,,,,,,,,,,,,,
VALVE AORT DIA25MM MECH SEW RNG ROT STD CUF,SUP-2356709,CDM,C1889,HCPCS,0278,RC,,,,both,,,15018.62,9762.10,,,,,,,,,,,,,
WEDGE FEM SZ 7-8 THK5MM SHT UNIV POST KNEE CO CHROM PRI,SUP-2346039,CDM,C1776,CPT,0278,RC,,,,both,,,3574.89,2323.68,,,,,,,,,,,,,
SYSTEM CAST NO BOOT SZ 3 TCC-EZ DISP,SUP-2244454,CDM,C1713,HCPCS,0278,RC,,,,both,,,505.41,328.52,,,,,,,,,,,,,
GRAFT VASC STR 7 MMX50 CM STD WALL N RING EPTFE CARBOFLO,SUP-2761304,CDM,C1768,CPT,0278,RC,,,,both,,,1910.78,1242.01,,,,,,,,,,,,,
CATHETER EP 7FRX115CM F CRV QPLR 1 7 4MM BI DIR DEFL,SUP-2248474,CDM,C1730,HCPCS,0272,RC,,,,both,,,6119.86,3977.91,,,,,,,,,,,,,
MESH HERN SQ 8X8 IN FULL RESRB FOR SFT TISS RECON PHASIX,SUP-2855254,CDM,C1781,HCPCS,0278,RC,,,,both,,,18902.80,12286.82,,,,,,,,,,,,,
AMPHETAMINE-DEXTROAMPHETAMINE 10 MG PO TABS,RX-9081,CDM,6370000000,HCPCS,0637,RC,00555-0972-02,NDC,,both,1,UN,3.90,2.53,,,,,,,,,,,,,
PLATE BNE L29MM 6 H TI STR FOR 1.5MM SCR MOD HND SYS,SUP-2191107,CDM,C1713,HCPCS,0278,RC,,,,both,,,1306.84,849.45,,,,,,,,,,,,,
OCCLUDER VASC FLO RST L 12 MM BLB DIA 4.5 MM SIL RUBBER,SUP-2129866,CDM,C1817,HCPCS,0278,RC,,,,both,,,138.16,89.80,,,,,,,,,,,,,
PLATE BONE 6 HOLE 2X10 MM SAGITTAL SPILT BAR CURVED TITANIUM,SUP-2838389,CDM,C1713,HCPCS,0278,RC,,,,both,,,1180.33,767.21,,,,,,,,,,,,,
SPACER SPNL 12MM MAG INDIR DCOMPR STRL SUPERION,SUP-2392700,CDM,C1821,HCPCS,0278,RC,,,,both,,,21980.00,14287.00,,,,,,,,,,,,,
PROSTHESIS OSS BCKT HNDL 0.6X4.5 MM 1 MM TI,SUP-2638178,CDM,L8613,CPT,0278,RC,,,,both,,,713.53,463.79,,,,,,,,,,,,,
LINER ACET OD50MM ID28MM 10DEG NEUT MARATHON CEMENTLESS,SUP-2250506,CDM,C1776,CPT,0278,RC,,,,both,,,3636.12,2363.48,,,,,,,,,,,,,
FORCEPS ELECSURG CUT L33CM OD5MM EVEREST,SUP-2312646,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
HC I&D Abscess Vulva Perineum,PX-4505640500,CDM,56405,CPT,0450,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
GUIDEPIN SURG L16MM CRUC RET FLX,SUP-2201245,CDM,C1776,CPT,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
PLATE BNE MIDFACE 40 MM DORA PLLA-PGA STRL RESORB XG,SUP-2479401,CDM,C1713,HCPCS,0278,RC,,,,both,,,4938.12,3209.78,,,,,,,,,,,,,
PLATE BONE L20MM THK1MM 12 H TI LCK COMPR ADPT MINI FRAG FOR,SUP-2191209,CDM,C1713,HCPCS,0278,RC,,,,both,,,2710.13,1761.58,,,,,,,,,,,,,
PLATE PHLANG HD 1.5MM RT STRL VAL,SUP-2546075,CDM,C1713,HCPCS,0278,RC,,,,both,,,1619.58,1052.73,,,,,,,,,,,,,
VALVE CSF PROGRAMMABLE 40 MM PRECIS CYL UNITZ CATH LO HAKIM,SUP-2666439,CDM,C1889,HCPCS,0278,RC,,,,both,,,15857.00,10307.05,,,,,,,,,,,,,
PLATE 4.5MM TI CURVED NARROW LCP PLATE 14 HOLE STERILE,SUP-2546927,CDM,C1713,HCPCS,0278,RC,,,,both,,,3116.83,2025.94,,,,,,,,,,,,,
SHUNT NEUROSURGICAL L90CM STD REG W INTEGR PERI CATH OPN,SUP-2628592,CDM,C1729,HCPCS,0272,RC,,,,both,,,14974.38,9733.35,,,,,,,,,,,,,
COLLAR CERV SFT DENS W/ CHIN SUPP ADJ AD CNTOUR HK AND LOOP,SUP-2324378,CDM,L0120,HCPCS,0272,RC,,,,both,,,16.64,10.82,,,,,,,,,,,,,
KIT ANCHR DISP FOR KNOTLESS SUTURETAK SHAVERDRILL,SUP-2121611,CDM,2720000010,LOCAL,0272,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
SCREW BNE L 12 MM DIA2 MM TI MAND ST AXS NS UNIV 2.0 MP,SUP-2909574,CDM,C1713,HCPCS,0278,RC,,,,both,,,299.74,194.83,,,,,,,,,,,,,
HC Mra Abdomen W/ Contrast,PX-6187418500,CDM,C8900,CPT,0618,RC,,,,both,,,4365.00,2837.25,,,,,,,,,,,,,
HC Diabetes Indiv/30min,PX-9420010800,CDM,G0108,HCPCS,0940,RC,,,,inpatient,,,160.00,104.00,,,,,,,,,,,,,
CATHETER CV SINGLE LUMEN 5 FRX70 CM HYDRPHLC STYL RADPICC,SUP-2125526,CDM,C1751,HCPCS,0278,RC,,,,both,,,214.46,139.40,,,,,,,,,,,,,
TRAY KYPHOPLASTY BAL 4ML L10MM DIA18.3MM NDL 10GA SYR 20ML,SUP-2361537,CDM,C1727,CPT,0278,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
PI PICC KIT 1-L 4 FR X 55 CM AGBA/TIPTRACKER,SUP-2565194,CDM,C1751,HCPCS,0278,RC,,,,both,,,633.12,411.53,,,,,,,,,,,,,
ALLOGRAFT BNE CHIPS 1-8 MM 15 CC CANC DEMINERALIZED BNE BIO,SUP-2637037,CDM,C1713,HCPCS,0278,RC,,,,both,,,5051.07,3283.20,,,,,,,,,,,,,
HC Diabetes Indiv/30min,PX-9420010800,CDM,G0108,HCPCS,0942,RC,,,,outpatient,,,160.00,104.00,,,,,,,,,,,,,
COLLAR CERV COT DIAL HT ADJ XL PT ACCS WIND VISTA,SUP-2123900,CDM,L0190,HCPCS,0272,RC,,,,both,,,102.71,66.76,,,,,,,,,,,,,
BLADE SAW W8XL75MM THK1MM RECIP,SUP-2363317,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1058.02,687.71,,,,,,,,,,,,,
PLATE BNE THK 0.75 MM PANEL 1.7 MM 2 X 21 H MAXILLOFCL,SUP-2909645,CDM,C1713,HCPCS,0278,RC,,,,both,,,7286.53,4736.24,,,,,,,,,,,,,
WIRE FIX TRCR PT 0.9X100 MM SINGLE END SMOOTH RND KIRSCHNER,SUP-2321714,CDM,C1713,HCPCS,0278,RC,,,,both,,,65.94,42.86,,,,,,,,,,,,,
SCREW INTFR L25MM DIA9MM UNIV TI CANN BLNT NONABSORBABLE,SUP-2366617,CDM,C1713,HCPCS,0278,RC,,,,both,,,520.46,338.30,,,,,,,,,,,,,
CATHETER HD DL 14 FRX30 CM ADMIN FULL KT STR TAPR TIP,SUP-2267003,CDM,C1752,HCPCS,0278,RC,,,,both,,,354.82,230.63,,,,,,,,,,,,,
GRAFT BONE SUB 15CC MG BASE COMPND INJ MOLD BIOCOMPATIBLE,SUP-2418112,CDM,C1713,HCPCS,0278,RC,,,,both,,,13894.50,9031.42,,,,,,,,,,,,,
SCREW BONE L6MM DIA2MM STD CORT CRANIOMAXILLOFACIAL TI SELF,SUP-2189359,CDM,C1713,HCPCS,0278,RC,,,,both,,,106.76,69.39,,,,,,,,,,,,,
SURGICAL PROCEDURE KIT 018 25 CM 21 GA VENA CAVA NEVERTOUCH,SUP-2752526,CDM,C1888,HCPCS,0272,RC,,,,both,,,921.75,599.14,,,,,,,,,,,,,
BRACE ORTH CIRC THGH 13-15.5 IN CTR 12-13 IN CALF 10-12 IN RT MEDIAL,SUP-2916924,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1036.48,673.71,,,,,,,,,,,,,
CATHETER CTO 5FR L110CM CROSSING PROF 2MM SHTH 6FR 0.014IN,SUP-2124796,CDM,C1769,HCPCS,0272,RC,,,,both,,,6264.30,4071.79,,,,,,,,,,,,,
TM STEM POR BPLR SY,SUP-2212128,CDM,C1776,CPT,0278,RC,,,,both,,,10990.00,7143.50,,,,,,,,,,,,,
HC Diabetes Indiv/30min,PX-9420010800,CDM,G0108,HCPCS,0940,RC,,,,outpatient,,,160.00,104.00,,,,,,,,,,,,,
GUIDEWIRE VASC L145CM DIA0035IN S STL PTFE HVY DUTY SAFE T J,SUP-2167580,CDM,C1769,HCPCS,0272,RC,,,,both,,,33.79,21.96,,,,,,,,,,,,,
STRUT EXT FIX L 145-205 MM MED LINEAR,SUP-2898582,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3972.10,2581.86,,,,,,,,,,,,,
MESH HERN PTCH 3.5X1.8 IN PRESHAPE ONLAY KNITTED PROLITE,SUP-2227233,CDM,C1781,HCPCS,0278,RC,,,,both,,,126.10,81.96,,,,,,,,,,,,,
INTRODUCER RF 17 GAX150 MM COOLIEF,SUP-2237171,CDM,2720000010,LOCAL,0272,RC,,,,both,,,354.98,230.74,,,,,,,,,,,,,
NEEDLE BX 18GA L15CM ORNG S STL PLAS HNDL AUTO PROGRAMMABLE,SUP-2133807,CDM,C1894,HCPCS,0272,RC,,,,both,,,156.97,102.03,,,,,,,,,,,,,
TROCAR ARTHSCP N THRD N OPT VW BLDELSS BLNT TIP W HNDL W OUT,SUP-2166824,CDM,C1894,HCPCS,0272,RC,,,,both,,,632.14,410.89,,,,,,,,,,,,,
TUBE TRACHEOSTOMY FENESTRATED ADULT  UNCUFFED ADAPTER OBTURA,SUP-2793424,CDM,2720000010,LOCAL,0272,RC,,,,both,,,416.21,270.54,,,,,,,,,,,,,
HC Extremity Venogram,PX-3613600500,CDM,36005,CPT,0361,RC,,,,inpatient,,,6875.00,4468.75,,,,,,,,,,,,,
GUIDEWIRE VASC L 40 CM DIA 0.018 IN CRV RAD 2 MM HVY DBL FLX,SUP-2760014,CDM,C1769,HCPCS,0272,RC,,,,both,,,137.97,89.68,,,,,,,,,,,,,
SET ENDOBRONCH BLK PED 7FR L65CM ETT 7MM BAL SPHR W/ SYR,SUP-2169658,CDM,2720000010,LOCAL,0272,RC,,,,both,,,761.45,494.94,,,,,,,,,,,,,
CATHETER KIT DL 5 FR PLCMNT POWERPICC,SUP-2126775,CDM,C1751,HCPCS,0278,RC,,,,both,,,580.90,377.58,,,,,,,,,,,,,
PLATE BNE ORBIT MED RT TEF,SUP-2468399,CDM,C1713,HCPCS,0278,RC,,,,both,,,125.57,81.62,,,,,,,,,,,,,
HC Ot Manual Therapy per 15 Min.,PX-4309714000,CDM,97140,CPT,0430,RC,,,,inpatient,,,194.00,126.10,,,,,,,,,,,,,
HC IV Push Diff Drug,PX-2609637500,CDM,96375,CPT,0260,RC,,,,both,,,91.00,59.15,,,,,,,,,,,,,
EPLERENONE 25 MG PO TABS,RX-36983,CDM,6370000000,HCPCS,0637,RC,60687-0451-21,NDC,,both,1,UN,18.80,12.22,,,,,,,,,,,,,
BUR SURG BALL 5 MM 21 CM FLUT LG BOR MIDAS REX 8 LEGEND,SUP-2664677,CDM,2720000010,LOCAL,0272,RC,,,,both,,,583.79,379.46,,,,,,,,,,,,,
CATHETER HD RVS TUNNELED 53 CM 33 CM KT PALINDROME PRECIS RT,SUP-2626976,CDM,C1750,HCPCS,0278,RC,,,,both,,,954.97,620.73,,,,,,,,,,,,,
EXPANDER TISS L6XW4XH3.5CM 70CC FIL VOL STD PLAS BRST SIL,SUP-2113723,CDM,C1789,HCPCS,0278,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
CATHETER ANGIOPLSTY MUSTANG L 75 CM BALLOON L 20 MM DIA 7 MM,SUP-2142564,CDM,C1725,HCPCS,0272,RC,,,,both,,,596.60,387.79,,,,,,,,,,,,,
INSTRUMENT EXT FIX REARFOOT ANK ARTH FOR SIDEKCK FIX,SUP-2400593,CDM,C1713,HCPCS,0278,RC,,,,both,,,19047.24,12380.71,,,,,,,,,,,,,
ANCHOR SUTURE DBL LD W/ NDL 5MM DRL Y-KNOT RC 2 HI-FI,SUP-2422968,CDM,C1713,HCPCS,0278,RC,,,,both,,,2054.50,1335.42,,,,,,,,,,,,,
HYDROXYZINE PAMOATE 50 MG PO CAPS,RX-3778,CDM,6370000000,HCPCS,0637,RC,50268-0399-11,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
RELOAD STPLR ARTICULATING LINEAR 45 MM END CUT ENDOPATH ETS,SUP-2257558,CDM,2720000010,LOCAL,0272,RC,,,,both,,,457.69,297.50,,,,,,,,,,,,,
HC Layer Clos Face 2.6-5.0 Cm,PX-4501205200,CDM,12052,CPT,0450,RC,,,,inpatient,,,1216.00,790.40,,,,,,,,,,,,,
NAIL IM L300MM DIA10MM THK1.5MM 1.5M CURVATURE RAD UNIV,SUP-2186413,CDM,C1713,HCPCS,0278,RC,,,,both,,,3741.00,2431.65,,,,,,,,,,,,,
BONE GROWTH STIM OSTEOGEN M,SUP-2136058,CDM,E0749,HCPCS,0278,RC,,,,both,,,16704.80,10858.12,,,,,,,,,,,,,
ANCHOR SUT DIA5.5MM W/ ORTHOCORD SUT HEALIX BR,SUP-2249424,CDM,C1713,HCPCS,0278,RC,,,,both,,,1274.84,828.65,,,,,,,,,,,,,
PLATE BNE L128MM 8 H ST L PROX BILAT TIB S STL NEUT LOK,SUP-2177835,CDM,C1713,HCPCS,0278,RC,,,,both,,,4266.76,2773.39,,,,,,,,,,,,,
PROBE MICROWAVE ABLATION L 25 CM DIA13 GA CABLE L 1.4 M STRL,SUP-2908895,CDM,C1886,HCPCS,0278,RC,,,,both,,,8792.00,5714.80,,,,,,,,,,,,,
PLATE BNE L 186 X W 12.7 MM THK 3.5 MM SCREW DIA2.7/3.5 MM 72464314N,SUP-2933523,CDM,C1713,HCPCS,0278,RC,,,,both,,,7925.52,5151.59,,,,,,,,,,,,,
WIRE TRCR 11M X 100MM SGL END,SUP-2392813,CDM,C1769,HCPCS,0272,RC,,,,both,,,80.07,52.05,,,,,,,,,,,,,
GRAFT NRV PROTCT L4CM ID5MM CLLGN ABSRB PERIPH NEURAWRAP,SUP-2244319,CDM,C9352,HCPCS,0278,RC,,,,both,,,5766.17,3748.01,,,,,,,,,,,,,
TUBE GASTROJEJU 14FR L22CM STOMA L1.5CM MICRO GJET,SUP-2713901,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4016.06,2610.44,,,,,,,,,,,,,
CATHETER PTCA 4FR L150CM BLLN L120MM DIA2MM 14ATM 0.014IN,SUP-2172592,CDM,C1725,HCPCS,0272,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
BOLT EX FX MAXFRAME MULTIPAR PIN MNT,SUP-2737904,CDM,2720000010,LOCAL,0272,RC,,,,both,,,512.95,333.42,,,,,,,,,,,,,
PLATE BNE SM W11XL50MM THK15MM 90DEG 4X3 H TI T SHP R ANG,SUP-2190927,CDM,C1713,HCPCS,0278,RC,,,,both,,,956.07,621.45,,,,,,,,,,,,,
STEM FEM 28 MM HIP MOD NK PROFEMUR,SUP-2400560,CDM,C1776,CPT,0278,RC,,,,both,,,2527.70,1643.00,,,,,,,,,,,,,
DRIVER SURG SNAP OFF STRL DISP STROPP,SUP-2913521,CDM,2720000010,LOCAL,0272,RC,,,,both,,,637.99,414.69,,,,,,,,,,,,,
PLATE BONE MESH 1.3X100X100 MM 5X5 MM TITANIUM,SUP-2838346,CDM,C1713,HCPCS,0278,RC,,,,both,,,6904.86,4488.16,,,,,,,,,,,,,
INSERT HUM CONSTRN 6+ MM 36 MM SHLDR AEQUALIS REVERSED FX,SUP-2715647,CDM,C1776,CPT,0278,RC,,,,both,,,4890.55,3178.86,,,,,,,,,,,,,
SET CLLR SZ P1 SORBATEX EXTRA PD ANTIBACT MIAMI JR,SUP-2276576,CDM,L0120,HCPCS,0274,RC,,,,both,,,187.68,121.99,,,,,,,,,,,,,
MESH SURG W8XL10IN ELLIPSE W/ ECHO PS POS SYS FOR LAP,SUP-2125920,CDM,C1781,HCPCS,0278,RC,,,,both,,,4838.74,3145.18,,,,,,,,,,,,,
STAPLER INT L37CM STPL 25MM CIR ENDOSCP CRV INTLUMN B FRM,SUP-2218994,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1060.88,689.57,,,,,,,,,,,,,
LEAD EXTENSION KIT 60 CM BLU,SUP-2457569,CDM,C1883,HCPCS,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
SCREW BEND INSRT FOR LOK RECON TI PLT,SUP-2193365,CDM,C1713,HCPCS,0278,RC,,,,both,,,191.23,124.30,,,,,,,,,,,,,
PIN FIX TRCR PT 1 END 0.093X9 IN RND END SS NS STEINMANN,SUP-2791594,CDM,C1713,HCPCS,0278,RC,,,,both,,,11.87,7.72,,,,,,,,,,,,,
COIL VASC NEST EMBOLUS L 14 CM DIA12 MM STD SFT HELCL,SUP-2385127,CDM,C1889,HCPCS,0278,RC,,,,both,,,240.15,156.10,,,,,,,,,,,,,
ANCHOR SUT OD2.9MM MICROMAX FLX,SUP-2137186,CDM,C1713,HCPCS,0278,RC,,,,both,,,885.48,575.56,,,,,,,,,,,,,
HEAD HUM H22MM DIA40MM STD SHLDR FOR COMPHSVE FRAC SYS,SUP-2404610,CDM,C1776,CPT,0278,RC,,,,both,,,2643.88,1718.52,,,,,,,,,,,,,
COIL VASC I-ED COIL L 10 CM DIA 0.012 IN SECONDARY 2-3 MM,SUP-2865319,CDM,C1889,HCPCS,0278,RC,,,,both,,,5432.20,3530.93,,,,,,,,,,,,,
SCREW BNE L34MM DIA3.8MM CORT FULL THRD S STL MULT DIR N,SUP-2414114,CDM,C1713,HCPCS,0278,RC,,,,both,,,360.44,234.29,,,,,,,,,,,,,
BRACE KNEE SM FOR 15-18IN LT PAT PREFABRICATED AIRTECH FRME,SUP-2151021,CDM,L3660,HCPCS,0274,RC,,,,both,,,931.29,605.34,,,,,,,,,,,,,
SCREW BNE COMPR 6.5X90 MM 15 MM HDLSS BITE,SUP-2644930,CDM,C1713,HCPCS,0278,RC,,,,both,,,1612.39,1048.05,,,,,,,,,,,,,
BIT DRILL STOP 1.5X24 MM 88 MM HEXAGONAL COUPLING TITANIUM N,SUP-2841978,CDM,2720000010,LOCAL,0272,RC,,,,both,,,505.54,328.60,,,,,,,,,,,,,
PACK VITRCTMY VLV CANN VITREOUS DISP CONSTELLATION,SUP-2109957,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2324.82,1511.13,,,,,,,,,,,,,
GRAFT BNE W18XH8XL18MM EVANS FOR TIPEEK FT OSTEOTMY WDG SYS,SUP-2183040,CDM,C1713,HCPCS,0278,RC,,,,both,,,5986.82,3891.43,,,,,,,,,,,,,
NEEDLE PUNCTURE W/LUER-LOCK,SUP-2761700,CDM,2720000010,LOCAL,0272,RC,,,,both,,,530.50,344.82,,,,,,,,,,,,,
COIL VASC I-ED COIL L 15 CM DIA 0.012 IN SECONDARY 5 MM,SUP-2865309,CDM,C1889,HCPCS,0278,RC,,,,both,,,5008.30,3255.39,,,,,,,,,,,,,
ENDOPROSTHESIS VASC VIABAHN L 7.5CM 7MM 120CM 7FR RADIOPAQUE,SUP-2719625,CDM,C1768,HCPCS,0278,RC,,,,both,,,11093.62,7210.85,,,,,,,,,,,,,
IMMOBILIZER KNEE AD L22IN FOR UP TO 27IN THGH UNIV FOAM NYL,SUP-2197966,CDM,L1830,CPT,0274,RC,,,,both,,,179.61,116.75,,,,,,,,,,,,,
NAIL R 11MMX380MM LNG GAM,SUP-2370055,CDM,C1713,HCPCS,0278,RC,,,,both,,,4474.50,2908.42,,,,,,,,,,,,,
SCREW BNE STD 2.7X9 MM CRANIOMAXILLOFACIAL MAXDRIVE LEVEL 1,SUP-2467771,CDM,C1713,HCPCS,0278,RC,,,,both,,,341.51,221.98,,,,,,,,,,,,,
SYSTEM VEIN HARV ENDOSCP INCL DISECT AND HARVER ROD TRCR,SUP-2385158,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2102.23,1366.45,,,,,,,,,,,,,
POURCHEZXPRESSO/SAFETRAC COMB KT TIP TO HUB LEN 32 CM IMPL,SUP-2354976,CDM,C1752,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
HYDROCORTISONE 10 MG PO TABS,RX-3733,CDM,6370000000,HCPCS,0637,RC,50268-0406-15,NDC,,both,1,UN,8.30,5.39,,,,,,,,,,,,,
GRAFT VASC L30CM DIA38MM THOR CLLGN SFT FLX WVN DBL VEL,SUP-2227719,CDM,C1768,CPT,0278,RC,,,,both,,,1921.30,1248.84,,,,,,,,,,,,,
TUBERCULIN PPD 5 UNIT/0.1ML ID SOLN,RX-8259,CDM,2500000003,HCPCS,0250,RC,09999-9904-09,NDC,,both,0.1,ML,54.10,35.16,,,,,,,,,,,,,
CATHETER HD CRV EXTN LEG 12 FRX20 CM SHT TERM SLIM KT NIAG,SUP-2126483,CDM,C1752,HCPCS,0278,RC,,,,both,,,405.06,263.29,,,,,,,,,,,,,
ROD GRP 5.5MM,SUP-2232025,CDM,C1713,HCPCS,0278,RC,,,,both,,,2125.78,1381.76,,,,,,,,,,,,,
BRACE WR CIRC 7 1/4IN TO 8IN L RT REG IMMOB LOOP LCK W/ STAY,SUP-2324900,CDM,L3931,HCPCS,0274,RC,,,,both,,,30.27,19.68,,,,,,,,,,,,,
FIBER LASER HOLMIUM GI,SUP-2885367,CDM,2720000010,LOCAL,0272,RC,,,,both,,,395.64,257.17,,,,,,,,,,,,,
CATHETER DRNGE 14FR L45CM NDL 18GA 0.038IN PERC TRCR STYL,SUP-2168509,CDM,C1729,HCPCS,0272,RC,,,,both,,,242.16,157.40,,,,,,,,,,,,,
SCREW BNE CONN CANN FOR EXPERT TIB NAIL NS,SUP-2799381,CDM,C1713,HCPCS,0278,RC,,,,both,,,1428.17,928.31,,,,,,,,,,,,,
CROWN DENT 4UR UPPER RT LAT PRIMARY REFILL SS UNITEK,SUP-2322222,CDM,D6783,CPT,0278,RC,,,,both,,,12.40,8.06,,,,,,,,,,,,,
SET INTRO SUP ARW FLX SHTH L 11 CM DIA 8 FR GUIDEWIRE 45 CM,SUP-2383428,CDM,C1894,HCPCS,0272,RC,,,,both,,,65.31,42.45,,,,,,,,,,,,,
TITANIUM END CAP FOR TITANIUM ELASTIC NAIL3.0-4.0MM-STERILE,SUP-2549738,CDM,C1713,HCPCS,0278,RC,,,,both,,,349.29,227.04,,,,,,,,,,,,,
TUBE VENT 1.14 MM TOUMA W/ TAB SIL,SUP-2466627,CDM,L8699,HCPCS,0278,RC,,,,both,,,44.78,29.11,,,,,,,,,,,,,
ALLOGRAFT BNE FIB FRZN DSTL,SUP-2321785,CDM,C1713,HCPCS,0278,RC,,,,both,,,2794.60,1816.49,,,,,,,,,,,,,
INSERT TIB THK 13 MM SZ 3 ACTIVIT-E KNEE CR CONSTRND STRL,SUP-2893916,CDM,C1776,CPT,0278,RC,,,,both,,,12403.00,8061.95,,,,,,,,,,,,,
PLATE BNE 5 H TARSALIS T SHP,SUP-2243240,CDM,C1713,HCPCS,0278,RC,,,,both,,,4013.74,2608.93,,,,,,,,,,,,,
CATHETER GUID ENVOY DA L 95 CM OD 6 FR ID 0.071 IN STR,SUP-2458143,CDM,C1887,HCPCS,0272,RC,,,,both,,,2957.00,1922.05,,,,,,,,,,,,,
CATHETER DIAG 3FR ID0.027IN L150CM HYDRPHLC COAT MICCATH STR,SUP-2305467,CDM,C1887,HCPCS,0272,RC,,,,both,,,2712.96,1763.42,,,,,,,,,,,,,
PLATE 3.5MM TI LCP MEDIAL PROXIMAL TIBIA 18H RT 275MM-STER,SUP-2549593,CDM,C1713,HCPCS,0278,RC,,,,both,,,5329.37,3464.09,,,,,,,,,,,,,
MESH SURG 24X18 CMX1 MM DLMC,SUP-2395333,CDM,C1781,HCPCS,0278,RC,,,,both,,,4213.88,2739.02,,,,,,,,,,,,,
SCREW SPNL PEDCL 4.5X30 MM TI,SUP-2175366,CDM,C1713,HCPCS,0278,RC,,,,both,,,5551.52,3608.49,,,,,,,,,,,,,
STEM TIB L75MM DIA18MM KNEE EXTN STABILIZING PRI FLUT,SUP-2253315,CDM,C1713,HCPCS,0278,RC,,,,both,,,3249.90,2112.43,,,,,,,,,,,,,
GRAFT DBM PUTTY 2.5CC INFLUX,SUP-2737866,CDM,C1713,HCPCS,0278,RC,,,,both,,,2154.04,1400.13,,,,,,,,,,,,,
SEGMENTAL TM PROX FEM BODY 38MM OFFSET,SUP-2502394,CDM,C1776,CPT,0278,RC,,,,both,,,18369.00,11939.85,,,,,,,,,,,,,
TOTAL KNEE REPLACEMENT KIT END-DELIVERY 15 GAX60 MM 3 CC ANK,SUP-2866913,CDM,C1713,HCPCS,0278,RC,,,,both,,,8949.00,5816.85,,,,,,,,,,,,,
PIN FIX STD LCK STRL IMP FRELOK,SUP-2197721,CDM,C1713,HCPCS,0278,RC,,,,both,,,199.42,129.62,,,,,,,,,,,,,
HEAD FEM DIA36MM -6MM OFFSET 12/14 CONSTRN FRDM,SUP-2405359,CDM,C1776,CPT,0278,RC,,,,both,,,3824.52,2485.94,,,,,,,,,,,,,
AMOXICILLIN-POT CLAVULANATE 250-125 MG PO TABS,RX-22992,CDM,6370000000,HCPCS,0637,RC,00781-1874-31,NDC,,both,1,UN,15.00,9.75,,,,,,,,,,,,,
SCREW CANC 5.0MMX55.0MM POLARUS,SUP-2107659,CDM,C1713,HCPCS,0278,RC,,,,both,,,467.86,304.11,,,,,,,,,,,,,
CATHETER SUPRPUB 14FR L23CM 1 OBT STYL CONN TUBE SET RETEN,SUP-2171259,CDM,C2627,HCPCS,0272,RC,,,,both,,,173.33,112.66,,,,,,,,,,,,,
LEAD NERVE STIM 90 CM EXCLAIM,SUP-2615512,CDM,C1778,HCPCS,0278,RC,,,,both,,,9891.00,6429.15,,,,,,,,,,,,,
INSERTER SURG T-CONNECTOR SPINE CODE 46,SUP-2232130,CDM,2780000010,LOCAL,0278,RC,,,,both,,,1937.38,1259.30,,,,,,,,,,,,,
BATTERY MOD HEARTMATE II,SUP-2356035,CDM,C1713,HCPCS,0278,RC,,,,both,,,832.10,540.86,,,,,,,,,,,,,
KIT CARTER-THOMASON II PRT CLSR SYS INCL 1-SUT PASS,SUP-2171685,CDM,C1713,HCPCS,0278,RC,,,,both,,,524.10,340.66,,,,,,,,,,,,,
SCREW SPNL L 6 MM BLACKARMOR CARBON PEEK THORLUM M8 STRL,SUP-2917073,CDM,C1713,HCPCS,0278,RC,,,,both,,,1695.60,1102.14,,,,,,,,,,,,,
HC CT Guidance Needle Placement,PX-3507701200,CDM,77012,CPT,0350,RC,,,,both,,,621.00,403.65,,,,,,,,,,,,,
MICRO ACC SET 5F NIT,SUP-2116525,CDM,C1894,HCPCS,0272,RC,,,,both,,,138.16,89.80,,,,,,,,,,,,,
CANNULA ENDOSCP DIA 5.6 MM CUT W/ HOLE NONSTERILE LTX FREE,SUP-2906537,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1227.74,798.03,,,,,,,,,,,,,
C WIRE FIX L5IN DIA0.045IN SPADE TIP FOR SM BNE TRAUM,SUP-2166606,CDM,C1713,HCPCS,0278,RC,,,,both,,,22.42,14.57,,,,,,,,,,,,,
GRAFT OTO 0.6-0.9CM POR PORCINE SM INTEST SUBMUCOSA LAM,SUP-2170503,CDM,C1763,HCPCS,0278,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
PROBE RF ABLAT 90-S CRUISE SERFAS ENERGY,SUP-2361322,CDM,2720000010,LOCAL,0272,RC,,,,both,,,618.01,401.71,,,,,,,,,,,,,
LEAD DEFIB RELIANCE SG L 59 CM SIL EPTFE STEROID ENDOCARD RT,SUP-2148614,CDM,C1777,HCPCS,0275,RC,,,,both,,,8691.52,5649.49,,,,,,,,,,,,,
PACEMAKER CARD ACCOLADE EL W 4.45 X H 5.88 CM THK 0.75 CM,SUP-2149252,CDM,C1785,HCPCS,0275,RC,,,,both,,,13231.96,8600.77,,,,,,,,,,,,,
PLATE BNE RAD STYLOID DIVERGENT ACU-LOC 2,SUP-2107023,CDM,C1713,HCPCS,0278,RC,,,,both,,,2414.66,1569.53,,,,,,,,,,,,,
BRACE WRISTXSM FOR 14.6CM LT PROTCT PD ADJ BAR D RNG CLSR,SUP-2324887,CDM,L3931,HCPCS,0272,RC,,,,both,,,41.07,26.70,,,,,,,,,,,,,
DEFIBRILLATOR CARD W537XH779CM D099CM SGL CHMBR VR IS 1 DF 1,SUP-2149168,CDM,C1722,HCPCS,0275,RC,,,,both,,,47360.62,30784.40,,,,,,,,,,,,,
LEAD PACE QPLR 2.6 FRX95 CM 3D SPRL TINES IS4-LLLL ACUITY X4,SUP-2148717,CDM,C1900,HCPCS,0275,RC,,,,both,,,6154.40,4000.36,,,,,,,,,,,,,
PLATE BNE TIB LG 0.2 CM,SUP-2321910,CDM,C1713,HCPCS,0278,RC,,,,both,,,4003.50,2602.27,,,,,,,,,,,,,
CONNECTOR ROD OD35X35MM POST CERV PARA DBL SIERRA,SUP-2245451,CDM,C1713,HCPCS,0278,RC,,,,both,,,163.47,106.26,,,,,,,,,,,,,
PLATE BNE W11XL246MM THK3.7MM 14 H NONSTERILE L MED DST TIB,SUP-2185600,CDM,C1713,HCPCS,0278,RC,,,,both,,,4656.43,3026.68,,,,,,,,,,,,,
CAP SPNL 2 H LCK ANTR CERV PLT SNOWCAP,SUP-2207860,CDM,C1713,HCPCS,0278,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
RITUXIMAB-HYALURONIDASE HUMAN 1600-26800 MG -UT/13.4ML SC SOLN,RX-139195,CDM,J9311,HCPCS,0636,RC,50242-0109-01,NDC,,both,13.4,ML,21646.40,14070.16,,,,,,,,,,,,,
ANCHOR SUT OD14MM SHT SFT FOR LAT EPICONDYLITIS REP,SUP-2137228,CDM,C1713,HCPCS,0278,RC,,,,both,,,2215.58,1440.13,,,,,,,,,,,,,
SCREW BONE LOK 6.5MM DIA 40MML TIMAX CNCLLS HXGNL HEAD 22MML,SUP-2588746,CDM,C1713,HCPCS,0278,RC,,,,both,,,135.52,88.09,,,,,,,,,,,,,
BIT DRILL 2MM REUSABLE NON,SUP-2824802,CDM,2720000010,LOCAL,0272,RC,,,,both,,,630.48,409.81,,,,,,,,,,,,,
TRAY PICC SUBCL 2/L 5FR 45CML SIL RADPQ SHERLOCK MAG 9827507,SUP-2632709,CDM,C1751,HCPCS,0278,RC,,,,both,,,493.61,320.85,,,,,,,,,,,,,
SET ANCHR SUTURE 12CML NDL GI STRGHT BRAIDED PRE LDD FIXCOR,SUP-2638533,CDM,C1889,HCPCS,0278,RC,,,,both,,,486.70,316.35,,,,,,,,,,,,,
BARRIER ADH W3XL4IN UTER PELV ABSRB GYNECARE INTCEED,SUP-2218343,CDM,C1765,HCPCS,0278,RC,,,,both,,,1562.02,1015.31,,,,,,,,,,,,,
PLATE BNE L26MM 3X3 H BILAT MAND ORAL MAXILLOFACIAL TI ANG,SUP-2191465,CDM,C1713,HCPCS,0278,RC,,,,both,,,4305.88,2798.82,,,,,,,,,,,,,
MESH BONE SIZE 8 TTNM STNDRD LATEX FREE LEFT SBCCPTL CRNL,SUP-2677395,CDM,C1713,HCPCS,0278,RC,,,,both,,,1060.85,689.55,,,,,,,,,,,,,
CLIP NRV STIM DYN INLINE ACT M5,SUP-2310418,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1023.64,665.37,,,,,,,,,,,,,
SET IMPL GRPHC CA FOR 4.5MM PROX FEM LCK COMPR PLT,SUP-2183066,CDM,C1713,HCPCS,0278,RC,,,,both,,,74523.50,48440.27,,,,,,,,,,,,,
SET CATH HEMODIALYSI SPLIT STRM CHRONIC BASIC 14FR DIA 28CM,SUP-2610542,CDM,C1750,HCPCS,0278,RC,,,,both,,,967.12,628.63,,,,,,,,,,,,,
CLAMP SURG CASTANEDA MED 18X6 MM,SUP-2187123,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1000.34,650.22,,,,,,,,,,,,,
PLATE TI ANTEGRA TWO LEVEL LUMBAR/99MM-04.102.299,SUP-2866728,CDM,C1713,HCPCS,0278,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
MESH HERN L33.7XW26.1CM THICKNESS 15MM POLYPR EPTFE VENTRAL,SUP-2125811,CDM,C1781,HCPCS,0278,RC,,,,both,,,4560.54,2964.35,,,,,,,,,,,,,
BLADE IM L75MM DIA12.5MM NSTERILE CANC TI SPRL NTHREADED,SUP-2192128,CDM,C1713,HCPCS,0278,RC,,,,both,,,2259.64,1468.77,,,,,,,,,,,,,
HC Abscess Catheter Injection,PX-3614942400,CDM,49424,CPT,0361,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
STENT URET 360 DEG L 10 CM DIA 4.5 FR PIGTL OPN END KID CURL,SUP-2478856,CDM,C2617,HCPCS,0278,RC,,,,both,,,190.47,123.81,,,,,,,,,,,,,
PLATE BNE L 130 X W 11.2 MM THK 3.5 MM 8 H SS RT PROX RADIAL,SUP-2933120,CDM,C1713,HCPCS,0278,RC,,,,both,,,3066.21,1993.04,,,,,,,,,,,,,
BASEPLATE TIB N MOD LNG 67 MM KNEE OSS AVL,SUP-2441801,CDM,C1776,CPT,0278,RC,,,,both,,,9170.37,5960.74,,,,,,,,,,,,,
PATCH DURAL SYNTHETIC NON ABSORBABLE SUBSTITUTE NON IMMUNOGE,SUP-2825551,CDM,C1763,HCPCS,0278,RC,,,,both,,,1413.60,918.84,,,,,,,,,,,,,
BIT DRL TAPR HD 5 MMX9 IN BADGER,SUP-2765764,CDM,2720000010,LOCAL,0272,RC,,,,both,,,887.21,576.69,,,,,,,,,,,,,
PLATE BNE W22XL54MM STD 6X3 H NONSTERILE R DST RAD VOLAR TI,SUP-2180846,CDM,C1713,HCPCS,0278,RC,,,,both,,,2379.65,1546.77,,,,,,,,,,,,,
TUBE VENT 1.27 MM 2.45 MM 2.35 MM TRIUNE TRMPT SIL 510302,SUP-2535120,CDM,L8699,HCPCS,0278,RC,,,,both,,,68.77,44.70,,,,,,,,,,,,,
STEM FEM VERSYS 8 INCH BEADED FC 13X200MM STR STD BODY/NECK,SUP-2504238,CDM,C1776,CPT,0278,RC,,,,both,,,14217.92,9241.65,,,,,,,,,,,,,
CHOLANGIOGRAM KIT RX AUTOTOME UTOM XL SPHINTOM JAGWIRE 7544,SUP-2525333,CDM,C1769,HCPCS,0272,RC,,,,both,,,937.92,609.65,,,,,,,,,,,,,
SYSTEM IMPL DIA2.6/4.75 MM KNOTLESS SCORPION MULTFI NDL WHT,SUP-2930500,CDM,C1713,HCPCS,0278,RC,,,,both,,,7929.29,5154.04,,,,,,,,,,,,,
IMPLANT TOE JT WEIL TYP FOR HAMRTOE FIX SYS SWNSN,SUP-2397762,CDM,C1776,CPT,0278,RC,,,,both,,,1667.34,1083.77,,,,,,,,,,,,,
PLATE BONE L77MM 5 H LT LAT DSTL HUM LCK FOR 2.7/3.5MM SCR,SUP-2348655,CDM,C1713,HCPCS,0278,RC,,,,both,,,10355.72,6731.22,,,,,,,,,,,,,
STENT PERIPH L59MM DIA9X13MM CATH L135CM INTRO SHTH 8FR,SUP-2395685,CDM,C1874,HCPCS,0278,RC,,,,both,,,9862.74,6410.78,,,,,,,,,,,,,
SPACER SPNL SM W26XH40MM THORLUM PEEK CNTR INTBDY FUS ADD,SUP-2291510,CDM,C1889,HCPCS,0278,RC,,,,both,,,6430.72,4179.97,,,,,,,,,,,,,
ANCHOR SUT 2 DIA4.5MM BLU PEEK NONABSORBABLE ULTBRAID DBL,SUP-2341845,CDM,C1713,HCPCS,0278,RC,,,,both,,,974.34,633.32,,,,,,,,,,,,,
HC Inj Anes/Steroid C/D Facet Sg,PX-3616449000,CDM,64490,CPT,0361,RC,,,,inpatient,,,4864.00,3161.60,,,,,,,,,,,,,
BLADE SCRDRVR SELF RET ADD ON CPL T10 FIT,SUP-2365030,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1419.91,922.94,,,,,,,,,,,,,
CLIP INT LIG SM WIDE TI VESOCCLUDE,SUP-2757591,CDM,C1889,HCPCS,0278,RC,,,,both,,,26.38,17.15,,,,,,,,,,,,,
IMPLANT OTOLARYN 0.6MM DIAM 3.5MM LEN PLAT STAP PIST,SUP-2312554,CDM,L8613,CPT,0278,RC,,,,both,,,429.99,279.49,,,,,,,,,,,,,
PLATE SPNL 4 LEVEL 67 MM ANTR CERV ARCHON ACP,SUP-2563564,CDM,C1713,HCPCS,0278,RC,,,,both,,,2590.50,1683.82,,,,,,,,,,,,,
PIN EXT FIX HALF 3X20 MM 100 MM THRD TI NITRIDE STRL,SUP-2851107,CDM,2720000010,LOCAL,0272,RC,,,,both,,,279.46,181.65,,,,,,,,,,,,,
SAW RECIP H4MM THK635MM BLDE,SUP-2363296,CDM,2720000010,LOCAL,0272,RC,,,,both,,,244.32,158.81,,,,,,,,,,,,,
TREPHINE BONE RMR 14X8MM,SUP-2136783,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1508.77,980.70,,,,,,,,,,,,,
PIN FIX TRCR PT 1 END 0.177X9 IN THRD RND END NS STEINMANN,SUP-2791403,CDM,C1713,HCPCS,0278,RC,,,,both,,,82.21,53.44,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC SV IR 4FR 55CM 2 LUMAN RVS 3274355,SUP-2632666,CDM,C1751,HCPCS,0278,RC,,,,both,,,461.20,299.78,,,,,,,,,,,,,
DEVICE INFUS PERIPH EMER,SUP-2120632,CDM,C1751,HCPCS,0278,RC,,,,both,,,55.26,35.92,,,,,,,,,,,,,
OCCLUDER OCL12US TALENT AAA 12MM,SUP-2281269,CDM,C1768,CPT,0278,RC,,,,both,,,7771.50,5051.47,,,,,,,,,,,,,
"HC So Blood Typing, Abo",PX-3008690066,CDM,86900,CPT,0300,RC,,,,both,,,177.00,115.05,,,,,,,,,,,,,
SCREW INTFR L25MM DIA9MM KNEE TI GWIRE FIX CANN,SUP-2341647,CDM,C1713,HCPCS,0278,RC,,,,both,,,568.34,369.42,,,,,,,,,,,,,
PACEMAKER CARD CYLOS DR-T TI POLYUR SIL 2 CHMBR STD NOT MRI,SUP-2138083,CDM,C1785,HCPCS,0275,RC,,,,both,,,17238.60,11205.09,,,,,,,,,,,,,
SYRINGE VERT AUG MSTR ASMBLY CPLR ELBW STABILIT,SUP-2421787,CDM,2720000010,LOCAL,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
ALLOGRAFT BNE PWD 30 CC FD ASEP CORTICAL,SUP-2867156,CDM,C1762,CPT,0278,RC,,,,both,,,1557.13,1012.13,,,,,,,,,,,,,
NEEDLE HARVEST BONE MARROW,SUP-2737869,CDM,2720000010,LOCAL,0272,RC,,,,both,,,935.72,608.22,,,,,,,,,,,,,
PLATE SPNL W26XL43MM ANT THORLUM GRN TI LOK LO PROF FOR 55MM,SUP-2193111,CDM,C1713,HCPCS,0278,RC,,,,both,,,5024.00,3265.60,,,,,,,,,,,,,
PROSTHESIS OSS BELL 1.75-4.5X0.75-3.50 MM 0.2 MM TTP-VARIO,SUP-2266603,CDM,L8613,CPT,0278,RC,,,,both,,,957.70,622.50,,,,,,,,,,,,,
GUIDEWIRE VASC PRELUDE L 45 CM DIA 0.025 IN NIT PLAS RADIAL,SUP-2677291,CDM,C1769,HCPCS,0272,RC,,,,both,,,75.11,48.82,,,,,,,,,,,,,
PLATE CRAN W100XL100MM 4X4MM H TI MESH FOR USE W/ 1MM SCR,SUP-2190571,CDM,C1713,HCPCS,0278,RC,,,,both,,,7855.65,5106.17,,,,,,,,,,,,,
SCREW BNE L4MM DIA2MM CRANIOMAXILLOFACIAL TI EMGCY FOR,SUP-2189252,CDM,C1713,HCPCS,0278,RC,,,,both,,,243.10,158.01,,,,,,,,,,,,,
KIT INTRO L 45 CM DIA 5 FR GUIDEWIRE L 45 CM DIA 0.018 IN,SUP-2116538,CDM,C1894,HCPCS,0272,RC,,,,both,,,82.90,53.88,,,,,,,,,,,,,
SYSTEM ORTHOPEDIC 5.5 MM FDL,SUP-2431994,CDM,C1776,CPT,0278,RC,,,,both,,,4694.30,3051.29,,,,,,,,,,,,,
GRAFT HUM TISS L 3 X W 2 CM AMNION-CHORION-AMNION LAYR,SUP-2909271,CDM,Q4140,HCPCS,0636,RC,,,,both,,,7066.88,4593.47,,,,,,,,,,,,,
UREA 15 G PO PACK,RX-136732,CDM,6370000000,HCPCS,0637,RC,62530-0000-11,NDC,,both,1,UN,16.40,10.66,,,,,,,,,,,,,
SHEATH RESECTSCP 26FR YEL OBLQ BEAK CONN TB W/ CERAMIC,SUP-2261179,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2442.10,1587.36,,,,,,,,,,,,,
STENT BILI SOLOPS L 70 MM DIA12 FR AD STRL,SUP-2141425,CDM,C1876,HCPCS,0278,RC,,,,both,,,335.98,218.39,,,,,,,,,,,,,
GUIDEPIN ARTHSCP DIA0.054IN FOR POST TIB TEND DYSFUNCTION,SUP-2121851,CDM,2720000010,LOCAL,0272,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
CUP ACET DIA48MM UNIV HIP TI POR PRESSFIT PRI CEMENTLESS MH,SUP-2250729,CDM,C1776,CPT,0278,RC,,,,both,,,6864.04,4461.63,,,,,,,,,,,,,
BIT DRL DIA1MM STRYKR J LATCH FOR MOD HND SYS,SUP-2187627,CDM,2720000010,LOCAL,0272,RC,,,,both,,,273.78,177.96,,,,,,,,,,,,,
CATHETER IV TY 4 FRX20 CM PICC RADIOPAQUE MIDLN,SUP-2383957,CDM,C1751,HCPCS,0278,RC,,,,both,,,269.91,175.44,,,,,,,,,,,,,
NUSHIELD 2X3CM 6SQ CM,SUP-2314107,CDM,Q4160,HCPCS,0636,RC,,,,both,,,2287.49,1486.87,,,,,,,,,,,,,
GRAFT ALLGRFT CHIP CRUSH CANC FRZN RANG 40ML 1MM 8MM,SUP-2264740,CDM,C1713,HCPCS,0278,RC,,,,both,,,3274.17,2128.21,,,,,,,,,,,,,
ALLOGRAFT HUM TISS LORDTC 7 DEG 12X14.5X8.22X6.75 MM,SUP-2264945,CDM,C1713,HCPCS,0278,RC,,,,both,,,2911.35,1892.38,,,,,,,,,,,,,
HEAD SPNL SCREW ROD DIA 4.75/5 MM MULTAXL STRL CD HORZ 2PK,SUP-2928049,CDM,C1713,HCPCS,0278,RC,,,,both,,,3328.40,2163.46,,,,,,,,,,,,,
ALLOGRAFT BNE STRP 22X55 MM PRESERVON TRICORT MATRIGRAFT,SUP-2740788,CDM,C1713,HCPCS,0278,RC,,,,both,,,6589.13,4282.93,,,,,,,,,,,,,
CONNECTOR SPNL S STL STR SLT FOR 6.35MM ROD ISOLA,SUP-2255707,CDM,C1713,HCPCS,0278,RC,,,,both,,,2219.98,1442.99,,,,,,,,,,,,,
CATHETER INFUS L15CM OD6FR 3 LUMN JACC,SUP-2120618,CDM,C1751,HCPCS,0278,RC,,,,both,,,736.86,478.96,,,,,,,,,,,,,
SET DRNGE L41CM OD18FR ABCESS MP LOOP SGL LUMN RADPQ,SUP-2168141,CDM,2720000010,LOCAL,0272,RC,,,,both,,,303.86,197.51,,,,,,,,,,,,,
SPACER SPNL BLK CT XIA,SUP-2381173,CDM,C1713,HCPCS,0278,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
BUR SURG DIAMOND 3 MM 5 CM BALL MIDAS REX 8 CLRVW LP,SUP-2664912,CDM,2720000010,LOCAL,0272,RC,,,,both,,,786.00,510.90,,,,,,,,,,,,,
SNARE ENDO 35MM ELITE EXPRO,SUP-2104767,CDM,C1773,HCPCS,0272,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
KIT ARTHSCP FIX W/ DRL GUID OBT DISP FOR 2.8MM Q-FIX,SUP-2341381,CDM,C1713,HCPCS,0278,RC,,,,both,,,561.97,365.28,,,,,,,,,,,,,
ALLOGRAFT HUM TISS ALLOPATCH PLIABLE 1.5X1.5CM,SUP-2307621,CDM,Q4128,HCPCS,0636,RC,,,,both,,,489.84,318.40,,,,,,,,,,,,,
GRAFT HUM TISS R TIB FRZN,SUP-2307332,CDM,C1713,HCPCS,0278,RC,,,,both,,,4692.10,3049.86,,,,,,,,,,,,,
SCREW BNE L38MM DIA4MM PERIARTC S STL ST LOK FULL THRD FOR,SUP-2184955,CDM,C1713,HCPCS,0278,RC,,,,both,,,525.89,341.83,,,,,,,,,,,,,
SPACER SCREW SELF RET 2.7 MM MAND TI THREADLOCK TS 256779291,SUP-2466625,CDM,C1713,HCPCS,0278,RC,,,,both,,,278.93,181.30,,,,,,,,,,,,,
STENT PANCREATIC ZMMN L 4 CM DIA 3 FR GUIDEWIRE 0.018 IN PUR,SUP-2169489,CDM,C2617,HCPCS,0278,RC,,,,both,,,194.68,126.54,,,,,,,,,,,,,
GRAFT HUM TISS XL W60XL210MM FRZ DRY FASC LATA,SUP-2307097,CDM,C1762,CPT,0278,RC,,,,both,,,3438.68,2235.14,,,,,,,,,,,,,
GRAFT VASC L40CM ID6MM FLX KINK RESIST ACUSEAL,SUP-2395744,CDM,C1768,CPT,0278,RC,,,,both,,,4116.54,2675.75,,,,,,,,,,,,,
DEVICE FIX OD7-8MM SH FEM ANCHR SFT TISS FOR BELOW 35MM TUNN,SUP-2212831,CDM,C1713,HCPCS,0278,RC,,,,both,,,1877.72,1220.52,,,,,,,,,,,,,
ANCHOR LATERAL PEEK MANTICORE KNOTLESS 4.8MM WITH SUTURE LAS,SUP-2842562,CDM,C1713,HCPCS,0278,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
COLLAR CERV ADJ LP THERMOPLASTIC OSSUR MIAMI J,SUP-2388136,CDM,L0180,HCPCS,0274,RC,,,,both,,,939.80,610.87,,,,,,,,,,,,,
SHUNT SURG ADJ L 17 MM GRAVITATIONAL L 12 MM CATH DSTL L FX624T,SUP-2931041,CDM,C1729,HCPCS,0272,RC,,,,both,,,15818.35,10281.93,,,,,,,,,,,,,
SHEATH INTRO ACCEL L 20 CM DIA 6 FR L 60 CM DIA 22 GA NIT,SUP-2659244,CDM,C1894,HCPCS,0272,RC,,,,both,,,230.29,149.69,,,,,,,,,,,,,
GRAFT BNE SUB 10CC INJ FOR BNE AUG CORTOSS,SUP-2379532,CDM,C1713,HCPCS,0278,RC,,,,both,,,6056.18,3936.52,,,,,,,,,,,,,
PAMIDRONATE DISODIUM 30 MG/10ML IV SOLN,RX-32589,CDM,J2430,HCPCS,0636,RC,61703-0324-18,NDC,,both,10,ML,83.10,54.01,,,,,,,,,,,,,
BUR SURG CANN 6 MM,SUP-2598331,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2882.52,1873.64,,,,,,,,,,,,,
BRACE KNEE N SLIP 2XL COMFORTABLE BREATHABLE DONJOY RX WEB,SUP-2196495,CDM,L1812,HCPCS,0272,RC,,,,both,,,228.31,148.40,,,,,,,,,,,,,
STABILIZER FEM SM CO CHROM DURAC NP RT KNEE REV POST STBL,SUP-2364839,CDM,C1776,CPT,0278,RC,,,,both,,,7147.80,4646.07,,,,,,,,,,,,,
PLATE BNE L142MM 8 H NONSTERILE L ANTEROMEDIAL DST TIB S,SUP-2177676,CDM,C1713,HCPCS,0278,RC,,,,both,,,5189.98,3373.49,,,,,,,,,,,,,
SCREW BNE FIX 5.5X45 MM LG QWIX 11545SND] INTEGRA LIFESCIENCES CORP],SUP-2242892,CDM,C1713,HCPCS,0278,RC,,,,both,,,1124.12,730.68,,,,,,,,,,,,,
BRACE THMB XSM AD FOR 725 LESS THAN 8IN L9IN R WRST BLK,SUP-2196550,CDM,L3931,HCPCS,0272,RC,,,,both,,,279.18,181.47,,,,,,,,,,,,,
GUIDEWIRE ORTH DIA2.5MM FOR 5MM SCR,SUP-2187846,CDM,C1769,HCPCS,0272,RC,,,,both,,,732.56,476.16,,,,,,,,,,,,,
HEAD HUM BPLR 22.2 MM OD RVS MORSE TAPR CO CHROM BI ANGULAR,SUP-2404514,CDM,C1776,CPT,0278,RC,,,,both,,,1821.20,1183.78,,,,,,,,,,,,,
KIT SUTURE ANCHR L 15 MM DIA 4.5 MM PEEK KNOTLESS DRVR ONLY,SUP-2899027,CDM,C1713,HCPCS,0278,RC,,,,both,,,1217.54,791.40,,,,,,,,,,,,,
STAPLE INT THK1.8X1.3MM W15XL15-15MM ANK FT NIT SUP E,SUP-2378844,CDM,C1713,HCPCS,0278,RC,,,,both,,,2747.50,1785.87,,,,,,,,,,,,,
ABACAVIR SULFATE 300 MG PO TABS,RX-24438,CDM,6370000000,HCPCS,0637,RC,51079-0204-06,NDC,,both,1,UN,38.90,25.28,,,,,,,,,,,,,
DRILL SURG PROF MIC STRL ACUTRK 2 LTX DISP,SUP-2857806,CDM,2720000010,LOCAL,0272,RC,,,,both,,,844.66,549.03,,,,,,,,,,,,,
CATHETER EP A 5 MM 4 FRX100 CM 4 ELECTRD FIX,SUP-2248842,CDM,C1730,HCPCS,0272,RC,,,,both,,,307.72,200.02,,,,,,,,,,,,,
LEAD DEFIB OPTISURE L 58 CM DIA 8 FR POLYUR SIL ENDOCARD,SUP-2356414,CDM,C1777,HCPCS,0275,RC,,,,both,,,10676.00,6939.40,,,,,,,,,,,,,
STRAIGHT SCTN BLADE W/SRRTD EDGE RCTNGLR WNDW4MMX12CM5/PKG S,SUP-2574158,CDM,2720000010,LOCAL,0272,RC,,,,both,,,416.36,270.63,,,,,,,,,,,,,
CAP END 7.5 DEG 14 MM 10 MM CAGE VUMESH,SUP-2707739,CDM,C1889,HCPCS,0278,RC,,,,both,,,2983.00,1938.95,,,,,,,,,,,,,
PIN EXTERNAL FIXATION HALF PEDIATRIC 5X200 MM 50 MM ANKLE FO,SUP-2836746,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6685.53,4345.59,,,,,,,,,,,,,
BIT DRL L23X3MM STP TUNGSTEN CARB CANN RELF DISPOSABLE,SUP-2243910,CDM,2720000010,LOCAL,0272,RC,,,,both,,,587.43,381.83,,,,,,,,,,,,,
PLATE BNE RECON 3.5X117 MM PELV 9 HOLE LP WA SS NS,SUP-2863438,CDM,C1713,HCPCS,0278,RC,,,,both,,,1391.18,904.27,,,,,,,,,,,,,
PRESSURE MONITORING TRAY 0.015 IN 25 FRX25 CM CATH NDL SYR,SUP-2167884,CDM,C1751,HCPCS,0278,RC,,,,both,,,193.49,125.77,,,,,,,,,,,,,
CABLE ORTH 2X600 MM ASMBLY STRL,SUP-2563688,CDM,C1713,HCPCS,0278,RC,,,,both,,,1401.54,911.00,,,,,,,,,,,,,
CATHETER INTVASC OCCL EQL L 100 CM DIA 7 FR BALLOON DIA20 MM,SUP-2147468,CDM,C2628,HCPCS,0272,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
STYLET PACE L 80 CM DIA 0.016 IN SFT STIFFNESS STRL,SUP-2148857,CDM,C1713,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
RESERVOIR SHUNT 14MM SMALL TITANIUM RADIOPAQUE INTEGRATED CA,SUP-2830498,CDM,C1729,HCPCS,0272,RC,,,,both,,,1536.43,998.68,,,,,,,,,,,,,
WIRE FIX THRD OLV,SUP-2400242,CDM,C1769,HCPCS,0272,RC,,,,both,,,78.50,51.02,,,,,,,,,,,,,
PLATE BONE L128MM 7 H S STL T SHP BTTRS LO PROF RIG,SUP-2185759,CDM,C1713,HCPCS,0278,RC,,,,both,,,1750.61,1137.90,,,,,,,,,,,,,
BRACE KNEE N SLIP 2XL COMFORTABLE BREATHABLE DONJOY RX WEB,SUP-2196495,CDM,L1812,HCPCS,0274,RC,,,,both,,,228.31,148.40,,,,,,,,,,,,,
WIRE EXT FIX OLV 2X350 MM HYBRID DFS DYNAFIX,SUP-2474086,CDM,2720000010,LOCAL,0272,RC,,,,both,,,533.80,346.97,,,,,,,,,,,,,
SET INT FIX SCREW DIA1.5 MM 6 H LNG TI NEURO SQ XDRV 1 PK,SUP-2935558,CDM,C1713,HCPCS,0278,RC,,,,both,,,2000.18,1300.12,,,,,,,,,,,,,
IMMOBILIZER ORTH CUTAWAY LG 20 IN PERF WRP ARND FOAM,SUP-2194894,CDM,L1830,CPT,0274,RC,,,,both,,,56.52,36.74,,,,,,,,,,,,,
CLAMP REPROC PIN HII MRI 5 HL,SUP-2462897,CDM,2720000010,LOCAL,0272,RC,,,,both,,,610.13,396.58,,,,,,,,,,,,,
SCREW BNE L13MM DIA2.7MM NONLOCKING PLT GORILLA R3CON,SUP-2321342,CDM,C1713,HCPCS,0278,RC,,,,both,,,459.23,298.50,,,,,,,,,,,,,
LEAD PACE L90CM STEROID GORE ENDOCARD 2 COIL BPLR PASS FIX,SUP-2148562,CDM,C1895,HCPCS,0275,RC,,,,both,,,12560.00,8164.00,,,,,,,,,,,,,
SYSTEM DRAINAGE CATH SHUNT FOR EDS III,SUP-2308156,CDM,C1729,HCPCS,0272,RC,,,,both,,,121.24,78.81,,,,,,,,,,,,,
PROBE ABLATN 2 20 MM OPTABLATE,SUP-2864574,CDM,C1886,HCPCS,0278,RC,,,,both,,,15229.00,9898.85,,,,,,,,,,,,,
HEAD FEM DIA22MM +3.5MM NK BPLR CO CHROM 12/14 TAPR,SUP-2210662,CDM,C1776,CPT,0278,RC,,,,both,,,4082.00,2653.30,,,,,,,,,,,,,
CONTROLLER COIL XCEL DETACH HNDHLD 60 CYCLE STRL,SUP-2743577,CDM,2720000010,LOCAL,0272,RC,,,,both,,,643.70,418.40,,,,,,,,,,,,,
MESH COMPOSIX LP W ECHO PS ELP 72 IN X 92 IN,SUP-2125821,CDM,C1781,HCPCS,0278,RC,,,,both,,,3809.45,2476.14,,,,,,,,,,,,,
KIT CATH 7FR L12IN NDL 18GA L2.5IN SYR 3ML 0.032IN POLYUR,SUP-2383315,CDM,C1751,HCPCS,0278,RC,,,,both,,,157.63,102.46,,,,,,,,,,,,,
IMMOBILIZER ORTH CUTAWAY LG 20 IN PERF WRP ARND FOAM,SUP-2194894,CDM,L1830,CPT,0272,RC,,,,both,,,56.52,36.74,,,,,,,,,,,,,
PLATE BONE L120MM 6 H S STL T SHP,SUP-2198574,CDM,C1713,HCPCS,0278,RC,,,,both,,,485.95,315.87,,,,,,,,,,,,,
SCREW BNE LCK 1.5X18 MM ST VA W/ T4 STARDRV RECESS SS NS,SUP-2178001,CDM,C1713,HCPCS,0278,RC,,,,both,,,359.91,233.94,,,,,,,,,,,,,
UB BLADE FENCE RIGID 4IN X 5IN,SUP-2674215,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1193.67,775.89,,,,,,,,,,,,,
HC Brain Imaging Pet,PX-4047860800,CDM,78608,CPT,0404,RC,,,,outpatient,,,5713.00,3713.45,,,,,,,,,,,,,
TRAY CATH PICC GROSH NXT CLEARVUE INTERMED 4FR 0.033IN 60CM,SUP-2613420,CDM,C1751,HCPCS,0278,RC,,,,both,,,322.54,209.65,,,,,,,,,,,,,
BANDAGE SUPP ANK AK PELV,SUP-2388214,CDM,L5697,HCPCS,0272,RC,,,,both,,,222.03,144.32,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH FLX L 80 MM DIA 30/32 MM,SUP-2168756,CDM,C1874,HCPCS,0278,RC,,,,both,,,6468.40,4204.46,,,,,,,,,,,,,
SCREW BONE L4MM DIA1.5MM CORT TI SELF DRL NONLOCKING FULL,SUP-2403075,CDM,C1713,HCPCS,0278,RC,,,,both,,,123.09,80.01,,,,,,,,,,,,,
KIT VENT ASST CTRL L,SUP-2282556,CDM,Q0481,HCPCS,0274,RC,,,,both,,,22451.00,14593.15,,,,,,,,,,,,,
SPHINCTEROTOME ENDOSCOPIC TRUETOME 39 30MM 10/BX,SUP-2677338,CDM,2720000010,LOCAL,0272,RC,,,,both,,,536.19,348.52,,,,,,,,,,,,,
MESH SURG W2.54XL10CM POLYPR RECT FLAT FOR SFT TISS REP AND,SUP-2219803,CDM,C1781,HCPCS,0278,RC,,,,both,,,200.30,130.19,,,,,,,,,,,,,
SLING SHLDR M CHST CIRC 36IN TO 40IN UNIV BLU SUPP NEOPRNE,SUP-2324512,CDM,L3650,HCPCS,0272,RC,,,,both,,,88.67,57.64,,,,,,,,,,,,,
SLING SHLDR M CHST CIRC 36IN TO 40IN UNIV BLU SUPP NEOPRNE,SUP-2324512,CDM,L3650,HCPCS,0274,RC,,,,both,,,88.67,57.64,,,,,,,,,,,,,
BUR SURG DIA4MM RND PRECIS S2 F MOTORIZED RHINOSCOPIC SURG,SUP-2363778,CDM,2720000010,LOCAL,0272,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
COMPONENT GLEN PEGGED 5 4 MM SHLDR KEELED FIX UHMWPE STRL,SUP-2372870,CDM,C1776,CPT,0278,RC,,,,both,,,3355.40,2181.01,,,,,,,,,,,,,
KIT VENT ASST CTRL L,SUP-2282556,CDM,Q0481,HCPCS,0272,RC,,,,both,,,22451.00,14593.15,,,,,,,,,,,,,
BUR DENT 7X70 MM CARBIDE STRL PM2 80K,SUP-2134831,CDM,2720000010,LOCAL,0272,RC,,,,both,,,675.10,438.81,,,,,,,,,,,,,
HC Amniocentesis Any Method,PX-3615900000,CDM,59000,CPT,0361,RC,,,,inpatient,,,924.00,600.60,,,,,,,,,,,,,
BUSHING TIB STD DUR KINEMATIC,SUP-2376411,CDM,C1776,CPT,0278,RC,,,,both,,,733.35,476.68,,,,,,,,,,,,,
BRACE WLK L SHOE MAN 10 13 WOMAN 11 15 SHT PNEUMAT SEMI RIG,SUP-2196355,CDM,L4361,HCPCS,0272,RC,,,,both,,,122.96,79.92,,,,,,,,,,,,,
BLADE RTRCTR MED 45MMW X 70MML TTNM SPNL PRNGX5 DARK BLUE LM,SUP-2670391,CDM,2720000010,LOCAL,0272,RC,,,,both,,,873.71,567.91,,,,,,,,,,,,,
IMPLANT BLGCL TSSUE MTRX 475SQCM 55CMW X 10CML PRCNE INGNL,SUP-2676574,CDM,Q4130,HCPCS,0636,RC,,,,both,,,2857.40,1857.31,,,,,,,,,,,,,
BUNDLE CASE DISTRCTN CRAN MXLFCL 5 FULL SKULL RECON VSP,SUP-2862829,CDM,2720000010,LOCAL,0272,RC,,,,both,,,24334.50,15817.42,,,,,,,,,,,,,
KIT SURG BONE CEM MX AND DEL FOR VERT FX,SUP-2256274,CDM,C1713,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
GRAFT VASC GELWEAVE L 50 CM DIA28 MM POLYESTER GEL,SUP-2385049,CDM,C1768,CPT,0278,RC,,,,both,,,3532.50,2296.12,,,,,,,,,,,,,
BIT DRL CANN LG 14 MM QC STRL,SUP-2563710,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1601.05,1040.68,,,,,,,,,,,,,
IMPLANT LARYN L8MM DIA16FR INDWL RADPQ RNG CLASS BLOM-SINGER,SUP-2242359,CDM,L8509,HCPCS,0272,RC,,,,both,,,910.60,591.89,,,,,,,,,,,,,
INSERT TIB SZ 6 THK23MM SEMICONSTRAINED FIX GMK,SUP-2267551,CDM,C1776,CPT,0278,RC,,,,both,,,6860.90,4459.58,,,,,,,,,,,,,
KIT INTRO GLIDESHEATH L 16 CM OD 6 FR ID 0.087 IN TIP DIA,SUP-2384841,CDM,C1894,HCPCS,0272,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
CATHETER VENT DRNGE BG EXT 4 W STPCOCK DISP FOR CSF SYS,SUP-2244299,CDM,C1729,HCPCS,0272,RC,,,,both,,,448.42,291.47,,,,,,,,,,,,,
WASHER SPNL 2MM FIX BONE POLYAX TI MNRCH,SUP-2254526,CDM,C1713,HCPCS,0278,RC,,,,both,,,263.76,171.44,,,,,,,,,,,,,
CANNULA SUCTION DIA12 FR PRECALIBRATED CHARR DISP,SUP-2910148,CDM,2720000010,LOCAL,0272,RC,,,,both,,,563.94,366.56,,,,,,,,,,,,,
TOCILIZUMAB 400 MG/20ML IV SOLN,RX-104372,CDM,J3262,HCPCS,0636,RC,50242-0137-01,NDC,,both,20,ML,7834.70,5092.55,,,,,,,,,,,,,
VALVE PRESSURE PROGRAMMABLE 70MM H2O MED LO RANG HAKIM,SUP-2666794,CDM,C1889,HCPCS,0278,RC,,,,both,,,4370.19,2840.62,,,,,,,,,,,,,
GRAFT ENDOVASC L3.3CM DIA23MM AORT EXT ENDOPROS EXCLUDER,SUP-2395938,CDM,C1768,CPT,0278,RC,,,,both,,,7903.38,5137.20,,,,,,,,,,,,,
PLATE BNE STR 1.3X45 MM COND LUHR PANFIX,SUP-2364700,CDM,C1713,HCPCS,0278,RC,,,,both,,,661.28,429.83,,,,,,,,,,,,,
SCREW BONE 2.5MMX17MM REG EMER CROSS DRV,SUP-2262632,CDM,C1713,HCPCS,0278,RC,,,,both,,,91.41,59.42,,,,,,,,,,,,,
GUIDEWIRE VASC INQWIRE L 150 CM DIA 0.018 IN PTFE PERIPH STR,SUP-2301901,CDM,C1769,HCPCS,0272,RC,,,,both,,,32.97,21.43,,,,,,,,,,,,,
DEVICE EMB L25MM OD4MM 55DEG SFT DST TIP BRAID 4 FLX,SUP-2296740,CDM,C1884,HCPCS,0278,RC,,,,both,,,44745.00,29084.25,,,,,,,,,,,,,
CATHETER EP STEER SM 5 MM SPC 6 FR INQUIRY,SUP-2357432,CDM,C1730,HCPCS,0272,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
NAIL IM 10S L36CM DIA10MM 125DEG LT ORTHOAPEDIC RECON,SUP-2347680,CDM,C1713,HCPCS,0278,RC,,,,both,,,14741.67,9582.09,,,,,,,,,,,,,
SCREW BONE 2.2X6MM EMER LEIBINGER DELT SYS 2/EA,SUP-2364999,CDM,C1713,HCPCS,0278,RC,,,,both,,,182.59,118.68,,,,,,,,,,,,,
STRAP SPLNT NYL WHT 1INX14IN ROLYAN D RNG,SUP-2324779,CDM,L3908,HCPCS,0274,RC,,,,both,,,5.56,3.61,,,,,,,,,,,,,
DISTRACTOR EXT FIX L100MM ANK FT TELSCP LIN FOR TRUELOK,SUP-2316064,CDM,C1713,HCPCS,0278,RC,,,,both,,,1486.48,966.21,,,,,,,,,,,,,
RIVAROXABAN 2.5 MG PO TABS,RX-143788,CDM,6370000000,HCPCS,0637,RC,50458-0577-01,NDC,,both,1,UN,44.90,29.18,,,,,,,,,,,,,
SET INT FIX SCREW DIA1.5 MM 2X3 H TI NEURO RECTANGULAR PLATE,SUP-2936077,CDM,C1713,HCPCS,0278,RC,,,,both,,,23374.16,15193.20,,,,,,,,,,,,,
KIT INTRO L 10 CM DIA 5 FR GUIDEWIRE L 40CM NDL L 7CM SS GLD,SUP-2269689,CDM,C1894,HCPCS,0272,RC,,,,both,,,879.20,571.48,,,,,,,,,,,,,
PLATE BNE 18 H LT ANTEROLATERAL DSTL TIB NS,SUP-2897258,CDM,C1713,HCPCS,0278,RC,,,,both,,,5648.86,3671.76,,,,,,,,,,,,,
GRAFT CORNEAL PROC FEE,SUP-2164746,CDM,V2785,HCPCS,0810,RC,,,,both,,,10048.00,6531.20,,,,,,,,,,,,,
MESH C-QUR EDGE OBLONG OVL 3 INX6 IN,SUP-2265962,CDM,C1781,HCPCS,0278,RC,,,,both,,,918.45,596.99,,,,,,,,,,,,,
PLATE BNE 2.7X59 MM 5 HOLE,SUP-2200825,CDM,C1713,HCPCS,0278,RC,,,,both,,,401.92,261.25,,,,,,,,,,,,,
LIDOCAINE HCL URETHRAL/MUCOSAL 2 % EX PRSY,RX-147640,CDM,6370000000,HCPCS,0637,RC,25021-0673-76,NDC,,both,6,ML,26.80,17.42,,,,,,,,,,,,,
PHENOL-GLYCERIN 1.5-33 % MT LIQD,RX-122738,CDM,6370000000,HCPCS,0637,RC,78112-0000-68,NDC,,both,118,ML,20.20,13.13,,,,,,,,,,,,,
CABLE EP CATH QUAD TWST TO S PIN,SUP-2141308,CDM,2720000010,LOCAL,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
GRAFT VASC FLIXENE L 50 CM DIA 6 MM EPTFE STR STD WALL REINF,SUP-2480088,CDM,C1768,CPT,0278,RC,,,,both,,,3298.51,2144.03,,,,,,,,,,,,,
SHUTTLE SUT 45DEG R W CHIA IDEAL,SUP-2256803,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
GRAFT BNE PARTICULATE 5 CC DBM CORTICAL,SUP-2861447,CDM,C1713,HCPCS,0278,RC,,,,both,,,4233.57,2751.82,,,,,,,,,,,,,
DRILL SURG STP 8 MM IM ANTR REF ASCNT,SUP-2444933,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1229.31,799.05,,,,,,,,,,,,,
IMPLANT SUBTALAR L14MM DIA9MM ANK JT FOR ARTHROERESIS,SUP-2121855,CDM,C1776,CPT,0278,RC,,,,both,,,4694.30,3051.29,,,,,,,,,,,,,
DIVALPROEX SODIUM 125 MG PO CSDR,RX-27631,CDM,6370000000,HCPCS,0637,RC,00074-6114-13,NDC,,both,1,UN,8.90,5.78,,,,,,,,,,,,,
PLATE BNE ROT CORRECTION 1.5/2X32 MM 2X5 HOLE TI STRL,SUP-2569068,CDM,C1713,HCPCS,0278,RC,,,,both,,,2962.28,1925.48,,,,,,,,,,,,,
PLATE EXT FIX OPN ROCK SALVATION,SUP-2401125,CDM,C1713,HCPCS,0278,RC,,,,both,,,6236.04,4053.43,,,,,,,,,,,,,
VARIABLE TI SCREW LOCK SCREW 3.5MM X 10MM LGTH,SUP-2586567,CDM,C1713,HCPCS,0278,RC,,,,both,,,1175.36,763.98,,,,,,,,,,,,,
HC US Iu Fetal Trans/Cordocen S&I,PX-4027694100,CDM,76941,CPT,0402,RC,,,,both,,,1762.00,1145.30,,,,,,,,,,,,,
BLADE RETRACTOR 5 IN HIP STD T BAR HNDL SELF RET,SUP-2242481,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1128.80,733.72,,,,,,,,,,,,,
SYSTEM IMPL INCL NDL 1.3MM WHT WHT/BLUE WHT/BLACK,SUP-2122782,CDM,C1713,HCPCS,0278,RC,,,,both,,,4694.30,3051.29,,,,,,,,,,,,,
TRAY CATH MIDLN POWERMIDLINE MAXBARR 3FR 20CM 1 LUMAN RVRSE,SUP-2613516,CDM,C1751,HCPCS,0278,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
SYSTEM DEL IMPL L 25 X W 23 MM FOR RC REP STRL BIOBRACE RC,SUP-2930545,CDM,C1763,HCPCS,0278,RC,,,,both,,,10990.00,7143.50,,,,,,,,,,,,,
ALLOGRAFT HUM TISS AMNIO MEMBRN 2X4 CM DRY ALLOWRAP DRY,SUP-2717791,CDM,Q4150,HCPCS,0636,RC,,,,both,,,6181.88,4018.22,,,,,,,,,,,,,
ROD SPNL 28 MM TRANSITION,SUP-2230032,CDM,C1713,HCPCS,0278,RC,,,,both,,,6280.00,4082.00,,,,,,,,,,,,,
SUPPORT ORTHOPEDIC SM LT WRST,SUP-2330434,CDM,L3908,HCPCS,0274,RC,,,,both,,,25.12,16.33,,,,,,,,,,,,,
SCREW SPNL RECON 4X20 MM POSTED BLU VERTEX SEL,SUP-2630723,CDM,C1713,HCPCS,0278,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
CAGE SPNL MESH 28X22X15 MM 6 LOBE,SUP-2602087,CDM,C1889,HCPCS,0278,RC,,,,both,,,10487.60,6816.94,,,,,,,,,,,,,
Z DISCONTINUED NO SUB IDED CATHETER ANGIOPLSTY L40CM DIA5FR 0.035IN BAL INFLATED DIA4CM,SUP-2170365,CDM,C1725,HCPCS,0272,RC,,,,both,,,1381.60,898.04,,,,,,,,,,,,,
GUIDEWIRE VASC L180CM DIA0.025IN TAPR L7CM FLPY TIP L2.5CM,SUP-2167882,CDM,C1769,HCPCS,0272,RC,,,,both,,,39.97,25.98,,,,,,,,,,,,,
MONITOR CARD ASSERT-IQ 3 L 9.4 X H 46.5 MM THK 3.1 MM 1.2 ML,SUP-2873672,CDM,C1764,HCPCS,0278,RC,,,,both,,,15543.00,10102.95,,,,,,,,,,,,,
LINER TIB THK 11 MM SZ D1-2 POLYETHYL MTL BK KNEE CR STRL,SUP-2914452,CDM,C1776,CPT,0278,RC,,,,both,,,2260.80,1469.52,,,,,,,,,,,,,
CLAMP ENDOSCP 3 TO 9CM TB POST MTRX,SUP-2292892,CDM,C1713,HCPCS,0278,RC,,,,both,,,4304.97,2798.23,,,,,,,,,,,,,
FLUCONAZOLE 50 MG PO TABS,RX-10046,CDM,6370000000,HCPCS,0637,RC,70710-1137-03,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
DRESSING BIO COVERAGE AREA 35 SQ CM 200 MG PORCINE SM INTEST,SUP-2905507,CDM,Q4102,HCPCS,0636,RC,,,,both,,,1627.78,1058.06,,,,,,,,,,,,,
KIT INTRO INTROFLEX L 10 CM DIA 6 FR BONDED ADJ VLV DSTL LCK,SUP-2214541,CDM,C1894,HCPCS,0272,RC,,,,both,,,65.63,42.66,,,,,,,,,,,,,
HC Gastroesophag Reflx Test W/Tel Ph Eltrd|REDUCED SERVICES,PX-7509103500,CDM,91035,CPT,0750,RC,,,52,outpatient,,,1657.00,1077.05,,,,,,,,,,,,,
INTRODUCER,SUP-2821961,CDM,C1894,HCPCS,0272,RC,,,,both,,,10.96,7.12,,,,,,,,,,,,,
GRAFT VASC EXXCEL SFT L 80 CM DIA 6 MM EPTFE STR TW STRL,SUP-2227655,CDM,C1768,CPT,0278,RC,,,,both,,,2291.23,1489.30,,,,,,,,,,,,,
BIOPSY KIT BNE MAR 11 GAX10 CM TREK,SUP-2754748,CDM,2720000010,LOCAL,0272,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
ILLUMINATOR SURG EXAM LUMITEX VERSALIGHT,SUP-2713083,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
SCREW BNE L10MM DIA3.5MM HD DIA6MM STD CORT TI ST SM HEX,SUP-2189845,CDM,C1713,HCPCS,0278,RC,,,,both,,,59.35,38.58,,,,,,,,,,,,,
GRAFT HUM TISS W4XL7CM ULT THN ACELLULAR DERM FRZ DRY,SUP-2306987,CDM,C1762,CPT,0278,RC,,,,both,,,3516.80,2285.92,,,,,,,,,,,,,
STENT PERIPH COVERA L 40 MM DIA 7 MM CATH L 80 CM SHTH 8 FR,SUP-2418866,CDM,C1874,HCPCS,0278,RC,,,,both,,,8148.30,5296.39,,,,,,,,,,,,,
GRAFT BNE BLOCK 12X12X9 MM PATELLAR UNICORTICAL,SUP-2860945,CDM,C1713,HCPCS,0278,RC,,,,both,,,4983.18,3239.07,,,,,,,,,,,,,
GENERATOR CARD PLSE SPNL CRD STIM SYS PRECIS NOVI,SUP-2138777,CDM,C1767,HCPCS,0278,RC,,,,both,,,47100.00,30615.00,,,,,,,,,,,,,
DISTRACTION INTRNL DIST LFRT 1 ZRCH TELE RGHT 15 18 MM SCR,SUP-2679166,CDM,C1713,HCPCS,0278,RC,,,,both,,,18646.98,12120.54,,,,,,,,,,,,,
CATHETER INFUSION STR 2.4-3 FRX130 CM 20 CM RENEGADE STC-18,SUP-2141033,CDM,C1887,HCPCS,0272,RC,,,,both,,,1271.70,826.60,,,,,,,,,,,,,
PLATE BNE HUM 4.5/6.5X171 MM RT PROX LAT 8 HOLE BUTTRESS,SUP-2472606,CDM,C1713,HCPCS,0278,RC,,,,both,,,2338.99,1520.34,,,,,,,,,,,,,
PIN HALF HYBRID SELF DRL 45X150MM,SUP-2705300,CDM,2720000010,LOCAL,0272,RC,,,,both,,,669.76,435.34,,,,,,,,,,,,,
PLEDGET VASCULAR 3X6MM OVAL FIRM,SUP-2427112,CDM,C1768,CPT,0278,RC,,,,both,,,128.11,83.27,,,,,,,,,,,,,
HC Renal Biopsy Percutaneous,PX-3615020000,CDM,50200,CPT,0361,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
BUR SURG STD MED 60 K 4 MM HI SPD STRL UNIDRIVE DISP,SUP-2599308,CDM,2720000010,LOCAL,0272,RC,,,,both,,,606.90,394.48,,,,,,,,,,,,,
SHEATH INTRO PINNACLE DESTINATION 45CM 7FR COAT 5CM HS XCUT,SUP-2385267,CDM,C1894,HCPCS,0272,RC,,,,both,,,332.84,216.35,,,,,,,,,,,,,
ORTHOSES THERMOPLASTIC WRST HND COCKUP,SUP-2319134,CDM,L3908,HCPCS,0272,RC,,,,both,,,188.40,122.46,,,,,,,,,,,,,
STEM HUM L122MM DIA8MM SHLDR PPS FOR FRAC SYS COMPHSVE,SUP-2404913,CDM,C1776,CPT,0278,RC,,,,both,,,7749.52,5037.19,,,,,,,,,,,,,
REAMER SURG DIA12MM,SUP-2291549,CDM,C1713,HCPCS,0278,RC,,,,both,,,4079.39,2651.60,,,,,,,,,,,,,
CANISTER ASPIR ZOOM,SUP-2739216,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1114.70,724.55,,,,,,,,,,,,,
SPACER KNEE FEM POST SYS REV STABILIZING ATTUNE,SUP-2454502,CDM,C1776,CPT,0278,RC,,,,both,,,606.02,393.91,,,,,,,,,,,,,
PLATE BONE L W13.5XL358MM THK4.2MM 20 H BILAT TI STR RIG,SUP-2190836,CDM,C1713,HCPCS,0278,RC,,,,both,,,1912.26,1242.97,,,,,,,,,,,,,
PROBE ELECSURG 2.3 MMX1.9 MR HYBRIDAPC,SUP-2734128,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1686.18,1096.02,,,,,,,,,,,,,
SUPPORT ORTHOT WRST HND FNGR CUST ADJ W/O JT FABRICATED,SUP-2435767,CDM,L3808,HCPCS,0272,RC,,,,both,,,917.82,596.58,,,,,,,,,,,,,
SUPPORT ORTHOT WRST HND FNGR CUST ADJ W/O JT FABRICATED,SUP-2435767,CDM,L3808,HCPCS,0274,RC,,,,both,,,917.82,596.58,,,,,,,,,,,,,
NAIL IM PROX RT HUM LCK CANN T2,SUP-2361807,CDM,C1713,HCPCS,0278,RC,,,,both,,,4459.59,2898.73,,,,,,,,,,,,,
BOLT EXT FIX MR SAFE SCR POST MT SCHNZ FOR DISTR,SUP-2417127,CDM,2720000010,LOCAL,0272,RC,,,,both,,,753.32,489.66,,,,,,,,,,,,,
GRAFT BNE SUB 4CC CA SULF CA PHSPTE INJ REGEN PRO-DENSE,SUP-2399152,CDM,C1713,HCPCS,0278,RC,,,,both,,,4458.80,2898.22,,,,,,,,,,,,,
GRAFT HUMAN TISSUE 15X0 CM GENTRIX MATRIX PLUS,SUP-2106483,CDM,Q4166,HCPCS,0636,RC,,,,both,,,12487.78,8117.06,,,,,,,,,,,,,
HC So Hiv-2 Ab,PX-3028670266,CDM,86702,CPT,0302,RC,,,,both,,,109.00,70.85,,,,,,,,,,,,,
SCREW BNE L17MM DIA2MM MANDIBULOMAXILLARY IM FIX ORTHOANCHOR,SUP-2262926,CDM,C1713,HCPCS,0278,RC,,,,both,,,260.62,169.40,,,,,,,,,,,,,
NAIL IM 2.6X270 MM FIBULAR STRL LTX,SUP-2857587,CDM,C1713,HCPCS,0278,RC,,,,both,,,10616.34,6900.62,,,,,,,,,,,,,
BLADE SHAVER CRV SUCTION 65 DEG 4 MMX12 CM CONCV EDGE GRN,SUP-2602789,CDM,2720000010,LOCAL,0272,RC,,,,both,,,649.16,421.95,,,,,,,,,,,,,
KNIFE SURG FREER SEPT 7 IN ANGLED MICROFRANCE,SUP-2497729,CDM,2720000010,LOCAL,0272,RC,,,,both,,,382.89,248.88,,,,,,,,,,,,,
BOOT WALKING CAM,SUP-2390668,CDM,L4387,HCPCS,0272,RC,,,,both,,,998.52,649.04,,,,,,,,,,,,,
SLEEVE TROCAR L110MM DIAMETER 5MM SMOOTH DISPOSABLE WITHOUT,SUP-2804749,CDM,2720000010,LOCAL,0272,RC,,,,both,,,495.74,322.23,,,,,,,,,,,,,
STEM FEM L120MM OD12MM 125DEG CO CHROM COMP FULL COAT HIP,SUP-2198927,CDM,C1776,CPT,0278,RC,,,,both,,,29861.40,19409.91,,,,,,,,,,,,,
SPINAL KIT FACET FUSION LG NORTHSTAR,SUP-2741242,CDM,C1713,HCPCS,0278,RC,,,,both,,,8478.00,5510.70,,,,,,,,,,,,,
SCREW BNE L 130 MM DIA 7 MM LG CANN HDLSS STRL,SUP-2931454,CDM,C1713,HCPCS,0278,RC,,,,both,,,1131.22,735.29,,,,,,,,,,,,,
PLATE BNE L85MM 6 H NONSTERILE L PROX TIB S STL LO PROF,SUP-2185812,CDM,C1713,HCPCS,0278,RC,,,,both,,,3722.91,2419.89,,,,,,,,,,,,,
PLATE FUS INTCARP 2.4MM 7H 17MM TI VAL STRL,SUP-2546688,CDM,C1713,HCPCS,0278,RC,,,,both,,,3750.38,2437.75,,,,,,,,,,,,,
KIT TRL ANK FT STRL DISP APOLLOANKLE,SUP-2894237,CDM,2720000010,LOCAL,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
PLATE BNE W12XL160MM THK3.7MM LNG 6 H NONSTERILE PROX HUM S,SUP-2186017,CDM,C1713,HCPCS,0278,RC,,,,both,,,4552.37,2959.04,,,,,,,,,,,,,
BLADE SHAVER STR 4.2 MM SERRATED HEMOSTATIC DIEGO,SUP-2638101,CDM,2720000010,LOCAL,0272,RC,,,,both,,,600.46,390.30,,,,,,,,,,,,,
STEM FEM CONSTRN 21X225 MM HIP MOD,SUP-2364542,CDM,C1776,CPT,0278,RC,,,,both,,,12173.78,7912.96,,,,,,,,,,,,,
GRAFT VASC GRAD WALL 5-8 MMX35 CM STR TRMPT TAPR FLIXENE,SUP-2470335,CDM,C1768,CPT,0278,RC,,,,both,,,3599.66,2339.78,,,,,,,,,,,,,
KIT BNE GRFT SUB 15CC MINI INVASIVE INJ MIIG OSTEOSET,SUP-2399040,CDM,C1713,HCPCS,0278,RC,,,,both,,,4232.50,2751.12,,,,,,,,,,,,,
INSERT TIB CR 3 12 MM KNEE BEAR TECHNOLOGY X3 TRIATHLON,SUP-2431363,CDM,C1776,CPT,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
DEXTROSE 20 % IV SOLN,RX-2359,CDM,2580000003,HCPCS,0250,RC,00990-7935-19,NDC,,both,500,ML,123.30,80.14,,,,,,,,,,,,,
GUIDEWIRE VASC TRANSEND 300 L 300 CM 0.014 IN 2CM STR TIP X,SUP-2367925,CDM,C1769,HCPCS,0272,RC,,,,both,,,1834.39,1192.35,,,,,,,,,,,,,
KIT INTRO VSI L 30 CM DIA 5 FR GUIDEWIRE L 80 CM DIA 0.018,SUP-2383169,CDM,C1894,HCPCS,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
PLATE BNE LG RT MIS HV REV,SUP-2896856,CDM,C1713,HCPCS,0278,RC,,,,both,,,6119.86,3977.91,,,,,,,,,,,,,
K PHOS MONO-SOD PHOS DI & MONO 155-852-130 MG PO TABS,RX-10365,CDM,6370000000,HCPCS,0637,RC,64980-0104-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
INBONE  TALAR DOME SIZE 6 RIGHT LEFT,SUP-2483877,CDM,C1776,CPT,0278,RC,,,,both,,,8503.12,5527.03,,,,,,,,,,,,,
GUIDE PIN ORTHOPEDIC THRD 3.2X300 MM TIP,SUP-2342843,CDM,2720000010,LOCAL,0272,RC,,,,both,,,202.00,131.30,,,,,,,,,,,,,
TRAY CATH PICC POLY Q CATH 3FR 0.024IN 60CM 1 LUMAN 9153108,SUP-2632689,CDM,C1751,HCPCS,0278,RC,,,,both,,,516.53,335.74,,,,,,,,,,,,,
PLATE BNE SM NONSTERILE CRANIOFACIAL ORBIT TI ANAT FLR FOR,SUP-2190650,CDM,C1713,HCPCS,0278,RC,,,,both,,,4334.46,2817.40,,,,,,,,,,,,,
PLATE BNE L151MM 9 H BILAT S STL BROAD LO PROF RIG DYN,SUP-2185276,CDM,C1713,HCPCS,0278,RC,,,,both,,,1515.55,985.11,,,,,,,,,,,,,
TC-100 6.5MMX16MM P-T CANC SCREW 55MM,SUP-2818831,CDM,C1713,HCPCS,0278,RC,,,,both,,,358.81,233.23,,,,,,,,,,,,,
PLATE DIST ANT TIB RT 4HL 102MM,SUP-2705013,CDM,C1713,HCPCS,0278,RC,,,,both,,,6714.89,4364.68,,,,,,,,,,,,,
STEM RAD H42MM DIA7MM TI ALLOY CVD FOR PRI AND REV REPL,SUP-2181499,CDM,C1776,CPT,0278,RC,,,,both,,,7322.92,4759.90,,,,,,,,,,,,,
STENT URET STR 0.035 IN 3 CM 7 FRX22-30 CM 6 FR STIFF CNTOUR,SUP-2470186,CDM,C2617,HCPCS,0278,RC,,,,both,,,604.26,392.77,,,,,,,,,,,,,
BOJRAB UNIVERSAL,SUP-2680148,CDM,L8613,CPT,0278,RC,,,,both,,,1401.70,911.10,,,,,,,,,,,,,
HC Intro Cath Dialysis Circuit W Stent,PX-3613690300,CDM,36903,CPT,0361,RC,,,,both,,,11772.00,7651.80,,,,,,,,,,,,,
INTRODUCER SHTH 7FR (min order 10 eaches)L12CM DIA0.038IN HEMSTAS CLOSE TOL,SUP-2357132,CDM,C1894,HCPCS,0272,RC,,,,both,,,5.65,3.67,,,,,,,,,,,,,
GRAFT SKIN GRAFIX PRIME 1.5X2CM CYROPRESERVED,SUP-2319165,CDM,Q4132,HCPCS,0636,RC,,,,both,,,2486.88,1616.47,,,,,,,,,,,,,
PASSER SUT DIA1.8MM 45DEG L CRV STIFF SHFT SHRP ATRAUM TIP,SUP-2121814,CDM,2720000010,LOCAL,0272,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
PLATE BNE L232MM 12 H ST R MED DST TIB S STL VAR ANG LOK,SUP-2177645,CDM,C1713,HCPCS,0278,RC,,,,both,,,6318.47,4107.01,,,,,,,,,,,,,
WASHER SPNL SZ 5 S STL FIX TAPR VSP,SUP-2255573,CDM,C1713,HCPCS,0278,RC,,,,both,,,241.78,157.16,,,,,,,,,,,,,
PLATE BNE W7XL63MM THK1MM 8 H BILAT TI 1/4 TBLR RIG,SUP-2191006,CDM,C1713,HCPCS,0278,RC,,,,both,,,359.94,233.96,,,,,,,,,,,,,
DEXTROSE 5 % IV BOLUS,RX-40840055,CDM,J7060,HCPCS,0250,RC,00264-7510-10,NDC,,both,250,ML,17.00,11.05,,,,,,,,,,,,,
GRAFT HUM TISS M W16XL20CM THK1.2-2MM ACELLULAR DERM,SUP-2113185,CDM,Q4116,HCPCS,0636,RC,,,,both,,,37406.82,24314.43,,,,,,,,,,,,,
HC NM Liver/Spleen W/Vasc,PX-3417821600,CDM,78216,CPT,0341,RC,,,,both,,,442.00,287.30,,,,,,,,,,,,,
SCREW SPNL SD 4X11 MM VAR VENTURE,SUP-2293263,CDM,C1713,HCPCS,0278,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
GUIDE NERVE REP MTRX 1.5 MMX3 CM STRL NEURAGEN 3D LF,SUP-2877624,CDM,C9352,HCPCS,0278,RC,,,,both,,,9919.26,6447.52,,,,,,,,,,,,,
IMPLANT HUM TISS L 6 X W 4 CM DECELL PLCNTA MEMBRN TEND NEVE,SUP-2881949,CDM,C1762,CPT,0278,RC,,,,both,,,12434.40,8082.36,,,,,,,,,,,,,
MEMO STEP IMPLANT 18 02,SUP-2705874,CDM,C1713,HCPCS,0278,RC,,,,both,,,5327.95,3463.17,,,,,,,,,,,,,
GRAFT BNE L60MM FEM SHFT FRZ DRY MATRIGRFT,SUP-2264750,CDM,C1713,HCPCS,0278,RC,,,,both,,,2312.48,1503.11,,,,,,,,,,,,,
DEVICE TORQUE GUIDEWIRE 0.009-0.18 IN FOR CORONARY STRL,SUP-2105882,CDM,C1769,HCPCS,0272,RC,,,,both,,,21.98,14.29,,,,,,,,,,,,,
KIT CATH HEMODIALYSI DUET CHRONIC STD 10FR DIA 28/31CMLAV IN,SUP-2613276,CDM,C1750,HCPCS,0278,RC,,,,both,,,1447.54,940.90,,,,,,,,,,,,,
HC Change G to Gj Tube,PX-3614944600,CDM,49446,CPT,0361,RC,,,,outpatient,,,8583.00,5578.95,,,,,,,,,,,,,
GRAFT HUM TISS L 49-51 X W 4-6 MM THK 4-8 MM SZ 50 MM,SUP-2913233,CDM,C1762,CPT,0278,RC,,,,both,,,775.58,504.13,,,,,,,,,,,,,
TILENE STRP 4CMX40CM LT 3PK,SUP-2402554,CDM,C1781,HCPCS,0278,RC,,,,both,,,938.86,610.26,,,,,,,,,,,,,
PLATE SPNL L31MM 3 H ANT OCCIPITOCERVICAL TI INVRT Y,SUP-2255349,CDM,C1713,HCPCS,0278,RC,,,,both,,,6280.00,4082.00,,,,,,,,,,,,,
KIT THROMCTMY ANGIOJET ULTRA PWR PULSE Y STRL,SUP-2142029,CDM,C1757,HCPCS,0272,RC,,,,both,,,232.36,151.03,,,,,,,,,,,,,
PLATE BONE W12XL39MM THK1MM 2 H BILAT TI SEMI TBLR LO PROF,SUP-2190700,CDM,C1713,HCPCS,0278,RC,,,,both,,,213.08,138.50,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY HALO XP L 110 CM DIA 7 FR LOOP,SUP-2248784,CDM,C1731,HCPCS,0278,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
MESH HERN W9XL14CM POLY HYDRPHLC OVL MFIL SELF FIXATING,SUP-2174791,CDM,C1781,HCPCS,0278,RC,,,,both,,,1314.22,854.24,,,,,,,,,,,,,
SCORER ARTC CART CARTIFORM 20MM,SUP-2120739,CDM,2720000010,LOCAL,0272,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
PIN EXT FIX L9IN DIA9/64IN S STL TRCR PNT W/ FLAT TYP B,SUP-2342720,CDM,C1713,HCPCS,0278,RC,,,,both,,,1425.43,926.53,,,,,,,,,,,,,
STEM FEM TIB STR 28X145 MM 28X100X145 MM KNEE,SUP-2201648,CDM,C1776,CPT,0278,RC,,,,both,,,2621.12,1703.73,,,,,,,,,,,,,
BASKET STONE STR 3 FR 12 MMX120 CM 4 WIR W/O TIP NIT STRL,SUP-2767781,CDM,2720000010,LOCAL,0272,RC,,,,both,,,980.31,637.20,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9% IV BOLUS (PER WEIGHT),RX-40901010,CDM,2580000003,HCPCS,0258,RC,00990-7983-61,NDC,,both,150,ML,44.70,29.05,,,,,,,,,,,,,
GUIDEWIRE ORTH L900MM OD2MM S STL SMOOTH BALL TIP FOR,SUP-2343578,CDM,C1769,HCPCS,0272,RC,,,,both,,,1099.53,714.69,,,,,,,,,,,,,
GRAFT VASC CARBOFLO 6 MMX50 CM EPTFE FLX THN WALL SM BEAD,SUP-2126880,CDM,C1768,CPT,0278,RC,,,,both,,,3307.36,2149.78,,,,,,,,,,,,,
HC So Blood Type Antigen Donor Ea,PX-3008690266,CDM,86902,CPT,0300,RC,,,,both,,,172.00,111.80,,,,,,,,,,,,,
GRAFT BNE SUB 5CC CA PHSPTE HYALURONIC ACID CEM VOID FILL,SUP-2378761,CDM,C1713,HCPCS,0278,RC,,,,both,,,4364.60,2836.99,,,,,,,,,,,,,
KIT PT PRGM FOR SPNL CRD STIM SYS PRECIS SPECTR,SUP-2138827,CDM,C1787,HCPCS,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
CUFF URETH 6.5CM INHIBIZONE OCCL SPHIN FOR URIN CTRL SYS AMS,SUP-2138954,CDM,C1815,HCPCS,0278,RC,,,,both,,,17185.22,11170.39,,,,,,,,,,,,,
CATHETER INFUSION PULSE SPRY PRO L 90 CM DIA 4 FR SLT PAT L,SUP-2117022,CDM,C1757,HCPCS,0272,RC,,,,both,,,273.18,177.57,,,,,,,,,,,,,
POR ST/OSS CP/E1 LN/STD HD,SUP-2212420,CDM,C1776,CPT,0278,RC,,,,both,,,19665.82,12782.78,,,,,,,,,,,,,
BOOT WALKING HI TOP SM FT ANK LIFESTRIDE,SUP-2108144,CDM,L4386,HCPCS,0272,RC,,,,both,,,109.59,71.23,,,,,,,,,,,,,
SCREW SPNL L40MM DIA6.5MM CANC PEDCL TI MULTIAXIAL SEXTANT,SUP-2288501,CDM,C1713,HCPCS,0278,RC,,,,both,,,2496.30,1622.59,,,,,,,,,,,,,
GRAFT DURA REP L 4 X W 3 CM THK 0.4 MM ELECTROSPUN FIBER,SUP-2904021,CDM,C1763,HCPCS,0278,RC,,,,both,,,1469.52,955.19,,,,,,,,,,,,,
MATRIX BIO L 7 X W 20 CM FISH SKIN DERMAL SLD INTACT STRL,SUP-2909291,CDM,Q4158,HCPCS,0636,RC,,,,both,,,13627.60,8857.94,,,,,,,,,,,,,
BEARING TIB 14X79 MM K-GEL INLAY POLYETH AGC TOTAL,SUP-2441773,CDM,C1776,CPT,0278,RC,,,,both,,,1183.15,769.05,,,,,,,,,,,,,
BLADE SAW T HNDL 10 MM AO CONN FOR MANUAL BNE HARV,SUP-2415426,CDM,2720000010,LOCAL,0272,RC,,,,both,,,879.20,571.48,,,,,,,,,,,,,
SCREW ACET SPACER TIB,SUP-2449296,CDM,C1713,HCPCS,0278,RC,,,,both,,,621.72,404.12,,,,,,,,,,,,,
STENT BILI S.M.A.R.T. CTRL L 80 MM DIA 7 MM DEL SYS L 120 CM,SUP-2158586,CDM,C1876,HCPCS,0278,RC,,,,both,,,4624.84,3006.15,,,,,,,,,,,,,
HEAD FEM OFFSET 32 MM HIP CERM,SUP-2322454,CDM,C1776,CPT,0278,RC,,,,both,,,2706.68,1759.34,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9% IV BOLUS (PER WEIGHT),RX-40901010,CDM,J7040,HCPCS,0258,RC,00264-7800-10,NDC,,both,500,ML,29.80,19.37,,,,,,,,,,,,,
NAIL INTRMDLLRY LOK CNNLTD UNVRSL 7MM DIA 220MML TTNM ALLOY,SUP-2587501,CDM,C1713,HCPCS,0278,RC,,,,both,,,4384.48,2849.91,,,,,,,,,,,,,
HC Heparin Assay,PX-3058552000,CDM,85520,CPT,0305,RC,,,,both,,,200.00,130.00,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9% IV BOLUS (PER WEIGHT),RX-40901010,CDM,J7050,HCPCS,0258,RC,00264-7800-20,NDC,,both,250,ML,23.40,15.21,,,,,,,,,,,,,
ROD SPNL POST RT PRECUT SMOOTH HRD TI ALLOY OD6MM L35MM,SUP-2414708,CDM,C1713,HCPCS,0278,RC,,,,both,,,1070.74,695.98,,,,,,,,,,,,,
PLATE BNE SCREW DIA1.5 MM SM TI OCCPTL BUTTERFLY SHP NS DISP,SUP-2935997,CDM,C1713,HCPCS,0278,RC,,,,both,,,3337.82,2169.58,,,,,,,,,,,,,
ROD IM L150MM DIA11MM HUM LOK POLARUS,SUP-2107702,CDM,C1713,HCPCS,0278,RC,,,,both,,,6173.24,4012.61,,,,,,,,,,,,,
INDWELLING VOICE PROS LEF,SUP-2242341,CDM,L8509,HCPCS,0272,RC,,,,both,,,973.40,632.71,,,,,,,,,,,,,
BODY HUM PROXIMAGE 62 MM COMPHSVE SEG REV SYSTEML LAR,SUP-2136571,CDM,L3809,HCPCS,0274,RC,,,,both,,,11360.52,7384.34,,,,,,,,,,,,,
PLATE BONE LOK 133MML HLX10 STNLSS STEEL 1/3 TBLR NON ST,SUP-2588604,CDM,C1713,HCPCS,0278,RC,,,,both,,,535.37,347.99,,,,,,,,,,,,,
SHEATH URET L 40 CM OD 14 FR ID 12 FR STRL DISP CLEARPETRA,SUP-2937284,CDM,C1894,HCPCS,0272,RC,,,,both,,,1491.50,969.47,,,,,,,,,,,,,
GRAFT BONE SUB M REG RESRB MOLD MINERALIZED PLEXUR M,SUP-2293948,CDM,C1713,HCPCS,0278,RC,,,,both,,,4250.78,2763.01,,,,,,,,,,,,,
BIT DRL CANN LG 6/10X435 MM CERV QC CALIB STP SS NS,SUP-2188234,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1755.29,1140.94,,,,,,,,,,,,,
CATHETER BAL DIL 12FR L70CM 0.025IN PVC GWIRE DIL STRETCHING,SUP-2388518,CDM,C1725,HCPCS,0272,RC,,,,both,,,6908.00,4490.20,,,,,,,,,,,,,
CEMENT BNE HI VISC 40 GM PALACOS R PRO,SUP-2738874,CDM,C1713,HCPCS,0278,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
STENT CORONARY VERIFLEX MR L 24 MM DIA 5 MM SS RX BALLOON,SUP-2144508,CDM,C1876,HCPCS,0278,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
VENT CANN 10FR CONN DIA025IN L VENT PVC VENT CONN R ANG,SUP-2277637,CDM,C1729,HCPCS,0272,RC,,,,both,,,64.31,41.80,,,,,,,,,,,,,
GRAFT HUM TISS 11+CM FIB SEG STRUCTURAL FRZN,SUP-2165541,CDM,C1713,HCPCS,0278,RC,,,,both,,,1789.80,1163.37,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED LG UPCHARGE HD CERM,SUP-2212686,CDM,C1776,CPT,0278,RC,,,,both,,,1164.94,757.21,,,,,,,,,,,,,
PLATE BONE L4.5MM 4 H TI T FOR 4.5/5.5/6.5MM SCR L FRAG,SUP-2412039,CDM,C1713,HCPCS,0278,RC,,,,both,,,505.54,328.60,,,,,,,,,,,,,
CATHETER EMB 3FR L80CM BLLN DIA5MM 4.5FR INTRO 0.018IN ART,SUP-2214019,CDM,C1757,HCPCS,0272,RC,,,,both,,,359.40,233.61,,,,,,,,,,,,,
TRAY CATH MIDLN PROVENA MAXBARR 3FR 20CM 1 LUMAN S4153108BD,SUP-2632858,CDM,C1751,HCPCS,0278,RC,,,,both,,,529.75,344.34,,,,,,,,,,,,,
CANNULA PERFSN DIA 31 FR VEN ECLS 2 LUMEN STRL DISP PROTEK,SUP-2929864,CDM,2720000010,LOCAL,0272,RC,,,,both,,,39956.50,25971.72,,,,,,,,,,,,,
PLATE BNE L81MM 6 H 1 3RD TBLR LOK FOR 3.5MM SCR UNIV LOK,SUP-2411369,CDM,C1713,HCPCS,0278,RC,,,,both,,,465.72,302.72,,,,,,,,,,,,,
PROBE HATCHED TIP DEB TI SONIC 1,SUP-2305955,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1178.13,765.78,,,,,,,,,,,,,
SNARE SURG OVL 230 CM 25 GAX3 MM ISNARE,SUP-2736641,CDM,2720000010,LOCAL,0272,RC,,,,both,,,395.64,257.17,,,,,,,,,,,,,
BUSHING FEM SET POLYETH OSS AVL,SUP-2441789,CDM,C1776,CPT,0278,RC,,,,both,,,1031.49,670.47,,,,,,,,,,,,,
WRENCH SURG 8 11MM PT FOR DISTR OSTEOGENESIS RNG SYS,SUP-2176962,CDM,2720000010,LOCAL,0272,RC,,,,both,,,710.39,461.75,,,,,,,,,,,,,
PROBE ENDOSCP DISECT 90 DEG 28.5 CM SHFT FOR NEUROENDOSCOPE,SUP-2665081,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1222.40,794.56,,,,,,,,,,,,,
CROWN DENT PED NO7 SEC PRI M UP R ANTR CUSPID PREFABRICATED,SUP-2238773,CDM,D6783,CPT,0278,RC,,,,both,,,19.47,12.66,,,,,,,,,,,,,
SCREW SPNL L45MM DIA6.5MM TI SGL INNR POLYAX FOR 5.5MM ROD,SUP-2256227,CDM,C1713,HCPCS,0278,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
HC So1 Mycoplasma Igg,PX-3028673867,CDM,86738,CPT,0302,RC,,,,both,,,545.00,354.25,,,,,,,,,,,,,
LEAD PACE SETROX S L 45 CM DIA2.23 MM SIL INSUL FRACTAL COAT,SUP-2138046,CDM,C1898,HCPCS,0275,RC,,,,both,,,1161.80,755.17,,,,,,,,,,,,,
POST FIXATOR EXTERNAL 2HOLE RINGFIX MALE,SUP-2696089,CDM,2720000010,LOCAL,0272,RC,,,,both,,,412.60,268.19,,,,,,,,,,,,,
KIT PLNTR PLATE REP PEEK SINGLE TUNN NDL PASS INSRTR,SUP-2893400,CDM,C1713,HCPCS,0278,RC,,,,both,,,2424.08,1575.65,,,,,,,,,,,,,
GRAFT BNE FEM HD STRUT FD,SUP-2684087,CDM,C1762,CPT,0278,RC,,,,both,,,9624.10,6255.66,,,,,,,,,,,,,
CATHETER ANGIOPLSTY IMPACT L 120 CM SHFT 7 FR BALLOON L 4 CM,SUP-2124917,CDM,C1725,HCPCS,0272,RC,,,,both,,,958.74,623.18,,,,,,,,,,,,,
CAGE SPNL 19A H19MM DIA19MM CENTERPIECE T2,SUP-2292785,CDM,C1889,HCPCS,0278,RC,,,,both,,,21477.60,13960.44,,,,,,,,,,,,,
VALVE SHUNT 10 W/ PED BURHOLE RESVR MININAV,SUP-2108731,CDM,C1729,HCPCS,0272,RC,,,,both,,,1592.77,1035.30,,,,,,,,,,,,,
STAPLER INT SZ 10 4.8MM TI MULTFI VERSATACK,SUP-2283146,CDM,2720000010,LOCAL,0272,RC,,,,both,,,347.35,225.78,,,,,,,,,,,,,
I/B II KNEE PSCK II TIB ART SURF SIZE 59 25MM,SUP-2502019,CDM,C1776,CPT,0278,RC,,,,both,,,7536.00,4898.40,,,,,,,,,,,,,
IMPLANT BIO TISS W5XL10CM PORCINE DERM MTRX RECON THINNER BCP051010] TORNIER INC],SUP-2388574,CDM,C1763,HCPCS,0278,RC,,,,both,,,9417.49,6121.37,,,,,,,,,,,,,
PLATE BNE L56MM THK2MM 9 H NAR L DST RAD VOLAR ANAT TI FOR,SUP-2372937,CDM,C1713,HCPCS,0278,RC,,,,both,,,2590.50,1683.82,,,,,,,,,,,,,
BOLT EXT FIX HALF 8 MM PIN FIX STRL TRUELOK EVO LTX,SUP-2875626,CDM,2720000010,LOCAL,0272,RC,,,,both,,,338.37,219.94,,,,,,,,,,,,,
CYCLOPHOSPHAMIDE 500 MG IJ SOLR,RX-38271,CDM,J9076,HCPCS,0636,RC,10019-0955-01,NDC,,both,1,UN,358.10,232.76,,,,,,,,,,,,,
HC L-Spine Comp Inc Bend Min 6 Views,PX-3207211400,CDM,72114,CPT,0320,RC,,,,outpatient,,,1420.00,923.00,,,,,,,,,,,,,
FOUNDATION PRI INSRT SZ 1 9 MM ** SPEC ORD ONLY,SUP-2216226,CDM,C1776,CPT,0278,RC,,,,both,,,3092.90,2010.38,,,,,,,,,,,,,
HC Splint - Short Arm,PX-7612912500,CDM,29125,CPT,0761,RC,,,,both,,,700.00,455.00,,,,,,,,,,,,,
RING TRACTIONXSM 14-16IN CERV CLOSE BK W/ 2.5IN SKULL AND,SUP-2328117,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3124.30,2030.79,,,,,,,,,,,,,
LENS IOL BCNVX 8+ DIOPT 5 DEG 6X13 MM POST CHMBR,SUP-2392232,CDM,V2632,HCPCS,0276,RC,,,,both,,,433.32,281.66,,,,,,,,,,,,,
SCREW SPNL L45MM DIA7.5MM MULT AX REV ANG THRD LOK,SUP-2288006,CDM,C1713,HCPCS,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
PLATE BNE SM W11XL51MM THK3.3MM 0DEG 4 H BILAT TI STR RIG,SUP-2190774,CDM,C1713,HCPCS,0278,RC,,,,both,,,488.68,317.64,,,,,,,,,,,,,
ALLOGRAFT BNE DWL 10X15+ MM PRESERVON MATRIGRAFT,SUP-2740819,CDM,C1713,HCPCS,0278,RC,,,,both,,,1712.59,1113.18,,,,,,,,,,,,,
HC Rp Loclzj Tum Spect 1 Area Single Day Imaging,PX-3417880300,CDM,78803,CPT,0341,RC,,,,both,,,5028.00,3268.20,,,,,,,,,,,,,
SCREW BNE SET STD 6.5 MM 32 MM CANN THRD,SUP-2861008,CDM,C1713,HCPCS,0278,RC,,,,both,,,27012.04,17557.83,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY POLARIS X 270 DEG L 106 CM DIA 6,SUP-2652866,CDM,C1732,HCPCS,0278,RC,,,,both,,,1074.16,698.20,,,,,,,,,,,,,
RASP SURG 16MM CUP DISP FOR MTP FUS PLATING SYS OMNI,SUP-2223755,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1139.82,740.88,,,,,,,,,,,,,
SPHINCTEROTOME ENDOSCP CATH 6FR 0.035IN PUR TAPR TO 5FR W/,SUP-2169288,CDM,2720000010,LOCAL,0272,RC,,,,both,,,571.48,371.46,,,,,,,,,,,,,
SCREW BNE L8MM DIA2.4MM MAXILLOMANDIBULAR TI NONLOCKING HI,SUP-2403056,CDM,C1713,HCPCS,0278,RC,,,,both,,,226.08,146.95,,,,,,,,,,,,,
Z INACTIVE SUPPLIER LINER ACET OD38MM ID28MM +5MM HIP E1 MAX ROM RINGLOC,SUP-2408959,CDM,C1776,CPT,0278,RC,,,,both,,,10895.80,7082.27,,,,,,,,,,,,,
"HC Urine,Microalbumin,Quantitativ",PX-3078204300,CDM,82043,CPT,0307,RC,,,,inpatient,,,129.00,83.85,,,,,,,,,,,,,
PLATE BNE MAXILLOFCL 6 MESH KT NS FACE ID,SUP-2909612,CDM,C1713,HCPCS,0278,RC,,,,both,,,46232.32,30051.01,,,,,,,,,,,,,
FIBER LASER 200 SER BALL TIP COMPATIBLE HOLM DISP,SUP-2540069,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1629.69,1059.30,,,,,,,,,,,,,
COMPONENT ARTC 2.5X3MM OFFSET PATELLOFEMORAL HEMICAP,SUP-2123660,CDM,C1776,CPT,0278,RC,,,,both,,,14942.32,9712.51,,,,,,,,,,,,,
PLATE BNE STR NEURO 16 HOLE LP TI PUR STRL LEVEL 1,SUP-2491533,CDM,C1713,HCPCS,0278,RC,,,,both,,,683.99,444.59,,,,,,,,,,,,,
TUBE VENT DIA127MM 137MM IIF TAPR BLU ULTRASIL SIL THN,SUP-2313876,CDM,L8699,HCPCS,0278,RC,,,,both,,,76.33,49.61,,,,,,,,,,,,,
SPACER KNEE 3-10 8 MM DSTL SYS REV GUIDE ATTUNE,SUP-2454498,CDM,C1776,CPT,0278,RC,,,,both,,,1617.10,1051.11,,,,,,,,,,,,,
ALLOGRAFT BNE 2.5 CC FIBER KORE,SUP-2736955,CDM,C1713,HCPCS,0278,RC,,,,both,,,1872.23,1216.95,,,,,,,,,,,,,
LIDOCAINE HCL 4 % EX SOLN,RX-4450,CDM,6370000000,HCPCS,0637,RC,09999-9917-20,NDC,,both,15,ML,54.00,35.10,,,,,,,,,,,,,
KIT IMPL L450MM DIA4MM TIM IM AND ENDCAP THE NANCY NAIL,SUP-2253253,CDM,C1713,HCPCS,0278,RC,,,,both,,,725.34,471.47,,,,,,,,,,,,,
CATHETER PERI DLYS 15FR L42CM SIL 2 CUF HIGHLY KINK RESIST,SUP-2283888,CDM,C1750,HCPCS,0278,RC,,,,both,,,141.49,91.97,,,,,,,,,,,,,
PLATE BNE 95 DEG SHFT L 204 MM BLADE L 50 MM 12 H SS CNDYL,SUP-2908306,CDM,C1713,HCPCS,0278,RC,,,,both,,,3696.41,2402.67,,,,,,,,,,,,,
STENT CORONARY EXPRESS 2 L 8 MM DIA 3 MM GUIDE CATH 5 FR NP,SUP-2139861,CDM,C1876,HCPCS,0278,RC,,,,both,,,4160.50,2704.32,,,,,,,,,,,,,
STEM FEM M LNG HIP REMEDY,SUP-2319835,CDM,C1776,CPT,0278,RC,,,,both,,,8635.00,5612.75,,,,,,,,,,,,,
DRESSING NEG PRSS L35CM SYS PREVENA + PEEL AND PLC,SUP-2419100,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1877.72,1220.52,,,,,,,,,,,,,
CATHETER CRICOTHYROTOMY SET 4 MMX4.2 CM 6 MMX7.5 CM MELK,SUP-2760018,CDM,C1769,HCPCS,0272,RC,,,,both,,,932.58,606.18,,,,,,,,,,,,,
SCREW BONE LOK 3.5MM DIA 44MML TTNM VRBLE ANGLE SRFX ST,SUP-2586582,CDM,C1713,HCPCS,0278,RC,,,,both,,,1175.84,764.30,,,,,,,,,,,,,
CUTTER BOLT THOR LUM SPNL FOR INNR TB,SUP-2289764,CDM,C1713,HCPCS,0278,RC,,,,both,,,1551.76,1008.64,,,,,,,,,,,,,
SCREW BONE 2.7MM DIA 6MML CORTICAL HEX,SUP-2588490,CDM,C1713,HCPCS,0278,RC,,,,both,,,57.96,37.67,,,,,,,,,,,,,
COIL NEUROVASCULAR OPTMA L 20 CM DIA 6 MM SZ 0.018 IN PLAT,SUP-2753873,CDM,C1889,HCPCS,0278,RC,,,,both,,,5950.30,3867.69,,,,,,,,,,,,,
CAGE SPNL 4 DEG 10X18X55 MM EXPANDABLE PEEK COROENT XLCT,SUP-2560176,CDM,C1889,HCPCS,0278,RC,,,,both,,,16328.00,10613.20,,,,,,,,,,,,,
GUIDEWIRE VASC ARW L 175 CM DIA 0.035 IN J L 3 MM PTFE X,SUP-2383456,CDM,C1769,HCPCS,0272,RC,,,,both,,,108.58,70.58,,,,,,,,,,,,,
SPACER KNEE 5MMXSM DSTL POST DURAC,SUP-2364865,CDM,C1776,CPT,0278,RC,,,,both,,,1387.88,902.12,,,,,,,,,,,,,
KIT DRNGE EMGCY VLV REPL INCLUDE CAP SLDE CLMP SCIS BLU,SUP-2133385,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1067.60,693.94,,,,,,,,,,,,,
BLADE SAW OSCLLTNG 19MM CUT EDGE 80MM CUT DEPTH 1.2MM CUT TH,SUP-2605468,CDM,2720000010,LOCAL,0272,RC,,,,both,,,67.26,43.72,,,,,,,,,,,,,
SYSTEM PRP FACILITATES RAP PREP OF AUTOLGS FR A SM SAMP OF,SUP-2120722,CDM,2720000010,LOCAL,0272,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
SPLINT RST PAN MIT SP M LF,SUP-2163832,CDM,L3807,HCPCS,0274,RC,,,,both,,,220.68,143.44,,,,,,,,,,,,,
IMMOBILIZER ORTH CUTAWAY MED 20 IN KNEE ADJ PERF FOAM,SUP-2194893,CDM,L1830,CPT,0272,RC,,,,both,,,53.38,34.70,,,,,,,,,,,,,
SCREW WDG FEM L15MM DSTL KNEE PRI PRESSFIT LEGION,SUP-2346335,CDM,C1713,HCPCS,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
CATHETER INTVASC OCCL PRUITT L 23 CM DIA 9 FR BALLOON DIA18,SUP-2264223,CDM,C2628,HCPCS,0272,RC,,,,both,,,1629.66,1059.28,,,,,,,,,,,,,
SCREW BNE L 150 MM DIA 3.5 MM SS CORTICAL ST NS EVOS,SUP-2931632,CDM,C1713,HCPCS,0278,RC,,,,both,,,233.96,152.07,,,,,,,,,,,,,
BLADE RETRACTOR SCOVILLE 1X3.5 IN SLD PRNG SHRP LAMINECTOMY,SUP-2484769,CDM,C1713,HCPCS,0278,RC,,,,both,,,264.01,171.61,,,,,,,,,,,,,
HC Acute Hepatitis Panel,PX-3018007400,CDM,80074,CPT,0301,RC,,,,both,,,416.00,270.40,,,,,,,,,,,,,
HC Pbb Carpal Tunnel Inj Pmc,PX-5102052600,CDM,20526,CPT,0510,RC,,,,inpatient,,,775.00,503.75,,,,,,,,,,,,,
MESH SURG TOT PELV GUID CANN REP KT PROLIFT,SUP-2219786,CDM,C1781,HCPCS,0278,RC,,,,both,,,8977.26,5835.22,,,,,,,,,,,,,
CATHETER CVC 2LUM HANDS-OFF 7FR 30CM,SUP-2664442,CDM,C1751,HCPCS,0278,RC,,,,both,,,65.12,42.33,,,,,,,,,,,,,
PLATE BONE L256MM BLDE W11.7XL30MM 90DEG 14 H STRL BILAT S,SUP-2185454,CDM,C1713,HCPCS,0278,RC,,,,both,,,4745.14,3084.34,,,,,,,,,,,,,
KIT TRNSDUC PRSS MON 10 CA,SUP-2214649,CDM,C1751,HCPCS,0278,RC,,,,both,,,116.18,75.52,,,,,,,,,,,,,
HC Assay of Testosterone Total,PX-3018440300,CDM,84403,CPT,0301,RC,,,,both,,,359.00,233.35,,,,,,,,,,,,,
CLAMP EXT FIX PIN LG NS,SUP-2188503,CDM,2720000010,LOCAL,0272,RC,,,,both,,,963.98,626.59,,,,,,,,,,,,,
INDOCYANINE GREEN 25 MG IV SOLR,RX-10266,CDM,2500000003,HCPCS,0250,RC,70100-0725-01,NDC,,both,1,UN,1643.60,1068.34,,,,,,,,,,,,,
TUBE FEED 16FR 108IN 15ML BLLN JEJUSTMY RADPQ CONN W/ DEPTH,SUP-2384673,CDM,2720000010,LOCAL,0272,RC,,,,both,,,453.48,294.76,,,,,,,,,,,,,
BIT DRL DIA115MM HLLW FOR 95MM MULTILOC PROX HUM NAILING,SUP-2178936,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1191.63,774.56,,,,,,,,,,,,,
CATHETER EP 6FR L105CM 5MM SPC DECAPOLAR 270DEG STD CRV,SUP-2141318,CDM,C1732,HCPCS,0272,RC,,,,both,,,1931.10,1255.21,,,,,,,,,,,,,
SCREW BONE L12MM OD2MM MINI CRANIOMAXILLOFACIAL VIT LUHR LP,SUP-2364682,CDM,C1713,HCPCS,0278,RC,,,,both,,,15.17,9.86,,,,,,,,,,,,,
METHYLPREDNISOLONE SODIUM SUCC 500 MG IJ SOLR,RX-10581,CDM,J2919,HCPCS,0636,RC,00009-0758-01,NDC,,both,1,UN,139.70,90.80,,,,,,,,,,,,,
GUIDEWIRE URO L150CM L3CM OD0035IN 3CM TIP FLX TIP FIX COR,SUP-2141736,CDM,C1769,HCPCS,0272,RC,,,,both,,,90.21,58.64,,,,,,,,,,,,,
DEFIBRILLATOR IMPL COGNIS TI CRT BPLR RV IS1 LV DF1 CONN,SUP-2149259,CDM,C1882,HCPCS,0275,RC,,,,both,,,82268.00,53474.20,,,,,,,,,,,,,
PLATE PELVIC CVD 6 HOLE R108,SUP-2473598,CDM,C1713,HCPCS,0278,RC,,,,both,,,1161.80,755.17,,,,,,,,,,,,,
LOOP SUT DIA8MM GUID ROD BRAID FOR G-FORCE TENODESIS,SUP-2399124,CDM,2720000010,LOCAL,0272,RC,,,,both,,,445.88,289.82,,,,,,,,,,,,,
BLADE RTRCTR MRDNG LG 2INW X 3 34NL TTNM F  UNVRSL RING UL,SUP-2676582,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1092.19,709.92,,,,,,,,,,,,,
WEDGE TIB SM SZ 1 THK10MM KNEE PRI PRESSFIT FULL FLAT BLK,SUP-2377111,CDM,C1713,HCPCS,0278,RC,,,,both,,,3244.12,2108.68,,,,,,,,,,,,,
PIN FIX L635MM OD4MM CORT N CANN SELF TAP DRL N LOK SNAP,SUP-2409680,CDM,C1713,HCPCS,0278,RC,,,,both,,,351.90,228.73,,,,,,,,,,,,,
NAIL IM L300MM OD15MM PUR TI FEM NONLOCKING CANN FLX E,SUP-2192724,CDM,C1713,HCPCS,0278,RC,,,,both,,,794.73,516.57,,,,,,,,,,,,,
PLATE BNE W8XL100MM THK2MM 0DEG 12 H BILAT S STL STR RIG,SUP-2186183,CDM,C1713,HCPCS,0278,RC,,,,both,,,1019.53,662.69,,,,,,,,,,,,,
VALVE SHUNT STRATA II STRATA NSC,SUP-2628603,CDM,C1889,HCPCS,0278,RC,,,,both,,,15936.60,10358.79,,,,,,,,,,,,,
STENT CORONARY EXPRESS 2 L 24 MM DIA2.5 MM GUIDE CATH 6 FR,SUP-2144274,CDM,C1876,HCPCS,0278,RC,,,,both,,,2508.86,1630.76,,,,,,,,,,,,,
PLATE BNE L97MM 4 H R LAT PROX PERIARTC TIB S STL LOK COMPR,SUP-2198433,CDM,C1713,HCPCS,0278,RC,,,,both,,,3808.60,2475.59,,,,,,,,,,,,,
GUIDEWIRE VASC SYNCHRO 215CM 0.014IN SEG 35CM ACCS STD STR,SUP-2866243,CDM,C1769,HCPCS,0272,RC,,,,both,,,2335.06,1517.79,,,,,,,,,,,,,
PLATE BNE L117MM 6 H L PROX TIB S STL SM BEND VAR ANG LOK,SUP-2177913,CDM,C1713,HCPCS,0278,RC,,,,both,,,5146.27,3345.08,,,,,,,,,,,,,
PIN DIL 28MM NAIL TENFUSE,SUP-2401424,CDM,2720000010,LOCAL,0272,RC,,,,both,,,593.46,385.75,,,,,,,,,,,,,
COMPONENT FEM KNEE CRUC RET CR FLX LT UNISX PRI PRESSFIT,SUP-2200894,CDM,C1776,CPT,0278,RC,,,,both,,,15082.99,9803.94,,,,,,,,,,,,,
CATHETER HD DL 14.5 FRX19 CM 36 CM STR SYMTRC TIP PALINDROME,SUP-2283935,CDM,C1750,HCPCS,0278,RC,,,,both,,,805.76,523.74,,,,,,,,,,,,,
CAGE SPNL BULLETED 10 DEG 60X18X9 MM COROENT XL,SUP-2557524,CDM,C1889,HCPCS,0278,RC,,,,both,,,13244.52,8608.94,,,,,,,,,,,,,
GUIDEWIRE VASC L 145 CM DIA 0.035 IN TAPR L 15 CM X FLPY TIP,SUP-2167668,CDM,C1769,HCPCS,0272,RC,,,,both,,,40.60,26.39,,,,,,,,,,,,,
SPLINT ORTH PLASTALUME 6.25X6.25 IN FNGR W/ BLB RADLUC,SUP-2276775,CDM,L3933,HCPCS,0272,RC,,,,both,,,5.78,3.76,,,,,,,,,,,,,
HC Iadna Streptococcus Group B Amplified Probe Tq,PX-3068765300,CDM,87653,CPT,0306,RC,,,,both,,,105.00,68.25,,,,,,,,,,,,,
KIT REP FOR 9.6FR SGL LUMN CTRL VEN CATH HCKMN,SUP-2127719,CDM,C1751,HCPCS,0278,RC,,,,both,,,449.02,291.86,,,,,,,,,,,,,
CATHETER INTRAAORTIC BLLN 7.5 FR 25 CC,SUP-2227326,CDM,C1725,HCPCS,0272,RC,,,,both,,,2559.10,1663.41,,,,,,,,,,,,,
SPACER HIP 46MM SH 1 PC SLD POLY METH METHACRYLATE S STL,SUP-2223673,CDM,C1713,HCPCS,0278,RC,,,,both,,,8650.70,5622.95,,,,,,,,,,,,,
MESH CRAN W60XL60MM PROF H0.1MM MIC UP FACE,SUP-2366214,CDM,C1713,HCPCS,0278,RC,,,,both,,,1664.99,1082.24,,,,,,,,,,,,,
AUGMENT TIB SZ 3 THK10MM UNIV DST KNEE POR WDG STP PRESSFIT,SUP-2250966,CDM,C1776,CPT,0278,RC,,,,both,,,4500.25,2925.16,,,,,,,,,,,,,
SPHINCTEROTOME ENDOSCP DOME 5.5 FR 0.021 INX260 CM OMNI,SUP-2737410,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1105.28,718.43,,,,,,,,,,,,,
IMPLANT OTO L3.75MM PIST DIA0.5MM NIT FLROPLAS SMRT,SUP-2312821,CDM,2780000010,LOCAL,0278,RC,,,,both,,,939.58,610.73,,,,,,,,,,,,,
CATHETER HD STR EXTN 12.5 FRX28 CM LT DL STP TIP SIL HEMCATH,SUP-2627314,CDM,C1750,HCPCS,0278,RC,,,,both,,,20.22,13.14,,,,,,,,,,,,,
REAMER MTP 21MM FEM SH CUST,SUP-2320320,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1632.80,1061.32,,,,,,,,,,,,,
KIT LASER L45CM MICRO ACCESS VENACURE NEVERTOUCH,SUP-2116796,CDM,C1888,HCPCS,0272,RC,,,,both,,,2342.44,1522.59,,,,,,,,,,,,,
HC So Hiv-2 Rna,PX-3068753867,CDM,87538,CPT,0306,RC,,,,both,,,118.00,76.70,,,,,,,,,,,,,
PROSTHESIS OSS SHEA HA/FP 3X5.4 MM 1.14 MM HA FLROPLAS,SUP-2637896,CDM,L8613,CPT,0278,RC,,,,both,,,1269.13,824.93,,,,,,,,,,,,,
NEOMYCIN SULFATE 500 MG PO TABS,RX-5472,CDM,6370000000,HCPCS,0637,RC,00093-1177-01,NDC,,both,1,UN,5.00,3.25,,,,,,,,,,,,,
SPLINT WRST L INSTABILITY INJ LOOP LOK W STAY FIRM SUPP,SUP-2276658,CDM,L3908,HCPCS,0272,RC,,,,both,,,16.45,10.69,,,,,,,,,,,,,
INTRODUCER SHTH OD6FR .038IN DIL GWIRE PINN,SUP-2141014,CDM,C1894,HCPCS,0272,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
NAIL ELAS SS 2X440MM,SUP-2547600,CDM,C1713,HCPCS,0278,RC,,,,both,,,788.83,512.74,,,,,,,,,,,,,
PEG FIX SUBCHONDRIAL TI,SUP-2257720,CDM,C1713,HCPCS,0278,RC,,,,both,,,301.44,195.94,,,,,,,,,,,,,
NEXGEN LPS-FLEX OPTION FEMORAL SIZE E-LT,SUP-2502889,CDM,C1776,CPT,0278,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
HC Slctv Cath Carotid/Innom Art Angio Intrcranl Art,PX-3613622300,CDM,36223,CPT,0361,RC,,,,both,,,5589.00,3632.85,,,,,,,,,,,,,
RIGHT/LEFT IBO BLDE SET FOR USE W/ STRYKR TPS RECIP SAW,SUP-2363316,CDM,2720000010,LOCAL,0272,RC,,,,both,,,581.31,377.85,,,,,,,,,,,,,
CATHETER GUID L 30 CM OD 7 FR ID 1.8 MM J SHP FIX HK DEL,SUP-2665331,CDM,C1887,HCPCS,0272,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
PROBE SNR L230CM DIA2.3MM CLR SUCT N CNTCT COAG TARGETED VIS,SUP-2166256,CDM,2720000010,LOCAL,0272,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
PLATE BNE L118MM 6 H NONSTERILE R LAT PROX TIB S STL LOK,SUP-2185712,CDM,C1713,HCPCS,0278,RC,,,,both,,,4177.96,2715.67,,,,,,,,,,,,,
GRAFT BIO TISS W13XL15CM HERN FOR IMPLANTATION TO REINF SFT,SUP-2170303,CDM,C1781,HCPCS,0278,RC,,,,both,,,12246.00,7959.90,,,,,,,,,,,,,
COMPONENT FEM 6X2MM OFFSET UNICAP,SUP-2123699,CDM,C1776,CPT,0278,RC,,,,both,,,13993.47,9095.76,,,,,,,,,,,,,
AMOXICILLIN-POT CLAVULANATE 250-62.5 MG/5ML PO SUSR,RX-9080,CDM,340b,HCPCS,0637,RC,09999-9903-77,NDC,,both,5,ML,13.40,8.71,,,,,,,,,,,,,
TERCONAZOLE 0.4 % VA CREA,RX-11510,CDM,6370000000,HCPCS,0637,RC,51672-1304-06,NDC,,both,45,GR,162.00,105.30,,,,,,,,,,,,,
NKII ULTRA ALL-POLY TIBIA LT SZ 0 11MM,SUP-2509862,CDM,C1776,CPT,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
SYSTEM SHTH 9FR L40CM OD0.157IN ID0.13IN TIP ID0.122IN STD CSGWORBC19M] MEDTRONIC CARDIAC RTHYM MGT],SUP-2282358,CDM,C1892,HCPCS,0272,RC,,,,both,,,664.90,432.18,,,,,,,,,,,,,
GRAFT BNE SUB 125ML PSTE MIX INQU +,SUP-2247319,CDM,C1713,HCPCS,0278,RC,,,,both,,,1381.60,898.04,,,,,,,,,,,,,
NAIL INTRMDLLRY L40CM D14MM FMRL RTRGRDE CNNLTD LOK M/DN,SUP-2467342,CDM,C1713,HCPCS,0278,RC,,,,both,,,4512.37,2933.04,,,,,,,,,,,,,
SCREW SPNL L12MM DIA4.5MM CANC ANTR CERV TI SELF DRL VAR ANG,SUP-2254606,CDM,C1713,HCPCS,0278,RC,,,,both,,,813.26,528.62,,,,,,,,,,,,,
PLATE BONE L17MM 2 H LT S STL L SHP RIG NEUT NONCOMPRESSION,SUP-2186156,CDM,C1713,HCPCS,0278,RC,,,,both,,,184.38,119.85,,,,,,,,,,,,,
COLLAR TRACHEOTOMY M H3.25IN FOR 13-16IN NK POLY FOAM TWO,SUP-2196876,CDM,L0120,HCPCS,0272,RC,,,,both,,,28.39,18.45,,,,,,,,,,,,,
LINER ACET CONSTRN 28 MM EPSILON,SUP-2448626,CDM,C1776,CPT,0278,RC,,,,both,,,124428.78,80878.71,,,,,,,,,,,,,
TRIAL SURG 6MM MIDFOOT BIOFOAM,SUP-2397845,CDM,2720000010,LOCAL,0272,RC,,,,both,,,797.56,518.41,,,,,,,,,,,,,
PLATE BNE SM L53MM 3X3 H BILAT TI T OBLQ LIMIT CNTCT DYN,SUP-2190941,CDM,C1713,HCPCS,0278,RC,,,,both,,,823.56,535.31,,,,,,,,,,,,,
CLAMP SWVL TMPLT FOR LIMB RECONSTRUCT SYS ORTHOFIX,SUP-2405364,CDM,C1713,HCPCS,0278,RC,,,,both,,,417.62,271.45,,,,,,,,,,,,,
KWIRE FIX L102MM DIA11MM LMH,SUP-2398600,CDM,C1776,CPT,0278,RC,,,,both,,,31.40,20.41,,,,,,,,,,,,,
KIT PICC MAX BARR ANTIMICR/ANITTHROM PRELOAD 5.5FR X 55CM 2L,SUP-2864582,CDM,C1751,HCPCS,0278,RC,,,,both,,,856.18,556.52,,,,,,,,,,,,,
KIT CATHETER PAINBUSTER 100ML X 1ML PER HR STD ON Q,SUP-2236821,CDM,C1713,HCPCS,0278,RC,,,,both,,,116.18,75.52,,,,,,,,,,,,,
GUIDEWIRE VASC L180CM DIA0.038IN TIP L3IN NIT COR POLYUR JKT,SUP-2385123,CDM,C1769,HCPCS,0272,RC,,,,both,,,153.86,100.01,,,,,,,,,,,,,
CUBE EXTERNAL FIXATION 4 HOLE STAINLESS STEEL,SUP-2586503,CDM,2720000010,LOCAL,0272,RC,,,,both,,,795.64,517.17,,,,,,,,,,,,,
APPEL TYP KNOT PUSH 5MM 40CM,SUP-2138694,CDM,2720000010,LOCAL,0272,RC,,,,both,,,709.64,461.27,,,,,,,,,,,,,
ADAPTER FEM NEUT KNEE BOLT PFC SIG,SUP-2253595,CDM,C1776,CPT,0278,RC,,,,both,,,699.59,454.73,,,,,,,,,,,,,
PLATE BNE L 201 MM SCREW DIA 4.5 MM 12 H BOW COMPR LCK NS,SUP-2933379,CDM,C1713,HCPCS,0278,RC,,,,both,,,4162.07,2705.35,,,,,,,,,,,,,
ADAPTER HUM HD STD TAPR FOR COMPHSVE REV SHLDR SYS,SUP-2404757,CDM,C1776,CPT,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
GRAFT HUM TISS W29XL100MM THK3-12MM FEM CORT FRZN,SUP-2307357,CDM,C1713,HCPCS,0278,RC,,,,both,,,1267.68,823.99,,,,,,,,,,,,,
PLATE BNE L51MM THK3.3MM 4 H BILAT S STL STR LIMIT CNTCT,SUP-2185127,CDM,C1713,HCPCS,0278,RC,,,,both,,,816.97,531.03,,,,,,,,,,,,,
CATHETER CRYOABLATION C2 CRYOBALLOON L 105 CM CHANNEL 3.7 MM,SUP-2422295,CDM,C2618,HCPCS,0272,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
PLATE BONE W12XL183MM THK1MM 11 H BILAT TI SEMI TBLR LO PROF,SUP-2190709,CDM,C1713,HCPCS,0278,RC,,,,both,,,376.99,245.04,,,,,,,,,,,,,
TRAY CATH PICC POLY Q CATH 4FR 0.024/0.032IN 60CM 2 LUMAN RV,SUP-2613432,CDM,C1751,HCPCS,0278,RC,,,,both,,,609.47,396.16,,,,,,,,,,,,,
INTRODUCER EP 10 FR 63 CM LEN HEMSTATIC VLV AD TRIO HEM,SUP-2357212,CDM,C1893,HCPCS,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
STAPLE BNE SUPER ELASTIC 20X20X20 MM RELD HIMAX DYNAFORCE,SUP-2175189,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4867.00,3163.55,,,,,,,,,,,,,
PROBE NSL STR W/ SMK EVAC,SUP-2713681,CDM,2720000010,LOCAL,0272,RC,,,,both,,,852.29,553.99,,,,,,,,,,,,,
SIZER BRST DIA161CM P5CM 750CC GEL RND MOD + PROF,SUP-2300922,CDM,2720000010,LOCAL,0272,RC,,,,both,,,894.90,581.68,,,,,,,,,,,,,
STEM HUM L200MM DIA8MM REV M TAPR FOUNDATION,SUP-2217335,CDM,C1776,CPT,0278,RC,,,,both,,,8980.40,5837.26,,,,,,,,,,,,,
PLATE BNE DIA24 MM THK 0.5 MM SCREW DIA1.7 MM MAXILLOFCL,SUP-2909564,CDM,C1713,HCPCS,0278,RC,,,,both,,,4416.91,2870.99,,,,,,,,,,,,,
BRACE THMB UNIV LT SPICA,SUP-2319328,CDM,L3906,HCPCS,0274,RC,,,,both,,,25.28,16.43,,,,,,,,,,,,,
ALLOGRAFT BNE WHL FEM FRZN RT HD,SUP-2717939,CDM,C1762,CPT,0278,RC,,,,both,,,40678.70,26441.15,,,,,,,,,,,,,
PLATE BONE W100XL100MM CRANIOMAXILLOFACIAL TI SCRN FOR 1.3MM,SUP-2190683,CDM,C1713,HCPCS,0278,RC,,,,both,,,5029.02,3268.86,,,,,,,,,,,,,
BAR SPNL SZ 8 L74.5MM RAD 220MM SUP INFERIOR CRAN GLD TI,SUP-2193295,CDM,C1713,HCPCS,0278,RC,,,,both,,,7878.26,5120.87,,,,,,,,,,,,,
HOOK SPNL BLDE W5.5MM BILAT PEDCL TI NEUT OPN FOR 5.5MM ROD,SUP-2254439,CDM,C1713,HCPCS,0278,RC,,,,both,,,2025.30,1316.44,,,,,,,,,,,,,
FIBER LASER 272 MICRON 3/PKG STERILE INCLUDES 1,SUP-2574063,CDM,2720000010,LOCAL,0272,RC,,,,both,,,871.95,566.77,,,,,,,,,,,,,
MASK FULL FACE W/ PREM HDGEAR SM COMFORTGEL,SUP-2326785,CDM,C1713,HCPCS,0278,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
PLATE X VA LCK 2.4/2.7MM LG TI STRL,SUP-2546957,CDM,C1713,HCPCS,0278,RC,,,,both,,,3785.71,2460.71,,,,,,,,,,,,,
VALVE AORT SZ 21 H16MM CUF DIA26MM TISS ANNULUS DIA21MM SUP,SUP-2355875,CDM,C1889,HCPCS,0278,RC,,,,both,,,15684.30,10194.79,,,,,,,,,,,,,
COMPONENT MAND CNDYL RT TLTS FOR LCK SYS TI NS LEVEL 1,SUP-2460292,CDM,C1889,HCPCS,0278,RC,,,,both,,,3301.99,2146.29,,,,,,,,,,,,,
INSTRUMENT PACK PIN,SUP-2878039,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1341.88,872.22,,,,,,,,,,,,,
DRILL SL 4.3 MM FOR RG FEM NAT NAIL SYS,SUP-2198659,CDM,2720000010,LOCAL,0272,RC,,,,both,,,321.54,209.00,,,,,,,,,,,,,
PLATE BNE L 208 X W 10.7 MM THK 3.4 MM SCREW DIA 3.5 MM 18 H,SUP-2932967,CDM,C1713,HCPCS,0278,RC,,,,both,,,3416.63,2220.81,,,,,,,,,,,,,
WIRE FIX OLV 2 MM MP,SUP-2465402,CDM,C1713,HCPCS,0278,RC,,,,both,,,4496.48,2922.71,,,,,,,,,,,,,
HC Pain Major,PX-3600007516,CDM,3600007516,LOCAL,0360,RC,,,,both,,,2879.00,1871.35,,,,,,,,,,,,,
SEEDS COMS SZ 14N PLAQ P/N 2029CLS1,SUP-2247263,CDM,C2642,HCPCS,0278,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
SHUNT CV MED CAR ART NL8505500,SUP-2633898,CDM,2720000010,LOCAL,0272,RC,,,,both,,,728.32,473.41,,,,,,,,,,,,,
PLATE BNE 3 H ORTHODONTIC TRAUM CRSS SHP ANCHR W CURLED END,SUP-2417695,CDM,C1713,HCPCS,0278,RC,,,,both,,,410.27,266.68,,,,,,,,,,,,,
PLATE BNE L260MM THK37MM 20 H BILAT S STL STR LO PROF RIG,SUP-2177150,CDM,C1713,HCPCS,0278,RC,,,,both,,,2982.15,1938.40,,,,,,,,,,,,,
PLATE BONE L5MM 8 H RT DSTL MEDL TIB LCK W/O TAB FOR 3.5MM,SUP-2349085,CDM,C1713,HCPCS,0278,RC,,,,both,,,4109.69,2671.30,,,,,,,,,,,,,
DEVICE EMB L14MM OD3MM 55DEG SFT DST TIP BRAID 4 FLX,SUP-2296700,CDM,C1884,HCPCS,0278,RC,,,,both,,,43925.46,28551.55,,,,,,,,,,,,,
FLUOCINONIDE 0.05 % EX SOLN,RX-3190,CDM,6370000000,HCPCS,0637,RC,00168-0134-60,NDC,,both,60,ML,180.10,117.06,,,,,,,,,,,,,
COMPONENT HIP HYBRID,SUP-2212667,CDM,C1776,CPT,0278,RC,,,,both,,,13502.00,8776.30,,,,,,,,,,,,,
RXG PLATE STR 4 HLE 40MM 24MM BRG RDCD HOLE SPCNG T06MM,SUP-2679389,CDM,C1713,HCPCS,0278,RC,,,,both,,,2658.98,1728.34,,,,,,,,,,,,,
SUCRALFATE 1 G PO TABS,RX-11442,CDM,6370000000,HCPCS,0637,RC,59762-0401-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PLATE L DSTL RAD DRSL 2.4MM -20D 3H HD 3H SHFT TI STRL,SUP-2546757,CDM,C1713,HCPCS,0278,RC,,,,both,,,1821.39,1183.90,,,,,,,,,,,,,
GRAFT SYNTHECEL DURA REPAIR 1X3IN,SUP-2717544,CDM,C1763,HCPCS,0278,RC,,,,both,,,1570.79,1021.01,,,,,,,,,,,,,
HC So Acth,PX-3078202466,CDM,82024,CPT,0307,RC,,,,both,,,288.00,187.20,,,,,,,,,,,,,
PLATE BUR H L DIA18.5MM 5 H TI BENT W/O TAB NONCOMPRESSION,SUP-2136516,CDM,C1713,HCPCS,0278,RC,,,,both,,,662.54,430.65,,,,,,,,,,,,,
PLATE BNE L62MM 3 H S STL LOK COMPR FOR 3.5MM SCR LCP,SUP-2184179,CDM,C1713,HCPCS,0278,RC,,,,both,,,1784.84,1160.15,,,,,,,,,,,,,
HC Hgb/Rbcs Fetal Fetomaternal Hemrrg Rosette,PX-3058546100,CDM,85461,CPT,0305,RC,,,,inpatient,,,254.00,165.10,,,,,,,,,,,,,
PLATE BNE L370MM 18 H NONSTERILE L CNDYL S STL CRV LOK,SUP-2177868,CDM,C1713,HCPCS,0278,RC,,,,both,,,6791.04,4414.18,,,,,,,,,,,,,
HC So Antidepressant Tricyclic 1/2,PX-3018033567,CDM,G0480,CPT,0301,RC,,,,both,,,609.00,395.85,,,,,,,,,,,,,
OXF CEM FEM/CEM TIB/STD AS/BLD,SUP-2212437,CDM,C1776,CPT,0278,RC,,,,both,,,14444.00,9388.60,,,,,,,,,,,,,
PLATE BNE FRAG 2.7X60 MM NS,SUP-2518448,CDM,C1713,HCPCS,0278,RC,,,,both,,,1752.12,1138.88,,,,,,,,,,,,,
PLATE BNE L 143 MM SCREW DIA 3.5 MM 12 SHFT H TI 1/3 TUBLR,SUP-2908126,CDM,C1713,HCPCS,0278,RC,,,,both,,,2502.42,1626.57,,,,,,,,,,,,,
PLATE BONE L153MM 18 H STRL S STL COMPR FOR 2.7MM SCR EVOS,SUP-2349626,CDM,C1713,HCPCS,0278,RC,,,,both,,,2616.34,1700.62,,,,,,,,,,,,,
CATHETER EP LG4 10 MM 6 FRX110 CM HEXA DYN XT,SUP-2462285,CDM,C1730,HCPCS,0272,RC,,,,both,,,2103.80,1367.47,,,,,,,,,,,,,
CUTTER SURG OD31MM TUNGSTEN CARB HI LINE XS III,SUP-2108792,CDM,C1713,HCPCS,0278,RC,,,,both,,,538.23,349.85,,,,,,,,,,,,,
BLADE RETRCT L5CM BLK FINISH SHRP HK SPNL MED LAT SELF RET,SUP-2382491,CDM,2720000010,LOCAL,0272,RC,,,,both,,,432.28,280.98,,,,,,,,,,,,,
ANCHOR SUT OD5.5MM LACTOSORB L15 COPOLYMER 2 TWO MAXBRAID 905940] ZIMMER BIOMET INC],SUP-2137198,CDM,C1713,HCPCS,0278,RC,,,,both,,,1086.44,706.19,,,,,,,,,,,,,
TRIAL KNEE POST FEM ROT PLATFRM REV ATTUNE,SUP-2436168,CDM,2720000010,LOCAL,0272,RC,,,,both,,,119.32,77.56,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH FLX L 73 MM DIA20 MM SHTH 16 FR SS,SUP-2170649,CDM,C1874,HCPCS,0278,RC,,,,both,,,9407.44,6114.84,,,,,,,,,,,,,
KIT INTRO ONESTIC L 11 CM DIA 5 FR GUIDEWIRE L 40 CM DIA,SUP-2876547,CDM,C1894,HCPCS,0272,RC,,,,both,,,254.34,165.32,,,,,,,,,,,,,
APPLIER CLP XL 10 MMX34 CM MANUAL LOAD HEM-O-LOK ENDO10,SUP-2656816,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3595.30,2336.94,,,,,,,,,,,,,
TUBE TYMPANOSTOMY DIA1.14 MM INNR FLANGE DIA1.58 MM FLROPLAS,SUP-2901961,CDM,L8699,HCPCS,0278,RC,,,,both,,,66.47,43.21,,,,,,,,,,,,,
PLATE BONE THK0.8MM 12 H LCK COMPR BILAT NEUT MALL OFFSET,SUP-2107081,CDM,C1713,HCPCS,0278,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
SLEEVE DRL DIA27MM SGL END DISPOSABLE,SUP-2193799,CDM,2720000010,LOCAL,0272,RC,,,,both,,,480.99,312.64,,,,,,,,,,,,,
SHEARS LAPSCP L34CM DIA10MM PSTL GRP UCIS REPROC HARM,SUP-2257661,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1073.16,697.55,,,,,,,,,,,,,
PLATE BONE 6 H TI BROAD HYBRID COMPR FOR 4.5MM SCR ALPS,SUP-2413750,CDM,C1713,HCPCS,0278,RC,,,,both,,,1080.73,702.47,,,,,,,,,,,,,
APPLIER CLP L33MM DIA5MM 20 M/L TI CLP ENDO MULT ROT LIGACLP,SUP-2257549,CDM,2720000010,LOCAL,0272,RC,,,,both,,,405.78,263.76,,,,,,,,,,,,,
GRAFT VASC IMPRA L 35 CM DIA 6 MM EPTFE STR STD WALL N RING,SUP-2761265,CDM,C1768,CPT,0278,RC,,,,both,,,1384.43,899.88,,,,,,,,,,,,,
HC Special Doses Verification,PX-3337733100,CDM,77331,CPT,0333,RC,,,,outpatient,,,672.00,436.80,,,,,,,,,,,,,
PLATE 3.5MM TI LCP PERIARTIC PROX HUM 4H 127MM RT STRL,SUP-2546843,CDM,C1713,HCPCS,0278,RC,,,,both,,,5767.43,3748.83,,,,,,,,,,,,,
SET DRL PIN AND GRFT PASS WIRE TRANSFIX II,SUP-2121629,CDM,2720000010,LOCAL,0272,RC,,,,both,,,477.28,310.23,,,,,,,,,,,,,
TARLATAMAB-DLLE 1 MG IV SOLR,RX-167968,CDM,J9026,HCPCS,0636,RC,55513-0059-01,NDC,,both,1,UN,4320.00,2808.00,,,,,,,,,,,,,
CATHETER CRICO CUF SPEC OP MELK EMER,SUP-2169662,CDM,C1769,HCPCS,0272,RC,,,,both,,,1121.61,729.05,,,,,,,,,,,,,
KNIFE OPHTHLMC 45DG 4.5NL 1MMW 0.2MM THK DMND ANGLD SNGLE ED,SUP-2467717,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2238.98,1455.34,,,,,,,,,,,,,
HC So Antidepressant Tricyclic 1/2,PX-3018033566,CDM,G0480,CPT,0301,RC,,,,outpatient,,,380.00,247.00,,,,,,,,,,,,,
CATHETER URET OPN END,SUP-2836005,CDM,C1758,HCPCS,0278,RC,,,,both,,,60.92,39.60,,,,,,,,,,,,,
SMALL RAIL 200MM,SUP-2724393,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3523.08,2290.00,,,,,,,,,,,,,
COMPONENT TIB 0.0X1MM OFFSET UNICAP,SUP-2123709,CDM,C1776,CPT,0278,RC,,,,both,,,2053.56,1334.81,,,,,,,,,,,,,
SCREW 16MM 22MM LAG PLT,SUP-2243267,CDM,C1713,HCPCS,0278,RC,,,,both,,,629.44,409.14,,,,,,,,,,,,,
PLATE BNE PROMO 1 LT BABY GORILLA,SUP-2750992,CDM,C1713,HCPCS,0278,RC,,,,both,,,5444.76,3539.09,,,,,,,,,,,,,
HC Inf Agent Det Nucleic Acid Clostridium Amp Probe,PX-3068749300,CDM,87493,CPT,0306,RC,,,,both,,,171.00,111.15,,,,,,,,,,,,,
TUBE NG AD DIA20FR BLLN L8X1.5IN SPEC FOR ES VARICES BLAKMR,SUP-2127130,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1726.09,1121.96,,,,,,,,,,,,,
FORCEP RETRV ALLIGATOR 5.2 FRX65 CM TOOTH SINGLE JAW,SUP-2835705,CDM,2720000010,LOCAL,0272,RC,,,,both,,,969.04,629.88,,,,,,,,,,,,,
INSERT TIB SZ 5 THK9MM CRUCE RET BAL SYS,SUP-2314817,CDM,C1713,HCPCS,0278,RC,,,,both,,,3316.78,2155.91,,,,,,,,,,,,,
SUPPORT ORTHOT WRST HND CUST TURNBUCKLE W/NONTORSION JT,SUP-2435777,CDM,L3916,HCPCS,0274,RC,,,,both,,,1369.64,890.27,,,,,,,,,,,,,
STENT PERIPH EXPRESS SD MR L 19 MM DIA 5 MM CATH L 150 CM,SUP-2142391,CDM,C1876,HCPCS,0278,RC,,,,both,,,3846.50,2500.22,,,,,,,,,,,,,
PLATE BONE THK1.5MM 2X2 H CRANIOMAXILLOFACIAL ORAL SLV TI,SUP-2181771,CDM,C1713,HCPCS,0278,RC,,,,both,,,2371.64,1541.57,,,,,,,,,,,,,
GRAFT BNE SUB 3ML VOID FILL RESRB PTTY MASTERGRFT,SUP-2288541,CDM,C9359,HCPCS,0278,RC,,,,both,,,1268.56,824.56,,,,,,,,,,,,,
CUP 1 PC ACET POR CO CHROM PRESSFIT FLR RIM POR PLSM SPRY,SUP-2136394,CDM,C1776,CPT,0278,RC,,,,both,,,19793.62,12865.85,,,,,,,,,,,,,
PUMP CTRL URETH INHIBZN FOR AMS 800 SYS,SUP-2138948,CDM,C1815,HCPCS,0278,RC,,,,both,,,22155.84,14401.30,,,,,,,,,,,,,
SHEETING IMPL 0.03X6X8IN REINF SIL SILAS,SUP-2134689,CDM,C1763,HCPCS,0278,RC,,,,both,,,546.36,355.13,,,,,,,,,,,,,
HC Cisternal or Lat Cervical Punc,PX-3616105500,CDM,61055,CPT,0361,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
ROD SPNL TI OD45 MM X L200 MM SAG,SUP-2279805,CDM,C1713,HCPCS,0278,RC,,,,both,,,2945.32,1914.46,,,,,,,,,,,,,
PLATE BONE L249MM THK6MM 11 H RT FEM CNDYL TI BTTRS RIG CLLR,SUP-2190900,CDM,C1713,HCPCS,0278,RC,,,,both,,,3681.21,2392.79,,,,,,,,,,,,,
SPACER SPNL 37X12X6 MM MIDLN VBR,SUP-2320300,CDM,C1889,HCPCS,0278,RC,,,,both,,,25151.40,16348.41,,,,,,,,,,,,,
GUIDEWIRE ORTH THRD TC SER TI6 FOR 2.0/2.5,SUP-2609665,CDM,C1769,HCPCS,0272,RC,,,,both,,,25.34,16.47,,,,,,,,,,,,,
IMMOBILIZER SLNG LOOP CLOSURE UNIV UNISX SHLDR PROCARE,SUP-2196933,CDM,L3660,HCPCS,0274,RC,,,,both,,,21.26,13.82,,,,,,,,,,,,,
SCREW SPNL L14MM S STL ST THRD UNIV BULL SHP HD DISTR PIN,SUP-2274177,CDM,C1713,HCPCS,0278,RC,,,,both,,,68.83,44.74,,,,,,,,,,,,,
KIT TUNNELED CTRL VEN CATH DBL LUMN 10.1 FRX74 CM L,SUP-2332925,CDM,C1751,HCPCS,0278,RC,,,,both,,,486.70,316.35,,,,,,,,,,,,,
"HC Non-Auto,Urine W/O Microscopy",PX-3078100200,CDM,81002,CPT,0307,RC,,,,both,,,14.00,9.10,,,,,,,,,,,,,
LINER ACET W/ VIT E TRABECULAR MTL,SUP-2212340,CDM,C1776,CPT,0278,RC,,,,both,,,7944.20,5163.73,,,,,,,,,,,,,
PLATE BNE THK 1.4 MM SCREW DIA2.2 MM 2 X 21 H PLL,SUP-2883320,CDM,C1713,HCPCS,0278,RC,,,,both,,,16061.10,10439.71,,,,,,,,,,,,,
SPACER JT CARPOMETACARPAL SPHR INTERPOSITI,SUP-2399054,CDM,C1776,CPT,0278,RC,,,,both,,,7787.20,5061.68,,,,,,,,,,,,,
GRAFT BONE PUTTY DEMINERLIZED BONE MTRX 1CC ALLOFUSE,SUP-2113944,CDM,C9359,HCPCS,0278,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
LINER ACET OD52MM ID28MM 0DEG MARATHON HIP REV NEUT DURALOC,SUP-2250497,CDM,C1776,CPT,0278,RC,,,,both,,,3887.32,2526.76,,,,,,,,,,,,,
SPACER TIB SM L8MM DURAMER SL GRDIAN,SUP-2304388,CDM,C1713,HCPCS,0278,RC,,,,both,,,4144.80,2694.12,,,,,,,,,,,,,
SCREW BONE STD 22MM ACUTRK 2,SUP-2107282,CDM,C1713,HCPCS,0278,RC,,,,both,,,1438.12,934.78,,,,,,,,,,,,,
STAPLE POD CLOVER 4 LEG 12.5 MMX16 MMX18 MM,SUP-2137800,CDM,2780000010,LOCAL,0278,RC,,,,both,,,6908.00,4490.20,,,,,,,,,,,,,
GUIDEWIRE VASC 1.5 MM 0.014 INX300 CM STD,SUP-2280904,CDM,C1769,HCPCS,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
GRAFT VASC HEMSHLD GLD L 15 CM DIA16 MM POLYESTER BOV CLLGN,SUP-2266033,CDM,C1768,CPT,0278,RC,,,,both,,,1286.24,836.06,,,,,,,,,,,,,
TUBE VENT SHEEHY 1.27 MM 1.3 MM 2.75 MM CLLR BUTTON SIL,SUP-2459529,CDM,L8699,HCPCS,0278,RC,,,,both,,,28.20,18.33,,,,,,,,,,,,,
PLATE BNE L250MM HIP TI 7 CBL FOR ACCORD SYS,SUP-2345380,CDM,C1713,HCPCS,0278,RC,,,,both,,,2983.00,1938.95,,,,,,,,,,,,,
ACETIC ACID 5 % SOLN,RX-14702,CDM,6370000000,HCPCS,0637,RC,51552-0055-03,NDC,,both,250,ML,194.10,126.16,,,,,,,,,,,,,
PLATE BNE L 135 MM SCREW DIA 4.5 MM 8 H COMPR LCK NS EVOS,SUP-2932914,CDM,C1713,HCPCS,0278,RC,,,,both,,,2987.71,1942.01,,,,,,,,,,,,,
SPACER SPNL W18XH7-14XL40MM 3-15DEG LAT LUM INTBDY FUS TI,SUP-2420848,CDM,C1889,HCPCS,0278,RC,,,,both,,,19468.00,12654.20,,,,,,,,,,,,,
INJECTOR BNE GRFT SUB 5CC PELLET 4.8MM PRELD PRECIS EFFICIENT,SUP-2399142,CDM,C1713,HCPCS,0278,RC,,,,both,,,1774.67,1153.54,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY HEXAPOLAR FIX LUMINAL STRL,SUP-2729636,CDM,C1730,HCPCS,0272,RC,,,,both,,,1105.28,718.43,,,,,,,,,,,,,
BIT DRL LNG 13 GAX23.6 CM PRESTON,SUP-2464779,CDM,2720000010,LOCAL,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
PIN DISTR L14MM SELF DRL CASPR,SUP-2108436,CDM,C1713,HCPCS,0278,RC,,,,both,,,331.46,215.45,,,,,,,,,,,,,
WIRE FIX SMOOTH 1.4X100 MM KIRSCHNER VARIAX,SUP-2362640,CDM,C1713,HCPCS,0278,RC,,,,both,,,70.65,45.92,,,,,,,,,,,,,
BLADE ENDO STD CRPL TUNN REL DISP SMARTREL,SUP-2304074,CDM,2720000010,LOCAL,0272,RC,,,,both,,,737.90,479.63,,,,,,,,,,,,,
SCREW CANN VA LCK OPTILINK  5.0X30MM,SUP-2657208,CDM,C1713,HCPCS,0278,RC,,,,both,,,771.97,501.78,,,,,,,,,,,,,
CATHETER ANGIOPLSTY L105CM BAL L20MM DIA2MM 14ATM BURST RATE,SUP-2101442,CDM,C1725,HCPCS,0272,RC,,,,both,,,690.80,449.02,,,,,,,,,,,,,
SUPPORT ORTHOT KNEE DISC OR DIAL LCK FOR ADJ KNEE FLX,SUP-2435669,CDM,L2425,HCPCS,0274,RC,,,,both,,,405.85,263.80,,,,,,,,,,,,,
BUR SURG L14CM HD L36MM DIA25MM MTCH HD TELSCP MIDAS REX,SUP-2281645,CDM,2720000010,LOCAL,0272,RC,,,,both,,,370.65,240.92,,,,,,,,,,,,,
HC Ophthalmic US Dx B-Scan,PX-4027651200,CDM,76512,CPT,0402,RC,,,,both,,,750.00,487.50,,,,,,,,,,,,,
GRAFT BNE SUB W10XL15MM TRICORT ILIUM CREST BLK FRZ DRY,SUP-2293824,CDM,C1713,HCPCS,0278,RC,,,,both,,,788.14,512.29,,,,,,,,,,,,,
TUBE TRACH DIA7MM PVC SPRL REINF CUF TRACHFLX,SUP-2384498,CDM,C1713,HCPCS,0278,RC,,,,both,,,433.32,281.66,,,,,,,,,,,,,
PIN FIX L40MM OD2MM LACTOSORB COPOLYMER ABSRB SGL USE,SUP-2212968,CDM,C1713,HCPCS,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
SUPPORT ORTHOT KNEE DISC OR DIAL LCK FOR ADJ KNEE FLX,SUP-2435669,CDM,L2425,HCPCS,0272,RC,,,,both,,,405.85,263.80,,,,,,,,,,,,,
CATHETER PICC KT SAFT MST SGL LUMN 6FR RVS TAPR DIA 15.5GA,SUP-2118955,CDM,C1751,HCPCS,0278,RC,,,,both,,,414.48,269.41,,,,,,,,,,,,,
GRAFT HUMAN TSSUE MTRX 48SQCM THIN SM 4CMW X 12CML 023 051,SUP-2675763,CDM,Q4116,HCPCS,0636,RC,,,,both,,,4841.88,3147.22,,,,,,,,,,,,,
ABRASOR DIAMOND COARSE 320MM X 3.5MM X 3.4MM BALL TIP JOIMAX,SUP-2848826,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1500.92,975.60,,,,,,,,,,,,,
GRASPER LAP SHFT DIA24MM WHT STL W MINIGRIP HNDL REUSE,SUP-2384376,CDM,C1713,HCPCS,0278,RC,,,,both,,,753.07,489.50,,,,,,,,,,,,,
SPLINT ORTH AD L24IN FOR 29IN THGH UNIV KNEE FOAM,SUP-2196749,CDM,L1830,CPT,0272,RC,,,,both,,,47.19,30.67,,,,,,,,,,,,,
BIT DRILL 1.8 MM WITH STRYKER JLATCH FOR BASIC TROCAR SYSTEM,SUP-2838103,CDM,2720000010,LOCAL,0272,RC,,,,both,,,639.62,415.75,,,,,,,,,,,,,
ALLOGRAFT BNE DWL 14X30-35 MM PRESERVON X LNG REV FLEXIGRAFT,SUP-2740908,CDM,C1713,HCPCS,0278,RC,,,,both,,,3711.26,2412.32,,,,,,,,,,,,,
PLATE BNE 4X5 H R CRANIOMAXILLOFACIAL TI L SHP FOR 1MM SCR,SUP-2190607,CDM,C1713,HCPCS,0278,RC,,,,both,,,1002.29,651.49,,,,,,,,,,,,,
SULFACETAMIDE-PREDNISOLONE 10-0.23 % OP SOLN,RX-70392,CDM,6370000000,HCPCS,0637,RC,24208-0317-05,NDC,,both,5,ML,67.50,43.87,,,,,,,,,,,,,
STEM FEM 41MM SZ 1 HIP TARA POR HD,SUP-2255794,CDM,C1776,CPT,0278,RC,,,,both,,,1246.58,810.28,,,,,,,,,,,,,
SET SHTH DESTINO TWST L 45 CM 7 FR CRV BEND 9 MM STD UNIDIR,SUP-2604661,CDM,C1887,HCPCS,0272,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
MATRIX 1.4MM BIT DRILL W/12MM,SUP-2823233,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1324.61,861.00,,,,,,,,,,,,,
GRAFT BIO TISS W4XL4CM FET BOV ANTIMIC DERM REP SCAFFOLD,SUP-2243703,CDM,Q4110,HCPCS,0636,RC,,,,both,,,2260.80,1469.52,,,,,,,,,,,,,
CONNECTOR TBNG DISMANTLING W/ STPCOCK LUERLOCK,SUP-2261235,CDM,2720000010,LOCAL,0272,RC,,,,both,,,445.00,289.25,,,,,,,,,,,,,
CATHETER IAB 0.025 IN 8 FRX26 IN 6 IN 50 CC INTRO STOPCOCK,SUP-2877609,CDM,C1894,HCPCS,0272,RC,,,,both,,,3579.60,2326.74,,,,,,,,,,,,,
COMPONENT FEM 1 LT CONSTRN CNDYL,SUP-2220849,CDM,C1776,CPT,0278,RC,,,,both,,,16466.16,10703.00,,,,,,,,,,,,,
ELECTRODE ELECSURG NDL 16.5 GA 0.9X18 CM RF SOLOIST LEVEEN,SUP-2149346,CDM,C1713,HCPCS,0278,RC,,,,both,,,3501.10,2275.71,,,,,,,,,,,,,
ANCHOR SUT L19.1MM DIA5.5MM BIOCOMPOSITE FULL THRD KNOTLESS,SUP-2121683,CDM,C1713,HCPCS,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
PLATE BLADE ANGL 130 DEG 12H /70MM/200MM STRL,SUP-2547492,CDM,C1713,HCPCS,0278,RC,,,,both,,,3494.22,2271.24,,,,,,,,,,,,,
APPLICATOR ELECSURG STR 6X65 MM W/ SUCTION DISP,SUP-2734131,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1975.06,1283.79,,,,,,,,,,,,,
MESH HERN L37XW28MM COMP FOR LAP OPN VENTRAL REP SYMBOTEX,SUP-2283404,CDM,C1781,HCPCS,0278,RC,,,,both,,,8666.97,5633.53,,,,,,,,,,,,,
COMPONENT TIB CR 00 16 MM LT KNEE PRIMARY STEM CEM NP CONG,SUP-2210053,CDM,C1776,CPT,0278,RC,,,,both,,,4143.23,2693.10,,,,,,,,,,,,,
PLATE SPNL CERV 57.5 MM ANTR TI ZEPHIR,SUP-2280050,CDM,C1713,HCPCS,0278,RC,,,,both,,,3798.71,2469.16,,,,,,,,,,,,,
HANDLE LITHO EMGCY STRL LTX DISP,SUP-2865623,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1416.93,921.00,,,,,,,,,,,,,
CATHETER ANGIOPLSTY POLARCATH L 135 CM BALLOON L 120 MM DIA,SUP-2141988,CDM,C1725,HCPCS,0272,RC,,,,both,,,3174.54,2063.45,,,,,,,,,,,,,
ANCHOR SUT SZ 2 PNCRYL WHT ROT CUF BIOKNOTLESS RC,SUP-2256605,CDM,C1713,HCPCS,0278,RC,,,,both,,,907.46,589.85,,,,,,,,,,,,,
KIT 5FR 3 LUMN PWR PICC HF HI FLOW W 70CM NITENOL GWIRE,SUP-2125553,CDM,C1751,HCPCS,0278,RC,,,,both,,,462.33,300.51,,,,,,,,,,,,,
COLLAR CERV 3 1/4X10-12IN SM TRACH OPN ADJ PHIL,SUP-2195259,CDM,L0120,HCPCS,0274,RC,,,,both,,,39.56,25.71,,,,,,,,,,,,,
GRAFT STENT 16 FR AAA,SUP-2395965,CDM,C1768,CPT,0278,RC,,,,both,,,11275.74,7329.23,,,,,,,,,,,,,
POTASSIUM CHLORIDE 2 MEQ/ML IV SOLN,RX-6429,CDM,J3480,HCPCS,0636,RC,63323-0965-05,NDC,,both,5,ML,54.10,35.16,,,,,,,,,,,,,
BIT DRL OD37MM COUNTSINK,SUP-2417209,CDM,2720000010,LOCAL,0272,RC,,,,both,,,700.22,455.14,,,,,,,,,,,,,
BLADE SHAVER 4.2 MM STLTH FRR,SUP-2765851,CDM,2720000010,LOCAL,0272,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
CATHETER ETER CTRL VEN L16CM OD5FR 032IN GWIRE KT SGL LUMN N,SUP-2383267,CDM,C1751,HCPCS,0278,RC,,,,both,,,50.18,32.62,,,,,,,,,,,,,
CATHETER NEPHSTMY 7FR L55CM HI PRSS BLLN 30FR L12CM SHTH,SUP-2138878,CDM,C1726,HCPCS,0272,RC,,,,both,,,842.24,547.46,,,,,,,,,,,,,
IMPLANT FRESH CORNEA LEFT,SUP-2855178,CDM,V2785,HCPCS,0810,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
TIP ASPIR CLAW MIC 1.6X2 MM 12 CM FOR BNE CUT SONOPET IQ,SUP-2791055,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3288.62,2137.60,,,,,,,,,,,,,
DEVICE CRAN FIX XL ST CRAN LOOP FIX SYS,SUP-2263029,CDM,C1713,HCPCS,0278,RC,,,,both,,,482.93,313.90,,,,,,,,,,,,,
SCREW BONE L11MM THRD DIA2.4MM HD DIA3.8MM COR DIA1.6MM,SUP-2349258,CDM,C1713,HCPCS,0278,RC,,,,both,,,204.67,133.04,,,,,,,,,,,,,
GUN BNE CEM DEL SZ 2 W/ BNE FILL DEV FOR KYPHOPAK TY KYPHON,SUP-2293482,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
BIT DRL PROF FOR 4.7MM SCR ACUTRK 2,SUP-2107152,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1108.42,720.47,,,,,,,,,,,,,
PROBE APC DIAM 2.3MM 7FR LEN 9FT10IN 300CM,SUP-2217942,CDM,C1713,HCPCS,0278,RC,,,,both,,,723.77,470.45,,,,,,,,,,,,,
NERVE STIMULATOR KIT N RECHRG FULL IMPL PKG,SUP-2857914,CDM,C1767,HCPCS,0278,RC,,,,both,,,48575.80,31574.27,,,,,,,,,,,,,
COMP SHRT ST/RGX GLD/STD HD,SUP-2212465,CDM,C1776,CPT,0278,RC,,,,both,,,18840.00,12246.00,,,,,,,,,,,,,
KIT INFUS PRT 8FR ATTCH GROSH CATH SIL PLAS INJ SGL LUMN,SUP-2420320,CDM,C1788,HCPCS,0278,RC,,,,both,,,879.20,571.48,,,,,,,,,,,,,
BLADE RTRCTR 18MMW X 7NL SLGHTLY CRVD RGGLS RDMND,SUP-2460247,CDM,2720000010,LOCAL,0272,RC,,,,both,,,485.32,315.46,,,,,,,,,,,,,
DRAIN SURG SGL COLL PT TB FOR ATS BG OASIS,SUP-2227402,CDM,C1729,HCPCS,0272,RC,,,,both,,,144.31,93.80,,,,,,,,,,,,,
CATHETER INFUSION L 145 CM DIA 6 FR STRL,SUP-2383131,CDM,C1887,HCPCS,0272,RC,,,,both,,,342.26,222.47,,,,,,,,,,,,,
STENT URET DBL PGTL 0.035 IN 3 CM 5 FRX24 CM 6 FR POLARIS,SUP-2537711,CDM,C2617,HCPCS,0278,RC,,,,both,,,592.08,384.85,,,,,,,,,,,,,
SCREW BNE MAND 2.3X17 MM SELF RET TI CENTRE-DRIVE,SUP-2463194,CDM,C1713,HCPCS,0278,RC,,,,both,,,203.22,132.09,,,,,,,,,,,,,
HC X-Ray Knee 1-2 Views,PX-3207356000,CDM,73560,CPT,0320,RC,,,,both,,,424.00,275.60,,,,,,,,,,,,,
PLATE BONE L71MM THK3.8MM 4 H BILAT S STL NAR DYN COMPR FOR,SUP-2185203,CDM,C1713,HCPCS,0278,RC,,,,both,,,199.39,129.60,,,,,,,,,,,,,
CATHETER ART SET 035X60 CM 5.8 FRX24 CM NYL BUNEGIN-ALBIN,SUP-2760074,CDM,C1769,HCPCS,0272,RC,,,,both,,,261.44,169.94,,,,,,,,,,,,,
FRAME EXT FIX OD180MM CIR ASSEMB SIDEKCK,SUP-2400709,CDM,C1713,HCPCS,0278,RC,,,,both,,,14701.48,9555.96,,,,,,,,,,,,,
MESH HERN REP DIA15CM P4HB MFIL RESRB RND W HYDRGEL BARR,SUP-2126269,CDM,C1781,HCPCS,0278,RC,,,,both,,,10870.68,7065.94,,,,,,,,,,,,,
PLATE BNE 3.5X92 MM 7 HOLE,SUP-2198757,CDM,C1713,HCPCS,0278,RC,,,,both,,,914.37,594.34,,,,,,,,,,,,,
ALLOGRAFT DERMAL PTCH THCK 2.75-3.25 MM 7X5 CM ACELLULAR,SUP-2321764,CDM,C1713,HCPCS,0278,RC,,,,both,,,8792.00,5714.80,,,,,,,,,,,,,
MATRIX BIO L 7 X W 20 CM FISH SKIN DERMAL STD INTACT STRL,SUP-2909218,CDM,Q4158,HCPCS,0636,RC,,,,both,,,11209.80,7286.37,,,,,,,,,,,,,
HC Rm Private Detoxification,PX-1160000000,CDM,1160000000,CPT,0116,RC,,,,inpatient,,,2441.00,1586.65,,,,,,,,,,,,,
ROD IM POLARUS,SUP-2107701,CDM,C1713,HCPCS,0278,RC,,,,both,,,3318.98,2157.34,,,,,,,,,,,,,
COLLAR CERV CNTOUR LNG NAR 24X2 IN 17-22 IN MED FOAM PROCARE,SUP-2196863,CDM,L0120,HCPCS,0272,RC,,,,both,,,10.71,6.96,,,,,,,,,,,,,
FRACTURE ADAPTER SZ 5,SUP-2817839,CDM,C1776,CPT,0278,RC,,,,both,,,8682.10,5643.36,,,,,,,,,,,,,
LITHOTRIPTER SURG L195CM DIA3.2MM BSKT 30MM BULL TIP ROT,SUP-2312979,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1344.61,874.00,,,,,,,,,,,,,
WAND ABLATN 70 MM PLASMA COBLATOR,SUP-2342040,CDM,2720000010,LOCAL,0272,RC,,,,both,,,643.70,418.40,,,,,,,,,,,,,
COMPONENT KNEE FOR PK 3900 LEG,SUP-2212671,CDM,C1776,CPT,0278,RC,,,,both,,,12246.00,7959.90,,,,,,,,,,,,,
GRAFT ENDOVASC L 18FR L14CM OD23MM ID18.5-21.5MM,SUP-2395960,CDM,C1768,CPT,0278,RC,,,,both,,,12874.00,8368.10,,,,,,,,,,,,,
WIRE FIX L30CM DIA1.2MM BEAD LOOP LUQ,SUP-2410236,CDM,C1713,HCPCS,0278,RC,,,,both,,,116.97,76.03,,,,,,,,,,,,,
HC Aspiration of Bladder W/Ins,PX-3615110200,CDM,51102,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
GRAFT BNE PTTY 5 CC DBM OPTIUM,SUP-2264863,CDM,C1713,HCPCS,0278,RC,,,,both,,,1617.41,1051.32,,,,,,,,,,,,,
IMPLANT OPHTH GLAUCOMA 32X350 MM EYE SMOOTH SIL BAERVELDT,SUP-2102257,CDM,L8610,HCPCS,0278,RC,,,,both,,,2766.34,1798.12,,,,,,,,,,,,,
EXTRACTOR SURG EASYOUT 3 MM QR ACUTRK,SUP-2857693,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1259.14,818.44,,,,,,,,,,,,,
SCREW BONE L11MM DIA2MM SNAP OFF SELF COMPRESSIVE TWST OFF,SUP-2224032,CDM,C1713,HCPCS,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
COLLAR CERV CNTOUR LNG NAR 24X2 IN 17-22 IN MED FOAM PROCARE,SUP-2196863,CDM,L0120,HCPCS,0274,RC,,,,both,,,10.71,6.96,,,,,,,,,,,,,
SYSTEM THERMOABLATION 28GA THRMCPL 20GA L180MM CANN,SUP-2293678,CDM,C1894,HCPCS,0272,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
KNIFE SURG W3MM SWVL STR BLDE REUSE S STL BALLENGER,SUP-2161598,CDM,C1713,HCPCS,0278,RC,,,,both,,,327.72,213.02,,,,,,,,,,,,,
GRAFT BONE SPCR LORDTC FRZ DRY CORT 7DEG L 11MMXW 14MMXH 5MM,SUP-2294196,CDM,C1713,HCPCS,0278,RC,,,,both,,,2706.68,1759.34,,,,,,,,,,,,,
SPHERE EMB LC BEAD PARTIC SZ 100-300 UM 2 ML SULPHONATE YEL,SUP-2135325,CDM,C1889,HCPCS,0278,RC,,,,both,,,6264.30,4071.79,,,,,,,,,,,,,
PIN GUIDE OMEGA TAP 45MM,SUP-2701917,CDM,C1713,HCPCS,0278,RC,,,,both,,,1045.62,679.65,,,,,,,,,,,,,
HOLDER NDL L55IN JAW L9MM S STL TUNGSTEN CARB G SATIN FINISH,SUP-2161165,CDM,2720000010,LOCAL,0272,RC,,,,both,,,746.19,485.02,,,,,,,,,,,,,
CATHETER HD MAXIMAL BARR TY 035 12 FRX25 CM DL TURBO-FLO HD,SUP-2759843,CDM,C1752,HCPCS,0278,RC,,,,both,,,509.81,331.38,,,,,,,,,,,,,
SEGMENT FEM OD21MM 5DEGXSM TRAPEZOIDAL FLARE COMP SCR FORGED,SUP-2222170,CDM,C1713,HCPCS,0278,RC,,,,both,,,6004.94,3903.21,,,,,,,,,,,,,
SCREWDRIVER BLADE 2/2.3X94 MM CROSS DRV TERM SS STRL,SUP-2466553,CDM,2720000010,LOCAL,0272,RC,,,,both,,,331.71,215.61,,,,,,,,,,,,,
SYSTEM CPAP PORTABLE MACH LIGHTWEIGHT Z1,SUP-2240643,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1190.06,773.54,,,,,,,,,,,,,
SCREW BNE L20MM DIA2MM CORT S STL ST LOK FULL THRD T6,SUP-2183213,CDM,C1713,HCPCS,0278,RC,,,,both,,,127.30,82.74,,,,,,,,,,,,,
SUTURE ANCHR SUTFIX CVD 1.9MM W/ TWO 1-0 ULTRABRAID SUT BLU,SUP-2341935,CDM,C1713,HCPCS,0278,RC,,,,both,,,1404.68,913.04,,,,,,,,,,,,,
BLADE SURG 50MM ACET REV SYS EZOUT,SUP-2365135,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
SEGMENT FEM COMP L SZ 3 W75XH50MM LT DSTL TILASTAN,SUP-2265084,CDM,C1776,CPT,0278,RC,,,,both,,,4791.64,3114.57,,,,,,,,,,,,,
PLATE BNE W3.6MM W/ 5 L12MM DIA2.5MM AND 4 L14MM DIA2.5MM,SUP-2389092,CDM,C1713,HCPCS,0278,RC,,,,both,,,12230.30,7949.69,,,,,,,,,,,,,
REAMER SURG 2.2X83 MM STRL CROSSTIE,SUP-2175005,CDM,2720000010,LOCAL,0272,RC,,,,both,,,777.15,505.15,,,,,,,,,,,,,
MATRIX HUM TISS L 5 X W 9 CM THK 0.2-1 MM ACELLULAR DERMAL,SUP-2909256,CDM,Q4122,HCPCS,0636,RC,,,,both,,,9877.81,6420.58,,,,,,,,,,,,,
ST APG SYNV RASP SM +5 LINV,SUP-2514072,CDM,2720000010,LOCAL,0272,RC,,,,both,,,723.46,470.25,,,,,,,,,,,,,
APPLIER CLIP 90/225MM DOUBLE BAYONET STANDARD PHYNOX,SUP-2826144,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7748.04,5036.23,,,,,,,,,,,,,
NUT EXT FIX DIA10MM FLNG FOR SALVATION EXT FIX,SUP-2401145,CDM,2720000010,LOCAL,0272,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
HC So Prothrombin Time|NOT REASONABLE AND NECESSARY,PX-3058561066,CDM,85610,CPT,0305,RC,,,GZ,both,,,36.00,23.40,,,,,,,,,,,,,
GRAFT VASC ARTEGRAFT L 40 CM DIA 7 MM CLLGN BOV CAR ART,SUP-2120672,CDM,C1768,CPT,0278,RC,,,,both,,,7815.46,5080.05,,,,,,,,,,,,,
SET SCR SPNL M6 CONN MAS RECON SYS VERTEX,SUP-2289105,CDM,C1713,HCPCS,0278,RC,,,,both,,,404.12,262.68,,,,,,,,,,,,,
PLATE BNE L246MM THK3.7MM 14 H NONSTERILE R DST MED TIB S,SUP-2185536,CDM,C1713,HCPCS,0278,RC,,,,both,,,3954.64,2570.52,,,,,,,,,,,,,
GUIDEWIRE ORTH L230MM DIA28MM SMOOTH FOR 65MM SCR,SUP-2319464,CDM,C1769,HCPCS,0272,RC,,,,both,,,106.76,69.39,,,,,,,,,,,,,
BIT DRL FISH TAIL UNIV 30 MM SOLITAIRE,SUP-2685254,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1792.94,1165.41,,,,,,,,,,,,,
LINER ACET OD74MM ID32MM +4MM OFFSET HIP GVF POLYETH TI NEUT,SUP-2250260,CDM,C1776,CPT,0278,RC,,,,both,,,10294.18,6691.22,,,,,,,,,,,,,
CONTROLLER PT IPGS EON EON C EON MINI PROTEGE PROTEGE MRI,SUP-2355982,CDM,C1787,HCPCS,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
SCREW BONE L7MM DIA1MM CORT CRANIOMAXILLOFACIAL TI ST FULL,SUP-2189038,CDM,C1713,HCPCS,0278,RC,,,,both,,,1420.85,923.55,,,,,,,,,,,,,
BUR SURG COARSE DIAMOND 4 MM 94 MM RND CRV HI SPD SS VISAO,SUP-2628980,CDM,2720000010,LOCAL,0272,RC,,,,both,,,765.06,497.29,,,,,,,,,,,,,
VALVE HYDROCEPHALUS 20 PED W/ SHUNT ASST AND BUR H RESVR,SUP-2108749,CDM,C1729,HCPCS,0272,RC,,,,both,,,8990.95,5844.12,,,,,,,,,,,,,
BIT DRL L310MM DIA15MM CANN FLX FOR EXPERT LAT FEM NAILING,SUP-2178893,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2005.68,1303.69,,,,,,,,,,,,,
IMPLANT HUM TISS RT MEDL MENIS BNE BLOCK GLD STD,SUP-2881311,CDM,C1762,CPT,0278,RC,,,,both,,,15700.00,10205.00,,,,,,,,,,,,,
INSERT TIB SZ 3 THK9.5MM RT MEDL LT LAT KNEE FIX BEAR,SUP-2251272,CDM,C1776,CPT,0278,RC,,,,both,,,2361.28,1534.83,,,,,,,,,,,,,
SUPPORT ORTHOT ANK KNEE THGH CALF CUST SINGLE FREE STIRRUP,SUP-2435631,CDM,L2000,HCPCS,0272,RC,,,,both,,,3167.13,2058.63,,,,,,,,,,,,,
CANNULA RF 20 GAUGEX100MM 10MM,SUP-2236629,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1139.82,740.88,,,,,,,,,,,,,
BIT DRL L45MM MOD FLEX DISP FOR ACET CUP SCR,SUP-2204019,CDM,2720000010,LOCAL,0272,RC,,,,both,,,570.22,370.64,,,,,,,,,,,,,
KNIFE SURG OPHTH 45 DEG 3.5 MM CORNEA ANGLED DBL BVL,SUP-2133070,CDM,2720000010,LOCAL,0272,RC,,,,both,,,52.81,34.33,,,,,,,,,,,,,
NAIL IM L360MM DIA10MM FEM TIB KNEE G TI CANN LOK AG RG,SUP-2347086,CDM,C1713,HCPCS,0278,RC,,,,both,,,2963.66,1926.38,,,,,,,,,,,,,
SCREW BONE L12MM DIA2.8MM TI FIX CORT CANN FULL THRD ST,SUP-2107372,CDM,C1713,HCPCS,0278,RC,,,,both,,,1271.70,826.60,,,,,,,,,,,,,
BOLT EXT FIX CANN RNG MT FOR SCHNZ SCREW MR SAFE NS,SUP-2179135,CDM,2720000010,LOCAL,0272,RC,,,,both,,,660.09,429.06,,,,,,,,,,,,,
PLATE BNE 5 HOLE 90 DEG 1.2 MM,SUP-2491853,CDM,C1713,HCPCS,0278,RC,,,,both,,,920.81,598.53,,,,,,,,,,,,,
HC Thoracic Myelogram S&I,PX-3207225500,CDM,72255,CPT,0320,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
PASSER SUTURE SHRP TIP 60 DEG ARTHSCP UP RVS TIP SPEEDSNARE,SUP-2745451,CDM,2720000010,LOCAL,0272,RC,,,,both,,,957.70,622.50,,,,,,,,,,,,,
BLADE SCREWDRIVER 27MM DIA QUICK COUPLING CENTRE DRIVE,SUP-2694415,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1496.27,972.58,,,,,,,,,,,,,
GUIDE DRILL 4.5MM 90 DEG CANN LC-ANGLED BLADE PLATE,SUP-2548631,CDM,C1713,HCPCS,0278,RC,,,,both,,,3289.12,2137.93,,,,,,,,,,,,,
CATHETER PD COILED INF 42 CM 4.5 CM CLASSIC 1 CUF,SUP-2469784,CDM,C1750,HCPCS,0278,RC,,,,both,,,687.66,446.98,,,,,,,,,,,,,
HC So Assay of Protein Other,PX-3018415766,CDM,84157,CPT,0301,RC,,,,inpatient,,,40.00,26.00,,,,,,,,,,,,,
SUPPORT ORTHOT THOR LUMBAR SACR CUST SAG CTRL SFT ANTR APRON,SUP-2435541,CDM,L0466,HCPCS,0274,RC,,,,both,,,1074.16,698.20,,,,,,,,,,,,,
ADAPTER PACE LD OSCOR L 10 CM SIL INSUL UPLR IS 1 CONN,SUP-2356430,CDM,C1883,HCPCS,0278,RC,,,,both,,,1491.50,969.47,,,,,,,,,,,,,
PLATE BONE RECONSTRUCTION LARGE 2 MM DOUBLE ANGLE TITANIUM M,SUP-2837758,CDM,C1713,HCPCS,0278,RC,,,,both,,,9365.68,6087.69,,,,,,,,,,,,,
BUPIVACAINE-MELOXICAM ER 200-6 MG/7ML IJ SOLN,RX-154730,CDM,J0668,HCPCS,0636,RC,47426-0503-01,NDC,,both,7,ML,912.60,593.19,,,,,,,,,,,,,
PLATE BONE TUBULAR 26 MM 2 HOLE 1/3 STERILE PERILOC,SUP-2837388,CDM,C1713,HCPCS,0278,RC,,,,both,,,490.37,318.74,,,,,,,,,,,,,
SCREW BNE L36MM DIA3MM PROSTEP MICA,SUP-2398119,CDM,C1713,HCPCS,0278,RC,,,,both,,,1748.98,1136.84,,,,,,,,,,,,,
DRILL SURGICAL DIA2.5MM CALIBRATED PILOT,SUP-2878398,CDM,2720000010,LOCAL,0272,RC,,,,both,,,675.10,438.81,,,,,,,,,,,,,
GRAFT BONE 5MM-20MM RANG 45ML L VOL TISS FRZN CORT CANC,SUP-2307409,CDM,C1713,HCPCS,0278,RC,,,,both,,,3812.34,2478.02,,,,,,,,,,,,,
PLATE BNE STR 27X0.35 MM NEURO 6 HOLE W/ TAB TI NS LEVEL 1,SUP-2499461,CDM,C1713,HCPCS,0278,RC,,,,both,,,706.31,459.10,,,,,,,,,,,,,
PLATE BNE L170MM THK3MM 9 H BILAT S STL STR LOK COMPR RECON,SUP-2185341,CDM,C1713,HCPCS,0278,RC,,,,both,,,1633.87,1062.02,,,,,,,,,,,,,
SHUNT VLV PRECHAMBER 4X9X14 CM 19 CM H2O 1 CONN PAEDIGAV,SUP-2846926,CDM,C1889,HCPCS,0278,RC,,,,both,,,6315.83,4105.29,,,,,,,,,,,,,
VALVE MITRL DIA31MM STD TI MECH FLEX SEW CUF STIFFENING RNG,SUP-2352679,CDM,C1889,HCPCS,0278,RC,,,,both,,,14990.36,9743.73,,,,,,,,,,,,,
SHUNT CSF L10CM PROSA,SUP-2825718,CDM,C1889,HCPCS,0278,RC,,,,both,,,12055.97,7836.38,,,,,,,,,,,,,
ALLOGRAFT BNE CROSS SECT 10 MM CALCANEUS MATRIGRAFT,SUP-2741036,CDM,C1713,HCPCS,0278,RC,,,,both,,,1847.20,1200.68,,,,,,,,,,,,,
PLATE BNE L 95 X W 11.2 MM THK 3.5 MM 5 H SS LT PROX RADIAL,SUP-2933168,CDM,C1713,HCPCS,0278,RC,,,,both,,,2735.25,1777.91,,,,,,,,,,,,,
SYSTEM INTRO 7FR L13CM NDL 18GA GWIRE L45CM DIA0.038IN STD,SUP-2302494,CDM,C1894,HCPCS,0272,RC,,,,both,,,85.72,55.72,,,,,,,,,,,,,
STENT URTRL 7FR DIA 16CML TCFLX OPEN WPSH CATH LTHSTNT ST S,SUP-2721364,CDM,C2617,HCPCS,0278,RC,,,,both,,,290.20,188.63,,,,,,,,,,,,,
HC Clsd Tx Shoulder Dislc W/Manipulation Req Anes,PX-4502365500,CDM,23655,CPT,0450,RC,,,,both,,,1633.00,1061.45,,,,,,,,,,,,,
PLATE BNE L220MM 9 H L PROX TIB TI NONCOMPRESSION FOR 4.5MM,SUP-2190735,CDM,C1713,HCPCS,0278,RC,,,,both,,,4065.64,2642.67,,,,,,,,,,,,,
HC So1 Complement C-3/C-4,PX-3028616067,CDM,86160,CPT,0302,RC,,,,outpatient,,,315.00,204.75,,,,,,,,,,,,,
SPLINT WRST FA L INSTABILITY INJ 8IN IMMOB LOOP LOK ABDUCTED,SUP-2276632,CDM,L3809,HCPCS,0272,RC,,,,both,,,22.33,14.51,,,,,,,,,,,,,
CATHETER ANGIOPLSTY 18 ATM 4 FRX190 CM 2X300 MM SABERX,SUP-2866052,CDM,C1725,HCPCS,0272,RC,,,,both,,,1261.90,820.23,,,,,,,,,,,,,
SUPPORT ORTHOT THOR LUMBAR SACR CUST SAG CTRL SFT ANTR APRON,SUP-2435541,CDM,L0466,HCPCS,0272,RC,,,,both,,,1074.16,698.20,,,,,,,,,,,,,
ALPRAZOLAM 1 MG PO TABS,RX-326,CDM,6370000000,HCPCS,0637,RC,65862-0678-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
CENTRALIZER STEM REV LG 12/14 16 MM DSTL HIP TAPR SPECTRON,SUP-2434612,CDM,C1776,CPT,0278,RC,,,,both,,,298.93,194.30,,,,,,,,,,,,,
SPLINT CLAV XSM 20 24IN WHT HVY PD FELT FOAM CNTCT CLSR,SUP-2196987,CDM,L3650,HCPCS,0274,RC,,,,both,,,17.40,11.31,,,,,,,,,,,,,
DEVICE COCHLEAR PEDIATRIC SLEEPER SIMULATOR LEVEL,SUP-2165014,CDM,L8614,HCPCS,0278,RC,,,,both,,,39250.00,25512.50,,,,,,,,,,,,,
PROBE FLX TIP TRNSLUMN A PACE 2.4X135CM SWAN GANZ,SUP-2214434,CDM,C1713,HCPCS,0278,RC,,,,both,,,362.20,235.43,,,,,,,,,,,,,
PLATE BONE DUAL CMPRSSN HLX12 TTNM CNTRD F2.7MM LOK SCREW S,SUP-2720930,CDM,C1713,HCPCS,0278,RC,,,,both,,,1144.91,744.19,,,,,,,,,,,,,
BRACE KNEE POSTOP 1 SZ FITS MOST SH UNIV UNISX FASTEN ON HNG,SUP-2150852,CDM,L1832,HCPCS,0274,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
SYSTEM IMPLANT ECLIPSE SPEEDCAP,SUP-2753230,CDM,C1713,HCPCS,0278,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
CLIP LIG HORZ TANT M 6/CR - M,SUP-2383510,CDM,C1889,HCPCS,0278,RC,,,,both,,,18.15,11.80,,,,,,,,,,,,,
HC MRI-Spine Lumbar WO Contrast,PX-6127214800,CDM,72148,CPT,0612,RC,,,,both,,,4976.00,3234.40,,,,,,,,,,,,,
HC Intmd Wnd Repair S/Tr/Ext,PX-4501203700,CDM,12037,CPT,0450,RC,,,,both,,,2009.00,1305.85,,,,,,,,,,,,,
HC Quan MRI Alys Brain W/O Diagnostic MRI Same Sess,PX-6110865000,CDM,0865T,CPT,0611,RC,,,,both,,,1344.00,873.60,,,,,,,,,,,,,
FIBER LASER HOLM SUREFLEX 10807] FORTEC MEDICAL INC],SUP-2225687,CDM,2720000010,LOCAL,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
COMPONENT TOE JT PHLANG M L18MM TI UNIV POR COAT PRI PRSS,SUP-2319772,CDM,C1776,CPT,0278,RC,,,,both,,,5862.38,3810.55,,,,,,,,,,,,,
AGENT HEMSTAT HUM FBRN SEAL EVICEL KT,SUP-2256934,CDM,2720000010,LOCAL,0272,RC,,,,both,,,14360.32,9334.21,,,,,,,,,,,,,
MESH C-QUR EDGEXL OBLONG OVL 7 INX9 IN,SUP-2265968,CDM,C1781,HCPCS,0278,RC,,,,both,,,2983.00,1938.95,,,,,,,,,,,,,
DRESSING 10X10CM WND HEALING PTCH TALYMED,SUP-2266130,CDM,Q4127,HCPCS,0636,RC,,,,both,,,4082.00,2653.30,,,,,,,,,,,,,
STEM HUM SZ 13 DIA13MM PROX SHLDR TI HYDROXYAPETITE RM,SUP-2379015,CDM,C1776,CPT,0278,RC,,,,both,,,11304.00,7347.60,,,,,,,,,,,,,
CUP ACET OD42MM ID22MM UHMWPE COMPR MOLD PVT BPLR,SUP-2314497,CDM,C1776,CPT,0278,RC,,,,both,,,2135.20,1387.88,,,,,,,,,,,,,
PLATE BONE CRANIAL MESH 40.2X50.2X0.3MM TITANIUM NEURO PLATI,SUP-2827184,CDM,C1713,HCPCS,0278,RC,,,,both,,,1494.33,971.31,,,,,,,,,,,,,
CATHETER INTVASC ULTRASOUND SONICATH ULTRA DIA 9 FR FREQ 9,SUP-2139881,CDM,C1753,HCPCS,0278,RC,,,,both,,,2034.22,1322.24,,,,,,,,,,,,,
CRANIAL ACCESS KIT MANUAL CRAN ROTARY HNDPC DISP HITHSP04,SUP-2666707,CDM,2720000010,LOCAL,0272,RC,,,,both,,,923.32,600.16,,,,,,,,,,,,,
RING ACET TI PLSM SPRY HIP GRP 1 CONSTRN LCK COMPHSVE SYS,SUP-2222480,CDM,C1713,HCPCS,0278,RC,,,,both,,,2501.32,1625.86,,,,,,,,,,,,,
PLATE BNE 5 H CROSSCHECK UTIL ORTHOLOC 3DI,SUP-2398219,CDM,C1713,HCPCS,0278,RC,,,,both,,,5215.54,3390.10,,,,,,,,,,,,,
MESH CRAN W50XL50MM THK0.8MM RAP RESRB FOR 1.5MM SCR FIX,SUP-2194073,CDM,C1781,HCPCS,0278,RC,,,,both,,,4846.59,3150.28,,,,,,,,,,,,,
SCREW BONE SELF TAPPING 2.4X16 MM TITANIUM MATRIXMANDIBLE,SUP-2837729,CDM,C1713,HCPCS,0278,RC,,,,both,,,365.75,237.74,,,,,,,,,,,,,
CATHETER VENTRICULAR PORTNOY FLNG 18 CM FULL BA W/ STYL,SUP-2851451,CDM,C1729,HCPCS,0272,RC,,,,both,,,1129.43,734.13,,,,,,,,,,,,,
BALLOON DIL 12FR DIA4MM 0.035IN DISP FOR STRICTURE OF BILI,SUP-2170668,CDM,C1726,HCPCS,0272,RC,,,,both,,,737.90,479.63,,,,,,,,,,,,,
GUIDEWIRE ORTH L 600 MM DIA 3 MM BALL TIP STRL,SUP-2930408,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1218.32,791.91,,,,,,,,,,,,,
BLADE SHAVER SERRATED STD 75 DEG 2.9 MM N DSTL SUCTION STRL,SUP-2638419,CDM,2720000010,LOCAL,0272,RC,,,,both,,,453.29,294.64,,,,,,,,,,,,,
CATHETER DRAINAGE MP 10 FR NAVARRE,SUP-2128424,CDM,C1729,HCPCS,0272,RC,,,,both,,,213.52,138.79,,,,,,,,,,,,,
PLATE BNE BROAD 5.5X306 MM 17 HOLE SS LCP,SUP-2569378,CDM,C1713,HCPCS,0278,RC,,,,both,,,1079.38,701.60,,,,,,,,,,,,,
DRESSING BIO W3XL7CM PORCINE TRILAYER MTRX FEN OASIS ULT,SUP-2341248,CDM,Q4124,HCPCS,0636,RC,,,,both,,,959.43,623.63,,,,,,,,,,,,,
GRAFT VASC INTERGARD L 30 CM DIA24 MM THK 0.38 MM POLYESTER,SUP-2695249,CDM,C1768,CPT,0278,RC,,,,both,,,1570.13,1020.58,,,,,,,,,,,,,
ADAPTER PACE LD OSCOR L 17 CM SIL INSUL LV1 BPLR IS1 CONN,SUP-2356255,CDM,C1883,HCPCS,0278,RC,,,,both,,,266.90,173.48,,,,,,,,,,,,,
WIRE FIX FOR L QWIX SCR L250MM OD2.5MM K,SUP-2243648,CDM,C1713,HCPCS,0278,RC,,,,both,,,222.12,144.38,,,,,,,,,,,,,
PLATE BONE L12MM THK0.3MM 2 H TI STR ULT LO PROF MATRIXNEURO,SUP-2255851,CDM,C1713,HCPCS,0278,RC,,,,both,,,227.96,148.17,,,,,,,,,,,,,
COLLAR CERV MED DENS UNIV 24X4 IN CNTOUR PROCARE LF,SUP-2195755,CDM,L0180,HCPCS,0274,RC,,,,both,,,7.10,4.61,,,,,,,,,,,,,
BELT RIB XL 6 IN M ELASTIC VELCRO CLOSURE,SUP-2194761,CDM,L0220,HCPCS,0274,RC,,,,both,,,22.95,14.92,,,,,,,,,,,,,
HC Allergen Spec Ige Crude Allergen Extract Each|UNUSUAL NON-OVERLAPPING SERVICE,PX-3058600300,CDM,86003,CPT,0305,RC,,,XU,both,,,44.00,28.60,,,,,,,,,,,,,
PACK ORTH INSTR OVR DRL COMPR SLV RECTANGULAR DRVR FOR 5 MM,SUP-2902310,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1702.19,1106.42,,,,,,,,,,,,,
BIT DRILL CANN 11.2 LRG QC,SUP-2718103,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1915.34,1244.97,,,,,,,,,,,,,
POTASSIUM CHLORIDE 10 MEQ/100ML IV SOLN,RX-11074,CDM,J3480,HCPCS,0636,RC,00990-7074-26,NDC,,both,100,ML,54.10,35.16,,,,,,,,,,,,,
PLATE SPNL L40MM 6 H ANT CERV BILAT TI 2 LEV INTEGR LOK,SUP-2293203,CDM,C1713,HCPCS,0278,RC,,,,both,,,2088.10,1357.26,,,,,,,,,,,,,
PLATE BNE STR MINI MED 2X0.6 MM 4 HOLE LP FOR SCR TI STRL,SUP-2496290,CDM,C1713,HCPCS,0278,RC,,,,both,,,252.83,164.34,,,,,,,,,,,,,
FIBER LASER 0.4 MM FOR KTP/YAG,SUP-2225667,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1205.76,783.74,,,,,,,,,,,,,
DEFIBRILLATOR IMPL LUMAX 740 HF-T TI EPOXY RESIN SIL 3 CHMBR,SUP-2138412,CDM,C1722,HCPCS,0275,RC,,,,both,,,61230.00,39799.50,,,,,,,,,,,,,
COMPONENT TIB 3 8 MM KNEE,SUP-2200489,CDM,C1776,CPT,0278,RC,,,,both,,,1980.84,1287.55,,,,,,,,,,,,,
BIOPSY KIT 19 GAX60 CM 7 FR TRNSJUG LIV FLX TIP 4 SWAB TLAB,SUP-2876888,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2072.40,1347.06,,,,,,,,,,,,,
CATHETER INFUSION UNI-FUSE L 135CM 5FR SLT 5CM 0.035 IN BALL,SUP-2117041,CDM,C1757,HCPCS,0272,RC,,,,both,,,1303.10,847.01,,,,,,,,,,,,,
PATCH DURA REP W4XL4CM BOV PERICARD GLUTARHYD NONPYROGENIC,SUP-2130235,CDM,C1763,HCPCS,0278,RC,,,,both,,,1350.80,878.02,,,,,,,,,,,,,
HC Remove Eyelid FB,PX-4506793800,CDM,67938,CPT,0450,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED CEM HI FLX M HXLPE TI,SUP-2212712,CDM,C1776,CPT,0278,RC,,,,both,,,26158.59,17003.08,,,,,,,,,,,,,
GRAFT HUM TISS POST TIBIALIS TEND SM DIAM ALL FLD DIAM 75MM,SUP-2307282,CDM,C1762,CPT,0278,RC,,,,both,,,3925.00,2551.25,,,,,,,,,,,,,
BOLT ORTHOPEDIC FUSION 6.5X75 MM MIDFOOT SS NS,SUP-2184090,CDM,C1713,HCPCS,0278,RC,,,,both,,,1468.11,954.27,,,,,,,,,,,,,
KIT EVLT-2 PROC L45CM VENACURE,SUP-2117299,CDM,C1713,HCPCS,0278,RC,,,,both,,,2135.20,1387.88,,,,,,,,,,,,,
MICRUSPHERE XL 6MMX12CM,SUP-2464405,CDM,C1889,HCPCS,0278,RC,,,,both,,,6231.33,4050.36,,,,,,,,,,,,,
CATHETER CARD ABLATION THERMOCOOL SF L 115 CM 7.5 FR B-B CRV,SUP-2248522,CDM,C1732,HCPCS,0278,RC,,,,both,,,7583.10,4929.01,,,,,,,,,,,,,
PLATE BNE L 213 X W 12 MM THK 3 MM SCREW DIA 3.5 MM 15 H SS,SUP-2933516,CDM,C1713,HCPCS,0278,RC,,,,both,,,6589.92,4283.45,,,,,,,,,,,,,
PLATE BNE L85MM THK3.4MM 6 H BILAT S STL STR LOK COMPR FOR,SUP-2185133,CDM,C1713,HCPCS,0278,RC,,,,both,,,839.13,545.43,,,,,,,,,,,,,
TRIAL NERVE STIM KT INSTRUMENT STIM BLDR AFT ADV,SUP-2435498,CDM,C1820,HCPCS,0278,RC,,,,both,,,37306.34,24249.12,,,,,,,,,,,,,
HC Veeg by Tech Ea Incr 12-26 Hr Cont R-T Mntr,PX-7409571600,CDM,95716,CPT,0740,RC,,,,both,,,5500.00,3575.00,,,,,,,,,,,,,
INTRODUCER CATH L1.9CM PUR SHLD FOR PICC AND MIDLN CATH,SUP-2133168,CDM,C1894,HCPCS,0272,RC,,,,both,,,147.42,95.82,,,,,,,,,,,,,
PIN FIX L4.5MM S STL CERCLAGE THRD POS,SUP-2187033,CDM,C1713,HCPCS,0278,RC,,,,both,,,498.76,324.19,,,,,,,,,,,,,
CATHETER HD STR 14 FRX24 CM LT SET W/ 2 STYL SPLIT CATH III,SUP-2627109,CDM,C1750,HCPCS,0278,RC,,,,both,,,59.66,38.78,,,,,,,,,,,,,
SCREW BNE L10MM DIA1.5MM CORT TI ST FULL THRD COMPR T4,SUP-2181283,CDM,C1713,HCPCS,0278,RC,,,,both,,,139.10,90.41,,,,,,,,,,,,,
BUR SURG L 95 MM DIA2.35 MM HD DIA 7 MM DIAMOND NS REUSE,SUP-2929092,CDM,2720000010,LOCAL,0272,RC,,,,both,,,396.64,257.82,,,,,,,,,,,,,
GRAFT BNE SUB 10CC FOAM PK VERSATILE COMPR RESIST VITOSS 21022110] STRYKER ORTHOBIOLOGICS],SUP-2368196,CDM,C1713,HCPCS,0278,RC,,,,both,,,5049.12,3281.93,,,,,,,,,,,,,
BLADE SAW W0.70XL1.17IN THK0.20IN OSC CRESC THN PRECIS TPS 2296031417] STRYKER INSTRUMENT DIV],SUP-2367267,CDM,C1713,HCPCS,0278,RC,,,,both,,,349.67,227.29,,,,,,,,,,,,,
BLADE SHAVER ARTHSCP MINI 2.9 MMX7 CM CUT DYONICS PWR EP 1,SUP-2340748,CDM,2720000010,LOCAL,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
COIL VASC NEST EMBOLUS L 20 CM DIA 6 MM CATH DIA 0.035 IN,SUP-2169462,CDM,C1889,HCPCS,0278,RC,,,,both,,,370.52,240.84,,,,,,,,,,,,,
SHEATH INTRO PINNACLE PRECIS ACCS SYS L 10 CM 5 FR NIT STIFF,SUP-2538028,CDM,C1894,HCPCS,0272,RC,,,,both,,,194.21,126.24,,,,,,,,,,,,,
BLADE SAW OSCLLTNG 11.5MMW X7MML 0.4MM THK 0.6MM THK CUT INT,SUP-2605372,CDM,2720000010,LOCAL,0272,RC,,,,both,,,343.77,223.45,,,,,,,,,,,,,
RING EXT FIX ID165MM TI C FBR HYBRID FIX 1 4 FOR DST TIB,SUP-2188612,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1092.22,709.94,,,,,,,,,,,,,
HC X-Ray Exam Bil Hips 5/> Views,PX-3207352300,CDM,73523,CPT,0320,RC,,,,both,,,128.00,83.20,,,,,,,,,,,,,
KIT CATH URTRL BLLN DLTN 5MM X 4CM URO EZDLTE,SUP-2725734,CDM,C1726,HCPCS,0272,RC,,,,both,,,700.22,455.14,,,,,,,,,,,,,
NEW 24X30 CM DS4000 IMAG PLT,SUP-2303643,CDM,C1713,HCPCS,0278,RC,,,,both,,,1234.02,802.11,,,,,,,,,,,,,
COLLAR CERV L20XW4IN L CNTOUR COT STOCK M DENS STOUT AD FOR,SUP-2196871,CDM,L0120,HCPCS,0274,RC,,,,both,,,12.75,8.29,,,,,,,,,,,,,
ALLOGRAFT BNE OSTEOTMY WDG FD IRRADIATED,SUP-2867106,CDM,C1762,CPT,0278,RC,,,,both,,,5181.47,3367.96,,,,,,,,,,,,,
Elite H Drill Template Kit,SUP-2550451,CDM,C1713,HCPCS,0278,RC,,,,both,,,190.97,124.13,,,,,,,,,,,,,
ELRANATAMAB-BCMM 44 MG/1.1ML SC SOLN,RX-165064,CDM,J1323,HCPCS,0636,RC,00069-2522-01,NDC,,both,0.3,ML,6496.50,4222.72,,,,,,,,,,,,,
EXTENSION STEM L23MM DIA12.7MM KNEE TIV ALLOY FLUT M/G,SUP-2200365,CDM,C1776,CPT,0278,RC,,,,both,,,4755.53,3091.09,,,,,,,,,,,,,
PLATE BONE DUAL CMPRSSN HLX30 RCNSTRCTN F/2.7MM LOK SCREW ST,SUP-2461645,CDM,C1713,HCPCS,0278,RC,,,,both,,,2028.50,1318.52,,,,,,,,,,,,,
CATHETER HEMO DYLS OR HD L 33 CM DIA15.5 FR INSRTN L 28 CM,SUP-2896199,CDM,C1750,HCPCS,0278,RC,,,,both,,,1704.55,1107.96,,,,,,,,,,,,,
BIT DRL L122MM DIA2.7MM ADD ON FIT FOR VARIAX 2 EL LOK PLT,SUP-2377985,CDM,2720000010,LOCAL,0272,RC,,,,both,,,529.72,344.32,,,,,,,,,,,,,
SET NEPHSTMY 14FR L25CM BLLN L15CM DIA12MM FOR URET DRNGE,SUP-2171214,CDM,C1729,HCPCS,0272,RC,,,,both,,,861.93,560.25,,,,,,,,,,,,,
PLATE TIBIA DISTAL 3.5MM TI LCP LOW BEND MEDIAL 8H RIGHT 161MM,SUP-2549696,CDM,C1713,HCPCS,0278,RC,,,,both,,,4046.24,2630.06,,,,,,,,,,,,,
PRESSURIZER BONE CEM 45DEG ACET HD NK,SUP-2408414,CDM,C1713,HCPCS,0278,RC,,,,both,,,2392.68,1555.24,,,,,,,,,,,,,
SHEATH PERIPH 65FR L90CM DEFLECTION L9MM AT 180DEG,SUP-2298496,CDM,C1887,HCPCS,0272,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
POST EXT FIX STR,SUP-2750002,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1318.80,857.22,,,,,,,,,,,,,
GRAFT HUM TISS SZ 8 X 8 CM AMNIO MEMBRN RESRB AIR DRY SPEC,SUP-2913448,CDM,Q4173,HCPCS,0636,RC,,,,both,,,16067.38,10443.80,,,,,,,,,,,,,
HC NM Hepatobiliary Imaging W Pharm,PX-3417822700,CDM,78227,CPT,0341,RC,,,,both,,,4423.00,2874.95,,,,,,,,,,,,,
NEEDLE BX LIV 14G/15CM,SUP-2236350,CDM,C1786,HCPCS,0275,RC,,,,both,,,19311.00,12552.15,,,,,,,,,,,,,
JOINT SHOULDER HUMERAL PROSTHESIS EQUINOXE MID SEGMENT 25MM,SUP-2855530,CDM,C1776,CPT,0278,RC,,,,both,,,19389.50,12603.17,,,,,,,,,,,,,
ALLOGRAFT BNE 10 CC DBM BONUS TRIAD,SUP-2607051,CDM,C1889,HCPCS,0278,RC,,,,both,,,12363.75,8036.44,,,,,,,,,,,,,
GRAFT SFT TISS 15X30 MM BOV PERICARD MEMBRN COPIOS,SUP-2335281,CDM,C1713,HCPCS,0278,RC,,,,both,,,474.14,308.19,,,,,,,,,,,,,
SET INTRO SUP ARW FLX SHTH L 11 CM DIA 8 FR HYDRPHLC,SUP-2754008,CDM,C1892,HCPCS,0272,RC,,,,both,,,141.30,91.84,,,,,,,,,,,,,
CATHETER INTRO 9X7FR L50.7CM WRK L47CM PEBAX OUTER,SUP-2356363,CDM,C1893,HCPCS,0272,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
REGULATOR SUCTION CONT INTERMITTENT DISS M VACUTRON,SUP-2305890,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
PLATE BONE THK0.9MM OFFSET 0MM 10 H RT MAX ORAL,SUP-2191113,CDM,C1713,HCPCS,0278,RC,,,,both,,,1350.20,877.63,,,,,,,,,,,,,
PLATE BNE L 195 X W 11.4 MM THK 3.4 MM SCREW DIA2.7/3.5 MM 72464015,SUP-2932805,CDM,C1713,HCPCS,0278,RC,,,,both,,,7970.11,5180.57,,,,,,,,,,,,,
PLATE X LCK 2.4/2.7MM 36X20 LG STRL,SUP-2547592,CDM,C1713,HCPCS,0278,RC,,,,both,,,2348.72,1526.67,,,,,,,,,,,,,
HC Calcium Total,PX-3018231000,CDM,82310,CPT,0301,RC,,,,both,,,101.00,65.65,,,,,,,,,,,,,
PIN EXT FIX L25MM OD5MM HA SALVATION,SUP-2401149,CDM,2720000010,LOCAL,0272,RC,,,,both,,,574.62,373.50,,,,,,,,,,,,,
PLATE BNE THK06MM 34 H MIDFACE TI STR LO PROF LEV 1 SIL FOR,SUP-2262720,CDM,C1713,HCPCS,0278,RC,,,,both,,,939.49,610.67,,,,,,,,,,,,,
HC So Thyroxine Total,PX-3018443666,CDM,84436,CPT,0301,RC,,,,both,,,38.00,24.70,,,,,,,,,,,,,
COLLAR CERV FLAT REG 3 IN 1 PC IMMOB REHAB ORNG PROCARE,SUP-2196864,CDM,L0190,HCPCS,0272,RC,,,,both,,,25.47,16.56,,,,,,,,,,,,,
PLATE BONE L135MM 8 H BILAT COMPR STR BROAD FOR 4.5MM SCR,SUP-2343797,CDM,C1713,HCPCS,0278,RC,,,,both,,,2287.40,1486.81,,,,,,,,,,,,,
GRAFT BNE PTTY 1 CC GRFT 513102] MUSCULOSKELETAL TRANSPLANT FOUNDATION],SUP-2307521,CDM,C9359,HCPCS,0278,RC,,,,both,,,555.78,361.26,,,,,,,,,,,,,
PROPHECY PATIENT SPEC GUIDES FOR INFINITY WITH FOOTPRINT,SUP-2830300,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2847.98,1851.19,,,,,,,,,,,,,
OMALIZUMAB 300 MG/2  ML SC SOSY,RX-166986,CDM,J2357,HCPCS,0636,RC,50242-0227-01,NDC,,both,2,ML,8689.40,5648.11,,,,,,,,,,,,,
HC So Serotonin,PX-3018426066,CDM,84260,CPT,0301,RC,,,,outpatient,,,75.00,48.75,,,,,,,,,,,,,
CATHETER VENTRICULAR FEN,SUP-2666776,CDM,C1729,HCPCS,0272,RC,,,,both,,,961.25,624.81,,,,,,,,,,,,,
HC So Serotonin,PX-3018426066,CDM,84260,CPT,0301,RC,,,,inpatient,,,75.00,48.75,,,,,,,,,,,,,
IMPLANT TOE 1.6 MM 9.34X4.5X6.04 MM LG KT,SUP-2564343,CDM,C1776,CPT,0278,RC,,,,both,,,4170.49,2710.82,,,,,,,,,,,,,
SYSTEM ATHRCTMY ROTLNK ADV ROT PRE CONN STRL,SUP-2147025,CDM,C1894,HCPCS,0272,RC,,,,both,,,816.40,530.66,,,,,,,,,,,,,
GRAFT BNE 5ML B TCP TYP 1 BOV CLLGN PTTY BIOLOGIC SUB,SUP-2316223,CDM,C9359,HCPCS,0278,RC,,,,both,,,3375.50,2194.07,,,,,,,,,,,,,
PUSHER KNOT SUT CUT CVD STRL DISP FAST FIX,SUP-2341635,CDM,C1713,HCPCS,0278,RC,,,,both,,,363.20,236.08,,,,,,,,,,,,,
COUPLER ANAS MICROVASCULAR 1MM GRY,SUP-2419427,CDM,C1889,HCPCS,0278,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
SCREW BNE NLCK 2.7 X20 MM T10 DRV FT STRL VARIAX 2,SUP-2457403,CDM,C1713,HCPCS,0278,RC,,,,both,,,452.79,294.31,,,,,,,,,,,,,
KIT EXTN L60CM DP BRAIN STIM ACTIVA,SUP-2284463,CDM,C1883,HCPCS,0278,RC,,,,both,,,2496.30,1622.59,,,,,,,,,,,,,
ADAPTER TUBING DUAL VALVE Y CHECK VALUE OPTISTAR ELITE,SUP-2427451,CDM,C1713,HCPCS,0278,RC,,,,both,,,409.77,266.35,,,,,,,,,,,,,
PLATE BNE GRP 2.7 MM CLAV A LEVEL NS ALPS FAST DISP,SUP-2499404,CDM,C1713,HCPCS,0278,RC,,,,both,,,207.24,134.71,,,,,,,,,,,,,
HC Demo/Eval Aer Neb Mdi Ippb,PX-4109466400,CDM,94664,CPT,0410,RC,,,,inpatient,,,660.00,429.00,,,,,,,,,,,,,
SNARE ENDOSCP POLYP 2.8 MMX230 CM OVL ASMBLY SNAREMASTER +,SUP-2475212,CDM,2720000010,LOCAL,0272,RC,,,,both,,,717.87,466.62,,,,,,,,,,,,,
SCREW BONE L28MM TITANIUMWITH TOP HAT FOR BRISTOW LATARJET,SUP-2256867,CDM,C1713,HCPCS,0278,RC,,,,both,,,935.72,608.22,,,,,,,,,,,,,
SOCKS PROSTHETIC SINGLE PLY FIT LF,SUP-2388228,CDM,L8470,HCPCS,0274,RC,,,,both,,,17.55,11.41,,,,,,,,,,,,,
ELECTRODE ES H24FR L LOOP 12 16DEG PLSM LOOP ESG F RESECTION 5PK,SUP-2313587,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1346.24,875.06,,,,,,,,,,,,,
CATHETER ETER GUID 70DEG TIP F 70 DST SNUS SFT RELIEVA FLX,SUP-2546012,CDM,C1726,HCPCS,0272,RC,,,,both,,,1161.80,755.17,,,,,,,,,,,,,
MESH HERN OVL 12X10 IN POCKETED BIORESORBABLE PHASIX ST,SUP-2855274,CDM,C1781,HCPCS,0278,RC,,,,both,,,40804.30,26522.79,,,,,,,,,,,,,
INFUSION PUMP KIT 10 IN 270 CC W/ 2 SILVERSOAKER ON-Q,SUP-2236846,CDM,C2626,HCPCS,0278,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
PLATE BONE L108MM 6 H STD BILAT COMPR CNTOUR + BROAD FOR,SUP-2349000,CDM,C1713,HCPCS,0278,RC,,,,both,,,1937.13,1259.13,,,,,,,,,,,,,
SYSTEM INFUSION BENEPHIT CV L 30 CM SHTH 8 FR BIFURCATE CATH,SUP-2117155,CDM,C1751,HCPCS,0278,RC,,,,both,,,5636.30,3663.59,,,,,,,,,,,,,
SIZER SURG GEL 6 CM 15.5 CM 770 CC MSZF NATRELLE INSPIRA,SUP-2475363,CDM,2720000010,LOCAL,0272,RC,,,,both,,,753.60,489.84,,,,,,,,,,,,,
SPLINT WRST WRP ARND UNIV 8 IN FOREARM RT COOL BLU,SUP-2336238,CDM,L3908,HCPCS,0272,RC,,,,both,,,15.57,10.12,,,,,,,,,,,,,
PIN EXTERNAL FIXATION HALF 5X20 MM ARROW STAINLESS STEEL NON,SUP-2836751,CDM,2720000010,LOCAL,0272,RC,,,,both,,,243.98,158.59,,,,,,,,,,,,,
GRAFT VASC MAXIFLO L 50 CM DIA 6 MM EPTFE SEAL PTFE TW STRL,SUP-2392562,CDM,C1768,CPT,0278,RC,,,,both,,,2147.76,1396.04,,,,,,,,,,,,,
GRAFT BNE PTTY 2 CC DBM INTERGRO,SUP-2136618,CDM,C9359,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
COLLAR CERV 3IN 12 24IN L TRACH OPN W  CHIN SUPP ADJUSTABLE,SUP-2431856,CDM,L0174,HCPCS,0274,RC,,,,both,,,182.91,118.89,,,,,,,,,,,,,
DIST HUM LAT RT 11H 103MM STE,SUP-2588820,CDM,C1713,HCPCS,0278,RC,,,,both,,,2718.49,1767.02,,,,,,,,,,,,,
SCREW BNE L50MM DIA6.5MM THRD L16MM STD CANC S STL,SUP-2373832,CDM,C1713,HCPCS,0278,RC,,,,both,,,146.01,94.91,,,,,,,,,,,,,
PUMP ENTERAL FEED 1-500ML/HR 1ML INCREMENT W/POLE CLAMP ST,SUP-2719878,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
GRAFT HUM TISS W3XL4CM MTRX CRD AMNION,SUP-2753990,CDM,C1765,HCPCS,0278,RC,,,,both,,,6594.00,4286.10,,,,,,,,,,,,,
VALVE SHUNT FLO CTRL SM PERF LEVEL 2 W/ BIOGLDE DELT,SUP-2631428,CDM,C1889,HCPCS,0278,RC,,,,both,,,4188.73,2722.67,,,,,,,,,,,,,
TRAY PICC POWERPICC PROVENA L 55 CM DIA 4 FR CATH 18 GA,SUP-2632844,CDM,C1751,HCPCS,0278,RC,,,,both,,,461.20,299.78,,,,,,,,,,,,,
SPHERE EMB LAVA-18 2 ML EVA TANTALUM PWDR PERIPH VASC LIQ,SUP-2899326,CDM,C1889,HCPCS,0278,RC,,,,both,,,7065.00,4592.25,,,,,,,,,,,,,
TESTOSTERONE 50 MG/5GM (1%) TD GEL,RX-104350,CDM,6370000000,HCPCS,0637,RC,00832-1120-35,NDC,,both,5,GR,46.50,30.22,,,,,,,,,,,,,
PLATE SPNL 1 HOLE 8 MM LCK CVR REGATTA,SUP-2711095,CDM,C1713,HCPCS,0278,RC,,,,both,,,675.10,438.81,,,,,,,,,,,,,
ANCHOR SUTURE PRE LD 2-0 5 MM 2 BRAIDED TWO STRND,SUP-2608437,CDM,C1713,HCPCS,0278,RC,,,,both,,,497.60,323.44,,,,,,,,,,,,,
GRAFT VENTRICULAR ASST DEV SZ 7.6 CM SHRT OUTFLO BEND REL,SUP-2894943,CDM,C1889,HCPCS,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
COLLAR CERV MULT POST BRAC VISTA,SUP-2388138,CDM,L0190,HCPCS,0272,RC,,,,both,,,2380.12,1547.08,,,,,,,,,,,,,
HYDROCORTISONE SOD SUC (PF) 100 MG IJ SOLR (PLAIN VIAL),RX-4083046,CDM,J1720,HCPCS,0636,RC,00009-0825-01,NDC,,both,1,UN,110.20,71.63,,,,,,,,,,,,,
IMPL CAPPED KNEE GSF FXCM FEMTIB SUR STDPAT,SUP-2212248,CDM,C1776,CPT,0278,RC,,,,both,,,16180.36,10517.23,,,,,,,,,,,,,
BEARING TOE SM POLYETH PHLANG IMPL,SUP-2404749,CDM,C1776,CPT,0278,RC,,,,both,,,1836.90,1193.98,,,,,,,,,,,,,
ENDRING SPNL DIA10MM 0DEG TI RND PRESSFIT SYNMESH,SUP-2193237,CDM,C1889,HCPCS,0278,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 8X240 MM FRZN ASEP PERONEUS LONGUS TEND,SUP-2866983,CDM,C1762,CPT,0278,RC,,,,both,,,3346.93,2175.50,,,,,,,,,,,,,
STYLET PACE L58CM REACH L40MM RAD 14MM 0016IN DEFL ENABLES,SUP-2356063,CDM,C1713,HCPCS,0278,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
PLATE BNE CLAV 3.5 MM RT DSTL 16 HOLE FOR SCREW STRL,SUP-2518243,CDM,C1713,HCPCS,0278,RC,,,,both,,,4154.22,2700.24,,,,,,,,,,,,,
GRAFT BONE 10ML IMPL HUM TISS DEMIN PUTTY BONE ALLGRFT DBM,SUP-2414011,CDM,C1713,HCPCS,0278,RC,,,,both,,,4750.82,3088.03,,,,,,,,,,,,,
SLING LIFT PCH W13XL19IN SWTH W5XL54IN UNIV PERF FOAM ADJ,SUP-2194775,CDM,L3650,HCPCS,0272,RC,,,,both,,,21.70,14.10,,,,,,,,,,,,,
FLOSS CLEANING PROBE TIP 3 IN 1,SUP-2719736,CDM,2720000010,LOCAL,0272,RC,,,,both,,,69.08,44.90,,,,,,,,,,,,,
BOLT ORTH LCK 16-100 MM MEAS DEV FOR FEM NAIL NS,SUP-2563931,CDM,C1713,HCPCS,0278,RC,,,,both,,,1848.20,1201.33,,,,,,,,,,,,,
NEEDLE VENTING 14 GAX3.5 IN,SUP-2256976,CDM,C1713,HCPCS,0278,RC,,,,both,,,401.92,261.25,,,,,,,,,,,,,
ETOMIDATE 2 MG/ML IV SOLN,RX-20472,CDM,2500000003,HCPCS,0250,RC,00409-6695-02,NDC,,both,5,ML,54.10,35.16,,,,,,,,,,,,,
DRILL SURG 1 TRIGGER MOD HALL TITAN,SUP-2607716,CDM,2720000010,LOCAL,0272,RC,,,,both,,,25897.15,16833.15,,,,,,,,,,,,,
SCREW BONE LOCKING 2X6 MM SELFDRILLING TITANIUM NON STERILE,SUP-2837731,CDM,C1713,HCPCS,0278,RC,,,,both,,,490.15,318.60,,,,,,,,,,,,,
PLATE BNE TBLR 2.7X49 MM 6 HOLE 1/4 TI,SUP-2536108,CDM,C1713,HCPCS,0278,RC,,,,both,,,397.84,258.60,,,,,,,,,,,,,
PIN FIX DBL DIAMOND 0.093X9 IN SS NS STEINMANN,SUP-2791595,CDM,C1713,HCPCS,0278,RC,,,,both,,,12.81,8.33,,,,,,,,,,,,,
PLATE BNE 25 MM MOD Y SHP RIGID SAG CRV 6 TRI SHP HOLE BLU,SUP-2478291,CDM,C1713,HCPCS,0278,RC,,,,both,,,629.22,408.99,,,,,,,,,,,,,
SCREW INTRF CANN 10X25 MM RND HD CRKSCR TIP TI STRL SOFTSILK,SUP-2849125,CDM,C1713,HCPCS,0278,RC,,,,both,,,1318.80,857.22,,,,,,,,,,,,,
GUIDEWIRE ORTH 0.045X5 IN MALIBU,SUP-2709732,CDM,C1769,HCPCS,0272,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
CLIP ANEUR NO14 L25MM OPN 14MM 35DEG 1.67N STD TI BAYNT SERR,SUP-2306069,CDM,C1889,HCPCS,0278,RC,,,,both,,,1740.82,1131.53,,,,,,,,,,,,,
INBONE  FUSION ROD 7.0 MM 7.0 MM X 45 MM LG,SUP-2459231,CDM,C1713,HCPCS,0278,RC,,,,both,,,5231.24,3400.31,,,,,,,,,,,,,
PLUG MESH L ANCHR 5CM RIM 5CM SYN POLYPR POLIGLECAPRONE 25,SUP-2220110,CDM,C1781,HCPCS,0278,RC,,,,both,,,637.67,414.49,,,,,,,,,,,,,
BRACE W/ STRNL PD KT COMPLT BLK M CNTOUR TLSO,SUP-2123919,CDM,L0462,HCPCS,0274,RC,,,,both,,,1020.19,663.12,,,,,,,,,,,,,
LISINOPRIL 10 MG PO TABS,RX-10449,CDM,6370000000,HCPCS,0637,RC,00904-6798-61,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
SHEATH LD INTRO SAFSHTH ULTRA L 13 CM DIA 7 FR GUIDEWIRE L,SUP-2159474,CDM,C1892,HCPCS,0272,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
MARKER SURG FIDUCIAL 2X2 CM SPACER CLP SFT TISS STRL BIOZORB,SUP-2716281,CDM,A4648,CPT,0278,RC,,,,both,,,3815.10,2479.81,,,,,,,,,,,,,
MESH SURG W8XL12CM THK1MM EPTFE CORDUROY SURF FOR VENTRAL,SUP-2395329,CDM,C1781,HCPCS,0278,RC,,,,both,,,1111.56,722.51,,,,,,,,,,,,,
COIL VASC AZUR HYDROCOIL L 15 CM DIA 4 MM 0.018 IN HELCL,SUP-2518910,CDM,C1889,HCPCS,0278,RC,,,,both,,,1172.63,762.21,,,,,,,,,,,,,
DEFIBRILLATOR IMPL ILESTO HF-T TI EPOXY RESIN SIL 3 CHMBR,SUP-2138455,CDM,C1882,HCPCS,0275,RC,,,,both,,,47885.00,31125.25,,,,,,,,,,,,,
SCREW BNE L15MM OD23MM TI CORT ST FULL THRD CRSS FIT SM HEX,SUP-2364120,CDM,C1713,HCPCS,0278,RC,,,,both,,,365.65,237.67,,,,,,,,,,,,,
KIT PICC CATHETER AD 5FR L50CM GWIRE L1775IN 0018IN POLYUR 2,SUP-2383478,CDM,C1751,HCPCS,0278,RC,,,,both,,,197.79,128.56,,,,,,,,,,,,,
BIT DRL L115MM DIA1.9MM STP 35MM STRYKR END DISP FOR,SUP-2366428,CDM,2720000010,LOCAL,0272,RC,,,,both,,,523.44,340.24,,,,,,,,,,,,,
HC So Amino Acids Quantitation Each,PX-3018213166,CDM,82131,CPT,0301,RC,,,,both,,,156.00,101.40,,,,,,,,,,,,,
COMPONENT FEM SZ 6 NP LT KNEE PRI CRUC RET CEM STEMLESS,SUP-2349034,CDM,C1776,CPT,0278,RC,,,,both,,,11351.10,7378.21,,,,,,,,,,,,,
STRUT HEXAPOD SM,SUP-2491201,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
BRACE WR ADULTXL LT INSTABILITY INJ,SUP-2198769,CDM,L3809,HCPCS,0272,RC,,,,both,,,69.39,45.10,,,,,,,,,,,,,
ARIPIPRAZOLE 10 MG PO TABS,RX-34369,CDM,6370000000,HCPCS,0637,RC,16714-0143-01,NDC,,both,1,UN,5.30,3.44,,,,,,,,,,,,,
PROBE NERVE STIM MONOPOLAR SLIM PRASS FLSH TIP STRL DISP,SUP-2902112,CDM,2720000010,LOCAL,0272,RC,,,,both,,,370.21,240.64,,,,,,,,,,,,,
VALVE SHUNT HI PRESSURE CSF FLO CTRL DELT,SUP-2284511,CDM,C1713,HCPCS,0278,RC,,,,both,,,2083.30,1354.14,,,,,,,,,,,,,
CANNULA ART 10 MM,SUP-2106274,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3736.60,2428.79,,,,,,,,,,,,,
STENT BILI ST-2 SOEH TANNENBAUM L 5 CM DIA10 FR ENDOSCP,SUP-2738114,CDM,C2625,HCPCS,0278,RC,,,,both,,,405.06,263.29,,,,,,,,,,,,,
HC OB ER Level 5,PX-4509928501,CDM,99285,CPT,0450,RC,,,,inpatient,,,3911.00,2542.15,,,,,,,,,,,,,
KNIFE SURG KLEINSASSER 9.75 INX8 MM CRV PT MICROFRANCE LF,SUP-2485002,CDM,2720000010,LOCAL,0272,RC,,,,both,,,575.62,374.15,,,,,,,,,,,,,
MATRIX BIO L 9.4 X W 4.7 IN SZ 288 SQCM PORCINE TEND DERIVED,SUP-2909292,CDM,A2008,HCPCS,0636,RC,,,,both,,,16309.16,10600.95,,,,,,,,,,,,,
SHEATH INTRO PRELUDEEASE L 11 CM DIA 7 FR TIP L 3 MM,SUP-2740566,CDM,C1894,HCPCS,0272,RC,,,,both,,,108.80,70.72,,,,,,,,,,,,,
GRAFT HUM TISS W76XL200MM N MESHED SKIN CRYOPRESERVED,SUP-2264847,CDM,C1713,HCPCS,0278,RC,,,,both,,,1594.74,1036.58,,,,,,,,,,,,,
FILGRASTIM-SNDZ 300 MCG/0.5ML IJ SOSY,RX-131187,CDM,Q5101,HCPCS,0636,RC,61314-0318-01,NDC,,both,0.5,ML,809.40,526.11,,,,,,,,,,,,,
CYSTOURETHROSCOPE FLX OD 16.5 FR WORKING CHANNEL 7.2 FR,SUP-2882440,CDM,2720000010,LOCAL,0272,RC,,,,both,,,499.26,324.52,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 80 CM DIA 8 MM STR TW SLDE GDS,SUP-2227380,CDM,C1768,CPT,0278,RC,,,,both,,,3119.12,2027.43,,,,,,,,,,,,,
CATHETER URET 6/10FR L50CM INJ LUMN DIA0.05IN AQ 2 LUMN,SUP-2171300,CDM,C1758,HCPCS,0278,RC,,,,both,,,136.28,88.58,,,,,,,,,,,,,
SCREW BNE FT 4X26 MM 12 MM CANC SM HEX SOCKET SS NS LCP,SUP-2183724,CDM,C1713,HCPCS,0278,RC,,,,both,,,54.76,35.59,,,,,,,,,,,,,
PLATE BONE THK1MM 6 H MIDFACE GLD BSSO FOR 2MM SCR LORENZ,SUP-2402952,CDM,C1713,HCPCS,0278,RC,,,,both,,,1011.08,657.20,,,,,,,,,,,,,
SPACER SPNL SM W26XH14MM THORLUM PEEK FLAT INTBDY FUS ADD,SUP-2291502,CDM,C1889,HCPCS,0278,RC,,,,both,,,13056.12,8486.48,,,,,,,,,,,,,
WEDGE EVANS 3D PRNT TI SM 17X8MM,SUP-2320323,CDM,C1713,HCPCS,0278,RC,,,,both,,,6868.75,4464.69,,,,,,,,,,,,,
COIL EMB L14.2CM DIA10-4MM COMPATIBLE GWIRE 0.018IN PLAT,SUP-2168428,CDM,C1889,HCPCS,0278,RC,,,,both,,,257.73,167.52,,,,,,,,,,,,,
PLATE X VA LCK 2.4/2.7MM SM STRL,SUP-2546955,CDM,C1713,HCPCS,0278,RC,,,,both,,,3681.43,2392.93,,,,,,,,,,,,,
ADAPTER HRT ALRM CTRL,SUP-2282559,CDM,Q0508,HCPCS,0274,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
PLATE BNE L217MM 12 H NONSTERILE L PROX TIB S STL,SUP-2185705,CDM,C1713,HCPCS,0278,RC,,,,both,,,3819.46,2482.65,,,,,,,,,,,,,
SET LD EXTRACTION EVOLUTION SHORTIE L 13.6 CM OD 17 FR ID 11,SUP-2170681,CDM,C1773,HCPCS,0272,RC,,,,both,,,2734.03,1777.12,,,,,,,,,,,,,
PLATE BNE W11XL154MM THK4.2MM 10 H MTPHSEAL S STL LOK COMPR,SUP-2185263,CDM,C1713,HCPCS,0278,RC,,,,both,,,2557.40,1662.31,,,,,,,,,,,,,
SYSTEM CLSR NDL STR SUT GUID SUT PASS CARTER-THOMASON II,SUP-2171687,CDM,2720000010,LOCAL,0272,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
DEXTROSE 5% IV SOLN NEONATE,RX-40840076,CDM,2580000003,HCPCS,0258,RC,00264-7510-00,NDC,,both,1000,ML,34.00,22.10,,,,,,,,,,,,,
SET SUPRPUB ACC SHTH L12CM DIA16FR FOR ENDO PROC OBRIEN,SUP-2171272,CDM,C2627,HCPCS,0272,RC,,,,both,,,271.30,176.34,,,,,,,,,,,,,
RING EXT FIX FULL L140MM SIDEKCK,SUP-2400638,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3121.16,2028.75,,,,,,,,,,,,,
STENT URET RESONANCE L 26 CM CATH L 71.5 CM DIA 6 FR SHTH L,SUP-2171371,CDM,C2625,HCPCS,0278,RC,,,,both,,,766.03,497.92,,,,,,,,,,,,,
NIVOLUMAB 40 MG/4ML IV SOLN,RX-128572,CDM,J9299,HCPCS,0636,RC,00003-3772-11,NDC,,both,4,ML,3812.70,2478.25,,,,,,,,,,,,,
HC CT Chest W/WO Contrast,PX-3527127000,CDM,71270,CPT,0352,RC,,,,inpatient,,,2630.00,1709.50,,,,,,,,,,,,,
DILATOR ENDOSCP CATHETER  L18MM DIA6FR BLLN L40MM DIA6MM PRS,SUP-2436488,CDM,2720000010,LOCAL,0272,RC,,,,both,,,899.08,584.40,,,,,,,,,,,,,
TUBE INNR EAR MYR VENT FLNG W/ TAB 1.02 MM ID TYTAN TI STRL,SUP-2277596,CDM,L8699,HCPCS,0278,RC,,,,both,,,138.16,89.80,,,,,,,,,,,,,
PLATE BNE L W10.1XL84MM THK3.5MM 6 H BILAT S STL STR RIG,SUP-2186211,CDM,C1713,HCPCS,0278,RC,,,,both,,,1339.40,870.61,,,,,,,,,,,,,
SCREW BNE L80MM DIA4MM ST BLU CORT TI ST NONCANNULATED LOK,SUP-2192303,CDM,C1713,HCPCS,0278,RC,,,,both,,,843.40,548.21,,,,,,,,,,,,,
SPLINT ARM L W25XL14IN FOR 8-21IN LIMB TRNSLUC FAB POLYSTYR,SUP-2328638,CDM,L3702,HCPCS,0272,RC,,,,both,,,31.53,20.49,,,,,,,,,,,,,
PLATE BNE L100MM 7 H L SUP CLAV S STL LOK COMPR FOR 3.5MM,SUP-2184146,CDM,C1713,HCPCS,0278,RC,,,,both,,,2736.48,1778.71,,,,,,,,,,,,,
EPINEPHRINE 1 MG/ML IJ SOLN (MIXTURES ONLY),RX-430031,CDM,J0169,HCPCS,0636,RC,76329-9060-00,NDC,,both,0.1,ML,54.10,35.16,,,,,,,,,,,,,
STEM FEM L200MM OD10MM TIB KNEE CEM SPLINED BOW CVD IMP,SUP-2405527,CDM,C1776,CPT,0278,RC,,,,both,,,4556.14,2961.49,,,,,,,,,,,,,
ALLOGRAFT BNE STRUT 15 CM SEG FEM,SUP-2321804,CDM,C1713,HCPCS,0278,RC,,,,both,,,2216.84,1440.95,,,,,,,,,,,,,
SHOE ORTHOT CUST DENNIS BRN SPLNT,SUP-2435749,CDM,L3640,HCPCS,0272,RC,,,,both,,,122.49,79.62,,,,,,,,,,,,,
GRAFT HUM TISS W4-10XH0.009-0.13XL33MM N MESHED DERM TISS,SUP-2112980,CDM,Q4116,HCPCS,0636,RC,,,,both,,,53.38,34.70,,,,,,,,,,,,,
IMETELSTAT SODIUM 188 MG IV SOLR|DISCARDED DRUG NOT ADMINISTE,RX-168241,CDM,J0870,HCPCS,0636,RC,82959-0111-01,NDC,JW,both,6,ML,29979.60,19486.74,,,,,,,,,,,,,
COMPONENT TIB CR ALL POLY 9MM SZ 1,SUP-2222623,CDM,C1776,CPT,0278,RC,,,,both,,,4521.60,2939.04,,,,,,,,,,,,,
LIDO-EPINEPHRINE-TETRACAINE 4-0.18-0.5 % EX GEL,RX-153363,CDM,6370000000,HCPCS,0637,RC,71266-6290-01,NDC,,both,3,ML,79.20,51.48,,,,,,,,,,,,,
KIT IR FULL SMRT CT PICC 6 FR 2 LUMN STD TAPR .018 X 130 CM,SUP-2118452,CDM,C1751,HCPCS,0278,RC,,,,both,,,258.74,168.18,,,,,,,,,,,,,
SUPPORT ORTHOT FT CUST ABDUCTN ROT BAR W/O SHOE,SUP-2435712,CDM,L3150,HCPCS,0274,RC,,,,both,,,230.48,149.81,,,,,,,,,,,,,
LEAD ANAS CPLR EXT FLO CPLR,SUP-2900199,CDM,2720000010,LOCAL,0272,RC,,,,both,,,545.58,354.63,,,,,,,,,,,,,
IMPLANT HUM TISS DIA16 MM SM THOR AORT REDUC THROMBOSIS,SUP-2933163,CDM,C1762,CPT,0278,RC,,,,both,,,25248.43,16411.48,,,,,,,,,,,,,
BASEPLATE TIB L67MM LNG KNEE UHMWPE STEM NONMODULAR ORTH,SUP-2405771,CDM,C1776,CPT,0278,RC,,,,both,,,8633.43,5611.73,,,,,,,,,,,,,
KIT ELECTROPHYSIOLOGY EPSTAR L 65 CM DIA 6 FR SPC 2-8-2 MM,SUP-2641911,CDM,C1730,HCPCS,0272,RC,,,,both,,,5809.00,3775.85,,,,,,,,,,,,,
SHEATH INTRO SUREFLEX L 72 CM DIA 8.5 FR DSTL CRV DIA17 MM,SUP-2131524,CDM,C1766,CPT,0272,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
DEVICE VES CLOSURE MONOPOLAR TIP 335 DEG 5 MMX34 CM LIGASURE,SUP-2174893,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2449.20,1591.98,,,,,,,,,,,,,
SCREW BNE HD 5X35 MM FOR FRAC REP FIX OSTEOTMY JT FUSION,SUP-2175041,CDM,C1713,HCPCS,0278,RC,,,,both,,,1624.95,1056.22,,,,,,,,,,,,,
PIN BLUNT HALF 200X30MM,SUP-2695684,CDM,C1713,HCPCS,0278,RC,,,,both,,,794.11,516.17,,,,,,,,,,,,,
ENDCAP ORTH EXTN 0MM HINDFOOT AQUA TI CANN T25 STARDRV,SUP-2189266,CDM,C1713,HCPCS,0278,RC,,,,both,,,607.87,395.12,,,,,,,,,,,,,
CPS SHRT CENTERING SLEEVE 27MM,SUP-2506439,CDM,C1776,CPT,0278,RC,,,,both,,,932.58,606.18,,,,,,,,,,,,,
HEMOCONCENTRATOR PERF ACCSRY CONN HEMOCOR HPH MINI,SUP-2484378,CDM,2720000010,LOCAL,0272,RC,,,,both,,,332.81,216.33,,,,,,,,,,,,,
PORT INFUS CATH DIA9.6FR TI PREATTACH SIL PEEL APART INTRO,SUP-2127727,CDM,C1788,HCPCS,0278,RC,,,,both,,,800.70,520.45,,,,,,,,,,,,,
DVR LOCK EXTRA LNG R ST,SUP-2587118,CDM,C1713,HCPCS,0278,RC,,,,both,,,3713.05,2413.48,,,,,,,,,,,,,
PATCH CV CORMATRIX SZ 2 X 10 CM PORCINE PERICARD CLOSURE,SUP-2140412,CDM,C1768,CPT,0278,RC,,,,both,,,926.30,602.09,,,,,,,,,,,,,
MICROSPHERE EMB EMBOSPHERE DIA 50-100 UM 2 CC 20 CC SYR GRA,SUP-2700439,CDM,C1889,HCPCS,0278,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
GRAFT VASC STD WALLED INTEGR RNG IMPL L40CM L40CM ID6MM,SUP-2395836,CDM,C1768,CPT,0278,RC,,,,both,,,3460.28,2249.18,,,,,,,,,,,,,
COMPONENT TIB INLAY 2 KNEE STRL RESTORIS,SUP-2265740,CDM,C1776,CPT,0278,RC,,,,both,,,4149.48,2697.16,,,,,,,,,,,,,
PLATE BNE CRV R108 58.5 MM PELV 4 HOLE SS MATTA,SUP-2362681,CDM,C1713,HCPCS,0278,RC,,,,both,,,2395.82,1557.28,,,,,,,,,,,,,
PLATE BNE THK06MM 4 H MIDFACE TI STR LO PROF LEV 1 SIL FOR,SUP-2262715,CDM,C1713,HCPCS,0278,RC,,,,both,,,238.45,154.99,,,,,,,,,,,,,
GRFT CRUSH CANC 1-4MM 15CC PUROS,SUP-2693925,CDM,C1713,HCPCS,0278,RC,,,,both,,,1921.68,1249.09,,,,,,,,,,,,,
SCREW BONE L65MM DIA2.7MM STD CORT FULL THRD CANN ST LCK S,SUP-2348735,CDM,C1713,HCPCS,0278,RC,,,,both,,,328.95,213.82,,,,,,,,,,,,,
STENT BILI FORMULA 418 L 24 MM DIA 8 MM DEL SYS L 80 CM SHTH,SUP-2170446,CDM,C1876,HCPCS,0278,RC,,,,both,,,2750.26,1787.67,,,,,,,,,,,,,
OBTURATOR SHTH 5FRX26CM LUERLOCK,SUP-2355474,CDM,C1894,HCPCS,0272,RC,,,,both,,,17.27,11.23,,,,,,,,,,,,,
HEAD RADIAL 3+ MM 9X19 MM 7.5 MM ELBW STRL,SUP-2789483,CDM,C1776,CPT,0278,RC,,,,both,,,8324.83,5411.14,,,,,,,,,,,,,
BIT DRILL FOR 3.5MM SCR SH IMPL,SUP-2232054,CDM,C1713,HCPCS,0278,RC,,,,both,,,580.90,377.58,,,,,,,,,,,,,
PLATE EXT FIX NEUT STP OFF NS DISP SMRT TSF,SUP-2933350,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2340.84,1521.55,,,,,,,,,,,,,
APPLIER CLP MED LG 5 MMX45 CM MANUAL LOAD HEM-O-LOK ENDO5,SUP-2656813,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4066.30,2643.09,,,,,,,,,,,,,
STENT ESOPH HANAROSTENT L 150 MM DIA22 MM DEL SYS L 700 MM,SUP-2417323,CDM,C1874,HCPCS,0278,RC,,,,both,,,6860.90,4459.58,,,,,,,,,,,,,
Z ON EXTENDED BACKORDER VALVE CHST DRN 30ML W/ 30ML COLL PNEUMOSTAT,SUP-2227348,CDM,C1729,HCPCS,0272,RC,,,,both,,,108.93,70.80,,,,,,,,,,,,,
GRAFT TENDON FASCIA LATA > 150CM FRESH FROZEN,SUP-2866788,CDM,C1762,CPT,0278,RC,,,,both,,,3042.66,1977.73,,,,,,,,,,,,,
HC So Insulin Antibodies,PX-3028633766,CDM,86337,CPT,0302,RC,,,,outpatient,,,815.00,529.75,,,,,,,,,,,,,
INTRODUCER INTUB FROVA,SUP-2169466,CDM,C1894,HCPCS,0272,RC,,,,both,,,233.15,151.55,,,,,,,,,,,,,
K WIRE FIX L6IN DIA0.062IN TRCR PNT 6PK,SUP-2412238,CDM,C1713,HCPCS,0278,RC,,,,both,,,171.57,111.52,,,,,,,,,,,,,
BIT DRL L280MM DIA11MM W/O STP CANN CONIC QUIK CPL REUSE,SUP-2188235,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1441.98,937.29,,,,,,,,,,,,,
TRIAL INSRT L20MM SZ 2 TIB REV PROVEN,SUP-2359243,CDM,C1776,CPT,0278,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
GUIDEWIRE VASC L 260 CM DIA 0.035 IN TAPR L 4 CM FLPY TIP L,SUP-2638704,CDM,C1769,HCPCS,0272,RC,,,,both,,,284.11,184.67,,,,,,,,,,,,,
GRAFT BONE 2.5 CC OSTEOAMP,SUP-2424594,CDM,C1713,HCPCS,0278,RC,,,,both,,,3042.66,1977.73,,,,,,,,,,,,,
PLUG VASC AMPLATZER UNCONSTRAINED L 8 MM DIA14 MM DEL SYS L,SUP-2116332,CDM,C1889,HCPCS,0278,RC,,,,both,,,2515.14,1634.84,,,,,,,,,,,,,
CATHETER ANGIOPLSTY 20MMX6X110CM BAL DIL PTV NUCLEUSX,SUP-2309686,CDM,C1725,HCPCS,0272,RC,,,,both,,,2681.78,1743.16,,,,,,,,,,,,,
PERICARDIOCENTESIS SET 8.5 FRX22 CM,SUP-2760013,CDM,C1729,HCPCS,0272,RC,,,,both,,,701.01,455.66,,,,,,,,,,,,,
TUBING STBL DIA12MM DISPOSABLE CARDIOVAC DA VINCI ENDOWRIST,SUP-2246649,CDM,C1713,HCPCS,0278,RC,,,,both,,,910.60,591.89,,,,,,,,,,,,,
GUIDEWIRE VASC L 180 CM DIA 0.018 IN TAPR L 7 CM FLPY TIP L,SUP-2167840,CDM,C1769,HCPCS,0272,RC,,,,both,,,158.60,103.09,,,,,,,,,,,,,
PLATE RETEN AUTOCAPTURE + LD TOOL USED W E3AC+ FLX SUT PASS,SUP-2256895,CDM,C1713,HCPCS,0278,RC,,,,both,,,218.54,142.05,,,,,,,,,,,,,
FENTANYL (SUBLIMAZE) 0.05 MG/ML INFUSION (PED) UNDILUTED,RX-4090323,CDM,J3010,HCPCS,0636,RC,00409-9094-31,NDC,,both,20,ML,60.30,39.19,,,,,,,,,,,,,
PLATE BNE L105MM 4 H NONSTERILE POST MED PROX TIB S STL LOK,SUP-2177794,CDM,C1713,HCPCS,0278,RC,,,,both,,,3106.46,2019.20,,,,,,,,,,,,,
IMPLANT OTO L8MM SHFT DIA0.8MM HA PLASTIPORE GBERG,SUP-2312579,CDM,L8613,CPT,0278,RC,,,,both,,,1078.59,701.08,,,,,,,,,,,,,
SHEATH INTRO FAST-CATH L 23 CM DIA 8 FR GUIDEWIRE 0.038 IN,SUP-2355577,CDM,C1894,HCPCS,0272,RC,,,,both,,,113.04,73.48,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY L 92 CM 6FR 4MM B CRV QPLR UNIDIR,SUP-2248665,CDM,C1733,HCPCS,0272,RC,,,,both,,,2157.18,1402.17,,,,,,,,,,,,,
GRAFT HUM TISS L 25-30 X W 15 MM THK T1 10 MM T2 7 MM IL,SUP-2913322,CDM,C1713,HCPCS,0278,RC,,,,both,,,4895.26,3181.92,,,,,,,,,,,,,
PUTTY ALLGRFT DEMIN BONE MTRX SYR VOL 2ML ALLOGENIX,SUP-2402965,CDM,C1713,HCPCS,0278,RC,,,,both,,,1058.18,687.82,,,,,,,,,,,,,
SCREW BNE CORTICAL 2.7X22 MM FUSION HEX DRV YEL WRST SS NS,SUP-2851925,CDM,C1713,HCPCS,0278,RC,,,,both,,,352.06,228.84,,,,,,,,,,,,,
NAIL IM L32CM DIA93MM UNIV TIB YEL TI ALLY NAT NAIL,SUP-2208206,CDM,C1713,HCPCS,0278,RC,,,,both,,,4864.24,3161.76,,,,,,,,,,,,,
AID HEARING BONE ANCHORED 6 MAX BRN,SUP-2823403,CDM,L8690,HCPCS,0278,RC,,,,both,,,13282.20,8633.43,,,,,,,,,,,,,
WASHER ORTHPDC TTNM FLAT F4.5 5MM CNNLTD SCREW SSTM TMX,SUP-2723556,CDM,C1713,HCPCS,0278,RC,,,,both,,,97.34,63.27,,,,,,,,,,,,,
"HC So Gel Diffusion, Qualitative",PX-3028633166,CDM,86331,CPT,0302,RC,,,,both,,,41.00,26.65,,,,,,,,,,,,,
BUR ORTH L 20 MM DIA 3.1 MM SHANNON RECTA 3 LG STRL DISP,SUP-2896797,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1444.40,938.86,,,,,,,,,,,,,
PROSTHESIS OSS L2 56MM HD OD15X2MM DST END CUP OD145MM TI HA,SUP-2232508,CDM,L8613,CPT,0278,RC,,,,both,,,651.49,423.47,,,,,,,,,,,,,
SCREW BONE L12MM OD3.5MM CORT DSTL VOLAR RAD TI POLYAX ST,SUP-2361567,CDM,C1713,HCPCS,0278,RC,,,,both,,,266.90,173.48,,,,,,,,,,,,,
AMIODARONE HCL IN DEXTROSE 150-4.21 MG/100ML-% IV SOLN,RX-108515,CDM,2500000003,HCPCS,0250,RC,43066-0150-10,NDC,,both,100,ML,199.60,129.74,,,,,,,,,,,,,
RETRIEVER ENDOSCP FIRM 2.5X6 MM 180 CM MERCI 2.5 V SER,SUP-2365839,CDM,C1757,HCPCS,0272,RC,,,,both,,,10660.30,6929.19,,,,,,,,,,,,,
URETEROSCOPE FLX 270 DEG FLD OF VW 90 DEG WORKING L 680 MM,SUP-2929753,CDM,C1747,HCPCS,0272,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
ALLOGRAFT BNE WHL ILIUM,SUP-2321821,CDM,C1713,HCPCS,0278,RC,,,,both,,,10286.64,6686.32,,,,,,,,,,,,,
ELECTRODE NERVE STIM MED INTOP LD ACCSRY GRDIAN,SUP-2854976,CDM,2720000010,LOCAL,0272,RC,,,,both,,,894.90,581.68,,,,,,,,,,,,,
WEDGE TIB SZ 3-4 THK10MM KNEE FULL STP HNG REV LEGION,SUP-2346600,CDM,C1776,CPT,0278,RC,,,,both,,,5695.96,3702.37,,,,,,,,,,,,,
WIRE MANDRIN VAN BUREN CRV 6FR,SUP-2160578,CDM,C1769,HCPCS,0272,RC,,,,both,,,95.90,62.33,,,,,,,,,,,,,
FILTER VASC 65CM 9FR INTRO 30MM PERM RETRIEVABLE MRI SAFE,SUP-2169013,CDM,C1880,HCPCS,0278,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
PLATE BONE CURVED 12 MM 1 MM 6 HOLE TITANIUM NON STERILE,SUP-2837791,CDM,C1713,HCPCS,0278,RC,,,,both,,,1455.08,945.80,,,,,,,,,,,,,
GRAFT BNE SUB 15CC SZ 17 7MM DEMIN CANC CHIP FRZ DRY,SUP-2307251,CDM,C1713,HCPCS,0278,RC,,,,both,,,1257.07,817.10,,,,,,,,,,,,,
PLATE BONE L153.5MM 8 H RT MEDL DSTL TIB TI FOR,SUP-2418840,CDM,C1713,HCPCS,0278,RC,,,,both,,,8635.00,5612.75,,,,,,,,,,,,,
SYSTEM RE-ENTRY OFFROAD CATH L 70 CM SHFT DIA 5 FR BALLOON,SUP-2145862,CDM,C1725,HCPCS,0272,RC,,,,both,,,8478.00,5510.70,,,,,,,,,,,,,
TIP ASPIR L38IN CUT W28XL2MM UNIV CLAW DCOMPR FOR SONOPET,SUP-2363702,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1788.51,1162.53,,,,,,,,,,,,,
NAIL IM L360MM DIA13MM FEM TI CANN LOK AG RG T2,SUP-2368970,CDM,C1713,HCPCS,0278,RC,,,,both,,,4239.00,2755.35,,,,,,,,,,,,,
PIN EXT FIX L28CM DIA2.4MM SPADE TIP 3MM EYELET GRFT PASS,SUP-2341287,CDM,2720000010,LOCAL,0272,RC,,,,both,,,675.10,438.81,,,,,,,,,,,,,
PHENTOLAMINE MESYLATE 5 MG IJ SOLR,RX-10947,CDM,J2760,HCPCS,0636,RC,68094-0101-20,NDC,,both,1,UN,2413.90,1569.03,,,,,,,,,,,,,
TUNNELER SURG FLUID SHTH 11 GAX10 IN REMOVABLE WNG STRL ON Q,SUP-2424463,CDM,C1713,HCPCS,0278,RC,,,,both,,,65.94,42.86,,,,,,,,,,,,,
LEFLUNOMIDE 20 MG PO TABS,RX-23873,CDM,6370000000,HCPCS,0637,RC,62332-0062-30,NDC,,both,1,UN,5.00,3.25,,,,,,,,,,,,,
EXPANDER TISS GEL 7.8 CM PROJCT 15.5X15.5 CM 850 CC ARTOURA,SUP-2301025,CDM,C1789,HCPCS,0278,RC,,,,both,,,5024.00,3265.60,,,,,,,,,,,,,
CATHETER PERIPH DIA3.2MM WC 2MM VW SPINPERC,SUP-2392608,CDM,C1751,HCPCS,0278,RC,,,,both,,,2402.10,1561.36,,,,,,,,,,,,,
PLATE BNE TBLR 2.7X41 MM 5 HOLE 1/4 SS,SUP-2536105,CDM,C1713,HCPCS,0278,RC,,,,both,,,358.27,232.88,,,,,,,,,,,,,
ALLOGRAFT BNE FRZN IRRADIATED FEM HD,SUP-2867201,CDM,C1762,CPT,0278,RC,,,,both,,,4000.20,2600.13,,,,,,,,,,,,,
STENT BILI WALLFLEX L 40 MM DIA10 MM CATH L 75 CM SHTH 9 FR,SUP-2141604,CDM,C1874,HCPCS,0278,RC,,,,both,,,12305.66,7998.68,,,,,,,,,,,,,
SCREW BNE L34MM DIA4MM CORT S STL ST NONCANNULATED LOK FULL,SUP-2185070,CDM,C1713,HCPCS,0278,RC,,,,both,,,428.30,278.39,,,,,,,,,,,,,
MESH CRAN W50XL50MM THK0.5MM RAP RESRB FOR 1.5MM SCR FIX,SUP-2194071,CDM,C1781,HCPCS,0278,RC,,,,both,,,4642.18,3017.42,,,,,,,,,,,,,
GUIDEWIRE VASC AMPLTZ SST L 260 CM DIA 0.035 IN TIP L 5 CM,SUP-2763467,CDM,C1769,HCPCS,0272,RC,,,,both,,,276.32,179.61,,,,,,,,,,,,,
SCREW GUID FOR AUG RM COMPHSVE RVS SHLDR SYS,SUP-2205384,CDM,C1713,HCPCS,0278,RC,,,,both,,,183.69,119.40,,,,,,,,,,,,,
ANCHOR SUT DIA5.5MM BIOCRYL RAPIDE ABSRB KNOTLESS HEALIX,SUP-2249439,CDM,C1713,HCPCS,0278,RC,,,,both,,,2957.88,1922.62,,,,,,,,,,,,,
TUBE CHST SET 8 FRX18 CM 1 LUMEN 3 SIDEPRT THAL-QUICK,SUP-2760091,CDM,C1729,HCPCS,0272,RC,,,,both,,,439.07,285.40,,,,,,,,,,,,,
STEM HUM OD4MM MIC CO CHROM SHLDR REV PRI CEM PRESSFIT,SUP-2404540,CDM,C1776,CPT,0278,RC,,,,both,,,14067.20,9143.68,,,,,,,,,,,,,
SET PICC L 15 CM DIA 5.5 FR SHTH L 7 CM DIA 5.5 FR,SUP-2887027,CDM,C1751,HCPCS,0278,RC,,,,both,,,558.92,363.30,,,,,,,,,,,,,
GRAFT HUM TISS FLOWABLE 0.6 CC CONNECTIVE TISS MTRX INTERFYL,SUP-2845979,CDM,Q4171,HCPCS,0636,RC,,,,both,,,3603.15,2342.05,,,,,,,,,,,,,
STENT NEURO SURPS STREAMLINE L 25 MM DIA 4 MM COCR INTCRAN,SUP-2884355,CDM,C1876,HCPCS,0278,RC,,,,both,,,45530.00,29594.50,,,,,,,,,,,,,
CATHETER EP 2-18-2-8-2 MM 7 FRX110 CM HALO XP,SUP-2248466,CDM,C1731,HCPCS,0278,RC,,,,both,,,3033.24,1971.61,,,,,,,,,,,,,
IMPLANT OTO L4.5MM PIST DIA0.6MM WELL DIA1MM FLROPLAS,SUP-2312590,CDM,L8613,CPT,0278,RC,,,,both,,,409.86,266.41,,,,,,,,,,,,,
BRACE ORTH CUST FABRICATED RIGID W/O INTFACE LNR PLAS,SUP-2388142,CDM,L0482,HCPCS,0274,RC,,,,both,,,4080.59,2652.38,,,,,,,,,,,,,
MESH SURG DIA 3.2 IN LG POLY-4-HYDROXYBUTYRATE POLYGLY ACD,SUP-2937422,CDM,C1781,HCPCS,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
KIT INTRO MICROEZ L 50 CM CATH 4.5 FR NDL L 5 CM PTFE ORN,SUP-2125498,CDM,C1894,HCPCS,0272,RC,,,,both,,,193.02,125.46,,,,,,,,,,,,,
GRAFT BNE SUB 5CC CA PHSPTE INJ VOID FILL FOR,SUP-2414251,CDM,C1713,HCPCS,0278,RC,,,,both,,,10248.96,6661.82,,,,,,,,,,,,,
COMPONENT FEM SZ 7 KNEE HNG AXLE LEGION,SUP-2346404,CDM,C1776,CPT,0278,RC,,,,both,,,1268.56,824.56,,,,,,,,,,,,,
INSERT TIB SZ 5 THK19MM UNIV KNEEX3 BEAR TECHNOLOGY CNDYL,SUP-2373223,CDM,C1776,CPT,0278,RC,,,,both,,,6183.29,4019.14,,,,,,,,,,,,,
INTRODUCER PACE LD SAFSHTH WORLEY 120 DEG L 62 CM DIA 7 FR,SUP-2356427,CDM,C1894,HCPCS,0272,RC,,,,both,,,1664.20,1081.73,,,,,,,,,,,,,
GRAFT HUMAN TSSUE EVANS WEDGE 2MMW X 22MML X 14MMH PRE SHPD,SUP-2573320,CDM,C1713,HCPCS,0278,RC,,,,both,,,2922.56,1899.66,,,,,,,,,,,,,
PLATE 15 H 230MM,SUP-2485234,CDM,C1713,HCPCS,0278,RC,,,,both,,,3373.93,2193.05,,,,,,,,,,,,,
BLADE SAW W13.5XL25.5MM THK0.4MM CUT THK0.6MM FN TOOTH,SUP-2166586,CDM,2720000010,LOCAL,0272,RC,,,,both,,,182.12,118.38,,,,,,,,,,,,,
GUIDEWIRE ORTH BLNT TIP 1.4X510 MM DISP,SUP-2684359,CDM,C1769,HCPCS,0272,RC,,,,both,,,320.28,208.18,,,,,,,,,,,,,
RELOAD STPLR X THN 45 MM REINF SIGNIA LD GRY TRI-STAPLE 2.0,SUP-2858002,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1405.21,913.39,,,,,,,,,,,,,
PLATE BNE THK1MM 6 H TI FOREFOOT MIDFOOT BILAT POLYAX LOK,SUP-2398224,CDM,C1713,HCPCS,0278,RC,,,,both,,,4521.60,2939.04,,,,,,,,,,,,,
SLING ORTH ADJ STRP UNIV 5.4X5 IN 19X13 IN SHLDR DLX,SUP-2195027,CDM,L3660,HCPCS,0274,RC,,,,both,,,31.43,20.43,,,,,,,,,,,,,
BUR SURG ACROMIONIZER 5.5X130 MM W/ LAT PROTCT VIO STRL DISP,SUP-2599846,CDM,2720000010,LOCAL,0272,RC,,,,both,,,388.07,252.25,,,,,,,,,,,,,
GUIDEWIRE ORTH THRD 2.8X300 MM FOR CANN SCREW NS 03333015,SUP-2789107,CDM,C1769,HCPCS,0272,RC,,,,both,,,538.82,350.23,,,,,,,,,,,,,
DRIVER SURG OD2X35MM HEX ARTC FOR FIX SYS CORETRAK SIDEKCK,SUP-2399886,CDM,2720000010,LOCAL,0272,RC,,,,both,,,342.26,222.47,,,,,,,,,,,,,
RESERVOIR SHUNT 20MM TITANIUM INTEGRATED CATHETER L600MM FLU,SUP-2830493,CDM,C1889,HCPCS,0278,RC,,,,both,,,1314.91,854.69,,,,,,,,,,,,,
MICROSPHERE EMB CNTOUR SE DIA 700-900 UM 2 ML PVA PREFIL SYR,SUP-2141199,CDM,C1889,HCPCS,0278,RC,,,,both,,,831.79,540.66,,,,,,,,,,,,,
Colorectal Scrn; Hi Risk Ind,CASE-G0105,LOCAL,G0105,CPT,,,,,,outpatient,,,9619.23,5771.54,,,,,,,,,,,,,
Vulvectomy Simple Partial,CASE-56620,LOCAL,56620,CPT,0360,RC,,,,outpatient,,,24744.20,14846.52,,,,,,,,,,,,,
Colorectal Scrn; Hi Risk Ind,CASE-G0105,LOCAL,G0105,CPT,0360,RC,,,,outpatient,,,9619.23,5771.54,,,,,,,,,,,,,
Vulvectomy Simple Partial,CASE-56620,LOCAL,56620,CPT,,,,,,outpatient,,,24744.20,14846.52,,,,,,,,,,,,,
CATHETER VENTRICULAR NON-PRESSURE TBNG BLU STRP,SUP-2666734,CDM,C1729,HCPCS,0272,RC,,,,both,,,52.19,33.92,,,,,,,,,,,,,
TAP SURG SCR SLD BONE SPNL CLR CODE 3.7MM DYNALOK,SUP-2290320,CDM,C1713,HCPCS,0278,RC,,,,both,,,1589.53,1033.19,,,,,,,,,,,,,
KIT FIX EL TI 2 HUM CONDYLE HEXALOBULAR 2 SCR DISCVR,SUP-2215461,CDM,C1776,CPT,0278,RC,,,,both,,,4213.88,2739.02,,,,,,,,,,,,,
IMPLANT BRST SIL SIENTRA TEXT RND LO PROJCT 310CC,SUP-2339854,CDM,C1789,HCPCS,0278,RC,,,,both,,,2810.30,1826.69,,,,,,,,,,,,,
NAIL IM FEM 15X240 MM RT PROX PIRIFORMIS FOSSA STRL DISP,SUP-2463969,CDM,C1713,HCPCS,0278,RC,,,,both,,,5403.94,3512.56,,,,,,,,,,,,,
NAIL IM L210MM OD12MM 130DEG S STL PROX MEDIOLATERAL FEM,SUP-2351367,CDM,C1713,HCPCS,0278,RC,,,,both,,,1931.48,1255.46,,,,,,,,,,,,,
PLATE BNE L 130 X W 12 MM THK 3 MM SCREW DIA 3.5 MM 12 H SS 72469512,SUP-2933125,CDM,C1713,HCPCS,0278,RC,,,,both,,,3124.61,2031.00,,,,,,,,,,,,,
DILATOR ENDOSCP DIA11 13MM BLLN L80MM ES FIX WIRE BLLN DISPO,SUP-2436491,CDM,2720000010,LOCAL,0272,RC,,,,both,,,756.74,491.88,,,,,,,,,,,,,
GRAFT HUM TISS W4XL7CM NOM THK2MM MAXFORC EXTRM HUM DERM,SUP-2399139,CDM,Q4107,HCPCS,0636,RC,,,,both,,,9231.60,6000.54,,,,,,,,,,,,,
CATHETER GUID VISTA BRT TIP L 90 CM SHTH 6 FR GUIDEWIRE,SUP-2155677,CDM,C1887,HCPCS,0272,RC,,,,both,,,431.75,280.64,,,,,,,,,,,,,
BLADE MID SZ GLIDESCOPE TIP TO FR OF HNDL 82MM THICKNESS AT,SUP-2392651,CDM,2720000010,LOCAL,0272,RC,,,,both,,,15229.00,9898.85,,,,,,,,,,,,,
KIT GWIRE DIA2/2.4MM FOR ORTH BONE FIX RDY FOR SURG,SUP-2225501,CDM,C1769,HCPCS,0272,RC,,,,both,,,562.37,365.54,,,,,,,,,,,,,
NAIL FEM ANTEGRADE/RETROGRADE 12MM 280MM TI F/BIOMET - 12MM,SUP-2412885,CDM,C1713,HCPCS,0278,RC,,,,both,,,3651.82,2373.68,,,,,,,,,,,,,
SLING URETH VAG PROLAPSE REP W/ INTEPRO,SUP-2140310,CDM,C1771,HCPCS,0278,RC,,,,both,,,4380.30,2847.19,,,,,,,,,,,,,
Dstr Nrolytc Agnt Parverteb Fct Sngl Crvcl/Thora|LEFT SIDE,CASE-64633,LOCAL,64633,CPT,,,,,LT,outpatient,,,11822.95,7093.77,,,,,,,,,,,,,
Dstr Nrolytc Agnt Parverteb Fct Sngl Crvcl/Thora|LEFT SIDE,CASE-64633,LOCAL,64633,CPT,0360,RC,,,LT,outpatient,,,11822.95,7093.77,,,,,,,,,,,,,
HC Layer Closure Face <2.5 Cm,CASE-12051,LOCAL,12051,CPT,0450,RC,,,,outpatient,,,14635.83,8781.50,,,,,,,,,,,,,
"Tendon Sheath Incision|RIGHT HAND, FIFTH DIGIT|UNUSUAL NON-OVERLAPPING SERVICE",CASE-26055,LOCAL,26055,CPT,0360,RC,,,F9|XU,outpatient,,,17980.23,10788.14,,,,,,,,,,,,,
"Tendon Sheath Incision|RIGHT HAND, FIFTH DIGIT|UNUSUAL NON-OVERLAPPING SERVICE",CASE-26055,LOCAL,26055,CPT,,,,,F9|XU,outpatient,,,17980.23,10788.14,,,,,,,,,,,,,
PLATE BNE L113MM THK3MM 6 H BILAT S STL STR LOK COMPR RECON,SUP-2185335,CDM,C1713,HCPCS,0278,RC,,,,both,,,1386.75,901.39,,,,,,,,,,,,,
SCREW BNE L10MM DIA3.5MM CALCNL EL TI LOK HEXALOBE,SUP-2106642,CDM,C1713,HCPCS,0278,RC,,,,both,,,395.64,257.17,,,,,,,,,,,,,
PLATE BONE 3D PRNT SM MIDFACE MAND TI TRUMATCH,SUP-2860370,CDM,C1713,HCPCS,0278,RC,,,,both,,,30655.51,19926.08,,,,,,,,,,,,,
CATHETER DRNGE 32FR 4 WNG DISP FOR NEPHSTMY MALECOTS,SUP-2128994,CDM,C1729,HCPCS,0272,RC,,,,both,,,77.31,50.25,,,,,,,,,,,,,
CATHETER PERI L90CM OD2.5MM STR W/ CATH W/OUT RESVR N,SUP-2108711,CDM,C1729,HCPCS,0272,RC,,,,both,,,442.02,287.31,,,,,,,,,,,,,
STENT GRFT VASC POWERLINK INTUITRAK L 88 MM DIA,SUP-2217557,CDM,C1768,CPT,0278,RC,,,,both,,,8933.30,5806.64,,,,,,,,,,,,,
SET PICC L 15 CM DIA 4.5 FR SHTH L 7 CM DIA 4.5 FR,SUP-2887023,CDM,C1751,HCPCS,0278,RC,,,,both,,,525.64,341.67,,,,,,,,,,,,,
SCREW BONE LOK 5.5MM DIA 105MML TTNM CRTCL FLLY THRDD SOLID,SUP-2587390,CDM,C1713,HCPCS,0278,RC,,,,both,,,459.32,298.56,,,,,,,,,,,,,
BUR SURG M DIA5MM RND FLUT,SUP-2367420,CDM,2720000010,LOCAL,0272,RC,,,,both,,,296.86,192.96,,,,,,,,,,,,,
INSERT ACET OD44MM ID22MM 20DEG UHMWPE HIP COMP SER I OMFIT,SUP-2369977,CDM,C1776,CPT,0278,RC,,,,both,,,884.91,575.19,,,,,,,,,,,,,
ROD SPNL L36MM OD5.5MM POST LORDOSED LEV 2 TRANSITION,SUP-2230036,CDM,C1713,HCPCS,0278,RC,,,,both,,,5338.00,3469.70,,,,,,,,,,,,,
PLATE SPNL L 26 MM TI ANTR CERV LEVEL 2 NS SONOMA,SUP-2887248,CDM,C1713,HCPCS,0278,RC,,,,both,,,57.34,37.27,,,,,,,,,,,,,
BLADE SURG L28CM DIA4MM TIP L13MM 1 PC BEAV STR SHRP ROUNDED,SUP-2256843,CDM,2720000010,LOCAL,0272,RC,,,,both,,,822.68,534.74,,,,,,,,,,,,,
PLATE BONE L104MM 4 H STRL BILAT CLVRLF NONCOMPRESSION BTTRS,SUP-2343787,CDM,C1713,HCPCS,0278,RC,,,,both,,,2686.40,1746.16,,,,,,,,,,,,,
BUPIVACAINE-EPINEPHRINE 0.25% -1:200000 IJ SOLN (MIXTURES ONLY),RX-430034,CDM,2500000003,HCPCS,0250,RC,00409-1752-50,NDC,,both,50,ML,97.80,63.57,,,,,,,,,,,,,
PLATE BONE L80MM 3 H LT MEDL DSTL HUM FOR 2.7/3.5MM SCR EVOS,SUP-2341158,CDM,C1713,HCPCS,0278,RC,,,,both,,,6974.88,4533.67,,,,,,,,,,,,,
Insertion Intrauterine Device Iud,CASE-58300,LOCAL,58300,CPT,,,,,,outpatient,,,22267.28,13360.37,,,,,,,,,,,,,
Insertion Intrauterine Device Iud,CASE-58300,LOCAL,58300,CPT,0360,RC,,,,outpatient,,,22267.28,13360.37,,,,,,,,,,,,,
"HC Injection Small Joint/Bursa|RIGHT HAND, FOURTH DIGIT",CASE-20600,LOCAL,20600,CPT,0361,RC,,,F8,outpatient,,,10476.23,6285.74,,,,,,,,,,,,,
POST EXT FIX 3 H FOR RNG FIX SYS TRUELOK,SUP-2316131,CDM,2720000010,LOCAL,0272,RC,,,,both,,,496.37,322.64,,,,,,,,,,,,,
BIT DRILL L70MM DIA15MM JACOBS CHUCK REUSABLE,SUP-2480006,CDM,2720000010,LOCAL,0272,RC,,,,both,,,496.78,322.91,,,,,,,,,,,,,
SCREW SPNL L45MM DIA6.5MM CANC PEDCL PEEK ST CANN,SUP-2287312,CDM,C1713,HCPCS,0278,RC,,,,both,,,5273.94,3428.06,,,,,,,,,,,,,
GRAFT HUM TISS M PERF THN REGENERATIVE TISS MTRX CNTOUR,SUP-2113438,CDM,Q4116,HCPCS,0636,RC,,,,both,,,32122.20,20879.43,,,,,,,,,,,,,
PACK NEUROSURGICAL MYRIAD HNDPC L 13 CM DIA11 GA S3,SUP-2930307,CDM,2720000010,LOCAL,0272,RC,,,,both,,,46465.22,30202.39,,,,,,,,,,,,,
FILTER ASPIR ABS DISP PSI TEC III LYSONIX +,SUP-2152207,CDM,C1880,HCPCS,0278,RC,,,,both,,,109.90,71.43,,,,,,,,,,,,,
PLATE BNE L94MM 6 H ST L SUP CLAV TI LOK COMPR FOR 35MM SCR,SUP-2180888,CDM,C1713,HCPCS,0278,RC,,,,both,,,3201.17,2080.76,,,,,,,,,,,,,
KIT REP FULL THRD DISP FOR HALLUX VALGUS MINI TIGHTROPE,SUP-2122785,CDM,C1713,HCPCS,0278,RC,,,,both,,,2135.20,1387.88,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 80 CM DIA 5-8 MM EPTFE LNG TAPR TW,SUP-2695235,CDM,C1768,CPT,0278,RC,,,,both,,,3558.37,2312.94,,,,,,,,,,,,,
GRAFT NRV L2CM ID3MM CLLGN PERIPH NEURAWRAP,SUP-2244316,CDM,C9361,HCPCS,0278,RC,,,,both,,,3390.32,2203.71,,,,,,,,,,,,,
HC So Tissue Culture Tumor,PX-3118823966,CDM,88239,CPT,0311,RC,,,,inpatient,,,267.00,173.55,,,,,,,,,,,,,
STAPLE BNE FIX SZ 23 X 20 MM RAPID COMPR STRL LAPIPLASTY,SUP-2893065,CDM,C1713,HCPCS,0278,RC,,,,both,,,11379.36,7396.58,,,,,,,,,,,,,
PLATE BONE L64MM 3 H STRL RT MEDL DSTL TIB S STL PART ARTC,SUP-2349715,CDM,C1713,HCPCS,0278,RC,,,,both,,,6868.28,4464.38,,,,,,,,,,,,,
Peri-Implant Capsulectomy Breast Complete,CASE-19371,LOCAL,19371,CPT,,,,,,outpatient,,,120170.93,72102.56,,,,,,,,,,,,,
Neuroplasty &/Transposition Ulnar Nerve Elbow|RIGHT SIDE,CASE-64718,LOCAL,64718,CPT,,,,,RT,outpatient,,,18647.30,11188.38,,,,,,,,,,,,,
Lam Facetectomy&Foramot 1 Vrt Sgm Ea Addl Sgm,CASE-63048,LOCAL,63048,CPT,0360,RC,,,,outpatient,,,56162.02,33697.21,,,,,,,,,,,,,
Osteoplasty Radius/Ulna Shortening|RIGHT SIDE,CASE-25390,LOCAL,25390,CPT,0360,RC,,,RT,outpatient,,,34253.13,20551.88,,,,,,,,,,,,,
Prep Site F/S/N/H/F/G/M/D Gt 1st 100 Sq Cm/1pct,CASE-15004,LOCAL,15004,CPT,0360,RC,,,,outpatient,,,27102.72,16261.63,,,,,,,,,,,,,
Prep Site F/S/N/H/F/G/M/D Gt 1st 100 Sq Cm/1pct,CASE-15004,LOCAL,15004,CPT,,,,,,outpatient,,,27102.72,16261.63,,,,,,,,,,,,,
Cystourethroscopy Inj Chemodenervation Bladder|UNUSUAL NON-OVERLAPPING SERVICE,CASE-52287,LOCAL,52287,CPT,0360,RC,,,XU,outpatient,,,25647.80,15388.68,,,,,,,,,,,,,
Lam Facetectomy&Foramot 1 Vrt Sgm Ea Addl Sgm,CASE-63048,LOCAL,63048,CPT,,,,,,outpatient,,,56162.02,33697.21,,,,,,,,,,,,,
Cystourethroscopy Inj Chemodenervation Bladder|UNUSUAL NON-OVERLAPPING SERVICE,CASE-52287,LOCAL,52287,CPT,,,,,XU,outpatient,,,25647.80,15388.68,,,,,,,,,,,,,
Peri-Implant Capsulectomy Breast Complete,CASE-19371,LOCAL,19371,CPT,0360,RC,,,,outpatient,,,120170.93,72102.56,,,,,,,,,,,,,
Osteoplasty Radius/Ulna Shortening|RIGHT SIDE,CASE-25390,LOCAL,25390,CPT,,,,,RT,outpatient,,,34253.13,20551.88,,,,,,,,,,,,,
Hysteroscopy Diagnostic Separate Procedure,CASE-58555,LOCAL,58555,CPT,,,,,,outpatient,,,19261.23,11556.74,,,,,,,,,,,,,
Hysteroscopy Diagnostic Separate Procedure,CASE-58555,LOCAL,58555,CPT,0360,RC,,,,outpatient,,,19261.23,11556.74,,,,,,,,,,,,,
Neuroplasty &/Transposition Ulnar Nerve Elbow|RIGHT SIDE,CASE-64718,LOCAL,64718,CPT,0360,RC,,,RT,outpatient,,,18647.30,11188.38,,,,,,,,,,,,,
HC N Block Inj Intercost Sng|RIGHT SIDE,CASE-64420,LOCAL,64420,CPT,0360,RC,,,RT,outpatient,,,4376.67,2626.00,,,,,,,,,,,,,
SYSTEM IMPL MENISCAL ROOT REPAIR W/SWIVELOCK,SUP-2731857,CDM,C1713,HCPCS,0278,RC,,,,both,,,5338.00,3469.70,,,,,,,,,,,,,
IMMOBILIZER KNEE SM L19IN FOR 14 16IN BLU CANVS T BAR STAY,SUP-2336065,CDM,L1830,CPT,0272,RC,,,,both,,,40.07,26.05,,,,,,,,,,,,,
MESH HERN W1XL4IN INGUINAL POLYPR MFIL RECTANG,SUP-2125743,CDM,C1781,HCPCS,0278,RC,,,,both,,,76.30,49.59,,,,,,,,,,,,,
ACYCLOVIR 200 MG/5ML PO SUSP,RX-8970,CDM,340b,HCPCS,0637,RC,09999-9901-02,NDC,,both,5,ML,3.00,1.95,,,,,,,,,,,,,
KIT BNE CEMENT SINGLE DBL VAC MIXING DEL SYS STRL DISP,SUP-2884017,CDM,2720000010,LOCAL,0272,RC,,,,both,,,387.73,252.02,,,,,,,,,,,,,
BIT DRL L7MM DIA3.2MM CANN,SUP-2337746,CDM,2720000010,LOCAL,0272,RC,,,,both,,,709.64,461.27,,,,,,,,,,,,,
IMPLANT INTBDY FUS LUM LORDTC ALIF OR PLIF 19X24MM BAK VISTA,SUP-2414391,CDM,C1776,CPT,0278,RC,,,,both,,,18106.81,11769.43,,,,,,,,,,,,,
LINER ACET NEUT LONGEVITY,SUP-2448627,CDM,C1776,CPT,0278,RC,,,,both,,,98556.75,64061.89,,,,,,,,,,,,,
CAST ORTH 4 IN KIT W/O BOOT EZ,SUP-2427662,CDM,C1713,HCPCS,0278,RC,,,,both,,,405.31,263.45,,,,,,,,,,,,,
DEFIBRILLATOR IMPL EMBLEM W 83.1 X H 69.1 MM D 12.7 MM 59.5,SUP-2149156,CDM,C1722,HCPCS,0275,RC,,,,both,,,64370.00,41840.50,,,,,,,,,,,,,
SET INSTR IMPL SCR DIA6.5/7.3MM COMBINED CANN,SUP-2183060,CDM,C1713,HCPCS,0278,RC,,,,both,,,141088.05,91707.23,,,,,,,,,,,,,
DHS TRIPLE REAMER-COMPLETE FOR DHS PLATES-SHORT BARREL,SUP-2548674,CDM,C1713,HCPCS,0278,RC,,,,both,,,4715.21,3064.89,,,,,,,,,,,,,
PLATE BONE STRAIGHT 2 MM 12 HOLE PRECONTOURED TITANIUM LIGHT,SUP-2837752,CDM,C1713,HCPCS,0278,RC,,,,both,,,3488.23,2267.35,,,,,,,,,,,,,
SCREW BONE 9X25MM INTRF BIOABSRB STRL ENDO-FIX,SUP-2341349,CDM,C1713,HCPCS,0278,RC,,,,both,,,596.60,387.79,,,,,,,,,,,,,
ENOXAPARIN SODIUM 100 MG/ML IJ SOSY,RX-157664,CDM,J1650,HCPCS,0636,RC,00075-0623-00,NDC,,both,1,ML,142.90,92.88,,,,,,,,,,,,,
Grafting of Autologous Fat by Lipo Ea Addl 50 Cc,CASE-15772,LOCAL,15772,CPT,,,,,,outpatient,,,65234.35,39140.61,,,,,,,,,,,,,
Grafting of Autologous Fat by Lipo Ea Addl 50 Cc,CASE-15772,LOCAL,15772,CPT,0360,RC,,,,outpatient,,,65234.35,39140.61,,,,,,,,,,,,,
Laparoscopy W/Rmvl Adnexal Structures|LEFT SIDE,CASE-58661,LOCAL,58661,CPT,0360,RC,,,LT,outpatient,,,39313.72,23588.23,,,,,,,,,,,,,
"Tx Open Tendon Flexor Toe 1 Tendon Spx|LEFT FOOT, SECOND DIGIT",CASE-28232,LOCAL,28232,CPT,0360,RC,,,T1,outpatient,,,24836.20,14901.72,,,,,,,,,,,,,
Laparoscopy W/Rmvl Adnexal Structures|LEFT SIDE,CASE-58661,LOCAL,58661,CPT,,,,,LT,outpatient,,,39313.72,23588.23,,,,,,,,,,,,,
Hemorrhoidectomy Ntrnl & Xtrnl 1 Column/Group,CASE-46255,LOCAL,46255,CPT,0360,RC,,,,outpatient,,,11242.40,6745.44,,,,,,,,,,,,,
Injection Aa&/Strd Intercostal Nrv Ea Addl Lvl|RIGHT SIDE,CASE-64421,LOCAL,64421,CPT,,,,,RT,outpatient,,,4376.67,2626.00,,,,,,,,,,,,,
"Tendon Sheath Incision|LEFT HAND, THUMB|UNUSUAL NON-OVERLAPPING SERVICE",CASE-26055,LOCAL,26055,CPT,,,,,FA|XU,outpatient,,,17980.23,10788.14,,,,,,,,,,,,,
"Inj Dx/Ther Agnt Paravert Facet Joint, Cerv/Thorac, 2nd Level|LEFT SIDE",CASE-64491,LOCAL,64491,CPT,0360,RC,,,LT,outpatient,,,4402.88,2641.73,,,,,,,,,,,,,
Hemorrhoidectomy Ntrnl & Xtrnl 1 Column/Group,CASE-46255,LOCAL,46255,CPT,,,,,,outpatient,,,11242.40,6745.44,,,,,,,,,,,,,
"Inj Dx/Ther Agnt Paravert Facet Joint, Cerv/Thorac, 2nd Level|LEFT SIDE",CASE-64491,LOCAL,64491,CPT,,,,,LT,outpatient,,,4402.88,2641.73,,,,,,,,,,,,,
"Tendon Sheath Incision|LEFT HAND, THUMB|UNUSUAL NON-OVERLAPPING SERVICE",CASE-26055,LOCAL,26055,CPT,0360,RC,,,FA|XU,outpatient,,,17980.23,10788.14,,,,,,,,,,,,,
Injection Aa&/Strd Intercostal Nrv Ea Addl Lvl|RIGHT SIDE,CASE-64421,LOCAL,64421,CPT,0360,RC,,,RT,outpatient,,,4376.67,2626.00,,,,,,,,,,,,,
"Tx Open Tendon Flexor Toe 1 Tendon Spx|LEFT FOOT, SECOND DIGIT",CASE-28232,LOCAL,28232,CPT,,,,,T1,outpatient,,,24836.20,14901.72,,,,,,,,,,,,,
GRAFT HUM TISS SZ A 2.5X2CM THK50-100UM OPHTH AMNIO MEM STK,SUP-2135258,CDM,V2790,HCPCS,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
ANCHOR SUTURE WHITE/GREEN CO BRAID USP NO2 SUTURE QUICKWHIP,SUP-2824865,CDM,C1713,HCPCS,0278,RC,,,,both,,,182.87,118.87,,,,,,,,,,,,,
ACETAMINOPHEN-CODEINE 120-12 MG/5ML PO SOLN,RX-14468,CDM,6370000000,HCPCS,0637,RC,99999-9903-96,NDC,,both,5,ML,2.70,1.75,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9% BOLUS (FLUID RESUSCITATION),RX-4081440,CDM,2580000003,HCPCS,0250,RC,00990-7983-61,NDC,,both,1000,ML,297.50,193.37,,,,,,,,,,,,,
PLATE BNE L78MM BLDE W5.8XL38MM 130DEG 4 H ST BILAT PELV,SUP-2186598,CDM,C1713,HCPCS,0278,RC,,,,both,,,1737.49,1129.37,,,,,,,,,,,,,
CONNECTOR SPNL L36-56MM POST OCCIPITOCERVICOTHORACIC T STR,SUP-2230465,CDM,C1713,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
SCREW BNE LCK 2.4X8 MM METATRSL STRL MSP,SUP-2472408,CDM,C1713,HCPCS,0278,RC,,,,both,,,347.22,225.69,,,,,,,,,,,,,
NAIL IM TIB 8X390 MM TI STRL TNADVANCED,SUP-2789173,CDM,C1713,HCPCS,0278,RC,,,,both,,,4781.87,3108.22,,,,,,,,,,,,,
GRAFT VASC GORTX L 30 CM DIA 8 MM EPTFE STR STD WALL N RING,SUP-2396432,CDM,C1768,CPT,0278,RC,,,,both,,,1001.66,651.08,,,,,,,,,,,,,
STAPLER ENDO DIA12MM SIZE3.5MM L45MM BLU TISS LNAR CUT LN 6,SUP-2257592,CDM,2720000010,LOCAL,0272,RC,,,,both,,,752.09,488.86,,,,,,,,,,,,,
RISANKIZUMAB-RZAA 600 MG/10ML IV SOLN,RX-158794,CDM,J2327,HCPCS,0636,RC,00074-5015-01,NDC,,both,10,ML,30620.30,19903.19,,,,,,,,,,,,,
GRAFT BIO TISS W6XL5CM THK2MM NONDENATURED CLLGN BOV RECTANG,SUP-2243679,CDM,C9360,HCPCS,0278,RC,,,,both,,,1695.60,1102.14,,,,,,,,,,,,,
Parathyroidectomy/Exploration Parathyroids,CASE-60500,LOCAL,60500,CPT,0360,RC,,,,outpatient,,,48494.65,29096.79,,,,,,,,,,,,,
Laparoscopy Radical Nephrectomy,CASE-50545,LOCAL,50545,CPT,0360,RC,,,,outpatient,,,54271.45,32562.87,,,,,,,,,,,,,
Surgical Arthroscopy Sho W/Coracoacrm Ligm Rls|RIGHT SIDE,CASE-29826,LOCAL,29826,CPT,0360,RC,,,RT,outpatient,,,52628.60,31577.16,,,,,,,,,,,,,
Implant Neurostim/Receiver,CASE-64590,LOCAL,64590,CPT,0360,RC,,,,outpatient,,,58501.13,35100.68,,,,,,,,,,,,,
Laparoscopy Radical Nephrectomy,CASE-50545,LOCAL,50545,CPT,,,,,,outpatient,,,54271.45,32562.87,,,,,,,,,,,,,
Surgical Arthroscopy Sho W/Coracoacrm Ligm Rls|RIGHT SIDE,CASE-29826,LOCAL,29826,CPT,,,,,RT,outpatient,,,52628.60,31577.16,,,,,,,,,,,,,
Parathyroidectomy/Exploration Parathyroids,CASE-60500,LOCAL,60500,CPT,,,,,,outpatient,,,48494.65,29096.79,,,,,,,,,,,,,
Implant Neurostim/Receiver,CASE-64590,LOCAL,64590,CPT,,,,,,outpatient,,,58501.13,35100.68,,,,,,,,,,,,,
HC Peripheral Block - Femoral Single or Saphenous W/Img Gdn,CASE-64447,LOCAL,64447,CPT,0360,RC,,,,outpatient,,,59248.25,35548.95,,,,,,,,,,,,,
GRAFT HUM TISS FIB SHFT BNE FRZN ALLGRFT 150MM LEN 8 15MM W,SUP-2264753,CDM,C1713,HCPCS,0278,RC,,,,both,,,2400.88,1560.57,,,,,,,,,,,,,
LEAD PACE FINELINE II STEROX EZ L 52 CM DIA 5.1 FR POLYUR,SUP-2148670,CDM,C1898,HCPCS,0275,RC,,,,both,,,1164.94,757.21,,,,,,,,,,,,,
KIT SLNG BIOARC SP,SUP-2140292,CDM,C1771,HCPCS,0278,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
NARROW PLT STERILIZER 4.5X87 MM 5 HL,SUP-2818127,CDM,C1713,HCPCS,0278,RC,,,,both,,,1123.90,730.53,,,,,,,,,,,,,
SET STRL FOR 4.5MM 90DEG NONSTERILE CANN LC ANG BLDE INSTR,SUP-2183072,CDM,C1713,HCPCS,0278,RC,,,,both,,,12986.26,8441.07,,,,,,,,,,,,,
SUPPORT ORTHOT WRST HND FNGR CUST CABLE DRIVEN FABRICATED,SUP-2435770,CDM,L3901,HCPCS,0274,RC,,,,both,,,5470.16,3555.60,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 70 X 40 CM DIA 8 X 8 MM EPTFE,SUP-2396236,CDM,C1768,CPT,0278,RC,,,,both,,,6449.56,4192.21,,,,,,,,,,,,,
Removal Implant Deep,CASE-20680,LOCAL,20680,CPT,,,,,,outpatient,,,21331.45,12798.87,,,,,,,,,,,,,
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|RIGHT HAND, SECOND DIGIT",CASE-26160,LOCAL,26160,CPT,0360,RC,,,F6,outpatient,,,14019.07,8411.44,,,,,,,,,,,,,
HC Peripheral Block - Femoral Single or Saphenous W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE|LEFT SIDE,CASE-64447,LOCAL,64447,CPT,0360,RC,,,XU|LT,outpatient,,,33893.43,20336.06,,,,,,,,,,,,,
Laryngoscopy Exc Tum&/Stripping Cords/Epiglott,CASE-31540,LOCAL,31540,CPT,,,,,,outpatient,,,16278.60,9767.16,,,,,,,,,,,,,
"Inj Dx/Ther Agnt Paravert Facet Joint, Cerv/Thorac, 2nd Level|RIGHT SIDE",CASE-64491,LOCAL,64491,CPT,0360,RC,,,RT,outpatient,,,4402.88,2641.73,,,,,,,,,,,,,
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|RIGHT HAND, SECOND DIGIT",CASE-26160,LOCAL,26160,CPT,,,,,F6,outpatient,,,14019.07,8411.44,,,,,,,,,,,,,
Laryngoscopy Exc Tum&/Stripping Cords/Epiglott,CASE-31540,LOCAL,31540,CPT,0360,RC,,,,outpatient,,,16278.60,9767.16,,,,,,,,,,,,,
"Inj Dx/Ther Agnt Paravert Facet Joint, Cerv/Thorac, 2nd Level|RIGHT SIDE",CASE-64491,LOCAL,64491,CPT,,,,,RT,outpatient,,,4402.88,2641.73,,,,,,,,,,,,,
Removal Implant Deep,CASE-20680,LOCAL,20680,CPT,0360,RC,,,,outpatient,,,21331.45,12798.87,,,,,,,,,,,,,
BURR SURG 4MM DIA HD LNG MIC 70MML 10MML HD CARBIDE SM BNE B,SUP-2605567,CDM,2720000010,LOCAL,0272,RC,,,,both,,,73.98,48.09,,,,,,,,,,,,,
SCREW BNE L 18 MM DIA2.3 MM TI MAND ST AXS NS UNIV,SUP-2909537,CDM,C1713,HCPCS,0278,RC,,,,both,,,322.82,209.83,,,,,,,,,,,,,
PLATE SPNL SM FOR LAMINOPLASTY FIX SYS NEWBRIDGE,SUP-2316050,CDM,C1713,HCPCS,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
LARGE EXTERNAL FIXATOR TRAUMA KIT-STERILE,SUP-2546225,CDM,C1713,HCPCS,0278,RC,,,,both,,,10833.38,7041.70,,,,,,,,,,,,,
GRAFT BNE SUB GRFT 5CC VIA FRM MOLD,SUP-2393059,CDM,C1713,HCPCS,0278,RC,,,,both,,,6013.10,3908.51,,,,,,,,,,,,,
PLATE BNE RECON 3.5X156 MM 12 HOLE LCK LP SS NS,SUP-2184032,CDM,C1713,HCPCS,0278,RC,,,,both,,,2490.81,1619.03,,,,,,,,,,,,,
BUR SURG TAPR 2.3X15.9 MM 7 CM FOOTED SM BOR MIDAS REX 8,SUP-2664898,CDM,2720000010,LOCAL,0272,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
GUIDEWIRE VASC L 260 CM DIA 0.035 IN TAPR L 20 CM CRV RAD,SUP-2638702,CDM,C1769,HCPCS,0272,RC,,,,both,,,229.31,149.05,,,,,,,,,,,,,
SCREW BONE LAG 10MM DIA 75MML FNAIL,SUP-2724205,CDM,C1713,HCPCS,0278,RC,,,,both,,,1688.25,1097.36,,,,,,,,,,,,,
GUIDEWIRE ORTH SHT SALVATION,SUP-2852538,CDM,C1769,HCPCS,0272,RC,,,,both,,,1811.78,1177.66,,,,,,,,,,,,,
Intraop Sentinel Lymph Node ID W/Dye Injection|LEFT SIDE,CASE-38900,LOCAL,38900,CPT,,,,,LT,outpatient,,,37215.55,22329.33,,,,,,,,,,,,,
Cysto W/Ureteroscopy W/Rmvl/Manj Stones|RIGHT SIDE,CASE-52352,LOCAL,52352,CPT,,,,,RT,outpatient,,,16985.90,10191.54,,,,,,,,,,,,,
"Fasct Prtl Palmar 1 Dgt Prox Iphal Jt W/WO Rpr|RIGHT HAND, THUMB",CASE-26123,LOCAL,26123,CPT,0360,RC,,,F5,outpatient,,,16150.42,9690.25,,,,,,,,,,,,,
Bronchoscopy W/Plmt Fiducial Markers Single/Mult,CASE-31626,LOCAL,31626,CPT,0360,RC,,,,outpatient,,,41182.03,24709.22,,,,,,,,,,,,,
"Fasct Prtl Palmar 1 Dgt Prox Iphal Jt W/WO Rpr|RIGHT HAND, THUMB",CASE-26123,LOCAL,26123,CPT,,,,,F5,outpatient,,,16150.42,9690.25,,,,,,,,,,,,,
HC Lyr Clos Sc Tk Ext 2.6-7 Cm,CASE-12032,LOCAL,12032,CPT,0450,RC,,,,outpatient,,,23027.98,13816.79,,,,,,,,,,,,,
Cysto W/Ureteroscopy W/Rmvl/Manj Stones|RIGHT SIDE,CASE-52352,LOCAL,52352,CPT,0360,RC,,,RT,outpatient,,,16985.90,10191.54,,,,,,,,,,,,,
"Laminec/Facetect/Foramin,Cervical",CASE-63045,LOCAL,63045,CPT,,,,,,outpatient,,,53693.92,32216.35,,,,,,,,,,,,,
"Laminec/Facetect/Foramin,Cervical",CASE-63045,LOCAL,63045,CPT,0360,RC,,,,outpatient,,,53693.92,32216.35,,,,,,,,,,,,,
Repair Complex Trunk 2.6-7.5 Cm|UNUSUAL NON-OVERLAPPING SERVICE,CASE-13101,LOCAL,13101,CPT,,,,,XU,outpatient,,,16746.05,10047.63,,,,,,,,,,,,,
Bronchoscopy W/Plmt Fiducial Markers Single/Mult,CASE-31626,LOCAL,31626,CPT,,,,,,outpatient,,,41182.03,24709.22,,,,,,,,,,,,,
Repair Complex Trunk 2.6-7.5 Cm|UNUSUAL NON-OVERLAPPING SERVICE,CASE-13101,LOCAL,13101,CPT,0360,RC,,,XU,outpatient,,,16746.05,10047.63,,,,,,,,,,,,,
Intraop Sentinel Lymph Node ID W/Dye Injection|LEFT SIDE,CASE-38900,LOCAL,38900,CPT,0360,RC,,,LT,outpatient,,,37215.55,22329.33,,,,,,,,,,,,,
IMPLANT FACE L 52 X W 40 MM THK 2.3 MM ORBIT FLR MINIPLATE,SUP-2883518,CDM,C1713,HCPCS,0278,RC,,,,both,,,2975.84,1934.30,,,,,,,,,,,,,
RX MESH106 X 30 X 06MM SM GRID,SUP-2669267,CDM,C1713,HCPCS,0278,RC,,,,both,,,4245.25,2759.41,,,,,,,,,,,,,
STENT CORONARY XIENCE PRIM L 11 MM DIA 3 MM COCR POLYMER,SUP-2106183,CDM,C1874,HCPCS,0278,RC,,,,both,,,4239.00,2755.35,,,,,,,,,,,,,
SCREW BONE L20MM OD2.7MM MULT DIR LCK,SUP-2136281,CDM,C1713,HCPCS,0278,RC,,,,both,,,602.88,391.87,,,,,,,,,,,,,
MESH HERN W15XL20CM OPTIMIZED COMP OPN SKRT PARIETEX,SUP-2174715,CDM,C1781,HCPCS,0278,RC,,,,both,,,2386.18,1551.02,,,,,,,,,,,,,
MARKER SURG TISS W2XH1XL2CM BIOZORB LO PROF,SUP-2535481,CDM,A4648,CPT,0278,RC,,,,both,,,3061.50,1989.97,,,,,,,,,,,,,
WIRE EXT FIX L400MM DIA1.8MM S STL BAYNT PNT W/ STPR FOR,SUP-2342296,CDM,C1769,HCPCS,0272,RC,,,,both,,,19736.78,12828.91,,,,,,,,,,,,,
ABUTMENT FOR 3MM FLNG FIX 5.5MM BAHA BA210,SUP-2164963,CDM,L8614,HCPCS,0278,RC,,,,both,,,7429.24,4829.01,,,,,,,,,,,,,
ARH SLIDE-LOC LONG STEM 6MM RIGHT,SUP-2830413,CDM,C1776,CPT,0278,RC,,,,both,,,4631.50,3010.47,,,,,,,,,,,,,
PROSTHESIS OSS PISTON 0.8X5.5 MM MCGEE SS,SUP-2637760,CDM,L8613,CPT,0278,RC,,,,both,,,264.17,171.71,,,,,,,,,,,,,
TIP ASPIR L11.9CM DIA1.57MM FOR ULTRASONIC SURG ASPIR CUSA,SUP-2243961,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3088.19,2007.32,,,,,,,,,,,,,
HC Fresh Frozen Plasma Thawing,PX-3008692700,CDM,86927,CPT,0300,RC,,,,outpatient,,,247.00,160.55,,,,,,,,,,,,,
Myomectomy 5/> Myomas &/>250 Gm Abdomina,CASE-58146,LOCAL,58146,CPT,0360,RC,,,,outpatient,,,49107.08,29464.25,,,,,,,,,,,,,
"HC Repair Nail Bed|LEFT HAND, THIRD DIGIT",CASE-11760,LOCAL,11760,CPT,0450,RC,,,F2,outpatient,,,17935.63,10761.38,,,,,,,,,,,,,
Induced Abortion Dilation & Evacuation,CASE-59841,LOCAL,59841,CPT,,,,,,outpatient,,,17908.68,10745.21,,,,,,,,,,,,,
Ercp Remove Foreign Body/Stent Biliary/Panc Duct,CASE-43275,LOCAL,43275,CPT,0360,RC,,,,outpatient,,,24659.35,14795.61,,,,,,,,,,,,,
Myomectomy 5/> Myomas &/>250 Gm Abdomina,CASE-58146,LOCAL,58146,CPT,,,,,,outpatient,,,49107.08,29464.25,,,,,,,,,,,,,
Colonoscopy W/Biopsy Single/Multiple|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-45380,LOCAL,45380,CPT,,,,,74,outpatient,,,11125.28,6675.17,,,,,,,,,,,,,
HC Cv Cath Plac W/Port Tun >5,CASE-36561,LOCAL,36561,CPT,0361,RC,,,,outpatient,,,15970.62,9582.37,,,,,,,,,,,,,
Ercp Remove Foreign Body/Stent Biliary/Panc Duct,CASE-43275,LOCAL,43275,CPT,,,,,,outpatient,,,24659.35,14795.61,,,,,,,,,,,,,
Induced Abortion Dilation & Evacuation,CASE-59841,LOCAL,59841,CPT,0360,RC,,,,outpatient,,,17908.68,10745.21,,,,,,,,,,,,,
Ostectomy Calcaneus Spur W/WO Plntar Fascial Rls|LEFT SIDE,CASE-28119,LOCAL,28119,CPT,,,,,LT,outpatient,,,62141.05,37284.63,,,,,,,,,,,,,
Ostectomy Calcaneus Spur W/WO Plntar Fascial Rls|LEFT SIDE,CASE-28119,LOCAL,28119,CPT,0360,RC,,,LT,outpatient,,,62141.05,37284.63,,,,,,,,,,,,,
"HC Debrid,Subq Ea Addt'l 20sqcm",CASE-11045,LOCAL,11045,CPT,0361,RC,,,,outpatient,,,20451.32,12270.79,,,,,,,,,,,,,
Colonoscopy W/Biopsy Single/Multiple|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-45380,LOCAL,45380,CPT,0360,RC,,,74,outpatient,,,11125.28,6675.17,,,,,,,,,,,,,
SCREW BONE SCHANZ 2.5 MM 4X22 MM SYMPHYSIS SELFDRILLING TITA,SUP-2842153,CDM,C1713,HCPCS,0278,RC,,,,both,,,1426.50,927.22,,,,,,,,,,,,,
PLATE BNE L53MM 3X7 H S STL T LOK COMPR FOR 2MM SCR MOD,SUP-2186320,CDM,C1713,HCPCS,0278,RC,,,,both,,,1161.77,755.15,,,,,,,,,,,,,
EVOS VOL PLATE 10H LEFT STD TI 141MM NS,SUP-2819155,CDM,C1713,HCPCS,0278,RC,,,,both,,,9213.55,5988.81,,,,,,,,,,,,,
PLATE BNE LINDORF 2X6 MM CHIN MOD GRIFFIN TI,SUP-2457438,CDM,C1713,HCPCS,0278,RC,,,,both,,,614.84,399.65,,,,,,,,,,,,,
IMPLANT FACE L 42 X W 41 MM THK 0.85 MM SCREW DIA 0.5 MM,SUP-2883452,CDM,C1713,HCPCS,0278,RC,,,,both,,,3210.52,2086.84,,,,,,,,,,,,,
PLATE BNE VOLAR WIDE RT DSTL RADIAL VOLAR 3 HOLE NS,SUP-2464207,CDM,C1713,HCPCS,0278,RC,,,,both,,,810.12,526.58,,,,,,,,,,,,,
CATHETER TEMP PACE L 110 CM DIA 5 FR PROX 1 CM TRNSVEN,SUP-2127503,CDM,2720000010,LOCAL,0272,RC,,,,both,,,689.98,448.49,,,,,,,,,,,,,
WEDGE ACF ILIUM CREST TRADITION ALLGRFT 24 - 26 MM FRZ DRY,SUP-2294068,CDM,C1713,HCPCS,0278,RC,,,,both,,,3604.72,2343.07,,,,,,,,,,,,,
HC Peripheral Block - Femoral Continuous W/Img Gdn,PX-3606444800,CDM,64448,CPT,0360,RC,,,,both,,,2895.00,1881.75,,,,,,,,,,,,,
PLATE LK COMPRSS NAR 12 HL 223MM,SUP-2702813,CDM,C1713,HCPCS,0278,RC,,,,both,,,1048.45,681.49,,,,,,,,,,,,,
CATHETER ATHRCTMY KITTYCAT L 140 CM DIA 5 FR GUIDEWIRE 0.014,SUP-2124798,CDM,C1769,HCPCS,0272,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
HC Sinogram,PX-3207608000,CDM,76080,CPT,0320,RC,,,,both,,,600.00,390.00,,,,,,,,,,,,,
GRAFT TISS LIGMNT PAT W/ QUAD BISC,SUP-2165548,CDM,C1713,HCPCS,0278,RC,,,,both,,,5510.70,3581.95,,,,,,,,,,,,,
Injection Aa&/Strd Genicular Nrv Branches W/Img|LEFT SIDE,CASE-64454,LOCAL,64454,CPT,,,,,LT,outpatient,,,4392.15,2635.29,,,,,,,,,,,,,
Chromotubation Oviduct W/Materials,CASE-58350,LOCAL,58350,CPT,,,,,,outpatient,,,27958.98,16775.39,,,,,,,,,,,,,
Dilation Esoph Unguided Sound/Bougie 1/Mult Pass,CASE-43450,LOCAL,43450,CPT,,,,,,outpatient,,,11870.40,7122.24,,,,,,,,,,,,,
Chromotubation Oviduct W/Materials,CASE-58350,LOCAL,58350,CPT,0360,RC,,,,outpatient,,,27958.98,16775.39,,,,,,,,,,,,,
Dilation Esoph Unguided Sound/Bougie 1/Mult Pass,CASE-43450,LOCAL,43450,CPT,0360,RC,,,,outpatient,,,11870.40,7122.24,,,,,,,,,,,,,
Injection Aa&/Strd Genicular Nrv Branches W/Img|LEFT SIDE,CASE-64454,LOCAL,64454,CPT,0360,RC,,,LT,outpatient,,,4392.15,2635.29,,,,,,,,,,,,,
SCREW BONE L38MM DIA4MM PARTIALLY THRD HD M CANN FLOWERCUBE,SUP-2225336,CDM,C1713,HCPCS,0278,RC,,,,both,,,756.68,491.84,,,,,,,,,,,,,
PLATE BNE TBLR 73 MM 6-HOLE 1/3,SUP-2518438,CDM,C1713,HCPCS,0278,RC,,,,both,,,1868.30,1214.39,,,,,,,,,,,,,
SHEATH MICROINTRODUCER 7FR L7CM CLOSUREFAST,SUP-2172422,CDM,C1894,HCPCS,0272,RC,,,,both,,,95.77,62.25,,,,,,,,,,,,,
SCREW BONE SELFTAPPING 2X6 MM MANDIBULAR 20/PK TITANIUM NONS,SUP-2842274,CDM,C1713,HCPCS,0278,RC,,,,both,,,251.89,163.73,,,,,,,,,,,,,
CATHETER PICC SGL LUMN COMP ONLY NRS N PWR INJ SIL N COAT N,SUP-2120073,CDM,C1751,HCPCS,0278,RC,,,,both,,,183.69,119.40,,,,,,,,,,,,,
GRAFT BONE SUB 10CC DEMIN HUM BONE W/ POLOXAMER RESRB PUTTY,SUP-2244481,CDM,C9359,HCPCS,0278,RC,,,,both,,,8007.00,5204.55,,,,,,,,,,,,,
PUMP PAIN 400ML FLO RATE 2-14ML/HR SEL A FLO ON-Q,SUP-2236812,CDM,C9804,HCPCS,0272,RC,,,,both,,,659.40,428.61,,,,,,,,,,,,,
PLATE BNE L100MM 6 H ST ANT ANK S STL LOK COMPR FOR ARTH,SUP-2177142,CDM,C1713,HCPCS,0278,RC,,,,both,,,4399.61,2859.75,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC SV 4FR 55CM 2 LUMAN RVS TAP 3274108,SUP-2632663,CDM,C1751,HCPCS,0278,RC,,,,both,,,459.38,298.60,,,,,,,,,,,,,
COIL EMB L4CM DIA0.02IN LOOP DIA2MM COMPLX EXTRA SFT FILL,SUP-2323427,CDM,C1889,HCPCS,0278,RC,,,,both,,,6154.40,4000.36,,,,,,,,,,,,,
SPACER SPNL CNTRL PC B 20X32-44 MM VBR,SUP-2430767,CDM,C1889,HCPCS,0278,RC,,,,both,,,14660.66,9529.43,,,,,,,,,,,,,
CATHETER CARD ABLATION EZ STEER L 115 CM 8 FR 4 MM F-J CRV,SUP-2486857,CDM,C1733,HCPCS,0272,RC,,,,both,,,2628.18,1708.32,,,,,,,,,,,,,
Ligamentous Reconstruction Knee Extra-Articular,CASE-27427,LOCAL,27427,CPT,0360,RC,,,,outpatient,,,77952.75,46771.65,,,,,,,,,,,,,
Surgical Arthroscopy Shoulder Removal Loose/FB|SEPARATE STRUCTURE|RIGHT SIDE,CASE-29819,LOCAL,29819,CPT,0360,RC,,,XS|RT,outpatient,,,63631.85,38179.11,,,,,,,,,,,,,
Ligamentous Reconstruction Knee Extra-Articular,CASE-27427,LOCAL,27427,CPT,,,,,,outpatient,,,77952.75,46771.65,,,,,,,,,,,,,
Surgical Arthroscopy Shoulder Removal Loose/FB|SEPARATE STRUCTURE|RIGHT SIDE,CASE-29819,LOCAL,29819,CPT,,,,,XS|RT,outpatient,,,63631.85,38179.11,,,,,,,,,,,,,
HC Chemotx Admn Prtl Cavity,PX-3319644600,CDM,96446,CPT,0331,RC,,,,outpatient,,,1444.00,938.60,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC SV 3FR 45CM 1 LUMAN RVRSE T 9173108,SUP-2632693,CDM,C1751,HCPCS,0278,RC,,,,both,,,647.72,421.02,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.521,SUP-2860038,CDM,C1713,HCPCS,0278,RC,,,,both,,,38045.18,24729.37,,,,,,,,,,,,,
GRAFT HUM TISS FRZN ALLGRFT HUM W/O ROT CUF PROX STRUCTURAL,SUP-2307342,CDM,C1762,CPT,0278,RC,,,,both,,,15938.64,10360.12,,,,,,,,,,,,,
PIN FIX HALF LG 15X55 MM 3 MM,SUP-2861364,CDM,C1713,HCPCS,0278,RC,,,,both,,,174.65,113.52,,,,,,,,,,,,,
ALLODERM SELECT RESTORE X-LARGE PERFORATED - THICK 2.4 0.4MM,SUP-2822080,CDM,Q4116,HCPCS,0636,RC,,,,both,,,45508.02,29580.21,,,,,,,,,,,,,
INTRODUCER PACE LD DIA 8.5 FR HEMOSTAS,SUP-2357105,CDM,C1894,HCPCS,0272,RC,,,,both,,,138.16,89.80,,,,,,,,,,,,,
KIT OLV WIRE M FOR BONE FIX,SUP-2225526,CDM,2720000010,LOCAL,0272,RC,,,,both,,,499.89,324.93,,,,,,,,,,,,,
PLATE BNE L 287 X W 11.5 MM THK 3.6 MM SCREW DIA 3.5 MM 24 HL LT,SUP-2937393,CDM,C1713,HCPCS,0278,RC,,,,both,,,8672.99,5637.44,,,,,,,,,,,,,
CATHETER CV KT 5 FRX16 CM 16 GA JUG PUNC SPRING WIRE GUIDE,SUP-2763319,CDM,C1751,HCPCS,0278,RC,,,,both,,,57.78,37.56,,,,,,,,,,,,,
BUR SURG L13CM OD3MM 40DEG ENT BULL DMND 30K,SUP-2277859,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1454.61,945.50,,,,,,,,,,,,,
LEVEL NEURO ST PLATE ULTRNE STR WTAB NEURO SCRW4 HOLE 22 MM,SUP-2676758,CDM,C1713,HCPCS,0278,RC,,,,both,,,494.42,321.37,,,,,,,,,,,,,
NAIL IM L260MM DIA11MM L R HUM BLU TI AG RG BENT CANN LOK,SUP-2179654,CDM,C1713,HCPCS,0278,RC,,,,both,,,5042.27,3277.48,,,,,,,,,,,,,
PILOCARPINE HCL 1 % OP SOLN,RX-6279,CDM,6370000000,HCPCS,0637,RC,61314-0203-15,NDC,,both,15,ML,354.90,230.68,,,,,,,,,,,,,
RING FIX 10-12.3MM CAPSULAR TENS EXP COMPRESSIBLE REFORM,SUP-2110078,CDM,L8610,HCPCS,0278,RC,,,,both,,,696.08,452.45,,,,,,,,,,,,,
ROD ORTH THRD 250 MM PILLAR,SUP-2749921,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1780.38,1157.25,,,,,,,,,,,,,
GRAFT DURA 1X3IN PURIFIED CLLGN MTRX REGEN DURAGN SECUR,SUP-2244018,CDM,C1713,HCPCS,0278,RC,,,,both,,,1703.29,1107.14,,,,,,,,,,,,,
BLADE SURG SAW 40X44.60 MM REPEAT STERNOTOMY HALL,SUP-2166588,CDM,2720000010,LOCAL,0272,RC,,,,both,,,78.50,51.02,,,,,,,,,,,,,
"Tendon Sheath Incision|LEFT HAND, THUMB",CASE-26055,LOCAL,26055,CPT,,,,,FA,outpatient,,,10472.33,6283.40,,,,,,,,,,,,,
"Repair Extensor Tendon Finger W/O Graft Each|LEFT HAND, THUMB",CASE-26418,LOCAL,26418,CPT,,,,,FA,outpatient,,,18205.07,10923.04,,,,,,,,,,,,,
"Tendon Sheath Incision|LEFT HAND, THUMB",CASE-26055,LOCAL,26055,CPT,0360,RC,,,FA,outpatient,,,10472.33,6283.40,,,,,,,,,,,,,
HC >= 12 Lead Ekg|ADJ,CASE-93005,LOCAL,93005,CPT,0730,RC,,,ADJ,outpatient,,,3397.33,2038.40,,,,,,,,,,,,,
"Repair Extensor Tendon Finger W/O Graft Each|LEFT HAND, THUMB",CASE-26418,LOCAL,26418,CPT,0360,RC,,,FA,outpatient,,,18205.07,10923.04,,,,,,,,,,,,,
HC Inj Lympho for Sentinal Node|RIGHT SIDE,CASE-38792,LOCAL,38792,CPT,0361,RC,,,RT,outpatient,,,34780.88,20868.53,,,,,,,,,,,,,
Dstr Nrolytc Agnt Parverteb Fct Sngl Crvcl/Thora|BILATERAL PROCEDURE,CASE-64633,LOCAL,64633,CPT,0360,RC,,,50,outpatient,,,11822.95,7093.77,,,,,,,,,,,,,
Cysto W/Urtroscopy&/Pyeloscopy Dx|RIGHT SIDE,CASE-52351,LOCAL,52351,CPT,0360,RC,,,RT,outpatient,,,20388.92,12233.35,,,,,,,,,,,,,
Dstr Nrolytc Agnt Parverteb Fct Sngl Crvcl/Thora|BILATERAL PROCEDURE,CASE-64633,LOCAL,64633,CPT,,,,,50,outpatient,,,11822.95,7093.77,,,,,,,,,,,,,
Cysto W/Urtroscopy&/Pyeloscopy Dx|RIGHT SIDE,CASE-52351,LOCAL,52351,CPT,,,,,RT,outpatient,,,20388.92,12233.35,,,,,,,,,,,,,
CATHETER ARTHERECTOMY OTW 0.9X80 CM TURBO ELITE,SUP-2353045,CDM,C1885,CPT,0278,RC,,,,both,,,4867.00,3163.55,,,,,,,,,,,,,
CROWN DENT 3 S STL LO RT 1ST PRI M MINIMAL ADJ PRETRIMMED,SUP-2238877,CDM,D6783,CPT,0278,RC,,,,both,,,25.87,16.82,,,,,,,,,,,,,
BURR PTERYGIUM DIAMOND DISK SHAPE 5.5MM,SUP-2471106,CDM,2720000010,LOCAL,0272,RC,,,,both,,,320.44,208.29,,,,,,,,,,,,,
"HC So Cortisol,Free",PX-3018253066,CDM,82530,CPT,0301,RC,,,,both,,,355.00,230.75,,,,,,,,,,,,,
ROD SPNL CONN 5.5/6X500 MM COCR NS,SUP-2592124,CDM,C1713,HCPCS,0278,RC,,,,both,,,596.60,387.79,,,,,,,,,,,,,
ROD ORTHOPEDIC 2 MM W/ SPACER KT ORTHOFLEX,SUP-2396951,CDM,C1713,HCPCS,0278,RC,,,,both,,,2496.30,1622.59,,,,,,,,,,,,,
MUPIROCIN 2 % EX OINT,RX-10674,CDM,6370000000,HCPCS,0637,RC,45802-0112-22,NDC,,both,22,GR,40.50,26.32,,,,,,,,,,,,,
IMPLANT SYNTH L 91 X W 56 MM THK 4 MM POLYETHYL CRANIOFACIAL,SUP-2883679,CDM,C1713,HCPCS,0278,RC,,,,both,,,5084.35,3304.83,,,,,,,,,,,,,
BIT DRILL STOP 1.8X16 MM 82 MM HEXAGONAL COUPLING TITANIUM N,SUP-2841982,CDM,2720000010,LOCAL,0272,RC,,,,both,,,635.22,412.89,,,,,,,,,,,,,
PLATE BONE L75MM CRANIOMAXILLOFACIAL MAND MOD 3 DIM MCS LUHR,SUP-2364676,CDM,C1713,HCPCS,0278,RC,,,,both,,,1172.82,762.33,,,,,,,,,,,,,
GRAFT HUM TISS CHORION BASE THCK 4X4 CM AMNIO ACTISHIELD,SUP-2759475,CDM,C1762,CPT,0278,RC,,,,both,,,6864.04,4461.63,,,,,,,,,,,,,
Excision Skin Abd Infraumbilical Panniculectomy,CASE-15830,LOCAL,15830,CPT,0360,RC,,,,outpatient,,,67391.00,40434.60,,,,,,,,,,,,,
Rcnstj Midface Lefort I 1 Piece W/Bone Grafts,CASE-21145,LOCAL,21145,CPT,0360,RC,,,,outpatient,,,144916.48,86949.89,,,,,,,,,,,,,
Exc Breast Les Preop Plmt Rad Marker Open 1 Les|RIGHT SIDE,CASE-19125,LOCAL,19125,CPT,0360,RC,,,RT,outpatient,,,28302.72,16981.63,,,,,,,,,,,,,
Rcnstj Midface Lefort I 1 Piece W/Bone Grafts,CASE-21145,LOCAL,21145,CPT,,,,,,outpatient,,,144916.48,86949.89,,,,,,,,,,,,,
"Laminec/Facetect/Foramin,Thoracic",CASE-63046,LOCAL,63046,CPT,,,,,,outpatient,,,67375.70,40425.42,,,,,,,,,,,,,
HC Biopsy/Exc Lymph Node Needle|TECHNICAL COMPONENT|RIGHT SIDE,CASE-38505,LOCAL,38505,CPT,0361,RC,,,TC|RT,outpatient,,,17422.92,10453.75,,,,,,,,,,,,,
Exc Breast Les Preop Plmt Rad Marker Open 1 Les|RIGHT SIDE,CASE-19125,LOCAL,19125,CPT,,,,,RT,outpatient,,,28302.72,16981.63,,,,,,,,,,,,,
"Laminec/Facetect/Foramin,Thoracic",CASE-63046,LOCAL,63046,CPT,0360,RC,,,,outpatient,,,67375.70,40425.42,,,,,,,,,,,,,
Excision Skin Abd Infraumbilical Panniculectomy,CASE-15830,LOCAL,15830,CPT,,,,,,outpatient,,,67391.00,40434.60,,,,,,,,,,,,,
HC >= 12 Lead Ekg|PBB CHARGE,CASE-93005,LOCAL,93005,CPT,0730,RC,,,PBB,outpatient,,,1895.83,1137.50,,,,,,,,,,,,,
SCREW SPNL L45MM DIA6.5MM PEEK HA PEDCL MULTIAXIAL,SUP-2289209,CDM,C1713,HCPCS,0278,RC,,,,both,,,3855.45,2506.04,,,,,,,,,,,,,
PROSTHESIS OSS TRL 4 MM TRL REPL SS PORP,SUP-2638069,CDM,L8613,CPT,0278,RC,,,,both,,,475.21,308.89,,,,,,,,,,,,,
TUBE ENTRL FEED PUSH METHOD 0.035 IN 20 FRX4.47 MM FLO 20,SUP-2737404,CDM,C1769,HCPCS,0272,RC,,,,both,,,533.80,346.97,,,,,,,,,,,,,
PLATE BNE L107MM 8 H 1 3RD TBLR LOK FOR 3.5MM SCR UNIV LOK,SUP-2411374,CDM,C1713,HCPCS,0278,RC,,,,both,,,507.14,329.64,,,,,,,,,,,,,
IRINOTECAN HCL LIPOSOME 43 MG/10ML IV SUSP,RX-173423,CDM,J9205,HCPCS,0636,RC,15054-0043-01,NDC,,both,10,ML,8579.60,5576.74,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.538,SUP-2860055,CDM,C1713,HCPCS,0278,RC,,,,both,,,50881.50,33072.97,,,,,,,,,,,,,
PLATE BNE BAR 8MM DBL Y 6 HS FOR 2MM SCR H UNIV FIX SYS,SUP-2366329,CDM,C1713,HCPCS,0278,RC,,,,both,,,683.83,444.49,,,,,,,,,,,,,
SCREW BNE EMGCY 2.4X6 MM T8 TI NS,SUP-2189470,CDM,C1713,HCPCS,0278,RC,,,,both,,,189.97,123.48,,,,,,,,,,,,,
SCREW SPNL 14 MM DISTRCTN,SUP-2354558,CDM,C1713,HCPCS,0278,RC,,,,both,,,204.10,132.66,,,,,,,,,,,,,
GII STEP HEMI WDG SZ1-2 {} 15,SUP-2511029,CDM,C1776,CPT,0278,RC,,,,both,,,2650.16,1722.60,,,,,,,,,,,,,
SEGMENTAL SHIELD HINGE SVC KIT SIZE E,SUP-2502436,CDM,C1776,CPT,0278,RC,,,,both,,,4775.94,3104.36,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.501,SUP-2860018,CDM,C1713,HCPCS,0278,RC,,,,both,,,33123.86,21530.51,,,,,,,,,,,,,
Removal Tissue Expander W/O Insertion Implant|BILATERAL PROCEDURE,CASE-11971,LOCAL,11971,CPT,0360,RC,,,50,outpatient,,,37181.08,22308.65,,,,,,,,,,,,,
Egd Intrmural US Needle Aspirate/Biopsy Esophags|REDUCED SERVICES,CASE-43238,LOCAL,43238,CPT,0360,RC,,,52,outpatient,,,25646.83,15388.10,,,,,,,,,,,,,
Excision Ganglion Wrist Dorsal/Volar Primary|LEFT SIDE,CASE-25111,LOCAL,25111,CPT,0360,RC,,,LT,outpatient,,,13993.17,8395.90,,,,,,,,,,,,,
Neuroplasty &/Transposition Ulnar Nerve Elbow,CASE-64718,LOCAL,64718,CPT,,,,,,outpatient,,,20188.32,12112.99,,,,,,,,,,,,,
Laps Fulg/Exc Ovary Viscera/Peritoneal Surface|RIGHT SIDE,CASE-58662,LOCAL,58662,CPT,0360,RC,,,RT,outpatient,,,33680.15,20208.09,,,,,,,,,,,,,
Removal Tissue Expander W/O Insertion Implant|BILATERAL PROCEDURE,CASE-11971,LOCAL,11971,CPT,,,,,50,outpatient,,,37181.08,22308.65,,,,,,,,,,,,,
Laps Total Hysterect 250 Gm/< W/Rmvl Tube/Ovary,CASE-58571,LOCAL,58571,CPT,0360,RC,,,,outpatient,,,83106.78,49864.07,,,,,,,,,,,,,
HC Inj Aa&/Strd Other Peripheral Nerve/Branch,CASE-64450,LOCAL,64450,CPT,0450,RC,,,,outpatient,,,3976.05,2385.63,,,,,,,,,,,,,
Laps Fulg/Exc Ovary Viscera/Peritoneal Surface|RIGHT SIDE,CASE-58662,LOCAL,58662,CPT,,,,,RT,outpatient,,,33680.15,20208.09,,,,,,,,,,,,,
Egd Intrmural US Needle Aspirate/Biopsy Esophags|REDUCED SERVICES,CASE-43238,LOCAL,43238,CPT,,,,,52,outpatient,,,25646.83,15388.10,,,,,,,,,,,,,
Injection Aa&/Strd Intercostal Nrv Ea Addl Lvl|LEFT SIDE,CASE-64421,LOCAL,64421,CPT,,,,,LT,outpatient,,,4274.93,2564.96,,,,,,,,,,,,,
Cysto W/Insert Ureteral Stent|LEFT SIDE,CASE-52332,LOCAL,52332,CPT,0360,RC,,,LT,outpatient,,,24845.92,14907.55,,,,,,,,,,,,,
Excision Ganglion Wrist Dorsal/Volar Primary|LEFT SIDE,CASE-25111,LOCAL,25111,CPT,,,,,LT,outpatient,,,13993.17,8395.90,,,,,,,,,,,,,
Injection Aa&/Strd Intercostal Nrv Ea Addl Lvl|LEFT SIDE,CASE-64421,LOCAL,64421,CPT,0360,RC,,,LT,outpatient,,,4274.93,2564.96,,,,,,,,,,,,,
Neuroplasty &/Transposition Ulnar Nerve Elbow,CASE-64718,LOCAL,64718,CPT,0360,RC,,,,outpatient,,,20188.32,12112.99,,,,,,,,,,,,,
Laps Total Hysterect 250 Gm/< W/Rmvl Tube/Ovary,CASE-58571,LOCAL,58571,CPT,,,,,,outpatient,,,83106.78,49864.07,,,,,,,,,,,,,
Cysto W/Insert Ureteral Stent|LEFT SIDE,CASE-52332,LOCAL,52332,CPT,,,,,LT,outpatient,,,24845.92,14907.55,,,,,,,,,,,,,
BIT DRL 2.8 MM QC SS STRL,SUP-2875234,CDM,2720000010,LOCAL,0272,RC,,,,both,,,614.81,399.63,,,,,,,,,,,,,
DEFIBRILLATOR IMPL DYNAGEN EL W 5.37 X H 7.68 CM D 0.99 CM,SUP-2149176,CDM,C1721,HCPCS,0275,RC,,,,both,,,35233.94,22902.06,,,,,,,,,,,,,
HEAD FEM 15+ MM 32 MM HIP,SUP-2439597,CDM,C1776,CPT,0278,RC,,,,both,,,1483.65,964.37,,,,,,,,,,,,,
SYSTEM TRACTIONXL ADJ OPN BK HALO RNG COMPLT C GRAPHITE TI,SUP-2328134,CDM,L0810,HCPCS,0272,RC,,,,both,,,7536.00,4898.40,,,,,,,,,,,,,
HC Peripheral Block - Tap Unilateral Infusion,PX-3606448700,CDM,64487,CPT,0360,RC,,,,both,,,996.00,647.40,,,,,,,,,,,,,
SEED BRACHYTHERAPY LOAD 5.01-6.0 MCI STRL ADVANTAGE 2029FLS1] ISOAID LLC],SUP-2247272,CDM,C2642,HCPCS,0278,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
HC So Estradiol,PX-3018267066,CDM,82670,CPT,0301,RC,,,,both,,,43.00,27.95,,,,,,,,,,,,,
PLATE BNE W7.5XL43MM THK1.6MM 5X3 H L DST VOLAR RAD TI RIG,SUP-2191019,CDM,C1713,HCPCS,0278,RC,,,,both,,,2523.37,1640.19,,,,,,,,,,,,,
PLATE BNE RADIAL HD 1 LNG PROX FIX ANGLE FIX MAX STRENGTH SS,SUP-2397917,CDM,C1713,HCPCS,0278,RC,,,,both,,,4113.40,2673.71,,,,,,,,,,,,,
CATHETER INTVASC ULTRASOUND ULTRA ICE L 110 CM DIA 9 FR,SUP-2141334,CDM,C1759,HCPCS,0272,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
HC Parathyrd Planar W/WO Subtrj,PX-3417807100,CDM,78071,CPT,0341,RC,,,,outpatient,,,8208.00,5335.20,,,,,,,,,,,,,
JOINT GREAT TOE MED MTL HEMI,SUP-2519588,CDM,C1776,CPT,0278,RC,,,,both,,,4574.98,2973.74,,,,,,,,,,,,,
PLATE BNE L151MM 9 H L DST LAT FIBULAR S STL LOK COMPR FOR,SUP-2184164,CDM,C1713,HCPCS,0278,RC,,,,both,,,1807.04,1174.58,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 80 CM DIA 5 MM EPTFE STR STD WALL,SUP-2396181,CDM,C1768,CPT,0278,RC,,,,both,,,3224.78,2096.11,,,,,,,,,,,,,
DRILL SURG L30MM DIA3MM SH,SUP-2266526,CDM,2720000010,LOCAL,0272,RC,,,,both,,,533.80,346.97,,,,,,,,,,,,,
TEMPLATE SZ PATELLAR NXGN,SUP-2437565,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1073.88,698.02,,,,,,,,,,,,,
PROSTHESIS OTO L375MM SHFT OD05MM NIT MID EAR STAP PIST,SUP-2232483,CDM,L8613,CPT,0278,RC,,,,both,,,975.35,633.98,,,,,,,,,,,,,
TRAY CATH MIDLN POWERGLIDE STRL SELD MAXBARR 18GA 10CM 1 LUM,SUP-2613566,CDM,C1751,HCPCS,0278,RC,,,,both,,,487.74,317.03,,,,,,,,,,,,,
BIT DRL L30MM DIA3.8MM FLX W/O STP QUIK NONRADIOLUCENT,SUP-2252737,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1637.67,1064.49,,,,,,,,,,,,,
"Open Tx Phalangeal Shaft Fracture Prox/Middle Ea|RIGHT HAND, SECOND DIGIT",CASE-26735,LOCAL,26735,CPT,,,,,F6,outpatient,,,24723.05,14833.83,,,,,,,,,,,,,
Intraop Sentinel Lymph Node ID W/Dye Injection,CASE-38900,LOCAL,38900,CPT,,,,,,outpatient,,,56496.30,33897.78,,,,,,,,,,,,,
Intraop Sentinel Lymph Node ID W/Dye Injection,CASE-38900,LOCAL,38900,CPT,0360,RC,,,,outpatient,,,56496.30,33897.78,,,,,,,,,,,,,
Ndsc Eval Intstinal Pouch Dx W/Collj Spec Spx,CASE-44385,LOCAL,44385,CPT,0360,RC,,,,outpatient,,,7038.73,4223.24,,,,,,,,,,,,,
Ndsc Eval Intstinal Pouch Dx W/Collj Spec Spx,CASE-44385,LOCAL,44385,CPT,,,,,,outpatient,,,7038.73,4223.24,,,,,,,,,,,,,
"Open Tx Phalangeal Shaft Fracture Prox/Middle Ea|RIGHT HAND, SECOND DIGIT",CASE-26735,LOCAL,26735,CPT,0360,RC,,,F6,outpatient,,,24723.05,14833.83,,,,,,,,,,,,,
"Inj Dx/Ther Agnt Paravert Facet Joint, Cerv/Thorac, 2nd Level|LEFT SIDE|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA",CASE-64491,LOCAL,64491,CPT,,,,,LT|74,outpatient,,,4509.37,2705.62,,,,,,,,,,,,,
"Open Tx Phalangeal Shaft Fracture Prox/Middle Ea|LEFT HAND, FOURTH DIGIT",CASE-26735,LOCAL,26735,CPT,,,,,F3,outpatient,,,27517.88,16510.73,,,,,,,,,,,,,
Trurl Electrosurg Rescj Prostate Bleed Complete,CASE-52601,LOCAL,52601,CPT,0360,RC,,,,outpatient,,,26595.93,15957.56,,,,,,,,,,,,,
Trurl Electrosurg Rescj Prostate Bleed Complete,CASE-52601,LOCAL,52601,CPT,,,,,,outpatient,,,26595.93,15957.56,,,,,,,,,,,,,
"Inj Dx/Ther Agnt Paravert Facet Joint, Cerv/Thorac, 2nd Level|LEFT SIDE|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA",CASE-64491,LOCAL,64491,CPT,0360,RC,,,LT|74,outpatient,,,4509.37,2705.62,,,,,,,,,,,,,
"Open Tx Phalangeal Shaft Fracture Prox/Middle Ea|LEFT HAND, FOURTH DIGIT",CASE-26735,LOCAL,26735,CPT,0360,RC,,,F3,outpatient,,,27517.88,16510.73,,,,,,,,,,,,,
PASSER SUT 0DEG NDL W/ PLGA IMPLANTS MENIS REP SYS TRUESPAN,SUP-2256749,CDM,C1713,HCPCS,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
CATHETER CV DL 6 FR TY W/ MICROINTRODUCER POWERPICC SOLO 2,SUP-2126390,CDM,C1751,HCPCS,0278,RC,,,,both,,,404.37,262.84,,,,,,,,,,,,,
CROWN DENT REST M SEC UP LT SZ DUL6 S STL PERM AD,SUP-2322207,CDM,D6783,CPT,0278,RC,,,,both,,,41.13,26.73,,,,,,,,,,,,,
IMPLANT HUM TISS L 20 X H 7.5 MM CANC FT COTTON WDG TEXT,SUP-2932831,CDM,C1762,CPT,0278,RC,,,,both,,,5204.33,3382.81,,,,,,,,,,,,,
PIN POS L4.5MM S STL CERCLAGE FOR LOK COMPR PLT,SUP-2187039,CDM,C1713,HCPCS,0278,RC,,,,both,,,498.76,324.19,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 3 CC ADIPOSE MTRX RENUVA HD,SUP-2761881,CDM,C1762,CPT,0278,RC,,,,both,,,4019.20,2612.48,,,,,,,,,,,,,
HC Inj Trigger Pt 1-2 Musc Grps,PX-5102055200,CDM,20552,CPT,0510,RC,,,,inpatient,,,613.00,398.45,,,,,,,,,,,,,
STEM RAD L32MM OD10MM UNIV TI POR PLSM SPRY ANTR DSTL ELBW,SUP-2404381,CDM,C1776,CPT,0278,RC,,,,both,,,4782.22,3108.44,,,,,,,,,,,,,
GUIDEWIRE VASC IMPELLA RP DIA 0.027 IN PTFE STR TIP STIFF,SUP-2106271,CDM,C1769,HCPCS,0272,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
NAIL IM L340MM DIA10.5MM TI ALLOY RG CORELOCK TECHNOLOGY,SUP-2405538,CDM,C1713,HCPCS,0278,RC,,,,both,,,8003.86,5202.51,,,,,,,,,,,,,
CONNECTOR SPNL ROD 5.5X110 MM STR SS CD HORZ,SUP-2631080,CDM,C1713,HCPCS,0278,RC,,,,both,,,4713.14,3063.54,,,,,,,,,,,,,
GUIDEWIRE VASC MORPHEUS L 80 CM DIA 0.018 IN SS PERIPH STRL,SUP-2734842,CDM,C1769,HCPCS,0272,RC,,,,both,,,12.72,8.27,,,,,,,,,,,,,
SIZER SURG POLARUS 3,SUP-2525728,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2408.38,1565.45,,,,,,,,,,,,,
PLATE INTERPEDICULAR ANTR STD TI UNIV 54MM LEN,SUP-2290570,CDM,C1713,HCPCS,0278,RC,,,,both,,,4160.50,2704.32,,,,,,,,,,,,,
CEMENT BNE RADIOPAQUE FAST SET ACRYL RESIN HI VISC SIMPLEXHV,SUP-2374946,CDM,C1776,CPT,0278,RC,,,,both,,,328.29,213.39,,,,,,,,,,,,,
CATHETER MIDLINE AGBA PI 2-L 5.5FR X 15CM,SUP-2850035,CDM,C1751,HCPCS,0278,RC,,,,both,,,555.78,361.26,,,,,,,,,,,,,
Optx Patllr Fx W/Int Fixj/Patllc&Soft Tiss Rpr|LEFT SIDE,CASE-27524,LOCAL,27524,CPT,0360,RC,,,LT,outpatient,,,27814.60,16688.76,,,,,,,,,,,,,
Arthrs Wrst Exc&/Rpr Triang Fibrocart&/Joint|RIGHT SIDE,CASE-29846,LOCAL,29846,CPT,,,,,RT,outpatient,,,28722.50,17233.50,,,,,,,,,,,,,
Arthrs Wrst Exc&/Rpr Triang Fibrocart&/Joint|RIGHT SIDE,CASE-29846,LOCAL,29846,CPT,0360,RC,,,RT,outpatient,,,28722.50,17233.50,,,,,,,,,,,,,
HC Inj Trigger Pt 1-2 Musc Grps,CASE-20552,LOCAL,20552,CPT,0510,RC,,,,outpatient,,,3709.65,2225.79,,,,,,,,,,,,,
Optx Patllr Fx W/Int Fixj/Patllc&Soft Tiss Rpr|LEFT SIDE,CASE-27524,LOCAL,27524,CPT,,,,,LT,outpatient,,,27814.60,16688.76,,,,,,,,,,,,,
SET INTRO SKATER SHTH L 18 CM DIA 6 FR DIL 4FR NIT PLAT COAX,SUP-2120118,CDM,C1894,HCPCS,0272,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
SUPPORT WR M AD LT CRPL TUNN REG FIRM SUPP CRPLGARD BLK,SUP-2324891,CDM,L3931,HCPCS,0272,RC,,,,both,,,48.92,31.80,,,,,,,,,,,,,
SYSTEM CALIB 36FR SL GASTRECTOMY NS W/O BLB VISIGI 3D,SUP-2138631,CDM,C1713,HCPCS,0278,RC,,,,both,,,643.70,418.40,,,,,,,,,,,,,
PLATE BNE L25MM THK3.3MM 2 H BILAT S STL RIG STR DYN COMPR,SUP-2186326,CDM,C1713,HCPCS,0278,RC,,,,both,,,413.13,268.53,,,,,,,,,,,,,
AMPICILLIN SODIUM 250 MG IJ SOLR,RX-473,CDM,J0290,HCPCS,0636,RC,65219-0014-01,NDC,,both,1,UN,54.10,35.16,,,,,,,,,,,,,
HC Hip Dislocation Reduction,PX-4502725000,CDM,27250,CPT,0450,RC,,,,inpatient,,,383.00,248.95,,,,,,,,,,,,,
BOOT CAST XL L13.5IN TOE W6IN BLK CANVS NONSLIP ROCK SOLE,SUP-2196785,CDM,L4631,HCPCS,0274,RC,,,,both,,,14.85,9.65,,,,,,,,,,,,,
PLATE BONE SM L78MM 6 H STD BILAT COMPR CNTOUR + FOR 3.5MM,SUP-2348993,CDM,C1713,HCPCS,0278,RC,,,,both,,,1343.20,873.08,,,,,,,,,,,,,
CATHETER CARD ABLATION EZ STEER THERMOCOOL L 115CM 7.5FR D-F,SUP-2248506,CDM,C1732,HCPCS,0278,RC,,,,both,,,4301.80,2796.17,,,,,,,,,,,,,
PIN FIX L9IN OD5/64IN S STL TYP A STNMN,SUP-2342708,CDM,C1713,HCPCS,0278,RC,,,,both,,,201.02,130.66,,,,,,,,,,,,,
Enteroscopy > 2nd Prtn Abltj Lesion,CASE-44369,LOCAL,44369,CPT,0360,RC,,,,outpatient,,,10419.67,6251.80,,,,,,,,,,,,,
Insj/Rplcmt Breast Implant Sep Day Mastectomy|BILATERAL PROCEDURE,CASE-19342,LOCAL,19342,CPT,,,,,50,outpatient,,,70422.50,42253.50,,,,,,,,,,,,,
Insj/Rplcmt Breast Implant Sep Day Mastectomy|BILATERAL PROCEDURE,CASE-19342,LOCAL,19342,CPT,0360,RC,,,50,outpatient,,,70422.50,42253.50,,,,,,,,,,,,,
Arthroscopy Knee W/Meniscus Rpr Medial/Lateral,CASE-29882,LOCAL,29882,CPT,,,,,,outpatient,,,78681.33,47208.80,,,,,,,,,,,,,
Enteroscopy > 2nd Prtn Abltj Lesion,CASE-44369,LOCAL,44369,CPT,,,,,,outpatient,,,10419.67,6251.80,,,,,,,,,,,,,
Arthroscopy Knee W/Meniscus Rpr Medial/Lateral,CASE-29882,LOCAL,29882,CPT,0360,RC,,,,outpatient,,,78681.33,47208.80,,,,,,,,,,,,,
Colonoscopy W/Biopsy Single/Multiple|UNUSUAL NON-OVERLAPPING SERVICE,CASE-45380,LOCAL,45380,CPT,0360,RC,,,XU,outpatient,,,14270.10,8562.06,,,,,,,,,,,,,
Unlisted Laparoscopy Procedure Stomach,CASE-43659,LOCAL,43659,CPT,0360,RC,,,,outpatient,,,33063.68,19838.21,,,,,,,,,,,,,
"Open Tx Distal Phalangeal Fracture Each|RIGHT HAND, SECOND DIGIT",CASE-26765,LOCAL,26765,CPT,,,,,F6,outpatient,,,25789.52,15473.71,,,,,,,,,,,,,
Colonoscopy W/Biopsy Single/Multiple|UNUSUAL NON-OVERLAPPING SERVICE,CASE-45380,LOCAL,45380,CPT,,,,,XU,outpatient,,,14270.10,8562.06,,,,,,,,,,,,,
"Open Tx Distal Phalangeal Fracture Each|RIGHT HAND, SECOND DIGIT",CASE-26765,LOCAL,26765,CPT,0360,RC,,,F6,outpatient,,,25789.52,15473.71,,,,,,,,,,,,,
Unlisted Laparoscopy Procedure Stomach,CASE-43659,LOCAL,43659,CPT,,,,,,outpatient,,,33063.68,19838.21,,,,,,,,,,,,,
NATURAL-HIP STEM CALC REPL SZ 1/10MM,SUP-2210886,CDM,C1776,CPT,0278,RC,,,,both,,,13695.11,8901.82,,,,,,,,,,,,,
HC Cytp Concentration Smears & Interpretation,PX-3118810800,CDM,88108,CPT,0311,RC,,,,both,,,291.00,189.15,,,,,,,,,,,,,
PLATE BNE L 159 X W 10 MM THK 2 MM SCREW DIA2.7/3.5 MM 11 H 72465311N,SUP-2932854,CDM,C1713,HCPCS,0278,RC,,,,both,,,5350.56,3477.86,,,,,,,,,,,,,
PROBE NERVE STIM FLSH TIP 100 MM,SUP-2631505,CDM,2720000010,LOCAL,0272,RC,,,,both,,,610.32,396.71,,,,,,,,,,,,,
ALLOGRAFT BNE FEM SHFT 26-50 MMX0.3 CM FD,SUP-2717847,CDM,C1762,CPT,0278,RC,,,,both,,,3515.67,2285.19,,,,,,,,,,,,,
SCREW BONE L14MM OD2.5MM TI CORT SM HD T8 ST,SUP-2101274,CDM,C1713,HCPCS,0278,RC,,,,both,,,335.73,218.22,,,,,,,,,,,,,
Excision Pilonidal Cyst/Sinus Simple,CASE-11770,LOCAL,11770,CPT,,,,,,outpatient,,,16435.90,9861.54,,,,,,,,,,,,,
Sigmoidoscopy Flx Dx W/Collj Spec Br/Wa if Pfrmd,CASE-45330,LOCAL,45330,CPT,,,,,,outpatient,,,6734.43,4040.66,,,,,,,,,,,,,
Carpectomy All Bones Proximal Row,CASE-25215,LOCAL,25215,CPT,0360,RC,,,,outpatient,,,29971.03,17982.62,,,,,,,,,,,,,
Excision Pilonidal Cyst/Sinus Simple,CASE-11770,LOCAL,11770,CPT,0360,RC,,,,outpatient,,,16435.90,9861.54,,,,,,,,,,,,,
Carpectomy All Bones Proximal Row,CASE-25215,LOCAL,25215,CPT,,,,,,outpatient,,,29971.03,17982.62,,,,,,,,,,,,,
Sigmoidoscopy Flx Dx W/Collj Spec Br/Wa if Pfrmd,CASE-45330,LOCAL,45330,CPT,0360,RC,,,,outpatient,,,6734.43,4040.66,,,,,,,,,,,,,
BLADE SURG STP AKIN,SUP-2897519,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1095.86,712.31,,,,,,,,,,,,,
CLIP ANEURYSM SUNDT MINI #7 FORWARD ANGLE 8.5MM 201835,SUP-2844636,CDM,C1889,HCPCS,0278,RC,,,,both,,,867.36,563.78,,,,,,,,,,,,,
PLATE BONE THK1.8MM 8 H STRNL TI STR LCK,SUP-2262581,CDM,C1713,HCPCS,0278,RC,,,,both,,,1618.20,1051.83,,,,,,,,,,,,,
DRILL SURG PEGGED 0.25 IN GLEN STR,SUP-2449762,CDM,2720000010,LOCAL,0272,RC,,,,both,,,480.42,312.27,,,,,,,,,,,,,
COVER BUR H DIA17MM 6 H TI NONCOMPRESSION LO PROF W/O TAB,SUP-2191321,CDM,C1713,HCPCS,0278,RC,,,,both,,,722.20,469.43,,,,,,,,,,,,,
SYSTEM DEL ACUITY PRO LD,SUP-2141881,CDM,C1887,HCPCS,0272,RC,,,,both,,,1846.32,1200.11,,,,,,,,,,,,,
ANCHOR SUT S STL OD29MM ULTRAFIX RC,SUP-2166457,CDM,C1713,HCPCS,0278,RC,,,,both,,,608.81,395.73,,,,,,,,,,,,,
PLATE BONE THK0.6MM SH 2X2 H LT CRANIOMAXILLOFACIAL TI L,SUP-2191173,CDM,C1713,HCPCS,0278,RC,,,,both,,,918.76,597.19,,,,,,,,,,,,,
MICROSPHERE EMB CNTOUR SE DIA 500-700 UM 1 ML PVA PREFIL SYR,SUP-2148449,CDM,C1889,HCPCS,0278,RC,,,,both,,,445.69,289.70,,,,,,,,,,,,,
COMPONENT FEM SM L65MM R DST KNEE ROT HNG GMRS,SUP-2376511,CDM,C1776,CPT,0278,RC,,,,both,,,17297.95,11243.67,,,,,,,,,,,,,
PLATFORM ACC 5.5CM CHAN W/ INTRO GELPOINT,SUP-2119680,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2747.50,1785.87,,,,,,,,,,,,,
CATHETER ETER EP L115CM OD7FR L4MM 2 5 2MM SPC M QPLR BIDIR STEER,SUP-2356990,CDM,C1733,HCPCS,0272,RC,,,,both,,,2245.10,1459.31,,,,,,,,,,,,,
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|RIGHT HAND, FIFTH DIGIT",CASE-26160,LOCAL,26160,CPT,,,,,F9,outpatient,,,8598.17,5158.90,,,,,,,,,,,,,
Low cost skin substitute app,CASE-C5276,LOCAL,C5276,CPT,,,,,,outpatient,,,33893.43,20336.06,,,,,,,,,,,,,
Colsc Flx With Directed Submucosal Njx Any Sbst|COLORECTAL CANCER SCREEN,CASE-45381,LOCAL,45381,CPT,0360,RC,,,PT,outpatient,,,11259.08,6755.45,,,,,,,,,,,,,
Low cost skin substitute app,CASE-C5276,LOCAL,C5276,CPT,0360,RC,,,,outpatient,,,33893.43,20336.06,,,,,,,,,,,,,
Low cost skin substitute app,CASE-C5275,LOCAL,C5275,CPT,,,,,,outpatient,,,33893.43,20336.06,,,,,,,,,,,,,
Colsc Flx With Directed Submucosal Njx Any Sbst|COLORECTAL CANCER SCREEN,CASE-45381,LOCAL,45381,CPT,,,,,PT,outpatient,,,11259.08,6755.45,,,,,,,,,,,,,
Injection Aa&/Strd Ilioinguinal Ih Nerves|LEFT SIDE,CASE-64425,LOCAL,64425,CPT,0360,RC,,,LT,outpatient,,,3949.83,2369.90,,,,,,,,,,,,,
Injection Aa&/Strd Ilioinguinal Ih Nerves|LEFT SIDE,CASE-64425,LOCAL,64425,CPT,,,,,LT,outpatient,,,3949.83,2369.90,,,,,,,,,,,,,
Low cost skin substitute app,CASE-C5275,LOCAL,C5275,CPT,0360,RC,,,,outpatient,,,33893.43,20336.06,,,,,,,,,,,,,
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|RIGHT HAND, FIFTH DIGIT",CASE-26160,LOCAL,26160,CPT,0360,RC,,,F9,outpatient,,,8598.17,5158.90,,,,,,,,,,,,,
Suction Assisted Lipectomy Lower Extremity|BILATERAL PROCEDURE,CASE-15879,LOCAL,15879,CPT,0360,RC,,,50,outpatient,,,124491.02,74694.61,,,,,,,,,,,,,
Rpr Nonunion Scaphoid Carpal Bne W/WO Rdl Stylec|RIGHT SIDE,CASE-25440,LOCAL,25440,CPT,,,,,RT,outpatient,,,37078.45,22247.07,,,,,,,,,,,,,
Suction Assisted Lipectomy Lower Extremity|BILATERAL PROCEDURE,CASE-15879,LOCAL,15879,CPT,,,,,50,outpatient,,,124491.02,74694.61,,,,,,,,,,,,,
Rpr Nonunion Scaphoid Carpal Bne W/WO Rdl Stylec|RIGHT SIDE,CASE-25440,LOCAL,25440,CPT,0360,RC,,,RT,outpatient,,,37078.45,22247.07,,,,,,,,,,,,,
FORCEPS BIPOLAR 1.5MM DISPOSABLE,SUP-2760177,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
ETOPOSIDE 100 MG/5ML IV SOLN,RX-125367,CDM,J9181,HCPCS,0636,RC,16729-0114-31,NDC,,both,5,ML,54.10,35.16,,,,,,,,,,,,,
PLATE BNE STR 2-2.5X160X2.8 MM 20 HOLE RECON LCK TI STRL,SUP-2460959,CDM,C1713,HCPCS,0278,RC,,,,both,,,5219.25,3392.51,,,,,,,,,,,,,
PLATE BNE RECON UNIV 3.5 MM 10 HOLE 2 COMPR FOR SCR TI NS,SUP-2478918,CDM,C1713,HCPCS,0278,RC,,,,both,,,1490.34,968.72,,,,,,,,,,,,,
BUR SURG MED 9.9 MM COR TOOL FOR HD-G1,SUP-2848303,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1066.78,693.41,,,,,,,,,,,,,
GUIDE WIRE AND DRL 250=LENGTH 20=DIAMETER SGL TRCR OPT FOR,SUP-2392815,CDM,C1769,HCPCS,0272,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
NAIL IM 120 DEG L 240 MM DIA10 MM LNG TI ALLOY RT HIP,SUP-2904173,CDM,C1713,HCPCS,0278,RC,,,,both,,,10341.56,6722.01,,,,,,,,,,,,,
NEEDLE BX DIA25GA FN ENDOSCP SHARKCORE,SUP-2174335,CDM,C1713,HCPCS,0278,RC,,,,both,,,1125.38,731.50,,,,,,,,,,,,,
GRAFT VASC HEMSHLD PLAT L 30 CM DIA 6 MM POLYESTER BOV CLLGN,SUP-2265920,CDM,C1768,CPT,0278,RC,,,,both,,,1988.09,1292.26,,,,,,,,,,,,,
Removal Intrauterine Device Iud,CASE-58301,LOCAL,58301,CPT,,,,,,outpatient,,,26861.78,16117.07,,,,,,,,,,,,,
Esophagogastroduodenoscopy US Scope W/Adj Strxrs,CASE-43237,LOCAL,43237,CPT,0360,RC,,,,outpatient,,,10921.32,6552.79,,,,,,,,,,,,,
Inj for Sacroiliac Jt Anesth|RIGHT SIDE,CASE-G0260,LOCAL,G0260,CPT,0360,RC,,,RT,outpatient,,,4376.67,2626.00,,,,,,,,,,,,,
Lithotripsy Xtrcorp Shock Wave|RIGHT SIDE,CASE-50590,LOCAL,50590,CPT,0360,RC,,,RT,outpatient,,,21512.93,12907.76,,,,,,,,,,,,,
Cysto Bladder W/Ureteral Catheterization|RIGHT SIDE,CASE-52005,LOCAL,52005,CPT,0360,RC,,,RT,outpatient,,,15816.33,9489.80,,,,,,,,,,,,,
Cysto Bladder W/Ureteral Catheterization|RIGHT SIDE,CASE-52005,LOCAL,52005,CPT,,,,,RT,outpatient,,,15816.33,9489.80,,,,,,,,,,,,,
Lithotripsy Xtrcorp Shock Wave|RIGHT SIDE,CASE-50590,LOCAL,50590,CPT,,,,,RT,outpatient,,,21512.93,12907.76,,,,,,,,,,,,,
Esophagogastroduodenoscopy US Scope W/Adj Strxrs,CASE-43237,LOCAL,43237,CPT,,,,,,outpatient,,,10921.32,6552.79,,,,,,,,,,,,,
Intraop Sentinel Lymph Node ID W/Dye Injection|RIGHT SIDE,CASE-38900,LOCAL,38900,CPT,,,,,RT,outpatient,,,43090.02,25854.01,,,,,,,,,,,,,
Inj for Sacroiliac Jt Anesth|RIGHT SIDE,CASE-G0260,LOCAL,G0260,CPT,,,,,RT,outpatient,,,4376.67,2626.00,,,,,,,,,,,,,
Removal Intrauterine Device Iud,CASE-58301,LOCAL,58301,CPT,0360,RC,,,,outpatient,,,26861.78,16117.07,,,,,,,,,,,,,
Intraop Sentinel Lymph Node ID W/Dye Injection|RIGHT SIDE,CASE-38900,LOCAL,38900,CPT,0360,RC,,,RT,outpatient,,,43090.02,25854.01,,,,,,,,,,,,,
HC Chemo-Intrathecal Reservoir Tx,PX-3319654200,CDM,96542,CPT,0331,RC,,,,both,,,201.00,130.65,,,,,,,,,,,,,
WEDGE ANK W18MM D18MM THK6.5MM EVANS TECH TI PORUS 3D OPN,SUP-2122988,CDM,C1776,CPT,0278,RC,,,,both,,,6280.00,4082.00,,,,,,,,,,,,,
PICK ENDOSCP CHONDRAL 30 DEG 7 CM NANO ARTHSCP STRL BONESYNC,SUP-2859819,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
INTRODUCER SHTH L60CM 7FR LAT VEIN HK BRAID SFSHTH WORLEY,SUP-2356597,CDM,C1892,HCPCS,0272,RC,,,,both,,,1664.20,1081.73,,,,,,,,,,,,,
SCREW BNE L50MM OD6.5MM STD NONSTERILE TI CANC CORT ST SELF,SUP-2374389,CDM,C1713,HCPCS,0278,RC,,,,both,,,1266.05,822.93,,,,,,,,,,,,,
SHEATH INTRO PERFRMR L 30 CM DIA11 FR GUIDEWIRE 0.038 IN,SUP-2168430,CDM,C1894,HCPCS,0272,RC,,,,both,,,25.37,16.49,,,,,,,,,,,,,
HC Arthrogram Hip S&I,PX-3227352500,CDM,73525,CPT,0322,RC,,,,inpatient,,,1013.00,658.45,,,,,,,,,,,,,
MESH HERN ELLIPSE 14X12 IN W/ ECHO2 POS SYS VENTRALIGHT ST,SUP-2855276,CDM,C1781,HCPCS,0278,RC,,,,both,,,6719.60,4367.74,,,,,,,,,,,,,
MESH BIO W6XL8CM BOV PERICARD NONCROSSLINKED CLLGN MTRX,SUP-2130299,CDM,C9354,HCPCS,0278,RC,,,,both,,,4612.16,2997.90,,,,,,,,,,,,,
STRAP BITE BLOCK CLAV HVY DUTY,SUP-2148720,CDM,L3650,HCPCS,0274,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
CATHETER GUID ATTAIN SEL II 130 DEG L 65 CM OD 2.4 MM ID 5.7,SUP-2282174,CDM,C1887,HCPCS,0272,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
GRAFT DERMAL STRUCTURAL ULTRA THCK 20X8 CMX1.8 MM FLEXHD,SUP-2307484,CDM,Q4128,HCPCS,0636,RC,,,,both,,,14248.57,9261.57,,,,,,,,,,,,,
SHEATH GUID 11.5X8.5FR L71MM M CRV L22MM BIDIR STEER CARTO,SUP-2248638,CDM,C1766,CPT,0272,RC,,,,both,,,3111.74,2022.63,,,,,,,,,,,,,
HC Inject Tendon Origin/Insert|RIGHT SIDE,CASE-20551,LOCAL,20551,CPT,0361,RC,,,RT,outpatient,,,4032.27,2419.36,,,,,,,,,,,,,
Laps Vaginal Hysterectomy Uterus 250 Gm/<,CASE-58550,LOCAL,58550,CPT,0360,RC,,,,outpatient,,,42674.65,25604.79,,,,,,,,,,,,,
Laps Vaginal Hysterectomy Uterus 250 Gm/<,CASE-58550,LOCAL,58550,CPT,,,,,,outpatient,,,42674.65,25604.79,,,,,,,,,,,,,
Injection Aa&/Strd Intercostal Nrv Ea Addl Lvl,CASE-64421,LOCAL,64421,CPT,,,,,,outpatient,,,4008.43,2405.06,,,,,,,,,,,,,
Injection Aa&/Strd Intercostal Nrv Ea Addl Lvl,CASE-64421,LOCAL,64421,CPT,0360,RC,,,,outpatient,,,4008.43,2405.06,,,,,,,,,,,,,
ALLOGRAFT BNE GRND 90 CC FD ASEP CORTICAL CANC,SUP-2867114,CDM,C1762,CPT,0278,RC,,,,both,,,2953.17,1919.56,,,,,,,,,,,,,
SET TB L3M HI PRSS DISP KAIRISON,SUP-2108506,CDM,2720000010,LOCAL,0272,RC,,,,both,,,543.72,353.42,,,,,,,,,,,,,
"HC So Sugars, Single, Quant",PX-3018437866,CDM,84378,CPT,0301,RC,,,,both,,,74.00,48.10,,,,,,,,,,,,,
GRAFT VASC HEMSHLD GLD L 100 CM DIA10 X 10 MM BRANCH 60CM RT,SUP-2535438,CDM,C1768,CPT,0278,RC,,,,both,,,2569.96,1670.47,,,,,,,,,,,,,
ENDOSCOPIC KIT RETRV SYS SL DIR DRV LCA,SUP-2119770,CDM,2720000010,LOCAL,0272,RC,,,,both,,,540.08,351.05,,,,,,,,,,,,,
SPLINT WR ADULTXL LT THMB NEOPRNE TRIOXON LNR FIRM STRP ON,SUP-2326120,CDM,L3908,HCPCS,0272,RC,,,,both,,,138.00,89.70,,,,,,,,,,,,,
MESH MXLFCL 251X16 MM 0.8 MM SM GRID PDLLA STRL RESORB X,SUP-2473843,CDM,C1713,HCPCS,0278,RC,,,,both,,,8122.80,5279.82,,,,,,,,,,,,,
HC Cart-T Therapy Receipt & Prep Car-T Cells F/Admin,PX-8723822700,CDM,38227,CPT,0873,RC,,,,both,,,4194.00,2726.10,,,,,,,,,,,,,
RATCHETING COMPRESSION PLATE 15X14,SUP-2823111,CDM,C1713,HCPCS,0278,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
RING EXT FIX DIA105MM FULL TAY SPAT FRME,SUP-2342959,CDM,C1713,HCPCS,0278,RC,,,,both,,,6198.20,4028.83,,,,,,,,,,,,,
HC Special Stain Group 1 Microorganisms I&R,PX-3128831200,CDM,88312,CPT,0312,RC,,,,both,,,219.00,142.35,,,,,,,,,,,,,
COIL EMB 3MMX4CM MIC NEUROVASC XSFT MIC NEUROVASC GALAXY G3,SUP-2249164,CDM,C1889,HCPCS,0278,RC,,,,both,,,7481.58,4863.03,,,,,,,,,,,,,
NAIL-EX FEM RECON LAT ENTRY 16X300MM LT TI STRL,SUP-2546287,CDM,C1713,HCPCS,0278,RC,,,,both,,,4288.64,2787.62,,,,,,,,,,,,,
HC Biopsy Liver Percutan Needle,PX-3614700000,CDM,47000,CPT,0361,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
Exc Rct Tum Not Incl Muscularis Propria,CASE-45171,LOCAL,45171,CPT,,,,,,outpatient,,,52162.77,31297.66,,,,,,,,,,,,,
HC Peripheral Block - Femoral Single or Saphenous W/Img Gdn|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64447,LOCAL,64447,CPT,0360,RC,,,LT|XU,outpatient,,,39947.87,23968.72,,,,,,,,,,,,,
Injection Aa&/Strd Ilioinguinal Ih Nerves,CASE-64425,LOCAL,64425,CPT,,,,,,outpatient,,,3952.75,2371.65,,,,,,,,,,,,,
HC Perq Vert Agmntj Cavity Crtj Uni/Bi Cannulation,CASE-22513,LOCAL,22513,CPT,0361,RC,,,,outpatient,,,26110.17,15666.10,,,,,,,,,,,,,
Excision Prepatellar Bursa|BILATERAL PROCEDURE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-27340,LOCAL,27340,CPT,,,,,50|XU,outpatient,,,50593.62,30356.17,,,,,,,,,,,,,
HC Biopsy Liver Percutan Needle,CASE-47000,LOCAL,47000,CPT,0361,RC,,,,outpatient,,,11453.53,6872.12,,,,,,,,,,,,,
Excision Prepatellar Bursa|BILATERAL PROCEDURE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-27340,LOCAL,27340,CPT,0360,RC,,,50|XU,outpatient,,,50593.62,30356.17,,,,,,,,,,,,,
Exc Rct Tum Not Incl Muscularis Propria,CASE-45171,LOCAL,45171,CPT,0360,RC,,,,outpatient,,,52162.77,31297.66,,,,,,,,,,,,,
Injection Aa&/Strd Ilioinguinal Ih Nerves,CASE-64425,LOCAL,64425,CPT,0360,RC,,,,outpatient,,,3952.75,2371.65,,,,,,,,,,,,,
ALLOGRAFT BNE CHIP 1-8 MM 80 CC CORTICAL CANC,SUP-2264691,CDM,C1713,HCPCS,0278,RC,,,,both,,,2395.04,1556.78,,,,,,,,,,,,,
COMPONENT TALAR SZ 0 UHMWPE LT ANK STRL SALTO TALARIS,SUP-2931180,CDM,C1776,CPT,0278,RC,,,,both,,,23503.21,15277.09,,,,,,,,,,,,,
LINER ACET OD60MM ID32MM ENDRN CONSTRN DURALOC,SUP-2250716,CDM,C1776,CPT,0278,RC,,,,both,,,7499.58,4874.73,,,,,,,,,,,,,
SPACER FEM M/L THK10MM R LAT DST DURAC,SUP-2377224,CDM,C1776,CPT,0278,RC,,,,both,,,3.14,2.04,,,,,,,,,,,,,
TRAY CATH PICC GROSH NXT 5FR 0.026N 55CM 2 LUMAN RVS 7927508,SUP-2632686,CDM,C1751,HCPCS,0278,RC,,,,both,,,455.65,296.17,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED ULTRA HI DEMAND CERM ON CERM STRYKERHCERM] STRYKER CORP],SUP-2365977,CDM,C1776,CPT,0278,RC,,,,both,,,22608.00,14695.20,,,,,,,,,,,,,
GRAFT BIO TISS W7.5XL13.8IN PORCINE DERM RIFAMPIN,SUP-2125841,CDM,C1781,HCPCS,0278,RC,,,,both,,,46158.00,30002.70,,,,,,,,,,,,,
SCREW BONE L22MM OD3.5MM CORT,SUP-2412507,CDM,C1713,HCPCS,0278,RC,,,,both,,,121.64,79.07,,,,,,,,,,,,,
PLATE BONE L142MM THK3.1MM 12 H BILAT S STL LCK COMPR RECON,SUP-2348697,CDM,C1713,HCPCS,0278,RC,,,,both,,,5771.79,3751.66,,,,,,,,,,,,,
VALVE AORT L12CM DIA28MM TISS ANNULUS DIA25MM CLLGN MSTR LO,SUP-2355124,CDM,C1713,HCPCS,0278,RC,,,,both,,,10048.00,6531.20,,,,,,,,,,,,,
TUNNELER MAINSTAY,SUP-2877974,CDM,C1730,HCPCS,0272,RC,,,,both,,,568.34,369.42,,,,,,,,,,,,,
INSERT TIB TOT STBL 11/9 STD 10 MM FEM ARTC KNEE CONSTRN FLX,SUP-2378401,CDM,C1776,CPT,0278,RC,,,,both,,,4587.54,2981.90,,,,,,,,,,,,,
PIN FIX FOR ZEPHIR ANT CERV PLATING SYS,SUP-2291191,CDM,C1713,HCPCS,0278,RC,,,,both,,,202.88,131.87,,,,,,,,,,,,,
TAP SURG SCR CANN CORT S CPL QUIK CONN 4.5MM,SUP-2412629,CDM,C1713,HCPCS,0278,RC,,,,both,,,857.22,557.19,,,,,,,,,,,,,
SCREWDRIVER SURG 3.5MM REDUC SCR,SUP-2232117,CDM,C1713,HCPCS,0278,RC,,,,both,,,1202.62,781.70,,,,,,,,,,,,,
SCREW INTFR L30MM DIA11MM FULL THRD STAR DRV FOR ACL RECON,SUP-2212844,CDM,C1713,HCPCS,0278,RC,,,,both,,,1340.78,871.51,,,,,,,,,,,,,
Allograft for Spine Surgery Only Structural,CASE-20931,LOCAL,20931,CPT,0360,RC,,,,outpatient,,,55728.82,33437.29,,,,,,,,,,,,,
HC Inj Trigger Pt 1-2 Musc Grps|PBB CHARGE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-20552,LOCAL,20552,CPT,0510,RC,,,PBB|XU,outpatient,,,3313.92,1988.35,,,,,,,,,,,,,
Exc Tumor Soft Tiss Back/Flank Subfascial 5 Cm/>,CASE-21933,LOCAL,21933,CPT,,,,,,outpatient,,,23206.62,13923.97,,,,,,,,,,,,,
Revise Ulnar Nerve at Wrist,CASE-64719,LOCAL,64719,CPT,0360,RC,,,,outpatient,,,23601.80,14161.08,,,,,,,,,,,,,
Arthroplasty Patella W/O Prosthesis|BILATERAL PROCEDURE,CASE-27437,LOCAL,27437,CPT,0360,RC,,,50,outpatient,,,50593.62,30356.17,,,,,,,,,,,,,
Removal Intact Breast Implant|BILATERAL PROCEDURE,CASE-19328,LOCAL,19328,CPT,,,,,50,outpatient,,,71967.40,43180.44,,,,,,,,,,,,,
Arthroplasty Patella W/O Prosthesis|BILATERAL PROCEDURE,CASE-27437,LOCAL,27437,CPT,,,,,50,outpatient,,,50593.62,30356.17,,,,,,,,,,,,,
Exc Tumor Soft Tiss Back/Flank Subfascial 5 Cm/>,CASE-21933,LOCAL,21933,CPT,0360,RC,,,,outpatient,,,23206.62,13923.97,,,,,,,,,,,,,
Revise Ulnar Nerve at Wrist,CASE-64719,LOCAL,64719,CPT,,,,,,outpatient,,,23601.80,14161.08,,,,,,,,,,,,,
Removal Intact Breast Implant|BILATERAL PROCEDURE,CASE-19328,LOCAL,19328,CPT,0360,RC,,,50,outpatient,,,71967.40,43180.44,,,,,,,,,,,,,
Insj/Rplcmt Breast Implant Sep Day Mastectomy|RIGHT SIDE,CASE-19342,LOCAL,19342,CPT,0360,RC,,,RT,outpatient,,,77089.20,46253.52,,,,,,,,,,,,,
Allograft for Spine Surgery Only Structural,CASE-20931,LOCAL,20931,CPT,,,,,,outpatient,,,55728.82,33437.29,,,,,,,,,,,,,
Insj/Rplcmt Breast Implant Sep Day Mastectomy|RIGHT SIDE,CASE-19342,LOCAL,19342,CPT,,,,,RT,outpatient,,,77089.20,46253.52,,,,,,,,,,,,,
PLATE BONE L342MM 16 H RT DSTL LAT FEM S STL LCK FOR 4.5MM,SUP-2348219,CDM,C1713,HCPCS,0278,RC,,,,both,,,14863.50,9661.27,,,,,,,,,,,,,
FOOTPLATE BNE LNG L210MM ALUMINUM MAXFRAME,SUP-2176972,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4685.57,3045.62,,,,,,,,,,,,,
IMMOBILIZER KNEE PERF FOAM 12 IN T BAR ADJ MEDL BLK CUTAWAY,SUP-2336323,CDM,L1830,CPT,0274,RC,,,,both,,,43.93,28.55,,,,,,,,,,,,,
ROD EXT FIX STR LNG 4X325 MM CRANIOMAXILLOFACIAL TI LEVEL 1,SUP-2490236,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2576.90,1674.98,,,,,,,,,,,,,
PLATE BONE L32MM 4 H LCK RECON BILAT RIG FOR 2.7MM SCR,SUP-2348294,CDM,C1713,HCPCS,0278,RC,,,,both,,,4127.06,2682.59,,,,,,,,,,,,,
WIRE BNE FIX DIA1.6 MM THRD NS LEOS KIRSCHNER,SUP-2933033,CDM,C1713,HCPCS,0278,RC,,,,both,,,121.52,78.99,,,,,,,,,,,,,
SCREW BNE L 40 MM DIA 3 MM TI CANN HDLSS NS LEOS,SUP-2932589,CDM,C1713,HCPCS,0278,RC,,,,both,,,801.64,521.07,,,,,,,,,,,,,
SET URET STENT UNIVERSA SFT 30CM 7FR WIREGUIDE MULTILENGTH,SUP-2835793,CDM,C2617,HCPCS,0278,RC,,,,both,,,292.08,189.85,,,,,,,,,,,,,
SEGMENT HUM TOT REPL 100MM MOSAIC,SUP-2136205,CDM,C1776,CPT,0278,RC,,,,both,,,25311.54,16452.50,,,,,,,,,,,,,
DEFIBRILLATOR CARD 76GM 35CC W40XH73MM THK14MM DF1 IS1 CONN,SUP-2356259,CDM,C1722,HCPCS,0275,RC,,,,both,,,31400.82,20410.53,,,,,,,,,,,,,
GRAFT TISS FRZ DRY ILIUM BICORT STRP ASEP 22MML 55CM,SUP-2307123,CDM,C1713,HCPCS,0278,RC,,,,both,,,2930.50,1904.82,,,,,,,,,,,,,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,0250,RC,00264-1510-32,NDC,,both,100,ML,21.30,13.84,,,,,,,,,,,,,
KIT PARACENT 8FR L5IN POLYUR 18GAX7.5IN RND WALL NDL 3 W,SUP-2383253,CDM,C1729,HCPCS,0272,RC,,,,both,,,256.44,166.69,,,,,,,,,,,,,
PLATE BNE TIB 3.5X216 MM RT MEDL DSTL PERI ARTC 14 HOLE SS,SUP-2422117,CDM,C1713,HCPCS,0278,RC,,,,both,,,2463.17,1601.06,,,,,,,,,,,,,
STEM FEM SZ 5 SH TAPR HIP TI POR PLSM SPRY HI OFFSET,SUP-2349070,CDM,C1776,CPT,0278,RC,,,,both,,,13784.60,8959.99,,,,,,,,,,,,,
TSSERIES BIT DRILL 2.5MM SCREW,SUP-2586644,CDM,2720000010,LOCAL,0272,RC,,,,both,,,503.22,327.09,,,,,,,,,,,,,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,0250,RC,00264-7510-20,NDC,,both,250,ML,31.90,20.73,,,,,,,,,,,,,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,0258,RC,00264-1510-31,NDC,,both,50,ML,20.90,13.58,,,,,,,,,,,,,
CATHETER ANGIOPLSTY AGNT L 144 MM BALLOON L 12 MM DIA2.75 MM,SUP-2892823,CDM,C9610,HCPCS,0272,RC,,,,both,,,19389.50,12603.17,,,,,,,,,,,,,
Exc Rct Procidentia W/Anast Perineal Approach,CASE-45130,LOCAL,45130,CPT,,,,,,outpatient,,,11491.67,6895.00,,,,,,,,,,,,,
Anterior Instrumentation 2-3 Vertebral Segments|UNUSUAL NON-OVERLAPPING SERVICE,CASE-22845,LOCAL,22845,CPT,0360,RC,,,XU,outpatient,,,57982.27,34789.36,,,,,,,,,,,,,
Arthrt Expl Drg/Rmvl Loose/FB Iphal Jt Ea,CASE-26080,LOCAL,26080,CPT,,,,,,outpatient,,,15095.27,9057.16,,,,,,,,,,,,,
Transection/Avulsion Oth Spinal Nrv Xdrl|RIGHT SIDE,CASE-64772,LOCAL,64772,CPT,0360,RC,,,RT,outpatient,,,28722.50,17233.50,,,,,,,,,,,,,
Transection/Avulsion Oth Spinal Nrv Xdrl|RIGHT SIDE,CASE-64772,LOCAL,64772,CPT,,,,,RT,outpatient,,,28722.50,17233.50,,,,,,,,,,,,,
Exc Rct Procidentia W/Anast Perineal Approach,CASE-45130,LOCAL,45130,CPT,0360,RC,,,,outpatient,,,11491.67,6895.00,,,,,,,,,,,,,
Anterior Instrumentation 2-3 Vertebral Segments|UNUSUAL NON-OVERLAPPING SERVICE,CASE-22845,LOCAL,22845,CPT,,,,,XU,outpatient,,,57982.27,34789.36,,,,,,,,,,,,,
Arthrt Expl Drg/Rmvl Loose/FB Iphal Jt Ea,CASE-26080,LOCAL,26080,CPT,0360,RC,,,,outpatient,,,15095.27,9057.16,,,,,,,,,,,,,
CAP END 0MM CANN LOK FOR CENTRONAIL ANK COMPR NAILING SYS,SUP-2316327,CDM,C1713,HCPCS,0278,RC,,,,both,,,688.10,447.26,,,,,,,,,,,,,
HC So Hiv-1 & Hiv-2 Ab,PX-3068738966,CDM,87389,CPT,0306,RC,,,,both,,,121.00,78.65,,,,,,,,,,,,,
KIT DRL PIN L100MM DIA1.5MM ABSRB W/ K WIRE GUID SL BNE,SUP-2121830,CDM,C1713,HCPCS,0278,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
SHEATH RESECTSCP BLU 28FR STD USA ELITE,SUP-2313082,CDM,C1894,HCPCS,0272,RC,,,,both,,,3615.18,2349.87,,,,,,,,,,,,,
PLATE BNE W100XL100MM CRANIOMAXILLOFACIAL TI MESH SCRN FOR,SUP-2190572,CDM,C1713,HCPCS,0278,RC,,,,both,,,2094.38,1361.35,,,,,,,,,,,,,
MORPHINE SULFATE 4 MG/ML IV SOLN,RX-155570,CDM,J2270,HCPCS,0636,RC,00641-6125-01,NDC,,both,0.5,ML,54.10,35.16,,,,,,,,,,,,,
TI LCP PROX LATERAL TIBIA PL 11 HOLES/260MM/LEFT-STERILE,SUP-2549444,CDM,C1713,HCPCS,0278,RC,,,,both,,,4886.88,3176.47,,,,,,,,,,,,,
GUIDEWIRE VASC SPYGLS DISCOVER JAGWIRE L 180 CM TIP L 5 CM,SUP-2754406,CDM,C1769,HCPCS,0272,RC,,,,both,,,404.28,262.78,,,,,,,,,,,,,
Nasal/Sinus Ndsc W/Partial Ethmoidectomy,CASE-31254,LOCAL,31254,CPT,0360,RC,,,,outpatient,,,31794.17,19076.50,,,,,,,,,,,,,
Unlisted Laparoscopy Procedure Uterus,CASE-58578,LOCAL,58578,CPT,0360,RC,,,,outpatient,,,83833.35,50300.01,,,,,,,,,,,,,
Removal Implant Deep|LEFT SIDE,CASE-20680,LOCAL,20680,CPT,,,,,LT,outpatient,,,8359.73,5015.84,,,,,,,,,,,,,
Unlisted Laparoscopy Procedure Uterus,CASE-58578,LOCAL,58578,CPT,,,,,,outpatient,,,83833.35,50300.01,,,,,,,,,,,,,
Unlisted Procedure Arthroscopy,CASE-29999,LOCAL,29999,CPT,0360,RC,,,,outpatient,,,36019.23,21611.54,,,,,,,,,,,,,
Neuroplasty &/Transpos Median Nrv Carpal Tunne|RIGHT SIDE,CASE-64721,LOCAL,64721,CPT,,,,,RT,outpatient,,,10801.13,6480.68,,,,,,,,,,,,,
Unlisted Procedure Arthroscopy,CASE-29999,LOCAL,29999,CPT,,,,,,outpatient,,,36019.23,21611.54,,,,,,,,,,,,,
Neuroplasty &/Transpos Median Nrv Carpal Tunne|RIGHT SIDE,CASE-64721,LOCAL,64721,CPT,0360,RC,,,RT,outpatient,,,10801.13,6480.68,,,,,,,,,,,,,
Removal Implant Deep|LEFT SIDE,CASE-20680,LOCAL,20680,CPT,0360,RC,,,LT,outpatient,,,8359.73,5015.84,,,,,,,,,,,,,
"Correction Hammertoe|RIGHT FOOT, FIFTH DIGIT",CASE-28285,LOCAL,28285,CPT,,,,,T9,outpatient,,,15851.55,9510.93,,,,,,,,,,,,,
Nasal/Sinus Ndsc W/Partial Ethmoidectomy,CASE-31254,LOCAL,31254,CPT,,,,,,outpatient,,,31794.17,19076.50,,,,,,,,,,,,,
"Correction Hammertoe|RIGHT FOOT, FIFTH DIGIT",CASE-28285,LOCAL,28285,CPT,0360,RC,,,T9,outpatient,,,15851.55,9510.93,,,,,,,,,,,,,
STEM FEM SZ 12 L190MM STD OFFSET MONOLITHIC SLVLSS REV,SUP-2345516,CDM,C1776,CPT,0278,RC,,,,both,,,16516.40,10735.66,,,,,,,,,,,,,
CATHETER CV KT 7 FRX16 CM 3L PRESSURE INJ SPRING WIRE GUIDE,SUP-2763337,CDM,C1751,HCPCS,0278,RC,,,,both,,,273.81,177.98,,,,,,,,,,,,,
UNIVERSAL WIRE FIXATION BOLT 17.5MM,SUP-2605901,CDM,2720000010,LOCAL,0272,RC,,,,both,,,462.52,300.64,,,,,,,,,,,,,
DEFIBRILLATOR CARDIOVERTER IMP SGL CHMBR 109G 57ML 39 J DEL,SUP-2357742,CDM,C1722,HCPCS,0275,RC,,,,both,,,46393.50,30155.77,,,,,,,,,,,,,
PLATE BNE HUM 3.5X109 MM RT PERIARTICULAR PROX 3 HOLE LCK LP,SUP-2177818,CDM,C1713,HCPCS,0278,RC,,,,both,,,5208.00,3385.20,,,,,,,,,,,,,
MODEL ANAT MAXILLA 3D CT BASE OSTEOVIEW,SUP-2883626,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4386.52,2851.24,,,,,,,,,,,,,
PLATE BNE MESHED 126X126X1 MM SM GRID PDLLA STRL RESORB X,SUP-2459732,CDM,C1713,HCPCS,0278,RC,,,,both,,,9648.31,6271.40,,,,,,,,,,,,,
HC Repair Complex Trunk 2.6-7.5 Cm,PX-4501310100,CDM,13101,CPT,0450,RC,,,,both,,,1227.00,797.55,,,,,,,,,,,,,
SCREW BNE L18MM DOA2.7MM NONLOCKING FOR TUFFNEK TECHNOLOGY,SUP-2321180,CDM,C1713,HCPCS,0278,RC,,,,both,,,540.08,351.05,,,,,,,,,,,,,
SCREW BNE L10MM DIA4MM CANC BIODUR ALLY ST SELF DRL CANN,SUP-2409799,CDM,C1713,HCPCS,0278,RC,,,,both,,,562.69,365.75,,,,,,,,,,,,,
ACCESS KIT 20 GAX0.018 IN AXERA RX,SUP-2424407,CDM,C1769,HCPCS,0272,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
TIOTROPIUM BROMIDE 2.5 MCG/ACT IN AERS,RX-173421,CDM,6370000000,HCPCS,0637,RC,00597-0100-51,NDC,,both,4,GR,337.50,219.37,,,,,,,,,,,,,
PLATE BNE L262MM 19 H R ANTLAT DST TIB TI LOK COMPR FOR 35MM,SUP-2190974,CDM,C1713,HCPCS,0278,RC,,,,both,,,4900.19,3185.12,,,,,,,,,,,,,
BIT DRL TWST 1.6X40 MM 7 MM BOD COUNTSINK SONICWELD RX,SUP-2477353,CDM,2720000010,LOCAL,0272,RC,,,,both,,,824.38,535.85,,,,,,,,,,,,,
Laparoscopy Surg Cholecystectomy,CASE-47562,LOCAL,47562,CPT,0360,RC,,,,outpatient,,,31749.33,19049.60,,,,,,,,,,,,,
Laparoscopy Surg Cholecystectomy,CASE-47562,LOCAL,47562,CPT,,,,,,outpatient,,,31749.33,19049.60,,,,,,,,,,,,,
PLATE BNE L211MM 14 H NONSTERILE R LAT PROX TIB S STL LOK,SUP-2185622,CDM,C1713,HCPCS,0278,RC,,,,both,,,4013.67,2608.89,,,,,,,,,,,,,
PYRIDOSTIGMINE BROMIDE 60 MG/5ML PO SOLN,RX-145396,CDM,340b,HCPCS,0637,RC,66689-0406-10,NDC,,both,2.5,ML,59.70,38.80,,,,,,,,,,,,,
TI MATRIXMANDIBLE 4 HOLE BOX,SUP-2823039,CDM,C1713,HCPCS,0278,RC,,,,both,,,1079.22,701.49,,,,,,,,,,,,,
PLATE BNE 5 H FIBULAR NS UNITE,SUP-2896553,CDM,C1713,HCPCS,0278,RC,,,,both,,,1252.86,814.36,,,,,,,,,,,,,
TITAN INFL PENILE PROS CYL SET 14 CM,SUP-2165372,CDM,C1813,HCPCS,0278,RC,,,,both,,,10892.66,7080.23,,,,,,,,,,,,,
KIT REMOT CTRL 3 FOR DP BRAIN STIM VERCISE,SUP-2140423,CDM,C1787,HCPCS,0278,RC,,,,both,,,2025.30,1316.44,,,,,,,,,,,,,
KIT INTRO PED,SUP-2417197,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2961.02,1924.66,,,,,,,,,,,,,
"Open Tx Articular Fracture Mcp/IP Joint Ea|LEFT HAND, FOURTH DIGIT",CASE-26746,LOCAL,26746,CPT,,,,,F3,outpatient,,,28454.53,17072.72,,,,,,,,,,,,,
"Open Tx Articular Fracture Mcp/IP Joint Ea|LEFT HAND, FOURTH DIGIT",CASE-26746,LOCAL,26746,CPT,0360,RC,,,F3,outpatient,,,28454.53,17072.72,,,,,,,,,,,,,
"Remv Vert Body,Cerv,One Sgmt",CASE-63081,LOCAL,63081,CPT,0360,RC,,,,outpatient,,,60430.45,36258.27,,,,,,,,,,,,,
Rpr Ingun Hernia Sliding Any Age|LEFT SIDE,CASE-49525,LOCAL,49525,CPT,0360,RC,,,LT,outpatient,,,31194.02,18716.41,,,,,,,,,,,,,
"Remv Vert Body,Cerv,One Sgmt",CASE-63081,LOCAL,63081,CPT,,,,,,outpatient,,,60430.45,36258.27,,,,,,,,,,,,,
HC Repair Tun or Non Cath W/Port,CASE-36576,LOCAL,36576,CPT,0361,RC,,,,outpatient,,,17408.95,10445.37,,,,,,,,,,,,,
Rpr Ingun Hernia Sliding Any Age|LEFT SIDE,CASE-49525,LOCAL,49525,CPT,,,,,LT,outpatient,,,31194.02,18716.41,,,,,,,,,,,,,
CATHETER CV MAXIMAL BARR TY 7 FRX20 CM 3L RIFAMPIN SPECTRUM,SUP-2759875,CDM,C1751,HCPCS,0278,RC,,,,both,,,475.84,309.30,,,,,,,,,,,,,
CATHETER ART DL 0.018 IN 5 FRX90 CM MONITORING,SUP-2798486,CDM,C1727,CPT,0278,RC,,,,both,,,92.79,60.31,,,,,,,,,,,,,
BLADE SURG FOR CAP FIX STRL,SUP-2424043,CDM,2720000010,LOCAL,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
ALLOSYNC DBM CORTICAL FIBERS 1.0CC,SUP-2811279,CDM,C1713,HCPCS,0278,RC,,,,both,,,536.94,349.01,,,,,,,,,,,,,
STENT URET 6FR L12CM SIL CLS TIP DBL J,SUP-2313752,CDM,C2617,HCPCS,0278,RC,,,,both,,,426.91,277.49,,,,,,,,,,,,,
DRIVER SURG CANN SHFT FEN CREO,SUP-2418318,CDM,2720000010,LOCAL,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
PORT CT SIL FIL SUT H 8FR ATTACH TRINIFLEX CATH,SUP-2269554,CDM,C1788,HCPCS,0278,RC,,,,both,,,998.52,649.04,,,,,,,,,,,,,
WIRE BNE FIX L 350 MM DIA2 MM DRL TIP STRL EVOS KIRSCHNER,SUP-2933537,CDM,C1713,HCPCS,0278,RC,,,,both,,,459.38,298.60,,,,,,,,,,,,,
SCREW BONE L9MM DIA2MM CORT CRANIOMAXILLOFACIAL TI ST,SUP-2188967,CDM,C1713,HCPCS,0278,RC,,,,both,,,887.05,576.58,,,,,,,,,,,,,
MESH CRAN CUSTOMIZED + MED PRIORITY STRL MEDPOR,SUP-2862758,CDM,C1713,HCPCS,0278,RC,,,,both,,,56400.77,36660.50,,,,,,,,,,,,,
SHUNT NEUROSURGICAL L31CM OD9FR REG W/O RESVR T PRT,SUP-2264215,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2979.86,1936.91,,,,,,,,,,,,,
TAP ST 2.5 MM REUNITE SM SCR FIX SYS,SUP-2212975,CDM,C1713,HCPCS,0278,RC,,,,both,,,860.36,559.23,,,,,,,,,,,,,
INSERT TIB STD NEUT UNIV PRI UNCONSTRAINED 12MM THCK M,SUP-2397052,CDM,C1776,CPT,0278,RC,,,,both,,,8650.70,5622.95,,,,,,,,,,,,,
TRAY CATH HEMODIALYSI DUO SPLIT ACTE 13FR DIA 30CM STRGHT 2L,SUP-2610503,CDM,C1752,HCPCS,0278,RC,,,,both,,,288.88,187.77,,,,,,,,,,,,,
ANCHOR SUTURE DIAMETER 6.5MM WITH THREE NO2 HI FI 17MM NEEDL,SUP-2824899,CDM,C1713,HCPCS,0278,RC,,,,both,,,1468.89,954.78,,,,,,,,,,,,,
ROD SPNL 5.5X16 MM TI UNID,SUP-2269767,CDM,C1713,HCPCS,0278,RC,,,,both,,,5523.26,3590.12,,,,,,,,,,,,,
DRILL TWST L 67 MM DIA1.1 MM STP 5 MM HND HEX NS DISP LORENZ,SUP-2935678,CDM,2720000010,LOCAL,0272,RC,,,,both,,,433.32,281.66,,,,,,,,,,,,,
STEM EXTN TIB 13MMDIA 45MML POR MLRY HD,SUP-2408821,CDM,C1776,CPT,0278,RC,,,,both,,,30574.18,19873.22,,,,,,,,,,,,,
"Rpr/Advmnt Flxr Tdn Zone 2 W/O Fr Grft Ea Tendon|RIGHT HAND, THIRD DIGIT",CASE-26356,LOCAL,26356,CPT,,,,,F7,outpatient,,,29367.62,17620.57,,,,,,,,,,,,,
"Rpr/Advmnt Flxr Tdn Zone 2 W/O Fr Grft Ea Tendon|RIGHT HAND, THIRD DIGIT",CASE-26356,LOCAL,26356,CPT,0360,RC,,,F7,outpatient,,,29367.62,17620.57,,,,,,,,,,,,,
CLAMP EXT FIX LOK SCR FOR PENNING MINIFIXATOR,SUP-2316460,CDM,C1713,HCPCS,0278,RC,,,,both,,,56.65,36.82,,,,,,,,,,,,,
CONFORMER OPHTH SM W0.75XH0.22XL0.87IN PMMA HRD CLR PLAS H,SUP-2236381,CDM,L8610,HCPCS,0278,RC,,,,both,,,141.30,91.84,,,,,,,,,,,,,
ANCHOR SUTURE STRL SUTURELOC,SUP-2882171,CDM,C1713,HCPCS,0278,RC,,,,both,,,6280.00,4082.00,,,,,,,,,,,,,
PLATE BNE LCK UNIV 3.5 MM 5 HOLE CONTOURED 2 COMPR RECON,SUP-2466320,CDM,C1713,HCPCS,0278,RC,,,,both,,,1159.16,753.45,,,,,,,,,,,,,
REAMER SURG OD4.8MM BNE CANN HIP RESURF,SUP-2342344,CDM,2720000010,LOCAL,0272,RC,,,,both,,,441.64,287.07,,,,,,,,,,,,,
ROD IM UNIV 7 DEG PFC,SUP-2456052,CDM,C1713,HCPCS,0278,RC,,,,both,,,1604.54,1042.95,,,,,,,,,,,,,
KIT INSTR 13MM CRUC RET DISP PROCHONDRIX,SUP-2363972,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6239.75,4055.84,,,,,,,,,,,,,
PLATE BNE STR 2.3X105 MM 16 HOLE FRAC FOR SCR TI LEVEL 1,SUP-2481100,CDM,C1713,HCPCS,0278,RC,,,,both,,,1312.99,853.44,,,,,,,,,,,,,
CATHETER THROMCTMY SYNTEL L 80 CM 5FR 11MM 1.5CC 3CC FLX TIP,SUP-2119457,CDM,C1757,HCPCS,0272,RC,,,,both,,,19.56,12.71,,,,,,,,,,,,,
SCREW BNE L32MM OD42MM NONLOCKING COMPR,SUP-2321255,CDM,C1713,HCPCS,0278,RC,,,,both,,,580.90,377.58,,,,,,,,,,,,,
GRAFT VASC TAPR SHT 7-4 MMX40 CM STD WALL EPTFE CARBOFLO,SUP-2761272,CDM,C1768,CPT,0278,RC,,,,both,,,1740.41,1131.27,,,,,,,,,,,,,
BASKET STONE STR 1.9 FR 12 MMX120 CM 4 WIR W/O TIP NIT STRL,SUP-2767534,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1260.46,819.30,,,,,,,,,,,,,
KNIFE SURG DISCECTOMY 190 MM BAYNT,SUP-2277784,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1664.51,1081.93,,,,,,,,,,,,,
ADAPTER LD L 17 CM SIL INSUL UPLR LV1 RECEPTACLE IS1 CONN,SUP-2616253,CDM,C1883,HCPCS,0278,RC,,,,both,,,973.40,632.71,,,,,,,,,,,,,
BLADE SAW SAG FOR STRNOTMY HALL,SUP-2166598,CDM,2720000010,LOCAL,0272,RC,,,,both,,,266.90,173.48,,,,,,,,,,,,,
Arthrs Wrst Exc&/Rpr Triang Fibrocart&/Joint|LEFT SIDE,CASE-29846,LOCAL,29846,CPT,,,,,LT,outpatient,,,26085.67,15651.40,,,,,,,,,,,,,
Ercp Biliary/Panc Duct Stent Exchange W/Dil&Wire,CASE-43276,LOCAL,43276,CPT,,,,,,outpatient,,,30691.30,18414.78,,,,,,,,,,,,,
Ercp Biliary/Panc Duct Stent Exchange W/Dil&Wire,CASE-43276,LOCAL,43276,CPT,0360,RC,,,,outpatient,,,30691.30,18414.78,,,,,,,,,,,,,
Arthrs Wrst Exc&/Rpr Triang Fibrocart&/Joint|LEFT SIDE,CASE-29846,LOCAL,29846,CPT,0360,RC,,,LT,outpatient,,,26085.67,15651.40,,,,,,,,,,,,,
SET CATH HEMODIALYSI BIOFLXTESIO CHRONIC STNDRD 6.5FR DIA 29,SUP-2610623,CDM,C1750,HCPCS,0278,RC,,,,both,,,185.89,120.83,,,,,,,,,,,,,
SET INTRO SUP ARW FLX SHTH L 90 CM DIA 5 FR HYDRPHLC,SUP-2383401,CDM,C1894,HCPCS,0272,RC,,,,both,,,416.05,270.43,,,,,,,,,,,,,
GUIDEWIRE ORTH 1.4 MM DISP,SUP-2223990,CDM,C1769,HCPCS,0272,RC,,,,both,,,31.40,20.41,,,,,,,,,,,,,
BIT DRILL D4MM LNG ORNG XTRFX EXTRNL FXTN SSTM,SUP-2472074,CDM,2720000010,LOCAL,0272,RC,,,,both,,,393.29,255.64,,,,,,,,,,,,,
SYSTEM RINGFIX 1 HL HALF PIN POST,SUP-2469032,CDM,2720000010,LOCAL,0272,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
CEMENT BONE 10GM ACRYL W/ CNTRST AGNT AND TANT,SUP-2342070,CDM,C1713,HCPCS,0278,RC,,,,both,,,838.38,544.95,,,,,,,,,,,,,
ENDCAP SPNL 17X22MM TI OVL MESH,SUP-2254468,CDM,C1713,HCPCS,0278,RC,,,,both,,,671.96,436.77,,,,,,,,,,,,,
GRAFT BNE SUB 1.2CC FOAM PK STBL COMPR RESIST VITOSS BA2X,SUP-2368193,CDM,C1713,HCPCS,0278,RC,,,,both,,,973.40,632.71,,,,,,,,,,,,,
HC Assay of Phenylalanine Blood,PX-3018403000,CDM,84030,CPT,0301,RC,,,,inpatient,,,609.00,395.85,,,,,,,,,,,,,
DEVICE FIX STERNALOCK BLU,SUP-2691303,CDM,C1713,HCPCS,0278,RC,,,,both,,,2939.04,1910.38,,,,,,,,,,,,,
"HC Debrid,Bone Ea Addl 20sqcm",PX-3611104700,CDM,11047,CPT,0361,RC,,,,both,,,840.00,546.00,,,,,,,,,,,,,
LENS INTOCU +6.0 TO +34.0 DIOPT CYL PWR 5.25 DIOPT L13MM,SUP-2111949,CDM,V2787,HCPCS,0276,RC,,,,both,,,415.00,269.75,,,,,,,,,,,,,
SYSTEM FIX STD FEM W/ SHTH 8MM SCR L23MM DIA8-8.5MM,SUP-2249565,CDM,C1713,HCPCS,0278,RC,,,,both,,,2753.78,1789.96,,,,,,,,,,,,,
PLATE BNE L35MM THK13MM 6 H NONSTERILE HND TI STR LOK VAR,SUP-2176870,CDM,C1713,HCPCS,0278,RC,,,,both,,,1685.14,1095.34,,,,,,,,,,,,,
SHEATH INTRO PRELUDE L 4 CM DIA 5 FR GUIDEWIRE L 40 CM DIA,SUP-2303306,CDM,C1893,HCPCS,0272,RC,,,,both,,,103.46,67.25,,,,,,,,,,,,,
Suction Assisted Lipectomy Trunk,CASE-15877,LOCAL,15877,CPT,0360,RC,,,,outpatient,,,31881.63,19128.98,,,,,,,,,,,,,
Rpr Nonunion/Malunion Radius/Ulna W/O Autograft,CASE-25400,LOCAL,25400,CPT,0360,RC,,,,outpatient,,,28877.75,17326.65,,,,,,,,,,,,,
Rpr Nonunion/Malunion Radius/Ulna W/O Autograft,CASE-25400,LOCAL,25400,CPT,,,,,,outpatient,,,28877.75,17326.65,,,,,,,,,,,,,
HC Drain/Inj Joint/Bursa W/US Large|PBB CHARGE|LEFT SIDE,CASE-20611,LOCAL,20611,CPT,0510,RC,,,PBB|LT,outpatient,,,5989.75,3593.85,,,,,,,,,,,,,
Autograft Spine Surgery Local From Same Incision,CASE-20936,LOCAL,20936,CPT,0360,RC,,,,outpatient,,,84992.27,50995.36,,,,,,,,,,,,,
Autograft Spine Surgery Local From Same Incision,CASE-20936,LOCAL,20936,CPT,,,,,,outpatient,,,84992.27,50995.36,,,,,,,,,,,,,
Suction Assisted Lipectomy Trunk,CASE-15877,LOCAL,15877,CPT,,,,,,outpatient,,,31881.63,19128.98,,,,,,,,,,,,,
CONNECTOR SPNL THORLUM TI PARA SM STAT FOR 5 6MM ROD USS II,SUP-2193434,CDM,C1713,HCPCS,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
SCREW BONE L40MM OD8MM STD S STL CORT ST SELF DRL CANN,SUP-2343404,CDM,C1713,HCPCS,0278,RC,,,,both,,,1535.08,997.80,,,,,,,,,,,,,
NUT EXT FIX CIR NYL,SUP-2400605,CDM,2720000010,LOCAL,0272,RC,,,,both,,,31.40,20.41,,,,,,,,,,,,,
KIT SURG PWR MINIMALLY INVASIVE INSTR STRL LF DISP FJ-2000,SUP-2881141,CDM,2720000010,LOCAL,0272,RC,,,,both,,,898.04,583.73,,,,,,,,,,,,,
MESH SURG PRESHAPED LG 2.4X5.4 IN,SUP-2126289,CDM,C1781,HCPCS,0278,RC,,,,both,,,178.98,116.34,,,,,,,,,,,,,
GUIDEWIRE ORTH MULT HOLE 13 MM PROTCT SL FOR ALFN NS EXPERT,SUP-2799294,CDM,C1769,HCPCS,0272,RC,,,,both,,,2288.06,1487.24,,,,,,,,,,,,,
WIRE EXT FIX L400MM OD1.8MM BAYNT FOR SIDEKCK FREE CIR FIX,SUP-2400661,CDM,C1776,CPT,0278,RC,,,,both,,,207.24,134.71,,,,,,,,,,,,,
KIT INTRO INTRACLUDE DIA19 FR HEMOSTATIC STRL,SUP-2214548,CDM,C1894,HCPCS,0272,RC,,,,both,,,1624.95,1056.22,,,,,,,,,,,,,
STAPLER INT CIR EXTRA THICK 28 MM W/ TRI-STAPLE LF,SUP-2787716,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3427.15,2227.65,,,,,,,,,,,,,
PLATE BNE PROF THK 1 MM 8 H SCREW DIA2 MM MED TI MIDFACE STR,SUP-2883949,CDM,C1713,HCPCS,0278,RC,,,,both,,,1026.78,667.41,,,,,,,,,,,,,
Dstr Nrolytc Agnt Parverteb Fct Addl Crvcl/Thora|RIGHT SIDE,CASE-64634,LOCAL,64634,CPT,,,,,RT,outpatient,,,11822.95,7093.77,,,,,,,,,,,,,
Laparoscopic Appendectomy,CASE-44970,LOCAL,44970,CPT,0360,RC,,,,outpatient,,,30901.53,18540.92,,,,,,,,,,,,,
Anrct Xm Surg Req Anes General Spi/Edrl Dx|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-45990,LOCAL,45990,CPT,0360,RC,,,74,outpatient,,,38660.22,23196.13,,,,,,,,,,,,,
HC Inj Tendon Sheath/Ligament|PBB CHARGE|RIGHT SIDE,CASE-20550,LOCAL,20550,CPT,0510,RC,,,PBB|RT,outpatient,,,3539.25,2123.55,,,,,,,,,,,,,
HC Joint Injection/Aspir Large WO US|PBB CHARGE|RIGHT SIDE,CASE-20610,LOCAL,20610,CPT,0510,RC,,,PBB|RT,outpatient,,,1445.17,867.10,,,,,,,,,,,,,
Anrct Xm Surg Req Anes General Spi/Edrl Dx|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-45990,LOCAL,45990,CPT,,,,,74,outpatient,,,38660.22,23196.13,,,,,,,,,,,,,
Laparoscopic Appendectomy,CASE-44970,LOCAL,44970,CPT,,,,,,outpatient,,,30901.53,18540.92,,,,,,,,,,,,,
Revise Ulnar Nerve at Wrist|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64719,LOCAL,64719,CPT,0360,RC,,,LT|XU,outpatient,,,23601.80,14161.08,,,,,,,,,,,,,
Revise Ulnar Nerve at Wrist|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64719,LOCAL,64719,CPT,,,,,LT|XU,outpatient,,,23601.80,14161.08,,,,,,,,,,,,,
Dstr Nrolytc Agnt Parverteb Fct Addl Crvcl/Thora|RIGHT SIDE,CASE-64634,LOCAL,64634,CPT,0360,RC,,,RT,outpatient,,,11822.95,7093.77,,,,,,,,,,,,,
Egd Transoral Control Bleeding Any Method|UNUSUAL NON-OVERLAPPING SERVICE,CASE-43255,LOCAL,43255,CPT,0360,RC,,,XU,outpatient,,,11247.33,6748.40,,,,,,,,,,,,,
Arthrs Aided Ant Cruciate Ligm Rpr/Agmntj/Rcnstj|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-29888,LOCAL,29888,CPT,,,,,RT|XU,outpatient,,,78681.33,47208.80,,,,,,,,,,,,,
Arthrs Aided Ant Cruciate Ligm Rpr/Agmntj/Rcnstj|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-29888,LOCAL,29888,CPT,0360,RC,,,RT|XU,outpatient,,,78681.33,47208.80,,,,,,,,,,,,,
Egd Transoral Control Bleeding Any Method|UNUSUAL NON-OVERLAPPING SERVICE,CASE-43255,LOCAL,43255,CPT,,,,,XU,outpatient,,,11247.33,6748.40,,,,,,,,,,,,,
KIT CATH L66CM OD7FR PROX ITH REV CLS TIP SIL ANCHR CONN,SUP-2284616,CDM,C1755,HCPCS,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
KIT EEG ELECTRD L 40.5 MM 12 CONTACT RF PRB STRL DISP EVO,SUP-2936468,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3532.50,2296.12,,,,,,,,,,,,,
URETEROSCOPE FLX GLOB RVS 77 FR TIP DIGITAL LITHOVUE,SUP-2141753,CDM,C1747,HCPCS,0272,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
SCREW BNE L130MM DIA3.5MM STD CORT S STL ST NONCANNULATED,SUP-2183568,CDM,C1713,HCPCS,0278,RC,,,,both,,,248.66,161.63,,,,,,,,,,,,,
CLAMP REPROC EXT FIX D R ADJ 4MM,SUP-2679121,CDM,2720000010,LOCAL,0272,RC,,,,both,,,780.79,507.51,,,,,,,,,,,,,
PLATE BNE X MED 1.5X0.8 MM MIDFACE 4 HOLE W/ TAB STRL,SUP-2461998,CDM,C1713,HCPCS,0278,RC,,,,both,,,815.77,530.25,,,,,,,,,,,,,
PLATE BNE NAR 4.5X103 MM 6 HOLE SS DCP,SUP-2569164,CDM,C1713,HCPCS,0278,RC,,,,both,,,255.60,166.14,,,,,,,,,,,,,
INTRODUCER TUBE TY PERC FLX CIAGLIA BLU RHINO,SUP-2759813,CDM,C1769,HCPCS,0272,RC,,,,both,,,1276.22,829.54,,,,,,,,,,,,,
STEM HUM SZ 1 DIA8MM LNG CO CHROM CEM MONOBLOC EPIPHYSIS,SUP-2250978,CDM,C1776,CPT,0278,RC,,,,both,,,11963.40,7776.21,,,,,,,,,,,,,
HYDROXYUREA 500 MG PO CAPS,RX-10236,CDM,6370000000,HCPCS,0637,RC,68084-0284-01,NDC,,both,1,UN,4.20,2.73,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 80 CM DIA 6 MM STR TW HELIX,SUP-2525455,CDM,C1768,CPT,0278,RC,,,,both,,,2011.36,1307.38,,,,,,,,,,,,,
SUPPORT ORTHOT METATRSL CUST BAR WDG BTWN SOLE,SUP-2435727,CDM,L3410,HCPCS,0272,RC,,,,both,,,262.82,170.83,,,,,,,,,,,,,
SPHINCTEROTOME ENDO CATH 7FR ACROBAT 0.035IN ACCSRY CHAN,SUP-2170219,CDM,C1769,HCPCS,0272,RC,,,,both,,,1186.92,771.50,,,,,,,,,,,,,
Exploration Penetrating Wound Spx Extremity|LEFT SIDE,CASE-20103,LOCAL,20103,CPT,0360,RC,,,LT,outpatient,,,19800.32,11880.19,,,,,,,,,,,,,
HC Joint Injection/Aspir Large WO US|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-20610,LOCAL,20610,CPT,0510,RC,,,LT|XU,outpatient,,,4544.58,2726.75,,,,,,,,,,,,,
Tx Anal Fstl Trans/Supra/Xtrasphnctrc Incl Seton,CASE-46280,LOCAL,46280,CPT,,,,,,outpatient,,,13537.77,8122.66,,,,,,,,,,,,,
Exploration Penetrating Wound Spx Extremity|LEFT SIDE,CASE-20103,LOCAL,20103,CPT,,,,,LT,outpatient,,,19800.32,11880.19,,,,,,,,,,,,,
"Correction Hammertoe|LEFT FOOT, SECOND DIGIT",CASE-28285,LOCAL,28285,CPT,0360,RC,,,T1,outpatient,,,38410.67,23046.40,,,,,,,,,,,,,
"Correction Hammertoe|LEFT FOOT, SECOND DIGIT",CASE-28285,LOCAL,28285,CPT,,,,,T1,outpatient,,,38410.67,23046.40,,,,,,,,,,,,,
Surgical Arthroscopy Shoulder Repair Slap Lesion|RIGHT SIDE,CASE-29807,LOCAL,29807,CPT,0360,RC,,,RT,outpatient,,,49295.13,29577.08,,,,,,,,,,,,,
Tx Anal Fstl Trans/Supra/Xtrasphnctrc Incl Seton,CASE-46280,LOCAL,46280,CPT,0360,RC,,,,outpatient,,,13537.77,8122.66,,,,,,,,,,,,,
HC Inj Trigger Pt 1-2 Musc Grps|PBB CHARGE,CASE-20552,LOCAL,20552,CPT,0510,RC,,,PBB,outpatient,,,985.83,591.50,,,,,,,,,,,,,
Surgical Arthroscopy Shoulder Repair Slap Lesion|RIGHT SIDE,CASE-29807,LOCAL,29807,CPT,,,,,RT,outpatient,,,49295.13,29577.08,,,,,,,,,,,,,
HC Level V Surg Pathology Gross&Microscopic Exam,PX-3128830700,CDM,88307,CPT,0312,RC,,,,both,,,657.00,427.05,,,,,,,,,,,,,
SCREW BNE L36MM OD43MM TI LO EXT ST SELF DRL CANN FIX STBL,SUP-2242829,CDM,C1713,HCPCS,0278,RC,,,,both,,,1462.61,950.70,,,,,,,,,,,,,
SET INTRO MICRO-STICK SHTH L 9 CM DIA 5 FR 7 CM NIT REG COAX,SUP-2627288,CDM,C1894,HCPCS,0272,RC,,,,both,,,17.52,11.39,,,,,,,,,,,,,
GRAFT TISS SPCR CERV CANC FRZ DRY ALLGRFT 6MM,SUP-2307221,CDM,C1713,HCPCS,0278,RC,,,,both,,,3004.89,1953.18,,,,,,,,,,,,,
EXPANDER TISS NACL 6.7 CM PROJCT 13X11 CM 400 CC SHT HT STRL,SUP-2873911,CDM,C1889,HCPCS,0278,RC,,,,both,,,4239.00,2755.35,,,,,,,,,,,,,
SET VASC ACCS PEELWY L 15.5 CM INTRO L 20 CM DIA14 FR,SUP-2168021,CDM,C1892,HCPCS,0272,RC,,,,both,,,127.80,83.07,,,,,,,,,,,,,
PLATE BONE L342MM 15 H LT PROX FEM LCK FOR 4.5MM SCR,SUP-2351129,CDM,C1713,HCPCS,0278,RC,,,,both,,,14787.36,9611.78,,,,,,,,,,,,,
UNIT PRASS PR EMG 12.5MM 2 CHAN SM,SUP-2284325,CDM,C1713,HCPCS,0278,RC,,,,both,,,430.24,279.66,,,,,,,,,,,,,
CAP NAIL FEM HIP FOR ESSENTIAL INSTR,SUP-2347911,CDM,C1776,CPT,0278,RC,,,,both,,,604.64,393.02,,,,,,,,,,,,,
HEAD SPNL SCREW ROD DIA 4.75/5 MM UNIAXIAL STRL CD HORZ 2PK,SUP-2928050,CDM,C1713,HCPCS,0278,RC,,,,both,,,4584.40,2979.86,,,,,,,,,,,,,
"Reconstruction Nail Bed W/Graft|LEFT HAND, FOURTH DIGIT",CASE-11762,LOCAL,11762,CPT,0360,RC,,,F3,outpatient,,,33643.98,20186.39,,,,,,,,,,,,,
Destruction Neurolytic Agt Genicular Nerve W/Img|RIGHT SIDE,CASE-64624,LOCAL,64624,CPT,,,,,RT,outpatient,,,12448.15,7468.89,,,,,,,,,,,,,
Destruction Neurolytic Agt Genicular Nerve W/Img|RIGHT SIDE,CASE-64624,LOCAL,64624,CPT,0360,RC,,,RT,outpatient,,,12448.15,7468.89,,,,,,,,,,,,,
"Reconstruction Nail Bed W/Graft|LEFT HAND, FOURTH DIGIT",CASE-11762,LOCAL,11762,CPT,,,,,F3,outpatient,,,33643.98,20186.39,,,,,,,,,,,,,
Neuroplasty &/Transpos Median Nrv Carpal Tunne|BILATERAL PROCEDURE,CASE-64721,LOCAL,64721,CPT,,,,,50,outpatient,,,18647.30,11188.38,,,,,,,,,,,,,
Rpr 1st Ingun Hrna Age 5 Yrs/> Reducible|RIGHT SIDE,CASE-49505,LOCAL,49505,CPT,0360,RC,,,RT,outpatient,,,35504.27,21302.56,,,,,,,,,,,,,
Rpr 1st Ingun Hrna Age 5 Yrs/> Reducible|RIGHT SIDE,CASE-49505,LOCAL,49505,CPT,,,,,RT,outpatient,,,35504.27,21302.56,,,,,,,,,,,,,
Neuroplasty &/Transpos Median Nrv Carpal Tunne|BILATERAL PROCEDURE,CASE-64721,LOCAL,64721,CPT,0360,RC,,,50,outpatient,,,18647.30,11188.38,,,,,,,,,,,,,
HC Peripheral Block - Tap Unilateral Injection,PX-3606448600,CDM,64486,CPT,0360,RC,,,,inpatient,,,996.00,647.40,,,,,,,,,,,,,
MESH WND DERM REP FET BOV DERM IONIC SLV PRIMATRIX AG FEN,SUP-2243709,CDM,Q4110,HCPCS,0636,RC,,,,both,,,27624.15,17955.70,,,,,,,,,,,,,
WIRE FIX L150MM OD1.1MM NICKEL CHROM SMOOTH DBL END TRCR,SUP-2321644,CDM,C1713,HCPCS,0278,RC,,,,both,,,100.48,65.31,,,,,,,,,,,,,
CAGE SPNL H32MM DIA15MM ANT THORLUM TI RND MESH INTBDY FUS,SUP-2193225,CDM,C1889,HCPCS,0278,RC,,,,both,,,6940.81,4511.53,,,,,,,,,,,,,
BLADE IM L75MM DIA12.5MM FEM G TI CANN SPRL FR CUT EDGE FOR,SUP-2180043,CDM,C1713,HCPCS,0278,RC,,,,both,,,1557.13,1012.13,,,,,,,,,,,,,
GRAFT BIO TISS W3.9XL7.9IN PORCINE DERM RIFAMPIN,SUP-2125836,CDM,C1781,HCPCS,0278,RC,,,,both,,,15847.58,10300.93,,,,,,,,,,,,,
PLATE 8HL 2.7X93MM,SUP-2484713,CDM,C1713,HCPCS,0278,RC,,,,both,,,476.09,309.46,,,,,,,,,,,,,
HC Peripheral Block - Tap Unilateral Injection,PX-3606448600,CDM,64486,CPT,0360,RC,,,,outpatient,,,996.00,647.40,,,,,,,,,,,,,
TRAY CATH PICC POLY Q CATH BSC 4FR 0.034IN 60CM 1 LU 9154115,SUP-2632692,CDM,C1751,HCPCS,0278,RC,,,,both,,,349.92,227.45,,,,,,,,,,,,,
WASHER ORTHOPEDIC WIRE FOR PLATE,SUP-2389786,CDM,C1713,HCPCS,0278,RC,,,,both,,,204.10,132.66,,,,,,,,,,,,,
HANDLE RMR PIN PUL JCBS CHK FOR KNEE LIG RECON,SUP-2121289,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1598.26,1038.87,,,,,,,,,,,,,
GRAFT VASC GORTX L 70 CM DIA 4.5-6.5 MM EPTFE TAPR STD WALL,SUP-2396445,CDM,C1768,CPT,0278,RC,,,,both,,,1890.28,1228.68,,,,,,,,,,,,,
HC Calcium Ionized,PX-3018233000,CDM,82330,CPT,0301,RC,,,,both,,,172.00,111.80,,,,,,,,,,,,,
CONTROLLER SYS MONITOR LT VENTRICULAR HEARTMATE II,SUP-2356031,CDM,C1713,HCPCS,0278,RC,,,,both,,,17270.00,11225.50,,,,,,,,,,,,,
SCREW BONE L130MM DIA6.5MM STD CORT TI ST SELF DRL CANN,SUP-2343336,CDM,C1713,HCPCS,0278,RC,,,,both,,,1696.51,1102.73,,,,,,,,,,,,,
SCREW BNE L 50 MM DIA 8 MM SS ST SD CANN FULL THRD RVS CUT,SUP-2901056,CDM,C1713,HCPCS,0278,RC,,,,both,,,1039.31,675.55,,,,,,,,,,,,,
KIT OXMTR CATH 8.5FR L16CM 3 LUMN CTRL LUMN OLIGON PRESEP,SUP-2214762,CDM,C1751,HCPCS,0278,RC,,,,both,,,1617.10,1051.11,,,,,,,,,,,,,
COUNTERSINK SURG SM DISP FOR IO FIX X-POST IOFIX 2.0,SUP-2223763,CDM,2720000010,LOCAL,0272,RC,,,,both,,,781.86,508.21,,,,,,,,,,,,,
Excision Pilonidal Cyst/Sinus Extensive,CASE-11771,LOCAL,11771,CPT,0360,RC,,,,outpatient,,,14346.68,8608.01,,,,,,,,,,,,,
"Tendon Sheath Incision|LEFT HAND, FIFTH DIGIT",CASE-26055,LOCAL,26055,CPT,0360,RC,,,F4,outpatient,,,10476.23,6285.74,,,,,,,,,,,,,
Chemodenervation Internal Anal Sphincter,CASE-46505,LOCAL,46505,CPT,0360,RC,,,,outpatient,,,14692.70,8815.62,,,,,,,,,,,,,
"Rpr Coltrl Ligm Mtcarphlngl/Iphal Jt|LEFT HAND, THUMB",CASE-26540,LOCAL,26540,CPT,,,,,FA,outpatient,,,25505.92,15303.55,,,,,,,,,,,,,
"Tendon Sheath Incision|LEFT HAND, FIFTH DIGIT",CASE-26055,LOCAL,26055,CPT,,,,,F4,outpatient,,,10476.23,6285.74,,,,,,,,,,,,,
Laps Tx Ectopic Preg W/Salping&/Oophorectomy|LEFT SIDE,CASE-59151,LOCAL,59151,CPT,,,,,LT,outpatient,,,28643.98,17186.39,,,,,,,,,,,,,
Laps Tx Ectopic Preg W/Salping&/Oophorectomy|LEFT SIDE,CASE-59151,LOCAL,59151,CPT,0360,RC,,,LT,outpatient,,,28643.98,17186.39,,,,,,,,,,,,,
Cystourethroscopy W/Dest &/Rmvl Med Bladder Tum,CASE-52235,LOCAL,52235,CPT,0360,RC,,,,outpatient,,,19320.70,11592.42,,,,,,,,,,,,,
Cysto W/Urtroscopy&/Pyeloscopy Dx|UNUSUAL NON-OVERLAPPING SERVICE,CASE-52351,LOCAL,52351,CPT,,,,,XU,outpatient,,,30397.12,18238.27,,,,,,,,,,,,,
"Rpr Coltrl Ligm Mtcarphlngl/Iphal Jt|LEFT HAND, THUMB",CASE-26540,LOCAL,26540,CPT,0360,RC,,,FA,outpatient,,,25505.92,15303.55,,,,,,,,,,,,,
"Inj Dx/Ther Agnt Paravert Facet Joint, Cerv/Thorac, 2nd Level|BILATERAL PROCEDURE",CASE-64491,LOCAL,64491,CPT,,,,,50,outpatient,,,4392.15,2635.29,,,,,,,,,,,,,
Cysto W/Urtroscopy&/Pyeloscopy Dx|UNUSUAL NON-OVERLAPPING SERVICE,CASE-52351,LOCAL,52351,CPT,0360,RC,,,XU,outpatient,,,30397.12,18238.27,,,,,,,,,,,,,
Cysto W/Rescj/Fulg Orthopic Ureterocele Uni/Bi,CASE-52300,LOCAL,52300,CPT,,,,,,outpatient,,,37383.42,22430.05,,,,,,,,,,,,,
Total Thyroid Lobectomy Uni W/WO Isthmusectomy,CASE-60220,LOCAL,60220,CPT,0360,RC,,,,outpatient,,,45861.93,27517.16,,,,,,,,,,,,,
Chemodenervation Internal Anal Sphincter,CASE-46505,LOCAL,46505,CPT,,,,,,outpatient,,,14692.70,8815.62,,,,,,,,,,,,,
HC Pbb Carpal Tunnel Inj Pmc|PBB CHARGE,CASE-20526,LOCAL,20526,CPT,0510,RC,,,PBB,outpatient,,,1161.33,696.80,,,,,,,,,,,,,
Total Thyroid Lobectomy Uni W/WO Isthmusectomy,CASE-60220,LOCAL,60220,CPT,,,,,,outpatient,,,45861.93,27517.16,,,,,,,,,,,,,
Cystourethroscopy W/Dest &/Rmvl Med Bladder Tum,CASE-52235,LOCAL,52235,CPT,,,,,,outpatient,,,19320.70,11592.42,,,,,,,,,,,,,
"Inj Dx/Ther Agnt Paravert Facet Joint, Cerv/Thorac, 2nd Level|BILATERAL PROCEDURE",CASE-64491,LOCAL,64491,CPT,0360,RC,,,50,outpatient,,,4392.15,2635.29,,,,,,,,,,,,,
Cysto W/Rescj/Fulg Orthopic Ureterocele Uni/Bi,CASE-52300,LOCAL,52300,CPT,0360,RC,,,,outpatient,,,37383.42,22430.05,,,,,,,,,,,,,
Excision Pilonidal Cyst/Sinus Extensive,CASE-11771,LOCAL,11771,CPT,,,,,,outpatient,,,14346.68,8608.01,,,,,,,,,,,,,
PLEDGET CV DEBAKEY L 10.2 X W 5.1 CM THK 0.28 MM POLYESTER,SUP-2761353,CDM,C1768,CPT,0278,RC,,,,both,,,262.63,170.71,,,,,,,,,,,,,
BENDER ROD LT CORONAL PLANE,SUP-2232088,CDM,2780000010,LOCAL,0278,RC,,,,both,,,2216.84,1440.95,,,,,,,,,,,,,
GUIDE DRL HND HELD DISP ISOTAC,SUP-2341301,CDM,C1713,HCPCS,0278,RC,,,,both,,,155.12,100.83,,,,,,,,,,,,,
SEALER ENDOSCP NANO COAT OPN DIV CRV L JAW LIGASURE IMPACT,SUP-2283567,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1859.60,1208.74,,,,,,,,,,,,,
ANCHOR SUTURE BRAID 2-0 MO-6 5 MM NDL TI WHT BLU V-LOX,SUP-2762297,CDM,C1713,HCPCS,0278,RC,,,,both,,,844.66,549.03,,,,,,,,,,,,,
WALKER BOOT HI PRESSURE MED ANK AIR TRIO,SUP-2227874,CDM,L4386,HCPCS,0272,RC,,,,both,,,187.93,122.15,,,,,,,,,,,,,
SPLINT WRST SM R THMB SPICA COT POLY FAB LTHR WRKHRD ORIG,SUP-2326135,CDM,L3908,HCPCS,0272,RC,,,,both,,,72.06,46.84,,,,,,,,,,,,,
HC Veeg by Tech 2-12 Hr Cont R-T Monitoring,PX-7409571300,CDM,95713,CPT,0740,RC,,,,inpatient,,,4222.00,2744.30,,,,,,,,,,,,,
STENT COR 12MM 2.25MM RADPQ MRK RX MICROTRAC DEL,SUP-2296910,CDM,C1874,HCPCS,0278,RC,,,,both,,,2103.80,1367.47,,,,,,,,,,,,,
RING 5/8 160MM FOR TRUELOK FIX SYS,SUP-2316184,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1982.85,1288.85,,,,,,,,,,,,,
AZELASTINE HCL 0.1 % NA SOLN,RX-19179,CDM,6370000000,HCPCS,0637,RC,42291-0094-30,NDC,,both,30,ML,66.80,43.42,,,,,,,,,,,,,
RETRACTOR SURG W 26 MM BLADE EXT NS DISP SIG LTP,SUP-2886550,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 40 CM DIA12 X 6 MM EPTFE BIFURCATE,SUP-2396244,CDM,C1768,CPT,0278,RC,,,,both,,,2998.70,1949.15,,,,,,,,,,,,,
Exc Lesion Spermatic Cord Separate Procedure|UNUSUAL NON-OVERLAPPING SERVICE,CASE-55520,LOCAL,55520,CPT,,,,,XU,outpatient,,,31033.47,18620.08,,,,,,,,,,,,,
Exc Lesion Spermatic Cord Separate Procedure|UNUSUAL NON-OVERLAPPING SERVICE,CASE-55520,LOCAL,55520,CPT,0360,RC,,,XU,outpatient,,,31033.47,18620.08,,,,,,,,,,,,,
BASEPLATE TIB INLAY KNEE,SUP-2440395,CDM,C1776,CPT,0278,RC,,,,both,,,226.08,146.95,,,,,,,,,,,,,
KIT DRL DIA7MM PROX BICEPS REP ACC,SUP-2417351,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1209.78,786.36,,,,,,,,,,,,,
CHEEK RETRACTOR RING FOR WIRE,SUP-2823422,CDM,C1713,HCPCS,0278,RC,,,,both,,,938.55,610.06,,,,,,,,,,,,,
ALLOGRAFT HUM TISS FD IRRADIATED PERICARD,SUP-2866900,CDM,C1762,CPT,0278,RC,,,,both,,,1940.52,1261.34,,,,,,,,,,,,,
BUR SURG 10.7 MM TREPHINE FOR OTO SPINE,SUP-2607577,CDM,2720000010,LOCAL,0272,RC,,,,both,,,559.83,363.89,,,,,,,,,,,,,
CATHETER HD STR 15.5 FRX24 CM DL UNCUF BASIC SET HEM-FLO XF,SUP-2269536,CDM,C1881,HCPCS,0278,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
GRAFT VASC GELSFT L 15 CM DIA10 MM POLYESTER GEL ABD PERIPH,SUP-2384930,CDM,C1768,CPT,0278,RC,,,,both,,,751.25,488.31,,,,,,,,,,,,,
GRAFT BONE SUB 5CC DBM W/ RPM PUROS,SUP-2415799,CDM,C1713,HCPCS,0278,RC,,,,both,,,2232.54,1451.15,,,,,,,,,,,,,
GRAFT BNE SUB 20CC DBM BIOCOMPOSITE OSTEOSET PTTY INJ,SUP-2399060,CDM,C1734,HCPCS,0278,RC,,,,both,,,6289.42,4088.12,,,,,,,,,,,,,
MEROPENEM 500 MG IV SOLR,RX-17379,CDM,J2185,HCPCS,0636,RC,63323-0507-20,NDC,,both,1,UN,54.10,35.16,,,,,,,,,,,,,
Cysto W/Insert Ureteral Stent|RIGHT SIDE,CASE-52332,LOCAL,52332,CPT,0360,RC,,,RT,outpatient,,,17990.08,10794.05,,,,,,,,,,,,,
Ostc Prtl Exostc/Condylc Metar Head|RIGHT SIDE,CASE-28288,LOCAL,28288,CPT,,,,,RT,outpatient,,,16523.18,9913.91,,,,,,,,,,,,,
Cysto W/Insert Ureteral Stent|RIGHT SIDE,CASE-52332,LOCAL,52332,CPT,,,,,RT,outpatient,,,17990.08,10794.05,,,,,,,,,,,,,
Ostc Prtl Exostc/Condylc Metar Head|RIGHT SIDE,CASE-28288,LOCAL,28288,CPT,0360,RC,,,RT,outpatient,,,16523.18,9913.91,,,,,,,,,,,,,
HC Inj Anes/Steroid C/D Facet Sg,CASE-64490,LOCAL,64490,CPT,0361,RC,,,,outpatient,,,7507.82,4504.69,,,,,,,,,,,,,
LEAD NERVE STIM L 50 CM KT PERC 16 CONTACT STRL INFINION PRO,SUP-2905209,CDM,C1778,HCPCS,0278,RC,,,,both,,,10048.00,6531.20,,,,,,,,,,,,,
CATHETERIZATION KIT ART 025 18 GAX4.45 CM 18/25 GA 3 CC LF,SUP-2865587,CDM,C1751,HCPCS,0278,RC,,,,both,,,59.35,38.58,,,,,,,,,,,,,
GRAFT BONE SUB 3ML CA PHOS PUTTY FOR CRS NORIAN,SUP-2193975,CDM,C1713,HCPCS,0278,RC,,,,both,,,3152.56,2049.16,,,,,,,,,,,,,
PUSHER KNOT 6TH FNGR W/ SUT PASS DISP,SUP-2121576,CDM,2720000010,LOCAL,0272,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
CATHETER GUID SHEATHLESS EAUCATH L 100 CM DIA 7.5 FR JR4,SUP-2517609,CDM,C1887,HCPCS,0272,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
FIBER LASER HI PWR END FIRE EVOLVE,SUP-2225587,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2590.50,1683.82,,,,,,,,,,,,,
HC Bx Breast Add Lesion Strtctc,PX-3611908200,CDM,19082,CPT,0361,RC,,,,inpatient,,,3707.00,2409.55,,,,,,,,,,,,,
CATHETER SUPP SOFIA EX L 105 CM DSTL L 9 CM OD 5.2 FR PROX,SUP-2739137,CDM,C1887,HCPCS,0272,RC,,,,both,,,5524.83,3591.14,,,,,,,,,,,,,
SCREW BONE 3.5MM DIA 110MML CORTICAL SELF TAPPING STERILE,SUP-2588564,CDM,C1713,HCPCS,0278,RC,,,,both,,,80.73,52.47,,,,,,,,,,,,,
Arthrd Ant Ntrbd Min Dsc Ea Addl Interspace,CASE-22585,LOCAL,22585,CPT,,,,,,outpatient,,,64443.02,38665.81,,,,,,,,,,,,,
Rmvl/Revj Sling Stress Incontinence,CASE-57287,LOCAL,57287,CPT,,,,,,outpatient,,,23448.87,14069.32,,,,,,,,,,,,,
"Amputation Metatarsal W/Toe Single|RIGHT FOOT, THIRD DIGIT",CASE-28810,LOCAL,28810,CPT,0360,RC,,,T7,outpatient,,,28867.77,17320.66,,,,,,,,,,,,,
Rpr Aa Hernia Recr 3-10 Cm Ncrc8/Strangulated,CASE-49616,LOCAL,49616,CPT,,,,,,outpatient,,,79982.37,47989.42,,,,,,,,,,,,,
Rpr Aa Hernia Recr 3-10 Cm Ncrc8/Strangulated,CASE-49616,LOCAL,49616,CPT,0360,RC,,,,outpatient,,,79982.37,47989.42,,,,,,,,,,,,,
HC N Block Inj Suprascapular Nerv|LEFT SIDE,CASE-64418,LOCAL,64418,CPT,0360,RC,,,LT,outpatient,,,4316.75,2590.05,,,,,,,,,,,,,
Rmvl/Revj Sling Stress Incontinence,CASE-57287,LOCAL,57287,CPT,0360,RC,,,,outpatient,,,23448.87,14069.32,,,,,,,,,,,,,
"Amputation Metatarsal W/Toe Single|RIGHT FOOT, THIRD DIGIT",CASE-28810,LOCAL,28810,CPT,,,,,T7,outpatient,,,28867.77,17320.66,,,,,,,,,,,,,
Arthrd Ant Ntrbd Min Dsc Ea Addl Interspace,CASE-22585,LOCAL,22585,CPT,0360,RC,,,,outpatient,,,64443.02,38665.81,,,,,,,,,,,,,
TEMPLATE SURG ROD FLX PREF 2,SUP-2577917,CDM,C1821,HCPCS,0278,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
BAG BLD TRNSFUS CONSOLIDATED VENTRICULAR ASST DEV BLK,SUP-2356005,CDM,Q0508,HCPCS,0274,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
PLATE BONE SM W10XL73MM THK3.4MM 6 H UNIV DSTL HUM RAD ULN,SUP-2343768,CDM,C1713,HCPCS,0278,RC,,,,both,,,1215.27,789.93,,,,,,,,,,,,,
HINGE EXT FIX IN LN SALVATION,SUP-2401123,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2075.54,1349.10,,,,,,,,,,,,,
DRILL SURG CANN 6.1 MM STRT MICRONAIL,SUP-2521557,CDM,2720000010,LOCAL,0272,RC,,,,both,,,599.74,389.83,,,,,,,,,,,,,
SUPPORT ORTHOT KNEE LCK W/INTEGR RELEASE MECHANISM,SUP-2435668,CDM,L2415,HCPCS,0272,RC,,,,both,,,343.96,223.57,,,,,,,,,,,,,
PIN EXT FIX L 275 MM DIA 5 MM SS TRANSFIXING UNILAT NS DISP,SUP-2931245,CDM,C1713,HCPCS,0278,RC,,,,both,,,1011.71,657.61,,,,,,,,,,,,,
HEAD HUM RESURF HA COAT SZ 8 COPELAND,SUP-2403992,CDM,C1776,CPT,0278,RC,,,,both,,,15951.20,10368.28,,,,,,,,,,,,,
KIT PT PRGMR NEUROSTIMULATOR AVTIVIA DBS,SUP-2284468,CDM,C1787,HCPCS,0278,RC,,,,both,,,3736.60,2428.79,,,,,,,,,,,,,
COMPONENT HIP CMNTLS P3,SUP-2351398,CDM,C1776,CPT,0278,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
TRAY PICC 6FR POLYUR TRIM LEN DBL LUMN PWR INJ PASV VLV CT,SUP-2126393,CDM,C1751,HCPCS,0278,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
FIBER LASER 1000 MH N TAPR POLISHED TIP HOLM ACCUMAX 5/BX,SUP-2537765,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2116.11,1375.47,,,,,,,,,,,,,
CATHETER ETER PEEL A WAY SHTH,SUP-2384050,CDM,C1751,HCPCS,0278,RC,,,,both,,,32.88,21.37,,,,,,,,,,,,,
PLATE BNE SIDE L 30 X W 30 MM THK 0.5 MM SCREW DIA1.7 MM PLL,SUP-2883208,CDM,C1713,HCPCS,0278,RC,,,,both,,,2851.09,1853.21,,,,,,,,,,,,,
ANCHOR SUT SZ 2-0 PEEK CRV TIP NDL MENIS FIBERWIRE,SUP-2121861,CDM,C1776,CPT,0278,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
Laps Surg Rpr Recurrent Inguinal Hernia|BILATERAL PROCEDURE,CASE-49651,LOCAL,49651,CPT,,,,,50,outpatient,,,64059.98,38435.99,,,,,,,,,,,,,
Laps Surg Rpr Recurrent Inguinal Hernia|BILATERAL PROCEDURE,CASE-49651,LOCAL,49651,CPT,0360,RC,,,50,outpatient,,,64059.98,38435.99,,,,,,,,,,,,,
Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq|COLORECTAL CANCER SCREEN,CASE-45385,LOCAL,45385,CPT,0360,RC,,,PT,outpatient,,,10921.62,6552.97,,,,,,,,,,,,,
Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq|COLORECTAL CANCER SCREEN,CASE-45385,LOCAL,45385,CPT,,,,,PT,outpatient,,,10921.62,6552.97,,,,,,,,,,,,,
HC External Version,CASE-59412,LOCAL,59412,CPT,0720,RC,,,,outpatient,,,3039.93,1823.96,,,,,,,,,,,,,
SCREW BNE SCHNZ 6X250 MM SD HA STRL,SUP-2563702,CDM,C1713,HCPCS,0278,RC,,,,both,,,480.99,312.64,,,,,,,,,,,,,
BRACE WLK L SHOE MAN 10 13 WOMAN 11 15 SHT PNEUMAT SEMI RIG,SUP-2196355,CDM,L4361,HCPCS,0274,RC,,,,both,,,122.96,79.92,,,,,,,,,,,,,
SUPPORT ORTHOT WRST ELBW HND CUST ADJ FIT W/O JT FABRICATED,SUP-2435762,CDM,L3762,HCPCS,0274,RC,,,,both,,,1928.18,1253.32,,,,,,,,,,,,,
MESH MONOFILAMENT 10CM X 25CM,SUP-2873696,CDM,C1781,HCPCS,0278,RC,,,,both,,,7457.50,4847.37,,,,,,,,,,,,,
SCREW BONE L10MM DIA2.9MM PUR TI ST NONLOCKING MATRIXRIB,SUP-2181526,CDM,C1713,HCPCS,0278,RC,,,,both,,,475.71,309.21,,,,,,,,,,,,,
Thyroidectomy Total/Subtotal Lmtd Neck Dissect,CASE-60252,LOCAL,60252,CPT,,,,,,outpatient,,,51478.48,30887.09,,,,,,,,,,,,,
"Open Tx Phalangeal Shaft Fracture Prox/Middle Ea|LEFT HAND, THIRD DIGIT",CASE-26735,LOCAL,26735,CPT,,,,,F2,outpatient,,,25539.03,15323.42,,,,,,,,,,,,,
Rpr Xtnsr Tdn Cntrl Slip Tiss W/Lat Band Ea Fngr,CASE-26426,LOCAL,26426,CPT,,,,,,outpatient,,,10930.15,6558.09,,,,,,,,,,,,,
Rpr Xtnsr Tdn Cntrl Slip Tiss W/Lat Band Ea Fngr,CASE-26426,LOCAL,26426,CPT,0360,RC,,,,outpatient,,,10930.15,6558.09,,,,,,,,,,,,,
Thyroidectomy Total/Subtotal Lmtd Neck Dissect,CASE-60252,LOCAL,60252,CPT,0360,RC,,,,outpatient,,,51478.48,30887.09,,,,,,,,,,,,,
Open Tx Carpal Scaphoid Navicular Fracture|LEFT SIDE,CASE-25628,LOCAL,25628,CPT,0360,RC,,,LT,outpatient,,,25882.23,15529.34,,,,,,,,,,,,,
"Open Tx Phalangeal Shaft Fracture Prox/Middle Ea|LEFT HAND, THIRD DIGIT",CASE-26735,LOCAL,26735,CPT,0360,RC,,,F2,outpatient,,,25539.03,15323.42,,,,,,,,,,,,,
Open Tx Carpal Scaphoid Navicular Fracture|LEFT SIDE,CASE-25628,LOCAL,25628,CPT,,,,,LT,outpatient,,,25882.23,15529.34,,,,,,,,,,,,,
PLATE BNE L121MM THK1.3MM 100DEG 12 H TI TBLR FOR 3.5MM SCR,SUP-2412031,CDM,C1713,HCPCS,0278,RC,,,,both,,,299.56,194.71,,,,,,,,,,,,,
CHOLECALCIFEROL 125 MCG (5000 UT) PO CAPS,RX-15636,CDM,6370000000,HCPCS,0637,RC,50268-0868-11,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PLATE BNE L51MM +90DEG 2X5 H NONSTERILE DST DORS RAD TI L,SUP-2190199,CDM,C1713,HCPCS,0278,RC,,,,both,,,2218.28,1441.88,,,,,,,,,,,,,
PEN MRK 80DEG 20MM TOT HD ARTC 2 PSS ELECTRD LIN ISOLATOR,SUP-2124464,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8085.50,5255.57,,,,,,,,,,,,,
GUIDEWIRE VASC GLIDEWIRE ADVANTAGE L 180 CM DIA 0.035 IN TIP,SUP-2385543,CDM,C1769,HCPCS,0272,RC,,,,both,,,670.39,435.75,,,,,,,,,,,,,
BIT REPROC DRL REPROC 3/32 0.093X5 IN HI PERF TIP GRY,SUP-2538337,CDM,2720000010,LOCAL,0272,RC,,,,both,,,456.87,296.97,,,,,,,,,,,,,
PROSTHESIS OSS 2 MM 4X3.25 MM 1.45 MM DORNHOFFER PART HA TI,SUP-2469813,CDM,L8613,CPT,0278,RC,,,,both,,,1293.65,840.87,,,,,,,,,,,,,
PLATE BNE ORBIT FLR SM 1.5X0.4 MM RT SMRT 3D TI STRL LEVEL 1,SUP-2518088,CDM,C1713,HCPCS,0278,RC,,,,both,,,3735.00,2427.75,,,,,,,,,,,,,
SYSTEM ACCS WATCHMAN FXD L 75 CM OD 5 MM ID 4.2 MM SINGLE,SUP-2754214,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
Laps Surg Cholecystectomy W/Cholangiography,CASE-47563,LOCAL,47563,CPT,0360,RC,,,,outpatient,,,29742.55,17845.53,,,,,,,,,,,,,
Laps Surg Cholecystectomy W/Cholangiography,CASE-47563,LOCAL,47563,CPT,,,,,,outpatient,,,29742.55,17845.53,,,,,,,,,,,,,
Colonoscopy W/Biopsy Single/Multiple|COLORECTAL CANCER SCREEN|UNUSUAL NON-OVERLAPPING SERVICE,CASE-45380,LOCAL,45380,CPT,,,,,PT|XU,outpatient,,,14159.27,8495.56,,,,,,,,,,,,,
HC Biopsy/Exc Lymph Node Needle|LEFT SIDE,CASE-38505,LOCAL,38505,CPT,0361,RC,,,LT,outpatient,,,15734.67,9440.80,,,,,,,,,,,,,
Colonoscopy W/Biopsy Single/Multiple|COLORECTAL CANCER SCREEN|UNUSUAL NON-OVERLAPPING SERVICE,CASE-45380,LOCAL,45380,CPT,0360,RC,,,PT|XU,outpatient,,,14159.27,8495.56,,,,,,,,,,,,,
HC Inj Aa&/Strd Greater Occipital Nerve|BILATERAL PROCEDURE,CASE-64405,LOCAL,64405,CPT,0450,RC,,,50,outpatient,,,3592.43,2155.46,,,,,,,,,,,,,
SCREW BNE ST 2.7X85 MM CRTX T8 STARDRV RECESS SS NS,SUP-2757636,CDM,C1713,HCPCS,0278,RC,,,,both,,,156.62,101.80,,,,,,,,,,,,,
GORE TAG THORACIC BRANCH ENDOPROSTHESIS 21MMX8MMX10CM 20FR,SUP-2855595,CDM,C1768,CPT,0278,RC,,,,both,,,100480.00,65312.00,,,,,,,,,,,,,
SUTURE ENDOSCOPIC LONG CINCH,SUP-2878002,CDM,2720000010,LOCAL,0272,RC,,,,both,,,573.05,372.48,,,,,,,,,,,,,
SHEATH NRV STIM UNIV DYN DISP NEUROVISION,SUP-2310410,CDM,C1894,HCPCS,0272,RC,,,,both,,,194.68,126.54,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY HALO XP L 110 CM 7 FR 2-8-2 MM,SUP-2699999,CDM,C1730,HCPCS,0272,RC,,,,both,,,1092.78,710.31,,,,,,,,,,,,,
MARKER BRST BX 14GA TI FOR PRB CORMARK,SUP-2195641,CDM,A4648,CPT,0278,RC,,,,both,,,333.15,216.55,,,,,,,,,,,,,
SPACER ANTR CERV 14X17X8MM 5 DEG PEEK,SUP-2211542,CDM,C1821,HCPCS,0278,RC,,,,both,,,5966.00,3877.90,,,,,,,,,,,,,
INTRODUCER SHTH L13CM OD10.5FR DIL L20CM SPL AWAY VLV,SUP-2289322,CDM,C1892,HCPCS,0272,RC,,,,both,,,172.70,112.25,,,,,,,,,,,,,
SCREW BONE L90MM DIA6.4MM TIB KNEE BLU TI PARTIALLY THRD HEX,SUP-2347266,CDM,C1713,HCPCS,0278,RC,,,,both,,,2342.22,1522.44,,,,,,,,,,,,,
FIBER LASER SURG FIBER 365 MH HOLM SUREFLEX,SUP-2225688,CDM,2720000010,LOCAL,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
Fasct Prtl Palmr Addl Dgt Prox Iphal Jt W/WO Rpr,CASE-26125,LOCAL,26125,CPT,,,,,,outpatient,,,16150.42,9690.25,,,,,,,,,,,,,
Colon Ca Scrn Not Hi Rsk Ind,CASE-G0121,LOCAL,G0121,CPT,,,,,,outpatient,,,9595.52,5757.31,,,,,,,,,,,,,
Colon Ca Scrn Not Hi Rsk Ind,CASE-G0121,LOCAL,G0121,CPT,0360,RC,,,,outpatient,,,9595.52,5757.31,,,,,,,,,,,,,
Laparoscopy Surg Rpr Initial Inguinal Hernia|LEFT SIDE,CASE-49650,LOCAL,49650,CPT,,,,,LT,outpatient,,,49051.32,29430.79,,,,,,,,,,,,,
Laparoscopy Surg Rpr Initial Inguinal Hernia|LEFT SIDE,CASE-49650,LOCAL,49650,CPT,0360,RC,,,LT,outpatient,,,49051.32,29430.79,,,,,,,,,,,,,
Insertion Breast Implant Same Day of Mastectomy|BILATERAL PROCEDURE,CASE-19340,LOCAL,19340,CPT,,,,,50,outpatient,,,63938.85,38363.31,,,,,,,,,,,,,
HC Drain/Inj Joint/Bursa W/US Large|PBB CHARGE,CASE-20611,LOCAL,20611,CPT,0510,RC,,,PBB,outpatient,,,4337.67,2602.60,,,,,,,,,,,,,
Fasct Prtl Palmr Addl Dgt Prox Iphal Jt W/WO Rpr,CASE-26125,LOCAL,26125,CPT,0360,RC,,,,outpatient,,,16150.42,9690.25,,,,,,,,,,,,,
HC Gastroesophag Reflx Test W/Tel Ph Eltrd|REDUCED SERVICES,CASE-91035,LOCAL,91035,CPT,0750,RC,,,52,outpatient,,,1795.08,1077.05,,,,,,,,,,,,,
Insertion Breast Implant Same Day of Mastectomy|BILATERAL PROCEDURE,CASE-19340,LOCAL,19340,CPT,0360,RC,,,50,outpatient,,,63938.85,38363.31,,,,,,,,,,,,,
SCREW CORT 3.5MM DIAX40MM LNG,SUP-2205634,CDM,C1713,HCPCS,0278,RC,,,,both,,,15.70,10.20,,,,,,,,,,,,,
SHEATH GUID TRANSSEPTAL DIL TORFLEX 8 FR,SUP-2131521,CDM,C1894,HCPCS,0272,RC,,,,both,,,266.90,173.48,,,,,,,,,,,,,
PLATE BNE L72MM 4 H ST DST POSTEROLATERAL TIB S STL T SHP,SUP-2177707,CDM,C1713,HCPCS,0278,RC,,,,both,,,3072.65,1997.22,,,,,,,,,,,,,
PLATE ACET STR MATTA SS 10 118.5MM,SUP-2465158,CDM,C1713,HCPCS,0278,RC,,,,both,,,1067.60,693.94,,,,,,,,,,,,,
CATHETER CV 4 FRX55 CM SINGLE LUMEN PWR INJ XCELA,SUP-2117122,CDM,C1751,HCPCS,0278,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
PLATE SPNL L84MM UNIV CERV ANT 4 LEV TI STD REFLX,SUP-2380885,CDM,C1713,HCPCS,0278,RC,,,,both,,,6022.52,3914.64,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH FLX L 56 MM DIA14 MM SHTH 16 FR SS,SUP-2170643,CDM,C1768,CPT,0278,RC,,,,both,,,9686.90,6296.48,,,,,,,,,,,,,
INTRODUCER TUBE 24/26/28FR L100CM PERC FOR TRACH CIAGLIA BLU,SUP-2168764,CDM,C1894,HCPCS,0272,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
ANCHOR SUT OD55MM 2 3 PEEK OPTMA POLYMER TANT MRK MACBRIDE,SUP-2212836,CDM,C1713,HCPCS,0278,RC,,,,both,,,1268.56,824.56,,,,,,,,,,,,,
GRAFT SFT TISS 1 CC CRYOPRESERVED PLCNTA VIAFLOW C,SUP-2495869,CDM,C1713,HCPCS,0278,RC,,,,both,,,6063.34,3941.17,,,,,,,,,,,,,
SCREW BNE L3MM DIA1.2MM CORT CRANIOMAXILLOFACIAL SIL S STL 5PK,SUP-2366083,CDM,C1713,HCPCS,0278,RC,,,,both,,,228.12,148.28,,,,,,,,,,,,,
Excision Distal Ulna Partial/Complete,CASE-25240,LOCAL,25240,CPT,,,,,,outpatient,,,27877.25,16726.35,,,,,,,,,,,,,
Excision Distal Ulna Partial/Complete,CASE-25240,LOCAL,25240,CPT,0360,RC,,,,outpatient,,,27877.25,16726.35,,,,,,,,,,,,,
HC Remove Lung Catheter,CASE-32552,LOCAL,32552,CPT,0361,RC,,,,outpatient,,,6534.12,3920.47,,,,,,,,,,,,,
MESH HERN CIR 11 CM W/ ECHO 2 POS SYS POLYPR VENTRALIGHT ST,SUP-2126499,CDM,C1781,HCPCS,0278,RC,,,,both,,,1598.26,1038.87,,,,,,,,,,,,,
WASHER ORTH LCK 3.5 MM BNE THRD LIP SOCKET SS NS SURFIX DISP,SUP-2851965,CDM,C1713,HCPCS,0278,RC,,,,both,,,485.38,315.50,,,,,,,,,,,,,
PLATE SET SM UPPER EXTREMITY FRAG OUTLIER,SUP-2340933,CDM,C1713,HCPCS,0278,RC,,,,both,,,27161.00,17654.65,,,,,,,,,,,,,
SCREW BNE L38MM DIA5.5MM CORT TI ANK NONLOCKING FULL THRD,SUP-2398574,CDM,C1713,HCPCS,0278,RC,,,,both,,,320.28,208.18,,,,,,,,,,,,,
CATHETER CTRL VEN QUAD LUMN N TUNNELED FULL KT POLYUR CDC42854P1A] TELEFLEX ARROW INTL INC],SUP-2383386,CDM,C1751,HCPCS,0278,RC,,,,both,,,396.27,257.58,,,,,,,,,,,,,
CAGE SPNL 7X18X60 MM LAT COROENT XL+,SUP-2560069,CDM,C1889,HCPCS,0278,RC,,,,both,,,13257.08,8617.10,,,,,,,,,,,,,
SCREW CANC 4X16,SUP-2741734,CDM,C1713,HCPCS,0278,RC,,,,both,,,83.21,54.09,,,,,,,,,,,,,
DEXTROSE 5 % IV BOLUS,RX-40840055,CDM,2580000003,HCPCS,0258,RC,00264-1510-32,NDC,,both,250,ML,53.20,34.58,,,,,,,,,,,,,
PLATE BONE 51MML HLX2 STNLSS STEEL BTTRSS F/2.7MM/3.5MM SCRE,SUP-2477601,CDM,C1713,HCPCS,0278,RC,,,,both,,,1503.90,977.53,,,,,,,,,,,,,
ELECTRODE ELECSURG COAG 3 FRX110 CM BUGBY FLX XC STRL,SUP-2585776,CDM,2720000010,LOCAL,0272,RC,,,,both,,,271.83,176.69,,,,,,,,,,,,,
SHUNT CV 3 MMX15 CMX4.3 MM CAR HALLIN ENDRTRMY,SUP-2633892,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3082.95,2003.92,,,,,,,,,,,,,
IMPLANT SPINE INTERBOD ANTER CERV DAKOTA 14MM X 12MM X 10MM,SUP-2858713,CDM,C1889,HCPCS,0278,RC,,,,both,,,6813.80,4428.97,,,,,,,,,,,,,
DEXTROSE 5 % IV BOLUS,RX-40840055,CDM,J7060,HCPCS,0258,RC,00264-7510-10,NDC,,both,250,ML,17.00,11.05,,,,,,,,,,,,,
IMMOBILIZER SHOULDER SLING SWATHE DLX,SUP-2196951,CDM,L3660,HCPCS,0272,RC,,,,both,,,22.98,14.94,,,,,,,,,,,,,
Ligamentous Reconstruction Knee Extra-Articular|RIGHT SIDE,CASE-27427,LOCAL,27427,CPT,,,,,RT,outpatient,,,78681.33,47208.80,,,,,,,,,,,,,
"Amputation Toe Interphalangeal Joint|LEFT FOOT, SECOND DIGIT",CASE-28825,LOCAL,28825,CPT,,,,,T1,outpatient,,,15502.60,9301.56,,,,,,,,,,,,,
Surg Tx Anal Fistula Intersphincteric,CASE-46275,LOCAL,46275,CPT,0360,RC,,,,outpatient,,,11048.27,6628.96,,,,,,,,,,,,,
"Amputation Toe Interphalangeal Joint|LEFT FOOT, SECOND DIGIT",CASE-28825,LOCAL,28825,CPT,0360,RC,,,T1,outpatient,,,15502.60,9301.56,,,,,,,,,,,,,
Ligamentous Reconstruction Knee Extra-Articular|RIGHT SIDE,CASE-27427,LOCAL,27427,CPT,0360,RC,,,RT,outpatient,,,78681.33,47208.80,,,,,,,,,,,,,
Colpocleisis Le Fort Type,CASE-57120,LOCAL,57120,CPT,,,,,,outpatient,,,50888.27,30532.96,,,,,,,,,,,,,
HC Rt Bronch Dx Clear Airway,CASE-31645,LOCAL,31645,CPT,0361,RC,,,,outpatient,,,28712.22,17227.33,,,,,,,,,,,,,
Surg Tx Anal Fistula Intersphincteric,CASE-46275,LOCAL,46275,CPT,,,,,,outpatient,,,11048.27,6628.96,,,,,,,,,,,,,
Brnchsc Ebus Guided Sampl 3/> Node Station/Strux,CASE-31653,LOCAL,31653,CPT,,,,,,outpatient,,,36283.67,21770.20,,,,,,,,,,,,,
Colpocleisis Le Fort Type,CASE-57120,LOCAL,57120,CPT,0360,RC,,,,outpatient,,,50888.27,30532.96,,,,,,,,,,,,,
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level|BILATERAL PROCEDURE,CASE-64483,LOCAL,64483,CPT,,,,,50,outpatient,,,3978.53,2387.12,,,,,,,,,,,,,
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level|BILATERAL PROCEDURE,CASE-64483,LOCAL,64483,CPT,0360,RC,,,50,outpatient,,,3978.53,2387.12,,,,,,,,,,,,,
Brnchsc Ebus Guided Sampl 3/> Node Station/Strux,CASE-31653,LOCAL,31653,CPT,0360,RC,,,,outpatient,,,36283.67,21770.20,,,,,,,,,,,,,
HC So Rh Phenotype Complete,PX-3008690666,CDM,86906,CPT,0300,RC,,,,both,,,334.00,217.10,,,,,,,,,,,,,
PLATE SPNL CERV ANTR STD 1 LEV 24MM LEN UNIV LANX,SUP-2136798,CDM,C1713,HCPCS,0278,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
PORT INFUS OD8FR 2 LUMN PLAS FILL N VLV NH BIOFLO,SUP-2118788,CDM,C1788,HCPCS,0278,RC,,,,both,,,1899.70,1234.80,,,,,,,,,,,,,
COIL NEUROVASCULAR GDC-10 L 4 CM DIA2.5 MM MICROCATHETER,SUP-2365660,CDM,C1889,HCPCS,0278,RC,,,,both,,,4600.41,2990.27,,,,,,,,,,,,,
NEEDLE SUTURE L8.75IN SLIGHTLY CURVED REVERDIN,SUP-2802448,CDM,2720000010,LOCAL,0272,RC,,,,both,,,759.35,493.58,,,,,,,,,,,,,
SET SCR SPNL TI INNR FOR HD TO HD CONN 3.5MM ROD OCT SYS,SUP-2255335,CDM,C1713,HCPCS,0278,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
SCOPOLAMINE 1 MG/3DAYS TD PT72,RX-27696,CDM,6370000000,HCPCS,0637,RC,45802-0580-01,NDC,,both,1,UN,72.30,46.99,,,,,,,,,,,,,
IMPLANT OPHTH 1.25X4.5X100MM SIL STRP,SUP-2213510,CDM,L8610,HCPCS,0278,RC,,,,both,,,44.59,28.98,,,,,,,,,,,,,
HC I&D Breast Abscess Deep,PX-4501902000,CDM,19020,CPT,0450,RC,,,,both,,,4946.00,3214.90,,,,,,,,,,,,,
STIMULATOR NERVE 4.32 MM PERC EXTN KT INTERSTIM QUAD,SUP-2550568,CDM,C1883,HCPCS,0278,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
BUR SURG RND DMND NONFLUTED L750MM OD05MM,SUP-2284185,CDM,C1713,HCPCS,0278,RC,,,,both,,,453.48,294.76,,,,,,,,,,,,,
GRAFT VASC STR 12 MMX15 CM X0.038 MM AORT CV BOV INTERGARD,SUP-2465833,CDM,C1768,CPT,0278,RC,,,,both,,,1365.24,887.41,,,,,,,,,,,,,
HOLDER IMPL PIN ANT CERV FIX FOR PLT ATLNTS,SUP-2291119,CDM,C1713,HCPCS,0278,RC,,,,both,,,221.43,143.93,,,,,,,,,,,,,
VALVE GLAUCOMA W13XL16MM THK2.1MM SIL NONOBSTRUCTIVE SYS,SUP-2308657,CDM,C1783,HCPCS,0278,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
Conization Cervix W/WO D&C Rpr Knife/Laser,CASE-57520,LOCAL,57520,CPT,0360,RC,,,,outpatient,,,26627.13,15976.28,,,,,,,,,,,,,
Pelvic Examination W/Anesthesia Other Than Local,CASE-57410,LOCAL,57410,CPT,0360,RC,,,,outpatient,,,11056.17,6633.70,,,,,,,,,,,,,
Conization Cervix W/WO D&C Rpr Knife/Laser,CASE-57520,LOCAL,57520,CPT,,,,,,outpatient,,,26627.13,15976.28,,,,,,,,,,,,,
Pelvic Examination W/Anesthesia Other Than Local,CASE-57410,LOCAL,57410,CPT,,,,,,outpatient,,,11056.17,6633.70,,,,,,,,,,,,,
HC Joint Injection/Aspir Medium WO US|PBB CHARGE,CASE-20605,LOCAL,20605,CPT,0510,RC,,,PBB,outpatient,,,2289.08,1373.45,,,,,,,,,,,,,
APPLICATOR BRACHYTHERAPY BLLN W4XL6CM 60-65CC ELLIPSOIDAL,SUP-2239829,CDM,C1887,HCPCS,0272,RC,,,,both,,,8635.00,5612.75,,,,,,,,,,,,,
PLATE BONE INSERT 0.8 MM HALF HEIGHT MATRIXMIDFACE,SUP-2838506,CDM,C1713,HCPCS,0278,RC,,,,both,,,584.67,380.04,,,,,,,,,,,,,
CATHETER INFUS L150/5CM MIC STR PROWLER SEL +,SUP-2248999,CDM,C1887,HCPCS,0272,RC,,,,both,,,3918.94,2547.31,,,,,,,,,,,,,
ANCHOR SUT 65MM LD W TWO STRANDS OF NO 2 STD BRAID POLY,SUP-2362554,CDM,C1713,HCPCS,0278,RC,,,,both,,,1497.78,973.56,,,,,,,,,,,,,
ALLOGRAFT BNE FIBER LG CORTICAL INCITE,SUP-2538792,CDM,C1889,HCPCS,0278,RC,,,,both,,,7149.78,4647.36,,,,,,,,,,,,,
SCREW BONE EMERGENCY 2.4X6 MM CORTICAL MANDIBULAR CRANIOFACI,SUP-2838272,CDM,C1713,HCPCS,0278,RC,,,,both,,,241.78,157.16,,,,,,,,,,,,,
CHUCK DRL 5/32IN COR ORAL MAX JCBS,SUP-2362645,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3120.69,2028.45,,,,,,,,,,,,,
SCREW BONE L6MM OD1.2 CORT CRANIOMAXILLOFACIAL NONCANNULATED,SUP-2363326,CDM,C1713,HCPCS,0278,RC,,,,both,,,133.89,87.03,,,,,,,,,,,,,
Redo Excis Lumbar Disk|RIGHT SIDE,CASE-63042,LOCAL,63042,CPT,0360,RC,,,RT,outpatient,,,47127.68,28276.61,,,,,,,,,,,,,
Tr/Trnspl Tdn Carp/Mtcrpl Hand W/O Fr Grf Ea Tdn|RIGHT SIDE,CASE-26480,LOCAL,26480,CPT,0360,RC,,,RT,outpatient,,,27877.25,16726.35,,,,,,,,,,,,,
Colposcopy Cervix Bx Cervix & Endocrv Curretage,CASE-57454,LOCAL,57454,CPT,,,,,,outpatient,,,21192.82,12715.69,,,,,,,,,,,,,
"Exc Lesion Eyelid W/O Clsr/W/Simple Dir Closure|UPPER RIGHT, EYELID",CASE-67840,LOCAL,67840,CPT,0360,RC,,,E3,outpatient,,,18581.43,11148.86,,,,,,,,,,,,,
Redo Excis Lumbar Disk|RIGHT SIDE,CASE-63042,LOCAL,63042,CPT,,,,,RT,outpatient,,,47127.68,28276.61,,,,,,,,,,,,,
Colposcopy Cervix Bx Cervix & Endocrv Curretage,CASE-57454,LOCAL,57454,CPT,0360,RC,,,,outpatient,,,21192.82,12715.69,,,,,,,,,,,,,
Implnt Bio Implnt for Soft Tissue Reinforcement|LEFT SIDE,CASE-15777,LOCAL,15777,CPT,0360,RC,,,LT,outpatient,,,131721.93,79033.16,,,,,,,,,,,,,
Implnt Bio Implnt for Soft Tissue Reinforcement|LEFT SIDE,CASE-15777,LOCAL,15777,CPT,,,,,LT,outpatient,,,131721.93,79033.16,,,,,,,,,,,,,
Tr/Trnspl Tdn Carp/Mtcrpl Hand W/O Fr Grf Ea Tdn|RIGHT SIDE,CASE-26480,LOCAL,26480,CPT,,,,,RT,outpatient,,,27877.25,16726.35,,,,,,,,,,,,,
Post Colporrhaphy Rectocele W/WO Perineorrhaphy,CASE-57250,LOCAL,57250,CPT,0360,RC,,,,outpatient,,,86066.25,51639.75,,,,,,,,,,,,,
"Exc Lesion Eyelid W/O Clsr/W/Simple Dir Closure|UPPER RIGHT, EYELID",CASE-67840,LOCAL,67840,CPT,,,,,E3,outpatient,,,18581.43,11148.86,,,,,,,,,,,,,
Post Colporrhaphy Rectocele W/WO Perineorrhaphy,CASE-57250,LOCAL,57250,CPT,,,,,,outpatient,,,86066.25,51639.75,,,,,,,,,,,,,
PIN SCHNZ 6.0MM AO CONN,SUP-2321647,CDM,C1713,HCPCS,0278,RC,,,,both,,,580.90,377.58,,,,,,,,,,,,,
DEFIBRILLATOR CARD 66GM 31CC W51XH68MM THK12MM DF1 IS1 CONN,SUP-2356266,CDM,C1722,HCPCS,0275,RC,,,,both,,,36245.02,23559.26,,,,,,,,,,,,,
IMPLANT OSS L4.75MM OD.5MM NIT FLROPLAS STAP PIST IMPLABLE,SUP-2312822,CDM,L8613,CPT,0278,RC,,,,both,,,799.10,519.41,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE 2.5 CC DBM FLOWABLE FIBER AMBIENT STOR,SUP-2933249,CDM,C1762,CPT,0278,RC,,,,both,,,847.80,551.07,,,,,,,,,,,,,
SHEATH INTRO 8.5FR L72CM TIP L22.4MM 0.032IN BIDIR M CRV,SUP-2148501,CDM,C1894,HCPCS,0272,RC,,,,both,,,2747.50,1785.87,,,,,,,,,,,,,
CONT MESH F TEMPOROPARIETAL PED L06MM,SUP-2681438,CDM,C1713,HCPCS,0278,RC,,,,both,,,16354.12,10630.18,,,,,,,,,,,,,
PLATE BNE THK0.6MM BAR L5MM 100DEG 5 H L,SUP-2366297,CDM,C1713,HCPCS,0278,RC,,,,both,,,498.51,324.03,,,,,,,,,,,,,
PLATE BONE PRECONTOURED 1 MM 4 HOLE ADAPTION TITANIUM MATRIX,SUP-2842349,CDM,C1713,HCPCS,0278,RC,,,,both,,,1382.54,898.65,,,,,,,,,,,,,
VALVE SPEAK SZ 6 SIL CANN MONT,SUP-2138745,CDM,L8501,HCPCS,0274,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
DEFIBRILLATOR CRD BPLR 2 CHMBR IS-1 DF-1 CONN RST EPIC II DR,SUP-2356558,CDM,C1721,HCPCS,0275,RC,,,,both,,,57305.00,37248.25,,,,,,,,,,,,,
IMPL NAIL FEMORAL PF LT 13X340MM,SUP-2701287,CDM,C1713,HCPCS,0278,RC,,,,both,,,10746.34,6985.12,,,,,,,,,,,,,
TRAY PICC SUBCL 1/L 5FR 55CML SIL PWR INJ RADPQ PEEL 7918518,SUP-2632685,CDM,C1751,HCPCS,0278,RC,,,,both,,,737.90,479.63,,,,,,,,,,,,,
BASEPLATE GLEN SM UNIV SHLDR CAP COAT UNIVERSE REVERS,SUP-2123259,CDM,C1776,CPT,0278,RC,,,,both,,,4553.00,2959.45,,,,,,,,,,,,,
"HC So Organic Acid, Single,Quant",PX-3018392166,CDM,83921,CPT,0301,RC,,,,both,,,382.00,248.30,,,,,,,,,,,,,
"Partical Excision Bone Phalanx Toe|RIGHT FOOT, FIFTH DIGIT",CASE-28124,LOCAL,28124,CPT,0360,RC,,,T9,outpatient,,,27989.30,16793.58,,,,,,,,,,,,,
"Tendon Sheath Incision|RIGHT HAND, FOURTH DIGIT",CASE-26055,LOCAL,26055,CPT,0360,RC,,,F8,outpatient,,,10127.95,6076.77,,,,,,,,,,,,,
Bronchoscopy Needle Bx Trachea Main Stem&/Bron,CASE-31629,LOCAL,31629,CPT,,,,,,outpatient,,,41472.12,24883.27,,,,,,,,,,,,,
"Tendon Sheath Incision|RIGHT HAND, FOURTH DIGIT",CASE-26055,LOCAL,26055,CPT,,,,,F8,outpatient,,,10127.95,6076.77,,,,,,,,,,,,,
Anoscopy Dx W/HRA &Chem Agnts Enhancement W/Bx,CASE-46607,LOCAL,46607,CPT,,,,,,outpatient,,,13907.28,8344.37,,,,,,,,,,,,,
"Exc Tum/Vasc Mal Sft Tiss Hand/Fngr Subq <1.5cm|RIGHT HAND, THIRD DIGIT",CASE-26115,LOCAL,26115,CPT,0360,RC,,,F7,outpatient,,,11429.78,6857.87,,,,,,,,,,,,,
Arthroscopy Knee W/Meniscus Rpr Medial/Lateral|LEFT SIDE,CASE-29882,LOCAL,29882,CPT,0360,RC,,,LT,outpatient,,,39947.87,23968.72,,,,,,,,,,,,,
"Exc Tum/Vasc Mal Sft Tiss Hand/Fngr Subq <1.5cm|RIGHT HAND, THIRD DIGIT",CASE-26115,LOCAL,26115,CPT,,,,,F7,outpatient,,,11429.78,6857.87,,,,,,,,,,,,,
Bronchoscopy Needle Bx Trachea Main Stem&/Bron,CASE-31629,LOCAL,31629,CPT,0360,RC,,,,outpatient,,,41472.12,24883.27,,,,,,,,,,,,,
Anoscopy Dx W/HRA &Chem Agnts Enhancement W/Bx,CASE-46607,LOCAL,46607,CPT,0360,RC,,,,outpatient,,,13907.28,8344.37,,,,,,,,,,,,,
"Partical Excision Bone Phalanx Toe|RIGHT FOOT, FIFTH DIGIT",CASE-28124,LOCAL,28124,CPT,,,,,T9,outpatient,,,27989.30,16793.58,,,,,,,,,,,,,
Arthroscopy Knee W/Meniscus Rpr Medial/Lateral|LEFT SIDE,CASE-29882,LOCAL,29882,CPT,,,,,LT,outpatient,,,39947.87,23968.72,,,,,,,,,,,,,
Bx/Exc Lymph Node Open Deep Axillary Node|BILATERAL PROCEDURE,CASE-38525,LOCAL,38525,CPT,0360,RC,,,50,outpatient,,,60695.68,36417.41,,,,,,,,,,,,,
Bx/Exc Lymph Node Open Deep Axillary Node|BILATERAL PROCEDURE,CASE-38525,LOCAL,38525,CPT,,,,,50,outpatient,,,60695.68,36417.41,,,,,,,,,,,,,
CATHETER NASOBILIARY 7.5FR L250CM STL TEF W/ GWIRE DISP,SUP-2148627,CDM,C1883,HCPCS,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
"HC Est Pt, Outpt Visit Level 4|RESIDENT/TEACHING PHYS SERV",PX-7619921400,CDM,99214,CPT,0761,RC,,,GC,both,,,313.00,203.45,,,,,,,,,,,,,
TUBE LARYNCTMY L55MM DIA8MM CLR SIL STD DISP PROVOX,SUP-2124366,CDM,2720000010,LOCAL,0272,RC,,,,both,,,406.63,264.31,,,,,,,,,,,,,
ANCHOR SUT OD55MM 2 TWO PEEK OPTMA POLYMER FOR ROT CUF REP,SUP-2212838,CDM,C1713,HCPCS,0278,RC,,,,both,,,1488.36,967.43,,,,,,,,,,,,,
PIN EXT FIX L180MM DIA5MM THRD L40MM HALF,SUP-2197300,CDM,2720000010,LOCAL,0272,RC,,,,both,,,621.72,404.12,,,,,,,,,,,,,
DEVICE FIX MOTORIZED PUSH BTTN FIRING MECHANISM TACK INLINE,SUP-2902724,CDM,C1713,HCPCS,0278,RC,,,,both,,,3258.22,2117.84,,,,,,,,,,,,,
SCREW FOR BKWALT RETRCT 50-4637,SUP-2382093,CDM,C1713,HCPCS,0278,RC,,,,both,,,100.32,65.21,,,,,,,,,,,,,
PLATE BNE CNDYL 95 DEG 70X92 MM 5 HOLE SS STRL,SUP-2185488,CDM,C1713,HCPCS,0278,RC,,,,both,,,2949.59,1917.23,,,,,,,,,,,,,
SPRINT PNS SINGLE LEAD SYSTEM,SUP-2355008,CDM,C1778,HCPCS,0278,RC,,,,both,,,15386.00,10000.90,,,,,,,,,,,,,
GRAFT HUM TISS 100MM FRZN ALLGRFT HUM W ROT CUF PROX,SUP-2307320,CDM,C1713,HCPCS,0278,RC,,,,both,,,11410.26,7416.67,,,,,,,,,,,,,
SHEATH DESTIN SL 6FR R2P 149CM,SUP-2633198,CDM,C1894,HCPCS,0272,RC,,,,both,,,947.50,615.87,,,,,,,,,,,,,
ANCHOR BONE TOGGLELOC 7 PE W/ZIPLOOP,SUP-2589109,CDM,C1713,HCPCS,0278,RC,,,,both,,,2067.88,1344.12,,,,,,,,,,,,,
Exc Tumor Soft Tissue Thigh/Knee Subfasc <5cm|LEFT SIDE,CASE-27328,LOCAL,27328,CPT,0360,RC,,,LT,outpatient,,,24419.20,14651.52,,,,,,,,,,,,,
Exc Rct Tum Incl Muscularis Propria,CASE-45172,LOCAL,45172,CPT,,,,,,outpatient,,,13950.62,8370.37,,,,,,,,,,,,,
HC Inj Lympho for Sentinal Node,CASE-38792,LOCAL,38792,CPT,0361,RC,,,,outpatient,,,43965.23,26379.14,,,,,,,,,,,,,
Exc Rct Tum Incl Muscularis Propria,CASE-45172,LOCAL,45172,CPT,0360,RC,,,,outpatient,,,13950.62,8370.37,,,,,,,,,,,,,
Exc Tumor Soft Tissue Thigh/Knee Subfasc <5cm|LEFT SIDE,CASE-27328,LOCAL,27328,CPT,,,,,LT,outpatient,,,24419.20,14651.52,,,,,,,,,,,,,
Arthrs Knee W/Meniscectomy Med&Lat W/Shaving|RIGHT SIDE,CASE-29880,LOCAL,29880,CPT,0360,RC,,,RT,outpatient,,,23627.50,14176.50,,,,,,,,,,,,,
HC Debride Subq First 20 Sq Cm|SEPARATE STRUCTURE,CASE-11042,LOCAL,11042,CPT,0361,RC,,,XS,outpatient,,,23014.95,13808.97,,,,,,,,,,,,,
"Tendon Sheath Incision|LEFT HAND, FOURTH DIGIT",CASE-26055,LOCAL,26055,CPT,,,,,F3,outpatient,,,8311.27,4986.76,,,,,,,,,,,,,
Arthrs Knee W/Meniscectomy Med&Lat W/Shaving|RIGHT SIDE,CASE-29880,LOCAL,29880,CPT,,,,,RT,outpatient,,,23627.50,14176.50,,,,,,,,,,,,,
"Tendon Sheath Incision|LEFT HAND, FOURTH DIGIT",CASE-26055,LOCAL,26055,CPT,0360,RC,,,F3,outpatient,,,8311.27,4986.76,,,,,,,,,,,,,
KIT EEG ELECTRD L 26.5 MM 8 CONTACT STRL DISP EVO,SUP-2936437,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3030.10,1969.56,,,,,,,,,,,,,
COMPONENT TOT SHLDR CAPPED HA S2 TORNIER,SUP-2388886,CDM,C1776,CPT,0278,RC,,,,both,,,18212.00,11837.80,,,,,,,,,,,,,
DRILL SURG 5.5X220 MM DSTL SS GAM 12145180] STRYKER ORTHOPEDICS HOWM],SUP-2368456,CDM,2720000010,LOCAL,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
ROD GRADUATED TELESCOPIC,SUP-2699972,CDM,2720000010,LOCAL,0272,RC,,,,both,,,593.21,385.59,,,,,,,,,,,,,
ALLOGRAFT BNE 10X45.1-50 MM BONE-PATELLAR TENDON-BONE,SUP-2866882,CDM,C1762,CPT,0278,RC,,,,both,,,7934.78,5157.61,,,,,,,,,,,,,
TUBE TRACH DIA7MM S STL CUF FIT REINF SPRL COR KINK RESIST,SUP-2384500,CDM,C1713,HCPCS,0278,RC,,,,both,,,467.86,304.11,,,,,,,,,,,,,
CATHETER 24FR RIGHT ANGLE SILICONE THO,SUP-2825232,CDM,C1729,HCPCS,0272,RC,,,,both,,,43.96,28.57,,,,,,,,,,,,,
CATHETER MULTI-PURPOSE DRAIN 8FR L25CM GWIRE DIA0.038IN POLYUR MTL,SUP-2381889,CDM,C1729,HCPCS,0272,RC,,,,both,,,233.62,151.85,,,,,,,,,,,,,
PERI-LOC 4.5MM S-T LOCK SCREW 90MM,SUP-2819187,CDM,C1713,HCPCS,0278,RC,,,,both,,,1181.77,768.15,,,,,,,,,,,,,
GRAFT HUM TISS W5XL110MM FIB STRUT FRZN,SUP-2307387,CDM,C1713,HCPCS,0278,RC,,,,both,,,2999.45,1949.64,,,,,,,,,,,,,
SYSTEM NEUROSTIMULATOR W48XH53CM D11MM RECHRG PROTG MRI IPG,SUP-2356757,CDM,C1820,HCPCS,0278,RC,,,,both,,,51810.00,33676.50,,,,,,,,,,,,,
PLATE BNE L 125.73 X W 5.08 MM THK 1 MM 20 H TI STR NS DISP,SUP-2936479,CDM,C1713,HCPCS,0278,RC,,,,both,,,2314.18,1504.22,,,,,,,,,,,,,
HC Perq Vert Agmntj Cavity Crtj Uni/Bi Cannulj Lmbr,CASE-22514,LOCAL,22514,CPT,0361,RC,,,,outpatient,,,26578.12,15946.87,,,,,,,,,,,,,
Repair Intermediate S/a/T/E >30.0 Cm,CASE-12037,LOCAL,12037,CPT,0360,RC,,,,outpatient,,,40102.92,24061.75,,,,,,,,,,,,,
Repair Intermediate S/a/T/E >30.0 Cm,CASE-12037,LOCAL,12037,CPT,,,,,,outpatient,,,40102.92,24061.75,,,,,,,,,,,,,
Fissurectomy Incl Sphincterotomy When Performed,CASE-46200,LOCAL,46200,CPT,0360,RC,,,,outpatient,,,11064.83,6638.90,,,,,,,,,,,,,
Fissurectomy Incl Sphincterotomy When Performed,CASE-46200,LOCAL,46200,CPT,,,,,,outpatient,,,11064.83,6638.90,,,,,,,,,,,,,
Prq Skeletal Fixj Metacarpal Fx Each Bone|RIGHT SIDE,CASE-26608,LOCAL,26608,CPT,0360,RC,,,RT,outpatient,,,10984.13,6590.48,,,,,,,,,,,,,
Prq Skeletal Fixj Metacarpal Fx Each Bone|RIGHT SIDE,CASE-26608,LOCAL,26608,CPT,,,,,RT,outpatient,,,10984.13,6590.48,,,,,,,,,,,,,
PIN FIX 10 DSTL RADIOULNAR JT LCK,SUP-2435795,CDM,C1713,HCPCS,0278,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
SUPPORT ORTHOT ELBW CUST ADJ W/POS LCK JT PREFABRICATED,SUP-2435760,CDM,L3761,HCPCS,0272,RC,,,,both,,,1288.59,837.58,,,,,,,,,,,,,
INSERT TIB TOP AUG REV VANGUARD 360,SUP-2448656,CDM,C1776,CPT,0278,RC,,,,both,,,2190.15,1423.60,,,,,,,,,,,,,
COMPONENT FEM KNEE OPT PC NXGN,SUP-2201155,CDM,C1776,CPT,0278,RC,,,,both,,,11101.47,7215.96,,,,,,,,,,,,,
INTERFACE LOWER EXTREMITY SFT AK PLAS,SUP-2388187,CDM,L2830,HCPCS,0274,RC,,,,both,,,231.79,150.66,,,,,,,,,,,,,
CATHETER ANGIOPLSTY OTW 0.035 IN 20 ATM 5 FRX80 CM 4X300 MM,SUP-2865955,CDM,C1725,HCPCS,0272,RC,,,,both,,,511.04,332.18,,,,,,,,,,,,,
TECLISTAMAB-CQYV 153 MG/1.7ML SC SOLN,RX-160726,CDM,J9380,HCPCS,0636,RC,57894-0450-01,NDC,,both,1.7,ML,30089.00,19557.85,,,,,,,,,,,,,
HANDPIECE SURG 6 IN BEND-A-BEAM ABC,SUP-2225595,CDM,2720000010,LOCAL,0272,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
MATRIX BONE GRFT SUB DEMIN TREL-XPRESS 300 10 ML PUTTY,SUP-2244482,CDM,C9359,HCPCS,0278,RC,,,,both,,,10942.90,7112.88,,,,,,,,,,,,,
HC So1 Anti Nuclear Antibody,PX-3028603867,CDM,86038,CPT,0302,RC,,,,both,,,43.00,27.95,,,,,,,,,,,,,
IMMUNE GLOBULIN (HUMAN) 10 GM/100ML IV SOLN,RX-104397,CDM,J1459,HCPCS,0636,RC,44206-0437-10,NDC,,both,100,ML,5659.90,3678.93,,,,,,,,,,,,,
Arthrs Kne Surg W/Meniscectomy Med/Lat W/Shvg|LEFT SIDE,CASE-29881,LOCAL,29881,CPT,,,,,LT,outpatient,,,26225.77,15735.46,,,,,,,,,,,,,
Excision Excessive Skin & Subq Tissue Abdomen,CASE-15847,LOCAL,15847,CPT,0360,RC,,,,outpatient,,,71122.50,42673.50,,,,,,,,,,,,,
Laryngoscopy Direct Operative W/Biopsy,CASE-31535,LOCAL,31535,CPT,,,,,,outpatient,,,20618.32,12370.99,,,,,,,,,,,,,
"Tenolysis Extensor Tendon Hand/Finger Each|LEFT HAND, SECOND DIGIT",CASE-26445,LOCAL,26445,CPT,,,,,F1,outpatient,,,16467.32,9880.39,,,,,,,,,,,,,
Arthrs Kne Surg W/Meniscectomy Med/Lat W/Shvg|LEFT SIDE,CASE-29881,LOCAL,29881,CPT,0360,RC,,,LT,outpatient,,,26225.77,15735.46,,,,,,,,,,,,,
"Tenolysis Extensor Tendon Hand/Finger Each|LEFT HAND, SECOND DIGIT",CASE-26445,LOCAL,26445,CPT,0360,RC,,,F1,outpatient,,,16467.32,9880.39,,,,,,,,,,,,,
Appl Skin Cell Ssp Agrft T/a/L 1st 480 Sq Cm/<,CASE-15015,LOCAL,15015,CPT,0360,RC,,,,outpatient,,,54254.85,32552.91,,,,,,,,,,,,,
Excision Excessive Skin & Subq Tissue Abdomen,CASE-15847,LOCAL,15847,CPT,,,,,,outpatient,,,71122.50,42673.50,,,,,,,,,,,,,
"HC Aerosol, Hhn, Mdi, Ippb|ADJ",CASE-94640,LOCAL,94640,CPT,0410,RC,,,ADJ,outpatient,,,65496.65,39297.99,,,,,,,,,,,,,
Perq Nl/Pl Lithotrp Simple Up to 2 Cm 1 Location|RIGHT SIDE,CASE-50080,LOCAL,50080,CPT,,,,,RT,outpatient,,,66313.48,39788.09,,,,,,,,,,,,,
Vulvectomy Simple Partial|BILATERAL PROCEDURE,CASE-56620,LOCAL,56620,CPT,0360,RC,,,50,outpatient,,,21688.33,13013.00,,,,,,,,,,,,,
Appl Skin Cell Ssp Agrft T/a/L 1st 480 Sq Cm/<,CASE-15015,LOCAL,15015,CPT,,,,,,outpatient,,,54254.85,32552.91,,,,,,,,,,,,,
Vulvectomy Simple Partial|BILATERAL PROCEDURE,CASE-56620,LOCAL,56620,CPT,,,,,50,outpatient,,,21688.33,13013.00,,,,,,,,,,,,,
Laryngoscopy Direct Operative W/Biopsy,CASE-31535,LOCAL,31535,CPT,0360,RC,,,,outpatient,,,20618.32,12370.99,,,,,,,,,,,,,
HC Inj Lympho for Sentinal Node|SEPARATE PRACTITIONER,CASE-38792,LOCAL,38792,CPT,0361,RC,,,XP,outpatient,,,68714.83,41228.90,,,,,,,,,,,,,
Perq Nl/Pl Lithotrp Simple Up to 2 Cm 1 Location|RIGHT SIDE,CASE-50080,LOCAL,50080,CPT,0360,RC,,,RT,outpatient,,,66313.48,39788.09,,,,,,,,,,,,,
SMALL KNOT PUSHER,SUP-2811802,CDM,2720000010,LOCAL,0272,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
PLATE SPNL L32MM 6 H TI ANT CERV 2 LEV PRECONTOURED BILAT,SUP-2415772,CDM,C1713,HCPCS,0278,RC,,,,both,,,3391.20,2204.28,,,,,,,,,,,,,
AMIODARONE HCL 200 MG PO TABS,RX-9066,CDM,6370000000,HCPCS,0637,RC,29300-0359-16,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 1 CC AMNION AMNIFLO CRYOPRESERVED,SUP-2138667,CDM,2780000010,LOCAL,0278,RC,,,,both,,,6892.30,4479.99,,,,,,,,,,,,,
DEBRIDER SURG SHFT L 255 MM DIA 8 MM IM CNL SUCTION CURET,SUP-2910632,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4867.00,3163.55,,,,,,,,,,,,,
BIOPSY PROCEDURE KIT UNIV LNG BLDELSS PRB MARKER MAMTOM MUK302] DEVICOR MED PRODUCTS MAMMOTOME],SUP-2195661,CDM,C1713,HCPCS,0278,RC,,,,both,,,1847.89,1201.13,,,,,,,,,,,,,
HC Platelet Aggregation in Vitro Each Agent,PX-3058557600,CDM,85576,CPT,0305,RC,,,,both,,,85.00,55.25,,,,,,,,,,,,,
PLATE BNE L230MM 10 H ST L CNDYL S STL CRV LOK COMPR VAR,SUP-2177854,CDM,C1713,HCPCS,0278,RC,,,,both,,,6315.11,4104.82,,,,,,,,,,,,,
BRACE ORTHOPEDIC SM LT WRST LTHR,SUP-2194370,CDM,L3809,HCPCS,0274,RC,,,,both,,,25.94,16.86,,,,,,,,,,,,,
DEVICE GRFT DEL ANGLED 15 CM VENTED BIOXPRESS,SUP-2431986,CDM,2720000010,LOCAL,0272,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
CAFFEINE CITRATE 60 MG/3ML IV SOLN,RX-104852,CDM,J0706,HCPCS,0636,RC,63323-0407-03,NDC,,both,3,ML,179.10,116.41,,,,,,,,,,,,,
HC Ins Cath Ren Art 1st Unilat,PX-3613625100,CDM,36251,CPT,0361,RC,,,,both,,,10063.00,6540.95,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP L260CM DIA0038IN SUP STIFF STD STR TIP HI,SUP-2141504,CDM,C1769,HCPCS,0272,RC,,,,both,,,440.79,286.51,,,,,,,,,,,,,
Realignment Extensor Tendon Hand Each Tendon,CASE-26437,LOCAL,26437,CPT,,,,,,outpatient,,,12375.22,7425.13,,,,,,,,,,,,,
Arthrodesis Posterior/Pstlat Tq 1ntrspc Lumbar,CASE-22612,LOCAL,22612,CPT,0360,RC,,,,outpatient,,,80923.48,48554.09,,,,,,,,,,,,,
Bronchoscopy Bronchial/Endobrncl Bx 1+ Sites,CASE-31625,LOCAL,31625,CPT,0360,RC,,,,outpatient,,,28712.22,17227.33,,,,,,,,,,,,,
Bronchoscopy Bronchial/Endobrncl Bx 1+ Sites,CASE-31625,LOCAL,31625,CPT,,,,,,outpatient,,,28712.22,17227.33,,,,,,,,,,,,,
Arthrodesis Posterior/Pstlat Tq 1ntrspc Lumbar,CASE-22612,LOCAL,22612,CPT,,,,,,outpatient,,,80923.48,48554.09,,,,,,,,,,,,,
Arthrodesis Cmbn Tq 1ntrspc Each Additional,CASE-22634,LOCAL,22634,CPT,0360,RC,,,,outpatient,,,136204.48,81722.69,,,,,,,,,,,,,
Open Tx Distal Fibular Fracture Lat Malleolus|RIGHT SIDE,CASE-27792,LOCAL,27792,CPT,,,,,RT,outpatient,,,40282.88,24169.73,,,,,,,,,,,,,
Realignment Extensor Tendon Hand Each Tendon,CASE-26437,LOCAL,26437,CPT,0360,RC,,,,outpatient,,,12375.22,7425.13,,,,,,,,,,,,,
Open Tx Distal Fibular Fracture Lat Malleolus|RIGHT SIDE,CASE-27792,LOCAL,27792,CPT,0360,RC,,,RT,outpatient,,,40282.88,24169.73,,,,,,,,,,,,,
Arthrodesis Cmbn Tq 1ntrspc Each Additional,CASE-22634,LOCAL,22634,CPT,,,,,,outpatient,,,136204.48,81722.69,,,,,,,,,,,,,
HC Myoglobin,PX-3018387400,CDM,83874,CPT,0301,RC,,,,both,,,311.00,202.15,,,,,,,,,,,,,
PLATE SPNL L35MM ANT LUM S STL CDH SPIRE,SUP-2292652,CDM,C1713,HCPCS,0278,RC,,,,both,,,10519.00,6837.35,,,,,,,,,,,,,
SPLINT ORTH W4IN LT HND BASE THMB SPICA ROLYAN,SUP-2324964,CDM,L3931,HCPCS,0274,RC,,,,both,,,91.91,59.74,,,,,,,,,,,,,
SCREW BNE L8MM OD2.7MM LOK FOR PLT TUFFNEK TECHNOLOGY,SUP-2321094,CDM,C1713,HCPCS,0278,RC,,,,both,,,714.35,464.33,,,,,,,,,,,,,
KIT INTRO AXCESS L 23 CM DIA 7 FR 0.035-0.038 IN W/O WIRE,SUP-2876447,CDM,C1894,HCPCS,0272,RC,,,,both,,,248.06,161.24,,,,,,,,,,,,,
Prq Impltj Neurostimulator Eltrd Peripheral Nrv,CASE-64555,LOCAL,64555,CPT,,,,,,outpatient,,,24438.05,14662.83,,,,,,,,,,,,,
Rpr Coltrl Ligm Mtcarphlngl/Iphal Jt,CASE-26540,LOCAL,26540,CPT,0360,RC,,,,outpatient,,,24147.52,14488.51,,,,,,,,,,,,,
Dbrdmt Fx&/Dislc Subq T/M/F Bone,CASE-11012,LOCAL,11012,CPT,,,,,,outpatient,,,43946.80,26368.08,,,,,,,,,,,,,
Prq Impltj Neurostimulator Eltrd Peripheral Nrv,CASE-64555,LOCAL,64555,CPT,0360,RC,,,,outpatient,,,24438.05,14662.83,,,,,,,,,,,,,
Dbrdmt Fx&/Dislc Subq T/M/F Bone,CASE-11012,LOCAL,11012,CPT,0360,RC,,,,outpatient,,,43946.80,26368.08,,,,,,,,,,,,,
Rpr Coltrl Ligm Mtcarphlngl/Iphal Jt,CASE-26540,LOCAL,26540,CPT,,,,,,outpatient,,,24147.52,14488.51,,,,,,,,,,,,,
KIT GASTROSTMY 16FR L80CM L260CM UTHANE 2 LUMN POS ANCHR,SUP-2168204,CDM,C1894,HCPCS,0272,RC,,,,both,,,788.20,512.33,,,,,,,,,,,,,
GRAFT BONE SUB SM MTRX 3 STRP COLLAGRFT,SUP-2197446,CDM,C1713,HCPCS,0278,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
DISC COR SLDE INTERVERTEBRAL SZ B UNIV,SUP-2390785,CDM,C1713,HCPCS,0278,RC,,,,both,,,14130.00,9184.50,,,,,,,,,,,,,
HC Trluml Balo Angiop Addl Vein,PX-3613724900,CDM,37249,CPT,0361,RC,,,,both,,,8583.00,5578.95,,,,,,,,,,,,,
SLEEVE FEM SLT 1 LG STD UNIV 13 MM PROX REV PRSS FT CMNTLS,SUP-2344360,CDM,C1776,CPT,0278,RC,,,,both,,,6381.27,4147.83,,,,,,,,,,,,,
DEVICE URIN SPHIN CTRL W/O INHIBZN AMS 800,SUP-2138917,CDM,C1815,HCPCS,0278,RC,,,,both,,,13188.00,8572.20,,,,,,,,,,,,,
NEEDLE BX ECHOGENIC TIP 18 GAX25 CM SAMPLE NOTCH TRU-CORE II,SUP-2876677,CDM,2720000010,LOCAL,0272,RC,,,,both,,,204.10,132.66,,,,,,,,,,,,,
INTRODUCER SHTH 0.018 IN 7 FRX4 CM 21 GAX4 CM ORNG PRELUDE,SUP-2303314,CDM,C1893,HCPCS,0272,RC,,,,both,,,103.46,67.25,,,,,,,,,,,,,
GLUCAGON HCL (DIAGNOSTIC) 1 MG IJ SOLR,RX-130194,CDM,J1611,HCPCS,0636,RC,63323-0596-11,NDC,,both,1,UN,1453.00,944.45,,,,,,,,,,,,,
BRACE KNEE 2XL FOR 255 28IN NEOPRENE OPN POPLITEAL WRP ARND,SUP-2196842,CDM,L1810,HCPCS,0272,RC,,,,both,,,65.56,42.61,,,,,,,,,,,,,
COMPONENT FEM A/P60MM UNIV CO CHROM LT MEDL RT LAT KNEE PRI,SUP-2200426,CDM,C1776,CPT,0278,RC,,,,both,,,8408.92,5465.80,,,,,,,,,,,,,
BLADE ENDO FOR SFT TISS PLNTR FASC REL SYS ENDOBLDE,SUP-2122780,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2810.30,1826.69,,,,,,,,,,,,,
Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx,CASE-28270,LOCAL,28270,CPT,0360,RC,,,,outpatient,,,38410.67,23046.40,,,,,,,,,,,,,
Hysteroscopy Endometrial Ablation,CASE-58563,LOCAL,58563,CPT,0360,RC,,,,outpatient,,,30012.72,18007.63,,,,,,,,,,,,,
Hysteroscopy Endometrial Ablation,CASE-58563,LOCAL,58563,CPT,,,,,,outpatient,,,30012.72,18007.63,,,,,,,,,,,,,
HC Inj Anes/Steroid C/D Facet Sg|BILATERAL PROCEDURE,CASE-64490,LOCAL,64490,CPT,0361,RC,,,50,outpatient,,,4392.15,2635.29,,,,,,,,,,,,,
Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx,CASE-28270,LOCAL,28270,CPT,,,,,,outpatient,,,38410.67,23046.40,,,,,,,,,,,,,
COMPLETION REV FEM SHIM LG/LG+,SUP-2513632,CDM,C1776,CPT,0278,RC,,,,both,,,2006.46,1304.20,,,,,,,,,,,,,
HOOK 3714113 COTTLE DBL 3MM,SUP-2705133,CDM,C1713,HCPCS,0278,RC,,,,both,,,327.31,212.75,,,,,,,,,,,,,
SYSTEM EMBOLIC PROTCT DIA5MM NICKEL TI TEMP EMBOSHIELD,SUP-2240288,CDM,C1880,HCPCS,0278,RC,,,,both,,,5322.30,3459.49,,,,,,,,,,,,,
STEM FEM SZ 2 STD HIP CEMENTLESS QUADRA R,SUP-2267203,CDM,C1776,CPT,0278,RC,,,,both,,,19808.69,12875.65,,,,,,,,,,,,,
GUIDEWIRE VASC L 100 CM DIA 0.035 IN CRV RAD 5 MM SS REUT,SUP-2167579,CDM,C1769,HCPCS,0272,RC,,,,both,,,205.98,133.89,,,,,,,,,,,,,
SHEATH RENAL ACC HYDRPHLC RADIOPQ CONT FLO AMPLTZ OPQ 24,SUP-2168947,CDM,C1894,HCPCS,0272,RC,,,,both,,,81.51,52.98,,,,,,,,,,,,,
BUR SURG 7.5MMDIA 4.5MML LNG FLUT DR CUT HD TPS MIDAS REX,SUP-2363367,CDM,2720000010,LOCAL,0272,RC,,,,both,,,350.36,227.73,,,,,,,,,,,,,
SET INTRO SUPER SHTH L 5 CM DIA 5 FR NIT WIRE TEARWY SUPER,SUP-2627263,CDM,C1894,HCPCS,0272,RC,,,,both,,,10.80,7.02,,,,,,,,,,,,,
CONE TIB AUG ASYM C RL/LM KNEE REV TRITANIUM TRIATHLON,SUP-2373584,CDM,C1776,CPT,0278,RC,,,,both,,,12950.77,8418.00,,,,,,,,,,,,,
COMPONENT FEM L67.5MM KNEE SEG IMP MOST OPTIONS,SUP-2208263,CDM,C1776,CPT,0278,RC,,,,both,,,8647.56,5620.91,,,,,,,,,,,,,
CATHETER KIT 3L 7 FRX8 IN GUIDE RAULERSON CVC ARROWG+ARD BLU,SUP-2383322,CDM,C1751,HCPCS,0278,RC,,,,both,,,151.10,98.21,,,,,,,,,,,,,
Mastopexy|LEFT SIDE,CASE-19316,LOCAL,19316,CPT,0360,RC,,,LT,outpatient,,,77089.20,46253.52,,,,,,,,,,,,,
"Tendon Sheath Incision|RIGHT HAND, FIFTH DIGIT",CASE-26055,LOCAL,26055,CPT,0360,RC,,,F9,outpatient,,,10542.43,6325.46,,,,,,,,,,,,,
Total Thyroid Lobectomy Uni W/WO Isthmusectomy|LEFT SIDE,CASE-60220,LOCAL,60220,CPT,0360,RC,,,LT,outpatient,,,41041.75,24625.05,,,,,,,,,,,,,
Total Thyroid Lobectomy Uni W/WO Isthmusectomy|LEFT SIDE,CASE-60220,LOCAL,60220,CPT,,,,,LT,outpatient,,,41041.75,24625.05,,,,,,,,,,,,,
Mastopexy|LEFT SIDE,CASE-19316,LOCAL,19316,CPT,,,,,LT,outpatient,,,77089.20,46253.52,,,,,,,,,,,,,
"Tendon Sheath Incision|RIGHT HAND, FIFTH DIGIT",CASE-26055,LOCAL,26055,CPT,,,,,F9,outpatient,,,10542.43,6325.46,,,,,,,,,,,,,
HC Trigger Point 3 or More|PBB CHARGE,CASE-20553,LOCAL,20553,CPT,0510,RC,,,PBB,outpatient,,,1204.67,722.80,,,,,,,,,,,,,
ELECTRODE ENDOSCP MPLR RLER DISP 24FR,SUP-2261200,CDM,2720000010,LOCAL,0272,RC,,,,both,,,520.71,338.46,,,,,,,,,,,,,
ADAPTER O2 DPLX INLET STEM AND TWO CK OUTLETS,SUP-2301210,CDM,2720000010,LOCAL,0272,RC,,,,both,,,519.98,337.99,,,,,,,,,,,,,
GUIDEWIRE ORTH 3.2X400 MM W/ DRL TIP NS,SUP-2757722,CDM,C1769,HCPCS,0272,RC,,,,both,,,287.37,186.79,,,,,,,,,,,,,
PLATE SPNL W37MM CVR PILLAR SA,SUP-2317122,CDM,C1821,HCPCS,0278,RC,,,,both,,,1161.80,755.17,,,,,,,,,,,,,
PLATE BONE W15XL120MM THK2MM 5 H BILAT TI THN BLDE RIG,SUP-2190983,CDM,C1713,HCPCS,0278,RC,,,,both,,,1346.78,875.41,,,,,,,,,,,,,
SEALER ENDOSCP 3 MM 5 MMX25 CM CRV VES CUT TISS ENSEAL TRIO,SUP-2257599,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1084.43,704.88,,,,,,,,,,,,,
IMPLANT NSL SIL ANAT 4.4X2.7X1.00X0.79X0.95X0.42X0.70X0.50CM,SUP-2242094,CDM,2780000010,LOCAL,0278,RC,,,,both,,,832.10,540.86,,,,,,,,,,,,,
PLATE BNE ULN LO PROF SHORTNG GENERATION II RAYHACK,SUP-2397320,CDM,C1713,HCPCS,0278,RC,,,,both,,,3353.52,2179.79,,,,,,,,,,,,,
"Prq Skel Fixj Phlngl Shft Fx Prox/Middle Px/F/T|LEFT HAND, FOURTH DIGIT",CASE-26727,LOCAL,26727,CPT,0360,RC,,,F3,outpatient,,,29346.28,17607.77,,,,,,,,,,,,,
"Prq Skel Fixj Phlngl Shft Fx Prox/Middle Px/F/T|LEFT HAND, FOURTH DIGIT",CASE-26727,LOCAL,26727,CPT,,,,,F3,outpatient,,,29346.28,17607.77,,,,,,,,,,,,,
HC Joint Injection/Aspir Large WO US|RIGHT SIDE,CASE-20610,LOCAL,20610,CPT,0510,RC,,,RT,outpatient,,,4343.83,2606.30,,,,,,,,,,,,,
Dstr Nrolytc Agnt Parverteb Fct Sngl Crvcl/Thora,CASE-64633,LOCAL,64633,CPT,0360,RC,,,,outpatient,,,11775.07,7065.04,,,,,,,,,,,,,
Osteot W/WO Lngth Shrt/Corrj Metar Xcp 1st Ea|LEFT SIDE,CASE-28308,LOCAL,28308,CPT,,,,,LT,outpatient,,,56315.75,33789.45,,,,,,,,,,,,,
Tendon Sheath Incision,CASE-26055,LOCAL,26055,CPT,0360,RC,,,,outpatient,,,19801.68,11881.01,,,,,,,,,,,,,
Largsc Exc Tum&/Strpg Cords/Epigl Mcrscp/Tlscp|LEFT SIDE,CASE-31541,LOCAL,31541,CPT,0360,RC,,,LT,outpatient,,,20621.47,12372.88,,,,,,,,,,,,,
Largsc Exc Tum&/Strpg Cords/Epigl Mcrscp/Tlscp|LEFT SIDE,CASE-31541,LOCAL,31541,CPT,,,,,LT,outpatient,,,20621.47,12372.88,,,,,,,,,,,,,
Osteot W/WO Lngth Shrt/Corrj Metar Xcp 1st Ea|LEFT SIDE,CASE-28308,LOCAL,28308,CPT,0360,RC,,,LT,outpatient,,,56315.75,33789.45,,,,,,,,,,,,,
Cysto W/Removal of Lesions Small,CASE-52224,LOCAL,52224,CPT,,,,,,outpatient,,,21932.63,13159.58,,,,,,,,,,,,,
HC Trigger Point 3 or More,CASE-20553,LOCAL,20553,CPT,0510,RC,,,,outpatient,,,3592.43,2155.46,,,,,,,,,,,,,
Dstr Nrolytc Agnt Parverteb Fct Sngl Crvcl/Thora,CASE-64633,LOCAL,64633,CPT,,,,,,outpatient,,,11775.07,7065.04,,,,,,,,,,,,,
HC Rm Private Detoxification,PX-1160000000,CDM,1160000000,CPT,,,,,,outpatient,,,2644.42,1586.65,,,,,,,,,,,,,
Tendon Sheath Incision,CASE-26055,LOCAL,26055,CPT,,,,,,outpatient,,,19801.68,11881.01,,,,,,,,,,,,,
Cysto W/Removal of Lesions Small,CASE-52224,LOCAL,52224,CPT,0360,RC,,,,outpatient,,,21932.63,13159.58,,,,,,,,,,,,,
BIT DRL DIA16MM FOR SM BNE PLATING SYS ORTHOLOC 3DI,SUP-2398069,CDM,2720000010,LOCAL,0272,RC,,,,both,,,599.74,389.83,,,,,,,,,,,,,
SET DRNGE UTHANE COOK COPE TYP LOK LOOP RNG MCLEAN,SUP-2168258,CDM,C1729,HCPCS,0272,RC,,,,both,,,503.19,327.07,,,,,,,,,,,,,
SPACER SPNL TI IMPL H18 TO 23MM 7DEG SM XPAND,SUP-2229123,CDM,C1821,HCPCS,0278,RC,,,,both,,,15700.00,10205.00,,,,,,,,,,,,,
BUR SURG BALL 1.5 MM 10 CM FLUT FOR MA-10 BEAR SL,SUP-2848267,CDM,2720000010,LOCAL,0272,RC,,,,both,,,578.83,376.24,,,,,,,,,,,,,
TIP EXTRACTOR FOR HINDFOOT TTC/TC INNR NAIL REMOVAL NS DISP,SUP-2909122,CDM,2720000010,LOCAL,0272,RC,,,,both,,,620.15,403.10,,,,,,,,,,,,,
GASTROSTOMY SET PUL METHOD 24 FRX150 CM 5.5 FR 260 CM PEG24,SUP-2738137,CDM,C1769,HCPCS,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
TORSEMIDE 10 MG PO TABS,RX-18292,CDM,6370000000,HCPCS,0637,RC,50268-0755-11,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
CANNULA ENDOSCP W/ OBTURATOR FLOWPORT II,SUP-2663978,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1249.94,812.46,,,,,,,,,,,,,
PLATE BONE 2 H LNG TI STR FOR CRAN CLSR SYS,SUP-2243970,CDM,C1713,HCPCS,0278,RC,,,,both,,,171.48,111.46,,,,,,,,,,,,,
DEFIBRILLATOR IMPL MOMENTUM X4 W 5.37 X H 8.08 CM D 0.99 CM,SUP-2420681,CDM,C1882,HCPCS,0275,RC,,,,both,,,52883.88,34374.52,,,,,,,,,,,,,
BUR SURG DIA6MM RND PRECIS RIM GLDE TECHNOLOGY RAP SMOOTH,SUP-2363787,CDM,2720000010,LOCAL,0272,RC,,,,both,,,437.65,284.47,,,,,,,,,,,,,
PLATE BNE SHRT TALO NAVICULAR POLYAXL LCK T10 SM FRAG NS,SUP-2902440,CDM,C1713,HCPCS,0278,RC,,,,both,,,4745.48,3084.56,,,,,,,,,,,,,
BAND LIGATOR LAPAROSCOPY SM SYS LAP-BAND,SUP-2113472,CDM,C1713,HCPCS,0278,RC,,,,both,,,8556.50,5561.72,,,,,,,,,,,,,
IMPLANT BIO TISS L25CM ID2MM PERIPH NRV CLLGN CONDUIT,SUP-2378811,CDM,C9353,HCPCS,0278,RC,,,,both,,,3441.44,2236.94,,,,,,,,,,,,,
INTERTAN SET SCREW,SUP-2821023,CDM,C1713,HCPCS,0278,RC,,,,both,,,1647.78,1071.06,,,,,,,,,,,,,
BRACE ORTH CARBON FIBER FRME LT KNEE ACL DROPLOCK HINGE S/TH,SUP-2915019,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1554.49,1010.42,,,,,,,,,,,,,
CATHETER KIT 8.5 FR 50 CC REPL INSRTN FOR USE W/ ALL OF IAB,SUP-2877618,CDM,2720000010,LOCAL,0272,RC,,,,both,,,580.90,377.58,,,,,,,,,,,,,
REAMER SURG L12MM OD8MM STP CONIC T2,SUP-2361771,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2635.09,1712.81,,,,,,,,,,,,,
DILATOR PROS OD17FR PROVOX,SUP-2124314,CDM,L8514,HCPCS,0274,RC,,,,both,,,259.05,168.38,,,,,,,,,,,,,
Redo Excis Lumbar Disk|LEFT SIDE,CASE-63042,LOCAL,63042,CPT,,,,,LT,outpatient,,,49545.73,29727.44,,,,,,,,,,,,,
Thoracoscopy With Biopsyies of Pleura,CASE-32609,LOCAL,32609,CPT,,,,,,outpatient,,,34308.52,20585.11,,,,,,,,,,,,,
Redo Excis Lumbar Disk|LEFT SIDE,CASE-63042,LOCAL,63042,CPT,0360,RC,,,LT,outpatient,,,49545.73,29727.44,,,,,,,,,,,,,
Exc Breast Les Preop Plmt Rad Marker Open 1 Les|BILATERAL PROCEDURE,CASE-19125,LOCAL,19125,CPT,,,,,50,outpatient,,,31503.33,18902.00,,,,,,,,,,,,,
Thoracoscopy With Biopsyies of Pleura,CASE-32609,LOCAL,32609,CPT,0360,RC,,,,outpatient,,,34308.52,20585.11,,,,,,,,,,,,,
Excision Distal Ulna Partial/Complete|RIGHT SIDE,CASE-25240,LOCAL,25240,CPT,,,,,RT,outpatient,,,27877.25,16726.35,,,,,,,,,,,,,
Exc Breast Les Preop Plmt Rad Marker Open 1 Les|BILATERAL PROCEDURE,CASE-19125,LOCAL,19125,CPT,0360,RC,,,50,outpatient,,,31503.33,18902.00,,,,,,,,,,,,,
Prtl Exc B1 Tarsal/Metar B1 Xcp Talus/Calcaneus|LEFT SIDE,CASE-28122,LOCAL,28122,CPT,,,,,LT,outpatient,,,23414.38,14048.63,,,,,,,,,,,,,
Excision Distal Ulna Partial/Complete|RIGHT SIDE,CASE-25240,LOCAL,25240,CPT,0360,RC,,,RT,outpatient,,,27877.25,16726.35,,,,,,,,,,,,,
Tx Missed Abortion First Trimester Surgical,CASE-59820,LOCAL,59820,CPT,0360,RC,,,,outpatient,,,17573.62,10544.17,,,,,,,,,,,,,
Prtl Exc B1 Tarsal/Metar B1 Xcp Talus/Calcaneus|LEFT SIDE,CASE-28122,LOCAL,28122,CPT,0360,RC,,,LT,outpatient,,,23414.38,14048.63,,,,,,,,,,,,,
Tx Missed Abortion First Trimester Surgical,CASE-59820,LOCAL,59820,CPT,,,,,,outpatient,,,17573.62,10544.17,,,,,,,,,,,,,
SCREW EXT FIX L200MM DIA5MM THRD L80MM CORT TI SELF DRL,SUP-2193169,CDM,C1713,HCPCS,0278,RC,,,,both,,,525.76,341.74,,,,,,,,,,,,,
PLASMABLADE ES L5.5-15CM SPAT TIP W3MM INTEGR SUCT TELSCP BEND,SUP-2281813,CDM,2720000010,LOCAL,0272,RC,,,,both,,,979.68,636.79,,,,,,,,,,,,,
COIL NEUROVASCULAR DELTAFILL 18 L 42 CM DIA12 MM PRIMARY DIA,SUP-2518798,CDM,C1889,HCPCS,0278,RC,,,,both,,,10687.99,6947.19,,,,,,,,,,,,,
DRILL SURG PREMIER AFFIRM,SUP-2598515,CDM,2720000010,LOCAL,0272,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
HC Blood Culture Multiplex Pcr 2|UNUSUAL NON-OVERLAPPING SERVICE,PX-3008715400,CDM,87154,CPT,0300,RC,,,XU,outpatient,,,524.00,340.60,,,,,,,,,,,,,
CROWN REFIL 1ST M 41104108 D-UR-3,SUP-2322185,CDM,D6783,CPT,0278,RC,,,,both,,,33.60,21.84,,,,,,,,,,,,,
PROBE OPHTH LASER FLEX NIT TAPR TIP ILLUMINATED MIDFIELD LT,SUP-2129228,CDM,2720000010,LOCAL,0272,RC,,,,both,,,436.99,284.04,,,,,,,,,,,,,
STEM FEM SZ 00 STD SH NK HIP HA QUADRA H,SUP-2267241,CDM,C1776,CPT,0278,RC,,,,both,,,16145.13,10494.33,,,,,,,,,,,,,
SHEATH INTRO FAST-CATH DUO L 23 CM DIA 9 FR CATH 4/5 FR,SUP-2357121,CDM,C1894,HCPCS,0272,RC,,,,both,,,33.91,22.04,,,,,,,,,,,,,
BLADE SHV L11CM DIA4MM 5000RPM N ROT LNG CRV SHFT AUTO EM,SUP-2284151,CDM,2720000010,LOCAL,0272,RC,,,,both,,,732.00,475.80,,,,,,,,,,,,,
"Repair Each Addnl Digit Nerve|LEFT HAND, THUMB",CASE-64832,LOCAL,64832,CPT,,,,,FA,outpatient,,,33739.18,20243.51,,,,,,,,,,,,,
Surgical Arthroscopy Shoulder Dstl Claviculc|LEFT SIDE,CASE-29824,LOCAL,29824,CPT,0360,RC,,,LT,outpatient,,,63164.85,37898.91,,,,,,,,,,,,,
Removal Cerclage Suture Under Anesthesia,CASE-59871,LOCAL,59871,CPT,0360,RC,,,,outpatient,,,16402.63,9841.58,,,,,,,,,,,,,
"Repair Each Addnl Digit Nerve|LEFT HAND, THUMB",CASE-64832,LOCAL,64832,CPT,0360,RC,,,FA,outpatient,,,33739.18,20243.51,,,,,,,,,,,,,
Surgical Arthroscopy Shoulder Dstl Claviculc|LEFT SIDE,CASE-29824,LOCAL,29824,CPT,,,,,LT,outpatient,,,63164.85,37898.91,,,,,,,,,,,,,
Removal Cerclage Suture Under Anesthesia,CASE-59871,LOCAL,59871,CPT,,,,,,outpatient,,,16402.63,9841.58,,,,,,,,,,,,,
SCREW BNE X DRV 2X7 MM CRANIOMAXILLOFACIAL DRILL-FREE LEVEL1,SUP-2461567,CDM,C1713,HCPCS,0278,RC,,,,both,,,176.44,114.69,,,,,,,,,,,,,
PERI-LOC 2.5MM T7 CRTX SCREW 30MM S-T,SUP-2820432,CDM,C1713,HCPCS,0278,RC,,,,both,,,295.13,191.83,,,,,,,,,,,,,
CEFOXITIN SODIUM 1 G IV SOLR,RX-9461,CDM,J0694,HCPCS,0636,RC,63323-0341-25,NDC,,both,1,UN,54.10,35.16,,,,,,,,,,,,,
TRAY CATH HEMODIALYSI BREVIA ACUTE 11FR DIA 24CML IN 5496240,SUP-2632897,CDM,C1752,HCPCS,0278,RC,,,,both,,,643.70,418.40,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9 % IV BOLUS,RX-103555,CDM,2580000003,HCPCS,0258,RC,00990-7983-61,NDC,,both,250,ML,74.40,48.36,,,,,,,,,,,,,
COLLAR CERV FIRM 3X21IN XL,SUP-2276594,CDM,L0120,HCPCS,0274,RC,,,,both,,,6.69,4.35,,,,,,,,,,,,,
STENT BILI S.M.A.R.T. CTRL L 120 MM DIA 6 MM DEL SYS L 120,SUP-2155353,CDM,C1876,HCPCS,0278,RC,,,,both,,,4615.80,3000.27,,,,,,,,,,,,,
ANCHOR SUTURE UHMWPE POLYESTER TI BTTN WASHER EXTRATHORACIC ST 1PK,SUP-2905469,CDM,C1713,HCPCS,0278,RC,,,,both,,,5589.20,3632.98,,,,,,,,,,,,,
GRAFT HUM TISS 25MG AMNIO MEM UMB CRD MTRX PARTICULATE FOR,SUP-2420276,CDM,Q4155,HCPCS,0636,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
HC CT C-Spine W/O Contrast,PX-3527212500,CDM,72125,CPT,0352,RC,,,,both,,,1973.00,1282.45,,,,,,,,,,,,,
SULFASALAZINE 500 MG PO TBEC,RX-7563,CDM,6370000000,HCPCS,0637,RC,59762-0104-06,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
CATHETER THROMCTMY QUICKCLEAR L 130 CM DIA10 FR NOM DIA,SUP-2823716,CDM,C1757,HCPCS,0272,RC,,,,both,,,4867.00,3163.55,,,,,,,,,,,,,
SHEATH INTRO L 43 CM CATH 7 FR FCPS SZ 5.5/7 FR STR AD W/O,SUP-2157190,CDM,C1894,HCPCS,0272,RC,,,,both,,,51.81,33.68,,,,,,,,,,,,,
SOCKET EXT FIX L30MM S STL THRD FOR ILIZ TAY SPAT FRME,SUP-2342276,CDM,C1713,HCPCS,0278,RC,,,,both,,,389.86,253.41,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9 % IV BOLUS,RX-103555,CDM,2580000003,HCPCS,0250,RC,00990-7983-61,NDC,,both,250,ML,74.40,48.36,,,,,,,,,,,,,
CATHETER EP L115CM OD6FR 2 7MM SPC 6 POLE F 10 PIN DR FIX,SUP-2248460,CDM,C1730,HCPCS,0272,RC,,,,both,,,527.52,342.89,,,,,,,,,,,,,
CAGE SPNL H4MM DIA10MM ANT CERV THORLUM TI RND CORPECTOMY,SUP-2193206,CDM,C1889,HCPCS,0278,RC,,,,both,,,4336.34,2818.62,,,,,,,,,,,,,
Arthrodesis Combined Tq 1ntrspc Lumbar,CASE-22633,LOCAL,22633,CPT,,,,,,outpatient,,,104559.38,62735.63,,,,,,,,,,,,,
Arthrodesis Combined Tq 1ntrspc Lumbar,CASE-22633,LOCAL,22633,CPT,0360,RC,,,,outpatient,,,104559.38,62735.63,,,,,,,,,,,,,
KIT INFUS PMP 100ML 2M/HR SOAK CATH L2.5IN N NARC ON-Q,SUP-2236824,CDM,C9804,HCPCS,0272,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
STEM FEM SZ 8 L205MM OD14MM TI HA DST CALCAR HIP NEUT CEM,SUP-2374300,CDM,C1776,CPT,0278,RC,,,,both,,,16191.10,10524.21,,,,,,,,,,,,,
TOTAL KNEE REPLACEMENT KIT SIDE-DELIVERY 11 GAX120 MM 3 CC,SUP-2866888,CDM,C1713,HCPCS,0278,RC,,,,both,,,7834.30,5092.29,,,,,,,,,,,,,
PACEMAKER CARD VALITUDE W 4.45 X H 6.13 MM THK 0.75 MM 15.2,SUP-2149289,CDM,C2621,HCPCS,0275,RC,,,,both,,,17411.30,11317.34,,,,,,,,,,,,,
ROD SPNL L 90 MM DIA 6 MM TI ALLOY PREBENT NS PASS LP,SUP-2926375,CDM,C1713,HCPCS,0278,RC,,,,both,,,2433.50,1581.77,,,,,,,,,,,,,
GRAFT FRZ DRY ALLGRFT 50-99CM2,SUP-2165569,CDM,C1713,HCPCS,0278,RC,,,,both,,,1004.80,653.12,,,,,,,,,,,,,
LENS INTOCU +1.0 DIOPT L13MM DIA6MM 5DEG HAPTIC ANG POST,SUP-2110618,CDM,V2632,HCPCS,0276,RC,,,,both,,,1378.46,896.00,,,,,,,,,,,,,
PLATE BNE 7 H FIB FLX,SUP-2896543,CDM,C1713,HCPCS,0278,RC,,,,both,,,2194.86,1426.66,,,,,,,,,,,,,
BUR SURG FLUT 4.2 MM BRL SUCTION IRRIGATING STR,SUP-2638216,CDM,2720000010,LOCAL,0272,RC,,,,both,,,635.88,413.32,,,,,,,,,,,,,
TIP CATH 0DEG SPHENOID SNUS GUID FOR BLLN SINUPLASTY SYS,SUP-2106373,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1004.80,653.12,,,,,,,,,,,,,
KIT CATH 8FR L16CM CTRL VEN DBL LUMN W/ BLU FLEXTIP CATH,SUP-2120606,CDM,C1751,HCPCS,0278,RC,,,,both,,,170.82,111.03,,,,,,,,,,,,,
TI PLUG SYS 7 CM 3PK,SUP-2402542,CDM,C1781,HCPCS,0278,RC,,,,both,,,590.32,383.71,,,,,,,,,,,,,
Surgical Arthroscopy Shoulder Repair Slap Lesion,CASE-29807,LOCAL,29807,CPT,,,,,,outpatient,,,61748.13,37048.88,,,,,,,,,,,,,
Tympanostomy General Anesthesia|BILATERAL PROCEDURE,CASE-69436,LOCAL,69436,CPT,0360,RC,,,50,outpatient,,,12542.83,7525.70,,,,,,,,,,,,,
Prtl Exc Pst Vrt Intrnsc B1y Les 1 Vrt Sgm Thrc,CASE-22101,LOCAL,22101,CPT,,,,,,outpatient,,,96656.97,57994.18,,,,,,,,,,,,,
Unlisted Px Female Genital System Nonobstetrical,CASE-58999,LOCAL,58999,CPT,,,,,,outpatient,,,18155.25,10893.15,,,,,,,,,,,,,
Prtl Exc Pst Vrt Intrnsc B1y Les 1 Vrt Sgm Thrc,CASE-22101,LOCAL,22101,CPT,0360,RC,,,,outpatient,,,96656.97,57994.18,,,,,,,,,,,,,
Biopsy Cervix Single/Mult/Excision of Lesion Spx,CASE-57500,LOCAL,57500,CPT,0360,RC,,,,outpatient,,,18247.45,10948.47,,,,,,,,,,,,,
Biopsy Vaginal Mucosa Simple|UNUSUAL NON-OVERLAPPING SERVICE,CASE-57100,LOCAL,57100,CPT,,,,,XU,outpatient,,,35169.87,21101.92,,,,,,,,,,,,,
Unlisted Px Female Genital System Nonobstetrical,CASE-58999,LOCAL,58999,CPT,0360,RC,,,,outpatient,,,18155.25,10893.15,,,,,,,,,,,,,
Surgical Arthroscopy Shoulder Repair Slap Lesion,CASE-29807,LOCAL,29807,CPT,0360,RC,,,,outpatient,,,61748.13,37048.88,,,,,,,,,,,,,
Biopsy Cervix Single/Mult/Excision of Lesion Spx,CASE-57500,LOCAL,57500,CPT,,,,,,outpatient,,,18247.45,10948.47,,,,,,,,,,,,,
Biopsy Vaginal Mucosa Simple|UNUSUAL NON-OVERLAPPING SERVICE,CASE-57100,LOCAL,57100,CPT,0360,RC,,,XU,outpatient,,,35169.87,21101.92,,,,,,,,,,,,,
Tympanostomy General Anesthesia|BILATERAL PROCEDURE,CASE-69436,LOCAL,69436,CPT,,,,,50,outpatient,,,12542.83,7525.70,,,,,,,,,,,,,
PROBE TEMP TRPL LUMEN COMPLETE BRAIN PRB KT W/ TEMP PRB,SUP-2666700,CDM,2720000010,LOCAL,0272,RC,,,,both,,,607.02,394.56,,,,,,,,,,,,,
PLATE BONE L49MM 6 H S STL QTR TBLR ECT,SUP-2198592,CDM,C1713,HCPCS,0278,RC,,,,both,,,160.45,104.29,,,,,,,,,,,,,
PLATE 3.5MM TI LCP TM PROX TIBIA PLATE 4H 81MM LEFT-STER,SUP-2549540,CDM,C1713,HCPCS,0278,RC,,,,both,,,3427.59,2227.93,,,,,,,,,,,,,
HC So Receptor Assay Nonendocrine,PX-3018423866,CDM,84238,CPT,0301,RC,,,,outpatient,,,213.00,138.45,,,,,,,,,,,,,
PLATE 10HL 146MM,SUP-2479428,CDM,C1713,HCPCS,0278,RC,,,,both,,,1780.13,1157.08,,,,,,,,,,,,,
EXTENDER BTTN FOOTPRINT 20X5MM SLT FOR ACL RECON TIGHTROPE,SUP-2121402,CDM,C1713,HCPCS,0278,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
COLLAR CERV FLAT REG 3 IN 1 PC IMMOB REHAB ORNG PROCARE,SUP-2196864,CDM,L0190,HCPCS,0274,RC,,,,both,,,25.47,16.56,,,,,,,,,,,,,
HC Ot Ther Ex per 15 Min|OP OCCUPATIONAL THERAPY SERV|SERVICES PROVIDED IN WHOLE OR IN PARTY BY AN OTA FOR MEDICARE PATIENTS|UNUSUAL NON-OVERLAPPING SERVICE,PX-4309711000,CDM,97110,CPT,0430,RC,,,GO|CO|XU,both,,,195.00,126.75,,,,,,,,,,,,,
Exc B9 Lesion Mrgn Xcp Sk Tg T/a/L 2.1-3.0 Cm,CASE-11403,LOCAL,11403,CPT,,,,,,outpatient,,,27678.73,16607.24,,,,,,,,,,,,,
Exc B9 Lesion Mrgn Xcp Sk Tg T/a/L 2.1-3.0 Cm,CASE-11403,LOCAL,11403,CPT,0360,RC,,,,outpatient,,,27678.73,16607.24,,,,,,,,,,,,,
"Inj Dx/Ther Agnt Paravert Facet Joint, Cerv/Thorac, Add Level",CASE-64492,LOCAL,64492,CPT,0360,RC,,,,outpatient,,,4392.15,2635.29,,,,,,,,,,,,,
Cysto W/Ureteroscopy W/Rmvl/Manj Stones,CASE-52352,LOCAL,52352,CPT,,,,,,outpatient,,,13171.90,7903.14,,,,,,,,,,,,,
Surgical Arthroscopy Shoulder Repair Slap Lesion|LEFT SIDE,CASE-29807,LOCAL,29807,CPT,,,,,LT,outpatient,,,61748.13,37048.88,,,,,,,,,,,,,
Mast Modf Rad W/Ax Lymph Nod W/WO Pect/Alis Min|RIGHT SIDE,CASE-19307,LOCAL,19307,CPT,,,,,RT,outpatient,,,47040.78,28224.47,,,,,,,,,,,,,
Tenodesis Long Tendon Biceps|RIGHT SIDE,CASE-23430,LOCAL,23430,CPT,,,,,RT,outpatient,,,49295.13,29577.08,,,,,,,,,,,,,
Tenodesis Long Tendon Biceps|RIGHT SIDE,CASE-23430,LOCAL,23430,CPT,0360,RC,,,RT,outpatient,,,49295.13,29577.08,,,,,,,,,,,,,
Surgical Arthroscopy Shoulder Repair Slap Lesion|LEFT SIDE,CASE-29807,LOCAL,29807,CPT,0360,RC,,,LT,outpatient,,,61748.13,37048.88,,,,,,,,,,,,,
Mast Modf Rad W/Ax Lymph Nod W/WO Pect/Alis Min|RIGHT SIDE,CASE-19307,LOCAL,19307,CPT,0360,RC,,,RT,outpatient,,,47040.78,28224.47,,,,,,,,,,,,,
"Inj Dx/Ther Agnt Paravert Facet Joint, Cerv/Thorac, Add Level",CASE-64492,LOCAL,64492,CPT,,,,,,outpatient,,,4392.15,2635.29,,,,,,,,,,,,,
Cysto W/Ureteroscopy W/Rmvl/Manj Stones,CASE-52352,LOCAL,52352,CPT,0360,RC,,,,outpatient,,,13171.90,7903.14,,,,,,,,,,,,,
FIBER LASER SIDE FIRE HPS,SUP-2225584,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
ALLOGRAFT HUM TISS GRAFIX PRIME 1.5X2CM CYROPRESERVED,SUP-2319161,CDM,Q4133,HCPCS,0636,RC,,,,both,,,2486.88,1616.47,,,,,,,,,,,,,
HC Glucose Blood Reagent Strip,PX-3018294800,CDM,82948,CPT,0301,RC,,,,both,,,16.00,10.40,,,,,,,,,,,,,
SHEATH INTRO PINNACLE R/O II L 6 CM DIA 7 FR 2.5 CM 0.038 IN,SUP-2385190,CDM,C1894,HCPCS,0272,RC,,,,both,,,88.14,57.29,,,,,,,,,,,,,
STRUT EXT FIX MOTR LNG,SUP-2479661,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5908.22,3840.34,,,,,,,,,,,,,
HC Daily Hospital at Home,PX-1610000000,CDM,1610000000,LOCAL,0161,RC,,,,inpatient,,,2441.00,1586.65,,,,,,,,,,,,,
TRIAL PLATE HK 1.3 MM ROLANDO FRAC,SUP-2525718,CDM,C1713,HCPCS,0278,RC,,,,both,,,1142.96,742.92,,,,,,,,,,,,,
IMPLANT PENILE L15CM CYL INFL MINOCYCLINE RIFAMPIN,SUP-2140297,CDM,C1813,HCPCS,0278,RC,,,,both,,,17536.90,11398.98,,,,,,,,,,,,,
K WIRE FIX L400MM DIA1.8MM S STL SGL TRCR SMOOTH DRL PNT,SUP-2372157,CDM,2720000010,LOCAL,0272,RC,,,,both,,,532.54,346.15,,,,,,,,,,,,,
Esophagoscopy Flexible Transoral With Biopsy,CASE-43202,LOCAL,43202,CPT,0360,RC,,,,outpatient,,,7369.15,4421.49,,,,,,,,,,,,,
Ndsc Dcmprn Spinal Cord 1 W/Lamot Ntrspc Lumbar,CASE-62380,LOCAL,62380,CPT,0360,RC,,,,outpatient,,,46405.53,27843.32,,,,,,,,,,,,,
Esophagoscopy Flexible Transoral With Biopsy,CASE-43202,LOCAL,43202,CPT,,,,,,outpatient,,,7369.15,4421.49,,,,,,,,,,,,,
Ndsc Dcmprn Spinal Cord 1 W/Lamot Ntrspc Lumbar,CASE-62380,LOCAL,62380,CPT,,,,,,outpatient,,,46405.53,27843.32,,,,,,,,,,,,,
HC Daily Hospital at Home,PX-1610000000,CDM,1610000000,LOCAL,,,,,,outpatient,,,2644.42,1586.65,,,,,,,,,,,,,
HC Inj Anesth Celiac Plexus|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64530,LOCAL,64530,CPT,0361,RC,,,XU,outpatient,,,34686.70,20812.02,,,,,,,,,,,,,
Placement Seton,CASE-46020,LOCAL,46020,CPT,,,,,,outpatient,,,10848.07,6508.84,,,,,,,,,,,,,
Placement Seton,CASE-46020,LOCAL,46020,CPT,0360,RC,,,,outpatient,,,10848.07,6508.84,,,,,,,,,,,,,
TRAY CATH 5FR 2 LUMN MAX BARR SHERLOCK 3CG TPS STYL PWR,SUP-2125513,CDM,C1751,HCPCS,0278,RC,,,,both,,,771.18,501.27,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC FT MAXBARR 5FR 55CM 1 LUMAN RVS TAP,SUP-2613436,CDM,C1751,HCPCS,0278,RC,,,,both,,,712.15,462.90,,,,,,,,,,,,,
PLATE 3.5MM TI LCP OLECRANON 10 HOLES RIGHT 190MM,SUP-2549529,CDM,C1713,HCPCS,0278,RC,,,,both,,,3615.58,2350.13,,,,,,,,,,,,,
SLEEVE FEM +4MM OFFSET MOD REV 12/14 TAPR REDAPT,SUP-2350890,CDM,2720000010,LOCAL,0272,RC,,,,both,,,832.10,540.86,,,,,,,,,,,,,
ENDCAP SPNL OD13MM 0DEG TI RND DISTRACTIBLE MESH INTBDY FUS,SUP-2291985,CDM,C1889,HCPCS,0278,RC,,,,both,,,832.10,540.86,,,,,,,,,,,,,
KIT FIX 2.4MM DRL TIP GWIRE CANN BNE TUNN PLUG DRL BIT DISP,SUP-2341339,CDM,C1713,HCPCS,0278,RC,,,,both,,,1650.42,1072.77,,,,,,,,,,,,,
GUIDEWIRE VASC ANGLED 3 CM 0.035 INX260 CM STD NIT GLIDEWIRE,SUP-2385574,CDM,C1769,HCPCS,0272,RC,,,,both,,,160.14,104.09,,,,,,,,,,,,,
VALVE PRESSURE PROGRAMMABLE 120 CM BA STRP,SUP-2666786,CDM,C1889,HCPCS,0278,RC,,,,both,,,23991.61,15594.55,,,,,,,,,,,,,
CATHETER ABLAT 7FR L115CM 2-5-2MM SPC TIP L4MM BND 1MM QPLR,SUP-2357029,CDM,C1733,HCPCS,0272,RC,,,,both,,,2515.14,1634.84,,,,,,,,,,,,,
STEM FEM L290MM TI FINN TOT DPHSEAL SEG,SUP-2407265,CDM,C1776,CPT,0278,RC,,,,both,,,21716.24,14115.56,,,,,,,,,,,,,
BIT DRL L260MM DIA8MM CANN FOR IM LIMB LENGTHENING SYS,SUP-2312222,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1538.60,1000.09,,,,,,,,,,,,,
CATHETER DRAINAGE LCK 038 14 FRX14 CM 5 CM BILI RESOLV,SUP-2467946,CDM,C1729,HCPCS,0272,RC,,,,both,,,210.38,136.75,,,,,,,,,,,,,
Arthrd Ant Interbody Min Dsc Crv Below C2,CASE-22554,LOCAL,22554,CPT,,,,,,outpatient,,,64443.02,38665.81,,,,,,,,,,,,,
Excision Ganglion Wrist Dorsal/Volar Primary|RIGHT SIDE,CASE-25111,LOCAL,25111,CPT,,,,,RT,outpatient,,,13817.35,8290.41,,,,,,,,,,,,,
Excision Ganglion Wrist Dorsal/Volar Primary|RIGHT SIDE,CASE-25111,LOCAL,25111,CPT,0360,RC,,,RT,outpatient,,,13817.35,8290.41,,,,,,,,,,,,,
Mastectomy Partial W/Axillary Lymphadenectomy,CASE-19302,LOCAL,19302,CPT,,,,,,outpatient,,,56947.80,34168.68,,,,,,,,,,,,,
Rpr Recrt Ingun Hernia Any Age Incarcerated,CASE-49521,LOCAL,49521,CPT,0360,RC,,,,outpatient,,,31178.87,18707.32,,,,,,,,,,,,,
Arthrd Ant Interbody Min Dsc Crv Below C2,CASE-22554,LOCAL,22554,CPT,0360,RC,,,,outpatient,,,64443.02,38665.81,,,,,,,,,,,,,
Mastectomy Partial W/Axillary Lymphadenectomy,CASE-19302,LOCAL,19302,CPT,0360,RC,,,,outpatient,,,56947.80,34168.68,,,,,,,,,,,,,
Revision Peri-Implant Capsule Breast,CASE-19370,LOCAL,19370,CPT,,,,,,outpatient,,,104951.48,62970.89,,,,,,,,,,,,,
Rpr Recrt Ingun Hernia Any Age Incarcerated,CASE-49521,LOCAL,49521,CPT,,,,,,outpatient,,,31178.87,18707.32,,,,,,,,,,,,,
Revision Peri-Implant Capsule Breast,CASE-19370,LOCAL,19370,CPT,0360,RC,,,,outpatient,,,104951.48,62970.89,,,,,,,,,,,,,
HC Biliary Endo W/Stone Removal,PX-3614755400,CDM,47554,CPT,0361,RC,,,,both,,,8583.00,5578.95,,,,,,,,,,,,,
HC Adrenal Arteriogram Unilateral,PX-3237573100,CDM,75731,CPT,0323,RC,,,,both,,,3142.00,2042.30,,,,,,,,,,,,,
PIN HALF FIXATION M4 L200MM THREAD L30MM STAINLESS STEEL,SUP-2586486,CDM,2720000010,LOCAL,0272,RC,,,,both,,,506.58,329.28,,,,,,,,,,,,,
SPLINT THMB L FOR 8-9IN WRST L ADJ STAY SPICA 3 DIM MOLDING,SUP-2334802,CDM,L3908,HCPCS,0274,RC,,,,both,,,74.10,48.16,,,,,,,,,,,,,
STEM VERSYS ENHANCED TAPER FEM 9X110MM,SUP-2203492,CDM,C1776,CPT,0278,RC,,,,both,,,12899.12,8384.43,,,,,,,,,,,,,
RING CAPSULAR TENS DIA13MM STABILEYES,SUP-2247789,CDM,L8610,HCPCS,0278,RC,,,,both,,,596.60,387.79,,,,,,,,,,,,,
SET INT FIX SCREW DIA1.5 MM CRANIOMAXILOFACIAL MED DOG BNE,SUP-2935199,CDM,C1713,HCPCS,0278,RC,,,,both,,,8945.86,5814.81,,,,,,,,,,,,,
BLOCK TIB AUG 8 10 MM PROX FULL CEM BOTH SIDE UHMWPE RT-PLUS,SUP-2450903,CDM,C1776,CPT,0278,RC,,,,both,,,1714.44,1114.39,,,,,,,,,,,,,
HOOK SPNL 90DEG RT TI TYP S VEPTR II,SUP-2181852,CDM,C1713,HCPCS,0278,RC,,,,both,,,1183.78,769.46,,,,,,,,,,,,,
HEAD FEM DIA38MM CODE D L DIAM METASUL,SUP-2204639,CDM,C1776,CPT,0278,RC,,,,both,,,4673.89,3038.03,,,,,,,,,,,,,
CAGE SPNL MESH 15X12X17 MM 6 LOBE,SUP-2602076,CDM,C1889,HCPCS,0278,RC,,,,both,,,9969.50,6480.17,,,,,,,,,,,,,
NAIL FEM RG 12MM 320MM,SUP-2405539,CDM,C1713,HCPCS,0278,RC,,,,both,,,9137.40,5939.31,,,,,,,,,,,,,
ADAPTER ORTH RNG LNG SLT OFFSET,SUP-2749955,CDM,2720000010,LOCAL,0272,RC,,,,both,,,555.78,361.26,,,,,,,,,,,,,
Arthrs Aided Ant Cruciate Ligm Rpr/Agmntj/Rcnstj|RIGHT SIDE,CASE-29888,LOCAL,29888,CPT,0360,RC,,,RT,outpatient,,,59248.25,35548.95,,,,,,,,,,,,,
Rpr Aa Hernia 1st > 10 Cm Ncrc8/Strangulated|UNUSUAL NON-OVERLAPPING SERVICE,CASE-49596,LOCAL,49596,CPT,,,,,XU,outpatient,,,101611.85,60967.11,,,,,,,,,,,,,
Chemodenervation Muscle Neck Unilat for Dystonia|BILATERAL PROCEDURE,CASE-64616,LOCAL,64616,CPT,,,,,50,outpatient,,,7691.12,4614.67,,,,,,,,,,,,,
Rpr Aa Hernia 1st > 10 Cm Ncrc8/Strangulated|UNUSUAL NON-OVERLAPPING SERVICE,CASE-49596,LOCAL,49596,CPT,0360,RC,,,XU,outpatient,,,101611.85,60967.11,,,,,,,,,,,,,
Surgical Arthroscopy Shoulder Biceps Tenodesis,CASE-29828,LOCAL,29828,CPT,,,,,,outpatient,,,55001.43,33000.86,,,,,,,,,,,,,
Surgical Arthroscopy Shoulder Biceps Tenodesis,CASE-29828,LOCAL,29828,CPT,0360,RC,,,,outpatient,,,55001.43,33000.86,,,,,,,,,,,,,
"Inj Dx/Ther Agnt Paravert Facet Joint, Cerv/Thorac, Add Level|RIGHT SIDE",CASE-64492,LOCAL,64492,CPT,0360,RC,,,RT,outpatient,,,4376.67,2626.00,,,,,,,,,,,,,
Chemodenervation Muscle Neck Unilat for Dystonia|BILATERAL PROCEDURE,CASE-64616,LOCAL,64616,CPT,0360,RC,,,50,outpatient,,,7691.12,4614.67,,,,,,,,,,,,,
Arthrs Aided Ant Cruciate Ligm Rpr/Agmntj/Rcnstj|RIGHT SIDE,CASE-29888,LOCAL,29888,CPT,,,,,RT,outpatient,,,59248.25,35548.95,,,,,,,,,,,,,
Chromotubation Oviduct W/Materials|UNUSUAL NON-OVERLAPPING SERVICE,CASE-58350,LOCAL,58350,CPT,,,,,XU,outpatient,,,44854.13,26912.48,,,,,,,,,,,,,
Chromotubation Oviduct W/Materials|UNUSUAL NON-OVERLAPPING SERVICE,CASE-58350,LOCAL,58350,CPT,0360,RC,,,XU,outpatient,,,44854.13,26912.48,,,,,,,,,,,,,
"Inj Dx/Ther Agnt Paravert Facet Joint, Cerv/Thorac, Add Level|RIGHT SIDE",CASE-64492,LOCAL,64492,CPT,,,,,RT,outpatient,,,4376.67,2626.00,,,,,,,,,,,,,
TRAY CATH HEMODIALYSI HEM CATH STRL ACTE 11.5FR DIA 15CM STR BX/1,SUP-2610537,CDM,C1752,HCPCS,0278,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
PLATE BNE HK 40 MM 5 HOLE,SUP-2865059,CDM,C1713,HCPCS,0278,RC,,,,both,,,3413.18,2218.57,,,,,,,,,,,,,
PATCH DURA L 3.5 X W 0.8 IN SURF AREA2.8 SQ IN BOV PERICARD,SUP-2884063,CDM,C1763,HCPCS,0278,RC,,,,both,,,1252.86,814.36,,,,,,,,,,,,,
PLATE BNE SM 8 H R MIDFOOT TI POLYAX U SHP LOK COMPR LO PROF,SUP-2398192,CDM,C1713,HCPCS,0278,RC,,,,both,,,5466.74,3553.38,,,,,,,,,,,,,
SCREW BONE FEM HIP CANN SET,SUP-2347912,CDM,C1713,HCPCS,0278,RC,,,,both,,,411.59,267.53,,,,,,,,,,,,,
GUIDEWIRE ORTH 3.2X400 MM W/ DRL TIP STRL,SUP-2789594,CDM,C1769,HCPCS,0272,RC,,,,both,,,402.33,261.51,,,,,,,,,,,,,
MODEL ANAT MANDIBULAR/MAXILLARY RECON CASE BNDL W/ MTL INSRT,SUP-2883644,CDM,2720000010,LOCAL,0272,RC,,,,both,,,21018.91,13662.29,,,,,,,,,,,,,
CATHETER ABLATN MED 2-5-2 4 MM 7 FRX110 1304-7-25-M-TH THER,SUP-2487902,CDM,C1733,HCPCS,0272,RC,,,,both,,,2044.14,1328.69,,,,,,,,,,,,,
FLUMAZENIL 1 MG/10ML IV SOLN,RX-39745,CDM,2500000003,HCPCS,0250,RC,00143-9783-01,NDC,,both,2,ML,54.10,35.16,,,,,,,,,,,,,
CATHETER CV PRESSURE MONITORING TY 015 2.5 FRX2.5 CM,SUP-2760150,CDM,C1751,HCPCS,0278,RC,,,,both,,,214.87,139.67,,,,,,,,,,,,,
SMALL PLATE 2X25MM 3.5MM,SUP-2820873,CDM,C1713,HCPCS,0278,RC,,,,both,,,992.93,645.40,,,,,,,,,,,,,
"Arthrodesis Interphalangeal Jt W/WO Int Fixj|RIGHT HAND, FIFTH DIGIT",CASE-26860,LOCAL,26860,CPT,,,,,F9,outpatient,,,30879.72,18527.83,,,,,,,,,,,,,
Peri-Implant Capsulectomy Breast Complete|LEFT SIDE,CASE-19371,LOCAL,19371,CPT,,,,,LT,outpatient,,,39853.23,23911.94,,,,,,,,,,,,,
Nasal/Sinus Ndsc Surg W/Dilation Frontal Sinus|BILATERAL PROCEDURE,CASE-31296,LOCAL,31296,CPT,0360,RC,,,50,outpatient,,,53466.13,32079.68,,,,,,,,,,,,,
Peri-Implant Capsulectomy Breast Complete|LEFT SIDE,CASE-19371,LOCAL,19371,CPT,0360,RC,,,LT,outpatient,,,39853.23,23911.94,,,,,,,,,,,,,
"Arthrodesis Interphalangeal Jt W/WO Int Fixj|RIGHT HAND, FIFTH DIGIT",CASE-26860,LOCAL,26860,CPT,0360,RC,,,F9,outpatient,,,30879.72,18527.83,,,,,,,,,,,,,
Nasal/Sinus Ndsc Surg W/Dilation Frontal Sinus|BILATERAL PROCEDURE,CASE-31296,LOCAL,31296,CPT,,,,,50,outpatient,,,53466.13,32079.68,,,,,,,,,,,,,
COMPONENT FEM PS G RT KNEE PC NXGN,SUP-2201497,CDM,C1776,CPT,0278,RC,,,,both,,,14195.94,9227.36,,,,,,,,,,,,,
SYSTEM ICD CRT HF-T W/ HOME MON LUMAX 340,SUP-2138124,CDM,C1722,HCPCS,0275,RC,,,,both,,,59663.55,38781.31,,,,,,,,,,,,,
SHAFT SURG DRL LEVERAGE LFS DISP 8MM,SUP-2311380,CDM,2720000010,LOCAL,0272,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
PLATE BNE W6.3XL49MM THK1.6MM +90DEG 2X4 H DST RAD TI L SHP,SUP-2191026,CDM,C1713,HCPCS,0278,RC,,,,both,,,1886.95,1226.52,,,,,,,,,,,,,
COMPONENT FEM CRUC RET N POR RT 74MM MEDL LAT 47MM ANT POST,SUP-2252374,CDM,C1776,CPT,0278,RC,,,,both,,,8468.58,5504.58,,,,,,,,,,,,,
KIT INSTR SHT W/ MTL SPEAR TRCR DRL DISP FOR 2.9MM PUSHLOCK,SUP-2121759,CDM,2720000010,LOCAL,0272,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 30 CM DIA 6 MM EPTFE STR STD WALL,SUP-2477545,CDM,C1768,CPT,0278,RC,,,,both,,,974.75,633.59,,,,,,,,,,,,,
NEOSTIGMINE METHYLSULFATE 5 MG/5ML IV SOSY,RX-131329,CDM,J2710,HCPCS,0636,RC,71266-2003-02,NDC,,both,0.5,ML,54.10,35.16,,,,,,,,,,,,,
VALVE HYDROCEPHALUS SYS W/ SPRUNG RESVR PROGAV 2.0,SUP-2108744,CDM,C1729,HCPCS,0272,RC,,,,both,,,8478.47,5511.01,,,,,,,,,,,,,
GUIDEWIRE VASC RDRUN L 300 CM DIA 0.018 IN TAPR L 7 CM FLPY,SUP-2168250,CDM,C1769,HCPCS,0272,RC,,,,both,,,299.87,194.92,,,,,,,,,,,,,
BIT DRL LP 9 MM W/ EZ SHUTTLE SUTURE LOOP STRL,SUP-2608860,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1554.43,1010.38,,,,,,,,,,,,,
IMPLANT LARYN 1ML GEL INJ VOCAL CRD MEDIALIZATION PROLARYN,SUP-2303664,CDM,L8607,HCPCS,0278,RC,,,,both,,,2307.90,1500.13,,,,,,,,,,,,,
"Rpr Xtnsr Tdn Cntrl Slip Tiss W/Lat Band Ea Fngr|RIGHT HAND, SECOND DIGIT",CASE-26426,LOCAL,26426,CPT,0360,RC,,,F6,outpatient,,,10930.15,6558.09,,,,,,,,,,,,,
HC Lyr Clos Nk Hnd Ft 2.6-5 Cm,CASE-12042,LOCAL,12042,CPT,0450,RC,,,,outpatient,,,14635.83,8781.50,,,,,,,,,,,,,
HC Inj Anes/Steroid C/D Facet Sg|LEFT SIDE,CASE-64490,LOCAL,64490,CPT,0361,RC,,,LT,outpatient,,,4402.88,2641.73,,,,,,,,,,,,,
"Rpr Xtnsr Tdn Cntrl Slip Tiss W/Lat Band Ea Fngr|RIGHT HAND, SECOND DIGIT",CASE-26426,LOCAL,26426,CPT,,,,,F6,outpatient,,,10930.15,6558.09,,,,,,,,,,,,,
PLATE BNE L 79 MM SCREW DIA2.4/2.7 MM 7 HD 5 SHFT H LT DSTL,SUP-2913578,CDM,C1713,HCPCS,0278,RC,,,,both,,,6943.48,4513.26,,,,,,,,,,,,,
GUIDEWIRE VASC L145CM TAPR L7CM TIP L25CM DIA0018IN S STL,SUP-2167587,CDM,C1769,HCPCS,0272,RC,,,,both,,,49.49,32.17,,,,,,,,,,,,,
BIT DRILL DIA2.9MM DISTAL RADIAL VOLAR PLATING SYSTEM,SUP-2492337,CDM,2720000010,LOCAL,0272,RC,,,,both,,,292.02,189.81,,,,,,,,,,,,,
MATRIX BIO DIA 80 MM FISH SKIN SIL DERMAL SPRL PERF FEN MRK,SUP-2909231,CDM,Q4158,HCPCS,0636,RC,,,,both,,,72110.10,46871.56,,,,,,,,,,,,,
PROBE DOPPLER PENCIL,SUP-2321985,CDM,2720000010,LOCAL,0272,RC,,,,both,,,486.70,316.35,,,,,,,,,,,,,
ALLOGRAFT HUMAN TISS MAXXEUS TIBIALIS POSTERIOR FZ,SUP-2875991,CDM,C1762,CPT,0278,RC,,,,both,,,5554.35,3610.33,,,,,,,,,,,,,
SPACER FEM 8 MM POST REV CONSTRN SCREW N-K II,SUP-2448991,CDM,C1776,CPT,0278,RC,,,,both,,,635.85,413.30,,,,,,,,,,,,,
KIT INFL 18IN FOR SNUS DIL SYS NUVENT,SUP-2284167,CDM,2720000010,LOCAL,0272,RC,,,,both,,,702.10,456.36,,,,,,,,,,,,,
IMPLANT BIO TISS W15XL25CM REGEN PORCINE CLLGN RECT,SUP-2125847,CDM,C1781,HCPCS,0278,RC,,,,both,,,24617.60,16001.44,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 7.5X170-225 MM POST TEND FLEXIGRAFT,SUP-2740867,CDM,C1762,CPT,0278,RC,,,,both,,,3632.82,2361.33,,,,,,,,,,,,,
TRIAMTERENE-HCTZ 37.5-25 MG PO TABS,RX-8132,CDM,6370000000,HCPCS,0637,RC,68084-0750-25,NDC,,both,1,UN,3.70,2.40,,,,,,,,,,,,,
MESH HERN SM W6XL7CM PTFE FOR REP OF HIATAL PARAESOPHAGEAL,SUP-2126071,CDM,C1781,HCPCS,0278,RC,,,,both,,,817.44,531.34,,,,,,,,,,,,,
GRAFT VASC EXXCEL SFT L 40 CM DIA 6 MM EPTFE STR STD WALL,SUP-2227642,CDM,C1768,CPT,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
PLATE BONE STRAIGHT 2X22 MM MANDIBULAR 4 HOLE TENSION BAND T,SUP-2838418,CDM,C1713,HCPCS,0278,RC,,,,both,,,1551.79,1008.66,,,,,,,,,,,,,
PLATE SPNL J-HOOK X25 TI EXPEDIUM MCC,SUP-2718827,CDM,C1713,HCPCS,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
NAIL IM L400MM DIA13MM 130DEG LNG LT HIP TIM CANN LCK FOR,SUP-2137056,CDM,C1713,HCPCS,0278,RC,,,,both,,,8518.88,5537.27,,,,,,,,,,,,,
BUTTON SEPT DIA3CM THK4MM STD NSL SILIC1 1 PC TRIMMED FOR,SUP-2381500,CDM,C1889,HCPCS,0278,RC,,,,both,,,415.42,270.02,,,,,,,,,,,,,
"Fasct Prtl Palmr Addl Dgt Prox Iphal Jt W/WO Rpr|RIGHT HAND, FOURTH DIGIT",CASE-26125,LOCAL,26125,CPT,,,,,F8,outpatient,,,16150.42,9690.25,,,,,,,,,,,,,
Laps Fulg/Exc Ovary Viscera/Peritoneal Surface,CASE-58662,LOCAL,58662,CPT,,,,,,outpatient,,,37187.75,22312.65,,,,,,,,,,,,,
"Fasct Prtl Palmr Addl Dgt Prox Iphal Jt W/WO Rpr|RIGHT HAND, FOURTH DIGIT",CASE-26125,LOCAL,26125,CPT,0360,RC,,,F8,outpatient,,,16150.42,9690.25,,,,,,,,,,,,,
Laps Fulg/Exc Ovary Viscera/Peritoneal Surface,CASE-58662,LOCAL,58662,CPT,0360,RC,,,,outpatient,,,37187.75,22312.65,,,,,,,,,,,,,
Dstrj Lesion Penis Simple Laser,CASE-54057,LOCAL,54057,CPT,,,,,,outpatient,,,18710.68,11226.41,,,,,,,,,,,,,
Optx Dstl Radl X-Artic Fx/Epiphysl Sep|LEFT SIDE,CASE-25607,LOCAL,25607,CPT,,,,,LT,outpatient,,,28591.93,17155.16,,,,,,,,,,,,,
Dstrj Lesion Penis Simple Laser,CASE-54057,LOCAL,54057,CPT,0360,RC,,,,outpatient,,,18710.68,11226.41,,,,,,,,,,,,,
Arthrp Intercarpal/Carp/Mtcrpl Jt Suspension|RIGHT SIDE,CASE-25448,LOCAL,25448,CPT,,,,,RT,outpatient,,,28672.77,17203.66,,,,,,,,,,,,,
Optx Dstl Radl X-Artic Fx/Epiphysl Sep|LEFT SIDE,CASE-25607,LOCAL,25607,CPT,0360,RC,,,LT,outpatient,,,28591.93,17155.16,,,,,,,,,,,,,
Arthrp Intercarpal/Carp/Mtcrpl Jt Suspension|RIGHT SIDE,CASE-25448,LOCAL,25448,CPT,0360,RC,,,RT,outpatient,,,28672.77,17203.66,,,,,,,,,,,,,
BLADE SHV L11CM OD4MM 40DEG ANG AGG MICRODEBRIDER ESSX,SUP-2363536,CDM,2720000010,LOCAL,0272,RC,,,,both,,,401.89,261.23,,,,,,,,,,,,,
PACEMAKER CARD LEGEND II SR TI SINGLE CHMBR IS1 CONN UPLR,SUP-2149060,CDM,C1786,HCPCS,0275,RC,,,,both,,,52438.00,34084.70,,,,,,,,,,,,,
NAIL IM TIB UNIV 8 MMX39 CM LCK CANN TI STRL VERSANAIL,SUP-2463411,CDM,C1713,HCPCS,0278,RC,,,,both,,,3987.80,2592.07,,,,,,,,,,,,,
PLATE SURFACE 3.5MM QUADRILATERAL LONG STERILE,SUP-2546016,CDM,C1713,HCPCS,0278,RC,,,,both,,,1981.15,1287.75,,,,,,,,,,,,,
SCREW BONE CORT FULL THRD N CANN ST N LCK S STL NSTERILE,SUP-2198232,CDM,C1713,HCPCS,0278,RC,,,,both,,,41.26,26.82,,,,,,,,,,,,,
ALLOGRAFT BNE STRP 50X25X8 MM FD DEMINERALIZED CANC LIFEFLEX,SUP-2866839,CDM,C1762,CPT,0278,RC,,,,both,,,2452.03,1593.82,,,,,,,,,,,,,
SHUNT CAR 9 FRX31 CM OUTLYING 2 BLLN OCCL TPORT PRUITT F3,SUP-2589471,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4298.66,2794.13,,,,,,,,,,,,,
COMPONENT TIB SZ 1 AP40MM ML58MM MIC KNEE PURPLE/STRIPPED,SUP-2201515,CDM,C1776,CPT,0278,RC,,,,both,,,8878.35,5770.93,,,,,,,,,,,,,
PLATE 3.5MM TI LCP PROXIMAL TIBIA LOW BEND 12H 180MM RT STER,SUP-2546872,CDM,C1713,HCPCS,0278,RC,,,,both,,,4969.74,3230.33,,,,,,,,,,,,,
LEAD PACE BPLR 86 CM LT VENTRIC QUICKSITE,SUP-2356620,CDM,C1900,HCPCS,0275,RC,,,,both,,,5338.00,3469.70,,,,,,,,,,,,,
SIMETHICONE 80 MG PO CHEW,RX-7227,CDM,6370000000,HCPCS,0637,RC,77333-0812-25,NDC,,both,1,UN,1.70,1.10,,,,,,,,,,,,,
PLATE QUIKFLAP 3X2 RIGID SD AXS,SUP-2718049,CDM,C1713,HCPCS,0278,RC,,,,both,,,6226.62,4047.30,,,,,,,,,,,,,
SET DILATOR 18FR SUPRAPUBIC  PEEL AWAY,SUP-2665179,CDM,C2627,HCPCS,0272,RC,,,,both,,,492.35,320.03,,,,,,,,,,,,,
GRAFT BNE CHIP FRZ DRY CANC CORT 1MM 8MM RANG 40CC READIGRFT,SUP-2264693,CDM,C1713,HCPCS,0278,RC,,,,both,,,1317.67,856.49,,,,,,,,,,,,,
MESH HERN L W5.4XL7IN POLYPR EPTFE OVL SELF EXP PTCH,SUP-2125711,CDM,C1781,HCPCS,0278,RC,,,,both,,,2847.04,1850.58,,,,,,,,,,,,,
ROD EXT FIX L450MM DIA11MM C CONN FOR HOFFMANN III MRI SYS,SUP-2372232,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1305.61,848.65,,,,,,,,,,,,,
BIT DRL 4.5 MM W/ PENETRATION STP PREP OF TUNN MPFL RECON GA,SUP-2776114,CDM,2720000010,LOCAL,0272,RC,,,,both,,,438.03,284.72,,,,,,,,,,,,,
BRACE TRACTION HALO VEST LG,SUP-2328123,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
ELECTRODE ELECSURG ANGLED LOOP 12 DEG 30 24-28 FR 0.02 IN,SUP-2472699,CDM,2720000010,LOCAL,0272,RC,,,,both,,,474.77,308.60,,,,,,,,,,,,,
PLATE BNE H MINI MAXLOCK,SUP-2400409,CDM,C1713,HCPCS,0278,RC,,,,both,,,3070.92,1996.10,,,,,,,,,,,,,
SCREW SPNL CANN 3.5X44 MM FT CORRIDOR,SUP-2593570,CDM,C1713,HCPCS,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
CLIP MED INT USE SM TI SMALLER TIGHTER LEG GAP SMTH RED,SUP-2895516,CDM,C1889,HCPCS,0278,RC,,,,both,,,1.19,0.77,,,,,,,,,,,,,
HC Cesarean Section,PX-3609079900,CDM,3609079900,LOCAL,0360,RC,,,,inpatient,,,19177.00,12465.05,,,,,,,,,,,,,
IRON SUCROSE 300 MG IN NS 250 ML IVPB,RX-4082516,CDM,J1756,HCPCS,0636,RC,99999-9917-95,NDC,,both,250,ML,811.30,527.34,,,,,,,,,,,,,
KETOROLAC TROMETHAMINE 60 MG/2ML IM SOLN,RX-97627,CDM,J1885,HCPCS,0636,RC,00641-6043-25,NDC,,both,2,ML,54.10,35.16,,,,,,,,,,,,,
TRAY CATH PICC POLY Q CATH 4FR 0.034IN 60CM 1 LUMAN 3154107,SUP-2632643,CDM,C1751,HCPCS,0278,RC,,,,both,,,314.94,204.71,,,,,,,,,,,,,
SCREW BNE ST 2.7X20 MM MAND MINI PLATING CROSS PIN HD TI 5PK,SUP-2366183,CDM,C1713,HCPCS,0278,RC,,,,both,,,227.40,147.81,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED CEM SCREW PIN HI FLX M POLYETH,SUP-2212714,CDM,C1776,CPT,0278,RC,,,,both,,,12944.46,8413.90,,,,,,,,,,,,,
CLAMP REPROC JETX BAR PIN MR SAFE 10.5MM 5MM,SUP-2475623,CDM,2720000010,LOCAL,0272,RC,,,,both,,,515.56,335.11,,,,,,,,,,,,,
SCREW SET SPNL 179721001] JNJ HEALTHCARE],SUP-2256229,CDM,C1713,HCPCS,0278,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
MESH BIO BOV CLLGN AND HUM FIBROBLASTS 140 MM LEN 100 MM W,SUP-2314084,CDM,Q4101,HCPCS,0636,RC,,,,both,,,5350.56,3477.86,,,,,,,,,,,,,
PLATE BNE W29XL40MM 4.5X5MM H SPC CRAN TI MESH FOR 1MM SCR,SUP-2190565,CDM,C1713,HCPCS,0278,RC,,,,both,,,2370.70,1540.95,,,,,,,,,,,,,
ROD EXT FIX L250MM DIA11MM UNIV C FBR RADLUC CONN,SUP-2188658,CDM,2720000010,LOCAL,0272,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
COLLAR CERV FLX N ADJ PREFABRICATED OFF THE SHLF BRAC,SUP-2388131,CDM,L0120,HCPCS,0274,RC,,,,both,,,71.59,46.53,,,,,,,,,,,,,
ENDCAP ORTHOPEDIC 0.5 CM HUM NAIL,SUP-2412249,CDM,C1713,HCPCS,0278,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
WASHER ORTH OD8MM ID4MM THK1MM S STL FOR 4MM CANN SCR SYS,SUP-2343600,CDM,C1713,HCPCS,0278,RC,,,,both,,,274.12,178.18,,,,,,,,,,,,,
FORCEP SURG TAPR 3608T LOWER ANTR SS X-TRAC,SUP-2238496,CDM,2720000010,LOCAL,0272,RC,,,,both,,,706.47,459.21,,,,,,,,,,,,,
BLADE SAW THK0.38MM CUT D10MM CUT EDGE 9MM OSC THN PRECIS,SUP-2367235,CDM,2720000010,LOCAL,0272,RC,,,,both,,,104.31,67.80,,,,,,,,,,,,,
KIT NEUROSTIMULATOR L 45 CM DIA1.35 MM PERIPH PERM RECV,SUP-2917082,CDM,C1816,LOCAL,0278,RC,,,,both,,,9420.00,6123.00,,,,,,,,,,,,,
BUR SURG DIAMOND 0.8 MM 5 CM BALL MIDAS REX 8 CLRVW LP,SUP-2664902,CDM,2720000010,LOCAL,0272,RC,,,,both,,,624.23,405.75,,,,,,,,,,,,,
BLADE RTRCTR RVL 45MMW X 50MML TTNM LMBR 15DG ANGLD TTHD ULT,SUP-2457455,CDM,2720000010,LOCAL,0272,RC,,,,both,,,570.00,370.50,,,,,,,,,,,,,
PLATE 3.5MM TI LCP TM PROX HUMERUS LONG 8H SHAFT 196MM STER,SUP-2549717,CDM,C1713,HCPCS,0278,RC,,,,both,,,5672.72,3687.27,,,,,,,,,,,,,
SCREW SPNL 7146016,SUP-2599237,CDM,C1713,HCPCS,0278,RC,,,,both,,,9420.00,6123.00,,,,,,,,,,,,,
STENT ENDOPROS L2.5CM DIA7MM CATH 8FR L75CM BAL DIA7MM,SUP-2396553,CDM,C1874,HCPCS,0278,RC,,,,both,,,8870.50,5765.82,,,,,,,,,,,,,
COLLAR CERV FLX N ADJ PREFABRICATED OFF THE SHLF BRAC,SUP-2388131,CDM,L0120,HCPCS,0272,RC,,,,both,,,71.59,46.53,,,,,,,,,,,,,
BLADE RMR PERC SELF EXP X-REAM,SUP-2397142,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1731.55,1125.51,,,,,,,,,,,,,
STEM FEM SEG 10 CM LT KNEE REDUC RESECT TAPR COMPRESS,SUP-2441850,CDM,C1776,CPT,0278,RC,,,,both,,,19753.74,12839.93,,,,,,,,,,,,,
TUBE VENT W98XL12MM DIA114MM BLU ULTRASIL SIL T RICHARD,SUP-2313875,CDM,L8699,HCPCS,0278,RC,,,,both,,,63.96,41.57,,,,,,,,,,,,,
KIT ENDOSCP CANN XL TIP PLAS ARTHSCP ATRAUM ACCS RADIOPAQUE,SUP-2882278,CDM,2720000010,LOCAL,0272,RC,,,,both,,,926.30,602.09,,,,,,,,,,,,,
BLADE SAW OSCLLTNG 10MMW X 13MML 0.4MM THK 0.6MM THK CUT SM,SUP-2586281,CDM,2720000010,LOCAL,0272,RC,,,,both,,,65.12,42.33,,,,,,,,,,,,,
DRESSING NSL L4CM SYN PROPRIETARY POLYMER FOAM FIRM,SUP-2367517,CDM,2720000010,LOCAL,0272,RC,,,,both,,,340.03,221.02,,,,,,,,,,,,,
"HC So Osmolality, Urine",PX-3018393566,CDM,83935,CPT,0301,RC,,,,both,,,28.00,18.20,,,,,,,,,,,,,
DRILL SURG BUSHING 2.5 OFFSET TRABECULAR MTL BIGLIANI/FLATOW,SUP-2436807,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1370.61,890.90,,,,,,,,,,,,,
COUNTERSINK SURG FOR 1.5-2MM CORT SCR MINI FRAG SYS,SUP-2187351,CDM,2720000010,LOCAL,0272,RC,,,,both,,,732.56,476.16,,,,,,,,,,,,,
PROBE LITHO 9FR L60CM EHL,SUP-2313971,CDM,2720000010,LOCAL,0272,RC,,,,both,,,792.54,515.15,,,,,,,,,,,,,
PATIROMER SORBITEX CALCIUM 8.4 G PO PACK,RX-131944,CDM,6370000000,HCPCS,0637,RC,53436-0084-01,NDC,,both,1,UN,159.80,103.87,,,,,,,,,,,,,
TUBE VENT SHEP 1.02 MM 1.32 MM EAR FOR MYRINGOTOMY FLROPLAS,SUP-2312778,CDM,L8699,HCPCS,0278,RC,,,,both,,,19.59,12.73,,,,,,,,,,,,,
INTRODUCER SHTH L12CM L50CM OD10FR HEMSTAS VLV SIDEPRT DIL,SUP-2355607,CDM,C1894,HCPCS,0272,RC,,,,both,,,2.67,1.74,,,,,,,,,,,,,
REAMER SURG 18MM MT JT CONE GEN 2,SUP-2398338,CDM,2720000010,LOCAL,0272,RC,,,,both,,,967.12,628.63,,,,,,,,,,,,,
PLATE BONE L W13.5XL34MM THK4.2MM 2 H BILAT TI STR RIG LIMIT,SUP-2190803,CDM,C1713,HCPCS,0278,RC,,,,both,,,543.63,353.36,,,,,,,,,,,,,
RECON PLATE 13X154MM 3.5MM,SUP-2818475,CDM,C1713,HCPCS,0278,RC,,,,both,,,5025.57,3266.62,,,,,,,,,,,,,
SUPPORT ORTHOT CUST FULL SOLE HEEL WDG BTWN SOLE,SUP-2435728,CDM,L3420,HCPCS,0274,RC,,,,both,,,154.83,100.64,,,,,,,,,,,,,
MESH HERN 9X13CM POLY CLLGN COAT PRESHAPED W SLT 3 DIM,SUP-2752163,CDM,C1781,HCPCS,0278,RC,,,,both,,,522.87,339.87,,,,,,,,,,,,,
CORE SLIDING UHMPWE 7MM,SUP-2878147,CDM,C1776,CPT,0278,RC,,,,both,,,6421.61,4174.05,,,,,,,,,,,,,
PLATE BNE 2.7X100 MM 12 HOLE SS DCP,SUP-2569133,CDM,C1713,HCPCS,0278,RC,,,,both,,,360.94,234.61,,,,,,,,,,,,,
BIT DRL 4 MM W/ STP FOR FRDM WRST ARTHROPLAST,SUP-2852120,CDM,2720000010,LOCAL,0272,RC,,,,both,,,926.80,602.42,,,,,,,,,,,,,
SET INT FIX SCREW DIA1.5 MM 4 H TI NEURO 2 SQ PLATE 12 PK,SUP-2936501,CDM,C1713,HCPCS,0278,RC,,,,both,,,46136.02,29988.41,,,,,,,,,,,,,
CATHETER CV MAXIMAL BARR TY 032 7 FRX20 IN 13 GA 3L SPECTRUM,SUP-2759721,CDM,C1751,HCPCS,0278,RC,,,,both,,,505.54,328.60,,,,,,,,,,,,,
PLATE BONE RAD SHORTNG KIENBOCK RAYHACK,SUP-2397322,CDM,C1713,HCPCS,0278,RC,,,,both,,,3441.44,2236.94,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED CEM LNR ADD ON XLPE,SUP-2212519,CDM,C1776,CPT,0278,RC,,,,both,,,1293.68,840.89,,,,,,,,,,,,,
STENT BILI L29MM CATH L80CM BLLN L30MM DIA5MM 0.035IN 316L,SUP-2159242,CDM,C1876,HCPCS,0278,RC,,,,both,,,2182.30,1418.49,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE 10 CC CELLULAR BNE MTRX SYGNACEL CBM,SUP-2929809,CDM,C1713,HCPCS,0278,RC,,,,both,,,14632.40,9511.06,,,,,,,,,,,,,
GUIDEWIRE ORTH SPNL NTHRD SHRP TIP L720MM OD142MM,SUP-2286839,CDM,C1769,HCPCS,0272,RC,,,,both,,,221.94,144.26,,,,,,,,,,,,,
GUIDEWIRE AR896320,SUP-2843934,CDM,C1769,HCPCS,0272,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
CATHETER HEMO DYLS OR HD ADMIN BASIC KT DBL LUMN POLYUR,SUP-2174119,CDM,C1751,HCPCS,0278,RC,,,,both,,,249.69,162.30,,,,,,,,,,,,,
PROSTHESIS OTOLARYN L3.5MM WELL DIA1MM PIST DIA0.4MM TI BCKT,SUP-2312800,CDM,L8613,CPT,0278,RC,,,,both,,,622.10,404.36,,,,,,,,,,,,,
PORT IMPL INFUSION SINGLE LUMEN 9.6 FRX76 CM LP DOME,SUP-2126168,CDM,C1788,HCPCS,0278,RC,,,,both,,,876.06,569.44,,,,,,,,,,,,,
GRAFT VASC FLX 6 MMX60 CM TW SM BEAD N RING EPTFE CARBOFLO,SUP-2761470,CDM,C1768,CPT,0278,RC,,,,both,,,3395.60,2207.14,,,,,,,,,,,,,
ANCHOR SUT OD4.5MM FULL THRD TI PRELD W/ FORC FBR INSITE,SUP-2396984,CDM,C1713,HCPCS,0278,RC,,,,both,,,889.25,578.01,,,,,,,,,,,,,
CLAMP EXT FIX NS,SUP-2188499,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2123.74,1380.43,,,,,,,,,,,,,
ALBENDAZOLE 200 MG PO TABS,RX-8979,CDM,6370000000,HCPCS,0637,RC,00591-2712-02,NDC,,both,1,UN,435.80,283.27,,,,,,,,,,,,,
BIT DRL QC 2.8X200 MM 110 MM CALIB STRL,SUP-2563761,CDM,2720000010,LOCAL,0272,RC,,,,both,,,488.52,317.54,,,,,,,,,,,,,
STEM TIB L127MM OD11MM PRI STABILIZING EXTN MRS,SUP-2376467,CDM,C1776,CPT,0278,RC,,,,both,,,9161.89,5955.23,,,,,,,,,,,,,
CATHETER REPROC EP INQUIRY DECAPOLAR 6FR,SUP-2465663,CDM,C1730,HCPCS,0272,RC,,,,both,,,694.19,451.22,,,,,,,,,,,,,
BIT DRL L80MM DIA2.5MM SLD SIDE CUT FOR EL STBL SYS IJS,SUP-2340182,CDM,2720000010,LOCAL,0272,RC,,,,both,,,833.67,541.89,,,,,,,,,,,,,
GRAFT HUM TISS 23MMX16MM DWL BONE IMPL HUM TISS CANC CORT,SUP-2293891,CDM,C1713,HCPCS,0278,RC,,,,both,,,11278.88,7331.27,,,,,,,,,,,,,
SET INTRO MICROPUNCTURE DIA 4 FR NIT PERIPH ECHOGENIC STRL,SUP-2168405,CDM,C1894,HCPCS,0272,RC,,,,both,,,114.23,74.25,,,,,,,,,,,,,
SPLINT WRST FA L INSTABILITY INJ LOOP LOK FIRM SUPP VYN STRP,SUP-2276619,CDM,L3908,HCPCS,0274,RC,,,,both,,,15.86,10.31,,,,,,,,,,,,,
MATRIX BIO LG SZ 196 SQCM FISH SKIN LT DORSUM RT PALMAR MANO,SUP-2909252,CDM,Q4158,HCPCS,0636,RC,,,,both,,,26441.94,17187.26,,,,,,,,,,,,,
BLADE RTRCTR BLFR 241MMD ARM STNLSS STEEL ADLT ABDMNL SELF R,SUP-2703309,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1092.72,710.27,,,,,,,,,,,,,
HC Biofeedback Train Any Meth,PX-4309090100,CDM,90901,CPT,0430,RC,,,,both,,,177.00,115.05,,,,,,,,,,,,,
STENT BILI ROYAL L 14 MM DIA 9 MM AD STRL,SUP-2141183,CDM,C1876,HCPCS,0278,RC,,,,both,,,2967.30,1928.74,,,,,,,,,,,,,
BRACE ORTHOPEDIC CTRL KNEE POS LIN,SUP-2315981,CDM,L1833,HCPCS,0274,RC,,,,both,,,360.47,234.31,,,,,,,,,,,,,
GRAFT EVAR L166MM DIA23X13MM PROX DST AAA C DST DSGN,SUP-2295199,CDM,C1768,CPT,0278,RC,,,,both,,,31321.50,20358.97,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY DIA 7 FR DUODECAPOLAR 20 POLE,SUP-2725655,CDM,C1731,HCPCS,0278,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
BRACE KNEE L17-27IN FOR 30.5IN UNIV FOAM HNG STRP CLSR,SUP-2150858,CDM,L1810,HCPCS,0274,RC,,,,both,,,280.25,182.16,,,,,,,,,,,,,
INTRODUCER PACE LD WORLEY ADV SHTH L 50 CM DIA 9 FR TIP DIA,SUP-2303506,CDM,C1892,HCPCS,0272,RC,,,,both,,,1071.53,696.49,,,,,,,,,,,,,
CATHETER PERITONEAL DLYS TENCK INF 31 CM 1 CUF SIL QUINT,SUP-2754739,CDM,C1752,HCPCS,0278,RC,,,,both,,,169.40,110.11,,,,,,,,,,,,,
CEMENT BNE PMMA OSSEOFLEX CD-H,SUP-2490951,CDM,C1713,HCPCS,0278,RC,,,,both,,,1017.52,661.39,,,,,,,,,,,,,
CANNULA THRMCPL SENS AIRFLOW NSL ORAL 1 CHAN AD 1.5MM CONN,SUP-2330161,CDM,2720000010,LOCAL,0272,RC,,,,both,,,527.52,342.89,,,,,,,,,,,,,
PIN EXT FIX TRANSFIX 3X100 MM BLU,SUP-2205299,CDM,C1713,HCPCS,0278,RC,,,,both,,,398.00,258.70,,,,,,,,,,,,,
HC So Dna Antibody|UNUSUAL NON-OVERLAPPING SERVICE,PX-3028622566,CDM,86225,CPT,0302,RC,,,XU,both,,,397.00,258.05,,,,,,,,,,,,,
GRAFT BNE FIBER 15 CC OSTEOAMP SEL,SUP-2424598,CDM,C1713,HCPCS,0278,RC,,,,both,,,10555.39,6861.00,,,,,,,,,,,,,
CATHETER URODYN FLD FIL SIL RECT BAL AD SHFT SZ 10 FR BAL SZ,SUP-2263382,CDM,C1726,HCPCS,0272,RC,,,,both,,,597.86,388.61,,,,,,,,,,,,,
ESCITALOPRAM OXALATE 10 MG PO TABS,RX-33512,CDM,6370000000,HCPCS,0637,RC,65862-0374-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
HC Sternum Min 2 Views,PX-3207112000,CDM,71120,CPT,0320,RC,,,,outpatient,,,668.00,434.20,,,,,,,,,,,,,
HEAD RAD H12MM DIA24MM ELBW CO CHROM LO PROF DSTL EDGE L2L,SUP-2418599,CDM,C1776,CPT,0278,RC,,,,both,,,5457.32,3547.26,,,,,,,,,,,,,
PLATE SPNL 14 MM,SUP-2163891,CDM,C1713,HCPCS,0278,RC,,,,both,,,5039.70,3275.80,,,,,,,,,,,,,
CAP SGL SITE LPSCPC SEAL,SUP-2219933,CDM,C1713,HCPCS,0278,RC,,,,both,,,753.60,489.84,,,,,,,,,,,,,
CATHETER DRAINAGE PIG 8.5 FRX50 CM BILI SET 32 HOLE UTHANE,SUP-2168185,CDM,C1729,HCPCS,0272,RC,,,,both,,,166.89,108.48,,,,,,,,,,,,,
EXTENSION TIB STEM L 20 MM TI KNEE CR CEM STRL ITOTAL,SUP-2904369,CDM,C1776,CPT,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
ORTHOLOC SPS 3.5MM BIT DRILL,SUP-2822291,CDM,2720000010,LOCAL,0272,RC,,,,both,,,866.64,563.32,,,,,,,,,,,,,
HEAD FEM OD54MM CO CHROM MTL HIP CEM CONSERVE +,SUP-2304506,CDM,C1776,CPT,0278,RC,,,,both,,,15700.00,10205.00,,,,,,,,,,,,,
CEMENT BNE DOUGH 20 CC 40 GM,SUP-2197444,CDM,C1713,HCPCS,0278,RC,,,,both,,,216.50,140.72,,,,,,,,,,,,,
CAGE SPNL L12XW12XH12MM 4 LOBE MESH ANAT FOOTPRINT MOD IMP,SUP-2317732,CDM,C1889,HCPCS,0278,RC,,,,both,,,6066.48,3943.21,,,,,,,,,,,,,
CLAMP SPINE SUSP ANTR CERV SYS S STL COLORADO 2,SUP-2290522,CDM,C1713,HCPCS,0278,RC,,,,both,,,2389.54,1553.20,,,,,,,,,,,,,
GUIDEWIRE ORTH DBL RND 1.3X400 MM,SUP-2766039,CDM,C1769,HCPCS,0272,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
MATRIX HUM TISS L 5 X W 5 CM DECELL PLCNTA MEMBRN,SUP-2909325,CDM,Q4201,HCPCS,0636,RC,,,,both,,,3673.80,2387.97,,,,,,,,,,,,,
GRAFT ENDOVASC L7CM DIA12MM IL EXT EXCLUDER,SUP-2395950,CDM,C1768,CPT,0278,RC,,,,both,,,9263.00,6020.95,,,,,,,,,,,,,
HC So1 Hla Class II Typing Ea,PX-3108138267,CDM,81382,CPT,0310,RC,,,,both,,,144.00,93.60,,,,,,,,,,,,,
GUIDEWIRE VASC GLIDEWIRE ADVANTAGE L 180 CM DIA 0.014 IN TIP,SUP-2385539,CDM,C1769,HCPCS,0272,RC,,,,both,,,907.77,590.05,,,,,,,,,,,,,
STRAP CLAV SM BCKL CLSR FOAM CONSTR COT STOCK 3 W POST VECT,SUP-2194669,CDM,L3670,HCPCS,0274,RC,,,,both,,,14.82,9.63,,,,,,,,,,,,,
GUIDEWIRE VASC L180CM DIA0025IN HYDRPHLC STD ANG FIX COR,SUP-2302957,CDM,C1769,HCPCS,0272,RC,,,,both,,,141.30,91.84,,,,,,,,,,,,,
STEM FEM SZ 3 L145MM CALCAR HIP 12/14 TAPR ENDUR,SUP-2420928,CDM,C1776,CPT,0278,RC,,,,both,,,13715.52,8915.09,,,,,,,,,,,,,
PLATE BONE L94MM 4 H RT LAT PROX TIB S STL LCK FOR 4.5MM SCR,SUP-2348227,CDM,C1713,HCPCS,0278,RC,,,,both,,,14665.53,9532.59,,,,,,,,,,,,,
GUIDE SURG PLN TI LP DISTRCTN CUSTOMIZABLE BILATERAL VSP,SUP-2883944,CDM,2720000010,LOCAL,0272,RC,,,,both,,,21584.99,14030.24,,,,,,,,,,,,,
GRAFT VASC GELSFT L 40 CM DIA 6 MM POLYESTER GEL ABD PERIPH,SUP-2384961,CDM,C1768,CPT,0278,RC,,,,both,,,1074.88,698.67,,,,,,,,,,,,,
BIT DRL 3.8X35 MM QUICKSET,SUP-2454001,CDM,2720000010,LOCAL,0272,RC,,,,both,,,442.27,287.48,,,,,,,,,,,,,
INSERT ACET OD46MM ID28MM 6MM OFFSET 20DEG X FRE HIP ECC,SUP-2379060,CDM,C1776,CPT,0278,RC,,,,both,,,3232.94,2101.41,,,,,,,,,,,,,
TUNNELER SURG L 300 MM SM RIGID NO RNG MARKING STRL DISP 10/PK,SUP-2928805,CDM,2720000010,LOCAL,0272,RC,,,,both,,,377.11,245.12,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC 6FR 55CM 3 LUMAN RVS TAPR PWR INJ W,SUP-2613371,CDM,C1751,HCPCS,0278,RC,,,,both,,,892.55,580.16,,,,,,,,,,,,,
DEVICE VASC CLOSURE VASOSEAL DIA 5-8 FR FEM ART CLLGN,SUP-2227421,CDM,C1760,HCPCS,0278,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
PLATE BNE L105MM 8 H LOK 2 COMPR FOR 3.5MM SCR UNIV LOK SYS,SUP-2411375,CDM,C1713,HCPCS,0278,RC,,,,both,,,983.20,639.08,,,,,,,,,,,,,
HANDPIECE LASER OTO MICRO-G,SUP-2713744,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1106.85,719.45,,,,,,,,,,,,,
MESH CRANIAL CONTOURABLE 1.5X30X40X0.5 MM RAPID RESORBABLE S,SUP-2838573,CDM,C1713,HCPCS,0278,RC,,,,both,,,1593.55,1035.81,,,,,,,,,,,,,
CATHETER ANGIO GLIDECATH L 100 CM DIA 5 FR DIA1.12 MM STR,SUP-2385523,CDM,C1887,HCPCS,0272,RC,,,,both,,,173.33,112.66,,,,,,,,,,,,,
ALLOGRAFT BNE INJ 2.5 CC FD DBM DBX,SUP-2737040,CDM,C1713,HCPCS,0278,RC,,,,both,,,1425.31,926.45,,,,,,,,,,,,,
DEFIBRILLATOR IMPL LUMAX 500 DR-T W 55 X H 66 MM D 12 MM 30,SUP-2138273,CDM,C1721,HCPCS,0275,RC,,,,both,,,55735.00,36227.75,,,,,,,,,,,,,
CAGE SPNL L10XW10XH8MM 4 LOBE MESH ANAT FOOTPRINT MOD IMP,SUP-2317723,CDM,C1889,HCPCS,0278,RC,,,,both,,,3990.94,2594.11,,,,,,,,,,,,,
FILLER BNE VOID 2 ML CALCIUM SULF CALCIUM PHOSPHATE INJ,SUP-2902295,CDM,C1713,HCPCS,0278,RC,,,,both,,,10522.14,6839.39,,,,,,,,,,,,,
PLATE BNE L211MM 14 H ST R LAT PROX TIB S STL LOK COMPR LO,SUP-2185623,CDM,C1713,HCPCS,0278,RC,,,,both,,,4414.78,2869.61,,,,,,,,,,,,,
PLATE BONE 4 H STR OMNI,SUP-2223995,CDM,C1713,HCPCS,0278,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
COMPONENT FEM 1 KNEE RESTORIS,SUP-2265732,CDM,C1776,CPT,0278,RC,,,,both,,,6676.43,4339.68,,,,,,,,,,,,,
ELECTRODE ELECSURG RF 100 MM SELF GRND NITRODE,SUP-2366982,CDM,C1713,HCPCS,0278,RC,,,,both,,,8252.17,5363.91,,,,,,,,,,,,,
CONNECTOR SHUNT TYP A,SUP-2666433,CDM,C1889,HCPCS,0278,RC,,,,both,,,115.36,74.98,,,,,,,,,,,,,
PLATE BNE TBLR 73 MM 6 HOLE 1/3 STRL,SUP-2518439,CDM,C1713,HCPCS,0278,RC,,,,both,,,1956.22,1271.54,,,,,,,,,,,,,
PROSTHESIS OSS MIC 3X3.5 MM 0.9 MM MONOLITHIC CENTERED TI,SUP-2638165,CDM,L8613,CPT,0278,RC,,,,both,,,1037.64,674.47,,,,,,,,,,,,,
IMPLANT OTO W4MM W/ 12MM ABUTMENT BKUP PONTO SYS,SUP-2319889,CDM,L8690,HCPCS,0278,RC,,,,both,,,10676.00,6939.40,,,,,,,,,,,,,
PIN EXT FIX L 40 MM DIA 5 MM HA HALF STRL DISP,SUP-2933031,CDM,2720000010,LOCAL,0272,RC,,,,both,,,717.05,466.08,,,,,,,,,,,,,
GRAFT VASC RESTOREFLOW SZ 30 CM FEM ART BLD TYP A B AB O,SUP-2417672,CDM,C1768,CPT,0278,RC,,,,both,,,24551.66,15958.58,,,,,,,,,,,,,
DEVICE STRNL CLSR M D14MM SGL FT TALON PLT BONE,SUP-2262521,CDM,C1713,HCPCS,0278,RC,,,,both,,,4066.30,2643.09,,,,,,,,,,,,,
GRAFT SFT TISS BOV CLLGN 2.0 SQ 20CMX20CM SURGIMEND,SUP-2243684,CDM,C9360,HCPCS,0278,RC,,,,both,,,22608.00,14695.20,,,,,,,,,,,,,
INSERT SCRDRVR TORX STARDRV T6 FOR SCREW STRL DISP OPERACE,SUP-2913550,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1923.82,1250.48,,,,,,,,,,,,,
CATHETER DRNGE L60CM DIA10.2FR 0.038IN TRCR STYL NDL,SUP-2169797,CDM,C1729,HCPCS,0272,RC,,,,both,,,398.81,259.23,,,,,,,,,,,,,
SYSTEM EXT FIX HINGED RAIL STD 420 MM HOFFMANN PVC-FREE STRL,SUP-2486639,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5077.38,3300.30,,,,,,,,,,,,,
ADENOSINE 12 MG/4ML IV SOLN,RX-39477,CDM,J0153,HCPCS,0636,RC,67457-0854-00,NDC,,both,1,ML,54.10,35.16,,,,,,,,,,,,,
SCREW INTFR L30MM DIA6-8MM TIB TCP/PLA BIOABSRB,SUP-2249564,CDM,C1713,HCPCS,0278,RC,,,,both,,,2157.18,1402.17,,,,,,,,,,,,,
SET LD INTRO FLOWGUARD L 20 CM DIA 9 FR 12 ML ART VLV,SUP-2281864,CDM,C1894,HCPCS,0272,RC,,,,both,,,105.35,68.48,,,,,,,,,,,,,
CANNULA SUCTION DIAMETER 2MM SHARP TIP 45DEG MINOP,SUP-2825705,CDM,2720000010,LOCAL,0272,RC,,,,both,,,987.00,641.55,,,,,,,,,,,,,
COIL EMB L30CM DIA 14MM HELIX FBR 0.021IN MICROCATHETER,SUP-2281265,CDM,C1889,HCPCS,0278,RC,,,,both,,,1962.50,1275.62,,,,,,,,,,,,,
STAPLER INT 60 MM RELD TRISTAPLE TECHNOLOGY BLK STRL SEAMGRD,SUP-2489651,CDM,C1713,HCPCS,0278,RC,,,,both,,,656.26,426.57,,,,,,,,,,,,,
LEAD PACE ATTAIN ABIL + MRI SURESCAN L 88 CM DIA 5.3 FR SIL,SUP-2281928,CDM,C1900,HCPCS,0275,RC,,,,both,,,4865.52,3162.59,,,,,,,,,,,,,
KIT REV CATH ITH DST SPNL SEG,SUP-2284618,CDM,C1755,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
KIT ORTHOPEDIC SHORT 56MM INTERMEDIATE LEFT DISTAL RADIUS VARIAX F/T8 INSTRUMENT STERILE,SUP-2696117,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5211.46,3387.45,,,,,,,,,,,,,
PLATE D FIBULA EVOS 2.7/3.5MM 5H L 93MM,SUP-2750035,CDM,C1713,HCPCS,0278,RC,,,,both,,,6776.91,4404.99,,,,,,,,,,,,,
GUIDEWIRE VASC L 180 CM DIA 0.035 IN T1 FIX COR,SUP-2141994,CDM,C1769,HCPCS,0272,RC,,,,both,,,61.86,40.21,,,,,,,,,,,,,
ANTENNA ABLAT SYS L15CM SHT THERMOSPHERE TECHNOLOGY FOR PERC,SUP-2172370,CDM,C1886,HCPCS,0278,RC,,,,both,,,10510.84,6832.05,,,,,,,,,,,,,
GUIDEWIRE VASC COON L 260 CM DIA 0.038 IN TAPR L 15 CM FLPY,SUP-2167858,CDM,C1769,HCPCS,0272,RC,,,,both,,,78.97,51.33,,,,,,,,,,,,,
CATHETER THROMCTMY QUICKCLEAR L 85 CM DIA10 FR NOM DIA 0.130,SUP-2823591,CDM,C1757,HCPCS,0272,RC,,,,both,,,10990.00,7143.50,,,,,,,,,,,,,
GRAFT HUM TISS W10 20MMXL165 25CM ALLGRFT TEND QUADRICEPS,SUP-2307294,CDM,C1762,CPT,0278,RC,,,,both,,,5697.22,3703.19,,,,,,,,,,,,,
HC Injection for Cholangiogram,PX-3614753100,CDM,47531,CPT,0361,RC,,,,outpatient,,,12375.00,8043.75,,,,,,,,,,,,,
GALILEO TROCH NAIL 9MMX20CMX125 DEGREE,SUP-2828801,CDM,C1713,HCPCS,0278,RC,,,,both,,,6892.30,4479.99,,,,,,,,,,,,,
INFUSION PUMP KIT PAINBUSTER 2.5 IN 400 CC ON-Q SILVERSOAKER,SUP-2236829,CDM,C1713,HCPCS,0278,RC,,,,both,,,690.80,449.02,,,,,,,,,,,,,
STRATTICE RCNSTRCTVE TSSUE MTRX PRFRTD 15 35 FIRM,SUP-2680183,CDM,Q4116,HCPCS,0636,RC,,,,both,,,51976.42,33784.67,,,,,,,,,,,,,
INSERT TIB SZ B KNEE POLYETH SEG,SUP-2200500,CDM,C1776,CPT,0278,RC,,,,both,,,890.19,578.62,,,,,,,,,,,,,
GRAFT HUMAN TISSUE KNEE FEMORAL LEFT LATERAL CONDYLE,SUP-2863727,CDM,C1762,CPT,0278,RC,,,,both,,,36643.80,23818.47,,,,,,,,,,,,,
STEM RADIAL 8X28 MM TI NS,SUP-2190891,CDM,C1776,CPT,0278,RC,,,,both,,,7503.03,4876.97,,,,,,,,,,,,,
HC So Dhea Sulfate,PX-3018262766,CDM,82627,CPT,0301,RC,,,,both,,,327.00,212.55,,,,,,,,,,,,,
OYSTER SHELL CALCIUM 500 MG PO TABS,RX-5955,CDM,6370000000,HCPCS,0637,RC,00904-1883-61,NDC,,both,1,UN,0.40,0.26,,,,,,,,,,,,,
GUIDEWIRE ORTH L 450 MM DIA2.8 MM THRD FOR CANN SYS PK NS,SUP-2907915,CDM,C1769,HCPCS,0272,RC,,,,both,,,923.63,600.36,,,,,,,,,,,,,
INTRODUCER CATH 16FR ORNG SUPRPUB PLAS SHRP TIP BVL TRCR,SUP-2391835,CDM,C1894,HCPCS,0272,RC,,,,both,,,64.06,41.64,,,,,,,,,,,,,
DEVICE INFL SYR DGT W HONOR HEMSTAS VLV BASIXCOMPAK 30 ATM,SUP-2302691,CDM,C1713,HCPCS,0278,RC,,,,both,,,122.46,79.60,,,,,,,,,,,,,
SCREW BNE L54MM DIA3.5MM STD CORT DST TIB TI ST LOK FULL,SUP-2413583,CDM,C1713,HCPCS,0278,RC,,,,both,,,552.64,359.22,,,,,,,,,,,,,
PLATE BONE SH STRL TARSAL METATRSL FUS FOR 2.7MM SCR VLP,SUP-2349942,CDM,C1713,HCPCS,0278,RC,,,,both,,,5010.34,3256.72,,,,,,,,,,,,,
CANNULATED DRILL 15MM,SUP-2816447,CDM,2720000010,LOCAL,0272,RC,,,,both,,,527.52,342.89,,,,,,,,,,,,,
SCREW BNE L95MM DIA7.3MM CORT S STL ST CANN LOK FULL THRD,SUP-2184943,CDM,C1713,HCPCS,0278,RC,,,,both,,,475.84,309.30,,,,,,,,,,,,,
PIN FIX L2IN W/ HNDL STNMN P.F.C.,SUP-2253358,CDM,C1713,HCPCS,0278,RC,,,,both,,,678.24,440.86,,,,,,,,,,,,,
DRILL SURG 9 MM FOR MINI PLATE SYS DIVERGENCE,SUP-2630667,CDM,2720000010,LOCAL,0272,RC,,,,both,,,513.23,333.60,,,,,,,,,,,,,
REAMER SURG OD46MM S STL ACET SPHR CUTTINGEDGE,SUP-2361870,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1752.12,1138.88,,,,,,,,,,,,,
SCREW SPNL MULTAXL 5X25 MM CANN FOR 4.5 MM ROD SHILLA,SUP-2630580,CDM,C1713,HCPCS,0278,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
HC Reposition Ivc Filter,PX-3613719200,CDM,37192,CPT,0361,RC,,,,both,,,8583.00,5578.95,,,,,,,,,,,,,
HC Drug Screen Quantitative Phenobarbital,PX-3018018400,CDM,80184,CPT,0301,RC,,,,both,,,306.00,198.90,,,,,,,,,,,,,
SCREW BONE L30MM DIA3.5MM PROX FEM CANN T15 HEXALOBE PEDILOC,SUP-2318561,CDM,C1713,HCPCS,0278,RC,,,,both,,,1826.66,1187.33,,,,,,,,,,,,,
FILTER VASC OPTEASE DIA28 MM INTRO 8 FR NIT CLOSED CAGE LP,SUP-2157002,CDM,C1880,HCPCS,0278,RC,,,,both,,,2983.00,1938.95,,,,,,,,,,,,,
CATHETER EP MAP RESPON 6FR QPLR 5MM ELECTRD SPC JSN CRV,SUP-2356797,CDM,C1730,HCPCS,0272,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
CATHETER GRFT POS DIA18 FR RVD 16-32 MM POLYUR TRILOBE,SUP-2395632,CDM,C1725,HCPCS,0272,RC,,,,both,,,1978.20,1285.83,,,,,,,,,,,,,
PLATE COMPRSS VARIAX2 NRW 5H 66MM,SUP-2703712,CDM,C1713,HCPCS,0278,RC,,,,both,,,1766.88,1148.47,,,,,,,,,,,,,
SCREW BONE L6MM DIA1.5MM CORT MAXILLOMANDIBULAR GRN TI SELF,SUP-2137242,CDM,C1713,HCPCS,0278,RC,,,,both,,,135.02,87.76,,,,,,,,,,,,,
FIBER LASER 1000UM HOLM LT GUID,SUP-2313983,CDM,C1713,HCPCS,0278,RC,,,,both,,,2822.20,1834.43,,,,,,,,,,,,,
GRAFT VASC ALBOGRFT POLY 16 MMX8 MM DIAX50 CM L KNIT BIFUR,SUP-2264274,CDM,C1768,CPT,0278,RC,,,,both,,,2041.00,1326.65,,,,,,,,,,,,,
CLAMP EXT FIX LCK LG 2D,SUP-2473751,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1852.57,1204.17,,,,,,,,,,,,,
COMPONENT FEM OPTETRAK AK,SUP-2223151,CDM,C1776,CPT,0278,RC,,,,both,,,5.02,3.26,,,,,,,,,,,,,
BUR SURG DIA6MM EXTRA COARSE RND DMND CUT ELITE,SUP-2363995,CDM,2720000010,LOCAL,0272,RC,,,,both,,,443.96,288.57,,,,,,,,,,,,,
GRAFT HUM TISS AMBIENT 0.5 CC FLOWABLE PLCNTA TISS VIAFLOW,SUP-2759453,CDM,C1762,CPT,0278,RC,,,,both,,,2343.44,1523.24,,,,,,,,,,,,,
DIFFUSER GAS CO2 DISP DEV CARBONAID,SUP-2175227,CDM,2720000010,LOCAL,0272,RC,,,,both,,,659.40,428.61,,,,,,,,,,,,,
PEG GLENOIDXL DIA56MM SHLDR UHMWPE 1020XLK ANCHR FOR,SUP-2250038,CDM,C1776,CPT,0278,RC,,,,both,,,5855.63,3806.16,,,,,,,,,,,,,
DRESSING BIO L 8 X W 6 CM FISH SKIN 21 PRE MESHED STRL,SUP-2909173,CDM,Q4158,HCPCS,0636,RC,,,,both,,,9137.40,5939.31,,,,,,,,,,,,,
ECH STRAIGHT 190MM +15 CALCAR SZ 11,SUP-2822848,CDM,C1776,CPT,0278,RC,,,,both,,,18507.16,12029.65,,,,,,,,,,,,,
DRIVER SURG HEX 2 MM ACTUATION FOR FIBULAR NAIL STRL DISP,SUP-2909093,CDM,2720000010,LOCAL,0272,RC,,,,both,,,690.80,449.02,,,,,,,,,,,,,
PLATE BNE L W135XL242MM THK42MM 13 H BILAT TI NAR RIG NEUT,SUP-2190826,CDM,C1713,HCPCS,0278,RC,,,,both,,,1799.63,1169.76,,,,,,,,,,,,,
KIT SURG BNE CEMENT MX DEL SYS CEMENT CTRL CLUTCH FLX EXT,SUP-2885587,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4160.94,2704.61,,,,,,,,,,,,,
PLATE BNE BROAD 4.5X103 MM 6 HOLE SS DCP,SUP-2569174,CDM,C1713,HCPCS,0278,RC,,,,both,,,355.76,231.24,,,,,,,,,,,,,
TRANEXAMIC ACID 100 MG/ML FOR NEBULIZATION,RX-4082649,CDM,2500000003,HCPCS,0250,RC,55150-0188-10,NDC,,both,5,ML,54.10,35.16,,,,,,,,,,,,,
HC Cardiac Stress Test,PX-4829301700,CDM,93017,CPT,0482,RC,,,,both,,,1474.00,958.10,,,,,,,,,,,,,
SCREW BNE L120MM DIA6MM THRD L20MM CORT OSTEOTITE,SUP-2316311,CDM,C1713,HCPCS,0278,RC,,,,both,,,427.42,277.82,,,,,,,,,,,,,
PIN EXTERNAL FIXATION HALF SHORT 5X30 MM TITANIUM NITRIDE ST,SUP-2836774,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1224.41,795.87,,,,,,,,,,,,,
BLADE SAW L 111 MM L 33 MM THK MATERIAL 0.4 MM CUT 0.6 MM,SUP-2929133,CDM,2720000010,LOCAL,0272,RC,,,,both,,,557.10,362.11,,,,,,,,,,,,,
DRILL SURG 7.5X25 MM TRABECULAR MTL RVS +,SUP-2436864,CDM,2720000010,LOCAL,0272,RC,,,,both,,,536.94,349.01,,,,,,,,,,,,,
STEM FEM L267MM OD11MM BOW FLUT TI ALLY HA DST HIP REV MOD,SUP-2375777,CDM,C1776,CPT,0278,RC,,,,both,,,7916.57,5145.77,,,,,,,,,,,,,
DEXTROSE 5 % IV SOLN INTERMITTENT INFUSION,RX-40840103,CDM,J7060,HCPCS,0258,RC,00264-7510-20,NDC,,both,250,ML,31.90,20.73,,,,,,,,,,,,,
ALLOGRAFT BNE 60-115 MM FD RIB ORAGRAFT,SUP-2740906,CDM,C1713,HCPCS,0278,RC,,,,both,,,1055.64,686.17,,,,,,,,,,,,,
PLATE BNE L77MM 6 H TI FIBULAR COMP LOK COMPR LO PROF,SUP-2413681,CDM,C1713,HCPCS,0278,RC,,,,both,,,718.81,467.23,,,,,,,,,,,,,
SAW SURGICAL OSCILLATING PNEUMATIC POWERPRO HALL,SUP-2586416,CDM,2720000010,LOCAL,0272,RC,,,,both,,,11503.39,7477.20,,,,,,,,,,,,,
PLATE BNE L117MM 7 H ST R POSTEROLATERAL DST HUM S STL LOK,SUP-2417016,CDM,C1713,HCPCS,0278,RC,,,,both,,,3093.15,2010.55,,,,,,,,,,,,,
SCREW BONE SELF TAPPING 2.4X8 MM CORTICAL CRUCIFORM RECESS S,SUP-2837811,CDM,C1713,HCPCS,0278,RC,,,,both,,,118.69,77.15,,,,,,,,,,,,,
SCREW BNE L10MM DIA1.5MM S STL ST LOK FULL THRD T4 STARDRV,SUP-2184856,CDM,C1713,HCPCS,0278,RC,,,,both,,,297.45,193.34,,,,,,,,,,,,,
PLATE BNE W13.5XL178MM THK4.2MM 10 H BILAT S STL NAR LIMIT,SUP-2185244,CDM,C1713,HCPCS,0278,RC,,,,both,,,1565.82,1017.78,,,,,,,,,,,,,
LOW PROFILE SUTURE LASSO 45 DEGREE,SUP-2812975,CDM,C1713,HCPCS,0278,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
HC MRI-Upper Ext Jnt WO Cont|BILATERAL PROCEDURE,PX-6107322100,CDM,73221,CPT,0610,RC,,,50,both,,,3764.00,2446.60,,,,,,,,,,,,,
SPLINT ORTH L3IN STD PLAS FNGR MLLT W/O PD STAX,SUP-2198709,CDM,L3913,HCPCS,0272,RC,,,,both,,,5.18,3.37,,,,,,,,,,,,,
TRIAL CRUC RET ARTC SURF PROV BLU 10MM NXGN,SUP-2201311,CDM,C1776,CPT,0278,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
DRESSING WND FEN 10X15 CM SHT EXTRACELLULAR MTRX MATRISTEM,SUP-2106524,CDM,Q4166,HCPCS,0636,RC,,,,both,,,2497.05,1623.08,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 60 MM DIA 7 MM DEL SHTH 3.3ML,SUP-2936811,CDM,C1713,HCPCS,0278,RC,,,,both,,,10241.11,6656.72,,,,,,,,,,,,,
HC So Hexagonal Phospholipid,PX-3058559866,CDM,85598,CPT,0305,RC,,,,both,,,57.00,37.05,,,,,,,,,,,,,
CANNULA ENDOSCP SUCTION 4 MMX12 CM SIMMEN INSUL ANGULAR,SUP-2774730,CDM,2720000010,LOCAL,0272,RC,,,,both,,,715.83,465.29,,,,,,,,,,,,,
BUR SURG L9CM HD L16.4MM DIA3MM TAPR FOOTED L BOR MIDAS REX,SUP-2284684,CDM,2720000010,LOCAL,0272,RC,,,,both,,,335.70,218.20,,,,,,,,,,,,,
SIZE 1 COLLAR LAT ASSEMBLYRAD STEM IMPLANT 6MM,SUP-2492492,CDM,C1713,HCPCS,0278,RC,,,,both,,,4631.50,3010.47,,,,,,,,,,,,,
GRAFT VASC STR 12 MMX15 CM AORT ARCH 1 LAYR SFT HEMSHLD GLD,SUP-2473142,CDM,C1768,CPT,0278,RC,,,,both,,,1286.40,836.16,,,,,,,,,,,,,
WASHER 14MM PROF,SUP-2589107,CDM,C1713,HCPCS,0278,RC,,,,both,,,1097.24,713.21,,,,,,,,,,,,,
GUIDEWIRE LD 60 CM,SUP-2615480,CDM,C1769,HCPCS,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
GUIDEWIRE VASC SYNCHRO 14 200CM 0.014IN SEG 35CM ACCS STR,SUP-2367843,CDM,C1769,HCPCS,0272,RC,,,,both,,,1877.72,1220.52,,,,,,,,,,,,,
HEAD FEM SM DIA36MM CO CHROM AMISTEM,SUP-2267308,CDM,C1776,CPT,0278,RC,,,,both,,,1598.26,1038.87,,,,,,,,,,,,,
SYSTEM ORTH SECURITIZATION SHLDR ADJ REVERSED AEQUALIS,SUP-2715377,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1210.47,786.81,,,,,,,,,,,,,
ASSEMBLY SHUNT CATH DSTL L 120 CM SM SNAP STRL STRATAMR II,SUP-2929977,CDM,C1889,HCPCS,0278,RC,,,,both,,,18526.00,12041.90,,,,,,,,,,,,,
SHUNT CEREBROSPINAL FLUID PRESSURE RATING HORIZONTAL 0.0 CWS,SUP-2843218,CDM,C1889,HCPCS,0278,RC,,,,both,,,12600.16,8190.10,,,,,,,,,,,,,
CATHETER EP CSL 5-5-5 MM 7 FRX65 CM RESPON,SUP-2356773,CDM,C1730,HCPCS,0272,RC,,,,both,,,1416.14,920.49,,,,,,,,,,,,,
UNISPACER 50MM X 2MM MED RT,SUP-2202428,CDM,C1776,CPT,0278,RC,,,,both,,,10362.00,6735.30,,,,,,,,,,,,,
HC Assay of Osmolality Urine,PX-3018393500,CDM,83935,CPT,0301,RC,,,,both,,,214.00,139.10,,,,,,,,,,,,,
PLATE BNE L81MM 12 H S STL LO PROF LOK COMPR FOR 2MM SCR,SUP-2186311,CDM,C1713,HCPCS,0278,RC,,,,both,,,1111.43,722.43,,,,,,,,,,,,,
ELECTRODE ENDOSCP MPLR BAYNT W  INTERCHANGEABLE TIP CONIC,SUP-2436275,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1746.47,1135.21,,,,,,,,,,,,,
BRACE WALKING LP MED 5.5-10 IN 6.5-11 IN AD M MAXTRAX AIR,SUP-2427327,CDM,L4360,HCPCS,0272,RC,,,,both,,,93.76,60.94,,,,,,,,,,,,,
GRAFT HUM TISS W4XL12CM THK04 08MM ACELLULAR DERM MTRX,SUP-2307446,CDM,Q4128,HCPCS,0636,RC,,,,both,,,2486.10,1615.96,,,,,,,,,,,,,
SPLINT WR AND FRARM TITEX W/ LOOP LCK LT M,SUP-2195255,CDM,L3809,HCPCS,0274,RC,,,,both,,,17.52,11.39,,,,,,,,,,,,,
GRAFT BNE SUB 10CC DBM FRZ DRY I/C CHMBR,SUP-2264798,CDM,C1762,CPT,0278,RC,,,,both,,,2803.55,1822.31,,,,,,,,,,,,,
PEG 3350-KCL-NABCB-NACL-NASULF 236 G PO SOLR,RX-10839,CDM,6370000000,HCPCS,0637,RC,43386-0090-19,NDC,,both,4000,ML,108.00,70.20,,,,,,,,,,,,,
PROBE ULTRASONIC W/ OSC BUR TIP,SUP-2261219,CDM,2720000010,LOCAL,0272,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
SCREW BNE L 42 MM DIA 7 MM TI CANN FT HD NS LEOS,SUP-2931542,CDM,C1713,HCPCS,0278,RC,,,,both,,,1179.23,766.50,,,,,,,,,,,,,
SUPPORT WR SM AD LT CRPL TUNN REG FIRM SUPP CRPLGARD BLK,SUP-2324889,CDM,L3931,HCPCS,0274,RC,,,,both,,,42.83,27.84,,,,,,,,,,,,,
PLATE BNE L220MM 9 H NONSTERILE R PROX LAT TIB S STL LOK,SUP-2184881,CDM,C1713,HCPCS,0278,RC,,,,both,,,3997.38,2598.30,,,,,,,,,,,,,
ECONAZOLE NITRATE 1 % EX CREA,RX-9915,CDM,6370000000,HCPCS,0637,RC,51672-1303-01,NDC,,both,15,GR,112.70,73.25,,,,,,,,,,,,,
BIT DRL QC LG LNG 7.5 MM FOR CANN SCREW STRL,SUP-2789113,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2129.17,1383.96,,,,,,,,,,,,,
SCREW BNE L 18 MM DIA2 MM TI CORTICAL LOWER EXTREMITY BLU NS,SUP-2905673,CDM,C1713,HCPCS,0278,RC,,,,both,,,240.71,156.46,,,,,,,,,,,,,
PATCH CV IMPRA L 90 X W 20 MM THK 0.4 MM EPTFE OVL SHP TW,SUP-2127806,CDM,C1768,CPT,0278,RC,,,,both,,,712.78,463.31,,,,,,,,,,,,,
LINER ACET CEM HIP HYBIRD XLPE,SUP-2379163,CDM,C1776,CPT,0278,RC,,,,both,,,12560.00,8164.00,,,,,,,,,,,,,
GRFT CRUSH CANC 1-4MM 30CC PUROS,SUP-2693926,CDM,C1713,HCPCS,0278,RC,,,,both,,,3096.04,2012.43,,,,,,,,,,,,,
SCREW BNE L 26 MM DIA2.5 MM TI CANN HDLSS NS LEOS,SUP-2932617,CDM,C1713,HCPCS,0278,RC,,,,both,,,760.98,494.64,,,,,,,,,,,,,
ALLOGRAFT BNE DIVERTED TUBE 3/4 FILL PREFIL FOR E,SUP-2538801,CDM,C1889,HCPCS,0278,RC,,,,both,,,932.58,606.18,,,,,,,,,,,,,
BIT DRL CALIB XLN 4.2 MM STRL,SUP-2789937,CDM,2720000010,LOCAL,0272,RC,,,,both,,,833.39,541.70,,,,,,,,,,,,,
CATHETER URODYN DL 7 FRX30 CM VLY,SUP-2835711,CDM,C1726,HCPCS,0272,RC,,,,both,,,60.79,39.51,,,,,,,,,,,,,
CLIP ANEUR BLDE L15MM MAX OPN 9.2MM 70GM STD TEMP PHYNOX,SUP-2108390,CDM,C1889,HCPCS,0278,RC,,,,both,,,1008.88,655.77,,,,,,,,,,,,,
BASEPLATE GLEN OD25MM 15DEG HALF WDG AUG REVERSED AEQUALIS,SUP-2388802,CDM,C1776,CPT,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
PLATE BONE L45MM 7 H RT 1ST METATARSOPHALANGEAL,SUP-2137081,CDM,C1713,HCPCS,0278,RC,,,,both,,,2594.27,1686.28,,,,,,,,,,,,,
SMALL ACP PLATE 27 5 HOLES L 44,SUP-2706085,CDM,C1713,HCPCS,0278,RC,,,,both,,,356.08,231.45,,,,,,,,,,,,,
OSCILLATOR BLADE COATED 19.5 X95 X1.27 MM 5PK,SUP-2605495,CDM,2720000010,LOCAL,0272,RC,,,,both,,,109.90,71.43,,,,,,,,,,,,,
HC So Lipoprotein Bld Hr Fraction,PX-3018370166,CDM,83701,CPT,0301,RC,,,,both,,,183.00,118.95,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY INQUIRY DIA 6 FR SPC 5 MM EXT,SUP-2357651,CDM,C1730,HCPCS,0272,RC,,,,both,,,1389.36,903.08,,,,,,,,,,,,,
OBTURATOR SHTH 8FRX15CM LUERLOCK,SUP-2355472,CDM,C1894,HCPCS,0272,RC,,,,both,,,19.63,12.76,,,,,,,,,,,,,
CATHETER ENDOBRONCHIAL BLK SET 9 FRX65 CM 7 MM COHEN TIP STD,SUP-2759867,CDM,2720000010,LOCAL,0272,RC,,,,both,,,948.97,616.83,,,,,,,,,,,,,
ARM EXT FIX XLN ARTC 3 ARTH FOR SIDEKCK STLTH REARFOOT FIX,SUP-2400635,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2675.28,1738.93,,,,,,,,,,,,,
ENDCAP ORTH 0MM EXTN TI T40 STARDRV RECESS FOR EXPERT CANN,SUP-2179662,CDM,C1713,HCPCS,0278,RC,,,,both,,,755.14,490.84,,,,,,,,,,,,,
HEAD FEM MOD 8- MM 46 MM HIP BIRMINGHAM HIPTM RESURF,SUP-2435176,CDM,C1776,CPT,0278,RC,,,,both,,,10833.00,7041.45,,,,,,,,,,,,,
PUNCH SURG OD4MM ETHM BONE RELIEVA CIRCA,SUP-2106341,CDM,C1713,HCPCS,0278,RC,,,,both,,,668.82,434.73,,,,,,,,,,,,,
DRONEDARONE HCL 400 MG PO TABS,RX-98239,CDM,6370000000,HCPCS,0637,RC,00024-4142-60,NDC,,both,1,UN,60.80,39.52,,,,,,,,,,,,,
GRAFT TISSUE HUMAN THERASKIN 4.0 X 6.5,SUP-2745400,CDM,Q4121,HCPCS,0636,RC,,,,both,,,3763.29,2446.14,,,,,,,,,,,,,
BUR REPROC SURG 4.5MM BUR REPROC HELICUT SLATE,SUP-2652927,CDM,2720000010,LOCAL,0272,RC,,,,both,,,72.38,47.05,,,,,,,,,,,,,
RELOAD STPL 45MM CRV TIP ARTC FOR MEDIUM/THICK TISS,SUP-2283355,CDM,2720000010,LOCAL,0272,RC,,,,both,,,869.03,564.87,,,,,,,,,,,,,
GRAFT DERMAL STRUCTURAL ULTRA THCK 25X20 CMX1.8-4 MM FLEXHD,SUP-2307488,CDM,Q4128,HCPCS,0636,RC,,,,both,,,44521.84,28939.20,,,,,,,,,,,,,
TRIATHLON CR TIB INSRT TRL NO 3 - 13MM,SUP-2363757,CDM,C1776,CPT,0278,RC,,,,both,,,402.08,261.35,,,,,,,,,,,,,
TRAY CATH HEMODIALYSI NIAG ACUTE 13.5FR DIA 24CML IN 5575240,SUP-2632906,CDM,C1752,HCPCS,0278,RC,,,,both,,,608.53,395.54,,,,,,,,,,,,,
BIT DRL KT 3.2X200 MM CANN DYN AX FIX 1.8 MM HOLE,SUP-2644556,CDM,2720000010,LOCAL,0272,RC,,,,both,,,522.68,339.74,,,,,,,,,,,,,
HC MRI Lower Ext W/ Cont,PX-6107371900,CDM,73719,CPT,0610,RC,,,,both,,,5019.00,3262.35,,,,,,,,,,,,,
GUIDEWIRE VASC VICTORY 18 L 300 CM DIA 0.018 INL TIP L 2 CM,SUP-2140830,CDM,C1769,HCPCS,0272,RC,,,,both,,,571.48,371.46,,,,,,,,,,,,,
GRAFT BNE W5XL40MM FIB FRZN SHFT,SUP-2307377,CDM,C1713,HCPCS,0278,RC,,,,both,,,1946.61,1265.30,,,,,,,,,,,,,
DRILL 10MM,SUP-2841573,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1227.74,798.03,,,,,,,,,,,,,
GRAFT BONE 1ML DEMIN BONE MTRX PUTTY STRL IMP ACCELL,SUP-2242680,CDM,C9359,HCPCS,0278,RC,,,,both,,,789.18,512.97,,,,,,,,,,,,,
HC Gbl Office/OP Consltj New/Est Pt Mod Mdm 40 Minutes,PX-9829924401,CDM,99244,CPT,0982,RC,,,,outpatient,,,837.00,544.05,,,,,,,,,,,,,
GUIDEWIRE ORTH NO EYELET 2.4 MMX10 IN SMOOTH STRL DISP,SUP-2848551,CDM,C1769,HCPCS,0272,RC,,,,both,,,491.25,319.31,,,,,,,,,,,,,
GRAFT BNE 2-10 MM CRUSH FD CANC,SUP-2684149,CDM,C1713,HCPCS,0278,RC,,,,both,,,8054.10,5235.16,,,,,,,,,,,,,
PIN FIX BUTTRESS 1.8X18 MM TI NS,SUP-2189682,CDM,C1713,HCPCS,0278,RC,,,,both,,,195.40,127.01,,,,,,,,,,,,,
GRAFT BONE SUB 20CC HIGHLY PURIFIED TYP I CLLGN HA B,SUP-2310444,CDM,C1713,HCPCS,0278,RC,,,,both,,,4160.50,2704.32,,,,,,,,,,,,,
PLATE BNE L 162 X W 11 MM THK 3 MM SCREW DIA2.7/3.5 MM 13 H 72466113N,SUP-2933010,CDM,C1713,HCPCS,0278,RC,,,,both,,,5567.85,3619.10,,,,,,,,,,,,,
BRACE THMB AD SM FOR 6-6.875IN LT MCP BLK ALIDRY FAB BRTH,SUP-2323970,CDM,L3931,HCPCS,0272,RC,,,,both,,,92.50,60.12,,,,,,,,,,,,,
TUBE MYR ID1.27MM WHT FLROPLAS CLLR BTTN FOR OTITIS MEDIA,SUP-2312594,CDM,L8699,HCPCS,0278,RC,,,,both,,,23.33,15.16,,,,,,,,,,,,,
LEAD PACE COROX OTW L 87 CM DIA1.8 MM POLYUR IRIDIUM OXIDE,SUP-2138066,CDM,C1900,HCPCS,0275,RC,,,,both,,,5011.44,3257.44,,,,,,,,,,,,,
BIT DRL 4.5 MM,SUP-2862306,CDM,2720000010,LOCAL,0272,RC,,,,both,,,465.72,302.72,,,,,,,,,,,,,
PLATE BONE 4X18 HOLE RIGHT RECONSTRUCTION WITH CONDYLAR HEAD,SUP-2838421,CDM,C1713,HCPCS,0278,RC,,,,both,,,17715.88,11515.32,,,,,,,,,,,,,
PLATE BNE THK1MM 16 H MINI CRANIOMAXILLOFACIAL TI STR REG,SUP-2366316,CDM,C1713,HCPCS,0278,RC,,,,both,,,1483.71,964.41,,,,,,,,,,,,,
ANCHOR SUT L THRD FOR ANK FUS PLATING SYS BB-TAK,SUP-2123201,CDM,C1713,HCPCS,0278,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
BRUSH CYTO 3FR L115CM DISP,SUP-2313965,CDM,2720000010,LOCAL,0272,RC,,,,both,,,736.42,478.67,,,,,,,,,,,,,
PLATE BONE ADAPTION 0.5 MM 7 HOLE TITANIUM NON STERILE LOW P,SUP-2838362,CDM,C1713,HCPCS,0278,RC,,,,both,,,1013.59,658.83,,,,,,,,,,,,,
BRACE KNEE SZ 4 16-17INXL MID PAT Q FR CLSR IN 2SL BIOSKIN,SUP-2174972,CDM,L1820,HCPCS,0272,RC,,,,both,,,181.96,118.27,,,,,,,,,,,,,
GUIDEPIN ORTHOPAEDIC CALIBRATED 1.6X152 MM THREADED TIP WITH,SUP-2836611,CDM,C1713,HCPCS,0278,RC,,,,both,,,219.30,142.54,,,,,,,,,,,,,
CATHETER DEL CARR L 152 CM LG COMP HYDRPHLC 1 LUMEN VAR PK 5,SUP-2934069,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5950.30,3867.69,,,,,,,,,,,,,
PLATE BNE STR MED 1 MM 4 HOLE W/ INTERMED SPACE STRL,SUP-2457062,CDM,C1713,HCPCS,0278,RC,,,,both,,,550.03,357.52,,,,,,,,,,,,,
BLADE SAW 12 MM MANUAL HARVESTOR,SUP-2415427,CDM,2720000010,LOCAL,0272,RC,,,,both,,,709.64,461.27,,,,,,,,,,,,,
KIT INSTR BLU DISP PRO-TOE VO,SUP-2397814,CDM,2720000010,LOCAL,0272,RC,,,,both,,,618.58,402.08,,,,,,,,,,,,,
STEM FEM MS 30 POLISHED OFFST CEM HIP 6.0,SUP-2204692,CDM,C1776,CPT,0278,RC,,,,both,,,10369.54,6740.20,,,,,,,,,,,,,
STEM FEM HIP LO HD CNTR FBR MTL PRI NEUT BEAD FBR MTL 00784001210] ZIMMER BIOMET INC],SUP-2203082,CDM,C1776,CPT,0278,RC,,,,both,,,15529.18,10093.97,,,,,,,,,,,,,
PLATE BNE 6 H MIC TI NONSTERILE 1.5MM SCR .6MM,SUP-2262680,CDM,C1713,HCPCS,0278,RC,,,,both,,,160.52,104.34,,,,,,,,,,,,,
SCREW BNE L85MM OD3.5MM S STL CORT ST LOK FULL THRD LO PROF,SUP-2348382,CDM,C1713,HCPCS,0278,RC,,,,both,,,1175.68,764.19,,,,,,,,,,,,,
HALF PIN EXT FIX L 130 MM DIA 6 MM THRD L 30 MM HA COAT SD,SUP-2899011,CDM,C1713,HCPCS,0278,RC,,,,both,,,777.15,505.15,,,,,,,,,,,,,
NUT AND WSHR FOR SHEFFIELD STERILISATION TY SYS,SUP-2316259,CDM,C1713,HCPCS,0278,RC,,,,both,,,234.31,152.30,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 40 CM DIA 5 MM STR REINF SLDE GDS,SUP-2681172,CDM,C1768,CPT,0278,RC,,,,both,,,1290.29,838.69,,,,,,,,,,,,,
GRAFT VASC GORTX L 50 CM DIA 6-8 MM EPTFE TAPR STD WALL N,SUP-2396456,CDM,C1768,CPT,0278,RC,,,,both,,,1635.94,1063.36,,,,,,,,,,,,,
WASHER ORTHOPEDIC SPIKED ANKLE SCREW GRIDLOCK,SUP-2878529,CDM,C1713,HCPCS,0278,RC,,,,both,,,596.60,387.79,,,,,,,,,,,,,
GRAFT BNE CHIP FRZN CANC CORT 17MM 10MM RANG 30CC,SUP-2307404,CDM,C1713,HCPCS,0278,RC,,,,both,,,1609.66,1046.28,,,,,,,,,,,,,
GUIDEWIRE VASC ARISTOTLE ZOOM WIRE 14 L 200CM 0.014IN SUPP,SUP-2656741,CDM,C1769,HCPCS,0272,RC,,,,both,,,1742.70,1132.75,,,,,,,,,,,,,
SCREW BNE 4X20MM F ANK N LOK PART THRD MAXLOCK EXTRM,SUP-2400213,CDM,C1713,HCPCS,0278,RC,,,,both,,,841.52,546.99,,,,,,,,,,,,,
WASHER ORTH LCK 2.7 MM BNE THRD LIP SOCKET SS STRL SURFIX,SUP-2852097,CDM,C1713,HCPCS,0278,RC,,,,both,,,456.96,297.02,,,,,,,,,,,,,
PLATE BNE 2 H SPRING NS PRO,SUP-2902477,CDM,C1713,HCPCS,0278,RC,,,,both,,,1120.51,728.33,,,,,,,,,,,,,
PLATE BNE L PREBENT TI 11 H 10MM ADV 17MM LE FORT I FOR,SUP-2366355,CDM,C1713,HCPCS,0278,RC,,,,both,,,1132.22,735.94,,,,,,,,,,,,,
ALLOGRAFT BNE DBM + CORTICAL 10 CC FD,SUP-2717770,CDM,C1713,HCPCS,0278,RC,,,,both,,,4944.62,3214.00,,,,,,,,,,,,,
IMPLANT MENIS L13MM DIA1.1MM PROPRIETARY SELF REINF,SUP-2166737,CDM,C1776,CPT,0278,RC,,,,both,,,1621.31,1053.85,,,,,,,,,,,,,
SET INTRO REMINGTON L 13 CM DIA11 FR GUIDEWIRE 0.038 IN NDL,SUP-2137984,CDM,C1894,HCPCS,0272,RC,,,,both,,,94.20,61.23,,,,,,,,,,,,,
BRACE ORTHOPEDIC IMMOB KNEE CUST,SUP-2265015,CDM,L1810,HCPCS,0274,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
GRAFT BNE H10MM IL CREST WDG PRESERVON MATRIGRFT,SUP-2264839,CDM,C1713,HCPCS,0278,RC,,,,both,,,1746.81,1135.43,,,,,,,,,,,,,
R-T DEL II FEM NAIL 8X32,SUP-2818077,CDM,C1713,HCPCS,0278,RC,,,,both,,,5177.86,3365.61,,,,,,,,,,,,,
HC Screening Breast Tomo,PX-4037706300,CDM,77063,CPT,0403,RC,,,,outpatient,,,110.00,71.50,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.429,SUP-2859993,CDM,C1713,HCPCS,0278,RC,,,,both,,,37928.69,24653.65,,,,,,,,,,,,,
GRAFT VASC HEMSHLD PLAT L 15 CM DIA20 MM POLYESTER BOV CLLGN,SUP-2227695,CDM,C1768,CPT,0278,RC,,,,both,,,1446.03,939.92,,,,,,,,,,,,,
PLATE BONE FUSION 3.5X79 MM RIGHT ANKLE HINDFOOT 3 HOLE UTIL,SUP-2837550,CDM,C1713,HCPCS,0278,RC,,,,both,,,7340.38,4771.25,,,,,,,,,,,,,
SODIUM BICARBONATE 8.4 % IV SOLN,RX-7309,CDM,2500000003,HCPCS,0250,RC,51754-5001-01,NDC,,both,25,ML,54.10,35.16,,,,,,,,,,,,,
SCREW BNE L 14 MM DIA2 MM TI CANN HD NS LEOS,SUP-2932604,CDM,C1713,HCPCS,0278,RC,,,,both,,,729.61,474.25,,,,,,,,,,,,,
KIT INTRO ARW THMS L 4 IN DIA 8.5 FR 0.035 IN SIDEPRT,SUP-2120576,CDM,C1894,HCPCS,0272,RC,,,,both,,,96.90,62.98,,,,,,,,,,,,,
TRAY APPL BRACHYTHERAPY SAVI 6-1,SUP-2164401,CDM,C1728,HCPCS,0278,RC,,,,both,,,8635.00,5612.75,,,,,,,,,,,,,
AGENT VISCOELASTIC 8.5ML CLR POLYDIMETHYLSILOXANE RETIN,SUP-2109825,CDM,C1814,HCPCS,0278,RC,,,,both,,,1488.93,967.80,,,,,,,,,,,,,
BIT DRILL 7 MM FOR COMPRESSION SCREW TRIGEN INTERTAN,SUP-2837135,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1273.14,827.54,,,,,,,,,,,,,
LEAD PACE OSCOR SIL INSUL MYOCARDIAL RT ATRIOVENTRICULAR,SUP-2356431,CDM,C1898,HCPCS,0275,RC,,,,both,,,1522.90,989.88,,,,,,,,,,,,,
HC Drug Screen Quantitative Tacrolimus,PX-3018019700,CDM,80197,CPT,0301,RC,,,,both,,,232.00,150.80,,,,,,,,,,,,,
PIN BTTRS L16MM DIA1.8MM DST RAD TAN T8 STARDRV RECESS VAR,SUP-2181135,CDM,C1713,HCPCS,0278,RC,,,,both,,,418.31,271.90,,,,,,,,,,,,,
INSERT TIB SZ 3 THK15MM KNEE GVF ROT PLATFRM PFC SIG TC3,SUP-2253756,CDM,C1776,CPT,0278,RC,,,,both,,,6600.28,4290.18,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 70 CM DIA 4 MM EPTFE STR TW N RING,SUP-2396331,CDM,C1768,CPT,0278,RC,,,,both,,,3287.58,2136.93,,,,,,,,,,,,,
LEAD PACE FINELINE II STEROX L 52 CM DIA 7 FR SIL STEROID,SUP-2148662,CDM,C1898,HCPCS,0275,RC,,,,both,,,1190.06,773.54,,,,,,,,,,,,,
GUIDEWIRE ORTHOPEDIC 0.054X6 IN,SUP-2107895,CDM,C1769,HCPCS,0272,RC,,,,both,,,47.10,30.61,,,,,,,,,,,,,
GRAFT BIO TISS OMEGA3 MARIGEN 3X7CM,SUP-2261685,CDM,Q4158,HCPCS,0636,RC,,,,both,,,3661.24,2379.81,,,,,,,,,,,,,
ALLOGRAFT HUM TISS GRACILIS TEND 5X230 MM FRZN GRAFTLINK,SUP-2264761,CDM,C1762,CPT,0278,RC,,,,both,,,3586.67,2331.34,,,,,,,,,,,,,
TRAY CATH MIDLN POWERGLIDE PRO BASIC 22GA 8CM WNG 1 F122087T,SUP-2632746,CDM,C1751,HCPCS,0278,RC,,,,both,,,213.52,138.79,,,,,,,,,,,,,
GRAFT VASC GORTX L 80 CM DIA 8 MM RNG L 70 CM EPTFE STR TW,SUP-2396171,CDM,C1768,CPT,0278,RC,,,,both,,,4637.78,3014.56,,,,,,,,,,,,,
REMIFENTANIL HCL 2 MG IV SOLR,RX-18400,CDM,2500000003,HCPCS,0250,RC,72078-0035-02,NDC,,both,1,UN,774.70,503.55,,,,,,,,,,,,,
CATHETER MULTPURP DRN J TIP 8FRX25CM STIFF CANN W/ TRCR,SUP-2141067,CDM,C1729,HCPCS,0272,RC,,,,both,,,216.66,140.83,,,,,,,,,,,,,
PIN FIX L40MM DIA2.7MM DRL GUID PROV FOR PLATING SYS,SUP-2343966,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1717.83,1116.59,,,,,,,,,,,,,
PLATE BNE 7 H R LAPIDUS TI LO PROF MAL FOR 35MM SCR CONTOURS,SUP-2316435,CDM,C1713,HCPCS,0278,RC,,,,both,,,4372.01,2841.81,,,,,,,,,,,,,
MARKER IDENTIFIER BX SITE MRI,SUP-2382011,CDM,A4648,CPT,0278,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
NAIL ELASTIC SS 4.0MM 440MM,SUP-2547602,CDM,C1713,HCPCS,0278,RC,,,,both,,,1016.73,660.87,,,,,,,,,,,,,
SET INTRO SUP ARW FLX SHTH L 80 CM DIA 7 FR HYDRPHLC,SUP-2383410,CDM,C1894,HCPCS,0272,RC,,,,both,,,122.46,79.60,,,,,,,,,,,,,
HC Insj Non-Tunneled Central Venous Cath Age 5 Yr/>,PX-7613655600,CDM,36556,CPT,0761,RC,,,,both,,,9955.00,6470.75,,,,,,,,,,,,,
SCREW BNE L50MM DIA5MM CORT TI ST DBL LD THRD FOR PHOENIX,SUP-2412128,CDM,C1713,HCPCS,0278,RC,,,,both,,,734.76,477.59,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 50 CM DIA 7 MM EPTFE STR TW,SUP-2525469,CDM,C1768,CPT,0278,RC,,,,both,,,2116.33,1375.61,,,,,,,,,,,,,
REAMER SURG DIA 7.5 MM CANN SFT TISS FIX FOR TENODESIS SYS,SUP-2908584,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1921.68,1249.09,,,,,,,,,,,,,
ALLOGRAFT BNE DBM 5 CC VESUVIUS 4104K5005DP,SUP-2717994,CDM,C1713,HCPCS,0278,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
WASHER COUNTSINK BICONCAVE RND,SUP-2364320,CDM,C1713,HCPCS,0278,RC,,,,both,,,592.30,384.99,,,,,,,,,,,,,
CARTRIDGE TPE DIA3.1MM W/ ASAHI PLSMFLO PLSM SEP,SUP-2312277,CDM,2720000010,LOCAL,0272,RC,,,,both,,,968.16,629.30,,,,,,,,,,,,,
SCREW STRM MDS 2.4X14MM RS ST,SUP-2653985,CDM,C1713,HCPCS,0278,RC,,,,both,,,561.28,364.83,,,,,,,,,,,,,
STENT BILI PGTL 2.3 MM AD 7 FRX50 MM ETHYLENE VLY ACETT,SUP-2421727,CDM,C1876,HCPCS,0278,RC,,,,both,,,182.40,118.56,,,,,,,,,,,,,
PROXIMAL LAT TIB PLATE LEFT 8 HOLE,SUP-2829401,CDM,C1713,HCPCS,0278,RC,,,,both,,,7520.30,4888.19,,,,,,,,,,,,,
CATHETER REPROC EP 4 FR 15-25 MM LASSO,SUP-2471903,CDM,C1730,HCPCS,0272,RC,,,,both,,,3070.45,1995.79,,,,,,,,,,,,,
PLATE BNE MAXILLOFCL 2 MESH KT NS FACE ID,SUP-2909543,CDM,C1713,HCPCS,0278,RC,,,,both,,,37171.35,24161.38,,,,,,,,,,,,,
OXYCODONE HCL 5 MG PO TABS,RX-10814,CDM,6370000000,HCPCS,0637,RC,42858-0001-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PLATE BNE SM W11XL129MM THK3.3MM 0DEG 10 H BILAT TI STR,SUP-2190784,CDM,C1713,HCPCS,0278,RC,,,,both,,,654.88,425.67,,,,,,,,,,,,,
WAND ABLAT FOR TNSLCTMY ADENOIDECTOMY COBLATION PROCISE MAX,SUP-2342050,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1178.88,766.27,,,,,,,,,,,,,
DILATOR SET HEG UTER DBL END CANVS RL,SUP-2850403,CDM,2720000010,LOCAL,0272,RC,,,,both,,,370.99,241.14,,,,,,,,,,,,,
SET URET STENT POLARIS ULTRA L 28 CM DIA 5 FR PERCFLX,SUP-2139168,CDM,C2617,HCPCS,0278,RC,,,,both,,,481.93,313.25,,,,,,,,,,,,,
GRAFT TISS FRZN ALLGRFT SHFT TIB STRUCTURAL 50MM LEN,SUP-2307364,CDM,C1713,HCPCS,0278,RC,,,,both,,,2275.46,1479.05,,,,,,,,,,,,,
"HC RBC Antigen Typing,Genotyping 12 Blood Group System Genes",PX-3100282066,CDM,0282U,CPT,0310,RC,,,,inpatient,,,830.00,539.50,,,,,,,,,,,,,
ALLOGRAFT BNE 100 MM FEM SHFT STRL BIO LF DISP,SUP-2632313,CDM,C1762,CPT,0278,RC,,,,both,,,3441.44,2236.94,,,,,,,,,,,,,
KIT CATH CTRL VEN AD L16CM DIA12FR BLU FLX TIP POLYUR,SUP-2120592,CDM,C1751,HCPCS,0278,RC,,,,both,,,277.70,180.50,,,,,,,,,,,,,
GUIDEWIRE VASC L 40 CM 0.018 IN L 5 CM SS MANDREL PLAT COIL,SUP-2823947,CDM,C1769,HCPCS,0272,RC,,,,both,,,110.15,71.60,,,,,,,,,,,,,
MARKER RAD L7MM DIA4MM NIT COIL SUPERLOCK,SUP-2381758,CDM,A4648,CPT,0278,RC,,,,both,,,858.48,558.01,,,,,,,,,,,,,
STRAP CLAV XL PD W3XL4IN STD FOAM PD STOCKINET MTL TOOTH,SUP-2276603,CDM,L3650,HCPCS,0272,RC,,,,both,,,15.32,9.96,,,,,,,,,,,,,
FOOT PLATE EXT FIX DIA180 MM SHRT NS DISP MONK RING,SUP-2881110,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4999.67,3249.79,,,,,,,,,,,,,
PIN FIX L9IN DIA2MM ST S STL 2 SIDE SGL DMND 1 END PNT STYL,SUP-2150482,CDM,C1713,HCPCS,0278,RC,,,,both,,,13.53,8.79,,,,,,,,,,,,,
MESH BIO ALLOMAX 3INX6INMESH BIO ALLO,SUP-2849864,CDM,C1762,CPT,0278,RC,,,,both,,,8155.84,5301.30,,,,,,,,,,,,,
MESH SURG L 20 X W 15 CM POLYPRO POLYLACTIC ACD GRP,SUP-2901749,CDM,C1781,HCPCS,0278,RC,,,,both,,,2447.69,1591.00,,,,,,,,,,,,,
CATHETER CV FULL TY 7 FRX20 CM 3L CUTLMY701JABRMCUSTOM0020,SUP-2759954,CDM,C1751,HCPCS,0278,RC,,,,both,,,448.67,291.64,,,,,,,,,,,,,
HC Transesophageal Echo,PX-4839331200,CDM,93312,CPT,0483,RC,,,,outpatient,,,1699.00,1104.35,,,,,,,,,,,,,
NEEDLE BX MED CANULATED STRL CORB LF,SUP-2472088,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1272.99,827.44,,,,,,,,,,,,,
ROD SPNL L55MM DIA5.5MM POST TI PREBENT SMOOTH CRV CDH,SUP-2290663,CDM,C1713,HCPCS,0278,RC,,,,both,,,1691.99,1099.79,,,,,,,,,,,,,
SCREW BONE INTLOK CORT FULL THRD N CANN ST LCK NSTERILE 4.3,SUP-2204962,CDM,C1713,HCPCS,0278,RC,,,,both,,,524.91,341.19,,,,,,,,,,,,,
KIT INT FIX 12 MM BUSHING SET SCR STRL TIP-LOC,SUP-2912744,CDM,C1713,HCPCS,0278,RC,,,,both,,,3918.72,2547.17,,,,,,,,,,,,,
HC Cast - Long Leg,PX-4502934500,CDM,29345,CPT,0450,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
PAD ORTHOT SCOLIOSIS CUST TENS BASE FIT ADJ,SUP-2435569,CDM,L1005,HCPCS,0272,RC,,,,both,,,9061.47,5889.96,,,,,,,,,,,,,
STAPLE BONE FIXATION W22XH20XL22MM SUPERELASTIC ERGONOMIC LOW PROFILE BROAD BRIDGE DYNACLIP,SUP-2878406,CDM,C1713,HCPCS,0278,RC,,,,both,,,7991.30,5194.34,,,,,,,,,,,,,
VALVE PERICARD AORT HRT BIOPROSTHESIS PERIMT MAGNA SZ 21MM 300021MM] EDWARDS LIFESCIENCES CORP],SUP-2214091,CDM,C1713,HCPCS,0278,RC,,,,both,,,16799.00,10919.35,,,,,,,,,,,,,
DISSECTOR ULTRASONIC SONICISION 7 5MM 39CM CURVED JAW CORDLESS,SUP-2863658,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1281.12,832.73,,,,,,,,,,,,,
CHOLANGIOGRAM KIT RX AUTOTOME UTOM XL SPHINTOM JAGWIRE 7585,SUP-2525339,CDM,C1769,HCPCS,0272,RC,,,,both,,,844.66,549.03,,,,,,,,,,,,,
LENS IOL BCNVX 3+ DIOPT 6 MM POST CHMBR SIL SOFPORT,SUP-2418483,CDM,V2630,CPT,0276,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
SCREW SPNL MULTAXL 6.5X45 MM ESSENCE KT,SUP-2631914,CDM,C1713,HCPCS,0278,RC,,,,both,,,8102.77,5266.80,,,,,,,,,,,,,
KIT NRG RF TRANSSEPTAL,SUP-2739134,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3171.40,2061.41,,,,,,,,,,,,,
PLATE PERIARTICULAR PROX HUM 3.5MM 14H 307MM RT SS LCP STRL,SUP-2546058,CDM,C1713,HCPCS,0278,RC,,,,both,,,6158.17,4002.81,,,,,,,,,,,,,
STYLET PACE L65CM DEFL LOC +,SUP-2356064,CDM,C1713,HCPCS,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
GUIDEWIRE VASC STRUXURE L 60 CM DIA 0.032 IN NIT SS STAND,SUP-2613260,CDM,C1769,HCPCS,0272,RC,,,,both,,,121.99,79.29,,,,,,,,,,,,,
CATHETER URETH MEAS AMS,SUP-2140261,CDM,C1813,HCPCS,0278,RC,,,,both,,,12167.50,7908.87,,,,,,,,,,,,,
CLIP EXT FIX DYNAMIZATION FOR M COMB CLMP,SUP-2188523,CDM,2720000010,LOCAL,0272,RC,,,,both,,,338.90,220.28,,,,,,,,,,,,,
COLLAR BK SZ UNIV VISTA,SUP-2196895,CDM,L0120,HCPCS,0272,RC,,,,both,,,61.51,39.98,,,,,,,,,,,,,
SPACER SPNL W10XH7XL23MM 0DEG PEEK OPTMA INTERVERTEBRAL LUM,SUP-2211907,CDM,C1821,HCPCS,0278,RC,,,,both,,,7065.00,4592.25,,,,,,,,,,,,,
RESERVOIR VENT DRNGE 01ML BTM INLET CONN BA IMPREG CSF,SUP-2277901,CDM,2720000010,LOCAL,0272,RC,,,,both,,,894.62,581.50,,,,,,,,,,,,,
BINDER ABD UNIV H9IN WAIST 45-62IN E SFT COT PREM 3 PNL,SUP-2197075,CDM,L0450,HCPCS,0274,RC,,,,both,,,20.72,13.47,,,,,,,,,,,,,
BLADE RTRCTR 45MMW X 60MML TTNM LEFT SCRL PRNGX5 GREEN LMBRT,SUP-2460573,CDM,2720000010,LOCAL,0272,RC,,,,both,,,888.40,577.46,,,,,,,,,,,,,
AGENT HEMOSTATIC 3 ML SYNTH FOR MILD MOD BLEED STRL PURASTAT,SUP-2881769,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
URETEROSCOPE FLX 100 DEG FLD VW SHFT L 670 MM WORKING,SUP-2909499,CDM,C1747,HCPCS,0272,RC,,,,both,,,3689.50,2398.17,,,,,,,,,,,,,
PLATE BONE THK0.9MM OFFSET 0MM 10 H LT MAX ORAL,SUP-2191114,CDM,C1713,HCPCS,0278,RC,,,,both,,,1571.57,1021.52,,,,,,,,,,,,,
DEVICE ENDOSKELETAL SYS KNEE SHIN SINGLE AXIS MANUAL LCK,SUP-2388216,CDM,L5810,HCPCS,0272,RC,,,,both,,,1312.87,853.37,,,,,,,,,,,,,
GUIDEWIRE ORTH DIA0.034IN W/ TRCR TIP LSR MRK DISP FOR MIC,SUP-2122473,CDM,C1769,HCPCS,0272,RC,,,,both,,,69.08,44.90,,,,,,,,,,,,,
SCREW BNE CANN LNG THRD 4X38 MM,SUP-2194004,CDM,C1713,HCPCS,0278,RC,,,,both,,,577.19,375.17,,,,,,,,,,,,,
PLATE BONE L14MM S STL 5 H PHILOS PROX HUM PLT STRL F/3.5MM,SUP-2186014,CDM,C1713,HCPCS,0278,RC,,,,both,,,4360.39,2834.25,,,,,,,,,,,,,
SCREW BNE PART THRD 80 5 MM PANTA,SUP-2422233,CDM,C1713,HCPCS,0278,RC,,,,both,,,1770.52,1150.84,,,,,,,,,,,,,
COIL EMB L50CM OD0.020IN LOOP OD14MM STD NIT COMPLX FRME,SUP-2323379,CDM,C1889,HCPCS,0278,RC,,,,both,,,7366.44,4788.19,,,,,,,,,,,,,
ELECTRODE KIT RF 15 CM 3 PRB COOL TIP,SUP-2243995,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5495.00,3571.75,,,,,,,,,,,,,
ENDCAP SPNL L22MM 0DEG FUS VLIFT,SUP-2380360,CDM,C1713,HCPCS,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
PLATE BONE 8 HOLEXSHAPED STRNL CBL TRITIUM SCP,SUP-2335597,CDM,C1713,HCPCS,0278,RC,,,,both,,,2182.30,1418.49,,,,,,,,,,,,,
GUIDEWIRE VASC VASSALLO GT L 190 CM DIA 0.018 IN TIP LOAD 4,SUP-2909324,CDM,C1769,HCPCS,0272,RC,,,,both,,,61.58,40.03,,,,,,,,,,,,,
PATCH AMNION 2 LAYR PROTCT 4 X 4CM STERISHIELD II,SUP-2138664,CDM,C1762,CPT,0278,RC,,,,both,,,5950.30,3867.69,,,,,,,,,,,,,
GUIDEWIRE ORTH L400MM DIA3.1MM TRCR TIP DISP,SUP-2277483,CDM,C1769,HCPCS,0272,RC,,,,both,,,659.40,428.61,,,,,,,,,,,,,
WAND ABLAT DIA23MM ARTHSCP RF EFF END TIP W HND CTRL FOR,SUP-2256735,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1108.42,720.47,,,,,,,,,,,,,
INSERTER SUTURE WIRE FOR RC REP ARTHROTUNNELER,SUP-2908648,CDM,2720000010,LOCAL,0272,RC,,,,both,,,543.22,353.09,,,,,,,,,,,,,
CENTESIS CATH 5F 12CM PGTL FIXED LUER 20GA INTRDCR NDLE 4 HO,SUP-2481965,CDM,C1729,HCPCS,0272,RC,,,,both,,,119.32,77.56,,,,,,,,,,,,,
PLATE BNE L 40 MM RT TCP,SUP-2535869,CDM,C1713,HCPCS,0278,RC,,,,both,,,4006.64,2604.32,,,,,,,,,,,,,
MESH HERN W15XL25CM OPN TISS SEPARATING PHYSIOMESH,SUP-2219747,CDM,C1781,HCPCS,0278,RC,,,,both,,,5305.97,3448.88,,,,,,,,,,,,,
KIT CATH HEMODIALYSI DUOGLIDE ACUTE 13FR DIA 24CML I 5624240,SUP-2632913,CDM,C1752,HCPCS,0278,RC,,,,both,,,750.90,488.08,,,,,,,,,,,,,
TUBE VENT 1.02 MM 1 MM 2.44/2.16 MM PAPARELLA W/ TAB 510043C,SUP-2535085,CDM,L8699,HCPCS,0278,RC,,,,both,,,40.07,26.05,,,,,,,,,,,,,
CATHETER INTRAAORTIC BAL 8FR 30CC L25.3IN SHTH L6IN CTRL,SUP-2383457,CDM,C1713,HCPCS,0278,RC,,,,both,,,2474.32,1608.31,,,,,,,,,,,,,
BLOCK SIL RECTANG DUROMETER SFT 12.0 CMX7.0 CMX1.5 CM,SUP-2242095,CDM,C1713,HCPCS,0278,RC,,,,both,,,926.30,602.09,,,,,,,,,,,,,
SCREW BNE L16MM DIA2.7MM CORT DST FIBULAR TI ST,SUP-2413247,CDM,C1713,HCPCS,0278,RC,,,,both,,,126.48,82.21,,,,,,,,,,,,,
PLATE BNE THK1MM 20 H ORAL MAXILLOFACIAL MAND TI STR BILAT,SUP-2262952,CDM,C1713,HCPCS,0278,RC,,,,both,,,924.98,601.24,,,,,,,,,,,,,
SPLINT WRST FA R INSTABILITY INJ IMMOB LOOP LOK ABDUCTED,SUP-2276637,CDM,L3809,HCPCS,0274,RC,,,,both,,,22.17,14.41,,,,,,,,,,,,,
TUBE ET OD10.7MM ID8MM STD PVC DISP FOR EMG NIM TRIVANTANGE,SUP-2284334,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1139.66,740.78,,,,,,,,,,,,,
BUR SURG 9.1 MM ACORN FLUT DISECT TOOL LEGEND,SUP-2176903,CDM,2720000010,LOCAL,0272,RC,,,,both,,,339.12,220.43,,,,,,,,,,,,,
VALVE PUDENZ 12MM DIAM,SUP-2244291,CDM,C1729,HCPCS,0272,RC,,,,both,,,2140.54,1391.35,,,,,,,,,,,,,
FILTER VASC OPTEASE L 90 CM NIT CLOSED CAGE LP LNG SIDE,SUP-2157004,CDM,C1725,HCPCS,0272,RC,,,,both,,,5063.63,3291.36,,,,,,,,,,,,,
TRASTUZUMAB-HYALURONIDASE-OYSK 600-10000 MG-UNT/5ML SC SOLN,RX-145976,CDM,J9356,HCPCS,0636,RC,50242-0077-01,NDC,,both,5,ML,13464.70,8752.05,,,,,,,,,,,,,
BONE HOLDING FORCEPS-SOFT RATCHET F/PLATES TO 22MM WIDE,SUP-2548934,CDM,C1713,HCPCS,0278,RC,,,,both,,,2285.07,1485.30,,,,,,,,,,,,,
SHEATH INTRO PERFRMR L 40 CM DIA 7 FR GUIDEWIRE 0.035 IN,SUP-2168695,CDM,C1894,HCPCS,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
LENS IOL 21.5 DIOPT SIL BLU PMMA POST CHMBR BCNVX 3,SUP-2881362,CDM,V2787,HCPCS,0276,RC,,,,both,,,1.00,0.65,,,,,,,,,,,,,
ALLOGRAFT BNE DWL 9X30-35 MM PRESERVON XLNG CANC FLEXIGRAFT,SUP-2740990,CDM,C1762,CPT,0278,RC,,,,both,,,3783.32,2459.16,,,,,,,,,,,,,
NAIL IM L440MM DIA35MM OLECRANON LT BLU S STL E FLX,SUP-2186445,CDM,C1713,HCPCS,0278,RC,,,,both,,,947.18,615.67,,,,,,,,,,,,,
CATHETER DEL ACCS FOR CHOLANGIOPANCREATOSCOPY SPYSCOPE DS,SUP-2149617,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7693.00,5000.45,,,,,,,,,,,,,
SYSTEM TKR SZ 6-7 HNG LINK ASMBLY LEGION,SUP-2346314,CDM,C1776,CPT,0278,RC,,,,both,,,3347.24,2175.71,,,,,,,,,,,,,
CATHETER THROMCTMY LIGHTNING FLSH L 100 CM BER TIP S HTORQ,SUP-2865161,CDM,C1757,HCPCS,0272,RC,,,,both,,,31368.60,20389.59,,,,,,,,,,,,,
TEMPLATE SURG ROD 150 MM FLX,SUP-2864129,CDM,C1713,HCPCS,0278,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
CATHETER ETER HAD ADMIN SET STR 115FRX24CM TRI FLO,SUP-2269581,CDM,C1752,HCPCS,0278,RC,,,,both,,,184.00,119.60,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY L 110 CM DIA 6 FR SPC 10 MM LG 4,SUP-2526002,CDM,C1730,HCPCS,0272,RC,,,,both,,,517.38,336.30,,,,,,,,,,,,,
BIT DRL DIA3.5MM CALIB FOR PEDILOC PLT L FRAG SYS,SUP-2318880,CDM,2720000010,LOCAL,0272,RC,,,,both,,,944.83,614.14,,,,,,,,,,,,,
SOUND PROCESSOR KIT 2 BAHA 6 MAX,SUP-2858111,CDM,L8690,HCPCS,0278,RC,,,,both,,,19422.19,12624.42,,,,,,,,,,,,,
PLATE SPNL L35MM UNIV TI POST LUM PREBENT STD OFFSET BILAT,SUP-2293344,CDM,C1713,HCPCS,0278,RC,,,,both,,,4201.73,2731.12,,,,,,,,,,,,,
NEEDLE INTRO 10GA L9IN BVL TIP MTCH GRND W/O SYR N RADPQ ACM,SUP-2366867,CDM,C1713,HCPCS,0278,RC,,,,both,,,320.85,208.55,,,,,,,,,,,,,
CLIP MED L235CM L2.8MM 11MM OPN HEMSTAT FIX RESOL,SUP-2149433,CDM,C1889,HCPCS,0278,RC,,,,both,,,480.61,312.40,,,,,,,,,,,,,
SPACER DSTL AUG 10 MM REV VANGUARD,SUP-2446635,CDM,C1776,CPT,0278,RC,,,,both,,,226.08,146.95,,,,,,,,,,,,,
CONNECTOR TI DOM CL 45 CL 55,SUP-2279853,CDM,C1713,HCPCS,0278,RC,,,,both,,,2775.76,1804.24,,,,,,,,,,,,,
MESH SURG W4XL6IN OMEGA 3 FATTY ACIDS NAT BIORESORBABLE,SUP-2265964,CDM,C1781,HCPCS,0278,RC,,,,both,,,1061.32,689.86,,,,,,,,,,,,,
POLARUS 3 NAIL TARGETING LOCKING BOLT,SUP-2639742,CDM,C1713,HCPCS,0278,RC,,,,both,,,1613.96,1049.07,,,,,,,,,,,,,
HC Pt Therapeutic Activities 15 Min|OP OCCUPATIONAL THERAPY SERV|DOCUMENTATION ON FILE|SERVICES PROVIDED IN WHOLE OR IN PARTY BY AN OTA FOR MEDICARE PATIENTS|UNUSUAL NON-OVERLAPPING SERVICE,PX-4209753000,CDM,97530,CPT,0420,RC,,,GO|KX|CO|XU,both,,,144.00,93.60,,,,,,,,,,,,,
PLATE BNE MAXILLOFCL 4 MESH NS FACE ID,SUP-2909524,CDM,C1713,HCPCS,0278,RC,,,,both,,,34646.19,22520.02,,,,,,,,,,,,,
FIGHTER ACT STLTH,SUP-2253541,CDM,C1776,CPT,0278,RC,,,,both,,,4907.19,3189.67,,,,,,,,,,,,,
CABLE CERV FIX S STL STRL CINCH SEAT WIRE,SUP-2257004,CDM,C1769,HCPCS,0272,RC,,,,both,,,78.50,51.02,,,,,,,,,,,,,
COIL EMB L4CM DIA2.5MM EXTRA SFT 3D DETACH AXIUM PRIM,SUP-2295032,CDM,C1889,HCPCS,0278,RC,,,,both,,,5322.30,3459.49,,,,,,,,,,,,,
PLATE BNE L125MM 7 H ST L LAT DST FIBULAR S STL LOK COMPR,SUP-2177421,CDM,C1713,HCPCS,0278,RC,,,,both,,,1980.21,1287.14,,,,,,,,,,,,,
NEEDLE SUTURE L8.25IN SHARP LIGATURE FOR RIGHT HAND DESCHAMP,SUP-2802977,CDM,2720000010,LOCAL,0272,RC,,,,both,,,433.32,281.66,,,,,,,,,,,,,
INSERT HUM OD42MM THK+9MM A-12.5 SHLDR RETENTIVE REVERSED,SUP-2388719,CDM,C1776,CPT,0278,RC,,,,both,,,587.18,381.67,,,,,,,,,,,,,
CATHETER CV FULL SAFETY TY 8 FRX15 CM DL J TIP SPECTRUM,SUP-2759815,CDM,C1751,HCPCS,0278,RC,,,,both,,,431.31,280.35,,,,,,,,,,,,,
INSERT ACET OD62MM ID44MM HIP ULTAMET ARTC MOD STBL PINN,SUP-2250310,CDM,C1776,CPT,0278,RC,,,,both,,,9553.76,6209.94,,,,,,,,,,,,,
SHUNT CSF SHUNT SYSTEM WITH CONTROL RESERVOIR WITHOUT GRAVIT,SUP-2825821,CDM,C1889,HCPCS,0278,RC,,,,both,,,8478.47,5511.01,,,,,,,,,,,,,
TROCAR SURG DBL SL 5X150 MM ASMBLY,SUP-2517249,CDM,2720000010,LOCAL,0272,RC,,,,both,,,690.80,449.02,,,,,,,,,,,,,
PIN HOLDING HD SHT NXGN,SUP-2438146,CDM,C1713,HCPCS,0278,RC,,,,both,,,63.59,41.33,,,,,,,,,,,,,
SLING ORTH CHST CIRC 32-36IN SM BLK UNIV HUM CUF SHLDR SUPP,SUP-2324515,CDM,L3675,HCPCS,0272,RC,,,,both,,,79.47,51.66,,,,,,,,,,,,,
PARTICLE EMB BEAR NSPVA DIA 500-710 UM 100 MG PVA HYDRPHLC,SUP-2677312,CDM,C1889,HCPCS,0278,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
HANDLE LARYNSCP 3.5V STD FBROPT NT RECHRG NIMH LI ION BTTRY,SUP-2238186,CDM,2720000010,LOCAL,0272,RC,,,,both,,,913.74,593.93,,,,,,,,,,,,,
COMPONENT TIB CRUCE RET R PRI STEM CEM NP POLYETH ULT CONG,SUP-2209426,CDM,C1776,CPT,0278,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
INSERT TALAR SZ 1 THK15MM LT UHMWPE SALTO TALARIS,SUP-2244153,CDM,C1776,CPT,0278,RC,,,,both,,,8271.07,5376.20,,,,,,,,,,,,,
PLATE BNE CLAV STD 3.5X110 MM LT 10 HOLE SUP NS A.L.P.S,SUP-2471021,CDM,C1713,HCPCS,0278,RC,,,,both,,,4490.20,2918.63,,,,,,,,,,,,,
INSERT SNUS TARSI HYPERPRONATION FT HYPROCURE 8,SUP-2236087,CDM,C1776,CPT,0278,RC,,,,both,,,4961.20,3224.78,,,,,,,,,,,,,
GRAFT BNE PTTY 10 CC PREHYDRATED DBM TENSIX,SUP-2489190,CDM,C1713,HCPCS,0278,RC,,,,both,,,7479.48,4861.66,,,,,,,,,,,,,
ANCHOR SUTURE KNOTLESS 4.5 MM REELX STT,SUP-2362564,CDM,C1713,HCPCS,0278,RC,,,,both,,,1613.96,1049.07,,,,,,,,,,,,,
CATHETER EP DIAG MAP M CRV QPLR 2-5-2MM SPC 4MM TIP BI DIR,SUP-2356980,CDM,C1733,HCPCS,0272,RC,,,,both,,,2172.88,1412.37,,,,,,,,,,,,,
GRAFT BIO TISS OASIS WND MATRIX 3X7CM FEN,SUP-2341252,CDM,Q4102,HCPCS,0636,RC,,,,both,,,719.25,467.51,,,,,,,,,,,,,
PLATE BONE 6 H TI 3RD TBLR LCK,SUP-2419535,CDM,C1713,HCPCS,0278,RC,,,,both,,,753.60,489.84,,,,,,,,,,,,,
INSERT TIB BEAR 12MM UHMWPE FINN - 12MM,SUP-2406086,CDM,C1776,CPT,0278,RC,,,,both,,,2587.36,1681.78,,,,,,,,,,,,,
CARBON FIBER BAR 6MM X 300MM,SUP-2720795,CDM,2720000010,LOCAL,0272,RC,,,,both,,,776.21,504.54,,,,,,,,,,,,,
KIT INTRO L 10 CM DIA 5 FR 4 CM NIT SHFT SS TIP STD DIL MIC,SUP-2615881,CDM,C1894,HCPCS,0272,RC,,,,both,,,73.95,48.07,,,,,,,,,,,,,
KIT OLV WIRE M ADV W/ T15 SCRS DRVR PLATING DEPTH GA FOR,SUP-2225527,CDM,C1713,HCPCS,0278,RC,,,,both,,,499.89,324.93,,,,,,,,,,,,,
PLATE BNE X REG 1.5 MM MIDFACE TI,SUP-2754970,CDM,C1713,HCPCS,0278,RC,,,,both,,,678.24,440.86,,,,,,,,,,,,,
PLATE BONE MINI CVD,SUP-2418783,CDM,C1713,HCPCS,0278,RC,,,,both,,,1405.18,913.37,,,,,,,,,,,,,
CATHETER HD SHT TERM 11.5 FRX15 CM DL STYL HEMCATH DSL15IJ,SUP-2627304,CDM,C1752,HCPCS,0278,RC,,,,both,,,14.82,9.63,,,,,,,,,,,,,
PLATE BNE L 90 X W 10.7 MM THK 3.4 MM SCREW DIA 3.5 MM 7 H 72441007,SUP-2932757,CDM,C1713,HCPCS,0278,RC,,,,both,,,1105.78,718.76,,,,,,,,,,,,,
BUR SURG DIA2MM S STL DMND TAPR RND REUSE FOR ELITE SABER 582012320] STRYKER CORP],SUP-2364023,CDM,2720000010,LOCAL,0272,RC,,,,both,,,433.01,281.46,,,,,,,,,,,,,
HC So1 Factor XI,PX-3058527067,CDM,85270,CPT,0305,RC,,,,both,,,48.00,31.20,,,,,,,,,,,,,
PLATE BNE CRV 4.5X301 MM RT CNDYL 14 HOLE VA LCK NS VA-LCP,SUP-2758216,CDM,C1713,HCPCS,0278,RC,,,,both,,,6320.13,4108.08,,,,,,,,,,,,,
CATHETER THOR 28FR L20IN PVC STR RADPQ SENTNL LN TBNG W/,SUP-2154968,CDM,C1729,HCPCS,0272,RC,,,,both,,,25.50,16.57,,,,,,,,,,,,,
ROD EXTRNL FXTN LG TTNM MNDBLE MXLFCL PRE BENT,SUP-2679285,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2513.10,1633.51,,,,,,,,,,,,,
PLATE BONE L140MM THK1.4MM SHFT W7.5MM 20 H STRL FLX FOR,SUP-2349697,CDM,C1713,HCPCS,0278,RC,,,,both,,,4629.62,3009.25,,,,,,,,,,,,,
GRAFT HUM TISS 2X3CM AMNIOCORD,SUP-2305709,CDM,Q4187,HCPCS,0636,RC,,,,both,,,3752.30,2438.99,,,,,,,,,,,,,
HC NM Tumor Localization Mult,PX-3417880100,CDM,78801,CPT,0341,RC,,,,both,,,2681.00,1742.65,,,,,,,,,,,,,
PLATE BONE L25X10MM 100DEG 2X3 H RT CRANIOMAXILLOFACIAL TI L,SUP-2191280,CDM,C1713,HCPCS,0278,RC,,,,both,,,817.66,531.48,,,,,,,,,,,,,
SCREW CORTEX ST 2.4X50MM W/3.5MM HD,SUP-2547212,CDM,C1713,HCPCS,0278,RC,,,,both,,,171.66,111.58,,,,,,,,,,,,,
GRAFT BNE GRAN 5 CC VI RESRB CERM MASTERGRAFT,SUP-2743386,CDM,C1713,HCPCS,0278,RC,,,,both,,,1142.96,742.92,,,,,,,,,,,,,
TAP 5MM MOD CT XIA,SUP-2381176,CDM,C1713,HCPCS,0278,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
CONNECTOR ST 360 SLV 12-18MM,SUP-2205091,CDM,C1713,HCPCS,0278,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
PLATE BNE 2 H MED TI ALLOY STR LCK NS LEOS,SUP-2933601,CDM,C1713,HCPCS,0278,RC,,,,both,,,2934.33,1907.31,,,,,,,,,,,,,
STERILE DRILL BOLD DIA3 2IN1 L32MM AO NON CANULATED,SUP-2586517,CDM,2720000010,LOCAL,0272,RC,,,,both,,,743.40,483.21,,,,,,,,,,,,,
PLATE BNE L34MM 3 H BILAT S STL STR RECON NONLOCKING,SUP-2197668,CDM,C1713,HCPCS,0278,RC,,,,both,,,817.62,531.45,,,,,,,,,,,,,
MEMANTINE HCL 10 MG PO TABS,RX-36966,CDM,6370000000,HCPCS,0637,RC,00904-6506-61,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
SCREW BNE PEGGED 2.5X10 MM THRD MULTIDIRECTIONAL STRL LTX,SUP-2861105,CDM,C1713,HCPCS,0278,RC,,,,both,,,582.16,378.40,,,,,,,,,,,,,
PLATE BONE L171MM 6 H LT SHFT FOR BUTTRESSING MULTIFRAGMENT,SUP-2152509,CDM,C1713,HCPCS,0278,RC,,,,both,,,4155.19,2700.87,,,,,,,,,,,,,
REFILL KIT 4.5 CC NANO TECHNOLOGY ADH PRIM,SUP-2176752,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1033.06,671.49,,,,,,,,,,,,,
PLATE BNE L196MM 10 H NONSTERILE L MED DST TIB LOK FOR 35MM,SUP-2348485,CDM,C1713,HCPCS,0278,RC,,,,both,,,13127.40,8532.81,,,,,,,,,,,,,
SCREW BNE LCK 2.3X15 MM SELF RET TI STRL MAXDRIVE,SUP-2457286,CDM,C1713,HCPCS,0278,RC,,,,both,,,412.75,268.29,,,,,,,,,,,,,
COMPONENT HUM SM L6IN EL INTERCHANGEABLE LNG FLNG ASSEMB,SUP-2205924,CDM,C1776,CPT,0278,RC,,,,both,,,16145.19,10494.37,,,,,,,,,,,,,
PAD ORTHOT THOR CUST,SUP-2435576,CDM,L1060,HCPCS,0272,RC,,,,both,,,306.62,199.30,,,,,,,,,,,,,
ALLOGRAFT HUM TISS BIOFIX +,SUP-2225301,CDM,C1713,HCPCS,0278,RC,,,,both,,,6870.32,4465.71,,,,,,,,,,,,,
PROPRANOLOL HCL 60 MG PO TABS,RX-6659,CDM,6370000000,HCPCS,0637,RC,69238-2080-01,NDC,,both,1,UN,3.20,2.08,,,,,,,,,,,,,
SCREW 5.0MM TI RECON W T25 STARDRIVE 80MM STERILE,SUP-2546400,CDM,C1713,HCPCS,0278,RC,,,,both,,,609.76,396.34,,,,,,,,,,,,,
PLATE BNE W9XL61MM THK1MM 5 H TI 1/3 TBLR LIMIT CNTCT DYN,SUP-2190949,CDM,C1713,HCPCS,0278,RC,,,,both,,,506.14,328.99,,,,,,,,,,,,,
ALLOGRAFT HUM TISS ASEP PERONEUS LONGUS TEND,SUP-2867038,CDM,C1762,CPT,0278,RC,,,,both,,,4989.46,3243.15,,,,,,,,,,,,,
CONNECTOR SPNL ANCHR SHT CASPIAN,SUP-2517371,CDM,C1713,HCPCS,0278,RC,,,,both,,,4553.00,2959.45,,,,,,,,,,,,,
PACEMAKER CARD INGENIO TI SINGLE CHMBR 1 LD CONN BATTERY PWR,SUP-2149154,CDM,C1786,HCPCS,0275,RC,,,,both,,,13188.00,8572.20,,,,,,,,,,,,,
GUIDEWIRE ENDO L450CM DIA0.025IN STR,SUP-2141520,CDM,C1769,HCPCS,0272,RC,,,,both,,,720.94,468.61,,,,,,,,,,,,,
SUPPORT LUM VISTA 627,SUP-2123916,CDM,L0457,HCPCS,0272,RC,,,,both,,,331.27,215.33,,,,,,,,,,,,,
SCREW INTRF KT PROC IFIX DISP,SUP-2402617,CDM,C1713,HCPCS,0278,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
SCREW BNE TOT WR 2.7X12 MM SURFIX,SUP-2610346,CDM,C1713,HCPCS,0278,RC,,,,both,,,867.80,564.07,,,,,,,,,,,,,
EXPANDER TISS 3X5CM P3CM 36CC RECT SMOOTH INTEGRA,SUP-2328137,CDM,C1789,HCPCS,0278,RC,,,,both,,,2496.30,1622.59,,,,,,,,,,,,,
PATCH DURA SUB N BIO EPTFE STRL CRAN TUMOR TRAUM 4X4CM 0.3MM,SUP-2395376,CDM,C1713,HCPCS,0278,RC,,,,both,,,722.20,469.43,,,,,,,,,,,,,
HFN A/R SCREW 55MM STER,SUP-2588684,CDM,C1713,HCPCS,0278,RC,,,,both,,,747.79,486.06,,,,,,,,,,,,,
IMPLANT EL JT HD RAD TRANSFORMING EXTREMITIES ASCENSION MOD,SUP-2244259,CDM,C1776,CPT,0278,RC,,,,both,,,8421.48,5473.96,,,,,,,,,,,,,
GUIDE SURG ENDONASAL ACCS LG STRL SPIWAY LTX,SUP-2877808,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1786.66,1161.33,,,,,,,,,,,,,
SET SCR BRKOFF M10 REDUC,SUP-2293093,CDM,C1713,HCPCS,0278,RC,,,,both,,,552.64,359.22,,,,,,,,,,,,,
SCREW BONE L100MM D13MM 145DG CNCLLS HIP TTNM SELF TPPNG NNL,SUP-2482156,CDM,C1713,HCPCS,0278,RC,,,,both,,,1416.14,920.49,,,,,,,,,,,,,
CLIP SURG L155CM CHN DIA2.8MM OPN W11IN RESOL 360 10/BX,SUP-2676488,CDM,2720000010,LOCAL,0272,RC,,,,both,,,562.06,365.34,,,,,,,,,,,,,
COIL NEUROVASCULAR CASHMERE 14 L 25 CM LOOP DIA10 MM PRIMARY,SUP-2249276,CDM,C1889,HCPCS,0278,RC,,,,both,,,4172.75,2712.29,,,,,,,,,,,,,
PLATE BNE TIB 2.7/3.5X142 MM RT MEDL DSTL 6 HOLE VA LCK SS,SUP-2177634,CDM,C1713,HCPCS,0278,RC,,,,both,,,5306.03,3448.92,,,,,,,,,,,,,
BIT DRILL L320MM OD5MM CLBRTD ANKLE ARTHRDSS NAIL SSTM PHNX,SUP-2493318,CDM,2720000010,LOCAL,0272,RC,,,,both,,,414.48,269.41,,,,,,,,,,,,,
INTRODUCER KIT VASCULAR SPLIT SHEATH 8FR X 25CM,SUP-2424648,CDM,C1894,HCPCS,0272,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
ELECTRODE KNF 26-28FR WHT BRANCHES RED STEM COLLINS,SUP-2332861,CDM,C1713,HCPCS,0278,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
CATHETER SUPP NAVIEN L 115 CM OD 0.084 IN ID 0.072 IN DSTL 8,SUP-2522811,CDM,C1887,HCPCS,0272,RC,,,,both,,,3846.50,2500.22,,,,,,,,,,,,,
K WIRE FIX L450MM DIA16MM NIT BLNT TIP,SUP-2232215,CDM,C1713,HCPCS,0278,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
GENII CONST ART ISRT SZ7-8 9MM,SUP-2827846,CDM,C1776,CPT,0278,RC,,,,both,,,2292.20,1489.93,,,,,,,,,,,,,
MARKER SM18-1-20 MAGSEED-18G-20CM,SUP-2902928,CDM,A4648,CPT,0278,RC,,,,both,,,1419.28,922.53,,,,,,,,,,,,,
SCREW EXT SD 6X250 MM 80 MM THRD TI SCHNZ,SUP-2193176,CDM,C1713,HCPCS,0278,RC,,,,both,,,560.05,364.03,,,,,,,,,,,,,
CATHETER PERITONEAL L 39 CM PED TENCK CURL 1 CUF STRL ARGY,SUP-2905038,CDM,C1750,HCPCS,0278,RC,,,,both,,,262.19,170.42,,,,,,,,,,,,,
FRAME EXT FIX L160MM CIR ASSEMB SIDEKCK,SUP-2400708,CDM,2720000010,LOCAL,0272,RC,,,,both,,,13586.78,8831.41,,,,,,,,,,,,,
SOCK PROSTHETIC IA BODY,SUP-2388155,CDM,L0984,HCPCS,0272,RC,,,,both,,,166.80,108.42,,,,,,,,,,,,,
NAPHAZOLINE-PHENIRAMINE 0.025-0.3 % OP SOLN,RX-5384,CDM,6370000000,HCPCS,0637,RC,00065-0085-15,NDC,,both,15,ML,54.10,35.16,,,,,,,,,,,,,
DEXTROSE-SODIUM CHLORIDE 5-0.45 % IV SOLN,RX-15861,CDM,J3490,HCPCS,0250,RC,00338-0085-03,NDC,,both,500,ML,38.30,24.89,,,,,,,,,,,,,
SCREW BNE L32MM DIA2.7MM ST CORT S STL ST NONCANNULATED LOK,SUP-2177117,CDM,C1713,HCPCS,0278,RC,,,,both,,,630.20,409.63,,,,,,,,,,,,,
PLATE SPNL L60MM UNIV CERV ANT 4 LEV TI STD REFLX,SUP-2380879,CDM,C1713,HCPCS,0278,RC,,,,both,,,3359.80,2183.87,,,,,,,,,,,,,
FIBER LASER 270UM DISPOSABLE  HOLM,SUP-2436279,CDM,2720000010,LOCAL,0272,RC,,,,both,,,843.62,548.35,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP ACROBAT L 260 CM DIA 0.025 IN RADIOPAQUE,SUP-2170137,CDM,C1769,HCPCS,0272,RC,,,,both,,,558.92,363.30,,,,,,,,,,,,,
VEST PT HOLSTER SM 14 IN VENTRICULAR THORATEC HEARTMATE,SUP-2356007,CDM,Q0499,HCPCS,0274,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
DRILL SURG CALIB 3.5X130 MM STP,SUP-2766123,CDM,2720000010,LOCAL,0272,RC,,,,both,,,926.30,602.09,,,,,,,,,,,,,
GRAFT VASC FLX 7 MMX70 CM STD WALL N RING EPTFE CARBOFLO,SUP-2761481,CDM,C1768,CPT,0278,RC,,,,both,,,3416.92,2221.00,,,,,,,,,,,,,
HANDPIECE STEREOTACTIC 12GA L12CM BRST BX LNG GUID,SUP-2239996,CDM,2720000010,LOCAL,0272,RC,,,,both,,,791.91,514.74,,,,,,,,,,,,,
ARIPIPRAZOLE 2 MG PO TABS,RX-70306,CDM,6370000000,HCPCS,0637,RC,65162-0896-09,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
COMPONENT CRANIOFACIAL CUSTOMIZED LG PRIORITY + PEEK NS LTX,SUP-2862817,CDM,C1713,HCPCS,0278,RC,,,,both,,,59393.10,38605.51,,,,,,,,,,,,,
PATCH BIO W4XL6CM BOV PERICARDIUMXENOSURE,SUP-2264300,CDM,C1713,HCPCS,0278,RC,,,,both,,,1755.26,1140.92,,,,,,,,,,,,,
SUPPORT ORTHOT HND FNGR W/NONTORSION ELASTIC PREFABRICATED,SUP-2435787,CDM,L3930,HCPCS,0272,RC,,,,both,,,235.31,152.95,,,,,,,,,,,,,
GRAFT HUMAN TSSUE L12XW6CM RGNRTVE TSSUE MTRX THN READY USE,SUP-2491359,CDM,Q4116,HCPCS,0636,RC,,,,both,,,7963.04,5175.98,,,,,,,,,,,,,
SCREW BNE SELF RET MIC 1.5X5 MM MAND DRILL-FREE CENTRE-DRIVE,SUP-2496571,CDM,C1713,HCPCS,0278,RC,,,,both,,,185.54,120.60,,,,,,,,,,,,,
SCREW INTRF L12MM DIA8MM BIO-TENODESIS,SUP-2121452,CDM,C1713,HCPCS,0278,RC,,,,both,,,832.10,540.86,,,,,,,,,,,,,
GUIDEWIRE VASC L300CM DIA0.014IN TIP L8CM SCITANIUM,SUP-2145957,CDM,C1769,HCPCS,0272,RC,,,,both,,,461.58,300.03,,,,,,,,,,,,,
CATHETER CV KT 0.032 IN 16 GAX20 CM SINGLE LUMEN EXTN LN,SUP-2763360,CDM,C1751,HCPCS,0278,RC,,,,both,,,219.80,142.87,,,,,,,,,,,,,
POST ORTHOPEDIC 1 HOLE W/ 12MM BOLT TRUELOK,SUP-2316106,CDM,2720000010,LOCAL,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
BIT DRL DIA32MM FLX SHFT REUSE FOR OCCIPITAL CERV FUS SYS,SUP-2179054,CDM,2720000010,LOCAL,0272,RC,,,,both,,,690.80,449.02,,,,,,,,,,,,,
SLEEVE GASTRECTOMY CALIB SYS VISIGI 3D 40 FR,SUP-2138633,CDM,C1713,HCPCS,0278,RC,,,,both,,,961.41,624.92,,,,,,,,,,,,,
PROSTHESIS PENILE PMP M ASMBLY TITAN TCH,SUP-2847985,CDM,C1813,HCPCS,0278,RC,,,,both,,,18840.00,12246.00,,,,,,,,,,,,,
PLATE BONE LT DSTL RAD W,SUP-2136554,CDM,C1713,HCPCS,0278,RC,,,,both,,,619.21,402.49,,,,,,,,,,,,,
PLATE BNE L247MM 8 H NONSTERILE R PROX FEM S STL LO PROF,SUP-2186136,CDM,C1713,HCPCS,0278,RC,,,,both,,,4056.60,2636.79,,,,,,,,,,,,,
MATRIX PARTICULATE AMNIOBAND 40MG,SUP-2719485,CDM,Q4168,HCPCS,0636,RC,,,,both,,,3089.76,2008.34,,,,,,,,,,,,,
LABETALOL HCL 5 MG/ML IV SOLN,RX-10372,CDM,J1920,HCPCS,0636,RC,00409-2339-34,NDC,,both,1,ML,54.10,35.16,,,,,,,,,,,,,
BURR LNG MICRO ROUND DIAMOND 4MM STER,SUP-2586367,CDM,2720000010,LOCAL,0272,RC,,,,both,,,68.86,44.76,,,,,,,,,,,,,
HEAD FEM HIP UPLR CEM HI DEMAND KT,SUP-2347957,CDM,C1776,CPT,0278,RC,,,,both,,,6280.00,4082.00,,,,,,,,,,,,,
CATHETER ABLATN D-D 2-5-2 MM 2MM 7 FRX115 CM EZ STEER LF,SUP-2248510,CDM,C1732,HCPCS,0272,RC,,,,both,,,6066.48,3943.21,,,,,,,,,,,,,
CATHETER HEMO DYLS OR HD L20CM OD15FR ADMIN CHRONIC BASIC KT,SUP-2116554,CDM,C1750,HCPCS,0278,RC,,,,both,,,1698.74,1104.18,,,,,,,,,,,,,
PAIN PMP2 250 CC PMP W/ STD 2.5 IN AND 5.0 IN EXFEN,SUP-2363507,CDM,C1772,HCPCS,0278,RC,,,,both,,,769.30,500.04,,,,,,,,,,,,,
INTRODUCER TUBE SET 6 FR PERC SET CIAGLIA BLU RHINO SHILEY,SUP-2760031,CDM,C1769,HCPCS,0272,RC,,,,both,,,1206.14,783.99,,,,,,,,,,,,,
COLLAR CERV L18IN H3.25IN L TRACH OPN AD PHIL,SUP-2195258,CDM,L0180,HCPCS,0274,RC,,,,both,,,39.94,25.96,,,,,,,,,,,,,
PACK MTRX PORCINE L10 CMXW7 CM FEN STRL MATRISTEM,SUP-2106513,CDM,Q4166,HCPCS,0636,RC,,,,both,,,5505.05,3578.28,,,,,,,,,,,,,
COMPONENT FEM PS 3 UNISX LT KNEE PRIMARY CEM STEMLESS BASIC,SUP-2378090,CDM,C1776,CPT,0278,RC,,,,both,,,6215.32,4039.96,,,,,,,,,,,,,
INCOBOTULINUMTOXINA 100 UNITS IM SOLR,RX-106138,CDM,J0588,HCPCS,0636,RC,00259-1610-01,NDC,,both,1,UN,1507.50,979.87,,,,,,,,,,,,,
CATHETER ABLAT D-F CRV BIDIR TACTICATH CNTCT FORC SENS,SUP-2418133,CDM,C2630,CPT,0272,RC,,,,both,,,8478.00,5510.70,,,,,,,,,,,,,
KIT INTRO VAXCEL MINI-STICK SHTH 15 CM 5 FR SS PLAT TIP,SUP-2118968,CDM,C1894,HCPCS,0272,RC,,,,both,,,12.09,7.86,,,,,,,,,,,,,
PLATE BNE SCREW DIA 3.5 MM LG SS RT INTRAPELVIC ACET STD,SUP-2905560,CDM,C1713,HCPCS,0278,RC,,,,both,,,8684.89,5645.18,,,,,,,,,,,,,
RING EXT FIX 200 MM,SUP-2197267,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3673.80,2387.97,,,,,,,,,,,,,
COMPONENT GLEN 52 MM SHLDR W/ 56 MM ARTC SURF TRABECULAR MTL,SUP-2436900,CDM,C1776,CPT,0278,RC,,,,both,,,5024.00,3265.60,,,,,,,,,,,,,
WIRE BRST LOC L35CM NDL L14CM OD20GA BEAD BARB GHIATAS,SUP-2126438,CDM,C1819,HCPCS,0278,RC,,,,both,,,97.03,63.07,,,,,,,,,,,,,
BRACE ORTH CRUC RIGID TLSO PLAS,SUP-2388141,CDM,L0472,HCPCS,0274,RC,,,,both,,,997.58,648.43,,,,,,,,,,,,,
GRAFT ALLGRFT TEND PAT PRE SHP MACHINED FRZN 10MM MAXXEUS,SUP-2165608,CDM,C1713,HCPCS,0278,RC,,,,both,,,9313.24,6053.61,,,,,,,,,,,,,
MONOPOLAR STIMULATING PRB STRL SGL USE ONLY,SUP-2354657,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
ANCHOR SUT DIA6.5MM TWINFIX ULT PK W/ SUT WHT BLU,SUP-2341844,CDM,C1713,HCPCS,0278,RC,,,,both,,,846.17,550.01,,,,,,,,,,,,,
COMPONENT FEM SZ 0 LT CO CHROM NP REV CONSTRN N-K II,SUP-2209859,CDM,C1776,CPT,0278,RC,,,,both,,,16943.44,11013.24,,,,,,,,,,,,,
GRAFT VASC STD WALL 5 MMX50 CM STR RNG REINF ADVANTA VXT,SUP-2473849,CDM,C1768,CPT,0278,RC,,,,both,,,1297.35,843.28,,,,,,,,,,,,,
PIN FIX DIAMOND PT 2 END 3/32 X9 IN 4 PT STYL SMOOTH PLN,SUP-2150492,CDM,C1713,HCPCS,0278,RC,,,,both,,,12.78,8.31,,,,,,,,,,,,,
SCREW BONE L28MM OD6.3MM VIT CORT NONLOCKING BOSWORTH,SUP-2364658,CDM,C1713,HCPCS,0278,RC,,,,both,,,755.33,490.96,,,,,,,,,,,,,
PLATE CRAN SZ 3 PEEK SYN HRD TISS W/ SKULL MOD,SUP-2194241,CDM,C1713,HCPCS,0278,RC,,,,both,,,29912.58,19443.18,,,,,,,,,,,,,
OLECRANON PLATE LT 21HOLE 194MM,SUP-2587101,CDM,C1713,HCPCS,0278,RC,,,,both,,,3580.10,2327.06,,,,,,,,,,,,,
BRACE LS M 15DEG BK HK RECV MAT SFT BRTH LNR RIG TAPR PLAS,SUP-2195545,CDM,L0625,HCPCS,0272,RC,,,,both,,,948.28,616.38,,,,,,,,,,,,,
PLATE BONE L45MM THK1.6MM 14DEG 7 H LT 1ST,SUP-2137079,CDM,C1713,HCPCS,0278,RC,,,,both,,,1890.15,1228.60,,,,,,,,,,,,,
NEEDLE 20GAX5CM BREAST MAMMO,SUP-2120042,CDM,C1819,HCPCS,0278,RC,,,,both,,,109.90,71.43,,,,,,,,,,,,,
SUPPORT ORTHOT FNGR CUST ADJ W/O JT FABRICATED SFT INTFACE,SUP-2435789,CDM,L3933,HCPCS,0272,RC,,,,both,,,549.78,357.36,,,,,,,,,,,,,
BUR SURG DIA1 MM HUB II ROSEN STRL DISP HI-LINE XS,SUP-2928849,CDM,2720000010,LOCAL,0272,RC,,,,both,,,315.76,205.24,,,,,,,,,,,,,
COMPONENT PAT SZ 35MM POLYETH RND RESURF RESTORIS MCK,SUP-2368534,CDM,C1776,CPT,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
GLUCAGON EMERGENCY 1 MG/ML IJ SOLR,RX-148605,CDM,J1611,HCPCS,0636,RC,63323-0582-82,NDC,,both,1,UN,1608.90,1045.78,,,,,,,,,,,,,
GRAFT ALLGRFT TEND PAT BISECTED FRZN,SUP-2165587,CDM,C1713,HCPCS,0278,RC,,,,both,,,6710.18,4361.62,,,,,,,,,,,,,
MESH SURG W15XL20CM OPTIMIZED COMP SKIRTED PARIETEX,SUP-2174718,CDM,C1781,HCPCS,0278,RC,,,,both,,,3985.45,2590.54,,,,,,,,,,,,,
PLATE BNE MAXILLOFCL 5 MESH NS FACE ID,SUP-2909575,CDM,C1713,HCPCS,0278,RC,,,,both,,,36913.87,23994.02,,,,,,,,,,,,,
GRAFT BNE 3D 30 CC CORTICAL FIBER,SUP-2125433,CDM,C1713,HCPCS,0278,RC,,,,both,,,8478.00,5510.70,,,,,,,,,,,,,
WIRE FIXATION W1.25XL150MM THREADED DISPOSABLE KIRSCHNER 6PK,SUP-2472096,CDM,2720000010,LOCAL,0272,RC,,,,both,,,417.27,271.23,,,,,,,,,,,,,
PROSTHESIS VOICE OD16FR SIL DUCKBILL BLOM SINGER,SUP-2242309,CDM,L8509,HCPCS,0274,RC,,,,both,,,127.17,82.66,,,,,,,,,,,,,
PLATE BNE L27MM THK1.2MM 0DEG 4 H BILAT S STL STR RIG LIMIT,SUP-2186167,CDM,C1713,HCPCS,0278,RC,,,,both,,,969.38,630.10,,,,,,,,,,,,,
MICROCATHETER GUID CANTATA L 135 CM OD 2.8 FR ID 0.025 IN,SUP-2171038,CDM,C1887,HCPCS,0272,RC,,,,both,,,910.60,591.89,,,,,,,,,,,,,
DEVICE OCCL CLP L50MM LNG HD ARTC THMB CTRL MAL SHFT FOR,SUP-2124456,CDM,C1889,HCPCS,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
PRECISION CONNECTOR M1 55 CM,SUP-2679262,CDM,C1883,HCPCS,0278,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
PROBE SURG L400MM OD4MM,SUP-2261218,CDM,2720000010,LOCAL,0272,RC,,,,both,,,433.82,281.98,,,,,,,,,,,,,
BRACE QXXLG,SUP-2174973,CDM,L1820,HCPCS,0274,RC,,,,both,,,160.14,104.09,,,,,,,,,,,,,
SCREW BNE L28MM DIA6.5MM SHLDR CNTR FOR RSA REUNION,SUP-2373751,CDM,C1713,HCPCS,0278,RC,,,,both,,,501.14,325.74,,,,,,,,,,,,,
PLATE BNE LCK 94 MM LT DSTL LAT TIB PERIARTICULAR 6 HOLE,SUP-2468662,CDM,C1713,HCPCS,0278,RC,,,,both,,,4263.99,2771.59,,,,,,,,,,,,,
PLATE BONE 4.5MM OFFSET SHLDR REPLICATOR EQUINOXE,SUP-2223289,CDM,C1713,HCPCS,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
NAIL IM ARTH 13X540 MM RT T2,SUP-2458403,CDM,C1713,HCPCS,0278,RC,,,,both,,,14907.15,9689.65,,,,,,,,,,,,,
ALLOGRAFT BNE STRP 15X20X6 MM FD SPNG CANC READIGRAFT BLX,SUP-2741073,CDM,C1713,HCPCS,0278,RC,,,,both,,,2627.30,1707.74,,,,,,,,,,,,,
PLATE LCK NAVICULAR 2.4/2.7MM SS STRL,SUP-2546014,CDM,C1713,HCPCS,0278,RC,,,,both,,,2578.10,1675.76,,,,,,,,,,,,,
BREAST LESION LOC WIRE SET GHIATAS BEAD SILK MAMM GLAND 19,SUP-2242571,CDM,C1819,HCPCS,0278,RC,,,,both,,,226.08,146.95,,,,,,,,,,,,,
GRAFT BNE SUB 10CC CA SULF HA INJ BIPHASIC OSTEOCONDUCTIVE,SUP-2402599,CDM,C1713,HCPCS,0278,RC,,,,both,,,9796.80,6367.92,,,,,,,,,,,,,
COMPONENT HUM FLNG 3.5X84 MM LT SHLDR BOND COAT MOSAIC STRL,SUP-2215485,CDM,C1776,CPT,0278,RC,,,,both,,,11451.58,7443.53,,,,,,,,,,,,,
NAIL IM L160MM DIA11MM NONSTERILE AQUA L/R DST FEM TI LOK,SUP-2191738,CDM,C1713,HCPCS,0278,RC,,,,both,,,5147.62,3345.95,,,,,,,,,,,,,
PLATE BONE L90MM THK0.6MM 20 H CRANIOMAXILLOFACIAL TI STR LO,SUP-2191136,CDM,C1713,HCPCS,0278,RC,,,,both,,,1019.24,662.51,,,,,,,,,,,,,
SET INFUS PRT L75CM OD66FR ID13MM STD POLYUR CATHETER TI DEV,SUP-2118802,CDM,C1788,HCPCS,0278,RC,,,,both,,,951.42,618.42,,,,,,,,,,,,,
SPLINT ORTHOPEDIC NT LG 10.5 IN RT HND FOREARM COLLES PADDED,SUP-2306271,CDM,L3906,HCPCS,0272,RC,,,,both,,,26.69,17.35,,,,,,,,,,,,,
PLATE BNE L 113 MM SCREW DIA 4.5 MM 6 H SS NAR COMPR NLCK,SUP-2933360,CDM,C1713,HCPCS,0278,RC,,,,both,,,1634.94,1062.71,,,,,,,,,,,,,
PLATE BNE L79MM 2 H NONSTERILE POST MED PROX TIB S STL LOK,SUP-2177792,CDM,C1713,HCPCS,0278,RC,,,,both,,,3073.90,1998.03,,,,,,,,,,,,,
SET INT FIX SCREW DIA1.5 MM 6 H LNG TI NEURO SQ XDRV 12 PK,SUP-2935338,CDM,C1713,HCPCS,0278,RC,,,,both,,,24027.28,15617.73,,,,,,,,,,,,,
STEM HUM UNIV STD L122MM DIA8MM SHLDR CO CHROM PRI CEM,SUP-2404590,CDM,C1776,CPT,0278,RC,,,,both,,,12368.46,8039.50,,,,,,,,,,,,,
HC So RBC Pretx Incubatj W/Chemicl,PX-3008697266,CDM,86972,CPT,0300,RC,,,,both,,,494.00,321.10,,,,,,,,,,,,,
GRAFT DERMAL FEN 2X2 CM CLLGN TISS MTRX,SUP-2243690,CDM,Q4110,HCPCS,0636,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
KIT SHUNT HYDROCEPHALUS VLV REG PS MED STRATA NSC,SUP-2284512,CDM,C1889,HCPCS,0278,RC,,,,both,,,11921.14,7748.74,,,,,,,,,,,,,
GRAFT BNE SUB W20XL15MM TRICORT ILIUM CREST BLK FRZ DRY,SUP-2293831,CDM,C1713,HCPCS,0278,RC,,,,both,,,3158.84,2053.25,,,,,,,,,,,,,
ROD SPNL 5.5X510MM RT POST TI SMOOTH STR HRD,SUP-2137260,CDM,C1713,HCPCS,0278,RC,,,,both,,,807.11,524.62,,,,,,,,,,,,,
CATHETER DIAG L135CM SHFT DIA0.026X0.039IN SPC L15MM TIP,SUP-2353124,CDM,C1887,HCPCS,0272,RC,,,,both,,,2935.90,1908.33,,,,,,,,,,,,,
CATHETER ANGIOPLSTY L140CM BAL L100MM DIA10MM 7ATM COR FIX,SUP-2140452,CDM,C1725,HCPCS,0272,RC,,,,both,,,656.26,426.57,,,,,,,,,,,,,
HC MRI-Spine Cervical W Contrast,PX-6127214200,CDM,72142,CPT,0612,RC,,,,outpatient,,,4190.00,2723.50,,,,,,,,,,,,,
ANCHOR SUT DIA4.5MM BIOCRYL RAPIDE ABSRB 2 PERMACORD SZ 2,SUP-2256701,CDM,C1713,HCPCS,0278,RC,,,,both,,,1535.46,998.05,,,,,,,,,,,,,
ANCHOR SUT DIA1.3MM W/ 3-0 ETHBND V-4 NDL DRL BIT MIC,SUP-2249369,CDM,C1713,HCPCS,0278,RC,,,,both,,,929.44,604.14,,,,,,,,,,,,,
CATHETER IVUS VISIONS PV .018 L 135 CM COAT L 31 CM OUTER,SUP-2327231,CDM,C1753,HCPCS,0278,RC,,,,both,,,2417.80,1571.57,,,,,,,,,,,,,
DRESSING GEL F/REAGENT COMBO BIODYNAMIC HEMATOGEL THERAPY AURIX,SUP-2878091,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
GUIDEWIRE FIX 3MMX100CM IM SMOOTH TIP ZMS,SUP-2410277,CDM,C1769,HCPCS,0272,RC,,,,both,,,165.60,107.64,,,,,,,,,,,,,
GRAFT HUMAN TISSUE THICK 12X6 CM HYDRATED BIOLOGIC TISSUE MA,SUP-2838608,CDM,C1763,HCPCS,0278,RC,,,,both,,,6681.92,4343.25,,,,,,,,,,,,,
BACID PO TABS,RX-82506,CDM,6370000000,HCPCS,0637,RC,64980-0164-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
SCREW BNE 9 MM CANN STRL GAITWAY,SUP-2487986,CDM,C1713,HCPCS,0278,RC,,,,both,,,9404.30,6112.79,,,,,,,,,,,,,
PROSTHESIS OSS STAP 4.5 MM 0.5 MM ECLIPSE FLAT RIBBON NIT,SUP-2466541,CDM,L8613,CPT,0278,RC,,,,both,,,1051.27,683.33,,,,,,,,,,,,,
PLATE BNE 5DEG L MT GRFT SPANNING GORILLA,SUP-2321462,CDM,C1713,HCPCS,0278,RC,,,,both,,,6363.21,4136.09,,,,,,,,,,,,,
CATHETER CV KT 8 FRX20 CM DL PRESSURE INJ J ARROWG+ARD BLU,SUP-2763333,CDM,C1751,HCPCS,0278,RC,,,,both,,,324.05,210.63,,,,,,,,,,,,,
CATHETER HD KT 12 FRX25 CM DL STR SFT TIP PRE CRV HI VOL,SUP-2762991,CDM,C1752,HCPCS,0278,RC,,,,both,,,402.55,261.66,,,,,,,,,,,,,
ANCHOR SUT DIA1.4MM SGL LD SFT JUGGERKNOT,SUP-2212948,CDM,C1713,HCPCS,0278,RC,,,,both,,,1076.14,699.49,,,,,,,,,,,,,
KIT MICROINTRODUCER 4FR ECHOGENIC NDL L7CM 21GA STIFF COAX,SUP-2118822,CDM,C1894,HCPCS,0272,RC,,,,both,,,71.91,46.74,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 50 CM DIA 6 MM STR TW REINF,SUP-2525449,CDM,C1768,CPT,0278,RC,,,,both,,,952.02,618.81,,,,,,,,,,,,,
CATHETER INTVASC ULTRASOUND ULTRA ICE + L 110 CM DIA 8.5 FR,SUP-2140873,CDM,C1753,HCPCS,0278,RC,,,,both,,,5809.00,3775.85,,,,,,,,,,,,,
BUR SURG DR LNG 8X14 MM FLUT SLIDE CUT QD14-S/QD14-G1/QD14,SUP-2848150,CDM,2720000010,LOCAL,0272,RC,,,,both,,,420.57,273.37,,,,,,,,,,,,,
PUMP MS 700 LGX PRECONNECT,SUP-2139020,CDM,C1813,HCPCS,0278,RC,,,,both,,,26523.58,17240.33,,,,,,,,,,,,,
FIXED MODIFIED HALL REAMER 10.0MM,SUP-2823792,CDM,C1713,HCPCS,0278,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
HEAD HUM H18XL35MM DIA48MM STD SHLDR TI HA STEM PRESSFIT,SUP-2399859,CDM,C1776,CPT,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
CATHETER CTRL VEN PED 4FR L8CM 0.021IN DBL LUMN,SUP-2383319,CDM,C1751,HCPCS,0278,RC,,,,both,,,227.96,148.17,,,,,,,,,,,,,
HEMOSTAT ENDOSCP CATHETER 7FR L220CM ACC CHN 28MM FOR,SUP-2171165,CDM,C1052,HCPCS,0278,RC,,,,both,,,7222.00,4694.30,,,,,,,,,,,,,
PLATE BNE T LG 1.5X27X1 MM MIDFACE 8 HOLE W/ TAB TI STRL,SUP-2518115,CDM,C1713,HCPCS,0278,RC,,,,both,,,823.31,535.15,,,,,,,,,,,,,
HC MRI-Spine Cervical W Contrast,PX-6127214200,CDM,72142,CPT,0612,RC,,,,inpatient,,,4190.00,2723.50,,,,,,,,,,,,,
GRAFT BNE PTTY 5 CC BIOACTIVE MTRX STRL BONESYNC LTX,SUP-2859806,CDM,C1713,HCPCS,0278,RC,,,,both,,,2371.01,1541.16,,,,,,,,,,,,,
BUNDLE CASE ORTHOGNATHIC POSTOP VSP POSTOPORTHOG,SUP-2862821,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7657.02,4977.06,,,,,,,,,,,,,
BOLT EXT FIX 2 MM MP SALVATION,SUP-2851285,CDM,2720000010,LOCAL,0272,RC,,,,both,,,825.82,536.78,,,,,,,,,,,,,
SPACER SPNL W8XH7-14XL26MM THORACOLUM TI SELF EXP LUM INTBDY,SUP-2230599,CDM,C1821,HCPCS,0278,RC,,,,both,,,12560.00,8164.00,,,,,,,,,,,,,
LEAD PACE BPLR 40 CM 100 CM TRNSVEN TEMP ACTIVE FIX DISP,SUP-2282229,CDM,C1713,HCPCS,0278,RC,,,,both,,,483.56,314.31,,,,,,,,,,,,,
DEVICE NEUROSTIMULATOR PK MOD 30580134 FOR NEUROSTIM SYS,SUP-2278061,CDM,C1820,HCPCS,0278,RC,,,,both,,,35011.00,22757.15,,,,,,,,,,,,,
TRUSS OSTEOTMY W20MM D16MM THK8MM UOTS IMPL,SUP-2101182,CDM,C1713,HCPCS,0278,RC,,,,both,,,9922.40,6449.56,,,,,,,,,,,,,
RING RETRCT SM/M SHTH L14CM INCIS RANG 2.5-8CM RIG ORTH,SUP-2119767,CDM,2720000010,LOCAL,0272,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
PLATE FOOT LK H PLT SM,SUP-2701550,CDM,C1713,HCPCS,0278,RC,,,,both,,,1989.50,1293.17,,,,,,,,,,,,,
GRAFT VASC GORTX L 80 CM DIA 8 MM RNG L 20 CM EPTFE STR TW,SUP-2396166,CDM,C1768,CPT,0278,RC,,,,both,,,3212.22,2087.94,,,,,,,,,,,,,
CONNECTOR SPNL DIA5.5X5.5MM PARA ROD TOP LD FOR DEFORMITY,SUP-2316092,CDM,C1713,HCPCS,0278,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
GRAFT BNE BLOCK 6.25X2X0.4 CM 10 CC PLATFORM CM,SUP-2691581,CDM,C1713,HCPCS,0278,RC,,,,both,,,6232.90,4051.38,,,,,,,,,,,,,
GRAFT BONE L10XW2.5CM DEMIN BONE MTRX MAGNIFUSE II,SUP-2279579,CDM,C1713,HCPCS,0278,RC,,,,both,,,15646.62,10170.30,,,,,,,,,,,,,
INTRODUCER SHTH 0.032 IN LAMP 90 8 FRX81 CM 8 FRX85 CM CRV,SUP-2357229,CDM,C1893,HCPCS,0272,RC,,,,both,,,690.80,449.02,,,,,,,,,,,,,
ALLOGRAFT CELLULAR ALLOFUSE SELECT  CM 5CC,SUP-2653972,CDM,C1713,HCPCS,0278,RC,,,,both,,,9184.50,5969.92,,,,,,,,,,,,,
GAUGE DEPTH 4MM CANN COUNTSINK,SUP-2319583,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2879.38,1871.60,,,,,,,,,,,,,
COMPONENT ARTC SURF 12 MM KNEE NXGN LEG,SUP-2402783,CDM,C1776,CPT,0278,RC,,,,both,,,6382.99,4148.94,,,,,,,,,,,,,
TUBE CJ TT ORIG W/ 15MM ADPT SZ 6,SUP-2384437,CDM,C1713,HCPCS,0278,RC,,,,both,,,430.18,279.62,,,,,,,,,,,,,
COMPONENT TIB TY SZ 3 STD POLYETH R ANK NONCOATED PRI,SUP-2397115,CDM,C1776,CPT,0278,RC,,,,both,,,3771.14,2451.24,,,,,,,,,,,,,
PLATE BNE L 299 MM SCREW DIA 4.5 MM 18 H BOW COMPR LCK NS,SUP-2933225,CDM,C1713,HCPCS,0278,RC,,,,both,,,5120.56,3328.36,,,,,,,,,,,,,
SCREW BNE HDLSS 7.2X50 MM CALCANEUS HINDFOOT NAIL NS PHANTOM,SUP-2749660,CDM,C1713,HCPCS,0278,RC,,,,both,,,2995.56,1947.11,,,,,,,,,,,,,
COMPONENT ARTC 6X6MM OFFSET L35MM FEM HD CO CHROM ALLOY,SUP-2123646,CDM,C1776,CPT,0278,RC,,,,both,,,19939.00,12960.35,,,,,,,,,,,,,
STENT PERIPH SMRT RADIANZ L 60 MM DIA 7 MM DEL SYS L 190 CM,SUP-2866202,CDM,C1725,HCPCS,0272,RC,,,,both,,,3730.07,2424.55,,,,,,,,,,,,,
GRAFT VASC 6MMX50CM ACUSEAL,SUP-2395745,CDM,C1768,CPT,0278,RC,,,,both,,,4914.10,3194.16,,,,,,,,,,,,,
DRILL TWST L40MM DIA16MM 5MM STP CRANIOMAXILLOFACIAL S STL,SUP-2263017,CDM,2720000010,LOCAL,0272,RC,,,,both,,,559.14,363.44,,,,,,,,,,,,,
MEDROXYPROGESTERONE ACETATE 10 MG PO TABS,RX-4854,CDM,6370000000,HCPCS,0637,RC,00555-0779-02,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PLATE BNE L255MM 16 H BILAT S STL STR NONCOMPRESSION RECON,SUP-2410187,CDM,C1713,HCPCS,0278,RC,,,,both,,,1562.78,1015.81,,,,,,,,,,,,,
HC CT Facial Bones W/WO Contrast,PX-3517048800,CDM,70488,CPT,0351,RC,,,,both,,,2630.00,1709.50,,,,,,,,,,,,,
GUIDE SURG FOR 2.3MM ICONIX TY,SUP-2366691,CDM,C1713,HCPCS,0278,RC,,,,both,,,1566.86,1018.46,,,,,,,,,,,,,
KIT CVC 66FR FOR SGL LUMN CATHETER BRVC,SUP-2126560,CDM,C1894,HCPCS,0272,RC,,,,both,,,621.72,404.12,,,,,,,,,,,,,
SYSTEM INTRO ACUSTK II SS WIRE W/O GUIDEWIRE RADIOPAQUE,SUP-2147742,CDM,C1894,HCPCS,0272,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
NEEDLE SHRP STR 3 MMX23 CM DEL TAPR SHFT,SUP-2775073,CDM,2720000010,LOCAL,0272,RC,,,,both,,,486.13,315.98,,,,,,,,,,,,,
SCREW SET BRK OFF STRL CD HORZ MODULEX 559200009,SUP-2849987,CDM,C1713,HCPCS,0278,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
CATHETER ANGIOPLSTY OTW 5 FRX100 MM POLARCATH,SUP-2141984,CDM,C1725,HCPCS,0272,RC,,,,both,,,3278.16,2130.80,,,,,,,,,,,,,
GRAFT VASC HEMSHLD GLD L 40CM 12X7MM POLYESTER BOV BIFURCATE,SUP-2266067,CDM,C1768,CPT,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
MESH SPNL COLOSSEUM CVD 14MMX16MMX28MM,SUP-2417951,CDM,C1889,HCPCS,0278,RC,,,,both,,,12874.00,8368.10,,,,,,,,,,,,,
PIN EXT FIX L80X20MM FOR RX-FX MINI RAIL FIX,SUP-2396846,CDM,2720000010,LOCAL,0272,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
VINCRISTINE SULFATE 1 MG/ML IV SOLN,RX-8597,CDM,J9370,HCPCS,0636,RC,61703-0309-06,NDC,,both,2,ML,102.30,66.49,,,,,,,,,,,,,
HC Pt Adl Training 15mn,PX-4209753500,CDM,97535,CPT,0420,RC,,,,inpatient,,,174.00,113.10,,,,,,,,,,,,,
GRAFT DERMAL PLIABLE THN 16X8 CMX0.7-1.4 MM FLEXHD,SUP-2307562,CDM,Q4128,HCPCS,0636,RC,,,,both,,,11937.50,7759.37,,,,,,,,,,,,,
TROCAR ENDOSCP L 150 MM DIA11 MM LNG OPT FIX CANN DOLPHIN,SUP-2896238,CDM,2720000010,LOCAL,0272,RC,,,,both,,,474.80,308.62,,,,,,,,,,,,,
SPHINCTEROTOME ENDOSCP 7/25 MM 6 FRX195 CM PUL TYP,SUP-2481238,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1633.59,1061.83,,,,,,,,,,,,,
KIT BIOSURGE W/ 2.5CC ALLOSYNC PURE,SUP-2665302,CDM,C1713,HCPCS,0278,RC,,,,both,,,3956.40,2571.66,,,,,,,,,,,,,
PLATE BONE W12XL167MM THK1MM 10 H BILAT S STL SEMI TBLR LO,SUP-2184871,CDM,C1713,HCPCS,0278,RC,,,,both,,,873.74,567.93,,,,,,,,,,,,,
WIRE BRST LOC 2 BARB 19 GAX7 CM 20 CM CHESBROUGH,SUP-2759082,CDM,C1819,HCPCS,0278,RC,,,,both,,,70.05,45.53,,,,,,,,,,,,,
PLATE BNE L207MM 13 H NONSTERILE L POSTEROLATERAL DST,SUP-2177404,CDM,C1713,HCPCS,0278,RC,,,,both,,,1858.85,1208.25,,,,,,,,,,,,,
PLATE CRAN 140X60X40 MM PT SPEC IMPL PEEK,SUP-2860134,CDM,C1713,HCPCS,0278,RC,,,,both,,,33119.46,21527.65,,,,,,,,,,,,,
ALLOGRAFT BNE CHIP 1-9 MM 50 CC FD CANC,SUP-2717763,CDM,C1713,HCPCS,0278,RC,,,,both,,,1699.31,1104.55,,,,,,,,,,,,,
PLATE BNE 4 H STR FOR SM BNES ORTHOLOC 3DI,SUP-2398060,CDM,C1713,HCPCS,0278,RC,,,,both,,,1654.78,1075.61,,,,,,,,,,,,,
PLATE BNE MESHED 52X31X1 MM SM GRID PDLLA RESORB X STRL,SUP-2478483,CDM,C1713,HCPCS,0278,RC,,,,both,,,2215.30,1439.94,,,,,,,,,,,,,
SHEATH URO 11/13FR L36CM URETRAL NAVIGATOR ACCS,SUP-2139216,CDM,C1894,HCPCS,0272,RC,,,,both,,,383.74,249.43,,,,,,,,,,,,,
PAD CLLR CERV UNIV AD REPL,SUP-2124221,CDM,L0172,HCPCS,0274,RC,,,,both,,,31.78,20.66,,,,,,,,,,,,,
STEM EXTN 10MMX80MM NMC,SUP-2222908,CDM,C1776,CPT,0278,RC,,,,both,,,3589.02,2332.86,,,,,,,,,,,,,
PLATE BNE W9XL93MM THK1MM 8 H TI 1/3 TBLR W/ CLLR LOK COMPR,SUP-2190954,CDM,C1713,HCPCS,0278,RC,,,,both,,,537.22,349.19,,,,,,,,,,,,,
PLATE BNE STR NEURO 8 HOLE ULTRA LO PROF W/ TAB TI LEVEL 1,SUP-2525643,CDM,C1713,HCPCS,0278,RC,,,,both,,,706.31,459.10,,,,,,,,,,,,,
DRILL TWST L72MM DIA1.2MM STP 10MM FOR 1.2MM LAG SCR DENT,SUP-2267817,CDM,C1713,HCPCS,0278,RC,,,,both,,,378.34,245.92,,,,,,,,,,,,,
STAPLE CARTRIDGE STR 13X10 MM TI,SUP-2166804,CDM,C1713,HCPCS,0278,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
PLATE BONE L87MM THK3.8MM 11 H BILAT S STL NAR DYN COMPR FOR,SUP-2185212,CDM,C1713,HCPCS,0278,RC,,,,both,,,696.61,452.80,,,,,,,,,,,,,
SET PICC L 1 3/4 IN DIA22 GA SHTH L 1 1/4 IN DIA 3 FR,SUP-2887112,CDM,C1769,HCPCS,0272,RC,,,,both,,,66.57,43.27,,,,,,,,,,,,,
IMPLANT SZ 1 LMH IMPL SYS,SUP-2398601,CDM,C1776,CPT,0278,RC,,,,both,,,10362.00,6735.30,,,,,,,,,,,,,
NAIL IM L400MM DIA13MM NONSTERILE GRN TIB TI CANN LCK,SUP-2192874,CDM,C1713,HCPCS,0278,RC,,,,both,,,4107.87,2670.12,,,,,,,,,,,,,
GRAFT HUM TISS W3XL3.5CM AMNIO MEMBRN TRNSLUC GRID PAT SGL,SUP-2113886,CDM,Q4154,HCPCS,0636,RC,,,,both,,,5191.36,3374.38,,,,,,,,,,,,,
BASKET STONE REMV L115CM OPN W10MM CHN SZ 1.2MM 3 NAIL DISP,SUP-2313150,CDM,2720000010,LOCAL,0272,RC,,,,both,,,751.72,488.62,,,,,,,,,,,,,
BEAM FIX 5.5X145 MM AXIS,SUP-2610010,CDM,C1713,HCPCS,0278,RC,,,,both,,,4050.60,2632.89,,,,,,,,,,,,,
PLATE BNE L137MM 10 H NONSTERILE L PROX TIB S STL LO PROF,SUP-2185816,CDM,C1713,HCPCS,0278,RC,,,,both,,,3806.25,2474.06,,,,,,,,,,,,,
GRAFT BNE PTTY 7.5 GM BIOACTIVE OSTEOFUSE,SUP-2225964,CDM,C9359,HCPCS,0278,RC,,,,both,,,6683.49,4344.27,,,,,,,,,,,,,
CAGE SPNL W20XH16XL26MM TI ANT THORLUM INTBDY FUS OVL TAPR,SUP-2291589,CDM,C1889,HCPCS,0278,RC,,,,both,,,7457.50,4847.37,,,,,,,,,,,,,
CATHETER CV MAXIMAL BARR TY 025 5 FRX12 CM 3L STRL,SUP-2759915,CDM,C1751,HCPCS,0278,RC,,,,both,,,459.13,298.43,,,,,,,,,,,,,
URETEROSCOPE FLX 105 DEG L 70 CM SHTH OD 9FR 6PC/BX,SUP-2889752,CDM,C1747,HCPCS,0272,RC,,,,both,,,18369.00,11939.85,,,,,,,,,,,,,
DEVICE ENDOSKELETAL SYS PROSTHETIC BK INNR SOCKET CUSH LNR,SUP-2388210,CDM,L5679,HCPCS,0274,RC,,,,both,,,1538.82,1000.23,,,,,,,,,,,,,
PACEMAKER CARD ALTRUA 60 W 42 X H 42 MM THK 8 MM 23.4 GM,SUP-2149277,CDM,C1786,HCPCS,0275,RC,,,,both,,,9655.50,6276.07,,,,,,,,,,,,,
MESH SYNTH STRP SCAFFOLD TEND LIGMNT REP ABSRB RECT,SUP-2388578,CDM,C1781,HCPCS,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
ORTHOPAEDIC KIT HIP PART HD LNR CERAMAX,SUP-2254033,CDM,C1776,CPT,0278,RC,,,,both,,,6908.00,4490.20,,,,,,,,,,,,,
PROSTHESIS PENILE CYLINDER/PUMP 16 CM,SUP-2165358,CDM,C1813,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
HC Postural Drainage Sub,PX-4109466800,CDM,94668,CPT,0410,RC,,,,inpatient,,,109.00,70.85,,,,,,,,,,,,,
STENT GRFT VASC AFX COCR STRATA IL INFRARENAL SELF EXPND,SUP-2217644,CDM,C1768,CPT,0278,RC,,,,both,,,34398.70,22359.15,,,,,,,,,,,,,
SLEEVE FEM +0MM OFFSET MOD 12/14 TAPR REDAPT,SUP-2350889,CDM,C1776,CPT,0278,RC,,,,both,,,832.10,540.86,,,,,,,,,,,,,
CANNULA PERF ART 6 FRX9 IN 3/16 IN THN VENTED GRY HUB DLP,SUP-2494940,CDM,2720000010,LOCAL,0272,RC,,,,both,,,288.16,187.30,,,,,,,,,,,,,
HC Mra Pelvis W&W/O Contrast,PX-6100892000,CDM,C8920,HCPCS,0610,RC,,,,both,,,4893.00,3180.45,,,,,,,,,,,,,
HC Clsd Tx Patella Disloc WO,PX-4502756000,CDM,27560,CPT,0450,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
SCREW BONE L75MM DIA5MM IM LCK FOR FEM NAIL RECON RICHARDS,SUP-2342531,CDM,C1713,HCPCS,0278,RC,,,,both,,,222.34,144.52,,,,,,,,,,,,,
STENT PERIPH L80MM DIA6MM DEL SYS L125CM SHTH 6FR 0.035IN,SUP-2170398,CDM,C1874,HCPCS,0278,RC,,,,both,,,5636.30,3663.59,,,,,,,,,,,,,
PLATE B1 THK1.8MM 4 H STRNL THOR CP TI STR LCK LEV 1 FOR,SUP-2262579,CDM,C1713,HCPCS,0278,RC,,,,both,,,1648.50,1071.52,,,,,,,,,,,,,
STEM HUM DIA8MM SHLDR CO CHROM NP COMPHSVE,SUP-2403968,CDM,C1776,CPT,0278,RC,,,,both,,,7187.46,4671.85,,,,,,,,,,,,,
CATHETER CV SET 032 10 FRX15 CM 10 GA 5 LUMEN QUINT SPECTRUM,SUP-2759731,CDM,C1751,HCPCS,0278,RC,,,,both,,,420.32,273.21,,,,,,,,,,,,,
COMPONENT ARTC SURF TIB 3-4 EF 12 MM KNEE STRP YEL NXGN LPS,SUP-2208732,CDM,C1776,CPT,0278,RC,,,,both,,,3504.24,2277.76,,,,,,,,,,,,,
HC Glb Auto Cryo Pbpc Infusion,PX-9823824100,CDM,38241,CPT,0982,RC,,,,both,,,1849.00,1201.85,,,,,,,,,,,,,
ANCHOR NONSUTURE 10MM FIXATION MENISCAL BIOSTINGER,SUP-2828681,CDM,C1713,HCPCS,0278,RC,,,,both,,,331.46,215.45,,,,,,,,,,,,,
SET VASC ACCS PEELWY L 15.5 CM INTRO L 20 CM DIA12 FR,SUP-2168019,CDM,C1892,HCPCS,0272,RC,,,,both,,,127.80,83.07,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY L 115 CM DIA 6 FR SPC 2-8-2 MM,SUP-2894348,CDM,C1730,HCPCS,0272,RC,,,,both,,,615.31,399.95,,,,,,,,,,,,,
PLATE BNE RT ANTR TI AXSOS 3,SUP-2550579,CDM,C1713,HCPCS,0278,RC,,,,both,,,12246.00,7959.90,,,,,,,,,,,,,
GRAFT VASC GORTX L 10 CM DIA 6 MM RNG L 10 CM EPTFE STR STD,SUP-2396091,CDM,C1768,CPT,0278,RC,,,,both,,,684.52,444.94,,,,,,,,,,,,,
METOPROLOL TARTRATE 25 MG PO TABS,RX-37637,CDM,6370000000,HCPCS,0637,RC,65862-0062-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
STAPLE BONE FIX 1.5X1.5MM A11 B8 C8 WIRE OSSTPL,SUP-2190914,CDM,C1713,HCPCS,0278,RC,,,,both,,,2496.30,1622.59,,,,,,,,,,,,,
CONNECTOR SPNL TOP LD 5.5X5.5 MM SIDE BY SIDE SFS,SUP-2582942,CDM,C1713,HCPCS,0278,RC,,,,both,,,2813.44,1828.74,,,,,,,,,,,,,
PLATE BNE M CALCNL MESH VARIAX,SUP-2371664,CDM,C1713,HCPCS,0278,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
STEM HUM 9.5X125MM MOD II,SUP-2408649,CDM,C1776,CPT,0278,RC,,,,both,,,8176.56,5314.76,,,,,,,,,,,,,
VALVE HEMOSTAS MBA DIA 9 FR POLYCARB SIL Y LG BOR STRL,SUP-2303050,CDM,C1713,HCPCS,0278,RC,,,,both,,,68.26,44.37,,,,,,,,,,,,,
HC So Glucose,PX-3018294766,CDM,82947,CPT,0301,RC,,,,both,,,38.00,24.70,,,,,,,,,,,,,
BIT DRL L100MM DIA2MM 3 FLUT QUIK CPL FOR OSC DRL ATTCH,SUP-2187578,CDM,2720000010,LOCAL,0272,RC,,,,both,,,306.34,199.12,,,,,,,,,,,,,
BAND ORTHODONTIC M SZ 31 LO MAND S STL SEAMLESS CHAIRSIDE,SUP-2176640,CDM,D6783,CPT,0278,RC,,,,both,,,23.08,15.00,,,,,,,,,,,,,
SET URET STENT MARD L 26 CM DIA 6 FR PERCFLX HYDROPLUS,SUP-2141632,CDM,C2617,HCPCS,0278,RC,,,,both,,,313.22,203.59,,,,,,,,,,,,,
FORCEPS SURG AOS PERIMODIOLAR ELECTRD,SUP-2165056,CDM,C1713,HCPCS,0278,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
SODIUM CHLORIDE FLUSH 0.9 % IV SOLN,RX-102477,CDM,2500000003,HCPCS,0250,RC,08290-3065-46,NDC,,both,10,ML,54.10,35.16,,,,,,,,,,,,,
OLMESARTAN MEDOXOMIL 5 MG PO TABS,RX-32761,CDM,6370000000,HCPCS,0637,RC,68462-0436-30,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
IMPLANT OTO L4.5MM HD DIA1.6MM INCUS HA DBL NOTCH WEHRS,SUP-2312815,CDM,L8613,CPT,0278,RC,,,,both,,,1165.98,757.89,,,,,,,,,,,,,
ILLUMINATOR BLDE MINIMALLY INVASIVE SURG W/ INFORMATIONAL,SUP-2232231,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2920.20,1898.13,,,,,,,,,,,,,
KIT ORTH 15X300MMX130 RT R2.0 LEGION,SUP-2370028,CDM,C1713,HCPCS,0278,RC,,,,both,,,6097.25,3963.21,,,,,,,,,,,,,
COIL NEUROVASCULAR DELTAMAXX CERECYTE L 55 CM DIA18 MM,SUP-2462153,CDM,C1889,HCPCS,0278,RC,,,,both,,,9163.90,5956.53,,,,,,,,,,,,,
PLATE BNE W5XL41MM THK1.5MM 7 H TI METATARSAL FOREFOOT,SUP-2398012,CDM,C1713,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
CATHETER GUID MOD CBL PERIPH VASC COR W/O HYDRPHLC COAT AD,SUP-2157939,CDM,C1887,HCPCS,0272,RC,,,,both,,,173.64,112.87,,,,,,,,,,,,,
NIVOLUMAB 120 MG/12ML IV SOLN,RX-155930,CDM,J9299,HCPCS,0636,RC,00003-3756-14,NDC,,both,12,ML,11438.10,7434.76,,,,,,,,,,,,,
DRESSING WND BIO FISH SKIN FENESTRATED 3CM X 7CM RSFH ONLY,SUP-2859690,CDM,Q4158,HCPCS,0636,RC,,,,both,,,3951.38,2568.40,,,,,,,,,,,,,
ANCHOR SUT L14MM OD3MM TWO 2-0 TIGERTAIL IMP BIO-SUTTAK,SUP-2121593,CDM,C1713,HCPCS,0278,RC,,,,both,,,879.20,571.48,,,,,,,,,,,,,
GENERATOR PLSE W502XH668MM 135MM SPNL CRD MRI COMPATIBLE,SUP-2101982,CDM,C1767,HCPCS,0278,RC,,,,both,,,45530.00,29594.50,,,,,,,,,,,,,
BUR SURG DIAMOND LNG 3.2 MM COARSE MATCHSTICK QD14-S/QD14-G1,SUP-2848155,CDM,2720000010,LOCAL,0272,RC,,,,both,,,381.01,247.66,,,,,,,,,,,,,
TROCAR SURG TARGETING LNG 5 MM FOR M/DN IM NAIL,SUP-2478334,CDM,2720000010,LOCAL,0272,RC,,,,both,,,351.90,228.73,,,,,,,,,,,,,
BOLT EXT FIX SLT WIRE MR CONDITIONAL FOR DISTR OSTEOGENESIS,SUP-2187901,CDM,C1713,HCPCS,0278,RC,,,,both,,,145.04,94.28,,,,,,,,,,,,,
IMPLANT ANK FUS W18MM D18MM THK8MM COT WDG FOR OSTEOTMY,SUP-2101116,CDM,C1713,HCPCS,0278,RC,,,,both,,,11088.75,7207.69,,,,,,,,,,,,,
PLATE BNE L 208 MM SCREW DIA 4.5 MM 12 H NAR COMPR LCK STRL,SUP-2933076,CDM,C1713,HCPCS,0278,RC,,,,both,,,2219.20,1442.48,,,,,,,,,,,,,
ALLOGRAFT BNE 10X10X20 MM BIOEXPAND,SUP-2637003,CDM,C1713,HCPCS,0278,RC,,,,both,,,3999.54,2599.70,,,,,,,,,,,,,
ALLOGRAFT HUM TISS FRZN IRRADIATED PAT TEND W/ QUAD,SUP-2867110,CDM,C1762,CPT,0278,RC,,,,both,,,9396.45,6107.69,,,,,,,,,,,,,
MESH 15X20CM OPN FLX COMP PHYSIOMESH,SUP-2219746,CDM,C1781,HCPCS,0278,RC,,,,both,,,3236.02,2103.41,,,,,,,,,,,,,
TRAY CATH PICC POLY Q CATH 4FR 0.034IN 60CM 1 LUMAN 9154108,SUP-2632691,CDM,C1751,HCPCS,0278,RC,,,,both,,,516.53,335.74,,,,,,,,,,,,,
INSERT TOE IMPLANTXSM PHLANG IMP,SUP-2404755,CDM,C1776,CPT,0278,RC,,,,both,,,2160.32,1404.21,,,,,,,,,,,,,
BASKET SPEC RETRV STONE 1.3 FRX90 CM THMB WHL SM OPTIFLEX,SUP-2487951,CDM,2720000010,LOCAL,0272,RC,,,,both,,,735.29,477.94,,,,,,,,,,,,,
PACEMAKER CARD STD PERM SGL CHMBR UPLR IS1 CONN INTEGRITY,SUP-2357331,CDM,C1786,HCPCS,0275,RC,,,,both,,,14742.30,9582.49,,,,,,,,,,,,,
SAW SURG STRGHT SAG PERM LEVER FLFSMLL BNE MICROPOWER HALL,SUP-2605593,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8930.29,5804.69,,,,,,,,,,,,,
BLADE SAW 25.4X63.5X0.38 MM RECIP THN STRL PRECIS LTX,SUP-2862502,CDM,2720000010,LOCAL,0272,RC,,,,both,,,387.48,251.86,,,,,,,,,,,,,
PLATE EXT FIX L155MM SH ALUM FT RNG FOR ILIZ TAY SPAT FRME,SUP-2340789,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8969.88,5830.42,,,,,,,,,,,,,
BIT DRL L58MM DIA1.9MM FOR 0.2MM SCR REUSE,SUP-2365241,CDM,2720000010,LOCAL,0272,RC,,,,both,,,335.98,218.39,,,,,,,,,,,,,
GRAFT VASC IMPRA L 50 CM DIA 6 MM EPTFE FLX TW RING HEMO,SUP-2761455,CDM,C1768,CPT,0278,RC,,,,both,,,2747.53,1785.89,,,,,,,,,,,,,
COMPONENT FEM CNDYL END LT SZ 6,SUP-2208258,CDM,C1776,CPT,0278,RC,,,,both,,,26649.18,17321.97,,,,,,,,,,,,,
HC Non Stress Test,PX-9205902500,CDM,59025,CPT,0920,RC,,,,both,,,1112.00,722.80,,,,,,,,,,,,,
SHEATH TG0655517 6.5F 55CM 17MM,SUP-2298495,CDM,C1894,HCPCS,0272,RC,,,,both,,,1805.50,1173.57,,,,,,,,,,,,,
SCREW BNE L30MM DIA6.5MM HD L3.5MM CANC HIP X3 TRITANIUM,SUP-2372714,CDM,C1713,HCPCS,0278,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
GUIDEWIRE VASC L 80 CM DIA 0.035 IN CRV RAD 3 MM SS PTFE,SUP-2167565,CDM,C1769,HCPCS,0272,RC,,,,both,,,49.96,32.47,,,,,,,,,,,,,
MATRIX HUM TISS L 4 X W 3 CM DECELL PLCNTA MEMBRN,SUP-2909224,CDM,Q4201,HCPCS,0636,RC,,,,both,,,2841.70,1847.10,,,,,,,,,,,,,
BUR SURG BALL 3 MM 10 CM SYMTRC SM BOR MIDAS REX 8 LEGEND,SUP-2664486,CDM,2720000010,LOCAL,0272,RC,,,,both,,,499.39,324.60,,,,,,,,,,,,,
HC Collect Blood From Arterial Line,PX-7613779900,CDM,37799,CPT,0761,RC,,,,outpatient,,,1845.00,1199.25,,,,,,,,,,,,,
STAPLE BNE FIX NO1 BRDG W20MM LEG L20X20MM WIRE DIA2X2MM OS,SUP-2194226,CDM,C1713,HCPCS,0278,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
HEAD HUM DIA50MM THK28MM SHLDR CO CHROM PRI STD OFFSET NK,SUP-2372844,CDM,C1776,CPT,0278,RC,,,,both,,,4287.04,2786.58,,,,,,,,,,,,,
PLATE BONE L396MM 18 H LT PROX FEM LCK FOR 4.5MM SCR,SUP-2351130,CDM,C1713,HCPCS,0278,RC,,,,both,,,15899.08,10334.40,,,,,,,,,,,,,
SURGICAL PROCEDURE KIT CRANIOTOMY INCL 14 MM DISP PERF,SUP-2257408,CDM,2720000010,LOCAL,0272,RC,,,,both,,,759.25,493.51,,,,,,,,,,,,,
TOBRAMYCIN 40 MG/ML NEBULIZATION (NDC),RX-4082702,CDM,J3260,HCPCS,0636,RC,67457-0428-30,NDC,,both,7.5,ML,54.10,35.16,,,,,,,,,,,,,
CATHETER ANGIOPLSTY L90CM SHFT OD5.8FR BAL L4CM OD10MM OVR,SUP-2139691,CDM,C1725,HCPCS,0272,RC,,,,both,,,524.38,340.85,,,,,,,,,,,,,
ALLOGRAFT HUM TISS AMNIO MEMBRN PROVENDA,SUP-2762324,CDM,C1762,CPT,0278,RC,,,,both,,,4838.11,3144.77,,,,,,,,,,,,,
DEVICE EXT FIX ULTEM POLYMER PK STRL FOR DSTL RAD FX,SUP-2199199,CDM,C1713,HCPCS,0278,RC,,,,both,,,3882.99,2523.94,,,,,,,,,,,,,
GRAFT DERMACELL DERMAL 12CM X 21CM�MESHED MATRIX,SUP-2866795,CDM,Q4122,HCPCS,0636,RC,,,,both,,,24418.90,15872.28,,,,,,,,,,,,,
GRAFT TISS FRZN ALLGRFT RIB SEG 50 -300MM LX5-30MM W,SUP-2307296,CDM,C1713,HCPCS,0278,RC,,,,both,,,540.08,351.05,,,,,,,,,,,,,
FOOTPEDAL ATHRCTMY DYNAGLIDE REPL NS,SUP-2664401,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6914.28,4494.28,,,,,,,,,,,,,
NAIL IM TIB 10MM DIA 24CML STRL VERSANAIL DEPUY ORTHOPEDICS,SUP-2412332,CDM,C1713,HCPCS,0278,RC,,,,both,,,4288.99,2787.84,,,,,,,,,,,,,
DEFIBRILLATOR CRD BPLR ATR VENTRIC 2 CHMBR ATLS DR V242RSTSYS] ST JUDE MED CARDIAC RHYM MGMT],SUP-2356550,CDM,C1721,HCPCS,0275,RC,,,,both,,,57571.90,37421.73,,,,,,,,,,,,,
STEM HUM L115MM DIA7MM UNIV DST SHLDR TI PRI REV CEM FOR UP,SUP-2372850,CDM,C1776,CPT,0278,RC,,,,both,,,10163.55,6606.31,,,,,,,,,,,,,
SUPPORT ORTHOT CUST HEEL WDG,SUP-2435721,CDM,L3350,HCPCS,0274,RC,,,,both,,,64.75,42.09,,,,,,,,,,,,,
PIN PROV FIX L40MM DIA3.5MM PERI-LOC INSTR,SUP-2343975,CDM,C1713,HCPCS,0278,RC,,,,both,,,1401.07,910.70,,,,,,,,,,,,,
SHUNT CAR 9 FR OUTLYING W/O T PRT EIFU PRUITT F3,SUP-2589472,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3607.86,2345.11,,,,,,,,,,,,,
SUPPORT ORTHOT SACROILIAC PELV CUST FLX STRP PREFABRICATED,SUP-2435551,CDM,L0621,HCPCS,0274,RC,,,,both,,,244.10,158.66,,,,,,,,,,,,,
COMPONENT HUM 80MM SHLDR PROX REV MOD MOSAIC,SUP-2403499,CDM,C1776,CPT,0278,RC,,,,both,,,15878.98,10321.34,,,,,,,,,,,,,
MOLD FEM HIP STEM L125MM OD9MM HD OD43MM SIL W/ S STL REINF,SUP-2408619,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4848.16,3151.30,,,,,,,,,,,,,
WIRE FIX TROCAR PT 2 END 0.054X4 IN SS NS KIRSCHNER,SUP-2791250,CDM,C1713,HCPCS,0278,RC,,,,both,,,8.35,5.43,,,,,,,,,,,,,
DISTRACTION INTRNL ST SIZER 51 525 06 71 51 525 09 71 51 525,SUP-2499483,CDM,C1713,HCPCS,0278,RC,,,,both,,,330.96,215.12,,,,,,,,,,,,,
PLATE BNE BROAD 4.5X233 MM 13 HOLE SS LCP,SUP-2569366,CDM,C1713,HCPCS,0278,RC,,,,both,,,751.25,488.31,,,,,,,,,,,,,
TUBE SET 1.9 MMX30 CM LNG LAP TIP NEXUS SONASTAR,SUP-2748597,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3165.12,2057.33,,,,,,,,,,,,,
NAIL IM L440MM DIA2.5MM PROX TIB PNK TI ALLY FOR E STBL MOD,SUP-2192727,CDM,C1713,HCPCS,0278,RC,,,,both,,,822.87,534.87,,,,,,,,,,,,,
IMMUNE GLOBULIN (OCTAGAM) 10%,RX-4081765,CDM,J1568,HCPCS,0636,RC,68982-0850-03,NDC,,both,100,ML,5730.40,3724.76,,,,,,,,,,,,,
PLATE BNE 4 HOLE TI NS LC-DCP,SUP-2190802,CDM,C1713,HCPCS,0278,RC,,,,both,,,233.93,152.05,,,,,,,,,,,,,
ALLOGRAFT BNE CHIP 1-4 MM 30 CC CANC,SUP-2739091,CDM,C1713,HCPCS,0278,RC,,,,both,,,2386.40,1551.16,,,,,,,,,,,,,
ALLOGRAFT TISS ASEPTICALLY PROC 4X200 MM SEMITENDINOSUS,SUP-2264582,CDM,C1713,HCPCS,0278,RC,,,,both,,,4747.68,3085.99,,,,,,,,,,,,,
CATHETER GUID GL3 AD 8 FRX100 CM RADIOPAQUE TIP VKG OPTMA,SUP-2103860,CDM,C1887,HCPCS,0272,RC,,,,both,,,218.17,141.81,,,,,,,,,,,,,
RING EXT FIX 150 MM 5/8 MR SAFE TI NS,SUP-2799571,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1832.19,1190.92,,,,,,,,,,,,,
CANNULA ARTHSCP VENT HIP BHR ID2.3MM,SUP-2351309,CDM,2720000010,LOCAL,0272,RC,,,,both,,,697.08,453.10,,,,,,,,,,,,,
SUPPORT ORTHOT SACROILIAC PELV CUST FLX STRP PREFABRICATED,SUP-2435551,CDM,L0621,HCPCS,0272,RC,,,,both,,,244.10,158.66,,,,,,,,,,,,,
PROCEDURE KIT SD LOCATE GUIDE,SUP-2381760,CDM,C1713,HCPCS,0278,RC,,,,both,,,3124.30,2030.79,,,,,,,,,,,,,
BALLOON VERT AUG SYS L20MM W/ 11GA NDL 4ML SYR CVD RADPQ,SUP-2361556,CDM,C1894,HCPCS,0272,RC,,,,both,,,8007.00,5204.55,,,,,,,,,,,,,
PLATE BONE 3D EXTRA SM 04MM THK TTNM RIGHT ORBTL FLOOR,SUP-2681175,CDM,C1713,HCPCS,0278,RC,,,,both,,,3059.84,1988.90,,,,,,,,,,,,,
GRAFT VASC PTCH 150X25X0.65 MM RVS LOCKNIT CLLGN COAT HEMGRD,SUP-2535424,CDM,C1768,CPT,0278,RC,,,,both,,,538.10,349.76,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 50 MM DIA 7 MM DEL SHTH,SUP-2934157,CDM,C1713,HCPCS,0278,RC,,,,both,,,6550.04,4257.53,,,,,,,,,,,,,
CLINIMIX/DEXTROSE (5/20) 5 % IV SOLN,RX-25753,CDM,2500000003,HCPCS,0250,RC,00338-1101-04,NDC,,both,2000,ML,471.50,306.47,,,,,,,,,,,,,
PACEMAKER CARD ESSENTIO MRI W 4.45 X H 4.81 CM THK 0.75 CM,SUP-2149244,CDM,C1786,HCPCS,0275,RC,,,,both,,,8478.00,5510.70,,,,,,,,,,,,,
KIT INSTR DIA1.5MM STR SFT KT DISP FOR JUGGERKNOT SYS,SUP-2212954,CDM,C1713,HCPCS,0278,RC,,,,both,,,946.02,614.91,,,,,,,,,,,,,
BRACKET TRAC SUPP KNEE TBL BTTRS LEG HLDR LT BRKT FT,SUP-2197869,CDM,C1713,HCPCS,0278,RC,,,,both,,,8474.86,5508.66,,,,,,,,,,,,,
SUPPORT ORTHOT THOR LUMBAR SACR CUST FLX TRUNK SUPP T9,SUP-2435538,CDM,L0455,HCPCS,0272,RC,,,,both,,,981.88,638.22,,,,,,,,,,,,,
SET INTRO SUP ARW FLX SHTH L 80 CM DIA 8 FR HYDRPHLC,SUP-2383416,CDM,C1894,HCPCS,0272,RC,,,,both,,,312.43,203.08,,,,,,,,,,,,,
MESH HERN W10XL13IN UNCOATED MFIL POLYPR ELLIPSE LTWT ABSRB,SUP-2125903,CDM,C1781,HCPCS,0278,RC,,,,both,,,4675.46,3039.05,,,,,,,,,,,,,
PLATE BNE L82MM 4 H L PROX TIB S STL LOK COMPR FOR 4.5MM,SUP-2185710,CDM,C1713,HCPCS,0278,RC,,,,both,,,4124.67,2681.04,,,,,,,,,,,,,
MARKER BRST BX 2ND SITE TRIMARK EVIVA,SUP-2240068,CDM,A4648,CPT,0278,RC,,,,both,,,203.75,132.44,,,,,,,,,,,,,
CATHETER KIT HYBRID PICC 6 FRX55 CM 145 CM WIRE PASV XCELA,SUP-2117280,CDM,C1751,HCPCS,0278,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
GRAFT BIO TISS 3CC BOV FLOWABLE,SUP-2244049,CDM,Q4114,HCPCS,0636,RC,,,,both,,,16475.61,10709.15,,,,,,,,,,,,,
BIT DRL CANN 4X180 MM AUTOFIX 6,SUP-2538440,CDM,2720000010,LOCAL,0272,RC,,,,both,,,485.13,315.33,,,,,,,,,,,,,
CATHETER CV 3L 0.035 IN 12 FRX8 IN SILK SUTURE KT,SUP-2120586,CDM,C1751,HCPCS,0278,RC,,,,both,,,337.24,219.21,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED STD STRYKNEES] STRYKER CORP],SUP-2365997,CDM,C1776,CPT,0278,RC,,,,both,,,10971.16,7131.25,,,,,,,,,,,,,
TOOL RELEASE REACTIV8,SUP-2877975,CDM,C1730,HCPCS,0272,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
STEM EXTN FEM OR TIB FOR PROVEN OD10MM L 80MM,SUP-2359180,CDM,C1776,CPT,0278,RC,,,,both,,,3611.00,2347.15,,,,,,,,,,,,,
GRAFT BONE PROSTHETIC COMP HUM PROX RT W/ ROT CUF,SUP-2307436,CDM,C1762,CPT,0278,RC,,,,both,,,26533.00,17246.45,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED RESURF CORMET,SUP-2365448,CDM,C1776,CPT,0278,RC,,,,both,,,24021.00,15613.65,,,,,,,,,,,,,
LEADWIRE KNDL DL DRCT CNCT DSPSBLE SHLD EKG 6 LEAD NHN KHDN,SUP-2917064,CDM,C1713,HCPCS,0278,RC,,,,both,,,42.08,27.35,,,,,,,,,,,,,
PLUG VASC LG 10 MM AZUR,SUP-2853097,CDM,C1889,HCPCS,0278,RC,,,,both,,,7455.93,4846.35,,,,,,,,,,,,,
BLADE RETRACTOR HENLY 76MML LEFT RIGHT,SUP-2677345,CDM,2720000010,LOCAL,0272,RC,,,,both,,,388.54,252.55,,,,,,,,,,,,,
CONNECTOR SPNL TI END TO END ROD TO ROD FOR 5.5MM ROD MNRCH,SUP-2254577,CDM,C1713,HCPCS,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
SET VASC ACCS TRANSSEPTAL DIL L 93 CM DIA13 FR GUIDEWIRE L,SUP-2887623,CDM,C1769,HCPCS,0272,RC,,,,both,,,3438.30,2234.89,,,,,,,,,,,,,
PIN FIX L9IN OD9/64IN S STL TYP D STNMN,SUP-2342721,CDM,C1713,HCPCS,0278,RC,,,,both,,,237.57,154.42,,,,,,,,,,,,,
ALLOGRAFT BNE COSTAL CART 5 CM,SUP-2321773,CDM,C1762,CPT,0278,RC,,,,both,,,1742.70,1132.75,,,,,,,,,,,,,
CATHETER CV 5 FRX55 CM ENDEXO NURSING KT 2 NIT WIRE BIOFLO,SUP-2734872,CDM,C1751,HCPCS,0278,RC,,,,both,,,135.65,88.17,,,,,,,,,,,,,
SUPPORT ORTHOT THOR LUMBAR SACR CUST TRIPLANAR CTRL LNR,SUP-2435547,CDM,L0488,HCPCS,0274,RC,,,,both,,,2842.01,1847.31,,,,,,,,,,,,,
NA CHONDROIT SULF-NA HYALURON 20-15 MG/0.5ML IO SOSY,RX-155596,CDM,6370000000,HCPCS,0637,RC,08065-1839-05,NDC,,both,.5,ML,1140.10,741.06,,,,,,,,,,,,,
PLATE BNE PERIARTICULAR 2.7/3.5X220 MM LT DSTL PL 18 HOLE SS,SUP-2410561,CDM,C1713,HCPCS,0278,RC,,,,both,,,2297.60,1493.44,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH ALPHA2 L 204 MM DIA 42 MM SHTH 20 FR,SUP-2911980,CDM,C1768,CPT,0278,RC,,,,both,,,67535.12,43897.83,,,,,,,,,,,,,
ALLOGRAFT HUMAN TISS PAT W/ EXT MECHANISM IRR,SUP-2875982,CDM,C1762,CPT,0278,RC,,,,both,,,13050.63,8482.91,,,,,,,,,,,,,
HC Chemo Admin Subq/Intramusc,PX-3319640100,CDM,96401,CPT,0331,RC,,,,outpatient,,,254.00,165.10,,,,,,,,,,,,,
SHEATH INTRO HEARTSPAN L 61 CM DIA 8.5 FR NDL L 71 CM STL,SUP-2516627,CDM,C1893,HCPCS,0272,RC,,,,both,,,75.83,49.29,,,,,,,,,,,,,
PLATE BNE ANT LAT R TIBIAXYS,SUP-2243000,CDM,C1713,HCPCS,0278,RC,,,,both,,,4928.26,3203.37,,,,,,,,,,,,,
BRACE ORTH AD SM FOR 8 9IN HND SHT R THMB SPICA BLK,SUP-2196531,CDM,L3923,HCPCS,0274,RC,,,,both,,,123.75,80.44,,,,,,,,,,,,,
PLATE BNE L 52 MM TI RT DSTL VOLAR RADIAL EXT STD NS VARIAX,SUP-2900649,CDM,C1713,HCPCS,0278,RC,,,,both,,,4656.90,3026.98,,,,,,,,,,,,,
STRAP ORTHOT PERONEAL CUST PREFABRICATED OFF THE SHLF,SUP-2435566,CDM,L0980,HCPCS,0274,RC,,,,both,,,48.39,31.45,,,,,,,,,,,,,
SCREW BONE 2X6MM CORT HEX S STL ECT,SUP-2198242,CDM,C1713,HCPCS,0278,RC,,,,both,,,34.38,22.35,,,,,,,,,,,,,
TUBE STOR 1.8ML EXTERNALLY THRD UNIV NUNC,SUP-2124936,CDM,C1894,HCPCS,0272,RC,,,,both,,,7.44,4.84,,,,,,,,,,,,,
TAP SURG AO CONN 3.2 MM,SUP-2421717,CDM,2720000010,LOCAL,0272,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
KIT EVAC 400CC DIA1/8IN H PAT 12.5IN 3 SPR RND SHP PVC DRN,SUP-2127101,CDM,C1729,HCPCS,0272,RC,,,,both,,,24.24,15.76,,,,,,,,,,,,,
COMPONENT HIP FOR PK 6100,SUP-2212669,CDM,C1776,CPT,0278,RC,,,,both,,,19154.00,12450.10,,,,,,,,,,,,,
BUR SURG TORNADO MINI 2-80 MM RND + FMS,SUP-2637141,CDM,2720000010,LOCAL,0272,RC,,,,both,,,237.38,154.30,,,,,,,,,,,,,
HC Inj Proc for Retro Cystography,PX-3615161000,CDM,51610,CPT,0361,RC,,,,inpatient,,,3707.00,2409.55,,,,,,,,,,,,,
SCREW BONE L42MM DIA5MM CORT DSTL ST FULL THRD FOR AFFIXUS,SUP-2137054,CDM,C1713,HCPCS,0278,RC,,,,both,,,717.99,466.69,,,,,,,,,,,,,
IMPLANT HUM TISS L 80 MM FIBULAR SHFT PRESERVON ALLGRFT STRL,SUP-2933138,CDM,C1762,CPT,0278,RC,,,,both,,,3119.90,2027.93,,,,,,,,,,,,,
CONNECTOR SPNL SZ 4 L26-27MM STD POST S STL FIX TRNSVRS,SUP-2254367,CDM,C1713,HCPCS,0278,RC,,,,both,,,2981.43,1937.93,,,,,,,,,,,,,
CUP ACET CEM 28 MM HIP HW W/ PLATE,SUP-2447856,CDM,C1776,CPT,0278,RC,,,,both,,,1003.23,652.10,,,,,,,,,,,,,
PLATE BNE W5.6XL50MM 8 H STR HI STRENGTH FOR FLX FRAG FIX,SUP-2411672,CDM,C1713,HCPCS,0278,RC,,,,both,,,1502.84,976.85,,,,,,,,,,,,,
KIT LASER TREAT L65CM NDL 21GA 0.035IN GLD TIP FBR LNG ACC,SUP-2116798,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
SPLINT FINGER SIZE 5.5 STAX,SUP-2895961,CDM,L3933,HCPCS,0274,RC,,,,both,,,5.50,3.57,,,,,,,,,,,,,
BONE CEMENT MIXING KIT KYPHOPLASTY,SUP-2765275,CDM,C1713,HCPCS,0278,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
DEVICE RESECT ENDOSCP MUCOSAL FOR L GASTROSCP CAPTIVATOR,SUP-2141570,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1051.12,683.23,,,,,,,,,,,,,
TAP SURG L95MM DIA1.7MM SELF DRL,SUP-2365076,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2148.55,1396.56,,,,,,,,,,,,,
PLATE BNE L 172.82 X W 8.26 MM THK 2.8 MM SCREW DIA2/2.3 MM,SUP-2936980,CDM,C1713,HCPCS,0278,RC,,,,both,,,11206.66,7284.33,,,,,,,,,,,,,
SPLINT FINGER SIZE 5.5 STAX,SUP-2895961,CDM,L3933,HCPCS,0272,RC,,,,both,,,5.50,3.57,,,,,,,,,,,,,
GRAFT BONE 2.5CC HCT/P 361 REGULATED VIABLE CELLULAR,SUP-2419111,CDM,C1713,HCPCS,0278,RC,,,,both,,,5369.40,3490.11,,,,,,,,,,,,,
CATHETER THOR 36FR L23CM DIA12MM POLYVI CHL TAPR CONN TIP,SUP-2227434,CDM,C1729,HCPCS,0272,RC,,,,both,,,21.29,13.84,,,,,,,,,,,,,
INSERT TIB KNEE ARTC SURF FLAT CRUC RET A B PUR LT RT 11MM,SUP-2199500,CDM,C1776,CPT,0278,RC,,,,both,,,6011.22,3907.29,,,,,,,,,,,,,
PLATE BNE STRUT 2X45X1.3 MM 12 HOLE RECTANGULAR VA LCK SS NS,SUP-2178039,CDM,C1713,HCPCS,0278,RC,,,,both,,,1829.77,1189.35,,,,,,,,,,,,,
INFINITY ADAPTIS TALDOME SZ3 INFINITY ADAPTIS,SUP-2822349,CDM,C1776,CPT,0278,RC,,,,both,,,9272.42,6027.07,,,,,,,,,,,,,
ROD RELINE MAS TI 5.5X55MM LORDOTIC,SUP-2880394,CDM,C1713,HCPCS,0278,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
INSERTER CVR TAPR H FOR REFLCT SYS,SUP-2349965,CDM,C1776,CPT,0278,RC,,,,both,,,31.40,20.41,,,,,,,,,,,,,
PORT E DIA8MM FOR 8MM DA VINCI XI SYS SINGLE-SITE,SUP-2246786,CDM,2720000010,LOCAL,0272,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
ALLOGRAFT HUM TISS FRZN ASEP PATELLAR TEND W/ QUAD,SUP-2867093,CDM,C1762,CPT,0278,RC,,,,both,,,24242.84,15757.85,,,,,,,,,,,,,
PLATE BNE L 65 X W 8 MM THK 3.5 MM SCREW DIA2.7 MM 8 H SS 72440308,SUP-2932904,CDM,C1713,HCPCS,0278,RC,,,,both,,,1547.20,1005.68,,,,,,,,,,,,,
ANCHOR SUT SM 1.9MM NO5 AND NO1 POLY SFT DBL LD W/ TWO NO2,SUP-2341895,CDM,C1713,HCPCS,0278,RC,,,,both,,,1094.60,711.49,,,,,,,,,,,,,
GRAFT HUM TISS M W12XL16CM THK1.6MM +/-0.4MM WHL ALLGRFT,SUP-2113184,CDM,Q4116,HCPCS,0636,RC,,,,both,,,22441.58,14587.03,,,,,,,,,,,,,
PLATE BNE L 3.54 CM THK 0.6 MM SCREW DIA2 MM 8 H TI ORBIT NS,SUP-2936567,CDM,C1713,HCPCS,0278,RC,,,,both,,,637.42,414.32,,,,,,,,,,,,,
PHENOBARBITAL 10 MG/ML IJ SOLN (NEO),RX-4090138,CDM,J2560,HCPCS,0636,RC,09999-9906-59,NDC,,both,1,ML,79.80,51.87,,,,,,,,,,,,,
SHEATH INTRO 8FR L25CM 0.038IN SIL TRICSP VLV W/O GWIRE,SUP-2139634,CDM,C1894,HCPCS,0272,RC,,,,both,,,595.03,386.77,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 15X30 MM FD PERIO FASC LATA ORAGRAFT,SUP-2740985,CDM,C1762,CPT,0278,RC,,,,both,,,247.09,160.61,,,,,,,,,,,,,
TREMELIMUMAB-ACTL 300 MG/15ML IV SOLN|DISCARDED DRUG NOT ADMINISTE,RX-160346,CDM,J9347,HCPCS,0636,RC,00310-4535-30,NDC,JW,both,3.75,ML,30196.10,19627.46,,,,,,,,,,,,,
PLATE BONE LOCKING 4.5X255 MM RIGHT LATERAL PROXIMAL TIBIAL,SUP-2837468,CDM,C1713,HCPCS,0278,RC,,,,both,,,11909.08,7740.90,,,,,,,,,,,,,
COIL EMB L4CM OD2MM MICROCATHETER COMPATIBILITY 0.0165IN,SUP-2296666,CDM,C1889,HCPCS,0278,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
RESERVOIR VENTRICULAR 6MM STD PLAS STRL HOLTER RICKHAM,SUP-2666415,CDM,C1889,HCPCS,0278,RC,,,,both,,,1216.66,790.83,,,,,,,,,,,,,
CATHETER HD PRE CRV 13.5 FRX20 CM KT HI FLO NIAG,SUP-2125587,CDM,C1752,HCPCS,0278,RC,,,,both,,,257.48,167.36,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9 % IV BOLUS NEONATE,RX-40840079,CDM,J7050,HCPCS,0258,RC,00264-7800-20,NDC,,both,250,ML,23.40,15.21,,,,,,,,,,,,,
STENT GRFT VASC POWERLINK INTUITRAK L 55 MM OD 20 X 20 MM,SUP-2217558,CDM,C1768,CPT,0278,RC,,,,both,,,7363.30,4786.14,,,,,,,,,,,,,
BUR SURG DIA 3.1 MM HUB XLIII DIAMOND STRL DISP HI-LINE XS,SUP-2929109,CDM,2720000010,LOCAL,0272,RC,,,,both,,,782.27,508.48,,,,,,,,,,,,,
PLATE BNE DELT SM 96 MM LT DSTL DORS RADIAL 6 HOLE BUTTRESS,SUP-2467567,CDM,C1713,HCPCS,0278,RC,,,,both,,,2050.48,1332.81,,,,,,,,,,,,,
GRAFT VASC GELSFT L 30 CM DIA 8 MM POLYESTER GEL ABD PERIPH,SUP-2384955,CDM,C1768,CPT,0278,RC,,,,both,,,2797.74,1818.53,,,,,,,,,,,,,
DECOMPRESSION KIT STD 20 MM MIC HK SHAVER TUBESET NEXUS,SUP-2748590,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2700.40,1755.26,,,,,,,,,,,,,
HOLDER PLT NONSTERILE REUSE ATLNTS,SUP-2279324,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1238.16,804.80,,,,,,,,,,,,,
KIT INTRO SHTH L 10 CM DIA 4.5 FR GUIDEWIRE L 65 CM DIA,SUP-2120531,CDM,C1892,HCPCS,0272,RC,,,,both,,,100.48,65.31,,,,,,,,,,,,,
ALLOGRAFT HUM TISS STRP 25X10X7 MM MTRX OI,SUP-2135424,CDM,C1762,CPT,0278,RC,,,,both,,,3381.78,2198.16,,,,,,,,,,,,,
BIT DRL L95MM DIA1.5MM STRL TI JCBS CHK NONRADIOPAQUE W/O,SUP-2187195,CDM,2720000010,LOCAL,0272,RC,,,,both,,,386.53,251.24,,,,,,,,,,,,,
ARTHRITIS HOT 10-15 % EX CREA,RX-12275,CDM,6370000000,HCPCS,0637,RC,41167-0060-06,NDC,,both,85,GR,9.60,6.24,,,,,,,,,,,,,
GUIDEWIRE VASC AVIGO L 205 CM COIL L 5 CM DIA 0.014 IN,SUP-2518869,CDM,C1769,HCPCS,0272,RC,,,,both,,,1538.60,1000.09,,,,,,,,,,,,,
COMPONENT KNEE CEM K8 STD,SUP-2351386,CDM,C1776,CPT,0278,RC,,,,both,,,6908.00,4490.20,,,,,,,,,,,,,
STAPLE CARTRIDGE STR 16X25 MM TI,SUP-2166816,CDM,C1713,HCPCS,0278,RC,,,,both,,,425.03,276.27,,,,,,,,,,,,,
PLATE BNE DSTL 20X1 MM RT MAX 12 HOLE MOD TI,SUP-2487460,CDM,C1713,HCPCS,0278,RC,,,,both,,,13145.99,8544.89,,,,,,,,,,,,,
ALLOGRAFT BNE PARTICULATE 250-1000 MH 1 CC CANC ORAGRAFT,SUP-2740948,CDM,C1713,HCPCS,0278,RC,,,,both,,,288.50,187.52,,,,,,,,,,,,,
PLATE BNE T 1.5X1 MM 6 MM LT 2X3 HOLE C-TUBE HK BRIDGE TI NS,SUP-2468186,CDM,C1713,HCPCS,0278,RC,,,,both,,,1367.47,888.86,,,,,,,,,,,,,
SYSTEM CHARGING AC PWR SUPL RECHARGER ANT SHLDR BELT RC,SUP-2284469,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7504.60,4877.99,,,,,,,,,,,,,
HLF PN 2.5X80X20 BRN BLNT TIP,SUP-2489271,CDM,C1713,HCPCS,0278,RC,,,,both,,,486.45,316.19,,,,,,,,,,,,,
CATHETER ATHRCTMY SILVERHAWK L 110 CM TIP L 6 CM SHTH 8 FR,SUP-2424887,CDM,C1714,HCPCS,0272,RC,,,,both,,,3409.66,2216.28,,,,,,,,,,,,,
LEVEL NEURO ST MESH 3D ULTRNE NEURO SCRW100 MM DIA T06 MM C,SUP-2676605,CDM,C1713,HCPCS,0278,RC,,,,both,,,6333.88,4117.02,,,,,,,,,,,,,
GRAFT HUM TISS W4XL16CM THK0.9-1.99MM ACELLULAR DERM MTRX,SUP-2402509,CDM,Q4126,HCPCS,0636,RC,,,,both,,,10048.00,6531.20,,,,,,,,,,,,,
GRAFT 04 07MM 2CMX5CM THN DEHYDR ALLOPATCH HD,SUP-2307042,CDM,Q4128,HCPCS,0636,RC,,,,both,,,1062.26,690.47,,,,,,,,,,,,,
PLATE BNE THK 1 MM BAR 16 MM SCREW DIA2 MM 6 H MINI CRV NS,SUP-2883142,CDM,C1713,HCPCS,0278,RC,,,,both,,,1885.04,1225.28,,,,,,,,,,,,,
TUBING SUCT INFLO OUTFLO FORKED SET ST DISP INTELJET,SUP-2341416,CDM,2720000010,LOCAL,0272,RC,,,,both,,,760.67,494.44,,,,,,,,,,,,,
SCREW LUHR MINI LP 2.0X10MM,SUP-2364681,CDM,C1713,HCPCS,0278,RC,,,,both,,,489.84,318.40,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 70 CM DIA10 MM EPTFE STR STD WALL,SUP-2681769,CDM,C1768,CPT,0278,RC,,,,both,,,1723.17,1120.06,,,,,,,,,,,,,
HALF RING 180 MM INT DIAM,SUP-2818050,CDM,2720000010,LOCAL,0272,RC,,,,both,,,9320.15,6058.10,,,,,,,,,,,,,
GRAFT HUM TISS W100XL180MM FASC LATA FRZN,SUP-2307273,CDM,C1762,CPT,0278,RC,,,,both,,,3656.56,2376.76,,,,,,,,,,,,,
CATHETER ANGIO 90CML AD AAA STNT GRFT DBL LUMN DBL CHRONIC,SUP-2217696,CDM,C1887,HCPCS,0272,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
STRAP CLAV L BCKL CLSR FOAM CONSTR COT STOCK 3 W POST VECT,SUP-2194673,CDM,L3670,HCPCS,0272,RC,,,,both,,,13.47,8.76,,,,,,,,,,,,,
HC Med Nut Therapy Ind Fu 15 Min,PX-9429780300,CDM,97803,CPT,0940,RC,,,,outpatient,,,42.00,27.30,,,,,,,,,,,,,
PLATE BNE CALCANEAL FRAC MED TAB ORTHOLOC,SUP-2476704,CDM,C1713,HCPCS,0278,RC,,,,both,,,3994.08,2596.15,,,,,,,,,,,,,
NAIL IM L235MM DIA10MM NK 130DEG UNIV GRN PROX FEM TI,SUP-2191931,CDM,C1713,HCPCS,0278,RC,,,,both,,,3756.16,2441.50,,,,,,,,,,,,,
BLADE RTRCTR CHRNLEY LNG 1NW X 6 34NL X 3IND FINTL INCSN J,SUP-2700974,CDM,2720000010,LOCAL,0272,RC,,,,both,,,386.60,251.29,,,,,,,,,,,,,
CATHETER REPROC EP 4 FR 15-25 MM DUO,SUP-2471500,CDM,C1731,HCPCS,0278,RC,,,,both,,,3070.45,1995.79,,,,,,,,,,,,,
WIRE FIX DIAMOND PT 2 END 0.035X9 IN SS NS KIRSCHNER KI71211,SUP-2791278,CDM,C1713,HCPCS,0278,RC,,,,both,,,8.98,5.84,,,,,,,,,,,,,
PIN FIX ENDOBROW 2.1X4 MM STRL SONICWELD RX,SUP-2472570,CDM,C1713,HCPCS,0278,RC,,,,both,,,352.50,229.12,,,,,,,,,,,,,
ANCHOR SUT L12.7MM DIA3MM SHLDR PEEK KNOTLESS W/ SZ 2,SUP-2121614,CDM,C1713,HCPCS,0278,RC,,,,both,,,1208.90,785.78,,,,,,,,,,,,,
SYSTEM CPRP CONC UP TO 18X BASELINE ADJ LEUK CONC ANGEL,SUP-2120730,CDM,2720000010,LOCAL,0272,RC,,,,both,,,918.45,596.99,,,,,,,,,,,,,
NEEDLE TRANSSEPTAL KT BRK 1 SM CURL INTRO NXT STEER SHTH,SUP-2357289,CDM,C1766,CPT,0272,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
CLAMP SURG SINGLE SHT OCPTL PROTEX CT,SUP-2584530,CDM,C1713,HCPCS,0278,RC,,,,both,,,496.12,322.48,,,,,,,,,,,,,
SLEEVE SURG DRL SGL END 43 MM DIA DISPOSABLE ST,SUP-2204937,CDM,C1713,HCPCS,0278,RC,,,,both,,,393.29,255.64,,,,,,,,,,,,,
LINER ACET 38X27 MM SCR IN +5 HI WALL RINGLOC+,SUP-2447220,CDM,C1776,CPT,0278,RC,,,,both,,,2585.79,1680.76,,,,,,,,,,,,,
SCREW BNE L28MM DIA4MM CORT TI ST LOK FULL THRD TRIGEN,SUP-2348129,CDM,C1713,HCPCS,0278,RC,,,,both,,,1163.50,756.27,,,,,,,,,,,,,
BAR EXT FIX 11X200 MM CARBON XTRAFIX,SUP-2481563,CDM,2720000010,LOCAL,0272,RC,,,,both,,,589.94,383.46,,,,,,,,,,,,,
K WIRE FIX L450MM DIA3.2MM S STL DBL SHRP TIP SMOOTH FOR,SUP-2368453,CDM,C1713,HCPCS,0278,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
GRAFT BNE WDG 0 DEG 30X12X10 MM FIBULAR,SUP-2860939,CDM,C1713,HCPCS,0278,RC,,,,both,,,7473.20,4857.58,,,,,,,,,,,,,
HC So Mycoplasma Igg,PX-3028673866,CDM,86738,CPT,0302,RC,,,,both,,,218.00,141.70,,,,,,,,,,,,,
TAP SURG L180MM DIA4MM HEX CPL FOR 6MM 2 COR SCR,SUP-2179457,CDM,2720000010,LOCAL,0272,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
STAPLER INT L16CM STD UNIV RELD DISP TRI-STAPLE ENDO GIA,SUP-2283270,CDM,2720000010,LOCAL,0272,RC,,,,both,,,396.11,257.47,,,,,,,,,,,,,
SCREW BONE IMPL CANN HDLSS LAG HPS TI 2.0MMX38MM EXTREMIFIX,SUP-2319465,CDM,C1713,HCPCS,0278,RC,,,,both,,,1114.70,724.55,,,,,,,,,,,,,
PLATE BNE LG LT LAPIDUS STRATUM,SUP-2607233,CDM,C1713,HCPCS,0278,RC,,,,both,,,4475.91,2909.34,,,,,,,,,,,,,
PLATE BONE 3D PRNT MED MIDFACE MAND TI TRUMATCH,SUP-2860372,CDM,C1713,HCPCS,0278,RC,,,,both,,,41843.33,27198.16,,,,,,,,,,,,,
HC Thrombolytic Venous Therapy,PX-3613721200,CDM,37212,CPT,0361,RC,,,,both,,,8583.00,5578.95,,,,,,,,,,,,,
CLAMP SURG PARL CONN 18 MM 6.5-6.5 MM SINGLE REVERE,SUP-2584883,CDM,C1713,HCPCS,0278,RC,,,,both,,,1036.20,673.53,,,,,,,,,,,,,
DEVICE CATH MEAS,SUP-2140281,CDM,2720000010,LOCAL,0272,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
KIT OXGNTR W/ ACCSRY TANDEMLUNG,SUP-2152643,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6280.00,4082.00,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA PLU MAXBARR 3FR S1193108D5,SUP-2632796,CDM,C1751,HCPCS,0278,RC,,,,both,,,893.83,580.99,,,,,,,,,,,,,
LONG DRL 3.0X30 10/PK KIT0733,SUP-2266525,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5338.00,3469.70,,,,,,,,,,,,,
BUR SURG OD40MM LNG DMND ECOARSE RND N FLUT ST FOR TPS,SUP-2363361,CDM,2720000010,LOCAL,0272,RC,,,,both,,,315.51,205.08,,,,,,,,,,,,,
BLADE ENDOSCP SHV DIA4MM 15DEG ANG SNUS CRV SERR CONCAVE,SUP-2313826,CDM,C1713,HCPCS,0278,RC,,,,both,,,392.47,255.11,,,,,,,,,,,,,
HOOK BNE L1IN,SUP-2252707,CDM,C1713,HCPCS,0278,RC,,,,both,,,1689.32,1098.06,,,,,,,,,,,,,
CENTRALIZER STEM DIA10MM DST FEM HIP POS PMMA ECHO,SUP-2406617,CDM,C1776,CPT,0278,RC,,,,both,,,1004.80,653.12,,,,,,,,,,,,,
SCREW BNE SD 2X5 MM CRUCFRM AUTO DRV,SUP-2319378,CDM,C1713,HCPCS,0278,RC,,,,both,,,141.36,91.88,,,,,,,,,,,,,
BRACE ORTH GAUNTLET ANK FT OTS,SUP-2388167,CDM,L1971,HCPCS,0274,RC,,,,both,,,1808.64,1175.62,,,,,,,,,,,,,
HC Applicaton on-Body Injector,PX-7619637700,CDM,96377,CPT,0761,RC,,,,inpatient,,,111.00,72.15,,,,,,,,,,,,,
CAST ORTHOT ANK KNEE FEM CUST FRAC RIGID,SUP-2435652,CDM,L2136,HCPCS,0274,RC,,,,both,,,3570.43,2320.78,,,,,,,,,,,,,
PIN FIX TROCAR PT 2 END 3/32X9 IN 2 PT STYL SMOOTH PLN STRL,SUP-2150464,CDM,C1713,HCPCS,0278,RC,,,,both,,,12.94,8.41,,,,,,,,,,,,,
SUPPORT ORTHOT LOWER EXTREMITY PELV CTRL BND BELT UNILAT,SUP-2435688,CDM,L2630,HCPCS,0274,RC,,,,both,,,655.51,426.08,,,,,,,,,,,,,
PLATE BNE TBLR 3.5X40 MM 3 HOLE 1/3 SS NS LCP,SUP-2185924,CDM,C1713,HCPCS,0278,RC,,,,both,,,407.01,264.56,,,,,,,,,,,,,
SUPPORT ORTHOT KNEE CUST LIMIT RANG OF MOTN,SUP-2435653,CDM,L2184,HCPCS,0274,RC,,,,both,,,327.94,213.16,,,,,,,,,,,,,
SPINDLE ORTH 2XS 25 MM 800 LB MINI TAPR COMPRESS,SUP-2441871,CDM,C1776,CPT,0278,RC,,,,both,,,11261.61,7320.05,,,,,,,,,,,,,
STENT BILI ZILVER L 6 CM DIA 8 MM INTRO L 208 CM DIA 7 FR,SUP-2169574,CDM,C1876,HCPCS,0278,RC,,,,both,,,4640.92,3016.60,,,,,,,,,,,,,
TUBE TRACH NEO L86MM OD53MM ID35MM SIL CUF STR NK FLNG W,SUP-2352027,CDM,2720000010,LOCAL,0272,RC,,,,both,,,629.76,409.34,,,,,,,,,,,,,
GRAFT BNE PTTY 8 CC MOLD DBM XEMPLIFI +,SUP-2423035,CDM,C9359,HCPCS,0278,RC,,,,both,,,2386.40,1551.16,,,,,,,,,,,,,
SCREW BNE L40MM DIA4.75MM HD DIA3.5MM CORT FIX ANG,SUP-2407406,CDM,C1713,HCPCS,0278,RC,,,,both,,,395.64,257.17,,,,,,,,,,,,,
TUBE CALIB REALIZE GAST ASYMMETRICAL,SUP-2219866,CDM,2720000010,LOCAL,0272,RC,,,,both,,,367.38,238.80,,,,,,,,,,,,,
SYSTEM CATH INFSN 4FR DIA 135CML PEBAX OCCLDNG WIRE ACCSSPLS,SUP-2677052,CDM,C1751,HCPCS,0278,RC,,,,both,,,151.19,98.27,,,,,,,,,,,,,
ENDO FUSE  FUSION BEAM 60X25MM,SUP-2484144,CDM,C1713,HCPCS,0278,RC,,,,both,,,9313.24,6053.61,,,,,,,,,,,,,
COMPONENT PAT SZ 4 RESURF AUG GMK,SUP-2267457,CDM,C1776,CPT,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
INTERFYL 1.0 ML FLOWABLE,SUP-2818017,CDM,Q4171,HCPCS,0636,RC,,,,both,,,5129.19,3333.97,,,,,,,,,,,,,
BRACE ORTH THGH CIRC 13-15.5 IN XS SZ 1 ALUM SUEDE RL KNEE,SUP-2914964,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1251.82,813.68,,,,,,,,,,,,,
WIRE EXT FIX L 355 MM DIA1.8 MM CORTICAL DRL TIP NS DISP,SUP-2932913,CDM,C1713,HCPCS,0278,RC,,,,both,,,714.73,464.57,,,,,,,,,,,,,
HC Treat Humerus Fracture,PX-4502457700,CDM,24577,CPT,0450,RC,,,,both,,,1633.00,1061.45,,,,,,,,,,,,,
CATHETER HD PRECRV 13.5 FRX13 CM DL HI FLO IC TY MAHRK ELITE,SUP-2626905,CDM,C1752,HCPCS,0278,RC,,,,both,,,283.51,184.28,,,,,,,,,,,,,
PLATE BONE L135MM STD 9 H LT DSTL VOLAR RAD S STL LCK FOR,SUP-2348325,CDM,C1713,HCPCS,0278,RC,,,,both,,,17711.33,11512.36,,,,,,,,,,,,,
SHELL ACET 62 MM HIP 3 HOLE HA REFLECTION INTERFIT,SUP-2434631,CDM,C1776,CPT,0278,RC,,,,both,,,6518.64,4237.12,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA FT PLU MAXBARR S1275108FD4,SUP-2632807,CDM,C1751,HCPCS,0278,RC,,,,both,,,745.44,484.54,,,,,,,,,,,,,
SHEATH INTRO FAST-CATH L 62 CM DIA10 FR DIL L 67 CM,SUP-2357190,CDM,C1894,HCPCS,0272,RC,,,,both,,,323.42,210.22,,,,,,,,,,,,,
HC Drug Screen Quantitative Gentamicin,PX-3018017000,CDM,80170,CPT,0301,RC,,,,inpatient,,,147.00,95.55,,,,,,,,,,,,,
STENT GRFT VASC BODY L 110 MM DIA20 MM LIMB L 30 MM DIA20 MM,SUP-2217662,CDM,C1768,CPT,0278,RC,,,,both,,,37052.00,24083.80,,,,,,,,,,,,,
CATHETER IVUS EAGLE EYE GLD CORONARY,SUP-2327216,CDM,C1753,HCPCS,0278,RC,,,,both,,,2307.90,1500.13,,,,,,,,,,,,,
HEAD HUM H15MM OD40MM TI SHLDR TOT RVS MOD BIOMOD,SUP-2404604,CDM,C1776,CPT,0278,RC,,,,both,,,4879.56,3171.71,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE 10 CC CORTICOCANCELLOUS ALLGRFT,SUP-2932826,CDM,C1762,CPT,0278,RC,,,,both,,,40820.00,26533.00,,,,,,,,,,,,,
SPLINT THMB M L5IN SH LT 1 STRP THERMOPLASTIC INSRT,SUP-2324195,CDM,L3931,HCPCS,0274,RC,,,,both,,,42.26,27.47,,,,,,,,,,,,,
BRACE KNEE MCL LCL EC HNG NEOPRENE W POPLITEAL PAT UNIV,SUP-2196414,CDM,L1810,HCPCS,0274,RC,,,,both,,,119.48,77.66,,,,,,,,,,,,,
CATHETER ANGIOPLSTY L80CM BAL L20MM DIA4MM SHTH DIA5FR,SUP-2104282,CDM,C1725,HCPCS,0272,RC,,,,both,,,659.40,428.61,,,,,,,,,,,,,
HC Continuous Inhale Tx Addl Hour,PX-4109464500,CDM,94645,CPT,0410,RC,,,,inpatient,,,16.00,10.40,,,,,,,,,,,,,
BLOCK CARVING CONTOURED SILICONE,SUP-2757603,CDM,C1889,HCPCS,0278,RC,,,,both,,,1303.10,847.01,,,,,,,,,,,,,
GUIDEWIRE VASC IQ L 185 CM DIA 0.014 IN SIL STR TIP STRL,SUP-2139930,CDM,C1769,HCPCS,0272,RC,,,,both,,,1208.90,785.78,,,,,,,,,,,,,
GRAFT BONE 5GM 5ML PARTICULATE SYNTH OSTEOCONDUCTIVE CLLGN,SUP-2288535,CDM,C1713,HCPCS,0278,RC,,,,both,,,978.55,636.06,,,,,,,,,,,,,
CATHETER SET DRAINAGE 6 FRX15 CM SINGLE LUMEN PIG MP UTHANE,SUP-2168624,CDM,C1729,HCPCS,0272,RC,,,,both,,,248.53,161.54,,,,,,,,,,,,,
PLATE BONE T WIDE 2.8 MM 8 HOLE TITANIUM STERILE MATRIXRIB,SUP-2837696,CDM,C1713,HCPCS,0278,RC,,,,both,,,4227.23,2747.70,,,,,,,,,,,,,
ANCHOR SUTURE SFT 1 MM MINI STP DRL STRL JUGGERKNOT,SUP-2745481,CDM,C1776,CPT,0278,RC,,,,both,,,739.53,480.69,,,,,,,,,,,,,
SCREW BNE L5MM DIA1.5MM MIC CORT CRANIOMAXILLOFACIAL TI LEV 256780591] KLS MARTIN LP],SUP-2262821,CDM,C1713,HCPCS,0278,RC,,,,both,,,185.01,120.26,,,,,,,,,,,,,
POTASSIUM CHLORIDE (CENTRAL) 0.2 MEQ/ML SYRINGE (PED-NEO) <50 ML,RX-4090162,CDM,J3480,HCPCS,0636,RC,00338-0705-48,NDC,,both,100,ML,54.10,35.16,,,,,,,,,,,,,
PACEMAKER CARD ADAPTA W 52.3 X H 45.4 MM D 7.5 MM 13.1 CC 2,SUP-2282310,CDM,C1785,HCPCS,0275,RC,,,,both,,,8222.28,5344.48,,,,,,,,,,,,,
EPINEPHRINE HCL (NASAL) 0.1 % NA SOLN,RX-19604,CDM,6370000000,HCPCS,0637,RC,42023-0103-01,NDC,,both,30,ML,1440.80,936.52,,,,,,,,,,,,,
GRAFT VASC L40CM OD26MM SIDE BRANCH L15CM OD10MM ARCH BRANCH,SUP-2385008,CDM,C1768,CPT,0278,RC,,,,both,,,6719.60,4367.74,,,,,,,,,,,,,
STENT BILI ZILVER 635 L 40 MM DIA14 MM DEL SYS L 80 CM SHTH,SUP-2170320,CDM,C1876,HCPCS,0278,RC,,,,both,,,1972.83,1282.34,,,,,,,,,,,,,
SCREW SPNL L35MM DIA7MM CANC SACR TI POLYAX NONCANNULATED,SUP-2254432,CDM,C1713,HCPCS,0278,RC,,,,both,,,2778.90,1806.28,,,,,,,,,,,,,
GRAFT TUBE 11MM,SUP-2812121,CDM,2720000010,LOCAL,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
ALLOGRAFT HUM TISS ACHILLES TEND BNE BLOCK,SUP-2264668,CDM,C1762,CPT,0278,RC,,,,both,,,2888.80,1877.72,,,,,,,,,,,,,
SHEATH INTRO PERFRMR L 13 CM DIA10 FR GUIDEWIRE 0.038 IN,SUP-2168246,CDM,C1894,HCPCS,0272,RC,,,,both,,,97.47,63.36,,,,,,,,,,,,,
HC Trach Tube Change,PX-3600000034,CDM,3600000034,LOCAL,0360,RC,,,,both,,,1451.00,943.15,,,,,,,,,,,,,
PC TOUMA VENT TUBE WTAB 1.14MM ID 50D,SUP-2682417,CDM,L8699,HCPCS,0278,RC,,,,both,,,60.35,39.23,,,,,,,,,,,,,
ANCHOR SUT L17.9MM DIA5MM TI W/ 2 FIBERWIRE BIO CRKSCR,SUP-2121495,CDM,C1713,HCPCS,0278,RC,,,,both,,,816.40,530.66,,,,,,,,,,,,,
TRAY CATH PICC GROSH NXT MAXBARR 5FR 0.026IN 45CM 2 9827508D,SUP-2632710,CDM,C1751,HCPCS,0278,RC,,,,both,,,787.98,512.19,,,,,,,,,,,,,
GUIDEWIRE ORTHPDC 2.4MM DIA 100CML TEAR DROP NAT NAIL ST,SUP-2459213,CDM,C1769,HCPCS,0272,RC,,,,both,,,486.45,316.19,,,,,,,,,,,,,
GUIDE NDL DISP 16-18GA,SUP-2164618,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1193.20,775.58,,,,,,,,,,,,,
PIN FIX SINGLE DIAMOND 0.109X9 IN RND END SS NS STEINMANN,SUP-2791602,CDM,C1713,HCPCS,0278,RC,,,,both,,,16.86,10.96,,,,,,,,,,,,,
SCREW BONE L100MM DIA6.5MM THRD L20MM CANN GUID ASNS 2,SUP-2362441,CDM,C1713,HCPCS,0278,RC,,,,both,,,950.16,617.60,,,,,,,,,,,,,
GRAFT HUM TISS 1000MG PLCNTA TISS AMNIOFILL,SUP-2305715,CDM,C1762,CPT,0278,RC,,,,both,,,7065.00,4592.25,,,,,,,,,,,,,
COMPONENT TALAR SZ 1 RT CO CHROM CEM USE SALTO TALARIS,SUP-2417001,CDM,C1776,CPT,0278,RC,,,,both,,,16605.89,10793.83,,,,,,,,,,,,,
COLLAR CERV M H3XL17IN COT M DENS FOAM BRTH ADJ LO-CONTOUR,SUP-2335996,CDM,L0180,HCPCS,0272,RC,,,,both,,,12.21,7.94,,,,,,,,,,,,,
SHEATH ACCS 30 FRX16 CM OPQ AMPLATZ,SUP-2835767,CDM,C1894,HCPCS,0272,RC,,,,both,,,81.51,52.98,,,,,,,,,,,,,
BRACE WRIST/THUMB AD L7IN UNIV LT SFT IMMOB JT LACE STAY,SUP-2324010,CDM,L3931,HCPCS,0272,RC,,,,both,,,31.27,20.33,,,,,,,,,,,,,
BUR SURG BALL 4 MMX10 CM FLUT SM BOR MIDAS REX LEGEND,SUP-2627621,CDM,2720000010,LOCAL,0272,RC,,,,both,,,316.29,205.59,,,,,,,,,,,,,
PORT INFUS CATH 7FR LO PROF 2 SLIMPRT PEEL APART PERC INTRO,SUP-2127736,CDM,C1788,HCPCS,0278,RC,,,,both,,,1033.06,671.49,,,,,,,,,,,,,
MESH CRAN THK 0.6 MM SCREW DIA1.5 MM TI GRD II RT PARIETL,SUP-2935054,CDM,C1713,HCPCS,0278,RC,,,,both,,,18337.60,11919.44,,,,,,,,,,,,,
CEFAZOLIN SODIUM 2 G SOLR (MIXTURES ONLY),RX-430073,CDM,J0690,HCPCS,0636,RC,60505-6231-00,NDC,,both,1,UN,54.10,35.16,,,,,,,,,,,,,
CUP ACET CEM 22 MM HIP HW W/ PLATE,SUP-2447855,CDM,C1776,CPT,0278,RC,,,,both,,,1624.95,1056.22,,,,,,,,,,,,,
MESH HERN W6XL6IN POLYPR VENTRAL BIOABSRB FLX MFIL SQ,SUP-2219765,CDM,C1781,HCPCS,0278,RC,,,,both,,,1854.33,1205.31,,,,,,,,,,,,,
ELECTRODE ES URLGY 26FR DIA PNTD TIP FACMI USAELTE LATEX F,SUP-2721389,CDM,2720000010,LOCAL,0272,RC,,,,both,,,371.93,241.75,,,,,,,,,,,,,
SCREW SCHANZ SELF DRILLING 4.0MM 175MM HA COATING STER,SUP-2547743,CDM,C1713,HCPCS,0278,RC,,,,both,,,781.42,507.92,,,,,,,,,,,,,
ANCHOR SUT DIA5.5MM W/ SZ 3-0 BIOCRYLRAPIDE ORTHOCORD SUT,SUP-2256658,CDM,C1713,HCPCS,0278,RC,,,,both,,,2681.56,1743.01,,,,,,,,,,,,,
CATHETER EP JSN 5 MM SPC 5 FRX120 CM 1 MM,SUP-2356793,CDM,C1730,HCPCS,0272,RC,,,,both,,,120.61,78.40,,,,,,,,,,,,,
MIDOSTAURIN 25 MG PO CAPS,RX-138604,CDM,2500000003,HCPCS,0250,RC,00078-0698-99,NDC,,both,1,UN,1035.20,672.88,,,,,,,,,,,,,
KIT CATH HEMODIALYSI NIAG ACUTE 13.5FR DIA 20CML INS 5593200,SUP-2632908,CDM,C1752,HCPCS,0278,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
GRAFT DERMAL THCK 12X6 CMX0.8-1.7 MM BRST KT ACELLULAR DERM,SUP-2307009,CDM,C1762,CPT,0278,RC,,,,both,,,12294.26,7991.27,,,,,,,,,,,,,
HEAD FEM M DIA36MM HIP PNK BIOLOX DELT ALUMINA MTRX 12/14,SUP-2304836,CDM,C1776,CPT,0278,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
GRAFT SPNG CANC 1.4,SUP-2415401,CDM,C1713,HCPCS,0278,RC,,,,both,,,3585.88,2330.82,,,,,,,,,,,,,
CATHETER TEMP PACE DIA 5 FR TRNSVEN BPLR BALLOON,SUP-2126032,CDM,2720000010,LOCAL,0272,RC,,,,both,,,580.90,377.58,,,,,,,,,,,,,
GRAFT VASC GELSFT L 25 CM DIA22 MM POLYESTER GEL ABD PERIPH,SUP-2384949,CDM,C1768,CPT,0278,RC,,,,both,,,1228.24,798.36,,,,,,,,,,,,,
CLOTRIMAZOLE 1 % VA CREA,RX-1769,CDM,6370000000,HCPCS,0637,RC,51672-2003-06,NDC,,both,45,GR,18.30,11.89,,,,,,,,,,,,,
CUFF VENTRICULAR ASST DEV APCL SLD STRL HEARTMATE 3,SUP-2895266,CDM,C1889,HCPCS,0278,RC,,,,both,,,1695.60,1102.14,,,,,,,,,,,,,
NIVOLUMAB 10 MG/ML IV (MIXTURES ONLY),RX-1150051,CDM,J9299,HCPCS,0636,RC,00003-3772-11,NDC,,both,4,ML,3812.70,2478.25,,,,,,,,,,,,,
SPACER HUM +12MM OFFSET 12DEG TRABECULAR MTL,SUP-2199141,CDM,C1776,CPT,0278,RC,,,,both,,,2428.79,1578.71,,,,,,,,,,,,,
SYSTEM RETRACTOR VIEWLINE,SUP-2415684,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3925.00,2551.25,,,,,,,,,,,,,
FIBER LASER 197 FT KRA-CPAOCHXL HDMI,SUP-2798094,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1742.73,1132.77,,,,,,,,,,,,,
KIT DBS EXT TST CABLE STRL DISP SENSIGHT,SUP-2882983,CDM,2720000010,LOCAL,0272,RC,,,,both,,,447.45,290.84,,,,,,,,,,,,,
OXYTOCIN 30 UNITS IN 500 ML INFUSION,RX-40850002,CDM,J2590,HCPCS,0636,RC,09999-9900-87,NDC,,both,500,ML,66.20,43.03,,,,,,,,,,,,,
SET URET STENT L 24 CM DIA 7 FR GUIDEWIRE L 145 CM DIA 0.038,SUP-2171274,CDM,C2617,HCPCS,0278,RC,,,,both,,,422.80,274.82,,,,,,,,,,,,,
MESH HERN COMP 20X15 CM MONOFILAMENT EZ TO USE PARIETENE DS,SUP-2752203,CDM,C1781,HCPCS,0278,RC,,,,both,,,10035.31,6522.95,,,,,,,,,,,,,
HFN IN CAP FLUSH IMPINGING STER,SUP-2588691,CDM,C1713,HCPCS,0278,RC,,,,both,,,571.95,371.77,,,,,,,,,,,,,
PLATE BNE L29MM THK1MM NONSTERILE DORS MTCRPL HND TI LOK VAR,SUP-2181015,CDM,C1713,HCPCS,0278,RC,,,,both,,,1875.21,1218.89,,,,,,,,,,,,,
TUBE TRACH SZ 8.0 CUF X HORZ LEN PVC BLU LN,SUP-2351967,CDM,2720000010,LOCAL,0272,RC,,,,both,,,178.89,116.28,,,,,,,,,,,,,
CATHETER CV TY 7 FRX20 CM 3L RIFAMPIN SPECTRUM,SUP-2759832,CDM,C1751,HCPCS,0278,RC,,,,both,,,367.79,239.06,,,,,,,,,,,,,
CATHETER INTVASC OCCL ECLIPSE 2L BALLOON L 9 MM DIA 6 MM,SUP-2717629,CDM,C2628,HCPCS,0272,RC,,,,both,,,5322.30,3459.49,,,,,,,,,,,,,
GUIDEWIRE VASC L 180 CM DIA 0.035 IN TAPR L 7 CM FLX TIP 6,SUP-2167743,CDM,C1769,HCPCS,0272,RC,,,,both,,,33.35,21.68,,,,,,,,,,,,,
COUNTERSINK SURG FT ANK CANN FOR 2/2.4MM QUICKFIX SCR SYS,SUP-2122469,CDM,2720000010,LOCAL,0272,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
NAIL IM 10X300 MM LT TIBIOTALOCALCANEAL PHANTOM P31300300LS,SUP-2743195,CDM,C1713,HCPCS,0278,RC,,,,both,,,10362.00,6735.30,,,,,,,,,,,,,
SCREW CANC TI 4MMX1422MM TL9MM,SUP-2695552,CDM,C1713,HCPCS,0278,RC,,,,both,,,149.46,97.15,,,,,,,,,,,,,
KIT AUTOTRNS AUTOLGS PLT CONC DISP FOR HARV SMARTPREP 2 51404] TERUMO CARDIOVASCULAR],SUP-2384888,CDM,C1713,HCPCS,0278,RC,,,,both,,,1271.70,826.60,,,,,,,,,,,,,
SPACER 46X3MM M LT,SUP-2209017,CDM,C1776,CPT,0278,RC,,,,both,,,12629.08,8208.90,,,,,,,,,,,,,
PRESSURIZER BONE CEM ACET 1 EA,SUP-2408532,CDM,C1713,HCPCS,0278,RC,,,,both,,,420.76,273.49,,,,,,,,,,,,,
PLATE BNE L235MM 10 H ST R PERIARTC PROX HUM S STL LOK LO,SUP-2177815,CDM,C1713,HCPCS,0278,RC,,,,both,,,6004.25,3902.76,,,,,,,,,,,,,
HC Portal Vein Catheterization,PX-3613648100,CDM,36481,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
SHEATH INTRO PERFRMR L 85 CM OD 8 FR ID 2.6 MM GUIDEWIRE,SUP-2168368,CDM,C1894,HCPCS,0272,RC,,,,both,,,213.21,138.59,,,,,,,,,,,,,
PACEMAKER CARD SENSIA DR W 47.9 X H 44.7 MM D 7.5 MM TI 2,SUP-2282481,CDM,C1785,HCPCS,0275,RC,,,,both,,,7899.14,5134.44,,,,,,,,,,,,,
SCREW BONE SELFTAPPING 2.7X6 MM CORTEX FOREFOOT MIDFOOT FULL,SUP-2837199,CDM,C1713,HCPCS,0278,RC,,,,both,,,213.21,138.59,,,,,,,,,,,,,
IMPLANT OSS L5.8MM FLNG DIA3.5MM 1.17MM HA HD HAPEX SHFT,SUP-2312813,CDM,L8613,CPT,0278,RC,,,,both,,,1230.28,799.68,,,,,,,,,,,,,
SET INT FIX SCREW DIA1.5 MM 2 H TI NEURO STR PLT 12 PK STRL,SUP-2935487,CDM,C1713,HCPCS,0278,RC,,,,both,,,7871.98,5116.79,,,,,,,,,,,,,
STEM HUM L125MM OD9.5MM UNIV CO CHROM SHLDR PRI CEM IMP,SUP-2404714,CDM,C1776,CPT,0278,RC,,,,both,,,11275.74,7329.23,,,,,,,,,,,,,
MARKER BRST BX 11GA FOR PRB 11 MAMMOMARK,SUP-2195638,CDM,A4648,CPT,0278,RC,,,,both,,,333.15,216.55,,,,,,,,,,,,,
BIT DRL CANN 2X145 MM QC STRL,SUP-2563798,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1400.94,910.61,,,,,,,,,,,,,
SUPPORT ORTHOT THOR LUMBAR SACR CUST FLX TRUNK SUPP,SUP-2435537,CDM,L0450,HCPCS,0272,RC,,,,both,,,460.07,299.05,,,,,,,,,,,,,
MESH SURG SM ARC THK0.4MM SLV CRANIOFACIAL TI MALL CNTOUR,SUP-2181574,CDM,C1781,HCPCS,0278,RC,,,,both,,,2566.01,1667.91,,,,,,,,,,,,,
SHEATH INTRO DIA2.8 FR PEELWY STRL,SUP-2384065,CDM,C1894,HCPCS,0272,RC,,,,both,,,74.10,48.16,,,,,,,,,,,,,
SHUNT CV DIA275MM 14MM BTWN BLB IC SIL TAPR TIP RADPQ,SUP-2278142,CDM,C1889,HCPCS,0278,RC,,,,both,,,255.41,166.02,,,,,,,,,,,,,
PLATE BONE THK0.8MM 6 H LCK COMPR BILAT NEUT MALL FOR,SUP-2107082,CDM,C1713,HCPCS,0278,RC,,,,both,,,1193.20,775.58,,,,,,,,,,,,,
SET URET STENT UTHANE L 24 CM POS L 46 CM DIA 7.0 FR SLV L,SUP-2168928,CDM,C2617,HCPCS,0278,RC,,,,both,,,441.58,287.03,,,,,,,,,,,,,
PLATE BNE L118MM 9 H CNTOUR LOK 2 COMPR FOR 3.5MM SCR UNIV,SUP-2411376,CDM,C1713,HCPCS,0278,RC,,,,both,,,1003.92,652.55,,,,,,,,,,,,,
SYSTEM IV INFUSION 4 FRX135 CM 10 CM 1 CC,SUP-2740490,CDM,2720000010,LOCAL,0272,RC,,,,both,,,397.21,258.19,,,,,,,,,,,,,
ALLOGRAFT BNE 10 CC FIBER VIABLE MTRX FIBERCEL,SUP-2541277,CDM,C1713,HCPCS,0278,RC,,,,both,,,16328.00,10613.20,,,,,,,,,,,,,
BLADE SAW 6 MM GRFT HARV TRITON,SUP-2628263,CDM,2720000010,LOCAL,0272,RC,,,,both,,,837.60,544.44,,,,,,,,,,,,,
CLIP ANEURYSM SUNDTKEES 9MM FENESTRATED STRAIGHT 201686,SUP-2848947,CDM,C1889,HCPCS,0278,RC,,,,both,,,795.61,517.15,,,,,,,,,,,,,
GRAFT HUM TISS SZ 9 MM TRICORT WDG,SUP-2913402,CDM,C1762,CPT,0278,RC,,,,both,,,5991.12,3894.23,,,,,,,,,,,,,
HC MRI-Chest W Contrast,PX-6107155100,CDM,71551,CPT,0610,RC,,,,both,,,4190.00,2723.50,,,,,,,,,,,,,
CATHETER ANGIOPLSTY RINGER BALLOON L 20 MM DIA 4.5 MM,SUP-2910485,CDM,C1725,HCPCS,0272,RC,,,,both,,,8792.00,5714.80,,,,,,,,,,,,,
SIZER SURG NACL BRST CNTOUR PROF HI STRL,SUP-2748623,CDM,2720000010,LOCAL,0272,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
SHUNT SURG STD MINI LO FLO THREE-PIECE CATH W/ORESERVOIR NPH,SUP-2666623,CDM,C1889,HCPCS,0278,RC,,,,both,,,9293.24,6040.61,,,,,,,,,,,,,
KIT BNE CEM 180GM MIX UNIV W/ BWL CART TWR HI VAC ROTOR,SUP-2366877,CDM,C1713,HCPCS,0278,RC,,,,both,,,253.87,165.02,,,,,,,,,,,,,
HC X-Ray Ankle Rout 3 Views,PX-3207361000,CDM,73610,CPT,0320,RC,,,,both,,,558.00,362.70,,,,,,,,,,,,,
SCREW BNE SEMICONSTRAINED 4.5X25 MM WRST LCK CAP STRL FRDM,SUP-2852884,CDM,C1713,HCPCS,0278,RC,,,,both,,,1457.37,947.29,,,,,,,,,,,,,
ZINC OXIDE 40 % EX PSTE,RX-110359,CDM,6370000000,HCPCS,0637,RC,69968-0006-11,NDC,,both,28,GR,11.30,7.34,,,,,,,,,,,,,
INTRODUCER DIAG PEEL-APART L 15 CM DIA 6.5 FR PTFE PERC LNG,SUP-2127715,CDM,C1894,HCPCS,0272,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
STEM HUM L132MM DIA10MM STD UNIV SHLDR TI GLOB AP,SUP-2249966,CDM,C1776,CPT,0278,RC,,,,both,,,6908.00,4490.20,,,,,,,,,,,,,
CAGE SPNL 20 DEG 34X24X8 MM ALIF MODULUS,SUP-2736327,CDM,C1889,HCPCS,0278,RC,,,,both,,,17898.00,11633.70,,,,,,,,,,,,,
MESH GYN W3XL24CM POLYPR UNIDIR Y CNTOUR FOR TRANSABDOMINAL,SUP-2165313,CDM,C1781,HCPCS,0278,RC,,,,both,,,3719.33,2417.56,,,,,,,,,,,,,
MESH CRAN CUSTOMIZED + LG PRIORITY STRL MEDPOR,SUP-2862759,CDM,C1713,HCPCS,0278,RC,,,,both,,,64996.02,42247.41,,,,,,,,,,,,,
DIBUCAINE 1 % EX OINT,RX-2412,CDM,6370000000,HCPCS,0637,RC,00536-1211-95,NDC,,both,28,GR,22.10,14.36,,,,,,,,,,,,,
VALVE TRACH SPEAK CLR,SUP-2322025,CDM,L8501,HCPCS,0272,RC,,,,both,,,198.61,129.10,,,,,,,,,,,,,
ALLOGRAFT BNE GRND 30 CC FD IRRADIATED CANC,SUP-2867069,CDM,C1762,CPT,0278,RC,,,,both,,,1422.89,924.88,,,,,,,,,,,,,
BIT DRL ADJ,SUP-2792032,CDM,2720000010,LOCAL,0272,RC,,,,both,,,887.74,577.03,,,,,,,,,,,,,
SHUNT CSF 0-20CM H2O WITH DISTAL CATHETER PROGAV 2 PROSA,SUP-2821879,CDM,C1889,HCPCS,0278,RC,,,,both,,,17562.84,11415.85,,,,,,,,,,,,,
WASHER LKNG STTSCH RFNA 5 DEG RT ST,SUP-2718097,CDM,C1713,HCPCS,0278,RC,,,,both,,,2873.73,1867.92,,,,,,,,,,,,,
PLATE BNE H0.6MM BAR L4MM 5 H MID FACE G TI Y LEIBINGER,SUP-2366250,CDM,C1713,HCPCS,0278,RC,,,,both,,,537.13,349.13,,,,,,,,,,,,,
BOLT IM L62MM DIA3.9MM STRL BLU CORT TI ST FULL THRD LCK,SUP-2192220,CDM,C1713,HCPCS,0278,RC,,,,both,,,723.93,470.55,,,,,,,,,,,,,
PLATE BNE L 142 X W 9.5 MM THK 1.5 MM SCREW DIA 3.5 MM 12 H 72440512N,SUP-2933099,CDM,C1713,HCPCS,0278,RC,,,,both,,,1368.85,889.75,,,,,,,,,,,,,
ENDCAP HUM L50MM TI PROX SHLDR INTERCALARY FLUT MRS,SUP-2376503,CDM,C1713,HCPCS,0278,RC,,,,both,,,3054.91,1985.69,,,,,,,,,,,,,
DILATOR NOTTINGHAM 1 STP HYDR+ COAT 12 FR TO 18 FR TAPR 70CM,SUP-2139732,CDM,C2627,HCPCS,0272,RC,,,,both,,,431.00,280.15,,,,,,,,,,,,,
SHEATH INTRO 14FR 15CML DRNGE CATH BAN PEEL,SUP-2141071,CDM,C1894,HCPCS,0272,RC,,,,both,,,142.46,92.60,,,,,,,,,,,,,
PLATE BONE 4 H 3RD LCK TBLR,SUP-2122775,CDM,C1713,HCPCS,0278,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
PLATE BNE FUSION LG MIDFOOT FT STRL A.L.P.S,SUP-2466502,CDM,C1713,HCPCS,0278,RC,,,,both,,,2546.29,1655.09,,,,,,,,,,,,,
WAND ABLAT PTR PLSM 2 ORNG DEPTH MRK REFLX ULT,SUP-2342037,CDM,2720000010,LOCAL,0272,RC,,,,both,,,956.13,621.48,,,,,,,,,,,,,
CATHETER URET 7.0FRX70CM OPN END POLYVINYLCHLORIDE,SUP-2168888,CDM,C1758,HCPCS,0278,RC,,,,both,,,32.19,20.92,,,,,,,,,,,,,
"HC New Pt, E/M Level 2",PX-5109920200,CDM,99202,CPT,0510,RC,,,,both,,,296.00,192.40,,,,,,,,,,,,,
DEFIBRILLATOR IMPL LUMAX 740 HF-T 59 X66MM 13MM CELLULAR 40J,SUP-2138411,CDM,C1882,HCPCS,0275,RC,,,,both,,,84780.00,55107.00,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY L 80 CM DIA 5 FR SPC 5 MM D CRV,SUP-2248644,CDM,C1730,HCPCS,0272,RC,,,,both,,,1777.24,1155.21,,,,,,,,,,,,,
CATHETER INTVASC OCCL EQL L 65 CM DIA 7 FR BALLOON DIA27 MM,SUP-2147469,CDM,C2628,HCPCS,0272,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
SCREW GLEN L 40 MM DIA 8 MM REV MOD CNTRL STRL ALTIVATE RVS,SUP-2904156,CDM,C1776,CPT,0278,RC,,,,both,,,6250.17,4062.61,,,,,,,,,,,,,
SAW HAND JSPH 7 1/2NL 37MML BLADE NASAL RGHT ANGLD BNT PDGTT,SUP-2468502,CDM,2720000010,LOCAL,0272,RC,,,,both,,,457.37,297.29,,,,,,,,,,,,,
"HC New Pt, Outpt Visit Level 4",PX-7619920400,CDM,99204,CPT,0761,RC,,,,inpatient,,,344.00,223.60,,,,,,,,,,,,,
GUIDEWIRE URO L150CM 0038IN S STL PTFE STR TIP SMOOTH FLAT,SUP-2312597,CDM,C1769,HCPCS,0272,RC,,,,both,,,113.07,73.50,,,,,,,,,,,,,
HC So Hepatitis B Core Antibody,PX-3028670466,CDM,86704,CPT,0302,RC,,,,inpatient,,,59.00,38.35,,,,,,,,,,,,,
GRAFT VASC GORTX L 10 CM DIA 3 MM EPTFE TW PED SHUNT STRL,SUP-2396676,CDM,C1768,CPT,0278,RC,,,,both,,,995.38,647.00,,,,,,,,,,,,,
BRACE WRST SUPP LG 7.5-8.5 IN RT STABILIZING,SUP-2196519,CDM,L3931,HCPCS,0274,RC,,,,both,,,26.72,17.37,,,,,,,,,,,,,
IMPLANT OP RM MINI-MONSTER 4.0 X 28MM H,SUP-2320541,CDM,C1713,HCPCS,0278,RC,,,,both,,,741.04,481.68,,,,,,,,,,,,,
PIN EXTERNAL FIXATION HALF XSHORT 5X35 MM TITANIUM NITRIDE S,SUP-2836776,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1102.58,716.68,,,,,,,,,,,,,
COMPONENT ARTC SURF KNEE,SUP-2200488,CDM,C1776,CPT,0278,RC,,,,both,,,1886.51,1226.23,,,,,,,,,,,,,
SUBSTITUTE BNE GRFT 35X20X7MM SM DEMIN BNE CANC N IRRADIATED,SUP-2354398,CDM,C1713,HCPCS,0278,RC,,,,both,,,1924.82,1251.13,,,,,,,,,,,,,
PLATE BONE W14XL210MM THK3.8MM 90DEG 11 H LT TIB S STL L SHP,SUP-2185792,CDM,C1713,HCPCS,0278,RC,,,,both,,,2391.93,1554.75,,,,,,,,,,,,,
ALLOGRAFT HUM TISS XL 60X210 MM FD FASC LATA,SUP-2792181,CDM,C1762,CPT,0278,RC,,,,both,,,4396.00,2857.40,,,,,,,,,,,,,
PLATE BONE DUAL CMPRSSN HLX16 CNTRD F/3.5MM LOK SCREW ST,SUP-2495380,CDM,C1713,HCPCS,0278,RC,,,,both,,,2076.36,1349.63,,,,,,,,,,,,,
MESH SYN W10XL15CM THK2MM EPTFE ABD OVL BIOMATERIAL,SUP-2395345,CDM,C1781,HCPCS,0278,RC,,,,both,,,2270.22,1475.64,,,,,,,,,,,,,
SLING SHLDR UNIV SWTH W5XL54IN PCH W13XL19IN LTWT PERF FOAM,SUP-2195038,CDM,L3660,HCPCS,0274,RC,,,,both,,,27.41,17.82,,,,,,,,,,,,,
SCREW BNE PART THRD 5X55 MM PANTA,SUP-2609753,CDM,C1713,HCPCS,0278,RC,,,,both,,,2072.65,1347.22,,,,,,,,,,,,,
KIT SURG PROC 2 SPLNT PT SPEC INSTR PLN,SUP-2194242,CDM,2720000010,LOCAL,0272,RC,,,,both,,,9945.95,6464.87,,,,,,,,,,,,,
AGENT HEMOSTATIC NOZ L 10 CM 1.65 GM THROM PRELD BLLW STRL,SUP-2898789,CDM,2720000010,LOCAL,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
STENT BILI L24MM BLLN L25MM DIA5MM CATH L80CM DIA6FR,SUP-2159026,CDM,C1876,HCPCS,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
BRACE ORTHOPEDIC TLSO LUMBAR S/C SHELL/PANEL PREFABRICATED,SUP-2265012,CDM,L0450,HCPCS,0272,RC,,,,both,,,4998.88,3249.27,,,,,,,,,,,,,
SCREW BNE L 75 MM DIA 3.5 MM TI LCK T15 STARDRV NS V,SUP-2905977,CDM,C1713,HCPCS,0278,RC,,,,both,,,1175.36,763.98,,,,,,,,,,,,,
APPLIER PORT GASTRIC BAND DISPOSABLE RAPIDPORT EZ,SUP-2119242,CDM,2720000010,LOCAL,0272,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
COMPONENT ULN L75MM 4MM OFFSET BOND COAT RT ELBW BEAR DISCVR,SUP-2136204,CDM,C1776,CPT,0278,RC,,,,both,,,13831.70,8990.60,,,,,,,,,,,,,
PLATE POS QUADANG 110 DEG/90 DEG/90 DEG/70 DEG,SUP-2548637,CDM,C1713,HCPCS,0278,RC,,,,both,,,356.67,231.84,,,,,,,,,,,,,
DISSECTOR ENDOSCP L18CM ARTC W/ TRNSF TAPE LUMITIP,SUP-2124450,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
RING ACET HIP TI POLY CONSTRN X RET RNGLOC II,SUP-2403875,CDM,C1776,CPT,0278,RC,,,,both,,,640.56,416.36,,,,,,,,,,,,,
PIN FIXATION L40MM DIAMETER 4.5MM PLLA SELF REINFORCED SMART,SUP-2855304,CDM,C1713,HCPCS,0278,RC,,,,both,,,532.98,346.44,,,,,,,,,,,,,
GUIDEWIRE VASC STR 3 CM 035X260 STIFF COR HYDRPHLC CANALIZER,SUP-2120023,CDM,C1769,HCPCS,0272,RC,,,,both,,,160.77,104.50,,,,,,,,,,,,,
ELECTRODE RF ABLATIONXL 25CM 7CM STARBURST,SUP-2117214,CDM,2720000010,LOCAL,0272,RC,,,,both,,,715.92,465.35,,,,,,,,,,,,,
SEALANT TISS 10 CC FOR HUM FIBRIN VISTASEAL,SUP-2427765,CDM,C1713,HCPCS,0278,RC,,,,both,,,1562.65,1015.72,,,,,,,,,,,,,
CARTRIDGE SAW TIP OSCILLATING FALCON 25 x 1.27 x 90mm,SUP-2364923,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1472.66,957.23,,,,,,,,,,,,,
SEED BRACHYTHERAPY LOAD 3.01-4.0 MCI STRL ADVANTAGE 2029DLS1] ISOAID LLC],SUP-2247266,CDM,C2640,HCPCS,0278,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
LEVEL CMF PLATE MINI FRN CVD 20 MM SCRW5 HOLE T10 MM CP TT,SUP-2677936,CDM,C1713,HCPCS,0278,RC,,,,both,,,478.47,311.01,,,,,,,,,,,,,
COMPONENT HIP BPLR 5 HIP5ZI1800] ZIMMER BIOMET INC],SUP-2212583,CDM,C1776,CPT,0278,RC,,,,both,,,10048.00,6531.20,,,,,,,,,,,,,
CATHETER ANGIOPLSTY L135CM SHFT OD5.8FR BAL L4CM OD10MM OVR,SUP-2139692,CDM,C1725,HCPCS,0272,RC,,,,both,,,581.59,378.03,,,,,,,,,,,,,
ALLOGRAFT BNE CHIPS 1-8 MM 5 CC CANC DEMINERALIZED BNE BIO,SUP-2637035,CDM,C1713,HCPCS,0278,RC,,,,both,,,1827.86,1188.11,,,,,,,,,,,,,
DRESSING BIOLOGICAL L15XW6CM PORCINE EXTRACELLULAR MATRIX SHEET STERILE DISPOSABLE FOR SOFT TISSUE REINFORCEMENT MATRISTEM RS,SUP-2106516,CDM,Q4166,HCPCS,0636,RC,,,,both,,,4184.99,2720.24,,,,,,,,,,,,,
BASEPLATE TIB 1F 2T CEM UNIV PRI REV STEM STD CO CHROM,SUP-2221014,CDM,C1776,CPT,0278,RC,,,,both,,,9043.20,5878.08,,,,,,,,,,,,,
PLATE BNE ANGLED 2.8 MM LT 7X23 HOLE RECON PT SPEC,SUP-2860108,CDM,C1713,HCPCS,0278,RC,,,,both,,,28659.72,18628.82,,,,,,,,,,,,,
SCREW BNE L40MM DIA5MM HEX HD DIA3.5MM CORT TIB TI ALLY FIX,SUP-2413027,CDM,C1713,HCPCS,0278,RC,,,,both,,,579.58,376.73,,,,,,,,,,,,,
PLATE BNE MEDL CLMN SM 2.7/3.5 MM MIDFOOT 9 HOLE COMPR TI,SUP-2398186,CDM,C1713,HCPCS,0278,RC,,,,both,,,4662.90,3030.88,,,,,,,,,,,,,
IMPLANT OPHTH NORTH CAROLINA EYE BNK,SUP-2309109,CDM,V2785,HCPCS,0810,RC,,,,both,,,13816.00,8980.40,,,,,,,,,,,,,
DRAINAGE KIT CUST,SUP-2302899,CDM,C1729,HCPCS,0272,RC,,,,both,,,423.81,275.48,,,,,,,,,,,,,
PEG FEM AUG THK10MM KNEE VANGUARD,SUP-2407853,CDM,C1776,CPT,0278,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
CATHETER CV FULL SAFETY TY 032 7 FRX26.5 CM 3L STD,SUP-2759919,CDM,C1751,HCPCS,0278,RC,,,,both,,,367.00,238.55,,,,,,,,,,,,,
VERSACROSS RF WIRE 12.5FR 180CM/67CM PIGTAIL D0,SUP-2857954,CDM,C1769,HCPCS,0272,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
PIN HALF EXT FIX UNILAT 6MM DIA 25MM THRD LEN TI ALLY HEX,SUP-2342849,CDM,C1713,HCPCS,0278,RC,,,,both,,,1921.90,1249.23,,,,,,,,,,,,,
PASSER SUT L220MM 45DEG NIT LT CRV EXT REINF SHFT FOR HIP,SUP-2121815,CDM,2720000010,LOCAL,0272,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
FORCEPS BX STD 5.5FR L50CM SHFT 1.85MM INT JUG APPRCH DISP,SUP-2157334,CDM,2720000010,LOCAL,0272,RC,,,,both,,,452.16,293.90,,,,,,,,,,,,,
SYSTEM DEL FLIPPER L 80 CM DIA 0.041 IN GUIDEWIRE 0.035 IN,SUP-2168802,CDM,C1889,HCPCS,0278,RC,,,,both,,,348.23,226.35,,,,,,,,,,,,,
IMPLANT HUM TISS L 7 X W 7 CM PLCNTA MTRX MEMBRN MINIMALLY,SUP-2905531,CDM,C1762,CPT,0278,RC,,,,both,,,14616.70,9500.85,,,,,,,,,,,,,
PRESSURE INJECT AG BL THREE-LUM PI CVC KIT 3-L 7 FR X 20 CM,SUP-2660679,CDM,C1751,HCPCS,0278,RC,,,,both,,,423.74,275.43,,,,,,,,,,,,,
HANDPIECE LASER 125 MM W/ SMK EVAC,SUP-2713687,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5620.60,3653.39,,,,,,,,,,,,,
COIL EMB L10CM OD0.020IN NIT J STRTCH RESIST FILL SFT STBL,SUP-2323421,CDM,C1889,HCPCS,0278,RC,,,,both,,,7281.66,4733.08,,,,,,,,,,,,,
SCREW BONE L76MM OD3.5MM COARSE THRD CRUCFRM WDRUFF HD,SUP-2362307,CDM,C1713,HCPCS,0278,RC,,,,both,,,25.81,16.78,,,,,,,,,,,,,
ALLOGRAFT BNE BOAT 100X25 MM 10 CC FD DBM CORTICAL FIBER,SUP-2717787,CDM,C1713,HCPCS,0278,RC,,,,both,,,8365.37,5437.49,,,,,,,,,,,,,
KETAMINE HCL 100 MG/100ML IV SOLN,RX-151558,CDM,2500000003,HCPCS,0250,RC,09999-9916-97,NDC,,both,100,ML,68.50,44.52,,,,,,,,,,,,,
ENDOPROSTHESIS VASC VIABAHN L 15CM 8MM 75CM 8FR HEPARIN,SUP-2396622,CDM,C1874,HCPCS,0278,RC,,,,both,,,11906.88,7739.47,,,,,,,,,,,,,
ASSEMBLY VALGUS BUSHING,SUP-2359179,CDM,C1776,CPT,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
DEFIBRILLATOR IMPL EPIC + DR THK 12.9 MM 30 J 33 CC 70 GM TI,SUP-2356542,CDM,C1721,HCPCS,0275,RC,,,,both,,,80070.00,52045.50,,,,,,,,,,,,,
OMNI BASE HYSTEROSCOPE,SUP-2721031,CDM,2720000010,LOCAL,0272,RC,,,,both,,,15684.30,10194.79,,,,,,,,,,,,,
TRAY CATH HEMODIALYSI 400XL ACTE 14FR DIA 24CM STRGHT TAPR T,SUP-2610528,CDM,C1752,HCPCS,0278,RC,,,,both,,,295.16,191.85,,,,,,,,,,,,,
GRAFT DERM ALLGRFT DERM 1MM 16X20CM CORTIVA,SUP-2335287,CDM,C1762,CPT,0278,RC,,,,both,,,24598.13,15988.78,,,,,,,,,,,,,
GUIDEWIRE 1.2MMX9IN BX OF 5 STRL,SUP-2341058,CDM,C1769,HCPCS,0272,RC,,,,both,,,121.20,78.78,,,,,,,,,,,,,
GRAFT HUM TISS 9.5SQCM AMNIO MEMBRN MESH ALLGRFT DEHYDR N,SUP-2305742,CDM,Q4186,HCPCS,0636,RC,,,,both,,,4772.80,3102.32,,,,,,,,,,,,,
BRIDGE TELSCP W/ 2 LOK CHAN,SUP-2261152,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2577.91,1675.64,,,,,,,,,,,,,
SCREW BONE CORT MALL 4.5X35 MM,SUP-2184386,CDM,C1713,HCPCS,0278,RC,,,,both,,,54.60,35.49,,,,,,,,,,,,,
PEG FIX LCK 2.2X10 MM SMOOTH NS DVR,SUP-2462037,CDM,C1713,HCPCS,0278,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
SET CLLR AD H2 1/4IN FOR 13-21IN NK SHT BLU PLAS HK AND,SUP-2124215,CDM,L0172,HCPCS,0272,RC,,,,both,,,96.96,63.02,,,,,,,,,,,,,
GRAFT BONE SUBSTITUTE 1ML GEL MIXED WITH PRP DERIVED FROM WHOLE BLOOD OR BONE MARROW STIMUBLAST,SUP-2120746,CDM,C1713,HCPCS,0278,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
CHIARI MLFRMTN PLATE MDFD CRSCNT SHAPE 06MM THICK CP TTNM,SUP-2707375,CDM,C1713,HCPCS,0278,RC,,,,both,,,3433.87,2232.02,,,,,,,,,,,,,
SCREW SET MULTAXL 6.5X45 MM FOR 4.75 MM ROD FEN CD HORZ,SUP-2629320,CDM,C1713,HCPCS,0278,RC,,,,both,,,4027.05,2617.58,,,,,,,,,,,,,
JOINT TOE ANGLED 0 DEG 16 MM PIP IM 1 PC NIT SMRT TOE II,SUP-2431339,CDM,C1776,CPT,0278,RC,,,,both,,,2624.41,1705.87,,,,,,,,,,,,,
SODIUM TETRADECYL SULFATE 3 % IV SOLN,RX-41793,CDM,2500000003,HCPCS,0250,RC,24201-0201-01,NDC,,both,2,ML,442.80,287.82,,,,,,,,,,,,,
INSTRUMENT ROD CUT STRL DISP CARBOCLEAR,SUP-2883028,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
DILATOR FASCIAL SET 14FR 20CM,SUP-2665305,CDM,C2627,HCPCS,0272,RC,,,,both,,,50.55,32.86,,,,,,,,,,,,,
HEAD FEM UPLR 58 MM HIP,SUP-2207891,CDM,C1776,CPT,0278,RC,,,,both,,,1422.42,924.57,,,,,,,,,,,,,
ELECTRODE NDL CANN L25CM ARRY DIA3.5CM FOR OPN AND PERC RF,SUP-2139747,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5761.90,3745.23,,,,,,,,,,,,,
CONNECTOR SPNL OFFSET 35-47.5 MM UPPER THOR DOMINO INFIN,SUP-2285408,CDM,C1713,HCPCS,0278,RC,,,,both,,,2646.58,1720.28,,,,,,,,,,,,,
GUIDEWIRE INTRO L 450 MM DIA2.8 MM THRD NS DISP,SUP-2905628,CDM,C1769,HCPCS,0272,RC,,,,both,,,925.01,601.26,,,,,,,,,,,,,
GRAFT BNE SUB 10CC VI DIA3MM CA SULF PELLET RESRB PRELD,SUP-2399038,CDM,C1713,HCPCS,0278,RC,,,,both,,,2165.69,1407.70,,,,,,,,,,,,,
GUIDEWIRE ORTH FOR BIOCOMPRESSION SCR,SUP-2121893,CDM,C1769,HCPCS,0272,RC,,,,both,,,21.98,14.29,,,,,,,,,,,,,
PLATE BNE 12 H G ORBIT RIM CRANIOMAXILLOFACIAL TI RIG FOR,SUP-2191140,CDM,C1713,HCPCS,0278,RC,,,,both,,,1373.75,892.94,,,,,,,,,,,,,
WASHER ORTH OLECRANON SLED,SUP-2389623,CDM,C1713,HCPCS,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
KNIFE 3714171 JOSEPH BUTTON END STR,SUP-2705672,CDM,2720000010,LOCAL,0272,RC,,,,both,,,496.91,322.99,,,,,,,,,,,,,
BIT DRILL SURG 2.5 MM ALPS DISP,SUP-2607153,CDM,2720000010,LOCAL,0272,RC,,,,both,,,389.11,252.92,,,,,,,,,,,,,
SHEATH INTRO FLX ANSEL 55CM 6 FR 0.018/0.038 IN AQ MULTPURP,SUP-2169821,CDM,C1894,HCPCS,0272,RC,,,,both,,,162.84,105.85,,,,,,,,,,,,,
SCREW SPNL 4.5X35 MM FOR 4.75 MM ROD ATS CD HORZ SOLERA,SUP-2629451,CDM,C1713,HCPCS,0278,RC,,,,both,,,3355.88,2181.32,,,,,,,,,,,,,
NA FERRIC GLUC CPLX IN SUCROSE 12.5 MG/ML IV SOLN,RX-24932,CDM,J2916,HCPCS,0636,RC,00143-9570-01,NDC,,both,5,ML,182.90,118.88,,,,,,,,,,,,,
LEAD PACE L75CM CRV H16MM INTRO 5FR L HRT LO PROF STEER TIP,SUP-2356058,CDM,C1900,HCPCS,0275,RC,,,,both,,,5024.00,3265.60,,,,,,,,,,,,,
STENT BILI PRECIS L 40 MM DIA 6 MM CATH L 135 CM DIA 8 FR,SUP-2158909,CDM,C1876,HCPCS,0278,RC,,,,both,,,5887.50,3826.87,,,,,,,,,,,,,
HC Cesarean Section,PX-3609079900,CDM,3609079900,LOCAL,0360,RC,,,,outpatient,,,19177.00,12465.05,,,,,,,,,,,,,
KIT BNE CEMENT PROX FEM PRESSURIZER BRKWY NOZ RESTRICTORS,SUP-2884211,CDM,C1776,CPT,0278,RC,,,,both,,,432.82,281.33,,,,,,,,,,,,,
LUBRIFRESH P.M. OP OINT,RX-21064,CDM,6370000000,HCPCS,0637,RC,00023-0312-04,NDC,,both,3.5,GR,44.00,28.60,,,,,,,,,,,,,
VALVE SHUNT HYDROCEPHALUS 10CM H2O W/ SHUNT ASST PROGAV 2.0,SUP-2108740,CDM,C1729,HCPCS,0272,RC,,,,both,,,9010.01,5856.51,,,,,,,,,,,,,
CATHETER HAD AD 13.5FR L28CM LUMN OD2MM ID2MM TIP L11CM SIL,SUP-2127707,CDM,C1752,HCPCS,0278,RC,,,,both,,,1045.15,679.35,,,,,,,,,,,,,
HC So Rubeola Igg / Igm,PX-3028676566,CDM,86765,CPT,0302,RC,,,,both,,,121.00,78.65,,,,,,,,,,,,,
SPEAR TRCR CONCL PT OBT BIO-FASTAK,SUP-2121025,CDM,C1713,HCPCS,0278,RC,,,,both,,,1491.50,969.47,,,,,,,,,,,,,
SCREW SPNL L35MM DIA5.5MM MULT AX REV ANG THRD LOK,SUP-2287976,CDM,C1713,HCPCS,0278,RC,,,,both,,,2041.00,1326.65,,,,,,,,,,,,,
GRAFT NRV PROTCT L4CM ID7MM CLLGN ABSRB PERIPH NEURAWRAP,SUP-2245948,CDM,C9353,HCPCS,0278,RC,,,,both,,,4642.84,3017.85,,,,,,,,,,,,,
GUIDEWIRE ORTH DBL RND 1.3X480 MM AOS,SUP-2766040,CDM,C1769,HCPCS,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
MESH HERN W15XL15CM THK0.5MM SYNTH ABD ABSRB COAT POLYPR,SUP-2265977,CDM,C1781,HCPCS,0278,RC,,,,both,,,474.14,308.19,,,,,,,,,,,,,
ANCHR SUT 2.3 MM ULTRABRAID BIORAPTOR,SUP-2848600,CDM,C1713,HCPCS,0278,RC,,,,both,,,952.83,619.34,,,,,,,,,,,,,
CATHETER EP D CRV 2-2-2 MM 6 FRX120 CM RESPON,SUP-2356772,CDM,C1730,HCPCS,0272,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
GUIDEWIRE VASC L 125 CM DIA 0.025 IN TAPR L 7 CM FLPY TIP L,SUP-2167649,CDM,C1769,HCPCS,0272,RC,,,,both,,,26.63,17.31,,,,,,,,,,,,,
CATHETER THROMCTMY AXS VECTA 74 L 115 CM PROX/DSTL OD,SUP-2551066,CDM,C1757,HCPCS,0272,RC,,,,both,,,7222.00,4694.30,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY POLARIS X 270DEG L 110 CM DIA 6,SUP-2700079,CDM,C1732,HCPCS,0272,RC,,,,both,,,380.10,247.06,,,,,,,,,,,,,
HC Joint Injection/Aspir Large WO US,PX-5102061000,CDM,20610,CPT,0510,RC,,,,outpatient,,,1092.00,709.80,,,,,,,,,,,,,
BUR SURG L25.4MM DIA1MM DMND RND NONFLUTED ELITE TPS,SUP-2363320,CDM,2720000010,LOCAL,0272,RC,,,,both,,,377.11,245.12,,,,,,,,,,,,,
PLATE BONE L128MM 9 H LT LAT DSTL HUM LCK FOR 2.7/3.5MM SCR,SUP-2348657,CDM,C1713,HCPCS,0278,RC,,,,both,,,12320.26,8008.17,,,,,,,,,,,,,
NERVE STIMULATOR KIT INSUL DIL STRL SAFEOP,SUP-2726377,CDM,2720000010,LOCAL,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
HC US Retroperitoneal Limited,PX-4027677500,CDM,76775,CPT,0402,RC,,,,both,,,964.00,626.60,,,,,,,,,,,,,
SCREW BNE L55MM OD6.5MM THRD L16MM TI CALCNL CANN HD COMPR,SUP-2401070,CDM,C1713,HCPCS,0278,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
SAVI PROCEDURE KIT,SUP-2702116,CDM,2720000010,LOCAL,0272,RC,,,,both,,,89.46,58.15,,,,,,,,,,,,,
PLATE BNE L57MM 8 H L CNDYL TI RIG NONCOMPRESSION FOR 2.4MM,SUP-2191475,CDM,C1713,HCPCS,0278,RC,,,,both,,,1735.98,1128.39,,,,,,,,,,,,,
ALLOGRAFT DERMAL THCK 18X6 CM RDY TO USE TISS MTRX ALLDERM,SUP-2113013,CDM,Q4116,HCPCS,0636,RC,,,,both,,,11702.78,7606.81,,,,,,,,,,,,,
TUBE MYR OD1MM ID004IN SIL UNIQUE DSGN COLLAPSIBLE FLAP SHEA,SUP-2312636,CDM,L8699,HCPCS,0278,RC,,,,both,,,62.77,40.80,,,,,,,,,,,,,
ISOPROTERENOL HCL 0.2 MG/ML IJ SOLN,RX-4034,CDM,2500000003,HCPCS,0250,RC,69918-0735-11,NDC,,both,0.1,ML,54.10,35.16,,,,,,,,,,,,,
SET URET ACC SHTH SPLNT PEEL AWAY FINLAYSON,SUP-2171220,CDM,C1892,HCPCS,0272,RC,,,,both,,,586.30,381.09,,,,,,,,,,,,,
PHENYLEPHRINE-COCOA BUTTER 0.25-88.44 % RE SUPP,RX-126649,CDM,2500000003,HCPCS,0250,RC,00536-1186-12,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
TROCAR ENDOSCP L 100 MM DIA12 MM STD OPT FIX CANN DOLPHIN,SUP-2896173,CDM,2720000010,LOCAL,0272,RC,,,,both,,,477.88,310.62,,,,,,,,,,,,,
PLUG BNE DIA8MM SM DIAM CEM,SUP-2408547,CDM,C1713,HCPCS,0278,RC,,,,both,,,769.30,500.04,,,,,,,,,,,,,
RING ANNULPLSTY TRICSP 26MM EDW MC3 4900T26] EDWARDS LIFESCIENCES CORP],SUP-2214221,CDM,C1713,HCPCS,0278,RC,,,,both,,,8462.30,5500.49,,,,,,,,,,,,,
SYSTEM EMBOLIC PROTCT GWIRE L300CM DIA0.014IN BSKT DIA6MM,SUP-2158108,CDM,C1769,HCPCS,0272,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
SYSTEM IMPL DEL PEC REP FOR FIX OF SFT TISS TO BNE,SUP-2121669,CDM,C1776,CPT,0278,RC,,,,both,,,3705.20,2408.38,,,,,,,,,,,,,
PLATE BNE W10XL50MM THK1.5MM 4X3 H BILAT S STL T SHP R ANG,SUP-2185865,CDM,C1713,HCPCS,0278,RC,,,,both,,,868.74,564.68,,,,,,,,,,,,,
CATHETER INTVASC OCCL DIA 7 FR BALLOON L 10 MM DIA10 MM SIL,SUP-2365835,CDM,C2628,HCPCS,0272,RC,,,,both,,,3300.77,2145.50,,,,,,,,,,,,,
SYSTEM CONC WHL BLD INPUT 60ML PLT RICH POOR PLSM OUTPT,SUP-2402589,CDM,C1713,HCPCS,0278,RC,,,,both,,,3571.75,2321.64,,,,,,,,,,,,,
PIN FIX L9IN DIA3.2MM FOR COMPHSVE REV SHLDR SYS STNMN,SUP-2408538,CDM,2720000010,LOCAL,0272,RC,,,,both,,,339.12,220.43,,,,,,,,,,,,,
MARKER LOCKING SCREWS 2.3MM,SUP-2498041,CDM,C1713,HCPCS,0278,RC,,,,both,,,32.97,21.43,,,,,,,,,,,,,
CABLE CONN MULTI-RADIOFREQUENCY MOD 4 SITE V3 NS LF DISP,SUP-2859195,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7460.64,4849.42,,,,,,,,,,,,,
ELECTRODE ELECSURG RESECT LOOP 12 DEG HI FREQ ENDOSCP TURIS,SUP-2313572,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1410.39,916.75,,,,,,,,,,,,,
SCREW BNE CANN 4.5X40 MM PARTIALLY THRD TI MAXICAN,SUP-2321695,CDM,C1713,HCPCS,0278,RC,,,,both,,,683.58,444.33,,,,,,,,,,,,,
DEVICE CLOSURE VES SEAL DIA 6-12 FR FEM VEIN FASTEST HEMOSTAS STRL,SUP-2909166,CDM,C1760,HCPCS,0278,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY INQUIRY L 110 CM 7FR TIP 1 MM 2XL,SUP-2705586,CDM,C1730,HCPCS,0272,RC,,,,both,,,1226.20,797.03,,,,,,,,,,,,,
GUIDEWIRE ORTH DIA2.7MM RM ROD BALL TIP FOR PEDINAIL SYS,SUP-2318962,CDM,C1769,HCPCS,0272,RC,,,,both,,,1359.31,883.55,,,,,,,,,,,,,
PACK NEUROSURGICAL MYRIAD HNDPC L 13 CM DIA13 GA,SUP-2930213,CDM,2720000010,LOCAL,0272,RC,,,,both,,,46398.78,30159.21,,,,,,,,,,,,,
SCREW BNE L12MM OD2.7MM NONLOCKING TUFFNEK TECHNOLOGY FOR,SUP-2321174,CDM,C1713,HCPCS,0278,RC,,,,both,,,438.82,285.23,,,,,,,,,,,,,
DEVICE THROMCTMY L200CM L155CM OD.028IN REPERFUSION CATH,SUP-2323632,CDM,C1757,HCPCS,0272,RC,,,,both,,,7190.60,4673.89,,,,,,,,,,,,,
CEMENT DENT SELF CURED LUTING ENH CAP FUJI I,SUP-2226110,CDM,C1713,HCPCS,0278,RC,,,,both,,,17.02,11.06,,,,,,,,,,,,,
VALVE AORT SZ 19MM BOV PERICARD TRANSCATHETER STENTED N ROT,SUP-2214330,CDM,C1889,HCPCS,0278,RC,,,,both,,,37680.00,24492.00,,,,,,,,,,,,,
CATHETER EP ADOL AD 9FR L90CM TEMP SGL HND SELF LOK 4 W TIP,SUP-2357566,CDM,C1759,HCPCS,0272,RC,,,,both,,,6246.90,4060.48,,,,,,,,,,,,,
BUNDLE CASE DISTRCTN CRAN MXLFCL 2 FULL SKULL RECON VSP,SUP-2862826,CDM,2720000010,LOCAL,0272,RC,,,,both,,,20163.89,13106.53,,,,,,,,,,,,,
CATHETER GUID L 90 CM DIA 6 FR 2 LUMEN WDG PRESSURE LL SYR,SUP-2148864,CDM,C2628,HCPCS,0272,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
SCREW INTFR L30MM DIA9MM KNEE PLLA CANN ABSRB RND HD,SUP-2249518,CDM,C1713,HCPCS,0278,RC,,,,both,,,910.60,591.89,,,,,,,,,,,,,
AMPICILLIN SODIUM 1 G IJ SOLR,RX-469,CDM,J0290,HCPCS,0636,RC,25021-0136-10,NDC,,both,1,UN,54.10,35.16,,,,,,,,,,,,,
VALVE MITRAL 29MM MITRIS RESILIA,SUP-2854411,CDM,C1889,HCPCS,0278,RC,,,,both,,,24492.00,15919.80,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED BPLR FIX CEM STEM,SUP-2365425,CDM,C1776,CPT,0278,RC,,,,both,,,6594.00,4286.10,,,,,,,,,,,,,
CONNECTOR SHUNT 1X1.9X11 MM RT ANGLE PLAS STRL ACCU-FLO,SUP-2666412,CDM,C1889,HCPCS,0278,RC,,,,both,,,304.86,198.16,,,,,,,,,,,,,
POST EXT FIX 4 H S STL M SUPP FOR ILIZ TAY SPAT FRME EXT,SUP-2342288,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1002.07,651.35,,,,,,,,,,,,,
PROBE BRST BX DIA10GA PRB US MAMTOM ELITE,SUP-2195607,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1204.57,782.97,,,,,,,,,,,,,
CATHETER CV SINGLE LUMEN 2.7 FRX71 CM LO PROF ADPT BRVC,SUP-2127877,CDM,C1751,HCPCS,0278,RC,,,,both,,,718.62,467.10,,,,,,,,,,,,,
UNIVERS II GLENOID INSTRUMENTATION SET,SUP-2815582,CDM,C1713,HCPCS,0278,RC,,,,both,,,109900.00,71435.00,,,,,,,,,,,,,
PROBE SURG ACET NS OSCAR 3 LTX,SUP-2875713,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2034.72,1322.57,,,,,,,,,,,,,
PLATE BNE BRIM W 10.5 MM DELT H 40 MM THK 2.5 MM H SPC 12 MM,SUP-2902351,CDM,C1713,HCPCS,0278,RC,,,,both,,,9604.95,6243.22,,,,,,,,,,,,,
BROMOCRIPTINE MESYLATE 2.5 MG PO TABS,RX-9297,CDM,6370000000,HCPCS,0637,RC,00574-0106-03,NDC,,both,1,UN,14.90,9.68,,,,,,,,,,,,,
INTRODUCER SHTH 0.035 IN 5.5 FRX6 CM CHECK- FLO CLMP PERFRMR,SUP-2168846,CDM,C1894,HCPCS,0272,RC,,,,both,,,69.80,45.37,,,,,,,,,,,,,
KNIFE NDL 6 FR 7 FRX200 CM 0.035 IN 4.2 MM ACTIVE CRD FUSION,SUP-2737416,CDM,2720000010,LOCAL,0272,RC,,,,both,,,571.48,371.46,,,,,,,,,,,,,
NEEDLE BIOPSY ION 19G IF1000 (CM),SUP-2844580,CDM,2720000010,LOCAL,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
COIL EMB L20MM UNRESTRAINED L4MM DIA4MM GWIRE 0.018IN FBR,SUP-2141086,CDM,C1889,HCPCS,0278,RC,,,,both,,,227.81,148.08,,,,,,,,,,,,,
STEM FEM PRSS FT 5 HIP PRIMARY CEM UPLR/BPLR LNR POLYETH,SUP-2267799,CDM,C1776,CPT,0278,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
HEAD FEM OD32MM +8 NK LEN 12/14 TAPR CO CHROM MTL ON POLY,SUP-2205557,CDM,C1776,CPT,0278,RC,,,,both,,,5777.60,3755.44,,,,,,,,,,,,,
GRAFT SURG 1MM PROC HUM DERM CLLGN RECTANG 8CMX20CM ALLOMAX,SUP-2126262,CDM,C1781,HCPCS,0278,RC,,,,both,,,11101.16,7215.75,,,,,,,,,,,,,
GRAFT SYNTH TISS 10ML VI GRAN BONE IMPL HA PRO OSTEON 500,SUP-2413078,CDM,C1713,HCPCS,0278,RC,,,,both,,,2571.66,1671.58,,,,,,,,,,,,,
GRAFT HUMAN TSSUE MTRX 192SQCM THICK 12CMW X 16CML 23 33MM,SUP-2676529,CDM,Q4116,HCPCS,0636,RC,,,,both,,,20802.50,13521.62,,,,,,,,,,,,,
PLATE BONE W12XL167MM THK1MM 10 H BILAT TI SEMI TBLR LO PROF,SUP-2190708,CDM,C1713,HCPCS,0278,RC,,,,both,,,352.40,229.06,,,,,,,,,,,,,
PEG KIT LP 24 FRX4.4 CM PUSH W/ ENFIT 1 STP BUTTON ENDOVIVE,SUP-2463811,CDM,2720000010,LOCAL,0272,RC,,,,both,,,538.51,350.03,,,,,,,,,,,,,
ACEBUTOLOL HCL 400 MG PO CAPS,RX-8940,CDM,6370000000,HCPCS,0637,RC,53746-0670-01,NDC,,both,1,UN,5.00,3.25,,,,,,,,,,,,,
KAR HA FEMORAL STEM 16MM,SUP-2823399,CDM,C1776,CPT,0278,RC,,,,both,,,17143.14,11143.04,,,,,,,,,,,,,
BRACE THORACOLUMBOSACRAL SM LTX W ADD STRP VELC CLSR E ANT,SUP-2195549,CDM,L0650,HCPCS,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
INTRODUCER CATH L3.5IN DIA7.5FR FOR CHOLANGIOGRAPHY TAUT,SUP-2384692,CDM,C1894,HCPCS,0272,RC,,,,both,,,92.63,60.21,,,,,,,,,,,,,
BIT DRL L270MM DIA38MM 3 FLUT QUIK CPL FOR MULTILOC HUM,SUP-2178940,CDM,2720000010,LOCAL,0272,RC,,,,both,,,815.40,530.01,,,,,,,,,,,,,
ORTHOPEDIC KIT SEG PROX TIB WASHER,SUP-2437238,CDM,C1713,HCPCS,0278,RC,,,,both,,,5312.88,3453.37,,,,,,,,,,,,,
HC So Drug Assay Voriconazole,PX-3018028566,CDM,80285,CPT,0301,RC,,,,both,,,256.00,166.40,,,,,,,,,,,,,
BLADE SHV L19CM DIA4.2MM TORPEDO HIP LEN TAPR TIP SCIS LIKE,SUP-2121978,CDM,2720000010,LOCAL,0272,RC,,,,both,,,317.14,206.14,,,,,,,,,,,,,
BRACE STRNL PD KT TLSO BLK SM,SUP-2123926,CDM,L0462,HCPCS,0272,RC,,,,both,,,281.60,183.04,,,,,,,,,,,,,
PLATE BNE L 53.3 X W 7.1 MM THK 2 MM SCREW DIA2/2.3 MM 6 H,SUP-2936112,CDM,C1713,HCPCS,0278,RC,,,,both,,,1453.82,944.98,,,,,,,,,,,,,
CATHETER CV 3L 6 FR PWR INJ N COAT CT COMPATIBLE POWERPICC,SUP-2126714,CDM,C1751,HCPCS,0278,RC,,,,both,,,739.47,480.66,,,,,,,,,,,,,
Z DISCONTINUED NO SUB IDED SPHINCTEROTOME WIRE GUID SGL LUMN SH NOSE 20MM CUT WIRE LEN,SUP-2141402,CDM,C1769,HCPCS,0272,RC,,,,both,,,532.36,346.03,,,,,,,,,,,,,
SET INTRO V-STICK DIA 4 FR 7 CM NIT COAX NONECHOGENIC STD,SUP-2269622,CDM,C1769,HCPCS,0272,RC,,,,both,,,120.89,78.58,,,,,,,,,,,,,
ALLOGRAFT BNE FOAM STRP 25X50X4 MM VITOSS BA,SUP-2319139,CDM,C1889,HCPCS,0278,RC,,,,both,,,4732.45,3076.09,,,,,,,,,,,,,
HC So Glucagon,PX-3018294366,CDM,82943,CPT,0301,RC,,,,both,,,767.00,498.55,,,,,,,,,,,,,
STENT 7X22 ULT W 035 ZIPWIRE GWIRE POLARIS,SUP-2141672,CDM,C2617,HCPCS,0278,RC,,,,both,,,574.84,373.65,,,,,,,,,,,,,
COMPONENT ARTC 25X3X3MM OFFSET,SUP-2123539,CDM,C1776,CPT,0278,RC,,,,both,,,12625.94,8206.86,,,,,,,,,,,,,
STEM HUM CEM 8B LNG 132.5 DEG 120 MM SHLDR AEQUALIS ASCEND,SUP-2715777,CDM,C1776,CPT,0278,RC,,,,both,,,13164.45,8556.89,,,,,,,,,,,,,
SCREW BONE SM L50MM DIA3.5MM HD DIA6MM CORT TI NONCANNULATED,SUP-2189879,CDM,C1713,HCPCS,0278,RC,,,,both,,,58.72,38.17,,,,,,,,,,,,,
CLONIDINE 0.3 MG/24HR TD PTWK,RX-143503,CDM,6370000000,HCPCS,0637,RC,00378-0873-16,NDC,,both,1,UN,278.60,181.09,,,,,,,,,,,,,
PROBE LITHO 5FR L60CM EHL DISP,SUP-2313970,CDM,2720000010,LOCAL,0272,RC,,,,both,,,630.86,410.06,,,,,,,,,,,,,
KETOCONAZOLE 2 % EX SHAM,RX-14132,CDM,6370000000,HCPCS,0637,RC,45802-0465-64,NDC,,both,120,ML,99.40,64.61,,,,,,,,,,,,,
PLATE BNE L 179 X W 10.5 MM THK 3 MM SCREW DIA2.7/3.5 MM 13 72466413,SUP-2932847,CDM,C1713,HCPCS,0278,RC,,,,both,,,5937.74,3859.53,,,,,,,,,,,,,
PLATE BONE L245MM 6 H TROCHANTERIC TI GRP SUPERCABLE,SUP-2262262,CDM,C1713,HCPCS,0278,RC,,,,both,,,8619.30,5602.54,,,,,,,,,,,,,
COIL NEUROVASCULAR TRUFILL DCS ORBIT 24CM 8MM DSTL LOOP,SUP-2459445,CDM,C1889,HCPCS,0278,RC,,,,both,,,6926.78,4502.41,,,,,,,,,,,,,
SCREW BNE L18MM DIA3.5MM CORT FT ANK TI LOK FULL THRD FOR,SUP-2398263,CDM,C1713,HCPCS,0278,RC,,,,both,,,417.62,271.45,,,,,,,,,,,,,
ENDCAP SPNL OD13MM 4DEG TI CO CHROM NIT T2 ALTITUDE,SUP-2292807,CDM,C1713,HCPCS,0278,RC,,,,both,,,832.10,540.86,,,,,,,,,,,,,
OMEGA-3-ACID ETHYL ESTERS 1 G PO CAPS,RX-41822,CDM,6370000000,HCPCS,0637,RC,70756-0423-22,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PLATE BNE L129MM 7 H ST L POSTEROLATERAL DST FIBULAR S STL,SUP-2177394,CDM,C1713,HCPCS,0278,RC,,,,both,,,2048.28,1331.38,,,,,,,,,,,,,
INTRODUCER TUBE SET 7.5/8.5/9 MM MULTI PERC TY PHAR 7.5 MM,SUP-2759714,CDM,C1769,HCPCS,0272,RC,,,,both,,,1607.30,1044.74,,,,,,,,,,,,,
CATHETER DIL CORONARY 1.2X12 MM MINI TREK,SUP-2848025,CDM,C1725,HCPCS,0272,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
PIN FIX SINGLE DIAMOND 0.078X9 IN RND END SS NS STEINMANN,SUP-2791599,CDM,C1713,HCPCS,0278,RC,,,,both,,,11.93,7.75,,,,,,,,,,,,,
SCREW BNE CORTICAL 3.5X26 MM FUSION HEX DRV YEL WRST SS NS,SUP-2852114,CDM,C1713,HCPCS,0278,RC,,,,both,,,673.81,437.98,,,,,,,,,,,,,
PLATE BONE L DSTL VOLAR RAD ADAPTIVE II TRILOK 2.5,SUP-2267958,CDM,C1713,HCPCS,0278,RC,,,,both,,,4094.56,2661.46,,,,,,,,,,,,,
GUIDEWIRE VASC L 180 CM DIA 0.035 IN TAPR L 4.5 CM FLX TIP L,SUP-2167753,CDM,C1769,HCPCS,0272,RC,,,,both,,,31.84,20.70,,,,,,,,,,,,,
DEFIBRILLATOR CRD BPLR 12.9 MM 32 CC 69 GM VENTRIC EPIC + VR V196RST] ST JUDE MED CARDIAC RHYM MGMT],SUP-2356533,CDM,C1722,HCPCS,0275,RC,,,,both,,,64903.80,42187.47,,,,,,,,,,,,,
POST EXT FIX ANK FT 5 H FOR TRUELOK FRME ASSEMB HEXAPOD SYS,SUP-2316133,CDM,2720000010,LOCAL,0272,RC,,,,both,,,522.62,339.70,,,,,,,,,,,,,
HC Removal of Foreign Body Simple,PX-4502052000,CDM,20520,CPT,0450,RC,,,,both,,,4946.00,3214.90,,,,,,,,,,,,,
NEEDLE PHACO 30 DEG 2.2 MM NS MICROFLOW 2.2 LF REUSE,SUP-2467799,CDM,2720000010,LOCAL,0272,RC,,,,both,,,925.80,601.77,,,,,,,,,,,,,
NAIL INTRMDLLRY LOK CNNLTD UNVRSL 8MM DIA 255MML TTNM ALLOY,SUP-2587449,CDM,C1713,HCPCS,0278,RC,,,,both,,,3716.94,2416.01,,,,,,,,,,,,,
VALVE CSF PROGRAMMABLE SM IN-LINE PRIMING ADPT CERTAS +,SUP-2666577,CDM,C1889,HCPCS,0278,RC,,,,both,,,11914.89,7744.68,,,,,,,,,,,,,
STEM HUM PROX SM 58 MM SHLDR REV SEG W/ BODY COMPHSVE,SUP-2442421,CDM,C1776,CPT,0278,RC,,,,both,,,11360.52,7384.34,,,,,,,,,,,,,
PROBE DRL GUID STD META-NAIL,SUP-2340922,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1824.43,1185.88,,,,,,,,,,,,,
CATHETER HD DL 14 FRX24 CM ADMIN BASIC KT SPLIT STRM,SUP-2267084,CDM,C1750,HCPCS,0278,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
FORCEP TISS BISH HARMON 0.3 MM STR TIP,SUP-2246240,CDM,2720000010,LOCAL,0272,RC,,,,both,,,382.01,248.31,,,,,,,,,,,,,
TRAY CATH HEMODIALYSI TRI FLO ACTE 11.5FR DIA 12CM PCED TAPR,SUP-2610593,CDM,C1752,HCPCS,0278,RC,,,,both,,,257.48,167.36,,,,,,,,,,,,,
SCREW BNE L 140 MM DIA 3.5 MM SS CORTICAL ST STRL EVOS,SUP-2931605,CDM,C1713,HCPCS,0278,RC,,,,both,,,214.05,139.13,,,,,,,,,,,,,
HC Sternum Min 2 Views,PX-3207112000,CDM,71120,CPT,0320,RC,,,,inpatient,,,668.00,434.20,,,,,,,,,,,,,
BLADE REPROC TURBINATE INFERIOR W/O TUBE 2MM,SUP-2653212,CDM,2720000010,LOCAL,0272,RC,,,,both,,,263.48,171.26,,,,,,,,,,,,,
MESH BIO PORCINE MTRX ABD 10CM LEN 20CM W 1.5MM THICKNESS P151020] MEDTRONIC COVIDIEN US SURGICAL],SUP-2174700,CDM,C9364,HCPCS,0278,RC,,,,both,,,13756.78,8941.91,,,,,,,,,,,,,
STENT NEPHURET L 22 CM DIA 8 FR PERCFLX THRD,SUP-2141082,CDM,C2617,HCPCS,0278,RC,,,,both,,,376.08,244.45,,,,,,,,,,,,,
HALOPERIDOL LACTATE 2 MG/ML PO CONC,RX-3585,CDM,340b,HCPCS,0637,RC,00121-0581-04,NDC,,both,1,ML,2.70,1.75,,,,,,,,,,,,,
SCREW BNE L9MM DIA2MM STD CORT CRANIOMAXILLOFACIAL TI ST,SUP-2189436,CDM,C1713,HCPCS,0278,RC,,,,both,,,140.58,91.38,,,,,,,,,,,,,
SYSTEM IMPL INCL PEEK SWIVELOCK ANCHR W/ FIBERTAPE NDL DRL,SUP-2122834,CDM,C1713,HCPCS,0278,RC,,,,both,,,5463.60,3551.34,,,,,,,,,,,,,
GRAFT DERMAL PLIABLE 16X8 CMX1-1.7 MM BRST KT FEN FLEXHD,SUP-2307571,CDM,Q4128,HCPCS,0636,RC,,,,both,,,22772.85,14802.35,,,,,,,,,,,,,
PLATE BNE W22XL45MM STD 6X2 H NONSTERILE L DST RAD VOLAR TI,SUP-2180845,CDM,C1713,HCPCS,0278,RC,,,,both,,,2314.49,1504.42,,,,,,,,,,,,,
ROD ORTH STR TEND APTO KT,SUP-2399191,CDM,C1713,HCPCS,0278,RC,,,,both,,,4144.80,2694.12,,,,,,,,,,,,,
GRAFT BNE 8MM TISS WDG COT,SUP-2321662,CDM,C1776,CPT,0278,RC,,,,both,,,4519.09,2937.41,,,,,,,,,,,,,
BASKET SPEC RETRV OLYPERCX PCNL,SUP-2798155,CDM,2720000010,LOCAL,0272,RC,,,,both,,,760.01,494.01,,,,,,,,,,,,,
SEATING CHISEL FOR INFANT OSTEOTOMY PLATE/260MM,SUP-2548623,CDM,C1713,HCPCS,0278,RC,,,,both,,,1469.61,955.25,,,,,,,,,,,,,
SHEATH INTRO 0.038 IN 8 FRX11 CM 18 GAX7 CM PRELUDE ACT,SUP-2798470,CDM,C1894,HCPCS,0272,RC,,,,both,,,37.08,24.10,,,,,,,,,,,,,
GRAFT HUM TISS W6XL16CM THK1.04-2.28MM THCK REGEN TISS MTRX,SUP-2113001,CDM,Q4116,HCPCS,0636,RC,,,,both,,,11015.12,7159.83,,,,,,,,,,,,,
SCREW SPNL SACR AND SACROILIAC S STL 6.5MMX30MM COLORADO 2,SUP-2290490,CDM,C1713,HCPCS,0278,RC,,,,both,,,2913.92,1894.05,,,,,,,,,,,,,
PROSTHESIS OTO L9MM SHFT OD0.8MM FLNG OD4MM MID EAR OSS TOT,SUP-2312578,CDM,L8613,CPT,0278,RC,,,,both,,,887.84,577.10,,,,,,,,,,,,,
BUR SURG DIA3MM FLUT MTCH TRANSNASAL,SUP-2284699,CDM,C1713,HCPCS,0278,RC,,,,both,,,1129.62,734.25,,,,,,,,,,,,,
CATHETER INFUSION PMP 4 ML/HR 2X2.5 IN 275 CC,SUP-2361464,CDM,C1751,HCPCS,0278,RC,,,,both,,,514.96,334.72,,,,,,,,,,,,,
K WIRE FIX L6IN DIA0.045IN S STL DBL TRCR HND BMT 6PK,SUP-2412237,CDM,C1713,HCPCS,0278,RC,,,,both,,,301.44,195.94,,,,,,,,,,,,,
SCREW BONE L7MM OD1.5MM ST TI CORT T4 DRV VLP,SUP-2350899,CDM,C1713,HCPCS,0278,RC,,,,both,,,274.72,178.57,,,,,,,,,,,,,
STENT PERIPH LIFESTENT L 150 MM DIA 7 MM CATH L 130 CM DIA 6,SUP-2128196,CDM,C1876,HCPCS,0278,RC,,,,both,,,10032.30,6520.99,,,,,,,,,,,,,
KIT BNE CEM PREP FEM QUIK-USE EACH ONLY,SUP-2199467,CDM,C1713,HCPCS,0278,RC,,,,both,,,351.68,228.59,,,,,,,,,,,,,
GUIDEWIRE VASC L145CM DIA0.035IN CRV RAD 3MM TAPR L7CM FLPY,SUP-2167914,CDM,C1769,HCPCS,0272,RC,,,,both,,,64.18,41.72,,,,,,,,,,,,,
CATHETER CV 3L 5 FR FULL NURSING TY POWERPICC SOLO 2,SUP-2125644,CDM,C1751,HCPCS,0278,RC,,,,both,,,777.90,505.63,,,,,,,,,,,,,
PASSER SUT CAPSULECLOSE SCORPION,SUP-2121459,CDM,2720000010,LOCAL,0272,RC,,,,both,,,10974.30,7133.29,,,,,,,,,,,,,
HEAD HUM 44/17 CA REVERS UNIVERS,SUP-2123381,CDM,C1776,CPT,0278,RC,,,,both,,,7379.00,4796.35,,,,,,,,,,,,,
INTRODUCER LD PLCMNT 9FR 30CM N PEEL AWAY N COR SNUS ACCS,SUP-2357204,CDM,C1894,HCPCS,0272,RC,,,,both,,,62.80,40.82,,,,,,,,,,,,,
SPLINT HND ANTIMICROBIAL LG 8 IN WRST LT ROLYAN HANZ WHFO,SUP-2326334,CDM,L3906,HCPCS,0274,RC,,,,both,,,138.03,89.72,,,,,,,,,,,,,
SPLINT ORTHOPEDIC SLIP ON SM 8 IN LT WRST PLUSH FOAM LNR NYL,SUP-2276659,CDM,L3908,HCPCS,0272,RC,,,,both,,,17.05,11.08,,,,,,,,,,,,,
ALLOGRACT HUM TISS AMNIOBAND MEMBRANE 18MM DISK,SUP-2905517,CDM,Q4151,HCPCS,0636,RC,,,,both,,,1599.36,1039.58,,,,,,,,,,,,,
MESH SURG L 30 X W 30 CM POLYPRO VENTRAL MONOFILAMENT,SUP-2901704,CDM,C1781,HCPCS,0278,RC,,,,both,,,401.04,260.68,,,,,,,,,,,,,
HC Pt Elec Stim Unattended|OP PT SERVICES|DOCUMENTATION ON FILE|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS,PX-4209701400,CDM,G0283,HCPCS,0420,RC,,,GP|KX|CQ,outpatient,,,206.00,133.90,,,,,,,,,,,,,
TUBE VENT NO3 DIA1.50MM SIL PAPARELLA TUPE III,SUP-2312787,CDM,L8699,HCPCS,0278,RC,,,,both,,,40.04,26.03,,,,,,,,,,,,,
BALLOON NSL EPISTAXIS STRL,SUP-2261407,CDM,C1726,HCPCS,0272,RC,,,,both,,,233.93,152.05,,,,,,,,,,,,,
PLATE BNE L158MM 11 H ST R ANTLAT DST TIB S STL LO PROF,SUP-2185955,CDM,C1713,HCPCS,0278,RC,,,,both,,,4547.94,2956.16,,,,,,,,,,,,,
COMPONENT GLEN KEELED 90 DEG SHLDR STR ALL POLYETH BI-ANG,SUP-2431679,CDM,C1776,CPT,0278,RC,,,,both,,,5256.36,3416.63,,,,,,,,,,,,,
STEM TIB L150MM DIA12MM TI KNEE PRI GEN II LEGION,SUP-2346007,CDM,C1776,CPT,0278,RC,,,,both,,,3351.95,2178.77,,,,,,,,,,,,,
HEAD HUM H27MM DIA44MM SHLDR CO CHROM TOT REV BIO MOD,SUP-2404616,CDM,C1776,CPT,0278,RC,,,,both,,,3405.33,2213.46,,,,,,,,,,,,,
GRAFT VASC 6 MMX70 CM 50 CM RNG GORTX,SUP-2396007,CDM,C1768,CPT,0278,RC,,,,both,,,3259.32,2118.56,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 70 MM DIA 7 MM DEL SHTH,SUP-2934216,CDM,C1713,HCPCS,0278,RC,,,,both,,,8785.72,5710.72,,,,,,,,,,,,,
HC Clsd Tx Femur W or W/O Mani,PX-4502750200,CDM,27502,CPT,0450,RC,,,,both,,,4969.00,3229.85,,,,,,,,,,,,,
ENDOPROSTHESIS BILI VIABIL L 6 CM DIA 8 MM L 40 CM NIT NO H,SUP-2396669,CDM,C1874,HCPCS,0278,RC,,,,both,,,8543.94,5553.56,,,,,,,,,,,,,
BLADE RETRACTOR MCCULLOCH NAR 30 MM MUSCLE TI,SUP-2489447,CDM,2720000010,LOCAL,0272,RC,,,,both,,,354.91,230.69,,,,,,,,,,,,,
GRAFT HUM TISS DISC 17 MM SZ 2 SQCM AMNION-CHORION-AMNION,SUP-2909327,CDM,Q4137,HCPCS,0636,RC,,,,both,,,2109.61,1371.25,,,,,,,,,,,,,
SYSTEM SKIN CLSR 60CM 2-OCTYL CYNOACRLT W/ MESH DISPNS,SUP-2218877,CDM,2720000010,LOCAL,0272,RC,,,,both,,,464.47,301.91,,,,,,,,,,,,,
PACEMAKER CRD 2 CHMBR 44X52X7 MM 28.7 GM PULSAR MAX,SUP-2148603,CDM,C1785,HCPCS,0275,RC,,,,both,,,16321.72,10609.12,,,,,,,,,,,,,
SHAFT IMPL INSRT SPNL MESH CATLYST,SUP-2285271,CDM,C1713,HCPCS,0278,RC,,,,both,,,479.32,311.56,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED H4 HA UPLR BPLR,SUP-2419700,CDM,C1776,CPT,0278,RC,,,,both,,,4396.00,2857.40,,,,,,,,,,,,,
KIT CATH HEMODIALYSI RELIANCE XK CHRONIC EXCHANGE 16 5327420,SUP-2632950,CDM,C1750,HCPCS,0278,RC,,,,both,,,7088.55,4607.56,,,,,,,,,,,,,
PEGFILGRASTIM (INF DEV) 6 MG/0.6ML SC SOSY,RX-173422,CDM,J2506,HCPCS,0636,RC,55513-0192-01,NDC,,both,0.6,ML,18933.10,12306.51,,,,,,,,,,,,,
IMMOBILIZER ORTH ADJ UNIV SHLDR CANVS NAVY NS,SUP-2336314,CDM,L3670,HCPCS,0274,RC,,,,both,,,25.72,16.72,,,,,,,,,,,,,
IMPLANT COSMETIC POLYETHYL ZB FLAT MED WIDTH STRL DISP,SUP-2936123,CDM,C1713,HCPCS,0278,RC,,,,both,,,7275.38,4729.00,,,,,,,,,,,,,
HC Fungus ID Yeast,PX-3008710600,CDM,87106,CPT,0300,RC,,,,both,,,57.00,37.05,,,,,,,,,,,,,
ROD REPROC CFBR XTRNFX MED XTRNFXTR 8X120MM,SUP-2478630,CDM,2720000010,LOCAL,0272,RC,,,,both,,,157.41,102.32,,,,,,,,,,,,,
SCREW BONE L10MM OD2.7MM TI CORT DSTL FIBULAR ST LCK FULL,SUP-2137066,CDM,C1713,HCPCS,0278,RC,,,,both,,,362.67,235.74,,,,,,,,,,,,,
HC So Cold Agglutinin,PX-3028615766,CDM,86157,CPT,0302,RC,,,,both,,,38.00,24.70,,,,,,,,,,,,,
AGENT HEMSTAT 4.5ML GEL VITAGEL 21130205] STRYKER CORP],SUP-2361945,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1318.80,857.22,,,,,,,,,,,,,
HC Biopsy Bone Marrow,PX-7613822100,CDM,38221,CPT,0761,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
PLATE BONE CALCNL,SUP-2247331,CDM,C1713,HCPCS,0278,RC,,,,both,,,3011.26,1957.32,,,,,,,,,,,,,
SEALER TISS L25CM ADV BPLR STR RND TIP LAP APPRCH ENSEAL,SUP-2257690,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5727.71,3723.01,,,,,,,,,,,,,
SCREW BNE L 3 MM DIA1.2 MM XDRV EMER NS DISP LORENZ,SUP-2934828,CDM,C1713,HCPCS,0278,RC,,,,both,,,221.06,143.69,,,,,,,,,,,,,
CATHETER CV DL 0.018 IN 5 FR RAD BASIC TY SS POWERPICC 2,SUP-2125542,CDM,C1751,HCPCS,0278,RC,,,,both,,,261.12,169.73,,,,,,,,,,,,,
PLATE BNE W8XL76MM THK2MM 0DEG 9 H BILAT S STL STR RIG DYN,SUP-2186181,CDM,C1713,HCPCS,0278,RC,,,,both,,,295.16,191.85,,,,,,,,,,,,,
CATHETER GUID 5.2FR L115CM ID0.057IN PTFE LNR S STL BRAID,SUP-2367783,CDM,C1887,HCPCS,0272,RC,,,,both,,,3611.00,2347.15,,,,,,,,,,,,,
INTRODUCER BRST BX CELERO,SUP-2239957,CDM,C1894,HCPCS,0272,RC,,,,both,,,335.98,218.39,,,,,,,,,,,,,
SHEATH INTRO PRELUDE L 23 CM DIA 6 FR 80 CM 0.038 IN POLYPRO,SUP-2493361,CDM,C1894,HCPCS,0272,RC,,,,both,,,97.18,63.17,,,,,,,,,,,,,
"HC New Pt, E/M Level 2|MULTIPLE OUTPATIENT HOSPITAL E/M ENCOUNTERS ON THE SAME DATE",PX-5109920200,CDM,99202,CPT,0510,RC,,,27,both,,,296.00,192.40,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 80 CM DIA 5-8 MM EPTFE SHRT TAPR,SUP-2763160,CDM,C1768,CPT,0278,RC,,,,both,,,1678.39,1090.95,,,,,,,,,,,,,
COMP SHRT ST/POLY GLD/VRSDL/INS,SUP-2212449,CDM,C1776,CPT,0278,RC,,,,both,,,18840.00,12246.00,,,,,,,,,,,,,
REDAPT SLVD MONO STEM 240MM SZ 19 SO,SUP-2511021,CDM,C1776,CPT,0278,RC,,,,both,,,17270.00,11225.50,,,,,,,,,,,,,
IMPLANT OTO 37 X 62 MM LT HELCL EAR RIM 2PC RECON POROUS,SUP-2883474,CDM,L8699,HCPCS,0278,RC,,,,both,,,1999.43,1299.63,,,,,,,,,,,,,
COMPONENT FEM SZ 3 L REV POST STBL GMK,SUP-2267609,CDM,C1776,CPT,0278,RC,,,,both,,,19866.78,12913.41,,,,,,,,,,,,,
BRACE WRST LACER W O ABDUCTED THMB UNIV L,SUP-2276645,CDM,L3931,HCPCS,0274,RC,,,,both,,,15.92,10.35,,,,,,,,,,,,,
RING EXT FIX DIA105 MM U SHP NS DISP SMRT TSF,SUP-2933115,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5771.85,3751.70,,,,,,,,,,,,,
PLATE BONE L52XW25MM STD RT DSTL VOLAR RAD TI CNTOUR LO PROF,SUP-2361546,CDM,C1713,HCPCS,0278,RC,,,,both,,,2954.46,1920.40,,,,,,,,,,,,,
ANCHOR SUTURE 2 3.5 MM 2 DURABRAID PK W/ NDL TI TWINFIX,SUP-2849121,CDM,C1713,HCPCS,0278,RC,,,,both,,,615.44,400.04,,,,,,,,,,,,,
GUIDEWIRE .035X7 ST,SUP-2639688,CDM,C1769,HCPCS,0272,RC,,,,both,,,53.38,34.70,,,,,,,,,,,,,
KIT PIN AND RMR SALTO TALARIS,SUP-2244122,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3780.56,2457.36,,,,,,,,,,,,,
HC Ablate Pulm Tumor Perq Crybl,PX-3613299400,CDM,32994,CPT,0361,RC,,,,both,,,10314.00,6704.10,,,,,,,,,,,,,
HMRL BEARING 36 MM STD VITE,SUP-2505943,CDM,C1776,CPT,0278,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
GUIDEWIRE VASC L150CM DIA0.035IN TIP L8CM LNG TAPR STR NIT,SUP-2385567,CDM,C1769,HCPCS,0272,RC,,,,both,,,109.96,71.47,,,,,,,,,,,,,
BONE MARROW ASPIRATION 11GA 15CM W/ SIDEHOLES-STERILE,SUP-2550438,CDM,2720000010,LOCAL,0272,RC,,,,both,,,291.55,189.51,,,,,,,,,,,,,
SLEEVE TIB L3CM TI POR PROX KNEE REDUC SZ OSS MARTI VIERZON,SUP-2406485,CDM,C1776,CPT,0278,RC,,,,both,,,5892.21,3829.94,,,,,,,,,,,,,
KIT CAGE SPINAL APREVO 2-LEVEL,SUP-2912823,CDM,C1889,HCPCS,0278,RC,,,,both,,,100480.00,65312.00,,,,,,,,,,,,,
SET URET STENT UTHANE MAC-LOC L 25 CM DIA12 FR GUIDEWIRE L,SUP-2835752,CDM,C2627,HCPCS,0278,RC,,,,both,,,722.14,469.39,,,,,,,,,,,,,
MESH HERN 6X4IN 2D POLY RECT PARTIALLY ABSRB KNIT MFIL,SUP-2174774,CDM,C1781,HCPCS,0278,RC,,,,both,,,257.32,167.26,,,,,,,,,,,,,
KIT LD L60CM 8 ELECTRD PERC COMP CONTAIN LD ANCHR GWIRE NDL,SUP-2284647,CDM,C1778,HCPCS,0278,RC,,,,both,,,5966.00,3877.90,,,,,,,,,,,,,
ANCHOR SUTURE DIAMETER 6.5MM KNOTLESS DT WITH NO2 HI-FI CROS,SUP-2824880,CDM,C1713,HCPCS,0278,RC,,,,both,,,1293.68,840.89,,,,,,,,,,,,,
NAIL IM L150MM DIA7.5MM ST HUM TI CANN LOK PROX BEND S2,SUP-2192537,CDM,C1713,HCPCS,0278,RC,,,,both,,,5186.34,3371.12,,,,,,,,,,,,,
PLATE BNE BURR HOLE CVR 17 MM 6 HOLE LP CONTOURED TI NS,SUP-2479308,CDM,C1713,HCPCS,0278,RC,,,,both,,,855.56,556.11,,,,,,,,,,,,,
DEXTROSE 5 % IV SOLN INTERMITTENT INFUSION,RX-40840103,CDM,2580000003,HCPCS,0258,RC,00264-1510-31,NDC,,both,250,ML,104.20,67.73,,,,,,,,,,,,,
REAMER LAG SCR LNG 32MM FOR CEPHALOMEDULLARY NAT NAIL SYS,SUP-2198640,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1511.03,982.17,,,,,,,,,,,,,
NEXGEN LCCK ART SURF EF 5-6/GREEN 10MM,SUP-2503357,CDM,C1776,CPT,0278,RC,,,,both,,,5375.68,3494.19,,,,,,,,,,,,,
UNIT COMPR DISTR EXTENDS TO 5CM FOR SM FIX,SUP-2316030,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1076.27,699.58,,,,,,,,,,,,,
CLAMP EXT FIX CORR 4 ANGULAR,SUP-2197307,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1836.90,1193.98,,,,,,,,,,,,,
MODAFINIL 200 MG PO TABS,RX-24703,CDM,6370000000,HCPCS,0637,RC,68084-0721-21,NDC,,both,1,UN,76.10,49.46,,,,,,,,,,,,,
SUPPORT ORTHOT KNEE CUST SWEDISH TYP,SUP-2435617,CDM,L1850,HCPCS,0272,RC,,,,both,,,806.57,524.27,,,,,,,,,,,,,
PLATE BONE SINUS TARSI CALCANEUS LEFT TITANIUM ARSENAL FOOT PLATING SYSTEM FOR 2.2/2.7/3.5MM SCREW,SUP-2878285,CDM,C1713,HCPCS,0278,RC,,,,both,,,5259.50,3418.67,,,,,,,,,,,,,
GUIDEWIRE VASC L180MM DIA0.018MM TAPR L15CM FLPY TIP L3CM,SUP-2170334,CDM,C1769,HCPCS,0272,RC,,,,both,,,116.87,75.97,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP ANGLED 0.035 INX260 CM SS JAGWIRE DISP,SUP-2141542,CDM,C1769,HCPCS,0272,RC,,,,both,,,628.79,408.71,,,,,,,,,,,,,
STAPLE BNE COMPR 201X20 IN SS,SUP-2122157,CDM,C1713,HCPCS,0278,RC,,,,both,,,1909.12,1240.93,,,,,,,,,,,,,
DIPYRIDAMOLE 25 MG PO TABS,RX-2528,CDM,6370000000,HCPCS,0637,RC,00115-1070-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
CATHETER DRAIN 10F 25CM TGHT LOOP W/ RADIOPAQUE MRKR BND PG,SUP-2659160,CDM,C1729,HCPCS,0272,RC,,,,both,,,247.18,160.67,,,,,,,,,,,,,
SCREW BNE L9MM DIA2.3MM THOR STRNL TI LOK DRL FREE LEV 1,SUP-2262553,CDM,C1713,HCPCS,0278,RC,,,,both,,,170.00,110.50,,,,,,,,,,,,,
KIT NEG PRSS FOR NONLIN OR UPTO 90CM LIN INCIS PREVENA +,SUP-2262374,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1877.72,1220.52,,,,,,,,,,,,,
SCREW BNE L70MM DIA5MM CORT G TI ST LOK FULL THRD T25,SUP-2189537,CDM,C1713,HCPCS,0278,RC,,,,both,,,569.03,369.87,,,,,,,,,,,,,
BRACE ORTH LUMBAR W/O RIGID STAY LSO,SUP-2388148,CDM,L0628,HCPCS,0272,RC,,,,both,,,310.86,202.06,,,,,,,,,,,,,
PATIENT MNL AND MAG,SUP-2357364,CDM,2720000010,LOCAL,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
INTRODUCER SHTH AD L12CM DIA6FR 0.032IN CV PERM VLV NO RADPQ,SUP-2355390,CDM,C1894,HCPCS,0272,RC,,,,both,,,81.64,53.07,,,,,,,,,,,,,
BIT DRL L220MM DIA4.6MM 3/16 SQ CANN,SUP-2321611,CDM,2720000010,LOCAL,0272,RC,,,,both,,,818.60,532.09,,,,,,,,,,,,,
RITUXIMAB-ARRX 500 MG/50ML IV SOLN,RX-153028,CDM,Q5123,HCPCS,0636,RC,55513-0326-01,NDC,,both,50,ML,10322.00,6709.30,,,,,,,,,,,,,
SCREW BONE FT COPOLYMER RESRB ORTH PLATING SYS ABSRB,SUP-2412907,CDM,C1713,HCPCS,0278,RC,,,,both,,,668.19,434.32,,,,,,,,,,,,,
EXTRACTOR SURG SM EZ OUT REMOVAL TOOL AO QC FOR FIBULAR NAIL,SUP-2909105,CDM,2720000010,LOCAL,0272,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
ANCHOR SUT ROT CUF W/ ORTHOCORD 2 SUT QUICKANCHR +,SUP-2256679,CDM,C1713,HCPCS,0278,RC,,,,both,,,1431.84,930.70,,,,,,,,,,,,,
ROD SPNL ANTR RT CVD SMOOTH S STL 5.0MM DIA 50MM LEN,SUP-2290499,CDM,C1713,HCPCS,0278,RC,,,,both,,,1356.48,881.71,,,,,,,,,,,,,
ALLOGRAFT BNE WHL FIB FRZN LT,SUP-2717942,CDM,C1762,CPT,0278,RC,,,,both,,,9514.20,6184.23,,,,,,,,,,,,,
"HC Occl Dev in Vein Art, Angioseal, Vasc Plug",PX-3610026900,CDM,G0269,CPT,0361,RC,,,,both,,,305.00,198.25,,,,,,,,,,,,,
PLATE BNE HUM 85 MM LT DSTL LAT 9 HOLE STRL LTX,SUP-2861606,CDM,C1713,HCPCS,0278,RC,,,,both,,,3434.72,2232.57,,,,,,,,,,,,,
SUPPORT ORTHOT LOWER EXTREMITY CUST BAR CHROM PLT NICKEL,SUP-2435694,CDM,L2750,HCPCS,0272,RC,,,,both,,,221.28,143.83,,,,,,,,,,,,,
ALLOGRAFT BNE BLOCK FD ASEP CANC,SUP-2867067,CDM,C1762,CPT,0278,RC,,,,both,,,1745.06,1134.29,,,,,,,,,,,,,
PLATE BNE ELBW SET PERI-LOC,SUP-2351352,CDM,C1713,HCPCS,0278,RC,,,,both,,,16861.80,10960.17,,,,,,,,,,,,,
PAMIDRONATE DISODIUM 6 MG/ML IV SOLN,RX-33886,CDM,J2430,HCPCS,0636,RC,61703-0325-18,NDC,,both,10,ML,261.00,169.65,,,,,,,,,,,,,
CANNULA ATRIAL/VENTRICULAR 32FR L10.7MM INFLO BVS5000,SUP-2106279,CDM,C1713,HCPCS,0278,RC,,,,both,,,3422.60,2224.69,,,,,,,,,,,,,
GRAFT VASC PTCH 6 MMX40 CM BIOPROSTHESIS PROCOL,SUP-2237244,CDM,C1768,CPT,0278,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
TIP SUCT PRB 5MM QUIK DC W/ IRRIG H NEZHAT-DORSEY REPROC,SUP-2125886,CDM,C1713,HCPCS,0278,RC,,,,both,,,704.62,458.00,,,,,,,,,,,,,
PATCH CV CARDIOCEL L 4 X W 4 CM THK 0.5 MM BOV PERICARD,SUP-2433943,CDM,C1768,CPT,0278,RC,,,,both,,,5240.66,3406.43,,,,,,,,,,,,,
CATHETER PICC 6FR L55CM 16.5/19/19GA PEELABLE SHEATH/DILATOR,SUP-2117123,CDM,C1751,HCPCS,0278,RC,,,,both,,,622.60,404.69,,,,,,,,,,,,,
GRAFT VASC L 40 CM DIA12 X 6 MM POLYESTER THOR ABD AORT,SUP-2227626,CDM,C1768,CPT,0278,RC,,,,both,,,2289.69,1488.30,,,,,,,,,,,,,
SCREW BNE L16MM OD35MM TI REARFT LOK HEX TOT FT SYS,SUP-2243252,CDM,C1713,HCPCS,0278,RC,,,,both,,,712.94,463.41,,,,,,,,,,,,,
ROD SPNL POST CRV PREBENT SMOOTH TI ALLY OD5.5MM L90MM,SUP-2415873,CDM,C1713,HCPCS,0278,RC,,,,both,,,942.75,612.79,,,,,,,,,,,,,
CUSTOM KT PTCA INFL DEV K05 00052M,SUP-2302817,CDM,C1713,HCPCS,0278,RC,,,,both,,,232.83,151.34,,,,,,,,,,,,,
"HC Pt Therapeutic Exercise,Ea 15 Min|OP PT SERVICES|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS|UNUSUAL NON-OVERLAPPING SERVICE",PX-4209711000,CDM,97110,CPT,0420,RC,,,GP|CQ|XU,both,,,195.00,126.75,,,,,,,,,,,,,
TOOL REMOVAL DIA 3.5 MM STRL DISP FLEX-THREAD,SUP-2900444,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2179.16,1416.45,,,,,,,,,,,,,
HC X-Ray Exam Uni Hip W/Pelvis 4/> Views,PX-3207350300,CDM,73503,CPT,0320,RC,,,,both,,,128.00,83.20,,,,,,,,,,,,,
STENT URTRL 45FR DIA 22CML SLCNE TCFLX DBLE PGTL OPEN END C,SUP-2722572,CDM,C2617,HCPCS,0278,RC,,,,both,,,172.39,112.05,,,,,,,,,,,,,
NEEDLE INJ FLX 6 FRX50 CM,SUP-2767913,CDM,2720000010,LOCAL,0272,RC,,,,both,,,889.47,578.16,,,,,,,,,,,,,
HC So1 Assay of Psa Total|NOT REASONABLE AND NECESSARY,PX-3018415367,CDM,84153,CPT,0301,RC,,,GZ,both,,,57.00,37.05,,,,,,,,,,,,,
SCREW INTRF L30MM DIA10MM SHTH L L30MM TIB BIOCRYL RAPIDE,SUP-2256830,CDM,C1713,HCPCS,0278,RC,,,,both,,,2829.14,1838.94,,,,,,,,,,,,,
MESH HERN W5XH5IN INT ABD OMEGA 3 FATTY ACID POLYPR SQ SEE,SUP-2265994,CDM,C1781,HCPCS,0278,RC,,,,both,,,1095.86,712.31,,,,,,,,,,,,,
ANCHOR SUT DIA4.5MM W/ ULTRATAPE COBRAID BLU HEALICOIL,SUP-2341902,CDM,C1713,HCPCS,0278,RC,,,,both,,,1623.66,1055.38,,,,,,,,,,,,,
BIT DRL 1.2X85 MM 4 MM STP TPS END NS UNIV NEURO III LTX,SUP-2862795,CDM,2720000010,LOCAL,0272,RC,,,,both,,,709.55,461.21,,,,,,,,,,,,,
GRAFT BNE 451842,SUP-2684156,CDM,C1713,HCPCS,0278,RC,,,,both,,,2939.04,1910.38,,,,,,,,,,,,,
SPACER FEM M H10MM DSTL RNG TERM SEG ENDO-MODEL-M,SUP-2265089,CDM,C1776,CPT,0278,RC,,,,both,,,876.06,569.44,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY L 110 CM DIA 7 FR LOOP DIA 60 MM,SUP-2248707,CDM,C1730,HCPCS,0272,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
"HC So Cholinesterase, RBC",PX-3018248266,CDM,82482,CPT,0301,RC,,,,both,,,274.00,178.10,,,,,,,,,,,,,
TUBE MYR 114MM DIAM GRN GRMMT TAB FLROPLAS SHEP,SUP-2313656,CDM,L8699,HCPCS,0278,RC,,,,both,,,26.60,17.29,,,,,,,,,,,,,
HC So Drg Scrn Class List A,PX-3018030766,CDM,80307,CPT,0301,RC,,,,inpatient,,,79.00,51.35,,,,,,,,,,,,,
WIRE FIX SHRP 1.5X350 MM NS PHANTOM XL KIRSCHNER DISP,SUP-2750843,CDM,2720000010,LOCAL,0272,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
BRACE ORTH SZ 1 RT THMB CMC PUSH METAGRIP,SUP-2324629,CDM,L3924,HCPCS,0272,RC,,,,both,,,226.08,146.95,,,,,,,,,,,,,
TROCAR ARTHSCP N THRD N OPT VW BLDELSS SHRP TIP W O HNDL W O,SUP-2166823,CDM,2720000010,LOCAL,0272,RC,,,,both,,,681.54,443.00,,,,,,,,,,,,,
SCREW BONE L42MM OD4.5MM S STL CORT ST NONLOCKING FULL THRD,SUP-2344161,CDM,C1713,HCPCS,0278,RC,,,,both,,,193.55,125.81,,,,,,,,,,,,,
HC So Drg Scrn Class List A,PX-3018030766,CDM,80307,CPT,0301,RC,,,,outpatient,,,79.00,51.35,,,,,,,,,,,,,
EXPANDER TISS NACL 7.8 CM PROJCT 15.5 CM 1000 CC VERSAFIL,SUP-2300334,CDM,C1789,HCPCS,0278,RC,,,,both,,,1491.50,969.47,,,,,,,,,,,,,
HC Gbl Office/OP Consltj New/Est Pt High Mdm 55 Minutes,PX-9829924501,CDM,99245,CPT,0982,RC,,,,inpatient,,,1137.00,739.05,,,,,,,,,,,,,
MORPHINE SULFATE 2 MG/ML IJ SOLN,RX-5170,CDM,J2272,HCPCS,0636,RC,76045-0004-01,NDC,,both,0.5,ML,54.10,35.16,,,,,,,,,,,,,
GUIDEWIRE SURG SZ 1 2 METATARSAL DCOMPR IMPL,SUP-2398631,CDM,C1769,HCPCS,0272,RC,,,,both,,,1422.42,924.57,,,,,,,,,,,,,
PROSTHESIS VOICE 20FR 10MM HRD VLV INDWL BLOM-SINGER ADVNTG,SUP-2242280,CDM,L8509,HCPCS,0272,RC,,,,both,,,1067.60,693.94,,,,,,,,,,,,,
PLATE BONE MESHED 100X0.6 MM CRANIAL RECONSTRUCTION RIGID TI,SUP-2837716,CDM,C1713,HCPCS,0278,RC,,,,both,,,7385.28,4800.43,,,,,,,,,,,,,
VALVE MITRL MECH 23 MM OPTIFIRM,SUP-2265203,CDM,C1713,HCPCS,0278,RC,,,,both,,,10048.00,6531.20,,,,,,,,,,,,,
RETRACTOR EXTENDED WEAR PANNICULUS SM,SUP-2880686,CDM,2720000010,LOCAL,0272,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
OSTEOTOME SURG OD12MM BLDE THN FLX,SUP-2408595,CDM,2720000010,LOCAL,0272,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
PIN FIX L35MM SET CBL RDY,SUP-2410276,CDM,C1713,HCPCS,0278,RC,,,,both,,,791.75,514.64,,,,,,,,,,,,,
TI LCP DISTAL FEMUR PLATE 13 HOLES/316MM/RIGHT-STERILE,SUP-2549455,CDM,C1713,HCPCS,0278,RC,,,,both,,,5594.29,3636.29,,,,,,,,,,,,,
HC Wound Debridement Tis 20 Cm/<,PX-4509759700,CDM,97597,CPT,0450,RC,,,,both,,,413.00,268.45,,,,,,,,,,,,,
DEVICE STRNL CLSR MULTIIMPLANT STRNLOCK 360,SUP-2403038,CDM,C1713,HCPCS,0278,RC,,,,both,,,8949.00,5816.85,,,,,,,,,,,,,
PLATE FUS INTCARP 2.4MM 7H 17MM SS VAL STRL,SUP-2546045,CDM,C1713,HCPCS,0278,RC,,,,both,,,3437.58,2234.43,,,,,,,,,,,,,
FILIFORM URO 5FR L125IN WVN COUDE TIP DIL CATHETER REUSE,SUP-2128965,CDM,C1726,HCPCS,0272,RC,,,,both,,,200.21,130.14,,,,,,,,,,,,,
COMPONENT FEM UNI 4 KNEE PRESERVATION,SUP-2427742,CDM,C1776,CPT,0278,RC,,,,both,,,9052.62,5884.20,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE SZ 50 X 25 X 4 MM 5 CC CER GRAN TYPE-I,SUP-2930814,CDM,C1763,HCPCS,0278,RC,,,,both,,,4678.60,3041.09,,,,,,,,,,,,,
PLATE BNE RESRB INION,SUP-2365889,CDM,C1713,HCPCS,0278,RC,,,,both,,,3644.66,2369.03,,,,,,,,,,,,,
TRAY PROC CHOLE,SUP-2219052,CDM,2720000010,LOCAL,0272,RC,,,,both,,,646.90,420.48,,,,,,,,,,,,,
SCREW BNE L8MM DIA27MM MTPHSEAL TAN ST LO PROF COMPR T8,SUP-2180925,CDM,C1713,HCPCS,0278,RC,,,,both,,,131.19,85.27,,,,,,,,,,,,,
ANTENNA ABLAT L30CM PERC W/ THERMOSPHERE TECHNOLOGY EMPRINT,SUP-2283239,CDM,2720000010,LOCAL,0272,RC,,,,both,,,12790.16,8313.60,,,,,,,,,,,,,
SUPPORT ORTHOT HIP JT LOWER EXTREMITY PELV CTRL CABLE PLAS,SUP-2435686,CDM,L2627,HCPCS,0272,RC,,,,both,,,6050.84,3933.05,,,,,,,,,,,,,
SCREW BNE L28MM OD3.5MM LOK TUFFNEK TECHNOLOGY FOR PLT,SUP-2321128,CDM,C1713,HCPCS,0278,RC,,,,both,,,647.63,420.96,,,,,,,,,,,,,
DEXTROSE 5 % IN LACTATED RINGERS IV BOLUS,RX-40840058,CDM,2580000003,HCPCS,0250,RC,00264-7751-00,NDC,,both,250,ML,6.40,4.16,,,,,,,,,,,,,
AGENT HEMOSTATIC 3 ML 2.5 PEPTIDE STRL PURAGEL,SUP-2880696,CDM,2720000010,LOCAL,0272,RC,,,,both,,,10990.00,7143.50,,,,,,,,,,,,,
BRACE ORTHOPEDIC LUMBAR MIAMI,SUP-2319301,CDM,L0642,HCPCS,0272,RC,,,,both,,,3959.54,2573.70,,,,,,,,,,,,,
ADAPTER LD DF1 TO IS1 CONN EXT PPM,SUP-2148913,CDM,C1883,HCPCS,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
SEGMENT FEM L30CM INTERCALARY FINN CPS,SUP-2406909,CDM,C1776,CPT,0278,RC,,,,both,,,16968.56,11029.56,,,,,,,,,,,,,
NEEDLE NERVE BLOCK INSUL 23 GAX2.75 IN,SUP-2125386,CDM,2720000010,LOCAL,0272,RC,,,,both,,,839.95,545.97,,,,,,,,,,,,,
ALLOGRAFT HUM TISS LG 10 CC DEMINERALIZED CORTICAL NUCEL,SUP-2314103,CDM,C1713,HCPCS,0278,RC,,,,both,,,10754.50,6990.42,,,,,,,,,,,,,
CATHETER SUPP TRAILBLAZER L 90 CM DIA 0.03 IN SHTH 4 FR,SUP-2716003,CDM,C1887,HCPCS,0272,RC,,,,both,,,477.28,310.23,,,,,,,,,,,,,
HOOK SPNL M PEDCL S STL NEUT BILAT FOR 5.5MM ROD CDH LEG,SUP-2288175,CDM,C1713,HCPCS,0278,RC,,,,both,,,1861.39,1209.90,,,,,,,,,,,,,
SET INTRO SUP ARW FLX SHTH L 65 CM DIA 8 FR HYDRPHLC,SUP-2383415,CDM,C1894,HCPCS,0272,RC,,,,both,,,481.68,313.09,,,,,,,,,,,,,
CATHETER INTVASC LITHO E8 WORKING L 150 CM L 80 MM DIA 5 MM,SUP-2894715,CDM,C1768,CPT,0278,RC,,,,both,,,14758.00,9592.70,,,,,,,,,,,,,
CATHETER BILI 16FR SIL SFT SIDE H RADPQ TANT MRK PLAS,SUP-2134680,CDM,C1875,HCPCS,0278,RC,,,,both,,,486.70,316.35,,,,,,,,,,,,,
FOOTPLATE EXT FIX 120 MM PVC FREE TRUELOK +,SUP-2645678,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1349.92,877.45,,,,,,,,,,,,,
CLINDAMYCIN PHOSPHATE 300 MG/2ML IJ SOLN,RX-82303,CDM,J0736,HCPCS,0636,RC,00009-0870-26,NDC,,both,2,ML,54.10,35.16,,,,,,,,,,,,,
BASEPLATE HUM TRABECULAR MTL REV,SUP-2199139,CDM,C1776,CPT,0278,RC,,,,both,,,7624.74,4956.08,,,,,,,,,,,,,
CATHETER PH MONITORING 2 CHANNEL 6 FRX25 CM VERSAFLEX LPR,SUP-2173700,CDM,C1713,HCPCS,0278,RC,,,,both,,,4016.06,2610.44,,,,,,,,,,,,,
PLATE BNE 14 H ST BILAT S STL NAR CRV LOK COMPR FOR 35MM SCR,SUP-2178046,CDM,C1713,HCPCS,0278,RC,,,,both,,,2468.61,1604.60,,,,,,,,,,,,,
PORT INFUS 9.6FR SGL,SUP-2126567,CDM,C1788,HCPCS,0278,RC,,,,both,,,1504.06,977.64,,,,,,,,,,,,,
TI LCP DISTAL FEMUR PLATE 11 HOLES/276MM/LEFT-STERILE,SUP-2549454,CDM,C1713,HCPCS,0278,RC,,,,both,,,5487.75,3567.04,,,,,,,,,,,,,
PIN FIX L200MM DIA5MM S STL W/ CTRL THRD STNMN,SUP-2186935,CDM,C1713,HCPCS,0278,RC,,,,both,,,349.73,227.32,,,,,,,,,,,,,
BUR SHV L13CM DIA4MM 12000RPM DMND CVD SHFT TAPR SUCT TIP,SUP-2277867,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1122.86,729.86,,,,,,,,,,,,,
STENT ENDOPROS L10CM DIA5MM CATH 7FR L120CM BAL DIA5MM,SUP-2396493,CDM,C1874,HCPCS,0278,RC,,,,both,,,9263.00,6020.95,,,,,,,,,,,,,
RETRACTOR SINGLE USE CORDLESS ONETRAC LX 135MMX30MM,SUP-2740194,CDM,2720000010,LOCAL,0272,RC,,,,both,,,777.15,505.15,,,,,,,,,,,,,
GRAFT IMPL HUM TISS FRZ DRY ALLGRFT UNICORTICAL DWL W/O CART,SUP-2113897,CDM,C1713,HCPCS,0278,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
DEVICE FIX 55 MM STRL ENDOBUTTON CL BTB,SUP-2848581,CDM,C1713,HCPCS,0278,RC,,,,both,,,985.80,640.77,,,,,,,,,,,,,
DEVICE BNE FILL SZ 3 1ML 10GA DIR RADPQ FOR INTVENT THER DEL,SUP-2280928,CDM,2720000010,LOCAL,0272,RC,,,,both,,,346.66,225.33,,,,,,,,,,,,,
SLING URETH W2XL20CM PORCINE CLLGN SURGISIS BIODESIGN,SUP-2171314,CDM,C1763,HCPCS,0278,RC,,,,both,,,1224.60,795.99,,,,,,,,,,,,,
KIT INFANT EARCUP SANIBEL W TAB ELECTRODES,SUP-2858584,CDM,2720000010,LOCAL,0272,RC,,,,both,,,711.37,462.39,,,,,,,,,,,,,
SWEEP 6FR REPROS DEC MED STRYKER 401575,SUP-2845131,CDM,C1730,HCPCS,0272,RC,,,,both,,,329.20,213.98,,,,,,,,,,,,,
CROWN DENT NOEUL-5 PRI SEC M UP L S STL,SUP-2322203,CDM,D6783,CPT,0278,RC,,,,both,,,28.26,18.37,,,,,,,,,,,,,
COIL VASC I-ED COIL L 4 CM DIA 0.010 IN SECONDARY 2 MM,SUP-2865296,CDM,C1889,HCPCS,0278,RC,,,,both,,,4505.90,2928.83,,,,,,,,,,,,,
SYSTEM BONE CEM DEL INJ CANN DMND STYL W/O CEM EZ FLO,SUP-2342020,CDM,C1713,HCPCS,0278,RC,,,,both,,,1051.90,683.73,,,,,,,,,,,,,
CATHETER DIAG AD 6FR L55CM 0.07IN BLU S STL PTFE NYL,SUP-2158180,CDM,C1887,HCPCS,0272,RC,,,,both,,,257.17,167.16,,,,,,,,,,,,,
HC Screening Breast Tomo,PX-4037706300,CDM,77063,CPT,0403,RC,,,,inpatient,,,110.00,71.50,,,,,,,,,,,,,
TUBE VENT 1.14 MM 0.93 MM 2.8 MM REUT BOB W/ HOLE 520186,SUP-2472730,CDM,L8699,HCPCS,0278,RC,,,,both,,,35.29,22.94,,,,,,,,,,,,,
KIT INTRO L 10 CM DIA 4 FR 40 CM 0.018 IN 7CM PLAT TIP STD,SUP-2615865,CDM,C1894,HCPCS,0272,RC,,,,both,,,114.70,74.55,,,,,,,,,,,,,
PLATE BONE L154MM THK3.4MM 10 H BILAT S STL LCK COMPR NEUT,SUP-2348986,CDM,C1713,HCPCS,0278,RC,,,,both,,,3472.21,2256.94,,,,,,,,,,,,,
PIN FIX CLLRD 50 MM THRD,SUP-2315867,CDM,C1713,HCPCS,0278,RC,,,,both,,,276.32,179.61,,,,,,,,,,,,,
SYSTEM INTRO L60CM 6FR S STL STD DBL END GWIRE L60CM,SUP-2303016,CDM,C1769,HCPCS,0272,RC,,,,both,,,192.73,125.27,,,,,,,,,,,,,
SHAFT SCRDRVR M DIA1.5MM SELF HLD HEX CPL FOR MATRIXMANDIBLE,SUP-2179198,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2230.97,1450.13,,,,,,,,,,,,,
HOOK SPNL 6MM ROD DIA 6.5MM BLDE W 9.5MM LAM NEUT CLOSE,SUP-2415571,CDM,C1713,HCPCS,0278,RC,,,,both,,,1310.89,852.08,,,,,,,,,,,,,
CLIP ANEURYSM OPENING W1.5MM BLADE L2MM MICRO STRAIGHT CLOSI,SUP-2825393,CDM,C1889,HCPCS,0278,RC,,,,both,,,801.05,520.68,,,,,,,,,,,,,
GRAFT BNE CRUNCH 5 CC JR SUBSTITUTE DBM GRFT,SUP-2293912,CDM,C1713,HCPCS,0278,RC,,,,both,,,894.62,581.50,,,,,,,,,,,,,
INSERT TIB ROTATING HINGED 4 14 MM RT-PLUS,SUP-2450894,CDM,C1776,CPT,0278,RC,,,,both,,,2932.76,1906.29,,,,,,,,,,,,,
BLADE ENDOSCP COEQUAL LP ASMBLY SMARTRELEASE ONYX,SUP-2760601,CDM,2720000010,LOCAL,0272,RC,,,,both,,,467.86,304.11,,,,,,,,,,,,,
PLATE BNE SM L75MM 3X5 H BILAT TI T OBLQ LIMIT CNTCT DYN,SUP-2190943,CDM,C1713,HCPCS,0278,RC,,,,both,,,897.98,583.69,,,,,,,,,,,,,
PLATE BNE SM W11XL189MM THK34MM 14 H BILAT TI RIG NEUT LOK,SUP-2190792,CDM,C1713,HCPCS,0278,RC,,,,both,,,1786.31,1161.10,,,,,,,,,,,,,
ALLOGRAFT TISS CRYOPRESERVED 2X2 CM STRAVIX,SUP-2319185,CDM,Q4133,HCPCS,0636,RC,,,,both,,,2857.40,1857.31,,,,,,,,,,,,,
BLOCK CRANIOFACIAL SQ 63X38X3 MM SMOOTH SHELL SIL MEDPOR,SUP-2366444,CDM,C1713,HCPCS,0278,RC,,,,both,,,3358.26,2182.87,,,,,,,,,,,,,
KIT ACC HD EXT PLSE GENRTR,SUP-2355922,CDM,2720000010,LOCAL,0272,RC,,,,both,,,879.20,571.48,,,,,,,,,,,,,
SPACER TIB SZ 3.5 H8MM PROX WDG OPTETRAK LOGIC,SUP-2220974,CDM,C1776,CPT,0278,RC,,,,both,,,2967.30,1928.74,,,,,,,,,,,,,
SHEATH KIT NANONEEDLE 125 MM HI FLO OPERATIVE CRWN TIP FEN,SUP-2849271,CDM,2720000010,LOCAL,0272,RC,,,,both,,,624.86,406.16,,,,,,,,,,,,,
ALLOGRAFT BNE 250-1000 MH 1.20 CC FD CORTICAL PWD ORAGRAFT,SUP-2741035,CDM,C1713,HCPCS,0278,RC,,,,both,,,232.20,150.93,,,,,,,,,,,,,
CATHETER ANGIO SARAH DIA 5 FR RADIAL ART STRL,SUP-2385633,CDM,C1725,HCPCS,0272,RC,,,,both,,,172.70,112.25,,,,,,,,,,,,,
MATRIX BIO L 25 X W 20 CM FET BOV DERM DERMAL SLD STRL,SUP-2909326,CDM,Q4110,HCPCS,0636,RC,,,,both,,,24021.00,15613.65,,,,,,,,,,,,,
BASEPLATE TIB STD UNIV PRI STEM PRESSFIT POR CO CHROM SZ 1,SUP-2200366,CDM,C1776,CPT,0278,RC,,,,both,,,11570.27,7520.68,,,,,,,,,,,,,
SCREW BONE 2MM DIA 12MML TTNM ALLOY MXDRVE 8MM THRDD F/MLTDR,SUP-2493880,CDM,C1713,HCPCS,0278,RC,,,,both,,,312.40,203.06,,,,,,,,,,,,,
SURGICAL NAVIGATION PACK SUPL NAVIO,SUP-2342142,CDM,2720000010,LOCAL,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
BUR SURG MTCH HD STD 4X4 MM 3 MM DISECT TOOL PEG MIDAS REX,SUP-2137640,CDM,2720000010,LOCAL,0272,RC,,,,both,,,362.89,235.88,,,,,,,,,,,,,
LURBINECTEDIN 4 MG IV SOLR,RX-151029,CDM,J9223,HCPCS,0636,RC,68727-0712-01,NDC,,both,1,UN,23760.00,15444.00,,,,,,,,,,,,,
INSERT TIB THK13MM DST KNEE POLY MOD ROT HNG GMRS,SUP-2376379,CDM,C1776,CPT,0278,RC,,,,both,,,2745.46,1784.55,,,,,,,,,,,,,
HC Plmt Ureteral Stent Prq,PX-3615069500,CDM,50695,CPT,0361,RC,,,,outpatient,,,8583.00,5578.95,,,,,,,,,,,,,
GRAFT BONE SUB H12MM CANC CORT FIBULAR RNG PLUG WDG MECH FEE,SUP-2293803,CDM,C1713,HCPCS,0278,RC,,,,both,,,3045.80,1979.77,,,,,,,,,,,,,
WALKER PT M DIAB,SUP-2276716,CDM,L4387,HCPCS,0274,RC,,,,both,,,242.66,157.73,,,,,,,,,,,,,
COIL EMB L9CM LOOP OD5MM OD0.020IN NIT STRTCH RESIST FILL,SUP-2323396,CDM,C1889,HCPCS,0278,RC,,,,both,,,7049.30,4582.04,,,,,,,,,,,,,
EVOS VOLARIGHT PLATE 5H RIGHT WDE 78MM,SUP-2820167,CDM,C1713,HCPCS,0278,RC,,,,both,,,7751.56,5038.51,,,,,,,,,,,,,
GRAFT BONE SUB 1CC VIABLE BONE MTRX BIOFUSE,SUP-2224014,CDM,C1762,CPT,0278,RC,,,,both,,,1949.94,1267.46,,,,,,,,,,,,,
PLATE BONE SQUARE SHEET 50X50X3 MM STERILE SYNPOR,SUP-2837794,CDM,C1713,HCPCS,0278,RC,,,,both,,,3154.13,2050.18,,,,,,,,,,,,,
CATHETER DRAINAGE VENTRICULAR TRNSLUC SS EDM,SUP-2665143,CDM,C1729,HCPCS,0272,RC,,,,both,,,585.23,380.40,,,,,,,,,,,,,
PLATE BNE L100MM 20 H MAX BILAT TI STR NONCOMPRESSION LO,SUP-2191228,CDM,C1713,HCPCS,0278,RC,,,,both,,,1872.70,1217.25,,,,,,,,,,,,,
DILATOR URETH RENAL RADPQ CATH AMPLATZ,SUP-2171201,CDM,C1726,HCPCS,0272,RC,,,,both,,,1156.78,751.91,,,,,,,,,,,,,
BIOSURGE V WITH 12MM ALLOSYNC BUTTON,SUP-2811309,CDM,C1713,HCPCS,0278,RC,,,,both,,,3532.50,2296.12,,,,,,,,,,,,,
PROSTHESIS OSSCLR FRSBEE PRTL 117MM DIA DST END 3MM DIA HEA,SUP-2669520,CDM,L8613,CPT,0278,RC,,,,both,,,1086.31,706.10,,,,,,,,,,,,,
KNIFE SURG SKID ACET LIGMNT SS NS LF,SUP-2481985,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1221.24,793.81,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC HF 5FR 55CM 3 LUMAN RVRSE 1385108Q,SUP-2632639,CDM,C1751,HCPCS,0278,RC,,,,both,,,876.59,569.78,,,,,,,,,,,,,
CATHETER ABLATN 8 MM SPC SPEC CELSIUS DS,SUP-2466831,CDM,C1733,HCPCS,0272,RC,,,,both,,,4031.76,2620.64,,,,,,,,,,,,,
HC Insertion Picc W/Rs&I 5 Yr/>,PX-3613657300,CDM,36573,CPT,0361,RC,,,,both,,,5560.00,3614.00,,,,,,,,,,,,,
IMPLANT PIP 3X30MM 10DEG BEND PEEK DART W/ INSRTR DRL AND,SUP-2121837,CDM,C1713,HCPCS,0278,RC,,,,both,,,1868.30,1214.39,,,,,,,,,,,,,
FIBER LASER 365 MH N TAPR POLISHED TIP HOLM ACCUMAX 5/BX,SUP-2537763,CDM,2720000010,LOCAL,0272,RC,,,,both,,,954.97,620.73,,,,,,,,,,,,,
VASOPRESSIN 20 UNIT/ML SOLN (MIXTURES ONLY),RX-430007,CDM,J2598,HCPCS,0636,RC,42023-0164-25,NDC,,both,0.25,ML,54.10,35.16,,,,,,,,,,,,,
TRAY CATH MIDLN PROVENA PLU MAXBARR 3FR 20CM 1 LUMAN RVRSE T S4153108BDP,SUP-2613546,CDM,C1751,HCPCS,0278,RC,,,,both,,,527.52,342.89,,,,,,,,,,,,,
OXCARBAZEPINE 300 MG/5ML PO SUSP,RX-30479,CDM,340b,HCPCS,0637,RC,50268-0649-30,NDC,,both,5,ML,25.20,16.38,,,,,,,,,,,,,
GUIDEWIRE ORTH L 150 MM DIA1.4 MM SCREW DIA 3.5/4 MM THRD,SUP-2908509,CDM,C1769,HCPCS,0272,RC,,,,both,,,448.64,291.62,,,,,,,,,,,,,
HC Asp Injection Major Joint|BILATERAL PROCEDURE,PX-4502061000,CDM,20610,CPT,0450,RC,,,50,outpatient,,,1092.00,709.80,,,,,,,,,,,,,
CAGE SPNL 45X22X10 MM MODULUS XLW,SUP-2559259,CDM,C1889,HCPCS,0278,RC,,,,both,,,16579.20,10776.48,,,,,,,,,,,,,
PLATE BONE L14MM RT MAX TI T SHP FOR 1.3MM SCR,SUP-2190661,CDM,C1713,HCPCS,0278,RC,,,,both,,,1089.58,708.23,,,,,,,,,,,,,
CATH URET L 20 IN DIA 10 FRY ADLT DUAL LUM RADI ST LF DISP,SUP-2914403,CDM,C1758,HCPCS,0278,RC,,,,both,,,277.48,180.36,,,,,,,,,,,,,
CATHETERIZATION KIT 8.5 FRX20 CM ARROWG+ARD BLU +,SUP-2383395,CDM,C1751,HCPCS,0278,RC,,,,both,,,459.07,298.40,,,,,,,,,,,,,
PLATE NECK RADIAL HEAD LCP 3 HOLE 2.4MM SYNTHES 241.691,SUP-2849748,CDM,C1713,HCPCS,0278,RC,,,,both,,,60.51,39.33,,,,,,,,,,,,,
PLATE BNE 95 DEG SHFT L 236 MM BLADE L 50 MM 14 H SS CNDYL,SUP-2908364,CDM,C1713,HCPCS,0278,RC,,,,both,,,5535.57,3598.12,,,,,,,,,,,,,
GASTROSCOPE FLX FOV 120 DEG L 1.1 M OD 3.5 MM ID 2 MM UPPER,SUP-2895197,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6280.00,4082.00,,,,,,,,,,,,,
AMOXICILLIN 250 MG PO CAPS,RX-450,CDM,6370000000,HCPCS,0637,RC,16714-0298-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
ALLOGRAFT DERMAL UNMESHED 6X16 CMX1-2 MM PROLAYER EDM,SUP-2717799,CDM,C1763,HCPCS,0278,RC,,,,both,,,22568.75,14669.69,,,,,,,,,,,,,
STEM HUM SZ 1B L88MM 1325DEG LNG PTC FOR CONV SHLDR SYS,SUP-2399875,CDM,C1776,CPT,0278,RC,,,,both,,,14742.30,9582.49,,,,,,,,,,,,,
PLATE 3.5MM TI LCP MEDIAL PROXIMAL TIBIA 16H LT 249MM-STER,SUP-2549591,CDM,C1713,HCPCS,0278,RC,,,,both,,,5144.36,3343.83,,,,,,,,,,,,,
SCREW BONE CANNULATED LARGE 7X135 MM 32 MM SELFDRILLING PART,SUP-2836864,CDM,C1713,HCPCS,0278,RC,,,,both,,,1827.48,1187.86,,,,,,,,,,,,,
ALLOGRAFT BNE LG 5 CC FD DBM GRFT ORTHOBLEND,SUP-2787767,CDM,C1713,HCPCS,0278,RC,,,,both,,,2996.82,1947.93,,,,,,,,,,,,,
RASP SURG L18.3MM DIA3.2MM CUT ANG TAPR HELICOIDAL BLDE 5130080030] STRYKER INSTRUMENT DIV],SUP-2367488,CDM,2720000010,LOCAL,0272,RC,,,,both,,,367.73,239.02,,,,,,,,,,,,,
TIP ASPIR NAKAGAWA UNIV 0.8X3 MMX4.3 IN BNE SERRATED SONOPET,SUP-2791037,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1837.31,1194.25,,,,,,,,,,,,,
HEAD HUM DIA40MM THK18MM SHLDR CO CHROM PRI STD OFFSET NK 53524018] STRYKER ORTHOPEDICS HOWM],SUP-2372863,CDM,C1776,CPT,0278,RC,,,,both,,,5650.12,3672.58,,,,,,,,,,,,,
COIL EMB L10CM DIA4MM 0.02IN PERIPH COMPLX STD FRME,SUP-2323655,CDM,C1889,HCPCS,0278,RC,,,,both,,,3077.20,2000.18,,,,,,,,,,,,,
STAPLE INT L13XW13MM S STL COMPR INTERAXIS NONSTERILE IMPL,SUP-2243122,CDM,C1713,HCPCS,0278,RC,,,,both,,,2983.57,1939.32,,,,,,,,,,,,,
GRAFT VASC STD WALL 6 MMX10 CM STR RNG REINF ADVANTA VXT,SUP-2469231,CDM,C1768,CPT,0278,RC,,,,both,,,570.85,371.05,,,,,,,,,,,,,
PLATE BNE LP 1 MM NEURO 4X2 HOLE LADDER SQ SEG FOR SCR TI NS,SUP-2470479,CDM,C1713,HCPCS,0278,RC,,,,both,,,307.09,199.61,,,,,,,,,,,,,
HC So Tissue Level IV,PX-3128830566,CDM,88305,CPT,0312,RC,,,,both,,,968.00,629.20,,,,,,,,,,,,,
GRAFT HUM TISS BURN 5X5 CM MESHED CYTAL,SUP-2106462,CDM,Q4166,HCPCS,0636,RC,,,,both,,,2508.86,1630.76,,,,,,,,,,,,,
PLATE 3.5MM TI LCP POSTEROLATERAL DISTAL HUMERUS 3H LEFT,SUP-2549677,CDM,C1713,HCPCS,0278,RC,,,,both,,,2958.48,1923.01,,,,,,,,,,,,,
SCREW BONE L60MM DIA3.5MM CORT S STL ST FOR SM PLATING SYS,SUP-2349360,CDM,C1713,HCPCS,0278,RC,,,,both,,,174.21,113.24,,,,,,,,,,,,,
SET PICC L 55 CM DIA 4.5 FR SHTH L 7 CM DIA 4.5 FR,SUP-2887065,CDM,C1751,HCPCS,0278,RC,,,,both,,,639.52,415.69,,,,,,,,,,,,,
GRAFT BONE PRO DENS 12CC,SUP-2399149,CDM,C1713,HCPCS,0278,RC,,,,both,,,10152.00,6598.80,,,,,,,,,,,,,
PLATE BNE TI ALLOY LAPIDUS REV NS LEOS,SUP-2933560,CDM,C1713,HCPCS,0278,RC,,,,both,,,4107.12,2669.63,,,,,,,,,,,,,
ADAPTER ORTH TAPR FEM COMP COMPRESS/SRS 178950,SUP-2441883,CDM,C1776,CPT,0278,RC,,,,both,,,2077.11,1350.12,,,,,,,,,,,,,
PLATE BNE W8XL128MM THK3.3MM 16 H NONSTERILE BILAT PELV S,SUP-2186243,CDM,C1713,HCPCS,0278,RC,,,,both,,,2314.65,1504.52,,,,,,,,,,,,,
PLATE BNE L 46 X W 9 MM THK 1.1 MM SCREW DIA 3.5 MM 4 H SS,SUP-2932906,CDM,C1713,HCPCS,0278,RC,,,,both,,,338.87,220.27,,,,,,,,,,,,,
PLATE BNE L229MM 15 H ST R LAT DST FIBULAR S STL LOK COMPR,SUP-2177430,CDM,C1713,HCPCS,0278,RC,,,,both,,,2231.82,1450.68,,,,,,,,,,,,,
SEGMENT FEM OD23MM 5DEG SM TRAPEZOIDAL FLARE COMP SCR FORGED,SUP-2222175,CDM,C1776,CPT,0278,RC,,,,both,,,6004.94,3903.21,,,,,,,,,,,,,
COVER BUR H DIA7MM PLT LO PROF W/ TAB UNIV NEURO III,SUP-2363629,CDM,C1713,HCPCS,0278,RC,,,,both,,,788.52,512.54,,,,,,,,,,,,,
SCREW JONES FRACTR L 42 MM DIA 45 MM SLD NS,SUP-2896632,CDM,C1713,HCPCS,0278,RC,,,,both,,,2665.86,1732.81,,,,,,,,,,,,,
PROCESSOR SND BRN BAHA INTENSO,SUP-2164954,CDM,L8691,HCPCS,0274,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
COMPONENT HUM XSM L4IN UNIV DST EL TIV PLSM INTERCHANGEABLE,SUP-2205919,CDM,C1776,CPT,0278,RC,,,,both,,,15009.36,9756.08,,,,,,,,,,,,,
OBTURATOR SHTH 9FRX33CM SNAP LCK,SUP-2355510,CDM,C1894,HCPCS,0272,RC,,,,both,,,18.06,11.74,,,,,,,,,,,,,
CLASSIC CHS PL 12 SLOT 135 DEG,SUP-2818264,CDM,C1713,HCPCS,0278,RC,,,,both,,,6137.29,3989.24,,,,,,,,,,,,,
SET EMER 8.5FR L6CM NDL 15GA PNEUMOTHOR CATH,SUP-2169802,CDM,C1729,HCPCS,0272,RC,,,,both,,,178.92,116.30,,,,,,,,,,,,,
STEM FEM SZ 0 L N CLLRD POR NAT HIP,SUP-2210731,CDM,C1776,CPT,0278,RC,,,,both,,,24680.40,16042.26,,,,,,,,,,,,,
PLATE BNE L35MM 4 H TI STR,SUP-2262999,CDM,C1713,HCPCS,0278,RC,,,,both,,,646.46,420.20,,,,,,,,,,,,,
INTRODUCER SHTH 0.021 IN 4 FRX11 CM STR FLPY PRELUDE IDEAL,SUP-2798465,CDM,C1894,HCPCS,0272,RC,,,,both,,,190.41,123.77,,,,,,,,,,,,,
TREPHINE SURG OD7MM COR SL DISPOSABLE,SUP-2212796,CDM,C1713,HCPCS,0278,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
VALVE DRAINAGE PUDENZ 16 MM BURR HOLE HI PRESSURE,SUP-2244294,CDM,C1729,HCPCS,0272,RC,,,,both,,,1357.80,882.57,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 45 CM DIA 8 MM RNG L 5 CM EPTFE,SUP-2396272,CDM,C1768,CPT,0278,RC,,,,both,,,2270.22,1475.64,,,,,,,,,,,,,
BIT DRILL STOP MINI 1.25X44.5 MM 8 MM QUICK COUPLING NON STE,SUP-2842021,CDM,2720000010,LOCAL,0272,RC,,,,both,,,595.66,387.18,,,,,,,,,,,,,
SCREW BONE 35 MM ACCESS LIF-PTP,SUP-2721712,CDM,C1713,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
BLADE SAW W9MM THK0.4MM S TYP FOR ULN OSTEOTMY COMPR PLT,SUP-2389620,CDM,2720000010,LOCAL,0272,RC,,,,both,,,238.64,155.12,,,,,,,,,,,,,
WIRE SURG PRECUT 22 GAX6 MM,SUP-2185885,CDM,C1713,HCPCS,0278,RC,,,,both,,,27.00,17.55,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY L 80 CM DIA 5 FR TIP 3 MM SPC,SUP-2248649,CDM,C1730,HCPCS,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
PLATE BONE 8 H CRANIOMAXILLOFACIAL TI DBL Y SHP LO PROF RIG,SUP-2191313,CDM,C1713,HCPCS,0278,RC,,,,both,,,1072.62,697.20,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED STD UNI OXIN,SUP-2351347,CDM,C1776,CPT,0278,RC,,,,both,,,8179.70,5316.80,,,,,,,,,,,,,
GRAFT VASC STR STD WALL RING 6MM DIA 100CM LEN 50CM GORTX,SUP-2396008,CDM,C1768,CPT,0278,RC,,,,both,,,4370.88,2841.07,,,,,,,,,,,,,
GRAFT PUTTY SYNTH OSTEOVATIONEX IMPACTION FRMLA 3CC,SUP-2319788,CDM,C1713,HCPCS,0278,RC,,,,both,,,3171.40,2061.41,,,,,,,,,,,,,
SHEATH INTRO D'VILL L 65 CM DIA14 FR GUIDEWIRE 0.035 IN LNG,SUP-2615939,CDM,C1894,HCPCS,0272,RC,,,,both,,,737.90,479.63,,,,,,,,,,,,,
IMPLANT UNI TIB IMPL KT ZM,SUP-2200486,CDM,C1776,CPT,0278,RC,,,,both,,,4446.24,2890.06,,,,,,,,,,,,,
BURR SURG LINDE 4MM DIA HD MED MIC 50MML CARBIDE SM BNE RND,SUP-2605557,CDM,2720000010,LOCAL,0272,RC,,,,both,,,192.11,124.87,,,,,,,,,,,,,
ALLOGRAFT SPCR CERV TRIAD BIPORTAL,SUP-2311769,CDM,C1713,HCPCS,0278,RC,,,,both,,,7143.50,4643.27,,,,,,,,,,,,,
SUPPORT ORTHOT ANK KNEE CALF CUST SLD STIRRUP,SUP-2435630,CDM,L1980,HCPCS,0274,RC,,,,both,,,1143.12,743.03,,,,,,,,,,,,,
COIL NEUROVASCULAR MICROPLEX L 30 CM LOOP DIA 7 MM,SUP-2305209,CDM,C1889,HCPCS,0278,RC,,,,both,,,1975.06,1283.79,,,,,,,,,,,,,
SHIM SPNL SZ 25 MM INTDISC INSRTN MONITORING NS DISP,SUP-2886317,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1036.20,673.53,,,,,,,,,,,,,
STEM FEM L152MM OD11MM FINN L14CM HIP SEGMENTED COMP,SUP-2406101,CDM,C1776,CPT,0278,RC,,,,both,,,12917.65,8396.47,,,,,,,,,,,,,
HEAD FEM DIA32MM +5MM OFFSET 12/14 TAPR HIP CERAMIC BIOLOX,SUP-2251101,CDM,C1776,CPT,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
LOCKING FRAC PLATE 6 HOLE 43MM NON CMPRSSN 20MM THICK T 6L,SUP-2694215,CDM,C1713,HCPCS,0278,RC,,,,both,,,1847.14,1200.64,,,,,,,,,,,,,
KIT URET INFRAVISION L70CM DIA6FR,SUP-2366514,CDM,C2617,HCPCS,0278,RC,,,,both,,,803.21,522.09,,,,,,,,,,,,,
SET PICC L 15 CM DIA 4.5 FR SHTH L 7 CM DIA 4.5 FR GUIDEWIRE,SUP-2887022,CDM,C1751,HCPCS,0278,RC,,,,both,,,505.54,328.60,,,,,,,,,,,,,
STOCKING COMPR OPN TOE MED PET 30-40 MMHG UNISX BGE ASSURE,SUP-2724358,CDM,C1713,HCPCS,0278,RC,,,,both,,,122.43,79.58,,,,,,,,,,,,,
KIT ARTHSCP HIP MSTR DISP W/ KNF BLDE,SUP-2121991,CDM,C1769,HCPCS,0272,RC,,,,both,,,2019.02,1312.36,,,,,,,,,,,,,
SCREW SLF-DRL LK MATRIXMAND 2.0X8MM,SUP-2718089,CDM,C1713,HCPCS,0278,RC,,,,both,,,490.15,318.60,,,,,,,,,,,,,
PIN FIX SD 3X60X15 MM CORTICAL THRD MINIRAIL,SUP-2435292,CDM,2720000010,LOCAL,0272,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
PLATE BNE L 231 X W 10.7 MM THK 3.4 MM SCREW DIA 3.5 MM 20 H 72440720N,SUP-2932846,CDM,C1713,HCPCS,0278,RC,,,,both,,,3805.99,2473.89,,,,,,,,,,,,,
PLATE 12MM ASPN 62110012,SUP-2209277,CDM,C1713,HCPCS,0278,RC,,,,both,,,12560.00,8164.00,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC SOLO2 5FR 55CM 2 LUMAN RVS TAPR PWR,SUP-2613370,CDM,C1751,HCPCS,0278,RC,,,,both,,,800.32,520.21,,,,,,,,,,,,,
BLADE SHAVER 3.5 MM ULTRAGATOR,SUP-2765776,CDM,2720000010,LOCAL,0272,RC,,,,both,,,413.32,268.66,,,,,,,,,,,,,
SCREW BNE L14MM DIA5MM CNDYL S STL ST VAR ANG LOK COMPR T25,SUP-2178693,CDM,C1713,HCPCS,0278,RC,,,,both,,,792.13,514.88,,,,,,,,,,,,,
SCREW CRANIOMAXILLOFACIAL VIT 2.0MM DIA 18MML,SUP-2364642,CDM,C1713,HCPCS,0278,RC,,,,both,,,117.40,76.31,,,,,,,,,,,,,
HC Inj Proc Lymphangiogram,PX-3613879000,CDM,38790,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
GUIDEWIRE SPNL SYM OCT DIA 0.95 MM NS,SUP-2591518,CDM,C1769,HCPCS,0272,RC,,,,both,,,188.40,122.46,,,,,,,,,,,,,
LONG DRILL COMPATIBLE WITH KDPDKBP 1110 13 G,SUP-2702558,CDM,2720000010,LOCAL,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
ALLOGRAFT DERMAL SM MED 1.6/0.4 MM CNTOUR RDY TO USE ALLDERM,SUP-2458322,CDM,Q4116,HCPCS,0636,RC,,,,both,,,9002.38,5851.55,,,,,,,,,,,,,
STEM FEM NO 2 L203MM OD14MM TI HA POR HIP REV STR NEUT CEM,SUP-2375244,CDM,C1776,CPT,0278,RC,,,,both,,,14064.69,9142.05,,,,,,,,,,,,,
HC So Serpina 1 Gene,PX-3108133266,CDM,81332,CPT,0310,RC,,,,both,,,225.00,146.25,,,,,,,,,,,,,
SHEATH INTRO 7 FRX23 CM 29.5 CM TEARWY VLV DIL SAFSHTH II,SUP-2329871,CDM,C1892,HCPCS,0272,RC,,,,both,,,138.16,89.80,,,,,,,,,,,,,
PLATE BNE L195MM 8 H R CNDYL S STL VAR ANG LOK COMPR CRV,SUP-2177848,CDM,C1713,HCPCS,0278,RC,,,,both,,,5485.99,3565.89,,,,,,,,,,,,,
GRAFT HUM TISS L 250 MM DIA 8.5 MM SEMITENDINOSUS GRACILIS,SUP-2913221,CDM,C1762,CPT,0278,RC,,,,both,,,11687.08,7596.60,,,,,,,,,,,,,
MICROSPHERE EMB THERASPHERE 10 GBQ YTTRIUM-90 GLS DOSE VI,SUP-2135281,CDM,C2616,HCPCS,0278,RC,,,,both,,,54322.00,35309.30,,,,,,,,,,,,,
PATCH CV HEMGRD L 75 X W 14 MM THK 0.41 MM POLYESTER BOV,SUP-2535422,CDM,C1768,CPT,0278,RC,,,,both,,,454.01,295.11,,,,,,,,,,,,,
SHEATH INTRO BRT TIP L 11 CM DIA 5 FR DIL TIP L 25 MM GRA,SUP-2156024,CDM,C1894,HCPCS,0272,RC,,,,both,,,73.48,47.76,,,,,,,,,,,,,
SCREW BONE PLLA CORT FULL THRD N CANN N LCK RESRB NSTERILE,SUP-2166518,CDM,C1713,HCPCS,0278,RC,,,,both,,,441.20,286.78,,,,,,,,,,,,,
WIRE FIX L9IN DIA0.035IN S STL SHRP TIP DBL END K,SUP-2342696,CDM,C1713,HCPCS,0278,RC,,,,both,,,164.47,106.91,,,,,,,,,,,,,
PLATE BNE L87MM THK3.8MM 5 H BILAT S STL NAR DYN COMPR FOR,SUP-2185205,CDM,C1713,HCPCS,0278,RC,,,,both,,,1111.40,722.41,,,,,,,,,,,,,
BASKET EXTR 5MMX1.3CM SHTH 5FR ACCSRY CHAN 2MM MINI FOR ENDO,SUP-2169104,CDM,C1713,HCPCS,0278,RC,,,,both,,,687.66,446.98,,,,,,,,,,,,,
PLATE BNE LG LT MIS HV REV,SUP-2897010,CDM,C1713,HCPCS,0278,RC,,,,both,,,5962.86,3875.86,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA PLU MAXBARR 3FR S1173108D2,SUP-2632786,CDM,C1751,HCPCS,0278,RC,,,,both,,,793.35,515.68,,,,,,,,,,,,,
SHEATH INTRO PRELUDE L 23 CM DIA 6 FR 0.018 IN NIT 7CM 21 GA,SUP-2677276,CDM,C1894,HCPCS,0272,RC,,,,both,,,168.18,109.32,,,,,,,,,,,,,
PLATE BNE 150DEG FEM TRL DHS,SUP-2187958,CDM,C1713,HCPCS,0278,RC,,,,both,,,893.90,581.03,,,,,,,,,,,,,
SUPPORT ORTHOT ELBW CUST OFF-THE-SHELF W/MTL JT ELASTIC,SUP-2435757,CDM,L3710,HCPCS,0272,RC,,,,both,,,367.91,239.14,,,,,,,,,,,,,
NERVE STIMULATOR KIT PERIPH NERVE SYS CHANNEL A RECV STIMQ,SUP-2423763,CDM,C1816,LOCAL,0278,RC,,,,both,,,53380.00,34697.00,,,,,,,,,,,,,
WASHER ORTH DIA5.5MM SPIK,SUP-2184676,CDM,C1713,HCPCS,0278,RC,,,,both,,,114.14,74.19,,,,,,,,,,,,,
BASEPLATE GLEN L35MM DIA25MM STD POLYETH HA THRD POST,SUP-2388698,CDM,C1776,CPT,0278,RC,,,,both,,,6647.38,4320.80,,,,,,,,,,,,,
IMPLANT OSS L8.13MM DIA0.8MM INCUS STAP CRADL HD HA PLAS,SUP-2313677,CDM,L8613,CPT,0278,RC,,,,both,,,1019.87,662.92,,,,,,,,,,,,,
HC Transcath Therapy Emboliz S&,PX-3207589400,CDM,75894,CPT,0320,RC,,,,both,,,8583.00,5578.95,,,,,,,,,,,,,
SHUNT SURG SM UNIV W/ RA VENTILATOR 22097BM,SUP-2628153,CDM,C1729,HCPCS,0272,RC,,,,both,,,3757.95,2442.67,,,,,,,,,,,,,
DRILL SURG 4 MM CORTICAL,SUP-2644808,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2274.46,1478.40,,,,,,,,,,,,,
CATHETER URETERAL BLLN DILATION 5MM X 4CM URO EZDILATE,SUP-2727217,CDM,C1758,HCPCS,0278,RC,,,,both,,,606.02,393.91,,,,,,,,,,,,,
PLATE BNE VA 2.7X3.5 MM LT ANTR LAT 14 HOLE SS STRL VA-LCP,SUP-2177233,CDM,C1713,HCPCS,0278,RC,,,,both,,,7278.96,4731.32,,,,,,,,,,,,,
PLATE BNE CNDYL 2/2.5X31X26X1 MM RT 9 HOLE SMART3D TRAUM NS,SUP-2499063,CDM,C1713,HCPCS,0278,RC,,,,both,,,3223.15,2095.05,,,,,,,,,,,,,
INTRODUCER SHTH W51XH73XL557MM D13MM DIA7.8MM HYDRPHLC,SUP-2281174,CDM,C1894,HCPCS,0272,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
PLATE 4.5MM 3.5MM TI LCP METAPHYSEAL 16 HOLES,SUP-2549478,CDM,C1713,HCPCS,0278,RC,,,,both,,,3159.72,2053.82,,,,,,,,,,,,,
MESH HERN OPN 25X15 CM FLX COMP PHYSIOMESH,SUP-2257748,CDM,C1781,HCPCS,0278,RC,,,,both,,,4983.18,3239.07,,,,,,,,,,,,,
SNARE VASC DOTTER SHFT L 95 CM DIA 8 FR BSKT L 7 CM DIA 3 CM,SUP-2167937,CDM,C1713,HCPCS,0278,RC,,,,both,,,955.91,621.34,,,,,,,,,,,,,
CATHETER ANGIO MARINER L 80 CM 5 FR SOS OMNI1 NONBRAIDED,SUP-2118257,CDM,C1887,HCPCS,0272,RC,,,,both,,,759.88,493.92,,,,,,,,,,,,,
PUSHER KNOT SUT CUT DISP,SUP-2163482,CDM,2720000010,LOCAL,0272,RC,,,,both,,,587.97,382.18,,,,,,,,,,,,,
BURR ARTHSCP 5.5MM DIA ROUND FLTDX6 UNHDD BROWN HUB F/DSTL C,SUP-2589373,CDM,2720000010,LOCAL,0272,RC,,,,both,,,179.17,116.46,,,,,,,,,,,,,
CYTARABINE (PF) 100 MG/ML IJ SOLN,RX-20156,CDM,J9100,HCPCS,0636,RC,61703-0319-22,NDC,,both,20,ML,58.60,38.09,,,,,,,,,,,,,
SYSTEM THROMCTMY CLEANER15 L 65 CM DIA 7 FR SINUSOIDAL WIRE,SUP-2120125,CDM,C1757,HCPCS,0272,RC,,,,both,,,3320.08,2158.05,,,,,,,,,,,,,
PLATE BONE L67MM 6 H C FBR 1/3 TBLR,SUP-2152587,CDM,C1713,HCPCS,0278,RC,,,,both,,,1335.29,867.94,,,,,,,,,,,,,
LOCKING PLATE T10MM L SHAPE L7 HOLES,SUP-2679031,CDM,C1713,HCPCS,0278,RC,,,,both,,,1009.92,656.45,,,,,,,,,,,,,
STEM HUM CEM 140 DEG 6.5X115 MM SHLDR AEQUALIS,SUP-2715535,CDM,C1776,CPT,0278,RC,,,,both,,,10131.21,6585.29,,,,,,,,,,,,,
SPLINT WRST FA 6IN UNIV BLU L LOOP LOK W STAY COCK UP CANVS,SUP-2194434,CDM,L3809,HCPCS,0272,RC,,,,both,,,35.86,23.31,,,,,,,,,,,,,
GRAFT HUM TISS 2X2CM EPIFIX,SUP-2305749,CDM,Q4186,HCPCS,0636,RC,,,,both,,,3173.91,2063.04,,,,,,,,,,,,,
NAIL IM L440MM DIA3.5MM 8DEG UNIV ST LT BLU TIB CANN LOK,SUP-2192732,CDM,C1713,HCPCS,0278,RC,,,,both,,,1010.83,657.04,,,,,,,,,,,,,
PLATE BNE L 47.7 X W 30.02 MM THK 2 MM SCREW DIA2 MM 8 H TI,SUP-2936416,CDM,C1713,HCPCS,0278,RC,,,,both,,,2436.64,1583.82,,,,,,,,,,,,,
CATHETER INFUSION 2.6 FRX150 CM 5+ IN SAME PO CORSAIR PRO,SUP-2472440,CDM,C1887,HCPCS,0272,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
PLATE BNE W14XL86MM THK3.8MM 90DEG 4 H L TIB S STL L SHP,SUP-2185788,CDM,C1713,HCPCS,0278,RC,,,,both,,,1515.65,985.17,,,,,,,,,,,,,
KIT PICC IR 4FR SGL LUMEN6 FR RVS TAPR DIA17G INNR DIA W/,SUP-2118777,CDM,C1751,HCPCS,0278,RC,,,,both,,,433.32,281.66,,,,,,,,,,,,,
COMPONENT RND PRI STD CEM NP WITHOUTXRAY WIRE SZ 0 NAT KNEE,SUP-2208959,CDM,C1776,CPT,0278,RC,,,,both,,,14336.30,9318.59,,,,,,,,,,,,,
SCREW SPNL L35MM DIA4.35MM CANC PEDCL THORACOLUMBOSACRAL TI,SUP-2254680,CDM,C1713,HCPCS,0278,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
STENT PANCREATIC 7 FRX7 CM ADVANIX,SUP-2141441,CDM,C2625,HCPCS,0278,RC,,,,both,,,273.18,177.57,,,,,,,,,,,,,
COMPONENT FEM XSM R KNEE MOD ROT HNG REV CEM MONOGRAM,SUP-2421282,CDM,C1776,CPT,0278,RC,,,,both,,,20771.10,13501.21,,,,,,,,,,,,,
SHEATH LD INTRO SAFSHTH DIA 9 FR HYDROPHOBIC VLV HEMOSTATIC,SUP-2193984,CDM,C1892,HCPCS,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
NAIL IM L22CM DIA12MM TIBIOTALOCALCANEAL NIT DYNANAIL,SUP-2277457,CDM,C1713,HCPCS,0278,RC,,,,both,,,52909.00,34390.85,,,,,,,,,,,,,
BUR SURG DIAMOND 4 MM COARSE EXT STRL ELITE LTX,SUP-2859313,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1003.54,652.30,,,,,,,,,,,,,
DRESSING WND SGL LAYR MTRX ST DISP L2XW2IN,SUP-2243645,CDM,Q4108,HCPCS,0636,RC,,,,both,,,5545.24,3604.41,,,,,,,,,,,,,
GRAFT DERM CLLGN SURG PROC HUM RECTANG IMPL L20XW4CM,SUP-2125860,CDM,C1762,CPT,0278,RC,,,,both,,,6367.92,4139.15,,,,,,,,,,,,,
IMMOBILIZER ORTH CUTAWAY UNIV 14 IN 12-24 IN ADJ FOAM,SUP-2194895,CDM,L1830,CPT,0272,RC,,,,both,,,34.95,22.72,,,,,,,,,,,,,
STAPLER INT W4MM BLU TI FOR RELD HERN MESH FIX MULTFI ENDO,SUP-2283144,CDM,2720000010,LOCAL,0272,RC,,,,both,,,123.68,80.39,,,,,,,,,,,,,
HC So Assay of Vit B-2,PX-3018425266,CDM,84252,CPT,0301,RC,,,,both,,,165.00,107.25,,,,,,,,,,,,,
BUR SURG SHANK L13CM DIA3MM LILAC COARSE DMND RND,SUP-2365190,CDM,2720000010,LOCAL,0272,RC,,,,both,,,606.59,394.28,,,,,,,,,,,,,
PLATE BNE STR 2X35 MM 6 HOLE,SUP-2569073,CDM,C1713,HCPCS,0278,RC,,,,both,,,158.88,103.27,,,,,,,,,,,,,
KIT CATH HEMODIALYSI RETRO CHRONIC STD 16FR DIA 40CM 35CML I,SUP-2613318,CDM,C1750,HCPCS,0278,RC,,,,both,,,1318.80,857.22,,,,,,,,,,,,,
TRAY PICC AD 4FR TRIM LEN INTMED DBL LUMN SIL NRS NPOWER,SUP-2125580,CDM,C1751,HCPCS,0278,RC,,,,both,,,187.77,122.05,,,,,,,,,,,,,
SYSTEM TISS COLLCTN SM SFT PD SEG REV SYS MOD AUG REGENEREX,SUP-2402757,CDM,C1776,CPT,0278,RC,,,,both,,,11454.72,7445.57,,,,,,,,,,,,,
PLUNGER DRVR ASMBLY FOR ACUTRK 2 SCR SYS,SUP-2107357,CDM,C1713,HCPCS,0278,RC,,,,both,,,373.66,242.88,,,,,,,,,,,,,
HC So1 Microsomal Antibody,PX-3028637667,CDM,86376,CPT,0302,RC,,,,both,,,495.00,321.75,,,,,,,,,,,,,
DEVICE DIL MULT SNUS TOOL XPRESS,SUP-2217796,CDM,C1726,HCPCS,0272,RC,,,,both,,,3925.00,2551.25,,,,,,,,,,,,,
PROSTHESIS OSS PISTON 0.6X5 MM 0.6 MM FLROPLAS,SUP-2637731,CDM,L8613,CPT,0278,RC,,,,both,,,277.76,180.54,,,,,,,,,,,,,
BIT DRL QC 2.8X170 MM 80 MM CALIB NS,SUP-2563758,CDM,2720000010,LOCAL,0272,RC,,,,both,,,415.27,269.93,,,,,,,,,,,,,
KIT INTRO INTDYN TEARWY L 14 CM DIA12 FR GUIDEWIRE 0.038 IN,SUP-2125218,CDM,C1892,HCPCS,0272,RC,,,,both,,,165.35,107.48,,,,,,,,,,,,,
GRAFT HUM TISS PTCH 3X8 CM UMB CRD RESTORIGIN,SUP-2321895,CDM,Q4191,HCPCS,0636,RC,,,,both,,,7536.00,4898.40,,,,,,,,,,,,,
SET INSTR OSTEOCHNDRL FLAP REP MULTISHOT,SUP-2121826,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1632.80,1061.32,,,,,,,,,,,,,
STIMULATOR NERVE MIC,SUP-2240636,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
P GRSP 3.4 MM REG 1,SUP-2334699,CDM,C1763,HCPCS,0278,RC,,,,both,,,9420.00,6123.00,,,,,,,,,,,,,
MESH BIOLOGIC OVINE RUMEN PERM OVITEX 1S 6X10 CM,SUP-2383092,CDM,C1781,HCPCS,0278,RC,,,,both,,,3391.20,2204.28,,,,,,,,,,,,,
SCREW BNE LCK 2X14 MM CROSS DRV TI NS,SUP-2754968,CDM,C1713,HCPCS,0278,RC,,,,both,,,295.16,191.85,,,,,,,,,,,,,
CEMENT BNE 20ML 41GM FULL DOSE PMMA W/ TOBRA M VISC RADPQ,SUP-2374949,CDM,C1713,HCPCS,0278,RC,,,,both,,,753.60,489.84,,,,,,,,,,,,,
DEVICE GRFT DEL FOR BONE VOID FIL NORIAN,SUP-2419206,CDM,2720000010,LOCAL,0272,RC,,,,both,,,369.99,240.49,,,,,,,,,,,,,
ARCOS 18X200MM INTLKNG DIST,SUP-2506099,CDM,C1776,CPT,0278,RC,,,,both,,,10562.96,6865.92,,,,,,,,,,,,,
STAPLE BONE FIX W15XL14-14MM COMPR,SUP-2223979,CDM,C1713,HCPCS,0278,RC,,,,both,,,3001.84,1951.20,,,,,,,,,,,,,
PLATE BNE L 185 MM SCREW DIA 3.5 MM 16 H SS HUM FEM TIB,SUP-2931259,CDM,C1713,HCPCS,0278,RC,,,,both,,,2909.37,1891.09,,,,,,,,,,,,,
PASSER SUTURE 3MM LIGATURE GUIDE BLUNT STRAIGHT REUSABLE,SUP-2824102,CDM,2720000010,LOCAL,0272,RC,,,,both,,,396.33,257.61,,,,,,,,,,,,,
SCREW BONE L20MM DIA2MM STD CORT CRANIOMAXILLOFACIAL TI ST,SUP-2189676,CDM,C1713,HCPCS,0278,RC,,,,both,,,227.65,147.97,,,,,,,,,,,,,
PLATE BNE STRNL 2.3X86X23X1.8 MM THOR 34 HOLE LADDER LEVEL 1,SUP-2869247,CDM,C1713,HCPCS,0278,RC,,,,both,,,3180.73,2067.47,,,,,,,,,,,,,
HC NM Stress Muga With Med,PX-3417847300,CDM,78473,CPT,0341,RC,,,,outpatient,,,1275.00,828.75,,,,,,,,,,,,,
TIP ENDO SUCT STR 10 MM DIAM 33 CM LEN QUIK DC N COAG W/ H,SUP-2125888,CDM,C1713,HCPCS,0278,RC,,,,both,,,593.46,385.75,,,,,,,,,,,,,
PROGRAMMER NEUROSTIMULATOR PT GEN,SUP-2356762,CDM,C1767,HCPCS,0278,RC,,,,both,,,3114.41,2024.37,,,,,,,,,,,,,
HC Pain Minor,PX-3600007514,CDM,3600007514,LOCAL,0360,RC,,,,outpatient,,,2101.00,1365.65,,,,,,,,,,,,,
SUCROSE 24 % (PRESERVATIVE FREE) ORAL SOLN,RX-40850012,CDM,6370000000,HCPCS,0637,RC,09999-9900-20,NDC,,both,15,ML,3.80,2.47,,,,,,,,,,,,,
GRAFT HUM TISS W2XL3CM AMNIO MEMBRN TRNSLUC GRID PAT SGL,SUP-2113884,CDM,Q4154,HCPCS,0636,RC,,,,both,,,3249.90,2112.43,,,,,,,,,,,,,
SHEATH ENDOSCP L20CM DIA3MM SGL ACT JAW OUTER W FRCP INSRT,SUP-2261267,CDM,C1894,HCPCS,0272,RC,,,,both,,,2672.77,1737.30,,,,,,,,,,,,,
PLATE 2.7 VAL ANT PATELLA PL SS 3 HL/SM/ST,SUP-2718096,CDM,C1713,HCPCS,0278,RC,,,,both,,,6186.68,4021.34,,,,,,,,,,,,,
EXTRACTOR STONE 2.4FR L115CM BSKT DIA1CM 4/16 WIRE URIN,SUP-2171364,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1193.20,775.58,,,,,,,,,,,,,
MESH HERN W20XL20CM POLY HYDRPHLC SQ KNIT HNYCMB 3D FLAT,SUP-2752165,CDM,C1781,HCPCS,0278,RC,,,,both,,,763.99,496.59,,,,,,,,,,,,,
BIT DRL TWST 1.1X50 MM CYL ATTCH SS LEVEL 1 DISP,SUP-2460571,CDM,2720000010,LOCAL,0272,RC,,,,both,,,417.34,271.27,,,,,,,,,,,,,
SEGMENT EXT FIX MOD RT FOR RED II ALUM 515830204,SUP-2499038,CDM,C1713,HCPCS,0278,RC,,,,both,,,9146.88,5945.47,,,,,,,,,,,,,
CATHETER GUID JL5 8 FRX90 CM LG LUMEN FLX SH NYL LAUNCHER,SUP-2429824,CDM,C1887,HCPCS,0272,RC,,,,both,,,91.15,59.25,,,,,,,,,,,,,
STAPLER INT DIA5MM SHT FIX DEV W/ 20 TACK ABSORBATACK,SUP-2283223,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1105.19,718.37,,,,,,,,,,,,,
SEALANT TISS GLUE 4ML PLEUR AIR LEAK PROGEL,SUP-2126993,CDM,C1713,HCPCS,0278,RC,,,,both,,,3957.91,2572.64,,,,,,,,,,,,,
MINI PLATE Z SHAPE 6 HOLE RGHT 10 MM BAR 3MM WIDTH CP TTNM,SUP-2669687,CDM,C1713,HCPCS,0278,RC,,,,both,,,841.80,547.17,,,,,,,,,,,,,
COMPONENT TIB HINGED NEUT MED 65 MM KNEE ROTATIONAL PROS,SUP-2423135,CDM,C1776,CPT,0278,RC,,,,both,,,8587.90,5582.13,,,,,,,,,,,,,
PORT INFUS OD8FR ID16MM SHTH DIA8FR TI POLYUR SGL LUMN PASV,SUP-2118950,CDM,C1788,HCPCS,0278,RC,,,,both,,,643.70,418.40,,,,,,,,,,,,,
COIL EMB L15CM LOOP DIA4MM PERIPH SELF EXP HYDRGEL POLYMER,SUP-2385397,CDM,C1889,HCPCS,0278,RC,,,,both,,,3995.96,2597.37,,,,,,,,,,,,,
MESH WND DERM REP FET BOV DERM IONIC SIL PRIMATRIX AG FEN,SUP-2420902,CDM,Q4110,HCPCS,0636,RC,,,,both,,,16249.50,10562.17,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 80 CM DIA 8 MM STR STD WALL HELIX,SUP-2483442,CDM,C1768,CPT,0278,RC,,,,both,,,1799.97,1169.98,,,,,,,,,,,,,
DEVICE FIX ARTIFICIAL LIGMNT 7,SUP-2137259,CDM,C1713,HCPCS,0278,RC,,,,both,,,1828.74,1188.68,,,,,,,,,,,,,
COBICISTAT 150 MG PO TABS,RX-128000,CDM,6370000000,HCPCS,0637,RC,61958-1401-01,NDC,,both,1,UN,47.30,30.74,,,,,,,,,,,,,
PLATE BNE T MED 1.5X27X0.8 MM MIDFACE 8 HOLE W/ TAB TI NS,SUP-2469381,CDM,C1713,HCPCS,0278,RC,,,,both,,,781.48,507.96,,,,,,,,,,,,,
IMPLANT OTO L6MM PIST DIA0.4MM S STL FLROPLAS FISCH TYP,SUP-2312552,CDM,L8613,CPT,0278,RC,,,,both,,,221.06,143.69,,,,,,,,,,,,,
CATHETER PULM ART 5FR L100CM PVC 3 LUMN TRUE SZ THRMDIL,SUP-2214747,CDM,C1751,HCPCS,0278,RC,,,,both,,,978.93,636.30,,,,,,,,,,,,,
SCREW BONE L100MM OD10.5MM TI U-BLADE LAG SET FOR IM NAIL,SUP-2362207,CDM,C1713,HCPCS,0278,RC,,,,both,,,2861.17,1859.76,,,,,,,,,,,,,
COUNTERSINK SURG OD3MM HD SGL USE MONSTER,SUP-2320962,CDM,2720000010,LOCAL,0272,RC,,,,both,,,648.41,421.47,,,,,,,,,,,,,
PORT KIT 9.5FR MICROINTRODUCER POWERPORT DUO,SUP-2126330,CDM,C1788,HCPCS,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
LEVEL CMF PLATE MDFCE CVD WTAB 1.5 MM SCRW12 HOLE T0.4 MM C,SUP-2681870,CDM,C1713,HCPCS,0278,RC,,,,both,,,894.90,581.68,,,,,,,,,,,,,
PLATE BONE L25MM 4 H CRANIOMAXILLOFACIAL STR LO PROF,SUP-2191106,CDM,C1713,HCPCS,0278,RC,,,,both,,,165.79,107.76,,,,,,,,,,,,,
GAUGE DEPTH CANN 120 MM PERC VERSAFX II MAGNA-FX,SUP-2473823,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1210.91,787.09,,,,,,,,,,,,,
STAR PSI STANDARD BUNDLE WITH ANATOMICAL MODELS,SUP-2878302,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2998.70,1949.15,,,,,,,,,,,,,
SHEATH INTRO AVNT + DIA 6.5 FR CANN L 23 CM DIL 30 CM POLYUR,SUP-2157399,CDM,C1894,HCPCS,0272,RC,,,,both,,,51.81,33.68,,,,,,,,,,,,,
WEDGE FEM SZ 3 THK5MM STD UNIV DST KNEE CO CHROM PRI,SUP-2346020,CDM,C1776,CPT,0278,RC,,,,both,,,2241.96,1457.27,,,,,,,,,,,,,
DRESSING POST OPERATIVE RIGID BULK N WET BEAR,SUP-2388204,CDM,L5460,HCPCS,0272,RC,,,,both,,,1662.85,1080.85,,,,,,,,,,,,,
HANDPIECE LASER STR 60 MM STR TIP FIBERLASE HP-R,SUP-2713725,CDM,2720000010,LOCAL,0272,RC,,,,both,,,879.20,571.48,,,,,,,,,,,,,
MESH CRAN W90XL90MM PROF H0.6MM MIC UP FACE,SUP-2366218,CDM,C1713,HCPCS,0278,RC,,,,both,,,4478.33,2910.91,,,,,,,,,,,,,
SEED BRACHYTHERAPY LOAD 4.01-5.0 MCI STRL ADVANTAGE 2029ELS1] ISOAID LLC],SUP-2247269,CDM,C2642,HCPCS,0278,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
CHANNELSCOPE 30K 21.6 CM SHAFT WC DIAMETER 2 MM,SUP-2854429,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6066.48,3943.21,,,,,,,,,,,,,
CATHETER HD PRECRV 12.5 FRX32 CM LT DL STP TIP SIL HEMCATH,SUP-2627319,CDM,C1750,HCPCS,0278,RC,,,,both,,,20.41,13.27,,,,,,,,,,,,,
CATHETER NEPHROSTOMY 22FR 5CC MALECOT,SUP-2858159,CDM,C1729,HCPCS,0272,RC,,,,both,,,299.12,194.43,,,,,,,,,,,,,
BIT DRL 2.5 MM FRAG-LOC,SUP-2857696,CDM,2720000010,LOCAL,0272,RC,,,,both,,,684.52,444.94,,,,,,,,,,,,,
IMPLANT MPJ 11MM HEMI THE LESSER,SUP-2137763,CDM,C1776,CPT,0278,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
CATHETER IRRIGATION L 60 CM DIA 3 FR DSTL 6 MM BALLOON 0.5,SUP-2159450,CDM,C2628,HCPCS,0272,RC,,,,both,,,310.86,202.06,,,,,,,,,,,,,
ALLOGRAFT HUMAN TISSUE FROZEN GRACILIS TENDONGR-11,SUP-2913479,CDM,C1762,CPT,0278,RC,,,,both,,,4967.48,3228.86,,,,,,,,,,,,,
TWISTER WIRE OCHSNER 10.5 IN TUNGSTEN CARBIDE,SUP-2472774,CDM,2720000010,LOCAL,0272,RC,,,,both,,,759.75,493.84,,,,,,,,,,,,,
BLADE SAW NAR FOR HALL LINVATEC SYS PROPHECY INBONE,SUP-2397081,CDM,C1713,HCPCS,0278,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.518,SUP-2860035,CDM,C1713,HCPCS,0278,RC,,,,both,,,36957.17,24022.16,,,,,,,,,,,,,
GRAFT BNE SUB 13ML W11XH11XL11MM DEMIN CANC CUBOID CNFRM,SUP-2306903,CDM,C1713,HCPCS,0278,RC,,,,both,,,2282.06,1483.34,,,,,,,,,,,,,
SURGICAL PROCEDURE PACK EYE 23 GA CUST,SUP-2110950,CDM,C1713,HCPCS,0278,RC,,,,both,,,1802.20,1171.43,,,,,,,,,,,,,
COIL EMB L20CM DIA5MM 0.02IN PERIPH COMPLX STD FRME,SUP-2323661,CDM,C1889,HCPCS,0278,RC,,,,both,,,4678.60,3041.09,,,,,,,,,,,,,
CATHETER HD SET 0.035 INX60 CM 12 FRX13 CM DL DRP YOU-BEND,SUP-2763038,CDM,C1752,HCPCS,0278,RC,,,,both,,,198.95,129.32,,,,,,,,,,,,,
GRAFT HUM TISS W6XL10CM PLCNTA AMNIO MEM EPIXL,SUP-2305763,CDM,Q4186,HCPCS,0636,RC,,,,both,,,14020.13,9113.08,,,,,,,,,,,,,
SPACER HUM DIA36MM +9MM OFFSET SHLDR REV SEMICONSTRAINED,SUP-2254086,CDM,C1776,CPT,0278,RC,,,,both,,,2154.04,1400.13,,,,,,,,,,,,,
EXTRACTOR BILI STONE 7FR TAPR TO 5FR CATH L200CM DIA8.5MM,SUP-2149631,CDM,C1726,HCPCS,0272,RC,,,,both,,,310.86,202.06,,,,,,,,,,,,,
ROD EXT FIX EL HNG JT,SUP-2188628,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3779.78,2456.86,,,,,,,,,,,,,
PLATE BNE CVR REMOVER KT SET SOVEREIGN,SUP-2630943,CDM,C1713,HCPCS,0278,RC,,,,both,,,864.38,561.85,,,,,,,,,,,,,
SYSTEM MOD KNEE W/ PROLONG POLY,SUP-2212168,CDM,C1776,CPT,0278,RC,,,,both,,,11972.82,7782.33,,,,,,,,,,,,,
KYPHOPLASTY PACK 10 GA 4 ML STR OSSEOFLEX SB OCP0141,SUP-2516667,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3312.70,2153.25,,,,,,,,,,,,,
DEVICE LAPSCP SM DIA5CM HND ASST LAP-DISC,SUP-2257666,CDM,C1788,HCPCS,0278,RC,,,,both,,,1476.21,959.54,,,,,,,,,,,,,
ENDCAP ORTH L5MM ANK COMPR NAIL LOK,SUP-2316328,CDM,2720000010,LOCAL,0272,RC,,,,both,,,688.10,447.26,,,,,,,,,,,,,
SCREW BONE SELFTAPPING 3.5X125 MM CORTICAL DISTAL VOLAR RADI,SUP-2837009,CDM,C1713,HCPCS,0278,RC,,,,both,,,313.72,203.92,,,,,,,,,,,,,
GAUGE DEPTH PERIARTICULAR CANNULATED 35MM LOCKING SCREW,SUP-2494810,CDM,C1713,HCPCS,0278,RC,,,,both,,,652.02,423.81,,,,,,,,,,,,,
HC So Copper,PX-3018252566,CDM,82525,CPT,0301,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
BUR SURG 1.5X15 MM FOR PILOT DRL,SUP-2361339,CDM,2720000010,LOCAL,0272,RC,,,,both,,,150.72,97.97,,,,,,,,,,,,,
IMPLANT TOE JT SZ 30 1ST MTP FLEX W/ GRMMT,SUP-2242120,CDM,C1776,CPT,0278,RC,,,,both,,,7523.44,4890.24,,,,,,,,,,,,,
HEMODIALYSIS KIT RAD FREQ DEL DEV STRL REZUM,SUP-2424811,CDM,C1713,HCPCS,0278,RC,,,,both,,,4033.02,2621.46,,,,,,,,,,,,,
"HC Est Pt, E/M Level 3|RESIDENT/TEACHING PHYS SERV",PX-5109921300,CDM,99213,CPT,0510,RC,,,GC,both,,,257.00,167.05,,,,,,,,,,,,,
GRAFT HUM TISS L 250 MM DIA 8 MM ANTR TIBIALIS TEND FRZN,SUP-2913240,CDM,C1762,CPT,0278,RC,,,,both,,,10515.86,6835.31,,,,,,,,,,,,,
SCREW BNE L22MM DIA2.4MM S STL ST LOK FULL THRD T8 STARDRV,SUP-2184344,CDM,C1713,HCPCS,0278,RC,,,,both,,,315.22,204.89,,,,,,,,,,,,,
CYGNUS ANTR CERV 72MM PLTE MTI LVL,SUP-2664210,CDM,C1713,HCPCS,0278,RC,,,,both,,,3108.60,2020.59,,,,,,,,,,,,,
SUPPORT ORTHOPEDIC SLIP ON LG 8.5 IN WRST COMFORTFORM,SUP-2197053,CDM,L3906,HCPCS,0274,RC,,,,both,,,42.77,27.80,,,,,,,,,,,,,
FORCEPS BPLR L33CM DIA5MM SERR JAW DISP FOR PK SUPERPULSE,SUP-2313738,CDM,2720000010,LOCAL,0272,RC,,,,both,,,938.86,610.26,,,,,,,,,,,,,
BRACE ORTH ABDUCTN CTRL HIP ORTHOSIS CTRL,SUP-2388158,CDM,L1680,HCPCS,0272,RC,,,,both,,,3006.05,1953.93,,,,,,,,,,,,,
SYSTEM SINUPLASTY BLLN L16MM DIA6MM MAX TIP M-110 SGL HND,SUP-2106363,CDM,C1726,HCPCS,0272,RC,,,,both,,,5259.50,3418.67,,,,,,,,,,,,,
LEVEL CMF ST PLATE MINI TLTS CVD 20 25 MM SCRW6 HOLE 29 MM,SUP-2669725,CDM,C1713,HCPCS,0278,RC,,,,both,,,1348.44,876.49,,,,,,,,,,,,,
SUPPORT ORTHOT THOR LUMBAR SACR CUST SAG CTRL OFF THE SHLF,SUP-2435542,CDM,L0467,HCPCS,0274,RC,,,,both,,,1074.16,698.20,,,,,,,,,,,,,
CAGE SPNL W10XH9XL27MM 10-15DEG LUM PEEK INTBDY SELF EXP,SUP-2353369,CDM,C1889,HCPCS,0278,RC,,,,both,,,14130.00,9184.50,,,,,,,,,,,,,
BIT DRL L 370 MM DIA 3.2 MM STRL DISP PANGEA,SUP-2900602,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1420.85,923.55,,,,,,,,,,,,,
HC Interoperative U/S Guid Rd Mat,PX-4027696500,CDM,76965,CPT,0402,RC,,,,both,,,1167.00,758.55,,,,,,,,,,,,,
IMPLANT BEDROCK GRANITE IFUSE 10.5MM X 70MM,SUP-2858678,CDM,C1737,HCPCS,0278,RC,,,,both,,,11147.00,7245.55,,,,,,,,,,,,,
COMPONENT TIB CRUCFRM BEAD 1 MED IMPL PERIAPATITE HA POROUS,SUP-2377177,CDM,C1776,CPT,0278,RC,,,,both,,,6737.18,4379.17,,,,,,,,,,,,,
GRAFT BIO TISS OASIS ULTRA 3LAYER MATRIX 5X7CM MESHED,SUP-2341246,CDM,Q4124,HCPCS,0636,RC,,,,both,,,1394.03,906.12,,,,,,,,,,,,,
LIDOCAINE HCL 2 % IJ SOLN (MIXTURES ONLY),RX-430042,CDM,J2003,HCPCS,0636,RC,55150-0254-10,NDC,,both,1,ML,54.10,35.16,,,,,,,,,,,,,
POTASSIUM CHLORIDE ER 10 MEQ PO TBCR,RX-12184,CDM,6370000000,HCPCS,0637,RC,24979-0231-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
LIDOCAINE HCL 2 % IJ SOLN (MIXTURES ONLY),RX-430042,CDM,J2003,HCPCS,0636,RC,00409-4277-02,NDC,,both,1,ML,54.10,35.16,,,,,,,,,,,,,
HYDROCORTISONE (PERIANAL) 2.5 % EX CREA,RX-149995,CDM,6370000000,HCPCS,0637,RC,64980-0324-30,NDC,,both,30,GR,89.60,58.24,,,,,,,,,,,,,
DARBEPOETIN ALFA 40 MCG/ML IJ SOLN,RX-131222,CDM,J0881,HCPCS,0636,RC,55513-0003-04,NDC,,both,1,ML,913.40,593.71,,,,,,,,,,,,,
SHEATH INTRO CATAPULT L 15 CM DIA 4 FR GUIDEWIRE 0.018/0.035,SUP-2913621,CDM,C1894,HCPCS,0272,RC,,,,both,,,279.46,181.65,,,,,,,,,,,,,
TAP SURG JONES SCR 5.5 MM,SUP-2691278,CDM,C1889,HCPCS,0278,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
PIN FIX TIB BASE ATTUNE,SUP-2252815,CDM,C1713,HCPCS,0278,RC,,,,both,,,139.89,90.93,,,,,,,,,,,,,
GRAFT BIO TISS W2.4XL3.9IN PORCINE DERM RIFAMPIN,SUP-2125831,CDM,C1781,HCPCS,0278,RC,,,,both,,,4499.62,2924.75,,,,,,,,,,,,,
SHOE CAST WALKING XS PEDIATRIC,SUP-2306064,CDM,L4387,HCPCS,0274,RC,,,,both,,,40.82,26.53,,,,,,,,,,,,,
SCREW SPNL THN SHT 5.5X60 MM TSRH 3DX OSTEOGRIP MPA,SUP-2631176,CDM,C1713,HCPCS,0278,RC,,,,both,,,1491.50,969.47,,,,,,,,,,,,,
SPACER SPNL ENDPIECE B 0 DEG RT VBR,SUP-2430768,CDM,C1889,HCPCS,0278,RC,,,,both,,,10453.06,6794.49,,,,,,,,,,,,,
BLADE LARYNGOSCOPE MACINTOSH 1 MED AD 135X20 MM SS GRNLN,SUP-2393643,CDM,2720000010,LOCAL,0272,RC,,,,both,,,235.47,153.06,,,,,,,,,,,,,
DRILL SURG 30 MM SPARE PART KT SPEEDGUIDE,SUP-2491651,CDM,2720000010,LOCAL,0272,RC,,,,both,,,467.73,304.02,,,,,,,,,,,,,
SET LD EXTRACTION EVOLUTION SHORTIE L 13.6 CM OD 19 FR ID 11,SUP-2170682,CDM,C1773,HCPCS,0272,RC,,,,both,,,3136.86,2038.96,,,,,,,,,,,,,
GRAFT HUM TISS W4XL4CM AMNIO MEMBRN AMNIOEXCEL,SUP-2194321,CDM,Q4137,HCPCS,0636,RC,,,,both,,,3149.42,2047.12,,,,,,,,,,,,,
GRAFT HUM TISS 49SQCM DEHYDR HUM AMNION CHORION MEM MESH,SUP-2305757,CDM,Q4186,HCPCS,0636,RC,,,,both,,,32712.52,21263.14,,,,,,,,,,,,,
TUBE JEJUSTMY 12FR L27IN PUL RADPQ 2 PRT FEED ADPT,SUP-2127676,CDM,C1769,HCPCS,0272,RC,,,,both,,,137.38,89.30,,,,,,,,,,,,,
DICLOFENAC SODIUM 25 MG PO TBEC,RX-15339,CDM,6370000000,HCPCS,0637,RC,16571-0203-10,NDC,,both,1,UN,4.80,3.12,,,,,,,,,,,,,
TRAY HEMODLYS INSRT L15CM SHT TERM STR DLYS CATH,SUP-2125593,CDM,C1752,HCPCS,0278,RC,,,,both,,,639.68,415.79,,,,,,,,,,,,,
UNIT THER COMB CRYO W PD MULT USE W TB PWR OPERATED W BD,SUP-2196470,CDM,C1713,HCPCS,0278,RC,,,,both,,,398.62,259.10,,,,,,,,,,,,,
SCREW BNE L95MM DIA10.5MM TI U BLDE LAG GAM 3,SUP-2370429,CDM,C1713,HCPCS,0278,RC,,,,both,,,2402.10,1561.36,,,,,,,,,,,,,
COMPONENT FEM L7CM ELP SEG R DST KNEE RESURF ORTH SALV SYS,SUP-2405707,CDM,C1776,CPT,0278,RC,,,,both,,,20446.11,13289.97,,,,,,,,,,,,,
GUIDEWIRE ORTH L500MM OD15MM BLNT THORLUM FOR MINIMALLY,SUP-2335564,CDM,C1769,HCPCS,0272,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
NAIL IM L330MM DIA8MM TIB DK BLU TI SLD LOK BEND,SUP-2192757,CDM,C1713,HCPCS,0278,RC,,,,both,,,5188.54,3372.55,,,,,,,,,,,,,
DEVICE INT FIX SM 14 MM THOR DBL FT STRNL STRL TALON LEVEL 1,SUP-2869188,CDM,C1713,HCPCS,0278,RC,,,,both,,,4406.96,2864.52,,,,,,,,,,,,,
GLIPIZIDE ER 10 MG PO TB24,RX-37650,CDM,6370000000,HCPCS,0637,RC,16714-0896-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
BRACE QXXLG,SUP-2174973,CDM,L1820,HCPCS,0272,RC,,,,both,,,160.14,104.09,,,,,,,,,,,,,
SNARE ENDOSCP POLYP 2.8 MMX165 CM SET COLONSCP SNAREMASTER +,SUP-2481032,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1163.75,756.44,,,,,,,,,,,,,
HEAD FEM DIA28MM NK +0MM CERAMIC PRI TAPR 12/14 ALUMINA TRIL,SUP-2202659,CDM,C1776,CPT,0278,RC,,,,both,,,4900.28,3185.18,,,,,,,,,,,,,
WIRE EXT FIX L400MM DIA18MM ANK FT BAYNT W O STPR ELEMENT,SUP-2316138,CDM,2720000010,LOCAL,0272,RC,,,,both,,,359.81,233.88,,,,,,,,,,,,,
SUPPORT ORTHOT THOR LUMBAR SACR CUST SAGITTAL-CORONAL CTRL,SUP-2435543,CDM,L0468,HCPCS,0272,RC,,,,both,,,1346.15,875.00,,,,,,,,,,,,,
SCREW BONE L11MM DIA2.5MM CO CHROM MULTDIR LCK THRD PEGGED,SUP-2411658,CDM,C1713,HCPCS,0278,RC,,,,both,,,490.03,318.52,,,,,,,,,,,,,
ANCHOR SUTURE WHITE/BLUE BLUE WHITE/BLACK HI FI RIBBON FOR R,SUP-2825230,CDM,C1713,HCPCS,0278,RC,,,,both,,,1574.02,1023.11,,,,,,,,,,,,,
GUIDEWIRE VASC L 80 CM DIA 0.018 IN TIP L 5 CM NIT MANDREL,SUP-2828288,CDM,C1769,HCPCS,0272,RC,,,,both,,,69.43,45.13,,,,,,,,,,,,,
HC So RBC Pretx Incubatj W/Chemicl,PX-3008697066,CDM,86970,CPT,0300,RC,,,,inpatient,,,183.00,118.95,,,,,,,,,,,,,
ATTUNE RP TIB BASE SZ 1 POR,SUP-2251405,CDM,C1776,CPT,0278,RC,,,,both,,,3218.50,2092.02,,,,,,,,,,,,,
KNIFE SURG 2.4 MM RETROGADE SM JT,SUP-2765730,CDM,2720000010,LOCAL,0272,RC,,,,both,,,531.48,345.46,,,,,,,,,,,,,
PIN FIX L229MM DIA2MM S STL SMOOTH SGL BAYNT TIP STNMN,SUP-2252368,CDM,C1713,HCPCS,0278,RC,,,,both,,,18.84,12.25,,,,,,,,,,,,,
GRAFT BIO TISS W4XL7CM THCK 4 PLY PORCINE FOR PERICARD CLSR,SUP-2172038,CDM,C1768,CPT,0278,RC,,,,both,,,2608.71,1695.66,,,,,,,,,,,,,
SPLINT ORTHOPEDIC DLX MED 8-9.5 9.5-11 RT ANK FT CLOSED HEEL,SUP-2195191,CDM,L1930,HCPCS,0274,RC,,,,both,,,103.68,67.39,,,,,,,,,,,,,
PLATE BONE W203XL127MM THK0.2MM MH TI SH FOR 1.5MM SCR,SUP-2135906,CDM,C1713,HCPCS,0278,RC,,,,both,,,4383.44,2849.24,,,,,,,,,,,,,
ASSEMBLY BLDE DISP FOR SMARTREL ENDOSCP CRPL TUNN REL SYS,SUP-2303823,CDM,2720000010,LOCAL,0272,RC,,,,both,,,888.62,577.60,,,,,,,,,,,,,
GRAFT VASC HEMSHLD PLAT L 15 CM 30MM POLYESTER BOV CLLGN STR,SUP-2265919,CDM,C1768,CPT,0278,RC,,,,both,,,1296.32,842.61,,,,,,,,,,,,,
GUIDEWIRE VASC STR 15 CM 0.038 INX145 CM FLX TIP TAPR N LLT,SUP-2167678,CDM,C1769,HCPCS,0272,RC,,,,both,,,38.53,25.04,,,,,,,,,,,,,
BASKET SPEC RETRV 50 CM 30 CM ANGLED PROX SHFT RNG HNDL FB,SUP-2772708,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4315.08,2804.80,,,,,,,,,,,,,
GRAFT HUM TISS MEDL RT MENIS ALLGRFT,SUP-2335264,CDM,C9361,HCPCS,0278,RC,,,,both,,,21964.30,14276.79,,,,,,,,,,,,,
PLATE BONE L153.5MM 8 H LT MEDL DSTL TIB TI FOR,SUP-2225376,CDM,C1713,HCPCS,0278,RC,,,,both,,,5021.49,3263.97,,,,,,,,,,,,,
TRAY CTRL VEN POLYUR DBL LUMN STR J TIP GWIRE SCALP DIL,SUP-2167998,CDM,C1751,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
LEUCOVORIN CALCIUM 500 MG IJ SOLR,RX-23617,CDM,J0640,HCPCS,0636,RC,71288-0164-50,NDC,,both,1,UN,254.30,165.29,,,,,,,,,,,,,
SCREW BNE L6MM DIA2.3MM CRANIOMAXILLOFACIAL PUR ST EMGCY 5PK,SUP-2366170,CDM,C1713,HCPCS,0278,RC,,,,both,,,218.10,141.76,,,,,,,,,,,,,
GRAFT VASC INTERGARD L 70 CM DIA 8 MM THK 0.49 MM POLYESTER,SUP-2462139,CDM,C1768,CPT,0278,RC,,,,both,,,1785.12,1160.33,,,,,,,,,,,,,
CARBON FIBER BAR 6MM X 150MM,SUP-2730030,CDM,2720000010,LOCAL,0272,RC,,,,both,,,714.13,464.18,,,,,,,,,,,,,
BRA SURG LG 40-42IN WHT LYCRA FR HK AND LOOP CLSR WIDE ADJ,SUP-2336338,CDM,L8000,HCPCS,0272,RC,,,,both,,,107.61,69.95,,,,,,,,,,,,,
SET DIL RENAL AMPLTZ MOD 6-30FRX30CM SHTH LEN 20CM,SUP-2171221,CDM,C1713,HCPCS,0278,RC,,,,both,,,743.80,483.47,,,,,,,,,,,,,
CATHETER CARD ABLATION THERMOCOOL SMARTTOUCH L 115 CM 8FR DF,SUP-2248608,CDM,C1732,HCPCS,0278,RC,,,,both,,,9074.60,5898.49,,,,,,,,,,,,,
CATHETER ABLAT 7FR L115CM 2-5-2MM SPC TIP 3.5MM 4 ELECTRD D,SUP-2248839,CDM,C2630,CPT,0272,RC,,,,both,,,4160.50,2704.32,,,,,,,,,,,,,
TUBE JEJUNOSTOMY FEED 18 FRX30 CM 1.2 CM STOMA LP AMT G-JET,SUP-2424373,CDM,C1713,HCPCS,0278,RC,,,,both,,,1527.61,992.95,,,,,,,,,,,,,
PLATE BNE THK0.5MM 7 H CRANIOMAXILLOFACIAL BLU TI DBL Y,SUP-2366236,CDM,C1713,HCPCS,0278,RC,,,,both,,,616.48,400.71,,,,,,,,,,,,,
ROD SPNL STR 5X400 MM COCR STRL RELINE,SUP-2559367,CDM,C1713,HCPCS,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
KIT COOL PD SM HYDRGEL FOR TEMP MGMT SYS ARCTIC SUN,SUP-2127457,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4155.79,2701.26,,,,,,,,,,,,,
SET INTRO 16FR L70CM 0038IN FOR TRACHBRONCH STNT,SUP-2168376,CDM,C1894,HCPCS,0272,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
PLATE BNE STR 2.7X48 MM 6 HOLE RECON FOR SCR SS NS,SUP-2465692,CDM,C1713,HCPCS,0278,RC,,,,both,,,745.18,484.37,,,,,,,,,,,,,
HOLDER PLATE RING WIRE SS STRL,SUP-2875235,CDM,2720000010,LOCAL,0272,RC,,,,both,,,489.84,318.40,,,,,,,,,,,,,
SPLINT SPNL SM CHILD W5XL60CM BCKL STRP CNTCT CLSR PD MCLEOD,SUP-2197368,CDM,L3650,HCPCS,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
SYSTEM ENDO SOFT TISSUE RELEASE CLEARGUARD LE,SUP-2715890,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3124.30,2030.79,,,,,,,,,,,,,
SCREW BONE 16MM THRD 6.5X35MM CANC S STL,SUP-2198292,CDM,C1713,HCPCS,0278,RC,,,,both,,,66.47,43.21,,,,,,,,,,,,,
SPLINT SPNL SM CHILD W5XL60CM BCKL STRP CNTCT CLSR PD MCLEOD,SUP-2197368,CDM,L3650,HCPCS,0274,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
UNIT THER COMB CRYO W PD KNEE W TB PWR OPERATED W OUT BD,SUP-2150931,CDM,C1713,HCPCS,0278,RC,,,,both,,,329.13,213.93,,,,,,,,,,,,,
STEM FEM REV PRSS FIT CALCAR RESTR 237MML SZ 2 12 L BOW,SUP-2375188,CDM,C1776,CPT,0278,RC,,,,both,,,17042.66,11077.73,,,,,,,,,,,,,
PATCH DURA L 1.6 X W 1.6 IN SURF AREA2.6 SQ IN BOV PERICARD,SUP-2884038,CDM,C1763,HCPCS,0278,RC,,,,both,,,1472.66,957.23,,,,,,,,,,,,,
ROD SPNL ANTR RT CVD SMOOTH S STL 5.0MM DIA 300MM LEN,SUP-2290515,CDM,C1713,HCPCS,0278,RC,,,,both,,,2373.84,1543.00,,,,,,,,,,,,,
SET CATH L4.2CM OD5.9MM ID4MM W/ INTRO NDL 6ML SYR NO15,SUP-2168129,CDM,C1769,HCPCS,0272,RC,,,,both,,,763.02,495.96,,,,,,,,,,,,,
ALLOGRAFT BNE PROX FEM 10 CM FRZN RT HD,SUP-2717955,CDM,C1762,CPT,0278,RC,,,,both,,,24178.00,15715.70,,,,,,,,,,,,,
GRAFT BNE STRP 100X10X8 MM 16 CC DBM,SUP-2644339,CDM,C1713,HCPCS,0278,RC,,,,both,,,8974.12,5833.18,,,,,,,,,,,,,
DEFIBRILLATOR IMPL AMPLIA MRI QUAD SURESCAN W 51 X H 74 MM D,SUP-2282415,CDM,C1882,HCPCS,0275,RC,,,,both,,,59934.31,38957.30,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH L 54 MM DIA DSTL 10 MM SHTH 14 FR SS,SUP-2168725,CDM,C1768,CPT,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
MATRIX BONE 2ML DEMIN PASTE SYR INTERGRO,SUP-2414009,CDM,C1713,HCPCS,0278,RC,,,,both,,,1237.16,804.15,,,,,,,,,,,,,
MESH HERN L W4.1XL6.2IN R POLYPR L PORE KNIT LT 3DMAX,SUP-2125797,CDM,C1781,HCPCS,0278,RC,,,,both,,,598.80,389.22,,,,,,,,,,,,,
CLIP INT USE DIA17.5 MM THRD L 165 CM ENDOSCP DIA10.5-12 MM 12/3T,SUP-2881862,CDM,C1889,HCPCS,0278,RC,,,,both,,,1880.86,1222.56,,,,,,,,,,,,,
DILATOR ENDO BAL L8CM OD20MM CATH L180CM ESOPH REUSE FOR SM,SUP-2166038,CDM,C1725,HCPCS,0272,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
GRAFT VASC GORTX L 40 CM DIA 4-7 MM EPTFE TAPR STD WALL N,SUP-2396451,CDM,C1768,CPT,0278,RC,,,,both,,,1478.94,961.31,,,,,,,,,,,,,
SUPPORT ORTHOT ANK KNEE CUST SINGLE FREE MOLD PLAS,SUP-2435638,CDM,L2037,HCPCS,0274,RC,,,,both,,,4694.99,3051.74,,,,,,,,,,,,,
BUR SURG TAPR 1.7X15.8 MM 7 CM SM BOR MIDAS REX 8 LEGEND,SUP-2664809,CDM,2720000010,LOCAL,0272,RC,,,,both,,,325.30,211.44,,,,,,,,,,,,,
BODY FEM 19MM UNIV PROX SHAL MILLED MOD RESTR REV HIP SYS,SUP-2375564,CDM,C1713,HCPCS,0278,RC,,,,both,,,9808.10,6375.26,,,,,,,,,,,,,
SHEATH INTRO FLEXCATH CNTOUR L 65.5 CM DIA12 FR TIP SZ 20 MM,SUP-2882552,CDM,C1766,CPT,0272,RC,,,,both,,,4239.00,2755.35,,,,,,,,,,,,,
STEM HUM SZ 0 PRSS FIT + PROMOS,SUP-2351212,CDM,C1776,CPT,0278,RC,,,,both,,,3218.50,2092.02,,,,,,,,,,,,,
BIT DRL STP GLIDING H HERB WHPPL,SUP-2410166,CDM,2720000010,LOCAL,0272,RC,,,,both,,,755.52,491.09,,,,,,,,,,,,,
CATHETER DIL 5.8FR L180CM BLLN L4CM DIA8MM GWIRE 0.035IN,SUP-2149601,CDM,C1726,HCPCS,0272,RC,,,,both,,,774.32,503.31,,,,,,,,,,,,,
PLATE BNE L71MM 4 H SEMI TBLR FOR 4.5MM SCR,SUP-2411384,CDM,C1713,HCPCS,0278,RC,,,,both,,,173.89,113.03,,,,,,,,,,,,,
COMPONENT PATELLAR AUG MED THCK 22 MM FOR CONTINUUM KNEE SYS,SUP-2200594,CDM,C1776,CPT,0278,RC,,,,both,,,7919.08,5147.40,,,,,,,,,,,,,
TRAY NEO PICC 2 PREFIL SYRINGES PIGGY-BACKED 384825] ARGON MEDICAL DEVICES INC],SUP-2120076,CDM,C1751,HCPCS,0278,RC,,,,both,,,104.31,67.80,,,,,,,,,,,,,
CABLE EP CATH L 1.5 M 4 PIN DIAG CONN PUSH PUL HNDL,SUP-2676239,CDM,2720000010,LOCAL,0272,RC,,,,both,,,464.72,302.07,,,,,,,,,,,,,
HC So Testosterone Bioavailable,PX-3018441066,CDM,84410,CPT,0301,RC,,,,both,,,83.00,53.95,,,,,,,,,,,,,
CATHETER IV DL 5 FR DOT KT MBP GIVA PC POWERMIDLINE,SUP-2626741,CDM,C1751,HCPCS,0278,RC,,,,both,,,499.26,324.52,,,,,,,,,,,,,
PIN FIX L200MM DIA1.5MM ANK FT NIT ORIENTATION SGL END TRCR,SUP-2321612,CDM,2720000010,LOCAL,0272,RC,,,,both,,,450.59,292.88,,,,,,,,,,,,,
SHEATH INTRO 24FR L28CM HYDRPHLC DRYSEAL,SUP-2395743,CDM,C1894,HCPCS,0272,RC,,,,both,,,1051.90,683.73,,,,,,,,,,,,,
SCREW BNE L 10 MM DIA2.7 MM TI MAND ST LCK EMER AXS NS UNIV,SUP-2909542,CDM,C1713,HCPCS,0278,RC,,,,both,,,566.08,367.95,,,,,,,,,,,,,
CUP ACET CEM 10 DEG 22 MM HIP W/ PLATE,SUP-2447858,CDM,C1776,CPT,0278,RC,,,,both,,,946.71,615.36,,,,,,,,,,,,,
HFN A/R SCREW 60MM STER,SUP-2588685,CDM,C1713,HCPCS,0278,RC,,,,both,,,747.79,486.06,,,,,,,,,,,,,
GUIDEWIRE UROLOGICAL FIX COR 15 CM 0.038 INX145 CM BENT,SUP-2835677,CDM,C1769,HCPCS,0272,RC,,,,both,,,73.73,47.92,,,,,,,,,,,,,
PLATE BNE W17.5XL106MM THK5.2MM 6 H BILAT S STL BROAD LIMIT,SUP-2185285,CDM,C1713,HCPCS,0278,RC,,,,both,,,1010.36,656.73,,,,,,,,,,,,,
PROBE BPLR 7FR L350CM TIP 6.5MM YEL MULT ELECTRD FOR,SUP-2166261,CDM,2720000010,LOCAL,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
TIP UNTRASONIC HNDPC SEL 24KHZ STD TIP 5 FLUE DISP ST,SUP-2243015,CDM,C1713,HCPCS,0278,RC,,,,both,,,1115.99,725.39,,,,,,,,,,,,,
COMP SHRT ST/CONV GLD/STDHD,SUP-2212453,CDM,C1776,CPT,0278,RC,,,,both,,,22137.00,14389.05,,,,,,,,,,,,,
SET SPL CATH 14FRX32CM W/ TEARLAWAY SHTH INTRO VES DIL TUNN,SUP-2266946,CDM,C1750,HCPCS,0278,RC,,,,both,,,926.30,602.09,,,,,,,,,,,,,
GRAFT DURA W5XL7IN THK0.6MM CLLGN MEMBRN DURAMATRIX-ONLAY +,SUP-2365457,CDM,C1763,HCPCS,0278,RC,,,,both,,,3687.27,2396.73,,,,,,,,,,,,,
SCISSORS SURG MALIS BAY NEURO DEL MIC TIP SERR TI CVD 9,SUP-2382548,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1571.32,1021.36,,,,,,,,,,,,,
COIL VASC I-ED COIL L 20 CM DIA 0.012 IN SECONDARY 3-5 MM,SUP-2865321,CDM,C1889,HCPCS,0278,RC,,,,both,,,5667.70,3684.00,,,,,,,,,,,,,
STEM FEM SEG 9 CM DPHSEAL KNEE SMOOTH OSS,SUP-2449809,CDM,C1776,CPT,0278,RC,,,,both,,,11251.72,7313.62,,,,,,,,,,,,,
ANCHOR SUT DIA5MM TENODESIS W 1 NUMBER 2 HI FI SUT TENOLOK,SUP-2167247,CDM,C1713,HCPCS,0278,RC,,,,both,,,2508.86,1630.76,,,,,,,,,,,,,
SYSTEM ASPIR CVAC INTRACORPOREAL LITHO SUCTION STRL LF,SUP-2863726,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7693.00,5000.45,,,,,,,,,,,,,
SPACER FEM KNEE M 64MM ANTIBIO TREAT REMEDY,SUP-2319840,CDM,C1776,CPT,0278,RC,,,,both,,,8635.00,5612.75,,,,,,,,,,,,,
STENT PERIPH PALMAZ GEN L 29 MM DIA10 MM SHTH 8 FR GUIDE 10,SUP-2159241,CDM,C1877,HCPCS,0278,RC,,,,both,,,3975.24,2583.91,,,,,,,,,,,,,
DRESSING BIO L 10 X W 7 CM FISH SKIN 21 PRE MESHED STRL,SUP-2909162,CDM,Q4158,HCPCS,0636,RC,,,,both,,,12393.58,8055.83,,,,,,,,,,,,,
CONTROL REMOT VERCISE DP BRAIN STIM SYS,SUP-2140422,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2025.30,1316.44,,,,,,,,,,,,,
COMP SHRT ST/RGX GLD/VRSDL/INS,SUP-2212448,CDM,C1776,CPT,0278,RC,,,,both,,,18840.00,12246.00,,,,,,,,,,,,,
TUBE VENT BVL 1.4 MM EAR POPE GRMMT POLYETH BLU LF,SUP-2312807,CDM,L8699,HCPCS,0278,RC,,,,both,,,49.96,32.47,,,,,,,,,,,,,
CATHETER CV SET 018 4 FRX15 CM DL J TIP POLYURETHANE,SUP-2759959,CDM,C1751,HCPCS,0278,RC,,,,both,,,230.04,149.53,,,,,,,,,,,,,
PLATE BONE 12 H STRL STRNL TI ANG LCK FOR 3MM SCR,SUP-2192444,CDM,C1713,HCPCS,0278,RC,,,,both,,,4306.82,2799.43,,,,,,,,,,,,,
SHELL ACET DIA58MM LNR SZ DMI ORNG VERSAFITCUP DM,SUP-2267332,CDM,C1776,CPT,0278,RC,,,,both,,,4613.16,2998.55,,,,,,,,,,,,,
TAMP BNE SZ 3 L20MM BNE INFL BLLN KYPHX XPANDER,SUP-2281086,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2810.30,1826.69,,,,,,,,,,,,,
SYSTEM CAST 4 IN TOT CONTACT W/ X LG BOOT TCC-EZ,SUP-2268427,CDM,L4386,HCPCS,0272,RC,,,,both,,,340.69,221.45,,,,,,,,,,,,,
DEVICE PESSARY TNDM CUBE 7-5 2.25X1.75 IN PROCIDENTIA MILEX,SUP-2755566,CDM,A4562,HCPCS,0274,RC,,,,both,,,301.60,196.04,,,,,,,,,,,,,
DEVICE INFL FLD 20CC BILI FOR DEFLATION PRSS MON OF GI QNT,SUP-2169415,CDM,2720000010,LOCAL,0272,RC,,,,both,,,389.36,253.08,,,,,,,,,,,,,
PROSTHESIS PENILE L15CM MINOCYCLINE RIFAMPIN INHIBIZONE,SUP-2140260,CDM,C1813,HCPCS,0278,RC,,,,both,,,11068.50,7194.52,,,,,,,,,,,,,
DYNANITE COMP PLATE SEGMENTED 20/20,SUP-2814532,CDM,C1713,HCPCS,0278,RC,,,,both,,,10346.30,6725.09,,,,,,,,,,,,,
KIT CATH HEMODIALYSI AHDC SAFETY 12FR DIA 16CM 3 CDC12123P1A,SUP-2632983,CDM,C1751,HCPCS,0278,RC,,,,both,,,402.55,261.66,,,,,,,,,,,,,
KIT ARTHSCP INSTR DRL DIA1.8 MM MED CRV FLX FLUT SPEAR CANN,SUP-2882277,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1083.30,704.14,,,,,,,,,,,,,
IMPLANT OPHTH 22X285MM RETIN SL SCLER BCKL SIL STYL 70,SUP-2129438,CDM,C1784,HCPCS,0278,RC,,,,both,,,17.05,11.08,,,,,,,,,,,,,
NUT EXT FIX DIA10 MM QR LCK HEX NS DISP MONK RING,SUP-2899081,CDM,2720000010,LOCAL,0272,RC,,,,both,,,854.87,555.67,,,,,,,,,,,,,
SUPPORT ORTHOT THOR LUMBAR SACR CUST SAGITTAL-CORONAL SHLF,SUP-2435544,CDM,L0469,HCPCS,0274,RC,,,,both,,,1346.15,875.00,,,,,,,,,,,,,
PLATE BONE L29MM THK1.25MM 4 H BILAT MAND ORAL MAXILLOFACIAL,SUP-2191334,CDM,C1713,HCPCS,0278,RC,,,,both,,,1879.29,1221.54,,,,,,,,,,,,,
NEEDLE INTRO COAX UNIV 17 GAX15 CM TEMNO,SUP-2482409,CDM,C1894,HCPCS,0272,RC,,,,both,,,26.28,17.08,,,,,,,,,,,,,
ZOLEDRONIC ACID 4 MG/5ML IV CONC,RX-35640,CDM,J3489,HCPCS,0636,RC,67457-0390-54,NDC,,both,5,ML,129.80,84.37,,,,,,,,,,,,,
CATHETER GUID CS-H AD 8 FRX49 CM ACUITY BREAK-AWAY,SUP-2148957,CDM,C1887,HCPCS,0272,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
WIRE BNE FIX L 5 IN DIA 0.045 IN DMND PT BOTH END STRL,SUP-2933187,CDM,C1713,HCPCS,0278,RC,,,,both,,,79.91,51.94,,,,,,,,,,,,,
MESH CRAN W100XL100MM THK0.8MM RAP RESRB FOR 1.5MM SCR FIX,SUP-2194074,CDM,C1781,HCPCS,0278,RC,,,,both,,,11036.16,7173.50,,,,,,,,,,,,,
HC Respirator Motion Mgmt Simul,PX-3337729300,CDM,77293,CPT,0333,RC,,,,both,,,4423.00,2874.95,,,,,,,,,,,,,
SUPPORT ORTHOT CUST BILATERAL W/VERTICAL EXTN,SUP-2435579,CDM,L1085,HCPCS,0272,RC,,,,both,,,495.90,322.33,,,,,,,,,,,,,
ALLOGRAFT BNE SPACER 6 DEG 12X14X12 MM CERV FD LORDTC CANC,SUP-2736814,CDM,C1713,HCPCS,0278,RC,,,,both,,,2783.48,1809.26,,,,,,,,,,,,,
INSERT TIB SZ 1 THK12.5MM UNIV KNEE GVF POLYETH ROT PLATFRM,SUP-2253442,CDM,C1776,CPT,0278,RC,,,,both,,,3796.89,2467.98,,,,,,,,,,,,,
HC Asp Injection Major Joint,PX-4502061000,CDM,20610,CPT,0450,RC,,,,inpatient,,,1092.00,709.80,,,,,,,,,,,,,
STEM HUM 10MM FX COMPHSVE,SUP-2404526,CDM,C1776,CPT,0278,RC,,,,both,,,10795.32,7016.96,,,,,,,,,,,,,
TROCAR SURG DIA2MM FOR DST RAD FIX,SUP-2187735,CDM,2720000010,LOCAL,0272,RC,,,,both,,,587.56,381.91,,,,,,,,,,,,,
WIRE ORTH L500MM DIA0.3MM TI SMOOTH W/ NDL CANTHAL,SUP-2193155,CDM,C1713,HCPCS,0278,RC,,,,both,,,1136.37,738.64,,,,,,,,,,,,,
PROSTHESIS VOICE 16 FRX4 MM INDWL SFT VLV NS BLOM-SINGER,SUP-2242283,CDM,L8509,HCPCS,0274,RC,,,,both,,,1224.60,795.99,,,,,,,,,,,,,
DISTRACTOR SURG FAST PRECICE,SUP-2312262,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1774.10,1153.16,,,,,,,,,,,,,
PLATE BONE ORBITAL FLOOR 35X35X1.5 MM POROUS POLYETHYLENE ST,SUP-2837799,CDM,C1713,HCPCS,0278,RC,,,,both,,,2035.35,1322.98,,,,,,,,,,,,,
HC Postural Drainage Sub,PX-4109466800,CDM,94668,CPT,0410,RC,,,,outpatient,,,109.00,70.85,,,,,,,,,,,,,
PLATE 3.5MM TI LCP OLECRANON 4 HOLES LEFT 112MM-STERILE,SUP-2549522,CDM,C1713,HCPCS,0278,RC,,,,both,,,3606.70,2344.35,,,,,,,,,,,,,
HC Lymph Vessel X-Ray Trunk,PX-3207580700,CDM,75807,CPT,0320,RC,,,,both,,,2864.00,1861.60,,,,,,,,,,,,,
BAG TISS RETRV 1850ML L10.4IN MOUTH DIA6IN INTRO TRCR 15MM,SUP-2166308,CDM,2720000010,LOCAL,0272,RC,,,,both,,,498.44,323.99,,,,,,,,,,,,,
PLATE BNE 90 DEG 1X4 MM RINGFIX SYS,SUP-2365337,CDM,C1713,HCPCS,0278,RC,,,,both,,,351.68,228.59,,,,,,,,,,,,,
CARBAMAZEPINE 100 MG/5ML PO SUSP,RX-1356,CDM,340b,HCPCS,0637,RC,09999-9908-96,NDC,,both,5,ML,2.70,1.75,,,,,,,,,,,,,
SCREW BONE L28MM D4MM HEX HEAD D6.2MM CRTCL DST FMRL TTNM SE,SUP-2466427,CDM,C1713,HCPCS,0278,RC,,,,both,,,310.48,201.81,,,,,,,,,,,,,
COLLAR CERV 4.25IN 12IN SM TRACH OPN AD PHIL,SUP-2195257,CDM,L0180,HCPCS,0272,RC,,,,both,,,39.97,25.98,,,,,,,,,,,,,
ALPRAZOLAM 0.25 MG PO TABS,RX-324,CDM,6370000000,HCPCS,0637,RC,60687-0377-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
BRACE WLK SM M GRY LO PROF ANK LEG ROCK SOLE 5 LOOP LCK STRP,SUP-2334818,CDM,L4361,HCPCS,0274,RC,,,,both,,,171.13,111.23,,,,,,,,,,,,,
CATHETER PICC L55CM OD4FR DBL LUMN,SUP-2120641,CDM,C1751,HCPCS,0278,RC,,,,both,,,391.24,254.31,,,,,,,,,,,,,
TROCAR TIP NIT GWIRE 320MM,SUP-2114088,CDM,C1713,HCPCS,0278,RC,,,,both,,,169.56,110.21,,,,,,,,,,,,,
SYSTEM INTRO SAFSHTH II L 23 CM DIA 9 FR DIL 28.5 CM BLK,SUP-2419358,CDM,C1892,HCPCS,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
GRAFT BONE 0.1-4MM 120ML CANC CRUSH CHIP FRZ DRY,SUP-2294028,CDM,C1713,HCPCS,0278,RC,,,,both,,,5017.72,3261.52,,,,,,,,,,,,,
MIS LOCK CALC PLT LG EXD 3H RT,SUP-2586882,CDM,C1713,HCPCS,0278,RC,,,,both,,,2811.81,1827.68,,,,,,,,,,,,,
PROBE 25GA ENH STANDALONE VITRCTMY,SUP-2109927,CDM,C1713,HCPCS,0278,RC,,,,both,,,731.62,475.55,,,,,,,,,,,,,
DEVICE PESSARY DIA2.75IN SIL FLEX GELLHORN FOR 3RD DEG,SUP-2171827,CDM,A4562,HCPCS,0274,RC,,,,both,,,179.07,116.40,,,,,,,,,,,,,
GRAFT DURA PTCH SM 5X10 CM DURAMATER,SUP-2321732,CDM,C1713,HCPCS,0278,RC,,,,both,,,5181.00,3367.65,,,,,,,,,,,,,
CATHETER EP DIAG QPLR 6FRX100CM EXPLORER 360 JOSEPHSON FIX,SUP-2140171,CDM,C1730,HCPCS,0272,RC,,,,both,,,649.67,422.29,,,,,,,,,,,,,
OBTURATOR ENDO FLEX FOR AC TIGHTROPE TECH,SUP-2121674,CDM,C1713,HCPCS,0278,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
TRASTUZUMAB-QYYP 150 MG IV SOLR,RX-153554,CDM,Q5116,HCPCS,0636,RC,00069-0308-01,NDC,,both,1,UN,3512.40,2283.06,,,,,,,,,,,,,
PLATE BNE L386MM 18 H NONSTERILE L CNDYL S STL LOK COMPR,SUP-2183119,CDM,C1713,HCPCS,0278,RC,,,,both,,,4909.04,3190.88,,,,,,,,,,,,,
HANDLE COIL DETACH CEREPAK MECH RAPID RELIABLE STRL,SUP-2865225,CDM,2720000010,LOCAL,0272,RC,,,,both,,,886.39,576.15,,,,,,,,,,,,,
CATHETER REPROC ETER EP 5FR 5MM 4 POLE JSN,SUP-2270124,CDM,C1730,HCPCS,0272,RC,,,,both,,,101.80,66.17,,,,,,,,,,,,,
COIL EMB TWO DIM 3 MMX6 CM OPN LOOP DSTL TARGET 360 SFT,SUP-2365796,CDM,C1889,HCPCS,0278,RC,,,,both,,,5951.09,3868.21,,,,,,,,,,,,,
SCREW BNE 2.4X18 MM CORTICAL MSP,SUP-2308950,CDM,C1713,HCPCS,0278,RC,,,,both,,,301.44,195.94,,,,,,,,,,,,,
PROBE ABLATN MICROWAVE 14 GAX200 MM AMICA,SUP-2303521,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7834.30,5092.29,,,,,,,,,,,,,
DEVICE PESSARY DIA2.75IN SIL FLEX GELLHORN FOR 3RD DEG,SUP-2171827,CDM,A4562,HCPCS,0272,RC,,,,both,,,179.07,116.40,,,,,,,,,,,,,
GRAFT HUM TISS L 60 MM FIB SHFT LYOPH,SUP-2913248,CDM,C1762,CPT,0278,RC,,,,both,,,3196.52,2077.74,,,,,,,,,,,,,
PLATE BNE TBLR 3.5 MM 7 HOLE 1/3 2 COMPR LCK FOR SCR TI STRL,SUP-2479960,CDM,C1713,HCPCS,0278,RC,,,,both,,,527.83,343.09,,,,,,,,,,,,,
STEM EXTN TIB 10MM DIA 89MM LEN FINN - 10MM DIAM 89MM LEN,SUP-2406049,CDM,C1776,CPT,0278,RC,,,,both,,,3984.66,2590.03,,,,,,,,,,,,,
HC CT T-Spine W/O Contrast,PX-3527212800,CDM,72128,CPT,0352,RC,,,,both,,,2630.00,1709.50,,,,,,,,,,,,,
PLATE BNE W12XL103MM THK1MM 6 H BILAT S STL SEMI TBLR LO,SUP-2184867,CDM,C1713,HCPCS,0278,RC,,,,both,,,97.34,63.27,,,,,,,,,,,,,
DEFIBRILLATOR CARD 31.5CC W2.43XH2.69-2.89IN THK0.39IN 72GM,SUP-2149198,CDM,C1721,HCPCS,0275,RC,,,,both,,,38772.72,25202.27,,,,,,,,,,,,,
HC Ult Guidance Intraoperative,PX-4027699800,CDM,76998,CPT,0402,RC,,,,both,,,1401.00,910.65,,,,,,,,,,,,,
HC So2 Collagen Cross-Link N-Telopep,PX-3018252368,CDM,82523,CPT,0301,RC,,,,inpatient,,,254.00,165.10,,,,,,,,,,,,,
TRAY HEMODIALYSI W/O CATH FEN DRP GLOVEX1PR PROVIDONE SWBX3S,SUP-2613238,CDM,C1752,HCPCS,0278,RC,,,,both,,,163.28,106.13,,,,,,,,,,,,,
URETHRAL DILATION BLLN CATHETER,SUP-2827463,CDM,C1726,HCPCS,0272,RC,,,,both,,,606.65,394.32,,,,,,,,,,,,,
DRILL SURG 2 MM PERC W/ TIP NS INION OTPS LTX REUSE,SUP-2857869,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1463.24,951.11,,,,,,,,,,,,,
PLATE BONE L103MM 6 H BILAT COMPR STR BROAD FOR 4.5MM SCR,SUP-2343795,CDM,C1713,HCPCS,0278,RC,,,,both,,,1839.66,1195.78,,,,,,,,,,,,,
SYRINGE EAR ALL MTL 2 TIP,SUP-2159688,CDM,2720000010,LOCAL,0272,RC,,,,both,,,606.65,394.32,,,,,,,,,,,,,
GRAFT HUM TISS 3X8CM THCK AMNION,SUP-2419167,CDM,C1762,CPT,0278,RC,,,,both,,,10362.00,6735.30,,,,,,,,,,,,,
SPACER SPNL H12MM ASMBLY PRIMALOK SP,SUP-2319813,CDM,C1713,HCPCS,0278,RC,,,,both,,,20410.00,13266.50,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH SPIRAL-Z L 107 MM DIA11 MM SHTH 14 FR,SUP-2171073,CDM,C1768,CPT,0278,RC,,,,both,,,10801.60,7021.04,,,,,,,,,,,,,
PIN DRL DIA4MM ACL CLS EYELET FOR FEM FIX SYS TIGHTROPE,SUP-2121411,CDM,2720000010,LOCAL,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
PROSTHESIS OSS PISTON 0.8X5 MM SHEA CUP PLAT FLROPLAS,SUP-2637823,CDM,L8613,CPT,0278,RC,,,,both,,,405.78,263.76,,,,,,,,,,,,,
CATHETER HD 2 LUMEN 14 FRX28 CM KT,SUP-2159458,CDM,C1750,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
SUPPORT ORTHOT HIP KNEE ANK CUST TORSON BALL BEAR J,SUP-2435642,CDM,L2060,HCPCS,0274,RC,,,,both,,,1725.68,1121.69,,,,,,,,,,,,,
TUBE LACR DUCT 3MM M NASOLACR MONO CRWFRD,SUP-2224383,CDM,C1713,HCPCS,0278,RC,,,,both,,,687.66,446.98,,,,,,,,,,,,,
TOOL LEGEND 75CM 15MM BALL DMND,SUP-2279689,CDM,2720000010,LOCAL,0272,RC,,,,both,,,403.11,262.02,,,,,,,,,,,,,
PACEMAKER CARD 2 CHMBR PHILOSIIDR,SUP-2137974,CDM,C1786,HCPCS,0275,RC,,,,both,,,12726.42,8272.17,,,,,,,,,,,,,
GUIDEWIRE VASC HI TORQ PROCEED 25 DEG L 300 CM DIA 0.014 IN,SUP-2893018,CDM,C1769,HCPCS,0272,RC,,,,both,,,580.90,377.58,,,,,,,,,,,,,
CATHETER ETER EP 4FR 2 2 2MM ELECTRD SPC QPLR SUPREME,SUP-2356960,CDM,C1730,HCPCS,0272,RC,,,,both,,,596.60,387.79,,,,,,,,,,,,,
STENT URET SOFFLX L 8 CM DIA 4.7 FR POLYUR SMALLER SIZED,SUP-2826628,CDM,C2617,HCPCS,0278,RC,,,,both,,,298.61,194.10,,,,,,,,,,,,,
NIVOLUMAB-HYALURONIDASE-NVHY 600-10000 MG-UT/5ML SC SOLN,RX-170492,CDM,J9289,HCPCS,0636,RC,00003-6120-01,NDC,,both,5,ML,22876.10,14869.46,,,,,,,,,,,,,
PLATE SPNL W6.5XL17MM UNIV 2 H TI ANTR LUM LCK CVR SET SCR,SUP-2291665,CDM,C1713,HCPCS,0278,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
CONNECTOR SPNL L30MM OD5.5MM CLOSE OFFSET CREO AMP,SUP-2228675,CDM,C1713,HCPCS,0278,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
GUIDEWIRE AMPLATZ SUP STIFF PTFE COAT 0035 IN X 145CM J TIP,SUP-2141746,CDM,C1769,HCPCS,0272,RC,,,,both,,,99.13,64.43,,,,,,,,,,,,,
CANNULA VEN SHT 19 FR UNCOATED HLS,SUP-2663484,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1256.13,816.48,,,,,,,,,,,,,
BUR SURG OD16.8MM 24.1MM M CUT RND N FLUT STRL PERF CHK,SUP-2363339,CDM,2720000010,LOCAL,0272,RC,,,,both,,,294.19,191.22,,,,,,,,,,,,,
WASHER ORTH DIA3MM S STL THRD FOR 3MM CANN SCR,SUP-2184667,CDM,C1713,HCPCS,0278,RC,,,,both,,,336.42,218.67,,,,,,,,,,,,,
STENT GRFT VASC OVATION IX L 140 MM 185 MM 14/10 MM 10/12 FR,SUP-2217735,CDM,C1768,CPT,0278,RC,,,,both,,,13275.92,8629.35,,,,,,,,,,,,,
SAW BLDE W10XL70MM THK1.19MM RECIP CEM FOR LINVATEC HALL,SUP-2408658,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1868.30,1214.39,,,,,,,,,,,,,
PLATE BONE L52MM 7X3 H TI RAD LT DSTL VOLAR LCK COMPR LO,SUP-2361544,CDM,C1713,HCPCS,0278,RC,,,,both,,,2653.30,1724.64,,,,,,,,,,,,,
HALF PIN 4X40 TIN180MM LONG,SUP-2853191,CDM,C1713,HCPCS,0278,RC,,,,both,,,405.06,263.29,,,,,,,,,,,,,
BOLT ORTH TROCH CALCAR PLUG OBLONG MOD FOR MLRY HD HIP SYS,SUP-2405214,CDM,C1776,CPT,0278,RC,,,,both,,,1306.24,849.06,,,,,,,,,,,,,
STEM TIB DIA14MM BILAT ANK PLSM MID CEM PROPHECY INBONE,SUP-2397066,CDM,C1776,CPT,0278,RC,,,,both,,,1428.70,928.65,,,,,,,,,,,,,
CUTTER ENDOSCP DISP FOR MAXBRAID SUT,SUP-2212871,CDM,2720000010,LOCAL,0272,RC,,,,both,,,615.44,400.04,,,,,,,,,,,,,
GUIDEWIRE VASC L 190 CM DIA 0.035 IN SS PERIPH AMPLTZ X,SUP-2170312,CDM,C1769,HCPCS,0272,RC,,,,both,,,167.99,109.19,,,,,,,,,,,,,
GRAFT BNE SUB 5ML MTRX CELLULAR OSTEOCEL +,SUP-2310449,CDM,C1713,HCPCS,0278,RC,,,,both,,,5714.80,3714.62,,,,,,,,,,,,,
KIT PROS HEXALOBULAR CONDYLE,SUP-2215506,CDM,C1776,CPT,0278,RC,,,,both,,,4612.66,2998.23,,,,,,,,,,,,,
TAP SURG DIA4.5MM BNE SCR CANN QUIK CONN,SUP-2409919,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1366.15,888.00,,,,,,,,,,,,,
PROSTHESIS OSS OVL TOP 4X3X6.6 MM 1.15 MM TRIM CANN HA PORP,SUP-2637863,CDM,L8613,CPT,0278,RC,,,,both,,,1402.58,911.68,,,,,,,,,,,,,
GUIDEWIRE VASC CLOSUREFAST L 150 CM DIA 0.025 IN TIP L 1.5,SUP-2393089,CDM,C1769,HCPCS,0272,RC,,,,both,,,41.92,27.25,,,,,,,,,,,,,
FLUCONAZOLE IN SODIUM CHLORIDE 200-0.9 MG/100ML-% IV SOLN,RX-10049,CDM,J1450,HCPCS,0636,RC,25021-0184-82,NDC,,both,100,ML,54.10,35.16,,,,,,,,,,,,,
CAGE SPNL PARL 17X14X9 MM MP DIVERGENCE,SUP-2632024,CDM,C1889,HCPCS,0278,RC,,,,both,,,2433.50,1581.77,,,,,,,,,,,,,
PLATE BNE LO BEND 3.5X206 MM RT PROX TIB 14 HOLE SS NS LCP,SUP-2184312,CDM,C1713,HCPCS,0278,RC,,,,both,,,4152.81,2699.33,,,,,,,,,,,,,
FOSPHENYTOIN 50 MG PE/ML IJ SOLN (MIXTURES ONLY),RX-430014,CDM,Q2009,HCPCS,0636,RC,68462-0621-54,NDC,,both,2,ML,54.10,35.16,,,,,,,,,,,,,
DRAINAGE SET EXT 35 CM VENTRICULAR EVD CSF RADIOPAQUE STR,SUP-2851435,CDM,C1729,HCPCS,0272,RC,,,,both,,,863.15,561.05,,,,,,,,,,,,,
PLATE BONE L64MM THK0.6MM REG 16 H SLV TI STR FOR 1.5MM SCR,SUP-2402876,CDM,C1713,HCPCS,0278,RC,,,,both,,,693.94,451.06,,,,,,,,,,,,,
SEED BRACHYTHERAPY I-125 MICK 15 CART PROST BRACHYSOURCE,SUP-2129111,CDM,C2638,HCPCS,0278,RC,,,,both,,,36.11,23.47,,,,,,,,,,,,,
SCREW BNE L 130 MM DIA 3.5 MM SS CORTICAL ST NS EVOS,SUP-2932197,CDM,C1713,HCPCS,0278,RC,,,,both,,,181.84,118.20,,,,,,,,,,,,,
GUIDEWIRE ORTH L400MM DIA1.8MM S STL OLV DRL PNT RINGFIX,SUP-2372158,CDM,C1769,HCPCS,0272,RC,,,,both,,,984.70,640.05,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL PEEK SD800.511,SUP-2860193,CDM,C1713,HCPCS,0278,RC,,,,both,,,29479.58,19161.73,,,,,,,,,,,,,
ANCHOR SUTURE OD3.5MM PRE THREADED BIO ANCHOR,SUP-2828531,CDM,C1713,HCPCS,0278,RC,,,,both,,,461.14,299.74,,,,,,,,,,,,,
SYSTEM CARD ICD SYS 2 CHMBR W/ RIATA ST OPTIM SYS FOR V-255,SUP-2356557,CDM,C1721,HCPCS,0275,RC,,,,both,,,71906.00,46738.90,,,,,,,,,,,,,
HC Unlisted Proc Urinary System,PX-3615389900,CDM,53899,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
MESH BONE 45MML MODIFIED LATEX FREE MID FACE BODY,SUP-2677342,CDM,C1713,HCPCS,0278,RC,,,,both,,,7900.96,5135.62,,,,,,,,,,,,,
FLAVOXATE HCL 100 MG PO TABS,RX-10039,CDM,6370000000,HCPCS,0637,RC,00574-0115-01,NDC,,both,1,UN,5.00,3.25,,,,,,,,,,,,,
SCREW SCHANZ BLUNTED POINT 4.5MM 175MM/HA COATING-STERILE,SUP-2547737,CDM,C1713,HCPCS,0278,RC,,,,both,,,553.52,359.79,,,,,,,,,,,,,
SCREW BNE FT 5X75 MM CANN STRL,SUP-2460082,CDM,C1713,HCPCS,0278,RC,,,,both,,,536.06,348.44,,,,,,,,,,,,,
CUP ACET DIA52MM R HIP X3 MOB BEAR FOR RESTR ADM,SUP-2368461,CDM,C1776,CPT,0278,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
IMMUNE GLOBULIN (OCTAGAM) 10%,RX-4081765,CDM,J1568,HCPCS,0636,RC,68982-0850-04,NDC,,both,200,ML,11460.80,7449.52,,,,,,,,,,,,,
HEAD HUM ECC 48X18 MM SHLDR AFFINITI,SUP-2715312,CDM,C1776,CPT,0278,RC,,,,both,,,7603.51,4942.28,,,,,,,,,,,,,
SCREW BNE CANN 3.5X12 MM FA0120] ACUMED LLC],SUP-2107587,CDM,C1713,HCPCS,0278,RC,,,,both,,,618.58,402.08,,,,,,,,,,,,,
GRAFT BNE 10ML CANC MIC MORSL B-TCP VITOSS,SUP-2368164,CDM,C1713,HCPCS,0278,RC,,,,both,,,2176.02,1414.41,,,,,,,,,,,,,
SET SCR ORTH KNEE LOK LEGION,SUP-2421233,CDM,C1713,HCPCS,0278,RC,,,,both,,,331.58,215.53,,,,,,,,,,,,,
SUPPORT ORTHOT LOWER EXTREMITY CUST LACER MOLD TO PT MODEL,SUP-2435659,CDM,L2330,HCPCS,0274,RC,,,,both,,,1039.47,675.66,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA MAXBARR 3FR 55CM S9173108D,SUP-2632872,CDM,C1751,HCPCS,0278,RC,,,,both,,,618.52,402.04,,,,,,,,,,,,,
SET INTRO PEELWY L 15.5 CM DIA 7 FR DIL 20 CM GUIDEWIRE,SUP-2168014,CDM,C1892,HCPCS,0272,RC,,,,both,,,153.86,100.01,,,,,,,,,,,,,
INTRODUCER SHTH J 0.035 IN STRAIGHTENER FLSH PRELUDE,SUP-2303469,CDM,C1769,HCPCS,0272,RC,,,,both,,,25.97,16.88,,,,,,,,,,,,,
SUPPORT ORTHOT LUMBAR CUST SAG CTRL STRP PADDING STAY,SUP-2435556,CDM,L0641,HCPCS,0274,RC,,,,both,,,220.68,143.44,,,,,,,,,,,,,
KIT DRL BIT DIA2/3.2MM SHLDR REV PLATFRM EQUINOXE,SUP-2223409,CDM,2720000010,LOCAL,0272,RC,,,,both,,,914.37,594.34,,,,,,,,,,,,,
FOOTPLATE EXT FIX LNG 180 MM SET W/ RNG RX STRUT TRUELOK EVO,SUP-2875592,CDM,2720000010,LOCAL,0272,RC,,,,both,,,37664.30,24481.79,,,,,,,,,,,,,
CATHETER BAL DIL 9X4X5.8X75 SYNERGY,SUP-2139688,CDM,C1725,HCPCS,0272,RC,,,,both,,,551.86,358.71,,,,,,,,,,,,,
CATHETER INFUSION PMP 4 ML/HR 2X5 IN 550 CC,SUP-2365201,CDM,C1781,HCPCS,0278,RC,,,,both,,,690.17,448.61,,,,,,,,,,,,,
CENTRALIZER STEM DIA12MM UNIV DSTL HIP,SUP-2210694,CDM,C1776,CPT,0278,RC,,,,both,,,285.74,185.73,,,,,,,,,,,,,
IMMUNE GLOBULIN (OCTAGAM) 10%,RX-4081765,CDM,J1568,HCPCS,0636,RC,68982-0850-01,NDC,,both,20,ML,1146.10,744.96,,,,,,,,,,,,,
PLATE BNE L 55 X W 55 MM THK 1.4 MM SCREW DIA2.2 MM PLL,SUP-2883190,CDM,C1713,HCPCS,0278,RC,,,,both,,,4911.87,3192.72,,,,,,,,,,,,,
IMPLANT FACE L 65 X H 35 MM LAT PROJCT 11 MM LG POLYETHYL RT,SUP-2883502,CDM,C1713,HCPCS,0278,RC,,,,both,,,2067.63,1343.96,,,,,,,,,,,,,
PLATE 3.5MM CURVED BROAD LCP 26 HOLE-STERILE,SUP-2546108,CDM,C1713,HCPCS,0278,RC,,,,both,,,3569.68,2320.29,,,,,,,,,,,,,
LINER ACET SZ I OD66-68MM ID40MM 0DEG POLYETHYLENEX3 HIP FOR,SUP-2364436,CDM,C1776,CPT,0278,RC,,,,both,,,6452.23,4193.95,,,,,,,,,,,,,
BIT DRL L L266MM DIA16MM FEM FLX CANN QUIK CPL,SUP-2187060,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2369.85,1540.40,,,,,,,,,,,,,
GRAFT VASC W/ RADPQ MRK THORACOABDOMINAL 14MM BOR SIZEX25CM,SUP-2384990,CDM,C1768,CPT,0278,RC,,,,both,,,10487.60,6816.94,,,,,,,,,,,,,
CATHETER CHOLGM L18IN OD18GA LAP DISP,SUP-2331300,CDM,C1726,HCPCS,0272,RC,,,,both,,,207.33,134.76,,,,,,,,,,,,,
GRAFT HUM TISS W4XL4CM AMNIO MEMBRN AXOGRFT,SUP-2125453,CDM,C1762,CPT,0278,RC,,,,both,,,5024.00,3265.60,,,,,,,,,,,,,
ATROPINE SULFATE 1 MG/10ML IJ SOSY (MIXTURES ONLY),RX-430076,CDM,J0462,HCPCS,0636,RC,76329-3340-01,NDC,,both,5,ML,54.10,35.16,,,,,,,,,,,,,
STENT NEPHURET COPE L 28 CM DIA 8.5 FR UTHANE UPJ STRL,SUP-2168172,CDM,C2625,HCPCS,0278,RC,,,,both,,,345.43,224.53,,,,,,,,,,,,,
DRESSING KIT 13 CM PREVENA,SUP-2113633,CDM,C1781,HCPCS,0278,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
SHELL ACET PLSM COAT W/ HA 48MM NOVATION CERAMIC AHS,SUP-2221998,CDM,C1776,CPT,0278,RC,,,,both,,,6531.20,4245.28,,,,,,,,,,,,,
NEEDLE SUT FOR EXPRESSEW LL AND LLL SUT PASS EXPRESSEW LLL,SUP-2249389,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1194.46,776.40,,,,,,,,,,,,,
PLATE BNE SZ 185MM THK05MM FOR NEURO SHUNT USE LORENZ,SUP-2402903,CDM,C1713,HCPCS,0278,RC,,,,both,,,747.32,485.76,,,,,,,,,,,,,
CATHETER THROMCTMY PRONTO DIA 6 FR PTFE HYDRPHLC MARKER BND,SUP-2383128,CDM,C1757,HCPCS,0272,RC,,,,both,,,1522.90,989.88,,,,,,,,,,,,,
GRAFT BONE SUB 10CC FIL BONE VOID SOLUM IV,SUP-2163078,CDM,C1713,HCPCS,0278,RC,,,,both,,,3375.50,2194.07,,,,,,,,,,,,,
IMP SYS T-ROPE BTB-J W/8.5MM FLPCTR IIS,SUP-2811462,CDM,C1713,HCPCS,0278,RC,,,,both,,,2417.80,1571.57,,,,,,,,,,,,,
GRAFT VASC IMPRA L 40 CM DIA 8 MM EPTFE CENTERFLEX RING HEMO,SUP-2761397,CDM,C1768,CPT,0278,RC,,,,both,,,2132.91,1386.39,,,,,,,,,,,,,
PLATE BONE LOCKING STERNAL PRECONTOURED TITANIUM STERILE STE,SUP-2838431,CDM,C1713,HCPCS,0278,RC,,,,both,,,2874.98,1868.74,,,,,,,,,,,,,
BRACE WR LEN 9 1/8IN CIRC OVR 8 3/4INXL BGE D RNG LNG LEN LT,SUP-2324967,CDM,L3931,HCPCS,0272,RC,,,,both,,,44.49,28.92,,,,,,,,,,,,,
PROSTHESIS 4MM DIAM 8MM LEN TORP PLASTIPORE SHEA,SUP-2312575,CDM,L8613,CPT,0278,RC,,,,both,,,516.75,335.89,,,,,,,,,,,,,
SHEATH INTRO PEELWY L 30 CM DIA13 FR GUIDEWIRE 0.038 IN,SUP-2167891,CDM,C1892,HCPCS,0272,RC,,,,both,,,162.84,105.85,,,,,,,,,,,,,
LINER BPLR OD52-56MM ID28MM POLYETH CONVENE,SUP-2345766,CDM,C1776,CPT,0278,RC,,,,both,,,442.90,287.88,,,,,,,,,,,,,
K WIRE FIX DIA1.6MM S STL FOR DST VOLAR PLATING SYS,SUP-2414095,CDM,C1713,HCPCS,0278,RC,,,,both,,,58.15,37.80,,,,,,,,,,,,,
NALTREXONE HCL 50 MG PO TABS,RX-10685,CDM,6370000000,HCPCS,0637,RC,00406-1170-03,NDC,,both,1,UN,8.80,5.72,,,,,,,,,,,,,
TI MSH STR BEALS STY RGD BLU2 H20 SYS,SUP-2677461,CDM,C1713,HCPCS,0278,RC,,,,both,,,1666.37,1083.14,,,,,,,,,,,,,
STEM HUM 12 TI SHLDR UNCEMENTED FLUT,SUP-2204814,CDM,C1776,CPT,0278,RC,,,,both,,,13907.06,9039.59,,,,,,,,,,,,,
TIP IRR ASPIR 180 DEG 16GA,SUP-2391892,CDM,C1713,HCPCS,0278,RC,,,,both,,,703.36,457.18,,,,,,,,,,,,,
GRAFT BONE CRUSH FRZ DRY DEMIN CANC CORT 0.5MM-3MM RANG 15CC,SUP-2294039,CDM,C1713,HCPCS,0278,RC,,,,both,,,734.76,477.59,,,,,,,,,,,,,
GRAFT VASC INTERGARD L 40 CM DIA 8 MM THK 0.35 MM POLYESTER,SUP-2493733,CDM,C1768,CPT,0278,RC,,,,both,,,1612.17,1047.91,,,,,,,,,,,,,
CATHETER GUID UPSIZED WIDE 47 CM CPS DIR SL II,SUP-2356376,CDM,C1893,HCPCS,0272,RC,,,,both,,,553.90,360.03,,,,,,,,,,,,,
COMPONENT FEM A A/P44.5MM M/L55MM ZMLY POR LT KNEE PRI,SUP-2201315,CDM,C1776,CPT,0278,RC,,,,both,,,11000.99,7150.64,,,,,,,,,,,,,
CONNECTOR SPNL CRSS L20MM CERV TI OFFSET OASYS,SUP-2380738,CDM,C1713,HCPCS,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
ARCOS 21X250MM INTLKNG DIST,SUP-2506111,CDM,C1776,CPT,0278,RC,,,,both,,,10562.96,6865.92,,,,,,,,,,,,,
SUPPORT ORTH RT BRKT TRAC SPLNT TBL BTTRS FT LEG HLDR,SUP-2197868,CDM,C1713,HCPCS,0278,RC,,,,both,,,5648.86,3671.76,,,,,,,,,,,,,
PLATE BONE DIA100MM NONSTERILE CRAN TI RND CNTOUR MESH RIG,SUP-2190641,CDM,C1713,HCPCS,0278,RC,,,,both,,,7444.94,4839.21,,,,,,,,,,,,,
BLADE SHAVER RESECT 3.5X130 MM OVL MICRO STICK S1 DISP,SUP-2661214,CDM,2720000010,LOCAL,0272,RC,,,,both,,,405.56,263.61,,,,,,,,,,,,,
CHISEL SURG 8MM BX REUSE PYRAMETRIX ADV,SUP-2292608,CDM,C1713,HCPCS,0278,RC,,,,both,,,2074.47,1348.41,,,,,,,,,,,,,
HC Galactogram S&I,PX-3207705300,CDM,77053,CPT,0320,RC,,,,both,,,1175.00,763.75,,,,,,,,,,,,,
TUBING ASPIR PRB TY DISP SET SONASTAR,SUP-2305937,CDM,2720000010,LOCAL,0272,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
PLATE BNE LINDORF LEFORT 1 13X1.4 MM RT ORTHOGNATHIC MOD TI,SUP-2457042,CDM,C1713,HCPCS,0278,RC,,,,both,,,971.08,631.20,,,,,,,,,,,,,
HC Inj Proc for Retro Cystography,PX-3615161000,CDM,51610,CPT,0361,RC,,,,outpatient,,,3707.00,2409.55,,,,,,,,,,,,,
REAMER SURG SZ 18MM MTP ORTHOLOC 3DI,SUP-2900518,CDM,C1713,HCPCS,0278,RC,,,,both,,,1152.38,749.05,,,,,,,,,,,,,
CLAMP EXT FIX SM DIA4MM OPN ROD TO ROD CONN,SUP-2188701,CDM,2720000010,LOCAL,0272,RC,,,,both,,,939.77,610.85,,,,,,,,,,,,,
GUIDEWIRE VASC L145CM DIA0.035IN PTFE MOD J SHP TIP INTMED,SUP-2173638,CDM,C1769,HCPCS,0272,RC,,,,both,,,172.70,112.25,,,,,,,,,,,,,
PLATE BNE W19.5XL51MM NAR 6X3 H ST R DST RAD VOLAR TI VAR,SUP-2180835,CDM,C1713,HCPCS,0278,RC,,,,both,,,2596.81,1687.93,,,,,,,,,,,,,
SCREW BONE 2.3MM DIAM 10MM LEN CORT ST STD NONLOCKING HDED,SUP-2363447,CDM,C1713,HCPCS,0278,RC,,,,both,,,153.73,99.92,,,,,,,,,,,,,
GRAFT TISS FRZN ALLGRFT FEM SHFT 30MM,SUP-2307344,CDM,C1713,HCPCS,0278,RC,,,,both,,,2158.75,1403.19,,,,,,,,,,,,,
PIN EXT FIX 4 MM,SUP-2197281,CDM,2720000010,LOCAL,0272,RC,,,,both,,,621.72,404.12,,,,,,,,,,,,,
KNIFE SURG SZ 15 CART NEUT S STL STRL DISP SMILLIE,SUP-2342363,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1463.24,951.11,,,,,,,,,,,,,
CLAMP REPROC MINI BAR BAR MR SAFE JET X 6MM 10.5MM,SUP-2465455,CDM,2720000010,LOCAL,0272,RC,,,,both,,,515.56,335.11,,,,,,,,,,,,,
BLADE ENDOSCP SHAVER L 37 CM DIA 4 MM SPD 1200 RPM TRACH STR,SUP-2901937,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1592.61,1035.20,,,,,,,,,,,,,
POST EXT FIX CIR FEMALE 4 HOLE,SUP-2400692,CDM,2720000010,LOCAL,0272,RC,,,,both,,,426.41,277.17,,,,,,,,,,,,,
PLATE BNE L61MM 5 H S STL 1/3 TBLR W/ CLLR LIMIT CNTCT DYN,SUP-2185927,CDM,C1713,HCPCS,0278,RC,,,,both,,,458.79,298.21,,,,,,,,,,,,,
STEM FEM L180MM OD18MM 10MM BUILDUP CO CHROM HIP CALCAR REV,SUP-2203254,CDM,C1776,CPT,0278,RC,,,,both,,,21577.48,14025.36,,,,,,,,,,,,,
NAIL FIX L26MM OD2MM LACTOSORB COPOLYMER ABSRB SGL USE FOR,SUP-2212971,CDM,C1713,HCPCS,0278,RC,,,,both,,,929.44,604.14,,,,,,,,,,,,,
KIT TRACH TB L755MM OD119MM ID8MM PERC DIL FULL COMP BLU,SUP-2351758,CDM,2720000010,LOCAL,0272,RC,,,,both,,,871.70,566.60,,,,,,,,,,,,,
CATHETER VENT L15CM BA ACCU-FLO,SUP-2243777,CDM,C1729,HCPCS,0272,RC,,,,both,,,702.92,456.90,,,,,,,,,,,,,
SCREW SPNL TALL CLOSE BODY PHOENIX,SUP-2316624,CDM,C1713,HCPCS,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
SHEATH INTRO FAST-CATH L 61 CM DIA 8.5 FR DIL L 67 CM,SUP-2357148,CDM,C1893,HCPCS,0272,RC,,,,both,,,238.64,155.12,,,,,,,,,,,,,
"HC So1 Spectrophotometry, Analyte Nes",PX-3018431167,CDM,84311,CPT,0301,RC,,,,both,,,80.00,52.00,,,,,,,,,,,,,
HC So Acetylcholn Rcptr Modlg Antb,PX-3028604366,CDM,86043,CPT,0302,RC,,,,both,,,76.00,49.40,,,,,,,,,,,,,
CATHETER GUID ANGLE 110 DEG SINUS FLX RELIEVA,SUP-2106354,CDM,C1887,HCPCS,0272,RC,,,,both,,,1254.74,815.58,,,,,,,,,,,,,
INTRODUCER TUBE TY 8 FR PERC CIAGLIA BLU RHINO SHILEY,SUP-2760025,CDM,C1769,HCPCS,0272,RC,,,,both,,,1336.70,868.85,,,,,,,,,,,,,
PLATE BNE L 179.25 MM SCREW DIA2 MM 9 H LG TI RAMUS ANGLED,SUP-2936440,CDM,C1713,HCPCS,0278,RC,,,,both,,,6531.20,4245.28,,,,,,,,,,,,,
ANG BLDE PL 130 9H 80/152,SUP-2819399,CDM,C1713,HCPCS,0278,RC,,,,both,,,5649.96,3672.47,,,,,,,,,,,,,
RETRACTOR EXTENDED WEAR PANNICULUS REG,SUP-2880687,CDM,2720000010,LOCAL,0272,RC,,,,both,,,395.64,257.17,,,,,,,,,,,,,
HC Chemo It Inj Incl Spinal Punct,PX-3319645000,CDM,96450,CPT,0331,RC,,,,both,,,7197.00,4678.05,,,,,,,,,,,,,
FILLER BNE VOID 5ML INJ OSTEOVATIONEX,SUP-2319787,CDM,C1713,HCPCS,0278,RC,,,,both,,,5440.05,3536.03,,,,,,,,,,,,,
HC Inj Stelat Gangl Cerv Sym,PX-3616451000,CDM,64510,CPT,0361,RC,,,,inpatient,,,6875.00,4468.75,,,,,,,,,,,,,
GUIDEPIN SURG DIA2MM MINIMALLY INVASIVE SACROILIAC JT SURG,SUP-2337769,CDM,C1713,HCPCS,0278,RC,,,,both,,,204.10,132.66,,,,,,,,,,,,,
HALF PIN 4X120MM 30MM THR,SUP-2818387,CDM,2720000010,LOCAL,0272,RC,,,,both,,,785.82,510.78,,,,,,,,,,,,,
TRIAL TIB STEM TIB PROV SZ 6 NXGN,SUP-2201513,CDM,C1713,HCPCS,0278,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
KIT ANALGESIC PMP RPS SPIKE CONN CASETTE FILTER TRNSLUC TBNG,SUP-2892645,CDM,2720000010,LOCAL,0272,RC,,,,both,,,682.95,443.92,,,,,,,,,,,,,
DIVALPROEX SODIUM 500 MG PO TBEC,RX-2553,CDM,6370000000,HCPCS,0637,RC,00904-6861-61,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
KIT HIP ARTHRO INCL 17GA SPNL NDL NIT GWIRE 30CC SYR RUL,SUP-2366733,CDM,2720000010,LOCAL,0272,RC,,,,both,,,722.20,469.43,,,,,,,,,,,,,
SHEATH INTRO PINNACLE L 10 CM 5 FR SS HYDRPHLC PERIPHERAL,SUP-2385292,CDM,C1894,HCPCS,0272,RC,,,,both,,,371.78,241.66,,,,,,,,,,,,,
BIT DRL CALIB 3.3 MM HUM C LBL INSTRUMENT CASE STRL AFFIXUS,SUP-2606175,CDM,2720000010,LOCAL,0272,RC,,,,both,,,998.52,649.04,,,,,,,,,,,,,
GUIDEPIN ORTH FOR R SET TRUMATCH,SUP-2252966,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
OMEPRAZOLE 20 MG PO CPDR,RX-27694,CDM,6370000000,HCPCS,0637,RC,57237-0161-30,NDC,,both,1,UN,0.90,0.58,,,,,,,,,,,,,
PLATE BNE BROAD 3.5X198 MM 15 HOLE SS LCP,SUP-2569341,CDM,C1713,HCPCS,0278,RC,,,,both,,,545.73,354.72,,,,,,,,,,,,,
GRAFT ENDOVASC L142MM DIA32MM INTRO SHTH OD7.7MM ID6.7MM,SUP-2419732,CDM,C1768,CPT,0278,RC,,,,both,,,54202.68,35231.74,,,,,,,,,,,,,
NUT FIX 13.8MM MULT AX HEX,SUP-2415295,CDM,C1713,HCPCS,0278,RC,,,,both,,,635.66,413.18,,,,,,,,,,,,,
HC Ot Manual Therapy per 15 Min.|OP PT SERVICES|DOCUMENTATION ON FILE|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS,PX-4309714000,CDM,97140,CPT,0430,RC,,,GP|KX|CQ,outpatient,,,194.00,126.10,,,,,,,,,,,,,
BUTTON ARTHSCP W/ DRL GWIRE PASS PIN BONE TUNN PLUG ULT PAC,SUP-2341856,CDM,C1713,HCPCS,0278,RC,,,,both,,,1117.68,726.49,,,,,,,,,,,,,
ALLOGRAFT DRML THICK 6X16 CM READY USE TSSUE MTRX ALLDRM,SUP-2491846,CDM,Q4116,HCPCS,0636,RC,,,,both,,,10399.68,6759.79,,,,,,,,,,,,,
DEVICE FIX W5MM 12 ABSRB STRP DISP SECURESTRP,SUP-2219934,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1317.64,856.47,,,,,,,,,,,,,
CATHETER ETER DIAG L25MM ACHVE MAP,SUP-2281884,CDM,C1730,HCPCS,0272,RC,,,,both,,,2951.60,1918.54,,,,,,,,,,,,,
STENT URET DBL PGTL 0.038 IN 3 CM 8 FRX30 CM 6 FR POLARIS,SUP-2459383,CDM,C2617,HCPCS,0278,RC,,,,both,,,496.97,323.03,,,,,,,,,,,,,
PLATE BNE L 110 X W 10.2 MM THK 2.8 MM SCREW DIA 3.5 MM 10 H 72440910N,SUP-2933234,CDM,C1713,HCPCS,0278,RC,,,,both,,,1794.67,1166.54,,,,,,,,,,,,,
POUCH GENRTR FOR PACEMKR BARD PARSONNET,SUP-2137978,CDM,C1713,HCPCS,0278,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
SCREW SPNL EXT 60 MM TSRH 3DX,SUP-2631104,CDM,C1713,HCPCS,0278,RC,,,,both,,,555.65,361.17,,,,,,,,,,,,,
BENAZEPRIL HCL 20 MG PO TABS,RX-9221,CDM,6370000000,HCPCS,0637,RC,65862-0117-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
DOSTARLIMAB-GXLY 500 MG/10ML IV SOLN,RX-154623,CDM,J9272,HCPCS,0636,RC,00173-0898-03,NDC,,both,10,ML,34647.20,22520.68,,,,,,,,,,,,,
RHO D IMMUNE GLOBULIN 1500 UNITS IM SOSY,RX-129228,CDM,J2790,HCPCS,0636,RC,00562-7805-00,NDC,,both,1,UN,362.90,235.88,,,,,,,,,,,,,
HC Plmt Xtn Prosth Evasc Rpr,PX-3603470900,CDM,34709,CPT,0360,RC,,,,both,,,20612.00,13397.80,,,,,,,,,,,,,
VALSARTAN 80 MG PO TABS,RX-31209,CDM,6370000000,HCPCS,0637,RC,60687-0623-11,NDC,,both,1,UN,4.90,3.18,,,,,,,,,,,,,
PLATE BNE BROAD 4.5X196 MM 11 HOLE SS LC-DCP,SUP-2569270,CDM,C1713,HCPCS,0278,RC,,,,both,,,442.11,287.37,,,,,,,,,,,,,
PPICC PROVENA SOLO SP 4F DL MAX,SUP-2613540,CDM,C1751,HCPCS,0278,RC,,,,both,,,672.15,436.90,,,,,,,,,,,,,
SUPPORT ORTH HIP CIRC 28-48 IN SM MED SZ 2,SUP-2915041,CDM,2720000010,LOCAL,0272,RC,,,,both,,,731.05,475.18,,,,,,,,,,,,,
BLADE SAW SAG 202534] STRYKER CORP],SUP-2361842,CDM,2720000010,LOCAL,0272,RC,,,,both,,,186.05,120.93,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 40 CM DIA 6 MM EPTFE STR TW REINF 2,SUP-2477016,CDM,C1768,CPT,0278,RC,,,,both,,,758.03,492.72,,,,,,,,,,,,,
CATHETER SET 14 DIA. 65 CM LEN .038IN GWIRE W/ TEMP FEEDBACK,SUP-2327250,CDM,C1733,HCPCS,0272,RC,,,,both,,,4851.30,3153.34,,,,,,,,,,,,,
HC So1 Nephelometry Ea Analyte Nes,PX-3018388367,CDM,83883,CPT,0301,RC,,,,both,,,88.00,57.20,,,,,,,,,,,,,
PLATE BNE L 137 MM SCREW DIA 3.5 MM 7 H SS PROX HUM STR STRL,SUP-2933110,CDM,C1713,HCPCS,0278,RC,,,,both,,,7300.50,4745.32,,,,,,,,,,,,,
DEVICE CRD DRV MECHANISM ACTIVATOR II,SUP-2717311,CDM,C1713,HCPCS,0278,RC,,,,both,,,3995.05,2596.78,,,,,,,,,,,,,
LEAD DEFIB PERM VENT LD PACE BPLR ACT FIX SJ4 CONN 75CM LEN,SUP-2357375,CDM,C1895,HCPCS,0275,RC,,,,both,,,12560.00,8164.00,,,,,,,,,,,,,
HC Indwelling Catheter,PX-4505170200,CDM,51702,CPT,0450,RC,,,,inpatient,,,204.00,132.60,,,,,,,,,,,,,
ALLOGRAFT BNE SM 40-65 MM FD IRRADIATED CORTICAL SEG,SUP-2866970,CDM,C1762,CPT,0278,RC,,,,both,,,1670.48,1085.81,,,,,,,,,,,,,
CLAMP EXT FIX 6MM COMP BAR CLMP MRI SAFE STD W/ TIN HALF PIN,SUP-2342869,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3350.38,2177.75,,,,,,,,,,,,,
DRILL SURG MOD 16 MM RELIANT ACPS,SUP-2601919,CDM,C1713,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
PLUG VASC L18.4MM VES DIA5-7MM PERIPH NIT PTFE MIC,SUP-2281188,CDM,C1884,HCPCS,0278,RC,,,,both,,,5495.00,3571.75,,,,,,,,,,,,,
ELECTRODE ELECSURG CUT LOOP 22.5 FR 0.035 IN HF RESECT STRL,SUP-2470805,CDM,2720000010,LOCAL,0272,RC,,,,both,,,341.19,221.77,,,,,,,,,,,,,
BUR SURG L 13 MM DIA 2 MM SHANNON STR STRL DISP,SUP-2908926,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
JOINT SUBTALAR 8 MM TI MBA,SUP-2242696,CDM,C1776,CPT,0278,RC,,,,both,,,4270.40,2775.76,,,,,,,,,,,,,
PERFORATOR SURG CRAN DISP 9MM DIA 14MM LEN DGR-II,SUP-2106558,CDM,C1713,HCPCS,0278,RC,,,,both,,,759.88,493.92,,,,,,,,,,,,,
PLATE CRAN DIA18.5 MM THK 0.5 MM SCREW DIA1.5 MM TI SHUNT NS,SUP-2935839,CDM,C1713,HCPCS,0278,RC,,,,both,,,973.40,632.71,,,,,,,,,,,,,
PLATE BNE L 333 MM SCREW DIA 3.5/4.5 MM H 16 RT DSTL FEM,SUP-2931189,CDM,C1713,HCPCS,0278,RC,,,,both,,,19782.79,12858.81,,,,,,,,,,,,,
SHEETING SILAS 8X6 .030,SUP-2242093,CDM,C1713,HCPCS,0278,RC,,,,both,,,339.12,220.43,,,,,,,,,,,,,
SPACER SPNL W10XH9XL23MM 0DEG PEEK OPTMA INTERVERTEBRAL LUM,SUP-2137150,CDM,C1821,HCPCS,0278,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
SCREW BNE L14MM DIA2.7MM CORT DST FIBULAR TI ST,SUP-2413246,CDM,C1713,HCPCS,0278,RC,,,,both,,,202.84,131.85,,,,,,,,,,,,,
KIT PROCEDURE CANN BNDR INSRTR FASTFIX CRVD,SUP-2717591,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1648.50,1071.52,,,,,,,,,,,,,
BONE BIOPSY KIT HUNTINGTON GUID 18 GAX15 CM MADISON MINI,SUP-2476026,CDM,2720000010,LOCAL,0272,RC,,,,both,,,800.70,520.45,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.422,SUP-2859986,CDM,C1713,HCPCS,0278,RC,,,,both,,,35706.51,23209.23,,,,,,,,,,,,,
DILATOR TRANSSEPTAL L 85 CM OD 12 FR ID 0.035 IN GUIDEWIRE L,SUP-2913166,CDM,C1889,HCPCS,0278,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
HC So Hba1/Ahb2 Alpha Globulin,PX-3108125766,CDM,81257,CPT,0310,RC,,,,both,,,189.00,122.85,,,,,,,,,,,,,
MARKER BRST BX MOLLI L 12 CM DIA14 GA PRELD MR CONDITIONAL,SUP-2875964,CDM,A4648,CPT,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
SUPPORT WR SM LNG LEN RT FRARM WVN COT RUB FAB BGE FIRM W/,SUP-2324893,CDM,L3931,HCPCS,0274,RC,,,,both,,,41.01,26.66,,,,,,,,,,,,,
GUIDE SURG PLN NYL LP DISTRCTN CUSTOMIZABLE VSP,SUP-2883939,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5593.13,3635.53,,,,,,,,,,,,,
PERI SCR  45MM X 38MM,SUP-2720898,CDM,C1713,HCPCS,0278,RC,,,,both,,,135.84,88.30,,,,,,,,,,,,,
SCREW BNE L100MM DIA7.3MM THRD L32MM S STL ST SELF DRL CANN,SUP-2184003,CDM,C1713,HCPCS,0278,RC,,,,both,,,615.09,399.81,,,,,,,,,,,,,
NAIL IM L28CM OD10MM GRY TI TIB DSTL LCK CANN TRIGEN,SUP-2347127,CDM,C1713,HCPCS,0278,RC,,,,both,,,3887.16,2526.65,,,,,,,,,,,,,
KIT CATH 1.9FR X 6 CM EPIV W STYLET AND 27GA INTRODUCER,SUP-2874165,CDM,C1751,HCPCS,0278,RC,,,,both,,,144.75,94.09,,,,,,,,,,,,,
STENT BILI PALMAZ BLU L 19 MM DIA10-12 MM BALLOON EXPANDABLE,SUP-2102308,CDM,C1877,HCPCS,0278,RC,,,,both,,,4099.58,2664.73,,,,,,,,,,,,,
FIBER LASER HOLM 550 M MULTI-USE W/ H-30 PUR SMARTSYNC,SUP-2835947,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1614.75,1049.59,,,,,,,,,,,,,
STEM HUM DIA11MM SHLDR PRI PRESSFIT EQUINOXE,SUP-2223279,CDM,C1776,CPT,0278,RC,,,,both,,,5181.00,3367.65,,,,,,,,,,,,,
AMMONIA AROMATIC IN INHA,RX-439,CDM,6370000000,HCPCS,0637,RC,67777-0251-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
ALLOGRAFT BNE LG FRZN 1/3 HEMI PELVIS,SUP-2736961,CDM,C1762,CPT,0278,RC,,,,both,,,8919.26,5797.52,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.551,SUP-2860068,CDM,C1713,HCPCS,0278,RC,,,,both,,,62937.53,40909.39,,,,,,,,,,,,,
HUMERAL NAIL CAP 0MM,SUP-2818962,CDM,C1713,HCPCS,0278,RC,,,,both,,,712.72,463.27,,,,,,,,,,,,,
STENT PERIPH LIFESTENT L 100 MM DIA 6 MM CATH L 80 CM DIA 6,SUP-2420392,CDM,C1876,HCPCS,0278,RC,,,,both,,,4396.00,2857.40,,,,,,,,,,,,,
WEDGE SPNL 21X7X7 IN,SUP-2167324,CDM,C1713,HCPCS,0278,RC,,,,both,,,226.08,146.95,,,,,,,,,,,,,
PLATE BNE SM L92MM 2X3 H LAT TIBIOTALOCALCANEAL ANK TI,SUP-2398501,CDM,C1713,HCPCS,0278,RC,,,,both,,,5403.94,3512.56,,,,,,,,,,,,,
ALLOGRAFT DERMAL 4X6 CM DECELL DERMAL MTRX DERMAPURE,SUP-2388445,CDM,Q4152,HCPCS,0636,RC,,,,both,,,6264.30,4071.79,,,,,,,,,,,,,
PROGRAMMER COMMUNICATION W/HANDSET F/SACRAL NERVE STIMULATORS,SUP-2550572,CDM,C1787,HCPCS,0278,RC,,,,both,,,5787.02,3761.56,,,,,,,,,,,,,
ROD EXT FIX L300MM S STL THRD TELSCP ORIG CIR FOR TAY SPAT,SUP-2342306,CDM,2720000010,LOCAL,0272,RC,,,,both,,,411.18,267.27,,,,,,,,,,,,,
CATHETER ABLATN J-J 2-5-2 MM 3.5 MM 8 FRX115 CM THERMOCOOL,SUP-2248539,CDM,C1732,HCPCS,0272,RC,,,,both,,,7583.10,4929.01,,,,,,,,,,,,,
INTRODUCER LD L13CM OD6FR SPLITTABLE DIL W/ J TIP GWIRE SYR,SUP-2356433,CDM,C1892,HCPCS,0272,RC,,,,both,,,110.37,71.74,,,,,,,,,,,,,
SPACER SPNL 8MM GLD INDIR DCOMPR STRL SUPERION,SUP-2392698,CDM,C1821,HCPCS,0278,RC,,,,both,,,26062.00,16940.30,,,,,,,,,,,,,
SET URET STENT SOFFLX L 70 CM DIA 7.2FR GUIDEWIRE L 145CM RT,SUP-2835688,CDM,C2617,HCPCS,0278,RC,,,,both,,,280.72,182.47,,,,,,,,,,,,,
DRILL SURG 10GA VERT AUG AVAMAX,SUP-2361560,CDM,2720000010,LOCAL,0272,RC,,,,both,,,336.29,218.59,,,,,,,,,,,,,
SHEATH INTRO PINNACLE PRECIS ACCS SYS L 10 CM DIA 48FR BLK,SUP-2385255,CDM,C1769,HCPCS,0272,RC,,,,both,,,190.22,123.64,,,,,,,,,,,,,
SCREW BNE ZURICH 1.5X5 MM 3 MM DRILL-FREE HEX TI,SUP-2469542,CDM,C1713,HCPCS,0278,RC,,,,both,,,509.50,331.17,,,,,,,,,,,,,
CATHETER URET 4FRX70CM NYL RUTNR UNIV WDG,SUP-2171184,CDM,C1758,HCPCS,0278,RC,,,,both,,,60.23,39.15,,,,,,,,,,,,,
IMMOBILIZER SHOULDERXL W25XL57CM UNIV TITEX W/ BODY STRP,SUP-2197383,CDM,L3650,HCPCS,0274,RC,,,,both,,,10.64,6.92,,,,,,,,,,,,,
ANCHOR SUTURE THRD PAT 4.75 MM PEEK CROSS FT KNOTLESS DT,SUP-2423295,CDM,C1713,HCPCS,0278,RC,,,,both,,,1280.12,832.08,,,,,,,,,,,,,
HC ED Clsd Tx Elbow Disclocation,PX-4502460000,CDM,24600,CPT,0450,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
SET NEPHSTMY PERC ENTRY W/ 22GA 18GA S STL 20CM NDL SAFE T,SUP-2171232,CDM,C1713,HCPCS,0278,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
IMPLANT BRST NACL TEXT RND SIL SHELL MOD PROF ANT DIAPH VLV,SUP-2113280,CDM,C1789,HCPCS,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
PLATE SPNL SM L35MM TI POST OFFSET BILAT CD HORZ,SUP-2291780,CDM,C1713,HCPCS,0278,RC,,,,both,,,24570.50,15970.82,,,,,,,,,,,,,
POST EXT FIX CIR M 5 HOLE,SUP-2400703,CDM,2720000010,LOCAL,0272,RC,,,,both,,,458.44,297.99,,,,,,,,,,,,,
SUPPORT ORTHOT KNEE CUST LIMIT RANG OF MOTN,SUP-2435653,CDM,L2184,HCPCS,0272,RC,,,,both,,,327.94,213.16,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA 4FR 55CM 2 LUMAN R S9274108,SUP-2632874,CDM,C1751,HCPCS,0278,RC,,,,both,,,594.03,386.12,,,,,,,,,,,,,
SCREW 7.0X75MM LNG THRD CANN MAXTORQUE MSD0107075L] WRIGHT MEDICAL TECHNOLOGY INC],SUP-2400352,CDM,C1713,HCPCS,0278,RC,,,,both,,,818.91,532.29,,,,,,,,,,,,,
PROSTHESIS OSS L 5 MM SHFT DIA1.14 MM HD DIA 4 MM HA FLX H/A,SUP-2902100,CDM,L8613,CPT,0278,RC,,,,both,,,1587.90,1032.13,,,,,,,,,,,,,
CATHETER ANGIOPLSTY L 100 CM DIA 9 FR BALLOON L 30 MM DIA15,SUP-2140990,CDM,C1725,HCPCS,0272,RC,,,,both,,,1208.90,785.78,,,,,,,,,,,,,
SNARE SURG NDL EYE 13 MMX54 CM 12X12 FR WORKSTATION,SUP-2638742,CDM,C1773,HCPCS,0272,RC,,,,both,,,3537.87,2299.62,,,,,,,,,,,,,
STRAP CLAV SM 3 W HK,SUP-2428149,CDM,L3650,HCPCS,0272,RC,,,,both,,,17.62,11.45,,,,,,,,,,,,,
TAP BNE 3.5 MM,SUP-2319068,CDM,2720000010,LOCAL,0272,RC,,,,both,,,715.92,465.35,,,,,,,,,,,,,
"HC Gbl Est Pt, E/M Level 2",PX-9829921200,CDM,99212,CPT,0982,RC,,,,inpatient,,,300.00,195.00,,,,,,,,,,,,,
LIDOCAINE 4 % EX PTCH,RX-129559,CDM,6370000000,HCPCS,0637,RC,00536-1202-07,NDC,,both,1,UN,5.00,3.25,,,,,,,,,,,,,
PEG BNE FIX L8MM DIA2.5MM FULL THRD FOR ALPS HND FRAC SYS,SUP-2414055,CDM,C1713,HCPCS,0278,RC,,,,both,,,255.63,166.16,,,,,,,,,,,,,
KIT VASC ACC GWIRE L100CM ELITE,SUP-2124560,CDM,2720000010,LOCAL,0272,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
SPACER SPNL 6 DEG 30X8 MM 0.81 CC TI CRESCENT,SUP-2630182,CDM,C1889,HCPCS,0278,RC,,,,both,,,6656.80,4326.92,,,,,,,,,,,,,
PLATE BNE OLECRANON LNG ELBW EXT,SUP-2266346,CDM,C1713,HCPCS,0278,RC,,,,both,,,1990.76,1293.99,,,,,,,,,,,,,
STEM FEM REV CEM LT SZ 13 300MM LEN MALLORY-HEAD - LT SZ 13,SUP-2403331,CDM,C1776,CPT,0278,RC,,,,both,,,18227.70,11848.00,,,,,,,,,,,,,
BLADE TONGUE RUSSEL DAVIS 29MMW 67MML,SUP-2676000,CDM,2720000010,LOCAL,0272,RC,,,,both,,,362.61,235.70,,,,,,,,,,,,,
SET INJ SYR 10ML TB 08ML L15CM FOR PLACING BNE CEM FOR,SUP-2168823,CDM,C1713,HCPCS,0278,RC,,,,both,,,355.51,231.08,,,,,,,,,,,,,
PLATE BNE L154MM 8 H L LAT PROX TIB S STL LOK COMPR LO PROF,SUP-2185716,CDM,C1713,HCPCS,0278,RC,,,,both,,,4225.34,2746.47,,,,,,,,,,,,,
METHYLPHENIDATE HCL 5 MG PO TABS,RX-4988,CDM,6370000000,HCPCS,0637,RC,68084-0805-11,NDC,,both,1,UN,9.30,6.04,,,,,,,,,,,,,
AIRWAY LARYNGEAL ADULT SIZE 5 SOFT SILICONE REUSABLE LMA CLA,SUP-2824584,CDM,2720000010,LOCAL,0272,RC,,,,both,,,910.60,591.89,,,,,,,,,,,,,
BLADE RTRCTR MCCLLCH 6CMD STNLSS STEEL SPNL MSCLE WIDE ULTRA,SUP-2674040,CDM,2720000010,LOCAL,0272,RC,,,,both,,,408.29,265.39,,,,,,,,,,,,,
CATHETERIZATION KIT ART 018 20 GAX3.81 CM 18/25 GA 3 CC LF,SUP-2865588,CDM,C1751,HCPCS,0278,RC,,,,both,,,57.78,37.56,,,,,,,,,,,,,
DRILL 4.5MM FOR 5.5MM ANCHR SL,SUP-2419009,CDM,2720000010,LOCAL,0272,RC,,,,both,,,467.86,304.11,,,,,,,,,,,,,
HC Continuous Inhale Tx Addl Hour,PX-4109464500,CDM,94645,CPT,0410,RC,,,,outpatient,,,16.00,10.40,,,,,,,,,,,,,
SYSTEM LIF ILLUMINATION STERILE,SUP-2716321,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1899.70,1234.80,,,,,,,,,,,,,
SCREW BNE SD 6.5X75 MM CANN HEX SOCKET TI NS,SUP-2190079,CDM,C1713,HCPCS,0278,RC,,,,both,,,680.63,442.41,,,,,,,,,,,,,
PLATE BNE SM W11XL241MM THK34MM 18 H BILAT TI RIG NEUT LOK,SUP-2190797,CDM,C1713,HCPCS,0278,RC,,,,both,,,2243.62,1458.35,,,,,,,,,,,,,
STEM HIP SZ 2 STD OFFSET PROS ZZ ENDUR,SUP-2251938,CDM,C1776,CPT,0278,RC,,,,both,,,9219.04,5992.38,,,,,,,,,,,,,
ONABOTULINUMTOXINA 100 UNITS IJ SOLR,RX-102328,CDM,J0585,HCPCS,0636,RC,00023-1145-01,NDC,,both,1,UN,1920.50,1248.32,,,,,,,,,,,,,
SUPPORT ORTHOPEDIC WRST LG LT,SUP-2246904,CDM,L3908,HCPCS,0274,RC,,,,both,,,21.98,14.29,,,,,,,,,,,,,
STENT PERIPH PALMAZ L 30.3 MM DIA 3.5 MM SHTH 12-14 FR SS LG,SUP-2158988,CDM,C1877,HCPCS,0278,RC,,,,both,,,4239.00,2755.35,,,,,,,,,,,,,
SCREW BNE L40MM DIA3.5MM CORT DST TIB TI NONCANNULATED,SUP-2413375,CDM,C1713,HCPCS,0278,RC,,,,both,,,160.14,104.09,,,,,,,,,,,,,
CENTRALIZER STEM DIA20MM DSTL FEM HIP PMMA INVIS,SUP-2344517,CDM,C1776,CPT,0278,RC,,,,both,,,451.06,293.19,,,,,,,,,,,,,
EXTERNAL FIXATION SET COMPLETE PELVIS GALAXY FIX GEM LTX,SUP-2875646,CDM,C1713,HCPCS,0278,RC,,,,both,,,43288.35,28137.43,,,,,,,,,,,,,
PLATE BNE L 55.19 X W 33.91 MM THK 0.6 MM SCREW DIA1.5 MM 20,SUP-2935846,CDM,C1713,HCPCS,0278,RC,,,,both,,,3004.98,1953.24,,,,,,,,,,,,,
OCCLUDER CV FLO RST L 12 MM BLB DIA2.5 MM SIL RUBBER,SUP-2130329,CDM,C1760,HCPCS,0278,RC,,,,both,,,248.19,161.32,,,,,,,,,,,,,
ANCHOR SUT L19.1MM DIA4.75MM BIOCOMPOSITE CLS EYELET,SUP-2121699,CDM,C1713,HCPCS,0278,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
CATHETER EP 7FR L115CM 2-8-2MM SPC TIP 2MM 10 ELECTRD FJ,SUP-2248492,CDM,C1730,HCPCS,0272,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
PLATE BNE CONTOURABLE MESH LG 0.4 MM MASTOID TI BLU NS,SUP-2859917,CDM,C1713,HCPCS,0278,RC,,,,both,,,2939.04,1910.38,,,,,,,,,,,,,
GRAFT BONE SUB 10CC DEMIN BONE MTRX INJ FRZ DRY,SUP-2307006,CDM,C9359,HCPCS,0278,RC,,,,both,,,4011.07,2607.20,,,,,,,,,,,,,
BLADE SURG L80MM S STL HELIX FOR LCP DHHS SYS,SUP-2186779,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1035.98,673.39,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 220 MM DIA17 MM DEL SHTH,SUP-2934161,CDM,C1713,HCPCS,0278,RC,,,,both,,,19135.51,12438.08,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA MAXBARR 4FR 55CM S1294108PD,SUP-2632814,CDM,C1751,HCPCS,0278,RC,,,,both,,,878.42,570.97,,,,,,,,,,,,,
SLEEVE TROCAR L110MM DIAMETER 10MM THREADED DISPOSABLE WITH,SUP-2804744,CDM,2720000010,LOCAL,0272,RC,,,,both,,,671.74,436.63,,,,,,,,,,,,,
HC So Clot Factor Fletcher Fac,PX-3058529266,CDM,85292,CPT,0305,RC,,,,both,,,206.00,133.90,,,,,,,,,,,,,
CATHETER HD PRECRV 11.5 FRX12 CM DL W/ 2 SUTURE WNG DUOFLO,SUP-2627379,CDM,C1752,HCPCS,0278,RC,,,,both,,,36.14,23.49,,,,,,,,,,,,,
PLATE BNE CHIN 8 MM ORTHOGNATHIC GENIOPLASTY FOR SCR TI,SUP-2468183,CDM,C1713,HCPCS,0278,RC,,,,both,,,580.37,377.24,,,,,,,,,,,,,
SLEEVE TIB XSM THK40MM KNEE TI REGENEREX,SUP-2407891,CDM,C1776,CPT,0278,RC,,,,both,,,2110.08,1371.55,,,,,,,,,,,,,
GRAFT BNE SUB 16MM WDG SUBTUBULAR FOR DISTR ARTH,SUP-2321683,CDM,C1713,HCPCS,0278,RC,,,,both,,,10022.88,6514.87,,,,,,,,,,,,,
PORT INFUS IV APHERESIS CATH 9.6FR ATTCH POLYUR AIRGUARD,SUP-2125652,CDM,C1788,HCPCS,0278,RC,,,,both,,,1962.50,1275.62,,,,,,,,,,,,,
CATHETER GUID SOFIA L 115 CM DIA 6 FR ID 0.070 IN OD 0.082,SUP-2305417,CDM,C1887,HCPCS,0272,RC,,,,both,,,7253.40,4714.71,,,,,,,,,,,,,
HC So Hla Class II Typing Ea,PX-3108138266,CDM,81382,CPT,0310,RC,,,,both,,,203.00,131.95,,,,,,,,,,,,,
SET URET STENT C FLX L 6 CM CATH L 70 CM DIA 3.7 FR,SUP-2171309,CDM,C2617,HCPCS,0278,RC,,,,both,,,453.67,294.89,,,,,,,,,,,,,
SYSTEM OCCL DEL SHTH 9FR L80CM OD3.81MM ID3MM TIP 45DEG S,SUP-2355737,CDM,C1894,HCPCS,0272,RC,,,,both,,,2152.03,1398.82,,,,,,,,,,,,,
CROWN DENT 4 S STL PRI ANTR UP RT CTRL PREFABRICATED,SUP-2100354,CDM,D6783,CPT,0278,RC,,,,both,,,28.76,18.69,,,,,,,,,,,,,
SHEATH INTRO PERFRMR L 13 CM OD 7 FR ID 2.3 MM GUIDEWIRE,SUP-2168418,CDM,C1894,HCPCS,0272,RC,,,,both,,,89.18,57.97,,,,,,,,,,,,,
CATHETER INFUSION PULSE SPRY L 135 CM DIA 3 FR SLT PAT L 20,SUP-2118506,CDM,C1757,HCPCS,0272,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
PIN FIX 4X150 MM FOR TRACTION SS NS STEINMANN,SUP-2905607,CDM,C1713,HCPCS,0278,RC,,,,both,,,141.49,91.97,,,,,,,,,,,,,
CATHETER GUID MINNIE L 150 CM DIA 5 FR SHFT OD/ID PROX,SUP-2383153,CDM,C1887,HCPCS,0272,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
MATRIX BIO L 7 X W 20 CM FISH SKIN DERMAL STD INTACT STRL SINGLE,SUP-2909433,CDM,Q4158,HCPCS,0636,RC,,,,both,,,19565.34,12717.47,,,,,,,,,,,,,
LEAD PACE L52CM INTRO 9FR SIL INSUL TINES FIX IS-1 BPLR CONN,SUP-2356069,CDM,C1779,HCPCS,0275,RC,,,,both,,,1218.32,791.91,,,,,,,,,,,,,
COLLAR CERV H3XL22IN 1 SZ FIT MOST ADJ HK AND LOOP CLSR,SUP-2194445,CDM,L0180,HCPCS,0274,RC,,,,both,,,7.47,4.86,,,,,,,,,,,,,
NAIL IM L380MM DIA8.2MM BLU L FEM TI CANN LOK BEND FOR,SUP-2180349,CDM,C1713,HCPCS,0278,RC,,,,both,,,4180.91,2717.59,,,,,,,,,,,,,
GUIDEWIRE VASC L260CM TIP L5CM 0.25FR STR RND TIP TUNGSTEN,SUP-2420157,CDM,C1769,HCPCS,0272,RC,,,,both,,,549.81,357.38,,,,,,,,,,,,,
GRAFT BNE MAR M CONC,SUP-2163081,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8478.00,5510.70,,,,,,,,,,,,,
STAPLER INT LN REINF DRY VERIT CLLGN MTRX PSD 6 FIRING,SUP-2130284,CDM,C9354,HCPCS,0278,RC,,,,both,,,734.19,477.22,,,,,,,,,,,,,
STABILIZER SURG FOR NEUROFORM 3 CATH,SUP-2368105,CDM,C1874,HCPCS,0278,RC,,,,both,,,3720.90,2418.58,,,,,,,,,,,,,
TUBE TRACH NEO L36MM OD6MM ID4MM SIL CUF V NK FLNG BIVONA,SUP-2352445,CDM,2720000010,LOCAL,0272,RC,,,,both,,,597.10,388.11,,,,,,,,,,,,,
MATRIX BIO L 10 X W 7 CM FISH SKIN DERMAL FEN INTACT STRL,SUP-2909285,CDM,Q4158,HCPCS,0636,RC,,,,both,,,12974.48,8433.41,,,,,,,,,,,,,
COIL NEUROVASCULAR COSMOS 10 L 2 CM LOOP DIA2 MM,SUP-2305321,CDM,C1889,HCPCS,0278,RC,,,,both,,,4998.88,3249.27,,,,,,,,,,,,,
PASSER SUT L48IN 70DEG ANG UP 1 MFIL SHUTTLE ST DISP FOR,SUP-2341714,CDM,2720000010,LOCAL,0272,RC,,,,both,,,446.07,289.95,,,,,,,,,,,,,
CATHETER DIL BLLN L16MM DIA7MM HI PERF SFT TIP SMOOTH PASS,SUP-2106322,CDM,C1726,HCPCS,0272,RC,,,,both,,,490.47,318.81,,,,,,,,,,,,,
MICROCATHETER INFUSION PROGREAT ALPHA L 110 CM DIA2.7 FR,SUP-2385150,CDM,C1887,HCPCS,0272,RC,,,,both,,,1045.62,679.65,,,,,,,,,,,,,
ALLOGRAFT BNE 8.5X240 MM ANTR TIBIALIS,SUP-2866874,CDM,C1762,CPT,0278,RC,,,,both,,,4435.72,2883.22,,,,,,,,,,,,,
SCREW SPNL MULTAXL 4.5X30 MM CANN FOR 4.5 MM ROD SHILLA,SUP-2630591,CDM,C1713,HCPCS,0278,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
ALLOGRAFT BNE SHT 25X20X5 MM CANC CONFORM Q-PACK,SUP-2737083,CDM,C1713,HCPCS,0278,RC,,,,both,,,3296.22,2142.54,,,,,,,,,,,,,
SUPPORT ANK TRICOT 7.75-8.5 IN SM VLY PROCARE DLX,SUP-2195733,CDM,L4350,HCPCS,0274,RC,,,,both,,,33.54,21.80,,,,,,,,,,,,,
DISTRACTION EXTRNL HRZNTL CROSS BAR ASSEMB RED 2 CMPLTE BLCK,SUP-2681287,CDM,C1713,HCPCS,0278,RC,,,,both,,,5132.58,3336.18,,,,,,,,,,,,,
PLATE BNE CRESCENT 1.25 MM 2X2 HOLE TI NS MATRIXMANDIBLE,SUP-2181767,CDM,C1713,HCPCS,0278,RC,,,,both,,,1773.79,1152.96,,,,,,,,,,,,,
SCREW BNE CRTX 2.4X12 MM PLUSDRIVE RECESS LCK CRUCFRM STRL,SUP-2569984,CDM,C1713,HCPCS,0278,RC,,,,both,,,62.17,40.41,,,,,,,,,,,,,
COLLAR CERV M H3XL17IN COT M DENS FOAM BRTH ADJ LO-CONTOUR,SUP-2335996,CDM,L0180,HCPCS,0274,RC,,,,both,,,12.21,7.94,,,,,,,,,,,,,
BRACE WRIST/THUMB AD L7IN UNIV LT SFT IMMOB JT LACE STAY,SUP-2324010,CDM,L3931,HCPCS,0274,RC,,,,both,,,31.27,20.33,,,,,,,,,,,,,
SHEET THERMOPLASTIC W18XL24IN THK0.09IN STD CHAR SLD SPLNT,SUP-2323989,CDM,L4350,HCPCS,0272,RC,,,,both,,,156.97,102.03,,,,,,,,,,,,,
SCREW BONE L70MM OD5.5MM CORT SLD FULL THRD STRL,SUP-2413183,CDM,C1713,HCPCS,0278,RC,,,,both,,,540.36,351.23,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY L 110CM 5FR TIP 1MM PED FIX A CRV,SUP-2248875,CDM,C1730,HCPCS,0272,RC,,,,both,,,1055.04,685.78,,,,,,,,,,,,,
DISSECTOR DBL END,SUP-2319920,CDM,C1713,HCPCS,0278,RC,,,,both,,,593.46,385.75,,,,,,,,,,,,,
PLATE BNE L THK0.3MM STD UNIV CRANIOMAXILLOFACIAL TI COMPLX,SUP-2366221,CDM,C1713,HCPCS,0278,RC,,,,both,,,2751.30,1788.34,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY LASSOSTAR NAV L 115 CM DIA 4 FR,SUP-2530193,CDM,C1732,HCPCS,0278,RC,,,,both,,,4939.22,3210.49,,,,,,,,,,,,,
PIN EXT FIX ARTC BAR OFFSET CONVERGING TOMAHAWK MINI FIX,SUP-2400613,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1114.70,724.55,,,,,,,,,,,,,
BLADE OPHTH SZ 0.8 MM GONIOTOMY 2 TRAPEZOIDAL SERRATED,SUP-2881876,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1409.86,916.41,,,,,,,,,,,,,
URETEROSCOPE RIGID ASPIR SYS STRL DISP CVAC  MIN ORDER 2BX,SUP-2904956,CDM,C1747,HCPCS,0272,RC,,,,both,,,10974.30,7133.29,,,,,,,,,,,,,
MESH CRAN L 190 X W 140 MM THK 0.6 MM SCREW DIA1.5/1.7 MM XL,SUP-2883534,CDM,C1713,HCPCS,0278,RC,,,,both,,,57009.75,37056.34,,,,,,,,,,,,,
ENDO FUSE  FUSION ROD 3 X 50MM,SUP-2464055,CDM,C1713,HCPCS,0278,RC,,,,both,,,4016.06,2610.44,,,,,,,,,,,,,
BOLT 7.0X40 SHT POST TIX0207088,SUP-2293711,CDM,C1713,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
Z DUP USE 2355961 ADAPTER PACE L60CM LD SGL 8 EXTN,SUP-2356743,CDM,C1883,HCPCS,0278,RC,,,,both,,,1868.30,1214.39,,,,,,,,,,,,,
GRAFT HUM TISS W4XL12CM THK0.75-1.50MM DERM DECELLULARIZED,SUP-2264717,CDM,Q4122,HCPCS,0636,RC,,,,both,,,4253.32,2764.66,,,,,,,,,,,,,
STAPLER INT VASC 45 MM TI,SUP-2395622,CDM,2720000010,LOCAL,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
POR ST/OSS CP/LG E1 LN/LG HD,SUP-2212416,CDM,C1776,CPT,0278,RC,,,,both,,,18526.00,12041.90,,,,,,,,,,,,,
VALVE AORT CARP EDW PERIMT MAGNA MT OD 25 MM ID 24 MM SEW,SUP-2214107,CDM,C1713,HCPCS,0278,RC,,,,both,,,18212.00,11837.80,,,,,,,,,,,,,
GUIDEWIRE VASC PNS L 145 CM DIA 0.035 IN TIP L 3 MM PTFE J,SUP-2429610,CDM,C1769,HCPCS,0272,RC,,,,both,,,5.71,3.71,,,,,,,,,,,,,
GRAFT DERMAL RECT 40X20 CM REGENERATIVE CLLGN MTRX XENMATRIX,SUP-2126243,CDM,C1781,HCPCS,0278,RC,,,,both,,,74385.97,48350.88,,,,,,,,,,,,,
MESH CRAN W7.5XL11CM THK.6MM SHFT L4MM TI PLATING GRID,SUP-2277534,CDM,C1781,HCPCS,0278,RC,,,,both,,,1645.36,1069.48,,,,,,,,,,,,,
HC So2 Alpha Fetoprotein|NOT REASONABLE AND NECESSARY,PX-3018210568,CDM,82105,CPT,0301,RC,,,GZ,outpatient,,,163.00,105.95,,,,,,,,,,,,,
CATHETER EMB FOGARTY L 60 CM DIA2 FR DIA 4 MM FLAT PK PUR,SUP-2214580,CDM,C1757,HCPCS,0272,RC,,,,both,,,263.76,171.44,,,,,,,,,,,,,
IMPLANT SPCR ARTELON ARTH,SUP-2120682,CDM,C1776,CPT,0278,RC,,,,both,,,6437.00,4184.05,,,,,,,,,,,,,
BUR REPROC SHV 4MM ABRADER ELITE AQUA,SUP-2652934,CDM,2720000010,LOCAL,0272,RC,,,,both,,,102.21,66.44,,,,,,,,,,,,,
CATHETER EMB FOGARTY L 80 CM DIA 4 FR BALLOON DIA 9 MM,SUP-2214009,CDM,C1757,HCPCS,0272,RC,,,,both,,,97.50,63.37,,,,,,,,,,,,,
NAIL IM L26CM DIA8.5MM TIB KNEE GRY TI CANN LCK RG BEND,SUP-2347073,CDM,C1713,HCPCS,0278,RC,,,,both,,,3906.95,2539.52,,,,,,,,,,,,,
GUIDEWIRE VASC L 180 CM 0.025 IN L 7 CM FLPY TIP 2CM STR TIP,SUP-2638694,CDM,C1769,HCPCS,0272,RC,,,,both,,,32.44,21.09,,,,,,,,,,,,,
MESH PLUG PERFIX LT 1 IN X 1.4 IN SM,SUP-2125786,CDM,C1781,HCPCS,0278,RC,,,,both,,,483.56,314.31,,,,,,,,,,,,,
GRAFT TISS FRZN ALLGRFT FEM PROX W O HD L,SUP-2307311,CDM,C1713,HCPCS,0278,RC,,,,both,,,11101.72,7216.12,,,,,,,,,,,,,
PIN FIX AXIS STD GMRS,SUP-2452012,CDM,C1776,CPT,0278,RC,,,,both,,,2355.47,1531.06,,,,,,,,,,,,,
BUR ENDOSCP SHAVER 60 DEG SHFT DIA 4 MM ENT CRV DBL SERRATED,SUP-2885540,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1491.50,969.47,,,,,,,,,,,,,
HC US OB 1st Tr Fetal Translu Sgl,PX-4027681300,CDM,76813,CPT,0402,RC,,,,both,,,806.00,523.90,,,,,,,,,,,,,
GRAFT BNE SUB 5ML HA FAST SET PTTY FILL BNE VOID CA PHSPTE,SUP-2194288,CDM,C9359,HCPCS,0278,RC,,,,both,,,4660.07,3029.05,,,,,,,,,,,,,
GRAFT BONE 0.5-3MM 90ML CORT CANC CRUSH CHIP FRZN,SUP-2294137,CDM,C1713,HCPCS,0278,RC,,,,both,,,2995.56,1947.11,,,,,,,,,,,,,
SET INT FIX SCREW DIA1.5 MM 6 H LNG TI NEURO STR PLT 1 PK,SUP-2935383,CDM,C1713,HCPCS,0278,RC,,,,both,,,1755.26,1140.92,,,,,,,,,,,,,
COIL VASC NEST EMBOLUS L 7 CM DIA 4 MM STD SFT HELCL,SUP-2604641,CDM,C1889,HCPCS,0278,RC,,,,both,,,226.08,146.95,,,,,,,,,,,,,
COLLAR CERV SFT 375X21IN XL,SUP-2276588,CDM,L0120,HCPCS,0272,RC,,,,both,,,6.19,4.02,,,,,,,,,,,,,
ALLOGRAFT BNE CHIP 1-4 MM 15 CC FRZN CRUSH CANC,SUP-2743354,CDM,C1713,HCPCS,0278,RC,,,,both,,,1563.72,1016.42,,,,,,,,,,,,,
PACK VITRECTOMY DIA25 GA SURG PROC,SUP-2905473,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1959.36,1273.58,,,,,,,,,,,,,
CATHETER EP DIAG MAP M CRV OCTAPOLAR 2-5-2MM SPC 2MM TIP,SUP-2356864,CDM,C1730,HCPCS,0272,RC,,,,both,,,1949.94,1267.46,,,,,,,,,,,,,
PLATE BNE LG TI MIDFACE 3D PRNT NS DISP ACCUPLATE,SUP-2934723,CDM,C1713,HCPCS,0278,RC,,,,both,,,38920.30,25298.19,,,,,,,,,,,,,
SCREW BONE L48MM HDLSS MIS,SUP-2201525,CDM,C1713,HCPCS,0278,RC,,,,both,,,232.67,151.24,,,,,,,,,,,,,
DISC INTERVERTEBRAL W16XH7MM D14MM CERV CO CHROM MOLYBDENUM,SUP-2231424,CDM,C1889,HCPCS,0278,RC,,,,both,,,10990.00,7143.50,,,,,,,,,,,,,
SCREW BONE L74MM OD7MM THRD L17MM PUR HINDFOOT ANK CANN SH,SUP-2320951,CDM,C1713,HCPCS,0278,RC,,,,both,,,2724.42,1770.87,,,,,,,,,,,,,
PLATE BNE L 153 MM SCREW DIA2 MM 20 SHFT H SS ADPT COMB VA,SUP-2907742,CDM,C1713,HCPCS,0278,RC,,,,both,,,4007.52,2604.89,,,,,,,,,,,,,
PROSTHESIS OSS 2.25-5.6 MM 1.5X2.5 MM OFFSET NANO HA TI SIL,SUP-2473607,CDM,L8613,CPT,0278,RC,,,,both,,,1223.56,795.31,,,,,,,,,,,,,
SYSTEM FIX FEM 10X20 MM TI RETROSCREW,SUP-2849260,CDM,C1713,HCPCS,0278,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
PLATE BNE TI MIDFACE RECON 3 PLATE CUSTOMIZED FACE ID,SUP-2883366,CDM,C1713,HCPCS,0278,RC,,,,both,,,36204.26,23532.77,,,,,,,,,,,,,
BROACH SM/M 3S HEMI,SUP-2390489,CDM,2720000010,LOCAL,0272,RC,,,,both,,,816.40,530.66,,,,,,,,,,,,,
CLIP ENDOSCP L165CM NIT PT PRELD HND WHL MOD 11/6T,SUP-2319929,CDM,C1889,HCPCS,0278,RC,,,,both,,,1598.26,1038.87,,,,,,,,,,,,,
ALLOGRAFT BNE W/O HD WHL FEM,SUP-2321807,CDM,C1713,HCPCS,0278,RC,,,,both,,,12123.54,7880.30,,,,,,,,,,,,,
BIT DRL CANN 4.5X233 MM 130 MM QC JCBS CHK SS STRL DISP,SUP-2187343,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1220.24,793.16,,,,,,,,,,,,,
SCALPEL SURG CRV 10 MM FOR HRD TISS REMOVAL SIL DISP,SUP-2305939,CDM,C1713,HCPCS,0278,RC,,,,both,,,1257.57,817.42,,,,,,,,,,,,,
DEVICE SUTURING CUF OPUS AUTO,SUP-2342055,CDM,2720000010,LOCAL,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
HEAD FEM DIA28MM NK L+0MM STD CO CHROM V40 TAPR PRI LFIT 62645128] STRYKER CORP],SUP-2364465,CDM,C1776,CPT,0278,RC,,,,both,,,1046.25,680.06,,,,,,,,,,,,,
TIRE SCLER OD7MM ID2.5MM SIL CNVX SYMMETRICAL STYL,SUP-2213479,CDM,L8610,HCPCS,0278,RC,,,,both,,,70.96,46.12,,,,,,,,,,,,,
COMPONENT ARTC L35MM 8X8MM OFFSET FEM HD CO CHROM ALLOY,SUP-2123650,CDM,C1776,CPT,0278,RC,,,,both,,,19939.00,12960.35,,,,,,,,,,,,,
TAP SURG 3.5MM STD THRD MTL TIP SYM,SUP-2433921,CDM,2720000010,LOCAL,0272,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
CATHETER NEPHSTMY 10FR L19.5CM CANN COPE LOOP,SUP-2167498,CDM,C1729,HCPCS,0272,RC,,,,both,,,422.96,274.92,,,,,,,,,,,,,
GUIDEPIN ORTH L300MM DIA1.9MM CO CHROM FULL THRD,SUP-2343574,CDM,2720000010,LOCAL,0272,RC,,,,both,,,328.95,213.82,,,,,,,,,,,,,
ANCHOR SUTURE 2-0 2.9 MM WHT COBRAID BLU OSTEORAPTOR,SUP-2434528,CDM,C1713,HCPCS,0278,RC,,,,both,,,943.60,613.34,,,,,,,,,,,,,
ZIDOVUDINE 10 MG/ML PO SYRP,RX-11693,CDM,340b,HCPCS,0637,RC,49702-0212-48,NDC,,both,10,ML,12.20,7.93,,,,,,,,,,,,,
PLATE BNE W11XL136MM THK4.2MM 9 H MTPHSEAL S STL LOK COMPR,SUP-2185262,CDM,C1713,HCPCS,0278,RC,,,,both,,,2514.48,1634.41,,,,,,,,,,,,,
ALLOGRAFT BNE COTTON WDG 22X16X10 MM FD STRL LF DISP,SUP-2461017,CDM,C1889,HCPCS,0278,RC,,,,both,,,2388.76,1552.69,,,,,,,,,,,,,
DEFIBRILLATOR IMPL TELIGEN W 6.17 X H 7.45 CM D 0.99 CM 31.5,SUP-2149195,CDM,C1721,HCPCS,0275,RC,,,,both,,,47728.00,31023.20,,,,,,,,,,,,,
STEM HUM MOD STD 10X120 MM SHLDR COCR POROUS GLOB FX,SUP-2249924,CDM,C1776,CPT,0278,RC,,,,both,,,8478.00,5510.70,,,,,,,,,,,,,
COIL NEUROVASCULAR TARGET XL 360 DEG L 15 CM DIA 5 MM,SUP-2368047,CDM,C1889,HCPCS,0278,RC,,,,both,,,8286.46,5386.20,,,,,,,,,,,,,
AIRWAY ESOPH 1.5 INF LMA PROSEAL LF REUSE,SUP-2383623,CDM,2720000010,LOCAL,0272,RC,,,,both,,,856.59,556.78,,,,,,,,,,,,,
HC So Ab Toxoplasma,PX-3028677766,CDM,86777,CPT,0302,RC,,,,both,,,190.00,123.50,,,,,,,,,,,,,
PLATE BNE RECON 3.5X70 MM 6 HOLE SS,SUP-2569081,CDM,C1713,HCPCS,0278,RC,,,,both,,,352.31,229.00,,,,,,,,,,,,,
STAPLE BNE FIX BRDG W12MM LEG L12X15MM WIRE DIA1.5X1.5MM S,SUP-2194216,CDM,C1713,HCPCS,0278,RC,,,,both,,,894.90,581.68,,,,,,,,,,,,,
EXTRACTOR STONE TIPLSS 4.5 FRX65 CM NIT NCIRCLE,SUP-2835756,CDM,2720000010,LOCAL,0272,RC,,,,both,,,509.31,331.05,,,,,,,,,,,,,
BIT DRILL TWIST 2.7 QUICK COUPLING SCALED,SUP-2713858,CDM,2720000010,LOCAL,0272,RC,,,,both,,,826.61,537.30,,,,,,,,,,,,,
CATHETER INTVASC OCCL FOGARTY L 80 CM DIA 8 FR BALLOON DIA,SUP-2214271,CDM,C2628,HCPCS,0272,RC,,,,both,,,698.59,454.08,,,,,,,,,,,,,
KIT REP OD135FR RED LEG 2 LUMN CATHETER ETERS HCKMN,SUP-2126565,CDM,C1751,HCPCS,0278,RC,,,,both,,,420.76,273.49,,,,,,,,,,,,,
KIT DISP RETACTOR SYS SERENGETINO 484-4507-1 MINIMALLY,SUP-2258075,CDM,C1713,HCPCS,0278,RC,,,,both,,,2731.80,1775.67,,,,,,,,,,,,,
KIT BAL DISECT KII LO PROF OVL 5MMX55MM,SUP-2418457,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1130.40,734.76,,,,,,,,,,,,,
MATRIX BIO L 10 X W 18 CM SZ 180 SQCM FISH SKIN SIL DERMAL,SUP-2909215,CDM,Q4158,HCPCS,0636,RC,,,,both,,,19116.32,12425.61,,,,,,,,,,,,,
HC Rp Loclzj Tumor/Dstrbj Agent Tomog Spect,PX-3417883100,CDM,78831,CPT,0341,RC,,,,both,,,2681.00,1742.65,,,,,,,,,,,,,
VALVE AORT KONECT RESILIA TISS ANNULUS 29 MM SEW RNG DIA 40,SUP-2624864,CDM,C1889,HCPCS,0278,RC,,,,both,,,47100.00,30615.00,,,,,,,,,,,,,
MICROSPHERE EMB CNTOUR DIA 900-1200 UM 2 ML PVA,SUP-2140326,CDM,C1889,HCPCS,0278,RC,,,,both,,,805.10,523.31,,,,,,,,,,,,,
GRAFT BONE 5MM SPCR LORDTC MAINTAIN ALLGRFT,SUP-2232324,CDM,C1889,HCPCS,0278,RC,,,,both,,,2323.60,1510.34,,,,,,,,,,,,,
HEAD FEM PRI CERAMIC ON CERAMIC ZIRCONIA 32MM DIA +0 NK LEN,SUP-2211114,CDM,C1776,CPT,0278,RC,,,,both,,,6301.98,4096.29,,,,,,,,,,,,,
BRACE ORTHOPEDIC TLSO LUMBAR S/C SHELL/PANEL PREFABRICATED,SUP-2265012,CDM,L0450,HCPCS,0274,RC,,,,both,,,4998.88,3249.27,,,,,,,,,,,,,
BOOT AMBULTNG BOOT ADL DKBLU,SUP-2272967,CDM,L4397,HCPCS,0274,RC,,,,both,,,170.50,110.82,,,,,,,,,,,,,
BRACE WR RT INSTABILITY INJ LACE AD SM,SUP-2197946,CDM,L3809,HCPCS,0272,RC,,,,both,,,40.82,26.53,,,,,,,,,,,,,
BRACE WRST SUPP LG 7.5-8.5 IN RT STABILIZING,SUP-2196519,CDM,L3931,HCPCS,0272,RC,,,,both,,,26.72,17.37,,,,,,,,,,,,,
HC So Hepatitis B Core Antibody,PX-3028670466,CDM,86704,CPT,0302,RC,,,,outpatient,,,59.00,38.35,,,,,,,,,,,,,
PLATE BNE L227MM THK3MM 12 H BILAT S STL STR LOK COMPR RECON,SUP-2185347,CDM,C1713,HCPCS,0278,RC,,,,both,,,1854.39,1205.35,,,,,,,,,,,,,
POTASSIUM ACETATE 2 MEQ/ML IV SOLN,RX-6420,CDM,2500000003,HCPCS,0250,RC,00409-3294-51,NDC,,both,50,ML,64.40,41.86,,,,,,,,,,,,,
CAGE SPNL BULLETED 10 DEG 50X22X9 MM COROENT XLW,SUP-2557538,CDM,C1889,HCPCS,0278,RC,,,,both,,,13982.42,9088.57,,,,,,,,,,,,,
HC Herpes Virus-6 Direct Probe,PX-3018753200,CDM,87532,CPT,0301,RC,,,,both,,,89.00,57.85,,,,,,,,,,,,,
COMPONENT TIB SZ 3 CH AP43MM ML67MM H10MM UNIV KNEE YEL,SUP-2200664,CDM,C1776,CPT,0278,RC,,,,both,,,4239.00,2755.35,,,,,,,,,,,,,
BLADE SURG DISP KOBYGARD,SUP-2319776,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3303.28,2147.13,,,,,,,,,,,,,
STENT CORONARY ABSORB GT1 L 8 MM DIA2.5 MM PLLA PDLLA,SUP-2105648,CDM,C1874,HCPCS,0278,RC,,,,both,,,2433.50,1581.77,,,,,,,,,,,,,
CATHETER ANGIOPLSTY FLSH MINI L 135 CM BALLOON L 8 MM DIA 3,SUP-2319852,CDM,C1713,HCPCS,0278,RC,,,,both,,,3921.86,2549.21,,,,,,,,,,,,,
PLATE BNE W12XL183MM THK1MM 11 H BILAT S STL SEMI TBLR LO,SUP-2184872,CDM,C1713,HCPCS,0278,RC,,,,both,,,905.07,588.30,,,,,,,,,,,,,
BASKET POLYP RETRV L6CM OD3CM CATH L240CM OD7FR 2.8MM MIN,SUP-2171320,CDM,2720000010,LOCAL,0272,RC,,,,both,,,832.10,540.86,,,,,,,,,,,,,
ROD SPNL 3.5 MMX8 CM TI,SUP-2414630,CDM,C1713,HCPCS,0278,RC,,,,both,,,671.96,436.77,,,,,,,,,,,,,
KIT CATH HEMODIALYSI HEMOSPLIT XK CHRONIC MICROINTRO 5693270,SUP-2632961,CDM,C1750,HCPCS,0278,RC,,,,both,,,1694.66,1101.53,,,,,,,,,,,,,
RING EXT FIX 3/4 210 MM MONOTUBE,SUP-2462892,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1769.39,1150.10,,,,,,,,,,,,,
SHEATH INTRO BAN PEEL L 30 CM DIA12 FR STRL,SUP-2141073,CDM,C1894,HCPCS,0272,RC,,,,both,,,160.08,104.05,,,,,,,,,,,,,
SYSTEM SHUNT W/ BA STRIPE PERITONEAL CATH 120CM W/ DRAINAGE,SUP-2666831,CDM,C1729,HCPCS,0272,RC,,,,both,,,1953.43,1269.73,,,,,,,,,,,,,
PLATE BONE RT VOLAR DSTL RAD S STL FOR 2.4/2.7MM 1.8MM BTTRS,SUP-2186098,CDM,C1713,HCPCS,0278,RC,,,,both,,,2339.93,1520.95,,,,,,,,,,,,,
MARKER BRST BX L12CM 18GA NIT Q SHP INTRO FREE HND TUMARK,SUP-2239915,CDM,A4648,CPT,0278,RC,,,,both,,,226.08,146.95,,,,,,,,,,,,,
STEM FEM PRESS FIT DUAL MORSE 65001105] ENCORE MEDICAL - DJO SURGICAL],SUP-2217406,CDM,C1776,CPT,0278,RC,,,,both,,,8578.48,5576.01,,,,,,,,,,,,,
SLEEVE DRL SZ 5MM CODE GRN DISP TRUKOR,SUP-2341081,CDM,2720000010,LOCAL,0272,RC,,,,both,,,907.46,589.85,,,,,,,,,,,,,
RING EXT FIX 160 MM HINDFOOT W/ H SALVATION,SUP-2846118,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2207.42,1434.82,,,,,,,,,,,,,
TRAY CATH HEMODIALYSI BREVIA ACUTE 11FR DIA 15CML IN 5496150,SUP-2632895,CDM,C1752,HCPCS,0278,RC,,,,both,,,592.52,385.14,,,,,,,,,,,,,
BAR REDUCER EXTN NS OSCAR 3 LTX,SUP-2875729,CDM,2720000010,LOCAL,0272,RC,,,,both,,,954.56,620.46,,,,,,,,,,,,,
NAIL IM TIB UNIV 10 MMX42 CM TI NAT NAIL,SUP-2461339,CDM,C1713,HCPCS,0278,RC,,,,both,,,4864.24,3161.76,,,,,,,,,,,,,
CATHETER HD STR AD 15.5 FRX55 CM LT DL VASCPAK KT DURAFLO 2,SUP-2487490,CDM,C1750,HCPCS,0278,RC,,,,both,,,1004.80,653.12,,,,,,,,,,,,,
IMPL SPNE DB VG-VLAG-0050,SUP-2431580,CDM,C1889,HCPCS,0278,RC,,,,both,,,16767.60,10898.94,,,,,,,,,,,,,
GUIDEWIRE ORTH 83.2X.5 MM FOR RECON LCK NS,SUP-2799279,CDM,C1769,HCPCS,0272,RC,,,,both,,,587.56,381.91,,,,,,,,,,,,,
BRACE WR RT INSTABILITY INJ LACE AD SM,SUP-2197946,CDM,L3809,HCPCS,0274,RC,,,,both,,,40.82,26.53,,,,,,,,,,,,,
GRAFT BNE GRAN 1-6 MM 30 CC CANC BI-OSTETIC,SUP-2134725,CDM,C1889,HCPCS,0278,RC,,,,both,,,8336.70,5418.85,,,,,,,,,,,,,
MESH HERN CIR 8 IN W/ ECHO2 POS SYS POLYPR PHASIX ST,SUP-2855261,CDM,C1781,HCPCS,0278,RC,,,,both,,,21992.56,14295.16,,,,,,,,,,,,,
LINER ACET L60MM NEUT LO PROF CANC ESCALADE,SUP-2315279,CDM,C1713,HCPCS,0278,RC,,,,both,,,276.32,179.61,,,,,,,,,,,,,
IMPLANT FIX 2 TETHERED TWINLOCK,SUP-2342081,CDM,C1776,CPT,0278,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
PACEMAKER CRD SINGLE CHAMBERED CLOSED LOOP EVIA SR-T,SUP-2138087,CDM,C1786,HCPCS,0275,RC,,,,both,,,15574.40,10123.36,,,,,,,,,,,,,
PLATE BNE SPCR 3MM 4 H NONSTERILE MIDFOOT TI VAR ANG LOK OPN,SUP-2181214,CDM,C1713,HCPCS,0278,RC,,,,both,,,3294.65,2141.52,,,,,,,,,,,,,
GRAFT NRV L30MM DIA2-3MM PERIPH NAT CONN CBL PROC FOR RECON,SUP-2124849,CDM,C1762,CPT,0278,RC,,,,both,,,14035.80,9123.27,,,,,,,,,,,,,
PLATE BNE T 2X3 HOLE COMPR NS LTX,SUP-2855828,CDM,C1713,HCPCS,0278,RC,,,,both,,,351.68,228.59,,,,,,,,,,,,,
GRAFT BNE 20CC W/ BIOACTIVE GLS MOLD MTRX PLATFORM,SUP-2719784,CDM,C1713,HCPCS,0278,RC,,,,both,,,22765.00,14797.25,,,,,,,,,,,,,
OSTEOTOME SURG L93MM DIA12MM FLX ERGO HNDL CANN TREPH GRY,SUP-2375017,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1136.05,738.43,,,,,,,,,,,,,
DRILL SURG CRTX 3.2 MM PROX QR NS LTX,SUP-2855985,CDM,2720000010,LOCAL,0272,RC,,,,both,,,427.04,277.58,,,,,,,,,,,,,
POST EXT FIX 2 H FOR SIDEKCK FREE CIR FIX M,SUP-2400669,CDM,2720000010,LOCAL,0272,RC,,,,both,,,279.46,181.65,,,,,,,,,,,,,
HC So Cytopath C/V Auto Fluid Redo,PX-3118817566,CDM,88175,CPT,0311,RC,,,,both,,,36.00,23.40,,,,,,,,,,,,,
DISSECTOR DIERKS 2 LNG 18.5CM7 1/4IN,SUP-2495024,CDM,2720000010,LOCAL,0272,RC,,,,both,,,561.81,365.18,,,,,,,,,,,,,
FOOTPLATE EXT FIX D 180 MM RX STRL TRUELOK EVO LTX,SUP-2875618,CDM,2720000010,LOCAL,0272,RC,,,,both,,,15233.52,9901.79,,,,,,,,,,,,,
DRILL SURG KATSUYA 2 MM STRL LTX DISP,SUP-2860992,CDM,2720000010,LOCAL,0272,RC,,,,both,,,485.13,315.33,,,,,,,,,,,,,
DEVICE INFL PRSS G INDIC DISP,SUP-2106379,CDM,C1726,HCPCS,0272,RC,,,,both,,,46.82,30.43,,,,,,,,,,,,,
HC Fna WO Imaging Guidance,PX-4501002100,CDM,10021,CPT,0450,RC,,,,both,,,1531.00,995.15,,,,,,,,,,,,,
CATHETER ANGIOPLSTY OTW 035IN 6FRX80CM 8X40MM ADMIRAL XTREME,SUP-2280424,CDM,C1725,HCPCS,0272,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
POST SURG CANN CONN FOR 2.5 MM WIRE NS,SUP-2863400,CDM,2720000010,LOCAL,0272,RC,,,,both,,,427.70,278.00,,,,,,,,,,,,,
BUR SURGICAL PEDIATRIC SMALL L13MM TITANIUM WITH SUTURE FIXA,SUP-2825577,CDM,2720000010,LOCAL,0272,RC,,,,both,,,393.38,255.70,,,,,,,,,,,,,
SET SCR SPNL L35MM DIA5.2MM PEDCL HA TI ALLOY FOR DYN STBL,SUP-2414473,CDM,C1713,HCPCS,0278,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
TRAY CATH HEMODIALYSI DUOGLIDE ACUTE 13FR DIA 12.5CML INSER,SUP-2613243,CDM,C1752,HCPCS,0278,RC,,,,both,,,885.35,575.48,,,,,,,,,,,,,
PLATE BNE L MINI REG 2-2.5X1 MM RT LCK SMRT TI LEVEL 1,SUP-2485992,CDM,C1713,HCPCS,0278,RC,,,,both,,,1495.83,972.29,,,,,,,,,,,,,
HC Joint Injection/Aspir Large WO US|BILATERAL PROCEDURE,PX-5102061000,CDM,20610,CPT,0510,RC,,,50,outpatient,,,1092.00,709.80,,,,,,,,,,,,,
PACEMAKER CRD 52X42X6 MM 11 CC 23 GM TI VERITY ADX XL SR,SUP-2357330,CDM,C1786,HCPCS,0275,RC,,,,both,,,13502.00,8776.30,,,,,,,,,,,,,
SET URET STENT C FLX L 20 CM CATH L 70 CM DIA 3.7 FR,SUP-2171230,CDM,C2617,HCPCS,0278,RC,,,,both,,,632.71,411.26,,,,,,,,,,,,,
METHOTREXATE SODIUM (PF) 1 GM/40ML IJ SOLN,RX-117356,CDM,J9260,HCPCS,0636,RC,61703-0408-41,NDC,,both,40,ML,105.80,68.77,,,,,,,,,,,,,
GRAFT HUM TISS XL 9X9CM DEHYDR AMNION CHORION MEM EPIFIX,SUP-2305765,CDM,Q4186,HCPCS,0636,RC,,,,both,,,19546.53,12705.24,,,,,,,,,,,,,
PLATE BNE THK 2.8 MM SM DBL ANGLE STR NS DISP TRAUMAONE,SUP-2937019,CDM,C1713,HCPCS,0278,RC,,,,both,,,10095.10,6561.81,,,,,,,,,,,,,
DRILL SURG L4.5MM FT CANN FOR MOV GREAT TOE SYS,SUP-2244013,CDM,2720000010,LOCAL,0272,RC,,,,both,,,820.51,533.33,,,,,,,,,,,,,
SCREW INTFR L20MM DIA2.7MM PLLA BIOCOMPRESSION,SUP-2121889,CDM,C1713,HCPCS,0278,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
SUPPORT ORTHOT ANK KNEE CUST MULTILIGAMENTOUS PREFABRICATED,SUP-2435624,CDM,L1906,HCPCS,0274,RC,,,,both,,,318.33,206.91,,,,,,,,,,,,,
STAPLER INT DIA5MM 25 ABSRB STRP FIX DISP FOR HERN MESH,SUP-2219935,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1622.12,1054.38,,,,,,,,,,,,,
SCREW BONE SELF TAPPING 2X14 MM LOCKING TITANIUM MATRIXMANDI,SUP-2837733,CDM,C1713,HCPCS,0278,RC,,,,both,,,475.65,309.17,,,,,,,,,,,,,
SCREW BNE L 20 MM DIA 3 MM SHRT TI CANN COMPR STRL DARTFIRE,SUP-2900526,CDM,C1713,HCPCS,0278,RC,,,,both,,,1535.46,998.05,,,,,,,,,,,,,
FORCEPS OPHTH 25GA END GRSP REVOLUTION DISPOSABLE GRIESHABER,SUP-2109693,CDM,C1713,HCPCS,0278,RC,,,,both,,,473.51,307.78,,,,,,,,,,,,,
HEAD FEM DIA28MM +5MM OFFSET 12 14 TAPR HIP MTL BIOLOX FORTE,SUP-2251172,CDM,C1776,CPT,0278,RC,,,,both,,,4623.34,3005.17,,,,,,,,,,,,,
CATHETER ABLATN MED LG CURL 2-5-2 MM 4 MM 7 FRX115 CM,SUP-2356995,CDM,C1733,HCPCS,0272,RC,,,,both,,,2348.69,1526.65,,,,,,,,,,,,,
MINERAL OIL LIGHT OIL,RX-27386,CDM,6370000000,HCPCS,0637,RC,63323-0254-10,NDC,,both,10,ML,196.00,127.40,,,,,,,,,,,,,
SCREW BNE MULT DIRECTION 3.5X12MM T15 COBALT CHROM NS ALPS,SUP-2457271,CDM,C1713,HCPCS,0278,RC,,,,both,,,465.03,302.27,,,,,,,,,,,,,
GRAFT HUM TISS L 6 X W 2 CM AMNION-CHORION-AMNION LAYR,SUP-2909269,CDM,Q4140,HCPCS,0636,RC,,,,both,,,9889.71,6428.31,,,,,,,,,,,,,
HC So Leptospira Ab's,PX-3028672066,CDM,86720,CPT,0302,RC,,,,both,,,375.00,243.75,,,,,,,,,,,,,
HC So Mycobacteria ID by Maldi,PX-3008711866,CDM,87118,CPT,0300,RC,,,,both,,,79.00,51.35,,,,,,,,,,,,,
SCREW BNE CANN 3.5X28 MM HDLSS,SUP-2221502,CDM,C1713,HCPCS,0278,RC,,,,both,,,1055.04,685.78,,,,,,,,,,,,,
LONG CALI DRILL 4.9MM CANN,SUP-2496893,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2173.38,1412.70,,,,,,,,,,,,,
SET INTRO KOLENDA SHTH L 5.5 CM INTRO DIA1.88 MM GUIDEWIRE,SUP-2169480,CDM,C1894,HCPCS,0272,RC,,,,both,,,675.10,438.81,,,,,,,,,,,,,
CATHETER DRAINAGE 2 EYE 38 FR RETENTION HD REINF TIP PEZ,SUP-2126195,CDM,C2627,HCPCS,0272,RC,,,,both,,,63.18,41.07,,,,,,,,,,,,,
GRAFT W7XL10CM ENT REP BIODESIGN,SUP-2170298,CDM,C1763,HCPCS,0278,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
CATHETER CV KT 0.018 IN PEDIATRIC 4 FRX8 CM DL STR SFT TIP,SUP-2763362,CDM,C1751,HCPCS,0278,RC,,,,both,,,387.48,251.86,,,,,,,,,,,,,
GRAFT TISS FRZ DRY FIB WDG ACF 12 22MML 9 13MM 8MM THICKNESS,SUP-2307149,CDM,C1713,HCPCS,0278,RC,,,,both,,,1870.97,1216.13,,,,,,,,,,,,,
CATHETER DRAINAGE FIX LUER 4 FRX12 CM 4 SH 1 STP,SUP-2303158,CDM,C1729,HCPCS,0272,RC,,,,both,,,119.32,77.56,,,,,,,,,,,,,
IMPLANT WRST OD15MM ID7MM CRPL STD HD IMPLABLE MAESTRO,SUP-2407289,CDM,C1776,CPT,0278,RC,,,,both,,,2898.22,1883.84,,,,,,,,,,,,,
GRAFT DURA 4X5 CM SUTURABLE BCNVX BOV PERICARD DURAGN,SUP-2457670,CDM,C1763,HCPCS,0278,RC,,,,both,,,1222.40,794.56,,,,,,,,,,,,,
STENT ENDOPROS L15CM DIA6MM CATH 7FR L75CM BAL DIA6MM,SUP-2396551,CDM,C1874,HCPCS,0278,RC,,,,both,,,11523.80,7490.47,,,,,,,,,,,,,
STEM FEM 46MM LNG WDG HIP INTERSPACE,SUP-2223683,CDM,C1776,CPT,0278,RC,,,,both,,,10205.00,6633.25,,,,,,,,,,,,,
SPHERE STRL PASSIVE MARKER 30,SUP-2430172,CDM,C1713,HCPCS,0278,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
TIP ASPIR THRD ADPT ULTRAFLOW STTL,SUP-2110009,CDM,2720000010,LOCAL,0272,RC,,,,both,,,788.14,512.29,,,,,,,,,,,,,
GRAFT HUM TISS L18CM GRACILIS FRZN SGL STRND,SUP-2113927,CDM,C1713,HCPCS,0278,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
KIT PLT RICH PLSM AUTOLGS REGENKT,SUP-2366727,CDM,C1713,HCPCS,0278,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
IMPLANT OSS L2-5.6MM 2.5-3.5MM TI ADJ OFFSET PART AD ALTO,SUP-2232504,CDM,L8613,CPT,0278,RC,,,,both,,,1308.19,850.32,,,,,,,,,,,,,
BIT DRL L110MM DIA1.8MM QUIK CPL CALIB W/O STP REUSE,SUP-2187295,CDM,2720000010,LOCAL,0272,RC,,,,both,,,409.96,266.47,,,,,,,,,,,,,
STRAP CORRECT PD VARUS VALGUS,SUP-2388177,CDM,L2270,HCPCS,0274,RC,,,,both,,,136.24,88.56,,,,,,,,,,,,,
TUBING CNTRST DEL L 51 CM 1.36 CC AIRLESS ROTATING KEEP FLX,SUP-2302649,CDM,C1713,HCPCS,0278,RC,,,,both,,,15.51,10.08,,,,,,,,,,,,,
WIRE FIX L102MM DIA1.6MM S STL SMOOTH DBL BAYNT TIP K,SUP-2412981,CDM,C1713,HCPCS,0278,RC,,,,both,,,178.04,115.73,,,,,,,,,,,,,
GRAFT HUM TISS L HUM WHL W O CUF FRZN,SUP-2307323,CDM,C1713,HCPCS,0278,RC,,,,both,,,13584.61,8830.00,,,,,,,,,,,,,
LINER GLEN SM THK4MM SHLDR POLY POR MOD BIOMOD,SUP-2404670,CDM,C1776,CPT,0278,RC,,,,both,,,2263.47,1471.26,,,,,,,,,,,,,
IMPLANT TOE JT 20 METATARSAL HEMI GREAT TOE SYS MOV IMPLABLE,SUP-2244248,CDM,C1776,CPT,0278,RC,,,,both,,,8793.60,5715.84,,,,,,,,,,,,,
ATEZOLIZUMAB 60MG/ML IV SOLN (MIXTURES ONLY),RX-1150518,CDM,J9022,HCPCS,0636,RC,50242-0918-01,NDC,,both,14,ML,23364.20,15186.73,,,,,,,,,,,,,
STENT PERIPH L15CM DIA7MM CATH 7FR L120CM BLLN DIA7MM,SUP-2396632,CDM,C1874,HCPCS,0278,RC,,,,both,,,11837.80,7694.57,,,,,,,,,,,,,
VALVE CSF H SM CSF FLOW CTRL X HI PRESSURE,SUP-2628538,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3311.70,2152.60,,,,,,,,,,,,,
INSERT ACET OD56MM ID40MM HIP ULTAMET COBAL CHROME ARTC MOD,SUP-2250307,CDM,C1776,CPT,0278,RC,,,,both,,,9045.08,5879.30,,,,,,,,,,,,,
TRAY CATH MIDLN POWERGLIDE PRO BASIC 18GA 10CM WNGD F118100T,SUP-2632723,CDM,C1751,HCPCS,0278,RC,,,,both,,,244.73,159.07,,,,,,,,,,,,,
SYSTEM DEL 7FR PANCREAS NAVIFLEX RX,SUP-2149499,CDM,C2625,HCPCS,0278,RC,,,,both,,,258.64,168.12,,,,,,,,,,,,,
CATHETERIZATION KIT ART 018 20 GAX4.45 CM 18/25 GA 3 CC LF,SUP-2865589,CDM,C1751,HCPCS,0278,RC,,,,both,,,142.87,92.87,,,,,,,,,,,,,
PLATE BNE H0.5MM 24 H MID FACE BLU TI STR COND MAL,SUP-2366240,CDM,C1713,HCPCS,0278,RC,,,,both,,,1705.99,1108.89,,,,,,,,,,,,,
WIRE FIX L 6 IN DIA24 GA SS PRESTRETCH NS DISP OMNIMAX,SUP-2935363,CDM,C1713,HCPCS,0278,RC,,,,both,,,131.88,85.72,,,,,,,,,,,,,
CATHETER ATHRCTMY PREDATOR 360 L 325 CM DIA1.25 MM DIAMOND,SUP-2159521,CDM,C1769,HCPCS,0272,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
SCREW BONE STAINLESS STEEL ST CORTICAL 3.5X50MM,SUP-2721584,CDM,C1713,HCPCS,0278,RC,,,,both,,,134.02,87.11,,,,,,,,,,,,,
MATRIX HUM TISS L 4 X W 10 CM THK 0.2-1 MM ACELLULAR DERMAL,SUP-2909315,CDM,Q4122,HCPCS,0636,RC,,,,both,,,9678.42,6290.97,,,,,,,,,,,,,
CONNECTOR VENT DRNGE OD1.8MM ID1.2MM S STL 3 W Y SHP,SUP-2243837,CDM,2720000010,LOCAL,0272,RC,,,,both,,,517.35,336.28,,,,,,,,,,,,,
PACEMAKER CARD ADVISA SR MRI SURESCAN W 51 X H 42 MM D 8 MM,SUP-2282301,CDM,C1786,HCPCS,0275,RC,,,,both,,,9043.04,5877.98,,,,,,,,,,,,,
LINER ACET OD64MM ID28MM HIP MARATHON NEUT SNAP IN REV PINN,SUP-2250347,CDM,C1776,CPT,0278,RC,,,,both,,,3994.08,2596.15,,,,,,,,,,,,,
SCREW BONE L14MM OD3MM CANN DYN COMPR LAG SMOOTH CONCL BVL,SUP-2321044,CDM,C1713,HCPCS,0278,RC,,,,both,,,690.17,448.61,,,,,,,,,,,,,
FIBER LASER FLT RNDD TIP HIGH POWER W/SHTH 200UM F/RDTN SCPS,SUP-2574062,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1017.14,661.14,,,,,,,,,,,,,
JOINT TOE HINGED 1 FLX,SUP-2399030,CDM,C1776,CPT,0278,RC,,,,both,,,2543.40,1653.21,,,,,,,,,,,,,
PLATE BNE L125MM 7 H R DST LAT FIBULAR S STL LOK COMPR FOR,SUP-2184161,CDM,C1713,HCPCS,0278,RC,,,,both,,,1721.19,1118.77,,,,,,,,,,,,,
HC So Cellular Stim for Biomarker,PX-3028635266,CDM,86352,CPT,0302,RC,,,,outpatient,,,303.00,196.95,,,,,,,,,,,,,
REAMER SURG 10MM STRL FOR HAMRTOE HTR IMPL SYS,SUP-2390550,CDM,C1776,CPT,0278,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
BRACE ORTH ADJACENT FIT ELBW CUST FIT,SUP-2388191,CDM,L3760,HCPCS,0272,RC,,,,both,,,1755.26,1140.92,,,,,,,,,,,,,
"HC Trans, Esb, L/S, Single",PX-3606448300,CDM,64483,CPT,0360,RC,,,,both,,,2817.00,1831.05,,,,,,,,,,,,,
SUPPORT ORTHOT HEEL HEEL PD,SUP-2435736,CDM,L3480,HCPCS,0274,RC,,,,both,,,176.41,114.67,,,,,,,,,,,,,
BASEPLATE TIB L71MM SHT UHMWPE NONMODULAR OSS,SUP-2405769,CDM,C1776,CPT,0278,RC,,,,both,,,8322.57,5409.67,,,,,,,,,,,,,
SCREW SET REPL FOR KATALYST BPLR RADIAL HD,SUP-2852034,CDM,C1776,CPT,0278,RC,,,,both,,,1104.90,718.18,,,,,,,,,,,,,
SUPPORT ORTHOT THGH LOWER EXTREMITY WT BEAR QAUDRI LAT BRIM,SUP-2435673,CDM,L2510,HCPCS,0274,RC,,,,both,,,2283.35,1484.18,,,,,,,,,,,,,
PLATE BNE 5 H TI L DST CORONOID FIBULAR MOD FOR 2.5MM SCR,SUP-2411727,CDM,C1713,HCPCS,0278,RC,,,,both,,,3053.34,1984.67,,,,,,,,,,,,,
POST 12 PIN 2HL,SUP-2696088,CDM,2720000010,LOCAL,0272,RC,,,,both,,,729.11,473.92,,,,,,,,,,,,,
CANNULA ENDOSCP L 110 MM DIA15 MM STD BLDELSS TROCAR SLV,SUP-2896260,CDM,2720000010,LOCAL,0272,RC,,,,both,,,499.23,324.50,,,,,,,,,,,,,
IMMOBILIZER KNEE UNIV L19IN FOR 12-24IN THGH FOAM T BAR,SUP-2336080,CDM,L1830,CPT,0272,RC,,,,both,,,46.91,30.49,,,,,,,,,,,,,
PLATE BNE W10XL77MM THK3.3MM HK D15MM 8 H R CLAV S STL LOK,SUP-2185834,CDM,C1713,HCPCS,0278,RC,,,,both,,,2194.48,1426.41,,,,,,,,,,,,,
STEM XL TAPER 20X235MM,SUP-2505016,CDM,C1776,CPT,0278,RC,,,,both,,,8817.12,5731.13,,,,,,,,,,,,,
CATHETER INFUSION ENDOVASC DEV 12 FRX135 CM US COR EKOSONIC,SUP-2214804,CDM,C1887,HCPCS,0272,RC,,,,both,,,20676.90,13439.98,,,,,,,,,,,,,
ELECTRODE RF 90DEG SUCT DISPOSABLE VAPR PREMIERE 90,SUP-2256732,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
TRIAL TIB 11MM SM S1 A/P LIP CONSTRN DURAC,SUP-2364860,CDM,C1776,CPT,0278,RC,,,,both,,,486.70,316.35,,,,,,,,,,,,,
CATHETER DRNGE 6.5FR 15CM GEN TOT ABSCESSION,SUP-2118556,CDM,C1729,HCPCS,0272,RC,,,,both,,,213.96,139.07,,,,,,,,,,,,,
KIT MICROINTRODUCER 4FR GWIRE L40CM DIA0.018IN ECHOGENIC NDL,SUP-2120522,CDM,C1894,HCPCS,0272,RC,,,,both,,,141.61,92.05,,,,,,,,,,,,,
SET INT FIX SCREW DIA1.5 MM TI NEURO 3 Y SHP XLN PLATE 1 PK,SUP-2936712,CDM,C1713,HCPCS,0278,RC,,,,both,,,4493.34,2920.67,,,,,,,,,,,,,
PLATE BONE L88MM 3 H S STL CLVRLF,SUP-2198576,CDM,C1713,HCPCS,0278,RC,,,,both,,,499.70,324.80,,,,,,,,,,,,,
ALLOGRAFT BNE HUM SHFT 160X2 MM FD,SUP-2717863,CDM,C1762,CPT,0278,RC,,,,both,,,4463.54,2901.30,,,,,,,,,,,,,
TRAY CATH PICC RADPICC BSC 5FR 0.042N 60CM 1 LUMAN R 3165335,SUP-2632647,CDM,C1751,HCPCS,0278,RC,,,,both,,,184.32,119.81,,,,,,,,,,,,,
PATCH CV HEMSHLD L 6 X W 0.3 IN THK 0.76 MM POLYESTER BOV,SUP-2694186,CDM,C1768,CPT,0278,RC,,,,both,,,409.14,265.94,,,,,,,,,,,,,
SET CHOLANGIOGRAPHY ENDO CATH 3FR L43CM NDL 16GA L12CM,SUP-2168107,CDM,C1894,HCPCS,0272,RC,,,,both,,,249.63,162.26,,,,,,,,,,,,,
HOOK SPNL ANGLED 6X7.5 MM LT MARINER,SUP-2737717,CDM,C1713,HCPCS,0278,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
SET INT FIX SCREW DIA1.5 MM TI NEURO Y PLT XDRV 1 PK STRL,SUP-2935513,CDM,C1713,HCPCS,0278,RC,,,,both,,,2241.96,1457.27,,,,,,,,,,,,,
GLYBURIDE 2.5 MG PO TABS,RX-10126,CDM,6370000000,HCPCS,0637,RC,00093-8343-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
MICROCATHETER INFUSION RAPIDTRANSIT L 150 CM L 50CM 1 MARKER,SUP-2158104,CDM,C1887,HCPCS,0272,RC,,,,both,,,3206.41,2084.17,,,,,,,,,,,,,
CONTROLLER DETACH AZUR PERIPH HELCL PUSHABLE 18 SYS STRL,SUP-2385394,CDM,2720000010,LOCAL,0272,RC,,,,both,,,595.03,386.77,,,,,,,,,,,,,
STEM FEM CLLRD 16 MM KNEE REV LCS COMPLETE,SUP-2453518,CDM,C1776,CPT,0278,RC,,,,both,,,920.02,598.01,,,,,,,,,,,,,
FORCEP BX CRV 30 DEG 7 MMX25 CM 14 MM JAW DBL ACT INSUL HNDL,SUP-2850476,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4939.35,3210.58,,,,,,,,,,,,,
SCREW BNE L 12 MM DIA2 MM MAXILLOMANDIBULAR SD NS AXS,SUP-2909475,CDM,C1713,HCPCS,0278,RC,,,,both,,,778.25,505.86,,,,,,,,,,,,,
EVOS 3.5/4.5 PP TROC RING PL R 12H 295,SUP-2931254,CDM,C1713,HCPCS,0278,RC,,,,both,,,21337.09,13869.11,,,,,,,,,,,,,
BIT DRILL CALIB RF 4.9MM,SUP-2474906,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1221.24,793.81,,,,,,,,,,,,,
PLATE SPNL W16XL44MM STD 1 H XLNK POST LUM S STL FIX CONN,SUP-2255569,CDM,C1713,HCPCS,0278,RC,,,,both,,,4165.21,2707.39,,,,,,,,,,,,,
CATHETER CV SINGLE LUMEN 4 FR SM VEIN BASIC W/ TCS POWERPICC,SUP-2759201,CDM,C1751,HCPCS,0278,RC,,,,both,,,1045.78,679.76,,,,,,,,,,,,,
MESH HERN W1.3XL1.6IN M POLYPR INGUINAL NONABSORBABLE,SUP-2125787,CDM,C1781,HCPCS,0278,RC,,,,both,,,486.39,316.15,,,,,,,,,,,,,
GRAFT HUM TISS 9MM OSTEOCHNDRL CHONDROFIX,SUP-2200259,CDM,C1713,HCPCS,0278,RC,,,,both,,,10898.94,7084.31,,,,,,,,,,,,,
ALLOGRAFT BNE BLOCK 10X10X10 MM 1 CC PRO OSTEON 500R,SUP-2684309,CDM,C1713,HCPCS,0278,RC,,,,both,,,1029.92,669.45,,,,,,,,,,,,,
SCREW PEDCL SPNL LCK VAR TI 6.5MMDIA 45MML,SUP-2415531,CDM,C1713,HCPCS,0278,RC,,,,both,,,1092.72,710.27,,,,,,,,,,,,,
WASHER ORTH DIA7MM FOR CANN SCR,SUP-2184680,CDM,C1713,HCPCS,0278,RC,,,,both,,,68.08,44.25,,,,,,,,,,,,,
CANNULA DEL 15GA DRL L60MM KNEE END DEL FOR ARTHRO ACCUPORT,SUP-2402765,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
CATHETER GUID RAPIDO L 75 CM WORKING L 69 CM OD 6 FR ID 4.9,SUP-2148899,CDM,C1887,HCPCS,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
GRAFT HUM TISS XL W15XL24CM THK07 14MM THN ACELLULAR,SUP-2307617,CDM,Q4128,HCPCS,0636,RC,,,,both,,,40928.52,26603.54,,,,,,,,,,,,,
CATHETER EMB FOGARTY L 80 CM DIA 4 FR DIA 9 MM TUBE PK RED,SUP-2214590,CDM,C1757,HCPCS,0272,RC,,,,both,,,189.00,122.85,,,,,,,,,,,,,
PLATE CRAN 180X120X40 MM PT SPEC IMPL PEEK,SUP-2860154,CDM,C1713,HCPCS,0278,RC,,,,both,,,46802.01,30421.31,,,,,,,,,,,,,
GRAFT EVAR L150MM DIA44X40MM PROX DST THOR C DSGN VALIANT,SUP-2281717,CDM,C1768,CPT,0278,RC,,,,both,,,54871.50,35666.47,,,,,,,,,,,,,
SYSTEM TISS GLUE 10ML KT BIOLOGIC FBRN SEAL TISSEEL VALUPAK,SUP-2129972,CDM,C9250,HCPCS,0636,RC,,,,both,,,1659.80,1078.87,,,,,,,,,,,,,
STEM FEM SZ 0 STD UNIV + HIP,SUP-2351177,CDM,C1776,CPT,0278,RC,,,,both,,,5768.18,3749.32,,,,,,,,,,,,,
GRAFT DERM CLLGN SURG PROC HUM RECTANG IMPL L20XW6CM,SUP-2125864,CDM,C1781,HCPCS,0278,RC,,,,both,,,11932.00,7755.80,,,,,,,,,,,,,
KIT CVC BODY FOR 9.5FR 2 LUMN PEEL APART INTRO GROSH,SUP-2127902,CDM,C1713,HCPCS,0278,RC,,,,both,,,411.34,267.37,,,,,,,,,,,,,
GRAFT BNE L25MM H15MM IL CREST WDG FRZ DRY MATRIGRFT,SUP-2264803,CDM,C1713,HCPCS,0278,RC,,,,both,,,2369.54,1540.20,,,,,,,,,,,,,
GRAFT PTTY SYN STIMULAN RAP CURE 5CC,SUP-2135331,CDM,C1713,HCPCS,0278,RC,,,,both,,,2763.20,1796.08,,,,,,,,,,,,,
BASEPLATE TIB SM SZ 1 MOD ROT HNG MONOGRAM,SUP-2376374,CDM,C1776,CPT,0278,RC,,,,both,,,7939.65,5160.77,,,,,,,,,,,,,
PLATE CRAN 80X40X40 MM PT SPEC IMPL PEEK,SUP-2860123,CDM,C1713,HCPCS,0278,RC,,,,both,,,27220.03,17693.02,,,,,,,,,,,,,
TAP SURG DIA5MM 2 LD,SUP-2256858,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6201.50,4030.97,,,,,,,,,,,,,
CANNULA ENDOSCP L 70 MM DIA11 MM SHRT BLDELSS TROCAR SLV,SUP-2896328,CDM,2720000010,LOCAL,0272,RC,,,,both,,,436.15,283.50,,,,,,,,,,,,,
HMRS/G I-II CIRCLIPS,SUP-2512640,CDM,C1776,CPT,0278,RC,,,,both,,,811.06,527.19,,,,,,,,,,,,,
BIT DRL 9.5 MMX7 IN JCBS CHK END,SUP-2457948,CDM,2720000010,LOCAL,0272,RC,,,,both,,,752.31,489.00,,,,,,,,,,,,,
CATHETER PERITONEAL DLYS IMPLANTATION STYL INF 42 CM STYL,SUP-2475475,CDM,C1769,HCPCS,0272,RC,,,,both,,,279.46,181.65,,,,,,,,,,,,,
BOWL BNE CEM MIX SPAT CURET SMARTMIX CTS,SUP-2253061,CDM,2720000010,LOCAL,0272,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
BLADE SAW KEEN RECIP CEM REPROC FOR STRYKR SYS 7/6/5/4/2000,SUP-2408663,CDM,2720000010,LOCAL,0272,RC,,,,both,,,883.75,574.44,,,,,,,,,,,,,
HC So1 Hemoglobin Electrophoresis,PX-3018302067,CDM,83020,CPT,0301,RC,,,,both,,,79.00,51.35,,,,,,,,,,,,,
IMPLANT STAP L3.75MM DIA0.6MM NIT MID EAR STAP INCUS WIRE,SUP-2313865,CDM,2780000010,LOCAL,0278,RC,,,,both,,,840.48,546.31,,,,,,,,,,,,,
PLATE BNE L 257 MM SCREW DIA 4.5 MM 14 H SS NAR COMPR NLCK,SUP-2933469,CDM,C1713,HCPCS,0278,RC,,,,both,,,2182.14,1418.39,,,,,,,,,,,,,
BRACE WRST LACER W O ABDUCTED THMB UNIV R,SUP-2276646,CDM,L3931,HCPCS,0274,RC,,,,both,,,15.89,10.33,,,,,,,,,,,,,
WASHER ORTH SZ 12.7MM S STL BTRFLY FOR FIX,SUP-2343056,CDM,C1713,HCPCS,0278,RC,,,,both,,,761.45,494.94,,,,,,,,,,,,,
ECLIPSE TI HUMERAL HEAD SIZE 51/21,SUP-2815509,CDM,C1776,CPT,0278,RC,,,,both,,,10990.00,7143.50,,,,,,,,,,,,,
IMMOBOLIZER SHLDR SUPP UNIV UNISX M,SUP-2136721,CDM,L3660,HCPCS,0272,RC,,,,both,,,47.10,30.61,,,,,,,,,,,,,
LENS POST CHMBR 3 PC ACRYL 21.5 ANTR ASYM BCNVX 6.0MM OPT,SUP-2110491,CDM,V2632,HCPCS,0276,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
MATRIX 1.4MM TROCAR BIT DRILL,SUP-2823266,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1028.54,668.55,,,,,,,,,,,,,
IMPLANT PATELLA SUTPLT II STAR POLE FRAC S STRL,SUP-2751544,CDM,C1713,HCPCS,0278,RC,,,,both,,,9404.30,6112.79,,,,,,,,,,,,,
GRAFT HUM TISS AMBIENT 2 CC FLOWABLE PLCNTA TISS VIAFLOW,SUP-2759544,CDM,C1762,CPT,0278,RC,,,,both,,,9562.59,6215.68,,,,,,,,,,,,,
SCREW BNE L78MM OD7MM THRD L17MM PUR HINDFOOT ANK CANN SHT,SUP-2320769,CDM,C1713,HCPCS,0278,RC,,,,both,,,1582.56,1028.66,,,,,,,,,,,,,
UNISPACER 54MM X 4MM MED LT,SUP-2202427,CDM,C1776,CPT,0278,RC,,,,both,,,10126.50,6582.22,,,,,,,,,,,,,
BIT DRL 6 MM,SUP-2602158,CDM,2720000010,LOCAL,0272,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
GRAFT HUM TISS W22XL50MM ILIUM BICORT STRP FRZ DRY,SUP-2307122,CDM,C1713,HCPCS,0278,RC,,,,both,,,2437.24,1584.21,,,,,,,,,,,,,
ADAPTER TIB OFFSET SZ 2.5MM KNEE REV VANGUARD 360,SUP-2408002,CDM,C1776,CPT,0278,RC,,,,both,,,1821.20,1183.78,,,,,,,,,,,,,
PHENYLEPHRINE HCL (PRESSORS) 10 MG/ML IV SOLN,RX-127963,CDM,J2371,HCPCS,0636,RC,00641-6142-25,NDC,,both,0.01,ML,54.10,35.16,,,,,,,,,,,,,
PIN FIX L25MM OD2MM FT PROV PERI-LOC VLP,SUP-2344025,CDM,C1713,HCPCS,0278,RC,,,,both,,,944.20,613.73,,,,,,,,,,,,,
SODIUM CHLORIDE 3 % IV SOLN,RX-7321,CDM,J7131,HCPCS,0258,RC,00264-7805-10,NDC,,both,500,ML,54.10,35.16,,,,,,,,,,,,,
PIN ABSRB ST 2.0X30.0MM,SUP-2412906,CDM,C1776,CPT,0278,RC,,,,both,,,951.42,618.42,,,,,,,,,,,,,
SEGMENTAL PROXIMAL TIBIA SIZE 3,SUP-2502380,CDM,C1776,CPT,0278,RC,,,,both,,,22918.86,14897.26,,,,,,,,,,,,,
PLATE BNE OPN WDG PROX METATARSAL OSTEOTMY FIX 5MM,SUP-2243305,CDM,C1713,HCPCS,0278,RC,,,,both,,,6005.25,3903.41,,,,,,,,,,,,,
"HC So Calcium,Urine 24 Hr",PX-3018234066,CDM,82340,CPT,0301,RC,,,,both,,,29.00,18.85,,,,,,,,,,,,,
SAW SURG 0.060 IN CAPTURE WIDE SLOT LCS,SUP-2454060,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3306.42,2149.17,,,,,,,,,,,,,
"HC So Cryoglobulin,Qualitative",PX-3018259566,CDM,82595,CPT,0301,RC,,,,both,,,214.00,139.10,,,,,,,,,,,,,
CAP SPNL POST FACET JT LOK FOR INTEGR ROD REDUC CREO MIS,SUP-2228804,CDM,C1713,HCPCS,0278,RC,,,,both,,,188.40,122.46,,,,,,,,,,,,,
ALLOGRAFT BNE FIB SHFT 15 CM,SUP-2423907,CDM,C1889,HCPCS,0278,RC,,,,both,,,3248.49,2111.52,,,,,,,,,,,,,
HC Pt Vasopneumatic Device Therapy|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS,PX-4209701600,CDM,97016,CPT,0420,RC,,,CQ,outpatient,,,206.00,133.90,,,,,,,,,,,,,
MESH SURG W9XL13CM POLY HYDRPHLC 2D FLAT SHT PARIETEX,SUP-2174771,CDM,C1781,HCPCS,0278,RC,,,,both,,,235.66,153.18,,,,,,,,,,,,,
CATHETER EP CSL CRV 4MM SPC 7 FRX90 CM MARINR,SUP-2281828,CDM,C1730,HCPCS,0272,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
NAIL INTRMDLLRY 9MM X 420MM 125DG RIGHT F/HIP FRAC AFFXS,SUP-2588660,CDM,C1713,HCPCS,0278,RC,,,,both,,,6752.38,4389.05,,,,,,,,,,,,,
HC So Vdrl (Titer),PX-3028659366,CDM,86593,CPT,0302,RC,,,,both,,,99.00,64.35,,,,,,,,,,,,,
GRAFT HUM TISS W13XL30MM THK13MM FRZ DRY ALLGRFT BLK CANC,SUP-2307114,CDM,C1713,HCPCS,0278,RC,,,,both,,,2771.40,1801.41,,,,,,,,,,,,,
GRAFT VASC GORTX L 100 CM DIA 6 MM RNG L 60 CM EPTFE STR TW,SUP-2396124,CDM,C1768,CPT,0278,RC,,,,both,,,3680.08,2392.05,,,,,,,,,,,,,
PLATE BNE RECON 2.5 MM 20 HOLE RECON PT SPEC TI,SUP-2860090,CDM,C1713,HCPCS,0278,RC,,,,both,,,12671.47,8236.46,,,,,,,,,,,,,
SET SCR SPNL HEX G4 CDH SEXTANT II,SUP-2288456,CDM,C1713,HCPCS,0278,RC,,,,both,,,657.20,427.18,,,,,,,,,,,,,
"DYNACLIP STAPLE, 4-LEG, QUATTRO, 22MM X 16MM X 16MM STERILE, PRELOADED (INSERTER)",SUP-2878451,CDM,C1713,HCPCS,0278,RC,,,,both,,,11194.10,7276.16,,,,,,,,,,,,,
HANDPIECE BX SAVI SCOUT DISP,SUP-2517638,CDM,C1819,HCPCS,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
IMPLANT TALAR SZ 1 ANK LT VANTAGE,SUP-2223466,CDM,C1776,CPT,0278,RC,,,,both,,,10990.00,7143.50,,,,,,,,,,,,,
SODIUM CHLORIDE 3 % IV SOLN,RX-7321,CDM,J7131,HCPCS,0250,RC,00264-7805-10,NDC,,both,500,ML,54.10,35.16,,,,,,,,,,,,,
IMPLANT WR OD15MM ID7MM +2MM CRPL HD MAESTRO,SUP-2407290,CDM,C1776,CPT,0278,RC,,,,both,,,3410.04,2216.53,,,,,,,,,,,,,
BLADE SURG HNDL CRV ATRAUM CAPSLTMY STRL DISP SAFECUT,SUP-2910489,CDM,2720000010,LOCAL,0272,RC,,,,both,,,758.31,492.90,,,,,,,,,,,,,
PLATE BNE L 102 MM SCREW DIA2.7/3.5 MM 5 H LT MEDL DSTL HUM,SUP-2931317,CDM,C1713,HCPCS,0278,RC,,,,both,,,4964.34,3226.82,,,,,,,,,,,,,
PLATE BNE L183MM 11 H SEMI TBLR FOR 45MM SCR L FRAG SYS,SUP-2411421,CDM,C1713,HCPCS,0278,RC,,,,both,,,248.41,161.47,,,,,,,,,,,,,
ELECTRODE ELECSURG 24-28 FR BRL,SUP-2312910,CDM,C1713,HCPCS,0278,RC,,,,both,,,849.68,552.29,,,,,,,,,,,,,
BUR SURG 4MM PRECIS RND,SUP-2365195,CDM,2720000010,LOCAL,0272,RC,,,,both,,,778.41,505.97,,,,,,,,,,,,,
PLUG MESH SM ANCHR 5CM RIM 5CM 3D THERMOFORMED FLAT,SUP-2220109,CDM,C1781,HCPCS,0278,RC,,,,both,,,711.84,462.70,,,,,,,,,,,,,
HC Lymphangiogram Uni S&I Rt,PX-3207580100,CDM,75801,CPT,0320,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
SCREW BNE L65MM DIA5MM TIB KNEE G TI FULL THRD HEX DRV INT,SUP-2347248,CDM,C1713,HCPCS,0278,RC,,,,both,,,1452.85,944.35,,,,,,,,,,,,,
LEAD NEUROSTIMULATOR L45CM DIA13MM PERC 4 ELECTRD IN LN CONN,SUP-2278192,CDM,C1767,HCPCS,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
GRAFT BNE DWL FRZ DRY UNICORTICAL L 14-40MM OD 15MM,SUP-2307088,CDM,C1713,HCPCS,0278,RC,,,,both,,,1927.96,1253.17,,,,,,,,,,,,,
RING EXT FIX 200 MM 5/8 MR SAFE TI NS,SUP-2863456,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2381.28,1547.83,,,,,,,,,,,,,
TUBE EXT FIX L250MM OD25MM RED C FOR UNILAT MONOTB TRIAX,SUP-2372615,CDM,C1713,HCPCS,0278,RC,,,,both,,,675.10,438.81,,,,,,,,,,,,,
FORCEPS ES L33CM DIA5MM CUT ERGO CUT BLDE TRIG HND ACT,SUP-2313979,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2530.84,1645.05,,,,,,,,,,,,,
HC MRI Brain WO Ctrst,PX-6117055100,CDM,70551,CPT,0611,RC,,,,both,,,5059.00,3288.35,,,,,,,,,,,,,
ALLOGRAFT BNE STRP 20-40X10-30 MM FD ILIUM BICORTICAL,SUP-2717882,CDM,C1762,CPT,0278,RC,,,,both,,,3447.97,2241.18,,,,,,,,,,,,,
GRAFT VASC GORTX L 110 CM DIA 6 MM RNG L 60 CM EPTFE STR TW,SUP-2396125,CDM,C1768,CPT,0278,RC,,,,both,,,4474.50,2908.42,,,,,,,,,,,,,
GUIDE WIRE THRD 400 MM,SUP-2316308,CDM,C1769,HCPCS,0272,RC,,,,both,,,826.89,537.48,,,,,,,,,,,,,
SCREW BONE STEM LCK KNEE AGC,SUP-2406283,CDM,C1713,HCPCS,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
WEDGE TIB AUG HALF 26 DEG,SUP-2201700,CDM,C1776,CPT,0278,RC,,,,both,,,2320.46,1508.30,,,,,,,,,,,,,
WAND ABLAT SHFT 3.7MM 90DEG BVL COBLATION STARVAC 90,SUP-2342004,CDM,C1713,HCPCS,0278,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
PACKAGE GRFT DEL BNE W CANN LT BIO,SUP-2380352,CDM,C1713,HCPCS,0278,RC,,,,both,,,1841.99,1197.29,,,,,,,,,,,,,
PLATE SPINE FIX 10MM 1 LEV AMBASSADOR,SUP-2163960,CDM,C1713,HCPCS,0278,RC,,,,both,,,2983.00,1938.95,,,,,,,,,,,,,
CATHETER THROMCTMY EMBOVAC L 125 CM PROX/DSTL OD,SUP-2707591,CDM,C1757,HCPCS,0272,RC,,,,both,,,9619.20,6252.48,,,,,,,,,,,,,
COIL EMB L10CM LOOP DIA4MM PERIPH SELF EXP HYDRGEL POLYMER 45480410] TERUMO MEDICAL CORP],SUP-2385411,CDM,C1889,HCPCS,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
PLATE BNE L 46 MM SCREW DIA 3.5 MM 4 SHFT H SS RECON VA,SUP-2907617,CDM,C1713,HCPCS,0278,RC,,,,both,,,2720.03,1768.02,,,,,,,,,,,,,
EXPANDER TISS 2.6X1.7X0.8 IN KT CONT EXT DERMACLOSE XL,SUP-2391439,CDM,C1789,HCPCS,0278,RC,,,,both,,,4078.86,2651.26,,,,,,,,,,,,,
STEM HUM PRSS FIT EQUINOXE,SUP-2223290,CDM,C1776,CPT,0278,RC,,,,both,,,42.39,27.55,,,,,,,,,,,,,
PLATE BNE L16MM BLU 8 FOR GUID GROWTH SYS,SUP-2316392,CDM,C1713,HCPCS,0278,RC,,,,both,,,867.71,564.01,,,,,,,,,,,,,
CANNULA SUCTION UMIDIFYING MOIST AIR STRL DISP,SUP-2471273,CDM,2720000010,LOCAL,0272,RC,,,,both,,,909.44,591.14,,,,,,,,,,,,,
STENT NEPHURET EXPEL L 22 CM DIA10 FR FLEXITHANE HYDRPHLC 2,SUP-2146911,CDM,C2617,HCPCS,0278,RC,,,,both,,,379.94,246.96,,,,,,,,,,,,,
VON GRAEFE KNIFE 2,SUP-2672833,CDM,2720000010,LOCAL,0272,RC,,,,both,,,383.74,249.43,,,,,,,,,,,,,
DARBEPOETIN ALFA 150 MCG/0.3ML IJ SOSY,RX-131231,CDM,J0881,HCPCS,0636,RC,55513-0027-04,NDC,,both,0.3,ML,3425.00,2226.25,,,,,,,,,,,,,
BUR SURG DIA1.5 MM XSH TWST DRL STRL REUSE HI-LINE,SUP-2929406,CDM,2720000010,LOCAL,0272,RC,,,,both,,,484.22,314.74,,,,,,,,,,,,,
ENDOSCOPIC KIT COLON W/ 2 OZ 2 END SEAL HYDR ORCA W/O SPNG,SUP-2473924,CDM,2720000010,LOCAL,0272,RC,,,,both,,,46.60,30.29,,,,,,,,,,,,,
PLATE BNE L100MM 5 H RIG SPN FOR 45MM SCR L FRAG SYS,SUP-2411395,CDM,C1713,HCPCS,0278,RC,,,,both,,,652.02,423.81,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 70 CM DIA 5MM STR STD WALL SLDE GDS,SUP-2461988,CDM,C1768,CPT,0278,RC,,,,both,,,1885.76,1225.74,,,,,,,,,,,,,
INTRODUCER CATH L12CM OD5FR 0.038IN GWIRE VEN SHTH,SUP-2355259,CDM,C1894,HCPCS,0272,RC,,,,both,,,24.34,15.82,,,,,,,,,,,,,
PLATE BONE THK1.5MM 32 H LEV 1 THOR TI LCK FOR 2.3MM SCR,SUP-2262534,CDM,C1713,HCPCS,0278,RC,,,,both,,,4113.09,2673.51,,,,,,,,,,,,,
BIT DRL OD1.7MM SLD INTOSS FIX SYS,SUP-2400073,CDM,2720000010,LOCAL,0272,RC,,,,both,,,618.58,402.08,,,,,,,,,,,,,
HC So Sirolimus,PX-3018019566,CDM,80195,CPT,0301,RC,,,,both,,,125.00,81.25,,,,,,,,,,,,,
DRILL SURG OD52MM L CANN,SUP-2244277,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1042.70,677.75,,,,,,,,,,,,,
HC So Allergen Specific Ige Qual Mul,PX-3058600566,CDM,86005,CPT,0305,RC,,,,both,,,63.00,40.95,,,,,,,,,,,,,
TRUMATCH HP FEM O KIT SZ2,SUP-2823514,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
DEFIBRILLATOR CARD W5.90CM 40J 20SEC 10YR 3 CHMBR CARD,SUP-2138121,CDM,C1882,HCPCS,0275,RC,,,,both,,,82259.33,53468.56,,,,,,,,,,,,,
IMPLANT OSS L4.5MM PIST DIA0.4MM WELL DIA1MM STAP S STL,SUP-2312799,CDM,L8613,CPT,0278,RC,,,,both,,,556.13,361.48,,,,,,,,,,,,,
HC Ot Ther Ex per 15 Min|OP PT SERVICES|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS,PX-4309711000,CDM,97110,CPT,0430,RC,,,GP|CQ,both,,,195.00,126.75,,,,,,,,,,,,,
PLATE 4.5MM TI LCP MEDIAL PROXIMAL TIBIA 8H RT 178MM STER,SUP-2549609,CDM,C1713,HCPCS,0278,RC,,,,both,,,5065.92,3292.85,,,,,,,,,,,,,
STERILE WATER FOR INJECTION (MIXTURES ONLY),RX-430028,CDM,2500000003,HCPCS,0250,RC,00264-7850-20,NDC,,both,250,ML,54.10,35.16,,,,,,,,,,,,,
SCREW BONE L3MM DIA1.5MM SLV CORT TI SELF DRL NONCANNULATED,SUP-2181626,CDM,C1713,HCPCS,0278,RC,,,,both,,,326.62,212.30,,,,,,,,,,,,,
ACETAMINOPHEN 325 MG PO TABS,RX-101,CDM,6370000000,HCPCS,0637,RC,49483-0340-01,NDC,,both,1,UN,0.30,0.19,,,,,,,,,,,,,
SCREW ACET 140 DEG 100 MM HIP NS,SUP-2251193,CDM,C1713,HCPCS,0278,RC,,,,both,,,1120.98,728.64,,,,,,,,,,,,,
HC Strep a Ag Eia,PX-3068743000,CDM,87430,CPT,0306,RC,,,,outpatient,,,128.00,83.20,,,,,,,,,,,,,
PLATE BNE TBLR 37 MM 3-HOLE 1/3,SUP-2518432,CDM,C1713,HCPCS,0278,RC,,,,both,,,1868.30,1214.39,,,,,,,,,,,,,
GRAFT BNE 1 CC CELLULAR BNE MTRX V92 FC+,SUP-2742067,CDM,C1713,HCPCS,0278,RC,,,,both,,,2201.93,1431.25,,,,,,,,,,,,,
KIT CATH 12FR L4CM TIP L2CM NONCOMPLIANT BLLN LO PROF,SUP-2139184,CDM,C1726,HCPCS,0272,RC,,,,both,,,926.93,602.50,,,,,,,,,,,,,
STRUT EXT FIX SM 14 MM INFIX,SUP-2683731,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8164.00,5306.60,,,,,,,,,,,,,
SPACER TIB SCREW N-K II,SUP-2449004,CDM,C1776,CPT,0278,RC,,,,both,,,409.77,266.35,,,,,,,,,,,,,
SNARE VASC 6FR L120CM DIA9-15MM CATH L100CM STD INTERLACED,SUP-2302535,CDM,C1773,HCPCS,0272,RC,,,,both,,,1055.04,685.78,,,,,,,,,,,,,
VALVE AORT CARP EDW PERIMT RSR DIA19 MM BOV PERICARD COCR,SUP-2214067,CDM,C1889,HCPCS,0278,RC,,,,both,,,13863.10,9011.01,,,,,,,,,,,,,
NAIL IM SHT 125 DEG 11 MM HIP FRAC SYS STRL CHIMAERA,SUP-2646602,CDM,C1713,HCPCS,0278,RC,,,,both,,,4101.91,2666.24,,,,,,,,,,,,,
PLATE NSL W40XL50MM THK0.25MM PUR POLYDIOXANONE FLX RECTANG,SUP-2301042,CDM,C1713,HCPCS,0278,RC,,,,both,,,938.86,610.26,,,,,,,,,,,,,
STEM HUM L197MM DIA8MM 135DEG UNIV SHLDR TI ARTHROPLASTY,SUP-2249964,CDM,C1776,CPT,0278,RC,,,,both,,,15508.46,10080.50,,,,,,,,,,,,,
CANNULA SURG LNG 8 MM SCREW 00249004080,SUP-2459611,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1511.03,982.17,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP L150CM DIA0.035IN TIP L15CM BENT PTFE,SUP-2139326,CDM,C1769,HCPCS,0272,RC,,,,both,,,50.96,33.12,,,,,,,,,,,,,
GUIDEWIRE SURG L150MM DIA2.3MM NICKEL CHROM SMOOTH SGL END,SUP-2321624,CDM,C1713,HCPCS,0278,RC,,,,both,,,92.32,60.01,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL PEEK SD800.541,SUP-2860222,CDM,C1713,HCPCS,0278,RC,,,,both,,,45894.24,29831.26,,,,,,,,,,,,,
PLATE BONE MINI MTP PKT,SUP-2400414,CDM,C1713,HCPCS,0278,RC,,,,both,,,5827.84,3788.10,,,,,,,,,,,,,
PROBE COAG 6.9FR L2.2M CONV SIDE FIRE BLT IN FLTR 2200SC FIAPC,SUP-2217947,CDM,2720000010,LOCAL,0272,RC,,,,both,,,796.93,518.00,,,,,,,,,,,,,
PLATE BNE L 115 MM SCREW DIA 3.5 MM 5 H MEDL DSTL FEM CNDYL,SUP-2931192,CDM,C1713,HCPCS,0278,RC,,,,both,,,7823.31,5085.15,,,,,,,,,,,,,
HC IR Plmt Uret Stent Prq New WO,PX-3615069400,CDM,50694,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
ARTHROFLEX 50X90X1.5MM,SUP-2811354,CDM,Q4125,HCPCS,0636,RC,,,,both,,,10956.40,7121.66,,,,,,,,,,,,,
BAG BLD TRNSFUS CONSOLIDATED RT VENTRICULAR ASST DEV,SUP-2356016,CDM,Q0508,HCPCS,0272,RC,,,,both,,,1102.14,716.39,,,,,,,,,,,,,
SET INT FIX SCREW DIA1.5 MM TI NEURO 2 Y SHP XLN PLATE 12 PK,SUP-2936651,CDM,C1713,HCPCS,0278,RC,,,,both,,,48377.98,31445.69,,,,,,,,,,,,,
IMMOBILIZER ORTH ADJ UNIV SHLDR CANVS NAVY NS,SUP-2336314,CDM,L3670,HCPCS,0272,RC,,,,both,,,25.72,16.72,,,,,,,,,,,,,
PLATE BONE REG L12MM 2X2 H MIDFACE SLV TI RT L SHP FOR 1.5MM,SUP-2402877,CDM,C1713,HCPCS,0278,RC,,,,both,,,398.78,259.21,,,,,,,,,,,,,
PLATE BNE THK 0.6 MM SCREW DIA1.5 MM TI RT,SUP-2935836,CDM,C1713,HCPCS,0278,RC,,,,both,,,1180.64,767.42,,,,,,,,,,,,,
PLATE BONE L30MM 14 H TI NAR HYBRID COMPR FOR 4.5MM SCR ALPS,SUP-2413749,CDM,C1713,HCPCS,0278,RC,,,,both,,,1049.61,682.25,,,,,,,,,,,,,
BEARING HUM DIA36-44MM STD E1 FOR COMPHSVE REV SHLDR SYS,SUP-2408946,CDM,C1776,CPT,0278,RC,,,,both,,,4841.88,3147.22,,,,,,,,,,,,,
KIT COR DCOMPR 15CC FOR INJ INDUCTIVE GRFT PRO STIM,SUP-2399133,CDM,C1713,HCPCS,0278,RC,,,,both,,,23628.50,15358.52,,,,,,,,,,,,,
EXTRACTOR STONE TIPLSS 2.2 FRX115 CM 2 CM MOD BSKT NCIRCLE,SUP-2835782,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1063.52,691.29,,,,,,,,,,,,,
TI STERNAL LOCKING DOUBLE-T,SUP-2823425,CDM,C1713,HCPCS,0278,RC,,,,both,,,3234.83,2102.64,,,,,,,,,,,,,
PRAMIPEXOLE DIHYDROCHLORIDE 0.125 MG PO TABS,RX-21287,CDM,6370000000,HCPCS,0637,RC,68462-0330-90,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
SCREW EXT FIX L150MM DIA5MM THRD L150MM S STL SELF DRL MR,SUP-2186985,CDM,C1713,HCPCS,0278,RC,,,,both,,,461.77,300.15,,,,,,,,,,,,,
HC CT Facial Bones W/ Contrast,PX-3517048700,CDM,70487,CPT,0351,RC,,,,both,,,2630.00,1709.50,,,,,,,,,,,,,
CEMENT BNE SM 4ML CA PHSPTE VOID FILL INJ RESRB,SUP-2293453,CDM,C1713,HCPCS,0278,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
PLATE BONE L107MM 8 H BILAT ELBW 1/3 TBLR LCK COMPR FOR,SUP-2348938,CDM,C1713,HCPCS,0278,RC,,,,both,,,1666.05,1082.93,,,,,,,,,,,,,
END CAP 16X10MM EXT T40 STARDRV TI STRL,SUP-2546238,CDM,C1889,HCPCS,0278,RC,,,,both,,,755.14,490.84,,,,,,,,,,,,,
PLATE BNE SM CALCANEUS RAREFT FOR TOT FT SYS 2,SUP-2243251,CDM,C1713,HCPCS,0278,RC,,,,both,,,6191.23,4024.30,,,,,,,,,,,,,
CATHETER ANGIOPLSTY VASCUTRAK L 140 CM BALLOON L 15 CM,SUP-2128680,CDM,C1725,HCPCS,0272,RC,,,,both,,,1962.50,1275.62,,,,,,,,,,,,,
GRAFT HUM TISS L60-80MM DIA7.5-10.5MM FRZN FLEXIGRFT,SUP-2264760,CDM,C1713,HCPCS,0278,RC,,,,both,,,7567.27,4918.73,,,,,,,,,,,,,
HC Injection for Cholangiogram,PX-3614753100,CDM,47531,CPT,0361,RC,,,,inpatient,,,12375.00,8043.75,,,,,,,,,,,,,
CLONIDINE 0.1 MG/24HR TD PTWK,RX-143501,CDM,6370000000,HCPCS,0637,RC,00378-0871-16,NDC,,both,1,UN,119.30,77.54,,,,,,,,,,,,,
ROD W/ HEX 40MM TI ALLOY CVD,SUP-2415261,CDM,C1713,HCPCS,0278,RC,,,,both,,,1425.56,926.61,,,,,,,,,,,,,
DEFIBRILLATOR IMPL EVERA MRI XT SURESCAN W 51 X H 68 MM D 13,SUP-2282399,CDM,C1721,HCPCS,0275,RC,,,,both,,,35168.00,22859.20,,,,,,,,,,,,,
ANCHOR SUT PEEK OD4.5MM ORTHOCORD HEALIX ADV FORC FBR,SUP-2249462,CDM,C1713,HCPCS,0278,RC,,,,both,,,1281.12,832.73,,,,,,,,,,,,,
SEED BRACHYTHERAPY LOOSE 6.01-7.0 MCI NS ADVANTAGE,SUP-2247277,CDM,C2643,HCPCS,0278,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
SPACER EXT FIX 5 MM SIDEKCK EZ FRAME EF3005PK,SUP-2493824,CDM,2720000010,LOCAL,0272,RC,,,,both,,,530.66,344.93,,,,,,,,,,,,,
CATHETER SUPRPUB DIA12FR PLAS DISP RUSCH,SUP-2383925,CDM,C2627,HCPCS,0272,RC,,,,both,,,50.59,32.88,,,,,,,,,,,,,
LEAD NEUROSTIMULATOR L50CM DIA1MM 5MM SPC 4 ELECTRD PERC TRL,SUP-2357675,CDM,C1778,HCPCS,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
GUIDEWIRE ORTH L1.1MM INTRO,SUP-2121824,CDM,C1769,HCPCS,0272,RC,,,,both,,,197.82,128.58,,,,,,,,,,,,,
HC Mra Lower Ext W/O Contrast,PX-6107372501,CDM,C8913,CPT,0610,RC,,,,both,,,4365.00,2837.25,,,,,,,,,,,,,
GRAFT VASC TW 8 MMX50 CM STR REINF RNG SLDE GDS ADVANTA VXT,SUP-2468689,CDM,C1768,CPT,0278,RC,,,,both,,,2116.33,1375.61,,,,,,,,,,,,,
GUIDEWIRE HYDRPHLC ANG REG TIP 0038INX150CM ZIPWIRE,SUP-2139335,CDM,C1769,HCPCS,0272,RC,,,,both,,,168.56,109.56,,,,,,,,,,,,,
EXTENSION STEM L40MM PROX FEM MOD PC GMRS,SUP-2376556,CDM,C1776,CPT,0278,RC,,,,both,,,7254.34,4715.32,,,,,,,,,,,,,
PLATE BNE L60MM 4 H NONSTERILE L PROX TIB S STL LO PROF,SUP-2185810,CDM,C1713,HCPCS,0278,RC,,,,both,,,3677.73,2390.52,,,,,,,,,,,,,
PLATE BNE W17.5XL206MM THK5.2MM 11 H BILAT S STL BROAD LOK,SUP-2185296,CDM,C1713,HCPCS,0278,RC,,,,both,,,1805.56,1173.61,,,,,,,,,,,,,
BIT DRILL EX LONG CALIBRATED 4.3MM,SUP-2741119,CDM,2720000010,LOCAL,0272,RC,,,,both,,,538.82,350.23,,,,,,,,,,,,,
EPIFIX 2X3CM 6SQ CM SHEET,SUP-2305750,CDM,Q4186,HCPCS,0636,RC,,,,both,,,4069.44,2645.14,,,,,,,,,,,,,
HC Mra Up Extremities W/Cont,PX-6107322500,CDM,73225,CPT,0610,RC,,,,both,,,4365.00,2837.25,,,,,,,,,,,,,
TRIAL SCREW TALAR,SUP-2223541,CDM,C1713,HCPCS,0278,RC,,,,both,,,172.70,112.25,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 15 CM DIA 5 MM EPTFE STR TW N RING,SUP-2396334,CDM,C1768,CPT,0278,RC,,,,both,,,1262.28,820.48,,,,,,,,,,,,,
GUIDEWIRE ORTH SMOOTH 22X800 MM FOR HUM NAILING SYS T2,SUP-2368576,CDM,C1769,HCPCS,0272,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
PLATE BNE METATARSOPHALANGEAL RT 6 HOLE REV,SUP-2525795,CDM,C1713,HCPCS,0278,RC,,,,both,,,4807.34,3124.77,,,,,,,,,,,,,
"HC Est Pt, Outpt Visit Level 3",PX-7619921300,CDM,99213,CPT,0761,RC,,,,both,,,257.00,167.05,,,,,,,,,,,,,
COMPONENT TIB UNI 3 12 MM RT LAT MEDL KNEE M/G,SUP-2205997,CDM,C1776,CPT,0278,RC,,,,both,,,4477.64,2910.47,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH FLX L 39 MM DIA 32 MM SHTH 20 FR RVD,SUP-2170109,CDM,C1874,HCPCS,0278,RC,,,,both,,,5664.56,3681.96,,,,,,,,,,,,,
ENDOPROBE MOD STD STR 23 GA,SUP-2247215,CDM,C1713,HCPCS,0278,RC,,,,both,,,528.56,343.56,,,,,,,,,,,,,
TRASTUZUMAB 150 MG IV SOLR,RX-138289,CDM,J9355,HCPCS,0636,RC,50242-0132-01,NDC,,both,1,UN,4519.70,2937.80,,,,,,,,,,,,,
HC So Flow Cytometry,PX-3118818466,CDM,88184,CPT,0311,RC,,,,both,,,246.00,159.90,,,,,,,,,,,,,
SPLINT ORTH L3IN STD PLAS FNGR MLLT W/O PD STAX,SUP-2198709,CDM,L3913,HCPCS,0274,RC,,,,both,,,5.18,3.37,,,,,,,,,,,,,
PLATE TI 13 TUBULAR 10 HL,SUP-2704881,CDM,C1713,HCPCS,0278,RC,,,,both,,,375.86,244.31,,,,,,,,,,,,,
PLATE BNE 130 DEG PEDIATRIC 3.5X114 MM 19/12 MM 7 HOLE LCP,SUP-2799199,CDM,C1713,HCPCS,0278,RC,,,,both,,,2618.07,1701.75,,,,,,,,,,,,,
DEVICE SPNL OFFSET 80 MM LAT,SUP-2175452,CDM,C1713,HCPCS,0278,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
ALIGNRITE WRIST BLK SHRT RGHT MED,SUP-2462313,CDM,L3906,HCPCS,0274,RC,,,,both,,,54.13,35.18,,,,,,,,,,,,,
NAIL IM L480MM DIA13MM L LAT FEM LT GRN TI CANN LOK CRV,SUP-2179784,CDM,C1713,HCPCS,0278,RC,,,,both,,,5203.26,3382.12,,,,,,,,,,,,,
CATHETER HD KT 12 FRX16 CM DL INTRO INJ NDL TISS DIL SUTURE,SUP-2762984,CDM,C1752,HCPCS,0278,RC,,,,both,,,271.30,176.34,,,,,,,,,,,,,
STENT URET L 30 CM DIA 6 FR PTFE GUIDEWIRE L 100 CM DIA BLK,SUP-2312680,CDM,C2617,HCPCS,0278,RC,,,,both,,,439.57,285.72,,,,,,,,,,,,,
SHEATH GUID 6FR L45CM ID2.2MM GWIRE 0.018X0.038IN RENAL DBL,SUP-2169815,CDM,C1894,HCPCS,0272,RC,,,,both,,,188.40,122.46,,,,,,,,,,,,,
CAP PROTCT EXT FIX 5X4.5 MM TRANSFX,SUP-2362753,CDM,C1713,HCPCS,0278,RC,,,,both,,,6.28,4.08,,,,,,,,,,,,,
SCREW BNE L25MM DIA5MM CORT CONIC S STL ST CANN LOK FULL,SUP-2184909,CDM,C1713,HCPCS,0278,RC,,,,both,,,643.70,418.40,,,,,,,,,,,,,
SCREW BNE COMPR FOR MULT LCK HUM NAILING SYS NAIL NS,SUP-2799397,CDM,C1713,HCPCS,0278,RC,,,,both,,,1887.83,1227.09,,,,,,,,,,,,,
GRAFT BONE SUB W6.5XH25XL20MM 10DEG B TRICALCIUM PHOS GRAN,SUP-2194022,CDM,C1713,HCPCS,0278,RC,,,,both,,,3081.60,2003.04,,,,,,,,,,,,,
INSTRUMENT EXT FIX UNIV MINI TOOL TOMAHAWK SIDEKCK,SUP-2400711,CDM,2720000010,LOCAL,0272,RC,,,,both,,,445.88,289.82,,,,,,,,,,,,,
PASSER WIRE AC STRL DISP,SUP-2910486,CDM,2720000010,LOCAL,0272,RC,,,,both,,,527.52,342.89,,,,,,,,,,,,,
CATHETER ABLAT 7FR L115CM 1-7-4MM SPC TIP 4MM 4 ELECTRD DF,SUP-2248496,CDM,C1733,HCPCS,0272,RC,,,,both,,,2628.18,1708.32,,,,,,,,,,,,,
PLATE BNE L 100 DEG 1.7X5 MM LT 6 HOLE BAR TI GLD NS,SUP-2366306,CDM,C1713,HCPCS,0278,RC,,,,both,,,644.01,418.61,,,,,,,,,,,,,
CATHETER DRAINAGE 0.038 IN 8.5 FRX25 CM MP NLCK 6 SP UTHANE,SUP-2168159,CDM,C1729,HCPCS,0272,RC,,,,both,,,198.98,129.34,,,,,,,,,,,,,
ROD SPNL L360MM DIA5.5MM CERV TI THRD VERTEX SEL,SUP-2289125,CDM,C1713,HCPCS,0278,RC,,,,both,,,1675.66,1089.18,,,,,,,,,,,,,
WIRE FIX L4IN OD.9MM XSM SM PHALINX K,SUP-2396964,CDM,C1713,HCPCS,0278,RC,,,,both,,,40.82,26.53,,,,,,,,,,,,,
DEXTROSE 5 % IV SOLN INTERMITTENT INFUSION,RX-40840103,CDM,2580000003,HCPCS,0250,RC,00264-1510-32,NDC,,both,250,ML,53.20,34.58,,,,,,,,,,,,,
HC Chemo Push Each Addt Drug,PX-3319641100,CDM,96411,CPT,0331,RC,,,,outpatient,,,432.00,280.80,,,,,,,,,,,,,
COMPONENT FEM SZ 4 RT KNEE CO CHROM NP PRI CEM STEMLESS,SUP-2304635,CDM,C1776,CPT,0278,RC,,,,both,,,9817.21,6381.19,,,,,,,,,,,,,
CONFORMER EYE 28 X 24 X 10 MM SZ 5 LG STEEPER ANTR CRV VLT,SUP-2883205,CDM,2720000010,LOCAL,0272,RC,,,,both,,,789.80,513.37,,,,,,,,,,,,,
RING RADLUC 1 3 190MM,SUP-2316274,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1037.64,674.47,,,,,,,,,,,,,
DEXTROSE 5 % IV SOLN INTERMITTENT INFUSION,RX-40840103,CDM,J7060,HCPCS,0250,RC,00264-7510-10,NDC,,both,250,ML,17.00,11.05,,,,,,,,,,,,,
CYANOCOBALAMIN 1000 MCG/ML IJ SOLN,RX-2007,CDM,J3420,HCPCS,0636,RC,69680-0112-25,NDC,,both,0.1,ML,54.10,35.16,,,,,,,,,,,,,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,0636,RC,00049-0014-83,NDC,,both,1,UN,83.80,54.47,,,,,,,,,,,,,
"HC So Spectrophotometry, Analyte Nes",PX-3018431166,CDM,84311,CPT,0301,RC,,,,both,,,298.00,193.70,,,,,,,,,,,,,
GUIDEWIRE VASC ACCS 4FR W CO AX INTRO S STL ECHOGENIC SET,SUP-2424403,CDM,C1769,HCPCS,0272,RC,,,,both,,,58.09,37.76,,,,,,,,,,,,,
HC Cardiac Rehab Phase 3 - 15 Visits,PX-9900000040,CDM,9900000040,LOCAL,0990,RC,,,,both,,,38.00,24.70,,,,,,,,,,,,,
CATHETER KIT DL 8 FRX6 IN CV BLU FLEXTIP ARROWG+ARD BLU,SUP-2120597,CDM,C1751,HCPCS,0278,RC,,,,both,,,200.33,130.21,,,,,,,,,,,,,
GRAFT BONE SUB 5CC L1-10MM CANC CRUSH FRZ DRY,SUP-2165595,CDM,C1713,HCPCS,0278,RC,,,,both,,,386.22,251.04,,,,,,,,,,,,,
BRACE WALKING LP MED 5.5-10 IN 6.5-11 IN AD M MAXTRAX AIR,SUP-2427327,CDM,L4360,HCPCS,0274,RC,,,,both,,,93.76,60.94,,,,,,,,,,,,,
HIP IMPLANT SYSTEM 4.75MM SPEEDBRIDGE,SUP-2816786,CDM,C1713,HCPCS,0278,RC,,,,both,,,7834.30,5092.29,,,,,,,,,,,,,
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5ML PO SOLN,RX-29302,CDM,J7510,HCPCS,0637,RC,99999-9917-37,NDC,,both,5,ML,2.70,1.75,,,,,,,,,,,,,
VARENICLINE TARTRATE 0.5 MG PO TABS,RX-76444,CDM,6370000000,HCPCS,0637,RC,49884-0155-76,NDC,,both,1,UN,4.50,2.92,,,,,,,,,,,,,
HEAD HUM DIA40MM THK12MM SHLDR CO CHROM PRI STD OFFSET NK,SUP-2372831,CDM,C1776,CPT,0278,RC,,,,both,,,5609.61,3646.25,,,,,,,,,,,,,
SCREW BNE L50MM DIA5MM UNICORTICAL FEM TI ST LOK 2 COR FULL,SUP-2180157,CDM,C1713,HCPCS,0278,RC,,,,both,,,716.30,465.59,,,,,,,,,,,,,
BUR SURG COARSE DIAMOND 3 MM 10 CM BALL MIDAS REX 8 LEGEND,SUP-2664481,CDM,2720000010,LOCAL,0272,RC,,,,both,,,390.36,253.73,,,,,,,,,,,,,
SCREW BONE L40MM DIA9.5MM THRD L12.7MM S STL INTERMED LAG,SUP-2343606,CDM,C1713,HCPCS,0278,RC,,,,both,,,4142.29,2692.49,,,,,,,,,,,,,
HC Insert Picc Cath,PX-4503656900,CDM,36569,CPT,0450,RC,,,,outpatient,,,4942.00,3212.30,,,,,,,,,,,,,
GRAFT VASC GORTX L 70 CM DIA 6 MM RNG L 60 CM EPTFE STR STD,SUP-2396095,CDM,C1768,CPT,0278,RC,,,,both,,,2885.66,1875.68,,,,,,,,,,,,,
PLATE BNE W14XL85MM THK3.8MM 4 H R TIB L SHP BTTRS L ANG S,SUP-2185775,CDM,C1713,HCPCS,0278,RC,,,,both,,,681.38,442.90,,,,,,,,,,,,,
DRESSING WND 3 LAYR 7X10 CM MTRX CYTAL,SUP-2106529,CDM,Q4166,HCPCS,0636,RC,,,,both,,,6744.72,4384.07,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 260 MM DIA22/13 MM DEL,SUP-2934213,CDM,C1713,HCPCS,0278,RC,,,,both,,,22144.72,14394.07,,,,,,,,,,,,,
STAPLE INT WHT BLU GRN REINF FOR ENDOPATH ETS45 SEAMGRD,SUP-2395317,CDM,C1713,HCPCS,0278,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
SET TRAUMA FIXATION 3.5MM DISTAL HUMERAL F/LCP PLATE,SUP-2177062,CDM,C1713,HCPCS,0278,RC,,,,both,,,190183.33,123619.16,,,,,,,,,,,,,
KIT INTRO MINI ACCS NONVASCULAR 6FRX20CM 4FR W DIL 0038,SUP-2303022,CDM,C1894,HCPCS,0272,RC,,,,both,,,192.73,125.27,,,,,,,,,,,,,
CATHETER ATHRCTMY ROTLNK L 135 MM DIA 0.058 IN BUR DIA1.75,SUP-2147020,CDM,C1724,HCPCS,0278,RC,,,,both,,,3091.33,2009.36,,,,,,,,,,,,,
CAGE SPINL EXCEED INTERBODY DEVICE 22 MM L X 10 MM W X 11 MM H 8DEG LORDOTIC,SUP-2934668,CDM,C1889,HCPCS,0278,RC,,,,both,,,15684.30,10194.79,,,,,,,,,,,,,
PIN GUID L2.5IN DIA0.062IN FOR FT PLATING SYS EXTREMILOCK,SUP-2319606,CDM,C1713,HCPCS,0278,RC,,,,both,,,160.14,104.09,,,,,,,,,,,,,
SCREW BNE L70MM DIA4MM HEX HD DIA62MM CORT DST FEM TI ST,SUP-2205007,CDM,C1713,HCPCS,0278,RC,,,,both,,,349.29,227.04,,,,,,,,,,,,,
CATHETER INFUSION UNI-FUSE L 135 CM DIA 5 FR SLT PAT L 50 CM,SUP-2118485,CDM,C1757,HCPCS,0272,RC,,,,both,,,356.70,231.85,,,,,,,,,,,,,
BASKET STONE REMV L45CM L24CM OD22CM ODSEC12FR NIT BILI,SUP-2168101,CDM,C1713,HCPCS,0278,RC,,,,both,,,1175.62,764.15,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH ALPHA L 154 MM DIA 30 MM NIT POLYPRO,SUP-2751297,CDM,C1874,HCPCS,0278,RC,,,,both,,,33073.81,21497.98,,,,,,,,,,,,,
GRAFT BNE SUB 20CC VI DIA4.8MM CA SULF PELLET RESRB PRELD,SUP-2399031,CDM,C1713,HCPCS,0278,RC,,,,both,,,3307.77,2150.05,,,,,,,,,,,,,
BUPIVACAINE-EPINEPHRINE 0.5% -1:200000 IJ SOLN,RX-9318,CDM,2500000003,HCPCS,0250,RC,63323-0463-57,NDC,,both,1,ML,54.10,35.16,,,,,,,,,,,,,
PLATE BNE 3 X 2 H 3D SQ SEG NS,SUP-2883292,CDM,C1713,HCPCS,0278,RC,,,,both,,,1098.37,713.94,,,,,,,,,,,,,
HC Ot Eval Low Complex,PX-4349716500,CDM,97165,CPT,0434,RC,,,,both,,,184.00,119.60,,,,,,,,,,,,,
FIXATOR ORTH WRST LO PROF W 4 25MM SCHNZ SCR 200MM C FBR ROD,SUP-2179121,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2980.65,1937.42,,,,,,,,,,,,,
TEMPLATE SURG LEV 1 THOR RIB KEYRING,SUP-2262536,CDM,2720000010,LOCAL,0272,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
COMPONENT KNEE CEM PRIMARY SCORP,SUP-2379190,CDM,C1776,CPT,0278,RC,,,,both,,,13502.00,8776.30,,,,,,,,,,,,,
STENT COLON UFLX PRECIS L 87 MM WORKING L 100 CM DIA25 MM,SUP-2149676,CDM,C1876,HCPCS,0278,RC,,,,both,,,5369.40,3490.11,,,,,,,,,,,,,
BLADE ENDOSCP SHAVER 12 DEG L 11 CM DIA 4 MM SPD 1500 RPM,SUP-2902118,CDM,2720000010,LOCAL,0272,RC,,,,both,,,657.64,427.47,,,,,,,,,,,,,
PLATE DIST ANT TIB RT 6HL 127MM,SUP-2695698,CDM,C1713,HCPCS,0278,RC,,,,both,,,6866.55,4463.26,,,,,,,,,,,,,
BIT DRL LATITUDE EV DISP,SUP-2715606,CDM,2720000010,LOCAL,0272,RC,,,,both,,,866.64,563.32,,,,,,,,,,,,,
SEGMENTAL STR FLUTED STEM 12X130MM,SUP-2502462,CDM,C1776,CPT,0278,RC,,,,both,,,10286.64,6686.32,,,,,,,,,,,,,
WIRE BRST LESION L7.7CM DIA20GA LOC DUALOK,SUP-2126946,CDM,C1819,HCPCS,0278,RC,,,,both,,,484.82,315.13,,,,,,,,,,,,,
PLATE SPNL BURR HOLE CVR 5 MM CRAN GRDIAN,SUP-2637197,CDM,C1713,HCPCS,0278,RC,,,,both,,,372.62,242.20,,,,,,,,,,,,,
VALVE SPEAK W/ O2 PRT PHONATE,SUP-2283884,CDM,L8501,HCPCS,0272,RC,,,,both,,,79.91,51.94,,,,,,,,,,,,,
KNIFE SRGCL BLLNGR 3MM BLADE 8NL BNT SWVL LATEX FREE,SUP-2494303,CDM,2720000010,LOCAL,0272,RC,,,,both,,,416.46,270.70,,,,,,,,,,,,,
TUBE ET L40CM DIA8MM LSR RESIST FOAM SURROUND MAGILL CUF,SUP-2383547,CDM,2720000010,LOCAL,0272,RC,,,,both,,,316.89,205.98,,,,,,,,,,,,,
HC Alpha-1-Antitrypsin Total,PX-3018210300,CDM,82103,CPT,0301,RC,,,,both,,,208.00,135.20,,,,,,,,,,,,,
GUIDEWIRE VASC STR 0.035 INX300 CM SELECTIVA,SUP-2424960,CDM,C1769,HCPCS,0272,RC,,,,both,,,202.00,131.30,,,,,,,,,,,,,
DEFIBRILLATOR IMPL LUMAX 540 DR-T 55 X 66MM 13 MM 40J MOB,SUP-2138261,CDM,C1721,HCPCS,0275,RC,,,,both,,,37052.00,24083.80,,,,,,,,,,,,,
CATHETER EP CRD 5 MM 4 FR 10 FIX CRV INQUIRY,SUP-2357389,CDM,C1730,HCPCS,0272,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
CANNULA ENDOSCP DIL 3 MM FOR INTRO OF 27091S 2ND SAFETY PRB,SUP-2767836,CDM,2720000010,LOCAL,0272,RC,,,,both,,,871.38,566.40,,,,,,,,,,,,,
BRACE THMB AD SM FOR 6-6.875IN LT MCP BLK ALIDRY FAB BRTH,SUP-2323970,CDM,L3931,HCPCS,0274,RC,,,,both,,,92.50,60.12,,,,,,,,,,,,,
GRAFT VASC GELWEAVE L 40 CM DIA28 MM L 15 CM 10 MM AG FLO,SUP-2385036,CDM,C1768,CPT,0278,RC,,,,both,,,5228.10,3398.26,,,,,,,,,,,,,
PLATE BNE L10MM N COMPR CHIN BILAT 20MM SCR H DIA 4 H RIG,SUP-2366338,CDM,C1713,HCPCS,0278,RC,,,,both,,,871.57,566.52,,,,,,,,,,,,,
BRACE ORTHOPEDIC LUMBAR MIAMI,SUP-2319301,CDM,L0642,HCPCS,0274,RC,,,,both,,,3959.54,2573.70,,,,,,,,,,,,,
CATHETER ANGIO GLIDECATH L 150 CM DIA 4 FR DIA1.05 MM IMA,SUP-2615634,CDM,C1887,HCPCS,0272,RC,,,,both,,,164.54,106.95,,,,,,,,,,,,,
HEAD ALUMINA 32MM 0MM 5-40,SUP-2364457,CDM,C1776,CPT,0278,RC,,,,both,,,2754.57,1790.47,,,,,,,,,,,,,
NEEDLE TRANSSEPTAL FLEXCATH CROSS L 65 CM DIA12 FR ACCS DIL,SUP-2882553,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
PLATE BNE L53MM THK1.2MM 2X8 H TI T FOR 2MM SCR,SUP-2191243,CDM,C1713,HCPCS,0278,RC,,,,both,,,1151.41,748.42,,,,,,,,,,,,,
COMPONENT PATELLAR 3 PEG STD KNEE MOD RND RP PRIMARY CEM,SUP-2252414,CDM,C1776,CPT,0278,RC,,,,both,,,5188.54,3372.55,,,,,,,,,,,,,
BLADE SAW OSCLLTNG 5.5MMW X25.5MML 0.6MM/0.8MM THK CUT BRAZO,SUP-2605487,CDM,2720000010,LOCAL,0272,RC,,,,both,,,82.36,53.53,,,,,,,,,,,,,
CATHETER INFUSION PULSE SPRY L 90 CM DIA 5 FR SLT PAT L 5 CM,SUP-2118499,CDM,C1757,HCPCS,0272,RC,,,,both,,,832.10,540.86,,,,,,,,,,,,,
SUPPORT ORTHOT CUST FURNISHING INIT ORTHOSIS ONLY,SUP-2435584,CDM,L1200,HCPCS,0272,RC,,,,both,,,5066.39,3293.15,,,,,,,,,,,,,
MAXLOCK EXTRM WSHR,SUP-2401260,CDM,C1713,HCPCS,0278,RC,,,,both,,,625.49,406.57,,,,,,,,,,,,,
DEXTROSE 5 % IN LACTATED RINGERS IV BOLUS,RX-40840058,CDM,2580000003,HCPCS,0258,RC,00264-7751-00,NDC,,both,250,ML,6.40,4.16,,,,,,,,,,,,,
TOOL BORING MED 9.5X10.4 MM M18 FOR TPS SYS,SUP-2363347,CDM,2720000010,LOCAL,0272,RC,,,,both,,,489.75,318.34,,,,,,,,,,,,,
IMPLANT TOE JT CANN HEMI AND METATRSL HD IMPL SYS LESSER JT,SUP-2392820,CDM,C1776,CPT,0278,RC,,,,both,,,5636.30,3663.59,,,,,,,,,,,,,
PROBE MON NEURO DISP,SUP-2115733,CDM,C1713,HCPCS,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
PLATE BONE 6 H MAND STR W/ BAR,SUP-2365233,CDM,C1713,HCPCS,0278,RC,,,,both,,,2577.41,1675.32,,,,,,,,,,,,,
CAGE SPINAL W14XH8XL16MM 8DEG ZERO PROFILE TOMCAT,SUP-2550522,CDM,C1889,HCPCS,0278,RC,,,,both,,,8792.00,5714.80,,,,,,,,,,,,,
STRAP CLAV STD L,SUP-2276600,CDM,L3650,HCPCS,0272,RC,,,,both,,,14.19,9.22,,,,,,,,,,,,,
NAIL IM L440MM DIA25MM OLECRANON ROSE RED S STL E FLX,SUP-2186443,CDM,C1713,HCPCS,0278,RC,,,,both,,,849.53,552.19,,,,,,,,,,,,,
SCREW COMPR 1.5X9MM HEADLESS SS STRL,SUP-2546183,CDM,C1713,HCPCS,0278,RC,,,,both,,,751.68,488.59,,,,,,,,,,,,,
CATHETER ABLAT 7FR L115CM 1-7-4MM SPC TIP 4MM 4 ELECTRD,SUP-2248516,CDM,C1732,HCPCS,0272,RC,,,,both,,,6669.36,4335.08,,,,,,,,,,,,,
IMPLANT GYN L 7 X W 4 CM ALLGRFT FASC LATA PROC UNI DIR STRL,SUP-2896107,CDM,C1762,CPT,0278,RC,,,,both,,,3771.14,2451.24,,,,,,,,,,,,,
ALLOPATCH HD MESHED THIN 04 07MM 4CM X 4CM HYDRATED,SUP-2726037,CDM,Q4128,HCPCS,0636,RC,,,,both,,,3200.13,2080.08,,,,,,,,,,,,,
PIN FIX SM REPL AXLE,SUP-2372335,CDM,C1713,HCPCS,0278,RC,,,,both,,,3305.16,2148.35,,,,,,,,,,,,,
SIDEPLATE STD BARL 140 DEG 16H STRL LCP DHHS,SUP-2547668,CDM,C1713,HCPCS,0278,RC,,,,both,,,2968.49,1929.52,,,,,,,,,,,,,
BLADE RTRCTR MCCLLCH 27MMW X 50MML SPNL MSCLE WIDE RGGLS RDM,SUP-2670371,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1591.89,1034.73,,,,,,,,,,,,,
BIT DRILL JLATCH 2.2X135 MM 20 MM,SUP-2841965,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2942.81,1912.83,,,,,,,,,,,,,
RING EXT FIX FULL 140 MM NS TRUELOK LTX,SUP-2875055,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1772.47,1152.11,,,,,,,,,,,,,
MESH SURG W10XL15CM THK1MM OVL BIOMATERIAL MYCROMESH,SUP-2395361,CDM,C1781,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
PROSTHESIS TESTICULAR XS 22X3 CM SIL ELASTMR NACL TOROSA,SUP-2165301,CDM,C1713,HCPCS,0278,RC,,,,both,,,7542.28,4902.48,,,,,,,,,,,,,
SCREW BNE L 120 MM DIA 3.5 MM SS CORTICAL ST STRL EVOS,SUP-2931996,CDM,C1713,HCPCS,0278,RC,,,,both,,,206.11,133.97,,,,,,,,,,,,,
SCREW BNE DPHSEAL KNEE TI LOK,SUP-2405832,CDM,C1713,HCPCS,0278,RC,,,,both,,,763.02,495.96,,,,,,,,,,,,,
DEVICE PESSARY SZ 3 SIL FIT RNG MILEX,SUP-2171769,CDM,A4562,HCPCS,0272,RC,,,,both,,,228.75,148.69,,,,,,,,,,,,,
RELOAD STPLR RADIAL MED 2 MM VASC TRI-STAPLE,SUP-2787707,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2151.12,1398.23,,,,,,,,,,,,,
PLATE RECON THRDLCK TS ANGLE ANGLE 27 MM SCREW 30 HOLE T30,SUP-2679089,CDM,C1713,HCPCS,0278,RC,,,,both,,,4889.64,3178.27,,,,,,,,,,,,,
PACEMAKER CARD INVIVE W 1.75 X H 2.4 IN THK 0.76 CM 34 GM,SUP-2149292,CDM,C2621,HCPCS,0275,RC,,,,both,,,24178.00,15715.70,,,,,,,,,,,,,
GRAFT TIB DST L ALLGRFT,SUP-2335299,CDM,C1713,HCPCS,0278,RC,,,,both,,,21964.30,14276.79,,,,,,,,,,,,,
INTRODUCER HEMSTAS 8FR L85CM GWIRE 0.038IN 5CM J W/ DIL FAST,SUP-2355578,CDM,C1894,HCPCS,0272,RC,,,,both,,,151.51,98.48,,,,,,,,,,,,,
HC M/Phmtrc Alys Ish Quant/Semiq Mnl per Spec Each,PX-3128836900,CDM,88369,CPT,0312,RC,,,,both,,,360.00,234.00,,,,,,,,,,,,,
CUTTER SUT TENSIONER,SUP-2121615,CDM,2720000010,LOCAL,0272,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
MESH CRAN L 90 X W 90 MM SCREW DIA2 MM TI PANEL NS DISP,SUP-2936495,CDM,C1713,HCPCS,0278,RC,,,,both,,,3840.22,2496.14,,,,,,,,,,,,,
IMPLANT HUM TISS L 6 X W 4 CM PLCNTA MTRX MEMBRN MINIMALLY,SUP-2905502,CDM,C1762,CPT,0278,RC,,,,both,,,7159.20,4653.48,,,,,,,,,,,,,
DEXTROSE 5 % AND 0.9 % NACL IV BOLUS|DISCARDED DRUG NOT ADMINISTE,RX-40840054,CDM,2580000003,HCPCS,0258,RC,00264-7610-00,NDC,JW,both,250,ML,8.50,5.52,,,,,,,,,,,,,
TREPHINE BONE BX ORTH DISECT SZ 11 MM SHRP STR,SUP-2136787,CDM,C1776,CPT,0278,RC,,,,both,,,1585.70,1030.70,,,,,,,,,,,,,
HC Vasc Embolize Occlude Artery,PX-3613724200,CDM,37242,CPT,0361,RC,,,,both,,,20612.00,13397.80,,,,,,,,,,,,,
PLATE BNE W11XL138MM THK33MM 10 H BILAT MTPHSEAL TI LOK,SUP-2190764,CDM,C1713,HCPCS,0278,RC,,,,both,,,2811.93,1827.75,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE MED 5.4 CC CORTICOCANCELLOUS VIABLE,SUP-2933296,CDM,C1762,CPT,0278,RC,,,,both,,,26546.31,17255.10,,,,,,,,,,,,,
BLADE SCREWDRIVER 2X84.5 MM CMF MMF INSIDE TIP SS LEVEL 1,SUP-2469114,CDM,2720000010,LOCAL,0272,RC,,,,both,,,470.12,305.58,,,,,,,,,,,,,
INTRODUCER VASC 6FR 10CM LEN W/OUT CRV HEMSTAT VLV 45CM DIL,SUP-2385252,CDM,C1894,HCPCS,0272,RC,,,,both,,,215.09,139.81,,,,,,,,,,,,,
BIOMEPRO PO CPDR,RX-155409,CDM,6370000000,HCPCS,0637,RC,26608-0001-54,NDC,,both,1,UN,9.00,5.85,,,,,,,,,,,,,
SHEATH INTRO FLX RAABE L 70 CM OD 5 FR GUIDEWIRE 0.038 IN,SUP-2168824,CDM,C1894,HCPCS,0272,RC,,,,both,,,152.29,98.99,,,,,,,,,,,,,
ANCHOR SUT L76MM DIA27MM TI ST SELF DRL FOR 2 0 FORC FBR,SUP-2399136,CDM,C1776,CPT,0278,RC,,,,both,,,926.30,602.09,,,,,,,,,,,,,
PAD ORTHOT LUMBAR RIB CUST,SUP-2435574,CDM,L1040,HCPCS,0274,RC,,,,both,,,251.01,163.16,,,,,,,,,,,,,
CATHETER ABLAT OD7.5FR 2-5-2MM SPC 4 POLE DEFL C THRMSTER,SUP-2248929,CDM,C1732,HCPCS,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
ASSEMBLY ADPT 39MM TOT RVS SHLDR PROS CA REVERS,SUP-2123338,CDM,C1776,CPT,0278,RC,,,,both,,,6751.00,4388.15,,,,,,,,,,,,,
PLATE BNE STR 3.5X235 MM 18 HOLE RECON LCK SS STRL,SUP-2474971,CDM,C1713,HCPCS,0278,RC,,,,both,,,2059.56,1338.71,,,,,,,,,,,,,
GRAFT NERVE REP L 6 X W 3 CM AMNIO MEMBRN MULTLYRED MTRX,SUP-2914053,CDM,C1762,CPT,0278,RC,,,,both,,,12481.50,8112.97,,,,,,,,,,,,,
OSTEOTOME SURG L8IN BLDE W95MM CRV SMITH PETERSON,SUP-2161289,CDM,C1713,HCPCS,0278,RC,,,,both,,,265.36,172.48,,,,,,,,,,,,,
SCREW SPNL 4.5X55 MM HA TSRH 3DX OSTEOGRIP,SUP-2631153,CDM,C1713,HCPCS,0278,RC,,,,both,,,2088.10,1357.26,,,,,,,,,,,,,
GUIDEWIRE URLGCL 0038N DIA 150CML 3CML TIP STRGHT TIP STIFF,SUP-2722858,CDM,C1769,HCPCS,0272,RC,,,,both,,,110.21,71.64,,,,,,,,,,,,,
INSTRUMENT KIT 2.5X7 MM NANO SWIVELOCK DISP,SUP-2421833,CDM,2720000010,LOCAL,0272,RC,,,,both,,,926.30,602.09,,,,,,,,,,,,,
BRACE ORTHOPEDIC IMMOB KNEE CUST,SUP-2265015,CDM,L1810,HCPCS,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
STAPLE KIT 15X15/17 MM STRL INSTAFIX LTX DISP,SUP-2857581,CDM,C1713,HCPCS,0278,RC,,,,both,,,3654.96,2375.72,,,,,,,,,,,,,
ALLOGRAFT BNE 60 MM FEM SHFT STRL BIO LF DISP,SUP-2632312,CDM,C1762,CPT,0278,RC,,,,both,,,3165.12,2057.33,,,,,,,,,,,,,
COMPONENT TALAR SZ 4 ANK CO CHROME POR CEM BASE PLT REV AGIL,SUP-2252061,CDM,C1776,CPT,0278,RC,,,,both,,,9187.64,5971.97,,,,,,,,,,,,,
SYSTEM THERMOABLATION COBRA FUSION 50 L 50 MM INTEGR PACE,SUP-2124418,CDM,C1713,HCPCS,0278,RC,,,,both,,,14130.00,9184.50,,,,,,,,,,,,,
WIRE TRCR .045X4.72IN K,SUP-2402826,CDM,C1713,HCPCS,0278,RC,,,,both,,,662.54,430.65,,,,,,,,,,,,,
PERC NCOMPASS NITINOL TIPLESS STONE EXTRACTOR,SUP-2827000,CDM,2720000010,LOCAL,0272,RC,,,,both,,,799.76,519.84,,,,,,,,,,,,,
NEEDLE TRANSSEPTAL 19GA L56CM 50DEG BVL ANG S STL BRK CRV SM,SUP-2357224,CDM,C1713,HCPCS,0278,RC,,,,both,,,659.40,428.61,,,,,,,,,,,,,
KIT ANGIO XCELA DIA 5 FR STRL,SUP-2117191,CDM,C1751,HCPCS,0278,RC,,,,both,,,653.12,424.53,,,,,,,,,,,,,
SCREW BNE LCK 2.7X10 MM CANC,SUP-2397416,CDM,C1713,HCPCS,0278,RC,,,,both,,,1117.84,726.60,,,,,,,,,,,,,
HC Plmt Ureteral Stent Prq,PX-3615069500,CDM,50695,CPT,0361,RC,,,,inpatient,,,8583.00,5578.95,,,,,,,,,,,,,
ANCHOR SUT W/ ETHBND SZ 4-0 DRL P-3 PRECIS PT NDL WHT,SUP-2256609,CDM,C1713,HCPCS,0278,RC,,,,both,,,1171.22,761.29,,,,,,,,,,,,,
TRAY PICC 3FR SGL LUMN CATHETER FULL PROC SFTY FLSH,SUP-2125615,CDM,C1751,HCPCS,0278,RC,,,,both,,,324.68,211.04,,,,,,,,,,,,,
PACEMAKER CARD EDORA DR-T W 44 X H 48 MM D 6.5 MM 11 CC 23,SUP-2138476,CDM,C1785,HCPCS,0275,RC,,,,both,,,17898.00,11633.70,,,,,,,,,,,,,
STEM FEM SZ 2 L115MM NK L32MM 36MM OFFSET 132DEG HIP FORGED,SUP-2375349,CDM,C1776,CPT,0278,RC,,,,both,,,6256.14,4066.49,,,,,,,,,,,,,
HC Arthrocent/Aspiration Maj Jnt,PX-3612061000,CDM,20610,CPT,0361,RC,,,,both,,,1245.00,809.25,,,,,,,,,,,,,
GRAFT VASC INTERGARD L 50 CM DIA18 X 9 MM THK 0.49 MM,SUP-2462938,CDM,L8670,HCPCS,0278,RC,,,,both,,,2492.44,1620.09,,,,,,,,,,,,,
SHEATH DIL TIGHTRAIL 11FR,SUP-2353155,CDM,C1894,HCPCS,0272,RC,,,,both,,,6091.60,3959.54,,,,,,,,,,,,,
PLATE SPNL ANTR CERV C-TEK MAXAN 14521008,SUP-2689239,CDM,C1713,HCPCS,0278,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
STEM SPLINE 12.0X170MM STRAIGHT,SUP-2505070,CDM,C1776,CPT,0278,RC,,,,both,,,9646.08,6269.95,,,,,,,,,,,,,
GRAFT BIO TISS W4XL12CM THK08 17MM THCK STRUCTURAL,SUP-2307469,CDM,Q4128,HCPCS,0636,RC,,,,both,,,4461.34,2899.87,,,,,,,,,,,,,
COVER SCR TI UNIGRIP HEX CONN FOR BAHA SYS,SUP-2164931,CDM,2720000010,LOCAL,0272,RC,,,,both,,,486.70,316.35,,,,,,,,,,,,,
CATHETER CTRL VEN L20CM OD5FR .032IN GWIRE KT SGL LUMN N AK04210] TELEFLEX ARROW INTL INC],SUP-2383264,CDM,C1751,HCPCS,0278,RC,,,,both,,,53.69,34.90,,,,,,,,,,,,,
HC Plcmt Prostate Radioelem Ndl/C,PX-3615587500,CDM,55875,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
CATHETER HD STR EXTN 11.5 FRX24 CM SHT TERM DL HEMCATH,SUP-2627310,CDM,C1752,HCPCS,0278,RC,,,,both,,,20.22,13.14,,,,,,,,,,,,,
DEFIBRILLATOR IMPL COGNIS RF HE TI CRT RF HI ENERGY STRL,SUP-2149059,CDM,C1722,HCPCS,0275,RC,,,,both,,,81640.00,53066.00,,,,,,,,,,,,,
CONTROLLER DETACH FOR WEB ANEUR EMB SYS,SUP-2418995,CDM,2720000010,LOCAL,0272,RC,,,,both,,,580.90,377.58,,,,,,,,,,,,,
GRAFT HUM TISS W4XL4CM WHL MEM AMNIO SHT NO ANG AMINOFIX,SUP-2305726,CDM,V2790,HCPCS,0274,RC,,,,both,,,4980.04,3237.03,,,,,,,,,,,,,
BUR SURG DIA 7 MM HUB II BRL STRL REUSE HI-LINE,SUP-2928974,CDM,2720000010,LOCAL,0272,RC,,,,both,,,396.86,257.96,,,,,,,,,,,,,
PLATE BNE BAR L 4 MM 4 H SAG SPLIT CRV LCK NS SMARTLOCK,SUP-2909478,CDM,C1713,HCPCS,0278,RC,,,,both,,,2777.33,1805.26,,,,,,,,,,,,,
BEARING TOE L PHLANG MTL BK IMP,SUP-2404752,CDM,C1776,CPT,0278,RC,,,,both,,,2879.38,1871.60,,,,,,,,,,,,,
EXPANDER BRST TISS 650CC W13XH13CM P8.2CM SIL SMOOTH ULT HI,SUP-2301019,CDM,C1789,HCPCS,0278,RC,,,,both,,,5495.00,3571.75,,,,,,,,,,,,,
STEM FEM SZ 10 L130MM HIP CO CHROM POR HI OFFSET 12/14 TAPR,SUP-2345298,CDM,C1776,CPT,0278,RC,,,,both,,,14266.59,9273.28,,,,,,,,,,,,,
BOLT EXT FIX 6.5X190 MM SALVATION,SUP-2484347,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5212.40,3388.06,,,,,,,,,,,,,
STAPLER INT AD L L25MM DIA12MM INTLUMN WHT TI CIR CUT 2 ROW,SUP-2283256,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4686.17,3046.01,,,,,,,,,,,,,
IMPL KNEE RECON RAD 6MM COLLAR SZ 2,SUP-2706514,CDM,C1776,CPT,0278,RC,,,,both,,,9354.69,6080.55,,,,,,,,,,,,,
EPOETIN ALFA-EPBX 3000 UNIT/ML IJ SOLN,RX-142362,CDM,Q5106,HCPCS,0636,RC,00069-1306-10,NDC,,both,1,ML,97.70,63.50,,,,,,,,,,,,,
ROD ORTHOPEDIC 2 MM SZR GRN ORTHOFLEX,SUP-2319097,CDM,C1713,HCPCS,0278,RC,,,,both,,,1208.90,785.78,,,,,,,,,,,,,
VALVE MITRL CARP EDW PERIMT + DIA21 MM BOV PERICARD COCR,SUP-2214289,CDM,C1713,HCPCS,0278,RC,,,,both,,,17144.40,11143.86,,,,,,,,,,,,,
AIRWAY LARYNGEAL INFANT CHILDREN 10-20KG SIZE 2 CONNECTOR 15,SUP-2824815,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1036.20,673.53,,,,,,,,,,,,,
PLATE BNE LCK,SUP-2136961,CDM,C1713,HCPCS,0278,RC,,,,both,,,8792.00,5714.80,,,,,,,,,,,,,
DRILL TWST L50MM OD13MM 8MM STP J LATCH N RADLUC DISPOSABLE,SUP-2366402,CDM,2720000010,LOCAL,0272,RC,,,,both,,,329.86,214.41,,,,,,,,,,,,,
HC So1 Sgot (Ast),PX-3018445067,CDM,84450,CPT,0301,RC,,,,both,,,15.00,9.75,,,,,,,,,,,,,
SCREW SPNL L12MM DIA3.5MM MINI CANC POST OCCIPITAL CERV,SUP-2254388,CDM,C1713,HCPCS,0278,RC,,,,both,,,3391.20,2204.28,,,,,,,,,,,,,
SCREW BNE 2X16 MM VARIAX,SUP-2363428,CDM,C1713,HCPCS,0278,RC,,,,both,,,262.82,170.83,,,,,,,,,,,,,
SPLINT IM SM W4MM TI ALLOY MATRIXRIB,SUP-2181512,CDM,C1713,HCPCS,0278,RC,,,,both,,,2220.77,1443.50,,,,,,,,,,,,,
PLATE BONE 5 H TI STR LO PROF FOR 2.4MM SCR,SUP-2123113,CDM,C1713,HCPCS,0278,RC,,,,both,,,2182.30,1418.49,,,,,,,,,,,,,
PACEMAKER CARD ADAPTA W 47.9 X H 44.7 MM D 7.5 MM 12.1 CC,SUP-2282306,CDM,C1785,HCPCS,0275,RC,,,,both,,,9322.31,6059.50,,,,,,,,,,,,,
HC Central Ven Cath 5+ Yrs,PX-4503655600,CDM,36556,CPT,0450,RC,,,,inpatient,,,9955.00,6470.75,,,,,,,,,,,,,
WIRE FIX THRD BLNT K,SUP-2232046,CDM,C1713,HCPCS,0278,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
MOLD SPCR 12MM STEM W/ 54X21X64MM HD SHLDR CEM STAGEONE,SUP-2136796,CDM,C1776,CPT,0278,RC,,,,both,,,6016.24,3910.56,,,,,,,,,,,,,
ALLOGRAFT BNE CHIP 20 CC,SUP-2335643,CDM,C1713,HCPCS,0278,RC,,,,both,,,18840.00,12246.00,,,,,,,,,,,,,
CATHETER PTCA L135CM DIA7FR BLLN L200MM DIA7MM 0.035IN,SUP-2172775,CDM,C1725,HCPCS,0272,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
GRAFT DERM MTRX HUM TISS PLIABLE FLD SUPPLE ULT THCK,SUP-2307567,CDM,Q4128,HCPCS,0636,RC,,,,both,,,6358.50,4133.02,,,,,,,,,,,,,
THERAPY ABLATION CATH THERMISTOR 1304 7 25 E TE8 TH,SUP-2698838,CDM,C1733,HCPCS,0272,RC,,,,both,,,2747.50,1785.87,,,,,,,,,,,,,
CUTTER CLP PROCTOLOGY OTSC,SUP-2881867,CDM,2720000010,LOCAL,0272,RC,,,,both,,,938.86,610.26,,,,,,,,,,,,,
CATHETER THROMCTMY L 65 CM DIA 6 FR S WAVE WIRE SYNTH GRFT,SUP-2227490,CDM,C1757,HCPCS,0272,RC,,,,both,,,1821.20,1183.78,,,,,,,,,,,,,
INSERT TIB L STANDARD+ THK10MM POLYETH UNIV MENIS BEAR PRI,SUP-2250754,CDM,C1776,CPT,0278,RC,,,,both,,,3982.78,2588.81,,,,,,,,,,,,,
STENT COLONIC/DUODENAL WSTNT L 90 MM DIA20 MM WORKING L 230,SUP-2149765,CDM,C1876,HCPCS,0278,RC,,,,both,,,5530.48,3594.81,,,,,,,,,,,,,
"HC Pt Therapeutic Exercise,Ea 15 Min",PX-4209711000,CDM,97110,CPT,0420,RC,,,,both,,,195.00,126.75,,,,,,,,,,,,,
SET INT FIX BURR H PLATE DIA18.5 MM SCREW DIA1.5 MM 15-7382,SUP-2936401,CDM,C1713,HCPCS,0278,RC,,,,both,,,2307.90,1500.13,,,,,,,,,,,,,
LEGION ELIP RESURF PAT W/JRNY PEG 32,SUP-2822784,CDM,C1776,CPT,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
SYSTEM DRAINAGE 15 MM CATH SHUNT FOR EDS III,SUP-2308157,CDM,C1729,HCPCS,0272,RC,,,,both,,,441.99,287.29,,,,,,,,,,,,,
MESH SURG 30CM LEN 20CM W THK2MM SYN ABD N ABSRB RECT EXP,SUP-2126082,CDM,C1781,HCPCS,0278,RC,,,,both,,,6477.82,4210.58,,,,,,,,,,,,,
PLATE BONE LT DSTL RAD VOLAR TI FOR 1.8/2.4/2.7MM SCR,SUP-2191017,CDM,C1713,HCPCS,0278,RC,,,,both,,,2172.38,1412.05,,,,,,,,,,,,,
NAIL IM LNG 130 DEG 11X420 MM RT HIP AFFIXUS,SUP-2460731,CDM,C1713,HCPCS,0278,RC,,,,both,,,6992.78,4545.31,,,,,,,,,,,,,
CATHETER NAVI-STAR J CRV SFT TIP 7FR,SUP-2248475,CDM,C1732,HCPCS,0272,RC,,,,both,,,6119.86,3977.91,,,,,,,,,,,,,
MESH HERN L DIA8CM VENTRAL POLYPR EPTFE CIR SELF EXP PTCH,SUP-2125721,CDM,C1781,HCPCS,0278,RC,,,,both,,,1768.13,1149.28,,,,,,,,,,,,,
PLATE BNE L55-65MM TROCHANTERIC HIP MALLORY-HEAD TI 2 PC,SUP-2405219,CDM,C1713,HCPCS,0278,RC,,,,both,,,1371.55,891.51,,,,,,,,,,,,,
GUIDEWIRE ENDSCPC URLGCL 0.025MM DIA 150CML 3CML ANGLD TIP R,SUP-2471771,CDM,C1769,HCPCS,0272,RC,,,,both,,,137.09,89.11,,,,,,,,,,,,,
CATHETER PERI DLYS AD L57CM DIA15FR DBL CUF COILED LIN,SUP-2283900,CDM,C1750,HCPCS,0278,RC,,,,both,,,345.71,224.71,,,,,,,,,,,,,
CATHETER DRNGE N LOK .038 GUID WIRE STR 10FR 25CM RESOLV,SUP-2303381,CDM,C1729,HCPCS,0272,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
SET INTRO MICRO-STICK L 9 CM DIA 4 FR GUIDEWIRE L 45 CM DIA,SUP-2267051,CDM,C1894,HCPCS,0272,RC,,,,both,,,50.24,32.66,,,,,,,,,,,,,
PLATE BNE L35MM SHT 2X2 H NONSTERILE BILAT 1ST MTP FUS S,SUP-2184831,CDM,C1713,HCPCS,0278,RC,,,,both,,,2780.00,1807.00,,,,,,,,,,,,,
PLATE BNE L217MM THK3.3MM 18 H BILAT S STL RIG STR DYN,SUP-2186338,CDM,C1713,HCPCS,0278,RC,,,,both,,,2281.15,1482.75,,,,,,,,,,,,,
MESH HERN SM DIA8CM INGUINAL CIR SELF EXP PTCH KUGEL,SUP-2125977,CDM,C1781,HCPCS,0278,RC,,,,both,,,335.98,218.39,,,,,,,,,,,,,
BUR DENT HD DIA1MM CARB CRSS CUT FISS RND NONFLUTED,SUP-2367590,CDM,C1713,HCPCS,0278,RC,,,,both,,,408.45,265.49,,,,,,,,,,,,,
DEVICE SUT L7IN 0 GRN POLY SURGDAC COAT BRAID 3 STIT SGL USE,SUP-2787656,CDM,2720000010,LOCAL,0272,RC,,,,both,,,570.51,370.83,,,,,,,,,,,,,
SPHINCTEROTOME BILI OR PANCREAS SEAL CAP PRECUT DISP STR,SUP-2313218,CDM,2720000010,LOCAL,0272,RC,,,,both,,,319.15,207.45,,,,,,,,,,,,,
VALVE AORT BIOPROSTHESES 27 MM MODEL 3000TFX PERIMT MAGNA,SUP-2214109,CDM,C1713,HCPCS,0278,RC,,,,both,,,21336.30,13868.59,,,,,,,,,,,,,
GRAFT HUM TISS L100MM FRZN SHFT TIB STRUCTURAL ALLGRFT,SUP-2307366,CDM,C1713,HCPCS,0278,RC,,,,both,,,3317.69,2156.50,,,,,,,,,,,,,
GRAFT BNE SUB 30CC SZ 17 10MM CANC CHIP TISS FRZN CRUSH,SUP-2307396,CDM,C1713,HCPCS,0278,RC,,,,both,,,1525.35,991.48,,,,,,,,,,,,,
SCREW BNE PART THRD 4.5X42 MM CANN W/ LG HEX SOCKET SD ST,SUP-2190416,CDM,C1713,HCPCS,0278,RC,,,,both,,,544.04,353.63,,,,,,,,,,,,,
CATHETER ETER IV POLY MIDLN SGL LUMN MAX BARR OD3FR,SUP-2125577,CDM,C1751,HCPCS,0278,RC,,,,both,,,226.08,146.95,,,,,,,,,,,,,
COIL VASC AZUR HYDROPACK L 60 CM SZ 18 MICROCATHETER 2.4/2.8,SUP-2896816,CDM,C1889,HCPCS,0278,RC,,,,both,,,5077.38,3300.30,,,,,,,,,,,,,
GUIDEWIRE ORTH SHRP 2.2X500 MM STRL AEQUALIS,SUP-2846066,CDM,C1769,HCPCS,0272,RC,,,,both,,,499.26,324.52,,,,,,,,,,,,,
PLATE BNE L 116 X W 17 MM THK 1.4 MM SCREW DIA2.2 MM,SUP-2909545,CDM,C1713,HCPCS,0278,RC,,,,both,,,15464.41,10051.87,,,,,,,,,,,,,
ELECTRODE LARYNGEAL MAGSTIM SIZE 8/9,SUP-2844647,CDM,2720000010,LOCAL,0272,RC,,,,both,,,431.75,280.64,,,,,,,,,,,,,
FEEDING TUBE KIT LP 12 FRX1 CM BLLN BUTTON SIL CLR MINI 1,SUP-2754568,CDM,2720000010,LOCAL,0272,RC,,,,both,,,914.87,594.67,,,,,,,,,,,,,
GUIDEWIRE ORTH OD2.4MM DRL TIP W/O EYELET DISP,SUP-2341124,CDM,C1769,HCPCS,0272,RC,,,,both,,,205.45,133.54,,,,,,,,,,,,,
MESH HERN CIR 4.5 IN W/ ECHO 2 POS SYS PHASIX ST,SUP-2422302,CDM,C1781,HCPCS,0278,RC,,,,both,,,6766.70,4398.35,,,,,,,,,,,,,
ROD SPNL HEX 6.35 MMX6 CM LEVEL-1 TI SYNERGY,SUP-2415478,CDM,C1713,HCPCS,0278,RC,,,,both,,,706.47,459.21,,,,,,,,,,,,,
TUNNELER SURG L 12 IN DIA16 GA STRL DISP ON-Q,SUP-2917192,CDM,2720000010,LOCAL,0272,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
EXTENDER SURG L60MM DISP FOR ULTSONIC REV SYS ULT DRV 3,SUP-2408554,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1381.60,898.04,,,,,,,,,,,,,
HC So Calr Gene Analysis,PX-3108121966,CDM,81219,CPT,0310,RC,,,,both,,,395.00,256.75,,,,,,,,,,,,,
PLATE BNE L 56 MM SCREW DIA2.4/2.7 MM 7 HD 3 SHFT H RT DSTL,SUP-2913587,CDM,C1713,HCPCS,0278,RC,,,,both,,,5143.32,3343.16,,,,,,,,,,,,,
SPLINT WRST FA R INSTABILITY INJ IMMOB LOOP LOK ABDUCTED,SUP-2276637,CDM,L3809,HCPCS,0272,RC,,,,both,,,22.17,14.41,,,,,,,,,,,,,
HC So Dgp Antibody Each Ig Class,PX-3028625866,CDM,86258,CPT,0302,RC,,,,both,,,40.00,26.00,,,,,,,,,,,,,
BLADE RTRCTR BLFR 4ND ABDMNL WIRE LTRL JARIT NON ST,SUP-2485511,CDM,2720000010,LOCAL,0272,RC,,,,both,,,867.49,563.87,,,,,,,,,,,,,
KNEE IMMOB 22IN QUAL PLUSXL,SUP-2195534,CDM,L1830,CPT,0274,RC,,,,both,,,115.55,75.11,,,,,,,,,,,,,
CATHETER CARD ABLATION NAVISTAR L 115CM 7FR 4MM F CRV UNIDIR,SUP-2248942,CDM,C1732,HCPCS,0278,RC,,,,both,,,6119.86,3977.91,,,,,,,,,,,,,
PLATE STRNL CLOSURE 70 DEG 8 H TI L NS STERNALOCK BLU,SUP-2894528,CDM,C1713,HCPCS,0278,RC,,,,both,,,1535.46,998.05,,,,,,,,,,,,,
GUIDE SURG RT TIB RESECT TRIATHLON,SUP-2364720,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1237.16,804.15,,,,,,,,,,,,,
GRAFT VASC STR 16 MMX15 CM AORT ARCH 1 LAYR SFT HEMSHLD GLD,SUP-2463790,CDM,C1768,CPT,0278,RC,,,,both,,,1324.83,861.14,,,,,,,,,,,,,
RITUXIMAB (RITUXAN) 10 MG/ML IV SOLN (MIXTURES ONLY),RX-430010,CDM,J9312,HCPCS,0636,RC,50242-0051-21,NDC,,both,10,ML,2705.90,1758.83,,,,,,,,,,,,,
CATHETER HD SHT TERM 14 FRX24 CM ADMIN BASIC SET PRECRV,SUP-2269515,CDM,C1752,HCPCS,0278,RC,,,,both,,,248.06,161.24,,,,,,,,,,,,,
POWDER HAEMOSTATIC MICFIB CLLGN 5GM ABSRB WHT AVIT,SUP-2125828,CDM,C1713,HCPCS,0278,RC,,,,both,,,2135.20,1387.88,,,,,,,,,,,,,
STENT CORONARY JOSTENT GRAFTMASTER L 19 MM DIA 3.5 MM GUIDE,SUP-2106199,CDM,C1874,HCPCS,0278,RC,,,,both,,,7520.30,4888.19,,,,,,,,,,,,,
SLEEVE FEM 45MM LATERAL/MEDIAL FULL COAT REV PORCOAT ATTUNE,SUP-2251469,CDM,C1776,CPT,0278,RC,,,,both,,,8297.14,5393.14,,,,,,,,,,,,,
PEEK CANN B,SUP-2417907,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3293.86,2141.01,,,,,,,,,,,,,
FENTANYL CITRATE (PF) 2500 MCG/50ML IJ SOLN,RX-133096,CDM,J3010,HCPCS,0636,RC,00409-9094-41,NDC,,both,0.5,ML,54.10,35.16,,,,,,,,,,,,,
GUIDEWIRE ORTH 600 MM STR,SUP-2162704,CDM,C1769,HCPCS,0272,RC,,,,both,,,281.34,182.87,,,,,,,,,,,,,
PROBE COAG 9.6FR L2.2M CONVENIENT BLT IN FLTR 2200A FIAPC,SUP-2217935,CDM,2720000010,LOCAL,0272,RC,,,,both,,,761.45,494.94,,,,,,,,,,,,,
FILLER BNE 10 CC 14 DWL BI-OSTETIC,SUP-2115821,CDM,C1713,HCPCS,0278,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
PATELLAR COMP OVL RESURFACE,SUP-2349040,CDM,C1776,CPT,0278,RC,,,,both,,,2857.40,1857.31,,,,,,,,,,,,,
HC So Brucella Antibody,PX-3028662266,CDM,86622,CPT,0302,RC,,,,both,,,253.00,164.45,,,,,,,,,,,,,
INFUVITE ADULT IV SOLN,RX-169304,CDM,2500000003,HCPCS,0250,RC,54643-5649-01,NDC,,both,10,ML,88.50,57.52,,,,,,,,,,,,,
BLADE SCALP 85MM TIP AND HNDL CANADY HYBRID PLSM,SUP-2391727,CDM,C1713,HCPCS,0278,RC,,,,both,,,1146.10,744.96,,,,,,,,,,,,,
HC Peripheral Block - Axillary W/Img Gdn,PX-3606441700,CDM,64417,CPT,0360,RC,,,,outpatient,,,2895.00,1881.75,,,,,,,,,,,,,
EXPANDER TISS 5.2-6 CM 12X9.8 CM 225-280 CC MID ALLOX2,SUP-2471207,CDM,C1889,HCPCS,0278,RC,,,,both,,,5181.00,3367.65,,,,,,,,,,,,,
WIRE OLIVE 1.8MM X 400MM,SUP-2498241,CDM,2720000010,LOCAL,0272,RC,,,,both,,,803.84,522.50,,,,,,,,,,,,,
SHUNT COR L18MM DIA225MM NONPROGRAMMABLE GUIDANT W/O RESVR,SUP-2582817,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1591.67,1034.59,,,,,,,,,,,,,
CLASSIC SPCNDR PL 90 10SL,SUP-2820713,CDM,C1713,HCPCS,0278,RC,,,,both,,,5497.67,3573.49,,,,,,,,,,,,,
IMPLANT HUM TISS L 8 X W 4 CM AMNION/CHORION MEMBRN DEHYDR,SUP-2905524,CDM,C1762,CPT,0278,RC,,,,both,,,9429.42,6129.12,,,,,,,,,,,,,
PROBE SPNL 90DEG BALL TIP LNG MTRX,SUP-2292921,CDM,C1713,HCPCS,0278,RC,,,,both,,,926.30,602.09,,,,,,,,,,,,,
BIT DRL QC 2X140 MM 60 MM CALIB NS,SUP-2563747,CDM,2720000010,LOCAL,0272,RC,,,,both,,,439.69,285.80,,,,,,,,,,,,,
JOINT TOE SM MINI 12 MTL HD,SUP-2392826,CDM,C1776,CPT,0278,RC,,,,both,,,5338.00,3469.70,,,,,,,,,,,,,
CATHETER ANGIOPLSTY 2XL L 75 CM BALLOON L 40 MM DIA14 MM,SUP-2142058,CDM,C1725,HCPCS,0272,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
BUR SURG HI,SUP-2666758,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1618.10,1051.76,,,,,,,,,,,,,
I/B II KNEE TIB TRAY 69 PLUS 60 A/P X 81MM M/L,SUP-2502005,CDM,C1776,CPT,0278,RC,,,,both,,,10148.48,6596.51,,,,,,,,,,,,,
SET INTRO PERFRMR L 5.5 CM DIA 4 FR GUIDEWIRE L 30 CM DIA,SUP-2169705,CDM,C1894,HCPCS,0272,RC,,,,both,,,104.41,67.87,,,,,,,,,,,,,
RING EXT FIX SWVL HNDL 4.75 IN W/ MULTIPLE TEETH LASER BINOC,SUP-2481829,CDM,2720000010,LOCAL,0272,RC,,,,both,,,749.42,487.12,,,,,,,,,,,,,
FEEDING TUBE KIT LP 12 FRX0.8 CM BUTTON MINI 1 LF,SUP-2754596,CDM,2720000010,LOCAL,0272,RC,,,,both,,,425.03,276.27,,,,,,,,,,,,,
HC Venous Sel Cath Plcmt 2nd Ord,PX-3613601200,CDM,36012,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
MESH HERN RECT 10X6 IN FULL RESRB FOR SFT TISS PHASIX,SUP-2855252,CDM,C1781,HCPCS,0278,RC,,,,both,,,16406.50,10664.22,,,,,,,,,,,,,
SCREW BONE L120MM DIA4.5MM CORT TI N ST N SELF DRL,SUP-2190372,CDM,C1713,HCPCS,0278,RC,,,,both,,,97.34,63.27,,,,,,,,,,,,,
ANCHOR SUTURE 2.8MM SELF PUNCHING WITH TWO 1.3MM WHITE/BLUE,SUP-2825066,CDM,C1713,HCPCS,0278,RC,,,,both,,,1502.18,976.42,,,,,,,,,,,,,
BUR SURG DIAMOND 2.5 MM 9 CM MTCH HD TELSCP MIDAS REX LEGEND,SUP-2632224,CDM,2720000010,LOCAL,0272,RC,,,,both,,,445.69,289.70,,,,,,,,,,,,,
CONNECTOR SPNL PARA ROD 35 635 DBL SIERRA,SUP-2245453,CDM,C1713,HCPCS,0278,RC,,,,both,,,108.27,70.38,,,,,,,,,,,,,
HC Joint Injection/Aspir Medium WO US,PX-5102060500,CDM,20605,CPT,0510,RC,,,,outpatient,,,908.00,590.20,,,,,,,,,,,,,
PLATE BNE RECON 2.7 MM MAND 27 HOLE FULL FOR SCR TI LEVEL 1,SUP-2460886,CDM,C1713,HCPCS,0278,RC,,,,both,,,4156.76,2701.89,,,,,,,,,,,,,
HEAD SPNL SCREW ROD DIA 5.5/6 MM REDUCTION UNIAXIAL STRL CD,SUP-2926665,CDM,C1713,HCPCS,0278,RC,,,,both,,,2606.20,1694.03,,,,,,,,,,,,,
STAPLE BNE FIX INTERAXIS L 9 MM LEG L 9 X 9 X W 1.5 MM THK,SUP-2893424,CDM,C1713,HCPCS,0278,RC,,,,both,,,2471.18,1606.27,,,,,,,,,,,,,
PLATE BONE THK0.5MM 6 H ORBIT GRN TI CVD HX FOR 1.5MM SCR,SUP-2135901,CDM,C1713,HCPCS,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
ALLOGRAFT PROCHONDRIX CR 11.0 X 1.0MM,SUP-2751542,CDM,C1762,CPT,0278,RC,,,,both,,,11916.30,7745.59,,,,,,,,,,,,,
SPACER FEM L THK5MM R MED DST DURAC,SUP-2377205,CDM,C1776,CPT,0278,RC,,,,both,,,2345.42,1524.52,,,,,,,,,,,,,
MANOMETER PRSS INTDISC DGT,SUP-2342059,CDM,C1713,HCPCS,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
SPLINT ORTHOPEDIC SUPP LG 8 IN LT WRST COCK UP ELASTIC,SUP-2108133,CDM,L3809,HCPCS,0272,RC,,,,both,,,43.96,28.57,,,,,,,,,,,,,
NEOMYCIN-BACITRACIN ZN-POLYMYX 5-400-10000 OP OINT,RX-38701,CDM,6370000000,HCPCS,0637,RC,24208-0780-55,NDC,,both,3.5,GR,205.10,133.31,,,,,,,,,,,,,
DRILL TWST L 60 MM DIA1.2 MM STP 4 MM LAG NS DISP LEIBINGER,SUP-2883192,CDM,2720000010,LOCAL,0272,RC,,,,both,,,549.72,357.32,,,,,,,,,,,,,
PROBE NERVE STIM MONOPOLAR PNMI0275] PRECISION MEDICAL INC],SUP-2329783,CDM,2720000010,LOCAL,0272,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
DEVICE FUS OBLQ LAT LUMBER INTBDY 9MMX28MMX15MM ZEUS O,SUP-2115748,CDM,C1713,HCPCS,0278,RC,,,,both,,,13345.00,8674.25,,,,,,,,,,,,,
BLADE SAW 35X10 MM STRNM FOR PRIMARY,SUP-2607460,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1731.46,1125.45,,,,,,,,,,,,,
ENDOPROSTHESIS VASC WSTNT RP L 49 MM DIA10 MM CATH TOT L 100,SUP-2148426,CDM,C1876,HCPCS,0278,RC,,,,both,,,5181.00,3367.65,,,,,,,,,,,,,
CABLE ORTH L91CM DIA1.8MM CO CHROM SMOOTH CBL-READY 00223200228] ZIMMER BIOMET TRAUMA],SUP-2410266,CDM,C1713,HCPCS,0278,RC,,,,both,,,1262.66,820.73,,,,,,,,,,,,,
DRESSING WOND KERECIS MARIGEN 3CM X 3.5CM,SUP-2866742,CDM,Q4158,HCPCS,0636,RC,,,,both,,,1912.26,1242.97,,,,,,,,,,,,,
ROD SPNL 5.5X120 MM ARM15T TI ARMDA,SUP-2562284,CDM,C1713,HCPCS,0278,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
TRIGEN 4.0 DIAPHYSEAL DRILL,SUP-2818908,CDM,2720000010,LOCAL,0272,RC,,,,both,,,727.95,473.17,,,,,,,,,,,,,
ALLOGRAFT BNE CAGE 2 CC DBM VESUVIUS,SUP-2717990,CDM,C1713,HCPCS,0278,RC,,,,both,,,2127.51,1382.88,,,,,,,,,,,,,
GRAFT BNE SUB 20CC W25XH8XL100MM FOAM STRP COMPR RESIST FLX,SUP-2361881,CDM,C1713,HCPCS,0278,RC,,,,both,,,15729.52,10224.19,,,,,,,,,,,,,
GRAFT HUM TISS DIA 45 MM FEM HD NK FD STERIGRAFT,SUP-2913177,CDM,C1762,CPT,0278,RC,,,,both,,,8817.12,5731.13,,,,,,,,,,,,,
STENT COLON Z-STENT L 8 CM FLARED END 35 MM SHFT 25 MM INTRO,SUP-2169504,CDM,C1877,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
INSERT TIB ONLAY KNEE 30453659S] MAKO],SUP-2265745,CDM,C1776,CPT,0278,RC,,,,both,,,1660.56,1079.36,,,,,,,,,,,,,
CLAMP AD MULTIPLANAR FOR LIMB RECON SYS,SUP-2316079,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4760.81,3094.53,,,,,,,,,,,,,
SCREW INTRF L28MM OD6MM BIOSTEON WDG SHP ROUNDED THRD CRUC,SUP-2366625,CDM,C1713,HCPCS,0278,RC,,,,both,,,712.09,462.86,,,,,,,,,,,,,
BUR SURG RND 2.3 MM 66 MM FLUT FOR DRL SYS SS INDIGO,SUP-2628952,CDM,2720000010,LOCAL,0272,RC,,,,both,,,174.33,113.31,,,,,,,,,,,,,
GRAFT TISS HUMAN THERASKIN 1.75 X 1.75 3 SQ CM,SUP-2716336,CDM,Q4121,HCPCS,0636,RC,,,,both,,,2641.68,1717.09,,,,,,,,,,,,,
PIN FIX TROCAR PT 2 END 1/8X9 IN 2 PT STYL SMOOTH PLN STRL,SUP-2150460,CDM,C1713,HCPCS,0278,RC,,,,both,,,15.61,10.15,,,,,,,,,,,,,
SODIUM CHLORIDE 1 G PO TABS,RX-7328,CDM,6370000000,HCPCS,0637,RC,00223-1760-01,NDC,,both,1,UN,0.40,0.26,,,,,,,,,,,,,
BLADE SHV L11CM DIA4MM 5000RPM STR SNUS M4 ROT OFFSET CUT,SUP-2284144,CDM,2720000010,LOCAL,0272,RC,,,,both,,,768.17,499.31,,,,,,,,,,,,,
BUR SURG PRECIS 15 DEG 4 MMX12.5 CM RND DSTL BEND ORNG IBUR,SUP-2859501,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1158.19,752.82,,,,,,,,,,,,,
POST EXT FIX 2 H M,SUP-2898594,CDM,C1713,HCPCS,0278,RC,,,,both,,,433.32,281.66,,,,,,,,,,,,,
PLATE BNE 1.5/2X55X1.5 MM 9 HOLE SS LC-DCP,SUP-2569199,CDM,C1713,HCPCS,0278,RC,,,,both,,,293.59,190.83,,,,,,,,,,,,,
GRAFT HUM TISS W10XL60MM FIBULAR STRUT RND,SUP-2307390,CDM,C1713,HCPCS,0278,RC,,,,both,,,3585.57,2330.62,,,,,,,,,,,,,
BUR SURG DIA 3.1 MM HUB III NEURO CUT STRL DISP HI-LINE XS,SUP-2929255,CDM,2720000010,LOCAL,0272,RC,,,,both,,,442.68,287.74,,,,,,,,,,,,,
SCREW BNE EMGCY 2.5X13 MM TI MAXDRIVE LEVEL 1 258741361,SUP-2461407,CDM,C1713,HCPCS,0278,RC,,,,both,,,213.43,138.73,,,,,,,,,,,,,
PLATE BNE L44MM STD 2X2 H NONSTERILE R BILAT 1ST MTP FUS S,SUP-2184836,CDM,C1713,HCPCS,0278,RC,,,,both,,,2929.68,1904.29,,,,,,,,,,,,,
SHEATH DIL EVOLUTION L 40.6 CM OD 19 FR ID 11 FR SS MECH SET,SUP-2170519,CDM,C1773,HCPCS,0272,RC,,,,both,,,3862.20,2510.43,,,,,,,,,,,,,
DILATOR SURG PRB 14.5 MM AVS ARIA,SUP-2524283,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2186.32,1421.11,,,,,,,,,,,,,
"HC So Ca 15-3, (27.29)",PX-3028630066,CDM,86300,CPT,0302,RC,,,,both,,,140.00,91.00,,,,,,,,,,,,,
KIT HIP ARTHROSCOPY DISTENTION NEEDLE GUIDEWIRE SWITCHING ST,SUP-2828618,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1227.71,798.01,,,,,,,,,,,,,
POLISHER CAPSULE 45 DEG 20 GA 0.3 MM ANGLED TIP MTL,SUP-2462199,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1030.71,669.96,,,,,,,,,,,,,
PLATE BONE L162MM 4X20X4 H BILAT MAND ORAL MAXILLOFACIAL TI,SUP-2191431,CDM,C1713,HCPCS,0278,RC,,,,both,,,9607.46,6244.85,,,,,,,,,,,,,
GRAFT HUM TISS 7.5-9.5X170-220 MM PERONEUS TEND FLEXIGRAFT,SUP-2740793,CDM,C1762,CPT,0278,RC,,,,both,,,3560.29,2314.19,,,,,,,,,,,,,
SCREW INTFR L30MM DIA7MM KNEE PLLA CANN ABSRB RND HD,SUP-2249502,CDM,C1713,HCPCS,0278,RC,,,,both,,,1337.64,869.47,,,,,,,,,,,,,
ALLOGRACT HUM TISS AMNIOBAND MEMBRANE 2X4CM,SUP-2907550,CDM,Q4151,HCPCS,0636,RC,,,,both,,,2875.74,1869.23,,,,,,,,,,,,,
BAG SHWR PROTECT DISP,SUP-2356015,CDM,Q0501,HCPCS,0274,RC,,,,both,,,763.02,495.96,,,,,,,,,,,,,
CATHETER HD LT 16 FRX32 CM SPLIT TIP STR SET SPLIT STRM,SUP-2267089,CDM,C1750,HCPCS,0278,RC,,,,both,,,715.92,465.35,,,,,,,,,,,,,
BOLT EXT FIX M6 L18MM W HEX 10MM S STL,SUP-2242956,CDM,2720000010,LOCAL,0272,RC,,,,both,,,44.05,28.63,,,,,,,,,,,,,
ALLOGRAFT BNE OSTEOTMY WDG FRZN ASEP,SUP-2867123,CDM,C1762,CPT,0278,RC,,,,both,,,2434.13,1582.18,,,,,,,,,,,,,
SAW SURG COMPLETE IM,SUP-2448360,CDM,2720000010,LOCAL,0272,RC,,,,both,,,25151.40,16348.41,,,,,,,,,,,,,
GUIDEWIRE VASC GLIDEWIRE GT L 180CM 0.016IN TIP 2 CM NIT STR,SUP-2538032,CDM,C1769,HCPCS,0272,RC,,,,both,,,970.26,630.67,,,,,,,,,,,,,
BIT DRL L152MM DIA3.5MM FOR IM LIMB LENGTHENING SYS PRECICE,SUP-2312224,CDM,2720000010,LOCAL,0272,RC,,,,both,,,728.48,473.51,,,,,,,,,,,,,
ATTACHMENT HNDPC L9CM DIA3.2MM STR L BOR MIDAS REX LEGEND,SUP-2284668,CDM,C1713,HCPCS,0278,RC,,,,both,,,3764.36,2446.83,,,,,,,,,,,,,
STEM XL TAPER 17X135MM,SUP-2505005,CDM,C1776,CPT,0278,RC,,,,both,,,7046.16,4580.00,,,,,,,,,,,,,
ROD ORTHOPEDIC STBL 4.5 MM INTER-PHALANGEAL INTERPHLEX,SUP-2266337,CDM,C1713,HCPCS,0278,RC,,,,both,,,1168.08,759.25,,,,,,,,,,,,,
IMPLANT OPHTH SCLER TISS WHL,SUP-2303761,CDM,C1762,CPT,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
PEG BNE FIX L16MM DIA2.5MM DST VOLAR RAD PARTIALLY THRD FOR,SUP-2414242,CDM,C1713,HCPCS,0278,RC,,,,both,,,290.76,188.99,,,,,,,,,,,,,
LASER URETERAL CATHETER,SUP-2826994,CDM,C1758,HCPCS,0278,RC,,,,both,,,99.22,64.49,,,,,,,,,,,,,
GUIDEWIRE ORTHOPEDIC 0.094MM DIA 9INL,SUP-2640114,CDM,C1769,HCPCS,0272,RC,,,,both,,,62.80,40.82,,,,,,,,,,,,,
HC Wheelchair Training per 15 Min,PX-4209754200,CDM,97542,CPT,0420,RC,,,,inpatient,,,154.00,100.10,,,,,,,,,,,,,
BIT DRILL STOP 90 DEGREE 1.8X21 MM 14 MM FOR SCREWDRIVER NON,SUP-2842089,CDM,2720000010,LOCAL,0272,RC,,,,both,,,953.93,620.05,,,,,,,,,,,,,
SET CARDPLG 50ML TBL LN L10FT DIA3/16IN STD DEL W/ ARREST,SUP-2330951,CDM,2720000010,LOCAL,0272,RC,,,,both,,,772.44,502.09,,,,,,,,,,,,,
PLATE BONE LCK L CRV LT 15 H TI PROX TIB PLATING SYS ALPS,SUP-2413719,CDM,C1713,HCPCS,0278,RC,,,,both,,,4203.68,2732.39,,,,,,,,,,,,,
LEAD PACE MYOPORE BP 54 L 54 CM SIL BODY EPICARD BPLR,SUP-2138181,CDM,C1895,HCPCS,0275,RC,,,,both,,,1161.80,755.17,,,,,,,,,,,,,
HC Ot Ther Ex per 15 Min,PX-4309711000,CDM,97110,CPT,0430,RC,,,,both,,,195.00,126.75,,,,,,,,,,,,,
MESH SURG 20X15CM RECT PARIETEX PROGRIP,SUP-2174795,CDM,C1781,HCPCS,0278,RC,,,,both,,,923.47,600.26,,,,,,,,,,,,,
SCREW BNE 3X12 MM SNAP-OFF,SUP-2608923,CDM,C1713,HCPCS,0278,RC,,,,both,,,1248.78,811.71,,,,,,,,,,,,,
ALLOGRAFT HUMAN TISS PAT W/ EXT MECHANISM ASP,SUP-2875981,CDM,C1762,CPT,0278,RC,,,,both,,,15869.56,10315.21,,,,,,,,,,,,,
PROSTHESIS OSS L 5 MM SHFT DIA1.14 MM HD DIA 3 MM HA FLX H/A,SUP-2902123,CDM,L8613,CPT,0278,RC,,,,both,,,1445.03,939.27,,,,,,,,,,,,,
STIMULATOR NERVE IMPL PULSE GENRTR 16 CHANNEL OCTRODE ETERNA,SUP-2858400,CDM,C1822,CPT,0278,RC,,,,both,,,59346.00,38574.90,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC FT 5FR 55CM 2 LUMAN RVS TA 1275108F,SUP-2632635,CDM,C1751,HCPCS,0278,RC,,,,both,,,608.66,395.63,,,,,,,,,,,,,
BLADE SCREWDRIVER TORX 17 UNIV 2 MM S/D STAR/T-DRIVE T7,SUP-2469495,CDM,2720000010,LOCAL,0272,RC,,,,both,,,423.59,275.33,,,,,,,,,,,,,
LOOP ELECSURG 21FR CUT BPLR,SUP-2261122,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1216.47,790.71,,,,,,,,,,,,,
TUBE TRACH BIVONA PED L60MM OD4.7MM ID3MM SIL UNCUFFED,SUP-2933969,CDM,2720000010,LOCAL,0272,RC,,,,both,,,553.90,360.03,,,,,,,,,,,,,
COUPLER EXT FIX FOR 8MM ROD TO ROD OR POST HOFFMANN II MRI,SUP-2372211,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
GRAFT HUM TISS W20-24XL45MM THK5-30MM ILIUM TRICORT STRP,SUP-2307164,CDM,C1713,HCPCS,0278,RC,,,,both,,,4358.32,2832.91,,,,,,,,,,,,,
BIT DRILL DIA2MM HEX ADD CANNULATED DRIVER,SUP-2481556,CDM,2720000010,LOCAL,0272,RC,,,,both,,,536.06,348.44,,,,,,,,,,,,,
ANCHOR SUT FOR SPNL CRD STIM SWIFT LOCK,SUP-2356643,CDM,C1713,HCPCS,0278,RC,,,,both,,,407.67,264.99,,,,,,,,,,,,,
CEMENT BNE MAX VISC,SUP-2736290,CDM,C1713,HCPCS,0278,RC,,,,both,,,6123.00,3979.95,,,,,,,,,,,,,
CATHETER IVUS VISIONS PV .014P L 150 CM SHTH 5 FR GUIDE CATH,SUP-2898637,CDM,C1753,HCPCS,0278,RC,,,,both,,,1672.05,1086.83,,,,,,,,,,,,,
LIDOCAINE-EPINEPHRINE (PF) 2 %-1:200000 IJ SOLN,RX-169110,CDM,J2004,HCPCS,0636,RC,63323-0489-02,NDC,,both,20,ML,135.20,87.88,,,,,,,,,,,,,
GRAFT BONE SUB 15CC TRICORT ILIUM BLK FRZ DRY,SUP-2115983,CDM,C1713,HCPCS,0278,RC,,,,both,,,2125.78,1381.76,,,,,,,,,,,,,
BAG DRNGE REPL 700ML HERM II,SUP-2244306,CDM,C1729,HCPCS,0272,RC,,,,both,,,489.56,318.21,,,,,,,,,,,,,
SCREW BONE 3.0MM X 80MM DUAL TRAK CLAVICLE S,SUP-2639496,CDM,C1713,HCPCS,0278,RC,,,,both,,,4113.40,2673.71,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE 5 CC CORTICOCANCELLOUS ALLGRFT FRZN,SUP-2933017,CDM,C1762,CPT,0278,RC,,,,both,,,5822.69,3784.75,,,,,,,,,,,,,
CAGE SPNL H9XL10MM TI ANT THORLUM INTBDY FUS RND PYRAMESH,SUP-2291991,CDM,C1889,HCPCS,0278,RC,,,,both,,,3176.30,2064.59,,,,,,,,,,,,,
BUR SURG DIAMOND LNG 4 MM 7.5 CM BALL MIDAS REX LEGEND,SUP-2630541,CDM,2720000010,LOCAL,0272,RC,,,,both,,,530.91,345.09,,,,,,,,,,,,,
SHEATH CATH INTRO 8.5FR L71CM TRANSSEPTAL SM CURL BRK CRV,SUP-2357288,CDM,C1894,HCPCS,0272,RC,,,,both,,,3231.06,2100.19,,,,,,,,,,,,,
CATHETER ETER HAD ADMIN BASIC SET 155FRX28CM HEMO FLOW XF,SUP-2269538,CDM,C1881,HCPCS,0278,RC,,,,both,,,449.02,291.86,,,,,,,,,,,,,
SCREW BNE L30MM OD65MM THRD L16MM CANC NONCANNULATED STD,SUP-2373830,CDM,C1713,HCPCS,0278,RC,,,,both,,,125.29,81.44,,,,,,,,,,,,,
PORT INFUS CATH DIA6.6FR TI ATTCH SIL PEEL APART INTRO SGL,SUP-2126176,CDM,C1788,HCPCS,0278,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
CATHETER THROMCTMY PRONTO LP L 138 CM DIA 5 FR RX SECT 25,SUP-2763424,CDM,C1757,HCPCS,0272,RC,,,,both,,,1896.56,1232.76,,,,,,,,,,,,,
SET SHTH DESTINO TWST L 90 CM DIA 8.5 FR CRV BEND 17 MM DIL,SUP-2616238,CDM,C1766,CPT,0272,RC,,,,both,,,1868.30,1214.39,,,,,,,,,,,,,
LASER SURG W/ 3 YR WARR SELECTA DUET,SUP-2713806,CDM,2720000010,LOCAL,0272,RC,,,,both,,,219800.00,142870.00,,,,,,,,,,,,,
RING CATRCT PMMA TYP 14C AX L24-28MM FOR NRML MYOPIC EYE,SUP-2224372,CDM,L8610,HCPCS,0278,RC,,,,both,,,562.06,365.34,,,,,,,,,,,,,
SET SCR SPNL L5-7MM PEDFUSE,SUP-2353729,CDM,C1713,HCPCS,0278,RC,,,,both,,,2983.00,1938.95,,,,,,,,,,,,,
PLATE BONE THK1.5MM 5X2 H CVD 3D,SUP-2365234,CDM,C1713,HCPCS,0278,RC,,,,both,,,2267.90,1474.13,,,,,,,,,,,,,
IMMOBILIZER KNEE CUTAWAY 16 IN,SUP-2336079,CDM,L1830,CPT,0272,RC,,,,both,,,40.29,26.19,,,,,,,,,,,,,
GRAFT VASC GORTX L 30 CM DIA 8 MM RNG L 20 CM STR TW,SUP-2396163,CDM,C1768,CPT,0278,RC,,,,both,,,1852.60,1204.19,,,,,,,,,,,,,
PLATE POST SPINE BODY ASPN 8MM,SUP-2415557,CDM,C1713,HCPCS,0278,RC,,,,both,,,8949.00,5816.85,,,,,,,,,,,,,
HC So Parathyroid Hormone,PX-3018397066,CDM,83970,CPT,0301,RC,,,,both,,,308.00,200.20,,,,,,,,,,,,,
INSTRUMENT FIX MINI FIX HNG,SUP-2316470,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5851.39,3803.40,,,,,,,,,,,,,
NEEDLE SPNL CRD STIM FOR PAIN RELF ENTRADA SC4200,SUP-2138847,CDM,2720000010,LOCAL,0272,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
BRACE ORTH ABDUCTN CTRL HIP ORTHOSIS CTRL,SUP-2388158,CDM,L1680,HCPCS,0274,RC,,,,both,,,3006.05,1953.93,,,,,,,,,,,,,
COIL VASC RUBY POD PLAT TUNGSTEN ALLOY INIT STRL,SUP-2487075,CDM,C1889,HCPCS,0278,RC,,,,both,,,31368.60,20389.59,,,,,,,,,,,,,
SHORT NAIL 11X135-TROCHANTERIC,SUP-2371035,CDM,C1713,HCPCS,0278,RC,,,,both,,,2237.25,1454.21,,,,,,,,,,,,,
GRAFT BNE INJ 5 CC REGENERATIVE PRO-DENSE,SUP-2759598,CDM,C1713,HCPCS,0278,RC,,,,both,,,5216.61,3390.80,,,,,,,,,,,,,
ORTHOPEDIC KIT GLENOSPHERE 46 MM EXP EXT LCK CAP,SUP-2451423,CDM,C1776,CPT,0278,RC,,,,both,,,3611.00,2347.15,,,,,,,,,,,,,
BRUSH ES OD18GA CRD CRV,SUP-2110003,CDM,C1713,HCPCS,0278,RC,,,,both,,,383.08,249.00,,,,,,,,,,,,,
HC Lyr Clos Nk Hnd Ft 7.6-12.5,PX-4501204400,CDM,12044,CPT,0450,RC,,,,both,,,1941.00,1261.65,,,,,,,,,,,,,
CLOZAPINE 25 MG PO TABS,RX-9648,CDM,6370000000,HCPCS,0637,RC,00378-0825-01,NDC,,both,1,UN,3.80,2.47,,,,,,,,,,,,,
PLATE BNE L 257 MM SCREW DIA 3.5/4.5 MM 9 H LT TROCHANTERIC 72583109,SUP-2932912,CDM,C1713,HCPCS,0278,RC,,,,both,,,21181.66,13768.08,,,,,,,,,,,,,
STENT CAR L40MM DIA9MM CATH 7FR L135CM GWIRE 0.014IN NIT,SUP-2158973,CDM,C1876,HCPCS,0278,RC,,,,both,,,6264.30,4071.79,,,,,,,,,,,,,
SCREW BNE L85MM OD5MM THRD L30MM DK PUR CORT FEM TI ST CANN,SUP-2180325,CDM,C1713,HCPCS,0278,RC,,,,both,,,473.57,307.82,,,,,,,,,,,,,
SHUTTLE SUT STR CRESC W CHIA IDEAL,SUP-2256806,CDM,2720000010,LOCAL,0272,RC,,,,both,,,737.90,479.63,,,,,,,,,,,,,
TRIAL SURG INSTR 22X22X12MM BIOFOAM EVANS,SUP-2397869,CDM,C1776,CPT,0278,RC,,,,both,,,797.56,518.41,,,,,,,,,,,,,
HC Perq Replacement Gtube Not Req Revj Gstrst Trc,PX-4504376200,CDM,43762,CPT,0450,RC,,,,outpatient,,,935.00,607.75,,,,,,,,,,,,,
SUPPORT ORTHOPEDIC SLIP ON LG 8.5 IN WRST COMFORTFORM,SUP-2197053,CDM,L3906,HCPCS,0272,RC,,,,both,,,42.77,27.80,,,,,,,,,,,,,
SUPPORT ORTHOT THOR LUMBAR SACR CUST SAG CTRL OFF THE SHLF,SUP-2435542,CDM,L0467,HCPCS,0272,RC,,,,both,,,1074.16,698.20,,,,,,,,,,,,,
LIDOCAINE HCL 2 % IJ SOLN (MIXTURES ONLY),RX-430042,CDM,J2003,HCPCS,0636,RC,55150-0164-02,NDC,,both,1,ML,54.10,35.16,,,,,,,,,,,,,
CATHETER THERMOABLATION TORONTO RF TRANSSEPTAL SEPTOSTOMY,SUP-2131522,CDM,C1733,HCPCS,0272,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
COMPONENT FEM XL L KNEE REV CEM CRUCE RET STEM NONBEADED,SUP-2377072,CDM,C1776,CPT,0278,RC,,,,both,,,5116.44,3325.69,,,,,,,,,,,,,
MESH HERN W3.5XL3.5IN SQ ABD O3FA COAT POLYPR STR KNIT,SUP-2265993,CDM,C1781,HCPCS,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
KIT DSG M W DEHP ST DISPOSABLE VAC VERAFLO CLEANSE,SUP-2262379,CDM,2720000010,LOCAL,0272,RC,,,,both,,,422.08,274.35,,,,,,,,,,,,,
DOCETAXEL 160 MG/16ML IV SOLN,RX-104726,CDM,J9171,HCPCS,0636,RC,62332-0678-16,NDC,,both,16,ML,921.60,599.04,,,,,,,,,,,,,
ROD SPNL L50MM OD6MM TI ANT POST SMOOTH MAX RAD IMPL XIA,SUP-2380138,CDM,C1713,HCPCS,0278,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
STEM FEM SZ 13.5 RT HIP HA STD BODY DSTL TEXT APR,SUP-2211003,CDM,C1776,CPT,0278,RC,,,,both,,,16817.84,10931.60,,,,,,,,,,,,,
BLADE RETRACTOR HOHMN 21 CMX29 MM,SUP-2659986,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2436.36,1583.63,,,,,,,,,,,,,
BIT DRL DIA2MM QUIK REL MSDCL20] ACUMED LLC],SUP-2107721,CDM,2720000010,LOCAL,0272,RC,,,,both,,,175.84,114.30,,,,,,,,,,,,,
STAPLER SKIN POWERED L320MM 35MM VASC TISS 12 FIRING B FRM,SUP-2219819,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1104.02,717.61,,,,,,,,,,,,,
ANCHOR SUT NO1 FIBERWIRE UHMWPE W/ NDL FIBERTAK DX,SUP-2123219,CDM,C1713,HCPCS,0278,RC,,,,both,,,667.25,433.71,,,,,,,,,,,,,
PIN ORTH SMOOTH DBL SHRP TIP TRCR S STL NONSTERILE 2.8MM,SUP-2363713,CDM,C1713,HCPCS,0278,RC,,,,both,,,38.47,25.01,,,,,,,,,,,,,
GRAFT NRV L50MM DIA2-3MM PERIPH NAT CONN CBL PROC FOR RECON,SUP-2124850,CDM,C1763,HCPCS,0278,RC,,,,both,,,21160.46,13754.30,,,,,,,,,,,,,
SHELL ACET 46 MM HIP NO HOLE HA REFLECTION,SUP-2434738,CDM,C1776,CPT,0278,RC,,,,both,,,6053.92,3935.05,,,,,,,,,,,,,
GRAFT BONE SUB 2.5CC DBM PUTTY W/ RPM,SUP-2415793,CDM,C9359,HCPCS,0278,RC,,,,both,,,2147.76,1396.04,,,,,,,,,,,,,
SCREW BONE L26MM DIA5.7MM TI CANC NONCANNULATED LCK FULL,SUP-2106784,CDM,C1713,HCPCS,0278,RC,,,,both,,,552.64,359.22,,,,,,,,,,,,,
SUPPORT ORTHOT THOR LUMBAR SACR CUST SAGITTAL-CORONAL CTRL,SUP-2435543,CDM,L0468,HCPCS,0274,RC,,,,both,,,1346.15,875.00,,,,,,,,,,,,,
GRAFT TEND SEMI TENDOSIS ALLGRFT FRZ DRY 20 259CM L 3 10MM,SUP-2307125,CDM,C1762,CPT,0278,RC,,,,both,,,5420.68,3523.44,,,,,,,,,,,,,
ENVELOP TISS LG 8X6.9 CM SFT SUPPLE CORMATRIX CANGAROO EMC,SUP-2653869,CDM,C1889,HCPCS,0278,RC,,,,both,,,2967.30,1928.74,,,,,,,,,,,,,
PLATE BNE BROAD 4.5X197 MM 11 HOLE SS LCP,SUP-2569364,CDM,C1713,HCPCS,0278,RC,,,,both,,,689.07,447.90,,,,,,,,,,,,,
PLATE CRAN 180X100X40 MM PT SPEC IMPL PEEK,SUP-2860149,CDM,C1713,HCPCS,0278,RC,,,,both,,,42768.68,27799.64,,,,,,,,,,,,,
GRAFT BIO TISS W24XL63IN RECT XENMATRIX,SUP-2126238,CDM,C1781,HCPCS,0278,RC,,,,both,,,9172.25,5961.96,,,,,,,,,,,,,
STRAP CLAV SELF-ADJSTBLE L,SUP-2195528,CDM,L3650,HCPCS,0272,RC,,,,both,,,21.38,13.90,,,,,,,,,,,,,
BLADE SURG BLACKLINE 45X22.5 MM TEETHED 2 LEVEL SS TI LF,SUP-2763779,CDM,2720000010,LOCAL,0272,RC,,,,both,,,520.11,338.07,,,,,,,,,,,,,
ANCHOR SUT L3.5MM KNOTLESS FIX SYS PINTON,SUP-2388893,CDM,C1776,CPT,0278,RC,,,,both,,,2967.61,1928.95,,,,,,,,,,,,,
PROSTHESIS VOICE RAPID EXCHANGE 20 FRX10 MM NS BLOM-SINGER,SUP-2242337,CDM,L8509,HCPCS,0272,RC,,,,both,,,1378.46,896.00,,,,,,,,,,,,,
NIVOLUMAB 100 MG/10ML IV SOLN,RX-128573,CDM,J9299,HCPCS,0636,RC,00003-3774-12,NDC,,both,10,ML,9531.70,6195.60,,,,,,,,,,,,,
OMALIZUMAB 75 MG/0.5ML SC SOSY,RX-144252,CDM,J2357,HCPCS,0636,RC,50242-0214-01,NDC,,both,0.5,ML,2172.40,1412.06,,,,,,,,,,,,,
AGENT HEMSTAT 8ML FLX TIP MTRX + DISP SURGIFLO,SUP-2218262,CDM,2720000010,LOCAL,0272,RC,,,,both,,,374.48,243.41,,,,,,,,,,,,,
PLATE BNE W8XL84MM THK2MM 0DEG 10 H BILAT S STL STR RIG DYN,SUP-2186182,CDM,C1713,HCPCS,0278,RC,,,,both,,,889.28,578.03,,,,,,,,,,,,,
ALLOGRAFT DERMAL MESHED THN 8X4 CMX0.4-0.7 MM ALLOPATCH HD,SUP-2480052,CDM,Q4128,HCPCS,0636,RC,,,,both,,,4900.28,3185.18,,,,,,,,,,,,,
RESERVOIR 20MM BURR HOLE WITHOUT SHUNT ASSISTANT HYDRO PROGA,SUP-2825796,CDM,C1889,HCPCS,0278,RC,,,,both,,,7388.26,4802.37,,,,,,,,,,,,,
PLATE BNE L CLAV CTRL 3RD S STL FOR FACTURE,SUP-2121731,CDM,C1713,HCPCS,0278,RC,,,,both,,,2323.60,1510.34,,,,,,,,,,,,,
DRILL SURG 7 MM FOR BNE GRFT ASMBLY,SUP-2857903,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5394.52,3506.44,,,,,,,,,,,,,
SUPPORT ORTHOT FNGR CUST ADJ W/O JT FABRICATED SFT INTFACE,SUP-2435789,CDM,L3933,HCPCS,0274,RC,,,,both,,,549.78,357.36,,,,,,,,,,,,,
CANNULA SURG W/O STOPCOCK 70 MM 3.2 MM FOR IRRIGATION,SUP-2794081,CDM,2720000010,LOCAL,0272,RC,,,,both,,,475.87,309.32,,,,,,,,,,,,,
STAPLER INT CARTRIDGE EXTRA THICK 80 MM TRI-STAPLE BLK GIA,SUP-2787700,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1185.82,770.78,,,,,,,,,,,,,
CURETTE SURG L229MM SZ 1 BNE STR OVL CUP RUGGLES,SUP-2161387,CDM,C1713,HCPCS,0278,RC,,,,both,,,727.54,472.90,,,,,,,,,,,,,
GRAFT HUM TISS PARTICULATE 100 MG CONNECTIVE TISS INTERFYL,SUP-2845980,CDM,Q4171,HCPCS,0636,RC,,,,both,,,4662.90,3030.88,,,,,,,,,,,,,
BOOT CAST PEDIATRIC 5.5X2.5 IN ROCKER SHOE CANVS,SUP-2336135,CDM,L4387,HCPCS,0274,RC,,,,both,,,17.43,11.33,,,,,,,,,,,,,
HC Level II Surg Pathology Gross&Microscopic Exam,PX-3128830200,CDM,88302,CPT,0312,RC,,,,both,,,368.00,239.20,,,,,,,,,,,,,
PLATE BNE NAR 4.5X183 MM 11 HOLE SS DCP,SUP-2569169,CDM,C1713,HCPCS,0278,RC,,,,both,,,343.67,223.39,,,,,,,,,,,,,
PLATE BNE L 167 MM SCREW DIA 4.5 MM 9 H NAR COMPR NLCK NS,SUP-2933752,CDM,C1713,HCPCS,0278,RC,,,,both,,,1780.22,1157.14,,,,,,,,,,,,,
CATHETER THROMCTMY SOLITAIRE X L 40 MM DIA 4 MM PUSH SPC 10,SUP-2434107,CDM,C1757,HCPCS,0272,RC,,,,both,,,21125.92,13731.85,,,,,,,,,,,,,
GRAFT DURA W2XL2IN REABSORBABLE MTRX SUB FOR SFT TISS REP,SUP-2244081,CDM,C1763,HCPCS,0278,RC,,,,both,,,953.18,619.57,,,,,,,,,,,,,
HC Treat Big Toe Fx,PX-4502849000,CDM,28490,CPT,0450,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
CATHETER IVL SHOCKWAVE  4.0MM 135CM,SUP-2850094,CDM,C1725,HCPCS,0272,RC,,,,both,,,10833.00,7041.45,,,,,,,,,,,,,
CATHETER ABLAT 8FR L115CM 2-5-2MM SPC TIP 3.5MM 6 ELECTRD D,SUP-2248601,CDM,C1732,HCPCS,0278,RC,,,,both,,,4374.02,2843.11,,,,,,,,,,,,,
GRAFT BONE PRIMAGEN 5CC,SUP-2402836,CDM,C1713,HCPCS,0278,RC,,,,both,,,5495.00,3571.75,,,,,,,,,,,,,
SCREW BNE 4/PK L 6 MM DIA2.2 MM PLA GLYCOLIDE CRANIOMAXILLOFACIAL,SUP-2884155,CDM,C1713,HCPCS,0278,RC,,,,both,,,1153.29,749.64,,,,,,,,,,,,,
PLATE BNE L72MM SHT 1 H ST R MED DST HUM S STL VAR ANG FOR,SUP-2177589,CDM,C1713,HCPCS,0278,RC,,,,both,,,4258.28,2767.88,,,,,,,,,,,,,
PLATE EXT FIX L155MM LNG S STL 8 H CONN COMP IMP ILIZ,SUP-2342268,CDM,C1713,HCPCS,0278,RC,,,,both,,,2083.33,1354.16,,,,,,,,,,,,,
SCREW BNE L 70 MM DIA2.4 MM TI CORTICAL T8 STARDRV BRZ TUBE,SUP-2905740,CDM,C1713,HCPCS,0278,RC,,,,both,,,629.73,409.32,,,,,,,,,,,,,
GRAFT BNE 1.5 CC ACTIFUSE ABX,SUP-2208432,CDM,C1713,HCPCS,0278,RC,,,,both,,,1287.40,836.81,,,,,,,,,,,,,
ROD SPNL 7550552000] ZIMMER SPINE],SUP-2415721,CDM,C1713,HCPCS,0278,RC,,,,both,,,1252.86,814.36,,,,,,,,,,,,,
COMPONENT TIB BASEPLT UNI LM/RL 9MM S EIUS,SUP-2364884,CDM,C1776,CPT,0278,RC,,,,both,,,5950.30,3867.69,,,,,,,,,,,,,
SCREW SPNL 45X6.5MM PEDCL MULT AX CORT NONCANNULATED S STL,SUP-2415296,CDM,C1713,HCPCS,0278,RC,,,,both,,,1885.88,1225.82,,,,,,,,,,,,,
STENT PERIPH L5CM DIA6MM CATH L120CM FEM IL AV ACC EPTFE,SUP-2396548,CDM,C1874,HCPCS,0278,RC,,,,both,,,9969.50,6480.17,,,,,,,,,,,,,
MATRIX BIO L 12 X W 10 CM FET BOV DERM IONIC SLV DERMAL SLD,SUP-2909235,CDM,Q4110,HCPCS,0636,RC,,,,both,,,14444.00,9388.60,,,,,,,,,,,,,
SET NEPHSTMY CATHETER 83FR L30CM 0038IN 6 SIDEPRT PERC FOR,SUP-2167941,CDM,C1769,HCPCS,0272,RC,,,,both,,,418.12,271.78,,,,,,,,,,,,,
NAIL IM L 25 CM DIA11 MM TI L TIBL STRL TRIGEN MAX,SUP-2931459,CDM,C1713,HCPCS,0278,RC,,,,both,,,6691.97,4349.78,,,,,,,,,,,,,
CEFAZOLIN IN SODIUM CHLORIDE 2-0.9 GM/100ML-% IV SOLN,RX-135152,CDM,J0690,HCPCS,0636,RC,99990-0043-19,NDC,,both,100,ML,54.10,35.16,,,,,,,,,,,,,
BRACKET EXT FIX L LG SALVATION SEF11112,SUP-2493328,CDM,2720000010,LOCAL,0272,RC,,,,both,,,901.18,585.77,,,,,,,,,,,,,
ANCHOR SUT L14.5MM DIA3MM BIOCOMP SUTTAK,SUP-2121592,CDM,C1713,HCPCS,0278,RC,,,,both,,,832.10,540.86,,,,,,,,,,,,,
Z DISCONTINUED CATHETER IABP 7FR 34CC SHTH LAIN FBROPT DATASCP SYS,SUP-2227312,CDM,C1725,HCPCS,0272,RC,,,,both,,,2976.06,1934.44,,,,,,,,,,,,,
CATHETER GUID RAPIDO WORKING L 47 CM DIA 8 FR SS PTFE PEBAX,SUP-2148900,CDM,C1887,HCPCS,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
DRILL SURG LNG STRL ACUTRK 2 LTX DISP,SUP-2857810,CDM,2720000010,LOCAL,0272,RC,,,,both,,,938.86,610.26,,,,,,,,,,,,,
JOINT SUBTALAR 10.5 MM ANK,SUP-2318977,CDM,C1776,CPT,0278,RC,,,,both,,,4317.50,2806.37,,,,,,,,,,,,,
JOINT FNGR HINGED 5 16.5X2.1/5X3.2 MM 9.9 MM PROX MP,SUP-2852848,CDM,C1776,CPT,0278,RC,,,,both,,,10797.68,7018.49,,,,,,,,,,,,,
SHEATH INTRO PRELUDEEASE 23CM 4FR 80 CM NDL 2.5 CM PLAS,SUP-2677191,CDM,C1894,HCPCS,0272,RC,,,,both,,,171.44,111.44,,,,,,,,,,,,,
STAPLER ENDOSCP BIOABSORBABLE STPL LN REINF ENDOPATH SEAMGRD,SUP-2395279,CDM,C1781,HCPCS,0278,RC,,,,both,,,493.23,320.60,,,,,,,,,,,,,
FIBER LASER 272 MH HOLM REUSE EMPFBX272HRC,SUP-2540072,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3761.88,2445.22,,,,,,,,,,,,,
SPHINCTEROTOME ENDO L25MM OD5-4FR 0.021IN BLK PRECRV ULT,SUP-2169379,CDM,2720000010,LOCAL,0272,RC,,,,both,,,555.78,361.26,,,,,,,,,,,,,
KIT INTRO ARW SHTH L 10 CM DIA 7 FR GUIDEWIRE L 45 CM DIA,SUP-2763320,CDM,C1769,HCPCS,0272,RC,,,,both,,,106.45,69.19,,,,,,,,,,,,,
"HC Gbl New Pt, E/M Level 2|MULTIPLE OUTPATIENT HOSPITAL E/M ENCOUNTERS ON THE SAME DATE",PX-9829920200,CDM,99202,CPT,0982,RC,,,27,both,,,365.00,237.25,,,,,,,,,,,,,
DEFIBRILLATOR CARD 2 CHMBR DF4-LLHH/IS-1 CONN W/ RF TELMTRY,SUP-2356292,CDM,C1721,HCPCS,0275,RC,,,,both,,,39412.65,25618.22,,,,,,,,,,,,,
BIT DRL DIA4.5MM TWST CROWE PNT FOR PHOENIX AG FEM NAIL SYS,SUP-2412151,CDM,2720000010,LOCAL,0272,RC,,,,both,,,533.80,346.97,,,,,,,,,,,,,
LIDOCAINE-EPINEPHRINE 1 %-1:100000 IJ SOLN,RX-10427,CDM,J2004,HCPCS,0636,RC,63323-0482-57,NDC,,both,20,ML,54.10,35.16,,,,,,,,,,,,,
SCREW BONE LOCKING 3X16 MM STERNAL SELFDRILLING TITANIUM STE,SUP-2837701,CDM,C1713,HCPCS,0278,RC,,,,both,,,742.30,482.49,,,,,,,,,,,,,
SCREW BONE L55MM D55MM THRD L16MM CNCLLS SELF DRLLNG SELF TP,SUP-2482922,CDM,C1713,HCPCS,0278,RC,,,,both,,,592.83,385.34,,,,,,,,,,,,,
IMPLANT GREAT TOE BIOACTION METATRSL SM NEUT CO CHROM TI,SUP-2303800,CDM,C1776,CPT,0278,RC,,,,both,,,2496.30,1622.59,,,,,,,,,,,,,
PLATE SPINE SACR RT COLORADO 2 SACR AND SACROILIAC S STL,SUP-2290564,CDM,C1713,HCPCS,0278,RC,,,,both,,,7369.58,4790.23,,,,,,,,,,,,,
PLATE BNE H0.5MM 6X2 H UP FACE BLU TI 3D MAL LEIBINGER UNIV,SUP-2366233,CDM,C1713,HCPCS,0278,RC,,,,both,,,1290.95,839.12,,,,,,,,,,,,,
STAPLE STR ASSEMB 10MM X 10MM,SUP-2321572,CDM,C1713,HCPCS,0278,RC,,,,both,,,4824.61,3136.00,,,,,,,,,,,,,
GUIDEWIRE VASC H2O L 150 CM DIA 0.018 IN NIT COR HYDRPHLC,SUP-2302582,CDM,C1769,HCPCS,0272,RC,,,,both,,,147.42,95.82,,,,,,,,,,,,,
CATHETER EXT WRK CHAN 90 EDGE,SUP-2381748,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1199.48,779.66,,,,,,,,,,,,,
GUIDEPIN ORTH BAL KNEE TEMP,SUP-2315861,CDM,C1713,HCPCS,0278,RC,,,,both,,,2637.60,1714.44,,,,,,,,,,,,,
GRAFT MTRX DERM HUM TISS ACELLULAR FRZ DRY THCK 4CMX7CM,SUP-2306911,CDM,C1762,CPT,0278,RC,,,,both,,,2651.13,1723.23,,,,,,,,,,,,,
PERI-LOC 4.5MM T25 TI CTX SCREW 40MM S-T,SUP-2819744,CDM,C1713,HCPCS,0278,RC,,,,both,,,475.14,308.84,,,,,,,,,,,,,
HC Treatment Devices Complex,PX-3337733400,CDM,77334,CPT,0333,RC,,,,both,,,2276.00,1479.40,,,,,,,,,,,,,
RASP SURG RIORDAN NSL HANDHELD SGL END STR TAPR FLAT BLDE,SUP-2367146,CDM,C1713,HCPCS,0278,RC,,,,both,,,481.83,313.19,,,,,,,,,,,,,
CATHETER CTRL VEN DBL LUMN N TUNNELED BASIC KT POLYUR,SUP-2120599,CDM,C1751,HCPCS,0278,RC,,,,both,,,177.72,115.52,,,,,,,,,,,,,
BROAD PLT STERILIZER 4.5X231 MM 14 HL,SUP-2818455,CDM,C1713,HCPCS,0278,RC,,,,both,,,2229.53,1449.19,,,,,,,,,,,,,
PLEDGET VASC W3/16XL3/8IN THK1/16IN PTFE SFT,SUP-2384372,CDM,C1768,CPT,0278,RC,,,,both,,,26.44,17.19,,,,,,,,,,,,,
BIT DRL L 205/110 MM DIA2.5 MM CALIB AO QC NS REUSE V,SUP-2908171,CDM,2720000010,LOCAL,0272,RC,,,,both,,,868.78,564.71,,,,,,,,,,,,,
PLATE BNE BROAD 3.5X224 MM 17 HOLE SS LCP,SUP-2569343,CDM,C1713,HCPCS,0278,RC,,,,both,,,578.55,376.06,,,,,,,,,,,,,
TEMPORAL BONE PLATE LG 25MM X 45MM 6MM 15MM SSTM CP TTNM,SUP-2677465,CDM,C1713,HCPCS,0278,RC,,,,both,,,1060.85,689.55,,,,,,,,,,,,,
GRAFT HUM TISS,SUP-2213682,CDM,V2785,HCPCS,0278,RC,,,,both,,,15700.00,10205.00,,,,,,,,,,,,,
HC Lactoferrin Fecal Qualitative,PX-3018363000,CDM,83630,CPT,0301,RC,,,,both,,,123.00,79.95,,,,,,,,,,,,,
SHELL ACET OD50MM GRP C BIOFOAM TI POR HIP PRESSFIT DYNASTY,SUP-2304551,CDM,C1776,CPT,0278,RC,,,,both,,,8164.00,5306.60,,,,,,,,,,,,,
HC So T-3 Uptake,PX-3018447966,CDM,84479,CPT,0301,RC,,,,both,,,40.00,26.00,,,,,,,,,,,,,
SCREW BNE L 110 MM DIA 6.5 MM TI ST SD CANN FULL THRD RVS,SUP-2900988,CDM,C1713,HCPCS,0278,RC,,,,both,,,961.66,625.08,,,,,,,,,,,,,
INSERT TIB ARTC SURF CRUC RET MOLD PUR LT RT 9MM THCK 58MM,SUP-2201263,CDM,C1776,CPT,0278,RC,,,,both,,,4127.22,2682.69,,,,,,,,,,,,,
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,RX-23128,CDM,J0133,HCPCS,0636,RC,55150-0154-10,NDC,,both,10,ML,64.70,42.05,,,,,,,,,,,,,
STABILIZER 045MMX25IN OLV CROSSCHECK,SUP-2401429,CDM,C1713,HCPCS,0278,RC,,,,both,,,445.88,289.82,,,,,,,,,,,,,
SUTURE MORPHIX 3.5MM ANCHR W/ 2 USP NO0 DBL ARMED 100004235,SUP-2277451,CDM,C1776,CPT,0278,RC,,,,both,,,1909.12,1240.93,,,,,,,,,,,,,
TI NUT 45MM CORTEX SCREWS,SUP-2704873,CDM,C1713,HCPCS,0278,RC,,,,both,,,109.90,71.43,,,,,,,,,,,,,
HC US Abdominal Limited,PX-4027670500,CDM,76705,CPT,0402,RC,,,,both,,,1336.00,868.40,,,,,,,,,,,,,
SET URET STENT MARD L 24 CM DIA 4.8 FR GUIDEWIRE 0.035 IN,SUP-2139048,CDM,C2617,HCPCS,0278,RC,,,,both,,,450.75,292.99,,,,,,,,,,,,,
SCREW BONE L12MM DIA2.8MM NONLOCKING SLD FOR PLATING SYS,SUP-2223996,CDM,C1713,HCPCS,0278,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
LEAD DEFIB COR SINUS OVR THE WIRE QP S-75 SENTUS,SUP-2138437,CDM,C1900,HCPCS,0275,RC,,,,both,,,5011.44,3257.44,,,,,,,,,,,,,
AUGMENT FEM SZ 10 KNEE REV NP RT STRL EMPOWR 3D KNEE,SUP-2890702,CDM,C1776,CPT,0278,RC,,,,both,,,15386.00,10000.90,,,,,,,,,,,,,
DRILL SURGICAL 2MM DIA 2.5MML TITANIUM CANNULATED,SUP-2586645,CDM,2720000010,LOCAL,0272,RC,,,,both,,,836.81,543.93,,,,,,,,,,,,,
CATHETER VASC ELLIPSYS SHTH 6 FR GUIDEWIRE 0.014 IN RVD 2 MM,SUP-2859466,CDM,C1889,HCPCS,0278,RC,,,,both,,,28103.00,18266.95,,,,,,,,,,,,,
MESH HERN W20.3XL25.4CM POLY 4 HYDROXYBUTYRATE SYN RECTANG,SUP-2125871,CDM,C1781,HCPCS,0278,RC,,,,both,,,19923.30,12950.14,,,,,,,,,,,,,
INTRODUCER DIAG PEEL-APART L 15 CM DIA13 FR PTFE PERC NO CRV,SUP-2127884,CDM,C1894,HCPCS,0272,RC,,,,both,,,228.44,148.49,,,,,,,,,,,,,
SHUNT SURG SM ASSY LO,SUP-2628145,CDM,C1729,HCPCS,0272,RC,,,,both,,,3130.74,2034.98,,,,,,,,,,,,,
PLATE BNE M L64MM NONSTERILE R CALCNL S STL VAR ANG LOK FOR,SUP-2178421,CDM,C1713,HCPCS,0278,RC,,,,both,,,3035.63,1973.16,,,,,,,,,,,,,
PROBE LITHO ELEC HYDRLC RIWOLITH STRL DISP L770MM OD5FR,SUP-2332791,CDM,C1713,HCPCS,0278,RC,,,,both,,,606.02,393.91,,,,,,,,,,,,,
CATHETER HD STR AD 15.5 FRX48 CM LT DL BASIC KT DURAFLO 2,SUP-2464722,CDM,C1750,HCPCS,0278,RC,,,,both,,,857.22,557.19,,,,,,,,,,,,,
PIN FIX REDUCTION SM 15 MM TCP,SUP-2530500,CDM,C1713,HCPCS,0278,RC,,,,both,,,292.02,189.81,,,,,,,,,,,,,
LEAD NERVE STIM 50 CM 3-6 TRL LINEAR,SUP-2765586,CDM,C1883,HCPCS,0278,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
SPHINCTEROTOME 44 20MM TRUETOME,SUP-2141622,CDM,2720000010,LOCAL,0272,RC,,,,both,,,501.30,325.84,,,,,,,,,,,,,
SUBSTITUTE BNE GRFT 10 CC DEMINERALIZED CORTICAL FIBER HSA,SUP-2881923,CDM,C1713,HCPCS,0278,RC,,,,both,,,5055.40,3286.01,,,,,,,,,,,,,
STEM GLOBAL UNITE REV SZ 8,SUP-2512721,CDM,C1776,CPT,0278,RC,,,,both,,,7975.60,5184.14,,,,,,,,,,,,,
VALVE SHUNT LUMBAR PERITONEAL TALL CHLD AD 91 CM YEL,SUP-2257215,CDM,2780000010,LOCAL,0278,RC,,,,both,,,2367.56,1538.91,,,,,,,,,,,,,
FIBER LASER 272UM DUST THULIUM,SUP-2885341,CDM,2720000010,LOCAL,0272,RC,,,,both,,,631.14,410.24,,,,,,,,,,,,,
CATHETER CV FULL SAFETY TY 025 PEDIATRIC 5 FRX5 CM 3L,SUP-2760000,CDM,C1751,HCPCS,0278,RC,,,,both,,,382.73,248.77,,,,,,,,,,,,,
STENT BILI ZILVER 518 L 20 MM DIA 4 MM DEL SYS L 125 CM SHTH,SUP-2170059,CDM,C1876,HCPCS,0278,RC,,,,both,,,2924.91,1901.19,,,,,,,,,,,,,
CATHETER GUID 7X5FR L62CM WRK L59CM ACUTE CRV PEBAX INNR,SUP-2356393,CDM,C1887,HCPCS,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
CABLE SURG L610MM DIA1.8MM CO CHROM SL CTRL,SUP-2252407,CDM,C1713,HCPCS,0278,RC,,,,both,,,1262.28,820.48,,,,,,,,,,,,,
HC ER Level 1,PX-4509928100,CDM,99281,CPT,0450,RC,,,,both,,,660.00,429.00,,,,,,,,,,,,,
HC Sickling RBC Reduction,PX-3058566000,CDM,85660,CPT,0305,RC,,,,inpatient,,,228.00,148.20,,,,,,,,,,,,,
STEM HUM ALTIVATE REV STD SHELL 12 X 220MM,SUP-2890873,CDM,C1776,CPT,0278,RC,,,,both,,,36653.22,23824.59,,,,,,,,,,,,,
INTRODUCER KYPHOPLASTY SZ 3 8GA 42MM BVL OSTEO KYPHON 1 STP,SUP-2281650,CDM,C1894,HCPCS,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
GUIDEWIRE SURG PARL 4-4.5 MM SCR RIVAL,SUP-2644843,CDM,C1769,HCPCS,0272,RC,,,,both,,,1951.20,1268.28,,,,,,,,,,,,,
MARKER BRST TISS SPRING 17 GA SS ULTRACOR,SUP-2759178,CDM,A4648,CPT,0278,RC,,,,both,,,206.96,134.52,,,,,,,,,,,,,
PROBE OPHTH LASER STR STRL 23GA,SUP-2129218,CDM,2720000010,LOCAL,0272,RC,,,,both,,,344.52,223.94,,,,,,,,,,,,,
PLATE BNE COMPR SM 2.7X68 MM 8 HOLE DYN NS DCP LTX,SUP-2861901,CDM,C1713,HCPCS,0278,RC,,,,both,,,426.91,277.49,,,,,,,,,,,,,
CAGE SPNL LORDTC 16X13X7 MM PEEK,SUP-2401533,CDM,C1889,HCPCS,0278,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
IMPLANT SHLDR SPCR INTERSPACE STD FOR TWO STG REV,SUP-2223700,CDM,C1776,CPT,0278,RC,,,,both,,,12965.06,8427.29,,,,,,,,,,,,,
PLATE BNE TIB RT DSTL MEDL 15 HOLE LCK STRL A.L.P.S,SUP-2466121,CDM,C1713,HCPCS,0278,RC,,,,both,,,4556.52,2961.74,,,,,,,,,,,,,
BLADE SHAVER CUT 4.5X120 MM AGGRESSIVE DK GRY GRN UNIDRIVE,SUP-2585904,CDM,2720000010,LOCAL,0272,RC,,,,both,,,243.35,158.18,,,,,,,,,,,,,
SUPPORT ORTHOT THOR LUMBAR SACR CUST SAGITTAL-CORONAL SHLF,SUP-2435544,CDM,L0469,HCPCS,0272,RC,,,,both,,,1346.15,875.00,,,,,,,,,,,,,
IMPLANT BRST SMOOTH MOD PROF X,SUP-2748658,CDM,C1889,HCPCS,0278,RC,,,,both,,,3014.40,1959.36,,,,,,,,,,,,,
MATRIX BIO L 7 X W 7 CM SZ 300 SQCM ACELLULAR FISH SKIN,SUP-2909197,CDM,Q4158,HCPCS,0636,RC,,,,both,,,23550.00,15307.50,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.445,SUP-2860009,CDM,C1713,HCPCS,0278,RC,,,,both,,,51978.30,33785.89,,,,,,,,,,,,,
ANCHOR SUTURE 5.5MM WITH WITH 3 HI FI NUMBER 2 SUTURES GENES,SUP-2824877,CDM,C1713,HCPCS,0278,RC,,,,both,,,1783.52,1159.29,,,,,,,,,,,,,
GRAFT TISS FRZ DRY ALLGRFT ACF SPCR CERV SPNL IMPL 7X4MM,SUP-2414384,CDM,C1762,CPT,0278,RC,,,,both,,,3218.50,2092.02,,,,,,,,,,,,,
RELOAD STPL SZ 2.5MM L45MM 0DEG UNIV WHT TI ROTICULATING,SUP-2283058,CDM,2720000010,LOCAL,0272,RC,,,,both,,,568.09,369.26,,,,,,,,,,,,,
BOLT EXT FIX WIRE SIDEKCK EZ FRAME EF1500PK,SUP-2484070,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7517.16,4886.15,,,,,,,,,,,,,
GRAFT BNE PTTY DEMIN BNE MTRX 2CC,SUP-2402605,CDM,C1713,HCPCS,0278,RC,,,,both,,,1215.18,789.87,,,,,,,,,,,,,
CATHETER KIT 3L 7 FRX8 IN GUIDE RAULERSON CVC POLYURETHANE,SUP-2383299,CDM,C1751,HCPCS,0278,RC,,,,both,,,141.46,91.95,,,,,,,,,,,,,
KIT CAGE SPINAL APREVO 3-LEVEL,SUP-2912824,CDM,C1889,HCPCS,0278,RC,,,,both,,,119320.00,77558.00,,,,,,,,,,,,,
PLATE BNE L 4 H L TARSOMETATARSAL S STL BILAT POLYAX U SHP,SUP-2397475,CDM,C1713,HCPCS,0278,RC,,,,both,,,4314.36,2804.33,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE XL 16 CC CORTICOCANCELLOUS VIABLE 004,SUP-2936806,CDM,C1762,CPT,0278,RC,,,,both,,,16174.14,10513.19,,,,,,,,,,,,,
STEM RAD L29X19MM DIA7MM NK OFFSET 4MM TI ALIGN,SUP-2340142,CDM,C1776,CPT,0278,RC,,,,both,,,5416.50,3520.72,,,,,,,,,,,,,
PANCRELIPASE (LIP-PROT-AMYL) 5000-24000 UNITS PO CPEP,RX-141346,CDM,6370000000,HCPCS,0637,RC,73562-0115-01,NDC,,both,1,UN,9.60,6.24,,,,,,,,,,,,,
RETRIEVER THROMCTMY MERCI L4 DIA2 MM NIT STRL,SUP-2367770,CDM,C1773,HCPCS,0272,RC,,,,both,,,8792.00,5714.80,,,,,,,,,,,,,
COLLAR CERV 4.25IN 12IN SM TRACH OPN AD PHIL,SUP-2195257,CDM,L0180,HCPCS,0274,RC,,,,both,,,39.97,25.98,,,,,,,,,,,,,
NAIL IM L360MM DIA11MM 125DEG R TROCHANTERIC FEM HIP TI R2,SUP-2370530,CDM,C1713,HCPCS,0278,RC,,,,both,,,6594.00,4286.10,,,,,,,,,,,,,
PIN ALIGN 2.5X150 MM STRL AEQUALIS REVERSED II DISP,SUP-2715608,CDM,2720000010,LOCAL,0272,RC,,,,both,,,395.64,257.17,,,,,,,,,,,,,
METHYLENE BLUE (ANTIDOTE) 50 MG/10ML IV SOLN,RX-135014,CDM,Q9968,HCPCS,0636,RC,00517-0374-05,NDC,,both,10,ML,1347.80,876.07,,,,,,,,,,,,,
ANCHOR SUT OD2.9MM ABSRB 1 SZ 2 PRELD ULTRABRAID STRL STR,SUP-2341671,CDM,C1713,HCPCS,0278,RC,,,,both,,,762.49,495.62,,,,,,,,,,,,,
DEVICE THROMCTMY CLN XT L 135 CM DIA 6 FR SINUSOIDAL WIRE,SUP-2120126,CDM,C1724,HCPCS,0278,RC,,,,both,,,2496.30,1622.59,,,,,,,,,,,,,
PIN FIX DIAMOND PT 2 END 9/64X9 IN 4 PT STYL SMOOTH PLN STRL,SUP-2150500,CDM,C1713,HCPCS,0278,RC,,,,both,,,15.23,9.90,,,,,,,,,,,,,
CONNECTOR SPINE SACR AND SACR IL S STL 6.35MM COLORADO 2,SUP-2290621,CDM,C1713,HCPCS,0278,RC,,,,both,,,3048.94,1981.81,,,,,,,,,,,,,
PLATE BNE LP LG LT SUP CLAV 8 HOLE MIDSHAFT ACU-SINCH,SUP-2106985,CDM,C1713,HCPCS,0278,RC,,,,both,,,3362.94,2185.91,,,,,,,,,,,,,
PLATE TI LOCKING 1.3MM PHALANGE BASE 2H HEAD 5H SHAFT STER,SUP-2546882,CDM,C1713,HCPCS,0278,RC,,,,both,,,1755.79,1141.26,,,,,,,,,,,,,
GRAFT BONE 14X26MM BONE MECH IMPACTED WDG CORT FRZ DRY,SUP-2293770,CDM,C1713,HCPCS,0278,RC,,,,both,,,8173.42,5312.72,,,,,,,,,,,,,
NICOTINE POLACRILEX 2 MG MT GUM,RX-10717,CDM,6370000000,HCPCS,0637,RC,00536-1362-23,NDC,,both,1,UN,1.90,1.23,,,,,,,,,,,,,
TRAY NERVE BLOCK ST300C OPM BPSK STRL LF DISP DESIGN OPTIONS,SUP-2936633,CDM,2720000010,LOCAL,0272,RC,,,,both,,,37.84,24.60,,,,,,,,,,,,,
IMPLANT WR JT L37MM 9MM TAPR CRPL PLT MAESTRO,SUP-2407357,CDM,C1713,HCPCS,0278,RC,,,,both,,,4772.80,3102.32,,,,,,,,,,,,,
TECH SURGICAL BOSTON ENDO,SUP-2114054,CDM,2720000010,LOCAL,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
METHYLPHENIDATE HCL 10 MG PO TABS,RX-4986,CDM,6370000000,HCPCS,0637,RC,68084-0823-11,NDC,,both,1,UN,7.50,4.87,,,,,,,,,,,,,
STENT TRACHBRONCH WSTNT L 20 MM DIA12 MM SHTH 9 FR CATH L 75,SUP-2142675,CDM,C1876,HCPCS,0278,RC,,,,both,,,2983.00,1938.95,,,,,,,,,,,,,
PLATE T 8 H,SUP-2321417,CDM,C1713,HCPCS,0278,RC,,,,both,,,3286.01,2135.91,,,,,,,,,,,,,
PIN DISTRACTOR 16 MM TI STRL 0460002910S,SUP-2591710,CDM,C1713,HCPCS,0278,RC,,,,both,,,219.80,142.87,,,,,,,,,,,,,
GUIDEWIRE SURG LNG DIA25MM SPHR VAR ANG FOR 5MM CANN SCR LCP,SUP-2179119,CDM,C1769,HCPCS,0272,RC,,,,both,,,2433.56,1581.81,,,,,,,,,,,,,
BLADE SHV L18CM DIA2.9MM 15DEG AIRWY M4 ROT ANG TIP LNG DBL,SUP-2277857,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2032.21,1320.94,,,,,,,,,,,,,
PLATE BNE L 65 MM SCREW DIA2 MM 12 SHFT H SS ADPT VA SLV,SUP-2907842,CDM,C1713,HCPCS,0278,RC,,,,both,,,2893.13,1880.53,,,,,,,,,,,,,
PLATE BONE W8XL96MM THK3.3MM 12 H STRL BILAT PELV S STL,SUP-2186240,CDM,C1713,HCPCS,0278,RC,,,,both,,,1472.44,957.09,,,,,,,,,,,,,
SCISSORS LAPSCP 5MM L45CM BPLR CUT AND COAG DISP,SUP-2312663,CDM,2720000010,LOCAL,0272,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
CATHETER INTVASC ULTRASOUND ACUSON ACUNAV L 90 CM DIA10 FR,SUP-2481454,CDM,C1753,HCPCS,0278,RC,,,,both,,,2348.41,1526.47,,,,,,,,,,,,,
STEM HUM L140MM DIA10MM UNIV SHLDR CO CHROM PORCOAT CEM PRI,SUP-2249922,CDM,C1776,CPT,0278,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
BIT DRL CANN ADD ON CPL FOR 5MM ASNS III SCR,SUP-2365000,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1569.37,1020.09,,,,,,,,,,,,,
ANCHOR SUTURE 20 12.7X3 MM HIP FIBERWIRE KNOTLESS BIOCOMPOSI,SUP-2836433,CDM,C1713,HCPCS,0278,RC,,,,both,,,1397.30,908.24,,,,,,,,,,,,,
CATHETER DRNGE 8FR L40CM GWIRE 0.038IN BILI W/ LCK PGTL,SUP-2120142,CDM,C1729,HCPCS,0272,RC,,,,both,,,245.30,159.44,,,,,,,,,,,,,
PROSTHESIS VOICE 22.5FR 12.5MM RADPQ VLV SEAT ENLD ESOPH,SUP-2124411,CDM,L8509,HCPCS,0272,RC,,,,both,,,1060.22,689.14,,,,,,,,,,,,,
KIT NDL 17GA L20CM MRK L3MM DIA1.2MM SFT TISS G PLCMNT,SUP-2420704,CDM,A4648,CPT,0278,RC,,,,both,,,253.30,164.64,,,,,,,,,,,,,
BRACE WLK SM M GRY LO PROF ANK LEG ROCK SOLE 5 LOOP LCK STRP,SUP-2334818,CDM,L4361,HCPCS,0272,RC,,,,both,,,171.13,111.23,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 50 MM DIA 6 MM DEL SHTH 2.4ML,SUP-2936809,CDM,C1713,HCPCS,0278,RC,,,,both,,,7315.63,4755.16,,,,,,,,,,,,,
GRAFT BONE CHIP MILLED FRZN CANC CORT 2MM-5MM RANG 90CC,SUP-2307429,CDM,C1713,HCPCS,0278,RC,,,,both,,,8013.85,5209.00,,,,,,,,,,,,,
VITAFOL-OB PO TABS,RX-34527,CDM,6370000000,HCPCS,0637,RC,00642-0079-12,NDC,,both,1,UN,19.20,12.48,,,,,,,,,,,,,
PACK INSTR DARTFIRE EDGE D1040000,SUP-2849008,CDM,C1713,HCPCS,0278,RC,,,,both,,,405.06,263.29,,,,,,,,,,,,,
CLAMP CONN 6.5 TO 6.5MM PARA REVERE,SUP-2230107,CDM,C1713,HCPCS,0278,RC,,,,both,,,1036.20,673.53,,,,,,,,,,,,,
BUTTON FIX TI SHLDR FOR MULTIPLE FIBERTAPE STRL AC DOG BNE,SUP-2121671,CDM,C1713,HCPCS,0278,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 8X4 CM TEND REINF MTRX PURAFORCE,SUP-2716036,CDM,C1765,HCPCS,0278,RC,,,,both,,,6908.00,4490.20,,,,,,,,,,,,,
GUIDEWIRE VASC L180CM DIA0.035IN LNG TIP 1.5MM HYDRPHLC J,SUP-2385575,CDM,C1769,HCPCS,0272,RC,,,,both,,,140.83,91.54,,,,,,,,,,,,,
BASEPLATE GLEN DIA25MM STD REVERSED AEQUALIS PERFORM,SUP-2388798,CDM,C1776,CPT,0278,RC,,,,both,,,5237.52,3404.39,,,,,,,,,,,,,
CATHETER ANGIO RAVI MG2 038 5 FRX150 CM SS GLIDECATH XP,SUP-2852409,CDM,C1887,HCPCS,0272,RC,,,,both,,,167.17,108.66,,,,,,,,,,,,,
ORTHOPAEDIC KIT ATLS,SUP-2761973,CDM,C1713,HCPCS,0278,RC,,,,both,,,2449.20,1591.98,,,,,,,,,,,,,
PLATE BNE PED W23XL159MM 90DEG 7 H ST DST CNDYL FEM S STL LO,SUP-2177214,CDM,C1713,HCPCS,0278,RC,,,,both,,,3082.79,2003.81,,,,,,,,,,,,,
HC Washed Red Blood Cells Each,PX-3900902200,CDM,P9022,CPT,0390,RC,,,,both,,,1536.00,998.40,,,,,,,,,,,,,
GRAFT VASC GELSFT + ERS 90 DEG L 100 CM DIA10 MM SIDE BRANCH,SUP-2894819,CDM,C1768,CPT,0278,RC,,,,both,,,6641.10,4316.71,,,,,,,,,,,,,
PLATE BNE HUM 227 MM LT PROX 14 HOLE LO NS A.L.P.S,SUP-2477254,CDM,C1713,HCPCS,0278,RC,,,,both,,,6405.60,4163.64,,,,,,,,,,,,,
PIN BONE FIXATION L30MM OD3.2MM NON LOCKING RESORBABLE SMOOT,SUP-2855300,CDM,C1713,HCPCS,0278,RC,,,,both,,,516.34,335.62,,,,,,,,,,,,,
GUIDEWIRE ORTHOPEDIC 9 INX2 MM STRL DISP,SUP-2479689,CDM,C1769,HCPCS,0272,RC,,,,both,,,82.24,53.46,,,,,,,,,,,,,
WASHER ORTH REDUCTION WIRE 7 MM SLT,SUP-2749889,CDM,C1713,HCPCS,0278,RC,,,,both,,,555.78,361.26,,,,,,,,,,,,,
PLATE BNE RECON 120 DEG 2.7X3 MM MAND 8 HOLE ANGLED FRAC TI,SUP-2475141,CDM,C1713,HCPCS,0278,RC,,,,both,,,3506.91,2279.49,,,,,,,,,,,,,
INTERBODY ASMBLY 16X14X7 - 7,SUP-2335267,CDM,C1713,HCPCS,0278,RC,,,,both,,,5966.00,3877.90,,,,,,,,,,,,,
SET INTRO PEELWY L 15.5 CM DIA13 FR DIL L 20 CM GUIDEWIRE,SUP-2168020,CDM,C1892,HCPCS,0272,RC,,,,both,,,125.91,81.84,,,,,,,,,,,,,
WASHER EXT FIX DYNAMIZATION STRL DISP SMRT TSF,SUP-2933914,CDM,2720000010,LOCAL,0272,RC,,,,both,,,194.52,126.44,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA MAXBARR 4FR 55CM S1294108D,SUP-2632808,CDM,C1751,HCPCS,0278,RC,,,,both,,,931.86,605.71,,,,,,,,,,,,,
PLATE BNE SM W10.1XL166MM THK3.5MM 14 H BILAT S STL CRV RIG,SUP-2186265,CDM,C1713,HCPCS,0278,RC,,,,both,,,2567.17,1668.66,,,,,,,,,,,,,
COLLAR CERV SM H4.25IN FOR 10-13IN PLASTAZOTE FOAM 2 PC L,SUP-2336008,CDM,L0140,HCPCS,0272,RC,,,,both,,,30.33,19.71,,,,,,,,,,,,,
GRAFT DERMAL N FEN 8X4 CMX2.2-3.5 MM DERMAL MTRX PARADERM,SUP-2742066,CDM,C1763,HCPCS,0278,RC,,,,both,,,7814.68,5079.54,,,,,,,,,,,,,
ALLOGRAFT BNE CHIP 3-6 MM 30 CC PRESERVON CANC READIGRAFT,SUP-2740970,CDM,C1713,HCPCS,0278,RC,,,,both,,,1249.81,812.38,,,,,,,,,,,,,
DEFIBRILLATOR IMPL ALTRUA20 TI SINGLE CHMBR BATTERY PWR STRL,SUP-2149106,CDM,C1722,HCPCS,0275,RC,,,,both,,,10676.00,6939.40,,,,,,,,,,,,,
PLATE BNE CLAV CS3 2.7 MM LT LAT VA LCK COMPR TI STRL VALCP,SUP-2789381,CDM,C1713,HCPCS,0278,RC,,,,both,,,3990.56,2593.86,,,,,,,,,,,,,
PERI-LOC 2.5MM S-T LOCK SCREW 14MM,SUP-2819439,CDM,C1713,HCPCS,0278,RC,,,,both,,,804.09,522.66,,,,,,,,,,,,,
STAPLE BONE W10XH10XL10MM NIT SUPERELASTIC FIX DYNACLIP,SUP-2418089,CDM,C1713,HCPCS,0278,RC,,,,both,,,6201.50,4030.97,,,,,,,,,,,,,
PLATE BNE W10XL56MM THK1.5MM 4X4 H BILAT S STL T R ANG LOK,SUP-2185867,CDM,C1713,HCPCS,0278,RC,,,,both,,,876.12,569.48,,,,,,,,,,,,,
SCREW BNE ST 2.7X80 MM CRTX T8 STARDRV RECESS SS NS,SUP-2757635,CDM,C1713,HCPCS,0278,RC,,,,both,,,143.69,93.40,,,,,,,,,,,,,
WIRE DRL KT 1-6.5 MM EXCHANGE TUBE STRL,SUP-2905284,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
RECON PLATE 13X205MM 4.5MM,SUP-2818434,CDM,C1713,HCPCS,0278,RC,,,,both,,,5710.88,3712.07,,,,,,,,,,,,,
GUIDEPIN ORTH L150MM DIA1.2MM SCR FOR DELT XTEND REV SHLDR,SUP-2252750,CDM,C1713,HCPCS,0278,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9% BOLUS (FLUID RESUSCITATION)|DISCARDED DRUG NOT ADMINISTE,RX-4081440,CDM,J7050,HCPCS,0258,RC,00264-7800-20,NDC,JW,both,1000,ML,93.50,60.77,,,,,,,,,,,,,
CANNULA CEMENT STRL DISP,SUP-2917071,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2983.00,1938.95,,,,,,,,,,,,,
SYSTEM KNEE FLX NXGN,SUP-2212150,CDM,C1776,CPT,0278,RC,,,,both,,,11972.82,7782.33,,,,,,,,,,,,,
CATHETER DRAINAGE 25 MMX8CM UNITZ SNAP ASMBLY RESERVOIR BASE,SUP-2278323,CDM,C1729,HCPCS,0272,RC,,,,both,,,481.52,312.99,,,,,,,,,,,,,
CARRIER ENDO 17R F/50-2040 LT LARYNSCP REPL,SUP-2383871,CDM,2720000010,LOCAL,0272,RC,,,,both,,,845.23,549.40,,,,,,,,,,,,,
PLATE 3.5MM TI LCP OLECRANON 2 HOLES LEFT 86MM-STERILE,SUP-2549520,CDM,C1713,HCPCS,0278,RC,,,,both,,,3455.73,2246.22,,,,,,,,,,,,,
NAIL FEMORAL RETROGRADE D11X340MM,SUP-2761707,CDM,C1713,HCPCS,0278,RC,,,,both,,,11194.10,7276.16,,,,,,,,,,,,,
GRAFT BNE GEL 1 CC INJ DBM GRFT 41120A] MEDTRONIC USA INC],SUP-2278318,CDM,C1713,HCPCS,0278,RC,,,,both,,,427.04,277.58,,,,,,,,,,,,,
FOOTPLATE BONE 10 MM RIGHT ANTERIOR MAXILLARY MONOAXIAL SPLI,SUP-2837821,CDM,C1713,HCPCS,0278,RC,,,,both,,,2090.30,1358.69,,,,,,,,,,,,,
RETRACTOR SURG BLDE W155MM RHINOPLASTY SGL END W/O PRNG HND,SUP-2244334,CDM,C1713,HCPCS,0278,RC,,,,both,,,443.46,288.25,,,,,,,,,,,,,
RELOAD STPLR LD UNIT 25 USE SS TI WHT EEA DISP,SUP-2787748,CDM,2720000010,LOCAL,0272,RC,,,,both,,,985.39,640.50,,,,,,,,,,,,,
TC-100 4.5M S-T CRTX SCREW 76MM,SUP-2818935,CDM,C1713,HCPCS,0278,RC,,,,both,,,363.67,236.39,,,,,,,,,,,,,
HC So Cryptococcus Antibody,PX-3028664166,CDM,86641,CPT,0302,RC,,,,both,,,233.00,151.45,,,,,,,,,,,,,
PLATE BONE ORBITAL FLOOR 35X35X0.8 MM SMOOTH STERILE SYNPOR,SUP-2837803,CDM,C1713,HCPCS,0278,RC,,,,both,,,2176.02,1414.41,,,,,,,,,,,,,
STENT DIVERTER FLOW FREDX 21 3.0MM X 14 / 19,SUP-2855011,CDM,C1876,HCPCS,0278,RC,,,,both,,,46227.08,30047.60,,,,,,,,,,,,,
PLATE BONE 1.5 MM CRANIOFACIAL REINFORCED FAN WITH EXPOSED F,SUP-2837806,CDM,C1713,HCPCS,0278,RC,,,,both,,,4648.77,3021.70,,,,,,,,,,,,,
SCREW BNE DIA3MM PLNTR GRAV,SUP-2399115,CDM,C1713,HCPCS,0278,RC,,,,both,,,3212.22,2087.94,,,,,,,,,,,,,
BIT DRL SLD 2.5X110 MM FOR UNIV 2 WRST IMPL SYS STRL,SUP-2610344,CDM,2720000010,LOCAL,0272,RC,,,,both,,,687.50,446.87,,,,,,,,,,,,,
DISTRACTION INTRNL PLATE MICRO TRACK TRACK PLUS ALVLR STBLZR,SUP-2694328,CDM,C1713,HCPCS,0278,RC,,,,both,,,929.03,603.87,,,,,,,,,,,,,
COUPLING EXT FIX HINGED RAIL FOR ADV LRS SYS NS LTX,SUP-2875012,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2028.72,1318.67,,,,,,,,,,,,,
COMPONENT FEM SZ 9 R KNEE CO CHROM CEM POST STBL MOD LO,SUP-2378547,CDM,C1776,CPT,0278,RC,,,,both,,,12497.20,8123.18,,,,,,,,,,,,,
SAW SURG CAPTURE 0.040 IN W/ HNDL N-K II,SUP-2449162,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1836.90,1193.98,,,,,,,,,,,,,
PLATE BNE 2X5 H CRANIOMAXILLOFACIAL TI Y SHP FOR 1MM SCR,SUP-2190608,CDM,C1713,HCPCS,0278,RC,,,,both,,,1004.49,652.92,,,,,,,,,,,,,
SCREW BNE L42MM DIA3.5MM CORT ST NONCANNULATED NONLOCKING,SUP-2413376,CDM,C1713,HCPCS,0278,RC,,,,both,,,158.76,103.19,,,,,,,,,,,,,
CATHETER ANGIOPLSTY 2XL L 75 CM BALLOON L 40 MM DIA16 MM,SUP-2147269,CDM,C1725,HCPCS,0272,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
PROSTHESIS VOICE 20 FRX14 MM INDWL HRD VLV NS BLOM-SINGER,SUP-2242282,CDM,L8509,HCPCS,0274,RC,,,,both,,,1067.60,693.94,,,,,,,,,,,,,
STEM HUM L 210 MM SZ 15 XLN PLASMA SPRY POROUS TI SHLDR,SUP-2912557,CDM,C1776,CPT,0278,RC,,,,both,,,26847.00,17450.55,,,,,,,,,,,,,
CAP NAIL L 8 MM DIA11 MM TIB LOWER EXTREMITY STRL PICCOLO,SUP-2930791,CDM,C1713,HCPCS,0278,RC,,,,both,,,286.02,185.91,,,,,,,,,,,,,
SLEEVE FEM OFFSET 4 MM LG TI HIP REV FOR CERAMYS CHOICE,SUP-2929687,CDM,C1776,CPT,0278,RC,,,,both,,,418.88,272.27,,,,,,,,,,,,,
PLATE BNE H0.6MM 6X6 H UP FACE G TI 3D LEIBINGER UNIV 2,SUP-2366270,CDM,C1713,HCPCS,0278,RC,,,,both,,,2874.89,1868.68,,,,,,,,,,,,,
SHEATH INTRO AD 8FR L59CM DIL L67CM 0032IN PTFE INTCARD,SUP-2294364,CDM,C1893,HCPCS,0272,RC,,,,both,,,219.80,142.87,,,,,,,,,,,,,
COVER BURR H L 25.9 X W 20 MM SCREW DIA1.5 MM SM TI OBLNG,SUP-2936555,CDM,C1713,HCPCS,0278,RC,,,,both,,,552.64,359.22,,,,,,,,,,,,,
INTRODUCER KYPHOPLASTY SZ 2 10GA 3.4MM TRCR RADPQ KYPHON T34B] MEDTRONIC SOFAMOR DANEK],SUP-2293708,CDM,C1894,HCPCS,0272,RC,,,,both,,,745.75,484.74,,,,,,,,,,,,,
CATHETER THOR 36FR L23IN PVC R ANG 5 EYE TAPR CONN TIP SFT,SUP-2227440,CDM,C1729,HCPCS,0272,RC,,,,both,,,34.98,22.74,,,,,,,,,,,,,
SPIRONOLACTONE 100 MG PO TABS,RX-11425,CDM,6370000000,HCPCS,0637,RC,68382-0662-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
SUPPORT ORTHOT THGH LOWER EXTREMITY GLUTEAL ISCHIAL WT BEAR,SUP-2435672,CDM,L2500,HCPCS,0274,RC,,,,both,,,885.95,575.87,,,,,,,,,,,,,
"LYMPHOCYTE,ANTI-THYMO IMM GLOB 50 MG/ML IV SOLN",RX-169135,CDM,J7504,HCPCS,0636,RC,00009-7224-02,NDC,,both,5,ML,14930.90,9705.08,,,,,,,,,,,,,
IMPLANT TOE JT SM SZ 4S FLX HNG GRMMT SWNSN,SUP-2399923,CDM,C1776,CPT,0278,RC,,,,both,,,2863.68,1861.39,,,,,,,,,,,,,
GRAFT HUM TISS W4XL16CM THK07 14MM THN ACELLULAR HYDRATED,SUP-2307558,CDM,Q4128,HCPCS,0636,RC,,,,both,,,5508.35,3580.43,,,,,,,,,,,,,
CATHETER NEPHROSTOMY BLLN 10 MMX15 CM W/ SHTH ULTRAXX,SUP-2835968,CDM,C1726,HCPCS,0272,RC,,,,both,,,727.00,472.55,,,,,,,,,,,,,
CATHETER US 8FR L90CM 4 W STEERING PRECIS FOR SIEMENS,SUP-2248453,CDM,C1759,HCPCS,0272,RC,,,,both,,,8211.10,5337.21,,,,,,,,,,,,,
PLATE BNE L79MM THK34MM 6 H BILAT PUBIC S STL LO PROF RIG,SUP-2184020,CDM,C1713,HCPCS,0278,RC,,,,both,,,2480.41,1612.27,,,,,,,,,,,,,
SODIUM CHLORIDE (PF) 0.9 % IJ SOLN,RX-147478,CDM,A4216,HCPCS,0250,RC,63323-0186-10,NDC,,both,10,ML,9.90,6.43,,,,,,,,,,,,,
ORTHOLOC SPS 185MM STANDARD10 HOLE PLATE,SUP-2822320,CDM,C1713,HCPCS,0278,RC,,,,both,,,8597.32,5588.26,,,,,,,,,,,,,
HC Prothrombin Time Qw|NOT REASONABLE AND NECESSARY,PX-3058561005,CDM,85610,CPT,0305,RC,,,GZ,both,,,109.00,70.85,,,,,,,,,,,,,
IMMOBILIZER SHLDR L FOR 40-44IN RIB FOAM WRST NYL HUM CUF E,SUP-2196922,CDM,L3650,HCPCS,0272,RC,,,,both,,,17.43,11.33,,,,,,,,,,,,,
GRAFT TISS FRZ DRY ALLGRFT ILIUM STRP BICORT ASEP 6CM,SUP-2307132,CDM,C1713,HCPCS,0278,RC,,,,both,,,2256.88,1466.97,,,,,,,,,,,,,
STENT EVAR L79MM DIA8-11MM CATH L80CM INTRO SHTH 8FR,SUP-2395678,CDM,C1874,HCPCS,0278,RC,,,,both,,,11049.66,7182.28,,,,,,,,,,,,,
PROSTHESIS OSS EAR 0.5X3.75 MM,SUP-2312788,CDM,L8613,CPT,0278,RC,,,,both,,,468.43,304.48,,,,,,,,,,,,,
D-RAD VOLAR PLATE 5H LEFT STANDARD TI,SUP-2819154,CDM,C1713,HCPCS,0278,RC,,,,both,,,3746.33,2435.11,,,,,,,,,,,,,
CATHETER ABLATN F-F CRV 2-5-2 MM 3.5 MM 8 FRX115 CM EZ STEER,SUP-2248507,CDM,C2630,CPT,0272,RC,,,,both,,,4301.80,2796.17,,,,,,,,,,,,,
BLADE LARYN L22.5CM DIA3.5MM 60-500RPM DBL CRV ANG TIP LO,SUP-2284138,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1747.50,1135.87,,,,,,,,,,,,,
CATHETER HD STR 24 CM 19 CM 2 VLV VASCPAK BIOFLO DURAMAX,SUP-2486139,CDM,C1750,HCPCS,0278,RC,,,,both,,,1224.60,795.99,,,,,,,,,,,,,
CATHETER ABLATN EP 7 FR MED MAP COOL PATH,SUP-2102236,CDM,C2630,CPT,0272,RC,,,,both,,,4003.50,2602.27,,,,,,,,,,,,,
SCREW BONE SELFDRILLING 2X6 MM MANDIBULAR LOCKING 5/PK TITAN,SUP-2842313,CDM,C1713,HCPCS,0278,RC,,,,both,,,488.84,317.75,,,,,,,,,,,,,
SPLINT WRST M L10IN FOR 6 7IN R FA VYN FLANNEL LN SLIP ON,SUP-2276623,CDM,L3908,HCPCS,0274,RC,,,,both,,,18.27,11.88,,,,,,,,,,,,,
MATRIX BIO MED SZ 147 SQCM FISH SKIN LT DORSUM RT PALMAR,SUP-2909195,CDM,Q4158,HCPCS,0636,RC,,,,both,,,14252.46,9264.10,,,,,,,,,,,,,
SPHERE GLEN OD36MM GLENOSPHRS ARW,SUP-2224542,CDM,C1776,CPT,0278,RC,,,,both,,,5181.00,3367.65,,,,,,,,,,,,,
SCREW BNE L14MM DIA3.5MM CORT DST TIB TYP II ANODIZED TI ST,SUP-2411682,CDM,C1713,HCPCS,0278,RC,,,,both,,,165.79,107.76,,,,,,,,,,,,,
NEEDLE INJ LL 21 GA 5 MMX36 CM,SUP-2767266,CDM,2720000010,LOCAL,0272,RC,,,,both,,,555.78,361.26,,,,,,,,,,,,,
PLATE BNE L130MM THK37MM 10 H R J S STL LO PROF RIG RECON,SUP-2177159,CDM,C1713,HCPCS,0278,RC,,,,both,,,2424.17,1575.71,,,,,,,,,,,,,
PLATE SPNL ADJUSTABLE KEEL VUEPOINT II,SUP-2312172,CDM,C1713,HCPCS,0278,RC,,,,both,,,4553.00,2959.45,,,,,,,,,,,,,
CATHETER PERITONEAL DLYS STD 13X25MMX120CM BA IMPREG OPN END,SUP-2284394,CDM,C1713,HCPCS,0278,RC,,,,both,,,402.49,261.62,,,,,,,,,,,,,
BLADE LARYNGOSCOPE MACINTOSH 2 4.5X0.875X1 IN GRN SPEC,SUP-2149971,CDM,2720000010,LOCAL,0272,RC,,,,both,,,142.21,92.44,,,,,,,,,,,,,
COMPONENT FEM CEM 2XS UNISX LT KNEE REV CR STEM N BEAD VIT,SUP-2377026,CDM,C1776,CPT,0278,RC,,,,both,,,11068.50,7194.52,,,,,,,,,,,,,
EVOS CABLE STAINLESS STEEL W/CRIMP,SUP-2931366,CDM,C1713,HCPCS,0278,RC,,,,both,,,2132.85,1386.35,,,,,,,,,,,,,
TAP SURG L35MM CORT THRD CANN FOR 4.2MM 2 COR SCR,SUP-2187424,CDM,C1713,HCPCS,0278,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA BASIC 4FR 55CM 2 LUMAN RVS,SUP-2613560,CDM,C1751,HCPCS,0278,RC,,,,both,,,603.23,392.10,,,,,,,,,,,,,
BRACE ORTH AD SM FOR 8 9IN HND SHT R THMB SPICA BLK,SUP-2196531,CDM,L3923,HCPCS,0272,RC,,,,both,,,123.75,80.44,,,,,,,,,,,,,
KIT PICC DIA1.9 FR POLYUR COMPLETE 2 LUMEN CATH PEELWY INTRO,SUP-2911900,CDM,C1751,HCPCS,0278,RC,,,,both,,,499.26,324.52,,,,,,,,,,,,,
SLING M SYS W/ INHIBIZONE INVANCE,SUP-2140286,CDM,C1771,HCPCS,0278,RC,,,,both,,,14601.00,9490.65,,,,,,,,,,,,,
NEEDLE CRYOABLATION ICEROD 1.5MM +,SUP-2225662,CDM,C2618,HCPCS,0272,RC,,,,both,,,4121.25,2678.81,,,,,,,,,,,,,
PLATE STR 1.5MM 12H TI STRL VAL,SUP-2546889,CDM,C1713,HCPCS,0278,RC,,,,both,,,1713.75,1113.94,,,,,,,,,,,,,
PLATE SPNL LCK 9 MM THRD CVR SHORELINE ACS,SUP-2750400,CDM,C1713,HCPCS,0278,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
SCREW INTRF L35MM DIA12MM CANN 1.5MM BIOABSRB PLLA RND THRD,SUP-2341003,CDM,C1713,HCPCS,0278,RC,,,,both,,,672.40,437.06,,,,,,,,,,,,,
BLADE SHAVER CRV 40 DEG 4.8 MM SERRATED HEMOSTATIC CONVX,SUP-2638102,CDM,2720000010,LOCAL,0272,RC,,,,both,,,587.09,381.61,,,,,,,,,,,,,
PLATE BNE L 60 MM BAR 9 MM 3 H SHRT TI CRANIOMAXILLOFACIAL,SUP-2883481,CDM,C1713,HCPCS,0278,RC,,,,both,,,697.58,453.43,,,,,,,,,,,,,
NAIL IM L205MM DIA7.5MM 120DEG STRL BLU L/R HUM TI CANN LCK,SUP-2192485,CDM,C1713,HCPCS,0278,RC,,,,both,,,5324.06,3460.64,,,,,,,,,,,,,
PIN FIX L200MM OD1.8MM TRCR PNT ST DISP,SUP-2405549,CDM,C1713,HCPCS,0278,RC,,,,both,,,465.91,302.84,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 100 CM DIA 8 MM EPTFE STR TW REINF,SUP-2498187,CDM,C1768,CPT,0278,RC,,,,both,,,1788.36,1162.43,,,,,,,,,,,,,
PLATE BONE LOCKING HOLEX4 T SHAPED LEFT DORSAL DISTAL,SUP-2721080,CDM,C1713,HCPCS,0278,RC,,,,both,,,2930.19,1904.62,,,,,,,,,,,,,
PIN 12 SELF DRILL 10MM THRD 3X80MM,SUP-2705304,CDM,C1713,HCPCS,0278,RC,,,,both,,,373.03,242.47,,,,,,,,,,,,,
SCREW BNE L32MM OD4.5MM TI CANN SHT THRD HD COMPR DARCO,SUP-2401021,CDM,C1713,HCPCS,0278,RC,,,,both,,,781.86,508.21,,,,,,,,,,,,,
NEEDLE SPNL 2 TRCR TIP DISP,SUP-2290632,CDM,2720000010,LOCAL,0272,RC,,,,both,,,406.63,264.31,,,,,,,,,,,,,
PACK TISS REM 1IN TX1 MICROTIP ULTRASONIC SURG ASPIR TISS,SUP-2384732,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2402.10,1561.36,,,,,,,,,,,,,
TROCAR SURGICAL 5MM DIA SINUS WCANNULA NON STERILE,SUP-2705632,CDM,2720000010,LOCAL,0272,RC,,,,both,,,472.66,307.23,,,,,,,,,,,,,
PLATE BONE W15XL152MM THK2MM 7 H BILAT TI THN BLDE RIG,SUP-2190985,CDM,C1713,HCPCS,0278,RC,,,,both,,,1576.25,1024.56,,,,,,,,,,,,,
HEAD FEM PLANAR 46 MM CALCAR HIP,SUP-2441559,CDM,C1776,CPT,0278,RC,,,,both,,,847.80,551.07,,,,,,,,,,,,,
PROSTHESIS OSS COIL L275MM DST END DIA145MM TI KRAUS K HELIX,SUP-2232514,CDM,L8613,CPT,0278,RC,,,,both,,,1561.05,1014.68,,,,,,,,,,,,,
BUR SURG L14CM HD L351MM DIA3MM TAPR L BOR MIDAS REX,SUP-2277726,CDM,2720000010,LOCAL,0272,RC,,,,both,,,364.81,237.13,,,,,,,,,,,,,
SHEATH INTRO HEARTSPAN L 63 CM DIA 8.5 FR NDL L 71 CM ML2,SUP-2516628,CDM,C1893,HCPCS,0272,RC,,,,both,,,13.03,8.47,,,,,,,,,,,,,
STEM FEM L255MM DIA13X18MM NK L36+21+8MM XLN L HIP BOW TI,SUP-2253198,CDM,C1776,CPT,0278,RC,,,,both,,,18071.33,11746.36,,,,,,,,,,,,,
SUPPORT WRST PUL LACE CLOSURE UNIV RT PROCARE QUICK-FIT,SUP-2195779,CDM,L3931,HCPCS,0272,RC,,,,both,,,35.11,22.82,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9 % IV BOLUS NEONATE,RX-40840079,CDM,2580000003,HCPCS,0250,RC,00990-7983-61,NDC,,both,150,ML,44.70,29.05,,,,,,,,,,,,,
HC Thrmbc/Nfs Dialysis W Pta,PX-3613690500,CDM,36905,CPT,0361,RC,,,,outpatient,,,11772.00,7651.80,,,,,,,,,,,,,
PATCH VASC HEMAPATCH L 75 X W 75 MM THK 0.65 MM POLYESTER,SUP-2227516,CDM,C1781,HCPCS,0278,RC,,,,both,,,538.10,349.76,,,,,,,,,,,,,
HC So Genomic Seq Dna&Rna Analys Neo 5-50 Gene,PX-3108145066,CDM,81450,CPT,0310,RC,,,,both,,,4002.00,2601.30,,,,,,,,,,,,,
BUR SHV L13CM DIA4MM 15DEG TAPR DMND CHOANAL ATRESIA 30K HI,SUP-2277872,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1502.65,976.72,,,,,,,,,,,,,
HC Assay of Progesterone,PX-3018414400,CDM,84144,CPT,0301,RC,,,,both,,,332.00,215.80,,,,,,,,,,,,,
CATHETER INFUSION SINGLE LUMEN 7 FRX6 IN SLIC,SUP-2383499,CDM,C1751,HCPCS,0278,RC,,,,both,,,31.15,20.25,,,,,,,,,,,,,
SCREW SPNL SACR AND SACROILIAC TI 7.0MMX35MM COLORADO 2,SUP-2290595,CDM,C1713,HCPCS,0278,RC,,,,both,,,3369.22,2189.99,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.425,SUP-2859989,CDM,C1713,HCPCS,0278,RC,,,,both,,,40190.43,26123.78,,,,,,,,,,,,,
RING EXT FIX DIA200MM HALF FOR TRUELOK RNG FIX SYS,SUP-2316182,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1890.94,1229.11,,,,,,,,,,,,,
GRAFT VASC INTERGARD L 70 CM DIA10 MM THK 0.49 MM POLYESTER,SUP-2227581,CDM,C1768,CPT,0278,RC,,,,both,,,1839.04,1195.38,,,,,,,,,,,,,
SCREW UNIV,SUP-2209055,CDM,C1713,HCPCS,0278,RC,,,,both,,,1026.78,667.41,,,,,,,,,,,,,
DEVICE DRNGE CLR TUTOPLAST 1/3 CORNEA SCLER,SUP-2247190,CDM,V2785,HCPCS,0278,RC,,,,both,,,1158.66,753.13,,,,,,,,,,,,,
BALLOON STONE EXTR OD8.5X12X15MM CATH L275CM OD6.6FR 0.035IN,SUP-2170825,CDM,2720000010,LOCAL,0272,RC,,,,both,,,656.26,426.57,,,,,,,,,,,,,
ANCHOR SUT LOOP W/ ORTHOCORD LUPINE +,SUP-2249327,CDM,C1713,HCPCS,0278,RC,,,,both,,,901.18,585.77,,,,,,,,,,,,,
PROBE RF 17 GAX75 MM PMP THORACOOL,SUP-2753314,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1193.20,775.58,,,,,,,,,,,,,
SCREW CORK L STRYKR INSTR T HNDL CORN SEVERS EXTR FEM HD,SUP-2361588,CDM,C1713,HCPCS,0278,RC,,,,both,,,2891.94,1879.76,,,,,,,,,,,,,
STENT URETERAL IMAJIN SILICONE W/ POSITIONER,SUP-2848795,CDM,C2617,HCPCS,0278,RC,,,,both,,,439.29,285.54,,,,,,,,,,,,,
SCREW SPNL MULTAXL 4.5X20 MM FOR 4.75 MM ROD ATS,SUP-2629325,CDM,C1713,HCPCS,0278,RC,,,,both,,,2863.68,1861.39,,,,,,,,,,,,,
ALLOGRAFT BNE INJ 8 CC IGNITE PWR MIX,SUP-2759448,CDM,C1713,HCPCS,0278,RC,,,,both,,,6096.69,3962.85,,,,,,,,,,,,,
SHEATH INTRO FAST-CATH L 63 CM DIA 8 FR DIL L 67 CM,SUP-2357250,CDM,C1893,HCPCS,0272,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
INTRODUCER SHTH L45CM OD4FR TIP L7CM OD0.018IN S STL WIRE S,SUP-2117379,CDM,C1894,HCPCS,0272,RC,,,,both,,,61.14,39.74,,,,,,,,,,,,,
HARVESTER BONE W/ FILTER INSERT 8MM,SUP-2715942,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4396.00,2857.40,,,,,,,,,,,,,
VALVE ENDOBRONCHIAL ZEPHYR DIA 5.5-8.5 MM NIT IMPL LP,SUP-2930255,CDM,C1889,HCPCS,0278,RC,,,,both,,,8179.70,5316.80,,,,,,,,,,,,,
SCREW BONE CORT LCK S STL HUM 3.8MMX20MM EQUINOXE,SUP-2223440,CDM,C1713,HCPCS,0278,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9 % IV BOLUS NEONATE,RX-40840079,CDM,J7030,HCPCS,0250,RC,00338-0049-04,NDC,,both,1000,ML,42.50,27.62,,,,,,,,,,,,,
SUPPORT WRST PUL LACE CLOSURE UNIV RT PROCARE QUICK-FIT,SUP-2195779,CDM,L3931,HCPCS,0274,RC,,,,both,,,35.11,22.82,,,,,,,,,,,,,
SCREW SPNL L 55 MM DIA 7.5 MM CFR-PEEK PEDCL FEN STRL,SUP-2883111,CDM,C1713,HCPCS,0278,RC,,,,both,,,8792.00,5714.80,,,,,,,,,,,,,
HOOK SPNL BLDE W5MM LT LAM TI OFFSET OPN FOR 5.5MM ROD MOSS,SUP-2254450,CDM,C1713,HCPCS,0278,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
LEAD PACE L80CM ENDO LV UNI/BIPOLAR LV1 SGL ELECTRD PASS,SUP-2148679,CDM,C1898,HCPCS,0275,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
DEVICE MENIS REP SEQUENT CRV 7 IMPLANTS,SUP-2167209,CDM,C1713,HCPCS,0278,RC,,,,both,,,4635.46,3013.05,,,,,,,,,,,,,
HC Sel Cath Plcmt 2nd Order Brach,PX-3613621600,CDM,36216,CPT,0361,RC,,,,outpatient,,,6875.00,4468.75,,,,,,,,,,,,,
SHUNT ARTOTMY 27 F 89 CM LEN TAPR VLV LO FLO W/O RESVR BVL,SUP-2174291,CDM,2720000010,LOCAL,0272,RC,,,,both,,,760.70,494.45,,,,,,,,,,,,,
DUAL OUTER DIAM SCR REVERE SCR MOD,SUP-2232365,CDM,C1713,HCPCS,0278,RC,,,,both,,,2603.06,1691.99,,,,,,,,,,,,,
WIRE FIX OD1.6MM K,SUP-2152541,CDM,C1713,HCPCS,0278,RC,,,,both,,,35.17,22.86,,,,,,,,,,,,,
LEAD NERVE STIM 60 CM PERC PADDLE 8 CHANNEL TRIPOLE,SUP-2355938,CDM,C1778,HCPCS,0278,RC,,,,both,,,11618.00,7551.70,,,,,,,,,,,,,
COIL HELI MICROPLEX SFT SZ 18 LOOP 2MM X 4CM,SUP-2305199,CDM,C1889,HCPCS,0278,RC,,,,both,,,1654.78,1075.61,,,,,,,,,,,,,
ALLOGRAFT BNE GRAN 6 CC HA/TCP CANC STRL VENADO,SUP-2718012,CDM,C1713,HCPCS,0278,RC,,,,both,,,17584.00,11429.60,,,,,,,,,,,,,
BEARING HUM DIA36-44MM +3MM OFFSET ARCOMXL FOR COMPHSVE REV,SUP-2409554,CDM,C1776,CPT,0278,RC,,,,both,,,3202.80,2081.82,,,,,,,,,,,,,
PLATE BONE STRAIGHT 1.5 MM 20 HOLE TITANIUM MATRIXMANDIBLE,SUP-2837749,CDM,C1713,HCPCS,0278,RC,,,,both,,,4198.18,2728.82,,,,,,,,,,,,,
SUPPORT WR SM LNG LEN RT FRARM WVN COT RUB FAB BGE FIRM W/,SUP-2324893,CDM,L3931,HCPCS,0272,RC,,,,both,,,41.01,26.66,,,,,,,,,,,,,
RETRACTOR SYS DP SCROT,SUP-2140289,CDM,2720000010,LOCAL,0272,RC,,,,both,,,816.40,530.66,,,,,,,,,,,,,
GLIPIZIDE 5 MG PO TABS,RX-10117,CDM,6370000000,HCPCS,0637,RC,00904-6637-61,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
GRAFT BNE W13XL34MM FOR DIA38MM GLEN GLENOJET,SUP-2123640,CDM,C1713,HCPCS,0278,RC,,,,both,,,15543.00,10102.95,,,,,,,,,,,,,
CONNECTOR ROD M XLNK FOR VERTEX RECON SYS,SUP-2289103,CDM,C1713,HCPCS,0278,RC,,,,both,,,1267.78,824.06,,,,,,,,,,,,,
HC Sacroiliac Jnts Min 3 Views,PX-3207220200,CDM,72202,CPT,0320,RC,,,,outpatient,,,938.00,609.70,,,,,,,,,,,,,
CEMENT BNE W/ HA RADPQ FOR KYPHOPLASTY KYPHON ACTIVOS 10,SUP-2293455,CDM,C1713,HCPCS,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
SET ANCHR GI W/ SAF-T-PEXY T-FASTENERS,SUP-2236743,CDM,C1713,HCPCS,0278,RC,,,,both,,,371.12,241.23,,,,,,,,,,,,,
PROSTHESIS TESTICULAR NACL MED AD CHLD TOROSA,SUP-2165399,CDM,C1889,HCPCS,0278,RC,,,,both,,,4553.00,2959.45,,,,,,,,,,,,,
GUIDEWIRE VASC L 145 CM DIA 0.035 IN TIP 3 MM PTFE J,SUP-2147066,CDM,C1769,HCPCS,0272,RC,,,,both,,,30.55,19.86,,,,,,,,,,,,,
ELECTRODE LAP MNPLR 35MM DIA 33CML L HOOK RGHT ANGLD TIP PR,SUP-2675803,CDM,2720000010,LOCAL,0272,RC,,,,both,,,617.14,401.14,,,,,,,,,,,,,
BIT DRL L102MM OD1.9MM STP D20.0MM N RADLUC NSTERILE REUSE,SUP-2366432,CDM,2720000010,LOCAL,0272,RC,,,,both,,,782.71,508.76,,,,,,,,,,,,,
SCREW INTRF PEEK INTRAFIX ADV 7MMX30MM,SUP-2176895,CDM,C1713,HCPCS,0278,RC,,,,both,,,1212.04,787.83,,,,,,,,,,,,,
NEEDLE BRST LOC 20 GA 9CM REPOSITIONAL DISP KOPAN,SUP-2169673,CDM,C1819,HCPCS,0278,RC,,,,both,,,127.77,83.05,,,,,,,,,,,,,
FIBER LSR HOLM 200UM,SUP-2225705,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
STEM HUM L130MM DIA12MM UNIV TI ALLY W/ PALMA COAT REV,SUP-2193872,CDM,C1776,CPT,0278,RC,,,,both,,,12234.38,7952.35,,,,,,,,,,,,,
ROD EXT FIX DIA11MM L220MM SEMI CIR CRV HOFFMANN 3,SUP-2372224,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1450.68,942.94,,,,,,,,,,,,,
PATCH BIOLOGIC SURG 10CM WX16CM L .55MM THICKNESSXENOSURE,SUP-2264164,CDM,C1781,HCPCS,0278,RC,,,,both,,,2760.06,1794.04,,,,,,,,,,,,,
HEAD REAMER 2 11.5 MM RETROCUTTER,SUP-2120871,CDM,C1713,HCPCS,0278,RC,,,,both,,,819.54,532.70,,,,,,,,,,,,,
SCREW BNE SCHNZ 2.5/4 MM 12 MM THRD TI NS,SUP-2860071,CDM,C1713,HCPCS,0278,RC,,,,both,,,2672.77,1737.30,,,,,,,,,,,,,
SYSTEM INTRO SHTH 7FR L25CM ORNG HUB W O SIDEPRT SPLITTABLE,SUP-2303231,CDM,C1892,HCPCS,0272,RC,,,,both,,,138.47,90.01,,,,,,,,,,,,,
IMPLANT NSL M W1.1XL4.4CM THK0.35CM SIL MID DORS AUG FOR,SUP-2242099,CDM,2780000010,LOCAL,0278,RC,,,,both,,,832.10,540.86,,,,,,,,,,,,,
DEVICE TISS REMOVING L25.25IN OD4MMXL HYSTEROSCOPIC SGL USE,SUP-2239920,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2892.98,1880.44,,,,,,,,,,,,,
CONNECTOR SHUNT 1X1.9X17.8 MM STR PLAS STRL ACCU-FLO,SUP-2666411,CDM,C1889,HCPCS,0278,RC,,,,both,,,280.12,182.08,,,,,,,,,,,,,
PAD ORTHOT LUMBAR CUST DEROTATION,SUP-2435587,CDM,L1240,HCPCS,0272,RC,,,,both,,,257.48,167.36,,,,,,,,,,,,,
SPHINCTEROTOME ENDSCPC 6FR DIA DST TIP 6MML TIP 15MML CUT WI,SUP-2677701,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1469.87,955.42,,,,,,,,,,,,,
SUPPORT ORTHOT HIP JT LOWER EXTREMITY PELV CTRL HVY DTY,SUP-2435684,CDM,L2620,HCPCS,0274,RC,,,,both,,,707.79,460.06,,,,,,,,,,,,,
CATHETER PD COILED AD 62 CM 16 CM 23 CM KT 3 CUF EXT,SUP-2516624,CDM,C1750,HCPCS,0278,RC,,,,both,,,1566.86,1018.46,,,,,,,,,,,,,
GRAFT BNE STRP 16 CC ISOTIS PURE,SUP-2644344,CDM,C1713,HCPCS,0278,RC,,,,both,,,8974.12,5833.18,,,,,,,,,,,,,
GRAFT HUM TISS GRACILIS TEND FRZ DRY,SUP-2137247,CDM,C1762,HCPCS,0278,RC,,,,both,,,2589.24,1683.01,,,,,,,,,,,,,
PROSTHESIS 1.65MM DIAM 2.1MM LEN INCUS DBL NOTCH HA WEHRS,SUP-2312567,CDM,L8613,CPT,0278,RC,,,,both,,,1145.47,744.56,,,,,,,,,,,,,
PLATE BONE STRL T SHP VAR LCK FOR 2.7MM SCR VLP FT PERC,SUP-2349924,CDM,C1713,HCPCS,0278,RC,,,,both,,,3578.82,2326.23,,,,,,,,,,,,,
SPLINT FNGR OVL 8 11,SUP-2100002,CDM,L3933,HCPCS,0274,RC,,,,both,,,28.51,18.53,,,,,,,,,,,,,
ALLOGRAFT HUM TISS DERMAL REGENRATION MTRX 12X6 CM AXIS,SUP-2763315,CDM,C1762,CPT,0278,RC,,,,both,,,8471.72,5506.62,,,,,,,,,,,,,
PLATE BNE SZ 2.6 MM MIDFACE PMI NS DISP ACCUPLATE,SUP-2936197,CDM,C1713,HCPCS,0278,RC,,,,both,,,39805.78,25873.76,,,,,,,,,,,,,
SPLINT FNGR OVL 8 11,SUP-2100002,CDM,L3933,HCPCS,0272,RC,,,,both,,,28.51,18.53,,,,,,,,,,,,,
STEM FEM STD OFFSET 6-10 W/ TRUNNION GLD MALLORY-HEAD EXACT,SUP-2442625,CDM,C1776,CPT,0278,RC,,,,both,,,2289.06,1487.89,,,,,,,,,,,,,
CLAMP ROD TO ROD,SUP-2749492,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2747.50,1785.87,,,,,,,,,,,,,
HC So Phenobarbital,PX-3018018466,CDM,80184,CPT,0301,RC,,,,both,,,113.00,73.45,,,,,,,,,,,,,
BIT DRL STP 9.3 MM NS GOTFRIED PCCP,SUP-2644768,CDM,2720000010,LOCAL,0272,RC,,,,both,,,499.51,324.68,,,,,,,,,,,,,
OCCLUDER GORE CARDIOFORM ASD 27MM 10FR,SUP-2855590,CDM,C1817,HCPCS,0278,RC,,,,both,,,26234.70,17052.55,,,,,,,,,,,,,
BEVACIZUMAB-BVZR 25 MG/ML IV SOLN (MIXTURES ONLY),RX-430061,CDM,Q5118,HCPCS,0636,RC,00069-0315-01,NDC,,both,4,ML,1766.60,1148.29,,,,,,,,,,,,,
KIT BEAD OSTEOCURE RESRB CA SULF BONE VOID FIL FAST SET 7MM,SUP-2400547,CDM,C1713,HCPCS,0278,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
GRAFT VASC RESTOREFLOW SZ 75-79 CM SAPH VEIN BLD TYP A B AB,SUP-2884052,CDM,C1768,CPT,0278,RC,,,,both,,,34065.86,22142.81,,,,,,,,,,,,,
PERFORATOR CRAN DGR-II MINI 1.57 MM DISP,SUP-2106559,CDM,2720000010,LOCAL,0272,RC,,,,both,,,700.22,455.14,,,,,,,,,,,,,
SPHINCTEROTOME ENDOSCP CANN 4.4 FRX20 MM DREAMWIRE TRUETOME,SUP-2141619,CDM,C1769,HCPCS,0272,RC,,,,both,,,1238.95,805.32,,,,,,,,,,,,,
ALLOGRAFT BNE PWD 15 CC FD IRRADIATED CANC,SUP-2867088,CDM,C1762,CPT,0278,RC,,,,both,,,885.95,575.87,,,,,,,,,,,,,
PIN BTTRS L20MM DIA1.8MM DST RAD S STL LOK STARDRV T8,SUP-2183129,CDM,C1713,HCPCS,0278,RC,,,,both,,,315.22,204.89,,,,,,,,,,,,,
SCREW CRTX FT SELF TAP HEX HD 4.5MM DIA 50MML,SUP-2342665,CDM,C1713,HCPCS,0278,RC,,,,both,,,57.87,37.62,,,,,,,,,,,,,
BUR SURG BRL 4 MM + STRL FMS VUE DISP,SUP-2624803,CDM,2720000010,LOCAL,0272,RC,,,,both,,,234.87,152.67,,,,,,,,,,,,,
IMPLANT BIO L 6 X W 8.2 CM PORCINE TEND DERIVED,SUP-2909164,CDM,A2008,HCPCS,0636,RC,,,,both,,,8616.16,5600.50,,,,,,,,,,,,,
PLATE BONE PT SPEC SPLNT ORTHOGNATHIC INTERMED,SUP-2257767,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3182.70,2068.75,,,,,,,,,,,,,
TETRACYCLINE HCL 500 MG PO CAPS,RX-7797,CDM,6370000000,HCPCS,0637,RC,69238-1523-01,NDC,,both,1,UN,11.10,7.21,,,,,,,,,,,,,
PLATE BNE L29MM THK1MM MINI 6 H CP TI CRV TLTS FOR 2 25MM,SUP-2262965,CDM,C1713,HCPCS,0278,RC,,,,both,,,1128.48,733.51,,,,,,,,,,,,,
CATHETER ABLATN J-J 2-5-2 MM 3.5 MM 8 FRX115 CM THERMOCOOL,SUP-2248539,CDM,C1732,HCPCS,0278,RC,,,,both,,,7583.10,4929.01,,,,,,,,,,,,,
STENT URET MARD L 24-30 CM DIA 7 FR PERCFLX HYDROPLUS SFT,SUP-2141626,CDM,C1874,HCPCS,0278,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
PROSTHESIS OSS L 2 MM DIA1.1 MM HD DIA2.5 MM TI PART FULL,SUP-2902036,CDM,L8613,CPT,0278,RC,,,,both,,,1398.68,909.14,,,,,,,,,,,,,
HC CT Cologrph Dx WO/W Cont,PX-3507426200,CDM,74262,CPT,0350,RC,,,,outpatient,,,2630.00,1709.50,,,,,,,,,,,,,
SYSTEM FIXATION SCREOPTILINK 5.0 VAL SLF TPNG SD 80,SUP-2718041,CDM,C1776,CPT,0278,RC,,,,both,,,570.13,370.58,,,,,,,,,,,,,
SCREW BNE 4MM 70 20 FOR GALAXY FIX SYS,SUP-2316041,CDM,C1713,HCPCS,0278,RC,,,,both,,,314.13,204.18,,,,,,,,,,,,,
PROBE SURG JAKO 2 MM 300 MM LARYNGEAL STR,SUP-2458295,CDM,2720000010,LOCAL,0272,RC,,,,both,,,480.58,312.38,,,,,,,,,,,,,
TRIAL PLATE STR 0.8 MM 10 HOLE,SUP-2525716,CDM,C1713,HCPCS,0278,RC,,,,both,,,844.66,549.03,,,,,,,,,,,,,
RING EXT FIX DIA230MM TAY 2/3 SPAT FRME ILIZ,SUP-2342979,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6061.14,3939.74,,,,,,,,,,,,,
CROWN DENT STRP U3 PEDIATRIC UPPER CUSPID,SUP-2337144,CDM,D6783,CPT,0278,RC,,,,both,,,37.02,24.06,,,,,,,,,,,,,
CABLE SPNL L470MM DIA1MM THOR LUM S STL SGL LD CRMP,SUP-2186853,CDM,C1713,HCPCS,0278,RC,,,,both,,,753.60,489.84,,,,,,,,,,,,,
FIBERTAPE STERNAL CLOSURE WITH CUTTING NDL,SUP-2814066,CDM,2720000010,LOCAL,0272,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
IMPLANT OTO 4MM W/ 6MM ABUTMENT TI FOR BAHA FAST SURG BAHA 3,SUP-2164960,CDM,L8690,HCPCS,0278,RC,,,,both,,,8748.04,5686.23,,,,,,,,,,,,,
GRAFT BNE L16-40MM OD16MM UNICORTICAL DWL FRZ DRY IMPL,SUP-2307089,CDM,C1762,CPT,0278,RC,,,,both,,,1927.96,1253.17,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY L 92 CM 6FR 1MM D CRV FIX BLU,SUP-2248674,CDM,C1730,HCPCS,0272,RC,,,,both,,,954.56,620.46,,,,,,,,,,,,,
HC Admin Influenza Vaccine,PX-7710000800,CDM,G0008,HCPCS,0771,RC,,,,outpatient,,,85.00,55.25,,,,,,,,,,,,,
PLATE BONE L136MM 18 H STRL S STL LCK COMPR FOR 2.7MM SCR,SUP-2349620,CDM,C1713,HCPCS,0278,RC,,,,both,,,4842.82,3147.83,,,,,,,,,,,,,
PLATE RAD HD NECK 2.4MM 4H TI LCP,SUP-2549714,CDM,C1713,HCPCS,0278,RC,,,,both,,,2018.67,1312.14,,,,,,,,,,,,,
COUNTERSINK SURG CANN FOR 4MM SCR,SUP-2187349,CDM,2720000010,LOCAL,0272,RC,,,,both,,,998.17,648.81,,,,,,,,,,,,,
GUIDEWIRE ORTH THRD 1.25X150 MM DMND PT NS,SUP-2607877,CDM,C1769,HCPCS,0272,RC,,,,both,,,62.67,40.74,,,,,,,,,,,,,
ALLOGRAFT BNE FEM 11 MMX0.4 CM FD CROSS SECT,SUP-2717811,CDM,C1762,CPT,0278,RC,,,,both,,,2883.74,1874.43,,,,,,,,,,,,,
GRAFT BONE L12XW12XH5MM 5DEG UNIV PEEK TI COMP SPCR ANTR,SUP-2317023,CDM,C1713,HCPCS,0278,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
GRAFT VASC GORTX L 80 CM DIA 7 MM RNG L 30 CM EPTFE STR TW,SUP-2396127,CDM,C1768,CPT,0278,RC,,,,both,,,3020.68,1963.44,,,,,,,,,,,,,
BIT DRL DIA4MM DISP FOR TIBIOTALOCALCANEAL FUS SYS DYNANAIL,SUP-2277481,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
SET TBNG 23KHZ MFLD EXCEL CUSA,SUP-2243953,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1359.62,883.75,,,,,,,,,,,,,
MASK LARYN PED SZ 5 40ML AIRWY DEV ONLY REINF REUSE LMA,SUP-2383564,CDM,2720000010,LOCAL,0272,RC,,,,both,,,873.86,568.01,,,,,,,,,,,,,
DISTRACTOR SURG 25 MM 1-1.2 MM MAND 36 HOLE INT TI ZURICH II,SUP-2473868,CDM,2720000010,LOCAL,0272,RC,,,,both,,,16969.66,11030.28,,,,,,,,,,,,,
MESH BIOLOGIC OVINE RUMEN PERM OVITEX 2S 20X20 CM,SUP-2383100,CDM,C1781,HCPCS,0278,RC,,,,both,,,30144.00,19593.60,,,,,,,,,,,,,
ANCHOR SUTURE PRE LD 2 1.4 MM SURELOCK UHMWIPE,SUP-2608902,CDM,C1713,HCPCS,0278,RC,,,,both,,,1234.40,802.36,,,,,,,,,,,,,
BUR SURG HUB III CRANIOTOME CUT STRL REUSE HI-LINE,SUP-2928858,CDM,2720000010,LOCAL,0272,RC,,,,both,,,544.92,354.20,,,,,,,,,,,,,
SUPPORT ORTHOT CUST SOLE WDG OUTSIDE,SUP-2435722,CDM,L3360,HCPCS,0274,RC,,,,both,,,100.79,65.51,,,,,,,,,,,,,
LCKNG PL CVD2X816 H GRID T1.5MM CP TI,SUP-2500129,CDM,C1713,HCPCS,0278,RC,,,,both,,,2830.68,1839.94,,,,,,,,,,,,,
GRAFT HUMAN TSSUE W1XL4CM THK1.04 2.28MM THICK RGNRTVE TSSUE,SUP-2487772,CDM,Q4116,HCPCS,0636,RC,,,,both,,,926.30,602.09,,,,,,,,,,,,,
CATHETERIZATION KIT AD 8 FRX5-1/8 IN ARROWG+ARD BLU +,SUP-2383333,CDM,C1751,HCPCS,0278,RC,,,,both,,,184.79,120.11,,,,,,,,,,,,,
PLATE BNE L37MM 3 H S STL 1/3 TBLR W/ CLLR LIMIT CNTCT DYN,SUP-2185923,CDM,C1713,HCPCS,0278,RC,,,,both,,,396.64,257.82,,,,,,,,,,,,,
KIT TKR CEM FEM TIB CPS VIT E SURF AND PAT PERSONA,SUP-2212229,CDM,C1776,CPT,0278,RC,,,,both,,,16054.82,10435.63,,,,,,,,,,,,,
STABILIT MX FRACTURE KIT BASE SHRT,SUP-2702593,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7309.92,4751.45,,,,,,,,,,,,,
KICKSTAND EXT FIX 175 X 210 MM ALUM PIN TO BAR NS DISP MONK,SUP-2909053,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3272.67,2127.24,,,,,,,,,,,,,
SHELL ACET OD54MM LNR DMG DBL MOBILITY MPACT,SUP-2267372,CDM,C1776,CPT,0278,RC,,,,both,,,7567.40,4918.81,,,,,,,,,,,,,
SCREW BNE L60MM DIA5.5MM TOT ANK PARTIALLY THRD ORTHOLOC,SUP-2398580,CDM,C1713,HCPCS,0278,RC,,,,both,,,731.62,475.55,,,,,,,,,,,,,
BUR SURG DMND RND N FLUT EXTRA COARSE SABER SHANK ST 40MM,SUP-2363993,CDM,2720000010,LOCAL,0272,RC,,,,both,,,493.58,320.83,,,,,,,,,,,,,
SET PRB 2.5MM PERC DISCECTOMY NUCLEOTOME,SUP-2164733,CDM,C1713,HCPCS,0278,RC,,,,both,,,7536.00,4898.40,,,,,,,,,,,,,
ALLOGRAFT BNE DBM 10 CC VESUVIUS 4104K1010DC,SUP-2717988,CDM,C1713,HCPCS,0278,RC,,,,both,,,1823.56,1185.31,,,,,,,,,,,,,
HC 3d Plan,PX-3337729500,CDM,77295,CPT,0333,RC,,,,both,,,6474.00,4208.10,,,,,,,,,,,,,
PLATE BNE W10.2XL117MM THK2.7MM 9 H BILAT S STL STR LO PROF,SUP-2186196,CDM,C1713,HCPCS,0278,RC,,,,both,,,1472.57,957.17,,,,,,,,,,,,,
SHEATH INTRO PRELUDE L 11CM DIA 5FR 7CM 18GA SS POLYPRO TBNG,SUP-2458347,CDM,C1894,HCPCS,0272,RC,,,,both,,,38.37,24.94,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA PLU MAXBARR 4FR S1294108D5,SUP-2632813,CDM,C1751,HCPCS,0278,RC,,,,both,,,1134.36,737.33,,,,,,,,,,,,,
GRAFT HUM TISS BIOINTEGRATIVE 30X30 MM W/ INTRO LAT TAPESTRY,SUP-2867248,CDM,C1763,HCPCS,0278,RC,,,,both,,,4427.40,2877.81,,,,,,,,,,,,,
PORT INFUS SGL LUMN ATTCH POLYUR OPN END CATH 8FR POWERPRT,SUP-2126513,CDM,C1788,HCPCS,0278,RC,,,,both,,,681.38,442.90,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH RENU L 54 MM DIA 36 MM SHTH 22 FR RVD,SUP-2170458,CDM,C1874,HCPCS,0278,RC,,,,both,,,16864.94,10962.21,,,,,,,,,,,,,
WASHER ORTH OD4MM G CNTOUR MAXTORQUE,SUP-2399469,CDM,C1776,CPT,0278,RC,,,,both,,,442.74,287.78,,,,,,,,,,,,,
IOFLUPANE I 123 185 MBQ/2.5ML IV SOLN,RX-104599,CDM,A9584,HCPCS,0343,RC,17156-0210-01,NDC,,both,1,UN,5690.90,3699.08,,,,,,,,,,,,,
IMPLANT ANTIREFLX SZ 14 LAPSCP FUNDIC SPRNG MRI COMPATIBLE,SUP-2219560,CDM,C1889,HCPCS,0278,RC,,,,both,,,20375.46,13244.05,,,,,,,,,,,,,
SPACER SPNL CRV 0 DEG 27X11X6 MM TRANSFORAMINAL PLATEAU,SUP-2430683,CDM,C1889,HCPCS,0278,RC,,,,both,,,9734.00,6327.10,,,,,,,,,,,,,
EXTENSION EXT FIX MONOAX SHT OPN BODY PHOENIX,SUP-2657927,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
IMPLANT SUBTALAR BUNION CORRECTION SYS STRL LF NANOPLASTY 3D,SUP-2893049,CDM,C1713,HCPCS,0278,RC,,,,both,,,14123.72,9180.42,,,,,,,,,,,,,
DEFIBRILLATOR CARD W2.43XH2.93IN D0.39IN 2.54OZ SGL CHMBR,SUP-2149192,CDM,C1722,HCPCS,0275,RC,,,,both,,,36310.96,23602.12,,,,,,,,,,,,,
INSERT TIB SZ 4 THK17MM SEMICONSTRAINED FIX GMK,SUP-2267515,CDM,C1776,CPT,0278,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
MESH HERN W20XL25CM BIOABSRB FLM TECHNOLOGY COMP SYMBOTEX,SUP-2173622,CDM,C1781,HCPCS,0278,RC,,,,both,,,7502.65,4876.72,,,,,,,,,,,,,
SCREW BNE CANN SHT THRD 3X44 MM SS NS,SUP-2183417,CDM,C1713,HCPCS,0278,RC,,,,both,,,748.89,486.78,,,,,,,,,,,,,
NAIL IM L240MM DIA7.5MM 120DEG UNIV NONSTERILE DK BLU L/R,SUP-2192488,CDM,C1713,HCPCS,0278,RC,,,,both,,,5832.49,3791.12,,,,,,,,,,,,,
PLATE BONE L227MM 18 H STRL S STL COMPR FOR 3.5MM SCR EVOS,SUP-2349643,CDM,C1713,HCPCS,0278,RC,,,,both,,,3213.32,2088.66,,,,,,,,,,,,,
STENT PERIPH L200MM DIA6MM CATH L120CM 6FR 0.035IN,SUP-2173214,CDM,C1876,HCPCS,0278,RC,,,,both,,,5966.00,3877.90,,,,,,,,,,,,,
KIT TKR TRABECULAR MTL FEM TIB PAT AND PROLONG SURF PERSONA,SUP-2212238,CDM,C1776,CPT,0278,RC,,,,both,,,18252.82,11864.33,,,,,,,,,,,,,
BIT DRL OD22MM DISPOSABLE FOR SM SCR FIX SYS REUNITE,SUP-2137298,CDM,2720000010,LOCAL,0272,RC,,,,both,,,432.57,281.17,,,,,,,,,,,,,
MESH GYN POLYPR ULT LTWT SMARTMESH TECHNOLOGY FOR ANT PELV,SUP-2165311,CDM,C1781,HCPCS,0278,RC,,,,both,,,4122.82,2679.83,,,,,,,,,,,,,
PLATE BONE W53XL85MM THK0.3MM CRANIOMAXILLOFACIAL TI PNL,SUP-2402754,CDM,C1713,HCPCS,0278,RC,,,,both,,,2590.50,1683.82,,,,,,,,,,,,,
KIT INTRO VSI L 15 CM DIA 5 FR GUIDEWIRE L 60 CM DIA 0.018,SUP-2763489,CDM,C1892,HCPCS,0272,RC,,,,both,,,155.43,101.03,,,,,,,,,,,,,
METRONIDAZOLE 0.75 % EX CREA,RX-19805,CDM,6370000000,HCPCS,0637,RC,00168-0323-46,NDC,,both,45,GR,321.20,208.78,,,,,,,,,,,,,
RITUXIMAB-ABBS (TRUXIMA) 10 MG/ML IV SOLN (MIXTURES ONLY),RX-1150545,CDM,Q5115,HCPCS,0636,RC,63459-0103-10,NDC,,both,10,ML,2435.20,1582.88,,,,,,,,,,,,,
PROBE XL NRV STIM DISPOSABLE NEURO TRA VEO,SUP-2164082,CDM,C1713,HCPCS,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
TEMPLATE SURG M W6.5XL19MM 10DEG IM CHT FIX SYS ANG SZ NIT,SUP-2194204,CDM,C1776,CPT,0278,RC,,,,both,,,3799.40,2469.61,,,,,,,,,,,,,
SCREW BNE L20MM DIA3MM LOK PLATING SYS MOTOBAND CP,SUP-2175140,CDM,C1713,HCPCS,0278,RC,,,,both,,,833.67,541.89,,,,,,,,,,,,,
SCREW BNE L 55 MM DIA 5.5 MM CANN HDLSS NS,SUP-2896544,CDM,C1713,HCPCS,0278,RC,,,,both,,,1880.86,1222.56,,,,,,,,,,,,,
SHEATH INTRO INPUT L 11 CM DIA 6 FR OBTURATOR ACTIVE LCK HUB,SUP-2294581,CDM,C1894,HCPCS,0272,RC,,,,both,,,17.27,11.23,,,,,,,,,,,,,
KIT SURG INTERPHALANGEAL STRL,SUP-2319762,CDM,C1776,CPT,0278,RC,,,,both,,,709.64,461.27,,,,,,,,,,,,,
ANCHOR SUT 5MM NO 2 W/ TWO BRAID POLY AND NDL SFT TISS,SUP-2362553,CDM,C1713,HCPCS,0278,RC,,,,both,,,632.40,411.06,,,,,,,,,,,,,
RELOAD STPLR CRV TIP SM LNG VASC THN 45 MM WHT,SUP-2787710,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1730.93,1125.10,,,,,,,,,,,,,
NEXGEN LPS ART SURF EF 7-10/STR BLU 23MM,SUP-2201983,CDM,C1776,CPT,0278,RC,,,,both,,,2413.09,1568.51,,,,,,,,,,,,,
MATRIX HUM TISS L 4 X W 8 CM THK 0.2-1 MM ACELLULAR DERMAL,SUP-2909228,CDM,Q4122,HCPCS,0636,RC,,,,both,,,7022.61,4564.70,,,,,,,,,,,,,
PIN SURG L20MM OD2.4MM DRL TIP THRD SHLDR STAR,SUP-2365262,CDM,2720000010,LOCAL,0272,RC,,,,both,,,56.52,36.74,,,,,,,,,,,,,
PUSHER KNOT ENDOSCP OPN TIP REUSE 5MM DIA 40CM LEN APPEL,SUP-2243658,CDM,2720000010,LOCAL,0272,RC,,,,both,,,530.19,344.62,,,,,,,,,,,,,
BASEPLATE TIB SZ 1 BIOFOAM SCR H ADV,SUP-2304791,CDM,C1776,CPT,0278,RC,,,,both,,,8044.68,5229.04,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 20 CM DIA 6 MM EPTFE STR STD WALL,SUP-2396183,CDM,C1768,CPT,0278,RC,,,,both,,,1039.34,675.57,,,,,,,,,,,,,
TAP SURG L130MM QUIK CPL FOR 4.5MM CORT SHFT SCR 3.2MM DRL,SUP-2187414,CDM,2720000010,LOCAL,0272,RC,,,,both,,,584.57,379.97,,,,,,,,,,,,,
STEM FEM SEG 15 CM DPHSEAL KNEE SMOOTH OSS,SUP-2449812,CDM,C1776,CPT,0278,RC,,,,both,,,11768.88,7649.77,,,,,,,,,,,,,
SCREW BONE CNNLTD 8MM DIA 65MML TIMAX 16MML THRDD NON ST,SUP-2586857,CDM,C1713,HCPCS,0278,RC,,,,both,,,749.83,487.39,,,,,,,,,,,,,
PLATE BONE LOK 184MML HLX12 STNLSS STEEL ST RIGHT LTRL DST F,SUP-2588182,CDM,C1713,HCPCS,0278,RC,,,,both,,,2343.19,1523.07,,,,,,,,,,,,,
SHEATH URET ACCS 9.5 FRX28 CM DIL FLX,SUP-2835790,CDM,C1894,HCPCS,0272,RC,,,,both,,,418.19,271.82,,,,,,,,,,,,,
BRACE ORTHPDC D RING SM ADLT 21.6 CM 14.6 16.5 CM RIGHT WRIS,SUP-2457443,CDM,L3931,HCPCS,0272,RC,,,,both,,,40.95,26.62,,,,,,,,,,,,,
HC So Vitamin A,PX-3018459066,CDM,84590,CPT,0301,RC,,,,inpatient,,,354.00,230.10,,,,,,,,,,,,,
SPLINT ANK FT XL R POST LEAF LTWT SEMI RIG ROLYAN,SUP-2326016,CDM,L4397,HCPCS,0274,RC,,,,both,,,113.89,74.03,,,,,,,,,,,,,
ALLOGRAFT BNE SPACER 8 DEG 23-27X24-32X21 MM FD ANGLED FRA,SUP-2736756,CDM,C1713,HCPCS,0278,RC,,,,both,,,13658.40,8877.96,,,,,,,,,,,,,
LEVEL CMF ST PLATE RECON TLTS ANGLE LFT 20 25 MM SCRW26 HO,SUP-2679060,CDM,C1713,HCPCS,0278,RC,,,,both,,,5662.55,3680.66,,,,,,,,,,,,,
PLATE 3.5MM TI LCP POSTEROMEDIAL PROX TIBIA 10H 183 MM STER,SUP-2546841,CDM,C1713,HCPCS,0278,RC,,,,both,,,3954.48,2570.41,,,,,,,,,,,,,
TIP ASPIR SERRATED LG 2X2.51 MM 12 CM SONOPET IQ,SUP-2791058,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3151.93,2048.75,,,,,,,,,,,,,
BIT DRL HALF PIN DIA 6 MM NONSTEP NS DISP,SUP-2933689,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1562.50,1015.62,,,,,,,,,,,,,
PLATE BNE 1/3 TBLR 5 HOLE W/ CLLRD NS LTX,SUP-2861945,CDM,C1713,HCPCS,0278,RC,,,,both,,,213.46,138.75,,,,,,,,,,,,,
CATHETER PICC ARROW TAPERFREE 4FR 55CM 1-LUMEN,SUP-2887041,CDM,C1751,HCPCS,0278,RC,,,,both,,,520.20,338.13,,,,,,,,,,,,,
MATRIX BIO L 7 X W 20 CM SZ 252 SQCM FISH SKIN DERMAL MESHED,SUP-2909277,CDM,Q4158,HCPCS,0636,RC,,,,both,,,14867.90,9664.13,,,,,,,,,,,,,
SCREW TUBE ORTH LAT COMMON NS REUSE PRECIS MIS,SUP-2899000,CDM,C1713,HCPCS,0278,RC,,,,both,,,847.80,551.07,,,,,,,,,,,,,
SCREW STRNL L 12 MM DIA2.7 MM TI ALLOY SD NS MATRIXSTERNUM,SUP-2904225,CDM,C1713,HCPCS,0278,RC,,,,both,,,534.30,347.29,,,,,,,,,,,,,
PLATE BNE L106MM 7 H NONSTERILE L ANTLAT DST TIB S STL LO,SUP-2185948,CDM,C1713,HCPCS,0278,RC,,,,both,,,4055.12,2635.83,,,,,,,,,,,,,
NEEDLE BX 20GA L15CM COAX TEMNO,SUP-2133830,CDM,C1713,HCPCS,0278,RC,,,,both,,,698.84,454.25,,,,,,,,,,,,,
PLATE BNE L118MM WRST S STL SHT BEND LOK COMPR FOR FUS LCP,SUP-2177229,CDM,C1713,HCPCS,0278,RC,,,,both,,,5060.02,3289.01,,,,,,,,,,,,,
SHEATH TUNN L12IN DIA11GA ON-Q,SUP-2236803,CDM,C1894,HCPCS,0272,RC,,,,both,,,85.09,55.31,,,,,,,,,,,,,
MESH DERM IMPL SFT TISS MTRX PORCINE 6X8CM INTEXEN LP,SUP-2140305,CDM,C1781,HCPCS,0278,RC,,,,both,,,2669.79,1735.36,,,,,,,,,,,,,
GRAFT VASC HEMSHLD PLAT L 15 CM DIA24 MM POLYESTER BOV CLLGN,SUP-2265917,CDM,C1768,CPT,0278,RC,,,,both,,,1430.14,929.59,,,,,,,,,,,,,
CATHETER HEMODIALYSI TRI FLO ACTE 11.5FR DIA 24CM STRGHT TAP,SUP-2610640,CDM,C1752,HCPCS,0278,RC,,,,both,,,153.86,100.01,,,,,,,,,,,,,
BUR SURG 5 MMX21 CM W/ LG BOR FLUT BALL MIDAS REX LEGEND,SUP-2628135,CDM,2720000010,LOCAL,0272,RC,,,,both,,,500.64,325.42,,,,,,,,,,,,,
GUIDEWIRE VASC ANGLED 3 CM 0.035 INX180 CM STD NIT GLIDEWIRE,SUP-2385573,CDM,C1769,HCPCS,0272,RC,,,,both,,,142.87,92.87,,,,,,,,,,,,,
COIL NEUROVASCULAR CEREPAK UNIF L 17 CM DIA 5 MM PRIMARY DIA,SUP-2865181,CDM,C1889,HCPCS,0278,RC,,,,both,,,7080.83,4602.54,,,,,,,,,,,,,
KIT PROC LATARJET,SUP-2256896,CDM,C1713,HCPCS,0278,RC,,,,both,,,3161.98,2055.29,,,,,,,,,,,,,
DAPSONE 25 MG PO TABS,RX-2132,CDM,6370000000,HCPCS,0637,RC,70954-0135-10,NDC,,both,1,UN,4.50,2.92,,,,,,,,,,,,,
PLATE BNE L 50.67 X W 5.72 MM THK 1.6 MM 7 H GRD III TI MOD,SUP-2936910,CDM,C1713,HCPCS,0278,RC,,,,both,,,1629.66,1059.28,,,,,,,,,,,,,
COMPONENT TIB SZ 1 THICKNESS 10MM POLYETH NP LT LAT RT MEDL,SUP-2200429,CDM,C1776,CPT,0278,RC,,,,both,,,4551.43,2958.43,,,,,,,,,,,,,
SET ADPT FOR 44 CABLE PK,SUP-2137937,CDM,C1883,HCPCS,0278,RC,,,,both,,,935.72,608.22,,,,,,,,,,,,,
SCREW BNE CANN 6.5X40 MM 16 MM COMPR HDLSS THRD EXTREMIFIX,SUP-2319489,CDM,C1713,HCPCS,0278,RC,,,,both,,,3058.36,1987.93,,,,,,,,,,,,,
KIT CATH HEMODIALYSI GLIDEPATH CHRONIC STD 14.5FR DIA 20CM 1,SUP-2613289,CDM,C1750,HCPCS,0278,RC,,,,both,,,1374.85,893.65,,,,,,,,,,,,,
GRAFT EVAR L70MM DIA36X36MM C DST DSGN FOR ABD AORT ANEUR,SUP-2295274,CDM,C1768,CPT,0278,RC,,,,both,,,24256.50,15766.72,,,,,,,,,,,,,
COMPONENT TOT KNEE CEM STD S-STEM,SUP-2379193,CDM,C1776,CPT,0278,RC,,,,both,,,13737.50,8929.37,,,,,,,,,,,,,
BIT DRL TAPR 3.2 MM OCCIPITOCERVICAL INFIN,SUP-2632003,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1387.10,901.61,,,,,,,,,,,,,
WEDGE EVANS ADDUCTION STRUCTURAL ALLGRFT 20 DEG 8 MM,SUP-2321672,CDM,C1713,HCPCS,0278,RC,,,,both,,,6099.45,3964.64,,,,,,,,,,,,,
SHEATH INTRO PINNACLE L 11 CM DIA 4 FR W/O GUIDEWIRE STRL,SUP-2141019,CDM,C1894,HCPCS,0272,RC,,,,both,,,359.53,233.69,,,,,,,,,,,,,
SCREW SPINAL 4X32MM TITANIUM CANNULATED CORTICAL UCSS,SUP-2290869,CDM,C1713,HCPCS,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
PLATE MIS PLANTARPOWER,SUP-2652617,CDM,C1713,HCPCS,0278,RC,,,,both,,,5636.30,3663.59,,,,,,,,,,,,,
PLATE BONE SM LT GLD 3D ORBIT FLR FOR 1.2MM SCR,SUP-2363678,CDM,C1713,HCPCS,0278,RC,,,,both,,,4292.44,2790.09,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY LASSOSTAR NAV L 115 CM DIA 7 FR,SUP-2248923,CDM,C1732,HCPCS,0278,RC,,,,both,,,4549.86,2957.41,,,,,,,,,,,,,
CLAMP SURG 00361IN AD 3 H WIRE SLDE STD TISS REUSE,SUP-2316250,CDM,2720000010,LOCAL,0272,RC,,,,both,,,973.27,632.63,,,,,,,,,,,,,
INTRODUCER TUBE CATH 14 FRX70 CM STIFFENING STYL INTUB FROVA,SUP-2759925,CDM,2720000010,LOCAL,0272,RC,,,,both,,,323.07,210.00,,,,,,,,,,,,,
PROBE SURG WORST 9 MMX5.9 IN PGTL CRV BLNT RND KNURLED HNDL,SUP-2465763,CDM,2720000010,LOCAL,0272,RC,,,,both,,,616.38,400.65,,,,,,,,,,,,,
BRACE ORTH L8IN FOR 10IN WRST UNIV R NYL QUICK FIT,SUP-2197071,CDM,L3908,HCPCS,0274,RC,,,,both,,,30.30,19.69,,,,,,,,,,,,,
RESERVOIR CSF BRDN 20 MM 1.2X2.2 MM 1.2X2.2 MM DBL DOME BTM,SUP-2852579,CDM,C1889,HCPCS,0278,RC,,,,both,,,1067.54,693.90,,,,,,,,,,,,,
GRAFT BNE 2 GM DBM FIBERSTACK,SUP-2861496,CDM,C1713,HCPCS,0278,RC,,,,both,,,5659.85,3678.90,,,,,,,,,,,,,
CATHETER THOR 32FR L16IN CLR PVC THERMOSENSITIVE SHRP TRCR,SUP-2154959,CDM,C1729,HCPCS,0272,RC,,,,both,,,147.23,95.70,,,,,,,,,,,,,
GRAFT HUM TISS 8MM ALLO-SPAN,SUP-2354360,CDM,C1713,HCPCS,0278,RC,,,,both,,,7065.00,4592.25,,,,,,,,,,,,,
KIT CATH 20GA L1.75IN RAD ART POLYUR RADPQ THN WALL INTRO,SUP-2383259,CDM,C1894,HCPCS,0272,RC,,,,both,,,64.06,41.64,,,,,,,,,,,,,
PLATE BNE SUPER ELASTIC W/ SCREW FOR MOTOCLIP DYNAFORCE,SUP-2431539,CDM,C1713,HCPCS,0278,RC,,,,both,,,3946.98,2565.54,,,,,,,,,,,,,
SCREW BONE L20MM DIA3.4MM HEX DRVR DIA2MM BLU ST CANN FULL,SUP-2136634,CDM,C1713,HCPCS,0278,RC,,,,both,,,937.26,609.22,,,,,,,,,,,,,
MESH CRAN L 90 X W 90 MM THK 0.6 MM SCREW DIA1.5/1.7 MM MED,SUP-2883503,CDM,C1713,HCPCS,0278,RC,,,,both,,,20563.39,13366.20,,,,,,,,,,,,,
BUTTON BACKSTOP ALL SUTURE RADIOLUCENT MICROLINK,SUP-2828520,CDM,C1713,HCPCS,0278,RC,,,,both,,,6069.62,3945.25,,,,,,,,,,,,,
PLATE BONE L112MM BLDE W11.7XL40MM 90DEG 6 H STRL BILAT TI,SUP-2190863,CDM,C1713,HCPCS,0278,RC,,,,both,,,2939.42,1910.62,,,,,,,,,,,,,
GRIP CBL L125MM STD TROCHANTERIC HIP 5 CBL ACCORD,SUP-2345207,CDM,C1776,CPT,0278,RC,,,,both,,,5777.60,3755.44,,,,,,,,,,,,,
PLATE BNE RADIAL LNG WIDE LT VOLAR DSTL,SUP-2646873,CDM,C1713,HCPCS,0278,RC,,,,both,,,2410.01,1566.51,,,,,,,,,,,,,
CUP ACET CRV FOR ALLOFIT TI,SUP-2449523,CDM,C1776,CPT,0278,RC,,,,both,,,2218.41,1441.97,,,,,,,,,,,,,
VALVE AORT MSTR SER CUF DIA20 MM TISS ANNULUS DIA15 MM,SUP-2894049,CDM,C1889,HCPCS,0278,RC,,,,both,,,29651.02,19273.16,,,,,,,,,,,,,
GRAFT BIO TISS W7.5XL11IN RECT XENMATRIX,SUP-2125848,CDM,C1781,HCPCS,0278,RC,,,,both,,,33598.00,21838.70,,,,,,,,,,,,,
ROD TEND W4XL24.5MM STD SIL HUNTER,SUP-2401386,CDM,C1713,HCPCS,0278,RC,,,,both,,,3554.48,2310.41,,,,,,,,,,,,,
OBTURATOR ENDOSCP CINCHLOCK FLX,SUP-2663982,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1815.67,1180.19,,,,,,,,,,,,,
PLATE BNE CRV 0.8 MM 8 HOLE CONTOURED SM GRID PLLA-PGA STRL,SUP-2489900,CDM,C1713,HCPCS,0278,RC,,,,both,,,847.83,551.09,,,,,,,,,,,,,
INSERT TIB SZ 1 THICKNESS 11MM UNIV POLYETH PRI NEUT UNI,SUP-2342172,CDM,C1776,CPT,0278,RC,,,,both,,,1893.42,1230.72,,,,,,,,,,,,,
CLASSIC CHS PL 14 SLOT 135 DEG,SUP-2818351,CDM,C1713,HCPCS,0278,RC,,,,both,,,7279.46,4731.65,,,,,,,,,,,,,
GRAFT BIOLOGIC BLK CORLN HA 12MMX30MMX30MM PRO OSTEON 500,SUP-2413076,CDM,C1713,HCPCS,0278,RC,,,,both,,,4984.59,3239.98,,,,,,,,,,,,,
BUR SURG MTCH HD 3 MMX14 CM TRI-FLAT MIDAS REX LEGEND,SUP-2627701,CDM,2720000010,LOCAL,0272,RC,,,,both,,,413.32,268.66,,,,,,,,,,,,,
COMPONENT TIB SHT 1 LT APEX 3D ARC,SUP-2742085,CDM,C1776,CPT,0278,RC,,,,both,,,14031.88,9120.72,,,,,,,,,,,,,
CATHETER THERMODILUTION 5 FRX110 CM CRITCATH TD,SUP-2848489,CDM,C1727,CPT,0278,RC,,,,both,,,295.63,192.16,,,,,,,,,,,,,
SCREW BNE L45MM DIA65MM THRD L16MM ST TAN CANN SELF DRL,SUP-2417606,CDM,C1713,HCPCS,0278,RC,,,,both,,,1041.48,676.96,,,,,,,,,,,,,
CONTOURED MESH GRDNR STYLE 10MM STNDRD STYLE T 6L 4V ST,SUP-2681258,CDM,C1713,HCPCS,0278,RC,,,,both,,,9743.23,6333.10,,,,,,,,,,,,,
ROD SPNL THRD LNG 250 MM MR SAFE NS,SUP-2863452,CDM,C1713,HCPCS,0278,RC,,,,both,,,207.21,134.69,,,,,,,,,,,,,
MATRIX HUM TISS L 8 X W 8 CM DECELL PLCNTA MEMBRN,SUP-2909261,CDM,Q4201,HCPCS,0636,RC,,,,both,,,24287.90,15787.13,,,,,,,,,,,,,
IMPLANT TOE JT DIA11MM ZIRCONIUM ORTHOSPHERE,SUP-2399051,CDM,C1776,CPT,0278,RC,,,,both,,,7787.20,5061.68,,,,,,,,,,,,,
CANNULA ENDOSCP 11GA L120MM END DEL ACCUPORT,SUP-2414253,CDM,2720000010,LOCAL,0272,RC,,,,both,,,213.52,138.79,,,,,,,,,,,,,
PLATE BNE THK0.6MM 6 H MAND TI T LO PROF FOR 2MM SCR MINI,SUP-2262942,CDM,C1713,HCPCS,0278,RC,,,,both,,,256.38,166.65,,,,,,,,,,,,,
COSYNTROPIN 0.25 MG IJ SOLR,RX-9686,CDM,J0834,HCPCS,0636,RC,00781-3440-71,NDC,,both,1,UN,461.20,299.78,,,,,,,,,,,,,
PLATE BNE W17.5XL142MM THK5.2MM 8 H BILAT S STL BROAD LIMIT,SUP-2185289,CDM,C1713,HCPCS,0278,RC,,,,both,,,1400.28,910.18,,,,,,,,,,,,,
JOINT TOE HAMRTOE 10 DEG 3.3 MM TOE-LEGIT,SUP-2749828,CDM,C1776,CPT,0278,RC,,,,both,,,3758.58,2443.08,,,,,,,,,,,,,
GUIDEWIRE INTRO L 230 MM DIA1.6 MM ENTRY TROCAR FOR FIBULAR,SUP-2909115,CDM,C1769,HCPCS,0272,RC,,,,both,,,129.53,84.19,,,,,,,,,,,,,
HC Core Needle Bx Lung/Mediastinum Perq W/Img,PX-3613240800,CDM,32408,CPT,0361,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
KIT CATH CATH 12FR L8IN GWIRE 0.035IN,SUP-2383316,CDM,C1752,HCPCS,0278,RC,,,,both,,,352.31,229.00,,,,,,,,,,,,,
VALVE MITRL ON-X TISS ANNULUS 25 MM ORIFICE 23.4 MM SZ 25,SUP-2175262,CDM,C1889,HCPCS,0278,RC,,,,both,,,15696.86,10202.96,,,,,,,,,,,,,
DEFIBRILLATOR IMPL PHOTON U DR 29 J 37 ML 74 GM 2 CHMBR STRL,SUP-2320137,CDM,C1721,HCPCS,0275,RC,,,,both,,,78500.00,51025.00,,,,,,,,,,,,,
PLATE BONE L121MM 10 H S STL SELF COMPR FOR 3.5MM SCR ECT,SUP-2198567,CDM,C1713,HCPCS,0278,RC,,,,both,,,300.28,195.18,,,,,,,,,,,,,
NEEDLE SPNL Y 200 MM ES2 LT,SUP-2532843,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1163.37,756.19,,,,,,,,,,,,,
PLATE BNE L L36MM 4 H NONSTERILE BILAT FOREFOOT TI X SHP VAR,SUP-2181211,CDM,C1713,HCPCS,0278,RC,,,,both,,,3469.54,2255.20,,,,,,,,,,,,,
BUR SURG L72MM DIA4MM LNG RND FN DMND VISAO,SUP-2278122,CDM,2720000010,LOCAL,0272,RC,,,,both,,,491.79,319.66,,,,,,,,,,,,,
URSODIOL 300 MG PO CAPS,RX-11624,CDM,6370000000,HCPCS,0637,RC,00591-3159-01,NDC,,both,1,UN,4.60,2.99,,,,,,,,,,,,,
PLATE BONE L59MM 5 H FIB TI STR LCK FOR 2.7/3/3.5/4MM SCR,SUP-2420143,CDM,C1713,HCPCS,0278,RC,,,,both,,,4282.80,2783.82,,,,,,,,,,,,,
PLATE BNE L242MM 10 H NONSTERILE L CNDYL S STL LOK COMPR,SUP-2183115,CDM,C1713,HCPCS,0278,RC,,,,both,,,4376.25,2844.56,,,,,,,,,,,,,
CATHETER KIT DL 5 FR PWR 3CG PLCMNT,SUP-2126772,CDM,C1751,HCPCS,0278,RC,,,,both,,,847.80,551.07,,,,,,,,,,,,,
BLADE SHV DIA4MM 40DEG CRV SERR DISECT CONCAVE WIND FOR,SUP-2313828,CDM,2720000010,LOCAL,0272,RC,,,,both,,,337.24,219.21,,,,,,,,,,,,,
BAR EXT FIX CRV 11X175 MM CARBON XTRAFIX,SUP-2472619,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1707.66,1109.98,,,,,,,,,,,,,
HC So T Cell Absolute,PX-3028636066,CDM,86360,CPT,0302,RC,,,,inpatient,,,253.00,164.45,,,,,,,,,,,,,
ROD EXT FIX L500MM DIA11MM UNIV C FBR RADLUC CONN 39489R] DEPUY SYNTHES USA],SUP-2188671,CDM,2720000010,LOCAL,0272,RC,,,,both,,,546.36,355.13,,,,,,,,,,,,,
SLING SHLDR UNIV SWTH W5XL54IN PCH W13XL19IN LTWT PERF FOAM,SUP-2195038,CDM,L3660,HCPCS,0272,RC,,,,both,,,27.41,17.82,,,,,,,,,,,,,
ANCHOR SUTURE 4.75X20 MM BIO-SWIVELOCK,SUP-2121701,CDM,C1713,HCPCS,0278,RC,,,,both,,,1705.02,1108.26,,,,,,,,,,,,,
SUPPORT ORTH LO SPINE ADJ VISTA 464 TLSO,SUP-2123918,CDM,L0464,HCPCS,0272,RC,,,,both,,,993.81,645.98,,,,,,,,,,,,,
GRAFT BONE LT ILIUM WHL TRAD FRZN,SUP-2294152,CDM,C1713,HCPCS,0278,RC,,,,both,,,15345.18,9974.37,,,,,,,,,,,,,
HC OB ER Level 5|MULTIPLE OUTPATIENT HOSPITAL E/M ENCOUNTERS ON THE SAME DATE,PX-4509928501,CDM,99285,CPT,0450,RC,,,27,outpatient,,,3911.00,2542.15,,,,,,,,,,,,,
NAPROXEN 500 MG PO TABS,RX-5393,CDM,6370000000,HCPCS,0637,RC,68462-0190-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PLATE MXLFCL 06MM THK MED CMMRCLLY PURE TTNM CHRI MLFRMTN M,SUP-2681399,CDM,C1713,HCPCS,0278,RC,,,,both,,,4472.40,2907.06,,,,,,,,,,,,,
CEFEPIME HCL 2 G IV SOLR,RX-27311,CDM,J0692,HCPCS,0636,RC,60505-6147-00,NDC,,both,1,UN,81.30,52.84,,,,,,,,,,,,,
GRAFT VASC PTCH 10X1 CM BOV PERICARD TAPR BIOLOGIC XENOSURE,SUP-2424199,CDM,C1768,CPT,0278,RC,,,,both,,,1064.46,691.90,,,,,,,,,,,,,
FIBER LASER ROBOTIC OMNIGUIDE,SUP-2225672,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3617.28,2351.23,,,,,,,,,,,,,
DEFIBRILLATOR IMPL LUMAX 540 HF-T 59X 66MM 13MM 40J SCOUTPRO,SUP-2138192,CDM,C1882,HCPCS,0275,RC,,,,both,,,72063.00,46840.95,,,,,,,,,,,,,
IMPLANT FACE 47 X 28 MM THK 3 MM POLYETHYL LT INFERIOR MEDL,SUP-2883146,CDM,C1713,HCPCS,0278,RC,,,,both,,,1555.68,1011.19,,,,,,,,,,,,,
CATHETER EP SFT TIP DECAPOLAR STEER INQUIRY,SUP-2516508,CDM,C1730,HCPCS,0272,RC,,,,both,,,1307.81,850.08,,,,,,,,,,,,,
ALLOGRAFT BNE FRZN IRRADIATED ANTR TIBIALIS,SUP-2867111,CDM,C1762,CPT,0278,RC,,,,both,,,4614.70,2999.55,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 70 CM DIA 5-8 MM EPTFE SHRT TAPR,SUP-2476212,CDM,C1768,CPT,0278,RC,,,,both,,,872.64,567.22,,,,,,,,,,,,,
COMPONENT TIB SZ 2 LT FIX CEM GMK,SUP-2267563,CDM,C1776,CPT,0278,RC,,,,both,,,5436.94,3534.01,,,,,,,,,,,,,
LEAD NEUROSTIMULATOR L50CM TRL W/ PRELD ENH STYL,SUP-2141907,CDM,C1778,HCPCS,0278,RC,,,,both,,,3693.90,2401.03,,,,,,,,,,,,,
GRAFT BONE SUB 5CC VIABLE BONE MTRX BIOFUSE,SUP-2224016,CDM,C1762,CPT,0278,RC,,,,both,,,8515.68,5535.19,,,,,,,,,,,,,
RELOAD STPL 60MM CRV TIP ARTC FOR MEDIUM/VASCULAR TISS,SUP-2283361,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2111.27,1372.33,,,,,,,,,,,,,
DILTIAZEM HCL ER COATED BEADS 300 MG PO CP24,RX-29276,CDM,6370000000,HCPCS,0637,RC,60687-0228-01,NDC,,both,1,UN,7.20,4.68,,,,,,,,,,,,,
GRAFT HUM TISS 0.75CC CART EXTRACELLULAR MTRX FOR SCAFFOLD,SUP-2120735,CDM,C1713,HCPCS,0278,RC,,,,both,,,2119.50,1377.67,,,,,,,,,,,,,
PLATE BNE HK SM 3.5/4.5X285 MM RT FEM PROX 8 STRL VALCP,SUP-2789194,CDM,C1713,HCPCS,0278,RC,,,,both,,,8576.41,5574.67,,,,,,,,,,,,,
PLATE BNE SM W11XL163MM THK34MM 12 H BILAT TI RIG NEUT LOK,SUP-2190789,CDM,C1713,HCPCS,0278,RC,,,,both,,,1191.38,774.40,,,,,,,,,,,,,
GRAFT BONE CHIP FRZ DRY DEMIN CANC 1.7MM-10MM RANG 60CC,SUP-2294032,CDM,C1713,HCPCS,0278,RC,,,,both,,,2402.10,1561.36,,,,,,,,,,,,,
LOW PRFLE NEURO PLATE 3X2 HOLES CRVD SQRE SGMNTS 06MM 15MM,SUP-2676649,CDM,C1713,HCPCS,0278,RC,,,,both,,,820.76,533.49,,,,,,,,,,,,,
PLATE BNE W13.5XL124MM THK4.2MM 7 H BILAT S STL NAR LIMIT,SUP-2185237,CDM,C1713,HCPCS,0278,RC,,,,both,,,1252.29,813.99,,,,,,,,,,,,,
NEEDLE SUT CAPSULECLOSE SCORPION,SUP-2121460,CDM,2720000010,LOCAL,0272,RC,,,,both,,,769.30,500.04,,,,,,,,,,,,,
SEED BRACHYTHERAPY LOAD 5.01-6.0 MCI STRL ADVANTAGE 2029FLS2] ISOAID LLC],SUP-2247273,CDM,C2642,HCPCS,0278,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
SPLINT FNGR M 3IN WIRE FOAM EXTN ASST BROAD CRV DORS CNTR PD,SUP-2194873,CDM,L3933,HCPCS,0272,RC,,,,both,,,60.26,39.17,,,,,,,,,,,,,
SET INTRO PERFRMR L 13 CM DIL L 20 CM OD 5.5 FR ID 1.8 MM,SUP-2168254,CDM,C1894,HCPCS,0272,RC,,,,both,,,47.10,30.61,,,,,,,,,,,,,
GRAFT HUM TISS R FEM FRZN,SUP-2307326,CDM,C1713,HCPCS,0278,RC,,,,both,,,16942.81,11012.83,,,,,,,,,,,,,
LEVEL NEURO MESH SPCLTY KSSM SCRN MESH PANEL RGLR 3MM CP TT,SUP-2681097,CDM,C1713,HCPCS,0278,RC,,,,both,,,929.69,604.30,,,,,,,,,,,,,
SCREW BONE L85MM DIA3.5MM S STL ST LCK T20 DRV PERI-LOC,SUP-2349997,CDM,C1713,HCPCS,0278,RC,,,,both,,,1401.07,910.70,,,,,,,,,,,,,
CARBAMAZEPINE 100 MG PO CHEW,RX-1355,CDM,6370000000,HCPCS,0637,RC,00904-3854-61,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
BUR SURG L3.8MM DIA3MM EXT PRECIS NEURO MTCH HD,SUP-2363484,CDM,2720000010,LOCAL,0272,RC,,,,both,,,510.09,331.56,,,,,,,,,,,,,
HC Thrmbc/Nfs Dialysis W Stent,PX-3613690600,CDM,36906,CPT,0361,RC,,,,both,,,18820.00,12233.00,,,,,,,,,,,,,
SCREW SYS PARTIALLY THRD LAG SCRS TI THRD 35 MM CANN 09 MM,SUP-2392907,CDM,C1713,HCPCS,0278,RC,,,,both,,,563.63,366.36,,,,,,,,,,,,,
GRAFT VASC RESTOREFLOW SZ 50-59 CM SAPH VEIN BLD TYP A B AB,SUP-2884053,CDM,C1768,CPT,0278,RC,,,,both,,,30297.86,19693.61,,,,,,,,,,,,,
HC Splint App Long Leg|BILATERAL PROCEDURE,PX-4502950500,CDM,29505,CPT,0450,RC,,,50,outpatient,,,214.00,139.10,,,,,,,,,,,,,
SCREW BONE L8MM OD4.5MM STD TI CORT ST LCK FULL THRD L HEX,SUP-2413627,CDM,C1713,HCPCS,0278,RC,,,,both,,,390.43,253.78,,,,,,,,,,,,,
COIL EMB L18CM OD6MM 10 STRTCH RESIST FRAMING FIL FNSH,SUP-2305176,CDM,C1889,HCPCS,0278,RC,,,,both,,,4772.80,3102.32,,,,,,,,,,,,,
HC So Endomysial Antibody Each Immunoglobulin Class,PX-3028623166,CDM,86231,CPT,0302,RC,,,,both,,,36.00,23.40,,,,,,,,,,,,,
INSERTER SURG CAP FOR AG FEM NAT NAIL SYS,SUP-2198679,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1241.93,807.25,,,,,,,,,,,,,
BAR EXT FIX CRV 11X210 MM CARBON XTRAFIX,SUP-2534564,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1645.58,1069.63,,,,,,,,,,,,,
PLATE BNE SM THK0.3MM STD UNIV CRANIOMAXILLOFACIAL TI,SUP-2366223,CDM,C1713,HCPCS,0278,RC,,,,both,,,2465.25,1602.41,,,,,,,,,,,,,
HC Unlisted Procedure Nervous System,PX-3616499900,CDM,64999,CPT,0361,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
MORPHINE SULFATE (CONCENTRATE) 100 MG/5ML PO SOLN,RX-117786,CDM,340b,HCPCS,0637,RC,00054-0517-44,NDC,,both,0.125,ML,2.70,1.75,,,,,,,,,,,,,
COLLAR CERV CNTOUR LG 22.5X4.5 IN 15-20 IN MED FOAM PROCARE,SUP-2196862,CDM,L0180,HCPCS,0272,RC,,,,both,,,9.01,5.86,,,,,,,,,,,,,
WASHER SPNL DIA17MM TI BTTRS SYS FIX,SUP-2292220,CDM,C1713,HCPCS,0278,RC,,,,both,,,657.20,427.18,,,,,,,,,,,,,
IMPLANT RAD SZ 1 RT,SUP-2243498,CDM,C1776,CPT,0278,RC,,,,both,,,21706.73,14109.37,,,,,,,,,,,,,
KIT PROS SPHIN CONN CUF SZR BLNT NDL TBNG IMP,SUP-2140265,CDM,C1815,HCPCS,0278,RC,,,,both,,,1648.50,1071.52,,,,,,,,,,,,,
SLEEVE TIB L7CM PROX KNEE FOR ORTH SALV SYS,SUP-2406465,CDM,C1776,CPT,0278,RC,,,,both,,,11289.87,7338.42,,,,,,,,,,,,,
COMPONENT FEM HIP UPLR CEM LO DEMAND KT,SUP-2347954,CDM,C1776,CPT,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
ATTACHMENT BUR MTL CUT LEGEND MIDAS REX,SUP-2284670,CDM,C1713,HCPCS,0278,RC,,,,both,,,5473.71,3557.91,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED CUP HD LNR ST POROUS XLPE CERM,SUP-2212319,CDM,C1776,CPT,0278,RC,,,,both,,,16068.26,10444.37,,,,,,,,,,,,,
PLATE BNE W10XL56MM THK1.2MM 90DEG 4X4 H BILAT S STL T SHP,SUP-2185866,CDM,C1713,HCPCS,0278,RC,,,,both,,,935.34,607.97,,,,,,,,,,,,,
GRAFT DERM 4CMX7CM THCK 0.4-0.8MM MTRX HUM TISS ACELLULAR,SUP-2306895,CDM,C1762,CPT,0278,RC,,,,both,,,1689.70,1098.30,,,,,,,,,,,,,
GRAFT TISS FRZ DRY CORT BLK 9X11 X 11MM CRNRSTN SR,SUP-2293783,CDM,C1713,HCPCS,0278,RC,,,,both,,,3611.00,2347.15,,,,,,,,,,,,,
CATHETER THROMCTMY ZELANTEDVT CLOTHUNTER L 105 CM DIA 8 FR,SUP-2867276,CDM,C1757,HCPCS,0272,RC,,,,both,,,19562.20,12715.43,,,,,,,,,,,,,
PIN BNE FIX MED SHOULDERED CADENCE,SUP-2933381,CDM,C1713,HCPCS,0278,RC,,,,both,,,382.83,248.84,,,,,,,,,,,,,
TUBE MYR 127MM DIAM VENT SIL DURAVENT,SUP-2313728,CDM,L8699,HCPCS,0278,RC,,,,both,,,51.03,33.17,,,,,,,,,,,,,
SET IMPL GRPHC CA INSTR W/ DRL BIT COUNTSINK SCR HNDL SL,SUP-2183070,CDM,C1713,HCPCS,0278,RC,,,,both,,,113747.44,73935.84,,,,,,,,,,,,,
GRAFT VASC HEMSHLD PLAT L 30 CM DIA 7 MM POLYESTER BOV CLLGN,SUP-2491622,CDM,C1768,CPT,0278,RC,,,,both,,,1877.75,1220.54,,,,,,,,,,,,,
PLATE BNE L W10.1XL182MM THK3.5MM 13 H BILAT S STL STR RIG,SUP-2186221,CDM,C1713,HCPCS,0278,RC,,,,both,,,1821.86,1184.21,,,,,,,,,,,,,
BLADE SURG SHT MOD STBL ISCHIAL SCR,SUP-2403456,CDM,C1776,CPT,0278,RC,,,,both,,,3543.18,2303.07,,,,,,,,,,,,,
WIRE ORTH TROCHANTERIC S STL L24IN OD.048IN,SUP-2342789,CDM,C1713,HCPCS,0278,RC,,,,both,,,237.57,154.42,,,,,,,,,,,,,
GRAFT TISS FRZN ALLGRFT SHFT FEM STRUCTURAL 100MM,SUP-2307347,CDM,C1762,CPT,0278,RC,,,,both,,,3309.75,2151.34,,,,,,,,,,,,,
STALIF TT IMPL H11 MM 8 DEG LORDTC MIDLN 5.5X 25 MM 4 SCR,SUP-2320302,CDM,C1889,HCPCS,0278,RC,,,,both,,,25434.00,16532.10,,,,,,,,,,,,,
ALLOGRAFT BNE 10 CC FD DEMINERALIZED CORTICAL FLEXIGRAFT,SUP-2740949,CDM,C1713,HCPCS,0278,RC,,,,both,,,2746.40,1785.16,,,,,,,,,,,,,
FORCEPS LAPSCP L310MM OD10MM DISECT RT ANG DBL ACT W/ RATCH,SUP-2332845,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3262.46,2120.60,,,,,,,,,,,,,
CATHETER DRAINAGE EXPEL L 25 CM DIA14 FR FLEXITHANE HYDRPHLC,SUP-2652767,CDM,C1729,HCPCS,0272,RC,,,,both,,,276.32,179.61,,,,,,,,,,,,,
PASSER SUTURE HUMPBACK 16 MM FLUSHPORT SCORPION,SUP-2849257,CDM,2720000010,LOCAL,0272,RC,,,,both,,,12230.30,7949.69,,,,,,,,,,,,,
SCREW INTFR L23MM DIA8MM BIOCRYL RAPIDE ABSRB MILAGRO ADV,SUP-2249509,CDM,C1713,HCPCS,0278,RC,,,,both,,,1698.74,1104.18,,,,,,,,,,,,,
BLADE SURG HK ANGLED ENDOTRAC 2055A6,SUP-2459363,CDM,2720000010,LOCAL,0272,RC,,,,both,,,525.76,341.74,,,,,,,,,,,,,
NAIL IM TIB 9X255 MM TI STRL TNADVANCED,SUP-2789171,CDM,C1713,HCPCS,0278,RC,,,,both,,,4559.15,2963.45,,,,,,,,,,,,,
STRAP CORRECT PD VARUS VALGUS,SUP-2388177,CDM,L2270,HCPCS,0272,RC,,,,both,,,136.24,88.56,,,,,,,,,,,,,
CATHETER GUID AXS CATLYST 7 L 125 CM PROX/DSTL OD,SUP-2715844,CDM,C1887,HCPCS,0272,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
INTRODUCER TUBE SET 6.5/7/7.5/8 MM MULTI PERC TY W/ PHAR,SUP-2759710,CDM,C1769,HCPCS,0272,RC,,,,both,,,1791.37,1164.39,,,,,,,,,,,,,
PLATE BNE W13.5XL134MM THK4.2MM 7 H BILAT S STL NAR LOK,SUP-2185238,CDM,C1713,HCPCS,0278,RC,,,,both,,,1218.01,791.71,,,,,,,,,,,,,
ICD COBALT XT DR MRI DF1 2 CHMBR,SUP-2582921,CDM,C1721,HCPCS,0275,RC,,,,both,,,46237.94,30054.66,,,,,,,,,,,,,
PLATE BONE L RT GLD 3D ORBIT FLR FOR 1.2MM SCR,SUP-2363677,CDM,C1713,HCPCS,0278,RC,,,,both,,,4249.96,2762.47,,,,,,,,,,,,,
"HC So Helminth, Nos",PX-3028668266,CDM,86682,CPT,0302,RC,,,,both,,,268.00,174.20,,,,,,,,,,,,,
SCREW BONE L46MM DIA5MM L HDLSS COMPR FULL THRD,SUP-2122563,CDM,C1713,HCPCS,0278,RC,,,,both,,,1491.50,969.47,,,,,,,,,,,,,
SM FRAG PLT STERILIZER 3.5X61 MM 5 HL,SUP-2820735,CDM,C1713,HCPCS,0278,RC,,,,both,,,1050.80,683.02,,,,,,,,,,,,,
SYSTEM FIX 16X14X8 MM CERV SPINE UNISON-C,SUP-2335268,CDM,C1713,HCPCS,0278,RC,,,,both,,,8792.00,5714.80,,,,,,,,,,,,,
SCREW BONE L28MM DIA2.7MM CORT DSTL RAD NONLOCKING FULL THRD,SUP-2136252,CDM,C1713,HCPCS,0278,RC,,,,both,,,169.56,110.21,,,,,,,,,,,,,
IMPLANT BRST 450CC DIA13.6CM P4.2CM SIL GEL SMOOTH RND MOD,SUP-2300347,CDM,C1789,HCPCS,0278,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
STENT CAR 7X40 MM ENROUTE,SUP-2431179,CDM,C1884,HCPCS,0278,RC,,,,both,,,8098.06,5263.74,,,,,,,,,,,,,
RELOAD STPLR 45 MM FOR SIGNIA INTELLIGENT LD UNIT,SUP-2858009,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1762.95,1145.92,,,,,,,,,,,,,
GUIDEWIRE VASC L450MM NIT BLNT CDH LONGITUDE,SUP-2279589,CDM,C1769,HCPCS,0272,RC,,,,both,,,221.94,144.26,,,,,,,,,,,,,
BLADE SAW L 73 X W 7 MM L 12.5 MM BROAD RASP SM RECIP FOR,SUP-2929559,CDM,2720000010,LOCAL,0272,RC,,,,both,,,821.80,534.17,,,,,,,,,,,,,
BIT TWST DRL L66MM DIA1.2MM STP 10MM ADD ON QUIK CPL SHFT,SUP-2267823,CDM,2720000010,LOCAL,0272,RC,,,,both,,,291.39,189.40,,,,,,,,,,,,,
SHEEHY CLLR BTTN VENT TUBE 127MM ID FLRPLSTC 50 PACK,SUP-2680287,CDM,L8699,HCPCS,0278,RC,,,,both,,,22.51,14.63,,,,,,,,,,,,,
STEM FEM CLLRD PRSS FIT LO OFFSET FORGED CO CHROM SZ 0,SUP-2221735,CDM,C1776,CPT,0278,RC,,,,both,,,15448.80,10041.72,,,,,,,,,,,,,
KIT INTRO L14CM DIA11FR GWIRE L50CM DIA0.038IN NDL 18GA,SUP-2357067,CDM,C1892,HCPCS,0272,RC,,,,both,,,122.46,79.60,,,,,,,,,,,,,
COVER BUR H DIA20MM CRANIOMAXILLOFACIAL PLT LO PROF W/ TAB,SUP-2366207,CDM,C1713,HCPCS,0278,RC,,,,both,,,741.45,481.94,,,,,,,,,,,,,
SUPPORT KNEE OPN PAT SM KNEE NEOPRNE,SUP-2195466,CDM,L1810,HCPCS,0274,RC,,,,both,,,12.25,7.96,,,,,,,,,,,,,
HC Joint Injection/Aspir Large WO US,PX-5102061000,CDM,20610,CPT,0510,RC,,,,inpatient,,,1092.00,709.80,,,,,,,,,,,,,
SHEATH INTRO PERFRMR L 13 CM OD 8 FR ID 2.6 MM DIL L 20 CM,SUP-2168227,CDM,C1894,HCPCS,0272,RC,,,,both,,,45.91,29.84,,,,,,,,,,,,,
BIT DRL L40MM DIA2.7MM DISP FOR PROX ULNA PLT DST EL SET,SUP-2340183,CDM,2720000010,LOCAL,0272,RC,,,,both,,,200.96,130.62,,,,,,,,,,,,,
SPLINT WR AD L FOR 7.5-8.5IN STRP L4IN VENT ELAS,SUP-2324481,CDM,L3908,HCPCS,0272,RC,,,,both,,,44.15,28.70,,,,,,,,,,,,,
PLATE BNE LT FIFTH METATRSL SPRL,SUP-2896522,CDM,C1713,HCPCS,0278,RC,,,,both,,,3921.86,2549.21,,,,,,,,,,,,,
PLATE BNE EXT BUTTERFLY MID/FLAT FT,SUP-2222608,CDM,C1713,HCPCS,0278,RC,,,,both,,,6028.80,3918.72,,,,,,,,,,,,,
PLATE BNE L246MM 8 H HIP S STL 8 BND CBL RDY,SUP-2410269,CDM,C1713,HCPCS,0278,RC,,,,both,,,2545.97,1654.88,,,,,,,,,,,,,
SHOE ORTHOT ADDITION INSOLE LTHR,SUP-2435737,CDM,L3500,HCPCS,0272,RC,,,,both,,,82.77,53.80,,,,,,,,,,,,,
"HC Laryngoscopy,Indirect,Dx",PX-4503150500,CDM,31505,CPT,0450,RC,,,,both,,,214.00,139.10,,,,,,,,,,,,,
TROCAR SURG L150MM DIA12MM DIL TIP STBL SL FOR WRK PRT,SUP-2218907,CDM,2720000010,LOCAL,0272,RC,,,,both,,,770.37,500.74,,,,,,,,,,,,,
CEFTRIAXONE SODIUM 2 G SOLR (MIXTURES ONLY),RX-430030,CDM,J0696,HCPCS,0636,RC,00409-7336-04,NDC,,both,1,UN,54.10,35.16,,,,,,,,,,,,,
CATHETER VENT DRNGE L15CM DOTTED ROUNDEDXRAY DTECT TANT TIP,SUP-2243778,CDM,C1729,HCPCS,0272,RC,,,,both,,,1022.95,664.92,,,,,,,,,,,,,
RAVULIZUMAB-CWVZ 300 MG/3ML IV SOLN|DISCARDED DRUG NOT ADMINISTE,RX-152086,CDM,J1303,HCPCS,0636,RC,25682-0025-01,NDC,JW,both,3,ML,19269.70,12525.30,,,,,,,,,,,,,
CANNULA ENDOSCP 11GA L120MM SIDE DEL ACCUPORT,SUP-2414252,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1494.64,971.52,,,,,,,,,,,,,
CORT SCREW 70MM 3.5,SUP-2818702,CDM,C1713,HCPCS,0278,RC,,,,both,,,300.31,195.20,,,,,,,,,,,,,
ANCHOR SUT 23MM 12MM 1 STRND SELF PUNCHING ICONIX,SUP-2362562,CDM,C1713,HCPCS,0278,RC,,,,both,,,3359.80,2183.87,,,,,,,,,,,,,
GRAFT VASC IMPRA L 10 CM DIA13 MM EPTFE STR STD WALL LG,SUP-2761248,CDM,C1768,CPT,0278,RC,,,,both,,,751.53,488.49,,,,,,,,,,,,,
CLAMP EXT FIX 4 POS MULTIPIN,SUP-2188524,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1873.64,1217.87,,,,,,,,,,,,,
LEVER ROD,SUP-2232112,CDM,C1713,HCPCS,0278,RC,,,,both,,,3987.80,2592.07,,,,,,,,,,,,,
GRAFT BNE TEND PALMARIS LONGUS MUSCLE,SUP-2321739,CDM,C1762,CPT,0278,RC,,,,both,,,5495.00,3571.75,,,,,,,,,,,,,
CATHETER CARD ABLATION RF MARINR MC L 110 CM DIA 7 FR TIP L,SUP-2749540,CDM,C1732,HCPCS,0278,RC,,,,both,,,1805.50,1173.57,,,,,,,,,,,,,
KIT BONE GRFT SUB 3CC END DEL CANN NDL 11GA L120MM COMPLT FT,SUP-2208436,CDM,C1713,HCPCS,0278,RC,,,,both,,,7771.50,5051.47,,,,,,,,,,,,,
TUBE SET TRUVIC,SUP-2855180,CDM,2720000010,LOCAL,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
IMMOBILIZER KNEE UNIV L19IN FOR 12-24IN THGH FOAM T BAR,SUP-2336080,CDM,L1830,CPT,0274,RC,,,,both,,,46.91,30.49,,,,,,,,,,,,,
HC Rm Private OB,PX-1120000000,CDM,1120000000,LOCAL,0112,RC,,,,inpatient,,,2515.00,1634.75,,,,,,,,,,,,,
CABLE EP CATH INQUIRY L 110 CM DIA 6 FR SPC 2-5-2 MM STEER,SUP-2677781,CDM,C1730,HCPCS,0272,RC,,,,both,,,578.80,376.22,,,,,,,,,,,,,
SCREW SPNL MULTAXL 9X100 MM BLLST,SUP-2423589,CDM,C1713,HCPCS,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
BUMETANIDE 1 MG PO TABS,RX-9310,CDM,6370000000,HCPCS,0637,RC,50268-0131-15,NDC,,both,1,UN,4.50,2.92,,,,,,,,,,,,,
COIL EMB 10 L6CM OD3MM HELCL STRTCH RESIST FNSH HYDRGEL,SUP-2305152,CDM,C1889,HCPCS,0278,RC,,,,both,,,4490.20,2918.63,,,,,,,,,,,,,
SCREW BNE L24MM DIA2.7MM LOK FOR R3CON PLATING SYS GORILLA,SUP-2321284,CDM,C1713,HCPCS,0278,RC,,,,both,,,907.46,589.85,,,,,,,,,,,,,
SCREW INTFR 11MM 35MM 1MM CANN KNEE ABSRB POLY L LACTIC ACID,SUP-2366523,CDM,C1713,HCPCS,0278,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
CAGE SPNL 15 DEG 45X22X10 MM COHERE XLW,SUP-2736439,CDM,C1889,HCPCS,0278,RC,,,,both,,,16799.00,10919.35,,,,,,,,,,,,,
PLATE BNE L123MM 7 H ST R SUP ANT CLAV TI LOK COMPR W LAT,SUP-2180869,CDM,C1713,HCPCS,0278,RC,,,,both,,,3285.51,2135.58,,,,,,,,,,,,,
KIT PLT CONC SYS MINI W/ ACD A AND BD SEP TB TRNQT ALC PREP,SUP-2402586,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
CATHETER CV TRPL LUMEN 5 FRX55 CM BASIC KT TCS POWERPICC HF,SUP-2759203,CDM,C1751,HCPCS,0278,RC,,,,both,,,1250.98,813.14,,,,,,,,,,,,,
SCREW SPNL L10MM OD4MM CERV VAR ANG THRD,SUP-2353289,CDM,C1713,HCPCS,0278,RC,,,,both,,,219.80,142.87,,,,,,,,,,,,,
CATHETER CTRL VEN 5FR 16CM LEN SGL LUMN N TUNNELED BASIC KT,SUP-2120594,CDM,C1751,HCPCS,0278,RC,,,,both,,,89.49,58.17,,,,,,,,,,,,,
CATHETER DRAINAGE 26X49 MMX35 CM VENTRICULAR LUERLOCK CONN,SUP-2284403,CDM,C1729,HCPCS,0272,RC,,,,both,,,407.32,264.76,,,,,,,,,,,,,
PLATE BNE 17 H MIDFOOT S STL BILAT VAR ANG LOK COMPR FOR,SUP-2184814,CDM,C1713,HCPCS,0278,RC,,,,both,,,5144.61,3344.00,,,,,,,,,,,,,
GUIDEWIRE UROLOGICAL STR 3 CM 0.035 INX150 CM EZ GLIDER,SUP-2312667,CDM,C1769,HCPCS,0272,RC,,,,both,,,110.21,71.64,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED CEM DURAC SCORP,SUP-2365623,CDM,C1776,CPT,0278,RC,,,,both,,,9411.02,6117.16,,,,,,,,,,,,,
SYSTEM PREPPING PRE-OP SING WRAP 2%CHLORHEXIDINE GLUCO 7.5,SUP-2110449,CDM,V2632,HCPCS,0276,RC,,,,both,,,15.64,10.17,,,,,,,,,,,,,
GRAFT BIO TISS W7XL10CM HIATAL HERN PRESHAPED BIODESIGN,SUP-2170065,CDM,C1763,HCPCS,0278,RC,,,,both,,,5209.26,3386.02,,,,,,,,,,,,,
GRAFT DERMAL MESH 2X2 CM FEN WND MTRX MIRODERM,SUP-2431546,CDM,Q4175,HCPCS,0636,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
BLADE SCREWDRIVER 1.5X58 MM CENTRE DRV RATCHETED MAX-DRIVE,SUP-2457260,CDM,2720000010,LOCAL,0272,RC,,,,both,,,757.62,492.45,,,,,,,,,,,,,
TUBE BYPS 8 MM SALIVARY CLR MONTGOMERY,SUP-2139774,CDM,2720000010,LOCAL,0272,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
ALLOGRAFT BNE FD IRRADIATED RT WHL FIBULAR,SUP-2867168,CDM,C1762,CPT,0278,RC,,,,both,,,4832.46,3141.10,,,,,,,,,,,,,
ALLOGRAFT BNE 5MM SPCR CERV CORT,SUP-2364361,CDM,C1889,HCPCS,0278,RC,,,,both,,,4504.33,2927.81,,,,,,,,,,,,,
PLATE BNE L 34 MM SCREW DIA2.7 MM 4 SHFT H SS COMPACT STR VA NS,SUP-2911959,CDM,C1713,HCPCS,0278,RC,,,,both,,,3193.16,2075.55,,,,,,,,,,,,,
HC 25 Hydroxy Includes Fractions if Performed|NOT REASONABLE AND NECESSARY,PX-3018230600,CDM,82306,CPT,0301,RC,,,GZ,both,,,233.00,151.45,,,,,,,,,,,,,
PLATE BONE 7 H TI BROAD HYBRID COMPR FOR 4.5MM SCR ALPS,SUP-2413751,CDM,C1713,HCPCS,0278,RC,,,,both,,,1140.13,741.08,,,,,,,,,,,,,
SPLINT WRST FA L INSTABILITY INJ LOOP LOK FIRM SUPP VYN STRP,SUP-2276619,CDM,L3908,HCPCS,0272,RC,,,,both,,,15.86,10.31,,,,,,,,,,,,,
HC Mra Pelvis Without Contrast,PX-6100891900,CDM,C8919,CPT,0610,RC,,,,both,,,4365.00,2837.25,,,,,,,,,,,,,
PIN FIX L9IN DIA28MM ST S STL 3 SIDE DBL TRCR BOTH END PNT,SUP-2150526,CDM,C1713,HCPCS,0278,RC,,,,both,,,25.78,16.76,,,,,,,,,,,,,
CHANLDRY 10 COLONODUODENOSIFGASTRO CONN,SUP-2728887,CDM,C1713,HCPCS,0278,RC,,,,both,,,18473.75,12007.94,,,,,,,,,,,,,
ANCHOR SUT 93CM 5MM WHT 2 QUICKDRAW MINI BELAY,SUP-2399088,CDM,C1713,HCPCS,0278,RC,,,,both,,,2229.40,1449.11,,,,,,,,,,,,,
ELECTRODE ELECSURG DISPER RITA,SUP-2752471,CDM,2720000010,LOCAL,0272,RC,,,,both,,,536.94,349.01,,,,,,,,,,,,,
POST EXT FIX FEMALE 4 HOLE,SUP-2471881,CDM,2720000010,LOCAL,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
MEGESTROL ACETATE 40 MG PO TABS,RX-4871,CDM,6370000000,HCPCS,0637,RC,00555-0607-02,NDC,,both,1,UN,3.20,2.08,,,,,,,,,,,,,
GUIDEWIRE ORTH DIA2 MM BALL TIP STRL -RSFH,SUP-2881204,CDM,C1769,HCPCS,0272,RC,,,,both,,,464.72,302.07,,,,,,,,,,,,,
PLATE BNE LCK 3.5 MM 6 HOLE COMPR STRL ALPS LTX,SUP-2861815,CDM,C1713,HCPCS,0278,RC,,,,both,,,834.42,542.37,,,,,,,,,,,,,
BURR SRGCL 5.3MM DIA HEAD CRBDE TRPHNE CTTNG RED F/SPNE NEUR,SUP-2586374,CDM,2720000010,LOCAL,0272,RC,,,,both,,,543.91,353.54,,,,,,,,,,,,,
TAP BNE SPNL CANN QUIK CONN SEXTANT 45MM DIA,SUP-2290637,CDM,C1713,HCPCS,0278,RC,,,,both,,,1617.60,1051.44,,,,,,,,,,,,,
BOOT CAST XSM BLK UNISX AD SQ OPN TOE FOREFOOT CLSR HIGHER,SUP-2176231,CDM,L4386,HCPCS,0272,RC,,,,both,,,40.54,26.35,,,,,,,,,,,,,
MESH CRAN L 122 X W 122 MM THK 0.75 MM SCREW DIA1.7 MM PLLA,SUP-2883511,CDM,C1713,HCPCS,0278,RC,,,,both,,,13260.22,8619.14,,,,,,,,,,,,,
SYSTEM AUTOTRANSFUSION EMGCY CELL SALV,SUP-2280764,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2207.55,1434.91,,,,,,,,,,,,,
ANCHOR SUTURE ANK FIBERWIRE,SUP-2122818,CDM,C1776,CPT,0278,RC,,,,both,,,1648.50,1071.52,,,,,,,,,,,,,
SUPERMX COMPRESSION STAPLE 18WX15L,SUP-2814267,CDM,C1713,HCPCS,0278,RC,,,,both,,,6578.30,4275.89,,,,,,,,,,,,,
GUIDEWIRE VASC L 260 CM DIA 0.035 IN FLX TIP L 15 CM SS PTFE,SUP-2638690,CDM,C1769,HCPCS,0272,RC,,,,both,,,185.45,120.54,,,,,,,,,,,,,
TUBING SET SUC IRR W/ EXCHG TIP FOR ROSI SYS STRL LTX,SUP-2865325,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2584.22,1679.74,,,,,,,,,,,,,
CAGE SPNL W10XH12XL22MM SELF EXP,SUP-2354933,CDM,C1889,HCPCS,0278,RC,,,,both,,,12560.00,8164.00,,,,,,,,,,,,,
HC So Cea|NOT REASONABLE AND NECESSARY,PX-3018237866,CDM,82378,CPT,0301,RC,,,GZ,both,,,67.00,43.55,,,,,,,,,,,,,
HC So 17-Hydroxyprogesterone,PX-3018349866,CDM,83498,CPT,0301,RC,,,,inpatient,,,553.00,359.45,,,,,,,,,,,,,
PLATE BNE UNIV 5TH METATARSAL HK,SUP-2123143,CDM,C1713,HCPCS,0278,RC,,,,both,,,2904.50,1887.92,,,,,,,,,,,,,
STAPLER XL L26CM ULT UNIV HNDL ENDO GIA,SUP-2283271,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1163.84,756.50,,,,,,,,,,,,,
STENT PERIPH L50MM DIAM 6MM CATH L120CM VASC,SUP-2396484,CDM,C1874,HCPCS,0278,RC,,,,both,,,7693.00,5000.45,,,,,,,,,,,,,
STENT BILI PALMAZ XL L 40 MM DIA10 MM SHTH 10 FR SS TRNSHEP,SUP-2158992,CDM,C1877,HCPCS,0278,RC,,,,both,,,3264.03,2121.62,,,,,,,,,,,,,
CANNULA ARTHSCP SPNL NANO KT DISP,SUP-2937189,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1397.30,908.24,,,,,,,,,,,,,
SCREW INTRF L10MM OD3MM LACTOSORB COPOLYMER POLY L LACTIC,SUP-2137286,CDM,C1713,HCPCS,0278,RC,,,,both,,,1092.72,710.27,,,,,,,,,,,,,
CRYOABLATION KIT PROST RENAL ICEROD +,SUP-2225660,CDM,C2618,HCPCS,0272,RC,,,,both,,,11702.00,7606.30,,,,,,,,,,,,,
SCREW BNE 2.7MMX12MM CORT N CANN FULL THRD N ST DRL N LOK,SUP-2411013,CDM,C1713,HCPCS,0278,RC,,,,both,,,57.96,37.67,,,,,,,,,,,,,
TUBE EAR VENT ARMSTRONG GROM 1.14 MM FLUROPLAST BLUE STERILE,SUP-2866539,CDM,L8699,HCPCS,0278,RC,,,,both,,,116.49,75.72,,,,,,,,,,,,,
BLADE RTRCTR BLFR 3 1/2ND ABDMNL WIRE LTRL JARIT NON ST,SUP-2483288,CDM,2720000010,LOCAL,0272,RC,,,,both,,,346.47,225.21,,,,,,,,,,,,,
WASHER ORTH FOR 4 MM CANN SCREW STRL,SUP-2788653,CDM,C1713,HCPCS,0278,RC,,,,both,,,106.13,68.98,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL PEEK SD800.543,SUP-2860224,CDM,C1713,HCPCS,0278,RC,,,,both,,,46228.34,30048.42,,,,,,,,,,,,,
VALVE MITRL OPN PVT AP360 DIA24 MM ORIFICE 22.8 MM TISS,SUP-2278413,CDM,C1889,HCPCS,0278,RC,,,,both,,,9840.76,6396.49,,,,,,,,,,,,,
SCREW BONE L6MM DIA1.5MM STD CORT HEX HD ECT,SUP-2205632,CDM,C1713,HCPCS,0278,RC,,,,both,,,34.54,22.45,,,,,,,,,,,,,
SCREW BNE L55MM DIA35MM STD CORT TI DST FEM ST NONCANNULATED,SUP-2204958,CDM,C1713,HCPCS,0278,RC,,,,both,,,289.79,188.36,,,,,,,,,,,,,
IMPLANT COSMETIC SZ 95 X 58 X 4.5 MM POLYETHYL CRAN STRL,SUP-2935409,CDM,C1713,HCPCS,0278,RC,,,,both,,,3868.48,2514.51,,,,,,,,,,,,,
CATHETER DRNGE ABSC ALL PURP TIGHT LOOP SET W/ TEMP TIP,SUP-2147896,CDM,C2617,HCPCS,0278,RC,,,,both,,,421.61,274.05,,,,,,,,,,,,,
SET ORTH TRAC 43-66CM CRWN FULL ASMBLY BREMER HALO SYS,SUP-2255680,CDM,C1713,HCPCS,0278,RC,,,,both,,,2072.40,1347.06,,,,,,,,,,,,,
SCREW BNE L45MM DIA6.5MM HD FOR FRAC REP AND FIX OSTEOTMY,SUP-2175054,CDM,C1713,HCPCS,0278,RC,,,,both,,,1907.55,1239.91,,,,,,,,,,,,,
GRAFT SPCR SPNL IMPL C RNG 5MM ALLOCRAFT,SUP-2364344,CDM,C1713,HCPCS,0278,RC,,,,both,,,3903.74,2537.43,,,,,,,,,,,,,
CLINDAMYCIN (CLEOCIN) 6 MG/ML IVPB (PED) >/=50 ML,RX-4090064,CDM,J0737,HCPCS,0636,RC,00338-3410-50,NDC,,both,50,ML,54.10,35.16,,,,,,,,,,,,,
ELECTRODE ELECTROTHERAPY NIT MPLR L200MM VENOM,SUP-2366968,CDM,C1713,HCPCS,0278,RC,,,,both,,,6452.01,4193.81,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.405,SUP-2859969,CDM,C1713,HCPCS,0278,RC,,,,both,,,31372.05,20391.83,,,,,,,,,,,,,
NEEDLE RHOTON STRAIGHT 12 SEMI SHARP TITANIUM,SUP-2459728,CDM,2720000010,LOCAL,0272,RC,,,,both,,,465.66,302.68,,,,,,,,,,,,,
BIT DRL 2.7 MM FOR TOT WRST FUSION DISP,SUP-2852076,CDM,2720000010,LOCAL,0272,RC,,,,both,,,922.12,599.38,,,,,,,,,,,,,
HC Repr Smp Not Face >30cm,PX-4501200700,CDM,12007,CPT,0450,RC,,,,both,,,1445.00,939.25,,,,,,,,,,,,,
PLATE BONE L28MM 12 H TI NAR HYBRID COMPR FOR 4.5MM SCR ALPS,SUP-2413748,CDM,C1713,HCPCS,0278,RC,,,,both,,,990.20,643.63,,,,,,,,,,,,,
COIL NEUROVASCULAR CASHMERE 14 CERECYTE L 19 CM DIA12 MM,SUP-2457374,CDM,C1889,HCPCS,0278,RC,,,,both,,,6594.44,4286.39,,,,,,,,,,,,,
HC Cta Pelvis W & W/O Cont,PX-3527219100,CDM,72191,CPT,0352,RC,,,,both,,,3184.00,2069.60,,,,,,,,,,,,,
NEXGEN KNEE LPS OPT FEM SZ D RT,SUP-2201886,CDM,C1776,CPT,0278,RC,,,,both,,,7090.12,4608.58,,,,,,,,,,,,,
COLLAR EXTRIC PED 1.5IN FOR 8-18IN FR 1 PC FLAT LOK TAB CLS,SUP-2194417,CDM,L0120,HCPCS,0272,RC,,,,both,,,18.09,11.76,,,,,,,,,,,,,
AZITHROMYCIN 250 MG PO TABS,RX-20943,CDM,6370000000,HCPCS,0637,RC,42291-0082-30,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
BLADE RTRCTR JNNTTA 10MMW X 95MMD SPNL PSTRR FOSSA MAL,SUP-2491082,CDM,2720000010,LOCAL,0272,RC,,,,both,,,335.95,218.37,,,,,,,,,,,,,
SHUNT NEUROSURGICAL EXT 3.3X5 DIA P/D INLET 30CML SIL ELASTM,SUP-2615567,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2585.04,1680.28,,,,,,,,,,,,,
STENT CAR ENROUTE L 20 MM DIA 6 MM WORKING L 57 CM CROSSING,SUP-2431164,CDM,C1876,HCPCS,0278,RC,,,,both,,,7693.00,5000.45,,,,,,,,,,,,,
HC So Blood Typing Patient Serum,PX-3008690466,CDM,86904,CPT,0300,RC,,,,both,,,163.00,105.95,,,,,,,,,,,,,
SYSTEM BRST BX STD STEREOTACTIC NDL BREVERA,SUP-2572372,CDM,2720000010,LOCAL,0272,RC,,,,both,,,913.74,593.93,,,,,,,,,,,,,
QUARTEX INLINE HK,SUP-2228836,CDM,C1713,HCPCS,0278,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
DEVICE COMPR SM 1CM DIA38MM HI F SPINDLE,SUP-2406894,CDM,C1776,CPT,0278,RC,,,,both,,,11143.86,7243.51,,,,,,,,,,,,,
KYPHOPLASTY KIT BLLN 11 GAX10 MM FRAC IVAS ELITE DISP,SUP-2423878,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8607.02,5594.56,,,,,,,,,,,,,
DICYCLOMINE HCL 10 MG/ML IM SOLN,RX-2417,CDM,J0500,HCPCS,0636,RC,72266-0127-05,NDC,,both,1,ML,70.80,46.02,,,,,,,,,,,,,
CAGE SPNL SQ LNG 12X65 MM CERV VU MESH FOOT PRINT VUMESH,SUP-2707701,CDM,C1889,HCPCS,0278,RC,,,,both,,,17584.00,11429.60,,,,,,,,,,,,,
CANNULA ENDOSCP 30 CM W/ GUIDE KT TORQ CAP VAC PRT GUIDEWIRE,SUP-2866236,CDM,C1769,HCPCS,0272,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
BIT DRL TWST 5.75 INX146 MM CASPR ULTRA LF,SUP-2469658,CDM,2720000010,LOCAL,0272,RC,,,,both,,,505.85,328.80,,,,,,,,,,,,,
DEVICE FIX ARTICULATING RELD W/ 5 DP PURCH RELIATACK,SUP-2752197,CDM,C1713,HCPCS,0278,RC,,,,both,,,271.23,176.30,,,,,,,,,,,,,
WIRE FIX L450MM DIA2MM S STL DMND PNT DBL SHRP TIP SMOOTH K,SUP-2372600,CDM,C1713,HCPCS,0278,RC,,,,both,,,47.10,30.61,,,,,,,,,,,,,
KIT EXTN L40CM 1X8 NEUROSTIMULATOR FOR SPNL CRD STIM,SUP-2284455,CDM,C1883,HCPCS,0278,RC,,,,both,,,1868.30,1214.39,,,,,,,,,,,,,
CATHETER NEPHSTMY L35CM DIA20FR W/ 2 FLX STYL DRNGE BG CONN,SUP-2139307,CDM,C1729,HCPCS,0272,RC,,,,both,,,238.67,155.14,,,,,,,,,,,,,
MESH SURG W9XL15CM ABSRB BIO-A,SUP-2395751,CDM,C1781,HCPCS,0278,RC,,,,both,,,2292.20,1489.93,,,,,,,,,,,,,
INDOMETHACIN 50 MG PO CAPS,RX-3898,CDM,6370000000,HCPCS,0637,RC,50268-0431-11,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
CLAMP PERI ARTICULAR PIN,SUP-2678700,CDM,2720000010,LOCAL,0272,RC,,,,both,,,367.25,238.71,,,,,,,,,,,,,
RING EXT FIX FULL 180 MM CARBON FIBER NS,SUP-2799523,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3494.22,2271.24,,,,,,,,,,,,,
PLATE BNE LCK 142 MM LT DSTL LAT TIB PERIARTICULAR 10 HOLE,SUP-2474840,CDM,C1713,HCPCS,0278,RC,,,,both,,,4388.18,2852.32,,,,,,,,,,,,,
PROBE ABLATION L130MM TIP DIA4MM 90DEG CERAMIC ASPIRATING MONOPOLAR LOW PROFILE OPES,SUP-2123441,CDM,C1713,HCPCS,0278,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
STERILE WATER FOR INJECTION (MIXTURES ONLY),RX-430028,CDM,2500000003,HCPCS,0250,RC,63323-0185-10,NDC,,both,10,ML,54.10,35.16,,,,,,,,,,,,,
BIT DRL L180MM DIA4.3MM QUIK CPL W/O STP REUSE,SUP-2187279,CDM,2720000010,LOCAL,0272,RC,,,,both,,,338.90,220.28,,,,,,,,,,,,,
KIT STEERABLE LG VERSACROSS WIRE AND SHEATH,SUP-2525908,CDM,C1766,CPT,0272,RC,,,,both,,,5385.10,3500.31,,,,,,,,,,,,,
VALVE VENTRICULAR SHUNT L1.5CM OD2.8MM 0CM WATER PRESSURE VE,SUP-2821800,CDM,C1889,HCPCS,0278,RC,,,,both,,,2098.24,1363.86,,,,,,,,,,,,,
NEXGEN LPS ART SURF EF 3-4/STR YEL 17MM,SUP-2208733,CDM,C1776,CPT,0278,RC,,,,both,,,2413.40,1568.71,,,,,,,,,,,,,
SPLINT ORTHOPEDIC SLIP ON SM 8 IN LT WRST PLUSH FOAM LNR NYL,SUP-2276659,CDM,L3908,HCPCS,0274,RC,,,,both,,,17.05,11.08,,,,,,,,,,,,,
WASHER ORTH SM DIA7MM FLAT RND S STL FOR 2.7-3.5-4MM SCR,SUP-2411297,CDM,C1713,HCPCS,0278,RC,,,,both,,,66.25,43.06,,,,,,,,,,,,,
GRAFT BNE SUB 5CC DEMIN BNE MTRX PTTY OSTEOINDUCTIVE INJ,SUP-2306996,CDM,C9359,HCPCS,0278,RC,,,,both,,,2213.70,1438.90,,,,,,,,,,,,,
ENDOPROSTHESIS VASC VIABAHN L 10 CM DIA 8 MM NIT EPTFE LNR,SUP-2396483,CDM,C1874,HCPCS,0278,RC,,,,both,,,7693.00,5000.45,,,,,,,,,,,,,
REAMER SURG OD7MM HUM SHLDR STRL ACORN MILAGRO,SUP-2256777,CDM,2720000010,LOCAL,0272,RC,,,,both,,,960.84,624.55,,,,,,,,,,,,,
CIRCUIT VEN DRNGE W/ BUB TRAP EC BYPS PROC ANGIOVAC,SUP-2118780,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
PLATE EXT FIX L 115 MM 10 H SHRT CONN OVL SLOT NS DISP ILIZ,SUP-2932898,CDM,2720000010,LOCAL,0272,RC,,,,both,,,782.61,508.70,,,,,,,,,,,,,
PLATE BNE L262MM 14 H ST R MED DST TIB S STL VAR ANG LOK,SUP-2177649,CDM,C1713,HCPCS,0278,RC,,,,both,,,7046.66,4580.33,,,,,,,,,,,,,
SYSTEM RIGIDLOOP ADJ CORTICAL XL,SUP-2749358,CDM,C1713,HCPCS,0278,RC,,,,both,,,2408.38,1565.45,,,,,,,,,,,,,
SCREW BNE L 30 MM DIA2.4 MM SS CORTICAL T8 STARDRV SLV TUBE,SUP-2905714,CDM,C1713,HCPCS,0278,RC,,,,both,,,420.38,273.25,,,,,,,,,,,,,
SET NEUROSURGICAL 10MM BUMPER ST TRANSITION,SUP-2231440,CDM,C1776,CPT,0278,RC,,,,both,,,901.18,585.77,,,,,,,,,,,,,
STERILE WATER FOR INJECTION (MIXTURES ONLY),RX-430028,CDM,2500000003,HCPCS,0250,RC,00990-7990-09,NDC,,both,1000,ML,54.10,35.16,,,,,,,,,,,,,
PLATE BNE L 180 MM 12 H LT PROX HUM CRV STRL EVOS,SUP-2931244,CDM,C1713,HCPCS,0278,RC,,,,both,,,6153.14,3999.54,,,,,,,,,,,,,
SCREW CRAN 4PK L 4 MM DIA2.2 MM PLLA PGA PDLA RESRB STRL DELT,SUP-2883351,CDM,C1713,HCPCS,0278,RC,,,,both,,,1153.29,749.64,,,,,,,,,,,,,
PLATE BNE MINI WRST TI 4 CORNER LIMIT FUS MOD HUB CAP,SUP-2107844,CDM,C1713,HCPCS,0278,RC,,,,both,,,3573.32,2322.66,,,,,,,,,,,,,
STENT LARYNGEAL MONTGOMERY L 12 X W 10 X H 40 MM MED SIL,SUP-2138742,CDM,C1875,HCPCS,0278,RC,,,,both,,,562.06,365.34,,,,,,,,,,,,,
STERILE WATER FOR INJECTION (MIXTURES ONLY),RX-430028,CDM,2500000003,HCPCS,0250,RC,00338-0013-06,NDC,,both,2000,ML,54.10,35.16,,,,,,,,,,,,,
PLATE BNE L56MM THK1.3MM 2X8 H HND TI T SHP LOK TRILOK FOR,SUP-2267941,CDM,C1713,HCPCS,0278,RC,,,,both,,,3198.72,2079.17,,,,,,,,,,,,,
CATHETER CV SINGLE LUMEN 4 FR PWR INJ N COAT POWERPICC,SUP-2126700,CDM,C1751,HCPCS,0278,RC,,,,both,,,564.73,367.07,,,,,,,,,,,,,
CATHETER ETER URET OPN END 5 FR,SUP-2312755,CDM,C1758,HCPCS,0278,RC,,,,both,,,86.66,56.33,,,,,,,,,,,,,
CATHETER CRYOABLATION 28 MM ARCTIC FRONT ADVANCED,SUP-2460587,CDM,C1733,HCPCS,0272,RC,,,,both,,,14130.00,9184.50,,,,,,,,,,,,,
ANCHOR SUT 13MM HIP W 1 NO Y KNOT FLX,SUP-2167267,CDM,C1713,HCPCS,0278,RC,,,,both,,,1678.08,1090.75,,,,,,,,,,,,,
KIT DRN CANN 70MM W/ OBT SHRP TRCR,SUP-2361365,CDM,C1729,HCPCS,0272,RC,,,,both,,,2983.72,1939.42,,,,,,,,,,,,,
MESH MXLFCL 52X52 MM 0.6 MM FOIL PLLA-PGA STRL RESORB XG,SUP-2493356,CDM,C1713,HCPCS,0278,RC,,,,both,,,3354.87,2180.67,,,,,,,,,,,,,
PLATE BNE H0.6MM 6 H CRANIOMAXILLOFACIAL G TI CRV W/ BAR,SUP-2366253,CDM,C1713,HCPCS,0278,RC,,,,both,,,755.33,490.96,,,,,,,,,,,,,
TRIAMCINOLONE ACETONIDE 40 MG/ML IJ SUSP,RX-8120,CDM,J3301,HCPCS,0636,RC,00003-0293-05,NDC,,both,1,ML,54.10,35.16,,,,,,,,,,,,,
PLATE ROT CORR 2MM 2H HD 4H SHFT TI STRL LCP,SUP-2549722,CDM,C1713,HCPCS,0278,RC,,,,both,,,2946.61,1915.30,,,,,,,,,,,,,
PLATE BONE 130DEG 5 H SUPCNDYL S STL COMPR FRELOK,SUP-2197724,CDM,C1713,HCPCS,0278,RC,,,,both,,,1537.34,999.27,,,,,,,,,,,,,
CATHETER URET 4FR L70CM 0.028IN OPN END FLEXITIP FOR DRNGE,SUP-2171268,CDM,C1758,HCPCS,0278,RC,,,,both,,,55.95,36.37,,,,,,,,,,,,,
DEVICE ENDO L200CM SHTH OD1.9MM GRSP HYBRID JAW,SUP-2391615,CDM,2720000010,LOCAL,0272,RC,,,,both,,,359.69,233.80,,,,,,,,,,,,,
PLATE BNE FIBULAR 2.7X118 MM LT LAT DSTL 6 HOLE NS VA-LCP,SUP-2758198,CDM,C1713,HCPCS,0278,RC,,,,both,,,2834.54,1842.45,,,,,,,,,,,,,
BASEPLATE GLEN REVERSED SM SHLDR EQUINOXE,SUP-2451445,CDM,C1713,HCPCS,0278,RC,,,,both,,,4239.00,2755.35,,,,,,,,,,,,,
SCREW EBA ONE CEPHALIC,SUP-2714106,CDM,C1713,HCPCS,0278,RC,,,,both,,,2449.20,1591.98,,,,,,,,,,,,,
PLATE 4.5MM TI LCP TM PROX TIBIA 10H 190MM RIGHT STERILE,SUP-2549641,CDM,C1713,HCPCS,0278,RC,,,,both,,,5122.19,3329.42,,,,,,,,,,,,,
PLATE BONE L95MM 12 H MAND TI LCK FOR 2MM SCR,SUP-2191233,CDM,C1713,HCPCS,0278,RC,,,,both,,,3365.14,2187.34,,,,,,,,,,,,,
CATHETER ANGIOPLSTY 18 ATM 4 FRX190 CM 2.5X30 MM SABERX,SUP-2866053,CDM,C1725,HCPCS,0272,RC,,,,both,,,987.56,641.91,,,,,,,,,,,,,
SCREW INTRF BIOSURE REGENESORB 11MMX35MM,SUP-2341931,CDM,C1713,HCPCS,0278,RC,,,,both,,,1073.13,697.53,,,,,,,,,,,,,
GRAFT WDG IMPACTED FRZ DRY 12X20 TANGENT,SUP-2293768,CDM,C1713,HCPCS,0278,RC,,,,both,,,8173.42,5312.72,,,,,,,,,,,,,
PLATE BNE L85MM 6 H NONSTERILE R PROX TIB S STL LO PROF,SUP-2185811,CDM,C1713,HCPCS,0278,RC,,,,both,,,3579.73,2326.82,,,,,,,,,,,,,
BARICITINIB 1 MG PO TABS,RX-148124,CDM,6370000000,HCPCS,0637,RC,00002-4732-30,NDC,,both,1,UN,415.20,269.88,,,,,,,,,,,,,
LEVOFLOXACIN 750 MG PO TABS,RX-28964,CDM,6370000000,HCPCS,0637,RC,00904-6353-61,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
CATHETER ANGIOPLSTY OTW 0.035 IN 24 ATM 5 FRX135 CM 3X20 MM,SUP-2865912,CDM,C1725,HCPCS,0272,RC,,,,both,,,445.10,289.31,,,,,,,,,,,,,
PLATE BNE LAPIDUS 3.5/4 MM DORS MEDL NS LTX,SUP-2857063,CDM,C1713,HCPCS,0278,RC,,,,both,,,7583.10,4929.01,,,,,,,,,,,,,
COMPONENT TALAR SZ 2 RT ANK DOME SLOPED XT REV STRL,SUP-2933030,CDM,C1776,CPT,0278,RC,,,,both,,,33252.60,21614.19,,,,,,,,,,,,,
GRAFT BNE SUB 1.5CC RHPDGF-BB/-TCP FOR ANK HINDFOOT ARTH,SUP-2400114,CDM,C1713,HCPCS,0278,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
LEAD NERVE STIM 16C 60 CM LAMITRODE TRIPOLE,SUP-2615509,CDM,C1778,HCPCS,0278,RC,,,,both,,,12968.20,8429.33,,,,,,,,,,,,,
SPLINT ORTH D RNG CLOSURE UNIV 8 IN WRST FOREARM RT,SUP-2336336,CDM,L3809,HCPCS,0274,RC,,,,both,,,20.63,13.41,,,,,,,,,,,,,
CHISEL SURG EXTRACTION TIP NS,SUP-2800142,CDM,C1713,HCPCS,0278,RC,,,,both,,,636.42,413.67,,,,,,,,,,,,,
PLATE BNE L 80 X W 8 MM THK 3.2 MM SCREW DIA2.7 MM 10 H SS 72440110,SUP-2932759,CDM,C1713,HCPCS,0278,RC,,,,both,,,2496.93,1623.00,,,,,,,,,,,,,
GRAFT VASC STR STD WALL RING 8MM DIA 50CM LEN GORTX,SUP-2396016,CDM,C1768,CPT,0278,RC,,,,both,,,2351.86,1528.71,,,,,,,,,,,,,
CAGE SPNL L W14XH20XL16MM 0DEG CERV THORLUM C FBR POLYMER,SUP-2256203,CDM,C1889,HCPCS,0278,RC,,,,both,,,3030.23,1969.65,,,,,,,,,,,,,
GUIDEWIRE INTRMDLRY BALL TP SS 2.4MMX70CM,SUP-2460195,CDM,C1769,HCPCS,0272,RC,,,,both,,,507.14,329.64,,,,,,,,,,,,,
GENERATOR NEUROSTIMULATOR 16GM THK7MM VAGUS NRV SGL PIN,SUP-2265161,CDM,C1767,HCPCS,0278,RC,,,,both,,,85868.01,55814.21,,,,,,,,,,,,,
FAMOTIDINE 200 MG/20ML IV SOLN,RX-125407,CDM,J1308,HCPCS,0636,RC,67457-0457-20,NDC,,both,1,ML,54.10,35.16,,,,,,,,,,,,,
WASHER FOR NUT 17.5/11.8MM STERILE,SUP-2761699,CDM,C1713,HCPCS,0278,RC,,,,both,,,204.04,132.63,,,,,,,,,,,,,
DRILL SURG 75000 RPM I.D. TCH TECHNOLOGY KNURLED HSNG 8 SLOT,SUP-2898915,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1342.35,872.53,,,,,,,,,,,,,
HANDPIECE BPLR LG CRD,SUP-2227494,CDM,C1713,HCPCS,0278,RC,,,,both,,,9074.60,5898.49,,,,,,,,,,,,,
HC Trim Nondystrophic Nails,PX-4501171900,CDM,11719,CPT,0450,RC,,,,both,,,195.00,126.75,,,,,,,,,,,,,
CUP ACET OD49MM ID32MM ALL POLYETH CEM REFLCT,SUP-2345431,CDM,C1776,CPT,0278,RC,,,,both,,,2004.26,1302.77,,,,,,,,,,,,,
SHEARS ENDOSCP L23CM DIA5MM ULTRASONIC CRV TIP W/ ADV,SUP-2219105,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1206.98,784.54,,,,,,,,,,,,,
PROPOFOL 200 MG/20ML IV EMUL,RX-133090,CDM,J2704,HCPCS,0636,RC,63323-0269-25,NDC,,both,20,ML,54.10,35.16,,,,,,,,,,,,,
ADAPTER PIN HLDR 90DEG FISCHER,SUP-2414034,CDM,2720000010,LOCAL,0272,RC,,,,both,,,879.20,571.48,,,,,,,,,,,,,
RESERVOIR SHUNT L16MM OD20MM TITANIUM SET INTEGRATED L600MM,SUP-2830494,CDM,C1889,HCPCS,0278,RC,,,,both,,,1543.37,1003.19,,,,,,,,,,,,,
CATHETER NEPHSTMY L35CM OD14FR LCK PGTL M-DRAIN,SUP-2303559,CDM,C1729,HCPCS,0272,RC,,,,both,,,40.85,26.55,,,,,,,,,,,,,
BIT DRL J NOTCH 1.5X115 MM TWST MORRISON STYL DISP,SUP-2422297,CDM,2720000010,LOCAL,0272,RC,,,,both,,,597.60,388.44,,,,,,,,,,,,,
BOLT EXT FIX CLMP 2 PC FOR SCHNZ SCREW NS,SUP-2799565,CDM,2720000010,LOCAL,0272,RC,,,,both,,,700.00,455.00,,,,,,,,,,,,,
GRAFT DERMAL STRUCTURAL ULTRA THCK 16X8 CMX1.8-4 MM BRST KT,SUP-2307515,CDM,Q4128,HCPCS,0636,RC,,,,both,,,21866.65,14213.32,,,,,,,,,,,,,
PATCH DURAL SUBSTITUTE NON ABSORBABLE POLYURETHANE STERILE C,SUP-2821555,CDM,C1763,HCPCS,0278,RC,,,,both,,,2975.02,1933.76,,,,,,,,,,,,,
ALLOGRAFT BNE STRP 35X60 MM PRESERVON TRICORT MATRIGRAFT,SUP-2740792,CDM,C1713,HCPCS,0278,RC,,,,both,,,7687.32,4996.76,,,,,,,,,,,,,
COLLAR CERV M W4XL21IN FIRM FOAM SERP STYL WSH,SUP-2276597,CDM,L0120,HCPCS,0272,RC,,,,both,,,7.38,4.80,,,,,,,,,,,,,
PLATE BNE FIBULAR 2.7X209 MM RT LAT DSTL 13 HOLE NS VA-LCP,SUP-2758205,CDM,C1713,HCPCS,0278,RC,,,,both,,,3523.58,2290.33,,,,,,,,,,,,,
PROBE ARTHSCP BLU INTEGR CBL DYONIC EFLEX TACS,SUP-2341731,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1758.40,1142.96,,,,,,,,,,,,,
FIBER HOLM LSR SIDE FIRING,SUP-2225717,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2182.30,1418.49,,,,,,,,,,,,,
PLATE BNE L 180 X W 10.5 MM THK 3 MM SCREW DIA2.7/3.5 MM 14 72466614,SUP-2933040,CDM,C1713,HCPCS,0278,RC,,,,both,,,6297.90,4093.63,,,,,,,,,,,,,
FOLLOWER URO 26FR L36CM PLAS STR TIP THRD DISP PHIL,SUP-2384627,CDM,C1726,HCPCS,0272,RC,,,,both,,,79.25,51.51,,,,,,,,,,,,,
BIT DRL L50MM OD1.2MM STP D6.0MM,SUP-2364176,CDM,2720000010,LOCAL,0272,RC,,,,both,,,482.96,313.92,,,,,,,,,,,,,
SCREW CORTICAL 3.5X30MM,SUP-2198417,CDM,C1713,HCPCS,0278,RC,,,,both,,,35.58,23.13,,,,,,,,,,,,,
COIL EMB 10 L12CM OD5MM COMPLX STRTCH RESIST FNSH V TRAK,SUP-2305170,CDM,C1889,HCPCS,0278,RC,,,,both,,,2882.52,1873.64,,,,,,,,,,,,,
CATHETER URET 5FR L120CM 0.038IN MOD OPN END,SUP-2168917,CDM,C1758,HCPCS,0278,RC,,,,both,,,32.66,21.23,,,,,,,,,,,,,
HC Assay of Uric Acid Other Source,PX-3018456000,CDM,84560,CPT,0301,RC,,,,both,,,149.00,96.85,,,,,,,,,,,,,
HC So Thyroglobulin,PX-3018443266,CDM,84432,CPT,0301,RC,,,,outpatient,,,63.00,40.95,,,,,,,,,,,,,
HC Culture Blood,PX-3008704000,CDM,87040,CPT,0300,RC,,,,both,,,344.00,223.60,,,,,,,,,,,,,
PLATE BONE L122MM 10 H POST LAT S STL 1/3 TBLR LCK COMPR FOR,SUP-2349798,CDM,C1713,HCPCS,0278,RC,,,,both,,,2820.41,1833.27,,,,,,,,,,,,,
PLATE BNE ANT MED R TIBIAXYS,SUP-2242998,CDM,C1713,HCPCS,0278,RC,,,,both,,,3762.03,2445.32,,,,,,,,,,,,,
HC Mlc Device(S) for Imrt,PX-3337733800,CDM,77338,CPT,0333,RC,,,,both,,,1593.00,1035.45,,,,,,,,,,,,,
PLATE BNE THK1MM 4 H CRANIOMAXILLOFACIAL TI MINI REG STR,SUP-2366313,CDM,C1713,HCPCS,0278,RC,,,,both,,,436.30,283.59,,,,,,,,,,,,,
L CONN PL 17 HLS 335MM LG,SUP-2853456,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2537.15,1649.15,,,,,,,,,,,,,
GRAFT BNE PTTY 5 CC CLLGN MOZAIK,SUP-2431103,CDM,C9359,HCPCS,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
PIN FIX DBL DIAMOND 0.141X9 IN THRD SS NS STEINMANN,SUP-2791388,CDM,C1713,HCPCS,0278,RC,,,,both,,,81.14,52.74,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY DECANAV L 115 CM 7 FR 2 MM F CRV,SUP-2248952,CDM,C1732,HCPCS,0272,RC,,,,both,,,2986.14,1940.99,,,,,,,,,,,,,
MARKER BRST BX L12CM OD18GA NITINOLXSHAPE INTRO FRE HND FOR,SUP-2239914,CDM,A4648,CPT,0278,RC,,,,both,,,2588.93,1682.80,,,,,,,,,,,,,
GRASPER ARTHSCP OD34MM STR SHFT BLNT TIP NONRATCHETING HNDL,SUP-2120910,CDM,C1713,HCPCS,0278,RC,,,,both,,,3124.30,2030.79,,,,,,,,,,,,,
HC Hand Routine Min 3 Views,PX-3207313000,CDM,73130,CPT,0320,RC,,,,both,,,623.00,404.95,,,,,,,,,,,,,
FLAT WASHER 5.0MM STERILE,SUP-2489432,CDM,C1713,HCPCS,0278,RC,,,,both,,,167.52,108.89,,,,,,,,,,,,,
SUPPORT ORTHOT KNEE CUST SWEDISH TYP,SUP-2435617,CDM,L1850,HCPCS,0274,RC,,,,both,,,806.57,524.27,,,,,,,,,,,,,
INSERT TIB BEAR SZ 4 THK16MM KNEE X3 CNDYL STABILIZING,SUP-2373218,CDM,C1776,CPT,0278,RC,,,,both,,,6057.06,3937.09,,,,,,,,,,,,,
ALLOGRAFT BNE DBM + CORTICAL 1 CC FD,SUP-2717768,CDM,C1713,HCPCS,0278,RC,,,,both,,,972.18,631.92,,,,,,,,,,,,,
TRIAL HD 45MM HUM BPLR,SUP-2372579,CDM,C1713,HCPCS,0278,RC,,,,both,,,1911.38,1242.40,,,,,,,,,,,,,
DEXTROSE 5 % IV SOLN INTERMITTENT INFUSION,RX-40840103,CDM,2580000003,HCPCS,0258,RC,00264-7510-00,NDC,,both,250,ML,8.50,5.52,,,,,,,,,,,,,
DRIVER SURG UNIV QUIK CONN T10 FOR VOLAR DST RAD PLATING,SUP-2340189,CDM,2720000010,LOCAL,0272,RC,,,,both,,,317.61,206.45,,,,,,,,,,,,,
BLADE LARYNGOSCOPE MACINTOSH 3 MED AD 130X22 MM GRNLN,SUP-2381520,CDM,2720000010,LOCAL,0272,RC,,,,both,,,121.49,78.97,,,,,,,,,,,,,
HOOK RETRCT KRAYENBUEHL SM 2.7 MM 7.25 IN NERVE BLNT TIP NS,SUP-2473668,CDM,2720000010,LOCAL,0272,RC,,,,both,,,205.70,133.70,,,,,,,,,,,,,
SCREW TITANIUM 3.5 X 8MM,SUP-2462166,CDM,C1713,HCPCS,0278,RC,,,,both,,,569.22,369.99,,,,,,,,,,,,,
SUPPORT ORTHOT LOWER EXTREMITY CUST BAR CHROM PLT NICKEL,SUP-2435694,CDM,L2750,HCPCS,0274,RC,,,,both,,,221.28,143.83,,,,,,,,,,,,,
MESH HERN RECT 12X8 IN MONOFILAMENT SCAFFOLD PHASIX,SUP-2736741,CDM,C1781,HCPCS,0278,RC,,,,both,,,25214.20,16389.23,,,,,,,,,,,,,
PLATE BNE HUM MED RT DSTL 5 HOLE SS NS LCP,SUP-2185887,CDM,C1713,HCPCS,0278,RC,,,,both,,,3648.18,2371.32,,,,,,,,,,,,,
GRAFT HUM TISS W4XL7CM THK08 17MM THCK ACELLULAR HYDRATED,SUP-2307467,CDM,Q4128,HCPCS,0636,RC,,,,both,,,2651.13,1723.23,,,,,,,,,,,,,
GRAFT BNE 25CC DBM CRUSH MIX PREHYDRATED TENSIX,SUP-2400563,CDM,C1713,HCPCS,0278,RC,,,,both,,,3733.46,2426.75,,,,,,,,,,,,,
BUR SURG LNG 3X20 MM MICA DISP,SUP-2398174,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1202.62,781.70,,,,,,,,,,,,,
PLATE BNE 2.7 MM W/ 1 MM STP NS LTX,SUP-2857022,CDM,C1713,HCPCS,0278,RC,,,,both,,,3158.84,2053.25,,,,,,,,,,,,,
ANCHOR SUTURE WITH THREE NO 2 HI FI SUTURES 17MM LENGTH 4.5M,SUP-2825103,CDM,C1713,HCPCS,0278,RC,,,,both,,,1528.55,993.56,,,,,,,,,,,,,
REAMER SURGICAL DIA2.7MM CANNULATED,SUP-2123474,CDM,2720000010,LOCAL,0272,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
GRAFT BNE FEM HD 4.5 CM W/O CART 6578411730] ZIMMER BIOMET INC],SUP-2210354,CDM,C1776,CPT,0278,RC,,,,both,,,8732.34,5676.02,,,,,,,,,,,,,
BOOT TRAC L L20IN FOR 18IN CALF CONVOLUTED FOAM LNR STAY,SUP-2196870,CDM,L4631,HCPCS,0274,RC,,,,both,,,36.33,23.61,,,,,,,,,,,,,
GUIDEWIRE VASC SYNCHRO 10 L 300 CM DIA 0.010 IN DSTL SEG L,SUP-2367859,CDM,C1769,HCPCS,0272,RC,,,,both,,,2022.16,1314.40,,,,,,,,,,,,,
PLATE BNE L118MM 6 H L LAT DST FIBULAR S STL VAR ANG LOK,SUP-2177723,CDM,C1713,HCPCS,0278,RC,,,,both,,,2539.51,1650.68,,,,,,,,,,,,,
PLATE BNE MEDL SM 3.5/4 MM CLMN NS FPS LTX,SUP-2856866,CDM,C1713,HCPCS,0278,RC,,,,both,,,5290.90,3439.08,,,,,,,,,,,,,
INSTRUMENT ABLATN ACCS 2 VERTEBRA,SUP-2874138,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6845.20,4449.38,,,,,,,,,,,,,
PROSTHESIS VOICE 20FR 10MM HRD VLV INDWL BLOM-SINGER ADVNTG,SUP-2242280,CDM,L8509,HCPCS,0274,RC,,,,both,,,1067.60,693.94,,,,,,,,,,,,,
BIT DRL L225MM DIA3.2MM ST QUIK CPL NONRADIOPAQUE W/O STP,SUP-2187167,CDM,2720000010,LOCAL,0272,RC,,,,both,,,600.87,390.57,,,,,,,,,,,,,
BUR SURG DIA4MM CARB RND,SUP-2367605,CDM,2720000010,LOCAL,0272,RC,,,,both,,,686.88,446.47,,,,,,,,,,,,,
KETOROLAC TROMETHAMINE 15 MG/ML IJ SOLN,RX-22472,CDM,J1885,HCPCS,0636,RC,62332-0599-01,NDC,,both,1,ML,54.10,35.16,,,,,,,,,,,,,
TUBE TRACH 4.5X56 MM 35545C56] BRYAN MEDICAL INC],SUP-2151575,CDM,A7521,HCPCS,0278,RC,,,,both,,,533.64,346.87,,,,,,,,,,,,,
COMPONENT TIB SZ 2 THK19MM RT KNEE POLYETH NP CRUC RET PRI,SUP-2209428,CDM,C1776,CPT,0278,RC,,,,both,,,4143.23,2693.10,,,,,,,,,,,,,
BLADE RTRCTR YOUNG 1INW X 1ND 8 14NL PRSTTE URLGCL NTCHD,SUP-2672981,CDM,2720000010,LOCAL,0272,RC,,,,both,,,477.53,310.39,,,,,,,,,,,,,
CAP CBL VENT ASST MOD MECH CIRCULATORY SUPP HEARTMATE III,SUP-2356028,CDM,C1713,HCPCS,0278,RC,,,,both,,,536.94,349.01,,,,,,,,,,,,,
IMMOBILIZER ORTHOPEDICS SM UNIV L R SHLDR SLNG,SUP-2195044,CDM,L3660,HCPCS,0272,RC,,,,both,,,25.62,16.65,,,,,,,,,,,,,
DILATOR URETH 8-20FR L37CM W/ SIDEPRT SET S-CURVE,SUP-2171366,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1240.93,806.60,,,,,,,,,,,,,
CONNECTOR SPNL SM TI OFFSET LOK SCR FOR 5.5MM ROD TSRH-3D,SUP-2289993,CDM,C1713,HCPCS,0278,RC,,,,both,,,2875.77,1869.25,,,,,,,,,,,,,
WIRE EXT FIX L 500 MM DIA2 MM SS SMTH HALF PT NS DISP MONK,SUP-2899106,CDM,2720000010,LOCAL,0272,RC,,,,both,,,682.17,443.41,,,,,,,,,,,,,
GRAFT BNE FRZN LAT MED FEM HEMICONDYLE IMPL ALLGRFT L50 TO,SUP-2264763,CDM,C1713,HCPCS,0278,RC,,,,both,,,4424.29,2875.79,,,,,,,,,,,,,
KIT INSTR ANTI-DRIFTBOLT REAMER PK OUT STRL DISP MOTOBAND CP,SUP-2893329,CDM,2720000010,LOCAL,0272,RC,,,,both,,,879.20,571.48,,,,,,,,,,,,,
BLADE RETRACTOR SHT TEETH 65X20 MM PUR FLEXI-SPINE,SUP-2467750,CDM,2720000010,LOCAL,0272,RC,,,,both,,,902.94,586.91,,,,,,,,,,,,,
MESH HERN 15X7.5 CM N ABSRB KEYHOLE INGUINAL PARIETENE LF,SUP-2752195,CDM,C1781,HCPCS,0278,RC,,,,both,,,468.30,304.39,,,,,,,,,,,,,
GRAFT NRV REP L3CM DIA1.5MM TYP 1 CLLGN ABSRB SEMIPERMEABLE,SUP-2244347,CDM,C9352,HCPCS,0278,RC,,,,both,,,4337.69,2819.50,,,,,,,,,,,,,
CAGE SPNL MESH 15X12X9 MM 6 LOBE,SUP-2602068,CDM,C1889,HCPCS,0278,RC,,,,both,,,6458.98,4198.34,,,,,,,,,,,,,
PLATE BONE THK2.8MM 8 H NONSTERILE STRNL TI STR MATRIXRIB,SUP-2181527,CDM,C1713,HCPCS,0278,RC,,,,both,,,3987.02,2591.56,,,,,,,,,,,,,
IMPLANT ORBIT INFERIOR 2/3 LT MEDPOR,SUP-2366499,CDM,C1713,HCPCS,0278,RC,,,,both,,,11802.88,7671.87,,,,,,,,,,,,,
GREAT TOE METATRSL SZ 2 RT CO CHROM INTEGRA,SUP-2242673,CDM,C1776,CPT,0278,RC,,,,both,,,6760.42,4394.27,,,,,,,,,,,,,
BOLT FIX L90MM DIA65MM ST MIDFOOT FUS S STL,SUP-2177267,CDM,C1713,HCPCS,0278,RC,,,,both,,,1648.66,1071.63,,,,,,,,,,,,,
SYSTEM DRAINAGE EXT CSF SAMPLING SITE ACCUDRAIN,SUP-2244106,CDM,2720000010,LOCAL,0272,RC,,,,both,,,674.91,438.69,,,,,,,,,,,,,
SEALANT SURG 13 YR DURA AUTOSPRAY NUS-109 ADHERUS,SUP-2381863,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2846.50,1850.22,,,,,,,,,,,,,
SYRINGE INJ BONE CEM DEL,SUP-2194167,CDM,C1713,HCPCS,0278,RC,,,,both,,,603.73,392.42,,,,,,,,,,,,,
SCREW SPNL 4.5X60 MM HA TSRH 3DX OSTEOGRIP,SUP-2631156,CDM,C1713,HCPCS,0278,RC,,,,both,,,2088.10,1357.26,,,,,,,,,,,,,
SLEEVE IM 100DEG LT BLU TI LCK FOR SPRL BLDE 9-12MM NAIL,SUP-2191876,CDM,C1713,HCPCS,0278,RC,,,,both,,,1185.60,770.64,,,,,,,,,,,,,
CATHETER EPIDURAL BEND MRK 19 GAX24 IN E-CAP STYL TUN-L-XL,SUP-2164784,CDM,C1754,HCPCS,0278,RC,,,,both,,,256.13,166.48,,,,,,,,,,,,,
SCREW BONE L10MM DIA4.5MM CORT FEM S STL ST NONLOCKING FULL,SUP-2318712,CDM,C1713,HCPCS,0278,RC,,,,both,,,159.32,103.56,,,,,,,,,,,,,
HC Assay of Iron,PX-3018354000,CDM,83540,CPT,0301,RC,,,,both,,,105.00,68.25,,,,,,,,,,,,,
IMPLANT FACE 33 X 38 MM THK 0.8 MM POLYETHYL RT ORBIT ZYG,SUP-2883153,CDM,C1713,HCPCS,0278,RC,,,,both,,,3310.31,2151.70,,,,,,,,,,,,,
SET INTRO MICRO-STICK SHTH L 9 CM DIA 4 FR NIT COAX STIFF,SUP-2627259,CDM,C1894,HCPCS,0272,RC,,,,both,,,33.28,21.63,,,,,,,,,,,,,
FIBER LASER 1000U 100W ETFE SIL FLEXSHIELD HI PWR POLISHED,SUP-2141813,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2160.19,1404.12,,,,,,,,,,,,,
LINER ACET OD64MM ID28MM +4MM OFFSET 10DEG HIP MARATHON,SUP-2250364,CDM,C1776,CPT,0278,RC,,,,both,,,4396.00,2857.40,,,,,,,,,,,,,
POINTER NAVIGATION DISPOSABLE TOUCH N GO AXIEM,SUP-2280216,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1519.10,987.41,,,,,,,,,,,,,
SCREW BNE MALL 4.5X55 MM,SUP-2530685,CDM,C1713,HCPCS,0278,RC,,,,both,,,83.21,54.09,,,,,,,,,,,,,
FIBER LASER 200 MH FLEXSHIELD BALL SHP OUTPT TIP ETFE SIL,SUP-2417488,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1417.84,921.60,,,,,,,,,,,,,
MESH HERN W30XL30CM POLYGLACTIN 910 WVN KNIT VCRL,SUP-2220332,CDM,C1781,HCPCS,0278,RC,,,,both,,,2797.90,1818.63,,,,,,,,,,,,,
ACYCLOVIR 400 MG PO TABS,RX-8971,CDM,6370000000,HCPCS,0637,RC,50268-0061-15,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
BALLOON ENDO FOR CLR VISIBILITY OF EUS PROC FITS OLY PENTAX,SUP-2360903,CDM,C1726,HCPCS,0272,RC,,,,both,,,56.36,36.63,,,,,,,,,,,,,
SCREW BNE L16MM DIA3.5MM LOK FOR TUFFNEK TECHNOLOGY GORILLA,SUP-2321122,CDM,C1713,HCPCS,0278,RC,,,,both,,,604.45,392.89,,,,,,,,,,,,,
KIT INSTR W/ IMPL PRELD TUNN BTTN SYS FOR PLNTR PLT REP,SUP-2175157,CDM,C1713,HCPCS,0278,RC,,,,both,,,4790.07,3113.55,,,,,,,,,,,,,
HC Phys Performnce Test Ea 15 Min,PX-4209775000,CDM,97750,CPT,0420,RC,,,,outpatient,,,194.00,126.10,,,,,,,,,,,,,
GRAFT HUM TISS W20XL20CM THK07 14MM THN ACELLULAR HYDRATED,SUP-2307572,CDM,Q4128,HCPCS,0636,RC,,,,both,,,32812.72,21328.27,,,,,,,,,,,,,
WIRE ORTH CTRL EXT FIX UNILAT IMPLANTS JETXSMOOTH S STL,SUP-2342856,CDM,2720000010,LOCAL,0272,RC,,,,both,,,608.28,395.38,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 40 CM DIA 4-6 MM SHRT TAPR SLDE GDS,SUP-2476142,CDM,C1768,CPT,0278,RC,,,,both,,,848.65,551.62,,,,,,,,,,,,,
GRAFT BNE 60CC 1 8MM CANC CRUSH CHIP READIGRFT,SUP-2264825,CDM,C1713,HCPCS,0278,RC,,,,both,,,2115.73,1375.22,,,,,,,,,,,,,
BUR 8MM M CORNERSTONE,SUP-2363351,CDM,2720000010,LOCAL,0272,RC,,,,both,,,960.84,624.55,,,,,,,,,,,,,
RECLAIM ASSEMBLY TENSILE BAR,SUP-2515476,CDM,2720000010,LOCAL,0272,RC,,,,both,,,488.58,317.58,,,,,,,,,,,,,
ROD SPNL ANTR RT SMOOTH S STL 5.0MM DIA 440MM LEN,SUP-2290520,CDM,C1713,HCPCS,0278,RC,,,,both,,,2697.26,1753.22,,,,,,,,,,,,,
GUIDEWIRE ENDO L250CM SAVARY-GILLIARD,SUP-2417513,CDM,C1769,HCPCS,0272,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
SYRINGE MED 1 CC DEFLUX PREFIL 159034] OCEANA THERAPEUTICS INC],SUP-2312331,CDM,L8604,HCPCS,0278,RC,,,,both,,,5964.27,3876.78,,,,,,,,,,,,,
BIT DRL DIA 3.2 MM PIN DIA 4 MM STP NS DISP MAV MINI,SUP-2933152,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1170.44,760.79,,,,,,,,,,,,,
BRACE KNEE SZ 4 16-17INXL MID PAT Q FR CLSR IN 2SL BIOSKIN,SUP-2174972,CDM,L1820,HCPCS,0274,RC,,,,both,,,181.96,118.27,,,,,,,,,,,,,
HC So Catecholamines Fractionated,PX-3018238466,CDM,82384,CPT,0301,RC,,,,both,,,174.00,113.10,,,,,,,,,,,,,
FIXATOR 5/8 RNG 200MM FRDM CIR,SUP-2400666,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2741.22,1781.79,,,,,,,,,,,,,
GUIDEWIRE VASC J 0.035 INX50 CM FIX COR HEPARIN SS SAFE-T-J,SUP-2167611,CDM,C1769,HCPCS,0272,RC,,,,both,,,38.65,25.12,,,,,,,,,,,,,
DISTAL POSTERIOR LATERAL HUMERUS TRIAL 4 HOLELEFT,SUP-2704935,CDM,C1713,HCPCS,0278,RC,,,,both,,,587.31,381.75,,,,,,,,,,,,,
SHEATH INTRO GLIDESHEATH L 10 CM OD 5 FR ID 0.074 IN SPRING,SUP-2385324,CDM,C1893,HCPCS,0272,RC,,,,both,,,144.75,94.09,,,,,,,,,,,,,
SHUNT CSF 15CM H2O GRAVITATIONAL UNIT PEDIATRIC RESERVOIR VE,SUP-2821854,CDM,C1889,HCPCS,0278,RC,,,,both,,,10002.97,6501.93,,,,,,,,,,,,,
SCREW BNE L16MM DIA3.5MM NONLOCKING FOR TUFFNEK TECHNOLOGY,SUP-2321196,CDM,C1713,HCPCS,0278,RC,,,,both,,,494.55,321.46,,,,,,,,,,,,,
COIL EMB L10CM DIA0.02IN LOOP DIA4MM COMPLX EXTRA SFT FILL,SUP-2323437,CDM,C1889,HCPCS,0278,RC,,,,both,,,7975.60,5184.14,,,,,,,,,,,,,
BRACE FT HEEL FTDROP AND PRSS REL CNTRCT REG AD UNIV UNISX,SUP-2326319,CDM,L4396,HCPCS,0274,RC,,,,both,,,200.52,130.34,,,,,,,,,,,,,
DEXTROSE 5 % IN LACTATED RINGERS IV BOLUS,RX-40840058,CDM,2580000003,HCPCS,0250,RC,00338-0125-03,NDC,,both,250,ML,25.50,16.57,,,,,,,,,,,,,
PROCESSOR SND STL GRY PONTO 4,SUP-2430318,CDM,L8690,HCPCS,0278,RC,,,,both,,,12858.30,8357.89,,,,,,,,,,,,,
INJECTOR BONE CEMENT VERTEPORT X4 8GA MANIFOLD�,SUP-2863095,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1543.31,1003.15,,,,,,,,,,,,,
DART SURG L30MM DIA25MM 10DEG PEEK PIP,SUP-2121833,CDM,C1713,HCPCS,0278,RC,,,,both,,,1868.30,1214.39,,,,,,,,,,,,,
GUIDEWIRE VASC GLIDEWIRE L 150 CM DIA 0.035 IN TIP L 8 CM,SUP-2140130,CDM,C1769,HCPCS,0272,RC,,,,both,,,108.14,70.29,,,,,,,,,,,,,
GUIDEWIRE VASC RDRUN PC NIMB L 145 CM DIA 0.035 IN TAPR L,SUP-2168471,CDM,C1769,HCPCS,0272,RC,,,,both,,,87.39,56.80,,,,,,,,,,,,,
GRAFT BIO TISS OMEGA3 MARIGEN MICRO 8SQCM,SUP-2909376,CDM,Q4158,HCPCS,0636,RC,,,,both,,,1968.78,1279.71,,,,,,,,,,,,,
DEFIBRILLATOR IMPL RESONATE X4 W 5.37 X H 8.18 CM D 0.99 CM,SUP-2149888,CDM,C1882,HCPCS,0275,RC,,,,both,,,61408.98,39915.84,,,,,,,,,,,,,
CANNULA ARTHSCP L35IN DIA63MM INNR PRSS SENS FOR 87K FLD,SUP-2166826,CDM,C1894,HCPCS,0272,RC,,,,both,,,1491.31,969.35,,,,,,,,,,,,,
HC Echo Tee Guid Tcat Icar/Vessel Structural Intvn,PX-4839335500,CDM,93355,CPT,0483,RC,,,,both,,,2093.00,1360.45,,,,,,,,,,,,,
INSTRUMENT SCREW BNE L48MM CONSTRN CNDYL KNEE HEX HD STEM FOR LEG NXGN,SUP-2201524,CDM,2720000010,LOCAL,0272,RC,,,,both,,,226.08,146.95,,,,,,,,,,,,,
PLATE BNE SM TI L CALCNL LOK,SUP-2106920,CDM,C1713,HCPCS,0278,RC,,,,both,,,7162.34,4655.52,,,,,,,,,,,,,
GRAFT HUMAN TSSUE FIRM 30X15 CM RCNSTRCTVE TSSUE MTRX STRTTC,SUP-2485459,CDM,Q4130,HCPCS,0636,RC,,,,both,,,43262.92,28120.90,,,,,,,,,,,,,
PLATE BLADE ANGL 130 DEG 6H /90MM/104MM,SUP-2547511,CDM,C1713,HCPCS,0278,RC,,,,both,,,2505.59,1628.63,,,,,,,,,,,,,
RING EXT FIX DIA155 MM HALF RED NS DISP SMRT TSF,SUP-2933338,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4338.57,2820.07,,,,,,,,,,,,,
WIRE FIX L100MM DIA11MM K UNIVERSAL2,SUP-2243201,CDM,C1713,HCPCS,0278,RC,,,,both,,,88.67,57.64,,,,,,,,,,,,,
SPACER SPNL 4 DEG 25X20X10 MM,SUP-2380370,CDM,C1713,HCPCS,0278,RC,,,,both,,,3956.40,2571.66,,,,,,,,,,,,,
KIT ELECTROPHYSIOLOGY REF PTCH LOCATION MAG FOR AFFERA MAP,SUP-2911930,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3925.00,2551.25,,,,,,,,,,,,,
SET GUID RESECT FOR 5 TIB 4 R FEM HI PERF SIG TRUMATCH,SUP-2252964,CDM,C1713,HCPCS,0278,RC,,,,both,,,2041.00,1326.65,,,,,,,,,,,,,
DRILL SURG 3.8 MM PEG INVISION,SUP-2850660,CDM,2720000010,LOCAL,0272,RC,,,,both,,,637.42,414.32,,,,,,,,,,,,,
NIMODIPINE 30 MG PO CAPS,RX-10722,CDM,6370000000,HCPCS,0637,RC,69452-0209-13,NDC,,both,1,UN,13.00,8.45,,,,,,,,,,,,,
ALLOGRAFT HUM TISS POST TIBIALIS ASEP DBL STRND,SUP-2422330,CDM,C1762,CPT,0278,RC,,,,both,,,6594.00,4286.10,,,,,,,,,,,,,
PLATE SPNL L22MM LEV 1 ANTR BILAT CERV TI LCK LO PROF,SUP-2254578,CDM,C1713,HCPCS,0278,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
SPLINT KNEE UNIV FOR LESS THAN 36IN L24IN FOAM LAM ELAS CNTCT,SUP-2197156,CDM,L3650,HCPCS,0274,RC,,,,both,,,45.34,29.47,,,,,,,,,,,,,
NIPPER SURG THN LN 5 IN SS,SUP-2305687,CDM,2720000010,LOCAL,0272,RC,,,,both,,,421.07,273.70,,,,,,,,,,,,,
THORACENTESIS PRCNTSS SET 8F X 17 CM VLVD STEP FIXED LUER PG,SUP-2699822,CDM,C1729,HCPCS,0272,RC,,,,both,,,219.80,142.87,,,,,,,,,,,,,
HC So2 Alpha Fetoprotein,PX-3018210568,CDM,82105,CPT,0301,RC,,,,outpatient,,,163.00,105.95,,,,,,,,,,,,,
SET INTRO SUP ARW FLX SHTH L 11 CM DIA 5 FR GUIDEWIRE 45 CM,SUP-2383425,CDM,C1894,HCPCS,0272,RC,,,,both,,,142.87,92.87,,,,,,,,,,,,,
GRAFT VASC RESTOREFLOW PA TRUNK STRL,SUP-2884013,CDM,C1768,CPT,0278,RC,,,,both,,,25901.86,16836.21,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED UNI K10] STRYKER CORP],SUP-2365622,CDM,C1776,CPT,0278,RC,,,,both,,,8244.01,5358.61,,,,,,,,,,,,,
LINEZOLID 600 MG/300ML IV SOLN,RX-133069,CDM,J2020,HCPCS,0636,RC,66794-0219-63,NDC,,both,300,ML,108.70,70.65,,,,,,,,,,,,,
GRAFT HUM TISS DIA 44 MM CORTICAL FEM HD FRZN STRL,SUP-2913410,CDM,C1762,CPT,0278,RC,,,,both,,,4823.04,3134.98,,,,,,,,,,,,,
PIN FIX L40MM SET CBL RDY,SUP-2198052,CDM,C1713,HCPCS,0278,RC,,,,both,,,791.75,514.64,,,,,,,,,,,,,
GUIDEWIRE VASC CHIKAI BLK 18 L 200 CM DIA 0.018/0.014 IN,SUP-2518870,CDM,C1769,HCPCS,0272,RC,,,,both,,,2351.86,1528.71,,,,,,,,,,,,,
GRAFT HUM TISS XL 10X15 CM FRSH FRZN FASC LATA TEND,SUP-2777424,CDM,C1762,CPT,0278,RC,,,,both,,,2763.20,1796.08,,,,,,,,,,,,,
ALLOSYNC CB DBM PUTTY 10CC,SUP-2816376,CDM,C1713,HCPCS,0278,RC,,,,both,,,3659.67,2378.79,,,,,,,,,,,,,
TRUESPAN MENIS REP SYS PLGA 24 DEG ORTHOCORD VIO BRAID COMP,SUP-2256751,CDM,C1713,HCPCS,0278,RC,,,,both,,,2728.66,1773.63,,,,,,,,,,,,,
PROSTHESIS OSS STAP 0.6X4 MM PISTON TI,SUP-2471196,CDM,L8613,CPT,0278,RC,,,,both,,,391.31,254.35,,,,,,,,,,,,,
CATHETER DRAINAGE 2 EYE 14 FR PROPORTIONATE HD PEZ,SUP-2126191,CDM,C2627,HCPCS,0272,RC,,,,both,,,22.07,14.35,,,,,,,,,,,,,
PIN EXT FIX HALF L150MM DIA4MM CONT THRD L35MM,SUP-2202029,CDM,C1713,HCPCS,0278,RC,,,,both,,,109.90,71.43,,,,,,,,,,,,,
PLATE BONE L14MM THK0.6MM 3 H REG MIDFACE TI TRIANG FOR,SUP-2402890,CDM,C1713,HCPCS,0278,RC,,,,both,,,659.40,428.61,,,,,,,,,,,,,
POST FIX X 20 MM LAPIDUS SYS FOR 4.5 MM SCREW IO FRDM,SUP-2864925,CDM,C1713,HCPCS,0278,RC,,,,both,,,5557.80,3612.57,,,,,,,,,,,,,
ROD EXT FIX SM L156MM DIA4MM 120DEG UNIV C FBR CRV CONN,SUP-2188718,CDM,C1713,HCPCS,0278,RC,,,,both,,,583.10,379.01,,,,,,,,,,,,,
KIT PRB L440MM DIA3.9MM BLU SWISS LITHOCLAST TRIL,SUP-2141780,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2806.78,1824.41,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE 2.5 CC CER GRAN TYPE-I BOV CLLGN RPM,SUP-2930789,CDM,C1763,HCPCS,0278,RC,,,,both,,,2433.50,1581.77,,,,,,,,,,,,,
SCREW BONE L4MM DIA1.6MM TI SELF DRL CRUC FOR CRAN PLATING,SUP-2280076,CDM,C1713,HCPCS,0278,RC,,,,both,,,184.73,120.07,,,,,,,,,,,,,
HC Radiologic Small Intestine Follow-Through Study,PX-3207424800,CDM,74248,CPT,0320,RC,,,,both,,,1063.00,690.95,,,,,,,,,,,,,
COMPASS VENTRICULAR DRAINAGE FOR HYDROCEPHALUS VALVE PROGAV,SUP-2821850,CDM,C1729,HCPCS,0272,RC,,,,both,,,4672.19,3036.92,,,,,,,,,,,,,
TROCAR STNMN PIN 0.079INX9IN,SUP-2363711,CDM,C1713,HCPCS,0278,RC,,,,both,,,27.44,17.84,,,,,,,,,,,,,
CATHETER HD PRECRV 13 FRX20 CM SHT TERM BASIC SET DUO-SPLIT,SUP-2627190,CDM,C1752,HCPCS,0278,RC,,,,both,,,238.64,155.12,,,,,,,,,,,,,
LOW PRFLE NEURO PLATE STRGHT 4 HOLE RGLR CP TTNM ST,SUP-2676765,CDM,C1713,HCPCS,0278,RC,,,,both,,,310.33,201.71,,,,,,,,,,,,,
GUIDEPIN ORTH SHLDR TEMP NS,SUP-2315866,CDM,C1713,HCPCS,0278,RC,,,,both,,,2637.60,1714.44,,,,,,,,,,,,,
SHOE ORTHOT WOMAN CUST OXFORD INTEGR PART OF BRAC,SUP-2435714,CDM,L3224,HCPCS,0274,RC,,,,both,,,191.29,124.34,,,,,,,,,,,,,
CIPROFLOXACIN HCL 750 MG PO TABS,RX-25120,CDM,6370000000,HCPCS,0637,RC,59651-0873-50,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
"HC RBC Antigen Typing,Genotyping 12 Blood Group System Genes",PX-3100282066,CDM,0282U,CPT,0310,RC,,,,outpatient,,,830.00,539.50,,,,,,,,,,,,,
WIRE FIX TROCAR PT 2 END 0.045X9 IN 4 DIAMOND SS KIRSCHNER 6PK,SUP-2876902,CDM,C1713,HCPCS,0278,RC,,,,both,,,121.08,78.70,,,,,,,,,,,,,
MESH HERN W15XL21CM ABD PTFE SYN NONABSORBABLE OVL,SUP-2126074,CDM,C1781,HCPCS,0278,RC,,,,both,,,72.85,47.35,,,,,,,,,,,,,
CLAMP EXT FIX 2 H BODY COMPLT RAIL,SUP-2197295,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1130.40,734.76,,,,,,,,,,,,,
DRESSING BIO W2XL2IN THN CLLGN GLYCOSAMINOGLYCAN WND MTRX,SUP-2243646,CDM,Q4108,HCPCS,0636,RC,,,,both,,,10057.23,6537.20,,,,,,,,,,,,,
HC Cardiopulm Resuscitation,PX-4509295000,CDM,92950,CPT,0450,RC,,,,outpatient,,,424.00,275.60,,,,,,,,,,,,,
CATHETER PTCA L150CM BLLN L8CM DIA3MM SHTH 4FR GWIRE,SUP-2128518,CDM,C1725,HCPCS,0272,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
EVOS 3.5/4.5PP TROC RING PL L 3H X 132MM,SUP-2931282,CDM,C1713,HCPCS,0278,RC,,,,both,,,20698.10,13453.76,,,,,,,,,,,,,
TAP SURG L 43 MM DIA2.2 MM SCREW DIA 6 MM SHRT SD HEX NS,SUP-2909559,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1249.63,812.26,,,,,,,,,,,,,
CATHETER KIT DL PEDIATRIC 4 FRX13 CM 20 GA ANTIMICROBIAL,SUP-2429390,CDM,C1751,HCPCS,0278,RC,,,,both,,,399.41,259.62,,,,,,,,,,,,,
SUPPORT ORTHOT THOR LUMBAR SACR CUST CORSET FRONT,SUP-2435563,CDM,L0970,HCPCS,0274,RC,,,,both,,,302.54,196.65,,,,,,,,,,,,,
SHELL ACET SPIK 40 MM HIP REFLECTION,SUP-2434758,CDM,C1776,CPT,0278,RC,,,,both,,,5658.28,3677.88,,,,,,,,,,,,,
GRAFT VASC HEMSHLD GLD L 30 CM 18 MM POLYESTER BOV CLLGN STR,SUP-2227276,CDM,C1768,CPT,0278,RC,,,,both,,,1695.63,1102.16,,,,,,,,,,,,,
PLATE BNE L242MM 12 H R LAT DST PERIARTC FEM S STL,SUP-2410534,CDM,C1713,HCPCS,0278,RC,,,,both,,,2359.68,1533.79,,,,,,,,,,,,,
HC Remove Brain Cavity Fluid,PX-5106102000,CDM,61020,CPT,0510,RC,,,,both,,,2894.00,1881.10,,,,,,,,,,,,,
SCREW BNE COMPR 4X36 MM FIBULAR ANK FT MTL OSSIOFIBULARER,SUP-2641867,CDM,C1713,HCPCS,0278,RC,,,,both,,,4082.00,2653.30,,,,,,,,,,,,,
ANCHOR SUT L28MM DIA4.5MM BIOCOMPOSITE SELF PUNCHING,SUP-2121507,CDM,C1713,HCPCS,0278,RC,,,,both,,,1303.10,847.01,,,,,,,,,,,,,
PROBE LITHO 6MMX120CM OD2FR EHL,SUP-2313059,CDM,2720000010,LOCAL,0272,RC,,,,both,,,950.57,617.87,,,,,,,,,,,,,
SYSTEM MESH HRNIA PANEL BOWLS SM 03MM THK TTNM ORBTL CNTRD,SUP-2676690,CDM,C1713,HCPCS,0278,RC,,,,both,,,983.13,639.03,,,,,,,,,,,,,
PIN OCCL W10MM STD W/ APPL DISP FOR HEMORRHAGE,SUP-2381977,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1405.15,913.35,,,,,,,,,,,,,
SIZER SURG DIA9.5MM MALL,SUP-2165380,CDM,C1813,HCPCS,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
GUIDEWIRE ORTHOPEDIC L70CM DIA3MM TEAR DROP,SUP-2480450,CDM,C1769,HCPCS,0272,RC,,,,both,,,424.34,275.82,,,,,,,,,,,,,
COLLAR CERV SM FOAM LF,SUP-2330406,CDM,L0120,HCPCS,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
IMPL KWIRES TROCAR 3813 2 090,SUP-2707054,CDM,C1713,HCPCS,0278,RC,,,,both,,,110.69,71.95,,,,,,,,,,,,,
GRAFT BNE 2.5 CC DEMINERALIZED BNE FIBER PROGRAFT,SUP-2858504,CDM,C1713,HCPCS,0278,RC,,,,both,,,1219.89,792.93,,,,,,,,,,,,,
HC Transesophageal Echo,PX-4809331300,CDM,93313,CPT,0480,RC,,,,both,,,3039.00,1975.35,,,,,,,,,,,,,
SCREW INT FIX LCK FX ADPT TY EQUINOXE,SUP-2223412,CDM,C1713,HCPCS,0278,RC,,,,both,,,1720.72,1118.47,,,,,,,,,,,,,
BUR IRRIG STR 3MM,SUP-2313830,CDM,C1713,HCPCS,0278,RC,,,,both,,,388.79,252.71,,,,,,,,,,,,,
BIT DRL DIA4.5MM CANN W/ QUIK CONN FOR PLATING SYS PERI-LOC,SUP-2344002,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4172.75,2712.29,,,,,,,,,,,,,
ALLOGRAFT HUM TISS MESH 3X2 CM SMR2T AMNION CHORION EPIFIX,SUP-2871319,CDM,Q4186,HCPCS,0636,RC,,,,both,,,3517.43,2286.33,,,,,,,,,,,,,
MAND ANGLE PLATE T.S.LCKNG RT LNG 3 X 3 2.3MM SSTM T 6L 4V T,SUP-2501151,CDM,C1713,HCPCS,0278,RC,,,,both,,,1471.03,956.17,,,,,,,,,,,,,
PLATE K ORBITAL 3 MM CP TITANIUM,SUP-2681106,CDM,C1713,HCPCS,0278,RC,,,,both,,,1917.60,1246.44,,,,,,,,,,,,,
VALVE SHUNT PED ASST PRSS LEV 0 LAYING 10CM H2O UPR 20MM,SUP-2108718,CDM,C1729,HCPCS,0272,RC,,,,both,,,4341.65,2822.07,,,,,,,,,,,,,
PLATE BNE L213MM 12 H NONSTERILE L MED DST TIB S STL LOK,SUP-2177453,CDM,C1713,HCPCS,0278,RC,,,,both,,,3853.85,2505.00,,,,,,,,,,,,,
SPACER ORTH TALAR PT SPEC,SUP-2742002,CDM,C1776,CPT,0278,RC,,,,both,,,28024.50,18215.92,,,,,,,,,,,,,
SPACER TALUS CUSTOM IMPLANT **OR DIRECTOR APPROVAL REQUIRED*,SUP-2823666,CDM,C1776,CPT,0278,RC,,,,both,,,47084.30,30604.79,,,,,,,,,,,,,
SCREW BONE L30MM OD6.5MM HDLSS CANN COMPR SH THRD,SUP-2122289,CDM,C1713,HCPCS,0278,RC,,,,both,,,1805.50,1173.57,,,,,,,,,,,,,
SCREW BONE L130MM DIA4MM SCHNZ DISP,SUP-2150266,CDM,C1713,HCPCS,0278,RC,,,,both,,,89.08,57.90,,,,,,,,,,,,,
DEVICE ISOLATION MIXED PACK,SUP-2887768,CDM,2720000010,LOCAL,0272,RC,,,,both,,,624.86,406.16,,,,,,,,,,,,,
PLATE BNE THK0.8MM BAR 12MM UNIV 6 H CRANIOMAXILLOFACIAL TI,SUP-2366264,CDM,C1713,HCPCS,0278,RC,,,,both,,,775.17,503.86,,,,,,,,,,,,,
LEVEL CMF SCREW CRSSDRVE TNTNG DRILL FR15 X 4 MM THD TTL7 M,SUP-2707278,CDM,C1713,HCPCS,0278,RC,,,,both,,,284.61,185.00,,,,,,,,,,,,,
PLATE BNE L76MM THK2MM LNG L CALCNL S STL LOK COMPR FOR,SUP-2185991,CDM,C1713,HCPCS,0278,RC,,,,both,,,2107.47,1369.86,,,,,,,,,,,,,
CATHETER KIT STATLOK PICC,SUP-2384066,CDM,C1751,HCPCS,0278,RC,,,,both,,,607.59,394.93,,,,,,,,,,,,,
VALVE CSF PERF LEVEL 1 NEONATE 90 CM DELT,SUP-2628519,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3473.56,2257.81,,,,,,,,,,,,,
RING EXT FIX HALF 160 MM CARBON FIBER RINGFIX,SUP-2365279,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3328.40,2163.46,,,,,,,,,,,,,
REAMER SURG L87MM DIA17MM QUIK CPL FOR 2.0/2.3 TRILOK ARTH,SUP-2267855,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1164.94,757.21,,,,,,,,,,,,,
PLATE BNE FIBULAR LT 3 HOLE LCK ANAT STRL ALPS LTX,SUP-2861804,CDM,C1713,HCPCS,0278,RC,,,,both,,,2464.46,1601.90,,,,,,,,,,,,,
TRAY EPIDURAL TUOHY NDL L 1.5 IN DIA18 GA SGL SHT CLR FEN,SUP-2936763,CDM,2720000010,LOCAL,0272,RC,,,,both,,,50.40,32.76,,,,,,,,,,,,,
PLATE BNE SM TI ORBIT 3D PRNT NS DISP ACCUPLATE,SUP-2934969,CDM,C1713,HCPCS,0278,RC,,,,both,,,29453.20,19144.58,,,,,,,,,,,,,
SPACER SPINE 27MM 10MMW 10MM HT TANT ZM,SUP-2414299,CDM,C1776,CPT,0278,RC,,,,both,,,10644.60,6918.99,,,,,,,,,,,,,
CAPSAICIN 0.025 % EX CREA,RX-1350,CDM,6370000000,HCPCS,0637,RC,50268-0195-60,NDC,,both,60,GR,14.40,9.36,,,,,,,,,,,,,
HC Central Ven Cath 5+ Yrs,PX-4503655600,CDM,36556,CPT,0450,RC,,,,outpatient,,,9955.00,6470.75,,,,,,,,,,,,,
HC Custom Hand/Finger Static,PX-2740391301,CDM,L3913,HCPCS,0274,RC,,,,outpatient,,,900.00,585.00,,,,,,,,,,,,,
BIT DRL TWST CYL 16 MM STP 15 X 50 MM S STL,SUP-2262748,CDM,2720000010,LOCAL,0272,RC,,,,both,,,389.36,253.08,,,,,,,,,,,,,
CARVEDILOL 25 MG PO TABS,RX-15748,CDM,6370000000,HCPCS,0637,RC,00904-7308-61,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
GUIDEWIRE VASC LUNDERQUIST L 145 CM DIA 0.035 IN TAPR 11 CM,SUP-2170673,CDM,C1769,HCPCS,0272,RC,,,,both,,,145.79,94.76,,,,,,,,,,,,,
TUBE VENT MOD 1.27 MM 6 MM 7.6 MM PHOSPHORYLCHOLINE COAT SIL,SUP-2467729,CDM,L8699,HCPCS,0278,RC,,,,both,,,59.60,38.74,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH FLX L 55 MM PROX/DSTL 18 MM SHTH,SUP-2171049,CDM,C1874,HCPCS,0278,RC,,,,both,,,6471.54,4206.50,,,,,,,,,,,,,
IMPLANT NSL L23MM MOMETASONE FUROATE PROPEL ? ORDER MULTIPLES OF 5 EACH,SUP-2246419,CDM,C2625,HCPCS,0278,RC,,,,both,,,3406.90,2214.48,,,,,,,,,,,,,
DISPOSABLE KIT FOR 3.5MM PUSHLOCK,SUP-2812460,CDM,2720000010,LOCAL,0272,RC,,,,both,,,659.40,428.61,,,,,,,,,,,,,
CUSTOM KT DLYS KT-1540,SUP-2263925,CDM,C1752,HCPCS,0278,RC,,,,both,,,11.62,7.55,,,,,,,,,,,,,
SYSTEM REP SYNTH GRFT W/ TENS ADJ SUT NDL DP CONN TOOL W/,SUP-2140238,CDM,C1771,HCPCS,0278,RC,,,,both,,,6352.22,4128.94,,,,,,,,,,,,,
PIN FIX L300MM OD3MM S STL SMOOTH BLNT TIP IMPL,SUP-2199026,CDM,C1713,HCPCS,0278,RC,,,,both,,,533.80,346.97,,,,,,,,,,,,,
HC Cad MRI Image,PX-6100893700,CDM,C8937,CPT,0610,RC,,,,both,,,1190.00,773.50,,,,,,,,,,,,,
TOCILIZUMAB-AAZG 200 MG/10ML IV SOLN,RX-167519,CDM,Q5135,HCPCS,0636,RC,65219-0592-10,NDC,,both,10,ML,2888.70,1877.65,,,,,,,,,,,,,
BARREL SPNL L8MM STD PEEK ASMBLY SPFIX,SUP-2231412,CDM,C1821,HCPCS,0278,RC,,,,both,,,8792.00,5714.80,,,,,,,,,,,,,
DULOXETINE HCL 20 MG PO CPEP,RX-39275,CDM,6370000000,HCPCS,0637,RC,68180-0294-07,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
CEFTOLOZANE-TAZOBACTAM 1.5 (1-0.5) G IV SOLR,RX-128570,CDM,J0695,HCPCS,0636,RC,67919-0030-01,NDC,,both,1,UN,1002.60,651.69,,,,,,,,,,,,,
GRAFT VASC GELWEAVE L 40 CM DIA24 MM SIDE BRANCH L 15 MM DIA,SUP-2385033,CDM,C1768,CPT,0278,RC,,,,both,,,2464.33,1601.81,,,,,,,,,,,,,
PLATE 25 ADAPTIVE II TRILOK DST RAD,SUP-2267959,CDM,C1713,HCPCS,0278,RC,,,,both,,,4299.29,2794.54,,,,,,,,,,,,,
SHUNT COR 12FR SHFT L1.1CM BLB 4MM STD FLO W/O RESVR,SUP-2214558,CDM,2720000010,LOCAL,0272,RC,,,,both,,,172.70,112.25,,,,,,,,,,,,,
GUIDEWIRE VASC L 45 CM DIA 0.018 IN SS PERIPH AD X STIFF MIC,SUP-2117371,CDM,C1769,HCPCS,0272,RC,,,,both,,,71.31,46.35,,,,,,,,,,,,,
CATHETER THORACENTHESIS RT ANGLED 3.6 FR PLEUR-EVAC,SUP-2384350,CDM,C1729,HCPCS,0272,RC,,,,both,,,23.52,15.29,,,,,,,,,,,,,
PLATE BNE 2/2.4X73X2 MM 9 HOLE SS LC-DCP,SUP-2569209,CDM,C1713,HCPCS,0278,RC,,,,both,,,333.31,216.65,,,,,,,,,,,,,
ROD COMPR FOR ARTH NAIL SYS PANTA,SUP-2243643,CDM,C1713,HCPCS,0278,RC,,,,both,,,2123.33,1380.16,,,,,,,,,,,,,
PLATE SPNL IMPL L20X16MM CENTERPIECE,SUP-2292780,CDM,C1889,HCPCS,0278,RC,,,,both,,,21477.60,13960.44,,,,,,,,,,,,,
BAR EXT FIX 11X350 MM CARBON,SUP-2749998,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1629.66,1059.28,,,,,,,,,,,,,
CATH 7/110/2.5/7-4 QUAD STD,SUP-2424678,CDM,C1732,HCPCS,0272,RC,,,,both,,,7379.00,4796.35,,,,,,,,,,,,,
GRAFT BNE SUB W25XL10CM DBX STRP FRZ DRY FOR VOID FILL,SUP-2306998,CDM,C1713,HCPCS,0278,RC,,,,both,,,3937.56,2559.41,,,,,,,,,,,,,
BUR SURG DIA1.6 MM TUNGSTEN CARBIDE TAPR 2 RNG STRL DISP,SUP-2928847,CDM,2720000010,LOCAL,0272,RC,,,,both,,,471.19,306.27,,,,,,,,,,,,,
HC So Adenovirus Antibody,PX-3028660366,CDM,86603,CPT,0302,RC,,,,both,,,418.00,271.70,,,,,,,,,,,,,
KIT THR HYBRID CEM STEM TRABECULAR MTL CUP VIT E LNR AND,SUP-2212107,CDM,C1776,CPT,0278,RC,,,,both,,,16745.62,10884.65,,,,,,,,,,,,,
HC Duplex Scan Artl Infl&Ven O/F Hemo Compl Bi Std,PX-9219398500,CDM,93985,CPT,0921,RC,,,,both,,,1222.00,794.30,,,,,,,,,,,,,
LEAD DEFIB 7FR L60CM TIP TO PROX COIL 17CM SIL OPTIM EXT,SUP-2356222,CDM,C1777,HCPCS,0275,RC,,,,both,,,10676.00,6939.40,,,,,,,,,,,,,
STRIP SCLER L125MMXW5MM THICKNESS 1MM SIL SLD TRAP DOOR,SUP-2213472,CDM,C1784,HCPCS,0278,RC,,,,both,,,59.66,38.78,,,,,,,,,,,,,
SCREW BNE L14MM DIA2.4MM S STL CANC SELF DRL CANN,SUP-2184192,CDM,C1713,HCPCS,0278,RC,,,,both,,,487.42,316.82,,,,,,,,,,,,,
ROD SPNL L240MM DIA3.2MM POST TI THRD LEG VERTEX MAX,SUP-2286756,CDM,C1713,HCPCS,0278,RC,,,,both,,,832.10,540.86,,,,,,,,,,,,,
ALLOGRAFT BNE 1 CC FRZN CRYOPRESERVED BNE MTRX VIVIGEN,SUP-2740836,CDM,C1713,HCPCS,0278,RC,,,,both,,,1423.33,925.16,,,,,,,,,,,,,
BIT DRL OD1.4MM RIG FOR SFT ANCHR JUGGERKNOT,SUP-2212950,CDM,2720000010,LOCAL,0272,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
PLATE BONE X LNG THK1MM 4 H MIDFACE GLD STR FOR 2MM SCR,SUP-2402948,CDM,C1713,HCPCS,0278,RC,,,,both,,,342.26,222.47,,,,,,,,,,,,,
SET CATH RALRSN INTRNL DUOFLO CH,SUP-2358809,CDM,C1752,HCPCS,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
GRAFT BNE SUB 5CC CRUNCH DBM GRFTON,SUP-2294018,CDM,C1713,HCPCS,0278,RC,,,,both,,,2498.66,1624.13,,,,,,,,,,,,,
MESH HERN REP CHST WALL 12INCH X 12INCH DISPOSABLE/SNGLE,SUP-2227329,CDM,C1781,HCPCS,0278,RC,,,,both,,,266.12,172.98,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.418,SUP-2859982,CDM,C1713,HCPCS,0278,RC,,,,both,,,33317.28,21656.23,,,,,,,,,,,,,
SCREW BNE CRTX 2.4X65 MM ST T8 STARDRV RECESS TI NS,SUP-2758281,CDM,C1713,HCPCS,0278,RC,,,,both,,,191.10,124.21,,,,,,,,,,,,,
TRUMATCH MIDFACE/MANDIBLE TI 3D PRNT IMPLANT/ ORBIT,SUP-2194246,CDM,C1713,HCPCS,0278,RC,,,,both,,,25749.57,16737.22,,,,,,,,,,,,,
BENDAMUSTINE HCL (TREANDA) 25 MG IV SOLR,RX-101082,CDM,J9033,HCPCS,0636,RC,63459-0390-08,NDC,,both,1,UN,438.10,284.76,,,,,,,,,,,,,
SET INT FIX SCREW DIA1.5 MM TI NEURO Y DBL PLATE 1 PK STRL,SUP-2935637,CDM,C1713,HCPCS,0278,RC,,,,both,,,2078.68,1351.14,,,,,,,,,,,,,
PLATE BNE 3.5X37 MM 3 HOLE SS DCP,SUP-2569135,CDM,C1713,HCPCS,0278,RC,,,,both,,,193.42,125.72,,,,,,,,,,,,,
GRAFT BNE 5 CC OSTEOSURGE 100,SUP-2641798,CDM,C1713,HCPCS,0278,RC,,,,both,,,2234.90,1452.68,,,,,,,,,,,,,
MATRIX HUM TISS L 8 X W 10 CM THK 0.2-1 MM ACELLULAR DERMAL,SUP-2909205,CDM,Q4122,HCPCS,0636,RC,,,,both,,,19356.81,12581.93,,,,,,,,,,,,,
REAMER SURG SZ 2MM CROSSCHECK,SUP-2399367,CDM,2720000010,LOCAL,0272,RC,,,,both,,,715.92,465.35,,,,,,,,,,,,,
QUARTER-TUBULAR PLATE 7 HOLE,SUP-2819058,CDM,C1713,HCPCS,0278,RC,,,,both,,,721.85,469.20,,,,,,,,,,,,,
REAMER MTP SPIN GRD CUP M 21MM,SUP-2419180,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1142.96,742.92,,,,,,,,,,,,,
BIT DRL L 175/90 MM DIA2 MM SCREW DIA2.7 MM CALIB AO QC CLR ST,SUP-2913758,CDM,2720000010,LOCAL,0272,RC,,,,both,,,933.05,606.48,,,,,,,,,,,,,
ALLOGRAFT BNE MATCHSTICK SM 60X3-6 MM FD CORTICAL CANC,SUP-2866841,CDM,C1762,CPT,0278,RC,,,,both,,,1011.24,657.31,,,,,,,,,,,,,
STAPLER INT CIR MED THCK 25 MM 3/3.5/4 MM TRI-STAPLE PUR EEA,SUP-2858011,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3328.56,2163.56,,,,,,,,,,,,,
GRAFT STENT THOR 42X42X100 MM 25 FR PROX FREEFLO STR VALIANT,SUP-2298548,CDM,C1768,CPT,0278,RC,,,,both,,,53364.30,34686.79,,,,,,,,,,,,,
PLATE BNE L 69 MM SCREW DIA2.4/2.7 MM 6 HD 4 SHFT H RT DSTL,SUP-2913571,CDM,C1713,HCPCS,0278,RC,,,,both,,,6173.65,4012.87,,,,,,,,,,,,,
INSERT TIB PS HI FLX 9MM SZ 0,SUP-2223192,CDM,C1776,CPT,0278,RC,,,,both,,,4195.04,2726.78,,,,,,,,,,,,,
HC Drainage Catheter Exchange,PX-3614942300,CDM,49423,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
COLLAR CERV REG DENS SHT TWO PC PED ATLS,SUP-2319289,CDM,L0140,HCPCS,0274,RC,,,,both,,,48.32,31.41,,,,,,,,,,,,,
TUBING EXPANSION FLX 1 ACCULIF,SUP-2381474,CDM,C1713,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
HC MRI-Upper Ext W & WO Cont,PX-6107322000,CDM,73220,CPT,0610,RC,,,,both,,,5578.00,3625.70,,,,,,,,,,,,,
BIT DRL L105MM DIA2MM W/O STP N RADPQ DISP,SUP-2243615,CDM,2720000010,LOCAL,0272,RC,,,,both,,,581.87,378.22,,,,,,,,,,,,,
BAND GAST W/ CALIB TUBE,SUP-2257756,CDM,C1889,HCPCS,0278,RC,,,,both,,,9949.88,6467.42,,,,,,,,,,,,,
CATHETER VENT DRNGE L45CM OD1.3MM ID0.8MM SIL DST ATR TYP A,SUP-2243793,CDM,C1729,HCPCS,0272,RC,,,,both,,,144.13,93.68,,,,,,,,,,,,,
GRAFT VASC GORTX L 20 CM DIA 3 MM EPTFE TW PED SHUNT STRL,SUP-2396677,CDM,C1768,CPT,0278,RC,,,,both,,,1576.28,1024.58,,,,,,,,,,,,,
KIT ELBOW BEARING ORTHOPAEDIC CONDYLAR HEXALOBULAR,SUP-2879195,CDM,C1776,CPT,0278,RC,,,,both,,,7536.00,4898.40,,,,,,,,,,,,,
INTRODUCER VASC 3.5FR L35CM S STL W/OUT CRV W/OUT HEMSTAT,SUP-2126203,CDM,C1894,HCPCS,0272,RC,,,,both,,,98.60,64.09,,,,,,,,,,,,,
LINER ACET SZ 25 OD38MM ID22MM 0DEG THK5.8MM HIP UHMWPE TPLR,SUP-2404283,CDM,C1776,CPT,0278,RC,,,,both,,,5242.23,3407.45,,,,,,,,,,,,,
BAG SHWR PROTECT DISP,SUP-2356015,CDM,Q0501,HCPCS,0272,RC,,,,both,,,763.02,495.96,,,,,,,,,,,,,
CATHETER FIST WAVELINQ ENDOAVF WORKING L ART VEN 50/42 CM,SUP-2422090,CDM,C1725,HCPCS,0272,RC,,,,both,,,29830.00,19389.50,,,,,,,,,,,,,
SUPPORT LUM VISTA 627,SUP-2123916,CDM,L0457,HCPCS,0274,RC,,,,both,,,331.27,215.33,,,,,,,,,,,,,
BALLOON KYPHOPLASTY MED 15 MM VERT MITTEL STRL SYNFLATE,SUP-2758538,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1909.12,1240.93,,,,,,,,,,,,,
IMPLANT PENILE L 15 CM INFPUB PRECONNECT INFLATABLE,SUP-2930710,CDM,C1813,HCPCS,0278,RC,,,,both,,,43685.25,28395.41,,,,,,,,,,,,,
GRAFT BNE SUB 3CC DBM BIOCOMPOSITE OSTEOSET PERIARTC FOR SM,SUP-2399099,CDM,C1734,HCPCS,0278,RC,,,,both,,,2077.24,1350.21,,,,,,,,,,,,,
STEM FEM SEG 7 CM RT KNEE REDUC RESECT TAPR COMPRESS,SUP-2441845,CDM,C1776,CPT,0278,RC,,,,both,,,17888.58,11627.58,,,,,,,,,,,,,
KNIFE SURG REINER CAST 7 IN CRV SATIN FINISH SS MTL REUSE,SUP-2476730,CDM,2720000010,LOCAL,0272,RC,,,,both,,,425.66,276.68,,,,,,,,,,,,,
PLATE BNE W10.3XL137.6MM THK3.7MM 10 H TI LOK COMPR LO PROF,SUP-2413710,CDM,C1713,HCPCS,0278,RC,,,,both,,,1029.92,669.45,,,,,,,,,,,,,
PLATE BNE W17.5XL188MM THK5.2MM 10 H BILAT S STL BROAD LOK,SUP-2185294,CDM,C1713,HCPCS,0278,RC,,,,both,,,1696.04,1102.43,,,,,,,,,,,,,
CATHETER ABLATN MED CURL 4 MM 2-5-2 MM 7 FRX110 CM COOL PATH,SUP-2357492,CDM,C2630,CPT,0272,RC,,,,both,,,4631.50,3010.47,,,,,,,,,,,,,
NAIL FIX OD4MMX46MMX7.6MM MINI TI MTCRPL WR ARTH IMPLATE,SUP-2340238,CDM,C1713,HCPCS,0278,RC,,,,both,,,1813.35,1178.68,,,,,,,,,,,,,
KIT ART LN CATH 20GA L12CM,SUP-2383352,CDM,C1894,HCPCS,0272,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
STENT NEURO SURPS EVOLVE L 12 MM DIA 4 MM COCR PLAT FLO,SUP-2541448,CDM,C1876,HCPCS,0278,RC,,,,both,,,42898.68,27884.14,,,,,,,,,,,,,
NEEDLE TRANSSEPTAL AD 18GA L71CM 30DEG BVL BRK XS CRV S STL,SUP-2357590,CDM,C1893,HCPCS,0272,RC,,,,both,,,656.26,426.57,,,,,,,,,,,,,
MODERATE DMD KNEE SYS/NETSHAPE,SUP-2212166,CDM,C1776,CPT,0278,RC,,,,both,,,10343.16,6723.05,,,,,,,,,,,,,
CANCELLOUS SCREW 8020090,SUP-2843466,CDM,C1713,HCPCS,0278,RC,,,,both,,,1287.40,836.81,,,,,,,,,,,,,
SCREW IL 8.0 MM DIAM TI,SUP-2415540,CDM,C1713,HCPCS,0278,RC,,,,both,,,2943.56,1913.31,,,,,,,,,,,,,
MATRIX RESTRATA WOUND 12.5CM X 17.5CM,SUP-2874123,CDM,A2007,HCPCS,0636,RC,,,,both,,,27946.00,18164.90,,,,,,,,,,,,,
GUIDEWIRE VASC L 145 CM DIA 0.035 IN J2 TIP MOVABLE COR,SUP-2147065,CDM,C1769,HCPCS,0272,RC,,,,both,,,42.26,27.47,,,,,,,,,,,,,
PIN EXTRNL FXTN CLCNS TRBCLR METAL TOTAL ANKLE SSTM,SUP-2720892,CDM,2720000010,LOCAL,0272,RC,,,,both,,,719.85,467.90,,,,,,,,,,,,,
S/D BLADE94MMX2.0MM USR DRIVER LCKING,SUP-2499119,CDM,2720000010,LOCAL,0272,RC,,,,both,,,527.39,342.80,,,,,,,,,,,,,
PLATE BONE THK0.75MM 6 H RESRB POLYMER CRANIOMAXILLOFACIAL,SUP-2364978,CDM,C1713,HCPCS,0278,RC,,,,both,,,508.55,330.56,,,,,,,,,,,,,
COMPONENT TOT SHLDR CAPPED STD HA,SUP-2197231,CDM,C1776,CPT,0278,RC,,,,both,,,11461.00,7449.65,,,,,,,,,,,,,
SCREW INT FIX L16MM DIA1.1MM L 80L/20D COPOLYMER MENIS ARW,SUP-2166738,CDM,C1713,HCPCS,0278,RC,,,,both,,,1416.11,920.47,,,,,,,,,,,,,
DEFIBRILLATOR IMPL ITREVIA DX W 55 X H 65 MM D 11 MM 33 CC,SUP-2138373,CDM,C1722,HCPCS,0275,RC,,,,both,,,39250.00,25512.50,,,,,,,,,,,,,
PIN FIX ANCHR 4X40 MM GUIDEPIN ORTH FOR SURG NAVIGATION SYS,SUP-2657177,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1478.41,960.97,,,,,,,,,,,,,
GRAFT BNE SUB SM HIGHLY PURIFIED TYP I CLLGN HA B,SUP-2310445,CDM,C1713,HCPCS,0278,RC,,,,both,,,1962.50,1275.62,,,,,,,,,,,,,
PLATE SPNL L39MM UNIV CERV ANT 3 LEV TI STD REFLX,SUP-2380868,CDM,C1713,HCPCS,0278,RC,,,,both,,,3077.20,2000.18,,,,,,,,,,,,,
SCREW BNE L58MM DIA4MM CORT S STL ST NONCANNULATED LOK FULL,SUP-2185081,CDM,C1713,HCPCS,0278,RC,,,,both,,,461.58,300.03,,,,,,,,,,,,,
SYSTEM ENDO FIX ARTHROTUNNELER + TUNNELPRO LAT IMPL,SUP-2388892,CDM,C1713,HCPCS,0278,RC,,,,both,,,1978.20,1285.83,,,,,,,,,,,,,
DEFIBRILLATOR CARD IS1 CONN 2 CHMBR CARDIOVERTER UPLR AND,SUP-2236351,CDM,C1882,HCPCS,0275,RC,,,,both,,,67120.64,43628.42,,,,,,,,,,,,,
GRAFT BONE SUB 10X11X14MM CERV TRIAD,SUP-2310532,CDM,C1713,HCPCS,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
NAIL IM L350MM OD11MM SUBTROCHANTERIC ROD RT ZCKL II,SUP-2364775,CDM,C1713,HCPCS,0278,RC,,,,both,,,4502.76,2926.79,,,,,,,,,,,,,
SCREW BNE 7X25 MM 8 MM W/ HD STRL BIORCI,SUP-2848552,CDM,C1713,HCPCS,0278,RC,,,,both,,,643.01,417.96,,,,,,,,,,,,,
BUTTON SUTURE CRADLE ADJ LOOP INFIN DISP,SUP-2846781,CDM,C1713,HCPCS,0278,RC,,,,both,,,1890.03,1228.52,,,,,,,,,,,,,
BIT DRILL SURG L 296 MM DIA 3.2 MM PANGEA SPNL SYS STRL,SUP-2900803,CDM,2720000010,LOCAL,0272,RC,,,,both,,,877.63,570.46,,,,,,,,,,,,,
TAFASITAMAB-CXIX 200 MG IV SOLR,RX-151542,CDM,J9349,HCPCS,0636,RC,50881-0013-03,NDC,,both,1,UN,4020.20,2613.13,,,,,,,,,,,,,
SPACER SPNL W14XH7MM D12MM 7DEG ANT CERV INTBDY FUS INTEGR,SUP-2231372,CDM,C1821,HCPCS,0278,RC,,,,both,,,7536.00,4898.40,,,,,,,,,,,,,
ROD RMR L950MM DIA3MM W/ OFFSET BALL TIP,SUP-2188110,CDM,2720000010,LOCAL,0272,RC,,,,both,,,412.91,268.39,,,,,,,,,,,,,
PLATE DSTL RAD DRSL 2.4MM RAD CLMN 5H SHFT TI STRL VA LCP,SUP-2546760,CDM,C1713,HCPCS,0278,RC,,,,both,,,2256.97,1467.03,,,,,,,,,,,,,
KIT ABLAT PRB 17GA L10MM 2 OSTEOCOOL RF,SUP-2293686,CDM,C1886,HCPCS,0278,RC,,,,both,,,12560.00,8164.00,,,,,,,,,,,,,
NEEDLE HLDR LPRSCPY SELF RGHTNG 3.5MMX32CM NON INSLTD CRVD S,SUP-2473473,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2831.71,1840.61,,,,,,,,,,,,,
BIT DRL CANN 90-120 MM QR NS ACUTRK 6/7 LF DISP,SUP-2518492,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1340.78,871.51,,,,,,,,,,,,,
BIT DRL L100MM DIA2.5MM PROX TIB TI CALIB NONRADIOLUCENT,SUP-2412634,CDM,2720000010,LOCAL,0272,RC,,,,both,,,322.16,209.40,,,,,,,,,,,,,
SET INTRO PERFRMR L 13 CM DIA10 FR TIP 3 MM GUIDEWIRE 0.038,SUP-2168222,CDM,C1894,HCPCS,0272,RC,,,,both,,,127.92,83.15,,,,,,,,,,,,,
SCREW CORT 1.5MM SS HEX HD 18MM,SUP-2198410,CDM,C1713,HCPCS,0278,RC,,,,both,,,192.80,125.32,,,,,,,,,,,,,
CATHETER INFUSION UNI-FUSE L 45 CM 5FR SLT 5CM 0.035 IN BALL,SUP-2117037,CDM,C1757,HCPCS,0272,RC,,,,both,,,835.24,542.91,,,,,,,,,,,,,
SOCK PROSTHETIC IA BODY,SUP-2388155,CDM,L0984,HCPCS,0274,RC,,,,both,,,166.80,108.42,,,,,,,,,,,,,
BIT DRL JCBS 2.9 MM HUM CALIB NS,SUP-2474901,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1001.66,651.08,,,,,,,,,,,,,
PLATE 3.5MM TI CURVED NARROW LCP 20 HOLE-STERILE,SUP-2546923,CDM,C1713,HCPCS,0278,RC,,,,both,,,3633.33,2361.66,,,,,,,,,,,,,
PIN FIX L9IN OD3/32IN S STL THRD TYP A STNMN,SUP-2342676,CDM,C1713,HCPCS,0278,RC,,,,both,,,356.36,231.63,,,,,,,,,,,,,
STAPLE BNE FIX W8XL20MM CO CHROM SPIK LIG LO PROF W/ ATTCH,SUP-2120785,CDM,C1713,HCPCS,0278,RC,,,,both,,,248.06,161.24,,,,,,,,,,,,,
BIT DRL FLX 3.2 MM OCCIPITOCERVICAL INFIN,SUP-2660497,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3467.75,2254.04,,,,,,,,,,,,,
PATCH HERN XL W10.8XL13.7IN UNCOATED MFIL PROPYLENE OVL,SUP-2125902,CDM,C1781,HCPCS,0278,RC,,,,both,,,6268.38,4074.45,,,,,,,,,,,,,
BIN STRL COMPR WIRE FRCP MOD,SUP-2193970,CDM,C1713,HCPCS,0278,RC,,,,both,,,1106.60,719.29,,,,,,,,,,,,,
DRILL SURG ULTRA AFFIRM,SUP-2598516,CDM,2720000010,LOCAL,0272,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
SET INTRO SUP ARW FLX SHTH L 45 CM DIA 6 FR HYDRPHLC RENAL,SUP-2383430,CDM,C1894,HCPCS,0272,RC,,,,both,,,244.92,159.20,,,,,,,,,,,,,
ANCHOR SUT OD5.5MM TI 3 NO 2 SUT WHT COBRAID BLU COBRAID BLK,SUP-2341860,CDM,C1713,HCPCS,0278,RC,,,,both,,,933.37,606.69,,,,,,,,,,,,,
SPACING 115CM LEN 7 F DEFL CRISTA CATH 20 POLE 1-3-1 PR,SUP-2248715,CDM,C1733,HCPCS,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
STEM HUM L55MM DIA11MM MIC SHLDR CO CHROM POR CEM PRESSFIT,SUP-2404547,CDM,C1776,CPT,0278,RC,,,,both,,,16773.88,10903.02,,,,,,,,,,,,,
CHOLANGIOGRAM KIT RX AUTOTOME UTOM XL SPHINTOM JAGWIRE 7192,SUP-2525321,CDM,C1769,HCPCS,0272,RC,,,,both,,,741.83,482.19,,,,,,,,,,,,,
BLADE SAW OSCLLTNG 9.12MMW X25.22MML 0.64MM/0.64MM THK CUT B,SUP-2605486,CDM,2720000010,LOCAL,0272,RC,,,,both,,,77.50,50.37,,,,,,,,,,,,,
HC ER Level 3,PX-4509928300,CDM,99283,CPT,0450,RC,,,,outpatient,,,1556.00,1011.40,,,,,,,,,,,,,
PLATE BNE STR 28 MM 5 HOLE W/ COMPR GORILLA,SUP-2321441,CDM,C1713,HCPCS,0278,RC,,,,both,,,3505.81,2278.78,,,,,,,,,,,,,
ADAPTER INTRO 9FR HEMSTAT TEAR AWAY VLV SIDE PRT EXT WNG,SUP-2329878,CDM,C1894,HCPCS,0272,RC,,,,both,,,147.74,96.03,,,,,,,,,,,,,
SCREW BNE ST 3.5X26 MM LCK W/ STARDRV RECESS,SUP-2569717,CDM,C1713,HCPCS,0278,RC,,,,both,,,98.44,63.99,,,,,,,,,,,,,
SCREW BNE CORTICAL LG 2.7X24 MM FUSION HEX DRV SS STRL,SUP-2852007,CDM,C1713,HCPCS,0278,RC,,,,both,,,505.45,328.54,,,,,,,,,,,,,
ALLOGRAFT HUMAN TISS AXIOFILL 500MG,SUP-2865149,CDM,C1762,CPT,0278,RC,,,,both,,,4097.70,2663.50,,,,,,,,,,,,,
SCREW BNE L6MM DIA1.8MM LT BLU TI ST FULL THRD EMGCY,SUP-2181641,CDM,C1713,HCPCS,0278,RC,,,,both,,,327.50,212.87,,,,,,,,,,,,,
PROSTHESIS LARYN L6MM OD17FR INDWL LO AIRFLO RESISTANCE FOR,SUP-2124302,CDM,L8509,HCPCS,0274,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
CAGE SPNL 0 DEG 13X16X18-21 MM CORPECTOMY W/ SET SCREW CAPRI,SUP-2520289,CDM,C1889,HCPCS,0278,RC,,,,both,,,19782.00,12858.30,,,,,,,,,,,,,
BEARING HUM DIA36-44MM +3MM OFFSET STD E1 FOR COMPHSVE RVS,SUP-2408947,CDM,C1776,CPT,0278,RC,,,,both,,,1667.34,1083.77,,,,,,,,,,,,,
FORCEPS SURG L7 3 4IN DBL ACT CUT BLDE JANSEN STRUYCKEN,SUP-2161536,CDM,2720000010,LOCAL,0272,RC,,,,both,,,905.58,588.63,,,,,,,,,,,,,
JOINT FNGR 20 PROX INTERPHALANGEAL FOR PYROCARBON PIP,SUP-2852864,CDM,C1776,CPT,0278,RC,,,,both,,,8301.38,5395.90,,,,,,,,,,,,,
BAR EXT FIX 11X500 MM CARBON XTRAFIX,SUP-2475116,CDM,2720000010,LOCAL,0272,RC,,,,both,,,817.62,531.45,,,,,,,,,,,,,
COLLAR CERV L18IN H3.25IN L TRACH OPN AD PHIL,SUP-2195258,CDM,L0180,HCPCS,0272,RC,,,,both,,,39.94,25.96,,,,,,,,,,,,,
SHELL ACET SPIK 42 MM HIP REFLECTION,SUP-2434759,CDM,C1776,CPT,0278,RC,,,,both,,,5645.72,3669.72,,,,,,,,,,,,,
ROD SPNL L240MM DIA3.2MM R POST TI SMOOTH FOR VERTEX MAX,SUP-2286683,CDM,C1713,HCPCS,0278,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
PHYTONADIONE 10 MG/ML IJ SOLN,RX-11023,CDM,J3430,HCPCS,0636,RC,00409-9158-01,NDC,,both,0.2,ML,56.40,36.66,,,,,,,,,,,,,
HC So1 Encephalitis California,PX-3028665167,CDM,86651,CPT,0302,RC,,,,both,,,44.00,28.60,,,,,,,,,,,,,
PIN FIX TIB 6 LT KNEE REF OFFSET ROSA REUSE,SUP-2656956,CDM,C1713,HCPCS,0278,RC,,,,both,,,1730.14,1124.59,,,,,,,,,,,,,
SHEATH RENAL DIL AMPLATZ TYP 24FRX17CM,SUP-2141697,CDM,C1894,HCPCS,0272,RC,,,,both,,,134.74,87.58,,,,,,,,,,,,,
SCREW SPNL L12MM DIA4.8MM CANC ANTR CERV TI LCK VAR ANG,SUP-2254604,CDM,C1713,HCPCS,0278,RC,,,,both,,,945.14,614.34,,,,,,,,,,,,,
STAPLE INTERNAL W22XL16MM VITALLIUM WIRE,SUP-2704414,CDM,C1713,HCPCS,0278,RC,,,,both,,,575.25,373.91,,,,,,,,,,,,,
PLATE BNE L138MM 8 H L LAT PROX PERIARTC HUM LOK COMPR,SUP-2410732,CDM,C1713,HCPCS,0278,RC,,,,both,,,4429.57,2879.22,,,,,,,,,,,,,
IMPLANT HUM TISS L 22 X 6 MM CANC FT EVANS WDG TEXT OSTEOTOM,SUP-2933244,CDM,C1762,CPT,0278,RC,,,,both,,,5918.77,3847.20,,,,,,,,,,,,,
SHEATH INTRO SENTRANT L 64 CM DIA22 FR GUIDEWIRE 0.035 IN,SUP-2749561,CDM,C1894,HCPCS,0272,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
SPHERE OPHTH DIA18 MM ORBIT SMTH SURF TUNN POROUS ANTR SURF,SUP-2883185,CDM,L8610,HCPCS,0278,RC,,,,both,,,2098.21,1363.84,,,,,,,,,,,,,
SCREW BONE L20MM DIA3.5MM CORT DSTL RAD ULN TI THRD HD FOR,SUP-2119933,CDM,C1713,HCPCS,0278,RC,,,,both,,,325.78,211.76,,,,,,,,,,,,,
BRACE WALKING LP MED 5.5-10 IN 6.5-11 IN WOMEN MAXTRAX AIR,SUP-2428155,CDM,L4360,HCPCS,0274,RC,,,,both,,,97.50,63.37,,,,,,,,,,,,,
KIT STYL L70CM FOR CATHETER,SUP-2416952,CDM,2720000010,LOCAL,0272,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
PLATE BNE L78MM THK3.7MM 6 H BILAT S STL STR LO PROF RIG,SUP-2184026,CDM,C1713,HCPCS,0278,RC,,,,both,,,2009.82,1306.38,,,,,,,,,,,,,
ENDCAP SPNL DIA6.35MM TI TYPHOON MNRCH,SUP-2254528,CDM,C1713,HCPCS,0278,RC,,,,both,,,847.80,551.07,,,,,,,,,,,,,
BRACE ORTH MOLD ANK FT,SUP-2388164,CDM,L1945,HCPCS,0272,RC,,,,both,,,2917.09,1896.11,,,,,,,,,,,,,
PLATE BNE LCK 5X156 MM RT DSTL FEM 5 HOLE COMPR SS NS LCP,SUP-2184887,CDM,C1713,HCPCS,0278,RC,,,,both,,,4306.70,2799.35,,,,,,,,,,,,,
GRAFT BONE 10ML DEMIN BONE MTRX BONUS II,SUP-2136834,CDM,C1713,HCPCS,0278,RC,,,,both,,,5338.00,3469.70,,,,,,,,,,,,,
POST EXT FIX RT ANGLE NS MAXFRAME,SUP-2758007,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1218.45,791.99,,,,,,,,,,,,,
BRACE ORTH MOLD ANK FT,SUP-2388164,CDM,L1945,HCPCS,0274,RC,,,,both,,,2917.09,1896.11,,,,,,,,,,,,,
CATHETER SET 0.018 IN 5 FRX60 CM CV DL STD TURBO-FLO,SUP-2168838,CDM,C1751,HCPCS,0278,RC,,,,both,,,260.62,169.40,,,,,,,,,,,,,
PLATE BNE L145MM 8 H R PROX MED PERIARTC TIB S STL,SUP-2410553,CDM,C1713,HCPCS,0278,RC,,,,both,,,2380.37,1547.24,,,,,,,,,,,,,
BLADE SURG EXTRACTOR HNDL,SUP-2653711,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2720.97,1768.63,,,,,,,,,,,,,
HOOK SPNL BLDE W6.5MM THRT BILAT PEDCL S STL NEUT OPN NAR,SUP-2257015,CDM,C1713,HCPCS,0278,RC,,,,both,,,3412.24,2217.96,,,,,,,,,,,,,
CROWN FRM SZ 113 8MM RT CTRL ANTR UP TRNSPAR STRP OFF,SUP-2238376,CDM,D6783,CPT,0278,RC,,,,both,,,5.97,3.88,,,,,,,,,,,,,
LINER FEM OD42MM ID26MM BPLR CENTRAX,SUP-2364422,CDM,C1776,CPT,0278,RC,,,,both,,,2119.97,1377.98,,,,,,,,,,,,,
RING FIX 180MM FULL USED IN STLTH REARFOOT,SUP-2400653,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4034.90,2622.68,,,,,,,,,,,,,
IMPLANT TOE STD 3X3MM 10DEG UNIQUE DSTL CROSS H CROSSTIE,SUP-2175161,CDM,C1713,HCPCS,0278,RC,,,,both,,,6203.07,4032.00,,,,,,,,,,,,,
HC Perq Replacement Gtube Not Req Revj Gstrst Trc,PX-3614376200,CDM,43762,CPT,0361,RC,,,,both,,,935.00,607.75,,,,,,,,,,,,,
PLATE BNE L78MM THK385MM 6 H BILAT S STL STR WIDE ANG LO,SUP-2177153,CDM,C1713,HCPCS,0278,RC,,,,both,,,1240.21,806.14,,,,,,,,,,,,,
IMMOBILIZER KNEE CUTAWAY 16 IN,SUP-2336079,CDM,L1830,CPT,0274,RC,,,,both,,,40.29,26.19,,,,,,,,,,,,,
GRAFT VASC IMPRA L 80 CM DIA 6 MM EPTFE FLX STD WALL RING,SUP-2126887,CDM,C1768,CPT,0278,RC,,,,both,,,3614.17,2349.21,,,,,,,,,,,,,
SPACER SPNL W10XH8-12XL26MM CALIB,SUP-2230680,CDM,C1821,HCPCS,0278,RC,,,,both,,,13188.00,8572.20,,,,,,,,,,,,,
DECOMPRESSION KIT CRV 17 GAX6 IN PRB 1 INTRO CANN 1 PRB CLN,SUP-2366994,CDM,C1894,HCPCS,0272,RC,,,,both,,,5874.81,3818.63,,,,,,,,,,,,,
SPLINT WR FRARM PED L4IN LT TIETEX COCK UP LOOP LCK W/ STAY,SUP-2195514,CDM,L3931,HCPCS,0272,RC,,,,both,,,24.43,15.88,,,,,,,,,,,,,
CATHETER CV 2 LUMEN 5 FRX160 CM CT MORPHEUS SMRT PICC,SUP-2116957,CDM,C1751,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
CATHETER HD PASS TY 13.5 FRX16 CM 1.8/1.9 CC PRE CRV MAHRK,SUP-2754730,CDM,C1750,HCPCS,0278,RC,,,,both,,,537.82,349.58,,,,,,,,,,,,,
CLIP INT LIG XL N ABSRB SMOOTH V SHPD TIP TI,SUP-2757599,CDM,C1889,HCPCS,0278,RC,,,,both,,,110.84,72.05,,,,,,,,,,,,,
GRAFT BNE LG GRAN 5-9 MM 30 CC SYNTH W/VI HA PRO OSTEON 500R,SUP-2413087,CDM,C1713,HCPCS,0278,RC,,,,both,,,1281.12,832.73,,,,,,,,,,,,,
BLADE SAW SAG 190110127SS] ZIMMER BIOMET INC],SUP-2205533,CDM,C1713,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
COIL VASC NEST EMBOLUS L 7 CM DIA10 MM CATH DIA 0.018 IN,SUP-2170984,CDM,C1889,HCPCS,0278,RC,,,,both,,,338.68,220.14,,,,,,,,,,,,,
"HC So2 Immunoassay,Analyte,Nos",PX-3018352068,CDM,83520,CPT,0301,RC,,,,inpatient,,,496.00,322.40,,,,,,,,,,,,,
PROBE THERMOABLATION COBRA COOLED SS 5 ELECTRD INSUL TIP,SUP-2124415,CDM,C1713,HCPCS,0278,RC,,,,both,,,10676.00,6939.40,,,,,,,,,,,,,
KIT OLV WIRE M ADV W/ GWIRE SCRDRVR PLATING DEPTH GA E-KT,SUP-2225377,CDM,2720000010,LOCAL,0272,RC,,,,both,,,952.05,618.83,,,,,,,,,,,,,
SPLINT ORTHOPEDIC DLX MED 8-9.5 9.5-11 RT ANK FT CLOSED HEEL,SUP-2195191,CDM,L1930,HCPCS,0272,RC,,,,both,,,103.68,67.39,,,,,,,,,,,,,
KIT ORTH W/ 120MM 11GA CANN 5ML SYR FT ANK END DEL DISP FOR,SUP-2402779,CDM,C1713,HCPCS,0278,RC,,,,both,,,12249.14,7961.94,,,,,,,,,,,,,
BIT DRILL KLS NOTCH 18X70MM,SUP-2262755,CDM,2720000010,LOCAL,0272,RC,,,,both,,,422.33,274.51,,,,,,,,,,,,,
CATHETER CTRL VEN 4.8FR L20CM SGL LUMN VES DIL GWIRE 18GA,SUP-2124938,CDM,C1751,HCPCS,0278,RC,,,,both,,,45.91,29.84,,,,,,,,,,,,,
SPLINT WR FRARM RIGHTXL INSTABILITY INJ W/ STAY FIRM SUPP,SUP-2195253,CDM,L3931,HCPCS,0274,RC,,,,both,,,17.52,11.39,,,,,,,,,,,,,
HOLDER NDLE MICRO 8 1/2NL 1MMW JAW TTNM BNT STRGHT ROUND HND,SUP-2477032,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5253.53,3414.79,,,,,,,,,,,,,
BIT DRL 11 MMX9 IN BADGER,SUP-2765732,CDM,2720000010,LOCAL,0272,RC,,,,both,,,594.43,386.38,,,,,,,,,,,,,
SHOE CAST WALKING XS PEDIATRIC,SUP-2306064,CDM,L4387,HCPCS,0272,RC,,,,both,,,40.82,26.53,,,,,,,,,,,,,
SEALER BPLR DIA6.0MM DISP AQUAMANTYS,SUP-2281802,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
STENT BILI PALMAZ GEN L 59 MM EXPANSION DIA10 MM SHTH 8 FR,SUP-2159284,CDM,C1877,HCPCS,0278,RC,,,,both,,,2150.90,1398.08,,,,,,,,,,,,,
GRAFT HUM TISS L 4 X W 6 CM PLCNTA MEMBRN ALLGRFT CROSS,SUP-2909407,CDM,Q4109,HCPCS,0636,RC,,,,both,,,65312.00,42452.80,,,,,,,,,,,,,
ACETYLCYSTEINE 200 MG/ML IV SOLN,RX-38303,CDM,J0132,HCPCS,0636,RC,70069-0788-01,NDC,,both,3,ML,54.10,35.16,,,,,,,,,,,,,
GRAFT VASC W/ RADPQ MRK SIDE BRANCH LEN THOR ARCH 12MM BOR,SUP-2385004,CDM,C1768,CPT,0278,RC,,,,both,,,6091.60,3959.54,,,,,,,,,,,,,
BIT DRILL DIAMETER 1.4MM SUTURE PASSING CMC MICROLINK,SUP-2825007,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2311.83,1502.69,,,,,,,,,,,,,
NAIL IM L180MM DIA11MM UNIV ANK TI SIL STR RG NONLOCKING,SUP-2412891,CDM,C1713,HCPCS,0278,RC,,,,both,,,4467.91,2904.14,,,,,,,,,,,,,
PROSTHESIS VOICE RAPID EXCHANGE 20 FRX10 MM NS BLOM-SINGER,SUP-2242337,CDM,L8509,HCPCS,0274,RC,,,,both,,,1378.46,896.00,,,,,,,,,,,,,
PLUG ACET DOME H CONTINUUM,SUP-2203894,CDM,C1776,CPT,0278,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
BRACE ORTHOPEDIC FOAM SHT SM UNIV 8.5 IN CONFOR FLEX-N-FIT,SUP-2428146,CDM,L1930,HCPCS,0274,RC,,,,both,,,50.27,32.68,,,,,,,,,,,,,
IMPLANT BIO SZ 250 SQCM FISH SKIN DERMAL FEN 11 INTACT FLAT,SUP-2909233,CDM,Q4158,HCPCS,0636,RC,,,,both,,,25905.00,16838.25,,,,,,,,,,,,,
LEAD DBS L 42 CM DIA 0.5 MM DIRECTIONAL W/ MARKER STRL DISP,SUP-2883087,CDM,C1883,HCPCS,0278,RC,,,,both,,,12006.58,7804.28,,,,,,,,,,,,,
FIBER GYN BP-LE OMNIGUIDE,SUP-2225631,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
VALVE PULM HOMOGRAFT SZ 28 MM CONDUIT STRL,SUP-2175246,CDM,2720000010,LOCAL,0272,RC,,,,both,,,22922.00,14899.30,,,,,,,,,,,,,
SCREW BNE ST 1.5X16 MM CRTX W/ FLUT TIP TI GLD NS LF,SUP-2189235,CDM,C1713,HCPCS,0278,RC,,,,both,,,228.59,148.58,,,,,,,,,,,,,
SEED BRACHYTHERAPY LOAD 7.01-8.0 MCI STRL ADVANTAGE 2029HLS2] ISOAID LLC],SUP-2247279,CDM,C2642,HCPCS,0278,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
DEVICE COUNT TORQUE 1.2 NM LIMITING ATTCH NS LCP,SUP-2863390,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4605.00,2993.25,,,,,,,,,,,,,
KIT PROC L65CM 0.035IN NDL 19GA NEVER TCH FRS GLD TIP FBR,SUP-2116799,CDM,C1894,HCPCS,0272,RC,,,,both,,,4553.00,2959.45,,,,,,,,,,,,,
ANCHOR SUT PEEK SGL STRND OD35MM TWINLOOP,SUP-2366677,CDM,C1713,HCPCS,0278,RC,,,,both,,,406.94,264.51,,,,,,,,,,,,,
SCREW BNE L11MM OD2.7MM LOK FOR PLT TUFFNEK TECHNOLOGY,SUP-2321097,CDM,C1713,HCPCS,0278,RC,,,,both,,,582.47,378.61,,,,,,,,,,,,,
PLATE BNE WIDE MEDL LT 4 HOLE CLMN FUSION SS STRL SOLE MCF,SUP-2875511,CDM,C1713,HCPCS,0278,RC,,,,both,,,11863.08,7711.00,,,,,,,,,,,,,
PROBE VAPORFLEX BIPOLAR 320MM X 2.5MM W/ BALL TIP DISP,SUP-2848821,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1563.72,1016.42,,,,,,,,,,,,,
IMPLANT WR OD15MM ID7MM +4MM CRPL HD IMPLABLE FOR TOT WR SYS,SUP-2407356,CDM,C1776,CPT,0278,RC,,,,both,,,4772.80,3102.32,,,,,,,,,,,,,
SHEATH GUID L 25 CM DIA 6 FR DIL L 32.5 CM GUIDEWIRE 0.035,SUP-2890405,CDM,C1887,HCPCS,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
STEM EXTN L120MM OD10MM FEM KNEE PRSS FIT POST STBL LEGION,SUP-2349131,CDM,C1776,CPT,0278,RC,,,,both,,,4540.44,2951.29,,,,,,,,,,,,,
GRAFT DURA W3XL3IN ULTRAPURE DURAGN+ EACH=5 UNITS,SUP-2922558,CDM,C1713,HCPCS,0278,RC,,,,both,,,2100.06,1365.04,,,,,,,,,,,,,
BEARING TIB 51MM AXLE PED MRS,SUP-2376473,CDM,C1776,CPT,0278,RC,,,,both,,,7097.50,4613.37,,,,,,,,,,,,,
PROBE SURG 6.4FR L2.13CM 1.5CM ESOPH IMPED SPC PH 1 CHAN,SUP-2336773,CDM,2720000010,LOCAL,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
SLING GYN POLYPR TRNSVAG MID URETH SYS DESARA BLU TV,SUP-2152277,CDM,C1771,HCPCS,0278,RC,,,,both,,,3378.64,2196.12,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED BPLR MTL HD SELF CNTR,SUP-2257247,CDM,C1776,CPT,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
FIBER LASER 1000 MH N TAPR POLISHED TIP HOLM ACCUMAX,SUP-2458813,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1991.58,1294.53,,,,,,,,,,,,,
BLOCK TIB PLT HALF MEDL RT LAT LT W/ 2 SCR SZ 2 10MM THCK,SUP-2359282,CDM,C1776,CPT,0278,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
GRAFT BNE SUB 90ML 01 4MM CANC CRUSH CHIP MORSELIZED FRZ,SUP-2307067,CDM,C1713,HCPCS,0278,RC,,,,both,,,4003.50,2602.27,,,,,,,,,,,,,
WIRE FIX TELLURIDE K FOR MIS SPNL FIX SYS,SUP-2211174,CDM,C1713,HCPCS,0278,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
NAIL IM L440MM DIA2.5MM PROX TIB ROSE RED TI E STBL,SUP-2192728,CDM,C1713,HCPCS,0278,RC,,,,both,,,889.44,578.14,,,,,,,,,,,,,
SLEEVE DECOMPRESSION DIA 40 FR SHRT GASTRECTOMY 3D CALIB SYS,SUP-2883550,CDM,C1889,HCPCS,0278,RC,,,,both,,,4804.20,3122.73,,,,,,,,,,,,,
DISP INSTR KIT FOR TENO SCRW,SUP-2811900,CDM,2720000010,LOCAL,0272,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
CATHETER HD RAULERSON 11.5 FRX15 CM IJ DL BASIC SET DUOFLO,SUP-2627386,CDM,C1752,HCPCS,0278,RC,,,,both,,,207.24,134.71,,,,,,,,,,,,,
SCREW BONE L70MM OD4.5MM STD CORT ST NONLOCKING FULL THRD LO,SUP-2343761,CDM,C1713,HCPCS,0278,RC,,,,both,,,55.95,36.37,,,,,,,,,,,,,
PLUG VASC UNCONSTRAINED L11MM DIA6MM GWIRE 0.038IN W/ SELF,SUP-2355705,CDM,C1889,HCPCS,0278,RC,,,,both,,,3830.80,2490.02,,,,,,,,,,,,,
ENDRING SPNL DIA15MM 0DEG BLU TI RND PRESSFIT FOR VERT BODY,SUP-2193239,CDM,C1889,HCPCS,0278,RC,,,,both,,,416.21,270.54,,,,,,,,,,,,,
MATRIX BIO L 10 X W 7 CM FISH SKIN DERMAL INTACT OMEGA3 10/BX,SUP-2909377,CDM,Q4158,HCPCS,0636,RC,,,,both,,,10990.00,7143.50,,,,,,,,,,,,,
PLATE BONE L47MM 3 H LT POST DSTL TIB LCK FOR 3.5MM SCR,SUP-2349802,CDM,C1713,HCPCS,0278,RC,,,,both,,,5878.39,3820.95,,,,,,,,,,,,,
GUIDEWIRE VASC L 110 CM DIA 0.038 IN CRV RAD 3 MM STR J DBL,SUP-2760010,CDM,C1769,HCPCS,0272,RC,,,,both,,,203.85,132.50,,,,,,,,,,,,,
FIBER ENT-L,SUP-2225614,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
ELECTRODE NDL L4IN INSUL LO PWR SET EDGE,SUP-2283487,CDM,C1713,HCPCS,0278,RC,,,,both,,,16.30,10.59,,,,,,,,,,,,,
CATHETER HD PRECRV 15.5X22 CM LT DL BASIC SET HEMO-FLOW XF,SUP-2627245,CDM,C1750,HCPCS,0278,RC,,,,both,,,32.19,20.92,,,,,,,,,,,,,
HC Replac Central Nt Cath WO Port,PX-3613658000,CDM,36580,CPT,0361,RC,,,,both,,,1961.00,1274.65,,,,,,,,,,,,,
PLATE EXTERNAL FIXATION 160MM FOOT ALUMINUM,SUP-2586491,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5638.31,3664.90,,,,,,,,,,,,,
FILLER BNE GRFT L 45 X W 20 X H 7 MM DEMINERALIZED CANC SHT,SUP-2894878,CDM,C1713,HCPCS,0278,RC,,,,both,,,7269.10,4724.91,,,,,,,,,,,,,
PIN EXT FIX HALF 3X80 MM 20 MM BLNT TIP BRN XTRAFIX,SUP-2466340,CDM,2720000010,LOCAL,0272,RC,,,,both,,,486.45,316.19,,,,,,,,,,,,,
CANNULA IV 3/8 IN 18 CM 17 FRX12.5 IN BIO-MEDICUS,SUP-2465291,CDM,2720000010,LOCAL,0272,RC,,,,both,,,963.67,626.39,,,,,,,,,,,,,
CATHETER IRRIG 2 LUMN DST ST 11MM 5FR 40CM LEN,SUP-2264231,CDM,C1757,HCPCS,0272,RC,,,,both,,,310.86,202.06,,,,,,,,,,,,,
DEVICE ENDOSKELETAL SYS KNEE SHIN FRIC SINGLE AXIS ULT,SUP-2388217,CDM,L5811,HCPCS,0272,RC,,,,both,,,1916.97,1246.03,,,,,,,,,,,,,
BUR SURG DIAMOND 4.5 MM 9 CM MTCH HD TELSCP MIDAS REX LEGEND,SUP-2632226,CDM,2720000010,LOCAL,0272,RC,,,,both,,,374.51,243.43,,,,,,,,,,,,,
COMPONENT FEM KNEE KT STRL IUNI,SUP-2904912,CDM,C1776,CPT,0278,RC,,,,both,,,5612.75,3648.29,,,,,,,,,,,,,
PROBE ENDOSCP T TYP 2.3 MMX1.9 MR HYBRIDKNIFE I-JET,SUP-2734135,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1755.26,1140.92,,,,,,,,,,,,,
PLATE BNE WDG 10 MM BOW ARW EVANS GORILLA,SUP-2751041,CDM,C1713,HCPCS,0278,RC,,,,both,,,3917.15,2546.15,,,,,,,,,,,,,
GRAFT BNE MED 6.25 CC MTRX FIBERGRAFT BG,SUP-2434440,CDM,C1713,HCPCS,0278,RC,,,,both,,,6217.20,4041.18,,,,,,,,,,,,,
KIT FECAL MGMT 3 FLTR BG 1 SYR 1 SFT SIL CATH TEMP,SUP-2151500,CDM,2720000010,LOCAL,0272,RC,,,,both,,,335.98,218.39,,,,,,,,,,,,,
SPLINT DORS NT M 10 14 WOM 11 15 SZ L XL,SUP-2196391,CDM,L4398,HCPCS,0272,RC,,,,both,,,97.53,63.39,,,,,,,,,,,,,
CATHETER THROMCTMY INTHRILL L 65 CM DIA 8 FR RVD 4-10 FR,SUP-2862337,CDM,C1757,HCPCS,0272,RC,,,,both,,,6908.00,4490.20,,,,,,,,,,,,,
ANCHOR SUTURE DBL LD SLIDING 2 2.9 MM W/ NDL JUGGERKNOT,SUP-2745264,CDM,C1776,CPT,0278,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
ENDOPROSTHESIS VASC VIABAHN L 2.5CM 7MM 120CM 7FR RADIOPAQUE,SUP-2396651,CDM,C1874,HCPCS,0278,RC,,,,both,,,10013.46,6508.75,,,,,,,,,,,,,
SET PICC L 15CM DIA 5.5FR SHTH L 7CM DIA 5.5FR PR-41552-BAS,SUP-2887216,CDM,C1751,HCPCS,0278,RC,,,,both,,,396.27,257.58,,,,,,,,,,,,,
SCREW SPNL 3.5 MM DIAM,SUP-2415759,CDM,C1713,HCPCS,0278,RC,,,,both,,,1507.20,979.68,,,,,,,,,,,,,
BIT DRILL JUGGERKNOT FLEXBL LNG,SUP-2589270,CDM,2720000010,LOCAL,0272,RC,,,,both,,,358.71,233.16,,,,,,,,,,,,,
SPACER SPNL H8XL23MM LORD LUM PEEK FOR BNE FUS ELEV,SUP-2291292,CDM,C1889,HCPCS,0278,RC,,,,both,,,12089.00,7857.85,,,,,,,,,,,,,
WEIGHT EYELID 1GM STD GLD SMOOTH SURF RND TAPR EDGE STRL IMP,SUP-2247198,CDM,C1713,HCPCS,0278,RC,,,,both,,,722.20,469.43,,,,,,,,,,,,,
HC T-Spine Routine W/ Swimmer 3 Views,PX-3207207200,CDM,72072,CPT,0320,RC,,,,both,,,596.00,387.40,,,,,,,,,,,,,
SHUNT CSF CONNECTOR 1.9MM CATHETER ID1.2MM OD2.5MM DIFFERENT,SUP-2825721,CDM,C1889,HCPCS,0278,RC,,,,both,,,13038.60,8475.09,,,,,,,,,,,,,
CATHETER HD SWAN NK 112.8 CM PRESTRNL PERITONEAL 2 CUF ARGY,SUP-2626974,CDM,C1750,HCPCS,0278,RC,,,,both,,,1314.94,854.71,,,,,,,,,,,,,
RING ANNULPLSTY SZ 24 OD30MM ID22MM AP136MM MI VLV TI RIG,SUP-2355847,CDM,C1713,HCPCS,0278,RC,,,,both,,,4898.40,3183.96,,,,,,,,,,,,,
ALLOGRAFT TISS 3X4 CM MTRX REGENERATIVE,SUP-2393052,CDM,Q4170,HCPCS,0636,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
SHELL ACET SLD BK COCR ALLOY 50MM VITALOCK,SUP-2364625,CDM,C1776,CPT,0278,RC,,,,both,,,3065.43,1992.53,,,,,,,,,,,,,
HC Repair Cv Cath WO Subq Port or Pump,PX-4503657500,CDM,36575,CPT,0450,RC,,,,both,,,706.00,458.90,,,,,,,,,,,,,
PROPOFOL 500 MG/50ML IV EMUL,RX-133091,CDM,J2704,HCPCS,0636,RC,63323-0269-50,NDC,,both,50,ML,86.30,56.09,,,,,,,,,,,,,
STERILE WATER FOR INJECTION IJ SOLN,RX-7484,CDM,2500000003,HCPCS,0250,RC,00409-4887-17,NDC,,both,10,ML,54.10,35.16,,,,,,,,,,,,,
PLATE BONE L87MM THK3.8MM 20 H BILAT S STL NAR DYN COMPR FOR,SUP-2185215,CDM,C1713,HCPCS,0278,RC,,,,both,,,1387.75,902.04,,,,,,,,,,,,,
STAPLE BNE COMPR 18 MM 15 MM CONT 2 LEG BME ELITE,SUP-2564467,CDM,C1713,HCPCS,0278,RC,,,,both,,,4052.55,2634.16,,,,,,,,,,,,,
GUIDEWIRE ORTH DIA1.6MM THRD FOR PEDILOC LCK PROX FEM PLT,SUP-2318865,CDM,C1769,HCPCS,0272,RC,,,,both,,,732.25,475.96,,,,,,,,,,,,,
HC So Antistreptolysin O Ab,PX-3028606067,CDM,86060,CPT,0302,RC,,,,both,,,37.00,24.05,,,,,,,,,,,,,
GRAFT HUM TISS W137XH7XL95MM STD LORD FRZ DRY SPCR CC NAT,SUP-2306982,CDM,C1713,HCPCS,0278,RC,,,,both,,,3516.80,2285.92,,,,,,,,,,,,,
ELECTRODE LO TEMP TREAT CAP 3.0MM 45DEG ARTHWAND,SUP-2341961,CDM,C1713,HCPCS,0278,RC,,,,both,,,882.34,573.52,,,,,,,,,,,,,
CATHETER PD COILED PED 52 CM 6.5 CM CLASSIC 1 CUF,SUP-2480210,CDM,C1750,HCPCS,0278,RC,,,,both,,,577.76,375.54,,,,,,,,,,,,,
OXYGENATOR W/ INTEGR HARDSHELL RESERVOIRXCOATING RIGHTINLET,SUP-2384844,CDM,2720000010,LOCAL,0272,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
STEM HUM L75MM OD7MM UNIV CO CHROME SHLDR MOD PRI W O BODY,SUP-2376490,CDM,C1776,CPT,0278,RC,,,,both,,,6280.79,4082.51,,,,,,,,,,,,,
IMP SYS T-ROPE RT-J W/8.0MM FLPCTR IIS,SUP-2811810,CDM,C1713,HCPCS,0278,RC,,,,both,,,2182.30,1418.49,,,,,,,,,,,,,
PLATE BNE OPN WDG 3.5 MM FORE FT W/ STEM,SUP-2609147,CDM,C1713,HCPCS,0278,RC,,,,both,,,6027.04,3917.58,,,,,,,,,,,,,
COMPONENT TALAR DOMED 4 3+ MM ANK INVISION,SUP-2850489,CDM,C1776,CPT,0278,RC,,,,both,,,17213.48,11188.76,,,,,,,,,,,,,
CLIP IMPL BLADE L 7.5/6.7 MM MAXIMAL OPENING 5 MM CLS FORC,SUP-2929097,CDM,C1889,HCPCS,0278,RC,,,,both,,,1331.58,865.53,,,,,,,,,,,,,
WIRE CADDY ACC RETRV UNOBTRUSTIVE,SUP-2367019,CDM,C1713,HCPCS,0278,RC,,,,both,,,198.29,128.89,,,,,,,,,,,,,
ALLOGRAFT BNE LORDTC 5 DEG 23-27X23-30X14.75X5-6 MM LAT VG1,SUP-2740831,CDM,C1713,HCPCS,0278,RC,,,,both,,,9592.89,6235.38,,,,,,,,,,,,,
MARKER BRST BX MOLLI L 8 CM DIA14 GA PRELD MR CONDITIONAL,SUP-2875963,CDM,A4648,CPT,0278,RC,,,,both,,,2610.38,1696.75,,,,,,,,,,,,,
RING 5 8 200MM FOR TRUELOK FIX SYS,SUP-2316186,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2224.47,1445.91,,,,,,,,,,,,,
SPLINT ORTHOT M L LIMB REST HND FNGR WRST WIRE FOAM FRME,SUP-2194508,CDM,L3807,HCPCS,0272,RC,,,,both,,,111.53,72.49,,,,,,,,,,,,,
GRAFT BNE SUB 10CC CA PHSPTE INJ DRILLABLE VOID FILL NORIAN,SUP-2182828,CDM,C9359,HCPCS,0278,RC,,,,both,,,7263.70,4721.40,,,,,,,,,,,,,
ENOXAPARIN SODIUM 300 MG/3ML IJ SOLN,RX-106118,CDM,J1650,HCPCS,0636,RC,00548-5608-00,NDC,,both,3,ML,184.10,119.66,,,,,,,,,,,,,
PLATE BNE W10.2XL195MM THK2.7MM 15 H BILAT S STL STR LO,SUP-2186202,CDM,C1713,HCPCS,0278,RC,,,,both,,,1851.44,1203.44,,,,,,,,,,,,,
WRENCH L SOCKET,SUP-2491354,CDM,2720000010,LOCAL,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
HC Pre-Pooled Cryoprecipitate,PX-3900901200,CDM,P9012,CPT,0390,RC,,,,outpatient,,,384.00,249.60,,,,,,,,,,,,,
MESH SURG L 20 X W 15 CM GLYCOLIDE LACTIDE COPOLYMER,SUP-2931124,CDM,C1781,HCPCS,0278,RC,,,,both,,,10362.00,6735.30,,,,,,,,,,,,,
EZETIMIBE 10 MG PO TABS,RX-34153,CDM,6370000000,HCPCS,0637,RC,68382-0773-16,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
MESH AUG CUSTOMIZED KT STRL MEDPOR LTX,SUP-2862742,CDM,C1713,HCPCS,0278,RC,,,,both,,,24002.16,15601.40,,,,,,,,,,,,,
MESH SURG 10.5 X 20 CM SUTURE SZ 6-0 OVINE PGA REINF TISS,SUP-2914809,CDM,C1781,HCPCS,0278,RC,,,,both,,,11118.74,7227.18,,,,,,,,,,,,,
PLATE BNE LG RT DBL LISFRANC STRATUM,SUP-2497793,CDM,C1713,HCPCS,0278,RC,,,,both,,,6675.39,4339.00,,,,,,,,,,,,,
PORT INFUS 96FR TI SIL PWR INJ SGL LUMN FULL SZ PROF ATTCH,SUP-2126316,CDM,C1788,HCPCS,0278,RC,,,,both,,,1067.60,693.94,,,,,,,,,,,,,
GRAFT BONE CORTICAL STRUT FD IRR,SUP-2875988,CDM,C1713,HCPCS,0278,RC,,,,both,,,2282.00,1483.30,,,,,,,,,,,,,
POST FIX L L31MM DIA10MM TAPR,SUP-2123531,CDM,C1776,CPT,0278,RC,,,,both,,,1617.10,1051.11,,,,,,,,,,,,,
IMPLANT SACROILIAC L30MM DIA7MM IFUSE,SUP-2337773,CDM,C1713,HCPCS,0278,RC,,,,both,,,10440.50,6786.32,,,,,,,,,,,,,
PLATE BNE W175XL318MM THK52MM 17 H ST BILAT S STL BROAD CRV,SUP-2185315,CDM,C1713,HCPCS,0278,RC,,,,both,,,2985.07,1940.30,,,,,,,,,,,,,
CRANIAL KT W TWO DRL BITS,SUP-2244101,CDM,C1713,HCPCS,0278,RC,,,,both,,,864.07,561.65,,,,,,,,,,,,,
SCREW BNE L50MM DIA4.5MM THRD L12MM S STL PARTIALLY THRDED,SUP-2184438,CDM,C1713,HCPCS,0278,RC,,,,both,,,79.82,51.88,,,,,,,,,,,,,
CATHETER MAP 8FR L105CM LOOP DIA15MM 3-3-3MM ELECTRD SPC,SUP-2357573,CDM,C1732,HCPCS,0278,RC,,,,both,,,5143.32,3343.16,,,,,,,,,,,,,
WEDGE TIB SZ 3-4 5MM L MED R LAT KNEE HEMI STP SCR ON,SUP-2346178,CDM,C1776,CPT,0278,RC,,,,both,,,4000.36,2600.23,,,,,,,,,,,,,
DISTRACTOR SURG WOOD 15X10 MM RT MAND BIDIR TI ZURICH II,SUP-2470961,CDM,C1776,CPT,0278,RC,,,,both,,,12763.10,8296.01,,,,,,,,,,,,,
CATHETER ELECHEMSTAS 10FR L210CM NDL 25GA OD0.51MM ID0.24MM,SUP-2149312,CDM,2720000010,LOCAL,0272,RC,,,,both,,,679.37,441.59,,,,,,,,,,,,,
ALLOGRAFT BNE 10 CC FD FIBER PLIAFX PRIM,SUP-2740842,CDM,C1713,HCPCS,0278,RC,,,,both,,,3149.95,2047.47,,,,,,,,,,,,,
HC IV Inf 1st Hour Ea New Drug,PX-2609636700,CDM,96367,CPT,0260,RC,,,,both,,,98.00,63.70,,,,,,,,,,,,,
PIN BONE FIX L40MM CROSS CANN L15 AXL,SUP-2137195,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1340.78,871.51,,,,,,,,,,,,,
HEAD FEM 28 MM HIP BIOLOX DELT,SUP-2448637,CDM,C1776,CPT,0278,RC,,,,both,,,12420.27,8073.18,,,,,,,,,,,,,
SYSTEM CAST 4 IN TOT CONTACT W/ X LG BOOT TCC-EZ,SUP-2268427,CDM,L4386,HCPCS,0274,RC,,,,both,,,340.69,221.45,,,,,,,,,,,,,
MATRIX BIO L 2 X W 2 CM SZ 7 SQCM FISH SKIN DERMAL PREMESHED BX/10,SUP-2909359,CDM,Q4158,HCPCS,0636,RC,,,,both,,,2518.28,1636.88,,,,,,,,,,,,,
SCREW BONE 65MM DIA 100MML CNCLLS HXGNL HEAD 16MML PRTLLY T,SUP-2722502,CDM,C1713,HCPCS,0278,RC,,,,both,,,77.62,50.45,,,,,,,,,,,,,
INTRODUCER HEMSTAS MAX 7FRX23CM SHTH W/ 0.025 IN GWIRE AND,SUP-2355566,CDM,C1894,HCPCS,0272,RC,,,,both,,,48.67,31.64,,,,,,,,,,,,,
DEVICE FIXAITON MENIS QUICK-T TWINFIX TI 3.5MM,SUP-2341596,CDM,C1713,HCPCS,0278,RC,,,,both,,,906.68,589.34,,,,,,,,,,,,,
BLADE SURG SAW W48.1XL61MM THK64MM THN W FLARE,SUP-2361934,CDM,2720000010,LOCAL,0272,RC,,,,both,,,88.83,57.74,,,,,,,,,,,,,
IMPLANT TOE JT SZ 2 L15MM REG TI MED BILAT PERF H LPT,SUP-2397910,CDM,C1776,CPT,0278,RC,,,,both,,,2760.06,1794.04,,,,,,,,,,,,,
HC Red Blood Cells Each Unit,PX-3900902100,CDM,P9021,CPT,0390,RC,,,,inpatient,,,1275.00,828.75,,,,,,,,,,,,,
SET EMB TRUFILL 10 ML 1 GM 1 GM N-BCA TANTALUM ETHIODIZED,SUP-2913680,CDM,C1889,HCPCS,0278,RC,,,,both,,,14287.00,9286.55,,,,,,,,,,,,,
TUBE VENT ID1.14MM 6IFD GRN SIL STRL T GOODE,SUP-2277940,CDM,L8699,HCPCS,0278,RC,,,,both,,,75.52,49.09,,,,,,,,,,,,,
CAGE SPNL INTBDY 3.5X17 MM STAND ALONE SCREW DIVERGENCE 2PK,SUP-2660610,CDM,C1889,HCPCS,0278,RC,,,,both,,,828.96,538.82,,,,,,,,,,,,,
PLATE BNE 110 DEG MED BAR MINI LT CRANIOMAXILLOFACIAL L SHP,SUP-2883157,CDM,C1713,HCPCS,0278,RC,,,,both,,,1502.58,976.68,,,,,,,,,,,,,
GRAFT BONE SUB 5CC FIL BONE VOID SOLUM IV,SUP-2163077,CDM,C1763,HCPCS,0278,RC,,,,both,,,2182.30,1418.49,,,,,,,,,,,,,
GUIDEWIRE VASC VSI TRU-TORQUE L 150 CM DIA 0.035 IN PTFE,SUP-2383183,CDM,C1769,HCPCS,0272,RC,,,,both,,,229.22,148.99,,,,,,,,,,,,,
BIT DRL DIA6MM S STL TRABECULAR MTL GLEN STP CANN REUSE,SUP-2208226,CDM,2720000010,LOCAL,0272,RC,,,,both,,,722.20,469.43,,,,,,,,,,,,,
HC Sickling RBC Reduction,PX-3058566000,CDM,85660,CPT,0305,RC,,,,outpatient,,,228.00,148.20,,,,,,,,,,,,,
MATRIX BIO L 25 X W 10 CM FET BOV DERM IONIC SLV DERMAL SLD,SUP-2909293,CDM,Q4110,HCPCS,0636,RC,,,,both,,,16249.50,10562.17,,,,,,,,,,,,,
PLATE BNE L90MM THK3.5-4.5MM 4 H NONSTERILE R MED TI DST,SUP-2190911,CDM,C1713,HCPCS,0278,RC,,,,both,,,4480.43,2912.28,,,,,,,,,,,,,
BIT DRL CANN LG 12X190 MM QC TI NS EXPERT,SUP-2863380,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1541.08,1001.70,,,,,,,,,,,,,
GUARD SET 2 WT 20X14 CM 35 GM HYDRPHLC LIGHT 3 PK TI TILENE,SUP-2402549,CDM,C1781,HCPCS,0278,RC,,,,both,,,1931.10,1255.21,,,,,,,,,,,,,
RING EXT FIX HALF 160 MM TI NS,SUP-2863453,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1479.98,961.99,,,,,,,,,,,,,
TIP SURG HARD TISS BONESCAPEL ULTRASONIC,SUP-2141638,CDM,C2617,HCPCS,0278,RC,,,,both,,,1753.88,1140.02,,,,,,,,,,,,,
GRAFT HUM TISS W8XL16CM THK08 17MM ACELLULAR HYDRATED DERM,SUP-2307549,CDM,Q4128,HCPCS,0636,RC,,,,both,,,12910.11,8391.57,,,,,,,,,,,,,
GRAFT PULM VLV ALLGRFT,SUP-2175267,CDM,2720000006,LOCAL,0272,RC,,,,both,,,34524.30,22440.79,,,,,,,,,,,,,
STEM TIB L127MM OD9MM PRI STABILIZING EXTN W O BODY MRS,SUP-2376469,CDM,C1776,CPT,0278,RC,,,,both,,,6634.04,4312.13,,,,,,,,,,,,,
METHOTREXATE SODIUM (PF) 50 MG/2ML IJ SOLN|DISCARDED DRUG NOT ADMINISTE,RX-117354,CDM,J9250,HCPCS,0636,RC,00143-9519-10,NDC,JW,both,0.5,ML,54.10,35.16,,,,,,,,,,,,,
PLATE BNE L288MM 21 H NONSTERILE R ANTLAT DST TIB S STL LO,SUP-2185974,CDM,C1713,HCPCS,0278,RC,,,,both,,,4499.12,2924.43,,,,,,,,,,,,,
COUNTERSINK DRL DIA2.7MM CANN FOR HDLSS COMPR SCR SYS REDUCT,SUP-2340176,CDM,2720000010,LOCAL,0272,RC,,,,both,,,541.65,352.07,,,,,,,,,,,,,
WIRE ORTH SMOOTH DBL SHRP TIP S STL SMOOTH OLV TIP ORTHOFIX,SUP-2315991,CDM,C1713,HCPCS,0278,RC,,,,both,,,211.13,137.23,,,,,,,,,,,,,
STEM FEM CEM SZ 17 165MM LGTH INTRIGUE - SZ 17 165MM LEN,SUP-2406817,CDM,C1776,CPT,0278,RC,,,,both,,,8773.16,5702.55,,,,,,,,,,,,,
SYSTEM FIX SHFT L36CM DIA5MM FAST L67MM POLY LACTIDE ABSRB,SUP-2125760,CDM,C1713,HCPCS,0278,RC,,,,both,,,847.80,551.07,,,,,,,,,,,,,
PLATE BNE HUM LNG 3.5X266 MM LT DSTL X ARTC 12 HOLE SS NS,SUP-2184052,CDM,C1713,HCPCS,0278,RC,,,,both,,,4787.68,3111.99,,,,,,,,,,,,,
TRAY CATH PICC POLY Q CATH BSC 5FR 0.034IN 60CM 2 LU 9255115,SUP-2632697,CDM,C1751,HCPCS,0278,RC,,,,both,,,433.63,281.86,,,,,,,,,,,,,
SODIUM CHLORIDE (HYPERTONIC) 2 % OP SOLN,RX-11404,CDM,6370000000,HCPCS,0637,RC,24208-0276-15,NDC,,both,15,ML,71.80,46.67,,,,,,,,,,,,,
TRAY INTRODUCER BLUE RHINO G2 MULTI PDT,SUP-2718706,CDM,C1769,HCPCS,0272,RC,,,,both,,,1791.37,1164.39,,,,,,,,,,,,,
GRAFT HUMAN TISSUE 10X10 CM FOR XENOGRAFT GENTRIX MATRIX PLUS,SUP-2106482,CDM,Q4166,HCPCS,0636,RC,,,,both,,,8478.00,5510.70,,,,,,,,,,,,,
CATHETER DIAG 2.6X2FR L150CM DST L6CM ID0.019IN MIC,SUP-2367852,CDM,C1887,HCPCS,0272,RC,,,,both,,,2961.02,1924.66,,,,,,,,,,,,,
CAP PROTCT FOR 2.5MM K WIRE,SUP-2188573,CDM,C1713,HCPCS,0278,RC,,,,both,,,158.35,102.93,,,,,,,,,,,,,
PPICC PROVENA SOLO 3F SLEEVE TL,SUP-2613553,CDM,C1751,HCPCS,0278,RC,,,,both,,,630.48,409.81,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED ULTRA HI DEMAND CERM ON CERM BIOMETHMONM] ZIMMER BIOMET INC],SUP-2137337,CDM,C1776,CPT,0278,RC,,,,both,,,23236.00,15103.40,,,,,,,,,,,,,
HC Catheterize for Urine Spec,PX-4500961200,CDM,P9612,CPT,0450,RC,,,,outpatient,,,76.00,49.40,,,,,,,,,,,,,
TRAY CATH HEMODIALYSI ZENYSI DL ACUTE 11FR DIA 15CM A865150G,SUP-2632944,CDM,C1752,HCPCS,0278,RC,,,,both,,,869.00,564.85,,,,,,,,,,,,,
HC Iaad Ia Hpylori Stool,PX-3068733800,CDM,87338,CPT,0306,RC,,,,both,,,332.00,215.80,,,,,,,,,,,,,
SCREW BNE 2.4MM DIA 14MML STAINLES STL CANCELLOU HEXHD FLLY,SUP-2604357,CDM,C1713,HCPCS,0278,RC,,,,both,,,48.32,31.41,,,,,,,,,,,,,
BLOCK TIB AUG REV 7 5 MM RL/LM KNEE BKRS,SUP-2434287,CDM,C1776,CPT,0278,RC,,,,both,,,2788.32,1812.41,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP L480CM DIA0018IN TIP L6CM TRITON STR RADPQ,SUP-2141519,CDM,C1769,HCPCS,0272,RC,,,,both,,,565.99,367.89,,,,,,,,,,,,,
PLATE BNE L171MM 10 H ST R MED PROX TIB S STL LOK COMPR LO,SUP-2185643,CDM,C1713,HCPCS,0278,RC,,,,both,,,4308.21,2800.34,,,,,,,,,,,,,
INLAY IM POLYMER STRL RFN-ADVANCED,SUP-2913527,CDM,C1713,HCPCS,0278,RC,,,,both,,,962.72,625.77,,,,,,,,,,,,,
HC Injection Im Sub Q,PX-2609637200,CDM,96372,CPT,0260,RC,,,,both,,,102.00,66.30,,,,,,,,,,,,,
BIT DRL SURG 25 MM SLD W/ STP DISP,SUP-2223991,CDM,2720000010,LOCAL,0272,RC,,,,both,,,546.36,355.13,,,,,,,,,,,,,
FASTAK ECONOMY PACK 100 2.8MM,SUP-2841400,CDM,C1713,HCPCS,0278,RC,,,,both,,,266.90,173.48,,,,,,,,,,,,,
ALLOGRAFT PLACENTAL MATRIX 4CM X 4CM AMNIOBAND,SUP-2877947,CDM,C1762,CPT,0278,RC,,,,both,,,7696.89,5002.98,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY INQUIRY L 110 CM 6FR LG OCTAPOLAR,SUP-2498967,CDM,C1730,HCPCS,0272,RC,,,,both,,,374.63,243.51,,,,,,,,,,,,,
MODULE ACCESS PRONE TRANSPSOAS LATERAL INTERBODY FUSION,SUP-2933964,CDM,2720000010,LOCAL,0272,RC,,,,both,,,9734.00,6327.10,,,,,,,,,,,,,
PLATE BNE 3X8 H ST S STL T SHP LOK COMPR W SHT THRD DRL GUID,SUP-2177476,CDM,C1713,HCPCS,0278,RC,,,,both,,,1448.89,941.78,,,,,,,,,,,,,
DISC ARTIFICIAL SZ 4 5DEG UNIV INTERVERTEBRAL LUM CO CHROM,SUP-2255732,CDM,C1889,HCPCS,0278,RC,,,,both,,,16956.00,11021.40,,,,,,,,,,,,,
CATHETER ABLAT 7FR L100CM 0.025IN ENDOVENOUS RF CLOSUREFAST,SUP-2393078,CDM,C1888,HCPCS,0272,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
SCREW BNE DRILL-FREE MIC 1.5X4 MM STRL MAXDRIVE LEVEL1 NEURO,SUP-2540267,CDM,C1713,HCPCS,0278,RC,,,,both,,,200.99,130.64,,,,,,,,,,,,,
STENT URET 2 FLX 038 7 FRX30 CM PGTL SENSOR POLARIS ULTRA,SUP-2754252,CDM,C2617,HCPCS,0278,RC,,,,both,,,617.36,401.28,,,,,,,,,,,,,
GRAFT HUM TISS W4XL8CM THK0.38-1.02MM SKIN REGENERATIVE TISS,SUP-2261538,CDM,Q4107,HCPCS,0636,RC,,,,both,,,10804.74,7023.08,,,,,,,,,,,,,
HC So Lipoprotein A,PX-3018217266,CDM,82172,CPT,0301,RC,,,,both,,,63.00,40.95,,,,,,,,,,,,,
CATHETER ANGIOPLSTY 3.25X8 MM CORONARY APEX MRAIL,SUP-2139940,CDM,C1725,HCPCS,0272,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
CATHETER HD DL 11.5 FRX12 CM ADMIN FULL KT HYDR TIP DURAFLO,SUP-2267008,CDM,C1750,HCPCS,0278,RC,,,,both,,,219.80,142.87,,,,,,,,,,,,,
COUPLER ANAS 4 MM DOPPLER 20 MHZ WHT DISP FLO CPLR,SUP-2900202,CDM,C1889,HCPCS,0278,RC,,,,both,,,3444.58,2238.98,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 100 GM AMNIO MEMBRN PARTICULATE NEOX FLO,SUP-2648690,CDM,Q4155,HCPCS,0636,RC,,,,both,,,3925.00,2551.25,,,,,,,,,,,,,
LIDOCAINE 4 % EX CREA,RX-23461,CDM,6370000000,HCPCS,0637,RC,00496-0882-05,NDC,,both,5,GR,31.50,20.47,,,,,,,,,,,,,
COMPONENT ARTC 35X17MM CURVATURE 15MM CAPITATE WRISTMOTION,SUP-2123590,CDM,C1776,CPT,0278,RC,,,,both,,,25104.30,16317.79,,,,,,,,,,,,,
HC So2 Collagen Cross-Link N-Telopep,PX-3018252368,CDM,82523,CPT,0301,RC,,,,outpatient,,,254.00,165.10,,,,,,,,,,,,,
CATHETER ANGIOPLSTY L135CM BAL L40MM DIA7MM 0.035IN PERIPH,SUP-2101678,CDM,C1725,HCPCS,0272,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
MOUNT TBL 2 MICROTOUCH,SUP-2364166,CDM,2720000010,LOCAL,0272,RC,,,,both,,,266.84,173.45,,,,,,,,,,,,,
SYSTEM IMPL W/ SZ 0 BLU FIBERWIRE SUT NDL LNG RETRV RUL CPR,SUP-2122323,CDM,C1776,CPT,0278,RC,,,,both,,,3438.30,2234.89,,,,,,,,,,,,,
SEALANT TISS FIBRIN 10 CC HUM 4 PK KT VISTASEAL,SUP-2738901,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5660.23,3679.15,,,,,,,,,,,,,
PLATE BNE MESHED LG 0.6 MM MXLFCL NEURO 250065309,SUP-2525644,CDM,C1713,HCPCS,0278,RC,,,,both,,,4469.60,2905.24,,,,,,,,,,,,,
MICROCATHETER GUID PG PRO L 165 CM PROX/DSTL OD 2.8 FR,SUP-2734754,CDM,C1887,HCPCS,0272,RC,,,,both,,,1915.40,1245.01,,,,,,,,,,,,,
PLATE BNE L80MM 4 H S STL T SHP BTTRS LO PROF RIG,SUP-2185763,CDM,C1713,HCPCS,0278,RC,,,,both,,,558.92,363.30,,,,,,,,,,,,,
GRAFT HUM TISS 5MM CERV PARA MAINTAIN,SUP-2232316,CDM,C1713,HCPCS,0278,RC,,,,both,,,2323.60,1510.34,,,,,,,,,,,,,
BLADE RETRACTOR 17 CM LT INT PIN MAST QUAD,SUP-2631631,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1571.57,1021.52,,,,,,,,,,,,,
VALVE CSF PROGRAMMABLE LUMBAR LO FLO SHUNT W/O ANTECHAMBER,SUP-2666631,CDM,C1889,HCPCS,0278,RC,,,,both,,,9712.74,6313.28,,,,,,,,,,,,,
HC Ablate Bone Tumor(S) Perq,PX-3612098300,CDM,20983,CPT,0361,RC,,,,both,,,10314.00,6704.10,,,,,,,,,,,,,
GRAFT VASC L80CM L20CM OD6MM STD WALL RING STRL STR GORTX,SUP-2396004,CDM,C1768,CPT,0278,RC,,,,both,,,3048.94,1981.81,,,,,,,,,,,,,
CATHETER BLLN CHN SZ 2.8MM L350CM DIA13MM 0.035IN ABV INJ,SUP-2312957,CDM,C1751,HCPCS,0278,RC,,,,both,,,573.74,372.93,,,,,,,,,,,,,
DRILL GUIDE 23OVERDRILL 25NEUT CENTR,SUP-2695628,CDM,C1713,HCPCS,0278,RC,,,,both,,,769.30,500.04,,,,,,,,,,,,,
KIT INFUS PMP 270ML 4ML/HR 2ML/SITE SOAK CATH L2.5IN,SUP-2236828,CDM,C9804,HCPCS,0272,RC,,,,both,,,339.12,220.43,,,,,,,,,,,,,
DRIVER NAV2024 SOLERA 475 STD MAS,SUP-2281197,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2806.38,1824.15,,,,,,,,,,,,,
GUIDEWIRE VASC L145CM DIA0.035IN TIP L10CM S STL PTFE 2 FLX,SUP-2167670,CDM,C1769,HCPCS,0272,RC,,,,both,,,40.98,26.64,,,,,,,,,,,,,
COLLAR CERV 4IN 24IN M XLN M DENS AD CNTOUR HK AND LOOP CLSR,SUP-2194441,CDM,L0120,HCPCS,0274,RC,,,,both,,,11.05,7.18,,,,,,,,,,,,,
COIL EMB INST PNEUMAT FOR SYS DETACHER AXIUM ID,SUP-2172953,CDM,C1889,HCPCS,0278,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
IMMOBILIZER SHLDR SWTH UNIV DEV BLK P.A.D. III,SUP-2336074,CDM,L3650,HCPCS,0274,RC,,,,both,,,167.86,109.11,,,,,,,,,,,,,
PLATE BNE STR BROAD 5 HOLE COMPR VARIAX,SUP-2365254,CDM,C1713,HCPCS,0278,RC,,,,both,,,2010.92,1307.10,,,,,,,,,,,,,
GUIDEWIRE VASC SPRING 0.018 IN 0.46 MMX45 CM SLD STR SFT TIP,SUP-2846974,CDM,C1769,HCPCS,0272,RC,,,,both,,,104.25,67.76,,,,,,,,,,,,,
COLLAR CERV SM H4.25IN FOR 10-13IN PLASTAZOTE FOAM 2 PC L,SUP-2336008,CDM,L0140,HCPCS,0274,RC,,,,both,,,30.33,19.71,,,,,,,,,,,,,
IMPLANT OP RM CALC PLT CALCNL FRACT,SUP-2321443,CDM,C1713,HCPCS,0278,RC,,,,both,,,4401.50,2860.97,,,,,,,,,,,,,
ADJ CONNECT ROD STD,SUP-2695688,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1254.74,815.58,,,,,,,,,,,,,
HC Surgery Level 6 Base,PX-3600000006,CDM,3600000006,LOCAL,0360,RC,,,,outpatient,,,9199.00,5979.35,,,,,,,,,,,,,
TRAY TIB SZ 2X TI ALLOY RT ANK TOT ANAT TRI CORTICAL,SUP-2931386,CDM,C1776,CPT,0278,RC,,,,both,,,21661.29,14079.84,,,,,,,,,,,,,
BUR SURG L 125 MM DIA2.35 MM HD DIA 4.5 MM DIAMOND NS REUSE,SUP-2929414,CDM,2720000010,LOCAL,0272,RC,,,,both,,,360.06,234.04,,,,,,,,,,,,,
ROD EXT FIX LNG 11X220 MM NS BRDG,SUP-2421792,CDM,C1713,HCPCS,0278,RC,,,,both,,,2154.83,1400.64,,,,,,,,,,,,,
HC Bladder Scan,PX-4505179800,CDM,51798,CPT,0450,RC,,,,outpatient,,,191.00,124.15,,,,,,,,,,,,,
MESH HERN RECTANGULAR 25X40 CM PREPERITONEAL ENFORM,SUP-2539550,CDM,C1781,HCPCS,0278,RC,,,,both,,,41780.84,27157.55,,,,,,,,,,,,,
BIT DRILL TWST L43MM DIA1.1MM 5MM STP IQ SER FOR SYS,SUP-2136985,CDM,2720000010,LOCAL,0272,RC,,,,both,,,546.36,355.13,,,,,,,,,,,,,
HC Duplex Scan Artl Infl&Ven O/F Hemo Compl Uni Std,PX-9219398600,CDM,93986,CPT,0921,RC,,,,outpatient,,,920.00,598.00,,,,,,,,,,,,,
ROD EXT FIX ALIGN FEM SIG LCS HP,SUP-2456161,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2430.36,1579.73,,,,,,,,,,,,,
STEM RADIAL SM 4.5 ULN WRST MOD COCR 1ST CHOICE,SUP-2852861,CDM,C1776,CPT,0278,RC,,,,both,,,13295.36,8641.98,,,,,,,,,,,,,
PLATE BONE LOK 3.5MM DIA HLX12 RIGHT LTRL PRXML TBL,SUP-2588158,CDM,C1713,HCPCS,0278,RC,,,,both,,,3994.90,2596.68,,,,,,,,,,,,,
REPAIR 14CM 20CM 5.5IN SYNTHECEL DURA X,SUP-2880392,CDM,C1763,HCPCS,0278,RC,,,,both,,,7526.58,4892.28,,,,,,,,,,,,,
BIT DRL 4.5X35 MM ALLOFIT,SUP-2448646,CDM,2720000010,LOCAL,0272,RC,,,,both,,,748.89,486.78,,,,,,,,,,,,,
WASHER ORTH SPIDER HUM STRL AFFIXUS NAT NAIL,SUP-2606871,CDM,C1713,HCPCS,0278,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
VALVULOTOME ANGIOSCOPIC L 98 CM DIA1.5 MM HYDRPHLC DEPTH GRN,SUP-2264162,CDM,2720000010,LOCAL,0272,RC,,,,both,,,11300.86,7345.56,,,,,,,,,,,,,
SODIUM PHOSPHATE 3 MMOL/ML PO SOLN (PED-NEO),RX-4090214,CDM,6370000000,HCPCS,0637,RC,09999-9910-68,NDC,,both,1,ML,11.00,7.15,,,,,,,,,,,,,
HC Spine Thoracolumbar 2 Views,PX-3207208000,CDM,72080,CPT,0320,RC,,,,both,,,286.00,185.90,,,,,,,,,,,,,
HC Splint Appl Long Arm,PX-4502910500,CDM,29105,CPT,0450,RC,,,,outpatient,,,867.00,563.55,,,,,,,,,,,,,
TRAY CATH MIDLN PROVENA MAXBARR 4FR 20CM 2 LUMAN S4254108BD,SUP-2632864,CDM,C1751,HCPCS,0278,RC,,,,both,,,611.14,397.24,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED CEM W/O PAT POROUS HA,SUP-2365948,CDM,C1776,CPT,0278,RC,,,,both,,,11897.46,7733.35,,,,,,,,,,,,,
SUPPORT ORTHOT LUMBAR CUST SAG CTRL STRP PADDING STAY,SUP-2435556,CDM,L0641,HCPCS,0272,RC,,,,both,,,220.68,143.44,,,,,,,,,,,,,
PLATE BONE L71MM 4 H STR SEMITUBULAR FOR 4.5MM,SUP-2343802,CDM,C1713,HCPCS,0278,RC,,,,both,,,545.20,354.38,,,,,,,,,,,,,
HC Sgpt (Alt),PX-3018446000,CDM,84460,CPT,0301,RC,,,,both,,,152.00,98.80,,,,,,,,,,,,,
ENDCAP ORTH GRN TI FOR 3-4MM E NAIL SYS,SUP-2192721,CDM,C1713,HCPCS,0278,RC,,,,both,,,233.84,152.00,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED PRIMARY CEM X3 TRIATHLON,SUP-2365632,CDM,C1776,CPT,0278,RC,,,,both,,,10990.00,7143.50,,,,,,,,,,,,,
MESH CRANIAL CONTOURABLE 1.5X20X30X0.25 MM RAPID RESORBABLE,SUP-2838571,CDM,C1713,HCPCS,0278,RC,,,,both,,,1250.66,812.93,,,,,,,,,,,,,
SHEATH INTRO ACCEL L 20 CM DIA 6 FR TRUEGLIDE ACCS 3 PC,SUP-2659239,CDM,C1894,HCPCS,0272,RC,,,,both,,,131.72,85.62,,,,,,,,,,,,,
HC Treat Clavicle Fx,PX-4502350000,CDM,23500,CPT,0450,RC,,,,both,,,630.00,409.50,,,,,,,,,,,,,
CATHETER INTVASC ULTRASOUND OPTICROSS 5 L 135 CM DIA 3 FR,SUP-2884934,CDM,C1887,HCPCS,0272,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
LEAD PACE L35CM L5CM OD7.5FR POLYUR SIL TRNSVEN UPLR DF-1,SUP-2282252,CDM,C1896,HCPCS,0275,RC,,,,both,,,1856.87,1206.97,,,,,,,,,,,,,
SCREW BONE L18MM OD3.5MM NONLOCKING TI,SUP-2321023,CDM,C1713,HCPCS,0278,RC,,,,both,,,292.33,190.01,,,,,,,,,,,,,
CATHETER DRNGE 10FR L40CM 0.038IN BILI LCK PGTL SLIP SKATER,SUP-2120143,CDM,C1729,HCPCS,0272,RC,,,,both,,,245.30,159.44,,,,,,,,,,,,,
ALLOGRAFT BNE CHIP 0.1-2 MM 30 CC PRESERVON CANC READIGRAFT,SUP-2741067,CDM,C1713,HCPCS,0278,RC,,,,both,,,1186.73,771.37,,,,,,,,,,,,,
KENSINGTON GUIDE WIRE BONE BIOPSY KIT 11 G 10 CM,SUP-2477116,CDM,2720000010,LOCAL,0272,RC,,,,both,,,596.60,387.79,,,,,,,,,,,,,
DEFIBRILLATOR IMPL ATLS II HF THK 14 MM 30 J 41 CC 79 GM TI,SUP-2356591,CDM,C1882,HCPCS,0275,RC,,,,both,,,66725.00,43371.25,,,,,,,,,,,,,
TUBE VENT FOR SH TERM APPLICATIONS LIKE AIRPLANE TRAVEL,SUP-2277599,CDM,L8699,HCPCS,0278,RC,,,,both,,,53.57,34.82,,,,,,,,,,,,,
KIT SGL LUMN PICC CATH 45CM NRS FULL TY W/ MICEZ SFTY MIC,SUP-2125617,CDM,C1751,HCPCS,0278,RC,,,,both,,,780.92,507.60,,,,,,,,,,,,,
GRAFT BNE SUB 5CC CA PHSPTE INJ DRILLABLE VOID FILL NORIAN,SUP-2182827,CDM,C1713,HCPCS,0278,RC,,,,both,,,3695.50,2402.07,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 40 CM DIA 6MM STR STD WALL SLDE GDS,SUP-2669690,CDM,C1768,CPT,0278,RC,,,,both,,,1286.21,836.04,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 80 CM DIA 4-7 MM EPTFE LNG TAPR TW,SUP-2461570,CDM,C1768,CPT,0278,RC,,,,both,,,3177.77,2065.55,,,,,,,,,,,,,
SUPPORT ORTHOT THGH LOWER EXTREMITY GLUTEAL ISCHIAL WT BEAR,SUP-2435672,CDM,L2500,HCPCS,0272,RC,,,,both,,,885.95,575.87,,,,,,,,,,,,,
OBTURATOR ENDOSCP FOR RC REP ARTHROTUNNELER,SUP-2908726,CDM,2720000010,LOCAL,0272,RC,,,,both,,,552.64,359.22,,,,,,,,,,,,,
HC Hepatitis B Core Antibody Hbcab Total|NOT REASONABLE AND NECESSARY,PX-3028670400,CDM,86704,CPT,0302,RC,,,GZ,both,,,32.00,20.80,,,,,,,,,,,,,
GRAFT FEM SHFT ALLGRFT FRZ DRY 100MM MATRIGRFT,SUP-2264749,CDM,C1713,HCPCS,0278,RC,,,,both,,,2570.47,1670.81,,,,,,,,,,,,,
PLATE BONE 10 H TI BROAD HYBRID COMPR FOR 4.5MM SCR ALPS,SUP-2413754,CDM,C1713,HCPCS,0278,RC,,,,both,,,1349.51,877.18,,,,,,,,,,,,,
ALLOGRAFT BNE FRZN ASEP LT PROX TIB W/ PATELLAR,SUP-2867048,CDM,C1762,CPT,0278,RC,,,,both,,,15839.73,10295.82,,,,,,,,,,,,,
DISTRACTION INTRNL DIST LFRT 3MNO MTTHWS TSSR 1.5 1.8 MM SC,SUP-2694296,CDM,C1713,HCPCS,0278,RC,,,,both,,,17269.03,11224.87,,,,,,,,,,,,,
ATORVASTATIN CALCIUM 20 MG PO TABS,RX-19178,CDM,6370000000,HCPCS,0637,RC,68084-0098-11,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
BOBBIN VT 127MM ID BLUE TI,SUP-2669488,CDM,L8699,HCPCS,0278,RC,,,,both,,,68.58,44.58,,,,,,,,,,,,,
SCREW CORT 3.5MM DIAX28MM LNG,SUP-2198416,CDM,C1713,HCPCS,0278,RC,,,,both,,,76.36,49.63,,,,,,,,,,,,,
SMARTBAND LIG KT,SUP-2313541,CDM,2720000010,LOCAL,0272,RC,,,,both,,,398.21,258.84,,,,,,,,,,,,,
KIT CVC 7FR L8IN POLYUR BLU FLEXTIP 3 LUMN W SPRINGWIRE,SUP-2120607,CDM,C1751,HCPCS,0278,RC,,,,both,,,263.76,171.44,,,,,,,,,,,,,
GRAFT FIB SHFT FRZ DRY ALLGRFT 76-98MM,SUP-2335273,CDM,C1713,HCPCS,0278,RC,,,,both,,,1805.50,1173.57,,,,,,,,,,,,,
BUR SURG DIA1.8 MM HUB II NEURO CUT STRL REUSE HI-LINE,SUP-2929129,CDM,2720000010,LOCAL,0272,RC,,,,both,,,931.04,605.18,,,,,,,,,,,,,
ITRACONAZOLE 100 MG PO CAPS,RX-10364,CDM,6370000000,HCPCS,0637,RC,60687-0299-95,NDC,,both,1,UN,15.00,9.75,,,,,,,,,,,,,
PROCESSOR SND SYS,SUP-2141841,CDM,L8691,HCPCS,0278,RC,,,,both,,,11147.00,7245.55,,,,,,,,,,,,,
SCREW BNE L 48 MM DIA2.4 MM TI ST LCK T7 DRV NS VLP,SUP-2931518,CDM,C1713,HCPCS,0278,RC,,,,both,,,375.54,244.10,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC HF 5FR 55CM 3 LUMAN RVRSE 3385108Q,SUP-2632679,CDM,C1751,HCPCS,0278,RC,,,,both,,,597.57,388.42,,,,,,,,,,,,,
SCREW BNE L 70 MM DIA2.7 MM TI LCK T8 STARDRV AQUA STRL V,SUP-2905735,CDM,C1713,HCPCS,0278,RC,,,,both,,,1274.27,828.28,,,,,,,,,,,,,
LINER ACET CONSTRN 0 DEG 4+ MM NEUT 44X70 MM HIP LCK GVF TI,SUP-2250290,CDM,C1776,CPT,0278,RC,,,,both,,,11021.40,7163.91,,,,,,,,,,,,,
BELLADONNA ALKALOIDS-OPIUM 16.2-60 MG RE SUPP,RX-24731,CDM,6370000000,HCPCS,0637,RC,00574-7040-12,NDC,,both,1,UN,120.50,78.32,,,,,,,,,,,,,
HC Pt Gait Training Ea 15 Min|OP PT SERVICES|DOCUMENTATION ON FILE|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS,PX-4209711600,CDM,97116,CPT,0420,RC,,,GP|KX|CQ,both,,,164.00,106.60,,,,,,,,,,,,,
SUTURE PASSER CAPFIX 70 DEG,SUP-2801015,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1210.00,786.50,,,,,,,,,,,,,
CANNULA PERF FMRL VSSL ARTRL 38N ACCPTNCE 21FR DIA 7NL CRMD,SUP-2725020,CDM,2720000010,LOCAL,0272,RC,,,,both,,,839.67,545.79,,,,,,,,,,,,,
MASK CPAP LG VITERA,SUP-2423088,CDM,2720000010,LOCAL,0272,RC,,,,both,,,326.56,212.26,,,,,,,,,,,,,
PLATE BNE STR REG CRANIOFACIAL NEURO 4 HOLE LP CONTOURED NS,SUP-2470400,CDM,C1713,HCPCS,0278,RC,,,,both,,,290.01,188.51,,,,,,,,,,,,,
BIT DRL L155MM DIA2.7MM SHT CANN CALIB QUIK CONN FOR,SUP-2344006,CDM,2720000010,LOCAL,0272,RC,,,,both,,,427.92,278.15,,,,,,,,,,,,,
BODY HUM L40MM SHLDR M FEM TAPR COMP MRS,SUP-2376475,CDM,C1776,CPT,0278,RC,,,,both,,,6584.58,4279.98,,,,,,,,,,,,,
ANCHOR SUT NO 2 PRELD NDL L12CM OD17GA SECUR ADJ GI ENTUIT,SUP-2170291,CDM,C1713,HCPCS,0278,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
MATRIX BIO SZ 250-540 SQCM FISH SKIN DERMAL MESHED 21 SINGLE,SUP-2909426,CDM,Q4158,HCPCS,0636,RC,,,,both,,,27082.50,17603.62,,,,,,,,,,,,,
SCREW BNE L 12 MM DIA 3.5 MM TI LCK T15 STARDRV TUBE PK STRL,SUP-2905753,CDM,C1713,HCPCS,0278,RC,,,,both,,,862.18,560.42,,,,,,,,,,,,,
VALVE CSF PROGRAMMABLE IMPL 2PC SHUNT W/ ANTECHAMBER OSV II,SUP-2666654,CDM,C1889,HCPCS,0278,RC,,,,both,,,9557.47,6212.36,,,,,,,,,,,,,
VALSARTAN 40 MG PO TABS,RX-33541,CDM,6370000000,HCPCS,0637,RC,60687-0612-11,NDC,,both,1,UN,3.80,2.47,,,,,,,,,,,,,
WIRE FIX DIA1.4MM BLNT FOR MIS SPINE TELLURIDE K,SUP-2137004,CDM,C1776,CPT,0278,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
SPLINT WRST M L10IN FOR 6 7IN R FA VYN FLANNEL LN SLIP ON,SUP-2276623,CDM,L3908,HCPCS,0272,RC,,,,both,,,18.27,11.88,,,,,,,,,,,,,
INTRODUCER SET G2-MULTI PERC 7.5/8.5/9 MM EVAC DIL BLU RHINO,SUP-2759708,CDM,C1769,HCPCS,0272,RC,,,,both,,,1438.91,935.29,,,,,,,,,,,,,
WASHER ORTH DIA 3.5 MM CORTICAL ELBW LP STRL DISP A.L.P.S.,SUP-2885053,CDM,C1713,HCPCS,0278,RC,,,,both,,,291.08,189.20,,,,,,,,,,,,,
EVOS 3.5MM CVD PROX HUM PL 6H R 114,SUP-2931193,CDM,C1713,HCPCS,0278,RC,,,,both,,,5606.94,3644.51,,,,,,,,,,,,,
BRACE ORTH CLOSURE SM AD BK SHLDR BLK QUIKDRAW PRO,SUP-2123908,CDM,L0628,HCPCS,0274,RC,,,,both,,,165.64,107.67,,,,,,,,,,,,,
HC Bx Breast 1st Les MR Image,PX-3611908500,CDM,19085,CPT,0361,RC,,,,inpatient,,,6672.00,4336.80,,,,,,,,,,,,,
PLATE BONE 1.2MM TI CRANIOFACIAL 6 H STR MCPLUS,SUP-2363682,CDM,C1713,HCPCS,0278,RC,,,,both,,,342.04,222.33,,,,,,,,,,,,,
CROTALIDAE POLYVAL IMMUNE FAB IV SOLR,RX-29313,CDM,J0840,HCPCS,0636,RC,50633-0110-12,NDC,,both,1,UN,9434.10,6132.16,,,,,,,,,,,,,
VALVE TRACH SPEAK SHILEY,SUP-2516374,CDM,L8501,HCPCS,0274,RC,,,,both,,,79.91,51.94,,,,,,,,,,,,,
PLATE BNE SM W11XL155MM THK3.3MM 0DEG 12 H BILAT TI STR RIG,SUP-2190788,CDM,C1713,HCPCS,0278,RC,,,,both,,,736.74,478.88,,,,,,,,,,,,,
HC So Hsv Culture,PX-3008725266,CDM,87252,CPT,0300,RC,,,,both,,,236.00,153.40,,,,,,,,,,,,,
SIZER BRST 525CC P5.8CM W14.5XH13.2CM SIL STYL MF MOD HT,SUP-2113578,CDM,2720000010,LOCAL,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
CAGE SPNL MESH 15X12X11 MM 6 LOBE,SUP-2602070,CDM,C1889,HCPCS,0278,RC,,,,both,,,7074.42,4598.37,,,,,,,,,,,,,
SCREW BNE AD L48MM DIA24MM UNICORTICAL TI ST NONCANNULATED,SUP-2181162,CDM,C1713,HCPCS,0278,RC,,,,both,,,388.51,252.53,,,,,,,,,,,,,
PLATE BNE T MINI 1.5 MM 9X4 HOLE,SUP-2346878,CDM,C1713,HCPCS,0278,RC,,,,both,,,318.40,206.96,,,,,,,,,,,,,
CLIP ANEURYSM OPENING W1.7MM BLADE L3MM MICRO PHYNOX CURVED,SUP-2821650,CDM,C1889,HCPCS,0278,RC,,,,both,,,833.23,541.60,,,,,,,,,,,,,
SCREW BNE HIP 6.5X80 MM RECON THRD XL40 TI STRL FRNADVANCED,SUP-2789378,CDM,C1713,HCPCS,0278,RC,,,,both,,,747.82,486.08,,,,,,,,,,,,,
MESH SURG M W4.5XL10CM UNDERLAY 7CM CONN OD1.9CM ID1.3CM,SUP-2219791,CDM,C1781,HCPCS,0278,RC,,,,both,,,930.04,604.53,,,,,,,,,,,,,
CONNECTOR SPNL 5.5-6/6.35X12 MM LAT SGL HD OPN,SUP-2421858,CDM,C1713,HCPCS,0278,RC,,,,both,,,2041.00,1326.65,,,,,,,,,,,,,
HC Place Cath Xtrnl Carotid,PX-3613622700,CDM,36227,CPT,0361,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
PPICC PROV SOLO PED 3F SLEEVE DELTA,SUP-2613523,CDM,C1751,HCPCS,0278,RC,,,,both,,,1022.38,664.55,,,,,,,,,,,,,
CATHETER REPERFUSION 0.068 INX132 CM UNIQUE ACE 68,SUP-2323549,CDM,C1757,HCPCS,0272,RC,,,,both,,,7504.60,4877.99,,,,,,,,,,,,,
SCREW BNE L4MM DIA15MM CRANIOMAXILLOFACIAL TI ALLY ULT LO,SUP-2262842,CDM,C1713,HCPCS,0278,RC,,,,both,,,198.23,128.85,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED UPLR AUSTIN-MOORE,SUP-2351341,CDM,C1776,CPT,0278,RC,,,,both,,,4204.46,2732.90,,,,,,,,,,,,,
GRAFT HUM TISS W4XL4CM AMNIO MEMBRN AMBRIO2,SUP-2247194,CDM,V2790,HCPCS,0278,RC,,,,both,,,1983.32,1289.16,,,,,,,,,,,,,
NERVE STIMULATOR KIT IMPL PULSE KT,SUP-2141900,CDM,C1820,HCPCS,0278,RC,,,,both,,,54322.00,35309.30,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9 % IV BOLUS NEONATE,RX-40840079,CDM,J7040,HCPCS,0250,RC,00264-7800-10,NDC,,both,500,ML,29.80,19.37,,,,,,,,,,,,,
SCREWDRIVER SURG DISPOSABLE N CANN NAVIGUS,SUP-2284447,CDM,C1713,HCPCS,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
LIFT OTOLOGICAL H 1 MM BCI 602 STRL DISP BONEBRIDGE,SUP-2905147,CDM,L8690,HCPCS,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
SET SHTH DESTINO TWST L 55 CM DIA 7 FR CRV BEND 9 MM DIL 73,SUP-2604662,CDM,C1887,HCPCS,0272,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
GRAFT BONE SUB 5CC GEL GRFTON,SUP-2307524,CDM,C1713,HCPCS,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
MYCOPHENOLATE SODIUM 180 MG PO TBEC,RX-38062,CDM,J7518,HCPCS,0636,RC,00904-6785-04,NDC,,both,1,UN,18.70,12.15,,,,,,,,,,,,,
CLIP BRAIDED 360 CATHETER RESOLUTION ULTRA – UOM 1 EACH,SUP-2754413,CDM,C1889,HCPCS,0278,RC,,,,both,,,837.66,544.48,,,,,,,,,,,,,
ELECTRODE CUT RITECUT R ANG 3FR 65CM,SUP-2313512,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1493.23,970.60,,,,,,,,,,,,,
PASSER SUTURE SIDE LOAD QUATTRO GTS,SUP-2745503,CDM,2720000010,LOCAL,0272,RC,,,,both,,,10990.00,7143.50,,,,,,,,,,,,,
PLATE BNE W9.2XL121MM THK1.3MM 100DEG 10 H TI TBLR FOR,SUP-2412030,CDM,C1713,HCPCS,0278,RC,,,,both,,,310.86,202.06,,,,,,,,,,,,,
GRAFT BNE SUB 30CC SZ 0212 0850MM DEMIN CORT PWD FRZ DRY,SUP-2307259,CDM,C1713,HCPCS,0278,RC,,,,both,,,1872.82,1217.33,,,,,,,,,,,,,
BELT BK CRISSCROSS W/ SHLDR STRP CONTAINS VELC CLSR ELAS,SUP-2324538,CDM,L0642,HCPCS,0272,RC,,,,both,,,76.02,49.41,,,,,,,,,,,,,
NERVE STIMULATOR KIT REMOT CTRL PT PRGM PRECIS SPECTR,SUP-2141947,CDM,C1787,HCPCS,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
CATHETER ABLATN STD CRV 2.5 MM 8 MM 7 FR QPLR 8 MM BLZR II,SUP-2141269,CDM,C1733,HCPCS,0272,RC,,,,both,,,4034.90,2622.68,,,,,,,,,,,,,
ADAPTER FEM 5DEG KNEE PFC SIG,SUP-2253593,CDM,C1776,CPT,0278,RC,,,,both,,,4635.90,3013.33,,,,,,,,,,,,,
BIPOLAR LINER 53/54/55MM OD X 28MM ID,SUP-2501863,CDM,C1776,CPT,0278,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
HC Rp Loclzj Tum Plnr 1 Area Single Day Imaging,PX-3417880000,CDM,78800,CPT,0341,RC,,,,both,,,1691.00,1099.15,,,,,,,,,,,,,
DRILL SURG 24X33MM PROX SL CANN,SUP-2400090,CDM,2720000010,LOCAL,0272,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
INSULIN SYRINGE/NEEDLE U-500 31G X 6MM 0.5 ML MISC,RX-136197,CDM,2500000003,HCPCS,0250,RC,08290-3267-30,NDC,,both,1,UN,54.10,35.16,,,,,,,,,,,,,
DEVICE ARTOTMY CLOSURE MANTA DIA14 FR CLLGN FEM ART FOR VASC,SUP-2740190,CDM,C1760,HCPCS,0278,RC,,,,both,,,2276.50,1479.72,,,,,,,,,,,,,
CATHETER DLYS L28CM DIA14.5FR SHTH L13CM PLAS TUNN VAXCEL +,SUP-2117117,CDM,C1881,HCPCS,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
IMMOBILIZER KNEE RIGID LT W/O KNEE JT CUST FABRICATED,SUP-2417693,CDM,L1834,HCPCS,0272,RC,,,,both,,,2263.94,1471.56,,,,,,,,,,,,,
HC Gonadotropin Follicle Stimulating Hormone,PX-3018300100,CDM,83001,CPT,0301,RC,,,,both,,,643.00,417.95,,,,,,,,,,,,,
BIT DRL 2.9X140 MM KT DRL STP 3MM ALLEN WRNCH DYN AX FIX,SUP-2644590,CDM,2720000010,LOCAL,0272,RC,,,,both,,,401.67,261.09,,,,,,,,,,,,,
ELECTRODE ELECSURG BUTTON 7 FR HI FREQ BUGBEE FLX UROLOGY,SUP-2468552,CDM,2720000010,LOCAL,0272,RC,,,,both,,,668.00,434.20,,,,,,,,,,,,,
STD STAPLE 10MM OBLIQUE,SUP-2721828,CDM,C1713,HCPCS,0278,RC,,,,both,,,335.04,217.78,,,,,,,,,,,,,
KIT INTRO MINI STK MAX L 10 CM DIA 5 FR 7 CM ECHOGENIC STD,SUP-2118823,CDM,C1894,HCPCS,0272,RC,,,,both,,,119.63,77.76,,,,,,,,,,,,,
PIN EXT FIX L 220 MM DIA 4 MM THRD L 55 MM HA HALF,SUP-2898497,CDM,C1713,HCPCS,0278,RC,,,,both,,,734.76,477.59,,,,,,,,,,,,,
PUMP PAIN 400X5ML HR ON Q C BLOC ON DEMAND W REFIL,SUP-2236809,CDM,C9804,HCPCS,0272,RC,,,,both,,,690.80,449.02,,,,,,,,,,,,,
GRAFT VASC GORTX L 70 CM DIA10 MM RNG L 50 CM EPTFE STR TW,SUP-2396173,CDM,C1768,CPT,0278,RC,,,,both,,,3786.84,2461.45,,,,,,,,,,,,,
SHEATH INTRO GLIDESHEATH L 10CM 6FR 0.087IN SPRING WALL PUNC,SUP-2384747,CDM,C1894,HCPCS,0272,RC,,,,both,,,150.72,97.97,,,,,,,,,,,,,
PROSTHESIS PENILE ACCSRY KT,SUP-2140318,CDM,2720000010,LOCAL,0272,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
TUBE SALIVARY BYPS N ADH 12 191X38X12 MM ESOPH MONTGOMERY,SUP-2138740,CDM,2720000010,LOCAL,0272,RC,,,,both,,,621.72,404.12,,,,,,,,,,,,,
SHEATH INTRO HEARTSPAN L 81 CM DIA 8.5 FR NDL L 89 CM ML1,SUP-2497458,CDM,C1893,HCPCS,0272,RC,,,,both,,,28.04,18.23,,,,,,,,,,,,,
MESH CRAN L 52.37 X W 31.01 MM THK 0.61 MM TI EXT CHIARI,SUP-2935988,CDM,C1713,HCPCS,0278,RC,,,,both,,,5454.18,3545.22,,,,,,,,,,,,,
SCREW BNE CANN 5X38 MM PART THRD TIM NS,SUP-2467197,CDM,C1713,HCPCS,0278,RC,,,,both,,,551.29,358.34,,,,,,,,,,,,,
CATHETER VENTRICULAR SYSTEM VENTRICULAR RESERVOIR RIGHT ANGL,SUP-2826649,CDM,C1729,HCPCS,0272,RC,,,,both,,,1685.77,1095.75,,,,,,,,,,,,,
SCREW BNE L 5 MM DIA1.8 MM CRANIOMAXILOFACIAL HI TORQUE XDRV,SUP-2935482,CDM,C1713,HCPCS,0278,RC,,,,both,,,3177.68,2065.49,,,,,,,,,,,,,
SCREW BONE L20MM DIA2MM CORT CRANIOMAXILLOFACIAL TI ST,SUP-2189339,CDM,C1713,HCPCS,0278,RC,,,,both,,,221.37,143.89,,,,,,,,,,,,,
CATHETER CV FULL TY 018 4 FRX15 CM DL J TIP STR NDL SPECTRUM,SUP-2759856,CDM,C1751,HCPCS,0278,RC,,,,both,,,577.38,375.30,,,,,,,,,,,,,
HC US Dup Scn Aorta Ivc Ltd,PX-9219397900,CDM,93979,CPT,0921,RC,,,,both,,,1888.00,1227.20,,,,,,,,,,,,,
ALBUMIN HUMAN 5 % IV SOLN,RX-8982,CDM,P9041,HCPCS,0636,RC,44206-0310-50,NDC,,both,250,ML,517.50,336.37,,,,,,,,,,,,,
PERI LOC 2.7 SUP MED CLAV LK PLATE 6H RT,SUP-2821149,CDM,C1713,HCPCS,0278,RC,,,,both,,,6563.70,4266.40,,,,,,,,,,,,,
CONNECTOR SPNL 1/4 STD POST S STL TRNSVRS CONN XLNK FIX FOR,SUP-2255597,CDM,C1713,HCPCS,0278,RC,,,,both,,,3240.48,2106.31,,,,,,,,,,,,,
COMPONENT PAT SM KNEE PRI REV PCA,SUP-2377626,CDM,C1776,CPT,0278,RC,,,,both,,,3740.37,2431.24,,,,,,,,,,,,,
BOLT EXT FIX UNIV WIRE NS TRUELOK LTX,SUP-2875030,CDM,2720000010,LOCAL,0272,RC,,,,both,,,846.23,550.05,,,,,,,,,,,,,
ELECTRODE DEFIB AD 1 PC DEFIB CPR SYS CPR-D-PADZ,SUP-2416161,CDM,C1713,HCPCS,0278,RC,,,,both,,,465.69,302.70,,,,,,,,,,,,,
HC Med Nut Therapy Ind Fu 15 Min,PX-9429780300,CDM,97803,CPT,0940,RC,,,,inpatient,,,42.00,27.30,,,,,,,,,,,,,
INTRODUCER HEMSTAS FAST CATH 14FRX30CM SHTH W/ L LUMN 0.038,SUP-2355552,CDM,C1894,HCPCS,0272,RC,,,,both,,,63.59,41.33,,,,,,,,,,,,,
SCREW FIX L200MM DIA5MM S STL BLNT TRCR PNT MR CONDITIONAL,SUP-2186957,CDM,C1713,HCPCS,0278,RC,,,,both,,,268.60,174.59,,,,,,,,,,,,,
ALLOGRAFT BNE CHIP 5 CC MAP 3,SUP-2335292,CDM,C1889,HCPCS,0278,RC,,,,both,,,6751.00,4388.15,,,,,,,,,,,,,
POST EXT FIX 3 H FOR SIDEKCK FREE CIR FIX M,SUP-2400684,CDM,2720000010,LOCAL,0272,RC,,,,both,,,292.02,189.81,,,,,,,,,,,,,
HC Apply Long Arm Cast,PX-4502906500,CDM,29065,CPT,0450,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
KIT INT FIX IMPL INSTR SYNDESMOTIC FIX DEV W/ BLNT GWIRE,SUP-2399135,CDM,C1713,HCPCS,0278,RC,,,,both,,,2606.20,1694.03,,,,,,,,,,,,,
HC Iadna Sarscov2& Inf a&B Mult Amp Probe,PX-3068763600,CDM,87636,CPT,0306,RC,,,,both,,,170.00,110.50,,,,,,,,,,,,,
SUPPORT ORTHOT LOWER EXTREMITY PELV CTRL BND BELT UNILAT,SUP-2435688,CDM,L2630,HCPCS,0272,RC,,,,both,,,655.51,426.08,,,,,,,,,,,,,
ANCHOR SUT OD4.5MM BIOCOMP W/ 2X STRND NDL INSITE FT,SUP-2388891,CDM,C1713,HCPCS,0278,RC,,,,both,,,2172.88,1412.37,,,,,,,,,,,,,
SYSTEM ENDOSCP VES HARV CONIC DISECT TIP W/ SYRNGE CANN AND,SUP-2227759,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1792.94,1165.41,,,,,,,,,,,,,
BEVACIZUMAB-BVZR 25 MG/ML IV SOLN (MIXTURES ONLY),RX-430061,CDM,Q5118,HCPCS,0636,RC,00069-0342-01,NDC,,both,16,ML,7066.40,4593.16,,,,,,,,,,,,,
BELL CIRC 1.6 CM REUSE,SUP-2473548,CDM,2720000010,LOCAL,0272,RC,,,,both,,,623.86,405.51,,,,,,,,,,,,,
SYSTEM INTRO L20CM 6FR NIT STD DBL END GWIRE L60CM,SUP-2303023,CDM,C1894,HCPCS,0272,RC,,,,both,,,195.62,127.15,,,,,,,,,,,,,
PLATE BONE DUAL CMPRSSN 37MML HLX3 11MM THK STNLSS STEEL F/,SUP-2721568,CDM,C1713,HCPCS,0278,RC,,,,both,,,331.21,215.29,,,,,,,,,,,,,
FIBER LASER 940 MH UNSHEATHED SCP SAFE SMA905 STRL DISP,SUP-2768497,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4200.38,2730.25,,,,,,,,,,,,,
FIBER LASER DVDF-200 DVI-SC CONV,SUP-2798104,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3414.50,2219.42,,,,,,,,,,,,,
CATHETER CARD ABLATION CELSIUS RMT THERMOCOOL L 130 CM DIA 8,SUP-2248583,CDM,C2630,CPT,0272,RC,,,,both,,,6066.48,3943.21,,,,,,,,,,,,,
INTRO CANN W/STYLET 5PK 6IN 17G,SUP-2366995,CDM,C1713,HCPCS,0278,RC,,,,both,,,336.61,218.80,,,,,,,,,,,,,
GUIDEWIRE VASC L260CM DIA0.035IN TAPR 3CM HYDRPHLC NIT ANG,SUP-2148166,CDM,C1769,HCPCS,0272,RC,,,,both,,,562.06,365.34,,,,,,,,,,,,,
SURGICAL PROCEDURE PACK EYE 25 GA CUST,SUP-2110951,CDM,C1713,HCPCS,0278,RC,,,,both,,,1824.18,1185.72,,,,,,,,,,,,,
GUIDEWIRE ORTH 125X150 MM THRD TIP RAD PLATE SYS SS,SUP-2184108,CDM,C1769,HCPCS,0272,RC,,,,both,,,648.06,421.24,,,,,,,,,,,,,
INSERT ACET SZ P5 OD58-60MM ID28MM THK10MM 0DEG X FRE CO,SUP-2376202,CDM,C1776,CPT,0278,RC,,,,both,,,2751.90,1788.73,,,,,,,,,,,,,
KIT THROMCTMY TREVO XP PROVUE L 180 CM RETRV L 32 MM DIA 4,SUP-2367764,CDM,C1757,HCPCS,0272,RC,,,,both,,,21964.30,14276.79,,,,,,,,,,,,,
ALLOGRAFT BNE WHL ULNA,SUP-2321921,CDM,C1713,HCPCS,0278,RC,,,,both,,,8713.50,5663.77,,,,,,,,,,,,,
HC I&D Abscess Bartholin Gland,PX-4505642000,CDM,56420,CPT,0450,RC,,,,both,,,214.00,139.10,,,,,,,,,,,,,
CATHETER CTRL VEN AD 7FR L60CM POLYUR 3 LUMN N TUNNELED,SUP-2383988,CDM,C1751,HCPCS,0278,RC,,,,both,,,925.23,601.40,,,,,,,,,,,,,
BLADE SURG SAW SAG S STL 750MM LEN 75MM CUT DEPTH 250MM W,SUP-2364340,CDM,2720000010,LOCAL,0272,RC,,,,both,,,168.18,109.32,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 70 MM DIA 7 MM DEL SHTH 3.7ML,SUP-2936812,CDM,C1713,HCPCS,0278,RC,,,,both,,,11496.58,7472.78,,,,,,,,,,,,,
PACEMAKER CARD AVEIR DR TI 2 CHMBR LEADLESS STRL,SUP-2905537,CDM,C1605,HCPCS,0275,RC,,,,both,,,78343.00,50922.95,,,,,,,,,,,,,
TIP ABLATN 23 KHZ STD STRL CUSA CLARITY LTX,SUP-2863642,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2649.63,1722.26,,,,,,,,,,,,,
FELT PTFE NOM THICKNESS 2.87MM 4INX4IN DIAM,SUP-2126672,CDM,C1781,HCPCS,0278,RC,,,,both,,,433.32,281.66,,,,,,,,,,,,,
KNIFE SURG BALLENGER SWVL 8 IN 5 MM BAYNT SHP,SUP-2469584,CDM,2720000010,LOCAL,0272,RC,,,,both,,,521.68,339.09,,,,,,,,,,,,,
PLATE EXT FIX SHT 140 MM FT RNG TI NS,SUP-2800128,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2811.93,1827.75,,,,,,,,,,,,,
RAIL INT FIX NEW AD 250 MM,SUP-2517843,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3504.24,2277.76,,,,,,,,,,,,,
KIT HEMO DYLS OR HD CATH 15.5FR L28CM STD CHRONIC PEEL AWAY,SUP-2120053,CDM,C1751,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
PLATE VARIAX POLYAX NAVICULAR LK LT,SUP-2703202,CDM,C1713,HCPCS,0278,RC,,,,both,,,4892.75,3180.29,,,,,,,,,,,,,
"HC So Htlv or Hiv Ab, Western Blot",PX-3028668966,CDM,86689,CPT,0302,RC,,,,both,,,183.00,118.95,,,,,,,,,,,,,
CROWN FORM DENT STRP U3 PRIMARY ANTR UPPER RT LAT PLAS,SUP-2322250,CDM,D6783,CPT,0278,RC,,,,both,,,40.76,26.49,,,,,,,,,,,,,
PLATE BNE CRANIOFACIAL N COMPR I R TI 30MM SCR H DIA 11 H,SUP-2366357,CDM,C1713,HCPCS,0278,RC,,,,both,,,1071.21,696.29,,,,,,,,,,,,,
FILM OPHTH ABSORBABLE 50X25 MM GEL STRL GELFLM,SUP-2424888,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1021.57,664.02,,,,,,,,,,,,,
SCREW BNE SNAP OFF 2.7X16 MM NS HALLI-FIX DISP,SUP-2242900,CDM,C1713,HCPCS,0278,RC,,,,both,,,1139.57,740.72,,,,,,,,,,,,,
RETRIEVER ENDOSCP L160CM SHTH DIA2.5MM NET 4X5.5CM PLAT,SUP-2391611,CDM,2720000010,LOCAL,0272,RC,,,,both,,,312.40,203.06,,,,,,,,,,,,,
BRACE ANK 2 X SM M SHOE 3-5 WOMEN SHOE 4-6 AD SWEDE O X8,SUP-2325306,CDM,L1930,HCPCS,0274,RC,,,,both,,,68.42,44.47,,,,,,,,,,,,,
CHOLANGIOGRAM KIT RX AUTOTOME UTOM XL SPHINTOM JAGWIRE 7172,SUP-2525319,CDM,C1769,HCPCS,0272,RC,,,,both,,,656.54,426.75,,,,,,,,,,,,,
SET SCR EXT FIX L8MM HEX FIX FOR ILIZ TAY SPAT FRME SYS,SUP-2342377,CDM,C1713,HCPCS,0278,RC,,,,both,,,730.99,475.14,,,,,,,,,,,,,
WAND ABLATOR LIGHT WAVE WITH SUCTION 4MMX165MM 90DEG,SUP-2824436,CDM,2720000010,LOCAL,0272,RC,,,,both,,,738.72,480.17,,,,,,,,,,,,,
SCALPEL SURG TIP 25MM MPLR CANADY HYBRID PLSM,SUP-2391726,CDM,C1713,HCPCS,0278,RC,,,,both,,,1114.70,724.55,,,,,,,,,,,,,
BUR SURG MED 2.4 MM,SUP-2166717,CDM,2720000010,LOCAL,0272,RC,,,,both,,,254.34,165.32,,,,,,,,,,,,,
AMINOCAPROIC ACID 500 MG PO TABS,RX-9063,CDM,6370000000,HCPCS,0637,RC,72205-0049-30,NDC,,both,1,UN,48.80,31.72,,,,,,,,,,,,,
HC Drain Mouth Lesion,PX-4504080100,CDM,40801,CPT,0450,RC,,,,both,,,1337.00,869.05,,,,,,,,,,,,,
SCORPIO-FLEX CRX3 SZ 3 - 24,SUP-2365098,CDM,C1776,CPT,0278,RC,,,,both,,,4773.68,3102.89,,,,,,,,,,,,,
HC NM Radioimmunotherapy Procedure,PX-3427940300,CDM,79403,CPT,0342,RC,,,,both,,,6197.00,4028.05,,,,,,,,,,,,,
HC MRI-Angio Neck WO Contrast,PX-6157054700,CDM,70547,CPT,0615,RC,,,,outpatient,,,4844.00,3148.60,,,,,,,,,,,,,
BUR SURG MTCH HD FLUT SM BOR MIDAS REX LEGEND,SUP-2627637,CDM,2720000010,LOCAL,0272,RC,,,,both,,,287.18,186.67,,,,,,,,,,,,,
STEM FEM L178MM DIA108MM JUNCTION BX LOK BOLT BAL KNEE,SUP-2431847,CDM,C1776,CPT,0278,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
KIT INFUS 6FR POLYUR CATH FOOTPRINT PEEL APART INTRO SIL FIL,SUP-2127759,CDM,C1788,HCPCS,0278,RC,,,,both,,,891.76,579.64,,,,,,,,,,,,,
BRACE KNEE MCL LCL EC HNG NEOPRENE W POPLITEAL PAT UNIV,SUP-2196414,CDM,L1810,HCPCS,0272,RC,,,,both,,,119.48,77.66,,,,,,,,,,,,,
MESH SYNTH INGUINAL N ABSRB RECT POLYPR OVL FLAT SH 18CM,SUP-2265905,CDM,C1781,HCPCS,0278,RC,,,,both,,,135.52,88.09,,,,,,,,,,,,,
SCREW BNE L 8 MM DIA 4.5 MM LCK BLNT TIP STRL EVOS,SUP-2931131,CDM,C1713,HCPCS,0278,RC,,,,both,,,1488.67,967.64,,,,,,,,,,,,,
STENT TRACHBRONCH WSTNT L 40 MM DIA20 MM SHTH 11 FR CATH L,SUP-2147042,CDM,C1876,HCPCS,0278,RC,,,,both,,,3673.80,2387.97,,,,,,,,,,,,,
PLATE BNE MESHED 26X26X1 MM SM GRID PLLA-PGA STRL RESORB XG,SUP-2461689,CDM,C1713,HCPCS,0278,RC,,,,both,,,1561.96,1015.27,,,,,,,,,,,,,
HC Assay of Triiodothyronine T3 Free,PX-3018448100,CDM,84481,CPT,0301,RC,,,,both,,,181.00,117.65,,,,,,,,,,,,,
KIT L90CM OD12FR CATHETER CTRL VEN DBL LUMN TUNNELED BASIC,SUP-2126156,CDM,C1751,HCPCS,0278,RC,,,,both,,,494.02,321.11,,,,,,,,,,,,,
MESH HERN RECTANGULAR 30X40 CM PREPERITONEAL ENFORM,SUP-2539551,CDM,C1781,HCPCS,0278,RC,,,,both,,,50136.38,32588.65,,,,,,,,,,,,,
PIN FIX TARGETER 3.5X40 MM,SUP-2351294,CDM,2720000010,LOCAL,0272,RC,,,,both,,,431.06,280.19,,,,,,,,,,,,,
IMPLANT SYNTH 78 X 61 MM THK 18 MM SM POLYETHYL RT TEMPORAL,SUP-2883436,CDM,C1713,HCPCS,0278,RC,,,,both,,,4745.04,3084.28,,,,,,,,,,,,,
STENT URET UNIVERSA FIRM L 22 CM DIA 6 FR POLYUR AQ BRAIDED,SUP-2171436,CDM,C2617,HCPCS,0278,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
MATRIX WND DERM HUM ACELLULAR 6MM MTRX HD 5CMX8CM,SUP-2335295,CDM,Q4345,HCPCS,0636,RC,,,,both,,,14111.16,9172.25,,,,,,,,,,,,,
CATHETER PICC L55CM OD5FR ID15.5GA GWIRE L145CM SGL LUMN,SUP-2118961,CDM,C1751,HCPCS,0278,RC,,,,both,,,287.91,187.14,,,,,,,,,,,,,
SCREW SPNL L50MM OD6.5MM 30DEG TI POST ST VAR ANG CANN THRD,SUP-2230544,CDM,C1713,HCPCS,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
BAND SCLER W2.5XL125MM THK0.6MM SIL CIR CERCLAGE PERM BCKL,SUP-2213473,CDM,C1784,HCPCS,0278,RC,,,,both,,,37.68,24.49,,,,,,,,,,,,,
PROBE US L330MM DIA33MM LITHO SWISS LITHOCLAST,SUP-2139433,CDM,C1713,HCPCS,0278,RC,,,,both,,,1725.62,1121.65,,,,,,,,,,,,,
ROD PUSH GUIDEWIRE,SUP-2934549,CDM,C1769,HCPCS,0272,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
WIRE FIX L150MM OD1.4MM NICKEL CHROM THRD SGL END TRCR TIP,SUP-2321627,CDM,C1713,HCPCS,0278,RC,,,,both,,,172.70,112.25,,,,,,,,,,,,,
CLIP ENDOSCP 7 FRX230 CM 2.8 MM INSTINCT,SUP-2858585,CDM,2720000010,LOCAL,0272,RC,,,,both,,,697.08,453.10,,,,,,,,,,,,,
SCREW BNE CORTICAL 2.7X20 MM FUSION HEX DRV YEL WRST SS NS,SUP-2851924,CDM,C1713,HCPCS,0278,RC,,,,both,,,649.85,422.40,,,,,,,,,,,,,
HC Thromblytic Art/Ven Therapy,PX-3613721300,CDM,37213,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
KIT PICC CATH L 50 CM DIA 6 FR GUIDEWIRE 0.018 IN NDL L 7 CM,SUP-2884237,CDM,C1751,HCPCS,0278,RC,,,,both,,,947.24,615.71,,,,,,,,,,,,,
PLATE BNE L116MM 4 H ST L OLECRANON TI LO PROF VAR ANG LOK,SUP-2180820,CDM,C1713,HCPCS,0278,RC,,,,both,,,3886.63,2526.31,,,,,,,,,,,,,
SET INTRO EXACTA L 10 CM DIA 8.5 FR CANN L 7 CM DIA16 GA,SUP-2662689,CDM,C1894,HCPCS,0272,RC,,,,both,,,87.20,56.68,,,,,,,,,,,,,
GRAFT ALLGRFT SH CANC 20MMX50MM,SUP-2415402,CDM,C1713,HCPCS,0278,RC,,,,both,,,4050.60,2632.89,,,,,,,,,,,,,
OXYGENATOR FX15 W/O RESERVOIR,SUP-2849774,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1039.34,675.57,,,,,,,,,,,,,
GRAFT BNE SUB SM W8XH10XL8MM COMPRESSIBLE SPNG PROVIDE,SUP-2138502,CDM,C1713,HCPCS,0278,RC,,,,both,,,2523.30,1640.14,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY L 110 CM DIA 6 FR E CRV,SUP-2148873,CDM,C1732,HCPCS,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
IMPLANT HUM TISS L 2-2.4 X W 1-2 CM THK 1.8-2.2 MM 2XS,SUP-2894574,CDM,C1762,CPT,0278,RC,,,,both,,,1407.60,914.94,,,,,,,,,,,,,
SCREW BNE L45MM OD65MM S STL HINDFOOT LOK ADVANSYS SURFIX,SUP-2243420,CDM,C1713,HCPCS,0278,RC,,,,both,,,1248.31,811.40,,,,,,,,,,,,,
PLATE BNE L 73 MM SCREW DIA2 MM 3 HD 10 SHFT H TI T SHP MINI,SUP-2908017,CDM,C1713,HCPCS,0278,RC,,,,both,,,3114.00,2024.10,,,,,,,,,,,,,
KIT INT FIX W4.75XL19.1MM 2ND W/ SWIVELOCK FOR ACL/PCL REP,SUP-2121407,CDM,C1713,HCPCS,0278,RC,,,,both,,,2590.50,1683.82,,,,,,,,,,,,,
SCREW COMPR 6.5X40MM HEADLESS THRD LEN 16MM STRL,SUP-2546138,CDM,C1713,HCPCS,0278,RC,,,,both,,,987.06,641.59,,,,,,,,,,,,,
BIT DRL L 255 MM DIA2.1 MM STP 22 MM SEEG NS DISP,SUP-2935163,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1058.18,687.82,,,,,,,,,,,,,
PLATE BNE LCK LG LT CLAV 8 HOLE,SUP-2266344,CDM,C1713,HCPCS,0278,RC,,,,both,,,1990.57,1293.87,,,,,,,,,,,,,
"HC So Antibody Virus, Nos",PX-3028679066,CDM,86790,CPT,0302,RC,,,,outpatient,,,87.00,56.55,,,,,,,,,,,,,
PROBE E ENDOSCP J 5MMX45CM DISPOSABLE ST 0250070555,SUP-2361229,CDM,2720000010,LOCAL,0272,RC,,,,both,,,671.58,436.53,,,,,,,,,,,,,
COAGULATION FACTOR VIIA RECOMB 2 MG IV SOLR,RX-92854,CDM,J7189,HCPCS,0636,RC,00169-7202-01,NDC,,both,1,UN,16579.00,10776.35,,,,,,,,,,,,,
HC So Insulin,PX-3018352566,CDM,83525,CPT,0301,RC,,,,both,,,402.00,261.30,,,,,,,,,,,,,
NAIL IM L420MM DIA13MM 125DEG LT LAT FEM TI CANN LCK AG ANG,SUP-2361814,CDM,C1713,HCPCS,0278,RC,,,,both,,,5898.80,3834.22,,,,,,,,,,,,,
PLATE BONE LNG 4X6 H MIDFACE GLD TI LT L SHP RIG TI GRD 4,SUP-2135916,CDM,C1713,HCPCS,0278,RC,,,,both,,,766.16,498.00,,,,,,,,,,,,,
DEVICE SPNL INTBDY POST COR OCTAVE 8MM,SUP-2264522,CDM,C1713,HCPCS,0278,RC,,,,both,,,10990.00,7143.50,,,,,,,,,,,,,
WIRE FIX 3+ MM 2X220 MM PRO KIRSCHNER,SUP-2536051,CDM,2720000010,LOCAL,0272,RC,,,,both,,,141.30,91.84,,,,,,,,,,,,,
ENDCAP ORTH NONSTERILE S STL END FOR OLECRANON OSTEOTMY,SUP-2183156,CDM,C1889,HCPCS,0278,RC,,,,both,,,853.01,554.46,,,,,,,,,,,,,
NAIL FIX L 70 MM DIA 5.5 MM LG THRD TRIM STRL OSSIOFIBER,SUP-2904328,CDM,C1713,HCPCS,0278,RC,,,,both,,,4976.90,3234.98,,,,,,,,,,,,,
MICRO BONE PLATE DOUBLE Y SHAPE 8 HOLE CP TITANIUM,SUP-2677935,CDM,C1713,HCPCS,0278,RC,,,,both,,,537.25,349.21,,,,,,,,,,,,,
HC Iop Tx 30 Min,PX-9149083200,CDM,90832,CPT,0914,RC,,,,both,,,896.00,582.40,,,,,,,,,,,,,
DRILL SURG 5MM LNG PIN FOR BIO-TRANSFIX II,SUP-2121628,CDM,C1713,HCPCS,0278,RC,,,,both,,,926.30,602.09,,,,,,,,,,,,,
PLATE BNE L 57 MM SCREW DIA2.4 MM 8 SHFT H TI STR COMPACT,SUP-2907778,CDM,C1713,HCPCS,0278,RC,,,,both,,,4185.56,2720.61,,,,,,,,,,,,,
EXTRACTOR STONE 1.7FR L115CM BSKT DIA11MM NIT FOR URET STONE,SUP-2170591,CDM,2720000010,LOCAL,0272,RC,,,,both,,,740.13,481.08,,,,,,,,,,,,,
"HC Plate,Leuk Red,Cmv-Neg,Irr Ea",PX-3900905300,CDM,P9053,CPT,0390,RC,,,,both,,,2279.00,1481.35,,,,,,,,,,,,,
SYSTEM HRT VLV REP MITRL TRICSP ANNULPLSTY W/ DURAFLO 26MM,SUP-2214204,CDM,C1889,HCPCS,0278,RC,,,,both,,,9734.00,6327.10,,,,,,,,,,,,,
PLATE BNE L 77 MM SCREW DIA 4.5 MM 4 H NAR COMPR NLCK NS,SUP-2933398,CDM,C1713,HCPCS,0278,RC,,,,both,,,1574.71,1023.56,,,,,,,,,,,,,
BIT DRL L145MM DIA3.2MM ST 3 FLUT QUIK CPL NONRADIOPAQUE,SUP-2187597,CDM,2720000010,LOCAL,0272,RC,,,,both,,,420.32,273.21,,,,,,,,,,,,,
HC Fo W/Joint Custom Fit,PX-2740393501,CDM,L3935,HCPCS,0272,RC,,,,both,,,734.00,477.10,,,,,,,,,,,,,
CORE SLIDING UHMPWE 11MM REVISION,SUP-2878125,CDM,C1776,CPT,0278,RC,,,,both,,,7297.05,4743.08,,,,,,,,,,,,,
HC So Immunology Procedure,PX-3028684966,CDM,86849,CPT,0302,RC,,,,both,,,27.00,17.55,,,,,,,,,,,,,
SMALL ACP PLATE 27 8 HOLES L 68,SUP-2706086,CDM,C1713,HCPCS,0278,RC,,,,both,,,408.83,265.74,,,,,,,,,,,,,
REINFORCEMENT STPL LN SUREFORM BLK SEAMGRD 1BSGXI60BK,SUP-2762592,CDM,C1781,HCPCS,0278,RC,,,,both,,,656.26,426.57,,,,,,,,,,,,,
HC Sclerotherapy Multiple Veins,PX-3613647100,CDM,36471,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
PUNCH AORT 3.8MM 5 3/4IN DISP PSTL GRP HNDL CONE TIP CUT,SUP-2227559,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
PLATE BNE L ANAT TENS SIDE PLNTR PYTHON LAPIPLASTY,SUP-2389089,CDM,C1713,HCPCS,0278,RC,,,,both,,,5636.30,3663.59,,,,,,,,,,,,,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1938,HCPCS,0636,RC,63323-0280-01,NDC,,both,2,ML,54.10,35.16,,,,,,,,,,,,,
GUIDE WIRE 1.3 MMX35.6 CM NIT,SUP-2608337,CDM,C1769,HCPCS,0272,RC,,,,both,,,661.60,430.04,,,,,,,,,,,,,
IMPLANT TOE SM L13MM PROX L7MM DIA2.8MM DST L5.5MM DIA4MM,SUP-2397780,CDM,C1776,CPT,0278,RC,,,,both,,,1548.02,1006.21,,,,,,,,,,,,,
CARBON FIBER ROD 9.5MMX150MM,SUP-2828990,CDM,C1713,HCPCS,0278,RC,,,,both,,,1083.30,704.14,,,,,,,,,,,,,
KIT TRNSDUC 84IN 4IN TBNG 1 SGL LN PRT AND RESVR POLE MT,SUP-2214662,CDM,C1713,HCPCS,0278,RC,,,,both,,,90.56,58.86,,,,,,,,,,,,,
SUPPORT ORTHOT KNEE CUST DBL UPR PREFABRICATED OFF THE SHLF,SUP-2435619,CDM,L1852,HCPCS,0274,RC,,,,both,,,2371.58,1541.53,,,,,,,,,,,,,
SCREW INTFR L23MM DIA8MM BIOCOMPOSITE BIO-TENODESIS,SUP-2121356,CDM,C1713,HCPCS,0278,RC,,,,both,,,1083.30,704.14,,,,,,,,,,,,,
CATHETER PULM ART 4FR L110CM INTRO 5FR BAL 0.60CC DIA6MM,SUP-2120571,CDM,C1727,CPT,0278,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
COMPONENT FEM SZ 1 LT POST STBL CEM GMK,SUP-2267589,CDM,C1776,CPT,0278,RC,,,,both,,,8439.22,5485.49,,,,,,,,,,,,,
PLATE EXT FIX 1 H CIR FIX SIDEKCK FREE,SUP-2400607,CDM,2720000010,LOCAL,0272,RC,,,,both,,,244.92,159.20,,,,,,,,,,,,,
TRAY KYPHOPLASTY BLLN 4ML L20MM DIA16.1MM NDL 11GA SYR 20ML,SUP-2367078,CDM,C1713,HCPCS,0278,RC,,,,both,,,16485.00,10715.25,,,,,,,,,,,,,
BUR ROBOT SURG DIA 5 MM CYL STRL DISP REAL INTELLIGENCE CORI,SUP-2927270,CDM,C1776,CPT,0278,RC,,,,both,,,299.02,194.36,,,,,,,,,,,,,
"HC Aerosol, Hhn, Mdi, Ippb",PX-4109464000,CDM,94640,CPT,0410,RC,,,,both,,,186.00,120.90,,,,,,,,,,,,,
ENDOSCOPIC KIT COLON W/ 1.1 OZ LUBE HYDR ORCA W/O BRSH,SUP-2472601,CDM,2720000010,LOCAL,0272,RC,,,,both,,,44.81,29.13,,,,,,,,,,,,,
PROCESSOR SND SLV GRY BAHA INTENSO,SUP-2164953,CDM,L8691,HCPCS,0278,RC,,,,both,,,9891.00,6429.15,,,,,,,,,,,,,
KIT INTRO DIA 6 FR PERC TUOHY BORST 1 PC STRL,SUP-2876527,CDM,C1894,HCPCS,0272,RC,,,,both,,,185.26,120.42,,,,,,,,,,,,,
DRILL TWST L27MM DIA1.4MM W/O STP NONRADIOLUCENT DENT END,SUP-2374212,CDM,2720000010,LOCAL,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
SPLINT THMB AD M FOR 6.5-7.5IN RT WR REG TRIOXON LINING,SUP-2324738,CDM,L3931,HCPCS,0272,RC,,,,both,,,60.95,39.62,,,,,,,,,,,,,
PLATE BNE SZ 20MM 2 H COMPR,SUP-2243484,CDM,C1713,HCPCS,0278,RC,,,,both,,,5659.38,3678.60,,,,,,,,,,,,,
BLOCK ORTH AIMING LT PROX LAT HUM LCK FOR PLATE TI AXSOS 3,SUP-2472735,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2321.09,1508.71,,,,,,,,,,,,,
BIT DRL L82MM OD1MM 20MM STP TWST DENT N RADLUC DISP,SUP-2267816,CDM,2720000010,LOCAL,0272,RC,,,,both,,,490.47,318.81,,,,,,,,,,,,,
SUPPORT ORTHOT CUST OUTFLARE WDG,SUP-2435725,CDM,L3390,HCPCS,0274,RC,,,,both,,,140.42,91.27,,,,,,,,,,,,,
GUIDEWIRE VASC 145CM 0.035IN TIP 2.5CM RAD 3MM HEPARIN,SUP-2167603,CDM,C1769,HCPCS,0272,RC,,,,both,,,36.14,23.49,,,,,,,,,,,,,
KIT GASTJEJUSTMY 16FR L45CM BAL 7-10ML SIL TRANSGASTRIC JEJU,SUP-2236564,CDM,2720000010,LOCAL,0272,RC,,,,both,,,733.69,476.90,,,,,,,,,,,,,
SET BILI STENT COT-LNG L 18 CM DIA10 FR PUSH L 170 CM GUIDE,SUP-2169130,CDM,C2625,HCPCS,0278,RC,,,,both,,,401.92,261.25,,,,,,,,,,,,,
BIT DRL L58MM DIA1.6MM FOR 20MM 2/2.3MM BNE SCR LEIBINGER,SUP-2366422,CDM,2720000010,LOCAL,0272,RC,,,,both,,,433.60,281.84,,,,,,,,,,,,,
DEFIBRILLATOR CRD SINGLE CHMBR 30 J STR CURRENT VR,SUP-2356047,CDM,C1722,HCPCS,0275,RC,,,,both,,,71435.00,46432.75,,,,,,,,,,,,,
GUIDEWIRE VASC AGIL 14 L 205 CM DIA 0.014 IN TAPR L 42 CM SS,SUP-2158113,CDM,C1769,HCPCS,0272,RC,,,,both,,,926.30,602.09,,,,,,,,,,,,,
NAIL INTRMDLLRY 10.5MM DIA 380MML TTNM ALLOY PRXML TBL ANTGR,SUP-2588059,CDM,C1713,HCPCS,0278,RC,,,,both,,,4585.15,2980.35,,,,,,,,,,,,,
PLATE SPNL OD 32MM L100MM UNIV TI ANT OCCIPITAL 3 H TEMPLT,SUP-2286686,CDM,C1713,HCPCS,0278,RC,,,,both,,,7220.43,4693.28,,,,,,,,,,,,,
SPLINT THMB AD M FOR 6.5-7.5IN RT WR REG TRIOXON LINING,SUP-2324738,CDM,L3931,HCPCS,0274,RC,,,,both,,,60.95,39.62,,,,,,,,,,,,,
GUIDEWIRE ORTH DIA16MM FOR 37MM CANN LOK SCR,SUP-2188304,CDM,C1769,HCPCS,0272,RC,,,,both,,,685.05,445.28,,,,,,,,,,,,,
GRAFT BNE SUB W20-24XL55MM ILIUM TRICORT STRP FRZ DRY FOR,SUP-2307166,CDM,C9362,HCPCS,0278,RC,,,,both,,,5972.28,3881.98,,,,,,,,,,,,,
I/B II CCK TIB ART SURF SIZE 5925MM HEIGHT,SUP-2502089,CDM,C1776,CPT,0278,RC,,,,both,,,10110.80,6572.02,,,,,,,,,,,,,
PLATE BNE HK SM 3.5/4.5X211 MM RT FEM PROX 5 STRL VA-LCP,SUP-2750911,CDM,C1713,HCPCS,0278,RC,,,,both,,,7790.56,5063.86,,,,,,,,,,,,,
PLATE PL DSTL HUM LAT SUPP 3.5MM 9H RT 143MM LCP STRL,SUP-2547567,CDM,C1713,HCPCS,0278,RC,,,,both,,,3725.08,2421.30,,,,,,,,,,,,,
COMP FEM AUG BTN SM/MED 10 DTL,SUP-2513643,CDM,C1776,CPT,0278,RC,,,,both,,,430.18,279.62,,,,,,,,,,,,,
ELECTRODE RESECT 24FR WIRE 02IN,SUP-2313575,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1692.46,1100.10,,,,,,,,,,,,,
SCREW BONE LOK 6.5MM DIA 75MML TIMAX CNCLLS HXGNL DRIVE HEAD,SUP-2588749,CDM,C1713,HCPCS,0278,RC,,,,both,,,140.70,91.45,,,,,,,,,,,,,
CATHETER VALVULOPLASTY TYSHAK NUCLS L 100 CM 5.5 FR 2 CM 4MM,SUP-2659671,CDM,C1725,HCPCS,0272,RC,,,,both,,,2339.43,1520.63,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 4X4 CM AMNIO WND MTRX BIOSKIN,SUP-2759454,CDM,Q4163,HCPCS,0636,RC,,,,both,,,7456.90,4846.98,,,,,,,,,,,,,
STAPLE MENIS ABSRB 13MM,SUP-2212870,CDM,C1713,HCPCS,0278,RC,,,,both,,,1422.42,924.57,,,,,,,,,,,,,
RING TRNSJUG INTRAHEPATIC 18GA NDL L55CM 7FR INTRO PED ACCS,SUP-2168279,CDM,C1894,HCPCS,0272,RC,,,,both,,,1671.27,1086.33,,,,,,,,,,,,,
MARKER GRFT SCANLAN A/C LOC,SUP-2336955,CDM,A4648,CPT,0278,RC,,,,both,,,59.66,38.78,,,,,,,,,,,,,
GUIDEWIRE UROLOGICAL ZIPWIRE 0.025IN 150CM 3CM TAPER,SUP-2862316,CDM,C1769,HCPCS,0272,RC,,,,both,,,168.56,109.56,,,,,,,,,,,,,
APPLICATOR TY BRACHYTHERAPY SAVI 10-1,SUP-2164404,CDM,C1728,HCPCS,0272,RC,,,,both,,,8635.00,5612.75,,,,,,,,,,,,,
CATH REPROC SOFTTIP BM VIKING JSN 4POLE 6FR 5MM 110CM,SUP-2526063,CDM,C1730,HCPCS,0272,RC,,,,both,,,113.89,74.03,,,,,,,,,,,,,
NAIL IM L440MM DIA3MM PROX TIB G TI ALLY,SUP-2192729,CDM,C1713,HCPCS,0278,RC,,,,both,,,868.74,564.68,,,,,,,,,,,,,
COIL EMB L3CM OD3MM .020IN NIT NEUROVASC COMPLX SFT FILL,SUP-2323388,CDM,C1889,HCPCS,0278,RC,,,,both,,,7360.16,4784.10,,,,,,,,,,,,,
TRASTUZUMAB-STRF 420 MG IV SOLR,RX-170232,CDM,J3376,HCPCS,0636,RC,69448-0016-11,NDC,,both,1,UN,10667.60,6933.94,,,,,,,,,,,,,
PLATE BURR H DIA21.77 MM THK 1.32 MM SCREW DIA1.5 MM SZ 17,SUP-2935900,CDM,C1713,HCPCS,0278,RC,,,,both,,,712.78,463.31,,,,,,,,,,,,,
CUTTER PIN 63MM SIDE CUT L22 3 8IN S STL,SUP-2161239,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2059.15,1338.45,,,,,,,,,,,,,
KIT GUIDEPIN DIA2MM DRL TIP SHT THRD PIN UNICAP,SUP-2123695,CDM,C1713,HCPCS,0278,RC,,,,both,,,973.40,632.71,,,,,,,,,,,,,
GRAFT BNE PTTY 10 CC PRE-MIXED MOLD SYR DBM PUROS LF,SUP-2205389,CDM,C1734,HCPCS,0278,RC,,,,both,,,3909.30,2541.04,,,,,,,,,,,,,
ALLOGRAFT BNE 100 MM PRESERVON FEM SHFT MATRIGRAFT,SUP-2741089,CDM,C1762,CPT,0278,RC,,,,both,,,2647.59,1720.93,,,,,,,,,,,,,
PLATE BONE 168MML HLX8 STNLSS STEEL CLVRLF F/3.5MM SCREW SM,SUP-2494295,CDM,C1713,HCPCS,0278,RC,,,,both,,,1210.91,787.09,,,,,,,,,,,,,
WALKER SHT LEG DLX BLK XL,SUP-2276714,CDM,L4387,HCPCS,0274,RC,,,,both,,,86.60,56.29,,,,,,,,,,,,,
SEGMENT FEM SZ 34C PROX MTPHSEAL CALCAR HIP MALLORY-HEAD TI,SUP-2403418,CDM,C1776,CPT,0278,RC,,,,both,,,15072.00,9796.80,,,,,,,,,,,,,
BRACE ORTH L8IN FOR 10IN WRST UNIV R NYL QUICK FIT,SUP-2197071,CDM,L3908,HCPCS,0272,RC,,,,both,,,30.30,19.69,,,,,,,,,,,,,
STAPLE SPNL SINGLE 13 MM CD HORZ,SUP-2630057,CDM,C1713,HCPCS,0278,RC,,,,both,,,759.88,493.92,,,,,,,,,,,,,
STAPLER 60MM POWERED ECHELON 3000 LONG 440MM,SUP-2855404,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1389.17,902.96,,,,,,,,,,,,,
WASHER ORTH L5.5MM TI POST SCR,SUP-2269748,CDM,C1713,HCPCS,0278,RC,,,,both,,,1563.72,1016.42,,,,,,,,,,,,,
PEG BONE FIXATION 2MM DIA 10MML COBALT CHROMIUM,SUP-2862336,CDM,C1713,HCPCS,0278,RC,,,,both,,,349.29,227.04,,,,,,,,,,,,,
PROBE ABLAT 90DEG ASPIR MULTIPORT BPLR RF 1 PC ELECTRD ERGO,SUP-2123447,CDM,2720000010,LOCAL,0272,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
CATHETER EP MED 2 MM 1 MM 5 FRX110 CM INQUIRY,SUP-2357430,CDM,C1730,HCPCS,0272,RC,,,,both,,,823.34,535.17,,,,,,,,,,,,,
ROD SPNL DIA 6 MM CARBON FIBER PEDCL PT SPEC CRV STRL,SUP-2883041,CDM,C1713,HCPCS,0278,RC,,,,both,,,49455.00,32145.75,,,,,,,,,,,,,
RING ANNULPLSTY 27MM FLX ADJ ATTUNE,SUP-2355754,CDM,C1889,HCPCS,0278,RC,,,,both,,,3344.10,2173.66,,,,,,,,,,,,,
HEAD HUM 48X44 MM OFFSET HEMICAP OVO,SUP-2776724,CDM,C1776,CPT,0278,RC,,,,both,,,12625.94,8206.86,,,,,,,,,,,,,
PIN EXTERNAL FIXATION HALF LONG 6X45 MM TITANIUM NITRIDE STE,SUP-2836809,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1251.82,813.68,,,,,,,,,,,,,
NANOBITER STRAIGHT TIP AR10911D1,SUP-2843604,CDM,2720000010,LOCAL,0272,RC,,,,both,,,832.10,540.86,,,,,,,,,,,,,
LINER ACET CUP NEUT REV SNAP IN MTL ON POLY POLYETH ECC 64MM,SUP-2202277,CDM,C1776,CPT,0278,RC,,,,both,,,3642.40,2367.56,,,,,,,,,,,,,
BIT DRL L13MM DIA2.8MM TAP FOR POLARUS 2 HUM ROD SYS,SUP-2107700,CDM,2720000010,LOCAL,0272,RC,,,,both,,,194.68,126.54,,,,,,,,,,,,,
CATHETER PACE 6FR L110CM 1CM ELECTRD SPACE R HRT CARD VENT,SUP-2355217,CDM,C1730,HCPCS,0272,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
MESH CRANIAL CONTOURABLE 1.5X100X0.5 MM RAPID RESORBABLE STE,SUP-2838577,CDM,C1713,HCPCS,0278,RC,,,,both,,,10948.24,7116.36,,,,,,,,,,,,,
GRAFT HUM TISS R LAT FEM KNEE FRSH ASEP HEMI CNDYL,SUP-2113918,CDM,C1713,HCPCS,0278,RC,,,,both,,,35874.50,23318.42,,,,,,,,,,,,,
CONNECTOR SPNL THORLUM TI PARA SM STAT FOR 6MM ROD USS II,SUP-2193433,CDM,C1713,HCPCS,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
PLATE BNE SELLA RECON 20X20X0.3 MM W/ TAB PLLA-PGA STRL,SUP-2463081,CDM,C1713,HCPCS,0278,RC,,,,both,,,2376.38,1544.65,,,,,,,,,,,,,
PLATE BNE THK 2.6 MM SM TI RAMUS DBL ANGLE NS DISP TRAUMAONE,SUP-2935755,CDM,C1713,HCPCS,0278,RC,,,,both,,,9781.10,6357.71,,,,,,,,,,,,,
STRAP FNGR W5/8IN BGE BUDDY HK LOOP CLSR ROLYAN,SUP-2324809,CDM,L3933,HCPCS,0274,RC,,,,both,,,4.24,2.76,,,,,,,,,,,,,
WALKER SHT LEG DLX BLK XL,SUP-2276714,CDM,L4387,HCPCS,0272,RC,,,,both,,,86.60,56.29,,,,,,,,,,,,,
SCREW BNE L 120 MM DIA 3.5 MM SS CORTICAL ST NS EVOS,SUP-2932168,CDM,C1713,HCPCS,0278,RC,,,,both,,,180.61,117.40,,,,,,,,,,,,,
BLADE SHAVER EXPANDABLE NS FLAREHAWK 7 LTX,SUP-2877232,CDM,2720000010,LOCAL,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
ACETAMINOPHEN 325 MG RE SUPP,RX-104,CDM,6370000000,HCPCS,0637,RC,51672-2116-02,NDC,,both,1,UN,8.80,5.72,,,,,,,,,,,,,
SYSTEM BLLN DISECT ACCS OVL KII,SUP-2420137,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
BOOT AMBULTNG BOOT ADL DKBLU,SUP-2272967,CDM,L4397,HCPCS,0272,RC,,,,both,,,170.50,110.82,,,,,,,,,,,,,
CLIP SURG L155CM CHN DIA2.8MM OPN W11IN RESOL 360 20/BX,SUP-2679024,CDM,C1889,HCPCS,0278,RC,,,,both,,,562.06,365.34,,,,,,,,,,,,,
OSTEOTOME SURG L67MM DIA6MM FLX HARRIS,SUP-2375015,CDM,2720000010,LOCAL,0272,RC,,,,both,,,798.03,518.72,,,,,,,,,,,,,
BIT DRL L280MM DIA17MM L QUIK CPL CANN,SUP-2178841,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1824.91,1186.19,,,,,,,,,,,,,
ROD EXT FIX L280MM DIA8MM C FBR CONN REUSE,SUP-2188746,CDM,2720000010,LOCAL,0272,RC,,,,both,,,444.00,288.60,,,,,,,,,,,,,
GRAFT BNE SUB W12XH22XL38MM BOV CANC WDG RECT CANCELLO-PURE,SUP-2397870,CDM,C1713,HCPCS,0278,RC,,,,both,,,5532.68,3596.24,,,,,,,,,,,,,
IMPLANT PELV RECON PORCINE CLLGN GRFT HERN 1 LAYR ADV TISS,SUP-2168799,CDM,C1763,HCPCS,0278,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
COMPONENT FEM SEG C RT DSTL KNEE,SUP-2437243,CDM,C1776,CPT,0278,RC,,,,both,,,21406.95,13914.52,,,,,,,,,,,,,
SET HAD CATHETER 155FR L15CM BASIC STR EXTN DIL SCALP VLV,SUP-2266989,CDM,C1752,HCPCS,0278,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
BIT DRL 8 GA STR HND COMPATIBLE OSSEOFLEX,SUP-2480478,CDM,2720000010,LOCAL,0272,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
BASKET URO DIA1.8CM SHTH L50CM DIA5/8FR NIT FOR STONE REM,SUP-2168209,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1175.62,764.15,,,,,,,,,,,,,
LEAD NEUROSTIMULATOR 8 CNTCT L70CM TRL STYL LIN ST,SUP-2138786,CDM,C1778,HCPCS,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
GRAFT VASC EXXCEL SFT L 80 CM SUPP L 60 CM DIA 6 MM EPTFE,SUP-2266066,CDM,C1768,CPT,0278,RC,,,,both,,,4377.16,2845.15,,,,,,,,,,,,,
CRANIAL ACCESS KIT W/ DRUG 2 DRL BIT NO RAZOR,SUP-2852685,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2543.40,1653.21,,,,,,,,,,,,,
HC Bld Bank Phys Svcs Authj Devij Standard Reprt,PX-3058607900,CDM,86079,CPT,0305,RC,,,,both,,,175.00,113.75,,,,,,,,,,,,,
SHEATH URET ACCS NAVIGATOR 11/13 FR X 46 CM,SUP-2141691,CDM,C1894,HCPCS,0272,RC,,,,both,,,349.26,227.02,,,,,,,,,,,,,
BIT DRL DIA4.1MM TIB FOR ARTH NAIL SYS PANTA 2,SUP-2417298,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1598.48,1039.01,,,,,,,,,,,,,
STENT PERIPH LIFESTENT L 120 MM DIA 6 MM CATH L 130 CM DIA 6,SUP-2128185,CDM,C1876,HCPCS,0278,RC,,,,both,,,6908.00,4490.20,,,,,,,,,,,,,
INSERT HUM H+15MM DIA36MM CONSTRN SHLDR POLYETH AEQUALIS,SUP-2399864,CDM,C1776,CPT,0278,RC,,,,both,,,3744.45,2433.89,,,,,,,,,,,,,
EEA CIR STPLR W TRISTAPLE TECHNOLOGY 31MM M THICK,SUP-2172450,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3327.33,2162.76,,,,,,,,,,,,,
HC Sedimentation Rate RBC Non-Automated,PX-3058565100,CDM,85651,CPT,0305,RC,,,,both,,,166.00,107.90,,,,,,,,,,,,,
SHEATH INTRO L 36 IN DIA12 FR SS NIT WIRE FEM CRV INNR LD,SUP-2169590,CDM,C1725,HCPCS,0272,RC,,,,both,,,769.27,500.03,,,,,,,,,,,,,
DEVICE VENTRICULAR ASST KT,SUP-2356020,CDM,C1713,HCPCS,0278,RC,,,,both,,,274750.00,178587.50,,,,,,,,,,,,,
PLATE BONE STRUT 2 MM 2X18 HOLE RAPID RESORBABLE STERILE RAP,SUP-2838596,CDM,C1713,HCPCS,0278,RC,,,,both,,,2428.79,1578.71,,,,,,,,,,,,,
SCREW BNE L10MM DIA42MM NONLOCKING GORILLA PLATING SYS R3CON,SUP-2321380,CDM,C1713,HCPCS,0278,RC,,,,both,,,463.15,301.05,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED UNI STEJK4] STRYKER CORP],SUP-2365945,CDM,C1776,CPT,0278,RC,,,,both,,,8478.00,5510.70,,,,,,,,,,,,,
KIT KYPHOPLASTY IVAS ELITE BALLOON L 10 MM NDL 10 GA SINGLE,SUP-2653969,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4264.31,2771.80,,,,,,,,,,,,,
SCREW BNE L24MM TIP DIA4MM 2.5MM HEX STD ST ST FULL THRD,SUP-2107343,CDM,C1713,HCPCS,0278,RC,,,,both,,,1431.84,930.70,,,,,,,,,,,,,
SHEATH INTRO 50 DEG 0.038 INX180 CM 8.5 FRX63 CM HEARTSPAN,SUP-2464796,CDM,C1893,HCPCS,0272,RC,,,,both,,,448.39,291.45,,,,,,,,,,,,,
SET VASC ACCS PERFRMR L 13 CM OD 6 FR ID 2 MM GUIDEWIRE L 40,SUP-2168554,CDM,C1894,HCPCS,0272,RC,,,,both,,,104.25,67.76,,,,,,,,,,,,,
GUIDEWIRE VASC L 175 MM DIA 0.018 IN SS STR STEER,SUP-2158112,CDM,C1769,HCPCS,0272,RC,,,,both,,,960.84,624.55,,,,,,,,,,,,,
HC So Ethosuximide (Zarontin),PX-3018016866,CDM,80168,CPT,0301,RC,,,,both,,,470.00,305.50,,,,,,,,,,,,,
BATTERY VENT ASST L PT WAIST PK,SUP-2282573,CDM,Q0498,HCPCS,0272,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
IMPLANT OPHTH BCKL 2.5X6 MM CONVX TIRE SCLER STYL 286 SIL,SUP-2382004,CDM,C1784,HCPCS,0278,RC,,,,both,,,66.57,43.27,,,,,,,,,,,,,
STAPLER INT 10X15X13 MM NIT MEMOFIX,SUP-2609671,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3436.35,2233.63,,,,,,,,,,,,,
SNARE VASC 1 SNR L 65 CM DIA25 MM DIA 6 FR SATIN FINISH L 65,SUP-2303146,CDM,C1773,HCPCS,0272,RC,,,,both,,,832.10,540.86,,,,,,,,,,,,,
BIT DRILL QUICK COUPLING 4.5X170/196 MM 3 FLUTED STERILE TC1,SUP-2837040,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1583.82,1029.48,,,,,,,,,,,,,
KIT INTRO L 11 CM DIA 4 FR GUIDEWIRE L 45 CM DIA 0.025 IN SS,SUP-2876486,CDM,C1894,HCPCS,0272,RC,,,,both,,,144.44,93.89,,,,,,,,,,,,,
SUPPORT ORTHOT ANK KNEE CUST MULTILIGAMENTOUS PREFABRICATED,SUP-2435624,CDM,L1906,HCPCS,0272,RC,,,,both,,,318.33,206.91,,,,,,,,,,,,,
GUIDEWIRE VASC L300CM DIA0.035IN 6MM SFT FIX COR FLX J TIP,SUP-2355725,CDM,C1769,HCPCS,0272,RC,,,,both,,,175.84,114.30,,,,,,,,,,,,,
CONE TIB M H25MM ECC 3 D MTL,SUP-2267617,CDM,C1776,CPT,0278,RC,,,,both,,,12385.73,8050.72,,,,,,,,,,,,,
KIT CATH PALINDROME IMPL DL,SUP-2174248,CDM,C1881,HCPCS,0278,RC,,,,both,,,1267.68,823.99,,,,,,,,,,,,,
CATHETER ANGIOPLSTY L135CM BAL L15MM DIA4MM HYDROPHOBIC RAP,SUP-2101617,CDM,C1725,HCPCS,0272,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
SPLINT ANK REG UNIV STRRP AIR AND GEL FOR CLD THER,SUP-2276708,CDM,L4350,HCPCS,0274,RC,,,,both,,,44.27,28.78,,,,,,,,,,,,,
STENT BILI SYM L 44 MM DIA 8 MM CATH L 75 CM DIA 7 FR NIT AD,SUP-2140190,CDM,C1874,HCPCS,0278,RC,,,,both,,,3196.77,2077.90,,,,,,,,,,,,,
PLATE BNE HUM LNG 3.5X302 MM RT DSTL X ARTC 14 HOLE SS NS,SUP-2184046,CDM,C1713,HCPCS,0278,RC,,,,both,,,5271.65,3426.57,,,,,,,,,,,,,
BOLT EXT FIX M CIR HOFFMANN LRF,SUP-2363119,CDM,2720000010,LOCAL,0272,RC,,,,both,,,330.64,214.92,,,,,,,,,,,,,
BLADE CRV NAR 1MM ARACH,SUP-2306288,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1028.95,668.82,,,,,,,,,,,,,
CANNULA KNEE ENTRY RECONSTRUCTION INSTRUMENT,SUP-2824435,CDM,2720000010,LOCAL,0272,RC,,,,both,,,837.19,544.17,,,,,,,,,,,,,
PLATE CRAN 180X40X40 MM PT SPEC IMPL PEEK,SUP-2860128,CDM,C1713,HCPCS,0278,RC,,,,both,,,28198.14,18328.79,,,,,,,,,,,,,
TIP IRRIG ASPIR CRV 03MM IT 03MM ULTRAFLOW,SUP-2110006,CDM,C1713,HCPCS,0278,RC,,,,both,,,946.71,615.36,,,,,,,,,,,,,
GRAFT BONE CHIP FRZ DRY CANC 90CC,SUP-2113910,CDM,C1713,HCPCS,0278,RC,,,,both,,,5039.70,3275.80,,,,,,,,,,,,,
VALVE MI ORIFICE DIA22.5MM TISS ANNULUS DIA27MM 85DEG,SUP-2355141,CDM,C1889,HCPCS,0278,RC,,,,both,,,10362.00,6735.30,,,,,,,,,,,,,
CATHETER CARD ABLATION NAVISTAR DS L 115 CM 7 FR F CRV ORN,SUP-2248941,CDM,C1732,HCPCS,0278,RC,,,,both,,,7215.72,4690.22,,,,,,,,,,,,,
PROBE BRST BX DIA10GA ENCOR,SUP-2126858,CDM,2720000010,LOCAL,0272,RC,,,,both,,,486.70,316.35,,,,,,,,,,,,,
CATHETER CV FULL TY 7 FRX20 CM 3L CUTLMY701JABRMCUSTOM0004,SUP-2760038,CDM,C1751,HCPCS,0278,RC,,,,both,,,455.27,295.93,,,,,,,,,,,,,
MATRIX BIO L 7 X W 10 CM FISH SKIN DERMAL STD INTACT STRL SINGLE,SUP-2909432,CDM,Q4158,HCPCS,0636,RC,,,,both,,,10776.48,7004.71,,,,,,,,,,,,,
PLATE BNE ANGLED BLADE 130 DEG 60 MM 85 MM 4 HOLE TI NS DCP,SUP-2569043,CDM,C1713,HCPCS,0278,RC,,,,both,,,2770.61,1800.90,,,,,,,,,,,,,
GRAFT VASC L45CM DIA4-7MM PTFE CBAS HEP SURF STD WALLED,SUP-2395785,CDM,C1768,CPT,0278,RC,,,,both,,,4060.02,2639.01,,,,,,,,,,,,,
CLOSURE SPNL GLD TI ALLOY FOR EXTN BAR RIB SUPP VEPTR,SUP-2193299,CDM,C1713,HCPCS,0278,RC,,,,both,,,1915.40,1245.01,,,,,,,,,,,,,
PLATE BONE CRANIAL SHORT 6 HOLE GAP 28.8X14.5X0.4MM TITANIUM,SUP-2827183,CDM,C1713,HCPCS,0278,RC,,,,both,,,529.09,343.91,,,,,,,,,,,,,
PASSER SUT 16MM STR MULTFI SCORPION,SUP-2121203,CDM,2720000010,LOCAL,0272,RC,,,,both,,,12544.30,8153.79,,,,,,,,,,,,,
COMPONENT HIP CAPPED H2 INSITU BIOLOGIC COCR,SUP-2308993,CDM,C1776,CPT,0278,RC,,,,both,,,14444.00,9388.60,,,,,,,,,,,,,
DEVICE OCCL CLP L35MM PRELD FOR THORACOSCOPIC PROC GILLINOV,SUP-2124471,CDM,C1889,HCPCS,0278,RC,,,,both,,,11775.00,7653.75,,,,,,,,,,,,,
CAP END NAIL OLECRANON OSTEOTMY,SUP-2177095,CDM,C1713,HCPCS,0278,RC,,,,both,,,1812.66,1178.23,,,,,,,,,,,,,
DISC NEUROSURGICAL N PROGRAMMABLE SM W/O RESERVOIR PROGAV,SUP-2846928,CDM,C1889,HCPCS,0278,RC,,,,both,,,1271.42,826.42,,,,,,,,,,,,,
GRAFT BONE PRO DENS 15CC,SUP-2399150,CDM,C1713,HCPCS,0278,RC,,,,both,,,11985.29,7790.44,,,,,,,,,,,,,
STENT URET POLARIS L 22 CM DIA 6 FR PERCFLX HYDROPLUS 2,SUP-2139074,CDM,C2617,HCPCS,0278,RC,,,,both,,,509.50,331.17,,,,,,,,,,,,,
SPACER SPNL 20X11X14MM INTBDY ANTR CERV TRABECULAR MTL VBR,SUP-2414288,CDM,C1889,HCPCS,0278,RC,,,,both,,,12560.00,8164.00,,,,,,,,,,,,,
BASEPLATE SHLDR SM AUGMENTED W/ TAPR ADPT FOR COMPHSVE REV,SUP-2205381,CDM,C1776,CPT,0278,RC,,,,both,,,5809.00,3775.85,,,,,,,,,,,,,
STERILIZATION SET SPARE HUM AIMING BLOCK,SUP-2469831,CDM,C1713,HCPCS,0278,RC,,,,both,,,879.20,571.48,,,,,,,,,,,,,
PROBE ENDOSCP ARTHSCP 90 DEG 3 MM ABLATN,SUP-2314074,CDM,C1713,HCPCS,0278,RC,,,,both,,,405.06,263.29,,,,,,,,,,,,,
DRILL SONIC ANCHOR 2.8,SUP-2465292,CDM,2720000010,LOCAL,0272,RC,,,,both,,,967.12,628.63,,,,,,,,,,,,,
RONGEUR SURG FRIEDMAN 5.5 IN SS,SUP-2238709,CDM,2720000010,LOCAL,0272,RC,,,,both,,,825.79,536.76,,,,,,,,,,,,,
ALLOGRAFT BNE PLUG 15 MM OSTEOCHNDRL,SUP-2866832,CDM,C1762,CPT,0278,RC,,,,both,,,13423.50,8725.27,,,,,,,,,,,,,
AMITRIPTYLINE HCL 10 MG PO TABS,RX-432,CDM,6370000000,HCPCS,0637,RC,50268-0037-15,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
GRAFT VASC L 30 MM ID 5 MM CLLGN BOV CAR ART WOVEN,SUP-2880948,CDM,C1768,CPT,0278,RC,,,,both,,,8255.06,5365.79,,,,,,,,,,,,,
ALLOGRAFT HUMAN TISSUE SALERA 2CM X 3CM DEHYDRATED,SUP-2907553,CDM,C1762,CPT,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
IMPLANT PENILE L18CM CYL INFL MINOCYCLINE RIFAMPIN,SUP-2140298,CDM,C1813,HCPCS,0278,RC,,,,both,,,19559.50,12713.67,,,,,,,,,,,,,
SPLINT WR AD L FOR 7.5-8.5IN STRP L4IN VENT ELAS,SUP-2324481,CDM,L3908,HCPCS,0274,RC,,,,both,,,44.15,28.70,,,,,,,,,,,,,
MAXCESS MAS TLIF 2 KT ACC,SUP-2310439,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5887.50,3826.87,,,,,,,,,,,,,
BELIMUMAB 400 MG IV SOLR,RX-104661,CDM,J0490,HCPCS,0636,RC,49401-0102-01,NDC,,both,1,UN,6366.20,4138.03,,,,,,,,,,,,,
PLATE BNE L 47 X W 10.7 MM THK 3.4 MM SCREW DIA 3.5 MM 4 H 72440704,SUP-2932890,CDM,C1713,HCPCS,0278,RC,,,,both,,,1201.65,781.07,,,,,,,,,,,,,
IMPLANT HUM TISS W5XL5CM THK1MM PERICARD MULTDIR TUTOPLAST,SUP-2335276,CDM,C1768,CPT,0278,RC,,,,both,,,2590.50,1683.82,,,,,,,,,,,,,
ALLOGRAFT BNE BLOCK TRICORT 800129,SUP-2743374,CDM,C1713,HCPCS,0278,RC,,,,both,,,10267.80,6674.07,,,,,,,,,,,,,
BUR SURG CUT 18 DEG 3 MM MED GRIT CONVX SIDE SHIELDED DIEGO,SUP-2638100,CDM,2720000010,LOCAL,0272,RC,,,,both,,,433.01,281.46,,,,,,,,,,,,,
MESH SURG 49X49X0.6 MM 3D TI LEVEL 1 NEURO,SUP-2470450,CDM,C1713,HCPCS,0278,RC,,,,both,,,1327.47,862.86,,,,,,,,,,,,,
PLATE BNE SZ 2.6 MM TI MANDIBULAR DBL ANGLE NS DISP,SUP-2934853,CDM,C1713,HCPCS,0278,RC,,,,both,,,63877.02,41520.06,,,,,,,,,,,,,
BEAM ANK FUS L165MM DIA7MM 11MM PROX SALVATION,SUP-2400803,CDM,C1713,HCPCS,0278,RC,,,,both,,,4892.12,3179.88,,,,,,,,,,,,,
PLATE BNE L79MM 6 H LOK 2 COMPR FOR 3.5MM SCR UNIV LOK SYS,SUP-2411370,CDM,C1713,HCPCS,0278,RC,,,,both,,,898.04,583.73,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY POLARIS X 270DEG L 110 CM DIA 6,SUP-2700079,CDM,C1732,HCPCS,0278,RC,,,,both,,,380.10,247.06,,,,,,,,,,,,,
SENSOR CARD OUTPT L60IN VAMP AD SYS FLOTRAC,SUP-2214570,CDM,C1713,HCPCS,0278,RC,,,,both,,,1071.12,696.23,,,,,,,,,,,,,
PORT HND ACCS INJ INTRO LAP DISP TRIPRT,SUP-2313599,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1054.26,685.27,,,,,,,,,,,,,
PEN ABLAT CARD RF SYS CARDIOBLATE,SUP-2278863,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6264.30,4071.79,,,,,,,,,,,,,
GUIDEWIRE VASC L80CM DIA0.035IN TIP L23CM PTFE BENT STR FIX,SUP-2302724,CDM,C1769,HCPCS,0272,RC,,,,both,,,32.19,20.92,,,,,,,,,,,,,
BRACE ORTHOPEDIC MED FT SPLNT MULT PODUS,SUP-2332643,CDM,L4396,HCPCS,0274,RC,,,,both,,,248.06,161.24,,,,,,,,,,,,,
ACETAMINOPHEN 160 MG PO CHEW,RX-8941,CDM,6370000000,HCPCS,0637,RC,00904-6645-24,NDC,,both,1,UN,0.80,0.52,,,,,,,,,,,,,
NEEDLE SUTURE PASS PTS ANIKA,SUP-2761961,CDM,2720000010,LOCAL,0272,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
ANCHOR SUT OD6.5MM INTRALINE PEEK,SUP-2421259,CDM,C1713,HCPCS,0278,RC,,,,both,,,569.91,370.44,,,,,,,,,,,,,
PLATE BONE L142MM THK3.7MM 6 H RT DSTL MEDL TIB TI LCK COMPR,SUP-2190881,CDM,C1713,HCPCS,0278,RC,,,,both,,,4519.81,2937.88,,,,,,,,,,,,,
STENT PERIPH ABS PRO L 100 MM DIA 5 MM CATH L 80 CM DIA 8 FR,SUP-2104773,CDM,C1876,HCPCS,0278,RC,,,,both,,,3077.20,2000.18,,,,,,,,,,,,,
IMPLANT FNGR JT SZ 1 PROX INTERPHALANGEAL FUS,SUP-2243141,CDM,C1776,CPT,0278,RC,,,,both,,,3775.28,2453.93,,,,,,,,,,,,,
BRACE ORTH FRAC FEM CAST MOLD KAFO L2128] TIDEWATER PROSTHETICS],SUP-2388171,CDM,L2128,HCPCS,0274,RC,,,,both,,,4592.53,2985.14,,,,,,,,,,,,,
VALVE HYDROCEPHALUS 10 WITH SHUNT ASSISTANT AND CONTROL RESE,SUP-2826125,CDM,C1889,HCPCS,0278,RC,,,,both,,,8777.12,5705.13,,,,,,,,,,,,,
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,RX-22473,CDM,J1885,HCPCS,0636,RC,63323-0162-01,NDC,,both,0.5,ML,54.10,35.16,,,,,,,,,,,,,
COMPONENT FEM SM UNIV POST KNEE CO CHROM NP MOD CEM MONO,SUP-2364838,CDM,C1776,CPT,0278,RC,,,,both,,,5080.27,3302.18,,,,,,,,,,,,,
PLATE BNE LISFRANC MED RT OMNI,SUP-2610166,CDM,C1713,HCPCS,0278,RC,,,,both,,,5557.80,3612.57,,,,,,,,,,,,,
PLATE BNE W12XL232MM THK3.7MM LNG 10 H NONSTERILE PROX HUM,SUP-2186021,CDM,C1713,HCPCS,0278,RC,,,,both,,,4906.09,3188.96,,,,,,,,,,,,,
ENDCAP IM NAIL 0MM OFFSET TIB FOR PHOENIX SYS,SUP-2412149,CDM,C1713,HCPCS,0278,RC,,,,both,,,483.56,314.31,,,,,,,,,,,,,
ANCHOR SUT DIA2.9MM WHT COBRAID BLK W/ TWO COBRAID SUT,SUP-2341807,CDM,C1713,HCPCS,0278,RC,,,,both,,,998.52,649.04,,,,,,,,,,,,,
KIT ENDO VEIN HARV VASOVIEW,SUP-2227755,CDM,C1713,HCPCS,0278,RC,,,,both,,,778.72,506.17,,,,,,,,,,,,,
PROSTHESIS KNEE 7.5X18.5MM L STUD UNI FEM CE,SUP-2123697,CDM,C1776,CPT,0278,RC,,,,both,,,1318.80,857.22,,,,,,,,,,,,,
SET INTRO MICROPUNCTURE CATH 10CM 5FR 7CM NIT PLAT ECHOGENIC,SUP-2170487,CDM,C1894,HCPCS,0272,RC,,,,both,,,59.47,38.66,,,,,,,,,,,,,
TAP BNE 65MM FOR DANEK FEN RATCH SCRDRVR,SUP-2289243,CDM,C1713,HCPCS,0278,RC,,,,both,,,313.18,203.57,,,,,,,,,,,,,
SET CIRC BRTH NEO L150CM 2 LIMB EXPIRATORY VLV PRESSEMBLED,SUP-2237225,CDM,C1713,HCPCS,0278,RC,,,,both,,,196.22,127.54,,,,,,,,,,,,,
TI STERNAL LCKNG DOUBLE T-PL,SUP-2823436,CDM,C1713,HCPCS,0278,RC,,,,both,,,3526.85,2292.45,,,,,,,,,,,,,
LACTATED RINGERS IV BOLUS,RX-40840057,CDM,J7120,HCPCS,0258,RC,00264-7750-00,NDC,,both,250,ML,6.40,4.16,,,,,,,,,,,,,
MESH TISS L 250 MM DIA 5 MM TYP 1 CLLGN MTRX PLLA,SUP-2895935,CDM,C1781,HCPCS,0278,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
SUPPORT ORTHOT LUMBAR SACR CUST SAGITTAL-CORONAL CTRL ABD,SUP-2435555,CDM,L0636,HCPCS,0272,RC,,,,both,,,3838.43,2494.98,,,,,,,,,,,,,
JOINT SACROILIAC 10X50 MM IFUSE-TORQ,SUP-2713924,CDM,C1713,HCPCS,0278,RC,,,,both,,,9734.00,6327.10,,,,,,,,,,,,,
MATRIX BIO L 1.75 X W 1.75 CM FISH SKIN DERMAL INTACT OMEGA3,SUP-2909329,CDM,Q4158,HCPCS,0636,RC,,,,both,,,1284.26,834.77,,,,,,,,,,,,,
ALLOGRAFT HUM TISS FRZN ASEP LT LAT HALF MENIS,SUP-2866994,CDM,C1762,CPT,0278,RC,,,,both,,,16266.30,10573.09,,,,,,,,,,,,,
GRAFT SFT TISS X THCK 40X25 CM RECON TISS MTRX STRATTICE,SUP-2482660,CDM,Q4130,HCPCS,0636,RC,,,,both,,,99016.76,64360.89,,,,,,,,,,,,,
SET URET STENT L 28 CM DIA 7 FR CATH POS 6 FR PERCFLX +,SUP-2727311,CDM,C2617,HCPCS,0278,RC,,,,both,,,371.71,241.61,,,,,,,,,,,,,
CATHETER ANGIO CORODYN A L 50 CM DIA 5 FR BALLOON DIA 8 MM,SUP-2842669,CDM,C1725,HCPCS,0272,RC,,,,both,,,273.18,177.57,,,,,,,,,,,,,
HC Theraputc Proc Imprv Resp Func Oth Than G0237 1-1 Ea 15min,PX-4190023800,CDM,G0238,CPT,0419,RC,,,,both,,,96.00,62.40,,,,,,,,,,,,,
PLATE BONE ORBITAL FLOOR SMALL LEFT PREFORMED TITANIUM DARK,SUP-2837770,CDM,C1713,HCPCS,0278,RC,,,,both,,,6150.00,3997.50,,,,,,,,,,,,,
BAR EXT FIX L60MM DIA4MM S STL CONN FOR SM FIX,SUP-2188725,CDM,2720000010,LOCAL,0272,RC,,,,both,,,95.83,62.29,,,,,,,,,,,,,
CABLE ORTH DIA2MM HIP CO CHROM W/ CLMP ACCORD,SUP-2345204,CDM,C1776,CPT,0278,RC,,,,both,,,1109.05,720.88,,,,,,,,,,,,,
CANNULA ORTH SHFT DRV PATH SUPERPATH,SUP-2304387,CDM,C1713,HCPCS,0278,RC,,,,both,,,433.32,281.66,,,,,,,,,,,,,
GUIDEWIRE VASC L300CM DIA0.014IN TIP L2CM S STL HYDRPHLC,SUP-2367926,CDM,C1769,HCPCS,0272,RC,,,,both,,,2436.64,1583.82,,,,,,,,,,,,,
COMPONENT HUM SUPEROLATERAL RESECT UNIVERS REVERS,SUP-2845821,CDM,C1776,CPT,0278,RC,,,,both,,,5118.36,3326.93,,,,,,,,,,,,,
SUPPORT ORTHOT THGH LOWER EXTREMITY WT BEAR QAUDRI LAT BRIM,SUP-2435673,CDM,L2510,HCPCS,0272,RC,,,,both,,,2283.35,1484.18,,,,,,,,,,,,,
PLATE STRNL CLOSURE THK 1.5 MM 12 H TI NAR Y LP NS,SUP-2894473,CDM,C1713,HCPCS,0278,RC,,,,both,,,3560.76,2314.49,,,,,,,,,,,,,
FLANGE ACET PAR 5 SH W,SUP-2403454,CDM,C1776,CPT,0278,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
MATRIX RESTRATA WOUND 1.3CM X 2.5CM,SUP-2874115,CDM,A2007,HCPCS,0636,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
SUPPORT ORTHOT LUMBAR SACR CUST SAGITTAL-CORONAL CTRL ABD,SUP-2435555,CDM,L0636,HCPCS,0274,RC,,,,both,,,3838.43,2494.98,,,,,,,,,,,,,
NAIL IM 8.5 MMX38 CM FAN,SUP-2347219,CDM,C1713,HCPCS,0278,RC,,,,both,,,4132.24,2685.96,,,,,,,,,,,,,
VANCOMYCIN HCL 1.25 G IV SOLR,RX-144941,CDM,J3374,HCPCS,0636,RC,67457-0823-12,NDC,,both,1,UN,115.60,75.14,,,,,,,,,,,,,
CATHETER NEPHROSTOMY MCOT 8 FRX20 CM SIL,SUP-2835735,CDM,C1729,HCPCS,0272,RC,,,,both,,,266.27,173.08,,,,,,,,,,,,,
CEFTAZIDIME 2 G IV SOLR,RX-27291,CDM,J0713,HCPCS,0636,RC,44567-0236-10,NDC,,both,1,UN,57.50,37.37,,,,,,,,,,,,,
BOLT TROCH MEDALLION 24MM,SUP-2408757,CDM,C1713,HCPCS,0278,RC,,,,both,,,1331.36,865.38,,,,,,,,,,,,,
KIT INTRO VSI L 10 CM DIA 5 FR GUIDEWIRE L 40CM DIA 0.018 IN,SUP-2120526,CDM,C1894,HCPCS,0272,RC,,,,both,,,97.34,63.27,,,,,,,,,,,,,
LACTATED RINGERS IV BOLUS,RX-40840057,CDM,J7120,HCPCS,0250,RC,00338-0117-03,NDC,,both,250,ML,19.20,12.48,,,,,,,,,,,,,
GUIDEWIRE 1.35MM,SUP-2423331,CDM,C1769,HCPCS,0272,RC,,,,both,,,62.80,40.82,,,,,,,,,,,,,
CATHETER KIT 0.018 INX17.75 IN 5 FRX40 CM DL BLU FLEXTIP,SUP-2384052,CDM,C1751,HCPCS,0278,RC,,,,both,,,259.49,168.67,,,,,,,,,,,,,
BISOPROLOL FUMARATE 10 MG PO TABS,RX-18287,CDM,6370000000,HCPCS,0637,RC,70954-0456-10,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
TUBE TYMPANOSTOMY SM L4.5MM DIA1.27MM INNR EAR CLR SIL T,SUP-2284013,CDM,L8699,HCPCS,0278,RC,,,,both,,,104.12,67.68,,,,,,,,,,,,,
CATHETER EP 120CML 6FR 2-5-2MM MAP HEXAPOLAR ELECTRD SPC,SUP-2101983,CDM,C1730,HCPCS,0272,RC,,,,both,,,741.04,481.68,,,,,,,,,,,,,
TUBE GASTROJEJU 14FR JEJU L15CM STOMA L1.2CM EN LO PROF,SUP-2119810,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1527.61,992.95,,,,,,,,,,,,,
BODY TOP LD ILLIAC FIX FOR DEFORMITY CORR SYS FIREBIRD,SUP-2316794,CDM,2720000010,LOCAL,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
PLATE BNE RECTANGULAR SM 1.5X0.2 MM SCRN MESH JANNETTA TI NS,SUP-2496615,CDM,C1713,HCPCS,0278,RC,,,,both,,,904.54,587.95,,,,,,,,,,,,,
KIT SONIC ANCHOR FORCE FIB 2.5X10MM 2 0,SUP-2488013,CDM,C1713,HCPCS,0278,RC,,,,both,,,1016.36,660.63,,,,,,,,,,,,,
LENS IOL ASPHERIC 10+ DIOPT 5 MM MLPC CYL PWR 1.25,SUP-2392072,CDM,V2787,HCPCS,0276,RC,,,,both,,,499.00,324.35,,,,,,,,,,,,,
SYSTEM RECHARGING NEUROSTIMULATOR RECHRG BTTRY PK PWR SUPL,SUP-2284644,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3388.06,2202.24,,,,,,,,,,,,,
MATRIX BNE SUB OSTEOCONDUCTIVE SCFLD STRP MOZAIK 10ML,SUP-2244488,CDM,C1713,HCPCS,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
KIT INTRO VSI L 10 CM DIA 5FR NIT TUNGSTEN TIP SIL ECHOGENIC,SUP-2763446,CDM,C1894,HCPCS,0272,RC,,,,both,,,70.34,45.72,,,,,,,,,,,,,
ORTHOANCHOR SCREW XD DF15 X8MM THRD20MM TSSUE CLLR RCTNGLR,SUP-2681000,CDM,C1713,HCPCS,0278,RC,,,,both,,,437.59,284.43,,,,,,,,,,,,,
PUNCH OPHTH DIA8.25MM NONVACUUM DISP FOR DONOR CORNEAL BRRN,SUP-2261435,CDM,2720000010,LOCAL,0272,RC,,,,both,,,190.91,124.09,,,,,,,,,,,,,
SCREW BNE L30MM DIA2.7MM STD CORT S STL NONCANNULATED FULL,SUP-2183349,CDM,C1713,HCPCS,0278,RC,,,,both,,,134.93,87.70,,,,,,,,,,,,,
BRACE THORACOLUMBOSACRAL SM LTX W ADD STRP VELC CLSR E ANT,SUP-2195549,CDM,L0650,HCPCS,0274,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
BIT DRILL SURG 4.5 MM SLD STRL ALPS DISP,SUP-2607150,CDM,2720000010,LOCAL,0272,RC,,,,both,,,561.24,364.81,,,,,,,,,,,,,
BRACE WRST LACER W O ABDUCTED THMB UNIV R,SUP-2276646,CDM,L3931,HCPCS,0272,RC,,,,both,,,15.89,10.33,,,,,,,,,,,,,
HEAD HUM H15MM DIA40MM SHLDR CO CHROM TOT REV BIO MOD,SUP-2404611,CDM,C1776,CPT,0278,RC,,,,both,,,3067.78,1994.06,,,,,,,,,,,,,
REAMER SURG 9MM FEM FULL FLUT,SUP-2249542,CDM,C1713,HCPCS,0278,RC,,,,both,,,854.08,555.15,,,,,,,,,,,,,
CATHETER QUATTRO 3 KT LUMN,SUP-2416143,CDM,C1751,HCPCS,0278,RC,,,,both,,,2909.02,1890.86,,,,,,,,,,,,,
BOOT CAST XSM BLK UNISX AD SQ OPN TOE FOREFOOT CLSR HIGHER,SUP-2176231,CDM,L4386,HCPCS,0274,RC,,,,both,,,40.54,26.35,,,,,,,,,,,,,
TM POR ST/TM CUP/LG VIT ELN/LG STD HD,SUP-2402810,CDM,C1776,CPT,0278,RC,,,,both,,,16745.62,10884.65,,,,,,,,,,,,,
COMPONENT TOT SHLDR CAPPED STD S1 ANAT,SUP-2419701,CDM,C1776,CPT,0278,RC,,,,both,,,13502.00,8776.30,,,,,,,,,,,,,
HEAD FEM DIA28MM NK L+0MM HIP ALUMINA CERAMIC 12/14 TAPR,SUP-2344797,CDM,C1776,CPT,0278,RC,,,,both,,,4837.17,3144.16,,,,,,,,,,,,,
PLATE BNE L W12XL119MM THK1MM 7 H BILAT TI SEMI TBLR LO,SUP-2190705,CDM,C1713,HCPCS,0278,RC,,,,both,,,490.94,319.11,,,,,,,,,,,,,
TUBE VENT 1.14 MM ARMSTR BVL GRMMT FLUORO-PACIFIC,SUP-2434177,CDM,L8699,HCPCS,0278,RC,,,,both,,,58.18,37.82,,,,,,,,,,,,,
PLATE BNE L421MM 18 H NONSTERILE PROX FEM S STL HK LO PROF,SUP-2186068,CDM,C1713,HCPCS,0278,RC,,,,both,,,5387.11,3501.62,,,,,,,,,,,,,
SHELL ACET SZ I DIA70MM HIP TRITANIUMX3 BEAR TECHNOLOGY,SUP-2363284,CDM,C1776,CPT,0278,RC,,,,both,,,9870.28,6415.68,,,,,,,,,,,,,
FOIL DNTL 25MMW X 7MML 01MM THK RSRB X LATEX FREE ALVLR,SUP-2669845,CDM,C1713,HCPCS,0278,RC,,,,both,,,1081.82,703.18,,,,,,,,,,,,,
KIT EEG ELECTRD L 16 MM 5 CONTACT STRL DISP EVO,SUP-2936756,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2854.26,1855.27,,,,,,,,,,,,,
SCREW BNE CANN 5X100 MM PERI ARTC LCK SS NS LCP,SUP-2184733,CDM,C1713,HCPCS,0278,RC,,,,both,,,541.65,352.07,,,,,,,,,,,,,
PLATE BNE 24 DEG L 174 X W 8.5 MM THK 1.6 MM 13 H SS LT DSTL,SUP-2933044,CDM,C1713,HCPCS,0278,RC,,,,both,,,5198.43,3378.98,,,,,,,,,,,,,
TAP SURG L 50 MM DIA2.2 MM SCREW 6 MM SD DENT NS LF DISP,SUP-2883129,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1226.48,797.21,,,,,,,,,,,,,
BLADE SAW KYOCERA ORTHOSTAR 90X13MM,SUP-2222799,CDM,C1713,HCPCS,0278,RC,,,,both,,,414.48,269.41,,,,,,,,,,,,,
PLATE BNE CERV SM 2.7X76 MM 9 HOLE TI,SUP-2536118,CDM,C1713,HCPCS,0278,RC,,,,both,,,430.81,280.03,,,,,,,,,,,,,
PLATE BNE FIBULAR 2.7X92 MM LT LAT DSTL 4 HOLE NS VA-LCP,SUP-2758194,CDM,C1713,HCPCS,0278,RC,,,,both,,,2545.54,1654.60,,,,,,,,,,,,,
PLATE BNE L73MM 6 H BILAT S STL CNTOUR 2 COMPR FOR 35MM SCR,SUP-2411340,CDM,C1713,HCPCS,0278,RC,,,,both,,,362.23,235.45,,,,,,,,,,,,,
GRAFT BNE SUB M SZ 14 28MM 20CC B TRICALCIUM PHSPTE SYN,SUP-2194013,CDM,C1713,HCPCS,0278,RC,,,,both,,,2967.30,1928.74,,,,,,,,,,,,,
SET PICC INSERTION 4.5FR,SUP-2624225,CDM,C1892,HCPCS,0272,RC,,,,both,,,118.69,77.15,,,,,,,,,,,,,
COVER BUR H DIA17MM 6 H TI FOR 1.5MM SCR,SUP-2191189,CDM,C1713,HCPCS,0278,RC,,,,both,,,543.22,353.09,,,,,,,,,,,,,
BUR SURG L78MM DIA3MM XLN FN DMND RND,SUP-2284192,CDM,C1713,HCPCS,0278,RC,,,,both,,,491.79,319.66,,,,,,,,,,,,,
PLATE CRANIOFACIAL MAND RECON COMPR 2.7MM 12 H 150MM VIT,SUP-2364677,CDM,C1713,HCPCS,0278,RC,,,,both,,,2926.48,1902.21,,,,,,,,,,,,,
PROCEDURE PACK GRFT DEL,SUP-2384786,CDM,C1713,HCPCS,0278,RC,,,,both,,,1915.40,1245.01,,,,,,,,,,,,,
CATHETER EP JSN 10 MM 6 FRX120 CM SUPREME,SUP-2492236,CDM,C1730,HCPCS,0272,RC,,,,both,,,420.76,273.49,,,,,,,,,,,,,
BUR REVERSED TAPERED CUTTING 30K,SUP-2653407,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1502.65,976.72,,,,,,,,,,,,,
SCREW BNE L16MM DIA1.3MM CORT TI ST FULL THRD W/ CRUCFRM,SUP-2189219,CDM,C1713,HCPCS,0278,RC,,,,both,,,227.90,148.13,,,,,,,,,,,,,
CLIP SURG VES .196INX6X1MM BLDE KLEINERT KUTZ FN CVD PILLING,SUP-2384441,CDM,C1713,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
GUIDEWIRE ORTH L300MM DIA2.5MM CO CHROM DRL TIP FOR LCP,SUP-2179013,CDM,C1769,HCPCS,0272,RC,,,,both,,,189.44,123.14,,,,,,,,,,,,,
GRAFT VASC HEMSHLD PLAT L 50 CM DIA26 MM BRANCH SZ 12/10/8/8,SUP-2694337,CDM,C1768,CPT,0278,RC,,,,both,,,5589.64,3633.27,,,,,,,,,,,,,
COMPONENT FEM SZ 55 L KNEE CO CHROM POR POST STABILIZING,SUP-2406178,CDM,C1776,CPT,0278,RC,,,,both,,,20023.78,13015.46,,,,,,,,,,,,,
SUTURE ANCHR Q-FIX MINI ALL SUT 1.8MM,SUP-2341944,CDM,C1713,HCPCS,0278,RC,,,,both,,,1259.93,818.95,,,,,,,,,,,,,
CATHETER ART PRESSURE MONITORING TY 021 4 FRX12 CM FEM,SUP-2760101,CDM,C1751,HCPCS,0278,RC,,,,both,,,220.55,143.36,,,,,,,,,,,,,
PROBE CRYOABLATION L 11 IN OD 8 MM BALL TIP STRL DISP,SUP-2889680,CDM,C9808,HCPCS,0272,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY PENTARAY NAV INSRTN L 115CM 2-6-2,SUP-2248593,CDM,C1732,HCPCS,0278,RC,,,,both,,,5177.86,3365.61,,,,,,,,,,,,,
KIT PICC CATH AD 7FR L76CM POLYUR DBL LUMN BASIC NPOWER INJ,SUP-2125581,CDM,C1751,HCPCS,0278,RC,,,,both,,,276.32,179.61,,,,,,,,,,,,,
PLATE BSSO SLIDING COLOGNE40MM,SUP-2676897,CDM,C1713,HCPCS,0278,RC,,,,both,,,1640.52,1066.34,,,,,,,,,,,,,
GRAFT HUMAN TSSUE W3XL7CM THK1.04 2.28MM THICK RGNRTVE TSSUE,SUP-2483327,CDM,Q4116,HCPCS,0636,RC,,,,both,,,2738.08,1779.75,,,,,,,,,,,,,
SCREW BONE SCHANZ 2.5 MM 4X60 MM BLUNT TIP TITANIUM NONSTERI,SUP-2842148,CDM,C1713,HCPCS,0278,RC,,,,both,,,1164.94,757.21,,,,,,,,,,,,,
GRAFT HUM TISS W20XL15MM THK12MM FRZ DRY ALLGRFT BLK CANC,SUP-2307119,CDM,C1713,HCPCS,0278,RC,,,,both,,,2511.50,1632.47,,,,,,,,,,,,,
TI MATRIXMIDFACE SCREW  1.3MM  450395305,SUP-2844118,CDM,C1713,HCPCS,0278,RC,,,,both,,,2634.99,1712.74,,,,,,,,,,,,,
TRUMATCH SHLDR APG GUIDE,SUP-2823513,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2041.00,1326.65,,,,,,,,,,,,,
GUIDEWIRE ANKLE ARTHOSCOPY 1.6MM,SUP-2814280,CDM,C1769,HCPCS,0272,RC,,,,both,,,78.50,51.02,,,,,,,,,,,,,
COMPONENT FEM SZ 8 R KNEE CO CHROM CEM CONSTRN REV LEGION,SUP-2346845,CDM,C1776,CPT,0278,RC,,,,both,,,18482.04,12013.33,,,,,,,,,,,,,
PICC KIT CHLOROGUARD 5.5 FR VPS PRECIS ARROWG+ARD BLU +,SUP-2763313,CDM,C1751,HCPCS,0278,RC,,,,both,,,876.06,569.44,,,,,,,,,,,,,
LEVEL CMF PLATE MDFCE STR WTAB 1.5 MM SCRW24 HOLE T0.4 MM C,SUP-2677539,CDM,C1713,HCPCS,0278,RC,,,,both,,,1115.33,724.96,,,,,,,,,,,,,
ALLOGRAFT DERMAL THCK 6X12 CM RDY TO USE TISS MTRX ALLDERM,SUP-2113020,CDM,Q4116,HCPCS,0636,RC,,,,both,,,7379.00,4796.35,,,,,,,,,,,,,
KIT PENILE PROS W/ SUT TIE CONN CLLT 22GA AND 15GA NDL FOR,SUP-2138943,CDM,C1813,HCPCS,0278,RC,,,,both,,,3108.60,2020.59,,,,,,,,,,,,,
GUIDEWIRE ORTH OLV 8X800 MM ESTREMO,SUP-2719786,CDM,C1769,HCPCS,0272,RC,,,,both,,,596.60,387.79,,,,,,,,,,,,,
COMPONENT FEM M DURAC NP RT KNEE CRUC RET REV CEM STEM MOD,SUP-2364833,CDM,C1776,CPT,0278,RC,,,,both,,,7022.83,4564.84,,,,,,,,,,,,,
ANCHOR SFT TISS W/ DEPLOYING SUT BTB TIGHTROPE,SUP-2121386,CDM,C1713,HCPCS,0278,RC,,,,both,,,1397.30,908.24,,,,,,,,,,,,,
KIT INTRO L 10 CM SS WIRE/TIP MIC B BVL CLR HUB ECHOGENIC,SUP-2117380,CDM,C1894,HCPCS,0272,RC,,,,both,,,61.14,39.74,,,,,,,,,,,,,
SHAFT RAD TRADTIONAL ALLGRFT 40 MM FRZ DRY,SUP-2294109,CDM,C1713,HCPCS,0278,RC,,,,both,,,1029.92,669.45,,,,,,,,,,,,,
ELECTRODE CORTICAL 2 X 8 T TAIL KT STRL DISP EVO,SUP-2934766,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4286.10,2785.96,,,,,,,,,,,,,
HALOPERIDOL LACTATE 2 MG/ML PO CONC,RX-3585,CDM,340b,HCPCS,0637,RC,09999-9910-16,NDC,,both,1,ML,2.70,1.75,,,,,,,,,,,,,
ROD IM ALIGN LCS HP,SUP-2454019,CDM,C1713,HCPCS,0278,RC,,,,both,,,263.76,171.44,,,,,,,,,,,,,
AGENT HEMSTAT W4XL4IN OXIDIZED REGENERATED CELOS STRUCTURED,SUP-2218215,CDM,2720000010,LOCAL,0272,RC,,,,both,,,349.23,227.00,,,,,,,,,,,,,
DRILL F. 6+7MM SCR DENT SHFT,SUP-2366420,CDM,2720000010,LOCAL,0272,RC,,,,both,,,478.44,310.99,,,,,,,,,,,,,
SET CATH HEMODIALYSI ARW CANNON II PLU CHRONIC 15FR DIA 24CM,SUP-2613330,CDM,C1750,HCPCS,0278,RC,,,,both,,,1114.70,724.55,,,,,,,,,,,,,
GRAFT HUM TISS DIA19MM THK15MM MT RESTORING DISC,SUP-2321677,CDM,C1776,CPT,0278,RC,,,,both,,,8352.40,5429.06,,,,,,,,,,,,,
WEDGE ACET AUG 50 MM,SUP-2363288,CDM,C1713,HCPCS,0278,RC,,,,both,,,8845.38,5749.50,,,,,,,,,,,,,
"HC So Factor Xa, Lmwh",PX-3058552066,CDM,85520,CPT,0305,RC,,,,both,,,879.00,571.35,,,,,,,,,,,,,
NAIL IM L360MM DIA11MM UNIV TIB LT GRN TI CANN LOK FLUT,SUP-2179849,CDM,C1713,HCPCS,0278,RC,,,,both,,,4441.12,2886.73,,,,,,,,,,,,,
BIT DRL DIA2.9 MM PROX CORTICAL MANUAL NS DISP HPS,SUP-2913321,CDM,2720000010,LOCAL,0272,RC,,,,both,,,427.04,277.58,,,,,,,,,,,,,
GRAFT BONE SUB 5ML PUTTY BIOLOGIC SPINE SURG BIOACTIVE KINEX,SUP-2232312,CDM,C1713,HCPCS,0278,RC,,,,both,,,2417.80,1571.57,,,,,,,,,,,,,
ANCHOR SUTURE 4.5MM IMPLANT CROSSFT,SUP-2824396,CDM,C1713,HCPCS,0278,RC,,,,both,,,1764.68,1147.04,,,,,,,,,,,,,
PLATE BONE W16XL16MM 4 H BILAT TI BOXED SHP LO PROF RIG NEUT,SUP-2191134,CDM,C1713,HCPCS,0278,RC,,,,both,,,822.68,534.74,,,,,,,,,,,,,
GRAFT HUM TISS W35XL35MM THK2MM ACELLULAR DERM MTRX,SUP-2264663,CDM,Q4125,HCPCS,0636,RC,,,,both,,,8084.24,5254.76,,,,,,,,,,,,,
PLATE BONE BIOBRIDGE 110MM RIB 18 HOLE RESORBABLE,SUP-2837606,CDM,C1713,HCPCS,0278,RC,,,,both,,,3372.36,2192.03,,,,,,,,,,,,,
COIL EMB L31CM OD7MM 10 STRTCH RESIST FRAMING FIL FNSH,SUP-2305182,CDM,C1889,HCPCS,0278,RC,,,,both,,,5149.60,3347.24,,,,,,,,,,,,,
SCREW BNE CANN 4X22 MM FT,SUP-2606137,CDM,C1713,HCPCS,0278,RC,,,,both,,,421.76,274.14,,,,,,,,,,,,,
ANCHOR SUTURE LIGMNT 2 W/ TAPE WHT BLU LABRALTAPE DISP,SUP-2422112,CDM,C1713,HCPCS,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
MIDAZOLAM HCL 2 MG/2ML IJ SOLN,RX-40872,CDM,J2250,HCPCS,0636,RC,00641-6057-25,NDC,,both,0.5,ML,54.10,35.16,,,,,,,,,,,,,
CATHETER GUID BNCHMRK 071 L 95 CM OD 6 FR ID 0.071 IN IN SEL,SUP-2323567,CDM,C1887,HCPCS,0272,RC,,,,both,,,2998.70,1949.15,,,,,,,,,,,,,
COMPONENT FEM L200MM KNEE TOT SEG IMP MOST OPTIONS,SUP-2208268,CDM,C1776,CPT,0278,RC,,,,both,,,11671.38,7586.40,,,,,,,,,,,,,
PACLITAXEL 300 MG/50ML IV CONC,RX-31097,CDM,J9267,HCPCS,0636,RC,23155-0884-31,NDC,,both,50,ML,205.40,133.51,,,,,,,,,,,,,
SCREW BNE L10MM DIA2.4MM TI ST LOK FULL THRD MATRIXMANDIBLE,SUP-2181751,CDM,C1713,HCPCS,0278,RC,,,,both,,,586.87,381.47,,,,,,,,,,,,,
PSN TIB HALF BLOCK SZ EF LL 5MM,SUP-2508711,CDM,C1776,CPT,0278,RC,,,,both,,,2763.20,1796.08,,,,,,,,,,,,,
PLATE BNE W10XL67MM THK1.5MM 3X5 H BILAT S STL T SHP R ANG,SUP-2185870,CDM,C1713,HCPCS,0278,RC,,,,both,,,960.53,624.34,,,,,,,,,,,,,
PLATE BONE L164MM 8 H LT OLECRANON TI FOR 2.7/3.5MM SCR,SUP-2419185,CDM,C1713,HCPCS,0278,RC,,,,both,,,3029.47,1969.16,,,,,,,,,,,,,
STENT CORONARY VELOC L 28 MM DIA2.5 MM SS HEPARIN OTW STRL,SUP-2156005,CDM,C1874,HCPCS,0278,RC,,,,both,,,5322.30,3459.49,,,,,,,,,,,,,
ALLOGRAFT ADIPOSE EXTRACELLULAR MTRX 3 CC LENEVA,SUP-2636342,CDM,C1762,CPT,0278,RC,,,,both,,,7308.35,4750.43,,,,,,,,,,,,,
SCREW BNE L40MM DIA5.5MM CORT FT ANK S STL ST SELF DRL CANN,SUP-2398100,CDM,C1713,HCPCS,0278,RC,,,,both,,,1585.70,1030.70,,,,,,,,,,,,,
PLATE BONE L46MM THK3.1MM 4 H BILAT S STL LCK COMPR RECON,SUP-2348685,CDM,C1713,HCPCS,0278,RC,,,,both,,,4020.46,2613.30,,,,,,,,,,,,,
TUBING PMP L50FT DIA05IN FOR 27224P CF 1 2ID 1 16WALL,SUP-2261222,CDM,2720000010,LOCAL,0272,RC,,,,both,,,360.03,234.02,,,,,,,,,,,,,
MATRIX BIO L 12 X W 10 CM FET BOV DERM DERMAL SLD STRL,SUP-2909316,CDM,Q4110,HCPCS,0636,RC,,,,both,,,12560.00,8164.00,,,,,,,,,,,,,
SCREW BNE L26MM DIA5MM CORT TI SELF DRL LOK FULL THRD HEX HD,SUP-2190330,CDM,C1713,HCPCS,0278,RC,,,,both,,,634.91,412.69,,,,,,,,,,,,,
SCREW SPNL MULTAXL 8.5X60 MM CANC CD HORZ,SUP-2628372,CDM,C1713,HCPCS,0278,RC,,,,both,,,3355.88,2181.32,,,,,,,,,,,,,
GUIDEWIRE SURG 0.032X14 IN MATRYX SCR NIT,SUP-2765763,CDM,C1769,HCPCS,0272,RC,,,,both,,,86.41,56.17,,,,,,,,,,,,,
HC Biofeedback (Any Modality),PX-4209090100,CDM,90901,CPT,0420,RC,,,,both,,,177.00,115.05,,,,,,,,,,,,,
PROBE ULTRASOUND TRIPLANE,SUP-2225698,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4521.60,2939.04,,,,,,,,,,,,,
WIRE FIX L70MM DIA0.6MM S STL SMOOTH BOTH END TRCR PNT K,SUP-2186873,CDM,C1713,HCPCS,0278,RC,,,,both,,,254.56,165.46,,,,,,,,,,,,,
PLATE SPNL L30MM 2 H TI LOK BTTRS,SUP-2193070,CDM,C1713,HCPCS,0278,RC,,,,both,,,1949.94,1267.46,,,,,,,,,,,,,
SPACER SPNL 10X16MM 7 DEG 10MM H COALITION AGX R,SUP-2231101,CDM,C1821,HCPCS,0278,RC,,,,both,,,4396.00,2857.40,,,,,,,,,,,,,
CLAMP EXT FIX DIA 4/5/6 MM UNIV HALF PIN,SUP-2898426,CDM,2720000010,LOCAL,0272,RC,,,,both,,,734.76,477.59,,,,,,,,,,,,,
GUIDEWIRE VASC SYNCHRO 300CM 0.014IN SEG 35CM STD PRESHAPED,SUP-2866244,CDM,C1769,HCPCS,0272,RC,,,,both,,,2906.23,1889.05,,,,,,,,,,,,,
"HC So Mononuclear Cell Antigen,Quan",PX-3028635666,CDM,86356,CPT,0302,RC,,,,both,,,64.00,41.60,,,,,,,,,,,,,
KIT INFUS PRT DIA7FR SIL PLAS 2 LUMN L SEPT PEEL APART,SUP-2127757,CDM,C1788,HCPCS,0278,RC,,,,both,,,1519.76,987.84,,,,,,,,,,,,,
BUR SURG COARSE DIAMOND 3 MM 9 CM MTCH HD MIDAS REX LEGEND,SUP-2631879,CDM,2720000010,LOCAL,0272,RC,,,,both,,,380.35,247.23,,,,,,,,,,,,,
SPACER SPNL H8XL50MM 6DEG VERT BODY CLYDESDALE,SUP-2285061,CDM,C1821,HCPCS,0278,RC,,,,both,,,11514.38,7484.35,,,,,,,,,,,,,
PLATE BNE L59.5MM 12 H L DST RAD VOLAR S STL LOK COMPR CLMN,SUP-2184082,CDM,C1713,HCPCS,0278,RC,,,,both,,,2418.27,1571.88,,,,,,,,,,,,,
PURAPLYAM (4.0X4.0) 16 sq cm,SUP-2635402,CDM,Q4196,HCPCS,0636,RC,,,,both,,,5416.50,3520.72,,,,,,,,,,,,,
PLATE SPNL THK2MM 32 H THOR RIB CP TITANIUMXSHAPED LCK FOR,SUP-2262535,CDM,C1713,HCPCS,0278,RC,,,,both,,,5400.80,3510.52,,,,,,,,,,,,,
HC CT Heart No Contrast Quant Eval Coronry Calcium,PX-3507557100,CDM,75571,CPT,0350,RC,,,,inpatient,,,362.00,362.00,,,,,,,,,,,,,
ACCESSORY KIT SEERLT 3CH AHA,SUP-2226176,CDM,2720000010,LOCAL,0272,RC,,,,both,,,695.20,451.88,,,,,,,,,,,,,
FORCEPS BX WRK L110MM CHN L2MM DIA1.7MM SUPERDIMENSION,SUP-2381730,CDM,C1713,HCPCS,0278,RC,,,,both,,,347.28,225.73,,,,,,,,,,,,,
MILRINONE LACTATE 10 MG/10ML IV SOLN,RX-123636,CDM,J2260,HCPCS,0636,RC,00143-9710-01,NDC,,both,10,ML,54.10,35.16,,,,,,,,,,,,,
VALVE HEMSTAS ADJ ROT,SUP-2282186,CDM,C1887,HCPCS,0272,RC,,,,both,,,83.59,54.33,,,,,,,,,,,,,
SHEATH INTFR SCR L TIB TCP/PLA BIOABSRB BIO-INTRAFIX,SUP-2249562,CDM,C1776,CPT,0278,RC,,,,both,,,2006.46,1304.20,,,,,,,,,,,,,
ASCORBIC ACID 500 MG PO TABS,RX-664,CDM,6370000000,HCPCS,0637,RC,00904-0523-61,NDC,,both,1,UN,0.40,0.26,,,,,,,,,,,,,
PLATE BNE L 144 X W 12 MM THK 0.75 MM SCREW DIA1.7 MM PLL,SUP-2883143,CDM,C1713,HCPCS,0278,RC,,,,both,,,13445.48,8739.56,,,,,,,,,,,,,
ANCHOR SUT DIA1.3MM MIC W/ SZ 4-0 ETHBND EXCEL C-1 TAPERCUT,SUP-2249377,CDM,C1713,HCPCS,0278,RC,,,,both,,,1968.78,1279.71,,,,,,,,,,,,,
PLATE BNE 3 X 4 H CRANIOMAXILLOFACIAL REG DISTRCTN NS,SUP-2883212,CDM,C1713,HCPCS,0278,RC,,,,both,,,1834.51,1192.43,,,,,,,,,,,,,
SCREW SPNL L35MM DIA6.25MM CANC PEDCL S STL NO CUT ISOLA VSP,SUP-2255681,CDM,C1713,HCPCS,0278,RC,,,,both,,,1516.62,985.80,,,,,,,,,,,,,
BIT DRL TWST 1.6X50 MM 10 MM W/ STP NOTCH STRL SONICWELD RX,SUP-2459005,CDM,2720000010,LOCAL,0272,RC,,,,both,,,559.14,363.44,,,,,,,,,,,,,
NAIL INTRAMEDULLARY L25MM OD2.4MM 96L/4D PLA RESORBABLE SMAR,SUP-2824707,CDM,C1713,HCPCS,0278,RC,,,,both,,,594.43,386.38,,,,,,,,,,,,,
GRAFT HUM TISS BIDIR 4X2 CM GRID PAT AMNIO MEMBRN BIOVANCE,SUP-2651375,CDM,Q4154,HCPCS,0636,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
INFLUENZA VIRUS VACC SPLIT PF 0.5 ML IM SUSY,RX-129230,CDM,90656,HCPCS,0636,RC,58160-0912-41,NDC,,both,.5,ML,97.40,63.31,,,,,,,,,,,,,
STEM ULN SZ 4 L75MM L CEM CONSTRN NEXEL,SUP-2203815,CDM,C1776,CPT,0278,RC,,,,both,,,13345.00,8674.25,,,,,,,,,,,,,
SPLINT ORTH D RNG CLOSURE UNIV 8 IN WRST FOREARM RT,SUP-2336336,CDM,L3809,HCPCS,0272,RC,,,,both,,,20.63,13.41,,,,,,,,,,,,,
MESH HERN W55XL128CM DIA5CM POLYPR PTCH W EXT OVERLAY 3D,SUP-2218332,CDM,C1781,HCPCS,0278,RC,,,,both,,,847.86,551.11,,,,,,,,,,,,,
MESH SURG L W4.5XL10CM UNDERLAY 10CM CONN OD1.9CM ID1.3CM,SUP-2219789,CDM,C1781,HCPCS,0278,RC,,,,both,,,812.29,527.99,,,,,,,,,,,,,
INTRODUCER SHTH SL2 SIDE H RADPQ TIP MRK HEMSTAS TECHNOLOGY,SUP-2357210,CDM,C1893,HCPCS,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
STENT ESOPH WALLFLEX L 10 CM DIA18 FR DIA PROX/DSTL,SUP-2140108,CDM,C1876,HCPCS,0278,RC,,,,both,,,5863.17,3811.06,,,,,,,,,,,,,
STENT NEURO SURPS EVOLVE L 15 MM DIA 5 MM COCR PLAT FLO,SUP-2541461,CDM,C2617,HCPCS,0278,RC,,,,both,,,42898.68,27884.14,,,,,,,,,,,,,
PLATE BONE 16 H BLU STR FOR MICROFIXATION STRNL CLSR,SUP-2414186,CDM,C1713,HCPCS,0278,RC,,,,both,,,2549.68,1657.29,,,,,,,,,,,,,
IMPLANT TOE L16MM 0DEG PROX INTERPHALANGEAL NIT NEUT 1 PC,SUP-2379129,CDM,C1776,CPT,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
GUIDEWIRE VASC SYNCHRO 10 L 200 CM DIA 0.010 IN DSTL SEG L,SUP-2367858,CDM,C1769,HCPCS,0272,RC,,,,both,,,2336.16,1518.50,,,,,,,,,,,,,
RITUXIMAB (RITUXAN) 10 MG/ML IV SOLN (MIXTURES ONLY)|DISCARDED DRUG NOT ADMINISTE,RX-430010,CDM,J9312,HCPCS,0636,RC,50242-0051-21,NDC,JW,both,10,ML,2705.90,1758.83,,,,,,,,,,,,,
MESH HERN L15.2XW7.6CM POLYPR ABD ABSRB RECTANG SEPRAMESH,SUP-2125922,CDM,C1781,HCPCS,0278,RC,,,,both,,,644.64,419.02,,,,,,,,,,,,,
LEAD PACE EASYTRAK L 65 CM SIL POLYUR ENDOCARD LT,SUP-2148677,CDM,C1900,HCPCS,0275,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
GRAFT BNE MTRX 2.5 CC CELLULAR BNE MTRX V92,SUP-2434350,CDM,C1713,HCPCS,0278,RC,,,,both,,,4992.60,3245.19,,,,,,,,,,,,,
GRAFT BONE 1.7-10MM 15ML CANC CRUSH CHIP FRZN,SUP-2294132,CDM,C1713,HCPCS,0278,RC,,,,both,,,778.72,506.17,,,,,,,,,,,,,
PLATE BNE STR 2.7X3 MM 20 HOLE RECON LCK FOR SCR TI GLD,SUP-2499142,CDM,C1713,HCPCS,0278,RC,,,,both,,,4004.54,2602.95,,,,,,,,,,,,,
GRAFT INFORCE TISS 5CMX5CM PORCINE,SUP-2244086,CDM,C1763,HCPCS,0278,RC,,,,both,,,10110.80,6572.02,,,,,,,,,,,,,
PERI-LOC 4.5MM T25 TI LCK SCREW 95MM S-T,SUP-2819242,CDM,C1713,HCPCS,0278,RC,,,,both,,,1245.73,809.72,,,,,,,,,,,,,
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,0636,RC,55150-0282-09,NDC,,both,1,UN,230.00,149.50,,,,,,,,,,,,,
BLOCK TIB AUG 3 10 MM KNEE,SUP-2201564,CDM,C1776,CPT,0278,RC,,,,both,,,3605.82,2343.78,,,,,,,,,,,,,
COMPONENT FEM SZ 1 L POR CRUCE RET BAL REV SYS,SUP-2314659,CDM,C1776,CPT,0278,RC,,,,both,,,7008.48,4555.51,,,,,,,,,,,,,
FILGRASTIM-AYOW 480 MCG/0.8ML SC SOSY,RX-157757,CDM,Q5125,HCPCS,0636,RC,70121-1570-01,NDC,,both,0.8,ML,750.50,487.82,,,,,,,,,,,,,
BOOT FT FLEECE MED ANK CONTRACTURE W/ OUT SOLE,SUP-2336234,CDM,L4396,HCPCS,0274,RC,,,,both,,,137.41,89.32,,,,,,,,,,,,,
CONNECTOR SPNL DOMINO OPN POST ANT 2 ROD SPNL SYS 45MM TO,SUP-2631251,CDM,C1713,HCPCS,0278,RC,,,,both,,,2176.02,1414.41,,,,,,,,,,,,,
STENT URETH 8.5FR L90CM PTFE DIV SGL J OPN END,SUP-2313761,CDM,C2617,HCPCS,0278,RC,,,,both,,,1089.89,708.43,,,,,,,,,,,,,
KIT PICC DIA 6 FR GUIDEWIRE L 80 CM GUIDEWIRE NIT HYDRPHLC,SUP-2909919,CDM,C1751,HCPCS,0278,RC,,,,both,,,769.93,500.45,,,,,,,,,,,,,
FILTER SMK EVAC NEPTUNE 2 NEPTUNE 3 3-PORT,SUP-2151926,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1216.03,790.42,,,,,,,,,,,,,
DRILL 25MM,SUP-2841576,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1114.70,724.55,,,,,,,,,,,,,
SUPPORT ORTHOT MTCRPL HND OFF-THE-SHELF PREFABRICATED,SUP-2435779,CDM,L3918,HCPCS,0272,RC,,,,both,,,272.08,176.85,,,,,,,,,,,,,
ALIGNRITE WRIST BLK SHRT RGHT MED,SUP-2462313,CDM,L3906,HCPCS,0272,RC,,,,both,,,54.13,35.18,,,,,,,,,,,,,
COUPLER EXT FIX LOK 3X3 MM,SUP-2464145,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1782.58,1158.68,,,,,,,,,,,,,
PROBE EXTRACTION FOR SLAPHAMMER NS OSCAR 3 LTX,SUP-2875691,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1708.16,1110.30,,,,,,,,,,,,,
CATHETER HD DL 15.5 FRX20 CM PRE CRV HEMO-FLOW XF,SUP-2627244,CDM,C1750,HCPCS,0278,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
STRUT EXT FIX L 100 MM STATIC,SUP-2898488,CDM,2720000010,LOCAL,0272,RC,,,,both,,,606.02,393.91,,,,,,,,,,,,,
COLLAR CERV M W4XL21IN FIRM FOAM SERP STYL WSH,SUP-2276597,CDM,L0120,HCPCS,0274,RC,,,,both,,,7.38,4.80,,,,,,,,,,,,,
TRAY CTRL VEN CATH 5FR L15CM 0.035IN GWIRE TIP NDL BASEPLT G01915] COOK MEDICAL INC],SUP-2167824,CDM,C1751,HCPCS,0278,RC,,,,both,,,114.55,74.46,,,,,,,,,,,,,
STENT ESOPH EVOLUTION L 15 CM BODY DIA20 MM FLANGE DIA25 MM,SUP-2170567,CDM,C1874,HCPCS,0278,RC,,,,both,,,5199.84,3379.90,,,,,,,,,,,,,
HC Immunofluorescence PR Spec Ea Add Singl Antb Stn,PX-3128835000,CDM,88350,CPT,0312,RC,,,,outpatient,,,369.00,239.85,,,,,,,,,,,,,
HC So Dhea Level,PX-3018262666,CDM,82626,CPT,0301,RC,,,,outpatient,,,131.00,85.15,,,,,,,,,,,,,
COMPONENT TALAR DOMED 1 LT FT ANK SLOPED XT,SUP-2244192,CDM,C1776,CPT,0278,RC,,,,both,,,33252.60,21614.19,,,,,,,,,,,,,
SMOG ENEMA,RX-408105755,CDM,2500000003,HCPCS,0250,RC,09999-9996-74,NDC,,both,330,ML,44.60,28.99,,,,,,,,,,,,,
SUPPORT ORTHOT MTCRPL HND OFF-THE-SHELF PREFABRICATED,SUP-2435779,CDM,L3918,HCPCS,0274,RC,,,,both,,,272.08,176.85,,,,,,,,,,,,,
SLEEVE CBL SM OD16MM VIT DALL M,SUP-2377577,CDM,C1713,HCPCS,0278,RC,,,,both,,,453.42,294.72,,,,,,,,,,,,,
PLATE BONE UNIV L50MM RIB NONCOMPRESSION RIBLOC,SUP-2107916,CDM,C1713,HCPCS,0278,RC,,,,both,,,4034.90,2622.68,,,,,,,,,,,,,
DEXTROSE 5 % IV SOLN INTERMITTENT INFUSION,RX-40840103,CDM,2580000003,HCPCS,0250,RC,00264-1510-31,NDC,,both,250,ML,104.20,67.73,,,,,,,,,,,,,
HC Inc Thromb Hemorrhoid Ext,PX-4504608300,CDM,46083,CPT,0450,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
SAW SURG OSCILLATING HALL TITAN PRO9300B,SUP-2607718,CDM,2720000010,LOCAL,0272,RC,,,,both,,,21972.15,14281.90,,,,,,,,,,,,,
DEFIBRILLATOR IMPL GALLANT HF L 79 X W 51 X H 12 MM 37 CC 81,SUP-2889718,CDM,C1882,HCPCS,0275,RC,,,,both,,,43646.00,28369.90,,,,,,,,,,,,,
PLATE BNE L 177 MM SCREW DIA2.7 MM 20 SHFT H TI ADPT COMB,SUP-2907581,CDM,C1713,HCPCS,0278,RC,,,,both,,,4487.22,2916.69,,,,,,,,,,,,,
RETRACTOR SURG W18XL240MM S STL SHT NAR TIP HOHMN,SUP-2410972,CDM,C1713,HCPCS,0278,RC,,,,both,,,579.58,376.73,,,,,,,,,,,,,
PROBE CRYOABLATION L10CM ALUM SMOOTH MAL CRYOICE,SUP-2124442,CDM,C2618,HCPCS,0272,RC,,,,both,,,7222.00,4694.30,,,,,,,,,,,,,
MESH CRAN W90XL90MM PROF H0.3MM MIC MID FACE,SUP-2366217,CDM,C1713,HCPCS,0278,RC,,,,both,,,4579.69,2976.80,,,,,,,,,,,,,
TRIFECTA VIABLE CELL ALLGRFT 1CC,SUP-2232315,CDM,C1713,HCPCS,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
SYSTEM IMPL S STL KNOTLESS FOR SYNDESMOSIS REP TIGHTROPE,SUP-2122825,CDM,C1713,HCPCS,0278,RC,,,,both,,,3689.50,2398.17,,,,,,,,,,,,,
NEEDLE OPHTH DIX SPUD FB W/ SLIDING HNDL SS,SUP-2497610,CDM,2720000010,LOCAL,0272,RC,,,,both,,,590.13,383.58,,,,,,,,,,,,,
PLATE BONE THK0.3MM CRANIOFACIAL ORBIT TI MESH MALL FOR,SUP-2190685,CDM,C1713,HCPCS,0278,RC,,,,both,,,4527.88,2943.12,,,,,,,,,,,,,
KIT PI PICC 2-L 5 FRX55 CM WITH PRELO,SUP-2826671,CDM,C1751,HCPCS,0278,RC,,,,both,,,886.89,576.48,,,,,,,,,,,,,
GRAFT BONE SUB 5CC DEMIN BONE MTRX ORTHOBLEND FOR SM DEFCT,SUP-2294019,CDM,C1713,HCPCS,0278,RC,,,,both,,,3746.02,2434.91,,,,,,,,,,,,,
PLATE BNE L27MM 100DEG 3X4 H R CRANIOMAXILLOFACIAL TI L SHP,SUP-2191161,CDM,C1713,HCPCS,0278,RC,,,,both,,,1167.14,758.64,,,,,,,,,,,,,
SET BILI DRNGE 12FR L30CM GWIRE 0.038IN 5 H PGTL POLYETH,SUP-2141064,CDM,C1729,HCPCS,0272,RC,,,,both,,,550.91,358.09,,,,,,,,,,,,,
CATHETER INFUSION FOUNTAIN L 135 CM DIA 4 FR SEG L 10 CM,SUP-2302762,CDM,C1751,HCPCS,0278,RC,,,,both,,,365.03,237.27,,,,,,,,,,,,,
DEXTROSE 5 % IV SOLN INTERMITTENT INFUSION,RX-40840103,CDM,2580000003,HCPCS,0250,RC,00264-7510-00,NDC,,both,250,ML,8.50,5.52,,,,,,,,,,,,,
HC X-Ray Os Calcis Min 2 Views,PX-3207365000,CDM,73650,CPT,0320,RC,,,,both,,,376.00,244.40,,,,,,,,,,,,,
ALLOGRAFT BNE 1-4 MM 15 CC FD CORTICAL CANC,SUP-2867102,CDM,C1762,CPT,0278,RC,,,,both,,,850.16,552.60,,,,,,,,,,,,,
ALLOGRAFT DERMAL 1X1 CMX1.27 3.30 MM TISSUE MATRIX ALLODERM,SUP-2459017,CDM,Q4116,HCPCS,0636,RC,,,,both,,,219.80,142.87,,,,,,,,,,,,,
DRILL SURG 6 MM PATELLO FEM JT IM GENDER SOL,SUP-2437878,CDM,2720000010,LOCAL,0272,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
PLATE BNE RECON 2-2.5X222X2 MM 32 HOLE ANGLED-ANGLED TI,SUP-2539586,CDM,C1713,HCPCS,0278,RC,,,,both,,,7790.91,5064.09,,,,,,,,,,,,,
CATHETER ETER 7FR 5FR REFLEXION SPRL,SUP-2357500,CDM,C1730,HCPCS,0272,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
INTRODUCER GUID REDUC RAD SSR4 8FRX60CM 038IN SWARTZ,SUP-2357182,CDM,C1893,HCPCS,0272,RC,,,,both,,,486.70,316.35,,,,,,,,,,,,,
SYSTEM FIX ORTHO BOLT WIRE EXT SHRT LRF 15 20MM,SUP-2701752,CDM,2720000010,LOCAL,0272,RC,,,,both,,,330.64,214.92,,,,,,,,,,,,,
ACETAMINOPHEN 10 MG/ML IV SOLN,RX-103580,CDM,J0131,HCPCS,0636,RC,63323-0434-41,NDC,,both,65,ML,54.10,35.16,,,,,,,,,,,,,
CONNECTOR SPNL OFFSET 20 MM PROTEX,SUP-2584143,CDM,C1713,HCPCS,0278,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
DARBEPOETIN ALFA 25 MCG/0.42ML IJ SOSY,RX-131221,CDM,J0881,HCPCS,0636,RC,55513-0057-01,NDC,,both,0.42,ML,570.90,371.08,,,,,,,,,,,,,
IMPLANT OTO L4.25MM OD.5MM PLAT TI PIST SHT BODY CLR DEPTH,SUP-2284071,CDM,L8613,CPT,0278,RC,,,,both,,,596.60,387.79,,,,,,,,,,,,,
PLATE BNE CRV MINI 2X1 MM CRANIOMAXILLOFACIAL 7 HOLE TI NS,SUP-2489623,CDM,C1713,HCPCS,0278,RC,,,,both,,,509.90,331.43,,,,,,,,,,,,,
BIT DRILL 4.5MM 3 FLUTED QC,SUP-2819221,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1455.89,946.33,,,,,,,,,,,,,
BRACE ORTH CIRC THGH 23.5-26.5 IN CTR 17-19 IN CALF 18-20 IN 11-0865-5,SUP-2918712,CDM,2720000010,LOCAL,0272,RC,,,,both,,,342.76,222.79,,,,,,,,,,,,,
PLATE BNE L142MM 6 H NONSTERILE L MED DST TIB S STL LOK,SUP-2185584,CDM,C1713,HCPCS,0278,RC,,,,both,,,4456.23,2896.55,,,,,,,,,,,,,
PLATE BNE 10 H RT ANTEROLATERAL DSTL TIB NS,SUP-2896881,CDM,C1713,HCPCS,0278,RC,,,,both,,,5491.86,3569.71,,,,,,,,,,,,,
HC Prothrombin Time Qw,PX-3058561005,CDM,85610,CPT,0305,RC,,,,both,,,109.00,70.85,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED BPLR UPLR PRSS FT STEM H5MEDACTA] MEDACTA USA],SUP-2267790,CDM,C1776,CPT,0278,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
SCREW BNE L36MM DIA4.5MM CORT TI ANK LOK FULL THRD LO PROF,SUP-2398527,CDM,C1713,HCPCS,0278,RC,,,,both,,,649.98,422.49,,,,,,,,,,,,,
IMPLANT TOE JT 24X15MM PROX SL CANNULINK,SUP-2400048,CDM,C1713,HCPCS,0278,RC,,,,both,,,1139.82,740.88,,,,,,,,,,,,,
GRAFT HUM TISS 2CC PLCNTA MTRX FLOWABLE IMMUNOSUPPRESSIVE W/,SUP-2340458,CDM,C1762,CPT,0278,RC,,,,both,,,8949.00,5816.85,,,,,,,,,,,,,
CATHETER CV TY 7 FRX20 CM 3L CUTLMY701JABRMCUSTOM0003,SUP-2759795,CDM,C1751,HCPCS,0278,RC,,,,both,,,367.76,239.04,,,,,,,,,,,,,
SLEEVE INSRT FOR ASNS III CANN SCR SYS 32MM GWIRE,SUP-2377942,CDM,C1769,HCPCS,0272,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
INSERT HUM DIA36MM THK+6MM B-12.5DEG SHLDR REVERSED,SUP-2388712,CDM,C1776,CPT,0278,RC,,,,both,,,3631.41,2360.42,,,,,,,,,,,,,
METHYLPREDNISOLONE SODIUM SUCC 1000 MG IJ SOLR,RX-10577,CDM,J2919,HCPCS,0636,RC,00143-9851-01,NDC,,both,1,UN,240.90,156.58,,,,,,,,,,,,,
CATHETER THROMCTMY LIGHTNING BOLT HTORQ + L 115 CM DIA12 FR,SUP-2930561,CDM,C1757,HCPCS,0272,RC,,,,both,,,30520.80,19838.52,,,,,,,,,,,,,
FIBER LASER FLAT TIP 800 MH ASMBLY HOLM,SUP-2300072,CDM,C1713,HCPCS,0278,RC,,,,both,,,2041.00,1326.65,,,,,,,,,,,,,
HEAD FEMORAL COCR 12/14 40MM +0,SUP-2504658,CDM,C1776,CPT,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
FILTER VASC L 150 CM DIA 0.035 IN SS TEF VENA CAVA FEM,SUP-2113960,CDM,C1880,HCPCS,0278,RC,,,,both,,,3752.30,2438.99,,,,,,,,,,,,,
MORCELLATOR ENDO OD2.9MM ROTARY DISP TRUCLEAR INCIS +,SUP-2341839,CDM,C1782,HCPCS,0272,RC,,,,both,,,2227.83,1448.09,,,,,,,,,,,,,
SET INTRO FLX PEELWY L 11 CM DIA23 FR GUIDEWIRE L 150 CM DIA,SUP-2889625,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
IMPLANT HUM TISS 4X6CM MEMBRN AMNIO DEHYDR ALLGRFT,SUP-2225383,CDM,C1713,HCPCS,0278,RC,,,,both,,,9247.30,6010.74,,,,,,,,,,,,,
AUGMENT ACET PART HMSPHR SZ 50 MM 20 MM THCK MULT H POR,SUP-2199311,CDM,C1776,CPT,0278,RC,,,,both,,,9168.80,5959.72,,,,,,,,,,,,,
CATHETER KIT 4 IN CV DL HEMSTAS VLV NDL,SUP-2120579,CDM,C1751,HCPCS,0278,RC,,,,both,,,283.23,184.10,,,,,,,,,,,,,
BIT DRILL SURG DIA2 MM AO STYL NS DISP,SUP-2930412,CDM,2720000010,LOCAL,0272,RC,,,,both,,,576.98,375.04,,,,,,,,,,,,,
PLATE BNE L232MM 14 H ST L ANTEROMEDIAL DST TIB S STL VAR,SUP-2177689,CDM,C1713,HCPCS,0278,RC,,,,both,,,7297.27,4743.23,,,,,,,,,,,,,
BOLT EXT FIX LP SHT UNIV WIRE TRUELOK +,SUP-2875033,CDM,2720000010,LOCAL,0272,RC,,,,both,,,507.74,330.03,,,,,,,,,,,,,
PLATE BNE 14 H NONSTERILE STRNL TI DBL T SHP LOK FOR 3MM,SUP-2192442,CDM,C1713,HCPCS,0278,RC,,,,both,,,3050.20,1982.63,,,,,,,,,,,,,
BIT DRL DIA2MM FT FOR CHARLOTTE CLAW PLT,SUP-2397354,CDM,2720000010,LOCAL,0272,RC,,,,both,,,508.68,330.64,,,,,,,,,,,,,
HC Incis/Drain Scrotum/Testis Epididym,PX-4505470000,CDM,54700,CPT,0450,RC,,,,both,,,2099.00,1364.35,,,,,,,,,,,,,
MESH PARIETEX TWO DIM 20 CM X 20 CM,SUP-2174776,CDM,C1781,HCPCS,0278,RC,,,,both,,,381.26,247.82,,,,,,,,,,,,,
GRAFT TISS FRZN ALLGRFT FEM DSTL TRAD LT,SUP-2294159,CDM,C1713,HCPCS,0278,RC,,,,both,,,10597.50,6888.37,,,,,,,,,,,,,
INTRODUCER SHTH RAD MINI ACCS GRN HUB 6FRX11CM PRELUDE,SUP-2303278,CDM,C1894,HCPCS,0272,RC,,,,both,,,100.92,65.60,,,,,,,,,,,,,
RETRACTOR SURG MAS TLIF HOOP SHIM DISP MAXCESS,SUP-2310435,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
SCREW BNE L 15 MM DIA2 MM TI INTERMAXILLARY FIX SYS NS DISP,SUP-2935002,CDM,C1713,HCPCS,0278,RC,,,,both,,,378.06,245.74,,,,,,,,,,,,,
APPLIER CLP L12.99IN W/ 16 TI CLP GRY PSTL GRP DISP ENDO,SUP-2283170,CDM,2720000010,LOCAL,0272,RC,,,,both,,,658.43,427.98,,,,,,,,,,,,,
CAGE SPNL MESH 28X22X10 MM 6 LOBE,SUP-2602086,CDM,C1889,HCPCS,0278,RC,,,,both,,,8459.16,5498.45,,,,,,,,,,,,,
SYSTEM SEAL 5ML SPINE DURA HYDRGEL POLYETH GLYCOL,SUP-2243116,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2744.93,1784.20,,,,,,,,,,,,,
PLATE BNE L109MM THK3.3MM 9 H BILAT S STL RIG STR DYN COMPR,SUP-2186333,CDM,C1713,HCPCS,0278,RC,,,,both,,,1065.87,692.82,,,,,,,,,,,,,
PLATE BONE L37MM 3 H S STL 1/3 TBLR ECT,SUP-2198530,CDM,C1713,HCPCS,0278,RC,,,,both,,,116.90,75.98,,,,,,,,,,,,,
PROCESSOR SND BGE NEUT BAHA CORDELLE II,SUP-2165022,CDM,L8614,HCPCS,0278,RC,,,,both,,,9357.20,6082.18,,,,,,,,,,,,,
ALLOGRAFT BNE 0.5 CC FD DBM GRFT,SUP-2787760,CDM,C1713,HCPCS,0278,RC,,,,both,,,350.11,227.57,,,,,,,,,,,,,
SCREW BNE L38MM DIA4.5MM ST CORT NONLOCKING L FRAG SET,SUP-2348858,CDM,C1713,HCPCS,0278,RC,,,,both,,,172.23,111.95,,,,,,,,,,,,,
COMPONENT ULN XSM L4.5IN R EL TIV PLSM INTERCHANGEABLE CEM,SUP-2205946,CDM,C1776,CPT,0278,RC,,,,both,,,14871.04,9666.18,,,,,,,,,,,,,
ROD SPNL POST SMOOTH TI ALLOY 5.5MM DIA 130MM LEN,SUP-2289287,CDM,C1713,HCPCS,0278,RC,,,,both,,,602.88,391.87,,,,,,,,,,,,,
IMPLANT BIO L 7 X W 20 CM FISH SKIN DERMAL SLD INTACT FLAT,SUP-2909270,CDM,Q4158,HCPCS,0636,RC,,,,both,,,17668.15,11484.30,,,,,,,,,,,,,
"HC ER Level 5|MULTIPLE OUTPATIENT HOSPITAL E/M ENCOUNTERS ON THE SAME DATE|SIGNIFICANT, SEPARATELY IDENTIFIABLE EVALUATION AND MANAGEMENT SERVICE BY THE SAME PHYSICIAN ON THE SAME DAY OF THE PROCEDURE OR OTHER SERVICE",PX-4509928500,CDM,99285,CPT,0450,RC,,,27|25,outpatient,,,3911.00,2542.15,,,,,,,,,,,,,
SURFACE ARTC TIB CONSTRN CNDYL KNEE MOD TIV SZ 59 25MM IB II,SUP-2205849,CDM,C1776,CPT,0278,RC,,,,both,,,7767.10,5048.61,,,,,,,,,,,,,
COVER SCR HEX DISP FOR TWO STG SURG PROC,SUP-2319870,CDM,C1713,HCPCS,0278,RC,,,,both,,,643.70,418.40,,,,,,,,,,,,,
KIT LD REP ATR SINGLE CHMBR IS1 CONN STRL,SUP-2148912,CDM,2720000010,LOCAL,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
CATHETER HD STR 14.5 FRX40 CM LT DL STP BASIC SET HEMO-FLOW,SUP-2627205,CDM,C1750,HCPCS,0278,RC,,,,both,,,169.56,110.21,,,,,,,,,,,,,
SCREW BNE SNAP OFF DRV FOR FRAC REP AND FIX OSTEOTMY JT FUS,SUP-2175120,CDM,C1713,HCPCS,0278,RC,,,,both,,,918.45,596.99,,,,,,,,,,,,,
GUIDEWIRE 20X30CM RECTANG,SUP-2419664,CDM,C1769,HCPCS,0272,RC,,,,both,,,25066.62,16293.30,,,,,,,,,,,,,
GRAFT VASC CARBOFLO 8 MMX50 CM EPTFE FLX THN WALL SM BEAD,SUP-2126881,CDM,C1768,CPT,0278,RC,,,,both,,,7093.04,4610.48,,,,,,,,,,,,,
HEADGEAR MASK CPAP COMB W/ LOOPS SWIFT FX,SUP-2193982,CDM,C1713,HCPCS,0278,RC,,,,both,,,210.38,136.75,,,,,,,,,,,,,
CHOLESTYRAMINE 4 G PO PACK,RX-9588,CDM,6370000000,HCPCS,0637,RC,67877-0298-09,NDC,,both,1,UN,4.40,2.86,,,,,,,,,,,,,
FUSEFORCE STRL SZR KT,SUP-2399890,CDM,2720000010,LOCAL,0272,RC,,,,both,,,536.94,349.01,,,,,,,,,,,,,
GRAFT HUM TISS 4X4CM DEHYDR AMNIO MEMBRN ALLGRFT FLOWERPATCH,SUP-2225382,CDM,2780000010,LOCAL,0278,RC,,,,both,,,6970.80,4531.02,,,,,,,,,,,,,
NAIL-EX FEM RECON 14X300MM RT PRFMIS FOSSA STRL,SUP-2546539,CDM,C1713,HCPCS,0278,RC,,,,both,,,6138.51,3990.03,,,,,,,,,,,,,
GRAFT VASC IMPRA CARBOFLO L 80 CM DIA 7-4 MM EPTFE CARBON,SUP-2761514,CDM,C1768,CPT,0278,RC,,,,both,,,4808.38,3125.45,,,,,,,,,,,,,
WEDGE TIB SZ 7-8 10MM L MED R LAT KNEE HEMI STP LEGION,SUP-2346578,CDM,C1776,CPT,0278,RC,,,,both,,,4226.44,2747.19,,,,,,,,,,,,,
HC Phys Performnce Test Ea 15 Min,PX-4209775000,CDM,97750,CPT,0420,RC,,,,inpatient,,,194.00,126.10,,,,,,,,,,,,,
COIL NEUROVASCULAR GDC-10 360 DEG L 4 CM DIA2 MM,SUP-2362410,CDM,C1889,HCPCS,0278,RC,,,,both,,,3.80,2.47,,,,,,,,,,,,,
JOINT TOE CANN SCR 6.5 MM PLANAR W/ BLADE PRO-TOE VO,SUP-2486951,CDM,C1776,CPT,0278,RC,,,,both,,,430.18,279.62,,,,,,,,,,,,,
SUPPORT ORTHOT HIP JT LOWER EXTREMITY PELV CTRL CABLE PLAS,SUP-2435686,CDM,L2627,HCPCS,0274,RC,,,,both,,,6050.84,3933.05,,,,,,,,,,,,,
SCREW BNE L80MM OD7MM THRD L21MM PUR HINDFOOT ANK CANN M,SUP-2320772,CDM,C1713,HCPCS,0278,RC,,,,both,,,1307.81,850.08,,,,,,,,,,,,,
BIT DRL 9.3 MM NS GOTFRIED PCCP,SUP-2644757,CDM,2720000010,LOCAL,0272,RC,,,,both,,,764.72,497.07,,,,,,,,,,,,,
BRACE WRISTXL L8IN RT FOAM LOOP LCK CLSR W/ THMB SPICA,SUP-2324354,CDM,L3931,HCPCS,0274,RC,,,,both,,,70.68,45.94,,,,,,,,,,,,,
SCREW BNE EMGCY 2.4X9 MM T8 TI NS,SUP-2189474,CDM,C1713,HCPCS,0278,RC,,,,both,,,949.85,617.40,,,,,,,,,,,,,
CATHETER ART THERMODILUTION .035 IN 7 FRX110 CM PULM 2 LUMEN,SUP-2662685,CDM,C1751,HCPCS,0278,RC,,,,both,,,195.94,127.36,,,,,,,,,,,,,
ALLOGRAFT BNE DWL 12X30-35 MM PRESERVON XLNG CANC FLEXIGRAFT,SUP-2264646,CDM,C1762,CPT,0278,RC,,,,both,,,3783.32,2459.16,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY LASSO L 115 CM DIA 7 FR SPC 4 MM,SUP-2538037,CDM,C1730,HCPCS,0272,RC,,,,both,,,1087.48,706.86,,,,,,,,,,,,,
SET BNE BX AND INFUS W COAX CRV 10G 10MM INTRO NDL AND 13G,SUP-2168818,CDM,C1713,HCPCS,0278,RC,,,,both,,,737.90,479.63,,,,,,,,,,,,,
PLATE BNE 5 H RT CRANIOMAXILLOFACIAL L SHP W/O BAR NS,SUP-2883241,CDM,C1713,HCPCS,0278,RC,,,,both,,,669.20,434.98,,,,,,,,,,,,,
PLATE BNE DBL ANGLED MED 2.5 MM RECON PT SPEC,SUP-2860100,CDM,C1713,HCPCS,0278,RC,,,,both,,,28600.38,18590.25,,,,,,,,,,,,,
COLESEVELAM HCL 625 MG PO TABS,RX-28372,CDM,6370000000,HCPCS,0637,RC,68462-0433-18,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
GRAFT SFT TISS 20X30 MM BOV PERICARD MEMBRN COPIOS,SUP-2335282,CDM,C1762,CPT,0278,RC,,,,both,,,712.78,463.31,,,,,,,,,,,,,
CARVEDILOL 6.25 MG PO TABS,RX-15747,CDM,6370000000,HCPCS,0637,RC,00904-7306-61,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
BUR SURG L14CM DIA7.5MM BALL FLUT L BOR MIDAS REX LEGEND,SUP-2284379,CDM,2720000010,LOCAL,0272,RC,,,,both,,,368.70,239.65,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED STD PRSS FT N-K,SUP-2212611,CDM,C1776,CPT,0278,RC,,,,both,,,12013.64,7808.87,,,,,,,,,,,,,
BIT DRL OD4.3MM SHT VALOR,SUP-2397589,CDM,2720000010,LOCAL,0272,RC,,,,both,,,624.86,406.16,,,,,,,,,,,,,
WIRE LIG 24GA DIA0.02IN S STL INSTR,SUP-2136072,CDM,C1713,HCPCS,0278,RC,,,,both,,,194.68,126.54,,,,,,,,,,,,,
SPLINT WR AD M L1/8IN FOR 3.5-4.5IN BGE RT FRARM HND PRE FRM,SUP-2324807,CDM,L3906,HCPCS,0274,RC,,,,both,,,94.64,61.52,,,,,,,,,,,,,
CAGE SPNL STATIC 18X16 MM TI X-CORE 2 7180016P2,SUP-2561279,CDM,C1889,HCPCS,0278,RC,,,,both,,,13816.00,8980.40,,,,,,,,,,,,,
CONNECTOR EXT FIX PIN ANGLED,SUP-2898450,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1208.90,785.78,,,,,,,,,,,,,
KIT INTRO MAK-NV L 20 CM DIA 6 FR GUIDEWIRE L 60/80 CM DIA,SUP-2303021,CDM,C1894,HCPCS,0272,RC,,,,both,,,207.33,134.76,,,,,,,,,,,,,
SPHINCTEROTOME ENDOSCP CANN 4.9 FRX20 MM 0.035 IN JAGTOME,SUP-2149817,CDM,C1713,HCPCS,0278,RC,,,,both,,,978.83,636.24,,,,,,,,,,,,,
BASKET SPEC RETRV 1.2 MM 286 CM 1 MM DIR VIS SPYGLS,SUP-2419081,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1641.53,1066.99,,,,,,,,,,,,,
BIT DRL 3 FLUT 2.5 MMX9 IN CALIB,SUP-2795898,CDM,2720000010,LOCAL,0272,RC,,,,both,,,336.07,218.45,,,,,,,,,,,,,
INFUVITE PEDIATRIC IV SOLN,RX-135742,CDM,2500000003,HCPCS,0250,RC,54643-5646-01,NDC,,both,5,ML,138.30,89.89,,,,,,,,,,,,,
STEM FEM SEG 3 150/200/240 MM HIP REV NK ENDUR,SUP-2454655,CDM,C1776,CPT,0278,RC,,,,both,,,3859.06,2508.39,,,,,,,,,,,,,
CUP ACET MULT H 44MM ACUMATCH A SER,SUP-2221815,CDM,C1776,CPT,0278,RC,,,,both,,,6028.80,3918.72,,,,,,,,,,,,,
PIN EXT FIX L 100 MM DIA 35 MM THRD DIA 4 MM SS NS DISP MAV,SUP-2931204,CDM,2720000010,LOCAL,0272,RC,,,,both,,,906.20,589.03,,,,,,,,,,,,,
CATHETER ARTHERECTOMY LASER 5 FRX1.7 MM OTW,SUP-2353090,CDM,C1885,CPT,0278,RC,,,,both,,,6594.00,4286.10,,,,,,,,,,,,,
GRAFT BONE LT FEM WHL W/O HD TRAD FRZN,SUP-2294156,CDM,C1713,HCPCS,0278,RC,,,,both,,,14695.20,9551.88,,,,,,,,,,,,,
SYSTEM LD INTRO SELECTRA L 45 CM DIA 7 FR EXT HK CRV,SUP-2424591,CDM,C1893,HCPCS,0272,RC,,,,both,,,753.60,489.84,,,,,,,,,,,,,
MEROPENEM-VABORBACTAM 2 (1-1) G IV SOLR,RX-139607,CDM,J2186,HCPCS,0636,RC,70842-0120-06,NDC,,both,1,UN,1279.40,831.61,,,,,,,,,,,,,
SOTALOL HCL 120 MG PO TABS,RX-15723,CDM,6370000000,HCPCS,0637,RC,00093-1060-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
SCREW BNE L12MM DIA2MM CORT TI ST NONCANNULATED FULL THRD,SUP-2189648,CDM,C1713,HCPCS,0278,RC,,,,both,,,340.41,221.27,,,,,,,,,,,,,
ALLOGRACT HUM TISS AMNIOBAND MEMBRANE 2X3CM,SUP-2905486,CDM,Q4151,HCPCS,0636,RC,,,,both,,,2694.87,1751.67,,,,,,,,,,,,,
HC So Malaria Prep,PX-3008720766,CDM,87207,CPT,0300,RC,,,,inpatient,,,43.00,27.95,,,,,,,,,,,,,
FRACTURE KIT FULL LNG 10 ML W/ PWR CRV STABILIT MX,SUP-2484122,CDM,2720000010,LOCAL,0272,RC,,,,both,,,9548.58,6206.58,,,,,,,,,,,,,
PLATE BNE MEDL LT ANTR TIBIAXYS,SUP-2609011,CDM,C1713,HCPCS,0278,RC,,,,both,,,4581.13,2977.73,,,,,,,,,,,,,
GUIDEWIRE VASC ANGLED 0.018 INX180 CM STIFF SELECTIVA,SUP-2424959,CDM,C1769,HCPCS,0272,RC,,,,both,,,177.94,115.66,,,,,,,,,,,,,
INTRODUCER 7FR 14CM PEEL AWAY,SUP-2142735,CDM,C1894,HCPCS,0272,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
DYNANITE COMP PLATE 3-HOLE T 22MM,SUP-2814520,CDM,C1713,HCPCS,0278,RC,,,,both,,,8462.30,5500.49,,,,,,,,,,,,,
TOOL TUNN LNG 35 CM PRECIS,SUP-2141928,CDM,2720000010,LOCAL,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
COMPONENT FEM SM AP62MM ML66MM R CO CHROM NP CEM REV MOD,SUP-2253238,CDM,C1776,CPT,0278,RC,,,,both,,,15127.26,9832.72,,,,,,,,,,,,,
SCREW BNE SPADE PT 6X160 MM BLNT TROCAR SS HA STRL SCHNZ,SUP-2422830,CDM,C1713,HCPCS,0278,RC,,,,both,,,532.80,346.32,,,,,,,,,,,,,
KIT INTRO 18FR PRELD SAFE T PEXY T FASTENERS LOKING POLYUR,SUP-2124698,CDM,C1894,HCPCS,0272,RC,,,,both,,,690.71,448.96,,,,,,,,,,,,,
DRILL SURG CEM 1.5-3 FBT HI PERF SIG,SUP-2456271,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1560.58,1014.38,,,,,,,,,,,,,
MICROCATHETER VASC EXCELSIOR XT-27 FLX L 150 CM DSTL L 18 CM,SUP-2365845,CDM,C1725,HCPCS,0272,RC,,,,both,,,3163.24,2056.11,,,,,,,,,,,,,
CAP END F/RFNA 0MM STERILE,SUP-2719549,CDM,C1889,HCPCS,0278,RC,,,,both,,,590.54,383.85,,,,,,,,,,,,,
PLATE BNE 0 LT MCS,SUP-2315900,CDM,C1713,HCPCS,0278,RC,,,,both,,,5058.54,3288.05,,,,,,,,,,,,,
HC MRI Brain WO Ctrst|REDUCED SERVICES,PX-6117055100,CDM,70551,CPT,0611,RC,,,52,both,,,5059.00,3288.35,,,,,,,,,,,,,
ALLOGRAFT BNE FD ASEP FEM HD,SUP-2867014,CDM,C1762,CPT,0278,RC,,,,both,,,4429.76,2879.34,,,,,,,,,,,,,
BLADE DERMTOM REG THROW AWAY,SUP-2243522,CDM,2720000010,LOCAL,0272,RC,,,,both,,,158.57,103.07,,,,,,,,,,,,,
BIT DRILL NON QUICK COUPLING 4.5X165/180 MM JACOBS CHUCK END,SUP-2837051,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1023.39,665.20,,,,,,,,,,,,,
BRACE SPNL KNGHT TAY HEAT MOLD FOR LO BK STRAIN POST LAM,SUP-2123927,CDM,L0456,HCPCS,0274,RC,,,,both,,,3837.08,2494.10,,,,,,,,,,,,,
PUSHER KNOT CVD SUT CUT SLT CANN DISP FAST FIX 360,SUP-2341129,CDM,2720000010,LOCAL,0272,RC,,,,both,,,502.59,326.68,,,,,,,,,,,,,
GRAFT HUM TISS W4XL4CM WHL MEM AMNIO SHT NO ANG AMINOFIX,SUP-2305726,CDM,V2790,HCPCS,0278,RC,,,,both,,,4980.04,3237.03,,,,,,,,,,,,,
PLATE BONE L95MM 8 HOLE LOK DUAL CMPRSSN 27MM SCREW UNVRSL L,SUP-2481077,CDM,C1713,HCPCS,0278,RC,,,,both,,,921.12,598.73,,,,,,,,,,,,,
SCREW SPNL L13MM DIA4MM ANT CERV ST VAR ANG HELIX,SUP-2311594,CDM,C1713,HCPCS,0278,RC,,,,both,,,266.90,173.48,,,,,,,,,,,,,
PIN CRANIOMAXILLOFACIAL BONE REPOS FOR 3.2MM SCR,SUP-2364440,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1453.63,944.86,,,,,,,,,,,,,
GRAFT VASC VENAFLO II L 25 CM DIA 4-7 MM EPTFE CARBON STP N,SUP-2128782,CDM,C1768,CPT,0278,RC,,,,both,,,5513.46,3583.75,,,,,,,,,,,,,
GRAFT BNE PTTY 0.5 CC FD DBM STRL GRFT,SUP-2430048,CDM,C1713,HCPCS,0278,RC,,,,both,,,417.62,271.45,,,,,,,,,,,,,
INTRODUCER ORTH FOR STEM EXETER V40,SUP-2368333,CDM,C1713,HCPCS,0278,RC,,,,both,,,9817.52,6381.39,,,,,,,,,,,,,
SUPPORT ORTHOT TRILATERAL CUST LEGG PERTHES ORTHOSIS,SUP-2435604,CDM,L1720,HCPCS,0274,RC,,,,both,,,4176.42,2714.67,,,,,,,,,,,,,
KNIFE ELECSURG 1.5 MM TWIN PK ORISE GEL CATH ORISE PROKNIFE,SUP-2754409,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2920.20,1898.13,,,,,,,,,,,,,
STEM FEM HIP PRESSFIT LT PRI 35 MM OFFSET 11 MM DIA 130 MM,SUP-2198910,CDM,C1776,CPT,0278,RC,,,,both,,,20632.63,13411.21,,,,,,,,,,,,,
IMPLANT HUM TISS M W4XL7CM SKIN REGEN MTRX FRZ DRY ASEP,SUP-2112991,CDM,Q4116,HCPCS,0636,RC,,,,both,,,3052.08,1983.85,,,,,,,,,,,,,
KIT CATH HEMODIALYSI PWR TRIALYSI ACUTE 13FR DIA 30CML INSER,SUP-2613247,CDM,C1752,HCPCS,0278,RC,,,,both,,,896.78,582.91,,,,,,,,,,,,,
SCREW EXT FIX L 80 MM THRD L 20 MM DIA 4/3 MM SS ST NS SCHNZ,SUP-2908208,CDM,C1713,HCPCS,0278,RC,,,,both,,,266.62,173.30,,,,,,,,,,,,,
RIFAMPIN 300 MG PO CAPS,RX-11293,CDM,6370000000,HCPCS,0637,RC,60687-0586-11,NDC,,both,1,UN,8.40,5.46,,,,,,,,,,,,,
STEM FEM HI OFFSET 1 120 MM HIP NK SEG ENDUR,SUP-2454651,CDM,C1776,CPT,0278,RC,,,,both,,,3752.30,2438.99,,,,,,,,,,,,,
SCREW DISTRCTN QUICK START 14 MM PRE-PACKAGED STRL TSI DISP,SUP-2732066,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1953.77,1269.95,,,,,,,,,,,,,
CATHETER ANGIOPLASTY OTW 0.018 IN 130CM 5X150MM  018 DCB,SUP-2757489,CDM,C1725,HCPCS,0272,RC,,,,both,,,4615.80,3000.27,,,,,,,,,,,,,
SHOE ORTHOT MAR BAR ADDITION,SUP-2435744,CDM,L3595,HCPCS,0272,RC,,,,both,,,118.75,77.19,,,,,,,,,,,,,
KIT INTRO MINI STK II L 7 CM DIA 5 FR GUIDEWIRE L 60 CM DIA,SUP-2118837,CDM,C1894,HCPCS,0272,RC,,,,both,,,74.95,48.72,,,,,,,,,,,,,
COUNTERSINK CANN 4.0MM,SUP-2315874,CDM,C1713,HCPCS,0278,RC,,,,both,,,589.85,383.40,,,,,,,,,,,,,
PROBE SURG GROOVER 90 MM 2 LOBE NS OSCAR 3 LTX,SUP-2875720,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1519.76,987.84,,,,,,,,,,,,,
CATHETER ANGIO PGTL COR W/ SIDE H W/OUT HYDRPHLC COAT AD,SUP-2116593,CDM,C1725,HCPCS,0272,RC,,,,both,,,60.38,39.25,,,,,,,,,,,,,
ENDOPROSTHESIS VASC VIABAHN L 10CM 5MM 120CM 7FR HEPARIN,SUP-2719621,CDM,C1768,HCPCS,0278,RC,,,,both,,,10368.28,6739.38,,,,,,,,,,,,,
TIP ASPIR CLAW 1.7X2.8 MM 12 CM FOR BNE CUT SONOPET IQ DISP,SUP-2791056,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3040.78,1976.51,,,,,,,,,,,,,
COLLAR CERV FIRM DENS AD HK AND LOOP CLSR FOAM W COT CVR,SUP-2276586,CDM,L0120,HCPCS,0272,RC,,,,both,,,7.03,4.57,,,,,,,,,,,,,
INSERT TIB THK 10 MM SZ 4 UHMWPE RT ANK ANTR BIASED STRL,SUP-2932796,CDM,C1776,CPT,0278,RC,,,,both,,,13145.77,8544.75,,,,,,,,,,,,,
HC Unlisted Px Fml Genital Sys,PX-7615899901,CDM,58999,CPT,0761,RC,,,,both,,,595.00,386.75,,,,,,,,,,,,,
MATRIX BIO L 6 X W 4 CM FISH SKIN DERMAL INTACT STRL OMEGA3,SUP-2909263,CDM,Q4158,HCPCS,0636,RC,,,,both,,,4521.60,2939.04,,,,,,,,,,,,,
SCREW BNE L11MM DIA2MM CORT HND FT TI TRILOK APTUS,SUP-2268147,CDM,C1713,HCPCS,0278,RC,,,,both,,,570.85,371.05,,,,,,,,,,,,,
VERAPAMIL HCL ER 120 MG PO CP24,RX-25238,CDM,6370000000,HCPCS,0637,RC,00378-6320-01,NDC,,both,1,UN,6.60,4.29,,,,,,,,,,,,,
STEM FEM SZ 1 TI PPS PROX HIP REV MOD CLLRD BIPLANAR TAPR,SUP-2403437,CDM,C1776,CPT,0278,RC,,,,both,,,14795.68,9617.19,,,,,,,,,,,,,
ENDOPROSTHESIS VASC VIABAHN L 7.5CM 6MM 120CM 7FR HEPARIN,SUP-2396598,CDM,C1876,HCPCS,0278,RC,,,,both,,,12318.22,8006.84,,,,,,,,,,,,,
PLATE BONE PREFORMED LARGE 2.5 MM RIGHT MANDIBLE RECONSTRUCT,SUP-2837780,CDM,C1713,HCPCS,0278,RC,,,,both,,,11003.19,7152.07,,,,,,,,,,,,,
COMPONENT FEM HIP NP CEM,SUP-2347967,CDM,C1776,CPT,0278,RC,,,,both,,,7222.00,4694.30,,,,,,,,,,,,,
COMPONENT FEM B A/P 48.5MM M/L58MM ZMLY LT KNEE PRI CRUC RET,SUP-2200872,CDM,C1776,CPT,0278,RC,,,,both,,,13327.73,8663.02,,,,,,,,,,,,,
PLATE BONE L255MM 13 H RT LAT PROX TIB S STL LCK FOR 4.5MM,SUP-2348231,CDM,C1713,HCPCS,0278,RC,,,,both,,,15411.75,10017.64,,,,,,,,,,,,,
PAD ORTHOT SCOLIOSIS CUST TENS BASE FIT ADJ,SUP-2435569,CDM,L1005,HCPCS,0274,RC,,,,both,,,9061.47,5889.96,,,,,,,,,,,,,
HC Custom Hand/Finger Static,PX-2740391301,CDM,L3913,HCPCS,0272,RC,,,,outpatient,,,900.00,585.00,,,,,,,,,,,,,
SYSTEM LD DEL ACUITY BREAK-AWAY CORONARY VEN GUIDE CATH,SUP-2149158,CDM,C1769,HCPCS,0272,RC,,,,both,,,1808.64,1175.62,,,,,,,,,,,,,
SCREW 6X75MM STEM HMRL MODULAR INTRAMEDULLARY SHOULDER,SUP-2880536,CDM,C1713,HCPCS,0278,RC,,,,both,,,9184.50,5969.92,,,,,,,,,,,,,
GENERATOR NEUROSTIMULATOR THK7MM 18GM 10ML VAGUS NRV 2 PIN,SUP-2265162,CDM,C1767,HCPCS,0278,RC,,,,both,,,99229.53,64499.19,,,,,,,,,,,,,
RING ACET SZ 20 HIP UHMWPE MOD PRI REPL RNGLOC +,SUP-2403376,CDM,C1776,CPT,0278,RC,,,,both,,,357.96,232.67,,,,,,,,,,,,,
COMPONENT FEM TOT STBL XS RT KNEE,SUP-2364873,CDM,C1776,CPT,0278,RC,,,,both,,,16417.02,10671.06,,,,,,,,,,,,,
GUIDEWIRE UROLOGICAL ANGLED 8 CM 0.035 INX150 CM ZIPWIRE,SUP-2862342,CDM,C1769,HCPCS,0272,RC,,,,both,,,130.81,85.03,,,,,,,,,,,,,
BLADE REPROC SHV 4.5MM PLAT INCIS+ SLATE,SUP-2652938,CDM,2720000010,LOCAL,0272,RC,,,,both,,,290.61,188.90,,,,,,,,,,,,,
BAR EXT FIX L50MM DIA6MM COMP FOR JET-X FIX SYS,SUP-2342910,CDM,2720000010,LOCAL,0272,RC,,,,both,,,245.89,159.83,,,,,,,,,,,,,
HC So Ptt|NOT REASONABLE AND NECESSARY,PX-3058573066,CDM,85730,CPT,0305,RC,,,GZ,both,,,47.00,30.55,,,,,,,,,,,,,
STENT TRACHBRONCH WGRFT L 50 MM DIA12 MM CATH TOT L 116 CM,SUP-2148351,CDM,C1874,HCPCS,0278,RC,,,,both,,,6123.00,3979.95,,,,,,,,,,,,,
SLEEVE ILLUMINATION DIA13 GA FIBER PK STRL DISP MYRIAD-LX,SUP-2930200,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4396.00,2857.40,,,,,,,,,,,,,
GRAFT BONE SUB 1ML PUTTY CA PHOS SYNTH GRAN BIOABSRB ATTRAX,SUP-2310452,CDM,C1763,HCPCS,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
COLLAR CERV SM FOAM LF,SUP-2330406,CDM,L0120,HCPCS,0274,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
CATHETER CV SET 032 7 FRX15 CM 3L CUTLM701JABRMHCRDCAH,SUP-2759977,CDM,C1751,HCPCS,0278,RC,,,,both,,,241.78,157.16,,,,,,,,,,,,,
TRAY CATH MIDLN POWERGLIDE STRL SELD BASIC 18GA 10CM 1 LUMAN ST018100,SUP-2613565,CDM,C1751,HCPCS,0278,RC,,,,both,,,340.56,221.36,,,,,,,,,,,,,
GRAFT VASC GORTX L 30 CM DIA 5 MM EPTFE STR TW N RING STRL,SUP-2396687,CDM,C1768,CPT,0278,RC,,,,both,,,1174.36,763.33,,,,,,,,,,,,,
GRAFT STRP DEMIN CANC IRRADIATED ALLGRFT 26MM C 19MMX7MM,SUP-2125427,CDM,C1713,HCPCS,0278,RC,,,,both,,,6908.00,4490.20,,,,,,,,,,,,,
CATHETER ANGIO 9FR L45CM PLCMNT CUT AWAY COR SNUS ACCS,SUP-2149039,CDM,C1887,HCPCS,0272,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
TIP ENDO SUCT ANG 6 MM DIAM 30 CM LEN N COAG SIDE VENT PLAS,SUP-2152101,CDM,2720000010,LOCAL,0272,RC,,,,both,,,489.84,318.40,,,,,,,,,,,,,
IMPLANT HYB KN-LPS FLX TIV CEM FEM/MIS TM TIB/PRLG SUR/PAT,SUP-2212336,CDM,C1776,CPT,0278,RC,,,,both,,,14492.29,9419.99,,,,,,,,,,,,,
CATHETER PTCA L150CM BLLN L100MM DIA2MM GWIRE 0.018IN SHTH,SUP-2145374,CDM,C1725,HCPCS,0272,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
DISSECTOR SRGCL RHTN SPTLA SIZE 6 SM 7 1/2NL TTNM JARIT,SUP-2495071,CDM,2720000010,LOCAL,0272,RC,,,,both,,,527.74,343.03,,,,,,,,,,,,,
SYSTEM IMPL DELTOID LIGMNT RECON,SUP-2122811,CDM,C1776,CPT,0278,RC,,,,both,,,6138.70,3990.15,,,,,,,,,,,,,
PLATE BONE SM W11XL195MM THK3.3MM 0DEG 15 H BILAT TI STR RIG,SUP-2190793,CDM,C1713,HCPCS,0278,RC,,,,both,,,1237.51,804.38,,,,,,,,,,,,,
TI LCP DISTAL FEMUR PLATE 19 HOLE/436MM RIGHT-STERILE,SUP-2546863,CDM,C1713,HCPCS,0278,RC,,,,both,,,5730.44,3724.79,,,,,,,,,,,,,
PLATE BNE W19XL30MM 10 H RAD HD EL SYS BTTRS FOR 2MM SCR,SUP-2267953,CDM,C1713,HCPCS,0278,RC,,,,both,,,2891.94,1879.76,,,,,,,,,,,,,
CONNECTOR SPNL SM TI TSRH-3DX,SUP-2289709,CDM,C1713,HCPCS,0278,RC,,,,both,,,3020.68,1963.44,,,,,,,,,,,,,
RING FIX FULL SZ 180MM ALUMINUM MAXFRAME,SUP-2179157,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3540.07,2301.05,,,,,,,,,,,,,
SCREW BNE L8MM DIA2.7MM CORT TI ST NONLOCKING CRUCFRM,SUP-2189540,CDM,C1713,HCPCS,0278,RC,,,,both,,,424.21,275.74,,,,,,,,,,,,,
CATHETER NAVI-STAR J CRV SFT TIP 7FR,SUP-2248475,CDM,C1732,HCPCS,0278,RC,,,,both,,,6119.86,3977.91,,,,,,,,,,,,,
CATHETER HD PRECRV 15.5 FRX32 CM CHRONIC LT DL FULL DURAFLO,SUP-2497789,CDM,C1750,HCPCS,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
CATHETERIZATION SET ART 021 22 GAX5 CM 22 GA INDWL LF,SUP-2865586,CDM,C1751,HCPCS,0278,RC,,,,both,,,60.60,39.39,,,,,,,,,,,,,
SHEATH INTRO PRELUDE L 23 CM DIA 5 FR 0.018 IN 7 CM 21GA NIT,SUP-2479385,CDM,C1894,HCPCS,0272,RC,,,,both,,,168.18,109.32,,,,,,,,,,,,,
ANCHOR SUT L19.1MM DIA6.25MM CLS EYELET TENODESIS FOR PROX,SUP-2121430,CDM,C1713,HCPCS,0278,RC,,,,both,,,1287.40,836.81,,,,,,,,,,,,,
SCREW BONE CORT HEX HD,SUP-2198413,CDM,C1713,HCPCS,0278,RC,,,,both,,,38.56,25.06,,,,,,,,,,,,,
BLOCK ILIUM TRICORT TRAD ALLGRFT SM 20 - 30 MM LX8 - 14 MM W,SUP-2294060,CDM,C1713,HCPCS,0278,RC,,,,both,,,2006.46,1304.20,,,,,,,,,,,,,
COMPONENT TIB CR XS UNIV 11 MM DSTL STEM NP MONOBLOCK CEM,SUP-2376392,CDM,C1776,CPT,0278,RC,,,,both,,,3935.68,2558.19,,,,,,,,,,,,,
TRIFLURIDINE 1 % OP SOLN,RX-11595,CDM,6370000000,HCPCS,0637,RC,61314-0044-75,NDC,,both,7.5,ML,882.10,573.36,,,,,,,,,,,,,
SCREW SPINAL LOCKING 3X14 MM FOR STERNAL PLATE TITANIUM,SUP-2838334,CDM,C1713,HCPCS,0278,RC,,,,both,,,635.22,412.89,,,,,,,,,,,,,
SHEARS LAPSCP L35CM DIA5MM PSTL GRP OPEN/UNUSED ONLY KNF DN,SUP-2257665,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1053.09,684.51,,,,,,,,,,,,,
IMPLANT SYNTH 38 X 63 MM THK 6 MM POLYETHYL CRANIOFACIAL,SUP-2883170,CDM,C1713,HCPCS,0278,RC,,,,both,,,3752.43,2439.08,,,,,,,,,,,,,
KIT OCN004 OSTEOCOOL BNE ACCS 10G 095,SUP-2281272,CDM,C1894,HCPCS,0272,RC,,,,both,,,1424.30,925.79,,,,,,,,,,,,,
SHEATH INTRO PRELUDEEASE L 11 CM DIA 6 FR GUIDEWIRE 0.035 IN,SUP-2474314,CDM,C1894,HCPCS,0272,RC,,,,both,,,108.80,70.72,,,,,,,,,,,,,
GRAFT VASC L40CM DIA8MM STR STRTCH STD WALL N RNGD INTERING,SUP-2395851,CDM,C1768,CPT,0278,RC,,,,both,,,2785.18,1810.37,,,,,,,,,,,,,
PROBE NSL STR 90 DEG W/ LT HND MIRROR SMK EVAC,SUP-2713683,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1295.47,842.06,,,,,,,,,,,,,
ANCHOR SUTURE PALADIN 5.0MMX15.3MM WITH TWO NUMBER 2 HI FI S,SUP-2824800,CDM,C1713,HCPCS,0278,RC,,,,both,,,1197.91,778.64,,,,,,,,,,,,,
EXPANDER BRST W12.3XH12.9CM P6.5CM 450CC SIL NACL SHELL RND,SUP-2300639,CDM,C1789,HCPCS,0278,RC,,,,both,,,4615.80,3000.27,,,,,,,,,,,,,
FORCEPS SURG L200MM PELV RATCH FOR USE W SCR,SUP-2199236,CDM,C1713,HCPCS,0278,RC,,,,both,,,2111.30,1372.34,,,,,,,,,,,,,
PATCH CV FIBRIN SEAL 4.8X9.5 CM ABSORBABLE TACHOSIL,SUP-2130295,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2437.71,1584.51,,,,,,,,,,,,,
HC Venography Sinus/Jugular Catheter,PX-3207586000,CDM,75860,CPT,0320,RC,,,,both,,,7130.00,4634.50,,,,,,,,,,,,,
PLATE BNE DBL Y LG 1.5X19X1 MM MIDFACE 6 HOLE W/ TAB TI STRL,SUP-2463082,CDM,C1713,HCPCS,0278,RC,,,,both,,,915.62,595.15,,,,,,,,,,,,,
LEAD NERVE STIM KT PNE,SUP-2568743,CDM,C1778,HCPCS,0278,RC,,,,both,,,816.40,530.66,,,,,,,,,,,,,
PLATE BNE X 2.3X1.5 MM THOR RIB 16 HOLE LCK SLD LEVEL 1,SUP-2869172,CDM,C1713,HCPCS,0278,RC,,,,both,,,3709.60,2411.24,,,,,,,,,,,,,
STENT INTOCU H0.33XL1MM SNORKEL L0.25MM DIA120UM RT EYE TI,SUP-2227950,CDM,C1783,HCPCS,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
GRAFT BONE SUBSTITUTE 5CC CB DBM PUTTY STIMUBLAST,SUP-2120749,CDM,C1713,HCPCS,0278,RC,,,,both,,,2317.32,1506.26,,,,,,,,,,,,,
SHELL ACET L41-44MM 44MM LIMIT H POR RINGLOK RX 90,SUP-2406297,CDM,C1776,CPT,0278,RC,,,,both,,,8892.48,5780.11,,,,,,,,,,,,,
BOLD SCREW DIAM 3MM LG 10MM,SUP-2586427,CDM,C1713,HCPCS,0278,RC,,,,both,,,1154.48,750.41,,,,,,,,,,,,,
HC Elec Alys Implt Smpl Cn Npgt Prgrmg,PX-9209597600,CDM,95976,CPT,0920,RC,,,,both,,,121.00,78.65,,,,,,,,,,,,,
PSN PK ART SURF INS TIP,SUP-2508585,CDM,C1776,CPT,0278,RC,,,,both,,,367.38,238.80,,,,,,,,,,,,,
SCREW EXT FIX L150MM DIA4.5MM THRD L18MM CORT S STL STR,SUP-2186966,CDM,C1713,HCPCS,0278,RC,,,,both,,,205.73,133.72,,,,,,,,,,,,,
CATHETER INTVASC OCCL L 65 CM DIA 8 FR BALLOON DIA27 MM SHTH,SUP-2141026,CDM,C1725,HCPCS,0272,RC,,,,both,,,457.18,297.17,,,,,,,,,,,,,
GRAFT SYN 25ML CA SULF SCFLD HI STRENGTH INJ MIIG HV,SUP-2399043,CDM,C1713,HCPCS,0278,RC,,,,both,,,10252.10,6663.86,,,,,,,,,,,,,
SEED IODINE LOOSE IN VIAL K,SUP-2129116,CDM,C2639,HCPCS,0278,RC,,,,both,,,84.78,55.11,,,,,,,,,,,,,
SPONGE 5.5MMX7.5MMX80MM OVL SIL,SUP-2213491,CDM,L8610,HCPCS,0278,RC,,,,both,,,223.57,145.32,,,,,,,,,,,,,
UNISPACER KNEE SYS FEM RASP,SUP-2208947,CDM,C1713,HCPCS,0278,RC,,,,both,,,910.60,591.89,,,,,,,,,,,,,
PATCH VASC W5XL15CM THK1MM SFT TISS GORTX,SUP-2395295,CDM,C1781,HCPCS,0278,RC,,,,both,,,916.88,595.97,,,,,,,,,,,,,
PASSER SUT STR FIRSTPASS MINI,SUP-2349225,CDM,2720000010,LOCAL,0272,RC,,,,both,,,923.95,600.57,,,,,,,,,,,,,
COMPONENT TRAPEZIUM SZ 2 FNGR 1 PC FLX SWNSN,SUP-2397776,CDM,C1776,CPT,0278,RC,,,,both,,,5347.42,3475.82,,,,,,,,,,,,,
GRAFT HUM TISS AMBIENT 1 CC FLOWABLE PLCNTA TISS VIAFLOW,SUP-2759478,CDM,C1762,CPT,0278,RC,,,,both,,,6093.67,3960.89,,,,,,,,,,,,,
CONNECTOR SPNL L40MM ADJACENT LEV DEV W/ HALF JOG OFFSET FOR,SUP-2354917,CDM,C1713,HCPCS,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
TUBE ET AD OD12.7/14.5MM ID9MM SIL SGL LUMN CUF HI VOL LO,SUP-2383581,CDM,2720000010,LOCAL,0272,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
PLATE BNE MINI MED 4 HOLE LCK 2 BRK AWAY TAB TLTS TI LEVEL 1,SUP-2482350,CDM,C1713,HCPCS,0278,RC,,,,both,,,1118.22,726.84,,,,,,,,,,,,,
KIT MICROINTRODUCER 4FR ECHOGENIC NDL L7CM 21GA COAX NIT,SUP-2118821,CDM,C1769,HCPCS,0272,RC,,,,both,,,76.74,49.88,,,,,,,,,,,,,
SPLINT ORTHOPEDIC SUPP LG 8 IN LT WRST COCK UP ELASTIC,SUP-2108133,CDM,L3809,HCPCS,0274,RC,,,,both,,,43.96,28.57,,,,,,,,,,,,,
GUIDEWIRE SURG FOR PNCH FORCEP,SUP-2649719,CDM,C1769,HCPCS,0272,RC,,,,both,,,56.14,36.49,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP STR 0.035 INX450 CM VISIGLIDE G2403545AA,SUP-2473407,CDM,C1769,HCPCS,0272,RC,,,,both,,,10595.62,6887.15,,,,,,,,,,,,,
AZACITIDINE 100 MG IJ SUSR,RX-78420,CDM,J9025,HCPCS,0636,RC,00781-3491-94,NDC,,both,1,UN,129.60,84.24,,,,,,,,,,,,,
ASSEMBLY BLDE DISP SMARTRELEASE ONYX,SUP-2419627,CDM,2720000010,LOCAL,0272,RC,,,,both,,,837.34,544.27,,,,,,,,,,,,,
KIT ART LN 20GA L12CM FEP RADPQ 0.025X13.75IN SPR GWIRE,SUP-2383269,CDM,C1751,HCPCS,0278,RC,,,,both,,,97.65,63.47,,,,,,,,,,,,,
MICROCATHETER INFUSION PURSUE 150CM DIA 2.9/2FR 45DEG TIP,SUP-2459591,CDM,C1887,HCPCS,0272,RC,,,,both,,,1381.60,898.04,,,,,,,,,,,,,
FIBER LASER 550 MH UNSHEATHED SCP SAFE SMA905 STRL DISP,SUP-2768243,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3358.54,2183.05,,,,,,,,,,,,,
EPINEPHRINE 0.3 MG/0.3ML IJ SOAJ,RX-125413,CDM,J3490,HCPCS,0636,RC,49502-0500-01,NDC,,both,1,UN,1749.80,1137.37,,,,,,,,,,,,,
ALLOGRAFT BNE STRP 20X50X3-6 MM SPNG FD 2 CANC,SUP-2717785,CDM,C1713,HCPCS,0278,RC,,,,both,,,9725.58,6321.63,,,,,,,,,,,,,
BLADE RTRCTR RVL 50MML BLUNT VLT FANTRR CRVCL FSN DISTR TRA,SUP-2673084,CDM,2720000010,LOCAL,0272,RC,,,,both,,,482.74,313.78,,,,,,,,,,,,,
SCREW BNE COMPR 4 MM INSTRUMENT DISP,SUP-2641891,CDM,C1713,HCPCS,0278,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
HC Brain Canal Shunt Procedure,PX-5106107000,CDM,61070,CPT,0510,RC,,,,both,,,2232.00,1450.80,,,,,,,,,,,,,
PLATE BNE FUSION UNIV POST 3 HOLE NS LTX,SUP-2857129,CDM,C1713,HCPCS,0278,RC,,,,both,,,8898.76,5784.19,,,,,,,,,,,,,
GUIDEWIRE VASC ANGLED 035X150 STIFF ZIPWIRE,SUP-2141745,CDM,C1769,HCPCS,0272,RC,,,,both,,,184.51,119.93,,,,,,,,,,,,,
GRAFT BNE 3 CC X4 AUG,SUP-2463200,CDM,C1713,HCPCS,0278,RC,,,,both,,,39507.48,25679.86,,,,,,,,,,,,,
CATHETER VID GUID SPNL ENDO CATH 2 LUMN 3.0MM,SUP-2307775,CDM,C1725,HCPCS,0272,RC,,,,both,,,2132.06,1385.84,,,,,,,,,,,,,
BUR SURG L77MM DIA2MM XLN S STL DMND RND NONFLUTED INDIGO,SUP-2284189,CDM,C1713,HCPCS,0278,RC,,,,both,,,450.21,292.64,,,,,,,,,,,,,
HEAD HUM H22MM DIA44MM STD SHLDR CO CHROM PRI BPLR BIO MOD,SUP-2404615,CDM,C1776,CPT,0278,RC,,,,both,,,4662.90,3030.88,,,,,,,,,,,,,
SET PRSS MON 5FR L15CM 0.035IN POLYETH SGL LUMN STR TIP NDL,SUP-2167829,CDM,C1751,HCPCS,0278,RC,,,,both,,,113.39,73.70,,,,,,,,,,,,,
BLADE RTRCTR MCCLLCH 3CMD STNLSS STEEL SPNL MSCLE WIDE ULTRA,SUP-2672365,CDM,2720000010,LOCAL,0272,RC,,,,both,,,345.05,224.28,,,,,,,,,,,,,
HC Peripheral Block - Axillary W/Img Gdn,PX-3606441700,CDM,64417,CPT,0360,RC,,,,inpatient,,,2895.00,1881.75,,,,,,,,,,,,,
LINER ACET POR HIP ANTEVERTED W/ OXINIUM HD R3,SUP-2348015,CDM,C1776,CPT,0278,RC,,,,both,,,15386.00,10000.90,,,,,,,,,,,,,
CANNULA ART LNG 15 FR UNCOATED HLS,SUP-2663469,CDM,2720000010,LOCAL,0272,RC,,,,both,,,952.74,619.28,,,,,,,,,,,,,
GRAFT BONE CHIP FRZ DRY DEMIN CANC 1.7MM-10MM RANG 5CC,SUP-2294029,CDM,C1713,HCPCS,0278,RC,,,,both,,,395.64,257.17,,,,,,,,,,,,,
ADAPTER CBL NEO W6XH4XL25MM Y LUERLOCK,SUP-2281983,CDM,C1713,HCPCS,0278,RC,,,,both,,,359.91,233.94,,,,,,,,,,,,,
CEMENT BONE CONFLOW G,SUP-2736176,CDM,C1713,HCPCS,0278,RC,,,,both,,,643.76,418.44,,,,,,,,,,,,,
CABLE CATH 150 CM 24 PIN STRL LF,SUP-2867399,CDM,2720000010,LOCAL,0272,RC,,,,both,,,775.58,504.13,,,,,,,,,,,,,
ANCHOR SUTURE KNOTLESS 4.75 X19.1 MM TIGERTAPE LOOP BIOCOMP,SUP-2615623,CDM,C1713,HCPCS,0278,RC,,,,both,,,1664.20,1081.73,,,,,,,,,,,,,
SLING ORTH CHST CIRC 32-36IN SM BLK UNIV HUM CUF SHLDR SUPP,SUP-2324515,CDM,L3675,HCPCS,0274,RC,,,,both,,,79.47,51.66,,,,,,,,,,,,,
BIT DRILL 2MM DIA 216MML 420AB 455 STNLSS STEEL QCK CNNCT C,SUP-2722083,CDM,2720000010,LOCAL,0272,RC,,,,both,,,507.14,329.64,,,,,,,,,,,,,
PLATE SPNL BX 14X14 MM ULTRA LO PROF TI LIGHT GRN NS,SUP-2423200,CDM,C1713,HCPCS,0278,RC,,,,both,,,834.61,542.50,,,,,,,,,,,,,
GUIDEWIRE ORTH J TIP 0.025 INX260 CMX3 MM FIX COR,SUP-2610679,CDM,C1769,HCPCS,0272,RC,,,,both,,,69.74,45.33,,,,,,,,,,,,,
HC Joint Injection/Aspir Medium WO US,PX-5102060500,CDM,20605,CPT,0510,RC,,,,inpatient,,,908.00,590.20,,,,,,,,,,,,,
PLATE BNE W17.5XL278MM THK5.2MM 12 H NONSTERILE L CNDYL FEM,SUP-2185029,CDM,C1713,HCPCS,0278,RC,,,,both,,,4422.16,2874.40,,,,,,,,,,,,,
SHEATH GUID 115X85FR L71MM L CRV L50MM BIDIR STEER CARTO,SUP-2248639,CDM,C1766,CPT,0272,RC,,,,both,,,3155.70,2051.20,,,,,,,,,,,,,
POST HOFFMANN3 90DEG ANG DIA 11MM,SUP-2493635,CDM,2720000010,LOCAL,0272,RC,,,,both,,,538.51,350.03,,,,,,,,,,,,,
STAPLER EXT 65MM S STL AUTO DISP PURSTRING,SUP-2283033,CDM,2720000010,LOCAL,0272,RC,,,,both,,,375.51,244.08,,,,,,,,,,,,,
WAND ENDOSCP ELECTROCAUTERY WEREWOLF FASTSEAL 6.0 HEMOSTAS,SUP-2716212,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1051.90,683.73,,,,,,,,,,,,,
HEAD HUM RESURF SHLDR,SUP-2304827,CDM,C1776,CPT,0278,RC,,,,both,,,9420.00,6123.00,,,,,,,,,,,,,
SCREW BNE 35X16MM CORT TI G HEXADRIVE 15,SUP-2268361,CDM,C1713,HCPCS,0278,RC,,,,both,,,287.84,187.10,,,,,,,,,,,,,
KIT CRANIAL ACCESS SUBDURAL EVACUATING PORT SYSTEM STRL,SUP-2927884,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6647.38,4320.80,,,,,,,,,,,,,
HC Diabetes Group/30min,PX-9420010900,CDM,G0109,HCPCS,0940,RC,,,,outpatient,,,44.00,28.60,,,,,,,,,,,,,
PLATE BONE CONDYLAR 5 HOLE QUARTER TUBULAR STAINLESS STEEL S,SUP-2836700,CDM,C1713,HCPCS,0278,RC,,,,both,,,566.52,368.24,,,,,,,,,,,,,
PLATE BNE L29MM THK075MM 14 H NONSTERILE HND S STL WEB LOK,SUP-2417426,CDM,C1713,HCPCS,0278,RC,,,,both,,,1370.67,890.94,,,,,,,,,,,,,
COIL VASC EMBOLUS L 3 CM DIA 5 MM GUIDEWIRE 0.038 IN,SUP-2167813,CDM,C1889,HCPCS,0278,RC,,,,both,,,219.80,142.87,,,,,,,,,,,,,
PLATE BONE W23XL54MM THK2MM 13 H LT DSTL RAD TI ADAPTIVE FOR,SUP-2267974,CDM,C1713,HCPCS,0278,RC,,,,both,,,1566.86,1018.46,,,,,,,,,,,,,
CATHETER CV 3L 7 FRX8 IN KT ARROWG+ARD BLU,SUP-2383337,CDM,C1751,HCPCS,0278,RC,,,,both,,,212.77,138.30,,,,,,,,,,,,,
SCREW BNE L16MM DIA3MM FT BLU SELF DRL ST CANN DST THRD CYL,SUP-2396798,CDM,C1713,HCPCS,0278,RC,,,,both,,,384.65,250.02,,,,,,,,,,,,,
EXTENSION SET 0.5 CC M LUER LCK ACTIVATED VLV HANDISTRIP LF,SUP-2484890,CDM,C1713,HCPCS,0278,RC,,,,both,,,15.39,10.00,,,,,,,,,,,,,
PIN FIX L9IN DIA32MM ST S STL 3 SIDE DBL TRCR BOTH END PNT,SUP-2150516,CDM,C1713,HCPCS,0278,RC,,,,both,,,25.69,16.70,,,,,,,,,,,,,
PIN STRNL CLSR TI EMGCY REL,SUP-2192431,CDM,C1713,HCPCS,0278,RC,,,,both,,,285.74,185.73,,,,,,,,,,,,,
CATHETER CV 3L 7 FRX20 CM HEPARIN COAT,SUP-2214689,CDM,C1751,HCPCS,0278,RC,,,,both,,,154.55,100.46,,,,,,,,,,,,,
IMMOBILIZER ORTH CUTAWAY UNIV 14 IN 12-24 IN ADJ FOAM,SUP-2194895,CDM,L1830,CPT,0274,RC,,,,both,,,34.95,22.72,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH ALPHA2 L 160 MM DIA28 MM SHTH 16 FR,SUP-2911993,CDM,C1768,CPT,0278,RC,,,,both,,,66351.34,43128.37,,,,,,,,,,,,,
PLATE BONE 7 H LT PROX TIB TIM STD CRV LCK ALPS,SUP-2413729,CDM,C1713,HCPCS,0278,RC,,,,both,,,3329.97,2164.48,,,,,,,,,,,,,
TRAY TIB L63MM KNEE COMP INTLOK OFFSET FOR VANGUARD COMPLT,SUP-2405420,CDM,C1776,CPT,0278,RC,,,,both,,,5388.24,3502.36,,,,,,,,,,,,,
CATHETER HAD L28CM OD14.5FR POLYUR 2 LUMN SPL TIP CUF 5704230] BARD INC],SUP-2126524,CDM,C1750,HCPCS,0278,RC,,,,both,,,1456.96,947.02,,,,,,,,,,,,,
OCCLUDER CV CARDIOFORM DIA 30 MM CATH L 75 CM DIA10 FR PLAT,SUP-2395775,CDM,C1817,HCPCS,0278,RC,,,,both,,,29817.44,19381.34,,,,,,,,,,,,,
CLAMP SPNL S STL THORLUM FOR 5.5/5.5MM ROD REVERE,SUP-2230979,CDM,C1713,HCPCS,0278,RC,,,,both,,,920.02,598.01,,,,,,,,,,,,,
TWIST DRILL 15MM DIA X 28MM STOP DNTL LATCH SNGLE USE,SUP-2679092,CDM,2720000010,LOCAL,0272,RC,,,,both,,,446.70,290.35,,,,,,,,,,,,,
OXYMETAZOLINE HCL 0.05 % NA SOLN,RX-5943,CDM,6370000000,HCPCS,0637,RC,41100-0811-25,NDC,,both,30,ML,41.60,27.04,,,,,,,,,,,,,
PLATE BNE L 16.6 X W 17 MM THK 0.6 MM SCREW DIA2 MM SHRT TI,SUP-2936492,CDM,C1713,HCPCS,0278,RC,,,,both,,,803.84,522.50,,,,,,,,,,,,,
SHEATH INTRO FLX SHUTTLE L 90 CM OD 7 FR GUIDEWIRE 0.038 IN,SUP-2168796,CDM,C1894,HCPCS,0272,RC,,,,both,,,315.26,204.92,,,,,,,,,,,,,
"HC So Antidiuretic Hormone, Plasma",PX-3018458866,CDM,84588,CPT,0301,RC,,,,inpatient,,,74.00,48.10,,,,,,,,,,,,,
PLATE BNE BAR L6MM 4 H CRANIOMAXILLOFACIAL TI LO PROF FOR,SUP-2366203,CDM,C1713,HCPCS,0278,RC,,,,both,,,309.01,200.86,,,,,,,,,,,,,
PLATE CRAN 100X40X40 MM PT SPEC IMPL PEEK,SUP-2860124,CDM,C1713,HCPCS,0278,RC,,,,both,,,28083.85,18254.50,,,,,,,,,,,,,
SUPPORT ORTHOT HND FNGR CUST ADJ FIT STRP W/O JT FABRICATED,SUP-2435775,CDM,L3913,HCPCS,0272,RC,,,,both,,,697.80,453.57,,,,,,,,,,,,,
SCREW BNE L10MM DIA5MM S STL ST VAR ANG LOK FOR,SUP-2178690,CDM,C1713,HCPCS,0278,RC,,,,both,,,945.17,614.36,,,,,,,,,,,,,
SLEEVE CONN ID5.5MM SLV TI STRL ADJ TRNSVRS SET SCR ST360,SUP-2205136,CDM,C1713,HCPCS,0278,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
HC Diabetes Group/30min,PX-9420010900,CDM,G0109,HCPCS,0942,RC,,,,outpatient,,,44.00,28.60,,,,,,,,,,,,,
PLATE BNE STR SM 1.5X0.6 MM MIDFACE 4 HOLE TI GLD NS LEVEL 1,SUP-2499690,CDM,C1713,HCPCS,0278,RC,,,,both,,,430.97,280.13,,,,,,,,,,,,,
CATHETER INNR CPS AIM SL N022-59,SUP-2356607,CDM,C1887,HCPCS,0272,RC,,,,both,,,926.30,602.09,,,,,,,,,,,,,
BLADE REPROC BUR BARREL FORMULA 12-FLUT 4MM,SUP-2653134,CDM,2720000010,LOCAL,0272,RC,,,,both,,,77.62,50.45,,,,,,,,,,,,,
AGENT HEMSTAT SURG 2 VITAGEL RT,SUP-2361944,CDM,2720000010,LOCAL,0272,RC,,,,both,,,910.60,591.89,,,,,,,,,,,,,
BLADE SURG OPENER MAST QUAD,SUP-2631644,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1576.06,1024.44,,,,,,,,,,,,,
PROCHLORPERAZINE 25 MG RE SUPP,RX-11138,CDM,6370000000,HCPCS,0637,RC,00574-7226-12,NDC,,both,1,UN,75.00,48.75,,,,,,,,,,,,,
DRILL SURG STEM 18 MM FEM REV NXGN LCCK CRA,SUP-2438212,CDM,2720000010,LOCAL,0272,RC,,,,both,,,409.77,266.35,,,,,,,,,,,,,
HC Pain Minor,PX-3600007514,CDM,3600007514,LOCAL,0360,RC,,,,inpatient,,,2101.00,1365.65,,,,,,,,,,,,,
MULTIVIT-MIN GUMMIES CHILDRENS PO CHEW,RX-153023,CDM,6370000000,HCPCS,0637,RC,16500-0599-18,NDC,,both,1,UN,1.00,0.65,,,,,,,,,,,,,
INBONE  POLY SZ 5 10MM SULCUS,SUP-2471108,CDM,C1776,CPT,0278,RC,,,,both,,,3865.34,2512.47,,,,,,,,,,,,,
BIT DRL OD1.3MM S STL FOR EVOLVE TRIAD FIX SYS,SUP-2397954,CDM,2720000010,LOCAL,0272,RC,,,,both,,,496.12,322.48,,,,,,,,,,,,,
CATHETER DIAG TRK EXCEL-14 L 150 CM DSTL L 7.5 CM OD,SUP-2361687,CDM,C1887,HCPCS,0272,RC,,,,both,,,2682.82,1743.83,,,,,,,,,,,,,
VEST PT HOLSTER SM 14 IN VENTRICULAR THORATEC HEARTMATE,SUP-2356007,CDM,Q0499,HCPCS,0272,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
GRAFT HUM TISS DISC 16 MM REP AMNIO TISS MEMBRN,SUP-2423432,CDM,C1762,CPT,0278,RC,,,,both,,,1557.44,1012.34,,,,,,,,,,,,,
BLADE SAW OSCLLTNG 5MMW X12MML 0.4MM THK 0.6MM THK CUT INTRA,SUP-2605375,CDM,2720000010,LOCAL,0272,RC,,,,both,,,376.64,244.82,,,,,,,,,,,,,
COMPONENT HUMERALXSM L6IN UNIV DSTL ELBW TIV PLSM,SUP-2205921,CDM,C1776,CPT,0278,RC,,,,both,,,11417.04,7421.08,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.411,SUP-2859975,CDM,C1713,HCPCS,0278,RC,,,,both,,,33150.24,21547.66,,,,,,,,,,,,,
SEG TM HIP FLAT 7MM WASHE,SUP-2502393,CDM,C1776,CPT,0278,RC,,,,both,,,3405.33,2213.46,,,,,,,,,,,,,
BIT DRILL 3.2MM DIAMETER FOR ULTRAFIX RC SUTURE ANCHOR,SUP-2824086,CDM,2720000010,LOCAL,0272,RC,,,,both,,,486.35,316.13,,,,,,,,,,,,,
SET INTRO PERFRMR L 13 CM OD 7.5 MM ID 2.5 MM GUIDEWIRE,SUP-2169707,CDM,C1894,HCPCS,0272,RC,,,,both,,,39.56,25.71,,,,,,,,,,,,,
PIN FIX DIAMOND PT 2 END 7/64X9 IN 4 PT STYL SMOOTH PLN STRL,SUP-2150498,CDM,C1713,HCPCS,0278,RC,,,,both,,,12.59,8.18,,,,,,,,,,,,,
CATHETER URETERAL BLLN DILATION 4MM X10CM URO EZDILATE,SUP-2722038,CDM,C1726,HCPCS,0272,RC,,,,both,,,606.02,393.91,,,,,,,,,,,,,
CATHETER NAVISTAR SFT TIP D CURV,SUP-2248473,CDM,C1730,HCPCS,0272,RC,,,,both,,,5966.00,3877.90,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED BPLR PRIMARY STEM POROUS,SUP-2257249,CDM,C1776,CPT,0278,RC,,,,both,,,7536.00,4898.40,,,,,,,,,,,,,
SCREW BNE L36MM DIA4MM HD DIA8MM TI ST LOK DBL LD THRD HEX,SUP-2192258,CDM,C1713,HCPCS,0278,RC,,,,both,,,613.18,398.57,,,,,,,,,,,,,
CALCIUM POLYCARBOPHIL 625 MG PO TABS,RX-11046,CDM,6370000000,HCPCS,0637,RC,00536-4306-11,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
CATHETER ANGIOPLSTY L90CM BAL L15MM OD4MM DIL RX MRAIL,SUP-2140564,CDM,C1725,HCPCS,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
MESH BONE SM 0.6MM THK TTNM STNDRD PTTRN OUTSDE HOLE LATEX F,SUP-2501123,CDM,C1713,HCPCS,0278,RC,,,,both,,,4053.61,2634.85,,,,,,,,,,,,,
SHEATH INTRO PERFRMR CKFLO L 13 CM DIA 5 FR GUIDEWIRE 0.038,SUP-2642108,CDM,C1894,HCPCS,0272,RC,,,,both,,,125.57,81.62,,,,,,,,,,,,,
BASEPLATE GLEN HD DIA44MM REG BILAT UHMWPE PEGGED PRESSFIT,SUP-2193839,CDM,C1776,CPT,0278,RC,,,,both,,,3899.06,2534.39,,,,,,,,,,,,,
SHEATH INTRO DESTINO TWST L 55 CM DIA 6.5 FR DIL L 73 CM CRV,SUP-2217697,CDM,C1894,HCPCS,0272,RC,,,,both,,,2791.46,1814.45,,,,,,,,,,,,,
CATHETER HEMO DYLS OR HD AD L72CM INSRTN L55CM DIA14.5FR,SUP-2174154,CDM,C1750,HCPCS,0278,RC,,,,both,,,1780.88,1157.57,,,,,,,,,,,,,
ZINC OXIDE 20 % EX OINT,RX-8874,CDM,6370000000,HCPCS,0637,RC,75834-0170-02,NDC,,both,56.7,GR,32.70,21.25,,,,,,,,,,,,,
CATHETER INFUSION UNI-FUSE L 135CM 4FR SLT 20CM 0.035IN BALL,SUP-2117049,CDM,C1725,HCPCS,0272,RC,,,,both,,,1303.10,847.01,,,,,,,,,,,,,
PLATE BNE FEM 3.5/4.5X216 MM LT PROX 7 HOLE STRL VALCP,SUP-2789281,CDM,C1713,HCPCS,0278,RC,,,,both,,,7238.52,4705.04,,,,,,,,,,,,,
SHAFT SCRDRVR L520MM FOR RMR IRRIG ASPIR,SUP-2187571,CDM,2720000010,LOCAL,0272,RC,,,,both,,,13213.18,8588.57,,,,,,,,,,,,,
PROSTHESIS LARYN L6MM OD17FR INDWL LO AIRFLO RESISTANCE FOR,SUP-2124302,CDM,L8509,HCPCS,0272,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
TWIST DR W/SUT HL 2.4X127,SUP-2818449,CDM,2720000010,LOCAL,0272,RC,,,,both,,,581.75,378.14,,,,,,,,,,,,,
LEVEL CMF MESH STNDRD CNTRD 15 MM SCREW 148 X 82 MM T06 MM,SUP-2676647,CDM,C1713,HCPCS,0278,RC,,,,both,,,14167.52,9208.89,,,,,,,,,,,,,
WARFARIN SODIUM 7.5 MG PO TABS,RX-8752,CDM,6370000000,HCPCS,0637,RC,00093-1723-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
SYSTEM SET MINI RAIL,SUP-2457473,CDM,2720000010,LOCAL,0272,RC,,,,both,,,10600.64,6890.42,,,,,,,,,,,,,
PHENYTOIN 125 MG/5ML PO SUSP,RX-6255,CDM,340b,HCPCS,0637,RC,99999-4069-05,NDC,,both,4,ML,15.20,9.88,,,,,,,,,,,,,
PLATE BNE CRV 2X39 MM 15 MM ORTHOGNATHIC 6 HOLE BSSO TI,SUP-2480755,CDM,C1713,HCPCS,0278,RC,,,,both,,,592.20,384.93,,,,,,,,,,,,,
STAPLE INTERNAL FIXATION W20XH26XL20MM DYNACLIP FORTE,SUP-2878758,CDM,C1713,HCPCS,0278,RC,,,,both,,,10440.50,6786.32,,,,,,,,,,,,,
CATHETER ABLATION L 115 CM DIA12 FR DSTL DIA 35 MM GUIDEWIRE,SUP-2885416,CDM,C1733,HCPCS,0272,RC,,,,both,,,26533.00,17246.45,,,,,,,,,,,,,
DEXTROSE-SODIUM CHLORIDE 5-0.45 % IV SOLN,RX-15861,CDM,J3490,HCPCS,0258,RC,00338-0085-03,NDC,,both,500,ML,38.30,24.89,,,,,,,,,,,,,
GUIDEWIRE VASC L 80 CM DIA 0.035 IN TAPR L 8 CM TIP L 3 CM,SUP-2638712,CDM,C1769,HCPCS,0272,RC,,,,both,,,190.54,123.85,,,,,,,,,,,,,
ESCITALOPRAM OXALATE 5 MG/5ML PO SOLN,RX-34897,CDM,6370000000,HCPCS,0637,RC,09999-9910-61,NDC,,both,5,ML,13.50,8.77,,,,,,,,,,,,,
GUIDEPIN ORTH DIA2.5MM TRABECULAR MTL RVS SHLDR SYS,SUP-2208229,CDM,C1713,HCPCS,0278,RC,,,,both,,,879.20,571.48,,,,,,,,,,,,,
COUPLER ANAS DIA5MM POLYETH S STL GEM,SUP-2382628,CDM,C1889,HCPCS,0278,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
"HC Ventricular Puncture,Prev Burr Hole",PX-3616102600,CDM,61026,CPT,0361,RC,,,,both,,,744.00,483.60,,,,,,,,,,,,,
LIDOCAINE HCL 2 % IJ SOLN (MIXTURES ONLY),RX-430042,CDM,J2003,HCPCS,0636,RC,00409-2066-05,NDC,,both,1,ML,54.10,35.16,,,,,,,,,,,,,
HC Perq Replacement Gtube Not Req Revj Gstrst Trc,PX-4504376200,CDM,43762,CPT,0450,RC,,,,inpatient,,,935.00,607.75,,,,,,,,,,,,,
PLATE BNE L 440 MM SCREW DIA 3.5/4.5 MM 20 H PERIPROSTHETIC,SUP-2931405,CDM,C1713,HCPCS,0278,RC,,,,both,,,22183.32,14419.16,,,,,,,,,,,,,
LIDOCAINE HCL 2 % IJ SOLN (MIXTURES ONLY),RX-430042,CDM,J2003,HCPCS,0636,RC,00409-4277-01,NDC,,both,1,ML,54.10,35.16,,,,,,,,,,,,,
BLADE SURG 50 MM CALCAR RASP STYL EXACT,SUP-2443892,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1144.53,743.94,,,,,,,,,,,,,
GRAFT DURA 3X1 IN ONLAY SUTURELESS ENHANCED ABSRB DURAGN XS,SUP-2480909,CDM,C1763,HCPCS,0278,RC,,,,both,,,1442.45,937.59,,,,,,,,,,,,,
HC So1 Vdrl / Rpr,PX-3028659267,CDM,86592,CPT,0302,RC,,,,both,,,258.00,167.70,,,,,,,,,,,,,
PLATE BNE BURR HOLE CVR 0.3 MM LP CONTOURED TI NS,SUP-2458757,CDM,C1713,HCPCS,0278,RC,,,,both,,,739.56,480.71,,,,,,,,,,,,,
RONGEUR SURG KERRISON 40 DEG 2 MM,SUP-2115015,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2496.30,1622.59,,,,,,,,,,,,,
STAPLE BONE 8 MM OFFSET NITINOL,SUP-2866282,CDM,C1713,HCPCS,0278,RC,,,,both,,,5231.24,3400.31,,,,,,,,,,,,,
GRAFT ENDOVASC L15CM OD5MM CATH L120CM STENT FEM IL AV ACC,SUP-2396544,CDM,C1874,HCPCS,0278,RC,,,,both,,,11916.30,7745.59,,,,,,,,,,,,,
SPACER SPNL SQ 12X1 MM CERV ANTR VUMESH,SUP-2707716,CDM,C1889,HCPCS,0278,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
PLATE BNE W24XL31MM 5 H NONSTERILE BILAT HINDFOOT MIDFOOT S,SUP-2186359,CDM,C1713,HCPCS,0278,RC,,,,both,,,2396.07,1557.45,,,,,,,,,,,,,
PLATE BNE L 83 MM SCREW DIA2.7/3.5 MM 5 H SS RT OLECRANS,SUP-2931222,CDM,C1713,HCPCS,0278,RC,,,,both,,,5392.64,3505.22,,,,,,,,,,,,,
SCREW BNE L30MM OD10.5MM DISP ACL MULCH,SUP-2212890,CDM,C1713,HCPCS,0278,RC,,,,both,,,1378.46,896.00,,,,,,,,,,,,,
SPLINT WR FRARM PED L4IN LT TIETEX COCK UP LOOP LCK W/ STAY,SUP-2195514,CDM,L3931,HCPCS,0274,RC,,,,both,,,24.43,15.88,,,,,,,,,,,,,
SCREW LOCKING FOR IM NAIL 5X54MM XL25,SUP-2739168,CDM,C1713,HCPCS,0278,RC,,,,both,,,543.13,353.03,,,,,,,,,,,,,
ANCHOR SUTURE SHOE 1.4MML SOFT W/NEEDLE JUGGERKNOT,SUP-2589267,CDM,C1713,HCPCS,0278,RC,,,,both,,,1250.22,812.64,,,,,,,,,,,,,
SET INTRO PEELWY L 13 CM DIA24 FR DIL L 20 CM GUIDEWIRE,SUP-2168026,CDM,C1892,HCPCS,0272,RC,,,,both,,,183.66,119.38,,,,,,,,,,,,,
STEM FEM L115MM DIA13MM DST HIP TI POR STR BULL TIP MOD REV,SUP-2422100,CDM,C1776,CPT,0278,RC,,,,both,,,20849.60,13552.24,,,,,,,,,,,,,
GRAFT HUM TISS WHL PAT LIGMNT W/ QUAD EXTENSOR MECHANISM,SUP-2264795,CDM,C1762,CPT,0278,RC,,,,both,,,14839.80,9645.87,,,,,,,,,,,,,
DEVICE TARGET FT ANK RADLUC,SUP-2371636,CDM,C1713,HCPCS,0278,RC,,,,both,,,789.08,512.90,,,,,,,,,,,,,
GRAFT BNE L ANK TALUS FRSH REFRIGERATED,SUP-2264605,CDM,C1713,HCPCS,0278,RC,,,,both,,,20671.84,13436.70,,,,,,,,,,,,,
TUBE ET OD9.5MM ID7MM STD PVC NONREINFORCED EMG NIM,SUP-2284335,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1140.54,741.35,,,,,,,,,,,,,
SUPPORT ORTHOT THGH LOWER EXTREMITY WT BEAR NAR M-L BRIM,SUP-2435675,CDM,L2525,HCPCS,0272,RC,,,,both,,,3226.92,2097.50,,,,,,,,,,,,,
SET PRSS MON 3FR L8CM 0.018IN POLYETH SGL LUMN STR TIP NDL,SUP-2167821,CDM,C1751,HCPCS,0278,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
SYSTEM BRACHYTHERAPY DEL W/ THE I-125 SEED 3 DIFF LD OPTIONS,SUP-2129120,CDM,C2638,HCPCS,0278,RC,,,,both,,,119.32,77.56,,,,,,,,,,,,,
GRAFT BONE SUB 30ML CORTICOCANCELLOUS FRZN,SUP-2165566,CDM,C1713,HCPCS,0278,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 70 CM DIA12 MM EPTFE STR STD WALL,SUP-2396208,CDM,C1768,CPT,0278,RC,,,,both,,,2829.14,1838.94,,,,,,,,,,,,,
COMPONENT HUM STD L STEM DST STR SOLAR,SUP-2372321,CDM,C1776,CPT,0278,RC,,,,both,,,17115.26,11124.92,,,,,,,,,,,,,
MESH HERN RECT OVL 4X2 IN FLAT SHT KNITTED POLYPR PROLITE,SUP-2227232,CDM,C1781,HCPCS,0278,RC,,,,both,,,82.14,53.39,,,,,,,,,,,,,
APPLIER CLP L DIA1.7MM ROT SHFT AND INTEGR CART FOR VES CLSR,SUP-2264247,CDM,C1889,HCPCS,0278,RC,,,,both,,,1676.76,1089.89,,,,,,,,,,,,,
PLATE BNE W17.5XL318MM THK5.2MM 17 H NONSTERILE BILAT S STL,SUP-2185314,CDM,C1713,HCPCS,0278,RC,,,,both,,,2714.28,1764.28,,,,,,,,,,,,,
GRAFT BNE SPACER 5X3.4 MM MATRISPINE,SUP-2264618,CDM,2780000010,LOCAL,0278,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
PLATE BNE THK06MM 16 H TI CRAN MESH MIC RECT FOR 15MM SCR,SUP-2262702,CDM,C1713,HCPCS,0278,RC,,,,both,,,666.03,432.92,,,,,,,,,,,,,
CATHETER KIT 2 LUMEN 5 FR ASK04052SEH] TELEFLEX INC],SUP-2383959,CDM,C1751,HCPCS,0278,RC,,,,both,,,440.67,286.44,,,,,,,,,,,,,
SPHERE GLEN STD TI ECCENTER DSGN SHLDR EPOCA,SUP-2193868,CDM,C1776,CPT,0278,RC,,,,both,,,1995.28,1296.93,,,,,,,,,,,,,
SCREW IM L 52 MM DIA 3.5 MM TI CORTICAL T15 DRVR GLD STRL,SUP-2900419,CDM,C1713,HCPCS,0278,RC,,,,both,,,753.60,489.84,,,,,,,,,,,,,
MESH HERN W11XL15CM POLYPR INGUINAL NONABSORBABLE FOR LAP,SUP-2126054,CDM,C1781,HCPCS,0278,RC,,,,both,,,99.44,64.64,,,,,,,,,,,,,
CATHETER THROMCTMY ANGIOJET AVX L 50 CM DIA 6 FR RX,SUP-2277422,CDM,C1757,HCPCS,0272,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
SPHERE GLEN DIA38MM +4MM OFFSET LAT SHLDR FOR RVS EXP SYS,SUP-2223374,CDM,C1776,CPT,0278,RC,,,,both,,,3611.00,2347.15,,,,,,,,,,,,,
SCREW BNE CANN 6.5X35 MM ST SD TI STRL ASNS III,SUP-2374351,CDM,C1713,HCPCS,0278,RC,,,,both,,,830.84,540.05,,,,,,,,,,,,,
COMPONENT TIB 6 TOT ANK TRABECULAR MTL,SUP-2490848,CDM,C1776,CPT,0278,RC,,,,both,,,9831.34,6390.37,,,,,,,,,,,,,
HEAD FEM DIA36MM OFFSET 3MM 11 13 TAPR HIP ASPHERE M SPEC,SUP-2251080,CDM,C1776,CPT,0278,RC,,,,both,,,5179.12,3366.43,,,,,,,,,,,,,
LK RECON PLATE 6HL 94MM,SUP-2695559,CDM,C1713,HCPCS,0278,RC,,,,both,,,2192.98,1425.44,,,,,,,,,,,,,
RITUXIMAB 100 MG/10ML IV SOLN,RX-131189,CDM,J9312,HCPCS,0636,RC,50242-0051-21,NDC,,both,10,ML,2705.90,1758.83,,,,,,,,,,,,,
PLATE BNE W175XL206MM THK52MM 8 H ST L CNDYL FEM S STL LOK,SUP-2185021,CDM,C1713,HCPCS,0278,RC,,,,both,,,4595.33,2986.96,,,,,,,,,,,,,
GII STEP HEMI WDG SZ7-8 {} 10,SUP-2511028,CDM,C1776,CPT,0278,RC,,,,both,,,2656.44,1726.69,,,,,,,,,,,,,
LINER ACET LAT H 4+ MM 20 DEG 32X62-64 MM XLPE REFLECTION,SUP-2434803,CDM,C1776,CPT,0278,RC,,,,both,,,6217.20,4041.18,,,,,,,,,,,,,
MESH HERN OVL 8X6 IN INTRA-ABDOMINAL,SUP-2126048,CDM,C1781,HCPCS,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
CATHETER ABLATION SHFT L 110 CM DIA 7.5 FR TIP L 4 MM QD K2,SUP-2890569,CDM,C1769,HCPCS,0272,RC,,,,both,,,8635.00,5612.75,,,,,,,,,,,,,
BOOT CAST PEDIATRIC 5.5X2.5 IN ROCKER SHOE CANVS,SUP-2336135,CDM,L4387,HCPCS,0272,RC,,,,both,,,17.43,11.33,,,,,,,,,,,,,
SYSTEM DRAINAGE W/ VENTRICULAR CLR EDS 3,SUP-2851438,CDM,C1729,HCPCS,0272,RC,,,,both,,,818.72,532.17,,,,,,,,,,,,,
BLADE SAW L 85 MM L 27 MM THK MATERIAL 0.4 MM CUT 0.6 MM,SUP-2929252,CDM,2720000010,LOCAL,0272,RC,,,,both,,,572.39,372.05,,,,,,,,,,,,,
BIT DRL 4.2X270 MM,SUP-2496114,CDM,2720000010,LOCAL,0272,RC,,,,both,,,647.63,420.96,,,,,,,,,,,,,
CUSHION RAD 100X70 35L FIL VAC BG,SUP-2137738,CDM,L1830,CPT,0272,RC,,,,both,,,907.08,589.60,,,,,,,,,,,,,
SCREW BNE ST 2X12 MM CORTICAL COARSE PITCH TI NS,SUP-2189632,CDM,C1713,HCPCS,0278,RC,,,,both,,,182.12,118.38,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 50 CM DIA 6 MM OFFSET RNG L 30 CM,SUP-2396311,CDM,C1768,CPT,0278,RC,,,,both,,,2948.46,1916.50,,,,,,,,,,,,,
SHEATH URET 18 FRX17 CM W/ RADIOPAQUE STRIPE CLR AMPLATZ,SUP-2835995,CDM,C2627,HCPCS,0272,RC,,,,both,,,155.02,100.76,,,,,,,,,,,,,
GRAFT WEDGE BNE EVANS 6MM 20X25MM BONUS,SUP-2656710,CDM,C1713,HCPCS,0278,RC,,,,both,,,1837.53,1194.39,,,,,,,,,,,,,
BRACE LS M 15DEG BK HK RECV MAT SFT BRTH LNR RIG TAPR PLAS,SUP-2195545,CDM,L0625,HCPCS,0274,RC,,,,both,,,948.28,616.38,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY PENTARAY NAV INSRTN 115CM 4-4-4 D,SUP-2485389,CDM,C1732,HCPCS,0278,RC,,,,both,,,5425.92,3526.85,,,,,,,,,,,,,
ELECTRODE ES URLGY 4MM DIA BLACK FVPRZTN ELITE SSTM USA SRS,SUP-2722878,CDM,2720000010,LOCAL,0272,RC,,,,both,,,536.66,348.83,,,,,,,,,,,,,
INTRODUCER TUBE SET 7.5/8.5/9 MM MULTI PERC W/O PHAR 8.5 MM,SUP-2759717,CDM,C1769,HCPCS,0272,RC,,,,both,,,1561.37,1014.89,,,,,,,,,,,,,
COMPONENT TALAR FIN SWEEPER FIN SWEEPER TOT ANK REPL APEX 3D,SUP-2742290,CDM,C1776,CPT,0278,RC,,,,both,,,632.71,411.26,,,,,,,,,,,,,
PLATE BONE 6 H TI STR FOR 1.5MM SCR VLP MINI-MOD SM BONE SYS,SUP-2341192,CDM,C1713,HCPCS,0278,RC,,,,both,,,2351.36,1528.38,,,,,,,,,,,,,
GRAFT BNE SUB 5CC 25X25X8MM DEMIN BNE MTRX 3D SCFLD STRP,SUP-2335644,CDM,C9362,HCPCS,0278,RC,,,,both,,,7457.50,4847.37,,,,,,,,,,,,,
PLATE BNE L 176 X W 10.2 MM THK 2.8 MM SCREW DIA 3.5 MM 16 H 72440916,SUP-2933333,CDM,C1713,HCPCS,0278,RC,,,,both,,,2262.84,1470.85,,,,,,,,,,,,,
KIT CRAN ACCS NDL FRCP XYLOCAINE BIT DRL,SUP-2243818,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1365.90,887.83,,,,,,,,,,,,,
MESH CRAN CUSTOMIZED + SM MEDPOR PTERIONAL +,SUP-2862744,CDM,C1713,HCPCS,0278,RC,,,,both,,,41443.73,26938.42,,,,,,,,,,,,,
SCREW SPNL 16 DEG 43 MM NS TRINICA,SUP-2684829,CDM,C1713,HCPCS,0278,RC,,,,both,,,5259.50,3418.67,,,,,,,,,,,,,
BLADE SURG 10 MM BLNT SHTH TUBESET MIS NEXUS BONESCALPEL,SUP-2745901,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2321.46,1508.95,,,,,,,,,,,,,
SYSTEM DBM DEL CRV FINAL ASMBLY STRL DISP,SUP-2884246,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2326.74,1512.38,,,,,,,,,,,,,
IMPRESSION MATERIAL DENT ULT PK ACCSRY CINCH PLUS,SUP-2355846,CDM,C1713,HCPCS,0278,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
MESH HERN OBLONG 3X6 IN O3FA COAT POLYPR C-QUR TACSHIELD,SUP-2227255,CDM,C1781,HCPCS,0278,RC,,,,both,,,1381.60,898.04,,,,,,,,,,,,,
LINER ACET CUP 28 MM ID 48 MM TO 54 MM OD 0 DEG CERAMIC ON,SUP-2202650,CDM,C1776,CPT,0278,RC,,,,both,,,5857.67,3807.49,,,,,,,,,,,,,
PLANER SURG FACE IO FIX SYS,SUP-2400072,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
INTRODUCER SHTH KT 018 5 FRX10 CM 40 CM 21 GAX7 CM NIT VSI,SUP-2763444,CDM,C1894,HCPCS,0272,RC,,,,both,,,61.23,39.80,,,,,,,,,,,,,
NAIL IM 11X250 MM ANK HINDFOOT REV ARTH W/ GUIDE JIG TI LTX,SUP-2875680,CDM,C1713,HCPCS,0278,RC,,,,both,,,8616.16,5600.50,,,,,,,,,,,,,
STENT ENDOPROS W/ HOLES L8CM DIA10MM CATH L40CM BILI PERC NIT EPTFE,SUP-2396666,CDM,C1874,HCPCS,0278,RC,,,,both,,,9639.80,6265.87,,,,,,,,,,,,,
DEVICE ENDOSKELETAL SYS KNEE SHIN FRIC SINGLE AXIS ULT,SUP-2388217,CDM,L5811,HCPCS,0274,RC,,,,both,,,1916.97,1246.03,,,,,,,,,,,,,
OCTREOTIDE ACETATE 100 MCG/ML IJ SOLN,RX-91279,CDM,J2354,HCPCS,0636,RC,63323-0376-01,NDC,,both,0.5,ML,54.10,35.16,,,,,,,,,,,,,
EXPANDER BRST W10.7XH9.3CM P6.2CM 275CC SIL NACL TEXT SURF,SUP-2300652,CDM,C1789,HCPCS,0278,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
PLATE BNE L1 2X130X0.5 MM CRANIOMAXILLOFACIAL 9 HOLE TI STRL,SUP-2498809,CDM,C1713,HCPCS,0278,RC,,,,both,,,1199.92,779.95,,,,,,,,,,,,,
SUPPORT ANK UNIV LG PLAS,SUP-2330385,CDM,L4350,HCPCS,0274,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
RING EXT FIX DIA240 MM SS 5/8 NS DISP ILIZ,SUP-2933416,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4256.87,2766.97,,,,,,,,,,,,,
TRIAL KNEE IMPL SZ 3 TIB BASEPLT NS REUSE NKII,SUP-2209459,CDM,C1713,HCPCS,0278,RC,,,,both,,,1158.66,753.13,,,,,,,,,,,,,
WIRE BRST LOC 2 BARB 19 GAX5 CM 15 CM CHESBROUGH,SUP-2759087,CDM,C1819,HCPCS,0278,RC,,,,both,,,78.47,51.01,,,,,,,,,,,,,
SYSTEM DEL TRANSSEPTAL 035X135 CM 55 DEG 8.5 FRX79.4 CM TSX,SUP-2424692,CDM,C1713,HCPCS,0278,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
ALLOGRAFT BNE PARTICULATE 250-1000 MH 0.5 CC CANC ORAGRAFT,SUP-2740778,CDM,C1713,HCPCS,0278,RC,,,,both,,,219.93,142.95,,,,,,,,,,,,,
UNIT DRNGE AD CHILD 2500CC BG PLEUR CAV SGL CHMBR WET SUCT,SUP-2384314,CDM,C1729,HCPCS,0272,RC,,,,both,,,516.75,335.89,,,,,,,,,,,,,
PLATE BNE L113MM 6 H R OLECRANON EL TI LOK VARIAX,SUP-2376048,CDM,C1713,HCPCS,0278,RC,,,,both,,,3030.10,1969.56,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY LIVEWIRE L 95 CM DIA 7 FR TIP 2,SUP-2703684,CDM,C1730,HCPCS,0272,RC,,,,both,,,1005.18,653.37,,,,,,,,,,,,,
T-PLT RIGHT ANGLE 56MM STERIGHT HEAD 4HL SHAFT 4HL,SUP-2820732,CDM,C1713,HCPCS,0278,RC,,,,both,,,974.66,633.53,,,,,,,,,,,,,
CATHETER ETER EP OD7FR 2 20 2MM SPC L 6 POLE 10 PIN G DR FIX,SUP-2248462,CDM,C1730,HCPCS,0272,RC,,,,both,,,1017.36,661.28,,,,,,,,,,,,,
SHUNT CAR OUTLYING PRUITT 8 FR,SUP-2264221,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4298.66,2794.13,,,,,,,,,,,,,
NAIL INTRMDLLRY FMRL TTNM 14MM DIA 44CML VRSNL DEPUY,SUP-2587460,CDM,C1713,HCPCS,0278,RC,,,,both,,,4712.42,3063.07,,,,,,,,,,,,,
HC Perq Dev Breast 1st MR Guide,PX-3611928700,CDM,19287,CPT,0361,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
DUODENOSCOPE RIGID CTRL STRL EXALT D DISP M00542423,SUP-2480888,CDM,C1748,HCPCS,0278,RC,,,,both,,,12010.50,7806.82,,,,,,,,,,,,,
CONNECTOR ROD DIA5.5/6X5.5/6MM LAT HYBRID 2 SCR IL VITALITY,SUP-2402703,CDM,C1713,HCPCS,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
SHEATH INTRO PRELUDE L 11 CM DIA 7FR 0.035IN POLYPRO TBNG SS,SUP-2677200,CDM,C1894,HCPCS,0272,RC,,,,both,,,81.48,52.96,,,,,,,,,,,,,
HC So Preg Assoc Plasma Prot-a Pappa,PX-3018416366,CDM,84163,CPT,0301,RC,,,,both,,,49.00,31.85,,,,,,,,,,,,,
PAPAVERINE HCL 30 MG/ML IJ SOLN,RX-6030,CDM,J2440,HCPCS,0636,RC,54288-0142-01,NDC,,both,1,ML,93.50,60.77,,,,,,,,,,,,,
SCREW BONE L2MM DIA1MM CORT CRANIOMAXILLOFACIAL TI SELF DRL,SUP-2189045,CDM,C1713,HCPCS,0278,RC,,,,both,,,366.63,238.31,,,,,,,,,,,,,
SOCKS COMPR UPPER EXTREMITY FRAC BRAC,SUP-2388195,CDM,L3995,HCPCS,0274,RC,,,,both,,,86.10,55.96,,,,,,,,,,,,,
MESH HERN W8XL12IN RECT SEPRAMESH IP COMP,SUP-2125925,CDM,C1781,HCPCS,0278,RC,,,,both,,,3223.84,2095.50,,,,,,,,,,,,,
GRAFT HUM TISS L 30-53 X W 14 MM BNE BLOCK L 25-30 X W 14 X,SUP-2913405,CDM,C1762,CPT,0278,RC,,,,both,,,18111.52,11772.49,,,,,,,,,,,,,
PLATE BNE MINI THK1MM 2X2 H NAR CRANIOMAXILLOFACIAL ORAL,SUP-2181763,CDM,C1713,HCPCS,0278,RC,,,,both,,,1375.95,894.37,,,,,,,,,,,,,
REAMER SURG DIA2 MM PIP DEPTH STRL DISP TENFUSE,SUP-2902388,CDM,2720000010,LOCAL,0272,RC,,,,both,,,869.78,565.36,,,,,,,,,,,,,
MESH GYN L W8XL24CM FLAT POLYPR FOR TRANSABDOMINAL PELV,SUP-2165310,CDM,C1781,HCPCS,0278,RC,,,,both,,,2923.34,1900.17,,,,,,,,,,,,,
PIN DRL 9MM ACL PCL KNEE RG ALL IN 1 GUID RMR FLIPCUTTER II,SUP-2120818,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
FLUTICASONE PROPIONATE 50 MCG/ACT NA SUSP,RX-70536,CDM,6370000000,HCPCS,0637,RC,00054-3270-99,NDC,,both,16,GR,61.50,39.97,,,,,,,,,,,,,
STENT PERIPHERAL L40MM DIAMETER 6MM CATHETER L80CM FLARED VASCULAR,SUP-2128214,CDM,C1874,HCPCS,0278,RC,,,,both,,,6892.30,4479.99,,,,,,,,,,,,,
PLATE BONE L41MM 6 H BILAT MAXILLOFACIAL MAND ORAL TI CVD,SUP-2191328,CDM,C1713,HCPCS,0278,RC,,,,both,,,1657.29,1077.24,,,,,,,,,,,,,
PROBE CRYOABLATION SLIMLINE ROUND ICE 1.7MM,SUP-2716311,CDM,C2618,HCPCS,0272,RC,,,,both,,,4317.50,2806.37,,,,,,,,,,,,,
ELECTRODE ES URLGY 24 28FR DIA LNG 12DG CTTNG RLLR HF RSCTN,SUP-2722601,CDM,2720000010,LOCAL,0272,RC,,,,both,,,556.69,361.85,,,,,,,,,,,,,
LINER WLK BOOT VENTURE TALL SM,SUP-2151034,CDM,L4386,HCPCS,0274,RC,,,,both,,,48.98,31.84,,,,,,,,,,,,,
RING EXT FIX HALF 140 MM CIR SIDEKCK,SUP-2852536,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1168.08,759.25,,,,,,,,,,,,,
DRILL TWST L 58 MM DIA1.9 MM WORKING L 26 MM DENT SHFT FOR,SUP-2883483,CDM,2720000010,LOCAL,0272,RC,,,,both,,,327.97,213.18,,,,,,,,,,,,,
TUBE T SURG DRAIN 8F SIL STRL,SUP-2752235,CDM,C1729,HCPCS,0272,RC,,,,both,,,1215.37,789.99,,,,,,,,,,,,,
NAIL IM L360MM DIA11MM 130DEG SHT R PROX TROCHANTERIC FEM,SUP-2192016,CDM,C1713,HCPCS,0278,RC,,,,both,,,5134.03,3337.12,,,,,,,,,,,,,
PLATE BONE W8XL26MM THK2MM 0DEG 2 H BILAT TI STR RIG DYN,SUP-2191076,CDM,C1713,HCPCS,0278,RC,,,,both,,,893.30,580.64,,,,,,,,,,,,,
PLATE BNE THK 1 MM ADV 10 MM SCREW DIA2 MM MINI LT,SUP-2883204,CDM,C1713,HCPCS,0278,RC,,,,both,,,1977.98,1285.69,,,,,,,,,,,,,
STENT URET 8FR L26CM W/ HYDROGLIDE GWIRE INLAY OPTMA,SUP-2126652,CDM,C2617,HCPCS,0278,RC,,,,both,,,719.34,467.57,,,,,,,,,,,,,
SCREW SPNL LCK 6X27 MM NANOMETALENE VU APOD PRIM,SUP-2244815,CDM,C1713,HCPCS,0278,RC,,,,both,,,3611.00,2347.15,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE 1 CC DEMINERALIZED CORTICAL BNE FIBER,SUP-2933347,CDM,C1762,CPT,0278,RC,,,,both,,,837.69,544.50,,,,,,,,,,,,,
BURR DIAMOND BALL 4.0MM S4DG1,SUP-2843315,CDM,2720000010,LOCAL,0272,RC,,,,both,,,377.68,245.49,,,,,,,,,,,,,
KIT BNE FIX STPL BRIDGE L 10 X 10 MM MINI NIT ANK FT ULTRA,SUP-2897558,CDM,C1713,HCPCS,0278,RC,,,,both,,,3136.86,2038.96,,,,,,,,,,,,,
NIFEDIPINE ER OSMOTIC RELEASE 90 MG PO TB24,RX-27660,CDM,6370000000,HCPCS,0637,RC,68084-0603-21,NDC,,both,1,UN,14.10,9.16,,,,,,,,,,,,,
LINER WLK BOOT VENTURE TALL SM,SUP-2151034,CDM,L4386,HCPCS,0272,RC,,,,both,,,48.98,31.84,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 2X2 CM CRYOPRESERVED UMB CRD NEOX CRD 1K,SUP-2648684,CDM,Q4148,HCPCS,0636,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
OMALIZUMAB 150 MG SC SOLR,RX-36151,CDM,J2357,HCPCS,0636,RC,50242-0040-62,NDC,,both,1,UN,4344.70,2824.05,,,,,,,,,,,,,
VERTEBRAL BODY DEV 36MMX13MMX12DEG STALIF,SUP-2320303,CDM,C1889,HCPCS,0278,RC,,,,both,,,28244.30,18358.79,,,,,,,,,,,,,
PLATE BONE L93MM 16 H CRANIOFACIAL VIT STR COND FOR 1.3MM,SUP-2364695,CDM,C1713,HCPCS,0278,RC,,,,both,,,832.10,540.86,,,,,,,,,,,,,
CATHETER ATR FIX PRESSURE FULL 46 CM SHUNT FULL BA,SUP-2243867,CDM,2720000010,LOCAL,0272,RC,,,,both,,,316.36,205.63,,,,,,,,,,,,,
TUBE VENT ID127MM BLU POLYETH MORETZ,SUP-2313858,CDM,L8699,HCPCS,0278,RC,,,,both,,,33.13,21.53,,,,,,,,,,,,,
SILTUXIMAB 400 MG IV SOLR,RX-125989,CDM,J2860,HCPCS,0636,RC,73090-0421-01,NDC,,both,1,UN,18777.40,12205.31,,,,,,,,,,,,,
ANCHOR SUT DIA2.9MM SUT SZ 2 MAXBRAID BLU POLY DBL LD SGL,SUP-2212964,CDM,C1713,HCPCS,0278,RC,,,,both,,,1181.64,768.07,,,,,,,,,,,,,
GRAFT BONE L 150MM LT ANK WHL TRAD FRZN,SUP-2294189,CDM,C1713,HCPCS,0278,RC,,,,both,,,18651.60,12123.54,,,,,,,,,,,,,
SCREW BONE L10MM DIA2.7MM STD SM FRAG FT PLATING SYS,SUP-2319591,CDM,C1713,HCPCS,0278,RC,,,,both,,,414.48,269.41,,,,,,,,,,,,,
DEFIBRILLATOR CRD BPLR 67X50X14 MM 38 CC 78 GM ATLS + DR V243ROPT] ST JUDE MED CARDIAC RHYM MGMT],SUP-2356552,CDM,C1721,HCPCS,0275,RC,,,,both,,,51904.20,33737.73,,,,,,,,,,,,,
COIL VASC NEST EMBOLUS L 2 CM DIA2 MM CATH DIA 0.018 IN LOOP,SUP-2647205,CDM,C1889,HCPCS,0278,RC,,,,both,,,326.53,212.24,,,,,,,,,,,,,
HEAD HUM H15MM OD40MM STD CO CHROM SHLDR PRI REV TOT BPLR,SUP-2404692,CDM,C1776,CPT,0278,RC,,,,both,,,4989.46,3243.15,,,,,,,,,,,,,
WEDGE TIB L SZ 2 THK10MM TI L KNEE PRI PRESSFIT FULL FLUT,SUP-2377102,CDM,C1776,CPT,0278,RC,,,,both,,,1943.72,1263.42,,,,,,,,,,,,,
SYSTEM BONE MAR ASPIR NDL SYR LESS INVASIVE L15CM DIA11GA,SUP-2194029,CDM,C1713,HCPCS,0278,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
SHEATH INTRF L L30MM POLYPR FOR INTRAFIX ADV TIB FAST SYS,SUP-2256836,CDM,C1776,CPT,0278,RC,,,,both,,,1045.62,679.65,,,,,,,,,,,,,
RELOAD STPLR CRV TIP SM SHT SIGNIA,SUP-2787711,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2519.07,1637.40,,,,,,,,,,,,,
INSULIN REGULAR(HUMAN) IN NACL 100-0.9 UT/100ML-% IV SOLN,RX-147180,CDM,J1815,HCPCS,0637,RC,00338-0126-12,NDC,,both,100,ML,28.00,18.20,,,,,,,,,,,,,
SLING TVEZ 2.7MM TROCAL DESARA BLUE,SUP-2740343,CDM,C1771,HCPCS,0278,RC,,,,both,,,3604.72,2343.07,,,,,,,,,,,,,
KNIFE 3722151 MYRINGOPLASTY 2545 DEG,SUP-2667295,CDM,2720000010,LOCAL,0272,RC,,,,both,,,978.61,636.10,,,,,,,,,,,,,
BLADE SCREWDRIVER T7 AO,SUP-2691425,CDM,2720000010,LOCAL,0272,RC,,,,both,,,833.98,542.09,,,,,,,,,,,,,
INSERT FEM NK +3MM HIP CO CHROM MOLYBDENUM ALLY TAPR 1 ENDO,SUP-2405244,CDM,C1776,CPT,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
HALF RNG 120MM FRDM CIR FIX,SUP-2400630,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1372.18,891.92,,,,,,,,,,,,,
FIBER LASER 30 W SM FLX POWERFUL ENERGY FOR COAG HOLM,SUP-2462704,CDM,2720000010,LOCAL,0272,RC,,,,both,,,155301.26,100945.82,,,,,,,,,,,,,
COIL VASC RETRACTA L 14 CM DIA12 MM CATH 0.035 IN LOOP 3.7,SUP-2570698,CDM,C1889,HCPCS,0278,RC,,,,both,,,1617.10,1051.11,,,,,,,,,,,,,
IMPLANT BRST GEL 335 CC SMOOTH RND MOD PROF NATRELLE INSPIRA,SUP-2113709,CDM,C1789,HCPCS,0278,RC,,,,both,,,2967.30,1928.74,,,,,,,,,,,,,
KIT CHOLGM POLYUR W/ KARLAN BLLN CATH 4FR L60CM 5MM INTRO,SUP-2383431,CDM,C1729,HCPCS,0272,RC,,,,both,,,234.87,152.67,,,,,,,,,,,,,
STRATOGEN MEM 2 X 6 CM,SUP-2164200,CDM,Q4139,HCPCS,0636,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
KIT PICC MAX BARRIER PRLOADED 5FR X 55CM 2L,SUP-2864580,CDM,C1751,HCPCS,0278,RC,,,,both,,,732.66,476.23,,,,,,,,,,,,,
PLATE BNE L92MM 6 H BILAT S STL STR NONCOMPRESSION RECON RIG,SUP-2410177,CDM,C1713,HCPCS,0278,RC,,,,both,,,1014.25,659.26,,,,,,,,,,,,,
HC Remove Intrvas Foreign Body,PX-3613719700,CDM,37197,CPT,0361,RC,,,,both,,,8583.00,5578.95,,,,,,,,,,,,,
PANC STRAIGHT STENT KIT 5FX4CM,SUP-2676503,CDM,C2617,HCPCS,0278,RC,,,,both,,,547.05,355.58,,,,,,,,,,,,,
VALVE AORT EPIC MAX SZ 25 MM TISS ANNULUS DIA25 MM STENT,SUP-2893587,CDM,C1889,HCPCS,0278,RC,,,,both,,,15703.14,10207.04,,,,,,,,,,,,,
SCREW BONE L70MM OD4.5MM BLU MIDFOOT HINDFOOT ANK CANN SH,SUP-2320935,CDM,C1713,HCPCS,0278,RC,,,,both,,,1263.85,821.50,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED ADD ON CERM POLYETH,SUP-2365433,CDM,C1776,CPT,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
LEAD PACE L78CM DIA5.3FR SIL STEROID CARD ART VENT STR 2 439878] MEDTRONIC CARDIAC RTHYM MGT],SUP-2281934,CDM,C1900,HCPCS,0275,RC,,,,both,,,4909.99,3191.49,,,,,,,,,,,,,
KIT INSRT DIA2.4MM PERC INCL DISP 17GA SPNL NDL 1.1MM NIT,SUP-2121599,CDM,2720000010,LOCAL,0272,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
SACCHAROMYCES BOULARDII 250 MG PO CAPS,RX-37343,CDM,6370000000,HCPCS,0637,RC,04142-0000-07,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
SET PICC 1L 4FR X 55CM W TEG CHG,SUP-2887042,CDM,C1751,HCPCS,0278,RC,,,,both,,,1595.12,1036.83,,,,,,,,,,,,,
PLATE BNE THK1.5MM L TARSOMETATARSAL LAPIDUS TI STP 1 COMPR,SUP-2378913,CDM,C1713,HCPCS,0278,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
NAIL IM OD2MM HUM SMOOTH SHRP TIP LCK GUID PIN GROSSE-KEMPF,SUP-2362524,CDM,C1713,HCPCS,0278,RC,,,,both,,,605.86,393.81,,,,,,,,,,,,,
PLATE BNE L103MM 5 H ST L POSTEROLATERAL DST FIBULAR S STL,SUP-2420742,CDM,C1713,HCPCS,0278,RC,,,,both,,,1989.06,1292.89,,,,,,,,,,,,,
COUNTERSINK SURG BNE FOR 65 75MM HD SCR DARCO,SUP-2399161,CDM,2720000010,LOCAL,0272,RC,,,,both,,,480.42,312.27,,,,,,,,,,,,,
SHELL ACET OD58MM ID24MM HIP TI ALLY MH LOK MECHANISM,SUP-2409109,CDM,C1776,CPT,0278,RC,,,,both,,,6493.52,4220.79,,,,,,,,,,,,,
ELECTRODE ENDOSCP HF-RESECTION MED 12-30 DEG PLASMALOOP DISP,SUP-2477088,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1615.47,1050.06,,,,,,,,,,,,,
CATHETER HD DL 10 FRX18 CM STR CUF TIP SPLIT CATH III,SUP-2269496,CDM,C1752,HCPCS,0278,RC,,,,both,,,188.40,122.46,,,,,,,,,,,,,
CROWN FORM DENT STRP U4 PRIMARY ANTR UPPER RT CNTRL PLAS,SUP-2322244,CDM,D6783,CPT,0278,RC,,,,both,,,32.09,20.86,,,,,,,,,,,,,
GRAFT VASC FLX 6 MMX70 CM STD WALL SM BEAD EPTFE CARBOFLO,SUP-2761477,CDM,C1768,CPT,0278,RC,,,,both,,,3413.87,2219.02,,,,,,,,,,,,,
PACK BTTRY SURG SCRDRVR VARISPEED,SUP-2364443,CDM,2720000010,LOCAL,0272,RC,,,,both,,,887.36,576.78,,,,,,,,,,,,,
PLATE 3D PROFYLE 3 X 2 HL 23MM,SUP-2702852,CDM,C1713,HCPCS,0278,RC,,,,both,,,1486.63,966.31,,,,,,,,,,,,,
PLATE STRAIGHT 24 HOLE,SUP-2719535,CDM,C1713,HCPCS,0278,RC,,,,both,,,2072.40,1347.06,,,,,,,,,,,,,
GRAFT EVAR L11.5CM DIA18MM CONTRALATERAL LEG FOR AAA,SUP-2395905,CDM,C1768,CPT,0278,RC,,,,both,,,13451.76,8743.64,,,,,,,,,,,,,
ALLOGRAFT BNE WDG LG 25-30X10X15-25 MM FD IL CREST,SUP-2866875,CDM,C1762,CPT,0278,RC,,,,both,,,2296.91,1492.99,,,,,,,,,,,,,
MESH SURG XS OPTIMESH,SUP-2536959,CDM,C1713,HCPCS,0278,RC,,,,both,,,12560.00,8164.00,,,,,,,,,,,,,
HEAD ULN 16 WRST MOD COCR 1ST CHOICE,SUP-2852953,CDM,C1776,CPT,0278,RC,,,,both,,,4160.50,2704.32,,,,,,,,,,,,,
BUR SURG DIAMOND COARSE 6 MMX14 CM BALL LG BOR LEGEND,SUP-2627686,CDM,2720000010,LOCAL,0272,RC,,,,both,,,390.05,253.53,,,,,,,,,,,,,
NAIL IM L160MM DIA11.5MM LT HINDFOOT CANN LCK RG BENT,SUP-2347961,CDM,C1713,HCPCS,0278,RC,,,,both,,,18107.28,11769.73,,,,,,,,,,,,,
CURVED RECON 3.5MM 18X214MM,SUP-2818482,CDM,C1713,HCPCS,0278,RC,,,,both,,,5375.84,3494.30,,,,,,,,,,,,,
CAGE SPNL ANGLED 0 DEG 12X39-65 MM TI SM VBR,SUP-2431557,CDM,C1889,HCPCS,0278,RC,,,,both,,,26533.00,17246.45,,,,,,,,,,,,,
ALLOGRAFT NERVE 4-5X50 MM PROC STRL AVANCE LTX,SUP-2753341,CDM,C1762,CPT,0278,RC,,,,both,,,22695.92,14752.35,,,,,,,,,,,,,
DANAZOL 100 MG PO CAPS,RX-9714,CDM,6370000000,HCPCS,0637,RC,00555-0634-02,NDC,,both,1,UN,17.20,11.18,,,,,,,,,,,,,
MATRIX BIO L 10 X W 8 IN BOV CLLGN CHONDROITIN-6-SULFATE,SUP-2909331,CDM,Q4108,HCPCS,0636,RC,,,,both,,,38956.00,25321.40,,,,,,,,,,,,,
PROBE LASER 23 GA CRV ENDO OCU SMA906 W/ ALCO,SUP-2713795,CDM,2720000010,LOCAL,0272,RC,,,,both,,,513.70,333.90,,,,,,,,,,,,,
AGENT EMB OBSIDIO CATH ID 0.024 IN RVD 3 MM 1 ML SHR,SUP-2874851,CDM,C1889,HCPCS,0278,RC,,,,both,,,20001.80,13001.17,,,,,,,,,,,,,
WIRE ORTH THRD SGL SHRP TIP S STL 0.9MM DIA 102MM K,SUP-2363716,CDM,C1713,HCPCS,0278,RC,,,,both,,,37.37,24.29,,,,,,,,,,,,,
DEFIBRILLATOR CRD BPLR 12.9 MM 32 CC 69 GM VENTRIC EPIC + VR V196ROPT] ST JUDE MED CARDIAC RHYM MGMT],SUP-2356531,CDM,C1722,HCPCS,0275,RC,,,,both,,,52657.80,34227.57,,,,,,,,,,,,,
PROSTHESIS VOICE 16 FRX4 MM INDWL SFT VLV NS BLOM-SINGER,SUP-2242283,CDM,L8509,HCPCS,0272,RC,,,,both,,,1224.60,795.99,,,,,,,,,,,,,
CATHETER GUID L49CM OD8FR INTRO LD PLCMNT COR SNUS ACCS N,SUP-2148926,CDM,C1887,HCPCS,0272,RC,,,,both,,,1397.30,908.24,,,,,,,,,,,,,
CATHETER ANGIOPLSTY 12FR L70CM BAL L2.5CM DIA26MM 0.025IN,SUP-2388516,CDM,C1725,HCPCS,0272,RC,,,,both,,,8478.00,5510.70,,,,,,,,,,,,,
CABLE UNIT PT REF SENSOR,SUP-2356617,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
PRAMIPEXOLE DIHYDROCHLORIDE 1 MG PO TABS,RX-21288,CDM,6370000000,HCPCS,0637,RC,60687-0592-11,NDC,,both,1,UN,5.00,3.25,,,,,,,,,,,,,
INSERT TIB PS 3 13 MM KNEE,SUP-2391470,CDM,C1776,CPT,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
PLATE BNE 2X37X1.5 MM 7 HOLE SS DCP,SUP-2569123,CDM,C1713,HCPCS,0278,RC,,,,both,,,291.86,189.71,,,,,,,,,,,,,
MG II KNEE 8MM PAT 35MM DIA,SUP-2199563,CDM,C1776,CPT,0278,RC,,,,both,,,5204.86,3383.16,,,,,,,,,,,,,
DRESSING BIO 2000 MG TYP I/III BOV CLLGN MTRX FIBRILLAR SHLF,SUP-2905521,CDM,C1763,HCPCS,0278,RC,,,,both,,,10048.00,6531.20,,,,,,,,,,,,,
SPACER ORTHOPEDIC TIB MED 5 MM 2.5 MM PROX KNEE HEX SOCKET,SUP-2423136,CDM,C1776,CPT,0278,RC,,,,both,,,2935.90,1908.33,,,,,,,,,,,,,
ANCHOR SUT DIA6.5MM PEEK 3 ORTHOCORD SZ 2 L36IN VLT BLU,SUP-2249416,CDM,C1713,HCPCS,0278,RC,,,,both,,,261.25,169.81,,,,,,,,,,,,,
SCISSORS HYSTEROSCOPIC HND ACTUATED STRL DISP OMNI,SUP-2913672,CDM,2720000010,LOCAL,0272,RC,,,,both,,,580.90,377.58,,,,,,,,,,,,,
ROD SPNL 11X250 MM,SUP-2205340,CDM,C1713,HCPCS,0278,RC,,,,both,,,642.92,417.90,,,,,,,,,,,,,
STEM FEM REV 24X195 MM MONOBLOC ALTEON,SUP-2432458,CDM,C1776,CPT,0278,RC,,,,both,,,15481.61,10063.05,,,,,,,,,,,,,
TROCAR ENDOSCP L150MM DIA12MM BLDELSS OBT RADLUC STBL SL,SUP-2218265,CDM,2720000010,LOCAL,0272,RC,,,,both,,,91.06,59.19,,,,,,,,,,,,,
PLATE BNE 1ST METATARSOPHALANGEAL 7 DEG STD RT STRATUM,SUP-2499410,CDM,C1713,HCPCS,0278,RC,,,,both,,,5438.48,3535.01,,,,,,,,,,,,,
SET URET STENT SOFFLX L 16 CM DIA 6 FR POS L 46 CM DIA 7 FR,SUP-2835689,CDM,C2617,HCPCS,0278,RC,,,,both,,,346.59,225.28,,,,,,,,,,,,,
NAIL IM L240MM OD13MM TI FEM LOK AG CANN RG T2,SUP-2368964,CDM,C1713,HCPCS,0278,RC,,,,both,,,4239.00,2755.35,,,,,,,,,,,,,
CATHETER CENTESIS 4FR L7CM RADPQ KINK RESIST 2 L OVL SKIVED,SUP-2303563,CDM,C1729,HCPCS,0272,RC,,,,both,,,5.34,3.47,,,,,,,,,,,,,
PROBE HEMSTAT BICAP DST IRRIG ONLY 10FR,SUP-2313959,CDM,C1713,HCPCS,0278,RC,,,,both,,,816.40,530.66,,,,,,,,,,,,,
PLATE BNE L 48 MM SCREW DIA2.7 MM 6 SHFT H TI STR COMPACT,SUP-2907744,CDM,C1713,HCPCS,0278,RC,,,,both,,,3511.31,2282.35,,,,,,,,,,,,,
GUIDEWIRE VASC GLIDEWIRE 260CM 0.025IN TIP L 3 CM STD STR,SUP-2385102,CDM,C1769,HCPCS,0272,RC,,,,both,,,201.75,131.14,,,,,,,,,,,,,
CATHETER ANGIO WORLEY L 75 CM DIA 0.046 IN DIA 5 FR STD SFT,SUP-2301870,CDM,C1894,HCPCS,0272,RC,,,,both,,,309.92,201.45,,,,,,,,,,,,,
GRAFT HUMAN TSSUE ARCH WEDGE 16MMW X 22MML X 6MMH FRZE DRIED,SUP-2727149,CDM,C1762,CPT,0278,RC,,,,both,,,2738.39,1779.95,,,,,,,,,,,,,
GRAFT TISS FRZN ALLGRFT SHFT FEM 70MM LX10MM D,SUP-2307346,CDM,C1762,CPT,0278,RC,,,,both,,,2628.18,1708.32,,,,,,,,,,,,,
CABLE VENT ASST DEV L EXTN DRIVELINE HEARTWARE,SUP-2282531,CDM,C1713,HCPCS,0278,RC,,,,both,,,8164.00,5306.60,,,,,,,,,,,,,
CATHETER CV KT 0.018 IN PEDIATRIC 4 FRX5 CM 0.64 MMX45 CM,SUP-2763321,CDM,C1751,HCPCS,0278,RC,,,,both,,,100.48,65.31,,,,,,,,,,,,,
ROD SPNL SZ 12 RAD 220MM LUM GLD TI ALLOY EXTN VEPTR,SUP-2193330,CDM,C1713,HCPCS,0278,RC,,,,both,,,7501.46,4875.95,,,,,,,,,,,,,
WAND ABLAT BVL 30DEG 3MM,SUP-2341966,CDM,2720000010,LOCAL,0272,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
GRAFT HUM TISS 16CM W/O STRUT FRZN IRRADIATED ACHILLES,SUP-2137249,CDM,C1763,HCPCS,0278,RC,,,,both,,,4739.99,3080.99,,,,,,,,,,,,,
PLATE BNE T 3.5X87 MM 3X7 HOLE RT ANGLED SS LCP,SUP-2569407,CDM,C1713,HCPCS,0278,RC,,,,both,,,647.63,420.96,,,,,,,,,,,,,
SCREW INTRF L35MM DIA9MM KNEE PLLA HA BIOABSRB FOR ACL PCL,SUP-2341561,CDM,C1713,HCPCS,0278,RC,,,,both,,,926.46,602.20,,,,,,,,,,,,,
SPLINT RNG PIP FLX EXTN FNGR 3/4IN SM,SUP-2324608,CDM,L3808,HCPCS,0272,RC,,,,both,,,45.81,29.78,,,,,,,,,,,,,
SET ORTH GRPHC CA W/ IMPL AND INSTR FOR PERIPROSTHETIC SYS,SUP-2177074,CDM,C1713,HCPCS,0278,RC,,,,both,,,18047.31,11730.75,,,,,,,,,,,,,
SCREW BNE CANN 6.5X45 MM 20 MM THRD NS LTX,SUP-2856354,CDM,C1713,HCPCS,0278,RC,,,,both,,,1287.40,836.81,,,,,,,,,,,,,
HEAD FEM MED 36 MM HIP CERM,SUP-2322502,CDM,C1776,CPT,0278,RC,,,,both,,,2141.48,1391.96,,,,,,,,,,,,,
ENDCAP ORTH DIA12MM 0MM EXTN ST TI SPRL BLDE LOK T40,SUP-2180033,CDM,C1713,HCPCS,0278,RC,,,,both,,,732.37,476.04,,,,,,,,,,,,,
BUR SURG L14CM DIA3MM LEGEND PROX MTCH HD MIDAS REX CLRVW,SUP-2281566,CDM,C1713,HCPCS,0278,RC,,,,both,,,1129.62,734.25,,,,,,,,,,,,,
PLATE BONE L163MM 12 H NONSTERILE RT PROX TIB S STL LO PROF,SUP-2185817,CDM,C1713,HCPCS,0278,RC,,,,both,,,3708.21,2410.34,,,,,,,,,,,,,
HC So Vitamin K,PX-3018459766,CDM,84597,CPT,0301,RC,,,,inpatient,,,65.00,42.25,,,,,,,,,,,,,
SLEEVE CATH CATH-GARD L 80 CM DIA 7.5 FR TWISTLOCK ADPT,SUP-2127034,CDM,C1750,HCPCS,0278,RC,,,,both,,,37.81,24.58,,,,,,,,,,,,,
SCREW BONE L34MM DIA3MM PARTIALLY THRD HD M CANN FLOWERCUBE,SUP-2225324,CDM,C1713,HCPCS,0278,RC,,,,both,,,727.00,472.55,,,,,,,,,,,,,
IMPLANT BIO TISS W18 25XL250MM THCK CLLGN DERM MTRX XENMTRX,SUP-2126244,CDM,C1781,HCPCS,0278,RC,,,,both,,,62800.00,40820.00,,,,,,,,,,,,,
PADS SOUND PROCESSOR SOFTWEAR,SUP-2858178,CDM,L8690,HCPCS,0278,RC,,,,both,,,4.02,2.61,,,,,,,,,,,,,
IMPLANT OSS NOTCH 3X0.5 MM CENTER SHFT BEND FLANGE TI,SUP-2232512,CDM,L8613,CPT,0278,RC,,,,both,,,889.37,578.09,,,,,,,,,,,,,
SCREW BNE STYLOID 2X22 MM ST HI ANGLE T5 DRV,SUP-2462038,CDM,C1713,HCPCS,0278,RC,,,,both,,,156.59,101.78,,,,,,,,,,,,,
DEXTROSE 10 % IV SOLN,RX-2357,CDM,2580000003,HCPCS,0250,RC,00264-7520-10,NDC,,both,500,ML,38.30,24.89,,,,,,,,,,,,,
SCISSORS SURG 25GA CRV GRIESHABER,SUP-2109699,CDM,C1713,HCPCS,0278,RC,,,,both,,,555.78,361.26,,,,,,,,,,,,,
CUFF CO CIRC 43-71 MM FNGR AD SELF COILING N INVAS NS DISP,SUP-2885379,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1202.62,781.70,,,,,,,,,,,,,
BIT DRL SPRL FLX,SUP-2449499,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1003.23,652.10,,,,,,,,,,,,,
HC Bladder Scan,PX-7615179800,CDM,51798,CPT,0761,RC,,,,both,,,191.00,124.15,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY REFLEXION SPRL L 99CM 7FR 20 POLE,SUP-2700013,CDM,C1731,HCPCS,0278,RC,,,,both,,,905.14,588.34,,,,,,,,,,,,,
LEAD NEUROSTIMULATOR L60CM 8 ELECTRD LAMITRODE,SUP-2356739,CDM,C1778,HCPCS,0278,RC,,,,both,,,9734.00,6327.10,,,,,,,,,,,,,
HC Bladder Scan,PX-4025179800,CDM,51798,CPT,0402,RC,,,,both,,,191.00,124.15,,,,,,,,,,,,,
HC Bladder Scan,PX-4505179800,CDM,51798,CPT,0450,RC,,,,inpatient,,,191.00,124.15,,,,,,,,,,,,,
PIN POS PROS OFFSET HD ALIGN BIO MOD,SUP-2403976,CDM,C1713,HCPCS,0278,RC,,,,both,,,480.42,312.27,,,,,,,,,,,,,
PLATE BNE CLAV CS2 2.7 MM RT LAT VA LCK COMPR SS STRL VA-LCP,SUP-2750789,CDM,C1713,HCPCS,0278,RC,,,,both,,,3623.18,2355.07,,,,,,,,,,,,,
SHUNT SURG DELT ASMBLY 1 REG SPNL CEREB FLUID,SUP-2284557,CDM,C1889,HCPCS,0278,RC,,,,both,,,4013.05,2608.48,,,,,,,,,,,,,
GUIDEPIN SURG L80MM DIA0.09IN FOR ACL RECON,SUP-2212927,CDM,C1713,HCPCS,0278,RC,,,,both,,,752.60,489.19,,,,,,,,,,,,,
RING EXT FIX DIA255 MM 2/3 NS DISP TAY SPAT FRME,SUP-2932944,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7171.92,4661.75,,,,,,,,,,,,,
RING EXT FIX HALF 240 MM TI NS,SUP-2800049,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1909.18,1240.97,,,,,,,,,,,,,
GRAFT SFT TISS X THCK 30X20 CM RECON TISS MTRX STRATTICE,SUP-2475439,CDM,Q4130,HCPCS,0636,RC,,,,both,,,59405.66,38613.68,,,,,,,,,,,,,
STENT TRACHBRONCH AERO FULL CVR DIR VIS 16MMX40MM,SUP-2302399,CDM,C1874,HCPCS,0278,RC,,,,both,,,7693.00,5000.45,,,,,,,,,,,,,
COMPONENT TOT ANK ANTR OFFSET 1 12 MM 2 MM VIT E APEX 3D,SUP-2742222,CDM,C1776,CPT,0278,RC,,,,both,,,7065.00,4592.25,,,,,,,,,,,,,
BUPIVACAINE HCL 0.25 % IJ SOLN (MIXTURES ONLY),RX-430037,CDM,J0665,HCPCS,0636,RC,55150-0168-30,NDC,,both,30,ML,54.10,35.16,,,,,,,,,,,,,
GUIDEPIN SURG KT FOR MED SURG LPS-FLEX,SUP-2212344,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1962.50,1275.62,,,,,,,,,,,,,
INSERT TIB L59MM THK11MM KNEE CRUC RET LIP VANGUARD,SUP-2137389,CDM,C1776,CPT,0278,RC,,,,both,,,7912.80,5143.32,,,,,,,,,,,,,
SCREW BNE L40MM DIA5MM CORT CONIC S STL ST CANN LOK FULL,SUP-2184912,CDM,C1713,HCPCS,0278,RC,,,,both,,,563.76,366.44,,,,,,,,,,,,,
BOUGIE ESOPH HURST TUNGSTEN FIL 32FR SIL,SUP-2383702,CDM,2720000010,LOCAL,0272,RC,,,,both,,,355.82,231.28,,,,,,,,,,,,,
HC Unlisted Procedure Vascular Surgery,PX-3603779900,CDM,37799,CPT,0360,RC,,,,both,,,15457.00,10047.05,,,,,,,,,,,,,
GUIDEWIRE VASC COPE L 40 CM DIA 0.018 IN TAPR L 7 CM FLPY,SUP-2168469,CDM,C1769,HCPCS,0272,RC,,,,both,,,86.51,56.23,,,,,,,,,,,,,
TOBRAMYCIN 40 MG/ML NEBULIZATION (NDC),RX-4082702,CDM,J3260,HCPCS,0636,RC,09999-9919-73,NDC,,both,7.5,ML,54.10,35.16,,,,,,,,,,,,,
PROTECTOR ENDOSCP TIP FLX XL 10.7-17.9 MM DSTL STRL DISP,SUP-2865658,CDM,2720000010,LOCAL,0272,RC,,,,both,,,9.23,6.00,,,,,,,,,,,,,
PLATE BNE L NEUT 2.7X72 MM RT DSTL TIB 4 HOLE VA LCK COMPR,SUP-2177698,CDM,C1713,HCPCS,0278,RC,,,,both,,,2791.77,1814.65,,,,,,,,,,,,,
PLATE BNE 11 H ST L CUBOID TI MAL LO PROF FOR 24 27MM SCR,SUP-2180785,CDM,C1713,HCPCS,0278,RC,,,,both,,,2760.15,1794.10,,,,,,,,,,,,,
ADAPTER EXTRCTN CNNLTD CPHLMDLLRY ASIA NAT NAIL SSTM,SUP-2479183,CDM,C1713,HCPCS,0278,RC,,,,both,,,890.06,578.54,,,,,,,,,,,,,
CATHETER CV 3L 12 FRX27 CM OTW HICKMAN TRIFUSION,SUP-2126184,CDM,C1751,HCPCS,0278,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
CATHETER HD STR 12.5 FRX32 CM LT DL STP BASIC SET HEMCATH,SUP-2627317,CDM,C1750,HCPCS,0278,RC,,,,both,,,17.52,11.39,,,,,,,,,,,,,
K WIRE FIX DIA1.4MM SMOOTH THRD OLV TIP,SUP-2321638,CDM,2720000010,LOCAL,0272,RC,,,,both,,,373.66,242.88,,,,,,,,,,,,,
ALLOGRAFT BNE SPACER 8 23-27X21 MM FD NAR LORDTC ANTR FRA,SUP-2736743,CDM,C1713,HCPCS,0278,RC,,,,both,,,13018.03,8461.72,,,,,,,,,,,,,
GRAFT MTRX DERM HUM TISS ACELLULAR FRZN 5CMX7CM M HMTRX,SUP-2125442,CDM,Q4134,HCPCS,0636,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9 % IV BOLUS NEONATE|DISCARDED DRUG NOT ADMINISTE,RX-40840079,CDM,J7050,HCPCS,0258,RC,00264-7800-20,NDC,JW,both,250,ML,23.40,15.21,,,,,,,,,,,,,
CATHETER ABLATN A 2-5-2 MM 4 MM 6 FRX92 CM UNIDIR LF,SUP-2248664,CDM,C1733,HCPCS,0272,RC,,,,both,,,2157.18,1402.17,,,,,,,,,,,,,
SCREW BNE L40MM DIA4.5MM HUM G TI SELF CUT FULL THRD BLNT,SUP-2180227,CDM,C1713,HCPCS,0278,RC,,,,both,,,874.30,568.29,,,,,,,,,,,,,
FORCEPS SURG SCR FOR CONVENTUS CAGE SYS,SUP-2167424,CDM,C1713,HCPCS,0278,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
GRAFT HUM TISS W2XL4CM THK0.8-1.7MM ACELLULAR DERM ORAL CAV,SUP-2306908,CDM,C1762,CPT,0278,RC,,,,both,,,599.90,389.93,,,,,,,,,,,,,
PLATE BONE LOK HLX46 HDSHFT TTNM T SHPD OBLQUE ST,SUP-2724423,CDM,C1713,HCPCS,0278,RC,,,,both,,,1261.34,819.87,,,,,,,,,,,,,
WASHER ORTH DIA13MM TI FOR 6.7MM SCR,SUP-2123199,CDM,C1713,HCPCS,0278,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
ENDCAP NAIL L6.85MM HD L2.5MM 3MM HEX TIBIOTALOCALCANEAL,SUP-2277472,CDM,C1713,HCPCS,0278,RC,,,,both,,,1460.10,949.06,,,,,,,,,,,,,
JOINT EXT FIX BALL W/ ROD NS DISP,SUP-2885173,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1746.47,1135.21,,,,,,,,,,,,,
GUIDEWIRE VASC L145CM DIA0035IN FLPY TIP EXTN COMPATIBLE STR,SUP-2281742,CDM,C1769,HCPCS,0272,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
PIN EXT FIX MINI CLMP CONVERGING FOR CORRECTIVE OSTEOTMY,SUP-2400612,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1563.72,1016.42,,,,,,,,,,,,,
AMBI CHSP 8SL 180MM 150D,SUP-2818068,CDM,C1713,HCPCS,0278,RC,,,,both,,,4964.65,3227.02,,,,,,,,,,,,,
CANNULA SURG PERC 1.6 MM UNIV LCK SYS,SUP-2480117,CDM,2720000010,LOCAL,0272,RC,,,,both,,,641.69,417.10,,,,,,,,,,,,,
TIP SUCT L32CM OD5MM BALL TIP REPOSABLE STRYKEPROBE,SUP-2361200,CDM,2720000010,LOCAL,0272,RC,,,,both,,,421.23,273.80,,,,,,,,,,,,,
LEVEL NEURO ST MESH SPCLTY PTTSBRGH SMCRCLE NEURO SCRW61 X 4,SUP-2677464,CDM,C1713,HCPCS,0278,RC,,,,both,,,1781.01,1157.66,,,,,,,,,,,,,
PROFILE COSTAL CARTILAGE ALLOGRAFT SHEET LG,SUP-2727659,CDM,C1762,CPT,0278,RC,,,,both,,,2511.69,1632.60,,,,,,,,,,,,,
BRACE ORTHOPEDIC D RNG MED REG AD 8 IN RT ROLYANFIT,SUP-2325902,CDM,L3908,HCPCS,0274,RC,,,,both,,,51.65,33.57,,,,,,,,,,,,,
GRAFT BNE SPNG 50X20X5 MM DBM CANC,SUP-2641786,CDM,C1713,HCPCS,0278,RC,,,,both,,,5922.04,3849.33,,,,,,,,,,,,,
PIN FIX SKULL RADLUC WNG DSGN W/ FNGR GROOVES STRL DISP,SUP-2243876,CDM,2720000010,LOCAL,0272,RC,,,,both,,,844.06,548.64,,,,,,,,,,,,,
CATHETER ANGIOPLSTY SCOREFLEX NC 139 CM 10 CM 2.25 MM,SUP-2754697,CDM,C1725,HCPCS,0272,RC,,,,both,,,2119.50,1377.67,,,,,,,,,,,,,
PLATE BNE L178MM 8 H NONSTERILE L MED PROX TIB S STL LOK,SUP-2185676,CDM,C1713,HCPCS,0278,RC,,,,both,,,4220.88,2743.57,,,,,,,,,,,,,
GRAFT VASC INTERGARD L 50 CM DIA16 X 8 MM THK 0.38 MM,SUP-2461153,CDM,C1768,CPT,0278,RC,,,,both,,,1898.48,1234.01,,,,,,,,,,,,,
PLATE BONE EPICONDYLARXLATERAL LE X LNG,SUP-2107781,CDM,C1713,HCPCS,0278,RC,,,,both,,,3953.26,2569.62,,,,,,,,,,,,,
ALLOGRAFT BNE CRUSH 120 CC FRZN IRRADIATED CANC,SUP-2867149,CDM,C1762,CPT,0278,RC,,,,both,,,5369.40,3490.11,,,,,,,,,,,,,
TAP SURG FOR 6.5/7.3MM CANN SCR,SUP-2187432,CDM,C1713,HCPCS,0278,RC,,,,both,,,2171.75,1411.64,,,,,,,,,,,,,
ORA-SWEET PO SYRP,RX-5852,CDM,6370000000,HCPCS,0637,RC,00574-0304-16,NDC,,both,473,ML,78.80,51.22,,,,,,,,,,,,,
PIN BONE FIX L90MM DIA4MM,SUP-2368492,CDM,C1713,HCPCS,0278,RC,,,,both,,,436.96,284.02,,,,,,,,,,,,,
ASSEMBLY SEAL CAP DEXTRUS ENDOPATH,SUP-2219097,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2152.44,1399.09,,,,,,,,,,,,,
SYSTEM BONE HEALING EXT OSTEOGENESIS STIM EBI,SUP-2137326,CDM,E0749,HCPCS,0278,RC,,,,both,,,7065.00,4592.25,,,,,,,,,,,,,
MATRIX HUM TISS L 8 X W 12 CM THK 0.2-1 MM ACELLULAR DERMAL,SUP-2909333,CDM,Q4122,HCPCS,0636,RC,,,,both,,,23228.18,15098.32,,,,,,,,,,,,,
ANCHOR SUTURE SLIDING 2-0 SHT 2.9 MM 1.5 MM BLK JUGGERKNOT,SUP-2745525,CDM,C1776,CPT,0278,RC,,,,both,,,10205.00,6633.25,,,,,,,,,,,,,
TISSUE GRFT 13CMX22CM 8 LAYR TISS W/ PERFORATIONS SURGISIS,SUP-2169661,CDM,C1781,HCPCS,0278,RC,,,,both,,,3579.60,2326.74,,,,,,,,,,,,,
CONNECTOR VENT DRNGE OD1.8MM ID1.2MM S STL 3 W T SHP,SUP-2243838,CDM,2720000010,LOCAL,0272,RC,,,,both,,,695.89,452.33,,,,,,,,,,,,,
SCREW BNE FEM FOR REV KNEE SYS VANGUARD,SUP-2407545,CDM,C1713,HCPCS,0278,RC,,,,both,,,210.22,136.64,,,,,,,,,,,,,
ANCHOR SUT STR FOR SFT TISS MENIS REP SYS ULT FAST-FIX,SUP-2341773,CDM,C1713,HCPCS,0278,RC,,,,both,,,973.40,632.71,,,,,,,,,,,,,
IMMUNE GLOBULIN (OCTAGAM) 10%,RX-4081765,CDM,J1568,HCPCS,0636,RC,68982-0850-05,NDC,,both,300,ML,17191.20,11174.28,,,,,,,,,,,,,
SUTURE ANCHR BIORAPTOR 2.9 SUT ANCHR W/ 2 ULTRABRAID NO 2,SUP-2341672,CDM,C1713,HCPCS,0278,RC,,,,both,,,847.42,550.82,,,,,,,,,,,,,
IMPLANT BRST 620 645CC P65CM W154XH13CM NACL STYL 363LF,SUP-2113316,CDM,C1789,HCPCS,0278,RC,,,,both,,,2276.50,1479.72,,,,,,,,,,,,,
TUNNELER SURG DIA6MM BULL TIP KELLY-WICK,SUP-2128314,CDM,2720000010,LOCAL,0272,RC,,,,both,,,143.40,93.21,,,,,,,,,,,,,
KIT INTRO ARW THMS DIA 9 FR GUIDEWIRE 0.035 IN POLYUR PERC,SUP-2383288,CDM,C1894,HCPCS,0272,RC,,,,both,,,104.88,68.17,,,,,,,,,,,,,
PROSTHESIS NSL 7X2MM SEPT PERF RND 2 PC MAGNETICALLY COUPLED,SUP-2242443,CDM,C1713,HCPCS,0278,RC,,,,both,,,1036.20,673.53,,,,,,,,,,,,,
ENDCAP ORTH 5MM EXTN TI ALLY CANN T40 STARDRV RECESS G FOR,SUP-2179789,CDM,C1713,HCPCS,0278,RC,,,,both,,,789.96,513.47,,,,,,,,,,,,,
BRACE Q LG,SUP-2174971,CDM,L1820,HCPCS,0272,RC,,,,both,,,188.24,122.36,,,,,,,,,,,,,
PUMP PENILE PROS W/ INHIBIZONE AMS 700,SUP-2138970,CDM,C1813,HCPCS,0278,RC,,,,both,,,13652.72,8874.27,,,,,,,,,,,,,
STEM FEM REV 14X245 MM MONOBLOC ALTEON,SUP-2432431,CDM,C1776,CPT,0278,RC,,,,both,,,19035.78,12373.26,,,,,,,,,,,,,
FRACTURE ADAPTER SZ 6-9 TALL,SUP-2815878,CDM,C1776,CPT,0278,RC,,,,both,,,7112.10,4622.86,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH RENU L 127 MM PROX/DSTL L 80/47,SUP-2750814,CDM,C1874,HCPCS,0278,RC,,,,both,,,21000.32,13650.21,,,,,,,,,,,,,
KIT SHTH DESTINO L 87 CM L 67 CM DIA10 FR CRV BEND 50 MM,SUP-2616179,CDM,C1766,CPT,0272,RC,,,,both,,,2182.30,1418.49,,,,,,,,,,,,,
PLATE BNE CRV MINI 2-2.5X1 MM 2X6 HOLE LCK LADDER GRID TI,SUP-2468022,CDM,C1713,HCPCS,0278,RC,,,,both,,,1671.45,1086.44,,,,,,,,,,,,,
PLATE BNE L 75 MM SCREW DIA2.4 MM 12 SHFT H TI ADPT MINI,SUP-2907587,CDM,C1713,HCPCS,0278,RC,,,,both,,,3069.51,1995.18,,,,,,,,,,,,,
SCREW BONE LOCKING 4.5X120 MM CORTICAL TIBIAL FEMUR SELFTAPP,SUP-2837315,CDM,C1713,HCPCS,0278,RC,,,,both,,,1559.45,1013.64,,,,,,,,,,,,,
HC Holter Monitor,PX-7319322500,CDM,93225,CPT,0731,RC,,,,both,,,903.00,586.95,,,,,,,,,,,,,
PLATE BNE MESH PANEL 1X25X15X0.2 MM SCRN TI NS LEVEL 1,SUP-2464618,CDM,C1713,HCPCS,0278,RC,,,,both,,,528.65,343.62,,,,,,,,,,,,,
PLATE BNE PREBENT LG 2.6X2/2.3 MM TI MAG,SUP-2755237,CDM,C1713,HCPCS,0278,RC,,,,both,,,5071.10,3296.21,,,,,,,,,,,,,
DEFIBRILLATOR CRD 40 J 74X51X13 MM 36.3 CC 83 GM COBALT XT,SUP-2601071,CDM,C1882,HCPCS,0275,RC,,,,both,,,43646.00,28369.90,,,,,,,,,,,,,
PLATE BNE 135DEG 12 H SUPCNDYL S STL COMPR FREE LOK,SUP-2197730,CDM,C1713,HCPCS,0278,RC,,,,both,,,2009.60,1306.24,,,,,,,,,,,,,
BLOCK CUT SZ 3 TIB L MED CT APPRCH NONSTERILE MYKNEE,SUP-2267758,CDM,2720000010,LOCAL,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
CATHETER ANGIOPLSTY RIVAL L 135 CM BALLOON L 4 CM DIA 4 MM,SUP-2128430,CDM,C1725,HCPCS,0272,RC,,,,both,,,464.72,302.07,,,,,,,,,,,,,
MICROCATHETER INFUSION SUPERCROSS 120 DEG L 150 CM OD,SUP-2383138,CDM,C1887,HCPCS,0272,RC,,,,both,,,1601.40,1040.91,,,,,,,,,,,,,
PULLER PLUG DIA6MM DISP FOR ULTSONIC REV SYS ULT DRV 3,SUP-2408561,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1345.02,874.26,,,,,,,,,,,,,
CATHETER EP MED CRV 2-5-2 MM 5 FRX110 CM,SUP-2102175,CDM,C1730,HCPCS,0272,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
BOLT BNE FIX L185MM DIA65MM PROX L10MM DST L24MM MIDFOOT,SUP-2400776,CDM,C1713,HCPCS,0278,RC,,,,both,,,5212.40,3388.06,,,,,,,,,,,,,
SNARE VASC 1 SNR L 200 CM LOOP DIA 4 MM CATH L 175 CM,SUP-2702000,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1852.60,1204.19,,,,,,,,,,,,,
SCREW BNE L 95 MM DIA 4.5 MM ST LCK STRL EVOS,SUP-2931253,CDM,C1713,HCPCS,0278,RC,,,,both,,,958.49,623.02,,,,,,,,,,,,,
SUPPORT ORTHOT THOR LUMBAR SACR CUST TRIPLANAR CTRL LNR,SUP-2435547,CDM,L0488,HCPCS,0272,RC,,,,both,,,2842.01,1847.31,,,,,,,,,,,,,
CATHETER HD LT 10 FRX52 CM 22-25 CM ART CUF SET TROCAR TESIO,SUP-2627150,CDM,C1750,HCPCS,0278,RC,,,,both,,,945.14,614.34,,,,,,,,,,,,,
STYLET SURG VIPER PRIM,SUP-2255668,CDM,2720000010,LOCAL,0272,RC,,,,both,,,973.40,632.71,,,,,,,,,,,,,
CATHETER CV DL 7 FRX30 CM N TUNNELED BASIC KT,SUP-2120591,CDM,C1751,HCPCS,0278,RC,,,,both,,,96.71,62.86,,,,,,,,,,,,,
SCREW BNE CANC UNIV 4X36 MM ST PART THRD ULS,SUP-2459904,CDM,C1713,HCPCS,0278,RC,,,,both,,,74.54,48.45,,,,,,,,,,,,,
BUR SURG CYL 3X11.3 MM 10 CM BRL SM BOR MIDAS REX 8 LEGEND,SUP-2664508,CDM,2720000010,LOCAL,0272,RC,,,,both,,,473.01,307.46,,,,,,,,,,,,,
PLATE BNE L109MM 14 H L FIBULAR TIM LOK COMPR ANAT FOR,SUP-2413688,CDM,C1713,HCPCS,0278,RC,,,,both,,,2505.72,1628.72,,,,,,,,,,,,,
SHEATH INTRO HALO 1 L 25 CM DIA 4 FR DIL L 32.5 CM GUIDEWIRE,SUP-2877983,CDM,C1894,HCPCS,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
DURVALUMAB 500 MG/10ML IV SOLN,RX-138611,CDM,J9173,HCPCS,0636,RC,00310-4611-50,NDC,,both,10,ML,12368.70,8039.65,,,,,,,,,,,,,
PLATE BNE ANGLED 2.5 MM RT 7X23 HOLE RECON MAXILLA PT SPEC,SUP-2860095,CDM,C1713,HCPCS,0278,RC,,,,both,,,26250.71,17062.96,,,,,,,,,,,,,
CATHETER GUID GUIDER XF SFTIP 40 DEG L 90 CM DIA 6 FR DSTL,SUP-2367813,CDM,C1887,HCPCS,0272,RC,,,,both,,,924.42,600.87,,,,,,,,,,,,,
GRAFT TISS FRZ DRY ALLGRFT STRUT CORT TRAD 100X20MM,SUP-2294114,CDM,C1713,HCPCS,0278,RC,,,,both,,,1441.26,936.82,,,,,,,,,,,,,
CANNULA SUCTION MONOPOLAR 3 MMX20 CM COAG INSUL,SUP-2767731,CDM,2720000010,LOCAL,0272,RC,,,,both,,,930.13,604.58,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9 % IV BOLUS NEONATE,RX-40840079,CDM,J7040,HCPCS,0258,RC,00264-7800-10,NDC,,both,500,ML,29.80,19.37,,,,,,,,,,,,,
TUBE TRACHEOSTOMY REGULAR ADULT 0.6MM SILVER FENESTRATED UNC,SUP-2793415,CDM,2720000010,LOCAL,0272,RC,,,,both,,,188.87,122.77,,,,,,,,,,,,,
GRAFT BIO TISS MESH 8X6 CM MIROMATRIX MIROMESH,SUP-2305882,CDM,C1781,HCPCS,0278,RC,,,,both,,,4355.81,2831.28,,,,,,,,,,,,,
TUBE VENT 1.14 MM 4 MM 1.8 MM RAZRBAC TI BLU STRL,SUP-2477044,CDM,L8699,HCPCS,0278,RC,,,,both,,,77.09,50.11,,,,,,,,,,,,,
KIT XLINK W/ XVS MARKERS,SUP-2739163,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
LEVEL NEURO ST MESH SPCLTY PTTSBRGH SMCRCLE NEURO SCRW54 X 3,SUP-2707411,CDM,C1713,HCPCS,0278,RC,,,,both,,,1632.20,1060.93,,,,,,,,,,,,,
BUTTON FIX L14MM RND TWO PC FOR ACL RECON TIGHTROPE ABS,SUP-2121394,CDM,C1713,HCPCS,0278,RC,,,,both,,,671.96,436.77,,,,,,,,,,,,,
PLATE PROX TIB 3.5MM 12H RT STRL,SUP-2547552,CDM,C1713,HCPCS,0278,RC,,,,both,,,4391.07,2854.20,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9 % IV BOLUS NEONATE,RX-40840079,CDM,2580000003,HCPCS,0258,RC,00264-1800-32,NDC,,both,100,ML,23.00,14.95,,,,,,,,,,,,,
KNIFE SURG MIKAEEL 10 SCKL STR MOD,SUP-2469981,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1121.73,729.12,,,,,,,,,,,,,
KIT TKR TRABECULAR MTL FEM TIB STD SURF AND VIT E PAT,SUP-2212232,CDM,C1776,CPT,0278,RC,,,,both,,,19154.00,12450.10,,,,,,,,,,,,,
WEDGE ACF FIB TRAD ALLGRFT 6 MM FRZ DRY,SUP-2294092,CDM,C1713,HCPCS,0278,RC,,,,both,,,1482.08,963.35,,,,,,,,,,,,,
PLATE BNE W5XL23MM THK1MM 4 H S STL STR FOR 2MM SCR,SUP-2186148,CDM,C1713,HCPCS,0278,RC,,,,both,,,769.87,500.42,,,,,,,,,,,,,
TEMPORARY CNDLR IMPLNT RGHT 2.7MM LOK SSTM CP TTNM ST,SUP-2500417,CDM,C1889,HCPCS,0278,RC,,,,both,,,3972.32,2582.01,,,,,,,,,,,,,
CANNULA ENDOSCP SLT,SUP-2477717,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1141.20,741.78,,,,,,,,,,,,,
COVER BURR H DIA17 MM THK 0.5 MM PROF THK 0.6 MM SCREW DIA1,SUP-2883894,CDM,C1713,HCPCS,0278,RC,,,,both,,,719.06,467.39,,,,,,,,,,,,,
PLATE BNE 1.8MM THICKNESS TI 18 H LADDER STRNL,SUP-2262578,CDM,C1713,HCPCS,0278,RC,,,,both,,,2140.54,1391.35,,,,,,,,,,,,,
HC Multiple Sleep Latency or Maintenance Wakefulness Test,PX-9209580500,CDM,95805,CPT,0920,RC,,,,both,,,6931.00,4505.15,,,,,,,,,,,,,
ROD SPNL 4.75X50 MM PERC CCM CD HORZ SOLERA,SUP-2278963,CDM,C1713,HCPCS,0278,RC,,,,both,,,1044.05,678.63,,,,,,,,,,,,,
VALVE SHUNT CTRL FLO BUTTON PRESSURE LOW-LOW,SUP-2628267,CDM,C1889,HCPCS,0278,RC,,,,both,,,2690.35,1748.73,,,,,,,,,,,,,
DEFIBRILLATOR IMPL CLARIA MRI QUAD CRT-D SURESCAN W 51 X H,SUP-2282411,CDM,C1882,HCPCS,0275,RC,,,,both,,,52080.04,33852.03,,,,,,,,,,,,,
GRAFT BNE PTTY 10 CC DBM BEAST +,SUP-2742047,CDM,C1713,HCPCS,0278,RC,,,,both,,,7080.70,4602.45,,,,,,,,,,,,,
PLATE BNE L247MM 8 H ST L PROX FEM S STL LO PROF LOK COMPR,SUP-2186044,CDM,C1713,HCPCS,0278,RC,,,,both,,,4462.13,2900.38,,,,,,,,,,,,,
CLIP ANEUR W8XL7.5MM CO CHROM ALLOY FEN L TYP L SHP M BLDE,SUP-2306022,CDM,C1889,HCPCS,0278,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
STEM RADIAL 2 ELBW EXT RECON RHEAD,SUP-2463697,CDM,C1776,CPT,0278,RC,,,,both,,,4631.50,3010.47,,,,,,,,,,,,,
FENTANYL CITRATE (PF) 250 MCG/5ML IJ SOLN,RX-133094,CDM,J3010,HCPCS,0636,RC,00409-9094-25,NDC,,both,0.5,ML,54.10,35.16,,,,,,,,,,,,,
HEAD HUM DIA45MM THK21MM SHLDR CO CHROM PRI STD OFFSET NK 53504521] STRYKER ORTHOPEDICS HOWM],SUP-2372838,CDM,C1776,CPT,0278,RC,,,,both,,,4467.91,2904.14,,,,,,,,,,,,,
TECHNETIUM TC 99M EXAMETAZIME-WBC IV SOLN,RX-4082704,CDM,A9569,HCPCS,0343,RC,17156-0022-05,NDC,,both,1,UN,4265.40,2772.51,,,,,,,,,,,,,
ENDCAP ORTH 5 MM EBA 1,SUP-2719864,CDM,C1889,HCPCS,0278,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
PLATE 3.5MM TI LCP TM PROX HUMERUS LONG 6H SHAFT 160MM STER,SUP-2549716,CDM,C1713,HCPCS,0278,RC,,,,both,,,5464.04,3551.63,,,,,,,,,,,,,
FEMUR POR MET HD WO SCR D,SUP-2212574,CDM,C1776,CPT,0278,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
CONNECTOR SPNL PARL 10 MM TOP LOADING/CLOSED MARINER OUTRIG,SUP-2709832,CDM,C1713,HCPCS,0278,RC,,,,both,,,9420.00,6123.00,,,,,,,,,,,,,
ANCHOR SUT ORTHOCORD 4-0 DRL BIT OD1.3MM NDL C-1 TAPERPOINT,SUP-2256601,CDM,C1713,HCPCS,0278,RC,,,,both,,,1896.56,1232.76,,,,,,,,,,,,,
SYSTEM DEL ENDOSCP US W/ 22GA FNF PRELD NDL BEAC,SUP-2173692,CDM,A4648,CPT,0278,RC,,,,both,,,2059.84,1338.90,,,,,,,,,,,,,
SCREW SPNL L45MM DIA4.75MM SUPLMNT CANC TI MULTAXL ST TOP,SUP-2137265,CDM,C1713,HCPCS,0278,RC,,,,both,,,3067.91,1994.14,,,,,,,,,,,,,
PLATE BONE STR MIDFACE 2X34 H MALL LO PROF 2 STRP NONSTERILE,SUP-2363723,CDM,C1713,HCPCS,0278,RC,,,,both,,,2753.59,1789.83,,,,,,,,,,,,,
KIT VERSACOSS ACCESS  LARGE,SUP-2740412,CDM,C1769,HCPCS,0272,RC,,,,both,,,3265.60,2122.64,,,,,,,,,,,,,
PROSTHESIS OSS BRACKMAN MOD 0.8X8 MM 3 MM TRIM WIRE TORP,SUP-2638109,CDM,L8613,CPT,0278,RC,,,,both,,,791.12,514.23,,,,,,,,,,,,,
BLADE CVD 4.5MM INCIS + ELITE PLAT,SUP-2349223,CDM,C1713,HCPCS,0278,RC,,,,both,,,460.54,299.35,,,,,,,,,,,,,
IMPLANT SPINE 26X10X7MM 5 DEG PLIF CALIX PC STRL,SUP-2401479,CDM,C1889,HCPCS,0278,RC,,,,both,,,7536.00,4898.40,,,,,,,,,,,,,
PLATE BNE W8XL68MM THK2MM 0DEG 8 H BILAT S STL STR RIG DYN,SUP-2186180,CDM,C1713,HCPCS,0278,RC,,,,both,,,769.68,500.29,,,,,,,,,,,,,
RELOAD STPL 0.21MM L45MM 2MM 0.75MM CLSR UNIV GRY TI,SUP-2283057,CDM,2720000010,LOCAL,0272,RC,,,,both,,,964.55,626.96,,,,,,,,,,,,,
BIT DRL 1.7 MM MEMOFIX,SUP-2244267,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1249.47,812.16,,,,,,,,,,,,,
MANIFOLD KYPHOPLASTY NDL 10GA 8GM CEM DEL ASST UNIV,SUP-2361480,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1543.31,1003.15,,,,,,,,,,,,,
PLATE NEURO T 6L 4V TTNM ALLOY ULTRA LOW PRFLE BOX STYLE WT,SUP-2677364,CDM,C1713,HCPCS,0278,RC,,,,both,,,778.91,506.29,,,,,,,,,,,,,
HC Med Nut Therapy Ind Fu 15 Min,PX-9429780300,CDM,97803,CPT,0942,RC,,,,inpatient,,,42.00,27.30,,,,,,,,,,,,,
PIOGLITAZONE HCL 15 MG PO TABS,RX-25528,CDM,6370000000,HCPCS,0637,RC,33342-0054-10,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
STENT URET STR 0.038 IN 3 CM 5 FRX24 CM 6 FR POLARIS ULTRA,SUP-2458928,CDM,C2617,HCPCS,0278,RC,,,,both,,,494.64,321.52,,,,,,,,,,,,,
PLATE BONE 72MM 5 H MALL 3.5 LO PROF AVOID BEND,SUP-2321042,CDM,C1713,HCPCS,0278,RC,,,,both,,,3677.25,2390.21,,,,,,,,,,,,,
BUR SURG EGG 2.5 MM FOR RESURF TOOL F1,SUP-2423978,CDM,2720000010,LOCAL,0272,RC,,,,both,,,325.43,211.53,,,,,,,,,,,,,
HC Indwelling Catheter,PX-4505170200,CDM,51702,CPT,0450,RC,,,,outpatient,,,204.00,132.60,,,,,,,,,,,,,
KIT MICROINTRODUCER COAX STD NIT TUNGSTEN 0.018IN GWIRE,SUP-2118826,CDM,C1769,HCPCS,0272,RC,,,,both,,,75.36,48.98,,,,,,,,,,,,,
PIN FIX L22.9MM OD2.8MM 316L S STL 5 TRCR PNT PLN SMOOTH,SUP-2409659,CDM,C1713,HCPCS,0278,RC,,,,both,,,25.53,16.59,,,,,,,,,,,,,
ANTLAT DIST TIB PLATE XXL 31-HOLE LT,SUP-2829294,CDM,C1713,HCPCS,0278,RC,,,,both,,,5887.50,3826.87,,,,,,,,,,,,,
PLATE BNE RECON 2.7 MM MAND 21 HOLE LT ANGLED TI LEVEL 1,SUP-2478642,CDM,C1713,HCPCS,0278,RC,,,,both,,,3243.43,2108.23,,,,,,,,,,,,,
INSERT TIB SZ 2 THK16MM UNIV POST STBL CONG NEUT ANAT MOD,SUP-2252461,CDM,C1776,CPT,0278,RC,,,,both,,,4502.76,2926.79,,,,,,,,,,,,,
CATHETER INTVASC LITHO BALLOON L 40 MM DIA 4 MM PERIPH DIL,SUP-2417261,CDM,C1725,HCPCS,0272,RC,,,,both,,,8635.00,5612.75,,,,,,,,,,,,,
FOOTRING EXT FIX LNG 210 MM ALUM HOFFMANN,SUP-2472797,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5174.72,3363.57,,,,,,,,,,,,,
ANCHOR 4.75MM HEALIX ADVANCE KNOTLESS BR,SUP-2184947,CDM,C1713,HCPCS,0278,RC,,,,both,,,415.86,270.31,,,,,,,,,,,,,
SYSTEM SHLDR RVS TOT S1 BIOMET,SUP-2137606,CDM,C1776,CPT,0278,RC,,,,both,,,9420.00,6123.00,,,,,,,,,,,,,
GRAFT VASC INTERGARD L 70 CM DIA 7 MM THK 0.49 MM POLYESTER,SUP-2459343,CDM,C1768,CPT,0278,RC,,,,both,,,1785.12,1160.33,,,,,,,,,,,,,
CATHETER PRESSURE MEAS ENDOFLIP L 8 CM GI NSL TIP INTEGR,SUP-2749619,CDM,C1726,HCPCS,0272,RC,,,,both,,,1450.05,942.53,,,,,,,,,,,,,
ASSEMBLY ADPT 36MM HUM HD UNIVERS REVERS,SUP-2123334,CDM,C1776,CPT,0278,RC,,,,both,,,6751.00,4388.15,,,,,,,,,,,,,
PLATE BNE 6 H L HINDFOOT IMPL ADVANSYS TTC,SUP-2243041,CDM,C1713,HCPCS,0278,RC,,,,both,,,6491.92,4219.75,,,,,,,,,,,,,
SHEATH INTRO PERFRMR L 30 CM DIA10 FR GUIDEWIRE 0.038 IN,SUP-2168377,CDM,C1894,HCPCS,0272,RC,,,,both,,,101.36,65.88,,,,,,,,,,,,,
BUPIVACAINE HCL 0.5 % IJ SOLN (MIXTURES ONLY),RX-430038,CDM,J0665,HCPCS,0636,RC,00409-1162-01,NDC,,both,30,ML,54.10,35.16,,,,,,,,,,,,,
LEVALBUTEROL HCL 0.63 MG/3ML IN NEBU,RX-24915,CDM,J7614,HCPCS,0636,RC,00115-9931-78,NDC,,both,3,ML,5.40,3.51,,,,,,,,,,,,,
KIT IMPL DIA1.1MM CMC S STL REP MINI TIGHTROPE,SUP-2122813,CDM,C1713,HCPCS,0278,RC,,,,both,,,2810.30,1826.69,,,,,,,,,,,,,
PLATE BNE L18MM THK0.4MM 5 H CRANIOMAXILLOFACIAL BILAT BLU,SUP-2181560,CDM,C1713,HCPCS,0278,RC,,,,both,,,772.44,502.09,,,,,,,,,,,,,
MESH HERN W10XL12CM THK1.1MM 6MM GRID POLYPR OVINE,SUP-2383093,CDM,C1781,HCPCS,0278,RC,,,,both,,,6782.40,4408.56,,,,,,,,,,,,,
BLADE RETRACTOR 22 CMX29 MM VES WIDE,SUP-2659976,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2311.54,1502.50,,,,,,,,,,,,,
RETRIEVER THROMCTMY L 130 CM DIA 0.044 IN DSTL ACCS STRL,SUP-2365842,CDM,C1887,HCPCS,0272,RC,,,,both,,,3300.77,2145.50,,,,,,,,,,,,,
HC So Newborn Screen (Pku),PX-3018403066,CDM,84030,CPT,0301,RC,,,,both,,,564.00,366.60,,,,,,,,,,,,,
STAPLE BNE FIX 18X18 MM KEEL LCK NIT SUPERELASTIC TRIMAX,SUP-2866447,CDM,C1713,HCPCS,0278,RC,,,,both,,,6280.00,4082.00,,,,,,,,,,,,,
GRAFT BNE CRUSH 30 CC CANC,SUP-2165605,CDM,C1713,HCPCS,0278,RC,,,,both,,,1127.26,732.72,,,,,,,,,,,,,
HC Applicaton on-Body Injector,PX-7619637700,CDM,96377,CPT,0761,RC,,,,outpatient,,,111.00,72.15,,,,,,,,,,,,,
RETRACTOR SURG ORTH PROTECTOR SM SM 14 CM 2.5-8 CM FLX STRL,SUP-2864521,CDM,2720000010,LOCAL,0272,RC,,,,both,,,533.80,346.97,,,,,,,,,,,,,
ANCHOR SUT DIA5.5MM 2 ZIP 2 STRND PEEK FORC FBR,SUP-2366667,CDM,C1713,HCPCS,0278,RC,,,,both,,,734.76,477.59,,,,,,,,,,,,,
SETS W/ ECHOGENIC TIP NDL ANGIODYNAMICS 4.0F MIC ACC SET,SUP-2116526,CDM,C1894,HCPCS,0272,RC,,,,both,,,86.35,56.13,,,,,,,,,,,,,
CATHETER GUID PTFE S STL BRAIDING SHP INT MAMM .098IN VASC,SUP-2158066,CDM,C1887,HCPCS,0272,RC,,,,both,,,55.74,36.23,,,,,,,,,,,,,
SYSTEM VLV SHUNT ADJ DIFF PRSS 0-20CM H2O W/O GRAVITATIONAL,SUP-2108724,CDM,C1729,HCPCS,0272,RC,,,,both,,,10263.09,6671.01,,,,,,,,,,,,,
GRAFT HUM TISS M W60MMXL10CM FRZ DRY,SUP-2307105,CDM,C1762,CPT,0278,RC,,,,both,,,1958.42,1272.97,,,,,,,,,,,,,
REFL ACET FLEX DR W/TRKL END,SUP-2822561,CDM,C1776,CPT,0278,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
SET INT FIX BURR H PLATE DIA18.5 MM SCREW DIA1.5 MM,SUP-2935209,CDM,C1713,HCPCS,0278,RC,,,,both,,,40804.30,26522.79,,,,,,,,,,,,,
PLATE BNE TI LT LAPIDUS 2 MODE COMPR FOR HALLUX VALGUS NS,SUP-2896849,CDM,C1713,HCPCS,0278,RC,,,,both,,,4706.86,3059.46,,,,,,,,,,,,,
PORT ENDO W/ INFL BLB 50MM OMNIPRT,SUP-2383992,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1381.60,898.04,,,,,,,,,,,,,
HC Gbl Office/OP Consltj New/Est Pt Low Mdm 30 Minutes|RESIDENT/TEACHING PHYS SERV,PX-9829924301,CDM,99243,CPT,0982,RC,,,GC,outpatient,,,565.00,367.25,,,,,,,,,,,,,
CATHETER EP CS,SUP-2256927,CDM,C1730,HCPCS,0272,RC,,,,both,,,1208.90,785.78,,,,,,,,,,,,,
SUPPORT ORTHOT HIP JT LOWER EXTREMITY PELV CTRL HVY DTY,SUP-2435684,CDM,L2620,HCPCS,0272,RC,,,,both,,,707.79,460.06,,,,,,,,,,,,,
BUR SURG 9 MM RND FLUT STRL LTX,SUP-2862507,CDM,2720000010,LOCAL,0272,RC,,,,both,,,534.52,347.44,,,,,,,,,,,,,
HC Drug Screen Quantitative Phenytoin Total,PX-3018018500,CDM,80185,CPT,0301,RC,,,,both,,,319.00,207.35,,,,,,,,,,,,,
BASEPLATE GLEN AUG REVERSED 8 DEG SM RT POST SHLDR EQUINOXE,SUP-2451448,CDM,C1713,HCPCS,0278,RC,,,,both,,,5809.00,3775.85,,,,,,,,,,,,,
BUR H 26MM SELF-CLOSING,SUP-2137635,CDM,C1713,HCPCS,0278,RC,,,,both,,,1224.60,795.99,,,,,,,,,,,,,
PLATE 3.5MM TI LCP TM PROX TIBIA PLATE 8H 133MM RIGHT-STER,SUP-2549546,CDM,C1713,HCPCS,0278,RC,,,,both,,,3506.06,2278.94,,,,,,,,,,,,,
HC So Hcv Ultraquant,PX-3068752266,CDM,87522,CPT,0306,RC,,,,both,,,186.00,120.90,,,,,,,,,,,,,
CATHETER HD DL 14.5X23 CM 40 CM ADMIN FULL KT MAHRK MAXID,SUP-2283919,CDM,C1750,HCPCS,0278,RC,,,,both,,,576.50,374.72,,,,,,,,,,,,,
STENT ENDOPROS L10CM DIA8MM CATH 8FR L120CM 0.035IN VES,SUP-2396537,CDM,C1874,HCPCS,0278,RC,,,,both,,,8744.90,5684.18,,,,,,,,,,,,,
SCREW INTFR L20MM OD9MM UNIV TI KNEE CANN FULL THRD TAPR,SUP-2137211,CDM,C1713,HCPCS,0278,RC,,,,both,,,844.03,548.62,,,,,,,,,,,,,
CEMENT BONE 40GM HI VISC PALACOS R,SUP-2239056,CDM,C1713,HCPCS,0278,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
INSERT TIB REPL HD N-K II,SUP-2449214,CDM,C1776,CPT,0278,RC,,,,both,,,904.32,587.81,,,,,,,,,,,,,
HC Removal Aortic Assist Device,PX-7613396800,CDM,33968,CPT,0761,RC,,,,both,,,5920.00,3848.00,,,,,,,,,,,,,
GRAFT VASC 8X30 MM AORT ARCH SINGLE BRANCH WOVEN,SUP-2472450,CDM,C1768,CPT,0278,RC,,,,both,,,5177.86,3365.61,,,,,,,,,,,,,
WASHER FOR SCREW 14/7MM STERILE,SUP-2761697,CDM,C1713,HCPCS,0278,RC,,,,both,,,204.04,132.63,,,,,,,,,,,,,
CATHETER GUID AD L120CM BAL L15CM DIA4FR 0.038IN POLYUR,SUP-2141102,CDM,C1887,HCPCS,0272,RC,,,,both,,,194.68,126.54,,,,,,,,,,,,,
GRAFT VASC 6MMX70CM THN WALL STRTCH PROPATEN,SUP-2395811,CDM,C1768,CPT,0278,RC,,,,both,,,7196.88,4677.97,,,,,,,,,,,,,
IMPLANT FNGR JT SZ 2 FLEXSPAN FLX SWNSN,SUP-2397894,CDM,C1776,CPT,0278,RC,,,,both,,,2800.88,1820.57,,,,,,,,,,,,,
AUGMENT TIB SZ 5 THK10MM R MED L LAT KNEE CO CHROM REV,SUP-2373570,CDM,C1713,HCPCS,0278,RC,,,,both,,,1840.32,1196.21,,,,,,,,,,,,,
SUBSTITUTE BNE GRFT CORT STRUT FEM FRZ DRY,SUP-2264711,CDM,C1713,HCPCS,0278,RC,,,,both,,,2436.70,1583.85,,,,,,,,,,,,,
BAR SPNL STR TIP 5.5X200 MM HEX TEXT COCR,SUP-2707929,CDM,C1713,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
HC OP Traction Intermittent,PX-4209701200,CDM,97012,CPT,0420,RC,,,,inpatient,,,292.00,189.80,,,,,,,,,,,,,
SCREW IM NAIL L 70 MM DIA 4.5 MM TI LP STRL TRIGEN,SUP-2933850,CDM,C1713,HCPCS,0278,RC,,,,both,,,696.89,452.98,,,,,,,,,,,,,
BLADE RTRCTR BLFR 3 12ND LTRL BLADE SLIDE FNSTRTD,SUP-2672903,CDM,2720000010,LOCAL,0272,RC,,,,both,,,361.48,234.96,,,,,,,,,,,,,
HC Drug Screen Quantitative Gentamicin,PX-3018017000,CDM,80170,CPT,0301,RC,,,,outpatient,,,147.00,95.55,,,,,,,,,,,,,
PLATE BONE L177MM 14 H STRL S STL COMPR FOR 3.5MM SCR EVOS,SUP-2349641,CDM,C1713,HCPCS,0278,RC,,,,both,,,2552.38,1659.05,,,,,,,,,,,,,
BUTTON CBL 2.5MM TI HEX DRV FOR NCB POLYAX LOK PLT SYS,SUP-2413015,CDM,C1713,HCPCS,0278,RC,,,,both,,,496.78,322.91,,,,,,,,,,,,,
BLADE RTRCTR RVL 60MMW X 70MML TTNM LMBR 15DG ANGLD TTHD ULT,SUP-2477388,CDM,2720000010,LOCAL,0272,RC,,,,both,,,557.66,362.48,,,,,,,,,,,,,
BAXTER BEVELED BOBBIN VT 1.27MM FLPL,SUP-2500853,CDM,L8699,HCPCS,0278,RC,,,,both,,,33.28,21.63,,,,,,,,,,,,,
STEM ULN L3CM DIA6MM DSTL RAD EXT,SUP-2119918,CDM,C1776,CPT,0278,RC,,,,both,,,7432.38,4831.05,,,,,,,,,,,,,
PLATE BONE CURVED 3.5X70 MM 6 HOLE RECONSTRUCTION FOR SCREW,SUP-2836668,CDM,C1713,HCPCS,0278,RC,,,,both,,,3167.63,2058.96,,,,,,,,,,,,,
SUPPORT ORTHOPEDIC WRST LG LT,SUP-2246904,CDM,L3908,HCPCS,0272,RC,,,,both,,,21.98,14.29,,,,,,,,,,,,,
SET TB INTRO 8-14FR W/ 15CM PEEL AWAY SHTH NDL GWIRE 3 DIL,SUP-2168912,CDM,C1894,HCPCS,0272,RC,,,,both,,,336.77,218.90,,,,,,,,,,,,,
DRILL SURG RESECT 3.5 MM TIB ARC TOT ANK REPL SYS SS APEX 3D,SUP-2742292,CDM,2720000010,LOCAL,0272,RC,,,,both,,,632.71,411.26,,,,,,,,,,,,,
PLUG ACET SCR H CONTINUUM,SUP-2203895,CDM,C1776,CPT,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
PIN DRL SM SH DISP FOR 4.5/8.5MM BEAMING SYS,SUP-2223921,CDM,2720000010,LOCAL,0272,RC,,,,both,,,263.76,171.44,,,,,,,,,,,,,
PLATE BONE W10XL53MM THK1.5MM 3X3 H NEUT BILAT S STL T SHP,SUP-2185883,CDM,C1713,HCPCS,0278,RC,,,,both,,,841.27,546.83,,,,,,,,,,,,,
PROCESSER HEARING AID RT MOCCA BRN FOR PONTO + PWR SYS,SUP-2319908,CDM,L8691,HCPCS,0274,RC,,,,both,,,14114.30,9174.29,,,,,,,,,,,,,
SCREW BONE L70MM DIA6.5MM THRD L16MM TI CANN,SUP-2403466,CDM,C1713,HCPCS,0278,RC,,,,both,,,907.77,590.05,,,,,,,,,,,,,
STENT PERIPH ZILVER 518 L 20 MM DIA10 MM DEL SYS L 125 CM,SUP-2170480,CDM,C1876,HCPCS,0278,RC,,,,both,,,2868.39,1864.45,,,,,,,,,,,,,
GRAFT BNE 12MM WDG,SUP-2244475,CDM,C1713,HCPCS,0278,RC,,,,both,,,6006.73,3904.37,,,,,,,,,,,,,
SUPPORT ANK TRICOT 7.75-8.5 IN SM VLY PROCARE DLX,SUP-2195733,CDM,L4350,HCPCS,0272,RC,,,,both,,,33.54,21.80,,,,,,,,,,,,,
GUIDEWIRE VASC COON L 80 CM DIA 0.035 IN TAPR L 15 CM TIP,SUP-2168716,CDM,C1769,HCPCS,0272,RC,,,,both,,,101.99,66.29,,,,,,,,,,,,,
PROCESSOR HEARING AID CHROMA BGE LT EAR SND PROC CHAN WIND,SUP-2319859,CDM,L8690,HCPCS,0278,RC,,,,both,,,13345.00,8674.25,,,,,,,,,,,,,
ALLOGRAFT BNE FRZN ASEP RT RAD SHFT,SUP-2867045,CDM,C1762,CPT,0278,RC,,,,both,,,2386.40,1551.16,,,,,,,,,,,,,
PLATE BNE THK 0.6 MM ADV 3 MM SCREW DIA2 MM 4 H MINI CHIN,SUP-2883148,CDM,C1713,HCPCS,0278,RC,,,,both,,,1208.33,785.41,,,,,,,,,,,,,
GUIDEWIRE ENDO L80CM 20DEG SINUS RELIEVA VIGOR,SUP-2106357,CDM,C1769,HCPCS,0272,RC,,,,both,,,486.70,316.35,,,,,,,,,,,,,
SAMPLER SET BRONCHSCP REG 85 DEG CLOSED LOOP GRN ASCOPE 4,SUP-2752994,CDM,2720000010,LOCAL,0272,RC,,,,both,,,841.52,546.99,,,,,,,,,,,,,
PLATE POSTLAT DSTL HUM 3.5MM 14H RT 208MM LCP STRL,SUP-2547576,CDM,C1713,HCPCS,0278,RC,,,,both,,,3433.53,2231.79,,,,,,,,,,,,,
IMPL SYS MPFL BIO-COMP WITHOUT INSTRUM,SUP-2812285,CDM,C1713,HCPCS,0278,RC,,,,both,,,3218.50,2092.02,,,,,,,,,,,,,
LOCKING END CAP,SUP-2811090,CDM,C1889,HCPCS,0278,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
"HC Tolerance Test, Addit.",PX-3018295200,CDM,82952,CPT,0301,RC,,,,inpatient,,,72.00,46.80,,,,,,,,,,,,,
PLATE SPNL POST 18 MM,SUP-2430749,CDM,C1713,HCPCS,0278,RC,,,,both,,,13596.20,8837.53,,,,,,,,,,,,,
KIT CATH URTRL BLLN DLTN 8MM X15CM NPHRO EZDLTE,SUP-2727216,CDM,C1758,HCPCS,0278,RC,,,,both,,,700.22,455.14,,,,,,,,,,,,,
FOLLOWER URETH 10FR L34CM POLYMER DISP PHIL,SUP-2384622,CDM,C1726,HCPCS,0272,RC,,,,both,,,43.24,28.11,,,,,,,,,,,,,
PLUG IMPL BRAIN STIM L 17.1 MM SHFT L 12.8 MM DIA 1.3 MM CON,SUP-2889675,CDM,C1787,HCPCS,0278,RC,,,,both,,,900.08,585.05,,,,,,,,,,,,,
HANDPIECE FIX WASHER ASMBLY FACETGUN DISP,SUP-2175706,CDM,C1713,HCPCS,0278,RC,,,,both,,,6123.00,3979.95,,,,,,,,,,,,,
PROSTHESIS OSS VENT TUBE 1.52X0.060 MM W/TAB SHEA PARASOL,SUP-2312830,CDM,L8699,HCPCS,0278,RC,,,,both,,,258.30,167.89,,,,,,,,,,,,,
FONDAPARINUX SODIUM 7.5 MG/0.6ML SC SOLN,RX-104344,CDM,J1652,HCPCS,0636,RC,67457-0584-06,NDC,,both,0.6,ML,336.40,218.66,,,,,,,,,,,,,
LINER ACET PROV A 10 DEG 28 MM G7,SUP-2440257,CDM,C1776,CPT,0278,RC,,,,both,,,324.99,211.24,,,,,,,,,,,,,
COIL NEUROVASCULAR MICRUSPHERE XL 18 L 27 CM DIA 9 MM,SUP-2249294,CDM,C1889,HCPCS,0278,RC,,,,both,,,4858.05,3157.73,,,,,,,,,,,,,
SHEET THERMOPLASTIC W18XL24IN THK0.09IN STD CHAR SLD SPLNT,SUP-2323989,CDM,L4350,HCPCS,0274,RC,,,,both,,,156.97,102.03,,,,,,,,,,,,,
CATHETER HD PRE CRV 14 FRX20 CM DL 400 XL FULL TY,SUP-2266967,CDM,C1750,HCPCS,0278,RC,,,,both,,,287.62,186.95,,,,,,,,,,,,,
SCREW SPNL L30MM OD5.5MM TI CORT PEDCL NONCANNULATED TOP LD,SUP-2288109,CDM,C1713,HCPCS,0278,RC,,,,both,,,5181.00,3367.65,,,,,,,,,,,,,
FILLER DERMAL JUVEDERM VOLLURE XC 1ML,SUP-2901641,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1180.64,767.42,,,,,,,,,,,,,
EASYFUSE STAPLE 25X25 NITINOL 2-LEG,SUP-2830238,CDM,C1713,HCPCS,0278,RC,,,,both,,,5714.80,3714.62,,,,,,,,,,,,,
KIT SCREW GLENOID FIXATION REVERSE TORQUE DEFINING,SUP-2512469,CDM,C1776,CPT,0278,RC,,,,both,,,5581.66,3628.08,,,,,,,,,,,,,
CATHETER PD COILED AD 62 CM 7 CM 16.5 CM CLASSIC LG 2 CUF,SUP-2477228,CDM,C1750,HCPCS,0278,RC,,,,both,,,546.36,355.13,,,,,,,,,,,,,
SHEATH LD INTRO SAFSHTH ULTRA L 13 CM DIA 8 FR GUIDEWIRE L,SUP-2159475,CDM,C1894,HCPCS,0272,RC,,,,both,,,873.08,567.50,,,,,,,,,,,,,
KIT CATH PICC ERGOPACK MAX BARRIER SAFETY 5FR 55CM 2-LUMEN,SUP-2887020,CDM,C1751,HCPCS,0278,RC,,,,both,,,556.41,361.67,,,,,,,,,,,,,
PLATE BNE STR 6 HOLE COMPR NS LTX,SUP-2855839,CDM,C1713,HCPCS,0278,RC,,,,both,,,555.78,361.26,,,,,,,,,,,,,
CEMENT FLX FM/CEM TB/PRLG SURF/TM PT/TP PL,SUP-2212174,CDM,C1776,CPT,0278,RC,,,,both,,,17169.46,11160.15,,,,,,,,,,,,,
COMPONENT PAT OD38MM RESURF OVL IMP GEN II,SUP-2349041,CDM,C1776,CPT,0278,RC,,,,both,,,1858.35,1207.93,,,,,,,,,,,,,
BAND INT FIX WIDE 4 MM,SUP-2734577,CDM,C1713,HCPCS,0278,RC,,,,both,,,1271.95,826.77,,,,,,,,,,,,,
PLATE BNE L385MM 16 H NONSTERILE PROX FEM S STL HK LO PROF,SUP-2186066,CDM,C1713,HCPCS,0278,RC,,,,both,,,5221.35,3393.88,,,,,,,,,,,,,
PLATE BNE L31MM 4 H S STL 1/4 TBLR CLLRD FOR 2.7MM SCR,SUP-2411321,CDM,C1713,HCPCS,0278,RC,,,,both,,,206.99,134.54,,,,,,,,,,,,,
PROBE ENDOSCP ULTRASOUND W/ BLLN SHTH,SUP-2467078,CDM,2720000010,LOCAL,0272,RC,,,,both,,,560.80,364.52,,,,,,,,,,,,,
PIN FXTN STNMNN 332MM DIA 9INL THRDD TRCR POINT,SUP-2723589,CDM,C1713,HCPCS,0278,RC,,,,both,,,58.37,37.94,,,,,,,,,,,,,
MICROCATHETER INFUSION APOLLO ONYX TOT L 165 CM OD,SUP-2459734,CDM,C1887,HCPCS,0272,RC,,,,both,,,6242.32,4057.51,,,,,,,,,,,,,
CLAMP SURG DBL SHT OCPTL PROTEX CT,SUP-2584537,CDM,C1713,HCPCS,0278,RC,,,,both,,,496.12,322.48,,,,,,,,,,,,,
VALVE CSF PERF LEVEL 1 SM EXTRACTED DELT,SUP-2628541,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4967.54,3228.90,,,,,,,,,,,,,
SHELL ACET SZ D DIA50MM MH OSSEOTI 2 MOBILITY G7,SUP-2403476,CDM,C1776,CPT,0278,RC,,,,both,,,7950.48,5167.81,,,,,,,,,,,,,
CATHETER PERITONEAL L 34.25 CM CURL TO CUF 3 CM PED CURL,SUP-2905031,CDM,C1750,HCPCS,0278,RC,,,,both,,,363.05,235.98,,,,,,,,,,,,,
SCREW BNE NLCK 3X14 MM DBL STRT THRD SS JPS,SUP-2645433,CDM,C1713,HCPCS,0278,RC,,,,both,,,216.66,140.83,,,,,,,,,,,,,
STEM FEM L150MM DIA11MM RESECT LEV 34MM HD NK HIP CO CHROM,SUP-2405033,CDM,C1776,CPT,0278,RC,,,,both,,,14067.20,9143.68,,,,,,,,,,,,,
AZITHROMYCIN 500 MG IN NS 250 ML (PREMIX) IVPB,RX-4082448,CDM,J0456,HCPCS,0636,RC,99999-9917-51,NDC,,both,250,ML,54.10,35.16,,,,,,,,,,,,,
BLADE RETRACTOR MALL UNIV 4X10 IN ABD RNG W/ LIP,SUP-2472282,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1725.24,1121.41,,,,,,,,,,,,,
SCREW BONE L25MM OD9MM CORT,SUP-2166544,CDM,C1713,HCPCS,0278,RC,,,,both,,,430.75,279.99,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA PLU MAXBARR 4FR S1274108D4,SUP-2632802,CDM,C1751,HCPCS,0278,RC,,,,both,,,821.90,534.23,,,,,,,,,,,,,
PLATE BONE 1.5MM 4 H W/ BAR STR UNIV NEURO III,SUP-2363628,CDM,C1713,HCPCS,0278,RC,,,,both,,,434.80,282.62,,,,,,,,,,,,,
CUBE EXT FIX UNIV 1 HOLE SALVATION,SUP-2465040,CDM,2720000010,LOCAL,0272,RC,,,,both,,,788.14,512.29,,,,,,,,,,,,,
HC N Block Paravert Lumbar 1st,PX-3606449300,CDM,64493,CPT,0360,RC,,,,both,,,4864.00,3161.60,,,,,,,,,,,,,
GRAFT VASC VENAFLO II L 40 CM DIA 6 MM EPTFE CARBON,SUP-2761415,CDM,C1768,CPT,0278,RC,,,,both,,,2939.20,1910.48,,,,,,,,,,,,,
BUR SURG RND 2 MM EXT CARBIDE STRL LTX,SUP-2859492,CDM,2720000010,LOCAL,0272,RC,,,,both,,,702.67,456.74,,,,,,,,,,,,,
SHEARS SEAL L45CM DIA5MM CRV BLDE W ERGO GRP HNDL HARM ACE,SUP-2257349,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1700.15,1105.10,,,,,,,,,,,,,
BREXUCABTAGENE AUTOLEUCEL 200000000 CELLS IV SUSP,RX-151536,CDM,Q2053,HCPCS,0891,RC,71287-0219-01,NDC,,both,1,UN,3234000.00,2102100.00,,,,,,,,,,,,,
CATHETER ANGIO AD L130CM DIA5FR 0.038IN NONBRAIDED PGTL W/O(MIN ORDER 2 BX),SUP-2116597,CDM,C1887,HCPCS,0272,RC,,,,both,,,432.06,280.84,,,,,,,,,,,,,
BIT DRL 3.5 MM,SUP-2319111,CDM,2720000010,LOCAL,0272,RC,,,,both,,,715.92,465.35,,,,,,,,,,,,,
CATHETER GUID CS-EH STR RT 2.21X2.7 MMX63 CM EASYTRAK,SUP-2149015,CDM,C1887,HCPCS,0272,RC,,,,both,,,926.30,602.09,,,,,,,,,,,,,
STEM HUM L150 MM SM LATITUDE EV RT,SUP-2396773,CDM,C1776,CPT,0278,RC,,,,both,,,29535.31,19197.95,,,,,,,,,,,,,
EXTERNAL FIXATION SET HYBRID LIGHTWEIGHT PVC FREE STRL,SUP-2646341,CDM,C1713,HCPCS,0278,RC,,,,both,,,9071.02,5896.16,,,,,,,,,,,,,
NEEDLE EP003994S BRCKNBRGH AD,SUP-2282432,CDM,2720000010,LOCAL,0272,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
BASKET RETRV L1950MM DIA22MM MIN WRK CHN 28MM SFT BULL SHP,SUP-2313133,CDM,C1713,HCPCS,0278,RC,,,,both,,,1177.53,765.39,,,,,,,,,,,,,
HC So Vitamin A,PX-3018459066,CDM,84590,CPT,0301,RC,,,,outpatient,,,354.00,230.10,,,,,,,,,,,,,
GRAFT ENDOVASC L14CM AORT IL DIA28.5X14.5MM TRUNK,SUP-2396085,CDM,C1768,CPT,0278,RC,,,,both,,,32169.30,20910.04,,,,,,,,,,,,,
PLATE BNE CP TITATNIUM LT ANTEROLATERAL ANK FUSION STRL,SUP-2902276,CDM,C1713,HCPCS,0278,RC,,,,both,,,11021.40,7163.91,,,,,,,,,,,,,
SCREW BNE L 12 MM DIA2 MM MANDIBULAR ST NS AXS,SUP-2909500,CDM,C1713,HCPCS,0278,RC,,,,both,,,284.55,184.96,,,,,,,,,,,,,
PLATE BONE 7 H 7 PEG STD RT VOLAR S STL BEAR,SUP-2389759,CDM,C1713,HCPCS,0278,RC,,,,both,,,266.90,173.48,,,,,,,,,,,,,
STEM FEM L167MM OD19MM BOW TI ALLY PLSM SPRAYED HA DST HIP,SUP-2375657,CDM,C1776,CPT,0278,RC,,,,both,,,8764.37,5696.84,,,,,,,,,,,,,
PROTECTOR NERVE L 2 X W 2 CM PORCINE SODIUM HYALURONATE,SUP-2890377,CDM,C1763,HCPCS,0278,RC,,,,both,,,8380.66,5447.43,,,,,,,,,,,,,
BUNDLE CASE MICROTIA ADD TEMP VSP,SUP-2862838,CDM,2720000010,LOCAL,0272,RC,,,,both,,,12924.24,8400.76,,,,,,,,,,,,,
CATHETER HD DL 13.5 FRX70 CM 51 CM ADMIN BASIC KT HICKMAN,SUP-2126593,CDM,C1751,HCPCS,0278,RC,,,,both,,,1186.92,771.50,,,,,,,,,,,,,
INSERT SURG W3MM OP L10MM THK0.35MM MICROSAW MT1S-10 FOR,SUP-2327783,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
TIGHTROPE II RT RECON IB,SUP-2718075,CDM,C1713,HCPCS,0278,RC,,,,both,,,1774.10,1153.16,,,,,,,,,,,,,
BOLT EXT FIX LNG CONN MR CONDITIONAL FOR DISTR OSTEOGENESIS,SUP-2179134,CDM,C1713,HCPCS,0278,RC,,,,both,,,35.54,23.10,,,,,,,,,,,,,
GRAFT EVAR L150MM DIA36X36MM PROX DST FREE FLO STR CLS WEB,SUP-2298537,CDM,C1768,CPT,0278,RC,,,,both,,,58074.30,37748.29,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 30 CM DIA 6 MM EPTFE STR TW REINF 2,SUP-2669629,CDM,C1768,CPT,0278,RC,,,,both,,,609.13,395.93,,,,,,,,,,,,,
PLATE BNE L 1.5X0.8 MM 10 MM MIDFACE 2X2 HOLE W/ TAB TI NS,SUP-2494977,CDM,C1713,HCPCS,0278,RC,,,,both,,,919.39,597.60,,,,,,,,,,,,,
INTRODUCER THERMOABLATION STARBURST XL L 11 CM HRD COAX ACCS,SUP-2117218,CDM,C1894,HCPCS,0272,RC,,,,both,,,326.56,212.26,,,,,,,,,,,,,
PLATE BNE L50MM 3X3 H T SHP FOR 3.5MM SCR,SUP-2411361,CDM,C1713,HCPCS,0278,RC,,,,both,,,320.85,208.55,,,,,,,,,,,,,
GRAFT VASC IMPRA L 90 CM DIA 6 MM EPTFE FLX STD WALL RING,SUP-2126890,CDM,C1768,CPT,0278,RC,,,,both,,,2567.30,1668.74,,,,,,,,,,,,,
PLATE BONE W38XL53MM THK0.4MM 5X5MM SPC 8X11 H TI BILAT CRAN,SUP-2190618,CDM,C1713,HCPCS,0278,RC,,,,both,,,4453.78,2894.96,,,,,,,,,,,,,
CATHETER EXT WRK CHAN 45 EDGE,SUP-2381746,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1526.86,992.46,,,,,,,,,,,,,
DRESSING WOUND SURGICAL MATRIX THICK 10X20 CM MATRISTEM,SUP-2106499,CDM,Q4166,HCPCS,0636,RC,,,,both,,,16814.70,10929.55,,,,,,,,,,,,,
GRAFT BNE SUB W1.75XL5CM POSTEROLATERAL MAGNIFUSE,SUP-2293962,CDM,C1713,HCPCS,0278,RC,,,,both,,,8203.25,5332.11,,,,,,,,,,,,,
IMPLANT FUS TI PLSM SPR COAT IFUSE 7MM X 45MM,SUP-2337778,CDM,C1713,HCPCS,0278,RC,,,,both,,,9420.00,6123.00,,,,,,,,,,,,,
GUIDEWIRE VASC SENTAI SAMURAI RC L 190 CM SPRING COIL L 24,SUP-2140871,CDM,C1769,HCPCS,0272,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
CATHETER DRAINAGE SINGLE PIG 6 FRX250 CM TUBE NIT FLEXIMA,SUP-2480145,CDM,C1729,HCPCS,0272,RC,,,,both,,,333.12,216.53,,,,,,,,,,,,,
CONE XSMALL/SMALL 37X30X28.5 MM KNEE 2 ZONE TI TRABECULINK,SUP-2636330,CDM,C1776,CPT,0278,RC,,,,both,,,16437.37,10684.29,,,,,,,,,,,,,
D-RAD VOLAR PLATE 10H RIGHT STANDARD TI,SUP-2818922,CDM,C1713,HCPCS,0278,RC,,,,both,,,13690.87,8899.07,,,,,,,,,,,,,
HC Insert Bladder Catheter Non-Indwelling,PX-4505170100,CDM,51701,CPT,0450,RC,,,,inpatient,,,204.00,132.60,,,,,,,,,,,,,
PLATE BNE L142MM 6 H R ANTEROMEDIAL DST TIB S STL VAR ANG,SUP-2177658,CDM,C1713,HCPCS,0278,RC,,,,both,,,5571.77,3621.65,,,,,,,,,,,,,
DEVICE ABLATN ENDOMET,SUP-2239886,CDM,C1886,HCPCS,0278,RC,,,,both,,,12246.00,7959.90,,,,,,,,,,,,,
CABLE ELECTROTHERAPY LD 1X16 IN,SUP-2141962,CDM,2720000010,LOCAL,0272,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
VALVE SHUNT SYSTEM WITH DIFFERENTIAL PRESSURE UNIT 0CM AND D,SUP-2821804,CDM,C1889,HCPCS,0278,RC,,,,both,,,12471.73,8106.62,,,,,,,,,,,,,
CATHETER CV MAXIMAL BARR TY 8 FRX20 CM DL J TIP SPECTRUM,SUP-2759877,CDM,C1751,HCPCS,0278,RC,,,,both,,,467.86,304.11,,,,,,,,,,,,,
PROBE SURG OSTIUM 1.25 MM BALL TIP 1 END 90 DEG 8.25 IN SS,SUP-2483575,CDM,2720000010,LOCAL,0272,RC,,,,both,,,440.57,286.37,,,,,,,,,,,,,
ALLOGRAFT BNE 5 CC DEMINERALIZED BNE MTRX FIBER ALLOFIBER,SUP-2759529,CDM,C1713,HCPCS,0278,RC,,,,both,,,4735.12,3077.83,,,,,,,,,,,,,
SHEATH GUID 7FR L45CM HYDRPHLC COAT L35CM S STL COIL STR,SUP-2385456,CDM,C1894,HCPCS,0272,RC,,,,both,,,347.82,226.08,,,,,,,,,,,,,
CATHETER PTCA L130CM BLLN L220MM DIA5MM SHTH 5FR GWIRE,SUP-2128365,CDM,C2623,HCPCS,0278,RC,,,,both,,,8007.00,5204.55,,,,,,,,,,,,,
HC MRI Breast W Cont Bilateral,PX-6107704901,CDM,77049,CPT,0610,RC,,,,both,,,5019.00,3262.35,,,,,,,,,,,,,
SCREW BNE 5.5X45 MM FOR ROD TI,SUP-2256218,CDM,C1713,HCPCS,0278,RC,,,,both,,,1045.62,679.65,,,,,,,,,,,,,
GUIDEWIRE VASC L150CM DIA0.038IN TAPR 3CM HYDRPHLC NIT ANG,SUP-2148169,CDM,C1769,HCPCS,0272,RC,,,,both,,,86.63,56.31,,,,,,,,,,,,,
PLATE BONE LOK CMPRSSN HLX9 TIMAX CRTCL WIDE PRE CNTRD ANTMC,SUP-2588754,CDM,C1713,HCPCS,0278,RC,,,,both,,,3889.68,2528.29,,,,,,,,,,,,,
CANNULA SUCTION COAG 5 MMX20 CM INSUL,SUP-2772869,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2329.88,1514.42,,,,,,,,,,,,,
SCREW IM L 50 MM DIA 5 MM LAG STRL TRIGEN MAX,SUP-2931466,CDM,C1713,HCPCS,0278,RC,,,,both,,,1488.36,967.43,,,,,,,,,,,,,
BUR SHAVER HI VISIBILITY SHTH LG 4X180 MM FLAT TOP,SUP-2848631,CDM,2720000010,LOCAL,0272,RC,,,,both,,,285.74,185.73,,,,,,,,,,,,,
BUR SHV L13CM DIA3.6MM 12000RPM LNG CVD HI SPD CANN FOR,SUP-2277866,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1081.01,702.66,,,,,,,,,,,,,
SCREW CANCELLOUS FULLY THREADED 45MMX40MM LENGTH NCB,SUP-2497247,CDM,C1713,HCPCS,0278,RC,,,,both,,,372.59,242.18,,,,,,,,,,,,,
SIGMOIDOSCOPE FLX RECT DISP,SUP-2800976,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1314.09,854.16,,,,,,,,,,,,,
HC CT Soft Tissue Neck W/WO Contrast,PX-3517049200,CDM,70492,CPT,0351,RC,,,,inpatient,,,2388.00,1552.20,,,,,,,,,,,,,
INTRODUCER TUBE SET 28 FR PERC SET CIAGLIA BLU RHINO,SUP-2760021,CDM,C1769,HCPCS,0272,RC,,,,both,,,938.80,610.22,,,,,,,,,,,,,
KIT TLIF DISP TUF HOOP MAXCESS MAS,SUP-2310437,CDM,C1713,HCPCS,0278,RC,,,,both,,,8044.68,5229.04,,,,,,,,,,,,,
GUIDEWIRE VASC L 175 CM DIA16 FR MIC TAPR,SUP-2141066,CDM,C1769,HCPCS,0272,RC,,,,both,,,659.40,428.61,,,,,,,,,,,,,
HC NM Pulmonary Perfusion & Vent,PX-3417858200,CDM,78582,CPT,0341,RC,,,,both,,,5075.00,3298.75,,,,,,,,,,,,,
AGBA PI PICC KIT: 1L 4.5FR 40CM,SUP-2822086,CDM,C1751,HCPCS,0278,RC,,,,both,,,614.44,399.39,,,,,,,,,,,,,
KIT HAD AD 16FR L23CM GWIRE L70CM 0.038 ADMIN CATH DBL LUMN,SUP-2127836,CDM,C1750,HCPCS,0278,RC,,,,both,,,1486.95,966.52,,,,,,,,,,,,,
DEVICE RETRV L175CM OD2MM INTCRAN MICRO-MOVEMENT PRECIS,SUP-2280933,CDM,C1773,HCPCS,0272,RC,,,,both,,,10126.50,6582.22,,,,,,,,,,,,,
WAND ABLAT SABER STR,SUP-2341973,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1284.26,834.77,,,,,,,,,,,,,
GUIDEWIRE HYBRID .012/.014 DOUBLE ANGLE,SUP-2854079,CDM,C1769,HCPCS,0272,RC,,,,both,,,1444.40,938.86,,,,,,,,,,,,,
NAIL IM L280MM DIA9MM GRN FEM TI CANN LOK RG BEND RND FOR,SUP-2180058,CDM,C1713,HCPCS,0278,RC,,,,both,,,4791.80,3114.67,,,,,,,,,,,,,
CLAMP ROD 5.5-5.5MM SGL,SUP-2230103,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1036.20,673.53,,,,,,,,,,,,,
NAIL IM L260MM DIA9.5MM 120DEG ST BLU L/R HUM TI CANN LOK,SUP-2192516,CDM,C1713,HCPCS,0278,RC,,,,both,,,5231.74,3400.63,,,,,,,,,,,,,
IMPLANT TOTAL OSSCLR UNVRSL NTCHD 35MM DIA 10MM SHAFT 80M,SUP-2680128,CDM,L8613,CPT,0278,RC,,,,both,,,1360.81,884.53,,,,,,,,,,,,,
BATTERY VENT ASST L PT WAIST PK,SUP-2282573,CDM,Q0498,HCPCS,0274,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
BODY FEM MOD SPOUT UNIV PROX STD OFFSET REV TI 16.6MM 35MM,SUP-2204252,CDM,C1776,CPT,0278,RC,,,,both,,,12470.51,8105.83,,,,,,,,,,,,,
RETRIEVER GWIRE TIP 8MM CATH L100CM OD5.9FR ANGIO QUIK CRSS,SUP-2353172,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
COMPONENT TOT SHLDR CAPPED BIOMET8000] ZIMMER BIOMET INC],SUP-2137329,CDM,C1776,CPT,0278,RC,,,,both,,,25120.00,16328.00,,,,,,,,,,,,,
FORCEP ELECSURG BPLR 1.2 MM 19 CM IRRIGATING SILVERGLIDE,SUP-2859625,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3740.62,2431.40,,,,,,,,,,,,,
CATHETER ANGIOPLSTY POLARCATH L 135 CM BALLOON L 20 MM DIA 6,SUP-2141992,CDM,C1725,HCPCS,0272,RC,,,,both,,,2797.74,1818.53,,,,,,,,,,,,,
HC So T Cell Absolute,PX-3028636066,CDM,86360,CPT,0302,RC,,,,outpatient,,,253.00,164.45,,,,,,,,,,,,,
DVR VOLAR RIM L ST,SUP-2474808,CDM,C1713,HCPCS,0278,RC,,,,both,,,2728.66,1773.63,,,,,,,,,,,,,
PLATE BNE BAR 1.8 MM 4 H SHRT RT MIDFACE L SHP MALL MINI NS,SUP-2883151,CDM,C1713,HCPCS,0278,RC,,,,both,,,1452.25,943.96,,,,,,,,,,,,,
CATHETER THROMCTMY LIGHTNING BOLT INDIGO 7 L 130 CM ASPIR,SUP-2874863,CDM,C1757,HCPCS,0272,RC,,,,both,,,25182.80,16368.82,,,,,,,,,,,,,
SCREW BNE INTRF 7X25 MM FT COMPOSITCP 30,SUP-2608575,CDM,C1713,HCPCS,0278,RC,,,,both,,,1244.95,809.22,,,,,,,,,,,,,
BIT DRILL 1.5 QCURVE 85/60,SUP-2819035,CDM,2720000010,LOCAL,0272,RC,,,,both,,,816.27,530.58,,,,,,,,,,,,,
KIT ELBOW BEARING ORTHOPAEDIC ULNAR XSMALL DISCOVERY,SUP-2879197,CDM,C1776,CPT,0278,RC,,,,both,,,7912.80,5143.32,,,,,,,,,,,,,
MORPHINE SULFATE 1 MG/ML IJ SOLN,RX-5167,CDM,J2270,HCPCS,0636,RC,69374-0979-02,NDC,,both,2,ML,54.10,35.16,,,,,,,,,,,,,
TUBE ENDOSCP 50 CM LEN 19.5 MM OD 16.7 MM ID W/ TAPR TIP,SUP-2391609,CDM,2720000010,LOCAL,0272,RC,,,,both,,,635.19,412.87,,,,,,,,,,,,,
PLATE EXT FIX 120 DEG 180 MM FEM ARCH CARBON FIBER NS,SUP-2800193,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2712.80,1763.32,,,,,,,,,,,,,
STEM FEM L127MM DIA11MM PROX HIP STR CEM W/O POR BODY GMRS,SUP-2376427,CDM,C1776,CPT,0278,RC,,,,both,,,6699.03,4354.37,,,,,,,,,,,,,
STEM FEM MED LNG 54 MM HIP HI RELEASE WEDGED TAPR INTERSPACE,SUP-2424088,CDM,C1776,CPT,0278,RC,,,,both,,,10205.00,6633.25,,,,,,,,,,,,,
IMPLANT PEDALVERB MOD PDS 3000 BANDWIDTH 20HZ TO 12KHZ WT,SUP-2332647,CDM,C1713,HCPCS,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
HC Assay of Erythropoietin,PX-3018266800,CDM,82668,CPT,0301,RC,,,,both,,,384.00,249.60,,,,,,,,,,,,,
ALLOGRAFT BNE LG FRZN IRRADIATED CORTICAL SEG,SUP-2867223,CDM,C1762,CPT,0278,RC,,,,both,,,2657.85,1727.60,,,,,,,,,,,,,
CABLE ORTH L L50MM DIA1MM HIP TI ALLY SURG SMOOTH TROCH,SUP-2193592,CDM,C1713,HCPCS,0278,RC,,,,both,,,7608.53,4945.54,,,,,,,,,,,,,
QUICK RELEASE GLENOID DRILL SHORT 6MM,SUP-2841532,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 15X9 CM SHT AMNION/CHORION AMNIOFIX,SUP-2871497,CDM,C1762,CPT,0278,RC,,,,both,,,32781.60,21308.04,,,,,,,,,,,,,
ELECTRODE THERMOABLATION L 1393 MM TIP L 10 MM DIA19 GA,SUP-2881884,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7065.00,4592.25,,,,,,,,,,,,,
KIT ORTH 2 DRL 3 OLV WIRE DISPNSR SYS STRL DISP APOLLOANKLE,SUP-2894238,CDM,2720000010,LOCAL,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
CATHETER CARD ABLATION NAVISTAR DS L 115 CM 7 FR F CRV ORN,SUP-2248941,CDM,C1732,HCPCS,0272,RC,,,,both,,,7215.72,4690.22,,,,,,,,,,,,,
CATHETER PERI L90CM STD OPN END W/ WALL SLT BA IMPREG,SUP-2284524,CDM,C1729,HCPCS,0272,RC,,,,both,,,402.49,261.62,,,,,,,,,,,,,
PROBE SURG PEDIATRIC FOR 6/7 MM CANN SCR ACUTRK REUSE,SUP-2535348,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1827.48,1187.86,,,,,,,,,,,,,
HC So Acetylcholn Rcptr Bndng Antb,PX-3028604166,CDM,86041,CPT,0302,RC,,,,both,,,207.00,134.55,,,,,,,,,,,,,
WIRE FIX BLNT 1.5X350 MM TSI KIRSCHNER DISP,SUP-2536922,CDM,2720000010,LOCAL,0272,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
PLATE BNE W10XL118MM THK3.6MM 10 H BILAT S STL CRV RIG CLLR,SUP-2186255,CDM,C1713,HCPCS,0278,RC,,,,both,,,2270.28,1475.68,,,,,,,,,,,,,
BASEPLATE TIB AUG CASE UNIVERS REVERS,SUP-2845850,CDM,C1776,CPT,0278,RC,,,,both,,,15307.50,9949.87,,,,,,,,,,,,,
PLATE BONE L202MM THK4.5MM 9 H RT LAT TIB HD BTTRS TI RIG,SUP-2190893,CDM,C1713,HCPCS,0278,RC,,,,both,,,3309.12,2150.93,,,,,,,,,,,,,
HC Pentamidine Treatment,PX-4109464200,CDM,94642,CPT,0410,RC,,,,both,,,322.00,209.30,,,,,,,,,,,,,
BLADE RETRCT SZ 5 L MOUTH GAG RNG DAVIS,SUP-2243545,CDM,C1713,HCPCS,0278,RC,,,,both,,,621.78,404.16,,,,,,,,,,,,,
RESERVOIR VENT CATH L7CM OD3.1MM ID1.5MM 5 H SIL S STL STYL,SUP-2243791,CDM,C1729,HCPCS,0272,RC,,,,both,,,860.36,559.23,,,,,,,,,,,,,
GRAFT VASC GELSFT ERS L 100 CM SUPP L 85 CM DIA 8 MM,SUP-2384973,CDM,C1768,CPT,0278,RC,,,,both,,,2424.83,1576.14,,,,,,,,,,,,,
SPACER SPNL W10XH7XL27MM 6DEG TRANSFORAMINAL INTBDY FUS TI,SUP-2415043,CDM,C1821,HCPCS,0278,RC,,,,both,,,8164.00,5306.60,,,,,,,,,,,,,
KIT OPHTH 5ML PERFLUOROCARBON LIQ PROC PERFLUORON,SUP-2110015,CDM,C1784,HCPCS,0278,RC,,,,both,,,1862.65,1210.72,,,,,,,,,,,,,
PLATE BNE L118MM 6 H ST L DST LAT FIBULAR S STL VAR ANG LOK,SUP-2177724,CDM,C1713,HCPCS,0278,RC,,,,both,,,2788.38,1812.45,,,,,,,,,,,,,
"HC So Encephalitis, California",PX-3028665166,CDM,86651,CPT,0302,RC,,,,both,,,34.00,22.10,,,,,,,,,,,,,
PLATE BONE W7XL47MM THK1MM 6 H S STL QTR TBLR NONCOMPRESSION,SUP-2343852,CDM,C1713,HCPCS,0278,RC,,,,both,,,688.35,447.43,,,,,,,,,,,,,
SCREW SPNL MULTAXL 4X38 MM OCCIPITOCERVICAL UPPER THOR,SUP-2632001,CDM,C1713,HCPCS,0278,RC,,,,both,,,1789.80,1163.37,,,,,,,,,,,,,
PLATE BNE L 129 MM SCREW DIA 4.5 MM 6 H RT PROX LAT TIB NS,SUP-2932772,CDM,C1713,HCPCS,0278,RC,,,,both,,,9368.98,6089.84,,,,,,,,,,,,,
SCREW BNE L9MM OD2.7MM LOK FOR PLT TUFFNEK TECHNOLOGY,SUP-2321095,CDM,C1713,HCPCS,0278,RC,,,,both,,,1248.15,811.30,,,,,,,,,,,,,
GRAFT VASC EXXCEL SFT L 50 CM DIA 7 MM EPTFE STR STD WALL,SUP-2227645,CDM,C1768,CPT,0278,RC,,,,both,,,1386.91,901.49,,,,,,,,,,,,,
CROSSLINK SPNL SM OCCIPITOCERVICAL ROD TO ROD INFIN,SUP-2631936,CDM,C1713,HCPCS,0278,RC,,,,both,,,1938.95,1260.32,,,,,,,,,,,,,
COMPONENT FEM L R TROCHLEAR LCS,SUP-2250099,CDM,C1776,CPT,0278,RC,,,,both,,,9570.72,6220.97,,,,,,,,,,,,,
GUIDEWIRE VASC L 50 CM DIA 0.035 IN CRV RAD 3 MM SS PTFE,SUP-2167828,CDM,C1769,HCPCS,0272,RC,,,,both,,,69.39,45.10,,,,,,,,,,,,,
LEAD NERVE STIM 50 CM 3-6 CONTACT LINEAR,SUP-2458237,CDM,C1778,HCPCS,0278,RC,,,,both,,,5338.00,3469.70,,,,,,,,,,,,,
SET INTRO 16FR PERC W/ GWIRE,SUP-2133598,CDM,C1892,HCPCS,0272,RC,,,,both,,,276.32,179.61,,,,,,,,,,,,,
FOUNDATION CONSTRN PS INSRT SZ 2 11 MM,SUP-2216428,CDM,C1776,CPT,0278,RC,,,,both,,,4125.96,2681.87,,,,,,,,,,,,,
TIP SONOPET IQ STANDARD 20CM,SUP-2755026,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3267.67,2123.99,,,,,,,,,,,,,
PLATE BNE STR 2-2.5X25X1.5 MM 4 HOLE FRAC TI LEVEL 1,SUP-2469689,CDM,C1713,HCPCS,0278,RC,,,,both,,,1337.86,869.61,,,,,,,,,,,,,
GUIDEWIRE VASC L 145 CM DIA 0.035 IN TAPR L 7 CM FLX TIP 2,SUP-2167729,CDM,C1769,HCPCS,0272,RC,,,,both,,,44.46,28.90,,,,,,,,,,,,,
SHEATH INTRO FLX SHUTTLE SL L 90 CM OD 5 FR GUIDEWIRE,SUP-2169825,CDM,C1894,HCPCS,0272,RC,,,,both,,,304.58,197.98,,,,,,,,,,,,,
FIBER LASER 550UM HOLM,SUP-2225720,CDM,2720000010,LOCAL,0272,RC,,,,both,,,555.78,361.26,,,,,,,,,,,,,
ATEZOLIZUMAB 60MG/ML IV SOLN (MIXTURES ONLY),RX-1150518,CDM,J9022,HCPCS,0636,RC,50242-0917-01,NDC,,both,20,ML,33377.40,21695.31,,,,,,,,,,,,,
RESTRICTOR CEM FOR 10/11MM P.F.C.,SUP-2253282,CDM,C1713,HCPCS,0278,RC,,,,both,,,354.82,230.63,,,,,,,,,,,,,
BIT DRL KNOTLESS FOR SUTURE ANCHR ROT CUF REP STRL CROSS FT,SUP-2423297,CDM,2720000010,LOCAL,0272,RC,,,,both,,,731.93,475.75,,,,,,,,,,,,,
COIL VASC I-ED COIL L 20 CM DIA 0.012 IN SECONDARY 6 MM,SUP-2865310,CDM,C1889,HCPCS,0278,RC,,,,both,,,5369.40,3490.11,,,,,,,,,,,,,
IMPLANT BIO TISS W12XL25CM THK0.8MM BOV PERICARD CLLGN MTRX,SUP-2130303,CDM,C9354,HCPCS,0278,RC,,,,both,,,21293.97,13841.08,,,,,,,,,,,,,
IMPLANT DERM W50XH50XL80MM CLLGN RECTANG SHT ALLOMAX,SUP-2125852,CDM,C1781,HCPCS,0278,RC,,,,both,,,3956.40,2571.66,,,,,,,,,,,,,
HC Ot Massage 15 Min,PX-4309712400,CDM,97124,CPT,0430,RC,,,,both,,,194.00,126.10,,,,,,,,,,,,,
THORACENTESIS PRCNTSS SET 6F X 10 CM VLVD STEP SLIP,SUP-2677294,CDM,C1729,HCPCS,0272,RC,,,,both,,,141.30,91.84,,,,,,,,,,,,,
PLATE BNE L239MM 15 H BILAT S STL STR NONCOMPRESSION RECON,SUP-2410186,CDM,C1713,HCPCS,0278,RC,,,,both,,,1521.39,988.90,,,,,,,,,,,,,
IMPLANT BIO TISS W7XL10CM WND MTRX FEN MATRISTEM,SUP-2106523,CDM,Q4166,HCPCS,0636,RC,,,,both,,,827.70,538.00,,,,,,,,,,,,,
CATHETER HD STR 13.5 FRX24 CM DL SHT TERM NIAG,SUP-2126504,CDM,C1752,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
CICLOPIROX OLAMINE 0.77 % EX SUSP,RX-38962,CDM,6370000000,HCPCS,0637,RC,45802-0400-49,NDC,,both,30,ML,270.00,175.50,,,,,,,,,,,,,
CATHETER DRAINAGE 0.038 IN 8 FRX35 CM FIRM 5 HOLE FLEXIMA,SUP-2147836,CDM,C1729,HCPCS,0272,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
GRAFT BNE INJ 6 CC DEMINERALIZED FIBER GRFT,SUP-2574345,CDM,C1776,CPT,0278,RC,,,,both,,,4694.30,3051.29,,,,,,,,,,,,,
GRAFT HUM TISS L 22 X W 22 X H 6/4 MM IL CREST UNICORTICAL,SUP-2913420,CDM,C1762,CPT,0278,RC,,,,both,,,6427.58,4177.93,,,,,,,,,,,,,
BIT DRL L190MM DIA10MM ST TI CANN QUIK CPL W/O STP,SUP-2420744,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1743.39,1133.20,,,,,,,,,,,,,
ALLOGRAFT BNE PLUG 13X18-25 MM FD IRRADIATED,SUP-2866873,CDM,C1762,CPT,0278,RC,,,,both,,,1503.43,977.23,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED CEM STEM XLPE CHIPSNEPHCEMXLPE] SMITH AND NEPHEW ORTHOPAEDICS],SUP-2351334,CDM,C1776,CPT,0278,RC,,,,both,,,11319.70,7357.80,,,,,,,,,,,,,
SUPPORT ORTHOT HEEL HEEL PD,SUP-2435736,CDM,L3480,HCPCS,0272,RC,,,,both,,,176.41,114.67,,,,,,,,,,,,,
CHRONOS(TM) BETA-TCP WEDGE 14 DEG/RECTANGULAR-STERILE,SUP-2550433,CDM,C1713,HCPCS,0278,RC,,,,both,,,1949.09,1266.91,,,,,,,,,,,,,
STEM HUM CMNTLS 6.5X180 MM SHLDR REVERSED AEQUALIS,SUP-2715661,CDM,C1776,CPT,0278,RC,,,,both,,,10121.79,6579.16,,,,,,,,,,,,,
ECHOTIP OPEN-END URETERAL CATHETER,SUP-2826943,CDM,C1758,HCPCS,0278,RC,,,,both,,,63.80,41.47,,,,,,,,,,,,,
BUR SURG DR LNG 7.6X28.6 MM FLUT FOR HD/HD-G1,SUP-2848176,CDM,2720000010,LOCAL,0272,RC,,,,both,,,799.26,519.52,,,,,,,,,,,,,
FILTER VASC GRNFLD L 28 MM DIA12 FR SS VENA CAVA OTW N MRI,SUP-2142721,CDM,C1880,HCPCS,0278,RC,,,,both,,,3764.86,2447.16,,,,,,,,,,,,,
INSERT HUM +12 MM HT STD 36 MM DIAM RVS POLYETH AEQUALIS,SUP-2388642,CDM,C1776,CPT,0278,RC,,,,both,,,2323.60,1510.34,,,,,,,,,,,,,
SET INTRO 12FR L15CM DIA4MM CYSTIC DUCT ACCS PRT INTO PERI,SUP-2168313,CDM,C1894,HCPCS,0272,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
PLATE BNE THK 0.5 MM SCREW DIA1.7 MM PLL POLYGLYCOLIDE POLY,SUP-2883265,CDM,C1713,HCPCS,0278,RC,,,,both,,,11668.99,7584.84,,,,,,,,,,,,,
PIN FIX L229MM OD2.4MM S STL SMOOTH DMND PT SGL END BAYNT,SUP-2304040,CDM,C1713,HCPCS,0278,RC,,,,both,,,16.45,10.69,,,,,,,,,,,,,
CONNECTOR SPNL L12MM DIA45MM LAT TI CDH LEG,SUP-2279260,CDM,C1713,HCPCS,0278,RC,,,,both,,,2945.32,1914.46,,,,,,,,,,,,,
TWIST DRL SURG L 8 CM DIA1.5 MM STP D 12 MM DISECT TOOL STRL,SUP-2930016,CDM,2720000010,LOCAL,0272,RC,,,,both,,,672.71,437.26,,,,,,,,,,,,,
GUIDEWIRE VASC L 145 CM DIA 0.025 IN TAPR L 7 CM FLX TIP L 2,SUP-2167650,CDM,C1769,HCPCS,0272,RC,,,,both,,,36.27,23.58,,,,,,,,,,,,,
SPACER SPNL W32XH15MM D26MM 8DEG ANT LUM INTBDY FUS BLU PEEK,SUP-2182849,CDM,C1821,HCPCS,0278,RC,,,,both,,,20410.00,13266.50,,,,,,,,,,,,,
HC Hospice Room,PX-1150000000,CDM,1150000000,LOCAL,0115,RC,,,,inpatient,,,2441.00,1586.65,,,,,,,,,,,,,
PIN FIX 2X40MM RESRB REUNITE,SUP-2408519,CDM,C1713,HCPCS,0278,RC,,,,both,,,857.22,557.19,,,,,,,,,,,,,
CUP HUM DIA36MM +2MM OFFSET LT SHLDR CAP COAT UNIVERS,SUP-2123336,CDM,C1776,CPT,0278,RC,,,,both,,,4420.27,2873.18,,,,,,,,,,,,,
LACTATED RINGERS IV BOLUS,RX-40840057,CDM,J7120,HCPCS,0258,RC,00338-0117-03,NDC,,both,250,ML,19.20,12.48,,,,,,,,,,,,,
HC So1 Porphyrinsquantitive,PX-3018412067,CDM,84120,CPT,0301,RC,,,,both,,,65.00,42.25,,,,,,,,,,,,,
HEAD HUM 58X27 MM SHLDR TI BIO MOD,SUP-2449914,CDM,C1776,CPT,0278,RC,,,,both,,,3730.32,2424.71,,,,,,,,,,,,,
BURR ENDOSCP SHAVER 70 DEG DIA 4 MM ENT DIAMOND ANGLED,SUP-2900163,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4129.10,2683.91,,,,,,,,,,,,,
CONNECTOR SPNL ROD TO ROD MED 34-44 MM BLACKBIRD,SUP-2564723,CDM,C1713,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
PLATE BNE RECON 4.5X127 MM 8 HOLE STR NC RIGID CLLRD SS,SUP-2410179,CDM,C1713,HCPCS,0278,RC,,,,both,,,1117.75,726.54,,,,,,,,,,,,,
PLATE BNE L41MM SM 3 H GRN TI POST TIB ANK LOK COMPR FOR,SUP-2398411,CDM,C1713,HCPCS,0278,RC,,,,both,,,1309.38,851.10,,,,,,,,,,,,,
HC Uni Niv Arterial Low Ext Duplex,PX-9219392600,CDM,93926,CPT,0921,RC,,,,both,,,1471.00,956.15,,,,,,,,,,,,,
SHEATH INTRO DRYSEAL FLX L 45 CM DIA10 FR BODY DIA 4 MM,SUP-2719567,CDM,C1894,HCPCS,0272,RC,,,,both,,,1601.40,1040.91,,,,,,,,,,,,,
SCREW BNE COUNTSINK 2X2.7 MM,SUP-2435342,CDM,C1713,HCPCS,0278,RC,,,,both,,,913.74,593.93,,,,,,,,,,,,,
STEM FEM PRSS FT 16.25 40 MM OFFSET 34X133 MM HIP PROVIDENT,SUP-2390364,CDM,C1776,CPT,0278,RC,,,,both,,,24649.00,16021.85,,,,,,,,,,,,,
CUP HUM DIA36MM NEUT OFFSET SHLDR CAP UNIVERS REVERS,SUP-2123335,CDM,C1776,CPT,0278,RC,,,,both,,,8007.00,5204.55,,,,,,,,,,,,,
BLADE ENDO L220MM MPLR STEER NAV-X,SUP-2121999,CDM,C1713,HCPCS,0278,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
CATHETER ANGIOPLSTY WORKHORSE II 75 CM 5 FR 4 CM 7 MM,SUP-2117096,CDM,C1725,HCPCS,0272,RC,,,,both,,,477.28,310.23,,,,,,,,,,,,,
SUPPORT ORTHOT CUST FULL SOLE HEEL WDG BTWN SOLE,SUP-2435728,CDM,L3420,HCPCS,0272,RC,,,,both,,,154.83,100.64,,,,,,,,,,,,,
KIT PERICARDCENT NDL L 8 CM DIA18 GA CATH L 40 CM DIA 8.3 FR,SUP-2760071,CDM,C1729,HCPCS,0272,RC,,,,both,,,684.24,444.76,,,,,,,,,,,,,
PIN EXTERNAL FIXATION HALF 5X40 MM TITANIUM NITRIDE NON STER,SUP-2836779,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1629.50,1059.17,,,,,,,,,,,,,
ANCHOR SUT W/ SZ 2 ETHBND SUT CP-2 NDL GII QUICKANCHR +,SUP-2249348,CDM,C1713,HCPCS,0278,RC,,,,both,,,3102.32,2016.51,,,,,,,,,,,,,
BIT DRL DIA4.3MM SHT 2IN1 AO FOR HALLU-LOCK MTP ARTH SYS,SUP-2242910,CDM,2720000010,LOCAL,0272,RC,,,,both,,,805.16,523.35,,,,,,,,,,,,,
STEM HUM REVERSED 11X90 MM SHLDR ADJ AEQUALIS PTC,SUP-2715347,CDM,C1776,CPT,0278,RC,,,,both,,,10836.14,7043.49,,,,,,,,,,,,,
SCREW BNE L25MM DIA6.5MM CANC HIP FOR ACET CUP SYS LINEAGE,SUP-2304371,CDM,C1713,HCPCS,0278,RC,,,,both,,,587.81,382.08,,,,,,,,,,,,,
HC So1 Prothrombin Time|NOT REASONABLE AND NECESSARY,PX-3058561067,CDM,85610,CPT,0305,RC,,,GZ,both,,,7.00,4.55,,,,,,,,,,,,,
BUR SURG MTCH HD 4 MMX16 CM BRN MIS PRECIS,SUP-2365197,CDM,2720000010,LOCAL,0272,RC,,,,both,,,624.77,406.10,,,,,,,,,,,,,
CATHETER ANGIOPLSTY DORADO L 135 CM BALLOON L 15 CM DIA 6 MM,SUP-2126836,CDM,C1725,HCPCS,0272,RC,,,,both,,,769.30,500.04,,,,,,,,,,,,,
DEVICE SPEC REMOVING L 12.6 IN OD 3 MM HYSTEROSCOPIC STRL,SUP-2913647,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2856.96,1857.02,,,,,,,,,,,,,
PASSER CATH L36CM SHT MAL DISP FOR HYDROCEPHALUS SYS,SUP-2243782,CDM,C1894,HCPCS,0272,RC,,,,both,,,377.21,245.19,,,,,,,,,,,,,
CAFFEINE-SODIUM BENZOATE 125-125 MG/ML IJ SOLN,RX-1262,CDM,2500000003,HCPCS,0250,RC,00517-2502-01,NDC,,both,1,ML,112.60,73.19,,,,,,,,,,,,,
CATHETER MIDLINE PI 1-L 4FR X 20CM,SUP-2855516,CDM,C1751,HCPCS,0278,RC,,,,both,,,389.36,253.08,,,,,,,,,,,,,
GRAFT HUM TISS M COVERING WND INVIVO NUCEL,SUP-2314101,CDM,C1713,HCPCS,0278,RC,,,,both,,,4733.68,3076.89,,,,,,,,,,,,,
ENOXAPARIN SODIUM 60 MG/0.6ML IJ SOSY,RX-157662,CDM,J1650,HCPCS,0636,RC,63323-0607-88,NDC,,both,0.6,ML,68.60,44.59,,,,,,,,,,,,,
BRACE STRNL PD KT TLSO BLK SM,SUP-2123926,CDM,L0462,HCPCS,0274,RC,,,,both,,,281.60,183.04,,,,,,,,,,,,,
PROSTHESIS LARYN L8MM DIA20FR PRELD W/ SMRT INSRTR TRNSPAR,SUP-2124374,CDM,L8509,HCPCS,0272,RC,,,,both,,,753.60,489.84,,,,,,,,,,,,,
NAIL IM L38CM DIA10MM 135DEG L TROCHANTERIC LIME TI CANN,SUP-2347220,CDM,C1713,HCPCS,0278,RC,,,,both,,,15152.86,9849.36,,,,,,,,,,,,,
ALLOGRAFT BNE CHIP 0.1-2 MM 5 CC PRESERVON CANC READIGRAFT,SUP-2740887,CDM,C1713,HCPCS,0278,RC,,,,both,,,514.08,334.15,,,,,,,,,,,,,
PIN EXT FIX L85MM OD5MM TI CIR HALF HEX FIX RANCHO,SUP-2342567,CDM,C1713,HCPCS,0278,RC,,,,both,,,1017.30,661.24,,,,,,,,,,,,,
VALVE VENT REG POLYPR SIL PERF LEV 05 ELASTMR LO FLSH RESVR,SUP-2284400,CDM,C1713,HCPCS,0278,RC,,,,both,,,3473.56,2257.81,,,,,,,,,,,,,
STEM FEM L203MM OD38MM LNG CO CHROM HIP PRESSFIT FEN IMP,SUP-2198850,CDM,C1776,CPT,0278,RC,,,,both,,,3592.16,2334.90,,,,,,,,,,,,,
MATRIX BIO L 6 X W 8 CM SZ 86 SQCM FISH SKIN DERMAL MESHED 10/BX,SUP-2909437,CDM,Q4158,HCPCS,0636,RC,,,,both,,,7765.22,5047.39,,,,,,,,,,,,,
HC So 17-Hydroxyprogesterone,PX-3018349866,CDM,83498,CPT,0301,RC,,,,outpatient,,,553.00,359.45,,,,,,,,,,,,,
SPACER FEM DIA25MM UNIV DST HIP CEM OMFIT,SUP-2368408,CDM,C1776,CPT,0278,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
HC Blood Smear Peripheral Interp Phys W/Writ Report,PX-3058506000,CDM,85060,CPT,0305,RC,,,,both,,,61.00,39.65,,,,,,,,,,,,,
HC Closed Red Dislocated Lunate,PX-4502569000,CDM,25690,CPT,0450,RC,,,,both,,,1633.00,1061.45,,,,,,,,,,,,,
CANNULA SURG 48 MM W/ 2 TEETH TRANSBUCCAL,SUP-2463355,CDM,2720000010,LOCAL,0272,RC,,,,both,,,369.89,240.43,,,,,,,,,,,,,
HEAD HUM H18MM OD42MM OFFSET 1.5MM LO CO CHROM SFT TISS,SUP-2388756,CDM,C1776,CPT,0278,RC,,,,both,,,9295.97,6042.38,,,,,,,,,,,,,
PLATE BNE W23XL54MM THK2MM 13 H R DST RAD TI ADAPTIVE FOR,SUP-2267975,CDM,C1713,HCPCS,0278,RC,,,,both,,,2656.44,1726.69,,,,,,,,,,,,,
PROSTHESIS PENILE L 21 CM X W 12 MM PMP INFLATABLE,SUP-2930692,CDM,C1813,HCPCS,0278,RC,,,,both,,,42481.85,27613.20,,,,,,,,,,,,,
CLAMP REPROC PIN CPL ROD FIXATOR 575IN,SUP-2700104,CDM,2720000010,LOCAL,0272,RC,,,,both,,,344.33,223.81,,,,,,,,,,,,,
GRAFT ENDOVASC L3.3CM DIA28.5MM AORT EXT ENDOPROS EXCLUDER,SUP-2395940,CDM,C1768,CPT,0278,RC,,,,both,,,7416.68,4820.84,,,,,,,,,,,,,
PLATE BONE L235MM 13 H NONSTERILE RT MEDL DSTL TIB LCK FOR,SUP-2348489,CDM,C1713,HCPCS,0278,RC,,,,both,,,13310.15,8651.60,,,,,,,,,,,,,
NEURO FLAP FIX KIT 2 HOLE STRAIGHT PLATES SCREWS,SUP-2677534,CDM,C1713,HCPCS,0278,RC,,,,both,,,1018.99,662.34,,,,,,,,,,,,,
LINER ACET SZ 44-48 DIA28MM 5/15DEG MCS GXL,SUP-2221661,CDM,C1776,CPT,0278,RC,,,,both,,,6154.40,4000.36,,,,,,,,,,,,,
GRAFT VASC GORTX L 70 CM DIA 5 MM EPTFE STR TW N RING STRL,SUP-2396688,CDM,C1768,CPT,0278,RC,,,,both,,,2461.76,1600.14,,,,,,,,,,,,,
HC Lumbar Diskography,PX-3207229500,CDM,72295,CPT,0320,RC,,,,outpatient,,,3334.00,2167.10,,,,,,,,,,,,,
HEAD FEM MOD 0+ MM 22 MM HIP MTRX,SUP-2435185,CDM,C1776,CPT,0278,RC,,,,both,,,1814.92,1179.70,,,,,,,,,,,,,
PLATE BNE 2.4X80X2 MM 10 HOLE SS LCP,SUP-2569302,CDM,C1713,HCPCS,0278,RC,,,,both,,,438.66,285.13,,,,,,,,,,,,,
STAPLE BNE FIX W11XH10XL10MM DIA1.5MM NIT FIX LO EXT 2 PRNG,SUP-2190916,CDM,C1713,HCPCS,0278,RC,,,,both,,,1639.08,1065.40,,,,,,,,,,,,,
SCREWDRIVER SURG AO SHFT T2 RECON,SUP-2484859,CDM,C1713,HCPCS,0278,RC,,,,both,,,879.20,571.48,,,,,,,,,,,,,
HARD BONE INTRODUCER COMPATIBLE WITH KBDKBC 1110,SUP-2702553,CDM,2720000010,LOCAL,0272,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
PROSTHESIS OSS SCHEER PISTON SHT 0.6X4.33 MM SLIM SS,SUP-2637783,CDM,L8613,CPT,0278,RC,,,,both,,,317.27,206.23,,,,,,,,,,,,,
BIT DRILL - LG (HAND),SUP-2374050,CDM,2720000010,LOCAL,0272,RC,,,,both,,,596.54,387.75,,,,,,,,,,,,,
IBUPROFEN 200 MG PO TABS,RX-3841,CDM,6370000000,HCPCS,0637,RC,00904-7914-61,NDC,,both,1,UN,0.60,0.39,,,,,,,,,,,,,
RETRACTOR SURG L40MM OPENER CLOSER INSTR EXP MTRX X TUBE,SUP-2293012,CDM,C1713,HCPCS,0278,RC,,,,both,,,2562.77,1665.80,,,,,,,,,,,,,
PLATE SYNDESMOSIS 2 H BUTTRESS NS,SUP-2897149,CDM,C1713,HCPCS,0278,RC,,,,both,,,2351.86,1528.71,,,,,,,,,,,,,
PLATE BONE L113MM 8 H NONSTERILE RT LAT PROX TIB S STL FOR,SUP-2349726,CDM,C1713,HCPCS,0278,RC,,,,both,,,11193.32,7275.66,,,,,,,,,,,,,
PLATE BNE STR 2-2.5X46X1-2 MM 6 HOLE BSSO C LCK FOR 8 MM BRG,SUP-2464459,CDM,C1713,HCPCS,0278,RC,,,,both,,,1897.31,1233.25,,,,,,,,,,,,,
GRAFT TEND BTB HEMI W SHP BNE BLK ALLGRFT FRZ DRY 8 13CM L,SUP-2307049,CDM,C1713,HCPCS,0278,RC,,,,both,,,8485.94,5515.86,,,,,,,,,,,,,
STEM FEM L120MM DIA13MM KNEE CEM TAPR PFC SIG,SUP-2253327,CDM,C1776,CPT,0278,RC,,,,both,,,2317.32,1506.26,,,,,,,,,,,,,
METFORMIN HCL 850 MG PO TABS,RX-14719,CDM,6370000000,HCPCS,0637,RC,60687-0143-11,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PLATE BNE L235MM 10 H NONSTERILE L PERIARTC PROX HUM S STL,SUP-2184284,CDM,C1713,HCPCS,0278,RC,,,,both,,,5458.14,3547.79,,,,,,,,,,,,,
LACTULOSE 20 GM/30ML PO SOLN,RX-103297,CDM,6370000000,HCPCS,0637,RC,00116-4005-30,NDC,,both,30,ML,7.50,4.87,,,,,,,,,,,,,
FOSPHENYTOIN SODIUM 100 MG PE/2ML IJ SOLN,RX-88011,CDM,Q2009,HCPCS,0636,RC,68462-0621-02,NDC,,both,2,ML,54.10,35.16,,,,,,,,,,,,,
BUTTERFLY WASHER 21.7MM TI,SUP-2818363,CDM,C1713,HCPCS,0278,RC,,,,both,,,1824.43,1185.88,,,,,,,,,,,,,
PLATE B1 STP 2 MM SCREW DIA 3/3.5/4 MM TI ALLOY LT FT,SUP-2907618,CDM,C1713,HCPCS,0278,RC,,,,both,,,7523.53,4890.29,,,,,,,,,,,,,
GUIDE PILOT 5-10MM DISP,SUP-2171840,CDM,2720000010,LOCAL,0272,RC,,,,both,,,247.28,160.73,,,,,,,,,,,,,
STRUT EXT FIX XSH UNIV HINGED,SUP-2475657,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4396.00,2857.40,,,,,,,,,,,,,
"HC Gbl Est Pt, E/M Level 5",PX-9829921500,CDM,99215,CPT,0982,RC,,,,both,,,672.00,436.80,,,,,,,,,,,,,
NEEDLE SUTURE L8.25IN SHARP LIGATURE FOR RIGHT HAND HURD,SUP-2802482,CDM,2720000010,LOCAL,0272,RC,,,,both,,,359.12,233.43,,,,,,,,,,,,,
BUR SURG 16.8 MM TREPHINE FOR OTO SPINE,SUP-2607579,CDM,2720000010,LOCAL,0272,RC,,,,both,,,483.18,314.07,,,,,,,,,,,,,
MARKER FIDUCIAL CONCL 1.27 MM FOR IMAGE REG PINPT,SUP-2863141,CDM,A4648,CPT,0278,RC,,,,both,,,9.61,6.25,,,,,,,,,,,,,
COMPONENT CNDYL RT TEMP PROS,SUP-2363872,CDM,C1776,CPT,0278,RC,,,,both,,,3157.71,2052.51,,,,,,,,,,,,,
CATHETER CV DL 5 FR SHERLOCK 3CG TPS STYL BASIC TY POWERPICC,SUP-2759202,CDM,C1751,HCPCS,0278,RC,,,,both,,,1096.27,712.58,,,,,,,,,,,,,
SCREW BNE L16MM DIA35MM HEXADRIVE 15 TRILOK,SUP-2268378,CDM,C1713,HCPCS,0278,RC,,,,both,,,429.65,279.27,,,,,,,,,,,,,
KNOTLESS TENSIONTIGHT BUTTON IMPLANT SYS,SUP-2812569,CDM,C1713,HCPCS,0278,RC,,,,both,,,2747.50,1785.87,,,,,,,,,,,,,
COLLAR EXTRIC PED 1.5IN FOR 8-18IN FR 1 PC FLAT LOK TAB CLS,SUP-2194417,CDM,L0120,HCPCS,0274,RC,,,,both,,,18.09,11.76,,,,,,,,,,,,,
LEAD DEFIB LINOXSMART SD L 65 CM DIA2.6 MM TIP DISTANCE 18,SUP-2138095,CDM,C1895,HCPCS,0275,RC,,,,both,,,8792.00,5714.80,,,,,,,,,,,,,
ROD 275MM LNG FOR ORTHOFIX PREFIX FIX,SUP-2316292,CDM,2720000010,LOCAL,0272,RC,,,,both,,,538.13,349.78,,,,,,,,,,,,,
PLATE BONE L35MM THK0.3MM 6 H CRANIOMAXILLOFACIAL TI GAP RIG,SUP-2136518,CDM,C1713,HCPCS,0278,RC,,,,both,,,492.98,320.44,,,,,,,,,,,,,
PLATE BONE L123MM 6 H S STL BROAD NONLOCKING COMPR CNTOUR,SUP-2348969,CDM,C1713,HCPCS,0278,RC,,,,both,,,1946.27,1265.08,,,,,,,,,,,,,
GRAFT BNE MTRX XL 20 CC STRL FIBERGRAFT AERIDYAN 59000200,SUP-2874926,CDM,C1713,HCPCS,0278,RC,,,,both,,,19216.80,12490.92,,,,,,,,,,,,,
PLATE BNE L 150 X W 15 MM THK 0.75 MM SCREW DIA1.7 MM 8 H,SUP-2883187,CDM,C1713,HCPCS,0278,RC,,,,both,,,29162.03,18955.32,,,,,,,,,,,,,
SHAFT RMR L885MM MOD TRINKLE BIXCUT,SUP-2368274,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1804.56,1172.96,,,,,,,,,,,,,
PATCH HERN SM DIA3IN UNCOATED MFIL PROPYLENE CIR ABSRB BARR,SUP-2125894,CDM,C1781,HCPCS,0278,RC,,,,both,,,1253.80,814.97,,,,,,,,,,,,,
BLADE SHV OD4MM 40DEG CRV SNUS ADEN SERR CNVX WIND DIEGO,SUP-2313827,CDM,2720000010,LOCAL,0272,RC,,,,both,,,334.72,217.57,,,,,,,,,,,,,
GRAFT BNE 10ML SIL SOD CA PHOS OXIDE RECTANG CONT RESRB,SUP-2368192,CDM,C1713,HCPCS,0278,RC,,,,both,,,4264.12,2771.68,,,,,,,,,,,,,
INTRODUCER PEELWY 5FRX14CM 038IN ENDHOLE,SUP-2357091,CDM,C1892,HCPCS,0272,RC,,,,both,,,72.22,46.94,,,,,,,,,,,,,
HC Strep a Ag Eia,PX-3068743000,CDM,87430,CPT,0306,RC,,,,inpatient,,,128.00,83.20,,,,,,,,,,,,,
KIT HAD CATH L24CM DIA15FR TIP TO CUF 19CM TWO LUMN LNG,SUP-2383437,CDM,C1750,HCPCS,0278,RC,,,,both,,,894.90,581.68,,,,,,,,,,,,,
SCREW BNE L 12 MM DIA2.3 MM MANDIBULAR ST NS AXS,SUP-2909484,CDM,C1713,HCPCS,0278,RC,,,,both,,,323.70,210.40,,,,,,,,,,,,,
PLATE BONE W24XL85MM 12 H LT DSTL RAD TI LCK COMPR LO PROF,SUP-2136266,CDM,C1713,HCPCS,0278,RC,,,,both,,,4295.52,2792.09,,,,,,,,,,,,,
COIL EMB L14CM LOOP DIA10MM 0.018IN PLAT HYDRGEL POLYMER,SUP-2385393,CDM,C1889,HCPCS,0278,RC,,,,both,,,1099.03,714.37,,,,,,,,,,,,,
KGTI KENETIC GREAT TOE IMPL SYS INSTR TY DISP,SUP-2242676,CDM,C1713,HCPCS,0278,RC,,,,both,,,841.52,546.99,,,,,,,,,,,,,
SHEATH INTRO PEELWY L 15.5 CM DIA16 FR DIL 20 CM GUIDEWIRE,SUP-2167900,CDM,C1894,HCPCS,0272,RC,,,,both,,,109.96,71.47,,,,,,,,,,,,,
GRAFT VASC STR STD WALL N RNGD EPTFE 5MM DIA 60CM LEN,SUP-2395776,CDM,C1768,CPT,0278,RC,,,,both,,,4970.62,3230.90,,,,,,,,,,,,,
GRAFT HUM TISS W12XL36MM REV CORES FRZ DRY LIG RECON,SUP-2307073,CDM,C1713,HCPCS,0278,RC,,,,both,,,3314.90,2154.68,,,,,,,,,,,,,
LOCKING FRAC PLATE CRVD LNG NON CMPRSSN 20MM THICK T 6L 4V,SUP-2679057,CDM,C1713,HCPCS,0278,RC,,,,both,,,2578.94,1676.31,,,,,,,,,,,,,
HC Pt Vasopneumatic Device Therapy|OP PT SERVICES|DOCUMENTATION ON FILE|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS,PX-4209701600,CDM,97016,CPT,0420,RC,,,GP|KX|CQ,outpatient,,,206.00,133.90,,,,,,,,,,,,,
INTRODUCER VASC L14CM DIA16FR VLV PEELABLE TEARAWAY,SUP-2269550,CDM,C1892,HCPCS,0272,RC,,,,both,,,94.20,61.23,,,,,,,,,,,,,
PIN FIX L229MM OD4MM S STL SMOOTH SGL SHRP TIP SGL TRCR,SUP-2304050,CDM,C1713,HCPCS,0278,RC,,,,both,,,17.90,11.63,,,,,,,,,,,,,
COMPONENT TIB TY 3 73X47 MM,SUP-2390306,CDM,C1776,CPT,0278,RC,,,,both,,,4154.22,2700.24,,,,,,,,,,,,,
DEFIBRILLATOR IMPL LUMAX TI EPOXY RESIN SIL STRL,SUP-2138113,CDM,C1882,HCPCS,0275,RC,,,,both,,,78766.90,51198.48,,,,,,,,,,,,,
STERILE WATER FOR INJECTION (MIXTURES ONLY),RX-430028,CDM,2500000003,HCPCS,0250,RC,00409-4887-50,NDC,,both,50,ML,54.10,35.16,,,,,,,,,,,,,
CAGE SPNL 6X30 MM REV ABO TI STRL STALIF MIDLN,SUP-2577757,CDM,C1889,HCPCS,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
BUR SURG PRECIS 15 DEG 3 MMX12.5 CM RND DSTL BEND ORNG IBUR,SUP-2859500,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1114.70,724.55,,,,,,,,,,,,,
SET DILATOR DIA4 5 6 6FR SALIVARY ACCESS OTOLARYNGOLOGY,SUP-2874849,CDM,C1894,HCPCS,0272,RC,,,,both,,,675.10,438.81,,,,,,,,,,,,,
PLATE BNE RADIAL SM 43 MM RT DSTL VOLAR PERIARTICULAR 3 HOLE,SUP-2460887,CDM,C1713,HCPCS,0278,RC,,,,both,,,1790.46,1163.80,,,,,,,,,,,,,
PLATE BONE L25MM THK0.6MM 3X4 H BILAT CRANIOMAXILLOFACIAL TI,SUP-2191245,CDM,C1713,HCPCS,0278,RC,,,,both,,,769.30,500.04,,,,,,,,,,,,,
GUIDEWIRE VASC IMAG L40CM OD0018IN NIT COR PALLADIUM TIP STR,SUP-2303015,CDM,C1769,HCPCS,0272,RC,,,,both,,,59.66,38.78,,,,,,,,,,,,,
INSERT TIB L THK9MM STD L KNEE POLYETH NEUT REV MOD PCA,SUP-2377642,CDM,C1776,CPT,0278,RC,,,,both,,,5575.38,3624.00,,,,,,,,,,,,,
TUBE MYR 127MM DIAM WHT RED BLK CLLR BTTN PACIFIC COAT,SUP-2313849,CDM,L8699,HCPCS,0278,RC,,,,both,,,24.68,16.04,,,,,,,,,,,,,
KIT INST PREP JOINT STERILE,SUP-2715950,CDM,2720000010,LOCAL,0272,RC,,,,both,,,806.98,524.54,,,,,,,,,,,,,
SCREW BNE CROSSING 5X50 MM HINDFOOT HD THRD NAIL PHANTOM,SUP-2749709,CDM,C1713,HCPCS,0278,RC,,,,both,,,1036.20,673.53,,,,,,,,,,,,,
GRAFT HUM TISS L160MM ACHILLES TEND FRZN W/ BNE BLK,SUP-2264725,CDM,C1762,CPT,0278,RC,,,,both,,,6943.48,4513.26,,,,,,,,,,,,,
NEEDLE SPNL 24GA L3.5IN GERTIE MARX PNCL PT W/ INTRO,SUP-2241844,CDM,2720000010,LOCAL,0272,RC,,,,both,,,369.74,240.33,,,,,,,,,,,,,
INSTRUMENT STBL L25IN OD0045MM OLV,SUP-2398629,CDM,2720000010,LOCAL,0272,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
HANDPIECE SURG LAP 5 MMX28 CM PRECIS CUT COAG PLASMAJET DISP,SUP-2328049,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
PLATE BNE 50 MM CAGE TCP,SUP-2538160,CDM,C1713,HCPCS,0278,RC,,,,both,,,4493.34,2920.67,,,,,,,,,,,,,
SYSTEM RAP DEL DRL 4 S STL GUIDWIRE DEL INSTR ANG OVL HD,SUP-2341624,CDM,C1713,HCPCS,0278,RC,,,,both,,,550.60,357.89,,,,,,,,,,,,,
ARM IMMOB W ABDUCTION PLLW MED,SUP-2196389,CDM,L3670,HCPCS,0272,RC,,,,both,,,83.43,54.23,,,,,,,,,,,,,
INTRODUCER HEMSTAS FAST CATH 6.5FRX45CM 30 DEG CRV 0.038 IN,SUP-2355582,CDM,C1894,HCPCS,0272,RC,,,,both,,,128.74,83.68,,,,,,,,,,,,,
SLEEVE FEM L9MM PROX HIP PMMA MOD CNTR GENERATION 4,SUP-2406629,CDM,C1776,CPT,0278,RC,,,,both,,,1004.80,653.12,,,,,,,,,,,,,
BRACE ORTH 2X UPR KNEE FREE KAFO,SUP-2388169,CDM,L2036,HCPCS,0274,RC,,,,both,,,4743.47,3083.26,,,,,,,,,,,,,
SIGMA HP UNI POST LAT SHM 1-3,SUP-2513396,CDM,C1776,CPT,0278,RC,,,,both,,,860.36,559.23,,,,,,,,,,,,,
COVER BURR HOLE CONTOURED 18X0.3 MM 5 TI STRL LEVEL 1 NEURO,SUP-2458279,CDM,C1713,HCPCS,0278,RC,,,,both,,,1001.72,651.12,,,,,,,,,,,,,
SUCTION BLADE ANGLD 40DGRS DBL SRRTD EDGE RECT WNDW3MMX12CM5,SUP-2574173,CDM,2720000010,LOCAL,0272,RC,,,,both,,,597.92,388.65,,,,,,,,,,,,,
SCREW BNE L38MM OD3MM DST THRD L14MM LNG THRD CANN COMPR,SUP-2268359,CDM,C1713,HCPCS,0278,RC,,,,both,,,1519.13,987.43,,,,,,,,,,,,,
GRAFT BNE COTTON WDG 8 MM STRL TITAN 3-D,SUP-2742081,CDM,C1713,HCPCS,0278,RC,,,,both,,,5137.83,3339.59,,,,,,,,,,,,,
Z DUP USE 2693978 BLADE KEL 2INX6IN BKWALT,SUP-2248990,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1805.63,1173.66,,,,,,,,,,,,,
PLATE BNE TIBIOTALOCALCANEAL STD LT POST FLAT,SUP-2751237,CDM,C1713,HCPCS,0278,RC,,,,both,,,5690.47,3698.81,,,,,,,,,,,,,
GUIDEWIRE ORTH PARL 2.8 MM ADJ NS,SUP-2789125,CDM,C1769,HCPCS,0272,RC,,,,both,,,3887.70,2527.00,,,,,,,,,,,,,
CATHETER HAD 11.5FR L15CM STR POLYUR 3 LUMN FULL KT TR FL,SUP-2267013,CDM,C1751,HCPCS,0278,RC,,,,both,,,270.67,175.94,,,,,,,,,,,,,
GRAFT HUM TISS 7MM CERV F6183 4 007,SUP-2364351,CDM,C1713,HCPCS,0278,RC,,,,both,,,5255.04,3415.78,,,,,,,,,,,,,
PLATE BNE L66MM 5 H RECON FOR 35MM SCR UNIV LOK SYS,SUP-2199386,CDM,C1713,HCPCS,0278,RC,,,,both,,,1210.91,787.09,,,,,,,,,,,,,
CEMENT BONE ROTARY MIX 3 CC REINFORCED STERILE CRANIOS,SUP-2838514,CDM,C1713,HCPCS,0278,RC,,,,both,,,3758.58,2443.08,,,,,,,,,,,,,
BOLT EXT FIX 16 MM MP,SUP-2464551,CDM,2720000010,LOCAL,0272,RC,,,,both,,,113.04,73.48,,,,,,,,,,,,,
MANIPULATOR SURG ANDERSON-BARRETT 130 MM DBL END TI,SUP-2473357,CDM,2720000010,LOCAL,0272,RC,,,,both,,,732.72,476.27,,,,,,,,,,,,,
WASHER ORTH DIA12.7MM S STL RND FOR FIX,SUP-2343055,CDM,C1713,HCPCS,0278,RC,,,,both,,,453.82,294.98,,,,,,,,,,,,,
ARM IMMOB W ABDUCTION PLLW MED,SUP-2196389,CDM,L3670,HCPCS,0274,RC,,,,both,,,83.43,54.23,,,,,,,,,,,,,
PORT IMPL INFUSION 2 L LUMEN 10 FR SIL CATH X-PORTDUO MRI,SUP-2126179,CDM,C1788,HCPCS,0278,RC,,,,both,,,1397.30,908.24,,,,,,,,,,,,,
OCTREOTIDE ACETATE 30 MG IM KIT|DISCARDED DRUG NOT ADMINISTE,RX-24436,CDM,J2353,HCPCS,0636,RC,00078-0825-81,NDC,JW,both,1,UN,19908.20,12940.33,,,,,,,,,,,,,
PLATE BNE T MIDFACE CRANIOMAXILLOFACIAL 4 HOLE ARNETT W/ TAB,SUP-2465628,CDM,C1713,HCPCS,0278,RC,,,,both,,,757.12,492.13,,,,,,,,,,,,,
BLADE RTRCTR BLFR 2 58NW X 10 34NL X 2 34ND SPRPBC CNTR J,SUP-2701371,CDM,2720000010,LOCAL,0272,RC,,,,both,,,461.99,300.29,,,,,,,,,,,,,
SHEATH INTRO MAX L 12 CM DIA 7 FR GUIDEWIRE 0.038 IN,SUP-2356160,CDM,C1894,HCPCS,0272,RC,,,,both,,,28.26,18.37,,,,,,,,,,,,,
COVER BUR H DIA7MM STD UNIV CRANIOMAXILLOFACIAL TI LO PROF,SUP-2366286,CDM,2720000010,LOCAL,0272,RC,,,,both,,,790.81,514.03,,,,,,,,,,,,,
DEFIBRILLATOR IMPL KRONOS LV-T W 55 X H 55 MM D 13 MM 30 J,SUP-2138092,CDM,C1882,HCPCS,0275,RC,,,,both,,,81906.90,53239.48,,,,,,,,,,,,,
NEEDLE SUTURE L9IN BLUNT STEEP TURN LIGATURE FOR LEFT HAND D,SUP-2803011,CDM,2720000010,LOCAL,0272,RC,,,,both,,,316.23,205.55,,,,,,,,,,,,,
CATHETER ABLAT L160CM DIA4MM BPLR ELECTRD W13XL40MM ULT LNG,SUP-2172350,CDM,C1888,HCPCS,0272,RC,,,,both,,,7338.18,4769.82,,,,,,,,,,,,,
HC So Alpha 1 Antitrypsin,PX-3018210366,CDM,82103,CPT,0301,RC,,,,both,,,69.00,44.85,,,,,,,,,,,,,
GRAFT BNE SUB 5CC DEMIN BNE MTRX PTTY GRFTON,SUP-2294016,CDM,C1713,HCPCS,0278,RC,,,,both,,,2879.38,1871.60,,,,,,,,,,,,,
HC Lumbar Myelogram S&I,PX-3207226500,CDM,72265,CPT,0320,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
PACEMAKER CARD SENSIA SR W 42.9 X H 40.2 MM D 7.5 MM TI,SUP-2282484,CDM,C1786,HCPCS,0275,RC,,,,both,,,7373.51,4792.78,,,,,,,,,,,,,
SCREW SPNL POLYAX 04.5X25 MM ASMBLY REDUCTION,SUP-2175708,CDM,C1713,HCPCS,0278,RC,,,,both,,,6534.34,4247.32,,,,,,,,,,,,,
NEXGEN AC ART SURF 5-6/ GREEN 12MM,SUP-2503015,CDM,C1776,CPT,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
PASSER SUT PERC W/18G SPNL NDL,SUP-2121828,CDM,2720000010,LOCAL,0272,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
PLATE BNE 2/2.4X33X1.7 MM 4 HOLE SS LC-DCP,SUP-2569203,CDM,C1713,HCPCS,0278,RC,,,,both,,,265.96,172.87,,,,,,,,,,,,,
HC Immunofluorescence PR Spec Ea Add Singl Antb Stn,PX-3128835000,CDM,88350,CPT,0312,RC,,,,inpatient,,,369.00,239.85,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL PEEK SD800.530,SUP-2860211,CDM,C1713,HCPCS,0278,RC,,,,both,,,35653.76,23174.94,,,,,,,,,,,,,
KNIFE NDL CATH 10FR L165CM DIATHERMIC RNG 10FR ACCSRY CHAN,SUP-2169844,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1001.66,651.08,,,,,,,,,,,,,
PLATE FUSION VA LCP 1ST MTP 2.4/2.7MM MED 10 DEG RT TI STRL,SUP-2546976,CDM,C1713,HCPCS,0278,RC,,,,both,,,2938.10,1909.76,,,,,,,,,,,,,
HOFFMANN XPRESS 5 HOLE PIN CLAMP 2 POST,SUP-2488105,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1805.50,1173.57,,,,,,,,,,,,,
STENT CORONARY SYNERGY L 28 MM DIA2.25 MM CATH L 144 CM DIA,SUP-2146166,CDM,C1874,HCPCS,0278,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
SET THERMOABLATION PROCERVA,SUP-2139316,CDM,C1713,HCPCS,0278,RC,,,,both,,,4396.00,2857.40,,,,,,,,,,,,,
HC Percut Ablate Liver Rf,PX-3524738200,CDM,47382,CPT,0352,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
BRACE ORTH LUMBAR W/O RIGID STAY LSO,SUP-2388148,CDM,L0628,HCPCS,0274,RC,,,,both,,,310.86,202.06,,,,,,,,,,,,,
COMPONENT HUM 8X8MM 40MM ARTC SURF OFFSET HEMICAP,SUP-2123569,CDM,C1776,CPT,0278,RC,,,,both,,,12560.00,8164.00,,,,,,,,,,,,,
HC So1 Rickettsia Ab,PX-3028675767,CDM,86757,CPT,0302,RC,,,,both,,,443.00,287.95,,,,,,,,,,,,,
METOLAZONE 5 MG PO TABS,RX-10588,CDM,6370000000,HCPCS,0637,RC,00378-6173-01,NDC,,both,1,UN,9.30,6.04,,,,,,,,,,,,,
HEAD HUM 44X18 MM SHAPER GLOB CAP QC,SUP-2453843,CDM,C1776,CPT,0278,RC,,,,both,,,1573.14,1022.54,,,,,,,,,,,,,
VALVE TRACHEOSTOMA ADJ ATSV II STRT KT W/ HUMIDIFILTER CAP,SUP-2242324,CDM,2720000010,LOCAL,0272,RC,,,,both,,,925.04,601.28,,,,,,,,,,,,,
BLADE ENDOSCP SHAVER 360 DEG L 11 CM DIA 4 MM SPD 7500 RPM,SUP-2901963,CDM,2720000010,LOCAL,0272,RC,,,,both,,,748.58,486.58,,,,,,,,,,,,,
DEXTROSE 5 % IV SOLN INTERMITTENT INFUSION,RX-40840103,CDM,2580000003,HCPCS,0250,RC,00990-7922-61,NDC,,both,250,ML,74.40,48.36,,,,,,,,,,,,,
PLATE BNE X LG 2.4/2.7X36 MM LCK VA FUSION SS NS LCP,SUP-2184804,CDM,C1713,HCPCS,0278,RC,,,,both,,,3156.74,2051.88,,,,,,,,,,,,,
PENTOXIFYLLINE ER 400 MG PO TBCR,RX-21300,CDM,6370000000,HCPCS,0637,RC,00904-5448-61,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
AUGMENT FEM L70MM THK10MM R LAT L MED DST UNIV KNEE STD TI,SUP-2407799,CDM,C1776,CPT,0278,RC,,,,both,,,2599.92,1689.95,,,,,,,,,,,,,
CATHETER NEPHSTMY DIA34FR 4 WNG AMB REINF TIP NO MRK DISP,SUP-2128995,CDM,C1729,HCPCS,0272,RC,,,,both,,,76.74,49.88,,,,,,,,,,,,,
SCREW BNE L30MM DIA4MM LO PROF HD COMPR,SUP-2315946,CDM,C1713,HCPCS,0278,RC,,,,both,,,876.34,569.62,,,,,,,,,,,,,
CATHETER CV DL 5 FRX55 CM FULL TY EXCALIBUR INTRO GROSH NXT,SUP-2126670,CDM,C1751,HCPCS,0278,RC,,,,both,,,391.02,254.16,,,,,,,,,,,,,
CALAMINE 8-8 % EX LOTN,RX-78879,CDM,6370000000,HCPCS,0637,RC,00904-2533-21,NDC,,both,177,ML,6.40,4.16,,,,,,,,,,,,,
PLATE SPNL ANTR UNIV BEND 22MM STD LEN TECHTONIX,SUP-2362808,CDM,C1713,HCPCS,0278,RC,,,,both,,,2998.70,1949.15,,,,,,,,,,,,,
STIMULATOR NERVE CHARGER SYS EON MINI,SUP-2355971,CDM,C1820,HCPCS,0278,RC,,,,both,,,4239.00,2755.35,,,,,,,,,,,,,
CATHETER ANGIOPLSTY L143CM BAL L20MM DIA3.25MM 14ATM BURST,SUP-2103632,CDM,C1725,HCPCS,0272,RC,,,,both,,,1004.80,653.12,,,,,,,,,,,,,
COIL VASC NEST EMBOLUS L 3 CM DIA2 MM CATH DIA 0.018 IN LOOP,SUP-2638543,CDM,C1889,HCPCS,0278,RC,,,,both,,,326.53,212.24,,,,,,,,,,,,,
ATROPINE SULFATE 1 MG/10ML IJ SOSY,RX-137355,CDM,J0462,HCPCS,0636,RC,76329-3340-01,NDC,,both,5,ML,54.10,35.16,,,,,,,,,,,,,
HC So Dhea Level,PX-3018262666,CDM,82626,CPT,0301,RC,,,,inpatient,,,131.00,85.15,,,,,,,,,,,,,
IMPLANT HUM TISS L 4 X W 4 CM PLCNTA MTRX MEMBRN DEHYDR ASEP,SUP-2905522,CDM,Q4184,HCPCS,0636,RC,,,,both,,,12560.00,8164.00,,,,,,,,,,,,,
HC Gbl Office/OP Consltj New/Est Pt High Mdm 55 Minutes,PX-9829924501,CDM,99245,CPT,0982,RC,,,,outpatient,,,1137.00,739.05,,,,,,,,,,,,,
PROBE BX 14 GAX138 MM ULTRASOUND W/ INTEGR COAX CANN VACORA,SUP-2759181,CDM,2720000010,LOCAL,0272,RC,,,,both,,,694.44,451.39,,,,,,,,,,,,,
SYSTEM DRAINAGE 50-80 MM H2O 290-400 MM H2O TALL BRN,SUP-2851475,CDM,C1729,HCPCS,0272,RC,,,,both,,,4206.12,2733.98,,,,,,,,,,,,,
PLATE BONE 135DEG 10 H HIP FRELOK,SUP-2197726,CDM,C1713,HCPCS,0278,RC,,,,both,,,1080.16,702.10,,,,,,,,,,,,,
PLATE BONE THK2MM 12 H MAND BLU TI STR FOR 2/2.3MM SCR,SUP-2136806,CDM,C1713,HCPCS,0278,RC,,,,both,,,2084.96,1355.22,,,,,,,,,,,,,
CATHETER HD DL 13.5 FRX13.5 CM ADMIN BASIC KT MAHRK,SUP-2174223,CDM,C1751,HCPCS,0278,RC,,,,both,,,233.62,151.85,,,,,,,,,,,,,
BASEPLATE TIB L85XW60MM SZ 2 XL DURAC KNEE CEM,SUP-2377174,CDM,C1776,CPT,0278,RC,,,,both,,,3350.00,2177.50,,,,,,,,,,,,,
GRAFT BNE 25CC DBM SHP,SUP-2364717,CDM,C1713,HCPCS,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
SET URET STENT SOFFLX L 10 CM DIA 4.7 FR POS L 50 CM DIA 4.7,SUP-2168905,CDM,C2617,HCPCS,0278,RC,,,,both,,,419.10,272.41,,,,,,,,,,,,,
SPACER PREFRM FEM L 74 MM TIB L 74 MM GENTAMICIN KNEE STRL,SUP-2905381,CDM,C1776,CPT,0278,RC,,,,both,,,12089.00,7857.85,,,,,,,,,,,,,
IMMOBILIZER ORTHOPEDICS SM UNIV L R SHLDR SLNG,SUP-2195044,CDM,L3660,HCPCS,0274,RC,,,,both,,,25.62,16.65,,,,,,,,,,,,,
INTRODUCER IV CATH NEOMAGIC CATH L 40 CM DIA1.9/2 FR NDL 30,SUP-2874162,CDM,C1894,HCPCS,0272,RC,,,,both,,,227.96,148.17,,,,,,,,,,,,,
PORT SYS ATTACH TI INTRA-ARTERY BEAD SIL 7FR,SUP-2332931,CDM,C1788,HCPCS,0278,RC,,,,both,,,832.10,540.86,,,,,,,,,,,,,
STENT BILI PALMAZ L 39 MM DIA 4-9 MM MED SS TRNSHEP BALLOON,SUP-2158991,CDM,C1877,HCPCS,0278,RC,,,,both,,,3146.28,2045.08,,,,,,,,,,,,,
KIT INSTR BONE TEND DISP,SUP-2137212,CDM,C1713,HCPCS,0278,RC,,,,both,,,1893.42,1230.72,,,,,,,,,,,,,
SHEATH INTRO BASE CAMP 2.0 L 90 CM CATH 8 FR GUIDEWIRE 0.035,SUP-2928390,CDM,C1887,HCPCS,0272,RC,,,,both,,,3925.00,2551.25,,,,,,,,,,,,,
SUPPORT WR SM AD LT CRPL TUNN REG FIRM SUPP CRPLGARD BLK,SUP-2324889,CDM,L3931,HCPCS,0272,RC,,,,both,,,42.83,27.84,,,,,,,,,,,,,
GUIDEWIRE ORTH THRD 2.8X450 MM FOR CANN SCREW STRL,SUP-2789108,CDM,C1769,HCPCS,0272,RC,,,,both,,,804.97,523.23,,,,,,,,,,,,,
BOOT EQL BLK XL EA,SUP-2319312,CDM,L4360,HCPCS,0272,RC,,,,both,,,72.97,47.43,,,,,,,,,,,,,
BLADE SHAVER RESECT 4.5X120 MM FULL RAD BLU UNIDRIVE,SUP-2585906,CDM,2720000010,LOCAL,0272,RC,,,,both,,,255.13,165.83,,,,,,,,,,,,,
BOOT TRAC L L20IN FOR 18IN CALF CONVOLUTED FOAM LNR STAY,SUP-2196870,CDM,L4631,HCPCS,0272,RC,,,,both,,,36.33,23.61,,,,,,,,,,,,,
SCREW BONE L10MM DIA2.5MM CRTX ST T7 PERI-LOC,SUP-2350060,CDM,C1713,HCPCS,0278,RC,,,,both,,,187.33,121.76,,,,,,,,,,,,,
PLATE BNE THK0.6MM 2X2 H CRANIOMAXILLOFACIAL TI SQ 3D PROF,SUP-2366278,CDM,C1713,HCPCS,0278,RC,,,,both,,,685.05,445.28,,,,,,,,,,,,,
HC So Mpl Gene Analysis Common Variants,PX-3108133866,CDM,81338,CPT,0310,RC,,,,both,,,441.00,286.65,,,,,,,,,,,,,
PLATE BNE 180 MM FT TRULOK,SUP-2316140,CDM,C1713,HCPCS,0278,RC,,,,both,,,2000.18,1300.12,,,,,,,,,,,,,
CATHETER EP 5FR L115CM ELECTRD SPC 2-5-2MM TIP 2MM BND,SUP-2356878,CDM,C1730,HCPCS,0272,RC,,,,both,,,1657.92,1077.65,,,,,,,,,,,,,
CAP K WIRE HLDR TELLURIDE FOR MIS SPNL FIX SYS,SUP-2211173,CDM,C1713,HCPCS,0278,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
SET PICC 3L 6FR X 55CM TCG,SUP-2887073,CDM,C1751,HCPCS,0278,RC,,,,both,,,1097.96,713.67,,,,,,,,,,,,,
RING EXT FIX DIA210MM C FULL FOR HOFFMANN LRF SYS,SUP-2363154,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5000.14,3250.09,,,,,,,,,,,,,
PLATE BNE THK06MM 4 H REG TI R L LO PROF LEV 1 FIX FOR 2MM,SUP-2262933,CDM,C1713,HCPCS,0278,RC,,,,both,,,340.69,221.45,,,,,,,,,,,,,
WALKER SM SHT LEG NONSKID,SUP-2276712,CDM,L4387,HCPCS,0272,RC,,,,both,,,80.60,52.39,,,,,,,,,,,,,
WHITE PETROLATUM EX GEL,RX-28809,CDM,6370000000,HCPCS,0637,RC,84389-0111-38,NDC,,both,28.4,GR,54.10,35.16,,,,,,,,,,,,,
VALVE SPEAK W/ O2 PRT PHONATE,SUP-2283884,CDM,L8501,HCPCS,0274,RC,,,,both,,,79.91,51.94,,,,,,,,,,,,,
GUIDEWIRE VASC COUGAR XT L 190 CM DIA 0.014 IN TIP L 3 CM,SUP-2295072,CDM,C1769,HCPCS,0272,RC,,,,both,,,178.98,116.34,,,,,,,,,,,,,
BIT DRL 1.2X50 MM 6 MM W/ DENT INTFACE NS UNIV NEURO III LTX,SUP-2862794,CDM,2720000010,LOCAL,0272,RC,,,,both,,,632.36,411.03,,,,,,,,,,,,,
BIT DRL CALIB XLN 4.3 MM VAR THRD STRL,SUP-2789174,CDM,2720000010,LOCAL,0272,RC,,,,both,,,671.02,436.16,,,,,,,,,,,,,
EXPANDER TISS GEL 6.3 CM 16X11.3 CM 550 CC SV-T NATRELLE,SUP-2484236,CDM,C1889,HCPCS,0278,RC,,,,both,,,5099.36,3314.58,,,,,,,,,,,,,
WAND ABLAT 70DEG ICW 3MM COVAC,SUP-2341995,CDM,C1713,HCPCS,0278,RC,,,,both,,,681.38,442.90,,,,,,,,,,,,,
TRIAL KNEE DIA32MM THK10MM ASYM TOT STBL TRIATHLON,SUP-2363806,CDM,C1776,CPT,0278,RC,,,,both,,,219.80,142.87,,,,,,,,,,,,,
TAP BNE PEDCL SCR QUIK CONN 65MM DIA,SUP-2290730,CDM,C1713,HCPCS,0278,RC,,,,both,,,2311.54,1502.50,,,,,,,,,,,,,
HC ED Clsd Tx Shoulder WO Anes,PX-4502365000,CDM,23650,CPT,0450,RC,,,,outpatient,,,383.00,248.95,,,,,,,,,,,,,
PLATE BNE L145MM 8 H NONSTERILE R MED PROX TIB S STL LOK,SUP-2185638,CDM,C1713,HCPCS,0278,RC,,,,both,,,3873.06,2517.49,,,,,,,,,,,,,
DILATOR COAX 4FR 0.018X40CM MICPUNC ACC,SUP-2385654,CDM,C1894,HCPCS,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
NEEDLE PHACO 45 DEG STD 19 GA 2.75 MM TAPR TIP REUSE,SUP-2463468,CDM,2720000010,LOCAL,0272,RC,,,,both,,,97.34,63.27,,,,,,,,,,,,,
BLADE RETRACTOR HOHMN 11 CMX29 MM,SUP-2659978,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2037.42,1324.32,,,,,,,,,,,,,
PLATE CRAN THK0.2MM CRANIOFACIAL TI ORBIT B MESH MALL FOR,SUP-2190684,CDM,C1713,HCPCS,0278,RC,,,,both,,,4527.88,2943.12,,,,,,,,,,,,,
DRESSING WOUND SURGICAL MATRIX THICK 20X20 CM MATRISTEM,SUP-2106501,CDM,Q4166,HCPCS,0636,RC,,,,both,,,33629.40,21859.11,,,,,,,,,,,,,
ENDCAP ORTH STRL S STL END FOR OLECRANON OSTEOTMY NAIL,SUP-2177096,CDM,C1889,HCPCS,0278,RC,,,,both,,,838.66,545.13,,,,,,,,,,,,,
GRAFT HUM TISS W3-10MMX26-38CM SEMITENDINOSUS TEND FRZN,SUP-2307285,CDM,C1713,HCPCS,0278,RC,,,,both,,,5024.00,3265.60,,,,,,,,,,,,,
SUPPORT ORTHOT CUST FURNISHING INIT ORTHOSIS ONLY,SUP-2435584,CDM,L1200,HCPCS,0274,RC,,,,both,,,5066.39,3293.15,,,,,,,,,,,,,
SET URET STENT CNTOUR L 20 CM DIA 7 FR PTFE GUIDEWIRE 0.038,SUP-2479830,CDM,C2617,HCPCS,0278,RC,,,,both,,,451.88,293.72,,,,,,,,,,,,,
SCREW BNE L 85 MM DIA 6.7 MM SS FT HI TORQUE NS EVOS,SUP-2931196,CDM,C1713,HCPCS,0278,RC,,,,both,,,1063.83,691.49,,,,,,,,,,,,,
DEVICE STRNL CLSR MULTIIMPLANT STRNLOCK 360,SUP-2510512,CDM,C1713,HCPCS,0278,RC,,,,both,,,8949.00,5816.85,,,,,,,,,,,,,
GRAFT HUM TISS FRZN ALLGRFT MENIS W/ TIB PLATEAU HUM TISS LT,SUP-2307287,CDM,C1776,CPT,0278,RC,,,,both,,,18683.00,12143.95,,,,,,,,,,,,,
BIT DRILL LONG 4.5MM QC,SUP-2818686,CDM,2720000010,LOCAL,0272,RC,,,,both,,,944.20,613.73,,,,,,,,,,,,,
INSERT SYS 12 NEUT DURATN P4 28MM,SUP-2376138,CDM,C1776,CPT,0278,RC,,,,both,,,1338.43,869.98,,,,,,,,,,,,,
LOANER TRABECULAR MTL IMPLE,SUP-2414455,CDM,C1776,CPT,0278,RC,,,,both,,,6594.00,4286.10,,,,,,,,,,,,,
L-BUTT PLT STERILIZER 4 HL 86 MM LENGTH RIGHT,SUP-2818498,CDM,C1713,HCPCS,0278,RC,,,,both,,,2521.92,1639.25,,,,,,,,,,,,,
MESH HERN L30.5XW5CM THICKNESS 7MM POLYPR INGUINAL,SUP-2125746,CDM,C1781,HCPCS,0278,RC,,,,both,,,206.93,134.50,,,,,,,,,,,,,
KIT TBNG L9FT STRT UP EXT CG 500D EX,SUP-2416152,CDM,C1751,HCPCS,0278,RC,,,,both,,,748.20,486.33,,,,,,,,,,,,,
SOCKET EXT FIX L60MM S STL THRD FOR ILIZ TAY SPAT FRME,SUP-2342277,CDM,2720000010,LOCAL,0272,RC,,,,both,,,551.29,358.34,,,,,,,,,,,,,
HC ED Clsd Tx Shoulder WO Anes,PX-4502365000,CDM,23650,CPT,0450,RC,,,,inpatient,,,383.00,248.95,,,,,,,,,,,,,
BLADE SHAVER 3.5 MM PLAT DYONICS INCISIOR +,SUP-2849164,CDM,2720000010,LOCAL,0272,RC,,,,both,,,337.55,219.41,,,,,,,,,,,,,
CATHETER MAHRK ELITE ST 3 LUMN 12.5 FR X .016 CM,SUP-2283966,CDM,C1752,HCPCS,0278,RC,,,,both,,,342.86,222.86,,,,,,,,,,,,,
DEFIBRILLATOR CARD 30J STD SGL CHMBR LD BPLR REMOT MON,SUP-2357752,CDM,C1721,HCPCS,0275,RC,,,,both,,,59189.00,38472.85,,,,,,,,,,,,,
INSERT HUM LAT 6+ MM 42 MM SHLDR AEQUALIS REVERSED FX,SUP-2715640,CDM,C1776,CPT,0278,RC,,,,both,,,5213.97,3389.08,,,,,,,,,,,,,
GRAFT DERM L8CMXW4CM MTRX FLOWABLE FOR INTEGUMENTARY AUG,SUP-2321664,CDM,Q4126,HCPCS,0636,RC,,,,both,,,8970.35,5830.73,,,,,,,,,,,,,
CATHETER KT CTRL VEN PICC DBL LUMN,SUP-2164394,CDM,C1751,HCPCS,0278,RC,,,,both,,,417.62,271.45,,,,,,,,,,,,,
PLATE BNE SM W11XL124MM THK34MM 9 H BILAT TI RIG NEUT LOK,SUP-2190783,CDM,C1713,HCPCS,0278,RC,,,,both,,,1047.82,681.08,,,,,,,,,,,,,
PLATE BONE ANGLED BROAD 2 MM 3X3 HOLE PRECONTOURED TITANIUM,SUP-2837753,CDM,C1713,HCPCS,0278,RC,,,,both,,,3804.74,2473.08,,,,,,,,,,,,,
REAMER SURG 12MM FEM FULL FLUT,SUP-2249544,CDM,C1713,HCPCS,0278,RC,,,,both,,,555.78,361.26,,,,,,,,,,,,,
INTRODUCER SET MICPUNC PUSH + 5FR STIFF CANN NIT WIRE,SUP-2170560,CDM,C1894,HCPCS,0272,RC,,,,both,,,90.46,58.80,,,,,,,,,,,,,
IMPLANT OPHTH RETIN TIRE SIL,SUP-2213508,CDM,L8610,HCPCS,0278,RC,,,,both,,,53.38,34.70,,,,,,,,,,,,,
SCREW BONE L44MM DIA4.5MM CORT S STL ST NONCANNULATED,SUP-2363886,CDM,C1713,HCPCS,0278,RC,,,,both,,,80.54,52.35,,,,,,,,,,,,,
SCREW BONE L30 MM L9 MM OD3.5 MM ST SELF DRL CANN PARTIALLY,SUP-2321034,CDM,C1713,HCPCS,0278,RC,,,,both,,,585.77,380.75,,,,,,,,,,,,,
GUIDEWIRE VASC L180CM 0.035IN L 9.5CM 3CM HEPARIN AMPLTZ STR,SUP-2168521,CDM,C1769,HCPCS,0272,RC,,,,both,,,63.43,41.23,,,,,,,,,,,,,
PIN FIX L120MM DIA45MM S STL SGL END SMOOTH SHRP TIP FOR,SUP-2186913,CDM,C1713,HCPCS,0278,RC,,,,both,,,200.02,130.01,,,,,,,,,,,,,
HC Place Cath Thoracic Aorta,PX-3613622100,CDM,36221,CPT,0361,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
GRAFT BNE SUB W18X10MM D18MM THK10MM TI CANC RIG FIX FOR,SUP-2397885,CDM,C1713,HCPCS,0278,RC,,,,both,,,3925.00,2551.25,,,,,,,,,,,,,
ROD SPNL L210MM OD55MM TI ALLY POST R SMOOTH STR CDH,SUP-2279606,CDM,C1713,HCPCS,0278,RC,,,,both,,,2088.10,1357.26,,,,,,,,,,,,,
PLATE 3.5MM TI LCP PROXIMAL TIBIA LOW BEND 4H 76MM LT STER,SUP-2546866,CDM,C1713,HCPCS,0278,RC,,,,both,,,4546.47,2955.21,,,,,,,,,,,,,
HC CT T-Spine W/WO Contrast,PX-3527213000,CDM,72130,CPT,0352,RC,,,,both,,,2630.00,1709.50,,,,,,,,,,,,,
GUIDE WIRE THRDED 2.4 MMX304 MM STR,SUP-2815032,CDM,C1769,HCPCS,0272,RC,,,,both,,,94.20,61.23,,,,,,,,,,,,,
CANCELLOUS SCREW STERILIZER 4.0X30 MM P-T,SUP-2818174,CDM,C1713,HCPCS,0278,RC,,,,both,,,106.60,69.29,,,,,,,,,,,,,
DEFIBRILLATOR IMPL KRONOS W 55 X H 55 MM D 13 MM 30 J VVED,SUP-2138089,CDM,C1721,HCPCS,0275,RC,,,,both,,,63537.90,41299.63,,,,,,,,,,,,,
REAMER SURG DIA16MM NONSTERILE CANN HLLW FOR QUIK CPL DH DC,SUP-2255807,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2707.25,1759.71,,,,,,,,,,,,,
ALLOGRAFT BNE SPACER 14X11X5 MM FD LORDTC CORTICAL GRAFTECH,SUP-2791133,CDM,C1713,HCPCS,0278,RC,,,,both,,,3166.63,2058.31,,,,,,,,,,,,,
CATHETER CV MAXIMAL BARR TY 018 4 FRX15 CM 18 GA DL SPECTRUM,SUP-2759892,CDM,C1751,HCPCS,0278,RC,,,,both,,,563.13,366.03,,,,,,,,,,,,,
STENT CORONARY XIENCE PRIM LL L 28 MM DIA2.5 MM SYS L 143 CM,SUP-2104686,CDM,C1874,HCPCS,0278,RC,,,,both,,,4537.30,2949.24,,,,,,,,,,,,,
PLATE BNE L141MM 12 H S STL 1/3 TBLR LOK COMPR W/ CLLR FOR,SUP-2185941,CDM,C1713,HCPCS,0278,RC,,,,both,,,504.66,328.03,,,,,,,,,,,,,
TISURE 7 CMX10 CM 3PK,SUP-2402538,CDM,C1781,HCPCS,0278,RC,,,,both,,,989.10,642.91,,,,,,,,,,,,,
LIOTHYRONINE SODIUM 5 MCG PO TABS,RX-10443,CDM,6370000000,HCPCS,0637,RC,70377-0114-12,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
NAIL IM L360MM OD10MM TIB INTERCOMPRESSION,SUP-2362519,CDM,C1713,HCPCS,0278,RC,,,,both,,,1789.80,1163.37,,,,,,,,,,,,,
BRIMONIDINE TARTRATE 0.2 % OP SOLN,RX-17881,CDM,6370000000,HCPCS,0637,RC,24208-0411-05,NDC,,both,5,ML,65.30,42.44,,,,,,,,,,,,,
GRAFT BNE SUB 1CC DBM GEL FRZ DRY OPTIUM,SUP-2264856,CDM,C1713,HCPCS,0278,RC,,,,both,,,339.65,220.77,,,,,,,,,,,,,
TAP SURG L125MM OD27MM SM FRAG AO FIT FOR 27MM SCR,SUP-2377948,CDM,C1713,HCPCS,0278,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
BRACE WRISTXL L8IN RT FOAM LOOP LCK CLSR W/ THMB SPICA,SUP-2324354,CDM,L3931,HCPCS,0272,RC,,,,both,,,70.68,45.94,,,,,,,,,,,,,
STEM FEM SZ 0 CO CHROM LD,SUP-2210724,CDM,C1776,CPT,0278,RC,,,,both,,,3857.49,2507.37,,,,,,,,,,,,,
SCREW INTFR L30MM DIA8MM BIOCRYL RAPIDE ABSRB MILAGRO ADV,SUP-2249514,CDM,C1713,HCPCS,0278,RC,,,,both,,,1595.12,1036.83,,,,,,,,,,,,,
STENT CORONARY VERIFLEX MR L 12 MM DIA 3 MM SS RX BALLOON,SUP-2144487,CDM,C1876,HCPCS,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
COLLAR CERV XL H4XL20IN COT M DENS FOAM BRTH ADJ LO-CONTOUR,SUP-2335998,CDM,L0120,HCPCS,0274,RC,,,,both,,,13.53,8.79,,,,,,,,,,,,,
PLATE OPHTH L4 3 8IN LID RETRCT S STL JAEGER,SUP-2161099,CDM,C1713,HCPCS,0278,RC,,,,both,,,66.79,43.41,,,,,,,,,,,,,
GRAFT VASC FLX 7 MMX80 CM STD WALL N RING EPTFE CARBOFLO,SUP-2761506,CDM,C1768,CPT,0278,RC,,,,both,,,3906.79,2539.41,,,,,,,,,,,,,
PLATE BONE SM L52MM 4 H STD BILAT COMPR CNTOUR + FOR 3.5MM,SUP-2348991,CDM,C1713,HCPCS,0278,RC,,,,both,,,1200.05,780.03,,,,,,,,,,,,,
GRAFT EVAR STNT L20MM DIA10MM CATH L75CM SHTH 6FR N COAT,SUP-2142748,CDM,C1876,HCPCS,0278,RC,,,,both,,,3244.00,2108.60,,,,,,,,,,,,,
CONNECTOR SPNL CROSS,SUP-2211058,CDM,C1713,HCPCS,0278,RC,,,,both,,,2817.21,1831.19,,,,,,,,,,,,,
SPLINT WR AD M L1/8IN FOR 3.5-4.5IN BGE RT FRARM HND PRE FRM,SUP-2324807,CDM,L3906,HCPCS,0272,RC,,,,both,,,94.64,61.52,,,,,,,,,,,,,
SALVATION WIRE BOLT 2MM PREASSEMBLED WASHERLESS,SUP-2401136,CDM,2720000010,LOCAL,0272,RC,,,,both,,,731.62,475.55,,,,,,,,,,,,,
ABUTMENT OTO DIA9MM SND PROC DISP FOR PONTO SYS,SUP-2319873,CDM,L8690,HCPCS,0278,RC,,,,both,,,6578.30,4275.89,,,,,,,,,,,,,
PROBE ENDOSCP BPLR 350 CM,SUP-2308205,CDM,2720000010,LOCAL,0272,RC,,,,both,,,443.93,288.55,,,,,,,,,,,,,
PAD ORTHOT LUMBAR RIB CUST,SUP-2435574,CDM,L1040,HCPCS,0272,RC,,,,both,,,251.01,163.16,,,,,,,,,,,,,
SCREW BNE CANN 2.8X20 MM PART THRD BIODRIVE,SUP-2606679,CDM,C1713,HCPCS,0278,RC,,,,both,,,531.13,345.23,,,,,,,,,,,,,
GRAFT TIB STRUT ALLGRFT FRZN 20MMX200MM MATRIGRFT,SUP-2264789,CDM,C1713,HCPCS,0278,RC,,,,both,,,1278.07,830.75,,,,,,,,,,,,,
STEM FEM L317MM OD13MM BOW TRI SLOT PLSM SPRAYED HA DST HIP,SUP-2375912,CDM,C1776,CPT,0278,RC,,,,both,,,9793.03,6365.47,,,,,,,,,,,,,
FOLLOWER URETH BOUG TIP 8 FRX13.5 IN WOVEN PHIL DIL CATH,SUP-2126120,CDM,2720000010,LOCAL,0272,RC,,,,both,,,337.68,219.49,,,,,,,,,,,,,
SEED BRACHYTHERAPY FOR LOAD,SUP-2247275,CDM,C2642,HCPCS,0278,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
BRACE ORTH SAGITAL LUMBAR CTRL PREFABRICATED FLEXION,SUP-2388150,CDM,L0633,HCPCS,0274,RC,,,,both,,,738.50,480.02,,,,,,,,,,,,,
RING EXT FIX HALF 160 MM,SUP-2749879,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2816.58,1830.78,,,,,,,,,,,,,
ERGOCALCIFEROL 200 MCG/ML PO SOLN,RX-147614,CDM,340b,HCPCS,0637,RC,75834-0010-60,NDC,,both,0.25,ML,2.70,1.75,,,,,,,,,,,,,
DEVICE HEARING AD SZ 4MM W/ 6MM ABUTMENT COMP INSTR DISP FOR,SUP-2319875,CDM,L8690,HCPCS,0278,RC,,,,both,,,7222.00,4694.30,,,,,,,,,,,,,
OSS 5CM TAPERED DIAPH SEGMENT,SUP-2506337,CDM,C1776,CPT,0278,RC,,,,both,,,14356.08,9331.45,,,,,,,,,,,,,
PLATE BNE L 250.62 MM THK 2.8 MM LG TI DBL ANGLE NS DISP,SUP-2936878,CDM,C1713,HCPCS,0278,RC,,,,both,,,10519.00,6837.35,,,,,,,,,,,,,
PLATE X LCK 2.4/2.7MM 22X14 XS STRL,SUP-2547594,CDM,C1713,HCPCS,0278,RC,,,,both,,,2323.54,1510.30,,,,,,,,,,,,,
BIT DRL CANN 1.6X95 MM QC STRL,SUP-2563796,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1396.04,907.43,,,,,,,,,,,,,
DEFIBRILLATOR CRD BPLR ATR VENTRIC 2 CHMBR IS-1 ATLS DR,SUP-2356551,CDM,C1721,HCPCS,0275,RC,,,,both,,,69080.00,44902.00,,,,,,,,,,,,,
DISTRACTION INTRNL TUBE ADJ MDFCE BTTRSS ADJ LNGTH16 MM T 6L,SUP-2495471,CDM,C1713,HCPCS,0278,RC,,,,both,,,6497.01,4223.06,,,,,,,,,,,,,
CAGE SPNL STACKABLE 4 DEG LG 14X16X11 MM ANTR LUMBAR BENGAL,SUP-2256207,CDM,C1889,HCPCS,0278,RC,,,,both,,,7614.50,4949.42,,,,,,,,,,,,,
LINER BPLR OD57-60MM ID28MM UNIV FEM ACET,SUP-2344603,CDM,C1776,CPT,0278,RC,,,,both,,,436.93,284.00,,,,,,,,,,,,,
ALLOGRAFT BNE 1CC MTRX VIABLE BIO4,SUP-2362223,CDM,C1889,HCPCS,0278,RC,,,,both,,,1215.18,789.87,,,,,,,,,,,,,
WALKER PT M DIAB,SUP-2276716,CDM,L4387,HCPCS,0272,RC,,,,both,,,242.66,157.73,,,,,,,,,,,,,
SCREW BNE LCK 4X10 MM CANC STRL ALPS LTX,SUP-2861778,CDM,C1713,HCPCS,0278,RC,,,,both,,,1009.07,655.90,,,,,,,,,,,,,
SHEATH INTRO 5FR L12CM GWIRE 0.038IN ACT W/ SMOOTH TAPERS,SUP-2355637,CDM,C1894,HCPCS,0272,RC,,,,both,,,26.69,17.35,,,,,,,,,,,,,
PLATE CONDYLAR VA LCP TITANIUM CRVD  18HL RT 370MM,SUP-2653991,CDM,C1713,HCPCS,0278,RC,,,,both,,,6863.38,4461.20,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 80 CM DIA 8 MM STR TW HELIX,SUP-2484051,CDM,C1768,CPT,0278,RC,,,,both,,,2600.42,1690.27,,,,,,,,,,,,,
CATHETER CV 3L 12 FRX23 CM OTW HICKMAN TRIFUSION,SUP-2126183,CDM,C1751,HCPCS,0278,RC,,,,both,,,2764.61,1797.00,,,,,,,,,,,,,
GRAFT HUM TISS DIA21MM THK10MM MT LENGTHENING DISC,SUP-2321681,CDM,C1776,CPT,0278,RC,,,,both,,,8077.65,5250.47,,,,,,,,,,,,,
PLATE BONE L20MM 7 H TI NAR HYBRID COMPR FOR 4.5MM SCR ALPS,SUP-2413744,CDM,C1713,HCPCS,0278,RC,,,,both,,,840.26,546.17,,,,,,,,,,,,,
NAIL SURG L38MM DIA15MM HD FOR TRIATHLON REV KNEE SYS,SUP-2364726,CDM,C1713,HCPCS,0278,RC,,,,both,,,226.08,146.95,,,,,,,,,,,,,
GRAFT HUM TISS W7XL7CM CRYOPRESERVED AMNIO MEM LO PROF FOR,SUP-2116287,CDM,Q4148,HCPCS,0636,RC,,,,both,,,9090.30,5908.69,,,,,,,,,,,,,
GUIDEWIRE VASC ARW L 130 CM DIA 0.018 IN DSTL/PROX L 7,SUP-2384060,CDM,C1769,HCPCS,0272,RC,,,,both,,,455.83,296.29,,,,,,,,,,,,,
CRANIAL ACCESS KIT 5.31 MM W/ DRUG DRL BIT RAZOR,SUP-2852687,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1257.38,817.30,,,,,,,,,,,,,
STEM FEM REV CEM DEF PM SZ 00,SUP-2375346,CDM,C1776,CPT,0278,RC,,,,both,,,9418.12,6121.78,,,,,,,,,,,,,
INTRODUCER CATH 9FR 50CM BRAID WORLEY SAFSHTH,SUP-2282359,CDM,C1892,HCPCS,0272,RC,,,,both,,,664.90,432.18,,,,,,,,,,,,,
CATHETER PTCA L143CM BLLN L8MM DIA3.25MM 18ATM COR,SUP-2105045,CDM,C1725,HCPCS,0272,RC,,,,both,,,2033.12,1321.53,,,,,,,,,,,,,
GRAFT BNE STRP 100X20X5 MM DEMINERALIZED CORTICAL BNE INFLUX,SUP-2423706,CDM,C1713,HCPCS,0278,RC,,,,both,,,8462.30,5500.49,,,,,,,,,,,,,
PLATE BNE CONN 90 DEG 3 HOLE OFFSET NS,SUP-2800048,CDM,C1713,HCPCS,0278,RC,,,,both,,,325.59,211.63,,,,,,,,,,,,,
STENT URET UROGUIDE L 22 CM DIA 8.5 FR SIL NYL TETH HYDRPHLC,SUP-2480952,CDM,C2617,HCPCS,0278,RC,,,,both,,,352.53,229.14,,,,,,,,,,,,,
MESH HERN W4XL6IN MFIL RESRB RECT W/ HYDRGEL BARR SCFLD,SUP-2125882,CDM,C1781,HCPCS,0278,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
CATHETER CV MAXIMAL BARR TY 7 FRX20 CM 3L DRY SPECTRUM,SUP-2759882,CDM,C1751,HCPCS,0278,RC,,,,both,,,551.67,358.59,,,,,,,,,,,,,
PROBE ARTHSCP FOR SLIC SCR SYS NS BIOTRAK LF REUSE,SUP-2535223,CDM,2720000010,LOCAL,0272,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
GUIDEWIRE ORTH L230MM DIA2MM S STL THRD TIP SPADE PNT W/,SUP-2186889,CDM,C1769,HCPCS,0272,RC,,,,both,,,96.59,62.78,,,,,,,,,,,,,
PROBE SURG FUKUSHIMA-GIANNOTTA 7.25 IN STR RUGGLES-REDMOND,SUP-2465762,CDM,2720000010,LOCAL,0272,RC,,,,both,,,310.26,201.67,,,,,,,,,,,,,
BASKET RETRV L1550MM DIA32MM MIN WRK CHN 2MM 4 WIRE TRAP,SUP-2313130,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1161.11,754.72,,,,,,,,,,,,,
SUPPORT ORTHOT TRILATERAL CUST LEGG PERTHES ORTHOSIS,SUP-2435604,CDM,L1720,HCPCS,0272,RC,,,,both,,,4176.42,2714.67,,,,,,,,,,,,,
PLATE BNE FIBULAR LT LAT ANK 9 HOLE NS,SUP-2518405,CDM,C1713,HCPCS,0278,RC,,,,both,,,5570.36,3620.73,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.409,SUP-2859973,CDM,C1713,HCPCS,0278,RC,,,,both,,,33866.78,22013.41,,,,,,,,,,,,,
ATTACHMENT HNDPC L12.6CM STR INSTR SYS BLK MAX,SUP-2176911,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1770.96,1151.12,,,,,,,,,,,,,
SYSTEM HARVESTING GRAFT BONE 8MM OSTEOAUGER,SUP-2748438,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1596.69,1037.85,,,,,,,,,,,,,
BLADE SHV L8CM DIA3.5MM ENT ARTHSCP PRECIS CUT AGG SERR,SUP-2363531,CDM,2720000010,LOCAL,0272,RC,,,,both,,,474.36,308.33,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 80 CM DIA 5 MM RNG L 70 CM EPTFE,SUP-2396288,CDM,C1768,CPT,0278,RC,,,,both,,,4129.10,2683.91,,,,,,,,,,,,,
DIGIFUSE IMPLANT 2.0MM 0 DEGREE ANGLE SHRT,SUP-2586637,CDM,C1713,HCPCS,0278,RC,,,,both,,,5736.84,3728.95,,,,,,,,,,,,,
BASKET STONE 31 MM 2Q MECH LITHO,SUP-2492310,CDM,2720000010,LOCAL,0272,RC,,,,both,,,721.32,468.86,,,,,,,,,,,,,
GRAFT VASC GORTX L 70 CM DIA10 MM EPTFE STR STD WALL N RING,SUP-2396439,CDM,C1768,CPT,0278,RC,,,,both,,,2753.78,1789.96,,,,,,,,,,,,,
CABLE ELECSURG BPLR GENERATOR/IRRIGATOR INTERCONNECT NS LTX,SUP-2859253,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1509.74,981.33,,,,,,,,,,,,,
MESH DERM IMPL SFT TISS MTRX PORCINE 2X16CM INTEXEN LP,SUP-2140307,CDM,C1763,HCPCS,0278,RC,,,,both,,,1595.91,1037.34,,,,,,,,,,,,,
CONNECTOR NRV L15MM DIA5MM PORCINE EXTRACELLULAR MTRX,SUP-2124868,CDM,C1763,HCPCS,0278,RC,,,,both,,,6889.16,4477.95,,,,,,,,,,,,,
CETIRIZINE HCL 5 MG/5ML PO SOLN,RX-125364,CDM,6370000000,HCPCS,0637,RC,09999-9912-11,NDC,,both,2.5,ML,2.70,1.75,,,,,,,,,,,,,
PLATE BNE SET FOR SM LOWER EXTREMITY PERI-LOC,SUP-2351409,CDM,C1713,HCPCS,0278,RC,,,,both,,,6594.00,4286.10,,,,,,,,,,,,,
SCREW SPNL MULTAXL 4.5X50 MM 6.35 MM PEDCL FOR ROD RED LEG,SUP-2288978,CDM,C1713,HCPCS,0278,RC,,,,both,,,2088.10,1357.26,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 10 CM DIA 5 MM EPTFE STR TW N RING,SUP-2396333,CDM,C1768,CPT,0278,RC,,,,both,,,1011.08,657.20,,,,,,,,,,,,,
PLATE BONE 2 H STR RIG GRD 1/3 COMMERCIALLY PURE TI CRAN,SUP-2277530,CDM,C1713,HCPCS,0278,RC,,,,both,,,147.71,96.01,,,,,,,,,,,,,
NEEDLE CIRCLE 1/2 IN SUTURE TAPER L1.950IN DIA0.056IN ABD S STL,SUP-2387188,CDM,2720000010,LOCAL,0272,RC,,,,both,,,9.36,6.08,,,,,,,,,,,,,
PLATE BNE T 8 HOLE W/ PF HOLE FOR LG FRAG SET TC-100,SUP-2196669,CDM,C1713,HCPCS,0278,RC,,,,both,,,828.96,538.82,,,,,,,,,,,,,
GUIDEWIRE ORTH DIA15MM BITE 4 55MM COMPR SCR,SUP-2315941,CDM,C1769,HCPCS,0272,RC,,,,both,,,252.99,164.44,,,,,,,,,,,,,
STENT GRFT VASC AFX L 95 MM UNCOVERED L 20 MM DIA 25 MM,SUP-2217595,CDM,C1768,CPT,0278,RC,,,,both,,,11727.90,7623.13,,,,,,,,,,,,,
CATHETER VALVULOPLASTY TYSHAK L 70 CM DIA 3.5 FR 3 CM 5 MM,SUP-2659381,CDM,C1725,HCPCS,0272,RC,,,,both,,,1684.30,1094.79,,,,,,,,,,,,,
STEM FEM SEG 5 CM DPHSEAL KNEE SMOOTH OSS,SUP-2449807,CDM,C1776,CPT,0278,RC,,,,both,,,10905.53,7088.59,,,,,,,,,,,,,
STENT BILI WALLFLEX L 60 MM DIA 8 MM CATH L 75 CM DIA 8 FR,SUP-2141601,CDM,C1876,HCPCS,0278,RC,,,,both,,,8079.22,5251.49,,,,,,,,,,,,,
HC Custom Hand/Finger Static,PX-2740391301,CDM,L3913,HCPCS,0272,RC,,,,inpatient,,,900.00,585.00,,,,,,,,,,,,,
HC Cyanocobalamin Vitamin B-12,PX-3018260700,CDM,82607,CPT,0301,RC,,,,both,,,93.00,60.45,,,,,,,,,,,,,
GRAFT BNE 10 CC KIR FILL SYNTH,SUP-2430788,CDM,C1713,HCPCS,0278,RC,,,,both,,,5944.02,3863.61,,,,,,,,,,,,,
PLATE BNE L 73 MM SCREW DIA2 MM 5 HD 10 SHFT H SS T SHP VA ST,SUP-2909158,CDM,C1713,HCPCS,0278,RC,,,,both,,,3114.03,2024.12,,,,,,,,,,,,,
RING EXT FIX DIA130 MM LG FT NS DISP TSF,SUP-2933056,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4914.10,3194.16,,,,,,,,,,,,,
STEM HUM 6 150 DEG 6X101 MM SHLDR RASP TI,SUP-2427330,CDM,C1776,CPT,0278,RC,,,,both,,,9253.58,6014.83,,,,,,,,,,,,,
SET PICC L 20CM DIA 4FR SHTH L 7CM DIA 4FR,SUP-2887213,CDM,C1751,HCPCS,0278,RC,,,,both,,,275.69,179.20,,,,,,,,,,,,,
CROWN FORM DENT STRP U3 PRIMARY ANTR UPPER LT LAT PLAS,SUP-2322247,CDM,D6783,CPT,0278,RC,,,,both,,,40.44,26.29,,,,,,,,,,,,,
HEAD RAD DIA22MM LT ARH SYS SLIDE-LOC,SUP-2106903,CDM,C1776,CPT,0278,RC,,,,both,,,29588.22,19232.34,,,,,,,,,,,,,
GRAFT HUM TISS W7XL10CM THK1MM PROC DERM CLLGN RECTANG,SUP-2126259,CDM,C1781,HCPCS,0278,RC,,,,both,,,4906.25,3189.06,,,,,,,,,,,,,
LINER ACET DIA28MM 10DEG CONSTRN M SER S ROM,SUP-2253362,CDM,C1776,CPT,0278,RC,,,,both,,,6889.79,4478.36,,,,,,,,,,,,,
HC Custom Hand/Finger Static,PX-2740391301,CDM,L3913,HCPCS,0274,RC,,,,inpatient,,,900.00,585.00,,,,,,,,,,,,,
PLATE BNE STR 2-2.5X33X1.5 MM 4 HOLE FRAC TI STRL LEVEL 1,SUP-2475303,CDM,C1713,HCPCS,0278,RC,,,,both,,,1503.18,977.07,,,,,,,,,,,,,
ALLOGRAFT BNE STRUT 6-10 CM SEG FD FIB,SUP-2321798,CDM,C1713,HCPCS,0278,RC,,,,both,,,1654.78,1075.61,,,,,,,,,,,,,
GRAFT IMPL HUM TISS FRZ DRY ALLGRFT HUM SHFT BNE 60MM LEN,SUP-2307199,CDM,C1713,HCPCS,0278,RC,,,,both,,,2508.83,1630.74,,,,,,,,,,,,,
BIT DRL L190MM DIA12MM STRL TI CANN QUIK CPL W/O STP,SUP-2188299,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2171.78,1411.66,,,,,,,,,,,,,
PUMP BRST DBL ELECTR STAND NS PMP IN STYL MAXFLOW LF,SUP-2858135,CDM,2720000010,LOCAL,0272,RC,,,,both,,,499.26,324.52,,,,,,,,,,,,,
TAP SURG L 50 MM DIA1.7 MM SCREW DIA 5/6 MM SD DENT NS DISP,SUP-2909582,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1038.46,675.00,,,,,,,,,,,,,
LEAD PACE CAPSUR SENSE MRI SURESCAN L 53 CM DIA 5.3 FR,SUP-2281943,CDM,C1898,HCPCS,0275,RC,,,,both,,,1174.86,763.66,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.503,SUP-2860020,CDM,C1713,HCPCS,0278,RC,,,,both,,,33943.71,22063.41,,,,,,,,,,,,,
LINER ACET 42X54 MM HIP 2 MOBILITY XLPE OR3O,SUP-2434985,CDM,C1776,CPT,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
GRAFT ENDOVASC L2.5CM OD5MM CATH L120CM STENT FEM IL AV ACC,SUP-2396628,CDM,C1874,HCPCS,0278,RC,,,,both,,,10267.80,6674.07,,,,,,,,,,,,,
CATHETER GUID NAVICROSS L 135 CM DIA 1.39 MM L 40 CM ANGLED,SUP-2385614,CDM,C1887,HCPCS,0272,RC,,,,both,,,700.53,455.34,,,,,,,,,,,,,
HC Thoracic Fascial Plane Block Uni Injection,PX-3606446600,CDM,64466,CPT,0360,RC,,,,both,,,996.00,647.40,,,,,,,,,,,,,
GUIDEWIRE ORTH DIA1.37MM SMOOTH BLNT TIP DISP VIPER 2,SUP-2255667,CDM,C1769,HCPCS,0272,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
ANCHOR SPNL LUMBAR 27 MM INDEPENDENCE MIS,SUP-2663500,CDM,C1713,HCPCS,0278,RC,,,,both,,,2041.00,1326.65,,,,,,,,,,,,,
PLATE BONE L 3X3 H MAND TI CRESC SHP FOR 2MM SCR FIX LCKING,SUP-2191239,CDM,C1713,HCPCS,0278,RC,,,,both,,,4035.53,2623.09,,,,,,,,,,,,,
PLATE BONE L MINI 2 MM RIGHT MANDIBULAR LOCKING MALLEABLE TI,SUP-2838416,CDM,C1713,HCPCS,0278,RC,,,,both,,,1136.37,738.64,,,,,,,,,,,,,
SHEATH DIL TAPR 20 FRX17 CM KINK-RESISTANT PTFE AMPLATZ,SUP-2481236,CDM,C1894,HCPCS,0272,RC,,,,both,,,134.74,87.58,,,,,,,,,,,,,
HC Clsd Tx IP Disloc WO Anes,PX-4502866000,CDM,28660,CPT,0450,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
PORT INFUS 8FR TI PWR INJ ATTACH CHRONOFLEX CATH SIL FIL SUT,SUP-2127820,CDM,C1788,HCPCS,0278,RC,,,,both,,,1365.90,887.83,,,,,,,,,,,,,
CUP ACET FLNG C HIP CUST,SUP-2419096,CDM,C1776,CPT,0278,RC,,,,both,,,42704.00,27757.60,,,,,,,,,,,,,
GUIDEWIRE VASC L180CM DIA0.035IN L4CM DIA1.5MM J TIP PTFE S,SUP-2148286,CDM,C1769,HCPCS,0272,RC,,,,both,,,24.81,16.13,,,,,,,,,,,,,
PACEMAKER CARD ACCOLADE W 4.45 X H 4.81 CM THK 0.75 CM 13.2,SUP-2149248,CDM,C1786,HCPCS,0275,RC,,,,both,,,9938.10,6459.76,,,,,,,,,,,,,
PLATE CRAN L 45.7 X W 45.7 MM THK 0.5 MM SCREW DIA1.5 MM SM,SUP-2936881,CDM,C1713,HCPCS,0278,RC,,,,both,,,2719.24,1767.51,,,,,,,,,,,,,
SUTURE TIGERTAPE CERCLAGE W/O NEEDLE,SUP-2761686,CDM,C1713,HCPCS,0278,RC,,,,both,,,1491.50,969.47,,,,,,,,,,,,,
MESH GYN POLYPRO OR PPL Y SHP CNTOUR VPS PORE SACR TAIL,SUP-2896111,CDM,C1781,HCPCS,0278,RC,,,,both,,,4138.52,2690.04,,,,,,,,,,,,,
SCREW BNE L12MM DIA5MM NONSTERILE UNICORTICAL TI ST,SUP-2181299,CDM,C1713,HCPCS,0278,RC,,,,both,,,636.42,413.67,,,,,,,,,,,,,
RITUXIMAB (RITUXAN) 10 MG/ML IV SOLN (MIXTURES ONLY),RX-430010,CDM,J9312,HCPCS,0636,RC,50242-0053-06,NDC,,both,50,ML,13529.10,8793.91,,,,,,,,,,,,,
PLATE BNE CRV 4.5X195 MM LT CNDYL 8 HOLE VA LCK NS VA-LCP,SUP-2758212,CDM,C1713,HCPCS,0278,RC,,,,both,,,5544.86,3604.16,,,,,,,,,,,,,
CATH 7/110/2.5/7-4 QUAD STD,SUP-2424678,CDM,C1732,HCPCS,0278,RC,,,,both,,,7379.00,4796.35,,,,,,,,,,,,,
ENDOPROSTHESIS VASC VIABAHN L 10CM 6MM 120CM 6FR RADIOPAQUE,SUP-2396647,CDM,C1874,HCPCS,0278,RC,,,,both,,,11818.96,7682.32,,,,,,,,,,,,,
BLADE RTRCTR MED 45MMW X 130MML TTNM SPNL PRNGX5 LIGHT BLUE,SUP-2460989,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1164.85,757.15,,,,,,,,,,,,,
PLATE BNE L 241 MM SCREW DIA 4.5 MM 14 H NAR COMPR LCK NS,SUP-2932937,CDM,C1713,HCPCS,0278,RC,,,,both,,,2296.91,1492.99,,,,,,,,,,,,,
BAR CRV FIBERGLASS 380MM,SUP-2484869,CDM,C1713,HCPCS,0278,RC,,,,both,,,1852.57,1204.17,,,,,,,,,,,,,
GRAFT BNE 10MM CERV CORT,SUP-2364366,CDM,C1762,CPT,0278,RC,,,,both,,,4504.33,2927.81,,,,,,,,,,,,,
LINER ACET LAT J 35 DEG 36X66-68 MM HIP XLPE REFLECTION,SUP-2434811,CDM,C1776,CPT,0278,RC,,,,both,,,7429.24,4829.01,,,,,,,,,,,,,
COLLAR CERV PED 3IN 16IN M HEADMASTER,SUP-2324112,CDM,L0180,HCPCS,0274,RC,,,,both,,,262.19,170.42,,,,,,,,,,,,,
GRAFT VASC STR THN WALL N RNGD EPTFE SM BEAD 8MM DIA 80CM,SUP-2128212,CDM,C1768,CPT,0278,RC,,,,both,,,9659.14,6278.44,,,,,,,,,,,,,
SCAFFOLD SFT TISS FLOWABLE 1CC GRFTJKT,SUP-2399101,CDM,Q4113,HCPCS,0636,RC,,,,both,,,2818.15,1831.80,,,,,,,,,,,,,
OXYCODONE-ACETAMINOPHEN 5-325 MG PO TABS,RX-5940,CDM,6370000000,HCPCS,0637,RC,00406-0512-62,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
COIL EMB L40CM DIA10MM 360DEG SFT DETACH TARGET XL,SUP-2367752,CDM,C1889,HCPCS,0278,RC,,,,both,,,9420.00,6123.00,,,,,,,,,,,,,
BUR SURG M L8MM DIA4MM S STL OVL DMND FOR SM BONE,SUP-2166714,CDM,C1713,HCPCS,0278,RC,,,,both,,,353.72,229.92,,,,,,,,,,,,,
SPLINT WRST FA 6IN UNIV BLU L LOOP LOK W STAY COCK UP CANVS,SUP-2194434,CDM,L3809,HCPCS,0274,RC,,,,both,,,35.86,23.31,,,,,,,,,,,,,
SHUNT SURG ASCITES DBL VLV,SUP-2153662,CDM,C1729,HCPCS,0272,RC,,,,both,,,3450.86,2243.06,,,,,,,,,,,,,
ALLOGRAFT BNE PLATE 30X15X1 MM PRESERVON CORTICAL ORAGRAFT,SUP-2740943,CDM,C1713,HCPCS,0278,RC,,,,both,,,1146.60,745.29,,,,,,,,,,,,,
CATHETER CV JACC 5.5 FRX35 CM DL PRESSURE INJ ADV LF,SUP-2763381,CDM,C1751,HCPCS,0278,RC,,,,both,,,814.30,529.29,,,,,,,,,,,,,
KIT DISP MINI W/ AC 1 SEP TUBE TWO 30ML SYR 1 10ML SYR 1,SUP-2402585,CDM,C1713,HCPCS,0278,RC,,,,both,,,1356.48,881.71,,,,,,,,,,,,,
SUTURE ANCHR L15.5MM DIA6.5MM TI TWO 2 FIBERWIRE CRKSCR,SUP-2121529,CDM,C1713,HCPCS,0278,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
SHELL ACET TRIANG MILLER FRAME S-ROM,SUP-2455233,CDM,C1776,CPT,0278,RC,,,,both,,,5447.90,3541.13,,,,,,,,,,,,,
MICROCATHETER INTRVNTNL 0.021N ID 130CML NTNL STRGHT ROX 1 T,SUP-2652844,CDM,C1887,HCPCS,0272,RC,,,,both,,,2292.20,1489.93,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY RADIA L 95 CM DIA 7 FR SPC 2-14-2,SUP-2142361,CDM,C1731,HCPCS,0278,RC,,,,both,,,2983.00,1938.95,,,,,,,,,,,,,
ALLOGRAFT DERMAL 4X8 CMX3-3.3 MM DERMASPAN ACD,SUP-2866896,CDM,Q4126,HCPCS,0636,RC,,,,both,,,4939.85,3210.90,,,,,,,,,,,,,
SYNDESMOTIC DRILL 3.5MM,SUP-2841620,CDM,2720000010,LOCAL,0272,RC,,,,both,,,489.84,318.40,,,,,,,,,,,,,
CAGE SPNL 12-17 MM BLK CALIB,SUP-2229227,CDM,C1889,HCPCS,0278,RC,,,,both,,,14130.00,9184.50,,,,,,,,,,,,,
PROSTHESIS VOICE LO PRESSURE 16 FRX22 MM BLOM-SINGER,SUP-2242433,CDM,L8507,HCPCS,0274,RC,,,,both,,,514.96,334.72,,,,,,,,,,,,,
MESH HERN W3XL6IN POLYPR MID WT MFIL RECTANG OVL FLAT SH,SUP-2265904,CDM,C1781,HCPCS,0278,RC,,,,both,,,86.35,56.13,,,,,,,,,,,,,
CATHETER URET POLYVINYLCHLORIDE OPN END MOD ACCEPTS INSTR,SUP-2168915,CDM,C1758,HCPCS,0278,RC,,,,both,,,43.55,28.31,,,,,,,,,,,,,
MESH CRAN W206XL123MM THK0.6MM SLV TI CNTOUR FOR 1.5MM,SUP-2135905,CDM,C1713,HCPCS,0278,RC,,,,both,,,8625.58,5606.63,,,,,,,,,,,,,
COLLAR CERV REG DENS SHT TWO PC PED ATLS,SUP-2319289,CDM,L0140,HCPCS,0272,RC,,,,both,,,48.32,31.41,,,,,,,,,,,,,
INTRODUCER VASC HEMSTAS VLV W/ 60 DEG CRV 7FRX40CM FAST CATH,SUP-2355590,CDM,C1894,HCPCS,0272,RC,,,,both,,,124.82,81.13,,,,,,,,,,,,,
PROSTHESIS OSSCLR LITE TOTAL 3MM DIA HEAD 08MM/23MM DIA DS,SUP-2681501,CDM,L8613,CPT,0278,RC,,,,both,,,1381.25,897.81,,,,,,,,,,,,,
GRAFT BNE GEL 1 CC DBM GRFT,SUP-2306988,CDM,C1713,HCPCS,0278,RC,,,,both,,,596.60,387.79,,,,,,,,,,,,,
SAW CAST ENGEL 5-5/8 INX73 MM SATIN FINISH SS REUSE,SUP-2468748,CDM,2720000010,LOCAL,0272,RC,,,,both,,,664.30,431.79,,,,,,,,,,,,,
CATHETER DRNGE 12FR 40CM BILI TOT ABSCESSION,SUP-2118569,CDM,C1729,HCPCS,0272,RC,,,,both,,,237.70,154.50,,,,,,,,,,,,,
PLATE CRAN 200X60X40 MM PT SPEC IMPL PEEK,SUP-2860137,CDM,C1713,HCPCS,0278,RC,,,,both,,,32682.06,21243.34,,,,,,,,,,,,,
BIT DRL 6.5X210 MM AEQUALIS,SUP-2715484,CDM,2720000010,LOCAL,0272,RC,,,,both,,,686.09,445.96,,,,,,,,,,,,,
CATHETER DIAG L 10 CM PLAS MEWISSEN INFUSION MPEN-18 STRL,SUP-2140126,CDM,C1725,HCPCS,0272,RC,,,,both,,,236.54,153.75,,,,,,,,,,,,,
GRAFT HUM TISS W4XL8CM THN AMNIO BARR MEM CHORION FREE,SUP-2399186,CDM,C1762,CPT,0278,RC,,,,both,,,10085.68,6555.69,,,,,,,,,,,,,
BLADE SAW OSCILLATING 90X19X1 MM,SUP-2607491,CDM,2720000010,LOCAL,0272,RC,,,,both,,,73.98,48.09,,,,,,,,,,,,,
CATHETER EP CRD 5-5-5 MM SPC 6 FRX120 CM QPLR,SUP-2357016,CDM,C1730,HCPCS,0272,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
ENVELOPE PLSE GENRTR M W2.7XL2.5IN NEURO ANTIBACT ABSRB,SUP-2281260,CDM,C1889,HCPCS,0278,RC,,,,both,,,3124.30,2030.79,,,,,,,,,,,,,
HEPARIN SODIUM (PORCINE) 5000 UNIT/ML IJ SOLN,RX-10181,CDM,J1644,HCPCS,0636,RC,00409-2723-30,NDC,,both,0.5,ML,54.10,35.16,,,,,,,,,,,,,
SUPPORT ORTHOT ELBW CUST OFF-THE-SHELF W/MTL JT ELASTIC,SUP-2435757,CDM,L3710,HCPCS,0274,RC,,,,both,,,367.91,239.14,,,,,,,,,,,,,
KIT BNE GRFT SUB 25CC BEAD STD CURE RESRB INCL 2 MOLD,SUP-2399034,CDM,C1713,HCPCS,0278,RC,,,,both,,,3428.88,2228.77,,,,,,,,,,,,,
HC Rep Lac Smp Face 2.6-5.0 Cm,PX-4501201300,CDM,12013,CPT,0450,RC,,,,outpatient,,,632.00,410.80,,,,,,,,,,,,,
GRAFT BNE SUB M 5ML CANC DBM FRMBL CELLULAR VIVIGEN,SUP-2264670,CDM,C1713,HCPCS,0278,RC,,,,both,,,9052.24,5883.96,,,,,,,,,,,,,
SET STRL FOR 4.5MM CNDYL LCP PLT,SUP-2183063,CDM,C1713,HCPCS,0278,RC,,,,both,,,61413.25,39918.61,,,,,,,,,,,,,
KIT THROMCTMY 4MAX L 139 CM PROX/DSTL OD 6 FR/1.42 MM,SUP-2323545,CDM,C1887,HCPCS,0272,RC,,,,both,,,5683.40,3694.21,,,,,,,,,,,,,
STENT ESOPH L7CM OD18MM ODSEC23MM .038IN SELF EXP,SUP-2139595,CDM,C1874,HCPCS,0278,RC,,,,both,,,3.14,2.04,,,,,,,,,,,,,
RING EXT FIX FULL 140 MM CIR SIDEKCK,SUP-2850515,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2282.78,1483.81,,,,,,,,,,,,,
MARKER BREAST TUMARK PROFESS Q FOR BREVERA STD,SUP-2662948,CDM,A4648,CPT,0278,RC,,,,both,,,245.61,159.65,,,,,,,,,,,,,
AMPICILLIN-SULBACTAM 1500 (1000-500) MG IJ (MIXTURES ONLY),RX-430056,CDM,J0295,HCPCS,0636,RC,00641-6116-10,NDC,,both,1,UN,54.10,35.16,,,,,,,,,,,,,
KNIFE SRGCL BLLNGR 4MM BLADE 8NL BNT SWVL LATEX FREE,SUP-2494181,CDM,2720000010,LOCAL,0272,RC,,,,both,,,371.59,241.53,,,,,,,,,,,,,
POST EXT FIX CIR FEMALE 1 HOLE,SUP-2400606,CDM,2720000010,LOCAL,0272,RC,,,,both,,,350.27,227.68,,,,,,,,,,,,,
SUPPORT ORTHOT HND FNGR CUST ADJ FIT STRP W/O JT FABRICATED,SUP-2435775,CDM,L3913,HCPCS,0274,RC,,,,both,,,697.80,453.57,,,,,,,,,,,,,
AGENT HEMSTAT 2GM ABSRB SYNTH BONE PUTTY W/ SPAT,SUP-2106297,CDM,C1713,HCPCS,0278,RC,,,,both,,,467.86,304.11,,,,,,,,,,,,,
HOLDER NDLE TRTMN 4 3/4NL 9MML JAW CRVD ROUND HNDLE DLCTE W/,SUP-2476573,CDM,2720000010,LOCAL,0272,RC,,,,both,,,780.76,507.49,,,,,,,,,,,,,
DEVICE INFL 60ML 12ATM CONVENIENT LOK REL HNDL HI PRSS FLX,SUP-2302540,CDM,C1713,HCPCS,0278,RC,,,,both,,,141.30,91.84,,,,,,,,,,,,,
HC Intro Cath Dialysis Circuit W Pta,PX-3613690200,CDM,36902,CPT,0361,RC,,,,both,,,10303.00,6696.95,,,,,,,,,,,,,
PROSTHESIS OSS PISTON 0.8X4.25 MM MCGEE SS,SUP-2637755,CDM,L8613,CPT,0278,RC,,,,both,,,272.33,177.01,,,,,,,,,,,,,
GRAFT STENT 0.035 IN 7 MMX10 CM 8 FRX75 CM EPTFE VIABAHN,SUP-2396506,CDM,C1874,HCPCS,0278,RC,,,,both,,,9263.00,6020.95,,,,,,,,,,,,,
SPACER FEM SZ 1 THICKNESS 5MM TI LT MEDL KNEE PRI PRESSFIT,SUP-2208353,CDM,C1776,CPT,0278,RC,,,,both,,,4634.64,3012.52,,,,,,,,,,,,,
WASHER ORTH LT FEM NK LCK STRL CONQ FN,SUP-2933443,CDM,C1713,HCPCS,0278,RC,,,,both,,,6208.57,4035.57,,,,,,,,,,,,,
PLATE BNE L 1 MM LT 9 HOLE SS NS,SUP-2183610,CDM,C1713,HCPCS,0278,RC,,,,both,,,788.45,512.49,,,,,,,,,,,,,
GRAFT HUM TISS W5XL5CM PLCNTA MEM CRYOPRESERVED AMNION MTRX,SUP-2319164,CDM,Q4133,HCPCS,0636,RC,,,,both,,,8478.00,5510.70,,,,,,,,,,,,,
GUIDEWIRE ORTH L12IN OD1.5MM BLNT TIP CALIB MRK SCR DISP,SUP-2341338,CDM,C1769,HCPCS,0272,RC,,,,both,,,139.23,90.50,,,,,,,,,,,,,
PLATE BNE L 120.7 X W 8.3 MM THK 2.6 MM SCREW DIA2/2.3 MM 16,SUP-2936754,CDM,C1713,HCPCS,0278,RC,,,,both,,,5780.74,3757.48,,,,,,,,,,,,,
PAD ORTHOT THOR CUST,SUP-2435576,CDM,L1060,HCPCS,0274,RC,,,,both,,,306.62,199.30,,,,,,,,,,,,,
ROD SPNL TEND 3 MMX24.5 CM,SUP-2559087,CDM,C1713,HCPCS,0278,RC,,,,both,,,3554.48,2310.41,,,,,,,,,,,,,
METHOCARBAMOL 500 MG PO TABS,RX-4971,CDM,6370000000,HCPCS,0637,RC,31722-0533-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
SPACER SPNL 24X14X18 MM PEEK,SUP-2211891,CDM,C1821,HCPCS,0278,RC,,,,both,,,17816.36,11580.63,,,,,,,,,,,,,
WAND ARTHSCP 7.5IN MINI COBLATOR FOR LARYN SURG DISP,SUP-2342036,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1868.30,1214.39,,,,,,,,,,,,,
HEAD FEM 40 MM HIP BIOLOX DELT,SUP-2448640,CDM,C1776,CPT,0278,RC,,,,both,,,19386.36,12601.13,,,,,,,,,,,,,
GRAFT HUM TISS THK19-21MM IL CREST WDG TRICORT STRUCTURAL,SUP-2307028,CDM,C1713,HCPCS,0278,RC,,,,both,,,3463.42,2251.22,,,,,,,,,,,,,
"HC So Antidiuretic Hormone, Plasma",PX-3018458866,CDM,84588,CPT,0301,RC,,,,outpatient,,,74.00,48.10,,,,,,,,,,,,,
CATHETER ETER HAD ADMIN LNG TERM STR 145FRX28CM HEMO FLOW,SUP-2266974,CDM,C1750,HCPCS,0278,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
TOOL SZ DISSECTION/TRANSECTION DEV MULTITASC,SUP-2264264,CDM,2720000010,LOCAL,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
BURR DIAMOND MATCHSTICK 3.2MM L8NSDG1,SUP-2843296,CDM,2720000010,LOCAL,0272,RC,,,,both,,,449.84,292.40,,,,,,,,,,,,,
GUIDEWIRE VASC INQWIRE L 260 CM DIA 0.035 IN TIP L 10 CM,SUP-2701662,CDM,C1769,HCPCS,0272,RC,,,,both,,,34.29,22.29,,,,,,,,,,,,,
STEM FEM SZ 6 L159MM HI OFFSET CEMENTLESS PLATFRM,SUP-2351066,CDM,C1776,CPT,0278,RC,,,,both,,,13062.40,8490.56,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE 1-4 MM 15 CC CORTICOCANCELLOUS PROX,SUP-2913190,CDM,C1713,HCPCS,0278,RC,,,,both,,,2631.32,1710.36,,,,,,,,,,,,,
DILATOR UROLOGICAL SET 6-18 FRX37 CM FASCIAL PTFE,SUP-2835676,CDM,C2627,HCPCS,0272,RC,,,,both,,,996.64,647.82,,,,,,,,,,,,,
SET SCR SPNL TI INNR FOR 5.5MM ROD MOSS MIAMI,SUP-2254435,CDM,C1713,HCPCS,0278,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
LENS IOL BCNVX 6.5+ DIOPT 12.5 MM PMMA PLEXIGLAS,SUP-2129731,CDM,V2630,CPT,0276,RC,,,,both,,,78.50,51.02,,,,,,,,,,,,,
COMPONENT FEM L7CM RT DSTL HIP POLY REDUC SZ ELLIP SEG ORTH,SUP-2406471,CDM,C1776,CPT,0278,RC,,,,both,,,18905.94,12288.86,,,,,,,,,,,,,
NAIL IM L200MM DIA12MM NONSTERILE AQUA L/R DSTL FEM TI LCK,SUP-2191772,CDM,C1713,HCPCS,0278,RC,,,,both,,,4988.96,3242.82,,,,,,,,,,,,,
ELECTRODE EMG W2XL12MM SUBDERM GRN WHT S STL NDL 2 CHN PR,SUP-2284323,CDM,C1713,HCPCS,0278,RC,,,,both,,,346.97,225.53,,,,,,,,,,,,,
SCREW BONE L51MM OD3.5MM 6 CRUCFRM RECESS COARSE THRD WDRUFF,SUP-2362303,CDM,C1713,HCPCS,0278,RC,,,,both,,,24.49,15.92,,,,,,,,,,,,,
HC So Intrinsic Factor Antibodies,PX-3028634066,CDM,86340,CPT,0302,RC,,,,inpatient,,,140.00,91.00,,,,,,,,,,,,,
HC ER Level 3,PX-4509928300,CDM,99283,CPT,0450,RC,,,,inpatient,,,1556.00,1011.40,,,,,,,,,,,,,
PLATE BNE L178MM 8 H ST L MED PROX TIB S STL LOK COMPR LO,SUP-2185677,CDM,C1713,HCPCS,0278,RC,,,,both,,,4642.68,3017.74,,,,,,,,,,,,,
CROWN DENT E7 2ND PRIMARY M UPPER LT SS 5009568] PATTERSON DENTAL SUPPLY],SUP-2322218,CDM,D6783,CPT,0278,RC,,,,both,,,33.35,21.68,,,,,,,,,,,,,
INSERT TIB SZ 3 THK20MM STD CNDYL KNEE CONSTRN REV ADV II,SUP-2304730,CDM,C1776,CPT,0278,RC,,,,both,,,726.91,472.49,,,,,,,,,,,,,
BIT DRILL EXTRACTION SZ 2 MM SCREW DIA1.5-2 MM STRL DISP,SUP-2913631,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2472.75,1607.29,,,,,,,,,,,,,
SCREW BONE L75MM OD3.5MM STD TI CORT ST NONCANNULATED,SUP-2413385,CDM,C1713,HCPCS,0278,RC,,,,both,,,200.02,130.01,,,,,,,,,,,,,
SYRINGE MED 1 CC DEFLUX PREFIL 1092203] MCKESSON GENERAL MEDICAL],SUP-2266607,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5964.27,3876.78,,,,,,,,,,,,,
PLATE BONE L54MM THK1.4MM SHFT W7.5MM HD 19.8MM 6 H STRL,SUP-2349709,CDM,C1713,HCPCS,0278,RC,,,,both,,,5101.72,3316.12,,,,,,,,,,,,,
SET ORTH GRPHC CA W/ PLT FOR 3.5MM DSTL MEDL TIB W/OUT TAB,SUP-2177072,CDM,C1776,CPT,0278,RC,,,,both,,,67061.61,43590.05,,,,,,,,,,,,,
PLATE BNE BROAD 5.5X270 MM 15 HOLE SS LCP,SUP-2569376,CDM,C1713,HCPCS,0278,RC,,,,both,,,958.49,623.02,,,,,,,,,,,,,
SCREW BNE PED L12MM DIA3.5MM L R CORT PROX FEM TIB S STL ST,SUP-2318504,CDM,C1713,HCPCS,0278,RC,,,,both,,,207.49,134.87,,,,,,,,,,,,,
PLATE BNE STR MIC MED 1.5 MM CRANIOMAXILLOFACIAL 4 HOLE TI,SUP-2465718,CDM,C1713,HCPCS,0278,RC,,,,both,,,255.69,166.20,,,,,,,,,,,,,
TRIAMCINOLONE ACETONIDE 0.1 % EX OINT,RX-8118,CDM,6370000000,HCPCS,0637,RC,45802-0055-35,NDC,,both,15,GR,20.40,13.26,,,,,,,,,,,,,
BLADE SAW 31.8X.64X61.0MM HVY DUTY SAG,SUP-2367218,CDM,C1713,HCPCS,0278,RC,,,,both,,,339.12,220.43,,,,,,,,,,,,,
BIT DRL 3.8X45 MM QUICKSET,SUP-2454002,CDM,2720000010,LOCAL,0272,RC,,,,both,,,779.98,506.99,,,,,,,,,,,,,
ANCHOR SUTURE 1-0 SHT 1.4X1 MM SINGLE LD WHT JUGGERKNOT,SUP-2745512,CDM,C1776,CPT,0278,RC,,,,both,,,8635.00,5612.75,,,,,,,,,,,,,
SCREW SPNL L10MM DIA2MM CORT TI ST NONLOCKING FULL THRD,SUP-2189439,CDM,C1713,HCPCS,0278,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
PLATE BNE L121MM THK3.3MM 10 H BILAT S STL RIG STR DYN,SUP-2186334,CDM,C1713,HCPCS,0278,RC,,,,both,,,1097.18,713.17,,,,,,,,,,,,,
PLATE BNE FEM 3.5/4.5 MM RT PROX PERIPROSTHETIC NS VA-LCP,SUP-2757656,CDM,C1713,HCPCS,0278,RC,,,,both,,,4889.80,3178.37,,,,,,,,,,,,,
PLATE BNE L54MM 7 H BILAT S STL LOK COMPR LO PROF FOR 2MM,SUP-2186307,CDM,C1713,HCPCS,0278,RC,,,,both,,,2067.50,1343.87,,,,,,,,,,,,,
SET ORTH INSTR DRL DIA2.9 MM DRL PIN DIA1.25 MM Q-FIX ULTRA,SUP-2882979,CDM,2720000010,LOCAL,0272,RC,,,,both,,,737.90,479.63,,,,,,,,,,,,,
IMPLANT BIO L 7 X W 20 CM FISH SKIN DERMAL FEN 11 INTACT,SUP-2909250,CDM,Q4158,HCPCS,0636,RC,,,,both,,,13627.60,8857.94,,,,,,,,,,,,,
MARKER MOLLI RE.MARKABLE 12CM,SUP-2875966,CDM,A4648,CPT,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
PLATE SPNL 2 LEVEL 72 MM ANTR LUMBOSACRAL TI CITADEL,SUP-2584620,CDM,C1713,HCPCS,0278,RC,,,,both,,,10927.20,7102.68,,,,,,,,,,,,,
SCREW SPNL L10MM DIA4MM CANC TI ST NONCANNULATED NONLOCKING,SUP-2190141,CDM,C1713,HCPCS,0278,RC,,,,both,,,260.62,169.40,,,,,,,,,,,,,
RING EXT FIX 5/8 200 MM SALVATION,SUP-2850669,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3780.56,2457.36,,,,,,,,,,,,,
DESIPRAMINE HCL 10 MG PO TABS,RX-2283,CDM,6370000000,HCPCS,0637,RC,50742-0112-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
DRAIN SURG 16FR STEM 12IN XBAR 5IN GRAV T TB DEAVER,SUP-2127147,CDM,C1729,HCPCS,0272,RC,,,,both,,,37.68,24.49,,,,,,,,,,,,,
PACEMAKER CARD AZURE S SR MRI SURESCAN W 50.8 X H 42.6 MM D,SUP-2281732,CDM,C1786,HCPCS,0275,RC,,,,both,,,7693.00,5000.45,,,,,,,,,,,,,
STEM FEM L125MM OD12MM TI HA POR PROX KNEE STR PRESSFIT,SUP-2376525,CDM,C1776,CPT,0278,RC,,,,both,,,10953.58,7119.83,,,,,,,,,,,,,
SHEATH INTRO CARDIAGUIDE L 63 CM DIA 8.5 FR ML1 TYP FIX CRV,SUP-2574352,CDM,C1893,HCPCS,0272,RC,,,,both,,,442.74,287.78,,,,,,,,,,,,,
SUPPORT ORTHOT HND FNGR W/NONTORSION ELASTIC PREFABRICATED,SUP-2435787,CDM,L3930,HCPCS,0274,RC,,,,both,,,235.31,152.95,,,,,,,,,,,,,
GUIDEWIRE VASC L 260 CM DIA 0.035 IN TAPR L 15 CM FLPY TIP L,SUP-2167731,CDM,C1769,HCPCS,0272,RC,,,,both,,,64.68,42.04,,,,,,,,,,,,,
HC Wheelchair Training per 15 Min,PX-4209754200,CDM,97542,CPT,0420,RC,,,,outpatient,,,154.00,100.10,,,,,,,,,,,,,
SUBSTITUTE BONE GRFT M PROPEL DBM PUTTY,SUP-2310458,CDM,C9359,HCPCS,0278,RC,,,,both,,,1491.50,969.47,,,,,,,,,,,,,
TUBE EXT FIX CARBON 15X300 MM MONOTUBE TRIAX,SUP-2539884,CDM,2720000010,LOCAL,0272,RC,,,,both,,,514.33,334.31,,,,,,,,,,,,,
LINER ACET NEUT C 5+ MM 28 MM PROV G7,SUP-2441107,CDM,C1776,CPT,0278,RC,,,,both,,,169.56,110.21,,,,,,,,,,,,,
CATHETER REPROC INQUIRY QUAD,SUP-2470791,CDM,C1730,HCPCS,0272,RC,,,,both,,,479.01,311.36,,,,,,,,,,,,,
PACEMAKER CRD BI VENTRIC IS-1/IS4-LLLL QUADRA ALLURE MP RF,SUP-2356475,CDM,C2621,HCPCS,0275,RC,,,,both,,,24601.90,15991.23,,,,,,,,,,,,,
NIFEDIPINE ER OSMOTIC RELEASE 30 MG PO TB24,RX-28643,CDM,6370000000,HCPCS,0637,RC,68084-0597-11,NDC,,both,1,UN,6.80,4.42,,,,,,,,,,,,,
MESH ACET TI FEM HIP X CHANGE,SUP-2368354,CDM,C1713,HCPCS,0278,RC,,,,both,,,567.52,368.89,,,,,,,,,,,,,
CAP PROTCT L4.5MM EXT FIX FOR SCHNZ SCR STNMN PIN,SUP-2188587,CDM,C1776,CPT,0278,RC,,,,both,,,2752.21,1788.94,,,,,,,,,,,,,
STENT BILI XCEED L 120 MM DIA 6 MM DEL CATH L 120 CM INTRO 6,SUP-2105750,CDM,C1876,HCPCS,0278,RC,,,,both,,,4239.00,2755.35,,,,,,,,,,,,,
WIRE BRST LOC BEAD 20 GAX14 CM 35 CM BARB GHIATAS,SUP-2759084,CDM,C1819,HCPCS,0278,RC,,,,both,,,122.46,79.60,,,,,,,,,,,,,
GUIDEWIRE ORTH SKYHAWK,SUP-2658910,CDM,C1769,HCPCS,0272,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
PLATE BNE L 297 MM SCREW DIA 3.5/4.5 MM 14 H RT DSTL FEM,SUP-2931264,CDM,C1713,HCPCS,0278,RC,,,,both,,,19247.42,12510.82,,,,,,,,,,,,,
PLATE BNE L 221 MM SCREW DIA 4.5 MM 12 H NAR COMPR NLCK NS,SUP-2933846,CDM,C1713,HCPCS,0278,RC,,,,both,,,2468.79,1604.71,,,,,,,,,,,,,
PLATE BNE L220MM BRL L15IN 130DEG PELVIS BILAT S STL STD 10,SUP-2342437,CDM,C1713,HCPCS,0278,RC,,,,both,,,5573.81,3622.98,,,,,,,,,,,,,
PLATE BNE 1.5/2X83X1.5 MM 12 HOLE SS LCP,SUP-2569293,CDM,C1713,HCPCS,0278,RC,,,,both,,,395.48,257.06,,,,,,,,,,,,,
DEVICE TISS FIX L 23 MM DIA 8 MM STRL CITRELOCK XPRESS,SUP-2900540,CDM,C1713,HCPCS,0278,RC,,,,both,,,5127.62,3332.95,,,,,,,,,,,,,
ACETIC ACID 3 % SOLN,RX-15091,CDM,6370000000,HCPCS,0637,RC,51552-0051-06,NDC,,both,30,ML,54.10,35.16,,,,,,,,,,,,,
HC Intubation Emergent,PX-7613150000,CDM,31500,CPT,0761,RC,,,,outpatient,,,403.00,261.95,,,,,,,,,,,,,
TUBE VENT SHEEHY 1.27 MM 1.5 MM 3 MM FLROPLAS 525016,SUP-2473983,CDM,L8699,HCPCS,0278,RC,,,,both,,,22.11,14.37,,,,,,,,,,,,,
CLAMP EXT FIX BAR 11 MM PIN 5 MM COMBINATION NS DISP MONK,SUP-2909040,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2806.38,1824.15,,,,,,,,,,,,,
PLATE BONE L48MM STD 3 H RT DSTL VOLAR RAD S STL LO PROF,SUP-2341163,CDM,C1713,HCPCS,0278,RC,,,,both,,,2458.24,1597.86,,,,,,,,,,,,,
ORTHOPAEDIC KIT HIP STEM CUP SCREW APEX POROUS,SUP-2254035,CDM,C1776,CPT,0278,RC,,,,both,,,9891.00,6429.15,,,,,,,,,,,,,
GLUCOSE 40 % PO GEL,RX-81823,CDM,6370000000,HCPCS,0637,RC,09999-9917-06,NDC,,both,2,ML,2.70,1.75,,,,,,,,,,,,,
PLATE SPNL L48MM 8 H TI ANT CERV 3 LEV FIX STD LOK MAXAN,SUP-2414951,CDM,C1713,HCPCS,0278,RC,,,,both,,,2433.50,1581.77,,,,,,,,,,,,,
PLATE BONE W9XL37MM THK1.1MM 3 H DSTL ULN FIBULAR S STL 1/3,SUP-2343774,CDM,C1713,HCPCS,0278,RC,,,,both,,,481.24,312.81,,,,,,,,,,,,,
PLUG VASC AMPLATZER UNCONSTRAINED L 7 MM DIA10 MM DEL SYS L,SUP-2116330,CDM,C1889,HCPCS,0278,RC,,,,both,,,2285.92,1485.85,,,,,,,,,,,,,
PLATE BNE T 1.5X49 MM 4X9 HOLE FOR MINI FRAG SYS SS NS,SUP-2463312,CDM,C1713,HCPCS,0278,RC,,,,both,,,569.22,369.99,,,,,,,,,,,,,
STENT CORONARY XIENCE SKYPOINT L 48 MM DIA 3 MM SYS L 145 CM,SUP-2928550,CDM,C1874,HCPCS,0278,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
NITROFURANTOIN MONOHYD MACRO 100 MG PO CAPS,RX-10724,CDM,6370000000,HCPCS,0637,RC,52427-0285-01,NDC,,both,1,UN,26.80,17.42,,,,,,,,,,,,,
HEAD FEM PRSS FT HIP OXINUM R3,SUP-2351418,CDM,C1776,CPT,0278,RC,,,,both,,,17584.00,11429.60,,,,,,,,,,,,,
SCREW BNE L24MM DIA35MM STD ANK S STL LOK FIX ANG SYS SURFIX,SUP-2243356,CDM,C1713,HCPCS,0278,RC,,,,both,,,1130.02,734.51,,,,,,,,,,,,,
ENDPLATE SPNL SZ 3 H28MM DIA22MM TI MESH FOR THOR AND LUM,SUP-2254374,CDM,C1713,HCPCS,0278,RC,,,,both,,,452.16,293.90,,,,,,,,,,,,,
SCREW COMPR 2.4X11MM HEADLESS TI SHRT THRD STRL,SUP-2547016,CDM,C1713,HCPCS,0278,RC,,,,both,,,850.50,552.82,,,,,,,,,,,,,
GLUCOSE 40 % PO GEL,RX-81823,CDM,6370000000,HCPCS,0637,RC,00574-0069-30,NDC,,both,37.5,GR,14.20,9.23,,,,,,,,,,,,,
KYPHOPLASTY PACK 10 GA 2 ML STR OSSEOFLEX OCP0201,SUP-2516668,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3155.70,2051.20,,,,,,,,,,,,,
SCREW SPNL POLYAX 8.5X110 MM FEN FLUT EXT TAB EVEREST,SUP-2533772,CDM,C1713,HCPCS,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
BIT DRL T HNDL KEY,SUP-2601139,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1805.50,1173.57,,,,,,,,,,,,,
DEVICE SEAL 30 DEG 5 MMX28 CM ANGLE JAW AMBI LIGASURE,SUP-2174897,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1474.48,958.41,,,,,,,,,,,,,
SET SURG THYROPLASTY INSTR NONSTERILE 13 PC W/ CUST STRL TY,SUP-2138768,CDM,L8509,HCPCS,0272,RC,,,,both,,,8164.00,5306.60,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY LASSO NAV ECO L115CM 7/20FR 6MM,SUP-2248628,CDM,C1732,HCPCS,0272,RC,,,,both,,,4527.88,2943.12,,,,,,,,,,,,,
CATHETER DRAINAGE TY 7 FRX15 CM PLEURAL SELD PGTL FURMAN,SUP-2759778,CDM,C1729,HCPCS,0272,RC,,,,both,,,536.12,348.48,,,,,,,,,,,,,
LINER ACET 0 DEG 32MM ID 60MM OD HI RIM W/PEG RNWT BRSTN,SUP-2403317,CDM,C1776,CPT,0278,RC,,,,both,,,1871.44,1216.44,,,,,,,,,,,,,
KIT NEUROSTIMULATOR LD DIA127MM ELECTRD SPC 15MM QPLR STR,SUP-2278245,CDM,C1778,HCPCS,0278,RC,,,,both,,,10723.10,6970.01,,,,,,,,,,,,,
PLATE ANK JT FUSION TI RT PILON PRIMARY,SUP-2896558,CDM,C1713,HCPCS,0278,RC,,,,both,,,7218.86,4692.26,,,,,,,,,,,,,
PORT IMPL INFUSION SINGLE LUMEN 8 FRX45 CM POWERPORT ISP,SUP-2126313,CDM,C1788,HCPCS,0278,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
COIL VASC NEST EMBOLUS L 7 CM DIA12 MM CATH DIA 0.035 IN,SUP-2170988,CDM,C1889,HCPCS,0278,RC,,,,both,,,279.46,181.65,,,,,,,,,,,,,
STEM HUM 12X200 MM SHLDR RVS NP,SUP-2436922,CDM,C1776,CPT,0278,RC,,,,both,,,13578.93,8826.30,,,,,,,,,,,,,
LEVEL CMF ST PLATE MDFCE L SHP WTAB UNI 1.5 MM SCRW6 X 4 HO,SUP-2677638,CDM,C1713,HCPCS,0278,RC,,,,both,,,881.71,573.11,,,,,,,,,,,,,
FORCEPS BX STD 7FR L50CM SHFT 2.3MM OVL CUP SERR INT JUG,SUP-2157335,CDM,C1713,HCPCS,0278,RC,,,,both,,,452.16,293.90,,,,,,,,,,,,,
SPLINT ORTH SPICA THMB,SUP-2388192,CDM,L3807,HCPCS,0274,RC,,,,both,,,879.20,571.48,,,,,,,,,,,,,
BEAM FIX L75MM DIA7.5MM ARTH FOR CHARCOT DEFORMITY AXIS,SUP-2223953,CDM,C1713,HCPCS,0278,RC,,,,both,,,4239.00,2755.35,,,,,,,,,,,,,
SYSTEM THROMCTMY CLN XT L 135 CM DIA 6 FR GUIDEWIRE 0.035 IN,SUP-2120127,CDM,C1724,HCPCS,0278,RC,,,,both,,,4239.00,2755.35,,,,,,,,,,,,,
CATHETER ABLATN D-D 2-5-2 MM 2MM 7 FRX115 CM EZ STEER LF,SUP-2248510,CDM,C1732,HCPCS,0278,RC,,,,both,,,6066.48,3943.21,,,,,,,,,,,,,
STENT BILI L20MM 6FR 135CM CATH LEN 10MM DIAM AD,SUP-2158931,CDM,C2625,HCPCS,0278,RC,,,,both,,,5928.32,3853.41,,,,,,,,,,,,,
BRACE WALKING LP MED 5.5-10 IN 6.5-11 IN WOMEN MAXTRAX AIR,SUP-2428155,CDM,L4360,HCPCS,0272,RC,,,,both,,,97.50,63.37,,,,,,,,,,,,,
HC Bfb Traing W/Emg &/Manometry 1st 15 Min Cntct,PX-9179091200,CDM,90912,CPT,0917,RC,,,,both,,,143.00,92.95,,,,,,,,,,,,,
STENT BILI L18MM DIA5MM BLLN L20MM S STL SELF EXP LO PROF,SUP-2173165,CDM,C1876,HCPCS,0278,RC,,,,both,,,2245.10,1459.31,,,,,,,,,,,,,
BRACE ORTH CRUC RIGID TLSO PLAS,SUP-2388141,CDM,L0472,HCPCS,0272,RC,,,,both,,,997.58,648.43,,,,,,,,,,,,,
KIT CTRL VEN CATH PED L8CM DIA5FR POLYUR ANTIMIC DBL LUMN,SUP-2383320,CDM,C1751,HCPCS,0278,RC,,,,both,,,246.80,160.42,,,,,,,,,,,,,
KIT PICC 4FR L50CM PRSS INJ SGL LUMN BLU FLEXTIP W,SUP-2383370,CDM,C1751,HCPCS,0278,RC,,,,both,,,437.84,284.60,,,,,,,,,,,,,
DISPOSABLE KT 11MM,SUP-2200254,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2533.98,1647.09,,,,,,,,,,,,,
HC Bx Breast 1st Lesion US Img|BILATERAL PROCEDURE,PX-3611908300,CDM,19083,CPT,0361,RC,,,50,outpatient,,,7265.00,4722.25,,,,,,,,,,,,,
CATHETER ATHRCTMY LSR CLIRPATH,SUP-2353077,CDM,C1885,CPT,0278,RC,,,,both,,,5887.50,3826.87,,,,,,,,,,,,,
STRAP CLAV SELF-ADJSTBLE L,SUP-2195528,CDM,L3650,HCPCS,0274,RC,,,,both,,,21.38,13.90,,,,,,,,,,,,,
VITAMIN E 180 MG (400 UNIT) PO CAPS,RX-154146,CDM,6370000000,HCPCS,0637,RC,57896-0752-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
HC Who W/1 or More Customfit,PX-2740390501,CDM,L3905,HCPCS,0274,RC,,,,both,,,3295.00,2141.75,,,,,,,,,,,,,
POST EXT FIX 2 HOLE W/ THRD ATTCH,SUP-2749944,CDM,2720000010,LOCAL,0272,RC,,,,both,,,876.06,569.44,,,,,,,,,,,,,
HC Clsd Tx Patella Disloc W Anes,PX-4502756200,CDM,27562,CPT,0450,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
PLATE BNE H1.5MM 6 H MAND G TI TEMPLT COMPR LO PROF FOR 2MM,SUP-2366372,CDM,C1713,HCPCS,0278,RC,,,,both,,,1388.67,902.64,,,,,,,,,,,,,
PLATE BNE L160MM 8 H L MED DST HUM S STL VAR ANG FOR,SUP-2177586,CDM,C1713,HCPCS,0278,RC,,,,both,,,3918.56,2547.06,,,,,,,,,,,,,
PROSTHESIS VOICE OD16FR SIL DUCKBILL BLOM SINGER,SUP-2242309,CDM,L8509,HCPCS,0272,RC,,,,both,,,127.17,82.66,,,,,,,,,,,,,
PLATE BNE HK 2 HOLE,SUP-2518428,CDM,C1713,HCPCS,0278,RC,,,,both,,,3855.92,2506.35,,,,,,,,,,,,,
CONNECTOR CATH TWO PART AD FOR PERITONEAL DLYS FLX NK,SUP-2302452,CDM,C2628,HCPCS,0272,RC,,,,both,,,474.14,308.19,,,,,,,,,,,,,
FLUCYTOSINE 500 MG PO CAPS,RX-10052,CDM,6370000000,HCPCS,0637,RC,43386-0770-01,NDC,,both,1,UN,90.00,58.50,,,,,,,,,,,,,
SCREW SPNL L40MM DIA7MM CANC POST PEDCL THORLUM TI SIDE OPN,SUP-2193575,CDM,C1713,HCPCS,0278,RC,,,,both,,,2339.30,1520.54,,,,,,,,,,,,,
IMMOBILIZER KNEE L20IN AD 1 SZ FIT MOST UNIV WRP ARND OPN,SUP-2196742,CDM,L1830,CPT,0272,RC,,,,both,,,44.27,28.78,,,,,,,,,,,,,
SPLINT ORTHOPEDIC NT LG 10.5 IN RT HND FOREARM COLLES PADDED,SUP-2306271,CDM,L3906,HCPCS,0274,RC,,,,both,,,26.69,17.35,,,,,,,,,,,,,
PLUG ARTHROSCOPIC 2.4MM TIBIAL ACL/PCL TUNNEL,SUP-2370388,CDM,C1713,HCPCS,0278,RC,,,,both,,,140.17,91.11,,,,,,,,,,,,,
HEAD HUM H15MM DIA40MM CO CHROM ALLOY BPLR STD OFFSET REV,SUP-2193856,CDM,C1776,CPT,0278,RC,,,,both,,,7392.25,4804.96,,,,,,,,,,,,,
CATHETER DIAG 2.4X1.7FR L150CM ID0.0165IN 90DEG MIC,SUP-2367863,CDM,C1725,HCPCS,0272,RC,,,,both,,,2961.02,1924.66,,,,,,,,,,,,,
KNIFE SURG SERR AGG FOR SONOPET ULTRASONIC ASPIR,SUP-2363705,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2198.25,1428.86,,,,,,,,,,,,,
JOINT GREAT TOE 1 REG LPT,SUP-2399100,CDM,C1776,CPT,0278,RC,,,,both,,,4644.06,3018.64,,,,,,,,,,,,,
SCREW BNE DSTL 4.3X22 MM SHLDR PUR NS AEQUALIS,SUP-2715424,CDM,C1713,HCPCS,0278,RC,,,,both,,,401.92,261.25,,,,,,,,,,,,,
HC So Chemiluminescent Assay,PX-3018239766,CDM,82397,CPT,0301,RC,,,,inpatient,,,230.00,149.50,,,,,,,,,,,,,
SCREW BONE L12MM DIA2.7MM NONSTERILE CORT S STL ST,SUP-2177097,CDM,C1713,HCPCS,0278,RC,,,,both,,,319.62,207.75,,,,,,,,,,,,,
STAPLER INT L L28MM DIA5MM GI BLU TI BARIATRIC CIR CUT 2,SUP-2283257,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1459.75,948.84,,,,,,,,,,,,,
CATHETER INTVASC ULTRASOUND OPTICROSS 6 L 135 CM DIA 3.1 FR,SUP-2516545,CDM,C1753,HCPCS,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
COMPONENT TIB SZ 6 R REV GMK,SUP-2267557,CDM,C1776,CPT,0278,RC,,,,both,,,9785.81,6360.78,,,,,,,,,,,,,
HC Who W/1 or More Customfit,PX-2740390501,CDM,L3905,HCPCS,0272,RC,,,,both,,,3295.00,2141.75,,,,,,,,,,,,,
KIT INTRO ARW DIA 9 FR SPRING GUIDEWIRE L 17.75 IN DIA 0.035,SUP-2120640,CDM,C1894,HCPCS,0272,RC,,,,both,,,80.70,52.45,,,,,,,,,,,,,
LINER ACET 28X46-48 MM HIP ALUMINA CERM REFLECTION,SUP-2434786,CDM,C1776,CPT,0278,RC,,,,both,,,5532.68,3596.24,,,,,,,,,,,,,
HC Nasopharyngoscopy Sep Px,PX-3619251100,CDM,92511,CPT,0361,RC,,,,both,,,185.00,120.25,,,,,,,,,,,,,
CAGE SPINAL ANTERIOR LUMBAR 22MM AERO-AL,SUP-2867351,CDM,C1889,HCPCS,0278,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
SYSTEM CATH INFSN 4FR DIA 45CML 10CML PEBAX OCCLDNG WIRE ACC,SUP-2676952,CDM,C1751,HCPCS,0278,RC,,,,both,,,397.21,258.19,,,,,,,,,,,,,
BUR SURG MTCH HD LNG 1.8X2.4 MM 16 CM FLUT MIDAS REX 8,SUP-2664657,CDM,2720000010,LOCAL,0272,RC,,,,both,,,382.26,248.47,,,,,,,,,,,,,
KIT TKR HYBRID TRABECULAR MTL FEM CEM TIB VIT E SURF AND STD,SUP-2212235,CDM,C1776,CPT,0278,RC,,,,both,,,16682.82,10843.83,,,,,,,,,,,,,
NEEDLE BX 22GA FN ENDOSCP US FNB ACQUIRE,SUP-2149649,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1277.51,830.38,,,,,,,,,,,,,
NEEDLE HLDR 475IN DERF CARB BITE,SUP-2244530,CDM,C1713,HCPCS,0278,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
OCRELIZUMAB 300 MG/10ML IV SOLN,RX-137884,CDM,J2350,HCPCS,0636,RC,50242-0150-01,NDC,,both,10,ML,60890.90,39579.08,,,,,,,,,,,,,
LEUCOVORIN CALCIUM 500 MG/50ML IJ SOLN,RX-144407,CDM,J0640,HCPCS,0636,RC,63323-0631-50,NDC,,both,50,ML,348.90,226.78,,,,,,,,,,,,,
SPLINT WR FRARM RIGHTXL INSTABILITY INJ W/ STAY FIRM SUPP,SUP-2195253,CDM,L3931,HCPCS,0272,RC,,,,both,,,17.52,11.39,,,,,,,,,,,,,
KIT VASC FLTR L11IN SGL CANN SM FLTR EMBOL-X GLDE,SUP-2214498,CDM,C1884,HCPCS,0278,RC,,,,both,,,1440.16,936.10,,,,,,,,,,,,,
CATHETER EP 7FR L115CM 2-8-2MM SPC TIP 2MM DF CRV ADV COMPR,SUP-2248491,CDM,C1730,HCPCS,0272,RC,,,,both,,,2141.48,1391.96,,,,,,,,,,,,,
PROSTHESIS CNTR 2.5MM DIA 8MM LEN HA TORP STRASNICK,SUP-2313850,CDM,L8613,CPT,0278,RC,,,,both,,,982.82,638.83,,,,,,,,,,,,,
PLATE BNE THK0.6MM 4 H STD CRANIOMAXILLOFACIAL G TI CRV,SUP-2366294,CDM,C1713,HCPCS,0278,RC,,,,both,,,439.47,285.66,,,,,,,,,,,,,
CAP ORTH L0MM EXTN FOR IM NAIL TRIGEN,SUP-2347140,CDM,C1713,HCPCS,0278,RC,,,,both,,,1358.43,882.98,,,,,,,,,,,,,
WASHER ORTHOPEDIC LG 7.3 MM 13 MM OSTEOPOROTIC BNE SCREW TI,SUP-2468587,CDM,C1713,HCPCS,0278,RC,,,,both,,,249.76,162.34,,,,,,,,,,,,,
GRAFT VASC FUSION BIOLINE L 40 CM DIA 8 MM EPTFE POLYESTER,SUP-2669797,CDM,C1768,CPT,0278,RC,,,,both,,,4498.02,2923.71,,,,,,,,,,,,,
ROD ORTH THRD 120 MM,SUP-2123508,CDM,C1713,HCPCS,0278,RC,,,,both,,,273.18,177.57,,,,,,,,,,,,,
DEVICE TORQUE GLIDEWIRE DIA 0.010-0.038 IN ACCOMODATE WIRE,SUP-2385710,CDM,C1769,HCPCS,0272,RC,,,,both,,,20.41,13.27,,,,,,,,,,,,,
GRAFT HUM TISS FRZN 3 STRND GRFTLINK,SUP-2264636,CDM,C1713,HCPCS,0278,RC,,,,both,,,7642.45,4967.59,,,,,,,,,,,,,
GRAFT VASC STP 4-7 MMX50 CM STD WALL CARBOFLO CENTERFLEX,SUP-2761414,CDM,C1768,CPT,0278,RC,,,,both,,,2522.36,1639.53,,,,,,,,,,,,,
CATHETER HAD ADMIN FULL KT DBL LUMN POLYUR STR HYDR TIP CUF,SUP-2266965,CDM,C1752,HCPCS,0278,RC,,,,both,,,414.48,269.41,,,,,,,,,,,,,
POTASSIUM CHLORIDE 20 MEQ/100ML IV SOLN,RX-11076,CDM,J3480,HCPCS,0636,RC,00338-0705-48,NDC,,both,100,ML,54.10,35.16,,,,,,,,,,,,,
SCREW BNE PART THRD MINI 3.5X36 MM CANN TI,SUP-2316482,CDM,C1713,HCPCS,0278,RC,,,,both,,,571.48,371.46,,,,,,,,,,,,,
TEMPLATE SURG PLATE 11 STD RT CRAN MESHED,SUP-2482598,CDM,C1713,HCPCS,0278,RC,,,,both,,,1060.85,689.55,,,,,,,,,,,,,
COLLAR CERV M AD MIAMI J,SUP-2151872,CDM,L0172,HCPCS,0274,RC,,,,both,,,133.89,87.03,,,,,,,,,,,,,
NAIL IM 11MMX38CM RT FEM VERSANAIL,SUP-2412483,CDM,C1713,HCPCS,0278,RC,,,,both,,,5209.26,3386.02,,,,,,,,,,,,,
BUR SURG 6MM DMND CORNERSTONE,SUP-2363388,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1174.14,763.19,,,,,,,,,,,,,
COIL EMB L4CM DIA3MM 0.0165IN PLAT NYL FBR DETACH STRTCH,SUP-2296669,CDM,C1889,HCPCS,0278,RC,,,,both,,,2041.00,1326.65,,,,,,,,,,,,,
SCREW BNE L6MM DIA1.5MM CRANIOMAXILLOFACIAL NEURO ST LO,SUP-2366089,CDM,C1713,HCPCS,0278,RC,,,,both,,,163.06,105.99,,,,,,,,,,,,,
PLATE SPNL MESH 90X90X.6 MM 1.7 MM GLD,SUP-2363683,CDM,C1713,HCPCS,0278,RC,,,,both,,,3112.93,2023.40,,,,,,,,,,,,,
CATHETER ABLAT 8FR L115CM 2-5-2MM SPC TIP 3.5MM 6 ELECTRD D,SUP-2248601,CDM,C1732,HCPCS,0272,RC,,,,both,,,4374.02,2843.11,,,,,,,,,,,,,
PLATE BONE SM 3X3 H T SHP,SUP-2198578,CDM,C1713,HCPCS,0278,RC,,,,both,,,147.58,95.93,,,,,,,,,,,,,
TRIAL KNEE TIB WDG FOR HTO,SUP-2121040,CDM,2720000010,LOCAL,0272,RC,,,,both,,,643.70,418.40,,,,,,,,,,,,,
PIN ALIGN 3X170 MM AEQUALIS DISP,SUP-2715607,CDM,2720000010,LOCAL,0272,RC,,,,both,,,381.51,247.98,,,,,,,,,,,,,
CATHETER CARD ABLATION THERMOCOOL SMARTTOUCH L 115 CM 8FR DF,SUP-2248608,CDM,C1732,HCPCS,0272,RC,,,,both,,,9074.60,5898.49,,,,,,,,,,,,,
HC Mod Sed Same Phys/Qhp <5 Yrs,PX-3729915100,CDM,99151,CPT,0372,RC,,,,both,,,290.00,188.50,,,,,,,,,,,,,
CAGE SPNL W9XH8XL23MM 0DEG C FBR REINF POLYMER POST LUM,SUP-2255218,CDM,C1889,HCPCS,0278,RC,,,,both,,,11705.92,7608.85,,,,,,,,,,,,,
SET URET STENT SOFFLX L 12 CM DIA 4.7 FR POS L 50 CM DIA 4.7,SUP-2168902,CDM,C2617,HCPCS,0278,RC,,,,both,,,317.77,206.55,,,,,,,,,,,,,
INTRODUCER STEERABLE SHEATH MED CVD 8.5FR,SUP-2858169,CDM,C1766,CPT,0272,RC,,,,both,,,2804.02,1822.61,,,,,,,,,,,,,
WEDGE BNE W 20 X H 4.5 MM MED EVANS OSTEOTOM 3D PRNT TRUSS,SUP-2900964,CDM,C1713,HCPCS,0278,RC,,,,both,,,12350.09,8027.56,,,,,,,,,,,,,
SCREW SLF DRLG SCHANZ 4.0MM 3.0MM TI 80MM HA COATING STERILE,SUP-2549740,CDM,C1713,HCPCS,0278,RC,,,,both,,,852.45,554.09,,,,,,,,,,,,,
WIRE FIX TROCAR PT 1 END 1.2X100 MM SMOOTH FOR 3 MM SCREW TI,SUP-2372175,CDM,C1713,HCPCS,0278,RC,,,,both,,,31.40,20.41,,,,,,,,,,,,,
SCREW BNE ZURICH 1.5X5 MM 5 MM MXLFCL X DRV DRILL-FREE TI,SUP-2459240,CDM,C1713,HCPCS,0278,RC,,,,both,,,425.44,276.54,,,,,,,,,,,,,
CATHETER GUID BNCHMRK 071 L 95 CM OD 6 FR ID 0.071 IN SEL,SUP-2323569,CDM,C1887,HCPCS,0272,RC,,,,both,,,2998.70,1949.15,,,,,,,,,,,,,
BAG TISS CLSR DIA75CM TRNSPAR SIL SILO SPR LD PROX OPN SFT,SUP-2134674,CDM,C1713,HCPCS,0278,RC,,,,both,,,1497.78,973.56,,,,,,,,,,,,,
TROCAR SURG LNG ENTRY PORTAL VERSANAIL,SUP-2412786,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1406.72,914.37,,,,,,,,,,,,,
SNARE ENDOSCP 25 MMX230 CM POLYP BARB LOOP SD-16U-1 REPL,SUP-2467334,CDM,2720000010,LOCAL,0272,RC,,,,both,,,838.51,545.03,,,,,,,,,,,,,
SCREW BNE L8MM DIA24MM WRST S STL FOR LIMIT FUS SYS SPIDER,SUP-2242699,CDM,C1713,HCPCS,0278,RC,,,,both,,,259.68,168.79,,,,,,,,,,,,,
BLADE RTRCTR MED 45MMW X 60MML TTNM SPNL PRNGX5 GREEN LMBRTR,SUP-2668619,CDM,2720000010,LOCAL,0272,RC,,,,both,,,776.55,504.76,,,,,,,,,,,,,
SHOE ORTHOT CUST SLD STIRRUP TRANSFER NEW,SUP-2435748,CDM,L3630,HCPCS,0272,RC,,,,both,,,284.45,184.89,,,,,,,,,,,,,
PIN FIX L25MM DIA2.5MM PROV FOR EVOS SM PLATING SYS,SUP-2344056,CDM,C1713,HCPCS,0278,RC,,,,both,,,1066.03,692.92,,,,,,,,,,,,,
GUIDE PIN CALIB STYL SIX 2.4MM X 229MM,SUP-2409631,CDM,C1713,HCPCS,0278,RC,,,,both,,,65.56,42.61,,,,,,,,,,,,,
HC Pre-Pooled Cryoprecipitate,PX-3900901200,CDM,P9012,CPT,0390,RC,,,,inpatient,,,384.00,249.60,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY ISMUS L 110 CM DIA 7 FR 2-12-2 MM,SUP-2726705,CDM,C1731,HCPCS,0278,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
GRAFT TISS FRZN ALLGRFT RAD DST STRUCTURAL L,SUP-2307319,CDM,C1713,HCPCS,0278,RC,,,,both,,,4878.46,3171.00,,,,,,,,,,,,,
KNIFE SURG SEXTON 7 IN EAR REVERSIBLE SWVL HNDL,SUP-2493157,CDM,2720000010,LOCAL,0272,RC,,,,both,,,464.72,302.07,,,,,,,,,,,,,
CATHETER UROLOGICAL L 75 CM DIA 5.3 FR SIL BALLOON UPJ OCCL,SUP-2822051,CDM,C2628,HCPCS,0272,RC,,,,both,,,430.27,279.68,,,,,,,,,,,,,
PATCH CV HEMACAROTID L 75XW 8MM THK0.65MM POLYESTER BOV PK1,SUP-2540303,CDM,C1768,CPT,0278,RC,,,,both,,,381.04,247.68,,,,,,,,,,,,,
ENDOPROSTHESIS VASC EXCLUDER L 160 MM PROX/DSTL 37/20 MM,SUP-2913632,CDM,C1768,CPT,0278,RC,,,,both,,,91060.00,59189.00,,,,,,,,,,,,,
ROD EXT FIX L60MM THRD SALVATION,SUP-2401128,CDM,2720000010,LOCAL,0272,RC,,,,both,,,276.32,179.61,,,,,,,,,,,,,
PLATE BNE PROF H 0.6 MM DIA2 MM 2 H BAR 12 MM SCREW DIA2 MM,SUP-2883313,CDM,C1713,HCPCS,0278,RC,,,,both,,,249.44,162.14,,,,,,,,,,,,,
PLATE SLIM Y 6 SHAFT HL,SUP-2695695,CDM,C1713,HCPCS,0278,RC,,,,both,,,3683.85,2394.50,,,,,,,,,,,,,
PLATE BNE W11XL246MM THK3.7MM 14 H NONSTERILE R MED DST TIB,SUP-2185598,CDM,C1713,HCPCS,0278,RC,,,,both,,,4142.51,2692.63,,,,,,,,,,,,,
CATHETER DRAINAGE RESOLV L 25 CM DIA 8.5 FR GUIDEWIRE 0.038,SUP-2303377,CDM,C1729,HCPCS,0272,RC,,,,both,,,210.25,136.66,,,,,,,,,,,,,
KIT CATH 16GA L12IN CTRL VEN POLYUR SIDE H INTEGR SUT WNG,SUP-2383268,CDM,C1751,HCPCS,0278,RC,,,,both,,,70.34,45.72,,,,,,,,,,,,,
SCREW BONE LOCKING 2.7MM DIA 18MML CONICAL STERILE,SUP-2588215,CDM,C1713,HCPCS,0278,RC,,,,both,,,227.71,148.01,,,,,,,,,,,,,
TUBE MYR DIA1.02MM VENT SIL W/O TAB ST PAPARELLA,SUP-2313716,CDM,L8699,HCPCS,0278,RC,,,,both,,,38.09,24.76,,,,,,,,,,,,,
TRAY TIB SZ 4 LNG ANK PROPHECY INFIN,SUP-2397279,CDM,C1776,CPT,0278,RC,,,,both,,,13985.56,9090.61,,,,,,,,,,,,,
STENT GRFT VASC AFX L 75 MM UNCOVERED L 20 MM DIA 28 MM,SUP-2217600,CDM,C1768,CPT,0278,RC,,,,both,,,10644.60,6918.99,,,,,,,,,,,,,
DOPPLER US 55X275X13IN 3MHZ PRB 1129OZ DISPLAY GYN EARLY,SUP-2171684,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1600.93,1040.60,,,,,,,,,,,,,
KIT STPL BNE FIX BRDG 20MM LEG 20MM 8MM OFFSET WIRE 2X2MM,SUP-2194276,CDM,C1713,HCPCS,0278,RC,,,,both,,,3580.73,2327.47,,,,,,,,,,,,,
HC Urine Cult./Colony Count,PX-3008708600,CDM,87086,CPT,0300,RC,,,,both,,,150.00,97.50,,,,,,,,,,,,,
GRAFT VASC IMPRA L 10 CM DIA 7 MM EPTFE FLX STD WALL RING,SUP-2126872,CDM,C1768,CPT,0278,RC,,,,both,,,1155.52,751.09,,,,,,,,,,,,,
PROSTHESIS OSS MASS PISTON 0.6X4.50 MM EYE EAR FLROPLAS PLAT,SUP-2638118,CDM,L8613,CPT,0278,RC,,,,both,,,441.20,286.78,,,,,,,,,,,,,
INTRODUCER SHTH L14CM OD8.5FR GWIRE OD0.038IN VASC DI-LOCK,SUP-2357075,CDM,C1894,HCPCS,0272,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
CATHETER MAP 8FR L105CM LOOP DIA15MM 3-3-3MM ELECTRD SPC,SUP-2357573,CDM,C1732,HCPCS,0272,RC,,,,both,,,5143.32,3343.16,,,,,,,,,,,,,
R-T HUMERAL NAIL 8X30CM,SUP-2818079,CDM,C1713,HCPCS,0278,RC,,,,both,,,19843.39,12898.20,,,,,,,,,,,,,
FOOTPLATE EXT FIX 5 HOLE EXTN NS TRUELOK LTX,SUP-2875090,CDM,2720000010,LOCAL,0272,RC,,,,both,,,569.28,370.03,,,,,,,,,,,,,
INSERT TIB SZ 2-3 THK11MM LT KNEE HNG GUID MOTN LEGION,SUP-2346670,CDM,C1776,CPT,0278,RC,,,,both,,,7529.72,4894.32,,,,,,,,,,,,,
LINER ACET SZ 21 ID28MM 10DEG POLY HIP NONCONSTRAINED COMP,SUP-2403362,CDM,C1776,CPT,0278,RC,,,,both,,,5777.60,3755.44,,,,,,,,,,,,,
KIT LUM DRNGE EDM SYS EXT DRNGE AND MON CATHETER BG W TBNG,SUP-2284406,CDM,C1729,HCPCS,0272,RC,,,,both,,,751.21,488.29,,,,,,,,,,,,,
CATHETER DRAINAGE VLV 5 FRX10 CM 51IN SAFETY SPIN-LOCK ACCEL,SUP-2659272,CDM,C1729,HCPCS,0272,RC,,,,both,,,134.33,87.31,,,,,,,,,,,,,
OCCLUDER CV AMULET 2 DIA 34 MM NIT POLYESTER LAA STRL,SUP-2909498,CDM,C1817,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
CATHETER THROMCTMY LIGHTNING FLSH L 100 CM BER TIP S SEP12,SUP-2865162,CDM,C1757,HCPCS,0272,RC,,,,both,,,31368.60,20389.59,,,,,,,,,,,,,
WIRE TRL OD1.5MM SH PROV,SUP-2351111,CDM,C1713,HCPCS,0278,RC,,,,both,,,481.24,312.81,,,,,,,,,,,,,
KCL IN DEXTROSE-NACL 20-5-0.45 MEQ/L-%-% IV SOLN,RX-102358,CDM,2500000003,HCPCS,0250,RC,00264-7635-00,NDC,,both,1000,ML,54.10,35.16,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 45 CM DIA 6 MM STR HELIX SLDE GDS,SUP-2475708,CDM,C1768,CPT,0278,RC,,,,both,,,1775.23,1153.90,,,,,,,,,,,,,
PIN FIX L9IN DIA32MM ST S STL 2 SIDE SGL DMND 1 END PNT,SUP-2150474,CDM,C1713,HCPCS,0278,RC,,,,both,,,15.83,10.29,,,,,,,,,,,,,
ALLOGRAFT BNE 14 MM BIO AVS AL 77701404,SUP-2637012,CDM,C1713,HCPCS,0278,RC,,,,both,,,8504.63,5528.01,,,,,,,,,,,,,
CANNULA PERF AD 23FR L30IN TIP L197IN 3 8 CONN FEM ART NVENT,SUP-2282875,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1021.91,664.24,,,,,,,,,,,,,
PLATE BNE MESHED 126X126X0.3 MM SM GRID PDLLA STRL RESORB XG,SUP-2477456,CDM,C1713,HCPCS,0278,RC,,,,both,,,10848.61,7051.60,,,,,,,,,,,,,
CATHETER ETER BRACHYTHERAPY 5 6CM MULTILUMEN BLLN CONTURA,SUP-2239949,CDM,C1726,HCPCS,0272,RC,,,,both,,,8375.95,5444.37,,,,,,,,,,,,,
ROD EXT FIX W110XL120MM DIA4MM UNIV C FBR ANG T BAR,SUP-2188720,CDM,C1713,HCPCS,0278,RC,,,,both,,,1046.34,680.12,,,,,,,,,,,,,
BLOCK CUT SZ 4 DST FEM R MED CT APPRCH NONSTERILE MYKNEE,SUP-2267755,CDM,2720000010,LOCAL,0272,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
STEM RAD L20MM OD8MM 3 2MM CLLR LAT STD CLLR ASSEMB PGT,SUP-2370437,CDM,C1776,CPT,0278,RC,,,,both,,,4631.50,3010.47,,,,,,,,,,,,,
GRAFT BNE STRP 2.5X5 CMX3 MM DBM TI NS DBX,SUP-2653619,CDM,C1713,HCPCS,0278,RC,,,,both,,,2021.03,1313.67,,,,,,,,,,,,,
PASSER SUT WHT POLYPR CART COBRAID SMARTSTITCH MAGNUMWIRE,SUP-2342098,CDM,C1713,HCPCS,0278,RC,,,,both,,,980.75,637.49,,,,,,,,,,,,,
HC Asp Injection Major Joint,PX-4502061000,CDM,20610,CPT,0450,RC,,,,outpatient,,,1092.00,709.80,,,,,,,,,,,,,
VALVE MITRL BIOPROS PORCINE SZ 29MM,SUP-2214278,CDM,C1889,HCPCS,0278,RC,,,,both,,,17292.77,11240.30,,,,,,,,,,,,,
WIRE STRL K,SUP-2361764,CDM,C1713,HCPCS,0278,RC,,,,both,,,440.86,286.56,,,,,,,,,,,,,
TUBE ET OD8.5MM ID6MM NSL ORAL LSR RESIST 2 CUF MURPHY EYE,SUP-2283785,CDM,2720000010,LOCAL,0272,RC,,,,both,,,74.95,48.72,,,,,,,,,,,,,
BIT DRL M DIA2MM MED P2 DST P3 STP ADD ON DISP FOR IM SMRT,SUP-2379293,CDM,2720000010,LOCAL,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
PLATE BNE L158MM 6 H ST R DST HUM EXTRA ARTC S STL LOK,SUP-2177168,CDM,C1713,HCPCS,0278,RC,,,,both,,,4102.47,2666.61,,,,,,,,,,,,,
ALLOGRAFT DERMAL 18X6 CM TISS MTRX ALLDERM,SUP-2113079,CDM,Q4116,HCPCS,0636,RC,,,,both,,,12478.36,8110.93,,,,,,,,,,,,,
EXTRACTOR SURG EASYOUT 2 MM QR ACUTRK,SUP-2857691,CDM,2720000010,LOCAL,0272,RC,,,,both,,,960.84,624.55,,,,,,,,,,,,,
INSERT KNEE DIA35MM PAT,SUP-2165966,CDM,C1776,CPT,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
HC Catheterize for Urine Spec,PX-4500961200,CDM,P9612,CPT,0300,RC,,,,inpatient,,,76.00,49.40,,,,,,,,,,,,,
ALLOGRAFT BNE 0 DEG 10X16X6 MM COALITION AGX,SUP-2599260,CDM,C1762,CPT,0278,RC,,,,both,,,4521.60,2939.04,,,,,,,,,,,,,
BIT REPROC DRL CANN QUICK CPL 2.7MMX17.5CM,SUP-2653194,CDM,2720000010,LOCAL,0272,RC,,,,both,,,592.39,385.05,,,,,,,,,,,,,
QUICKSET ACE GRATER HEAD 47MM,SUP-2514452,CDM,C1776,CPT,0278,RC,,,,both,,,1532.32,996.01,,,,,,,,,,,,,
NAIL IM CEPHALOMEDULLARY 125 DEG LNG 13 MMX30 CM RT TI,SUP-2458234,CDM,C1713,HCPCS,0278,RC,,,,both,,,6685.75,4345.74,,,,,,,,,,,,,
SCREW BNE L9MM DIA23MM CRANIOMAXILLOFACIAL TI SELF RET CRSS,SUP-2262806,CDM,C1713,HCPCS,0278,RC,,,,both,,,204.92,133.20,,,,,,,,,,,,,
SHEATH INTRO PEELWY L 13 CM DIA26 FR DIL L 20 CM GUIDEWIRE,SUP-2168155,CDM,C1894,HCPCS,0272,RC,,,,both,,,105.16,68.35,,,,,,,,,,,,,
PLATE BNE L 265 X W 11.5 MM THK 3.6 MM SCREW DIA 3.5 MM 22 HL NS,SUP-2937392,CDM,C1713,HCPCS,0278,RC,,,,both,,,8419.91,5472.94,,,,,,,,,,,,,
SCREW BNE L100MM DIA35MM CORT S STL ST NONCANNULATED FULL,SUP-2178086,CDM,C1713,HCPCS,0278,RC,,,,both,,,85.85,55.80,,,,,,,,,,,,,
GRAFT VASC IMPRA L 70 CM DIA 7-4 MM EPTFE TAPR FLX TW SM,SUP-2761495,CDM,C1768,CPT,0278,RC,,,,both,,,3730.29,2424.69,,,,,,,,,,,,,
AMIKACIN SULFATE 500 MG/2ML IJ SOLN,RX-104408,CDM,J0278,HCPCS,0636,RC,23155-0290-31,NDC,,both,2,ML,54.10,35.16,,,,,,,,,,,,,
GABAPENTIN 300 MG PO CAPS,RX-18308,CDM,6370000000,HCPCS,0637,RC,00904-6666-61,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
DEFIBRILLATOR IMPL CONTAK RENEWAL III HE W 6.3 X H 8.26 CM,SUP-2149226,CDM,C1895,HCPCS,0275,RC,,,,both,,,85332.64,55466.22,,,,,,,,,,,,,
SLEEVE K WIRE 1.6MM/2MM TISS PROTCT FOR CONVENTUS CAGE SYS,SUP-2167376,CDM,C1713,HCPCS,0278,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
STEM RAD DIA7.5MM + 2 UNIV CO CHROM STR PRSS FIT DISP,SUP-2397983,CDM,C1776,CPT,0278,RC,,,,both,,,7030.46,4569.80,,,,,,,,,,,,,
LINER ACET CEM HIP HYBIRD HXLPE,SUP-2379162,CDM,C1776,CPT,0278,RC,,,,both,,,14130.00,9184.50,,,,,,,,,,,,,
PLATE BNE SM W11XL293MM THK34MM 22 H BILAT TI RIG NEUT LOK,SUP-2190800,CDM,C1713,HCPCS,0278,RC,,,,both,,,2492.28,1619.98,,,,,,,,,,,,,
PACK SURG PROC 1.2 GWIRE PASS PIN TUNN PLUG GA DISP RAP-PAC,SUP-2341130,CDM,C1769,HCPCS,0272,RC,,,,both,,,869.34,565.07,,,,,,,,,,,,,
ROD SPNL SZ 6 RAD 220MM LUM GLD TI ALLOY EXTN VEPTR,SUP-2193303,CDM,C1713,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
BAR EXT FIX L400MM DIA10.5MM C COMP UNILAT KNEE RND CROSS,SUP-2342878,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1854.89,1205.68,,,,,,,,,,,,,
STEM HUM L 125 MM DIA11.5/8/6 MM COCR LNG CEM 4 FLUT TOT,SUP-2910015,CDM,C1776,CPT,0278,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
TUBE VENT ID1.14MM SIL MICROGEL PAPARELLA NOTCH TAB FOR MYR,SUP-2284014,CDM,L8699,HCPCS,0278,RC,,,,both,,,85.78,55.76,,,,,,,,,,,,,
CATHETER HD SYMMETRICAL TIP 23 FRX40 CM STRL PALINDROMIC,SUP-2174234,CDM,C1750,HCPCS,0278,RC,,,,both,,,1700.37,1105.24,,,,,,,,,,,,,
MIRVETUXIMAB SORAVTANSINE-GYNX 100 MG/20ML IV SOLN,RX-160846,CDM,J9063,HCPCS,0636,RC,72903-0853-01,NDC,,both,20,ML,19533.20,12696.58,,,,,,,,,,,,,
MESH HERN W10XL12IN RECT FULL RESRB FOR SFT TISS RECON,SUP-2125872,CDM,C1781,HCPCS,0278,RC,,,,both,,,29924.20,19450.73,,,,,,,,,,,,,
BIT DRL OD2.0MM MRK,SUP-2137065,CDM,2720000010,LOCAL,0272,RC,,,,both,,,371.46,241.45,,,,,,,,,,,,,
PROSTHESIS VOICE 22.5FR 12.5MM RADPQ VLV SEAT ENLD ESOPH,SUP-2124411,CDM,L8509,HCPCS,0274,RC,,,,both,,,1060.22,689.14,,,,,,,,,,,,,
HC Cardiac Nonmonitored Exer Sess,PX-9439379700,CDM,93797,CPT,0943,RC,,,,both,,,309.00,200.85,,,,,,,,,,,,,
HC So Lipoprotein A,PX-3018369566,CDM,83695,CPT,0301,RC,,,,both,,,185.00,120.25,,,,,,,,,,,,,
DONGLE USB UPGRD CROSSFLOW,SUP-2908612,CDM,2720000010,LOCAL,0272,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
GRAFT VASC GELWEAVE L 30 CM DIA 38 MM POLYESTER GEL,SUP-2385027,CDM,C1768,CPT,0278,RC,,,,both,,,1231.67,800.59,,,,,,,,,,,,,
HC Add 15 Minutes (Anesthesia),PX-3700000001,CDM,3700000001,LOCAL,0370,RC,,,,both,,,368.00,239.20,,,,,,,,,,,,,
SUPPORT ORTHOT HIP KNEE ANK CUST TORSON BALL BEAR J,SUP-2435642,CDM,L2060,HCPCS,0272,RC,,,,both,,,1725.68,1121.69,,,,,,,,,,,,,
PLATE BONE SM L85MM THK1MM 7 H BILAT S STL 1/3 TBLR NEUT DYN,SUP-2185838,CDM,C1713,HCPCS,0278,RC,,,,both,,,584.04,379.63,,,,,,,,,,,,,
PLATE BNE W12XL55MM THK1MM 3 H BILAT S STL SEMI TBLR LO,SUP-2184864,CDM,C1713,HCPCS,0278,RC,,,,both,,,197.16,128.15,,,,,,,,,,,,,
PLATE BNE L42MM 2X4 H R TI OBLQ L SHP LO PROF RIG NEUT LOK,SUP-2191460,CDM,C1713,HCPCS,0278,RC,,,,both,,,1172.13,761.88,,,,,,,,,,,,,
PLATE BONE L15MM THK0.8MM 3X2 H LCK COMPR GRID TRAP TI MALL,SUP-2267908,CDM,C1713,HCPCS,0278,RC,,,,both,,,1979.27,1286.53,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH FLX L 39 MM DIA26 MM SHTH 18 FR RVD,SUP-2170106,CDM,C1874,HCPCS,0278,RC,,,,both,,,5338.00,3469.70,,,,,,,,,,,,,
STENT BILI WSTNT L 40 MM DIA10 MM CATH L 194 CM DIA 8 FR,SUP-2141482,CDM,C1876,HCPCS,0278,RC,,,,both,,,5282.05,3433.33,,,,,,,,,,,,,
SHEATH INTRO FLX ANSEL L 45 CM OD 12 FR ID 4.1 MM GUIDEWIRE,SUP-2171149,CDM,C1894,HCPCS,0272,RC,,,,both,,,167.52,108.89,,,,,,,,,,,,,
LEVETIRACETAM 100 MG/ML PO SOLN,RX-36590,CDM,340b,HCPCS,0637,RC,09999-9900-94,NDC,,both,2.5,ML,5.60,3.64,,,,,,,,,,,,,
METHYL SALICYLATE EX LIQD,RX-28829,CDM,6370000000,HCPCS,0637,RC,23535-0005-05,NDC,,both,29.5,ML,16.10,10.46,,,,,,,,,,,,,
SHUNT LP L80CM OD15MM CLS END W FIX TAB AND NDL RADPQ,SUP-2278369,CDM,C1755,HCPCS,0278,RC,,,,both,,,1491.44,969.44,,,,,,,,,,,,,
TUBE MYR DIA132MM L132MM T GRMMT SIL ST RICHARDS,SUP-2313725,CDM,L8699,HCPCS,0278,RC,,,,both,,,66.54,43.25,,,,,,,,,,,,,
WIRE FIX TRCR PT 1.2X150 MM KIRSCHNER,SUP-2267993,CDM,C1713,HCPCS,0278,RC,,,,both,,,75.36,48.98,,,,,,,,,,,,,
BIT DRL CANN LNG 12 MM STRL,SUP-2789946,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2699.87,1754.92,,,,,,,,,,,,,
SCREW BNE L22MM DIA2.4MM CORT TI ST FOR MOD HND SYS PRO-PAK,SUP-2189511,CDM,C1713,HCPCS,0278,RC,,,,both,,,226.43,147.18,,,,,,,,,,,,,
RECON PLATE 15X237MM 4.5MM,SUP-2820870,CDM,C1713,HCPCS,0278,RC,,,,both,,,6061.14,3939.74,,,,,,,,,,,,,
KIT INSRTN INTRO L 6 IN CATH DIA 7.5 FR 30/40 CC PACKAGED,SUP-2908613,CDM,C1894,HCPCS,0272,RC,,,,both,,,420.70,273.45,,,,,,,,,,,,,
HC So Assay Anti-Mullerian Horm,PX-3018216666,CDM,82166,CPT,0301,RC,,,,both,,,165.00,107.25,,,,,,,,,,,,,
KIT INTRO ONESTIC L 11 CM DIA 5 FR GUIDEWIRE L 45 CM DIA,SUP-2876546,CDM,C1894,HCPCS,0272,RC,,,,both,,,194.68,126.54,,,,,,,,,,,,,
GUIDEWIRE VASC PRESSUREWIRE X L 175 CM DIA 0.014 IN HYDRPHLC,SUP-2357540,CDM,C1769,HCPCS,0272,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
GRAFT BLK TRI CORT BONE FRZ DRY ALLGRFT 1.5-1.9CM,SUP-2165561,CDM,C1713,HCPCS,0278,RC,,,,both,,,2041.00,1326.65,,,,,,,,,,,,,
PROTECTOR NERVE L 8 X W 3 CM PORCINE SODIUM HYALURONATE,SUP-2890392,CDM,C1763,HCPCS,0278,RC,,,,both,,,15970.04,10380.53,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 80 CM DIA 6 MM STR TW SLDE GDS,SUP-2475168,CDM,C1768,CPT,0278,RC,,,,both,,,3119.12,2027.43,,,,,,,,,,,,,
BAR EXT FIX L L150MM DIA10.5MM C FBR JET-X,SUP-2342871,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1568.59,1019.58,,,,,,,,,,,,,
HC X-Ray Scapula,PX-3207301000,CDM,73010,CPT,0320,RC,,,,inpatient,,,569.00,369.85,,,,,,,,,,,,,
IMMOBILIZER SHLDR SWTH UNIV DEV BLK P.A.D. III,SUP-2336074,CDM,L3650,HCPCS,0272,RC,,,,both,,,167.86,109.11,,,,,,,,,,,,,
GRAFT DERMAL STRUCTURAL THCK 16X6 CMX0.8-1.7 MM BRST FLEXHD,SUP-2307510,CDM,Q4128,HCPCS,0636,RC,,,,both,,,16401.95,10661.27,,,,,,,,,,,,,
PLATE BONE WALL 1.5X0.6 MM MEDIAL RIGHT TITANIUM NON STERILE,SUP-2838378,CDM,C1713,HCPCS,0278,RC,,,,both,,,4171.80,2711.67,,,,,,,,,,,,,
PLATE BNE L L70MM NONSTERILE R CALCNL S STL VAR ANG LOK FOR,SUP-2178424,CDM,C1713,HCPCS,0278,RC,,,,both,,,3057.48,1987.36,,,,,,,,,,,,,
TRAY KYPHOPLASTY SZ 3 BLLN L20MM SYR 11GA 1ST FRAC RADPQ,SUP-2293654,CDM,C1894,HCPCS,0272,RC,,,,both,,,9900.42,6435.27,,,,,,,,,,,,,
MESH HERN W30XL26CM FLAT BG VCRL,SUP-2220334,CDM,C1781,HCPCS,0278,RC,,,,both,,,2407.38,1564.80,,,,,,,,,,,,,
ELECTRODE SUCTION SPATULA 5X330 MM,SUP-2850570,CDM,2720000010,LOCAL,0272,RC,,,,both,,,826.76,537.39,,,,,,,,,,,,,
IMPLANT COAT HA 12MM,SUP-2319778,CDM,C1776,CPT,0278,RC,,,,both,,,9407.44,6114.84,,,,,,,,,,,,,
PIN GUIDE PARTIALLY THRD,SUP-2137364,CDM,2720000010,LOCAL,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
PLATE BNE L203MM 13 H NONSTERILE R LAT DST FIBULAR S STL,SUP-2177426,CDM,C1713,HCPCS,0278,RC,,,,both,,,1913.61,1243.85,,,,,,,,,,,,,
SHEARS LAPSCP L35CM DIA5MM PSTL GRP BLNT CVD ACT BLDE ENDO,SUP-2257662,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6123.00,3979.95,,,,,,,,,,,,,
FILLER BONE VOID 5ML HA SYNTH CA PHOS PUTTY TISS IMPL CEM,SUP-2194290,CDM,C1713,HCPCS,0278,RC,,,,both,,,4660.07,3029.05,,,,,,,,,,,,,
ELECTRODE UROLOGY VPR GRV RL BAR 24-28FR STRL DISP F/CIRCON,SUP-2313183,CDM,2720000010,LOCAL,0272,RC,,,,both,,,489.31,318.05,,,,,,,,,,,,,
DEFIBRILLATOR IMPL COBALT XT VR MRI SURESCAN W 51 X H 66 MM,SUP-2582927,CDM,C1722,HCPCS,0275,RC,,,,both,,,37648.60,24471.59,,,,,,,,,,,,,
TRUFILL PUSH COIL COMPLEX 3MM,SUP-2464704,CDM,C1889,HCPCS,0278,RC,,,,both,,,3067.97,1994.18,,,,,,,,,,,,,
IMMOBILIZER PREMIER PRO KNEE 3 PNL CANVS 12 IN LTX FREE,SUP-2336073,CDM,L1830,CPT,0272,RC,,,,both,,,56.24,36.56,,,,,,,,,,,,,
PUTTY BONE 10 CC REINFORCED FAST SET STERILE CRANIOS,SUP-2838513,CDM,C1713,HCPCS,0278,RC,,,,both,,,12121.97,7879.28,,,,,,,,,,,,,
KIT NURSING PICC CT SINGLE LUM 45CM X 1 MM,SUP-2913463,CDM,C1751,HCPCS,0278,RC,,,,both,,,301.44,195.94,,,,,,,,,,,,,
PROBE LITHO 4.5FR L80CM ELEC HYDRLC CALCUTRIPT,SUP-2261212,CDM,2720000010,LOCAL,0272,RC,,,,both,,,392.69,255.25,,,,,,,,,,,,,
ARTHROSCOPIC KIT 2 MM PIN STRL INION OTPS LTX DISP,SUP-2857900,CDM,C1713,HCPCS,0278,RC,,,,both,,,1262.28,820.48,,,,,,,,,,,,,
PLATE BNE L139MM 2 H NONSTERILE L PROX FEM S STL LO PROF,SUP-2186037,CDM,C1713,HCPCS,0278,RC,,,,both,,,3719.17,2417.46,,,,,,,,,,,,,
FORCEPS NAVIGATION SYS DIA1.8MM OVL CUP ALWAYS ON TIP,SUP-2392611,CDM,C1713,HCPCS,0278,RC,,,,both,,,1780.38,1157.25,,,,,,,,,,,,,
PLATE BNE UPPER RAMUS 2.3 MM RT FRAC SMRT FOR SCR TI LEVEL 1,SUP-2469602,CDM,C1713,HCPCS,0278,RC,,,,both,,,1703.73,1107.42,,,,,,,,,,,,,
WASHER SLT FOR SHEFFIELD STERILISATION TY SYS,SUP-2316260,CDM,2720000010,LOCAL,0272,RC,,,,both,,,883.16,574.05,,,,,,,,,,,,,
CATHETER ANGIOPLSTY OTW 5 FRX130 CM 4X120 MM LUTONIX BSLX3513041205F] BARD PERIPHERAL VASCULAR],SUP-2127968,CDM,C2623,HCPCS,0278,RC,,,,both,,,4396.00,2857.40,,,,,,,,,,,,,
PLATE 3.5MM TI LCP PERIARTIC PROX HUMERUS 14H 307MM RT STER,SUP-2546853,CDM,C1713,HCPCS,0278,RC,,,,both,,,6773.83,4402.99,,,,,,,,,,,,,
OSSEOFLEX SB STEERABLE BLLN 10GA2ML,SUP-2702607,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2999.20,1949.48,,,,,,,,,,,,,
HC Splint Appl Long Arm,PX-4502910500,CDM,29105,CPT,0450,RC,,,,inpatient,,,867.00,563.55,,,,,,,,,,,,,
KIT TUNN TOOL L30CM IMPL NRV STIM SYS DRG MOD PROCLAIM,SUP-2357686,CDM,2720000010,LOCAL,0272,RC,,,,both,,,596.60,387.79,,,,,,,,,,,,,
SYSTEM FIX STD FEM W/ SHTH 9MM SCR L23MM DIA9-10MM INTRAFIX,SUP-2256827,CDM,C1776,CPT,0278,RC,,,,both,,,1783.52,1159.29,,,,,,,,,,,,,
SPHERE EMB 900 1200 MIC 20ML BLU PREFIL SYR EMBGLD,SUP-2303389,CDM,C1889,HCPCS,0278,RC,,,,both,,,861.46,559.95,,,,,,,,,,,,,
PROCESSOR SND SYS N5SP1,SUP-2141842,CDM,L8691,HCPCS,0278,RC,,,,both,,,25120.00,16328.00,,,,,,,,,,,,,
PLATE BONE W27XL44MM 5 H DSTL TIB TI A FOR 2.7/3.5/4MM SCR,SUP-2225361,CDM,C1713,HCPCS,0278,RC,,,,both,,,2019.65,1312.77,,,,,,,,,,,,,
SET INTRO REMINGTON L 13 CM DIA 7 FR GUIDEWIRE 0.038 IN NDL,SUP-2137980,CDM,C1892,HCPCS,0272,RC,,,,both,,,94.20,61.23,,,,,,,,,,,,,
BUPIVACAINE-EPINEPHRINE 0.5% -1:200000 IJ SOLN (MIXTURES ONLY),RX-430040,CDM,2500000003,HCPCS,0250,RC,63323-0462-17,NDC,,both,1,ML,54.10,35.16,,,,,,,,,,,,,
EPIFIX MESHED 3.5X3.5CM 8SQ CM,SUP-2305741,CDM,Q4186,HCPCS,0636,RC,,,,both,,,4248.42,2761.47,,,,,,,,,,,,,
CATHETER HAD L32CM DIA15.5FR BASIC LNG TERM POLYUR STR,SUP-2267097,CDM,C1881,HCPCS,0278,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
VALVE SHUNT REG ADJ MAG RESONANCE CONDITIONAL STRL STRATAMR,SUP-2910697,CDM,C1889,HCPCS,0278,RC,,,,both,,,16642.00,10817.30,,,,,,,,,,,,,
SPLINT WR INSTABILITY INJ LT PED COCK UP SM,SUP-2211572,CDM,C1821,HCPCS,0278,RC,,,,both,,,22.80,14.82,,,,,,,,,,,,,
GRAFT HUM TISS M THN CNTOUR RDY TO USE ALLDERM,SUP-2113054,CDM,Q4116,HCPCS,0636,RC,,,,both,,,15429.96,10029.47,,,,,,,,,,,,,
EXTRACTOR SURG FEM,SUP-2361690,CDM,2720000010,LOCAL,0272,RC,,,,both,,,632.30,410.99,,,,,,,,,,,,,
DILATOR SURG DIA65MM PRB SPNL SYS DISPOSABLE ARIA,SUP-2381019,CDM,C1713,HCPCS,0278,RC,,,,both,,,2186.32,1421.11,,,,,,,,,,,,,
DEVICE INT FIX SM 11 MM THOR SINGLE FT STRNL TALON LEVEL 1,SUP-2869145,CDM,C1713,HCPCS,0278,RC,,,,both,,,3464.96,2252.22,,,,,,,,,,,,,
PLATE BNE NAR 4.5X52 MM 3 HOLE SS LC-DCP,SUP-2569255,CDM,C1713,HCPCS,0278,RC,,,,both,,,196.88,127.97,,,,,,,,,,,,,
CATHETER HD TENCK 42 CM 2 CUF KT ARGY,SUP-2626784,CDM,C1750,HCPCS,0278,RC,,,,both,,,210.38,136.75,,,,,,,,,,,,,
SYSTEM EXT DRNGE COMPLT W/ 700ML GRAD COLLCTN BG 62IN TBNG 2,SUP-2243798,CDM,C1729,HCPCS,0272,RC,,,,both,,,866.64,563.32,,,,,,,,,,,,,
CLIP HEMSTAS 90 DEG 8.5 MM LNG LIG ARM YEL STRL EZ CLP LF,SUP-2865652,CDM,C1889,HCPCS,0278,RC,,,,both,,,187.65,121.97,,,,,,,,,,,,,
STENT BILI ABS L 100 MM UNCONSTRAINED DIA 8 MM CATH L 135 CM,SUP-2101756,CDM,C1876,HCPCS,0278,RC,,,,both,,,4000.36,2600.23,,,,,,,,,,,,,
HC Debride Subq First 20 Sq Cm,PX-3611104200,CDM,11042,CPT,0361,RC,,,,both,,,1247.00,810.55,,,,,,,,,,,,,
PLATE BONE BAR L4MM THK1MM 6 H MAXILLOFACIAL TI CVD LO PROF,SUP-2191192,CDM,C1713,HCPCS,0278,RC,,,,both,,,1266.05,822.93,,,,,,,,,,,,,
CATHETER EP CRD 1 10 MM 5 FRX120 CM SUPREME,SUP-2355172,CDM,C1730,HCPCS,0272,RC,,,,both,,,414.48,269.41,,,,,,,,,,,,,
GUIDEWIRE VASC SOLO + L 150 CM DIA 0.035 IN PTFE TRITON,SUP-2655880,CDM,C1769,HCPCS,0272,RC,,,,both,,,206.17,134.01,,,,,,,,,,,,,
EPIFIX 2X3CM 6SQ CM MESH,SUP-2305740,CDM,Q4186,HCPCS,0636,RC,,,,both,,,3702.06,2406.34,,,,,,,,,,,,,
DEFIBRILLATOR IMPL LUMOS W67XH55MM D12MM 32CC 80 GM 2 CHMBR,SUP-2138081,CDM,C1721,HCPCS,0275,RC,,,,both,,,40820.00,26533.00,,,,,,,,,,,,,
BUPIVACAINE-EPINEPHRINE 0.5% -1:200000 IJ SOLN (MIXTURES ONLY),RX-430040,CDM,2500000003,HCPCS,0250,RC,63323-0463-57,NDC,,both,1,ML,54.10,35.16,,,,,,,,,,,,,
MODEL ANAT SINGLE JAW SPLNT ORTHOGNATHIC VSP,SUP-2884204,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2270.06,1475.54,,,,,,,,,,,,,
PLATE BNE L69MM SHT 1 H ST L MED DST HUM S STL VAR ANG FOR,SUP-2177579,CDM,C1713,HCPCS,0278,RC,,,,both,,,4128.79,2683.71,,,,,,,,,,,,,
SCREW BNE 1.5X6 MM 3.5 MM THRD BROWLIFT BEAL HEX DRL FREE,SUP-2489129,CDM,C1713,HCPCS,0278,RC,,,,both,,,318.74,207.18,,,,,,,,,,,,,
SCREW CRANIOMAXILLOFACIAL CROSS PIN SELF DRL MID FACE TI,SUP-2363335,CDM,C1713,HCPCS,0278,RC,,,,both,,,126.17,82.01,,,,,,,,,,,,,
GRAFT DERMAL STRUCTURAL ULTRA THCK 20X6 CMX1.8-4 MM FLEXHD,SUP-2307483,CDM,Q4128,HCPCS,0636,RC,,,,both,,,10688.37,6947.44,,,,,,,,,,,,,
PLATE BNE L132MM 8 H ST POST DST TIB S STL T LOK COMPR FOR,SUP-2177437,CDM,C1713,HCPCS,0278,RC,,,,both,,,4413.27,2868.63,,,,,,,,,,,,,
CAGE SPNL W11XH8XL14MM LUM LORD INTBDY FUS TRIAD CC,SUP-2310536,CDM,C1889,HCPCS,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
GRAFT BNE SUB XL W10-20MMXL19.5-38CM VIABLE CELL TRINITY,SUP-2307242,CDM,C1713,HCPCS,0278,RC,,,,both,,,15072.00,9796.80,,,,,,,,,,,,,
SCREW BNE L20MM DIA24MM TI VAR ANG LOK ST STARDRV RECESS TB,SUP-2418149,CDM,C1713,HCPCS,0278,RC,,,,both,,,460.29,299.19,,,,,,,,,,,,,
GRAFT VASC FUSION BIOLINE L 80 CM DIA10 MM AX COMPLIANCE,SUP-2694230,CDM,C1768,CPT,0278,RC,,,,both,,,6655.42,4326.02,,,,,,,,,,,,,
PROSTHESIS OSS PISTON 0.8X4.5 MM 0.97 MM LT EAR SHEA CUP,SUP-2637797,CDM,L8613,CPT,0278,RC,,,,both,,,456.05,296.43,,,,,,,,,,,,,
PLATE BNE L 107 X W 12 MM THK 2.4 MM SCREW DIA2.7 MM 16 H SS 72469716,SUP-2933423,CDM,C1713,HCPCS,0278,RC,,,,both,,,2579.51,1676.68,,,,,,,,,,,,,
BIT DRILL TROCAR LONG F/ NAILS 8-11 SILE,SUP-2737586,CDM,2720000010,LOCAL,0272,RC,,,,both,,,323.29,210.14,,,,,,,,,,,,,
HC Lactate Dehydrogenase Ldh,PX-3018361500,CDM,83615,CPT,0301,RC,,,,both,,,112.00,72.80,,,,,,,,,,,,,
CANNULA OPHTH VLV 500 CPM CONSTELLATION VITRECTOMY TOT + PK,SUP-2109965,CDM,C1713,HCPCS,0278,RC,,,,both,,,2069.26,1345.02,,,,,,,,,,,,,
SPINAL SET LCK 35 MM CAP/ROD COMB 2 NEWPORT MIS,SUP-2245605,CDM,C1713,HCPCS,0278,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
SHEATH INTRO INPUT SSV L 13 CM DIA 7 FR DIL L 20 CM,SUP-2174531,CDM,C1894,HCPCS,0272,RC,,,,both,,,1286.77,836.40,,,,,,,,,,,,,
SHEATH INTRO PRELUDE ACT L 11 CM DIA 4.5 FR GUIDEWIRE L 50,SUP-2459148,CDM,C1894,HCPCS,0272,RC,,,,both,,,26.38,17.15,,,,,,,,,,,,,
KIT CA 5MM SPINEJACK,SUP-2361514,CDM,C1062,HCPCS,0278,RC,,,,both,,,11770.29,7650.69,,,,,,,,,,,,,
FIBER LASER OD200UM HOLM SIDE FIRING DISP SLM LN VERSAPULSE,SUP-2141788,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3800.97,2470.63,,,,,,,,,,,,,
GRAFT VASC IMPRA L 70 CM DIA 6 MM EPTFE FLX TW RING HEMO,SUP-2128209,CDM,C1768,CPT,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
PLATE BONE L85MM 4 H S STL LCK COMPR FOR 4.5MM SCR PERI-LOC,SUP-2348940,CDM,C1713,HCPCS,0278,RC,,,,both,,,3152.40,2049.06,,,,,,,,,,,,,
ALLOGRAFT BNE LG 4.1-5X0.7-0.9 CMX 1.8-2.2 MM FD NAR PROF,SUP-2499661,CDM,C1889,HCPCS,0278,RC,,,,both,,,2261.11,1469.72,,,,,,,,,,,,,
BRACE Q LG,SUP-2174971,CDM,L1820,HCPCS,0274,RC,,,,both,,,188.24,122.36,,,,,,,,,,,,,
IBAL TKA BEARING IMP PS SZ 7 18MM,SUP-2813186,CDM,C1776,CPT,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
NEEDLE CRYOABLATION ICESEED 1.5MM,SUP-2225682,CDM,C2618,HCPCS,0272,RC,,,,both,,,4356.75,2831.89,,,,,,,,,,,,,
SCREW BNE L16MM OD2.7MM TI FT ANK CANN SHT THRD HD COMPR,SUP-2400820,CDM,C1713,HCPCS,0278,RC,,,,both,,,599.74,389.83,,,,,,,,,,,,,
KIT BNE ACCS SZ 3 8GA W/ 1 CANN STYL DRL SPCR OSTEOCOOL,SUP-2293680,CDM,C1894,HCPCS,0272,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
STENT BILI L50MM 2.83MM DIAM AD ST-2 SOEH TANNENBAUM,SUP-2169328,CDM,C2617,HCPCS,0278,RC,,,,both,,,188.40,122.46,,,,,,,,,,,,,
CISATRACURIUM BESYLATE 20 MG/10ML IV SOLN,RX-120973,CDM,2500000003,HCPCS,0250,RC,63323-0417-10,NDC,,both,10,ML,105.80,68.77,,,,,,,,,,,,,
MESH HERN ELLIPSE 8X6IN W/ POS SYS PHASIX ST ECHO 2,SUP-2855262,CDM,C1781,HCPCS,0278,RC,,,,both,,,15700.00,10205.00,,,,,,,,,,,,,
BLADE RETRACTOR KOROS 2 IN SELF RET,SUP-2444063,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1752.12,1138.88,,,,,,,,,,,,,
SCREW BNE SEMICONSTRAINED 4.5X30 MM WRST LCK CAP STRL FRDM,SUP-2852843,CDM,C1713,HCPCS,0278,RC,,,,both,,,1533.76,996.94,,,,,,,,,,,,,
SET INTRO SUPER SHTH L 5 CM DIA 6.5 FR NIT WIRE TEARWY,SUP-2627269,CDM,C1894,HCPCS,0272,RC,,,,both,,,30.58,19.88,,,,,,,,,,,,,
CATHETER ANGIOPLSTY MARSH L 90 CM DIA 5.2 FR BALLOON L 1.5,SUP-2147579,CDM,C1725,HCPCS,0272,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
PLATE BNE L36MM THK0.9MM 7 H R CNDYL S STL LO PROF RIG NEUT,SUP-2186298,CDM,C1713,HCPCS,0278,RC,,,,both,,,1392.65,905.22,,,,,,,,,,,,,
GRAFT BONE SUB W8XH4.6-7XL22MM POST LUM INTBDY FUS SPCR FRZN,SUP-2306878,CDM,C1713,HCPCS,0278,RC,,,,both,,,8193.92,5326.05,,,,,,,,,,,,,
SHEATH URETH ACC 54 CM,SUP-2312759,CDM,C1894,HCPCS,0272,RC,,,,both,,,367.51,238.88,,,,,,,,,,,,,
SPHERE EMB ONCOZENE DIA 75 UM 2 ML HYDRGEL POLYZENE MIC WHT,SUP-2139572,CDM,C1889,HCPCS,0278,RC,,,,both,,,6908.00,4490.20,,,,,,,,,,,,,
PLATE BONE L134MM 10 H STRL RT LAT PROX TIB S STL FOR 3.5MM,SUP-2349727,CDM,C1713,HCPCS,0278,RC,,,,both,,,11330.38,7364.75,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9 % IV BOLUS NEONATE,RX-40840079,CDM,J7030,HCPCS,0258,RC,00338-0049-04,NDC,,both,1000,ML,42.50,27.62,,,,,,,,,,,,,
RESERVOIR VENTRICULAR DRAINAGE 8.5CM CATHETER LENGTH 14MM DI,SUP-2826645,CDM,C1889,HCPCS,0278,RC,,,,both,,,1681.94,1093.26,,,,,,,,,,,,,
LEAD DEFIB ENDOTK SQ ARRY XP L 70 CM SIL SUBQ SUTURE FIX DF1,SUP-2148542,CDM,C1895,HCPCS,0275,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
IMPLANT OSS L6.6MM HD DIA4X3MM 1.15MM CANN BLK MID EAR HA,SUP-2312563,CDM,L8613,CPT,0278,RC,,,,both,,,1440.69,936.45,,,,,,,,,,,,,
PIN FIX 3.1MM STNMN,SUP-2277485,CDM,C1713,HCPCS,0278,RC,,,,both,,,266.90,173.48,,,,,,,,,,,,,
PLATE BONE L4MM THK0.5MM 90DEG SH 3X3 H BILAT MAXILLOFACIAL,SUP-2181818,CDM,C1713,HCPCS,0278,RC,,,,both,,,1092.41,710.07,,,,,,,,,,,,,
PLATE 3.5 MM TI LCP POSTEROMEDIAL PROX TIBIA 8 H/157 MM STER,SUP-2546840,CDM,C1713,HCPCS,0278,RC,,,,both,,,3914.51,2544.43,,,,,,,,,,,,,
ODH 32MM S/+0 12/14 FEM HEAD,SUP-2830379,CDM,C1776,CPT,0278,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9 % IV BOLUS NEONATE,RX-40840079,CDM,2580000003,HCPCS,0250,RC,00264-1800-32,NDC,,both,100,ML,23.00,14.95,,,,,,,,,,,,,
CLIP ANEUR STR 7 MM,SUP-2337204,CDM,C1889,HCPCS,0278,RC,,,,both,,,960.84,624.55,,,,,,,,,,,,,
SYSTEM EN ACCS TB 12FR L43IN CORTRAK 2,SUP-2236634,CDM,2720000010,LOCAL,0272,RC,,,,both,,,191.10,124.21,,,,,,,,,,,,,
ALLOGRAFT BNE 40 MM PRESERVON FIBULAR SHFT MATRIGRAFT,SUP-2740995,CDM,C1762,CPT,0278,RC,,,,both,,,1601.84,1041.20,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA MAXBARR 3FR 55CM S3193108D,SUP-2632837,CDM,C1751,HCPCS,0278,RC,,,,both,,,594.06,386.14,,,,,,,,,,,,,
FENTANYL CITRATE (PF) 100 MCG/2ML IJ SOLN,RX-133093,CDM,J3010,HCPCS,0636,RC,00641-6027-25,NDC,,both,0.5,ML,54.10,35.16,,,,,,,,,,,,,
GRAFT BNE W20 70MM FEM HD W TROCH FRZN NO ANG R SIDE,SUP-2307308,CDM,C1713,HCPCS,0278,RC,,,,both,,,9784.24,6359.76,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9 % IV BOLUS NEONATE,RX-40840079,CDM,2580000003,HCPCS,0258,RC,00338-0049-11,NDC,,both,50,ML,24.70,16.05,,,,,,,,,,,,,
DOXAZOSIN MESYLATE 4 MG PO TABS,RX-9896,CDM,6370000000,HCPCS,0637,RC,00904-5524-61,NDC,,both,1,UN,3.90,2.53,,,,,,,,,,,,,
PLATE BONE W12XL55MM 3 H SEMI TBLR ECT,SUP-2198535,CDM,C1713,HCPCS,0278,RC,,,,both,,,132.95,86.42,,,,,,,,,,,,,
BLADE SURG FROSTED 20 MM 8 MM TIP,SUP-2227206,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1416.77,920.90,,,,,,,,,,,,,
GRAFT BNE WDG 9 MM TISS TRICORT,SUP-2391738,CDM,C1713,HCPCS,0278,RC,,,,both,,,2163.46,1406.25,,,,,,,,,,,,,
SCREW BNE ST 2.7X30 MM CORTICAL LCK T8 SS NS,SUP-2177458,CDM,C1713,HCPCS,0278,RC,,,,both,,,2156.61,1401.80,,,,,,,,,,,,,
KIT IMPL HIP HYB HIP-CEM,SUP-2212103,CDM,C1776,CPT,0278,RC,,,,both,,,15543.00,10102.95,,,,,,,,,,,,,
PROSTHESIS OSS PISTON 0.6X5.75 MM SCHKNT MALL ATTCH SS,SUP-2637752,CDM,L8613,CPT,0278,RC,,,,both,,,347.22,225.69,,,,,,,,,,,,,
IMPLANT MALAR W22XL44MM P3MM POR HDPE RT SHELL SYNTH,SUP-2182846,CDM,C1713,HCPCS,0278,RC,,,,both,,,1092.72,710.27,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED CEM SCORP NRG,SUP-2365625,CDM,C1776,CPT,0278,RC,,,,both,,,11359.86,7383.91,,,,,,,,,,,,,
GUIDEWIRE HYDR 0.014IN 8CM ANG 190CM,SUP-2303425,CDM,C1769,HCPCS,0272,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
STAPLER INT CIR XL EXTRA THICK 31 MM 4-5 MM BLK EEA,SUP-2787721,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5211.33,3387.36,,,,,,,,,,,,,
RESERVOIR SHUNT BURR HOLE 6.4X0.8 MM RADIOPAQUE POLYPR,SUP-2851296,CDM,C1889,HCPCS,0278,RC,,,,both,,,473.01,307.46,,,,,,,,,,,,,
COMPONENT FEM RESURF CODE D MTL ON MTL CEM CO CHROM 38MM HD,SUP-2204655,CDM,C1776,CPT,0278,RC,,,,both,,,18573.10,12072.51,,,,,,,,,,,,,
"HC Est Pt, E/M Level 4|MULTIPLE OUTPATIENT HOSPITAL E/M ENCOUNTERS ON THE SAME DATE",PX-5109921400,CDM,99214,CPT,0510,RC,,,27,both,,,313.00,203.45,,,,,,,,,,,,,
BIT DRL OD4.5MM CORT OPENER LOK AO FIT FOR SM FRAG SYS,SUP-2377972,CDM,2720000010,LOCAL,0272,RC,,,,both,,,762.71,495.76,,,,,,,,,,,,,
BINDER SUBMALAR FACE IMPL SIL L 4.9 CMX2.0 CMX0.57 CMX1.2 CM,SUP-2242096,CDM,2780000010,LOCAL,0278,RC,,,,both,,,1067.60,693.94,,,,,,,,,,,,,
GUIDEWIRE ORTH CANN 0.80X70 MM FIX FUSION SYS DIGIFUSE,SUP-2609635,CDM,C1769,HCPCS,0272,RC,,,,both,,,115.87,75.32,,,,,,,,,,,,,
HC Biopsy-Pleura Needle,PX-3613240000,CDM,32400,CPT,0361,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
STEM FEM L270MM OD14MM 135DEG HIP TI REV PRESSFIT MOD TAPR,SUP-2404205,CDM,C1776,CPT,0278,RC,,,,both,,,21942.32,14262.51,,,,,,,,,,,,,
TRIAL CV OCCL AMPLATZER AMULET LOBE DIA25 MM LAA PERC SELF,SUP-2905205,CDM,C1817,HCPCS,0278,RC,,,,both,,,37680.00,24492.00,,,,,,,,,,,,,
PLATE CRANIO-FACIAL T DBL 1.5MM 6 H 24MML TI,SUP-2402935,CDM,C1713,HCPCS,0278,RC,,,,both,,,310.86,202.06,,,,,,,,,,,,,
LEVEL CMF PLATE SMRT3D TRMA TLTS PRSMPHSS 20 25 MM SCRW12,SUP-2676833,CDM,C1713,HCPCS,0278,RC,,,,both,,,1601.78,1041.16,,,,,,,,,,,,,
IMMOBILIZER KNEE RIGID LT W/O KNEE JT CUST FABRICATED,SUP-2417693,CDM,L1834,HCPCS,0274,RC,,,,both,,,2263.94,1471.56,,,,,,,,,,,,,
PLATE BNE CRV 1.5X50X1 MM MIDFACE ORBIT 12 HOLE TI LEVEL 1,SUP-2422378,CDM,C1713,HCPCS,0278,RC,,,,both,,,853.30,554.64,,,,,,,,,,,,,
CATHETER DIL 11.5FR L200CM TAPR TIP 7FR L3CM 0.035IN TO DIL,SUP-2169250,CDM,C1729,HCPCS,0272,RC,,,,both,,,229.22,148.99,,,,,,,,,,,,,
LINER ACET 38X28 MM SCR IN +5 HI WALL RINGLOC+,SUP-2447221,CDM,C1776,CPT,0278,RC,,,,both,,,2684.70,1745.05,,,,,,,,,,,,,
GUIDEWIRE ORTH METATRSL GRP LAPIDUS CLMP SYS NS LF,SUP-2881091,CDM,C1769,HCPCS,0272,RC,,,,both,,,3178.78,2066.21,,,,,,,,,,,,,
HC Electro Cerebral Silence,PX-7409582400,CDM,95824,CPT,0740,RC,,,,both,,,4157.00,2702.05,,,,,,,,,,,,,
ENDOPROSTHESIS VASC ICAST L 38 MM DIA 8 MM CATH L 80 CM,SUP-2884883,CDM,C1874,HCPCS,0278,RC,,,,both,,,8106.22,5269.04,,,,,,,,,,,,,
ARM RETRACTOR LEYLA FLX TENS,SUP-2473420,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2408.38,1565.45,,,,,,,,,,,,,
STRM 1ST MPJ PLATE SM 7DEGREES RT,SUP-2471632,CDM,C1713,HCPCS,0278,RC,,,,both,,,5414.05,3519.13,,,,,,,,,,,,,
LINER TIB CEM KNEE CR XLPE PREMIER STRYK6] STRYKER ORTHOPEDICS HOWM],SUP-2379183,CDM,C1776,CPT,0278,RC,,,,both,,,12560.00,8164.00,,,,,,,,,,,,,
HC Sacroiliac Jnts Min 3 Views,PX-3207220200,CDM,72202,CPT,0320,RC,,,,inpatient,,,938.00,609.70,,,,,,,,,,,,,
WEDGE FEM SZ 6 THK20MM DSTL KNEE FOR HNG SYS LEGION,SUP-2346408,CDM,C1776,CPT,0278,RC,,,,both,,,3994.08,2596.15,,,,,,,,,,,,,
PLATE BNE L 100 DEG STD 1.7X12X0.55 MM RT 6 HOLE ADV BAR,SUP-2366249,CDM,C1713,HCPCS,0278,RC,,,,both,,,677.64,440.47,,,,,,,,,,,,,
CUTTER SUT SER 1 STR FIBERTAPE,SUP-2121026,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
HC MRI-Spine Lumbar WO & W Cont,PX-6127215800,CDM,72158,CPT,0612,RC,,,,both,,,3486.00,2265.90,,,,,,,,,,,,,
STIMULATOR NRV SPNL IMP PULSE PRECIS SPECTR AND CHARGING KT,SUP-2141892,CDM,C1820,HCPCS,0278,RC,,,,both,,,54322.00,35309.30,,,,,,,,,,,,,
SYSTEM DEL VENTRAX L 95 CM SHTH 8.5 FR L 101 CM MS SUPP,SUP-2930562,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
CATHETER EP SM 2-5-2 MM 7 FRX115 CM SAFIRE,SUP-2357030,CDM,C1733,HCPCS,0272,RC,,,,both,,,2276.50,1479.72,,,,,,,,,,,,,
SPLINT TRAC 12IN UNIV 3 PNL KNEE,SUP-2196752,CDM,L1830,CPT,0274,RC,,,,both,,,56.58,36.78,,,,,,,,,,,,,
CARTRIDGE GRFT DEL 5 CC INSTAFILL,SUP-2865331,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
FIBER LASER 940 MICRON 3/PKG STERILE INCLUDES 1,SUP-2574065,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1484.12,964.68,,,,,,,,,,,,,
KYPHOPLASTY PACK 10 GA 4 ML STR W/ BFD OSSEOFLEX SB OCP0114,SUP-2500037,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4396.00,2857.40,,,,,,,,,,,,,
SHEATH INTRO L28CM DIA16FR POLYETH HYDRPHLC W/O CRV HEMSTAT,SUP-2396256,CDM,C1894,HCPCS,0272,RC,,,,both,,,816.40,530.66,,,,,,,,,,,,,
TUBE JEJUNOSTOMY FEED 18 FRX45 CM 3.5 CM 7-10 CC LP MIC-KEY,SUP-2764874,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1054.79,685.61,,,,,,,,,,,,,
SCREW AUTO DRIVE 13.6X4MM,SUP-2719502,CDM,C1713,HCPCS,0278,RC,,,,both,,,160.93,104.60,,,,,,,,,,,,,
DEVICE TRACTION FOREARM HANDSTAND DISP,SUP-2846769,CDM,2720000010,LOCAL,0272,RC,,,,both,,,452.16,293.90,,,,,,,,,,,,,
ALLOGRACT HUM TISS AMNIOBAND MEMBRANE 3X4CM,SUP-2307622,CDM,Q4151,HCPCS,0636,RC,,,,both,,,3224.78,2096.11,,,,,,,,,,,,,
BLADE SRGCL SFTY LOCK DVCE SIZE 12 STNLSS STEEL RIB DSGN CNS,SUP-2570643,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5.43,3.53,,,,,,,,,,,,,
KIT INTRO MAK L 10 CM DIA 5 FR 40 CM 0.018 IN NIT COAX STD,SUP-2303005,CDM,C1894,HCPCS,0272,RC,,,,both,,,70.12,45.58,,,,,,,,,,,,,
PLATE BNE CALCANEAL 2.7X64 MM LT ANGLED STR SS STRL,SUP-2177442,CDM,C1713,HCPCS,0278,RC,,,,both,,,4603.55,2992.31,,,,,,,,,,,,,
SHEATH BAN PEAL 16FR 30MM,SUP-2141075,CDM,C1892,HCPCS,0272,RC,,,,both,,,160.08,104.05,,,,,,,,,,,,,
STRAP CLAV L BCKL CLSR FOAM CONSTR COT STOCK 3 W POST VECT,SUP-2194673,CDM,L3670,HCPCS,0274,RC,,,,both,,,13.47,8.76,,,,,,,,,,,,,
CATHETER UROLOGICAL INFUSION 5 FR 3 CC UTER GYNECATH CNTRST,SUP-2428126,CDM,C1713,HCPCS,0278,RC,,,,both,,,96.59,62.78,,,,,,,,,,,,,
HC Insertion Swan-Ganz Catheter,PX-4819350300,CDM,93503,CPT,0481,RC,,,,both,,,6214.00,4039.10,,,,,,,,,,,,,
KIT CATH HEMODIALYSI RELIANCE XK CHRONIC EXCHANGE 16 5327350,SUP-2632949,CDM,C1750,HCPCS,0278,RC,,,,both,,,7088.55,4607.56,,,,,,,,,,,,,
PLATE BONE L25MM THK1MM 4 H MAND TI TENS BND FOR 2MM SCR FIX,SUP-2191211,CDM,C1713,HCPCS,0278,RC,,,,both,,,1907.86,1240.11,,,,,,,,,,,,,
BOLT BNE FIX L145MM DIA5MM PROX L10MM DST L22MM MIDFOOT FUS,SUP-2400755,CDM,C1713,HCPCS,0278,RC,,,,both,,,4826.18,3137.02,,,,,,,,,,,,,
KIT PAIN PMP 400ML 4ML/HR ELASTOMERIC NONNARCOTIC 2 ON-Q,SUP-2236775,CDM,C9804,HCPCS,0272,RC,,,,both,,,364.24,236.76,,,,,,,,,,,,,
GRAFT HUM TISS 7X5 CM GENTRIX MTRX +,SUP-2106480,CDM,Q4166,HCPCS,0636,RC,,,,both,,,2967.30,1928.74,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY VIK L 65 CM DIA 6 FR SPC 2 MM,SUP-2142636,CDM,C1730,HCPCS,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
PLATE HEAD LCKNG PHALANGEAL 1.3MM LEFT-STERILE,SUP-2546066,CDM,C1713,HCPCS,0278,RC,,,,both,,,1523.69,990.40,,,,,,,,,,,,,
PLATE BNE L238MM 10X5 H S STL L DST LAT PERIARTC FEM LOK FOR,SUP-2372092,CDM,C1713,HCPCS,0278,RC,,,,both,,,4389.41,2853.12,,,,,,,,,,,,,
CATHETER CV TY 7 FRX20 CM 3L CUTLMY701JABRMCUSTOM0045,SUP-2759873,CDM,C1751,HCPCS,0278,RC,,,,both,,,520.83,338.54,,,,,,,,,,,,,
SCREW BNE L10MM DIA2MM STD TI NONLOCKING FULL THRD FOR HND,SUP-2319649,CDM,C1713,HCPCS,0278,RC,,,,both,,,222.94,144.91,,,,,,,,,,,,,
CATHETER ANGIOPLSTY MINI GHST L 40CM DIA 3.5FR 3CM 4.5MM,SUP-2659698,CDM,C1725,HCPCS,0272,RC,,,,both,,,1405.02,913.26,,,,,,,,,,,,,
DEVICE ENDSCPC FXTN 1650MML RTTBLE OPNCLSE FNCTNLTY QCKCLPP,SUP-2675479,CDM,2720000010,LOCAL,0272,RC,,,,both,,,648.98,421.84,,,,,,,,,,,,,
CATHETER EP 5FR L60CM 2-8-2MM SPC TIP 1MM 10 ELECTRD PCS,SUP-2248847,CDM,C1730,HCPCS,0272,RC,,,,both,,,825.82,536.78,,,,,,,,,,,,,
GUIDEWIRE FIX L6IN DIA0.045IN DBL TRCR,SUP-2319459,CDM,C1769,HCPCS,0272,RC,,,,both,,,78.50,51.02,,,,,,,,,,,,,
PLATE BNE L25MM 2 H BILAT S STL CNTOUR 2 COMPR FOR 35MM SCR,SUP-2411329,CDM,C1713,HCPCS,0278,RC,,,,both,,,300.15,195.10,,,,,,,,,,,,,
WAND ABLAT 50DEG KNEE FOR CART REP SYS FLO 50 COBLATION,SUP-2341943,CDM,2720000010,LOCAL,0272,RC,,,,both,,,926.93,602.50,,,,,,,,,,,,,
ATTACHMENT RETRCT FLEX 2 FNGR ASST SH 3.2X5.1 CM STABLESOFT,SUP-2218012,CDM,2720000010,LOCAL,0272,RC,,,,both,,,124.97,81.23,,,,,,,,,,,,,
SCREW BNE L42MM DIA3.5MM TI CORT DST TIB ST NONCANNULATED,SUP-2411698,CDM,C1713,HCPCS,0278,RC,,,,both,,,148.21,96.34,,,,,,,,,,,,,
STENT URETH UROLUME L 1.5 CM DIA 42 FR ELGILOY SELF,SUP-2140272,CDM,C1876,HCPCS,0278,RC,,,,both,,,13781.46,8957.95,,,,,,,,,,,,,
WARFARIN SODIUM 5 MG PO TABS,RX-8751,CDM,6370000000,HCPCS,0637,RC,62584-0994-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
VALVE PRESSURE PROGRAMMABLE W/ SIPHONGUARD MIC II,SUP-2666807,CDM,C1889,HCPCS,0278,RC,,,,both,,,18930.46,12304.80,,,,,,,,,,,,,
SCREW BNE L5MM OD15MM TI CRANIOMAXILLOFACIAL NONCANNULATED,SUP-2262790,CDM,C1713,HCPCS,0278,RC,,,,both,,,190.69,123.95,,,,,,,,,,,,,
CATHETER PERI L62.5CM L SWAN NK CURL DBL CUF ARGY,SUP-2283991,CDM,C1750,HCPCS,0278,RC,,,,both,,,672.09,436.86,,,,,,,,,,,,,
BUTTON FIX W8XL12MM TI ATTCH SYS ALLGRFT CONSTRUCT FOR,SUP-2121393,CDM,C1776,CPT,0278,RC,,,,both,,,449.02,291.86,,,,,,,,,,,,,
VALVE DRNGE W/ INTEGR PLAS CONN SIPHONGUARD PRIMING ADPT,SUP-2194061,CDM,C1889,HCPCS,0278,RC,,,,both,,,16468.70,10704.65,,,,,,,,,,,,,
IMMOBILIZER SHOULDERXL W25XL57CM UNIV TITEX W/ BODY STRP,SUP-2197383,CDM,L3650,HCPCS,0272,RC,,,,both,,,10.64,6.92,,,,,,,,,,,,,
GUIDEWIRE SURG L14IN DIA1.1MM S STL W/ TRCR TIP,SUP-2256614,CDM,C1769,HCPCS,0272,RC,,,,both,,,386.22,251.04,,,,,,,,,,,,,
SUBSTITUTE BONE GRFT COMPRESSIBLE SPNG M GROWTH FACT,SUP-2138503,CDM,C1713,HCPCS,0278,RC,,,,both,,,8035.26,5222.92,,,,,,,,,,,,,
ROD X MEDULLARY DSTL TIB UP ATTUNE,SUP-2454749,CDM,C1713,HCPCS,0278,RC,,,,both,,,1789.80,1163.37,,,,,,,,,,,,,
"HC Gbl Est Pt, E/M Level 4|RESIDENT/TEACHING PHYS SERV",PX-9829921400,CDM,99214,CPT,0982,RC,,,GC,outpatient,,,522.00,339.30,,,,,,,,,,,,,
PROCESSOR COCHLEAR SUPER POWER BAHA 5,SUP-2823578,CDM,L8690,HCPCS,0278,RC,,,,both,,,13502.00,8776.30,,,,,,,,,,,,,
GRAFT VASC HYBRID L 50 CM DIA 6 MM REINF SECT L 10 CM DIA 9,SUP-2395261,CDM,C1768,CPT,0278,RC,,,,both,,,8729.20,5673.98,,,,,,,,,,,,,
"HC Gbl Est Pt, E/M Level 2",PX-9829921200,CDM,99212,CPT,0982,RC,,,,outpatient,,,300.00,195.00,,,,,,,,,,,,,
GUIDEWIRE VASC ARW L 68 CM DIA 0.025 IN SS PERIPH MARKED,SUP-2838740,CDM,C1769,HCPCS,0272,RC,,,,both,,,31.40,20.41,,,,,,,,,,,,,
TOTAL KNEE REPLACEMENT KIT END-DELIVERY 11 GAX120 MM 5 CC,SUP-2866890,CDM,C1713,HCPCS,0278,RC,,,,both,,,8716.64,5665.82,,,,,,,,,,,,,
EXTERNAL FIXATION KIT DPHSEAL TIB STRL GALAXY UNYCO LTX,SUP-2875637,CDM,C1713,HCPCS,0278,RC,,,,both,,,8308.44,5400.49,,,,,,,,,,,,,
MESH GORE SYNECOR 30CM X 40CM RECTANGLE,SUP-2763180,CDM,C1781,HCPCS,0278,RC,,,,both,,,29107.80,18920.07,,,,,,,,,,,,,
ALLOGRAFT BNE 150 MM FD IRRADIATED TIB SHFT,SUP-2866918,CDM,C1762,CPT,0278,RC,,,,both,,,2505.72,1628.72,,,,,,,,,,,,,
SHEATH INTRO BASE CAMP SS POLYMER 1 LUMEN ROTATING,SUP-2878101,CDM,C1887,HCPCS,0272,RC,,,,both,,,3265.60,2122.64,,,,,,,,,,,,,
KIT CATH EPIDRL NDL L3.5IN OD17GA FLEXTIP + CATH,SUP-2384036,CDM,C1755,HCPCS,0278,RC,,,,both,,,124.09,80.66,,,,,,,,,,,,,
STEM FEM PRSS FT NEUT 10X130 MM COLLRED REDUC STD X-SERIES,SUP-2409351,CDM,C1776,CPT,0278,RC,,,,both,,,5966.00,3877.90,,,,,,,,,,,,,
PIN EXTERNAL FIXATION HALF SHORT 3X15 MM RADIAL DISTAL TITAN,SUP-2836764,CDM,2720000010,LOCAL,0272,RC,,,,both,,,843.69,548.40,,,,,,,,,,,,,
BRACE ANK 2 X SM M SHOE 3-5 WOMEN SHOE 4-6 AD SWEDE O X8,SUP-2325306,CDM,L1930,HCPCS,0272,RC,,,,both,,,68.42,44.47,,,,,,,,,,,,,
HC Admin Influenza Vaccine,PX-7710000800,CDM,G0008,HCPCS,0771,RC,,,,inpatient,,,85.00,55.25,,,,,,,,,,,,,
CLIP ANEURYSM 3 5/3MM MINI PERMANENT FENESTRATED 90 YASARGIL,SUP-2825541,CDM,C1889,HCPCS,0278,RC,,,,both,,,1196.84,777.95,,,,,,,,,,,,,
TUBE ENTRL FEED GASTRO-ENTERIC 20 FRX57.9 CM 7-10 CC MIC,SUP-2764443,CDM,2720000010,LOCAL,0272,RC,,,,both,,,545.95,354.87,,,,,,,,,,,,,
UB BLADE BIG BOY 3IN 6 1/2IN,SUP-2674155,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2393.59,1555.83,,,,,,,,,,,,,
HC US Guid Chor Villus Sampling,PX-4027694500,CDM,76945,CPT,0402,RC,,,,outpatient,,,783.00,508.95,,,,,,,,,,,,,
CEMENT BONE 20ML PCH W/ GENTMYCN M VISC CO,SUP-2217401,CDM,C1713,HCPCS,0278,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
ANCHOR SUT L14.5MM DIA3MM W/ TWO SUTS BIO-SUTTAK,SUP-2121591,CDM,C1713,HCPCS,0278,RC,,,,both,,,1168.08,759.25,,,,,,,,,,,,,
PLATE BNE L86MM 4 H R DST LAT FIBULAR S STL LOK COMPR FOR,SUP-2177413,CDM,C1713,HCPCS,0278,RC,,,,both,,,1651.64,1073.57,,,,,,,,,,,,,
SYSTEM POS VAG MERID DISP,SUP-2763314,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1315.66,855.18,,,,,,,,,,,,,
CLINDAMYCIN (CLEOCIN) 6 MG/ML SYRINGE (PED/NEO),RX-4090063,CDM,J0737,HCPCS,0636,RC,00338-3410-50,NDC,,both,50,ML,54.10,35.16,,,,,,,,,,,,,
ALLODERM SELECT RESTORE LARGE - MEDIUM 1.6 0.4MM,SUP-2826662,CDM,Q4116,HCPCS,0636,RC,,,,both,,,44145.26,28694.42,,,,,,,,,,,,,
GUIDEWIRE ORTH 2.5 MM FOR 7.3 MM CANN LCK SCREW NS,SUP-2799487,CDM,C1769,HCPCS,0272,RC,,,,both,,,473.57,307.82,,,,,,,,,,,,,
LENS INTOCU +13.0 DIOPT L13.5MM D5.37MM OD6.5MM 5DEG HAPTIC,SUP-2110501,CDM,V2632,HCPCS,0276,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
DRESSING WOUND SURGICAL MATRIX XSMALL 5X5 CM PLASTIC MATRISTEM,SUP-2106508,CDM,Q4166,HCPCS,0636,RC,,,,both,,,2156.55,1401.76,,,,,,,,,,,,,
GRAFT VASC IMPRA L 90 CM DIA 8 MM EPTFE STR TW N RING HEMO,SUP-2761376,CDM,C1768,CPT,0278,RC,,,,both,,,3383.44,2199.24,,,,,,,,,,,,,
PLATE BNE METATARSOPHALANGEAL LNG RT FORE FT FUSION,SUP-2609104,CDM,C1713,HCPCS,0278,RC,,,,both,,,6755.49,4391.07,,,,,,,,,,,,,
WASHER ORTH DIA7MM S STL,SUP-2122783,CDM,C1713,HCPCS,0278,RC,,,,both,,,100.79,65.51,,,,,,,,,,,,,
GRAFT BIO TISS 4X8CM THK04 1MM PROLAYER,SUP-2362228,CDM,C1763,HCPCS,0278,RC,,,,both,,,8279.55,5381.71,,,,,,,,,,,,,
BRACE WRIST SM 14.6 16.5CM LEFT PRTCTVE PDDNG ADJSTBLE BAR D,SUP-2480988,CDM,L3931,HCPCS,0272,RC,,,,both,,,36.64,23.82,,,,,,,,,,,,,
PLATE BONE 12 H ANTR LAT PROX FOR 4.5MM SCR,SUP-2349067,CDM,C1713,HCPCS,0278,RC,,,,both,,,1055.48,686.06,,,,,,,,,,,,,
BENEFIBER ON THE GO PO POWD,RX-132196,CDM,6370000000,HCPCS,0637,RC,86790-0162-80,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PLATE BNE L213MM 13 H L DST RAD VOLAR DPHSEAL MTPHSEAL S,SUP-2177225,CDM,C1713,HCPCS,0278,RC,,,,both,,,4894.26,3181.27,,,,,,,,,,,,,
GRAFT BONE 5ML DEMIN MTRX PASTE OSTEOFIL RT,SUP-2278379,CDM,C1713,HCPCS,0278,RC,,,,both,,,2210.56,1436.86,,,,,,,,,,,,,
LETROZOLE 2.5 MG PO TABS,RX-21509,CDM,6370000000,HCPCS,0637,RC,50268-0476-15,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
ANCHOR SUT DIA5MM TI W/ PRELD ULTRABRAID SUT TWINFIX,SUP-2341740,CDM,C1713,HCPCS,0278,RC,,,,both,,,875.34,568.97,,,,,,,,,,,,,
PLATE BONE 5X22X5 H BILAT TI DBL ANG RIG NONCOMPRESSION,SUP-2191423,CDM,C1713,HCPCS,0278,RC,,,,both,,,11724.76,7621.09,,,,,,,,,,,,,
PLATE EXT FIX L 45 MM 3 H SHRT CONN OVL SLOT NS DISP ILIZ,SUP-2933417,CDM,2720000010,LOCAL,0272,RC,,,,both,,,449.02,291.86,,,,,,,,,,,,,
PLATE BNE L 77 MM SCREW DIA 4.5 MM 4 H SS NAR COMPR NLCK,SUP-2933822,CDM,C1713,HCPCS,0278,RC,,,,both,,,1543.94,1003.56,,,,,,,,,,,,,
STENT PERIPH INNOVA L 150 MM DIA 5 MM CATH L 160 CM WORKING,SUP-2146844,CDM,C1876,HCPCS,0278,RC,,,,both,,,5573.50,3622.77,,,,,,,,,,,,,
WAND ABLAT TI 80 DEG 4MM,SUP-2341997,CDM,2720000010,LOCAL,0272,RC,,,,both,,,681.38,442.90,,,,,,,,,,,,,
LEVEL CMF ST PLATE ORBTL FLOOR SMART LEFT 15 MM SCRW35 X 35,SUP-2707414,CDM,C1713,HCPCS,0278,RC,,,,both,,,4365.23,2837.40,,,,,,,,,,,,,
IMPLANT COSMETIC SZ 13 X 38 X 3 MM POLYETHYL BLOCK STRL DISP,SUP-2935174,CDM,C1713,HCPCS,0278,RC,,,,both,,,1080.16,702.10,,,,,,,,,,,,,
STEM FEM L140MM OD12MM STD BODY NK OFFSET CO CHROM HIP PRI,SUP-2203081,CDM,C1776,CPT,0278,RC,,,,both,,,14144.13,9193.68,,,,,,,,,,,,,
BUSHING TIB 0MM OFFSET REV NEUT PROVEN GEN-FLEX,SUP-2359210,CDM,C1776,CPT,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
IMPLANT COSMETIC SZ 101 X 85 X 19 MM LG POLYETHYL RT,SUP-2934175,CDM,C1713,HCPCS,0278,RC,,,,both,,,6710.18,4361.62,,,,,,,,,,,,,
SULINDAC 150 MG PO TABS,RX-7578,CDM,6370000000,HCPCS,0637,RC,00591-5661-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
TRAY CATH HEMODIALYSI ZENYSI DL ACUTE 11FR DIA 15CM STRGHT 2,SUP-2613265,CDM,C1752,HCPCS,0278,RC,,,,both,,,814.05,529.13,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 45 CM DIA 4-6 MM SHRT TAPR HELIX,SUP-2525466,CDM,C1768,CPT,0278,RC,,,,both,,,1944.51,1263.93,,,,,,,,,,,,,
SCREW BNE HDLSS SHT 6.5X105 MM CANN COMPR NS LTX,SUP-2861222,CDM,C1713,HCPCS,0278,RC,,,,both,,,1746.47,1135.21,,,,,,,,,,,,,
DEFIBRILLATOR IMPL LUMAX W 59 MM 30 J TI EPOXY RESIN SIL 3,SUP-2138111,CDM,C1882,HCPCS,0275,RC,,,,both,,,66677.90,43340.63,,,,,,,,,,,,,
BUR SURG DIA 1MM GRU STERILE,SUP-2650030,CDM,2720000010,LOCAL,0272,RC,,,,both,,,18.68,12.14,,,,,,,,,,,,,
COMPONENT FEM BASIC PROXIMAL KNEE MOST OPTIONS,SUP-2509217,CDM,C1776,CPT,0278,RC,,,,both,,,11953.98,7770.09,,,,,,,,,,,,,
RITUXIMAB-ABBS (TRUXIMA) 10 MG/ML IV SOLN (MIXTURES ONLY),RX-1150545,CDM,Q5115,HCPCS,0636,RC,63459-0104-50,NDC,,both,50,ML,12176.00,7914.40,,,,,,,,,,,,,
SET PICC 3L 6FR X 55CM BP,SUP-2887072,CDM,C1751,HCPCS,0278,RC,,,,both,,,1104.24,717.76,,,,,,,,,,,,,
INFLATION DVCBSXT30 ATMBR20 MLMP952FL50MTL INSRT TLTRQUE DV,SUP-2701655,CDM,C1713,HCPCS,0278,RC,,,,both,,,130.62,84.90,,,,,,,,,,,,,
CABLE ORTH SWAGE 2 MM RCS COCR 745220,SUP-2450890,CDM,C1713,HCPCS,0278,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
INSTRUMENT SET EXTN ON DEMAND SET,SUP-2267690,CDM,C1713,HCPCS,0278,RC,,,,both,,,753.60,489.84,,,,,,,,,,,,,
COLCHICINE 0.6 MG PO TABS,RX-1821,CDM,6370000000,HCPCS,0637,RC,70010-0002-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PLATE QUIKFLAP 1X20 BURR 2X2 PLT,SUP-2718048,CDM,C1713,HCPCS,0278,RC,,,,both,,,5287.45,3436.84,,,,,,,,,,,,,
GRAFT BIO TISS W4XL4CM THK1 2MM PROLAYER,SUP-2362230,CDM,C1763,HCPCS,0278,RC,,,,both,,,4890.86,3179.06,,,,,,,,,,,,,
SCREW BONE 4.5X25MM MALL CORT S STL ECT,SUP-2198324,CDM,C1713,HCPCS,0278,RC,,,,both,,,59.60,38.74,,,,,,,,,,,,,
PLATE BONE W8XL100MM THK2MM 0DEG 12 H BILAT TI STR RIG DYN,SUP-2191075,CDM,C1713,HCPCS,0278,RC,,,,both,,,1980.56,1287.36,,,,,,,,,,,,,
COMPONENT PAT 34MM KNEE ARCM 1 PEG W/ WIRE FOR ONC SALV SYS,SUP-2404186,CDM,C1776,CPT,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 180 MM DIA11 MM DEL SHTH,SUP-2934584,CDM,C1713,HCPCS,0278,RC,,,,both,,,17223.06,11194.99,,,,,,,,,,,,,
SHEATH INTRO PERFRMR L 40 CM DIA 6 FR GUIDEWIRE 0.038 IN,SUP-2168449,CDM,C1894,HCPCS,0272,RC,,,,both,,,160.27,104.18,,,,,,,,,,,,,
PLATE BNE RECON 3.5 MM PELV 6 HOLE,SUP-2518362,CDM,C1713,HCPCS,0278,RC,,,,both,,,3061.50,1989.97,,,,,,,,,,,,,
GUIDEWIRE ORTH L300MM DIA32MM W CALIB AND QUIK REL FIT FOR,SUP-2377941,CDM,C1769,HCPCS,0272,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
GRAFT BONE SUB 2.5ML PUTTY DYNAGRFT,SUP-2247315,CDM,C1713,HCPCS,0278,RC,,,,both,,,800.70,520.45,,,,,,,,,,,,,
"HC So Antibody Virus, Nos",PX-3028679066,CDM,86790,CPT,0302,RC,,,,inpatient,,,87.00,56.55,,,,,,,,,,,,,
STENT GRFT VASC AFX L 75 MM UNCOVERED L 20 MM DIA 25 MM,SUP-2217591,CDM,C1768,CPT,0278,RC,,,,both,,,11115.60,7225.14,,,,,,,,,,,,,
HC CT L-Spine W/ Contrast,PX-3527213200,CDM,72132,CPT,0352,RC,,,,both,,,1973.00,1282.45,,,,,,,,,,,,,
DRESSING BIO W4XL5IN BOV CLLGN GLYCOSAMINOGLYCAN,SUP-2243932,CDM,Q4104,HCPCS,0636,RC,,,,both,,,25873.60,16817.84,,,,,,,,,,,,,
HC I & D Simple,PX-4501006000,CDM,10060,CPT,0450,RC,,,,inpatient,,,632.00,410.80,,,,,,,,,,,,,
CATHETER HD PRECRV 14 FRX12 CM SHT TERM DUOFLO 400XL,SUP-2627164,CDM,C1752,HCPCS,0278,RC,,,,both,,,178.98,116.34,,,,,,,,,,,,,
DEXAMETHASONE SODIUM PHOSPHATE 20 MG/5ML IJ SOLN,RX-125409,CDM,J1100,HCPCS,0636,RC,67457-0422-54,NDC,,both,0.5,ML,54.10,35.16,,,,,,,,,,,,,
CATHETER SET 7 FR RAPID INFUSION EXCHANGE DIL,SUP-2120642,CDM,C1769,HCPCS,0272,RC,,,,both,,,39.94,25.96,,,,,,,,,,,,,
TRAY CATH L20CM OD7FR 3 LUMN CTRL VEN CATH VES DIL GWIRE,SUP-2383948,CDM,C1751,HCPCS,0278,RC,,,,both,,,167.46,108.85,,,,,,,,,,,,,
PLATE BNE BURR HOLE 1.5X18X0.5 MM CVR CONTOURED W/ DRN HOLE,SUP-2480056,CDM,C1713,HCPCS,0278,RC,,,,both,,,669.95,435.47,,,,,,,,,,,,,
SCREW BNE L12MM DIA2MM L8MM THRD TI NONDRILLING THRDED,SUP-2262643,CDM,C1713,HCPCS,0278,RC,,,,both,,,316.04,205.43,,,,,,,,,,,,,
NEEDLE BIOPSY BRAIN 19CM,SUP-2842435,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1874.58,1218.48,,,,,,,,,,,,,
FLUMAZENIL 0.5 MG/5ML IV SOLN,RX-39744,CDM,2500000003,HCPCS,0250,RC,63323-0424-05,NDC,,both,2,ML,54.10,35.16,,,,,,,,,,,,,
PLATE BNE W9XL45MM THK1MM 4 H TI 1 3 TBLR W CLLR LOK COMPR,SUP-2190948,CDM,C1713,HCPCS,0278,RC,,,,both,,,513.55,333.81,,,,,,,,,,,,,
GENTAMICIN SULFATE 10 MG/ML IJ SOLN,RX-3425,CDM,J1580,HCPCS,0636,RC,63323-0173-01,NDC,,both,2,ML,54.10,35.16,,,,,,,,,,,,,
PLATE BNE VA RT VOLAR DSTL RADIAL 5X3 HOLE SS NS VA-LCP,SUP-2177270,CDM,C1713,HCPCS,0278,RC,,,,both,,,3099.18,2014.47,,,,,,,,,,,,,
CATHETER CV OXMTR 20 CM 3L SCVO2 MONITORING,SUP-2537554,CDM,C1751,HCPCS,0278,RC,,,,both,,,1036.20,673.53,,,,,,,,,,,,,
CALCITRIOL 0.25 MCG PO CAPS,RX-9350,CDM,6370000000,HCPCS,0637,RC,60687-0345-01,NDC,,both,1,UN,3.60,2.34,,,,,,,,,,,,,
BLADE 2MM DIA TURBINATOR ELONG TIP IRRIG DIEGO SYS SMOOTH,SUP-2313837,CDM,C1713,HCPCS,0278,RC,,,,both,,,386.94,251.51,,,,,,,,,,,,,
PLATE BONE PRECONTOURED 9 MM 2 HOLE TITANIUM LIGHT GREEN MAT,SUP-2842241,CDM,C1713,HCPCS,0278,RC,,,,both,,,220.43,143.28,,,,,,,,,,,,,
BUR SURG DIAMOND BALL 1 MMX7 CM SM BOR MIDAS REX LEGEND,SUP-2422257,CDM,2720000010,LOCAL,0272,RC,,,,both,,,381.57,248.02,,,,,,,,,,,,,
PLATE BNE TBLR 100 DEG 12 HOLE STRL LTX,SUP-2861635,CDM,C1713,HCPCS,0278,RC,,,,both,,,388.10,252.26,,,,,,,,,,,,,
RITUXIMAB-HYALURONIDASE HUMAN 1400-23400 MG -UT/11.7ML SC SOLN,RX-139194,CDM,J9311,HCPCS,0636,RC,50242-0108-01,NDC,,both,11.7,ML,18940.60,12311.39,,,,,,,,,,,,,
WASHER ORTH LG 13 MM FOR 4.5-6.3MM SCR STRL,SUP-2461937,CDM,C1713,HCPCS,0278,RC,,,,both,,,194.05,126.13,,,,,,,,,,,,,
ALLOGRAFT HUM TISS INJ 2 CC AMNIO FLUID PRO3-FA,SUP-2434348,CDM,C1762,CPT,0278,RC,,,,both,,,6280.00,4082.00,,,,,,,,,,,,,
MICRO PLATE SQUARE 6MM 15MM SYSTEM CP TITANIUM,SUP-2681099,CDM,C1713,HCPCS,0278,RC,,,,both,,,544.41,353.87,,,,,,,,,,,,,
NIVOLUMAB 10 MG/ML IV (MIXTURES ONLY),RX-1150051,CDM,J9299,HCPCS,0636,RC,00003-3774-12,NDC,,both,10,ML,9531.70,6195.60,,,,,,,,,,,,,
SUPPORT ORTHOT CUST OUTFLARE WDG,SUP-2435725,CDM,L3390,HCPCS,0272,RC,,,,both,,,140.42,91.27,,,,,,,,,,,,,
SUPPORT ORTHOT THOR LUMBAR SACR CUST FLX TRUNK SUPP,SUP-2435537,CDM,L0450,HCPCS,0274,RC,,,,both,,,460.07,299.05,,,,,,,,,,,,,
BURRROUNDHLRETRACT8 ROUND HL RETRACT 8 FLUT,SUP-2121967,CDM,2720000010,LOCAL,0272,RC,,,,both,,,317.14,206.14,,,,,,,,,,,,,
STAPLER INT CIR X THCK 25 MM 4/4.5/5 MM TRI-STAPLE BLK EEA,SUP-2858012,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3415.38,2220.00,,,,,,,,,,,,,
EXTENSION REM TOOL PROX HUM ACUTE PH FOR CONVENTUS CAGE SYS,SUP-2167378,CDM,2720000010,LOCAL,0272,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
GRAFT EVAR L82MM DIA20X20MM IL C DSGN ENDURANT II,SUP-2295237,CDM,C1768,CPT,0278,RC,,,,both,,,15229.00,9898.85,,,,,,,,,,,,,
COMPONENT HUM REG DIA35MM W7XL7MM OFFSET CO CHROM ARTC,SUP-2123553,CDM,C1776,CPT,0278,RC,,,,both,,,13611.90,8847.73,,,,,,,,,,,,,
IMPLANT THMB 75MM MOD STEM,SUP-2137791,CDM,C1776,CPT,0278,RC,,,,both,,,2590.50,1683.82,,,,,,,,,,,,,
ROD INSRTR FEM STP PIN REUSE RIGIDFIX,SUP-2256612,CDM,C1713,HCPCS,0278,RC,,,,both,,,681.38,442.90,,,,,,,,,,,,,
PACK NEUROSURGICAL SHTH L 50 X W 11 MM MYRIAD HNDPC L 13 CM NN-3000,SUP-2930297,CDM,2720000010,LOCAL,0272,RC,,,,both,,,22037.27,14324.23,,,,,,,,,,,,,
TUBING HEMCONC L36IN DIA0.25IN DHF W/ CONN,SUP-2352706,CDM,2720000010,LOCAL,0272,RC,,,,both,,,301.44,195.94,,,,,,,,,,,,,
CATHETER JET VENT 13G,SUP-2662065,CDM,2720000010,LOCAL,0272,RC,,,,both,,,335.98,218.39,,,,,,,,,,,,,
PLATE BONE METACARPAL MINI 2.7100X8X2.5 MM METATARSAL PHALAN,SUP-2837000,CDM,C1713,HCPCS,0278,RC,,,,both,,,2607.20,1694.68,,,,,,,,,,,,,
SCREW BNE L 60 MM DIA 6.5 MM SS CANN STRL EVOS,SUP-2931538,CDM,C1713,HCPCS,0278,RC,,,,both,,,1277.98,830.69,,,,,,,,,,,,,
PEG FIX LCK 2X26 MM T8 STARDRV NS VARIAX 2,SUP-2473001,CDM,2720000010,LOCAL,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
ROD EXT FIX 8MM 90DEG ADPT ACE-FISCHER,SUP-2414054,CDM,2720000010,LOCAL,0272,RC,,,,both,,,351.68,228.59,,,,,,,,,,,,,
MARKER BRST BX COIL 12 GA FOR ATEC BIODUR 108 SENOMARK ULTRA,SUP-2759147,CDM,A4648,CPT,0278,RC,,,,both,,,197.98,128.69,,,,,,,,,,,,,
SODIUM ZIRCONIUM CYCLOSILICATE 5 G PO PACK,RX-143095,CDM,6370000000,HCPCS,0637,RC,00310-1105-01,NDC,,both,1,UN,129.30,84.04,,,,,,,,,,,,,
GRAFT VASC GELWEAVE L 60 CM DIA28 MM POLYESTER GEL,SUP-2385054,CDM,C1768,CPT,0278,RC,,,,both,,,1591.51,1034.48,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA 3FR 55CM 1 LUMAN R S3173108,SUP-2632831,CDM,C1751,HCPCS,0278,RC,,,,both,,,473.07,307.50,,,,,,,,,,,,,
KIT HAD L40CM (SUB OPTION 2283941) CATH SYMMETRIC TIP 2 LUMN CATH SFTY SHTH TISS,SUP-2283920,CDM,C1750,HCPCS,0278,RC,,,,both,,,746.06,484.94,,,,,,,,,,,,,
GRAFT DURA 12X16 CM SUTURABLE BIO TISS BOV PERICARD DURAGN,SUP-2466261,CDM,C1763,HCPCS,0278,RC,,,,both,,,5202.20,3381.43,,,,,,,,,,,,,
HC Hepatitis B Surf Antibody Hbsab,PX-3028670600,CDM,86706,CPT,0302,RC,,,,both,,,551.00,358.15,,,,,,,,,,,,,
AFFINITY 2.5CMX2.5CM 7SQ CM,SUP-2314093,CDM,Q4159,HCPCS,0636,RC,,,,both,,,4003.50,2602.27,,,,,,,,,,,,,
SCREW SPNL L25MM OD6.5MM THORLUM REDUC LO PROF TOP LD REVERE,SUP-2231890,CDM,C1713,HCPCS,0278,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
SHUNT VENTRICULOPERTIONEAL REG W/O RESVR N PROGRAMMABLE,SUP-2244307,CDM,C1889,HCPCS,0278,RC,,,,both,,,2597.41,1688.32,,,,,,,,,,,,,
SLEEVE TROCAR L150MM DIAMETER 12MM SMOOTH DISPOSABLE WITH TA,SUP-2803691,CDM,2720000010,LOCAL,0272,RC,,,,both,,,816.34,530.62,,,,,,,,,,,,,
LGN STIKTITE POR STEM 18MMX160MM,SUP-2822931,CDM,C1776,CPT,0278,RC,,,,both,,,4144.80,2694.12,,,,,,,,,,,,,
PLATE BONE DUAL CMPRSSN 53MML HLX4 STNLSS STEEL RCNSTRCTN F/,SUP-2500646,CDM,C1713,HCPCS,0278,RC,,,,both,,,1200.55,780.36,,,,,,,,,,,,,
PLATE BNE L 403 MM SCREW DIA 3.5/4.5 MM 18 H RT TROCHANTERIC 72586218N,SUP-2933065,CDM,C1713,HCPCS,0278,RC,,,,both,,,21967.44,14278.84,,,,,,,,,,,,,
KIT ACC HIP CRV BLDE,SUP-2249574,CDM,C1713,HCPCS,0278,RC,,,,both,,,1827.48,1187.86,,,,,,,,,,,,,
STENT URET UNIVERSA FIRM L 28 CM DIA 6 FR POLYUR AQ BRAIDED,SUP-2171438,CDM,C2617,HCPCS,0278,RC,,,,both,,,502.71,326.76,,,,,,,,,,,,,
CATHETER KIT MULTI-MED 16 CM 3 LT CV MULTI-MED,SUP-2272478,CDM,C1751,HCPCS,0278,RC,,,,both,,,511.38,332.40,,,,,,,,,,,,,
COMPONENT FEM M RT KNEE POST STABILIZING REV PRI STEMLESS,SUP-2364855,CDM,C1776,CPT,0278,RC,,,,both,,,19731.76,12825.64,,,,,,,,,,,,,
GRAFT SYNTHETIC TISSUE GRANULE SMALL 0.71.4 MM 1 CC BETA TRI,SUP-2838531,CDM,C1713,HCPCS,0278,RC,,,,both,,,520.93,338.60,,,,,,,,,,,,,
BOLT EXT FIX 12 MM RR1200PK,SUP-2487154,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1130.40,734.76,,,,,,,,,,,,,
JOINT FNGR 30 MP SIL,SUP-2852869,CDM,C1776,CPT,0278,RC,,,,both,,,4812.46,3128.10,,,,,,,,,,,,,
PLATE BONE L93MM THK3.4MM 6 H BILAT NONLOCKING COMPR FOR,SUP-2348949,CDM,C1713,HCPCS,0278,RC,,,,both,,,1419.34,922.57,,,,,,,,,,,,,
LINER ACET SNAP IN NEUT STD 22X39 MM HIP PRIMARY DURASUL,SUP-2207438,CDM,C1776,CPT,0278,RC,,,,both,,,2347.15,1525.65,,,,,,,,,,,,,
DEXTROMETHORPHAN POLISTIREX ER 30 MG/5ML PO SUER,RX-9773,CDM,340b,HCPCS,0637,RC,09999-9908-39,NDC,,both,5,ML,15.80,10.27,,,,,,,,,,,,,
STENT BILI PALMAZ GEN L 29 MM EXPANSION DIA 5-10 MM SHTH,SUP-2159246,CDM,C1877,HCPCS,0278,RC,,,,both,,,3560.76,2314.49,,,,,,,,,,,,,
MODEL PT SPEC GLEN VIP 3D,SUP-2123500,CDM,C1776,CPT,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
ALUM HYDROXIDE-MAG CARBONATE 160-105 MG PO CHEW,RX-9016,CDM,6370000000,HCPCS,0637,RC,00904-5365-60,NDC,,both,1,UN,0.40,0.26,,,,,,,,,,,,,
PLATE BNE 2.7X20 MM 2 HOLE SS DCP,SUP-2569125,CDM,C1713,HCPCS,0278,RC,,,,both,,,229.69,149.30,,,,,,,,,,,,,
PLATE BNE RADIAL-ULNAR 30 DSTL WRST ASMBLY,SUP-2421734,CDM,C1713,HCPCS,0278,RC,,,,both,,,12864.58,8361.98,,,,,,,,,,,,,
ANCHOR SUTURE UHMWPE POLYESTER POLYPRO OR PPL TI BTTN WASHER ST 2PK,SUP-2905470,CDM,C1713,HCPCS,0278,RC,,,,both,,,11618.00,7551.70,,,,,,,,,,,,,
CROWN DENT E7 2ND PRIMARY M UPPER LT SS 7770625] 3M],SUP-2100305,CDM,D6783,CPT,0278,RC,,,,both,,,20.60,13.39,,,,,,,,,,,,,
ELECTRODE RF DIA23MM WDG DISPOSABLE FOR SM JT VAPR,SUP-2256731,CDM,2720000010,LOCAL,0272,RC,,,,both,,,904.32,587.81,,,,,,,,,,,,,
HC US Extrem Complete Nonvasc,PX-4027688100,CDM,76881,CPT,0402,RC,,,,outpatient,,,405.00,263.25,,,,,,,,,,,,,
T-PLT STERILIZER 4 HL 84 MM LENGTH,SUP-2820741,CDM,C1713,HCPCS,0278,RC,,,,both,,,1921.90,1249.23,,,,,,,,,,,,,
APPLIER CLP L6IN 28MM WRK CHN 11MM OPN TISS HEMSTAT REUSE,SUP-2141394,CDM,2720000010,LOCAL,0272,RC,,,,both,,,495.18,321.87,,,,,,,,,,,,,
PLATE BNE L 31.8 X W 5.1 MM THK 1 MM SCREW DIA2 MM 5 H GRD,SUP-2936044,CDM,C1713,HCPCS,0278,RC,,,,both,,,1259.14,818.44,,,,,,,,,,,,,
ANTENNA SURG ABLATN 17 CM MICROWAVE EVIDENT,SUP-2174872,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5181.00,3367.65,,,,,,,,,,,,,
ALLOGRAFT BNE BLOCK TRICORT 800128,SUP-2743367,CDM,C1713,HCPCS,0278,RC,,,,both,,,9206.48,5984.21,,,,,,,,,,,,,
PLATE BNE TBLR 2.7X33 MM 4 HOLE 1/4 SS,SUP-2536103,CDM,C1713,HCPCS,0278,RC,,,,both,,,336.29,218.59,,,,,,,,,,,,,
KIT INSTR TENFUSE PIP,SUP-2399029,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1111.56,722.51,,,,,,,,,,,,,
ELECTRODE ELECSURG ENDOTHERMAL ARTHSCP TACS,SUP-2314078,CDM,C1713,HCPCS,0278,RC,,,,both,,,926.30,602.09,,,,,,,,,,,,,
SCREW BNE CANN 1.7X60 MM COMPR,SUP-2389377,CDM,C1713,HCPCS,0278,RC,,,,both,,,1303.10,847.01,,,,,,,,,,,,,
STENT URET UNIVERSA FIRM L 18 CM DIA 6 FR POLYUR AQ BRAIDED,SUP-2836071,CDM,C2617,HCPCS,0278,RC,,,,both,,,270.45,175.79,,,,,,,,,,,,,
SCREW BNE 1.5MM DIAM 4MM LEN STD TI CORT CRANIO 5PK,SUP-2366192,CDM,C1713,HCPCS,0278,RC,,,,both,,,143.91,93.54,,,,,,,,,,,,,
PACK NEUROSURGICAL MYRIAD HNDPC L 10 CM DIA11 GA,SUP-2930220,CDM,2720000010,LOCAL,0272,RC,,,,both,,,46332.52,30116.14,,,,,,,,,,,,,
SET INTRO PEELWY L 15.5 CM DIA 8 FR DIL L 20 CM GUIDEWIRE,SUP-2167827,CDM,C1892,HCPCS,0272,RC,,,,both,,,301.44,195.94,,,,,,,,,,,,,
SCREW BNE L50MM OD3.5MM S STL CORT ST NONCANNULATED LOK,SUP-2348816,CDM,C1713,HCPCS,0278,RC,,,,both,,,913.74,593.93,,,,,,,,,,,,,
SET PICC L 55 CM DIA 6 FR SHTH L 7 CM DIA 6 FR,SUP-2886961,CDM,C1751,HCPCS,0278,RC,,,,both,,,2917.06,1896.09,,,,,,,,,,,,,
GRAFT BONE 10ML DEMIN MTRX PASTE OSTEOFIL RT,SUP-2293738,CDM,C1713,HCPCS,0278,RC,,,,both,,,2914.55,1894.46,,,,,,,,,,,,,
SCREW SET PERI-LOC VLP,SUP-2351453,CDM,C1713,HCPCS,0278,RC,,,,both,,,66727.10,43372.61,,,,,,,,,,,,,
HC CT T-Spine W/ Contrast,PX-3527212900,CDM,72129,CPT,0352,RC,,,,both,,,2630.00,1709.50,,,,,,,,,,,,,
CATHETER CV SINGLE LUMEN 5 FRX55 CM FULL TY INJ POWERPICC,SUP-2126370,CDM,C1751,HCPCS,0278,RC,,,,both,,,448.24,291.36,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 120 MM DIA13/10 MM DEL 12ML,SUP-2936840,CDM,C1713,HCPCS,0278,RC,,,,both,,,12943.08,8413.00,,,,,,,,,,,,,
HOOK MNPLTNG CLLR 7MM 4.9NL STNLSS STEEL RCTS MSCLE PLSHD FN,SUP-2501229,CDM,2720000010,LOCAL,0272,RC,,,,both,,,171.44,111.44,,,,,,,,,,,,,
SCREW HEADLESS 48MM,SUP-2510901,CDM,C1713,HCPCS,0278,RC,,,,both,,,109.90,71.43,,,,,,,,,,,,,
MESH SURG W7XL9IN UNCOATED MFIL POLYPR ABSRB HYDRGEL LO,SUP-2125909,CDM,C1781,HCPCS,0278,RC,,,,both,,,2907.64,1889.97,,,,,,,,,,,,,
BAR CONN FOR VERTEX RECON SYS XLNK,SUP-2286717,CDM,C1713,HCPCS,0278,RC,,,,both,,,178.98,116.34,,,,,,,,,,,,,
PIN FIX CLLRLSS 2.6 MM THRD ERGO,SUP-2451462,CDM,2720000010,LOCAL,0272,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9% IV BOLUS (PER WEIGHT)|DISCARDED DRUG NOT ADMINISTE,RX-40901010,CDM,J7050,HCPCS,0258,RC,00264-7800-20,NDC,JW,both,250,ML,23.40,15.21,,,,,,,,,,,,,
BIT DRL L190MM DIA11MM ST TI CANN QUIK CPL W/O STP,SUP-2188297,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1823.30,1185.14,,,,,,,,,,,,,
BIT DRL REMOVABLE STRL INCORE LAPIDUS REUSE,SUP-2465811,CDM,2720000010,LOCAL,0272,RC,,,,both,,,578.70,376.15,,,,,,,,,,,,,
ALLOGRAFT BTB WHOLE LT FZ ASP,SUP-2875971,CDM,C1762,CPT,0278,RC,,,,both,,,11839.53,7695.69,,,,,,,,,,,,,
KIT PT PRGMR FOR RESTORE NEUROSTIMULATOR MYSTIM,SUP-2278227,CDM,C1787,HCPCS,0278,RC,,,,both,,,3623.56,2355.31,,,,,,,,,,,,,
PLATE BNE PLNTR 2.8X42X16 MM RT 6 HOLE TI TRILOK TMT-1,SUP-2427834,CDM,C1713,HCPCS,0278,RC,,,,both,,,6257.71,4067.51,,,,,,,,,,,,,
COMPONENT FEM SZ 2 LT KNEE POST STBL NP REV CEM FOUNDATION,SUP-2215576,CDM,C1776,CPT,0278,RC,,,,both,,,13256.58,8616.78,,,,,,,,,,,,,
GRAFT BNE SUB 5CC VIABLE MTRX COMPRESSIBLE MOLD RDY TO USE,SUP-2370453,CDM,C1713,HCPCS,0278,RC,,,,both,,,6075.90,3949.33,,,,,,,,,,,,,
PLATE BNE L68.5MM 14 H R DST RAD VOLAR S STL LOK COMPR CLMN,SUP-2184077,CDM,C1713,HCPCS,0278,RC,,,,both,,,2489.30,1618.04,,,,,,,,,,,,,
CATHETER HD SYMMETRICAL TIP 14 FRX33 CM W/ TAL PALINDROMIC,SUP-2174221,CDM,C1750,HCPCS,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
RETRACTOR OPHTH NYL SMOOTH FINISH IRIS FLX HK DISP,SUP-2109676,CDM,2720000010,LOCAL,0272,RC,,,,both,,,318.58,207.08,,,,,,,,,,,,,
SYRINGE BONE GRFT PRECIS MX L,SUP-2402790,CDM,2720000010,LOCAL,0272,RC,,,,both,,,621.72,404.12,,,,,,,,,,,,,
PROSTHESIS 3.25MM DIAM 8.25MM LEN TORP W/ LINK DORNHOFFER,SUP-2312810,CDM,L8613,CPT,0278,RC,,,,both,,,1112.53,723.14,,,,,,,,,,,,,
PLATE BNE 3X8 H NONSTERILE TI T SHP LOK COMPR W SHT THRD DRL,SUP-2180913,CDM,C1713,HCPCS,0278,RC,,,,both,,,1434.10,932.16,,,,,,,,,,,,,
HC So Drg Scrn Class List A|NOT REASONABLE AND NECESSARY,PX-3018030766,CDM,80307,CPT,0301,RC,,,GZ,outpatient,,,79.00,51.35,,,,,,,,,,,,,
CAPTURED END CAP WITH POST 1MM,SUP-2828826,CDM,C1889,HCPCS,0278,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
SCREW SPNL EMGCY 3.1X11 MM LCK MAXDRIVE 258891191,SUP-2472435,CDM,C1713,HCPCS,0278,RC,,,,both,,,494.71,321.56,,,,,,,,,,,,,
SHEATH INTRO PRELUDE IDEAL L 23 CM DIA 5 FR 80CM 0.021IN STR,SUP-2740594,CDM,C1892,HCPCS,0272,RC,,,,both,,,154.96,100.72,,,,,,,,,,,,,
IMPLANT OPHTH NORTH CAROLINA EYE BNK,SUP-2309109,CDM,V2785,HCPCS,0278,RC,,,,both,,,13816.00,8980.40,,,,,,,,,,,,,
ALLOGRAFT DERMAL 50X60X3 MM ACELLULAR DERMAL MTRX ARTHROFLEX,SUP-2740837,CDM,Q4125,HCPCS,0636,RC,,,,both,,,10408.63,6765.61,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 6.5X9 CM TEND REINF MTRX PURAFORCE,SUP-2716035,CDM,C1765,HCPCS,0278,RC,,,,both,,,8164.00,5306.60,,,,,,,,,,,,,
COLLAR CERV CNTOUR LG 22.5X4.5 IN 15-20 IN MED FOAM PROCARE,SUP-2196862,CDM,L0180,HCPCS,0274,RC,,,,both,,,9.01,5.86,,,,,,,,,,,,,
ATTACHMENT POSER 360DEG ARTC STBL FOR POS THE APEX OF THE,SUP-2385709,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1620.87,1053.57,,,,,,,,,,,,,
GUIDEWIRE ORTH TROCAR PT 2 END 0.035X6 IN STRL LTX,SUP-2857933,CDM,C1769,HCPCS,0272,RC,,,,both,,,59.66,38.78,,,,,,,,,,,,,
MATRIX BIO L 7 X W 10 CM SZ 126 SQCM FISH SKIN DERMAL MESHED,SUP-2909199,CDM,Q4158,HCPCS,0636,RC,,,,both,,,6154.40,4000.36,,,,,,,,,,,,,
ROD SPNL POST R CRV SMOOTH TI ALLOYV 5.5MM DIA 45MM LEN,SUP-2415854,CDM,C1713,HCPCS,0278,RC,,,,both,,,1299.96,844.97,,,,,,,,,,,,,
BIT DRL L 135 MM DIA2.7 MM AO QC NS REUSE V,SUP-2905567,CDM,2720000010,LOCAL,0272,RC,,,,both,,,579.20,376.48,,,,,,,,,,,,,
PLATE CRAN 180X140X40 MM PT SPEC IMPL PEEK,SUP-2860158,CDM,C1713,HCPCS,0278,RC,,,,both,,,51114.49,33224.42,,,,,,,,,,,,,
SCREW BONE L50MM OD4MM LACTOSORB COPOLYMER SHLDR CANN FULL,SUP-2137296,CDM,C1713,HCPCS,0278,RC,,,,both,,,1086.44,706.19,,,,,,,,,,,,,
PLATE BNE L116MM 4 H ST R MED DST TIB S STL LOK COMPR FOR,SUP-2185579,CDM,C1713,HCPCS,0278,RC,,,,both,,,4939.09,3210.41,,,,,,,,,,,,,
SCREW BONE 4MM DIA 32MML CANCELLOUS SELF TAPPING,SUP-2720920,CDM,C1713,HCPCS,0278,RC,,,,both,,,116.43,75.68,,,,,,,,,,,,,
PIN FIX TRCR PT 1 END 0.109X9 IN 3 SHANK END SS NS STEINMANN,SUP-2791375,CDM,C1713,HCPCS,0278,RC,,,,both,,,21.04,13.68,,,,,,,,,,,,,
PACEMAKER CARD OPTIMIZER SMRT MINI IMPL PULSE GENRTR ALLEN,SUP-2866322,CDM,C1824,HCPCS,0278,RC,,,,both,,,81640.00,53066.00,,,,,,,,,,,,,
INTRODUCER SHTH 14FR L30CM DIA0.038IN CLOSE TOL EXTRUSION,SUP-2355437,CDM,C1894,HCPCS,0272,RC,,,,both,,,57.31,37.25,,,,,,,,,,,,,
HC Amylase,PX-3018215000,CDM,82150,CPT,0301,RC,,,,both,,,193.00,125.45,,,,,,,,,,,,,
HC So Hiv Genotype for Retrov Resist,PX-3068790166,CDM,87901,CPT,0306,RC,,,,both,,,1147.00,745.55,,,,,,,,,,,,,
MODULAR CUP NEUTRAL LINER LONGEVITY 44X28,SUP-2503727,CDM,C1776,CPT,0278,RC,,,,both,,,2041.00,1326.65,,,,,,,,,,,,,
CLAMP MED 6 POSITION MULTI PIN MR SAFE,SUP-2679120,CDM,2720000010,LOCAL,0272,RC,,,,both,,,564.32,366.81,,,,,,,,,,,,,
KNIFE SURG BLITZER 10 IN GRAD ANGLED TIP MICROFRANCE DISP,SUP-2470951,CDM,2720000010,LOCAL,0272,RC,,,,both,,,155.87,101.32,,,,,,,,,,,,,
PLATE BONE L139MM 12 H STRL S STL LCK COMPR FOR 3.5MM SCR,SUP-2349632,CDM,C1713,HCPCS,0278,RC,,,,both,,,2860.01,1859.01,,,,,,,,,,,,,
CATHETER CV DL 19 FRX30 CM PROC KT PWR INJ ARGY,SUP-2173949,CDM,C1751,HCPCS,0278,RC,,,,both,,,221.28,143.83,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 50 CM DIA 6 MM OFFSET RNG L 7 CM,SUP-2396281,CDM,C1768,CPT,0278,RC,,,,both,,,2493.16,1620.55,,,,,,,,,,,,,
EXPANDER TISS 8.3X5.5 CM 17 CM 100-120 CC TEXT SOFTSPAN,SUP-2459472,CDM,C1889,HCPCS,0278,RC,,,,both,,,1962.50,1275.62,,,,,,,,,,,,,
IMPLANT FACE L 43 X W 18 MM THK 3.2 MM RT INFERIOR ORBIT RIM,SUP-2883471,CDM,C1713,HCPCS,0278,RC,,,,both,,,1447.92,941.15,,,,,,,,,,,,,
GRAFT VASC HEMGRD BODY/BRANCH L 100/60 CM DIA10 X 10 MM,SUP-2227557,CDM,C1768,CPT,0278,RC,,,,both,,,3015.34,1959.97,,,,,,,,,,,,,
SCREW WDG FEM L5MM DSTL KNEE HNG LEGION,SUP-2346315,CDM,C1713,HCPCS,0278,RC,,,,both,,,497.38,323.30,,,,,,,,,,,,,
PLATE BNE STRNL 2.3X1.8 MM THOR 14 HOLE LCK BODY NS LEVEL 1,SUP-2869269,CDM,C1713,HCPCS,0278,RC,,,,both,,,1968.43,1279.48,,,,,,,,,,,,,
PLATE BNE W10.2XL169MM THK2.7MM 13 H BILAT S STL STR LO,SUP-2186200,CDM,C1713,HCPCS,0278,RC,,,,both,,,1700.50,1105.32,,,,,,,,,,,,,
PLATE BNE MESHED 206X1023X6 MM TI,SUP-2136553,CDM,C1713,HCPCS,0278,RC,,,,both,,,15229.00,9898.85,,,,,,,,,,,,,
STENT NEURO FRED TOT L 19 MM WORKING L 14 MM DIA 3 MM NIT,SUP-2754669,CDM,C1876,HCPCS,0278,RC,,,,both,,,44025.16,28616.35,,,,,,,,,,,,,
HC Thromb Mech 1st Vssl,PX-3613718400,CDM,37184,CPT,0361,RC,,,,both,,,10740.00,6981.00,,,,,,,,,,,,,
SUPPORT KNEE OPN PAT SM KNEE NEOPRNE,SUP-2195466,CDM,L1810,HCPCS,0272,RC,,,,both,,,12.25,7.96,,,,,,,,,,,,,
HOOK SPNL M PEDCL TI RAMPED THOR NAR BLDE FOR 5.5MM ROD CDH,SUP-2287867,CDM,C1713,HCPCS,0278,RC,,,,both,,,2377.77,1545.55,,,,,,,,,,,,,
GRAFT BNE FIBULAR STRUT 100MM,SUP-2293968,CDM,C1713,HCPCS,0278,RC,,,,both,,,2621.90,1704.23,,,,,,,,,,,,,
INTRODUCER SHTH 5 FRX55 CM W/ TUOHY-BORST SIDEARM FLX ANSEL,SUP-2423711,CDM,C1894,HCPCS,0272,RC,,,,both,,,166.83,108.44,,,,,,,,,,,,,
GRAFT HUM TISS 10X10MM PAT TEND PRESHAPED BIOCLEANSE,SUP-2335534,CDM,C1762,CPT,0278,RC,,,,both,,,11304.00,7347.60,,,,,,,,,,,,,
BIT DRL TWST 1X40 MM 8 MM W/ STP BOS ATTCH SS SONICWELD RX,SUP-2467335,CDM,2720000010,LOCAL,0272,RC,,,,both,,,559.14,363.44,,,,,,,,,,,,,
STEM TIB I-BEAM MED SHT KNEE,SUP-2846150,CDM,C1776,CPT,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
EZ SHOT 3 PLUS 22 G ASP NEEDLE,SUP-2707138,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1507.20,979.68,,,,,,,,,,,,,
TUBE VENT 7 MM 1.14 MM 2.3 MM STR FLROPLAS STRL 520082,SUP-2535135,CDM,L8699,HCPCS,0278,RC,,,,both,,,21.41,13.92,,,,,,,,,,,,,
TUBE INNR EAR MYR VENT FLNG W/ BVL TAB 1.14 MM ID SIL STRL,SUP-2277938,CDM,L8699,HCPCS,0278,RC,,,,both,,,140.04,91.03,,,,,,,,,,,,,
CEMENT BONE 25GM 17.25CC CA PHOS HA INJ PUTTY SYNTH TISS,SUP-2402964,CDM,C1713,HCPCS,0278,RC,,,,both,,,9658.64,6278.12,,,,,,,,,,,,,
COMPONENT FEM ROTATIONAL LG 25 MM LT PROS W/ ANTI-LUXATION,SUP-2265097,CDM,C1776,CPT,0278,RC,,,,both,,,15180.33,9867.21,,,,,,,,,,,,,
SCREW BONE L30MM DIA3.5MM MIDFOOT VAR ANG COMPR 1ST RAY,SUP-2420144,CDM,C1713,HCPCS,0278,RC,,,,both,,,500.17,325.11,,,,,,,,,,,,,
KIT INTRO ARW THMS L 10 CM DIA 8.5 FR GUIDEWIRE 0.035 IN,SUP-2383282,CDM,C1894,HCPCS,0272,RC,,,,both,,,83.40,54.21,,,,,,,,,,,,,
OCCLUDER CV FLO RST L 12 MM BLB DIA2.25 MM SIL RUBBER,SUP-2130328,CDM,C1760,HCPCS,0278,RC,,,,both,,,266.02,172.91,,,,,,,,,,,,,
BIOTENE DRY MOUTH MOIST SPRAY MT SOLN,RX-138581,CDM,6370000000,HCPCS,0637,RC,48582-0001-55,NDC,,both,44.3,ML,25.40,16.51,,,,,,,,,,,,,
STENT BILI S.M.A.R.T. L 80 MM DIA 6 MM NIT TRNSHEP SELF,SUP-2158911,CDM,C1876,HCPCS,0278,RC,,,,both,,,4286.10,2785.96,,,,,,,,,,,,,
DX KNOTLESS SWIVELOCK PEEK 4.75 MM,SUP-2815360,CDM,C1713,HCPCS,0278,RC,,,,both,,,1632.80,1061.32,,,,,,,,,,,,,
REAMER SURG 16 MM PHLANG,SUP-2432016,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
TUBE VENT SHEP GRMMT 1.02 MM 1.6 MM 2.3 MM FLROPLAS 520112,SUP-2535138,CDM,L8699,HCPCS,0278,RC,,,,both,,,24.08,15.65,,,,,,,,,,,,,
FORCEPS STONE REM 2.5FR L115CM GRSP DIA10MM FOR RETRIEVE,SUP-2171235,CDM,C1713,HCPCS,0278,RC,,,,both,,,581.78,378.16,,,,,,,,,,,,,
STAPLER INT 15X15X15 MM NIT MEMOFIX,SUP-2609677,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4586.63,2981.31,,,,,,,,,,,,,
HC So1 Assay of Volatiles,PX-3018460067,CDM,84600,CPT,0301,RC,,,,both,,,173.00,112.45,,,,,,,,,,,,,
TUBE VENT V-T GROMMET 1.27MM,SUP-2656690,CDM,L8699,HCPCS,0278,RC,,,,both,,,81.73,53.12,,,,,,,,,,,,,
PACEMAKER CARD INSIGNIA I ULTRA W 4.45 X H 5.02 CM THK 0.75,SUP-2148606,CDM,C1785,HCPCS,0275,RC,,,,both,,,19254.48,12515.41,,,,,,,,,,,,,
SLEEVE TIB STD UNIV POLYETH MOD CEM STEM ROT HNG REV,SUP-2376372,CDM,C1776,CPT,0278,RC,,,,both,,,1234.96,802.72,,,,,,,,,,,,,
GUIDEWIRE VASC L150CM DIA0.035IN TIP L3IN NIT COR POLYUR,SUP-2385571,CDM,C1769,HCPCS,0272,RC,,,,both,,,106.76,69.39,,,,,,,,,,,,,
TRAY CATH HEMODIALYSI DUO FLO ACTE 11.5FR DIA 20C MCDLT118IJ,SUP-2633019,CDM,C1750,HCPCS,0278,RC,,,,both,,,271.92,176.75,,,,,,,,,,,,,
CATHETER CARD ABLATION RF MARINR MC L 110 CM DIA 7 FR TIP L,SUP-2749540,CDM,C1732,HCPCS,0272,RC,,,,both,,,1805.50,1173.57,,,,,,,,,,,,,
PIN POS S STL CERCLAGE,SUP-2187032,CDM,C1713,HCPCS,0278,RC,,,,both,,,1186.92,771.50,,,,,,,,,,,,,
PLATE BONE L100MM 12 HOLE STNLSS STEEL CMPRSSN 27MM SCREW MI,SUP-2477821,CDM,C1713,HCPCS,0278,RC,,,,both,,,693.44,450.74,,,,,,,,,,,,,
INTRODUCER SHTH STEER SM CURL 164MM 85F 74CM HEARTSPAN,SUP-2302675,CDM,C1766,CPT,0272,RC,,,,both,,,2939.04,1910.38,,,,,,,,,,,,,
CATHETER PULM ART 7FR BLLN 1.25CC L110CM DIA11MM DBL LUMN,SUP-2383245,CDM,C1887,HCPCS,0272,RC,,,,both,,,182.12,118.38,,,,,,,,,,,,,
DRAIN SURG 10FR SIL RND HUBLESS RADPQ W O TRCR BLAK,SUP-2256673,CDM,C1729,HCPCS,0272,RC,,,,both,,,120.51,78.33,,,,,,,,,,,,,
PI PICC 2-LUMEN: 5FRX55CM WITH 80CM SS S,SUP-2822095,CDM,C1751,HCPCS,0278,RC,,,,both,,,350.42,227.77,,,,,,,,,,,,,
CATHETER PERIPH ATHRCTMY CLIRPATH TURBO + EXCIMER LSR,SUP-2353078,CDM,C1724,HCPCS,0278,RC,,,,both,,,5887.50,3826.87,,,,,,,,,,,,,
BLADE SCRDRVR FOR 1.2/1.7MM MIDFACE UPPERFACE,SUP-2364402,CDM,2720000010,LOCAL,0272,RC,,,,both,,,804.25,522.76,,,,,,,,,,,,,
CATHETER VENTRICULAR HI CLS PRESSURE 91 CM SHUNT ACCU-FLO,SUP-2243781,CDM,C1729,HCPCS,0272,RC,,,,both,,,281.03,182.67,,,,,,,,,,,,,
BOOT WALKING X SM,SUP-2194769,CDM,L4396,HCPCS,0274,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
STAPLE NITI SUPERMX W/INSTRS 20W X 15L,SUP-2745057,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7834.30,5092.29,,,,,,,,,,,,,
TRAY KYPHOPLASTY BAL 2ML L10MM DIA11.6MM NDL 10GA SYR 20ML,SUP-2367061,CDM,C1713,HCPCS,0278,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
CATHETER PI AGBA PICC KIT 2-L 5.5 FR X 50CM,SUP-2655670,CDM,C1751,HCPCS,0278,RC,,,,both,,,660.66,429.43,,,,,,,,,,,,,
PACK INSTR FOR MINIMALLY INVASIVE FT SURG,SUP-2398132,CDM,2720000010,LOCAL,0272,RC,,,,both,,,791.28,514.33,,,,,,,,,,,,,
EXPANDER BRST TISS 455CC W11XH11CM P7.6CM SIL SMOOTH ULT HI,SUP-2301017,CDM,C1789,HCPCS,0278,RC,,,,both,,,5495.00,3571.75,,,,,,,,,,,,,
CATHETER BAL OCCL L65CM OD7FR OD34FR,SUP-2139719,CDM,C2628,HCPCS,0272,RC,,,,both,,,438.03,284.72,,,,,,,,,,,,,
GENTAMICIN SULFATE 0.1 % EX OINT,RX-3424,CDM,6370000000,HCPCS,0637,RC,45802-0046-35,NDC,,both,15,GR,177.80,115.57,,,,,,,,,,,,,
PLATE 4.5MM TI LCP T 8 HOLES 147MM,SUP-2549654,CDM,C1713,HCPCS,0278,RC,,,,both,,,2369.41,1540.12,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 70 CM DIA 6MM L 70CM STR STD WALL,SUP-2396270,CDM,C1768,CPT,0278,RC,,,,both,,,4603.24,2992.11,,,,,,,,,,,,,
SCREW INTFR 10MM 25MM KNEE CANN ABSRB POLY L LACTIC ACID RND,SUP-2166999,CDM,C1713,HCPCS,0278,RC,,,,both,,,450.37,292.74,,,,,,,,,,,,,
GRAFT BNE WDG LG 6X19 MM EVANS TITAN 3-D,SUP-2423120,CDM,C1713,HCPCS,0278,RC,,,,both,,,6867.18,4463.67,,,,,,,,,,,,,
SHOE ORTHOT ADDITION INSOLE LTHR,SUP-2435737,CDM,L3500,HCPCS,0274,RC,,,,both,,,82.77,53.80,,,,,,,,,,,,,
IMPLANT TOP HAT LATARJET STRL,SUP-2256894,CDM,2720000010,LOCAL,0272,RC,,,,both,,,747.32,485.76,,,,,,,,,,,,,
OLANZAPINE 10 MG PO TBDP,RX-28160,CDM,6370000000,HCPCS,0637,RC,13668-0088-30,NDC,,both,1,UN,16.30,10.59,,,,,,,,,,,,,
HC Glucose Post Glucose Dose,PX-3018295000,CDM,82950,CPT,0301,RC,,,,both,,,274.00,178.10,,,,,,,,,,,,,
PATCH HERN SM W3.1XL4.7IN UNCOATED MFIL PROPYLENE OVL ABSRB,SUP-2125896,CDM,C1781,HCPCS,0278,RC,,,,both,,,1597.00,1038.05,,,,,,,,,,,,,
CABLE TRNSDUC FOR INTELJET CTRL UNIT,SUP-2340762,CDM,C1713,HCPCS,0278,RC,,,,both,,,1146.10,744.96,,,,,,,,,,,,,
COMPONENT TIB SZ A L MED KNEE UHMWPE ALPHA UNI FIX BEAR,SUP-2406147,CDM,C1776,CPT,0278,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
DEVICE TISS FIX FIBERTAG TIGHTROPE II INTERNALBRACE FLX ACL,SUP-2910478,CDM,C1713,HCPCS,0278,RC,,,,both,,,3214.58,2089.48,,,,,,,,,,,,,
PLUG TIB TY OFFSET ADPT TY,SUP-2405431,CDM,C1776,CPT,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
STEM FEM CEM LO OFFSET FORGED CO CHROM SZ 1 ACUMATCH C SER,SUP-2221723,CDM,C1776,CPT,0278,RC,,,,both,,,10676.00,6939.40,,,,,,,,,,,,,
LINER ACET ECC POLYETH 26MMX46MM 10DEG,SUP-2379025,CDM,C1776,CPT,0278,RC,,,,both,,,4753.96,3090.07,,,,,,,,,,,,,
CARTRIDGE SAW BLADE OSCILLATING TIP 19.5X1.28X105MM PRECISION FALCON,SUP-2367673,CDM,2720000010,LOCAL,0272,RC,,,,both,,,989.10,642.91,,,,,,,,,,,,,
LAG SCREW GUIDE SLEEVE,SUP-2678030,CDM,C1713,HCPCS,0278,RC,,,,both,,,1005.80,653.77,,,,,,,,,,,,,
RETRACTOR SURG RNG DIA 9 CM LG INTERCOSTAL INCISION SFT TISS,SUP-2890026,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1142.43,742.58,,,,,,,,,,,,,
PROBE PACE BPLR TEMP COBRA AFFIRM DISP,SUP-2124414,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3124.30,2030.79,,,,,,,,,,,,,
PLATE SPNL FIX 31 MM LP TI CD HORZ X10 CROSSLINK,SUP-2289539,CDM,C1713,HCPCS,0278,RC,,,,both,,,2386.40,1551.16,,,,,,,,,,,,,
GUIDEWIRE ORTH THRD 1.6 MM PERC NS LCP,SUP-2799836,CDM,C1769,HCPCS,0272,RC,,,,both,,,3210.05,2086.53,,,,,,,,,,,,,
BIT DRILL QUICK COUPLING MINI 1.8X32 MM NON STERILE,SUP-2837996,CDM,2720000010,LOCAL,0272,RC,,,,both,,,211.01,137.16,,,,,,,,,,,,,
PROSTHESIS LARYN L8MM DIA20FR PRELD W/ SMRT INSRTR TRNSPAR,SUP-2124374,CDM,L8509,HCPCS,0274,RC,,,,both,,,753.60,489.84,,,,,,,,,,,,,
COMPONENT TIB UNI 32MM X 6.5MM REPICCI II,SUP-2212779,CDM,C1776,CPT,0278,RC,,,,both,,,2468.04,1604.23,,,,,,,,,,,,,
HC Lumbar Diskography,PX-3207229500,CDM,72295,CPT,0320,RC,,,,inpatient,,,3334.00,2167.10,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 4X10 CM AMNION/CHORION MEMBRN EPIFIX,SUP-2305744,CDM,Q4186,HCPCS,0636,RC,,,,both,,,11194.13,7276.18,,,,,,,,,,,,,
GUIDEWIRE ORTH 13 MM PERC FOR FEM NAIL NS,SUP-2799288,CDM,C1769,HCPCS,0272,RC,,,,both,,,472.10,306.86,,,,,,,,,,,,,
GENERATOR NEUROSTIMULATOR 29GM W53XH48CM THK11CM SPNL CRD,SUP-2356758,CDM,C1820,HCPCS,0278,RC,,,,both,,,54522.96,35439.92,,,,,,,,,,,,,
HC US Spinal Canal and Contents,PX-4027680000,CDM,76800,CPT,0402,RC,,,,outpatient,,,693.00,450.45,,,,,,,,,,,,,
RETRACTOR SURG COLUMELLA W WT GRUBER,SUP-2244333,CDM,C1713,HCPCS,0278,RC,,,,both,,,407.67,264.99,,,,,,,,,,,,,
GUIDEWIRE VASC GLIDEWIRE GT L 180CM 0.016IN 90/60 DEG,SUP-2385631,CDM,C1769,HCPCS,0272,RC,,,,both,,,1029.92,669.45,,,,,,,,,,,,,
CUTTER ORTH PLATE STRL DISP STERNALOCK XP,SUP-2894466,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2041.00,1326.65,,,,,,,,,,,,,
SCREW BNE PARTIALLY THRD 5X110 MM PANTA 511110ND,SUP-2434155,CDM,C1713,HCPCS,0278,RC,,,,both,,,1420.10,923.06,,,,,,,,,,,,,
STENT URET L80CM OD6FR PERCFLX PTFE DIV CLOSE TIP,SUP-2139621,CDM,C2617,HCPCS,0278,RC,,,,both,,,602.38,391.55,,,,,,,,,,,,,
PLATE 2 CLMN DSTL VLR RAD 2.4MM 7H HD 2H SHFT RT STRL TI,SUP-2546705,CDM,C1713,HCPCS,0278,RC,,,,both,,,2537.37,1649.29,,,,,,,,,,,,,
GRAFT BONE SUB L 10ML CORT RESRB MOLD MINERALIZED PLEXUR M,SUP-2293949,CDM,C1713,HCPCS,0278,RC,,,,both,,,7979.53,5186.69,,,,,,,,,,,,,
STEM FEM 15X150 MM KNEE SS NS LF,SUP-2471858,CDM,C1776,CPT,0278,RC,,,,both,,,465.72,302.72,,,,,,,,,,,,,
KYPHOPLASTY TRAY 15/3 OSTEO INTRO CDS KYPHOPAK XPANDER II,SUP-2632078,CDM,C1713,HCPCS,0278,RC,,,,both,,,12898.49,8384.02,,,,,,,,,,,,,
SCREW BNE L 8 MM DIA1.7 MM TI CRANIOMAXILLOFACIAL ANCHR ST,SUP-2883602,CDM,C1713,HCPCS,0278,RC,,,,both,,,320.50,208.32,,,,,,,,,,,,,
PLATE BONE L215MM RIB RIBLOC,SUP-2107920,CDM,C1713,HCPCS,0278,RC,,,,both,,,6747.86,4386.11,,,,,,,,,,,,,
SYSTEM GRFT PREP FOR GPS III PLT CONC,SUP-2402583,CDM,C1713,HCPCS,0278,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
SPACER SPNL 7 DEG H A/P 9/8 MM A/P 11.5 MM M/L 12.5 MM SM,SUP-2881928,CDM,C1713,HCPCS,0278,RC,,,,both,,,2721.38,1768.90,,,,,,,,,,,,,
BRACE ORTHOPEDIC CTRL KNEE POS LIN,SUP-2315981,CDM,L1833,HCPCS,0272,RC,,,,both,,,360.47,234.31,,,,,,,,,,,,,
SHUNT VALVE SYSTEM SINGLE VALVE PRESSURE LEVEL H2O LAYING 14,SUP-2821788,CDM,C1889,HCPCS,0278,RC,,,,both,,,5525.43,3591.53,,,,,,,,,,,,,
HC Pt Parrafin Bath,PX-4209701800,CDM,97018,CPT,0420,RC,,,,both,,,144.00,93.60,,,,,,,,,,,,,
HC Leukored Rbcs Irradiated,PX-3900904000,CDM,P9040,CPT,0390,RC,,,,both,,,1536.00,998.40,,,,,,,,,,,,,
SYSTEM PMP CANSTR TBNG AND LID FLTR KT,SUP-2323588,CDM,2720000010,LOCAL,0272,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
HC Speech Therapy Group,PX-4439250800,CDM,92508,CPT,0443,RC,,,,both,,,249.00,161.85,,,,,,,,,,,,,
BASEPLATE TIB,SUP-2265739,CDM,C1776,CPT,0278,RC,,,,both,,,2488.23,1617.35,,,,,,,,,,,,,
HEAD HUM DIA40MM STEM H15MM STD SHLDR CO CHROME PORCOAT,SUP-2250655,CDM,C1776,CPT,0278,RC,,,,both,,,11550.80,7508.02,,,,,,,,,,,,,
STEM HUM DIA4MM FRAC IMPL COMPHSVE SHLDR SYS,SUP-2403966,CDM,C1776,CPT,0278,RC,,,,both,,,11194.10,7276.16,,,,,,,,,,,,,
CROWN DENT LR7 1ST PRI M INDIV SPACE MAINTAINER,SUP-2176685,CDM,D6783,CPT,0278,RC,,,,both,,,22.92,14.90,,,,,,,,,,,,,
CAP ADDON KNEE CUST GUID PSI,SUP-2212281,CDM,C1776,CPT,0278,RC,,,,both,,,17022.79,11064.81,,,,,,,,,,,,,
OCCLUDER CV HELEX L 75 CM DIA15 MM NIT EPTFE HYDRPHLC DBL,SUP-2395827,CDM,C1817,HCPCS,0278,RC,,,,both,,,19530.80,12695.02,,,,,,,,,,,,,
COMPRESSION BLK 100 MM RIG,SUP-2197286,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1224.60,795.99,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY INQUIRY AFOCUS L 110 CM DIA 5 FR,SUP-2357652,CDM,C1730,HCPCS,0272,RC,,,,both,,,3400.62,2210.40,,,,,,,,,,,,,
BIT DRL 2.5 MM FOR TOT WRST FUSION DISP,SUP-2852116,CDM,2720000010,LOCAL,0272,RC,,,,both,,,871.82,566.68,,,,,,,,,,,,,
PATELLA AUG 19MM M CONTINUUM KNEE SYS,SUP-2200593,CDM,C1776,CPT,0278,RC,,,,both,,,8779.44,5706.64,,,,,,,,,,,,,
SCREW BNE SD 3 MM SHFT 3-2.5X70 MM 15 MM CORTICAL,SUP-2646756,CDM,C1713,HCPCS,0278,RC,,,,both,,,281.00,182.65,,,,,,,,,,,,,
CONNECTOR SPNL 5.5MM OPN 5.5MM CLOSE 90DEG W ROD-ROD ASF,SUP-2311869,CDM,C1713,HCPCS,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
PLATE BNE MESHED 11 XL 0.6 MM RT CONTOURED TI NS,SUP-2478126,CDM,C1713,HCPCS,0278,RC,,,,both,,,17154.54,11150.45,,,,,,,,,,,,,
APPLIER CLP M L11IN TI MULT RNG HNDL 30 CLP STR LIGACLP,SUP-2219673,CDM,C1713,HCPCS,0278,RC,,,,both,,,178.92,116.30,,,,,,,,,,,,,
STRAP CLAV SM BCKL CLSR FOAM CONSTR COT STOCK 3 W POST VECT,SUP-2194669,CDM,L3670,HCPCS,0272,RC,,,,both,,,14.82,9.63,,,,,,,,,,,,,
"HC So2 Spectrophotometry, Analyte Nes",PX-3018431168,CDM,84311,CPT,0301,RC,,,,both,,,191.00,124.15,,,,,,,,,,,,,
ALLOGRAFT HUMERUS PROX+HD+CUF RT FZ IRR,SUP-2875977,CDM,C1762,CPT,0278,RC,,,,both,,,14932.90,9706.38,,,,,,,,,,,,,
BLADE SCREWDRIVER 2.3/2.7MM DIA DISTAL RADIAL T7,SUP-2704887,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1240.93,806.60,,,,,,,,,,,,,
PLATE BNE SET FOR LG FRAG PERI-LOC,SUP-2351389,CDM,C1713,HCPCS,0278,RC,,,,both,,,60523.50,39340.27,,,,,,,,,,,,,
CANNULA SURG INTUTER MANIP W/ TWO ACORNS COHEN,SUP-2332826,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1019.65,662.77,,,,,,,,,,,,,
GUIDEWIRE ORTHOPEDIC TRCR PT 1.35 MM,SUP-2121782,CDM,C1769,HCPCS,0272,RC,,,,both,,,62.80,40.82,,,,,,,,,,,,,
SERTRALINE HCL 50 MG PO TABS,RX-11351,CDM,6370000000,HCPCS,0637,RC,60687-0242-11,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
SCREW TENODESIS G FORC 4MMX10MM,SUP-2399116,CDM,C1713,HCPCS,0278,RC,,,,both,,,1491.50,969.47,,,,,,,,,,,,,
TUBE INNR EAR MYR VENT FLNG W/ TAB W/ V SHP TAB 1.14 MM ID,SUP-2277594,CDM,L8699,HCPCS,0278,RC,,,,both,,,54.32,35.31,,,,,,,,,,,,,
CATHETER KIT NICU PICC PLCMNT,SUP-2270684,CDM,C1751,HCPCS,0278,RC,,,,both,,,81.70,53.10,,,,,,,,,,,,,
IMPLANT BRST GEL 4.6 CM PROJCT 8.6 CM 185 CC ULTRA HI SILTEX,SUP-2300602,CDM,C1789,HCPCS,0278,RC,,,,both,,,3155.70,2051.20,,,,,,,,,,,,,
ANCHOR SUT 5.5MM HEALICOIL W/ ULTRATAPE BLU ULTRABRAID NO2,SUP-2341903,CDM,C1713,HCPCS,0278,RC,,,,both,,,1114.70,724.55,,,,,,,,,,,,,
ILLUMINATOR SURG MULTIFUNCTIONAL TBNG VERSALIGHT,SUP-2175744,CDM,C1713,HCPCS,0278,RC,,,,both,,,1563.72,1016.42,,,,,,,,,,,,,
CAP PROTCT FOR 18 2MM K WIRE,SUP-2188572,CDM,C1713,HCPCS,0278,RC,,,,both,,,88.80,57.72,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY PENTARAY NAV INSRTN L 115CM 2-6-2,SUP-2248593,CDM,C1732,HCPCS,0272,RC,,,,both,,,5177.86,3365.61,,,,,,,,,,,,,
GUIDEWIRE SURG L900MM OD3MM BALL NOSE DISP PRECICE UNYTE,SUP-2309746,CDM,C1769,HCPCS,0272,RC,,,,both,,,1299.96,844.97,,,,,,,,,,,,,
BIT DRL L210MM DIA32MM ST 3 FLUT QUIK CPL NONRADIOPAQUE,SUP-2187600,CDM,2720000010,LOCAL,0272,RC,,,,both,,,637.86,414.61,,,,,,,,,,,,,
FULL TIB WDG W/O SCR SZ 2,SUP-2359307,CDM,C1776,CPT,0278,RC,,,,both,,,2983.00,1938.95,,,,,,,,,,,,,
GRAFT STRP BNE MTRX TISS SYN 5CMX5CM INQU,SUP-2247318,CDM,C1713,HCPCS,0278,RC,,,,both,,,5206.12,3383.98,,,,,,,,,,,,,
SCREW BNE L28MM OD3MM TI LO EXT ST SELF DRL CANN FIX STBL,SUP-2242812,CDM,C1713,HCPCS,0278,RC,,,,both,,,1285.36,835.48,,,,,,,,,,,,,
PHENYLEPHRINE HCL (PRESSORS) 10 MG/ML IV SOLN,RX-127963,CDM,J2371,HCPCS,0636,RC,81284-0213-01,NDC,,both,0.01,ML,54.10,35.16,,,,,,,,,,,,,
JOINT SUBTALAR 12.5 MM ANK,SUP-2318979,CDM,C1713,HCPCS,0278,RC,,,,both,,,3727.18,2422.67,,,,,,,,,,,,,
TUBE VENT 0.76 MM 3.81 MM 1.6 MM PHOSPHORYLCHOLINE COAT SIL,SUP-2479469,CDM,L8699,HCPCS,0278,RC,,,,both,,,60.82,39.53,,,,,,,,,,,,,
PLATE BNE LCK XL LT CALCANEAL MESH STRL ALPS LTX,SUP-2860967,CDM,C1713,HCPCS,0278,RC,,,,both,,,4075.09,2648.81,,,,,,,,,,,,,
STENT NEURO SURPS STREAMLINE L 50 MM DIA 5 MM COCR INTCRAN,SUP-2884375,CDM,C1876,HCPCS,0278,RC,,,,both,,,49455.00,32145.75,,,,,,,,,,,,,
RELOAD STPLR ARTICULATING LINEAR 60 MM END CUT INSTRUCTION,SUP-2257588,CDM,2720000010,LOCAL,0272,RC,,,,both,,,424.31,275.80,,,,,,,,,,,,,
TUBE CHST SET 24 FRX41 CM 1 LUMEN 4 SIDEPRT THAL-QUICK,SUP-2760050,CDM,C1729,HCPCS,0272,RC,,,,both,,,584.67,380.04,,,,,,,,,,,,,
SEALANT HEMSTAT 5ML HUM FIBRIN THROM 2 VI APPL DEV EVICEL,SUP-2218326,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1415.07,919.80,,,,,,,,,,,,,
SET URET STENT L 24 CM DIA 6 FR GUIDEWIRE 0.038 IN SIL VLY,SUP-2171281,CDM,C2617,HCPCS,0278,RC,,,,both,,,463.15,301.05,,,,,,,,,,,,,
MESH HERN OPTIMIZED COMP 20X15 CM RND POLYESTER PARIETEX,SUP-2752191,CDM,C1781,HCPCS,0278,RC,,,,both,,,3847.07,2500.60,,,,,,,,,,,,,
POST FIX 4 H M,SUP-2197282,CDM,2720000010,LOCAL,0272,RC,,,,both,,,367.38,238.80,,,,,,,,,,,,,
STENT PERIPH ZILVER PTX L 120 MM DIA 6 MM CATH L 125 CM SHTH,SUP-2170400,CDM,C1874,HCPCS,0278,RC,,,,both,,,6264.30,4071.79,,,,,,,,,,,,,
ALLOGRAFT TEND SEMI TENDOSIS 5MMXGREATER THAN 200MM,SUP-2335257,CDM,C1713,HCPCS,0278,RC,,,,both,,,4317.50,2806.37,,,,,,,,,,,,,
MICONAZOLE NITRATE 2 % EX CREA,RX-5039,CDM,J3490,HCPCS,0637,RC,70000-0340-01,NDC,,both,28.4,GR,27.00,17.55,,,,,,,,,,,,,
MIDFACE KIT CUSTOMIZED RECON PEEK NS FACE ID LTX,SUP-2862809,CDM,2720000010,LOCAL,0272,RC,,,,both,,,47506.98,30879.54,,,,,,,,,,,,,
MESH HERN TIMESH 8X6 IN,SUP-2402533,CDM,C1781,HCPCS,0278,RC,,,,both,,,872.92,567.40,,,,,,,,,,,,,
CATHETER HEMO DYLS OR HD KT CHRONIC INTRO MTL L37CM L13CM,SUP-2117118,CDM,C1750,HCPCS,0278,RC,,,,both,,,1629.66,1059.28,,,,,,,,,,,,,
SPLINT HND ANTIMICROBIAL LG 8 IN WRST LT ROLYAN HANZ WHFO,SUP-2326334,CDM,L3906,HCPCS,0272,RC,,,,both,,,138.03,89.72,,,,,,,,,,,,,
STENT BILI ZILVER 635 L 12 CM DIA 8 MM INTRO L 200 CM DIA 6,SUP-2169477,CDM,C1876,HCPCS,0278,RC,,,,both,,,5331.72,3465.62,,,,,,,,,,,,,
SCREW BNE DRILL-FREE 2X15 MM 10 MM HEX HD ETCHED TI LEVEL 1,SUP-2477383,CDM,C1713,HCPCS,0278,RC,,,,both,,,595.63,387.16,,,,,,,,,,,,,
TRAY CATH HEMODIALYSI SFT LN ACTE 11.5FR DIA 12CM IN T114IJ2,SUP-2633026,CDM,C1752,HCPCS,0278,RC,,,,both,,,254.34,165.32,,,,,,,,,,,,,
PIN FIX ACL PCL WIRE PAC A FOR FAST-FIX 360 MENIS REP SYS,SUP-2341564,CDM,2720000010,LOCAL,0272,RC,,,,both,,,665.68,432.69,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 220 MM DIA 9 MM DEL SHTH 15ML,SUP-2936820,CDM,C1713,HCPCS,0278,RC,,,,both,,,16731.08,10875.20,,,,,,,,,,,,,
VALVE SUCTION CHANGE-OVER W/ CLMP HOLDER,SUP-2464457,CDM,2720000010,LOCAL,0272,RC,,,,both,,,845.32,549.46,,,,,,,,,,,,,
GRAFT BNE PTTY 5 CC CLLGN MEMBRN PLATFORM CM,SUP-2691587,CDM,C1713,HCPCS,0278,RC,,,,both,,,3118.02,2026.71,,,,,,,,,,,,,
PATCH ABD W20XL40CM RECT POLYAMIDE FBR NONABSORBABLE,SUP-2358736,CDM,2720000010,LOCAL,0272,RC,,,,both,,,19782.00,12858.30,,,,,,,,,,,,,
BEVACIZUMAB-AWWB 25 MG/ML IV SOLN (MIXTURES ONLY),RX-1150525,CDM,Q5107,HCPCS,0636,RC,55513-0206-01,NDC,,both,4,ML,2009.50,1306.17,,,,,,,,,,,,,
CATHETER GUID ZOOM 88 L 100 CM DIA 8 FR DSTL OD/ID 8,SUP-2878007,CDM,C1887,HCPCS,0272,RC,,,,both,,,9404.30,6112.79,,,,,,,,,,,,,
"HC So Ra Titer, Quantitative",PX-3028643166,CDM,86431,CPT,0302,RC,,,,both,,,21.00,13.65,,,,,,,,,,,,,
COIL DETACH 3MM DIA 10CM 3.1MM THER DIA NXT HELIX SFT 10,SUP-2172999,CDM,C1889,HCPCS,0278,RC,,,,both,,,2615.62,1700.15,,,,,,,,,,,,,
NANOBITER 15 DEGREE UP TIP AR10902D,SUP-2843580,CDM,2720000010,LOCAL,0272,RC,,,,both,,,748.89,486.78,,,,,,,,,,,,,
GUIDEPIN ORTH 3.5 MM SPADE TIP TAPR KNEE RECON INFIN DISP,SUP-2846783,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1095.23,711.90,,,,,,,,,,,,,
OSS SM TAPERED OSSEOTI AUGMENT,SUP-2506338,CDM,C1776,CPT,0278,RC,,,,both,,,4634.64,3012.52,,,,,,,,,,,,,
GRAFT BNE SUB 3ML CA PHSPTE ROTARY MIX PTTY VOID FILL INJ,SUP-2194286,CDM,C1713,HCPCS,0278,RC,,,,both,,,3134.03,2037.12,,,,,,,,,,,,,
STENT COR 28MM 2.5MM DEL SYS 145CM 0.014IN CO CHROM,SUP-2105440,CDM,C1874,HCPCS,0278,RC,,,,both,,,2241.96,1457.27,,,,,,,,,,,,,
DRESSING CELLERATE RX 5 GM SURG PWD HYDROLYZED CLLGN,SUP-2422826,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4694.30,3051.29,,,,,,,,,,,,,
CANFIELD TONSIL KNF 8 12,SUP-2669734,CDM,2720000010,LOCAL,0272,RC,,,,both,,,438.56,285.06,,,,,,,,,,,,,
MOLD TIB SPCR SM AP39MM ML58MM PMMA URETHANE GENT KASM,SUP-2315777,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4082.00,2653.30,,,,,,,,,,,,,
BRACE THMB LT FUNC POS ABDUCTED THMB W/ STAY STRP ON AD 8IN,SUP-2324312,CDM,L3931,HCPCS,0274,RC,,,,both,,,69.52,45.19,,,,,,,,,,,,,
ALLOGRAFT BNE PASTE 8 CC CANC PUROS,SUP-2692418,CDM,C1713,HCPCS,0278,RC,,,,both,,,2640.74,1716.48,,,,,,,,,,,,,
KYPHOPLASTY KIT BLLN 8 GAX15 MM SINGLE FRAC IVAS ELITE DISP,SUP-2424040,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4211.96,2737.77,,,,,,,,,,,,,
PROSTHESIS OTO 2 10MM TI CNTR TORP ADJUSTABLE MIC,SUP-2313847,CDM,L8613,CPT,0278,RC,,,,both,,,961.25,624.81,,,,,,,,,,,,,
PLATE BNE L53MM 0DEG 7 H NONSTERILE R 1ST MTP FUS TI VAR ANG,SUP-2181237,CDM,C1713,HCPCS,0278,RC,,,,both,,,4460.09,2899.06,,,,,,,,,,,,,
PLATE BONE L35MM 6 H MAND ORAL MAXILLOFACIAL TI STR TENS BND,SUP-2191345,CDM,C1713,HCPCS,0278,RC,,,,both,,,1725.43,1121.53,,,,,,,,,,,,,
CAGE SPNL MESH 22X17X10 MM 6 LOBE,SUP-2602082,CDM,C1889,HCPCS,0278,RC,,,,both,,,8110.62,5271.90,,,,,,,,,,,,,
TRAY CATH 4GA OR 18GA L8CM 0.018/21T DBL LUMN POLYP,SUP-2169663,CDM,C1751,HCPCS,0278,RC,,,,both,,,374.85,243.65,,,,,,,,,,,,,
PLATE BNE BURR HOLE CVR 18X1.5X0.6 MM W/ DRN HOLE FLAT TI NS,SUP-2481193,CDM,C1713,HCPCS,0278,RC,,,,both,,,783.05,508.98,,,,,,,,,,,,,
BRACE WRST LACER W O ABDUCTED THMB UNIV L,SUP-2276645,CDM,L3931,HCPCS,0272,RC,,,,both,,,15.92,10.35,,,,,,,,,,,,,
UPCHARGE PERFORM REVSE AUG BP,SUP-2388599,CDM,C1776,CPT,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
ALENDRONATE SODIUM 35 MG PO TABS,RX-29072,CDM,6370000000,HCPCS,0637,RC,16714-0632-01,NDC,,both,1,UN,5.90,3.83,,,,,,,,,,,,,
SET INTRO FLX ROSCH-UCHIDA L 40 CM OD 10 FR TROCAR STYL L,SUP-2168186,CDM,C1894,HCPCS,0272,RC,,,,both,,,1538.57,1000.07,,,,,,,,,,,,,
PLATE BNE 1X2 H CRANIOMAXILLOFACIAL TI DBL Y SHP FOR 1MM,SUP-2190611,CDM,C1713,HCPCS,0278,RC,,,,both,,,1061.63,690.06,,,,,,,,,,,,,
GUIDEWIRE UROLOGY ANGLED 0.025 INX150 CM COR HIWIRE,SUP-2835976,CDM,C1769,HCPCS,0272,RC,,,,both,,,105.41,68.52,,,,,,,,,,,,,
GREAT TOE METATRSL SZ 1 RT CO CHROM KINETIKOS,SUP-2242671,CDM,C1776,CPT,0278,RC,,,,both,,,5301.89,3446.23,,,,,,,,,,,,,
CATHETER PICC 5FR 3 LUMN MAXIMAL BARR TY W/ TPS STYL,SUP-2125514,CDM,C1751,HCPCS,0278,RC,,,,both,,,942.66,612.73,,,,,,,,,,,,,
SCREW BNE L34MM TIP DIA4MM HEX 2.5MM STD HND FT ST CANN,SUP-2107353,CDM,C1713,HCPCS,0278,RC,,,,both,,,1274.84,828.65,,,,,,,,,,,,,
CATHETER ABLATN STD CRV 2-5-2 MM 4 MM 7 FRX125 CM CELSIUS,SUP-2248581,CDM,C1733,HCPCS,0272,RC,,,,both,,,3293.86,2141.01,,,,,,,,,,,,,
TUBE VENT DIA1.14MM INTERFLANGE DISTANCE 3.5MM ACTIVENT SIL,SUP-2284019,CDM,L8699,HCPCS,0278,RC,,,,both,,,71.87,46.72,,,,,,,,,,,,,
GRAFT ENDOVASC L13CM AORT DIA31MM IL DIA14.5MM TRUNK,SUP-2395993,CDM,C1768,CPT,0278,RC,,,,both,,,27883.20,18124.08,,,,,,,,,,,,,
SHEATH INTRO PERFRMR L 30 CM DIA18 FR GUIDEWIRE 0.038 IN,SUP-2168684,CDM,C1894,HCPCS,0272,RC,,,,both,,,220.68,143.44,,,,,,,,,,,,,
DEFIBRILLATOR IMPL PROMOTE L 8 X W 5 X H 1.3 CM 30 J TI,SUP-2356732,CDM,C1882,HCPCS,0275,RC,,,,both,,,59660.00,38779.00,,,,,,,,,,,,,
MESH HERN ELLIPSE 10X8 IN POLYPR VENTRALIGHT ST,SUP-2126517,CDM,C1781,HCPCS,0278,RC,,,,both,,,4003.50,2602.27,,,,,,,,,,,,,
HINGE EXT FIX UNIV TRUELOK,SUP-2316167,CDM,2720000010,LOCAL,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
HC Pet/CT Skull Base to Mid Thigh,PX-4047881500,CDM,78815,CPT,0404,RC,,,,both,,,4790.00,3113.50,,,,,,,,,,,,,
SCREW BNE BLNT PT 5X25 MM 175 MM THRD SCHNZ STRL 02172525S,SUP-2750867,CDM,C1713,HCPCS,0278,RC,,,,both,,,455.49,296.07,,,,,,,,,,,,,
HEAD RADIAL MOD 2 26 MM ELBW EVOLVE,SUP-2397062,CDM,C1776,CPT,0278,RC,,,,both,,,4537.30,2949.24,,,,,,,,,,,,,
TIP SONOPET BARRACUDA 12CM IQ,SUP-2844703,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2977.72,1935.52,,,,,,,,,,,,,
ANCHOR SUTURE SFT 2.9 MM REUSE PNCH JUGGERKNOT,SUP-2608807,CDM,C1713,HCPCS,0278,RC,,,,both,,,1645.86,1069.81,,,,,,,,,,,,,
COUNTERSINK 4MM FOR IMP BONE CONDUCTION SYS,SUP-2319872,CDM,C1713,HCPCS,0278,RC,,,,both,,,675.10,438.81,,,,,,,,,,,,,
PLATE BNE L138MM 6 H ST R OLECRANON S STL LOK COMPR FOR 35MM,SUP-2185426,CDM,C1713,HCPCS,0278,RC,,,,both,,,3408.38,2215.45,,,,,,,,,,,,,
BIT DRL L195MM DIA3.2MM 3 FLUT QUIK CPL W/O STP REUSE FOR E,SUP-2187593,CDM,2720000010,LOCAL,0272,RC,,,,both,,,408.45,265.49,,,,,,,,,,,,,
SYSTEM BECKER W BLUE STRIPED TBNG AND SMRTSITE NDLLSS INJ,SUP-2284408,CDM,C1713,HCPCS,0278,RC,,,,both,,,536.88,348.97,,,,,,,,,,,,,
CATHETER ABLATN 4 MM SPC LNG REACH CELSIUS D7BTG5L,SUP-2468224,CDM,C1732,HCPCS,0272,RC,,,,both,,,3042.66,1977.73,,,,,,,,,,,,,
STEM FEM PRSS FT 6 HIP PRIMARY CEM UPLR/BPLR LNR POLYETH,SUP-2267800,CDM,C1776,CPT,0278,RC,,,,both,,,21509.00,13980.85,,,,,,,,,,,,,
HC Cardiac Rehab Phase 3 - Monthly (Other Ind),PX-9900000039,CDM,9900000039,LOCAL,0990,RC,,,,both,,,15.00,9.75,,,,,,,,,,,,,
DEXTROSE 5 % IV SOLN INTERMITTENT INFUSION,RX-40840103,CDM,2580000003,HCPCS,0258,RC,00264-1510-32,NDC,,both,250,ML,53.20,34.58,,,,,,,,,,,,,
SET ORTH IMPL 3.5MM MEDL PROX TIB S STL PLT LCP,SUP-2177071,CDM,C1713,HCPCS,0278,RC,,,,both,,,111033.29,72171.64,,,,,,,,,,,,,
CATHETER HD LT 10 FRX52 CM 21 CM ART SINGLE SET BIOFLX TESIO,SUP-2627158,CDM,C1750,HCPCS,0278,RC,,,,both,,,477.28,310.23,,,,,,,,,,,,,
SCREW BNE LCK 2.3X7 MM THOR DRL FREE LEVEL 1 RIBLOC SYS TI,SUP-2262538,CDM,C1713,HCPCS,0278,RC,,,,both,,,470.22,305.64,,,,,,,,,,,,,
HC Aerobic ID,PX-3008707700,CDM,87077,CPT,0300,RC,,,,both,,,83.00,53.95,,,,,,,,,,,,,
BASEPLATE TIB CLLRLSS STD KNEE ASMBLY BIMTRC,SUP-2448787,CDM,C1776,CPT,0278,RC,,,,both,,,1851.03,1203.17,,,,,,,,,,,,,
BOUGIE ESOPH HURST TUNGSTEN FIL 38FR SIL,SUP-2383705,CDM,2720000010,LOCAL,0272,RC,,,,both,,,459.88,298.92,,,,,,,,,,,,,
MESH HERN W6XL6IN POLYPR MID WT MFIL SQ RND FLAT SHT STR,SUP-2227328,CDM,C1781,HCPCS,0278,RC,,,,both,,,97.84,63.60,,,,,,,,,,,,,
COVER BUR H DIA12MM THK0.3MM TI ULT LO PROF NONCOMPRESSION,SUP-2255848,CDM,C1713,HCPCS,0278,RC,,,,both,,,860.99,559.64,,,,,,,,,,,,,
HC So Thyroglobulin,PX-3018443266,CDM,84432,CPT,0301,RC,,,,inpatient,,,63.00,40.95,,,,,,,,,,,,,
GRAFT BNE MORSL 2-6 MM 30 CC SCAFFOLD ATTRAX,SUP-2736504,CDM,C1713,HCPCS,0278,RC,,,,both,,,9184.50,5969.92,,,,,,,,,,,,,
RESERVOIR L60CM OD2.5MM 20MM D5.65MM EXTERNAL VENTRICULAR DR,SUP-2826646,CDM,C1889,HCPCS,0278,RC,,,,both,,,1475.93,959.35,,,,,,,,,,,,,
PLATE BNE MAXILLOFCL 6 MESH NS FACE ID,SUP-2909576,CDM,C1713,HCPCS,0278,RC,,,,both,,,39178.28,25465.88,,,,,,,,,,,,,
DILATOR VASC OD8-10FR PASS,SUP-2141507,CDM,C1726,HCPCS,0272,RC,,,,both,,,254.34,165.32,,,,,,,,,,,,,
PLATE BONE L94MM THK2.8MM 8 H BILAT S STL NONCOMPRESSION,SUP-2348977,CDM,C1713,HCPCS,0278,RC,,,,both,,,3807.25,2474.71,,,,,,,,,,,,,
ALLOGRAFT BNE CHIP CANC 800108,SUP-2743350,CDM,C1713,HCPCS,0278,RC,,,,both,,,1661.06,1079.69,,,,,,,,,,,,,
CATHETER CV 3L 5 FR MAX BARR TY POWERPICC SOLO 2,SUP-2125645,CDM,C1751,HCPCS,0278,RC,,,,both,,,861.36,559.88,,,,,,,,,,,,,
BLOCK CUT CORNEAL N SLT TEF 18 IN HT KAUFMAN,SUP-2129393,CDM,2720000010,LOCAL,0272,RC,,,,both,,,602.10,391.36,,,,,,,,,,,,,
ADAPTER TIB TY 0MM OFFSET MOD BAL REV SYS,SUP-2315556,CDM,C1776,CPT,0278,RC,,,,both,,,1783.52,1159.29,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED LG CUP HD LNR ST POROUS CERM EPOCH,SUP-2212320,CDM,C1776,CPT,0278,RC,,,,both,,,18152.37,11799.04,,,,,,,,,,,,,
MEMBRANE AMNIOTIC DS 4X8CM,SUP-2880402,CDM,C1762,CPT,0278,RC,,,,both,,,8164.00,5306.60,,,,,,,,,,,,,
PLATE BNE L60MM BRL L1.5IN 130DEG PELVIS BILAT S STL STD 2,SUP-2342409,CDM,C1713,HCPCS,0278,RC,,,,both,,,3426.53,2227.24,,,,,,,,,,,,,
K WIRE 0.045X6IN STANDARD STAINLESS STEEL,SUP-2878434,CDM,C1713,HCPCS,0278,RC,,,,both,,,56.52,36.74,,,,,,,,,,,,,
ADAPTER HD +0MM OFFSET 12/14 TAPR HIP TI BIOLOX OPT,SUP-2222438,CDM,C1776,CPT,0278,RC,,,,both,,,650.61,422.90,,,,,,,,,,,,,
RING EXT FIX DIA180 MM 1/2 PNK NS DISP SPAT FRME TSF,SUP-2933314,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3807.31,2474.75,,,,,,,,,,,,,
SET INT FIX SCREW DIA1.5 MM 2 H TI NEURO STR PLT 1 PK STRL,SUP-2935351,CDM,C1713,HCPCS,0278,RC,,,,both,,,656.26,426.57,,,,,,,,,,,,,
UNILATERAL BAHA KIT-CONFIRMING PONO 1356915 FOR BOTH LN,SUP-2165015,CDM,L8614,HCPCS,0278,RC,,,,both,,,20221.60,13144.04,,,,,,,,,,,,,
CATHETER NEPHROSTOMY PIG 038 IN 10 FRX25 CM REPL KT JINRO,SUP-2520663,CDM,C1729,HCPCS,0272,RC,,,,both,,,59.38,38.60,,,,,,,,,,,,,
SET PANCREATIC STENT ZMMN L 8 CM 7 FR 0.035 IN 2.8 MM,SUP-2738164,CDM,C2617,HCPCS,0278,RC,,,,both,,,445.88,289.82,,,,,,,,,,,,,
MESH CRANIAL DELTA 122MM X 122MM 0.75MM THK CRANIOFACIAL,SUP-2884145,CDM,C1713,HCPCS,0278,RC,,,,both,,,9514.73,6184.57,,,,,,,,,,,,,
GUARD BUR 20DEG LNG FOR SM BNE MICROPOWER MICRO100 SYS,SUP-2166319,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2960.55,1924.36,,,,,,,,,,,,,
PATCH DURA W10XL16CM BOV PERICARD DURA-GUARD,SUP-2130236,CDM,C1763,HCPCS,0278,RC,,,,both,,,3161.98,2055.29,,,,,,,,,,,,,
SCREW BNE CANN 13-16 MM SUBTALAR TI DP VARIO,SUP-2861391,CDM,C1713,HCPCS,0278,RC,,,,both,,,4909.52,3191.19,,,,,,,,,,,,,
PACK SAW BLDE 68MM D424MM CUT EDGE 10MM THK12MM FOR PWR,SUP-2365144,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3108.60,2020.59,,,,,,,,,,,,,
HC Imm Admn Sarscov2 Vaccine 1st/Only Component,PX-7719048000,CDM,90480,CPT,0771,RC,,,,both,,,140.00,91.00,,,,,,,,,,,,,
IMPLANT HAMRTOE 35MM MID PHALANX 32MM PROX ST NEXTRA,SUP-2137577,CDM,C1713,HCPCS,0278,RC,,,,both,,,2505.72,1628.72,,,,,,,,,,,,,
SCREW SPNL L10MM DIA3.5MM CANC TI ST MULTIAXIAL TOP LD,SUP-2286840,CDM,C1713,HCPCS,0278,RC,,,,both,,,2119.50,1377.67,,,,,,,,,,,,,
EPINEPHRINE 1 MG/10 ML IJ SOLN (MIXTURES ONLY),RX-430063,CDM,J0169,HCPCS,0636,RC,76329-3318-01,NDC,,both,1,ML,54.10,35.16,,,,,,,,,,,,,
SPLINT WR AND FRARM TITEX W/ LOOP LCK LT M,SUP-2195255,CDM,L3809,HCPCS,0272,RC,,,,both,,,17.52,11.39,,,,,,,,,,,,,
CEMENT PERM GLS IONOMER LUTING REFIL PK MAXICAP KETAC,SUP-2100207,CDM,C1713,HCPCS,0278,RC,,,,both,,,49.46,32.15,,,,,,,,,,,,,
SHEATH INTRF SCR DIA6-7MM,SUP-2122017,CDM,C1713,HCPCS,0278,RC,,,,both,,,6.28,4.08,,,,,,,,,,,,,
INTRA-AORTIC PUMP KIT 7.5 FR 30 CC BLLN CATH WAPA MEGA,SUP-2525604,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2857.87,1857.62,,,,,,,,,,,,,
GRAFT SYN TISS W10XL15CM THK2MM EPTFE SFT PTCH RECTANG FOR,SUP-2395290,CDM,C1781,HCPCS,0278,RC,,,,both,,,3642.40,2367.56,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED OXFORD,SUP-2137378,CDM,C1776,CPT,0278,RC,,,,both,,,12811.20,8327.28,,,,,,,,,,,,,
BRACE ORTH SZ 1 RT THMB CMC PUSH METAGRIP,SUP-2324629,CDM,L3924,HCPCS,0274,RC,,,,both,,,226.08,146.95,,,,,,,,,,,,,
PLATE BNE RECON 3.5 MM 3 HOLE STR STRL LTX,SUP-2861615,CDM,C1713,HCPCS,0278,RC,,,,both,,,659.78,428.86,,,,,,,,,,,,,
IMPLANT OPERATING ROOM MINI-MONSTER 4.0 X 30MM H,SUP-2430559,CDM,C1713,HCPCS,0278,RC,,,,both,,,657.36,427.28,,,,,,,,,,,,,
DISTRACTION EXTRNL DIST CRNIO MNDBLE FXTR W/WDGE 18 MM STEP,SUP-2488604,CDM,C1713,HCPCS,0278,RC,,,,both,,,17306.86,11249.46,,,,,,,,,,,,,
HC Chaplain Counsel Group,PX-9400900300,CDM,Q9003,CPT,0940,RC,,,,both,,,11.00,7.15,,,,,,,,,,,,,
WALKER SM SHT LEG NONSKID,SUP-2276712,CDM,L4387,HCPCS,0274,RC,,,,both,,,80.60,52.39,,,,,,,,,,,,,
BIT DRILL AO CALIBRATED 3.8MM,SUP-2750031,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1931.10,1255.21,,,,,,,,,,,,,
LINER ACET 40X26 MM SCR IN +5 RINGLOC+ MAX-ROM,SUP-2447214,CDM,C1776,CPT,0278,RC,,,,both,,,2472.75,1607.29,,,,,,,,,,,,,
PLATE BONE THK0.6MM 14 H MIDFACE GLD TI CVD RIG GRD 4 FOR,SUP-2135917,CDM,C1713,HCPCS,0278,RC,,,,both,,,832.10,540.86,,,,,,,,,,,,,
SCREW CORTICAL LOQTEQ VA 2.5X26MM,SUP-2719778,CDM,C1713,HCPCS,0278,RC,,,,both,,,3642.40,2367.56,,,,,,,,,,,,,
GRAFT BNE FIB SHFT 40X14-18 MM FD,SUP-2294102,CDM,C1713,HCPCS,0278,RC,,,,both,,,1153.01,749.46,,,,,,,,,,,,,
RETRACTOR SURG BVL 9 CMX18 MM METRX II DISP,SUP-2280169,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1259.49,818.67,,,,,,,,,,,,,
SCREW SPNL L 100 MM DIA 7.5 MM TI ALLOY IL CANN CONCL 2 LD,SUP-2926406,CDM,C1713,HCPCS,0278,RC,,,,both,,,5917.20,3846.18,,,,,,,,,,,,,
PLATE BNE RECON 3.5X260 MM 20 HOLE W/ WIDE ANGLE STR LP NS,SUP-2799253,CDM,C1713,HCPCS,0278,RC,,,,both,,,2088.26,1357.37,,,,,,,,,,,,,
GRAFT HUM TISS PTCH 14X1 CM TAPR BOV PERICARD PHOTOFIX LTX,SUP-2859714,CDM,C1768,CPT,0278,RC,,,,both,,,1130.40,734.76,,,,,,,,,,,,,
KWIRE 3.2X450MM,SUP-2473005,CDM,2720000010,LOCAL,0272,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
SCREW BNE L 20 MM DIA 3 MM TI CANN HD NS LEOS,SUP-2932588,CDM,C1713,HCPCS,0278,RC,,,,both,,,844.63,549.01,,,,,,,,,,,,,
BOLT EXT FIX 0.37 IN TIB LCK DOVE,SUP-2314017,CDM,C1713,HCPCS,0278,RC,,,,both,,,401.92,261.25,,,,,,,,,,,,,
DEVICE SUT SHFT L34CM DIA 10MM 2 JAW LD UNIT ENDOSTCH,SUP-2283124,CDM,2720000010,LOCAL,0272,RC,,,,both,,,637.89,414.63,,,,,,,,,,,,,
ANCHOR SUTURE STRL SUTURELOC AR-4551-1,SUP-2910535,CDM,C1713,HCPCS,0278,RC,,,,both,,,481.17,312.76,,,,,,,,,,,,,
DEVICE PESSARY SZ 3 SIL FIT RNG MILEX,SUP-2171769,CDM,A4562,HCPCS,0274,RC,,,,both,,,228.75,148.69,,,,,,,,,,,,,
CATHETER ANGIOPLSTY UTHN ST L 150 CM BALLOON L 2 CM DIA 8 MM,SUP-2147259,CDM,C1725,HCPCS,0272,RC,,,,both,,,646.71,420.36,,,,,,,,,,,,,
BLADE SAW SAG 5.5MMW X25.5MML 0.6MM/0.6MM THK CUT SM BNE HAL,SUP-2605395,CDM,2720000010,LOCAL,0272,RC,,,,both,,,137.53,89.39,,,,,,,,,,,,,
ALLOGRAFT BNE BLOCK 6.25X2X0.8 CM 20 CC CRBNT APATITE VENADO,SUP-2718022,CDM,C1713,HCPCS,0278,RC,,,,both,,,4842.32,3147.51,,,,,,,,,,,,,
COIL EMB L40CM OD0.020IN LOOP OD10MM STD NIT COMPLX FRME,SUP-2323372,CDM,C1889,HCPCS,0278,RC,,,,both,,,7222.00,4694.30,,,,,,,,,,,,,
ASSEMBLY FEM KNEE SZ 4 OXIN LT KNEE STRL LEGION HK,SUP-2909998,CDM,C1776,CPT,0278,RC,,,,both,,,47470.52,30855.84,,,,,,,,,,,,,
DISC INTERVERTEBRAL ARTIFICIAL LG 6 MM CERV SIMPLIFY,SUP-2751696,CDM,C1713,HCPCS,0278,RC,,,,both,,,15662.32,10180.51,,,,,,,,,,,,,
BUR SURG PRECIS 5 MMX13 CM RND LILAC STRL LTX,SUP-2859517,CDM,2720000010,LOCAL,0272,RC,,,,both,,,762.02,495.31,,,,,,,,,,,,,
SET INTRO L 14 CM DIA12 FR GUIDEWIRE 0.038 IN PTFE TEARWY,SUP-2226012,CDM,C1894,HCPCS,0272,RC,,,,both,,,50.24,32.66,,,,,,,,,,,,,
PLATE BNE L229MM 12 H S STL LOK COMPR BROAD CRV FOR 4.5/5MM,SUP-2185299,CDM,C1713,HCPCS,0278,RC,,,,both,,,1915.09,1244.81,,,,,,,,,,,,,
VLP TI 3.5MMX28MM CTX SCREW T15 S-T,SUP-2820342,CDM,C1713,HCPCS,0278,RC,,,,both,,,300.03,195.02,,,,,,,,,,,,,
"HC Gbl Est Pt, E/M Level 5|RESIDENT/TEACHING PHYS SERV",PX-9829921500,CDM,99215,CPT,0982,RC,,,GC,both,,,672.00,436.80,,,,,,,,,,,,,
STEM FEM NO 4 L165MM OD16MM TI HA POR HIP REV STR NEUT CEM,SUP-2375231,CDM,C1776,CPT,0278,RC,,,,both,,,13689.14,8897.94,,,,,,,,,,,,,
DRILL SURG CANN 2.8X20 MM 6 MM COUNTSINK TENOTAC,SUP-2749820,CDM,2720000010,LOCAL,0272,RC,,,,both,,,979.68,636.79,,,,,,,,,,,,,
HC Alkaline Phosphatase,PX-3018407500,CDM,84075,CPT,0301,RC,,,,both,,,161.00,104.65,,,,,,,,,,,,,
PATCH PERICARD SJM W/ ENCAP AC TECHNOLOGY 2X5CM,SUP-2355778,CDM,C1768,CPT,0278,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
HOLDER SURG SZ 8 HUM STEM FOR PRSS EPOCA,SUP-2194185,CDM,C1776,CPT,0278,RC,,,,both,,,982.88,638.87,,,,,,,,,,,,,
PLATE BONE ORBITAL FLOOR 24X24X0.8 MM POROUS POLYETHYLENE ST,SUP-2837795,CDM,C1713,HCPCS,0278,RC,,,,both,,,1826.54,1187.25,,,,,,,,,,,,,
SYSTEM AUTOGRFT TRNSF 10MM SM JT OSTEOCHNDRL DISP,SUP-2123218,CDM,C1713,HCPCS,0278,RC,,,,both,,,1398.87,909.27,,,,,,,,,,,,,
BLADE SURG SAFETY SZ 15C STAINLES STL FLFCRTRDGE BARD PARKER,SUP-2605896,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4.36,2.83,,,,,,,,,,,,,
CAGE SPNL W11XH4XL14MM CERV FUS SYS CRNRSTN,SUP-2286348,CDM,C1889,HCPCS,0278,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
RAVULIZUMAB-CWVZ 100 MG/ML IV SOLN (MIXTURES ONLY),RX-1150551,CDM,J1303,HCPCS,0636,RC,25682-0025-01,NDC,,both,21,ML,134887.50,87676.87,,,,,,,,,,,,,
DEXTROSE 5 % IN LACTATED RINGERS IV BOLUS,RX-40840058,CDM,2580000003,HCPCS,0258,RC,00338-0125-03,NDC,,both,250,ML,25.50,16.57,,,,,,,,,,,,,
BIT DRILL 2.0MM SYNTHES 323.002,SUP-2855403,CDM,2720000010,LOCAL,0272,RC,,,,both,,,406.66,264.33,,,,,,,,,,,,,
CATHETER EP CRD 2-10-2 MM 6 FRX120 CM RESPON,SUP-2356775,CDM,C1730,HCPCS,0272,RC,,,,both,,,1045.62,679.65,,,,,,,,,,,,,
STEM FEM SEG 7 CM DPHSEAL KNEE SMOOTH OSS,SUP-2449808,CDM,C1776,CPT,0278,RC,,,,both,,,11079.33,7201.56,,,,,,,,,,,,,
BOLT IM L18MM DIA3.9MM ST BLU CORT TI ST FULL THRD LOK HEX,SUP-2192170,CDM,C1713,HCPCS,0278,RC,,,,both,,,812.66,528.23,,,,,,,,,,,,,
DEFIBRILLATOR CARDIOVERTER SGL CHMBR 40J BPLR ADV VVEV,SUP-2138076,CDM,C1722,HCPCS,0275,RC,,,,both,,,42633.70,27711.90,,,,,,,,,,,,,
BLADE SURG BLACKLINE 47X26.5 MM BLNT 2 LEVEL SS TI LF,SUP-2763777,CDM,2720000010,LOCAL,0272,RC,,,,both,,,574.75,373.59,,,,,,,,,,,,,
HC Cytp Eval Fine Needle Aspirate Interp & Report,PX-3118817300,CDM,88173,CPT,0311,RC,,,,both,,,453.00,294.45,,,,,,,,,,,,,
PIN BONE FIX L150MM DIA4MM,SUP-2368498,CDM,2720000010,LOCAL,0272,RC,,,,both,,,436.96,284.02,,,,,,,,,,,,,
SET BX NDL 19GA SHTH 7FR L60CM CATH STR 5FR L65CM CRV 5FR,SUP-2120184,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2072.40,1347.06,,,,,,,,,,,,,
PLATE 22MM UNIV FOREFOOT,SUP-2243220,CDM,C1713,HCPCS,0278,RC,,,,both,,,5303.30,3447.14,,,,,,,,,,,,,
INSERT ACET ALPHA GG STD 48 MM 28 MM HIP METASUL ALLOFIT,SUP-2204500,CDM,C1776,CPT,0278,RC,,,,both,,,5909.17,3840.96,,,,,,,,,,,,,
COMPONENT OUTER 28/28 MM SFC,SUP-2389700,CDM,C1776,CPT,0278,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
STRAP CLAV STD L,SUP-2276600,CDM,L3650,HCPCS,0274,RC,,,,both,,,14.19,9.22,,,,,,,,,,,,,
BUR SURG RND 4.5X130 MM W/ LAT PROTCT GOLF BLU STRL DISP,SUP-2599843,CDM,2720000010,LOCAL,0272,RC,,,,both,,,357.30,232.24,,,,,,,,,,,,,
CATHETER PRSS MON 4FR L12CM TIP L2MM GWIRE 0.021IN ART STR J,SUP-2167837,CDM,C1751,HCPCS,0278,RC,,,,both,,,162.02,105.31,,,,,,,,,,,,,
PIN EXT FIX L35X18MM FOR RX FX MINI RAIL FIX,SUP-2396844,CDM,C1713,HCPCS,0278,RC,,,,both,,,351.68,228.59,,,,,,,,,,,,,
CATHETER ABLAT OD7.5FR 2-5-2MM SPC 4 POLE DEFL C THRMSTER,SUP-2248929,CDM,C1732,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
PROBE MICROWAVE ABLATION L 15 CM DIA15 GA STRL DISP NEUWAVE,SUP-2908862,CDM,C1886,HCPCS,0278,RC,,,,both,,,8792.00,5714.80,,,,,,,,,,,,,
CAPSAICIN 0.075 % EX CREA,RX-9399,CDM,6370000000,HCPCS,0637,RC,00536-1118-25,NDC,,both,57,GR,21.10,13.71,,,,,,,,,,,,,
CAGE SPNL LORDTC 10 DEG 30X24X14 MM ALIF EXPANDABLE SAHARA,SUP-2532986,CDM,C1889,HCPCS,0278,RC,,,,both,,,29830.00,19389.50,,,,,,,,,,,,,
SPHERE EMB LAVA-18 6 ML EVA TANTALUM PWDR PERIPH VASC LIQ,SUP-2899666,CDM,C1889,HCPCS,0278,RC,,,,both,,,18840.00,12246.00,,,,,,,,,,,,,
HC Drain/Inj Joint/Bursa W/US Large,PX-5102061100,CDM,20611,CPT,0510,RC,,,,outpatient,,,3707.00,2409.55,,,,,,,,,,,,,
DEVICE PESSARY RNG W/ SUPP FLD 3IN SZ 5,SUP-2171738,CDM,A4562,HCPCS,0274,RC,,,,both,,,194.68,126.54,,,,,,,,,,,,,
KIT SURG SEAL 4ML W/ DEL HSNG APPL TIP DISP COSEAL,SUP-2130350,CDM,C2615,HCPCS,0278,RC,,,,both,,,2460.72,1599.47,,,,,,,,,,,,,
HC So2 Alpha Fetoprotein,PX-3018210568,CDM,82105,CPT,0301,RC,,,,inpatient,,,163.00,105.95,,,,,,,,,,,,,
ELECTRODE ES RESECT W/ HF CBL PLSM BTTN,SUP-2314007,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1406.88,914.47,,,,,,,,,,,,,
SCREW BNE L34MM DIA4.5MM THRD L13MM CORT TI ST SELF DRL,SUP-2190380,CDM,C1713,HCPCS,0278,RC,,,,both,,,57.37,37.29,,,,,,,,,,,,,
PLATE BNE THK 1.4 MM PANEL 2.2 MM 1 X 21 H MAXILLOFCL PART,SUP-2909611,CDM,C1713,HCPCS,0278,RC,,,,both,,,9910.37,6441.74,,,,,,,,,,,,,
SHEATH INTRO PINNACLE L 10 CM DIA10 FR GUIDEWIRE 0.038 IN,SUP-2140488,CDM,C1876,HCPCS,0278,RC,,,,both,,,312.43,203.08,,,,,,,,,,,,,
SCREW IM NAIL L 70 MM DIA10.5 MM TI ALLOY RC LAG STRL GAMMA4,SUP-2904041,CDM,C1713,HCPCS,0278,RC,,,,both,,,7536.00,4898.40,,,,,,,,,,,,,
ALLOGRAFT BNE FEM SHFT 160-200 MMX0.3 CM FRZN,SUP-2717853,CDM,C1762,CPT,0278,RC,,,,both,,,6454.58,4195.48,,,,,,,,,,,,,
PLATE BNE W24XL62MM 12 H R DST RAD TI LOK COMPR LO PROF NAR,SUP-2411817,CDM,C1713,HCPCS,0278,RC,,,,both,,,3868.48,2514.51,,,,,,,,,,,,,
RESERVOIR EXT DRNGE 0.31ML L1.5CM SM FLAT BTM SIDE INLET,SUP-2244288,CDM,2720000010,LOCAL,0272,RC,,,,both,,,999.90,649.93,,,,,,,,,,,,,
ALLOGRAFT HUM TISS LG FD IRRADIATED FASC LATA,SUP-2867198,CDM,C1762,CPT,0278,RC,,,,both,,,4182.17,2718.41,,,,,,,,,,,,,
GRAFT SPREADER  AR19007GS,SUP-2843742,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
TRAY CATH HEMODIALYSI DUO FLO ACTE 11.5FR DIA 24CM MCDLT4424,SUP-2633020,CDM,C1750,HCPCS,0278,RC,,,,both,,,232.36,151.03,,,,,,,,,,,,,
HC Crystals-Joint Fluid,PX-3008906000,CDM,89060,CPT,0300,RC,,,,both,,,159.00,103.35,,,,,,,,,,,,,
KIT DEV TRNS VAG TAPING,SUP-2154528,CDM,C1771,HCPCS,0278,RC,,,,both,,,2496.30,1622.59,,,,,,,,,,,,,
KIT PMP LT VENT ASST DEV W/ PKT CTRL HEARTMATE II,SUP-2356046,CDM,C1713,HCPCS,0278,RC,,,,both,,,249630.00,162259.50,,,,,,,,,,,,,
BUR 55MM LNG EGG ATTCH,SUP-2363365,CDM,2720000010,LOCAL,0272,RC,,,,both,,,776.40,504.66,,,,,,,,,,,,,
STIMULATOR NERVE CHARGER BELT ANT ADH PD ADPT EON MINI,SUP-2356754,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
CATHETER OCCL 5FR L90CM BLLN L80MM IMAG GUID BRDG,SUP-2353169,CDM,C2628,HCPCS,0272,RC,,,,both,,,2904.50,1887.92,,,,,,,,,,,,,
COLLAR CERV XL H4XL20IN COT M DENS FOAM BRTH ADJ LO-CONTOUR,SUP-2335998,CDM,L0120,HCPCS,0272,RC,,,,both,,,13.53,8.79,,,,,,,,,,,,,
INSERT TIB SZ 7 THK13MM KNEE X3 CNDYL STBL BEAR TECHNOLOGY,SUP-2373230,CDM,C1776,CPT,0278,RC,,,,both,,,6918.05,4496.73,,,,,,,,,,,,,
PIN FIX TI EMER REL,SUP-2192432,CDM,C1713,HCPCS,0278,RC,,,,both,,,330.58,214.88,,,,,,,,,,,,,
EXTERNAL FIXATION KIT WRST STRL GALAXY,SUP-2646386,CDM,C1713,HCPCS,0278,RC,,,,both,,,9011.80,5857.67,,,,,,,,,,,,,
SHELL ACET OFFSET SM HYBRID,SUP-2439118,CDM,C1776,CPT,0278,RC,,,,both,,,1186.92,771.50,,,,,,,,,,,,,
TRAY EPIDURAL HUSTEAD NDL L 3.5 IN DIA18 GA SD LIDO HCL 5 ML,SUP-2936649,CDM,2720000010,LOCAL,0272,RC,,,,both,,,50.77,33.00,,,,,,,,,,,,,
CATHETER GUID L100CM OD5FR AD MPC COR W/O SIDE H W/O,SUP-2249315,CDM,C1887,HCPCS,0272,RC,,,,both,,,1388.88,902.77,,,,,,,,,,,,,
SROM MARATHON LINER M 28 10DEG,SUP-2512779,CDM,C1776,CPT,0278,RC,,,,both,,,4129.73,2684.32,,,,,,,,,,,,,
FIBER LASER HOLM 1000 MIC,SUP-2430214,CDM,2720000010,LOCAL,0272,RC,,,,both,,,10939.76,7110.84,,,,,,,,,,,,,
CATHETER INFUS 5FR L65CM 5CM GWIRE 0.035IN MEWISSEN,SUP-2141149,CDM,C1725,HCPCS,0272,RC,,,,both,,,257.48,167.36,,,,,,,,,,,,,
BLADE SAW KNEE 25.4MM CUT EDGE 90MM CUT DEPTH 1.27MM CUT THI,SUP-2605584,CDM,2720000010,LOCAL,0272,RC,,,,both,,,195.94,127.36,,,,,,,,,,,,,
PLATE BNE L336MM 16 H ST R CNDYL S STL CRV LOK COMPR VAR,SUP-2177864,CDM,C1713,HCPCS,0278,RC,,,,both,,,7014.73,4559.57,,,,,,,,,,,,,
BUR SURG SZ 2 X 22 X 72 MM SHANNON STYL CORTA BNE AO STRL,SUP-2899168,CDM,2720000010,LOCAL,0272,RC,,,,both,,,785.79,510.76,,,,,,,,,,,,,
NAIL IM L440MM DIA4MM PROX TIB PUR TI ALLY,SUP-2192733,CDM,C1713,HCPCS,0278,RC,,,,both,,,987.12,641.63,,,,,,,,,,,,,
GRAFT VASC XENOSURE L 8 X W 0.8 CM BOV PERICARD RECTANGULAR,SUP-2264287,CDM,C1768,CPT,0278,RC,,,,both,,,828.96,538.82,,,,,,,,,,,,,
PROSTHESIS OSS UNIV TI,SUP-2277634,CDM,L8613,CPT,0278,RC,,,,both,,,525.01,341.26,,,,,,,,,,,,,
GUIDE SURG PLN NYL LP CUSTOMIZABLE JAW IN A DAY RECON VSP,SUP-2883954,CDM,2720000010,LOCAL,0272,RC,,,,both,,,31321.50,20358.97,,,,,,,,,,,,,
GUIDEWIRE VASC L180CM DIA0.035IN HYDRPHLC STD STR FIX COR,SUP-2302964,CDM,C1769,HCPCS,0272,RC,,,,both,,,100.48,65.31,,,,,,,,,,,,,
CAGE SPNL 0 DEG 25X12 MM,SUP-2362925,CDM,C1889,HCPCS,0278,RC,,,,both,,,12285.88,7985.82,,,,,,,,,,,,,
BLADE REPROC TURBINATE INFERIOR M4 ROTAT W/O TUBE 2MM,SUP-2653211,CDM,2720000010,LOCAL,0272,RC,,,,both,,,377.62,245.45,,,,,,,,,,,,,
FLUOROURACIL 1 GM/20ML IV SOLN,RX-82204,CDM,J9190,HCPCS,0636,RC,63323-0117-20,NDC,,both,20,ML,54.10,35.16,,,,,,,,,,,,,
COMPONENT FEM L105MM KNEE SEG IMP MOST OPTIONS,SUP-2208265,CDM,C1776,CPT,0278,RC,,,,both,,,9495.36,6171.98,,,,,,,,,,,,,
SET ARTHRO CNNLA BLUNT OBTRTR FLOW PORT ACTRK STNDRD,SUP-2639872,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6904.86,4488.16,,,,,,,,,,,,,
PEG BNE FIX L10MM DIA2.5MM VOLAR PARTIALLY THRD FOR ANAT,SUP-2414240,CDM,C1776,CPT,0278,RC,,,,both,,,295.16,191.85,,,,,,,,,,,,,
SHOE ORTHOT MAR BAR ADDITION,SUP-2435744,CDM,L3595,HCPCS,0274,RC,,,,both,,,118.75,77.19,,,,,,,,,,,,,
ROD SPNL S STL STR L150MM L150MM OD5.5MM REVERE,SUP-2185225,CDM,C1713,HCPCS,0278,RC,,,,both,,,5175.44,3364.04,,,,,,,,,,,,,
EXPANDER BRST 550CC W7.1XL13.7CM P7.7CM SIL NACL SMOOTH,SUP-2300338,CDM,C1789,HCPCS,0278,RC,,,,both,,,3344.10,2173.66,,,,,,,,,,,,,
CUTTER D31MM DISPOSABLE HI LINE XS NEURO III,SUP-2108791,CDM,C1713,HCPCS,0278,RC,,,,both,,,344.49,223.92,,,,,,,,,,,,,
SCREW BNE L 40 MM DIA2 MM TI CORTICAL ST T6 DRV NS VLP,SUP-2932390,CDM,C1713,HCPCS,0278,RC,,,,both,,,178.16,115.80,,,,,,,,,,,,,
SCREW BNE L12MM DIA3.5MM CORT VOLAR TI NONCANNULATED LOK,SUP-2413995,CDM,C1713,HCPCS,0278,RC,,,,both,,,359.78,233.86,,,,,,,,,,,,,
STEM RAD H+0MM DIA9MM TI ELBW SMOOTH BULL TIP FOR HD SYS,SUP-2418598,CDM,C1776,CPT,0278,RC,,,,both,,,8007.00,5204.55,,,,,,,,,,,,,
GRAFT BONE SUB H7XL30MM CORT CRESC LORDTC C LN SPCR FRZ DRY,SUP-2293813,CDM,C1713,HCPCS,0278,RC,,,,both,,,17295.12,11241.83,,,,,,,,,,,,,
SCREW SPNL FT 12X60 MM SACROILIAC LAG FOR FIX SYS HA SI-LOK,SUP-2229813,CDM,C1713,HCPCS,0278,RC,,,,both,,,8792.00,5714.80,,,,,,,,,,,,,
KIT NCV TST LD L39IN W/ 2 PREGELLED DISC ELECTRD TOUCHPROOF,SUP-2308049,CDM,2720000010,LOCAL,0272,RC,,,,both,,,505.54,328.60,,,,,,,,,,,,,
CATHETER US 8FR L90CM HI RESOL 4 W STEERING PRECIS DOPP,SUP-2248452,CDM,C1759,HCPCS,0272,RC,,,,both,,,7520.30,4888.19,,,,,,,,,,,,,
PLATE BNE LCK 236 MM RT DSTL LAT FIBULAR 16 HOLE SS STRL,SUP-2463621,CDM,C1713,HCPCS,0278,RC,,,,both,,,2794.35,1816.33,,,,,,,,,,,,,
GUIDEWIRE ORTH L100CM DIA3MM S STL TEAR GTT,SUP-2413041,CDM,C1769,HCPCS,0272,RC,,,,both,,,486.45,316.19,,,,,,,,,,,,,
BAR EXT FIX CROSS 120 MM HORIZONTAL FOR RED DEV,SUP-2462232,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1385.71,900.71,,,,,,,,,,,,,
DILATOR ENDOSCP 53 FRX70 CM ESOPH SET,SUP-2737151,CDM,2720000010,LOCAL,0272,RC,,,,both,,,675.10,438.81,,,,,,,,,,,,,
SCREW BONE L20MM OD3MM LCK GRIDLOCK,SUP-2390561,CDM,C1713,HCPCS,0278,RC,,,,both,,,596.60,387.79,,,,,,,,,,,,,
SADDLE CABLE DIA 4.5 MM SS STRL EVOS,SUP-2931177,CDM,C1713,HCPCS,0278,RC,,,,both,,,1170.91,761.09,,,,,,,,,,,,,
GRAFT VASC GORTX L 70 CM DIA 8 MM RNG L 30 CM EPTFE STR STD,SUP-2396101,CDM,C1768,CPT,0278,RC,,,,both,,,2502.58,1626.68,,,,,,,,,,,,,
SHAFT RMR L510MM DIA8MM MOD TRINKLE BIXCUT,SUP-2366799,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1775.67,1154.19,,,,,,,,,,,,,
HC So Tissue Culture Lymphocyte,PX-3118823066,CDM,88230,CPT,0311,RC,,,,both,,,189.00,122.85,,,,,,,,,,,,,
ANCHOR SUTURE POLYMER SMALLEST SMTH SECUR DESIGN PERM,SUP-2895981,CDM,C1713,HCPCS,0278,RC,,,,both,,,124.03,80.62,,,,,,,,,,,,,
SLEEVE DRL DIA3.2MM FOR PROX HUM MEAS,SUP-2411560,CDM,2720000010,LOCAL,0272,RC,,,,both,,,555.15,360.85,,,,,,,,,,,,,
GUIDEWIRE ORTHOPEDIC 1.4X150 MM TROCAR PT 1 END,SUP-2422325,CDM,C1769,HCPCS,0272,RC,,,,both,,,226.96,147.52,,,,,,,,,,,,,
STEM FEM SZ 7 L250MM OD12.4MM NK L30MM R HIP CEM LNG BODY,SUP-2374732,CDM,C1776,CPT,0278,RC,,,,both,,,12356.53,8031.74,,,,,,,,,,,,,
ADAPTER FEM 5DEG STEM FOR PFC SIG REV,SUP-2253592,CDM,C1776,CPT,0278,RC,,,,both,,,1953.08,1269.50,,,,,,,,,,,,,
PLATE BNE RT FLX STRL F3 LTX,SUP-2861101,CDM,C1713,HCPCS,0278,RC,,,,both,,,1746.47,1135.21,,,,,,,,,,,,,
CATHETER ETER DRNGE MP SIMP LOC 85FRX25CM HYDRPHLC,SUP-2168322,CDM,C1729,HCPCS,0272,RC,,,,both,,,345.75,224.74,,,,,,,,,,,,,
HC So Hepatitis C Virus Genotyping,PX-3068790266,CDM,87902,CPT,0306,RC,,,,outpatient,,,1147.00,745.55,,,,,,,,,,,,,
DEXAMETHASONE 12 MG IN NS 50 ML IVPB,RX-4082426,CDM,J1100,HCPCS,0636,RC,99999-9917-38,NDC,,both,50,ML,362.90,235.88,,,,,,,,,,,,,
HC Joint Injection/Aspir Large WO US|PBB CHARGE|BILATERAL PROCEDURE,PX-5102061000,CDM,20610,CPT,0510,RC,,,PBB|50,outpatient,,,1092.00,709.80,,,,,,,,,,,,,
ALLOGRAFT BNE GRND 60 CC FD IRRADIATED CANC 921852,SUP-2867191,CDM,C1762,CPT,0278,RC,,,,both,,,1852.44,1204.09,,,,,,,,,,,,,
MEMBRANE REGENERATIVE MED 15X20 IN RESOLUT XT,SUP-2396734,CDM,C1713,HCPCS,0278,RC,,,,both,,,555.78,361.26,,,,,,,,,,,,,
CATHETER ENDOVENOUS 7FR L100CM W/O PK RF MIS-7F11 CLSR FAST,SUP-2393086,CDM,C1888,HCPCS,0272,RC,,,,both,,,2574.80,1673.62,,,,,,,,,,,,,
PLATE BNE L85MM HK D15MM 5 H R CLAV S STL LOK COMPR FOR,SUP-2185851,CDM,C1713,HCPCS,0278,RC,,,,both,,,3291.47,2139.46,,,,,,,,,,,,,
STRAP CLAV XL PD W3XL4IN STD FOAM PD STOCKINET MTL TOOTH,SUP-2276603,CDM,L3650,HCPCS,0274,RC,,,,both,,,15.32,9.96,,,,,,,,,,,,,
INTRODUCER SHTH RED HUB 4FRX23CM PRELUDE,SUP-2303264,CDM,C1894,HCPCS,0272,RC,,,,both,,,44.09,28.66,,,,,,,,,,,,,
CATHETER VASC L135CM OD4FR INFUS L50CM MATCHING OCCL WIRE,SUP-2302766,CDM,C1751,HCPCS,0278,RC,,,,both,,,372.09,241.86,,,,,,,,,,,,,
BUR SURG L72MM DIA3MM TOOL STL LNG FLUT RND,SUP-2284262,CDM,2720000010,LOCAL,0272,RC,,,,both,,,250.35,162.73,,,,,,,,,,,,,
IMPLANT OTOLRYNGOLOGY 04MM DIAM 45MM LEN LOOP STAP PIST,SUP-2313684,CDM,L8613,CPT,0278,RC,,,,both,,,485.13,315.33,,,,,,,,,,,,,
PLATE BNE DBL ANGLED SM 2.5 MM RECON PT SPEC,SUP-2860097,CDM,C1713,HCPCS,0278,RC,,,,both,,,27404.66,17813.03,,,,,,,,,,,,,
NAIL IM HUM PICCOLO 8.5MMX26CM,SUP-2152631,CDM,C1713,HCPCS,0278,RC,,,,both,,,5719.82,3717.88,,,,,,,,,,,,,
CATHETER CV DL 12 FRX90 CM LO PROF ADPT SIL HICKMAN,SUP-2126160,CDM,C1751,HCPCS,0278,RC,,,,both,,,1155.02,750.76,,,,,,,,,,,,,
MESH BONE 54MMW X 85MML 02MM THK TTNM F/15MM SCREW LATEX F,SUP-2681104,CDM,C1713,HCPCS,0278,RC,,,,both,,,2008.28,1305.38,,,,,,,,,,,,,
SCREW BONE L95MM D45MM CRTCL SELF TPPNG FLLY THRDD L HEX RCS,SUP-2464162,CDM,C1713,HCPCS,0278,RC,,,,both,,,103.49,67.27,,,,,,,,,,,,,
GRAFT VASC TW 8 MMX80 CM AORT STR REINF SLDE GDS ADVANTA VXT,SUP-2468148,CDM,C1768,CPT,0278,RC,,,,both,,,2399.09,1559.41,,,,,,,,,,,,,
ELECTRODE SURG MECHANOMYOGRAPHY TRAIN SS NS,SUP-2693685,CDM,2720000010,LOCAL,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
GRAFT BNE INJ 10 CC REGENERATIVE PRO-DENSE,SUP-2759449,CDM,C1713,HCPCS,0278,RC,,,,both,,,9254.15,6015.20,,,,,,,,,,,,,
PLATE BNE L208MM THK34MM 16 H BILAT S STL STR LIMIT CNTCT,SUP-2185154,CDM,C1713,HCPCS,0278,RC,,,,both,,,1944.66,1264.03,,,,,,,,,,,,,
COLLAR BK SZ UNIV VISTA,SUP-2196895,CDM,L0120,HCPCS,0274,RC,,,,both,,,61.51,39.98,,,,,,,,,,,,,
HC So Aml Kit Mutation,PX-3108127266,CDM,81272,CPT,0310,RC,,,,both,,,585.00,380.25,,,,,,,,,,,,,
PLATE BNE L253MM 14 H NONSTERILE R PROX TIB S STL,SUP-2185706,CDM,C1713,HCPCS,0278,RC,,,,both,,,3857.90,2507.63,,,,,,,,,,,,,
BLADE SAW OSTEOTMY HUB STYL DS,SUP-2535308,CDM,C1713,HCPCS,0278,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
GUIDEWIRE VASC L 300 CM DIA 0.014 IN DSTL TIP L 7 CM IT TIP,SUP-2154042,CDM,C1769,HCPCS,0272,RC,,,,both,,,1067.60,693.94,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED CMNTLS DURAC SCORP,SUP-2365624,CDM,C1776,CPT,0278,RC,,,,both,,,14974.82,9733.63,,,,,,,,,,,,,
BIT DRL DIA38MM STP 20MM QUIK CPL,SUP-2179052,CDM,2720000010,LOCAL,0272,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
HC Intro Need/Cath Car/Ver Art,PX-3613610000,CDM,36100,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
DEVICE REVASCULARIZATION 3D L 26 MM WORKING L 20 MM DIA 4.5,SUP-2323630,CDM,C1757,HCPCS,0272,RC,,,,both,,,16296.60,10592.79,,,,,,,,,,,,,
SCREW BNE SEMICONSTRAINED 4.5X40 MM WRST LCK CAP STRL FRDM,SUP-2852841,CDM,C1713,HCPCS,0278,RC,,,,both,,,1502.52,976.64,,,,,,,,,,,,,
INSTRUMENT PACK PIN WIRE PAC D FOR MENIS REP SYS STRL LF,SUP-2877955,CDM,2720000010,LOCAL,0272,RC,,,,both,,,827.55,537.91,,,,,,,,,,,,,
DEVICE ENDOSKELETAL SYS KNEE SHIN SINGLE AXIS MANUAL LCK,SUP-2388216,CDM,L5810,HCPCS,0274,RC,,,,both,,,1312.87,853.37,,,,,,,,,,,,,
PLATE BONE L159MM 20 H MAND TI LCK FOR 2MM SCR,SUP-2191234,CDM,C1713,HCPCS,0278,RC,,,,both,,,4633.38,3011.70,,,,,,,,,,,,,
HC US Guidance or Line Place W/ Permanent Image,PX-4027693700,CDM,76937,CPT,0402,RC,,,,both,,,593.00,385.45,,,,,,,,,,,,,
CATHETER SET GASTROSTMY 12 FRX35 CM 12 SP WILLS-OGLESBY,SUP-2168069,CDM,C1713,HCPCS,0278,RC,,,,both,,,498.57,324.07,,,,,,,,,,,,,
SCREW BNE L19MM DIA3.5MM HIP FULL THRD HEX HD COMPR,SUP-2342407,CDM,C1713,HCPCS,0278,RC,,,,both,,,420.32,273.21,,,,,,,,,,,,,
CROWN PRI S STL D-LL-5,SUP-2322201,CDM,D6783,CPT,0278,RC,,,,both,,,27.32,17.76,,,,,,,,,,,,,
HC Assay of Phosphorus Inorganic,PX-3018410000,CDM,84100,CPT,0301,RC,,,,both,,,83.00,53.95,,,,,,,,,,,,,
PLATE BNE STR 1.3X24X0.75 MM 6 HOLE LCK SS NS,SUP-2177981,CDM,C1713,HCPCS,0278,RC,,,,both,,,1185.66,770.68,,,,,,,,,,,,,
PLATE BONE 130DEG 4 H SUPCNDYL S STL COMPR FRELOK,SUP-2197723,CDM,C1713,HCPCS,0278,RC,,,,both,,,1313.43,853.73,,,,,,,,,,,,,
AMPICILLIN SODIUM 2 G IJ SOLR,RX-472,CDM,J0290,HCPCS,0636,RC,00781-3408-95,NDC,,both,1,UN,54.10,35.16,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP ANGLED 0.018 INX260 CM 3 CM X SUPP RDRUN,SUP-2738312,CDM,C1729,HCPCS,0272,RC,,,,both,,,458.44,297.99,,,,,,,,,,,,,
SCREW BNE L 80 MM DIA 4.5 MM CORTICAL ST STRL EVOS,SUP-2931188,CDM,C1713,HCPCS,0278,RC,,,,both,,,146.80,95.42,,,,,,,,,,,,,
PIN EXT FIX SM L150MM DIA3.5MM THRD L25MM MINI ST TRANSFX,SUP-2199168,CDM,C1713,HCPCS,0278,RC,,,,both,,,176.84,114.95,,,,,,,,,,,,,
CATHETER DRNGE 12FR L45CM 0.038IN 6 SIDEPRT PERC HYDRPHLC,SUP-2168508,CDM,C1729,HCPCS,0272,RC,,,,both,,,242.16,157.40,,,,,,,,,,,,,
GRAFT HUM TISS W8.5XL200MM TEND PRESUTURED DBL STRND,SUP-2123494,CDM,C1762,CPT,0278,RC,,,,both,,,7536.00,4898.40,,,,,,,,,,,,,
NAIL IM L460MM DIA10MM NONSTERILE AQUA L/R DSTL FEM TI LCK,SUP-2191730,CDM,C1713,HCPCS,0278,RC,,,,both,,,5390.50,3503.82,,,,,,,,,,,,,
HC Flow Volume Loop,PX-4609437500,CDM,94375,CPT,0460,RC,,,,both,,,936.00,608.40,,,,,,,,,,,,,
PIN PRECSION TM 9X495 MM,SUP-2854224,CDM,2720000010,LOCAL,0272,RC,,,,both,,,826.70,537.35,,,,,,,,,,,,,
ROD SPNL Z 5.5X300 MM TI MARINER OUTRIG,SUP-2709861,CDM,C1713,HCPCS,0278,RC,,,,both,,,7065.00,4592.25,,,,,,,,,,,,,
SCREW BONE L26MM DIA2.5MM HEX DRVR DIA1.5MM MAG ST CANN FULL,SUP-2205623,CDM,C1713,HCPCS,0278,RC,,,,both,,,1821.20,1183.78,,,,,,,,,,,,,
COMPONENT GLEN L THK4MM SHLDR POLY PEGGED MOD CONSTRN CEM,SUP-2404650,CDM,C1776,CPT,0278,RC,,,,both,,,5127.62,3332.95,,,,,,,,,,,,,
KIT STRNL CLOSURE SS LADDER CABLE PLATE SCREW STRL THORECON,SUP-2894486,CDM,C1713,HCPCS,0278,RC,,,,both,,,7065.00,4592.25,,,,,,,,,,,,,
SCREW PEDCL POLYAX CANC TOP LD CANN TI 5.5MM ROD 5.5MM DIA,SUP-2414588,CDM,C1713,HCPCS,0278,RC,,,,both,,,5122.13,3329.38,,,,,,,,,,,,,
RING EXT FIX ID180MM ANK FT FULL FOR TRUELOK FRME ASSEMB,SUP-2316173,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3359.05,2183.38,,,,,,,,,,,,,
SCREW SPNL L10MM DIA3.5MM MINI CANC POST OCCIPITAL CERV THOR,SUP-2256183,CDM,C1713,HCPCS,0278,RC,,,,both,,,3639.70,2365.80,,,,,,,,,,,,,
DABIGATRAN ETEXILATE MESYLATE 150 MG PO CAPS,RX-106476,CDM,6370000000,HCPCS,0637,RC,00597-0360-82,NDC,,both,1,UN,14.90,9.68,,,,,,,,,,,,,
GRAFT HUM TISS BIOINTEGRATIVE 70X50 MM W/ INSRTN SL TAPESTRY,SUP-2867241,CDM,C1763,HCPCS,0278,RC,,,,both,,,3862.20,2510.43,,,,,,,,,,,,,
STENT GRFT VASC AFX2 BODY L 100 MM DIA25 MM LIMB 40 MM 20 MM,SUP-2217670,CDM,C1874,HCPCS,0278,RC,,,,both,,,37441.36,24336.88,,,,,,,,,,,,,
GUIDEWIRE VASC L150CM DIA0.035IN STIFF HYDRPHLC ANG TIP,SUP-2302966,CDM,C1769,HCPCS,0272,RC,,,,both,,,93.79,60.96,,,,,,,,,,,,,
CROWN DENT LL5 SPACE MAINTAINER 1ST PERM STR WALLED SS,SUP-2176716,CDM,D6783,CPT,0278,RC,,,,both,,,21.79,14.16,,,,,,,,,,,,,
ROD SPNL Z 5.5X260 MM TI MARINER OUTRIG,SUP-2709857,CDM,C1713,HCPCS,0278,RC,,,,both,,,4082.00,2653.30,,,,,,,,,,,,,
COMPONENT SUBTALAR L15MM DIA9MM RESRB SFT THRD CYL BIOBLOCK,SUP-2242685,CDM,C1713,HCPCS,0278,RC,,,,both,,,6643.39,4318.20,,,,,,,,,,,,,
EXTENSION LD D4 25 CM DSTL SPL,SUP-2539657,CDM,C1883,HCPCS,0278,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
LEAD NERVE STIM 90 CM SPEC SURESCAN MRI 5-6-5,SUP-2659105,CDM,C1778,HCPCS,0278,RC,,,,both,,,19954.70,12970.55,,,,,,,,,,,,,
RESERVOIR CSF FOLTZ 19 MM SINGLE DOME REINF FLAT BTM,SUP-2852580,CDM,C1889,HCPCS,0278,RC,,,,both,,,1571.48,1021.46,,,,,,,,,,,,,
GRAFT BIO TISS W10XL10CM PORCINE REGEN TISS MTRX PLIABLE,SUP-2112979,CDM,Q4130,HCPCS,0636,RC,,,,both,,,9614.68,6249.54,,,,,,,,,,,,,
"HC So1 N.Gonorrhea, Dna, Amp Probe",PX-3068759167,CDM,87591,CPT,0306,RC,,,,both,,,44.00,28.60,,,,,,,,,,,,,
PLATE BNE 24 DEG L 48 X W 8.5 MM THK 1.6 MM 3 H SS RT DSTL,SUP-2932758,CDM,C1713,HCPCS,0278,RC,,,,both,,,3056.48,1986.71,,,,,,,,,,,,,
NUT SPNL LAT PLT LOK XLP,SUP-2311326,CDM,C1713,HCPCS,0278,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
COMPONENT FEM L TROCHANTERIC CALCAR HIP MALLORY-HEAD CO,SUP-2403679,CDM,C1776,CPT,0278,RC,,,,both,,,1469.52,955.19,,,,,,,,,,,,,
PATCH BIO L 15 X W 2.5 CM BOV PERICARD XENOSURE,SUP-2884014,CDM,C1768,CPT,0278,RC,,,,both,,,1723.86,1120.51,,,,,,,,,,,,,
PLATE BNE L 31.1 X W 3.2 MM THK 0.6 MM SCREW DIA1.65 MM 8 H,SUP-2936647,CDM,C1713,HCPCS,0278,RC,,,,both,,,624.86,406.16,,,,,,,,,,,,,
WASHER ORTH IMP F MAXICAN 4.5 MM SCR,SUP-2321037,CDM,C1713,HCPCS,0278,RC,,,,both,,,127.48,82.86,,,,,,,,,,,,,
PACEMAKER CARD PULSAR MAX DR TI 2 CHMBR IS1 COMPATIBLE CONN,SUP-2148601,CDM,C1785,HCPCS,0275,RC,,,,both,,,17882.30,11623.49,,,,,,,,,,,,,
HAMMER SURG QUISLING 7 IN INTNSL PADGETT,SUP-2484783,CDM,C1713,HCPCS,0278,RC,,,,both,,,695.07,451.80,,,,,,,,,,,,,
HC Rep Lac Smp Face 2.6-5.0 Cm,PX-4501201300,CDM,12013,CPT,0450,RC,,,,inpatient,,,632.00,410.80,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 50 MG UMB CRD CLARIX FLO,SUP-2648678,CDM,Q4155,HCPCS,0636,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
ROD EXT FIX 11X350MM C FBR,SUP-2188664,CDM,2720000010,LOCAL,0272,RC,,,,both,,,955.03,620.77,,,,,,,,,,,,,
CATHETER REPERFUSION L132CM INNR LUMN DIA0.068IN UNIQUE,SUP-2323551,CDM,C1725,HCPCS,0272,RC,,,,both,,,7441.80,4837.17,,,,,,,,,,,,,
ELECTRODE ES 12DEG LOOP HF RESECT MPLR DISPOSABLE,SUP-2313571,CDM,C1713,HCPCS,0278,RC,,,,both,,,556.69,361.85,,,,,,,,,,,,,
SCREW BNE L5MM DIA1.5MM UNIV SELF DRL CRSS PIN 5/EA,SUP-2366492,CDM,C1713,HCPCS,0278,RC,,,,both,,,190.47,123.81,,,,,,,,,,,,,
KIT CVC AD 7FR L20CM POLYUR BLU FLEXTIP ANTIMIC MULTILUMEN,SUP-2383391,CDM,C1751,HCPCS,0278,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
CHISEL 9 3 4IN CRV 1 2IN HIBBS,SUP-2244781,CDM,C1713,HCPCS,0278,RC,,,,both,,,177.35,115.28,,,,,,,,,,,,,
ELECTRODE VPR M LOOP FOR 12DEG TELESCOPES PLASMABUTTON,SUP-2313580,CDM,C1713,HCPCS,0278,RC,,,,both,,,1596.88,1037.97,,,,,,,,,,,,,
KIT INTRO INTDYN TEARWY DIA16 FR PTFE,SUP-2125219,CDM,C1894,HCPCS,0272,RC,,,,both,,,853.58,554.83,,,,,,,,,,,,,
ALLOGRAFT BNE 1000-2000 MH 2 CC FD CANC PWD ORAGRAFT,SUP-2740886,CDM,C1713,HCPCS,0278,RC,,,,both,,,478.66,311.13,,,,,,,,,,,,,
NEEDLE ASPIR 21GA L20-40MM WRK L700MM CHN 2MM DST END ADJ,SUP-2313394,CDM,2720000010,LOCAL,0272,RC,,,,both,,,374.92,243.70,,,,,,,,,,,,,
PLATE STRNL 7 H TI T SHP NS MATRIXSTERNUM,SUP-2904242,CDM,C1713,HCPCS,0278,RC,,,,both,,,2385.24,1550.41,,,,,,,,,,,,,
PLATE BNE W54XL85MM THK03MM 2 H CRAN TI BILAT MIC MESH,SUP-2262588,CDM,C1713,HCPCS,0278,RC,,,,both,,,2448.38,1591.45,,,,,,,,,,,,,
GUIDEWIRE VASC TORQ-FLEX L 130 CM DIA 0.018 IN FLX TIP L 8,SUP-2638734,CDM,C1769,HCPCS,0272,RC,,,,both,,,140.11,91.07,,,,,,,,,,,,,
TM MODULAR CUP 80MM CLUSTER-HOLE,SUP-2503667,CDM,C1776,CPT,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
SET LD EXTRACTION BYRD SHTH L 41/46CM 12.3FR 10 FR SZ AA BLU,SUP-2169594,CDM,C1894,HCPCS,0272,RC,,,,both,,,460.01,299.01,,,,,,,,,,,,,
MESH SURG W30XL45CM POLY MACROPOROUS FOR EXTRAPERITONEAL,SUP-2172438,CDM,C1781,HCPCS,0278,RC,,,,both,,,1018.74,662.18,,,,,,,,,,,,,
CATHETER INFUSION BENEPHIT XT L 105 CM SHTH 5 FR TARGETED,SUP-2117251,CDM,C1751,HCPCS,0278,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
RIGHT RADIAL STYLOID PLATE STERILE,SUP-2722441,CDM,C1713,HCPCS,0278,RC,,,,both,,,2445.06,1589.29,,,,,,,,,,,,,
HC Iadna Enterovirus Amplif Probe & Revrse Trnscrip,PX-3068749800,CDM,87498,CPT,0306,RC,,,,both,,,89.00,57.85,,,,,,,,,,,,,
BUR SURG SZ 3 235MM TUNGSTEN CARB SIDE CUT,SUP-2108789,CDM,C1713,HCPCS,0278,RC,,,,both,,,448.58,291.58,,,,,,,,,,,,,
ASSEMBLY NDL CVD FOR FAST-FIX MENIS REP SYS,SUP-2341568,CDM,C1713,HCPCS,0278,RC,,,,both,,,854.27,555.28,,,,,,,,,,,,,
STEM HUM L165MM DIA10MM LNG UNIV SHLDR CO CHROM CEM REV,SUP-2193877,CDM,C1776,CPT,0278,RC,,,,both,,,11224.97,7296.23,,,,,,,,,,,,,
PLATE BNE RECON 3.5X154 MM 13 HOLE SS,SUP-2569088,CDM,C1713,HCPCS,0278,RC,,,,both,,,450.75,292.99,,,,,,,,,,,,,
HC Myelogram Cervical,PX-3616230200,CDM,62302,CPT,0361,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
CONTROL REMOT FREELINK,SUP-2141943,CDM,C1787,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
CATHETER GUID HELI-FX ENDOANCHOR L 90 CM DIA18 FR NK,SUP-2280990,CDM,C1713,HCPCS,0278,RC,,,,both,,,7215.72,4690.22,,,,,,,,,,,,,
KCL IN DEXTROSE-NACL 40-5-0.45 MEQ/L-%-% IV SOLN,RX-102363,CDM,2500000003,HCPCS,0250,RC,00264-7638-00,NDC,,both,1000,ML,57.50,37.37,,,,,,,,,,,,,
BIT DRILL CANN LG 14 MM FLX QC NS,SUP-2422900,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2364.58,1536.98,,,,,,,,,,,,,
ALLOGRAFT BNE FD ASEP RIB CART,SUP-2867025,CDM,C1762,CPT,0278,RC,,,,both,,,1494.48,971.41,,,,,,,,,,,,,
PLATE SPNL POST 10 MM COR,SUP-2430746,CDM,C1713,HCPCS,0278,RC,,,,both,,,16915.18,10994.87,,,,,,,,,,,,,
BUR SURG DIA 6 MM HUB III ROSEN STRL REUSE HI-LINE,SUP-2928960,CDM,2720000010,LOCAL,0272,RC,,,,both,,,421.64,274.07,,,,,,,,,,,,,
BLADE REPROC SAW SAGITTAL SYS 4 AND 2000 29X1.32X84MM,SUP-2525943,CDM,C1776,CPT,0278,RC,,,,both,,,50.93,33.10,,,,,,,,,,,,,
PLATE BONE 12 H ANTR BOW LAT PROX FOR 3.5 SCR,SUP-2349061,CDM,C1713,HCPCS,0278,RC,,,,both,,,977.01,635.06,,,,,,,,,,,,,
BASEPLATE TIB KEELED 3-4 KNEE MOD FIN STEMMABLE NXGN MIS,SUP-2201020,CDM,C1776,CPT,0278,RC,,,,both,,,3326.83,2162.44,,,,,,,,,,,,,
STENT GRFT VASC AFX BODY L 80 MM DIA22 MM LIMB L 40 MM DIA16,SUP-2217622,CDM,C1874,HCPCS,0278,RC,,,,both,,,34398.70,22359.15,,,,,,,,,,,,,
COUNTERSINK SURG OD4.5MM HD SGL USE MONSTER,SUP-2320965,CDM,C1713,HCPCS,0278,RC,,,,both,,,675.10,438.81,,,,,,,,,,,,,
TEMPLATE SZ THK27MM 26 H MAND PLT TI STR LOK FOR 27MM SCR,SUP-2262980,CDM,C1713,HCPCS,0278,RC,,,,both,,,199.08,129.40,,,,,,,,,,,,,
CONT MESH PTERIONAL PED L06MM,SUP-2681437,CDM,C1713,HCPCS,0278,RC,,,,both,,,9430.55,6129.86,,,,,,,,,,,,,
PLATE BNE T RT 2X4 HOLE OBLQ COMPR NS LTX 3102244,SUP-2855817,CDM,C1713,HCPCS,0278,RC,,,,both,,,2062.98,1340.94,,,,,,,,,,,,,
POTASSIUM & SODIUM PHOSPHATES 280-160-250 MG PO PACK,RX-70284,CDM,6370000000,HCPCS,0637,RC,60258-0006-15,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
COIL EMB L60CM LOOP OD16MM OD0.020IN STD NIT COMPLX FRME,SUP-2323381,CDM,C1889,HCPCS,0278,RC,,,,both,,,7510.88,4882.07,,,,,,,,,,,,,
HC Diabetes Group/30min,PX-9420010900,CDM,G0109,HCPCS,0942,RC,,,,inpatient,,,44.00,28.60,,,,,,,,,,,,,
SCREW BNE LAG 105 MM ASMBLY TELSCP KEYLESS,SUP-2415890,CDM,C1713,HCPCS,0278,RC,,,,both,,,2543.40,1653.21,,,,,,,,,,,,,
BUR SURG FLUT BRL 15 DEG 14.2 MMX13.5 CM STRL DISP,SUP-2638400,CDM,2720000010,LOCAL,0272,RC,,,,both,,,678.24,440.86,,,,,,,,,,,,,
PROSTHESIS OSS 1.17X3.9 MM PART STRUT HA,SUP-2461568,CDM,L8613,CPT,0278,RC,,,,both,,,1109.68,721.29,,,,,,,,,,,,,
VALVE SHUNT PED CONTROL RESERVOIR,SUP-2711649,CDM,C1729,HCPCS,0272,RC,,,,both,,,1069.80,695.37,,,,,,,,,,,,,
INSERT TIB SZ 9 THK12MM UNIV CO CHROM UHMWPE KNEE ARTC PRI,SUP-2378284,CDM,C1776,CPT,0278,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
SCREW ACET THMB ASMBLY INSTRUMENT,SUP-2449670,CDM,C1713,HCPCS,0278,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
APPLICATOR SURG 7 CM LOCALIZER 22,SUP-2137815,CDM,A4648,CPT,0278,RC,,,,both,,,887.05,576.58,,,,,,,,,,,,,
PLATE 4.5MM LCP CONDYLAR 12 HOLES 278MM RIGHT STERILE,SUP-2547440,CDM,C1713,HCPCS,0278,RC,,,,both,,,4677.56,3040.41,,,,,,,,,,,,,
DEFIBRILLATOR CRD 2CHMBR 5.37X7.68X0.99 CM 31 CC RESONATE EL,SUP-2424806,CDM,C1721,HCPCS,0275,RC,,,,both,,,48428.22,31478.34,,,,,,,,,,,,,
MESH HERN SM W3.1XL4.7IN POLYPR EPTFE OVL SELF EXP PTCH FOR,SUP-2125710,CDM,C1781,HCPCS,0278,RC,,,,both,,,1523.21,990.09,,,,,,,,,,,,,
WASHER ORTH DIA5MM FOR 2MM SCR,SUP-2349661,CDM,C1713,HCPCS,0278,RC,,,,both,,,193.86,126.01,,,,,,,,,,,,,
INSERT TIB SZ 4 THK10MM UNIV KNEE POLYETH FIX BEAR PRI NEUT,SUP-2253552,CDM,C1776,CPT,0278,RC,,,,both,,,4907.19,3189.67,,,,,,,,,,,,,
NATALIZUMAB 300 MG/15ML IV CONC,RX-40120,CDM,J2323,HCPCS,0636,RC,64406-0008-01,NDC,,both,15,ML,26193.70,17025.90,,,,,,,,,,,,,
IMPLANT BRST W13.2-12.7XH11CM P6.1-7.5CM 450-540CC NACL,SUP-2300538,CDM,C1789,HCPCS,0278,RC,,,,both,,,3611.00,2347.15,,,,,,,,,,,,,
SPONGE SCLER BCKL 3X5MM STYL 506 OVL,SUP-2213490,CDM,C1784,HCPCS,0278,RC,,,,both,,,201.59,131.03,,,,,,,,,,,,,
ACETIC ACID 3 % SOLN,RX-15091,CDM,6370000000,HCPCS,0637,RC,09999-9917-50,NDC,,both,15,ML,54.10,35.16,,,,,,,,,,,,,
MESH BONE KSSM 06MM THK TTNM LATEX FREE RIGHT PTRNL MXLFCL,SUP-2707391,CDM,C1713,HCPCS,0278,RC,,,,both,,,6373.60,4142.84,,,,,,,,,,,,,
ANCHOR SUTURE WITH TWO NO 2 HI FI SUTURES 17MM LENGTH 5.5MM,SUP-2824896,CDM,C1713,HCPCS,0278,RC,,,,both,,,1437.49,934.37,,,,,,,,,,,,,
INSERT TIB 0 10 MM RT ANK POLYETH SALTO TALARIS,SUP-2244133,CDM,C1776,CPT,0278,RC,,,,both,,,3331.54,2165.50,,,,,,,,,,,,,
MATRIX DERM W8XL8CM BOV TISS N PERF PRIMTRX,SUP-2366726,CDM,Q4110,HCPCS,0636,RC,,,,both,,,8653.84,5625.00,,,,,,,,,,,,,
SODIUM CHLORIDE 5 % IV SOLN,RX-7323,CDM,2500000003,HCPCS,0250,RC,00264-7806-10,NDC,,both,500,ML,60.00,39.00,,,,,,,,,,,,,
COMPONENT ARTC SURF TIB 3-4 CD 14 MM KNEE YEL NXGN LPS,SUP-2201940,CDM,C1776,CPT,0278,RC,,,,both,,,2455.48,1596.06,,,,,,,,,,,,,
CATHETER NEPHROSTOMY X-FORCE N30 L 15 CM DIA 8 MM DULA LUMEN,SUP-2655876,CDM,C1729,HCPCS,0272,RC,,,,both,,,609.47,396.16,,,,,,,,,,,,,
COPELAND SHLDR W/ POLY GLD,SUP-2212469,CDM,C1776,CPT,0278,RC,,,,both,,,14130.00,9184.50,,,,,,,,,,,,,
RADIOFREQUENCY ABLATION KIT LNG 5/10 CM W/ POWERCURVE STAR,SUP-2487603,CDM,2720000010,LOCAL,0272,RC,,,,both,,,11717.44,7616.34,,,,,,,,,,,,,
INTRODUCER SHTH 45 CM 8 FRX13 CM 20 CM SSV SPLIT GUIDEWIRE,SUP-2424644,CDM,C1894,HCPCS,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
CANNULATED DRL 7X185MM,SUP-2417662,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1982.22,1288.44,,,,,,,,,,,,,
STENT URET DBL PGTL 0.035 INX150 CM 3 CM 7 FRX26 CM POLARIS,SUP-2537625,CDM,C2617,HCPCS,0278,RC,,,,both,,,702.26,456.47,,,,,,,,,,,,,
SCREW BNE L8MM DIA1.5MM HND 316L S STL ST VAR ANG LOK T4,SUP-2177992,CDM,C1713,HCPCS,0278,RC,,,,both,,,359.91,233.94,,,,,,,,,,,,,
COMPONENT FEM ENDO KNEE SM LT,SUP-2265071,CDM,C1776,CPT,0278,RC,,,,both,,,18312.48,11903.11,,,,,,,,,,,,,
AIRWAY ESOPH 4 AD 30 CC FLX CUF REINF WIRE TBNG LMA FASTRACH,SUP-2383563,CDM,2720000010,LOCAL,0272,RC,,,,both,,,873.86,568.01,,,,,,,,,,,,,
KIT MAG 24 SOFTWEAR PD,SUP-2165020,CDM,L8690,HCPCS,0278,RC,,,,both,,,580.90,377.58,,,,,,,,,,,,,
SCREW BNE L50MM DIA3.5MM SHT THRD HD MINI-MONSTER,SUP-2320524,CDM,C1713,HCPCS,0278,RC,,,,both,,,741.83,482.19,,,,,,,,,,,,,
PLATE BONE L112MM W11.7XL30MM 90DEG 6 H CANN LCK COMPR ANG,SUP-2185438,CDM,C1713,HCPCS,0278,RC,,,,both,,,2555.96,1661.37,,,,,,,,,,,,,
SCREW BONE L4MM DIA2MM TEAL CRANIOMAXILLOFACIAL TI ST FULL,SUP-2188974,CDM,C1713,HCPCS,0278,RC,,,,both,,,247.93,161.15,,,,,,,,,,,,,
CATHETER GUID 2.8X2.3FR L150X20CM ID0.021IN 45DEG PTFE NYL,SUP-2248995,CDM,C1887,HCPCS,0272,RC,,,,both,,,4025.83,2616.79,,,,,,,,,,,,,
SLITTER LD UNIV FOR INNR CATH CPS,SUP-2356361,CDM,C1893,HCPCS,0272,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
TELISOTUZUMAB VEDOTIN-TLLV 100 MG IV SOLR,RX-172131,CDM,J9326,HCPCS,0636,RC,00074-1055-01,NDC,,both,1,UN,40262.40,26170.56,,,,,,,,,,,,,
HC Detail Fetal Anat Exam +Gest,PX-4027681200,CDM,76812,CPT,0402,RC,,,,outpatient,,,528.00,343.20,,,,,,,,,,,,,
DEXTROSE-SODIUM CHLORIDE 5-0.45 % IV SOLN,RX-15861,CDM,J3490,HCPCS,0250,RC,00338-0085-04,NDC,,both,1000,ML,51.00,33.15,,,,,,,,,,,,,
AUGMENT FEM THK5MM BX CUT GUID S-ROM NOILES,SUP-2253243,CDM,C1776,CPT,0278,RC,,,,both,,,241.78,157.16,,,,,,,,,,,,,
PLATE VA VLP CONDYLAT TI CRVD 12H RRT 266MM,SUP-2744544,CDM,C1713,HCPCS,0278,RC,,,,both,,,5923.23,3850.10,,,,,,,,,,,,,
DRESSING POST OPERATIVE RIGID BULK N WET BEAR,SUP-2388204,CDM,L5460,HCPCS,0274,RC,,,,both,,,1662.85,1080.85,,,,,,,,,,,,,
NYSTATIN-TRIAMCINOLONE 100000-0.1 UNIT/GM-% EX OINT,RX-5755,CDM,6370000000,HCPCS,0637,RC,51672-1272-01,NDC,,both,15,GR,70.20,45.63,,,,,,,,,,,,,
CAGE SPNL LG OSTEOTMY CUST SYS TRUSS,SUP-2101150,CDM,C1889,HCPCS,0278,RC,,,,both,,,26690.00,17348.50,,,,,,,,,,,,,
SCREW BNE L30MM DIA3MM S STL ST COMPR ENH LCP DHHS,SUP-2178479,CDM,C1713,HCPCS,0278,RC,,,,both,,,257.51,167.38,,,,,,,,,,,,,
TOOL REMOVAL ANNULAR CLOSURE DEV STRL BARRICAID LTX DISP,SUP-2858411,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2009.60,1306.24,,,,,,,,,,,,,
PLATE BNE 2.7/3.5X184 MM LT PROX ULN X ARTC 10 HOLE LP VA,SUP-2180824,CDM,C1713,HCPCS,0278,RC,,,,both,,,4471.89,2906.73,,,,,,,,,,,,,
KNIFE SURGICAL LEBSCHE STERNAL LATEX FREE,SUP-2675687,CDM,2720000010,LOCAL,0272,RC,,,,both,,,442.49,287.62,,,,,,,,,,,,,
MINERAL OIL RE ENEM,RX-5087,CDM,6370000000,HCPCS,0637,RC,80196-0567-78,NDC,,both,133,ML,50.90,33.08,,,,,,,,,,,,,
KIT HEMO DYLS OR HD CATH AD 15.5FR L20CM BASIC PRECRV STK,SUP-2116541,CDM,C1750,HCPCS,0278,RC,,,,both,,,879.20,571.48,,,,,,,,,,,,,
CABLE ORTH 2X600 MM ASMBLY FLIP ANCHR STRL,SUP-2563689,CDM,C1713,HCPCS,0278,RC,,,,both,,,1379.34,896.57,,,,,,,,,,,,,
HC So Assay of Nucleotidase,PX-3018391566,CDM,83915,CPT,0301,RC,,,,both,,,397.00,258.05,,,,,,,,,,,,,
CUTTER ENDOSCP DIA8.5MM USED TO ELIMINATE TRANSOSSEOUS TUNN AR1204R085S] ARTHREX INC],SUP-2120850,CDM,C1713,HCPCS,0278,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
CANNULA BIO MEDICUS 23FR,SUP-2720545,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1033.34,671.67,,,,,,,,,,,,,
GRAFT VASC ARTEGRAFT L 50 CM DIA 6 MM CLLGN BOV CAR ART,SUP-2120665,CDM,C1768,CPT,0278,RC,,,,both,,,4706.86,3059.46,,,,,,,,,,,,,
CERAMENT BEAD TRAY,SUP-2893103,CDM,C1602,HCPCS,0278,RC,,,,both,,,12560.00,8164.00,,,,,,,,,,,,,
KRANIOS 1.6 MM CRAN CLSR SYS BUR H CVR M 18 MM,SUP-2244074,CDM,C1713,HCPCS,0278,RC,,,,both,,,486.70,316.35,,,,,,,,,,,,,
CATHETER CV KT 9 FRX11.5 CM DL FOR 7.5-8 FR INTRO NDL MAC,SUP-2763354,CDM,C1751,HCPCS,0278,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
STEM FEM SZ 6 L125MM STD HIP INSITU,SUP-2308958,CDM,C1776,CPT,0278,RC,,,,both,,,5181.00,3367.65,,,,,,,,,,,,,
DEVICE ULTRAGUIDE TFR HANDHELD SINGLE USE,SUP-2860383,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1507.20,979.68,,,,,,,,,,,,,
GRAFT BIO TISS W5XL10MM THK1MM PORCINE DERM CLLGN FOR HERN,SUP-2173076,CDM,C9364,HCPCS,0278,RC,,,,both,,,1991.14,1294.24,,,,,,,,,,,,,
STAPLER INT DIA25MM CLS STPL H1.5-2.2MM OPN LEG L5.2MM 22,SUP-2218870,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1430.62,929.90,,,,,,,,,,,,,
RING FIX 160MM 3/4IN,SUP-2197250,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3391.20,2204.28,,,,,,,,,,,,,
NAIL IM L320MM DIA13MM TIB TI CANN LCK RG GLD META-NAIL,SUP-2347528,CDM,C1713,HCPCS,0278,RC,,,,both,,,11558.81,7513.23,,,,,,,,,,,,,
PLATE CRAN 200X140X40 MM PT SPEC IMPL PEEK,SUP-2860159,CDM,C1713,HCPCS,0278,RC,,,,both,,,48059.27,31238.53,,,,,,,,,,,,,
MONSELS FERRIC SUBSULFATE EX SOLN,RX-121273,CDM,6370000000,HCPCS,0637,RC,10481-0112-08,NDC,,both,8,ML,52.50,34.12,,,,,,,,,,,,,
HC So Hep B Core Ab - Ref|NOT REASONABLE AND NECESSARY,PX-3028670468,CDM,86704,CPT,0302,RC,,,GZ,both,,,21.00,13.65,,,,,,,,,,,,,
BRACE ORTH CARBON FIBER FRME RT KNEE FOURCEPOINT HINGE L/TH,SUP-2914912,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1424.74,926.08,,,,,,,,,,,,,
PROSTHESIS PENILE 15 CM SCROT,SUP-2140259,CDM,C1813,HCPCS,0278,RC,,,,both,,,12167.50,7908.87,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL PEEK SD800.514,SUP-2860196,CDM,C1713,HCPCS,0278,RC,,,,both,,,28294.85,18391.65,,,,,,,,,,,,,
GRAFT VASC L80CM DIA6MM EPTFE PERIPH BYPS STD WALL,SUP-2128081,CDM,C1768,CPT,0278,RC,,,,both,,,16413.31,10668.65,,,,,,,,,,,,,
ROD RMR L950MM DIA3MM W/ STR BALL TIP,SUP-2188116,CDM,2720000010,LOCAL,0272,RC,,,,both,,,515.02,334.76,,,,,,,,,,,,,
GRAFT VASC GELSFT ERS L 75 CM SUPP L 60 CM DIA 6 MM,SUP-2384969,CDM,C1768,CPT,0278,RC,,,,both,,,1962.50,1275.62,,,,,,,,,,,,,
SUPPORT ORTHOT THGH LOWER EXTREMITY WT BEAR NAR M-L BRIM,SUP-2435675,CDM,L2525,HCPCS,0274,RC,,,,both,,,3226.92,2097.50,,,,,,,,,,,,,
SET INTRO MICROPUNCTURE CATH 10 CM 5FR 7CM SS PLAT ECHOGENIC,SUP-2170489,CDM,C1894,HCPCS,0272,RC,,,,both,,,73.73,47.92,,,,,,,,,,,,,
SUBSTITUTE BONE GRFT 5ML DEMIN PUTTY BONE CONT,SUP-2277640,CDM,C9359,HCPCS,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
SPLINT ORTH SPICA THMB,SUP-2388192,CDM,L3807,HCPCS,0272,RC,,,,both,,,879.20,571.48,,,,,,,,,,,,,
PLATE J RECON LO PROF 3.5MM 12H RT,SUP-2547583,CDM,C1713,HCPCS,0278,RC,,,,both,,,1841.08,1196.70,,,,,,,,,,,,,
PLATE BNE THK1MM MINI 4 H CRANIOMAXILLOFACIAL BLU STR UNIV,SUP-2366340,CDM,C1713,HCPCS,0278,RC,,,,both,,,280.78,182.51,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL PEEK SD800.538,SUP-2860219,CDM,C1713,HCPCS,0278,RC,,,,both,,,42390.63,27553.91,,,,,,,,,,,,,
STAPLE BNE ORTHOPEDIC 12 MM STRENGTH,SUP-2392828,CDM,C1713,HCPCS,0278,RC,,,,both,,,94.20,61.23,,,,,,,,,,,,,
CATHETER GUID MP 9 FRX45 CM SP ACUITY PRO CUT-AWAY,SUP-2149041,CDM,C1887,HCPCS,0272,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
HC COMPRESSION HEAD STD 7.6MM,SUP-2841248,CDM,C1889,HCPCS,0278,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
GRAFT INFLUX SPARC 10CC,SUP-2615610,CDM,C1713,HCPCS,0278,RC,,,,both,,,14852.20,9653.93,,,,,,,,,,,,,
BUR SURG RND 3 MM TELSCP FOR STRYKR SIGN ELITE ATTCH STRL,SUP-2877760,CDM,2720000010,LOCAL,0272,RC,,,,both,,,395.80,257.27,,,,,,,,,,,,,
IMPLANT PLAS BRST 300 CC FILL VOL SIL MOD PROF 3 CM PROJCT,SUP-2300405,CDM,C1789,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
GRAFT BNE PTTY 5 CC DBM TENSIX,SUP-2759483,CDM,C1713,HCPCS,0278,RC,,,,both,,,4568.70,2969.65,,,,,,,,,,,,,
PLATE BNE RECON 2-2.7X3 MM RT MAND 26 HOLE ANGLED TI NS,SUP-2469924,CDM,C1713,HCPCS,0278,RC,,,,both,,,6179.49,4016.67,,,,,,,,,,,,,
"HC So Herpes Simplex, Type 1",PX-3028669566,CDM,86695,CPT,0302,RC,,,,both,,,108.00,70.20,,,,,,,,,,,,,
SCREW BONE L8MM DIA2MM CORT CRANIOMAXILLOFACIAL TI ST FULL,SUP-2189431,CDM,C1713,HCPCS,0278,RC,,,,both,,,902.75,586.79,,,,,,,,,,,,,
TAP BNE SPNL PEDCL SCR QUIK CONN DYNALOK 65MM DIA,SUP-2289598,CDM,C1713,HCPCS,0278,RC,,,,both,,,1084.40,704.86,,,,,,,,,,,,,
BUR SURG CYL LG 4 MM LEADER PT,SUP-2521574,CDM,2720000010,LOCAL,0272,RC,,,,both,,,599.74,389.83,,,,,,,,,,,,,
CATHETER VENTRICULAR RT ANGLE 1.4X2.7 MMX25 CM ELASTMR TBNG,SUP-2666330,CDM,C1729,HCPCS,0272,RC,,,,both,,,419.94,272.96,,,,,,,,,,,,,
CEFAZOLIN SODIUM-DEXTROSE 1-4 GM-%(50ML) IV SOLR,RX-143619,CDM,J0690,HCPCS,0636,RC,00264-3103-11,NDC,,both,1,UN,75.50,49.07,,,,,,,,,,,,,
GUIDEWIRE VASC GLIDEWIRE ADVANTAGE L 300 CM DIA 0.014 IN TIP,SUP-2385540,CDM,C1769,HCPCS,0272,RC,,,,both,,,989.10,642.91,,,,,,,,,,,,,
CLAMP EXT FIX BAR TO PIN COMBINATION,SUP-2749991,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3061.50,1989.97,,,,,,,,,,,,,
CUSHION RAD 100X70 35L FIL VAC BG,SUP-2137738,CDM,L1830,CPT,0274,RC,,,,both,,,907.08,589.60,,,,,,,,,,,,,
SEEKER BALLOON L 17 MM DIA 5 MM FRONTAL FOR ENT,SUP-2901984,CDM,C1726,HCPCS,0272,RC,,,,both,,,3389.00,2202.85,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA PLU MAXBARR 3FR S1193108D3,SUP-2632794,CDM,C1751,HCPCS,0278,RC,,,,both,,,1127.57,732.92,,,,,,,,,,,,,
ENDOPROSTHESIS VASC EXCLUDER L 7 CM DIA12 MM SHTH L 45 CM,SUP-2395801,CDM,C1768,CPT,0278,RC,,,,both,,,9460.82,6149.53,,,,,,,,,,,,,
GUIDEWIRE ORTH L 220 MM DIA1.6 MM SCREW DIA 4.5/5 MM THRD,SUP-2907902,CDM,C1769,HCPCS,0272,RC,,,,both,,,489.27,318.03,,,,,,,,,,,,,
CATHETER GUID ATTAIN L 45 CM OD 3.3 MM ID 7.2 FR HYDRPHLC,SUP-2282166,CDM,C1887,HCPCS,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
ENDCAP ORTH L0MM DIA2.5MM STRL HUM TI NAIL EXTN HEX RECESS,SUP-2192529,CDM,C1713,HCPCS,0278,RC,,,,both,,,849.59,552.23,,,,,,,,,,,,,
SPINAL IMPLANT KIT SHLDR KNEE STRL ASSISTARM,SUP-2765731,CDM,2720000010,LOCAL,0272,RC,,,,both,,,489.84,318.40,,,,,,,,,,,,,
PLATE BENDING PLIERS 10MM SYSTEM,SUP-2678833,CDM,C1713,HCPCS,0278,RC,,,,both,,,505.92,328.85,,,,,,,,,,,,,
COVER BURR HOLE 17MM DIA 1MM THK RESORB X,SUP-2494600,CDM,C1713,HCPCS,0278,RC,,,,both,,,1014.97,659.73,,,,,,,,,,,,,
K WIRE FIX L150MM DIA1.8MM S STL W/ TRCR PNT,SUP-2184072,CDM,C1713,HCPCS,0278,RC,,,,both,,,21.92,14.25,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY PENTARAY NAV INSRTN 115CM 4-4-4 D,SUP-2485389,CDM,C1732,HCPCS,0272,RC,,,,both,,,5425.92,3526.85,,,,,,,,,,,,,
HC So RBC Pretx Incubatj W/Chemicl,PX-3008697066,CDM,86970,CPT,0300,RC,,,,outpatient,,,183.00,118.95,,,,,,,,,,,,,
ALLOGRAFT DERMAL 2X3 CM DERMAPURE,SUP-2388441,CDM,Q4152,HCPCS,0636,RC,,,,both,,,2543.40,1653.21,,,,,,,,,,,,,
STENT BILI S.M.A.R.T. L 80 MM DIA10 MM GUIDEWIRE 0.018 IN,SUP-2158897,CDM,C1876,HCPCS,0278,RC,,,,both,,,4509.04,2930.88,,,,,,,,,,,,,
VALVE AORT CARP EDW PERIMT DIA19 MM BOV PERICARD COCR,SUP-2214053,CDM,C1889,HCPCS,0278,RC,,,,both,,,16328.00,10613.20,,,,,,,,,,,,,
PROBE NERVE STIM DIA2.3 MM MONOPOLAR BALL TIP STRL DISP,SUP-2901988,CDM,2720000010,LOCAL,0272,RC,,,,both,,,380.07,247.05,,,,,,,,,,,,,
GRAFT BNE SPACER 8 DEG LG 12 MM FOR ALIF STRL LF DISP,SUP-2632278,CDM,C1713,HCPCS,0278,RC,,,,both,,,8504.63,5528.01,,,,,,,,,,,,,
"HC So2 Immunoassay,Analyte,Nos",PX-3018352068,CDM,83520,CPT,0301,RC,,,,outpatient,,,496.00,322.40,,,,,,,,,,,,,
KIT PROS MALL SPECTR,SUP-2139043,CDM,C2622,HCPCS,0278,RC,,,,both,,,15709.42,10211.12,,,,,,,,,,,,,
ROD EXT FIX 4X160 MM,SUP-2187109,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2364.99,1537.24,,,,,,,,,,,,,
STEM FEM SZ 8 STD HIP CLLRLSS MOD ENTRADA,SUP-2315476,CDM,C1776,CPT,0278,RC,,,,both,,,10738.80,6980.22,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED CERM ON CERM CHIPZIMCERCER] ZIMMER BIOMET INC],SUP-2212520,CDM,C1776,CPT,0278,RC,,,,both,,,21022.30,13664.49,,,,,,,,,,,,,
PLATE BNE THK0.6MM BAR L8MM 5 H STD G MID FACE TI Y LO PROF,SUP-2366251,CDM,C1713,HCPCS,0278,RC,,,,both,,,567.65,368.97,,,,,,,,,,,,,
GRASPER ENDOSCP ALLIGATOR 15 DEG 3.4 MM HK JAW WISHBONE,SUP-2849251,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3124.30,2030.79,,,,,,,,,,,,,
DEFIBRILLATOR CRD 40 J 4X7.3X1.4 CM 36 CC 77 CC UNIFY,SUP-2356314,CDM,C1882,HCPCS,0275,RC,,,,both,,,89490.00,58168.50,,,,,,,,,,,,,
VALVE CSF FLO BURR HOLE 16 MM CTRL LO PRESSURE DELT,SUP-2665089,CDM,C1889,HCPCS,0278,RC,,,,both,,,2084.65,1355.02,,,,,,,,,,,,,
CANNULA 25GA MAINTAINER CHAMBER,SUP-2854487,CDM,2720000010,LOCAL,0272,RC,,,,both,,,35.48,23.06,,,,,,,,,,,,,
WASHER ORTH DIA3.5MM CORT DST FIBULAR EL LO PROF FOR FRAC,SUP-2411678,CDM,C1713,HCPCS,0278,RC,,,,both,,,182.75,118.79,,,,,,,,,,,,,
VALVE CSF MINI,SUP-2666620,CDM,C1889,HCPCS,0278,RC,,,,both,,,9341.47,6071.96,,,,,,,,,,,,,
NATRELLE INSPIRA SCF 200CC BREAST IMPLANT,SUP-2669558,CDM,C1769,HCPCS,0278,RC,,,,both,,,4129.10,2683.91,,,,,,,,,,,,,
CATHETER VENTRICULAR 23 CM RT ANGLE CLP INTEGR PLUG IMPREG,SUP-2628450,CDM,C1729,HCPCS,0272,RC,,,,both,,,381.57,248.02,,,,,,,,,,,,,
CATHETER BLLN DIL FIX WIRE 7-8-9-10-11 MM 8 CM ELATION 5,SUP-2468470,CDM,C1726,HCPCS,0272,RC,,,,both,,,690.80,449.02,,,,,,,,,,,,,
GUIDE NAVIGATION DT NAVIGATED INFIN,SUP-2293671,CDM,C1713,HCPCS,0278,RC,,,,both,,,12372.89,8042.38,,,,,,,,,,,,,
PLATE BNE L 2.7 MM LT 2X3 HOLE SS NS,SUP-2186365,CDM,C1713,HCPCS,0278,RC,,,,both,,,1274.84,828.65,,,,,,,,,,,,,
PROBE BRST BX 12 GA BLU ELEVATION,SUP-2624837,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
SYSTEM MENIS REP W/ 12DEG ORTHOCORD VLT BRAID COMP 2-0 SUT,SUP-2249481,CDM,C1713,HCPCS,0278,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
PLATE BONE THK1.8MM 10 H STRNL BODY TI LCK,SUP-2262574,CDM,C1713,HCPCS,0278,RC,,,,both,,,1985.99,1290.89,,,,,,,,,,,,,
HC N Block Inj Suprascapular Nerv,PX-3606441800,CDM,64418,CPT,0360,RC,,,,both,,,2230.00,1449.50,,,,,,,,,,,,,
ADAPTER OTOLARYN DIA4.5MM ABUTMENT DIA6MM 3MM W PREMOUNTED,SUP-2319915,CDM,L8690,HCPCS,0278,RC,,,,both,,,9982.06,6488.34,,,,,,,,,,,,,
HC Treat Finger Fx Each,PX-4502672000,CDM,26720,CPT,0450,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
OSTEOTOME SURG L2413MM DIA64MM STR HIBBS,SUP-2198748,CDM,2720000010,LOCAL,0272,RC,,,,both,,,465.72,302.72,,,,,,,,,,,,,
STEM ULN L50MM DIA7.5MM STD E-CENTRIX,SUP-2398596,CDM,C1776,CPT,0278,RC,,,,both,,,3604.41,2342.87,,,,,,,,,,,,,
KIT CATH HEMODIALYSI RELIANCE XK CHRONIC EXCHANGE 16FR DIA 5,SUP-2613288,CDM,C1750,HCPCS,0278,RC,,,,both,,,1417.71,921.51,,,,,,,,,,,,,
IMPLANT PTERIONAL W43XL44MM L SMOOTH,SUP-2365257,CDM,C1889,HCPCS,0278,RC,,,,both,,,7112.10,4622.86,,,,,,,,,,,,,
SUPPORT ANK UNIV LG PLAS,SUP-2330385,CDM,L4350,HCPCS,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
SUPPORT ORTHOT CUST LEGG PERTHES ORTHOSIS SCOTTISH R,SUP-2435605,CDM,L1730,HCPCS,0272,RC,,,,both,,,3525.84,2291.80,,,,,,,,,,,,,
STAPLE BNE FIX BRIDGE L 25 X 20 X W 5 MM ULTRA NIT LP STRL,SUP-2897132,CDM,C1713,HCPCS,0278,RC,,,,both,,,5020.86,3263.56,,,,,,,,,,,,,
CATHETER DIAG SHFT L70CM DIA5FR 0.035IN SEG 2CM PLAT BND,SUP-2118525,CDM,C1887,HCPCS,0272,RC,,,,both,,,74.70,48.55,,,,,,,,,,,,,
SCREW BONE L35MM DIA4MM CORT DSTL LCK FULL THRD FOR 7MM,SUP-2318930,CDM,C1713,HCPCS,0278,RC,,,,both,,,610.67,396.94,,,,,,,,,,,,,
CATHETER HD LNG TERM ACCS CANNON II +,SUP-2383987,CDM,C1881,HCPCS,0278,RC,,,,both,,,1096.39,712.65,,,,,,,,,,,,,
SODIUM HYALURONATE (VISCOSUP) 20 MG/2ML IX SOSY,RX-127431,CDM,J7323,HCPCS,0636,RC,55566-4100-01,NDC,,both,2,ML,1063.90,691.53,,,,,,,,,,,,,
DRESSING WND MICRONIZED PARTIC 60 MG MICROMATRIX,SUP-2106470,CDM,Q4118,HCPCS,0636,RC,,,,both,,,716.67,465.84,,,,,,,,,,,,,
BIT DRL DIA4.3MM LNG FOR VALOR HINDFOOT FUS SYS,SUP-2397590,CDM,2720000010,LOCAL,0272,RC,,,,both,,,568.34,369.42,,,,,,,,,,,,,
SHAVER SURG 10MM W/ SIDE CUT IO-FLEX MICROBLADE,SUP-2115832,CDM,C1713,HCPCS,0278,RC,,,,both,,,4006.64,2604.32,,,,,,,,,,,,,
"HC So1 Immunoassay,Analyte,Nos",PX-3018352067,CDM,83520,CPT,0301,RC,,,,both,,,366.00,237.90,,,,,,,,,,,,,
SHEATH URET ACC 14FR L35CM HYDRPHLC FOR ESTABLISH A CONDUIT,SUP-2169834,CDM,C1894,HCPCS,0272,RC,,,,both,,,644.01,418.61,,,,,,,,,,,,,
HC Ot Ther Ex per 15 Min|OP OCCUPATIONAL THERAPY SERV|SERVICES PROVIDED IN WHOLE OR IN PARTY BY AN OTA FOR MEDICARE PATIENTS|DOCUMENTATION ON FILE,PX-4309711000,CDM,97110,CPT,0430,RC,,,GO|CO|KX,both,,,195.00,126.75,,,,,,,,,,,,,
BIT DRILL QUICK COUPLING 2.7X100/125 MM STERILE TC100 DISPOS,SUP-2837031,CDM,2720000010,LOCAL,0272,RC,,,,both,,,895.47,582.06,,,,,,,,,,,,,
TUBE VENT ID114MM S STL W O WIRE REUT BOB STYL,SUP-2313687,CDM,L8699,HCPCS,0278,RC,,,,both,,,95.71,62.21,,,,,,,,,,,,,
PUSHER SURG L195CM TAPR 50CM COIL TRUPUSH,SUP-2158114,CDM,C1769,HCPCS,0272,RC,,,,both,,,1877.09,1220.11,,,,,,,,,,,,,
COMPONENT FEM L8CM RT DSTL KNEE FINN STYL SEG IMP,SUP-2406045,CDM,C1776,CPT,0278,RC,,,,both,,,16494.42,10721.37,,,,,,,,,,,,,
PLATE BNE STR MINI REG 2 MM RT ORBIT 14 HOLE TI LEVEL 1,SUP-2473951,CDM,C1713,HCPCS,0278,RC,,,,both,,,795.83,517.29,,,,,,,,,,,,,
BIT DRILL SCALED AO 25X450MM,SUP-2695997,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1301.22,845.79,,,,,,,,,,,,,
SPACER RAD THER SPACEOAR VUE,SUP-2421823,CDM,C1889,HCPCS,0278,RC,,,,both,,,11304.00,7347.60,,,,,,,,,,,,,
LEAD TRL L50CM SPNL CRD PERC W ENH STYL IMAG RDY MRI FULL,SUP-2436546,CDM,C1778,HCPCS,0278,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
PLATE BONE L18MM 6 H TI NAR HYBRID COMPR FOR 4.5MM SCR ALPS,SUP-2413743,CDM,C1713,HCPCS,0278,RC,,,,both,,,811.97,527.78,,,,,,,,,,,,,
HYDROXYZINE PAMOATE 25 MG PO CAPS,RX-3777,CDM,6370000000,HCPCS,0637,RC,00904-7065-61,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
TRAB METAL FEMORAL CONE AGMT SMALL 50MM LEFT,SUP-2502237,CDM,C1776,CPT,0278,RC,,,,both,,,11618.00,7551.70,,,,,,,,,,,,,
PLATE BNE L 172 MM 6 H SCREW DIA 4.5 MM LT PROX FEM LG FRAG,SUP-2931368,CDM,C1713,HCPCS,0278,RC,,,,both,,,9679.84,6291.90,,,,,,,,,,,,,
LENS INTOCU +24.00 DIOPT L13MM DIA6MM HAPTIC REFRACTIVE,SUP-2129529,CDM,V2632,HCPCS,0276,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
HC Intmd Wnd Repair N-Hg/Gen,PX-4501204700,CDM,12047,CPT,0450,RC,,,,both,,,6021.00,3913.65,,,,,,,,,,,,,
NEEDLE ENDOSCP INJ 16 GA 55 16 MMX43 CM LL PUNC,SUP-2767362,CDM,2720000010,LOCAL,0272,RC,,,,both,,,675.19,438.87,,,,,,,,,,,,,
PLATE BNE L 56 MM 4 H SS RT DSTL RADIAL VOLAR STD STRL EVOS,SUP-2931336,CDM,C1713,HCPCS,0278,RC,,,,both,,,3144.08,2043.65,,,,,,,,,,,,,
HUMERAL HEAD CTA 54X23,SUP-2815448,CDM,C1776,CPT,0278,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
STENT URET SILHOUETTE COMFORT L 26 CM DIA 4.6 FR NIT SYNTH,SUP-2119484,CDM,C2617,HCPCS,0278,RC,,,,both,,,391.12,254.23,,,,,,,,,,,,,
PLATE BNE W6.3XL40MM THK1.6MM 3X3 H R DST RAD VOLAR S STL T,SUP-2186099,CDM,C1713,HCPCS,0278,RC,,,,both,,,1694.56,1101.46,,,,,,,,,,,,,
STAPLER ECHELON 3000 45MM COMPACT,SUP-2858744,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1227.61,797.95,,,,,,,,,,,,,
PLATE CRAN THK 0.5 MM SCREW DIA1.7 MM 4 H PLLA PDLA PGA STR,SUP-2883500,CDM,C1713,HCPCS,0278,RC,,,,both,,,1279.11,831.42,,,,,,,,,,,,,
GRAFT VASC FLX 7-4 MMX70 CM TW TAPR SM BEAD EPTFE CARBOFLO,SUP-2761493,CDM,C1768,CPT,0278,RC,,,,both,,,4308.39,2800.45,,,,,,,,,,,,,
SCREW BONE SELFTAPPING 2.7X36 MM CANCELLOUS FULLY THREADED H,SUP-2836896,CDM,C1713,HCPCS,0278,RC,,,,both,,,85.28,55.43,,,,,,,,,,,,,
SET INTRO FLX BLKN L 55 CM OD 7 FR CKFLO VLV STRL,SUP-2168572,CDM,C1894,HCPCS,0272,RC,,,,both,,,212.67,138.24,,,,,,,,,,,,,
BLADE RTRCTR CHRNLEY SHRT 1INW X 2 3/8NL X 4IND F/INTL INCSN,SUP-2497092,CDM,2720000010,LOCAL,0272,RC,,,,both,,,389.17,252.96,,,,,,,,,,,,,
GRAFT BNE FN 1-4 MM 90 CC FRZN CANC,SUP-2766764,CDM,C1713,HCPCS,0278,RC,,,,both,,,5445.70,3539.70,,,,,,,,,,,,,
DENOSUMAB-BBDZ 60 MG/ML SC SOSY,RX-172038,CDM,Q5136,HCPCS,0636,RC,61314-0240-63,NDC,,both,1,ML,4732.20,3075.93,,,,,,,,,,,,,
LIDOCAINE-EPINEPHRINE 1 %-1:100000 IJ SOLN,RX-10427,CDM,J2004,HCPCS,0636,RC,63323-0482-01,NDC,,both,20,ML,54.10,35.16,,,,,,,,,,,,,
SET VASC SNR MULTI-SNARE L 125 CM DIA10 MM INTRO L 105 CM,SUP-2125281,CDM,C1773,HCPCS,0272,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
CYCLOPHOSPHAMIDE 500 MG IJ SOLR|DISCARDED DRUG NOT ADMINISTE,RX-38271,CDM,J9076,HCPCS,0636,RC,10019-0955-01,NDC,JW,both,1,UN,358.10,232.76,,,,,,,,,,,,,
PUMP INFUS 100ML 2ML/HR W/ STD CATH PAINPMP,SUP-2361460,CDM,E0783,HCPCS,0278,RC,,,,both,,,276.32,179.61,,,,,,,,,,,,,
TUBE EXT FIX SEMI CIR CRV 85% RADLUC HOFFMANN XPRESS,SUP-2465634,CDM,2720000010,LOCAL,0272,RC,,,,both,,,675.10,438.81,,,,,,,,,,,,,
PLATE BNE NAR 4.5X167 MM 10 HOLE SS DCP,SUP-2569168,CDM,C1713,HCPCS,0278,RC,,,,both,,,324.68,211.04,,,,,,,,,,,,,
PLATE BNE L 1.5X0.6 MM 10 MM MIDFACE 3X3 HOLE W/ TAB TI NS,SUP-2497480,CDM,C1713,HCPCS,0278,RC,,,,both,,,876.28,569.58,,,,,,,,,,,,,
STEM FEM TAPR 12/14 UNCEMENTED TI ALLOY SM MAYO,SUP-2203725,CDM,C1776,CPT,0278,RC,,,,both,,,15532.01,10095.81,,,,,,,,,,,,,
CAGE SPNL L16XW16XH10MM 4 LOBE MESH ANAT FOOTPRINT MOD IMP,SUP-2317741,CDM,C1889,HCPCS,0278,RC,,,,both,,,6154.40,4000.36,,,,,,,,,,,,,
LIDOCAINE-EPINEPHRINE 1 %-1:100000 IJ SOLN,RX-10427,CDM,J2004,HCPCS,0636,RC,00409-3178-02,NDC,,both,20,ML,54.10,35.16,,,,,,,,,,,,,
STEM HUM L120MM DIA8MM UNIV DST SHLDR TI PRI REV CEM FOR UP,SUP-2372851,CDM,C1776,CPT,0278,RC,,,,both,,,8535.27,5547.93,,,,,,,,,,,,,
IMMOBILIZER SHLDR XL L20IN D10IN UNIV POLY COT W/ FOAM STRP,SUP-2196946,CDM,L3650,HCPCS,0274,RC,,,,both,,,24.21,15.74,,,,,,,,,,,,,
CATHETER PTCA L142CM BLLN L10MM DIA3MM COR MRAIL CUT,SUP-2146975,CDM,C1725,HCPCS,0272,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
IMMOBILIZER SHLDR XL L20IN D10IN UNIV POLY COT W/ FOAM STRP,SUP-2196946,CDM,L3650,HCPCS,0272,RC,,,,both,,,24.21,15.74,,,,,,,,,,,,,
CATHETER GUID CXI L 150 CM DIA 2.3 FR 0.014 IN SS ANGLED TIP,SUP-2168962,CDM,C1887,HCPCS,0272,RC,,,,both,,,659.37,428.59,,,,,,,,,,,,,
SCREW BNE SET 3 MM CANN 1/2 THRD EXT TAB,SUP-2861019,CDM,C1713,HCPCS,0278,RC,,,,both,,,22354.79,14530.61,,,,,,,,,,,,,
SCREW BNE ST 2X12 MM CRTX COARSE PITCH TI NS LF,SUP-2189672,CDM,C1713,HCPCS,0278,RC,,,,both,,,248.37,161.44,,,,,,,,,,,,,
SHEATH UROLOGICAL AMPLTZ L 16 CM DIL L 30 CM DIA18 FR RENAL,SUP-2835771,CDM,C1894,HCPCS,0272,RC,,,,both,,,122.99,79.94,,,,,,,,,,,,,
CLIP ANEUR CO CHROM ALLOY SLGHT BENT STD TYP 1/1MM OPN W,SUP-2306030,CDM,C1889,HCPCS,0278,RC,,,,both,,,722.20,469.43,,,,,,,,,,,,,
BLADE SHV PED L11CM DIA4MM 40DEG 1500RPM CRV FOR,SUP-2284148,CDM,2720000010,LOCAL,0272,RC,,,,both,,,646.59,420.28,,,,,,,,,,,,,
ANCHOR SUT TI WDG 5MM W TWO STRANDS OF FORCEFIBER,SUP-2362550,CDM,C1713,HCPCS,0278,RC,,,,both,,,737.02,479.06,,,,,,,,,,,,,
DEVICE TISS FIX FIBERTAG TIGHTROPE II,SUP-2903959,CDM,C1713,HCPCS,0278,RC,,,,both,,,1868.30,1214.39,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL PEEK SD800.555,SUP-2860236,CDM,C1713,HCPCS,0278,RC,,,,both,,,23802.14,15471.39,,,,,,,,,,,,,
RETRIEVER SUT 15DEG SELF RATCHETING MECHANISM PENETRATOR,SUP-2121651,CDM,C1713,HCPCS,0278,RC,,,,both,,,3611.00,2347.15,,,,,,,,,,,,,
SPLINT ORTHOT M L LIMB REST HND FNGR WRST WIRE FOAM FRME,SUP-2194508,CDM,L3807,HCPCS,0274,RC,,,,both,,,111.53,72.49,,,,,,,,,,,,,
GRAFT HUM TISS,SUP-2213682,CDM,V2785,HCPCS,0810,RC,,,,both,,,15700.00,10205.00,,,,,,,,,,,,,
SCREW BNE 34 MM FA4634] ACUMED LLC],SUP-2107618,CDM,C1713,HCPCS,0278,RC,,,,both,,,524.38,340.85,,,,,,,,,,,,,
TRASTUZUMAB-PKRB 420 MG IV SOLR,RX-149770,CDM,Q5113,HCPCS,0636,RC,63459-0305-47,NDC,,both,1,UN,8795.90,5717.33,,,,,,,,,,,,,
MICROCATHETER GUID TREVO PRO 18 L 157 CM PROX/DSTL OD,SUP-2367795,CDM,C1725,HCPCS,0272,RC,,,,both,,,2195.49,1427.07,,,,,,,,,,,,,
GRAFT HUM TISS W27-32XH11XL21-26MM 8DEG FRZN ANTR LUM INTBDY,SUP-2177053,CDM,C1713,HCPCS,0278,RC,,,,both,,,9420.00,6123.00,,,,,,,,,,,,,
ANCHOR SUT W/ ORTHOCORD KNOTLESS FOR ROT CUF REP VERSALOK,SUP-2249331,CDM,C1713,HCPCS,0278,RC,,,,both,,,2750.64,1787.92,,,,,,,,,,,,,
INTRODUCER DIAG PEEL-APART L 13 CM DIA 7 FR PTFE PERC LNG T,SUP-2127716,CDM,C1894,HCPCS,0272,RC,,,,both,,,239.86,155.91,,,,,,,,,,,,,
SHOE ORTHOT CUST SLD STIRRUP TRANSFER NEW,SUP-2435748,CDM,L3630,HCPCS,0274,RC,,,,both,,,284.45,184.89,,,,,,,,,,,,,
GRAFT HUM TISS W1.5XL1.5CM AMNIO MEMBRN ALLGRFT FULL RESRB,SUP-2194316,CDM,Q4137,HCPCS,0636,RC,,,,both,,,2037.86,1324.61,,,,,,,,,,,,,
CATHETER INFUS L100CM DIA5FR INFUS L10CM 0.035IN 1 LUMN VLV,SUP-2172522,CDM,C1751,HCPCS,0278,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
SUPPORT ORTHOT ANK KNEE CUST SINGLE FREE MOLD PLAS,SUP-2435638,CDM,L2037,HCPCS,0272,RC,,,,both,,,4694.99,3051.74,,,,,,,,,,,,,
HOOK SPNL PEDCL LG 5.5 MM,SUP-2175457,CDM,C1713,HCPCS,0278,RC,,,,both,,,3281.30,2132.84,,,,,,,,,,,,,
ADAPTER TI LCK 2 PC,SUP-2130777,CDM,C1713,HCPCS,0278,RC,,,,both,,,673.66,437.88,,,,,,,,,,,,,
GRAFT VASC HEMSHLD PLAT L 40 CM DIA20 X 11 MM POLYESTER BOV,SUP-2694286,CDM,C1768,CPT,0278,RC,,,,both,,,2582.21,1678.44,,,,,,,,,,,,,
CEMENT BNE 20GM HALF DOSE RADPQ ST VERTAPLEX,SUP-2366943,CDM,C1713,HCPCS,0278,RC,,,,both,,,1154.08,750.15,,,,,,,,,,,,,
PLATE BNE L26MM THK1MM NONSTERILE R PHLANG HD HND TI LOK VAR,SUP-2181008,CDM,C1713,HCPCS,0278,RC,,,,both,,,1471.59,956.53,,,,,,,,,,,,,
PRIMIDONE 250 MG PO TABS,RX-6544,CDM,6370000000,HCPCS,0637,RC,68084-0203-11,NDC,,both,1,UN,4.00,2.60,,,,,,,,,,,,,
CASPOFUNGIN ACETATE 70 MG IV SOLR,RX-29568,CDM,J0637,HCPCS,0636,RC,25021-0195-10,NDC,,both,1,UN,454.30,295.29,,,,,,,,,,,,,
WASHER ORTH PIN CONN FOR SIDEKCK STLTH REARFOOT FIX,SUP-2400620,CDM,C1713,HCPCS,0278,RC,,,,both,,,222.94,144.91,,,,,,,,,,,,,
ANCHOR SUT NO 2 SUT TI DURABRAID W/ 38IN USPNO 2.8MM DIA,SUP-2341044,CDM,C1713,HCPCS,0278,RC,,,,both,,,778.72,506.17,,,,,,,,,,,,,
PLATE BNE L370MM BLDE W48XL25MM 95DEG 22 H ST HIP S STL RIG,SUP-2186776,CDM,C1713,HCPCS,0278,RC,,,,both,,,4975.68,3234.19,,,,,,,,,,,,,
SLEEVE TIB L9CM TI POR PROX KNEE REDUC SZ OSS MARTI VIERZON,SUP-2406489,CDM,C1776,CPT,0278,RC,,,,both,,,17945.10,11664.31,,,,,,,,,,,,,
PIN EXT FIX HALF LNG 5X180 MM 35 MM THRD TIN SIDEKCK FRDM,SUP-2460889,CDM,2720000010,LOCAL,0272,RC,,,,both,,,335.98,218.39,,,,,,,,,,,,,
SPECULUM VAG L12IN BLDE L3 15 16XW1IN MIR AND SATIN FINISH,SUP-2160546,CDM,2720000010,LOCAL,0272,RC,,,,both,,,760.13,494.08,,,,,,,,,,,,,
SET ORTH GWIRE DRL BIT FOR CARPOMETACARPAL LIGMNT RECON,SUP-2121450,CDM,C1713,HCPCS,0278,RC,,,,both,,,1868.30,1214.39,,,,,,,,,,,,,
HEAD HUM DIA45MM THK15MM SHLDR CO CHROM PRI STD OFFSET NK 53504515] STRYKER ORTHOPEDICS HOWM],SUP-2372836,CDM,C1776,CPT,0278,RC,,,,both,,,4645.94,3019.86,,,,,,,,,,,,,
CLINIMIX E/DEXTROSE (5/20) 5 % IV SOLN,RX-23214,CDM,2500000003,HCPCS,0250,RC,00338-1125-04,NDC,,both,2000,ML,506.00,328.90,,,,,,,,,,,,,
HC Catheterize for Urine Spec,PX-4500961200,CDM,P9612,CPT,0450,RC,,,,inpatient,,,76.00,49.40,,,,,,,,,,,,,
PLATE BNE L127MM 13 H L MED DST HUM TIM LO PROF ALPS,SUP-2411736,CDM,C1713,HCPCS,0278,RC,,,,both,,,4259.72,2768.82,,,,,,,,,,,,,
ASPIRIN 16.2 MG/ML PO SUSP (FOR DESENSITIZATION),RX-4081285,CDM,6370000000,HCPCS,0637,RC,09999-9909-83,NDC,,both,0.6172839506172839506,ML,2.70,1.75,,,,,,,,,,,,,
BIT DRL 2.7 MM,SUP-2365029,CDM,2720000010,LOCAL,0272,RC,,,,both,,,514.33,334.31,,,,,,,,,,,,,
CATHETER DRAINAGE PIG 8.5 FRX25 CM BILI SET 6 HOLE UTHANE,SUP-2168130,CDM,C1729,HCPCS,0272,RC,,,,both,,,272.33,177.01,,,,,,,,,,,,,
NEEDLE MRK L30CM OD17GA STD SFT TISS STRL,SUP-2164650,CDM,A4648,CPT,0278,RC,,,,both,,,248.06,161.24,,,,,,,,,,,,,
PLATE BNE LCK 2.7X95 MM 8 HOLE CNTOUR 2 COMPR SS STRL,SUP-2493379,CDM,C1713,HCPCS,0278,RC,,,,both,,,962.50,625.62,,,,,,,,,,,,,
SCREW SPNL L32MM DIA3.5MM MINI CANC POST OCCIPITAL CERV THOR,SUP-2254411,CDM,C1713,HCPCS,0278,RC,,,,both,,,3121.16,2028.75,,,,,,,,,,,,,
WASHER ORTH TI DOME FOR 7MM SCR MONSTER,SUP-2320329,CDM,C1713,HCPCS,0278,RC,,,,both,,,626.43,407.18,,,,,,,,,,,,,
STENT BILI XPERT L 60 MM DIA 6 MM DEL SYS L 120 CM INTRO 5,SUP-2105871,CDM,C1876,HCPCS,0278,RC,,,,both,,,5024.00,3265.60,,,,,,,,,,,,,
STAPLE INT FIX W20XL20MM THK2.5X1.6MM ANK FT SUP E EASYCLIP,SUP-2378848,CDM,C1713,HCPCS,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
BASKET RETRV 1.9 FR NIT,SUP-2540077,CDM,2720000010,LOCAL,0272,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
PLATE BONE L35MM THK1MM 2X5 H BILAT HND Y SHP LCK TRILOK FOR,SUP-2267925,CDM,C1713,HCPCS,0278,RC,,,,both,,,2004.26,1302.77,,,,,,,,,,,,,
SHEATH INTRO L28CM DIA20FR POLYETH HYDRPHLC W/O CRV HEMSTAT,SUP-2396258,CDM,C1894,HCPCS,0272,RC,,,,both,,,926.30,602.09,,,,,,,,,,,,,
HC ED Rmvl Foreign Body Pharynx,PX-4504280900,CDM,42809,CPT,0450,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
SCREW INTRF 7X30 MM 1 MM GUIDEWIRE STRL CANNFLX SILK LTX,SUP-2876928,CDM,C1713,HCPCS,0278,RC,,,,both,,,540.71,351.46,,,,,,,,,,,,,
BLADE RTRCTR SHRT TEETH 15MMW X 25MML SPNL SELF RTNNG BLACK,SUP-2668375,CDM,2720000010,LOCAL,0272,RC,,,,both,,,773.95,503.07,,,,,,,,,,,,,
HC Red Blood Cells Each Unit,PX-3900902100,CDM,P9021,CPT,0390,RC,,,,outpatient,,,1275.00,828.75,,,,,,,,,,,,,
BOLT EXT FIX S STL RUS WIRE FOR ILIZ TAY SPAT FRME EXT FIX,SUP-2342844,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1538.13,999.78,,,,,,,,,,,,,
BLOCK CUT PROX TIB KNEE GUID VISIONAIRE GEN II,SUP-2351432,CDM,C1713,HCPCS,0278,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
CATHETER DRNGE L40CM OD8FR TOT ABSCESSION BILI,SUP-2118567,CDM,C1729,HCPCS,0272,RC,,,,both,,,237.70,154.50,,,,,,,,,,,,,
PASSER SUT SELF CAPTURE ROT CUF REP REUSE COBRA,SUP-2362568,CDM,2720000010,LOCAL,0272,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 220 MM DIA15 MM DEL SHTH 40ML,SUP-2937083,CDM,C1713,HCPCS,0278,RC,,,,both,,,14789.40,9613.11,,,,,,,,,,,,,
CROWN DENT 5 SEC PERM M LO LT S STL UNITEK,SUP-2238851,CDM,D6783,CPT,0278,RC,,,,both,,,122.27,79.48,,,,,,,,,,,,,
TIP RASP DIA8MM FN FOR SUCT TBNG FEATHERTOUCH,SUP-2284176,CDM,C1713,HCPCS,0278,RC,,,,both,,,899.30,584.54,,,,,,,,,,,,,
GRAFT VASC L40CM DIA8MM PTFE CBAS HEP SURF THN WALLED REM,SUP-2395822,CDM,C1768,CPT,0278,RC,,,,both,,,4540.44,2951.29,,,,,,,,,,,,,
GRAFT DERMAL PLIABLE THN LG 22X13 CMX0.7-1.4 MM BRST FLEXHD,SUP-2307607,CDM,C1768,CPT,0278,RC,,,,both,,,27813.49,18078.77,,,,,,,,,,,,,
NEBULIZER RESP C6ML SM VOL INHAL AD W/ MOUTHPC O2 TBNG,SUP-2227412,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2273.83,1477.99,,,,,,,,,,,,,
HEYMAN FOLLOWERS STR TIP COMPLT SET (10-24FR.),SUP-2128929,CDM,C1726,HCPCS,0272,RC,,,,both,,,62.80,40.82,,,,,,,,,,,,,
SCREW BNE CORTICAL 1.5X11 MM 3 MM ST SS NS,SUP-2459129,CDM,C1713,HCPCS,0278,RC,,,,both,,,182.43,118.58,,,,,,,,,,,,,
PLATE BNE THK1.5MM 6 H CRANIOMAXILLOFACIAL G FRAC UNIV 2,SUP-2366364,CDM,C1713,HCPCS,0278,RC,,,,both,,,1351.99,878.79,,,,,,,,,,,,,
CATHETER ANGIOPLSTY L120CM L150MM ODSEC5MM .035IN PERIPH OVR,SUP-2141205,CDM,C1725,HCPCS,0272,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
SAW SURG RECIP DEDICATED HND OP LCK BLADE CLLT KLS VAR SPD T,SUP-2605725,CDM,2720000010,LOCAL,0272,RC,,,,both,,,14329.33,9314.06,,,,,,,,,,,,,
NORETHINDRONE ACETATE 5 MG PO TABS,RX-10747,CDM,6370000000,HCPCS,0637,RC,68462-0304-50,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
GUIDEWIRE VASC EMERALD L 150 CM DIA 0.038 IN FLX TIP L 3 CM,SUP-2157323,CDM,C1769,HCPCS,0272,RC,,,,both,,,17.27,11.23,,,,,,,,,,,,,
CAP ENDOSCP SEAL H2O RESIST FOR GIF-H180,SUP-2472706,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1047.38,680.80,,,,,,,,,,,,,
HYDROMORPHONE HCL 0.2 MG/ML IV SOLN,RX-151804,CDM,J1171,HCPCS,0636,RC,71266-5035-01,NDC,,both,100,ML,177.10,115.11,,,,,,,,,,,,,
CATHETER URET 5FR TIP 14FR L70CM UNIV WDG FOR RG PYELOGRAM,SUP-2171185,CDM,C1758,HCPCS,0278,RC,,,,both,,,39.91,25.94,,,,,,,,,,,,,
CUP ACET OD52MM ID46MM CO CHROM HIP HMSPHR PRI PRSS FIT LO,SUP-2304483,CDM,C1776,CPT,0278,RC,,,,both,,,5809.00,3775.85,,,,,,,,,,,,,
NEEDLE 45DEG R ORTH SLDE,SUP-2366699,CDM,2720000010,LOCAL,0272,RC,,,,both,,,880.61,572.40,,,,,,,,,,,,,
SCREW BNE L16MM DIA13MM G CORT TI ALLY ST SELF RET W T4,SUP-2180970,CDM,C1713,HCPCS,0278,RC,,,,both,,,117.72,76.52,,,,,,,,,,,,,
HC Basic Metabolic Panel Calcium Total,PX-3018004800,CDM,80048,CPT,0301,RC,,,,both,,,330.00,214.50,,,,,,,,,,,,,
MANUAL STONE BSKT INSTR,SUP-2312880,CDM,2720000010,LOCAL,0272,RC,,,,both,,,587.18,381.67,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 10.5X92 MM TEND FLEXIGRAFT GRAFTLINK TS,SUP-2845893,CDM,C1762,CPT,0278,RC,,,,both,,,7815.46,5080.05,,,,,,,,,,,,,
SHOE ORTHOT ADDITION SPEC EXTN INSTEP LTHR,SUP-2435741,CDM,L3570,HCPCS,0274,RC,,,,both,,,241.31,156.85,,,,,,,,,,,,,
PACK IMPL SM DIA3.8MM INCLUDE PROX DSTL SCR TAPR LCK PIN,SUP-2123608,CDM,C1713,HCPCS,0278,RC,,,,both,,,5617.46,3651.35,,,,,,,,,,,,,
INTRODUCER PACE LD L 60 CM DIA 8 FR PEELABLE FOR TRNSVEN,SUP-2282112,CDM,C1894,HCPCS,0272,RC,,,,both,,,179.95,116.97,,,,,,,,,,,,,
AMITRIPTYLINE HCL 25 MG PO TABS,RX-435,CDM,6370000000,HCPCS,0637,RC,00904-7410-61,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
STEM FEM SEG 1.5 CM DPHSEAL KNEE OSS 161078,SUP-2441794,CDM,C1776,CPT,0278,RC,,,,both,,,15288.66,9937.63,,,,,,,,,,,,,
DRILL TWST L61MM DIA2.6MM STP 10MM AO QUIK CPL SHFT END,SUP-2267865,CDM,2720000010,LOCAL,0272,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
SHOE ORTHOT ADDITION SPEC EXTN INSTEP LTHR,SUP-2435741,CDM,L3570,HCPCS,0272,RC,,,,both,,,241.31,156.85,,,,,,,,,,,,,
SCREW BNE PERIARTICULAR 6.5X115 MM CANC FT HD HEX NS LTX,SUP-2861327,CDM,C1713,HCPCS,0278,RC,,,,both,,,232.86,151.36,,,,,,,,,,,,,
SYSTEM DRAINAGE INTRAVENTRICULAR CATH,SUP-2666768,CDM,C1729,HCPCS,0272,RC,,,,both,,,391.43,254.43,,,,,,,,,,,,,
CATHETER ABLATN SM CRV 7 FR,SUP-2141287,CDM,C1733,HCPCS,0272,RC,,,,both,,,2540.26,1651.17,,,,,,,,,,,,,
COMPONENT TIB MOD NEUT LG 75 MM KNEE ENDO-MODEL SL,SUP-2423701,CDM,C1776,CPT,0278,RC,,,,both,,,13453.39,8744.70,,,,,,,,,,,,,
CATHETER PRSS MON 4FR L12CM TIP 2MM 0.021IN STR J TIP W/ NDL,SUP-2167820,CDM,C1751,HCPCS,0278,RC,,,,both,,,106.79,69.41,,,,,,,,,,,,,
SUPPORT ANK ACHILLIES INVISION,SUP-2473835,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1535.46,998.05,,,,,,,,,,,,,
KIT CATH AD L36CM DIA14.5FR 1.6ML SIL DBL LUMN CVD SYMMETRIC,SUP-2174230,CDM,C1750,HCPCS,0278,RC,,,,both,,,1700.37,1105.24,,,,,,,,,,,,,
SPLINT RNG PIP FLX EXTN FNGR 3/4IN SM,SUP-2324608,CDM,L3808,HCPCS,0274,RC,,,,both,,,45.81,29.78,,,,,,,,,,,,,
MINI CMPRSSN PLATE STRGHT 6 HOLE 20MM CP TTNM,SUP-2707262,CDM,C1713,HCPCS,0278,RC,,,,both,,,672.27,436.98,,,,,,,,,,,,,
GRAFT BNE 5CC DBM PTTY PREHYDRATED TENSIX,SUP-2400566,CDM,C1713,HCPCS,0278,RC,,,,both,,,4436.82,2883.93,,,,,,,,,,,,,
BUR SURG HD DIA5MM S STL STR RND FLUT AGG,SUP-2367559,CDM,C1713,HCPCS,0278,RC,,,,both,,,410.49,266.82,,,,,,,,,,,,,
BASKET STONE REMV L115CM DIA10MM SHFT 24FR URO NIT SHFT 4,SUP-2126141,CDM,2720000010,LOCAL,0272,RC,,,,both,,,806.79,524.41,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.509,SUP-2860026,CDM,C1713,HCPCS,0278,RC,,,,both,,,37328.63,24263.61,,,,,,,,,,,,,
LEVEL CMF ST PLATE MDFCE LDDR WTAB 1.5 MM SCRW6 X 2 HOLES 2,SUP-2667274,CDM,C1713,HCPCS,0278,RC,,,,both,,,1100.26,715.17,,,,,,,,,,,,,
SCREW SPNL L30MM OD5.5MM TI CANC PEDCL ST TSRH-3D,SUP-2289888,CDM,C1713,HCPCS,0278,RC,,,,both,,,1491.50,969.47,,,,,,,,,,,,,
FILTER VASC GRNFLD L 28 MM DIA12 FR TI INTRO ENTRY KT PERM,SUP-2142720,CDM,C1880,HCPCS,0278,RC,,,,both,,,354.82,230.63,,,,,,,,,,,,,
PLATE BONE 8 H MEDL TIB,SUP-2319682,CDM,C1713,HCPCS,0278,RC,,,,both,,,8066.66,5243.33,,,,,,,,,,,,,
PROCESSOR SND HEARING MAIN MOD NEUT BGE NUCLS FRDM,SUP-2165042,CDM,L8690,HCPCS,0278,RC,,,,both,,,14280.72,9282.47,,,,,,,,,,,,,
PLATE STROPP SGL TUNN REP STRL PACKAGED KT THAT INCLUDE PEEK,SUP-2175158,CDM,C1776,CPT,0278,RC,,,,both,,,4790.07,3113.55,,,,,,,,,,,,,
BLADE LARYN L22CM DIA4MM 360DEG ROT ANG TIP DBL CVD LO PROF,SUP-2854044,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1894.05,1231.13,,,,,,,,,,,,,
PLATE BENDING PLIERS TRACK 10MM 23CM JAWS,SUP-2680413,CDM,C1713,HCPCS,0278,RC,,,,both,,,1049.26,682.02,,,,,,,,,,,,,
ALLOGRAFT BNE FRZN IRRADIATED RT PROX TIB W/ PATELLAR,SUP-2867177,CDM,C1762,CPT,0278,RC,,,,both,,,15302.79,9946.81,,,,,,,,,,,,,
COLLAR CERV 4IN 24IN M XLN M DENS AD CNTOUR HK AND LOOP CLSR,SUP-2194441,CDM,L0120,HCPCS,0272,RC,,,,both,,,11.05,7.18,,,,,,,,,,,,,
DEFIBRILLATOR IMPL COBALT XT HF MRI SURESCAN W 51 X H 71 MM,SUP-2601069,CDM,C1882,HCPCS,0275,RC,,,,both,,,43646.00,28369.90,,,,,,,,,,,,,
MESH SURG W10XL15CM POLY ANAT FOR R INGUINAL HERN PARIETEX,SUP-2174784,CDM,C1781,HCPCS,0278,RC,,,,both,,,377.71,245.51,,,,,,,,,,,,,
ALTEPLASE 2 MG IJ SOLR,RX-31310,CDM,J2997,HCPCS,0636,RC,50242-0041-64,NDC,,both,1,UN,1064.80,692.12,,,,,,,,,,,,,
CATHETER PULM ART L16CM OD8.5FR 3 LUMN OXMTR PRESEP,SUP-2214761,CDM,C1751,HCPCS,0278,RC,,,,both,,,1302.79,846.81,,,,,,,,,,,,,
MESH DULEX 1MM THICKNESS OVL 10.2 IN X 13.4 IN,SUP-2125809,CDM,C1781,HCPCS,0278,RC,,,,both,,,5277.40,3430.31,,,,,,,,,,,,,
NAIL IM AD L34MM DIA8.5MM RT TROCHANTERIC FEM ROSE TI CANN,SUP-2347332,CDM,C1713,HCPCS,0278,RC,,,,both,,,12091.83,7859.69,,,,,,,,,,,,,
PLATE CRAN 120X80X40 MM PT SPEC IMPL PEEK,SUP-2860140,CDM,C1713,HCPCS,0278,RC,,,,both,,,33842.61,21997.70,,,,,,,,,,,,,
CATHETER HD SYMMETRICAL 14.5 FRX19 CM PRE CRV PALINDROMIC,SUP-2283950,CDM,C1881,HCPCS,0278,RC,,,,both,,,1037.20,674.18,,,,,,,,,,,,,
NAIL IM L345MM DIA10MM NONSTERILE GRN TIB TI CANN LCK,SUP-2192802,CDM,C1713,HCPCS,0278,RC,,,,both,,,3833.44,2491.74,,,,,,,,,,,,,
NAIL IM L270MM DIA12MM TIB LT GRN TAN PROX BEND CANN RND,SUP-2180429,CDM,C1713,HCPCS,0278,RC,,,,both,,,4731.67,3075.59,,,,,,,,,,,,,
MESH CRAN CUSTOMIZED + SM PRIORITY STRL MEDPOR,SUP-2862757,CDM,C1713,HCPCS,0278,RC,,,,both,,,47703.88,31007.52,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP STR 0.035 INX270 CM VISIGLIDE (BX OF 10 EA),SUP-2479295,CDM,C1769,HCPCS,0272,RC,,,,both,,,5529.57,3594.22,,,,,,,,,,,,,
GRAFT BONE PUTTY IRRADIATED DEMINERLIZED BONE MTRX 10CC,SUP-2307529,CDM,C9359,HCPCS,0278,RC,,,,both,,,3497.96,2273.67,,,,,,,,,,,,,
NECK FEM L42MM 8DEG YEL MOD HIP REJUVENATE,SUP-2365871,CDM,C1776,CPT,0278,RC,,,,both,,,1940.52,1261.34,,,,,,,,,,,,,
DEXTROSE 10 % IV SOLN,RX-2357,CDM,2580000003,HCPCS,0258,RC,00264-7520-10,NDC,,both,500,ML,38.30,24.89,,,,,,,,,,,,,
VALVE CSF SM PERF LEVEL 1.5 W/ BIOGLDE DELT,SUP-2631427,CDM,C1889,HCPCS,0278,RC,,,,both,,,4188.73,2722.67,,,,,,,,,,,,,
ROD DISTRACTOR 120 MM FOR RIGID EXT FIX CARBON RED II,SUP-2472689,CDM,2720000010,LOCAL,0272,RC,,,,both,,,902.53,586.64,,,,,,,,,,,,,
IMMOBILIZER PREMIER PRO KNEE 3 PNL CANVS 12 IN LTX FREE,SUP-2336073,CDM,L1830,CPT,0274,RC,,,,both,,,56.24,36.56,,,,,,,,,,,,,
GUIDEPIN ORTH L358MM OD3.2MM FULL THRD CANN,SUP-2344063,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2083.33,1354.16,,,,,,,,,,,,,
LEVEL CMF ST PLATE MDFCE STR WTAB 1.5 MM SCRW4 HOLE 18 MM T,SUP-2676829,CDM,C1713,HCPCS,0278,RC,,,,both,,,459.70,298.80,,,,,,,,,,,,,
CATHETER PERI DLYS L62CM 2 CUF CURLED ARGY,SUP-2283891,CDM,C1750,HCPCS,0278,RC,,,,both,,,189.94,123.46,,,,,,,,,,,,,
TRIHEXYPHENIDYL HCL 5 MG PO TABS,RX-8167,CDM,6370000000,HCPCS,0637,RC,00591-5337-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
CATHETER ETER CTRL VEN 1LUMEN 7FRENCH W SURCUF GROSH,SUP-2127893,CDM,C1751,HCPCS,0278,RC,,,,both,,,939.17,610.46,,,,,,,,,,,,,
INTRODUCER SHTH L61CM PERI S STL REUSE,SUP-2243832,CDM,C1894,HCPCS,0272,RC,,,,both,,,305.71,198.71,,,,,,,,,,,,,
BENZOCAINE-MENTHOL 20-0.26 % MT GEL,RX-146575,CDM,6370000000,HCPCS,0637,RC,10310-0430-28,NDC,,both,7,GR,16.90,10.98,,,,,,,,,,,,,
PROBE LARYNGEAL STR,SUP-2713694,CDM,2720000010,LOCAL,0272,RC,,,,both,,,988.63,642.61,,,,,,,,,,,,,
CATHETER URET 6FR L75CM SIL BLLN OCCL URETEROPELVIC,SUP-2171205,CDM,C1726,HCPCS,0272,RC,,,,both,,,727.54,472.90,,,,,,,,,,,,,
CANNULA KYPHOPLASTY NDL 10GA 0.8ML SYR L5IN W/ CEM RADPQ,SUP-2366872,CDM,C1713,HCPCS,0278,RC,,,,both,,,230.66,149.93,,,,,,,,,,,,,
WIRE EXT FIX L370MM DIA1.8MM S STL BAYNT PNT FOR ILIZ TAY,SUP-2342295,CDM,C1769,HCPCS,0272,RC,,,,both,,,5263.14,3421.04,,,,,,,,,,,,,
FIBER LASER 262 FT KRA-CPAOCHXL HDMI,SUP-2798097,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2212.60,1438.19,,,,,,,,,,,,,
GUIDEWIRE VASC L260CM DIA0.018IN PTFE SIL STR VENT ASST DEV,SUP-2106270,CDM,C1769,HCPCS,0272,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
PLATE BONE LOK 5.5MM DIA HLX8 RIGHT LTRL PRXML TBL,SUP-2496334,CDM,C1713,HCPCS,0278,RC,,,,both,,,3932.79,2556.31,,,,,,,,,,,,,
COMPONENT PATELLAR 35 MM KNEE RESTORIS MCK,SUP-2265748,CDM,C1776,CPT,0278,RC,,,,both,,,2652.20,1723.93,,,,,,,,,,,,,
CATHETER ANGIOPLSTY L 200 CM BALLOON L 60 MM DIA 6 MM SHTH 5,SUP-2890466,CDM,C2623,HCPCS,0278,RC,,,,both,,,5024.00,3265.60,,,,,,,,,,,,,
DILATOR ENDOSCP HI PRESSURE 6X20 MM BILI RADIOPAQUE MAXPASS,SUP-2460754,CDM,C1726,HCPCS,0272,RC,,,,both,,,899.08,584.40,,,,,,,,,,,,,
VALVE PRESSURE PROGRAMMABLE 130 MM H2O HI RANG BACTISEAL,SUP-2666826,CDM,C1889,HCPCS,0278,RC,,,,both,,,8578.54,5576.05,,,,,,,,,,,,,
SPEEDBRG IMPLANTED SYS WITH PEEK SWVLK,SUP-2812572,CDM,C1713,HCPCS,0278,RC,,,,both,,,5024.00,3265.60,,,,,,,,,,,,,
GUIDEWIRE ORTHOPEDIC THRD,SUP-2316516,CDM,C1769,HCPCS,0272,RC,,,,both,,,90.12,58.58,,,,,,,,,,,,,
OSTEOTOME SURG OD20MM BLDE THN CVD END FLEX,SUP-2408598,CDM,C1713,HCPCS,0278,RC,,,,both,,,323.42,210.22,,,,,,,,,,,,,
SAW SURG JOS 190 RT BAYNT SHP CRV,SUP-2649606,CDM,2720000010,LOCAL,0272,RC,,,,both,,,338.71,220.16,,,,,,,,,,,,,
ALLOGRAFT HUM TISS ALLOPATCH PLIABLE 4X8CM,SUP-2307620,CDM,Q4128,HCPCS,0636,RC,,,,both,,,4860.72,3159.47,,,,,,,,,,,,,
BISACODYL 10 MG RE SUPP,RX-1080,CDM,6370000000,HCPCS,0637,RC,00574-7050-50,NDC,,both,1,UN,2.30,1.49,,,,,,,,,,,,,
OSTEOTOME SURG L9 1 2IN BLDE W1 4IN STR HIBBS,SUP-2161301,CDM,2720000010,LOCAL,0272,RC,,,,both,,,299.68,194.79,,,,,,,,,,,,,
APPLIER CLP CRV MED LG 8 IN MANUAL LOAD LCK LIG HEM-O-LOK,SUP-2656804,CDM,2720000010,LOCAL,0272,RC,,,,both,,,568.34,369.42,,,,,,,,,,,,,
WAND ELECSURG 90 DEG 3.5 MM INTEGR CABLE HALO COBLATION,SUP-2848687,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1249.00,811.85,,,,,,,,,,,,,
UNIT OUTPT DGT SIGNAL,SUP-2241825,CDM,C1713,HCPCS,0278,RC,,,,both,,,348.54,226.55,,,,,,,,,,,,,
MESH CRAN SM THK0.4MM LT ORBIT TI CNTOUR W/ CUT GUID FOR,SUP-2135915,CDM,C1713,HCPCS,0278,RC,,,,both,,,4694.30,3051.29,,,,,,,,,,,,,
MESH CRANIAL CONTOURABLE LARGE 0.6 MM PRECONTOURED TITANIUM,SUP-2842248,CDM,C1713,HCPCS,0278,RC,,,,both,,,3990.31,2593.70,,,,,,,,,,,,,
HC Njx Dx/Ther Sbst W/Indwelling Cath Intrlmnr Lmbr/Sac W/Img Gdn,PX-3606232700,CDM,62327,CPT,0360,RC,,,,inpatient,,,2895.00,1881.75,,,,,,,,,,,,,
HC Sel Cath Thor/Brach Init 3rd+,PX-3613621700,CDM,36217,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
PLATE BONE W14.9XL248MM THK1.2MM 15 H DSTL TIB S STL,SUP-2185744,CDM,C1713,HCPCS,0278,RC,,,,both,,,1650.01,1072.51,,,,,,,,,,,,,
CATHETER PERI DLYS L90CM OD2.5MM ID1.3MM,SUP-2284523,CDM,C1713,HCPCS,0278,RC,,,,both,,,406.79,264.41,,,,,,,,,,,,,
HC Perq Plmt Bile Duct Stent,PX-3614753800,CDM,47538,CPT,0361,RC,,,,both,,,8583.00,5578.95,,,,,,,,,,,,,
GLIMEPIRIDE 1 MG PO TABS,RX-16355,CDM,6370000000,HCPCS,0637,RC,55111-0320-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
RING ACET LCK 260 HIP RINGLOK,SUP-2449971,CDM,C1776,CPT,0278,RC,,,,both,,,339.12,220.43,,,,,,,,,,,,,
PATCH BIOLOGICAL L 8 X W 6 CM BOVINE PERICARDIUM STERILE XENOSURE,SUP-2264268,CDM,C1768,CPT,0278,RC,,,,both,,,2069.26,1345.02,,,,,,,,,,,,,
CATHETER ANGIOPLSTY UTHN L 75 CM BALLOON L 40 MM DIA 9 MM,SUP-2141831,CDM,C1725,HCPCS,0272,RC,,,,both,,,631.14,410.24,,,,,,,,,,,,,
DEFIBRILLATOR IMPL INVENTRA UHE DX TI EPOXY RESIN SIL SINGLE,SUP-2138432,CDM,C1722,HCPCS,0275,RC,,,,both,,,44745.00,29084.25,,,,,,,,,,,,,
BRUSH CYTO L200CM SHTH 75FR NIT DRV WIRE SFT STIFF BRIST,SUP-2391638,CDM,2720000010,LOCAL,0272,RC,,,,both,,,461.58,300.03,,,,,,,,,,,,,
GRAFT VASC HEMSHLD PLAT L 47 CM DIA28 MM BRANCH SZ 10/10/8/8,SUP-2694287,CDM,C1768,CPT,0278,RC,,,,both,,,7638.11,4964.77,,,,,,,,,,,,,
RING EXT FIX HALF 160 MM ALUM,SUP-2162655,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3562.02,2315.31,,,,,,,,,,,,,
KIT INTRO L 45 CM DIA 5 FR NDL L 7 CM NIT WIRE PLAT TIP A,SUP-2116528,CDM,C1894,HCPCS,0272,RC,,,,both,,,138.16,89.80,,,,,,,,,,,,,
CAGE SPNL 3D 15 DEG 28X11X17 MM WAVEFORM,SUP-2711485,CDM,C1889,HCPCS,0278,RC,,,,both,,,8321.00,5408.65,,,,,,,,,,,,,
MESH BIO POST TRANSOBTURATOR PORCINE CLLGN MTRX TENS SUT,SUP-2140309,CDM,C1771,HCPCS,0278,RC,,,,both,,,5951.09,3868.21,,,,,,,,,,,,,
SCREW BNE MYOMA 5X320 MM LAP FOR MANIPULATION,SUP-2470303,CDM,C1713,HCPCS,0278,RC,,,,both,,,444.18,288.72,,,,,,,,,,,,,
DISTRACTION INTRNL SCREW MXDRVEHEX ZRCH DRILL FREE 2.0 MM H,SUP-2678356,CDM,C1713,HCPCS,0278,RC,,,,both,,,509.50,331.17,,,,,,,,,,,,,
INTRODUCER PACE LD SOLO-TRAK KR DIA 7 FR PERC 10 LUMEN STRL,SUP-2282092,CDM,C1894,HCPCS,0272,RC,,,,both,,,193.80,125.97,,,,,,,,,,,,,
PLATE BNE BROAD 5.5X198 MM 11 HOLE SS LCP,SUP-2569372,CDM,C1713,HCPCS,0278,RC,,,,both,,,780.60,507.39,,,,,,,,,,,,,
STEM FEM L120MM OD10MM KNEE STR UNCEMENTED SPLINED VANGUARD,SUP-2405461,CDM,C1776,CPT,0278,RC,,,,both,,,3661.24,2379.81,,,,,,,,,,,,,
PERI LOC 4.5 FEM MID SHAFT LOCK PL 14 H,SUP-2819766,CDM,C1713,HCPCS,0278,RC,,,,both,,,9396.29,6107.59,,,,,,,,,,,,,
RING PESSARY SZ 4 275IN SIL W SUPP,SUP-2273826,CDM,A4562,HCPCS,0272,RC,,,,both,,,102.27,66.48,,,,,,,,,,,,,
WAND ELECSURG 90 DEG 4.5 MM INTEGR CABLE N SUCTION ELIM 90,SUP-2848688,CDM,2720000010,LOCAL,0272,RC,,,,both,,,609.95,396.47,,,,,,,,,,,,,
BRACE WR LEN 9 1/8IN CIRC OVR 8 3/4INXL BGE D RNG LNG LEN LT,SUP-2324967,CDM,L3931,HCPCS,0274,RC,,,,both,,,44.49,28.92,,,,,,,,,,,,,
HC Cystostomy Tube Change,PX-7615170500,CDM,51705,CPT,0761,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
GRAFT DERM FLD HYDRATED THCK KT BILAT BRST ACELLULAR DERM,SUP-2307582,CDM,Q4128,HCPCS,0636,RC,,,,both,,,7597.23,4938.20,,,,,,,,,,,,,
BLADE SURG 46 MM CALCAR RASP STYL EXACT,SUP-2443891,CDM,2720000010,LOCAL,0272,RC,,,,both,,,791.28,514.33,,,,,,,,,,,,,
STRAP ORTHOT PERONEAL CUST PREFABRICATED OFF THE SHLF,SUP-2435566,CDM,L0980,HCPCS,0272,RC,,,,both,,,48.39,31.45,,,,,,,,,,,,,
PACK VITRCTMY 20GA ANT PNEUMAT CUT W/ IRRIG DP,SUP-2129357,CDM,2720000010,LOCAL,0272,RC,,,,both,,,334.60,217.49,,,,,,,,,,,,,
STENT PERIPH TACK L 6 MM OD 4 FR ID 0.014 IN L 120 CM DIA 6,SUP-2716198,CDM,C1876,HCPCS,0278,RC,,,,both,,,6264.30,4071.79,,,,,,,,,,,,,
RING EXT FIX FULL 120 MM CIR SIDEKCK,SUP-2487292,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1949.94,1267.46,,,,,,,,,,,,,
DEFIBRILLATOR IMPL EPIC HF TI POLYUR SIL IS1/DF1 CONN BPLR,SUP-2356576,CDM,C1882,HCPCS,0275,RC,,,,both,,,61898.82,40234.23,,,,,,,,,,,,,
MESH HERN RECT OVL 4X1 IN FLAT SHT KNITTED POLYPR PROLITE,SUP-2227231,CDM,C1781,HCPCS,0278,RC,,,,both,,,67.51,43.88,,,,,,,,,,,,,
GUIDEWIRE ORTH L DIA2.8MM,SUP-2417459,CDM,C1769,HCPCS,0272,RC,,,,both,,,243.04,157.98,,,,,,,,,,,,,
PLATE BONE 176MML HLX22 STNLSS STEEL STRGHT RCNSTRCTN F/2.7M,SUP-2488178,CDM,C1713,HCPCS,0278,RC,,,,both,,,1707.66,1109.98,,,,,,,,,,,,,
BAR EXT FIX L L250MM DIA10.5MM C FBR JET-X,SUP-2342875,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1681.28,1092.83,,,,,,,,,,,,,
SCREW BNE L75MM DIA5MM PROX FEM S STL SELF DRL ST CONIC HD,SUP-2184729,CDM,C1713,HCPCS,0278,RC,,,,both,,,525.42,341.52,,,,,,,,,,,,,
KIT CATH HEMODIALYSI GLIDEPATH CHRONIC EXCHANGE 14.5 5397230 - ORDER UOM IS CA,SUP-2632953,CDM,C1750,HCPCS,0278,RC,,,,both,,,1341.88,872.22,,,,,,,,,,,,,
SCREW BNE PEDIATRIC 2-3/4 IN,SUP-2460205,CDM,C1713,HCPCS,0278,RC,,,,both,,,1434.20,932.23,,,,,,,,,,,,,
RECON PLATE 9X141MM 4.5MM,SUP-2818431,CDM,C1713,HCPCS,0278,RC,,,,both,,,4675.30,3038.94,,,,,,,,,,,,,
SET NEPHSTMY PERC PGTL CATH ONLY 8.3 FRX30 CM,SUP-2168885,CDM,C1729,HCPCS,0272,RC,,,,both,,,188.40,122.46,,,,,,,,,,,,,
GUIDEWIRE VASC VSI L 60 CM DIA 0.018 IN NIT MANDREL SS TIP,SUP-2763451,CDM,C1769,HCPCS,0272,RC,,,,both,,,54.95,35.72,,,,,,,,,,,,,
CATHETER DRAINAGE SINGLE LUMEN 10 FRX25 CM MP UTHANE,SUP-2168324,CDM,C1729,HCPCS,0272,RC,,,,both,,,291.45,189.44,,,,,,,,,,,,,
SCREW BONE L32MM DIA4MM FEMORAL DEEP THREADED NCB,SUP-2472330,CDM,C1713,HCPCS,0278,RC,,,,both,,,362.23,235.45,,,,,,,,,,,,,
COIL NEUROVASCULAR CASHMERE 14 L 8 CM LOOP DIA 4 MM PRIMARY,SUP-2249265,CDM,C1889,HCPCS,0278,RC,,,,both,,,3852.94,2504.41,,,,,,,,,,,,,
GRAFT BONE 10ML DEMIN BONE MTRX PUTTY PROC STRL IMP ACCELL,SUP-2247313,CDM,C9359,HCPCS,0278,RC,,,,both,,,4348.90,2826.78,,,,,,,,,,,,,
COMPONENT PAT SZ 0 10MM POLYETH NTRL KN FLX,SUP-2200039,CDM,C1776,CPT,0278,RC,,,,both,,,4521.60,2939.04,,,,,,,,,,,,,
PACK SURG CUST AV FISTULA JEWISH,SUP-2711641,CDM,C1713,HCPCS,0278,RC,,,,both,,,708.10,460.26,,,,,,,,,,,,,
BOLT IM L42MM DIA3.9MM BLU TI ALUM NIOBIUM TRCR TIP ST LOK,SUP-2192196,CDM,C1713,HCPCS,0278,RC,,,,both,,,599.02,389.36,,,,,,,,,,,,,
STENT PERIPH ZILVER 635 L 40 MM DIA10 MM DEL SYS L 125 CM,SUP-2171396,CDM,C1876,HCPCS,0278,RC,,,,both,,,1972.83,1282.34,,,,,,,,,,,,,
SHAFT FIB TRAD ALLGRFT 100 MM FRZN,SUP-2294144,CDM,C1713,HCPCS,0278,RC,,,,both,,,2260.80,1469.52,,,,,,,,,,,,,
PACK BX ASPIR BONE MAR CONC PROC NDL,SUP-2384782,CDM,C1713,HCPCS,0278,RC,,,,both,,,8776.30,5704.59,,,,,,,,,,,,,
SPHERE GLEN CRV DIA36MM STD TI FOR COMPHSVE REV SHLDR SYS,SUP-2409235,CDM,C1776,CPT,0278,RC,,,,both,,,6217.20,4041.18,,,,,,,,,,,,,
HC Injection Shunt,PX-3614942700,CDM,49427,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
DEVICE DRNGE CLR TUTOPLAST 1/3 CORNEA SCLER,SUP-2247190,CDM,V2785,HCPCS,0810,RC,,,,both,,,1158.66,753.13,,,,,,,,,,,,,
HC Inj Stelat Gangl Cerv Sym,PX-3616451000,CDM,64510,CPT,0361,RC,,,,outpatient,,,6875.00,4468.75,,,,,,,,,,,,,
PLATE 2 HL TWST ALUM RINGFIX SYS,SUP-2500275,CDM,C1713,HCPCS,0278,RC,,,,both,,,381.82,248.18,,,,,,,,,,,,,
TENSIONER SUTURE,SUP-2749338,CDM,2720000010,LOCAL,0272,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
DISC DENT DIA1/2IN X THN MAUVE ALUM OXIDE CNTOUR POL COARSE,SUP-2100104,CDM,D6783,CPT,0278,RC,,,,both,,,2.26,1.47,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9 % IV BOLUS NEONATE,RX-40840079,CDM,J7050,HCPCS,0250,RC,00264-7800-20,NDC,,both,250,ML,23.40,15.21,,,,,,,,,,,,,
SCREW DIAM 5MM L35MM PARTIALLY THRD,SUP-2243624,CDM,C1713,HCPCS,0278,RC,,,,both,,,1175.84,764.30,,,,,,,,,,,,,
DRILL SURG 10 MM SHORELINE ACS,SUP-2709726,CDM,2720000010,LOCAL,0272,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
HC So1 Heparin Asso1c Platelet Antibo,PX-3028602267,CDM,86022,CPT,0302,RC,,,,both,,,465.00,302.25,,,,,,,,,,,,,
BIT DRL L120MM DIA2.3MM RED PROX FIX TOT WRST FUS PLT,SUP-2389437,CDM,2720000010,LOCAL,0272,RC,,,,both,,,357.96,232.67,,,,,,,,,,,,,
BELT BK CRISSCROSS W/ SHLDR STRP CONTAINS VELC CLSR ELAS,SUP-2324538,CDM,L0642,HCPCS,0274,RC,,,,both,,,76.02,49.41,,,,,,,,,,,,,
SCREW BNE L8MM DIA2.7MM MAND CRANIOMAXILLOFACIAL G ST CRSS 5PK,SUP-2366177,CDM,C1713,HCPCS,0278,RC,,,,both,,,227.40,147.81,,,,,,,,,,,,,
CATHETER EP 6FR L110CM 5-5-5MM SPC STABILENE QPLR FIX,SUP-2141260,CDM,C1730,HCPCS,0272,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
PERI-LOC 4.5MM S-T CRTX SCREW 42MM,SUP-2819168,CDM,C1713,HCPCS,0278,RC,,,,both,,,194.93,126.70,,,,,,,,,,,,,
GRAFT HUM TISS W4XL4CM AMNIO MEMBRN AMBRIO2,SUP-2247194,CDM,V2790,HCPCS,0274,RC,,,,both,,,1983.32,1289.16,,,,,,,,,,,,,
PLATE DISTL LAT 3 H RT HUM,SUP-2467090,CDM,C1713,HCPCS,0278,RC,,,,both,,,6690.71,4348.96,,,,,,,,,,,,,
PLATE BONE LOCKING HOLEX14 LEFT LATERAL DISTAL FEMORAL,SUP-2588185,CDM,C1713,HCPCS,0278,RC,,,,both,,,4533.06,2946.49,,,,,,,,,,,,,
GRAFT BNE 200X25X8 MM 40 CC POROUS COLLAGEN MATRIX SIGNAFUSE,SUP-2731803,CDM,C1713,HCPCS,0278,RC,,,,both,,,21242.10,13807.36,,,,,,,,,,,,,
TRUVIEW 22MM 27MM PEEK,SUP-2400029,CDM,2720000010,LOCAL,0272,RC,,,,both,,,599.74,389.83,,,,,,,,,,,,,
LENS IOL ASPHERIC 31+ DIOPT 6X13 MM ACRYLATE RESTOR,SUP-2111461,CDM,V2788,HCPCS,0276,RC,,,,both,,,495.00,321.75,,,,,,,,,,,,,
TROCAR SURG AUTOCLV FOR 4MM CANN SPEEDLOCK,SUP-2366601,CDM,C1713,HCPCS,0278,RC,,,,both,,,402.89,261.88,,,,,,,,,,,,,
SYSTEM HIP UPLR CEMTD FEM W/ LRG MET HD,SUP-2347955,CDM,C1776,CPT,0278,RC,,,,both,,,3925.00,2551.25,,,,,,,,,,,,,
PROBE LASER DIRECTIONAL 25G,SUP-2863700,CDM,2720000010,LOCAL,0272,RC,,,,both,,,355.76,231.24,,,,,,,,,,,,,
CATHETER URET OLV TIP 4FRX70CM FLEXIMA,SUP-2139297,CDM,C1758,HCPCS,0278,RC,,,,both,,,29.67,19.29,,,,,,,,,,,,,
CANNULA ART PERF L 1 CM INSRTN L 15 CM CATH DIA13 GA CONN,SUP-2908651,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1556.53,1011.74,,,,,,,,,,,,,
SET INT FIX SCREW DIA1.5 MM 4 H XLN TI NEURO STR PLT SD HI,SUP-2935804,CDM,C1713,HCPCS,0278,RC,,,,both,,,1315.66,855.18,,,,,,,,,,,,,
PIN FIX DIA28MM LNG QUIK REL FOR CONG EL PLATING SYS STNMN,SUP-2107730,CDM,C1713,HCPCS,0278,RC,,,,both,,,248.06,161.24,,,,,,,,,,,,,
CATHETER CV SET 032 7 FRX15 CM 3L RIFAMPIN SPECTRUM,SUP-2759759,CDM,C1751,HCPCS,0278,RC,,,,both,,,133.67,86.89,,,,,,,,,,,,,
SPACER GRFT BNE ANTR 16MM SM 13 DEG LORDTC PUROS S2,SUP-2693853,CDM,C1713,HCPCS,0278,RC,,,,both,,,13354.42,8680.37,,,,,,,,,,,,,
GRAFT BIO TISS W7XL10CM HIATAL HERN STD FOR IMPLANTATION TO,SUP-2170839,CDM,C1763,HCPCS,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
SCREW BNE DIA3.5MM SURFIX LOK REPL FOR TOT WRST FUS SYS,SUP-2243056,CDM,C1713,HCPCS,0278,RC,,,,both,,,494.77,321.60,,,,,,,,,,,,,
GUIDEWIRE VASC L175CM DIA0035IN PTFE MOD S STL COIL PLAT,SUP-2281745,CDM,C1769,HCPCS,0272,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
TI LCP PROX LATERAL TIBIA PL 13 HOLES/300MM/LEFT-STERILE,SUP-2549446,CDM,C1713,HCPCS,0278,RC,,,,both,,,4980.10,3237.06,,,,,,,,,,,,,
HC Med Nut Therapy Ind Fu 15 Min,PX-9429780300,CDM,97803,CPT,0942,RC,,,,outpatient,,,42.00,27.30,,,,,,,,,,,,,
ANCHOR SUT ST COBRAID BLK BLU OD4.5MM SZ 2 TWINFIX ULT HA,SUP-2341851,CDM,C1713,HCPCS,0278,RC,,,,both,,,1180.64,767.42,,,,,,,,,,,,,
HC Venous Sel Cath Plcmt 1st Ord,PX-3613601100,CDM,36011,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
BUR SURG BALL 5 MM 10 CM FN FLUT SM BOR MIDAS REX 8 LEGEND,SUP-2664500,CDM,2720000010,LOCAL,0272,RC,,,,both,,,363.99,236.59,,,,,,,,,,,,,
FEMORAL VG CEM POR TIB/E1/PAT,SUP-2137308,CDM,C1713,HCPCS,0278,RC,,,,both,,,15112.82,9823.33,,,,,,,,,,,,,
HEAD RADIAL 6+ MM 10X22 MM 7.5 MM ELBW STRL,SUP-2789815,CDM,C1776,CPT,0278,RC,,,,both,,,8788.04,5712.23,,,,,,,,,,,,,
PLATE BNE 2 H POST RIM BROAD NS PRO,SUP-2902270,CDM,C1713,HCPCS,0278,RC,,,,both,,,2198.47,1429.01,,,,,,,,,,,,,
GUIDEWIRE VASC INQWIRE L 200 CM DIA 0.035 IN TIP L 3 MM PTFE,SUP-2301923,CDM,C1769,HCPCS,0272,RC,,,,both,,,37.37,24.29,,,,,,,,,,,,,
GUIDEWIRE ORTH 2.3 MM STP INSTR JUGGERLOC,SUP-2608603,CDM,C1769,HCPCS,0272,RC,,,,both,,,478.28,310.88,,,,,,,,,,,,,
PROBE CRYOABLATION SLIMLINE 1.7MM,SUP-2716314,CDM,C2618,HCPCS,0272,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
RESLIZUMAB 100 MG/10ML IV SOLN,RX-133696,CDM,J2786,HCPCS,0636,RC,59310-0610-31,NDC,,both,10,ML,3351.20,2178.28,,,,,,,,,,,,,
PUMP THROMCTMY FOR 3000 SER SYS ANGIOJET,SUP-2277416,CDM,C1713,HCPCS,0278,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
KIT ORTH EXT PROC PMT INSTR FLUT GWIRE TISS PROTCT DRL BIT,SUP-2400578,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3486.34,2266.12,,,,,,,,,,,,,
FENTANYL 100 MCG/HR TD PT72,RX-27908,CDM,6370000000,HCPCS,0637,RC,50742-0556-05,NDC,,both,1,UN,58.50,38.02,,,,,,,,,,,,,
GUIDEWIRE VASC INQWIRE L 260 CM 0.035IN TIP 1.5 MM J STD FIX,SUP-2479513,CDM,C1769,HCPCS,0272,RC,,,,both,,,32.03,20.82,,,,,,,,,,,,,
SCREW BNE L32.5MM HIP S STL COMPR DISP,SUP-2370967,CDM,C1713,HCPCS,0278,RC,,,,both,,,83.21,54.09,,,,,,,,,,,,,
COMPONENT PATELLAR DOMED 38 MM KNEE UHMWPE S-ROM NOILES,SUP-2455923,CDM,C1776,CPT,0278,RC,,,,both,,,2395.19,1556.87,,,,,,,,,,,,,
BLADE ES SPAT TIP W4MM TELSCP INTEGR SUCT 3.0S PLASMABLDE,SUP-2281811,CDM,2720000010,LOCAL,0272,RC,,,,both,,,857.22,557.19,,,,,,,,,,,,,
CLOVERLEAF PL 5H 120MM,SUP-2818807,CDM,C1713,HCPCS,0278,RC,,,,both,,,3411.30,2217.34,,,,,,,,,,,,,
AUGMENT PAT M THK19.5MM STD UNIV TRABECULAR MTL CEM PRI BLK,SUP-2200589,CDM,C1776,CPT,0278,RC,,,,both,,,7108.96,4620.82,,,,,,,,,,,,,
SHUNT LUMPERITON HI W/ CTRL RESVR N PROGRAMMABLE 15FR 3CM,SUP-2308230,CDM,C1713,HCPCS,0278,RC,,,,both,,,2138.87,1390.27,,,,,,,,,,,,,
SCREW BONE ANTR PLT 5.5MM 25MM,SUP-2229631,CDM,C1713,HCPCS,0278,RC,,,,both,,,3036.38,1973.65,,,,,,,,,,,,,
BIT DRL TWST TIP FOR 2.3MM BIORAPTOR ANCHR,SUP-2341800,CDM,2720000010,LOCAL,0272,RC,,,,both,,,494.55,321.46,,,,,,,,,,,,,
SET INTRO PERFRMR L 6 CM OD 3 FR ID 1 MM GUIDEWIRE 0.018 IN,SUP-2169798,CDM,C1894,HCPCS,0272,RC,,,,both,,,69.80,45.37,,,,,,,,,,,,,
CATHETER INFUSION PULSE SPRY L 135 CM DIA 4 FR SLT PAT L 10,SUP-2118501,CDM,C1751,HCPCS,0278,RC,,,,both,,,832.10,540.86,,,,,,,,,,,,,
MESH HERN W12.3XL6.3IN OMEGA 3 FATTY ACID COAT POLYPR,SUP-2265990,CDM,C1781,HCPCS,0278,RC,,,,both,,,3359.80,2183.87,,,,,,,,,,,,,
STRAP CLAV SM 3 W HK,SUP-2428149,CDM,L3650,HCPCS,0274,RC,,,,both,,,17.62,11.45,,,,,,,,,,,,,
HC NM Kidney Imag Vasc Flow Funct Ph,PX-3417870800,CDM,78708,CPT,0341,RC,,,,outpatient,,,2771.00,1801.15,,,,,,,,,,,,,
CATHETER DRAINAGE RESOLV L 25 CM DIA10 FR GUIDEWIRE 0.038 IN,SUP-2303333,CDM,C1729,HCPCS,0272,RC,,,,both,,,189.81,123.38,,,,,,,,,,,,,
CAP AIRWY MANIFOLD ACCSRY BALLARD LIBERATOR,SUP-2774316,CDM,C1887,HCPCS,0272,RC,,,,both,,,18.84,12.25,,,,,,,,,,,,,
HC Up Ext Fx Orth W/Wr Hinge,PX-2740376401,CDM,L3764,HCPCS,0274,RC,,,,both,,,2631.00,1710.15,,,,,,,,,,,,,
MESH HERN COMP 15 CM MONOFILAMENT EZ TO USE PARIETENE DS,SUP-2752202,CDM,C1781,HCPCS,0278,RC,,,,both,,,9007.03,5854.57,,,,,,,,,,,,,
PLATE BONE THK0.5MM 4 H BILAT CRAN TI STR LO PROF RIG NEUT,SUP-2190695,CDM,C1713,HCPCS,0278,RC,,,,both,,,278.96,181.32,,,,,,,,,,,,,
SCREW CONN CANN FOR HUM NAILING SYS MULTILOC,SUP-2178938,CDM,C1713,HCPCS,0278,RC,,,,both,,,1752.62,1139.20,,,,,,,,,,,,,
COIL VASC AZUR HYDROCOIL L 30 CM DIA12 MM MICROCATHETER,SUP-2385406,CDM,C1889,HCPCS,0278,RC,,,,both,,,4566.85,2968.45,,,,,,,,,,,,,
PIN EXT FIX L 50 MM DIA 5 MM SHRT TIN HALF STRL DISP JET-X,SUP-2933162,CDM,2720000010,LOCAL,0272,RC,,,,both,,,714.38,464.35,,,,,,,,,,,,,
PLATE BNE T 4.5X91 MM 4 HOLE LCP,SUP-2569409,CDM,C1713,HCPCS,0278,RC,,,,both,,,556.09,361.46,,,,,,,,,,,,,
PLATE BNE RECON 2.7X3 MM RT MAND 26 HOLE ANGLED FIX TI STRL,SUP-2500268,CDM,C1713,HCPCS,0278,RC,,,,both,,,9294.12,6041.18,,,,,,,,,,,,,
WRAP ELBW BREATHABLE UNIV FOREARM FOAM 2 ADJ STRAP PROCARE,SUP-2196799,CDM,L3702,HCPCS,0272,RC,,,,both,,,44.37,28.84,,,,,,,,,,,,,
LENGTHENER EXT FIX CLMP T SHP FOR DIA2 3MM PIN MINIRAIL,SUP-2316438,CDM,2720000010,LOCAL,0272,RC,,,,both,,,623.10,405.01,,,,,,,,,,,,,
WIRE GUIDE 13.5MM/3.2MM,SUP-2548797,CDM,C1769,HCPCS,0272,RC,,,,both,,,1333.43,866.73,,,,,,,,,,,,,
KIT SUTURE ANCHR DIA2.8 MM ALL PRELD 1.5 MM PASS TAPE ON,SUP-2899250,CDM,C1713,HCPCS,0278,RC,,,,both,,,1459.32,948.56,,,,,,,,,,,,,
"HC Neuromuscular Re-Education, Ot|OP PT SERVICES|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS",PX-4309711200,CDM,97112,CPT,0430,RC,,,GP|CQ,both,,,159.00,103.35,,,,,,,,,,,,,
PSN REV 3MM OFFSET STEM EXT 17X135MM,SUP-2508806,CDM,C1776,CPT,0278,RC,,,,both,,,6531.20,4245.28,,,,,,,,,,,,,
MESH CRANIAL STRAIGHT 1.5X100X100X0.5 MM RAPID RESORBABLE ST,SUP-2838583,CDM,C1713,HCPCS,0278,RC,,,,both,,,9891.00,6429.15,,,,,,,,,,,,,
CATHETER 3 LUMN PICC MAXIMAL BARR W/ SHERLOCK 3CG TPS STYL,SUP-2125515,CDM,C1751,HCPCS,0278,RC,,,,both,,,1158.66,753.13,,,,,,,,,,,,,
SYSTEM GWIRE L300CM DIA0035IN STD STEER HYDROPHOBIC STR TIP,SUP-2281749,CDM,C1769,HCPCS,0272,RC,,,,both,,,580.90,377.58,,,,,,,,,,,,,
HC Autologous Blood Process,PX-3008689000,CDM,86890,CPT,0300,RC,,,,both,,,518.00,336.70,,,,,,,,,,,,,
HC NM Kidney Imag Vasc Flow Funct Ph,PX-3417870800,CDM,78708,CPT,0341,RC,,,,inpatient,,,2771.00,1801.15,,,,,,,,,,,,,
RING EXT FIX FULL 180 MM CIR SIDEKCK,SUP-2850714,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2948.46,1916.50,,,,,,,,,,,,,
SCREW BNE L10MM DIA1.5MM HD DIA3MM CORT S STL NONCANNULATED,SUP-2183108,CDM,C1713,HCPCS,0278,RC,,,,both,,,25.12,16.33,,,,,,,,,,,,,
APPLIER ANEURYSM CLIP YASARGIL STANDARD BAYONET REUSABLE 9IN,SUP-2825557,CDM,C1889,HCPCS,0278,RC,,,,both,,,4831.36,3140.38,,,,,,,,,,,,,
TI LCP VOLR CLMN DSTL RADIUS PL 6H HEAD/3H SHAFT/LT-STERILE,SUP-2546653,CDM,C1713,HCPCS,0278,RC,,,,both,,,2979.39,1936.60,,,,,,,,,,,,,
STEM FEM SZ 13 L130MM PF VERSYS LD/FX,SUP-2203064,CDM,C1776,CPT,0278,RC,,,,both,,,4257.84,2767.60,,,,,,,,,,,,,
SCREW CRANIOMAXILLOFACIAL VIT 2.0MM DIA 6MML,SUP-2364636,CDM,C1713,HCPCS,0278,RC,,,,both,,,122.08,79.35,,,,,,,,,,,,,
JOINT SUBTALAR 6 SINUS TARSI ANK,SUP-2236092,CDM,C1713,HCPCS,0278,RC,,,,both,,,6217.20,4041.18,,,,,,,,,,,,,
SEED BRACHYTHERAPY FOR CALIB IOD I 125,SUP-2423884,CDM,C2638,HCPCS,0278,RC,,,,both,,,188.40,122.46,,,,,,,,,,,,,
BIT DRL HEX 3.2 MM TSRH 3DX,SUP-2631142,CDM,2720000010,LOCAL,0272,RC,,,,both,,,370.46,240.80,,,,,,,,,,,,,
COIL EMB L2CM LOOP DIA3MM 0.018IN PERIPH PLAT HYDRGEL,SUP-2385380,CDM,C1889,HCPCS,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
TRAP SPEC CUSA CLARITY,SUP-2604370,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3442.04,2237.33,,,,,,,,,,,,,
KIT TKR KNEE CRUCE RET CEM STD INSRT VERILAST LEGION GEN II,SUP-2348028,CDM,C1776,CPT,0278,RC,,,,both,,,6594.00,4286.10,,,,,,,,,,,,,
CATHETER UROLOGICAL PHILIPS 14 FR FOR FILIFORM BOUGIES 27576,SUP-2768118,CDM,2720000010,LOCAL,0272,RC,,,,both,,,337.36,219.28,,,,,,,,,,,,,
WRAP ELBW BREATHABLE UNIV FOREARM FOAM 2 ADJ STRAP PROCARE,SUP-2196799,CDM,L3702,HCPCS,0274,RC,,,,both,,,44.37,28.84,,,,,,,,,,,,,
LOCK SPNL BLU TI ALLOY FOR RIB SUPP VEPTR,SUP-2193301,CDM,C1713,HCPCS,0278,RC,,,,both,,,1331.36,865.38,,,,,,,,,,,,,
CARTRIDGE CO2 MED C DIOX GAS,SUP-2239970,CDM,2720000010,LOCAL,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
GRAFT DURA REP L 4 X W 3 CM THK 0.4 MM ELECTROSPUN FIBER ART3401,SUP-2904065,CDM,C1763,HCPCS,0278,RC,,,,both,,,1632.80,1061.32,,,,,,,,,,,,,
BRACE ORTH CIRC THGH 18.5-21 IN CTR 14-15 IN CALF 14-16 IN,SUP-2914942,CDM,2720000010,LOCAL,0272,RC,,,,both,,,349.04,226.88,,,,,,,,,,,,,
HC OP Traction Intermittent,PX-4209701200,CDM,97012,CPT,0420,RC,,,,outpatient,,,292.00,189.80,,,,,,,,,,,,,
CEMENT LNR BASE STD DYCAL PRISMA VLC,SUP-2238603,CDM,C1713,HCPCS,0278,RC,,,,both,,,584.76,380.09,,,,,,,,,,,,,
PLATE BNE L 119 MM SCREW DIA 3.5 MM 10 SHFT H TI 1/3 TUBLR,SUP-2907866,CDM,C1713,HCPCS,0278,RC,,,,both,,,2753.00,1789.45,,,,,,,,,,,,,
MARKER BRST BX 9 GA SHP 1 STEREOTACTIC GUID SYS TRIMARK ATEC,SUP-2240072,CDM,A4648,CPT,0278,RC,,,,both,,,178.98,116.34,,,,,,,,,,,,,
BTB IB TIGHTROPE W FLIPCUTTER III DRILL,SUP-2811641,CDM,C1713,HCPCS,0278,RC,,,,both,,,3563.90,2316.53,,,,,,,,,,,,,
INTRODUCER 10FR PEEL AWAY 6091] ABBOTT VASCULAR],SUP-2105937,CDM,C1892,HCPCS,0272,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
GRAFT HUMAN TSSUE W4XL12CM THK1.04 2.28MM THICK RGNRTVE TSSU,SUP-2480659,CDM,Q4116,HCPCS,0636,RC,,,,both,,,4920.38,3198.25,,,,,,,,,,,,,
GRAFT HUM TISS W220XH18 4XL300MM MESHED SKIN TISS ASEP DMND,SUP-2307518,CDM,Q4128,HCPCS,0636,RC,,,,both,,,48698.57,31654.07,,,,,,,,,,,,,
BRACE WRIST SM 14.6 16.5CM LEFT PRTCTVE PDDNG ADJSTBLE BAR D,SUP-2480988,CDM,L3931,HCPCS,0274,RC,,,,both,,,36.64,23.82,,,,,,,,,,,,,
HC MRI-Angio Neck WO Contrast,PX-6157054700,CDM,70547,CPT,0615,RC,,,,inpatient,,,4844.00,3148.60,,,,,,,,,,,,,
TUBE TRACH AD L130MM OD12.9MM ID9MM SIL UNCUF EXTRA LEN FIX,SUP-2352036,CDM,2720000010,LOCAL,0272,RC,,,,both,,,299.27,194.53,,,,,,,,,,,,,
HC US Guid Chor Villus Sampling,PX-4027694500,CDM,76945,CPT,0402,RC,,,,inpatient,,,783.00,508.95,,,,,,,,,,,,,
INSTRUMENT ORTH SKR TAB LAPIDUS SYS IO FRDM,SUP-2865098,CDM,2720000010,LOCAL,0272,RC,,,,both,,,734.76,477.59,,,,,,,,,,,,,
NAIL IM CANN 11X360 MM RT TROCHANTERIC FIX TI STRL,SUP-2192195,CDM,C1713,HCPCS,0278,RC,,,,both,,,4421.12,2873.73,,,,,,,,,,,,,
INSUFFLATION TBNG ROBOT SURG SET HI FLO DA VINCI 5,SUP-2884189,CDM,2720000010,LOCAL,0272,RC,,,,both,,,379.94,246.96,,,,,,,,,,,,,
PLATE BNE L148MM 8 H BILAT S STL T NONCOMPRESSION LO PROF,SUP-2185757,CDM,C1713,HCPCS,0278,RC,,,,both,,,1786.03,1160.92,,,,,,,,,,,,,
IMPLANT TOE SZ 20 FOREFOOT PRIMUS GREAT W/ GRMMT FUTURA,SUP-2399909,CDM,C1776,CPT,0278,RC,,,,both,,,3799.40,2469.61,,,,,,,,,,,,,
HC So Heroin Metabolite,PX-3018035666,CDM,G0480,CPT,0301,RC,,,,both,,,238.00,154.70,,,,,,,,,,,,,
HC So Factor VII,PX-3058523066,CDM,85230,CPT,0305,RC,,,,outpatient,,,280.00,182.00,,,,,,,,,,,,,
INSERT SCRDRVR TORX STARDRV T40 FOR SCREW STRL DISP OPERACE,SUP-2913596,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2748.07,1786.25,,,,,,,,,,,,,
DEVICE BONE NEEDLING GWIRE A CRV PLEURISTIK NANOFX,SUP-2123634,CDM,C1769,HCPCS,0272,RC,,,,both,,,832.10,540.86,,,,,,,,,,,,,
BLADE SHV ARTHSCP INCIS 4 MM STR STRL DISP,SUP-2341602,CDM,C1713,HCPCS,0278,RC,,,,both,,,441.17,286.76,,,,,,,,,,,,,
COCAINE HCL 40 MG/ML NA SOLN,RX-142257,CDM,C9046,HCPCS,0637,RC,70839-0362-04,NDC,,both,4,ML,1453.50,944.77,,,,,,,,,,,,,
LIFT HEEL SM WOM SUEDE LTHR TOP CVR ADJ A-LIFT,SUP-2227854,CDM,L3310,HCPCS,0274,RC,,,,both,,,16.23,10.55,,,,,,,,,,,,,
BUR SURG DIA3MM S STL DMND NEURO CVD DISP,SUP-2365187,CDM,2720000010,LOCAL,0272,RC,,,,both,,,572.74,372.28,,,,,,,,,,,,,
LIGATOR ENDOSCP MULTI-BAND XL 11-14 MM 122 CM 6 SHOT MBL6XLI,SUP-2737557,CDM,2720000010,LOCAL,0272,RC,,,,both,,,643.70,418.40,,,,,,,,,,,,,
SCREW BNE FT 4.5X72 MM CANN W/ LG HEX SOCKET SD ST TI NS,SUP-2190452,CDM,C1713,HCPCS,0278,RC,,,,both,,,557.38,362.30,,,,,,,,,,,,,
KIT ORTH DRL DIA 3.5 MM K WIRE DIA1.3 MM CANN STRL DISP,SUP-2913234,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1249.72,812.32,,,,,,,,,,,,,
KIT INSTR SCR DISP FOR PIP JT ARTH RETROFUSION,SUP-2121841,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
BENDER PLT RAD HD EVOLVE,SUP-2397210,CDM,C1713,HCPCS,0278,RC,,,,both,,,687.66,446.98,,,,,,,,,,,,,
GRAFT VASC GORTX L 100 CM DIA10 MM EPTFE STR STD WALL N RING,SUP-2396441,CDM,C1768,CPT,0278,RC,,,,both,,,2581.08,1677.70,,,,,,,,,,,,,
KIT CEM MIXING/DELIVERY 10CC RADPQ NDL 11GA L5IN W/O CEM PCD,SUP-2367027,CDM,C1713,HCPCS,0278,RC,,,,both,,,1457.84,947.60,,,,,,,,,,,,,
DRESSING WND 6 LAYR 7X10 CM MTRX CYTAL,SUP-2106532,CDM,Q4166,HCPCS,0636,RC,,,,both,,,8983.54,5839.30,,,,,,,,,,,,,
ROD REPROC SEMI CIR CRVD SS,SUP-2472209,CDM,C1713,HCPCS,0278,RC,,,,both,,,132.54,86.15,,,,,,,,,,,,,
GRAFT DERM HYDRATED THCK ACELLULAR DERM IMPL ALLGRFT,SUP-2307466,CDM,Q4128,HCPCS,0636,RC,,,,both,,,3282.49,2133.62,,,,,,,,,,,,,
BLADE RTRCTR MCCLLCH 20MMW X 70MML SPNL MSCLE NRRW RGGLS RDM,SUP-2668606,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1627.71,1058.01,,,,,,,,,,,,,
CATHETER NEUROVASC GUID 4.3FR L130CM DIA0.044IN DST ACCS W/,SUP-2367786,CDM,C1887,HCPCS,0272,RC,,,,both,,,3391.39,2204.40,,,,,,,,,,,,,
HOOK SPNL TI THOR LAM R ANG BLDE FOR 5.5MM ROD CDH LEG,SUP-2287874,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1193.20,775.58,,,,,,,,,,,,,
HC MR Sfty Implt&/FB Asmt Stf 1st 15 Min,PX-6107601400,CDM,76014,CPT,0610,RC,,,,both,,,77.00,50.05,,,,,,,,,,,,,
HC CT Cologrph Dx WO/W Cont,PX-3507426200,CDM,74262,CPT,0350,RC,,,,inpatient,,,2630.00,1709.50,,,,,,,,,,,,,
STEM VERSYS FM MC CLRLSS 12X140MM STD BODY STD NECK,SUP-2504326,CDM,C1776,CPT,0278,RC,,,,both,,,5966.00,3877.90,,,,,,,,,,,,,
HC So Chromosome Analysis Tissue,PX-3118826166,CDM,88261,CPT,0311,RC,,,,both,,,331.00,215.15,,,,,,,,,,,,,
WIRE EXT FIX L400MM DIA18MM REDUC MR SAFE,SUP-2255809,CDM,C1713,HCPCS,0278,RC,,,,both,,,668.95,434.82,,,,,,,,,,,,,
SCREW INTRF 7X20 MM PEEK OPTMA BIOSURE PK,SUP-2848613,CDM,C1713,HCPCS,0278,RC,,,,both,,,774.80,503.62,,,,,,,,,,,,,
SHEATH INTRO PRELUDEEASE 11CM 4FR 45 CM NDL 2.5 CM HYDRPHLC,SUP-2457140,CDM,C1894,HCPCS,0272,RC,,,,both,,,154.96,100.72,,,,,,,,,,,,,
BIT DRL DIA9.5MM IM FEM GEN II,SUP-2346858,CDM,2720000010,LOCAL,0272,RC,,,,both,,,642.92,417.90,,,,,,,,,,,,,
STENT BILI M L18MM BLLN L20MM DIA5MM CATH L80CM GWIRE,SUP-2159158,CDM,C1876,HCPCS,0278,RC,,,,both,,,2370.70,1540.95,,,,,,,,,,,,,
SAW SURG JOS 19 CM RT NSL BAYNT SS,SUP-2465021,CDM,2720000010,LOCAL,0272,RC,,,,both,,,425.82,276.78,,,,,,,,,,,,,
POST EXT FIX ANK FT 1 H FOR TRUELOK FRME ASSEMB HEXAPOD SYS,SUP-2316129,CDM,2720000010,LOCAL,0272,RC,,,,both,,,435.96,283.37,,,,,,,,,,,,,
KIT RECHRG SPNL CRD PULSE GENRTR STIM SYS SURG EQUIP PRECIS,SUP-2141891,CDM,C1820,HCPCS,0278,RC,,,,both,,,43960.00,28574.00,,,,,,,,,,,,,
MATRIX BIO SZ 250 SQCM FISH SKIN DERMAL SLD INTACT STRL 10/BX,SUP-2909457,CDM,Q4158,HCPCS,0636,RC,,,,both,,,23314.50,15154.42,,,,,,,,,,,,,
KIT STRT 1000ML PT DISCHRG BTL DSG GZ PD BLU WRAPPING INFO,SUP-2133737,CDM,C1729,HCPCS,0272,RC,,,,both,,,832.10,540.86,,,,,,,,,,,,,
ENDOPROSTHESIS VASC ICAST L 59 MM DIA 7 MM CATH L 120 CM,SUP-2884906,CDM,C1874,HCPCS,0278,RC,,,,both,,,8735.83,5678.29,,,,,,,,,,,,,
ELECTRODE ELECSURG ARRY MIC RECORDING,SUP-2665141,CDM,2720000010,LOCAL,0272,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
SPACER SPNL NO PROF 7 DEG 14X13X6 MM INTEGR NS SHORELINE ACS,SUP-2245650,CDM,C1821,HCPCS,0278,RC,,,,both,,,8792.00,5714.80,,,,,,,,,,,,,
BIT DRL L44.5MM DIA0.7MM STP 3MM STRYKR J LATCH FOR 1MM SCR,SUP-2187623,CDM,2720000010,LOCAL,0272,RC,,,,both,,,580.27,377.18,,,,,,,,,,,,,
GRAFT VASC HERO L 40 CM OD 19 FR ID 5 MM SIL NIT VEN OUTFLO,SUP-2516633,CDM,C1768,CPT,0278,RC,,,,both,,,7536.00,4898.40,,,,,,,,,,,,,
CLAMP EXT FIX DIA8/11MM S STEED DSTL RAD CLP ON MAG,SUP-2188533,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1277.98,830.69,,,,,,,,,,,,,
STEM FEM L175MM DIA12MM +30MM OFFSET NEUT CALCAR HIP REV,SUP-2344479,CDM,C1776,CPT,0278,RC,,,,both,,,18064.42,11741.87,,,,,,,,,,,,,
KNIFE SURG MIKAEEL 10 23 CM SCKL STRONG TTL,SUP-2459906,CDM,2720000010,LOCAL,0272,RC,,,,both,,,634.34,412.32,,,,,,,,,,,,,
DILTIAZEM HCL 30 MG PO TABS,RX-2475,CDM,6370000000,HCPCS,0637,RC,00093-0318-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
CATHETER THORACENTESIS RT ANGLE 3 FRX21 IN PVC DRN SFT,SUP-2384349,CDM,C1729,HCPCS,0272,RC,,,,both,,,65.47,42.56,,,,,,,,,,,,,
PLATE BONE SIZE 3 SHOULDER NAIL,SUP-2458648,CDM,C1713,HCPCS,0278,RC,,,,both,,,5768.18,3749.32,,,,,,,,,,,,,
NAIL FEM RG 13.5MMX420MM,SUP-2405542,CDM,C1713,HCPCS,0278,RC,,,,both,,,8700.94,5655.61,,,,,,,,,,,,,
GUIDEWIRE ORTH L220MM DIA3.2MM STD S STL SMOOTH DRL TIP FOR,SUP-2410861,CDM,C1769,HCPCS,0272,RC,,,,both,,,107.64,69.97,,,,,,,,,,,,,
CATHETER HEMODIALYSI TITAN HD CHRONIC 15.5FR DIA 55CM INTRNL,SUP-2610633,CDM,C1750,HCPCS,0278,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
PLATE BNE DBL ANGLED MED 2.5 MM RECON MAXILLA PT SPEC,SUP-2860101,CDM,C1713,HCPCS,0278,RC,,,,both,,,30345.59,19724.63,,,,,,,,,,,,,
GUIDEWIRE URO L150CM 0035IN 3CM STR TIP PTFE FLATWIRE WRP,SUP-2312642,CDM,C1769,HCPCS,0272,RC,,,,both,,,71.15,46.25,,,,,,,,,,,,,
EVOS 3.5/4.5 PP DIS FEM PL L 19H 387MM,SUP-2931160,CDM,C1713,HCPCS,0278,RC,,,,both,,,21380.26,13897.17,,,,,,,,,,,,,
ALLOGRAFT BNE MED 3.5-4X0.7-0.9 CMX 1.8-2.2 MM FD NAR PROF,SUP-2460913,CDM,C1889,HCPCS,0278,RC,,,,both,,,1930.00,1254.50,,,,,,,,,,,,,
GUIDE NERVE REP MTRX 3 MMX3 CM STRL NEURAGEN 3D LF,SUP-2877628,CDM,C9352,HCPCS,0278,RC,,,,both,,,10520.07,6838.05,,,,,,,,,,,,,
LITHOTRIPTER SURG FIBER SUREFLEX REUSE RLLF273TG] LASER VENTURES],SUP-2263897,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2041.00,1326.65,,,,,,,,,,,,,
"HC Trans, Esb, L/S, Single|BILATERAL PROCEDURE",PX-3606448300,CDM,64483,CPT,0360,RC,,,50,both,,,2817.00,1831.05,,,,,,,,,,,,,
IMPLANT ANK JT OD8MM YEL TI CONCL FOR ARTHROEREISIS,SUP-2365932,CDM,C1776,CPT,0278,RC,,,,both,,,4091.42,2659.42,,,,,,,,,,,,,
OXYCODONE HCL ER 20 MG PO T12A,RX-123651,CDM,6370000000,HCPCS,0637,RC,59011-0420-20,NDC,,both,1,UN,48.80,31.72,,,,,,,,,,,,,
HC Remove FB Foot,PX-4502819300,CDM,28193,CPT,0450,RC,,,,both,,,1649.00,1071.85,,,,,,,,,,,,,
STEM FEM INTLOK C 11X300 MM LT HIP BIMTRC,SUP-2449884,CDM,C1776,CPT,0278,RC,,,,both,,,15260.40,9919.26,,,,,,,,,,,,,
STENT URET IMAJIN L 22 MM DIA 6 FR SIL HYDRPHLC DBL LOOP,SUP-2844965,CDM,C2617,HCPCS,0278,RC,,,,both,,,439.29,285.54,,,,,,,,,,,,,
VALVE SHUNT SINGLE OPENING PRESSURE 20CM H2O WITH PREATTACHE,SUP-2821787,CDM,C1889,HCPCS,0278,RC,,,,both,,,4472.74,2907.28,,,,,,,,,,,,,
STENT NEPHURET RESOLV CONVERTX L 26 CM 10.3/8.3FR SUTURE LCK,SUP-2516567,CDM,C2617,HCPCS,0278,RC,,,,both,,,4694.30,3051.29,,,,,,,,,,,,,
GRAFT BNE SUB W10XH35XL25MM 10DEG B TRICALCIUM PHSPTE GRAN,SUP-2194025,CDM,C1713,HCPCS,0278,RC,,,,both,,,2258.41,1467.97,,,,,,,,,,,,,
GUIDEROD ORTH L1000MM DIA3MM PROX TIB BALL TIP FOR TRIGEN,SUP-2347059,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1388.88,902.77,,,,,,,,,,,,,
PLATE BONE 4 H RT TI PREBENT TENS BND MINI FOR 2MM SCR LCK,SUP-2191246,CDM,C1713,HCPCS,0278,RC,,,,both,,,1784.78,1160.11,,,,,,,,,,,,,
TRAY CATH DRNGE 65FR DIA 0038N GDWRE 25CML HDRPHLC CTD PGT,SUP-2705581,CDM,C1729,HCPCS,0272,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
CATHETER GUID 5.2FRX115CM 0.070IN ST NAVIEN,SUP-2173353,CDM,C1887,HCPCS,0272,RC,,,,both,,,5290.90,3439.08,,,,,,,,,,,,,
PLATE BNE W9XL81MM THK1MM 7 H TI 1/3 TBLR W/ CLLR LOK COMPR,SUP-2190952,CDM,C1713,HCPCS,0278,RC,,,,both,,,510.56,331.86,,,,,,,,,,,,,
IMPLANT GYN W4XL7CM DERM TUTOPLAST PROC ALLGRFT TISS FOR,SUP-2165389,CDM,C1762,CPT,0278,RC,,,,both,,,4191.90,2724.73,,,,,,,,,,,,,
ANCHOR SUTURE DA 4.75 MM PEEK KNOTLESS SYS OMEGA,SUP-2435279,CDM,C1713,HCPCS,0278,RC,,,,both,,,2245.10,1459.31,,,,,,,,,,,,,
PLATE BONE LOK DUAL CMPRSSN 92MML HLX7 STNLSS STEEL CNTRD ST,SUP-2588599,CDM,C1713,HCPCS,0278,RC,,,,both,,,932.58,606.18,,,,,,,,,,,,,
GRIP CBL L195MM STD TROCHANTERIC HIP 8 CBL ACCORD,SUP-2345208,CDM,C1776,CPT,0278,RC,,,,both,,,7762.08,5045.35,,,,,,,,,,,,,
SCREW BONE L30MM OD9.5MM 60DEG MAG UNIF COMPR STBL FIX REINF,SUP-2223910,CDM,C1713,HCPCS,0278,RC,,,,both,,,5322.30,3459.49,,,,,,,,,,,,,
GUIDEWIRE VASC STRT L 150 CM DIA 0.035 IN TIP L 10 CM DIA15,SUP-2148315,CDM,C1769,HCPCS,0272,RC,,,,both,,,67.29,43.74,,,,,,,,,,,,,
MESH HERN W7XL5.4IN OMEGA 3 FATTY ACID COAT POLYPR,SUP-2265984,CDM,C1781,HCPCS,0278,RC,,,,both,,,1648.50,1071.52,,,,,,,,,,,,,
BRACE ORTHPDC D RING SM ADLT 21.6 CM 14.6 16.5 CM RIGHT WRIS,SUP-2457443,CDM,L3931,HCPCS,0274,RC,,,,both,,,40.95,26.62,,,,,,,,,,,,,
GRAFT VASC 8 MMX25/15X70 CMX0.49 MM 30 CM RVS LOCKNIT HEMGRD,SUP-2471991,CDM,C1768,CPT,0278,RC,,,,both,,,3069.51,1995.18,,,,,,,,,,,,,
CATHETER CTRL VEN L12CM OD7FR .030IN GWIRE KT SGL LUMN N,SUP-2120595,CDM,C1751,HCPCS,0278,RC,,,,both,,,161.40,104.91,,,,,,,,,,,,,
GRAFT HUM TISS M W60MMX10CM FASC LATA FRZN,SUP-2307272,CDM,C1713,HCPCS,0278,RC,,,,both,,,1863.90,1211.53,,,,,,,,,,,,,
COLLAR CERV SFT 375X21IN XL,SUP-2276588,CDM,L0120,HCPCS,0274,RC,,,,both,,,6.19,4.02,,,,,,,,,,,,,
Z DISCONTINUED SEALER TISS L14CM DIA5MM ADV BPLR CRV TIP OPN APPRCH ENSEAL,SUP-2219726,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1205.89,783.83,,,,,,,,,,,,,
REAMER SURG DIA46MM ACET BSKT,SUP-2368443,CDM,C1713,HCPCS,0278,RC,,,,both,,,862.78,560.81,,,,,,,,,,,,,
STENT URET 45FR L10CM POLYMER HYDRPHLC OPN TIP RADPQ MRK,SUP-2313775,CDM,C2617,HCPCS,0278,RC,,,,both,,,255.50,166.07,,,,,,,,,,,,,
PLATE BONE STRUT 1.5 MM 2 HOLE RAPID RESORBABLE STERILE RAPI,SUP-2838554,CDM,C1713,HCPCS,0278,RC,,,,both,,,1863.90,1211.53,,,,,,,,,,,,,
SPLINT ANK FT XL R POST LEAF LTWT SEMI RIG ROLYAN,SUP-2326016,CDM,L4397,HCPCS,0272,RC,,,,both,,,113.89,74.03,,,,,,,,,,,,,
PLATE BNE L W135XL296MM THK42MM 16 H BILAT TI NAR RIG NEUT,SUP-2190832,CDM,C1713,HCPCS,0278,RC,,,,both,,,2443.42,1588.22,,,,,,,,,,,,,
METHYLERGONOVINE MALEATE 0.2 MG/ML IJ SOLN,RX-10571,CDM,J2210,HCPCS,0636,RC,51991-0144-17,NDC,,both,1,ML,113.70,73.90,,,,,,,,,,,,,
SCREW LOCKING 1.6X7MM,SUP-2741717,CDM,C1713,HCPCS,0278,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
REAMER SURG 10MM NONSTERILE FOR HAMRTOE HTR IMPL SYS,SUP-2390551,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2182.30,1418.49,,,,,,,,,,,,,
HEAD FEM DIA32MM NK L+0MM ALUMINA CERAMIC 12/14 TAPR,SUP-2344800,CDM,C1776,CPT,0278,RC,,,,both,,,4980.04,3237.03,,,,,,,,,,,,,
PLATE ANCHORAGE 2 MTP CP RT,SUP-2695662,CDM,C1713,HCPCS,0278,RC,,,,both,,,9571.66,6221.58,,,,,,,,,,,,,
ENDO FUSE  FUSION BEAM 45X15MM,SUP-2466732,CDM,C1713,HCPCS,0278,RC,,,,both,,,6402.46,4161.60,,,,,,,,,,,,,
STRAP FNGR W5/8IN BGE BUDDY HK LOOP CLSR ROLYAN,SUP-2324809,CDM,L3933,HCPCS,0272,RC,,,,both,,,4.24,2.76,,,,,,,,,,,,,
STENT URO DBL PGTL FIRM SUT HYDRPHLC POLYMER COAT POS THRD,SUP-2141667,CDM,C2617,HCPCS,0278,RC,,,,both,,,457.81,297.58,,,,,,,,,,,,,
ELECTRODE ENDOSCP HF-RESECTION 12-30 DEG PLASMA-OVALBUTTON,SUP-2467542,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1877.44,1220.34,,,,,,,,,,,,,
LEVEL NEURO MESH 3D NEURO SCRW125 X 125 MM T10 MM CP TTNM Q,SUP-2681433,CDM,C1713,HCPCS,0278,RC,,,,both,,,8569.75,5570.34,,,,,,,,,,,,,
PIN FIX DIAMOND PT 1 END 3/16X9 IN 3 PT STYL SMOOTH PLN STRL,SUP-2150476,CDM,C1713,HCPCS,0278,RC,,,,both,,,19.06,12.39,,,,,,,,,,,,,
HC RBC Irradiated Each Unit,PX-3900903800,CDM,P9038,CPT,0390,RC,,,,both,,,1444.00,938.60,,,,,,,,,,,,,
PIN EXT FIX HALF SELF-THREADED 6X180 MM TAPR NS TRUELOK,SUP-2875027,CDM,C1713,HCPCS,0278,RC,,,,both,,,323.11,210.02,,,,,,,,,,,,,
BIT DRL L35MM DIA3.2MM ACET SCR FLEX REFLCT,SUP-2345717,CDM,2720000010,LOCAL,0272,RC,,,,both,,,457.18,297.17,,,,,,,,,,,,,
SCREW BNE L60MM OD5MM 6.5MM TI HND FT ST CANN NONLOCKING,SUP-2107233,CDM,C1713,HCPCS,0278,RC,,,,both,,,3510.52,2281.84,,,,,,,,,,,,,
IMMOBILIZER ORTH M TIETEX SHLDR,SUP-2195526,CDM,L3650,HCPCS,0272,RC,,,,both,,,11.43,7.43,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY LASSOSTAR NAV L 115 CM DIA 7 FR,SUP-2248923,CDM,C1732,HCPCS,0272,RC,,,,both,,,4549.86,2957.41,,,,,,,,,,,,,
SCREW BONE L10MM DIA2MM HND VAR ANG LCK FLOWERCUBE,SUP-2225441,CDM,C1713,HCPCS,0278,RC,,,,both,,,374.29,243.29,,,,,,,,,,,,,
CATHETER INFUS 7FR L8IN SGL LUMN FOR USE W/ PERC SHTH INTRO,SUP-2383495,CDM,C1751,HCPCS,0278,RC,,,,both,,,27.26,17.72,,,,,,,,,,,,,
SCREW BNE L16MM DIA5MM PERIPROSTHETIC LOK,SUP-2381386,CDM,C1713,HCPCS,0278,RC,,,,both,,,813.26,528.62,,,,,,,,,,,,,
BIT DRL L221MM DIA4.3MM QUIK CPL REUSE,SUP-2187278,CDM,2720000010,LOCAL,0272,RC,,,,both,,,649.70,422.30,,,,,,,,,,,,,
SCREW BONE L5MM DIA2MM CORT TI ST LCK PLUSDRIVE RECESS,SUP-2189393,CDM,C1713,HCPCS,0278,RC,,,,both,,,503.78,327.46,,,,,,,,,,,,,
MESH HERN W3XL6IN SFT POLYPR OPN WV PROL SURGPRO,SUP-2219918,CDM,C1781,HCPCS,0278,RC,,,,both,,,790.02,513.51,,,,,,,,,,,,,
CLIP ANEUR 2X3MM S STL GRFT ENCIRCLE DISP SUNDT SLIM-LINE,SUP-2243078,CDM,C1713,HCPCS,0278,RC,,,,both,,,3658.10,2377.76,,,,,,,,,,,,,
HC Drain/Inject Joint/Bursa|PBB CHARGE|UNUSUAL NON-OVERLAPPING SERVICE,PX-4502060000,CDM,20600,CPT,0450,RC,,,PBB|XU,both,,,358.00,232.70,,,,,,,,,,,,,
BUR SURG DIA 4 MM RVS TAPR 2 RNG STRL DISP ELAN 4,SUP-2928881,CDM,2720000010,LOCAL,0272,RC,,,,both,,,393.13,255.53,,,,,,,,,,,,,
CEMENT DENT 25GM 35GM SELF CURED LUTING BONDS CHEMICALLY LT,SUP-2238616,CDM,C1713,HCPCS,0278,RC,,,,both,,,113.32,73.66,,,,,,,,,,,,,
INSERTION KIT PKGD SENSATION PLUS 40CC,SUP-2850007,CDM,C1894,HCPCS,0272,RC,,,,both,,,449.40,292.11,,,,,,,,,,,,,
COIL EMB L57CM OD0.020IN LOOP OD15MM STD NIT COMPLX FRME,SUP-2323380,CDM,C1889,HCPCS,0278,RC,,,,both,,,7470.06,4855.54,,,,,,,,,,,,,
ROD EXT FIX 11X300MM C FBR,SUP-2188661,CDM,2720000010,LOCAL,0272,RC,,,,both,,,813.73,528.92,,,,,,,,,,,,,
INTRODUCER NEUROSTIMULATOR LD FOR URIN CTRL INTERSTIM,SUP-2284431,CDM,C1894,HCPCS,0272,RC,,,,both,,,835.24,542.91,,,,,,,,,,,,,
ATTACHMENT DRL ELITE SABER LNG,SUP-2363305,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4351.79,2828.66,,,,,,,,,,,,,
CATHETER CTRL VEN 8FR NONPOWER INJ SGL LUMN W/ TISS,SUP-2127894,CDM,C1751,HCPCS,0278,RC,,,,both,,,1970.41,1280.77,,,,,,,,,,,,,
SHEATH INTRO L 10 CM DIA 3 FR NIT WIRE TEARWY SUPER,SUP-2627256,CDM,C1894,HCPCS,0272,RC,,,,both,,,543.22,353.09,,,,,,,,,,,,,
CATHETER EMB NOVASIL SYNTEL L 80 CM DIA 6 FR BALLOON DIA13,SUP-2264200,CDM,C1757,HCPCS,0272,RC,,,,both,,,499.26,324.52,,,,,,,,,,,,,
BLOCK ILIUM TRICORT TRAD ALLGRFT L 19 - 21 MM FRZ DRY,SUP-2294070,CDM,C1713,HCPCS,0278,RC,,,,both,,,2543.40,1653.21,,,,,,,,,,,,,
GRAFT BNE PTTY 0.5 CC JR DBM GRFT,SUP-2278348,CDM,C9359,HCPCS,0278,RC,,,,both,,,243.66,158.38,,,,,,,,,,,,,
DEFIBRILLATOR IMPL VIVA QUAD XT TI POLYUR SIL RUBBER 2 CHMBR,SUP-2282404,CDM,C1882,HCPCS,0275,RC,,,,both,,,54904.28,35687.78,,,,,,,,,,,,,
HC Removal Duct Glbldr Calculi,PX-3614754400,CDM,47544,CPT,0361,RC,,,,inpatient,,,8583.00,5578.95,,,,,,,,,,,,,
CATHETER ETER EP DIAG MAP M CRV QPLR 2 5 2MM SPC 5MM TIP BI DIR,SUP-2356986,CDM,C1733,HCPCS,0272,RC,,,,both,,,1868.30,1214.39,,,,,,,,,,,,,
SLEEVE POS DIA10MM UNIV SHLDR CO CHROM CEM PRI FOR HUM FRAC,SUP-2404532,CDM,C1776,CPT,0278,RC,,,,both,,,715.92,465.35,,,,,,,,,,,,,
NEEDLE SPNL 14GA L9CM DISPOSABLE TUOHY PS MED IMPL AND THER,SUP-2284399,CDM,C1713,HCPCS,0278,RC,,,,both,,,261.53,169.99,,,,,,,,,,,,,
SWANSON TI GREAT TOE IMPL HEMI ARTHROPLASTY CLR CODE SZ SET,SUP-2397936,CDM,C1776,CPT,0278,RC,,,,both,,,1865.16,1212.35,,,,,,,,,,,,,
STAPLE BNE FIX BRDG W20MM LEG L20X20MM WIRE DIA2X3MM S STL,SUP-2194228,CDM,C1713,HCPCS,0278,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
ANCHOR SFT TISS L17MM OD4MM DISP GUN ECLIPSE,SUP-2277473,CDM,C1713,HCPCS,0278,RC,,,,both,,,2810.30,1826.69,,,,,,,,,,,,,
PLATE BNE 3.5X265 MM 22 HOLE SS DCP,SUP-2569148,CDM,C1713,HCPCS,0278,RC,,,,both,,,483.56,314.31,,,,,,,,,,,,,
STEM FEM L121MM DIA11MM HIP EXT OFFSET REDUC NK LEN MEDL,SUP-2137013,CDM,C1713,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
COUNTERSINK SURG OD3.5MM HDLSS DISP MONSTER,SUP-2320971,CDM,C1713,HCPCS,0278,RC,,,,both,,,648.41,421.47,,,,,,,,,,,,,
SEALANT FISS PIT LO VISC KT PEARLESCENT,SUP-2322099,CDM,2720000010,LOCAL,0272,RC,,,,both,,,97.09,63.11,,,,,,,,,,,,,
DRIVER SURG T15 FEMALE TENOTAC,SUP-2749819,CDM,2720000010,LOCAL,0272,RC,,,,both,,,819.54,532.70,,,,,,,,,,,,,
"HC New Pt, Outpt Visit Level 4",PX-7619920400,CDM,99204,CPT,0761,RC,,,,outpatient,,,344.00,223.60,,,,,,,,,,,,,
STENT BILI SELF EXP 5FR CATHETER  219CM CATHETER  LEN AMSDAM,SUP-2436439,CDM,C1876,HCPCS,0278,RC,,,,both,,,4126.84,2682.45,,,,,,,,,,,,,
PLATE BNE VA 2 MM 6 HOLE LCK FRAC TI NS,SUP-2190286,CDM,C1713,HCPCS,0278,RC,,,,both,,,2509.24,1631.01,,,,,,,,,,,,,
ALLOGRAFT BNE COSTAL CART 5-8 CM,SUP-2321775,CDM,C1762,CPT,0278,RC,,,,both,,,3124.30,2030.79,,,,,,,,,,,,,
TUBE INNR EAR MYR VENT FLNG W/ TAB 1.27 MM ID STRL MORETZ,SUP-2284047,CDM,L8699,HCPCS,0278,RC,,,,both,,,60.32,39.21,,,,,,,,,,,,,
SUPPORT ORTH LO SPINE ADJ VISTA 464 TLSO,SUP-2123918,CDM,L0464,HCPCS,0274,RC,,,,both,,,993.81,645.98,,,,,,,,,,,,,
LEAD DEFIB LINOXSMART S DX L 65 CM TIP DISTANCE 17 CM PTIR,SUP-2138196,CDM,C1777,HCPCS,0275,RC,,,,both,,,8792.00,5714.80,,,,,,,,,,,,,
HC US Duplex Abd/Pelvis/Scrotum Ltd,PX-9219397600,CDM,93976,CPT,0921,RC,,,,both,,,1152.00,748.80,,,,,,,,,,,,,
GUIDEWIRE VASC L 50 CM DIA 0.018 IN TIP CRV RAD 3 MM HVY DBL,SUP-2759994,CDM,C1769,HCPCS,0272,RC,,,,both,,,133.67,86.89,,,,,,,,,,,,,
BIT DRL DIA4.5MM CANN DISP,SUP-2412628,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1339.84,870.90,,,,,,,,,,,,,
DISTRACTOR SURG L 20 MM 3 X 3 H LT MANDIBULAR PED NS,SUP-2883552,CDM,C1713,HCPCS,0278,RC,,,,both,,,22874.90,14868.68,,,,,,,,,,,,,
RETRACTOR W21MM H15MM L5CM TUBE D.6IN OD12MM SELF RET MEDL,SUP-2393992,CDM,C1894,HCPCS,0272,RC,,,,both,,,2182.30,1418.49,,,,,,,,,,,,,
CATHETER THOR 32FR DIA10.7MM POLYVI CHL TRCR TIP STR SFT,SUP-2384356,CDM,C1729,HCPCS,0272,RC,,,,both,,,20.72,13.47,,,,,,,,,,,,,
BENDING PIN FOR LOCKING ATTACHMENT PLATES,SUP-2548486,CDM,C1713,HCPCS,0278,RC,,,,both,,,936.85,608.95,,,,,,,,,,,,,
SPACER PROX CNTRLZR HIP 12/13MM VLIGN VERSYS,SUP-2203475,CDM,C1776,CPT,0278,RC,,,,both,,,244.92,159.20,,,,,,,,,,,,,
CATHETER NEPHROSTOMY PIG 6.5 FRX30 CM TOT ABSCESSION,SUP-2752473,CDM,C1729,HCPCS,0272,RC,,,,both,,,224.13,145.68,,,,,,,,,,,,,
SPHINCTEROTOME STONETOME BELOW CUT WIRE 30MM TIP 5MM,SUP-2149503,CDM,C1713,HCPCS,0278,RC,,,,both,,,1093.44,710.74,,,,,,,,,,,,,
HC Pvb Thoracic 2 or More Inj Site,PX-3606446200,CDM,64462,CPT,0360,RC,,,,both,,,2230.00,1449.50,,,,,,,,,,,,,
PIN HALF THRD 4X180 MM 55 MM CIR FIX,SUP-2400697,CDM,C1713,HCPCS,0278,RC,,,,both,,,458.44,297.99,,,,,,,,,,,,,
SHEATH INTRO FLX ANSEL 70CM 7FR ID 2.5MM 0.035IN AQ MULTPURP,SUP-2171142,CDM,C1894,HCPCS,0272,RC,,,,both,,,209.85,136.40,,,,,,,,,,,,,
COIL VASC AZUR HYDROCOIL L 4 CM DIA 4 MM MICROCATHETER 0.035,SUP-2385370,CDM,C1889,HCPCS,0278,RC,,,,both,,,769.30,500.04,,,,,,,,,,,,,
MORPHINE SULFATE (CONCENTRATE) 100 MG/5ML PO SOLN,RX-117786,CDM,340b,HCPCS,0637,RC,09999-9900-26,NDC,,both,0.125,ML,2.70,1.75,,,,,,,,,,,,,
HC Pt Adl Training 15mn|OP PT SERVICES,PX-4209753500,CDM,97535,CPT,0420,RC,,,GP,outpatient,,,174.00,113.10,,,,,,,,,,,,,
SUBSTITUTE BNE GRFT VOID FILL CA PHSPTE ST 3CC OSTEOVATION,SUP-2319786,CDM,C1713,HCPCS,0278,RC,,,,both,,,3576.46,2324.70,,,,,,,,,,,,,
RING EXT FIX ID205MM ALUM FULL FOR TAY SPAT FRME ILIZ,SUP-2342966,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6624.62,4306.00,,,,,,,,,,,,,
CATHETER CV 1 LUMEN 4 FR MAXIMAL BARR TY POWERPICC SOLO 2,SUP-2126373,CDM,C1751,HCPCS,0278,RC,,,,both,,,555.69,361.20,,,,,,,,,,,,,
CURETTE KYPHOPLASTY SZ 3 DIA8MM T TIP FOR VERTPLSTY EXPR,SUP-2293446,CDM,2720000010,LOCAL,0272,RC,,,,both,,,532.70,346.25,,,,,,,,,,,,,
SYRINGE BNE GRFT,SUP-2430776,CDM,2720000010,LOCAL,0272,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
ASPIRATION KIT BNE MAR 120 ML,SUP-2223568,CDM,C1713,HCPCS,0278,RC,,,,both,,,7567.40,4918.81,,,,,,,,,,,,,
CONNECTOR CATH Y 1X2 MM RADIOPAQUE POLYPR STRL,SUP-2851299,CDM,C1729,HCPCS,0272,RC,,,,both,,,3295.34,2141.97,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 60 CM DIA 6 MM EPTFE STR TW REINF 2,SUP-2486125,CDM,C1768,CPT,0278,RC,,,,both,,,1341.60,872.04,,,,,,,,,,,,,
CORKSCREW SURG 7.5 IN T HNDL,SUP-2138731,CDM,C1713,HCPCS,0278,RC,,,,both,,,530.66,344.93,,,,,,,,,,,,,
BLADE RETRACTOR 2 12INW LATERAL WIRE ULTRA,SUP-2670316,CDM,2720000010,LOCAL,0272,RC,,,,both,,,254.18,165.22,,,,,,,,,,,,,
POTASSIUM CHLORIDE IN NACL 20-0.9 MEQ/L-% IV SOLN,RX-102329,CDM,J3480,HCPCS,0636,RC,00264-7865-00,NDC,,both,1000,ML,54.10,35.16,,,,,,,,,,,,,
PLATE BNE MIDFACE 1.5X42X19X0.6 MM LT PARANASAL 22 HOLE NS,SUP-2494988,CDM,C1713,HCPCS,0278,RC,,,,both,,,2330.67,1514.94,,,,,,,,,,,,,
GRAFT VASC ADVANTA SST L 80 CM DIA 6 MM RNG L 20 CM EPTFE,SUP-2227385,CDM,C1768,CPT,0278,RC,,,,both,,,4684.91,3045.19,,,,,,,,,,,,,
SET DLYS HEMDLYS ACCS HEM CATH,SUP-2117387,CDM,C1881,HCPCS,0278,RC,,,,both,,,160.77,104.50,,,,,,,,,,,,,
PLATE BNE Y 1.5X29X1 MM MIDFACE 7 HOLE W/ TAB TI LEVEL 1,SUP-2422379,CDM,C1713,HCPCS,0278,RC,,,,both,,,815.93,530.35,,,,,,,,,,,,,
GUIDEWIRE VASC HIWIRE L 80 CM DIA 0.035 IN TAPR L 22 CM FLPY,SUP-2638726,CDM,C1769,HCPCS,0272,RC,,,,both,,,96.27,62.58,,,,,,,,,,,,,
ANCHOR SUT DIA5.5MM SZ 2 BLU WHT PEEK OPTMA COBRAID TWINFIX,SUP-2341841,CDM,C1713,HCPCS,0278,RC,,,,both,,,845.70,549.70,,,,,,,,,,,,,
EPINEPHRINE 0.15 MG/0.3ML IJ SOAJ,RX-125412,CDM,J0169,HCPCS,0636,RC,49502-0101-01,NDC,,both,1,UN,862.50,560.62,,,,,,,,,,,,,
HC Tips Revision,PX-3613718300,CDM,37183,CPT,0361,RC,,,,both,,,15457.00,10047.05,,,,,,,,,,,,,
SCREW BNE L30MM DIA65MM UNIV CTRL SHLDR NONLOCKING FOR,SUP-2123297,CDM,C1713,HCPCS,0278,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
LANSOPRAZOLE 30 MG PO TBDD,RX-147436,CDM,6370000000,HCPCS,0637,RC,65862-0896-10,NDC,,both,1,UN,28.50,18.52,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH ALPHA L 105 MM DIA24 MM SHTH 16 FR RVD,SUP-2170225,CDM,C1874,HCPCS,0278,RC,,,,both,,,50130.10,32584.56,,,,,,,,,,,,,
SCREW BNE L65MM DIA5MM TIB TI DBL LD FOR PHOENIX NAIL SYS,SUP-2412134,CDM,C1713,HCPCS,0278,RC,,,,both,,,627.37,407.79,,,,,,,,,,,,,
CATHETER THROMCTMY LIGHTNING BOLT INDIGO L 132 CM SHTH 6 FR,SUP-2930520,CDM,C1757,HCPCS,0272,RC,,,,both,,,24240.80,15756.52,,,,,,,,,,,,,
CATHETER CV 3L UNIV 5 FR W/ MAXIMAL BARR POWERPICC,SUP-2126713,CDM,C1751,HCPCS,0278,RC,,,,both,,,789.14,512.94,,,,,,,,,,,,,
PLATE SPNL L35MM SPINOUS PROC AFFIX II,SUP-2311358,CDM,C1713,HCPCS,0278,RC,,,,both,,,8635.00,5612.75,,,,,,,,,,,,,
ARTHREX MENISCAL DART 14MM 5-BOX,SUP-2812806,CDM,C1713,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
PLATE BNE TIB 4.5/6.5X109 MM LT PROX 5 HOLE SS EPI UNION,SUP-2461237,CDM,C1713,HCPCS,0278,RC,,,,both,,,4082.00,2653.30,,,,,,,,,,,,,
POUCH DISP PLAS ADD PROTCT PREVENT TAMPERING TEMP,SUP-2281987,CDM,2780000010,LOCAL,0278,RC,,,,both,,,197.88,128.62,,,,,,,,,,,,,
EXTENSION STEM STR 18X175 MM KNEE REV PERSONA,SUP-2508772,CDM,C1776,CPT,0278,RC,,,,both,,,4044.32,2628.81,,,,,,,,,,,,,
GRAFT BIO TISS W8XL16CM THK0.8-1.7MM THCK STRUCTURAL,SUP-2307479,CDM,C1713,HCPCS,0278,RC,,,,both,,,10132.15,6585.90,,,,,,,,,,,,,
RESTRICTOR CEM DIA12MM UNIV FEM CNL UHMWPE BIOSTP G,SUP-2253100,CDM,C1713,HCPCS,0278,RC,,,,both,,,172.70,112.25,,,,,,,,,,,,,
MESH HERN 75X15CM MACROPOROUS ULTRAPRO ADV,SUP-2257825,CDM,C1781,HCPCS,0278,RC,,,,both,,,410.15,266.60,,,,,,,,,,,,,
FILLER BONE VOID 3ML HA SYNTH CA PHOS PUTTY TISS IMPL CEM,SUP-2194287,CDM,C1713,HCPCS,0278,RC,,,,both,,,4066.30,2643.09,,,,,,,,,,,,,
SPLINT ANK REG UNIV STRRP AIR AND GEL FOR CLD THER,SUP-2276708,CDM,L4350,HCPCS,0272,RC,,,,both,,,44.27,28.78,,,,,,,,,,,,,
SET CLLR AD H2 1/4IN FOR 13-21IN NK SHT BLU PLAS HK AND,SUP-2124215,CDM,L0172,HCPCS,0274,RC,,,,both,,,96.96,63.02,,,,,,,,,,,,,
LUBIPROSTONE 8 MCG PO CAPS,RX-91534,CDM,6370000000,HCPCS,0637,RC,63304-0351-60,NDC,,both,1,UN,8.00,5.20,,,,,,,,,,,,,
PLATE BONE W5XL23MM THK0.9MM 4 H MINI S STL STR,SUP-2343833,CDM,C1713,HCPCS,0278,RC,,,,both,,,496.47,322.71,,,,,,,,,,,,,
PLATE LCK STRNL 8-H LAD T 1.8MM,SUP-2262585,CDM,C1713,HCPCS,0278,RC,,,,both,,,1098.65,714.12,,,,,,,,,,,,,
PLATE BNE L33MM THK1MM 2X6 H NONSTERILE HND TI ROT CORR LOK,SUP-2255846,CDM,C1713,HCPCS,0278,RC,,,,both,,,2194.73,1426.57,,,,,,,,,,,,,
GUIDEWIRE VASC L 220 CM DIA 0.035 IN TAPR L 6 CM FLPY TIP L,SUP-2638693,CDM,C1769,HCPCS,0272,RC,,,,both,,,172.42,112.07,,,,,,,,,,,,,
PLATE BONE LOK 93MML HLX8 STNLSS STEEL 14 TBLR ST,SUP-2724113,CDM,C1713,HCPCS,0278,RC,,,,both,,,679.18,441.47,,,,,,,,,,,,,
ROD SPNL ANTR SMOOTH TI ALLOY 5.5MM DIA 120MM LEN,SUP-2289286,CDM,C1713,HCPCS,0278,RC,,,,both,,,1403.58,912.33,,,,,,,,,,,,,
STENT URTRL 7FR DIA 30CML TCFLX DBLE PGTL OPEN END CLSSC SNG,SUP-2721959,CDM,C2617,HCPCS,0278,RC,,,,both,,,176.15,114.50,,,,,,,,,,,,,
ANCHOR SUTURE NO2 L16.5MM OD6MM 3.5MM DISPOSABLE BONE PUNCH,SUP-2842790,CDM,C1713,HCPCS,0278,RC,,,,both,,,882.69,573.75,,,,,,,,,,,,,
TUBE SUCT L7IN OD6FR TAPR TEARDROP MAL T FUKUSHIMA,SUP-2436395,CDM,2720000010,LOCAL,0272,RC,,,,both,,,405.00,263.25,,,,,,,,,,,,,
PACK PHACO 09MM 30DEG RND ABS LEG,SUP-2109846,CDM,C1713,HCPCS,0278,RC,,,,both,,,637.42,414.32,,,,,,,,,,,,,
IMPLANT COSMETIC SZ 38 X 50 X 1 MM POLYETHYL ORBIT FLR SMTH,SUP-2935214,CDM,C1713,HCPCS,0278,RC,,,,both,,,2392.68,1555.24,,,,,,,,,,,,,
PROBE SURG 0.028 IN ACUTRK,SUP-2535350,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2144.62,1394.00,,,,,,,,,,,,,
SCREW BNE L 40 MM DIA 4 MM TI ST SD CANN PARTIALLY THRD,SUP-2900619,CDM,C1713,HCPCS,0278,RC,,,,both,,,2339.30,1520.54,,,,,,,,,,,,,
CAGE SPNL MESH 15X12X13 MM 6 LOBE,SUP-2602072,CDM,C1889,HCPCS,0278,RC,,,,both,,,8079.22,5251.49,,,,,,,,,,,,,
PLATE BONE TIBIAL RIGHT PROXIMAL LATERAL 10 HOLE LOCKING,SUP-2836984,CDM,C1713,HCPCS,0278,RC,,,,both,,,8513.01,5533.46,,,,,,,,,,,,,
DEVICE DEL BNE GRFT 10 CM W/CANN OSTEOPRECISION,SUP-2123475,CDM,2720000010,LOCAL,0272,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
HC I&D Ischio Perirectal Abs,PX-4504604000,CDM,46040,CPT,0450,RC,,,,both,,,1217.00,791.05,,,,,,,,,,,,,
CATHETER CV MAXIMAL BARR TY 018 4 FRX8 CM 18 GA DL SPECTRUM,SUP-2759891,CDM,C1751,HCPCS,0278,RC,,,,both,,,566.24,368.06,,,,,,,,,,,,,
GRAFT HUM TISS W11XL30MM THK11MM FRZ DRY ALLGRFT BLK CANC,SUP-2307113,CDM,C1713,HCPCS,0278,RC,,,,both,,,2662.66,1730.73,,,,,,,,,,,,,
TITANIUM STRAIGHT BAR 101MM,SUP-2679249,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1039.31,675.55,,,,,,,,,,,,,
HC So Cbc W/O Diff,PX-3058502766,CDM,85027,CPT,0305,RC,,,,both,,,79.00,51.35,,,,,,,,,,,,,
SCREW SPNL 4.25X16MM CERV VAR SPIDER,SUP-2402175,CDM,C1713,HCPCS,0278,RC,,,,both,,,740.88,481.57,,,,,,,,,,,,,
ELECTRODE CORTICAL 1 X 8 KT STRL DISP EVO,SUP-2934934,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2675.28,1738.93,,,,,,,,,,,,,
COMPONENT TIB AUG SL LG,SUP-2445634,CDM,C1776,CPT,0278,RC,,,,both,,,1596.69,1037.85,,,,,,,,,,,,,
PLATE BNE L91MM 2 H ST R PERIARTC PROX HUM S STL LOK LO PROF,SUP-2177802,CDM,C1713,HCPCS,0278,RC,,,,both,,,5132.55,3336.16,,,,,,,,,,,,,
CANNULA SURG A INSUL MARS 3V,SUP-2417904,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3293.86,2141.01,,,,,,,,,,,,,
SCREW BNE L120MM DIA12MM HIP NAIL LAG FOR TRAUM GAM,SUP-2370995,CDM,C1713,HCPCS,0278,RC,,,,both,,,865.07,562.30,,,,,,,,,,,,,
BLADE SHAVER CLOSED 40 DEG 4 MM MALL STRL DISP,SUP-2648977,CDM,2720000010,LOCAL,0272,RC,,,,both,,,469.12,304.93,,,,,,,,,,,,,
GUIDE SURG 3D PRNT MIDFACE MAND TI TRUMATCH SD980.017,SUP-2860364,CDM,C1713,HCPCS,0278,RC,,,,both,,,9655.81,6276.28,,,,,,,,,,,,,
HEAD FEM MOD 0+ MM STD 32 MM 9/10 MM HIP TAPR ELITE,SUP-2456454,CDM,C1776,CPT,0278,RC,,,,both,,,1921.68,1249.09,,,,,,,,,,,,,
SHEATH INTRO FAST-CATH SWARTZ SL L 85 CM DIA10 FR GUIDEWIRE,SUP-2357209,CDM,C1893,HCPCS,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
GRAFT BNE PASTE 8 CC SYR DBM ORTHOBLAST II,SUP-2641748,CDM,C1713,HCPCS,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
DISSECTOR LAP BLLN VEIN,SUP-2329903,CDM,C1727,CPT,0278,RC,,,,both,,,949.85,617.40,,,,,,,,,,,,,
MICRO BONE PLATE 4 X 4 HOLES RCTNGLR SGMNTS .6MM 1.0MM SSTM,SUP-2496429,CDM,C1713,HCPCS,0278,RC,,,,both,,,1212.45,788.09,,,,,,,,,,,,,
METHYLPREDNISOLONE 4 MG PO TABS,RX-4993,CDM,J7509,HCPCS,0636,RC,00009-0056-02,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
STEM FEM PRSS FT 18X150 MM REV SLT GEN II,SUP-2435049,CDM,C1776,CPT,0278,RC,,,,both,,,5074.24,3298.26,,,,,,,,,,,,,
PROCESSOR SND 2 MM EXT SNAP CPL SLV NS BAHA LTX,SUP-2858116,CDM,L8693,HCPCS,0278,RC,,,,both,,,11628.58,7558.58,,,,,,,,,,,,,
GRAFT HUM TISS W12XL12CM THK1.04-2.28MM THCK REGEN TISS,SUP-2113000,CDM,Q4116,HCPCS,0636,RC,,,,both,,,16528.96,10743.82,,,,,,,,,,,,,
GUIDEWIRE VASC L 145 CM DIA 0.038 IN STR TIP TORQUE,SUP-2169671,CDM,C1769,HCPCS,0272,RC,,,,both,,,131.88,85.72,,,,,,,,,,,,,
SCREW BNE L 14 MM DIA 3.5 MM TI CORTICAL WR ST T15 DRV STRL,SUP-2931789,CDM,C1713,HCPCS,0278,RC,,,,both,,,135.93,88.35,,,,,,,,,,,,,
GRAFT BONE THK5MM FNGR JT LAPIDUS WDG,SUP-2321673,CDM,C1713,HCPCS,0278,RC,,,,both,,,7313.69,4753.90,,,,,,,,,,,,,
PIN FIX 1.6X6 MM FLAT HD US ACTIVATION POLY-D-L-LACTIC ACID,SUP-2474788,CDM,C1713,HCPCS,0278,RC,,,,both,,,268.63,174.61,,,,,,,,,,,,,
VALVE 10 WITH SPRUNG RESERVOIR MININAV,SUP-2821808,CDM,C1889,HCPCS,0278,RC,,,,both,,,1718.68,1117.14,,,,,,,,,,,,,
GRAFT VASC VENAFLO II L 35 CM DIA 4-7 MM EPTFE CARBON STP N,SUP-2128786,CDM,L8670,HCPCS,0278,RC,,,,both,,,5481.18,3562.77,,,,,,,,,,,,,
OCCLUDER CV 45 DEG 18 MM 8 FR AMPLATZER PFO,SUP-2357476,CDM,C1817,HCPCS,0278,RC,,,,both,,,31384.30,20399.79,,,,,,,,,,,,,
TRIAL PLATE CRV 0.8 MM ML,SUP-2525715,CDM,C1713,HCPCS,0278,RC,,,,both,,,1011.08,657.20,,,,,,,,,,,,,
PICC AGBA NAVICURVE 3L 6FR X 55CM TCG,SUP-2867377,CDM,C1751,HCPCS,0278,RC,,,,both,,,898.04,583.73,,,,,,,,,,,,,
SEALER BPLR MINI MINIMALLY INVASIVE FLX BPLR W/ SALN FLD DEL,SUP-2277932,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2062.98,1340.94,,,,,,,,,,,,,
PUTTY BONE GRAFT 5ML DBM,SUP-2632265,CDM,C1713,HCPCS,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
ANCHOR SUT BIOCRYL RAPIDE W/ PROKNOT TECHNOLOGY FOR JT RECON,SUP-2256594,CDM,C1713,HCPCS,0278,RC,,,,both,,,1789.80,1163.37,,,,,,,,,,,,,
SLEEVE EXT FIX DIA 4/5 MM CENTERING,SUP-2898477,CDM,2720000010,LOCAL,0272,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
PLATE BNE CLMN ARCH LG 2 MM LT MEDL TI GORILLA,SUP-2751074,CDM,C1713,HCPCS,0278,RC,,,,both,,,5016.15,3260.50,,,,,,,,,,,,,
CLAMP EXT FIX 10.5MM BAR TO 5MM PIN FRDM MR SAFE JET-X,SUP-2342892,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4614.39,2999.35,,,,,,,,,,,,,
CATHETER HD DL 14 FRX15 CM SLX TEMP DLYS FULL TY,SUP-2267000,CDM,C1752,HCPCS,0278,RC,,,,both,,,577.76,375.54,,,,,,,,,,,,,
BRACE ORTH ADJACENT FIT ELBW CUST FIT,SUP-2388191,CDM,L3760,HCPCS,0274,RC,,,,both,,,1755.26,1140.92,,,,,,,,,,,,,
CATHETER REPROC EP 6FRX115CM 10-ELECTRD 2-5-2MM,SUP-2653047,CDM,C1730,HCPCS,0272,RC,,,,both,,,441.77,287.15,,,,,,,,,,,,,
SCREW SPACER CROSS DRV TI,SUP-2496969,CDM,C1713,HCPCS,0278,RC,,,,both,,,278.93,181.30,,,,,,,,,,,,,
MESH HERNIAXL W18XL12IN OMEGA 3 FATTY ACID COAT POLYPR,SUP-2265992,CDM,C1781,HCPCS,0278,RC,,,,both,,,7253.40,4714.71,,,,,,,,,,,,,
CHLOROPROCAINE HCL (PF) 2 % IJ SOLN,RX-135448,CDM,J2401,HCPCS,0636,RC,63323-0477-27,NDC,,both,30,ML,209.60,136.24,,,,,,,,,,,,,
STEM HUM L135MM DIA14MM UNIV DST SHLDR TI PRI REV CEM FOR,SUP-2372856,CDM,C1776,CPT,0278,RC,,,,both,,,9865.88,6412.82,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL PEEK SD800.508,SUP-2860190,CDM,C1713,HCPCS,0278,RC,,,,both,,,26624.37,17305.84,,,,,,,,,,,,,
GUIDEWIRE ORTH L80CM DIA2.6MM S STL PARTIALLY THRD BEAD TIP,SUP-2412142,CDM,C1769,HCPCS,0272,RC,,,,both,,,267.53,173.89,,,,,,,,,,,,,
DEFIBRILLATOR CARD 15MM 39J SGL CHMBR BPLR REMOT MON ENABLED,SUP-2357741,CDM,C1722,HCPCS,0275,RC,,,,both,,,45530.00,29594.50,,,,,,,,,,,,,
SPACER SPNL 7 DEG 14X13X8 MM INTBDY SHORELINE RT,SUP-2709647,CDM,C1821,HCPCS,0278,RC,,,,both,,,4082.00,2653.30,,,,,,,,,,,,,
SHEATH INTRO PERFRMR L 80 CM DIA14 FR DIL L 91 CM GUIDEWIRE,SUP-2168516,CDM,C1894,HCPCS,0272,RC,,,,both,,,759.88,493.92,,,,,,,,,,,,,
STENT URO KT PGTL FLEX TIP TETHERED POS RADPQ Y 8FR 28CM,SUP-2171033,CDM,C2617,HCPCS,0278,RC,,,,both,,,419.76,272.84,,,,,,,,,,,,,
ALLOGRAFT BNE 5 CC DBM FIBER INTERGRO,SUP-2691578,CDM,C1713,HCPCS,0278,RC,,,,both,,,4917.24,3196.21,,,,,,,,,,,,,
SCREW BONE L4MM DIA2MM CORT CRANIOMAXILLOFACIAL TI ST + DRV,SUP-2189323,CDM,C1713,HCPCS,0278,RC,,,,both,,,265.96,172.87,,,,,,,,,,,,,
NAIL INTRMDLLRY 9.3MM DIA 360MML TTNM ALLOY PRFRMS FOSSA FMR,SUP-2588307,CDM,C1713,HCPCS,0278,RC,,,,both,,,5112.64,3323.22,,,,,,,,,,,,,
TROCAR 67MM LENGTH 2.0/2.7MM SYSTEM,SUP-2487850,CDM,2720000010,LOCAL,0272,RC,,,,both,,,861.49,559.97,,,,,,,,,,,,,
GUIDEWIRE VASC L150CM DIA0.018IN TIP L3IN SM VES NIT COR,SUP-2385559,CDM,C1769,HCPCS,0272,RC,,,,both,,,97.34,63.27,,,,,,,,,,,,,
LACTATED RINGERS IV BOLUS,RX-40840057,CDM,J7120,HCPCS,0250,RC,00264-7750-00,NDC,,both,250,ML,6.40,4.16,,,,,,,,,,,,,
PIN FIX L9IN DIA5/64IN SMOOTH SGL TRCR PT STNMN,SUP-2304035,CDM,C1713,HCPCS,0278,RC,,,,both,,,87.70,57.00,,,,,,,,,,,,,
SCREW BONE POLYAX 6.5MMX45MM,SUP-2311152,CDM,C1713,HCPCS,0278,RC,,,,both,,,4898.40,3183.96,,,,,,,,,,,,,
DRILL SURG ANGLED SELF CNTRG FORTIFY I LF,SUP-2598888,CDM,2720000010,LOCAL,0272,RC,,,,both,,,907.46,589.85,,,,,,,,,,,,,
SPACER SPNL TI INTBDY FUS C RNG XLNK FOR 55MM CDH LEG SYS,SUP-2292827,CDM,C1713,HCPCS,0278,RC,,,,both,,,891.76,579.64,,,,,,,,,,,,,
NEEDLE BX FLX TIP 18 GAX60 CM TRNSJUG LIV SYS STRL TLAB LTX,SUP-2876886,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2339.30,1520.54,,,,,,,,,,,,,
CROWN DENT NODUR-6 1ST PRI M UP R S STL,SUP-2322208,CDM,D6783,CPT,0278,RC,,,,both,,,33.60,21.84,,,,,,,,,,,,,
BRACE KNEE L17-27IN FOR 30.5IN UNIV FOAM HNG STRP CLSR,SUP-2150858,CDM,L1810,HCPCS,0272,RC,,,,both,,,280.25,182.16,,,,,,,,,,,,,
SCREW BONE 4.5X14MM SPNL VAR ANG ST,SUP-2353302,CDM,C1713,HCPCS,0278,RC,,,,both,,,2747.50,1785.87,,,,,,,,,,,,,
MESH SURG L THK0.4MM SLV TI MASTOID MALL CNTOUR LO PROF,SUP-2181586,CDM,C1781,HCPCS,0278,RC,,,,both,,,3097.30,2013.24,,,,,,,,,,,,,
SHEATH INTRO DRYSEAL FLX L 45 CM DIA12 FR BODY DIA 4.7 MM,SUP-2395727,CDM,C1894,HCPCS,0272,RC,,,,both,,,2263.94,1471.56,,,,,,,,,,,,,
HC So Vitamin E,PX-3018444666,CDM,84446,CPT,0301,RC,,,,outpatient,,,382.00,248.30,,,,,,,,,,,,,
RECON PLATE 4X46MM 3.5MM,SUP-2818473,CDM,C1713,HCPCS,0278,RC,,,,both,,,2942.24,1912.46,,,,,,,,,,,,,
DEVICE REVASCULARIZATION STNT L20MM CATHETER DIA0021IN VES,SUP-2281560,CDM,C1757,HCPCS,0272,RC,,,,both,,,19216.80,12490.92,,,,,,,,,,,,,
VALVE MITRL CARP EDW PERIMT DIA29 MM BOV PERICARD COCR WOVEN,SUP-2214766,CDM,C1889,HCPCS,0278,RC,,,,both,,,27632.00,17960.80,,,,,,,,,,,,,
IMMOBOLIZER SHLDR SUPP UNIV UNISX M,SUP-2136721,CDM,L3660,HCPCS,0274,RC,,,,both,,,47.10,30.61,,,,,,,,,,,,,
STAPLER INT L L33MM DIA5MM GI YEL TI BARIATRIC CIR CUT 2,SUP-2421062,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4498.90,2924.28,,,,,,,,,,,,,
HC Treatment Devices Inter,PX-3337733300,CDM,77333,CPT,0333,RC,,,,both,,,1471.00,956.15,,,,,,,,,,,,,
BLADE SAW L 21X85MM W LAT MALL PROTECTED W/ RBBN RETRCT,SUP-2388890,CDM,2720000010,LOCAL,0272,RC,,,,both,,,424.21,275.74,,,,,,,,,,,,,
BRUSH TISS EXTRACTOR PWR STRL DISP,SUP-2517589,CDM,2720000010,LOCAL,0272,RC,,,,both,,,196.25,127.56,,,,,,,,,,,,,
TRAY CATH HEMODIALYSI PWR TRIALYSI SLIM CATH ACTE 12 5865240,SUP-2632940,CDM,C1752,HCPCS,0278,RC,,,,both,,,1028.48,668.51,,,,,,,,,,,,,
CD BONE SCR 23X16MM 5/PKG,SUP-2679408,CDM,C1713,HCPCS,0278,RC,,,,both,,,203.22,132.09,,,,,,,,,,,,,
STENT CORONARY PK PAPYRUS L 15 MM DIA2.5 MM CATH L 140 CM OD,SUP-2422128,CDM,C1874,HCPCS,0278,RC,,,,both,,,11398.20,7408.83,,,,,,,,,,,,,
PROTECTOR NRV L20MM DIA7MM PORCINE EXTRACELLULAR MTRX WRP,SUP-2124860,CDM,C1763,HCPCS,0278,RC,,,,both,,,7887.68,5126.99,,,,,,,,,,,,,
CLAMP SURG ISOLATOR SYNERGY,SUP-2720063,CDM,2720000010,LOCAL,0272,RC,,,,both,,,16956.00,11021.40,,,,,,,,,,,,,
ANCHOR SUT SZ 2 ABSRB BIOKNOTLESS,SUP-2249363,CDM,C1713,HCPCS,0278,RC,,,,both,,,75.36,48.98,,,,,,,,,,,,,
CATHETER HEMO DYLS OR HD ADMIN COMP ONLY DBL LUMN POLYUR,SUP-2126508,CDM,C1752,HCPCS,0278,RC,,,,both,,,326.56,212.26,,,,,,,,,,,,,
HC So Assay of Metanephrines,PX-3018383566,CDM,83835,CPT,0301,RC,,,,both,,,177.00,115.05,,,,,,,,,,,,,
GUIDEWIRE VASC L180CM DIA0018IN HYDRPHLC STD ANG FIX COR,SUP-2302956,CDM,C1769,HCPCS,0272,RC,,,,both,,,145.54,94.60,,,,,,,,,,,,,
SCREW BNE L26MM DIA2.7MM DST RAD LOK FULL THRD SQ DRV HD LO,SUP-2411799,CDM,C1713,HCPCS,0278,RC,,,,both,,,452.16,293.90,,,,,,,,,,,,,
PLATE BNE ANTR MALL 8 HOLE TI,SUP-2525813,CDM,C1713,HCPCS,0278,RC,,,,both,,,3943.84,2563.50,,,,,,,,,,,,,
PLATE BNE TBLR 2.7X57 MM 7 HOLE 1/4 SS,SUP-2536109,CDM,C1713,HCPCS,0278,RC,,,,both,,,417.62,271.45,,,,,,,,,,,,,
"HC Total Protein, Urine",PX-3018415600,CDM,84156,CPT,0301,RC,,,,both,,,213.00,138.45,,,,,,,,,,,,,
WIRE FIX Y 1.28X559 MM ES2 COMPATIBLE LT FC12822B2,SUP-2734737,CDM,2720000010,LOCAL,0272,RC,,,,both,,,969.48,630.16,,,,,,,,,,,,,
SLEEVE IM 100DEG LT BLU TI FOR SPRL BLDE FEM NAIL,SUP-2192712,CDM,C1713,HCPCS,0278,RC,,,,both,,,1370.70,890.95,,,,,,,,,,,,,
HC So Vitamin E,PX-3018444666,CDM,84446,CPT,0301,RC,,,,inpatient,,,382.00,248.30,,,,,,,,,,,,,
SCREW BNE LCK 2.3X18 MM MAND SELF RET X DRV TI LEVEL 1,SUP-2468567,CDM,C1713,HCPCS,0278,RC,,,,both,,,408.64,265.62,,,,,,,,,,,,,
BUR SURGICAL TRABECULAR METAL TOTAL ANKLE ALTERNATE,SUP-2478397,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1052.09,683.86,,,,,,,,,,,,,
ROD SPNL L120MM DIA3MM POST BILAT TI SMOOTH SYNERGY SUMMIT,SUP-2254415,CDM,C1713,HCPCS,0278,RC,,,,both,,,1055.04,685.78,,,,,,,,,,,,,
BALLOON SINUPLASTY 6X16 MM SYS RELIEVA SPINPLUS,SUP-2106369,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8000.72,5200.47,,,,,,,,,,,,,
CATHETER INTVASC ULTRASOUND SONICATH ULTRA FREQ 20 MHZ STRL,SUP-2141112,CDM,C1753,HCPCS,0278,RC,,,,both,,,1643.01,1067.96,,,,,,,,,,,,,
HC Glucose Body Fluid Other Than Blood,PX-3018294500,CDM,82945,CPT,0301,RC,,,,both,,,192.00,124.80,,,,,,,,,,,,,
STAPLER INT L L28MM DIA5MM GI BLU TI BARIATRIC CIR CUT 2 ROW,SUP-2283258,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1086.91,706.49,,,,,,,,,,,,,
CATHETER INFUS 31FR L31CM 0.375IN CONN 2 LUMN BI CAVAL,SUP-2124559,CDM,C1729,HCPCS,0272,RC,,,,both,,,7693.00,5000.45,,,,,,,,,,,,,
INTRODUCER SHTH 0.018 IN 5 FRX23 CM SET CK FLO ACCS RADIAL,SUP-2168777,CDM,C1894,HCPCS,0272,RC,,,,both,,,138.47,90.01,,,,,,,,,,,,,
STENT URO KT DBL PGTL FLX TIP .038IN PTFE STIFF SUT,SUP-2139117,CDM,C2617,HCPCS,0278,RC,,,,both,,,454.39,295.35,,,,,,,,,,,,,
BIOPSY TRAY COMPHSVE 11 GAX152 MM BNE MAR SYS NDL ONCONTROL,SUP-2766677,CDM,C1830,HCPCS,0278,RC,,,,both,,,499.26,324.52,,,,,,,,,,,,,
GRAFT VASC L70CM ID6MM REM RNGD L60CM THN WALLED CBAS HEP,SUP-2395813,CDM,C1768,CPT,0278,RC,,,,both,,,7978.74,5186.18,,,,,,,,,,,,,
GUIDEWIRE VASC ARW L 60 CM DIA 0.025 IN NIT PERIPH MARKED,SUP-2763344,CDM,C1769,HCPCS,0272,RC,,,,both,,,43.71,28.41,,,,,,,,,,,,,
CATHETER DIAG L150CM OD0.042X0.034IN TIP OD1.9FR 15MM SPC,SUP-2353146,CDM,C1887,HCPCS,0272,RC,,,,both,,,637.42,414.32,,,,,,,,,,,,,
SPACER SPNL ANTEROLATERAL XL 17 MM RADLUC SUSTAIN,SUP-2585261,CDM,C1889,HCPCS,0278,RC,,,,both,,,7536.00,4898.40,,,,,,,,,,,,,
TROCAR ENDOSCP L100MM DIA12MM BLNT STBL SL DISP ENDOPATH,SUP-2219091,CDM,2720000010,LOCAL,0272,RC,,,,both,,,65.00,42.25,,,,,,,,,,,,,
HC Drug Assay Cyclosporine,PX-3018015800,CDM,80158,CPT,0301,RC,,,,both,,,326.00,211.90,,,,,,,,,,,,,
GUIDEWIRE SURG TI MH FOR EXPERT RG FEM NAIL,SUP-2178927,CDM,C1769,HCPCS,0272,RC,,,,both,,,2288.06,1487.24,,,,,,,,,,,,,
GRAFT HUM TISS 5CM OR SMER FIB SEG STRUCTURAL FRZN,SUP-2165545,CDM,C1713,HCPCS,0278,RC,,,,both,,,1271.70,826.60,,,,,,,,,,,,,
STENT COR 8MM OD2.75MM BARE MTL RX CO CHROM ALLOY,SUP-2104187,CDM,C1876,HCPCS,0278,RC,,,,both,,,2756.92,1792.00,,,,,,,,,,,,,
BASEPLATE GLEN +10MM OFFSET EXT CAGE,SUP-2223385,CDM,C1713,HCPCS,0278,RC,,,,both,,,5809.00,3775.85,,,,,,,,,,,,,
CATHETER CV SET 018 3 FRX8 CM 1 LUMEN J TIP,SUP-2760114,CDM,C1751,HCPCS,0278,RC,,,,both,,,143.44,93.24,,,,,,,,,,,,,
HC Lower Xtr Fascial Plane Block Uni Injection,PX-3606447300,CDM,64473,CPT,0360,RC,,,,outpatient,,,1238.00,804.70,,,,,,,,,,,,,
CATHETER ANGIOPLSTY 14 ATM 5 FRX139 CM 2.5X12 MM EMPIRA RX,SUP-2158511,CDM,C1725,HCPCS,0272,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
PATCH BIO TISS W4XL4CM BOV PERICARD,SUP-2130363,CDM,C1768,CPT,0278,RC,,,,both,,,835.87,543.32,,,,,,,,,,,,,
CATHETER ERCP L200CM L100CM OD5.5FR .025IN TFE SH TAPR TIP,SUP-2169061,CDM,C1726,HCPCS,0272,RC,,,,both,,,194.68,126.54,,,,,,,,,,,,,
PLATE BONE XLONG HLX4 06MM THK CP TTNM STRGHT LVLX1 F/15MM,SUP-2707485,CDM,C1713,HCPCS,0278,RC,,,,both,,,290.01,188.51,,,,,,,,,,,,,
INTRODUCER VASC 7FR 12CM LEN AD,SUP-2355251,CDM,C1894,HCPCS,0272,RC,,,,both,,,36.90,23.98,,,,,,,,,,,,,
SUBSTITUTE BONE GRFT 1CC DBM W/ RPM PASTE CANC,SUP-2415802,CDM,C1713,HCPCS,0278,RC,,,,both,,,499.26,324.52,,,,,,,,,,,,,
RELOAD STPL H1-2.5X45MM VASC THN TISS WHT 6 ROW B FRM SGL,SUP-2220066,CDM,2720000010,LOCAL,0272,RC,,,,both,,,386.82,251.43,,,,,,,,,,,,,
CANNULA SUCTION MONOPOLAR 3 MMX30 CM COAG INSUL,SUP-2767475,CDM,2720000010,LOCAL,0272,RC,,,,both,,,815.30,529.94,,,,,,,,,,,,,
CONNECTOR SPNL L40MM STD POST TI XLNK FIX ASMBLY TRNSVRS,SUP-2254569,CDM,C1713,HCPCS,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
GRAFT BNE 5 CC VOID FILL SYNTH,SUP-2430785,CDM,C1889,HCPCS,0278,RC,,,,both,,,3689.50,2398.17,,,,,,,,,,,,,
PLATE BNE THK0.8MM 4X2 H HND TI TRAP GRID TRILOK TECHNOLOGY,SUP-2267909,CDM,C1713,HCPCS,0278,RC,,,,both,,,2374.78,1543.61,,,,,,,,,,,,,
NOZZLE BNE CEM R ANG FOR VAC MIX SYS OPTVAC,SUP-2216842,CDM,C1713,HCPCS,0278,RC,,,,both,,,291.86,189.71,,,,,,,,,,,,,
HC MRI-Upper Ext W Cont,PX-6107321900,CDM,73219,CPT,0610,RC,,,,both,,,4976.00,3234.40,,,,,,,,,,,,,
INTRODUCER BX 12GA FOR 12 DEV CELERO,SUP-2240008,CDM,C1894,HCPCS,0272,RC,,,,both,,,67.20,43.68,,,,,,,,,,,,,
BUR SURG RND 6 MM 8 MM FLUT CARBIDE MSD AM33 STRL ULTRA PWR,SUP-2166779,CDM,2720000010,LOCAL,0272,RC,,,,both,,,187.87,122.12,,,,,,,,,,,,,
PROSTHESIS PENILE INFLATABLE 0 DEG 16 CM SCROT TITAN TCH LF,SUP-2848013,CDM,C1813,HCPCS,0278,RC,,,,both,,,37680.00,24492.00,,,,,,,,,,,,,
MATRIX BIO LG SZ 196 SQCM FISH SKIN RT DORSUM LT PALMAR MANO,SUP-2909238,CDM,Q4158,HCPCS,0636,RC,,,,both,,,16924.60,11000.99,,,,,,,,,,,,,
GUIDEWIRE VASC L 145 CM DIA 0.032 IN TIP 3 MM PTFE J FIX COR,SUP-2147056,CDM,C1769,HCPCS,0272,RC,,,,both,,,28.79,18.71,,,,,,,,,,,,,
BUR SURG L21CM DIA65MM CYL EXTRA COARSE DMND MIDAS REX,SUP-2277907,CDM,2720000010,LOCAL,0272,RC,,,,both,,,401.70,261.10,,,,,,,,,,,,,
HEAD FEM UPLR MOD SYS,SUP-2449746,CDM,C1776,CPT,0278,RC,,,,both,,,466.29,303.09,,,,,,,,,,,,,
PROSTHESIS OSS W2.3XL4.25MM RECON INCUS HD HA FULL CANN,SUP-2312576,CDM,L8613,CPT,0278,RC,,,,both,,,1016.54,660.75,,,,,,,,,,,,,
ALLOGRAFT ARTHROFLEX DECELLURIZ W/MATRACELL 20X25MM,SUP-2720119,CDM,Q4125,HCPCS,0636,RC,,,,both,,,3108.60,2020.59,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED CEM SCREW PIN GENDER SPEC FLX ZCKHIGLYPINGSF] ZIMMER BIOMET INC],SUP-2212707,CDM,C1776,CPT,0278,RC,,,,both,,,14015.77,9110.25,,,,,,,,,,,,,
PLATE BNE L184MM 11 H NONSTERILE R DST RAD VOLAR DPHSEAL,SUP-2184059,CDM,C1713,HCPCS,0278,RC,,,,both,,,4623.43,3005.23,,,,,,,,,,,,,
TRAY CATH HEMODIALYSI DUOGLIDE ACUTE 13FR DIA 20CML 5625200,SUP-2632915,CDM,C1752,HCPCS,0278,RC,,,,both,,,838.47,545.01,,,,,,,,,,,,,
MARKER SKIN 2 MM SPEE-D-MARK SDM20E,SUP-2323023,CDM,A4648,CPT,0278,RC,,,,both,,,111.38,72.40,,,,,,,,,,,,,
PLATE BNE L83MM 6 H L LAT PROX PERIARTC TIB S STL,SUP-2410537,CDM,C1713,HCPCS,0278,RC,,,,both,,,2318.29,1506.89,,,,,,,,,,,,,
GUIDEWIRE VASC THRUWAY L 300 CM DIA 0.014 IN SS SIL STR LNG,SUP-2148337,CDM,C1769,HCPCS,0272,RC,,,,both,,,335.98,218.39,,,,,,,,,,,,,
PLATE BNE THK0.8MM UNIV 8 H CRANIOMAXILLOFACIAL TI Y SHP,SUP-2366265,CDM,C1713,HCPCS,0278,RC,,,,both,,,857.57,557.42,,,,,,,,,,,,,
GRAFT HUM TISS W20XL15MM THK8MM FRZ DRY ALLGRFT BLK CANC,SUP-2307117,CDM,C1713,HCPCS,0278,RC,,,,both,,,2400.09,1560.06,,,,,,,,,,,,,
HC Basic Radiation Dosimetry Calc,PX-3337730000,CDM,77300,CPT,0333,RC,,,,both,,,586.00,380.90,,,,,,,,,,,,,
SET DIL PROTEK DUO DIA14/18/22/26 FR VEN STRL,SUP-2929862,CDM,2720000010,LOCAL,0272,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
FORCEP RETRV ALLIGATOR 5.2 FRX65 CM TOOTH DBL JAW,SUP-2835710,CDM,2720000010,LOCAL,0272,RC,,,,both,,,984.30,639.79,,,,,,,,,,,,,
IMMUNE GLOBULIN (HUMAN) 10 GM/100ML IJ SOLN,RX-107300,CDM,J1569,HCPCS,0636,RC,00944-2700-05,NDC,,both,100,ML,5151.00,3348.15,,,,,,,,,,,,,
HALOPERIDOL LACTATE 2 MG/ML PO CONC,RX-3585,CDM,340b,HCPCS,0637,RC,00121-0581-05,NDC,,both,1,ML,3.20,2.08,,,,,,,,,,,,,
CATHETER ANGIOPLSTY PFLX PRO L 135 CM BALLOON L 120 MM DIA 4,SUP-2156762,CDM,C1725,HCPCS,0272,RC,,,,both,,,617.95,401.67,,,,,,,,,,,,,
GAUGE DEPTH FOR 5MM LOK SCR TI TROCHANTERIC NAIL FIX,SUP-2188233,CDM,C1713,HCPCS,0278,RC,,,,both,,,2073.44,1347.74,,,,,,,,,,,,,
TIP ASPIR SPETZLER MIC UNIV 1.2X2 MMX4 IN OPN ANGLE SONOPET,SUP-2791038,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2020.31,1313.20,,,,,,,,,,,,,
INTRODUCER SHTH J 0.038 IN 5 FRX14 CM 18 GAX50 CM PEELWY,SUP-2357058,CDM,C1892,HCPCS,0272,RC,,,,both,,,113.04,73.48,,,,,,,,,,,,,
NAIL IM L255MM DIA10MM UNIV TIB TI CANN LCK BENT UNREAMED,SUP-2192791,CDM,C1713,HCPCS,0278,RC,,,,both,,,4193.31,2725.65,,,,,,,,,,,,,
HC CT Heart No Contrast Quant Eval Coronry Calcium,PX-3507557100,CDM,75571,CPT,0350,RC,,,,outpatient,,,362.00,362.00,,,,,,,,,,,,,
PLATE BNE 95 DEG SHFT L 92 MM BLADE L 50 MM SCREW DIA 4.5 MM,SUP-2907583,CDM,C1713,HCPCS,0278,RC,,,,both,,,3966.67,2578.34,,,,,,,,,,,,,
SLEEVE CBL M DIA1.6MM S STL DALL-M,SUP-2371519,CDM,C1713,HCPCS,0278,RC,,,,both,,,790.02,513.51,,,,,,,,,,,,,
PLATE BONE W16XL158MM THK5MM 7 H LT CNDYL FEM S STL BTTRS,SUP-2185803,CDM,C1713,HCPCS,0278,RC,,,,both,,,2308.37,1500.44,,,,,,,,,,,,,
BUR SURG DIA 5 MM HUB II BRL SOFTCUT STRL DISP HI-LINE XS,SUP-2929121,CDM,2720000010,LOCAL,0272,RC,,,,both,,,726.06,471.94,,,,,,,,,,,,,
PLATE BNE L81MM 4 H ST L SUP ANT CLAV S STL LOK COMPR W/,SUP-2177331,CDM,C1713,HCPCS,0278,RC,,,,both,,,2851.91,1853.74,,,,,,,,,,,,,
PLATE BNE STD RT 22 HOLE FOR ORTH FIX STRL POLARUS 3,SUP-2518204,CDM,C1713,HCPCS,0278,RC,,,,both,,,7284.80,4735.12,,,,,,,,,,,,,
PLATE COLINK AFX ONE THIRD TUBULAR 5 HOLE,SUP-2741109,CDM,C1713,HCPCS,0278,RC,,,,both,,,3925.00,2551.25,,,,,,,,,,,,,
GRAFT BNE DEMINERALIZED BNE MTRX 5 ML RT ALTIVA,SUP-2391500,CDM,C1713,HCPCS,0278,RC,,,,both,,,2590.50,1683.82,,,,,,,,,,,,,
PORT IMPL INFUSION SINGLE LUMEN 8 FR LP X-PORT ISP,SUP-2126616,CDM,C1788,HCPCS,0278,RC,,,,both,,,1460.10,949.06,,,,,,,,,,,,,
ELEVATOR ENDOSCP 10 CM NANOSCOPE,SUP-2849183,CDM,2720000010,LOCAL,0272,RC,,,,both,,,486.70,316.35,,,,,,,,,,,,,
STEM TIB L150MM DIA10MM TI KNEE PRI GEN II LEGION,SUP-2346006,CDM,C1776,CPT,0278,RC,,,,both,,,3112.53,2023.14,,,,,,,,,,,,,
"HC Pt Therapeutic Exercise,Ea 15 Min|OP PT SERVICES|DOCUMENTATION ON FILE|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS",PX-4209711000,CDM,97110,CPT,0420,RC,,,GP|KX|CQ,both,,,195.00,126.75,,,,,,,,,,,,,
BEVACIZUMAB-AWWB 25 MG/ML IV SOLN (MIXTURES ONLY),RX-1150525,CDM,Q5107,HCPCS,0636,RC,55513-0207-01,NDC,,both,16,ML,8037.80,5224.57,,,,,,,,,,,,,
TISSEEL VHSD 4 ML KT 1504515] BAXTER BIOSURGERY],SUP-2130319,CDM,C9250,HCPCS,0636,RC,,,,both,,,561.65,365.07,,,,,,,,,,,,,
MODULE TST NEUROVISION TST PLCMNT SCR DISPOSABLEXLIF,SUP-2311744,CDM,C1713,HCPCS,0278,RC,,,,both,,,6452.76,4194.29,,,,,,,,,,,,,
BLADE SHV OD4MM 40DEG STD SERR CLS DS ELITE COMPATIBLE DIEGO,SUP-2313526,CDM,C1713,HCPCS,0278,RC,,,,both,,,421.17,273.76,,,,,,,,,,,,,
VALVE VENTRICULAR SHUNT L90CM OD1.9MM 40CM VERTICAL WATER PR,SUP-2821785,CDM,C1889,HCPCS,0278,RC,,,,both,,,7154.90,4650.68,,,,,,,,,,,,,
GRAFT BONE SPCR FRZ DRY CORT H 5MM SM GRFTECH,SUP-2294202,CDM,C1713,HCPCS,0278,RC,,,,both,,,2380.12,1547.08,,,,,,,,,,,,,
PIN EXT FIX HALF 6X110 MM 40 MM THRD SS RINGFIX,SUP-2483167,CDM,2720000010,LOCAL,0272,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
INSERT TIB CR XS STD 11 MM KNEE DURAC,SUP-2377508,CDM,C1776,CPT,0278,RC,,,,both,,,6364.15,4136.70,,,,,,,,,,,,,
SCREW INTRF KNEE CANN ABSRB POLY-L LACTIC ACID TAPR HD 7MM,SUP-2341690,CDM,C1713,HCPCS,0278,RC,,,,both,,,973.40,632.71,,,,,,,,,,,,,
TIP ULTRSNC DEV 3 DEG L 180 MM CRV EXT M/F ULTRSNC STRL DISP,SUP-2883553,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2931.69,1905.60,,,,,,,,,,,,,
CATHETER CV MAXIMAL BARR TY 018 4 FRX12 CM 18 GA DL SPECTRUM,SUP-2759894,CDM,C1751,HCPCS,0278,RC,,,,both,,,577.57,375.42,,,,,,,,,,,,,
SCREW BNE LCK 3.5X8 MM SS NS SURFIX,SUP-2609223,CDM,C1713,HCPCS,0278,RC,,,,both,,,1114.23,724.25,,,,,,,,,,,,,
PLATE BNE HK 5TH METATRSL,SUP-2864970,CDM,C1713,HCPCS,0278,RC,,,,both,,,5614.32,3649.31,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 5 CM DIA 3 MM EPTFE STR TW N RING,SUP-2396324,CDM,C1768,CPT,0278,RC,,,,both,,,898.04,583.73,,,,,,,,,,,,,
ST APG SYNV RASP SM +7 LINV,SUP-2514073,CDM,2720000010,LOCAL,0272,RC,,,,both,,,723.46,470.25,,,,,,,,,,,,,
STEM HUM L55MM DIA14MM MIC SHLDR CO CHROM POR CEM PRESSFIT,SUP-2404550,CDM,C1776,CPT,0278,RC,,,,both,,,10484.46,6814.90,,,,,,,,,,,,,
HC So Drug Assay Amiodarone,PX-3018015166,CDM,80151,CPT,0301,RC,,,,both,,,189.00,122.85,,,,,,,,,,,,,
COMPONENT FEM BOSS 7.5 MM RT FEM KNEE MOD VANGUARD 360,SUP-2444765,CDM,C1776,CPT,0278,RC,,,,both,,,2048.85,1331.75,,,,,,,,,,,,,
ANCHOR SUT 4.75X22MM PEEK DBL LD SWIVELOCK W/ TIGERTAIL,SUP-2121705,CDM,C1713,HCPCS,0278,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
GUIDEWIRE VASC ROTAWIRE L 330 CM DIA 0.009 IN SS STR TIP,SUP-2147252,CDM,C1769,HCPCS,0272,RC,,,,both,,,351.02,228.16,,,,,,,,,,,,,
SET SCR SPNL TI FLSH BRK OFFSET TSRH-3DX,SUP-2289708,CDM,C1713,HCPCS,0278,RC,,,,both,,,393.91,256.04,,,,,,,,,,,,,
TRABECULAR METALTM TECHNOLOGY VBR 11X14X21.5MM,SUP-2415528,CDM,C1889,HCPCS,0278,RC,,,,both,,,12560.00,8164.00,,,,,,,,,,,,,
PLATE BNE L90MM 2 H R OLECRANON S STL VAR ANG LOK COMPR LO,SUP-2177184,CDM,C1713,HCPCS,0278,RC,,,,both,,,3239.13,2105.43,,,,,,,,,,,,,
COUPLER EXT FIX PIN TO ROD DELT FOR HOFFMANN III MOD SYS,SUP-2372219,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1947.43,1265.83,,,,,,,,,,,,,
CATHETER ANGIOPLSTY METACROSS 135 CM 5.4 FR 40 MM 4 MM OTW,SUP-2761781,CDM,C1725,HCPCS,0272,RC,,,,both,,,445.88,289.82,,,,,,,,,,,,,
PASSER SHUNT 36 CM PERITONEAL CATH DISP,SUP-2852598,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2931.91,1905.74,,,,,,,,,,,,,
PLATE BNE FEM 3.5X142 MM RT DSTL PROX 4 HOLE NS VA-LCP,SUP-2757670,CDM,C1713,HCPCS,0278,RC,,,,both,,,3686.61,2396.30,,,,,,,,,,,,,
SCREW BNE L5MM DIA1.5MM MIC CORT CRANIOMAXILLOFACIAL TI LEV 25678051] KLS MARTIN LP],SUP-2262820,CDM,C1713,HCPCS,0278,RC,,,,both,,,120.89,78.58,,,,,,,,,,,,,
HC Balo Angiop Ctr Dialysis Seg,PX-3613690700,CDM,36907,CPT,0361,RC,,,,both,,,8583.00,5578.95,,,,,,,,,,,,,
PROSTHESIS OSS SHEA 3X0.8X7 MM MALL SHFT HA TORP,SUP-2637878,CDM,L8613,CPT,0278,RC,,,,both,,,1399.84,909.90,,,,,,,,,,,,,
PROBE TIP ANGLE 0 DEGREES,SUP-2736163,CDM,2720000010,LOCAL,0272,RC,,,,both,,,926.30,602.09,,,,,,,,,,,,,
MESH CRAN L 41 X W 41 MM TI CLR NS DISP,SUP-2935337,CDM,C1713,HCPCS,0278,RC,,,,both,,,6207.78,4035.06,,,,,,,,,,,,,
BAG BLD TRNSFUS CONSOLIDATED RT VENTRICULAR ASST DEV,SUP-2356016,CDM,Q0508,HCPCS,0274,RC,,,,both,,,1102.14,716.39,,,,,,,,,,,,,
STAPLER INT USE DIA21 MM STPL H 4/4.5/5 MM XL X THCK CIR BLK,SUP-2896440,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4688.52,3047.54,,,,,,,,,,,,,
PLATE BNE L23MM 4 H S STL COMPR FOR 2MM SCR SM MINI FRAG,SUP-2411312,CDM,C1713,HCPCS,0278,RC,,,,both,,,186.30,121.09,,,,,,,,,,,,,
HC Antistreptolysin O Titer,PX-3028606000,CDM,86060,CPT,0302,RC,,,,both,,,120.00,78.00,,,,,,,,,,,,,
MYCOPHENOLATE MOFETIL 250 MG PO CAPS,RX-15113,CDM,J7517,HCPCS,0636,RC,00054-0163-25,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
GUIDEWIRE URO STR MOVABLE COR .035IN PTFE CTD 150CM,SUP-2312643,CDM,C1769,HCPCS,0272,RC,,,,both,,,42.39,27.55,,,,,,,,,,,,,
HC Bleeding Time Test,PX-3058500200,CDM,85002,CPT,0305,RC,,,,both,,,294.00,191.10,,,,,,,,,,,,,
DEXTROSE 5 % IV SOLN INTERMITTENT INFUSION,RX-40840103,CDM,2580000003,HCPCS,0258,RC,00990-7922-61,NDC,,both,250,ML,74.40,48.36,,,,,,,,,,,,,
HC Explore Wound Extremity,PX-4502010300,CDM,20103,CPT,0450,RC,,,,both,,,2188.00,1422.20,,,,,,,,,,,,,
PACEMAKER CARD EVIA HF-T BIV 3 CHMBR CLS TECHNOLOGY STRL,SUP-2138423,CDM,C2621,HCPCS,0275,RC,,,,both,,,21352.00,13878.80,,,,,,,,,,,,,
BIT DRILL AO T2 35X130MM,SUP-2701869,CDM,2720000010,LOCAL,0272,RC,,,,both,,,529.88,344.42,,,,,,,,,,,,,
GRAFT HUM TISS 2000MG PLCNTA TISS AMNIOFILL,SUP-2305717,CDM,C1762,CPT,0278,RC,,,,both,,,13188.00,8572.20,,,,,,,,,,,,,
AMANTADINE HCL 100 MG PO TABS,RX-20506,CDM,6370000000,HCPCS,0637,RC,10135-0692-01,NDC,,both,1,UN,3.20,2.08,,,,,,,,,,,,,
INSERT TIB BEAR SZ 1 THK11MM KNEE X3 CNDYL STABILIZING,SUP-2373195,CDM,C1776,CPT,0278,RC,,,,both,,,11530.08,7494.55,,,,,,,,,,,,,
GENTAMICIN IN SALINE 1.2-0.9 MG/ML-% IV SOLN,RX-15909,CDM,J1580,HCPCS,0636,RC,00338-0507-48,NDC,,both,100,ML,54.10,35.16,,,,,,,,,,,,,
KIT COOL M HYDRGEL COAT 3 LAYERED CONSTR NONINVASIVE DISP,SUP-2127458,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3876.33,2519.61,,,,,,,,,,,,,
PLATE BONE L390MM 24 H BILAT S STL BROAD LO PROF RIG DYN,SUP-2185283,CDM,C1713,HCPCS,0278,RC,,,,both,,,1819.38,1182.60,,,,,,,,,,,,,
SUPPORT ORTHOT HIP JT LOWER EXTREMITY PELV CTRL RECIP CABLE,SUP-2435687,CDM,L2628,HCPCS,0272,RC,,,,both,,,4435.12,2882.83,,,,,,,,,,,,,
METHYLNALTREXONE BROMIDE 8 MG/0.4ML SC SOSY,RX-173411,CDM,2500000003,HCPCS,0250,RC,65649-0552-04,NDC,,both,.4,ML,977.10,635.11,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED TOT STBL BASEPLT X3 TRIATHLON,SUP-2365631,CDM,C1776,CPT,0278,RC,,,,both,,,16092.50,10460.12,,,,,,,,,,,,,
GRAFT BNE PTTY 47 MM 5 CC CHIP CANC DBM ALLMTRX,SUP-2399140,CDM,C9359,HCPCS,0278,RC,,,,both,,,3208.30,2085.39,,,,,,,,,,,,,
KIT DRNGE PERI CONTAIN CATH AND STRT 4 1000ML BTL PLEURX,SUP-2133749,CDM,C1729,HCPCS,0272,RC,,,,both,,,2766.34,1798.12,,,,,,,,,,,,,
ALLOGRAFT BNE CRUSH 1-4 MM 5 CC FD IRRADIATED CANC,SUP-2866923,CDM,C1762,CPT,0278,RC,,,,both,,,395.64,257.17,,,,,,,,,,,,,
BALLOON ENT SINUS DIL SYS VENTERA,SUP-2341432,CDM,C1713,HCPCS,0278,RC,,,,both,,,1786.66,1161.33,,,,,,,,,,,,,
SET SUPRPUB CATH 12FR L25CM W/ MAC-LOC CLR CONN TB 1 W,SUP-2171360,CDM,C2627,HCPCS,0272,RC,,,,both,,,508.37,330.44,,,,,,,,,,,,,
SCREW BNE COMPR 8X34 MM 27.9 MM CORTICAL FT GOTFRIED PCCP,SUP-2644733,CDM,C1713,HCPCS,0278,RC,,,,both,,,159.64,103.77,,,,,,,,,,,,,
SCREW EXT FIX 6X190 MM SPADE PT MR CONDITIONAL FOR ADJ FIX,SUP-2418494,CDM,C1713,HCPCS,0278,RC,,,,both,,,512.29,332.99,,,,,,,,,,,,,
GUIDEWIRE VASC STR 7 CM 0.035 INX260 CM 3 CM AMPLATZ,SUP-2167952,CDM,C1769,HCPCS,0272,RC,,,,both,,,61.80,40.17,,,,,,,,,,,,,
CARDIOPLEGIC PF SOLN,RX-30275,CDM,2500000003,HCPCS,0250,RC,00409-7969-05,NDC,,both,1000,ML,488.80,317.72,,,,,,,,,,,,,
TUBE VENT 0.76 MM 3.81 MM 1.6 MM TINY TRIUNE SIL 510251,SUP-2473441,CDM,L8699,HCPCS,0278,RC,,,,both,,,51.84,33.70,,,,,,,,,,,,,
PLATE BNE L W135XL80MM THK42MM 4 H BILAT TI NAR RIG NEUT,SUP-2190808,CDM,C1713,HCPCS,0278,RC,,,,both,,,1022.67,664.74,,,,,,,,,,,,,
PLATE BONE L190MM 4 H TROCHANTERIC TI GRP SUPERCABLE,SUP-2262261,CDM,C1713,HCPCS,0278,RC,,,,both,,,6546.90,4255.48,,,,,,,,,,,,,
TUBE TYMPANOSTOMY DIA1.14 MM INNR FLANGE DIA 3.5 MM FLROPLAS,SUP-2901921,CDM,L8699,HCPCS,0278,RC,,,,both,,,86.13,55.98,,,,,,,,,,,,,
ANCHOR SUT DIA2.3MM BLU COBRAID CVD W/ NO2 ULTRABRAID SUT,SUP-2341133,CDM,C1713,HCPCS,0278,RC,,,,both,,,1698.74,1104.18,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED STEM AUG WDG K4MEDACTA] MEDACTA USA],SUP-2267794,CDM,C1776,CPT,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
SET SCR SPNL S STL BRK OFF FOR 5.5MM ROD CDH LEG,SUP-2288171,CDM,C1713,HCPCS,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
SUPPORT ORTHOT HIP JT LOWER EXTREMITY PELV CTRL RECIP CABLE,SUP-2435687,CDM,L2628,HCPCS,0274,RC,,,,both,,,4435.12,2882.83,,,,,,,,,,,,,
COMPONENT TOT KNEE MAKO,SUP-2378880,CDM,C1776,CPT,0278,RC,,,,both,,,1980.18,1287.12,,,,,,,,,,,,,
PLATE BNE MED TI MANDIBULAR PMI ORTHOGNATHIC 3D PRNT NS DISP,SUP-2934809,CDM,C1713,HCPCS,0278,RC,,,,both,,,24309.88,15801.42,,,,,,,,,,,,,
PLATE BONE 6 H FOREFOOT TI Y COMPR FOR 1.5/2/2.4MM SCR,SUP-2225437,CDM,C1713,HCPCS,0278,RC,,,,both,,,2509.49,1631.17,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY DECANAV L 115 CM 7 FR 2 MM F CRV,SUP-2248952,CDM,C1732,HCPCS,0278,RC,,,,both,,,2986.14,1940.99,,,,,,,,,,,,,
AMPHOTERICIN B 50 MG IV SOLR,RX-145510,CDM,J0285,HCPCS,0636,RC,39822-1055-05,NDC,,both,1,UN,276.00,179.40,,,,,,,,,,,,,
INSERT TIB SZ 5-6 THICKNESS 17MM UNIV STRP GRN PROLONG PRI,SUP-2201295,CDM,C1776,CPT,0278,RC,,,,both,,,1997.04,1298.08,,,,,,,,,,,,,
PLATE BNE ANTEROLATERAL LNG 2.7X56 MM RT CALCANEAL LCK STRL,SUP-2568774,CDM,C1713,HCPCS,0278,RC,,,,both,,,3489.73,2268.32,,,,,,,,,,,,,
ENDOPROSTHESIS VASC WSTNT RP L 60 MM DIA 8 MM CATH TOT L 100,SUP-2148381,CDM,C1876,HCPCS,0278,RC,,,,both,,,5181.00,3367.65,,,,,,,,,,,,,
MATRIX BIO SZ 114 SQCM FISH SKIN DERMAL MIC STRL GRAFTGUIDE,SUP-2909276,CDM,Q4158,HCPCS,0636,RC,,,,both,,,15429.96,10029.47,,,,,,,,,,,,,
ALLOGRAFT BNE SHT 25X20X7 MM CANC CONFORM Q-PACK,SUP-2737084,CDM,C1713,HCPCS,0278,RC,,,,both,,,4123.61,2680.35,,,,,,,,,,,,,
MESH CRANIAL CONTOURABLE 1.5X50X0.25 MM RAPID RESORBABLE STE,SUP-2838564,CDM,C1713,HCPCS,0278,RC,,,,both,,,5088.37,3307.44,,,,,,,,,,,,,
DEFIBRILLATOR IMPL INCEPTA W 6.17 X H 7.7 CM D 0.99 CM 32 CC,SUP-2149263,CDM,C1882,HCPCS,0275,RC,,,,both,,,55389.60,36003.24,,,,,,,,,,,,,
MICROPOWER SAGITTAL SAW,SUP-2605736,CDM,2720000010,LOCAL,0272,RC,,,,both,,,9096.08,5912.45,,,,,,,,,,,,,
HC Insert Picc Cath,PX-4503656900,CDM,36569,CPT,0450,RC,,,,inpatient,,,4942.00,3212.30,,,,,,,,,,,,,
EXTENSION STEM L175MM DIA11MM NK L130MM FLUT NXGN,SUP-2208712,CDM,C1776,CPT,0278,RC,,,,both,,,2527.70,1643.00,,,,,,,,,,,,,
PLATE BONE MEDIAL COLUMN RIGHT LONG TITANIUM ARSENAL FOOT PLATING SYSTEM FOR 2.2/2.7/3.5MM SCREW,SUP-2878139,CDM,C1713,HCPCS,0278,RC,,,,both,,,7991.30,5194.34,,,,,,,,,,,,,
SYSTEM TOT SHLDR REPL REV + PROMOS,SUP-2348003,CDM,C1776,CPT,0278,RC,,,,both,,,20410.00,13266.50,,,,,,,,,,,,,
CUBITAL TUNNEL BLADE 5 PACK,SUP-2604360,CDM,2720000010,LOCAL,0272,RC,,,,both,,,11766.90,7648.48,,,,,,,,,,,,,
ANCHOR SUT DIA1.4MM SFT SHT NDL SGL LD JUGGERKNOT,SUP-2212957,CDM,C1713,HCPCS,0278,RC,,,,both,,,1301.22,845.79,,,,,,,,,,,,,
PLATE BNE L 20 MM SCREW DIA2 MM MED CP TI MANDIBULAR FULL,SUP-2883712,CDM,C1713,HCPCS,0278,RC,,,,both,,,17216.34,11190.62,,,,,,,,,,,,,
STENT URET DBL PGTL 8.5 FRX24 CM TECOFLEX OPN END DUROMETER,SUP-2312738,CDM,C2617,HCPCS,0278,RC,,,,both,,,189.25,123.01,,,,,,,,,,,,,
LEAD PACE 5.3FR L88CM L VENT TRNSVEN STEROID ELUT IS-4-LLLL,SUP-2281930,CDM,C1900,HCPCS,0275,RC,,,,both,,,5024.00,3265.60,,,,,,,,,,,,,
PLATE BNE 95 DEG SHFT L 92 MM BLADE L 50 MM 5 H SS CNDYL,SUP-2907935,CDM,C1713,HCPCS,0278,RC,,,,both,,,3072.52,1997.14,,,,,,,,,,,,,
DEVICE NEUROSURGICAL SET VERIF PROGAV CHECKMATE,SUP-2108719,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1720.47,1118.31,,,,,,,,,,,,,
PLATE NEURO SM 1.5MM,SUP-2277736,CDM,C1713,HCPCS,0278,RC,,,,both,,,584.04,379.63,,,,,,,,,,,,,
V-D-RIGHT LK PL STD HD RIGHT SMPL,SUP-2818690,CDM,C1713,HCPCS,0278,RC,,,,both,,,694.44,451.39,,,,,,,,,,,,,
PROGRAMMER PT PROCLAIM DRG,SUP-2357383,CDM,C1787,HCPCS,0278,RC,,,,both,,,4596.77,2987.90,,,,,,,,,,,,,
PLATE BONE L35MM 6 H TI GAP FOR CRAN CLSR SYS,SUP-2243975,CDM,C1713,HCPCS,0278,RC,,,,both,,,429.02,278.86,,,,,,,,,,,,,
HC Assay of Triiodothyronine T3 Total Tt3,PX-3018448000,CDM,84480,CPT,0301,RC,,,,both,,,331.00,215.15,,,,,,,,,,,,,
BUR SURG DR MED 3X9.5 MM FLUT FOR HD-G1 CARBIDE,SUP-2848305,CDM,2720000010,LOCAL,0272,RC,,,,both,,,541.15,351.75,,,,,,,,,,,,,
CAGE SPNL EXPANDABLE 24X11X9-12 MM INTBDY SET SCREW MOJAVE,SUP-2493773,CDM,C1889,HCPCS,0278,RC,,,,both,,,12717.00,8266.05,,,,,,,,,,,,,
CEMENT DENT RADPQ KETAC,SUP-2100140,CDM,C1713,HCPCS,0278,RC,,,,both,,,484.78,315.11,,,,,,,,,,,,,
SYSTEM ORTH REV MOD TIB TAPE 63 SHT OSS,SUP-2441797,CDM,C1776,CPT,0278,RC,,,,both,,,8831.25,5740.31,,,,,,,,,,,,,
ATROPINE SULFATE 1 % OP SOLN,RX-736,CDM,6370000000,HCPCS,0637,RC,60219-1748-02,NDC,,both,2,ML,161.60,105.04,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 10 CM DIA 5 MM EPTFE STR STD WALL,SUP-2396177,CDM,C1768,CPT,0278,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
SCREW SPNL L6.5MM DIA3MM 0DEG TI SURG MESH FOR THOR AND LUM,SUP-2256180,CDM,C1713,HCPCS,0278,RC,,,,both,,,147.58,95.93,,,,,,,,,,,,,
CATHETER CV 16 GAX160 MM 1.7 MM PTFE GRY STRL SECALON-T DISP,SUP-2662691,CDM,C1751,HCPCS,0278,RC,,,,both,,,16.80,10.92,,,,,,,,,,,,,
STEM FEM 0 STD HIP SS QUDRA-C,SUP-2267297,CDM,C1776,CPT,0278,RC,,,,both,,,5526.40,3592.16,,,,,,,,,,,,,
NAIL IM FEM PEDIATRIC 6.5 MMX24 CM TI,SUP-2861972,CDM,C1713,HCPCS,0278,RC,,,,both,,,3997.47,2598.36,,,,,,,,,,,,,
LEUCOVORIN CALCIUM 100 MG/10ML IJ SOLN,RX-110195,CDM,J0640,HCPCS,0636,RC,63323-0631-10,NDC,,both,10,ML,71.10,46.21,,,,,,,,,,,,,
PAD THER UNIV HYDRGEL GEL TWO CHST LEG NONINVASIVE H2O,SUP-2127456,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1295.25,841.91,,,,,,,,,,,,,
AWL SURG DIA 4 MM CANN STR GRN,SUP-2934448,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1792.94,1165.41,,,,,,,,,,,,,
CATHETER BRACHYTHERAPY MULT LUMEN 4.5 CM BLLN CONTURAFLEX,SUP-2239950,CDM,C1726,HCPCS,0272,RC,,,,both,,,8223.66,5345.38,,,,,,,,,,,,,
BOOT EQL BLK XL EA,SUP-2319312,CDM,L4360,HCPCS,0274,RC,,,,both,,,72.97,47.43,,,,,,,,,,,,,
GRAFT BNE H20MM IL CREST WDG PRESERVON MATRIGRFT,SUP-2264844,CDM,C1713,HCPCS,0278,RC,,,,both,,,2780.47,1807.31,,,,,,,,,,,,,
SCREW BNE L35MM DIA5MM CORT TI LOK FULL THRD SHFT FOR T2 IM,SUP-2369901,CDM,C1713,HCPCS,0278,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
SCAFFOLD CELLULAR INJ 20CC SYR FOR STBL BONE DEFECTS,SUP-2399076,CDM,C1713,HCPCS,0278,RC,,,,both,,,3271.88,2126.72,,,,,,,,,,,,,
FILTER VASC GIANTURCO-ROEHM BIRD'S NEST DIA 40 MM CATH L 40,SUP-2168156,CDM,C1880,HCPCS,0278,RC,,,,both,,,4003.50,2602.27,,,,,,,,,,,,,
PLATE BONE W15XL200MM THK2MM 10 H BILAT S STL COVERLEAF RIG,SUP-2186011,CDM,C1713,HCPCS,0278,RC,,,,both,,,4582.20,2978.43,,,,,,,,,,,,,
GRAFT VASC GORTX L 70 CM DIA 8 MM RNG L 20 CM EPTFE STR TW,SUP-2396165,CDM,C1768,CPT,0278,RC,,,,both,,,2992.42,1945.07,,,,,,,,,,,,,
CATHETER ABLAT 7FR L115CM 1-7-4MM SPC TIP 4MM 4 ELECTRD,SUP-2248516,CDM,C1732,HCPCS,0278,RC,,,,both,,,6669.36,4335.08,,,,,,,,,,,,,
SNARE ENDOSCP POLYP LOOP OVL ASMBLY SHTH WIRE COLONSCP,SUP-2463221,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1435.70,933.20,,,,,,,,,,,,,
HOOK SPNL SM PEDCL IMP SFS,SUP-2317417,CDM,C1713,HCPCS,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
NAIL L 11MMX320MM LNG GAM,SUP-2370305,CDM,C1713,HCPCS,0278,RC,,,,both,,,4265.69,2772.70,,,,,,,,,,,,,
SCREW BONE 12.7MM THRD 55MM LAG S STL RED STRL FRELOK,SUP-2197690,CDM,C1713,HCPCS,0278,RC,,,,both,,,854.99,555.74,,,,,,,,,,,,,
PLATE BNE FEM LG 0.2 CM,SUP-2321786,CDM,C1713,HCPCS,0278,RC,,,,both,,,2854.26,1855.27,,,,,,,,,,,,,
GRAFT BNE CUBE 10X10X10 MM DBM ALLOSYNC,SUP-2845373,CDM,C1713,HCPCS,0278,RC,,,,both,,,1851.03,1203.17,,,,,,,,,,,,,
EXTENSION NEUROSTIMULATOR L60CM SPNL CRD OCTAPOLAR 1X8,SUP-2284456,CDM,C1883,HCPCS,0278,RC,,,,both,,,1877.72,1220.52,,,,,,,,,,,,,
SCREW BNE L 4 MM DIA2 MM TI MAND SD AXS NS UNIV 2.0 MP,SUP-2909526,CDM,C1713,HCPCS,0278,RC,,,,both,,,425.82,276.78,,,,,,,,,,,,,
CAP END OFFSET 15 MM PHOENIX,SUP-2517875,CDM,C1889,HCPCS,0278,RC,,,,both,,,483.56,314.31,,,,,,,,,,,,,
HC Canalith Repositioning Proc|OP PT SERVICES|ADJ,PX-4209599200,CDM,95992,CPT,0420,RC,,,GP|ADJ,both,,,333.00,216.45,,,,,,,,,,,,,
BLADE SURG 22 CARBON NS PERSONNA +,SUP-2133479,CDM,2720000010,LOCAL,0272,RC,,,,both,,,195.03,126.77,,,,,,,,,,,,,
HEAD HUM SZ 4 HA COAT SHLDR RESURF COPELAND,SUP-2403988,CDM,C1776,CPT,0278,RC,,,,both,,,9272.42,6027.07,,,,,,,,,,,,,
TRIAL-SET COPAL EXCHANGE G HIP S,SUP-2905383,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1224.60,795.99,,,,,,,,,,,,,
GUIDEWIRE UROLOGY STR 0.035 INX150 CM COR STIFF-BODY BIWIRE,SUP-2836007,CDM,C1769,HCPCS,0272,RC,,,,both,,,185.04,120.28,,,,,,,,,,,,,
PLUG ACET MET CTRL H MPACT,SUP-2267359,CDM,C1713,HCPCS,0278,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
SCREWDRIVER BLADE 2 MM MAXILLOMANDIBULAR SL FIX SCR MAXDRIVE,SUP-2457855,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1555.93,1011.35,,,,,,,,,,,,,
SPACER SPNL LUM 12MMX26MMX9-13MM CALIB,SUP-2231995,CDM,C1821,HCPCS,0278,RC,,,,both,,,13188.00,8572.20,,,,,,,,,,,,,
SET INTRO MICROPUNCTURE CATH L 10 CM 5 FR L 7 CM NIT PLAT,SUP-2170488,CDM,C1894,HCPCS,0272,RC,,,,both,,,58.22,37.84,,,,,,,,,,,,,
GRAFT EVAR IL BRANCH COMP L7CM DIA14.5MM NIT EPTFE FEP INT,SUP-2395802,CDM,C1768,CPT,0278,RC,,,,both,,,8638.14,5614.79,,,,,,,,,,,,,
BLOCK CORTICAL 11X11X9 IN CORNERSTONE,SUP-2277892,CDM,C1713,HCPCS,0278,RC,,,,both,,,3312.70,2153.25,,,,,,,,,,,,,
HANDLE INSTR ZONE NAVIGATOR SYS,SUP-2417073,CDM,2720000010,LOCAL,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
IMPLANT FACE SZ 40 X 52 MM THK 2.3 MM POLYETHYL ORBIT BARR,SUP-2883690,CDM,C1713,HCPCS,0278,RC,,,,both,,,3154.07,2050.15,,,,,,,,,,,,,
CAGE ACET CUP DIA64MM THK2MM LT COMMERCIALLY PURE TI MOD,SUP-2405115,CDM,C1776,CPT,0278,RC,,,,both,,,8930.16,5804.60,,,,,,,,,,,,,
SHEATH INTRO FAST-CATH L 12 CM DIA 4 FR GUIDEWIRE L 50 CM,SUP-2357139,CDM,C1894,HCPCS,0272,RC,,,,both,,,8.16,5.30,,,,,,,,,,,,,
HC Ot Therapeutic Activities 15 Min|OP PT SERVICES|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS|DOCUMENTATION ON FILE,PX-4309753000,CDM,97530,CPT,0430,RC,,,GP|CQ|KX,both,,,144.00,93.60,,,,,,,,,,,,,
ERGOCALCIFEROL 200 MCG/ML PO SOLN,RX-147614,CDM,340b,HCPCS,0637,RC,99999-1284-01,NDC,,both,0.25,ML,2.70,1.75,,,,,,,,,,,,,
CATHETERIZATION TRAY 4 FR DL NIT GUIDEWIRE POWERPICC PROVENA,SUP-2127010,CDM,C1751,HCPCS,0278,RC,,,,both,,,461.20,299.78,,,,,,,,,,,,,
CATHETER THROMCTMY INDIGO L 135 CM 6/6FR 0.014-0.038IN DYN,SUP-2323574,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6986.50,4541.22,,,,,,,,,,,,,
HC So Malaria Prep,PX-3008720766,CDM,87207,CPT,0300,RC,,,,outpatient,,,43.00,27.95,,,,,,,,,,,,,
TUBE VENT 1.27 MM 1 MM 2.7 MM BOB TI GLD STRL,SUP-2535064,CDM,L8699,HCPCS,0278,RC,,,,both,,,67.35,43.78,,,,,,,,,,,,,
PLATE BNE DBL Y 2X0.8 MM CHIN GENIOPLASTY FAB W/ TAB TI,SUP-2462306,CDM,C1713,HCPCS,0278,RC,,,,both,,,851.07,553.20,,,,,,,,,,,,,
SCREW BNE L40MM OD45MM TI CALCNL ANK CANN SHT THRD HD COMPR,SUP-2398951,CDM,C1713,HCPCS,0278,RC,,,,both,,,379.94,246.96,,,,,,,,,,,,,
SCREW SPNL 12 MM,SUP-2242800,CDM,C1713,HCPCS,0278,RC,,,,both,,,926.30,602.09,,,,,,,,,,,,,
GRAFT EVAR 14FR L82MM DIA16X16MM HI DENS MULTIFILAMENT POLY,SUP-2295253,CDM,C1768,CPT,0278,RC,,,,both,,,15204.63,9883.01,,,,,,,,,,,,,
POR FEM/CEM MON TIB/PAT,SUP-2137306,CDM,C1713,HCPCS,0278,RC,,,,both,,,13542.82,8802.83,,,,,,,,,,,,,
SPLINT KNEE UNIV FOR LESS THAN 36IN L24IN FOAM LAM ELAS CNTCT,SUP-2197156,CDM,L3650,HCPCS,0272,RC,,,,both,,,45.34,29.47,,,,,,,,,,,,,
EPINEPHRINE 5 MG IN NS 250 ML INFUSION,RX-4082235,CDM,2500000003,HCPCS,0250,RC,99999-9916-43,NDC,,both,250,ML,431.30,280.34,,,,,,,,,,,,,
BRACE ORTH SAGITAL LUMBAR CTRL PREFABRICATED FLEXION,SUP-2388150,CDM,L0633,HCPCS,0272,RC,,,,both,,,738.50,480.02,,,,,,,,,,,,,
STENT GRFT VASC TAG L 15 CM UNCOVERED L 4 MM PROX/DSTL,SUP-2423919,CDM,C1768,CPT,0278,RC,,,,both,,,63255.30,41115.94,,,,,,,,,,,,,
CATHETER ANGIOPLSTY RX 014 12 ATM 6 FRX140 CM 4X15 MM CUT,SUP-2141221,CDM,C1725,HCPCS,0272,RC,,,,both,,,2584.91,1680.19,,,,,,,,,,,,,
PORT INFUS 8FR POLYUR ATTCH CHRONOFLEX CATHETER TI OPN SUT H,SUP-2126310,CDM,C1788,HCPCS,0278,RC,,,,both,,,1303.10,847.01,,,,,,,,,,,,,
DEVICE PESSARY RNG W/ SUPP FLD 3IN SZ 5,SUP-2171738,CDM,A4562,HCPCS,0272,RC,,,,both,,,194.68,126.54,,,,,,,,,,,,,
PLATE BONE LOCKING HOLEX10 T SHAPED RIGHT DORSAL DISTAL,SUP-2721391,CDM,C1713,HCPCS,0278,RC,,,,both,,,3318.29,2156.89,,,,,,,,,,,,,
FIBER LASER 200U 50W ETFE SIL FLEXSHIELD HI PWR POLISHED OUTPT,SUP-2141810,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1174.27,763.28,,,,,,,,,,,,,
ADAPTER NAVIGATION PRB STRL DISP BRAINPATH,SUP-2930245,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1518.19,986.82,,,,,,,,,,,,,
KIT DUAL OSIA 2 SOUND PROCESSOR,SUP-2858182,CDM,L8690,HCPCS,0278,RC,,,,both,,,21681.70,14093.10,,,,,,,,,,,,,
SCREW BNE L 60 MM DIA 4.5 MM ST LCK STRL EVOS,SUP-2931198,CDM,C1713,HCPCS,0278,RC,,,,both,,,851.41,553.42,,,,,,,,,,,,,
MARKER PASS 5X12 FOR ROBOT,SUP-2232049,CDM,A4648,CPT,0278,RC,,,,both,,,3579.60,2326.74,,,,,,,,,,,,,
FRAME EXT FIX ASMBLY 160MM FOR SALVATION 2 SYS,SUP-2401160,CDM,2720000010,LOCAL,0272,RC,,,,both,,,26410.54,17166.85,,,,,,,,,,,,,
SCREW BONE CNNLTD CMPRSSN 3MM DIA LNG 22MML TTNM ALLOY SELF,SUP-2586442,CDM,C1713,HCPCS,0278,RC,,,,both,,,1029.20,668.98,,,,,,,,,,,,,
SET URET STENT L 30 CM DIA 4.8 FR SENSOR GUIDEWIRE 0.035 IN,SUP-2458021,CDM,C2617,HCPCS,0278,RC,,,,both,,,473.86,308.01,,,,,,,,,,,,,
GRAFT IMPL HUM TISS FRZN ALLGRFT FEM CORT STRUT BNE 200MM,SUP-2307362,CDM,C1713,HCPCS,0278,RC,,,,both,,,5736.37,3728.64,,,,,,,,,,,,,
BASEPLATE GLEN 20 DEG OD 27 MM ID 20 MM FULL WDG RECON STRL,SUP-2888638,CDM,C1776,CPT,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
STYLET SPNL 45 MM FOR RELINE K WIRELESS MAS,SUP-2421827,CDM,2720000010,LOCAL,0272,RC,,,,both,,,973.40,632.71,,,,,,,,,,,,,
CLINDAMYCIN 150 MG/ML IJ SOLN (MIXTURES ONLY),RX-430018,CDM,J0736,HCPCS,0636,RC,00009-0870-26,NDC,,both,2,ML,54.10,35.16,,,,,,,,,,,,,
PLATE BNE TROCH PERIPROSTHETIC STRL NCB,SUP-2862095,CDM,C1713,HCPCS,0278,RC,,,,both,,,15174.87,9863.67,,,,,,,,,,,,,
FILLER BNE GRFT 5 ML GENTAMICIN SULF HA CALCIUM SULF INJ,SUP-2893107,CDM,C1602,HCPCS,0278,RC,,,,both,,,12943.08,8413.00,,,,,,,,,,,,,
HC Drain/Inj Joint/Bursa W/US Large,PX-5102061100,CDM,20611,CPT,0510,RC,,,,inpatient,,,3707.00,2409.55,,,,,,,,,,,,,
PLATE BNE MESH PANEL STD 1.5X80X53X0.6 MM NEURO REG GRID,SUP-2480638,CDM,C1713,HCPCS,0278,RC,,,,both,,,2373.02,1542.46,,,,,,,,,,,,,
DIGITAL SCREW 2.0 X 30MM,SUP-2586643,CDM,C1713,HCPCS,0278,RC,,,,both,,,1357.30,882.24,,,,,,,,,,,,,
SCREW LAG T2 RECON 65X110MM,SUP-2701900,CDM,C1713,HCPCS,0278,RC,,,,both,,,663.17,431.06,,,,,,,,,,,,,
BLADE SURG DIA2 MM,SUP-2934100,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1730.14,1124.59,,,,,,,,,,,,,
ROD SPNL THORLUM STR TOP LD HEX END LO PROF S STL OD5.5MM 424521] DEPUY SYNTHES USA],SUP-2190804,CDM,C1713,HCPCS,0278,RC,,,,both,,,734.07,477.15,,,,,,,,,,,,,
INTRODUCER TRANSSEPTAL GUID 8FR L81CM DIL 8FR L85CM 0.032IN,SUP-2357242,CDM,C1893,HCPCS,0272,RC,,,,both,,,602.88,391.87,,,,,,,,,,,,,
SLEEVE INSRT SZ 8-11 E FOR T2 NAILING SYS,SUP-2368596,CDM,2720000010,LOCAL,0272,RC,,,,both,,,328.13,213.28,,,,,,,,,,,,,
ROD ORTH 10X135 MM AVASCULAR NECROSIS,SUP-2861956,CDM,C1713,HCPCS,0278,RC,,,,both,,,4249.74,2762.33,,,,,,,,,,,,,
COLLAR CERV FIRM DENS AD HK AND LOOP CLSR FOAM W COT CVR,SUP-2276586,CDM,L0120,HCPCS,0274,RC,,,,both,,,7.03,4.57,,,,,,,,,,,,,
SCREW BNE L70MM DIA6MM DST FEM TI ST CANN LOK FULL THRD,SUP-2191844,CDM,C1713,HCPCS,0278,RC,,,,both,,,650.95,423.12,,,,,,,,,,,,,
GRAFT BNE MIN W10MM WHL PAT W SMER BLK FRZN FLEXIGRFT,SUP-2264796,CDM,C1713,HCPCS,0278,RC,,,,both,,,11006.39,7154.15,,,,,,,,,,,,,
SPACER SPNL 10X22X60MM 10DEG TI MODULUS XLW,SUP-2421144,CDM,C1821,HCPCS,0278,RC,,,,both,,,13345.00,8674.25,,,,,,,,,,,,,
BOLT ARCOS LATERAL TROCH 24MM,SUP-2506130,CDM,C1776,CPT,0278,RC,,,,both,,,1381.60,898.04,,,,,,,,,,,,,
SCREW SYS PARTIALLY THRD LAG SCRS 316 L VM S THRD 2.5MM,SUP-2392876,CDM,C1713,HCPCS,0278,RC,,,,both,,,340.69,221.45,,,,,,,,,,,,,
PLUG VASC AMPLATZER II L 6 MM DIA 4 MM DEL SYS L 135 CM CATH,SUP-2116304,CDM,C1889,HCPCS,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
SUPPORT ORTHOT THOR LUMBAR SACR CUST CORSET FRONT,SUP-2435563,CDM,L0970,HCPCS,0272,RC,,,,both,,,302.54,196.65,,,,,,,,,,,,,
GRAFT HUM TISS W8XL16CM THK07 14MM THN ACELLULAR HYDRATED,SUP-2307586,CDM,Q4128,HCPCS,0636,RC,,,,both,,,21056.06,13686.44,,,,,,,,,,,,,
TUBING KIT RF COOLED FLUID 2 PRB IV SPIKE STRL COOLIEF LTX,SUP-2859189,CDM,2720000010,LOCAL,0272,RC,,,,both,,,597.67,388.49,,,,,,,,,,,,,
SCREW BONE CANNULATED 7X140 MM 16 MM SELFDRILLING PARTIAL TH,SUP-2836842,CDM,C1713,HCPCS,0278,RC,,,,both,,,2119.88,1377.92,,,,,,,,,,,,,
TUBE TRACH AD L88MM OD11MM ID8MM SIL CUF W TLK ATTCH MID,SUP-2352454,CDM,2720000010,LOCAL,0272,RC,,,,both,,,348.54,226.55,,,,,,,,,,,,,
STENT ENDOPROS L25CM DIA6MM CATH 7FR L120CM 0.035IN VES,SUP-2396603,CDM,C1874,HCPCS,0278,RC,,,,both,,,20425.70,13276.70,,,,,,,,,,,,,
KIT SUT DEV PUR TARGET WIRE W/ SNR CRV HNDL COR-KNOT MINI,SUP-2265306,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1224.60,795.99,,,,,,,,,,,,,
SCREW BONE L95MM DIA5MM CANN CONCL HD,SUP-2184932,CDM,C1713,HCPCS,0278,RC,,,,both,,,420.76,273.49,,,,,,,,,,,,,
CABLE ADPT APM,SUP-2141581,CDM,2720000010,LOCAL,0272,RC,,,,both,,,957.70,622.50,,,,,,,,,,,,,
NAIL IM M L260MM DIA11MM 5DEG HUM TI PROX BEND NK AG RG LOK,SUP-2408495,CDM,C1713,HCPCS,0278,RC,,,,both,,,445.88,289.82,,,,,,,,,,,,,
SCREW ARTHROERESIS SUBTALAR CONIC SFT THRD TI 11MM DIA 17MML,SUP-2399407,CDM,C1713,HCPCS,0278,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
HARDWARE ORTH LCK,SUP-2766753,CDM,C1769,HCPCS,0272,RC,,,,both,,,4553.00,2959.45,,,,,,,,,,,,,
DRILL TWST L87MM OD22MM CANN AO QUIK CPL SHFT END FOR K WIRE,SUP-2267868,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1620.24,1053.16,,,,,,,,,,,,,
ROD CONN 5.5 MM FRONT LD FIREBIRD NXG,SUP-2658355,CDM,C1713,HCPCS,0278,RC,,,,both,,,1648.50,1071.52,,,,,,,,,,,,,
SEALANT HEMOSTATIC 2 CC SUSP VITAGEL,SUP-2379550,CDM,C1713,HCPCS,0278,RC,,,,both,,,828.65,538.62,,,,,,,,,,,,,
PLATE BNE THK06MM 16 H MIDFACE TI STR LO PROF LEV 1 SIL FOR,SUP-2262718,CDM,C1713,HCPCS,0278,RC,,,,both,,,735.51,478.08,,,,,,,,,,,,,
TOLNAFTATE 1 % EX CREA,RX-8020,CDM,6370000000,HCPCS,0637,RC,51672-2020-02,NDC,,both,30,GR,23.50,15.27,,,,,,,,,,,,,
SHEATH INTRO L 14 CM DIA 9 FR GUIDEWIRE 0.038 IN PTFE X TW,SUP-2615900,CDM,C1894,HCPCS,0272,RC,,,,both,,,79.00,51.35,,,,,,,,,,,,,
POLYSACCHARIDE IRON COMPLEX 150 MG PO CAPS,RX-11050,CDM,6370000000,HCPCS,0637,RC,63044-0203-61,NDC,,both,1,UN,1.20,0.78,,,,,,,,,,,,,
STENT PERIPH SMRT RADIANZ L 100 MM DIA 6 MM DEL SYS L 190 CM,SUP-2866171,CDM,C1876,HCPCS,0278,RC,,,,both,,,4168.88,2709.77,,,,,,,,,,,,,
PROBE ARTHSCP HIP BLK INTEGR CBL EFLEX ABLAT,SUP-2341733,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1840.51,1196.33,,,,,,,,,,,,,
ALLOGRAFT BNE SPACER 7 MM CERV VIKOS,SUP-2538547,CDM,C1889,HCPCS,0278,RC,,,,both,,,2490.02,1618.51,,,,,,,,,,,,,
PASSER SUTURE 210X3.5MM HIP SLIM RAVEN,SUP-2828617,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4590.30,2983.69,,,,,,,,,,,,,
MIRTAZAPINE 30 MG PO TABS,RX-17465,CDM,6370000000,HCPCS,0637,RC,63739-0099-10,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
IMPLANT PENILE L21CM CYL INFL MINOCYCLINE RIFAMPIN,SUP-2140284,CDM,C1813,HCPCS,0278,RC,,,,both,,,7893.02,5130.46,,,,,,,,,,,,,
PLATE BNE L W13.5XL134MM THK4.2MM 7 H BILAT TI NAR RIG NEUT,SUP-2190814,CDM,C1713,HCPCS,0278,RC,,,,both,,,1337.89,869.63,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 60 CM DIA 6MM STR TW REMOVABLE RNG,SUP-2396293,CDM,C1768,CPT,0278,RC,,,,both,,,3557.62,2312.45,,,,,,,,,,,,,
HC Cardiopulm Resuscitation,PX-4509295000,CDM,92950,CPT,0450,RC,,,,inpatient,,,424.00,275.60,,,,,,,,,,,,,
PLATE BNE ACTIVE COMPR BROAD LG 4.5X109 MM 6 HOLE NS,SUP-2488517,CDM,C1713,HCPCS,0278,RC,,,,both,,,552.64,359.22,,,,,,,,,,,,,
MESH HERN XL W1.6XL2IN INGUINAL WHT POLYPR MFIL PLUG PTCH,SUP-2125753,CDM,C1781,HCPCS,0278,RC,,,,both,,,725.65,471.67,,,,,,,,,,,,,
HEAD SPNL SCREW ROD DIA 4.75/5 MM MULTAXL STRL CD HORZ 559200039,SUP-2927815,CDM,C1713,HCPCS,0278,RC,,,,both,,,1.66,1.08,,,,,,,,,,,,,
HC Rt Bronchoscopy Foreign Body Removal,PX-3613163500,CDM,31635,CPT,0361,RC,,,,both,,,5261.00,3419.65,,,,,,,,,,,,,
POTASSIUM PHOSPHATE 3 MMOL/ML IV SOLN (MIXTURES ONLY),RX-430008,CDM,2500000003,HCPCS,0250,RC,00409-7295-01,NDC,,both,15,ML,85.10,55.31,,,,,,,,,,,,,
BASEPLATE TIB SZ 4 STD CO CHROM PRI NP CEM STEM ADV II,SUP-2304787,CDM,C1776,CPT,0278,RC,,,,both,,,7094.52,4611.44,,,,,,,,,,,,,
SCREW TOE JT 10 DEG MED SLD ANGLED STRL PHALINX,SUP-2900632,CDM,C1713,HCPCS,0278,RC,,,,both,,,4744.54,3083.95,,,,,,,,,,,,,
PLATE BNE L 91 MM SCREW DIA 3.5 MM 6 H SS RL PROX TIB STRL,SUP-2931146,CDM,C1713,HCPCS,0278,RC,,,,both,,,6799.67,4419.79,,,,,,,,,,,,,
BAND ORTHODONTIC M SZ 30 LO MAND S STL SEAMLESS CHAIRSIDE,SUP-2176639,CDM,D6783,CPT,0278,RC,,,,both,,,21.48,13.96,,,,,,,,,,,,,
CLAMP EXT FIX ANG POST 11MM 30DEG 5 H PIN FOR HOFFMANN III,SUP-2372223,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2373.84,1543.00,,,,,,,,,,,,,
GRAFT DERM L10CM W5CM THK.8-1.7MM THCK DERMAMATRIX ACELLULAR,SUP-2306914,CDM,C1762,CPT,0278,RC,,,,both,,,4484.92,2915.20,,,,,,,,,,,,,
KIT SUTURE ANCHR L 12 MM DIA 4.2 MM LCK PRELD PASS TAPE ON,SUP-2899050,CDM,C1713,HCPCS,0278,RC,,,,both,,,1252.08,813.85,,,,,,,,,,,,,
CATHETER HD DL 14.5FRX28CM 45CM ADMIN CHRONIC PALINDROME,SUP-2283946,CDM,C1750,HCPCS,0278,RC,,,,both,,,1069.08,694.90,,,,,,,,,,,,,
SCREW BNE MAXILLOFACIAL CORT CENTRE-DRIVE 2.3 250850901] KLS MARTIN LP],SUP-2262626,CDM,C1713,HCPCS,0278,RC,,,,both,,,194.68,126.54,,,,,,,,,,,,,
WIRE FIX L6IN OD11MM S STL PARTIALLY THRD DBL SHRP TIP FOR,SUP-2137267,CDM,C1769,HCPCS,0272,RC,,,,both,,,776.37,504.64,,,,,,,,,,,,,
BRIVARACETAM 50 MG PO TABS,RX-133983,CDM,6370000000,HCPCS,0637,RC,50474-0570-09,NDC,,both,1,UN,110.50,71.82,,,,,,,,,,,,,
STEM FEM CEM 11 120 MM HIP PROS N V-LIGN STD OFFSET VERSYS,SUP-2439201,CDM,C1776,CPT,0278,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
LINER ACET SZ DML OD60MM ID28MM BRN DBL MOBILITY HIGHCROSS,SUP-2267323,CDM,C1776,CPT,0278,RC,,,,both,,,3730.32,2424.71,,,,,,,,,,,,,
HEAD FEM DIA22MM +0MM CO CHROME,SUP-2314550,CDM,C1776,CPT,0278,RC,,,,both,,,1984.48,1289.91,,,,,,,,,,,,,
ANCHOR SUT DIA2.8MM NO2 SUT TI ULTRABRAID TWINFIX,SUP-2341666,CDM,C1713,HCPCS,0278,RC,,,,both,,,767.38,498.80,,,,,,,,,,,,,
HC Transesophageal Echo,PX-4839331200,CDM,93312,CPT,0483,RC,,,,inpatient,,,1699.00,1104.35,,,,,,,,,,,,,
BODY VERT H 19-23 MM DIA19 MM 2XS BLACKARMOR CARBON PEEK,SUP-2917109,CDM,C1889,HCPCS,0278,RC,,,,both,,,56520.00,36738.00,,,,,,,,,,,,,
FOOTPLATE EXT FIX 160 MM 12224100] CAROMED INTL],SUP-2162653,CDM,C1713,HCPCS,0278,RC,,,,both,,,5144.58,3343.98,,,,,,,,,,,,,
SET PICC CONV FOR 5FR CATHETER SELD,SUP-2384041,CDM,C1751,HCPCS,0278,RC,,,,both,,,70.02,45.51,,,,,,,,,,,,,
FENTANYL CITRATE (PF) 250 MCG/5ML IJ SOLN|DISCARDED DRUG NOT ADMINISTE,RX-133094,CDM,J3010,HCPCS,0636,RC,00409-9094-25,NDC,JW,both,0.5,ML,54.10,35.16,,,,,,,,,,,,,
STEM FEM HI OFFSET BCD MAG NK W/ TRUNNION ARCOS,SUP-2443222,CDM,C1776,CPT,0278,RC,,,,both,,,1907.55,1239.91,,,,,,,,,,,,,
HC I&D Pilonidal Cyst Simple,PX-4501008000,CDM,10080,CPT,0450,RC,,,,both,,,1458.00,947.70,,,,,,,,,,,,,
PIN FIX L65MM SPD FOR JOURNEY II BCS KNEE SYS,SUP-2350287,CDM,C1713,HCPCS,0278,RC,,,,both,,,94.20,61.23,,,,,,,,,,,,,
ANCHOR SUT L19.5MM DIA7MM PEEK FORKED EYELET TENODESIS FOR,SUP-2121431,CDM,C1713,HCPCS,0278,RC,,,,both,,,1365.90,887.83,,,,,,,,,,,,,
PREM ST/RGX CP/E1 LN/STD HD,SUP-2212400,CDM,C1776,CPT,0278,RC,,,,both,,,18526.00,12041.90,,,,,,,,,,,,,
ALLOGRAFT BNE TIB SHFT 160X2 MM FRZN 31024268,SUP-2717865,CDM,C1762,CPT,0278,RC,,,,both,,,3631.00,2360.15,,,,,,,,,,,,,
HC So Hepatitis C Virus Genotyping,PX-3068790266,CDM,87902,CPT,0306,RC,,,,inpatient,,,1147.00,745.55,,,,,,,,,,,,,
ES TROCH NAIL RIGHT 11MMX45CMX130 DEGREE,SUP-2810991,CDM,C1713,HCPCS,0278,RC,,,,both,,,9090.30,5908.69,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 80 CM DIA 8 MM EPTFE STR TW REINF 2,SUP-2525451,CDM,C1768,CPT,0278,RC,,,,both,,,983.23,639.10,,,,,,,,,,,,,
PLATE BNE LCK NAR 4.5 MM 5 HOLE COMPR STRL ALPS LTX,SUP-2861819,CDM,C1713,HCPCS,0278,RC,,,,both,,,1280.74,832.48,,,,,,,,,,,,,
SCREW BNE CANN 4X32 MM FT,SUP-2342796,CDM,C1713,HCPCS,0278,RC,,,,both,,,408.83,265.74,,,,,,,,,,,,,
DOXEPIN HCL 50 MG PO CAPS,RX-2612,CDM,6370000000,HCPCS,0637,RC,00378-4250-01,NDC,,both,1,UN,4.00,2.60,,,,,,,,,,,,,
SCREW BNE LCK 10X2 MM VARIAX,SUP-2550585,CDM,C1713,HCPCS,0278,RC,,,,both,,,1033.06,671.49,,,,,,,,,,,,,
PLATE BNE STR 2.3 MM 27 HOLE FRAC FOR SCR TI LEVEL 1,SUP-2468678,CDM,C1713,HCPCS,0278,RC,,,,both,,,1554.33,1010.31,,,,,,,,,,,,,
ELECTRODE VPR FOR 12/30 LENS CBL PLASMABUTTON,SUP-2313585,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1474.86,958.66,,,,,,,,,,,,,
PASSER SUT DISP NOVOSTITCH,SUP-2163491,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1566.86,1018.46,,,,,,,,,,,,,
KIT TISS CLOSURE SUTURE USP 2-0 L 66 CM TENS CTRL L 2.6 X W,SUP-2930521,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3136.86,2038.96,,,,,,,,,,,,,
PLATE BNE THK 1 MM ADV 2 MM SCREW DIA2 MM MINI RT,SUP-2883174,CDM,C1713,HCPCS,0278,RC,,,,both,,,1649.82,1072.38,,,,,,,,,,,,,
GRAFT BONE SUB 1ML PUTTY CANC DEMIN INJ W/ CHIP PUROS,SUP-2205386,CDM,C1734,HCPCS,0278,RC,,,,both,,,1230.88,800.07,,,,,,,,,,,,,
SCREW BNE DIGITAL FUSION 2X34 MM TI TI6,SUP-2609625,CDM,C1713,HCPCS,0278,RC,,,,both,,,1357.30,882.24,,,,,,,,,,,,,
IMPLANT FACE L 40 X W 28 MM 7.5 MM LG RT ORBIT FLR WDG,SUP-2883583,CDM,C1713,HCPCS,0278,RC,,,,both,,,1886.42,1226.17,,,,,,,,,,,,,
COLLAR CERV PED 3IN 16IN M HEADMASTER,SUP-2324112,CDM,L0180,HCPCS,0272,RC,,,,both,,,262.19,170.42,,,,,,,,,,,,,
KNEE IMMOB 22IN QUAL PLUSXL,SUP-2195534,CDM,L1830,CPT,0272,RC,,,,both,,,115.55,75.11,,,,,,,,,,,,,
SUPPORT ORTHOT ANK KNEE CALF CUST SLD STIRRUP,SUP-2435630,CDM,L1980,HCPCS,0272,RC,,,,both,,,1143.12,743.03,,,,,,,,,,,,,
HC Asp Lum Disc Single/Multi Lev,PX-3616228700,CDM,62287,CPT,0361,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
CAPSULE ENDO CAM L26.2MM DIA11.4MM BIOCOMPATIBLE PLAS SB3-EX,SUP-2227941,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1664.83,1082.14,,,,,,,,,,,,,
KIT BONE CEM 80GM DBL MX VAC MXING SYS CART 2 NOZ FLTR TBNG,SUP-2136767,CDM,C1713,HCPCS,0278,RC,,,,both,,,744.18,483.72,,,,,,,,,,,,,
IMPLANT OTO L4.9MM DIA1.17MM LNG HA INCUS FULL CANN KARTUSH,SUP-2418998,CDM,L8613,CPT,0278,RC,,,,both,,,1171.09,761.21,,,,,,,,,,,,,
DEFIBRILLATOR CARD 76GM 35CC W40XH74MM THK14MM DF1 IS1 CONN,SUP-2356285,CDM,C1721,HCPCS,0275,RC,,,,both,,,33385.67,21700.69,,,,,,,,,,,,,
ENDCAP ORTH L20MM DIA15MM ST FEM TI NAIL SPRL BLDE EXTN LOK,SUP-2192144,CDM,C1713,HCPCS,0278,RC,,,,both,,,813.70,528.90,,,,,,,,,,,,,
CANNULA 5MM NDL 100MM 20GA PREM SL RF STR ACT TIP,SUP-2357719,CDM,2720000010,LOCAL,0272,RC,,,,both,,,37.68,24.49,,,,,,,,,,,,,
ADAPTER LD 5 32MM BPLR BIFUR,SUP-2355667,CDM,C1883,HCPCS,0278,RC,,,,both,,,1962.50,1275.62,,,,,,,,,,,,,
CATHETER CARD ABLATION NAVISTAR L 115CM 7FR 4MM F CRV UNIDIR,SUP-2248942,CDM,C1732,HCPCS,0272,RC,,,,both,,,6119.86,3977.91,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY L 60 CM DIA 5 FR SPC 2-8-2 MM TIP,SUP-2486634,CDM,C1730,HCPCS,0272,RC,,,,both,,,356.55,231.76,,,,,,,,,,,,,
SCREW BNE CORTICAL LG 2.7X20 MM FUSION HEX DRV SS STRL,SUP-2852008,CDM,C1713,HCPCS,0278,RC,,,,both,,,428.11,278.27,,,,,,,,,,,,,
PLATE BONE L2.7MM 7 H LCK COMPR PEDILOC,SUP-2318664,CDM,C1713,HCPCS,0278,RC,,,,both,,,2293.52,1490.79,,,,,,,,,,,,,
BLADE SHAVER CRV 15 DEG 4.8 MM SERRATED HEMOSTATIC CONVX,SUP-2638103,CDM,2720000010,LOCAL,0272,RC,,,,both,,,571.48,371.46,,,,,,,,,,,,,
BASEPLATE GLEN L AUGMENTED W/ TAPR ADPT COMPHSVE RVS SHLDR,SUP-2402734,CDM,C1776,CPT,0278,RC,,,,both,,,9294.40,6041.36,,,,,,,,,,,,,
PLATE 3.5MM TI LCP TM CLAVICLE 7H LT-15MM HOOK DEPTH-STER,SUP-2549673,CDM,C1713,HCPCS,0278,RC,,,,both,,,3880.47,2522.31,,,,,,,,,,,,,
PLATE BNE RT 16 HOLE,SUP-2198729,CDM,C1713,HCPCS,0278,RC,,,,both,,,4401.02,2860.66,,,,,,,,,,,,,
AMIVANTAMAB-VMJW 350 MG/7ML IV SOLN,RX-154727,CDM,J9061,HCPCS,0636,RC,57894-0501-01,NDC,,both,7,ML,10963.30,7126.14,,,,,,,,,,,,,
PLATE BNE L39MM 5 H S STL QTR TBLR MINI FRAG W/O CLLR,SUP-2186071,CDM,C1713,HCPCS,0278,RC,,,,both,,,114.61,74.50,,,,,,,,,,,,,
TRAZODONE HCL 50 MG PO TABS,RX-8085,CDM,6370000000,HCPCS,0637,RC,60687-0443-11,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PLATE BNE L35MM 4 H MAXILLOFACIAL ORAL TI CRESC LIMIT CNTCT,SUP-2191401,CDM,C1713,HCPCS,0278,RC,,,,both,,,2582.65,1678.72,,,,,,,,,,,,,
PLATE BNE BROAD 4.5X142 MM 8 HOLE SS LC-DCP,SUP-2569267,CDM,C1713,HCPCS,0278,RC,,,,both,,,386.85,251.45,,,,,,,,,,,,,
IMPLANT DENT W4XL4CM THK0.4MM NYL SMOOTH SUPRAFOIL,SUP-2335973,CDM,C1781,HCPCS,0278,RC,,,,both,,,14.92,9.70,,,,,,,,,,,,,
CATHETER MVS MC212150S HEADWAY 21 STR,SUP-2305465,CDM,C1887,HCPCS,0272,RC,,,,both,,,2345.58,1524.63,,,,,,,,,,,,,
CYCLOPENTOLATE-PHENYLEPHRINE 0.2-1 % OP SOLN,RX-9701,CDM,6370000000,HCPCS,0637,RC,00065-0359-02,NDC,,both,2,ML,166.60,108.29,,,,,,,,,,,,,
BINDER ABD UNIV H9IN WAIST 45-62IN E SFT COT PREM 3 PNL,SUP-2197075,CDM,L0450,HCPCS,0272,RC,,,,both,,,20.72,13.47,,,,,,,,,,,,,
SLEEVE TROCAR L150MM DIAMETER 10MM SMOOTH DISPOSABLE WITH TA,SUP-2804216,CDM,2720000010,LOCAL,0272,RC,,,,both,,,732.81,476.33,,,,,,,,,,,,,
TRAY BX L102MM OD11GA S STL NDL PWR BNE ACCS ONCONTROL,SUP-2383230,CDM,C1830,HCPCS,0278,RC,,,,both,,,461.58,300.03,,,,,,,,,,,,,
NAIL IM L 230 MM DIA 4 MM ULN TAPERED/OFFSET TIP FIXED-ANGLE,SUP-2912762,CDM,C1713,HCPCS,0278,RC,,,,both,,,11796.98,7668.04,,,,,,,,,,,,,
PLATE BNE MESHED 126X126X1 MM SPECIALITY SUN PAT PLLA-PGA,SUP-2477756,CDM,C1713,HCPCS,0278,RC,,,,both,,,12064.16,7841.70,,,,,,,,,,,,,
SHEATH DEL AMPLATZER TORQVUE TIP 45 DEG L 80 CM DIA14 FR OD,SUP-2858705,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2571.66,1671.58,,,,,,,,,,,,,
NAIL IM L260MM DIA7.5MM 120DEG ST BLU L/R HUM TI CANN LOK,SUP-2192492,CDM,C1713,HCPCS,0278,RC,,,,both,,,4455.66,2896.18,,,,,,,,,,,,,
PLATE BNE TBLR UNIV 2.7 MM 6 HOLE 1/4 2 COMPR LCK FOR SCR,SUP-2474079,CDM,C1713,HCPCS,0278,RC,,,,both,,,879.70,571.80,,,,,,,,,,,,,
ADAPTER ORTHOPEDIC TORQUE LIMITING PEAK FX,SUP-2472725,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3607.86,2345.11,,,,,,,,,,,,,
PLATE BONE W12XL199MM THK1MM 11 H BILAT S STL SEMI TBLR LO,SUP-2256650,CDM,C1713,HCPCS,0278,RC,,,,both,,,1695.60,1102.14,,,,,,,,,,,,,
PROBE BRST BX W/ VAC SET MAMTOM EX,SUP-2195637,CDM,2720000010,LOCAL,0272,RC,,,,both,,,718.43,466.98,,,,,,,,,,,,,
SPACER 56300810 12W 30MM X 8MM 10 DG TI,SUP-2429520,CDM,C1821,HCPCS,0278,RC,,,,both,,,15660.75,10179.49,,,,,,,,,,,,,
DEFIBRILLATOR IMPL ILESTO 7 VR-T W 52 X H 65 MM D 11 MM 40 J,SUP-2138301,CDM,C1722,HCPCS,0275,RC,,,,both,,,33707.90,21910.13,,,,,,,,,,,,,
COMPONENT FEM SZ 3 KNEE HNG AXLE LEGION,SUP-2346400,CDM,C1776,CPT,0278,RC,,,,both,,,1343.92,873.55,,,,,,,,,,,,,
PLATE BONE W14.9XL184MM THK1.2MM 11 H DSTL TIB S STL,SUP-2185740,CDM,C1713,HCPCS,0278,RC,,,,both,,,1283.95,834.57,,,,,,,,,,,,,
INTRODUCER HEMSTAS FAST CATH 7FRX12CM SHTH W/ 0.038 IN GWIRE,SUP-2355482,CDM,C1894,HCPCS,0272,RC,,,,both,,,26.69,17.35,,,,,,,,,,,,,
SHUNT CAR 9 FRX15 CM PRUITT-INAHARA,SUP-2264210,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1378.46,896.00,,,,,,,,,,,,,
CABLE SURG L750MM DIA1MM STRNL S STL SMOOTH NDL CUT EDGE W/,SUP-2186852,CDM,C1713,HCPCS,0278,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
FILTER KT ART 2 CANN AND 2 M 11IN OVERALL LEN EMBOL-X GLDE,SUP-2214495,CDM,C1884,HCPCS,0278,RC,,,,both,,,1507.42,979.82,,,,,,,,,,,,,
SYSTEM ELECTRODE DELIV EMBLEM S-ICD 2,SUP-2140137,CDM,C1725,HCPCS,0272,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
BUR SURG DIA1.5 MM HUB I TWST DRL STRL REUSE HI-LINE,SUP-2928934,CDM,2720000010,LOCAL,0272,RC,,,,both,,,471.25,306.31,,,,,,,,,,,,,
DRESSING WND ANTIMICROBIAL 12X12 IN JUMPSTART,SUP-2845383,CDM,2720000010,LOCAL,0272,RC,,,,both,,,635.85,413.30,,,,,,,,,,,,,
HC So Complement Total Ch-50,PX-3028616266,CDM,86162,CPT,0302,RC,,,,both,,,740.00,481.00,,,,,,,,,,,,,
ENDCAP ORTH 5MM FOR PEDINAIL PED IM FEM NAIL,SUP-2318890,CDM,C1713,HCPCS,0278,RC,,,,both,,,1038.56,675.06,,,,,,,,,,,,,
HC X-Ray Exam Bil Hips W/Pelvis 3-4 Views,PX-3207352200,CDM,73522,CPT,0320,RC,,,,both,,,853.00,554.45,,,,,,,,,,,,,
T-PLT STERILIZER 6 HL 116 MM LENGTH,SUP-2818507,CDM,C1713,HCPCS,0278,RC,,,,both,,,2259.98,1468.99,,,,,,,,,,,,,
SCREW INTRF L14MM OD9MM SUBTALAR FOR ARTHROEREISIS PROSTOP +,SUP-2121856,CDM,C1713,HCPCS,0278,RC,,,,both,,,3438.30,2234.89,,,,,,,,,,,,,
PLATE BONE LOK 97MML HLX12 STNLSS STEEL STRGHT RCNSTRCTN ST,SUP-2720493,CDM,C1713,HCPCS,0278,RC,,,,both,,,1630.04,1059.53,,,,,,,,,,,,,
GRAFT EVAR L12CM DIA14.5MM CONTRALATERAL LEG EXCLUDER,SUP-2395946,CDM,C1768,CPT,0278,RC,,,,both,,,13260.22,8619.14,,,,,,,,,,,,,
CEFIDEROCOL SULFATE TOSYLATE 1 G IV SOLR,RX-149129,CDM,J0699,HCPCS,0636,RC,59630-0266-01,NDC,,both,1,UN,1338.90,870.28,,,,,,,,,,,,,
NUT SPNL OUTERING 4.5 MM TI EXPEDIUM,SUP-2590813,CDM,C1713,HCPCS,0278,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
PIN EXT FIX L250MM DIA5MM THRD L60MM S STL TRANSFIXING APEX,SUP-2372471,CDM,C1713,HCPCS,0278,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
GRAFT BNE FEM SHFT 11 CM FD,SUP-2321805,CDM,C1713,HCPCS,0278,RC,,,,both,,,3658.10,2377.76,,,,,,,,,,,,,
ATTUNE RP TIB BASE SZ 1 CEM,SUP-2251437,CDM,C1776,CPT,0278,RC,,,,both,,,3218.50,2092.02,,,,,,,,,,,,,
SCREW BNE LCK,SUP-2898940,CDM,C1713,HCPCS,0278,RC,,,,both,,,289.67,188.29,,,,,,,,,,,,,
KIT CATH HEMODIALYSI GLIDEPATH CHRONIC EXCHANGE 14.5 5397420,SUP-2632957,CDM,C1750,HCPCS,0278,RC,,,,both,,,1341.88,872.22,,,,,,,,,,,,,
KIT HIP IMPL CAPPED H1 STD COCR HD VE LNR H1VEZIMMERBIOMET,SUP-2894109,CDM,C1776,CPT,0278,RC,,,,both,,,13973.00,9082.45,,,,,,,,,,,,,
ALLOGRAFT HUM TISS FRZN ASEP LT MEDL MENIS W/ BNE,SUP-2867143,CDM,C1762,CPT,0278,RC,,,,both,,,9688.78,6297.71,,,,,,,,,,,,,
GRAFT VASC GORTX L 50 CM DIA 7 MM EPTFE STR STD WALL N RING,SUP-2396429,CDM,C1768,CPT,0278,RC,,,,both,,,1450.68,942.94,,,,,,,,,,,,,
CATHETER INTVENT 0.014 IN 135 CM TURNPIKE LP,SUP-2605999,CDM,C1887,HCPCS,0272,RC,,,,both,,,1924.82,1251.13,,,,,,,,,,,,,
HC NM Stress Muga With Med,PX-3417847300,CDM,78473,CPT,0341,RC,,,,inpatient,,,1275.00,828.75,,,,,,,,,,,,,
HC So Anti Nuclear Antibody,PX-3028603866,CDM,86038,CPT,0302,RC,,,,both,,,505.00,328.25,,,,,,,,,,,,,
CATHETER EP LG 2-5-2 6 FRX110 STEER INQUIRY,SUP-2488439,CDM,C1730,HCPCS,0272,RC,,,,both,,,1425.56,926.61,,,,,,,,,,,,,
STIMULATOR NERVE 4.95X5.55X1.34 CM 30.4 CC 48.9 GM PROCLAIM,SUP-2421702,CDM,C1767,HCPCS,0278,RC,,,,both,,,47100.00,30615.00,,,,,,,,,,,,,
STENT BILI ST-2 SOEH TANNENBAUM L 14 CM DIA11.5 FR GUIDEWIRE,SUP-2738198,CDM,C2617,HCPCS,0278,RC,,,,both,,,241.78,157.16,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 4X200 MM FRZN GAM SEMITENDINOSUS,SUP-2866909,CDM,C1762,CPT,0278,RC,,,,both,,,2720.50,1768.32,,,,,,,,,,,,,
CONDUIT NRV L20MM ID4MM PROVEN CHOICE GRFT NEUROTUBE,SUP-2382609,CDM,C1713,HCPCS,0278,RC,,,,both,,,2182.30,1418.49,,,,,,,,,,,,,
KIT LD INTRO INTROFLEX DIA 9 FR J BPLR INSRTN FOR TEMP PACE,SUP-2214543,CDM,C1894,HCPCS,0272,RC,,,,both,,,83.96,54.57,,,,,,,,,,,,,
RING EXT FIX FULL 160 MM ALUM,SUP-2162654,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3956.40,2571.66,,,,,,,,,,,,,
PLATE BONE L169MM 9 H RT PROX HUM LCK FOR 4.5MM SCR PERI-LOC,SUP-2348277,CDM,C1713,HCPCS,0278,RC,,,,both,,,15868.62,10314.60,,,,,,,,,,,,,
PLATE BNE MESH PANEL STD 1.5X100X100X0.3 MM NEURO SM GRID,SUP-2472189,CDM,C1713,HCPCS,0278,RC,,,,both,,,2861.54,1860.00,,,,,,,,,,,,,
MESH HERN W26XL34CM THK1MM EPTFE 2 SURF ANTIMIC PROTCT GORE,SUP-2395344,CDM,C1781,HCPCS,0278,RC,,,,both,,,6584.58,4279.98,,,,,,,,,,,,,
RXG PLATE STR 8 HOLE T06MM,SUP-2681862,CDM,C1713,HCPCS,0278,RC,,,,both,,,647.28,420.73,,,,,,,,,,,,,
GRAFT NRV L70MM DIA4 5MM PERIPH NAT CONN CBL PROC FOR RECON,SUP-2418486,CDM,C1762,CPT,0278,RC,,,,both,,,29443.78,19138.46,,,,,,,,,,,,,
BIT DRL OD3.2MM FOR RADLUC TARGET SYS SIDEWNDR,SUP-2371638,CDM,2720000010,LOCAL,0272,RC,,,,both,,,516.53,335.74,,,,,,,,,,,,,
"HC RBC, Frz/Deg/Wsh, L/R. Irrad",PX-3900905700,CDM,P9057,CPT,0390,RC,,,,both,,,2154.00,1400.10,,,,,,,,,,,,,
PLATE BNE L 88 X W 10.2 MM THK 2.8 MM SCREW DIA 3.5 MM 8 H 72440608,SUP-2932925,CDM,C1713,HCPCS,0278,RC,,,,both,,,2363.16,1536.05,,,,,,,,,,,,,
SCREW BONE L17MM OD2.8MM LACTOSORB COPOLYMER SHLDR SLD FULL,SUP-2137289,CDM,C1713,HCPCS,0278,RC,,,,both,,,916.88,595.97,,,,,,,,,,,,,
KIT INTRO MAK-NV L 20 CM DIA 6 FR CHIBA NDL L 15 CM DIA21 GA,SUP-2499825,CDM,C1894,HCPCS,0272,RC,,,,both,,,143.44,93.24,,,,,,,,,,,,,
FIXATOR EXT FIX LNG HND N BRDG FRACTR STRL DISP NBX,SUP-2909398,CDM,C1713,HCPCS,0278,RC,,,,both,,,9624.10,6255.66,,,,,,,,,,,,,
SET INTRO SUP ARW FLX SHTH L 65 CM DIA 5 FR HYDRPHLC,SUP-2383400,CDM,C1894,HCPCS,0272,RC,,,,both,,,349.48,227.16,,,,,,,,,,,,,
SCREW BONE L57MM OD3.5MM 6 CRUCFRM COARSE THRD WDRUFF,SUP-2362304,CDM,C1713,HCPCS,0278,RC,,,,both,,,25.75,16.74,,,,,,,,,,,,,
HC So Trg Gene Rearrangement,PX-3108134266,CDM,81342,CPT,0310,RC,,,,both,,,374.00,243.10,,,,,,,,,,,,,
MESH BIO PORCINE MTRX ABD 10CM LEN 20CM W 1.5MM THICKNESS 151020] TISSUE SCIENCE LABORATORIES],SUP-2388448,CDM,C9364,HCPCS,0278,RC,,,,both,,,11605.44,7543.54,,,,,,,,,,,,,
GRAFT VASC HEMSHLD PLAT L 15 CM 26MM POLYESTER BOV CLLGN STR,SUP-2265918,CDM,C1768,CPT,0278,RC,,,,both,,,1358.36,882.93,,,,,,,,,,,,,
GRAFT BNE SM 5 CC PRO OSTEON 200R,SUP-2685764,CDM,C1713,HCPCS,0278,RC,,,,both,,,2364.42,1536.87,,,,,,,,,,,,,
PACK PRIMING ECMO,SUP-2867340,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
WEDGE TIB SM/M 7/6DEG L MED KNEE PEEK ABSRB FOR HTO OPN SYS,SUP-2121065,CDM,C1713,HCPCS,0278,RC,,,,both,,,5966.00,3877.90,,,,,,,,,,,,,
NEEDLE BRST BX L12CM OD9GA 20MM ATEC,SUP-2239991,CDM,2720000010,LOCAL,0272,RC,,,,both,,,791.91,514.74,,,,,,,,,,,,,
IMPLANT SHLDR 40MM VERSA-DIAL GLEN STD,SUP-2418154,CDM,C1776,CPT,0278,RC,,,,both,,,4003.50,2602.27,,,,,,,,,,,,,
CEMENT BNE DAM N-K II,SUP-2448994,CDM,C1713,HCPCS,0278,RC,,,,both,,,268.47,174.51,,,,,,,,,,,,,
ORTHOLOC SPS 140MM STANDARD7 HOLE PLATE,SUP-2822319,CDM,C1713,HCPCS,0278,RC,,,,both,,,8123.18,5280.07,,,,,,,,,,,,,
TRAY CATH HEMODIALYSI PWR TRIALYSI SLIM CATH ACTE 12 5855300,SUP-2632932,CDM,C1752,HCPCS,0278,RC,,,,both,,,979.96,636.97,,,,,,,,,,,,,
STENT URET STR 0.035 IN 3 CM 6 FRX22-30 CM CNTOURVL 18015519,SUP-2484376,CDM,C2617,HCPCS,0278,RC,,,,both,,,524.07,340.65,,,,,,,,,,,,,
PSN REV 3MM OFFSET STEM EXT 12X135MM,SUP-2508801,CDM,C1776,CPT,0278,RC,,,,both,,,6531.20,4245.28,,,,,,,,,,,,,
HC Pt Elec Stim Unattended|DOCUMENTATION ON FILE|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS,PX-4209701400,CDM,G0283,HCPCS,0420,RC,,,KX|CQ,outpatient,,,206.00,133.90,,,,,,,,,,,,,
CATHETER DIL BAL L16MM DIA6MM SINUS RELIEVA SOLO PRO,SUP-2106320,CDM,C1729,HCPCS,0272,RC,,,,both,,,2147.76,1396.04,,,,,,,,,,,,,
PLATE BNE BSSO MINI 2X24 MM 9 MM 10 MM DBL Y CRV FOR SCR TI,SUP-2461312,CDM,C1713,HCPCS,0278,RC,,,,both,,,1729.61,1124.25,,,,,,,,,,,,,
PLATE BNE 24 DEG L 76 X W 8.5 MM THK 1.6 MM 5 H SS LT DSTL,SUP-2933580,CDM,C1713,HCPCS,0278,RC,,,,both,,,7957.86,5172.61,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 240 MM DIA22/13 MM DEL,SUP-2934280,CDM,C1713,HCPCS,0278,RC,,,,both,,,21929.51,14254.18,,,,,,,,,,,,,
STENT BILI ABS L 20 MM UNCONSTRAINED DIA 6 MM CATH L 135 CM,SUP-2101748,CDM,C1876,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
BIT DRL L70MM DIA27MM CANN DST CUT FOR EL STBL SYS IJS,SUP-2340229,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1116.27,725.58,,,,,,,,,,,,,
PLATE BNE W7XL32MM THK1.2MM 3 H S STL T SHP MAL FOR 2.7MM,SUP-2186088,CDM,C1713,HCPCS,0278,RC,,,,both,,,1065.56,692.61,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED STD CEM GENDER SPEC FLX POLYETH,SUP-2212703,CDM,C1776,CPT,0278,RC,,,,both,,,12776.69,8304.85,,,,,,,,,,,,,
HC CT Abd/Pel W Cont,PX-3527417700,CDM,74177,CPT,0352,RC,,,,both,,,4901.00,3185.65,,,,,,,,,,,,,
CATHETER THROMCTMY INDIGO L 135 CM 6/6FR 0.014-0.038IN SEP 6,SUP-2323573,CDM,C1757,HCPCS,0272,RC,,,,both,,,5620.60,3653.39,,,,,,,,,,,,,
FLUTED ACORN 5MM,SUP-2176909,CDM,2720000010,LOCAL,0272,RC,,,,both,,,390.93,254.10,,,,,,,,,,,,,
PLATE BONE 11 H STR PRI RECON W/ TEMPLT FOR 2/2.3MM SCR,SUP-2365245,CDM,C1713,HCPCS,0278,RC,,,,both,,,8243.16,5358.05,,,,,,,,,,,,,
GRAFT DURA W3XL3IN CLLGN MEM SUTURABLE DURAMATRIX,SUP-2165131,CDM,C1763,HCPCS,0278,RC,,,,both,,,2430.80,1580.02,,,,,,,,,,,,,
SCREW BNE EMGCY 2.3X14 MM ST MINI PLATING CROSS PIN HD TI 5PK,SUP-2366174,CDM,C1713,HCPCS,0278,RC,,,,both,,,218.10,141.76,,,,,,,,,,,,,
CAPSULE ENDO CAM CALIB FRE REFLX W/ DEL SYS BRAVO,SUP-2227943,CDM,2720000010,LOCAL,0272,RC,,,,both,,,992.24,644.96,,,,,,,,,,,,,
GENERATOR NEUROSTIMULATOR PULSE SENZA,SUP-2308595,CDM,C1822,CPT,0278,RC,,,,both,,,48042.00,31227.30,,,,,,,,,,,,,
HC Detail Fetal Anat Exam +Gest,PX-4027681200,CDM,76812,CPT,0402,RC,,,,inpatient,,,528.00,343.20,,,,,,,,,,,,,
GUIDEWIRE VASC L 300 CM DIA 0.038 IN TAPR L 9.5 CM FLPY TIP,SUP-2167956,CDM,C1769,HCPCS,0272,RC,,,,both,,,79.91,51.94,,,,,,,,,,,,,
SCALPEL ELECSURG 85MM PLSM PADDLE BLDE CANADY HYBRID,SUP-2391728,CDM,C1713,HCPCS,0278,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP L150CM DIA0.035IN TIP 3CM PTFE NIT,SUP-2139369,CDM,C1769,HCPCS,0272,RC,,,,both,,,145.95,94.87,,,,,,,,,,,,,
CATHETER INTVASC LITHO C2PLUS L 138 CM 5 FR L 12 DIA 2.5 MM,SUP-2877801,CDM,C1761,CPT,0278,RC,,,,both,,,14758.00,9592.70,,,,,,,,,,,,,
GRAFT BNE PTTY 10 CC OSTEOSURGE 300C,SUP-2644326,CDM,C1713,HCPCS,0278,RC,,,,both,,,6612.84,4298.35,,,,,,,,,,,,,
PLATE BNE SM L94MM 8 H BILAT S STL LO PROF RIG LIMIT CNTCT,SUP-2186228,CDM,C1713,HCPCS,0278,RC,,,,both,,,1465.19,952.37,,,,,,,,,,,,,
INTRODUCER PERC INTRO FLX,SUP-2272870,CDM,C1894,HCPCS,0272,RC,,,,both,,,167.46,108.85,,,,,,,,,,,,,
DEXTROSE-SODIUM CHLORIDE 5-0.45 % IV SOLN,RX-15861,CDM,J3490,HCPCS,0258,RC,00338-0085-04,NDC,,both,1000,ML,51.00,33.15,,,,,,,,,,,,,
GRAFT VASC GORTX L 70 CM DIA 6 MM RNG L 30 CM EPTFE STR STD,SUP-2396094,CDM,C1768,CPT,0278,RC,,,,both,,,2603.06,1691.99,,,,,,,,,,,,,
PLATE BNE L 219 X W 12.7 MM THK 3.5 MM SCREW DIA2.7/3.5 MM 72464317,SUP-2933239,CDM,C1713,HCPCS,0278,RC,,,,both,,,8382.54,5448.65,,,,,,,,,,,,,
IMPLANT 14X26MM DISC INTBDY FUS LUM ANT W/ CAPINTERNAL FIX,SUP-2291442,CDM,2780000010,LOCAL,0278,RC,,,,both,,,13685.00,8895.25,,,,,,,,,,,,,
CATHETER CV SET 018 4 FRX8 CM DL J TIP CUDLM401JABRMHC,SUP-2759850,CDM,C1751,HCPCS,0278,RC,,,,both,,,334.16,217.20,,,,,,,,,,,,,
ALLOGRAFT HUM TISS SEMITENDINOSUS/GRACILIS TEND FRZN COMB,SUP-2321843,CDM,C1762,CPT,0278,RC,,,,both,,,5495.00,3571.75,,,,,,,,,,,,,
PLATE BNE W12XL270MM THK25MM LNG 12 H NONSTERILE BILAT PROX,SUP-2190994,CDM,C1713,HCPCS,0278,RC,,,,both,,,5580.97,3627.63,,,,,,,,,,,,,
SCREW BNE L32MM DIA3MM CANC ST CANN NONLOCKING LAG,SUP-2319426,CDM,C1713,HCPCS,0278,RC,,,,both,,,367.38,238.80,,,,,,,,,,,,,
SET SURG THYROPLASTY INSTR NONSTERILE 13 PC W/ CUST STRL TY,SUP-2138768,CDM,L8509,HCPCS,0274,RC,,,,both,,,8164.00,5306.60,,,,,,,,,,,,,
SPHERE EMB 900-1200UM 20ML SYR PUR TRISACRYL GEL RND PREFIL,SUP-2303392,CDM,C1889,HCPCS,0278,RC,,,,both,,,744.18,483.72,,,,,,,,,,,,,
INTRODUCER IV CATH NEOMAGIC CATH 1.9/2 FR SIL TIP PUSH BTTN,SUP-2874177,CDM,C1894,HCPCS,0272,RC,,,,both,,,134.71,87.56,,,,,,,,,,,,,
PLATE BONE 13 H LT DSTL LAT FEM LCK COMPR FOR 4.5MM SCR,SUP-2343751,CDM,C1713,HCPCS,0278,RC,,,,both,,,3555.42,2311.02,,,,,,,,,,,,,
BIT DRL L 205/110 MM DIA2.8 MM CALIB AO QC NS REUSE V,SUP-2908491,CDM,2720000010,LOCAL,0272,RC,,,,both,,,858.85,558.25,,,,,,,,,,,,,
PAD EXT FIX DISPOSABLE FOR FEM FT SIDEKCK EZ FRME FIX SYS,SUP-2399882,CDM,2720000010,LOCAL,0272,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
PLATE BNE MID FUS BRDG XSM L ST,SUP-2401274,CDM,C1713,HCPCS,0278,RC,,,,both,,,8861.08,5759.70,,,,,,,,,,,,,
SET SCR SPNL L9MM DIA1.5MM STD LUM TI OPTMA,SUP-2212644,CDM,C1713,HCPCS,0278,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
PLATE BNE 2 COMPR NAR 4.5X71 MM 4 HOLE CONTOURED FOR SCR,SUP-2471132,CDM,C1713,HCPCS,0278,RC,,,,both,,,372.59,242.18,,,,,,,,,,,,,
RT IB TIGHTROPE W FLIPCUTTER III DRILL,SUP-2811642,CDM,C1713,HCPCS,0278,RC,,,,both,,,3312.70,2153.25,,,,,,,,,,,,,
CATHETER HEMO DYLS OR HD KT LNG TERM ACC TWO LUMN 15FRX50CM,SUP-2120630,CDM,C1750,HCPCS,0278,RC,,,,both,,,1114.70,724.55,,,,,,,,,,,,,
BLADE SAGITTAL SAW 19.5MM X 50.0MM 5400-003-254S1,SUP-2844702,CDM,2720000010,LOCAL,0272,RC,,,,both,,,329.17,213.96,,,,,,,,,,,,,
WASHER ORTH SCREW DIA 4.5 MM DBL STRL EVOS,SUP-2933764,CDM,C1713,HCPCS,0278,RC,,,,both,,,741.04,481.68,,,,,,,,,,,,,
PROBE LASER 25GA STANDARD STRAIGHT STELLARIS PC,SUP-2494234,CDM,2720000010,LOCAL,0272,RC,,,,both,,,327.82,213.08,,,,,,,,,,,,,
KIT BAR SACRAL THRD 6X260MM STRL,SUP-2547194,CDM,C1713,HCPCS,0278,RC,,,,both,,,3529.74,2294.33,,,,,,,,,,,,,
PROBE SURG 45 CONTRALATERAL ACC DISP IO-FLEX,SUP-2115826,CDM,C1713,HCPCS,0278,RC,,,,both,,,489.84,318.40,,,,,,,,,,,,,
HC Lyr Clos Nk Hnd Ft <2.6cm,PX-4501204100,CDM,12041,CPT,0450,RC,,,,both,,,810.00,526.50,,,,,,,,,,,,,
BIT DRL DIA4MM CANN FOR 6.7MM SCR FOR FT ANK FUS MINI,SUP-2123192,CDM,2720000010,LOCAL,0272,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
PASSER SUTURE ARTH 5.5 MM ANCHR OGDEN TITAN,SUP-2174635,CDM,C1713,HCPCS,0278,RC,,,,both,,,77.97,50.68,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP L260CM DIA0.035IN BILI STD HI PERF STR,SUP-2149657,CDM,C1769,HCPCS,0272,RC,,,,both,,,551.38,358.40,,,,,,,,,,,,,
PLATE BNE SM W10XL87MM THK15MM 90DEG 3X7 H TI T SHP R ANG,SUP-2190937,CDM,C1713,HCPCS,0278,RC,,,,both,,,1542.12,1002.38,,,,,,,,,,,,,
PLATE BNE L277MM 10 H NONSTERILE PROX FEM S STL HK LO PROF,SUP-2186060,CDM,C1713,HCPCS,0278,RC,,,,both,,,4836.54,3143.75,,,,,,,,,,,,,
HC Assay of Ferritin|NOT REASONABLE AND NECESSARY,PX-3018272800,CDM,82728,CPT,0301,RC,,,GZ,both,,,255.00,165.75,,,,,,,,,,,,,
PLATE BNE ANTEROLATERAL SHT 2.7X40 MM RT CALCANEAL LCK STRL,SUP-2568770,CDM,C1713,HCPCS,0278,RC,,,,both,,,3356.85,2181.95,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 180 MM DIA15 MM DEL SHTH,SUP-2934166,CDM,C1713,HCPCS,0278,RC,,,,both,,,18184.49,11819.92,,,,,,,,,,,,,
PLATE BNE SM W10XL77MM THK15MM 90DEG 3X6 H TI T SHP R ANG,SUP-2190936,CDM,C1713,HCPCS,0278,RC,,,,both,,,1268.34,824.42,,,,,,,,,,,,,
PLATE BNE RECON 3.5X143 MM 11 HOLE LCK LP SS NS,SUP-2184031,CDM,C1713,HCPCS,0278,RC,,,,both,,,2412.37,1568.04,,,,,,,,,,,,,
PLATE BONE SM THK0.3MM MULT H ORBIT FLR TI MESH PREFRM FOR,SUP-2135899,CDM,C1713,HCPCS,0278,RC,,,,both,,,2135.20,1387.88,,,,,,,,,,,,,
PLATE BNE MED RT PLNTR SYS IMPL INSTRUMENT AXIS,SUP-2610221,CDM,C1713,HCPCS,0278,RC,,,,both,,,8289.60,5388.24,,,,,,,,,,,,,
STYLER SPNL SINGLE STP,SUP-2114058,CDM,2720000010,LOCAL,0272,RC,,,,both,,,690.80,449.02,,,,,,,,,,,,,
HC So Chemiluminescent Assay,PX-3018239766,CDM,82397,CPT,0301,RC,,,,outpatient,,,230.00,149.50,,,,,,,,,,,,,
ATTACHMENT POS 2S FNGR DISP STABLESOFT,SUP-2385708,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1836.90,1193.98,,,,,,,,,,,,,
PROBE DOPP L265MM TIP L2MM 8MHZ ENDO NSL BAYONATED HNDL DISP,SUP-2419092,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1746.63,1135.31,,,,,,,,,,,,,
PIN EXTERNAL FIXATION HALF ADULT 6X200 MM 20 MM ANKLE FOOT H,SUP-2836740,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3517.90,2286.63,,,,,,,,,,,,,
BLADE RTRCTR MCCLLCH 20MMW X 40MML SPNL MSCLE NRRW RGGLS RDM,SUP-2467343,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1610.54,1046.85,,,,,,,,,,,,,
PATCH BIO W9XL14CM THK1MM BOV PERICARD,SUP-2355779,CDM,C1768,CPT,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
TRAY CATHETER 5FR L135CM S STL 2 LUMN W GWIRE,SUP-2126388,CDM,C1751,HCPCS,0278,RC,,,,both,,,381.20,247.78,,,,,,,,,,,,,
IMMOBILIZER KNEE L20IN AD 1 SZ FIT MOST UNIV WRP ARND OPN,SUP-2196742,CDM,L1830,CPT,0274,RC,,,,both,,,44.27,28.78,,,,,,,,,,,,,
CHIPS BNE GRFT 30CC 1-4MM ALLGRFT CANC FRZ DRY PRESERVATION,SUP-2293748,CDM,C1713,HCPCS,0278,RC,,,,both,,,1756.39,1141.65,,,,,,,,,,,,,
PLATE BNE H1MM BAR L8MM 4 H MAND BLU TI MINI STR LOK,SUP-2366339,CDM,C1713,HCPCS,0278,RC,,,,both,,,421.17,273.76,,,,,,,,,,,,,
DISSECTOR ELECTROCAUTERY L 220 CM NDL L 1.5 MM CHANNEL,SUP-2881885,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1566.86,1018.46,,,,,,,,,,,,,
GUIDEWIRE VASC RDRUN L 145 CM DIA 0.035 IN TAPR L 11.5 CM,SUP-2873667,CDM,C1769,HCPCS,0272,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
PACEMAKER CARD AVEIR VR L 38 MM DIA 6.5 MM TI VENTRICULAR,SUP-2905601,CDM,C1605,HCPCS,0275,RC,,,,both,,,33127.00,21532.55,,,,,,,,,,,,,
STEM HUM UNIV STD L122MM DIA10MM SHLDR CO CHROM PRI CEM,SUP-2404592,CDM,C1776,CPT,0278,RC,,,,both,,,10949.18,7116.97,,,,,,,,,,,,,
STEM HUM 7 SHLDR CAP COAT STRL UNIVERS REVERS LF,SUP-2123315,CDM,C1776,CPT,0278,RC,,,,both,,,12560.00,8164.00,,,,,,,,,,,,,
IMPLANT ANK JT BRL PATENTED SLT DSGN SUBTALAR MBA TI,SUP-2242695,CDM,C1776,CPT,0278,RC,,,,both,,,6938.36,4509.93,,,,,,,,,,,,,
CAGE SPNL 25X11MM LUM CONVX FUSELOX,SUP-2152495,CDM,C1889,HCPCS,0278,RC,,,,both,,,6280.00,4082.00,,,,,,,,,,,,,
PLATE BNE L55MM 7X3 H R VOLAR DST RAD S STL VAR ANG LOK,SUP-2184123,CDM,C1713,HCPCS,0278,RC,,,,both,,,2191.06,1424.19,,,,,,,,,,,,,
MESH HERN W30.5XL35.6CM POLYPR PTFE NONABSORBABLE RECTANG,SUP-2125912,CDM,C1781,HCPCS,0278,RC,,,,both,,,6562.60,4265.69,,,,,,,,,,,,,
BLADE SAW OSCLLTNG 9MMW X12MML 0.4MM THK 0.6MM THK CUT INTRA,SUP-2605374,CDM,2720000010,LOCAL,0272,RC,,,,both,,,487.17,316.66,,,,,,,,,,,,,
SCREW BNE L75MM DIA6.5MM THRD L32MM TAN CANN SELF DRL HDLSS,SUP-2181471,CDM,C1713,HCPCS,0278,RC,,,,both,,,954.87,620.67,,,,,,,,,,,,,
PLATE BNE L 95 MM DIA2.7 MM 10 SHFT 5 HD H SS T SHP HG NS V,SUP-2905622,CDM,C1713,HCPCS,0278,RC,,,,both,,,3394.28,2206.28,,,,,,,,,,,,,
SCREW BNE PICK-UP,SUP-2467990,CDM,C1713,HCPCS,0278,RC,,,,both,,,327.06,212.59,,,,,,,,,,,,,
PROBE SUCT DIA2.5MM MIC BRSH FOR SM JT SERFAS ENERGY,SUP-2366561,CDM,2720000010,LOCAL,0272,RC,,,,both,,,445.94,289.86,,,,,,,,,,,,,
HC OP Traction Intermittent|OP PT SERVICES|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS,PX-4209701200,CDM,97012,CPT,0420,RC,,,GP|CQ,outpatient,,,292.00,189.80,,,,,,,,,,,,,
PLATE BONE TI OD6 MM MAXILLOFACIAL DBL ROW 2 MM SCR,SUP-2319373,CDM,C1713,HCPCS,0278,RC,,,,both,,,989.10,642.91,,,,,,,,,,,,,
CATHETER GUID 7X5FR L62CM WRK L59CM 90DEG CRV PEBAX INNR,SUP-2356395,CDM,2720000010,LOCAL,0272,RC,,,,both,,,307.72,200.02,,,,,,,,,,,,,
SCREW BNE AD AND PED L33MM DIA32MM HD DIA35MM CANC TI,SUP-2200774,CDM,C1713,HCPCS,0278,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
KNIFE SURG FUKUSHIMA CHEN 7.5 INX8 MM SCKL RUGGLES-REDMOND,SUP-2471686,CDM,2720000010,LOCAL,0272,RC,,,,both,,,546.61,355.30,,,,,,,,,,,,,
KIT PI PICC 1-L 4 FRX55 CM WITH PRELO,SUP-2826670,CDM,C1751,HCPCS,0278,RC,,,,both,,,837.44,544.34,,,,,,,,,,,,,
LEAD NERVE STIM KT,SUP-2568744,CDM,C1778,HCPCS,0278,RC,,,,both,,,1045.62,679.65,,,,,,,,,,,,,
GRAFT BNE 1MM 4MM RANG 30CC CHIP CRUSH FRZN CANC ALLGRFT,SUP-2264736,CDM,C1713,HCPCS,0278,RC,,,,both,,,1498.85,974.25,,,,,,,,,,,,,
EXTRACTOR STONE 2.2FR L115CM BSKT DIA8MM NIT FOR URET STONE,SUP-2171431,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1128.20,733.33,,,,,,,,,,,,,
FILTER VASC L103CM DIA9FR INTRO 28MM VENA CAVA AC DEL KT FOR,SUP-2127811,CDM,C1880,HCPCS,0278,RC,,,,both,,,2590.50,1683.82,,,,,,,,,,,,,
GUIDEWIRE VASC VIPERWIRE ADV L 335 CM DIA 0.014 IN SS PERIPH,SUP-2159533,CDM,C1769,HCPCS,0272,RC,,,,both,,,533.80,346.97,,,,,,,,,,,,,
KIT SUTURE ANCHR SZ 2 KNOTLESS IMPL NDL STRL DX FIBERTAK,SUP-2882188,CDM,C1713,HCPCS,0278,RC,,,,both,,,5495.00,3571.75,,,,,,,,,,,,,
GRAFT BNE SUB 1CC DBM BIOCOMPOSITE OSTEOSET PTTY INJ,SUP-2399056,CDM,C9359,HCPCS,0278,RC,,,,both,,,684.52,444.94,,,,,,,,,,,,,
IMPLANT SH W50XL76MM THK0.45MM MIC THN BIOMATERIAL OFF THE,SUP-2365182,CDM,C1713,HCPCS,0278,RC,,,,both,,,1905.98,1238.89,,,,,,,,,,,,,
CATHETER INFUSION UNI-FUSE L 90 CM 4FR SLT 5CM 0.035 IN BALL,SUP-2117044,CDM,C1725,HCPCS,0272,RC,,,,both,,,1303.10,847.01,,,,,,,,,,,,,
VALVE AORT DIA23MM ASCEND CONDUIT CARBO-SEAL VALSALVA,SUP-2352744,CDM,C1889,HCPCS,0278,RC,,,,both,,,19728.62,12823.60,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL PEEK SD800.535,SUP-2860216,CDM,C1713,HCPCS,0278,RC,,,,both,,,41146.56,26745.26,,,,,,,,,,,,,
MESH SYN ABD ABSRB PRESHAPED POLYGLACTIN 910 44CM LEN 30CM,SUP-2220335,CDM,C1781,HCPCS,0278,RC,,,,both,,,2546.48,1655.21,,,,,,,,,,,,,
CLIP EMG DYN STIM SZ L NEUROVISION,SUP-2309803,CDM,C1713,HCPCS,0278,RC,,,,both,,,1105.28,718.43,,,,,,,,,,,,,
CATHETER INFUSION FOUNTAIN L 135 CM DIA 4 FR TIP L 3 CM SEG,SUP-2303409,CDM,C1751,HCPCS,0278,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
WASHER ORTH OD17MM ID6MM SPIK FOR ACL PCL FIX SYS ACUFEX,SUP-2341563,CDM,C1713,HCPCS,0278,RC,,,,both,,,445.10,289.31,,,,,,,,,,,,,
Z INACTIVE UNKNOWN PART NUMBER KIT BNE CEM SZ 3 MIX MULT TAP ADPT XPEDE KYPHON,SUP-2293485,CDM,C1713,HCPCS,0278,RC,,,,both,,,926.93,602.50,,,,,,,,,,,,,
HC General Health Panel,PX-3018005000,CDM,80050,CPT,0301,RC,,,,both,,,137.00,89.05,,,,,,,,,,,,,
PATCH SURGICALXENOSURE W0.45XH1MMXL6CM PERICARD BOV,SUP-2264294,CDM,C1768,CPT,0278,RC,,,,both,,,813.26,528.62,,,,,,,,,,,,,
COLLAR CERV M AD MIAMI J,SUP-2151872,CDM,L0172,HCPCS,0272,RC,,,,both,,,133.89,87.03,,,,,,,,,,,,,
BIT DRL L60MM DIA1MM STRL MAXILLOFACIAL S STL W/ J LATCH,SUP-2187628,CDM,2720000010,LOCAL,0272,RC,,,,both,,,368.79,239.71,,,,,,,,,,,,,
SUPPORT ORTHOT CUST LEGG PERTHES ORTHOSIS SCOTTISH R,SUP-2435605,CDM,L1730,HCPCS,0274,RC,,,,both,,,3525.84,2291.80,,,,,,,,,,,,,
BRA SURG LG 40-42IN WHT LYCRA FR HK AND LOOP CLSR WIDE ADJ,SUP-2336338,CDM,L8000,HCPCS,0274,RC,,,,both,,,107.61,69.95,,,,,,,,,,,,,
SCREW BNE L90MM DIA5MM CANN LOK,SUP-2184922,CDM,C1713,HCPCS,0278,RC,,,,both,,,558.92,363.30,,,,,,,,,,,,,
SCREW BNE LCK 6.5X35 MM SS STRL SURFIX ADVANSYS,SUP-2243417,CDM,C1713,HCPCS,0278,RC,,,,both,,,932.58,606.18,,,,,,,,,,,,,
PIN CLAMP 5 HOLE,SUP-2853455,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2665.08,1732.30,,,,,,,,,,,,,
MESH PLATE SHORT TI,SUP-2814960,CDM,C1713,HCPCS,0278,RC,,,,both,,,5950.30,3867.69,,,,,,,,,,,,,
HC So Epstein-Barr Virus Vca,PX-3028666566,CDM,86665,CPT,0302,RC,,,,both,,,163.00,105.95,,,,,,,,,,,,,
PLATE BNE RECTANGULAR MIC 1X0.6 MM CRANIOMAXILLOFACIAL 3X2,SUP-2463780,CDM,C1713,HCPCS,0278,RC,,,,both,,,701.04,455.68,,,,,,,,,,,,,
QUINAPRIL HCL 5 MG PO TABS,RX-11254,CDM,6370000000,HCPCS,0637,RC,65862-0617-90,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
GRAFT VASC IMPRA L 40 CM DIA 3.5 MM EPTFE STR STD WALL N,SUP-2761273,CDM,C1768,CPT,0278,RC,,,,both,,,1576.09,1024.46,,,,,,,,,,,,,
HC Cerclage,PX-3615932000,CDM,59320,CPT,0361,RC,,,,both,,,4080.00,2652.00,,,,,,,,,,,,,
JOINT FNGR MP 50 WW PROX PYROCARBON,SUP-2610417,CDM,L8630,HCPCS,0278,RC,,,,both,,,7200.08,4680.05,,,,,,,,,,,,,
GRAFT SYNTH TISS 20X30X0.3 MM DENT RESRB CLLGN MEMBRN RCM6,SUP-2106459,CDM,C1763,HCPCS,0278,RC,,,,both,,,376.77,244.90,,,,,,,,,,,,,
KIT KYPHOPLASTY BALLOON L 25 MM DIA10 GA PRESSURE 700 PSI 7,SUP-2930381,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5821.56,3784.01,,,,,,,,,,,,,
STEM HUM OD7MM HYDROXYAPETITE SHLDR IMPL REUNION,SUP-2379009,CDM,C1776,CPT,0278,RC,,,,both,,,13056.12,8486.48,,,,,,,,,,,,,
BOLT ORTH FUSION 6.5X115 MM MIDFOOT TI NS,SUP-2799617,CDM,C1713,HCPCS,0278,RC,,,,both,,,1648.66,1071.63,,,,,,,,,,,,,
GRAFT HUM TISS L 8 X W 4 CM AMNIO MEMBRN CUST STRL,SUP-2913440,CDM,Q4173,HCPCS,0636,RC,,,,both,,,18243.40,11858.21,,,,,,,,,,,,,
MICROCATHETER ETER DIAG 25 2FR 160CM 11MM WDG,SUP-2418959,CDM,C1725,HCPCS,0272,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
BUR SURG L21CM HD L35.1MM DIA3MM TAPR L BOR MIDAS REX,SUP-2284390,CDM,2720000010,LOCAL,0272,RC,,,,both,,,384.21,249.74,,,,,,,,,,,,,
GRAFT BNE L100MM TIB SHFT FRZ DRY MATRIGRFT,SUP-2264859,CDM,C1713,HCPCS,0278,RC,,,,both,,,2333.96,1517.07,,,,,,,,,,,,,
WIRE SAW SURG FOR AMPUTATION GIGLI 300 MM LEN FLEX UNIV MTL,SUP-2257307,CDM,2720000010,LOCAL,0272,RC,,,,both,,,219.80,142.87,,,,,,,,,,,,,
INSERT HUM H10MM OD42MM STD ARW,SUP-2224541,CDM,C1776,CPT,0278,RC,,,,both,,,5191.36,3374.38,,,,,,,,,,,,,
REMOTE SLEEP PATIENT CONTROL,SUP-2849863,CDM,C1787,HCPCS,0278,RC,,,,both,,,4527.88,2943.12,,,,,,,,,,,,,
HC Cart-T Therapy Prepj Bld Drv T Lmphcyt F/Trans,PX-8723822600,CDM,38226,CPT,0872,RC,,,,both,,,1184.00,769.60,,,,,,,,,,,,,
SHEATH INTRO CEREBASE DA L 70 CM OD 8 FR ID 0.090 IN PTFE SS,SUP-2655900,CDM,C1894,HCPCS,0272,RC,,,,both,,,1500.92,975.60,,,,,,,,,,,,,
OCCLUDER SEPT 6FR WAIST L3MM DIA6MM ATR DISC DIA14X18MM,SUP-2355674,CDM,C1817,HCPCS,0278,RC,,,,both,,,20623.52,13405.29,,,,,,,,,,,,,
PLATE BONE MESHED 150X150X0.6 MM CRANIAL RECONSTRUCTION RIGI,SUP-2837713,CDM,C1713,HCPCS,0278,RC,,,,both,,,11867.32,7713.76,,,,,,,,,,,,,
RX PLATE DOUBLE Y SHAPE 6 HOLE 10MM PROFILE,SUP-2681420,CDM,C1713,HCPCS,0278,RC,,,,both,,,625.99,406.89,,,,,,,,,,,,,
SHEATH ENDOSCP CYSTOURETHROSCOPE 21 FRX7 MM CONT FLO,SUP-2313978,CDM,C1894,HCPCS,0272,RC,,,,both,,,3570.31,2320.70,,,,,,,,,,,,,
INSERT TIB SZ 2 THK12.5MM GVF POLYETH CRV FIX BEAR PFC,SUP-2253974,CDM,C1776,CPT,0278,RC,,,,both,,,3417.58,2221.43,,,,,,,,,,,,,
SCREW BONE CAP FOR GAM NAIL,SUP-2370986,CDM,C1713,HCPCS,0278,RC,,,,both,,,411.03,267.17,,,,,,,,,,,,,
KIT PT TRL INCLUDE EXT BELT AND BTTRY FOR SPNL CRD STIM,SUP-2141951,CDM,C1897,HCPCS,0278,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
SHEATH INTRO PERITONEAL 31 CM POLYPR TRNSLUC STRL DISP,SUP-2243866,CDM,C1894,HCPCS,0272,RC,,,,both,,,109.18,70.97,,,,,,,,,,,,,
PIN FIX ABSORBABLE 2X2 MM STRL,SUP-2462146,CDM,C1713,HCPCS,0278,RC,,,,both,,,634.28,412.28,,,,,,,,,,,,,
PLATE BNE W175XL296MM THK52MM 16 H BILAT TI RIG NEUT LOK,SUP-2256970,CDM,C1713,HCPCS,0278,RC,,,,both,,,2739.37,1780.59,,,,,,,,,,,,,
BASEPLATE GLEN MED SHLDR POROUS COAT REVERS,SUP-2422328,CDM,C1776,CPT,0278,RC,,,,both,,,5385.10,3500.31,,,,,,,,,,,,,
DRILL SURG 3.5X200 MM AO ATTCH 6.5 MM SCREW ADVANSYS,SUP-2243133,CDM,2720000010,LOCAL,0272,RC,,,,both,,,926.30,602.09,,,,,,,,,,,,,
NEXGEN PRECOAT AGMT BLOCK POSTERIOR SIZE E 5MM,SUP-2503284,CDM,C1776,CPT,0278,RC,,,,both,,,2499.44,1624.64,,,,,,,,,,,,,
NAIL IM HUM PICCOLO 8.5MMX22CM,SUP-2152629,CDM,C1713,HCPCS,0278,RC,,,,both,,,6932.49,4506.12,,,,,,,,,,,,,
SCREW 20MM CC FEM AUG BLK STK,SUP-2223077,CDM,C1713,HCPCS,0278,RC,,,,both,,,211.95,137.77,,,,,,,,,,,,,
BIT DRL THRD L10MM DIA5 73MM FOR SLIPPED CAPITAL FEM,SUP-2179056,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1337.89,869.63,,,,,,,,,,,,,
CHOLANGIOGRAM KIT RX AUTOTOME UTOM XL SPHINTOM JAGWIRE 7511,SUP-2525323,CDM,C1769,HCPCS,0272,RC,,,,both,,,847.80,551.07,,,,,,,,,,,,,
PLATE L FUSION VA LCP 2.4/2.7MM SHRT RT TI STRL,SUP-2546990,CDM,C1713,HCPCS,0278,RC,,,,both,,,3427.47,2227.86,,,,,,,,,,,,,
PLATE BONE L55MM 8 H BILAT MAND ORAL MAXILLOFACIAL TI STR LO,SUP-2191326,CDM,C1713,HCPCS,0278,RC,,,,both,,,1536.40,998.66,,,,,,,,,,,,,
AGENT HEMOSTATIC 4X3 CM SYVEKEXCEL,SUP-2266128,CDM,2720000010,LOCAL,0272,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
ELECTRODE EMG 25 MM 0.30 MM LFRIC CONCENTRIC SS TECA DISP 25/BX,SUP-2308208,CDM,2720000010,LOCAL,0272,RC,,,,both,,,872.92,567.40,,,,,,,,,,,,,
NAIL IM L 275 MM DIA11.5 MM ARTH OSTEOSYN NITINAIL,SUP-2898429,CDM,C1713,HCPCS,0278,RC,,,,both,,,34540.00,22451.00,,,,,,,,,,,,,
HC Catheterize for Urine Spec,PX-4500961200,CDM,P9612,CPT,0300,RC,,,,outpatient,,,76.00,49.40,,,,,,,,,,,,,
BATTERY CHARGER DBS NS ACTIVA RC,SUP-2882956,CDM,C1820,HCPCS,0278,RC,,,,both,,,8650.70,5622.95,,,,,,,,,,,,,
HC X-Ray Exam Chest 3 Views,PX-3247104700,CDM,71047,CPT,0324,RC,,,,outpatient,,,827.00,537.55,,,,,,,,,,,,,
GRAFT ENDOVASC L100MM DIA34MM SUPRARENAL AORT AFX VELA,SUP-2217608,CDM,C1768,CPT,0278,RC,,,,both,,,13420.36,8723.23,,,,,,,,,,,,,
CANNULA TANDEMHEART 72CM TRANSSEPTAL,SUP-2862988,CDM,C1889,HCPCS,0278,RC,,,,both,,,32970.00,21430.50,,,,,,,,,,,,,
VALVE MI ORIFICE DIA261MM TISS ANNULUS DIA37MM 85DEG LEAFLET,SUP-2355167,CDM,C1889,HCPCS,0278,RC,,,,both,,,13062.40,8490.56,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 80 CM DIA 5-8 MM EPTFE LNG TAPR STD,SUP-2681171,CDM,C1768,CPT,0278,RC,,,,both,,,1162.02,755.31,,,,,,,,,,,,,
BIT DRL DIA49MM SHT CANN CALIB FOR NAT NAIL AG FEM SYS,SUP-2198669,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1097.05,713.08,,,,,,,,,,,,,
MESH SYNTH ABD N ABSRB OVL POLYPR OBLONG OVL 36CM LEN 26CM,SUP-2265971,CDM,C1781,HCPCS,0278,RC,,,,both,,,5074.24,3298.26,,,,,,,,,,,,,
LABETALOL HCL 100 MG PO TABS,RX-10373,CDM,6370000000,HCPCS,0637,RC,23155-0723-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
SET URET STENT SOFFLX L 22 CM DIA 7 FR GUIDEWIRE L 145 CM,SUP-2168907,CDM,C2617,HCPCS,0278,RC,,,,both,,,434.07,282.15,,,,,,,,,,,,,
HC X-Ray Exam Chest 3 Views,PX-3247104700,CDM,71047,CPT,0324,RC,,,,inpatient,,,827.00,537.55,,,,,,,,,,,,,
DRESSING WOUND SURGICAL MATRIX XSMALL 7X10 CM PLASTIC MATRISTEM,SUP-2106510,CDM,Q4166,HCPCS,0636,RC,,,,both,,,6508.28,4230.38,,,,,,,,,,,,,
PLATE BNE L68MM 3 H BILAT TI T SHP LIMIT CNTCT DYN LOK,SUP-2190889,CDM,C1713,HCPCS,0278,RC,,,,both,,,923.47,600.26,,,,,,,,,,,,,
VALVE SHUNT REG EXTRACTED STRATA II,SUP-2628601,CDM,C1889,HCPCS,0278,RC,,,,both,,,13380.89,8697.58,,,,,,,,,,,,,
COIL NEUROVASCULAR L 6 CM DIA 3 MM PLAT TUNGSTEN STD,SUP-2884370,CDM,C1889,HCPCS,0278,RC,,,,both,,,6908.00,4490.20,,,,,,,,,,,,,
BEAM FIX 7.5X70 MM,SUP-2422264,CDM,C1713,HCPCS,0278,RC,,,,both,,,4239.00,2755.35,,,,,,,,,,,,,
CATHETER VENTILATOR L 40 CM DIA 4 MM PTFE LASER JET DL ENT,SUP-2662067,CDM,2720000010,LOCAL,0272,RC,,,,both,,,467.86,304.11,,,,,,,,,,,,,
HC Angiogram F/U Study,PX-3237589800,CDM,75898,CPT,0323,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
LACOSAMIDE 50 MG PO TABS,RX-96882,CDM,6370000000,HCPCS,0637,RC,00904-7244-68,NDC,,both,1,UN,5.60,3.64,,,,,,,,,,,,,
DEVICE ENDOSKELETAL SYS PROSTHETIC BK INNR SOCKET CUSH LNR,SUP-2388210,CDM,L5679,HCPCS,0272,RC,,,,both,,,1538.82,1000.23,,,,,,,,,,,,,
KIT VENT ASST FOR HEARTMATE III IMPL,SUP-2356026,CDM,C1713,HCPCS,0278,RC,,,,both,,,338865.66,220262.68,,,,,,,,,,,,,
CATHETER DUAL ACCESS 3.5F TWIN PASS V2,SUP-2172773,CDM,C1725,HCPCS,0272,RC,,,,both,,,1014.22,659.24,,,,,,,,,,,,,
SUPPORT ORTHOT CUST BILATERAL W/VERTICAL EXTN,SUP-2435579,CDM,L1085,HCPCS,0274,RC,,,,both,,,495.90,322.33,,,,,,,,,,,,,
HC So Angiotensin Conv Enzyme,PX-3018216466,CDM,82164,CPT,0301,RC,,,,both,,,232.00,150.80,,,,,,,,,,,,,
PLATE BONE L 2X2 H BX FOR 1.5MM CRAN FIX UNIV NEURO III SYS,SUP-2363626,CDM,C1713,HCPCS,0278,RC,,,,both,,,966.71,628.36,,,,,,,,,,,,,
GRAFT BNE PTTY 5 CC OSTEOSURGE 300C,SUP-2644325,CDM,C1713,HCPCS,0278,RC,,,,both,,,3560.76,2314.49,,,,,,,,,,,,,
GRAFT VASC GELSFT + L 25 CM DIA20 MM POLYESTER GEL,SUP-2384948,CDM,C1768,CPT,0278,RC,,,,both,,,1079.50,701.67,,,,,,,,,,,,,
BLOCK FEM SZ 9 THK5MM UNIV POST KNEE CO CHROM TOT STBL FULL,SUP-2378509,CDM,C1776,CPT,0278,RC,,,,both,,,2362.54,1535.65,,,,,,,,,,,,,
DIPHENHYDRAMINE HCL 12.5 MG/5ML PO LIQD,RX-12556,CDM,340b,HCPCS,0637,RC,69339-0152-01,NDC,,both,2.5,ML,5.30,3.44,,,,,,,,,,,,,
INTRODUCER SHTH 5 FRX4 CM SHT GRY HUB FOR DECLOT PRELUDE,SUP-2303308,CDM,C1893,HCPCS,0272,RC,,,,both,,,51.81,33.68,,,,,,,,,,,,,
HEAD FEM 8+ MM 12/14 XLN 36 MM HIP TAPR ALUMINA CERM,SUP-2434737,CDM,C1776,CPT,0278,RC,,,,both,,,4483.92,2914.55,,,,,,,,,,,,,
IMPLANT BIO TISS W6XL6CM PORCINE DERM MTRX RECON THINNER,SUP-2388576,CDM,C1713,HCPCS,0278,RC,,,,both,,,8605.17,5593.36,,,,,,,,,,,,,
SCREW BNE L50MM DIA3.5MM CORT S STL ST LOK FULL THRD,SUP-2184234,CDM,C1713,HCPCS,0278,RC,,,,both,,,338.90,220.28,,,,,,,,,,,,,
SHEATH URET ACC 14FR L45CM HYDRPHLC FOR ENDO URO PROC FLX,SUP-2170511,CDM,C1894,HCPCS,0272,RC,,,,both,,,463.87,301.52,,,,,,,,,,,,,
IMPLANT HUM TISS L 70 X W 40 MM THK 5 MM DECELL DERM,SUP-2931224,CDM,C1762,CPT,0278,RC,,,,both,,,14438.22,9384.84,,,,,,,,,,,,,
HC So Vitamin K,PX-3018459766,CDM,84597,CPT,0301,RC,,,,outpatient,,,65.00,42.25,,,,,,,,,,,,,
CATHETER GUID CXI L 135 CM DIA 2.3 FR 0.014 IN SS STR TIP,SUP-2638641,CDM,C1887,HCPCS,0272,RC,,,,both,,,659.37,428.59,,,,,,,,,,,,,
SCREW SPNL L70MM DIA6.5MM CANC PEDCL S STL VAR ANG,SUP-2287078,CDM,C1713,HCPCS,0278,RC,,,,both,,,3965.66,2577.68,,,,,,,,,,,,,
POLARIS ULTRA STENT SET,SUP-2494639,CDM,C2617,HCPCS,0278,RC,,,,both,,,544.63,354.01,,,,,,,,,,,,,
GRAFT VASC L15CM BOR 32MM MAX SKRT L32MM DIA42MM PROX CLLR,SUP-2384988,CDM,C1768,CPT,0278,RC,,,,both,,,9900.42,6435.27,,,,,,,,,,,,,
MICROSPHERE EMB EMBOSPHERE DIA100-300 UM 2 CC 20 CC SYR YEL,SUP-2303401,CDM,C1889,HCPCS,0278,RC,,,,both,,,778.72,506.17,,,,,,,,,,,,,
PLATE BNE W17.5XL242MM THK5.2MM 10 H NONSTERILE L CNDYL FEM,SUP-2185023,CDM,C1713,HCPCS,0278,RC,,,,both,,,4334.83,2817.64,,,,,,,,,,,,,
GRAFT HUM TISS DERMACELL POROUS 6X7CM 42SQCM,SUP-2909279,CDM,Q4122,HCPCS,0636,RC,,,,both,,,3413.18,2218.57,,,,,,,,,,,,,
GRAFT HUM TISS W5XL10CM NOM THK1.1MM STD HUM DERM REGEN,SUP-2399064,CDM,Q4107,HCPCS,0636,RC,,,,both,,,7523.44,4890.24,,,,,,,,,,,,,
PLATE BNE X 1.5 MM 12 MM C-TUBE BRIDGE TI NS LEVEL 1,SUP-2471560,CDM,C1713,HCPCS,0278,RC,,,,both,,,334.28,217.28,,,,,,,,,,,,,
WEIGHT EYELID 1.2GM STD GLD SMOOTH SURF RND TAPR EDGE STRL,SUP-2247199,CDM,L8610,HCPCS,0278,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
ULNAR COLUMN SMARTLOCK PLATE LNG LEFT,SUP-2484508,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1422.42,924.57,,,,,,,,,,,,,
STAPLE INT STR 20X20 MM JAWS ASMBLY NIT,SUP-2751541,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4318.60,2807.09,,,,,,,,,,,,,
GRAFT HUM TISS W20XL20CM THK18 4MM ACELLULAR DERM MTRX,SUP-2307482,CDM,Q4128,HCPCS,0636,RC,,,,both,,,35617.46,23151.35,,,,,,,,,,,,,
SET INTRO SUP ARW FLX SHTH L 24 CM DIA10 FR HYDRPHLC,SUP-2383397,CDM,C1894,HCPCS,0272,RC,,,,both,,,157.06,102.09,,,,,,,,,,,,,
PROSTHESIS URETH L6CM OCCL CUF W/O INHIBZN AMS 800,SUP-2138923,CDM,C1815,HCPCS,0278,RC,,,,both,,,13188.00,8572.20,,,,,,,,,,,,,
CUP ACET OD47MM ID22MM MTL ON POLYETH NEUT PRI CEM W/ SPCR,SUP-2203596,CDM,C1776,CPT,0278,RC,,,,both,,,2245.10,1459.31,,,,,,,,,,,,,
CATHETERIZATION KIT 13-1/8 IN 4 FRX40 CM BLU FLEXTIP,SUP-2383368,CDM,C1751,HCPCS,0278,RC,,,,both,,,506.17,329.01,,,,,,,,,,,,,
BLADE RTRCTR CSPR 50MM X 23MM BALL SNAP MED F/ANTRR CRVCL FS,SUP-2464768,CDM,2720000010,LOCAL,0272,RC,,,,both,,,415.52,270.09,,,,,,,,,,,,,
SET SUPRPUB CATH 8FR L15CM PERC POLYETH MCOT W/ NDL OBT,SUP-2171290,CDM,C2627,HCPCS,0272,RC,,,,both,,,109.90,71.43,,,,,,,,,,,,,
IMPLANT SHLDR TOT W/PERFO,SUP-2388594,CDM,C1776,CPT,0278,RC,,,,both,,,24963.00,16225.95,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.450,SUP-2860014,CDM,C1713,HCPCS,0278,RC,,,,both,,,59236.10,38503.46,,,,,,,,,,,,,
SCREW BNE L4MM DIA1.5MM SIL TI SELF DRL FULL THRD,SUP-2181627,CDM,C1713,HCPCS,0278,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
COIL VASC TORNADO EMBOLUS L 12.5 CM DIA10-4 MM CATH DIA,SUP-2168581,CDM,C1889,HCPCS,0278,RC,,,,both,,,301.44,195.94,,,,,,,,,,,,,
SHELL ACET DIA46MM LNR SZ B 2 H MPACT,SUP-2267360,CDM,C1776,CPT,0278,RC,,,,both,,,6558.96,4263.32,,,,,,,,,,,,,
CROWN DENT 4 S STL PRI ANTR UP LT LAT PREFABRICATED,SUP-2100359,CDM,D6783,CPT,0278,RC,,,,both,,,21.10,13.71,,,,,,,,,,,,,
PLATE BONE LT CALCNL FX TUBEROSITY BTTRS SINUS TARSI APPRCH,SUP-2321445,CDM,C1713,HCPCS,0278,RC,,,,both,,,6829.50,4439.17,,,,,,,,,,,,,
MONITOR CARD 1.4CC INSERTABLE SLIM PROF REMOT MONING RDY,SUP-2356338,CDM,C1764,HCPCS,0278,RC,,,,both,,,14758.00,9592.70,,,,,,,,,,,,,
PLATE BONE TMT RIGHT,SUP-2427832,CDM,C1713,HCPCS,0278,RC,,,,both,,,6692.91,4350.39,,,,,,,,,,,,,
ANCHOR VERSALOOP 1.5MM SL TAPE JNJ210216,SUP-2756509,CDM,C1713,HCPCS,0278,RC,,,,both,,,1921.68,1249.09,,,,,,,,,,,,,
STEM FEM L200MM DIA17MM DSTL CALCAR HIP TI MOD DPHSEAL MLRY,SUP-2403938,CDM,C1776,CPT,0278,RC,,,,both,,,9209.62,5986.25,,,,,,,,,,,,,
HC Surgery Level 6 Base,PX-3600000006,CDM,3600000006,LOCAL,0360,RC,,,,inpatient,,,9199.00,5979.35,,,,,,,,,,,,,
PIN EXT FIX L 200 MM DIA 6 MM THRD L 35 MM HA EXT STRL DISP,SUP-2932995,CDM,2720000010,LOCAL,0272,RC,,,,both,,,817.72,531.52,,,,,,,,,,,,,
MESH HERN W6XL6IN SFT POLYPR OPN WV PROL SURGPRO,SUP-2219917,CDM,C1781,HCPCS,0278,RC,,,,both,,,5732.01,3725.81,,,,,,,,,,,,,
SCREW BNE BIPLANAR ANAT FOR LAPIPLASTY SYS 2,SUP-2421328,CDM,C1713,HCPCS,0278,RC,,,,both,,,15056.30,9786.59,,,,,,,,,,,,,
BURR SURG 1.6MM DIA HD LNG MIC 3.8MML HD SM BNE TAPR CROS CT,SUP-2605573,CDM,2720000010,LOCAL,0272,RC,,,,both,,,97.03,63.07,,,,,,,,,,,,,
FIXATION SCREW WASHER,SUP-2829166,CDM,C1713,HCPCS,0278,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
SCREW BNE L40MM DIA4.5MM THRD L12MM S STL PARTIALLY THRDED,SUP-2184433,CDM,C1713,HCPCS,0278,RC,,,,both,,,71.34,46.37,,,,,,,,,,,,,
STEM FEM L250MM DIA15MM BEAD 10IN CO CHROM HIP REV NEUT,SUP-2203216,CDM,C1776,CPT,0278,RC,,,,both,,,19042.53,12377.64,,,,,,,,,,,,,
BAR EXT FIX L150MM DIA6MM COMP FOR JET-X FIX SYS,SUP-2342913,CDM,2720000010,LOCAL,0272,RC,,,,both,,,919.83,597.89,,,,,,,,,,,,,
PIN FIX 27X50MM RESRB RFS,SUP-2400585,CDM,C1713,HCPCS,0278,RC,,,,both,,,546.36,355.13,,,,,,,,,,,,,
PIN HALF FIXATION M6 L200MM THREAD L40MM STAINLESS STEEL,SUP-2586488,CDM,2720000010,LOCAL,0272,RC,,,,both,,,622.19,404.42,,,,,,,,,,,,,
NUT SPNL,SUP-2585559,CDM,C1713,HCPCS,0278,RC,,,,both,,,182.12,118.38,,,,,,,,,,,,,
ROD IM ATTUNE,SUP-2454769,CDM,C1713,HCPCS,0278,RC,,,,both,,,1208.90,785.78,,,,,,,,,,,,,
WIRE FIXATION 30 GAX500 MM NEEDLE TITANIUM STERILE,SUP-2838462,CDM,C1713,HCPCS,0278,RC,,,,both,,,531.92,345.75,,,,,,,,,,,,,
ELECTRODE ELECSURG NDL 12-30 DEG 24 FR ANGLED PLASMA BUTTON,SUP-2430218,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7051.91,4583.74,,,,,,,,,,,,,
MESH HERN OVL 6X4 IN POCKETED BIORESORBABLE PHASIX ST,SUP-2855270,CDM,C1781,HCPCS,0278,RC,,,,both,,,9184.50,5969.92,,,,,,,,,,,,,
GRAFT VASC DISTAFLO L 60 CM DIA 7 MM EPTFE CARBON PERIPH STR,SUP-2126812,CDM,C1768,CPT,0278,RC,,,,both,,,3038.86,1975.26,,,,,,,,,,,,,
KIT INSTRUMENT SPINAL SPINEJACK 5MM EXPANSION,SUP-2876963,CDM,C1062,HCPCS,0278,RC,,,,both,,,4359.36,2833.58,,,,,,,,,,,,,
SHEATH INTRO FAST-CATH 135 DEG L 60 CM DIA 8 FR DIL DIA 8 FR,SUP-2357187,CDM,C1893,HCPCS,0272,RC,,,,both,,,480.42,312.27,,,,,,,,,,,,,
LEAD DEFIB LINOXSMART TD L 65 CM DIA2.6 MM TIP DISTANCE 18,SUP-2138098,CDM,C1895,HCPCS,0275,RC,,,,both,,,8792.00,5714.80,,,,,,,,,,,,,
KIT PUMP BLOOD CANNULA BYPS TANDEMHEART LIFESPARC V24/A17,SUP-2717605,CDM,C1889,HCPCS,0278,RC,,,,both,,,56520.00,36738.00,,,,,,,,,,,,,
DEFIBRILLATOR IMPL ATLS II VR 36 J TI POLYUR SINGLE CHMBR,SUP-2357739,CDM,C1722,HCPCS,0275,RC,,,,both,,,40820.00,26533.00,,,,,,,,,,,,,
PLATE BNE L94MM 5 H ST R SUP ANT CLAV S STL LOK COMPR W/,SUP-2177332,CDM,C1713,HCPCS,0278,RC,,,,both,,,2902.24,1886.46,,,,,,,,,,,,,
BUMPER ORTH MAK OSS,SUP-2449865,CDM,C1776,CPT,0278,RC,,,,both,,,805.41,523.52,,,,,,,,,,,,,
PROSTHESIS OSS SHEA HA/FP 3X10 MM TRIM HA FLROPLAS TORP,SUP-2637895,CDM,L8613,CPT,0278,RC,,,,both,,,1356.29,881.59,,,,,,,,,,,,,
OSS SMOOTH STM W/SRW 90ST-10,SUP-2510685,CDM,C1776,CPT,0278,RC,,,,both,,,4018.57,2612.07,,,,,,,,,,,,,
PLATE BNE W11XL99MM THK33MM 7 H BILAT MTPHSEAL TI LOK COMPR,SUP-2190761,CDM,C1713,HCPCS,0278,RC,,,,both,,,2681.72,1743.12,,,,,,,,,,,,,
HC Duplex Scan Artl Infl&Ven O/F Hemo Compl Uni Std,PX-9219398600,CDM,93986,CPT,0921,RC,,,,inpatient,,,920.00,598.00,,,,,,,,,,,,,
HC Transcatheter Dlvr Enhncd Fixation Devices Rs&I,PX-3603471200,CDM,34712,CPT,0360,RC,,,,both,,,10303.00,6696.95,,,,,,,,,,,,,
PLATE BONE LOK 85MML HLX46 HDSHFT T SHPD ST,SUP-2730177,CDM,C1713,HCPCS,0278,RC,,,,both,,,1338.96,870.32,,,,,,,,,,,,,
CANNULA SIZE 11 MM,SUP-2801027,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1024.80,666.12,,,,,,,,,,,,,
HC ED Cl Red Fx Phlx Not Grt Toe,PX-4502851500,CDM,28515,CPT,0450,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
CATHETER EP DIAG MAP A CRV QPLR 5MM SPC 5MM TIP FIX EXP 360,SUP-2141286,CDM,C1730,HCPCS,0272,RC,,,,both,,,759.88,493.92,,,,,,,,,,,,,
SCREW BONE L4MM DIA1.3MM CORT CRANIOMAXILLOFACIAL TI ST,SUP-2189050,CDM,C1713,HCPCS,0278,RC,,,,both,,,323.11,210.02,,,,,,,,,,,,,
BAR EXT FIX L 750 MM DIA10.5 MM COMP STRL DISP JET-X,SUP-2933463,CDM,2720000010,LOCAL,0272,RC,,,,both,,,920.84,598.55,,,,,,,,,,,,,
INSERTER SURG AID FOR GUIDEWIRE,SUP-2433930,CDM,C1776,CPT,0278,RC,,,,both,,,110.90,72.08,,,,,,,,,,,,,
CURVED JAW 23CM LENGTH BOX 5,SUP-2693696,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
KIT BILI STENT PRE ASSEMB INSRTN 1725MM PUSH CATH LEN 2090MM,SUP-2313251,CDM,C1894,HCPCS,0272,RC,,,,both,,,205.14,133.34,,,,,,,,,,,,,
MATRIX BIO L 6 X W 14 CM SZ 84 SQCM FISH SKIN SIL DERMAL FEN SINGLE,SUP-2909458,CDM,Q4158,HCPCS,0636,RC,,,,both,,,14872.30,9666.99,,,,,,,,,,,,,
BLADE CUT DIA2.5IN S STL FOR 940 CAST REM SYS,SUP-2365263,CDM,2720000010,LOCAL,0272,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
DRILL TWST 1.5X27X16MM,SUP-2364182,CDM,2720000010,LOCAL,0272,RC,,,,both,,,672.62,437.20,,,,,,,,,,,,,
GRAFT BONE SUB 10ML HUM CORT BONE DEMIN FBR STAGRFT,SUP-2136832,CDM,C1713,HCPCS,0278,RC,,,,both,,,7357.81,4782.58,,,,,,,,,,,,,
PROSTHESIS VOICE 20 FRX14 MM INDWL HRD VLV NS BLOM-SINGER,SUP-2242282,CDM,L8509,HCPCS,0272,RC,,,,both,,,1067.60,693.94,,,,,,,,,,,,,
BIT DRL OD25MM CANN LAPIDUS SYS,SUP-2316382,CDM,2720000010,LOCAL,0272,RC,,,,both,,,666.37,433.14,,,,,,,,,,,,,
BUR ENDOSCP SHAVER L 12.5 CM DIA 4.5 MM SPD 12000 RPM ENT,SUP-2902001,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1088.54,707.55,,,,,,,,,,,,,
GUIDEWIRE T2 RECON 32X400MM,SUP-2704163,CDM,C1769,HCPCS,0272,RC,,,,both,,,883.13,574.03,,,,,,,,,,,,,
PLATE 3.5MM TI LCP MEDIAL PROXIMAL TIBIA 20H LEFT 301MM,SUP-2549598,CDM,C1713,HCPCS,0278,RC,,,,both,,,3876.05,2519.43,,,,,,,,,,,,,
PLATE TI LCP ULNA OSTEOTOMY 2.7MM 6 HOLES STERILE,SUP-2546717,CDM,C1713,HCPCS,0278,RC,,,,both,,,3704.35,2407.83,,,,,,,,,,,,,
SCREW BNE SYMM PROF 3.5X10 MM LCK TI NS SURFIX,SUP-2609173,CDM,C1713,HCPCS,0278,RC,,,,both,,,1129.93,734.45,,,,,,,,,,,,,
GRAFT HUM TISS W1XL2CM THK07 14MM THN ACELLULAR HYDRATED,SUP-2307551,CDM,Q4128,HCPCS,0636,RC,,,,both,,,339.12,220.43,,,,,,,,,,,,,
IMMUNE GLOBULIN (OCTAGAM) 10%,RX-4081765,CDM,J1568,HCPCS,0636,RC,68982-0850-02,NDC,,both,50,ML,2865.20,1862.38,,,,,,,,,,,,,
GUIDEWIRE VASC L80CM DIA0.035IN FLPY TIP L3CM TAPR L7CM CRV,SUP-2167999,CDM,C1769,HCPCS,0272,RC,,,,both,,,68.55,44.56,,,,,,,,,,,,,
PLATE BONE SM THK2.5MM 4X20X4 H BILAT MAXILLOFACIAL ORAL LT,SUP-2181776,CDM,C1713,HCPCS,0278,RC,,,,both,,,9062.35,5890.53,,,,,,,,,,,,,
BEARING TIB THK12MM KNEE CONSTRN REDUC SZ OSS,SUP-2406490,CDM,C1776,CPT,0278,RC,,,,both,,,2345.58,1524.63,,,,,,,,,,,,,
TOPIRAMATE 100 MG PO TABS,RX-18922,CDM,6370000000,HCPCS,0637,RC,00904-6929-61,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PLATE BNE 1ST MTP/MPJ SM 2.7 MM RT NS FPS LTX,SUP-2856856,CDM,C1713,HCPCS,0278,RC,,,,both,,,5438.48,3535.01,,,,,,,,,,,,,
INVISION SIZE 4 TALAR DOME,SUP-2459068,CDM,C1776,CPT,0278,RC,,,,both,,,17213.48,11188.76,,,,,,,,,,,,,
SCREW SPNL L30MM DIA6.5MM TI FOR ANT FIX SYS Z PLT II,SUP-2289594,CDM,C1713,HCPCS,0278,RC,,,,both,,,1645.05,1069.28,,,,,,,,,,,,,
SUPPORT ORTHOT THOR LUMBAR SACR CUST FLX TRUNK SUPP T9,SUP-2435538,CDM,L0455,HCPCS,0274,RC,,,,both,,,981.88,638.22,,,,,,,,,,,,,
PORT STD MRI PLAS SGL LUMN W/ 7.5FR DETACHED SIL CATH AND,SUP-2169589,CDM,C1788,HCPCS,0278,RC,,,,both,,,1142.96,742.92,,,,,,,,,,,,,
PLATE BNE L 154 X W 10.5 MM THK 3 MM SCREW DIA2.7/3.5 MM 11 72467311,SUP-2933155,CDM,C1713,HCPCS,0278,RC,,,,both,,,3358.23,2182.85,,,,,,,,,,,,,
BEAM BNE FIX L120MM DIA7MM FOR SALVATION SYS,SUP-2400786,CDM,C1713,HCPCS,0278,RC,,,,both,,,4892.12,3179.88,,,,,,,,,,,,,
PLATE BNE CLAV CS2 2.7 MM LT LAT VA LCK COMPR SS NS VA-LCP,SUP-2757605,CDM,C1713,HCPCS,0278,RC,,,,both,,,3293.36,2140.68,,,,,,,,,,,,,
PLATE BNE L 198 X W 10.2 MM THK 2.8 MM SCREW DIA 3.5 MM 18 H 72440918,SUP-2933192,CDM,C1713,HCPCS,0278,RC,,,,both,,,2318.58,1507.08,,,,,,,,,,,,,
SHEATH ROT CF INNR GRY 27.6FR,SUP-2313078,CDM,C1894,HCPCS,0272,RC,,,,both,,,5082.22,3303.44,,,,,,,,,,,,,
QUETIAPINE FUMARATE 100 MG PO TABS,RX-21824,CDM,6370000000,HCPCS,0637,RC,00904-6640-61,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
APPLIER CLIP 6.75IN ANEURYSM MINI FINGER TIP GRIP BAYONET RE,SUP-2826147,CDM,C1889,HCPCS,0278,RC,,,,both,,,4648.96,3021.82,,,,,,,,,,,,,
GUIDEWIRE VASC ARISTOTLE ZOOM WIRE 14 L 300CM 0.014IN SUPP,SUP-2656743,CDM,C1769,HCPCS,0272,RC,,,,both,,,1899.70,1234.80,,,,,,,,,,,,,
IMMOBILIZER SHLDR L FOR 40-44IN RIB FOAM WRST NYL HUM CUF E,SUP-2196922,CDM,L3650,HCPCS,0274,RC,,,,both,,,17.43,11.33,,,,,,,,,,,,,
GUIDEWIRE SINGLE ENDED TROCAR TIP SMOOTH 1.1 X 100MM,SUP-2321615,CDM,C1713,HCPCS,0278,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
PLATE PL DSTL HUM LAT SUPP 3.5MM 14H RT 208MM LCP STRL,SUP-2547578,CDM,C1713,HCPCS,0278,RC,,,,both,,,3627.39,2357.80,,,,,,,,,,,,,
PLATE BNE OLECRANON 2.7/3.5X169 MM RT ELBW 8 HOLE LP VA LCK,SUP-2180816,CDM,C1713,HCPCS,0278,RC,,,,both,,,3738.61,2430.10,,,,,,,,,,,,,
HC Njx Dx/Ther Sbst W/Indwelling Cath Intrlmnr Lmbr/Sac W/Img Gdn,PX-3606232700,CDM,62327,CPT,0360,RC,,,,outpatient,,,2895.00,1881.75,,,,,,,,,,,,,
TRACHEOTOMY TY,SUP-2277144,CDM,2720000010,LOCAL,0272,RC,,,,both,,,436.27,283.58,,,,,,,,,,,,,
PLATE BNE L72MM 6 H LOK 2 COMPR FOR 27MM SCR UNIV LOK SYS,SUP-2199367,CDM,C1713,HCPCS,0278,RC,,,,both,,,838.32,544.91,,,,,,,,,,,,,
SET DEL CARDPLG W ARREST AGNT ADD CASS TBL LN 50ML 6FT,SUP-2330952,CDM,2720000010,LOCAL,0272,RC,,,,both,,,659.40,428.61,,,,,,,,,,,,,
GRAFT BNE STRP 5X2X0.5 CM DBM ACCELL TBM,SUP-2641756,CDM,C1713,HCPCS,0278,RC,,,,both,,,2979.86,1936.91,,,,,,,,,,,,,
HC Assay of Gammaglobulin Ige,PX-3018278500,CDM,82785,CPT,0301,RC,,,,both,,,644.00,418.60,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED TIB UPCHARGE COMP MIS,SUP-2212687,CDM,C1776,CPT,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
PLATE BNE INFRAPECTINEAL LG LT QUADRILATERAL SURF STRL PRO,SUP-2536009,CDM,C1713,HCPCS,0278,RC,,,,both,,,5181.00,3367.65,,,,,,,,,,,,,
PLATE BNE SM W10.1XL129MM THK3.5MM 10 H BILAT S STL CRV RIG,SUP-2186263,CDM,C1713,HCPCS,0278,RC,,,,both,,,2182.96,1418.92,,,,,,,,,,,,,
KIT CATH 45DEG FIRM TIP EXT WRK CHN LOCATABLE GUID EDGE SDK3450OLYMPUS] SUPERDIMENSION INC],SUP-2381764,CDM,C1713,HCPCS,0278,RC,,,,both,,,4703.72,3057.42,,,,,,,,,,,,,
LIGATOR ENDOSCP MULTI-BAND 8.6-11.3 MM 4 SHOT SAEED,SUP-2737558,CDM,2720000010,LOCAL,0272,RC,,,,both,,,872.92,567.40,,,,,,,,,,,,,
STENT PERIPH L100MM DIA7MM CATH L135CM NIT SELF EXP RADPQ,SUP-2104821,CDM,C1876,HCPCS,0278,RC,,,,both,,,3925.00,2551.25,,,,,,,,,,,,,
APPLIER CLP HNDPC MULT FIRE MOD M/L-10 REUSE SURG CLP,SUP-2304324,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1566.86,1018.46,,,,,,,,,,,,,
HC Albumin,PX-3078204000,CDM,82040,CPT,0307,RC,,,,both,,,99.00,64.35,,,,,,,,,,,,,
LAPAROSCOPE RIGID L300MM OD5MM 0DEG WIDE DIRECT VIEW OPERATI,SUP-2808418,CDM,C1776,CPT,0278,RC,,,,both,,,8680.59,5642.38,,,,,,,,,,,,,
BUR 75X5MM LNG BALL FLUT,SUP-2279703,CDM,2720000010,LOCAL,0272,RC,,,,both,,,373.63,242.86,,,,,,,,,,,,,
PLATE BNE L90MM 5 H NONSTERILE DST TIB S STL T LOK COMPR,SUP-2177434,CDM,C1713,HCPCS,0278,RC,,,,both,,,2085.27,1355.43,,,,,,,,,,,,,
CLIP SURG IRRIG SYS RIO,SUP-2368438,CDM,C1760,HCPCS,0278,RC,,,,both,,,153.86,100.01,,,,,,,,,,,,,
SCREW BNE CANN 2.5X30 MM LAG SS,SUP-2392884,CDM,C1713,HCPCS,0278,RC,,,,both,,,601.31,390.85,,,,,,,,,,,,,
GUIDEWIRE VASC RDRUN PC NIMB L 180 CM DIA 0.035 IN TAPR L,SUP-2168472,CDM,C1769,HCPCS,0272,RC,,,,both,,,94.45,61.39,,,,,,,,,,,,,
ALLOGRAFT BNE STRP 20X50X3-6 MM DBM PUROS 61615205,SUP-2684572,CDM,C1713,HCPCS,0278,RC,,,,both,,,16306.02,10598.91,,,,,,,,,,,,,
PLATE BONE 4 H LT MINI PREBENT FOR ANG FX,SUP-2365249,CDM,C1713,HCPCS,0278,RC,,,,both,,,1008.00,655.20,,,,,,,,,,,,,
SLEEVE FEM THK35MM KNEE TI ALLY FULL POR COAT REV ATTUNE,SUP-2251455,CDM,C1776,CPT,0278,RC,,,,both,,,7350.11,4777.57,,,,,,,,,,,,,
HC So2 Cardiolipin Antibody,PX-3028614768,CDM,86147,CPT,0302,RC,,,,both,,,30.00,19.50,,,,,,,,,,,,,
SET PERF L203CM 12IN RED AND BLU AORT ROOT MULT SLIP CONN,SUP-2282554,CDM,C1713,HCPCS,0278,RC,,,,both,,,65.81,42.78,,,,,,,,,,,,,
CATHETER INFUSION MEWEISSEN L 65 CM DIA 5 FR SEG 10 CM,SUP-2141151,CDM,C1887,HCPCS,0272,RC,,,,both,,,237.16,154.15,,,,,,,,,,,,,
BIT DRL L270MM DIA12MM NONSTERILE LNG CANN L QUIK CPL FOR,SUP-2178906,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1368.35,889.43,,,,,,,,,,,,,
PLATE CRANIO-FACIAL L MAX 4 H MALL RT REG TI 0.6MM THCK,SUP-2135909,CDM,C1713,HCPCS,0278,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
SCREW INTFR L23MM DIA7MM PEEK W/ DISP SHTH,SUP-2121150,CDM,C1713,HCPCS,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
RING PESSARY SZ 4 275IN SIL W SUPP,SUP-2273826,CDM,A4562,HCPCS,0274,RC,,,,both,,,102.27,66.48,,,,,,,,,,,,,
CATHETER CV DL 5 FRX20 CM MAX BARR DRP KT BIOFLO,SUP-2118840,CDM,C1751,HCPCS,0278,RC,,,,both,,,514.96,334.72,,,,,,,,,,,,,
SEALANT TISS FIBRIN 2 CC DUPLOSPRAY TISSEEL 921052] BAXALTA US INC],SUP-2129878,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3052.08,1983.85,,,,,,,,,,,,,
STEM FEM L200MM DIA13MM STD OFFSET RT DSTL HIP CO CHROM STR,SUP-2405134,CDM,C1776,CPT,0278,RC,,,,both,,,14820.80,9633.52,,,,,,,,,,,,,
HC Fna Bx W/CT Gdn Ea Addl,PX-3611001000,CDM,10010,CPT,0361,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
GRAFT BNE WDG THCK ASEP IL CREST,SUP-2742342,CDM,C1713,HCPCS,0278,RC,,,,both,,,4360.68,2834.44,,,,,,,,,,,,,
STRIP BIOACTIVE KINEX 20 CC 25X100X8 MM,SUP-2232309,CDM,C1713,HCPCS,0278,RC,,,,both,,,6405.60,4163.64,,,,,,,,,,,,,
PLATE BNE L157MM THK3MM 10 H BILAT S STL STR LIMIT CNTCT DYN,SUP-2185342,CDM,C1713,HCPCS,0278,RC,,,,both,,,1959.89,1273.93,,,,,,,,,,,,,
GRAFT HUMAN TISSUE THICK 30X20 CM HYDRATED BIOLOGIC TISSUE M,SUP-2838619,CDM,C1763,HCPCS,0278,RC,,,,both,,,55681.93,36193.25,,,,,,,,,,,,,
HC Chemo Admin Subq/Intramusc,PX-3319640100,CDM,96401,CPT,0331,RC,,,,inpatient,,,254.00,165.10,,,,,,,,,,,,,
KNIFE OPHTHLMC 4.5NL 2MMW 0.2MM THK DMND TRFCT BLADE PUSH PU,SUP-2499879,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2465.53,1602.59,,,,,,,,,,,,,
CATHETER ETER VEN EXTN SET W INJ CAP 10FR TESIO,SUP-2269529,CDM,C1881,HCPCS,0278,RC,,,,both,,,40.82,26.53,,,,,,,,,,,,,
PIN DISTRACTOR L14MM CERV S STL W UNIV FIT,SUP-2194307,CDM,C1713,HCPCS,0278,RC,,,,both,,,219.80,142.87,,,,,,,,,,,,,
ELECTRODE ES 24FR R ANG NDL 12 30DEG HF RESECT PLSM NDL ESG,SUP-2313591,CDM,C1713,HCPCS,0278,RC,,,,both,,,1678.02,1090.71,,,,,,,,,,,,,
HC Pt Manual Therapy Ea 15|DOCUMENTATION ON FILE|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS|UNUSUAL NON-OVERLAPPING SERVICE,PX-4209714000,CDM,97140,CPT,0420,RC,,,KX|CQ|XU,both,,,194.00,126.10,,,,,,,,,,,,,
PLATE BNE CONTOURABLE MESH 70X0.4 MM NEURO TI BLU NS,SUP-2859909,CDM,C1713,HCPCS,0278,RC,,,,both,,,5017.09,3261.11,,,,,,,,,,,,,
BLADE SHV L11CM DIA2MM SNUS STR SHFT ELEV FOR SUBMUCOSAL,SUP-2284120,CDM,2720000010,LOCAL,0272,RC,,,,both,,,860.61,559.40,,,,,,,,,,,,,
GUIDEWIRE VASC MINI HYDRPHLC HYBRID X SFT TRAXCESS,SUP-2305452,CDM,C1769,HCPCS,0272,RC,,,,both,,,1805.50,1173.57,,,,,,,,,,,,,
BLADE RTRCTR 60MMW X 90MML TTNM SPNL WIDE PRNGX6 GOLD LMBRTR,SUP-2668629,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1164.85,757.15,,,,,,,,,,,,,
PLATE BONE CONTOUR MESH 100X100X0.6 MM RECONSTRUCTION TITANI,SUP-2837712,CDM,C1713,HCPCS,0278,RC,,,,both,,,7645.27,4969.43,,,,,,,,,,,,,
INSERT TIB SZ 1 1+ H6MM ANK POLYETH INFIN,SUP-2397281,CDM,C1776,CPT,0278,RC,,,,both,,,4898.40,3183.96,,,,,,,,,,,,,
JOINT FNGR CARPOMETACARPAL 40 SPHR PYROSPHERE DISP,SUP-2610450,CDM,C1776,CPT,0278,RC,,,,both,,,7699.56,5004.71,,,,,,,,,,,,,
DEVICE VASCULAR CLOSURE CELT ACD PLUS 5FR,SUP-2933944,CDM,C1760,HCPCS,0278,RC,,,,both,,,656.26,426.57,,,,,,,,,,,,,
BENDER STEM RAD HD EVOLVE,SUP-2397211,CDM,C1713,HCPCS,0278,RC,,,,both,,,1277.98,830.69,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9 % IV BOLUS NEONATE,RX-40840079,CDM,2580000003,HCPCS,0258,RC,00990-7983-61,NDC,,both,150,ML,44.70,29.05,,,,,,,,,,,,,
PACEMAKER CRD UPLR/BPLR SINGLE CHMBR IS-1 CONN SOLUS II SR,SUP-2356696,CDM,C1786,HCPCS,0275,RC,,,,both,,,14444.00,9388.60,,,,,,,,,,,,,
SPACER SPNL 8 MM,SUP-2708788,CDM,C1821,HCPCS,0278,RC,,,,both,,,10676.00,6939.40,,,,,,,,,,,,,
SCREW BNE 30 DEG L 8 MM DIA2.7 MM TI LCK VA T15 DRV NS LEOS,SUP-2931451,CDM,C1713,HCPCS,0278,RC,,,,both,,,450.28,292.68,,,,,,,,,,,,,
CAGE SPNL 13X20MM INTBDY FUS RADLUC BAK VISTA,SUP-2414373,CDM,C1889,HCPCS,0278,RC,,,,both,,,11775.00,7653.75,,,,,,,,,,,,,
SPLINT WR AD SM FOR 2.5-3IN LT MCP REG FIRM OUTER FAB HND,SUP-2324878,CDM,L3809,HCPCS,0272,RC,,,,both,,,46.19,30.02,,,,,,,,,,,,,
DRESSING BIO W2XL4CM CLLGN SH 0.1% POLYHEXMETHYLENEBIGUANIDE,SUP-2314088,CDM,Q4196,HCPCS,0636,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
VALVE TRACH SPEAK SHILEY,SUP-2516374,CDM,L8501,HCPCS,0272,RC,,,,both,,,79.91,51.94,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED HD ADD ON CERM,SUP-2212521,CDM,C1776,CPT,0278,RC,,,,both,,,808.55,525.56,,,,,,,,,,,,,
VALVULOTOME ANGIOSCOPIC L 40 CM DIA1.8 MM SHRT EXPANDABLE,SUP-2264163,CDM,C1713,HCPCS,0278,RC,,,,both,,,4235.86,2753.31,,,,,,,,,,,,,
ALLODERM THIN FENESTRATED 4X4,SUP-2826657,CDM,Q4116,HCPCS,0636,RC,,,,both,,,4323.78,2810.46,,,,,,,,,,,,,
SCREW BNE L100MM DIA65MM CANC TI ST SELF DRL NONCANNULATED,SUP-2190555,CDM,C1713,HCPCS,0278,RC,,,,both,,,100.64,65.42,,,,,,,,,,,,,
SET INTRO SILHOUETTE PEELWY L 13 CM DIA16 FR GUIDEWIRE 0.038,SUP-2169689,CDM,C1894,HCPCS,0272,RC,,,,both,,,166.42,108.17,,,,,,,,,,,,,
CATHETER ABLATN LG CRV 8 MM 2-5-2 MM 7 FRX110 CM SAFIRE TX,SUP-2357038,CDM,C1733,HCPCS,0272,RC,,,,both,,,3504.24,2277.76,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP L150CM DIA0.035IN TIP L3CM NIT COR,SUP-2171362,CDM,C1769,HCPCS,0272,RC,,,,both,,,119.73,77.82,,,,,,,,,,,,,
ANCHOR SUT DIA2.9MM 2 DBL ARM NONABSORBABLE ULTRABRAID,SUP-2341742,CDM,C1713,HCPCS,0278,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
GRAFT BNE SUB 20CC CA SULF CA PHSPTE INJ REGEN PRO-DENSE,SUP-2399154,CDM,C1713,HCPCS,0278,RC,,,,both,,,13778.32,8955.91,,,,,,,,,,,,,
BIT DRILL ARTHSCP 7MM OD ACL/PCL CNNLTD F/LGMNT RCNSTRCTN LA,SUP-2589234,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1600.14,1040.09,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9 % IV BOLUS NEONATE,RX-40840079,CDM,2580000003,HCPCS,0250,RC,00338-0049-11,NDC,,both,50,ML,24.70,16.05,,,,,,,,,,,,,
SCREW BONE L22MM OD4MM LCTSRB CPLMR SHLDR CNNLTD FLLY THRDD,SUP-2466661,CDM,C1713,HCPCS,0278,RC,,,,both,,,860.36,559.23,,,,,,,,,,,,,
BLADE REPROC SAW RECIP 3 MM CONN STRL LTX,SUP-2877811,CDM,2720000010,LOCAL,0272,RC,,,,both,,,964.36,626.83,,,,,,,,,,,,,
PIN FIX SINGLE DIAMOND 0.093X9 IN RND END SS NS STEINMANN,SUP-2791839,CDM,C1713,HCPCS,0278,RC,,,,both,,,12.18,7.92,,,,,,,,,,,,,
SCREW BNE LCK 5X110 MM CANN OPTILINK TECHNOLOGY STRL VALCP,SUP-2789509,CDM,C1713,HCPCS,0278,RC,,,,both,,,931.70,605.60,,,,,,,,,,,,,
PASSER SUT 90DEG STR NIT WIRE LOOP 2 FIBERSTICK MFIL SUT,SUP-2121958,CDM,C1769,HCPCS,0272,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
GRAFT DERM L12CMXW4CM CLLGN RECTANG IMPL ALLOMAX,SUP-2125853,CDM,C1781,HCPCS,0278,RC,,,,both,,,4772.80,3102.32,,,,,,,,,,,,,
DILATOR TRANSSEPTAL L 67 CM GUIDEWIRE L 230 CM HDPE HYPOTUBE PIGTAIL,SUP-2913475,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3265.60,2122.64,,,,,,,,,,,,,
ALLOGRAFT SKIN MESHED HUM TISS,SUP-2165585,CDM,C1762,CPT,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
SPACER FEM -2 MM MULTI-REFERENCE 4-IN-1 MICRO-MILL NXGN,SUP-2438070,CDM,C1776,CPT,0278,RC,,,,both,,,1328.22,863.34,,,,,,,,,,,,,
EXPANDER BRST TISS 750CC W15XH15CM P7.7CM SIL SMOOTH HI,SUP-2301024,CDM,C1789,HCPCS,0278,RC,,,,both,,,6531.20,4245.28,,,,,,,,,,,,,
KIT REPAIR SYNDESMOSIS SS STRL FIBULINK,SUP-2605957,CDM,C1713,HCPCS,0278,RC,,,,both,,,3678.38,2390.95,,,,,,,,,,,,,
HC Sel Cath Plcmt 2nd Order Brach,PX-3613621600,CDM,36216,CPT,0361,RC,,,,inpatient,,,6875.00,4468.75,,,,,,,,,,,,,
MESH SURG XL W4.8XL6.7IN R L PORE LTWT FOR INGUINAL HERN,SUP-2125798,CDM,C1781,HCPCS,0278,RC,,,,both,,,660.66,429.43,,,,,,,,,,,,,
HC Thrmbc/Nfs Dialysis W Pta,PX-3613690500,CDM,36905,CPT,0361,RC,,,,inpatient,,,11772.00,7651.80,,,,,,,,,,,,,
DISTRACTOR TIB L L330MM DIA14MM THRD SPINDLE,SUP-2188634,CDM,C1713,HCPCS,0278,RC,,,,both,,,1487.39,966.80,,,,,,,,,,,,,
SPLINT WR AD SM FOR 2.5-3IN LT MCP REG FIRM OUTER FAB HND,SUP-2324878,CDM,L3809,HCPCS,0274,RC,,,,both,,,46.19,30.02,,,,,,,,,,,,,
PROMETHAZINE HCL 25 MG RE SUPP,RX-11144,CDM,6370000000,HCPCS,0637,RC,00713-0526-12,NDC,,both,1,UN,83.90,54.53,,,,,,,,,,,,,
BRACE ORTH CLOSURE SM AD BK SHLDR BLK QUIKDRAW PRO,SUP-2123908,CDM,L0628,HCPCS,0272,RC,,,,both,,,165.64,107.67,,,,,,,,,,,,,
PLATE BNE L16MM S STL QUAD FOR GUID GROWTH SYS,SUP-2316427,CDM,C1713,HCPCS,0278,RC,,,,both,,,1234.40,802.36,,,,,,,,,,,,,
VALVE CSF PERF LEVEL 2 NEONATE 90 CM DELT,SUP-2628520,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3473.56,2257.81,,,,,,,,,,,,,
ELECTRODE ELECTROTHERAPY NIT MPLR 25GA L100MM VENOM,SUP-2366970,CDM,C1713,HCPCS,0278,RC,,,,both,,,5903.20,3837.08,,,,,,,,,,,,,
TUBING HUMIDIFICATION HI FLO 0.88 IN,SUP-2305967,CDM,C1713,HCPCS,0278,RC,,,,both,,,1460.10,949.06,,,,,,,,,,,,,
HC Nursery Level II R&B,PX-1720000000,CDM,1720000000,LOCAL,0172,RC,,,,inpatient,,,6836.00,4443.40,,,,,,,,,,,,,
ANCHOR SUT DIA4.5MM BIOCRYL RAPIDE ABSRB 3 PERMACORD SZ 2,SUP-2249460,CDM,C1713,HCPCS,0278,RC,,,,both,,,2125.78,1381.76,,,,,,,,,,,,,
TIP CRYOSURGERY L 8.5 MM DIA 3 MM GEN 2 STRL DISP IOVERA,SUP-2882197,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1505.94,978.86,,,,,,,,,,,,,
GUIDE SURG FOR ATLNTS VISN SCR,SUP-2293186,CDM,C1713,HCPCS,0278,RC,,,,both,,,3204.62,2083.00,,,,,,,,,,,,,
AXLE FEM STD KNEE OSS,SUP-2405831,CDM,C1776,CPT,0278,RC,,,,both,,,1130.40,734.76,,,,,,,,,,,,,
PLATE BNE RECON 3.5X166 MM 14 HOLE SS,SUP-2569089,CDM,C1713,HCPCS,0278,RC,,,,both,,,464.56,301.96,,,,,,,,,,,,,
RING EXT FIX L120MM DBL H FT FOR SIDEKCK FREE CIR FIX,SUP-2400633,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4176.20,2714.53,,,,,,,,,,,,,
FRACTURE ADAPTER SZ 6- 9 WIDE,SUP-2815879,CDM,C1776,CPT,0278,RC,,,,both,,,7112.10,4622.86,,,,,,,,,,,,,
PLATE BNE L111MM THK3.4MM 8 H BILAT S STL STR LOK COMPR FOR,SUP-2185137,CDM,C1713,HCPCS,0278,RC,,,,both,,,914.62,594.50,,,,,,,,,,,,,
PAD ORTHOT LUMBAR CUST DEROTATION,SUP-2435587,CDM,L1240,HCPCS,0274,RC,,,,both,,,257.48,167.36,,,,,,,,,,,,,
GUIDE RMR L850MM DIA2.5MM RM ATTCH CALIB W/ BALL TIP,SUP-2188274,CDM,2720000010,LOCAL,0272,RC,,,,both,,,459.63,298.76,,,,,,,,,,,,,
VEST HALO CERV TRAC ASMBLY M,SUP-2328130,CDM,L0861,HCPCS,0274,RC,,,,both,,,3592.16,2334.90,,,,,,,,,,,,,
OSTEOTOME SURG OD8MM BLDE THN FLX,SUP-2408593,CDM,2720000010,LOCAL,0272,RC,,,,both,,,464.72,302.07,,,,,,,,,,,,,
CATHETER CV PRESSURE MONITORING SET 018 PEDIATRIC 3 FRX5 CM,SUP-2760145,CDM,C1751,HCPCS,0278,RC,,,,both,,,108.17,70.31,,,,,,,,,,,,,
ALLOGRAFT BNE SPACER 21-26X27-32X21 MM FD ALIF ANTR APPRCH,SUP-2736758,CDM,C1713,HCPCS,0278,RC,,,,both,,,15087.17,9806.66,,,,,,,,,,,,,
CATHETER NEPHROSTOMY SET 035 6 FRX15 CM 19 GA SKATER,SUP-2753330,CDM,C1729,HCPCS,0272,RC,,,,both,,,245.30,159.44,,,,,,,,,,,,,
PLATE BNE HUM 203 MM LT DSTL POSTEROLATERAL 15 HOLE LCK NS,SUP-2518323,CDM,C1713,HCPCS,0278,RC,,,,both,,,4549.86,2957.41,,,,,,,,,,,,,
MESH SURGICAL 7.5CM X 7.5CM RESTRATA,SUP-2874126,CDM,A2007,HCPCS,0636,RC,,,,both,,,11775.00,7653.75,,,,,,,,,,,,,
GRAFT VASC IMPRA L 5 CM DIA 6 MM EPTFE STR STD WALL N RING,SUP-2761310,CDM,C1768,CPT,0278,RC,,,,both,,,286.02,185.91,,,,,,,,,,,,,
SPLINT TRAC 12IN UNIV 3 PNL KNEE,SUP-2196752,CDM,L1830,CPT,0272,RC,,,,both,,,56.58,36.78,,,,,,,,,,,,,
GUIDEWIRE L65IN S STL ENT HSE,SUP-2159976,CDM,C1769,HCPCS,0272,RC,,,,both,,,392.15,254.90,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED PRSS FT HD CERM,SUP-2212730,CDM,C1776,CPT,0278,RC,,,,both,,,12988.61,8442.60,,,,,,,,,,,,,
HEAD HUM LO OFFSET 15X41 MM 1.5 MM SHLDR AEQUALIS ASCEND FLX,SUP-2390580,CDM,C1776,CPT,0278,RC,,,,both,,,13098.51,8514.03,,,,,,,,,,,,,
GUIDEWIRE ORTH L100MM DIA3MM BALL TIP FOR S2 IM NAIL,SUP-2368573,CDM,C1769,HCPCS,0272,RC,,,,both,,,401.92,261.25,,,,,,,,,,,,,
HC Pt Therapeutic Activities 15 Min|OP PT SERVICES|DOCUMENTATION ON FILE|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS,PX-4209753000,CDM,97530,CPT,0420,RC,,,GP|KX|CQ,both,,,144.00,93.60,,,,,,,,,,,,,
PLATE BNE RNG ATTCH LG 3.5 MM RT PROX GTR TROCH STRL VALCP,SUP-2789578,CDM,C1713,HCPCS,0278,RC,,,,both,,,4796.57,3117.77,,,,,,,,,,,,,
PLATE 3.5MM TI LCP TM PROX TIBIA PLATE 4H 81MM RIGHT-STER,SUP-2549538,CDM,C1713,HCPCS,0278,RC,,,,both,,,4584.93,2980.20,,,,,,,,,,,,,
PLATE BNE Y LNG 1.5X0.6 MM NEURO LP TI STRL LEVEL 1,SUP-2496663,CDM,C1713,HCPCS,0278,RC,,,,both,,,661.63,430.06,,,,,,,,,,,,,
SHEARS ENDOSCP L23CM DIA5.5MM SCALP CRV DISP HARM,SUP-2218884,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1049.89,682.43,,,,,,,,,,,,,
STENT ESOPH ENDOMAXX L 100 MM DIA23 MM FLARE DIA28 MM DEL,SUP-2516651,CDM,C1874,HCPCS,0278,RC,,,,both,,,10048.00,6531.20,,,,,,,,,,,,,
GRAFT TEND HUNTER RNG KNOB END ACT LEN 18CM LX4MM W,SUP-2399192,CDM,C1713,HCPCS,0278,RC,,,,both,,,4003.50,2602.27,,,,,,,,,,,,,
ALUMINUM RENAL ABH BLADE 1 X 8,SUP-2703359,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1476.52,959.74,,,,,,,,,,,,,
SCREW BNE 3.6X22 MM ANCHORAGE 2 CP,SUP-2362124,CDM,C1713,HCPCS,0278,RC,,,,both,,,502.84,326.85,,,,,,,,,,,,,
GUIDEWIRE VASC L 30 CM DIA 0.015 IN CRV RAD 2 MM STR CRV DBL,SUP-2760064,CDM,C1769,HCPCS,0272,RC,,,,both,,,133.26,86.62,,,,,,,,,,,,,
BUR SURG ROSEN RND CUT NONFLUTED HI LN XSM TYP I SHT 60MM,SUP-2108770,CDM,C1713,HCPCS,0278,RC,,,,both,,,378.56,246.06,,,,,,,,,,,,,
PLATE 3.5MM TI LCP MEDIAL PROXIMAL TIBIA 20H LT 301MM-STER,SUP-2549599,CDM,C1713,HCPCS,0278,RC,,,,both,,,5504.01,3577.61,,,,,,,,,,,,,
DEVICE FIX BIOABSORBABLE 2.5 MM RIBBON ENDOTINE,SUP-2760658,CDM,C1713,HCPCS,0278,RC,,,,both,,,431.25,280.31,,,,,,,,,,,,,
PLATE BONE L82MM 6 H BILAT ELBW 1/3 TBLR LCK COMPR FOR 3.5MM,SUP-2348936,CDM,C1713,HCPCS,0278,RC,,,,both,,,1541.17,1001.76,,,,,,,,,,,,,
SINUS SCTN BURR ANGLD 70 DMNDBRR D3.6MM SHFT4MMX12CM 5/PK ST,SUP-2574164,CDM,2720000010,LOCAL,0272,RC,,,,both,,,734.51,477.43,,,,,,,,,,,,,
SCREW INTFR L25MM DIA10MM ANT CRUCE LIG TI CANN,SUP-2366525,CDM,C1713,HCPCS,0278,RC,,,,both,,,305.68,198.69,,,,,,,,,,,,,
HC Shoulder Complete Min 2 Views,PX-3207303000,CDM,73030,CPT,0320,RC,,,,both,,,425.00,276.25,,,,,,,,,,,,,
PLATE BNE DBL Y 0.6 MM FACE,SUP-2262676,CDM,C1713,HCPCS,0278,RC,,,,both,,,850.88,553.07,,,,,,,,,,,,,
LINER ACET OD60MM ID36MM +4MM OFFSET 10DEG HIP CROSSLINKED,SUP-2250569,CDM,C1776,CPT,0278,RC,,,,both,,,4654.74,3025.58,,,,,,,,,,,,,
BIT OVERDRILL L 229 MM DIA 5.5 MM LG AO NS DISP LEOS,SUP-2932991,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1111.84,722.70,,,,,,,,,,,,,
SCREW BONE L6MM DIA2MM STD CORT S STL ST FULL THRD HEX HD,SUP-2343867,CDM,C1713,HCPCS,0278,RC,,,,both,,,266.81,173.43,,,,,,,,,,,,,
HC Sel Cath Plcmt Seg Pa,PX-3613601500,CDM,36015,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
HC a Line Insertion,PX-7613662000,CDM,36620,CPT,0761,RC,,,,both,,,789.00,512.85,,,,,,,,,,,,,
PLATE BONE L46MM 6 H STRL S STL LCK COMPR FOR 2.7MM SCR EVOS,SUP-2349616,CDM,C1713,HCPCS,0278,RC,,,,both,,,2004.14,1302.69,,,,,,,,,,,,,
STEM FEM HI OFFSET 4 SHT HIP TAPR POROUS,SUP-2450686,CDM,C1776,CPT,0278,RC,,,,both,,,14205.36,9233.48,,,,,,,,,,,,,
CARTEOLOL HCL 1 % OP SOLN,RX-9417,CDM,6370000000,HCPCS,0637,RC,61314-0238-05,NDC,,both,5,ML,58.30,37.89,,,,,,,,,,,,,
BUPIVACAINE HCL 0.5 % IJ SOLN (MIXTURES ONLY),RX-430038,CDM,J0665,HCPCS,0636,RC,00409-1163-01,NDC,,both,30,ML,54.10,35.16,,,,,,,,,,,,,
SCREW BONE L9MM DIA2MM STD CORT CRANIOMAXILLOFACIAL TI ST,SUP-2189667,CDM,C1713,HCPCS,0278,RC,,,,both,,,217.16,141.15,,,,,,,,,,,,,
GUIDEWIRE VASC LUNDERQUIST L 145 CM DIA 0.038 IN PTFE PERIPH,SUP-2167789,CDM,C1769,HCPCS,0272,RC,,,,both,,,104.31,67.80,,,,,,,,,,,,,
DIATRIZOATE MEGLUMINE & SODIUM 66-10 % PO SOLN,RX-9828,CDM,Q9963,HCPCS,0636,RC,00270-0445-40,NDC,,both,5,ML,0.50,0.32,,,,,,,,,,,,,
PLATE BNE INTERCARPAL 2.4X15 MM 6 HOLE VA LCK FUSION SS NS,SUP-2799113,CDM,C1713,HCPCS,0278,RC,,,,both,,,3124.74,2031.08,,,,,,,,,,,,,
CLIP INT USE THRD L 165 CM ENDOSCP DIA 8.5-11 MM CAP D 7 MM,SUP-2881908,CDM,C1889,HCPCS,0278,RC,,,,both,,,2037.86,1324.61,,,,,,,,,,,,,
ROD EXT FIX L30MM DIA3MM MINI C CONN FOR MIC SYS HOFFMANN,SUP-2372513,CDM,C1713,HCPCS,0278,RC,,,,both,,,188.40,122.46,,,,,,,,,,,,,
HC Up Ext Fx Orth W/Wr Hinge,PX-2740376401,CDM,L3764,HCPCS,0272,RC,,,,both,,,2631.00,1710.15,,,,,,,,,,,,,
BIT DRL DIA2MM REUSE FOR SM FRAG PLATING SYS,SUP-2413954,CDM,2720000010,LOCAL,0272,RC,,,,both,,,368.54,239.55,,,,,,,,,,,,,
BAR EXT FIX L 600 MM DIA11 MM STRL DISP MAV,SUP-2933431,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2665.86,1732.81,,,,,,,,,,,,,
ROD SPNL L300MM DIA5.5MM TI Z SHP EXPEDIUM,SUP-2254759,CDM,C1713,HCPCS,0278,RC,,,,both,,,4154.22,2700.24,,,,,,,,,,,,,
BUR H RESVR SET W/CATHETER,SUP-2108707,CDM,C1729,HCPCS,0272,RC,,,,both,,,1460.95,949.62,,,,,,,,,,,,,
VALVE CSF FLO BURR HOLE 12 MM CTRL HI PRESSURE DELT,SUP-2629163,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2103.39,1367.20,,,,,,,,,,,,,
PLATE BNE L62MM 3 H ST TI HK LOK COMPR FOR 35MM SCR,SUP-2180907,CDM,C1713,HCPCS,0278,RC,,,,both,,,2141.51,1391.98,,,,,,,,,,,,,
PLATE BNE NAR 4.5X70 MM 4 HOLE SS LC-DCP,SUP-2569256,CDM,C1713,HCPCS,0278,RC,,,,both,,,217.60,141.44,,,,,,,,,,,,,
WASHER EXT FIX TABBED FOR 03.313.885 OR 03.311.050 MAXFRAME,SUP-2758005,CDM,2720000010,LOCAL,0272,RC,,,,both,,,307.50,199.87,,,,,,,,,,,,,
GRAFT VASC FLIXENE L 50 CM DIA 7 MM EPTFE STR STD WALL REINF,SUP-2479793,CDM,C1768,CPT,0278,RC,,,,both,,,3298.51,2144.03,,,,,,,,,,,,,
HC US Duplex Abd/Pelvis/Scrotum Comp,PX-9219397500,CDM,93975,CPT,0921,RC,,,,both,,,2625.00,1706.25,,,,,,,,,,,,,
NEEDLE TRANSSEPTAL BRK XS CRV S STL AD 18AGX89CM BRK,SUP-2357592,CDM,C1713,HCPCS,0278,RC,,,,both,,,684.52,444.94,,,,,,,,,,,,,
KIT ACCSRY PMP FOR INFLATABLE PENILE PROS STRL DISP AMS 700,SUP-2930702,CDM,C1813,HCPCS,0278,RC,,,,both,,,2848.61,1851.60,,,,,,,,,,,,,
PLATE EXT FIX LNG 180 MM FT RNG TI NS,SUP-2800131,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3033.93,1972.05,,,,,,,,,,,,,
CLAMP EXT FIX DBL PIN SWVL NS DISP MAV MINI,SUP-2933016,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2670.57,1735.87,,,,,,,,,,,,,
POR ST/RGX CP/LGXL/LG HD,SUP-2212377,CDM,C1776,CPT,0278,RC,,,,both,,,17270.00,11225.50,,,,,,,,,,,,,
SPLINT THMB M L5IN SH LT 1 STRP THERMOPLASTIC INSRT,SUP-2324195,CDM,L3931,HCPCS,0272,RC,,,,both,,,42.26,27.47,,,,,,,,,,,,,
PLATE BNE L169MM THK37MM 13 H BILAT S STL STR LO PROF RIG,SUP-2177145,CDM,C1713,HCPCS,0278,RC,,,,both,,,2572.19,1671.92,,,,,,,,,,,,,
PLATE BNE ORBIT FLR SM 1.5X0.4 MM LT SMRT 3D TI NS LEVEL 1,SUP-2488954,CDM,C1713,HCPCS,0278,RC,,,,both,,,3341.40,2171.91,,,,,,,,,,,,,
MESH HERN W15XH15CM POLYPR NONABSORBABLE SYN SQ PROL,SUP-2219795,CDM,C1781,HCPCS,0278,RC,,,,both,,,281.44,182.94,,,,,,,,,,,,,
DEVICE FIXATION LADDER PLATE WIDE 14 HOLES,SUP-2719531,CDM,C1713,HCPCS,0278,RC,,,,both,,,1899.70,1234.80,,,,,,,,,,,,,
BASEPLATE TIB N BEAD SM KNEE ASMBLY KINEMAX +,SUP-2452024,CDM,C1776,CPT,0278,RC,,,,both,,,5069.22,3294.99,,,,,,,,,,,,,
PROBE ABLATN RF XL 180 MM 50-S W/ INTEGR CABLE HND SERFAS,SUP-2557500,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1893.20,1230.58,,,,,,,,,,,,,
PACEMAKER CARD CYLOS DR W 42 X H 57 MM D 6 MM TI POLYUR SIL,SUP-2138038,CDM,C1785,HCPCS,0275,RC,,,,both,,,13812.86,8978.36,,,,,,,,,,,,,
GRAFT 160MG 20CC INJ MICRONIZED ALLGRFT EPIFIX,SUP-2305739,CDM,Q4145,HCPCS,0636,RC,,,,both,,,9107.57,5919.92,,,,,,,,,,,,,
SCREW BONE L8MM DIA2.4MM CORT TI ST NONCANNULATED FULL THRD,SUP-2181729,CDM,C1713,HCPCS,0278,RC,,,,both,,,365.75,237.74,,,,,,,,,,,,,
CROWN REFIL SEC M 41104103 E-LR-2,SUP-2322183,CDM,D6783,CPT,0278,RC,,,,both,,,29.58,19.23,,,,,,,,,,,,,
SCREW SPNL L45MM DIA5.5MM THORLUM TI VAR ANG TRUSS,SUP-2230344,CDM,C1713,HCPCS,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
CATHETER ABLAT 7FR L110CM 2.5MM SPC QPLR ASYM 4 CRV STR TIP,SUP-2141266,CDM,C1733,HCPCS,0272,RC,,,,both,,,4609.52,2996.19,,,,,,,,,,,,,
PACEMAKER CARD PHILOS II DR-T L 51 X W 44 X H 6 MM 12 CC 27,SUP-2137977,CDM,C1785,HCPCS,0275,RC,,,,both,,,16331.14,10615.24,,,,,,,,,,,,,
KNOTLESS MINI TR IMPLANT AR8908DS,SUP-2843917,CDM,C1713,HCPCS,0278,RC,,,,both,,,5950.30,3867.69,,,,,,,,,,,,,
STENT TRACHBRONCH WSTNT L 40 MM DIA18 MM SHTH 11 FR CATH L,SUP-2147038,CDM,C1876,HCPCS,0278,RC,,,,both,,,3464.93,2252.20,,,,,,,,,,,,,
SPACER SPNL H9XL23-27MM 8DEG NAR ANTR LUM FEM RNG APPRCH,SUP-2306883,CDM,C1713,HCPCS,0278,RC,,,,both,,,11740.15,7631.10,,,,,,,,,,,,,
SPHINCTEROTOME ENDOSCP 5 MM 4.4 FRX20 MM TRUTOME 8309,SUP-2484706,CDM,C1713,HCPCS,0278,RC,,,,both,,,917.16,596.15,,,,,,,,,,,,,
PLATE BNE L81MM 6 H L OLECRANON S STL LOK FOR 2.7/3.5MM SCR,SUP-2348706,CDM,C1713,HCPCS,0278,RC,,,,both,,,12183.20,7919.08,,,,,,,,,,,,,
COIL EMB L10CM OD5MM 2D HELI SFT STRTCH RESIST DETACH,SUP-2365733,CDM,C1889,HCPCS,0278,RC,,,,both,,,6129.12,3983.93,,,,,,,,,,,,,
STENT URETH UROLUME L 2 CM DIA 42 FR ELGILOY SELF EXPANDABLE,SUP-2140269,CDM,C1876,HCPCS,0278,RC,,,,both,,,9404.30,6112.79,,,,,,,,,,,,,
LEAD PLEXA S 60,SUP-2418500,CDM,C1777,HCPCS,0275,RC,,,,both,,,8164.00,5306.60,,,,,,,,,,,,,
CATHETER INTVASC ULTRASOUND ATLNTS L 135 CM DIA 6 FR,SUP-2141200,CDM,C1725,HCPCS,0272,RC,,,,both,,,2621.90,1704.23,,,,,,,,,,,,,
BASEPLATE TIB CEM 1 SM UNIV KNEE CRUCFRM BEAD HA POROUS,SUP-2377175,CDM,C1776,CPT,0278,RC,,,,both,,,6769.21,4399.99,,,,,,,,,,,,,
IMPLANT BIO W 7 X H 4 CM THK 2P PORCINE SM INTEST SUBMUCOSA CMCV-099-204,SUP-2884120,CDM,C1768,CPT,0278,RC,,,,both,,,4066.30,2643.09,,,,,,,,,,,,,
STENT URET 6FR L28CM PERCFLX HYDR+ SFT LOOP 2 DUROMETER,SUP-2139608,CDM,C2617,HCPCS,0278,RC,,,,both,,,494.61,321.50,,,,,,,,,,,,,
KIT INT FIX ACL INLINE DRL BIT DRL PNT K WIRE GUID WIRE TRCR,SUP-2136097,CDM,C1713,HCPCS,0278,RC,,,,both,,,4571.84,2971.70,,,,,,,,,,,,,
PROBE ARTHRO 60DEG 3.0MM WAND ABLAT BPLR W/ SUCT ENLARGED,SUP-2341639,CDM,2720000010,LOCAL,0272,RC,,,,both,,,596.60,387.79,,,,,,,,,,,,,
MICROCATHETER VASC RENEGADE HI FLO L 135 CM DSTL L 20 CM,SUP-2367868,CDM,C1887,HCPCS,0272,RC,,,,both,,,2397.70,1558.50,,,,,,,,,,,,,
SCREW OD13MM W 4MM STP,SUP-2365065,CDM,C1713,HCPCS,0278,RC,,,,both,,,275.91,179.34,,,,,,,,,,,,,
PLATE FIXATION BURR HOLE LG 26MM,SUP-2719503,CDM,C1713,HCPCS,0278,RC,,,,both,,,563.69,366.40,,,,,,,,,,,,,
PLATE BNE BROAD 4.5X394 MM 22 HOLE SS LC-DCP,SUP-2569273,CDM,C1713,HCPCS,0278,RC,,,,both,,,632.08,410.85,,,,,,,,,,,,,
BUTORPHANOL TARTRATE 1 MG/ML IJ SOLN,RX-9333,CDM,J0595,HCPCS,0636,RC,00409-1623-21,NDC,,both,0.5,ML,54.10,35.16,,,,,,,,,,,,,
PLATE BONE LOK NON CMPRSSN HLX20 25MM THK TTNM STRGHT LVLX1,SUP-2694213,CDM,C1713,HCPCS,0278,RC,,,,both,,,4282.61,2783.70,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 10 CM DIA 8 MM STR STD WALL HELIX,SUP-2493106,CDM,C1768,CPT,0278,RC,,,,both,,,440.35,286.23,,,,,,,,,,,,,
BLADE ENDOSCP CRV W/ HNDL STRL CAP-FIX LTX,SUP-2879951,CDM,2720000010,LOCAL,0272,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
CATHETER INTVASC L38CM OD9.3FR 3 LUMN 3 HEAT EXCHG BLLN FOR,SUP-2416142,CDM,C1751,HCPCS,0278,RC,,,,both,,,2727.03,1772.57,,,,,,,,,,,,,
GRAFT DERMAL PLIABLE THN 20X8 CMX0.7-1.4 MM PERF FLEXHD,SUP-2307573,CDM,Q4128,HCPCS,0636,RC,,,,both,,,635.19,412.87,,,,,,,,,,,,,
IMPLANT SZ 2 ULN HD ST PK,SUP-2379271,CDM,C1776,CPT,0278,RC,,,,both,,,4082.00,2653.30,,,,,,,,,,,,,
SHEATH INTRO MP SHT CRV 8 FRX77 CM GUID LD DBL WIRE PREFACE,SUP-2248486,CDM,C1892,HCPCS,0272,RC,,,,both,,,480.42,312.27,,,,,,,,,,,,,
ANCHOR SUTURE DIA 3.9 MM ACHILLES MIDSUBSTANCE SYS STRL DISP,SUP-2882225,CDM,C1713,HCPCS,0278,RC,,,,both,,,8635.00,5612.75,,,,,,,,,,,,,
VALVE AORT CARP EDW TISS ANNULUS 31 MM SEW RNG DIA 37 MM,SUP-2214052,CDM,C1889,HCPCS,0278,RC,,,,both,,,12638.50,8215.02,,,,,,,,,,,,,
GUIDEWIRE VASC L185CM DIA0.014IN NIT HYDRPHLC STR TIP,SUP-2148152,CDM,C1769,HCPCS,0272,RC,,,,both,,,398.18,258.82,,,,,,,,,,,,,
PLATE BNE L106MM BLDE W9.2XL35MM 90DEG 8 H BILAT S STL LOK,SUP-2185372,CDM,C1713,HCPCS,0278,RC,,,,both,,,3758.11,2442.77,,,,,,,,,,,,,
GENERATOR NEUROSTIMULATOR H54XL54MM 2 CHN DEV RECHRG BTTRY,SUP-2284467,CDM,C1820,HCPCS,0278,RC,,,,both,,,84466.00,54902.90,,,,,,,,,,,,,
GRAFT HUM TISS L23CM FLD DIA6MM FRZN DBL STRND ANT TIBIALIS,SUP-2113922,CDM,C1713,HCPCS,0278,RC,,,,both,,,5243.52,3408.29,,,,,,,,,,,,,
"HC Tolerance Test, Addit.",PX-3018295200,CDM,82952,CPT,0301,RC,,,,outpatient,,,72.00,46.80,,,,,,,,,,,,,
COMPONENT FEM KNEE CRUC RET LT UNISX PRI PRESSFIT POR SZ 1,SUP-2215666,CDM,C1776,CPT,0278,RC,,,,both,,,11137.58,7239.43,,,,,,,,,,,,,
PLATE SPNL L108MM ANT THORLUM TI LOK,SUP-2193103,CDM,C1713,HCPCS,0278,RC,,,,both,,,5699.10,3704.41,,,,,,,,,,,,,
CATHETER KT 1IN 2.5CM 100MLX1ML/HR ON-Q PAINBUSTER SOAK,SUP-2236783,CDM,C2626,HCPCS,0278,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
GRAFT BNE R HUM HD FRSH,SUP-2264641,CDM,C1713,HCPCS,0278,RC,,,,both,,,22117.09,14376.11,,,,,,,,,,,,,
PLATE BNE CRV L0MM R FLAT MAX PROC TI FOR 15MM MIC SCR,SUP-2262910,CDM,C1713,HCPCS,0278,RC,,,,both,,,907.90,590.13,,,,,,,,,,,,,
CATHETER URTRL DLTR 58FR DIA 8MM OD BLLN 24FR DIA INFLTD 75,SUP-2726293,CDM,C1758,HCPCS,0278,RC,,,,both,,,777.28,505.23,,,,,,,,,,,,,
SYRINGE GRFT DEL 7 CC ADV DISP,SUP-2731718,CDM,2720000010,LOCAL,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
COIL VASC TORNADO EMBOLUS L 8 CM DIA12 MM GUIDEWIRE 0.038 IN,SUP-2167755,CDM,C1889,HCPCS,0278,RC,,,,both,,,261.81,170.18,,,,,,,,,,,,,
COMPONENT FEM SZ 1 L POST STBL POR BAL SYS,SUP-2314627,CDM,C1776,CPT,0278,RC,,,,both,,,7636.48,4963.71,,,,,,,,,,,,,
CONNECTOR SPNL XLNK ASMBLY FIX TRNSVRS CONN ANTR STD TI,SUP-2415715,CDM,C1713,HCPCS,0278,RC,,,,both,,,1448.04,941.23,,,,,,,,,,,,,
KIT VENT ASST ACC SUPP L HEARTWARE,SUP-2282538,CDM,C1713,HCPCS,0278,RC,,,,both,,,16642.00,10817.30,,,,,,,,,,,,,
PATCH CV HEMSHLD PLAT FINESSE L 76 X W 8 MM THK 0.36 MM,SUP-2227665,CDM,C1768,CPT,0278,RC,,,,both,,,392.34,255.02,,,,,,,,,,,,,
STEM TIB PRSS FIT STR SALV REV POR TI ALLOY OD19.5MM L 89MM,SUP-2408829,CDM,C1776,CPT,0278,RC,,,,both,,,5393.42,3505.72,,,,,,,,,,,,,
BIT DRL DIA 4.3 MM LNG STP AO QC STRL DISP TRIGEN MAX,SUP-2933140,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1224.60,795.99,,,,,,,,,,,,,
GUIDEWIRE VASC L175CM DIA0035IN PTFE STR SHP TIP FLPY,SUP-2281743,CDM,C1769,HCPCS,0272,RC,,,,both,,,193.64,125.87,,,,,,,,,,,,,
WIRE FIX L4IN OD0045IN K FOR LESSER METATARSAL HD IMPL,SUP-2400126,CDM,C1713,HCPCS,0278,RC,,,,both,,,78.50,51.02,,,,,,,,,,,,,
RING EXT FIX ID165MM TI C FBR HYBRID 3/4 FOR DST TIB FRME,SUP-2188611,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1357.11,882.12,,,,,,,,,,,,,
COIL VASC HILAL MICROCOIL EMBOLUS L 1 CM CATH 0.018 IN,SUP-2638567,CDM,C1889,HCPCS,0278,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
GRAFT BNE SUB 10ML 25X50X8MM BA FOAM STRP PREFRM COMPR,SUP-2368187,CDM,C1713,HCPCS,0278,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
SLEEVE TROCAR L110MM DIAMETER 12MM THREADED DISPOSABLE WITH,SUP-2809465,CDM,2720000010,LOCAL,0272,RC,,,,both,,,662.76,430.79,,,,,,,,,,,,,
Z DISCONTINUED 2/27/25 MASS INACTIVE JR PORT PERITONEAL TI W/ 14.3FR,SUP-2845005,CDM,C1788,HCPCS,0278,RC,,,,both,,,621.72,404.12,,,,,,,,,,,,,
METOPROLOL TARTRATE 50 MG PO TABS,RX-5009,CDM,6370000000,HCPCS,0637,RC,51079-0801-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PLATE BONE DOUBLE Y MINI 2 MM MANDIBULAR LOCKING MALLEABLE T,SUP-2838415,CDM,C1713,HCPCS,0278,RC,,,,both,,,1228.68,798.64,,,,,,,,,,,,,
PROGRAMMER PT DBS ACTIVA,SUP-2665158,CDM,C1787,HCPCS,0278,RC,,,,both,,,5338.00,3469.70,,,,,,,,,,,,,
PIN BNE FIX L25MM OD2MM N LOK RESRB POLY L LACTIDE ACID,SUP-2166475,CDM,C1713,HCPCS,0278,RC,,,,both,,,466.38,303.15,,,,,,,,,,,,,
STENT URET SET SFT MFIL TETH 5FRX22CM UNIVERSA,SUP-2169458,CDM,C2617,HCPCS,0278,RC,,,,both,,,326.56,212.26,,,,,,,,,,,,,
HC Caregiver Training Strategies&Tq Ea Addl 15 Min,PX-4209755100,CDM,97551,CPT,0420,RC,,,,both,,,63.00,40.95,,,,,,,,,,,,,
SUPPORT ORTHOT KNEE CUST DBL UPR PREFABRICATED OFF THE SHLF,SUP-2435619,CDM,L1852,HCPCS,0272,RC,,,,both,,,2371.58,1541.53,,,,,,,,,,,,,
ANCHOR SUT DIA5MM TI SELF STARTING THRD DBL STRND MAG WIRE,SUP-2341374,CDM,C1714,HCPCS,0272,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
BUR SURG L3.8MM OD3MM LNG NEURO DMND MTCH HD DRL REUSE FOR,SUP-2367491,CDM,2720000010,LOCAL,0272,RC,,,,both,,,344.99,224.24,,,,,,,,,,,,,
CUP ACET MH NEUT 22X44 MM HIP MONOBLOCK NAT W/ SCREW HOLE,SUP-2202896,CDM,C1776,CPT,0278,RC,,,,both,,,9772.31,6352.00,,,,,,,,,,,,,
PLATE BNE M THK0.6MM 2X2 H L TI L SHP LO PROF LEV 1 FIX FOR,SUP-2262936,CDM,C1713,HCPCS,0278,RC,,,,both,,,528.65,343.62,,,,,,,,,,,,,
HC Ot Ther Ex per 15 Min|OP PT SERVICES|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS|UNUSUAL NON-OVERLAPPING SERVICE,PX-4309711000,CDM,97110,CPT,0430,RC,,,GP|CQ|XU,both,,,195.00,126.75,,,,,,,,,,,,,
INSERT TIB SZ 4 THK6MM ROT PLATFRM KNEE UHMWPE ANTIOXIDANT,SUP-2251846,CDM,C1776,CPT,0278,RC,,,,both,,,6732.16,4375.90,,,,,,,,,,,,,
GRAFT HUM TISS 6X4 CM REP AMNIO TISS MEMBRN,SUP-2422870,CDM,C1762,CPT,0278,RC,,,,both,,,8892.48,5780.11,,,,,,,,,,,,,
BENZOCAINE-MENTHOL 15-3.6 MG MT LOZG,RX-94141,CDM,6370000000,HCPCS,0637,RC,00904-6255-49,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
KIT INTRO PEELPRO L 14 CM DIA 5 FR PTFE TEARWY STD,SUP-2118929,CDM,C1892,HCPCS,0272,RC,,,,both,,,154.49,100.42,,,,,,,,,,,,,
SCREW BNE L40MM DIA6MM CORT TI ST CANN LOK FULL THRD HEX HD,SUP-2191862,CDM,C1713,HCPCS,0278,RC,,,,both,,,658.02,427.71,,,,,,,,,,,,,
SPLINT 31 TIB FIB PD PERF COAT ALUM FOAM LNR HIP AD,SUP-2210446,CDM,C1713,HCPCS,0278,RC,,,,both,,,734.76,477.59,,,,,,,,,,,,,
CONNECTOR SPNL TRNSVRS STD 15 MM CROSSLINK AX FOR 6MM ROD TI,SUP-2193734,CDM,C1713,HCPCS,0278,RC,,,,both,,,552.64,359.22,,,,,,,,,,,,,
KIT VENTRICULAR DRAINAGE COMB W/ NL850500V INS8420,SUP-2883558,CDM,C1729,HCPCS,0272,RC,,,,both,,,866.55,563.26,,,,,,,,,,,,,
HC Caregiver Training Strategies&Tq Ea Addl 15 Min,PX-4309755100,CDM,97551,CPT,0430,RC,,,,both,,,63.00,40.95,,,,,,,,,,,,,
SYSTEM SHUNT BURR HOLE STD 120-170 MM H2O HI PRESSURE BRN,SUP-2851279,CDM,C1729,HCPCS,0272,RC,,,,both,,,3591.88,2334.72,,,,,,,,,,,,,
HC Caregiver Training Strategies&Tq Ea Addl 15 Min,PX-4409755100,CDM,97551,CPT,0440,RC,,,,both,,,63.00,40.95,,,,,,,,,,,,,
PSEUDOEPHEDRINE-GUAIFENESIN ER 60-600 MG PO TB12,RX-27529,CDM,6370000000,HCPCS,0637,RC,00536-1333-36,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
SCREW SPNL L20MM DIA4MM S STL MONOAX REVERE,SUP-2230768,CDM,C1713,HCPCS,0278,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
SCREW BNE L60MM DIA4MM CORT CANC HIP S STL ST SELF DRL CANN,SUP-2370611,CDM,C1713,HCPCS,0278,RC,,,,both,,,455.17,295.86,,,,,,,,,,,,,
NIVOLUMAB 10 MG/ML IV (MIXTURES ONLY),RX-1150051,CDM,J9299,HCPCS,0636,RC,00003-3734-13,NDC,,both,24,ML,22876.10,14869.46,,,,,,,,,,,,,
NITINOL GUIDEWIRE 2MM DIAMETER X 38.5CM,SUP-2574103,CDM,C1769,HCPCS,0272,RC,,,,both,,,17.21,11.19,,,,,,,,,,,,,
PLATE BNE L 70 MM SCREW DIA2.4/2.7 MM 6 HD 4 SHFT H LT DSTL,SUP-2913554,CDM,C1713,HCPCS,0278,RC,,,,both,,,5913.19,3843.57,,,,,,,,,,,,,
PLATE BONE L213MM THK6MM 9 H RT FEM CNDYL TI BTTRS RIG CLLR,SUP-2190899,CDM,C1713,HCPCS,0278,RC,,,,both,,,3042.03,1977.32,,,,,,,,,,,,,
PLATE BONE 8 H TI Y SHP FOR 1.5MM SCR VLP MINI-MOD SM BONE,SUP-2351068,CDM,C1713,HCPCS,0278,RC,,,,both,,,4705.76,3058.74,,,,,,,,,,,,,
PLATE BONE CRANIOMAXILLOFACIAL 6 HOLE BOX CAR 17MM TITANIUM,SUP-2825715,CDM,C1713,HCPCS,0278,RC,,,,both,,,279.71,181.81,,,,,,,,,,,,,
PIN FIX DIAMOND PT 2 END 3/16X9 IN 4 PT STYL SMOOTH PLN STRL,SUP-2150490,CDM,C1713,HCPCS,0278,RC,,,,both,,,18.65,12.12,,,,,,,,,,,,,
PLATE BNE LCK 158 MM LT DSTL LAT FIBULAR 10 HOLE SS STRL,SUP-2457652,CDM,C1713,HCPCS,0278,RC,,,,both,,,2380.37,1547.24,,,,,,,,,,,,,
PLATE BNE L63MM 3 LOK 1 3 TBLR PLT 5 H,SUP-2371991,CDM,C1713,HCPCS,0278,RC,,,,both,,,32.97,21.43,,,,,,,,,,,,,
APPLIER CLP ENDOSAPHENOUS MED 5/7 MMX13 IN HORZ MTL LIG SYS,SUP-2656772,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5055.40,3286.01,,,,,,,,,,,,,
SHELL ACET RIM FLARED UNIV 41 MM PRIMARY PRSS FT SPIK TI,SUP-2210135,CDM,C1776,CPT,0278,RC,,,,both,,,5245.37,3409.49,,,,,,,,,,,,,
STENT GRFT VASC POWERLINK INTUITRAK L 155 MM 25/16 MM,SUP-2217567,CDM,C1768,CPT,0278,RC,,,,both,,,16485.00,10715.25,,,,,,,,,,,,,
HC Mra Pelvis With Contrast,PX-6100891800,CDM,C8918,CPT,0610,RC,,,,both,,,4365.00,2837.25,,,,,,,,,,,,,
COIL EMB L50CM DIA14MM 360DEG STD DETACH TARGET XL,SUP-2367730,CDM,C1889,HCPCS,0278,RC,,,,both,,,7294.69,4741.55,,,,,,,,,,,,,
CATHETER ETER EP 5FR L110CM 5MM SPC 4 ELECTRD A CRV AUTO ID,SUP-2248856,CDM,C1730,HCPCS,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
BIT DRL MINI FOR 3MM SH HALF PIN JET-X,SUP-2342888,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1522.90,989.88,,,,,,,,,,,,,
STENT URET STR 0.035 IN 4.8 FRX22-30 CM 6 FR BENSTON CNTOUR,SUP-2472708,CDM,C2617,HCPCS,0278,RC,,,,both,,,367.54,238.90,,,,,,,,,,,,,
SPACER SPNL LG ENDPLATE SCREW STRL XLR,SUP-2592034,CDM,C1889,HCPCS,0278,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
STAPLE BNE FIX 20X20X20MM NIT SUPERPLASTIC DYNAFORCE,SUP-2175190,CDM,C1713,HCPCS,0278,RC,,,,both,,,4317.50,2806.37,,,,,,,,,,,,,
HC US Extrem Complete Nonvasc,PX-4027688100,CDM,76881,CPT,0402,RC,,,,inpatient,,,405.00,263.25,,,,,,,,,,,,,
PLATE BNE W12XL196MM THK3.7MM LNG 8 H ST PROX HUM S STL LOK,SUP-2186020,CDM,C1713,HCPCS,0278,RC,,,,both,,,4867.60,3163.94,,,,,,,,,,,,,
IMPLANT SZ 2 LESSER METATARSAL HD SYS,SUP-2400122,CDM,C1776,CPT,0278,RC,,,,both,,,10930.34,7104.72,,,,,,,,,,,,,
SET URET STENT L 16 CM DIA 4.8 FR PTFE GUIDEWIRE 0.035 IN,SUP-2522184,CDM,C2617,HCPCS,0278,RC,,,,both,,,441.52,286.99,,,,,,,,,,,,,
ALLOGRAFT HUM TISS CRYOPRESERVED 4X2 CM UMB CRD CRYO-CORD,SUP-2740206,CDM,Q4237,HCPCS,0636,RC,,,,both,,,5284.62,3435.00,,,,,,,,,,,,,
ALLOGRAFT BNE PLUG 7 MM OSTEOCHNDRL,SUP-2866829,CDM,C1762,CPT,0278,RC,,,,both,,,9217.47,5991.36,,,,,,,,,,,,,
WIRE ORTH L229MM DIA1.6MM S STL DBL DMND BAYNT TIP SMOOTH K,SUP-2412970,CDM,C1713,HCPCS,0278,RC,,,,both,,,35.61,23.15,,,,,,,,,,,,,
CHOLECALCIFEROL 10 MCG/ML PO LIQD,RX-147756,CDM,340b,HCPCS,0637,RC,99992-0510-01,NDC,,both,1,ML,2.70,1.75,,,,,,,,,,,,,
DEVICE FIX OPN ABSRB STRP SECURESTRP,SUP-2219750,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1844.88,1199.17,,,,,,,,,,,,,
SHEARS ROBOTIC DIA8MM CRV FOR ULTRASONIC ENERGY HARM ACE,SUP-2246795,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1797.12,1168.13,,,,,,,,,,,,,
CATHETER HEMODLYS 14.5FR TOT L72CM INSRT L55CM CARBOTHANE,SUP-2283939,CDM,C1750,HCPCS,0278,RC,,,,both,,,1037.20,674.18,,,,,,,,,,,,,
ASPIRIN 81 MG PO CHEW,RX-680,CDM,6370000000,HCPCS,0637,RC,63739-0434-02,NDC,,both,1,UN,0.60,0.39,,,,,,,,,,,,,
HC Insert Bladder Catheter Non-Indwelling,PX-4505170100,CDM,51701,CPT,0450,RC,,,,outpatient,,,204.00,132.60,,,,,,,,,,,,,
PLATE BONE LOCKING 2.7/3.5 MM 8 HOLE RECONSTRUCTION PERILOC,SUP-2837488,CDM,C1713,HCPCS,0278,RC,,,,both,,,2786.91,1811.49,,,,,,,,,,,,,
TAP SURG L 70 MM DIA2.6 MM DELT,SUP-2883225,CDM,2720000010,LOCAL,0272,RC,,,,both,,,800.32,520.21,,,,,,,,,,,,,
IMMOBILIZER ORTH M TIETEX SHLDR,SUP-2195526,CDM,L3650,HCPCS,0274,RC,,,,both,,,11.43,7.43,,,,,,,,,,,,,
PLATE BNE 2.7X82 MM 9 HOLE SS LC-DCP,SUP-2569218,CDM,C1713,HCPCS,0278,RC,,,,both,,,316.04,205.43,,,,,,,,,,,,,
BAR EXT FIX 11X450 MM CARBON,SUP-2750000,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1705.02,1108.26,,,,,,,,,,,,,
CATHETER VENT SHUNT SLT STR STYL FLO H 1.2MM ID 2.5MM DIA,SUP-2108713,CDM,C1729,HCPCS,0272,RC,,,,both,,,722.99,469.94,,,,,,,,,,,,,
PACK VITRCTMY ANT DISP INFIN,SUP-2109881,CDM,2720000010,LOCAL,0272,RC,,,,both,,,585.61,380.65,,,,,,,,,,,,,
REAMER SURG FOR FEM NK COMPLETE OPENING SYS NS,SUP-2417586,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4624.91,3006.19,,,,,,,,,,,,,
GRAFT VASC L80CM DIA6MM PTFE CBAS HEP SURF THN WALLED REM,SUP-2395814,CDM,C1768,CPT,0278,RC,,,,both,,,8719.78,5667.86,,,,,,,,,,,,,
HC Removal Duct Glbldr Calculi,PX-3614754400,CDM,47544,CPT,0361,RC,,,,outpatient,,,8583.00,5578.95,,,,,,,,,,,,,
SHEATH INTRO DRYSEAL FLX L 33 CM DIA20 FR BODY DIA 7.5 MM,SUP-2395732,CDM,C1894,HCPCS,0272,RC,,,,both,,,2081.82,1353.18,,,,,,,,,,,,,
CAP END 0MM CANN LCK FOR CENTRONAIL ANK COMPR NAILING SYS,SUP-2316507,CDM,C1713,HCPCS,0278,RC,,,,both,,,674.60,438.49,,,,,,,,,,,,,
BLADE SURG STERNALOCK,SUP-2137256,CDM,2720000010,LOCAL,0272,RC,,,,both,,,480.42,312.27,,,,,,,,,,,,,
HC Chemo Infuse New Drug 1st Hour,PX-3359641700,CDM,96417,CPT,0335,RC,,,,both,,,377.00,245.05,,,,,,,,,,,,,
POST SURG ANK INTOSS FIX L14MM OD4.6MM 60DEG IOFIX,SUP-2223850,CDM,C1713,HCPCS,0278,RC,,,,both,,,3698.92,2404.30,,,,,,,,,,,,,
GRAFT SFT TISS 100 MG PARTICULATE IN VI TISS MTRX INTERFYL,SUP-2651385,CDM,Q4171,HCPCS,0636,RC,,,,both,,,4317.50,2806.37,,,,,,,,,,,,,
DARBEPOETIN ALFA 60 MCG/ML IJ SOLN,RX-131226,CDM,J0881,HCPCS,0636,RC,55513-0004-04,NDC,,both,1,ML,1370.00,890.50,,,,,,,,,,,,,
PROBE BRST BX TROCAR TIP 7 GA FOR MRI ENCOR,SUP-2128177,CDM,2720000010,LOCAL,0272,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
RING EXTERNAL FIXATION DIA160MM ALUMINUM HALF,SUP-2586493,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3903.87,2537.52,,,,,,,,,,,,,
KIT SPNL CRD STIM L70CM 16 LD PRECIS NEUROMODULATION,SUP-2138789,CDM,C1778,HCPCS,0278,RC,,,,both,,,9539.32,6200.56,,,,,,,,,,,,,
LOW PRFLE TTNM MESH PANEL REG GRID 100MM X 100MM 0.6MM 1.5 S,SUP-2488973,CDM,C1713,HCPCS,0278,RC,,,,both,,,9857.50,6407.37,,,,,,,,,,,,,
DVR VOLAR RIM NRW L ST,SUP-2587122,CDM,C1713,HCPCS,0278,RC,,,,both,,,2607.77,1695.05,,,,,,,,,,,,,
STENT PERIPH L60MM DIA7MM CATH L135CM IL LIFESTAR,SUP-2420437,CDM,C1876,HCPCS,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
HC CT Soft Tissue Neck W/WO Contrast,PX-3517049200,CDM,70492,CPT,0351,RC,,,,outpatient,,,2388.00,1552.20,,,,,,,,,,,,,
CATHETER 0.018 IN 130 CM 5X300 MM LUTONIX,SUP-2650212,CDM,C2623,HCPCS,0278,RC,,,,both,,,10362.00,6735.30,,,,,,,,,,,,,
BIT DRL L130MM OD3.5MM W/O STP NONRADIOLUCENT AO QUIK CPL,SUP-2361775,CDM,2720000010,LOCAL,0272,RC,,,,both,,,589.35,383.08,,,,,,,,,,,,,
BLOCK MEAS SCREW LEN LEN MEAS PLATE,SUP-2318989,CDM,C1713,HCPCS,0278,RC,,,,both,,,1573.14,1022.54,,,,,,,,,,,,,
MESH CRANIAL CONTOURABLE 1.5X15X25X0.5 MM RAPID RESORBABLE S,SUP-2838575,CDM,C1713,HCPCS,0278,RC,,,,both,,,1079.22,701.49,,,,,,,,,,,,,
CATHETER PTCA 5FR L130CM BLLN L150MM DIA4MM GWIRE 0.035IN,SUP-2128358,CDM,C2623,HCPCS,0278,RC,,,,both,,,6123.00,3979.95,,,,,,,,,,,,,
DRILL SURG LAG SCR INTERTAN TRIGEN,SUP-2347575,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3426.53,2227.24,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY SUPREME L 65 CM DIA 6 FR SPC,SUP-2356947,CDM,C1730,HCPCS,0272,RC,,,,both,,,2251.38,1463.40,,,,,,,,,,,,,
COMPONENT PAT OD28MM THICKNESS 10MM STD TI POLYETH POR PRI,SUP-2370402,CDM,C1776,CPT,0278,RC,,,,both,,,2420.94,1573.61,,,,,,,,,,,,,
STENT COR 8MM 2.5MM CROSSING 0.037IN BURST 16ATM S STL,SUP-2104182,CDM,C1876,HCPCS,0278,RC,,,,both,,,3231.06,2100.19,,,,,,,,,,,,,
BIT DRL L20MM OD3.2MM MULT QUIK CONN NONSTERILE REUSE,SUP-2364319,CDM,2720000010,LOCAL,0272,RC,,,,both,,,602.10,391.36,,,,,,,,,,,,,
GRAFT VASC FUSION BIOLINE L 40 CM DIA10 MM AX COMPLIANCE,SUP-2682140,CDM,C1768,CPT,0278,RC,,,,both,,,4498.02,2923.71,,,,,,,,,,,,,
DRILL SURG 9 MM IM HI PERF PATHWY,SUP-2453508,CDM,2720000010,LOCAL,0272,RC,,,,both,,,794.42,516.37,,,,,,,,,,,,,
SET CATH PERITONEAL DIALYSI V SER BASIC 15FR DIA MC20VS43LS,SUP-2633014,CDM,C1752,HCPCS,0278,RC,,,,both,,,737.90,479.63,,,,,,,,,,,,,
BUR SURG L 125 MM DIA2.35 MM HD DIA1.4 MM DIAMOND NS REUSE,SUP-2929333,CDM,2720000010,LOCAL,0272,RC,,,,both,,,410.18,266.62,,,,,,,,,,,,,
GRAFT ENDOVASC L10CM DIA27MM CONTRALATERAL LEG ENDOPROS USED,SUP-2395961,CDM,C1768,CPT,0278,RC,,,,both,,,13188.00,8572.20,,,,,,,,,,,,,
KIT INTCRAN PRSS MON PARENCHYMAL VENT TRNSDUC TIP CATH,SUP-2308096,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3865.34,2512.47,,,,,,,,,,,,,
GRAFT BNE 1 GM DBM FIBERSTACK,SUP-2861495,CDM,C1713,HCPCS,0278,RC,,,,both,,,2829.93,1839.45,,,,,,,,,,,,,
ENDCAP SPNL RND 4 DEG 22X22 MM TI X-CORE 2 7222204P2,SUP-2561379,CDM,C1889,HCPCS,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
OSTEOTOME SURG PWR LNG CRV ULT DRV 6MM,SUP-2408570,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2637.60,1714.44,,,,,,,,,,,,,
INSERT TIB SM SZ 1 2 THK10MM R KNEE POLYETH PRI NEUT,SUP-2350389,CDM,C1776,CPT,0278,RC,,,,both,,,5586.85,3631.45,,,,,,,,,,,,,
COMPONENT PAT STANDARD+ POLYETH NP CEM 3 PEG RND REV,SUP-2251248,CDM,C1776,CPT,0278,RC,,,,both,,,2122.64,1379.72,,,,,,,,,,,,,
BIT DRL DIA3.5MM QUIK CPL REUSE TARGETER,SUP-2343982,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1035.57,673.12,,,,,,,,,,,,,
BOLT IM L18MM DIA3.9MM NONSTERILE BLU CORT TI ST FULL THRD,SUP-2192169,CDM,C1713,HCPCS,0278,RC,,,,both,,,573.68,372.89,,,,,,,,,,,,,
TAP SURG DIA55MM QUIK CONN SCR,SUP-2179452,CDM,C1713,HCPCS,0278,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
PLATE BNE 5-10DEG 6 H R REV LOK COMPR MAL MTP TI FOR,SUP-2400370,CDM,C1713,HCPCS,0278,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
EXTRACTOR SURG END CAP EZ OUT FOR HINDFOOT TTC/TC NAIL SYS,SUP-2909078,CDM,2720000010,LOCAL,0272,RC,,,,both,,,769.30,500.04,,,,,,,,,,,,,
SCREW BNE SET STD 7.5 MM 32 MM CANN THRD,SUP-2861010,CDM,C1713,HCPCS,0278,RC,,,,both,,,25226.76,16397.39,,,,,,,,,,,,,
GRAFT BNE PASTE 2 CC SUBSTITUTE OPTEFORM,SUP-2223558,CDM,C1713,HCPCS,0278,RC,,,,both,,,1946.80,1265.42,,,,,,,,,,,,,
BIT DRILL RM 4 MM ACL CROSSPIN,SUP-2212874,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1290.54,838.85,,,,,,,,,,,,,
TWIST DRILL MRRSN/KLS MRTN2.0MMX105MM CYL LEV1 TRCR,SUP-2499281,CDM,2720000010,LOCAL,0272,RC,,,,both,,,476.93,310.00,,,,,,,,,,,,,
SPLINT FNGR M 3IN WIRE FOAM EXTN ASST BROAD CRV DORS CNTR PD,SUP-2194873,CDM,L3933,HCPCS,0274,RC,,,,both,,,60.26,39.17,,,,,,,,,,,,,
COMPRESSION SCREW SET,SUP-2841429,CDM,C1713,HCPCS,0278,RC,,,,both,,,38465.00,25002.25,,,,,,,,,,,,,
KIT INTRO MINI STK MAX L 10 CM DIA 5 FR 7 CM ECHOGENIC STIFF,SUP-2118824,CDM,C1769,HCPCS,0272,RC,,,,both,,,91.06,59.19,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL PEEK SD800.539,SUP-2860220,CDM,C1713,HCPCS,0278,RC,,,,both,,,42225.78,27446.76,,,,,,,,,,,,,
MESH HERN 30X20 CMX1.5 MM HYDRATED PORCINE CLLGN PERMACOL,SUP-2174703,CDM,C1781,HCPCS,0278,RC,,,,both,,,45397.40,29508.31,,,,,,,,,,,,,
CUP ACET OD43MM ID22MM MTL ON POLYETH NEUT PRI CEM W/ SPCR,SUP-2203593,CDM,C1776,CPT,0278,RC,,,,both,,,2255.78,1466.26,,,,,,,,,,,,,
PLATE BONE ORBITAL FLOOR SMALL 0.4 MM LEFT SUBCONDYLAR PRECO,SUP-2837769,CDM,C1713,HCPCS,0278,RC,,,,both,,,5939.00,3860.35,,,,,,,,,,,,,
PLATE EXT FIX LNG 140 MM FT RNG CARBON FIBER NS,SUP-2799529,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2138.53,1390.04,,,,,,,,,,,,,
ENDOPROSTHESIS BILI VIABIL L 8 CM DIA 8 MM L 200 CM W/O H,SUP-2883825,CDM,C1874,HCPCS,0278,RC,,,,both,,,9407.44,6114.84,,,,,,,,,,,,,
ROD SPNL 11X500 MM,SUP-2205344,CDM,C1713,HCPCS,0278,RC,,,,both,,,806.20,524.03,,,,,,,,,,,,,
DEVICE ENDOSKELETAL SYS PROSTHETIC BK MOLD DSTL CUSH,SUP-2388209,CDM,L5668,HCPCS,0274,RC,,,,both,,,267.03,173.57,,,,,,,,,,,,,
SCREW BNE L11MM DIA15MM PUR TI ALLY THRD AND ROUNDED HD LOK,SUP-2180999,CDM,C1713,HCPCS,0278,RC,,,,both,,,396.90,257.98,,,,,,,,,,,,,
CLAMP SURG CORRECTION ANQUIEIR,SUP-2197308,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1130.40,734.76,,,,,,,,,,,,,
KIT THROMCTMY STROKE FAST PK CATH AXS VECTA 74 L 132 CM,SUP-2884579,CDM,C1757,HCPCS,0272,RC,,,,both,,,9577.00,6225.05,,,,,,,,,,,,,
SHEATH ARTHSCP 2.8 MM DIA STPCOCK,SUP-2361366,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1019.87,662.92,,,,,,,,,,,,,
CATHETER URODYN BLLN 7.4 FRX30 CM W/ OVL PRT COUDE TIP,SUP-2835744,CDM,C1726,HCPCS,0272,RC,,,,both,,,149.97,97.48,,,,,,,,,,,,,
TRASTUZUMAB-DKST 150 MG IV SOLR,RX-148014,CDM,Q5114,HCPCS,0636,RC,67457-0991-15,NDC,,both,1,UN,2708.80,1760.72,,,,,,,,,,,,,
CATHETER ANGIO L 110 CM DIA 5 FR PIG FLSH STRL,SUP-2116792,CDM,C1887,HCPCS,0272,RC,,,,both,,,101.42,65.92,,,,,,,,,,,,,
KIT ACCSRY 1.5MM FOR INSTAFIX IMPL KT,SUP-2418145,CDM,2720000010,LOCAL,0272,RC,,,,both,,,778.72,506.17,,,,,,,,,,,,,
SEMI-TUBULAR PLATE 10X167MM,SUP-2820878,CDM,C1713,HCPCS,0278,RC,,,,both,,,913.74,593.93,,,,,,,,,,,,,
SCREW INTRF L25MM OD7MM CANN N ABSRB TI ADVNTG,SUP-2249493,CDM,C1713,HCPCS,0278,RC,,,,both,,,524.38,340.85,,,,,,,,,,,,,
STENT URET L 90 CM DIA 8 FR SIL BRAIDED DIV HYDRO-GLIDE,SUP-2126217,CDM,C2617,HCPCS,0278,RC,,,,both,,,544.48,353.91,,,,,,,,,,,,,
HOOK SUT PREASSEMBLED FOR RETRCT FISH,SUP-2194668,CDM,2720000010,LOCAL,0272,RC,,,,both,,,37.46,24.35,,,,,,,,,,,,,
MICROCATHETER DIAG NAVVUS L 335 CM WORKING L 150 CM DSTL,SUP-2150030,CDM,C1887,HCPCS,0272,RC,,,,both,,,2182.30,1418.49,,,,,,,,,,,,,
CONNECTOR NRV L15MM DIA3MM PORCINE EXTRACELLULAR MTRX,SUP-2124866,CDM,C1763,HCPCS,0278,RC,,,,both,,,6889.16,4477.95,,,,,,,,,,,,,
PIN FIX L60MM OD2MM LACTOSORB COPOLYMER ABSRB SGL USE,SUP-2212969,CDM,C1713,HCPCS,0278,RC,,,,both,,,709.64,461.27,,,,,,,,,,,,,
STEM HUM L120MM DIA9MM UNIV DST SHLDR TI PRI REV CEM FOR UP,SUP-2372852,CDM,C1776,CPT,0278,RC,,,,both,,,6264.30,4071.79,,,,,,,,,,,,,
SODIUM CHLORIDE BACTERIOSTATIC 0.9 % IJ SOLN,RX-14923,CDM,2500000003,HCPCS,0250,RC,00409-1966-01,NDC,,both,20,ML,54.10,35.16,,,,,,,,,,,,,
GENTAMICIN IN SALINE 2-0.9 MG/ML-% IV SOLN|DISCARDED DRUG NOT ADMINISTE,RX-15912,CDM,J1580,HCPCS,0636,RC,00338-0511-41,NDC,JW,both,50,ML,54.10,35.16,,,,,,,,,,,,,
PLATE BNE W17.5XL265MM THK5.2MM 14 H ST BILAT S STL BROAD,SUP-2185306,CDM,C1713,HCPCS,0278,RC,,,,both,,,2344.26,1523.77,,,,,,,,,,,,,
ANCHOR SUT DIA18MM DBL LD TWO STRND NO2 HI FI Y KNOT,SUP-2167264,CDM,C1713,HCPCS,0278,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
RING ANNULPLSTY CARP EDW CLASSIC DIA28MM OD 33.2MM TRICSP,SUP-2214184,CDM,C1889,HCPCS,0278,RC,,,,both,,,5024.00,3265.60,,,,,,,,,,,,,
RETRACTOR SURG BRST ABD LT CRDLSS MULTIPLE BLADE RADIALUX,SUP-2278408,CDM,2720000010,LOCAL,0272,RC,,,,both,,,753.60,489.84,,,,,,,,,,,,,
CEMENT FLX FEM/CEM TIB/PRLNGSURF/STD PAT/TAPER PLUG,SUP-2212157,CDM,C1776,CPT,0278,RC,,,,both,,,15219.52,9892.69,,,,,,,,,,,,,
CATHETER DIAG 6FR L125CM DST L9CM SIM CRV S STL BRAID SEL,SUP-2323618,CDM,C1887,HCPCS,0272,RC,,,,both,,,389.36,253.08,,,,,,,,,,,,,
CUP ACET DIA 67 MM SS TI SPRY HA HIP 2 MOBILITY CMTLS PF 3,SUP-2913847,CDM,C1776,CPT,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
KIT CRAN ACCS W/O DRUG,SUP-2243819,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1802.36,1171.53,,,,,,,,,,,,,
Colonoscopy Flx W/Endoscopic Mucosal Resection|UNUSUAL NON-OVERLAPPING SERVICE|COLORECTAL CANCER SCREEN,CASE-45390,LOCAL,45390,CPT,,,,,XU|PT,outpatient,,,15895.13,9537.08,,,,,,,,,,,,,
Colonoscopy Flx W/Endoscopic Mucosal Resection|UNUSUAL NON-OVERLAPPING SERVICE|COLORECTAL CANCER SCREEN,CASE-45390,LOCAL,45390,CPT,0360,RC,,,XU|PT,outpatient,,,15895.13,9537.08,,,,,,,,,,,,,
HC Inj Trigger Pt 1-2 Musc Grps|ADJ,CASE-20552,LOCAL,20552,CPT,0510,RC,,,ADJ,outpatient,,,1649.92,989.95,,,,,,,,,,,,,
Egd Transoral Biopsy Single/Multiple|UNUSUAL NON-OVERLAPPING SERVICE,CASE-43239,LOCAL,43239,CPT,0360,RC,,,XU,outpatient,,,15296.43,9177.86,,,,,,,,,,,,,
Arthrs Aided Ant Cruciate Ligm Rpr/Agmntj/Rcnstj|LEFT SIDE,CASE-29888,LOCAL,29888,CPT,0360,RC,,,LT,outpatient,,,58319.25,34991.55,,,,,,,,,,,,,
HC Joint Injection/Aspir Large WO US,CASE-20610,LOCAL,20610,CPT,0510,RC,,,,outpatient,,,2362.75,1417.65,,,,,,,,,,,,,
HC I&D Ischio Perirectal Abs,CASE-46040,LOCAL,46040,CPT,0450,RC,,,,outpatient,,,11281.07,6768.64,,,,,,,,,,,,,
Egd Transoral Biopsy Single/Multiple|UNUSUAL NON-OVERLAPPING SERVICE,CASE-43239,LOCAL,43239,CPT,,,,,XU,outpatient,,,15296.43,9177.86,,,,,,,,,,,,,
Arthrs Aided Ant Cruciate Ligm Rpr/Agmntj/Rcnstj|LEFT SIDE,CASE-29888,LOCAL,29888,CPT,,,,,LT,outpatient,,,58319.25,34991.55,,,,,,,,,,,,,
CATHETER ATHRCTMY CROSSER L 106 CM PERIPH S6 CTO,SUP-2126796,CDM,C1714,HCPCS,0272,RC,,,,both,,,9545.60,6204.64,,,,,,,,,,,,,
STAPLE BNE ORTHOPEDIC 10 MM STRENGTH,SUP-2392829,CDM,C1713,HCPCS,0278,RC,,,,both,,,67.76,44.04,,,,,,,,,,,,,
STEM HUM L200MM DIA7MM 135DEG CO CHROM MOLYBDENUM STD LNG,SUP-2204844,CDM,C1776,CPT,0278,RC,,,,both,,,10062.13,6540.38,,,,,,,,,,,,,
SCREW SPNL EXT TAB 12X50 MM SACROILIAC STRL SI-LOK SEL,SUP-2732365,CDM,C1713,HCPCS,0278,RC,,,,both,,,9184.50,5969.92,,,,,,,,,,,,,
BUR SURG DIA2.3 MM HUB II NEURO CUT STRL DISP HI-LINE XS,SUP-2929005,CDM,2720000010,LOCAL,0272,RC,,,,both,,,344.49,223.92,,,,,,,,,,,,,
CATHETER DRNGE L35CM DIA14FR THOR SUMP LOOP NONCOATED,SUP-2147734,CDM,C1729,HCPCS,0272,RC,,,,both,,,323.45,210.24,,,,,,,,,,,,,
BLADE SAW 78.7X40.5X0.64 MM RECIP STRL PRECIS LTX,SUP-2862493,CDM,2720000010,LOCAL,0272,RC,,,,both,,,351.71,228.61,,,,,,,,,,,,,
GRAFT VASC QUADFURCATED 20 MMX50 CM 10/10/8/8 MM HEMSHLD,SUP-2470100,CDM,C1768,CPT,0278,RC,,,,both,,,5383.78,3499.46,,,,,,,,,,,,,
SCREW BONE SELF TAPPING 2.7X10 MM TITANIUM MATRIXMANDIBLE,SUP-2837730,CDM,C1713,HCPCS,0278,RC,,,,both,,,395.64,257.17,,,,,,,,,,,,,
HC So Cellular Stim for Biomarker,PX-3028635266,CDM,86352,CPT,0302,RC,,,,inpatient,,,303.00,196.95,,,,,,,,,,,,,
CLIP HEMOSTASIS MANTIS 2.8MM X 235CM 10/BX,SUP-2855491,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1186.92,771.50,,,,,,,,,,,,,
GRAFT HUM TISS M W9.6XL19.3CM THCK THK2.4MM REGENERATIVE,SUP-2113441,CDM,Q4116,HCPCS,0636,RC,,,,both,,,31186.48,20271.21,,,,,,,,,,,,,
Neuroplasty &/Transposition Ulnar Nerve Elbow|LEFT SIDE,CASE-64718,LOCAL,64718,CPT,0360,RC,,,LT,outpatient,,,17664.27,10598.56,,,,,,,,,,,,,
Neuroplasty &/Transposition Ulnar Nerve Elbow|LEFT SIDE,CASE-64718,LOCAL,64718,CPT,,,,,LT,outpatient,,,17664.27,10598.56,,,,,,,,,,,,,
HC Rm Private OB,PX-1120000000,CDM,1120000000,LOCAL,,,,,,outpatient,,,2724.58,1634.75,,,,,,,,,,,,,
Nasal/Sinus Endoscopy W/Sphenoidotomy|BILATERAL PROCEDURE,CASE-31287,LOCAL,31287,CPT,0360,RC,,,50,outpatient,,,67513.15,40507.89,,,,,,,,,,,,,
Nasal/Sinus Endoscopy W/Sphenoidotomy|BILATERAL PROCEDURE,CASE-31287,LOCAL,31287,CPT,,,,,50,outpatient,,,67513.15,40507.89,,,,,,,,,,,,,
HC Hospice Room,PX-1150000000,CDM,1150000000,LOCAL,,,,,,outpatient,,,2644.42,1586.65,,,,,,,,,,,,,
HC US Spinal Canal and Contents,PX-4027680000,CDM,76800,CPT,0402,RC,,,,inpatient,,,693.00,450.45,,,,,,,,,,,,,
HC So Magnesium|NOT REASONABLE AND NECESSARY,PX-3018373566,CDM,83735,CPT,0301,RC,,,GZ,outpatient,,,58.00,37.70,,,,,,,,,,,,,
CAP PROTCT FOR 8MM C FBR ROD M EXT FIX,SUP-2188737,CDM,C1713,HCPCS,0278,RC,,,,both,,,20.69,13.45,,,,,,,,,,,,,
IBAL TKA FEM PS CEMENTED SZ 4 LEFT,SUP-2813386,CDM,C1776,CPT,0278,RC,,,,both,,,4396.00,2857.40,,,,,,,,,,,,,
STEM FEM L200MM L30MM OD12MM SZ 5 L HIP REV CEM BOW IMPL,SUP-2374698,CDM,C1776,CPT,0278,RC,,,,both,,,10620.11,6903.07,,,,,,,,,,,,,
NIVOLUMAB 240 MG/24ML IV SOLN,RX-140873,CDM,J9299,HCPCS,0636,RC,00003-3734-13,NDC,,both,24,ML,22876.10,14869.46,,,,,,,,,,,,,
HC Rep Cpx Sc Arm Lg 2.6-7.5cm,PX-4501312100,CDM,13121,CPT,0450,RC,,,,both,,,2071.00,1346.15,,,,,,,,,,,,,
TRAY GLEN SM SHLDR HA POR MOD BIOMOD,SUP-2404645,CDM,C1776,CPT,0278,RC,,,,both,,,3690.13,2398.58,,,,,,,,,,,,,
GRAFT BNE 0.75ML SUB VOID FILL RESRB PTTY MASTERGRFT,SUP-2288539,CDM,C9359,HCPCS,0278,RC,,,,both,,,231.01,150.16,,,,,,,,,,,,,
"Neuroplasty Other Arm/Leg Nerve,Open|LEFT SIDE",CASE-64708,LOCAL,64708,CPT,,,,,LT,outpatient,,,36018.77,21611.26,,,,,,,,,,,,,
"Neuroplasty Other Arm/Leg Nerve,Open|LEFT SIDE",CASE-64708,LOCAL,64708,CPT,0360,RC,,,LT,outpatient,,,36018.77,21611.26,,,,,,,,,,,,,
HC Rep Cpx Sc Arm Lg 2.6-7.5cm,CASE-13121,LOCAL,13121,CPT,0450,RC,,,,outpatient,,,20958.82,12575.29,,,,,,,,,,,,,
Surgical Arthroscopy Shoulder Removal Loose/FB,CASE-29819,LOCAL,29819,CPT,,,,,,outpatient,,,63631.85,38179.11,,,,,,,,,,,,,
Optx Dstl Radl I-Artic Fx/Epiphysl Sep 2 Frag|RIGHT SIDE,CASE-25608,LOCAL,25608,CPT,,,,,RT,outpatient,,,32206.15,19323.69,,,,,,,,,,,,,
Optx Dstl Radl I-Artic Fx/Epiphysl Sep 2 Frag|RIGHT SIDE,CASE-25608,LOCAL,25608,CPT,0360,RC,,,RT,outpatient,,,32206.15,19323.69,,,,,,,,,,,,,
HC Joint Injection/Aspir Medium WO US|PBB CHARGE|RIGHT SIDE,CASE-20605,LOCAL,20605,CPT,0510,RC,,,PBB|RT,outpatient,,,2289.08,1373.45,,,,,,,,,,,,,
Surgical Arthroscopy Shoulder Removal Loose/FB,CASE-29819,LOCAL,29819,CPT,0360,RC,,,,outpatient,,,63631.85,38179.11,,,,,,,,,,,,,
PIN XTRAFIX LG BLUNT 5 X 160 X 55MM,SUP-2721588,CDM,C1713,HCPCS,0278,RC,,,,both,,,445.03,289.27,,,,,,,,,,,,,
ALLOGRAFT HUM TISS SEMITENDINOSUS TEND 4X230 MM FRZN,SUP-2264598,CDM,C1713,HCPCS,0278,RC,,,,both,,,4304.00,2797.60,,,,,,,,,,,,,
SUBSTITUTE BONE GRFT 40X20X5MM DEMIN CANC FIL MTRX CNFRM FLX,SUP-2307021,CDM,C1713,HCPCS,0278,RC,,,,both,,,4750.51,3087.83,,,,,,,,,,,,,
CATHETER THOR 32FR L20IN PVC R ANG RADPQ SENTNL LN SENTNL,SUP-2154973,CDM,C1729,HCPCS,0272,RC,,,,both,,,64.62,42.00,,,,,,,,,,,,,
ALLODERM SELECT 12X12 MEDIUM 1.2-2.0,SUP-2827043,CDM,Q4116,HCPCS,0636,RC,,,,both,,,16833.54,10941.80,,,,,,,,,,,,,
GRAFT BNE PTTY FLX DBM GRFT,SUP-2280138,CDM,C9359,HCPCS,0278,RC,,,,both,,,540.08,351.05,,,,,,,,,,,,,
SCREW BNE L11MM OD2MM T6 LOK ST TI VLP,SUP-2350979,CDM,C1713,HCPCS,0278,RC,,,,both,,,609.16,395.95,,,,,,,,,,,,,
RING EXT FIX RADLUC 1/3 D 190 MM CE MARKED,SUP-2875118,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1016.89,660.98,,,,,,,,,,,,,
STAPLE BNE FIX W20XL20MM LEG L20MM SPD TI DRL BIT KT WIRE,SUP-2194273,CDM,C1713,HCPCS,0278,RC,,,,both,,,3983.75,2589.44,,,,,,,,,,,,,
HC Lower Xtr Fascial Plane Block Uni Injection,PX-3606447300,CDM,64473,CPT,0360,RC,,,,inpatient,,,1238.00,804.70,,,,,,,,,,,,,
KIT EXT FIX WRST MULTIPIN CLMP 200X15MM C CONN ROD,SUP-2372629,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4082.00,2653.30,,,,,,,,,,,,,
SCREW BONE 1.8X4MM STERILE RESCUE SELF TAPPING TITANIUM NEUR,SUP-2826030,CDM,C1713,HCPCS,0278,RC,,,,both,,,73.79,47.96,,,,,,,,,,,,,
Insj Multi-Component Inflatable Penile Prosth,CASE-54405,LOCAL,54405,CPT,,,,,,outpatient,,,84069.13,50441.48,,,,,,,,,,,,,
Insj Multi-Component Inflatable Penile Prosth,CASE-54405,LOCAL,54405,CPT,0360,RC,,,,outpatient,,,84069.13,50441.48,,,,,,,,,,,,,
"Rpr Coltrl Ligm Mtcarphlngl/Iphal Jt|LEFT HAND, SECOND DIGIT",CASE-26540,LOCAL,26540,CPT,0360,RC,,,F1,outpatient,,,19800.32,11880.19,,,,,,,,,,,,,
Exc B9 Lesion Mrgn Xcp Sk Tg S/N/H/F/G 1.1-2.0cm,CASE-11422,LOCAL,11422,CPT,,,,,,outpatient,,,13730.27,8238.16,,,,,,,,,,,,,
Adjnt Tis Trnsfr/Reargmt Any Area 30.1-60 Sq Cm,CASE-14301,LOCAL,14301,CPT,,,,,,outpatient,,,39447.80,23668.68,,,,,,,,,,,,,
Arthrs Knee Abrasion Arthrp/Mlt Drlg/Microfx|RIGHT SIDE,CASE-29879,LOCAL,29879,CPT,,,,,RT,outpatient,,,37142.73,22285.64,,,,,,,,,,,,,
Peri-Implant Capsulectomy Breast Complete|BILATERAL PROCEDURE,CASE-19371,LOCAL,19371,CPT,0360,RC,,,50,outpatient,,,62764.78,37658.87,,,,,,,,,,,,,
Destruction Neurolytic Agt Genicular Nerve W/Img|BILATERAL PROCEDURE,CASE-64624,LOCAL,64624,CPT,0360,RC,,,50,outpatient,,,4728.32,2836.99,,,,,,,,,,,,,
Laps Rpr Paraesphgl Hrna Incl Fundplsty W/Mesh,CASE-43282,LOCAL,43282,CPT,0360,RC,,,,outpatient,,,119564.02,71738.41,,,,,,,,,,,,,
Laps Rpr Paraesphgl Hrna Incl Fundplsty W/Mesh,CASE-43282,LOCAL,43282,CPT,,,,,,outpatient,,,119564.02,71738.41,,,,,,,,,,,,,
Peri-Implant Capsulectomy Breast Complete|BILATERAL PROCEDURE,CASE-19371,LOCAL,19371,CPT,,,,,50,outpatient,,,62764.78,37658.87,,,,,,,,,,,,,
Adjnt Tis Trnsfr/Reargmt Any Area 30.1-60 Sq Cm,CASE-14301,LOCAL,14301,CPT,0360,RC,,,,outpatient,,,39447.80,23668.68,,,,,,,,,,,,,
Destruction Neurolytic Agt Genicular Nerve W/Img|BILATERAL PROCEDURE,CASE-64624,LOCAL,64624,CPT,,,,,50,outpatient,,,4728.32,2836.99,,,,,,,,,,,,,
"Neuroplasty Other Arm/Leg Nerve,Open|RIGHT SIDE",CASE-64708,LOCAL,64708,CPT,,,,,RT,outpatient,,,35513.72,21308.23,,,,,,,,,,,,,
"Neuroplasty Other Arm/Leg Nerve,Open|RIGHT SIDE",CASE-64708,LOCAL,64708,CPT,0360,RC,,,RT,outpatient,,,35513.72,21308.23,,,,,,,,,,,,,
Exc B9 Lesion Mrgn Xcp Sk Tg S/N/H/F/G 1.1-2.0cm,CASE-11422,LOCAL,11422,CPT,0360,RC,,,,outpatient,,,13730.27,8238.16,,,,,,,,,,,,,
Arthrs Knee Abrasion Arthrp/Mlt Drlg/Microfx|RIGHT SIDE,CASE-29879,LOCAL,29879,CPT,0360,RC,,,RT,outpatient,,,37142.73,22285.64,,,,,,,,,,,,,
"Rpr Coltrl Ligm Mtcarphlngl/Iphal Jt|LEFT HAND, SECOND DIGIT",CASE-26540,LOCAL,26540,CPT,,,,,F1,outpatient,,,19800.32,11880.19,,,,,,,,,,,,,
DENOSUMAB 60 MG/ML SC SOSY,RX-145140,CDM,J0897,HCPCS,0636,RC,55513-0710-01,NDC,,both,1,ML,5532.60,3596.19,,,,,,,,,,,,,
GRAFT HUM TISS 5X5 CM GRAFIX COR,SUP-2319178,CDM,Q4132,HCPCS,0636,RC,,,,both,,,3312.70,2153.25,,,,,,,,,,,,,
BRACE THMB LT FUNC POS ABDUCTED THMB W/ STAY STRP ON AD 8IN,SUP-2324312,CDM,L3931,HCPCS,0272,RC,,,,both,,,69.52,45.19,,,,,,,,,,,,,
SLEEVE POS DIA11MM UNIV SHLDR CO CHROM CEM PRI FOR HUM FRAC,SUP-2404533,CDM,C1776,CPT,0278,RC,,,,both,,,659.24,428.51,,,,,,,,,,,,,
GRAFT SYNTHECEL DURA MATER 3X3 IN (7.5 CM X 7.5 CM),SUP-2719497,CDM,C1763,HCPCS,0278,RC,,,,both,,,2931.98,1905.79,,,,,,,,,,,,,
PLATE BONE NARROW MINI 3X3 HOLE TENSION MALLEABLE TITANIUM N,SUP-2837745,CDM,C1713,HCPCS,0278,RC,,,,both,,,1496.84,972.95,,,,,,,,,,,,,
PLATE BNE L52MM 7 H T SHP MINUS NCB,SUP-2411489,CDM,C1713,HCPCS,0278,RC,,,,both,,,1297.82,843.58,,,,,,,,,,,,,
GUIDEWIRE VASC ARW L 60 CM DIA 0.032 IN SS PERIPH SFT,SUP-2383361,CDM,C1769,HCPCS,0272,RC,,,,both,,,33.41,21.72,,,,,,,,,,,,,
PRESSURE MONITORING KIT INTCRAN PARENCHYMA HEX WRNCH CAMINO,SUP-2851494,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2752.02,1788.81,,,,,,,,,,,,,
HC NM Liver Scan/Spleen Scan,PX-3417821500,CDM,78215,CPT,0341,RC,,,,both,,,2195.00,1426.75,,,,,,,,,,,,,
TROCAR ENDOSCP L 70 MM DIA12 MM LAPSCP SHRT BLDELSS DOLPHIN,SUP-2896205,CDM,2720000010,LOCAL,0272,RC,,,,both,,,428.64,278.62,,,,,,,,,,,,,
SIGMA HP UNI FEM FIN BLK SZ 1,SUP-2513377,CDM,C1776,CPT,0278,RC,,,,both,,,5353.70,3479.90,,,,,,,,,,,,,
BASEPLATE NEXGEN ROTATING HINGE STEM TIBIAL PLATE SIZE 6,SUP-2502529,CDM,C1776,CPT,0278,RC,,,,both,,,10781.19,7007.77,,,,,,,,,,,,,
Unlisted Procedure Spine,CASE-22899,LOCAL,22899,CPT,,,,,,outpatient,,,61724.02,37034.41,,,,,,,,,,,,,
Colonoscopy W/Biopsy Single/Multiple|COLORECTAL CANCER SCREEN,CASE-45380,LOCAL,45380,CPT,0360,RC,,,PT,outpatient,,,11160.93,6696.56,,,,,,,,,,,,,
"Tendon Sheath Incision|LEFT HAND, THIRD DIGIT",CASE-26055,LOCAL,26055,CPT,0360,RC,,,F2,outpatient,,,10448.42,6269.05,,,,,,,,,,,,,
"Tendon Sheath Incision|LEFT HAND, THIRD DIGIT",CASE-26055,LOCAL,26055,CPT,,,,,F2,outpatient,,,10448.42,6269.05,,,,,,,,,,,,,
"Open Tx Phalangeal Shaft Fracture Prox/Middle Ea|LEFT HAND, FIFTH DIGIT",CASE-26735,LOCAL,26735,CPT,,,,,F4,outpatient,,,25428.48,15257.09,,,,,,,,,,,,,
Unlisted Procedure Spine,CASE-22899,LOCAL,22899,CPT,0360,RC,,,,outpatient,,,61724.02,37034.41,,,,,,,,,,,,,
"Open Tx Phalangeal Shaft Fracture Prox/Middle Ea|LEFT HAND, FIFTH DIGIT",CASE-26735,LOCAL,26735,CPT,0360,RC,,,F4,outpatient,,,25428.48,15257.09,,,,,,,,,,,,,
Laparoscopy W/Rmvl Adnexal Structures|BILATERAL PROCEDURE,CASE-58661,LOCAL,58661,CPT,0360,RC,,,50,outpatient,,,72043.93,43226.36,,,,,,,,,,,,,
Laparoscopy W/Rmvl Adnexal Structures|BILATERAL PROCEDURE,CASE-58661,LOCAL,58661,CPT,,,,,50,outpatient,,,72043.93,43226.36,,,,,,,,,,,,,
Colonoscopy W/Biopsy Single/Multiple|COLORECTAL CANCER SCREEN,CASE-45380,LOCAL,45380,CPT,,,,,PT,outpatient,,,11160.93,6696.56,,,,,,,,,,,,,
PASSER SUT FOR HIP ARTHRO CRESC XL ACCU-PASS DIR,SUP-2342824,CDM,2720000010,LOCAL,0272,RC,,,,both,,,910.60,591.89,,,,,,,,,,,,,
BIT DRL L80MM DIA1MM JCBS,SUP-2389483,CDM,2720000010,LOCAL,0272,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
NOZZLE SPRY FOR 2 RNG HNDPC L22 STRL DISP ELAN 4,SUP-2929259,CDM,2720000010,LOCAL,0272,RC,,,,both,,,367.10,238.61,,,,,,,,,,,,,
PRE 20MM 035 GW STR BX10,SUP-2679398,CDM,C1769,HCPCS,0272,RC,,,,both,,,13509.41,8781.12,,,,,,,,,,,,,
DEFIBRILLATOR IMPL LUMAX 540 VR-T 55 X 66MM 13MM 40J VVED,SUP-2138191,CDM,C1722,HCPCS,0275,RC,,,,both,,,50240.00,32656.00,,,,,,,,,,,,,
BIT DRL L100MM DIA2.7MM PROX TIB TI CALIB NONRADIOLUCENT,SUP-2412633,CDM,2720000010,LOCAL,0272,RC,,,,both,,,437.72,284.52,,,,,,,,,,,,,
COMPONENT HIP CMNTLS,SUP-2351396,CDM,C1776,CPT,0278,RC,,,,both,,,8792.00,5714.80,,,,,,,,,,,,,
STEM FEM XSM L115MM STD CO CHROMIUM KNEE EXTN CEM BILAT,SUP-2376291,CDM,C1776,CPT,0278,RC,,,,both,,,2428.48,1578.51,,,,,,,,,,,,,
GRAFT VASC IMPRA L 20 CM DIA 6 MM EPTFE FLX STD WALL RING,SUP-2761431,CDM,C1768,CPT,0278,RC,,,,both,,,1259.67,818.79,,,,,,,,,,,,,
PIN EXT FIX L80MM DIA25MM THRD L20MM HALF SELF DRL,SUP-2199721,CDM,C1713,HCPCS,0278,RC,,,,both,,,486.45,316.19,,,,,,,,,,,,,
KIT BNE PLATE SCREW DIA2.8 MM TI MANDIBULAR SECONDARY RECON FULL,SUP-2884161,CDM,C1713,HCPCS,0278,RC,,,,both,,,34681.30,22542.84,,,,,,,,,,,,,
DULOXETINE HCL 30 MG PO CPEP,RX-39276,CDM,6370000000,HCPCS,0637,RC,68180-0295-06,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
COMPONENT TIBIAL 9MM CORE STERILE LATEX SLIDING STAR,SUP-2879172,CDM,C1776,CPT,0278,RC,,,,both,,,6421.61,4174.05,,,,,,,,,,,,,
Insj/Rplcmt Breast Implant Sep Day Mastectomy|BILATERAL PROCEDURE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-19342,LOCAL,19342,CPT,0360,RC,,,50|XU,outpatient,,,120170.93,72102.56,,,,,,,,,,,,,
Laps Gstrc Rstrictiv Px Longitudinal Gastrectomy,CASE-43775,LOCAL,43775,CPT,,,,,,outpatient,,,86059.18,51635.51,,,,,,,,,,,,,
Open Tx Carpal Scaphoid Navicular Fracture|RIGHT SIDE,CASE-25628,LOCAL,25628,CPT,,,,,RT,outpatient,,,28554.78,17132.87,,,,,,,,,,,,,
Hrhc Ntrnl & Xtrnl 2/> Column/Group W/Fissu,CASE-46261,LOCAL,46261,CPT,0360,RC,,,,outpatient,,,17311.23,10386.74,,,,,,,,,,,,,
Insj/Rplcmt Breast Implant Sep Day Mastectomy|BILATERAL PROCEDURE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-19342,LOCAL,19342,CPT,,,,,50|XU,outpatient,,,120170.93,72102.56,,,,,,,,,,,,,
Xpedicul Decompress Throacic Cord,CASE-63055,LOCAL,63055,CPT,0360,RC,,,,outpatient,,,52822.57,31693.54,,,,,,,,,,,,,
Hrhc Ntrnl & Xtrnl 2/> Column/Group W/Fissu,CASE-46261,LOCAL,46261,CPT,,,,,,outpatient,,,17311.23,10386.74,,,,,,,,,,,,,
Thyroidectomy Total/Complete,CASE-60240,LOCAL,60240,CPT,0360,RC,,,,outpatient,,,50099.45,30059.67,,,,,,,,,,,,,
Thyroidectomy Total/Complete,CASE-60240,LOCAL,60240,CPT,,,,,,outpatient,,,50099.45,30059.67,,,,,,,,,,,,,
Arthrp Intercarpal/Carp/Mtcrpl Jt Suspension,CASE-25448,LOCAL,25448,CPT,,,,,,outpatient,,,28672.77,17203.66,,,,,,,,,,,,,
Open Tx Carpal Scaphoid Navicular Fracture|RIGHT SIDE,CASE-25628,LOCAL,25628,CPT,0360,RC,,,RT,outpatient,,,28554.78,17132.87,,,,,,,,,,,,,
Arthrp Intercarpal/Carp/Mtcrpl Jt Suspension,CASE-25448,LOCAL,25448,CPT,0360,RC,,,,outpatient,,,28672.77,17203.66,,,,,,,,,,,,,
Xpedicul Decompress Throacic Cord,CASE-63055,LOCAL,63055,CPT,,,,,,outpatient,,,52822.57,31693.54,,,,,,,,,,,,,
Laps Gstrc Rstrictiv Px Longitudinal Gastrectomy,CASE-43775,LOCAL,43775,CPT,0360,RC,,,,outpatient,,,86059.18,51635.51,,,,,,,,,,,,,
Cystourethroscopy Inj Chemodenervation Bladder,CASE-52287,LOCAL,52287,CPT,0360,RC,,,,outpatient,,,15313.88,9188.33,,,,,,,,,,,,,
Cystourethroscopy Inj Chemodenervation Bladder,CASE-52287,LOCAL,52287,CPT,,,,,,outpatient,,,15313.88,9188.33,,,,,,,,,,,,,
FIB NAIL LFT 2AP 1OBLQ 2.5MMX145MM,SUP-2829229,CDM,C1713,HCPCS,0278,RC,,,,both,,,8374.38,5443.35,,,,,,,,,,,,,
DEXTROSE 5 % IV SOLN INTERMITTENT INFUSION,RX-40840103,CDM,J7060,HCPCS,0258,RC,00264-7510-10,NDC,,both,250,ML,17.00,11.05,,,,,,,,,,,,,
HC Chemo Push Each Addt Drug,PX-3319641100,CDM,96411,CPT,0331,RC,,,,inpatient,,,432.00,280.80,,,,,,,,,,,,,
BLADE REPROC SHV 4.5MM INCIS + ELITE SLATE,SUP-2652931,CDM,2720000010,LOCAL,0272,RC,,,,both,,,54.82,35.63,,,,,,,,,,,,,
STENT COR 12MM 3MM DEL SYS 145CM 0.014IN CO CHROM,SUP-2105452,CDM,C1874,HCPCS,0278,RC,,,,both,,,1962.50,1275.62,,,,,,,,,,,,,
GRAFT BNE SUB 3ML HA FAST SET PTTY FILL BNE VOID CA PHSPTE,SUP-2194285,CDM,C9359,HCPCS,0278,RC,,,,both,,,2837.30,1844.24,,,,,,,,,,,,,
CATHETER DRNGE 16FR L40CM GWIRE 0.038IN 6 SIDEPRT STD,SUP-2168760,CDM,C1729,HCPCS,0272,RC,,,,both,,,263.16,171.05,,,,,,,,,,,,,
INSERT TIB SZ 4 THK14MM LT KNEE CRUC SUB UHMWPE PRI FIX,SUP-2304575,CDM,C1776,CPT,0278,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
CENTRALIZER VERSYS ADVOCATE PROXIMAL 14MM STD,SUP-2504399,CDM,C1776,CPT,0278,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
SCREW BNE L16MM DIA2.4MM CORT S STL ST NONCANNULATED,SUP-2183247,CDM,C1713,HCPCS,0278,RC,,,,both,,,131.69,85.60,,,,,,,,,,,,,
PLATE BONE L60MM 1 H LT LCK CONQ FN,SUP-2341200,CDM,C1713,HCPCS,0278,RC,,,,both,,,5416.50,3520.72,,,,,,,,,,,,,
SCREW SCHANZ BLNT PT 5X250MM HA COAT STRL,SUP-2547734,CDM,C1713,HCPCS,0278,RC,,,,both,,,572.77,372.30,,,,,,,,,,,,,
GUIDEWIRE ORTH 1.5X400 MM KNEE NIT NS DISP,SUP-2762003,CDM,C1769,HCPCS,0272,RC,,,,both,,,128.74,83.68,,,,,,,,,,,,,
GRAFT BONE ILIUM HEMI TRAD FRZN,SUP-2294150,CDM,C1713,HCPCS,0278,RC,,,,both,,,3968.96,2579.82,,,,,,,,,,,,,
DEXTROSE 5 % IV SOLN INTERMITTENT INFUSION,RX-40840103,CDM,J7060,HCPCS,0250,RC,00264-7510-20,NDC,,both,250,ML,31.90,20.73,,,,,,,,,,,,,
CATHETER ABLATN 4 MM SPC LNG REACH CELSIUS D7BTG5L,SUP-2468224,CDM,C1732,HCPCS,0278,RC,,,,both,,,3042.66,1977.73,,,,,,,,,,,,,
HC NM Thyroid Imaging,PX-3417801300,CDM,78013,CPT,0341,RC,,,,both,,,1847.00,1200.55,,,,,,,,,,,,,
Ercp W/Biopsy Single/Multiple,CASE-43261,LOCAL,43261,CPT,0360,RC,,,,outpatient,,,42358.45,25415.07,,,,,,,,,,,,,
Excision Choledochal Cyst,CASE-47715,LOCAL,47715,CPT,0360,RC,,,,outpatient,,,81297.67,48778.60,,,,,,,,,,,,,
Cysto W/Insert Ureteral Stent|BILATERAL PROCEDURE,CASE-52332,LOCAL,52332,CPT,,,,,50,outpatient,,,44129.50,26477.70,,,,,,,,,,,,,
Mastectomy Partial|RIGHT SIDE,CASE-19301,LOCAL,19301,CPT,0360,RC,,,RT,outpatient,,,35180.97,21108.58,,,,,,,,,,,,,
Cystourethroscopy|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-52000,LOCAL,52000,CPT,0360,RC,,,74,outpatient,,,13583.48,8150.09,,,,,,,,,,,,,
Ercp W/Biopsy Single/Multiple,CASE-43261,LOCAL,43261,CPT,,,,,,outpatient,,,42358.45,25415.07,,,,,,,,,,,,,
Mastectomy Partial|RIGHT SIDE,CASE-19301,LOCAL,19301,CPT,,,,,RT,outpatient,,,35180.97,21108.58,,,,,,,,,,,,,
Cystourethroscopy|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-52000,LOCAL,52000,CPT,,,,,74,outpatient,,,13583.48,8150.09,,,,,,,,,,,,,
Cysto W/Insert Ureteral Stent|BILATERAL PROCEDURE,CASE-52332,LOCAL,52332,CPT,0360,RC,,,50,outpatient,,,44129.50,26477.70,,,,,,,,,,,,,
Excision Choledochal Cyst,CASE-47715,LOCAL,47715,CPT,,,,,,outpatient,,,81297.67,48778.60,,,,,,,,,,,,,
DEFIBRILLATOR IMPL CONTAK RENEWAL III W 5.94 X H 7.77 CM D,SUP-2149223,CDM,C1722,HCPCS,0275,RC,,,,both,,,73790.00,47963.50,,,,,,,,,,,,,
TUBE GAST JEJU 14FR L22CM STOMA L1.7CM LO PROF BTTN FEED,SUP-2119818,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
BUR REPROC BARREL 6-FLT BEIGE,SUP-2526058,CDM,2720000010,LOCAL,0272,RC,,,,both,,,69.83,45.39,,,,,,,,,,,,,
SHEATH LD INTRO WORLEY ADV L 45 CM DIA 9 FR PEBAX LAT VEIN,SUP-2481363,CDM,C1892,HCPCS,0272,RC,,,,both,,,979.68,636.79,,,,,,,,,,,,,
MEDIHONEY WOUND/BURN DRESSING EX GEL,RX-103841,CDM,6370000000,HCPCS,0637,RC,66977-0106-06,NDC,,both,170,GR,99.50,64.67,,,,,,,,,,,,,
SCREW BNE L50MM OD4MM CANN LO PROF IMPL CAPTURE,SUP-2243895,CDM,C1713,HCPCS,0278,RC,,,,both,,,1004.52,652.94,,,,,,,,,,,,,
SCREW BNE WR 4.5X35 MM FRDM,SUP-2610391,CDM,C1713,HCPCS,0278,RC,,,,both,,,859.92,558.95,,,,,,,,,,,,,
BIT DRL CANN 2.1 MM,SUP-2362781,CDM,2720000010,LOCAL,0272,RC,,,,both,,,923.16,600.05,,,,,,,,,,,,,
Bx/Exc Lymph Node Open Deep Axillary Node|LEFT SIDE,CASE-38525,LOCAL,38525,CPT,,,,,LT,outpatient,,,46485.65,27891.39,,,,,,,,,,,,,
Sigmoidoscopy Flx Ndsc US Xm,CASE-45341,LOCAL,45341,CPT,,,,,,outpatient,,,10865.23,6519.14,,,,,,,,,,,,,
Repair Intermediate S/a/T/E >30.0 Cm|SEPARATE STRUCTURE,CASE-12037,LOCAL,12037,CPT,,,,,XS,outpatient,,,31881.63,19128.98,,,,,,,,,,,,,
Bx/Exc Lymph Node Open Deep Axillary Node|LEFT SIDE,CASE-38525,LOCAL,38525,CPT,0360,RC,,,LT,outpatient,,,46485.65,27891.39,,,,,,,,,,,,,
Injection Aa&/Strd Ilioinguinal Ih Nerves|RIGHT SIDE,CASE-64425,LOCAL,64425,CPT,0360,RC,,,RT,outpatient,,,3952.75,2371.65,,,,,,,,,,,,,
Injection Aa&/Strd Ilioinguinal Ih Nerves|RIGHT SIDE,CASE-64425,LOCAL,64425,CPT,,,,,RT,outpatient,,,3952.75,2371.65,,,,,,,,,,,,,
HC Incis/Drain Scrotum/Testis Epididym,CASE-54700,LOCAL,54700,CPT,0450,RC,,,,outpatient,,,19504.13,11702.48,,,,,,,,,,,,,
Repair Intermediate S/a/T/E >30.0 Cm|SEPARATE STRUCTURE,CASE-12037,LOCAL,12037,CPT,0360,RC,,,XS,outpatient,,,31881.63,19128.98,,,,,,,,,,,,,
HC Inj Tendon Sheath/Ligament|RIGHT SIDE,CASE-20550,LOCAL,20550,CPT,0510,RC,,,RT,outpatient,,,3533.83,2120.30,,,,,,,,,,,,,
Sigmoidoscopy Flx Ndsc US Xm,CASE-45341,LOCAL,45341,CPT,0360,RC,,,,outpatient,,,10865.23,6519.14,,,,,,,,,,,,,
CLIP ANEURYSM L2MM 1.5MM OPENING PHYNOX CURVED AVM KOPITNIK,SUP-2821652,CDM,C1889,HCPCS,0278,RC,,,,both,,,745.62,484.65,,,,,,,,,,,,,
PLATE BNE L 28 MM SCREW DIA2 MM 4 H BROAD LCK MINI FRAG SYS,SUP-2900546,CDM,C1713,HCPCS,0278,RC,,,,both,,,3461.85,2250.20,,,,,,,,,,,,,
HC Gbl Office/OP Consltj New/Est Pt Mod Mdm 40 Minutes,PX-9829924401,CDM,99244,CPT,0982,RC,,,,inpatient,,,837.00,544.05,,,,,,,,,,,,,
INTRAOSSEOUS FIX SYS TRL SZR FOR 22MM,SUP-2400076,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1482.08,963.35,,,,,,,,,,,,,
STENT PERIPH L5CM DIA7MM CATH L110CM NIT PTFE FLEX SELF EXP,SUP-2396480,CDM,C1874,HCPCS,0278,RC,,,,both,,,6437.00,4184.05,,,,,,,,,,,,,
PLATE BONE RT MAND RECON FOR 2.4MM SCR,SUP-2365237,CDM,C1713,HCPCS,0278,RC,,,,both,,,7837.50,5094.37,,,,,,,,,,,,,
CATHETER REPROC ULTRASOUND 8 FRX90 CM ACUSON ACUNAV,SUP-2469525,CDM,C1759,HCPCS,0272,RC,,,,both,,,2348.41,1526.47,,,,,,,,,,,,,
NAIL IM L33CM OD11MM TIB CANN LCK DELT RUSS TAY,SUP-2342520,CDM,C1713,HCPCS,0278,RC,,,,both,,,1139.82,740.88,,,,,,,,,,,,,
GRAFT BONE SUB 10CC W25XH8XL50MM NANOSTRUCTURED HA GRAN POR,SUP-2335285,CDM,C1713,HCPCS,0278,RC,,,,both,,,4396.00,2857.40,,,,,,,,,,,,,
RING EXT FIX 180MM 5 8 TL HEX,SUP-2316204,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3382.16,2198.40,,,,,,,,,,,,,
ASPIRIN 325 MG PO TBEC,RX-685,CDM,6370000000,HCPCS,0637,RC,00536-1232-01,NDC,,both,1,UN,0.20,0.13,,,,,,,,,,,,,
PLATE BONE L215MM 16 H NONSTERILE RT PROX TIB S STL LO PROF,SUP-2185821,CDM,C1713,HCPCS,0278,RC,,,,both,,,4008.71,2605.66,,,,,,,,,,,,,
GRAFT 4 10MM 15ML ALLGRFT CHIP CRUSH CANC FRZN READIGRFT,SUP-2264733,CDM,C1713,HCPCS,0278,RC,,,,both,,,712.87,463.37,,,,,,,,,,,,,
CIPROFLOXACIN HCL 250 MG PO TABS,RX-25118,CDM,6370000000,HCPCS,0637,RC,65862-0076-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
DEVICE RECON EMBOLIC COIL ARCH W86MM ANEUR NK W8MM VES,SUP-2248963,CDM,C1876,HCPCS,0278,RC,,,,both,,,39250.00,25512.50,,,,,,,,,,,,,
Rcnstj Mndblr Rami&/Bdy Sgtl Splt W/Int Rgd Fi,CASE-21196,LOCAL,21196,CPT,,,,,,outpatient,,,144916.48,86949.89,,,,,,,,,,,,,
Arthroscopy Knee W/Meniscus Rpr Medial&Lateral|LEFT SIDE,CASE-29883,LOCAL,29883,CPT,0360,RC,,,LT,outpatient,,,39678.00,23806.80,,,,,,,,,,,,,
Insj/Rplcmt Spinal Npg/Rcvr Pocket Crtj&Connj,CASE-63685,LOCAL,63685,CPT,,,,,,outpatient,,,89762.53,53857.52,,,,,,,,,,,,,
Insj/Rplcmt Spinal Npg/Rcvr Pocket Crtj&Connj,CASE-63685,LOCAL,63685,CPT,0360,RC,,,,outpatient,,,89762.53,53857.52,,,,,,,,,,,,,
Arthroscopy Knee W/Meniscus Rpr Medial&Lateral|LEFT SIDE,CASE-29883,LOCAL,29883,CPT,,,,,LT,outpatient,,,39678.00,23806.80,,,,,,,,,,,,,
"Correction Hammertoe|RIGHT FOOT, SECOND DIGIT",CASE-28285,LOCAL,28285,CPT,0360,RC,,,T6,outpatient,,,24682.93,14809.76,,,,,,,,,,,,,
"Rpr/Advmnt Flxr Tdn Zone 2 W/O Fr Grft Ea Tendon|LEFT HAND, FOURTH DIGIT",CASE-26356,LOCAL,26356,CPT,0360,RC,,,F3,outpatient,,,29931.07,17958.64,,,,,,,,,,,,,
"Correction Hammertoe|RIGHT FOOT, SECOND DIGIT",CASE-28285,LOCAL,28285,CPT,,,,,T6,outpatient,,,24682.93,14809.76,,,,,,,,,,,,,
"Rpr/Advmnt Flxr Tdn Zone 2 W/O Fr Grft Ea Tendon|LEFT HAND, FOURTH DIGIT",CASE-26356,LOCAL,26356,CPT,,,,,F3,outpatient,,,29931.07,17958.64,,,,,,,,,,,,,
Rcnstj Mndblr Rami&/Bdy Sgtl Splt W/Int Rgd Fi,CASE-21196,LOCAL,21196,CPT,0360,RC,,,,outpatient,,,144916.48,86949.89,,,,,,,,,,,,,
STENT GRFT VASC AFX2 BODY L 100 MM DIA28 MM LIMB 40 MM 20 MM,SUP-2217684,CDM,C1768,CPT,0278,RC,,,,both,,,37052.00,24083.80,,,,,,,,,,,,,
DRILL SURG STEM 15 MM TIB FLUT NXGN,SUP-2438091,CDM,2720000010,LOCAL,0272,RC,,,,both,,,579.33,376.56,,,,,,,,,,,,,
JOINT WRST 1 4+ MM CRPL UHMWPE FRDM,SUP-2851950,CDM,C1776,CPT,0278,RC,,,,both,,,4178.52,2716.04,,,,,,,,,,,,,
CATHETER ANGIOPLSTY L130CM BAL L220MM DIA6MM GWIRE 0.018IN,SUP-2126962,CDM,C2623,HCPCS,0278,RC,,,,both,,,8792.00,5714.80,,,,,,,,,,,,,
HYDROCORTISONE 1 % EX OINT,RX-3731,CDM,6370000000,HCPCS,0637,RC,00168-0020-31,NDC,,both,28.35,GR,29.60,19.24,,,,,,,,,,,,,
CATHETER URO L180CM DIA5FR BLLN L4CM DIA12FR 0.035IN BILI,SUP-2149781,CDM,C1726,HCPCS,0272,RC,,,,both,,,716.39,465.65,,,,,,,,,,,,,
RAIL ORTH 2 TRANSITION 5.5X500 MM 100 MM MESA,SUP-2732244,CDM,C1713,HCPCS,0278,RC,,,,both,,,6929.51,4504.18,,,,,,,,,,,,,
ALLOGRAFT BNE GRND 15 CC FD ASEP CORTICAL CANC,SUP-2867040,CDM,C1762,CPT,0278,RC,,,,both,,,2013.53,1308.79,,,,,,,,,,,,,
TUBE INNR EAR MYR VENT FLNG 1.14 MM ID FLROPLAS STRL WHT,SUP-2284043,CDM,L8699,HCPCS,0278,RC,,,,both,,,28.51,18.53,,,,,,,,,,,,,
"Capsulectomy/Capsulotomy Iphal Joint Each|RIGHT HAND, FOURTH DIGIT",CASE-26525,LOCAL,26525,CPT,,,,,F8,outpatient,,,21530.25,12918.15,,,,,,,,,,,,,
Lamnotmy Incl W/Dcmprsn Nrv Root 1 Intrspc Lumbr|LEFT SIDE,CASE-63030,LOCAL,63030,CPT,,,,,LT,outpatient,,,40835.12,24501.07,,,,,,,,,,,,,
"Tendon Sheath Incision|RIGHT HAND, SECOND DIGIT|UNUSUAL NON-OVERLAPPING SERVICE",CASE-26055,LOCAL,26055,CPT,,,,,F6|XU,outpatient,,,10615.30,6369.18,,,,,,,,,,,,,
"Tendon Sheath Incision|RIGHT HAND, SECOND DIGIT|UNUSUAL NON-OVERLAPPING SERVICE",CASE-26055,LOCAL,26055,CPT,0360,RC,,,F6|XU,outpatient,,,10615.30,6369.18,,,,,,,,,,,,,
HC Drain/Inj Joint/Bursa W/US Large,CASE-20611,LOCAL,20611,CPT,0510,RC,,,,outpatient,,,4337.67,2602.60,,,,,,,,,,,,,
"Capsulectomy/Capsulotomy Iphal Joint Each|RIGHT HAND, FOURTH DIGIT",CASE-26525,LOCAL,26525,CPT,0360,RC,,,F8,outpatient,,,21530.25,12918.15,,,,,,,,,,,,,
Lamnotmy Incl W/Dcmprsn Nrv Root 1 Intrspc Lumbr|LEFT SIDE,CASE-63030,LOCAL,63030,CPT,0360,RC,,,LT,outpatient,,,40835.12,24501.07,,,,,,,,,,,,,
HC Inj Tendon Sheath/Ligament|PBB CHARGE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-20550,LOCAL,20550,CPT,0510,RC,,,PBB|XU,outpatient,,,3124.33,1874.60,,,,,,,,,,,,,
SCREW BNE X DRV 2.7X21 MM TI THREADLOCK TS LEVEL 1,SUP-2462009,CDM,C1713,HCPCS,0278,RC,,,,both,,,298.83,194.24,,,,,,,,,,,,,
CARTRIDGE BNE MILL STRL PREP + LTX DISP,SUP-2859295,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2410.45,1566.79,,,,,,,,,,,,,
BRACE ORTH CIRC THGH 18.5-21 IN CTR 14-15 IN CALF 14-16 IN DROPLK,SUP-2916919,CDM,2720000010,LOCAL,0272,RC,,,,both,,,430.24,279.66,,,,,,,,,,,,,
SET INT FIX SCREW DIA1.5 MM TI NEURO Y PLT 12 PK STRL DISP,SUP-2935185,CDM,C1713,HCPCS,0278,RC,,,,both,,,23929.94,15554.46,,,,,,,,,,,,,
POSITIONER HRT NS STARFISH,SUP-2281002,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3925.00,2551.25,,,,,,,,,,,,,
KIT ELECTROPHYSIOLOGY NAVX PTCH ADVISOR HD GRID CATH,SUP-2899920,CDM,C1730,HCPCS,0272,RC,,,,both,,,7065.00,4592.25,,,,,,,,,,,,,
BLADE OPHTHLMC SHARP SM CTTNG EDGE MULTI SIDED SCLRTME,SUP-2573865,CDM,2720000010,LOCAL,0272,RC,,,,both,,,41.29,26.84,,,,,,,,,,,,,
SHEATH INTRO COMPASS L 45 CM OD 4 FR ID 1.60 MM GUIDEWIRE,SUP-2838701,CDM,C1894,HCPCS,0272,RC,,,,both,,,265.55,172.61,,,,,,,,,,,,,
HC So Alpha Fetoprotein|NOT REASONABLE AND NECESSARY,PX-3018210566,CDM,82105,CPT,0301,RC,,,GZ,both,,,58.00,37.70,,,,,,,,,,,,,
SCREW SPNL L40MM DIA5.5MM S STL FIX ANG FOR 5.5MM ROD CDH,SUP-2288234,CDM,C1713,HCPCS,0278,RC,,,,both,,,2349.19,1526.97,,,,,,,,,,,,,
PLATE BNE L 44 MM SCREW DIA2.4 MM 6 SHFT H SS COMPACT STR VA,SUP-2908105,CDM,C1713,HCPCS,0278,RC,,,,both,,,2790.89,1814.08,,,,,,,,,,,,,
CRANIO SCULPT FLOW BONE VOID FILLER10CC QTY001 EA,SUP-2669410,CDM,C1713,HCPCS,0278,RC,,,,both,,,10876.18,7069.52,,,,,,,,,,,,,
PLATE BNE VOLAR UNIV DSTL RADIAL 7 HOLE OPTILOCK,SUP-2466822,CDM,C1713,HCPCS,0278,RC,,,,both,,,2157.18,1402.17,,,,,,,,,,,,,
PLATE BONE CRANIOMAXILLOFACIAL 8 HOLE BOX CAR 24MM TITANIUM,SUP-2825444,CDM,C1713,HCPCS,0278,RC,,,,both,,,305.08,198.30,,,,,,,,,,,,,
PLATE BNE ADPT 2.7X161 MM 20 HOLE LCK COMPR SS STRL LCP,SUP-2789587,CDM,C1713,HCPCS,0278,RC,,,,both,,,1655.28,1075.93,,,,,,,,,,,,,
PLATE BNE COMPR NAR 5 HOLE,SUP-2205650,CDM,C1713,HCPCS,0278,RC,,,,both,,,412.22,267.94,,,,,,,,,,,,,
HC So Beta-2-Microglobulin,PX-3018223266,CDM,82232,CPT,0301,RC,,,,both,,,426.00,276.90,,,,,,,,,,,,,
Prtl Exc B1 Tarsal/Metar B1 Xcp Talus/Calcaneus|RIGHT SIDE,CASE-28122,LOCAL,28122,CPT,,,,,RT,outpatient,,,14414.72,8648.83,,,,,,,,,,,,,
Tx Incomplete Abortion Any Trimester Surgical,CASE-59812,LOCAL,59812,CPT,0360,RC,,,,outpatient,,,17454.55,10472.73,,,,,,,,,,,,,
Cysto W/Ureteroscopy W/Rmvl/Manj Stones|BILATERAL PROCEDURE,CASE-52352,LOCAL,52352,CPT,0360,RC,,,50,outpatient,,,19338.63,11603.18,,,,,,,,,,,,,
"Prq Skel Fixj Phlngl Shft Fx Prox/Middle Px/F/T|LEFT HAND, FIFTH DIGIT",CASE-26727,LOCAL,26727,CPT,,,,,F4,outpatient,,,15657.68,9394.61,,,,,,,,,,,,,
"Prq Skel Fixj Phlngl Shft Fx Prox/Middle Px/F/T|LEFT HAND, FIFTH DIGIT",CASE-26727,LOCAL,26727,CPT,0360,RC,,,F4,outpatient,,,15657.68,9394.61,,,,,,,,,,,,,
Tx Incomplete Abortion Any Trimester Surgical,CASE-59812,LOCAL,59812,CPT,,,,,,outpatient,,,17454.55,10472.73,,,,,,,,,,,,,
Cysto W/Ureteroscopy W/Rmvl/Manj Stones|BILATERAL PROCEDURE,CASE-52352,LOCAL,52352,CPT,,,,,50,outpatient,,,19338.63,11603.18,,,,,,,,,,,,,
"Amputation Toe Metatarsophalangeal Joint|RIGHT HAND, FOURTH DIGIT",CASE-28820,LOCAL,28820,CPT,0360,RC,,,F8,outpatient,,,15811.57,9486.94,,,,,,,,,,,,,
"Amputation Toe Metatarsophalangeal Joint|RIGHT HAND, FOURTH DIGIT",CASE-28820,LOCAL,28820,CPT,,,,,F8,outpatient,,,15811.57,9486.94,,,,,,,,,,,,,
Prtl Exc B1 Tarsal/Metar B1 Xcp Talus/Calcaneus|RIGHT SIDE,CASE-28122,LOCAL,28122,CPT,0360,RC,,,RT,outpatient,,,14414.72,8648.83,,,,,,,,,,,,,
CLOBAZAM 10 MG PO TABS,RX-111412,CDM,6370000000,HCPCS,0637,RC,60687-0423-11,NDC,,both,1,UN,11.70,7.60,,,,,,,,,,,,,
STEM ULN HD 4.5 MED PART MOD REPL 1ST CHOICE,SUP-2610433,CDM,C1776,CPT,0278,RC,,,,both,,,12502.32,8126.51,,,,,,,,,,,,,
DRILL SURG HI SPD FOR SPINE,SUP-2607500,CDM,2720000010,LOCAL,0272,RC,,,,both,,,28002.52,18201.64,,,,,,,,,,,,,
AUGMENT FEM 2XL THK12MM STD UNIV LT MEDL RT LAT DSTL KNEE,SUP-2407026,CDM,C1776,CPT,0278,RC,,,,both,,,2226.89,1447.48,,,,,,,,,,,,,
CATHETER ATHRCTMY DIAMONDBACK 360 SHFT L 200 CM CRWN DIA1.5,SUP-2159509,CDM,C1724,HCPCS,0278,RC,,,,both,,,11288.30,7337.39,,,,,,,,,,,,,
RECON PLATE 16X190MM 3.5MM,SUP-2818795,CDM,C1713,HCPCS,0278,RC,,,,both,,,4720.99,3068.64,,,,,,,,,,,,,
PLATE BNE L223MM 14 H NONSTERILE R MED PROX TIB S STL LOK,SUP-2185650,CDM,C1713,HCPCS,0278,RC,,,,both,,,4007.77,2605.05,,,,,,,,,,,,,
BURR SURG 1.2MM DIA HD LNG MIC 2.3MML HD SM BNE TAPR CROS CT,SUP-2605572,CDM,2720000010,LOCAL,0272,RC,,,,both,,,89.90,58.43,,,,,,,,,,,,,
DISTRACTION INTRNL ACT ARM RIGID RMTE DTCH43 MM T 6L 4V QT00,SUP-2669788,CDM,C1713,HCPCS,0278,RC,,,,both,,,3681.08,2392.70,,,,,,,,,,,,,
Split Agrft F/S/N/H/F/G/M/D Gt 1st 100 Cm/</1 %,CASE-15120,LOCAL,15120,CPT,,,,,,outpatient,,,27102.72,16261.63,,,,,,,,,,,,,
Arthrp Intercarpal/Carp/Mtcrpl Jt Suspension|LEFT SIDE,CASE-25448,LOCAL,25448,CPT,0360,RC,,,LT,outpatient,,,31599.97,18959.98,,,,,,,,,,,,,
Revision of Spinal Shunt,CASE-63744,LOCAL,63744,CPT,,,,,,outpatient,,,42658.98,25595.39,,,,,,,,,,,,,
Split Agrft F/S/N/H/F/G/M/D Gt 1st 100 Cm/</1 %,CASE-15120,LOCAL,15120,CPT,0360,RC,,,,outpatient,,,27102.72,16261.63,,,,,,,,,,,,,
Arthrp Intercarpal/Carp/Mtcrpl Jt Suspension|LEFT SIDE,CASE-25448,LOCAL,25448,CPT,,,,,LT,outpatient,,,31599.97,18959.98,,,,,,,,,,,,,
Parathyroidectomy/Exploration Parathyroids|SEPARATE STRUCTURE|RIGHT SIDE,CASE-60500,LOCAL,60500,CPT,,,,,XS|RT,outpatient,,,52340.88,31404.53,,,,,,,,,,,,,
Dstr Nrolytc Agnt Parverteb Fct Sngl Lmbr/Sacral|LEFT SIDE,CASE-64635,LOCAL,64635,CPT,0360,RC,,,LT,outpatient,,,11924.68,7154.81,,,,,,,,,,,,,
Nsl/Sinus Ndsc Max Antrost W/Rmvl Tiss Max Sinus|RIGHT SIDE,CASE-31267,LOCAL,31267,CPT,,,,,RT,outpatient,,,30051.25,18030.75,,,,,,,,,,,,,
Parathyroidectomy/Exploration Parathyroids|SEPARATE STRUCTURE|RIGHT SIDE,CASE-60500,LOCAL,60500,CPT,0360,RC,,,XS|RT,outpatient,,,52340.88,31404.53,,,,,,,,,,,,,
Exc Cyst/Aberrant Breast Tissue Open 1/> Lesion|LEFT SIDE,CASE-19120,LOCAL,19120,CPT,0360,RC,,,LT,outpatient,,,19518.68,11711.21,,,,,,,,,,,,,
Nsl/Sinus Ndsc Max Antrost W/Rmvl Tiss Max Sinus|RIGHT SIDE,CASE-31267,LOCAL,31267,CPT,0360,RC,,,RT,outpatient,,,30051.25,18030.75,,,,,,,,,,,,,
Dstr Nrolytc Agnt Parverteb Fct Sngl Lmbr/Sacral|LEFT SIDE,CASE-64635,LOCAL,64635,CPT,,,,,LT,outpatient,,,11924.68,7154.81,,,,,,,,,,,,,
Exc Cyst/Aberrant Breast Tissue Open 1/> Lesion|LEFT SIDE,CASE-19120,LOCAL,19120,CPT,,,,,LT,outpatient,,,19518.68,11711.21,,,,,,,,,,,,,
HC Joint Injection/Aspir Large WO US|PBB CHARGE|BILATERAL PROCEDURE,CASE-20610,LOCAL,20610,CPT,0510,RC,,,PBB|50,outpatient,,,2537.17,1522.30,,,,,,,,,,,,,
Revision of Spinal Shunt,CASE-63744,LOCAL,63744,CPT,0360,RC,,,,outpatient,,,42658.98,25595.39,,,,,,,,,,,,,
TUBE GASTROSTMY ENTRL FEED 22 FR 15 CC ENFIT CONN COMPAT,SUP-2309465,CDM,2720000010,LOCAL,0272,RC,,,,both,,,108.36,70.43,,,,,,,,,,,,,
DISSECTOR ENDOSCP MARYLAND 330 MM 29X10 MM CRV ROTO-CAM,SUP-2492560,CDM,C1713,HCPCS,0278,RC,,,,both,,,2585.16,1680.35,,,,,,,,,,,,,
PUMP PAIN MGMT 400ML 4ML/HR 2 W/ SIL SOAK CATH FOR ABD,SUP-2236838,CDM,C9804,HCPCS,0272,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
GUIDE WIRE 1.1 MMX18 IN,SUP-2811392,CDM,C1769,HCPCS,0272,RC,,,,both,,,153.86,100.01,,,,,,,,,,,,,
CATHETER INFUS L20CM DIA5FR POLYUR 2 LUMN RADPQ SH RVS TAPR,SUP-2118841,CDM,C1751,HCPCS,0278,RC,,,,both,,,172.70,112.25,,,,,,,,,,,,,
HC Joint Injection/Aspir Large WO US|BILATERAL PROCEDURE|PBB CHARGE,PX-5102061000,CDM,20610,CPT,0510,RC,,,50|PBB,outpatient,,,1092.00,709.80,,,,,,,,,,,,,
PLATE BONE 100DEG 6 H Y SHP STERNALOCK BLU,SUP-2419712,CDM,C1713,HCPCS,0278,RC,,,,both,,,2219.98,1442.99,,,,,,,,,,,,,
HC Clsd Tx Dist Phlnx Fx Manip,PX-4502675500,CDM,26755,CPT,0450,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
SCREW BNE L 8 MM DIA2.2 MM SM CANN STRL QFX,SUP-2932889,CDM,C1713,HCPCS,0278,RC,,,,both,,,624.04,405.63,,,,,,,,,,,,,
PI PICC 3-LUMEN: 6FRX50CM WITH 130CM SS,SUP-2827498,CDM,C1751,HCPCS,0278,RC,,,,both,,,412.60,268.19,,,,,,,,,,,,,
CATHETER PAIN PMP 25 CM 5 CC T PEEL NDL ON-Q SILVERSOAKER,SUP-2424454,CDM,C1713,HCPCS,0278,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
PLATE BNE BROAD 3.5X98 MM 8 HOLE SS DCP,SUP-2569150,CDM,C1713,HCPCS,0278,RC,,,,both,,,305.68,198.69,,,,,,,,,,,,,
CATHETER CTRL VEN 3.5FR 20CM LEN SGL LUMN N TUNNELED BASIC,SUP-2383451,CDM,C1751,HCPCS,0278,RC,,,,both,,,36.96,24.02,,,,,,,,,,,,,
SCREW BONE L6MM DIA2.7MM STD CORT S STL ST FULL THRD HEX HD,SUP-2343877,CDM,C1713,HCPCS,0278,RC,,,,both,,,234.06,152.14,,,,,,,,,,,,,
FORCEPS GRSP L2300MM DIA28MM RAT TOOTH AUTOCLV REUSE FOR REM,SUP-2313135,CDM,C1713,HCPCS,0278,RC,,,,both,,,1682.47,1093.61,,,,,,,,,,,,,
TRETINOIN 0.05 % EX CREA,RX-11577,CDM,6370000000,HCPCS,0637,RC,51672-1394-00,NDC,,both,20,GR,422.50,274.62,,,,,,,,,,,,,
PLATE BNE DBL ANGLED MED 2 MM RECON MAXILLA PT SPEC,SUP-2860084,CDM,C1713,HCPCS,0278,RC,,,,both,,,27382.68,17798.74,,,,,,,,,,,,,
HC Joint Injection/Aspir Large WO US|BILATERAL PROCEDURE|PBB CHARGE,CASE-20610,LOCAL,20610,CPT,0510,RC,,,50|PBB,outpatient,,,1548.08,928.85,,,,,,,,,,,,,
Int Hrhc by Ligation 2+ Hroid W/O Img Gdn,CASE-46946,LOCAL,46946,CPT,,,,,,outpatient,,,14079.87,8447.92,,,,,,,,,,,,,
Nsl/Sinus Ndsc Max Antrost W/Rmvl Tiss Max Sinus,CASE-31267,LOCAL,31267,CPT,,,,,,outpatient,,,27673.55,16604.13,,,,,,,,,,,,,
Nsl/Sinus Ndsc Max Antrost W/Rmvl Tiss Max Sinus,CASE-31267,LOCAL,31267,CPT,0360,RC,,,,outpatient,,,27673.55,16604.13,,,,,,,,,,,,,
Laparoscopy W/Rmvl Adnexal Structures,CASE-58661,LOCAL,58661,CPT,0360,RC,,,,outpatient,,,44983.12,26989.87,,,,,,,,,,,,,
"Tendon Sheath Incision|LEFT FOOT, GREAT TOE",CASE-26055,LOCAL,26055,CPT,0360,RC,,,TA,outpatient,,,13632.85,8179.71,,,,,,,,,,,,,
Cysto Bladder W/Ureteral Catheterization|BILATERAL PROCEDURE,CASE-52005,LOCAL,52005,CPT,0360,RC,,,50,outpatient,,,11197.78,6718.67,,,,,,,,,,,,,
Cysto Bladder W/Ureteral Catheterization|BILATERAL PROCEDURE,CASE-52005,LOCAL,52005,CPT,,,,,50,outpatient,,,11197.78,6718.67,,,,,,,,,,,,,
Laparoscopy W/Rmvl Adnexal Structures,CASE-58661,LOCAL,58661,CPT,,,,,,outpatient,,,44983.12,26989.87,,,,,,,,,,,,,
HC Gastroesophag Reflx Test W/Tel Ph Eltrd|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-91035,LOCAL,91035,CPT,0750,RC,,,74,outpatient,,,1795.08,1077.05,,,,,,,,,,,,,
"Tendon Sheath Incision|LEFT FOOT, GREAT TOE",CASE-26055,LOCAL,26055,CPT,,,,,TA,outpatient,,,13632.85,8179.71,,,,,,,,,,,,,
Int Hrhc by Ligation 2+ Hroid W/O Img Gdn,CASE-46946,LOCAL,46946,CPT,0360,RC,,,,outpatient,,,14079.87,8447.92,,,,,,,,,,,,,
CLIP INT SNAP OFF 2X15 MM TI,SUP-2175089,CDM,C1713,HCPCS,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED UPCHARGE VIVACIT-E,SUP-2212685,CDM,C1776,CPT,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
STENT BILI L 40 MM DIA 7 MM TRNSHEP STRL,SUP-2158580,CDM,C1876,HCPCS,0278,RC,,,,both,,,4132.24,2685.96,,,,,,,,,,,,,
GRAFT HUM TISS MIN W10MM WHL PAT LIG FRZN FLEXIGRFT,SUP-2264793,CDM,C1762,CPT,0278,RC,,,,both,,,11617.97,7551.68,,,,,,,,,,,,,
SCREW BNE L 5 MM DIA2.2 MM PLLA PGA PDLA CRANIOMAXILLOFACIAL,SUP-2909557,CDM,C1713,HCPCS,0278,RC,,,,both,,,2018.08,1311.75,,,,,,,,,,,,,
KIT IM NAIL L150MM DIA8MM PROX HUM LCK,SUP-2412504,CDM,C1713,HCPCS,0278,RC,,,,both,,,3890.46,2528.80,,,,,,,,,,,,,
CUSTOM KT PTCA INFL DEV K05 00053H (ORDER MUTLIPLES OF 5 EACH),SUP-2302818,CDM,C1713,HCPCS,0278,RC,,,,both,,,213.68,138.89,,,,,,,,,,,,,
COMPONENT FEM PS E 61.5X72 MM RT KNEE PC NXGN,SUP-2201496,CDM,C1776,CPT,0278,RC,,,,both,,,5557.33,3612.26,,,,,,,,,,,,,
CATHETER INFUS 6-8FR PROXIS,SUP-2355065,CDM,C1751,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
BAR EXT FIX L225MM DIA6MM COMP FOR JET-X FIX SYS,SUP-2342916,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1093.44,710.74,,,,,,,,,,,,,
DRESSING WND MULTLYR CLLGN MTRX 10X15 CM SHT MATRISTEM,SUP-2106527,CDM,Q4166,HCPCS,0636,RC,,,,both,,,6942.54,4512.65,,,,,,,,,,,,,
GRAFT VASC GELWEAVE L 30 CM DIA22 MM POLYESTER GEL,SUP-2385019,CDM,L8670,HCPCS,0278,RC,,,,both,,,1445.44,939.54,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL PEEK,SUP-2860183,CDM,C1713,HCPCS,0278,RC,,,,both,,,26028.72,16918.67,,,,,,,,,,,,,
PLATE 4.5MM TI LCP TM STRAIGHT RECON 13 HOLES 246MM,SUP-2549513,CDM,C1713,HCPCS,0278,RC,,,,both,,,1659.05,1078.38,,,,,,,,,,,,,
Rpr 1st Fem Hernia Any Age Incarcerated|RIGHT SIDE,CASE-49553,LOCAL,49553,CPT,,,,,RT,outpatient,,,44145.23,26487.14,,,,,,,,,,,,,
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 1 Level|LEFT SIDE,CASE-64493,LOCAL,64493,CPT,,,,,LT,outpatient,,,4008.43,2405.06,,,,,,,,,,,,,
Rpr 1st Fem Hernia Any Age Incarcerated|RIGHT SIDE,CASE-49553,LOCAL,49553,CPT,0360,RC,,,RT,outpatient,,,44145.23,26487.14,,,,,,,,,,,,,
Redo Excis Lumbar Disk|SEPARATE STRUCTURE,CASE-63042,LOCAL,63042,CPT,,,,,XS,outpatient,,,122627.57,73576.54,,,,,,,,,,,,,
Neuroplasty &/Transpos Median Nrv Carpal Tunne|LEFT SIDE,CASE-64721,LOCAL,64721,CPT,0360,RC,,,LT,outpatient,,,13074.93,7844.96,,,,,,,,,,,,,
Neuroplasty &/Transpos Median Nrv Carpal Tunne|LEFT SIDE,CASE-64721,LOCAL,64721,CPT,,,,,LT,outpatient,,,13074.93,7844.96,,,,,,,,,,,,,
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 1 Level|LEFT SIDE,CASE-64493,LOCAL,64493,CPT,0360,RC,,,LT,outpatient,,,4008.43,2405.06,,,,,,,,,,,,,
Cysto Calibration Dilat Urtl Strix/Stenosis,CASE-52281,LOCAL,52281,CPT,,,,,,outpatient,,,17798.18,10678.91,,,,,,,,,,,,,
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|RIGHT HAND, THUMB",CASE-26160,LOCAL,26160,CPT,,,,,F5,outpatient,,,14313.62,8588.17,,,,,,,,,,,,,
Redo Excis Lumbar Disk|SEPARATE STRUCTURE,CASE-63042,LOCAL,63042,CPT,0360,RC,,,XS,outpatient,,,122627.57,73576.54,,,,,,,,,,,,,
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|RIGHT HAND, THUMB",CASE-26160,LOCAL,26160,CPT,0360,RC,,,F5,outpatient,,,14313.62,8588.17,,,,,,,,,,,,,
Cysto Calibration Dilat Urtl Strix/Stenosis,CASE-52281,LOCAL,52281,CPT,0360,RC,,,,outpatient,,,17798.18,10678.91,,,,,,,,,,,,,
RING RINGFIX SYS ALUM 180MM,SUP-2696082,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4007.27,2604.73,,,,,,,,,,,,,
"HC So Porphobilinogen,Urine Quant",PX-3018411066,CDM,84110,CPT,0301,RC,,,,both,,,646.00,419.90,,,,,,,,,,,,,
HC Diabetes Group/30min,PX-9420010900,CDM,G0109,HCPCS,0940,RC,,,,inpatient,,,44.00,28.60,,,,,,,,,,,,,
ELECTRODE ES DIA3MM 50DEG KNEE SUCT W INTEGR HNDPC VAPR,SUP-2256739,CDM,2720000010,LOCAL,0272,RC,,,,both,,,998.52,649.04,,,,,,,,,,,,,
CATHETER ATHRCTMY JETSTREAM SC L 145 CM TIP DIA1.85 MM INTRO,SUP-2148529,CDM,C1724,HCPCS,0278,RC,,,,both,,,20253.00,13164.45,,,,,,,,,,,,,
HC So Intrinsic Factor Antibodies,PX-3028634066,CDM,86340,CPT,0302,RC,,,,outpatient,,,140.00,91.00,,,,,,,,,,,,,
GRAFT MTRX DERM HUM TISS ACELLULAR FRZ DRY THCK 4CMX16CM,SUP-2306913,CDM,C1762,CPT,0278,RC,,,,both,,,5776.44,3754.69,,,,,,,,,,,,,
ROD SPNL 3X120 MM,SUP-2564515,CDM,C1713,HCPCS,0278,RC,,,,both,,,67.35,43.78,,,,,,,,,,,,,
GUIDEWIRE ORTHOPEDIC W/ OLV 3 MMX980 CM STRL,SUP-2316303,CDM,C1769,HCPCS,0272,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
HC Inj Lympho for Sentinal Node|UNUSUAL NON-OVERLAPPING SERVICE,CASE-38792,LOCAL,38792,CPT,0361,RC,,,XU,outpatient,,,46974.72,28184.83,,,,,,,,,,,,,
"Corrj Hallux Valgus W/Sesmdc W/Rescj Prox Phal|LEFT FOOT, GREAT TOE",CASE-28292,LOCAL,28292,CPT,0360,RC,,,TA,outpatient,,,19193.93,11516.36,,,,,,,,,,,,,
Neuroplasty &/Transposition Ulnar Nerve Elbow|LEFT SIDE|SEPARATE STRUCTURE,CASE-64718,LOCAL,64718,CPT,0360,RC,,,LT|XS,outpatient,,,26319.58,15791.75,,,,,,,,,,,,,
Inject Rx Other Periph Nerve|LEFT SIDE,CASE-64640,LOCAL,64640,CPT,,,,,LT,outpatient,,,11924.68,7154.81,,,,,,,,,,,,,
Neuroplasty &/Transposition Ulnar Nerve Elbow|LEFT SIDE|SEPARATE STRUCTURE,CASE-64718,LOCAL,64718,CPT,,,,,LT|XS,outpatient,,,26319.58,15791.75,,,,,,,,,,,,,
"Corrj Hallux Valgus W/Sesmdc W/Rescj Prox Phal|LEFT FOOT, GREAT TOE",CASE-28292,LOCAL,28292,CPT,,,,,TA,outpatient,,,19193.93,11516.36,,,,,,,,,,,,,
Inject Rx Other Periph Nerve|LEFT SIDE,CASE-64640,LOCAL,64640,CPT,0360,RC,,,LT,outpatient,,,11924.68,7154.81,,,,,,,,,,,,,
GRAFT HUM TISS W5XL180MM FIB SHFT FRZN,SUP-2307382,CDM,C1713,HCPCS,0278,RC,,,,both,,,2787.28,1811.73,,,,,,,,,,,,,
GUIDEWIRE UROLOGICAL STR 3 CM 0.035 INX150 CM FLX EZ GLIDER,SUP-2312659,CDM,C1769,HCPCS,0272,RC,,,,both,,,103.43,67.23,,,,,,,,,,,,,
BOUGIE SURG 36FR TIP L12MM SIL HURST BLNT TIP ULT FLX,SUP-2277387,CDM,C1726,HCPCS,0272,RC,,,,both,,,576.50,374.72,,,,,,,,,,,,,
STRUT L INFIX 10MM,SUP-2205508,CDM,C1776,CPT,0278,RC,,,,both,,,8164.00,5306.60,,,,,,,,,,,,,
WAND ABLAT ELIM W/O SUCT 90DEG 4.5MM,SUP-2341960,CDM,C1713,HCPCS,0278,RC,,,,both,,,492.98,320.44,,,,,,,,,,,,,
HC Intubation Emergent,PX-7613150000,CDM,31500,CPT,0761,RC,,,,inpatient,,,403.00,261.95,,,,,,,,,,,,,
K WIRE FIX L450MM DIA2.85MM FOR COMP PROX FEM LAG SCR,SUP-2152588,CDM,C1713,HCPCS,0278,RC,,,,both,,,188.40,122.46,,,,,,,,,,,,,
INTRODUCER SHTH L14CM OD10.5FR 0.038IN ENDHOLE DI-LOCK DIL,SUP-2357098,CDM,C1892,HCPCS,0272,RC,,,,both,,,20.10,13.06,,,,,,,,,,,,,
PROBE VITRCTMY 20GA CONSTELLATION ULTRAVIT 5000,SUP-2109909,CDM,C1713,HCPCS,0278,RC,,,,both,,,715.92,465.35,,,,,,,,,,,,,
SCREW SPNL L15MM DIA4MM FIX ANG ANT CERV CANC TI ST,SUP-2293230,CDM,C1713,HCPCS,0278,RC,,,,both,,,893.96,581.07,,,,,,,,,,,,,
KIT INSTR OSTEOPRECISE CUT GUIDE REDUCER JOYSTICK FREEHAND,SUP-2893268,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
HC So Iadna Mycoplasma Genitalium Amplified Probe Tech,PX-3068756366,CDM,87563,CPT,0306,RC,,,,both,,,53.00,34.45,,,,,,,,,,,,,
GUIDEWIRE VASC L 145 CM DIA 0.025 IN TAPR L 7 CM FLX TIP L,SUP-2167591,CDM,C1769,HCPCS,0272,RC,,,,both,,,35.26,22.92,,,,,,,,,,,,,
STENT PERIPH LIFESTREAM L 58 MM DIA 7 MM CATH L 135 CM,SUP-2128344,CDM,C1874,HCPCS,0278,RC,,,,both,,,7567.40,4918.81,,,,,,,,,,,,,
COMPONENT FEM SZ 1 LT KNEE REV CEM ROT HNG UNISX IMP MOST,SUP-2208347,CDM,C1776,CPT,0278,RC,,,,both,,,21562.38,14015.55,,,,,,,,,,,,,
PLATE BNE THK2MM REG 20 H TI L LOK MINI FOR 23MM SCR,SUP-2262972,CDM,C1713,HCPCS,0278,RC,,,,both,,,3158.56,2053.06,,,,,,,,,,,,,
Implnt Bio Implnt for Soft Tissue Reinforcement|RIGHT SIDE,CASE-15777,LOCAL,15777,CPT,0360,RC,,,RT,outpatient,,,131721.93,79033.16,,,,,,,,,,,,,
Open Tx Metacarpal Fracture Single Ea Bone|LEFT SIDE,CASE-26615,LOCAL,26615,CPT,0360,RC,,,LT,outpatient,,,29464.35,17678.61,,,,,,,,,,,,,
Rpr/Advmnt Flxr Tdn Zone 2 W/O Fr Grft Ea Tendon,CASE-26356,LOCAL,26356,CPT,0360,RC,,,,outpatient,,,29367.62,17620.57,,,,,,,,,,,,,
Dstrj Lesion Anus Extensive,CASE-46924,LOCAL,46924,CPT,,,,,,outpatient,,,17477.42,10486.45,,,,,,,,,,,,,
Rpr/Advmnt Flxr Tdn Zone 2 W/O Fr Grft Ea Tendon,CASE-26356,LOCAL,26356,CPT,,,,,,outpatient,,,29367.62,17620.57,,,,,,,,,,,,,
Dstrj Lesion Anus Extensive,CASE-46924,LOCAL,46924,CPT,0360,RC,,,,outpatient,,,17477.42,10486.45,,,,,,,,,,,,,
Cysto W/Simple Removal Stone & Stent|RIGHT SIDE,CASE-52310,LOCAL,52310,CPT,,,,,RT,outpatient,,,12634.80,7580.88,,,,,,,,,,,,,
Cysto W/Simple Removal Stone & Stent|RIGHT SIDE,CASE-52310,LOCAL,52310,CPT,0360,RC,,,RT,outpatient,,,12634.80,7580.88,,,,,,,,,,,,,
Implnt Bio Implnt for Soft Tissue Reinforcement|RIGHT SIDE,CASE-15777,LOCAL,15777,CPT,,,,,RT,outpatient,,,131721.93,79033.16,,,,,,,,,,,,,
Open Tx Metacarpal Fracture Single Ea Bone|LEFT SIDE,CASE-26615,LOCAL,26615,CPT,,,,,LT,outpatient,,,29464.35,17678.61,,,,,,,,,,,,,
SPACER SPNL W12XH8XL14MM ANTR THORLUM INTBDY FUS PEEK OPTMA,SUP-2205474,CDM,C1821,HCPCS,0278,RC,,,,both,,,5548.85,3606.75,,,,,,,,,,,,,
WIRE FIX Y 1.28X559 MM ES2 COMPATIBLE LT FC12822B4,SUP-2735811,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1938.95,1260.32,,,,,,,,,,,,,
SCREW BNE L80 MM L17 MM OD5.5 MM SHT THRD MONSTER IMPL,SUP-2320702,CDM,C1713,HCPCS,0278,RC,,,,both,,,978.11,635.77,,,,,,,,,,,,,
PLATE BONE SPNL FLR ASPN 10 MM,SUP-2136962,CDM,C1713,HCPCS,0278,RC,,,,both,,,12246.00,7959.90,,,,,,,,,,,,,
EXTENDER NDL L3IN S STL PLAS W/ LUERLOCK ADPT STR DISP,SUP-2340423,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1431.84,930.70,,,,,,,,,,,,,
GRAFT DERMAL PLIABLE PRE THN MED 22X19 CMX0.7-1.4 MM FLEXHD,SUP-2430132,CDM,Q4128,HCPCS,0636,RC,,,,both,,,38308.00,24900.20,,,,,,,,,,,,,
PLATE BNE T MINI LNG 2-2.5X3X7X1 MM LCK PEREZ TI LEVEL 1,SUP-2487788,CDM,C1713,HCPCS,0278,RC,,,,both,,,2166.19,1408.02,,,,,,,,,,,,,
BLADE HANDLE 2050,SUP-2853239,CDM,C1713,HCPCS,0278,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
SLING UROLOGICAL MID-URETHRAL TRNSVAG 1 DEL ADVANTAGE ULTRA,SUP-2876039,CDM,C1771,HCPCS,0278,RC,,,,both,,,5301.48,3445.96,,,,,,,,,,,,,
STEM HUM L175MM SZ 8 REV MONOBLOCK,SUP-2217387,CDM,C1776,CPT,0278,RC,,,,both,,,19979.38,12986.60,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY LASSO NAV ECO L115CM 7/20FR 6MM,SUP-2248628,CDM,C1732,HCPCS,0278,RC,,,,both,,,4527.88,2943.12,,,,,,,,,,,,,
WAND ABLAT DIA3.75MM 50DEG THRMCPL TECHNOLOGY W/ INTEGR,SUP-2342018,CDM,2720000010,LOCAL,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
ALLOGRAFT BNE MED FRZN ASEP FIBULAR SEG,SUP-2867015,CDM,C1762,CPT,0278,RC,,,,both,,,1879.29,1221.54,,,,,,,,,,,,,
GRAFT BNE SUB 10ML SIL SOD CA PHOS OXIDE FOAM PK RECT CONT,SUP-2368184,CDM,C1713,HCPCS,0278,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
Dstr Nrolytc Agnt Parverteb Fct Sngl Lmbr/Sacral|RIGHT SIDE,CASE-64635,LOCAL,64635,CPT,,,,,RT,outpatient,,,11924.68,7154.81,,,,,,,,,,,,,
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 1 Level|RIGHT SIDE,CASE-64493,LOCAL,64493,CPT,0360,RC,,,RT,outpatient,,,3988.28,2392.97,,,,,,,,,,,,,
Ercp W/Sphincterotomy/Papillotomy,CASE-43262,LOCAL,43262,CPT,,,,,,outpatient,,,28028.73,16817.24,,,,,,,,,,,,,
HC Lyr Clos Nk Hnd Ft <2.6cm,CASE-12041,LOCAL,12041,CPT,0450,RC,,,,outpatient,,,20790.57,12474.34,,,,,,,,,,,,,
Dstr Nrolytc Agnt Parverteb Fct Sngl Lmbr/Sacral|RIGHT SIDE,CASE-64635,LOCAL,64635,CPT,0360,RC,,,RT,outpatient,,,11924.68,7154.81,,,,,,,,,,,,,
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 1 Level|RIGHT SIDE,CASE-64493,LOCAL,64493,CPT,,,,,RT,outpatient,,,3988.28,2392.97,,,,,,,,,,,,,
Ercp W/Sphincterotomy/Papillotomy,CASE-43262,LOCAL,43262,CPT,0360,RC,,,,outpatient,,,28028.73,16817.24,,,,,,,,,,,,,
IMPLANT OP RM LAPIDUS PLT 1MM STP PL,SUP-2321500,CDM,C1713,HCPCS,0278,RC,,,,both,,,3846.50,2500.22,,,,,,,,,,,,,
SHEATH INTRO SUREFLEX L 72 CM DIA 8.5 FR DSTL CRV DIA 50 MM,SUP-2131523,CDM,C1766,CPT,0272,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
ADAPTER FEM SZ E DIA50-52MM UHMWPE CONSTRN REFLCT,SUP-2344634,CDM,C1776,CPT,0278,RC,,,,both,,,6970.80,4531.02,,,,,,,,,,,,,
SCREW EDGE COMP DART FIRE,SUP-2857921,CDM,C1713,HCPCS,0278,RC,,,,both,,,1865.16,1212.35,,,,,,,,,,,,,
SET INT FIX SCREW DIA1.5 MM TI NEURO 3 DOG BNE PLATE XDRV 12,SUP-2935489,CDM,C1713,HCPCS,0278,RC,,,,both,,,26633.48,17311.76,,,,,,,,,,,,,
NAIL IM L260MM DIA7MM UNIV HUM TI CANN LCK VERSANAIL,SUP-2412497,CDM,C1713,HCPCS,0278,RC,,,,both,,,3648.68,2371.64,,,,,,,,,,,,,
GRAFT DELIVERY SYSTEM SET 9 CC W/ GRFT DBF CANN ACCELERATE,SUP-2787602,CDM,C1713,HCPCS,0278,RC,,,,both,,,5628.95,3658.82,,,,,,,,,,,,,
BRACE ORTHOPEDIC FOAM SHT SM UNIV 8.5 IN CONFOR FLEX-N-FIT,SUP-2428146,CDM,L1930,HCPCS,0272,RC,,,,both,,,50.27,32.68,,,,,,,,,,,,,
COIL VASC AZUR L 26 CM DIA10 MM MICROCATHETER 0.018 IN LOOP,SUP-2385435,CDM,C1889,HCPCS,0278,RC,,,,both,,,2568.90,1669.78,,,,,,,,,,,,,
HC Clsd Tx Hip Dislo Postarth,PX-4502726500,CDM,27265,CPT,0450,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
PLATEXRAY SZ 2 STOR PHOSPHOR SCANX,SUP-2238750,CDM,C1713,HCPCS,0278,RC,,,,both,,,693.85,451.00,,,,,,,,,,,,,
Cervical Lymphadec Modified Radical Neck Dsj|RIGHT SIDE,CASE-38724,LOCAL,38724,CPT,,,,,RT,outpatient,,,100799.45,60479.67,,,,,,,,,,,,,
HC Bx Breast 1st Lesion US Img|BILATERAL PROCEDURE,CASE-19083,LOCAL,19083,CPT,0361,RC,,,50,outpatient,,,10565.73,6339.44,,,,,,,,,,,,,
Colsc Flexible W/Transendoscopic Balloon Dilat|COLORECTAL CANCER SCREEN,CASE-45386,LOCAL,45386,CPT,0360,RC,,,PT,outpatient,,,16851.57,10110.94,,,,,,,,,,,,,
Cervical Lymphadec Modified Radical Neck Dsj|RIGHT SIDE,CASE-38724,LOCAL,38724,CPT,0360,RC,,,RT,outpatient,,,100799.45,60479.67,,,,,,,,,,,,,
Rinsj Rptd Biceps/Triceps Tdn Dstl W/WO Tdn Grf|RIGHT SIDE,CASE-24342,LOCAL,24342,CPT,0360,RC,,,RT,outpatient,,,35513.72,21308.23,,,,,,,,,,,,,
"Exc Tum/Vasc Mal Sft Tiss Hand/Fngr Subq <1.5cm|RIGHT HAND, SECOND DIGIT",CASE-26115,LOCAL,26115,CPT,0360,RC,,,F6,outpatient,,,13651.05,8190.63,,,,,,,,,,,,,
Realignment Extensor Tendon Hand Each Tendon|RIGHT SIDE,CASE-26437,LOCAL,26437,CPT,,,,,RT,outpatient,,,12375.22,7425.13,,,,,,,,,,,,,
Realignment Extensor Tendon Hand Each Tendon|RIGHT SIDE,CASE-26437,LOCAL,26437,CPT,0360,RC,,,RT,outpatient,,,12375.22,7425.13,,,,,,,,,,,,,
Colsc Flexible W/Transendoscopic Balloon Dilat|COLORECTAL CANCER SCREEN,CASE-45386,LOCAL,45386,CPT,,,,,PT,outpatient,,,16851.57,10110.94,,,,,,,,,,,,,
Rinsj Rptd Biceps/Triceps Tdn Dstl W/WO Tdn Grf|RIGHT SIDE,CASE-24342,LOCAL,24342,CPT,,,,,RT,outpatient,,,35513.72,21308.23,,,,,,,,,,,,,
Genioplasty Augmentation,CASE-21120,LOCAL,21120,CPT,,,,,,outpatient,,,144916.48,86949.89,,,,,,,,,,,,,
"Exc Tum/Vasc Mal Sft Tiss Hand/Fngr Subq <1.5cm|RIGHT HAND, SECOND DIGIT",CASE-26115,LOCAL,26115,CPT,,,,,F6,outpatient,,,13651.05,8190.63,,,,,,,,,,,,,
Colsc Flexible W/Control Bleeding Any Method|UNUSUAL NON-OVERLAPPING SERVICE,CASE-45382,LOCAL,45382,CPT,,,,,XU,outpatient,,,11298.15,6778.89,,,,,,,,,,,,,
Thyroidectomy Total/Complete|BILATERAL PROCEDURE,CASE-60240,LOCAL,60240,CPT,,,,,50,outpatient,,,52340.88,31404.53,,,,,,,,,,,,,
Colsc Flexible W/Control Bleeding Any Method|UNUSUAL NON-OVERLAPPING SERVICE,CASE-45382,LOCAL,45382,CPT,0360,RC,,,XU,outpatient,,,11298.15,6778.89,,,,,,,,,,,,,
Genioplasty Augmentation,CASE-21120,LOCAL,21120,CPT,0360,RC,,,,outpatient,,,144916.48,86949.89,,,,,,,,,,,,,
Thyroidectomy Total/Complete|BILATERAL PROCEDURE,CASE-60240,LOCAL,60240,CPT,0360,RC,,,50,outpatient,,,52340.88,31404.53,,,,,,,,,,,,,
SPLINT DORS NT M 10 14 WOM 11 15 SZ L XL,SUP-2196391,CDM,L4398,HCPCS,0274,RC,,,,both,,,97.53,63.39,,,,,,,,,,,,,
ZOLBETUXIMAB-CLZB 100 MG IV SOLR,RX-169536,CDM,J1326,HCPCS,0636,RC,00469-3425-10,NDC,,both,1,UN,4608.00,2995.20,,,,,,,,,,,,,
LINER ACET SZ DMI OD58MM ID28MM ORNG DBL MOBILITY HIGHCROSS,SUP-2267322,CDM,C1776,CPT,0278,RC,,,,both,,,4547.98,2956.19,,,,,,,,,,,,,
CATHETER URETH 14FR L25CM UTHANE NDL OBT CANN ASSEMB CONN,SUP-2171361,CDM,C2627,HCPCS,0272,RC,,,,both,,,165.32,107.46,,,,,,,,,,,,,
GUIDEWIRE VASC L260CM DIA0.018IN TIP L3CM STD NIT HYDRPHLC,SUP-2385561,CDM,C1769,HCPCS,0272,RC,,,,both,,,263.54,171.30,,,,,,,,,,,,,
MARKER RADIOGRAPHIC MAXFRAME,SUP-2255817,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2311.73,1502.62,,,,,,,,,,,,,
Arthrp Interpos Intercarpal/Metacarpal Joints|RIGHT SIDE,CASE-25447,LOCAL,25447,CPT,0360,RC,,,RT,outpatient,,,18997.85,11398.71,,,,,,,,,,,,,
Inj for Sacroiliac Jt Anesth|BILATERAL PROCEDURE,CASE-G0260,LOCAL,G0260,CPT,0360,RC,,,50,outpatient,,,4486.08,2691.65,,,,,,,,,,,,,
Open Tx Clavicular Fracture Internal Fixation|LEFT SIDE,CASE-23515,LOCAL,23515,CPT,,,,,LT,outpatient,,,44434.37,26660.62,,,,,,,,,,,,,
Rpr 1st Ingun Hrna Age 5 Yrs/> Reducible|LEFT SIDE,CASE-49505,LOCAL,49505,CPT,0360,RC,,,LT,outpatient,,,31153.93,18692.36,,,,,,,,,,,,,
Arthrp Interpos Intercarpal/Metacarpal Joints|RIGHT SIDE,CASE-25447,LOCAL,25447,CPT,,,,,RT,outpatient,,,18997.85,11398.71,,,,,,,,,,,,,
"Application Uniplane External Fixation System|RIGHT HAND, FIFTH DIGIT",CASE-20690,LOCAL,20690,CPT,0360,RC,,,F9,outpatient,,,20943.20,12565.92,,,,,,,,,,,,,
Mastectomy Simple Complete|LEFT SIDE,CASE-19303,LOCAL,19303,CPT,,,,,LT,outpatient,,,45111.25,27066.75,,,,,,,,,,,,,
Rpr 1st Ingun Hrna Age 5 Yrs/> Reducible|LEFT SIDE,CASE-49505,LOCAL,49505,CPT,,,,,LT,outpatient,,,31153.93,18692.36,,,,,,,,,,,,,
"Application Uniplane External Fixation System|RIGHT HAND, FIFTH DIGIT",CASE-20690,LOCAL,20690,CPT,,,,,F9,outpatient,,,20943.20,12565.92,,,,,,,,,,,,,
Open Tx Clavicular Fracture Internal Fixation|LEFT SIDE,CASE-23515,LOCAL,23515,CPT,0360,RC,,,LT,outpatient,,,44434.37,26660.62,,,,,,,,,,,,,
Inj for Sacroiliac Jt Anesth|BILATERAL PROCEDURE,CASE-G0260,LOCAL,G0260,CPT,,,,,50,outpatient,,,4486.08,2691.65,,,,,,,,,,,,,
Mastectomy Simple Complete|LEFT SIDE,CASE-19303,LOCAL,19303,CPT,0360,RC,,,LT,outpatient,,,45111.25,27066.75,,,,,,,,,,,,,
KIT ACCESS PORT 014CC RAPIDPORT EZ,SUP-2119255,CDM,C1713,HCPCS,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
SCREW BNE 6X105 MM NS LTX,SUP-2861117,CDM,C1713,HCPCS,0278,RC,,,,both,,,485.13,315.33,,,,,,,,,,,,,
BUR SURG IRR BULL DMND DIEGO PRECIS DIAM 3 MM BIT DIAM 40,SUP-2312828,CDM,2720000010,LOCAL,0272,RC,,,,both,,,538.82,350.23,,,,,,,,,,,,,
PLATE BNE L86MM 2 H NONSTERILE L OLECRANON S STL LOK COMPR,SUP-2185422,CDM,C1713,HCPCS,0278,RC,,,,both,,,2880.04,1872.03,,,,,,,,,,,,,
AUGMENT TIB SZ 6 THK5MM HNG SCREWED GMK,SUP-2267640,CDM,C1776,CPT,0278,RC,,,,both,,,4485.49,2915.57,,,,,,,,,,,,,
HC Pt Adl Training 15mn,PX-4209753500,CDM,97535,CPT,0420,RC,,,,outpatient,,,174.00,113.10,,,,,,,,,,,,,
HC Simulation Simple,PX-3337728000,CDM,77280,CPT,0333,RC,,,,both,,,1230.00,799.50,,,,,,,,,,,,,
LARYNGECTOMY KIT PULM 10/36 10/55 STD W/ PROVOX LARYTUBE,SUP-2424441,CDM,C1713,HCPCS,0278,RC,,,,both,,,1083.30,704.14,,,,,,,,,,,,,
PROCEDURE KIT STPL 8X8 MM STRL ARCUS,SUP-2308934,CDM,C1713,HCPCS,0278,RC,,,,both,,,3799.40,2469.61,,,,,,,,,,,,,
"Amp F/Th 1/2 Jt/Phalanx W/Neurect W/Dir Clsr|LEFT HAND, THIRD DIGIT",CASE-26951,LOCAL,26951,CPT,,,,,F2,outpatient,,,13700.88,8220.53,,,,,,,,,,,,,
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral Ea Addl,CASE-64484,LOCAL,64484,CPT,,,,,,outpatient,,,3919.93,2351.96,,,,,,,,,,,,,
Egd Ablate Tumor Polyp/Lesion W/Dilation& Wire,CASE-43270,LOCAL,43270,CPT,,,,,,outpatient,,,16300.10,9780.06,,,,,,,,,,,,,
Egd Ablate Tumor Polyp/Lesion W/Dilation& Wire,CASE-43270,LOCAL,43270,CPT,0360,RC,,,,outpatient,,,16300.10,9780.06,,,,,,,,,,,,,
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral Ea Addl,CASE-64484,LOCAL,64484,CPT,0360,RC,,,,outpatient,,,3919.93,2351.96,,,,,,,,,,,,,
"Amp F/Th 1/2 Jt/Phalanx W/Neurect W/Dir Clsr|LEFT HAND, THIRD DIGIT",CASE-26951,LOCAL,26951,CPT,0360,RC,,,F2,outpatient,,,13700.88,8220.53,,,,,,,,,,,,,
SUTURE GORTX SZ 6-0 L30IN NONABSORBABLE L13MM TTC-13 3/8 CIR 7M06B,SUP-2395576,CDM,C1713,HCPCS,0278,RC,,,,both,,,2731.80,1775.67,,,,,,,,,,,,,
GRAFT HUMAN TSSUE 3CMW X 4CML AMNTC MEM DHDRTD FBLGC SCFFLD,SUP-2727661,CDM,Q4128,HCPCS,0636,RC,,,,both,,,4775.63,3104.16,,,,,,,,,,,,,
GUIDEWIRE UROLOGY ANGLED 0.035 INX145 CM NIMB RDRUN PC,SUP-2835758,CDM,C1769,HCPCS,0272,RC,,,,both,,,133.92,87.05,,,,,,,,,,,,,
HC ED Closed Tx Mtp Dislocation,PX-4502863000,CDM,28630,CPT,0450,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
PLATE BNE L142MM 6 H ST R OLECRANON TI LO PROF VAR ANG LOK,SUP-2180815,CDM,C1713,HCPCS,0278,RC,,,,both,,,3920.26,2548.17,,,,,,,,,,,,,
DEVICE PESSARY TNDM CUBE 7-5 2.25X1.75 IN PROCIDENTIA MILEX,SUP-2755566,CDM,A4562,HCPCS,0272,RC,,,,both,,,301.60,196.04,,,,,,,,,,,,,
PLATE BNE L51MM THK1.2MM 0DEG 8 H BILAT S STL STR RIG LIMIT,SUP-2186171,CDM,C1713,HCPCS,0278,RC,,,,both,,,1299.43,844.63,,,,,,,,,,,,,
KIT EXT FIX MULTAXL CORRECTION SYS HEXAPOD FULL AUTO NS,SUP-2905693,CDM,2720000010,LOCAL,0272,RC,,,,both,,,591.29,384.34,,,,,,,,,,,,,
PLATE BNE H1MM 6 H MAND BLU TI MINI STR LOK LEIBINGER,SUP-2366342,CDM,C1713,HCPCS,0278,RC,,,,both,,,357.14,232.14,,,,,,,,,,,,,
COIL EMB L13CM OD0.020IN LOOP OD5MM NIT STRTCH RESIST FILL,SUP-2323397,CDM,C1889,HCPCS,0278,RC,,,,both,,,7165.48,4657.56,,,,,,,,,,,,,
PAD CLLR CERV UNIV AD REPL,SUP-2124221,CDM,L0172,HCPCS,0272,RC,,,,both,,,31.78,20.66,,,,,,,,,,,,,
HC I&D Cyst Abscess Mouth Simple,PX-4504080000,CDM,40800,CPT,0450,RC,,,,both,,,730.00,474.50,,,,,,,,,,,,,
SHEATH INTRO PINNACLE L 10 CM 6 FR SS HYDRPHLC PERIPHERAL,SUP-2385669,CDM,C1894,HCPCS,0272,RC,,,,both,,,30.62,19.90,,,,,,,,,,,,,
PLATE BROAD STR 6HL,SUP-2702875,CDM,C1713,HCPCS,0278,RC,,,,both,,,4004.76,2603.09,,,,,,,,,,,,,
SNARE VASC 7FR L120CM DIE-45MM CATH L100CM STD INTERLACED,SUP-2302539,CDM,C1773,HCPCS,0272,RC,,,,both,,,1055.04,685.78,,,,,,,,,,,,,
"HC So Fungus, Nes",PX-3028667166,CDM,86671,CPT,0302,RC,,,,both,,,43.00,27.95,,,,,,,,,,,,,
Cysto W/Urtroscopy&/Pyeloscopy Dx|LEFT SIDE,CASE-52351,LOCAL,52351,CPT,,,,,LT,outpatient,,,18524.88,11114.93,,,,,,,,,,,,,
Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq|SEPARATE STRUCTURE|COLORECTAL CANCER SCREEN,CASE-45385,LOCAL,45385,CPT,0360,RC,,,XS|PT,outpatient,,,10830.52,6498.31,,,,,,,,,,,,,
Insertion Breast Implant Same Day of Mastectomy,CASE-19340,LOCAL,19340,CPT,0360,RC,,,,outpatient,,,62764.78,37658.87,,,,,,,,,,,,,
Surgical Arthroscopy Shoulder Biceps Tenodesis|LEFT SIDE,CASE-29828,LOCAL,29828,CPT,0360,RC,,,LT,outpatient,,,49865.88,29919.53,,,,,,,,,,,,,
Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq|SEPARATE STRUCTURE|COLORECTAL CANCER SCREEN,CASE-45385,LOCAL,45385,CPT,,,,,XS|PT,outpatient,,,10830.52,6498.31,,,,,,,,,,,,,
Insertion Breast Implant Same Day of Mastectomy,CASE-19340,LOCAL,19340,CPT,,,,,,outpatient,,,62764.78,37658.87,,,,,,,,,,,,,
Cysto W/Urtroscopy&/Pyeloscopy Dx|LEFT SIDE,CASE-52351,LOCAL,52351,CPT,0360,RC,,,LT,outpatient,,,18524.88,11114.93,,,,,,,,,,,,,
Surgical Arthroscopy Shoulder Biceps Tenodesis|LEFT SIDE,CASE-29828,LOCAL,29828,CPT,,,,,LT,outpatient,,,49865.88,29919.53,,,,,,,,,,,,,
HC X-Ray Scapula,PX-3207301000,CDM,73010,CPT,0320,RC,,,,outpatient,,,569.00,369.85,,,,,,,,,,,,,
SHEATH TRANSSEPTAL L 72 CM DIA 8.5 FR CRV L 17 MM DIL L 95,SUP-2913156,CDM,C1893,HCPCS,0272,RC,,,,both,,,5385.10,3500.31,,,,,,,,,,,,,
PLATE BNE XSM W14XL22MM 4 H NONSTERILE BILAT S STL X SHP LO,SUP-2186325,CDM,C1713,HCPCS,0278,RC,,,,both,,,2338.36,1519.93,,,,,,,,,,,,,
Suction Assisted Lipectomy Upper Extremity|BILATERAL PROCEDURE,CASE-15878,LOCAL,15878,CPT,,,,,50,outpatient,,,48103.90,28862.34,,,,,,,,,,,,,
Arthrd Ant Interbody Min Dsc Crv Below C2|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-22554,LOCAL,22554,CPT,0360,RC,,,74,outpatient,,,46658.75,27995.25,,,,,,,,,,,,,
"Tendon Sheath Incision|RIGHT HAND, THIRD DIGIT",CASE-26055,LOCAL,26055,CPT,0360,RC,,,F7,outpatient,,,10039.98,6023.99,,,,,,,,,,,,,
Arthrd Ant Interbody Min Dsc Crv Below C2|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-22554,LOCAL,22554,CPT,,,,,74,outpatient,,,46658.75,27995.25,,,,,,,,,,,,,
Excision Malignant Lesion F/E/E/N/L 1.1-2.0 Cm,CASE-11642,LOCAL,11642,CPT,,,,,,outpatient,,,14635.83,8781.50,,,,,,,,,,,,,
Excision Malignant Lesion F/E/E/N/L 1.1-2.0 Cm,CASE-11642,LOCAL,11642,CPT,0360,RC,,,,outpatient,,,14635.83,8781.50,,,,,,,,,,,,,
Suction Assisted Lipectomy Upper Extremity|BILATERAL PROCEDURE,CASE-15878,LOCAL,15878,CPT,0360,RC,,,50,outpatient,,,48103.90,28862.34,,,,,,,,,,,,,
"Tendon Sheath Incision|RIGHT HAND, THIRD DIGIT",CASE-26055,LOCAL,26055,CPT,,,,,F7,outpatient,,,10039.98,6023.99,,,,,,,,,,,,,
BIT DRL 3.2X128 MM,SUP-2862472,CDM,2720000010,LOCAL,0272,RC,,,,both,,,104.66,68.03,,,,,,,,,,,,,
CATHETER INFUSION SINGLE LUMEN 5FRX100CM 30CM CRAGG-MCNAMARA,SUP-2172524,CDM,C1751,HCPCS,0278,RC,,,,both,,,307.72,200.02,,,,,,,,,,,,,
DEVICE BLLN DIL UROMX ULT HI PRSS HYDR+ COAT 30 FR X 8 MM,SUP-2139194,CDM,C1726,HCPCS,0272,RC,,,,both,,,777.28,505.23,,,,,,,,,,,,,
KNIFE 3722150 MYRINGOPLASTY 90115 DEG,SUP-2706207,CDM,2720000010,LOCAL,0272,RC,,,,both,,,686.88,446.47,,,,,,,,,,,,,
PLATE STRNL CLOSURE 6 H TI H CONCV NS STERNALOCK EZ,SUP-2894445,CDM,C1713,HCPCS,0278,RC,,,,both,,,1921.68,1249.09,,,,,,,,,,,,,
HC So1 Special Stain Grp 2,PX-3128831367,CDM,88313,CPT,0312,RC,,,,both,,,297.00,193.05,,,,,,,,,,,,,
BLADE RTRCTR MCCLLCH 7CMD SPNL MSCLE BLACK FNSH HOOK ULTRA,SUP-2672370,CDM,2720000010,LOCAL,0272,RC,,,,both,,,416.55,270.76,,,,,,,,,,,,,
SUPPORT ORTHOT CUST HEEL WDG,SUP-2435721,CDM,L3350,HCPCS,0272,RC,,,,both,,,64.75,42.09,,,,,,,,,,,,,
HC Collect Blood From Arterial Line,PX-7613779900,CDM,37799,CPT,0761,RC,,,,inpatient,,,1845.00,1199.25,,,,,,,,,,,,,
STEM XL POROUS 16.5X220MM BOWED,SUP-2504979,CDM,C1776,CPT,0278,RC,,,,both,,,9382.32,6098.51,,,,,,,,,,,,,
HC >= 12 Lead Ekg|UNUSUAL NON-OVERLAPPING SERVICE,CASE-93005,LOCAL,93005,CPT,0730,RC,,,XU,outpatient,,,29924.80,17954.88,,,,,,,,,,,,,
"Decompress Spinal Cord,1 Seg|LEFT SIDE",CASE-63056,LOCAL,63056,CPT,0360,RC,,,LT,outpatient,,,46568.92,27941.35,,,,,,,,,,,,,
"Decompress Spinal Cord,1 Seg|LEFT SIDE",CASE-63056,LOCAL,63056,CPT,,,,,LT,outpatient,,,46568.92,27941.35,,,,,,,,,,,,,
HC Inj Aa&/Strd Greater Occipital Nerve|RIGHT SIDE,CASE-64405,LOCAL,64405,CPT,0450,RC,,,RT,outpatient,,,3490.72,2094.43,,,,,,,,,,,,,
HC Non Stress Test,CASE-59025,LOCAL,59025,CPT,0920,RC,,,,outpatient,,,1531.83,919.10,,,,,,,,,,,,,
CATHETER INTRAAORTIC BAL 8FR 30CC ULT,SUP-2383460,CDM,C1713,HCPCS,0278,RC,,,,both,,,2873.10,1867.51,,,,,,,,,,,,,
HARVESTER BONE AVITUS 6MM,SUP-2720053,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4396.00,2857.40,,,,,,,,,,,,,
PEGFILGRASTIM-CBQV 6 MG/0.6ML SC SOSY,RX-144304,CDM,Q5111,HCPCS,0636,RC,70114-0101-01,NDC,,both,0.6,ML,12316.30,8005.59,,,,,,,,,,,,,
MORPHINE SULFATE (PF) 0.5 MG/ML IJ SOLN,RX-29464,CDM,J2274,HCPCS,0636,RC,00409-3814-12,NDC,,both,5,ML,60.90,39.58,,,,,,,,,,,,,
WAND ABLAT DIA3.5MM PRB ENERGY SUCT 50-S SERFAS,SUP-2367326,CDM,2720000010,LOCAL,0272,RC,,,,both,,,539.86,350.91,,,,,,,,,,,,,
PLATE BONE W14XL214MM THK3.8MM 90DEG 12 H RT TIB L BTTRS LT,SUP-2185774,CDM,C1713,HCPCS,0278,RC,,,,both,,,2256.15,1466.50,,,,,,,,,,,,,
SCREW BNE L95MM OD6.4MM BLU TI CORT ST SELF DRL,SUP-2347068,CDM,C1713,HCPCS,0278,RC,,,,both,,,704.62,458.00,,,,,,,,,,,,,
BRACE ORTHOPEDIC D RNG MED REG AD 8 IN RT ROLYANFIT,SUP-2325902,CDM,L3908,HCPCS,0272,RC,,,,both,,,51.65,33.57,,,,,,,,,,,,,
BLADE SHAVER SERRATED 0-40 DEG 4 MM MALL DSTL SUCTION STRL,SUP-2638417,CDM,2720000010,LOCAL,0272,RC,,,,both,,,469.12,304.93,,,,,,,,,,,,,
Revision of Reconstructed Breast|BILATERAL PROCEDURE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-19380,LOCAL,19380,CPT,,,,,50|XU,outpatient,,,132375.82,79425.49,,,,,,,,,,,,,
Removal Implant Deep|UNUSUAL NON-OVERLAPPING SERVICE,CASE-20680,LOCAL,20680,CPT,,,,,XU,outpatient,,,50593.62,30356.17,,,,,,,,,,,,,
Perq Nl/Pl Lithotrp Simple Up to 2 Cm 1 Location|LEFT SIDE,CASE-50080,LOCAL,50080,CPT,,,,,LT,outpatient,,,53517.70,32110.62,,,,,,,,,,,,,
Posterior Non-Segmental Instrumentation,CASE-22840,LOCAL,22840,CPT,0360,RC,,,,outpatient,,,95531.67,57319.00,,,,,,,,,,,,,
"Open Tx Phalangeal Shaft Fracture Prox/Middle Ea|RIGHT HAND, FIFTH DIGIT",CASE-26735,LOCAL,26735,CPT,0360,RC,,,F9,outpatient,,,32177.68,19306.61,,,,,,,,,,,,,
Posterior Non-Segmental Instrumentation,CASE-22840,LOCAL,22840,CPT,,,,,,outpatient,,,95531.67,57319.00,,,,,,,,,,,,,
Excision Hydrocele Unilateral|LEFT SIDE,CASE-55040,LOCAL,55040,CPT,0360,RC,,,LT,outpatient,,,18816.52,11289.91,,,,,,,,,,,,,
HC Debride Subq First 20 Sq Cm,CASE-11042,LOCAL,11042,CPT,0361,RC,,,,outpatient,,,20451.32,12270.79,,,,,,,,,,,,,
Rpr Aa Hernia 1st 3-10 Cm Reducible,CASE-49593,LOCAL,49593,CPT,0360,RC,,,,outpatient,,,65725.45,39435.27,,,,,,,,,,,,,
Excision Hydrocele Unilateral|LEFT SIDE,CASE-55040,LOCAL,55040,CPT,,,,,LT,outpatient,,,18816.52,11289.91,,,,,,,,,,,,,
Removal Implant Deep|UNUSUAL NON-OVERLAPPING SERVICE,CASE-20680,LOCAL,20680,CPT,0360,RC,,,XU,outpatient,,,50593.62,30356.17,,,,,,,,,,,,,
Optx Patllr Fx W/Int Fixj/Patllc&Soft Tiss Rpr,CASE-27524,LOCAL,27524,CPT,0360,RC,,,,outpatient,,,27814.60,16688.76,,,,,,,,,,,,,
Optx Patllr Fx W/Int Fixj/Patllc&Soft Tiss Rpr,CASE-27524,LOCAL,27524,CPT,,,,,,outpatient,,,27814.60,16688.76,,,,,,,,,,,,,
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 2nd Level|LEFT SIDE,CASE-64494,LOCAL,64494,CPT,0360,RC,,,LT,outpatient,,,3988.28,2392.97,,,,,,,,,,,,,
Rpr Aa Hernia 1st 3-10 Cm Reducible,CASE-49593,LOCAL,49593,CPT,,,,,,outpatient,,,65725.45,39435.27,,,,,,,,,,,,,
"Open Tx Phalangeal Shaft Fracture Prox/Middle Ea|RIGHT HAND, FIFTH DIGIT",CASE-26735,LOCAL,26735,CPT,,,,,F9,outpatient,,,32177.68,19306.61,,,,,,,,,,,,,
Perq Nl/Pl Lithotrp Simple Up to 2 Cm 1 Location|LEFT SIDE,CASE-50080,LOCAL,50080,CPT,0360,RC,,,LT,outpatient,,,53517.70,32110.62,,,,,,,,,,,,,
Revision of Reconstructed Breast|BILATERAL PROCEDURE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-19380,LOCAL,19380,CPT,0360,RC,,,50|XU,outpatient,,,132375.82,79425.49,,,,,,,,,,,,,
GRAFT VASC EXXCEL SFT L 80 CM DIA 8 MM EPTFE STR TW USFT,SUP-2266008,CDM,C1768,CPT,0278,RC,,,,both,,,1961.97,1275.28,,,,,,,,,,,,,
LEVEL CMF TMPLTE L SHP 25 310 70 XX 25 311 70 XX ALMNM QT001,SUP-2667280,CDM,C1713,HCPCS,0278,RC,,,,both,,,189.62,123.25,,,,,,,,,,,,,
COMPONENT GLEN 19X20MM 1MM OFFSET MATCHING OVO HD DIA58X55MM,SUP-2123638,CDM,C1776,CPT,0278,RC,,,,both,,,5108.78,3320.71,,,,,,,,,,,,,
KIT PNEUMOTHOR CATH 8FR L6.44IN NDL 18GA INJ SYR APPL PCH,SUP-2383256,CDM,C1729,HCPCS,0272,RC,,,,both,,,497.28,323.23,,,,,,,,,,,,,
DEVICE ARTOTMY CLOSURE TRACELET REG STRP L 19.2 CM PUR,SUP-2429852,CDM,C1713,HCPCS,0278,RC,,,,both,,,527.52,342.89,,,,,,,,,,,,,
VALVE AORT OPN PVT DIA26 MM ORIFICE 24.8 MM TISS ANNULUS,SUP-2282674,CDM,C1889,HCPCS,0278,RC,,,,both,,,10205.00,6633.25,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED ADV STRYBIPOLA] STRYKER CORP],SUP-2365969,CDM,C1776,CPT,0278,RC,,,,both,,,12403.00,8061.95,,,,,,,,,,,,,
RONGEUR SURG 5X230MM BX MOUTH,SUP-2183471,CDM,C1713,HCPCS,0278,RC,,,,both,,,114.61,74.50,,,,,,,,,,,,,
BLADE SURG SAW CRESC STRL S STL 32MM LEN 18.5MM W .51MM THCK,SUP-2361979,CDM,2720000010,LOCAL,0272,RC,,,,both,,,296.73,192.87,,,,,,,,,,,,,
Anesthesia Upper GI Endoscopic Px Ercp,CASE-00732,LOCAL,00732,CPT,,,,,,outpatient,,,28028.73,16817.24,,,,,,,,,,,,,
Incisional Biopsy Skin Single Lesion,CASE-11106,LOCAL,11106,CPT,,,,,,outpatient,,,16241.30,9744.78,,,,,,,,,,,,,
Sigmoidoscopy Flx Dx W/Collj Spec Br/Wa if Pfrmd|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-45330,LOCAL,45330,CPT,,,,,74,outpatient,,,7047.73,4228.64,,,,,,,,,,,,,
Sigmoidoscopy Flx Dx W/Collj Spec Br/Wa if Pfrmd|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-45330,LOCAL,45330,CPT,0360,RC,,,74,outpatient,,,7047.73,4228.64,,,,,,,,,,,,,
Incisional Biopsy Skin Single Lesion,CASE-11106,LOCAL,11106,CPT,0360,RC,,,,outpatient,,,16241.30,9744.78,,,,,,,,,,,,,
Anesthesia Upper GI Endoscopic Px Ercp,CASE-00732,LOCAL,00732,CPT,0370,RC,,,,outpatient,,,28028.73,16817.24,,,,,,,,,,,,,
MESH BONE SM 0.6MM THK TTNM LATEX FREE TMPRL MXLFCL,SUP-2488358,CDM,C1713,HCPCS,0278,RC,,,,both,,,4050.85,2633.05,,,,,,,,,,,,,
GRAFT NRV REP L2.5CM ID5MM PERIPH NRV TYP I CLLGN,SUP-2378809,CDM,C9355,HCPCS,0278,RC,,,,both,,,3381.78,2198.16,,,,,,,,,,,,,
SCREW BONE 2X8MM CORT TI BLU HEXADRIVE 6 TRILOK,SUP-2268141,CDM,C1713,HCPCS,0278,RC,,,,both,,,1544.88,1004.17,,,,,,,,,,,,,
RING EXT FIX 5/8 IN 150 MM ALUM MAXFRAME,SUP-2422831,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3378.80,2196.22,,,,,,,,,,,,,
BASKET STONE RETRV L110CM DIA7MM SHTH 22FR POLYIMIDE 12 WIRE,SUP-2141782,CDM,2720000010,LOCAL,0272,RC,,,,both,,,588.28,382.38,,,,,,,,,,,,,
HC Blood Count Reticulocyte Manual,PX-3058504400,CDM,85044,CPT,0305,RC,,,,both,,,16.00,10.40,,,,,,,,,,,,,
CATHETER INFUSION PULSE SPRY L 90 CM DIA 5 FR SLT PAT L 20,SUP-2118493,CDM,C1757,HCPCS,0272,RC,,,,both,,,832.10,540.86,,,,,,,,,,,,,
GRAFT HUM TISS 1ML AMNIO FLD ORTHOFLO,SUP-2305758,CDM,C1713,HCPCS,0278,RC,,,,both,,,4396.00,2857.40,,,,,,,,,,,,,
HC Bx Breast 1st Les MR Image,PX-3611908500,CDM,19085,CPT,0361,RC,,,,outpatient,,,6672.00,4336.80,,,,,,,,,,,,,
Z DISCONTINUED NO SUB IDED TUBE TYMPANOSTOMY U SHP UNINTERRUPTED BLD SUPL EZ INSRT,SUP-2247579,CDM,L8699,HCPCS,0278,RC,,,,both,,,80.07,52.05,,,,,,,,,,,,,
Neuroplasty &/Transposition Ulnar Nerve Elbow|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64718,LOCAL,64718,CPT,,,,,LT|XU,outpatient,,,29434.57,17660.74,,,,,,,,,,,,,
Mastectomy Partial|BILATERAL PROCEDURE,CASE-19301,LOCAL,19301,CPT,,,,,50,outpatient,,,60695.68,36417.41,,,,,,,,,,,,,
Colsc Flx With Directed Submucosal Njx Any Sbst,CASE-45381,LOCAL,45381,CPT,0360,RC,,,,outpatient,,,17679.90,10607.94,,,,,,,,,,,,,
Revision of Reconstructed Breast|UNUSUAL NON-OVERLAPPING SERVICE|LEFT SIDE,CASE-19380,LOCAL,19380,CPT,,,,,XU|LT,outpatient,,,87886.37,52731.82,,,,,,,,,,,,,
Cerclage Cervix Pregnancy Vaginal,CASE-59320,LOCAL,59320,CPT,0360,RC,,,,outpatient,,,21615.10,12969.06,,,,,,,,,,,,,
Cerclage Cervix Pregnancy Vaginal,CASE-59320,LOCAL,59320,CPT,,,,,,outpatient,,,21615.10,12969.06,,,,,,,,,,,,,
Surgical Arthroscopy Sho W/Coracoacrm Ligm Rls|LEFT SIDE,CASE-29826,LOCAL,29826,CPT,0360,RC,,,LT,outpatient,,,51672.72,31003.63,,,,,,,,,,,,,
Colsc Flx With Directed Submucosal Njx Any Sbst,CASE-45381,LOCAL,45381,CPT,,,,,,outpatient,,,17679.90,10607.94,,,,,,,,,,,,,
Mastectomy Partial|BILATERAL PROCEDURE,CASE-19301,LOCAL,19301,CPT,0360,RC,,,50,outpatient,,,60695.68,36417.41,,,,,,,,,,,,,
Endoscopic Papilla Cannulation Bile/Pancreatic,CASE-43273,LOCAL,43273,CPT,,,,,,outpatient,,,28028.73,16817.24,,,,,,,,,,,,,
Endoscopic Papilla Cannulation Bile/Pancreatic,CASE-43273,LOCAL,43273,CPT,0360,RC,,,,outpatient,,,28028.73,16817.24,,,,,,,,,,,,,
Surgical Arthroscopy Sho W/Coracoacrm Ligm Rls|LEFT SIDE,CASE-29826,LOCAL,29826,CPT,,,,,LT,outpatient,,,51672.72,31003.63,,,,,,,,,,,,,
Revision of Reconstructed Breast|UNUSUAL NON-OVERLAPPING SERVICE|LEFT SIDE,CASE-19380,LOCAL,19380,CPT,0360,RC,,,XU|LT,outpatient,,,87886.37,52731.82,,,,,,,,,,,,,
Neuroplasty &/Transposition Ulnar Nerve Elbow|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64718,LOCAL,64718,CPT,0360,RC,,,LT|XU,outpatient,,,29434.57,17660.74,,,,,,,,,,,,,
SHEATH NEPHSTMY L22CM DIA10MM RENAL ACCS BVL END GWIRE NOTCH,SUP-2126725,CDM,C1894,HCPCS,0272,RC,,,,both,,,150.22,97.64,,,,,,,,,,,,,
PLATE BNE CONTOURED 1.5X26X0.3 MM BURR HOLE CVR LP TI,SUP-2457016,CDM,C1713,HCPCS,0278,RC,,,,both,,,823.65,535.37,,,,,,,,,,,,,
NEEDLE ASPIR 21GA L700MM US GUID TREAT DST END FOR EFFICIENT,SUP-2436511,CDM,2720000010,LOCAL,0272,RC,,,,both,,,717.80,466.57,,,,,,,,,,,,,
SHEATH INTRO SOLOPATH WORKING L 35 CM EXPANDABLE L 30CM 22FR,SUP-2385691,CDM,C1894,HCPCS,0272,RC,,,,both,,,2166.60,1408.29,,,,,,,,,,,,,
ALBUMIN HUMAN 5 % IV SOLN,RX-8982,CDM,P9045,HCPCS,0636,RC,44206-0310-25,NDC,,both,250,ML,517.50,336.37,,,,,,,,,,,,,
RADIUM RA 223 DICHLORIDE 30 MCCI/ML IV SOLN,RX-133995,CDM,A9606,HCPCS,0343,RC,50419-0208-01,NDC,,both,1,UN,435.00,282.75,,,,,,,,,,,,,
TAP SURG ANTR REVERE OD5.5MM,SUP-2232142,CDM,2720000010,LOCAL,0272,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
SPHINCTEROTOME ENDOSCP ANGLED 0.025 INX30 MM KDVC631Q07303A,SUP-2468879,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1745.24,1134.41,,,,,,,,,,,,,
HC Alpha-Fetoprotein Serum|NOT REASONABLE AND NECESSARY,PX-3018210500,CDM,82105,CPT,0301,RC,,,GZ,both,,,202.00,131.30,,,,,,,,,,,,,
ALLOGRAFT BNE 10 CC VIABLE BNE MTRX BIO4 PS51001,SUP-2637049,CDM,C1713,HCPCS,0278,RC,,,,both,,,2111.96,1372.77,,,,,,,,,,,,,
SCREW BNE L 32 MM DIA2 MM NANO HDLSS COMPR NS ACUTRK 3,SUP-2912746,CDM,C1713,HCPCS,0278,RC,,,,both,,,3004.98,1953.24,,,,,,,,,,,,,
MARKER BIOPSY HYDROMARK PLUSACOPE 5 BRONCHO HG 5.6/2.8,SUP-2882668,CDM,A4648,CPT,0278,RC,,,,both,,,288.03,187.22,,,,,,,,,,,,,
Laparoscopy Supracervical Hysterectomy 250 Gm/<,CASE-58541,LOCAL,58541,CPT,,,,,,outpatient,,,40779.12,24467.47,,,,,,,,,,,,,
"Laminec/Facetect/Foramin,Lumbar",CASE-63047,LOCAL,63047,CPT,,,,,,outpatient,,,49388.92,29633.35,,,,,,,,,,,,,
"Suture Digital Nerve Hand/Foot 1 Nerve|RIGHT HAND, THUMB",CASE-64831,LOCAL,64831,CPT,0360,RC,,,F5,outpatient,,,18947.58,11368.55,,,,,,,,,,,,,
"Neuroplasty Sciatic Nerve,Open|LEFT SIDE",CASE-64712,LOCAL,64712,CPT,0360,RC,,,LT,outpatient,,,34242.53,20545.52,,,,,,,,,,,,,
"Suture Digital Nerve Hand/Foot 1 Nerve|RIGHT HAND, THUMB",CASE-64831,LOCAL,64831,CPT,,,,,F5,outpatient,,,18947.58,11368.55,,,,,,,,,,,,,
Laparoscopy Supracervical Hysterectomy 250 Gm/<,CASE-58541,LOCAL,58541,CPT,0360,RC,,,,outpatient,,,40779.12,24467.47,,,,,,,,,,,,,
"Laminec/Facetect/Foramin,Lumbar",CASE-63047,LOCAL,63047,CPT,0360,RC,,,,outpatient,,,49388.92,29633.35,,,,,,,,,,,,,
Prep Site Trunk/Arm/Leg 1st 100 Sq Cm/1pct,CASE-15002,LOCAL,15002,CPT,0360,RC,,,,outpatient,,,20257.35,12154.41,,,,,,,,,,,,,
"Neuroplasty Sciatic Nerve,Open|LEFT SIDE",CASE-64712,LOCAL,64712,CPT,,,,,LT,outpatient,,,34242.53,20545.52,,,,,,,,,,,,,
Prep Site Trunk/Arm/Leg 1st 100 Sq Cm/1pct,CASE-15002,LOCAL,15002,CPT,,,,,,outpatient,,,20257.35,12154.41,,,,,,,,,,,,,
HC Nursery Level II R&B,PX-1720000000,CDM,1720000000,LOCAL,,,,,,outpatient,,,7405.67,4443.40,,,,,,,,,,,,,
SCREW BONE 1.5MMX5MM ST CRUC TI CRAN PLATING SYS TIMESH,SUP-2277532,CDM,C1713,HCPCS,0278,RC,,,,both,,,155.43,101.03,,,,,,,,,,,,,
NAIL INTRAMEDULLARY DYNANAIL MINI L70 MM OD8 MM,SUP-2880114,CDM,C1713,HCPCS,0278,RC,,,,both,,,17788.10,11562.26,,,,,,,,,,,,,
GRAFT ACHILLES PRESHAPE FZ ASP,SUP-2858212,CDM,C1762,CPT,0278,RC,,,,both,,,6813.80,4428.97,,,,,,,,,,,,,
HOOK RETRCT SUGITA STRL DISP BRAINPATH SHEPHARD'S,SUP-2930206,CDM,2720000010,LOCAL,0272,RC,,,,both,,,316.26,205.57,,,,,,,,,,,,,
GUIDEWIRE VASC L185CM DIA0.014IN PTFE STEER J TIP PRIMEWIRE,SUP-2327235,CDM,C1769,HCPCS,0272,RC,,,,both,,,2119.50,1377.67,,,,,,,,,,,,,
BUR SURG FLUT BRL 60 DEG 4.2 MMX13.5 CM STRL DISP,SUP-2648964,CDM,2720000010,LOCAL,0272,RC,,,,both,,,679.37,441.59,,,,,,,,,,,,,
HC So1 Encephalitis Western Equine,PX-3028665467,CDM,86654,CPT,0302,RC,,,,both,,,44.00,28.60,,,,,,,,,,,,,
KIT BIO STABLE 5F DL 55CM CATHETER VLV PG,SUP-2118831,CDM,C1751,HCPCS,0278,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
CLAMP SRGCL CLEY 8 1/2NL 12MMW X 60MMD JAW F/PRTL OCCLSN LAT,SUP-2494973,CDM,2720000010,LOCAL,0272,RC,,,,both,,,631.89,410.73,,,,,,,,,,,,,
BIT DRL L12MM SZ 2MM GUID COUNT SINK AO CANN STP FIXOS,SUP-2379286,CDM,2720000010,LOCAL,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
PLATE BONE L110MM BLDE W5.8XL38MM 145DEG 6 H STRL BILAT PELV,SUP-2186672,CDM,C1713,HCPCS,0278,RC,,,,both,,,2498.18,1623.82,,,,,,,,,,,,,
BUPIVACAINE HCL 0.5 % IJ SOLN (MIXTURES ONLY),RX-430038,CDM,J0665,HCPCS,0636,RC,00409-1162-02,NDC,,both,30,ML,54.10,35.16,,,,,,,,,,,,,
SROM*ST XL36+8LNK22X17X275L,SUP-2540392,CDM,C1776,CPT,0278,RC,,,,both,,,14501.78,9426.16,,,,,,,,,,,,,
LEVOTHYROXINE SODIUM 137 MCG PO TABS,RX-10405,CDM,6370000000,HCPCS,0637,RC,60793-0857-01,NDC,,both,1,UN,5.20,3.38,,,,,,,,,,,,,
NEEDLE ASPIR 11GA L250MM BONE MAR,SUP-2384766,CDM,C1713,HCPCS,0278,RC,,,,both,,,626.43,407.18,,,,,,,,,,,,,
DIATRIZOATE MEGLUMINE & SODIUM 66-10 % PO SOLN,RX-9828,CDM,Q9963,HCPCS,0636,RC,00270-0445-35,NDC,,both,5,ML,2.30,1.49,,,,,,,,,,,,,
ANCHOR SUT PNCRYL 2-0 ABSRB 12DEG CRV NDL POLY BRAID FOR,SUP-2249491,CDM,C1713,HCPCS,0278,RC,,,,both,,,938.86,610.26,,,,,,,,,,,,,
Exc B9 Lesion Mrgn Xcp Sk Tg T/a/L 0.6-1.0 Cm,CASE-11401,LOCAL,11401,CPT,,,,,,outpatient,,,10835.58,6501.35,,,,,,,,,,,,,
Exc B9 Lesion Mrgn Xcp Sk Tg S/N/H/F/G 3.1-4.0cm,CASE-11424,LOCAL,11424,CPT,,,,,,outpatient,,,13632.85,8179.71,,,,,,,,,,,,,
Exc B9 Lesion Mrgn Xcp Sk Tg T/a/L 0.6-1.0 Cm,CASE-11401,LOCAL,11401,CPT,0360,RC,,,,outpatient,,,10835.58,6501.35,,,,,,,,,,,,,
Exc B9 Lesion Mrgn Xcp Sk Tg S/N/H/F/G 3.1-4.0cm,CASE-11424,LOCAL,11424,CPT,0360,RC,,,,outpatient,,,13632.85,8179.71,,,,,,,,,,,,,
SCREW BONE L65MM DIA3.5MM PROX CORT TIB TYP II ANODIZED TI,SUP-2411705,CDM,C1713,HCPCS,0278,RC,,,,both,,,193.42,125.72,,,,,,,,,,,,,
PLATE BNE L45MM 10DEG L 6 H TI 1ST MT BILAT 2 COMPR SLOT,SUP-2399648,CDM,C1713,HCPCS,0278,RC,,,,both,,,2540.26,1651.17,,,,,,,,,,,,,
SCREW BNE PART CANN 4X60 MM N-FORCE,SUP-2473013,CDM,C1713,HCPCS,0278,RC,,,,both,,,1789.80,1163.37,,,,,,,,,,,,,
COIL VASC MREYE EMBOLUS L 15 CM DIA15 MM CATH DIA 0.038 IN,SUP-2170435,CDM,C1889,HCPCS,0278,RC,,,,both,,,259.05,168.38,,,,,,,,,,,,,
HC So Factor VII,PX-3058523066,CDM,85230,CPT,0305,RC,,,,inpatient,,,280.00,182.00,,,,,,,,,,,,,
PLATE BNE 1ST MTP 5 DEG NAR 2.7 MM LT 5 HOLE,SUP-2857045,CDM,C1713,HCPCS,0278,RC,,,,both,,,8578.48,5576.01,,,,,,,,,,,,,
BIT DRL 2 MM W/ MINI-QUICK CONN ALPS FAST,SUP-2606625,CDM,2720000010,LOCAL,0272,RC,,,,both,,,42.20,27.43,,,,,,,,,,,,,
COMPONENT FEM SM LT KNEE ZPU LIBRA,SUP-2442382,CDM,C1776,CPT,0278,RC,,,,both,,,1073.88,698.02,,,,,,,,,,,,,
SUPPORT ORTHOT CUST SOLE WDG OUTSIDE,SUP-2435722,CDM,L3360,HCPCS,0272,RC,,,,both,,,100.79,65.51,,,,,,,,,,,,,
PIN EXT FIX TRANSFIX LNG 5X300 MM TIN SIDEKCK,SUP-2850838,CDM,2720000010,LOCAL,0272,RC,,,,both,,,634.28,412.28,,,,,,,,,,,,,
GUIDE NDL FOR ULTRASOUND PRB STRL MULTI-PRO 2000 DISP,SUP-2165784,CDM,2720000010,LOCAL,0272,RC,,,,both,,,543.22,353.09,,,,,,,,,,,,,
PLATE BONE L THK1.5MM 4X20X4 H MAND TI DBL ANG LCKING FOR,SUP-2191268,CDM,C1713,HCPCS,0278,RC,,,,both,,,8499.67,5524.79,,,,,,,,,,,,,
WASHER ORTH DIA13MM FOR CANN SCR,SUP-2184681,CDM,C1713,HCPCS,0278,RC,,,,both,,,75.45,49.04,,,,,,,,,,,,,
CATHETER HD TWO LUMEN 12 FRX6 IN LG BOR KT ARROWG+ARD BLU,SUP-2627031,CDM,C1752,HCPCS,0278,RC,,,,both,,,352.31,229.00,,,,,,,,,,,,,
"Arthrodesis Interphalangeal Jt W/WO Int Fixj|LEFT HAND, THUMB",CASE-26860,LOCAL,26860,CPT,0360,RC,,,FA,outpatient,,,24583.27,14749.96,,,,,,,,,,,,,
Nasal/Sinus Ndsc Surg W/Concha Bullosa Resection|RIGHT SIDE,CASE-31240,LOCAL,31240,CPT,0360,RC,,,RT,outpatient,,,52135.20,31281.12,,,,,,,,,,,,,
Nasal/Sinus Ndsc Surg W/Concha Bullosa Resection|RIGHT SIDE,CASE-31240,LOCAL,31240,CPT,,,,,RT,outpatient,,,52135.20,31281.12,,,,,,,,,,,,,
"Arthrodesis Interphalangeal Jt W/WO Int Fixj|LEFT HAND, THUMB",CASE-26860,LOCAL,26860,CPT,,,,,FA,outpatient,,,24583.27,14749.96,,,,,,,,,,,,,
HC Non Stress Test|UNUSUAL NON-OVERLAPPING SERVICE,CASE-59025,LOCAL,59025,CPT,0920,RC,,,XU,outpatient,,,3921.67,2353.00,,,,,,,,,,,,,
GRAFT BONE 2.5 CC GROWTH PROTEIN FACTOR MEDIUM,SUP-2424570,CDM,C1713,HCPCS,0278,RC,,,,both,,,4144.80,2694.12,,,,,,,,,,,,,
CLAMP CRAN TEXT 22 MM FLAPFIX FOR EXT FIX TI NS LF,SUP-2431406,CDM,C1713,HCPCS,0278,RC,,,,both,,,805.50,523.57,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY L 110 CM DIA 6 FR E CRV,SUP-2148873,CDM,C1732,HCPCS,0272,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
DRILL SURG CTRL N CEM MBT HI PERF SIG LCS,SUP-2456250,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1777.24,1155.21,,,,,,,,,,,,,
AM PICC SET: 2-L 5.5FRX55CM 130CM HYDR,SUP-2827502,CDM,C1751,HCPCS,0278,RC,,,,both,,,540.08,351.05,,,,,,,,,,,,,
BIT DRL OCPTL CERV THOR INFIN,SUP-2278949,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
AM PICC SET: 2-L 5.5FRX55CM 80CM HYDRO,SUP-2827503,CDM,C1751,HCPCS,0278,RC,,,,both,,,413.44,268.74,,,,,,,,,,,,,
PLATE BNE L117MM 7 H R DST POSTEROLATERAL HUM S STL LOK,SUP-2185895,CDM,C1713,HCPCS,0278,RC,,,,both,,,2810.49,1826.82,,,,,,,,,,,,,
COLLAR CERV H3XL22IN 1 SZ FIT MOST ADJ HK AND LOOP CLSR,SUP-2194445,CDM,L0180,HCPCS,0272,RC,,,,both,,,7.47,4.86,,,,,,,,,,,,,
GRAFT GYN 6X10CM FET BOV DERM MTRX SFT TISS REP CNFRM QUIK,SUP-2139396,CDM,C1763,HCPCS,0278,RC,,,,both,,,3917.12,2546.13,,,,,,,,,,,,,
Correction Hammertoe|LEFT SIDE,CASE-28285,LOCAL,28285,CPT,,,,,LT,outpatient,,,32745.13,19647.08,,,,,,,,,,,,,
Bx/Exc Lymph Node Open Deep Axillary Node,CASE-38525,LOCAL,38525,CPT,0360,RC,,,,outpatient,,,27590.48,16554.29,,,,,,,,,,,,,
"Dbrdmt Fx&/Dislc Subq T/M/F Bone|RIGHT HAND, FIFTH DIGIT",CASE-11012,LOCAL,11012,CPT,,,,,F9,outpatient,,,20298.53,12179.12,,,,,,,,,,,,,
Litholapaxy Comp/Lg > 2.5 Cm,CASE-52318,LOCAL,52318,CPT,,,,,,outpatient,,,23346.02,14007.61,,,,,,,,,,,,,
"Laminec/Facetect/Foramin,Lumbar|SEPARATE STRUCTURE",CASE-63047,LOCAL,63047,CPT,0360,RC,,,XS,outpatient,,,95752.97,57451.78,,,,,,,,,,,,,
HC Inj Anes/Steroid C/D Facet Sg|RIGHT SIDE,CASE-64490,LOCAL,64490,CPT,0361,RC,,,RT,outpatient,,,4402.88,2641.73,,,,,,,,,,,,,
HC Joint Injection/Aspir Large WO US|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-20610,LOCAL,20610,CPT,0510,RC,,,RT|XU,outpatient,,,5691.72,3415.03,,,,,,,,,,,,,
Septoplasty/Submucous Resecj W/WO Cartilage Grf,CASE-30520,LOCAL,30520,CPT,0360,RC,,,,outpatient,,,35011.15,21006.69,,,,,,,,,,,,,
Litholapaxy Comp/Lg > 2.5 Cm,CASE-52318,LOCAL,52318,CPT,0360,RC,,,,outpatient,,,23346.02,14007.61,,,,,,,,,,,,,
Septoplasty/Submucous Resecj W/WO Cartilage Grf,CASE-30520,LOCAL,30520,CPT,,,,,,outpatient,,,35011.15,21006.69,,,,,,,,,,,,,
"Laminec/Facetect/Foramin,Lumbar|SEPARATE STRUCTURE",CASE-63047,LOCAL,63047,CPT,,,,,XS,outpatient,,,95752.97,57451.78,,,,,,,,,,,,,
Strtctc Cptr Asstd Px Extradural Cranial,CASE-61782,LOCAL,61782,CPT,0360,RC,,,,outpatient,,,50503.92,30302.35,,,,,,,,,,,,,
"Dbrdmt Fx&/Dislc Subq T/M/F Bone|RIGHT HAND, FIFTH DIGIT",CASE-11012,LOCAL,11012,CPT,0360,RC,,,F9,outpatient,,,20298.53,12179.12,,,,,,,,,,,,,
Bx/Exc Lymph Node Open Deep Axillary Node,CASE-38525,LOCAL,38525,CPT,,,,,,outpatient,,,27590.48,16554.29,,,,,,,,,,,,,
Correction Hammertoe|LEFT SIDE,CASE-28285,LOCAL,28285,CPT,0360,RC,,,LT,outpatient,,,32745.13,19647.08,,,,,,,,,,,,,
Strtctc Cptr Asstd Px Extradural Cranial,CASE-61782,LOCAL,61782,CPT,,,,,,outpatient,,,50503.92,30302.35,,,,,,,,,,,,,
HC Fo W/Joint Custom Fit,PX-2740393501,CDM,L3935,HCPCS,0274,RC,,,,both,,,734.00,477.10,,,,,,,,,,,,,
PLATE BNE 2 MM 20 HOLE PT SPEC MATRIXMANDIBLE,SUP-2860072,CDM,C1713,HCPCS,0278,RC,,,,both,,,16247.62,10560.95,,,,,,,,,,,,,
GRAFT VASC ARTEGRAFT L 40 CM DIA 4 MM CLLGN BOV CAR ART,SUP-2880937,CDM,C1768,CPT,0278,RC,,,,both,,,11677.66,7590.48,,,,,,,,,,,,,
HC So Electrophoretic Test,PX-3018266466,CDM,82664,CPT,0301,RC,,,,both,,,128.00,83.20,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY LASSOSTAR NAV L 115 CM DIA 4 FR,SUP-2530193,CDM,C1732,HCPCS,0272,RC,,,,both,,,4939.22,3210.49,,,,,,,,,,,,,
INBONE  POLY SZ 1 16MM SULCUS TOTAL ANKLE,SUP-2459939,CDM,C1776,CPT,0278,RC,,,,both,,,5743.06,3732.99,,,,,,,,,,,,,
BLADE SURG BABY SZ SGL USE THROW-AWAY OMNI-TRACT,SUP-2243523,CDM,2720000010,LOCAL,0272,RC,,,,both,,,105.19,68.37,,,,,,,,,,,,,
HC I & D Simple,PX-4501006000,CDM,10060,CPT,0450,RC,,,,outpatient,,,632.00,410.80,,,,,,,,,,,,,
GRAFT DERM MTRX HUM TISS FLD HYDRATED THCK KT BILAT BRST,SUP-2307584,CDM,Q4128,HCPCS,0636,RC,,,,both,,,11838.59,7695.08,,,,,,,,,,,,,
CATHETER VALVULOPLASTY NUCLEUS-X L 110 CM DIA 9 FR 5 CM 28MM,SUP-2659661,CDM,C1725,HCPCS,0272,RC,,,,both,,,2981.84,1938.20,,,,,,,,,,,,,
LOCK DISTAL FIBULA PLT SS LT 4H,SUP-2815007,CDM,C1713,HCPCS,0278,RC,,,,both,,,1931.10,1255.21,,,,,,,,,,,,,
GRAFT PELV RECON INTEGRFT 2CMX7CM,SUP-2140208,CDM,C1771,HCPCS,0278,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
Ercp W/Biopsy Single/Multiple|UNUSUAL NON-OVERLAPPING SERVICE,CASE-43261,LOCAL,43261,CPT,,,,,XU,outpatient,,,28994.82,17396.89,,,,,,,,,,,,,
Exc B9 Lesion Mrgn Xcp Sk Tg T/a/L 3.1-4.0 Cm,CASE-11404,LOCAL,11404,CPT,0360,RC,,,,outpatient,,,22187.53,13312.52,,,,,,,,,,,,,
Ercp W/Biopsy Single/Multiple|UNUSUAL NON-OVERLAPPING SERVICE,CASE-43261,LOCAL,43261,CPT,0360,RC,,,XU,outpatient,,,28994.82,17396.89,,,,,,,,,,,,,
Exc B9 Lesion Mrgn Xcp Sk Tg T/a/L 3.1-4.0 Cm,CASE-11404,LOCAL,11404,CPT,,,,,,outpatient,,,22187.53,13312.52,,,,,,,,,,,,,
Exc B9 Lesion Mrgn Xcp Sk Tg S/N/H/F/G 0.5 Cm/<,CASE-11420,LOCAL,11420,CPT,,,,,,outpatient,,,13771.12,8262.67,,,,,,,,,,,,,
Exc B9 Lesion Mrgn Xcp Sk Tg S/N/H/F/G 0.5 Cm/<,CASE-11420,LOCAL,11420,CPT,0360,RC,,,,outpatient,,,13771.12,8262.67,,,,,,,,,,,,,
HC Peripheral Block - Femoral Single or Saphenous W/Img Gdn|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64447,LOCAL,64447,CPT,0360,RC,,,RT|XU,outpatient,,,37142.73,22285.64,,,,,,,,,,,,,
"HC Aerosol, Hhn, Mdi, Ippb",CASE-94640,LOCAL,94640,CPT,0410,RC,,,,outpatient,,,43462.45,26077.47,,,,,,,,,,,,,
VALVE TRACH SPEAK CLR,SUP-2322025,CDM,L8501,HCPCS,0274,RC,,,,both,,,198.61,129.10,,,,,,,,,,,,,
CATHETER THROMCTMY FOGARTY L 80 CM DIA 6 FR BALLOON DIA CLR,SUP-2214112,CDM,C1757,HCPCS,0272,RC,,,,both,,,308.13,200.28,,,,,,,,,,,,,
PLATE BNE FEM 90 DEG 180 MM ARCHED MR SAFE NS,SUP-2863457,CDM,C1713,HCPCS,0278,RC,,,,both,,,2859.28,1858.53,,,,,,,,,,,,,
SHUNT CV L14MM DIA1.5MM IC SIL TAPR TIP RADPQ CLRVW,SUP-2282638,CDM,C1889,HCPCS,0278,RC,,,,both,,,248.06,161.24,,,,,,,,,,,,,
PLATE BNE THK1MM 9 H 100DEG L CRANIOMAXILLOFACIAL TI MINI L,SUP-2366332,CDM,C1713,HCPCS,0278,RC,,,,both,,,798.69,519.15,,,,,,,,,,,,,
TUBE MYR 1MM DIAM VENT TAB SIL SHEA,SUP-2312640,CDM,L8699,HCPCS,0278,RC,,,,both,,,37.37,24.29,,,,,,,,,,,,,
ALLOGRAFT BNE PROX FEM 10 CM FRZN LT W/O HD,SUP-2717958,CDM,C1762,CPT,0278,RC,,,,both,,,9985.20,6490.38,,,,,,,,,,,,,
PROBE NRV STIM DIA0.5MM STD PRASS PR DISP,SUP-2284319,CDM,2720000010,LOCAL,0272,RC,,,,both,,,356.48,231.71,,,,,,,,,,,,,
CATHETER HD J STR 23 CM 2 CUF TY INTRO GUIDEWIRE INJ,SUP-2283902,CDM,C1750,HCPCS,0278,RC,,,,both,,,804.63,523.01,,,,,,,,,,,,,
PLATE BNE L23MM 4 H NONSTERILE S STL LOK COMPR W/ SHT THRD,SUP-2184180,CDM,C1713,HCPCS,0278,RC,,,,both,,,725.18,471.37,,,,,,,,,,,,,
WASHER SURG DIA4MM FLAT FOR MINI MONSTER SCR SYS,SUP-2320327,CDM,C1713,HCPCS,0278,RC,,,,both,,,486.70,316.35,,,,,,,,,,,,,
Repair Intermediate S/a/T/E 20.1-30.0 Cm,CASE-12036,LOCAL,12036,CPT,0360,RC,,,,outpatient,,,75340.57,45204.34,,,,,,,,,,,,,
Egd Transoral Biopsy Single/Multiple|SEPARATE STRUCTURE,CASE-43239,LOCAL,43239,CPT,,,,,XS,outpatient,,,13005.62,7803.37,,,,,,,,,,,,,
Exc Tumor Soft Tiss Face&Scalp Subfascial 2 Cm/>,CASE-21014,LOCAL,21014,CPT,0360,RC,,,,outpatient,,,22031.85,13219.11,,,,,,,,,,,,,
Egd Transoral Biopsy Single/Multiple|SEPARATE STRUCTURE,CASE-43239,LOCAL,43239,CPT,0360,RC,,,XS,outpatient,,,13005.62,7803.37,,,,,,,,,,,,,
Edg US Exam Surgical Alter Stom Duodenum/Jejunum,CASE-43259,LOCAL,43259,CPT,0360,RC,,,,outpatient,,,11107.75,6664.65,,,,,,,,,,,,,
Rpr Ingun Hernia Sliding Any Age|RIGHT SIDE,CASE-49525,LOCAL,49525,CPT,0360,RC,,,RT,outpatient,,,46507.68,27904.61,,,,,,,,,,,,,
Repair Intermediate S/a/T/E 20.1-30.0 Cm,CASE-12036,LOCAL,12036,CPT,,,,,,outpatient,,,75340.57,45204.34,,,,,,,,,,,,,
GI Tract Imaging Intraluminal Colon I&R,CASE-91113,LOCAL,91113,CPT,0750,RC,,,,outpatient,,,3481.83,2089.10,,,,,,,,,,,,,
Exc Tumor Soft Tiss Face&Scalp Subfascial 2 Cm/>,CASE-21014,LOCAL,21014,CPT,,,,,,outpatient,,,22031.85,13219.11,,,,,,,,,,,,,
Surg Nasopharyngoscopy Dilat Eustachian Tube Bi,CASE-69706,LOCAL,69706,CPT,0360,RC,,,,outpatient,,,22622.48,13573.49,,,,,,,,,,,,,
Hemorrhoid Ntrnl & Xtrnl 1 Column W/Fissurecto,CASE-46257,LOCAL,46257,CPT,,,,,,outpatient,,,16932.28,10159.37,,,,,,,,,,,,,
Exc Breast Les Preop Plmt Rad Marker Open 1 Les|RIGHT SIDE|SEPARATE PRACTITIONER,CASE-19125,LOCAL,19125,CPT,,,,,RT|XP,outpatient,,,113631.43,68178.86,,,,,,,,,,,,,
GI Tract Imaging Intraluminal Colon I&R,CASE-91113,LOCAL,91113,CPT,,,,,,outpatient,,,3481.83,2089.10,,,,,,,,,,,,,
Rpr Ingun Hernia Sliding Any Age|RIGHT SIDE,CASE-49525,LOCAL,49525,CPT,,,,,RT,outpatient,,,46507.68,27904.61,,,,,,,,,,,,,
Hemorrhoid Ntrnl & Xtrnl 1 Column W/Fissurecto,CASE-46257,LOCAL,46257,CPT,0360,RC,,,,outpatient,,,16932.28,10159.37,,,,,,,,,,,,,
Edg US Exam Surgical Alter Stom Duodenum/Jejunum,CASE-43259,LOCAL,43259,CPT,,,,,,outpatient,,,11107.75,6664.65,,,,,,,,,,,,,
Surg Nasopharyngoscopy Dilat Eustachian Tube Bi,CASE-69706,LOCAL,69706,CPT,,,,,,outpatient,,,22622.48,13573.49,,,,,,,,,,,,,
Exc Breast Les Preop Plmt Rad Marker Open 1 Les|RIGHT SIDE|SEPARATE PRACTITIONER,CASE-19125,LOCAL,19125,CPT,0360,RC,,,RT|XP,outpatient,,,113631.43,68178.86,,,,,,,,,,,,,
PROSTHESIS OTO L9MM OD3.25MM HA AND TI MID EAR OSS W/ SH,SUP-2284002,CDM,L8613,CPT,0278,RC,,,,both,,,1573.61,1022.85,,,,,,,,,,,,,
GRAFT DERMAL RECT 9.8X15.7 IN ANTIBACT XENMATRIX AB,SUP-2855245,CDM,C1781,HCPCS,0278,RC,,,,both,,,105059.38,68288.60,,,,,,,,,,,,,
SCREW BNE PEGGED 2.5X26 MM THRD MULTIDIRECTIONAL NS,SUP-2861096,CDM,C1713,HCPCS,0278,RC,,,,both,,,446.32,290.11,,,,,,,,,,,,,
CATHETER HAD L28CM OD14.5FR POLYUR STR SHTH INTRO DIL TUNN,SUP-2117422,CDM,C1750,HCPCS,0278,RC,,,,both,,,712.78,463.31,,,,,,,,,,,,,
CATHETER URET L70CM OD6FR POLYUR 2 SIDE EYE OLV TIP FLX,SUP-2129010,CDM,C1758,HCPCS,0278,RC,,,,both,,,21.26,13.82,,,,,,,,,,,,,
TRAY ACCS ENDOSCP W TWO BLDELSS STBL SLV 5 12X100MM,SUP-2220457,CDM,C1713,HCPCS,0278,RC,,,,both,,,290.61,188.90,,,,,,,,,,,,,
CATHETER THROMCTMY ZOOM 35 L 160 CM DIA 5 FR DSTL OD/ID 4,SUP-2739210,CDM,C1757,HCPCS,0272,RC,,,,both,,,5290.90,3439.08,,,,,,,,,,,,,
BLADE RTRCTR MAYO 2INW X 35NL ALMNM NON RDPQUE NON ST,SUP-2703357,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1370.67,890.94,,,,,,,,,,,,,
SHEATH INTRO ACCEL L 20CM DIA 6 FR L 60/145 CM DIA 21 GA NIT,SUP-2659242,CDM,C1894,HCPCS,0272,RC,,,,both,,,257.01,167.06,,,,,,,,,,,,,
KIT DSG 1.3X5.9X10CM STD SZ BLK NEG PRSS ABD SYS,SUP-2262323,CDM,2720000010,LOCAL,0272,RC,,,,both,,,958.39,622.95,,,,,,,,,,,,,
SCREW BONE L70MM DIA4MM STD CORT NONCANNULATED LCK PARTIALLY,SUP-2348844,CDM,C1713,HCPCS,0278,RC,,,,both,,,273.05,177.48,,,,,,,,,,,,,
FIBER LASER 30 DEG INFRATOME,SUP-2225607,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1648.50,1071.52,,,,,,,,,,,,,
CONNECTOR SPNL 21MM LEN LAT XLNK POST FIX 4.5 TO 6.5MM ROD,SUP-2229620,CDM,C1713,HCPCS,0278,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
GUIDEWIRE SURG L150MM DIA1.6MM,SUP-2405548,CDM,C1769,HCPCS,0272,RC,,,,both,,,123.09,80.01,,,,,,,,,,,,,
Mastopexy,CASE-19316,LOCAL,19316,CPT,0360,RC,,,,outpatient,,,77089.20,46253.52,,,,,,,,,,,,,
Mastopexy,CASE-19316,LOCAL,19316,CPT,,,,,,outpatient,,,77089.20,46253.52,,,,,,,,,,,,,
"Amputation Metatarsal W/Toe Single|RIGHT FOOT, FIFTH DIGIT",CASE-28810,LOCAL,28810,CPT,0360,RC,,,T9,outpatient,,,34933.33,20960.00,,,,,,,,,,,,,
"Amputation Metatarsal W/Toe Single|RIGHT FOOT, FIFTH DIGIT",CASE-28810,LOCAL,28810,CPT,,,,,T9,outpatient,,,34933.33,20960.00,,,,,,,,,,,,,
DEVICE ENDOSKELETAL SYS PROSTHETIC BK MOLD DSTL CUSH,SUP-2388209,CDM,L5668,HCPCS,0272,RC,,,,both,,,267.03,173.57,,,,,,,,,,,,,
GRAFT BIO TISS W4XL4CM FET BOV DERM SLD PRIMATRIX AG,SUP-2243708,CDM,Q4110,HCPCS,0636,RC,,,,both,,,2339.93,1520.95,,,,,,,,,,,,,
BIT DRL L300MM DIA13MM CANN,SUP-2188080,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1822.24,1184.46,,,,,,,,,,,,,
COMPONENT FEM LG LT KNEE ZNG LIBRA,SUP-2442358,CDM,C1776,CPT,0278,RC,,,,both,,,833.67,541.89,,,,,,,,,,,,,
GRAFT BNE SUB 30CC 4 10MM CANC CRUSH CHIP READIGRFT,SUP-2264822,CDM,C1713,HCPCS,0278,RC,,,,both,,,1052.84,684.35,,,,,,,,,,,,,
APPLICATOR BRACHYTHERAPY CONTURA BLLN L44CM DIA 5CM 58ML,SUP-2239952,CDM,C1728,HCPCS,0272,RC,,,,both,,,8375.95,5444.37,,,,,,,,,,,,,
DRAIN SURG 10 FRX250 CM NASOBILIARY KT,SUP-2167502,CDM,C1713,HCPCS,0278,RC,,,,both,,,320.28,208.18,,,,,,,,,,,,,
GUIDEWIRE VASC VASSALLO GT L 190 CM DIA 0.018 IN TIP LOAD 3,SUP-2909313,CDM,C1769,HCPCS,0272,RC,,,,both,,,118.25,76.86,,,,,,,,,,,,,
ALLOGRAFT BNE BLOCK 30X20X20 MM FD CANC,SUP-2792178,CDM,C1713,HCPCS,0278,RC,,,,both,,,3074.69,1998.55,,,,,,,,,,,,,
MESH SURG DIA70MM THK0.4MM SLV CRANIOFACIAL TI MALL CNTOUR,SUP-2181579,CDM,C1713,HCPCS,0278,RC,,,,both,,,5301.58,3446.03,,,,,,,,,,,,,
AUGMENT FEM M THK4MM STD UNIV R MED L LAT DST KNEE CEM BLK,SUP-2406993,CDM,C1776,CPT,0278,RC,,,,both,,,3356.66,2181.83,,,,,,,,,,,,,
WASHER ORTH L RND FOR 65 73MM CANN SCR,SUP-2184675,CDM,C1713,HCPCS,0278,RC,,,,both,,,456.34,296.62,,,,,,,,,,,,,
Revision of Reconstructed Breast|LEFT SIDE,CASE-19380,LOCAL,19380,CPT,0360,RC,,,LT,outpatient,,,49819.20,29891.52,,,,,,,,,,,,,
Cystourethroscopy Inj Chemodenervation Bladder|SEPARATE STRUCTURE,CASE-52287,LOCAL,52287,CPT,,,,,XS,outpatient,,,23349.62,14009.77,,,,,,,,,,,,,
HC Inj Aa&/Strd Other Peripheral Nerve/Branch|LEFT SIDE,CASE-64450,LOCAL,64450,CPT,0450,RC,,,LT,outpatient,,,4008.43,2405.06,,,,,,,,,,,,,
HC Joint Injection/Aspir Large WO US|BILATERAL PROCEDURE,CASE-20610,LOCAL,20610,CPT,0510,RC,,,50,outpatient,,,4401.90,2641.14,,,,,,,,,,,,,
Cystourethroscopy Inj Chemodenervation Bladder|SEPARATE STRUCTURE,CASE-52287,LOCAL,52287,CPT,0360,RC,,,XS,outpatient,,,23349.62,14009.77,,,,,,,,,,,,,
Revision of Reconstructed Breast|LEFT SIDE,CASE-19380,LOCAL,19380,CPT,,,,,LT,outpatient,,,49819.20,29891.52,,,,,,,,,,,,,
COMPONENT FEM SM L KNEE PRI CEM STEMLESS POST STABILIZING,SUP-2406880,CDM,C1776,CPT,0278,RC,,,,both,,,14956.45,9721.69,,,,,,,,,,,,,
COLLAR CERV H325XL19IN M TRACH CLS VELC CLSR CNTOUR LO DENS,SUP-2196900,CDM,L0120,HCPCS,0272,RC,,,,both,,,8.54,5.55,,,,,,,,,,,,,
HC Dress or Debride Burn Small,PX-4501602000,CDM,16020,CPT,0450,RC,,,,both,,,421.00,273.65,,,,,,,,,,,,,
PLATE BNE OLECRANON LNG 162 MM RT 19 HOLE EVOLVE EPS,SUP-2535926,CDM,C1713,HCPCS,0278,RC,,,,both,,,3965.82,2577.78,,,,,,,,,,,,,
RING EXT FIX HALF 80 MM NS TRUELOK LTX,SUP-2875062,CDM,2720000010,LOCAL,0272,RC,,,,both,,,923.16,600.05,,,,,,,,,,,,,
SCREW BNE LCK 2.7 X70 MM T10 DRV FT STRL VARIAX 2,SUP-2457673,CDM,C1713,HCPCS,0278,RC,,,,both,,,833.04,541.48,,,,,,,,,,,,,
STENT TRACHBRONCH WSTNT L 20 MM DIA14 MM SHTH 10 FR CATH L,SUP-2147032,CDM,C1876,HCPCS,0278,RC,,,,both,,,3199.50,2079.67,,,,,,,,,,,,,
DISC SHIM LENGTHENING FOR MARS 3V SYS,SUP-2232224,CDM,C1776,CPT,0278,RC,,,,both,,,1303.10,847.01,,,,,,,,,,,,,
GUIDEWIRE SURG L230MM DIA2MM BLK S STL FULL THRD SHRP TIP,SUP-2186887,CDM,C1769,HCPCS,0272,RC,,,,both,,,98.82,64.23,,,,,,,,,,,,,
CATHETER .014 6.0X150X135 POLARCATH,SUP-2141238,CDM,C1725,HCPCS,0272,RC,,,,both,,,3463.42,2251.22,,,,,,,,,,,,,
PLATE BONE RT STP METATARSOPHALANGEAL JT VAR LCK COMPR,SUP-2390554,CDM,C1713,HCPCS,0278,RC,,,,both,,,5526.40,3592.16,,,,,,,,,,,,,
HC Treat Humerus Fx,PX-4502453000,CDM,24530,CPT,0450,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
CATHETER THROMCTMY ANGIOJET SPIROFLEX VG L 135 CM DIA14 FR,SUP-2277424,CDM,C1757,HCPCS,0272,RC,,,,both,,,4694.30,3051.29,,,,,,,,,,,,,
SCREW BNE L 20 MM DIA2.7 MM TI HI TORQUE XDRV FOR 2.4 MM SYS,SUP-2934722,CDM,C1713,HCPCS,0278,RC,,,,both,,,346.66,225.33,,,,,,,,,,,,,
GUIDEPIN ORTH L14IN DIA3.2MM THRD DISP FOR VERSANAIL HUM 3PK,SUP-2411839,CDM,2720000010,LOCAL,0272,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
PLATE BNE CALCANEAL LG LT SINUS TARSI FRAC TI BABY GORILLA,SUP-2751019,CDM,C1713,HCPCS,0278,RC,,,,both,,,3414.75,2219.59,,,,,,,,,,,,,
LEVETIRACETAM IN NACL 1500 MG/100ML IV SOLN,RX-112653,CDM,J1953,HCPCS,0636,RC,67457-0266-00,NDC,,both,100,ML,163.90,106.53,,,,,,,,,,,,,
DRILL SURG N CEM 4-6 FBT HI PERF SIG,SUP-2456274,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1924.82,1251.13,,,,,,,,,,,,,
HC Treat Humerus Fx,PX-4502360000,CDM,23600,CPT,0450,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
CATHETER ABLAT 7FR L110CM TIP L8MM 2.5MM SPC QPLR L CRV,SUP-2141344,CDM,C1732,HCPCS,0278,RC,,,,both,,,7536.00,4898.40,,,,,,,,,,,,,
GUIDE GRFT ANCHR HELI-FX WORKING L 62 CM DIA16 FR DEFLECTED,SUP-2749556,CDM,C1768,CPT,0278,RC,,,,both,,,5529.54,3594.20,,,,,,,,,,,,,
PLATE BONE LOCKING SMALL 3.5X243X11X3.4 MM 16 HOLE COMPRESSI,SUP-2837438,CDM,C1713,HCPCS,0278,RC,,,,both,,,6350.49,4127.82,,,,,,,,,,,,,
PLATE PROFYLE M ROTATIONAL 23MM,SUP-2695492,CDM,C1713,HCPCS,0278,RC,,,,both,,,1470.62,955.90,,,,,,,,,,,,,
COIL EMB L30CM DIA0.02IN LOOP DIA4MM COMPLX STD FRME RUBY,SUP-2323658,CDM,C1889,HCPCS,0278,RC,,,,both,,,4992.60,3245.19,,,,,,,,,,,,,
GRAFT EVAR L50MM DIAM 8MM TRNSJUG INTRAHEPATIC VIATORR,SUP-2395921,CDM,C1874,HCPCS,0278,RC,,,,both,,,9718.30,6316.89,,,,,,,,,,,,,
FIBER LASER 295 FT KRA-CPAOCHXL HDMI,SUP-2798102,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2485.75,1615.74,,,,,,,,,,,,,
ALLOGRAFT BNE COTTON WDG 20X14X6.5 MM OSTEOTMY SYMALIGN,SUP-2740776,CDM,C1713,HCPCS,0278,RC,,,,both,,,5204.33,3382.81,,,,,,,,,,,,,
PLATE BONE LCK L CRV LT 7 H TI PROX TIB PLATING SYS ALPS,SUP-2413716,CDM,C1713,HCPCS,0278,RC,,,,both,,,4083.57,2654.32,,,,,,,,,,,,,
KIT INFUS PRT L76CM DIA9.6FR PLAS ATTCH SIL SGL LUMN FULL,SUP-2127735,CDM,C1788,HCPCS,0278,RC,,,,both,,,596.60,387.79,,,,,,,,,,,,,
SPLINT KNEE L16IN FOR 29IN THGH UNIV NYL FBR LAM ALUM FOAM,SUP-2196753,CDM,L1830,CPT,0272,RC,,,,both,,,43.08,28.00,,,,,,,,,,,,,
CATHETER 4FR 70CM GWIRE RAD BASIC TY ST PWR PICC SOLO,SUP-2125531,CDM,C1751,HCPCS,0278,RC,,,,both,,,377.87,245.62,,,,,,,,,,,,,
PLATE SPNL ADPT 5 HOLE TI BLU NS MATRIXNEURO,SUP-2181563,CDM,C1713,HCPCS,0278,RC,,,,both,,,697.08,453.10,,,,,,,,,,,,,
IMPLANT COSMETIC DIA18 MM POLYETHYL ORBIT SPHR STRL DISP,SUP-2935216,CDM,C1713,HCPCS,0278,RC,,,,both,,,1347.06,875.59,,,,,,,,,,,,,
PIN FXTN L45MM D4MM CABLE L508MM HIP STNLSS STEEL CABLE READ,SUP-2468796,CDM,C1713,HCPCS,0278,RC,,,,both,,,791.72,514.62,,,,,,,,,,,,,
FLUCONAZOLE 40 MG/ML PO SUSR,RX-14233,CDM,340b,HCPCS,0637,RC,09999-9917-77,NDC,,both,5,ML,25.80,16.77,,,,,,,,,,,,,
TUBE MYR 127MM DIAM BLU VENT TAB SIL DUTCHER,SUP-2313871,CDM,L8699,HCPCS,0278,RC,,,,both,,,59.41,38.62,,,,,,,,,,,,,
ANCHOR SUT MINILOK QUIK ANCHR W/ 2-0 ORTHOCORD RB-1 NDL AND,SUP-2249374,CDM,C1713,HCPCS,0278,RC,,,,both,,,86.07,55.95,,,,,,,,,,,,,
SPLINT ORTH 10IN KNEE BASIC,SUP-2197150,CDM,L1830,CPT,0272,RC,,,,both,,,30.52,19.84,,,,,,,,,,,,,
CENTRALIZER STEM OD8MM ALPINE,SUP-2315811,CDM,C1776,CPT,0278,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
PLATE BONE 4 H RT OLECRANON,SUP-2364577,CDM,C1713,HCPCS,0278,RC,,,,both,,,3373.62,2192.85,,,,,,,,,,,,,
PLATE BNE L172MM 10 H NONSTERILE L ANTEROMEDIAL DST TIB S,SUP-2177680,CDM,C1713,HCPCS,0278,RC,,,,both,,,5235.42,3403.02,,,,,,,,,,,,,
KIT KYPHOPLASTY CEM MX AND TRNSF PK FORTRESS +,SUP-2232194,CDM,2720000010,LOCAL,0272,RC,,,,both,,,800.70,520.45,,,,,,,,,,,,,
HEAD HUM H27MM DIA50MM CURVATURE DIA50MM SHLDR CO CHROM,SUP-2404505,CDM,C1776,CPT,0278,RC,,,,both,,,5287.76,3437.04,,,,,,,,,,,,,
PLATE BNE L31MM THK1.2MM 5 H BILAT HINDFT MIDFT S STL,SUP-2186126,CDM,C1713,HCPCS,0278,RC,,,,both,,,2057.17,1337.16,,,,,,,,,,,,,
PLATE BNE L342MM 16 H NONSTERILE L DST FEM LOK FOR 4.5MM,SUP-2348458,CDM,C1713,HCPCS,0278,RC,,,,both,,,11497.90,7473.63,,,,,,,,,,,,,
BUR DENT 8 FLUT 6 1.8 MM RND UNCOATED HNDPC RT ANGLE CARBIDE,SUP-2322154,CDM,2720000010,LOCAL,0272,RC,,,,both,,,351.68,228.59,,,,,,,,,,,,,
SHEATH INTRO BRT TIP L 23 CM DIA 8 FR DIL TIP L 35 MM BLU,SUP-2156046,CDM,C1894,HCPCS,0272,RC,,,,both,,,94.20,61.23,,,,,,,,,,,,,
SCREW BNE CORTICAL 2.7X18 MM TOT WR SS STRL,SUP-2610361,CDM,C1713,HCPCS,0278,RC,,,,both,,,463.40,301.21,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE L 10 MM DIA 7.5 MM CART ARAGONITE,SUP-2913154,CDM,C1763,HCPCS,0278,RC,,,,both,,,19154.00,12450.10,,,,,,,,,,,,,
SCREW CP LAG 3.6X34MM,SUP-2460800,CDM,C1713,HCPCS,0278,RC,,,,both,,,580.90,377.58,,,,,,,,,,,,,
BORTEZOMIB 3.5 MG IJ SOLR,RX-123853,CDM,J9041,HCPCS,0636,RC,25021-0262-10,NDC,,both,1,UN,115.20,74.88,,,,,,,,,,,,,
ALLOGRAFT HUM TISS FRZN ASEP PRESHAPED ACHILLES TEND,SUP-2867036,CDM,C1762,CPT,0278,RC,,,,both,,,7134.08,4637.15,,,,,,,,,,,,,
SHEATH INTRO FLX BLKN L 40 CM OD 8 FR ID 2.9 MM GUIDEWIRE,SUP-2168570,CDM,C1894,HCPCS,0272,RC,,,,both,,,111.34,72.37,,,,,,,,,,,,,
BUR SURG CYL 5X13.5 MM 9 CM FLUT LG BOR MIDAS REX 8,SUP-2664872,CDM,2720000010,LOCAL,0272,RC,,,,both,,,439.38,285.60,,,,,,,,,,,,,
SET INTRO SUP ARW FLX SHTH L 24 CM DIA 9 FR HYDRPHLC,SUP-2383417,CDM,C1894,HCPCS,0272,RC,,,,both,,,276.32,179.61,,,,,,,,,,,,,
CEMENT BNE 20ML 40GM HALF DOSE PMMA W/O GENT HI VISC RADPQ,SUP-2197461,CDM,C1713,HCPCS,0278,RC,,,,both,,,244.92,159.20,,,,,,,,,,,,,
COLLAR CERV SFT DENS UNIV 24X4.5 IN HK LOOP CLOSURE,SUP-2336316,CDM,L0120,HCPCS,0274,RC,,,,both,,,10.46,6.80,,,,,,,,,,,,,
NEEDLE TRANSSEPTAL L71CM FIX CRV C1 INSUL W/ RF ENERGY NRG,SUP-2131507,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY RADIA L 95 CM DIA 7 FR SPC 2 MM,SUP-2142363,CDM,C1731,HCPCS,0278,RC,,,,both,,,3249.90,2112.43,,,,,,,,,,,,,
VALVE DRAINAGE 0CM H2O SINGLE WITH 1200MM DISTAL CATHETER M,SUP-2821868,CDM,C1729,HCPCS,0272,RC,,,,both,,,13432.01,8730.81,,,,,,,,,,,,,
FIBER LASER 300 MH UNSHEATHED SCP SAFE SMA905 STRL DISP,SUP-2768241,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2503.52,1627.29,,,,,,,,,,,,,
CATHETER CV KT 0.032 IN AD 5 FR X 6 CM 16 GA SINGLE LUMEN,SUP-2763317,CDM,C1751,HCPCS,0278,RC,,,,both,,,84.78,55.11,,,,,,,,,,,,,
COLLAR CERV ADJ FOAM 2 PC THERMOPLASTIC,SUP-2388134,CDM,L0172,HCPCS,0274,RC,,,,both,,,431.62,280.55,,,,,,,,,,,,,
TIP CATH 110DEG MAX COMP SNUS GUID FOR BLLN SINUPLASTY SYS,SUP-2106367,CDM,C1887,HCPCS,0272,RC,,,,both,,,1004.80,653.12,,,,,,,,,,,,,
KIT CVC INJ PRES ARROW G +ARD BLUE PLUS 3 LUMEN 7 FRX20CM,SUP-2743279,CDM,C1751,HCPCS,0278,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
PLATE BNE HK SHT 2.7X12 MM RT CLAV VA LCK COMPR STRL VA-LCP,SUP-2750824,CDM,C1713,HCPCS,0278,RC,,,,both,,,3802.79,2471.81,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE 5 CC DBM FLOWABLE FIBER AMBIENT STOR,SUP-2933199,CDM,C1762,CPT,0278,RC,,,,both,,,1491.50,969.47,,,,,,,,,,,,,
ALLOGRAFT BNE WDG 0 DEG 9 MM LORDTC TRICORT STRL BIO DISP,SUP-2632311,CDM,C1713,HCPCS,0278,RC,,,,both,,,3026.96,1967.52,,,,,,,,,,,,,
PLATE BNE TOD BLDE L26MM DISPLC 4MM 90DEG ST S STL CANN,SUP-2185394,CDM,C1713,HCPCS,0278,RC,,,,both,,,2367.94,1539.16,,,,,,,,,,,,,
SET INTRO SUP ARW FLX SHTH L 11 CM DIA 9 FR HYDRPHLC,SUP-2120624,CDM,C1894,HCPCS,0272,RC,,,,both,,,141.30,91.84,,,,,,,,,,,,,
CATHETER ATHRCTMY ROTLNK L 135 CM DIA 0.058 IN BUR SZ 2.5,SUP-2142285,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4034.27,2622.28,,,,,,,,,,,,,
SCREW BNE MXLFCL TI NS,SUP-2189221,CDM,C1713,HCPCS,0278,RC,,,,both,,,307.25,199.71,,,,,,,,,,,,,
HC Rsf Lab Ecmc - Autopsy Blocks,PX-9900000126,CDM,9900000126,LOCAL,0990,RC,,,,both,,,7.00,4.55,,,,,,,,,,,,,
BUTTON NSL SEPT DIA3CM MED SIL 2 PART ADJ,SUP-2284096,CDM,C1889,HCPCS,0278,RC,,,,both,,,804.15,522.70,,,,,,,,,,,,,
FLUORESCEIN SODIUM 10 % IV SOLN,RX-137858,CDM,A9612,HCPCS,0636,RC,14789-0122-05,NDC,,both,0.5,ML,169.70,110.30,,,,,,,,,,,,,
MESH GORE SYNECOR 40CM X 40CM RECTANGLE,SUP-2763182,CDM,C1781,HCPCS,0278,RC,,,,both,,,38813.54,25228.80,,,,,,,,,,,,,
WIRE FIXATION 2IN 60MM KIRSCHNER,SUP-2210660,CDM,C1713,HCPCS,0278,RC,,,,both,,,37.68,24.49,,,,,,,,,,,,,
BUR DENT L70MM DIA1.8MM 80000RPM DMND DISP BOHRER PM2,SUP-2134822,CDM,2720000010,LOCAL,0272,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
KIT VENTRICULAR DRAINAGE 909707S VC1,SUP-2883647,CDM,C1729,HCPCS,0272,RC,,,,both,,,9794.51,6366.43,,,,,,,,,,,,,
GRAFT HUM TISS L195MM FRZN ALLGRFT ACHILLES GRFT TEND W/,SUP-2307276,CDM,C1762,CPT,0278,RC,,,,both,,,7070.65,4595.92,,,,,,,,,,,,,
SCREW IM L 36 MM DIA 3.5 MM TI CORTICAL ST FLUT THRD HD ZERO,SUP-2900422,CDM,C1713,HCPCS,0278,RC,,,,both,,,989.10,642.91,,,,,,,,,,,,,
COMPONENT FEM CEM SM UNISX RT KNEE REV CR STEM BEAD VIT,SUP-2377035,CDM,C1776,CPT,0278,RC,,,,both,,,13768.90,8949.78,,,,,,,,,,,,,
GRAFT VASC L 50 CM DIA14 MM POLYESTER THOR ABD AORT STR TB,SUP-2482837,CDM,C1768,CPT,0278,RC,,,,both,,,1399.94,909.96,,,,,,,,,,,,,
SCREW CONN FEM TI NAIL STD INSRT AND LOK INSTR FOR HNDL,SUP-2188258,CDM,C1713,HCPCS,0278,RC,,,,both,,,2558.85,1663.25,,,,,,,,,,,,,
CATHETER INFUSION 014 2.1/1.7 FRX150 CM STR MICRO ECHELON 10,SUP-2470027,CDM,C1887,HCPCS,0272,RC,,,,both,,,2461.76,1600.14,,,,,,,,,,,,,
SPLINT FNGR SZ 2 OPN TIP FOR FNGRTIP NAILBED INJ STAX,SUP-2195098,CDM,L3933,HCPCS,0274,RC,,,,both,,,7.03,4.57,,,,,,,,,,,,,
HANDPIECE VITRECTOMY 23 GA 225 + ESA VITESSE,SUP-2537895,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5991.12,3894.23,,,,,,,,,,,,,
CAP LCK S STL REVERE,SUP-2230742,CDM,C1713,HCPCS,0278,RC,,,,both,,,188.40,122.46,,,,,,,,,,,,,
SUPPORT ORTHOT KNEE ANTR CRUC LIGMNT CUST DEROTATION,SUP-2435612,CDM,L1840,HCPCS,0274,RC,,,,both,,,2662.44,1730.59,,,,,,,,,,,,,
PLATE BONE L120MM 6 H BILAT S STL SPN LCK COMPR LO PROF RIG,SUP-2185732,CDM,C1713,HCPCS,0278,RC,,,,both,,,1152.63,749.21,,,,,,,,,,,,,
SYSTEM LAP W/ GELSEAL CAP ALEXIS WND PROTECTOR/RETRACTOR,SUP-2119637,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
COMPONENT TIB CR 3XS UNIV PEDIATRIC 8 MM STEM NP MONOBLOCK,SUP-2376413,CDM,C1776,CPT,0278,RC,,,,both,,,3973.36,2582.68,,,,,,,,,,,,,
PUSHER KNOT CLOSED END 5X400 MM,SUP-2850582,CDM,2720000010,LOCAL,0272,RC,,,,both,,,366.12,237.98,,,,,,,,,,,,,
SIMVASTATIN 5 MG PO TABS,RX-11367,CDM,6370000000,HCPCS,0637,RC,70377-0001-14,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
GRAFT BNE REABSORABLE 40X30 MM MEMBRN CLLGN EXT BIOMEND,SUP-2335234,CDM,C1713,HCPCS,0278,RC,,,,both,,,850.94,553.11,,,,,,,,,,,,,
WIRE FIX DIA1.3MM ANK FT THRD OLV,SUP-2321635,CDM,C1713,HCPCS,0278,RC,,,,both,,,373.66,242.88,,,,,,,,,,,,,
TAP SURG POST OCCIPITOCERVICOTHORACIC FOR 3.5MM SCR ELLIPSE,SUP-2232211,CDM,C1713,HCPCS,0278,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
ELECTRODE ELECSURG LOOP MED 12 DEG BPLR QUICK-FIRE,SUP-2435504,CDM,2720000010,LOCAL,0272,RC,,,,both,,,855.18,555.87,,,,,,,,,,,,,
BUR SURG DIA5MM DMND RND EXTRA COARSE EXPOSE MRK 5 STP,SUP-2367586,CDM,2720000010,LOCAL,0272,RC,,,,both,,,410.49,266.82,,,,,,,,,,,,,
CATHETERIZATION KIT AD 7 FRX16 CM CV ARROWG+ARD,SUP-2383380,CDM,C1751,HCPCS,0278,RC,,,,both,,,254.18,165.22,,,,,,,,,,,,,
MEROPENEM 1 G IV SOLR,RX-17380,CDM,J2185,HCPCS,0636,RC,55150-0208-30,NDC,,both,1,UN,63.30,41.14,,,,,,,,,,,,,
BIT DRL L230MM DIA32MM 3 FLUT CALIB QUIK CONN,SUP-2199210,CDM,2720000010,LOCAL,0272,RC,,,,both,,,486.45,316.19,,,,,,,,,,,,,
STENT BILI L14MM BLLN L17MM DIA5MM CATH L135CM 14/12ATM,SUP-2159004,CDM,C1876,HCPCS,0278,RC,,,,both,,,2449.20,1591.98,,,,,,,,,,,,,
PLATE BONE W10.3XL85.6MM THK3.7MM 6 H TI LOK COMPR LO PROF,SUP-2413706,CDM,C1713,HCPCS,0278,RC,,,,both,,,621.72,404.12,,,,,,,,,,,,,
SET CATH L3.8CM OD5.1MM ID3.5MM W/ INTRO NDL 6ML SYR NO15,SUP-2168128,CDM,C1769,HCPCS,0272,RC,,,,both,,,788.14,512.29,,,,,,,,,,,,,
I/B II PSCK TIB ART SURF 59/54X12MM,SUP-2502042,CDM,C1776,CPT,0278,RC,,,,both,,,6568.88,4269.77,,,,,,,,,,,,,
LORAZEPAM 2 MG/ML PO CONC,RX-4571,CDM,340b,HCPCS,0637,RC,00121-0770-01,NDC,,both,0.25,ML,2.70,1.75,,,,,,,,,,,,,
SEALANT TISS FIBRIN 2 CC DUPLOSPRAY TISSEEL 921029] BAXALTA US INC],SUP-2129876,CDM,2720000010,LOCAL,0272,RC,,,,both,,,646.21,420.04,,,,,,,,,,,,,
PACEMAKER CARD PERM 2 CHMBR NOT MRI COMPATIBLE STD 2360L] ST JUDE MEDICAL INC],SUP-2356704,CDM,C1785,HCPCS,0275,RC,,,,both,,,14130.00,9184.50,,,,,,,,,,,,,
CONE FEM SM H30MM R DPHSEAL TRABECULAR MTL,SUP-2200209,CDM,C1776,CPT,0278,RC,,,,both,,,9558.16,6212.80,,,,,,,,,,,,,
KNIFE SURG FUKUSHIMA GIANNOTTA MIC 90 DEG 7.25 INX4.1 MM,SUP-2485319,CDM,2720000010,LOCAL,0272,RC,,,,both,,,510.03,331.52,,,,,,,,,,,,,
LENS INTOCU 21.5 DIOPT TRIFOCAL UV ABSRB AND BLU LT,SUP-2418691,CDM,V2788,HCPCS,0276,RC,,,,both,,,995.00,646.75,,,,,,,,,,,,,
SET VENT CATH L35CM OD2.9MM ID1.6MM BA STRP L STYL LUER,SUP-2244096,CDM,C1729,HCPCS,0272,RC,,,,both,,,352.94,229.41,,,,,,,,,,,,,
DEVICE SUT W/ V-LOC SUT SZ 2-0 L8IN ABSRB LD UNIT SUT BARB,SUP-2174811,CDM,2720000010,LOCAL,0272,RC,,,,both,,,396.05,257.43,,,,,,,,,,,,,
LEVEL NEURO ST PLATE ULTRNE LDDR WTAB NEURO SCRW2 X 2 HOLES,SUP-2681854,CDM,C1713,HCPCS,0278,RC,,,,both,,,856.78,556.91,,,,,,,,,,,,,
DISTALDORSO-ULNARDORSO-RADIALL-PLATESR6H,SUP-2816182,CDM,C1713,HCPCS,0278,RC,,,,both,,,3501.10,2275.71,,,,,,,,,,,,,
CATHETER SPEC RETRV 035 7-5 FRX200 CM 8.5 MM ABV TRI-EX,SUP-2738204,CDM,2720000010,LOCAL,0272,RC,,,,both,,,401.92,261.25,,,,,,,,,,,,,
HC Pericardiocentesis Including Imag Guid When Performed,PX-4503301600,CDM,33016,CPT,0450,RC,,,,both,,,3477.00,2260.05,,,,,,,,,,,,,
"HC So Enzyme Activity,Cells/Tissue",PX-3018265766,CDM,82657,CPT,0301,RC,,,,inpatient,,,223.00,144.95,,,,,,,,,,,,,
SCREW LANX MINI-INVAS 6.5X50,SUP-2137019,CDM,C1713,HCPCS,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
KIT INTRO ARW FLX SHTH L 10 CM DIA 9 FR POLYUR INTEGR,SUP-2763350,CDM,C1892,HCPCS,0272,RC,,,,both,,,228.59,148.58,,,,,,,,,,,,,
STENT INTRAOCULAR ISTENT INFINITE H 360 UM DIA 360 UM CNTRL,SUP-2866316,CDM,C1783,HCPCS,0278,RC,,,,both,,,5024.00,3265.60,,,,,,,,,,,,,
PROSTHESIS VOICE 22.5FR 4MM PRELD W/ SMRT INSRTR AND BRSH,SUP-2124407,CDM,L8509,HCPCS,0272,RC,,,,both,,,1029.35,669.08,,,,,,,,,,,,,
COVER BURR HOLE 17MM DIA 03MM THK CMMRCLLY PURE TTNM CNTRD,SUP-2677365,CDM,C1713,HCPCS,0278,RC,,,,both,,,713.44,463.74,,,,,,,,,,,,,
DRILL SURG L220MM 75MM COUNTSINK,SUP-2396985,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1055.04,685.78,,,,,,,,,,,,,
DEFIBRILLATOR CRD 2 CHMBR 51X69X12 MM 31 CC 71 GM GALLANT DR,SUP-2707576,CDM,C1721,HCPCS,0275,RC,,,,both,,,43313.16,28153.55,,,,,,,,,,,,,
PLATE TUBULAR 3.5MM 1/3 6HL,SUP-2720115,CDM,C1713,HCPCS,0278,RC,,,,both,,,985.58,640.63,,,,,,,,,,,,,
IMPLANT SYNTH LG PMMA CRAN CUSTOMIZED IMPL KT STRL MEDPOR,SUP-2883598,CDM,C1713,HCPCS,0278,RC,,,,both,,,52294.78,33991.61,,,,,,,,,,,,,
GAMMATILE THERAPY DEVICE 6 PACK,SUP-2855640,CDM,C2642,HCPCS,0278,RC,,,,both,,,16746.66,10885.33,,,,,,,,,,,,,
SCREW BNE L30MM DIA6.28MM S STL CANC CANN LOK FULL THRD,SUP-2370999,CDM,C1713,HCPCS,0278,RC,,,,both,,,699.28,454.53,,,,,,,,,,,,,
CATHETER GUID CLS4 6 FRX110 CM RUNWAY,SUP-2140731,CDM,C1887,HCPCS,0272,RC,,,,both,,,147.58,95.93,,,,,,,,,,,,,
CATHETER REPROC EP CRD DIAG RESPON,SUP-2467200,CDM,C1730,HCPCS,0272,RC,,,,both,,,245.71,159.71,,,,,,,,,,,,,
CAGE SPNL ACCULIF TL 6 9MM,SUP-2379556,CDM,C1889,HCPCS,0278,RC,,,,both,,,14915.00,9694.75,,,,,,,,,,,,,
COIL NEUROVASCULAR CASHMERE 14 L 12 CM LOOP DIA 5 MM PRIMARY,SUP-2249268,CDM,C1889,HCPCS,0278,RC,,,,both,,,3883.40,2524.21,,,,,,,,,,,,,
PLATE BNE L316MM 13 H NONSTERILE R DST FEM TI LOK COMPR FOR,SUP-2190729,CDM,C1713,HCPCS,0278,RC,,,,both,,,5128.09,3333.26,,,,,,,,,,,,,
BALL CARPAL LG NEUT,SUP-2471154,CDM,C1776,CPT,0278,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
IMPLANT TOE JT LESSER MT CANN CO CHROME 1175MM,SUP-2137786,CDM,C1776,CPT,0278,RC,,,,both,,,2590.50,1683.82,,,,,,,,,,,,,
SET SCR SPNL S STL BRKOFF FOR 6.35MM ROD CDH LEG,SUP-2288807,CDM,C1713,HCPCS,0278,RC,,,,both,,,455.14,295.84,,,,,,,,,,,,,
ROD SPNL ADJ 3.5X100 MM OCCIPITOCERVICAL COCRMOLY INFIN,SUP-2631926,CDM,C1713,HCPCS,0278,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
CUTTER SUTURE MENIS REP DEV JUGGERSTITCH DISP,SUP-2421745,CDM,2720000010,LOCAL,0272,RC,,,,both,,,467.23,303.70,,,,,,,,,,,,,
SPACER CORPECTOMY W14XH21XD12MM SM SAG PROF 3.5/3.5DEG NIKO,SUP-2231166,CDM,C1821,HCPCS,0278,RC,,,,both,,,9106.00,5918.90,,,,,,,,,,,,,
ACL FIBERTAG TIGHTROPE IMPLANT SYSTEM  AR1288QT80,SUP-2843664,CDM,C1713,HCPCS,0278,RC,,,,both,,,3061.50,1989.97,,,,,,,,,,,,,
IMPLANT SPNL H45 73MM 6DEG LUM W L ENDPLATE RATCH MECHANISM,SUP-2193205,CDM,C1889,HCPCS,0278,RC,,,,both,,,21352.00,13878.80,,,,,,,,,,,,,
HC Inj/Asp Maj Jnt or Bursa|BILATERAL PROCEDURE|PBB CHARGE,PX-7612061000,CDM,20610,CPT,0761,RC,,,50|PBB,outpatient,,,1092.00,709.80,,,,,,,,,,,,,
SET PERICARDCENT CATH 8.3FR NDL 18GA CATH L40CM NDL L15CM,SUP-2168548,CDM,C1729,HCPCS,0272,RC,,,,both,,,467.86,304.11,,,,,,,,,,,,,
MICROCATHETER GUID SASUKE L 145 CM SHFT OD DSTL/PROX,SUP-2487288,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1365.90,887.83,,,,,,,,,,,,,
SCREW BNE CORTICAL 3.5X36 MM STRL,SUP-2412514,CDM,C1713,HCPCS,0278,RC,,,,both,,,121.64,79.07,,,,,,,,,,,,,
GUIDEWIRE VASC ANGLED 3 CM 0.035 INX150 CM STIFF GLIDEWIRE,SUP-2385588,CDM,C1769,HCPCS,0272,RC,,,,both,,,163.28,106.13,,,,,,,,,,,,,
STEM FEM PRSS FT 3 HIP PRIMARY CEM UPLR/BPLR LNR POLYETH,SUP-2267797,CDM,C1776,CPT,0278,RC,,,,both,,,11932.00,7755.80,,,,,,,,,,,,,
OSS TIBIAL SLEEVE AUGMENT SM,SUP-2506412,CDM,C1776,CPT,0278,RC,,,,both,,,2274.93,1478.70,,,,,,,,,,,,,
WAND ABLAT R ANG 90DEG W/O SUCT 3.5MM,SUP-2341957,CDM,2720000010,LOCAL,0272,RC,,,,both,,,649.98,422.49,,,,,,,,,,,,,
ARCH EXT FIX DIA210MM FT C FBR POLYMER FOR HOFFMANN LRF SYS,SUP-2363183,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5821.56,3784.01,,,,,,,,,,,,,
BIT DRL DIA2.7MM STD CANN ADD ON QUIK CONN FOR PERIARTC,SUP-2410866,CDM,2720000010,LOCAL,0272,RC,,,,both,,,527.83,343.09,,,,,,,,,,,,,
GRAFT SPCR SPINE PARA PEEK VISTA P TANT BEAD MRK 27MM 8MMH,SUP-2414320,CDM,C1713,HCPCS,0278,RC,,,,both,,,9923.97,6450.58,,,,,,,,,,,,,
INSERT ACET OD48MM ID28MM GG METASUL HIP ALPHA UNCEMENTED,SUP-2204511,CDM,C1776,CPT,0278,RC,,,,both,,,6231.33,4050.36,,,,,,,,,,,,,
DEFIBRILLATOR IMPL EVERA MRI XT VR MRI SURESCAN W 51 X H 66,SUP-2282426,CDM,C1722,HCPCS,0275,RC,,,,both,,,42052.23,27333.95,,,,,,,,,,,,,
COIL NEUROVASCULAR OPTMA L 20 CM DIA 6 MM SZ 0.010 IN SFT,SUP-2753874,CDM,C1889,HCPCS,0278,RC,,,,both,,,5730.50,3724.82,,,,,,,,,,,,,
HC Exchange Biliary Drng Cath,PX-3614753600,CDM,47536,CPT,0361,RC,,,,both,,,11207.00,7284.55,,,,,,,,,,,,,
GRAFT VASC FLIXENE L 50 CM DIA 8 MM EPTFE STR GRAD REINF 3,SUP-2265948,CDM,C1768,CPT,0278,RC,,,,both,,,3673.80,2387.97,,,,,,,,,,,,,
SHANK SPNL SCREW L 55 MM DIA 7.5 MM OSTEOGRIP STRL CD HORZ 2PK,SUP-2928492,CDM,C1713,HCPCS,0278,RC,,,,both,,,2686.58,1746.28,,,,,,,,,,,,,
NEEDLE STIM L5IN STR INSRT NEUROMODULATION,SUP-2138807,CDM,C1713,HCPCS,0278,RC,,,,both,,,514.33,334.31,,,,,,,,,,,,,
CUTTER WIRE DBL ACT 7 IN SIDE CUT SAW EDGE TUNGSTEN CARBIDE,SUP-2273737,CDM,C1713,HCPCS,0278,RC,,,,both,,,740.54,481.35,,,,,,,,,,,,,
PIN EXT FIX TEMP PLATE,SUP-2468404,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1095.86,712.31,,,,,,,,,,,,,
ALLOGRAFT BNE HEMI PELVIS FRZN,SUP-2321868,CDM,C1713,HCPCS,0278,RC,,,,both,,,21308.04,13850.23,,,,,,,,,,,,,
CATHETER PET TI SGL LUMN PRT W/ 6.5FR DETACHED SIL AND,SUP-2169588,CDM,C1788,HCPCS,0278,RC,,,,both,,,1261.12,819.73,,,,,,,,,,,,,
GRAFT BNE SUB 7.5GM PTTY SYN SIGNAFUSE,SUP-2138529,CDM,C9359,HCPCS,0278,RC,,,,both,,,2896.65,1882.82,,,,,,,,,,,,,
PLATE BNE L53MM THK1.2MM 3X8 H TI T SHP FOR 2MM SCR,SUP-2191244,CDM,C1713,HCPCS,0278,RC,,,,both,,,1169.18,759.97,,,,,,,,,,,,,
T-PLT STERILIZER 8 HL 148 MM LENGTH,SUP-2818458,CDM,C1713,HCPCS,0278,RC,,,,both,,,3124.99,2031.24,,,,,,,,,,,,,
ANKLE FUSION PLATE ANTERIOR TT LT 6H,SUP-2815306,CDM,C1713,HCPCS,0278,RC,,,,both,,,9263.00,6020.95,,,,,,,,,,,,,
K WIRE FIX L6IN DIA1.6MM FEM TIB SMOOTH BAYNT TOT FT FOR,SUP-2412144,CDM,C1713,HCPCS,0278,RC,,,,both,,,82.90,53.88,,,,,,,,,,,,,
SET TRAVENOL A/O 5 PRNG MFLD,SUP-2130775,CDM,C1713,HCPCS,0278,RC,,,,both,,,657.17,427.16,,,,,,,,,,,,,
COMPONENT FEM L3CM L DST FEM KNEE RESURF ORTH SALV SYS,SUP-2405702,CDM,C1776,CPT,0278,RC,,,,both,,,17803.80,11572.47,,,,,,,,,,,,,
BIT DRL DIA3.2MM SLD FOR JONE FRAC SYS CHARLOTTE CAROLINA,SUP-2398090,CDM,2720000010,LOCAL,0272,RC,,,,both,,,433.32,281.66,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA IR 3FR 55CM 1 LUMA S3193335,SUP-2632838,CDM,C1751,HCPCS,0278,RC,,,,both,,,445.53,289.59,,,,,,,,,,,,,
SET INFUSION CATH L 40 CM DIA 5 FR SEG L 15 CM GUIDEWIRE,SUP-2168326,CDM,C1751,HCPCS,0278,RC,,,,both,,,277.54,180.40,,,,,,,,,,,,,
COUNTERSINK SND PROC 4MM W DISP FOR PONTO SYS,SUP-2319886,CDM,C1713,HCPCS,0278,RC,,,,both,,,653.91,425.04,,,,,,,,,,,,,
ANCHOR SUT L14.7MM DIA5.5MM PEEK W/ TWO SZ 2 FIBERWIRE,SUP-2121565,CDM,C1713,HCPCS,0278,RC,,,,both,,,648.41,421.47,,,,,,,,,,,,,
GRAFT PIP STRL ALLGRFT 2MM WX15MM L TENFUSE,SUP-2401369,CDM,C1776,CPT,0278,RC,,,,both,,,4229.58,2749.23,,,,,,,,,,,,,
PLATE TI LOCKING 1.3MM STRAIGHT 6 HOLES STERILE,SUP-2546878,CDM,C1713,HCPCS,0278,RC,,,,both,,,1404.30,912.79,,,,,,,,,,,,,
IMPLANT HUM TISS L 6 CM DIA 6 MM FEM VEIN COMPETENT VLV,SUP-2933507,CDM,C1762,CPT,0278,RC,,,,both,,,18835.54,12243.10,,,,,,,,,,,,,
TRAY PICC CATH 5FR POLYUR BASIC TRIM LEN SGL LUMN IR PWR,SUP-2125534,CDM,C1751,HCPCS,0278,RC,,,,both,,,371.46,241.45,,,,,,,,,,,,,
GUIDEPIN ORTH L 350 MM DIA 3.2 MM DRL TIP LG TARGETER STRL,SUP-2931157,CDM,C1713,HCPCS,0278,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
SUTURE NONABSORBABLE MONOFILAMENT 5-0 CV-6 PT-9 24 IN GORTX 6K06B,SUP-2395523,CDM,C1713,HCPCS,0278,RC,,,,both,,,3118.02,2026.71,,,,,,,,,,,,,
"HC New Pt, E/M Level 3",PX-5109920300,CDM,99203,CPT,0510,RC,,,,both,,,321.00,208.65,,,,,,,,,,,,,
BLADE REPROC M4 TRICUT ROTATABLE,SUP-2526001,CDM,2720000010,LOCAL,0272,RC,,,,both,,,198.26,128.87,,,,,,,,,,,,,
GUIDEPIN SURG L70MM DIA1MM FUS RECON SYS,SUP-2414158,CDM,2720000010,LOCAL,0272,RC,,,,both,,,94.20,61.23,,,,,,,,,,,,,
DROPERIDOL 2.5 MG/ML IJ SOLN,RX-2654,CDM,J1790,HCPCS,0636,RC,00143-9515-01,NDC,,both,0.25,ML,54.10,35.16,,,,,,,,,,,,,
PASSER SUTURE STR 12 GAX16 CM SFT TISS NOVAPASS,SUP-2863653,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1350.20,877.63,,,,,,,,,,,,,
SCREW BONE L28MM DIA3.5MM S STL PARTIALLY THRD HEX SOCK AX,SUP-2183536,CDM,C1713,HCPCS,0278,RC,,,,both,,,64.02,41.61,,,,,,,,,,,,,
PLATE BONE CRANIAL 4 HOLE X-PLATE 11X11MM TITANIUM NEURO PLA,SUP-2826282,CDM,C1713,HCPCS,0278,RC,,,,both,,,292.96,190.42,,,,,,,,,,,,,
SIZER MAMM 250CC DIA10.8CM P4CM NACL SMOOTH RND MOD + PROF,SUP-2300453,CDM,C1789,HCPCS,0278,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
BALLOON SPEC RETRV 0.035 IN 7-5 FRX200 CM 15 MM FUSION LTX,SUP-2737406,CDM,2720000010,LOCAL,0272,RC,,,,both,,,474.14,308.19,,,,,,,,,,,,,
GRAFT VASC TW 8 MMX70 CM STR SFT WRP TUNN ATTCH ADVANTA VXT,SUP-2468029,CDM,C1768,CPT,0278,RC,,,,both,,,1453.32,944.66,,,,,,,,,,,,,
CATHETER URET 5FR L70CM RT PVC WHSTL TIP USED FOR DRNGE RG,SUP-2168871,CDM,C1758,HCPCS,0278,RC,,,,both,,,52.94,34.41,,,,,,,,,,,,,
BIT DRL L125MM DIA3.2MM GRY ATTCH W/O STP NONRADIOLUCENT BI,SUP-2373943,CDM,2720000010,LOCAL,0272,RC,,,,both,,,473.36,307.68,,,,,,,,,,,,,
ENDOPROSTHESIS VASC WSTNT RP L 20 MM DIA 7 MM CATH TOT L 160,SUP-2148372,CDM,C1876,HCPCS,0278,RC,,,,both,,,3972.10,2581.86,,,,,,,,,,,,,
PIN FIX L9IN OD5/32IN S STL TYP D STNMN,SUP-2342724,CDM,C1713,HCPCS,0278,RC,,,,both,,,274.12,178.18,,,,,,,,,,,,,
KIT REP ANCHR LISFRANC INTERNALBRACE,SUP-2121457,CDM,C1713,HCPCS,0278,RC,,,,both,,,4694.30,3051.29,,,,,,,,,,,,,
PROCESSOR BONE MAR W/ ACC AND 2 RET LN BG,SUP-2255622,CDM,C1713,HCPCS,0278,RC,,,,both,,,1527.61,992.95,,,,,,,,,,,,,
COMPONENT 1X1.5MM OFFSET KNEE RESURF ARTC UNICAP,SUP-2123714,CDM,C1776,CPT,0278,RC,,,,both,,,2053.56,1334.81,,,,,,,,,,,,,
WASHER SPNL THORLUM PEDCL TI XIA,SUP-2379331,CDM,C1713,HCPCS,0278,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
PLATE BNE RADIAL 2.4X45 MM RT VOLAR CLMN DSTL 6X3 HOLE LCK,SUP-2177235,CDM,C1713,HCPCS,0278,RC,,,,both,,,2579.60,1676.74,,,,,,,,,,,,,
JOINT TOE STR 16 MM INTER-PHALANGEAL PROX W/ INSTR DYNANITE,SUP-2550531,CDM,C1776,CPT,0278,RC,,,,both,,,5950.30,3867.69,,,,,,,,,,,,,
BINDER BRST SM,SUP-2223739,CDM,L4386,HCPCS,0274,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
ENDOPROSTHESIS BILI VIABIL L 8 CM DIA10 MM L 200 CM H L 2CM,SUP-2883727,CDM,C1874,HCPCS,0278,RC,,,,both,,,9407.44,6114.84,,,,,,,,,,,,,
CATHETER THOR DIA36FR SIL STR W/ CLOT STP STAB-PULL END,SUP-2124836,CDM,C1729,HCPCS,0272,RC,,,,both,,,66.57,43.27,,,,,,,,,,,,,
ELECTRODE ELECSURG POWERBALL 24 FR MONOPOLAR FOR ELITE SYS,SUP-2141800,CDM,2720000010,LOCAL,0272,RC,,,,both,,,370.77,241.00,,,,,,,,,,,,,
GUIDEWIRE 09X120MM TRCR TIP PLN,SUP-2243909,CDM,C1769,HCPCS,0272,RC,,,,both,,,126.13,81.98,,,,,,,,,,,,,
RELOAD STPL L45MM DIA4.8MM GRN UNIV ROTIC SULU ENDO GIA,SUP-2283060,CDM,2720000010,LOCAL,0272,RC,,,,both,,,989.29,643.04,,,,,,,,,,,,,
PLATE BNE RECON 3.5X82 MM 7 HOLE SS,SUP-2569082,CDM,C1713,HCPCS,0278,RC,,,,both,,,362.67,235.74,,,,,,,,,,,,,
HC Perq Device Breast 1st Image,PX-3611928100,CDM,19281,CPT,0361,RC,,,,outpatient,,,5152.00,3348.80,,,,,,,,,,,,,
PROSTHESIS OSS 2.5-7 MM 1.5X2.5 MM 0.86X1.27 MM OFFSET NANO,SUP-2476831,CDM,L8613,CPT,0278,RC,,,,both,,,1524.94,991.21,,,,,,,,,,,,,
IMPLANT COSMETIC SZ 57 X 39 X 5 MM SM POLYETHYL LT MAND,SUP-2935193,CDM,C1713,HCPCS,0278,RC,,,,both,,,1686.18,1096.02,,,,,,,,,,,,,
VALVE AORT MECH ROT MSTR SER HRT VLV PTFE CUF 19MM,SUP-2355078,CDM,C1713,HCPCS,0278,RC,,,,both,,,10048.00,6531.20,,,,,,,,,,,,,
IMIGLUCERASE 400 UNITS IV SOLR,RX-26431,CDM,J1786,HCPCS,0636,RC,58468-4663-01,NDC,,both,1,UN,7803.60,5072.34,,,,,,,,,,,,,
PATELLA POLY LP 28MM,SUP-2397053,CDM,C1776,CPT,0278,RC,,,,both,,,5045.98,3279.89,,,,,,,,,,,,,
BEARING TIB OD65MM THK10MM KNEE ARCM MEDL LAT ARTC POST STBL,SUP-2404969,CDM,C1776,CPT,0278,RC,,,,both,,,2524.56,1640.96,,,,,,,,,,,,,
SET INTRO MICROPUNCTURE CATH L 10 CM 5 FR L 7 CM NIT,SUP-2633280,CDM,C1894,HCPCS,0272,RC,,,,both,,,72.09,46.86,,,,,,,,,,,,,
GRAFT BNE COTTON WDG 20X15X6 MM STRL RIPTIDE LTX,SUP-2866941,CDM,C1713,HCPCS,0278,RC,,,,both,,,9099.72,5914.82,,,,,,,,,,,,,
SET DIL SEQ STRL,SUP-2431882,CDM,2720000010,LOCAL,0272,RC,,,,both,,,973.40,632.71,,,,,,,,,,,,,
BENZTROPINE MESYLATE 0.5 MG PO TABS,RX-998,CDM,6370000000,HCPCS,0637,RC,69315-0136-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
BUPIVACAINE-EPINEPHRINE 0.25% -1:200000 IJ SOLN,RX-9317,CDM,2500000003,HCPCS,0250,RC,00409-1752-50,NDC,,both,1,ML,54.10,35.16,,,,,,,,,,,,,
HC Ther Ivntj Cog Funcj Cntct 1st 15 Mins,PX-4409712900,CDM,97129,CPT,0440,RC,,,,inpatient,,,186.00,120.90,,,,,,,,,,,,,
PLATE BNE MTP SM RT FUSION SLM LN,SUP-2397488,CDM,C1713,HCPCS,0278,RC,,,,both,,,3909.30,2541.04,,,,,,,,,,,,,
BLADE SCALPEL ENDOTRIG DISP,SUP-2691421,CDM,2720000010,LOCAL,0272,RC,,,,both,,,17584.00,11429.60,,,,,,,,,,,,,
PLATE BNE L232MM 12 H NONSTERILE R MED DST TIB S STL VAR,SUP-2177644,CDM,C1713,HCPCS,0278,RC,,,,both,,,5743.31,3733.15,,,,,,,,,,,,,
ACCESS KIT 19 GAX0.018 IN AXERA RX,SUP-2424406,CDM,C1713,HCPCS,0278,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
HC Car Seat Study Add 30 Min,PX-4109478100,CDM,94781,CPT,0410,RC,,,,inpatient,,,63.00,40.95,,,,,,,,,,,,,
KIT IMPL NDL TBNG CONN NAR FOR INSRTN CLS TOOL TI,SUP-2165393,CDM,C1813,HCPCS,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
PLATE BONE STRUT 0.4 MM CRANIAL 2X3 HOLE CURVED RIGID TITANI,SUP-2837704,CDM,C1713,HCPCS,0278,RC,,,,both,,,1247.21,810.69,,,,,,,,,,,,,
PLATE BNE L73MM 3 H R DST LAT FIBULAR S STL LOK COMPR FOR,SUP-2184154,CDM,C1713,HCPCS,0278,RC,,,,both,,,1622.06,1054.34,,,,,,,,,,,,,
EVOS VOL PLATE 5H RIGHT STD TI 81MM NS,SUP-2819172,CDM,C1713,HCPCS,0278,RC,,,,both,,,7782.02,5058.31,,,,,,,,,,,,,
PIN EXTERNAL FIXATION HALF 5X30 MM ARROW STAINLESS STEEL NON,SUP-2836753,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1690.42,1098.77,,,,,,,,,,,,,
ENDCAP ORTH FOR CANN TIB IM NAIL,SUP-2192166,CDM,C1713,HCPCS,0278,RC,,,,both,,,669.45,435.14,,,,,,,,,,,,,
SPACER SPNL H23XL32MM L10MM 8DEG LUM TI ALLY FOR SCR STBL,SUP-2279873,CDM,C1889,HCPCS,0278,RC,,,,both,,,13423.50,8725.27,,,,,,,,,,,,,
CATHETER ANGIOPLSTY 5.8FR L40CM BAL L30MM DIA8MM 0.035IN,SUP-2141000,CDM,C1725,HCPCS,0272,RC,,,,both,,,813.26,528.62,,,,,,,,,,,,,
COMPONENT TIB UNI SM 15 MM LL/RM KNEE ONLAY GEN,SUP-2344217,CDM,C1776,CPT,0278,RC,,,,both,,,5133.12,3336.53,,,,,,,,,,,,,
PIN HALF FIX M4 L200MM THRD L40MM S STL,SUP-2242953,CDM,C1713,HCPCS,0278,RC,,,,both,,,506.58,329.28,,,,,,,,,,,,,
ANCHOR SUT DIA5.5MM 2 WHT BLU PEEK OPTMA FULL THRD AWL,SUP-2341784,CDM,C1713,HCPCS,0278,RC,,,,both,,,1029.92,669.45,,,,,,,,,,,,,
NEEDLE 4FR MPIS TRNSTLSS PED ECHOGENIC,SUP-2170549,CDM,C1894,HCPCS,0272,RC,,,,both,,,86.98,56.54,,,,,,,,,,,,,
PASSER SUT 90DEG CRV TIP W/ WIRE LOOP FOR ARTHSCP BANKART,SUP-2121806,CDM,C1713,HCPCS,0278,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
AUGMENT FEM L55MM THK10MM RT MEDL LT LAT POST KNEE CONSTRN,SUP-2405656,CDM,C1713,HCPCS,0278,RC,,,,both,,,2386.40,1551.16,,,,,,,,,,,,,
SPACER HIP L150MM HD 54MM S STL 1 PC CEM GNTMYCN POLY METH,SUP-2223675,CDM,C1776,CPT,0278,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
SCREW BNE L36MM OD3MM FT AUTOFIX S STL IMPL FRAC SM BNE,SUP-2361676,CDM,C1713,HCPCS,0278,RC,,,,both,,,701.79,456.16,,,,,,,,,,,,,
SYSTEM FIX 5MM TI TWINFIX QUICK-T,SUP-2341595,CDM,C1713,HCPCS,0278,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
SPLINT SWEDISH AFO M RT WHT,SUP-2324310,CDM,L4350,HCPCS,0274,RC,,,,both,,,67.70,44.00,,,,,,,,,,,,,
GRAFT VASC FLX 6 MMX50 CM STD WALL SM BEAD EPTFE CARBOFLO,SUP-2761454,CDM,C1768,CPT,0278,RC,,,,both,,,2339.80,1520.87,,,,,,,,,,,,,
HC Removal Biliary Drng Cath,PX-3614753700,CDM,47537,CPT,0361,RC,,,,outpatient,,,6875.00,4468.75,,,,,,,,,,,,,
PLATE BNE L 151 X W 10.5 MM THK 3 MM SCREW DIA2.7/3.5 MM 9 H 72467709N,SUP-2933042,CDM,C1713,HCPCS,0278,RC,,,,both,,,3309.56,2151.21,,,,,,,,,,,,,
TUBE ET OD9.5MM ID7MM FOR EMG NIM TRIVANTAGE,SUP-2284333,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1099.44,714.64,,,,,,,,,,,,,
HEAD FEM OD28MM -3.5MM OFFSET CO CHROM HIP MOD METAFIX,SUP-2378835,CDM,C1776,CPT,0278,RC,,,,both,,,2235.68,1453.19,,,,,,,,,,,,,
SHELL ACET SZ 46MM GRP 0 UNIV YEL TI CLUS H W/ PLSM SPRY,SUP-2222457,CDM,C1776,CPT,0278,RC,,,,both,,,5275.20,3428.88,,,,,,,,,,,,,
CAGE SPNL W21XH36 56XL22MM 5DEG MIDTHORACIC INTBDY FUS TI,SUP-2182813,CDM,C1889,HCPCS,0278,RC,,,,both,,,20724.00,13470.60,,,,,,,,,,,,,
PLATE BNE STR 1 MM 4 HOLE CONTOURED SM GRID PLLA-PGA STRL LF,SUP-2479437,CDM,C1713,HCPCS,0278,RC,,,,both,,,550.03,357.52,,,,,,,,,,,,,
PASSER SUT 70DEG UP RETRV SGL PORTAL CAP RESTR SLINGSHOT,SUP-2366749,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1153.86,750.01,,,,,,,,,,,,,
EXTENSION STEM FEM 11X30 MM KNEE PRIMARY CMNTLS GMK,SUP-2571080,CDM,C1776,CPT,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
CATHETER ANGIOPLSTY FOX + L 135 CM BALLOON L 120 MM DIA 4 MM,SUP-2102230,CDM,C1725,HCPCS,0272,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
ORTHOLOC SPS 2.0MM BIT DRILL,SUP-2827731,CDM,2720000010,LOCAL,0272,RC,,,,both,,,907.46,589.85,,,,,,,,,,,,,
SHEATH INTRO GLIDESHEATH L 10 CM OD 6 FR ID 0.087 IN SPRING,SUP-2385326,CDM,C1893,HCPCS,0272,RC,,,,both,,,113.04,73.48,,,,,,,,,,,,,
NAIL IM L270MM DIA11MM UNIV TIB TI CANN LOK BENT UNREAMED,SUP-2192815,CDM,C1713,HCPCS,0278,RC,,,,both,,,4275.17,2778.86,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE 0.5 CC DBM FLOWABLE FIBER AMBIENT STOR,SUP-2933169,CDM,C1762,CPT,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
PATCH BIO LYOPLANT L 10 X W 4 CM BOV PERICARD STRL,SUP-2821556,CDM,C1763,HCPCS,0278,RC,,,,both,,,731.84,475.70,,,,,,,,,,,,,
WRENCH SURG SPNR,SUP-2355993,CDM,C1713,HCPCS,0278,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
HC So Bartonella Pcr,PX-3068747166,CDM,87471,CPT,0306,RC,,,,both,,,247.00,160.55,,,,,,,,,,,,,
PORT VLV TI STD POLYUR 8FR MEDI-PRT,SUP-2308251,CDM,C1788,HCPCS,0278,RC,,,,both,,,1025.24,666.41,,,,,,,,,,,,,
PATCH TISS 5X10 CM FOR CLLGN REP,SUP-2431728,CDM,C1763,HCPCS,0278,RC,,,,both,,,7714.98,5014.74,,,,,,,,,,,,,
BOLT ORTHOPEDIC LCK 4.9 MM TI NS,SUP-2192369,CDM,C1713,HCPCS,0278,RC,,,,both,,,489.84,318.40,,,,,,,,,,,,,
HC Rem/Repl Int Uret Stent,PX-3615038200,CDM,50382,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
PLATE BONE TEMPORAL 9 HOLE MESH 42.2X25.1X0.4MM TITANIUM NEU,SUP-2827191,CDM,C1713,HCPCS,0278,RC,,,,both,,,1294.62,841.50,,,,,,,,,,,,,
GRAFT VASC STR 6 MMX20 CM COAT W/ RNG SUPP FUSION BIOLINE,SUP-2468599,CDM,C1768,CPT,0278,RC,,,,both,,,1264.57,821.97,,,,,,,,,,,,,
HC Custom Finger Static,PX-2740393301,CDM,L3933,HCPCS,0272,RC,,,,outpatient,,,710.00,461.50,,,,,,,,,,,,,
ALLOGRAFT BNE CUBE 5 CC FD ASEP CANC,SUP-2867141,CDM,C1762,CPT,0278,RC,,,,both,,,322.16,209.40,,,,,,,,,,,,,
PACEMAKER CARD VITALITY 2 DR TI 2 CHMBR STRL,SUP-2149087,CDM,C1722,HCPCS,0275,RC,,,,both,,,92944.00,60413.60,,,,,,,,,,,,,
PROBE ENDOSCP L150CM OD1.5MM CONVENIENT BLT IN FLTR (ORDER MUTLIPLES OF 10 EACH),SUP-2217944,CDM,2720000010,LOCAL,0272,RC,,,,both,,,761.45,494.94,,,,,,,,,,,,,
SCREW CANN COMPR HDLSS 2 THRD TI 4.0MMX20MM,SUP-2392772,CDM,C1713,HCPCS,0278,RC,,,,both,,,563.82,366.48,,,,,,,,,,,,,
SCREW BNE L30MM DIA4MM CORT TI ST NONCANNULATED LOK FULL,SUP-2192251,CDM,C1713,HCPCS,0278,RC,,,,both,,,442.74,287.78,,,,,,,,,,,,,
SPLINT CLAV XL W3XL41IN SHLDR PD STRP MCLEOD,SUP-2197366,CDM,L3650,HCPCS,0272,RC,,,,both,,,44.90,29.18,,,,,,,,,,,,,
BUR SURG RND MED 4.8 MM 68 MM FLUT FOR DRL SYS SS,SUP-2628955,CDM,2720000010,LOCAL,0272,RC,,,,both,,,214.40,139.36,,,,,,,,,,,,,
SCREW BONE L115MM DIA3.5MM CORT ST,SUP-2183608,CDM,C1713,HCPCS,0278,RC,,,,both,,,145.54,94.60,,,,,,,,,,,,,
SUPPORT ORTHOT RIB CUST GUSSET ELASTIC,SUP-2435591,CDM,L1280,HCPCS,0274,RC,,,,both,,,247.37,160.79,,,,,,,,,,,,,
HC Pelvis Ap Only,PX-3207217000,CDM,72170,CPT,0320,RC,,,,both,,,420.00,273.00,,,,,,,,,,,,,
SCREW FIX 5.0 VAL SCREOPTILINK(TM),SUP-2715835,CDM,C1776,CPT,0278,RC,,,,both,,,570.13,370.58,,,,,,,,,,,,,
SHEATH INTRO FLX SHUTTLE L 80 CM OD 8 FR GUIDEWIRE 0.038 IN,SUP-2633276,CDM,C1894,HCPCS,0272,RC,,,,both,,,503.94,327.56,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY PENTARAY NAV INSRTN L 115CM 4-4-4,SUP-2248592,CDM,C1732,HCPCS,0278,RC,,,,both,,,5425.92,3526.85,,,,,,,,,,,,,
WALKER ANK L SHT STD BLK COMP SHELL NONSKID HK LO CLSR,SUP-2276717,CDM,L4387,HCPCS,0274,RC,,,,both,,,78.12,50.78,,,,,,,,,,,,,
TUBE GASTROSTMY 18FR L18IN 3 LUMN AUTO XCESS REFLUXING,SUP-2306842,CDM,2720000010,LOCAL,0272,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
GRAFT HUM TISS W6XL16CM THK2 279MM RDY TO USE ALLDERM,SUP-2423046,CDM,Q4116,HCPCS,0636,RC,,,,both,,,11222.36,7294.53,,,,,,,,,,,,,
LEVEL NEURO ST MESH 3D NEURO SCRW80 X 80 MM T06 MM CP TTNM,SUP-2681436,CDM,C1713,HCPCS,0278,RC,,,,both,,,5536.29,3598.59,,,,,,,,,,,,,
GUIDEWIRE VASC SAVION DLVR L 182 CM DIA 0.014 IN NIT POLYMER,SUP-2652811,CDM,C1769,HCPCS,0272,RC,,,,both,,,552.64,359.22,,,,,,,,,,,,,
BIT DRL DIA5MM CANN FOR 7MM HDLSS COMPR SCR,SUP-2397749,CDM,2720000010,LOCAL,0272,RC,,,,both,,,511.82,332.68,,,,,,,,,,,,,
HEAD FEM DIA32MM 5 OFFSET 10 12 TAPR HIP CO CHROME MTL ON,SUP-2253279,CDM,C1776,CPT,0278,RC,,,,both,,,2533.98,1647.09,,,,,,,,,,,,,
BLADE SURG L130MM DIA125MM NONSTERILE S STL HELIX TROCH FOR,SUP-2186790,CDM,C1776,CPT,0278,RC,,,,both,,,1065.56,692.61,,,,,,,,,,,,,
PLATE BNE L195MM 8 H ST L CNDYL S STL CRV LOK COMPR VAR ANG,SUP-2177851,CDM,C1713,HCPCS,0278,RC,,,,both,,,6034.23,3922.25,,,,,,,,,,,,,
SCREW INTRF L25MM OD7MM TI CANN NONABSORBABLE,SUP-2341508,CDM,C1713,HCPCS,0278,RC,,,,both,,,433.32,281.66,,,,,,,,,,,,,
BRACE KNEE FOR 26IN FOAM TELSCP FULL TECHNOLOGY QUIK LOK,SUP-2196499,CDM,L1832,HCPCS,0272,RC,,,,both,,,346.37,225.14,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA PLU MAXBARR 4FR S1294108D1,SUP-2632809,CDM,C1751,HCPCS,0278,RC,,,,both,,,853.30,554.64,,,,,,,,,,,,,
CURETTE SURG FUSION 2 8 IN 8.1X5.1 MM STR STD CUP HLLW HNDL,SUP-2482195,CDM,2720000010,LOCAL,0272,RC,,,,both,,,266.96,173.52,,,,,,,,,,,,,
CATHETER HD DL FLEXTIP KT FOR HI VOL INFUSION,SUP-2383289,CDM,C1752,HCPCS,0278,RC,,,,both,,,297.04,193.08,,,,,,,,,,,,,
NAIL IM FEM 15X250 MM RT PROX PIRIFORMIS FOSSA STRL DISP,SUP-2475337,CDM,C1713,HCPCS,0278,RC,,,,both,,,5215.54,3390.10,,,,,,,,,,,,,
PLATE BNE L 100 DEG STD 1.7X8X0.55 MM RT 6 HOLE BAR MALL,SUP-2366247,CDM,C1713,HCPCS,0278,RC,,,,both,,,656.26,426.57,,,,,,,,,,,,,
NAIL IM L360MM OD12MM TIB PLATFRM CANN LCK VERSANAIL,SUP-2412367,CDM,C1713,HCPCS,0278,RC,,,,both,,,3987.80,2592.07,,,,,,,,,,,,,
GRAFT BNE W10MM BISECTED PAT LIG W SMER BLK FRZN FLEXIGRFT,SUP-2264728,CDM,C1713,HCPCS,0278,RC,,,,both,,,7047.35,4580.78,,,,,,,,,,,,,
GRAFT BIO TISS MESH 20X10 CM MIROMATRIX MIROMESH,SUP-2115026,CDM,C1781,HCPCS,0278,RC,,,,both,,,18149.20,11796.98,,,,,,,,,,,,,
SHEATH LD INTRO SAFSHTH ULTRA L 13 CM DIA 9.5 FR GUIDEWIRE L,SUP-2159478,CDM,C1892,HCPCS,0272,RC,,,,both,,,174.62,113.50,,,,,,,,,,,,,
SET SUT ANCHR 1.4MM SFT SHT DISP JUGGERKNOT,SUP-2212959,CDM,2720000010,LOCAL,0272,RC,,,,both,,,868.65,564.62,,,,,,,,,,,,,
GUIDEWIRE UROLOGY DBL FLX 0.035 INX145 CM X STIFF AMPLATZ,SUP-2836140,CDM,C1769,HCPCS,0272,RC,,,,both,,,131.88,85.72,,,,,,,,,,,,,
PLATE BNE W17.5XL170MM THK5.2MM 6 H L CNDYL FEM S STL LOK,SUP-2185016,CDM,C1713,HCPCS,0278,RC,,,,both,,,4103.95,2667.57,,,,,,,,,,,,,
DRILL TWST L 38 MM DIA1 MM STP 3.5 MM SCREW DIA1.5 MM MRG3,SUP-2883877,CDM,2720000010,LOCAL,0272,RC,,,,both,,,320.28,208.18,,,,,,,,,,,,,
OBTURATOR BRACHYTHERAPY BLNT STRL SAVI BRACHY LF,SUP-2858442,CDM,2720000010,LOCAL,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
HC E/M Crit Care Each Addit 30min,PX-4509929200,CDM,99292,CPT,0450,RC,,,,outpatient,,,362.00,235.30,,,,,,,,,,,,,
PORT IMPL INFUSION 16X26 MM PWR INJ POLYURETHANE CATH XCELA,SUP-2118803,CDM,C1788,HCPCS,0278,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
ALLOGRAFT BNE 4-10 MM 15 CC FD IRRADIATED CORTICAL CANC,SUP-2866844,CDM,C1762,CPT,0278,RC,,,,both,,,626.43,407.18,,,,,,,,,,,,,
HC So Hla I Typing 1 Locus Lr,PX-3018137366,CDM,81373,CPT,0301,RC,,,,both,,,804.00,522.60,,,,,,,,,,,,,
DEVICE TISS REM DIA3MM L25.25IN ENDOSCP F/ IU POLYPS,SUP-2239913,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2064.02,1341.61,,,,,,,,,,,,,
SET PLUG FIST ENTEROCUTANEOUS CLLGN MULTPURP BIODESIGN,SUP-2169467,CDM,C1763,HCPCS,0278,RC,,,,both,,,12610.24,8196.66,,,,,,,,,,,,,
SET VASC ACCS PEELWY L 15.5 CM INTRO L 20 CM DIA18 FR,SUP-2168023,CDM,C1892,HCPCS,0272,RC,,,,both,,,182.12,118.38,,,,,,,,,,,,,
SUPPORT ORTHOT KNEE CUST POS LCK,SUP-2435609,CDM,L1831,HCPCS,0274,RC,,,,both,,,833.23,541.60,,,,,,,,,,,,,
MESH HERN W10XL10CM OPN TISS SEPARATING PHYSIOMESH,SUP-2219744,CDM,C1781,HCPCS,0278,RC,,,,both,,,1317.76,856.54,,,,,,,,,,,,,
BRACE ORTH LACE CLOSURE SM 5.5X6.25 IN WRST RT SPECTR,SUP-2319268,CDM,L3931,HCPCS,0274,RC,,,,both,,,26.75,17.39,,,,,,,,,,,,,
PLATE LOCK WAO,SUP-2705046,CDM,C1713,HCPCS,0278,RC,,,,both,,,286.37,186.14,,,,,,,,,,,,,
PLATE BNE W9XL25MM THK1MM 2 H TI 1/3 TBLR LIMIT CNTCT DYN,SUP-2190944,CDM,C1713,HCPCS,0278,RC,,,,both,,,424.75,276.09,,,,,,,,,,,,,
STENT COR 8MM 2.25MM RADPQ MRK RX MICROTRAC DEL,SUP-2296908,CDM,C1874,HCPCS,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
CANNULA BYPS TANDEMHEART BLD PMP KIT LIFESPARC,SUP-2665309,CDM,2720000010,LOCAL,0272,RC,,,,both,,,51810.00,33676.50,,,,,,,,,,,,,
HC Eval C/V Amniotic Fluid Protein Qual Ea Specimen,PX-3018411200,CDM,84112,CPT,0301,RC,,,,outpatient,,,193.00,125.45,,,,,,,,,,,,,
CATHETER GUID SPEX 35 L 135 CM OD 0.035 IN ID 0.063 IN,SUP-2227751,CDM,C1887,HCPCS,0272,RC,,,,both,,,508.68,330.64,,,,,,,,,,,,,
GRAFT BNE SUB SM CANC FRZN MORSELIZED W/ VIABLE CELL,SUP-2307239,CDM,C1713,HCPCS,0278,RC,,,,both,,,1350.20,877.63,,,,,,,,,,,,,
PLATE BNE FEM 3.5/4.5X216 MM LT PROX 7 HOLE NS VA-LCP,SUP-2757659,CDM,C1713,HCPCS,0278,RC,,,,both,,,6579.96,4276.97,,,,,,,,,,,,,
SPLINT CLAVICLE MED,SUP-2849722,CDM,C1713,HCPCS,0278,RC,,,,both,,,35.26,22.92,,,,,,,,,,,,,
HEAD RMR DIA17.5MM MDLLRY PILOT NOSE,SUP-2188101,CDM,C1713,HCPCS,0278,RC,,,,both,,,777.09,505.11,,,,,,,,,,,,,
BRACE ORTH CIRC THGH 13-15.5 IN CTR 12-13 IN CALF 10-12 IN XS,SUP-2915235,CDM,2720000010,LOCAL,0272,RC,,,,both,,,314.69,204.55,,,,,,,,,,,,,
PROSTHESIS OSS PISTON 0.8X5.75 MM SCHKNT MALL ATTCH SS,SUP-2637741,CDM,L8613,CPT,0278,RC,,,,both,,,344.49,223.92,,,,,,,,,,,,,
CATHETER ATHRCTMY PHOENIX L 130 CM DIA2.2 MM INTRO 6 FR,SUP-2823717,CDM,C1724,HCPCS,0278,RC,,,,both,,,9106.00,5918.90,,,,,,,,,,,,,
ROD DISTRCTN 24 MM WAVE D,SUP-2628467,CDM,C1713,HCPCS,0278,RC,,,,both,,,280.65,182.42,,,,,,,,,,,,,
CATHETER GUID MP HS 0.086 IN 8 FR W/ SH WISEGUIDE,SUP-2139638,CDM,C1887,HCPCS,0272,RC,,,,both,,,166.42,108.17,,,,,,,,,,,,,
SYSTEM IMPL MOD OPUS MAG,SUP-2342075,CDM,C1776,CPT,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
AMIKACIN SULFATE 1 GM/4ML IJ SOLN (MIXTURES ONLY),RX-430075,CDM,J0278,HCPCS,0636,RC,23155-0290-31,NDC,,both,2,ML,54.10,35.16,,,,,,,,,,,,,
STENT GRFT VASC ANCURE L 10 CM DIA22 MM POLYESTER TUBE,SUP-2139775,CDM,2720000010,LOCAL,0272,RC,,,,both,,,574.62,373.50,,,,,,,,,,,,,
PROSTHESIS 16F 5MM SPEC LEN INDWL VOICE,SUP-2242346,CDM,L8509,HCPCS,0274,RC,,,,both,,,916.88,595.97,,,,,,,,,,,,,
JOINT FNGR HINGED 20 16.7X3.6/6.9X2.2 MM 12.5X10.3 MM DSTL,SUP-2852888,CDM,C1776,CPT,0278,RC,,,,both,,,6911.93,4492.75,,,,,,,,,,,,,
PLATE BONE L228MM 15 HOLE RIGHT PSTRLTRL DST PRRTCLR HMRL LO,SUP-2498981,CDM,C1713,HCPCS,0278,RC,,,,both,,,3311.82,2152.68,,,,,,,,,,,,,
COIL EMB L2CM DIA1MM DETAIL FINISH RNDM COMPLX 10 SYS,SUP-2249142,CDM,C1889,HCPCS,0278,RC,,,,both,,,4741.97,3082.28,,,,,,,,,,,,,
PLATE BNE THK1MM M 4 H TI LOK FOR 2.7MM SCR 2MM MINI SYS,SUP-2262829,CDM,C1713,HCPCS,0278,RC,,,,both,,,916.88,595.97,,,,,,,,,,,,,
MILL BNE BWL W/ 2 BLDE DISP LEGEND MIDAS REX,SUP-2284675,CDM,2720000010,LOCAL,0272,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
IMPLANT BIO TISS 5X10CM SM SURG TEND INTEGRA REINF MTRX,SUP-2244430,CDM,C1763,HCPCS,0278,RC,,,,both,,,8109.43,5271.13,,,,,,,,,,,,,
COIL EMB DETACHABLE STD 10 MMX35 CM FRAME COMPLX RUBY,SUP-2323650,CDM,C1889,HCPCS,0278,RC,,,,both,,,4078.86,2651.26,,,,,,,,,,,,,
PLATE BNE L265MM THK3.3MM 22 H BILAT S STL RIG STR DYN,SUP-2186340,CDM,C1713,HCPCS,0278,RC,,,,both,,,1893.51,1230.78,,,,,,,,,,,,,
IRON DEXTRAN 50 MG/ML IJ SOLN,RX-3990,CDM,J1750,HCPCS,0636,RC,00023-6082-10,NDC,,both,0.5,ML,54.10,35.16,,,,,,,,,,,,,
CATHETER EP JSN 5 MM 4 FRX110 CM QPLR WOVEN,SUP-2424742,CDM,C1730,HCPCS,0272,RC,,,,both,,,722.20,469.43,,,,,,,,,,,,,
SYSTEM GASTRIC BANDING L ADJUSTABLE ACCESS PORT II OMNIFORM ADULT FOR WEIGHT LOSS LAPBAND AP,SUP-2119235,CDM,C1889,HCPCS,0278,RC,,,,both,,,10880.10,7072.06,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9% INTERMITTENT INFUSION,RX-40840102,CDM,J7050,HCPCS,0250,RC,00264-7800-20,NDC,,both,250,ML,23.40,15.21,,,,,,,,,,,,,
HC So Smear Complex Stain,PX-3008720966,CDM,87209,CPT,0300,RC,,,,both,,,119.00,77.35,,,,,,,,,,,,,
MOST ELLIPTICAL ALL-POLY PATELLA SMALL,SUP-2509222,CDM,C1776,CPT,0278,RC,,,,both,,,2967.30,1928.74,,,,,,,,,,,,,
SCREW IM L 20 MM DIA 3.5 MM TI CORTICAL ST FLUT THRD HD ZERO,SUP-2900387,CDM,C1713,HCPCS,0278,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
SPACER SPNL VERT 8 DEG 26X24X10 MM TANTALUM MARKER TI ZUMA,SUP-2245545,CDM,C1713,HCPCS,0278,RC,,,,both,,,20096.00,13062.40,,,,,,,,,,,,,
PLATE BONE THK2MM 4 H STRNL TI SH LCK,SUP-2262568,CDM,C1713,HCPCS,0278,RC,,,,both,,,1328.22,863.34,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9% INTERMITTENT INFUSION,RX-40840102,CDM,J7030,HCPCS,0258,RC,00338-0049-04,NDC,,both,250,ML,10.70,6.95,,,,,,,,,,,,,
SHEATH URET 14FR L55CM HYDRPHLC RADPQ 2 LUERLOCK STP COCK,SUP-2169835,CDM,C1894,HCPCS,0272,RC,,,,both,,,644.01,418.61,,,,,,,,,,,,,
GRAFT HUM TISS L 25-30 X W 18 MM THK T1 10 MM T2 7 MM IL,SUP-2913212,CDM,C1713,HCPCS,0278,RC,,,,both,,,5626.88,3657.47,,,,,,,,,,,,,
SHEATH CATH 11.5FR L72CM ID8.5FR CRV L30MM SM SFT TIP,SUP-2248641,CDM,C1766,CPT,0272,RC,,,,both,,,2342.44,1522.59,,,,,,,,,,,,,
PACK VITRCTMY POST CASS ILLUM DLX,SUP-2129358,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3009.12,1955.93,,,,,,,,,,,,,
GRAFT BNE CHIP CRUSH FRZN CANC 1MM 4MM RANG 40CC READIGRFT,SUP-2264741,CDM,C1713,HCPCS,0278,RC,,,,both,,,3822.54,2484.65,,,,,,,,,,,,,
SET INTRO PEELWY NIT DENNY MOD STRL,SUP-2168398,CDM,C1894,HCPCS,0272,RC,,,,both,,,146.83,95.44,,,,,,,,,,,,,
CASSETTE ANALGESIC PMP FILTER APC SYS NS LF DISP AMBIT,SUP-2892644,CDM,C9806,HCPCS,0272,RC,,,,both,,,820.33,533.21,,,,,,,,,,,,,
CLAMP TRANSFIXING PIN FOR ORTHOFIX PREFIX FIX,SUP-2316288,CDM,C1713,HCPCS,0278,RC,,,,both,,,679.75,441.84,,,,,,,,,,,,,
PLATE BNE STR 2-2.5X28X2 MM 4 HOLE FRAC NC LCK FOR SCR TI,SUP-2465584,CDM,C1713,HCPCS,0278,RC,,,,both,,,1346.53,875.24,,,,,,,,,,,,,
DRESSING WND 3 LAYR 5X5 CM MTRX CYTAL,SUP-2106528,CDM,Q4166,HCPCS,0636,RC,,,,both,,,2995.87,1947.32,,,,,,,,,,,,,
DEXAMETHASONE 20 MG IN NS 50 ML IVPB,RX-4082013,CDM,J1100,HCPCS,0636,RC,99999-9915-75,NDC,,both,50,ML,362.90,235.88,,,,,,,,,,,,,
SUPPORT BK LO FRIC PUL,SUP-2276691,CDM,L0641,HCPCS,0272,RC,,,,both,,,74.23,48.25,,,,,,,,,,,,,
HC So Antithyroglobulin Antibody,PX-3028680066,CDM,86800,CPT,0302,RC,,,,both,,,69.00,44.85,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9% INTERMITTENT INFUSION,RX-40840102,CDM,2580000003,HCPCS,0250,RC,00990-7983-61,NDC,,both,250,ML,74.40,48.36,,,,,,,,,,,,,
SET INTRO PERFRMR L 7 CM OD 4 FR ID 1.3 MM GUIDEWIRE 0.021,SUP-2168444,CDM,C1894,HCPCS,0272,RC,,,,both,,,89.87,58.42,,,,,,,,,,,,,
APPLICATOR ENDOSCP SPARE DEL ENDOCLOT,SUP-2865625,CDM,2720000010,LOCAL,0272,RC,,,,both,,,155.74,101.23,,,,,,,,,,,,,
COMPONENT FEM TIB TRABECULAR MTL IMPCT PROLONG SURF POR,SUP-2212251,CDM,C1776,CPT,0278,RC,,,,both,,,16660.78,10829.51,,,,,,,,,,,,,
CAGE SPNL LORDTC 8 MM LUMBAR,SUP-2256280,CDM,C1889,HCPCS,0278,RC,,,,both,,,13268.07,8624.25,,,,,,,,,,,,,
SUPPORT BK LO FRIC PUL,SUP-2276691,CDM,L0641,HCPCS,0274,RC,,,,both,,,74.23,48.25,,,,,,,,,,,,,
GUIDEWIRE VASC L 145 CM DIA 0.038 IN TIP L 3 MM TEF HYDRPHLC,SUP-2429606,CDM,C1769,HCPCS,0272,RC,,,,both,,,114.86,74.66,,,,,,,,,,,,,
PLATE BONE LOK 65MML HLX8 STNLSS STEEL STRGHT RCNSTRCTN ST,SUP-2721567,CDM,C1713,HCPCS,0278,RC,,,,both,,,1416.58,920.78,,,,,,,,,,,,,
TRAY CATH 4FR SGL LUMN INTMED MIDLN PER-Q-CATH,SUP-2125574,CDM,C1751,HCPCS,0278,RC,,,,both,,,241.15,156.75,,,,,,,,,,,,,
MESH BIOLOGIC OVINE RUMEN PERM OVITEX 10X12 CM,SUP-2383090,CDM,C1781,HCPCS,0278,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
PLATE BNE L217MM 18 H BILAT S STL CNTOUR 2 COMPR FOR 35MM,SUP-2411357,CDM,C1713,HCPCS,0278,RC,,,,both,,,1066.00,692.90,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 50 CM DIA 7 MM STR HELIX REINF,SUP-2681145,CDM,C1768,CPT,0278,RC,,,,both,,,1120.63,728.41,,,,,,,,,,,,,
ANCHOR SUT 5MM DRL 28MM BLK HNDL SELF PUNCHING W 3 NO2 HI,SUP-2167269,CDM,C1713,HCPCS,0278,RC,,,,both,,,2169.74,1410.33,,,,,,,,,,,,,
INTRODUCER CARD LD PLCMNT 9FRX47CM W/O HEMSTAT VLV COR SINUS,SUP-2357297,CDM,C1887,HCPCS,0272,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
DRILL SURG 3.5X130 MM FOR NAILING SYS STRL T2,SUP-2361774,CDM,2720000010,LOCAL,0272,RC,,,,both,,,757.37,492.29,,,,,,,,,,,,,
SHELL ACET DP 58 MM FEM HIP,SUP-2101360,CDM,C1776,CPT,0278,RC,,,,both,,,643.70,418.40,,,,,,,,,,,,,
GRAFT HUM TISS DERMACELL POROUS 1.75X1.75CM 3SQCM,SUP-2909323,CDM,Q4122,HCPCS,0636,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
PLATE BNE CNDYL 2X39 MM RT 7 HOLE FOR SCR MINI FRAG SYS SS,SUP-2489734,CDM,C1713,HCPCS,0278,RC,,,,both,,,714.13,464.18,,,,,,,,,,,,,
CLARITHROMYCIN 250 MG/5ML PO SUSR,RX-12886,CDM,340b,HCPCS,0637,RC,99999-9714-05,NDC,,both,5,ML,21.90,14.23,,,,,,,,,,,,,
WEDGE TIB SZ 5-6 5MM L MED R LAT KNEE HEMI STP SCR ON,SUP-2346179,CDM,C1776,CPT,0278,RC,,,,both,,,4147.16,2695.65,,,,,,,,,,,,,
PLATE BNE 8 H NONSTERILE S STL LOK COMPR ATTCH FOR 35 45MM,SUP-2177782,CDM,C1713,HCPCS,0278,RC,,,,both,,,1604.29,1042.79,,,,,,,,,,,,,
INSERT TIB REV KNEE EMPOWR VVC+ E+ SZ 3 19MM,SUP-2890768,CDM,C1776,CPT,0278,RC,,,,both,,,9336.79,6068.91,,,,,,,,,,,,,
SLING MID URETH SYS ACELLULAR HALO NEEDLEX2 GUID TUBE HNDL,SUP-2129054,CDM,C1771,HCPCS,0278,RC,,,,both,,,2841.23,1846.80,,,,,,,,,,,,,
SCREW CRANIO MAXILLOFACIAL CRSS DRV DRL FREE TI ALLY,SUP-2262633,CDM,C1713,HCPCS,0278,RC,,,,both,,,188.49,122.52,,,,,,,,,,,,,
PLUG BNE DIA14MM SM DIAM CEM,SUP-2408550,CDM,C1713,HCPCS,0278,RC,,,,both,,,301.44,195.94,,,,,,,,,,,,,
PLATE BNE 12 H NONSTERILE BILAT S STL NAR CRV LOK COMPR FOR,SUP-2178043,CDM,C1713,HCPCS,0278,RC,,,,both,,,1938.76,1260.19,,,,,,,,,,,,,
GUIDE PLUNG 6MM DEL CLR COR,SUP-2256812,CDM,2720000010,LOCAL,0272,RC,,,,both,,,540.08,351.05,,,,,,,,,,,,,
PLATE BNE ANGLED BLADE 130 DEG SM 4.5X60 MM 50 MM 4 STRL,SUP-2653573,CDM,C1713,HCPCS,0278,RC,,,,both,,,2146.66,1395.33,,,,,,,,,,,,,
BIT DRL 1.9X115 MM 35 MM END NS LTX,SUP-2862798,CDM,2720000010,LOCAL,0272,RC,,,,both,,,878.67,571.14,,,,,,,,,,,,,
GRAFT VASC 24-32 WPI 6 MMX20 CM VASC ACCS VECTRA REV,SUP-2127772,CDM,C1768,CPT,0278,RC,,,,both,,,3362.94,2185.91,,,,,,,,,,,,,
GRAFT ALLGRFT PTTY DBM INTERGRO,SUP-2414012,CDM,C1713,HCPCS,0278,RC,,,,both,,,593.46,385.75,,,,,,,,,,,,,
CHARGER NEUROSTIMULATOR EXT SPNL CRD FOR RECHARGING,SUP-2284643,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
WASHER ORTH DIA 7.5 MM ANK FIT ALL SCREW STRL APOLLOANKLE,SUP-2894179,CDM,C1713,HCPCS,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL PEEK SD800.540,SUP-2860221,CDM,C1713,HCPCS,0278,RC,,,,both,,,44166.61,28708.30,,,,,,,,,,,,,
FILGRASTIM-AAFI 480 MCG/0.8ML IJ SOSY,RX-143508,CDM,Q5110,HCPCS,0636,RC,00069-0292-01,NDC,,both,0.8,ML,2014.80,1309.62,,,,,,,,,,,,,
BIT DRL DIA3 4MM OVERDRL FOR TC CANN SCR SYS CAPTURE,SUP-2243906,CDM,2720000010,LOCAL,0272,RC,,,,both,,,728.76,473.69,,,,,,,,,,,,,
STENT ESOPH WALLFLEX L 15 CM DIA18 FR DIA PROX/DSTL 20,SUP-2140977,CDM,C1876,HCPCS,0278,RC,,,,both,,,6480.96,4212.62,,,,,,,,,,,,,
METAL CANNULA 4.5MM WITH DAM,SUP-2812618,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2552.82,1659.33,,,,,,,,,,,,,
BOLT SPINAL 5MM X 20MM ALIF FIX MODULUS STRL,SUP-2863084,CDM,C1889,HCPCS,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
KIT LD ANCHR STRL,SUP-2905260,CDM,L8699,HCPCS,0278,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
TUBING ASPIR FOR REPERFUSION CATH PMP CANSTR LID STRL MAX,SUP-2323635,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1161.80,755.17,,,,,,,,,,,,,
GRAFT BNE SUB 10CC CA PHSPTE ROTARY MIX PTTY VOID FILL INJ,SUP-2194292,CDM,C1713,HCPCS,0278,RC,,,,both,,,10111.43,6572.43,,,,,,,,,,,,,
BAR THRD 160MM FOR SHEFFIELD STRL TY SYS,SUP-2316267,CDM,2720000010,LOCAL,0272,RC,,,,both,,,115.02,74.76,,,,,,,,,,,,,
HC NM Lung Scan Perfusion Only,PX-3417858000,CDM,78580,CPT,0341,RC,,,,inpatient,,,2067.00,1343.55,,,,,,,,,,,,,
ANCHOR SUTURE SLIDING 6.5 MM SHLDR DBL LD GRN QUATTRO X,SUP-2745506,CDM,C1776,CPT,0278,RC,,,,both,,,1346.75,875.39,,,,,,,,,,,,,
SYSTEM W/ INTEMESH INTEXEN INVANCE,SUP-2138946,CDM,C1771,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
PLATE BONE SM L143MM 11 H STD BILAT COMPR CNTOUR + FOR 3.5MM,SUP-2348998,CDM,C1713,HCPCS,0278,RC,,,,both,,,1583.82,1029.48,,,,,,,,,,,,,
CATHETER INTVASC ULTRASOUND OPTICROSS 18 L 135 CM DIA 3.5 FR,SUP-2146906,CDM,C1753,HCPCS,0278,RC,,,,both,,,4474.50,2908.42,,,,,,,,,,,,,
GRAFT BNE PTTY 2.5 CC BIOMAX,SUP-2731740,CDM,C1713,HCPCS,0278,RC,,,,both,,,982.82,638.83,,,,,,,,,,,,,
HC Bil Niv Arterial Upp Ext Duplex,PX-9219393000,CDM,93930,CPT,0921,RC,,,,both,,,1661.00,1079.65,,,,,,,,,,,,,
BUR SURG PRECIS 5 MMX16 CM RND BRN STRL LTX,SUP-2859533,CDM,2720000010,LOCAL,0272,RC,,,,both,,,796.30,517.59,,,,,,,,,,,,,
GRAFT HUM TISS 12X4 CM N CROSSLINKED SCAFFOLD STRL GENTRIX,SUP-2106489,CDM,Q4166,HCPCS,0636,RC,,,,both,,,2856.52,1856.74,,,,,,,,,,,,,
PLATE BNE L278MM 12 H NONSTERILE L CNDYL S STL LOK COMPR,SUP-2183116,CDM,C1713,HCPCS,0278,RC,,,,both,,,4470.98,2906.14,,,,,,,,,,,,,
BIT DRILL 2.5MM EVOLVE EPS,SUP-2822476,CDM,2720000010,LOCAL,0272,RC,,,,both,,,427.04,277.58,,,,,,,,,,,,,
MESH BONE PTTSBRGH RGLR 03MM THK TTNM LATEX FREE MXLFCL,SUP-2707412,CDM,C1713,HCPCS,0278,RC,,,,both,,,1580.11,1027.07,,,,,,,,,,,,,
STRIP INT STPL 25MM VERIT CLLGN MTRX BOV PERICARD PERI-STRPS,SUP-2130370,CDM,C1713,HCPCS,0278,RC,,,,both,,,1231.26,800.32,,,,,,,,,,,,,
BOOT ANK AD L8 13IN FOR 16IN CALF UNIV DK BLU FLEECE LN,SUP-2165483,CDM,L4631,HCPCS,0274,RC,,,,both,,,145.38,94.50,,,,,,,,,,,,,
GRAFT BNE 25CC DBM PTTY PREHYDRATED TENSIX,SUP-2400564,CDM,C9359,HCPCS,0278,RC,,,,both,,,2797.74,1818.53,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 200 MM DIA 7 MM DEL SHTH,SUP-2934381,CDM,C1713,HCPCS,0278,RC,,,,both,,,15603.54,10142.30,,,,,,,,,,,,,
SCREW INTRF L35MM,SUP-2414760,CDM,C1713,HCPCS,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
GRAFT BNE SUB 30CC 1.7-10MM CANC CHIP MORSELIZED FRZ DRY,SUP-2307078,CDM,C1713,HCPCS,0278,RC,,,,both,,,1044.05,678.63,,,,,,,,,,,,,
TITANIUM MESH PANEL SML GRID 83MM X 50MM 3MM 10MM SYS CP T,SUP-2681327,CDM,C1713,HCPCS,0278,RC,,,,both,,,2651.86,1723.71,,,,,,,,,,,,,
CATHETER CV SINGLE LUMEN 018 IN 5 FRX55 CM 135 CM POWERPICC,SUP-2126371,CDM,C1751,HCPCS,0278,RC,,,,both,,,318.24,206.86,,,,,,,,,,,,,
INSERT TIB SZ 9 THK34MM ANTR POST KNEE UNI GEN,SUP-2344215,CDM,C1776,CPT,0278,RC,,,,both,,,3826.88,2487.47,,,,,,,,,,,,,
SPACER SPNL 6X14X11 MM STRUT VERTE-STACK CORNERSTONE PSR,SUP-2286342,CDM,C1889,HCPCS,0278,RC,,,,both,,,1640.65,1066.42,,,,,,,,,,,,,
BUR SURG RND MED 0.5 MM 64 MM ENT FLUT CARBIDE,SUP-2628878,CDM,2720000010,LOCAL,0272,RC,,,,both,,,567.27,368.73,,,,,,,,,,,,,
HC So Hemoglobin Chromatography,PX-3018302166,CDM,83021,CPT,0301,RC,,,,outpatient,,,267.00,173.55,,,,,,,,,,,,,
COVER BUR H DIA17MM 6 H BILAT TI CNTOUR RIG NONCOMPRESSION,SUP-2190696,CDM,C1713,HCPCS,0278,RC,,,,both,,,957.29,622.24,,,,,,,,,,,,,
PLATE BNE L97MM THK3.3MM 8 H BILAT S STL RIG STR DYN COMPR,SUP-2186332,CDM,C1713,HCPCS,0278,RC,,,,both,,,1024.58,665.98,,,,,,,,,,,,,
KIT SPL NEUROSTIMULATOR 2X8 CNTCT 30 CM,SUP-2138804,CDM,C1883,HCPCS,0278,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
CATHETER CARD ABLATION THERMOCOOL SMARTTOUCH SF L115CM 8FR F,SUP-2248618,CDM,C1732,HCPCS,0272,RC,,,,both,,,9410.58,6116.88,,,,,,,,,,,,,
PLATE BNE BAR 8 MM 4 H MINI LT MIDFACE L SHP MALL,SUP-2883165,CDM,C1713,HCPCS,0278,RC,,,,both,,,1545.23,1004.40,,,,,,,,,,,,,
STEM TAPER 16X135MM,SUP-2505141,CDM,C1776,CPT,0278,RC,,,,both,,,6782.40,4408.56,,,,,,,,,,,,,
PLATE BONE L70MM HK D15MM 4 H LT CLAV S STL LCK COMPR FOR,SUP-2185843,CDM,C1713,HCPCS,0278,RC,,,,both,,,2730.07,1774.55,,,,,,,,,,,,,
KIT NEUROSTIM LD SPNL BOOT ANCHR FOR INTERSTIM SPNL CRD,SUP-2284433,CDM,C1713,HCPCS,0278,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
ALLOGRAFT BNE SPACER 12.5X15X6 MM FD PARL CORTICAL CANC ACF,SUP-2736825,CDM,C1713,HCPCS,0278,RC,,,,both,,,4180.91,2717.59,,,,,,,,,,,,,
PLATE BNE 3.5X131 MM 10 HOLE SS LCP,SUP-2569323,CDM,C1713,HCPCS,0278,RC,,,,both,,,433.48,281.76,,,,,,,,,,,,,
INTRODUCER GWIRE L50CM L3MM 0.038IN S STL PTFE STR CRV FIX,SUP-2355266,CDM,C1769,HCPCS,0272,RC,,,,both,,,18.84,12.25,,,,,,,,,,,,,
PLATE BNE TIB 166 MM LAT 7 HOLE BUTTRESS HD TI NS LC-DCP,SUP-2569060,CDM,C1713,HCPCS,0278,RC,,,,both,,,2433.47,1581.76,,,,,,,,,,,,,
KIT CONVENIENCE STD FT ANK BONE GRFT BIOCUE ASPIR NDL DISP,SUP-2402590,CDM,C1713,HCPCS,0278,RC,,,,both,,,5024.00,3265.60,,,,,,,,,,,,,
STEM FEM PRSS FT -30 MM 8 14X205 MM CALCAR HIP RESECT REST,SUP-2374307,CDM,C1776,CPT,0278,RC,,,,both,,,18052.49,11734.12,,,,,,,,,,,,,
GRAFT BNE BLOCK LG TRICORT,SUP-2759482,CDM,C1713,HCPCS,0278,RC,,,,both,,,6369.77,4140.35,,,,,,,,,,,,,
GRIP CBL SM DIA1.6MM HIP VIT COMPHSVE RECON TRAUM DALL-M,SUP-2377579,CDM,C1776,CPT,0278,RC,,,,both,,,1274.84,828.65,,,,,,,,,,,,,
PLATE BNE L60MM 4 H NONSTERILE R PROX TIB S STL LO PROF,SUP-2185809,CDM,C1713,HCPCS,0278,RC,,,,both,,,3536.27,2298.58,,,,,,,,,,,,,
SPHINCTEROTOME ENDO OD6.5FR 0.035IN TAPR MFIL CUT WIRE DISP,SUP-2171035,CDM,2720000010,LOCAL,0272,RC,,,,both,,,580.90,377.58,,,,,,,,,,,,,
GUIDEWIRE FLX STK 1.2MMX18IN,SUP-2366743,CDM,C1769,HCPCS,0272,RC,,,,both,,,367.38,238.80,,,,,,,,,,,,,
FENTANYL-BUPIVACAINE-NACL 0.2-0.125-0.9 MG/100ML-% EP SOLN,RX-134631,CDM,2500000003,HCPCS,0250,RC,70092-1104-36,NDC,,both,100,ML,138.60,90.09,,,,,,,,,,,,,
DRILL SURG STEM TIB CEM NXGN,SUP-2438090,CDM,2720000010,LOCAL,0272,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
PROSTHESIS OSS 8.1 MM 1.1 MM WEHRS DBL NOTCH INCUS OTOSIL HA,SUP-2460792,CDM,L8613,CPT,0278,RC,,,,both,,,1533.11,996.52,,,,,,,,,,,,,
GUIDEWIRE VASC SYNCHRO 2 200CM 0.014IN SEG 35CM PRESHAPED,SUP-2367902,CDM,C1769,HCPCS,0272,RC,,,,both,,,2420.94,1573.61,,,,,,,,,,,,,
TRIAL UNIV STD FEM HD BPLR UPLR UHT V-40,SUP-2361589,CDM,C1776,CPT,0278,RC,,,,both,,,540.08,351.05,,,,,,,,,,,,,
PLATE BNE PLNTR 3.5X78 MM RT MEDL CLMN FUSION VA LCK SS NS,SUP-2178432,CDM,C1713,HCPCS,0278,RC,,,,both,,,5070.60,3295.89,,,,,,,,,,,,,
PROSTHESIS OSS CENTERED 0.2X1.45X1 MM PART TI PRECIS,SUP-2466218,CDM,L8613,CPT,0278,RC,,,,both,,,1115.52,725.09,,,,,,,,,,,,,
DEVICE RESECTING SZ 2.9 MM STRL DISP AVETA AUTO,SUP-2914493,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
HYDROXYZINE HCL 10 MG/5ML PO SYRP,RX-3771,CDM,340b,HCPCS,0637,RC,09999-9902-63,NDC,,both,5,ML,2.70,1.75,,,,,,,,,,,,,
HC Mech Removal Intracath S&I,PX-3207590200,CDM,75902,CPT,0320,RC,,,,outpatient,,,3098.00,2013.70,,,,,,,,,,,,,
NITROGLYCERIN IN D5W 200-5 MCG/ML-% IV SOLN,RX-15859,CDM,J2305,HCPCS,0636,RC,00338-1049-02,NDC,,both,250,ML,129.40,84.11,,,,,,,,,,,,,
BIT DRL DIA2 25MM OVERDRL FOR TC CANN SCR SYS CAPTURE,SUP-2243905,CDM,2720000010,LOCAL,0272,RC,,,,both,,,700.75,455.49,,,,,,,,,,,,,
APPLIER INT CLP LAP SM 5 MMX31 CM YEL DS,SUP-2850608,CDM,C1889,HCPCS,0278,RC,,,,both,,,3175.29,2063.94,,,,,,,,,,,,,
PLATE BNE 2.7X73 MM 8 HOLE SS LC-DCP,SUP-2569217,CDM,C1713,HCPCS,0278,RC,,,,both,,,297.04,193.08,,,,,,,,,,,,,
PLATE BNE CUT DSTL FEM KNEE REV NXGN LEG,SUP-2438072,CDM,C1713,HCPCS,0278,RC,,,,both,,,748.89,486.78,,,,,,,,,,,,,
DRESSING WND 4X5IN MTRX BOV CLLGN SGL,SUP-2243649,CDM,Q4108,HCPCS,0636,RC,,,,both,,,18431.80,11980.67,,,,,,,,,,,,,
MESH HERN L15XW23CM OBLONG INTRAABDOMINAL PLCMNT PROLITE,SUP-2265986,CDM,C1781,HCPCS,0278,RC,,,,both,,,2351.86,1528.71,,,,,,,,,,,,,
"HC X-Ray, Ribs, Pa Chest, 3",PX-3207110100,CDM,71101,CPT,0320,RC,,,,both,,,546.00,354.90,,,,,,,,,,,,,
GRAFT BNE STRP 22X18X8 MM DBM,SUP-2327816,CDM,C9362,HCPCS,0278,RC,,,,both,,,10412.24,6767.96,,,,,,,,,,,,,
DOLUTEGRAVIR SODIUM 50 MG PO TABS,RX-123363,CDM,6370000000,HCPCS,0637,RC,49702-0228-13,NDC,,both,1,UN,348.80,226.72,,,,,,,,,,,,,
PLATE VA DISTAL MEDIAL TIBIA 6H,SUP-2858201,CDM,C1713,HCPCS,0278,RC,,,,both,,,6080.39,3952.25,,,,,,,,,,,,,
IMPLANT OP RM MTP PLTS MTP 5 LNG PLT L,SUP-2321453,CDM,C1713,HCPCS,0278,RC,,,,both,,,4608.58,2995.58,,,,,,,,,,,,,
IMPLANT OP RM MINI-MONSTER 2.0 X 9MM HE,SUP-2320334,CDM,C1713,HCPCS,0278,RC,,,,both,,,581.69,378.10,,,,,,,,,,,,,
BLADE SURG L100MM S STL HELIX FOR LCP DHHS SYS,SUP-2186784,CDM,C1776,CPT,0278,RC,,,,both,,,1050.77,683.00,,,,,,,,,,,,,
SPLINT ORTHOPEDIC SPICA MED LG LT THMB HK LOOP CLOSURE VLY 0005785000000] ALIMED INC],SUP-2112560,CDM,L3924,HCPCS,0272,RC,,,,both,,,96.56,62.76,,,,,,,,,,,,,
COVER BURR HOLE ULTRA LOW PRFLE 25MM DIA LG HLX2X3 03MM THK,SUP-2681383,CDM,C1713,HCPCS,0278,RC,,,,both,,,910.63,591.91,,,,,,,,,,,,,
GUIDEWIRE VASC SKR L 175 CM DIA16 IN FLX X SUPP STRL,SUP-2141240,CDM,C1769,HCPCS,0272,RC,,,,both,,,737.90,479.63,,,,,,,,,,,,,
HC So Hla I Typing Complete Hr,PX-3108137966,CDM,81379,CPT,0310,RC,,,,both,,,413.00,268.45,,,,,,,,,,,,,
BOLT EXT FIX WIRE PRE ASSEMBLED SALVATION,SUP-2851100,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4301.80,2796.17,,,,,,,,,,,,,
SCREW BNE LOK MINI TI NONSTERILE 20MMX11MM MAXDRIVE,SUP-2262888,CDM,C1713,HCPCS,0278,RC,,,,both,,,352.40,229.06,,,,,,,,,,,,,
BODY RAD W15XH7MM 7.5MM WRST BEAR IMPL MAESTRO,SUP-2407293,CDM,C1776,CPT,0278,RC,,,,both,,,5204.55,3382.96,,,,,,,,,,,,,
PLATE BNE 130 DEG PEDIATRIC 2.7X46X12 MM HIP 2 HOLE SS STRL,SUP-2546021,CDM,C1713,HCPCS,0278,RC,,,,both,,,2499.66,1624.78,,,,,,,,,,,,,
REMOVER SPNL SCR COR NEO-SL KINETIC-SL,SUP-2264521,CDM,C1713,HCPCS,0278,RC,,,,both,,,1180.64,767.42,,,,,,,,,,,,,
GRAFT TISS FRZ DRY ALLGRFT FASC LATA HUM TISS 18CM LX100MM W,SUP-2307096,CDM,C1762,CPT,0278,RC,,,,both,,,3410.70,2216.95,,,,,,,,,,,,,
BLADE RETRCT 24X70MM CERV SLD TI LAT CASPER,SUP-2108276,CDM,C1713,HCPCS,0278,RC,,,,both,,,1514.30,984.29,,,,,,,,,,,,,
SET INTRO V-STICK DIA 5 FR SS COAX NONECHOGENIC STD,SUP-2120081,CDM,C1769,HCPCS,0272,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
MIXER BNE CEM 120GM 3 MIX OPTVAC VAC SYS 417300] ZB,SUP-2196559,CDM,2720000010,LOCAL,0272,RC,,,,both,,,806.98,524.54,,,,,,,,,,,,,
SHUNT PERI 7FR 90CM 13MM IDX25MMOD SM W OUT RESVR,SUP-2284555,CDM,C1713,HCPCS,0278,RC,,,,both,,,4013.05,2608.48,,,,,,,,,,,,,
HC Injection Treatment of Nerve,PX-3616468000,CDM,64680,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
KIT HEMSTAT MTRX 8ML PORCINE GEL HUM THROM ABSRB FLOWABLE 2993] JNJ HEALTHCARE],SUP-2256904,CDM,2720000010,LOCAL,0272,RC,,,,both,,,508.74,330.68,,,,,,,,,,,,,
CEFTRIAXONE SODIUM 1 G IV SOLR,RX-27308,CDM,J0696,HCPCS,0636,RC,00409-7333-04,NDC,,both,1,UN,54.10,35.16,,,,,,,,,,,,,
PLATE BONE SHFT L19MM BLDE L15MM THK0.9MM 2X2 H SH RT,SUP-2191180,CDM,C1713,HCPCS,0278,RC,,,,both,,,1063.83,691.49,,,,,,,,,,,,,
DEFIBRILLATOR IMPL INVENTRA PROMRI UHE DX TI EPOXY RESIN SIL,SUP-2138431,CDM,C1722,HCPCS,0275,RC,,,,both,,,44745.00,29084.25,,,,,,,,,,,,,
GRAFT BNE CHIP 4-10 MM 15 CC CANC PUREBONE,SUP-2424603,CDM,C1713,HCPCS,0278,RC,,,,both,,,687.94,447.16,,,,,,,,,,,,,
PATCH VASC HEMGRD L 75 X W 25 MM THK 0.65 MM POLYESTER BOV,SUP-2535427,CDM,C1768,CPT,0278,RC,,,,both,,,443.21,288.09,,,,,,,,,,,,,
LENS IOL TORIC PANOPTIX CLAREON CNWTT5 10.0D,SUP-2752034,CDM,V2788,HCPCS,0276,RC,,,,both,,,1015.00,659.75,,,,,,,,,,,,,
CATHETER EP LG CRV 5 FRX115 CM QPLR FIX,SUP-2356875,CDM,C1730,HCPCS,0272,RC,,,,both,,,1460.10,949.06,,,,,,,,,,,,,
HC Ther Ivntj Cog Funcj Cntct 1st 15 Mins|OP SPEECH LANGUAGE SERVICE,PX-4409712900,CDM,97129,CPT,0440,RC,,,GN,outpatient,,,186.00,120.90,,,,,,,,,,,,,
BOOT CAST SM W5XL11 1 4IN OPN TOE AND HEEL MOLD ROCK,SUP-2276728,CDM,L4386,HCPCS,0272,RC,,,,both,,,16.17,10.51,,,,,,,,,,,,,
ORTHOMESH RESORBABLE STRAIGHT ROW 50MMX50MMX0.5MM-STERILE,SUP-2550441,CDM,C1781,HCPCS,0278,RC,,,,both,,,2859.28,1858.53,,,,,,,,,,,,,
GUIDEWIRE VASC L 60 CM DIA 0.018 IN SS MANDREL GLD COIL,SUP-2823950,CDM,C1769,HCPCS,0272,RC,,,,both,,,95.14,61.84,,,,,,,,,,,,,
INSERT TIB L THK9MM STD UNIV NEUT PRI PCA,SUP-2362129,CDM,C1776,CPT,0278,RC,,,,both,,,2217.50,1441.37,,,,,,,,,,,,,
"HC So Protein S, Free",PX-3058530666,CDM,85306,CPT,0305,RC,,,,both,,,147.00,95.55,,,,,,,,,,,,,
PLATE BNE STR 25 MM TCP 08125,SUP-2535851,CDM,C1713,HCPCS,0278,RC,,,,both,,,3604.72,2343.07,,,,,,,,,,,,,
PIN FIX L215MM OD2.5MM SMOOTH SGL SHRP TIP S STL,SUP-2342381,CDM,C1713,HCPCS,0278,RC,,,,both,,,373.66,242.88,,,,,,,,,,,,,
CATHETER BLLN OCCL L150CM TIP L5MM BLLN L10MM OD4MM COR,SUP-2305408,CDM,C2628,HCPCS,0272,RC,,,,both,,,4592.25,2984.96,,,,,,,,,,,,,
SCREW BNE CANC 6.5X30 MM NO-PROFILE,SUP-2608692,CDM,C1713,HCPCS,0278,RC,,,,both,,,590.82,384.03,,,,,,,,,,,,,
ADAPTER FEM STEM CC REV TAPR W/ SCR 5DEG EXACTECH,SUP-2223074,CDM,C1776,CPT,0278,RC,,,,both,,,763.81,496.48,,,,,,,,,,,,,
POST ORTHOPEDIC 2 HOLE W/ 12MM BOLT TRUELOK,SUP-2316108,CDM,2720000010,LOCAL,0272,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
HC Perq Dev Breast Add MR Guide,PX-3611928800,CDM,19288,CPT,0361,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
STEM FEM L60MM DIA14MM KNEE TI ALLY CRSS SLT PRESSFIT REV,SUP-2251488,CDM,C1776,CPT,0278,RC,,,,both,,,3761.72,2445.12,,,,,,,,,,,,,
PLATE BNE W24XL31MM 5 H NONSTERILE BILAT MIDFOOT HINDFOOT TI,SUP-2191455,CDM,C1713,HCPCS,0278,RC,,,,both,,,2635.84,1713.30,,,,,,,,,,,,,
GRAFT DURA W4XL5IN WHT ABSRB MTRX CLLGN POR PLIABLE,SUP-2244085,CDM,C1763,HCPCS,0278,RC,,,,both,,,2687.87,1747.12,,,,,,,,,,,,,
KIT CATH 12FR L16CM MULTILUMEN CTRL VEN L BOR BLU FLEXTIP,SUP-2383307,CDM,C1751,HCPCS,0278,RC,,,,both,,,341.00,221.65,,,,,,,,,,,,,
ANCHOR SUT BIOCRYL RAPIDE ABSRB 2 PERMACORD SZ 2 L36IN BLU,SUP-2256704,CDM,C1713,HCPCS,0278,RC,,,,both,,,1566.86,1018.46,,,,,,,,,,,,,
PLATE BNE L 246 MM SCREW DIA 3.5/4.5 MM 10 H UTIL STRL EVOS,SUP-2933713,CDM,C1713,HCPCS,0278,RC,,,,both,,,16708.73,10860.67,,,,,,,,,,,,,
KIT STPL BONE FIX SUP ELAS MOTOCLIP 18MMX18MMX18MM,SUP-2175099,CDM,C1713,HCPCS,0278,RC,,,,both,,,2983.00,1938.95,,,,,,,,,,,,,
BOUGIE SURG CATH L 95 CM DIA 38 FR BALLOON L 16.6 CM SYR 60,SUP-2901848,CDM,2720000010,LOCAL,0272,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
EXTRACTOR SURG FOR BNE SCR REM INBNE II,SUP-2400024,CDM,2720000010,LOCAL,0272,RC,,,,both,,,307.72,200.02,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED BPLR PRSS FT CHIPSNEPHBIPPRS] SMITH AND NEPHEW ORTHOPAEDICS],SUP-2351332,CDM,C1776,CPT,0278,RC,,,,both,,,8085.50,5255.57,,,,,,,,,,,,,
FRACTURE KIT COMPLETE W/ POWERCURVE STABILIT,SUP-2474805,CDM,2720000010,LOCAL,0272,RC,,,,both,,,9420.00,6123.00,,,,,,,,,,,,,
TUBE VENT MOD 1.27 MM 6 MM 7.6 MM T TUBE SIL STRL,SUP-2535098,CDM,L8699,HCPCS,0278,RC,,,,both,,,55.33,35.96,,,,,,,,,,,,,
RETRIEVER FLAT WIRE LOOP STONE 3FRX115CM,SUP-2171233,CDM,C1713,HCPCS,0278,RC,,,,both,,,461.20,299.78,,,,,,,,,,,,,
RING FOOT SHRT 180MM,SUP-2703091,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5392.01,3504.81,,,,,,,,,,,,,
KNIFE SEPTUM FREER D SHAPED BLADE 16CM 6 14IN,SUP-2678372,CDM,2720000010,LOCAL,0272,RC,,,,both,,,329.95,214.47,,,,,,,,,,,,,
ANTI-ROTATION SCREW 5.0MMX105MM,SUP-2829516,CDM,C1713,HCPCS,0278,RC,,,,both,,,1365.90,887.83,,,,,,,,,,,,,
PLATE BONE L92MM 3 H STRL PROX HUM S STL STR FOR 3.5MM SCR,SUP-2341161,CDM,C1776,CPT,0278,RC,,,,both,,,8634.84,5612.65,,,,,,,,,,,,,
CATHETER PERITONEAL L 42.5 CM PED LT SWAN NK MISSOURI CURL,SUP-2905041,CDM,C1750,HCPCS,0278,RC,,,,both,,,806.70,524.35,,,,,,,,,,,,,
METHOTREXATE SODIUM 25 MG/ML IJ SOLN (MIXTURES ONLY),RX-40800525,CDM,J9260,HCPCS,0636,RC,61703-0408-41,NDC,,both,0.5,ML,54.10,35.16,,,,,,,,,,,,,
BIT DRL L190MM DIA2.7MM FT FOR 3.5MM SCR ADVANSYS,SUP-2243128,CDM,2720000010,LOCAL,0272,RC,,,,both,,,799.88,519.92,,,,,,,,,,,,,
HC Therapeutic Apheresis Plasma Pheresis,PX-5103651400,CDM,36514,CPT,0510,RC,,,,both,,,3511.00,2282.15,,,,,,,,,,,,,
KIT PICC INTERMED SAFT 5FR 2 LUMN VAXCEL M001455980,SUP-2117120,CDM,C1751,HCPCS,0278,RC,,,,both,,,498.07,323.75,,,,,,,,,,,,,
ANCHOR SUTURE 5.5 MM W/ 1MM HI-FI RIBBON ARGO KNOTLESS,SUP-2846779,CDM,C1713,HCPCS,0278,RC,,,,both,,,2347.97,1526.18,,,,,,,,,,,,,
SCREW BNE CORT HND TI L9MM OD1.2MM APTUS HEXADRIVE 4,SUP-2268009,CDM,C1713,HCPCS,0278,RC,,,,both,,,211.01,137.16,,,,,,,,,,,,,
PROSTHESIS PENILE L15CM INFL IFP APPRCH PRECONN W/ MS PMP,SUP-2138977,CDM,C1813,HCPCS,0278,RC,,,,both,,,30591.45,19884.44,,,,,,,,,,,,,
STEM FEM SZ 18 L140MM DIA14MM 12/14 TAPR CEM SYNERGY,SUP-2344529,CDM,C1776,CPT,0278,RC,,,,both,,,7967.75,5179.04,,,,,,,,,,,,,
GRAFT BNE SUB 30CC SZ 1-5MM MILLED CANC CHIP FRZ DRY,SUP-2307070,CDM,C1713,HCPCS,0278,RC,,,,both,,,1667.34,1083.77,,,,,,,,,,,,,
PIN OCCL L12IN OD14MM L TI SERR HD APPL STRL FOR HEMORRHAGE,SUP-2381978,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1310.95,852.12,,,,,,,,,,,,,
STEM HUM DIA11MM 132.5DEG STD SHLDR PROX BODY AEQUALIS FLX,SUP-2418013,CDM,C1776,CPT,0278,RC,,,,both,,,13489.44,8768.14,,,,,,,,,,,,,
OXAPROZIN 600 MG PO TABS,RX-10825,CDM,6370000000,HCPCS,0637,RC,69238-1120-01,NDC,,both,1,UN,6.60,4.29,,,,,,,,,,,,,
RABIES IMMUNE GLOBULIN 1500 UNIT/10ML IJ SOLN,RX-141162,CDM,90377,HCPCS,0636,RC,76125-0150-10,NDC,,both,10,ML,9801.40,6370.91,,,,,,,,,,,,,
COMP FEM AUG BTN STD+/LG+15DTL,SUP-2513646,CDM,C1776,CPT,0278,RC,,,,both,,,1306.24,849.06,,,,,,,,,,,,,
CATHETER DRAINAGE 12 FRX60 CM MP COPE SIMP LCK LOOP UTHANE,SUP-2168286,CDM,C1729,HCPCS,0272,RC,,,,both,,,272.33,177.01,,,,,,,,,,,,,
COMPONENT TIB 1PC PROX 65MM LGTH 13MM DIA FINN - 65MM LEN,SUP-2406143,CDM,C1776,CPT,0278,RC,,,,both,,,20767.96,13499.17,,,,,,,,,,,,,
FLUOROURACIL 1 GM/20ML IV SOLN|DISCARDED DRUG NOT ADMINISTE,RX-82204,CDM,J9190,HCPCS,0636,RC,63323-0117-20,NDC,JW,both,20,ML,54.10,35.16,,,,,,,,,,,,,
GRAFT BIO W4XL4CM DERM,SUP-2321663,CDM,Q4126,HCPCS,0636,RC,,,,both,,,5731.13,3725.23,,,,,,,,,,,,,
CARBOPLATIN 150 MG/15ML IV SOLN,RX-39266,CDM,J9045,HCPCS,0636,RC,61703-0339-22,NDC,,both,15,ML,67.00,43.55,,,,,,,,,,,,,
HC So2 Ptt,PX-3058573068,CDM,85730,CPT,0305,RC,,,,both,,,9.00,5.85,,,,,,,,,,,,,
HC MRI-Angio Head WO& W Contras,PX-6157054600,CDM,70546,CPT,0615,RC,,,,both,,,4794.00,3116.10,,,,,,,,,,,,,
BUPIVACAINE HCL (PF) 0.75 % IJ SOLN,RX-123633,CDM,J0665,HCPCS,0636,RC,00409-1582-18,NDC,,both,30,ML,90.10,58.56,,,,,,,,,,,,,
BUR SURG DR LNG 4.7X20 MM FLUT FOR HD/HD-G1,SUP-2848175,CDM,2720000010,LOCAL,0272,RC,,,,both,,,452.60,294.19,,,,,,,,,,,,,
BIT DRL L170MM WRK L139MM DIA45MM 3 FLUT REPL S STL TWST,SUP-2150441,CDM,2720000010,LOCAL,0272,RC,,,,both,,,493.33,320.66,,,,,,,,,,,,,
PLATE SPNL INFERIOR END LG STR,SUP-2194232,CDM,C1713,HCPCS,0278,RC,,,,both,,,15838.16,10294.80,,,,,,,,,,,,,
MICROCATHETER INFUSION PURSUE 150CM DIA 2.9/2FR TRUEFORM,SUP-2457144,CDM,C1887,HCPCS,0272,RC,,,,both,,,2166.60,1408.29,,,,,,,,,,,,,
SHEETING SILAS W6XL8IN THK0.040IN SIL REINF,SUP-2134690,CDM,C1713,HCPCS,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
BUTTON CERCLAGE DIA4MM S STL STEM CANN FOR 4.5MM SCR,SUP-2178463,CDM,C1713,HCPCS,0278,RC,,,,both,,,503.19,327.07,,,,,,,,,,,,,
PLATE BONE SM 117MML HLX8 STNLSS STEEL DELTA BTTRSS ST RIGHT,SUP-2727196,CDM,C1713,HCPCS,0278,RC,,,,both,,,2639.11,1715.42,,,,,,,,,,,,,
TUBE SALIVARY BYPASS RADIOPAQUE MONTGOMERY 191X40X14MM,SUP-2713904,CDM,C1889,HCPCS,0278,RC,,,,both,,,621.72,404.12,,,,,,,,,,,,,
SHELL ACET 46 MM HIP CERM REFLECTION,SUP-2434645,CDM,C1776,CPT,0278,RC,,,,both,,,5928.32,3853.41,,,,,,,,,,,,,
TROCAR ENDOSCP L110MM DIA5-11MM STD OPT SMOOTH RADLUC,SUP-2283177,CDM,2720000010,LOCAL,0272,RC,,,,both,,,455.61,296.15,,,,,,,,,,,,,
PIN EXT FIX TRANSFIX 4X300 MM,SUP-2197278,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1130.40,734.76,,,,,,,,,,,,,
IFOSFAMIDE 1 G IV SOLR,RX-10248,CDM,J9208,HCPCS,0636,RC,10019-0925-01,NDC,,both,1,UN,105.90,68.83,,,,,,,,,,,,,
K WIRE FIX L6IN DIA0.045IN 1600645] MICROAIRE SURGICAL INSTRUMENTS INC],SUP-2304023,CDM,C1713,HCPCS,0278,RC,,,,both,,,16.70,10.85,,,,,,,,,,,,,
GUIDEWIRE SMOOTH ALTA 3.2X100,SUP-2363487,CDM,C1769,HCPCS,0272,RC,,,,both,,,769.30,500.04,,,,,,,,,,,,,
CATHETER BLLN DIL 5.8FR L75CM BLLN 18FR L4CM 0.038IN HYDR+,SUP-2139191,CDM,C1726,HCPCS,0272,RC,,,,both,,,831.82,540.68,,,,,,,,,,,,,
PLATE BNE CLAV CS3 2.7 MM RT VA LCK COMPR SS STRL VA-LCP,SUP-2750822,CDM,C1713,HCPCS,0278,RC,,,,both,,,3458.27,2247.88,,,,,,,,,,,,,
CARTRIDGE BONE CEM MX UNIV VAC PLUNG W/ BRK OFF NOZ W/OUT,SUP-2397004,CDM,C1713,HCPCS,0278,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
LIFT HEEL SOLE NEOPRNE,SUP-2388189,CDM,L3310,HCPCS,0274,RC,,,,both,,,209.63,136.26,,,,,,,,,,,,,
BLADE SURGICAL CURVED CAPFIX,SUP-2880378,CDM,2720000010,LOCAL,0272,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
SUPPORT ORTHOT LOWER EXTREMITY CUST EXT STL SHANK,SUP-2435661,CDM,L2360,HCPCS,0274,RC,,,,both,,,145.98,94.89,,,,,,,,,,,,,
SCREW BONE L5MM OD1.5MM SLD CRANIOMAXILLOFACIAL VIT CROSS,SUP-2364634,CDM,C1713,HCPCS,0278,RC,,,,both,,,127.45,82.84,,,,,,,,,,,,,
SKID BNE MURPHY-LANE 11.75 IN 0.75X1-1/3 DBL END SS NS,SUP-2484771,CDM,C1713,HCPCS,0278,RC,,,,both,,,212.89,138.38,,,,,,,,,,,,,
GRAFT HUM TISS W14-18XL100MM FIB SHFT FRZ DRY,SUP-2307197,CDM,C1713,HCPCS,0278,RC,,,,both,,,2201.20,1430.78,,,,,,,,,,,,,
STENT PERIPH L200MM DIA6MM CATH L80CM VASC,SUP-2418940,CDM,C1876,HCPCS,0278,RC,,,,both,,,10974.30,7133.29,,,,,,,,,,,,,
SEEKER BAL L17MM DIA7MM SPHENOID SINUS FOR ENT,SUP-2284118,CDM,C1713,HCPCS,0278,RC,,,,both,,,1309.69,851.30,,,,,,,,,,,,,
K WIRE FIX L6IN DIA1.1MM ST S STL 3 SIDE DBL TRCR BOTH END,SUP-2150607,CDM,C1713,HCPCS,0278,RC,,,,both,,,13.06,8.49,,,,,,,,,,,,,
PLATE BNE L156MM 12 H L LAT DST PERIARTC FIBULAR S STL,SUP-2410569,CDM,C1713,HCPCS,0278,RC,,,,both,,,1842.21,1197.44,,,,,,,,,,,,,
CLIP DIL STRL PHANTOM XL DISP,SUP-2536923,CDM,2720000010,LOCAL,0272,RC,,,,both,,,447.45,290.84,,,,,,,,,,,,,
DEVICE RESECTING SZ 2.9 MM FLX FOR POLYP FIBROID STRL DISP,SUP-2914680,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
PLATE BNE L300MM 13 H L PROX TIB TI NONCOMPRESSION FOR,SUP-2190737,CDM,C1713,HCPCS,0278,RC,,,,both,,,4152.46,2699.10,,,,,,,,,,,,,
SHEATH INTRO FLX ANSEL L 45 CM OD 9 FR GUIDEWIRE 0.018/0.038,SUP-2170665,CDM,C1894,HCPCS,0272,RC,,,,both,,,174.21,113.24,,,,,,,,,,,,,
COMPONENT TIB TY 1.5 KNEE TRUMATCH,SUP-2452944,CDM,C1776,CPT,0278,RC,,,,both,,,2420.94,1573.61,,,,,,,,,,,,,
PLATE STRNL CLOSURE THK 1.5 MM 6 H TI BRIDGE H LP BLU NS,SUP-2894489,CDM,C1713,HCPCS,0278,RC,,,,both,,,2317.32,1506.26,,,,,,,,,,,,,
HC Epidural Blood Patch - Anes,PX-3706227300,CDM,62273,CPT,0370,RC,,,,inpatient,,,1586.00,1030.90,,,,,,,,,,,,,
PLATE BNE FEM 3.5/4.5X251 MM LT PROX 8 HOLE STRL VALCP,SUP-2789591,CDM,C1713,HCPCS,0278,RC,,,,both,,,7703.27,5007.13,,,,,,,,,,,,,
IMPLANT HUM TISS ALLGRFT SUPRAMALLEOLAR OSTEOTOM MODIFIABLE,SUP-2899157,CDM,C1713,HCPCS,0278,RC,,,,both,,,6433.08,4181.50,,,,,,,,,,,,,
PLATE BONE L87MM THK3.8MM 14 H BILAT S STL NAR DYN COMPR FOR,SUP-2185214,CDM,C1713,HCPCS,0278,RC,,,,both,,,830.47,539.81,,,,,,,,,,,,,
PROSTHESIS 3MM DIAM 51MM LEN PORP W LINK PARTIALLY CANN HA,SUP-2313681,CDM,L8613,CPT,0278,RC,,,,both,,,1280.84,832.55,,,,,,,,,,,,,
STENT TRACHBRONCH 6X40MM STNT GRFT 117CM 8FR DEL SYS NIT,SUP-2128280,CDM,C1874,HCPCS,0278,RC,,,,both,,,6578.30,4275.89,,,,,,,,,,,,,
COUPLER ANAS 1.5 MM MICROVASCULAR SINGLE POLYETH SS BLU GEM,SUP-2382617,CDM,C1713,HCPCS,0278,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
PLATE SPNL L5CM STD ANT THOR TI VANTAGE,SUP-2292707,CDM,C1713,HCPCS,0278,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
HC Office/OP Consltj New/Est Pt Mod Mdm 40 Minutes|RESIDENT/TEACHING PHYS SERV,PX-5109924400,CDM,99244,CPT,0510,RC,,,GC,both,,,299.00,194.35,,,,,,,,,,,,,
SPACER SPNL OD22MM TI INTBDY FUS VLIFT,SUP-2362884,CDM,C1889,HCPCS,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
LASER FBR 1000UM HOLM FLAT TIP FLEX DISP,SUP-2213045,CDM,C1713,HCPCS,0278,RC,,,,both,,,1937.38,1259.30,,,,,,,,,,,,,
HC Cardiac Rehab Phase 3 - Spouse,PX-9900000042,CDM,9900000042,LOCAL,0990,RC,,,,both,,,20.00,13.00,,,,,,,,,,,,,
TUBE INNR EAR MYR VENT REUT BOB W/O FLNG H 1.14 MM ID TYTAN,SUP-2277597,CDM,L8699,HCPCS,0278,RC,,,,both,,,161.40,104.91,,,,,,,,,,,,,
AXLE TIB STD COMP KINEMATIC,SUP-2376288,CDM,C1776,CPT,0278,RC,,,,both,,,2395.04,1556.78,,,,,,,,,,,,,
CUP ACET FLNG E RT HIP,SUP-2417196,CDM,C1776,CPT,0278,RC,,,,both,,,26690.00,17348.50,,,,,,,,,,,,,
RING ANNULPLSTY SZ 40 OD46MM ID39MM MI VLV SEMI RIG 3D POST,SUP-2355861,CDM,C1889,HCPCS,0278,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
BOOT WALKING PNEUMATIC LG HI TOP AIR LIFESTRIDE,SUP-2108147,CDM,L4386,HCPCS,0274,RC,,,,both,,,112.73,73.27,,,,,,,,,,,,,
COLLAR CERV EXTRIC COMB PK PERFIT ACE,SUP-2115130,CDM,L0120,HCPCS,0272,RC,,,,both,,,45.81,29.78,,,,,,,,,,,,,
MICROCATHETER GUID CANTATA L 150 CM OD 2.9 FR ID 0.027 IN,SUP-2638531,CDM,C1887,HCPCS,0272,RC,,,,both,,,982.07,638.35,,,,,,,,,,,,,
BURR SURG 3MM DIA HD 4MML HD CARBIDE CYL MICROPOWER MCR100 S,SUP-2605544,CDM,2720000010,LOCAL,0272,RC,,,,both,,,69.68,45.29,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA PLU MAXBARR 3FR S1173108D4,SUP-2632788,CDM,C1751,HCPCS,0278,RC,,,,both,,,799.63,519.76,,,,,,,,,,,,,
SPHERE EMBOLIZATION 45 150 MUM 100 MGVIAL BEARING NSPVA,SUP-2677311,CDM,C1889,HCPCS,0278,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
GUIDEWIRE ENDO L480CM OD0.035IN AQUA COAT SHORTER TAPR,SUP-2169526,CDM,C1769,HCPCS,0272,RC,,,,both,,,414.48,269.41,,,,,,,,,,,,,
CATHETER KIT 8.5 FR CV MULT LUMEN,SUP-2383955,CDM,C1751,HCPCS,0278,RC,,,,both,,,245.55,159.61,,,,,,,,,,,,,
KIT AUTOTRNS ATF 40 FAST STRT W/ 1 AT1 AUTOTRNS SET 1 ATR 40,SUP-2385069,CDM,C1713,HCPCS,0278,RC,,,,both,,,551.07,358.20,,,,,,,,,,,,,
SCREW BNE L32MM DIA4.5MM S STL CORT HIP ST NONCANNULATED,SUP-2343706,CDM,C1713,HCPCS,0278,RC,,,,both,,,171.63,111.56,,,,,,,,,,,,,
INSERT TIB SZ 1 THK7MM POST STBL BAL SYS,SUP-2314694,CDM,C1776,CPT,0278,RC,,,,both,,,2800.88,1820.57,,,,,,,,,,,,,
SOUND PROC HEARING DEV LT KT USER NS REUSE SAMBA2 BB,SUP-2905155,CDM,L8691,HCPCS,0278,RC,,,,both,,,16026.56,10417.26,,,,,,,,,,,,,
TUBE ENDOBRONCH 5 FR 65 CM LEN ARNDT,SUP-2168833,CDM,2720000010,LOCAL,0272,RC,,,,both,,,880.46,572.30,,,,,,,,,,,,,
COMPONENT ACET TRIFLANGED 23 MM HIP CUST,SUP-2418773,CDM,C1776,CPT,0278,RC,,,,both,,,40082.10,26053.36,,,,,,,,,,,,,
LINER ACET 15 DEG STD POLYETH 28MM SZ G ACUMATCH,SUP-2221894,CDM,C1776,CPT,0278,RC,,,,both,,,3014.40,1959.36,,,,,,,,,,,,,
SUPPORT ORTHOT ANK KNEE TIB CUST FRAC RIGID,SUP-2435650,CDM,L2116,HCPCS,0272,RC,,,,both,,,2182.11,1418.37,,,,,,,,,,,,,
ROD SPNL L50MM DYN STBL SYS DYNESYS,SUP-2414279,CDM,C1713,HCPCS,0278,RC,,,,both,,,7571.33,4921.36,,,,,,,,,,,,,
NAIL IM HUM UNIV 9X240 MM LCK CANN ENTRY TI STRL VERSANAIL,SUP-2461659,CDM,C1713,HCPCS,0278,RC,,,,both,,,4644.06,3018.64,,,,,,,,,,,,,
ANCHOR TEND 8 FOR REGENETEN BIOINDUCTIVE IMPL SYS,SUP-2600835,CDM,C1713,HCPCS,0278,RC,,,,both,,,1813.35,1178.68,,,,,,,,,,,,,
FIBER LASER DIA1000UM FLEXSHIELD COAT HOLM HI PWR POLISHED,SUP-2139423,CDM,C1713,HCPCS,0278,RC,,,,both,,,2116.11,1375.47,,,,,,,,,,,,,
GUIDEWIRE 11X120MM TRCR TIP PLN,SUP-2243904,CDM,C1769,HCPCS,0272,RC,,,,both,,,98.09,63.76,,,,,,,,,,,,,
KIT DRNGE L35CM DIA14FR NDL DIA22GA 0.038IN FIRM K,SUP-2147876,CDM,C1729,HCPCS,0272,RC,,,,both,,,471.47,306.46,,,,,,,,,,,,,
IMPLANT WR JT RAD COMP LT CO CHROM MOLYBDENUM SZ 1,SUP-2243497,CDM,C1776,CPT,0278,RC,,,,both,,,25615.84,16650.30,,,,,,,,,,,,,
CABLE ORTHOT HIP KNEE ANK PELV CUST TORSION,SUP-2435641,CDM,L2050,LOCAL,0272,RC,,,,both,,,1379.62,896.75,,,,,,,,,,,,,
PLATE BNE FEM 146 MM LT DSTL LAT CNDYL 6 HOLE BUTTRESS SS,SUP-2461627,CDM,C1713,HCPCS,0278,RC,,,,both,,,2235.49,1453.07,,,,,,,,,,,,,
GRAFT BNE MORSL LG 11 CC FIBERGRAFT BG,SUP-2736516,CDM,C1713,HCPCS,0278,RC,,,,both,,,8666.40,5633.16,,,,,,,,,,,,,
DICLOFENAC SODIUM 75 MG PO TBEC,RX-15341,CDM,6370000000,HCPCS,0637,RC,60687-0658-01,NDC,,both,1,UN,3.10,2.01,,,,,,,,,,,,,
SCREW BNE CANC 5X80 MM 32 MM FEM ST THRD TI STRL NCB,SUP-2458223,CDM,C1713,HCPCS,0278,RC,,,,both,,,424.34,275.82,,,,,,,,,,,,,
GRAFT VASC GELSFT L 45 CM DIA22 MM BRANCH DIA11 MM POLYESTER,SUP-2384941,CDM,C1768,CPT,0278,RC,,,,both,,,1504.81,978.13,,,,,,,,,,,,,
PLATE BNE L 33 X W 8 MM THK 3.5 MM SCREW DIA2.7 MM 4 H SS,SUP-2933117,CDM,C1713,HCPCS,0278,RC,,,,both,,,1364.55,886.96,,,,,,,,,,,,,
PLATE BNE W5XL50MM THK1-1.2MM 4X9 H BILAT TI T SHP RIG,SUP-2191058,CDM,C1713,HCPCS,0278,RC,,,,both,,,863.25,561.11,,,,,,,,,,,,,
SCREW BNE L55MM DIA5MM CORT TI ST LOK FULL THRD HD W/ HEX,SUP-2190321,CDM,C1713,HCPCS,0278,RC,,,,both,,,574.21,373.24,,,,,,,,,,,,,
GRAFT BNE STRP 20X15X7 MM COMPRESSIBLE BNE MTRX,SUP-2644319,CDM,C1713,HCPCS,0278,RC,,,,both,,,2819.41,1832.62,,,,,,,,,,,,,
BLADE SHAVER SERRATED 40 DEG 4 MM DSTL SUCTION ROTATABLE,SUP-2638420,CDM,2720000010,LOCAL,0272,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.508,SUP-2860025,CDM,C1713,HCPCS,0278,RC,,,,both,,,36765.95,23897.87,,,,,,,,,,,,,
SCREW BNE COMPR 7.2X120 MM 22 MM HIP GOTFRIED PCCP,SUP-2644729,CDM,C1713,HCPCS,0278,RC,,,,both,,,623.10,405.01,,,,,,,,,,,,,
BLADE SCRDRIVER CRUCFRM HLD SL NONCANNULATED FOR 1.3MM CORT,SUP-2187554,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3396.51,2207.73,,,,,,,,,,,,,
BUR SURG DIA3.2MM CARB FLUT SIDE CUT FOR 6.1CM SIL ATTCH,SUP-2176828,CDM,C1713,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
RISPERIDONE 1 MG PO TBDP,RX-35687,CDM,6370000000,HCPCS,0637,RC,49884-0315-52,NDC,,both,1,UN,18.40,11.96,,,,,,,,,,,,,
TRIFLUOPERAZINE HCL 1 MG PO TABS,RX-8161,CDM,6370000000,HCPCS,0637,RC,00781-8028-01,NDC,,both,1,UN,2.80,1.82,,,,,,,,,,,,,
ANTEROLATERAL PILON FUSION PLATE 18H RT,SUP-2814974,CDM,C1713,HCPCS,0278,RC,,,,both,,,15072.00,9796.80,,,,,,,,,,,,,
GRAFT BONE SUB 1CC DBM W/ RPM PUROS,SUP-2415798,CDM,C1713,HCPCS,0278,RC,,,,both,,,615.44,400.04,,,,,,,,,,,,,
HANDPIECE ELECSURG L45CM DIA5MM FR ACTUATED GRP PLATFRM,SUP-2313549,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1239.67,805.79,,,,,,,,,,,,,
BIT DRL LNG 4X150 MM S3 FAST GUIDE,SUP-2606605,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1473.95,958.07,,,,,,,,,,,,,
ALLOGRAFT BNE SPNG 50X20X7 MM CANC DBM,SUP-2135425,CDM,C1713,HCPCS,0278,RC,,,,both,,,3422.60,2224.69,,,,,,,,,,,,,
SET PROST SEEDING L20CM OD18GA NDL FLEX UTW,SUP-2381879,CDM,C1715,HCPCS,0272,RC,,,,both,,,34.54,22.45,,,,,,,,,,,,,
MESH HERN OPTIMIZED COMP 25X20 CM RND SKIRTED PARIETEX,SUP-2752189,CDM,C1781,HCPCS,0278,RC,,,,both,,,5670.59,3685.88,,,,,,,,,,,,,
SPACER SPNL LORDTC 7 DEG 18X15X8 MM HEDRON C,SUP-2732375,CDM,C1889,HCPCS,0278,RC,,,,both,,,5620.60,3653.39,,,,,,,,,,,,,
MESH HERN RND 15 CM OPTIMIZED COMP PARIETEX,SUP-2174712,CDM,C1781,HCPCS,0278,RC,,,,both,,,1594.84,1036.65,,,,,,,,,,,,,
BASKET STONE RETRV L120CM OD20MM SHTH OD3FR 4W NO TIP DISP,SUP-2141703,CDM,2720000010,LOCAL,0272,RC,,,,both,,,649.98,422.49,,,,,,,,,,,,,
MICROCATHETER GUID PLATO 17 45 DEG USABLE L 160 CM COAT L 90,SUP-2909733,CDM,C1887,HCPCS,0272,RC,,,,both,,,2983.00,1938.95,,,,,,,,,,,,,
HC So Cytoplasmic Tech Comp,PX-3118818566,CDM,88185,CPT,0311,RC,,,,both,,,55.00,35.75,,,,,,,,,,,,,
IMPLANT BRST NACL SMOOTH RND ADJ SPECTRUM,SUP-2748610,CDM,C1789,HCPCS,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
DILTIAZEM HCL ER COATED BEADS 180 MG PO CP24,RX-29272,CDM,6370000000,HCPCS,0637,RC,60687-0206-01,NDC,,both,1,UN,3.70,2.40,,,,,,,,,,,,,
CATHETER PERIT1AL DLYS L42CM OD15FR STR 1 SUBQ CUF LIN,SUP-2283890,CDM,C1750,HCPCS,0278,RC,,,,both,,,167.74,109.03,,,,,,,,,,,,,
ALLOGRAFT HUM TISS FRZN ASEP GRACILIS TEND,SUP-2867230,CDM,C1762,CPT,0278,RC,,,,both,,,3862.99,2510.94,,,,,,,,,,,,,
CATHETER VENTRICULAR 8 CM 14 CM STYL RT ANGLE BACTISEAL,SUP-2666830,CDM,C1729,HCPCS,0272,RC,,,,both,,,1656.07,1076.45,,,,,,,,,,,,,
ALLOGRAFT BNE STRUT SEG TIB,SUP-2321916,CDM,C1713,HCPCS,0278,RC,,,,both,,,3611.00,2347.15,,,,,,,,,,,,,
HEAD HUM OD22.2MM -2MM SHLDR BPLR INNR IMP FOR SHLDR,SUP-2404517,CDM,C1776,CPT,0278,RC,,,,both,,,4091.42,2659.42,,,,,,,,,,,,,
PLATE BNE GENIOPLASTY 2X10 MM TI,SUP-2457619,CDM,C1713,HCPCS,0278,RC,,,,both,,,666.53,433.24,,,,,,,,,,,,,
SCREW BNE L 34 MM DIA 3.2 MM FT COMPR,SUP-2883759,CDM,C1713,HCPCS,0278,RC,,,,both,,,1635.94,1063.36,,,,,,,,,,,,,
PLATE BNE W9.2XL25MM THK1.3MM 100DEG 2 H TI TBLR FOR 3.5MM,SUP-2412032,CDM,C1713,HCPCS,0278,RC,,,,both,,,241.78,157.16,,,,,,,,,,,,,
SCREW BNE ST 4.5X18 MM CRTX,SUP-2364654,CDM,C1713,HCPCS,0278,RC,,,,both,,,51.81,33.68,,,,,,,,,,,,,
STAPLER ENDO L45MM BLU STR ARTC NONABSORBABLE,SUP-2257563,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1145.75,744.74,,,,,,,,,,,,,
SCREW BONE L100MM DIA10.5MM LAG FOR AFFIXUS HIP FX NAIL SYS,SUP-2137049,CDM,C1713,HCPCS,0278,RC,,,,both,,,2799.78,1819.86,,,,,,,,,,,,,
CATHETER EMB FOGARTY L 80 CM DIA 5.5 FR BALLOON DIA,SUP-2214021,CDM,C1757,HCPCS,0272,RC,,,,both,,,332.21,215.94,,,,,,,,,,,,,
GRAFT BNE PTTY 20 CC BIOACTIVE MTRX STRL BONESYNC LTX,SUP-2859808,CDM,C1713,HCPCS,0278,RC,,,,both,,,8760.60,5694.39,,,,,,,,,,,,,
IMPLANT HUM TISS LT PROX ULN OSTEOARTICULAR CUST MATCHED,SUP-2932973,CDM,C1762,CPT,0278,RC,,,,both,,,10342.06,6722.34,,,,,,,,,,,,,
CATHETER ETER MIC OD 21 AND 17 TIP 90 DEG ECHELON 10,SUP-2172499,CDM,C1887,HCPCS,0272,RC,,,,both,,,2571.66,1671.58,,,,,,,,,,,,,
OSS 9CM ELLIPT PROX TIB BODY,SUP-2506415,CDM,C1776,CPT,0278,RC,,,,both,,,19739.61,12830.75,,,,,,,,,,,,,
GRAFT BNE SUB W05XH05XL05CM 15ML CANC HYDRPHLC FRZ DRY,SUP-2264689,CDM,C1713,HCPCS,0278,RC,,,,both,,,616.70,400.85,,,,,,,,,,,,,
GRAFT BNE CHIP 4-10 MM 60 CC FRZN COARSE CORTICAL CANC,SUP-2307433,CDM,C1713,HCPCS,0278,RC,,,,both,,,5831.01,3790.16,,,,,,,,,,,,,
SCREW SYNDESMOTIC L 42 MM DIA 4 MM TI ANK HEXALOBE HD LP -RSFH,SUP-2881305,CDM,C1713,HCPCS,0278,RC,,,,both,,,1036.20,673.53,,,,,,,,,,,,,
GUIDEWIRE VASC L 180 CM DIA 0.018 IN TIP L 6 MM PTFE J FIX,SUP-2301925,CDM,C1769,HCPCS,0272,RC,,,,both,,,39.72,25.82,,,,,,,,,,,,,
NAVIGATION KIT 17/18 GA NDL APPL,SUP-2135315,CDM,C1715,HCPCS,0272,RC,,,,both,,,62.80,40.82,,,,,,,,,,,,,
GRAFT VASC HEMSHLD PLAT L 60 CM 30MM POLYESTER BOV CLLGN STR,SUP-2265932,CDM,C1768,CPT,0278,RC,,,,both,,,1912.13,1242.88,,,,,,,,,,,,,
BOLT EXT FIX WIRE PRE ASSEMBLED MP SALVATION,SUP-2851275,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6236.04,4053.43,,,,,,,,,,,,,
PLATE BONE L239MM 95DEG 12 H BILAT SUPCNDYL PELV TI LO PROF,SUP-2412162,CDM,C1713,HCPCS,0278,RC,,,,both,,,1890.28,1228.68,,,,,,,,,,,,,
SCREW BNE L100MM DIA35MM ST CORT S STL ST FULL THRD T15,SUP-2178271,CDM,C1713,HCPCS,0278,RC,,,,both,,,247.24,160.71,,,,,,,,,,,,,
FIBERRING WITH SHUTTLE LOOP 35MM 12PACK,SUP-2814146,CDM,C1713,HCPCS,0278,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
SPLINT HND AD UNIV L W STAY WLK,SUP-2112604,CDM,L3807,HCPCS,0272,RC,,,,both,,,148.43,96.48,,,,,,,,,,,,,
SCREW BNE CANN SHT THRD 5.5X50 MM HDLSS NS MONSTER,SUP-2742658,CDM,C1713,HCPCS,0278,RC,,,,both,,,1323.04,859.98,,,,,,,,,,,,,
PLATE BNE L71MM 4 H ST R DST LAT FIBULAR VAR ANG LOK FOR,SUP-2349838,CDM,C1713,HCPCS,0278,RC,,,,both,,,5512.90,3583.38,,,,,,,,,,,,,
BOUGIE ESOPH HURST TUNGSTEN FIL 36FR SIL,SUP-2383704,CDM,2720000010,LOCAL,0272,RC,,,,both,,,425.22,276.39,,,,,,,,,,,,,
JOINT FNGR MP 30 SIL PREFLEX STRL,SUP-2536095,CDM,C1776,CPT,0278,RC,,,,both,,,2873.10,1867.51,,,,,,,,,,,,,
KIT STEREOTACTIC BX GUID TRAJECTORY CRAN EXT DISP NAVIGUS,SUP-2284361,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4932.94,3206.41,,,,,,,,,,,,,
WIRE FIXATION L30CM OD122MM LOOP LUQUE,SUP-2494541,CDM,C1713,HCPCS,0278,RC,,,,both,,,116.93,76.00,,,,,,,,,,,,,
PLATE SPNL LAT 20 MM 4 HOLE REGATTA,SUP-2711122,CDM,C1713,HCPCS,0278,RC,,,,both,,,11775.00,7653.75,,,,,,,,,,,,,
GRAFT BNE 5 CC SUBSTITUTE VITOSS FOAM,SUP-2361122,CDM,C1713,HCPCS,0278,RC,,,,both,,,4816.76,3130.89,,,,,,,,,,,,,
CATHETER HD DL 14.5 FRX27 CM MICROINTRODUCER KT HEMOSPLIT,SUP-2127856,CDM,C1750,HCPCS,0278,RC,,,,both,,,1694.66,1101.53,,,,,,,,,,,,,
COIL EMB L4CM OD2MM 0.018IN SFT HELCL STRTCH DETACH GDC-18,SUP-2365700,CDM,C1889,HCPCS,0278,RC,,,,both,,,3069.66,1995.28,,,,,,,,,,,,,
GUIDEWIRE VASC THRUWAY L 130 CM DIA 0.018 IN SS SIL J SHRT,SUP-2148317,CDM,C1769,HCPCS,0272,RC,,,,both,,,268.47,174.51,,,,,,,,,,,,,
PLATE BNE RECON 3.5X143 MM 11 HOLE W/ WIDE ANGLE STR LP NS,SUP-2799242,CDM,C1713,HCPCS,0278,RC,,,,both,,,1521.42,988.92,,,,,,,,,,,,,
SCREW BNE L4MM DIA1.5MM UNIV SELF DRL CRSS PIN,SUP-2366491,CDM,C1713,HCPCS,0278,RC,,,,both,,,222.69,144.75,,,,,,,,,,,,,
SET HAD CATH 40CMX15.5FR LNG TERM STR W/ SIDE H HI DENS,SUP-2267099,CDM,C1881,HCPCS,0278,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
SHEATH INTRO SILHOUETTE PEELWY L 30 CM DIA10 FR GUIDEWIRE,SUP-2168316,CDM,C1892,HCPCS,0272,RC,,,,both,,,154.65,100.52,,,,,,,,,,,,,
PROBE DISCECTOMY 17GA L6IN PERC LUM STR DISP DEKOMPRESSOR,SUP-2366993,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7483.47,4864.26,,,,,,,,,,,,,
SCREW BNE CORT HND TI L19MM OD1.5MM APTUS HEXADRIVE 4,SUP-2268059,CDM,C1713,HCPCS,0278,RC,,,,both,,,255.85,166.30,,,,,,,,,,,,,
SCREW BNE CANN 7.3X100 MM 16 MM PART THRD TI STRL TRAUM FIX,SUP-2861360,CDM,C1713,HCPCS,0278,RC,,,,both,,,931.45,605.44,,,,,,,,,,,,,
HC Bil Duct Dila W/ W/O Stent S&I,PX-3207436300,CDM,74363,CPT,0320,RC,,,,inpatient,,,2584.00,1679.60,,,,,,,,,,,,,
MESH HERN W6XH4IN OMEGA 3 FATTY ACID POLYPR OBLONG OVL BLT,SUP-2227207,CDM,C1781,HCPCS,0278,RC,,,,both,,,1070.74,695.98,,,,,,,,,,,,,
GUIDEWIRE EMBOLIC PROTCT ANGIOGUARD L 300 MM DIA 0.014 IN,SUP-2157306,CDM,C1769,HCPCS,0272,RC,,,,both,,,5495.00,3571.75,,,,,,,,,,,,,
SCREW BNE LNG THRD 4X23 MM,SUP-2315872,CDM,C1713,HCPCS,0278,RC,,,,both,,,725.34,471.47,,,,,,,,,,,,,
INTRODUCER SHTH STR 0.018 INX45 CM 7 FRX11 CM VENEFIT,SUP-2874946,CDM,C1894,HCPCS,0272,RC,,,,both,,,95.77,62.25,,,,,,,,,,,,,
PERI-LOC 2.7MM S-T CRTX SCREW 40MM,SUP-2819124,CDM,C1713,HCPCS,0278,RC,,,,both,,,258.89,168.28,,,,,,,,,,,,,
DEFIBRILLATOR CARDIOVERTER SGL CHMBR 40 J BPLR PREM DDD 20,SUP-2138265,CDM,C1722,HCPCS,0275,RC,,,,both,,,62501.86,40626.21,,,,,,,,,,,,,
COMPONENT FEM CEM 4 KNEE UC-PLUS,SUP-2450905,CDM,C1776,CPT,0278,RC,,,,both,,,5947.16,3865.65,,,,,,,,,,,,,
NAIL IM L160MM DIA9MM GRN FEM TI CANN LOK RG BEND RND FOR,SUP-2180052,CDM,C1713,HCPCS,0278,RC,,,,both,,,4938.75,3210.19,,,,,,,,,,,,,
PLATE BNE H1MM BAR L4MM 4 H R CRANIOMAXILLOFACIAL TI L,SUP-2366321,CDM,C1713,HCPCS,0278,RC,,,,both,,,681.22,442.79,,,,,,,,,,,,,
SCREW EXT FIX L100MM DIA5MM S STL BLNT TRCR PNT MR,SUP-2186953,CDM,C1713,HCPCS,0278,RC,,,,both,,,233.18,151.57,,,,,,,,,,,,,
BLADE SCREWDRIVER 2MM DIA F/X FIX MOLINA PIN,SUP-2497084,CDM,2720000010,LOCAL,0272,RC,,,,both,,,887.36,576.78,,,,,,,,,,,,,
VALVE AORT BIOPROSTHESIS 25 MM 505 HANCOCK II CINCH II ULTRA,SUP-2429969,CDM,C1713,HCPCS,0278,RC,,,,both,,,9420.00,6123.00,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 50 CM DIA 4-7 MM LNG REINF SLDE GDS,SUP-2681799,CDM,C1768,CPT,0278,RC,,,,both,,,823.97,535.58,,,,,,,,,,,,,
STEM FEM OD12MM CALCAR CEM ENCORE,SUP-2216962,CDM,C1776,CPT,0278,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
GRAFT VASC VENAFLO II L 20 CM DIA 6 MM EPTFE CARBON STR N,SUP-2128777,CDM,C1768,CPT,0278,RC,,,,both,,,1799.22,1169.49,,,,,,,,,,,,,
TROCAR Z THRD 1ST ENTRY HNDL DISP 11MM X100MM KII FIOS,SUP-2119722,CDM,2720000010,LOCAL,0272,RC,,,,both,,,395.64,257.17,,,,,,,,,,,,,
SPLINT WRST R INSTABILITY INJ LOOP LOK W STAY FIRM SUPP,SUP-2276663,CDM,L3908,HCPCS,0272,RC,,,,both,,,16.36,10.63,,,,,,,,,,,,,
KIT VASC CLOSURE VASOSEAL CLLGN MEDIATED EXTRAVASCULAR BLU,SUP-2227423,CDM,2720000010,LOCAL,0272,RC,,,,both,,,551.07,358.20,,,,,,,,,,,,,
CATHETER CARD ABLATION THERMOCOOL SMARTTOUCH L 115 CM 8FR DD,SUP-2248604,CDM,C1732,HCPCS,0272,RC,,,,both,,,9730.86,6325.06,,,,,,,,,,,,,
GRAFT DURA W3XL3IN ABSRB POR CLLGN MTRX BOV DP FLX TEND FOR,SUP-2244083,CDM,C1763,HCPCS,0278,RC,,,,both,,,1753.82,1139.98,,,,,,,,,,,,,
COMPR SRS PROX BDY - SM 48MM,SUP-2506565,CDM,C1776,CPT,0278,RC,,,,both,,,11360.52,7384.34,,,,,,,,,,,,,
PLATE DIST MEDIAL TIB 3.5MM 12H LT,SUP-2854200,CDM,C1713,HCPCS,0278,RC,,,,both,,,7414.51,4819.43,,,,,,,,,,,,,
"HC New Pt, Outpt Visit Level 2",PX-7619920200,CDM,99202,CPT,0761,RC,,,,inpatient,,,363.00,235.95,,,,,,,,,,,,,
SYSTEM MENIS REP W/ 27DEG ORTHOCORD VLT BRAID COMP 2-0 SUT,SUP-2249482,CDM,C1713,HCPCS,0278,RC,,,,both,,,1036.20,673.53,,,,,,,,,,,,,
RETRACTOR SURG MINI LIGHT SAPHO FIBEROPTIC,SUP-2227093,CDM,C1713,HCPCS,0278,RC,,,,both,,,1269.22,824.99,,,,,,,,,,,,,
MESH HERN W20XL30CM THN OXIDIZED REGENERATED CELOS POLYPR,SUP-2219763,CDM,C1781,HCPCS,0278,RC,,,,both,,,5209.35,3386.08,,,,,,,,,,,,,
SCREW SPNL L9MM DIA2.6MM TI ST FOR PLT FIX SYS CENTERPIECE,SUP-2290250,CDM,C1713,HCPCS,0278,RC,,,,both,,,149.15,96.95,,,,,,,,,,,,,
PROSTHESIS VOICE 20 FRX6 MM INDWL ESOPH FLANGE BLOM-SINGER,SUP-2242390,CDM,L8509,HCPCS,0274,RC,,,,both,,,904.32,587.81,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.549,SUP-2860066,CDM,C1713,HCPCS,0278,RC,,,,both,,,59286.65,38536.32,,,,,,,,,,,,,
ROD STR SPINE SMOOTH TI TENOR SPINE 5.5X210MM,SUP-2289295,CDM,C1713,HCPCS,0278,RC,,,,both,,,477.28,310.23,,,,,,,,,,,,,
PLATE BNE L230MM 10 H R DST EXTRAARTICULAR HUM S STL LOK,SUP-2184044,CDM,C1713,HCPCS,0278,RC,,,,both,,,4189.80,2723.37,,,,,,,,,,,,,
SHELL ACET DIA58MM GRP G BIOFOAM TI MTL FOAM HIP PRESSFIT,SUP-2304549,CDM,C1776,CPT,0278,RC,,,,both,,,4082.00,2653.30,,,,,,,,,,,,,
HC So Special Stain Grp 2,PX-3128831366,CDM,88313,CPT,0312,RC,,,,outpatient,,,239.00,155.35,,,,,,,,,,,,,
GRAFT SKIN GRAFIX PL PRIME 3X3CM LYPOPRESERVED,SUP-2319173,CDM,Q4133,HCPCS,0636,RC,,,,both,,,3532.50,2296.12,,,,,,,,,,,,,
SCREW BNE L14MM DIA2.4MM TI ST NONCANNULATED LOK FULL THRD,SUP-2181150,CDM,C1713,HCPCS,0278,RC,,,,both,,,459.13,298.43,,,,,,,,,,,,,
BRACE ORTH CIRC THGH 29.5-32 IN CTR 21-23 IN CALF 22-24 IN 11-1443-7,SUP-2918716,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1059.34,688.57,,,,,,,,,,,,,
GRAFT MTRX TISS HUM INJ CYMETRA MICRONIZED ALLDERM,SUP-2113358,CDM,Q4116,HCPCS,0636,RC,,,,both,,,850.94,553.11,,,,,,,,,,,,,
X LG METAL HEMI IMPLANT METAL HEMI SYSTEM,SUP-2494510,CDM,C1776,CPT,0278,RC,,,,both,,,4587.54,2981.90,,,,,,,,,,,,,
CEPHALEXIN 500 MG PO CAPS,RX-9500,CDM,6370000000,HCPCS,0637,RC,60687-0163-11,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
BRACE ORTH CIRC THGH 29.5-32 IN CTR 21-23 IN CALF 22-24 IN BLK LT,SUP-2915250,CDM,2720000010,LOCAL,0272,RC,,,,both,,,884.26,574.77,,,,,,,,,,,,,
STEM FEM L220MM OD13MM TI HA 80% POR DST CALCAR HIP DPHSEAL,SUP-2408331,CDM,C1776,CPT,0278,RC,,,,both,,,7975.60,5184.14,,,,,,,,,,,,,
IMPLANT HUM TISS L 3 X W 3 CM DECELL PLCNTA MEMBRN TEND NEVE,SUP-2881933,CDM,C1762,CPT,0278,RC,,,,both,,,6782.40,4408.56,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED PRSS FT,SUP-2212535,CDM,C1776,CPT,0278,RC,,,,both,,,14877.32,9670.26,,,,,,,,,,,,,
STEM FEM L102MM DIA9MM KNEE TI POR BODY STR CEM GMRS,SUP-2376419,CDM,C1776,CPT,0278,RC,,,,both,,,9248.09,6011.26,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 100 MM DIA 8 MM DEL SHTH 6.7ML,SUP-2936836,CDM,C1713,HCPCS,0278,RC,,,,both,,,11501.82,7476.18,,,,,,,,,,,,,
GRAFT HUM TISS 4X6CM THN UMB CRD CYGNUS SOLO,SUP-2393057,CDM,Q4170,HCPCS,0636,RC,,,,both,,,6499.80,4224.87,,,,,,,,,,,,,
BIT DRILL 2.1MM HIP INSTRUMENT SYSTEM PRESSFT,SUP-2842813,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1470.62,955.90,,,,,,,,,,,,,
ALLOGRAFT BNE WDG 40X30X10 MM FD IRRADIATED CALCANEUS,SUP-2866901,CDM,C1762,CPT,0278,RC,,,,both,,,1983.70,1289.40,,,,,,,,,,,,,
KIT CATH FOR CARD MAP REF LOCATION,SUP-2141347,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
STEM FEM L200MM OD19MM POR DST CALCAR MOD RLER HARDENED,SUP-2403940,CDM,C1776,CPT,0278,RC,,,,both,,,9455.95,6146.37,,,,,,,,,,,,,
SYSTEM LAP MED 18 CM INCISION CAP FOR SPEC EXTRACTION ALEXIS,SUP-2859553,CDM,2720000010,LOCAL,0272,RC,,,,both,,,737.90,479.63,,,,,,,,,,,,,
INSERTION KIT ARTVEN PED BIO-MEDICUS NEXTGEN,SUP-2480656,CDM,C1769,HCPCS,0272,RC,,,,both,,,248.69,161.65,,,,,,,,,,,,,
RING EXT FIX FULL 160 MM TI NS,SUP-2800051,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2955.49,1921.07,,,,,,,,,,,,,
PROSTHESIS PENILE 21X12 CM PRECONN MOMENTARY SQUEEZE PS CX,SUP-2862190,CDM,C1813,HCPCS,0278,RC,,,,both,,,34498.55,22424.06,,,,,,,,,,,,,
DEXTROSE-SODIUM CHLORIDE 5-0.225 % IV SOLN,RX-17858,CDM,J7042,HCPCS,0250,RC,00990-7924-03,NDC,,both,500,ML,55.30,35.94,,,,,,,,,,,,,
CLAMP EXT FIX STD PENNIG MINIFIXATOR,SUP-2316458,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1598.95,1039.32,,,,,,,,,,,,,
AP CLASSIC REVISION SLL STEM SZ 10,SUP-2506658,CDM,C1776,CPT,0278,RC,,,,both,,,10399.68,6759.79,,,,,,,,,,,,,
GUIDE RESECT NK ACCOLADE,SUP-2361536,CDM,C1776,CPT,0278,RC,,,,both,,,1141.39,741.90,,,,,,,,,,,,,
BIT DRL L125MM DIA2.3MM QUIK CPL NONRADIOLUCENT CANN W/O,SUP-2319434,CDM,2720000010,LOCAL,0272,RC,,,,both,,,536.94,349.01,,,,,,,,,,,,,
RFID SINGLEUSE 200SRS LSR FIBR,SUP-2722584,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1450.77,943.00,,,,,,,,,,,,,
AMPICILLIN 500 MG PO CAPS,RX-466,CDM,6370000000,HCPCS,0637,RC,00781-2145-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
BUR SURG L9CM HD L7.7MM DIA6MM ACORN FLUT L BOR MIDAS REX,SUP-2284654,CDM,2720000010,LOCAL,0272,RC,,,,both,,,331.84,215.70,,,,,,,,,,,,,
CATHETER ETER VENT L120CM ANTIBIO IMPREG,SUP-2280158,CDM,C1729,HCPCS,0272,RC,,,,both,,,1676.63,1089.81,,,,,,,,,,,,,
ROD SPNL L70MM DIA5.5MM THORACOLUMBOSACRAL CP TI PREBENT,SUP-2290745,CDM,C1713,HCPCS,0278,RC,,,,both,,,552.64,359.22,,,,,,,,,,,,,
HC Clsd Tx Cmc Disl WO Anesth,PX-4502667000,CDM,26670,CPT,0450,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
SCREW CRTX FT SELF TAP HEX HD 4.5MM DIA 48MML,SUP-2342664,CDM,C1713,HCPCS,0278,RC,,,,both,,,54.82,35.63,,,,,,,,,,,,,
IMPLANT THYROPLASTY SZ 8 SIL FOR FEM PT MONT,SUP-2138770,CDM,C1878,HCPCS,0278,RC,,,,both,,,1400.44,910.29,,,,,,,,,,,,,
BIT DRL L205MM DIA2.7MM STD QUIK CONN W/O STP N RADLUC,SUP-2410868,CDM,2720000010,LOCAL,0272,RC,,,,both,,,382.95,248.92,,,,,,,,,,,,,
SCREW BONE L60MM DIA6.5MM THRD L20MM CANN GUID ASNS 2,SUP-2362433,CDM,C1713,HCPCS,0278,RC,,,,both,,,862.09,560.36,,,,,,,,,,,,,
COVER BUR H DIA14MM PLT LO PROF W TAB UNIV NEURO III,SUP-2363631,CDM,C1713,HCPCS,0278,RC,,,,both,,,725.53,471.59,,,,,,,,,,,,,
INSERT TIB SZ 2 THK6.5MM KNEE UHMWPE INLAY RESTORIS MCK,SUP-2368680,CDM,C1776,CPT,0278,RC,,,,both,,,2863.68,1861.39,,,,,,,,,,,,,
SCREW ANT GIC53 BONE SCR 6.5X30MM 8968006,SUP-2291652,CDM,C1713,HCPCS,0278,RC,,,,both,,,4568.70,2969.65,,,,,,,,,,,,,
GRAFT DURA ABSRB CLLGN BASE ST 5IN 4IN CLLGN DURAMATRIX,SUP-2165122,CDM,C1763,HCPCS,0278,RC,,,,both,,,3891.28,2529.33,,,,,,,,,,,,,
BIT DRL CANN 7 MM KNEE SINGLE FLUT MTO,SUP-2849080,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2201.14,1430.74,,,,,,,,,,,,,
TUBE ENTRL FEED GASTRO-ENTERIC 16 FRX57.9 CM 7-10 CC MIC,SUP-2764421,CDM,2720000010,LOCAL,0272,RC,,,,both,,,559.33,363.56,,,,,,,,,,,,,
COLLAR CERV M H4.25IN POLYETH FOAM CA,SUP-2196884,CDM,L0120,HCPCS,0272,RC,,,,both,,,43.05,27.98,,,,,,,,,,,,,
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-102315,CDM,J2003,HCPCS,0636,RC,63323-0495-04,NDC,,both,1,ML,54.10,35.16,,,,,,,,,,,,,
REDAPT MODULAR SHELL 56MM,SUP-2511017,CDM,C1776,CPT,0278,RC,,,,both,,,6566.37,4268.14,,,,,,,,,,,,,
HEAD ULN MOD 19 MM ELBW,SUP-2610431,CDM,C1776,CPT,0278,RC,,,,both,,,5046.29,3280.09,,,,,,,,,,,,,
MARKER GRFT SIL DISK LTWT BIOCOMPATIBLE RADPQ DISP,SUP-2336956,CDM,A4648,CPT,0278,RC,,,,both,,,59.03,38.37,,,,,,,,,,,,,
GRAFT IMPL HUM TISS FRZ DRY ALLGRFT IL CREST BICORTICAL STRP,SUP-2294078,CDM,C1713,HCPCS,0278,RC,,,,both,,,2813.44,1828.74,,,,,,,,,,,,,
STAPLER INT AD L55MM DIA5MM THCK TISS TI LIN 2 ROW STR,SUP-2283029,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2009.03,1305.87,,,,,,,,,,,,,
LINER ACET OD68MM ID26MM CO CHROM FEM BPLR ASMBLY IMP,SUP-2207820,CDM,C1776,CPT,0278,RC,,,,both,,,3356.03,2181.42,,,,,,,,,,,,,
HC Rcnstj Polydactylous Digit Soft Tissue & Bone,PX-3602658700,CDM,26587,CPT,0360,RC,,,,inpatient,,,9955.00,6470.75,,,,,,,,,,,,,
BELT RIB ELAS FOAM FEM UNIV 6IN,SUP-2194538,CDM,L0220,HCPCS,0272,RC,,,,both,,,30.21,19.64,,,,,,,,,,,,,
COIL EMB L10CM DIA0.02IN LOOP DIA4MM CRV EXTRA SFT FILL,SUP-2323452,CDM,C1889,HCPCS,0278,RC,,,,both,,,7526.58,4892.28,,,,,,,,,,,,,
TRACE MINERALS CU-MN-SE-ZN 300-55-60-3000 MCG/ML IV SOLN,RX-151524,CDM,2500000003,HCPCS,0250,RC,00517-9305-25,NDC,,both,1,ML,162.10,105.36,,,,,,,,,,,,,
PLATE BNE L349MM 18 H R LAT DST FEM S STL LOK COMPR FOR,SUP-2410721,CDM,C1713,HCPCS,0278,RC,,,,both,,,4740.05,3081.03,,,,,,,,,,,,,
PLATE BNE L25MM DOGBNE SLNT W/ COMPR GORILLA,SUP-2321547,CDM,C1713,HCPCS,0278,RC,,,,both,,,4385.01,2850.26,,,,,,,,,,,,,
CUBE EXT FIX 2 H S STL RANCHO FOR ILIZ TAY SPAT FRME EXT,SUP-2342333,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1227.46,797.85,,,,,,,,,,,,,
BUR DENT 1X70 MM CARBIDE STRL PM2 80K,SUP-2134826,CDM,2720000010,LOCAL,0272,RC,,,,both,,,759.88,493.92,,,,,,,,,,,,,
INTRODUCER PIN DISPOSABLE FOR PARAPEDICULAR OPTIMESH 1500DS,SUP-2354623,CDM,2720000010,LOCAL,0272,RC,,,,both,,,188.40,122.46,,,,,,,,,,,,,
PLATE BONE L81MM 3 H PROX HUM LCK FOR 3.5MM SCR,SUP-2349161,CDM,C1713,HCPCS,0278,RC,,,,both,,,7108.33,4620.41,,,,,,,,,,,,,
NAIL IM L315MM OD10MM TIB PLATFRM CANN LCK VERSANAIL,SUP-2412337,CDM,C1713,HCPCS,0278,RC,,,,both,,,3143.14,2043.04,,,,,,,,,,,,,
MARKER TISS VERAFORM,SUP-2662074,CDM,A4648,CPT,0278,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
PLATE BNE L 121 X W 8 MM THK 3.5 MM SCREW DIA2.7 MM 15 H SS 72440315N,SUP-2932771,CDM,C1713,HCPCS,0278,RC,,,,both,,,1903.91,1237.54,,,,,,,,,,,,,
KIT INTRO SHTH MICROEZ L 50 CM CATH 5 FR NDL L 10 CM FLEXURA,SUP-2125499,CDM,C1894,HCPCS,0272,RC,,,,both,,,184.51,119.93,,,,,,,,,,,,,
INSERT ACET OD48MM ID28MM HIP ULTAMET COBAL CHROME ARTC MOD,SUP-2250323,CDM,C1776,CPT,0278,RC,,,,both,,,5442.88,3537.87,,,,,,,,,,,,,
BIT DRL L195MM DIA6MM ST 3 FLUT QUIK CPL NONRADIOPAQUE W O,SUP-2187614,CDM,2720000010,LOCAL,0272,RC,,,,both,,,673.40,437.71,,,,,,,,,,,,,
ANKLE FUSION PLATE LATERAL TT 4H,SUP-2815340,CDM,C1713,HCPCS,0278,RC,,,,both,,,6672.50,4337.12,,,,,,,,,,,,,
RING EXT FIX L140MM FT DBL H FOR SIDEKCK FREE CIR FIX,SUP-2400643,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4509.04,2930.88,,,,,,,,,,,,,
ANCHOR SUTURE 6.5 MM 2 SUTURE W/ NDL BIOSTEON INTRALINE,SUP-2608441,CDM,C1713,HCPCS,0278,RC,,,,both,,,1094.48,711.41,,,,,,,,,,,,,
PIN BNE FIX DIA17MM SUP E NIT SYS MEMOFIX,SUP-2244268,CDM,C1713,HCPCS,0278,RC,,,,both,,,869.91,565.44,,,,,,,,,,,,,
DRAINAGE KIT PEDIATRIC 85 CM W/ ICP CUP CATH 5-10 CM EXAFLOW,SUP-2666663,CDM,2720000010,LOCAL,0272,RC,,,,both,,,454.33,295.31,,,,,,,,,,,,,
KIT ART LN CATH 20GA L6IN NDL 21GA L2IN GWIRE L40CM,SUP-2120111,CDM,C1757,HCPCS,0272,RC,,,,both,,,67.98,44.19,,,,,,,,,,,,,
SCREW BNE LCK 2.4X9 MM VARIAX,SUP-2435318,CDM,C1713,HCPCS,0278,RC,,,,both,,,995.38,647.00,,,,,,,,,,,,,
HC So Aso Titer,PX-3028606066,CDM,86060,CPT,0302,RC,,,,outpatient,,,129.00,83.85,,,,,,,,,,,,,
CHOLANGIOGRAM KIT 0.025 INX260 CM 20 MM JAGTOME 39 SPHINTOM,SUP-2525334,CDM,C1769,HCPCS,0272,RC,,,,both,,,805.32,523.46,,,,,,,,,,,,,
SCREW FIX ANCHR TIMBERLINE,SUP-2415842,CDM,C1713,HCPCS,0278,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
KIT ARTHSCP INSTR INCLUDE CRV SPEAR W/ CIRCUMFERENTIAL,SUP-2121773,CDM,2720000010,LOCAL,0272,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
HC Inj Methylpred Acetate 1 Mg,PX-6360101000,CDM,J1010,HCPCS,0636,RC,,,,both,,,1.00,0.65,,,,,,,,,,,,,
STEM FEM SZ 15 RT HIP CO CHROM NP 12/14 APR,SUP-2210901,CDM,C1776,CPT,0278,RC,,,,both,,,9960.08,6474.05,,,,,,,,,,,,,
PROSTHESIS OSS PISTON 0.8X4 MM 0.97 MM LT EAR SHEA CUP,SUP-2637796,CDM,L8613,CPT,0278,RC,,,,both,,,457.03,297.07,,,,,,,,,,,,,
HC So Immunoassay,PX-3018351666,CDM,83516,CPT,0301,RC,,,,both,,,100.00,65.00,,,,,,,,,,,,,
SPONGE BNE GRFT CANC 10X7X4 MM OSTEOINDUCTIVE SCAFFOLD 2 PK,SUP-2431594,CDM,C1889,HCPCS,0278,RC,,,,both,,,2041.00,1326.65,,,,,,,,,,,,,
PLATE STRNL 6 H TI STR NS MATRIXSTERNUM,SUP-2904233,CDM,C1713,HCPCS,0278,RC,,,,both,,,1860.48,1209.31,,,,,,,,,,,,,
BONE GRAFT KIT COR DECOMPRESSION 15 CC INDUCTIVE PRO-STIM,SUP-2759595,CDM,C1713,HCPCS,0278,RC,,,,both,,,12638.50,8215.02,,,,,,,,,,,,,
PLATE BNE LP 21X0.4 MM 8 HOLE ARM BURR HOLE CVR Q-STYLE TI,SUP-2461721,CDM,C1713,HCPCS,0278,RC,,,,both,,,3230.78,2100.01,,,,,,,,,,,,,
COMPONENT GLEN LIP POLYETH COFLD SM,SUP-2344312,CDM,C1776,CPT,0278,RC,,,,both,,,3722.78,2419.81,,,,,,,,,,,,,
GRAFT DURA L 3 X W 1 IN TYP I CLLGN BOV ACHILLES TEND RESRB,SUP-2889748,CDM,C1763,HCPCS,0278,RC,,,,both,,,1293.62,840.85,,,,,,,,,,,,,
CATHETER ATHRCTMY SILVERHAWK L 135 MM EFFECTIVE L 132 CM TIP,SUP-2173079,CDM,C1714,HCPCS,0272,RC,,,,both,,,9404.30,6112.79,,,,,,,,,,,,,
SLEEVE KNEE PROSTHETIC,SUP-2323332,CDM,L5685,LOCAL,0274,RC,,,,both,,,379.94,246.96,,,,,,,,,,,,,
LEAD PACE L60CM ATR VENT SIL INSUL STEROID ELUT TEMP BPLR,SUP-2278401,CDM,C1898,HCPCS,0275,RC,,,,both,,,1462.46,950.60,,,,,,,,,,,,,
CATH GUIDE CPS LOCATOR MEDIUM EXTRA LONG 3D,SUP-2873675,CDM,C1887,HCPCS,0272,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
BIT DRL SHFT 4.2 MM DENT,SUP-2657076,CDM,2720000010,LOCAL,0272,RC,,,,both,,,375.04,243.78,,,,,,,,,,,,,
SET HEMSTAT SPR SYR PIST APPL FLTR TBNG VITAGEL,SUP-2379527,CDM,2720000010,LOCAL,0272,RC,,,,both,,,317.14,206.14,,,,,,,,,,,,,
ELECTRODE ELECSURG BALL TIP 8 FRX37 CM MONOPOLAR FULG BLU,SUP-2313732,CDM,C1713,HCPCS,0278,RC,,,,both,,,445.10,289.31,,,,,,,,,,,,,
DEVICE SUTURING CLOSURE 2-0 4 IN RELD GRN ENDOSTCH,SUP-2787723,CDM,2720000010,LOCAL,0272,RC,,,,both,,,352.18,228.92,,,,,,,,,,,,,
PLATE BNE PROF THK 1 MM 6 H SCREW DIA2 MM MED TI MIDFACE GLD,SUP-2883838,CDM,C1713,HCPCS,0278,RC,,,,both,,,951.42,618.42,,,,,,,,,,,,,
ELECTRODE ES 27X28FR DIA3MM BRN COAG BALL SHP FOR 24 28FR,SUP-2360974,CDM,C1713,HCPCS,0278,RC,,,,both,,,431.81,280.68,,,,,,,,,,,,,
IMPLANT COSMETIC SZ 35 X 32 X 4 MM SM POLYETHYL CHIN 3 PC SQ,SUP-2935184,CDM,C1713,HCPCS,0278,RC,,,,both,,,1874.58,1218.48,,,,,,,,,,,,,
MOLD FEM STEM L145MM DIA13MM HD DIA57MM HIP SIL CLLRLSS,SUP-2408621,CDM,C1776,CPT,0278,RC,,,,both,,,4848.16,3151.30,,,,,,,,,,,,,
SCREW BONE L14MM DIA2MM PARTIALLY THRD HD SM CANN FLOWERCUBE,SUP-2225319,CDM,C1713,HCPCS,0278,RC,,,,both,,,697.33,453.26,,,,,,,,,,,,,
GRAFT VASC HEMSHLD GLD L 30 CM 20 MM POLYESTER BOV CLLGN STR,SUP-2265894,CDM,C1768,CPT,0278,RC,,,,both,,,1296.82,842.93,,,,,,,,,,,,,
PROSTHESIS PENILE INFLATABLE 0 DEG 18 CM INFPUB TITAN TCH LF,SUP-2848009,CDM,C1813,HCPCS,0278,RC,,,,both,,,38811.97,25227.78,,,,,,,,,,,,,
ASPIRATION TRAY 102 MM ONCONTROL,SUP-2766680,CDM,2720000010,LOCAL,0272,RC,,,,both,,,481.46,312.95,,,,,,,,,,,,,
RESERVOIR CSF SM LUMPERITON TWO MTL CONN SPETZLER,SUP-2852601,CDM,C1889,HCPCS,0278,RC,,,,both,,,1109.55,721.21,,,,,,,,,,,,,
PLATE BNE W12XL268MM THK3.7MM LNG 12 H NONSTERILE PROX HUM,SUP-2186023,CDM,C1713,HCPCS,0278,RC,,,,both,,,5073.33,3297.66,,,,,,,,,,,,,
HEAD FEM OD28MM NK -3MM CO CHROM MTL ON POLY PRI,SUP-2406707,CDM,C1776,CPT,0278,RC,,,,both,,,10770.20,7000.63,,,,,,,,,,,,,
K WIRE FIX L229MM DIA1.1MM STYL 7 S STL DBL DMND PNT,SUP-2409634,CDM,C1713,HCPCS,0278,RC,,,,both,,,22.07,14.35,,,,,,,,,,,,,
CUTTER BOLT 52MM OUTER TB,SUP-2289763,CDM,C1713,HCPCS,0278,RC,,,,both,,,2292.73,1490.27,,,,,,,,,,,,,
GRAFT BIO TISS 4X8CM THK20 33MM PROLAYER,SUP-2362232,CDM,C1763,HCPCS,0278,RC,,,,both,,,9108.51,5920.53,,,,,,,,,,,,,
GRAFT BNE CHIP CRUSH FRZ DRY CANC 1MM 4MM RANG 40CC,SUP-2264678,CDM,C1713,HCPCS,0278,RC,,,,both,,,1571.98,1021.79,,,,,,,,,,,,,
SCREW SPNL L13MM DIA4.5MM CANC ANTR CERV TI ST LCK VAR ANG,SUP-2254601,CDM,C1713,HCPCS,0278,RC,,,,both,,,741.04,481.68,,,,,,,,,,,,,
BLADE SHV L27.5CM DIA3.5MM 60-500RPM LO PROF S STL LARYN DBL,SUP-2284139,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1616.88,1050.97,,,,,,,,,,,,,
IMPLANT ANK JT L15MM OD9MM TI SUBTALAR SFT THRD CANN CONIC,SUP-2388616,CDM,C1776,CPT,0278,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
RETRACTOR ENDOSCP SHFT L31MM DIA10MM TEAL ATRAUM ARTC 5,SUP-2283175,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1235.90,803.33,,,,,,,,,,,,,
PLATE BONE L97.2MM 14 H STRL BILAT VAR LCK NONCOMPRESSION,SUP-2349960,CDM,C1713,HCPCS,0278,RC,,,,both,,,8254.12,5365.18,,,,,,,,,,,,,
COMPONENT PAT DIA38MM THK9.5MM 3 PEG POLYETH CEM RND REV,SUP-2251242,CDM,C1776,CPT,0278,RC,,,,both,,,3259.32,2118.56,,,,,,,,,,,,,
STEM ULN HD 6.5 MED PART MOD REPL 1ST CHOICE,SUP-2610439,CDM,C1776,CPT,0278,RC,,,,both,,,12501.34,8125.87,,,,,,,,,,,,,
DEVICE EMB CATERPILLAR DEL WIRE L 155 CM CATH 0.056 IN RVD,SUP-2655907,CDM,C1889,HCPCS,0278,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
STAPLER ENDOSCP STD TISS LNAR CUT STPL LN 6 ROW TI N ABSRB,SUP-2257548,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1059.15,688.45,,,,,,,,,,,,,
POST EXT FIX FREE FOR JET-X EXT FIX,SUP-2342958,CDM,C1776,CPT,0278,RC,,,,both,,,4614.39,2999.35,,,,,,,,,,,,,
MODEL ANAT MAXILLOMANDIBULAR 3D CT BASE SEL CLR VITAL STRUCT,SUP-2883464,CDM,2720000010,LOCAL,0272,RC,,,,both,,,19320.07,12558.05,,,,,,,,,,,,,
BOOT CHARCOT TCC EZ EXTRA L,SUP-2194343,CDM,L4387,HCPCS,0274,RC,,,,both,,,312.27,202.98,,,,,,,,,,,,,
DOXORUBICIN HCL LIPOSOMAL 2 MG/ML IV SUSP,RX-169094,CDM,Q2050,HCPCS,0636,RC,70710-1530-01,NDC,,both,10,ML,445.20,289.38,,,,,,,,,,,,,
MIXER BNE CEM VAC BRKOFF NOZ PRISM II,SUP-2253058,CDM,2720000010,LOCAL,0272,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
ANCHOR SUT BLU WHT BIORAPTOR 1 NUMBER 2 PRELD ULTRABRAID CO,SUP-2341783,CDM,C1713,HCPCS,0278,RC,,,,both,,,985.96,640.87,,,,,,,,,,,,,
BUPROPION HCL ER (SR) 100 MG PO TB12,RX-18385,CDM,6370000000,HCPCS,0637,RC,68084-0697-11,NDC,,both,1,UN,3.60,2.34,,,,,,,,,,,,,
GUIDE WIRE .041 DIAMETER,SUP-2812186,CDM,C1769,HCPCS,0272,RC,,,,both,,,47.10,30.61,,,,,,,,,,,,,
PLATE BNE H MTCRPL 6 HOLE,SUP-2389577,CDM,C1713,HCPCS,0278,RC,,,,both,,,1491.50,969.47,,,,,,,,,,,,,
CATHETER DRAINAGE KINK RESIST 6 FRX30 CM,SUP-2126990,CDM,C1729,HCPCS,0272,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
SUPPORT ORTHOT CUST RNG FLANGE PLAS LTHR,SUP-2435581,CDM,L1100,HCPCS,0272,RC,,,,both,,,537.66,349.48,,,,,,,,,,,,,
HC So1 Allergen Specific,PX-3058600367,CDM,86003,CPT,0305,RC,,,,outpatient,,,17.00,11.05,,,,,,,,,,,,,
STEM HUM CMNTLS 9X100 MM SHLDR REVERSED AEQUALIS,SUP-2715663,CDM,C1776,CPT,0278,RC,,,,both,,,7785.63,5060.66,,,,,,,,,,,,,
CATHETER INT AORT BAL REDIGUARD FLEX 50CC 8.0FR,SUP-2744830,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2700.40,1755.26,,,,,,,,,,,,,
GRAFT VASC ARTEGRAFT L 30 CM DIA 7 MM CLLGN BOV CAR ART,SUP-2880935,CDM,C1768,CPT,0278,RC,,,,both,,,7721.26,5018.82,,,,,,,,,,,,,
PLATE BNE L156MM THK37MM 12 H R J S STL LO PROF RIG RECON,SUP-2177161,CDM,C1713,HCPCS,0278,RC,,,,both,,,2558.85,1663.25,,,,,,,,,,,,,
NEEDLE INSUFFLATION PNEUMOPERI 18 CM VERES SPRING LD BLNT LL,SUP-2767139,CDM,2720000010,LOCAL,0272,RC,,,,both,,,884.19,574.72,,,,,,,,,,,,,
TUBE SALIVARY BYPASS RADIOPAQUE MONTGOMERY 191X38X12MM,SUP-2713903,CDM,C1889,HCPCS,0278,RC,,,,both,,,715.92,465.35,,,,,,,,,,,,,
PLATE BNE CRV BROAD PEDIATRIC 3.5 MM 28 HOLE SS NS LCP,SUP-2799225,CDM,C1713,HCPCS,0278,RC,,,,both,,,3568.23,2319.35,,,,,,,,,,,,,
GUIDEWIRE VASC L185CM COR CTO RE ENTRY SYS STINGRAY,SUP-2140968,CDM,C1769,HCPCS,0272,RC,,,,both,,,1165.73,757.72,,,,,,,,,,,,,
PLATE BNE W33XL121MM 8 H R DST MED TIB S STL LOK COMPR NEUT,SUP-2185111,CDM,C1713,HCPCS,0278,RC,,,,both,,,3400.97,2210.63,,,,,,,,,,,,,
BASEPLATE TIB HYBRID 63 MM KNEE POLYETH OSS,SUP-2441735,CDM,C1776,CPT,0278,RC,,,,both,,,9566.01,6217.91,,,,,,,,,,,,,
STAPLER INT USE DIA21 MM STPL H 3/3.5/4 MM MED/THICK CIR,SUP-2898377,CDM,C1713,HCPCS,0278,RC,,,,both,,,3073.84,1998.00,,,,,,,,,,,,,
HC Venous Sel Blood Sampling,PX-3613650000,CDM,36500,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
HC X-Ray Ankle 2 Views,PX-3207360000,CDM,73600,CPT,0320,RC,,,,both,,,458.00,297.70,,,,,,,,,,,,,
RIFAXIMIN 550 MG PO TABS,RX-102296,CDM,6370000000,HCPCS,0637,RC,65649-0303-03,NDC,,both,1,UN,259.80,168.87,,,,,,,,,,,,,
HEAD HUM RESURF HA COAT SZ 3 COPELAND,SUP-2403987,CDM,C1776,CPT,0278,RC,,,,both,,,13976.14,9084.49,,,,,,,,,,,,,
KIT BNE GRFT XSM 1.4CC RHBMP-2 ABSRB CLLGN SPNG INFUSE,SUP-2287847,CDM,C1713,HCPCS,0278,RC,,,,both,,,5981.70,3888.10,,,,,,,,,,,,,
SET SUPRPUB CATH 16FR L30CM NDL 15GA MCOT FOR PERC URIN,SUP-2171110,CDM,C2627,HCPCS,0272,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
STAPLE DEPALMA 3/4 X 3/4,SUP-2487923,CDM,C1713,HCPCS,0278,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
WASHER ORTH OD12.7MM ID6.5MM S STL FOR 6.5MM CANN SCR,SUP-2342487,CDM,C1713,HCPCS,0278,RC,,,,both,,,2083.33,1354.16,,,,,,,,,,,,,
PACK IMPL 3.2MM PROXIMAL/ PHALANX PEEK PIP FUS HAT-TRICK,SUP-2349220,CDM,C1776,CPT,0278,RC,,,,both,,,4995.11,3246.82,,,,,,,,,,,,,
CATHETER ANGIOPLSTY METACROSS L 90 DIA PROX/DSTL,SUP-2385500,CDM,C1725,HCPCS,0272,RC,,,,both,,,486.70,316.35,,,,,,,,,,,,,
TRAY CATH HEMODIALYSI HEM CATH STRL ACTE 11.5FR DI MCDLTSL27,SUP-2633021,CDM,C1750,HCPCS,0278,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
GUIDEWIRE 6CM X 16CM RECTANG,SUP-2418078,CDM,C1769,HCPCS,0272,RC,,,,both,,,4009.78,2606.36,,,,,,,,,,,,,
GRAFT HUM TISS 3X3CM THCK CYGNUS MAX,SUP-2393050,CDM,Q4170,HCPCS,0636,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
MESH HERN W15.9XL26.1CM VENTRAL POLYPR EPTFE OVL,SUP-2125815,CDM,C1781,HCPCS,0278,RC,,,,both,,,2774.50,1803.42,,,,,,,,,,,,,
DEVICE PROSTHETIC SHRINKER BK L8440] TIDEWATER PROSTHETICS],SUP-2388226,CDM,L8440,HCPCS,0274,RC,,,,both,,,153.86,100.01,,,,,,,,,,,,,
STAPLE BONE M SCAPHOID,SUP-2351302,CDM,C1713,HCPCS,0278,RC,,,,both,,,373.66,242.88,,,,,,,,,,,,,
BEAM FUS L135MM DIA5.4MM FT ANK S STL G-BEAM,SUP-2417461,CDM,C1713,HCPCS,0278,RC,,,,both,,,5400.80,3510.52,,,,,,,,,,,,,
RING EXT FIX HALF 150 MM ALUM NS MAXFRAME,SUP-2757973,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3334.96,2167.72,,,,,,,,,,,,,
BIT DRL L40MM DIA2MM CANN POLYAX LOK SCR FOR DST VOLAR RAD,SUP-2421213,CDM,2720000010,LOCAL,0272,RC,,,,both,,,341.63,222.06,,,,,,,,,,,,,
COMPONENT PATELLAR E 12 MM ARTC KNEE,SUP-2200796,CDM,C1776,CPT,0278,RC,,,,both,,,9011.80,5857.67,,,,,,,,,,,,,
GRAFT TISS FRZN FEM CORT STRUT 150MML HALF 3MM,SUP-2307355,CDM,C1713,HCPCS,0278,RC,,,,both,,,4611.91,2997.74,,,,,,,,,,,,,
PLATE BNE THK10MM SHT R MED LOK POLYAX CLMN FUS FOR 24 27MM,SUP-2364496,CDM,C1713,HCPCS,0278,RC,,,,both,,,6180.78,4017.51,,,,,,,,,,,,,
PLATE BNE T 98 MM RT DSTL RADIAL DORS PERIARTICULAR 8 HOLE,SUP-2494551,CDM,C1713,HCPCS,0278,RC,,,,both,,,2649.47,1722.16,,,,,,,,,,,,,
GRAFT HUM TISS W6XL16CM THCK ACELLULAR DERM MTRX FRZ DRY,SUP-2306916,CDM,C1762,CPT,0278,RC,,,,both,,,8891.26,5779.32,,,,,,,,,,,,,
HC Skull Complete Min 4 Views,PX-3207026000,CDM,70260,CPT,0320,RC,,,,outpatient,,,996.00,647.40,,,,,,,,,,,,,
PLATE EXT FIX 4 H SIDEKCK FREE CIR FIX,SUP-2400693,CDM,2720000010,LOCAL,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
PLATE BONE L93MM 3 H RT PROX HUM LCK FOR 4.5MM SCR PERI-LOC,SUP-2348274,CDM,C1713,HCPCS,0278,RC,,,,both,,,14421.86,9374.21,,,,,,,,,,,,,
SAW WIRE 509 MM RESEGONE CAGE SYS CAPRI,SUP-2732241,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1227.90,798.13,,,,,,,,,,,,,
DRESSING BIO W2XL2IN BOV CLLGN GLYCOSAMINOGLYCAN,SUP-2243931,CDM,Q4104,HCPCS,0636,RC,,,,both,,,11287.48,7336.86,,,,,,,,,,,,,
PATCH CV HEMSHLD L 4.8 X W 0.2 IN THK 0.76 MM POLYESTER BOV,SUP-2486938,CDM,C1768,CPT,0278,RC,,,,both,,,395.17,256.86,,,,,,,,,,,,,
HC Skull Complete Min 4 Views,PX-3207026000,CDM,70260,CPT,0320,RC,,,,inpatient,,,996.00,647.40,,,,,,,,,,,,,
PLATE BNE L52MM THK1.5MM 3 H R S STL T OBLQ ANG LOK COMPR,SUP-2185824,CDM,C1713,HCPCS,0278,RC,,,,both,,,950.13,617.58,,,,,,,,,,,,,
PEG KIT 20 FR NON-SAFETY PUL PLCMNT TECH DLX PUL STRL PONSKY,SUP-2125974,CDM,2720000010,LOCAL,0272,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
HC Special Treatment Procedure,PX-3337747000,CDM,77470,CPT,0333,RC,,,,both,,,3782.00,2458.30,,,,,,,,,,,,,
LEAD NERVE STIM 60 CM 16 ELECTRD PENTA,SUP-2421248,CDM,C1778,HCPCS,0278,RC,,,,both,,,9420.00,6123.00,,,,,,,,,,,,,
PLATE BONE L198MM 16 HOLE RIGHT LTRL DST PRRTCLR FBLR STNLSS,SUP-2494903,CDM,C1713,HCPCS,0278,RC,,,,both,,,2132.00,1385.80,,,,,,,,,,,,,
KIT PICC CATH 4FR L40CM GWIRE L17.75IN 0.018IN POLYUR SGL,SUP-2384051,CDM,C1751,HCPCS,0278,RC,,,,both,,,256.91,166.99,,,,,,,,,,,,,
STAPLER INT INTRALUMINAL 28 MM 35 MM TILT TOP EEA DST SER,SUP-2283245,CDM,2720000010,LOCAL,0272,RC,,,,both,,,896.00,582.40,,,,,,,,,,,,,
PLATE 4.5MM TI LCP TM STRAIGHT RECON 4 HOLES 75MM,SUP-2549504,CDM,C1713,HCPCS,0278,RC,,,,both,,,1010.83,657.04,,,,,,,,,,,,,
PUTTY FIBER CORTICAL 5CC BB76050,SUP-2847027,CDM,C1713,HCPCS,0278,RC,,,,both,,,1968.78,1279.71,,,,,,,,,,,,,
HC So Plasminogen Activator,PX-3058541566,CDM,85415,CPT,0305,RC,,,,both,,,544.00,353.60,,,,,,,,,,,,,
CABLE SURG L750MM DIA1MM STRNL S STL SMOOTH W/OUT NDL CUT,SUP-2186851,CDM,C1713,HCPCS,0278,RC,,,,both,,,281.03,182.67,,,,,,,,,,,,,
CATHETER ETER 5FR PED MICPUNC INTR,SUP-2170539,CDM,C1894,HCPCS,0272,RC,,,,both,,,70.46,45.80,,,,,,,,,,,,,
MESH HERN W10XL15CM THN OXIDIZED REGENERATED CELOS POLYPR,SUP-2219766,CDM,C1781,HCPCS,0278,RC,,,,both,,,1761.13,1144.73,,,,,,,,,,,,,
HC Radiologic Exam Upr GI Trc Double Contrast Study,PX-3207424600,CDM,74246,CPT,0320,RC,,,,both,,,1412.00,917.80,,,,,,,,,,,,,
CATHETER DRNGE 30FR 4 WNG DISP FOR NEPHSTMY MALECOTS,SUP-2129078,CDM,C2627,HCPCS,0272,RC,,,,both,,,76.74,49.88,,,,,,,,,,,,,
BISACODYL 5 MG PO TBEC,RX-1079,CDM,6370000000,HCPCS,0637,RC,00904-6407-61,NDC,,both,1,UN,0.30,0.19,,,,,,,,,,,,,
ALLOGRAFT DERMAL 4X12 CMX1.04-2.28 MM ABD WALL REP ALLDERM,SUP-2112993,CDM,Q4116,HCPCS,0636,RC,,,,both,,,5212.40,3388.06,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.547,SUP-2860064,CDM,C1713,HCPCS,0278,RC,,,,both,,,58695.39,38152.00,,,,,,,,,,,,,
PLATE BNE SM 10 DEG 2.4/2.7X42 MM RT 1ST MTP FUSION VA-LCP,SUP-2432252,CDM,C1713,HCPCS,0278,RC,,,,both,,,3856.36,2506.63,,,,,,,,,,,,,
PLATE BNE STR NEUT 18.5X6X1 MM 4 HOLE SAG SPLIT NC MALL TI,SUP-2181837,CDM,C1713,HCPCS,0278,RC,,,,both,,,1433.10,931.51,,,,,,,,,,,,,
GRAFT VASC GORTX L 45 CM DIA 6 MM RNG L 5 CM EPTFE STR TW,SUP-2396150,CDM,C1768,CPT,0278,RC,,,,both,,,2279.64,1481.77,,,,,,,,,,,,,
GRAFT HUM TISS W2XL3CM WHL MEM AMNIO SHT NO ANG AMINOFIX,SUP-2305724,CDM,C1762,CPT,0278,RC,,,,both,,,3463.42,2251.22,,,,,,,,,,,,,
GRAFT BNE INJ 7 CC INDUCTIVE PRO-STIM,SUP-2759438,CDM,C1713,HCPCS,0278,RC,,,,both,,,10161.04,6604.68,,,,,,,,,,,,,
EXTRACTOR SURG L2 MMXTRACT ALL DISP FOR 2-2.5 MM BROKEN SCR,SUP-2337704,CDM,C1713,HCPCS,0278,RC,,,,both,,,816.40,530.66,,,,,,,,,,,,,
IMPLANT BRST 1030 CC SIL GEL SMTH ULTRA HI PROF STRL,SUP-2927331,CDM,C1789,HCPCS,0278,RC,,,,both,,,6358.50,4133.02,,,,,,,,,,,,,
CARB CON ROD 8MMX200MM,SUP-2469226,CDM,2720000010,LOCAL,0272,RC,,,,both,,,596.60,387.79,,,,,,,,,,,,,
PLATE SPNL LUM LOK AVS ANCHOR L,SUP-2363037,CDM,C1713,HCPCS,0278,RC,,,,both,,,1004.80,653.12,,,,,,,,,,,,,
HC So1 Immunoglobulinige,PX-3018278567,CDM,82785,CPT,0301,RC,,,,outpatient,,,48.00,31.20,,,,,,,,,,,,,
PACK SURG CUST ADULT ECMO LF SVMC,SUP-2741857,CDM,2720000010,LOCAL,0272,RC,,,,both,,,469.37,305.09,,,,,,,,,,,,,
LOXAPINE SUCCINATE 5 MG PO CAPS,RX-4601,CDM,6370000000,HCPCS,0637,RC,00591-0369-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
GRAFT VASC L70CM DIA6MM EPTFE PERIPH BYPS STD WALL NONRINGED,SUP-2126816,CDM,C1768,CPT,0278,RC,,,,both,,,6289.17,4087.96,,,,,,,,,,,,,
IMPLANT HUM TISS L 4 X W 2 CM PLCNTA MTRX MEMBRN DEHYDR ASEP,SUP-2905528,CDM,Q4184,HCPCS,0636,RC,,,,both,,,6280.00,4082.00,,,,,,,,,,,,,
GUIDEWIRE VASC L325CM STR TIP DIA0.014IN COR IMAG VIPEWIRE,SUP-2159523,CDM,C1769,HCPCS,0272,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
BEARING TIB SHT COMP ROT HNG KINEMATIC,SUP-2376472,CDM,C1776,CPT,0278,RC,,,,both,,,6960.44,4524.29,,,,,,,,,,,,,
COMPONENT FEM CR 49X60 MM KNEE BEAD IMPL HA POROUS DURAC,SUP-2377119,CDM,C1776,CPT,0278,RC,,,,both,,,10510.84,6832.05,,,,,,,,,,,,,
ENDCAP SPNL 18X40MM 0 DEG X COR,SUP-2310712,CDM,C1889,HCPCS,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
CONNECTOR T TMPLT SPINE CODE 46,SUP-2232129,CDM,C1713,HCPCS,0278,RC,,,,both,,,2122.64,1379.72,,,,,,,,,,,,,
GRAFT SFT TISS W6X16CM NAT BARR OPTIMIZE SURG PERF AMNIOFIX,SUP-2305727,CDM,V2790,HCPCS,0278,RC,,,,both,,,12443.82,8088.48,,,,,,,,,,,,,
FIBER LASER FLEXIVA PULSE 365,SUP-2718711,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1053.53,684.79,,,,,,,,,,,,,
GENERATOR PULSE IMPLANTABLE INSPIRE,SUP-2664095,CDM,C1767,HCPCS,0278,RC,,,,both,,,58944.08,38313.65,,,,,,,,,,,,,
VALVE HYDROCEPHALUS 35 WITH SHUNT ASSISTANT AND CONTROL RESE,SUP-2821860,CDM,C1889,HCPCS,0278,RC,,,,both,,,9775.61,6354.15,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY LASSO NAV ECO L 115 CM 7/15 FR D,SUP-2248625,CDM,C1732,HCPCS,0278,RC,,,,both,,,3673.80,2387.97,,,,,,,,,,,,,
PLATE BNE L93MM 4 H R MED PROX TIB S STL LOK COMPR LO PROF,SUP-2185631,CDM,C1713,HCPCS,0278,RC,,,,both,,,4155.76,2701.24,,,,,,,,,,,,,
WAND ARTHROSCOPICXL TIP 1.4MM 15DEG BPLR TOPAZ,SUP-2341213,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1422.42,924.57,,,,,,,,,,,,,
PLATE BNE L49MM -90DEG 2X4 H NONSTERILE L DST DORS RAD R,SUP-2177519,CDM,C1713,HCPCS,0278,RC,,,,both,,,2140.91,1391.59,,,,,,,,,,,,,
BIT DRL L 145/60 MM DIA2 MM SCREW DIA2.7 MM CALIB AO QC STRL,SUP-2907877,CDM,2720000010,LOCAL,0272,RC,,,,both,,,883.60,574.34,,,,,,,,,,,,,
CRCLG STRAIGHT PASSER LRG DISPOSABLE,SUP-2814143,CDM,2720000010,LOCAL,0272,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
PLATE BNE L63MM 3 H 135DEG S STL HIP COMPR LO PROF STD BRL,SUP-2374147,CDM,C1713,HCPCS,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
PLATE BNE BLDE L40MM SHFT L92MM THK45 52MM 95DEG 5 H ST,SUP-2186792,CDM,C1713,HCPCS,0278,RC,,,,both,,,3490.14,2268.59,,,,,,,,,,,,,
GRAFT OPHTH SZ B THK50-100UM W1.5XL2CM CONJUNCTIVOCHALASIS,SUP-2135256,CDM,V2790,HCPCS,0274,RC,,,,both,,,1868.30,1214.39,,,,,,,,,,,,,
HC Drainage Mouth Roof Lesion,PX-4504200000,CDM,42000,CPT,0450,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
VALVE CSF BURR HOLE 16 MM LO PRESSURE ANTI SIPHON DEV PUDENZ,SUP-2852583,CDM,C1889,HCPCS,0278,RC,,,,both,,,2248.84,1461.75,,,,,,,,,,,,,
PLATE BNE L35MM 9 H ORBIT RIM TI FOR 1.3MM SCR MOD FIX SYS,SUP-2190642,CDM,C1713,HCPCS,0278,RC,,,,both,,,1039.65,675.77,,,,,,,,,,,,,
SPACER SPNL H7XL25MM PEEK MET FUS CRESC,SUP-2292797,CDM,C1713,HCPCS,0278,RC,,,,both,,,6656.80,4326.92,,,,,,,,,,,,,
RESERVOIR SHUNT OD14MM THK4.8MM SM TI BUR H RADPQ,SUP-2108709,CDM,C1729,HCPCS,0272,RC,,,,both,,,929.03,603.87,,,,,,,,,,,,,
SCREW BNE CORTICAL 2.7X22 MM,SUP-2458998,CDM,C1713,HCPCS,0278,RC,,,,both,,,100.51,65.33,,,,,,,,,,,,,
MROM ARCOMXL ALLPOLY 32IDX48OD,SUP-2510896,CDM,C1776,CPT,0278,RC,,,,both,,,3541.92,2302.25,,,,,,,,,,,,,
PLATE BONE L140MM 8 H S STL BROAD SELF COMPR,SUP-2198607,CDM,C1713,HCPCS,0278,RC,,,,both,,,449.27,292.03,,,,,,,,,,,,,
BOLT L25MM SHEFFIELD RNG EXT FIX SYS,SUP-2316261,CDM,C1713,HCPCS,0278,RC,,,,both,,,13.38,8.70,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.444,SUP-2860008,CDM,C1713,HCPCS,0278,RC,,,,both,,,45382.11,29498.37,,,,,,,,,,,,,
BIO-UNI DISPOSABLE CUTTING KIT L17,SUP-2811436,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2543.40,1653.21,,,,,,,,,,,,,
COMPONENT PAT RND PRI STD CEM POR WITHOUTXRAY WIRE 26MM DIA,SUP-2200597,CDM,C1776,CPT,0278,RC,,,,both,,,5102.50,3316.62,,,,,,,,,,,,,
PLATE BNE L305MM 10 H HIP S STL 10 BND CBL RDY,SUP-2410270,CDM,C1713,HCPCS,0278,RC,,,,both,,,3104.83,2018.14,,,,,,,,,,,,,
BIT DRL L195MM DIA6MM STRL JCBS CHK NONRADIOPAQUE W/O STP,SUP-2187323,CDM,2720000010,LOCAL,0272,RC,,,,both,,,482.46,313.60,,,,,,,,,,,,,
SPACER TIB CONCV 10 MM UNI M/G,SUP-2437228,CDM,C1776,CPT,0278,RC,,,,both,,,1243.44,808.24,,,,,,,,,,,,,
SCREW BNE L35MM OD45MM STD CANC HIP NONLOCKING BLNT SECURFIT,SUP-2370009,CDM,C1713,HCPCS,0278,RC,,,,both,,,314.63,204.51,,,,,,,,,,,,,
IMPLANT COCHLEAR SLIM STR ELECTRD NUC CI24RE,SUP-2165055,CDM,L8614,HCPCS,0278,RC,,,,both,,,66646.50,43320.22,,,,,,,,,,,,,
MESH HERN 20X20 CM VENTRAL N ABSRB MACROPOROUS PARIETENE LF,SUP-2752194,CDM,C1781,HCPCS,0278,RC,,,,both,,,246.21,160.04,,,,,,,,,,,,,
PLATE BNE STR NAR 202 MM 14 HOLE BRIDGE N CONTACT POLYAX,SUP-2485042,CDM,C1713,HCPCS,0278,RC,,,,both,,,1728.38,1123.45,,,,,,,,,,,,,
GUIDE DRL DIA1.7MM INSRT LCK,SUP-2364409,CDM,2720000010,LOCAL,0272,RC,,,,both,,,655.22,425.89,,,,,,,,,,,,,
ROD EXT FIX 4X150 MM FOR CONSOLIDATION 3DX CARBON FIBER,SUP-2525359,CDM,2720000010,LOCAL,0272,RC,,,,both,,,322.13,209.38,,,,,,,,,,,,,
EXPANDER MAMM IMPL OVL TEXT 500ML,SUP-2113318,CDM,C1789,HCPCS,0278,RC,,,,both,,,3124.30,2030.79,,,,,,,,,,,,,
CLAMP SURG 5.5MM ROD CONNECTOR ROD PARALLEL SPINAL XIA,SUP-2879269,CDM,C1713,HCPCS,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
BIT DRL L115MM DIA1.6MM FLUT,SUP-2365239,CDM,2720000010,LOCAL,0272,RC,,,,both,,,871.51,566.48,,,,,,,,,,,,,
CATHETER ANGIOPLSTY 014 135 CM 3X20 MM QUANTUM MAV OTW,SUP-2139895,CDM,C1725,HCPCS,0272,RC,,,,both,,,687.66,446.98,,,,,,,,,,,,,
PLATE BNE L80MM 10 H MAXILLOFACIAL ORAL TI STR,SUP-2191405,CDM,C1713,HCPCS,0278,RC,,,,both,,,2760.69,1794.45,,,,,,,,,,,,,
GUIDEWIRE VASC L315CM SFT BAREWIRE,SUP-2105873,CDM,C1769,HCPCS,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
KIT SURG TALAR FIT TRIALS COMP LCK,SUP-2319756,CDM,C1776,CPT,0278,RC,,,,both,,,1849.46,1202.15,,,,,,,,,,,,,
PASSER SUTURE EXT 45 DEG RT STRL SPECTRUM MVP DISP,SUP-2765727,CDM,2720000010,LOCAL,0272,RC,,,,both,,,867.68,563.99,,,,,,,,,,,,,
LENS MX60USP 125MM +0100,SUP-2392381,CDM,V2787,HCPCS,0276,RC,,,,both,,,150.00,97.50,,,,,,,,,,,,,
NEEDLE ENDO ELMNT WORKING INJCTN,SUP-2747577,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8408.89,5465.78,,,,,,,,,,,,,
HYALURONIDASE BOVINE 150 UNIT/ML IJ SOLN,RX-91037,CDM,J3470,HCPCS,0636,RC,00548-9090-10,NDC,,both,0.02,ML,54.10,35.16,,,,,,,,,,,,,
CATHETER EP 6FR L115CM SPC 2-8-2MM XL SWP CSL CRV DECAPOLAR,SUP-2356920,CDM,C1730,HCPCS,0272,RC,,,,both,,,2813.44,1828.74,,,,,,,,,,,,,
GRAFT BNE KT 3 CC GENEX,SUP-2866999,CDM,C1713,HCPCS,0278,RC,,,,both,,,4330.06,2814.54,,,,,,,,,,,,,
PLATE BNE 45MM MPJ FUS TI ST,SUP-2243232,CDM,C1713,HCPCS,0278,RC,,,,both,,,4380.30,2847.19,,,,,,,,,,,,,
PLATE SPNL UNIV S STL CONN POST COLORADO 2 SACROILIAC FIX,SUP-2290571,CDM,C1713,HCPCS,0278,RC,,,,both,,,3289.78,2138.36,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 40 CM DIA 8 MM EPTFE STR TW N RING,SUP-2396353,CDM,C1768,CPT,0278,RC,,,,both,,,2022.16,1314.40,,,,,,,,,,,,,
CATHETER INFUSION CLEARWAY L 90 CM BALLOON L 50 MM DIA 5 MM,SUP-2227486,CDM,C1725,HCPCS,0272,RC,,,,both,,,3061.50,1989.97,,,,,,,,,,,,,
RESERVOIR CSF SM DRNGE FLD 1.1ML BA IMPREG L23CM VENT CATH,SUP-2284527,CDM,C1889,HCPCS,0278,RC,,,,both,,,894.62,581.50,,,,,,,,,,,,,
FOOT RING LNG DIA 140 MM ALUMINIUM,SUP-2497655,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4569.33,2970.06,,,,,,,,,,,,,
SIZER BRST OD14.2CM 425ML P4.1CM NACL SMOOTH RND MOD PROF,SUP-2300496,CDM,2720000010,LOCAL,0272,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
PERFORATOR SURG 11MM DIA 14MM CRANIAL SHARP COLOR-CODED DISP,SUP-2243194,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1303.10,847.01,,,,,,,,,,,,,
CATHETER DIAG 5.3X5.6FR L115CM ID0.058IN DST ACCS AXS,SUP-2368074,CDM,C1887,HCPCS,0272,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
CATHETER DIAG MEWISSEN STRL,SUP-2140127,CDM,C1751,HCPCS,0278,RC,,,,both,,,249.63,162.26,,,,,,,,,,,,,
HYDRALAZINE HCL 25 MG PO TABS,RX-3700,CDM,6370000000,HCPCS,0637,RC,51079-0075-20,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
AIRWAY KIT SZ ENDOBRONCHIAL FOR SPIRATION VLV SYS STRL LTX,SUP-2865659,CDM,2720000010,LOCAL,0272,RC,,,,both,,,989.10,642.91,,,,,,,,,,,,,
RHO D IMMUNE GLOBULIN 1500 UNITS IM (WRAPPER),RX-430077,CDM,J2790,HCPCS,0636,RC,00562-7805-00,NDC,,both,1,UN,362.90,235.88,,,,,,,,,,,,,
SCREW BNE 2.4MM DIA 12MML STAINLES STL HEXDRVR SPIDER,SUP-2604356,CDM,C1713,HCPCS,0278,RC,,,,both,,,294.16,191.20,,,,,,,,,,,,,
BIOPSY KIT 18 GAX60 CM 7 FR 5 FRX65 CM TRNSJUG LIV TLAB,SUP-2876887,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2339.30,1520.54,,,,,,,,,,,,,
HC Carboxyhemoglobin Quantitative,PX-3018237500,CDM,82375,CPT,0301,RC,,,,outpatient,,,120.00,78.00,,,,,,,,,,,,,
BAND FET MONITOR 11 YDX10 IN WHT,SUP-2735407,CDM,2720000010,LOCAL,0272,RC,,,,both,,,329.89,214.43,,,,,,,,,,,,,
SCREW BNE CANN LNG THRD 4X40 MM TI NS,SUP-2190032,CDM,C1713,HCPCS,0278,RC,,,,both,,,512.95,333.42,,,,,,,,,,,,,
SCREW BNE EMGCY MIC 1.8X5 MM MAND MIC SELF RET TI,SUP-2470209,CDM,C1713,HCPCS,0278,RC,,,,both,,,166.20,108.03,,,,,,,,,,,,,
NEXGEN FULL BLOCK TIBIAL AUGMENT 10MM SIZE 6,SUP-2503153,CDM,C1776,CPT,0278,RC,,,,both,,,3240.48,2106.31,,,,,,,,,,,,,
STRUT EXT FIX MED CE MARKED QUIK ADJ NS TRUELOK + LTX,SUP-2875010,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3191.34,2074.37,,,,,,,,,,,,,
NEEDLE BX 19GA L155MM TIP TRACKED,SUP-2392616,CDM,C1713,HCPCS,0278,RC,,,,both,,,2246.67,1460.34,,,,,,,,,,,,,
TRIAL NERVE STIM LD KT FREEDOM-8A,SUP-2423985,CDM,C1897,HCPCS,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
PLATE BONE CRANIAL 8 HOLE MATRIX 28X12MM TITANIUM NEURO PLAT,SUP-2825987,CDM,C1713,HCPCS,0278,RC,,,,both,,,303.01,196.96,,,,,,,,,,,,,
STEM HUM 6.3X125MM MOD II,SUP-2408647,CDM,C1776,CPT,0278,RC,,,,both,,,14704.62,9558.00,,,,,,,,,,,,,
FEE PROCEDURE FLOWTRIEVER THROMBECTOMY SYSTEM,SUP-2416593,CDM,C1757,HCPCS,0272,RC,,,,both,,,34540.00,22451.00,,,,,,,,,,,,,
STAPLE BNE COMPR LG 3X2 MM,SUP-2223644,CDM,C1713,HCPCS,0278,RC,,,,both,,,910.60,591.89,,,,,,,,,,,,,
COMPONENT ANK CTRL FIX TRANSLATING TRAUM CLMP JET-X,SUP-2342859,CDM,C1776,CPT,0278,RC,,,,both,,,7749.21,5036.99,,,,,,,,,,,,,
SPLINT WRST THMB XL L8IN R BLK FOAM D RNG CLSR ADJ REUSE,SUP-2336033,CDM,L3809,HCPCS,0272,RC,,,,both,,,20.82,13.53,,,,,,,,,,,,,
HDLS CMPN SCR 3.0X12 NS,SUP-2493444,CDM,C1713,HCPCS,0278,RC,,,,both,,,749.83,487.39,,,,,,,,,,,,,
FIBER LASER HOLM 550 MIC,SUP-2430217,CDM,C1713,HCPCS,0278,RC,,,,both,,,4925.56,3201.61,,,,,,,,,,,,,
HC Iaadiadoo Respiratory Synctial Virus,PX-3068780700,CDM,87807,CPT,0306,RC,,,,both,,,125.00,81.25,,,,,,,,,,,,,
BOLT EXT FIX 20 MM MP,SUP-2471481,CDM,2720000010,LOCAL,0272,RC,,,,both,,,113.04,73.48,,,,,,,,,,,,,
HC So2 Amino Acids 6 or < Ea Spec,PX-3018213968,CDM,82139,CPT,0301,RC,,,,both,,,410.00,266.50,,,,,,,,,,,,,
DEVICE PROSTHETIC TYP BK SOCKET MOLD,SUP-2388180,CDM,L2350,HCPCS,0272,RC,,,,both,,,2452.91,1594.39,,,,,,,,,,,,,
STENT PERIPH L20MM DIAM 10MM CATH L135CM CAR PRECIS,SUP-2158977,CDM,C1876,HCPCS,0278,RC,,,,both,,,3862.20,2510.43,,,,,,,,,,,,,
IMPLANT BIO TISS W4XL4CM PORCINE DERM MTRX RECON THINNER,SUP-2388572,CDM,C1713,HCPCS,0278,RC,,,,both,,,6100.24,3965.16,,,,,,,,,,,,,
COUNTERSINK DRL DIA2.4MM CANN DART-FIRE,SUP-2399836,CDM,2720000010,LOCAL,0272,RC,,,,both,,,414.48,269.41,,,,,,,,,,,,,
GRAFT BNE MED TIM-GRAFT FIB SEG,SUP-2393043,CDM,C1713,HCPCS,0278,RC,,,,both,,,2185.44,1420.54,,,,,,,,,,,,,
IMPLANT SHTH ANT TALUS CVR,SUP-2399164,CDM,C1713,HCPCS,0278,RC,,,,both,,,816.40,530.66,,,,,,,,,,,,,
COLLAR CERV PED H1.5/1.75/2IN FOR 8-18IN NK HDPE FOAM 1 PC,SUP-2196873,CDM,L0150,HCPCS,0272,RC,,,,both,,,16.20,10.53,,,,,,,,,,,,,
CATHETER INTVASC ULTRASOUND NUVISION ICE DIA10 FR STRL,SUP-2880095,CDM,C1759,HCPCS,0272,RC,,,,both,,,14130.00,9184.50,,,,,,,,,,,,,
SHEATH INTRO PINNACLE PRECIS ACCS SYS L 10 CM DIA 4 FR STIFF,SUP-2538026,CDM,C1894,HCPCS,0272,RC,,,,both,,,181.18,117.77,,,,,,,,,,,,,
ORTHOPAEDIC SET 60 MM CAP ROD COMB LCK NEWPORT MIS,SUP-2245601,CDM,C1713,HCPCS,0278,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
CATHETER DILATATION CRE RX BILIARY 18 20 MM 55 CM,SUP-2676539,CDM,C1726,HCPCS,0272,RC,,,,both,,,873.23,567.60,,,,,,,,,,,,,
CATHETER EP 7FR L95CM 5-5-5MM SPC 2MM TIP SUP L CURL,SUP-2356913,CDM,C1731,HCPCS,0278,RC,,,,both,,,3432.02,2230.81,,,,,,,,,,,,,
PLATE BNE DOGBONE 30 MM W/ COMPR GORILLA,SUP-2321544,CDM,C1713,HCPCS,0278,RC,,,,both,,,4461.94,2900.26,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP GLIDEWIRE L 260 CM DIA 0.035 IN TIP L 3 CM,SUP-2385258,CDM,C1769,HCPCS,0272,RC,,,,both,,,382.45,248.59,,,,,,,,,,,,,
HC So Testosterone Free,PX-3018440266,CDM,84402,CPT,0301,RC,,,,outpatient,,,98.00,63.70,,,,,,,,,,,,,
GUIDEWIRE VASC L 70 CM DIA 0.035 IN TIP L 3 MM DEPTH MARKING,SUP-2117326,CDM,C1769,HCPCS,0272,RC,,,,both,,,62.80,40.82,,,,,,,,,,,,,
DIST LAT HUM LCK PLATE 15,SUP-2476723,CDM,C1713,HCPCS,0278,RC,,,,both,,,3146.25,2045.06,,,,,,,,,,,,,
SORBITOL 70 % SOLN,RX-93927,CDM,340b,HCPCS,0637,RC,46287-0500-30,NDC,,both,30,ML,54.10,35.16,,,,,,,,,,,,,
HC >= 12 Lead Ekg,PX-7309300500,CDM,93005,CPT,0730,RC,,,,both,,,517.00,336.05,,,,,,,,,,,,,
FOUNDATION ULT CONG INSRT SZ 1 9 MM **SPECIAL ORD ONLY,SUP-2216512,CDM,C1776,CPT,0278,RC,,,,both,,,3438.30,2234.89,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP JAGWIRE L 450 CM DSTL TIP DIA 0.025 IN,SUP-2141539,CDM,C1769,HCPCS,0272,RC,,,,both,,,361.57,235.02,,,,,,,,,,,,,
CATHETER ABLAT 7.5FR L110CM TIP L4MM 2.5MM SPC QPLR STD CRV,SUP-2141330,CDM,C2630,CPT,0272,RC,,,,both,,,5338.00,3469.70,,,,,,,,,,,,,
STEM HUM CEM 14-100 MM SHLDR TI ASHCOM ANAT SHLDR,SUP-2440620,CDM,C1776,CPT,0278,RC,,,,both,,,6415.02,4169.76,,,,,,,,,,,,,
PLATE BNE X 2.3X2 MM THOR RIB 32 HOLE LCK SLD TI LEVEL 1 LTX,SUP-2869154,CDM,C1713,HCPCS,0278,RC,,,,both,,,5625.62,3656.65,,,,,,,,,,,,,
CROWN DENT SZ LL6 LO LT 1ST PERM M S STL THCK OCCLUSAL SURF,SUP-2238808,CDM,D6783,CPT,0278,RC,,,,both,,,24.46,15.90,,,,,,,,,,,,,
ALLOGRAFT BNE PROX HUM W/ SFT TISS,SUP-2321814,CDM,C1713,HCPCS,0278,RC,,,,both,,,14287.00,9286.55,,,,,,,,,,,,,
SCREWDRIVER BLADE 1.5 MM CROSS DRV SS,SUP-2479318,CDM,2720000010,LOCAL,0272,RC,,,,both,,,439.10,285.41,,,,,,,,,,,,,
PROBE HAINES STYLE5,SUP-2677556,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1320.12,858.08,,,,,,,,,,,,,
CATHETER ETER 24CM STD ALPHACURVE GLIDEPATH,SUP-2126479,CDM,C1881,HCPCS,0278,RC,,,,both,,,1374.85,893.65,,,,,,,,,,,,,
STENT GRFT VASC AFX L 55 MM DIA PROX/DSTL 16 MM COCR,SUP-2217703,CDM,C1768,CPT,0278,RC,,,,both,,,8462.30,5500.49,,,,,,,,,,,,,
PLATE BONE L80MM STRL LT POST ANK FUS FOR 3.5MM SCR PERI-LOC,SUP-2349832,CDM,C1713,HCPCS,0278,RC,,,,both,,,6700.76,4355.49,,,,,,,,,,,,,
BASEPLATE TIB N MOD LNG 63X10 MM KNEE POROUS OSS,SUP-2449774,CDM,C1776,CPT,0278,RC,,,,both,,,9687.53,6296.89,,,,,,,,,,,,,
RELOAD STPLR LINEAR 30 MM REG VERY THCK B FRM PROX,SUP-2220063,CDM,C1713,HCPCS,0278,RC,,,,both,,,37.68,24.49,,,,,,,,,,,,,
RING EXT FIX DIA200MM TI HALF MR CONDITIONAL FOR DISTR,SUP-2176968,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1721.19,1118.77,,,,,,,,,,,,,
ARTIFICIAL TEARS 83-15 % OP OINT,RX-122202,CDM,6370000000,HCPCS,0637,RC,00023-0312-04,NDC,,both,3.5,GR,44.00,28.60,,,,,,,,,,,,,
SUPPORT MAMM SURG 48-50 IN 2XL BRA,SUP-2336341,CDM,L8000,HCPCS,0272,RC,,,,both,,,123.50,80.27,,,,,,,,,,,,,
TROCAR ENDOSCP L 150 MM DIA 5 MM LNG BLDELSS FIX CANN,SUP-2896253,CDM,2720000010,LOCAL,0272,RC,,,,both,,,325.15,211.35,,,,,,,,,,,,,
ADAPTER HEARING AID TV 3.0 2.4 G PONTO,SUP-2430287,CDM,2720000010,LOCAL,0272,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
NAIL IM L150MM DIA8MM STRL HUM TI CANN LCK PROX BEND S2,SUP-2192539,CDM,C1713,HCPCS,0278,RC,,,,both,,,5277.84,3430.60,,,,,,,,,,,,,
MAGNESIUM CHLORIDE 64 MG PO TBEC,RX-141212,CDM,6370000000,HCPCS,0637,RC,68585-0005-75,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
CATHETER ATHRCTMY STLTH 360 L 145 CM DIA1.25 MM SHTH 6 FR,SUP-2159527,CDM,C1724,HCPCS,0278,RC,,,,both,,,10660.30,6929.19,,,,,,,,,,,,,
PLATE BNE L45-55MM TROCHANTERIC HIP MALLORY-HEAD TI 2 PC,SUP-2405218,CDM,C1713,HCPCS,0278,RC,,,,both,,,1142.96,742.92,,,,,,,,,,,,,
LID STERILIZTION CASE FOR CASE MOD SPNL SM FRAG,SUP-2489341,CDM,C1892,HCPCS,0272,RC,,,,both,,,455.39,296.00,,,,,,,,,,,,,
DRILL SURG STP STRT S-ROM,SUP-2455213,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2226.26,1447.07,,,,,,,,,,,,,
KNIFE NDL 5.5FR L200CM GWIRE 0.035IN CUT WIRE 5MM SPHINTOM,SUP-2149308,CDM,2720000010,LOCAL,0272,RC,,,,both,,,602.85,391.85,,,,,,,,,,,,,
INSERT TIB SZ 3 THK12MM UNIV UNI KNEE POLYETH UNI PRI NEUT,SUP-2251236,CDM,C1776,CPT,0278,RC,,,,both,,,4352.04,2828.83,,,,,,,,,,,,,
BOOT CAST L AD UNISX OPN TOE VELC CLSR TCC-EZ,SUP-2194357,CDM,L4386,HCPCS,0274,RC,,,,both,,,259.33,168.56,,,,,,,,,,,,,
POSITIONER RAD THER SCREW HD SET 4 CT BLK,SUP-2395103,CDM,C1713,HCPCS,0278,RC,,,,both,,,8.32,5.41,,,,,,,,,,,,,
GRAFT VASC INTERGARD L 70 CM DIA 8 MM THK 0.35 MM POLYESTER,SUP-2227615,CDM,C1768,CPT,0278,RC,,,,both,,,2113.94,1374.06,,,,,,,,,,,,,
PROBE MPLR INCREMENTING PRASS TIP FOR NIM RESPON NIM NEURO,SUP-2284322,CDM,2720000010,LOCAL,0272,RC,,,,both,,,652.12,423.88,,,,,,,,,,,,,
CENTRALIZER 11MM HERITAGE PROX HIP SL VERSYS,SUP-2211369,CDM,C1776,CPT,0278,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
SET INTRO VSI L 10 CM DIA 4 FR NIT MANDREL TIP SMTH STIFF,SUP-2120520,CDM,C1894,HCPCS,0272,RC,,,,both,,,171.13,111.23,,,,,,,,,,,,,
BRACE WLK SM SHOE MAN 4 7 WOMAN 5 8 SHT PNEUMAT SEMI RIG,SUP-2196357,CDM,L4361,HCPCS,0274,RC,,,,both,,,113.35,73.68,,,,,,,,,,,,,
HC Chest Tube Insertion,PX-3613255100,CDM,32551,CPT,0361,RC,,,,inpatient,,,4942.00,3212.30,,,,,,,,,,,,,
BIT DRILL 4.5MM DIA DISPO HOWMEDICA TOT KNEE SYS - 4.5MM,SUP-2377559,CDM,2720000010,LOCAL,0272,RC,,,,both,,,750.46,487.80,,,,,,,,,,,,,
RELOAD STPLR RADIAL 30 MM SALUTE LOAD ENDO GIA TRI-STAPLE,SUP-2126286,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1087.44,706.84,,,,,,,,,,,,,
SCREW PEDCL CANC FIX ANG N CANN TI 5.5MM ROD 8.5MM DIA 70MM,SUP-2280058,CDM,C1713,HCPCS,0278,RC,,,,both,,,3554.17,2310.21,,,,,,,,,,,,,
KIT THROMCTMY TREVO PROVUE NIT PLAT TUNGSTEN HYDRPHLC SLD,SUP-2367762,CDM,C1757,HCPCS,0272,RC,,,,both,,,23095.96,15012.37,,,,,,,,,,,,,
TUBE VENT ARMSTR R 1.14 MM 1 MM 2.7 MM FLROPLAS STRL 520501,SUP-2535145,CDM,L8699,HCPCS,0278,RC,,,,both,,,46.25,30.06,,,,,,,,,,,,,
STEM EXTN L65MM DIA16MM KNEE CEM GMK,SUP-2267632,CDM,C1776,CPT,0278,RC,,,,both,,,5402.37,3511.54,,,,,,,,,,,,,
PLATE BNE ORBIT FLR LG 0.4 MM LT SMRT GRV 3D TI STRL LEVEL 1,SUP-2518089,CDM,C1713,HCPCS,0278,RC,,,,both,,,3878.65,2521.12,,,,,,,,,,,,,
PORT LAP L12MM SFT FLX W 5 12MM CANN AND OBT FOR TRANSANAL,SUP-2283384,CDM,C1713,HCPCS,0278,RC,,,,both,,,1211.10,787.21,,,,,,,,,,,,,
STEM CPT 2 HIP LNG,SUP-2205955,CDM,C1776,CPT,0278,RC,,,,both,,,10301.71,6696.11,,,,,,,,,,,,,
INSERT TIBIALXS-SM THK11MM UNI UNI GEN,SUP-2344273,CDM,C1776,CPT,0278,RC,,,,both,,,2469.61,1605.25,,,,,,,,,,,,,
PLATE SPNL L19MM 2 H UNIV ANT LUM TI TRIANG CVR SET SCR,SUP-2291666,CDM,C1713,HCPCS,0278,RC,,,,both,,,2061.69,1340.10,,,,,,,,,,,,,
FILTER VASC L50MM DIA30MM INTRO 7FR L65CM VENA CAVA JUG W,SUP-2171004,CDM,C1880,HCPCS,0278,RC,,,,both,,,2747.50,1785.87,,,,,,,,,,,,,
GRAFT BNE PTTY MED 6 CC BIOACTIVE FIBERGRAFT BG GPS,SUP-2736519,CDM,C1713,HCPCS,0278,RC,,,,both,,,5934.60,3857.49,,,,,,,,,,,,,
K WIRE FIX L400MM DIA2MM S STL SGL END SMOOTH SHRP TIP SPRD,SUP-2186872,CDM,C1713,HCPCS,0278,RC,,,,both,,,668.95,434.82,,,,,,,,,,,,,
PLATE BONE L82MM 4 H RT OLECRANON W/ TINES FOR 2.7/3.5MM SCR,SUP-2341159,CDM,C1713,HCPCS,0278,RC,,,,both,,,4866.37,3163.14,,,,,,,,,,,,,
SET DIL L 45 CM DIA14 FR GUIDEWIRE 0.035 IN HYDRPHLC FOR,SUP-2170998,CDM,2720000010,LOCAL,0272,RC,,,,both,,,436.46,283.70,,,,,,,,,,,,,
MARKER FIDUCIAL 17 GA GLD,SUP-2247291,CDM,A4648,CPT,0278,RC,,,,both,,,96.30,62.59,,,,,,,,,,,,,
KIT SUT FIBERWIRE FOR LARGER COMPLX SFT TISS APPROXIMATION,SUP-2122089,CDM,C1713,HCPCS,0278,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
OSSEOFLEX SB STRAIGHT BLLN 10GA4ML,SUP-2677175,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2276.50,1479.72,,,,,,,,,,,,,
IMPLANT BONE STRP MOLD IL CREST MTRX 90MM FRZN OSTEOFIL ICM,SUP-2284711,CDM,C1713,HCPCS,0278,RC,,,,both,,,7834.30,5092.29,,,,,,,,,,,,,
TITANIUM MESH PANEL ROUND CNTRD 45MM DIA 6MM 15MM SSTM CP,SUP-2676588,CDM,C1713,HCPCS,0278,RC,,,,both,,,2386.97,1551.53,,,,,,,,,,,,,
SHEATH INTRO ARW GLIDETHRU L 10 CM DIA 4.5 FR DIL 4.5 FR,SUP-2887202,CDM,C1894,HCPCS,0272,RC,,,,both,,,47.41,30.82,,,,,,,,,,,,,
GUIDEWIRE VASC CLOSUREFAST L 45 CM DIA 0.018 IN PTFE SINGLE,SUP-2883978,CDM,C1769,HCPCS,0272,RC,,,,both,,,45.69,29.70,,,,,,,,,,,,,
SCREW BNE L 5 MM DIA2 MM MANDIBULAR SD NS UNIV AXS,SUP-2909481,CDM,C1713,HCPCS,0278,RC,,,,both,,,435.89,283.33,,,,,,,,,,,,,
GRAFT HUM TISS L200 500MM DIA10MM FEM SHFT FRZN,SUP-2307350,CDM,C1713,HCPCS,0278,RC,,,,both,,,6396.75,4157.89,,,,,,,,,,,,,
CATHETER INTVASC LITHO E8 WORKING L 150 CM L 80 MM DIA 4 MM,SUP-2895276,CDM,C1725,HCPCS,0272,RC,,,,both,,,14758.00,9592.70,,,,,,,,,,,,,
NAIL LAPIDUS 4-HOLE RT 42MM,SUP-2321064,CDM,C1713,HCPCS,0278,RC,,,,both,,,6264.30,4071.79,,,,,,,,,,,,,
STRUT EXT FIX XSH L91-121MM FOR TAY SPAT FRME FAST FX,SUP-2343006,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7309.92,4751.45,,,,,,,,,,,,,
SCISSORS 5IN CVD SUP CUT METZ,SUP-2162151,CDM,2720000010,LOCAL,0272,RC,,,,both,,,341.26,221.82,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.406,SUP-2859970,CDM,C1713,HCPCS,0278,RC,,,,both,,,31851.22,20703.29,,,,,,,,,,,,,
INSERT TIB FLX ULT CONG PROLONG NAT KNEE RT 22 MM SZ 3/4/5,SUP-2200122,CDM,C1776,CPT,0278,RC,,,,both,,,7316.20,4755.53,,,,,,,,,,,,,
KNIFE SURG BALLENGER SWVL 5 MM BAYNT MICROFRANCE,SUP-2485370,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2380.65,1547.42,,,,,,,,,,,,,
GRAFT HUM TISS INJ FLUID 0.25 CC AMNIO PLCNTA MEMBRN PRO3-F,SUP-2742030,CDM,C1762,CPT,0278,RC,,,,both,,,3022.25,1964.46,,,,,,,,,,,,,
COLLAR CERV SERP CNTOUR L235XH5IN L,SUP-2276596,CDM,L0120,HCPCS,0274,RC,,,,both,,,8.51,5.53,,,,,,,,,,,,,
ASSEMBLY EXT FIX LG KT SIDEKCK EZ FRAME,SUP-2851069,CDM,2720000010,LOCAL,0272,RC,,,,both,,,631.14,410.24,,,,,,,,,,,,,
BIT DRL CALIB STP 5/6.5 MM AOS,SUP-2766046,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1475.80,959.27,,,,,,,,,,,,,
SCREW BONE L19MM OD3.5MM CRUCFRM,SUP-2362293,CDM,C1713,HCPCS,0278,RC,,,,both,,,21.16,13.75,,,,,,,,,,,,,
WASHER ORTH BOWL 7 MM MONSTER,SUP-2742355,CDM,C1713,HCPCS,0278,RC,,,,both,,,379.16,246.45,,,,,,,,,,,,,
SET INT FIX SCREW DIA1.5 MM 6 H XLN TI NEURO DBL Y SHP PLATE 1PK,SUP-2937264,CDM,C1713,HCPCS,0278,RC,,,,both,,,1824.34,1185.82,,,,,,,,,,,,,
LCCK 7D SZ4 5MM 31X31 CPL,SUP-2502156,CDM,C1776,CPT,0278,RC,,,,both,,,12095.28,7861.93,,,,,,,,,,,,,
CONNECTOR OFFSET 3MM FOR GMK REV SYS,SUP-2267451,CDM,C1776,CPT,0278,RC,,,,both,,,7788.77,5062.70,,,,,,,,,,,,,
HC So Pryridoxal Phosphate Vit B-6,PX-3018420766,CDM,84207,CPT,0301,RC,,,,both,,,129.00,83.85,,,,,,,,,,,,,
SCREW BNE L 75 MM DIA2.7 MM TI LCK T8 RECESS CLR CODE STRL,SUP-2902127,CDM,C1713,HCPCS,0278,RC,,,,both,,,712.43,463.08,,,,,,,,,,,,,
HINGE EXT FIX L100MM ANK FT INLINE FOR TRUELOK FRME ASSEMB,SUP-2316080,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1252.73,814.27,,,,,,,,,,,,,
BASEPLATE GLEN STD POST AUG BILAT SHLDR POLY INVERSE,SUP-2344286,CDM,C1776,CPT,0278,RC,,,,both,,,6551.61,4258.55,,,,,,,,,,,,,
GRAFT BNE TIB 220 MM POST TEND,SUP-2335258,CDM,C1713,HCPCS,0278,RC,,,,both,,,8164.00,5306.60,,,,,,,,,,,,,
SUPPORT ORTHOT ANK JT TORSION CTRL ANK JT HALF SLD STIRRUP,SUP-2435663,CDM,L2375,HCPCS,0272,RC,,,,both,,,348.35,226.43,,,,,,,,,,,,,
PLATE BNE THK0.8MM 16 H CRANIOMAXILLOFACIAL GRY TI STR LOK,SUP-2366254,CDM,C1713,HCPCS,0278,RC,,,,both,,,1193.26,775.62,,,,,,,,,,,,,
PLATE BNE L240MM 140DEG 10 H S STL HIP LOK BILAT COMPR RIG,SUP-2370889,CDM,C1713,HCPCS,0278,RC,,,,both,,,2305.70,1498.70,,,,,,,,,,,,,
PLATE BNE L99MM HK D15MM 6 H L CLAVICULAR S STL LOK COMPR,SUP-2185856,CDM,C1713,HCPCS,0278,RC,,,,both,,,3384.70,2200.05,,,,,,,,,,,,,
CATHETER CV KT 9 FRX10 CM DL ANTIMICROBIAL FOR 7.5-8 FR MAC,SUP-2763353,CDM,C1751,HCPCS,0278,RC,,,,both,,,570.85,371.05,,,,,,,,,,,,,
PLATE BNE L 203 MM SCREW DIA 3.5 MM 13 H SS PROX HUM STR,SUP-2932802,CDM,C1713,HCPCS,0278,RC,,,,both,,,8760.60,5694.39,,,,,,,,,,,,,
GRAFT HUM TISS 4X4CM WND MTRX NEOX CRD 1K,SUP-2135262,CDM,Q4148,HCPCS,0636,RC,,,,both,,,5950.30,3867.69,,,,,,,,,,,,,
BAR PECTUS L 9.5 IN TI PREBENT NS PECTUS BLU,SUP-2895711,CDM,C1713,HCPCS,0278,RC,,,,both,,,15637.20,10164.18,,,,,,,,,,,,,
CATHETER GUID MERCI L 95 CM 9 FR 2.1MM BRAID REINF BIFURCATE,SUP-2365836,CDM,C1887,HCPCS,0272,RC,,,,both,,,3741.00,2431.65,,,,,,,,,,,,,
PLATE BNE L2MM 14 H TI LOK REG THREADLOCK TS,SUP-2262828,CDM,C1713,HCPCS,0278,RC,,,,both,,,1893.95,1231.07,,,,,,,,,,,,,
PLATE BNE L 86 MM LT 4 HOLE BUTTRESS TI NS,SUP-2569059,CDM,C1713,HCPCS,0278,RC,,,,both,,,4028.65,2618.62,,,,,,,,,,,,,
RETRACTOR SURG BLNT 25 MMX5 CM SPNL MEDL LAT DIL HLLW SS,SUP-2293010,CDM,C1713,HCPCS,0278,RC,,,,both,,,5135.66,3338.18,,,,,,,,,,,,,
ALLOGRAFT BNE FRZN IRRADIATED RT TALUS NO CART,SUP-2867173,CDM,C1762,CPT,0278,RC,,,,both,,,8188.34,5322.42,,,,,,,,,,,,,
GRAFT HUM TISS NRML THK230-320UM CLR PRE HYDRATION CORNEA W/,SUP-2261409,CDM,V2785,HCPCS,0810,RC,,,,both,,,1271.70,826.60,,,,,,,,,,,,,
HC MRI Breast W&WO Cont Incl Cad Bilateral,PX-6107704900,CDM,C8908,CPT,0610,RC,,,,inpatient,,,5627.00,3657.55,,,,,,,,,,,,,
IMPLANT SYNTH L 127 X W 76 MM THK 1.5 MM POLYETHYL,SUP-2883392,CDM,C1713,HCPCS,0278,RC,,,,both,,,3199.97,2079.98,,,,,,,,,,,,,
METHADONE HCL 10 MG/ML PO CONC,RX-15996,CDM,340b,HCPCS,0637,RC,09999-9910-19,NDC,,both,1,ML,2.70,1.75,,,,,,,,,,,,,
MESH C-QUR EDGE OBLONG OVL 6 INX9 IN,SUP-2265967,CDM,C1781,HCPCS,0278,RC,,,,both,,,2502.58,1626.68,,,,,,,,,,,,,
PATCH SURG GORTX L 34 X W 26 CM THK 1 MM EPTFE SFT TISS OVL,SUP-2679939,CDM,C1768,CPT,0278,RC,,,,both,,,8157.72,5302.52,,,,,,,,,,,,,
SCREW BNE CANN 6.5X80 MM COMPR FT TI STRL 04355780S,SUP-2787796,CDM,C1713,HCPCS,0278,RC,,,,both,,,1182.15,768.40,,,,,,,,,,,,,
SCREW SPNL L 30 MM DIA 6.5 MM BLACKARMOR CARBON PEEK TI-IT,SUP-2917066,CDM,C1713,HCPCS,0278,RC,,,,both,,,14287.00,9286.55,,,,,,,,,,,,,
HC Arterial Sampling/Monitoring,PX-4503662000,CDM,36620,CPT,0450,RC,,,,both,,,789.00,512.85,,,,,,,,,,,,,
SCREW BNE L40MM DIA6MM CORT ST NONCANNULATED NONLOCKING,SUP-2377554,CDM,C1713,HCPCS,0278,RC,,,,both,,,803.06,521.99,,,,,,,,,,,,,
BIT DRL L145MM DIA3.2MM ST TI 3 FLUT NDL PNT USED W/ RADLUC,SUP-2178870,CDM,2720000010,LOCAL,0272,RC,,,,both,,,898.39,583.95,,,,,,,,,,,,,
CATHETER THOR 32FR L23IN PVC 6 EYELET STR ATRAUM,SUP-2227433,CDM,C1729,HCPCS,0272,RC,,,,both,,,20.79,13.51,,,,,,,,,,,,,
PLATE BONE L131MM 10 HOLE RCNSTRCTN 35MM SCREW UNVRSL LOK SS,SUP-2498306,CDM,C1713,HCPCS,0278,RC,,,,both,,,1552.42,1009.07,,,,,,,,,,,,,
SCREW INTRF CANN 7X20 MM 2 MM RND HD TI SOFTSILK CLEAR-TRAC,SUP-2877888,CDM,C1713,HCPCS,0278,RC,,,,both,,,606.65,394.32,,,,,,,,,,,,,
PLATE BNE L40MM THK1MM 3X7 H NONSTERILE HND TI T SHP LOK VAR,SUP-2181004,CDM,C1713,HCPCS,0278,RC,,,,both,,,1570.79,1021.01,,,,,,,,,,,,,
GRAFT HUM TISS W27-32XH21XL21-26MM ANTR LUM INTBDY FUS SPCR,SUP-2306954,CDM,C1713,HCPCS,0278,RC,,,,both,,,16051.99,10433.79,,,,,,,,,,,,,
GRAFT BONE SUB 10ML TRICALCIUM PHOS GRAN CONT RESRB CONDUIT,SUP-2256852,CDM,C1763,HCPCS,0278,RC,,,,both,,,2084.96,1355.22,,,,,,,,,,,,,
CATHETER ABLATN MULTI 2-5-2MM 7 FRX110CM 40-60MM MARINR MC,SUP-2281837,CDM,C1733,HCPCS,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
TRAY TIB SZ 5 AP53.1MM ML80.6MM THK4.8MM KNEE CO CHROM ALLY,SUP-2250927,CDM,C1776,CPT,0278,RC,,,,both,,,8321.00,5408.65,,,,,,,,,,,,,
PROBE LITHO ULTRASOUND 1.5X370 MM FOR LUS-2 REUSE,SUP-2458466,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1074.07,698.15,,,,,,,,,,,,,
MESH CRANIAL CONTOURABLE 1.5X150X150X0.8 MM RAPID RESORBABLE,SUP-2838569,CDM,C1713,HCPCS,0278,RC,,,,both,,,18757.73,12192.52,,,,,,,,,,,,,
NAIL IM L280MM DIA10MM FEM TIB KNEE GLD TI CANN LCK AG RG,SUP-2347082,CDM,C1713,HCPCS,0278,RC,,,,both,,,4694.30,3051.29,,,,,,,,,,,,,
KIT INTRO L 45 CM DIA 5 FR NDL L 7 CM PLAT A BVL ECHOGENIC,SUP-2116529,CDM,C1894,HCPCS,0272,RC,,,,both,,,103.62,67.35,,,,,,,,,,,,,
ANCHOR SUT BLU ORTHOCORD BIOKNOTLESS +,SUP-2249364,CDM,C1713,HCPCS,0278,RC,,,,both,,,1347.06,875.59,,,,,,,,,,,,,
IMPLANT ORBIT SM W32XH13XL35MM THK1.2MM RT 3D FLR W/,SUP-2365170,CDM,C1713,HCPCS,0278,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
BIT DRL DIA4MM FORXTRACT-ALL V.2 SCR REM SYS,SUP-2337691,CDM,2720000010,LOCAL,0272,RC,,,,both,,,879.20,571.48,,,,,,,,,,,,,
SCREW BNE L 145 MM DIA 3.5 MM SS CORTICAL ST STRL EVOS,SUP-2932536,CDM,C1713,HCPCS,0278,RC,,,,both,,,228.15,148.30,,,,,,,,,,,,,
HC X-Ray Exam Abdomen 3+ Views,PX-3207402100,CDM,74021,CPT,0320,RC,,,,both,,,827.00,537.55,,,,,,,,,,,,,
MESH CRNL SIZE 1 06MM THK TTNM CNTRD STNDRD LATEX FREE BFRN,SUP-2707377,CDM,C1713,HCPCS,0278,RC,,,,both,,,8430.84,5480.05,,,,,,,,,,,,,
BIT DRL 5.5MM CANN CNTRSNK,SUP-2315875,CDM,2720000010,LOCAL,0272,RC,,,,both,,,546.36,355.13,,,,,,,,,,,,,
HANDLE OBTURATOR DETACHABLE NS ECTRA II LTX,SUP-2877785,CDM,2720000010,LOCAL,0272,RC,,,,both,,,867.11,563.62,,,,,,,,,,,,,
NAIL IM L340MM DIA115MM LNG UNIV FEM TI ALLY RG,SUP-2208192,CDM,C1713,HCPCS,0278,RC,,,,both,,,6313.16,4103.55,,,,,,,,,,,,,
SCREW BNE L60MM DIA7.3MM CORT S STL ST CANN LOK FULL THRD,SUP-2184935,CDM,C1713,HCPCS,0278,RC,,,,both,,,779.22,506.49,,,,,,,,,,,,,
HC Surgery Level 2 Base,PX-3600000002,CDM,3600000002,LOCAL,0360,RC,,,,both,,,4526.00,2941.90,,,,,,,,,,,,,
RESERVOIR SHUNT 14MM SMALL TITANIUM RADIOPAQUE GRADUATED VEN,SUP-2826651,CDM,C1889,HCPCS,0278,RC,,,,both,,,1573.17,1022.56,,,,,,,,,,,,,
PLATE CRAN 160X140X40 MM PT SPEC IMPL PEEK,SUP-2860157,CDM,C1713,HCPCS,0278,RC,,,,both,,,48239.51,31355.68,,,,,,,,,,,,,
SCREW BNE CORTICAL 2.7X14 MM FUSION HEX DRV YEL WRST SS NS,SUP-2851922,CDM,C1713,HCPCS,0278,RC,,,,both,,,503.09,327.01,,,,,,,,,,,,,
HC Neonatal Head,PX-4027650600,CDM,76506,CPT,0402,RC,,,,inpatient,,,836.00,543.40,,,,,,,,,,,,,
STAPLE CARTRIDGE 10X10 MM FOR ANGLED BNE ASMBLY,SUP-2421817,CDM,C1713,HCPCS,0278,RC,,,,both,,,4824.61,3136.00,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC SV IR 3FR 45CM 1 LUMAN RVRS 3173335,SUP-2632651,CDM,C1751,HCPCS,0278,RC,,,,both,,,439.16,285.45,,,,,,,,,,,,,
GUIDEWIRE ORTH 3.2+X230 MM W/ CALIB QUIK RELEASE FIT FIXOS,SUP-2457199,CDM,C1769,HCPCS,0272,RC,,,,both,,,141.30,91.84,,,,,,,,,,,,,
PLATE BNE W9XL97MM THK1MM 8 H TI 1/3 TBLR LIMIT CNTCT DYN,SUP-2190953,CDM,C1713,HCPCS,0278,RC,,,,both,,,540.21,351.14,,,,,,,,,,,,,
SHEATH INTRO BRAIDED COR 0.035 IN JUMBO 9 FRX40 CM WORLEY,SUP-2329849,CDM,C1892,HCPCS,0272,RC,,,,both,,,1287.40,836.81,,,,,,,,,,,,,
PROBE LASER 25GA PRECIS FBR CNTR PLAS HND PC STR DISP RFID,SUP-2109915,CDM,C1713,HCPCS,0278,RC,,,,both,,,3509.14,2280.94,,,,,,,,,,,,,
KIT VENTRICULAR DRAINAGE COMB W/ 10150 SYS 10520 CATH,SUP-2883581,CDM,C1729,HCPCS,0272,RC,,,,both,,,661.03,429.67,,,,,,,,,,,,,
HC Neonatal Head,PX-4027650600,CDM,76506,CPT,0402,RC,,,,outpatient,,,836.00,543.40,,,,,,,,,,,,,
DRESSING WND 3 LAYR 10X15 CM MTRX CYTAL,SUP-2106530,CDM,Q4166,HCPCS,0636,RC,,,,both,,,11564.62,7517.00,,,,,,,,,,,,,
ENDCAP ORTH LCK STD 15 MM 0 MM EXTN TI NS,SUP-2564344,CDM,C1713,HCPCS,0278,RC,,,,both,,,578.42,375.97,,,,,,,,,,,,,
PLATE BONE TUBULAR 61 MM 5 HOLE 1/3 WITH COLLAR STERILE TC10,SUP-2836663,CDM,C1713,HCPCS,0278,RC,,,,both,,,642.66,417.73,,,,,,,,,,,,,
BIT DRL L195MM DIA3MM FEM S STL W/ QUIK CPL DISP FOR NCB,SUP-2204936,CDM,2720000010,LOCAL,0272,RC,,,,both,,,455.39,296.00,,,,,,,,,,,,,
HC CT Angio Lower Ext W & W/O Cont,PX-3527370600,CDM,73706,CPT,0352,RC,,,,both,,,1973.00,1282.45,,,,,,,,,,,,,
GRAFT HUM TISS W8XH6XL6MM INTBDY FUS SPCR BONE INSERTXPANSE,SUP-2294021,CDM,C1713,HCPCS,0278,RC,,,,both,,,1997.04,1298.08,,,,,,,,,,,,,
PLATE SPNL 2 LEVEL 32 MM ANTR CERV TETH,SUP-2379303,CDM,C1713,HCPCS,0278,RC,,,,both,,,5193.56,3375.81,,,,,,,,,,,,,
SPECULUM VAG PEDERSON MED 7/8X3.5 IN,SUP-2475805,CDM,2720000010,LOCAL,0272,RC,,,,both,,,72.94,47.41,,,,,,,,,,,,,
HC Xr Wrist 2 Views,PX-3207310000,CDM,73100,CPT,0320,RC,,,,both,,,287.00,186.55,,,,,,,,,,,,,
SEGMENTAL FEM/TIB MALE-MALE 80MM,SUP-2502416,CDM,C1776,CPT,0278,RC,,,,both,,,8944.29,5813.79,,,,,,,,,,,,,
SHEATH INTRO PERFRMR L 13 CM OD 5 FR ID 1.7 MM GUIDEWIRE,SUP-2168351,CDM,C1894,HCPCS,0272,RC,,,,both,,,77.81,50.58,,,,,,,,,,,,,
SPLINT WRST FA UNIV R 8 IN,SUP-2276644,CDM,L3809,HCPCS,0272,RC,,,,both,,,14.63,9.51,,,,,,,,,,,,,
FIXATOR EXT FIX SHRT HND N BRDG FRACTR STRL DISP NBX,SUP-2909408,CDM,C1713,HCPCS,0278,RC,,,,both,,,9027.50,5867.87,,,,,,,,,,,,,
SET NEUROSURGICAL CK DEV NEURO W/ WIRE IO-FLEX,SUP-2115836,CDM,C1713,HCPCS,0278,RC,,,,both,,,2788.32,1812.41,,,,,,,,,,,,,
KIT SHTH DESTINO L 81 CM DIA 8.5 FR CRV BEND L 22 MM DIL 50,SUP-2616121,CDM,C1766,CPT,0272,RC,,,,both,,,2182.30,1418.49,,,,,,,,,,,,,
GRAFT VASC VENAFLO L 25 CM DIA 4-7 MM EPTFE CARBON STP STR,SUP-2127059,CDM,C1768,CPT,0278,RC,,,,both,,,1977.29,1285.24,,,,,,,,,,,,,
BUR SURG FLUT 60 DEG 4.2 MM BRL SUCTION IRRIGATING,SUP-2638217,CDM,2720000010,LOCAL,0272,RC,,,,both,,,669.51,435.18,,,,,,,,,,,,,
KNIFE SRGCL YASRGL BCKWRD CTTNG ARCHND LATEX FREE,SUP-2673044,CDM,2720000010,LOCAL,0272,RC,,,,both,,,390.71,253.96,,,,,,,,,,,,,
CATHETER ABLAT 7FR TIP L4MM 2.5MM SPC QPLR ASYM 4 CRV STD,SUP-2141276,CDM,C1733,HCPCS,0272,RC,,,,both,,,2951.60,1918.54,,,,,,,,,,,,,
SCREW BNE L38MM DIA5MM DST LAT FEM S STL ST LOK FULL THRD,SUP-2371498,CDM,C1713,HCPCS,0278,RC,,,,both,,,505.54,328.60,,,,,,,,,,,,,
SAW SURG CAPTURE 0.050 IN W/ HNDL N-K II MIS,SUP-2449237,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1356.48,881.71,,,,,,,,,,,,,
KIT INTRO PEELPRO L 14 CM DIA12 FR PTFE TEARWY STD,SUP-2118933,CDM,C1894,HCPCS,0272,RC,,,,both,,,172.70,112.25,,,,,,,,,,,,,
CLAMP EXT FIX DBL MULTIPIN STRL GALAXY FIX GEM LTX,SUP-2875644,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4868.13,3164.28,,,,,,,,,,,,,
STABILIZER SURG L15 CM PIN,SUP-2280167,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1040.31,676.20,,,,,,,,,,,,,
GRAFT EVAR L5X2CM ID8-10MM INTRO SHTH 10FR 0.035IN VIATORR,SUP-2395926,CDM,C1874,HCPCS,0278,RC,,,,both,,,12246.00,7959.90,,,,,,,,,,,,,
RELOAD STPL CRV TIP 45 MM GRY SIGNIA ENDO GIA TRISTAPLE 20,SUP-2283356,CDM,C1713,HCPCS,0278,RC,,,,both,,,2095.13,1361.83,,,,,,,,,,,,,
HOOK SPNL CONN 3.5-4 MM TRNSVRS YUKON OCT,SUP-2732180,CDM,C1713,HCPCS,0278,RC,,,,both,,,1491.50,969.47,,,,,,,,,,,,,
PLATE BNE L 56 MM 4 H SS LT DSTL VOLAR RADIAL WIDE LCK LP VA,SUP-2931331,CDM,C1713,HCPCS,0278,RC,,,,both,,,3397.17,2208.16,,,,,,,,,,,,,
LINER ACET LP 22X24 MM HIP SYS RINGLOK ARCOMXL,SUP-2449980,CDM,C1776,CPT,0278,RC,,,,both,,,3037.95,1974.67,,,,,,,,,,,,,
SCREW BNE L25MM DIA6.5MM CANC HIP TI NONLOCKING TORX DRV,SUP-2370277,CDM,C1713,HCPCS,0278,RC,,,,both,,,297.67,193.49,,,,,,,,,,,,,
GUIDEWIRE VASC RUNTHROUGH NS L 150 CM DIA 0.014 IN NIT SS,SUP-2384827,CDM,C1769,HCPCS,0272,RC,,,,both,,,332.84,216.35,,,,,,,,,,,,,
SCREW IM L 32 MM DIA 3.5 MM TI CORTICAL T15 DRVR GLD STRL,SUP-2900381,CDM,C1713,HCPCS,0278,RC,,,,both,,,659.40,428.61,,,,,,,,,,,,,
SYSTEM LOADING VALVE EVOLUT 26/29MM,SUP-2501425,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1224.60,795.99,,,,,,,,,,,,,
SCREW BNE 2X12 MM 8 MM X DRV DRILL-FREE TI LEVEL 1,SUP-2464760,CDM,C1713,HCPCS,0278,RC,,,,both,,,316.04,205.43,,,,,,,,,,,,,
PROSTHESIS OSS STAP 0.6X4 MM DE LA CRUZ PISTON FLROPLAS,SUP-2458913,CDM,L8613,CPT,0278,RC,,,,both,,,575.28,373.93,,,,,,,,,,,,,
PLATE BNE LG TI ORBIT 3D PRNT NS DISP ACCUPLATE,SUP-2934779,CDM,C1713,HCPCS,0278,RC,,,,both,,,34926.22,22702.04,,,,,,,,,,,,,
BIT DRL 12 MM OPENING FOR SUPRAPATELLAR INSTRUMENT T2,SUP-2488136,CDM,2720000010,LOCAL,0272,RC,,,,both,,,982.82,638.83,,,,,,,,,,,,,
PLATE BNE 9 H R DST CLAV LOK FOR 3.5MM SCR,SUP-2420259,CDM,C1713,HCPCS,0278,RC,,,,both,,,3384.92,2200.20,,,,,,,,,,,,,
EPIFIX DISC 18MM,SUP-2305747,CDM,Q4186,HCPCS,0636,RC,,,,both,,,2336.16,1518.50,,,,,,,,,,,,,
HC Venography Svc,PX-3207582700,CDM,75827,CPT,0320,RC,,,,inpatient,,,3006.00,1953.90,,,,,,,,,,,,,
POST EXT FIX 2 HOLE W/O THRD ATTCH,SUP-2749941,CDM,2720000010,LOCAL,0272,RC,,,,both,,,734.76,477.59,,,,,,,,,,,,,
PAD ORTHOT LAT TROCHANTERIC CUST,SUP-2435592,CDM,L1290,HCPCS,0274,RC,,,,both,,,219.99,142.99,,,,,,,,,,,,,
MICROCATHETER GUID TELEMARK WORKING L 150 CM SHFT DIA PROX,SUP-2759028,CDM,C1887,HCPCS,0272,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
CATHETER SINUS BAL L16MM DIA7MM RELIEVA SOLO PRO,SUP-2106323,CDM,C1729,HCPCS,0272,RC,,,,both,,,2577.31,1675.25,,,,,,,,,,,,,
CONNECTOR SPNL Z 16X150-300 MM OFFSET,SUP-2659060,CDM,C1713,HCPCS,0278,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
HC Drain/Inject Joint/Bursa,PX-4502060000,CDM,20600,CPT,0450,RC,,,,both,,,358.00,232.70,,,,,,,,,,,,,
SUPPORT ORTHOT FT METATRSL CUST ARCH ATTCH TO SHOE,SUP-2435708,CDM,L3080,HCPCS,0274,RC,,,,both,,,90.02,58.51,,,,,,,,,,,,,
PROBE HEAT HPU-20,SUP-2313015,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3367.68,2188.99,,,,,,,,,,,,,
EXTENSION STEM TIB STABILIZING REV SMOOTH STR Y 17.5MM DIA,SUP-2209373,CDM,C1776,CPT,0278,RC,,,,both,,,3469.70,2255.30,,,,,,,,,,,,,
GUIDEWIRE VASC JTP POLY 0.14IN 300CM 3CM,SUP-2143076,CDM,C1769,HCPCS,0272,RC,,,,both,,,1114.70,724.55,,,,,,,,,,,,,
KIT ACP DOUBLE SYRINGE SERIES II WITH ALCOHOL PAD BAND AID FEMALE TO FEMALE LUER SIDE PINCH CLAMP STOP COCK TOURNIQUET ANGEL WING INFUSION SET CUP HYPODERMIC NEEDLE,SUP-2120723,CDM,C1713,HCPCS,0278,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
PLATE BNE L183MM 10 H NONSTERILE POST MED PROX TIB S STL LOK,SUP-2177800,CDM,C1713,HCPCS,0278,RC,,,,both,,,3295.90,2142.33,,,,,,,,,,,,,
PLATE BNE VOLAR LT DSTL RADIAL HND DBL TIERED EXT,SUP-2137434,CDM,C1713,HCPCS,0278,RC,,,,both,,,2372.49,1542.12,,,,,,,,,,,,,
STAPLE BNE FIX BRDG W18MM LEG L18X15MM WIRE DIA2X2MM S STL,SUP-2194222,CDM,C1713,HCPCS,0278,RC,,,,both,,,2433.50,1581.77,,,,,,,,,,,,,
CATHETER VENTRICULAR 15X28 MMX15CM SHUNT SLT INNERVISION TIP,SUP-2277972,CDM,C1729,HCPCS,0272,RC,,,,both,,,639.15,415.45,,,,,,,,,,,,,
VALVE VENTRICULAR DRAINAGE 0 WITH DISTAL CATHETER MININAV,SUP-2825681,CDM,C1889,HCPCS,0278,RC,,,,both,,,2434.03,1582.12,,,,,,,,,,,,,
GRAFT HUM TISS W1XL12CM THK08 17MM THCK HYDRATED ACELLULAR,SUP-2307451,CDM,Q4128,HCPCS,0636,RC,,,,both,,,2532.88,1646.37,,,,,,,,,,,,,
PLATE POLYAX LK LAT COL LENGTHING 0MM,SUP-2462335,CDM,C1713,HCPCS,0278,RC,,,,both,,,3611.00,2347.15,,,,,,,,,,,,,
STEM FNGR JT SZ 3 PROX INTERPHALANGEAL SIL NONCOATED,SUP-2250680,CDM,L8630,HCPCS,0278,RC,,,,both,,,3755.44,2441.04,,,,,,,,,,,,,
CATHETER HAD ADMIN COMP ONLY DBL LUMN POLYUR STR HYDR TIP,SUP-2266972,CDM,C1752,HCPCS,0278,RC,,,,both,,,166.42,108.17,,,,,,,,,,,,,
HYDROXYZINE HCL 10 MG PO TABS,RX-3772,CDM,6370000000,HCPCS,0637,RC,00093-5060-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PAIN CTRL DEV,SUP-2196461,CDM,C1772,HCPCS,0278,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
BIT DRL OD3.2MM RADLUC,SUP-2362675,CDM,2720000010,LOCAL,0272,RC,,,,both,,,388.61,252.60,,,,,,,,,,,,,
GRAFT STR STD WALL N RING POLY KNIT RADIALLY 8MM DIA 70CM,SUP-2227575,CDM,C1768,CPT,0278,RC,,,,both,,,2882.68,1873.74,,,,,,,,,,,,,
CONSTRUCT PRE-SUTURED QUADLINK 9-11MM 60-75MM,SUP-2656688,CDM,C1762,CPT,0278,RC,,,,both,,,8143.59,5293.33,,,,,,,,,,,,,
COIL VASC HILAL MICROCOIL EMBOLUS L 1 CM DIA 3 MM CATH DIA,SUP-2168032,CDM,C1889,HCPCS,0278,RC,,,,both,,,120.58,78.38,,,,,,,,,,,,,
TRAY CATH CNTRL VENOU LUMENX3 12.5FR DIA SIL 1.6/0.7/0.7ML P,SUP-2613070,CDM,C1751,HCPCS,0278,RC,,,,both,,,1409.36,916.08,,,,,,,,,,,,,
GRAFT BNE STRP 20X15X5 MM COMPRESSIBLE BNE MTRX,SUP-2644318,CDM,C1713,HCPCS,0278,RC,,,,both,,,2742.16,1782.40,,,,,,,,,,,,,
PLATE BNE RECON 3.5 MM PELV 12 HOLE,SUP-2518365,CDM,C1713,HCPCS,0278,RC,,,,both,,,3532.50,2296.12,,,,,,,,,,,,,
BLADE REPROC SAW OSCIL LG BONE 19.5X95X1.27MM,SUP-2652957,CDM,2720000010,LOCAL,0272,RC,,,,both,,,92.88,60.37,,,,,,,,,,,,,
VALVE AORT L10CM DIA20MM ORIFICE DIA167MM TISS ANNULUS,SUP-2355084,CDM,C1713,HCPCS,0278,RC,,,,both,,,21823.00,14184.95,,,,,,,,,,,,,
SYSTEM IMPL MPFL TIGHTROPE,SUP-2731856,CDM,C1713,HCPCS,0278,RC,,,,both,,,6264.30,4071.79,,,,,,,,,,,,,
OCCLUDER CV FLO RST L 30 MM BLB DIA2.25 MM SIL RUBBER INT,SUP-2130337,CDM,C1760,HCPCS,0278,RC,,,,both,,,253.37,164.69,,,,,,,,,,,,,
SET BILI DRNGE CATH 7FR 0.035IN 5 SIDE H NSL PGTL,SUP-2169092,CDM,C1729,HCPCS,0272,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
CATHETER ANGIOPLSTY L120CM BAL L80MM DIA6MM SHTH 7FR 0.035IN,SUP-2141211,CDM,C1725,HCPCS,0272,RC,,,,both,,,2248.24,1461.36,,,,,,,,,,,,,
RXG FOIL 512X512 T10MM,SUP-2669332,CDM,C1713,HCPCS,0278,RC,,,,both,,,2959.83,1923.89,,,,,,,,,,,,,
TRAY TIB SZ 3 AP47MM ML71MM STD UNIV KNEE NP MOD + STEM PRI,SUP-2253289,CDM,C1776,CPT,0278,RC,,,,both,,,7302.38,4746.55,,,,,,,,,,,,,
PASSER SUTURE 3MM LIGATURE SHARP STRAIGHT REUSABLE,SUP-2824869,CDM,2720000010,LOCAL,0272,RC,,,,both,,,413.73,268.92,,,,,,,,,,,,,
TRAY CATH 5FR 2 LUMN MAXIMAL BARR STD W/ SHERLOCK STYL,SUP-2125639,CDM,C1751,HCPCS,0278,RC,,,,both,,,680.66,442.43,,,,,,,,,,,,,
BASEPLATE GLEN OD29MM STD TI POR SHLDR LAT AEQUALIS PERFORM,SUP-2388799,CDM,C1713,HCPCS,0278,RC,,,,both,,,5237.52,3404.39,,,,,,,,,,,,,
PLATE BNE L DST RAD VOLAR S STL LO PROF RIG NONCOMPRESSION,SUP-2186102,CDM,C1713,HCPCS,0278,RC,,,,both,,,2256.37,1466.64,,,,,,,,,,,,,
PLATE BONE L289MM 14 HOLE NNSTRLE CRVD FMRL SHAFT TTNM NCB,SUP-2480791,CDM,C1713,HCPCS,0278,RC,,,,both,,,1966.39,1278.15,,,,,,,,,,,,,
CONNECTOR ST 360 BLU 10-15MM S,SUP-2205087,CDM,C1713,HCPCS,0278,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
GRAFT BNE GRAN 1-2 MM 7.5 CC SUBSTITUTE MIS REFILL ACTIFUSE,SUP-2417667,CDM,C1713,HCPCS,0278,RC,,,,both,,,4913.57,3193.82,,,,,,,,,,,,,
PIN FIX L9IN DIA28MM ST S STL 2 SIDE SGL DMND 1 END PNT,SUP-2150484,CDM,C1713,HCPCS,0278,RC,,,,both,,,13.41,8.72,,,,,,,,,,,,,
CATHETER VENTILATOR L 70 CM DIA 4 MM PTFE LASER JET DL THOR,SUP-2662068,CDM,2720000010,LOCAL,0272,RC,,,,both,,,542.59,352.68,,,,,,,,,,,,,
ALLOGRAFT BNE SPACER 7 MM CERV CORTICAL CANC ELEMAX,SUP-2731767,CDM,C1713,HCPCS,0278,RC,,,,both,,,2433.50,1581.77,,,,,,,,,,,,,
KIT DRNGE PD W4XL4IN 500ML CATH VAC BTL W/ DRNGE LN DSG GZ,SUP-2133745,CDM,C1729,HCPCS,0272,RC,,,,both,,,172.70,112.25,,,,,,,,,,,,,
WASHER ORTH OVL 18X2 MM CANN SS NS,SUP-2178294,CDM,C1713,HCPCS,0278,RC,,,,both,,,244.20,158.73,,,,,,,,,,,,,
PLATE BNE 150DEG 5 H PROX FEM LOK FOR 3.5MM SCR PEDILOC,SUP-2318560,CDM,C1713,HCPCS,0278,RC,,,,both,,,7319.34,4757.57,,,,,,,,,,,,,
KIT HMRL EL ORTHOPAEDIC CONDYLAR ALIGNMENT HEXALOBULAR,SUP-2879150,CDM,C1776,CPT,0278,RC,,,,both,,,6345.94,4124.86,,,,,,,,,,,,,
BIT DRL L50MM DIA1.35MM TWST FOR 1.7MM SCR,SUP-2366404,CDM,2720000010,LOCAL,0272,RC,,,,both,,,437.43,284.33,,,,,,,,,,,,,
PLATE BNE COMPR SM 2.7X100 MM 12 HOLE DYN NS DCP LTX,SUP-2861904,CDM,C1713,HCPCS,0278,RC,,,,both,,,523.94,340.56,,,,,,,,,,,,,
HC Remove FB,PX-4501012100,CDM,10121,CPT,0450,RC,,,,both,,,4946.00,3214.90,,,,,,,,,,,,,
PLATE T FUSION VA LCP 2.4/2.7MM 2H HD STD TI STRL,SUP-2546988,CDM,C1713,HCPCS,0278,RC,,,,both,,,3424.11,2225.67,,,,,,,,,,,,,
CLAMP SURG STR FOR LIMB RECON SYS PROCALLUS,SUP-2316281,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1372.37,892.04,,,,,,,,,,,,,
HOOK RETRCT DIA12.5MM E THRD DISP DURAHK,SUP-2384707,CDM,C1819,HCPCS,0278,RC,,,,both,,,102.36,66.53,,,,,,,,,,,,,
GRAFT BNE H18XL25MM TRICORT PAT WDG FRZ DRY MATRIGRFT,SUP-2264810,CDM,C1713,HCPCS,0278,RC,,,,both,,,2288.59,1487.58,,,,,,,,,,,,,
SCREW BNE L36MM DIA4.3MM LNG S STL CORT ANK FT ST SELF DRL,SUP-2397701,CDM,C1713,HCPCS,0278,RC,,,,both,,,876.06,569.44,,,,,,,,,,,,,
CAGE SPNL W28XH12XL38MM 8DEG FOR ANT LUM INTBDY FUS BRIGADE,SUP-2310967,CDM,C1889,HCPCS,0278,RC,,,,both,,,15072.00,9796.80,,,,,,,,,,,,,
SUPPORT ORTHOT CERV THOR LUMBAR SACR CUST ANTR POST LAT,SUP-2435562,CDM,L0710,HCPCS,0274,RC,,,,both,,,6195.63,4027.16,,,,,,,,,,,,,
GRAFT HUM TISS 15X140X1.5MM DECELLULARIZED DERM W/ MATRACELL,SUP-2120779,CDM,Q4125,HCPCS,0636,RC,,,,both,,,6180.46,4017.30,,,,,,,,,,,,,
LAMOTRIGINE 100 MG PO TABS,RX-13982,CDM,6370000000,HCPCS,0637,RC,68084-0319-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
SET INSTR DISP SGL USE DUAFIT 17/10/0,SUP-2242114,CDM,C1713,HCPCS,0278,RC,,,,both,,,1224.60,795.99,,,,,,,,,,,,,
CATHETER PICC L55CM OD5FR KT SGL LUMN NRS FULL TY W/,SUP-2125621,CDM,C1751,HCPCS,0278,RC,,,,both,,,677.30,440.24,,,,,,,,,,,,,
CEMENT BNE 20 GM HI VISC RADIOPAQUE VERTAPLEX HV,SUP-2423940,CDM,C1713,HCPCS,0278,RC,,,,both,,,3268.49,2124.52,,,,,,,,,,,,,
DRESSING WND CARE W7XL10CM ACELLULAR FISH SKIN OMEGA3,SUP-2261686,CDM,Q4158,HCPCS,0636,RC,,,,both,,,12089.00,7857.85,,,,,,,,,,,,,
GUIDEWIRE VASC L 260 CM DIA 0.035 IN TAPR L 10 CM FLPY TIP 3,SUP-2167686,CDM,C1769,HCPCS,0272,RC,,,,both,,,37.90,24.63,,,,,,,,,,,,,
CHOICE INTERMEDIATE 182CM MAG 5PK,SUP-2664362,CDM,C1729,HCPCS,0272,RC,,,,both,,,222.94,144.91,,,,,,,,,,,,,
TROCAR ENDOSCOPIC L100MM DIA12MM THREADED FIRST ENTRY FOR ABDOMINAL ACCESS SYSTEM KII FIOS,SUP-2119664,CDM,C1713,HCPCS,0278,RC,,,,both,,,723.14,470.04,,,,,,,,,,,,,
DESONIDE 0.05 % EX CREA,RX-2291,CDM,6370000000,HCPCS,0637,RC,51672-1280-01,NDC,,both,15,GR,87.10,56.61,,,,,,,,,,,,,
MEPERIDINE HCL 50 MG/ML IJ SOLN,RX-4904,CDM,J2175,HCPCS,0636,RC,00641-6053-01,NDC,,both,0.5,ML,54.10,35.16,,,,,,,,,,,,,
INSERT ACET OD40MM ID22MM 20DEG UHMWPE HIP COMP SER I OMFIT,SUP-2369975,CDM,C1776,CPT,0278,RC,,,,both,,,2535.86,1648.31,,,,,,,,,,,,,
SCREW BNE LAG 2.3X36 MM TI,SUP-2468650,CDM,C1713,HCPCS,0278,RC,,,,both,,,253.27,164.63,,,,,,,,,,,,,
PLATE SPNL L25MM UNIV LEV 1 CERV ANT LOK BILAT VAR ANG TI,SUP-2293155,CDM,C1713,HCPCS,0278,RC,,,,both,,,2392.05,1554.83,,,,,,,,,,,,,
CATHETER CV FULL TY 032 8 FRX15 CM 12 GA DL J TIP SPECTRUM,SUP-2759725,CDM,C1751,HCPCS,0278,RC,,,,both,,,508.65,330.62,,,,,,,,,,,,,
PHENYLEPHRINE HCL 1 % NA SOLN,RX-6245,CDM,6370000000,HCPCS,0637,RC,00225-0810-47,NDC,,both,15,ML,54.10,35.16,,,,,,,,,,,,,
STEM FEM DIA15MM +0MM OFFSET LNG L HIP TI POLISHED REV BOW,SUP-2344353,CDM,C1776,CPT,0278,RC,,,,both,,,14403.18,9362.07,,,,,,,,,,,,,
CATHETER DRAINAGE RESOLV L 20 CM DIA 7.5 FR 0.038 IN J CRV,SUP-2460767,CDM,C1729,HCPCS,0272,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
BLADE RETRACTOR CLOWARD SPREADER 55MML BLUNT,SUP-2500829,CDM,2720000010,LOCAL,0272,RC,,,,both,,,382.89,248.88,,,,,,,,,,,,,
HC Treat Humerus Fx,PX-4502362500,CDM,23625,CPT,0450,RC,,,,both,,,4794.00,3116.10,,,,,,,,,,,,,
IMETELSTAT SODIUM 47 MG IV SOLR|DISCARDED DRUG NOT ADMINISTE,RX-168240,CDM,J0870,HCPCS,0636,RC,82959-0112-01,NDC,JW,both,1.5,ML,11242.40,7307.56,,,,,,,,,,,,,
GRAFT BNE SUB W9XL15MM TRICORT ILIUM CREST BLK FRZ DRY MECH,SUP-2293823,CDM,C1713,HCPCS,0278,RC,,,,both,,,1877.72,1220.52,,,,,,,,,,,,,
SHEATH INTRO SUPER SHTH RO L 25 CM DIA 8 FR GUIDEWIRE 0.038,SUP-2147313,CDM,C1894,HCPCS,0272,RC,,,,both,,,90.43,58.78,,,,,,,,,,,,,
SYSTEM BOOT TOT CNTCT CAST REG FOR MEDE-KAST TCC-EZ,SUP-2194356,CDM,L4386,HCPCS,0272,RC,,,,both,,,213.52,138.79,,,,,,,,,,,,,
DEVICE FIX BIOABSORBABLE 4.5 MM MIDFACE SUSP ENDOTINE,SUP-2760656,CDM,C1713,HCPCS,0278,RC,,,,both,,,1071.53,696.49,,,,,,,,,,,,,
MESH HERN 16X12CM L POLY CLLGN COAT ANAT W LAT SLT,SUP-2752161,CDM,C1781,HCPCS,0278,RC,,,,both,,,739.38,480.60,,,,,,,,,,,,,
IMPLANT BRST GEL 4.8 CM PROJCT 12.8 CM 405 CC RND MEMORYGEL,SUP-2758613,CDM,C1789,HCPCS,0278,RC,,,,both,,,3689.50,2398.17,,,,,,,,,,,,,
PLATE BNE L 124 X W 11 MM THK 3 MM SCREW DIA2.7/3.5 MM 7 H 72465507N,SUP-2932804,CDM,C1713,HCPCS,0278,RC,,,,both,,,5343.97,3473.58,,,,,,,,,,,,,
PROXIMAL HUMERAL PLATE SYSTEM CASE,SUP-2811369,CDM,C1713,HCPCS,0278,RC,,,,both,,,15684.30,10194.79,,,,,,,,,,,,,
PLATE BNE W200XL200MM THK1MM CRANIOMAXILLOFACIAL TI,SUP-2262591,CDM,C1713,HCPCS,0278,RC,,,,both,,,19720.99,12818.64,,,,,,,,,,,,,
POR ST/RGX CP/XL LN/STD HD,SUP-2212375,CDM,C1776,CPT,0278,RC,,,,both,,,18212.00,11837.80,,,,,,,,,,,,,
CONNECTOR ROD TI OD55 635 MM SDLD,SUP-2279799,CDM,C1713,HCPCS,0278,RC,,,,both,,,2361.28,1534.83,,,,,,,,,,,,,
STENT PERIPH ELUVIA L 120 MM DIA 7 MM CATH L 130 CM DIA 6 FR,SUP-2146904,CDM,C1876,HCPCS,0278,RC,,,,both,,,9718.30,6316.89,,,,,,,,,,,,,
DEVICE TISS FIX INT BRAC FLIP CUT III DRL FIBERSNARE SUTURE,SUP-2910087,CDM,C1713,HCPCS,0278,RC,,,,both,,,4653.92,3025.05,,,,,,,,,,,,,
HC So1 Fluorescent Antibody Screen,PX-3028625567,CDM,86255,CPT,0302,RC,,,,inpatient,,,588.00,382.20,,,,,,,,,,,,,
VEST HOLSTER POCKET SM CTRL,SUP-2356012,CDM,Q0499,HCPCS,0272,RC,,,,both,,,1339.52,870.69,,,,,,,,,,,,,
CATHETER INFUSION FASTRACKER 325 L 140 CM OD PROX/DSTL,SUP-2147319,CDM,C1887,HCPCS,0272,RC,,,,both,,,1270.88,826.07,,,,,,,,,,,,,
PLATE BNE FIBULAR 6 HOLE COMP LCK STRL ALPS LTX,SUP-2861799,CDM,C1713,HCPCS,0278,RC,,,,both,,,562.75,365.79,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP L260CM DIA0.038IN S STL STR COAT FLX DST,SUP-2172400,CDM,C1769,HCPCS,0272,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
ALLOGRAFT BNE 10 CC VIABLE BNE MTRX BIO4 PS51010,SUP-2637052,CDM,C1713,HCPCS,0278,RC,,,,both,,,10048.00,6531.20,,,,,,,,,,,,,
LETS KIT,RX-119627,CDM,6370000000,HCPCS,0637,RC,09999-9913-29,NDC,,both,3,ML,54.10,35.16,,,,,,,,,,,,,
DEFIBRILLATOR IMPL CONTAK CD 2 TI CRT 3 CHMBR LV1 IS1 UPLR,SUP-2140442,CDM,C1722,HCPCS,0275,RC,,,,both,,,71202.64,46281.72,,,,,,,,,,,,,
PLATE BONE STRUT 2X3 HOLE TITANIUM NON STERILE LOW PROFILE N,SUP-2838365,CDM,C1713,HCPCS,0278,RC,,,,both,,,1576.91,1024.99,,,,,,,,,,,,,
IMPLANT OSS L475MM PIST DIA06MM STAP PLAT FLROPLAS RBBN LOOP,SUP-2313670,CDM,L8613,CPT,0278,RC,,,,both,,,495.55,322.11,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED UPCHARGE STEM ENDO NAT LD/FX,SUP-2212690,CDM,C1776,CPT,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
BIT DRILL QUICK COUPLING 4.5X120/145 MM STERILE TC100 DISPOS,SUP-2837036,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1200.05,780.03,,,,,,,,,,,,,
COVER SCR H ACET REFLCT,SUP-2344764,CDM,C1713,HCPCS,0278,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
WEDGE TIB SZ 3-4 15MM KNEE REV FULL STP LEGION,SUP-2346596,CDM,C1776,CPT,0278,RC,,,,both,,,5474.59,3558.48,,,,,,,,,,,,,
CATHETER PERI DLYS COILED L V NK W/ DBL CUF SET 63CM,SUP-2267005,CDM,C1752,HCPCS,0278,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
ANCHOR SUTURE 2.1MM WITH ONE STRAND NUMBER 2 HI-FI GENESYS P,SUP-2824682,CDM,C1713,HCPCS,0278,RC,,,,both,,,1943.91,1263.54,,,,,,,,,,,,,
SPLINT ORTH 10IN KNEE BASIC,SUP-2197150,CDM,L1830,CPT,0274,RC,,,,both,,,30.52,19.84,,,,,,,,,,,,,
KIT BNE FIX PEEK STPL PLGA TACK CADDY STRL INTEGRITY,SUP-2902006,CDM,C1713,HCPCS,0278,RC,,,,both,,,1246.58,810.28,,,,,,,,,,,,,
SCREW BNE CORTICAL 4.5X62 MM SS,SUP-2198224,CDM,C1713,HCPCS,0278,RC,,,,both,,,18.84,12.25,,,,,,,,,,,,,
HC So Additional Panel Charge,PX-3028687066,CDM,86870,CPT,0302,RC,,,,both,,,381.00,247.65,,,,,,,,,,,,,
CATHETER INTERMED CEREGLIDE 71 L 132 CM PROX/DSTL OD,SUP-2893571,CDM,C1887,HCPCS,0272,RC,,,,both,,,8321.00,5408.65,,,,,,,,,,,,,
BARIUM SULFATE 2 % PO SUSP,RX-18299,CDM,2500000003,HCPCS,0250,RC,32909-0741-03,NDC,,both,450,ML,2.50,1.62,,,,,,,,,,,,,
PLATE BONE STR 10 H 0.8 MM STRL,SUP-2107085,CDM,C1713,HCPCS,0278,RC,,,,both,,,1651.64,1073.57,,,,,,,,,,,,,
PLATE BONE L94MM 4 H LT LAT PROX TIB S STL LCK FOR 4.5MM SCR,SUP-2348221,CDM,C1713,HCPCS,0278,RC,,,,both,,,12487.78,8117.06,,,,,,,,,,,,,
TRIAL INSRT CD TIB ARTC KNEE,SUP-2201988,CDM,C1776,CPT,0278,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
BASKET EXTR STONE THE WEB 7 FR X 220 CM SHTH 2.5 CM X 5 CM,SUP-2169438,CDM,2720000010,LOCAL,0272,RC,,,,both,,,533.80,346.97,,,,,,,,,,,,,
STAPLER ENDO THORACOSCOPIC SEAMGRD,SUP-2396263,CDM,C1713,HCPCS,0278,RC,,,,both,,,828.96,538.82,,,,,,,,,,,,,
MODULE NEUROSURGICAL MAS TRANSFORAMINAL LUM INTBDY FUS HOOP,SUP-2311773,CDM,C1713,HCPCS,0278,RC,,,,both,,,5118.83,3327.24,,,,,,,,,,,,,
BIT DRL L 10 IN DIA 4.8/1.8 MM HALF PIN DIA 6 MM CANN GRAD,SUP-2932838,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1573.23,1022.60,,,,,,,,,,,,,
PROSTHESIS OSS 0.4X3.75 MM SHFT TI STAP NOTCH HNDL LIPPY,SUP-2232479,CDM,L8613,CPT,0278,RC,,,,both,,,718.37,466.94,,,,,,,,,,,,,
COLLAR CERV ADJ FOAM 2 PC THERMOPLASTIC,SUP-2388134,CDM,L0172,HCPCS,0272,RC,,,,both,,,431.62,280.55,,,,,,,,,,,,,
SPLINT WR UNIV PED LT HND COCKUP ALUM STAY INSTABILITY INJ,SUP-2203821,CDM,L3908,HCPCS,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
CATHETER GUID WINGMAN 18 L 90 CM OD 0.05 IN TIP DIA 0.032 IN,SUP-2227765,CDM,C1887,HCPCS,0272,RC,,,,both,,,2028.44,1318.49,,,,,,,,,,,,,
ROCKER PLATE EXT FIX SIDEKCK EZ FRAME DISP,SUP-2399880,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5633.16,3661.55,,,,,,,,,,,,,
MESH BIO PORCINE MTRX ABD 20CM LEN 20CM W SURGISIS,SUP-2170304,CDM,C1713,HCPCS,0278,RC,,,,both,,,21477.60,13960.44,,,,,,,,,,,,,
ACYCLOVIR 800 MG PO TABS,RX-8972,CDM,6370000000,HCPCS,0637,RC,50268-0062-11,NDC,,both,1,UN,5.20,3.38,,,,,,,,,,,,,
PLATE BNE TBLR 49 MM 4-HOLE 1/3,SUP-2518434,CDM,C1713,HCPCS,0278,RC,,,,both,,,1868.30,1214.39,,,,,,,,,,,,,
ENVELOPE DEFIB BIOENVELOPE LG FIVE PK STRL,SUP-2138483,CDM,C1713,HCPCS,0278,RC,,,,both,,,14915.00,9694.75,,,,,,,,,,,,,
CATHETERIZATION KIT 0.032 IN 7 FRX8 IN 3L ARROWG+ARD +,SUP-2383335,CDM,C1751,HCPCS,0278,RC,,,,both,,,181.46,117.95,,,,,,,,,,,,,
INSERT TIB IMPCT ASMBLY N-K II,SUP-2449213,CDM,C1776,CPT,0278,RC,,,,both,,,1511.91,982.74,,,,,,,,,,,,,
STEM FEM L130MM OD11MM STD BODY NK OFFSET CO CHROM HIP PRI,SUP-2211295,CDM,C1776,CPT,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
DEVICE ENDOSKELETAL SYS KNEE SHIN FRIC,SUP-2388218,CDM,L5812,HCPCS,0274,RC,,,,both,,,1485.85,965.80,,,,,,,,,,,,,
JOINT FNGR MP 50 WW DSTL PYROCARBON,SUP-2610416,CDM,L8630,HCPCS,0278,RC,,,,both,,,4608.55,2995.56,,,,,,,,,,,,,
BIT DRL CANN 4.8X300 MM W/ ZH,SUP-2606141,CDM,2720000010,LOCAL,0272,RC,,,,both,,,594.46,386.40,,,,,,,,,,,,,
CATHETER ETER GUID 5FR MP2 JB2 CHAPERON,SUP-2305420,CDM,C1887,HCPCS,0272,RC,,,,both,,,1130.40,734.76,,,,,,,,,,,,,
MESH CRAN L 80.1 X W 50.8 MM THK 0.8 MM SCREW DIA1.5 MM MED,SUP-2936163,CDM,C1713,HCPCS,0278,RC,,,,both,,,5560.94,3614.61,,,,,,,,,,,,,
GRAFT SYNTH L100XW75MM THICK4MM FOAM COMPR RESIST PREFRM,SUP-2368178,CDM,C1713,HCPCS,0278,RC,,,,both,,,11049.66,7182.28,,,,,,,,,,,,,
GUIDE SURG REUSE DRL TAP SCR,SUP-2279325,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3411.42,2217.42,,,,,,,,,,,,,
PLATE BNE TBLR 3.5X42 MM 3 HOLE 1/3 2 COMPR LCK FOR SCR TI,SUP-2473465,CDM,C1713,HCPCS,0278,RC,,,,both,,,859.01,558.36,,,,,,,,,,,,,
TI MATRIXMIDFACE SCREW  1.3MM  450394401,SUP-2844114,CDM,C1713,HCPCS,0278,RC,,,,both,,,12254.79,7965.61,,,,,,,,,,,,,
DEVICE PESSARY RNG 3 64 MM W/ SUPP,SUP-2273825,CDM,A4562,HCPCS,0272,RC,,,,both,,,108.39,70.45,,,,,,,,,,,,,
AGENT SUBMUCOSAL LIFTING 5 ML SODIUM HYALURONATE PREFIL SYR,SUP-2913655,CDM,2720000010,LOCAL,0272,RC,,,,both,,,103.62,67.35,,,,,,,,,,,,,
HFN RH 130 DEG 15MM X 440MM,SUP-2588706,CDM,C1713,HCPCS,0278,RC,,,,both,,,7503.03,4876.97,,,,,,,,,,,,,
WIRE ORTH THRD PART DBL SHRP TIP S STL NONSTERILE 1.6MM DIA,SUP-2316517,CDM,C1713,HCPCS,0278,RC,,,,both,,,90.12,58.58,,,,,,,,,,,,,
SCREW BNE L20MM DIA3.5MM CORT DST RAD VOLAR TI NONLOCKING,SUP-2340298,CDM,C1713,HCPCS,0278,RC,,,,both,,,833.67,541.89,,,,,,,,,,,,,
CLAMP SPNL UNIV THORLUM TI SM STAT FOR OPN TRNSVRS BAR 6MM,SUP-2193455,CDM,C1713,HCPCS,0278,RC,,,,both,,,1705.02,1108.26,,,,,,,,,,,,,
GRAFT HUM TISS BIDIR 2X1 CM GRID PAT AMNIO MEMBRN BIOVANCE,SUP-2651372,CDM,Q4154,HCPCS,0636,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
BAR EXT FIX LNG CALIB TOMAHAWK MINI FIX SIDEKCK,SUP-2400616,CDM,2720000010,LOCAL,0272,RC,,,,both,,,891.76,579.64,,,,,,,,,,,,,
ALLOGRAFT BNE PROX TIB FRZN W/ TUBEROSITY RT,SUP-2717965,CDM,C1762,CPT,0278,RC,,,,both,,,13991.84,9094.70,,,,,,,,,,,,,
SONICWELD RX STERILE SONICPIN RXG 21 X 4 MM PLLA PGA,SUP-2681199,CDM,C1713,HCPCS,0278,RC,,,,both,,,287.47,186.86,,,,,,,,,,,,,
IMPACTOR SURG FIX BEAR TIB ATTUNE,SUP-2454781,CDM,C1776,CPT,0278,RC,,,,both,,,295.16,191.85,,,,,,,,,,,,,
SET CLLR STOUT SORBATEX PD BIOENGINEERED CMFRT ADJ BTTN,SUP-2247595,CDM,L0120,HCPCS,0272,RC,,,,both,,,174.84,113.65,,,,,,,,,,,,,
SCREW BNE CANN 7.3X80 MM PROX CONCL PART THRD SS NS LCP,SUP-2184788,CDM,C1713,HCPCS,0278,RC,,,,both,,,697.08,453.10,,,,,,,,,,,,,
SPLINT UP EXTRM MTL SPLNTS MTCRPL,SUP-2124890,CDM,L3913,HCPCS,0274,RC,,,,both,,,35.33,22.96,,,,,,,,,,,,,
BLOCK CUT FEM GUID FOR JOURNEY II KNEE SYS VISIONAIRE,SUP-2351451,CDM,2720000010,LOCAL,0272,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
CATHETER ETER EP 7FR L110CM ELECTRD SPC 2 9 1MM BND ELECTRD 1MM H L,SUP-2357629,CDM,C1730,HCPCS,0272,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
SCREW BNE L22MM DIA3.5MM CORT TI N ST FULL THRD FOR WRST,SUP-2189851,CDM,C1713,HCPCS,0278,RC,,,,both,,,55.80,36.27,,,,,,,,,,,,,
PLATE BNE W14XL181MM THK3.8MM 90DEG 9 H L TIB S STL L SHP,SUP-2185791,CDM,C1713,HCPCS,0278,RC,,,,both,,,4189.45,2723.14,,,,,,,,,,,,,
SCREW BNE LCK 1.7X6 MM NS AXS LTX 5PK,SUP-2862788,CDM,C1713,HCPCS,0278,RC,,,,both,,,362.26,235.47,,,,,,,,,,,,,
PLATE BNE CONTOURABLE MESH 30X0.6 MM RIGID TI SLV NS,SUP-2859911,CDM,C1713,HCPCS,0278,RC,,,,both,,,2426.59,1577.28,,,,,,,,,,,,,
ANCHOR SUT DIA4.5MM PEEK 2 ORTHOCORD SZ 2 L36IN VLT BLU,SUP-2249411,CDM,C1713,HCPCS,0278,RC,,,,both,,,1620.24,1053.16,,,,,,,,,,,,,
IMPLANT BRST 30ML 2W CK VLV FIL SYR TBNG KT,SUP-2113307,CDM,C1789,HCPCS,0278,RC,,,,both,,,34.01,22.11,,,,,,,,,,,,,
GRAFT BNE SUB 1CC 2MM GRAN ALLOGENIC MORPHOGENETIC PROT W,SUP-2138490,CDM,C1713,HCPCS,0278,RC,,,,both,,,1130.40,734.76,,,,,,,,,,,,,
PLATE BNE L88MM 3 H BILAT TI LOK COMPR RIG BTTRS THN BLDE,SUP-2190981,CDM,C1713,HCPCS,0278,RC,,,,both,,,1178.29,765.89,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY WOVENFLEXIE DIA 6 FR SPC 2-10 MM,SUP-2142740,CDM,C1730,HCPCS,0272,RC,,,,both,,,1472.66,957.23,,,,,,,,,,,,,
STENT ENDOPROS L15CM DIA6MM CATH 7FR L75CM 0.035IN VES,SUP-2396601,CDM,C1874,HCPCS,0278,RC,,,,both,,,11906.88,7739.47,,,,,,,,,,,,,
COMPONENT FEM POROUS 4 KNEE MILLER-GALANTE II,SUP-2199615,CDM,C1776,CPT,0278,RC,,,,both,,,22130.72,14384.97,,,,,,,,,,,,,
ALLOGRAFT BNE TIB 210X3 MM FD STRUT 1/2 SPLIT 31026022,SUP-2717903,CDM,C1762,CPT,0278,RC,,,,both,,,5802.59,3771.68,,,,,,,,,,,,,
IMPLANT GYN W4XL7CM FASC LATA TUTOPLAST PROC ALLGRFT TISS,SUP-2300759,CDM,C1762,CPT,0278,RC,,,,both,,,3611.00,2347.15,,,,,,,,,,,,,
HC Eeg Extended More Than 1 Hour,PX-7409581300,CDM,95813,CPT,0740,RC,,,,both,,,3429.00,2228.85,,,,,,,,,,,,,
SCREW SPNL L35MM DIA6.5MM STD CANC TI MULTIAXIAL ST TOP LEV,SUP-2415875,CDM,C1713,HCPCS,0278,RC,,,,both,,,3314.33,2154.31,,,,,,,,,,,,,
DRILL COUNTSINK MINI MAXLOCK EXTRM MTP POCKETLOCK,SUP-2400511,CDM,2720000010,LOCAL,0272,RC,,,,both,,,477.28,310.23,,,,,,,,,,,,,
BLADE OSTEOTOM L25MM FOR OPN WDG OSTEOTMY SYS SET,SUP-2121033,CDM,C1713,HCPCS,0278,RC,,,,both,,,445.88,289.82,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 50 CM DIA 7MM STR TW REINF SLDE GDE,SUP-2525467,CDM,C1768,CPT,0278,RC,,,,both,,,1694.38,1101.35,,,,,,,,,,,,,
HC So1 Hexagonal Phospholipid,PX-3058559867,CDM,85598,CPT,0305,RC,,,,both,,,22.00,14.30,,,,,,,,,,,,,
PLATE BNE CRV MINI XLN 2-2.5X1 MM MAND 6 HOLE LCK SAG TI,SUP-2487350,CDM,C1713,HCPCS,0278,RC,,,,both,,,1267.52,823.89,,,,,,,,,,,,,
ALLOGRAFT HUM TISS ALLOPATCH PLIABLE MESHED 4X4CM,SUP-2905484,CDM,Q4128,HCPCS,0636,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
SCREW BNE L115MM DIA65MM CANC S STL ST CANN NONLOCKING FULL,SUP-2199306,CDM,C1713,HCPCS,0278,RC,,,,both,,,124.22,80.74,,,,,,,,,,,,,
SYSTEM FIX IO L DISPOSABLE DRVR ASSEMB,SUP-2400053,CDM,C1776,CPT,0278,RC,,,,both,,,3689.50,2398.17,,,,,,,,,,,,,
AUGMENT GLEN FIX SM L SHLDR UHMWPE CAGE EQUINOXE,SUP-2435979,CDM,C1776,CPT,0278,RC,,,,both,,,5913.25,3843.61,,,,,,,,,,,,,
BURR ZYPHR ELITE RND FLUT 5.0MM,SUP-2367564,CDM,C1713,HCPCS,0278,RC,,,,both,,,854.08,555.15,,,,,,,,,,,,,
SPACER SPNL W14XH32MM D12MM 6DEG VERT BODY REPL HAWKEYE,SUP-2164232,CDM,C1889,HCPCS,0278,RC,,,,both,,,15960.62,10374.40,,,,,,,,,,,,,
STENT PERIPH ZILVER PTX L 40 MM DIA 8 MM CATH L 125 CM SHTH,SUP-2170408,CDM,C1874,HCPCS,0278,RC,,,,both,,,3689.50,2398.17,,,,,,,,,,,,,
PLATE BNE L301MM 20 H NONSTERILE R MED PROX TIB S STL LOK,SUP-2185662,CDM,C1713,HCPCS,0278,RC,,,,both,,,4586.44,2981.19,,,,,,,,,,,,,
WIRE EXT FIX L 400 MM DIA2 MM TI REDUCTION HALF PT NS DISP,SUP-2899056,CDM,2720000010,LOCAL,0272,RC,,,,both,,,492.20,319.93,,,,,,,,,,,,,
HC Change Cystostomy Tube Smpl,PX-4505170500,CDM,51705,CPT,0450,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
TRAY CATH PICC GROSH NXT MAXBARR 5FR 0.026IN 55CM 2 7927508D,SUP-2632687,CDM,C1751,HCPCS,0278,RC,,,,both,,,501.77,326.15,,,,,,,,,,,,,
PRECISION CONNECTOR M1 70 CM,SUP-2700482,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
GRAFT EVAR IL BRANCH COMP L10CM DIA14.5MM NIT EPTFE FEP,SUP-2395718,CDM,C1768,CPT,0278,RC,,,,both,,,33337.38,21669.30,,,,,,,,,,,,,
SCREW BNE L8MM DIA2.4MM TI ST FULL THRD MATRIXMANDIBLE,SUP-2181728,CDM,C1713,HCPCS,0278,RC,,,,both,,,367.07,238.60,,,,,,,,,,,,,
BUR SURG SYMTRC 7 MM 7.5 CM FOR DISECT TOOL MIDAS REX LEGEND,SUP-2630554,CDM,2720000010,LOCAL,0272,RC,,,,both,,,479.32,311.56,,,,,,,,,,,,,
ANCHOR SUT OD3.5MM 2 1 MAXBRAID ABSRB LACTOSCREW,SUP-2212847,CDM,C1713,HCPCS,0278,RC,,,,both,,,1244.95,809.22,,,,,,,,,,,,,
SUPPORT ORTHOT PIP FNGR DSTL INTERPHALANGEAL CUST W/O JT,SUP-2435785,CDM,L3927,HCPCS,0274,RC,,,,both,,,90.21,58.64,,,,,,,,,,,,,
BOLT MODULUS ALIF 5.0X17.5MM FIX 2PK,SUP-2880400,CDM,C1713,HCPCS,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
GRAFT BNE W22XL38MM THK8/10/12X3.5MM CANC FULL EVANS WDG,SUP-2399093,CDM,C1713,HCPCS,0278,RC,,,,both,,,5388.24,3502.36,,,,,,,,,,,,,
WEGDE TS TANGENT TISS 160826 IMP WG 8X26 FF,SUP-2293758,CDM,C1713,HCPCS,0278,RC,,,,both,,,8173.42,5312.72,,,,,,,,,,,,,
HC Dx Breast Tomo Uni|NOT REASONABLE AND NECESSARY,PX-4017706100,CDM,G0279,HCPCS,0401,RC,,,GZ,outpatient,,,153.00,99.45,,,,,,,,,,,,,
SLING ORTHOT CUST TRAPEZIUS,SUP-2435577,CDM,L1070,HCPCS,0272,RC,,,,both,,,317.61,206.45,,,,,,,,,,,,,
HEAD RAD DIA20MM CO CHROM W/ LCK SCR ALIGN,SUP-2340137,CDM,C1776,CPT,0278,RC,,,,both,,,5534.25,3597.26,,,,,,,,,,,,,
CATHETER SET CV STR 0.018 IN 12 CM 21 GA TY DL DRUG COAT,SUP-2428124,CDM,C1751,HCPCS,0278,RC,,,,both,,,524.29,340.79,,,,,,,,,,,,,
PLATE BNE H MINI LNG TI 10064709,SUP-2459575,CDM,C1713,HCPCS,0278,RC,,,,both,,,410.84,267.05,,,,,,,,,,,,,
CANNULA ENDOSCP L 70 MM DIA 5 MM SHRT BLDELSS TROCAR SLV,SUP-2896434,CDM,2720000010,LOCAL,0272,RC,,,,both,,,352.28,228.98,,,,,,,,,,,,,
SUPPORT ORTHOT HEEL METATRSL CUST LIFT ELEVATION PER INCH,SUP-2435716,CDM,L3300,HCPCS,0274,RC,,,,both,,,147.64,95.97,,,,,,,,,,,,,
WIRE FIX DIAMOND PT 2 END 0.054X5 IN SS NS KIRSCHNER,SUP-2791280,CDM,C1713,HCPCS,0278,RC,,,,both,,,7.82,5.08,,,,,,,,,,,,,
TRACHEOSTOMY KIT PEDIATRIC 17 GA 3.5 MMX4 CM SPL NDL UNCUF,SUP-2846609,CDM,2720000010,LOCAL,0272,RC,,,,both,,,551.10,358.21,,,,,,,,,,,,,
RING ANNULPLSTY CARP EDW PHY 24MM 28.7MM 22.9MM 274SQMM FLX2,SUP-2214156,CDM,C1889,HCPCS,0278,RC,,,,both,,,7206.30,4684.09,,,,,,,,,,,,,
TRAY BNE CEMENT BEAD CERAMENT,SUP-2893105,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
STENT BILI S.M.A.R.T. CTRL L 20 MM DIA 6 MM DEL SYS L 120 CM,SUP-2155348,CDM,C1876,HCPCS,0278,RC,,,,both,,,3543.80,2303.47,,,,,,,,,,,,,
PLATE BONE CRANIAL MEDIUM 6 HOLE GAP 38.8X15.3X0.4MM TITANIU,SUP-2826279,CDM,C1713,HCPCS,0278,RC,,,,both,,,562.37,365.54,,,,,,,,,,,,,
HEAD FEM OD28MM +7MM 12/14 TAPR LO WR FX TOUGH PLT TYP CRYS,SUP-2222422,CDM,C1776,CPT,0278,RC,,,,both,,,6028.80,3918.72,,,,,,,,,,,,,
GRAFT BONE SUB L50-90MM FLD FEM DIA7-12MM TIB 7.0-12MM FRZN,SUP-2417748,CDM,C1762,CPT,0278,RC,,,,both,,,6908.00,4490.20,,,,,,,,,,,,,
STAPLER REINF SEAMGRD ECHELON 45,SUP-2395314,CDM,C1713,HCPCS,0278,RC,,,,both,,,596.60,387.79,,,,,,,,,,,,,
BRA SURG 3XL WHT POST SURG MAMM COMPR DSG W/ REM STRP FR HK,SUP-2276930,CDM,L8000,HCPCS,0274,RC,,,,both,,,50.08,32.55,,,,,,,,,,,,,
PLATE COMPRSS BROAD CRVD 16 HL 199MM,SUP-2705334,CDM,C1713,HCPCS,0278,RC,,,,both,,,4393.80,2855.97,,,,,,,,,,,,,
COIL VASC AZUR CX L 9 CM DIA 6 MM MICROCATHETER 0.035 IN,SUP-2385439,CDM,C1889,HCPCS,0278,RC,,,,both,,,1910.69,1241.95,,,,,,,,,,,,,
CATHETER ANGIO GLIDECATH XP L 100 CM DIA 5 FR DIA1.22 MM STR,SUP-2385626,CDM,C1887,HCPCS,0272,RC,,,,both,,,86.76,56.39,,,,,,,,,,,,,
PLATE BNE SKULL BASE LG 0.4 MM RND MESH MALL UNIV NEURO III,SUP-2862737,CDM,C1713,HCPCS,0278,RC,,,,both,,,3154.82,2050.63,,,,,,,,,,,,,
SPLINT REST HND ADL L S DRBLUE BROAD,SUP-2165486,CDM,L3807,HCPCS,0274,RC,,,,both,,,140.26,91.17,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 70 CM DIA 6 MM L 50 CM STR TW,SUP-2396314,CDM,C1768,CPT,0278,RC,,,,both,,,4072.58,2647.18,,,,,,,,,,,,,
IMPLANT BRST W13XH135CM 450 475ML P53CM NACL STYL 468 FULL,SUP-2113354,CDM,C1789,HCPCS,0278,RC,,,,both,,,113.04,73.48,,,,,,,,,,,,,
VALVE MITRL CARP EDW PERIMT + DIA29 MM BOV PERICARD COCR,SUP-2214287,CDM,C1889,HCPCS,0278,RC,,,,both,,,17584.00,11429.60,,,,,,,,,,,,,
DORZOLAMIDE HCL-TIMOLOL MAL PF 2-0.5 % OP SOLN,RX-147265,CDM,6370000000,HCPCS,0637,RC,65862-0947-60,NDC,,both,0.25,UN,10.20,6.63,,,,,,,,,,,,,
PLATE BNE TI R CRANIOMAXILLOFACIAL 11 H ADV NONSTERILE LE,SUP-2366359,CDM,C1713,HCPCS,0278,RC,,,,both,,,1113.92,724.05,,,,,,,,,,,,,
SUPPORT ORTHOT FT CUST ABDUCTN ROT BAR W/SHOE,SUP-2435711,CDM,L3140,HCPCS,0274,RC,,,,both,,,252.05,163.83,,,,,,,,,,,,,
CANNULA SUCTION KAHN 13.25 IN UTER TRIGGER W/ SPARE TIP,SUP-2464035,CDM,2720000010,LOCAL,0272,RC,,,,both,,,599.58,389.73,,,,,,,,,,,,,
PLATE BONE L12MM THK0.3MM 4 H TI STR ULT LO PROF MATRIXNEURO,SUP-2181542,CDM,C1713,HCPCS,0278,RC,,,,both,,,261.88,170.22,,,,,,,,,,,,,
PLATE BNE LEFORT 0.6 MM RT FLAT LINDORF MOD TI,SUP-2458751,CDM,C1713,HCPCS,0278,RC,,,,both,,,956.73,621.87,,,,,,,,,,,,,
HEAD HUM 36 MM RT SHLDR SLIM ANAT SHLDR,SUP-2440652,CDM,C1776,CPT,0278,RC,,,,both,,,3942.27,2562.48,,,,,,,,,,,,,
PLATE BNE MESHED 51X51X1 MM SM GRID PLLA-PGA STRL RESORB XG,SUP-2457929,CDM,C1713,HCPCS,0278,RC,,,,both,,,3136.08,2038.45,,,,,,,,,,,,,
SPACER FEM SM THK5MM L MED DST DURAC,SUP-2377192,CDM,C1776,CPT,0278,RC,,,,both,,,2362.54,1535.65,,,,,,,,,,,,,
ANCHOR SUT DIA4.5MM W/ SZ 3-0 BIOCRYLRAPIDE ORTHOCORD SUT,SUP-2256657,CDM,C1713,HCPCS,0278,RC,,,,both,,,2317.32,1506.26,,,,,,,,,,,,,
HC NM Bone Multiple,PX-3417830500,CDM,78305,CPT,0341,RC,,,,both,,,2265.00,1472.25,,,,,,,,,,,,,
STAPLER INT POWDERED 45 MM LNG END CUT ECHELON CIR,SUP-2257515,CDM,C1713,HCPCS,0278,RC,,,,both,,,845.51,549.58,,,,,,,,,,,,,
BIT DRL DIA2.7 MM SCREW DIA 3.5 MM LNG CANN BUNION SYS NS,SUP-2899038,CDM,2720000010,LOCAL,0272,RC,,,,both,,,854.87,555.67,,,,,,,,,,,,,
PLATE BNE FIBULAR 2.7/3.5X116 MM RT POST LAT DSTL 6 HOLE SS,SUP-2184152,CDM,C1713,HCPCS,0278,RC,,,,both,,,1756.74,1141.88,,,,,,,,,,,,,
BUTTON RIGIDLOOP XL,SUP-2749357,CDM,C1713,HCPCS,0278,RC,,,,both,,,1259.14,818.44,,,,,,,,,,,,,
CATHETER ABLAT 7FR L115CM 1-7-4MM SPC TIP 4MM 4 ELECTRD FJ,SUP-2248500,CDM,C1733,HCPCS,0272,RC,,,,both,,,2628.18,1708.32,,,,,,,,,,,,,
STEM FEM L250MM L35MM OD165MM SZ 9 R HIP REV CEM BOW IMPL,SUP-2374705,CDM,C1776,CPT,0278,RC,,,,both,,,13172.93,8562.40,,,,,,,,,,,,,
SHAFT FEM TRAD ALLGRFT 70 MM FRZN,SUP-2294167,CDM,C1713,HCPCS,0278,RC,,,,both,,,2329.88,1514.42,,,,,,,,,,,,,
KIT SHTH INTRO 9FR L10CM PERC INTEGR HEMSTAS VLV SIDEPRT,SUP-2383378,CDM,C1894,HCPCS,0272,RC,,,,both,,,307.72,200.02,,,,,,,,,,,,,
SHEATH INTRO L25CM L31.5CM ID9FR BLK LNG TEAR AWAY VLV W/,SUP-2329860,CDM,C1894,HCPCS,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
HC M/Phmtrc Alys Ish Quant/Semiq Mnl Each Multiprb,PX-3128837700,CDM,88377,CPT,0312,RC,,,,both,,,1050.00,682.50,,,,,,,,,,,,,
SAW SURG 3-5 KNEE MOD POST CAPTURE ATTUNE,SUP-2454799,CDM,2720000010,LOCAL,0272,RC,,,,both,,,973.40,632.71,,,,,,,,,,,,,
PLATE BNE L 186 MM SCREW DIA 3.5/4.5 MM 6 H LT TROCHANTERIC 72586106N,SUP-2933170,CDM,C1713,HCPCS,0278,RC,,,,both,,,20905.34,13588.47,,,,,,,,,,,,,
REMOTE SCS SYS W 6.7 X H 13.8 CM D 0.7 CM 144 GM SMRT,SUP-2905296,CDM,C1787,HCPCS,0278,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
STEM MOD FEM REV NEUT PRESSFIT POR TAPR HIP SZ 1 200MM LEN,SUP-2217420,CDM,C1776,CPT,0278,RC,,,,both,,,13706.10,8908.96,,,,,,,,,,,,,
GRAFT TISS FRZN ALLGRFT WDG FIB RND COR IRRADIATED 18MM,SUP-2264757,CDM,C1713,HCPCS,0278,RC,,,,both,,,1562.34,1015.52,,,,,,,,,,,,,
PLATE 3.5MM TI LCP PERIARTIC PROX HUM 12H 271MM RT STRL,SUP-2546851,CDM,C1713,HCPCS,0278,RC,,,,both,,,6757.53,4392.39,,,,,,,,,,,,,
PLATE BNE L40MM 4 H NONSTERILE BILAT TARSOMETATARSAL TI STR,SUP-2181254,CDM,C1713,HCPCS,0278,RC,,,,both,,,2892.66,1880.23,,,,,,,,,,,,,
DEVICE CONTAINMENT FOR SYS TISS EXTR PNEUMOLINER,SUP-2313602,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1946.80,1265.42,,,,,,,,,,,,,
PLATE BONE STRAIGHT 1.5X50X50X0.8 MM MESH RAPID RESORBABLE S,SUP-2838584,CDM,C1713,HCPCS,0278,RC,,,,both,,,4916.93,3196.00,,,,,,,,,,,,,
BIT DRL L 100/30 MM DIA1.5 MM SCREW DIA2 MM CALIB AO QC CLR,SUP-2908123,CDM,2720000010,LOCAL,0272,RC,,,,both,,,764.90,497.18,,,,,,,,,,,,,
MESH HERN W6XH4IN INT ABD OMEGA 3 FATTY ACID POLYPR OBLONG,SUP-2265983,CDM,C1781,HCPCS,0278,RC,,,,both,,,973.40,632.71,,,,,,,,,,,,,
PLATE BNE L103MM THK2.3MM 16 H NONCOMPRESSION FRAC,SUP-2262992,CDM,C1713,HCPCS,0278,RC,,,,both,,,1390.45,903.79,,,,,,,,,,,,,
IMPLANT BIO TISS W6XL6CM FEN PRIMATRIX,SUP-2243711,CDM,Q4110,HCPCS,0636,RC,,,,both,,,4874.85,3168.65,,,,,,,,,,,,,
CAGE SPNL W36XH14MM D27MM 14DEG ANT LUM PEEK OPTMA,SUP-2415922,CDM,C1889,HCPCS,0278,RC,,,,both,,,15857.00,10307.05,,,,,,,,,,,,,
SAWBLADE STERNUM OFFSET 31.4X6X64MM,SUP-2646900,CDM,2720000010,LOCAL,0272,RC,,,,both,,,78.28,50.88,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA MAXBARR 4FR 55CM S3294108D,SUP-2632846,CDM,C1751,HCPCS,0278,RC,,,,both,,,609.35,396.08,,,,,,,,,,,,,
SET INSERTION ACCESS TRAY,SUP-2855519,CDM,C1751,HCPCS,0278,RC,,,,both,,,43.65,28.37,,,,,,,,,,,,,
GRAFT SYNTHETIC TISSUE GRANULE 1.42.8 MM 5 CC BETA TRICALCIU,SUP-2838534,CDM,C1713,HCPCS,0278,RC,,,,both,,,1611.13,1047.23,,,,,,,,,,,,,
VALVE AORT CARP EDW PERIMT THEON DIA29 MM SEW RNG DIA 40 MM,SUP-2214065,CDM,C1889,HCPCS,0278,RC,,,,both,,,17882.30,11623.49,,,,,,,,,,,,,
KIT DRL BIT DIA3MM LOC PIN TAMP K WIRE CORRESPONDING,SUP-2254036,CDM,2720000010,LOCAL,0272,RC,,,,both,,,863.59,561.33,,,,,,,,,,,,,
PENICILLIN G POTASSIUM 20000000 UNITS IJ SOLR,RX-6085,CDM,J2540,HCPCS,0636,RC,00049-0530-28,NDC,,both,1,UN,292.60,190.19,,,,,,,,,,,,,
CANNULA SURG GUIDE PIN LNG 3 MM,SUP-2474006,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1645.58,1069.63,,,,,,,,,,,,,
SCREW BNE L130MM DIA35MM CORT S STL ST NONCANNULATED FULL,SUP-2178092,CDM,C1713,HCPCS,0278,RC,,,,both,,,273.78,177.96,,,,,,,,,,,,,
CATHETER ETER PERI L90CM STD BA IMPREG OPN END W WALL SLT,SUP-2278359,CDM,C1750,HCPCS,0278,RC,,,,both,,,402.49,261.62,,,,,,,,,,,,,
HC Bedside Swallowing Eval,PX-4449261000,CDM,92610,CPT,0444,RC,,,,both,,,355.00,230.75,,,,,,,,,,,,,
IMPLANT HUM TISS L 21-30 CM DIA 3-10 MM SAPH VEIN ALLGRFT,SUP-2933384,CDM,C1762,CPT,0278,RC,,,,both,,,21112.89,13723.38,,,,,,,,,,,,,
PIN DISTRACTOR 2X141 MM TI LEVEL 1 DISP,SUP-2475100,CDM,C1713,HCPCS,0278,RC,,,,both,,,899.52,584.69,,,,,,,,,,,,,
IMPLANT TOE JT L16MM DIA3.2MM BLDE W5XL7.85IN 0DEG S STL,SUP-2397821,CDM,C1713,HCPCS,0278,RC,,,,both,,,1080.16,702.10,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY EP XT L 110CM 6FR SPC 4 OCTAPOLAR,SUP-2499090,CDM,C1730,HCPCS,0272,RC,,,,both,,,380.10,247.06,,,,,,,,,,,,,
PROGESTERONE 100 MG PO CAPS,RX-127951,CDM,6370000000,HCPCS,0637,RC,69452-0233-20,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
SCREW BNE CANN 5X30 MM CAPTURE HIGH-TORQUE,SUP-2609468,CDM,C1713,HCPCS,0278,RC,,,,both,,,1243.44,808.24,,,,,,,,,,,,,
PLATE CRAN 200X40X40 MM PT SPEC IMPL PEEK,SUP-2860129,CDM,C1713,HCPCS,0278,RC,,,,both,,,28837.76,18744.54,,,,,,,,,,,,,
ANCHOR SUTURE KNOTLESS 3.5 MM DRVR USE W/ 10313 NS REUSE,SUP-2762184,CDM,C1713,HCPCS,0278,RC,,,,both,,,571.48,371.46,,,,,,,,,,,,,
GRANISETRON HCL 1 MG/ML IV SOLN,RX-12552,CDM,J1626,HCPCS,0636,RC,00143-9744-10,NDC,,both,1,ML,54.10,35.16,,,,,,,,,,,,,
PIN FIX 1ST GENERATION FOR RETRCT CASPR,SUP-2415893,CDM,C1713,HCPCS,0278,RC,,,,both,,,910.60,591.89,,,,,,,,,,,,,
COMPONENT CRANIOFACIAL CUSTOMIZED XL PRIORITY + PEEK NS LTX,SUP-2862818,CDM,C1713,HCPCS,0278,RC,,,,both,,,68949.88,44817.42,,,,,,,,,,,,,
SCREW BNE L 45 MM DIA 7.5 MM SHANK OSTEOGRIP NS CD HORZ,SUP-2925413,CDM,C1713,HCPCS,0278,RC,,,,both,,,1444.40,938.86,,,,,,,,,,,,,
TRIAL PLATE COMPR 0.8 MM 6 HOLE,SUP-2525714,CDM,C1713,HCPCS,0278,RC,,,,both,,,637.42,414.32,,,,,,,,,,,,,
UNIVERSAL GRP,SUP-2289258,CDM,C1713,HCPCS,0278,RC,,,,both,,,1648.50,1071.52,,,,,,,,,,,,,
GRAFT HUM TISS L 50 MM DIA 4 CM CORTICAL FIB SHFT SEG FD,SUP-2913399,CDM,C1762,CPT,0278,RC,,,,both,,,2267.08,1473.60,,,,,,,,,,,,,
SCREW SPNL L45MM DIA5.5MM SUPLMNT CANC TI FIX ST TOP LEV,SUP-2137272,CDM,C1713,HCPCS,0278,RC,,,,both,,,2326.36,1512.13,,,,,,,,,,,,,
PLATE BNE L132MM 9 H R ANTLAT DST TIB TI LOK COMPR FOR,SUP-2190964,CDM,C1713,HCPCS,0278,RC,,,,both,,,4506.50,2929.22,,,,,,,,,,,,,
TRAY BX SZ 2 BLLN L15MM IBT ADD FRAC KYPHON EXPR KYPHON,SUP-2293627,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5331.72,3465.62,,,,,,,,,,,,,
CATHETER ATHRCTMY OCELOT PIXL L 150 CM DIA 5 FR GUIDEWIRE,SUP-2124795,CDM,C1753,HCPCS,0278,RC,,,,both,,,10974.30,7133.29,,,,,,,,,,,,,
Z DISCONTINUED NO SUB IDED BLADE LARYNSCP MILLER CH AD FBR OPT SZ 2 SM 152MMX13MM HEINE,SUP-2238187,CDM,2720000010,LOCAL,0272,RC,,,,both,,,678.24,440.86,,,,,,,,,,,,,
CAGE SPNL D 25 MM EXPANDABLE CORPECTOMY T2 STRATOSPHERE,SUP-2423825,CDM,C1889,HCPCS,0278,RC,,,,both,,,20410.00,13266.50,,,,,,,,,,,,,
STEM HUM L L150MM LT CO CHROM PRI CEM FOR TOT ELBW PROS,SUP-2388535,CDM,C1776,CPT,0278,RC,,,,both,,,29535.31,19197.95,,,,,,,,,,,,,
CLONAZEPAM 0.5 MG PO TABS,RX-9637,CDM,6370000000,HCPCS,0637,RC,50268-0173-15,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
ARH SLIDE-LOC NECK +1MM,SUP-2822968,CDM,C1776,CPT,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
DRESSING BIO L 20 X W 10 CM PORCINE CLLGN PHMB PURAPLY SX,SUP-2913696,CDM,C1763,HCPCS,0278,RC,,,,both,,,34540.00,22451.00,,,,,,,,,,,,,
COMPONENT FNGR JT SZ 40 DST MP PYROCARBON SIL SPCR,SUP-2244239,CDM,C1776,CPT,0278,RC,,,,both,,,4681.74,3043.13,,,,,,,,,,,,,
STAPLE BNE COMPR 20 MM 15 MM CONT 2 LEG BME ELITE,SUP-2564468,CDM,C1713,HCPCS,0278,RC,,,,both,,,4433.08,2881.50,,,,,,,,,,,,,
WASHER ORTH DIA65MM TI RND FOR 3MM CANN SCR,SUP-2190560,CDM,C1713,HCPCS,0278,RC,,,,both,,,72.16,46.90,,,,,,,,,,,,,
GRAFT BONE SUB 5ML SYR PASTE DEMIN MTRX GRFTON +,SUP-2293917,CDM,C1713,HCPCS,0278,RC,,,,both,,,1763.42,1146.22,,,,,,,,,,,,,
PLATE BNE T 2X28X1.5 MM 7 HOLE ORTHOGNATHIC FOR SCR LEVEL 1,SUP-2492614,CDM,C1713,HCPCS,0278,RC,,,,both,,,901.31,585.85,,,,,,,,,,,,,
PLATE BONE L102MM 3 H TI RT DSTL DORSOLATERAL HUM FOR 3.5MM,SUP-2418397,CDM,C1713,HCPCS,0278,RC,,,,both,,,2815.95,1830.37,,,,,,,,,,,,,
SPLINT ORTHOGNATHIC 1 JAW W/ GUIDANCE OPS VSP,SUP-2862841,CDM,2720000010,LOCAL,0272,RC,,,,both,,,9231.60,6000.54,,,,,,,,,,,,,
NEEDLE PROC PED 5FR L10CM PLAT NIT GWIRE L40CM 0018IN,SUP-2170541,CDM,C1894,HCPCS,0272,RC,,,,both,,,113.64,73.87,,,,,,,,,,,,,
SUPPORT ORTHOT KNEE CUST DBL UPR W/AIR OFF THE SHLF,SUP-2435616,CDM,L1848,HCPCS,0274,RC,,,,both,,,1628.40,1058.46,,,,,,,,,,,,,
PLATE BONE L108MM 6 H S STL NAR SELF COMPR,SUP-2198598,CDM,C1713,HCPCS,0278,RC,,,,both,,,277.36,180.28,,,,,,,,,,,,,
SCREW SPNL UNIAXIAL 4X15 MM PEDCL COCR CD HORZ SOLERA 5.5/6,SUP-2730580,CDM,C1713,HCPCS,0278,RC,,,,both,,,6622.26,4304.47,,,,,,,,,,,,,
STEM FEM EPOCH TIV HA/TCP COAT SZ 11 LT,SUP-2210194,CDM,C1776,CPT,0278,RC,,,,both,,,21966.50,14278.22,,,,,,,,,,,,,
PLATE BNE SIDE L 36 X W 36 MM THK 0.5 MM SCREW DIA1.7 MM PLL,SUP-2883147,CDM,C1713,HCPCS,0278,RC,,,,both,,,2914.36,1894.33,,,,,,,,,,,,,
GUIDE SUTURE KNOTLESS 3 MM OPN REP ANCHR KT SUTURE TAK DISP,SUP-2419282,CDM,C1713,HCPCS,0278,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
BLADE SAW L 73 MM L 15 MM THK MATERIAL 0.4 MM CUT 0.6 MM,SUP-2929422,CDM,2720000010,LOCAL,0272,RC,,,,both,,,934.87,607.67,,,,,,,,,,,,,
CUTTER KNOT ROTICULATING STR ARTHSCP,SUP-2122053,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1193.20,775.58,,,,,,,,,,,,,
DEVICE LD LOK L65CM STYL,SUP-2353131,CDM,C1773,HCPCS,0272,RC,,,,both,,,1983.44,1289.24,,,,,,,,,,,,,
HEAD FEM CONSTRN +6 MM 12/14 32 MM HIP MOD TYP 1 TAPR FRDM,SUP-2423251,CDM,C1776,CPT,0278,RC,,,,both,,,3152.56,2049.16,,,,,,,,,,,,,
SUTURE ANCHOR AR1920SF1,SUP-2843750,CDM,C1713,HCPCS,0278,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
ARMSTRONG X BVLD GRMMT 114MM ID BLUE FLRPLSTC 30 PACK,SUP-2680304,CDM,L8699,HCPCS,0278,RC,,,,both,,,37.90,24.63,,,,,,,,,,,,,
CATHETER US 8FR L90CM FOR SIEMENS SEQUOIA CYPRESS ACUSON,SUP-2248455,CDM,C1759,HCPCS,0272,RC,,,,both,,,7843.72,5098.42,,,,,,,,,,,,,
PROBE PEDCL STR,SUP-2211137,CDM,2720000010,LOCAL,0272,RC,,,,both,,,580.27,377.18,,,,,,,,,,,,,
BIT DRL L413MM DIA4.3MM FOR FEM NK SYSTEN,SUP-2179055,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1219.32,792.56,,,,,,,,,,,,,
KIT ACCS TRANSRADIAL SPR WIRE RADIALSOURCE RED 4FRX10CM,SUP-2157412,CDM,C1713,HCPCS,0278,RC,,,,both,,,101.27,65.83,,,,,,,,,,,,,
VALVE CSF IN LN REG 25 CM LUMPERITON LO PRESSURE SPETZLER,SUP-2852599,CDM,C1889,HCPCS,0278,RC,,,,both,,,2740.72,1781.47,,,,,,,,,,,,,
CATHETER HD SWAN NK 62 CM CURL CATH MISSOURI 2 CUF RT ARGY,SUP-2626973,CDM,C1750,HCPCS,0278,RC,,,,both,,,584.42,379.87,,,,,,,,,,,,,
GRAFT BNE SUB 1CC PTTY DBM FIBERS AND GLYC FRZ DRY OPTIUM,SUP-2264861,CDM,C1713,HCPCS,0278,RC,,,,both,,,323.48,210.26,,,,,,,,,,,,,
SCREW BONE DIA1.7MM L4MM CRANIOMAXILLOFACIAL LCK CROSS PIN,SUP-2363334,CDM,C1713,HCPCS,0278,RC,,,,both,,,146.76,95.39,,,,,,,,,,,,,
GRAFT BNE SUB 25X50X4MM 5ML STRP,SUP-2416974,CDM,C1713,HCPCS,0278,RC,,,,both,,,5767.49,3748.87,,,,,,,,,,,,,
SUPPORT ORTHOT KNEE CUST DBL UPR W/AIR OFF THE SHLF,SUP-2435616,CDM,L1848,HCPCS,0272,RC,,,,both,,,1628.40,1058.46,,,,,,,,,,,,,
NAIL IM END CAP PHOENIX,SUP-2606358,CDM,C1713,HCPCS,0278,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
SPACER FEM HD DIA54MM HIP 1.6GM GENTMYCN 1.6GM VANCO PMMA,SUP-2319828,CDM,C1776,CPT,0278,RC,,,,both,,,9184.50,5969.92,,,,,,,,,,,,,
HC Inj Tendon Sheath/Ligament,PX-5102055000,CDM,20550,CPT,0510,RC,,,,outpatient,,,1485.00,965.25,,,,,,,,,,,,,
COIL EMB L8CM OD4MM 10 STRTCH RESIST FRAMING FIL FNSH,SUP-2305162,CDM,C1889,HCPCS,0278,RC,,,,both,,,4521.60,2939.04,,,,,,,,,,,,,
TUBE EXT FIX CARBON 20X350 MM,SUP-2539886,CDM,2720000010,LOCAL,0272,RC,,,,both,,,938.23,609.85,,,,,,,,,,,,,
TALQUETAMAB-TGVS 3 MG/1.5ML SC SOLN,RX-165050,CDM,J3055,HCPCS,0636,RC,57894-0469-01,NDC,,both,1.5,ML,2495.50,1622.07,,,,,,,,,,,,,
HC So Antiepileptic Nos 1-3,PX-3018033966,CDM,G0480,CPT,0301,RC,,,,both,,,253.00,164.45,,,,,,,,,,,,,
CATHETER EMB TUFTEX L 80 CM DIA 6 FR BALLOON DIA13 MM,SUP-2264190,CDM,C1757,HCPCS,0272,RC,,,,both,,,373.66,242.88,,,,,,,,,,,,,
REUTER BOBBIN WHOLES VT 1.14 MM FLPL,SUP-2681459,CDM,L8699,HCPCS,0278,RC,,,,both,,,32.72,21.27,,,,,,,,,,,,,
COMPONENT FEM PS 3 UNISX LT KNEE PRIMARY CEM STEMLESS,SUP-2378132,CDM,C1776,CPT,0278,RC,,,,both,,,9553.76,6209.94,,,,,,,,,,,,,
TI ENDCAP T25 STRDRV 0MM EXTN NON-LCKNG/HUMERAL NAIL EX-STER,SUP-2546233,CDM,C1889,HCPCS,0278,RC,,,,both,,,516.81,335.93,,,,,,,,,,,,,
SCREW BONE CORTEX 1.5X4 MM RAPID RESORBABLE STERILE RAPIDSOR,SUP-2838539,CDM,C1713,HCPCS,0278,RC,,,,both,,,318.14,206.79,,,,,,,,,,,,,
DEVICE SPEC RETRV L175CM OD.4MM ODSEC5MMX5IN 5MM ARD INTCRAN,SUP-2280936,CDM,C1773,HCPCS,0272,RC,,,,both,,,8251.92,5363.75,,,,,,,,,,,,,
IMPL ELBOW RECON RAD HEAD SZ 3,SUP-2706512,CDM,C1776,CPT,0278,RC,,,,both,,,6675.95,4339.37,,,,,,,,,,,,,
FIBER LASER 230 FT KRA-CPAOCHXL HDMI,SUP-2798105,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2015.88,1310.32,,,,,,,,,,,,,
GRAFT VASC IMPRA L 40 CM DIA 8 MM EPTFE FLX TW RING HEMO,SUP-2761450,CDM,C1768,CPT,0278,RC,,,,both,,,2160.29,1404.19,,,,,,,,,,,,,
PLATE BNE 5DEG THK1.6MM M R MT REV GORILLA,SUP-2321477,CDM,C1713,HCPCS,0278,RC,,,,both,,,6648.95,4321.82,,,,,,,,,,,,,
STENT PERIPH L100MM DIAM 6MM CATH L120CM VASC W/ RADPQ MRK,SUP-2396600,CDM,C1874,HCPCS,0278,RC,,,,both,,,10748.22,6986.34,,,,,,,,,,,,,
LINER TIB KNEE HYBIRD XLPE PREMIER STRYK4] STRYKER ORTHOPEDICS HOWM],SUP-2379181,CDM,C1776,CPT,0278,RC,,,,both,,,13816.00,8980.40,,,,,,,,,,,,,
PLATE 3.5MM TI LCP TM PROX TIBIA PLATE 16H 237MM RIGHT-STER,SUP-2549561,CDM,C1713,HCPCS,0278,RC,,,,both,,,3748.78,2436.71,,,,,,,,,,,,,
PLATE BNE W5XL42MM THK1.5MM 0DEG 8 H BILAT S STL STR RIG,SUP-2186166,CDM,C1713,HCPCS,0278,RC,,,,both,,,647.88,421.12,,,,,,,,,,,,,
"HC So1 Molecular Pathology, Unlisted",PX-3108147967,CDM,81479,CPT,0310,RC,,,,both,,,101.00,65.65,,,,,,,,,,,,,
INTRODUCER HEMSTAS 7FRX45CM 30 DEG CRV .038IN GWIRE FAST,SUP-2355580,CDM,C1894,HCPCS,0272,RC,,,,both,,,127.17,82.66,,,,,,,,,,,,,
SCREW SPNL L25MM OD4.5MM PEDCL VAR ANG CANN SHANK SPHERX PPS,SUP-2311472,CDM,C1713,HCPCS,0278,RC,,,,both,,,1648.50,1071.52,,,,,,,,,,,,,
BIOXPRESS GRAFT DELIVERY 10CM BLUNT TIP,SUP-2811224,CDM,2720000010,LOCAL,0272,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
RELOAD STPL 45MM THN VASC TISS WHT W/ GRIPPING SURF,SUP-2283263,CDM,2720000010,LOCAL,0272,RC,,,,both,,,685.93,445.85,,,,,,,,,,,,,
GRAFT BNE SUB M SZ 1.4-2.8MM 10CC B TRICALCIUM PHSPTE SYN,SUP-2194011,CDM,C1713,HCPCS,0278,RC,,,,both,,,2769.48,1800.16,,,,,,,,,,,,,
GUIDEWIRE ORTH L70CM OD2.4MM CO CHROM S STL SMOOTH BLNT TIP,SUP-2410449,CDM,C1769,HCPCS,0272,RC,,,,both,,,153.20,99.58,,,,,,,,,,,,,
ROD REPROC EXT FIX HYBRID CARBN 11X125MM,SUP-2495467,CDM,C1713,HCPCS,0278,RC,,,,both,,,238.58,155.08,,,,,,,,,,,,,
STENT BILI PRECIS L 20 MM DIA 5 MM CATH L 135 CM DIA 8 FR,SUP-2158901,CDM,C1876,HCPCS,0278,RC,,,,both,,,5809.00,3775.85,,,,,,,,,,,,,
PLATE BNE Z SM 1.7 MM LT MIDFACE 4 HOLE GSP GLD NS LTX,SUP-2862761,CDM,C1713,HCPCS,0278,RC,,,,both,,,717.24,466.21,,,,,,,,,,,,,
TUBE ET OD10.4MM ID7MM EVAC ORAL MURPHY EYE TAPERGUARD CUF,SUP-2172241,CDM,2720000010,LOCAL,0272,RC,,,,both,,,75.71,49.21,,,,,,,,,,,,,
PLATE BNE BROAD 3.5X218 MM 18 HOLE SS DCP,SUP-2569158,CDM,C1713,HCPCS,0278,RC,,,,both,,,431.75,280.64,,,,,,,,,,,,,
GUIDEWIRE VASC 145CM 0.032IN TAPR 6 CM FLPY TIP 2 CM,SUP-2167654,CDM,C1769,HCPCS,0272,RC,,,,both,,,30.74,19.98,,,,,,,,,,,,,
GRAFT HUM TISS L 4 X W 6 CM THK 0.2 MM HUM AMNIO MEMBRN,SUP-2909416,CDM,Q4282,HCPCS,0636,RC,,,,both,,,19625.00,12756.25,,,,,,,,,,,,,
TRABECULAR MTL IMPLANTS TM-100 IMPLANTS LEN 11MM W 11MM HT,SUP-2414451,CDM,C1713,HCPCS,0278,RC,,,,both,,,6966.09,4527.96,,,,,,,,,,,,,
CATHETER PA L 110 CM DIA 7.5 FR INTRO DIA 8.5 FR BALLOON,SUP-2894080,CDM,2720000010,LOCAL,0272,RC,,,,both,,,571.48,371.46,,,,,,,,,,,,,
GRAFT VASC HEMSHLD PLAT L40CM 16X8MM POLYESTER BOV BIFURCATE,SUP-2265914,CDM,C1768,CPT,0278,RC,,,,both,,,2210.56,1436.86,,,,,,,,,,,,,
HC Inj Tendon Sheath/Ligament,PX-5102055000,CDM,20550,CPT,0510,RC,,,,inpatient,,,1485.00,965.25,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC SV BASIC 3FR 45CM 1 LUMAN R 9173118,SUP-2632694,CDM,C1751,HCPCS,0278,RC,,,,both,,,579.90,376.93,,,,,,,,,,,,,
PLATE BONE GENIOPLASTY 5MM,SUP-2262916,CDM,C1713,HCPCS,0278,RC,,,,both,,,10126.50,6582.22,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PLU MAXBARR 4FR 55CM 1 LU 1174108D3,SUP-2632627,CDM,C1751,HCPCS,0278,RC,,,,both,,,1008.88,655.77,,,,,,,,,,,,,
PLATE NARROW 10 HOLE RIGHT,SUP-2718087,CDM,C1713,HCPCS,0278,RC,,,,both,,,3862.20,2510.43,,,,,,,,,,,,,
ALLOGRAFT BNE FD IRRADIATED FEM HD 920495,SUP-2867052,CDM,C1762,CPT,0278,RC,,,,both,,,4537.14,2949.14,,,,,,,,,,,,,
PLATE BNE T 4.5X127 MM 6 HOLE LCP,SUP-2569410,CDM,C1713,HCPCS,0278,RC,,,,both,,,602.72,391.77,,,,,,,,,,,,,
GUIDEWIRE VASC L300CM DIA0.035IN S STL COR SLX STEER SFT,SUP-2157313,CDM,C1769,HCPCS,0272,RC,,,,both,,,261.88,170.22,,,,,,,,,,,,,
COIL EMB L6CM OD2MM 0.01IN SFT HELCL STRTCH RESIST DETACH,SUP-2365654,CDM,C1889,HCPCS,0278,RC,,,,both,,,2139.91,1390.94,,,,,,,,,,,,,
CATHETER CV 5 FRX55 CM 2 LUMEN PWR INJ XCELA,SUP-2117121,CDM,C1751,HCPCS,0278,RC,,,,both,,,366.75,238.39,,,,,,,,,,,,,
HC So1 Hepatitis B Core Antibody|NOT REASONABLE AND NECESSARY,PX-3028670467,CDM,86704,CPT,0302,RC,,,GZ,both,,,734.00,477.10,,,,,,,,,,,,,
PLATE BONE THK0.6MM 2MM OFFSET 3X5 H BILAT MAX,SUP-2191171,CDM,C1713,HCPCS,0278,RC,,,,both,,,1215.49,790.07,,,,,,,,,,,,,
MORPHINE SULFATE 15 MG PO TABS,RX-5178,CDM,6370000000,HCPCS,0637,RC,00054-0235-24,NDC,,both,1,UN,3.50,2.27,,,,,,,,,,,,,
STAPLE SPNL SINGLE 17 MM CD HORZ,SUP-2630059,CDM,C1713,HCPCS,0278,RC,,,,both,,,759.88,493.92,,,,,,,,,,,,,
"HC New Pt, Outpt Visit Level 5",PX-7619920500,CDM,99205,CPT,0761,RC,,,,both,,,387.00,251.55,,,,,,,,,,,,,
SCREW BNE L15MM DIA65MM PORCOAT CANC KNEE REV THRD LO PROF,SUP-2253373,CDM,C1713,HCPCS,0278,RC,,,,both,,,531.29,345.34,,,,,,,,,,,,,
GRAFT GRAN L SYNTH RESRB PROOSTEON 500R 15CC VI,SUP-2413084,CDM,C1713,HCPCS,0278,RC,,,,both,,,643.70,418.40,,,,,,,,,,,,,
OXYGENATOR PERFSN BARB CONN SZ 3/8 IN BLD FLO RATE 7 L/MIN,SUP-2895278,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
MESH HERN 10X10 CMX1.5 MM HYDRATED PORCINE CLLGN PERMACOL,SUP-2174699,CDM,C1781,HCPCS,0278,RC,,,,both,,,6878.42,4470.97,,,,,,,,,,,,,
SHEATH INTRO 0.021 IN 5 FRX10 CM 19-21 GAX40 MM GLIDESHEATH,SUP-2851654,CDM,C1894,HCPCS,0272,RC,,,,both,,,256.22,166.54,,,,,,,,,,,,,
HC Special Stain I&R Group III Enzyme Consituents,PX-3128831900,CDM,88319,CPT,0312,RC,,,,both,,,349.00,226.85,,,,,,,,,,,,,
WASHER SPNL LP 4.5 MM THORLUM PEDCL FOR 8.5MM SCREW TI XIA,SUP-2379339,CDM,C1713,HCPCS,0278,RC,,,,both,,,296.73,192.87,,,,,,,,,,,,,
SCREW BNE 4.5X28 MM MOTIONLOC,SUP-2606804,CDM,C1713,HCPCS,0278,RC,,,,both,,,589.94,383.46,,,,,,,,,,,,,
SCREW BNE EMGCY 2.5X13 MM STRNL LEVEL 1 MAXDRIVE 240241361,SUP-2869205,CDM,C1713,HCPCS,0278,RC,,,,both,,,80.04,52.03,,,,,,,,,,,,,
COMPONENT TOT SHLDR CAPPED RESURF S1EXACTECH] EXACTECH INC],SUP-2223655,CDM,C1776,CPT,0278,RC,,,,both,,,15700.00,10205.00,,,,,,,,,,,,,
COMPOUND RESTORATIVE 1.7GM NANOFILLED LT CURE M VISC,SUP-2238523,CDM,2720000010,LOCAL,0272,RC,,,,both,,,552.61,359.20,,,,,,,,,,,,,
NAIL IM L310MM DIA9MM UNIV TIB TI ALLY CANN LOK CORELOCK,SUP-2412950,CDM,C1713,HCPCS,0278,RC,,,,both,,,106.16,69.00,,,,,,,,,,,,,
ROD SPNL INLINE 6.35 MM ASF16S,SUP-2559406,CDM,C1713,HCPCS,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
IMPLANT BIO TISS W5XL10CM PORCINE DERM MTRX RECON THINNER BCP051020] TORNIER INC],SUP-2388575,CDM,C1763,HCPCS,0278,RC,,,,both,,,9896.65,6432.82,,,,,,,,,,,,,
PLATE BNE L119MM 7 H BROAD CNTOUR 2 COMPR FOR 4.5MM SCR L,SUP-2411406,CDM,C1713,HCPCS,0278,RC,,,,both,,,527.83,343.09,,,,,,,,,,,,,
DEVICE SECUREMENT PEDIATRIC UNIV FOAM ANCHR PD,SUP-2127661,CDM,C1751,HCPCS,0278,RC,,,,both,,,11.90,7.73,,,,,,,,,,,,,
BIT DRL L70MM OD4MM TWST W/O STP NONRADIOLUCENT SLD SCP,SUP-2413874,CDM,2720000010,LOCAL,0272,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
INTRODUCER PACE LD L 14 CM DIA 7 FR DI-LOCK DIL L 19 CM DIA,SUP-2357093,CDM,C1892,HCPCS,0272,RC,,,,both,,,16.96,11.02,,,,,,,,,,,,,
IMPLANT BIO TISS W6XL6CM REGEN PORCINE CLLGN SQ XENMATRIX,SUP-2126236,CDM,C1781,HCPCS,0278,RC,,,,both,,,3460.59,2249.38,,,,,,,,,,,,,
COUPLER EXT FIX 2 MM TIB W/SL OFFSET GEN II,SUP-2435052,CDM,C1776,CPT,0278,RC,,,,both,,,4056.88,2636.97,,,,,,,,,,,,,
RETRACTOR SURG L10IN BLDE W125IN S STL COBRA SMOOTH TIP PLN,SUP-2161266,CDM,2720000010,LOCAL,0272,RC,,,,both,,,370.14,240.59,,,,,,,,,,,,,
FLORANEX PO PACK,RX-93352,CDM,6370000000,HCPCS,0637,RC,64980-0146-98,NDC,,both,1,UN,5.90,3.83,,,,,,,,,,,,,
FENOFIBRATE 48 MG PO TABS,RX-40009,CDM,6370000000,HCPCS,0637,RC,60687-0618-21,NDC,,both,1,UN,5.70,3.70,,,,,,,,,,,,,
BLADE SHAVER DEBULKING 18 DEG 4X270 MM LARYNGEAL DBL BEND,SUP-2638096,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1020.06,663.04,,,,,,,,,,,,,
ALLOGRAFT BNE BLOCK 25-30X12X7-10 MM TRICORT STERIGRAFT,SUP-2319335,CDM,C1889,HCPCS,0278,RC,,,,both,,,4458.80,2898.22,,,,,,,,,,,,,
CATHETER BLLN DIL EXTR OVR THE WIRE ABV INJ ERCP INFL TO,SUP-2312988,CDM,C1726,HCPCS,0272,RC,,,,both,,,511.82,332.68,,,,,,,,,,,,,
ROD IM L200MM DIA8MM HUM TI CANN LOK TAPR PROF POLARUS 2,SUP-2107689,CDM,C1713,HCPCS,0278,RC,,,,both,,,6283.14,4084.04,,,,,,,,,,,,,
HC Uni/Ltd Niv Arterial Upp Ext Duplex,PX-9219393100,CDM,93931,CPT,0921,RC,,,,both,,,1484.00,964.60,,,,,,,,,,,,,
PERI-LOC TGR 4.5MM PF PIN 80MM,SUP-2819223,CDM,C1713,HCPCS,0278,RC,,,,both,,,1129.99,734.49,,,,,,,,,,,,,
SET SCR BNE L17.5MM DIA8MM TI FOR TROCHANTERIC NAILING SYS,SUP-2370393,CDM,C1713,HCPCS,0278,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
KIT INFUS PMP 400ML 5ML/HR SOAK CATH L5IN N NARC ON-Q,SUP-2236837,CDM,C9804,HCPCS,0272,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
COMPONENT ARTC 8.5X5MM OFFSET TROCHLEAR HEMICAP,SUP-2123687,CDM,C1776,CPT,0278,RC,,,,both,,,16673.40,10837.71,,,,,,,,,,,,,
CATHETER DRNGE L80CM OD1.5MM ID0.7MM LUM CLS TIP W/ 14GA,SUP-2244097,CDM,C1729,HCPCS,0272,RC,,,,both,,,1438.12,934.78,,,,,,,,,,,,,
PLATE BNE STR MINI 2-2.5X1 MM 12 HOLE LCK LADDER TI LEVEL 1,SUP-2468380,CDM,C1713,HCPCS,0278,RC,,,,both,,,1548.55,1006.56,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9% INTERMITTENT INFUSION,RX-40840102,CDM,2580000003,HCPCS,0258,RC,00990-7983-61,NDC,,both,250,ML,74.40,48.36,,,,,,,,,,,,,
LEAD NERVE STIM PNE,SUP-2568745,CDM,C1778,HCPCS,0278,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
COIL EMB L15CM PRI DIA0.020IN 2ND DIA6MM NIT COMPLX STD,SUP-2323360,CDM,C1889,HCPCS,0278,RC,,,,both,,,6644.24,4318.76,,,,,,,,,,,,,
STEM FEM SEG 3 CM DPHSEAL KNEE POROUS OSS,SUP-2449780,CDM,C1776,CPT,0278,RC,,,,both,,,13995.77,9097.25,,,,,,,,,,,,,
SPLINT WR AD M L6.25IN FOR 6.5-7.5IN LT REG W/ STAY ELAS,SUP-2309139,CDM,L3808,HCPCS,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
ALLOGRAFT BNE DWL 11 MM FRZN PRESHAPED PATELLAR FLEXIGRAFT,SUP-2741040,CDM,C1762,CPT,0278,RC,,,,both,,,9122.39,5929.55,,,,,,,,,,,,,
CATHETER CTRL VEN KT TRIFUSION 19CM STR TIP TO CUF 3 LUMN,SUP-2127761,CDM,C1751,HCPCS,0278,RC,,,,both,,,1915.40,1245.01,,,,,,,,,,,,,
RING PESSARY 6 3.25 IN W/ SUPP SIL,SUP-2171734,CDM,A4562,HCPCS,0274,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
LPS POROUS STEM 12.5X100MM STR,SUP-2513223,CDM,C1776,CPT,0278,RC,,,,both,,,11154.22,7250.24,,,,,,,,,,,,,
HC Before / After Bronchodilator,PX-4609406000,CDM,94060,CPT,0460,RC,,,,both,,,569.00,369.85,,,,,,,,,,,,,
DEVICE EMB CATERPILLAR DEL WIRE L 170 CM CATH 0.027 IN RVD,SUP-2655905,CDM,C1889,HCPCS,0278,RC,,,,both,,,3611.00,2347.15,,,,,,,,,,,,,
BUR SURG 5 MM STRT ORTHOSPHERE CMC,SUP-2521578,CDM,2720000010,LOCAL,0272,RC,,,,both,,,304.58,197.98,,,,,,,,,,,,,
ROD SPNL L40MM DIA4.75MM CO CHROM PREBENT CDH SOLERA,SUP-2284759,CDM,C1713,HCPCS,0278,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
COLLAR CERV TRACHEOTOMY SM AD 4.25 IN 10-13 IN PHILADELPHIA,SUP-2319297,CDM,L0172,HCPCS,0274,RC,,,,both,,,30.52,19.84,,,,,,,,,,,,,
BIT DRL 2.4 MM VERTEX SEL,SUP-2630739,CDM,2720000010,LOCAL,0272,RC,,,,both,,,513.23,333.60,,,,,,,,,,,,,
DRAINAGE SET LUMBAR INTEGR 1 PC ASMBLY M LL CONN EXAFLOW,SUP-2666670,CDM,C1729,HCPCS,0272,RC,,,,both,,,643.67,418.39,,,,,,,,,,,,,
STEM ULN L70MM SM STD PLSM COAT CO CHROM RT PRI CEM,SUP-2396772,CDM,C1776,CPT,0278,RC,,,,both,,,20305.91,13198.84,,,,,,,,,,,,,
KIT STRNL CLOSURE X CABLE PLATE KT INCLUDE SCREW CABLE STRL,SUP-2894323,CDM,C1713,HCPCS,0278,RC,,,,both,,,3862.20,2510.43,,,,,,,,,,,,,
HEMI GREAT TOE IMPL M,SUP-2319775,CDM,C1776,CPT,0278,RC,,,,both,,,5626.88,3657.47,,,,,,,,,,,,,
WIRE EXT FIX L385MM DIA1.8MM S STL DRL TIP FOR ILIZ TAY,SUP-2343003,CDM,2720000010,LOCAL,0272,RC,,,,both,,,950.29,617.69,,,,,,,,,,,,,
CATHETER KIT INSRTN TY PLEURAL DRAINAGE ASPIRA,SUP-2487165,CDM,C1729,HCPCS,0272,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
CATHETER GUID VISTA BRT TIP L 65 CM SHTH 7 FR GUIDEWIRE,SUP-2155676,CDM,C1887,HCPCS,0272,RC,,,,both,,,474.77,308.60,,,,,,,,,,,,,
HANDPIECE LASER CRV SHFT,SUP-2713751,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1918.54,1247.05,,,,,,,,,,,,,
MESH CRAN L 39.83 X W 23.57 MM THK 0.61 MM SCREW DIA1.5 MM,SUP-2937014,CDM,C1713,HCPCS,0278,RC,,,,both,,,5297.18,3443.17,,,,,,,,,,,,,
SHEATH FLD TUNN L8IN DIA11GA DISP ON-Q,SUP-2236758,CDM,C1894,HCPCS,0272,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
CATHETER BAL OCCL L100CM OD7FR OD34FR,SUP-2141681,CDM,C2628,HCPCS,0272,RC,,,,both,,,432.57,281.17,,,,,,,,,,,,,
SLEEVE FIX L 30 MM DIA2.1 MM BND 2 X 0.75 MM SIL TYP 70 STRL,SUP-2930290,CDM,C1784,HCPCS,0278,RC,,,,both,,,41.86,27.21,,,,,,,,,,,,,
SET INTRO MICRO-STICK SHTH L 9 CM DIA 4 FR SS COAX STIFF,SUP-2627260,CDM,C1894,HCPCS,0272,RC,,,,both,,,728.48,473.51,,,,,,,,,,,,,
SAW SURG AIR PWR STRNM FTPLT GRD FOR VETERINARY INSTRUMENT,SUP-2486851,CDM,2720000010,LOCAL,0272,RC,,,,both,,,19601.76,12741.14,,,,,,,,,,,,,
PLATE BNE L116MM 4 H NONSTERILE L MED DST TIB S STL LOK,SUP-2185580,CDM,C1713,HCPCS,0278,RC,,,,both,,,4411.73,2867.62,,,,,,,,,,,,,
KIT HIP IMPL CAPPED H2 ADV OTH HD H2ZIMMERBIOMET,SUP-2431795,CDM,C1776,CPT,0278,RC,,,,both,,,15072.00,9796.80,,,,,,,,,,,,,
GRAFT HUM TISS 1CC FLOWABLE PLCNTA TISS MTRX VIAFLOW,SUP-2399189,CDM,C1713,HCPCS,0278,RC,,,,both,,,6093.67,3960.89,,,,,,,,,,,,,
CABLE LT DISP FOR MAXCESS SYS,SUP-2310429,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
"HC So Total Protein, Urine",PX-3018415666,CDM,84156,CPT,0301,RC,,,,both,,,40.00,26.00,,,,,,,,,,,,,
BIT DRL L360MM OD42MM SM ST GRN AO QUIK CPL GAMMA3,SUP-2361620,CDM,2720000010,LOCAL,0272,RC,,,,both,,,449.81,292.38,,,,,,,,,,,,,
CLIP INT LIG LG CHEVRON SHP TI ORNG STRL DISP,SUP-2757597,CDM,C1889,HCPCS,0278,RC,,,,both,,,16.64,10.82,,,,,,,,,,,,,
PROSTHESIS PENILE L20CM DIA13MM CYL MALL 650,SUP-2140268,CDM,C1813,HCPCS,0278,RC,,,,both,,,6311.40,4102.41,,,,,,,,,,,,,
GRAFT DELIVERY SYSTEM SET 12 CC W/ GRFT DBF CANN ACCELERATE,SUP-2787603,CDM,C1713,HCPCS,0278,RC,,,,both,,,6577.39,4275.30,,,,,,,,,,,,,
JETXHALF PINS/EXTERNAL FIXATION/UNILATERAL/5 MM HALF PINS/5,SUP-2342929,CDM,C1713,HCPCS,0278,RC,,,,both,,,1806.16,1174.00,,,,,,,,,,,,,
PROSTHESIS PENILE SPHIN DEACTIVATION PK,SUP-2138916,CDM,C1713,HCPCS,0278,RC,,,,both,,,444.34,288.82,,,,,,,,,,,,,
PLATE BNE 0 DEG SCREW DIA 3/3.5/4 MM MED TI ALLOY RT 1ST,SUP-2907582,CDM,C1713,HCPCS,0278,RC,,,,both,,,6880.56,4472.36,,,,,,,,,,,,,
GUIDEWIRE ORTH L20IN DIA2MM NIT FOR MOD SHLDR SYS POLARUS,SUP-2107887,CDM,C1769,HCPCS,0272,RC,,,,both,,,229.22,148.99,,,,,,,,,,,,,
HC CT Heart Scan,PX-3527557200,CDM,75572,CPT,0480,RC,,,,both,,,2388.00,1552.20,,,,,,,,,,,,,
ANCHOR SUT DIA5.5MM KNOTLESS MULTIFIX S-ULTRA,SUP-2341941,CDM,C1713,HCPCS,0278,RC,,,,both,,,1117.84,726.60,,,,,,,,,,,,,
SET TRAC L SPINE EXT BRACING PROD ADJ CRWN BREMER HALO SYS,SUP-2255769,CDM,C1713,HCPCS,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
IMPLANT TOE SZ 40 FOREFOOT PRIMUS GREAT W/ GRMMT FUTURA,SUP-2399911,CDM,C1776,CPT,0278,RC,,,,both,,,4945.50,3214.57,,,,,,,,,,,,,
CATHETER ABLAT 7FR L60CM HEAT ELEMENT L7CM 0.025IN,SUP-2172372,CDM,C1888,HCPCS,0272,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
PLATE BNE 2.7X100 MM 11 HOLE SS LC-DCP,SUP-2569220,CDM,C1713,HCPCS,0278,RC,,,,both,,,347.13,225.63,,,,,,,,,,,,,
PLATE BNE DBL Y NEURO LP Q STYL FOR SCR TI LEVEL 1 LF,SUP-2471493,CDM,C1713,HCPCS,0278,RC,,,,both,,,1270.26,825.67,,,,,,,,,,,,,
TRAY CATH HEMODIALYSI HEM CATH ACTE 8FR DIA 18CM STRGHT RND,SUP-2610595,CDM,C1750,HCPCS,0278,RC,,,,both,,,732.88,476.37,,,,,,,,,,,,,
KIT INFSN 4FR CATH 90CML LNGTH 10CM CHECK RELF VLV HEMSTAS V,SUP-2676953,CDM,C1751,HCPCS,0278,RC,,,,both,,,457.18,297.17,,,,,,,,,,,,,
CATHETER PTCA 4FR L150CM QUADFLEX BLLN L15CM DIA2.5MM SHTH,SUP-2156486,CDM,C1725,HCPCS,0272,RC,,,,both,,,926.30,602.09,,,,,,,,,,,,,
HC Smoke/Tobac Counsel 3-10,PX-9429940600,CDM,99406,CPT,0940,RC,,,,outpatient,,,29.00,18.85,,,,,,,,,,,,,
HC Iadna Sarscov2 & Inf a&B & Rsv Mult Amp Probe Tq,PX-3068763700,CDM,87637,CPT,0306,RC,,,,outpatient,,,300.00,195.00,,,,,,,,,,,,,
AMIVANTAMAB-HYALURONIDASE-LPUJ 1600-20000 MG-UT/10ML SC SOLN,RX-174608,CDM,2500000003,HCPCS,0250,RC,57894-0510-01,NDC,,both,10,ML,35662.10,23180.36,,,,,,,,,,,,,
CATHETER ANGIOPLSTY CHARGER L 75 CM BALLOON L 20 MM DIA 6 MM,SUP-2145898,CDM,C1725,HCPCS,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
ANCHOR SUTURE 3.5 MM SUTURETAK,SUP-2198349,CDM,C1713,HCPCS,0278,RC,,,,both,,,536.63,348.81,,,,,,,,,,,,,
CATHETER HD STR 14 FRX32 CM LT SET W/ 2 STYL SPLIT CATH III,SUP-2627122,CDM,C1750,HCPCS,0278,RC,,,,both,,,75.36,48.98,,,,,,,,,,,,,
KIT NERVE STIM BARORECEPTOR NEUROMODULATION GENRTR CSL LD,SUP-2894037,CDM,C1825,HCPCS,0278,RC,,,,both,,,109900.00,71435.00,,,,,,,,,,,,,
SCREW SPNL L 50 MM DIA 6.5 MM BLACKARMOR CARBON PEEK TI-IT,SUP-2917081,CDM,C1713,HCPCS,0278,RC,,,,both,,,12089.00,7857.85,,,,,,,,,,,,,
PEEK SWIVELOCK BICEPS TENO 8X23 KIT,SUP-2812049,CDM,C1713,HCPCS,0278,RC,,,,both,,,2163.46,1406.25,,,,,,,,,,,,,
ANCHOR SUTURE BIO ABSORBABLE 3 MM 3 BRAIDED POLYESTER XCEL,SUP-2608443,CDM,C1713,HCPCS,0278,RC,,,,both,,,587.27,381.73,,,,,,,,,,,,,
PIN FIX DIA1.8MM PROV,SUP-2344033,CDM,2720000010,LOCAL,0272,RC,,,,both,,,904.60,587.99,,,,,,,,,,,,,
SCREW BONE L50MM DIA4.5MM HD NONLOCKING LO PROF FOR INTOSS,SUP-2223849,CDM,C1713,HCPCS,0278,RC,,,,both,,,1808.64,1175.62,,,,,,,,,,,,,
AMPLATZ RENAL DILATOR SET,SUP-2826946,CDM,C1726,HCPCS,0272,RC,,,,both,,,870.31,565.70,,,,,,,,,,,,,
INTRODUCER VLV PROGRAMMABLE 21.8 CM STRL MEDOS DISP,SUP-2666466,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1175.46,764.05,,,,,,,,,,,,,
PROSTHESIS OTO L10MM OD4/2.1MM HA AND S STL MID EAR OSS TOT,SUP-2284052,CDM,L8613,CPT,0278,RC,,,,both,,,1251.23,813.30,,,,,,,,,,,,,
STENT PERIPH SMRT RADIANZ L 120 MM DIA 6 MM DEL SYS L 190 CM,SUP-2866189,CDM,C1876,HCPCS,0278,RC,,,,both,,,5046.55,3280.26,,,,,,,,,,,,,
PLATE BONE L92MM 4 H STRL LT PROX HUM S STL CVD FOR 3.5MM,SUP-2349773,CDM,C1713,HCPCS,0278,RC,,,,both,,,8863.28,5761.13,,,,,,,,,,,,,
PROBE ELECSURG 7FR L270CM DISP ABC FLX,SUP-2166129,CDM,2720000010,LOCAL,0272,RC,,,,both,,,707.44,459.84,,,,,,,,,,,,,
GRAFT HUM TISS W4XL16CM THK08 17MM THCK PLIABLE BRST KT,SUP-2307583,CDM,Q4128,HCPCS,0636,RC,,,,both,,,10253.67,6664.89,,,,,,,,,,,,,
GRAFT DURA PTCH 4X5 CM DURAMATER,SUP-2321736,CDM,C1713,HCPCS,0278,RC,,,,both,,,1962.50,1275.62,,,,,,,,,,,,,
HC Pt Manual Therapy Ea 15|OP PT SERVICES|DOCUMENTATION ON FILE|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS,PX-4209714000,CDM,97140,CPT,0420,RC,,,GP|KX|CQ,both,,,194.00,126.10,,,,,,,,,,,,,
CYPROHEPTADINE HCL 4 MG PO TABS,RX-2033,CDM,6370000000,HCPCS,0637,RC,70752-0107-10,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
BIT DRL 2.5X14 MM CERV SPINE EZ PLATE DISP,SUP-2430802,CDM,2720000010,LOCAL,0272,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
CATHETER DIL L200CM TAPR L2CM OD6FR 0.035IN BILI PUR CONN,SUP-2170679,CDM,2720000010,LOCAL,0272,RC,,,,both,,,401.92,261.25,,,,,,,,,,,,,
HC So Hemoglobin Chromatography,PX-3018302166,CDM,83021,CPT,0301,RC,,,,inpatient,,,267.00,173.55,,,,,,,,,,,,,
ACETAZOLAMIDE SODIUM 500 MG IJ SOLR,RX-114,CDM,J1120,HCPCS,0636,RC,39822-0190-01,NDC,,both,1,UN,181.20,117.78,,,,,,,,,,,,,
BIT DRL FLUT 0.8X148 MM 15 MM HOUGH STAPEDIAL SS MICROFRANCE,SUP-2464810,CDM,2720000010,LOCAL,0272,RC,,,,both,,,420.85,273.55,,,,,,,,,,,,,
SOCK PROSTHETIC LNG FRAC,SUP-2388188,CDM,L2850,HCPCS,0272,RC,,,,both,,,152.76,99.29,,,,,,,,,,,,,
GUIDEWIRE VASC L180CM 7MM EXTRA SUPP ANGIOGAURD,SUP-2158277,CDM,C1769,HCPCS,0272,RC,,,,both,,,3532.50,2296.12,,,,,,,,,,,,,
BUR SURG TAPR 14 CM TELE ANGLED MIDAS REX LEGEND,SUP-2281701,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3037.20,1974.18,,,,,,,,,,,,,
STEM FEM SZ 5 L140MM DIA15MM NK L37MM 47MM OFFSET 132DEG 62650011] STRYKER CORP],SUP-2364476,CDM,C1776,CPT,0278,RC,,,,both,,,8903.78,5787.46,,,,,,,,,,,,,
IMPLANT PHLANG 10 FOREFOOT GREAT TOE SYS MOV,SUP-2244247,CDM,C1776,CPT,0278,RC,,,,both,,,7768.64,5049.62,,,,,,,,,,,,,
PROSTHESIS PENILE L18CM MINOCYCLINE RIFAMPIN INHIBIZONE,SUP-2140258,CDM,C1813,HCPCS,0278,RC,,,,both,,,5934.60,3857.49,,,,,,,,,,,,,
HC So Microdissection Laser,PX-3128838066,CDM,88380,CPT,0312,RC,,,,both,,,1298.00,843.70,,,,,,,,,,,,,
PLATE BNE L24MM 4 H CRANIOFACIAL TI STR,SUP-2262763,CDM,C1713,HCPCS,0278,RC,,,,both,,,231.95,150.77,,,,,,,,,,,,,
POLYMYXIN B-TRIMETHOPRIM 10000-0.1 UNIT/ML-% OP SOLN,RX-11596,CDM,6370000000,HCPCS,0637,RC,24208-0315-10,NDC,,both,10,ML,48.40,31.46,,,,,,,,,,,,,
PLATE BONE SM 8 H LT CLAV LCK,SUP-2107757,CDM,C1713,HCPCS,0278,RC,,,,both,,,3218.50,2092.02,,,,,,,,,,,,,
KIT PATELLA TEMPLATE ANTERIOR / STERILE,SUP-2739167,CDM,2720000010,LOCAL,0272,RC,,,,both,,,573.11,372.52,,,,,,,,,,,,,
SHEATH GUID 7FR L45CM DIA2.5MM 0.018/0.038IN RENAL DBL CLS,SUP-2169818,CDM,C1894,HCPCS,0272,RC,,,,both,,,316.76,205.89,,,,,,,,,,,,,
PLATE BNE L 178 X W 13.5 MM THK 4.2 MM SCREW DIA 4.5 MM,SUP-2908483,CDM,C1713,HCPCS,0278,RC,,,,both,,,1793.82,1165.98,,,,,,,,,,,,,
OCCLUDER CV AMPLATZER PI MUSCULAR VSD WAIST L 10 MM DIA20 MM,SUP-2737595,CDM,C1817,HCPCS,0278,RC,,,,both,,,20535.60,13348.14,,,,,,,,,,,,,
NEEDLE BRST LOC L5CM OD20GA N REPOSITIONABLE W/ FLEXSTRAND,SUP-2381876,CDM,C1819,HCPCS,0278,RC,,,,both,,,103.62,67.35,,,,,,,,,,,,,
SCREW BNE DRILL-FREE 1.5X4 MM TI STRL MAXDRIVE LEVEL 1 NEURO,SUP-2470682,CDM,C1713,HCPCS,0278,RC,,,,both,,,214.56,139.46,,,,,,,,,,,,,
MOSUNETUZUMAB-AXGB 30 MG/30ML IV SOLN,RX-161229,CDM,J9350,HCPCS,0636,RC,50242-0142-01,NDC,,both,30,ML,53935.70,35058.20,,,,,,,,,,,,,
BUR SURG L 95 MM DIA2.35 MM HD DIA1.4 MM DIAMOND NS REUSE,SUP-2928938,CDM,2720000010,LOCAL,0272,RC,,,,both,,,365.87,237.82,,,,,,,,,,,,,
PLATE BNE 1.5/2X31X1.2 MM 5 HOLE SS LC-DCP,SUP-2569193,CDM,C1713,HCPCS,0278,RC,,,,both,,,253.87,165.02,,,,,,,,,,,,,
ANCHOR SUT L19.1MM DIA4.75MM PEEK CLOSE EYELET W/ BLU,SUP-2121702,CDM,C1713,HCPCS,0278,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
DEVICE ARTOTMY CLOSURE PROSTAR XL DIA 8.5-10 FR HYDRPHLC TIP,SUP-2105646,CDM,C1760,HCPCS,0278,RC,,,,both,,,3092.90,2010.38,,,,,,,,,,,,,
SHELL ACET OD48MM TI-COAT HIP RESTORIS Z KLASSIC HD,SUP-2371076,CDM,C1776,CPT,0278,RC,,,,both,,,8037.74,5224.53,,,,,,,,,,,,,
GRAFT VASC L30CM ID12MM RNGD SECT L30CM STD WALLED STR GOR,SUP-2396027,CDM,C1768,CPT,0278,RC,,,,both,,,3410.04,2216.53,,,,,,,,,,,,,
STENT BILI PALMAZ GEN L 79 MM EXPANSION DIA 5-10 MM SHTH,SUP-2159303,CDM,C1877,HCPCS,0278,RC,,,,both,,,1993.90,1296.03,,,,,,,,,,,,,
SET IMPL UNIV NONSTERILE GRPHC CA W/ SCR PLT FOR DYN HIP,SUP-2183069,CDM,C1713,HCPCS,0278,RC,,,,both,,,46250.85,30063.05,,,,,,,,,,,,,
BRACE ORTH THGH CIRC 15.5-18.5 IN STD SM SZ 2 ALUMINIUM FRME,SUP-2915023,CDM,2720000010,LOCAL,0272,RC,,,,both,,,843.44,548.24,,,,,,,,,,,,,
TRAY TIB KNEE 2T3F FOR MODULAR/REVISION SYS PROVEN GEN-FLEX,SUP-2359219,CDM,C1776,CPT,0278,RC,,,,both,,,9498.50,6174.02,,,,,,,,,,,,,
GUIDEWIRE VASC INQWIRE L 260 CM DIA 0.035 IN PTFE PERIPH,SUP-2301911,CDM,C1769,HCPCS,0272,RC,,,,both,,,102.05,66.33,,,,,,,,,,,,,
CONNECTOR SPNL SM SIDE/FRONT LD,SUP-2317815,CDM,C1713,HCPCS,0278,RC,,,,both,,,2763.20,1796.08,,,,,,,,,,,,,
INSTRUMENT TRAY SONICPIN SONICFUSION,SUP-2486460,CDM,C1713,HCPCS,0278,RC,,,,both,,,2396.70,1557.85,,,,,,,,,,,,,
WAND ABLAT SHFT DIA33MM 20DEG CUT W 55MM CANN COBLATION,SUP-2341985,CDM,2720000010,LOCAL,0272,RC,,,,both,,,640.56,416.36,,,,,,,,,,,,,
CELECOXIB 100 MG PO CAPS,RX-24500,CDM,6370000000,HCPCS,0637,RC,33342-0156-11,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
SUPPORT ORTHOT THOR LUMBAR SACR CUST TRIPLANAR CTRL SHELL,SUP-2435546,CDM,L0480,HCPCS,0274,RC,,,,both,,,4276.30,2779.59,,,,,,,,,,,,,
CANNULA SUC IRR 5X280 MM 2 TRMPT VLV LASER GUIDE SEAL SS,SUP-2467733,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1126.38,732.15,,,,,,,,,,,,,
PROBE STEREOTACTIC 8GA L12CM FOR MAMTOM REVOLVE,SUP-2195618,CDM,2720000010,LOCAL,0272,RC,,,,both,,,533.27,346.63,,,,,,,,,,,,,
ROD SPNL L270MM OD55MM TI ALLY POST R SMOOTH STR CDH,SUP-2279612,CDM,C1713,HCPCS,0278,RC,,,,both,,,2357.76,1532.54,,,,,,,,,,,,,
BUR SURG L104MM DIA126MM TOOL BORING AGG FOR TPS MIDAS,SUP-2363346,CDM,2720000010,LOCAL,0272,RC,,,,both,,,389.49,253.17,,,,,,,,,,,,,
IMPLANT OSS L6MM HD 4MM THK3MM 1.17MM HA HD HAPEX SHFT FULL,SUP-2313861,CDM,L8613,CPT,0278,RC,,,,both,,,1004.80,653.12,,,,,,,,,,,,,
MANIFOLD ANGIO 3 PRT 200PSI LT ORIENTATION ADPT HALF BODY,SUP-2301387,CDM,C1713,HCPCS,0278,RC,,,,both,,,13.22,8.59,,,,,,,,,,,,,
BIT DRL DIA2.4MM SHLDR CANN FOR ACROMIOCLAVICULAR REP,SUP-2121658,CDM,2720000010,LOCAL,0272,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
GUIDEWIRE 16CMX20CM RECTANG,SUP-2420227,CDM,C1769,HCPCS,0272,RC,,,,both,,,13370.12,8690.58,,,,,,,,,,,,,
BLOCK SPRD CERV INTBDY 14MM CATLYST C,SUP-2291048,CDM,C1713,HCPCS,0278,RC,,,,both,,,822.84,534.85,,,,,,,,,,,,,
HC Abdominal Aortogram,PX-3237562500,CDM,75625,CPT,0323,RC,,,,inpatient,,,2979.00,1936.35,,,,,,,,,,,,,
"HC Pt Therapeutic Exercise,Ea 15 Min|OP OCCUPATIONAL THERAPY SERV|SERVICES PROVIDED IN WHOLE OR IN PARTY BY AN OTA FOR MEDICARE PATIENTS",PX-4209711000,CDM,97110,CPT,0420,RC,,,GO|CO,both,,,195.00,126.75,,,,,,,,,,,,,
SCREW BNE LCK 3.5X42 MM MULT DIR FOR T15,SUP-2411597,CDM,C1713,HCPCS,0278,RC,,,,both,,,640.37,416.24,,,,,,,,,,,,,
CONNECTOR SPNL XLNK ASMBLY FIX TRNSVRS CONN TI 4.75MM ROD,SUP-2415716,CDM,C1713,HCPCS,0278,RC,,,,both,,,1447.54,940.90,,,,,,,,,,,,,
HC Car Seat / Bed Test 60 Min,PX-4109478000,CDM,94780,CPT,0410,RC,,,,inpatient,,,124.00,80.60,,,,,,,,,,,,,
SPIKE CBL HIP S STL ACCORD,SUP-2345199,CDM,C1776,CPT,0278,RC,,,,both,,,469.74,305.33,,,,,,,,,,,,,
SET PROC L125CM OD12FR OPN END HYPOTONIC DUODENOGRAPHY,SUP-2167943,CDM,C1713,HCPCS,0278,RC,,,,both,,,375.67,244.19,,,,,,,,,,,,,
BIOPSY SET 19 GAX70 CM 7 FR STRT NDL SHTH,SUP-2168817,CDM,C1713,HCPCS,0278,RC,,,,both,,,1594.27,1036.28,,,,,,,,,,,,,
TRAY CATH PICC POLY Q CATH 5FR 0.034IN 60CM 2 LUMAN RVRSE TA,SUP-2613388,CDM,C1751,HCPCS,0278,RC,,,,both,,,388.10,252.26,,,,,,,,,,,,,
NEEDLE ASPIR 25GA SHTH DIA1.4MM CHN 2MM PULM EB US,SUP-2149679,CDM,C1713,HCPCS,0278,RC,,,,both,,,598.33,388.91,,,,,,,,,,,,,
STENT COR 16MM 2.75MM CATH L144CM PLAT CHROM ALLOY SELF,SUP-2145084,CDM,C1874,HCPCS,0278,RC,,,,both,,,4003.50,2602.27,,,,,,,,,,,,,
HC So Hemolysins/Agglutinins Auto,PX-3008694066,CDM,86940,CPT,0300,RC,,,,both,,,62.00,40.30,,,,,,,,,,,,,
CATH REPROC EP DIAG DYNAM XT STRBL LG4 10POL 2-5-2MM 6FR,SUP-2526003,CDM,C1730,HCPCS,0272,RC,,,,both,,,424.97,276.23,,,,,,,,,,,,,
PROBE 25GA + STD ALONE ENDO ILLUMINATOR CONSTELLATION,SUP-2109934,CDM,C1713,HCPCS,0278,RC,,,,both,,,406.25,264.06,,,,,,,,,,,,,
CATHETER INFUSION MINI 40 CM BENEPHIT PV,SUP-2117134,CDM,C1751,HCPCS,0278,RC,,,,both,,,5636.30,3663.59,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA MAXBARR 3FR 55CM S1193108PD,SUP-2632797,CDM,C1751,HCPCS,0278,RC,,,,both,,,856.15,556.50,,,,,,,,,,,,,
ALLOGRAFT BNE PROX TIB W/O PAT LIGMNT,SUP-2321913,CDM,C1713,HCPCS,0278,RC,,,,both,,,23550.00,15307.50,,,,,,,,,,,,,
VISE EXT FIX MOD 3 HOLE W/ 2 ROD,SUP-2467496,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1144.53,743.94,,,,,,,,,,,,,
HANDLE SRGCL KNIFE SIZE 3KL 5 78NL STNLSS STEEL MATTE FNSH,SUP-2700741,CDM,2720000010,LOCAL,0272,RC,,,,both,,,85.88,55.82,,,,,,,,,,,,,
"HC So1 Electron Microscopy, Diag",PX-3128834867,CDM,88348,CPT,0312,RC,,,,both,,,920.00,598.00,,,,,,,,,,,,,
IMPLANT DERM W100XL100MM CLLGN SQ SHT ALLOMAX,SUP-2125857,CDM,C1781,HCPCS,0278,RC,,,,both,,,9922.40,6449.56,,,,,,,,,,,,,
GRAFT VASC VENAFLO II L 20 CM DIA 4-7 MM EPTFE CARBON STP N,SUP-2128780,CDM,L8670,HCPCS,0278,RC,,,,both,,,5391.35,3504.38,,,,,,,,,,,,,
SCREW CANN 32MM THRD 5.5X150MM,SUP-2665195,CDM,C1713,HCPCS,0278,RC,,,,both,,,592.83,385.34,,,,,,,,,,,,,
CATHETER HAD AD 14.5FR L28CM PRECRV POLYUR DBL LUMN STP TIP,SUP-2266978,CDM,C1881,HCPCS,0278,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
MESH HERN REP SOFT-TISSUE RECON ELP W/ POS SYS 7X9INCH,SUP-2125918,CDM,C1781,HCPCS,0278,RC,,,,both,,,3928.14,2553.29,,,,,,,,,,,,,
CATHETER DEL CARR L 152 CM SM HYDRPHLC 1 LUMEN COMP VAR PK10,SUP-2912343,CDM,C1887,HCPCS,0272,RC,,,,both,,,5636.30,3663.59,,,,,,,,,,,,,
MYCOPHENOLATE MOFETIL HCL 500 MG IV SOLR,RX-23968,CDM,J7519,HCPCS,0636,RC,54288-0141-01,NDC,,both,1,UN,172.50,112.12,,,,,,,,,,,,,
PLATE BONE L40MM 3 H STRL BILAT 1/4 TBLR COMPR FOR 2.7MM SCR,SUP-2349936,CDM,C1713,HCPCS,0278,RC,,,,both,,,4766.68,3098.34,,,,,,,,,,,,,
CAGE SPNL L 73MM IM NIT SELF EXP 3 DIM FX MGMT,SUP-2167471,CDM,C1889,HCPCS,0278,RC,,,,both,,,15370.30,9990.69,,,,,,,,,,,,,
SUTURE ANCHOR Y-KNOT RC WITH NEEDLES,SUP-2824746,CDM,C1713,HCPCS,0278,RC,,,,both,,,3230.12,2099.58,,,,,,,,,,,,,
COUNTERSINK SURG CANN FOR 2.4MM SCR,SUP-2187346,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1168.05,759.23,,,,,,,,,,,,,
TUBE VENT 1.52 MM 1 MM 4.23/3.2 MM PAPARELLA W/ TAB SIL STRL,SUP-2479504,CDM,L8699,HCPCS,0278,RC,,,,both,,,32.25,20.96,,,,,,,,,,,,,
LEAD DBS L 42 CM DIA 0.5 MM DIR STRL DISP SENSIGHT,SUP-2882974,CDM,C1778,HCPCS,0278,RC,,,,both,,,11708.28,7610.38,,,,,,,,,,,,,
LOOP OSS TRAPEZ RIBBON 4.5 MM FLATTENED BND WIDE PLAT,SUP-2637832,CDM,L8613,CPT,0278,RC,,,,both,,,540.58,351.38,,,,,,,,,,,,,
SYSTEM ENDOSCP INNR RNG SZ 11 CM TRNSVAG GELSEAL CAP ALEXIS,SUP-2885195,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
SCREW BATTALION LLIF BIFUR LT CBL TIP,SUP-2419601,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1899.70,1234.80,,,,,,,,,,,,,
APPLIER CLP ENDOSCP LG 12 MMX14 IN LIG HORZ MTL LIG SYS,SUP-2656788,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2851.12,1853.23,,,,,,,,,,,,,
CANNULA SHRT MULTI TIP ROTATABLE FIXATED LEVEL 1,SUP-2498540,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1857.09,1207.11,,,,,,,,,,,,,
GUIDEWIRE THREADED TROCAR TIP,SUP-2714101,CDM,C1769,HCPCS,0272,RC,,,,both,,,816.40,530.66,,,,,,,,,,,,,
ROPINIROLE HCL 2 MG PO TABS,RX-21690,CDM,6370000000,HCPCS,0637,RC,50268-0744-11,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
Z DISCONTINUED USE 2718075 PIN FIX L50MM DIA5MM SFT TISS KNEE AMORPHOUS PLLA FOR ACL,SUP-2121112,CDM,C1713,HCPCS,0278,RC,,,,both,,,907.46,589.85,,,,,,,,,,,,,
HC Iadna Cytomegalovirus Amplified Probe Tq,PX-3068749600,CDM,87496,CPT,0306,RC,,,,both,,,88.00,57.20,,,,,,,,,,,,,
DRESSING WND TALYMED L 5 X W 5 CM POLY-N-ACETYL GLUCOSAMINE,SUP-2266131,CDM,Q4127,HCPCS,0636,RC,,,,both,,,2464.90,1602.18,,,,,,,,,,,,,
ARM EXT FIX ANAT JIG DNP,SUP-2499130,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1397.30,908.24,,,,,,,,,,,,,
SCREW BONE SELF TAPPING 3X20 MM LOCKING FOR STERNAL PLATE TI,SUP-2838336,CDM,C1713,HCPCS,0278,RC,,,,both,,,635.22,412.89,,,,,,,,,,,,,
CATHETER ABLATN F-J CRV 7 FR EZ STEER CS,SUP-2257362,CDM,C1730,HCPCS,0272,RC,,,,both,,,1758.40,1142.96,,,,,,,,,,,,,
PIN GUIDE L 450 MM DIA 3.2 MM DRL TIP STRL DISP,SUP-2932833,CDM,2720000010,LOCAL,0272,RC,,,,both,,,260.27,169.18,,,,,,,,,,,,,
HC Rep Lac Floor Mouth 0-2.5cm,PX-4504125000,CDM,41250,CPT,0450,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
NAIL FIX L 70 MM DIA 4.5 MM HND WR THRD TRIM STRL OSSIOFIBER,SUP-2904326,CDM,C1713,HCPCS,0278,RC,,,,both,,,6735.30,4377.94,,,,,,,,,,,,,
PAD TRACH STOMA 3 45X38 MM INNOVATIVE CUSH SIL.FLEX,SUP-2352876,CDM,C1713,HCPCS,0278,RC,,,,both,,,540.87,351.57,,,,,,,,,,,,,
HC Compatibility Test Incubate Ea Unit,PX-3008692100,CDM,86921,CPT,0300,RC,,,,both,,,187.00,121.55,,,,,,,,,,,,,
GRAFT HUM TISS 2X6CM AMNIOFIX,SUP-2305725,CDM,V2790,HCPCS,0278,RC,,,,both,,,1796.08,1167.45,,,,,,,,,,,,,
BUR SURG ROUTER TAPR OD1.5MM ELITE,SUP-2364035,CDM,2720000010,LOCAL,0272,RC,,,,both,,,383.96,249.57,,,,,,,,,,,,,
INTRODUCER MICPUNC SET SILHOUETTE TRNSTLSS S STL WIRE GUID W,SUP-2170551,CDM,C1894,HCPCS,0272,RC,,,,both,,,74.01,48.11,,,,,,,,,,,,,
BLADE SHV L L18CM DIA4.5MM LNG FULL RAD BONECUTTER CLR,SUP-2341683,CDM,2720000010,LOCAL,0272,RC,,,,both,,,348.16,226.30,,,,,,,,,,,,,
TRANDOLAPRIL 1 MG PO TABS,RX-17017,CDM,6370000000,HCPCS,0637,RC,68180-0566-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
TRIAL PLATE STR 1.3 MM 10 HOLE,SUP-2525721,CDM,C1713,HCPCS,0278,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
RATCHETING COMPRESSION PLATE 15X17,SUP-2822964,CDM,C1713,HCPCS,0278,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
PROBE LASER 23GA 78DEG NIT TIP PLAS FBR ILLUMINATED FLX CRV,SUP-2109954,CDM,2720000010,LOCAL,0272,RC,,,,both,,,659.40,428.61,,,,,,,,,,,,,
SCREW BONE L5MM OD2.0MM EMER CROSS DRV,SUP-2262631,CDM,C1713,HCPCS,0278,RC,,,,both,,,86.95,56.52,,,,,,,,,,,,,
PLATE CRAN L 20 MM THK 0.4 MM SCREW DIA1.5 MM TI SHUNT LP,SUP-2883648,CDM,C1713,HCPCS,0278,RC,,,,both,,,1227.65,797.97,,,,,,,,,,,,,
HC So Lyme Disease Ab by Westrn Blot,PX-3028661766,CDM,86617,CPT,0302,RC,,,,both,,,75.00,48.75,,,,,,,,,,,,,
CATHETER HAD 2 LUMN,SUP-2127694,CDM,C1750,HCPCS,0278,RC,,,,both,,,562.06,365.34,,,,,,,,,,,,,
GRAFT BIO TISS W6XL10CM PORCINE REGEN TISS MTRX PLIABLE,SUP-2112975,CDM,Q4130,HCPCS,0636,RC,,,,both,,,6179.52,4016.69,,,,,,,,,,,,,
SCREW INTFR L20MM DIA8MM OPN ARCHITECTURE DSGN BIOSURE,SUP-2341916,CDM,C1713,HCPCS,0278,RC,,,,both,,,1160.54,754.35,,,,,,,,,,,,,
SCREW BNE LCK 2.7X22 MM CORTICAL NS,SUP-2423257,CDM,C1713,HCPCS,0278,RC,,,,both,,,350.42,227.77,,,,,,,,,,,,,
CATHETER HD STR 12 FRX20 CM SHT TERM SLIM KT NIAG,SUP-2126490,CDM,C1752,HCPCS,0278,RC,,,,both,,,386.22,251.04,,,,,,,,,,,,,
COLLAR CERV AND PD SET CAPITAL ENH,SUP-2336001,CDM,L0174,HCPCS,0274,RC,,,,both,,,112.88,73.37,,,,,,,,,,,,,
RESECTOR PHLEBECTOMY DEV DIA 5.5 MM DISP PHASTIPP,SUP-2908886,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5020.86,3263.56,,,,,,,,,,,,,
SCREW BNE L 145 MM DIA 8 MM THRD L 40 MM SS ST SD CANN RVS,SUP-2900875,CDM,C1713,HCPCS,0278,RC,,,,both,,,1351.11,878.22,,,,,,,,,,,,,
INTRODUCER SHTH 0.018 IN 6 FRX20 CM 21 GAX15 CM SS TROCAR,SUP-2303020,CDM,C1894,HCPCS,0272,RC,,,,both,,,192.73,125.27,,,,,,,,,,,,,
GUIDEWIRE SURG L150MM DIA1.2MM NICKEL CHROM SMOOTH SGL END,SUP-2321618,CDM,C1713,HCPCS,0278,RC,,,,both,,,87.92,57.15,,,,,,,,,,,,,
BIT DRL DIA43MM LNG 2IN1 AO FOR HALLU LOCK MTP ARTH SYS,SUP-2242918,CDM,2720000010,LOCAL,0272,RC,,,,both,,,869.59,565.23,,,,,,,,,,,,,
SPLINT WRST SM L6IN R CANVS LACE UP FIRM SUPP REM MAL PALMAR,SUP-2194831,CDM,L3908,HCPCS,0272,RC,,,,both,,,29.36,19.08,,,,,,,,,,,,,
PLATE BNE FUSION LT ANTR ANK 9 HOLE CONSTRUCT,SUP-2609569,CDM,C1713,HCPCS,0278,RC,,,,both,,,6163.76,4006.44,,,,,,,,,,,,,
COLLAR CERV ADJ CHIN CUP THERMOPLASTIC,SUP-2388133,CDM,L0150,HCPCS,0274,RC,,,,both,,,295.82,192.28,,,,,,,,,,,,,
PLATE BNE K MINI 2/2.5X1 MM RT SUBCONDYLAR 9 HOLE LCK TI NS,SUP-2463650,CDM,C1713,HCPCS,0278,RC,,,,both,,,2707.75,1760.04,,,,,,,,,,,,,
SCREW BNE LCK 4X27.5 MM STRL IMN,SUP-2467277,CDM,C1713,HCPCS,0278,RC,,,,both,,,967.12,628.63,,,,,,,,,,,,,
HC Cul Bact Quan Aerobic Isol Xcpt UR Blood/Stool,PX-3068707100,CDM,87071,CPT,0306,RC,,,,both,,,289.00,187.85,,,,,,,,,,,,,
POST EXT FIX 3 HOLE W/O THRD ATTCH,SUP-2749942,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1215.18,789.87,,,,,,,,,,,,,
HC Blood Occult Fecal Hgb Deter Ia Qual Feces 1-3,PX-3018227400,CDM,82274,CPT,0301,RC,,,,both,,,89.00,57.85,,,,,,,,,,,,,
ELECTRODE ELECSURG CUT LOOP 30 DEG 28 FR 0.35 IN MONOPOLAR,SUP-2457480,CDM,2720000010,LOCAL,0272,RC,,,,both,,,391.21,254.29,,,,,,,,,,,,,
STAPLE CARTRIDGE STR 16X10 MM TI,SUP-2166812,CDM,C1713,HCPCS,0278,RC,,,,both,,,445.88,289.82,,,,,,,,,,,,,
PLASMA-LYTE A IV SOLN,RX-6331,CDM,2580000003,HCPCS,0250,RC,65219-0389-10,NDC,,both,1000,ML,80.50,52.32,,,,,,,,,,,,,
SYSTEM THROMCTMY POUNCE L 135 CM DIA 7 FR GUIDEWIRE 0.018 IN,SUP-2913918,CDM,C1757,HCPCS,0272,RC,,,,both,,,14130.00,9184.50,,,,,,,,,,,,,
BLADE RETRACTOR 64 MM HIP FIX STRT CUPX,SUP-2242469,CDM,2720000010,LOCAL,0272,RC,,,,both,,,737.90,479.63,,,,,,,,,,,,,
STEM FEM SZ 0 CO CHROM NP OFFSET NATURAL-HIP,SUP-2210871,CDM,C1776,CPT,0278,RC,,,,both,,,9470.24,6155.66,,,,,,,,,,,,,
VALVE CSF FLO CTRL ULTRA SM LOW-LOW MED PRESSURE DELT,SUP-2629161,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2064.61,1342.00,,,,,,,,,,,,,
ROD LNG FOR PREFIX FIX 125MM,SUP-2316291,CDM,C1713,HCPCS,0278,RC,,,,both,,,391.37,254.39,,,,,,,,,,,,,
SHEET CRAN W50XL50MM THK0.8MM RAP RESRB FOR 1.5MM SCR FIX,SUP-2194076,CDM,C1781,HCPCS,0278,RC,,,,both,,,3567.35,2318.78,,,,,,,,,,,,,
PLATE BNE 5 H LT OBLQ T2,SUP-2899032,CDM,C1713,HCPCS,0278,RC,,,,both,,,2581.87,1678.22,,,,,,,,,,,,,
PLATE BNE L98MM THK3.4MM 7 H BILAT S STL STR LOK COMPR FOR,SUP-2185135,CDM,C1713,HCPCS,0278,RC,,,,both,,,871.70,566.60,,,,,,,,,,,,,
PLEDGET VASCULAR 3X6MM OVAL SOFT,SUP-2427113,CDM,C1768,CPT,0278,RC,,,,both,,,106.48,69.21,,,,,,,,,,,,,
BLADE OPHTH DIA3MM PHACO ANG CRESC PNT DEL SATIN SLT BLDE,SUP-2110065,CDM,C1776,CPT,0278,RC,,,,both,,,73.79,47.96,,,,,,,,,,,,,
PLATE BNE L36MM 6 H TI DYN LOK COMPR FOR 2MM SCR MOD HND,SUP-2191480,CDM,C1713,HCPCS,0278,RC,,,,both,,,1200.27,780.18,,,,,,,,,,,,,
DEXRAZOXANE HCL 500 MG IV SOLR|DISCARDED DRUG NOT ADMINISTE,RX-145117,CDM,J1190,HCPCS,0636,RC,72611-0716-01,NDC,JW,both,1,UN,548.10,356.26,,,,,,,,,,,,,
BIT DRL CANN 11 MM KNEE SINGLE FLUT MTO,SUP-2849087,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2238.82,1455.23,,,,,,,,,,,,,
BAG TISS CLSR DIA3CM TRNSPAR SIL SILO SPR LD PROX OPN SFT,SUP-2134677,CDM,C1713,HCPCS,0278,RC,,,,both,,,1152.38,749.05,,,,,,,,,,,,,
RAVULIZUMAB-CWVZ 300 MG/3ML IV SOLN,RX-152086,CDM,J1303,HCPCS,0636,RC,25682-0025-01,NDC,,both,3,ML,19269.70,12525.30,,,,,,,,,,,,,
BLADE SURG AGGRESSIVE XL 4.2 MM + STRL FMS VUE DISP,SUP-2637154,CDM,2720000010,LOCAL,0272,RC,,,,both,,,320.28,208.18,,,,,,,,,,,,,
ALLOGRAFT HUM TISS ACHILLES TEND FRZN W/ BNE NO-RAD,SUP-2321828,CDM,C1762,CPT,0278,RC,,,,both,,,5636.30,3663.59,,,,,,,,,,,,,
AM PICC SET: 1-L 4.5FRX55CM 80CM HYDRO,SUP-2827501,CDM,C1751,HCPCS,0278,RC,,,,both,,,422.64,274.72,,,,,,,,,,,,,
PLATE BNE L90MM 6 H ST POSTEROLATERAL DST TIB S STL T SHP,SUP-2177709,CDM,C1713,HCPCS,0278,RC,,,,both,,,3195.39,2077.00,,,,,,,,,,,,,
ALLOGRAFT BNE GRND 15 CC FD IRRADIATED CANC,SUP-2867068,CDM,C1762,CPT,0278,RC,,,,both,,,912.80,593.32,,,,,,,,,,,,,
EXTENSION POST 6+ MM TI HUMELOCK II,SUP-2741762,CDM,2720000010,LOCAL,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
PLATE BNE L262MM 14 H NONSTERILE R MED DST TIB S STL VAR ANG,SUP-2177648,CDM,C1713,HCPCS,0278,RC,,,,both,,,6405.95,4163.87,,,,,,,,,,,,,
BEVACIZUMAB-BVZR 100 MG/4ML IV SOLN,RX-148790,CDM,Q5118,HCPCS,0636,RC,00069-0315-01,NDC,,both,4,ML,1766.60,1148.29,,,,,,,,,,,,,
SHAFT RMR L510MM OD8MM IM FEM MOD TRINKLE NONSTERILE BIXCUT,SUP-2368273,CDM,C1713,HCPCS,0278,RC,,,,both,,,1295.25,841.91,,,,,,,,,,,,,
STEM HUM DSTL 15X210 MM SHLDR AEQUALIS FLX REVIVE PTC,SUP-2715481,CDM,C1776,CPT,0278,RC,,,,both,,,30615.00,19899.75,,,,,,,,,,,,,
PROSTHESIS OSS 4X4X8 MM 5.7 MM RICHARDS CENTERED HA,SUP-2637876,CDM,L8613,CPT,0278,RC,,,,both,,,1214.65,789.52,,,,,,,,,,,,,
STENT GRFT VASC OVATION IX L 45 MM DIA PROX/DSTL 12/12,SUP-2217726,CDM,C1874,HCPCS,0278,RC,,,,both,,,13275.92,8629.35,,,,,,,,,,,,,
PATCH SYNTH ABD N ABSRB RECT EXP POLYTETRAFLUROETHYLENE 6CM,SUP-2395377,CDM,C1781,HCPCS,0278,RC,,,,both,,,562.06,365.34,,,,,,,,,,,,,
MESH SYN W20XL30CM 67% POLYGLY ACID 33% TRIMETHYLENE CRBNT,SUP-2395754,CDM,C1781,HCPCS,0278,RC,,,,both,,,12660.48,8229.31,,,,,,,,,,,,,
HC Pulse Ox Multiple Determine,PX-4609476100,CDM,94761,CPT,0460,RC,,,,outpatient,,,406.00,263.90,,,,,,,,,,,,,
GUIDEWIRE VASC HIWIRE L 150 CM 0.038 IN TAPR L 15 CM STR,SUP-2170343,CDM,C1769,HCPCS,0272,RC,,,,both,,,531.19,345.27,,,,,,,,,,,,,
BLADE CARTILAGE CHISEL MENEZES MST,SUP-2494245,CDM,2720000010,LOCAL,0272,RC,,,,both,,,538.86,350.26,,,,,,,,,,,,,
LINER ACET CUP PRI SNAP IN MTL ON POLY POLYETH 50MM-54MM OD 00612005032] ZIMMER BIOMET INC],SUP-2202175,CDM,C1776,CPT,0278,RC,,,,both,,,4176.20,2714.53,,,,,,,,,,,,,
PLATE BNE W7XL34MM THK1MM 3 H R S STL L OBLQ NEUT MAL LOK,SUP-2186086,CDM,C1713,HCPCS,0278,RC,,,,both,,,947.18,615.67,,,,,,,,,,,,,
SCREW SET M4X0.75 MM RND TIP 2.5 MM HEX PROTEX CT,SUP-2593143,CDM,C1713,HCPCS,0278,RC,,,,both,,,100.48,65.31,,,,,,,,,,,,,
PLATE BNE ORBIT FLR 1.5X0.2 MM MESHED BOWLE SHP TI GLD STRL,SUP-2485830,CDM,C1713,HCPCS,0278,RC,,,,both,,,1265.42,822.52,,,,,,,,,,,,,
CASSETTE EXPIRATORY SERVO-N,SUP-2747090,CDM,C1713,HCPCS,0278,RC,,,,both,,,2743.58,1783.33,,,,,,,,,,,,,
CONFORMER OPHTH STR SM,SUP-2236371,CDM,L8610,HCPCS,0278,RC,,,,both,,,200.96,130.62,,,,,,,,,,,,,
CATHETER HEMO DYLS OR HD SET AG LNG TERM ACC 15FRX42CM,SUP-2120628,CDM,C1750,HCPCS,0278,RC,,,,both,,,825.82,536.78,,,,,,,,,,,,,
CATHETER EP D 6 MM 20 MMX7 FRX115 CM DUO,SUP-2465282,CDM,C1732,HCPCS,0272,RC,,,,both,,,8245.64,5359.67,,,,,,,,,,,,,
SURGICAL PROCEDURE PACK 6 FR INSPIRE,SUP-2265138,CDM,C1713,HCPCS,0278,RC,,,,both,,,1859.67,1208.79,,,,,,,,,,,,,
SUTURE NONABSORBABLE MONOFILAMENT 7-0 BV1756 4X24 IN PRONOVA M3735,SUP-2219569,CDM,C1713,HCPCS,0278,RC,,,,both,,,372.62,242.20,,,,,,,,,,,,,
SALINE SPRAY 0.65 % NA SOLN,RX-14469,CDM,6370000000,HCPCS,0637,RC,00225-0380-80,NDC,,both,50,ML,9.50,6.17,,,,,,,,,,,,,
ENDPLATE SPNL DISK L12MM 14X16MM FOOTPRINT 7DEG VERT BODY,SUP-2420874,CDM,C1889,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
AUGMENT FEM L55MM THK6MM LT MEDL RT LAT DSTL KNEE CONSTRN,SUP-2405614,CDM,C1776,CPT,0278,RC,,,,both,,,2386.40,1551.16,,,,,,,,,,,,,
STRAP ELBW TENNIS UNIV FOAM D RNG,SUP-2336255,CDM,L3702,HCPCS,0274,RC,,,,both,,,9.70,6.30,,,,,,,,,,,,,
ARCOS 17X150MM SPL TPR DIST,SUP-2505998,CDM,C1776,CPT,0278,RC,,,,both,,,7812.32,5078.01,,,,,,,,,,,,,
TEMPLATE SZ SALVATION,SUP-2401126,CDM,2720000010,LOCAL,0272,RC,,,,both,,,499.26,324.52,,,,,,,,,,,,,
SCREW SPNL DIA14MM DISTRCTN SHADOW LN,SUP-2161614,CDM,C1713,HCPCS,0278,RC,,,,both,,,103.62,67.35,,,,,,,,,,,,,
BONE BPSY NDLE CMPTBLE WTH 11 G 10 CM KTS/NDLS 13 G,SUP-2479587,CDM,2720000010,LOCAL,0272,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
BIT DRILL JUGGERKNOT RIGID LNG,SUP-2589271,CDM,2720000010,LOCAL,0272,RC,,,,both,,,316.51,205.73,,,,,,,,,,,,,
COMPONENT FEM PAT PFJ L W OXINIUM AND RND,SUP-2347993,CDM,C1776,CPT,0278,RC,,,,both,,,9420.00,6123.00,,,,,,,,,,,,,
PACEMAKER CARD 10.4ML W50XH47MM THK6MM IS-1 CONN SGL CHMBR,SUP-2356454,CDM,C1786,HCPCS,0275,RC,,,,both,,,9420.00,6123.00,,,,,,,,,,,,,
HC OP Psych Tx 60 Min,PX-9149083702,CDM,90837,CPT,0914,RC,,,,both,,,470.00,305.50,,,,,,,,,,,,,
SCREW INTRF L20MM DIA9MM TIB RETROSCR,SUP-2121347,CDM,C1713,HCPCS,0278,RC,,,,both,,,872.92,567.40,,,,,,,,,,,,,
BLADE SAW SAG 70X13X1.47 MM SYS 6 STRL PERF SER LTX,SUP-2862543,CDM,2720000010,LOCAL,0272,RC,,,,both,,,374.92,243.70,,,,,,,,,,,,,
KNEE IMMOB 22IN QUAL + L,SUP-2195533,CDM,L1830,CPT,0274,RC,,,,both,,,61.32,39.86,,,,,,,,,,,,,
"HC Gbl Est Pt, E/M Level 3|RESIDENT/TEACHING PHYS SERV",PX-9829921300,CDM,99213,CPT,0982,RC,,,GC,outpatient,,,393.00,255.45,,,,,,,,,,,,,
HC So Hhv-6 Dna Quant,PX-3068753366,CDM,87533,CPT,0306,RC,,,,both,,,268.00,174.20,,,,,,,,,,,,,
BUR ENDOSCP SHAVER 15 DEG DIA2.9 MM SPD 6000 RPM CRV DIAMOND,SUP-2901928,CDM,2720000010,LOCAL,0272,RC,,,,both,,,989.73,643.32,,,,,,,,,,,,,
MICONAZOLE NITRATE 200 MG VA SUPP,RX-10604,CDM,6370000000,HCPCS,0637,RC,00472-1738-03,NDC,,both,1,UN,71.70,46.60,,,,,,,,,,,,,
HALF RING-SBF 100MM,SUP-2818185,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4446.87,2890.47,,,,,,,,,,,,,
RESERVOIR EXT DRNGE NEO L10MM DIA4MM FLD 01ML BTM INLET CONN,SUP-2277916,CDM,C1889,HCPCS,0278,RC,,,,both,,,853.14,554.54,,,,,,,,,,,,,
SALINE SPRAY 0.65 % NA SOLN,RX-14469,CDM,6370000000,HCPCS,0637,RC,00904-3865-75,NDC,,both,44,ML,4.20,2.73,,,,,,,,,,,,,
ANCHOR N SUT FIX 1.1 MM SZ 13 MM LEN W/O LOOP MENIS CNTOUR,SUP-2166729,CDM,C1776,CPT,0278,RC,,,,both,,,441.61,287.05,,,,,,,,,,,,,
HC Surgery Level 2 Addtl 15min,PX-3600000012,CDM,3600000012,LOCAL,0360,RC,,,,both,,,1930.00,1254.50,,,,,,,,,,,,,
PLATE BNE FEM 3.5X182 MM LT DSTL PROX 6 HOLE STRL VALCP,SUP-2789593,CDM,C1713,HCPCS,0278,RC,,,,both,,,4433.99,2882.09,,,,,,,,,,,,,
CABLE ORTHOT HIP KNEE ANK PELV CUST TORSION,SUP-2435641,CDM,L2050,LOCAL,0274,RC,,,,both,,,1379.62,896.75,,,,,,,,,,,,,
BLADE SURG FOR ADENOTOMES WT540601,SUP-2649904,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1126.79,732.41,,,,,,,,,,,,,
PROBE 2 CHAN PH PRB F/ ACID REFLX COMFORTEC M11 18CM DISP,SUP-2336772,CDM,2720000010,LOCAL,0272,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
LOSARTAN POTASSIUM-HCTZ 100-25 MG PO TABS,RX-24384,CDM,6370000000,HCPCS,0637,RC,00093-7368-98,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
TUBE VENT 1.27 MM 2.45 MM 2.35 MM TRIUNE TRMPT SIL 510301,SUP-2472217,CDM,L8699,HCPCS,0278,RC,,,,both,,,49.39,32.10,,,,,,,,,,,,,
SCREW BONE SELF DRL MINI TI NS 2.0MMX7MM MAXDRIVE,SUP-2262881,CDM,C1713,HCPCS,0278,RC,,,,both,,,154.80,100.62,,,,,,,,,,,,,
SUPPORT ORTHOT CUST SOLE WDG BTWN,SUP-2435723,CDM,L3370,HCPCS,0272,RC,,,,both,,,140.42,91.27,,,,,,,,,,,,,
GRAFT VASC HEMSHLD PLAT L 60 CM 24MM POLYESTER BOV CLLGN STR,SUP-2265929,CDM,C1768,CPT,0278,RC,,,,both,,,2348.72,1526.67,,,,,,,,,,,,,
COMPONENT FEM CRUC RET ASYM RT SZ 1 LOGIC,SUP-2220840,CDM,C1776,CPT,0278,RC,,,,both,,,17169.52,11160.19,,,,,,,,,,,,,
"HC So1 Cult,Pathognic Orgnsms,Screen",PX-3008708167,CDM,87081,CPT,0300,RC,,,,both,,,399.00,259.35,,,,,,,,,,,,,
PLATE BONE BROAD 4.5X375 MM 20 HOLE,SUP-2837424,CDM,C1713,HCPCS,0278,RC,,,,both,,,4660.07,3029.05,,,,,,,,,,,,,
MESH PTCH MK W POSIFLEX OVL 35 IN X 5 IN M,SUP-2126070,CDM,C1781,HCPCS,0278,RC,,,,both,,,412.91,268.39,,,,,,,,,,,,,
PLATE BNE MESHED LG RT CALCANEAL LCK NS A.L.P.S,SUP-2465006,CDM,C1713,HCPCS,0278,RC,,,,both,,,2997.07,1948.10,,,,,,,,,,,,,
BIT DRILL 2.8MM X 165MM STRL SYNTHES 310.288S,SUP-2849040,CDM,2720000010,LOCAL,0272,RC,,,,both,,,337.11,219.12,,,,,,,,,,,,,
BIT DRL NANOTACK,SUP-2608553,CDM,2720000010,LOCAL,0272,RC,,,,both,,,605.55,393.61,,,,,,,,,,,,,
VALVE AORT ON-X TISS ANNULUS 25 MM ORIFICE 23.4 MM STD,SUP-2484841,CDM,C1713,HCPCS,0278,RC,,,,both,,,15696.86,10202.96,,,,,,,,,,,,,
CANNULA SUCTION 360 DEG 3 MMX30 CM 8 MM FLARED MERCED PAL,SUP-2760841,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1051.90,683.73,,,,,,,,,,,,,
DRAIN WND POLY VYN CHL FIRM TRCR MID PERF L5IN OD9FR,SUP-2197888,CDM,C1729,HCPCS,0272,RC,,,,both,,,240.68,156.44,,,,,,,,,,,,,
GRAFT BNE 10 CC SUBSTITUTE ACTIFUSE,SUP-2129867,CDM,C1713,HCPCS,0278,RC,,,,both,,,3887.32,2526.76,,,,,,,,,,,,,
LENS IO +110 DIOPT L13MM DIA65MM A CONSTANT 1189 10DEG,SUP-2110359,CDM,V2632,HCPCS,0276,RC,,,,both,,,486.70,316.35,,,,,,,,,,,,,
STENT URET L 28 CM DIA 8 FR TIP L 3 CM ZIPWIRE 0.038 IN,SUP-2722598,CDM,C2617,HCPCS,0278,RC,,,,both,,,413.76,268.94,,,,,,,,,,,,,
CATHETER DIL BAL L16MM DIA5MM SINUS RELIEVA SOLO PRO,SUP-2106311,CDM,C1726,HCPCS,0272,RC,,,,both,,,2147.76,1396.04,,,,,,,,,,,,,
SUPPORT ORTHOT CERV THOR LUMBAR SACR CUST MILWAUKEE INIT,SUP-2435568,CDM,L1000,HCPCS,0274,RC,,,,both,,,5740.92,3731.60,,,,,,,,,,,,,
RAMUCIRUMAB 500 MG/50ML IV SOLN,RX-125955,CDM,J9308,HCPCS,0636,RC,00002-7678-01,NDC,,both,50,ML,21611.40,14047.41,,,,,,,,,,,,,
VALVE MITRL MECH EXPAND MSTR SER,SUP-2356720,CDM,C1889,HCPCS,0278,RC,,,,both,,,17659.36,11478.58,,,,,,,,,,,,,
ROD IM OD5/16IN FEM W/T-HANDLE,SUP-2365122,CDM,C1713,HCPCS,0278,RC,,,,both,,,1158.66,753.13,,,,,,,,,,,,,
AUGMENT TIB SZ 4 THK10MM R MED L LAT KNEE CO CHROM TOT STBL,SUP-2373568,CDM,C1776,CPT,0278,RC,,,,both,,,1840.32,1196.21,,,,,,,,,,,,,
GRAFT ALLGRFT DERM ACELLULAR HYDRATED THCK HUM TISS 5CM,SUP-2307473,CDM,Q4128,HCPCS,0636,RC,,,,both,,,5553.78,3609.96,,,,,,,,,,,,,
GORE PRECL VES GRD SZ 5 CMX6 CM,SUP-2395508,CDM,C1768,CPT,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
SURFACE ARTC SZ 1-2 THK23MM AP40MM ML58MM UNIV ANTR UHMWPE,SUP-2208695,CDM,C1776,CPT,0278,RC,,,,both,,,2185.44,1420.54,,,,,,,,,,,,,
SLING GYN MESH CONTINENCE SYS POLYPR BLU DESARA,SUP-2152276,CDM,C1771,HCPCS,0278,RC,,,,both,,,3265.60,2122.64,,,,,,,,,,,,,
STENT ENDOPROS L2.5CM DIA8MM CATH 8FR L75CM BAL DIA8MM,SUP-2396561,CDM,C1874,HCPCS,0278,RC,,,,both,,,8697.80,5653.57,,,,,,,,,,,,,
PLATE BNE MINI MAXLOCK EXTRM CLVRLF,SUP-2401266,CDM,C1713,HCPCS,0278,RC,,,,both,,,2932.76,1906.29,,,,,,,,,,,,,
SCREW BNE L17MM OD23MM X DRV TI EMGCY SELF RET,SUP-2262813,CDM,C1713,HCPCS,0278,RC,,,,both,,,213.43,138.73,,,,,,,,,,,,,
CATHETER VENTRICULAR DRAINAGE PEDIATRIC SMALL L180MM WITH ST,SUP-2825902,CDM,C1729,HCPCS,0272,RC,,,,both,,,977.70,635.50,,,,,,,,,,,,,
CAGE APR REINF RT 50MM,SUP-2137268,CDM,C1889,HCPCS,0278,RC,,,,both,,,72.22,46.94,,,,,,,,,,,,,
SCREW HEADLESS DART FIRE EDGE 3.0 X30MM,SUP-2855463,CDM,C1713,HCPCS,0278,RC,,,,both,,,1865.16,1212.35,,,,,,,,,,,,,
SCREW BNE L10MM OD3.2MM CORT NONCANNULATED NONLOCKING THRD,SUP-2397519,CDM,C1713,HCPCS,0278,RC,,,,both,,,219.80,142.87,,,,,,,,,,,,,
PLUG HERN SM W1XL1.35IN INGUINAL POLYPR REP PRESHAPED ONLAY,SUP-2125754,CDM,C1781,HCPCS,0278,RC,,,,both,,,389.67,253.29,,,,,,,,,,,,,
CATHETER DIAG L65CM OD0.063X0.05IN TIP OD3.1FR 50MM SPC,SUP-2353135,CDM,C1887,HCPCS,0272,RC,,,,both,,,524.38,340.85,,,,,,,,,,,,,
STENT URET 6FR L26CM 0.038IN 360DEG HYDRPHLC SOF-CURL,SUP-2313809,CDM,C2617,HCPCS,0278,RC,,,,both,,,317.14,206.14,,,,,,,,,,,,,
STAPLER INT CIR XLN X THCK 33 MM 4/4.5/5 MM TRI-STAPLE EEA,SUP-2858018,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5308.70,3450.65,,,,,,,,,,,,,
GUIDEWIRE ORTH L300MM DIA2.8MM S STL THRD SHRP TRCR TIP FOR,SUP-2186893,CDM,C1769,HCPCS,0272,RC,,,,both,,,112.13,72.88,,,,,,,,,,,,,
IMPL CAPPED H4 HEMI UNI/BIPOLAR EXACTECH,SUP-2435984,CDM,C1776,CPT,0278,RC,,,,both,,,6280.00,4082.00,,,,,,,,,,,,,
PLATE BNE L168MM 8 H ST R MED DST TIB S STL LOK COMPR FOR,SUP-2185587,CDM,C1713,HCPCS,0278,RC,,,,both,,,5037.44,3274.34,,,,,,,,,,,,,
PLATE BONE L120MM 8 H STRL LT ANTEROLATERAL DSTL TIB S STL,SUP-2349731,CDM,C1713,HCPCS,0278,RC,,,,both,,,12624.84,8206.15,,,,,,,,,,,,,
HC 1st Deg Burn Trtmnt,PX-4501600000,CDM,16000,CPT,0450,RC,,,,both,,,214.00,139.10,,,,,,,,,,,,,
GRAFT BNE SUB 15CC CA PHSPTE HA PTTY INJ HYDROSET,SUP-2366073,CDM,C1713,HCPCS,0278,RC,,,,both,,,14460.64,9399.42,,,,,,,,,,,,,
HC So Estrogens Total,PX-3018267266,CDM,82672,CPT,0301,RC,,,,outpatient,,,366.00,237.90,,,,,,,,,,,,,
TUBE EXT FIX HUM T2,SUP-2496956,CDM,2720000010,LOCAL,0272,RC,,,,both,,,632.71,411.26,,,,,,,,,,,,,
SCREW BNE SEMICONSTRAINED 4.5X45 MM WRST LCK CAP STRL FRDM,SUP-2852947,CDM,C1713,HCPCS,0278,RC,,,,both,,,1503.12,977.03,,,,,,,,,,,,,
CATHETER CV BEDSIDE SET 018 5 FRX60 CM 1 LUMEN TURBO-JECT,SUP-2759939,CDM,C1751,HCPCS,0278,RC,,,,both,,,328.38,213.45,,,,,,,,,,,,,
PLATE BNE TIBIOTALOCALCANEAL FUSION NS LTX,SUP-2857132,CDM,C1713,HCPCS,0278,RC,,,,both,,,9498.50,6174.02,,,,,,,,,,,,,
COMPONENT HIP CEM STD LNR XLPE,SUP-2212721,CDM,C1776,CPT,0278,RC,,,,both,,,6908.00,4490.20,,,,,,,,,,,,,
DRESSING BIO COVERAGE AREA 85 SQ CM 500 MG PORCINE SM INTEST,SUP-2905489,CDM,Q4102,HCPCS,0636,RC,,,,both,,,3751.52,2438.49,,,,,,,,,,,,,
CURVED BAR 500MM,SUP-2720980,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1956.06,1271.44,,,,,,,,,,,,,
"HC US Transvaginal, Non OB",PX-4027683000,CDM,76830,CPT,0402,RC,,,,both,,,1439.00,935.35,,,,,,,,,,,,,
TOOL IMPL FASTAC FLX LD,SUP-2138084,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1491.50,969.47,,,,,,,,,,,,,
FIXATOR EXT CALCNL OSTEOTMY MINIRAIL,SUP-2316505,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4392.61,2855.20,,,,,,,,,,,,,
STEM FEM 04 L250MM OD20X16.5MM TILASTAN MICROPOROUS HIP,SUP-2397014,CDM,C1776,CPT,0278,RC,,,,both,,,7300.50,4745.32,,,,,,,,,,,,,
STENT VASC SELF EXPANDABLE 7X120 MM 6 FRX75 CM EPIC,SUP-2138746,CDM,C1876,HCPCS,0278,RC,,,,both,,,4082.00,2653.30,,,,,,,,,,,,,
PLATE BNE L103MM THK3.8MM 6 H BILAT S STL NAR DYN COMPR FOR,SUP-2185206,CDM,C1713,HCPCS,0278,RC,,,,both,,,1176.87,764.97,,,,,,,,,,,,,
COLLAR CERV SM H425IN POLY FOAM PLAS SUPP TWO PC CA PROCARE,SUP-2196883,CDM,L0172,HCPCS,0274,RC,,,,both,,,42.42,27.57,,,,,,,,,,,,,
COMPONENT TOT ANK NEUT 1 9 MM POLYETH VIT E APEX 3D,SUP-2742164,CDM,C1776,CPT,0278,RC,,,,both,,,6633.25,4311.61,,,,,,,,,,,,,
MICROCATHETER DIAG FASTRACKER 325 TRANSEND L 105 CM DIA 3 FR,SUP-2148475,CDM,C1887,HCPCS,0272,RC,,,,both,,,1843.24,1198.11,,,,,,,,,,,,,
SCREW BONE L3.5MM DIA1.6MM TI SELF DRL CRUC FOR CRAN PLATING,SUP-2280075,CDM,C1713,HCPCS,0278,RC,,,,both,,,176.37,114.64,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 20 CM DIA 7 MM STR STD WALL HELIX,SUP-2461259,CDM,C1768,CPT,0278,RC,,,,both,,,583.95,379.57,,,,,,,,,,,,,
PLATE BNE CRV 310X11X1 MM MESH STRP SM GRID PDLLA STRL LF,SUP-2457108,CDM,C1713,HCPCS,0278,RC,,,,both,,,12556.45,8161.69,,,,,,,,,,,,,
STENT GRFT VASC TAG L 10 CM DIA PROX/DSTL 34/34 MM NIT,SUP-2396402,CDM,C1768,CPT,0278,RC,,,,both,,,48670.00,31635.50,,,,,,,,,,,,,
MESH SURG 170X138X1 MM 3D TI STRL LEVEL 1 NEURO ULTRAONE,SUP-2486320,CDM,C1713,HCPCS,0278,RC,,,,both,,,14157.63,9202.46,,,,,,,,,,,,,
PLATE BNE W10XL57MM THK1.5MM 4X3 H BILAT S STL T SHP R ANG,SUP-2185868,CDM,C1713,HCPCS,0278,RC,,,,both,,,902.78,586.81,,,,,,,,,,,,,
CEMENT BNE GENTAMICIN 40 GM SMARTSET GMV,SUP-2253085,CDM,C1713,HCPCS,0278,RC,,,,both,,,533.80,346.97,,,,,,,,,,,,,
SET CATH BILI DRN DSTL LOOP 12FR HYDRPHLC COAT W/ STD LCK,SUP-2141085,CDM,C1729,HCPCS,0272,RC,,,,both,,,230.70,149.95,,,,,,,,,,,,,
CAGE SPNL W10XH8XL28MM 5DEG ANTR THORLUM C FBR REINF,SUP-2254812,CDM,C1889,HCPCS,0278,RC,,,,both,,,12528.60,8143.59,,,,,,,,,,,,,
DRAIN SURG L0.375IN SIL CHN FLAT FULL FLOATED RADPQ CLS WND,SUP-2127327,CDM,C1729,HCPCS,0272,RC,,,,both,,,42.61,27.70,,,,,,,,,,,,,
ELECTRODE CORTICAL 2 X 6 KT STRL DISP EVO,SUP-2934977,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3567.04,2318.58,,,,,,,,,,,,,
BURR SURG 1MM DIA HD MIC CARBIDE SM BNE RND FLUTEX6 MICROPOW,SUP-2605577,CDM,2720000010,LOCAL,0272,RC,,,,both,,,143.59,93.33,,,,,,,,,,,,,
PLATE BNE W10.3XL98.6MM THK3.7MM 7 H TI LOK COMPR LO PROF,SUP-2413707,CDM,C1713,HCPCS,0278,RC,,,,both,,,690.80,449.02,,,,,,,,,,,,,
BOLT EXT FIX SLT WIRE DISP RINGFIX,SUP-2378775,CDM,C1713,HCPCS,0278,RC,,,,both,,,167.21,108.69,,,,,,,,,,,,,
WALKER LEG DLX BLK SHT L,SUP-2276713,CDM,L4387,HCPCS,0274,RC,,,,both,,,87.64,56.97,,,,,,,,,,,,,
MATRIX BIO L 4 X W 4 CM SZ 29 SQCM FISH SKIN DERMAL BX/5,SUP-2909374,CDM,Q4158,HCPCS,0636,RC,,,,both,,,4719.42,3067.62,,,,,,,,,,,,,
PLATE BNE L211MM 12 H ST L PROX ULN EXTRA ARTC S STL LO,SUP-2177211,CDM,C1713,HCPCS,0278,RC,,,,both,,,4098.52,2664.04,,,,,,,,,,,,,
PLATE BNE STRNL 2.3X53X19X1.8 MM THOR 18 HOLE LADDER LEVEL 1,SUP-2869268,CDM,C1713,HCPCS,0278,RC,,,,both,,,2135.29,1387.94,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 25X55 MM FD PERIO FASC LATA ORAGRAFT,SUP-2740898,CDM,C1762,CPT,0278,RC,,,,both,,,463.78,301.46,,,,,,,,,,,,,
CATHETER REPROC ULTRASOUND 9 FR VIEWFLEX XTRA ICE,SUP-2763557,CDM,C1759,HCPCS,0272,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
PLATE BONE RT ANTR ANK FUS SLIM ALIGNX,SUP-2417727,CDM,C1713,HCPCS,0278,RC,,,,both,,,7287.94,4737.16,,,,,,,,,,,,,
CROWN DENT AD SZ DLL7 RT LO 1ST PRI M S STL REPL THCK,SUP-2238869,CDM,D6783,CPT,0278,RC,,,,both,,,19.78,12.86,,,,,,,,,,,,,
PLATE BONE THK1.6MM 16 H MAND TI STR FOR 2/2.3MM SCR,SUP-2136792,CDM,C1713,HCPCS,0278,RC,,,,both,,,2678.42,1740.97,,,,,,,,,,,,,
MESH CRAN 135X90 MM 0.6 MM PLATE PROF PANEL OBLONG CP TI,SUP-2488057,CDM,C1713,HCPCS,0278,RC,,,,both,,,5510.57,3581.87,,,,,,,,,,,,,
GUIDEWIRE VASC L260CM DIA0035IN TAPR L6CM S STL PTFE FIX COR,SUP-2167684,CDM,C1769,HCPCS,0272,RC,,,,both,,,60.88,39.57,,,,,,,,,,,,,
KIT INTRO PEELPRO L 14 CM DIA 8 FR PTFE TEARWY STD,SUP-2118931,CDM,C1894,HCPCS,0272,RC,,,,both,,,154.49,100.42,,,,,,,,,,,,,
PROBE CYBERWAND RENALBLDR EA,SUP-2313963,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1733.28,1126.63,,,,,,,,,,,,,
PIN GUIDE L 300 MM DIA1.9 MM NTHRD FOR CANN SCREW STRL DISP,SUP-2932939,CDM,C1713,HCPCS,0278,RC,,,,both,,,191.60,124.54,,,,,,,,,,,,,
PLATE BONE CRANIAL 6 HOLE STRAIGHT 25.9X3.4MM TITANIUM NEURO,SUP-2825990,CDM,C1713,HCPCS,0278,RC,,,,both,,,123.09,80.01,,,,,,,,,,,,,
PROPRANOLOL 0.1 MG/ML INJ SOLN (PED-NEO),RX-4090139,CDM,J1800,HCPCS,0636,RC,09999-9906-60,NDC,,both,1,UN,11.00,7.15,,,,,,,,,,,,,
COMPONENT FEM L5CM L DST KNEE RESURF ORTH SALV SYS,SUP-2405704,CDM,C1776,CPT,0278,RC,,,,both,,,18383.13,11949.03,,,,,,,,,,,,,
CATHETER HD LT 15.5 FRX23 CM SET W/ SIDE H STYL SYMETREX,SUP-2627449,CDM,C1750,HCPCS,0278,RC,,,,both,,,596.60,387.79,,,,,,,,,,,,,
NEEDLE SURGICAL L6.5IN CURVED DELICATE HOUSE,SUP-2806063,CDM,2720000010,LOCAL,0272,RC,,,,both,,,457.47,297.36,,,,,,,,,,,,,
ALLOGRAFT DERMAL 15X140X1.5 MM ACELLULAR DERMAL ARTHROFLEX,SUP-2740766,CDM,Q4125,HCPCS,0636,RC,,,,both,,,5044.41,3278.87,,,,,,,,,,,,,
PLATE BONE L113MM 7 H LT PROX LAT TIB TI FOR 3.5MM SCR,SUP-2418114,CDM,C1713,HCPCS,0278,RC,,,,both,,,4385.95,2850.87,,,,,,,,,,,,,
GRAFT BONE SUB 25X50X4MM 5ML STRP BIOLOGIC SPINE SURG,SUP-2232306,CDM,C9362,HCPCS,0278,RC,,,,both,,,2417.80,1571.57,,,,,,,,,,,,,
HC Irrig Drug Delivery Device,PX-9400652300,CDM,96523,CPT,0940,RC,,,,both,,,275.00,178.75,,,,,,,,,,,,,
KIT BASIC 4FRX18GAX65CM PICC AND INTRO SGL LUMN SIL W/,SUP-2120072,CDM,C1751,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
LEVEL NEURO ST MESH 3D ULTRNE NEURO SCRW49 MM DIA T06 MM CP,SUP-2707387,CDM,C1713,HCPCS,0278,RC,,,,both,,,1460.23,949.15,,,,,,,,,,,,,
ELECTRODE RF L160MM DIA35MM END EFF VAPR,SUP-2256719,CDM,2720000010,LOCAL,0272,RC,,,,both,,,872.92,567.40,,,,,,,,,,,,,
PLATE BNE W175XL170MM THK52MM 6 H ST L CNDYL FEM S STL LOK,SUP-2185017,CDM,C1713,HCPCS,0278,RC,,,,both,,,4513.91,2934.04,,,,,,,,,,,,,
DEFIBRILLATOR CRD BPLR 40 CC 81 GM ATR IS-1 ATLAS+ HF,SUP-2356581,CDM,C1882,HCPCS,0275,RC,,,,both,,,63525.34,41291.47,,,,,,,,,,,,,
PATCH HERN W12.5XL15.5CM 28-35MM STOMA OPN POLYPR W/ EXP,SUP-2126076,CDM,C1781,HCPCS,0278,RC,,,,both,,,3534.86,2297.66,,,,,,,,,,,,,
ELECTRODE 5CM 1M AUTOCLV THRMCPL SENS W/ LEADER CBL RF,SUP-2172176,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2276.50,1479.72,,,,,,,,,,,,,
RING STEM SUPP 18X10 MM TILASTAN,SUP-2423133,CDM,C1776,CPT,0278,RC,,,,both,,,2373.84,1543.00,,,,,,,,,,,,,
GUIDEWIRE VASC L 80 CM DIA 0.035 IN TAPR L 9.5 CM FLPY TIP L,SUP-2168541,CDM,C1769,HCPCS,0272,RC,,,,both,,,53.32,34.66,,,,,,,,,,,,,
TIP SURG MECHANOMYOGRAPHY BALL SS NS,SUP-2693681,CDM,2720000010,LOCAL,0272,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
PROSTHESIS OSS 2.3X1.5 MM 2.25X3.5 MM 1.45 MM DSTL END TI,SUP-2232505,CDM,L8613,CPT,0278,RC,,,,both,,,1342.98,872.94,,,,,,,,,,,,,
HC Peripheral Block - Sciatic Single W/Img,PX-3606444500,CDM,64445,CPT,0360,RC,,,,both,,,2230.00,1449.50,,,,,,,,,,,,,
INTRODUCER US ATEC,SUP-2239944,CDM,C1894,HCPCS,0272,RC,,,,both,,,50.24,32.66,,,,,,,,,,,,,
HC So Drvvt,PX-3058561366,CDM,85613,CPT,0305,RC,,,,both,,,116.00,75.40,,,,,,,,,,,,,
GRAFT BNE LORDTC 5 MM CERV MONOLITHIC CORTICAL ALLOQUENT,SUP-2601443,CDM,C1713,HCPCS,0278,RC,,,,both,,,2637.60,1714.44,,,,,,,,,,,,,
BAR EXTRNL FXTN 11MM DIA 380MML CRBN FIBER CRVD XTRFX,SUP-2722165,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1852.57,1204.17,,,,,,,,,,,,,
TM SHT FLANGE CAGE LT 66/68/70 SHELL/58 LINER,SUP-2503954,CDM,C1776,CPT,0278,RC,,,,both,,,7121.52,4628.99,,,,,,,,,,,,,
PLATE BONE 6 H CLAV LCK,SUP-2247333,CDM,C1713,HCPCS,0278,RC,,,,both,,,2006.46,1304.20,,,,,,,,,,,,,
CATHETER URET 4.8FR L70CM 8FR CONE TIP W/ OPN END FOR RG,SUP-2171240,CDM,C1758,HCPCS,0278,RC,,,,both,,,63.62,41.35,,,,,,,,,,,,,
SPLINT FA WRST PED 6 IN L,SUP-2336053,CDM,L3908,HCPCS,0274,RC,,,,both,,,14.79,9.61,,,,,,,,,,,,,
PERI-LOC 2.7MM S-T LOCK SCREW 16MM,SUP-2819077,CDM,C1713,HCPCS,0278,RC,,,,both,,,941.15,611.75,,,,,,,,,,,,,
IMPLANT DERM W50XL160MM CLLGN RECTANG SHT ALLOMAX,SUP-2125855,CDM,C1781,HCPCS,0278,RC,,,,both,,,6342.80,4122.82,,,,,,,,,,,,,
BRACE KNEE AD LG UNISX R MED HNG FASTEN ON OPN,SUP-2196476,CDM,L1852,HCPCS,0274,RC,,,,both,,,1212.07,787.85,,,,,,,,,,,,,
TUBE SET SONICONE SHARPVAC DISP (MIN ORDER 5),SUP-2423014,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1825.13,1186.33,,,,,,,,,,,,,
GRAFT BNE PTTY 5 CC SYR DBM ACCELL EVO3,SUP-2641761,CDM,C1713,HCPCS,0278,RC,,,,both,,,3179.25,2066.51,,,,,,,,,,,,,
CATHETER HD LT 10 FRX52 CM 18 CM ART CUF SET BIOFLX TESIO,SUP-2627153,CDM,C1750,HCPCS,0278,RC,,,,both,,,162.78,105.81,,,,,,,,,,,,,
PROBE ABLATN MICROWAVE 14 GAX270 MM AMICA,SUP-2303522,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7520.30,4888.19,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH FLX L 80 MM DIA26/28 MM,SUP-2168755,CDM,C1874,HCPCS,0278,RC,,,,both,,,6970.80,4531.02,,,,,,,,,,,,,
ALLOGRAFT HUM TISS FRZN IRRADIATED GRACILIS TEND 921748,SUP-2867183,CDM,C1762,CPT,0278,RC,,,,both,,,2285.92,1485.85,,,,,,,,,,,,,
GUIDEWIRE VASC VASSALLO GT L 300 CM DIA 0.014 IN COAT L 12,SUP-2909243,CDM,C1769,HCPCS,0272,RC,,,,both,,,539.04,350.38,,,,,,,,,,,,,
KIT CATH W/ 14GA 8IN POLYUR CTRL VEN CATH 0.032IN GWIRE SGL,SUP-2383983,CDM,C1751,HCPCS,0278,RC,,,,both,,,43.93,28.55,,,,,,,,,,,,,
DELIVERY SYS STENT NAVIFLEX RX DIA10 FR PLAS PANCREATIC,SUP-2149500,CDM,C2625,HCPCS,0278,RC,,,,both,,,258.64,168.12,,,,,,,,,,,,,
SPACER DST CNTRLZR HIP 8MM OD RELIANCE,SUP-2375169,CDM,C1776,CPT,0278,RC,,,,both,,,346.66,225.33,,,,,,,,,,,,,
PLATE BNE L 45 MM SCREW DIA2 MM HD 2 SHFT 6 H SS CNDYL SLV,SUP-2905540,CDM,C1713,HCPCS,0278,RC,,,,both,,,2428.22,1578.34,,,,,,,,,,,,,
PLATE BONE W6.3XL47MM THK1.6MM 3X4 H RT DSTL VOLAR RAD TI,SUP-2191012,CDM,C1713,HCPCS,0278,RC,,,,both,,,1267.96,824.17,,,,,,,,,,,,,
SUPPORT ORTHOT FT CUST INSRT MOLD TO PT MODEL SPENCO,SUP-2435701,CDM,L3001,HCPCS,0272,RC,,,,both,,,374.48,243.41,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED LG UPCHARGE HD LNR,SUP-2212680,CDM,C1776,CPT,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
KIT ENOFIX SYNDESMOSIS REPAIR,SUP-2878958,CDM,C1713,HCPCS,0278,RC,,,,both,,,5275.20,3428.88,,,,,,,,,,,,,
NAIL IM LENGTHENING FOR TAA0960-F-220 SYS NS FITBONE TAA LTX,SUP-2875094,CDM,C1713,HCPCS,0278,RC,,,,both,,,70775.60,46004.14,,,,,,,,,,,,,
PLATE BNE MESHED 246X11X1 MM 2 HOLE CONTOURED SM GRID STRL,SUP-2467924,CDM,C1713,HCPCS,0278,RC,,,,both,,,5907.47,3839.86,,,,,,,,,,,,,
ELECTRODE WAND ABLAT 3MM 50DEG AMBIENT COVAC 50 IFS,SUP-2342013,CDM,2720000010,LOCAL,0272,RC,,,,both,,,890.19,578.62,,,,,,,,,,,,,
CURETTE SURG KORNER WESTERMANN 2 8 IN SINUS,SUP-2473446,CDM,2720000010,LOCAL,0272,RC,,,,both,,,329.95,214.47,,,,,,,,,,,,,
SCORPION NEEDLE KNEE,SUP-2811651,CDM,2720000010,LOCAL,0272,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP L150CM DIA0035IN S STL BENT STR STLFLEX TI,SUP-2436270,CDM,C1769,HCPCS,0272,RC,,,,both,,,81.11,52.72,,,,,,,,,,,,,
PLATE BONE W10XL112MM THK1.5MM 90DEG 4X9 H BILAT S STL T SHP,SUP-2185881,CDM,C1713,HCPCS,0278,RC,,,,both,,,1723.33,1120.16,,,,,,,,,,,,,
SLIDER NDL CRESC L,SUP-2366703,CDM,C1713,HCPCS,0278,RC,,,,both,,,766.91,498.49,,,,,,,,,,,,,
TRAY CATH PICC POLY Q CATH BSC 4FR 0.034IN 60CM 1 LU 9154105,SUP-2632690,CDM,C1751,HCPCS,0278,RC,,,,both,,,330.01,214.51,,,,,,,,,,,,,
CROWN DENT B5 PEDIATRIC 1ST PRIMARY M UPPER RT,SUP-2119395,CDM,D6783,CPT,0278,RC,,,,both,,,62.64,40.72,,,,,,,,,,,,,
AYR SALINE NASAL NA GEL,RX-15372,CDM,6370000000,HCPCS,0637,RC,00225-0525-47,NDC,,both,14.1,GR,54.10,35.16,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.410,SUP-2859974,CDM,C1713,HCPCS,0278,RC,,,,both,,,32330.38,21014.75,,,,,,,,,,,,,
GRAFT NRV REP L3CM DIA3MM TYP 1 CLLGN ABSRB SEMIPERMEABLE,SUP-2244351,CDM,C9352,HCPCS,0278,RC,,,,both,,,6594.00,4286.10,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.420,SUP-2859984,CDM,C1713,HCPCS,0278,RC,,,,both,,,35350.43,22977.78,,,,,,,,,,,,,
DEVICE EMB L18MM OD3.25MM 55DEG SFT DST TIP BRAID 4 FLX,SUP-2296711,CDM,C1884,HCPCS,0278,RC,,,,both,,,41831.08,27190.20,,,,,,,,,,,,,
SCREW BONE L76MM DIA4.5MM CORT TI N ST N SELF DRL,SUP-2190397,CDM,C1713,HCPCS,0278,RC,,,,both,,,73.07,47.50,,,,,,,,,,,,,
PLATE STRUT 1.5MM 8H OBLQ LT STRL VAL,SUP-2546078,CDM,C1713,HCPCS,0278,RC,,,,both,,,1491.75,969.64,,,,,,,,,,,,,
MESH HERN OVL 10X8 IN POCKETED BIORESORBABLE PHASIX ST,SUP-2855273,CDM,C1781,HCPCS,0278,RC,,,,both,,,27867.50,18113.87,,,,,,,,,,,,,
STENT ESOPH HANAROSTENT L 80MM 20MM L 1800MM 0.035IN,SUP-2912524,CDM,C1874,HCPCS,0278,RC,,,,both,,,8737.05,5679.08,,,,,,,,,,,,,
HEAD HUM 16X40 MM SHLDR RESURF TITAN,SUP-2244069,CDM,C1776,CPT,0278,RC,,,,both,,,15269.82,9925.38,,,,,,,,,,,,,
RING EXT FIX 160 MM 5/8 MR SAFE TI NS,SUP-2863408,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1986.11,1290.97,,,,,,,,,,,,,
SCREW INTRF 6X40MM BIOSTEON PLLA CROSS PIN,SUP-2362052,CDM,C1713,HCPCS,0278,RC,,,,both,,,745.62,484.65,,,,,,,,,,,,,
SET INFUS ORTHOFUSOR,SUP-2352681,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4333.20,2816.58,,,,,,,,,,,,,
OBTURATOR ENDOSCP CONCL NS ECTRA II LTX,SUP-2877786,CDM,2720000010,LOCAL,0272,RC,,,,both,,,425.31,276.45,,,,,,,,,,,,,
PLATE 4.5MM TI CURVED BROAD LCP TM 24 HOLES 443MM STERILE,SUP-2549501,CDM,C1713,HCPCS,0278,RC,,,,both,,,5135.47,3338.06,,,,,,,,,,,,,
DEFIBRILLATOR CARDIOVERTER 2 CHMBR 40 J BPLR STD VVED 20 SEC,SUP-2138117,CDM,C1721,HCPCS,0275,RC,,,,both,,,52567.78,34169.06,,,,,,,,,,,,,
PLATE BNE CRV 0.8 MM MEDL LAT HND STRL,SUP-2518384,CDM,C1713,HCPCS,0278,RC,,,,both,,,1538.60,1000.09,,,,,,,,,,,,,
KIT INTRO L 10 CM DIA 4 FR 40 CM 0.018IN 7CM NIT SHFT STIFF,SUP-2615950,CDM,C1894,HCPCS,0272,RC,,,,both,,,113.29,73.64,,,,,,,,,,,,,
BLOCK CUT KNEE PT SPEC INSTRUMENT FOR CAPPED,SUP-2212491,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
FELT VASC W6XL6IN THK2.87MM PTFE,SUP-2127686,CDM,C1768,CPT,0278,RC,,,,both,,,1428.39,928.45,,,,,,,,,,,,,
GRAFT HUM TISS 2X12CM STD THK1-2MM REGENERATIVE TISS MTRX,SUP-2399083,CDM,Q4107,HCPCS,0636,RC,,,,both,,,6408.74,4165.68,,,,,,,,,,,,,
SPLINT THMB STRTCH LOOP STRP MED LG RT LIGHTWEIGHT SPICA BLK,SUP-2336216,CDM,L3931,HCPCS,0274,RC,,,,both,,,36.27,23.58,,,,,,,,,,,,,
HC Bil Niv Arterial With Stress Tc,PX-9219392400,CDM,93924,CPT,0921,RC,,,,inpatient,,,1868.00,1214.20,,,,,,,,,,,,,
PLATE BNE STD IMPL R CALCLOCK,SUP-2399208,CDM,C1713,HCPCS,0278,RC,,,,both,,,2203.02,1431.96,,,,,,,,,,,,,
BUR DENT 35 INVRT CONE FRIC GRP CARBIDE,SUP-2322355,CDM,2720000010,LOCAL,0272,RC,,,,both,,,522.56,339.66,,,,,,,,,,,,,
PLATE BNE CRV 3.5 MM 12 HOLE RECON,SUP-2197687,CDM,C1713,HCPCS,0278,RC,,,,both,,,1245.95,809.87,,,,,,,,,,,,,
GRAFT BNE 100X25X4 MM 10 CC CALCIUM PHOSPHATE NANOSS 3D +,SUP-2731722,CDM,C1776,CPT,0278,RC,,,,both,,,6594.00,4286.10,,,,,,,,,,,,,
SPACER SPNL W18XH10XL55MM PEEK OPTMA COROENT XLF,SUP-2311626,CDM,C1821,HCPCS,0278,RC,,,,both,,,15072.00,9796.80,,,,,,,,,,,,,
SUPPORT ORTHOT HIP JT LOWER EXTREMITY PELV CTRL LCK,SUP-2435683,CDM,L2610,HCPCS,0274,RC,,,,both,,,667.25,433.71,,,,,,,,,,,,,
ANCHOR SUTURE DIL,SUP-2341591,CDM,C1713,HCPCS,0278,RC,,,,both,,,222.69,144.75,,,,,,,,,,,,,
STE LAT COL LENGTH PLT MED,SUP-2588799,CDM,C1713,HCPCS,0278,RC,,,,both,,,2015.13,1309.83,,,,,,,,,,,,,
KIT OXGNTR NATILUS SMART,SUP-2711657,CDM,2720000010,LOCAL,0272,RC,,,,both,,,12183.20,7919.08,,,,,,,,,,,,,
INSERT 3DKNEE SZ 2 9 MM LT CM,SUP-2216617,CDM,C1776,CPT,0278,RC,,,,both,,,3780.56,2457.36,,,,,,,,,,,,,
PLATE STRNL CLOSURE THK 1.5 MM 4 H TI STR LP NS STERNALOCK,SUP-2894450,CDM,C1713,HCPCS,0278,RC,,,,both,,,2034.72,1322.57,,,,,,,,,,,,,
SCREW CBS H COMPR 26MM,SUP-2321407,CDM,C1713,HCPCS,0278,RC,,,,both,,,954.56,620.46,,,,,,,,,,,,,
PIN DISTRACTOR L12MM TI,SUP-2181850,CDM,C1713,HCPCS,0278,RC,,,,both,,,219.80,142.87,,,,,,,,,,,,,
BIT DRL FISH TAIL UNIV 25 MM SOLITAIRE,SUP-2685253,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1880.86,1222.56,,,,,,,,,,,,,
EASYFUSE STAPLE MTP S NITINOL 4-LEG,SUP-2830242,CDM,C1713,HCPCS,0278,RC,,,,both,,,6123.00,3979.95,,,,,,,,,,,,,
HEPATITIS B IMMUNE GLOBULIN 110 UNIT/0.5ML IM SOSY,RX-155579,CDM,90371,HCPCS,0636,RC,13533-0636-03,NDC,,both,3,ML,1565.60,1017.64,,,,,,,,,,,,,
FOLLOWER URO 18FR L36CM HLLW PLAS URETH 1 EYE POLYMER BOUG,SUP-2384624,CDM,C1726,HCPCS,0272,RC,,,,both,,,42.39,27.55,,,,,,,,,,,,,
TETANUS-DIPHTH-ACELL PERTUSSIS 5-2.5-18.5 LF-MCG/0.5 IM SUSY,RX-155574,CDM,90715,HCPCS,0636,RC,58160-0842-52,NDC,,both,.5,ML,219.40,142.61,,,,,,,,,,,,,
APPLIER ANEURYSM CLIP L3.5IN EXTRA SMALL STANDARD FINGER TIP,SUP-2821649,CDM,C1889,HCPCS,0278,RC,,,,both,,,4495.22,2921.89,,,,,,,,,,,,,
KIT TRACH TB L70MM OD105MM ID7MM PERC DIL FULL COMP BLU LN,SUP-2351757,CDM,2720000010,LOCAL,0272,RC,,,,both,,,871.70,566.60,,,,,,,,,,,,,
KERECIS OMEGA3 SURIBLIND,SUP-2909169,CDM,Q4158,HCPCS,0636,RC,,,,both,,,9815.64,6380.17,,,,,,,,,,,,,
TREPROSTINIL 0.6 MG/ML IN SOLN,RX-98645,CDM,J7686,HCPCS,0636,RC,66302-0206-02,NDC,,both,2.9,ML,3558.20,2312.83,,,,,,,,,,,,,
VANCOMYCIN HCL 2 G IV SOLR,RX-168631,CDM,J3374,HCPCS,0636,RC,72078-0066-99,NDC,,both,1,UN,246.20,160.03,,,,,,,,,,,,,
SCREW BONE L100MM OD6.4MM BLU TI CORT ST SELF DRL,SUP-2347063,CDM,C1713,HCPCS,0278,RC,,,,both,,,843.53,548.29,,,,,,,,,,,,,
SCREW BONE L5MM DIA2MM BLU CRANIOMAXILLOFACIAL TI SELF DRL,SUP-2137243,CDM,C1713,HCPCS,0278,RC,,,,both,,,197.82,128.58,,,,,,,,,,,,,
SYSTEM PHACO OD9MM BASIC FLUIDICS MGMT SYS OZIL TORSIONAL,SUP-2109969,CDM,C1713,HCPCS,0278,RC,,,,both,,,489.84,318.40,,,,,,,,,,,,,
ALLOGRAFT BNE CRUSH 120 CC FD IRRADIATED CANC,SUP-2867181,CDM,C1762,CPT,0278,RC,,,,both,,,4698.23,3053.85,,,,,,,,,,,,,
HC X-Ray Low Ext Infant Min 2 Views,PX-3207359200,CDM,73592,CPT,0320,RC,,,,both,,,274.00,178.10,,,,,,,,,,,,,
SCREW BNE L24MM OD3MM CANN LO PROF IMPL CAPTURE,SUP-2243894,CDM,C1713,HCPCS,0278,RC,,,,both,,,914.56,594.46,,,,,,,,,,,,,
PHENYLEPHRINE HCL 0.125 % NA SOLN,RX-36952,CDM,6370000000,HCPCS,0637,RC,56184-0121-05,NDC,,both,15,ML,54.10,35.16,,,,,,,,,,,,,
GRAFT VASC IMPRA L 40 CM DIA 8 MM EPTFE FLX STD WALL RING,SUP-2761447,CDM,C1768,CPT,0278,RC,,,,both,,,1868.21,1214.34,,,,,,,,,,,,,
ELECTRODE ELECSURG BICOAGULATION 2 MMX105 CM MONOPOLAR,SUP-2477704,CDM,2720000010,LOCAL,0272,RC,,,,both,,,659.24,428.51,,,,,,,,,,,,,
ENVELOPE DEFIB BIOENVELOPE MED SINGLE PK STRL,SUP-2138479,CDM,C1713,HCPCS,0278,RC,,,,both,,,2983.00,1938.95,,,,,,,,,,,,,
PLATE BONE 11 H CRANIOMAXILLOFACIAL TI H SHP FOR 1.3MM,SUP-2190675,CDM,C1713,HCPCS,0278,RC,,,,both,,,1096.80,712.92,,,,,,,,,,,,,
PLATE BONE LOK HLX35 HDSHFT TTNM T SHPD OBLQUE ST,SUP-2722677,CDM,C1713,HCPCS,0278,RC,,,,both,,,1106.10,718.96,,,,,,,,,,,,,
PLATE BNE L90MM 4 H R PROX HUM HI ALPS,SUP-2411642,CDM,C1713,HCPCS,0278,RC,,,,both,,,6138.70,3990.15,,,,,,,,,,,,,
NIACIN ER (ANTIHYPERLIPIDEMIC) 500 MG PO TBCR,RX-27181,CDM,6370000000,HCPCS,0637,RC,47335-0539-81,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
GRASPER ENDOSCP L 30 CM DIA2.4 MM SLIM MINIGRIP HNDL INTEGR,SUP-2901844,CDM,2720000010,LOCAL,0272,RC,,,,both,,,690.80,449.02,,,,,,,,,,,,,
STIMULATOR FUS SPNL PK,SUP-2414475,CDM,E0749,HCPCS,0278,RC,,,,both,,,16547.80,10756.07,,,,,,,,,,,,,
HC Ribs Bilateral 1 View Cvr Min 4 Views,PX-3207111100,CDM,71111,CPT,0320,RC,,,,both,,,786.00,510.90,,,,,,,,,,,,,
STEM TIBIAL ENDO MODEL MOD CMNTLS 16X120MM,SUP-2657210,CDM,C1776,CPT,0278,RC,,,,both,,,6995.92,4547.35,,,,,,,,,,,,,
PLUG BONE DIA12X16MM POLY W/ DISP INSRTR ALLEN,SUP-2203668,CDM,C1713,HCPCS,0278,RC,,,,both,,,322.48,209.61,,,,,,,,,,,,,
GRAFT AMNIOTIC MEMBRANE FLOWERAMNIOPATCH 16MM DISC SIZE,SUP-2866792,CDM,Q4178,HCPCS,0636,RC,,,,both,,,4793.21,3115.59,,,,,,,,,,,,,
INTRODUCER INFUSION PMP ACCS AX KIT INSRTN IMPELLA 5.0,SUP-2431910,CDM,C1892,HCPCS,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
ANCHOR SUT 51MM NO2 GRN QUICKWHIP,SUP-2277455,CDM,C1713,HCPCS,0278,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
GRAFT BNE WDG 10 DEG 10 MM LAPIDUS,SUP-2321727,CDM,C1713,HCPCS,0278,RC,,,,both,,,6341.23,4121.80,,,,,,,,,,,,,
ANCHOR SUTURE NONABSORBABLE 35 MM TWIN LOOP SFT EYELET,SUP-2608455,CDM,C1713,HCPCS,0278,RC,,,,both,,,1066.75,693.39,,,,,,,,,,,,,
CANNULA ENDOSCP FLX 6 MMX8.5 CM W/ THRD SIL LEAFLET VLV BLK,SUP-2767566,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1010.51,656.83,,,,,,,,,,,,,
TUBE SZ 5.5 11 MM OVL,SUP-2349211,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1796.08,1167.45,,,,,,,,,,,,,
GRAFT BONE SUB 1CC DEMIN BONE MTRX GEL ALLOSYNC,SUP-2120755,CDM,C1776,CPT,0278,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
VALVE SHUNT LP HYDROCEPHALUS THER STRATA,SUP-2278372,CDM,C1889,HCPCS,0278,RC,,,,both,,,11801.28,7670.83,,,,,,,,,,,,,
SHEATH INTRO OSCOR ADELANTE BREEZEWAY 70 DEG L 61 CM DIA 8,SUP-2753183,CDM,C1887,HCPCS,0272,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
ELECTRODE ELECSURG L25CM DIA14GA ENH SEMI FLEX RF FOR TISS,SUP-2118729,CDM,C1894,HCPCS,0272,RC,,,,both,,,10205.00,6633.25,,,,,,,,,,,,,
SHUNT CSF ADJUSTABLE GRAVITATIONAL UNIT 0-20CM H2O WITH PEDI,SUP-2825850,CDM,C1889,HCPCS,0278,RC,,,,both,,,9218.35,5991.93,,,,,,,,,,,,,
CLAMP SURG FOR DAF SUPLMNT SCREW HOLDER 10037,SUP-2874949,CDM,2720000010,LOCAL,0272,RC,,,,both,,,953.93,620.05,,,,,,,,,,,,,
INSERT ORTH DIA5MM TI FOR LISS SCR H,SUP-2190746,CDM,C1713,HCPCS,0278,RC,,,,both,,,267.87,174.12,,,,,,,,,,,,,
VALVE MITRL EPIC + SZ 31 MM TISS ANNULUS DIA 31 MM STENT,SUP-2893566,CDM,C1889,HCPCS,0278,RC,,,,both,,,15706.28,10209.08,,,,,,,,,,,,,
SYSTEM IMPL S STL KNOTLESS SYNDESMOSIS TIGHTROPE XP,SUP-2122823,CDM,C1713,HCPCS,0278,RC,,,,both,,,4694.30,3051.29,,,,,,,,,,,,,
DILATOR URETH SET M BAL 8MMX8CM BAL 7 FRX30CM CATH,SUP-2171271,CDM,C1713,HCPCS,0278,RC,,,,both,,,629.26,409.02,,,,,,,,,,,,,
LINER ACET ECC 32X64 MM HIP,SUP-2202295,CDM,C1776,CPT,0278,RC,,,,both,,,3485.75,2265.74,,,,,,,,,,,,,
PLATE BONE L22MM BLDE L13MM 3X3 H RT ORAL MAXILLOFACIAL TI L,SUP-2191150,CDM,C1713,HCPCS,0278,RC,,,,both,,,969.32,630.06,,,,,,,,,,,,,
OSS 3CM RESURFACING RT,SUP-2506331,CDM,C1776,CPT,0278,RC,,,,both,,,18510.30,12031.69,,,,,,,,,,,,,
TRANSFER SET 9 LD VENTED MANIFOLD STRL PINNACLE LF,SUP-2774414,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2021.38,1313.90,,,,,,,,,,,,,
CABLE SPNL L470MM DIA1MM TI SGL LD CRMP,SUP-2193140,CDM,C1889,HCPCS,0278,RC,,,,both,,,753.60,489.84,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE 15 CC CORTICOCANCELLOUS ALLGRFT,SUP-2932969,CDM,C1762,CPT,0278,RC,,,,both,,,53128.80,34533.72,,,,,,,,,,,,,
BAND ANNULPLSTY COSGROVE-EDWARDS SZ 36 MM L 78.7 MM OD 43.6,SUP-2214201,CDM,C1713,HCPCS,0278,RC,,,,both,,,9734.00,6327.10,,,,,,,,,,,,,
HC So Prostatic Acid Phosphatase,PX-3018406666,CDM,84066,CPT,0301,RC,,,,both,,,179.00,116.35,,,,,,,,,,,,,
SCREW BNE L48MM DIA3.5MM S STL CANN FULL THRD HD HEX SOCK,SUP-2183654,CDM,C1713,HCPCS,0278,RC,,,,both,,,456.34,296.62,,,,,,,,,,,,,
CATHETER CV SINGLE LUMEN 3 FR SHERLOCK STYL GROSH,SUP-2126719,CDM,C1751,HCPCS,0278,RC,,,,both,,,527.52,342.89,,,,,,,,,,,,,
HC So1 Allergen Specific,PX-3058600367,CDM,86003,CPT,0305,RC,,,,inpatient,,,17.00,11.05,,,,,,,,,,,,,
GENDER FLX CEM FEM/CEM TIB/ PRLNG SURF/NO PAT,SUP-2212249,CDM,C1776,CPT,0278,RC,,,,both,,,12213.19,7938.57,,,,,,,,,,,,,
STENT TRACHBRONCH WSTNT L 60 MM DIA16 MM SHTH 10 FR CATH L,SUP-2147036,CDM,C1876,HCPCS,0278,RC,,,,both,,,3340.71,2171.46,,,,,,,,,,,,,
PLATE BNE 6 H NONSTERILE MANUBRIUM STRNL TI STAR SHP LOK,SUP-2192437,CDM,C1713,HCPCS,0278,RC,,,,both,,,2846.41,1850.17,,,,,,,,,,,,,
CABLE NRV STIM L9FT DISECT KARTUSH,SUP-2277646,CDM,2720000010,LOCAL,0272,RC,,,,both,,,452.16,293.90,,,,,,,,,,,,,
SPACER SPNL W22XH8XL45MM LORD 6DEG LAT INTBDY FUS SYS VEO,SUP-2164087,CDM,C1821,HCPCS,0278,RC,,,,both,,,21352.00,13878.80,,,,,,,,,,,,,
TUBE CABLE PASS L 400 MM SURG WIRE STRL LF DISP,SUP-2905585,CDM,2720000010,LOCAL,0272,RC,,,,both,,,764.24,496.76,,,,,,,,,,,,,
GRAFT DURA ABSRB CLLGN BASE ST SUB SPNL CRAN DURAPLASTY,SUP-2165121,CDM,C1763,HCPCS,0278,RC,,,,both,,,2085.46,1355.55,,,,,,,,,,,,,
COIL NEUROVASCULAR CASHMERE 14 L 22 CM LOOP DIA 9 MM PRIMARY,SUP-2249275,CDM,C1889,HCPCS,0278,RC,,,,both,,,4127.06,2682.59,,,,,,,,,,,,,
VALVE HEMOSTAS HONOR DIA 7.2 FR POLYCARB SIL MTL ROTATING,SUP-2303048,CDM,C1713,HCPCS,0278,RC,,,,both,,,75.93,49.35,,,,,,,,,,,,,
CLINDAMYCIN PHOSPHATE 900 MG/6ML IJ SOLN,RX-82302,CDM,J0736,HCPCS,0636,RC,00009-0902-11,NDC,,both,2,ML,54.10,35.16,,,,,,,,,,,,,
ANCHOR SUT LABRUM KNOTLESS WHT LABRALOCK P + W/ INSRTR HNDL,SUP-2342084,CDM,C1713,HCPCS,0278,RC,,,,both,,,2182.30,1418.49,,,,,,,,,,,,,
CATHETER HD 24 CM 19 CM CHRONIC DLYS COMPLETE KT W/ MAK,SUP-2462131,CDM,C1750,HCPCS,0278,RC,,,,both,,,847.80,551.07,,,,,,,,,,,,,
SHEATH RESECTSCP 28FR BLK OBLQ BEAK CONN TUBE FOR INFLO AND,SUP-2261180,CDM,C1894,HCPCS,0272,RC,,,,both,,,2464.74,1602.08,,,,,,,,,,,,,
SOUND PROCESSOR KIT FOR NEW RECIP KANSO 2,SUP-2858125,CDM,L8614,HCPCS,0278,RC,,,,both,,,32970.00,21430.50,,,,,,,,,,,,,
BIT DRL DIA 3.7 MM CORTICAL AO QC LG TARGETER SYS STRL DISP,SUP-2933208,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2222.18,1444.42,,,,,,,,,,,,,
Gluc-6-Phosphate Dehydrogenase Quantitative,PX-3018295567,CDM,82955,CPT,0301,RC,,,,both,,,62.00,40.30,,,,,,,,,,,,,
ELECTRODE OPN VES SEAL SMOOTH DISP PK SUPERPULSE,SUP-2313927,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1633.62,1061.85,,,,,,,,,,,,,
WAND ABLAT DIA3.75MM 90DEG ANG INTEGR CBL TURBOVAC,SUP-2341998,CDM,2720000010,LOCAL,0272,RC,,,,both,,,615.44,400.04,,,,,,,,,,,,,
HC So Creatine Kinase Isoenzyme,PX-3018255266,CDM,82552,CPT,0301,RC,,,,both,,,26.00,16.90,,,,,,,,,,,,,
SCREW LAG TAP INTERTROCHANTERIC AG NAIL SYS INTERTAN TRIGEN,SUP-2418076,CDM,C1713,HCPCS,0278,RC,,,,both,,,1516.62,985.80,,,,,,,,,,,,,
ROCURONIUM BROMIDE 50 MG/5ML IV SOLN,RX-95811,CDM,2500000003,HCPCS,0250,RC,65219-0442-05,NDC,,both,5,ML,54.10,35.16,,,,,,,,,,,,,
CATHETER GUID MIDWAY62 L 115 CM COAT L 30 CM DIA1.93 MM,SUP-2896795,CDM,C1887,HCPCS,0272,RC,,,,both,,,4992.60,3245.19,,,,,,,,,,,,,
HC So1 Chromosome Anal 15-20,PX-3118826267,CDM,88262,CPT,0311,RC,,,,both,,,189.00,122.85,,,,,,,,,,,,,
WAND ABLAT PLSM EVAC T AND A COBLATOR II,SUP-2342034,CDM,C1713,HCPCS,0278,RC,,,,both,,,1002.70,651.75,,,,,,,,,,,,,
MESH SZ 4X16CM IMPL FOR HUM ALLGRFT ACELLULAR DERM CLLGN,SUP-2300710,CDM,C1713,HCPCS,0278,RC,,,,both,,,5761.90,3745.23,,,,,,,,,,,,,
SALVATION 160MM TAB FT RNG,SUP-2401134,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1293.68,840.89,,,,,,,,,,,,,
NAIL IM L210MM OD10MM 130DEG CANN LOK MEDIOLATERAL BENT,SUP-2343921,CDM,C1713,HCPCS,0278,RC,,,,both,,,1708.79,1110.71,,,,,,,,,,,,,
SET URET STENT KWART RETRO INJ L22-32 CM DIA 6 FR INSRTR L,SUP-2835751,CDM,C2617,HCPCS,0278,RC,,,,both,,,403.18,262.07,,,,,,,,,,,,,
ZIPRASIDONE MESYLATE 20 MG IM SOLR,RX-33175,CDM,J3486,HCPCS,0636,RC,72266-0160-10,NDC,,both,1,UN,188.60,122.59,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.436,SUP-2860000,CDM,C1713,HCPCS,0278,RC,,,,both,,,45593.11,29635.52,,,,,,,,,,,,,
FLUOXETINE HCL 10 MG PO CAPS,RX-10069,CDM,6370000000,HCPCS,0637,RC,00904-7345-61,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
CONNECTOR SPNL ROD DIA 3.5/5.5 MM POST CERV PARALLEL DBL NS,SUP-2887232,CDM,C1713,HCPCS,0278,RC,,,,both,,,87.57,56.92,,,,,,,,,,,,,
PUTTY 1CC DBM INCL CANC BONE CHIP MTRX VIVEX,SUP-2393071,CDM,C1713,HCPCS,0278,RC,,,,both,,,987.53,641.89,,,,,,,,,,,,,
BLADE TNGE DINGMAN 3 LG 136X32X75 MM,SUP-2476735,CDM,2720000010,LOCAL,0272,RC,,,,both,,,583.35,379.18,,,,,,,,,,,,,
PROBE SURG GUIDEWIRE 2.4 MM ACUTRK 2,SUP-2525725,CDM,2720000010,LOCAL,0272,RC,,,,both,,,872.92,567.40,,,,,,,,,,,,,
LASER SURG WVLNGTH 190-534 NM 960-1064 NM 925-1070 NM 7 MM,SUP-2713601,CDM,2720000010,LOCAL,0272,RC,,,,both,,,857.22,557.19,,,,,,,,,,,,,
RING EXT FIX DIA180MM TAY 2/3 SPAT FRME ILIZ,SUP-2342977,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6182.97,4018.93,,,,,,,,,,,,,
BIT DRILL QUICK COUPLING 1.5X85 MM 1.5 MM WITHOUT STOP FOR C,SUP-2837899,CDM,2720000010,LOCAL,0272,RC,,,,both,,,327.50,212.87,,,,,,,,,,,,,
TI MATRIXMIDFACE SCREW  1.3MM  450395505,SUP-2844122,CDM,C1713,HCPCS,0278,RC,,,,both,,,86.76,56.39,,,,,,,,,,,,,
PROSTHESIS VOICE 17FR 6MM LESS STRAINED SPEAK VLV PROVOX,SUP-2124379,CDM,L8509,HCPCS,0274,RC,,,,both,,,940.08,611.05,,,,,,,,,,,,,
SCREW BNE L45MM DIA6MM CORT ST NONCANNULATED NONLOCKING,SUP-2377555,CDM,C1713,HCPCS,0278,RC,,,,both,,,772.44,502.09,,,,,,,,,,,,,
PROBE OPHTH 23GA LASER CVD FLEX NIT TAPR TIP,SUP-2129220,CDM,2720000010,LOCAL,0272,RC,,,,both,,,410.65,266.92,,,,,,,,,,,,,
HEAD FEM SKIRTED 40 MM HIP OFFSET COCR,SUP-2308969,CDM,C1776,CPT,0278,RC,,,,both,,,825.82,536.78,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED CEM HA,SUP-2365937,CDM,C1776,CPT,0278,RC,,,,both,,,5617.46,3651.35,,,,,,,,,,,,,
COMPONENT GLEN FIX DIA10MM SHLDR METAGLENE LNG PEG GLOB,SUP-2251207,CDM,C1776,CPT,0278,RC,,,,both,,,4744.54,3083.95,,,,,,,,,,,,,
CATHETER CV SET 025 5 FRX15 CM 3L CUTLM501JLSCABRMHC,SUP-2759860,CDM,C1751,HCPCS,0278,RC,,,,both,,,355.73,231.22,,,,,,,,,,,,,
SCREW SET HEX M4.5X0.75 MM RND TIP 3.5 MM HEX PROTEX CT,SUP-2593223,CDM,C1713,HCPCS,0278,RC,,,,both,,,100.48,65.31,,,,,,,,,,,,,
SPLINT FNGR W1 2IN 3PP BUDDY LOOP,SUP-2112615,CDM,L3933,HCPCS,0274,RC,,,,both,,,8.35,5.43,,,,,,,,,,,,,
CATHETER IV DL 4 FR MAX BARR NURSING TY PWR INJ POWERMIDLINE,SUP-2125694,CDM,C1751,HCPCS,0278,RC,,,,both,,,561.75,365.14,,,,,,,,,,,,,
PLATE BONE W38XL45MM THK1.5MM NONSTERILE TI RECTANG CNTOUR,SUP-2191099,CDM,C1713,HCPCS,0278,RC,,,,both,,,4384.07,2849.65,,,,,,,,,,,,,
IMPLANT OP RM MINI-MONSTER 2.5 X 11MM HD CANN SHT THRD SCR,SUP-2320390,CDM,C1713,HCPCS,0278,RC,,,,both,,,591.89,384.73,,,,,,,,,,,,,
PLATE BNE CONN 3 HOLE FOR DISTRCTN OSTEOGENESIS RNG SYS,SUP-2179149,CDM,C1713,HCPCS,0278,RC,,,,both,,,256.04,166.43,,,,,,,,,,,,,
MESNA 100 MG/ML IV SOLN,RX-10537,CDM,J9209,HCPCS,0636,RC,10019-0953-01,NDC,,both,2,ML,54.10,35.16,,,,,,,,,,,,,
HC So Primidone,PX-3018018866,CDM,80188,CPT,0301,RC,,,,both,,,155.00,100.75,,,,,,,,,,,,,
KIT SCR LEG L80MM DIA11MM COMPR L75MM DIA7MM INTEGR INTLOK,SUP-2347846,CDM,C1713,HCPCS,0278,RC,,,,both,,,4720.99,3068.64,,,,,,,,,,,,,
SCREW SPNL L6MM OD4.5MM GRY TI CORT CERV VAR ANG,SUP-2286771,CDM,C1713,HCPCS,0278,RC,,,,both,,,447.45,290.84,,,,,,,,,,,,,
GRAFT BONE SUB 7.5CC CORTICOCANCELLOUS PARTICULATE FRZ DRY,SUP-2165565,CDM,C1713,HCPCS,0278,RC,,,,both,,,486.70,316.35,,,,,,,,,,,,,
HANDPIECE ABLAT BPLR DISP FOR ATRICURE ABLAT UNIT L5.0CM,SUP-2124457,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6670.71,4335.96,,,,,,,,,,,,,
HEAD RAD H10MM DIA20MM ANT DST EL CO CHROM MOD CEM EXPLOR,SUP-2404359,CDM,C1776,CPT,0278,RC,,,,both,,,5495.00,3571.75,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY LASSO NAV ECO L 115 CM 7/15 FR D,SUP-2248625,CDM,C1732,HCPCS,0272,RC,,,,both,,,3673.80,2387.97,,,,,,,,,,,,,
PLATE BNE W10XL74MM THK15MM 3X5 H R TI T SHP OBLQ LO PROF,SUP-2190919,CDM,C1713,HCPCS,0278,RC,,,,both,,,1139.57,740.72,,,,,,,,,,,,,
GRAFT SYNTHECEL DURA REPAIR 4X5IN,SUP-2717545,CDM,C1763,HCPCS,0278,RC,,,,both,,,5164.52,3356.94,,,,,,,,,,,,,
TOCILIZUMAB-AAZG 400 MG/20ML IV SOLN,RX-167521,CDM,Q5135,HCPCS,0636,RC,65219-0594-20,NDC,,both,20,ML,5777.30,3755.24,,,,,,,,,,,,,
HC Remv/Revisn Boot/Body Cast,PX-7612970000,CDM,29700,CPT,0761,RC,,,,both,,,294.00,191.10,,,,,,,,,,,,,
JIG KNEE IMPL CR IDENTITY IMPRNT,SUP-2904395,CDM,2720000010,LOCAL,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
HC So Fructosamine,PX-3018298566,CDM,82985,CPT,0301,RC,,,,outpatient,,,274.00,178.10,,,,,,,,,,,,,
PLATE BONE L214MM 14 H BILAT LCK COMPR RIG FOR 3.5MM SCR,SUP-2348453,CDM,C1713,HCPCS,0278,RC,,,,both,,,5908.85,3840.75,,,,,,,,,,,,,
FIBER LASER FOR PVP GREENLIGHT LASERSCOPE,SUP-2835043,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
PLATE BNE TBLR 2.7X25 MM 3 HOLE 1/4 SS,SUP-2536101,CDM,C1713,HCPCS,0278,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
SCREW BNE L 44 MM DIA 5.5 MM SHRT TI CANN HD NS LEOS,SUP-2931500,CDM,C1713,HCPCS,0278,RC,,,,both,,,1073.50,697.77,,,,,,,,,,,,,
MIDAZOLAM HCL 5 MG/5ML IJ SOLN,RX-93518,CDM,J2250,HCPCS,0636,RC,00641-6059-01,NDC,,both,0.5,ML,54.10,35.16,,,,,,,,,,,,,
STENT BILI L 7 CM DIA 7 FR PERCFLX DUODENAL BEND INTRO KT W/,SUP-2149469,CDM,C2625,HCPCS,0278,RC,,,,both,,,269.10,174.91,,,,,,,,,,,,,
SURGICAL INSTRUMENT KIT 3 MM MINIMALLY INVASIVE PONTO BK UP,SUP-2430322,CDM,2720000010,LOCAL,0272,RC,,,,both,,,811.06,527.19,,,,,,,,,,,,,
HC So1 Immunoglob G Subclasses Each,PX-3018278767,CDM,82787,CPT,0301,RC,,,,inpatient,,,5.00,3.25,,,,,,,,,,,,,
SCREW BNE ST 1.85X14 MM 1.52X3 MM COARSE PITCH THRD LT BLU,SUP-2181794,CDM,C1713,HCPCS,0278,RC,,,,both,,,315.63,205.16,,,,,,,,,,,,,
PLATE BONE W50XL50MM 3X3MM H SPC CRAN TI MESH FOR 1MM SCR,SUP-2190568,CDM,C1713,HCPCS,0278,RC,,,,both,,,6033.51,3921.78,,,,,,,,,,,,,
BUTTON GAST 14FR STOMA L17CM APPLE SHP BLLN DURABLE EXT,SUP-2119875,CDM,C1889,HCPCS,0278,RC,,,,both,,,386.22,251.04,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE 20 CC CALCIUM SULF CALCIUM PHOSPHATE LO,SUP-2889960,CDM,C1713,HCPCS,0278,RC,,,,both,,,28260.00,18369.00,,,,,,,,,,,,,
MESH SURG DIA9CM WHT POLY CLLGN FLM RND MFIL BIOABSRB,SUP-2283406,CDM,C1781,HCPCS,0278,RC,,,,both,,,977.29,635.24,,,,,,,,,,,,,
GRAFT BNE SUB 25ML POLYMER HYALURONIC ACID BASE PSTE MIX,SUP-2247320,CDM,C1713,HCPCS,0278,RC,,,,both,,,2025.30,1316.44,,,,,,,,,,,,,
COMPONENT FEM SZ 5 KNEE CEM UNI PRESERVATION,SUP-2251254,CDM,C1776,CPT,0278,RC,,,,both,,,8390.08,5453.55,,,,,,,,,,,,,
PLATE BONE L142MM 6 H RT MEDL DSTL TIB TIM LCK COMPR FOR,SUP-2137059,CDM,C1713,HCPCS,0278,RC,,,,both,,,4608.74,2995.68,,,,,,,,,,,,,
SCREW BONE L14MM DIA2MM CORT TI ST LCK COARSE PITCH STARDRV,SUP-2189634,CDM,C1713,HCPCS,0278,RC,,,,both,,,205.98,133.89,,,,,,,,,,,,,
BLADE SAW W8XL70MM THK1.27MM OSC,SUP-2363318,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1024.02,665.61,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH FLX L 30 MM DIA24 MM SHTH 16 FR SS,SUP-2168963,CDM,C1874,HCPCS,0278,RC,,,,both,,,5922.04,3849.33,,,,,,,,,,,,,
TROCAR ENDOSCP SHFT L100MM DIA8MM TEAL BLDELSS W/ STBL,SUP-2218796,CDM,2720000010,LOCAL,0272,RC,,,,both,,,65.00,42.25,,,,,,,,,,,,,
SCREW BNE 4X14 MM,SUP-2199216,CDM,C1713,HCPCS,0278,RC,,,,both,,,60.29,39.19,,,,,,,,,,,,,
PLATE BNE BURR HOLE CVR 1.6X17 MM LP FOR SHUNT OR DRAINAGE,SUP-2431414,CDM,C1713,HCPCS,0278,RC,,,,both,,,779.98,506.99,,,,,,,,,,,,,
SCREW BNE L14MM OD2.7MM TI LOK FOR TOT FT SYS,SUP-2243271,CDM,C1713,HCPCS,0278,RC,,,,both,,,676.73,439.87,,,,,,,,,,,,,
BIT DRL QC 2X110 MM STRL,SUP-2563746,CDM,2720000010,LOCAL,0272,RC,,,,both,,,433.95,282.07,,,,,,,,,,,,,
SCREW SPNL L13MM DIA3.5MM CANC ANT CERV TI ALLY SELF DRL,SUP-2291182,CDM,C1713,HCPCS,0278,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
NEEDLE SUT PASS FOR QUATTRO SHLDR SYS,SUP-2402632,CDM,2720000010,LOCAL,0272,RC,,,,both,,,615.44,400.04,,,,,,,,,,,,,
PIN FIX CASPER 14 MM,SUP-2391504,CDM,C1713,HCPCS,0278,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
MESH SURG W15XL15CM SQ PARTIALLY ABSRB FLAT FOR SFT TISS,SUP-2220105,CDM,C1781,HCPCS,0278,RC,,,,both,,,526.01,341.91,,,,,,,,,,,,,
GRAFT BNE CRUSH 15 CC CANC,SUP-2312457,CDM,C1713,HCPCS,0278,RC,,,,both,,,1433.41,931.72,,,,,,,,,,,,,
PLATE MEDL CLMN LNG TI NC2M2 FOR DORS MIDFOOT RECON NS UNITE,SUP-2896767,CDM,C1713,HCPCS,0278,RC,,,,both,,,5334.86,3467.66,,,,,,,,,,,,,
SPACER SPNL 12 DEG 45X20X10-5.8 MM TITAN TI STRL ANTERALIGN,SUP-2859335,CDM,C1889,HCPCS,0278,RC,,,,both,,,21025.44,13666.54,,,,,,,,,,,,,
KIT SUTURING SUTURE L 48 IN DIA2 MM K WIRE L 200 MM DIA1.6,SUP-2910461,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3280.52,2132.34,,,,,,,,,,,,,
"HC Inj Proc Nfrosgrm/Urtrgrm, Complete",PX-3615043100,CDM,50431,CPT,0361,RC,,,,outpatient,,,6875.00,4468.75,,,,,,,,,,,,,
CATHETER BLLN DIL 6 FRX180 CM 15-18 MMX8 CM CRE,SUP-2149684,CDM,C1726,HCPCS,0272,RC,,,,both,,,605.89,393.83,,,,,,,,,,,,,
PRESSURIZER BNE CEMENT FEM HIP OPTVAC,SUP-2217083,CDM,C1713,HCPCS,0278,RC,,,,both,,,477.28,310.23,,,,,,,,,,,,,
GABAPENTIN 250 MG/5ML PO SOLN,RX-29169,CDM,340b,HCPCS,0637,RC,42192-0608-06,NDC,,both,2.5,ML,7.10,4.61,,,,,,,,,,,,,
TI LCP DISTAL FEMUR PLATE 17 HOLE/396MM RIGHT-STERILE,SUP-2546861,CDM,C1713,HCPCS,0278,RC,,,,both,,,5625.34,3656.47,,,,,,,,,,,,,
OXYGENATOR PERFSN POLYMETHYLPENTENE FIBER KT PED AMG,SUP-2895169,CDM,2720000010,LOCAL,0272,RC,,,,both,,,29987.00,19491.55,,,,,,,,,,,,,
TUBE VENT MOD ARMSTR 1.14 MM 1.14 MM 2.54 MM FLROPLAS 525181,SUP-2478107,CDM,L8699,HCPCS,0278,RC,,,,both,,,38.15,24.80,,,,,,,,,,,,,
INSERT ACET SZ P4 OD54-56MM ID32MM 10DEG OFFSET +4MM DUR CO,SUP-2376193,CDM,C1776,CPT,0278,RC,,,,both,,,2410.26,1566.67,,,,,,,,,,,,,
COLLAR CERV UNIV AD L13-19IN TRACH OPN TWO PC RIG POLYETH,SUP-2124202,CDM,L0120,HCPCS,0274,RC,,,,both,,,115.05,74.78,,,,,,,,,,,,,
FILLER DERMAL JUVEDERM VOLUX XC 1ML,SUP-2900489,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1350.20,877.63,,,,,,,,,,,,,
CRADLE SPNL RAD 220MM SUP CRAN GLD TI ALLOY RT ANG FOR RIB,SUP-2193284,CDM,C1889,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
HC Continuing Medical Physics,PX-3337733600,CDM,77336,CPT,0333,RC,,,,both,,,605.00,393.25,,,,,,,,,,,,,
GUIDE WIRE O 0.7MM 41CM 5/PKG,SUP-2574077,CDM,C1769,HCPCS,0272,RC,,,,both,,,64.78,42.11,,,,,,,,,,,,,
HC Inj Proc Cysto or Void,PX-3615160000,CDM,51600,CPT,0361,RC,,,,inpatient,,,1485.00,965.25,,,,,,,,,,,,,
PATCH CV GORTX NOM L 15 X W 5 CM THK 0.6 MM EPTFE CNFRM,SUP-2395302,CDM,C1768,CPT,0278,RC,,,,both,,,2282.78,1483.81,,,,,,,,,,,,,
BEARING TIB 12 MM POLYETH OSS AVL,SUP-2441785,CDM,C1776,CPT,0278,RC,,,,both,,,2811.87,1827.72,,,,,,,,,,,,,
SEALER TISS L45CM DIA5MM ARTC ADV BPLR CRV TIP LAP APPRCH,SUP-2219731,CDM,C1713,HCPCS,0278,RC,,,,both,,,8293.62,5390.85,,,,,,,,,,,,,
RING ACET GANZ ROOF W/ HK 38MM,SUP-2212026,CDM,C1776,CPT,0278,RC,,,,both,,,5592.34,3635.02,,,,,,,,,,,,,
GRAFT BNE PASTE 0.5 CC SYR DBM ORTHOBLAST II,SUP-2641745,CDM,C1713,HCPCS,0278,RC,,,,both,,,429.77,279.35,,,,,,,,,,,,,
WEDGE ILIUM CREST SPEC TRAD ALLGRFT 6 MM FRZ DRY,SUP-2294055,CDM,C1713,HCPCS,0278,RC,,,,both,,,3136.86,2038.96,,,,,,,,,,,,,
ANCHOR SUTURE SFT JUGGERKNOT,SUP-2608806,CDM,C1713,HCPCS,0278,RC,,,,both,,,2186.04,1420.93,,,,,,,,,,,,,
GENII TIB BSPL SZ3 LT HA COAT,SUP-2822759,CDM,C1776,CPT,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
CATHETER HEMO DYLS OR HD 15.5FR L28CM CHRONIC BASIC KT W/,SUP-2116517,CDM,C1750,HCPCS,0278,RC,,,,both,,,1381.60,898.04,,,,,,,,,,,,,
KIT INTRO VSI L 10 CM DIA 5 FR NIT MANDREL TUNGSTEN TIP REG,SUP-2120524,CDM,C1894,HCPCS,0272,RC,,,,both,,,94.20,61.23,,,,,,,,,,,,,
HC So Cebpa Gene Full Sequence,PX-3108121866,CDM,81218,CPT,0310,RC,,,,both,,,384.00,249.60,,,,,,,,,,,,,
GABAPENTIN 250 MG/5ML PO SOLN,RX-29169,CDM,340b,HCPCS,0637,RC,42192-0608-16,NDC,,both,2.5,ML,2.70,1.75,,,,,,,,,,,,,
ELECTRODE ELECSURG STR VES SEAL BRAISED PK SUPERPLUSE DISP,SUP-2312849,CDM,2720000010,LOCAL,0272,RC,,,,both,,,792.22,514.94,,,,,,,,,,,,,
BLADE ENDOSCP SHAVER L 22 CM DIA2.9 MM SPD 500-1500 RPM ENT,SUP-2901920,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1519.76,987.84,,,,,,,,,,,,,
BLADE ENDOSCP SHAVER 15 DEG L 13 CM DIA2.9 MM SPD 60-500 RPM,SUP-2902071,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1808.64,1175.62,,,,,,,,,,,,,
SET URET STENT C FLX L 12 CM CATH L 70 CM DIA 3.7 FR,SUP-2171251,CDM,C2617,HCPCS,0278,RC,,,,both,,,614.03,399.12,,,,,,,,,,,,,
PLATE 11HL LK LT,SUP-2491866,CDM,C1713,HCPCS,0278,RC,,,,both,,,3063.45,1991.24,,,,,,,,,,,,,
TIP ASPIR L79IN OD192MM ID15MM SFT TISS STR SUPERLONG,SUP-2363699,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2596.31,1687.60,,,,,,,,,,,,,
ALLOGRAFT BNE PLUG 10 MM FD IRRADIATED,SUP-2867103,CDM,C1762,CPT,0278,RC,,,,both,,,1897.19,1233.17,,,,,,,,,,,,,
STENT BILI S.M.A.R.T. CTRL L 80 MM DIA 8 MM DEL SYS L 120 CM,SUP-2155365,CDM,C1876,HCPCS,0278,RC,,,,both,,,4713.14,3063.54,,,,,,,,,,,,,
PLATE BNE STR 17X0.35 MM NEURO 2 HOLE W/ TAB TI STRL LEVEL 1,SUP-2498873,CDM,C1713,HCPCS,0278,RC,,,,both,,,353.16,229.55,,,,,,,,,,,,,
PLATE BNE L78MM 6 H L MED DST PERIARTC RAD VOLAR S STL LOK,SUP-2198466,CDM,C1713,HCPCS,0278,RC,,,,both,,,2483.87,1614.52,,,,,,,,,,,,,
HC So Helicobacter Phyloric Culture (First Cpt),PX-3008708168,CDM,87081,CPT,0300,RC,,,,both,,,22.00,14.30,,,,,,,,,,,,,
PLATE BONE W50XL85MM THK0.2MM MH TI SH FOR 1.5MM SCR LORENZ,SUP-2402908,CDM,C1781,HCPCS,0278,RC,,,,both,,,1519.76,987.84,,,,,,,,,,,,,
PLATE BNE L 177 MM SCREW DIA2.4 MM 20 SHFT H TI ADPT COMB,SUP-2907791,CDM,C1713,HCPCS,0278,RC,,,,both,,,3883.87,2524.52,,,,,,,,,,,,,
PLATE BNE W24XL62MM 12 H L DST RAD TI LOK COMPR LO PROF RIG,SUP-2411823,CDM,C1713,HCPCS,0278,RC,,,,both,,,3234.20,2102.23,,,,,,,,,,,,,
PLATE BNE L142MM 10 H L LAT DST PERIARTC TIB S STL LOK COMPR,SUP-2198446,CDM,C1713,HCPCS,0278,RC,,,,both,,,4388.18,2852.32,,,,,,,,,,,,,
ENDOPROSTHESIS VASC VIABAHN L 25CM 5MM 120CM 6FR RADIOPAQUE,SUP-2396643,CDM,C1874,HCPCS,0278,RC,,,,both,,,20658.06,13427.74,,,,,,,,,,,,,
SCREW BNE L40MM DIA7.5MM ST FULL THRD COMPR HDLSS ACUTRK 2,SUP-2106810,CDM,C1713,HCPCS,0278,RC,,,,both,,,1591.98,1034.79,,,,,,,,,,,,,
SCREW BNE EMGCY 1.4X9 MM ST NS AXS LTX,SUP-2862778,CDM,C1713,HCPCS,0278,RC,,,,both,,,323.17,210.06,,,,,,,,,,,,,
SPLINT WRST PADDED LG MTCRPL RT,SUP-2195719,CDM,L3809,HCPCS,0272,RC,,,,both,,,17.46,11.35,,,,,,,,,,,,,
SCREW BNE SET STD 5.5 MM 16 MM CANN THRD,SUP-2860999,CDM,C1713,HCPCS,0278,RC,,,,both,,,19094.72,12411.57,,,,,,,,,,,,,
PLATE CRAN 80X40X20 MM PT SPEC IMPL PEEK,SUP-2860176,CDM,C1713,HCPCS,0278,RC,,,,both,,,24228.55,15748.56,,,,,,,,,,,,,
SET PICC L 20 CM DIA 5 FR SHTH L 7 CM DIA 5 FR,SUP-2887011,CDM,C1751,HCPCS,0278,RC,,,,both,,,490.47,318.81,,,,,,,,,,,,,
PLATE BNE CRAN SM PEEK,SUP-2435345,CDM,C1713,HCPCS,0278,RC,,,,both,,,39410.67,25616.94,,,,,,,,,,,,,
CURETTE KYPHOPLASTY W/ 11GA NDL SPNL IVAS,SUP-2362212,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1312.77,853.30,,,,,,,,,,,,,
OXALIPLATIN 100 MG/20ML IV SOLN,RX-98540,CDM,J9263,HCPCS,0636,RC,25021-0233-20,NDC,,both,20,ML,144.00,93.60,,,,,,,,,,,,,
MESH HERN W20X20IN SFT POLYPR OPN WV PROL SURGPRO,SUP-2744748,CDM,C1781,HCPCS,0278,RC,,,,both,,,2328.09,1513.26,,,,,,,,,,,,,
SCREW ACET L 40 MM DIA 5 MM SS CORTICAL HIP STRL NOVAE VCI,SUP-2913814,CDM,C1713,HCPCS,0278,RC,,,,both,,,332.84,216.35,,,,,,,,,,,,,
MORCELLATOR ENDO L335MM OD4.75MM ROT SGL USE OUTER AND INNR,SUP-2332805,CDM,C1782,HCPCS,0272,RC,,,,both,,,1340.06,871.04,,,,,,,,,,,,,
STEM FEM L240MM OD16MM POR DST CALCAR MOD RLER HARDENED,SUP-2403944,CDM,C1776,CPT,0278,RC,,,,both,,,9794.76,6366.59,,,,,,,,,,,,,
GUIDEWIRE VASC HYBRID L 220 CM 0.012/0.007 IN D CRV STR TIP,SUP-2895591,CDM,C1769,HCPCS,0272,RC,,,,both,,,1993.90,1296.03,,,,,,,,,,,,,
GRAFT HUM TISS L230MM DIA4MM TEND HAMSTRING SEMI TENDINOSUS,SUP-2264788,CDM,C1713,HCPCS,0278,RC,,,,both,,,4014.40,2609.36,,,,,,,,,,,,,
VALVE SHUNT SM NSC ADJ W/ BIOGLDE STRATA,SUP-2631419,CDM,C1889,HCPCS,0278,RC,,,,both,,,12531.96,8145.77,,,,,,,,,,,,,
INSERT TIB BEAR POST STBL III 7493-0112,SUP-2452087,CDM,C1776,CPT,0278,RC,,,,both,,,2421.57,1574.02,,,,,,,,,,,,,
APPLIER CLP ENDOSCP MED LG 10 MMX13 IN LIG HORZ MTL LIG SYS,SUP-2656779,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2851.12,1853.23,,,,,,,,,,,,,
SET URET STENT SALLE L 12-18 CM DIA 4.7 FR CONN TUBE L 30 CM,SUP-2826998,CDM,C2625,HCPCS,0278,RC,,,,both,,,282.91,183.89,,,,,,,,,,,,,
PLATE BNE SQ MINI 2X0.6 MM 4X2 HOLE FOR SCREW NS 250240809,SUP-2472575,CDM,C1713,HCPCS,0278,RC,,,,both,,,744.12,483.68,,,,,,,,,,,,,
BLADE SHV 40DEG STD SERR DS 4MM,SUP-2313527,CDM,C1713,HCPCS,0278,RC,,,,both,,,431.31,280.35,,,,,,,,,,,,,
SPACER SPNL 20MM LO ENDPLATE 25X30MM FOOTPRINT 12DEG PEEK,SUP-2231235,CDM,C1821,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
TRACE MINERALS CU-MN-SE-ZN 60-3-6-1000 MCG/ML IV SOLN,RX-155858,CDM,2500000003,HCPCS,0250,RC,00517-9302-01,NDC,,both,1,ML,149.80,97.37,,,,,,,,,,,,,
IMMUNE GLOBULIN (GAMUNEX-C) 10%,RX-4081759,CDM,J1569,HCPCS,0636,RC,00944-2700-05,NDC,,both,100,ML,5151.00,3348.15,,,,,,,,,,,,,
BASEPLATE GLEN DIA28MM UNIV HA FOR COMPHSVE REV SHLDR SYS,SUP-2404725,CDM,C1776,CPT,0278,RC,,,,both,,,4239.00,2755.35,,,,,,,,,,,,,
SPINDLE INT FIX SM 12MM 400LB M FORC FEM POR INTFACE CPS,SUP-2406896,CDM,C1776,CPT,0278,RC,,,,both,,,9806.22,6374.04,,,,,,,,,,,,,
SCREW SPNL L35MM OD5.5MM S STL CANC PEDCL VAR ANG 76645535] MEDTRONIC SOFAMOR DANEK],SUP-2288922,CDM,C1713,HCPCS,0278,RC,,,,both,,,3404.39,2212.85,,,,,,,,,,,,,
GUIDEPIN ORTH FOR L SET TRUMATCH,SUP-2252965,CDM,C1776,CPT,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
STEM HUM 12-130 MM SHLDR TI ANAT SHLDR,SUP-2440606,CDM,C1776,CPT,0278,RC,,,,both,,,8901.90,5786.23,,,,,,,,,,,,,
RING EXT FIX 160MM 5/8 CIR FRDM,SUP-2400648,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2132.06,1385.84,,,,,,,,,,,,,
TRAY PICC CATHETER 6FR POLYUR FULL 3 LUMN NRS NONPOWER INJ,SUP-2126397,CDM,C1751,HCPCS,0278,RC,,,,both,,,596.91,387.99,,,,,,,,,,,,,
HC So Anti Dnase B,PX-3028621566,CDM,86215,CPT,0302,RC,,,,both,,,57.00,37.05,,,,,,,,,,,,,
ALLOGRAFT BNE CUBE 7.5 CC CANC,SUP-2867064,CDM,C1762,CPT,0278,RC,,,,both,,,668.19,434.32,,,,,,,,,,,,,
INSERT TIB 12MM THCK SM ARTC UNI UHMWPE MOB BEAR RT MEDL LT,SUP-2136599,CDM,C1713,HCPCS,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
BIT DRL OD6.4MM STP DISP FOR TRIGEN TAN FAN,SUP-2347045,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1891.44,1229.44,,,,,,,,,,,,,
BIT DRL QC 0.25 IN 25 MM U JT,SUP-2598584,CDM,2720000010,LOCAL,0272,RC,,,,both,,,580.90,377.58,,,,,,,,,,,,,
COMPONENT TIB TY CR 2 5 MM KNEE FIX BEAR POLYETH AOX ATTUNE,SUP-2846300,CDM,C1776,CPT,0278,RC,,,,both,,,4082.00,2653.30,,,,,,,,,,,,,
HC Chest Tube Insertion,PX-3613255100,CDM,32551,CPT,0361,RC,,,,outpatient,,,4942.00,3212.30,,,,,,,,,,,,,
STENT URIN DIV SUBQ CLOSE TIP 2 DIL 0.038IN STR GWIRE 8FR,SUP-2139622,CDM,C2617,HCPCS,0278,RC,,,,both,,,627.22,407.69,,,,,,,,,,,,,
TUBE MYR 1.14MM DIAM VENT SIL DONALDSON,SUP-2313874,CDM,L8699,HCPCS,0278,RC,,,,both,,,30.43,19.78,,,,,,,,,,,,,
PLATE BONE 3.7MM 9 H PROX HUM USE W/ 2.7MM 3.5MM SCR,SUP-2225495,CDM,C1713,HCPCS,0278,RC,,,,both,,,4619.57,3002.72,,,,,,,,,,,,,
SPLINT ORTH HND M 80DEG PLAS R MTCRPL JT W O STRP BRN,SUP-2112605,CDM,L3807,HCPCS,0274,RC,,,,both,,,167.71,109.01,,,,,,,,,,,,,
PLATE BNE L 33 X W 6.6 MM THK 0.6 MM SCREW DIA2 MM 4 H TI,SUP-2936864,CDM,C1713,HCPCS,0278,RC,,,,both,,,1673.62,1087.85,,,,,,,,,,,,,
SCREW BNE ST 2.7X12 MM CORTICAL HEX HD,SUP-2196671,CDM,C1713,HCPCS,0278,RC,,,,both,,,48.98,31.84,,,,,,,,,,,,,
"HC So Culture, Chlamydia, Any Source",PX-3008711066,CDM,87110,CPT,0300,RC,,,,outpatient,,,185.00,120.25,,,,,,,,,,,,,
SET URO 20 FR SUPRPUB ACC 12 CM LEN PEEL AWAY W/O OBT,SUP-2168916,CDM,C2627,HCPCS,0272,RC,,,,both,,,303.89,197.53,,,,,,,,,,,,,
PLATE BONE L21MM BLDE L17MM THK0.9MM SH 2X2 H RT,SUP-2191300,CDM,C1713,HCPCS,0278,RC,,,,both,,,896.78,582.91,,,,,,,,,,,,,
WASHER BOLT FIXATION FLT SLOTTED 4MM,SUP-2497045,CDM,C1713,HCPCS,0278,RC,,,,both,,,117.75,76.54,,,,,,,,,,,,,
ORTHOPAEDIC INSTRUMENT KIT 18X14X14 MM STPL DYNAFORCE HIMAXC,SUP-2866432,CDM,C1713,HCPCS,0278,RC,,,,both,,,4317.50,2806.37,,,,,,,,,,,,,
TAMP BNE INFLATABLE 2 10 MM KYPHON EXPRESS II,SUP-2664463,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3746.65,2435.32,,,,,,,,,,,,,
CATHETER CTRL VEN L23CM OD14.5FR CARBOTHANE CHRONIC MTL TUNN,SUP-2308264,CDM,C1751,HCPCS,0278,RC,,,,both,,,1388.29,902.39,,,,,,,,,,,,,
SCREW SPNL L SET FOR CONN SYS,SUP-2317813,CDM,C1713,HCPCS,0278,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
PLATE BNE W10.2XL39MM THK2.7MM 3 H BILAT S STL STR LO PROF,SUP-2186190,CDM,C1713,HCPCS,0278,RC,,,,both,,,1087.76,707.04,,,,,,,,,,,,,
DISTRACTION INTRNL EXTN CRDNC ACT ARM16 MM T 6L 4V QT001 EA,SUP-2494961,CDM,C1713,HCPCS,0278,RC,,,,both,,,3174.41,2063.37,,,,,,,,,,,,,
KIT THROMCTMY JET 7 L 132 CM PROX/DSTL OD 6 FR/2.16 MM,SUP-2880228,CDM,C1757,HCPCS,0272,RC,,,,both,,,7504.60,4877.99,,,,,,,,,,,,,
BUR SURG OD3MM MTCH HD NEURO DRL AM-8 TPS,SUP-2363482,CDM,2720000010,LOCAL,0272,RC,,,,both,,,503.44,327.24,,,,,,,,,,,,,
LIDOCAINE HCL 100 MG/5ML IJ SOSY,RX-134289,CDM,J2003,HCPCS,0636,RC,76329-3390-01,NDC,,both,2.5,ML,54.10,35.16,,,,,,,,,,,,,
LEAD ICD PASS FIX 2 COIL RIATA ST OPTIM,SUP-2356221,CDM,C1895,HCPCS,0275,RC,,,,both,,,15643.48,10168.26,,,,,,,,,,,,,
IMPLANT OSS L8.2MM HD 4.2MM THK2.3MM INCUS STAP HA HD HAPEX,SUP-2312819,CDM,L8613,CPT,0278,RC,,,,both,,,1178.50,766.02,,,,,,,,,,,,,
IMPLANT MALAR SUP PET 50X19X3MM LT DSGN RZ MEDPOR,SUP-2365272,CDM,C1776,CPT,0278,RC,,,,both,,,1500.92,975.60,,,,,,,,,,,,,
SCREW BNE L5MM OD1.5MM CRANIO MAXILLOFACIAL HD SELF DRL TI,SUP-2262615,CDM,C1713,HCPCS,0278,RC,,,,both,,,130.00,84.50,,,,,,,,,,,,,
LEAD PACE L100CM L VENT POLYUR SIL PLAT IRIDIUM PACE SENSE,SUP-2148684,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3617.28,2351.23,,,,,,,,,,,,,
SCREW BNE MALL 4.5X70 MM,SUP-2530686,CDM,C1713,HCPCS,0278,RC,,,,both,,,114.30,74.29,,,,,,,,,,,,,
COLLAR CERV SERP CNTOUR L235XH5IN L,SUP-2276596,CDM,L0120,HCPCS,0272,RC,,,,both,,,8.51,5.53,,,,,,,,,,,,,
HC Glb 	bone Marrow Harvest Autolog,PX-9823823200,CDM,38232,CPT,0982,RC,,,,both,,,14963.00,9725.95,,,,,,,,,,,,,
SCREW BNE SELF RET MINI 2X7 MM MAND DRILL-FREE CENTRE-DRIVE,SUP-2462733,CDM,C1713,HCPCS,0278,RC,,,,both,,,169.06,109.89,,,,,,,,,,,,,
IMPLANT FACE L 130 X W 130 MM THK 3 MM POLYETHYL EMBEDDED TI,SUP-2883612,CDM,C1713,HCPCS,0278,RC,,,,both,,,28043.72,18228.42,,,,,,,,,,,,,
WASHER SPNL DIA5.5MM TI FIX STPL MOSS MIAMI,SUP-2254453,CDM,C1713,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
PLATE SPNL 4 LEVEL 74 MM ANTR CERV NEO-SL,SUP-2430709,CDM,C1713,HCPCS,0278,RC,,,,both,,,6044.50,3928.92,,,,,,,,,,,,,
KIT NEUROVISION EMG HERNESS 8010016,SUP-2311742,CDM,C1713,HCPCS,0278,RC,,,,both,,,4681.74,3043.13,,,,,,,,,,,,,
BEARING TIBIAL STAR UHMWPE H8 MM ANKLE SLIDE CORE,SUP-2880136,CDM,C1776,CPT,0278,RC,,,,both,,,6421.61,4174.05,,,,,,,,,,,,,
HC 2d Echo W Contrast - WO Dop/Color Flow,PX-4839330700,CDM,C8923,CPT,0483,RC,,,,outpatient,,,1075.00,698.75,,,,,,,,,,,,,
TEMPLATE SZ LG GRID 125X125X0.6 MM MXLFCL RESORB-X LF,SUP-2479310,CDM,2720000010,LOCAL,0272,RC,,,,both,,,495.34,321.97,,,,,,,,,,,,,
MAGNET PATIENT REACTIV8,SUP-2877970,CDM,C1730,HCPCS,0272,RC,,,,both,,,279.46,181.65,,,,,,,,,,,,,
SET VASC ACCS BNCHMRK BMX96 L 100 CM OD 8 FR ID 0.096 IN,SUP-2653460,CDM,C1887,HCPCS,0272,RC,,,,both,,,2998.70,1949.15,,,,,,,,,,,,,
ENDOPROSTHESIS VASC WSTNT RP L 94 MM DIA10 MM CATH TOT L 100,SUP-2148390,CDM,C1876,HCPCS,0278,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
HC So Ehrlichia Chaffeensis Igg /Igm,PX-3028666666,CDM,86666,CPT,0302,RC,,,,outpatient,,,132.00,85.80,,,,,,,,,,,,,
WASHER ORTH FOR 3.5/4/4.5MM SCR FLOWERCUBE,SUP-2225525,CDM,C1713,HCPCS,0278,RC,,,,both,,,100.48,65.31,,,,,,,,,,,,,
BIT DRL FOR 4.75MM SUTURE ANCHR STRL REUSE ALPHAVENT OMEGA,SUP-2905791,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1271.70,826.60,,,,,,,,,,,,,
CATHETER INFUSION CLEARWAY L 80 CM BALLOON L 10 MM DIA 4 MM,SUP-2227479,CDM,C1725,HCPCS,0272,RC,,,,both,,,2307.90,1500.13,,,,,,,,,,,,,
KIT THROMCTMY STROKE FAST PK SZ 4 X 20 MM PEBAX PTFE COIL SS,SUP-2367918,CDM,C1757,HCPCS,0272,RC,,,,both,,,28873.56,18767.81,,,,,,,,,,,,,
SCREW BNE LCK 5X30 MM W/ T25 STARDRV FOR IM NAIL TI STRL,SUP-2179927,CDM,C1713,HCPCS,0278,RC,,,,both,,,648.03,421.22,,,,,,,,,,,,,
SURESPACE FEM SPACER MOLD MED,SUP-2540678,CDM,C1776,CPT,0278,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
BASEPLATE TIB 5 R MED PRI CEM UNI JOURNEY DEUCE,SUP-2346445,CDM,C1776,CPT,0278,RC,,,,both,,,3959.54,2573.70,,,,,,,,,,,,,
FORCEPS SURG THERM WIELDING ENTCEPS,SUP-2358752,CDM,C1713,HCPCS,0278,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
PLATE BNE HK SHT 2.7X9 MM LT CLAV VA LCK COMPR NS VA-LCP,SUP-2750823,CDM,C1713,HCPCS,0278,RC,,,,both,,,3456.64,2246.82,,,,,,,,,,,,,
SCREW BNE CANN 2.5X14 MM LAG SS,SUP-2392863,CDM,C1713,HCPCS,0278,RC,,,,both,,,378.37,245.94,,,,,,,,,,,,,
SCREW BNE L90MM DIA6.5MM THRD L16MM CANC S STL ST,SUP-2411274,CDM,C1713,HCPCS,0278,RC,,,,both,,,111.78,72.66,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED FEM ADV HD POROUS OXIN XLPE R3,SUP-2348014,CDM,C1776,CPT,0278,RC,,,,both,,,15386.00,10000.90,,,,,,,,,,,,,
TRAY TIB SZ 1 MOD OFFSET BKS,SUP-2315561,CDM,C1776,CPT,0278,RC,,,,both,,,6707.04,4359.58,,,,,,,,,,,,,
HC Ot Therapeutic Activities 15 Min|OP PT SERVICES|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS|UNUSUAL NON-OVERLAPPING SERVICE,PX-4309753000,CDM,97530,CPT,0430,RC,,,GP|CQ|XU,both,,,144.00,93.60,,,,,,,,,,,,,
MESH SURG 20 X 25 CM SUTURE SZ 5-0 OVINE PLGA REINF TISS,SUP-2914811,CDM,C1781,HCPCS,0278,RC,,,,both,,,25211.06,16387.19,,,,,,,,,,,,,
NAIL IM 6X140 MM FEM AG,SUP-2208078,CDM,C1713,HCPCS,0278,RC,,,,both,,,600.27,390.18,,,,,,,,,,,,,
PLATE TIBIA 4.5MM LCPV TM PROXIMAL 20 HOLES 370MM RT STERILE,SUP-2547544,CDM,C1713,HCPCS,0278,RC,,,,both,,,4861.69,3160.10,,,,,,,,,,,,,
DEVICE FIX TULIP STD 5.5 MM ASMBLY POLYAX MOD REFORM,SUP-2720026,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
K WIRE FIX L200MM DIA1.6MM FULL THRD,SUP-2362787,CDM,C1713,HCPCS,0278,RC,,,,both,,,131.88,85.72,,,,,,,,,,,,,
SPACER SPNL TI INTBDY FUS C RNG FOR 635MM ROD,SUP-2280179,CDM,C1889,HCPCS,0278,RC,,,,both,,,178.98,116.34,,,,,,,,,,,,,
SPACER NSL CATH W/ PRECIS FRM MICPOR RESVR RADPQ MRK BND,SUP-2106329,CDM,C2625,HCPCS,0278,RC,,,,both,,,2496.30,1622.59,,,,,,,,,,,,,
BAR BENT 11X175MM,SUP-2477709,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1707.66,1109.98,,,,,,,,,,,,,
ANCHOR SUT DIA55MM W NDL 2 STRND BIOSTEON INTRALINE FORC,SUP-2362555,CDM,C1713,HCPCS,0278,RC,,,,both,,,1088.01,707.21,,,,,,,,,,,,,
STENT URET POLARIS L 22 CM DIA 8 FR SENSOR GUIDEWIRE L 150,SUP-2754286,CDM,C2617,HCPCS,0278,RC,,,,both,,,550.32,357.71,,,,,,,,,,,,,
BRACE ORTHOPEDIC ADJ SAG RIGID PANEL PREFABRICATED LO,SUP-2124234,CDM,L1810,HCPCS,0274,RC,,,,both,,,1585.70,1030.70,,,,,,,,,,,,,
LEAD NEUROSTIMULATOR L60CM LAMITRODE TRIPOL 16C,SUP-2356734,CDM,C1778,HCPCS,0278,RC,,,,both,,,21556.10,14011.46,,,,,,,,,,,,,
HC So Activated Protein C (Apc),PX-3058530766,CDM,85307,CPT,0305,RC,,,,both,,,100.00,65.00,,,,,,,,,,,,,
PLATE BNE SIDE 135 DEG STD BRL 38 MM HIP 2 HOLE TALON,SUP-2391521,CDM,C1713,HCPCS,0278,RC,,,,both,,,1185.04,770.28,,,,,,,,,,,,,
HANDLE SET SCR TIB DSTL INSTR,SUP-2137064,CDM,C1713,HCPCS,0278,RC,,,,both,,,368.70,239.65,,,,,,,,,,,,,
JOINT WRST 5 FOR PYROCARBON LUNATE,SUP-2852855,CDM,C1776,CPT,0278,RC,,,,both,,,19911.53,12942.49,,,,,,,,,,,,,
PROBE ARTHSCP L220MM 60DEG MEAS FOR SUP CAPSULAR RECON,SUP-2121825,CDM,2720000010,LOCAL,0272,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
NUT ORTH W8MM DIA11MM TI FOR 45MM CORT SCR,SUP-2190559,CDM,C1713,HCPCS,0278,RC,,,,both,,,88.80,57.72,,,,,,,,,,,,,
FLEXIGRAFT CONN PRE SUTURED TEND,SUP-2264629,CDM,C1713,HCPCS,0278,RC,,,,both,,,4029.94,2619.46,,,,,,,,,,,,,
GRAFT VASC HEMSHLD PLAT L 60 CM 22MM POLYESTER BOV CLLGN STR,SUP-2265928,CDM,C1768,CPT,0278,RC,,,,both,,,4697.44,3053.34,,,,,,,,,,,,,
MESH BIO GRFT HERN PORCINE MTRX INGUINAL 15CM LEN 8CM W,SUP-2170063,CDM,C1781,HCPCS,0278,RC,,,,both,,,722.20,469.43,,,,,,,,,,,,,
BIT DRL STP OPENING 6 MM FOR OLECRANON OSTEOTMY NAIL NS,SUP-2757679,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1136.77,738.90,,,,,,,,,,,,,
INSTRUMENT ENDO DIA7MM ACL TIGHTROPE DB,SUP-2121398,CDM,C1713,HCPCS,0278,RC,,,,both,,,1460.10,949.06,,,,,,,,,,,,,
NAIL FEMORAL 14MM RETROGRADE,SUP-2752470,CDM,C1713,HCPCS,0278,RC,,,,both,,,11194.10,7276.16,,,,,,,,,,,,,
PLATE BNE XL L LOK CALCANEUS,SUP-2413699,CDM,C1713,HCPCS,0278,RC,,,,both,,,3445.68,2239.69,,,,,,,,,,,,,
STEM HUM 13 MM SHLDR REUNION RFX,SUP-2451924,CDM,C1776,CPT,0278,RC,,,,both,,,715.92,465.35,,,,,,,,,,,,,
CLAMP CRAN TEXT 18 MM FLAPFIX FOR EXT FIX TI STRL LF,SUP-2431409,CDM,C1713,HCPCS,0278,RC,,,,both,,,1277.35,830.28,,,,,,,,,,,,,
PLATE BNE MESHED SM 1.5X0.6 MM MIDFACE 6X2 HOLE TI NS,SUP-2472843,CDM,C1713,HCPCS,0278,RC,,,,both,,,1022.82,664.83,,,,,,,,,,,,,
HC Office/OP Consltj New/Est Pt Low Mdm 30 Minutes,PX-5109924300,CDM,99243,CPT,0510,RC,,,,both,,,185.00,120.25,,,,,,,,,,,,,
POST EXT FIX WIRE HYBRID RNG FOR 1.5/2MM HOFFMANN II,SUP-2372246,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1805.50,1173.57,,,,,,,,,,,,,
SCREW BONE FINE PITCH 2X5 MM MANDIBULAR SELFTAPPING 5/PK TIT,SUP-2842318,CDM,C1713,HCPCS,0278,RC,,,,both,,,264.20,171.73,,,,,,,,,,,,,
FIBER SURG LASER CO2 BEAMPATH,SUP-2225708,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2983.00,1938.95,,,,,,,,,,,,,
HC Diag Lumbar Spinal Puncture W/Fluor or CT,PX-3616232800,CDM,62328,CPT,0361,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
TACTRA MALL PENILE PROS 9.5MMX14-23 CM,SUP-2417952,CDM,C2622,HCPCS,0278,RC,,,,both,,,27993.10,18195.51,,,,,,,,,,,,,
FIBER LASER 200 MH BALL TIP SOLTIVE DISP,SUP-2540081,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1993.30,1295.64,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 100 MG 1 YR SHLF LIFE VIADISC NP,SUP-2740077,CDM,C1762,CPT,0278,RC,,,,both,,,25120.00,16328.00,,,,,,,,,,,,,
FIXATION BEAM 4.5 X120 MM,SUP-2604350,CDM,C1713,HCPCS,0278,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
HC Extrem Up Elbow Arthrogram,PX-3227308500,CDM,73085,CPT,0322,RC,,,,outpatient,,,3707.00,2409.55,,,,,,,,,,,,,
CEMENT FLX FEM/CEM TIB/STD SURF/NO PAT,SUP-2212159,CDM,C1776,CPT,0278,RC,,,,both,,,10771.93,7001.75,,,,,,,,,,,,,
PLATE BNE MAXILLOFCL 2 MESH NS FACE ID,SUP-2909541,CDM,C1713,HCPCS,0278,RC,,,,both,,,30117.37,19576.29,,,,,,,,,,,,,
NEEDLE BX L50.5CM 16GA TRANSEPTAL ROSS MOD COLAPINTO DSGN,SUP-2170008,CDM,2720000010,LOCAL,0272,RC,,,,both,,,780.48,507.31,,,,,,,,,,,,,
STENT CAR ENROUTE L 30 MM DIA 9 MM WORKING L 57 CM CROSSING,SUP-2431171,CDM,C1876,HCPCS,0278,RC,,,,both,,,8098.06,5263.74,,,,,,,,,,,,,
GUIDEWIRE THRD 3.2X230MM,SUP-2704858,CDM,C1769,HCPCS,0272,RC,,,,both,,,395.64,257.17,,,,,,,,,,,,,
ALLOGRAFT BNE STRP 15X40X2 MM CORTICAL FLEXIGRAFT,SUP-2740839,CDM,C1713,HCPCS,0278,RC,,,,both,,,1612.20,1047.93,,,,,,,,,,,,,
PLATE 3.5MM SPRING PLATE 1 HOLE-STERILE,SUP-2546015,CDM,C1713,HCPCS,0278,RC,,,,both,,,1104.06,717.64,,,,,,,,,,,,,
HC Trluml Perip Athrc Renal Art,PX-3610234000,CDM,0234T,HCPCS,0361,RC,,,,both,,,10136.00,6588.40,,,,,,,,,,,,,
FILLER DEMIN CANC 5CC,SUP-2138526,CDM,C1713,HCPCS,0278,RC,,,,both,,,1927.80,1253.07,,,,,,,,,,,,,
BIT DRILL COMPRESSION SCREW CANN 18MM,SUP-2813096,CDM,2720000010,LOCAL,0272,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
END CAP ORTH DIA1 MM TI FOR FIBULAR NAIL NS PHANTOM,SUP-2908990,CDM,C1889,HCPCS,0278,RC,,,,both,,,846.23,550.05,,,,,,,,,,,,,
ANCHOR SUTURE DIAMETER 5.5MM WITH NEEDLE SOFT TISSUE NONBIOA,SUP-2824897,CDM,C1713,HCPCS,0278,RC,,,,both,,,1733.28,1126.63,,,,,,,,,,,,,
SCREW BNE L14MM DIA2.3MM CORT LOK FOR VOLAR DST RAD PLATING,SUP-2107576,CDM,C1713,HCPCS,0278,RC,,,,both,,,342.26,222.47,,,,,,,,,,,,,
ANCHOR SUTURE NO2 DIAMETER 1.3MM LABRAL SHOULDER BLUE SINGLE,SUP-2828684,CDM,C1713,HCPCS,0278,RC,,,,both,,,1456.46,946.70,,,,,,,,,,,,,
ALLOGRAFT DERMAL UNMESHED 2X12 CMX1-2 MM PROLAYER,SUP-2717796,CDM,C1763,HCPCS,0278,RC,,,,both,,,8666.40,5633.16,,,,,,,,,,,,,
STENT TRACHBRONCH WSTNT L 90 MM DIA12 MM SHTH 9 FR CATH L,SUP-2147052,CDM,C1876,HCPCS,0278,RC,,,,both,,,5430.41,3529.77,,,,,,,,,,,,,
FLUOROMETHOLONE 0.25 % OP SUSP,RX-19722,CDM,6370000000,HCPCS,0637,RC,11980-0228-05,NDC,,both,5,ML,757.90,492.63,,,,,,,,,,,,,
COMPONENT FEM CEM 2XS UNISX LT KNEE REV CR STEM BEAD VIT,SUP-2377025,CDM,C1776,CPT,0278,RC,,,,both,,,14016.96,9111.02,,,,,,,,,,,,,
PLATE BNE L 156 MM SCREW DIA 3.5 MM 12 SHFT H SS MTPHSEAL VA,SUP-2907691,CDM,C1713,HCPCS,0278,RC,,,,both,,,3076.10,1999.46,,,,,,,,,,,,,
CATHETER SUPP RUBICON 35 L 135 CM DIA 5 FR TIP 2.84 FR PROX,SUP-2146040,CDM,C1887,HCPCS,0272,RC,,,,both,,,477.91,310.64,,,,,,,,,,,,,
TROCAR ENDOSCP DIA10 MM SZ 5/ 7/8 MM POLYUR BALLOON BLNT TIP,SUP-2896351,CDM,2720000010,LOCAL,0272,RC,,,,both,,,623.20,405.08,,,,,,,,,,,,,
SCREW SPNL L32MM DIA5.2MM CORT ANTR LUM ST VAR ANG AEGIS,SUP-2256321,CDM,C1713,HCPCS,0278,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 25X95 MM FD PERIO FASC LATA ORAGRAFT,SUP-2740992,CDM,C1762,CPT,0278,RC,,,,both,,,728.98,473.84,,,,,,,,,,,,,
SEALER LAP L20CM SHFT DIA10MM TISS FUS OPN INSTR STR BILAT,SUP-2283571,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1072.84,697.35,,,,,,,,,,,,,
MESH HERN W8XL9CM POLY ABSRB CLLGN FLM COMP HRSHOE SHP FOR,SUP-2174721,CDM,C1781,HCPCS,0278,RC,,,,both,,,2215.65,1440.17,,,,,,,,,,,,,
INTRODUCER SHTH STR 0.018 IN 6 FRX11 CM 21 GAX4 CM PRELUDE,SUP-2303222,CDM,C1894,HCPCS,0272,RC,,,,both,,,126.60,82.29,,,,,,,,,,,,,
STENT BILI S.M.A.R.T. CTRL L 30 MM DIA 6 MM DEL SYS L 120 CM,SUP-2155437,CDM,C1876,HCPCS,0278,RC,,,,both,,,3821.38,2483.90,,,,,,,,,,,,,
CATHETER DIAG 6FR L145CM WIRE CTRL VENTURE,SUP-2356654,CDM,C1887,HCPCS,0272,RC,,,,both,,,2289.06,1487.89,,,,,,,,,,,,,
PLATE STR 1.5MM 6H VAL,SUP-2546070,CDM,C1713,HCPCS,0278,RC,,,,both,,,1473.26,957.62,,,,,,,,,,,,,
KIT CATH HEMODIALYSI DECATHLON DF CHRONIC STD 16FR DIA 24CM,SUP-2613308,CDM,C1750,HCPCS,0278,RC,,,,both,,,1134.17,737.21,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.432,SUP-2859996,CDM,C1713,HCPCS,0278,RC,,,,both,,,43735.80,28428.27,,,,,,,,,,,,,
KIT CATH AD 12.5FR L90CM 3 LUMN CTRL VEN TUNNELED NONCOATED,SUP-2127693,CDM,C1751,HCPCS,0278,RC,,,,both,,,524.38,340.85,,,,,,,,,,,,,
HC Bx Bone Trocar/Needle Deep,PX-3612022500,CDM,20225,CPT,0361,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
IMPLANT TOE 3.4X3X26MM TWO STEP FOR HAMMER TOE,SUP-2878124,CDM,C1776,CPT,0278,RC,,,,both,,,5024.00,3265.60,,,,,,,,,,,,,
CUP ACET OD48MM ID28MM TI ALLY POLY TRABECULAR MTL POR 1 PC,SUP-2202898,CDM,C1776,CPT,0278,RC,,,,both,,,14130.00,9184.50,,,,,,,,,,,,,
GRAFT STENT 0.035 IN 6 MMX15 CM 7 FRX75 CM EPTFE VIABAHN,SUP-2396500,CDM,C1874,HCPCS,0278,RC,,,,both,,,10864.40,7061.86,,,,,,,,,,,,,
PLATE BONE STRUT 2 MM 2X10 HOLE RAPID RESORBABLE STERILE RAP,SUP-2838595,CDM,C1713,HCPCS,0278,RC,,,,both,,,1967.21,1278.69,,,,,,,,,,,,,
BROACH SURG DSTL 1 LESSER METATRSL PHLANG SYS,SUP-2609667,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1827.07,1187.60,,,,,,,,,,,,,
TUBE VENT 1.14 MM 1 MM 2.5X3.5 MM POPE SIL STRL,SUP-2477440,CDM,L8699,HCPCS,0278,RC,,,,both,,,42.86,27.86,,,,,,,,,,,,,
DEVICE SUT CAPT 38.2GM SHFT DIA3MM HD W6.3MM CARR DIA1.2MM,SUP-2139404,CDM,C2631,HCPCS,0278,RC,,,,both,,,2326.52,1512.24,,,,,,,,,,,,,
HC Bilirubin Direct,PX-3018224800,CDM,82248,CPT,0301,RC,,,,both,,,359.00,233.35,,,,,,,,,,,,,
SCREW BNE L110MM DIA7.3MM S STL ST CANN NONLOCKING,SUP-2184792,CDM,C1713,HCPCS,0278,RC,,,,both,,,741.45,481.94,,,,,,,,,,,,,
PLATE BNE LCK 210 MM RT DSTL LAT FIBULAR 14 HOLE SS STRL,SUP-2469509,CDM,C1713,HCPCS,0278,RC,,,,both,,,2628.78,1708.71,,,,,,,,,,,,,
GUIDEWIRE VASC GLIDEWIRE 45 DEG L 450 CM DIA 0.035 IN STIFF,SUP-2535565,CDM,C1769,HCPCS,0272,RC,,,,both,,,336.29,218.59,,,,,,,,,,,,,
TUBE VENT ID127MM WHT ST PACIFIC COAT FLROPLAS MYR,SUP-2313857,CDM,L8699,HCPCS,0278,RC,,,,both,,,26.75,17.39,,,,,,,,,,,,,
RING ACET DIA36MM FOR MOD CUP REPL LCK,SUP-2503584,CDM,C1776,CPT,0278,RC,,,,both,,,197.82,128.58,,,,,,,,,,,,,
CATHETER THROMCTMY RED 43 L 138 CM PTFE SS NIT COIL REDGLIDE,SUP-2880243,CDM,C1887,HCPCS,0272,RC,,,,both,,,7504.60,4877.99,,,,,,,,,,,,,
ALLOGRAFT BNE STRP MED FD IRRADIATED IL CREST,SUP-2867107,CDM,C1762,CPT,0278,RC,,,,both,,,5703.50,3707.27,,,,,,,,,,,,,
INTRODUCER SHTH LNG 8 FR SAFSHTH,SUP-2465231,CDM,C1894,HCPCS,0272,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
NAIL IM UNIV HUM VERSANAIL,SUP-2606563,CDM,C1713,HCPCS,0278,RC,,,,both,,,5325.44,3461.54,,,,,,,,,,,,,
IMPLANT BRST RND BASE 5.7 CM 11.9 CM 370 CC TEXT SHP HI GEL,SUP-2339891,CDM,C1789,HCPCS,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
CLIP ENDO L220CM CAP D6MM DIA11.5-14MM NIT HANDWHEEL THRD,SUP-2319931,CDM,C1889,HCPCS,0278,RC,,,,both,,,2194.86,1426.66,,,,,,,,,,,,,
SET EMB TRUFILL 10 ML 2 GM 1 GM N-BCA TANTALUM ETHIODIZED,SUP-2913676,CDM,C1889,HCPCS,0278,RC,,,,both,,,23707.00,15409.55,,,,,,,,,,,,,
GRAFT HUM TISS W16XL20CM THK15 22MM THCK ACELLULAR,SUP-2307569,CDM,Q4128,HCPCS,0636,RC,,,,both,,,28288.26,18387.37,,,,,,,,,,,,,
OFFSET END CAP 12X1MM,SUP-2722210,CDM,C1889,HCPCS,0278,RC,,,,both,,,464.72,302.07,,,,,,,,,,,,,
SEGMENT FEM L13CM INTERCALARY FINN CPS,SUP-2406903,CDM,C1776,CPT,0278,RC,,,,both,,,16284.04,10584.63,,,,,,,,,,,,,
SLING GYN L45XW1CM UNIV FLAT TAPE ANTR VAG POLYPR FOR URETH,SUP-2165318,CDM,C1771,HCPCS,0278,RC,,,,both,,,3194.95,2076.72,,,,,,,,,,,,,
PLATE BNE VA NEUT 2.7/3.5X202 MM RT DSTL TIB 12 HOLE LCK LP,SUP-2177682,CDM,C1713,HCPCS,0278,RC,,,,both,,,5943.42,3863.22,,,,,,,,,,,,,
CONVERTER GRAFT 22X113MM 18FR 7.1MM,SUP-2751318,CDM,C1874,HCPCS,0278,RC,,,,both,,,21000.32,13650.21,,,,,,,,,,,,,
PROBE SURG JAKO 90 DEG 2 MM 295 MM LARYNGEAL ANGLED,SUP-2459205,CDM,2720000010,LOCAL,0272,RC,,,,both,,,494.17,321.21,,,,,,,,,,,,,
CLIP ANEUR BLDE W7MM DIA2.5MM S STL GRFT SLIM-LINE,SUP-2243081,CDM,C1713,HCPCS,0278,RC,,,,both,,,5598.62,3639.10,,,,,,,,,,,,,
STEM FEM L30MM OD16MM UNIV CSTI POR KNEE PRI CEM FLUT IMP,SUP-2208275,CDM,C1776,CPT,0278,RC,,,,both,,,13621.32,8853.86,,,,,,,,,,,,,
COMPONENT TOT SHLDR CAPPED S5 RESURF,SUP-2419705,CDM,C1776,CPT,0278,RC,,,,both,,,8792.00,5714.80,,,,,,,,,,,,,
ANCHOR SUT 2 ORTHOCORD L36IN VLT BLU COMP BRAID SUT CP-2,SUP-2249448,CDM,C1713,HCPCS,0278,RC,,,,both,,,2719.24,1767.51,,,,,,,,,,,,,
ABLATOR ASPIRATING RF H50 APOLLO,SUP-2711654,CDM,2720000010,LOCAL,0272,RC,,,,both,,,816.40,530.66,,,,,,,,,,,,,
POROUS FEM W/ COCR HD ANDXLPE ALL POLY CUP,SUP-2347943,CDM,C1776,CPT,0278,RC,,,,both,,,16328.00,10613.20,,,,,,,,,,,,,
KIT CATHETER 7FR L20CM 2 TIP STR J DIL GWIRE INTRO,SUP-2383326,CDM,C1751,HCPCS,0278,RC,,,,both,,,135.27,87.93,,,,,,,,,,,,,
KIT DLYS .038 IN PEEL AWAY SHTH FLEX STIFFENER GWIRE SCALP,SUP-2120055,CDM,C1881,HCPCS,0278,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
ADAPTER SL +0MM OFFSET UNIV HIP TI V40 TAPR ACCOLADE II,SUP-2376607,CDM,C1776,CPT,0278,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
PLATE BONE L18MM THK0.6MM 2X3 H MIDFACE TI RECTANG MTRX FOR,SUP-2402891,CDM,C1713,HCPCS,0278,RC,,,,both,,,590.32,383.71,,,,,,,,,,,,,
GUIDEWIRE ORTH L230MM OD32MM TRCR TIP PLN,SUP-2243925,CDM,C1769,HCPCS,0272,RC,,,,both,,,266.27,173.08,,,,,,,,,,,,,
SCR MMF DF HEX ETCHD2X15MM TEMP USE,SUP-2669057,CDM,C1713,HCPCS,0278,RC,,,,both,,,595.63,387.16,,,,,,,,,,,,,
GRAFT TISS FRZN ALLGRFT ILIUM SEG 1/3 SPL,SUP-2113902,CDM,C1713,HCPCS,0278,RC,,,,both,,,4904.68,3188.04,,,,,,,,,,,,,
BRONCHOSCOPE GS BFLEX 2 SLIM 3.8 SU,SUP-2864556,CDM,2720000010,LOCAL,0272,RC,,,,both,,,815.14,529.84,,,,,,,,,,,,,
CANNULA OUTFLO VERSASCOPE,SUP-2257609,CDM,C1713,HCPCS,0278,RC,,,,both,,,602.88,391.87,,,,,,,,,,,,,
GRAFT ALLGRFT STRP DBM PLF 2.5CMX10CM GRFTON,SUP-2293903,CDM,C1713,HCPCS,0278,RC,,,,both,,,6296.11,4092.47,,,,,,,,,,,,,
COMPONENT FEM POLYMER MTL R LAT KNEE TIB BICOMPARTMENTAL,SUP-2165963,CDM,C1776,CPT,0278,RC,,,,both,,,22608.00,14695.20,,,,,,,,,,,,,
STEM FEM SZ 00 L110MM DIA9MM NK L26MM 28MM OFFSET 132DEG,SUP-2375321,CDM,C1776,CPT,0278,RC,,,,both,,,13325.53,8661.59,,,,,,,,,,,,,
POST EXT FIX PIN MT MULTIPARALLEL 5 HI NS MAXFRAME,SUP-2758002,CDM,2720000010,LOCAL,0272,RC,,,,both,,,640.84,416.55,,,,,,,,,,,,,
FORCEPS BX L 1150 MM DIA1.15 MM CHANNEL DIA1.2 MM LUNG RAT,SUP-2912537,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1495.43,972.03,,,,,,,,,,,,,
PLATE BONE LOK NON CMPRSSN HLX12 25MM THK TTNM STRGHT LVLX1,SUP-2679055,CDM,C1713,HCPCS,0278,RC,,,,both,,,2939.01,1910.36,,,,,,,,,,,,,
STEM FEM SHT EM KNEE W/ BODY VANGUARD PREMIER,SUP-2446340,CDM,C1776,CPT,0278,RC,,,,both,,,3447.72,2241.02,,,,,,,,,,,,,
STENT COR 8MM 2.25MM PACLITAXEL ELUT COAT CO CHROM ALLY,SUP-2105591,CDM,C1874,HCPCS,0278,RC,,,,both,,,2983.00,1938.95,,,,,,,,,,,,,
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 IJ SOLN,RX-106534,CDM,2500000003,HCPCS,0250,RC,63323-0468-17,NDC,,both,1,ML,54.10,35.16,,,,,,,,,,,,,
CATHETER INFUSION CLEARWAY BALLOON L 10 MM DIA1 MM PERIPH,SUP-2227350,CDM,C1725,HCPCS,0272,RC,,,,both,,,2135.20,1387.88,,,,,,,,,,,,,
HC MRI-Upper Ext WO Cont,PX-6107321800,CDM,73218,CPT,0610,RC,,,,outpatient,,,4976.00,3234.40,,,,,,,,,,,,,
CATHETER EP D CRV 2-5-2 MM 6 FRX115 CM,SUP-2303653,CDM,C1733,HCPCS,0272,RC,,,,both,,,207.24,134.71,,,,,,,,,,,,,
GRAFT DURA XS 7X5 IN REGEN MTRX DURAGN,SUP-2624232,CDM,C1763,HCPCS,0278,RC,,,,both,,,6215.38,4040.00,,,,,,,,,,,,,
PLATE BNE TRPL OSTEOTMY 45 DEG 3.5X75 MM LT 6 HOLE SS,SUP-2569188,CDM,C1713,HCPCS,0278,RC,,,,both,,,214.15,139.20,,,,,,,,,,,,,
TIP ASPIR L4.78IN DIA0.06IN SUCT EXT FLUE CRV DISP CUSA,SUP-2243959,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2259.98,1468.99,,,,,,,,,,,,,
BEAM FIX L85MM DIA5.5MM ARTH FOR CHARCOT DEFORMITY AXIS,SUP-2223940,CDM,C1713,HCPCS,0278,RC,,,,both,,,4050.60,2632.89,,,,,,,,,,,,,
SYSTEM ANCHR PELV PRESSIN,SUP-2141758,CDM,C1713,HCPCS,0278,RC,,,,both,,,635.85,413.30,,,,,,,,,,,,,
STENT BILI S.M.A.R.T. CTRL L 60 MM DIA10 MM DEL SYS L 80 CM,SUP-2155371,CDM,C1876,HCPCS,0278,RC,,,,both,,,3925.63,2551.66,,,,,,,,,,,,,
CROWN DENT SZ 4 NOEUL-4 SEC PRI M UP L S STL,SUP-2322195,CDM,D6783,CPT,0278,RC,,,,both,,,28.45,18.49,,,,,,,,,,,,,
WEDGE BNE BIOFOAM CANC TI ALLGRFT 14MMX10MMX22MMX5MM,SUP-2397883,CDM,C1713,HCPCS,0278,RC,,,,both,,,6393.04,4155.48,,,,,,,,,,,,,
FOOTPLATE EXT FIX 100 MM TRUELOK +,SUP-2645677,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1273.74,827.93,,,,,,,,,,,,,
PLATE BNE 7 H CALCANEAL S7 MIS NS VARIAX,SUP-2900795,CDM,C1713,HCPCS,0278,RC,,,,both,,,5154.62,3350.50,,,,,,,,,,,,,
NEEDLE PUNC W/ FNGR VLV 2 MM TIP 5 MMX45 CM LL,SUP-2850976,CDM,2720000010,LOCAL,0272,RC,,,,both,,,405.47,263.56,,,,,,,,,,,,,
ELECTRODE ELECSURG POWERBALL 24 FR FOR PRO SER RESECTOSCOPE,SUP-2754291,CDM,2720000010,LOCAL,0272,RC,,,,both,,,370.77,241.00,,,,,,,,,,,,,
DEVICE ENDOSKELETAL SYS BK ALIGNABLE SYS,SUP-2388219,CDM,L5910,HCPCS,0272,RC,,,,both,,,958.74,623.18,,,,,,,,,,,,,
BIT DRL DIA4.5MM CANN FOR TARGETER PLATING SYS PERI-LOC,SUP-2343991,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1489.40,968.11,,,,,,,,,,,,,
MESH HERN W30XL30CM POLYGLACTIN 910 WVN FLAT VCRL,SUP-2257602,CDM,C1781,HCPCS,0278,RC,,,,both,,,3278.10,2130.76,,,,,,,,,,,,,
CANNULA ARTHSCP 2.9 MM OPERATIVE SHT WINDOW NS LTX,SUP-2877933,CDM,2720000010,LOCAL,0272,RC,,,,both,,,722.04,469.33,,,,,,,,,,,,,
STENT GRFT VASC AFX BODY L 90 MM DIA28 MM LIMB 30 MM 20 MM,SUP-2217658,CDM,C1768,CPT,0278,RC,,,,both,,,34398.70,22359.15,,,,,,,,,,,,,
IMPLANT BRST 560CC DIA13.5CM P5.7CM SIL RESPON GEL FULL,SUP-2113694,CDM,C1789,HCPCS,0278,RC,,,,both,,,2778.90,1806.28,,,,,,,,,,,,,
FIBER LASER FLAT TIP 200 MH ASMBLY HOLM CMH1020FL] MEDWEST ASSOCIATES INC],SUP-2300073,CDM,C1713,HCPCS,0278,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
SYSTEM THROMCTMY POUNCE L 128 CM WORKING L 90 CM SHTH 10 FR,SUP-2913965,CDM,C1757,HCPCS,0272,RC,,,,both,,,21823.00,14184.95,,,,,,,,,,,,,
SCREW BNE L34MM DIA5MM CORT TI ST NONCANNULATED LOK FULL,SUP-2190246,CDM,C1713,HCPCS,0278,RC,,,,both,,,433.63,281.86,,,,,,,,,,,,,
TUBE TRACH AD L40MM KISTNER,SUP-2383846,CDM,2720000010,LOCAL,0272,RC,,,,both,,,159.83,103.89,,,,,,,,,,,,,
REAMER IM PRSS FLX 260MM DIA SENTNL,SUP-2198042,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1769.77,1150.35,,,,,,,,,,,,,
SYSTEM BUR H SHUNT YEL M PRSS W/ VLV DRNGE CATH VENT CATH,SUP-2308187,CDM,C1713,HCPCS,0278,RC,,,,both,,,2750.70,1787.95,,,,,,,,,,,,,
DRILL SURG RVS SHLDR KIT FOR 2-3.2 MM DRL BIT GPS DISP,SUP-2451485,CDM,2720000010,LOCAL,0272,RC,,,,both,,,950.79,618.01,,,,,,,,,,,,,
SCREW CANN 6.5X4.5MM,SUP-2211455,CDM,C1713,HCPCS,0278,RC,,,,both,,,3061.50,1989.97,,,,,,,,,,,,,
CATHETER IV OD4FR POLY MIDLN 1 LUMN MAX BARR,SUP-2125579,CDM,C1751,HCPCS,0278,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
PLATE BNE LCK WIDE RT TROCHANTERIC BRIDGE N CONTACT POLYAX,SUP-2492625,CDM,C1713,HCPCS,0278,RC,,,,both,,,3022.06,1964.34,,,,,,,,,,,,,
GRAFT BNE SUB 5CC CEM KT INJ CA PHSPTE LIQ PWD BWL SPAT SYR,SUP-2366470,CDM,C1713,HCPCS,0278,RC,,,,both,,,4741.93,3082.25,,,,,,,,,,,,,
FIBER LASER 200UM FLX HOLM DISPOSABLE,SUP-2313984,CDM,C1713,HCPCS,0278,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
SCREW BNE LCK 3.5X40 MM ST SS NS,SUP-2184250,CDM,C1713,HCPCS,0278,RC,,,,both,,,454.99,295.74,,,,,,,,,,,,,
PLATE BNE STR NAR 4.5X183 MM 11 HOLE 2 COMPR FOR SCR SS NS,SUP-2463098,CDM,C1713,HCPCS,0278,RC,,,,both,,,538.20,349.83,,,,,,,,,,,,,
ELECTRODE SUBDERM NDL L 18 MM CABLE L 2 M 2 CHANNEL PRASS PR,SUP-2901967,CDM,2720000010,LOCAL,0272,RC,,,,both,,,529.00,343.85,,,,,,,,,,,,,
HC Thromb Mech 2nd Vssl,PX-3613718500,CDM,37185,CPT,0361,RC,,,,both,,,4295.00,2791.75,,,,,,,,,,,,,
LASER SURG 532 NM 1 197.25IT AUTO SL130,SUP-2713781,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8917.60,5796.44,,,,,,,,,,,,,
SAMPLER SET BRONCHSCP LG 85 DEG CLOSED LOOP ORNG ASCOPE 4,SUP-2752995,CDM,2720000010,LOCAL,0272,RC,,,,both,,,963.98,626.59,,,,,,,,,,,,,
PLATE BONE L35MM BLDE W9.2XL80MM 90DEG 6 H BILAT S STL LCK,SUP-2185368,CDM,C1713,HCPCS,0278,RC,,,,both,,,2974.93,1933.70,,,,,,,,,,,,,
STENT COR 18MM 2MM 0.014IN HYDRPHLC RX LO PROF,SUP-2103672,CDM,C1876,HCPCS,0278,RC,,,,both,,,1962.50,1275.62,,,,,,,,,,,,,
SYSTEM BREATHING ADULT 22MM HME AND MR,SUP-2850079,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1529.12,993.93,,,,,,,,,,,,,
HC Dx Breast Tomo Uni,PX-4017706100,CDM,G0279,HCPCS,0401,RC,,,,inpatient,,,153.00,99.45,,,,,,,,,,,,,
GLYCERIN LIQD,RX-28815,CDM,340b,HCPCS,0637,RC,31722-0939-47,NDC,,both,473,ML,93.70,60.90,,,,,,,,,,,,,
MESH HERN 11X6CM MACROPOROUS KEYHOLE PARIETENE,SUP-2172439,CDM,C1781,HCPCS,0278,RC,,,,both,,,402.01,261.31,,,,,,,,,,,,,
SCREW SQ FIT 1.2X6MM,SUP-2366197,CDM,C1713,HCPCS,0278,RC,,,,both,,,175.78,114.26,,,,,,,,,,,,,
CATHETER THROMCTMY SYM PROHELIX L 102 CM DIA24 FR AUXILIARY,SUP-2887295,CDM,C1757,HCPCS,0272,RC,,,,both,,,3124.30,2030.79,,,,,,,,,,,,,
CATHETER DEL SYS 8 FRX47 CM APEEL CS,SUP-2357688,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1648.50,1071.52,,,,,,,,,,,,,
NIPPER NAIL CONCV CHROM 5 1/2IN,SUP-2243050,CDM,C1713,HCPCS,0278,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
KIT EXP NDL L6IN SOAK CATH L5IN T PEEL ON-Q,SUP-2236831,CDM,C2626,HCPCS,0278,RC,,,,both,,,128.74,83.68,,,,,,,,,,,,,
KWIRE FIX L6IN DIA11MM S STL 3 SIDE DBL TRCR BOTH END PNT,SUP-2150335,CDM,C1713,HCPCS,0278,RC,,,,both,,,7.50,4.87,,,,,,,,,,,,,
HC Surgery Level 4 Base,PX-3600000004,CDM,3600000004,LOCAL,0360,RC,,,,both,,,6734.00,4377.10,,,,,,,,,,,,,
SPLINT KNEE L16IN FOR 29IN THGH UNIV FOAM LAM 3IN E CNTCT,SUP-2197153,CDM,L1810,HCPCS,0274,RC,,,,both,,,32.37,21.04,,,,,,,,,,,,,
BIT DRILL QUICK DISCONNECT DISPOSABLE FOR 1.5MM WIRE,SUP-2431395,CDM,2720000010,LOCAL,0272,RC,,,,both,,,769.30,500.04,,,,,,,,,,,,,
CENTRALIZER VERSYS DISTAL 10MM,SUP-2504427,CDM,C1776,CPT,0278,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
PLATE BNE MESHED XL LT CALCANEAL LCK NS A.L.P.S,SUP-2497770,CDM,C1713,HCPCS,0278,RC,,,,both,,,3097.58,2013.43,,,,,,,,,,,,,
CUP ACET PATELLAR 3 1 STP CUT,SUP-2441709,CDM,C1776,CPT,0278,RC,,,,both,,,932.58,606.18,,,,,,,,,,,,,
ROD EXT FIX L382MM DIA11MM 90DEG UNIV C FBR SEMI CIR CRV,SUP-2188643,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1713.31,1113.65,,,,,,,,,,,,,
SCREW INTRF 10X35 MM ROUNDED EDGE FT PEEK OPTMA,SUP-2762239,CDM,C1713,HCPCS,0278,RC,,,,both,,,775.58,504.13,,,,,,,,,,,,,
PLATE DSTL VOLAR RT NAR 22 MMX52 MM,SUP-2361545,CDM,C1713,HCPCS,0278,RC,,,,both,,,2731.80,1775.67,,,,,,,,,,,,,
FLUCONAZOLE 40 MG/ML PO SUSR,RX-14233,CDM,340b,HCPCS,0637,RC,16714-0696-01,NDC,,both,2.5,ML,18.40,11.96,,,,,,,,,,,,,
TAP SURG SCR SLD BONE SPNL CLR CODE 4.5MM DYNALOK,SUP-2290322,CDM,C1713,HCPCS,0278,RC,,,,both,,,1470.56,955.86,,,,,,,,,,,,,
BUPRENORPHINE HCL 8 MG SL SUBL,RX-34712,CDM,J0571,HCPCS,0636,RC,60687-0492-21,NDC,,both,1,UN,15.80,10.27,,,,,,,,,,,,,
HC NM Acute GI Bleed Study,PX-3417827800,CDM,78278,CPT,0341,RC,,,,outpatient,,,2106.00,1368.90,,,,,,,,,,,,,
GRAFT VASC HEMSHLD PLAT L 50 CM DIA 32 MM BRANCH SZ 10 MM,SUP-2227365,CDM,C1768,CPT,0278,RC,,,,both,,,4132.59,2686.18,,,,,,,,,,,,,
ALLOGRAFT BNE STRP 22X45 MM PRESERVON TRICORT MATRIGRAFT,SUP-2741055,CDM,C1713,HCPCS,0278,RC,,,,both,,,4843.95,3148.57,,,,,,,,,,,,,
NEEDLE LAP 140 MM FOR FACE CLOSURE,SUP-2748429,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1559.45,1013.64,,,,,,,,,,,,,
CATHETER ANGIOPLSTY BAL PERIPH OVR THE WIRE SEMI COMPLIANT,SUP-2156284,CDM,C1725,HCPCS,0272,RC,,,,both,,,307.72,200.02,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA PLU MAXBARR 4FR S1294108D4,SUP-2632812,CDM,C1751,HCPCS,0278,RC,,,,both,,,884.70,575.05,,,,,,,,,,,,,
PLATE BONE L172MM 10 H S STL NAR SELF COMPR,SUP-2198602,CDM,C1713,HCPCS,0278,RC,,,,both,,,362.17,235.41,,,,,,,,,,,,,
BLADE SAG W/ 30MM MRK,SUP-2361940,CDM,2720000010,LOCAL,0272,RC,,,,both,,,338.90,220.28,,,,,,,,,,,,,
PLATE BONE L47MM 6 H S STL 1/4 TBLR QTR SLGHT CONCV W/O CLLR,SUP-2186072,CDM,C1713,HCPCS,0278,RC,,,,both,,,185.26,120.42,,,,,,,,,,,,,
MESH HERN 15X15 CM N ABSRB INGUINAL MACROPOROUS PARIETENE,SUP-2752193,CDM,C1781,HCPCS,0278,RC,,,,both,,,244.07,158.65,,,,,,,,,,,,,
GUIDEWIRE ENDSCPC URLGCL 0.35N DIA 150CML 3CML TIP HDRPHLC C,SUP-2466362,CDM,C1769,HCPCS,0272,RC,,,,both,,,150.78,98.01,,,,,,,,,,,,,
NERVE STIMULATOR KIT PROC EMG/NMJ NDL ELECTRD SAFEOP,SUP-2725212,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
DEVICE SUTURING N ABSRB 0 4 IN LD UNIT ENDOSTCH DISP,SUP-2787726,CDM,2720000010,LOCAL,0272,RC,,,,both,,,335.76,218.24,,,,,,,,,,,,,
PLATE BNE L90MM 4 H L PROX HUM HI ALPS,SUP-2411639,CDM,C1713,HCPCS,0278,RC,,,,both,,,4628.36,3008.43,,,,,,,,,,,,,
PLATE BNE L107MM 7 H ST R DST LAT FIBULAR VAR ANG LOK FOR,SUP-2349840,CDM,C1713,HCPCS,0278,RC,,,,both,,,6152.52,3999.14,,,,,,,,,,,,,
GUIDEWIRE VASC L185CM DIA0.014IN NIT HYDRPHLC ANG TIP,SUP-2148153,CDM,C1769,HCPCS,0272,RC,,,,both,,,532.36,346.03,,,,,,,,,,,,,
PLATE BLADE ANGL 130 DEG 9H /50MM/152MM STRL,SUP-2547719,CDM,C1713,HCPCS,0278,RC,,,,both,,,2465.65,1602.67,,,,,,,,,,,,,
PLATE SPNL L17MM UNIV ANTR LUMSACR CVR FIX UNITY 51,SUP-2316768,CDM,C1713,HCPCS,0278,RC,,,,both,,,1645.36,1069.48,,,,,,,,,,,,,
MOLD KNEE SPACER FEM ML DIA 70 MM AP DIA 48 MM TIB ML DIA 75,SUP-2905380,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
HOOK RETRCT 3 MM 90 DEG 9.5 IN NERVE ANGLED RUGGLES-REDMOND,SUP-2475862,CDM,2720000010,LOCAL,0272,RC,,,,both,,,422.49,274.62,,,,,,,,,,,,,
KIT LOCATION REFERENCE PATCH RHYTHMIA MAPPING SYSTEM,SUP-2424681,CDM,C1713,HCPCS,0278,RC,,,,both,,,2009.60,1306.24,,,,,,,,,,,,,
GRAFT BNE SUB M GRN CA CRBNT PTTY INJ RESRB SIGNAFUSE,SUP-2138528,CDM,C9359,HCPCS,0278,RC,,,,both,,,1448.33,941.41,,,,,,,,,,,,,
SHEATH UROLOGICAL X-FORCE L 22 CM DIA10 MM RENAL CLR STRL,SUP-2655873,CDM,C1729,HCPCS,0272,RC,,,,both,,,116.49,75.72,,,,,,,,,,,,,
PAINPUMP2 250 CC PMP W/ LUER LCK TBNG,SUP-2363508,CDM,C2626,HCPCS,0278,RC,,,,both,,,825.41,536.52,,,,,,,,,,,,,
DEVICE FIX DIA10MM CONT LOOP FOR ACL FIX ENDOBUTTON CL ULT,SUP-2341876,CDM,C1713,HCPCS,0278,RC,,,,both,,,1052.75,684.29,,,,,,,,,,,,,
CLAMP CIRC XS 1.1 CM GMCO REUSE,SUP-2393505,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1304.86,848.16,,,,,,,,,,,,,
PLATE BONE L63MM 3 H STRL LT POST DSTL TIB S STL PART ARTC,SUP-2349717,CDM,C1713,HCPCS,0278,RC,,,,both,,,4401.18,2860.77,,,,,,,,,,,,,
BIT DRL CANN 7.5 MM ACL VERSITOMIC,SUP-2608194,CDM,2720000010,LOCAL,0272,RC,,,,both,,,987.22,641.69,,,,,,,,,,,,,
SPACER SPNL 30X8 MM CRESCENT,SUP-2631448,CDM,C1889,HCPCS,0278,RC,,,,both,,,6656.80,4326.92,,,,,,,,,,,,,
BIT DRL 3.8X10 MM DURALOC,SUP-2453983,CDM,2720000010,LOCAL,0272,RC,,,,both,,,596.29,387.59,,,,,,,,,,,,,
ROD SPNL 5.5-6.3X500 MM COCRMOLY + APEX,SUP-2627781,CDM,C1713,HCPCS,0278,RC,,,,both,,,4176.20,2714.53,,,,,,,,,,,,,
PLATE BNE 4X2 H LOK GRID TRAP FOR 2MM SCR H DIA,SUP-2267948,CDM,C1713,HCPCS,0278,RC,,,,both,,,2077.42,1350.32,,,,,,,,,,,,,
ALLODERM SELECT RESTORE LARGEPERFORATED - THICK 2.4 0.4MM,SUP-2822079,CDM,Q4116,HCPCS,0636,RC,,,,both,,,45470.34,29555.72,,,,,,,,,,,,,
DEFIBRILLATOR AED IMPL MED DEV,SUP-2863121,CDM,C1833,HCPCS,0278,RC,,,,both,,,32185.00,20920.25,,,,,,,,,,,,,
GRAFT STRGHT ULTRA THIN WALL NON RNGD PLSTR 6MM DIA 40CM LNG,SUP-2463963,CDM,C1768,CPT,0278,RC,,,,both,,,1564.91,1017.19,,,,,,,,,,,,,
DEVICE SUTURING N ABSRB 2-0 6 IN LD UNIT ENDOSTCH DISP,SUP-2787730,CDM,2720000010,LOCAL,0272,RC,,,,both,,,345.62,224.65,,,,,,,,,,,,,
HEADLESS SCREW SZ 3.0MM X 30MM,SUP-2586636,CDM,C1713,HCPCS,0278,RC,,,,both,,,1073.16,697.55,,,,,,,,,,,,,
KIT HARV BONE GRFT,SUP-2353381,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4066.30,2643.09,,,,,,,,,,,,,
CATHETER THROMCTMY CLOTTRIEVER L 80 CM DIA11 FR DEPLOYED L,SUP-2417092,CDM,C1757,HCPCS,0272,RC,,,,both,,,15700.00,10205.00,,,,,,,,,,,,,
GUIDEWIRE ORTH TRCR PT 1 END 1.1X150 MM STRL,SUP-2789089,CDM,C1769,HCPCS,0272,RC,,,,both,,,1079.28,701.53,,,,,,,,,,,,,
HC So Lacosamide Level,PX-3018023566,CDM,80235,CPT,0301,RC,,,,both,,,185.00,120.25,,,,,,,,,,,,,
SCREW BNE FT 4.5X8 MM DARCO,SUP-2400983,CDM,C1713,HCPCS,0278,RC,,,,both,,,782.49,508.62,,,,,,,,,,,,,
HC Niv Venous Duplex Uni/Ltd Study,PX-9219397100,CDM,93971,CPT,0921,RC,,,,both,,,1625.00,1056.25,,,,,,,,,,,,,
BLADE RETRACTOR DISTRACTOR OLIF,SUP-2629253,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1939.77,1260.85,,,,,,,,,,,,,
IMPLANT BRST W14-13.7XH11.9CM P6.4-7.9CM 550-660CC NACL,SUP-2300539,CDM,C1789,HCPCS,0278,RC,,,,both,,,3563.90,2316.53,,,,,,,,,,,,,
SCREW BNE SD 2X8 MM CRUCFRM AUTO DRV,SUP-2319380,CDM,C1713,HCPCS,0278,RC,,,,both,,,115.87,75.32,,,,,,,,,,,,,
BODY VERT H 20-24 MM DIA19 MM SM BLACKARMOR CARBON PEEK,SUP-2917145,CDM,C1889,HCPCS,0278,RC,,,,both,,,45216.00,29390.40,,,,,,,,,,,,,
CATHETER ANGIO 5FR L65CM PERIPH HYDRPHLC C2 SHP GLDECATH,SUP-2385162,CDM,C1887,HCPCS,0272,RC,,,,both,,,173.52,112.79,,,,,,,,,,,,,
PLATE BNE CORONOID LG BUTTRESS EVOLVE TRIAD,SUP-2535909,CDM,C1713,HCPCS,0278,RC,,,,both,,,1591.98,1034.79,,,,,,,,,,,,,
HC So Vitamin C,PX-3018218066,CDM,82180,CPT,0301,RC,,,,both,,,461.00,299.65,,,,,,,,,,,,,
GUIDEWIRE VASC 145CM 0.035IN TIP 2.5CM RAD 1.5MM PTFE,SUP-2167599,CDM,C1769,HCPCS,0272,RC,,,,both,,,53.63,34.86,,,,,,,,,,,,,
K WIRE DBL TROCAR 1.4X127MM ST,SUP-2587153,CDM,C1713,HCPCS,0278,RC,,,,both,,,57.18,37.17,,,,,,,,,,,,,
BIT DRL 3.8X210 MM STRL VERSANAIL,SUP-2606668,CDM,2720000010,LOCAL,0272,RC,,,,both,,,954.81,620.63,,,,,,,,,,,,,
PLATE BONE L220MM 13 H LT PROX HUM LCK FOR 4.5MM SCR,SUP-2348286,CDM,C1713,HCPCS,0278,RC,,,,both,,,16843.27,10948.13,,,,,,,,,,,,,
CATH BLLN SCORING 5X20MM X 137CM OTW PTA ANGIOSCULPT,SUP-2353196,CDM,C1725,HCPCS,0272,RC,,,,both,,,2983.00,1938.95,,,,,,,,,,,,,
SCREW BNE L14MM DIA2.7MM ULN SHORTNG GENERATION II LO PROF,SUP-2397333,CDM,C1713,HCPCS,0278,RC,,,,both,,,436.46,283.70,,,,,,,,,,,,,
CAGE SPNL W12XH22XL14MM 6DEG STD CERV THORLUM C FBR POLYMER,SUP-2254531,CDM,C1889,HCPCS,0278,RC,,,,both,,,7614.50,4949.42,,,,,,,,,,,,,
FOSAPREPITANT DIMEGLUMINE 150 MG IV SOLR|DISCARDED DRUG NOT ADMINISTE,RX-107187,CDM,J1453,HCPCS,0636,RC,31722-0165-31,NDC,JW,both,1,UN,69.80,45.37,,,,,,,,,,,,,
ANCHOR SUTURE L12MM OD4MM ID1.8MM PRETHREADED WITH TWO SIZE,SUP-2824223,CDM,C1713,HCPCS,0278,RC,,,,both,,,722.07,469.35,,,,,,,,,,,,,
NEEDLE KIT BVL TIP,SUP-2737856,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
BIT DRL OD4.7MM BLU CANN COUNTSINK,SUP-2399463,CDM,2720000010,LOCAL,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
EXPANDER TISS 19X6.5 CM 17 CM 320-480 CC TEXT SOFTSPAN,SUP-2467554,CDM,C1889,HCPCS,0278,RC,,,,both,,,2590.50,1683.82,,,,,,,,,,,,,
TISSUE EPICORD 1X2CM,SUP-2716335,CDM,Q4187,HCPCS,0636,RC,,,,both,,,3083.48,2004.26,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 90 CM DIA 5 MM EPTFE STR STD WALL,SUP-2489517,CDM,C1768,CPT,0278,RC,,,,both,,,1097.56,713.41,,,,,,,,,,,,,
SHELL ACET OD56MM ID24MM UNIV TI MH RINGLOC,SUP-2403543,CDM,C1776,CPT,0278,RC,,,,both,,,4684.88,3045.17,,,,,,,,,,,,,
CATHETER ESOPH BAL,SUP-2237242,CDM,C1726,HCPCS,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
SCREW BNE LCK 1.7X12 MM T5 VARIAX,SUP-2695757,CDM,C1713,HCPCS,0278,RC,,,,both,,,509.94,331.46,,,,,,,,,,,,,
KIT ORTH SZ 25 MM STPL PREP STRL DISP DYNAFORCE,SUP-2893291,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
PLATE BNE CLMN RT DSTL DORS ULN STRL,SUP-2463657,CDM,C1713,HCPCS,0278,RC,,,,both,,,2445.06,1589.29,,,,,,,,,,,,,
TRAY PICC SUBCL 2/L 4FR 60CML PU RADPQ STYL SFTY EXC 3254105,SUP-2632658,CDM,C1751,HCPCS,0278,RC,,,,both,,,289.82,188.38,,,,,,,,,,,,,
BUR SURG DIAMOND X COARSE 4 MMX12 CM BALL SM BOR LEGEND,SUP-2627649,CDM,2720000010,LOCAL,0272,RC,,,,both,,,409.46,266.15,,,,,,,,,,,,,
DEFIBRILLATOR CARD 2 CHMBR CARDIOVERTER STD W/ 1 ACT FIX LD,SUP-2236357,CDM,C1721,HCPCS,0275,RC,,,,both,,,88610.80,57597.02,,,,,,,,,,,,,
PLATE BNE FIBULAR 2.7X92 MM LT LAT DSTL 4 HOLE STRL VALCP,SUP-2789391,CDM,C1713,HCPCS,0278,RC,,,,both,,,2795.35,1816.98,,,,,,,,,,,,,
BUR SURG DIA3MM RND PRECIS RIM GLDE TECHNOLOGY RAP SMOOTH,SUP-2363784,CDM,2720000010,LOCAL,0272,RC,,,,both,,,762.27,495.48,,,,,,,,,,,,,
SLEEVE KNEE RIGID SUPP ADJ JT,SUP-2388160,CDM,L1832,HCPCS,0272,RC,,,,both,,,2659.58,1728.73,,,,,,,,,,,,,
TAP SURGICAL SCREW DIAMETER 8MM,SUP-2842795,CDM,C1713,HCPCS,0278,RC,,,,both,,,1870.15,1215.60,,,,,,,,,,,,,
STAPLE BNE FIX W15XL15MM NIT COMPR W/ INSTR LO PROF FOR,SUP-2122350,CDM,C1713,HCPCS,0278,RC,,,,both,,,7206.30,4684.09,,,,,,,,,,,,,
TRAY EPIDURAL TUOHY NDL DIA20 GA SGL SHT LIDO NACL SYR BLU,SUP-2936714,CDM,2720000010,LOCAL,0272,RC,,,,both,,,58.18,37.82,,,,,,,,,,,,,
BIT DRL L165MM DIA2.8MM 2 FLUT QUIK CPL NONRADIOLUCENT STP,SUP-2187241,CDM,2720000010,LOCAL,0272,RC,,,,both,,,267.87,174.12,,,,,,,,,,,,,
NEEDLE BX RAMEL PLEURAL PNCH,SUP-2772934,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1127.67,732.99,,,,,,,,,,,,,
PLATE BNE THK0.6MM 3X2 H BILAT HND RECTANG NONCOMPRESSION,SUP-2267887,CDM,C1713,HCPCS,0278,RC,,,,both,,,703.36,457.18,,,,,,,,,,,,,
PLATE BNE FIBULAR 2.7/3.5X199 MM LT PL 16 HOLE BUTTRESS SS,SUP-2499496,CDM,C1713,HCPCS,0278,RC,,,,both,,,2132.00,1385.80,,,,,,,,,,,,,
CANNULA ENDOSCP TERNAMIAN ENDOTIP 11 MMX10.5 CM STOPCOCK,SUP-2767278,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2545.76,1654.74,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 70 CM DIA 7 MM STR STD WALL REINF,SUP-2525439,CDM,C1768,CPT,0278,RC,,,,both,,,992.65,645.22,,,,,,,,,,,,,
FENTANYL CIT-BUPIVACAINE HCL 2-0.125 MCG/ML-% EP SOLN,RX-167514,CDM,2500000003,HCPCS,0250,RC,71266-9228-01,NDC,,both,100,ML,74.20,48.23,,,,,,,,,,,,,
CLAMP MULT PIN FOR JET-X EXT FIX SYS,SUP-2342865,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2646.80,1720.42,,,,,,,,,,,,,
ALPRAZOLAM ER 0.5 MG PO TB24,RX-35864,CDM,6370000000,HCPCS,0637,RC,65862-0454-60,NDC,,both,1,UN,3.80,2.47,,,,,,,,,,,,,
BRACE WR THMB LT MCP CMC JT ELAS SUPP NEOPRNE WRP AD 1 SZ,SUP-2309135,CDM,L3908,HCPCS,0272,RC,,,,both,,,81.33,52.86,,,,,,,,,,,,,
THERAPEUTIC MULTIVIT/MINERAL PO TABS,RX-7856,CDM,6370000000,HCPCS,0637,RC,00005-4177-58,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
HYDROMORPHONE 1 MG/ML PCA (DISCRETE DOSING),RX-4081982,CDM,J1171,HCPCS,0636,RC,09999-9915-73,NDC,,both,30,ML,92.30,59.99,,,,,,,,,,,,,
BIT DRL L230MM DIA2.5MM ST 3 FLUT QUIK CPL NONRADIOPAQUE,SUP-2187617,CDM,2720000010,LOCAL,0272,RC,,,,both,,,698.56,454.06,,,,,,,,,,,,,
GRAFT VASC L60CM DIA6MM STR STRTCH THN WALLED INTERING,SUP-2395845,CDM,C1768,CPT,0278,RC,,,,both,,,4088.28,2657.38,,,,,,,,,,,,,
CATHETER CV SINGLE LUMEN 0.018 IN 5 FRX60 CM 65 CM TURBO FLO,SUP-2168805,CDM,C1751,HCPCS,0278,RC,,,,both,,,273.18,177.57,,,,,,,,,,,,,
SCREW BNE L 110 MM DIA 3.5 MM SS CORTICAL ST NS EVOS,SUP-2931867,CDM,C1713,HCPCS,0278,RC,,,,both,,,184.16,119.70,,,,,,,,,,,,,
ELECTRODE CONCL COAG 24/26FR,SUP-2261202,CDM,2720000010,LOCAL,0272,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
KIT CATH L5MM PRI OR REVISIONAL DCR UNILAT STENT TUBE AQL,SUP-2330967,CDM,C1726,HCPCS,0272,RC,,,,both,,,1136.68,738.84,,,,,,,,,,,,,
REAMER SURG W12MM METATRSL IMPL ENCOMPASS,SUP-2319782,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2778.90,1806.28,,,,,,,,,,,,,
TITAN HUM RESURF ARTHROPLASTY INSTR THRD STNMN PIN,SUP-2243667,CDM,C1713,HCPCS,0278,RC,,,,both,,,113.04,73.48,,,,,,,,,,,,,
HC Psa Screening,PX-3010010300,CDM,G0103,HCPCS,0301,RC,,,,both,,,343.00,222.95,,,,,,,,,,,,,
SCREW SPNL OPEN 6MM DIA 50MML 475MM THK STNLSS STEEL PDCLE,SUP-2721329,CDM,C1713,HCPCS,0278,RC,,,,both,,,538.20,349.83,,,,,,,,,,,,,
INTRODUCER GWIRE FIX COR DSGN W/ J TIP STD STR GUIDERIGHT,SUP-2355265,CDM,C1769,HCPCS,0272,RC,,,,both,,,18.84,12.25,,,,,,,,,,,,,
PLATE BNE W12XL135MM THK1MM 8 H BILAT S STL SEMI TBLR LO,SUP-2184869,CDM,C1713,HCPCS,0278,RC,,,,both,,,270.73,175.97,,,,,,,,,,,,,
SMALL PLATE 3X37MM 3.5MM,SUP-2820874,CDM,C1713,HCPCS,0278,RC,,,,both,,,1041.66,677.08,,,,,,,,,,,,,
PLATE COMPRSS CRV VARIAX 11HL,SUP-2695728,CDM,C1713,HCPCS,0278,RC,,,,both,,,3082.70,2003.75,,,,,,,,,,,,,
CATHETER CARD ABLATION NAVISTAR RMT THERMOCOOL L 130 CM DIA,SUP-2248934,CDM,C1732,HCPCS,0272,RC,,,,both,,,7831.16,5090.25,,,,,,,,,,,,,
TRAY CATH PICC GROSH BASIC 3FR 0.022IN 60CM 1 LUMAN 7755305,SUP-2632683,CDM,C1751,HCPCS,0278,RC,,,,both,,,331.58,215.53,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC BSC 4FR 55CM 1 LUMAN RVS TAPR PWR I,SUP-2613383,CDM,C1751,HCPCS,0278,RC,,,,both,,,440.86,286.56,,,,,,,,,,,,,
DEFIBRILLATOR CRD SINGLE CHMBR EPIC II VR,SUP-2356513,CDM,C1722,HCPCS,0275,RC,,,,both,,,69080.00,44902.00,,,,,,,,,,,,,
PIN FIX L9IN DIA4MM NONSTERILE S STL 2 SIDE DBL DMND BOTH,SUP-2150548,CDM,C1713,HCPCS,0278,RC,,,,both,,,129.78,84.36,,,,,,,,,,,,,
GRAFT VASC TW 6 MMX70 CM RNG SFT WRP TUNN ATTCH ADVANTA VXT,SUP-2472721,CDM,C1768,CPT,0278,RC,,,,both,,,1449.14,941.94,,,,,,,,,,,,,
MESH CRAN L 120 X W 120 MM THK 0.8 MM SCREW DIA1.5/1.7 MM LG,SUP-2883419,CDM,C1713,HCPCS,0278,RC,,,,both,,,28309.61,18401.25,,,,,,,,,,,,,
PLATE BNE W101XL224MM THK35MM 16 H BILAT TI STR RIG LOK,SUP-2191092,CDM,C1713,HCPCS,0278,RC,,,,both,,,2255.49,1466.07,,,,,,,,,,,,,
DROPERIDOL 2.5 MG/ML IJ SOLN,RX-2654,CDM,J1790,HCPCS,0636,RC,00517-9702-25,NDC,,both,0.25,ML,54.10,35.16,,,,,,,,,,,,,
FIBERS CORTICAL DEMIN 10CC INNOVASIS BB76100,SUP-2847028,CDM,C1713,HCPCS,0278,RC,,,,both,,,2939.04,1910.38,,,,,,,,,,,,,
RING EXT FIX FULL 180 MM CARBON DFS DYNAFIX,SUP-2534571,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1984.48,1289.91,,,,,,,,,,,,,
PLATE BNE STD NEUT LT MTC MEDIALMAX,SUP-2315910,CDM,C1713,HCPCS,0278,RC,,,,both,,,5011.44,3257.44,,,,,,,,,,,,,
CATHETERIZATION KIT 8.5 FRX16 CM CV ARROWG+ARD BLU +,SUP-2383387,CDM,C1751,HCPCS,0278,RC,,,,both,,,411.78,267.66,,,,,,,,,,,,,
RING EXT FIX DIA130 MM U SHP NS DISP SMRT TSF,SUP-2932933,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6352.91,4129.39,,,,,,,,,,,,,
MESH CRANIAL CONTOURABLE 1.5X50X0.8 MM RAPID RESORBABLE STER,SUP-2838578,CDM,C1713,HCPCS,0278,RC,,,,both,,,5288.39,3437.45,,,,,,,,,,,,,
HC Frenulectomy-Labial or Buccal,PX-3614081900,CDM,40819,CPT,0361,RC,,,,both,,,6344.00,4123.60,,,,,,,,,,,,,
KIT DEL PWR PULSE ADMIN Y SPIKE 1W STOPCOCK CATH 3000 SER,SUP-2142028,CDM,C1757,HCPCS,0272,RC,,,,both,,,106.76,69.39,,,,,,,,,,,,,
SCREW BNE L6MM DIA2MM CORT TI ST NONCANNULATED FULL THRD 0450340601] DEPUY SYNTHES USA],SUP-2181719,CDM,C1713,HCPCS,0278,RC,,,,both,,,254.97,165.73,,,,,,,,,,,,,
PLEDGET CV EDW L 10.2 X W 5.1 CM THK 0.91 MM PTFE FABRIC,SUP-2761358,CDM,C1768,CPT,0278,RC,,,,both,,,298.17,193.81,,,,,,,,,,,,,
PERI SCR  65MM X 95MM,SUP-2725999,CDM,C1713,HCPCS,0278,RC,,,,both,,,155.24,100.91,,,,,,,,,,,,,
COMPONENT PAT RND PRI STD PRESSFIT POR WITHOUT XRAY WIRE,SUP-2199554,CDM,C1776,CPT,0278,RC,,,,both,,,8706.59,5659.28,,,,,,,,,,,,,
MICROCATHETER GUID L153CM OD2.8X2.3FR ID0.021IN GWIRE,SUP-2172488,CDM,C1887,HCPCS,0272,RC,,,,both,,,1293.68,840.89,,,,,,,,,,,,,
COMPONENT CARPOMETACARPAL 40 LG NUGRIP,SUP-2610447,CDM,C1776,CPT,0278,RC,,,,both,,,7501.15,4875.75,,,,,,,,,,,,,
GRAFT BNE SUB 2.5CC FOAM PK VERSATILE COMPR RESIST VITOSS,SUP-2368194,CDM,C1713,HCPCS,0278,RC,,,,both,,,1551.16,1008.25,,,,,,,,,,,,,
HANDPIECE 5 MMX20 CM THUNDERBEAT ENDO FR ACTUATED GRP,SUP-2313547,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3202.80,2081.82,,,,,,,,,,,,,
STEM RADIAL L 1.842 IN DIA 0.322 IN SZ 4 COCR ALLOY ELBW MOD,SUP-2933675,CDM,C1776,CPT,0278,RC,,,,both,,,10039.02,6525.36,,,,,,,,,,,,,
SET FEM SZ 4 GMK SPHR,SUP-2417435,CDM,C1776,CPT,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
LINER ACET OD36MM ID22MM THK5.1MM 10DEG STD HIP POLYETH MOD,SUP-2202086,CDM,C1776,CPT,0278,RC,,,,both,,,2514.51,1634.43,,,,,,,,,,,,,
KIT INTRO L 11 CM DIA 6FR TUOHY BORST INTEGR HEMOSTATIC VLV,SUP-2601058,CDM,C1894,HCPCS,0272,RC,,,,both,,,82.27,53.48,,,,,,,,,,,,,
SCREW BNE CANN 4X36 MM COMPR FT TI STRL,SUP-2788104,CDM,C1713,HCPCS,0278,RC,,,,both,,,945.39,614.50,,,,,,,,,,,,,
CATHETER ETER PLCMNT KT,SUP-2126771,CDM,C1751,HCPCS,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
CATHETER ART PRESSURE MONITORING TY 018 3 FRX5 CM CPMSY300RA,SUP-2760100,CDM,C1751,HCPCS,0278,RC,,,,both,,,190.38,123.75,,,,,,,,,,,,,
KIT LD L50CM 5MM SPC BLU FOR NEUROSTIM,SUP-2308588,CDM,C1778,HCPCS,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
DEFIBRILLATOR CRD 63X51X12 MM 30 CC 69 GM SYS DF4 GALLANT VR,SUP-2876023,CDM,C1722,HCPCS,0275,RC,,,,both,,,50767.52,32998.89,,,,,,,,,,,,,
BOLT CONN DIA6MM FOR FEM KNEE SYS MAXM,SUP-2405662,CDM,C1713,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
GRAFT BONE L50XW7XH5MM 1.75ML CANC DEMIN STRP STRL,SUP-2125420,CDM,C1713,HCPCS,0278,RC,,,,both,,,686.88,446.47,,,,,,,,,,,,,
CATHETER GUID AD 7FR L55CM ID0.078IN RENAL DBL CRV W/ SLIX,SUP-2156084,CDM,C1887,HCPCS,0272,RC,,,,both,,,357.96,232.67,,,,,,,,,,,,,
BLADE RTRCTR MCCLLCH 8CMD SPNL MSCLE NRRW BLACK FNSH ULTRA,SUP-2672367,CDM,2720000010,LOCAL,0272,RC,,,,both,,,415.67,270.19,,,,,,,,,,,,,
PROBE LITHO L570MM DIA1MM PNEUMAT SWISS LITHOCLAST,SUP-2139041,CDM,2720000010,LOCAL,0272,RC,,,,both,,,747.85,486.10,,,,,,,,,,,,,
PLATE BONE DUAL CMPRSSN HLX10 TTNM CNTRD F/2.7MM SCREW UNVRS,SUP-2491568,CDM,C1713,HCPCS,0278,RC,,,,both,,,941.81,612.18,,,,,,,,,,,,,
OBINUTUZUMAB 1000 MG/40ML IV SOLN,RX-124246,CDM,J9301,HCPCS,0636,RC,50242-0070-01,NDC,,both,4,ML,2592.10,1684.86,,,,,,,,,,,,,
SCREW BNE L60MM DIA6.5MM THRD L16MM CORT S STL CANN ST SELF,SUP-2185086,CDM,C1713,HCPCS,0278,RC,,,,both,,,863.81,561.48,,,,,,,,,,,,,
BLADE RTRCTR MCCLLCH 7CMD STNLSS STEEL SPNL MSCLE WIDE ULTRA,SUP-2462361,CDM,2720000010,LOCAL,0272,RC,,,,both,,,825.13,536.33,,,,,,,,,,,,,
ENDOPROSTHESIS VASC VIABAHN L 5MM 9MM 120CM 8FR HEPARIN,SUP-2558722,CDM,C1768,CPT,0278,RC,,,,both,,,9391.74,6104.63,,,,,,,,,,,,,
CATHETER HD SET 15 FRX19 CM 21 GA DL AG MIC PUNC INTRO,SUP-2762999,CDM,C1750,HCPCS,0278,RC,,,,both,,,1036.20,673.53,,,,,,,,,,,,,
BLADE 24X45MM S STL MEDL SLD CERV RETRCT SYS,SUP-2108277,CDM,2720000010,LOCAL,0272,RC,,,,both,,,901.81,586.18,,,,,,,,,,,,,
SCREW PED GIC52 6.35-6.35MM CLS LAT CON 30MM SS7021430,SUP-2286996,CDM,C1713,HCPCS,0278,RC,,,,both,,,2343.07,1523.00,,,,,,,,,,,,,
VALVE CSF CRAN IMPL HYDROCEPHALUS OSV II 9OS721,SUP-2666690,CDM,C1889,HCPCS,0278,RC,,,,both,,,9503.05,6176.98,,,,,,,,,,,,,
HEAD 22MM BPLR MOD NK NK+,SUP-2372634,CDM,C1776,CPT,0278,RC,,,,both,,,452.16,293.90,,,,,,,,,,,,,
LEVALBUTEROL HCL 1.25 MG/3ML IN NEBU,RX-24916,CDM,J7614,HCPCS,0636,RC,76204-0900-11,NDC,,both,3,ML,7.20,4.68,,,,,,,,,,,,,
PRAMIPEXOLE DIHYDROCHLORIDE 0.25 MG PO TABS,RX-21290,CDM,6370000000,HCPCS,0637,RC,68462-0331-90,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
CLIP EASY BICORT FIX DEV 10X15X13,SUP-2706413,CDM,C1713,HCPCS,0278,RC,,,,both,,,3150.05,2047.53,,,,,,,,,,,,,
SCREW BNE L11MM DIA1.5MM HD DIA3MM CORT S STL NONCANNULATED,SUP-2183109,CDM,C1713,HCPCS,0278,RC,,,,both,,,114.11,74.17,,,,,,,,,,,,,
PLATE BONE L 12 H BILAT MANUBRIUM STRNL TI LCK STAR COKING,SUP-2192440,CDM,C1713,HCPCS,0278,RC,,,,both,,,3360.74,2184.48,,,,,,,,,,,,,
BUTTON SUT DIA3.5MM TI FOR PRI BKUP FIBERWIRE FIX OF ACL,SUP-2122814,CDM,C1713,HCPCS,0278,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
ROD EXT FIX L250MM DIA8MM C CONN HOFF III,SUP-2372457,CDM,2720000010,LOCAL,0272,RC,,,,both,,,596.60,387.79,,,,,,,,,,,,,
PLATE BONE 2 H 130DEG CCD ANG GLD TI ALLOY FOR FEM NK SYS,SUP-2181487,CDM,C1713,HCPCS,0278,RC,,,,both,,,2245.19,1459.37,,,,,,,,,,,,,
BRACE KNEE AD ALUM FOAM FULL UNIV HNG STRP CLSR ADJ X-ACT,SUP-2196492,CDM,L1833,HCPCS,0272,RC,,,,both,,,315.07,204.80,,,,,,,,,,,,,
HC So Lipid Cascade|NOT REASONABLE AND NECESSARY,PX-3018006168,CDM,80061,CPT,0301,RC,,,GZ,both,,,66.00,42.90,,,,,,,,,,,,,
BLADE SHV DIA4.5MM STR YEL LATCH FULL RAD BONECUTTER RESECT,SUP-2341525,CDM,2720000010,LOCAL,0272,RC,,,,both,,,247.28,160.73,,,,,,,,,,,,,
WIRE ORTH OD2MM L450MM FIX S STL DBL END SMOOTH DBL SHRP,SUP-2316255,CDM,C1713,HCPCS,0278,RC,,,,both,,,234.31,152.30,,,,,,,,,,,,,
HC So Rickettsia Ab,PX-3028675766,CDM,86757,CPT,0302,RC,,,,both,,,128.00,83.20,,,,,,,,,,,,,
CUBE EXT FIX 5 H S STL RANCHO FOR ILIZ TAY SPAT FRME EXT,SUP-2342336,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1614.27,1049.28,,,,,,,,,,,,,
HEAD FEM DIA50MM HIP ULT UPLR HLLW,SUP-2253258,CDM,C1776,CPT,0278,RC,,,,both,,,1051.27,683.33,,,,,,,,,,,,,
PACK FIX CL SZ CALC W CANN ENDOSCP DRL BIT GWIRE PASS PIN,SUP-2341011,CDM,2720000010,LOCAL,0272,RC,,,,both,,,957.70,622.50,,,,,,,,,,,,,
SIGMA HP UNI DISTAL SHIM 8MM,SUP-2513353,CDM,C1776,CPT,0278,RC,,,,both,,,3516.80,2285.92,,,,,,,,,,,,,
OXYTOCIN 10 UNIT/ML IJ SOLN,RX-5944,CDM,J2590,HCPCS,0636,RC,63323-0012-03,NDC,,both,0.3,ML,60.00,39.00,,,,,,,,,,,,,
ALLOGRAFT BNE ACHILLES TEND N SUTURED W/O BNE BLOCK,SUP-2424193,CDM,C1889,HCPCS,0278,RC,,,,both,,,6123.00,3979.95,,,,,,,,,,,,,
COMPONENT TIB SLIDE LCK 4 HINTERMANN SER H2,SUP-2751894,CDM,C1776,CPT,0278,RC,,,,both,,,5950.30,3867.69,,,,,,,,,,,,,
PLATE BNE L187MM 10 H NONSTERILE L MED DST TIB S STL LOK,SUP-2184175,CDM,C1713,HCPCS,0278,RC,,,,both,,,3815.35,2479.98,,,,,,,,,,,,,
IMPLANT OTO 3.3X1.6X4.5MM LNG INCUS HA DBL NOTCH WEHRS,SUP-2312569,CDM,L8613,CPT,0278,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
INSERT TIB SZ 1.5 THK8MM UNIV KNEE POLYETH CRUC RET POST LIP,SUP-2253778,CDM,C1776,CPT,0278,RC,,,,both,,,3214.10,2089.16,,,,,,,,,,,,,
PLATE BONE W6.3XL48MM THK1.6MM 5X3 H LT DSTL VOLAR RAD TI,SUP-2191010,CDM,C1713,HCPCS,0278,RC,,,,both,,,2587.23,1681.70,,,,,,,,,,,,,
HC CT Upper Extremity W/O Contrast,PX-3527320000,CDM,73200,CPT,0352,RC,,,,both,,,1973.00,1282.45,,,,,,,,,,,,,
BUR SURG MTL CUT 3X17.9 MM 14 CM LG BOR MIDAS REX 8 LEGEND,SUP-2664607,CDM,2720000010,LOCAL,0272,RC,,,,both,,,567.62,368.95,,,,,,,,,,,,,
COMPONENT FEM CNDYL KNEE MOD ROTATIONAL PROS REPL ENDO-MODEL,SUP-2423131,CDM,C1776,CPT,0278,RC,,,,both,,,23195.18,15076.87,,,,,,,,,,,,,
PIN MXLFCL 1.6X7 MM PDLLA STRL SONICPIN RX,SUP-2457240,CDM,C1713,HCPCS,0278,RC,,,,both,,,268.63,174.61,,,,,,,,,,,,,
KIT CATH REP 2.7FR SGL LUMN W/ TISS INGROWTH CUF BASIC TY,SUP-2127717,CDM,C1894,HCPCS,0272,RC,,,,both,,,593.46,385.75,,,,,,,,,,,,,
FIBER LSR HOLM 1000 DISP,SUP-2225592,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1011.08,657.20,,,,,,,,,,,,,
COIL NEUROVASCULAR MICRUSPHERE XL 10 L 14 CM DIA 5 MM,SUP-2249286,CDM,C1889,HCPCS,0278,RC,,,,both,,,4248.89,2761.78,,,,,,,,,,,,,
IMPLANT BRST W14.9XH12.5CM P5.6CM 525-575CC SIL NACL FILL,SUP-2300566,CDM,C1789,HCPCS,0278,RC,,,,both,,,2433.50,1581.77,,,,,,,,,,,,,
DEVICE ENDOSKELETAL SYS PROSTHETIC BK FLX INNR SOCKET,SUP-2388208,CDM,L5645,HCPCS,0272,RC,,,,both,,,2097.24,1363.21,,,,,,,,,,,,,
COLLAR CERV ADJ SM AD 10-20 IN 2 IN W/ PD MIAMI J,SUP-2196886,CDM,L0174,HCPCS,0274,RC,,,,both,,,143.56,93.31,,,,,,,,,,,,,
CARTRIDGE BNE TUNN L12MM L CURVTEK,SUP-2212882,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1466.38,953.15,,,,,,,,,,,,,
CARBIDOPA-LEVODOPA ER 50-200 MG PO TBCR,RX-26371,CDM,6370000000,HCPCS,0637,RC,50228-0461-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
STIMULATOR NERVE IMPL PULSE GENRTR PROTEGE,SUP-2615543,CDM,C1820,HCPCS,0278,RC,,,,both,,,47559.76,30913.84,,,,,,,,,,,,,
BIT DRL DIA3MM RND SHFT REUSE FOR ODONTID FIX APFELBAUM,SUP-2108503,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1467.95,954.17,,,,,,,,,,,,,
ALLOGRAFT BNE HUM SHFT 160X2 MM FRZN,SUP-2717864,CDM,C1762,CPT,0278,RC,,,,both,,,4563.83,2966.49,,,,,,,,,,,,,
PLATE HOLDING FORCEPS WITH SWIVEL FOOT/SIZE 2,SUP-2548917,CDM,C1713,HCPCS,0278,RC,,,,both,,,3298.85,2144.25,,,,,,,,,,,,,
CATHETER CV TY 7 FRX20 CM 3L CUTLMY701JABRMCUSTOM0002,SUP-2759794,CDM,C1751,HCPCS,0278,RC,,,,both,,,444.62,289.00,,,,,,,,,,,,,
MODULE MULT AX SCR SET SCR,SUP-2287246,CDM,C1713,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
HYDROCHLOROTHIAZIDE 25 MG PO TABS,RX-3720,CDM,6370000000,HCPCS,0637,RC,60687-0593-11,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
SET PNEUMOTHOR WAYNE,SUP-2171161,CDM,C1729,HCPCS,0272,RC,,,,both,,,754.54,490.45,,,,,,,,,,,,,
CEMENT FLX FM/CEM TB/PRLG SUR/XLPE PT/TP PL,SUP-2212173,CDM,C1776,CPT,0278,RC,,,,both,,,15699.94,10204.96,,,,,,,,,,,,,
ELECTRODE ENDOSCP 24FR 90DEG MPLR HF RESECT NDL DISPOSABLE,SUP-2312907,CDM,C1713,HCPCS,0278,RC,,,,both,,,377.33,245.26,,,,,,,,,,,,,
PLATE BNE L44MM 10DEG L 1ST MTP FT TI FUS FOR 27MM SCR,SUP-2319678,CDM,C1713,HCPCS,0278,RC,,,,both,,,6923.70,4500.40,,,,,,,,,,,,,
GRAFT VASC GORTX L 60 CM DIA 4-7 MM OFFSET RNG L 30 CM EPTFE,SUP-2396107,CDM,C1768,CPT,0278,RC,,,,both,,,2700.40,1755.26,,,,,,,,,,,,,
SCREW CORTICAL LOQTEQ 2.5 L12,SUP-2713866,CDM,C1713,HCPCS,0278,RC,,,,both,,,910.60,591.89,,,,,,,,,,,,,
MATRIX BIO L 7 X W 7 CM SZ 300 SQCM ACELLULAR FISH SKIN SINGLE,SUP-2909434,CDM,Q4158,HCPCS,0636,RC,,,,both,,,28260.00,18369.00,,,,,,,,,,,,,
SLEEVE HUM DIA13MM PMMA CNTR AUX MINI COMPR,SUP-2406921,CDM,C1776,CPT,0278,RC,,,,both,,,932.58,606.18,,,,,,,,,,,,,
DRESSING BIO L 3.5 X W 3 CM SZ 200 UM PORCINE SM INTEST,SUP-2905496,CDM,Q4103,HCPCS,0636,RC,,,,both,,,487.14,316.64,,,,,,,,,,,,,
CATHETER CV SET 032 8 FRX20 CM DL J TIP POLYURETHANE,SUP-2759961,CDM,C1751,HCPCS,0278,RC,,,,both,,,237.79,154.56,,,,,,,,,,,,,
BLADE RTRCTR CHRNLEY LNG 1NW X 6 3/4NL X 5IND F/INTL INCSN J,SUP-2480580,CDM,2720000010,LOCAL,0272,RC,,,,both,,,473.79,307.96,,,,,,,,,,,,,
HC Echo Cong Anom Complete,PX-4839330300,CDM,93303,CPT,0483,RC,,,,both,,,1853.00,1204.45,,,,,,,,,,,,,
CATHETER VENT DRNGE L14CM OD2.7MM ID1.4MM SIL BA STYL INTRO,SUP-2257149,CDM,2720000010,LOCAL,0272,RC,,,,both,,,954.56,620.46,,,,,,,,,,,,,
SCREW BONE L10MM DIA1.3MM STD CORT CRANIOMAXILLOFACIAL TI ST,SUP-2189007,CDM,C1713,HCPCS,0278,RC,,,,both,,,1161.80,755.17,,,,,,,,,,,,,
PROSTHESIS VOICE 20FR L6MM INDWL 2 VLV BLOM-SINGER,SUP-2242331,CDM,L8509,HCPCS,0274,RC,,,,both,,,1284.26,834.77,,,,,,,,,,,,,
BIT DRL 3.2MM LNG GLEN LATARJET,SUP-2256874,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4942.36,3212.53,,,,,,,,,,,,,
PIN EXT FIX L160MM DIA5MM THRD L30MM LNG S STL TI NITRIDE,SUP-2342921,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1206.14,783.99,,,,,,,,,,,,,
GRAFT EVAR L75MM DIA25MM SUPRARENAL EXTN INTUITRAK POWERFIT,SUP-2217570,CDM,C1768,CPT,0278,RC,,,,both,,,7834.30,5092.29,,,,,,,,,,,,,
INTRODUCER CATH BRITE TIP RADIANZ GUIDING 6FR 110CM RADIAL,SUP-2855186,CDM,C1894,HCPCS,0272,RC,,,,both,,,807.77,525.05,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.446,SUP-2860010,CDM,C1713,HCPCS,0278,RC,,,,both,,,55099.46,35814.65,,,,,,,,,,,,,
KIT BNE CEM PREP PLUG BRSH CURET SPNG W/ RESTRIC FOR FEM,SUP-2253093,CDM,C1713,HCPCS,0278,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
DRILL TWST OD2MM L75MM QUIK CONN,SUP-2397202,CDM,2720000010,LOCAL,0272,RC,,,,both,,,430.18,279.62,,,,,,,,,,,,,
CHIP CANC BONE 90CC LG MTF+,SUP-2307410,CDM,C1713,HCPCS,0278,RC,,,,both,,,7059.22,4588.49,,,,,,,,,,,,,
SCREW BONE SELF TAPPING 2.9X16 MM LOCKING TITANIUM MATRIXMAN,SUP-2837743,CDM,C1713,HCPCS,0278,RC,,,,both,,,670.83,436.04,,,,,,,,,,,,,
NIRSEVIMAB-ALIP 50 MG/0.5ML IM SOSY,RX-165016,CDM,90380,HCPCS,0636,RC,49281-0575-00,NDC,,both,0.5,ML,2502.60,1626.69,,,,,,,,,,,,,
SCREW BONE MONOAXIAL 3.5 MM OVAL HEAD FOR MAXILLARY DISTRACT,SUP-2837832,CDM,C1713,HCPCS,0278,RC,,,,both,,,419.82,272.88,,,,,,,,,,,,,
BIT DRL PAT OVL RESURF PEG,SUP-2346876,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1679.90,1091.93,,,,,,,,,,,,,
SPLINT DORSAL AFO SPLNT X RT W STRP,SUP-2163840,CDM,L4396,HCPCS,0274,RC,,,,both,,,97.28,63.23,,,,,,,,,,,,,
CAGE SPNL 0 DEG 14X12X8 MM ANTR CERV INTBDY TI MATISSE TICRO,SUP-2578054,CDM,C1889,HCPCS,0278,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
ACETAZOLAMIDE 250 MG PO TABS,RX-113,CDM,6370000000,HCPCS,0637,RC,64380-0834-06,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
HC Pt Estim-Manual Each 15 Min|OP PT SERVICES|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS,PX-4209703200,CDM,97032,CPT,0420,RC,,,GP|CQ,outpatient,,,206.00,133.90,,,,,,,,,,,,,
SCREW BONE L4MM DIA1.7MM CORT CRANIOMAXILLOFACIAL TI ST,SUP-2188948,CDM,C1713,HCPCS,0278,RC,,,,both,,,240.21,156.14,,,,,,,,,,,,,
IMPLANT BIO L 60 X W 40 MM CLLGN SPNG REINF STRL BIOBRACE,SUP-2930524,CDM,C1763,HCPCS,0278,RC,,,,both,,,12560.00,8164.00,,,,,,,,,,,,,
IMPLANT ANK FUSION DISP BX,SUP-2933444,CDM,C1776,CPT,0278,RC,,,,both,,,378.84,246.25,,,,,,,,,,,,,
SCREW BONE CORT LCK ACU-LOC 3.5X54 MM TI,SUP-2107545,CDM,C1713,HCPCS,0278,RC,,,,both,,,348.54,226.55,,,,,,,,,,,,,
PRESSURE MONITORING KIT INTCRAN CATH O2 MONITORING CAMINO,SUP-2851508,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2422.26,1574.47,,,,,,,,,,,,,
TRIAL BONE PLT 7 H TI SEMI TBLR TC-100 L FRAG SYS,SUP-2343743,CDM,C1713,HCPCS,0278,RC,,,,both,,,752.31,489.00,,,,,,,,,,,,,
SYSTEM IMPL MENIS ROOT REP W/ PEEK SWIVELOCK,SUP-2121865,CDM,C1713,HCPCS,0278,RC,,,,both,,,4380.30,2847.19,,,,,,,,,,,,,
MESH CRAN L 55 X W 55 MM THK 0.5 MM SCREW DIA1.7 MM PLLA PUR,SUP-2883565,CDM,C1713,HCPCS,0278,RC,,,,both,,,7101.30,4615.84,,,,,,,,,,,,,
HC Surgery Level 5 Base,PX-3600000005,CDM,3600000005,LOCAL,0360,RC,,,,both,,,8060.00,5239.00,,,,,,,,,,,,,
PLATE BNE L208MM THK2.1/2.5MM 14 H THOR STRNL PEEK LOK LSS,SUP-2262586,CDM,C1713,HCPCS,0278,RC,,,,both,,,1601.21,1040.79,,,,,,,,,,,,,
PLATE BNE L 61 MM SCREW DIA2.7 MM 2 HD 6 SHFT H SS TINE VA,SUP-2907563,CDM,C1713,HCPCS,0278,RC,,,,both,,,3732.20,2425.93,,,,,,,,,,,,,
ADAPTER FEM STEM REV TAPR 7DEG W/SCREW F/EXACTECH,SUP-2223075,CDM,C1776,CPT,0278,RC,,,,both,,,763.81,496.48,,,,,,,,,,,,,
SPLINT WRST XL AD L8IN FOR 85 95IN R NYL LN FOAM PUL ON,SUP-2276665,CDM,L3908,HCPCS,0274,RC,,,,both,,,16.42,10.67,,,,,,,,,,,,,
TEMAZEPAM 15 MG PO CAPS,RX-7753,CDM,6370000000,HCPCS,0637,RC,67877-0146-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PIN FIX THRD TRINICA SYS STRL,SUP-2205137,CDM,C1713,HCPCS,0278,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
SET SCREW BONE M6,SUP-2491828,CDM,C1713,HCPCS,0278,RC,,,,both,,,92.94,60.41,,,,,,,,,,,,,
OR INTVENT PK,SUP-2155845,CDM,C1894,HCPCS,0272,RC,,,,both,,,484.41,314.87,,,,,,,,,,,,,
GRAFT HUM TISS W3XL7CM THK2-3.5MM ACELLULAR DERM MTRX,SUP-2402520,CDM,Q4126,HCPCS,0636,RC,,,,both,,,6594.00,4286.10,,,,,,,,,,,,,
SPLINT WRST XL AD L8IN FOR 85 95IN R NYL LN FOAM PUL ON,SUP-2276665,CDM,L3908,HCPCS,0272,RC,,,,both,,,16.42,10.67,,,,,,,,,,,,,
PLATE BNE H0.5MM 10X10 H CRANIOMAXILLOFACIAL BLU TI 3D MAL,SUP-2366235,CDM,C1713,HCPCS,0278,RC,,,,both,,,4062.03,2640.32,,,,,,,,,,,,,
SPLINT ORTHOPEDIC BOUTONNIERE 10 FNGR BEAUTY STRENGTH,SUP-2325010,CDM,L3927,HCPCS,0272,RC,,,,both,,,253.27,164.63,,,,,,,,,,,,,
BRACE ORTH SH UNIV KNEE FAST HNG ROM STRP CLSR FOAM AD UNISX,SUP-2196518,CDM,L1810,HCPCS,0272,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
GRAFT BNE SPNG 12X12X12 MM DBM CANC,SUP-2641780,CDM,C1713,HCPCS,0278,RC,,,,both,,,2119.50,1377.67,,,,,,,,,,,,,
MESH SURG DIA20CM PARASTOMAL RND W/ CTRL BND NO H,SUP-2174730,CDM,C1781,HCPCS,0278,RC,,,,both,,,2120.41,1378.27,,,,,,,,,,,,,
SPLINT CLAV XL W3XL41IN SHLDR PD STRP MCLEOD,SUP-2197366,CDM,L3650,HCPCS,0274,RC,,,,both,,,44.90,29.18,,,,,,,,,,,,,
STEM FEM L130MM DIA13MM EXT OFFSET HIP ZMLY CEM CLLRD,SUP-2203446,CDM,C1776,CPT,0278,RC,,,,both,,,9980.18,6487.12,,,,,,,,,,,,,
TUBE ENDOBRONCH 35 FR RT BRONCHUS DBL LUMN W/OUT CPAP SYS,SUP-2384497,CDM,C1713,HCPCS,0278,RC,,,,both,,,368.79,239.71,,,,,,,,,,,,,
WEDGE TIB SZ 7-8 THK5MM RT MEDL LT LAT KNEE HNG REV HEMI STP,SUP-2346709,CDM,C1776,CPT,0278,RC,,,,both,,,4496.48,2922.71,,,,,,,,,,,,,
PLATE 3.5MM TI LCP PROXIMAL TIBIA LOW BEND 14H 206MM RT STER,SUP-2546874,CDM,C1713,HCPCS,0278,RC,,,,both,,,5023.03,3264.97,,,,,,,,,,,,,
CONNECTOR SPNL TI PARA SM STAT FOR 6MM ROD USS VENTROFIX,SUP-2193435,CDM,C1713,HCPCS,0278,RC,,,,both,,,1588.84,1032.75,,,,,,,,,,,,,
SCREW SPNL TAPR 4.5X12 MM OCCIPITOCERVICAL,SUP-2632005,CDM,C1713,HCPCS,0278,RC,,,,both,,,1664.20,1081.73,,,,,,,,,,,,,
BOLT EXT FIX 16.5 MM STRL TRUELOK EVO LTX,SUP-2875627,CDM,2720000010,LOCAL,0272,RC,,,,both,,,90.81,59.03,,,,,,,,,,,,,
WASHER SPNL 7X18 MM FOR SCREW TI NS USS,SUP-2423057,CDM,C1713,HCPCS,0278,RC,,,,both,,,693.94,451.06,,,,,,,,,,,,,
PLATE BNE CHAMPY MINI 110 DEG 2-2.5X1 MM LT MAND 6 HOLE TI,SUP-2470980,CDM,C1713,HCPCS,0278,RC,,,,both,,,1338.96,870.32,,,,,,,,,,,,,
POST TAPR L32MM DIA12MM FOR OVO ONLY HEMICAP,SUP-2123536,CDM,C1776,CPT,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
PLATE BNE GAP SM 4 HOLE NS UNIV NEURO III LTX,SUP-2862820,CDM,C1713,HCPCS,0278,RC,,,,both,,,1594.74,1036.58,,,,,,,,,,,,,
MESH HERN XL W22.1XL27.1CM POLYPR OVL UNCOATED MFIL,SUP-2125901,CDM,C1781,HCPCS,0278,RC,,,,both,,,4925.09,3201.31,,,,,,,,,,,,,
PIN FIX SERR FOR SCORP FEM BLK,SUP-2378533,CDM,C1713,HCPCS,0278,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
CATHETER INTVASC OCCL PRUITT L 27 CM 4 FR 9 MM PLIABLE,SUP-2589474,CDM,C2628,HCPCS,0272,RC,,,,both,,,1566.86,1018.46,,,,,,,,,,,,,
FORCEPS SURG 25GA FN TIP ECKARDT INT LIMITING MEMBRN PINN,SUP-2129184,CDM,2720000010,LOCAL,0272,RC,,,,both,,,424.53,275.94,,,,,,,,,,,,,
DEFIBRILLATOR IMPL VISIA AF VR W 51 X H 66 MM D 13 MM,SUP-2282418,CDM,C1722,HCPCS,0275,RC,,,,both,,,36115.31,23474.95,,,,,,,,,,,,,
GRAFT HUM TISS CARTIFORM CELL CLLGN TYP II,SUP-2319182,CDM,C1713,HCPCS,0278,RC,,,,both,,,25355.50,16481.07,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA FT PLU MAXBARR S1275108FD2,SUP-2632805,CDM,C1751,HCPCS,0278,RC,,,,both,,,739.16,480.45,,,,,,,,,,,,,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,0636,RC,44206-0251-05,NDC,,both,50,ML,517.50,336.37,,,,,,,,,,,,,
TRAY CATH PICC LUMENX3 6FR DIA 60CML PRPHRL W/0.018IN STRGHT,SUP-2613395,CDM,C1751,HCPCS,0278,RC,,,,both,,,360.47,234.31,,,,,,,,,,,,,
CAGE SPNL 12 DEG 12X45X22 MM CLYDESDALE,SUP-2277990,CDM,C1889,HCPCS,0278,RC,,,,both,,,11514.38,7484.35,,,,,,,,,,,,,
PLATE BONE TUBE 135 DEGREE 5 HOLE KEYLESS VERSA FX II,SUP-2463451,CDM,C1713,HCPCS,0278,RC,,,,both,,,1397.17,908.16,,,,,,,,,,,,,
PLATE BNE R DORS DST RAD S STL FOR 2.4/2.7MM SCR AND 1.8MM,SUP-2186097,CDM,C1713,HCPCS,0278,RC,,,,both,,,2742.22,1782.44,,,,,,,,,,,,,
ALLOGRAFT BNE STRP 20X1 CM FD DBM GRFT,SUP-2787764,CDM,C1713,HCPCS,0278,RC,,,,both,,,7603.82,4942.48,,,,,,,,,,,,,
ENDCAP SPNL 14 MM INFIX,SUP-2683620,CDM,C1713,HCPCS,0278,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
BUR SURG CUT RND N FLUT 20MM ZYPHR,SUP-2367561,CDM,C1713,HCPCS,0278,RC,,,,both,,,550.03,357.52,,,,,,,,,,,,,
BUR SURG L 8 MM DIA2 MM SCULPTING CYL FOR SM JT ARTH STRL,SUP-2881781,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2490.02,1618.51,,,,,,,,,,,,,
CORD CONN BAN STYL ADPT L HK NDL STRL REUSE F/ EVERST FCPS,SUP-2312666,CDM,2720000010,LOCAL,0272,RC,,,,both,,,464.72,302.07,,,,,,,,,,,,,
INTRODUCER SHTH 8.5FR L81CM 8.5FR DIL L85CM 0.032IN,SUP-2357267,CDM,C1893,HCPCS,0272,RC,,,,both,,,769.30,500.04,,,,,,,,,,,,,
MESH BONE 162MM DIA 2512MML 15MM THK RSRB X SM GRID LATEX,SUP-2694435,CDM,C1713,HCPCS,0278,RC,,,,both,,,10705.80,6958.77,,,,,,,,,,,,,
SAW NASAL JOSEPH LEFT,SUP-2677504,CDM,2720000010,LOCAL,0272,RC,,,,both,,,521.68,339.09,,,,,,,,,,,,,
STENT URET OPN END 8.5 FRX22 CM LUB FLX,SUP-2312724,CDM,C2617,HCPCS,0278,RC,,,,both,,,242.47,157.61,,,,,,,,,,,,,
SYSTEM SLNG POLYPR SGL INCIS DEL DEV FOR STRESS URIN INCONT,SUP-2139454,CDM,C1771,HCPCS,0278,RC,,,,both,,,6233.21,4051.59,,,,,,,,,,,,,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,0636,RC,44206-0251-10,NDC,,both,50,ML,517.50,336.37,,,,,,,,,,,,,
BLADE RTRCTR JNNTTA 5MM X 95MMW SPNL MAL RGGLS RDMND,SUP-2668358,CDM,2720000010,LOCAL,0272,RC,,,,both,,,172.76,112.29,,,,,,,,,,,,,
STEM HUM L121MM DIA12MM STD SHLDR PORCOAT FOR PLATFRM,SUP-2249855,CDM,C1776,CPT,0278,RC,,,,both,,,5024.00,3265.60,,,,,,,,,,,,,
K WIRE FIX L100MM DIA1.1MM SGL TRCR,SUP-2392811,CDM,C1769,HCPCS,0272,RC,,,,both,,,78.50,51.02,,,,,,,,,,,,,
GRAFT SFT TISS FRZN BONE BRDG LT LAT BIOCLEANSE MENIS IMP,SUP-2335262,CDM,C1713,HCPCS,0278,RC,,,,both,,,16956.00,11021.40,,,,,,,,,,,,,
TUBE SCTN 7FR DIA 8INL TRDRP TPRD STRGHT MAL,SUP-2472928,CDM,2720000010,LOCAL,0272,RC,,,,both,,,432.35,281.03,,,,,,,,,,,,,
BODY EXT FIX CTRL SHT FOR METADIAPHYSEAL PVC FREE PROCALLUS,SUP-2645898,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3087.19,2006.67,,,,,,,,,,,,,
MESH SYN ABD BIOMATERIAL N ABSRB EXP POLYTETRAFLUROETHYLENE 1DLMCPH04] WL GORE AND ASSOCIATES INC],SUP-2395349,CDM,C1781,HCPCS,0278,RC,,,,both,,,3030.10,1969.56,,,,,,,,,,,,,
RITUXIMAB-ABBS 100 MG/10ML IV SOLN,RX-148009,CDM,Q5115,HCPCS,0636,RC,63459-0103-10,NDC,,both,10,ML,2435.20,1582.88,,,,,,,,,,,,,
PLATE BNE ACET LT PELV POST WALL,SUP-2518346,CDM,C1713,HCPCS,0278,RC,,,,both,,,5893.78,3830.96,,,,,,,,,,,,,
ROD IM KNEE AGC,SUP-2445374,CDM,C1713,HCPCS,0278,RC,,,,both,,,833.67,541.89,,,,,,,,,,,,,
GUIDEWIRE VASC L180CM DIA0.035IN TIP L3IN NIT COR POLYUR,SUP-2385568,CDM,C1769,HCPCS,0272,RC,,,,both,,,143.62,93.35,,,,,,,,,,,,,
DRAINAGE KIT 80 CM LUMBAR OPN TIP BA IMPREG SIL,SUP-2666765,CDM,C1729,HCPCS,0272,RC,,,,both,,,432.03,280.82,,,,,,,,,,,,,
VLP 2.5MM TALUS PLT MDL L RIGHT 11X20MM ST,SUP-2820182,CDM,C1713,HCPCS,0278,RC,,,,both,,,5954.54,3870.45,,,,,,,,,,,,,
HC Fluoro Guidance for Needl Plac,PX-3207700200,CDM,77002,CPT,0320,RC,,,,both,,,936.00,608.40,,,,,,,,,,,,,
FIXATOR BNE L LNG BNE ADJ,SUP-2188577,CDM,2720000010,LOCAL,0272,RC,,,,both,,,11104.20,7217.73,,,,,,,,,,,,,
BIOCOMP SWVLK BICEPS TENO 8X23 KIT,SUP-2811897,CDM,C1713,HCPCS,0278,RC,,,,both,,,2257.66,1467.48,,,,,,,,,,,,,
PLATE BNE L60MM THK1.2MM DISTANCE BTWN H 9MM CALCNL TI FOR,SUP-2190978,CDM,C1713,HCPCS,0278,RC,,,,both,,,1811.12,1177.23,,,,,,,,,,,,,
GRAFT DERMAL N FEN 8X4 CMX0.4-0.8 MM DERMAL MTRX PARADERM,SUP-2742062,CDM,C1763,HCPCS,0278,RC,,,,both,,,5845.90,3799.83,,,,,,,,,,,,,
PROBE OPHTH VITRECTOMY 20 GA ACTIVE ASPIR ENDOPROBE,SUP-2225676,CDM,2720000010,LOCAL,0272,RC,,,,both,,,824.25,535.76,,,,,,,,,,,,,
PLEDGET SURG W1XL6IN THK1.65MM PTFE FELT RECT,SUP-2126028,CDM,C1768,CPT,0278,RC,,,,both,,,291.99,189.79,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.421,SUP-2859985,CDM,C1713,HCPCS,0278,RC,,,,both,,,36482.40,23713.56,,,,,,,,,,,,,
PLATE BONE LOK 158MML HLX10 STNLSS STEEL ST RIGHT LTRL DST F,SUP-2588181,CDM,C1713,HCPCS,0278,RC,,,,both,,,2218.22,1441.84,,,,,,,,,,,,,
CATHETER CV KT 8 FRX16 CM DL PRESSURE INJ ARROWG+ARD BLU +,SUP-2763375,CDM,C1751,HCPCS,0278,RC,,,,both,,,440.86,286.56,,,,,,,,,,,,,
PLATE STRNL CLOSURE 6 H TI O CONCV NS STERNALOCK EZ,SUP-2894519,CDM,C1713,HCPCS,0278,RC,,,,both,,,1902.84,1236.85,,,,,,,,,,,,,
VALVE CSF PROGRAMMABLE IN-LINE BACTISEAL CATH CERTAS +,SUP-2666576,CDM,C1889,HCPCS,0278,RC,,,,both,,,15765.06,10247.29,,,,,,,,,,,,,
VITASURE ABSRB HEMSTAT 3 GM ABSRB HEMSTAT W/ FLO CTRL,SUP-2379554,CDM,2720000010,LOCAL,0272,RC,,,,both,,,621.72,404.12,,,,,,,,,,,,,
PROSTHESIS PENILE 100ML INHIBZN ERECTILE RESTR INFL RESVR,SUP-2138962,CDM,C1813,HCPCS,0278,RC,,,,both,,,7190.60,4673.89,,,,,,,,,,,,,
ACET RECONSTRUCTION ROOF RING 58MM OD X54MM ID,SUP-2504600,CDM,C1776,CPT,0278,RC,,,,both,,,3994.08,2596.15,,,,,,,,,,,,,
ALLOGRAFT BNE SPACER 5 DEG 14 MM LORDTC PLIF BULL TIP STRL,SUP-2632320,CDM,C1713,HCPCS,0278,RC,,,,both,,,9383.95,6099.57,,,,,,,,,,,,,
SCREW BONE L6MM TI SELF DRL ORTHODONTIC ANCHR,SUP-2181500,CDM,C1713,HCPCS,0278,RC,,,,both,,,383.08,249.00,,,,,,,,,,,,,
MESH HERN ELLIPSE 13X10 IN W/ ECHO2 POS SYS POLYPR PHASIX ST,SUP-2855266,CDM,C1781,HCPCS,0278,RC,,,,both,,,42201.60,27431.04,,,,,,,,,,,,,
DRILL SURG MED SPD W/O HOSE FLFORTHPDC ORLORALMXLLFCL OTOLAR,SUP-2605427,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6192.55,4025.16,,,,,,,,,,,,,
RING EXT FIX HALF 130 MM TI NS,SUP-2799569,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1228.40,798.46,,,,,,,,,,,,,
GRAFT VASC FUSION BIOLINE L 80 CM DIA 6 MM EXTERNALLY SUPP,SUP-2266010,CDM,C1768,CPT,0278,RC,,,,both,,,7473.20,4857.58,,,,,,,,,,,,,
CANNULA CURVED CROSSBOW MANUAL FIXATION SET WITHOUT CHANNELS,SUP-2824676,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1567.17,1018.66,,,,,,,,,,,,,
RING EXT FIX STRUT TMPLT TRUELOK EVO,SUP-2875224,CDM,2720000010,LOCAL,0272,RC,,,,both,,,602.88,391.87,,,,,,,,,,,,,
PROSTHESIS OTO L4.5MM SHFT OD0.6MM L LOOP 0.8MM MID EAR STAP,SUP-2284054,CDM,L8613,CPT,0278,RC,,,,both,,,254.09,165.16,,,,,,,,,,,,,
WAND ABLAT FOR LARYN PROCISE LW COBLATION,SUP-2342045,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3112.34,2023.02,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9% INTERMITTENT INFUSION,RX-40840102,CDM,J7040,HCPCS,0258,RC,00264-7800-10,NDC,,both,250,ML,14.90,9.68,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9% INTERMITTENT INFUSION,RX-40840102,CDM,J7030,HCPCS,0250,RC,00338-0049-04,NDC,,both,250,ML,10.70,6.95,,,,,,,,,,,,,
CATHETER CARD ABLATION INTELLANAV XP L 110 CM DIA 7 FR STR,SUP-2141815,CDM,C1733,HCPCS,0272,RC,,,,both,,,7065.00,4592.25,,,,,,,,,,,,,
PLATE BONE L63MM 4 H T OBLQ STRL SM FRAG,SUP-2348451,CDM,C1713,HCPCS,0278,RC,,,,both,,,2016.32,1310.61,,,,,,,,,,,,,
STAPLER INT STR 2.5/3.5X60 MM RELD BIOABSORBABLE WHT SEAMGRD,SUP-2478040,CDM,2720000010,LOCAL,0272,RC,,,,both,,,550.29,357.69,,,,,,,,,,,,,
GRAFT HUM TISS W1XL12CM NOM THK1.5MM MAXSTRIP HUM DERM,SUP-2399108,CDM,Q4107,HCPCS,0636,RC,,,,both,,,5149.60,3347.24,,,,,,,,,,,,,
DRILL SURG CANN FOR STREAMLINE OCT SYS STREAMLINE MIS,SUP-2713164,CDM,C1769,HCPCS,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
PROBE CIRCUMFERENTIAL 2.3MMX6.9FR LENGTH 7 FT 2 IN,SUP-2719875,CDM,2720000010,LOCAL,0272,RC,,,,both,,,706.34,459.12,,,,,,,,,,,,,
FORCEP ELECSURG BPLR 15 DEG UP 0.7 MM 22 CM PRO SER BAYNT,SUP-2859608,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3922.65,2549.72,,,,,,,,,,,,,
PROGRAMMER SLEEP STUDY UPPER AIRWAY,SUP-2865143,CDM,C1787,HCPCS,0278,RC,,,,both,,,646.84,420.45,,,,,,,,,,,,,
MESH HERN W10XL15CM RIG TWO DIM FLAT SHT PARIETEX,SUP-2174777,CDM,C1781,HCPCS,0278,RC,,,,both,,,184.63,120.01,,,,,,,,,,,,,
CATHETER VENTRICULAR BA IMPREG HERM,SUP-2666764,CDM,C1729,HCPCS,0272,RC,,,,both,,,374.04,243.13,,,,,,,,,,,,,
DOCUSATE SODIUM 100 MG PO CAPS,RX-2566,CDM,6370000000,HCPCS,0637,RC,00904-7183-61,NDC,,both,1,UN,0.50,0.32,,,,,,,,,,,,,
BLADE SURG SERR DIM 4MM ANG 60DEG,SUP-2363533,CDM,2720000010,LOCAL,0272,RC,,,,both,,,453.20,294.58,,,,,,,,,,,,,
PROSTHESIS OSS EAR 3X7 MM CENTER,SUP-2304877,CDM,L8613,CPT,0278,RC,,,,both,,,1011.08,657.20,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 70 CM DIA 6 MM STR STD WALL REINF,SUP-2525438,CDM,C1768,CPT,0278,RC,,,,both,,,922.94,599.91,,,,,,,,,,,,,
HC Smoke/Tobac Counsel 3-10,PX-9429940600,CDM,99406,CPT,0940,RC,,,,inpatient,,,29.00,18.85,,,,,,,,,,,,,
HC So Hepatitis B Surface Ag - Ref,PX-3068734067,CDM,87340,CPT,0306,RC,,,,both,,,21.00,13.65,,,,,,,,,,,,,
HC Bil Niv Arterial Low Ext Duplex,PX-9219392500,CDM,93925,CPT,0921,RC,,,,both,,,1577.00,1025.05,,,,,,,,,,,,,
VALVE CSF STD AD FIN CATH STAINLESS STL CONN WHT DP,SUP-2852665,CDM,C1889,HCPCS,0278,RC,,,,both,,,3591.88,2334.72,,,,,,,,,,,,,
CANNULA SET 25 GA W/ HI FLO INFUSION LN STRL AVETA LTX DISP,SUP-2864523,CDM,2720000010,LOCAL,0272,RC,,,,both,,,765.28,497.43,,,,,,,,,,,,,
PROBE SURG 35MM 7DEG UNIV THORLUM TI SGL END ANG BALL HNDL,SUP-2287388,CDM,C1713,HCPCS,0278,RC,,,,both,,,1098.97,714.33,,,,,,,,,,,,,
"HC Creatinine,Serum",PX-3018256500,CDM,82565,CPT,0301,RC,,,,both,,,103.00,66.95,,,,,,,,,,,,,
PLATE BONE SHAFT 258MML HLX18 STRGHT NRRW NON CNTCT BRDGE PO,SUP-2459815,CDM,C1713,HCPCS,0278,RC,,,,both,,,1759.40,1143.61,,,,,,,,,,,,,
CATHETER PERIPHERALLY INSERTED CTRL VEN 28GA W/ 24GA INTRO,SUP-2394006,CDM,C1751,HCPCS,0278,RC,,,,both,,,134.39,87.35,,,,,,,,,,,,,
PLATE BNE L80MM 5 H ST R ANTLAT DST TIB S STL LO PROF NEUT,SUP-2185943,CDM,C1713,HCPCS,0278,RC,,,,both,,,4558.31,2962.90,,,,,,,,,,,,,
KIT ART LN PERC W/ 100CM GWIRE NO11 SCALP 18GA INSRT NDL,SUP-2214618,CDM,C1769,HCPCS,0272,RC,,,,both,,,189.91,123.44,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 50 CM DIA10 MM EPTFE STR STD WALL,SUP-2695224,CDM,C1768,CPT,0278,RC,,,,both,,,1337.70,869.50,,,,,,,,,,,,,
BALLOON EXTR DIA8.5X10X12X15MM CATH 6.6FR L200CM ACC CHN,SUP-2170588,CDM,2720000010,LOCAL,0272,RC,,,,both,,,558.92,363.30,,,,,,,,,,,,,
COOLCUT BALL ELCTRODE,SUP-2815767,CDM,2720000010,LOCAL,0272,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
HC NM Lung Scan Perfusion Only,PX-3417858000,CDM,78580,CPT,0341,RC,,,,outpatient,,,2067.00,1343.55,,,,,,,,,,,,,
LEAD PACE 5.3FR L88CM CARD VENT SIL STEROID STR 2 ELECTRD,SUP-2281935,CDM,C1900,HCPCS,0275,RC,,,,both,,,4903.71,3187.41,,,,,,,,,,,,,
CANNULA ART SHT 23 FR UNCOATED HLS,SUP-2663479,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1006.59,654.28,,,,,,,,,,,,,
PLATE BONE L4MM THK0.9MM 4X7 H BILAT TI T SHP RIG NEUT,SUP-2191131,CDM,C1713,HCPCS,0278,RC,,,,both,,,872.92,567.40,,,,,,,,,,,,,
SPACER SPNL W12XH7XL14MM 5DEG PEEK OPTMA INTERVERTEBRAL,SUP-2137142,CDM,C1821,HCPCS,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
ROD SPNL 2X30 MM,SUP-2564510,CDM,C1713,HCPCS,0278,RC,,,,both,,,46.63,30.31,,,,,,,,,,,,,
PLATE BONE L61MM 8 H STRL S STL LCK COMPR FOR 2.7MM SCR EVOS,SUP-2349617,CDM,C1713,HCPCS,0278,RC,,,,both,,,2278.26,1480.87,,,,,,,,,,,,,
CATHETER INFUS L150CM OD2.4 1.7FR ID.017IN MIC HYDRPHLC STR,SUP-2305464,CDM,C1887,HCPCS,0272,RC,,,,both,,,2529.27,1644.03,,,,,,,,,,,,,
PLATE BNE L 196 X W 11.4 MM THK 3.5 MM SCREW DIA 3.5 MM 15 H 72464615N,SUP-2932845,CDM,C1713,HCPCS,0278,RC,,,,both,,,3979.48,2586.66,,,,,,,,,,,,,
PLATE BNE STR LNG CRANIOFACIAL NEURO 2 HOLE LP NS LEVEL 1,SUP-2482448,CDM,C1713,HCPCS,0278,RC,,,,both,,,191.38,124.40,,,,,,,,,,,,,
GRAFT BNE PTTY 2.5 CC SYR DBM ACCELL EVO3,SUP-2641760,CDM,C1713,HCPCS,0278,RC,,,,both,,,1780.38,1157.25,,,,,,,,,,,,,
BIT DRILL QUICK COUPLING 1.5X85/110 MM STERILE TC100 DISPOSA,SUP-2837025,CDM,2720000010,LOCAL,0272,RC,,,,both,,,880.24,572.16,,,,,,,,,,,,,
ALLOGRAFT BNE STRP 10X2.5 CM DBM FIBERFUSE,SUP-2736953,CDM,C1713,HCPCS,0278,RC,,,,both,,,12236.58,7953.78,,,,,,,,,,,,,
HOLE SAW 25MM WITH 9.5MM DRILL CANNUL.,SUP-2817900,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2722.38,1769.55,,,,,,,,,,,,,
IMPLANT SUBTALAR 75MM BLU ANK SPCR CSTS STS,SUP-2396775,CDM,C1713,HCPCS,0278,RC,,,,both,,,4606.38,2994.15,,,,,,,,,,,,,
ALLOGRAFT BNE MED 3.5-4X1-2 CMX 1.8-2.2 MM FD STRL PROF LF,SUP-2465430,CDM,C1889,HCPCS,0278,RC,,,,both,,,2144.78,1394.11,,,,,,,,,,,,,
COMPONENT KNEE FOR PKG 5200 ZUK,SUP-2212674,CDM,C1776,CPT,0278,RC,,,,both,,,16328.00,10613.20,,,,,,,,,,,,,
HC Pt Ultrasound Each 15 Min|DOCUMENTATION ON FILE|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS,PX-4209703500,CDM,97035,CPT,0420,RC,,,KX|CQ,outpatient,,,194.00,126.10,,,,,,,,,,,,,
LINER ACET OD68MM ID36MM +4MM OFFSET MARATHON CROSSLINKED,SUP-2250490,CDM,C1776,CPT,0278,RC,,,,both,,,5827.84,3788.10,,,,,,,,,,,,,
KIT INTRO L15CM DIA6FR 0018IN TRCR STYL MAK NV,SUP-2303017,CDM,C1894,HCPCS,0272,RC,,,,both,,,207.33,134.76,,,,,,,,,,,,,
BLADE SHV L13CM DIA5.5MM RESECT RASP RECIP MOTN POWERASP,SUP-2122259,CDM,2720000010,LOCAL,0272,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
GRAFT BNE XS,SUP-2424568,CDM,C1713,HCPCS,0278,RC,,,,both,,,1070.11,695.57,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA PLU MAXBARR 5FR S1395108D4,SUP-2632829,CDM,C1751,HCPCS,0278,RC,,,,both,,,1173.36,762.68,,,,,,,,,,,,,
GRAFT VASC DYNAFLO L 80 CM DIA 8 MM EPTFE CARBON PERIPH STR,SUP-2126825,CDM,C1768,CPT,0278,RC,,,,both,,,6280.00,4082.00,,,,,,,,,,,,,
SET DEVICE SPINAL W/CANNULA BLADE ST DISP,SUP-2354636,CDM,2720000010,LOCAL,0272,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
CONNECTOR SPINE SPNL SYS TI TSRH 3D ROD 635MM L,SUP-2290001,CDM,C1713,HCPCS,0278,RC,,,,both,,,4179.34,2716.57,,,,,,,,,,,,,
HC Radium Ra223 Dichloride Ther (Non-Pmm),PX-2780960601,CDM,A9606,CPT,0278,RC,,,,both,,,470.00,305.50,,,,,,,,,,,,,
SURFACE ARTC THK10MM KNEE PUR UHMWPE CRUC RET MOLD REG,SUP-2201264,CDM,C1776,CPT,0278,RC,,,,both,,,3714.62,2414.50,,,,,,,,,,,,,
COMPONENT HUM 52X48MM ARTC OFFSET OVOMOTION,SUP-2123589,CDM,C1776,CPT,0278,RC,,,,both,,,13611.90,8847.73,,,,,,,,,,,,,
ROD REPROC EXT FIX CARBN FIBR 8.0X320MM,SUP-2480136,CDM,2720000010,LOCAL,0272,RC,,,,both,,,157.41,102.32,,,,,,,,,,,,,
SPLINT ORTH COTATION HUM ARM,SUP-2388194,CDM,L3980,HCPCS,0274,RC,,,,both,,,1736.42,1128.67,,,,,,,,,,,,,
UB BLADE MALLEABLE 6IN X 12IN,SUP-2672839,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1414.00,919.10,,,,,,,,,,,,,
SCREW BNE LAG 4.1X36 MM T10 TI,SUP-2364509,CDM,C1713,HCPCS,0278,RC,,,,both,,,1180.64,767.42,,,,,,,,,,,,,
PLATE BNE L199MM 12 H BROAD CNTOUR 2 COMPR FOR 45MM SCR L,SUP-2411427,CDM,C1713,HCPCS,0278,RC,,,,both,,,683.08,444.00,,,,,,,,,,,,,
CEMENT BNE 2GM HA CA PHSPTE MID EAR RESRB OTOMIMIX,SUP-2313856,CDM,C1713,HCPCS,0278,RC,,,,both,,,1345.96,874.87,,,,,,,,,,,,,
PLATE BNE LG TI MANDIBULAR PMI ORTHOGNATHIC 3D PRNT NS DISP,SUP-2934994,CDM,C1713,HCPCS,0278,RC,,,,both,,,31999.74,20799.83,,,,,,,,,,,,,
SCREW INTFR L23MM DIA7MM BIOCRYL RAPIDE ABSRB MILAGRO ADV,SUP-2249508,CDM,C1713,HCPCS,0278,RC,,,,both,,,2194.86,1426.66,,,,,,,,,,,,,
HC Hcg (Urine) Pregnancy Test,PX-3078102500,CDM,81025,CPT,0307,RC,,,,both,,,260.00,169.00,,,,,,,,,,,,,
VERAPAMIL HCL 40 MG PO TABS,RX-8529,CDM,6370000000,HCPCS,0637,RC,00591-0404-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
SOCK PROSTHETIC LNG FRAC,SUP-2388188,CDM,L2850,HCPCS,0274,RC,,,,both,,,152.76,99.29,,,,,,,,,,,,,
HC Path Consltj Surg Cytologic Exam Initial Site,PX-3118833300,CDM,88333,CPT,0311,RC,,,,both,,,954.00,620.10,,,,,,,,,,,,,
PLATE BNE CALCANEAL 65 MM NS FPS LTX,SUP-2856890,CDM,C1713,HCPCS,0278,RC,,,,both,,,4631.50,3010.47,,,,,,,,,,,,,
BODY HUM SZ 12 135DEG PROX SHLDR PORCOAT FOR ANAT PLATFRM,SUP-2249873,CDM,C1776,CPT,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
TOURNIQUET SURG 2XL TURQ HEMACLEAR,SUP-2918234,CDM,2720000010,LOCAL,0272,RC,,,,both,,,489.84,318.40,,,,,,,,,,,,,
OCCLUDER DUCT L7MM DIA6X4MM RETEN SKRT DIA10MM SHTH 6FR,SUP-2355741,CDM,C1889,HCPCS,0278,RC,,,,both,,,14058.41,9137.97,,,,,,,,,,,,,
MODIFIED BURR HOLE COVER DR BAJWA CNTRD3MM17MM D15 SSTM CP,SUP-2680899,CDM,C1713,HCPCS,0278,RC,,,,both,,,635.13,412.83,,,,,,,,,,,,,
GRAFT HUM TISS W4XL12CM THK0.9-1.99MM ACELLULAR DERM MTRX,SUP-2402508,CDM,Q4126,HCPCS,0636,RC,,,,both,,,8478.00,5510.70,,,,,,,,,,,,,
BUR ARTHRO ROUND RPRCSSD 3.5MM DIA FLTX6 HLLW ST,SUP-2589365,CDM,2720000010,LOCAL,0272,RC,,,,both,,,164.07,106.65,,,,,,,,,,,,,
BLADE ENDO UDIN AM,SUP-2399181,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1986.36,1291.13,,,,,,,,,,,,,
NEEDLE BRST LOC 20GA L9CM L20CM N REPOSITIONAL DISP BEAD,SUP-2126462,CDM,C1819,HCPCS,0278,RC,,,,both,,,517.79,336.56,,,,,,,,,,,,,
INSTRUMENT ORTH GUID RELEASE CUT EDGE STRL DISP SPEEDRELEASE,SUP-2893044,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
HC Trigeminal Nerve Block,PX-4506440000,CDM,64400,CPT,0450,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
PLATE BNE L103MM 5 H R POSTEROLATERAL DST FIBULAR S STL LOK,SUP-2184151,CDM,C1713,HCPCS,0278,RC,,,,both,,,1731.55,1125.51,,,,,,,,,,,,,
DAPTOMYCIN 350 MG IV SOLR,RX-142612,CDM,J0873,HCPCS,0636,RC,70594-0053-01,NDC,,both,1,UN,118.00,76.70,,,,,,,,,,,,,
ANCHOR SUTURE DIA1.4 MM SUTURE SZ 2 HA COAT 1 STRND XBRAID S,SUP-2908769,CDM,C1713,HCPCS,0278,RC,,,,both,,,1582.56,1028.66,,,,,,,,,,,,,
STAPLER INT REINF 45 MM BIODESIGN EZ 45,SUP-2737225,CDM,2720000010,LOCAL,0272,RC,,,,both,,,659.40,428.61,,,,,,,,,,,,,
CATHETER KIT 0.018 INX17.75 IN AD 5 FRX50 CM BLU FLEXTIP,SUP-2384054,CDM,C1751,HCPCS,0278,RC,,,,both,,,848.18,551.32,,,,,,,,,,,,,
CATHETER INFUS L135CM DIA4MM GWIRE 0.035IN INFUS L20CM VLV,SUP-2172512,CDM,C1751,HCPCS,0278,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
K WIRE FIX L70MM DIA0.9MM MET TRCR TIP MRK FOR FIXOS,SUP-2378785,CDM,C1769,HCPCS,0272,RC,,,,both,,,141.30,91.84,,,,,,,,,,,,,
PLATE BONE 7 H L115MM RT LAT FIBULAR ANK NONCOMPRESSION,SUP-2107093,CDM,C1713,HCPCS,0278,RC,,,,both,,,5482.44,3563.59,,,,,,,,,,,,,
CATHETER URODYN 3L 7.4 FRX30 CM POLYURETHANE,SUP-2835716,CDM,C1726,HCPCS,0272,RC,,,,both,,,66.35,43.13,,,,,,,,,,,,,
SCREW BNE LCK 4.5X26 MM ANK FUSION CONSTRUCT,SUP-2609769,CDM,C1713,HCPCS,0278,RC,,,,both,,,1010.04,656.53,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED UPCHARGE ZIMMERKNEUP] ZIMMER BIOMET INC],SUP-2212750,CDM,C1776,CPT,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
GRAFT BNE CRUSH 1-10 MM 15 CC CANC,SUP-2766761,CDM,C1713,HCPCS,0278,RC,,,,both,,,966.49,628.22,,,,,,,,,,,,,
FIBER LASER DIA550UM HOLM SIDE FIRING DISP BPH DUOTOME,SUP-2139444,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2320.55,1508.36,,,,,,,,,,,,,
CATHETER DIAG TRACSTAR L 95 CM DIA 0.088 IN HYDRPHLC LG DSTL,SUP-2739208,CDM,C1887,HCPCS,0272,RC,,,,both,,,3752.30,2438.99,,,,,,,,,,,,,
KIT ACC W/ QUIK CONN SUTURELESS WIND CONNOR L30CM TBNG BLNT,SUP-2138899,CDM,C1815,HCPCS,0278,RC,,,,both,,,4507.47,2929.86,,,,,,,,,,,,,
SPLINT HND RT REG FUNC POS ABDUCTN OPPOS THMB FIRM SUPP,SUP-2324560,CDM,L3906,HCPCS,0272,RC,,,,both,,,81.33,52.86,,,,,,,,,,,,,
BIT DRL L125MM DIA1.5MM 2 FLUT FOR J LATCH CPL,SUP-2179221,CDM,2720000010,LOCAL,0272,RC,,,,both,,,740.73,481.47,,,,,,,,,,,,,
BIT DRL MIC LNG ACUTRK 2,SUP-2218774,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1406.28,914.08,,,,,,,,,,,,,
CHOLANGIOGRAM KIT RX AUTOTOME UTOM XL SPHINTOM JAGWIRE 7118,SUP-2525311,CDM,C1769,HCPCS,0272,RC,,,,both,,,750.46,487.80,,,,,,,,,,,,,
HC Ot Orthotic Fit/Train Subsq per 15 Min,PX-4309776300,CDM,97763,CPT,0430,RC,,,,inpatient,,,160.00,104.00,,,,,,,,,,,,,
SHIELD PROTCT LO PROF SHT FOR T4 HLMT SYS,SUP-2366928,CDM,V2632,HCPCS,0276,RC,,,,both,,,34.51,22.43,,,,,,,,,,,,,
NAIL SS ELASTIC 3.0MM 440MM,SUP-2547601,CDM,C1713,HCPCS,0278,RC,,,,both,,,895.40,582.01,,,,,,,,,,,,,
PIN POSITIONING 5.0 MM VA STERILE,SUP-2546199,CDM,C1713,HCPCS,0278,RC,,,,both,,,595.34,386.97,,,,,,,,,,,,,
DILATOR NEUROMONITORING W 22 MM LAT LUMBAR INSUL TRIANG,SUP-2884782,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2920.20,1898.13,,,,,,,,,,,,,
PLATE BNE L128MM 8 H NONSTERILE R PROX BILAT TIB S STL NEUT,SUP-2184305,CDM,C1713,HCPCS,0278,RC,,,,both,,,3877.52,2520.39,,,,,,,,,,,,,
BAR ARCH OVERALL 5IN DENT,SUP-2160755,CDM,2720000010,LOCAL,0272,RC,,,,both,,,59.25,38.51,,,,,,,,,,,,,
COVER BURR H BASE SUPPORT CLP STRL SENSIGHT,SUP-2882962,CDM,C1713,HCPCS,0278,RC,,,,both,,,745.75,484.74,,,,,,,,,,,,,
IMPLANT URO AD 2.5ML INJ BULK AGNT FEM FOR TREAT STRESS,SUP-2165099,CDM,L8606,HCPCS,0278,RC,,,,both,,,2219.98,1442.99,,,,,,,,,,,,,
SCREW BNE HDLSS 2.5X28 MM COMPR PART THRD NS,SUP-2458356,CDM,C1713,HCPCS,0278,RC,,,,both,,,852.82,554.33,,,,,,,,,,,,,
SCREW BONE L4MM DIA2MM CORT TI ST NONLOCKING COARSE PITCH,SUP-2189624,CDM,C1713,HCPCS,0278,RC,,,,both,,,1029.92,669.45,,,,,,,,,,,,,
SCREW BNE L70MM DIA5MM CORT TI ST DBL LD THRD FOR PHOENIX,SUP-2412135,CDM,C1713,HCPCS,0278,RC,,,,both,,,693.94,451.06,,,,,,,,,,,,,
NAIL INTRAMEDULLARY 135 DEGREE 8.5 MMX28 CM RIGHT ROSE TRIGE,SUP-2837094,CDM,C1713,HCPCS,0278,RC,,,,both,,,9167.86,5959.11,,,,,,,,,,,,,
GRAFT BNE SUB 60CC SZ 01 4MM CRUSH CANC CHIP FRZN,SUP-2307397,CDM,C1713,HCPCS,0278,RC,,,,both,,,3929.62,2554.25,,,,,,,,,,,,,
BUR SURG 13 MM FLOWER PLATE AO ATTCH,SUP-2488395,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1820.82,1183.53,,,,,,,,,,,,,
CATHETER CARD ABLATION THERMOCOOL SMARTTOUCH L 115 CM 8FR FJ,SUP-2248607,CDM,C1732,HCPCS,0278,RC,,,,both,,,9730.86,6325.06,,,,,,,,,,,,,
GRAFT HUM TISS W5XL5CM THK08 17MM THCK HYDRATED ACELLULAR,SUP-2307471,CDM,Q4128,HCPCS,0636,RC,,,,both,,,4259.72,2768.82,,,,,,,,,,,,,
PROBE SPNL CRV BALL HNDL TSRH 3D,SUP-2289780,CDM,C1713,HCPCS,0278,RC,,,,both,,,1151.75,748.64,,,,,,,,,,,,,
MICROCATHETER GUID CANTATA L 135 CM OD 2.9 FR ID 0.027 IN,SUP-2638530,CDM,C1887,HCPCS,0272,RC,,,,both,,,953.93,620.05,,,,,,,,,,,,,
SCREW BNE L45MM DIA4.5MM THRD L22MM HD DIA8MM MALL S STL,SUP-2184553,CDM,C1713,HCPCS,0278,RC,,,,both,,,54.17,35.21,,,,,,,,,,,,,
PACEMAKER CARD AVEIR DR L 32.2 MM DIA 6.5 MM 1 ML 2.1 GM TI,SUP-2895732,CDM,C1786,HCPCS,0275,RC,,,,both,,,39721.00,25818.65,,,,,,,,,,,,,
GRAFT HUM TISS INJ FLUID THN 7X7 CM AMNIO PLCNTA PRO3-P,SUP-2742040,CDM,C1762,CPT,0278,RC,,,,both,,,11225.50,7296.57,,,,,,,,,,,,,
SCREW SPNL L40MM DIA6.5MM CANC THORACOLUMBOSACRAL PEDCL S,SUP-2288422,CDM,C1713,HCPCS,0278,RC,,,,both,,,2088.10,1357.26,,,,,,,,,,,,,
KNIFE SURG VIRCHOW 11.25 IN 158X19 MM BRAIN DBL EDGED STR,SUP-2485829,CDM,2720000010,LOCAL,0272,RC,,,,both,,,606.27,394.08,,,,,,,,,,,,,
BLADE CRVD MEDIAL HIP 12MM 16CM STER DISP,SUP-2800993,CDM,2720000010,LOCAL,0272,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
SCREW SET 8-32X0.25 MM,SUP-2846273,CDM,C1713,HCPCS,0278,RC,,,,both,,,15.70,10.20,,,,,,,,,,,,,
PLATE BNE L120MM 10 H TIB S STL LOK RECON FOR 4MM SCR AXSOS,SUP-2362717,CDM,C1713,HCPCS,0278,RC,,,,both,,,2622.21,1704.44,,,,,,,,,,,,,
DEVICE FIX FEM W/ ZIPLOOP TECHNOLOGY SYS TOGGLELOC,SUP-2212939,CDM,C1713,HCPCS,0278,RC,,,,both,,,4571.84,2971.70,,,,,,,,,,,,,
ELECTRODE ELECTROTHERAPY L10CM CBL L3M ADPT CBL L20CM RF,SUP-2357694,CDM,2720000010,LOCAL,0272,RC,,,,both,,,34.54,22.45,,,,,,,,,,,,,
CHLORDIAZEPOXIDE-CLIDINIUM 5-2.5 MG PO CAPS,RX-1738,CDM,6370000000,HCPCS,0637,RC,60687-0639-11,NDC,,both,1,UN,24.30,15.79,,,,,,,,,,,,,
HC So Jak2 Gene Analysis,PX-3108127066,CDM,81270,CPT,0310,RC,,,,both,,,529.00,343.85,,,,,,,,,,,,,
KIT INDIR DCOMPR SYS W/ DRVR INSRTR AND INTERSPINOUS GA,SUP-2392704,CDM,2720000010,LOCAL,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
PLATE BONE W17.5XL229MM THK5.2MM 12 H STRL BILAT S STL BROAD,SUP-2185300,CDM,C1713,HCPCS,0278,RC,,,,both,,,2106.00,1368.90,,,,,,,,,,,,,
PLATE BNE HK 2.7X12 MM RT CLAV BUTTON LCK COMPR STRL VA-LCP,SUP-2750827,CDM,C1713,HCPCS,0278,RC,,,,both,,,4189.76,2723.34,,,,,,,,,,,,,
SET PNEUMORTHORAX MP 10FR 30CM,SUP-2168512,CDM,C1894,HCPCS,0272,RC,,,,both,,,311.90,202.73,,,,,,,,,,,,,
TUBE ET OD9.8MM ID6.5MM EVAC ORAL MURPHY EYE TAPERGUARD CUF,SUP-2172240,CDM,2720000010,LOCAL,0272,RC,,,,both,,,48.01,31.21,,,,,,,,,,,,,
ROD SPNL L45MM DIA6.35MM RT ANTR TI STR SMOOTH MNRCH,SUP-2254517,CDM,C1713,HCPCS,0278,RC,,,,both,,,1042.48,677.61,,,,,,,,,,,,,
PLATE BNE W17.5XL300MM THK5.2MM 16 H S STL BROAD CRV LOK,SUP-2185311,CDM,C1713,HCPCS,0278,RC,,,,both,,,2588.49,1682.52,,,,,,,,,,,,,
ROD SPNL 5.5X500 MM 50 MM MESA RAIL 801H55500T50,SUP-2732242,CDM,C1713,HCPCS,0278,RC,,,,both,,,6929.51,4504.18,,,,,,,,,,,,,
HANDLE RATCH STRL DISP MOTOBAND CP,SUP-2893429,CDM,2720000010,LOCAL,0272,RC,,,,both,,,452.16,293.90,,,,,,,,,,,,,
DRILL 30MM,SUP-2841577,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1133.54,736.80,,,,,,,,,,,,,
PROSTHESIS OSS 06X4MM TI PIST,SUP-2232482,CDM,L8613,CPT,0278,RC,,,,both,,,567.24,368.71,,,,,,,,,,,,,
CAGE SPNL MESH 22X17X90 MM 6 LOBE,SUP-2602085,CDM,C1889,HCPCS,0278,RC,,,,both,,,19628.14,12758.29,,,,,,,,,,,,,
STEM FEM L167MM OD13MM BOW TRI SLOT PLSM SPRAYED HA DST HIP,SUP-2375870,CDM,C1776,CPT,0278,RC,,,,both,,,8596.06,5587.44,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 15 CC CELLENTRA ADV,SUP-2866899,CDM,C1713,HCPCS,0278,RC,,,,both,,,15105.91,9818.84,,,,,,,,,,,,,
CAP SCR DIA8MM HEX DIA3.5MM DST FEM TI LOK NCB,SUP-2411465,CDM,C1776,CPT,0278,RC,,,,both,,,445.03,289.27,,,,,,,,,,,,,
KIT HAD ADMIN CHRONIC SIDE H INTRO NDL J STR GWIRE SHTH INJ,SUP-2283955,CDM,C1881,HCPCS,0278,RC,,,,both,,,691.46,449.45,,,,,,,,,,,,,
SET DCOMPR 14FR DRNGE CATH 6FR GUID CATH GWIRE L480CM,SUP-2169298,CDM,C1729,HCPCS,0272,RC,,,,both,,,458.44,297.99,,,,,,,,,,,,,
CATHETER BLLN 85 CM GUIDE EMBOGUARD,SUP-2854946,CDM,C2628,HCPCS,0272,RC,,,,both,,,8042.51,5227.63,,,,,,,,,,,,,
ROD SPNL POST SMOOTH 5.5MM DIA 190MM LEN,SUP-2289293,CDM,C1713,HCPCS,0278,RC,,,,both,,,464.72,302.07,,,,,,,,,,,,,
SCREW BNE COMPR 3X8 MM LP HD BITE,SUP-2645005,CDM,C1713,HCPCS,0278,RC,,,,both,,,821.58,534.03,,,,,,,,,,,,,
BLADE RETRACTOR MALL UNIV 2X8 IN ABD RNG W/ LIP,SUP-2465270,CDM,2720000010,LOCAL,0272,RC,,,,both,,,895.25,581.91,,,,,,,,,,,,,
ALLOGRAFT BNE WDG 0 DEG 5 MM LORDTC TRICORT STRL BIO DISP,SUP-2637024,CDM,C1713,HCPCS,0278,RC,,,,both,,,3026.96,1967.52,,,,,,,,,,,,,
PLATE BNE ANGLED BLADE 130 DEG 152 MM 90 MM 9 HOLE TI NS DCP,SUP-2569052,CDM,C1713,HCPCS,0278,RC,,,,both,,,1644.58,1068.98,,,,,,,,,,,,,
SUPPORT ORTHOT THOR ANTR CUST DEROTATION,SUP-2435589,CDM,L1260,HCPCS,0272,RC,,,,both,,,267.03,173.57,,,,,,,,,,,,,
SYSTEM AUTOTRNS INTRAOP FOR ELECTIVE AORT SURG CELL SAVR,SUP-2225926,CDM,C1713,HCPCS,0278,RC,,,,both,,,1953.08,1269.50,,,,,,,,,,,,,
STENT BILI OMLNK L 28 MM DIA10 MM DIL DIA11 MM CATH L 135 CM,SUP-2101525,CDM,C1876,HCPCS,0278,RC,,,,both,,,4160.50,2704.32,,,,,,,,,,,,,
PIN ORTH L203.2MMM OD3.1MM S STL SMOOTH BLNT TIP RND BVL PT,SUP-2342642,CDM,C1713,HCPCS,0278,RC,,,,both,,,254.34,165.32,,,,,,,,,,,,,
SCREW 3.5MM TI CONICAL SLF-TPNG FULLY THREADED 55MM,SUP-2549319,CDM,C1713,HCPCS,0278,RC,,,,both,,,417.34,271.27,,,,,,,,,,,,,
FIXATOR EXT HING RINGFIX SYS LPROF 90DEG,SUP-2459740,CDM,2720000010,LOCAL,0272,RC,,,,both,,,663.17,431.06,,,,,,,,,,,,,
NAIL IM HUM 8 7MMX18CM,SUP-2348158,CDM,C1713,HCPCS,0278,RC,,,,both,,,9853.16,6404.55,,,,,,,,,,,,,
DUAL POCKETLOCK COUNTSINK,SUP-2400569,CDM,C1713,HCPCS,0278,RC,,,,both,,,524.38,340.85,,,,,,,,,,,,,
JOINT SUBTALAR 9 MM TI MBA,SUP-2244067,CDM,C1776,CPT,0278,RC,,,,both,,,7473.20,4857.58,,,,,,,,,,,,,
HC So Magnesium,PX-3018373566,CDM,83735,CPT,0301,RC,,,,inpatient,,,58.00,37.70,,,,,,,,,,,,,
GRAFT VASC GORTX L 70 CM DIA 6 MM RNG L 30 CM EPTFE STR TW,SUP-2396156,CDM,C1768,CPT,0278,RC,,,,both,,,3253.04,2114.48,,,,,,,,,,,,,
HC Dx Breast Tomo Bil,PX-4017706200,CDM,G0279,HCPCS,0401,RC,,,,both,,,99.00,64.35,,,,,,,,,,,,,
PLATE BNE TI MIDFACE RECON 5 PLATE CUSTOMIZED FACE ID,SUP-2883692,CDM,C1713,HCPCS,0278,RC,,,,both,,,40016.85,26010.95,,,,,,,,,,,,,
NAFTIFINE HCL 1 % EX CREA,RX-10683,CDM,6370000000,HCPCS,0637,RC,51672-1362-03,NDC,,both,60,GR,1798.90,1169.28,,,,,,,,,,,,,
PLATE BNE L97MM 8 H S STL 1/3 TBLR W/ CLLR LIMIT CNTCT DYN,SUP-2185933,CDM,C1713,HCPCS,0278,RC,,,,both,,,489.87,318.42,,,,,,,,,,,,,
KIT INTRO SHTH 5 CM GUIDEWIRE L 30 CM DIA 3 FR NDL L 1.5 IN,SUP-2734923,CDM,C1894,HCPCS,0272,RC,,,,both,,,13.19,8.57,,,,,,,,,,,,,
ALLOSYNC CANCELLOUS CUBES 30CC,SUP-2811231,CDM,C1713,HCPCS,0278,RC,,,,both,,,2020.59,1313.38,,,,,,,,,,,,,
NEEDLE ASPRIRATION 22GA EXPECT PULMONARY - BOX OF 5,SUP-2855141,CDM,2720000010,LOCAL,0272,RC,,,,both,,,615.75,400.24,,,,,,,,,,,,,
BASKET REPLACMENT SGL USE 30MM,SUP-2313287,CDM,2720000010,LOCAL,0272,RC,,,,both,,,903.25,587.11,,,,,,,,,,,,,
COMPONENT FEM SZ 6 L KNEE CO CHROM NAR POST STBL CEM,SUP-2206166,CDM,C1776,CPT,0278,RC,,,,both,,,10738.80,6980.22,,,,,,,,,,,,,
ALTEPLASE 100 MG IV SOLR,RX-9002,CDM,J2997,HCPCS,0636,RC,50242-0085-27,NDC,,both,1,UN,50602.10,32891.36,,,,,,,,,,,,,
ANCHOR SUT SM DIA1.7MM NO5 POLY SFT SGL LD W/ 1 NO2 SLD BLU,SUP-2341893,CDM,C1713,HCPCS,0278,RC,,,,both,,,938.86,610.26,,,,,,,,,,,,,
PIN VERIF LANDMARK CKPT NAVIO,SUP-2341232,CDM,C1713,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
SHEATH INTRO FUBUKI L 90 CM OD 7 FR ID 2.05 MM COAT L 15 CM,SUP-2530224,CDM,C1887,HCPCS,0272,RC,,,,both,,,1095.86,712.31,,,,,,,,,,,,,
TACK PLT FOR POLYAX COMPR PLATING SYS CLAW II,SUP-2397477,CDM,C1713,HCPCS,0278,RC,,,,both,,,241.78,157.16,,,,,,,,,,,,,
HEAD FEM DISASSEMBLY HIP ATTCH MTL,SUP-2440394,CDM,C1776,CPT,0278,RC,,,,both,,,579.33,376.56,,,,,,,,,,,,,
KIT CATHETER 135FR 13CM PRECRV MAHRK ELITE,SUP-2174262,CDM,C1750,HCPCS,0278,RC,,,,both,,,237.67,154.49,,,,,,,,,,,,,
SET PERI DLYS CATH L63CM DIA15FR BASIC SIL STR COILED R V,SUP-2267006,CDM,C1752,HCPCS,0278,RC,,,,both,,,675.10,438.81,,,,,,,,,,,,,
HC So Ova and Parasites,PX-3008717766,CDM,87177,CPT,0300,RC,,,,both,,,103.00,66.95,,,,,,,,,,,,,
ROD SPNL L65MM DIA6.35MM RT ANTR TI STR SMOOTH MNRCH,SUP-2254519,CDM,C1713,HCPCS,0278,RC,,,,both,,,722.20,469.43,,,,,,,,,,,,,
SCREW HI LO F/HEADBOARD ASMBLY ADVANTA,SUP-2239291,CDM,C1713,HCPCS,0278,RC,,,,both,,,1.44,0.94,,,,,,,,,,,,,
CATHETER GUID AL3 7 FR VKG OPTMA,SUP-2103949,CDM,C1887,HCPCS,0272,RC,,,,both,,,163.28,106.13,,,,,,,,,,,,,
SPLINT WRST FA Y L W O FOAM PD ALUMINUM PERF PREMOLDED DSGN,SUP-2195056,CDM,L3908,HCPCS,0272,RC,,,,both,,,13.75,8.94,,,,,,,,,,,,,
IMPLANT TOE L16MM D2MM LCTSRB CPLMR THRDD RSRBBLE HMMRTOE WE,SUP-2477252,CDM,C1776,CPT,0278,RC,,,,both,,,719.06,467.39,,,,,,,,,,,,,
BASEPLATE TIB MOD STD R MED PRI STEM CEM REPICCI II,SUP-2408375,CDM,C1776,CPT,0278,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL PEEK SD800.523,SUP-2860204,CDM,C1713,HCPCS,0278,RC,,,,both,,,32139.16,20890.45,,,,,,,,,,,,,
GUIDEWIRE VASC LUNDERQUIST L 260 CM 0.035IN 11CM 75/15MM DBL,SUP-2170505,CDM,C1769,HCPCS,0272,RC,,,,both,,,673.84,438.00,,,,,,,,,,,,,
PIN FIX L1IN KNEE SYS HD TOT STBL DURAC,SUP-2378554,CDM,C1776,CPT,0278,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
OSTEOTOME SURG SHT DIA9.5MM FOR ULTRASONIC REV SYS UDRV 3,SUP-2408566,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1566.86,1018.46,,,,,,,,,,,,,
HIP UPCHARGE LINER ZIMMER,SUP-2501340,CDM,C1776,CPT,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
HC Aspiration Bone Marrow,PX-7613822000,CDM,38220,CPT,0761,RC,,,,both,,,4946.00,3214.90,,,,,,,,,,,,,
ANCHOR ENDO L220CM STD GAST RIG FOR 3.2MM WRK CHAN GASTSCP,SUP-2319935,CDM,C1713,HCPCS,0278,RC,,,,both,,,1566.86,1018.46,,,,,,,,,,,,,
HEAD FEM DIA28MM +1.5MM OFFSET 12/14 TAPR HIP CERAMIC TI SL,SUP-2251087,CDM,C1776,CPT,0278,RC,,,,both,,,5363.12,3486.03,,,,,,,,,,,,,
DEVICE THRD L50MM DIA12MM TI ALLY L FEN CANN FOR SACROILIAC,SUP-2279554,CDM,C1713,HCPCS,0278,RC,,,,both,,,8164.00,5306.60,,,,,,,,,,,,,
BUR SURG BALL 5 MMX10 CM SYMMETRI MIDAS REX LEGEND,SUP-2627625,CDM,2720000010,LOCAL,0272,RC,,,,both,,,498.07,323.75,,,,,,,,,,,,,
HEAD FEM DIA40MM 3MM OFFSET 11 13 TAPR HIP CO CHROME MTL ON,SUP-2251127,CDM,C1776,CPT,0278,RC,,,,both,,,7850.63,5102.91,,,,,,,,,,,,,
PLATE BONE 17 H PRI RECON W/ TEMPLT,SUP-2365247,CDM,C1713,HCPCS,0278,RC,,,,both,,,8831.19,5740.27,,,,,,,,,,,,,
BEARING TIB L63/67MM THK24MM KNEE SUP STBL POST STBL CNDYL 183834] ZIMMER BIOMET ORTHOPEDICS],SUP-2407713,CDM,C1776,CPT,0278,RC,,,,both,,,5695.96,3702.37,,,,,,,,,,,,,
DEVICE EXT FIX DYN JT DISTRACTOR BODY HNG,SUP-2372640,CDM,2720000010,LOCAL,0272,RC,,,,both,,,10990.00,7143.50,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY INQUIRY OPTMA 110CM 7 FR TIP 2 MM,SUP-2489594,CDM,C1730,HCPCS,0272,RC,,,,both,,,1617.73,1051.52,,,,,,,,,,,,,
BUTTON GAST 20FR STOMA L35CM ADJUSTABLE APPLE SHP BLLN TAPR,SUP-2119900,CDM,2720000010,LOCAL,0272,RC,,,,both,,,511.32,332.36,,,,,,,,,,,,,
PLATE BONE MEDIALMAX POCKETLOCK NEUT B,SUP-2400134,CDM,C1713,HCPCS,0278,RC,,,,both,,,6264.30,4071.79,,,,,,,,,,,,,
MATRIX BIO L 25 X W 20 CM FET BOV DERM DERMAL MESHED STRL,SUP-2909317,CDM,Q4110,HCPCS,0636,RC,,,,both,,,26690.00,17348.50,,,,,,,,,,,,,
DELIVERY SYS VLV REP MITRACLIP 2 CLP CATH STEER SLV STRL,SUP-2106213,CDM,C1889,HCPCS,0278,RC,,,,both,,,94200.00,61230.00,,,,,,,,,,,,,
PACEMAKER CARD PHILOS II DR-T TI EPOXY RESIN 2 CHMBR MOB,SUP-2138059,CDM,C1785,HCPCS,0275,RC,,,,both,,,16017.14,10411.14,,,,,,,,,,,,,
ALLOGRAFT HUM TISS STRUT 35X10 MM FRZN HALF PATELLAR TEND,SUP-2866892,CDM,C1762,CPT,0278,RC,,,,both,,,6479.08,4211.40,,,,,,,,,,,,,
PLASMA-LYTE A IV SOLN,RX-6331,CDM,2580000003,HCPCS,0258,RC,65219-0389-00,NDC,,both,500,ML,77.70,50.50,,,,,,,,,,,,,
GRAFT HUMAN TISSUE THICK 20X10 CM HYDRATED BIOLOGIC TISSUE M,SUP-2838614,CDM,C1763,HCPCS,0278,RC,,,,both,,,18559.91,12063.94,,,,,,,,,,,,,
STEM FEM 4.5 HIP ACCOLADE TMZF,SUP-2364197,CDM,C1776,CPT,0278,RC,,,,both,,,7175.53,4664.09,,,,,,,,,,,,,
GUIDEWIRE VASC L150CM OD0.032IN L7CM TIP J TIP VASC IMAG,SUP-2355273,CDM,C1769,HCPCS,0272,RC,,,,both,,,3.14,2.04,,,,,,,,,,,,,
STENT BILI PALMAZ XL L 50 MM DIA10 MM SHTH 10 FR SS TRNSHEP,SUP-2158993,CDM,C1877,HCPCS,0278,RC,,,,both,,,5633.16,3661.55,,,,,,,,,,,,,
CROWN DENT E2 2ND PRIMARY M UPPER LT SS,SUP-2100308,CDM,D6783,CPT,0278,RC,,,,both,,,27.00,17.55,,,,,,,,,,,,,
PLATE BNE L36MM THK1MM 2X6 H NONSTERILE PHLANG BASE HND TI,SUP-2181006,CDM,C1713,HCPCS,0278,RC,,,,both,,,1722.13,1119.38,,,,,,,,,,,,,
DEVICE FIX W 30 N ABSRB FASTENERS LAP PERMAFIX,SUP-2125763,CDM,C1713,HCPCS,0278,RC,,,,both,,,5432.20,3530.93,,,,,,,,,,,,,
STAPLE BNE 50X10X13 MM EASYCLIP,SUP-2365477,CDM,C1713,HCPCS,0278,RC,,,,both,,,1962.50,1275.62,,,,,,,,,,,,,
DEFIBRILLATOR CARD W6.70XH6.70CM D1.20CM 30J 20SEC 9YR SGL,SUP-2138061,CDM,C1721,HCPCS,0275,RC,,,,both,,,40082.10,26053.36,,,,,,,,,,,,,
TIP ASPIR SUP LNG ULTRASONIC SONOPET,SUP-2419434,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2945.89,1914.83,,,,,,,,,,,,,
WIRE FIX .062MM K,SUP-2123452,CDM,C1769,HCPCS,0272,RC,,,,both,,,47.10,30.61,,,,,,,,,,,,,
ALLOGRAFT BNE 5 CC FIBER PLIAFX PRIM,SUP-2740838,CDM,C1713,HCPCS,0278,RC,,,,both,,,2123.46,1380.25,,,,,,,,,,,,,
CLIP MED SUTURE LESS 40 MM SYS 1 HND STRL ATRICLIP FLX V,SUP-2424443,CDM,C1889,HCPCS,0278,RC,,,,both,,,5809.00,3775.85,,,,,,,,,,,,,
LINER IMP ACET SHELL 32/52 SURPS,SUP-2359355,CDM,C1776,CPT,0278,RC,,,,both,,,5617.46,3651.35,,,,,,,,,,,,,
SCREW BNE L25MM DIA4.75MM CORT FIX ANG NONCANNULATED LOK,SUP-2407389,CDM,C1713,HCPCS,0278,RC,,,,both,,,367.38,238.80,,,,,,,,,,,,,
GUIDEWIRE VASC TAPR STD 0.014 INX205 CM 42 CM STEER AGIL,SUP-2459138,CDM,C1769,HCPCS,0272,RC,,,,both,,,1888.21,1227.34,,,,,,,,,,,,,
MOLD FEM STEM L135MM DIA11MM HIP SIL W/ S STL REINF,SUP-2408610,CDM,C1776,CPT,0278,RC,,,,both,,,2876.24,1869.56,,,,,,,,,,,,,
NECK FEM 2XL L65MM 126DEG TAPR 12/14MM OFFSET 40MM TILASTAN,SUP-2265100,CDM,C1776,CPT,0278,RC,,,,both,,,12886.56,8376.26,,,,,,,,,,,,,
LINER BPLR OD57-60MM ID28MM POLYETH CONVENE,SUP-2345767,CDM,C1776,CPT,0278,RC,,,,both,,,514.33,334.31,,,,,,,,,,,,,
SCREW BONE L11MM OD2.5MM FOREFOOT CANN SH THRD HDLSS SHRP,SUP-2320873,CDM,C1713,HCPCS,0278,RC,,,,both,,,653.12,424.53,,,,,,,,,,,,,
HC Epidural Blood Patch - Anes,PX-3706227300,CDM,62273,CPT,0370,RC,,,,outpatient,,,1586.00,1030.90,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC SV 4FR 55CM 2 LUMAN RVS TAP 1274108,SUP-2632634,CDM,C1751,HCPCS,0278,RC,,,,both,,,797.62,518.45,,,,,,,,,,,,,
AGENT HEMOSTATIC ABSORBABLE 1 GM PWD NACL STRL SURGFOAM,SUP-2517134,CDM,2720000010,LOCAL,0272,RC,,,,both,,,348.32,226.41,,,,,,,,,,,,,
VANCOMYCIN HCL 125 MG PO CAPS,RX-11628,CDM,6370000000,HCPCS,0637,RC,62559-0390-20,NDC,,both,1,UN,11.30,7.34,,,,,,,,,,,,,
CROWN FORM DENT STRP U4 PRIMARY ANTR UPPER LT CNTRL PLAS,SUP-2322240,CDM,D6783,CPT,0278,RC,,,,both,,,33.10,21.51,,,,,,,,,,,,,
GRAFT VASC GORTX L 90 CM DIA 8 MM RNG L 70 CM EPTFE STR TW,SUP-2396138,CDM,C1768,CPT,0278,RC,,,,both,,,3645.54,2369.60,,,,,,,,,,,,,
PLATE BNE L30MM 4 H FOREFOOT MULTIFUNCTIONAL FLAT SLIM DSGN,SUP-2243219,CDM,C1713,HCPCS,0278,RC,,,,both,,,3976.78,2584.91,,,,,,,,,,,,,
HEAD FEM OD36MM HIP BACKFILLED BFH TECHNOLOGY DYNASTY,SUP-2304508,CDM,C1776,CPT,0278,RC,,,,both,,,11562.27,7515.48,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 55 CM DIA 6 MM EPTFE STR STD WALL,SUP-2669693,CDM,C1768,CPT,0278,RC,,,,both,,,1690.29,1098.69,,,,,,,,,,,,,
SENNA-DOCUSATE SODIUM 8.6-50 MG PO TABS,RX-33357,CDM,6370000000,HCPCS,0637,RC,00536-1247-10,NDC,,both,1,UN,0.20,0.13,,,,,,,,,,,,,
RING EXT FIX HALF 120 MM CIR SIDEKCK,SUP-2850516,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1004.80,653.12,,,,,,,,,,,,,
MESH SURG W26XL34CM THK2MM EPTFE FOR CHST WALL RECON,SUP-2395338,CDM,C1781,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
GUIDEWIRE ORTH L15IN DIA1.1MM NIT FOR ANT CRUCE LIG RECON,SUP-2249554,CDM,C1769,HCPCS,0272,RC,,,,both,,,200.43,130.28,,,,,,,,,,,,,
COMP ST/POLY GLD/VRSDL HD,SUP-2212460,CDM,C1776,CPT,0278,RC,,,,both,,,17898.00,11633.70,,,,,,,,,,,,,
PLATE BONE RT NAVICULAR TIM FOR 2.5MM SCR ALPS,SUP-2413836,CDM,C1713,HCPCS,0278,RC,,,,both,,,1973.80,1282.97,,,,,,,,,,,,,
PROSTHESIS OSS PISTON 0.4X4.5 MM RICHARD SPRING BK FLROPLAS,SUP-2637900,CDM,L8613,CPT,0278,RC,,,,both,,,535.12,347.83,,,,,,,,,,,,,
PLATE BONE L56MM CALCNL FT PLATING SYS,SUP-2319609,CDM,C1713,HCPCS,0278,RC,,,,both,,,4298.66,2794.13,,,,,,,,,,,,,
SCREW BNE 5.5X40 MM 5TH METATRSL,SUP-2223987,CDM,C1713,HCPCS,0278,RC,,,,both,,,3758.58,2443.08,,,,,,,,,,,,,
BLADE LARYNGOSCOPE PHILIPS SZ1 EQIV 2 MILLER1.5,SUP-2665191,CDM,2720000010,LOCAL,0272,RC,,,,both,,,515.65,335.17,,,,,,,,,,,,,
CATHETER PTCA L80CM BLLN L4CM DIA8MM SHTH 5FR GWIRE 0.035IN,SUP-2170947,CDM,C1725,HCPCS,0272,RC,,,,both,,,348.85,226.75,,,,,,,,,,,,,
GRAFT BNE HEMI PAT TISS,SUP-2391737,CDM,C1713,HCPCS,0278,RC,,,,both,,,4838.74,3145.18,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE DIA 7.5 MM SZ 2 CART ARAGONITE POROUS,SUP-2913229,CDM,C1763,HCPCS,0278,RC,,,,both,,,20724.00,13470.60,,,,,,,,,,,,,
GRAFT HUM TISS 4X4CM 1-2MM STD REGENERATIVE TISS MTRX,SUP-2399084,CDM,Q4107,HCPCS,0636,RC,,,,both,,,7917.10,5146.11,,,,,,,,,,,,,
GRAFT IMPL HUM TISS FRZ DRY ALLGRFT CANC CORT DWL BONE 12MM,SUP-2307025,CDM,C1713,HCPCS,0278,RC,,,,both,,,1340.78,871.51,,,,,,,,,,,,,
PROBE SURG MENIS 10-3/8 IN 1.8 MM TIP STR SS,SUP-2488622,CDM,2720000010,LOCAL,0272,RC,,,,both,,,496.62,322.80,,,,,,,,,,,,,
SCREW SPNL ST 11.5X25 MM FIREBIRD,SUP-2658661,CDM,C1889,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
SCREW BONE SELFTAPPING 2.4X10 MM MANDIBULAR 20/PK TITANIUM N,SUP-2842289,CDM,C1713,HCPCS,0278,RC,,,,both,,,365.53,237.59,,,,,,,,,,,,,
HC Perq Device Breast Add Image,PX-3611928200,CDM,19282,CPT,0361,RC,,,,outpatient,,,1593.00,1035.45,,,,,,,,,,,,,
BLADE CHSL SM W10XL120MM THK1MM LNG STR DISP FOR KNEE EXTR,SUP-2341199,CDM,2720000010,LOCAL,0272,RC,,,,both,,,467.70,304.00,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 40 CM DIA 8MM STR STD WALL SLDE GDS,SUP-2669691,CDM,C1768,CPT,0278,RC,,,,both,,,1286.21,836.04,,,,,,,,,,,,,
PLATE BNE L 266 MM SCREW DIA 4.5 MM 16 H BOW COMPR LCK STRL,SUP-2933517,CDM,C1713,HCPCS,0278,RC,,,,both,,,4792.43,3115.08,,,,,,,,,,,,,
PLATE BNE L65MM 3 H L DST POSTEROLATERAL HUM S STL LOK,SUP-2185891,CDM,C1713,HCPCS,0278,RC,,,,both,,,2302.84,1496.85,,,,,,,,,,,,,
INTRODUCER SHTH BLLST 088 L 100 CM DIA 0.088 IN LNG HYDRPHLC,SUP-2717621,CDM,C1894,HCPCS,0272,RC,,,,both,,,1758.40,1142.96,,,,,,,,,,,,,
SHUNT SURG 53 CM 2-5 CM W/ RESERVOIR KT LO CLS UNI-SHUNT,SUP-2666558,CDM,C1889,HCPCS,0278,RC,,,,both,,,5017.69,3261.50,,,,,,,,,,,,,
HC Hemoglobin Methemoglobin Quantitative,PX-3018305000,CDM,83050,CPT,0301,RC,,,,outpatient,,,89.00,57.85,,,,,,,,,,,,,
GRAFT BNE FN 1-4 MM 30 CC FRZN CANC,SUP-2766765,CDM,C1713,HCPCS,0278,RC,,,,both,,,2111.02,1372.16,,,,,,,,,,,,,
GRAFT SFT TISS STRP FASC LATA IMPL ALLGRFT L150XW3MM,SUP-2264782,CDM,C1762,CPT,0278,RC,,,,both,,,634.44,412.39,,,,,,,,,,,,,
ANCHOR ENDOSCP L 38 CM DIA2.4 MM NDL W 12 MM STIT D 4 MM NIT,SUP-2881865,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1221.46,793.95,,,,,,,,,,,,,
SCREW BNE L34MM DIA2MM STD CORT S STL NONCANNULATED FULL,SUP-2183189,CDM,C1713,HCPCS,0278,RC,,,,both,,,112.85,73.35,,,,,,,,,,,,,
BONE HOLDING FORCEPS-SOFT RATCHET F/PLATES TO 19MM WIDE,SUP-2548933,CDM,C1713,HCPCS,0278,RC,,,,both,,,2221.42,1443.92,,,,,,,,,,,,,
ALLOGRAFT BNE STRUT 11 CM SEG FD FIB,SUP-2321800,CDM,C1713,HCPCS,0278,RC,,,,both,,,2094.38,1361.35,,,,,,,,,,,,,
SWIFTSTITCH HIP SUT PASS,SUP-2417055,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1077.02,700.06,,,,,,,,,,,,,
PLATE BNE L98MM 8 H POST LAT S STL 1/3 TBLR LOK COMPR FOR,SUP-2349797,CDM,C1713,HCPCS,0278,RC,,,,both,,,2576.75,1674.89,,,,,,,,,,,,,
RAKE HOOKS LONE STAR RETRCT SYS BLNT END SM CRV 4-FINGER E,SUP-2171548,CDM,C1713,HCPCS,0278,RC,,,,both,,,43.71,28.41,,,,,,,,,,,,,
TRUMATCH CT PIN GUIDE TIBIAL L,SUP-2823307,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
RESERVOIR 20MM WITHOUT SHUNT ASSISTANT HYDRO VORKAMMER PROGA,SUP-2826083,CDM,C1889,HCPCS,0278,RC,,,,both,,,6534.94,4247.71,,,,,,,,,,,,,
CATHETER INTVASC ULTRASOUND SOUNDSTAR ECO 3D L 90 CM 8 FR GE,SUP-2497682,CDM,C1759,HCPCS,0272,RC,,,,both,,,4081.06,2652.69,,,,,,,,,,,,,
BIT DRL DIA3/8IN FEM LUG FOR SCORP NRG IM TRIATHLON,SUP-2378552,CDM,2720000010,LOCAL,0272,RC,,,,both,,,337.24,219.21,,,,,,,,,,,,,
FIBER LASER INSTRUMENT PRT STONE BASKETS WIRE FIX ENDOSCP,SUP-2772962,CDM,2720000010,LOCAL,0272,RC,,,,both,,,693.94,451.06,,,,,,,,,,,,,
CATHETER HD STR AD 15.5 FRX20 CM LT DL VASCPAK KT DURAMAX LF,SUP-2477392,CDM,C1750,HCPCS,0278,RC,,,,both,,,769.30,500.04,,,,,,,,,,,,,
CAP SPNL LCK REVOLVE,SUP-2230508,CDM,C1713,HCPCS,0278,RC,,,,both,,,188.40,122.46,,,,,,,,,,,,,
PLATE BNE T SM 2.7X32 MM 2/3 HOLE TI,SUP-2486001,CDM,C1713,HCPCS,0278,RC,,,,both,,,287.94,187.16,,,,,,,,,,,,,
SCREW BNE IMPL CORT ANT CERV BLU 40MMX12MM REFLX,SUP-2380887,CDM,C1713,HCPCS,0278,RC,,,,both,,,744.18,483.72,,,,,,,,,,,,,
HYDROCORTISONE ACETATE 25 MG RE SUPP,RX-3738,CDM,6370000000,HCPCS,0637,RC,00574-7090-12,NDC,,both,1,UN,52.00,33.80,,,,,,,,,,,,,
INSERT TIB PS 1 10 MM KNEE PROVEN GEN-FLEX,SUP-2359100,CDM,C1776,CPT,0278,RC,,,,both,,,1152.38,749.05,,,,,,,,,,,,,
CATHETER DIALYSIS 19CM DUAL LUMEN PERMCATH,SUP-2718755,CDM,C1750,HCPCS,0278,RC,,,,both,,,813.29,528.64,,,,,,,,,,,,,
BLADE SAW SM HUB STYL FOR OSTEOTMY,SUP-2107136,CDM,2720000010,LOCAL,0272,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
"HC Est Pt, E/M Level 3|MULTIPLE OUTPATIENT HOSPITAL E/M ENCOUNTERS ON THE SAME DATE",PX-5109921300,CDM,99213,CPT,0510,RC,,,27,both,,,257.00,167.05,,,,,,,,,,,,,
GUIDEWIRE ORTH DRL TIP 1.6X200 MM SS NS KIRSCHNER,SUP-2863372,CDM,2720000010,LOCAL,0272,RC,,,,both,,,103.59,67.33,,,,,,,,,,,,,
GRAFT BNE SUB XL W20XH7XL50MM COMPRESSIBLE SPNG STRP PROVIDE,SUP-2138509,CDM,C1713,HCPCS,0278,RC,,,,both,,,9594.33,6236.31,,,,,,,,,,,,,
BASEPLATE GLEN HD DIA50MM REG BILAT UHMWPE PEGGED PRESSFIT,SUP-2193842,CDM,C1776,CPT,0278,RC,,,,both,,,3739.68,2430.79,,,,,,,,,,,,,
BOLT EXT FIX OFFSET WIRE MR CONDITIONAL FOR DISTR,SUP-2179132,CDM,C1713,HCPCS,0278,RC,,,,both,,,136.15,88.50,,,,,,,,,,,,,
SCREW BONE L18MM D2.5MM HEX DRVR D1.5MM MGNTA SELF TPPNG CNN,SUP-2478550,CDM,C1713,HCPCS,0278,RC,,,,both,,,1053.85,685.00,,,,,,,,,,,,,
GRAFT HUM TISS L 2 X W 2 CM HYDRPHLC AMNIO MEMBRN PROTCT,SUP-2894615,CDM,C1762,CPT,0278,RC,,,,both,,,3557.62,2312.45,,,,,,,,,,,,,
SLEEVE NAIL INSRT DIA8-13MM E SPI,SUP-2368597,CDM,2720000010,LOCAL,0272,RC,,,,both,,,328.13,213.28,,,,,,,,,,,,,
HC US Abdomen Complete,PX-4027670000,CDM,76700,CPT,0402,RC,,,,both,,,1432.00,930.80,,,,,,,,,,,,,
SCREW BNE L 5 MM DIA2.3 MM CRANIOFACIAL CROSS PIN HD EMER 5PK,SUP-2884169,CDM,C1713,HCPCS,0278,RC,,,,both,,,2192.98,1425.44,,,,,,,,,,,,,
TRIAL SURG SCREW DIA1.3-5 MM RECESS HEX SOCKET STRL DISP,SUP-2913515,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1099.57,714.72,,,,,,,,,,,,,
NAFCILLIN SODIUM 2 G IJ SOLR,RX-5335,CDM,J2290,HCPCS,0636,RC,55150-0123-15,NDC,,both,1,UN,71.90,46.73,,,,,,,,,,,,,
KIT CEMENT BONE COMBO W/MIXER 20GM KYPHON HV-R,SUP-2540321,CDM,C1713,HCPCS,0278,RC,,,,both,,,300.84,195.55,,,,,,,,,,,,,
LENS IOL SN60WF 12.0D,SUP-2111294,CDM,V2632,HCPCS,0276,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY SUPREME L 120 CM DIA 5 FR SPC 2-5,SUP-2489220,CDM,C1730,HCPCS,0272,RC,,,,both,,,124.34,80.82,,,,,,,,,,,,,
STEM FEM STD OFFSET 5-9 MAG NK W/ TRUNNION TAPRLOK,SUP-2442567,CDM,C1776,CPT,0278,RC,,,,both,,,1031.49,670.47,,,,,,,,,,,,,
SPHERE ORBIT DIA18MM PMMA FOR RET EYE SOCK CNTOUR,SUP-2236376,CDM,L8610,HCPCS,0278,RC,,,,both,,,169.56,110.21,,,,,,,,,,,,,
CATHETER SNUS BLLN L24MM DIA7MM HI PERF DIL INT SNUS IRRIG,SUP-2106327,CDM,C1729,HCPCS,0272,RC,,,,both,,,517.47,336.36,,,,,,,,,,,,,
NAIL IM L405MM DIA8MM UNIV DK BLU PROX TIB TI BEND CANN LOK,SUP-2180391,CDM,C1713,HCPCS,0278,RC,,,,both,,,4576.36,2974.63,,,,,,,,,,,,,
UNIT BRST BX L14CM L20MM OD9GA HNDPC ATEC,SUP-2239993,CDM,2720000010,LOCAL,0272,RC,,,,both,,,596.60,387.79,,,,,,,,,,,,,
SPLINT HND AD UNIV L W STAY WLK,SUP-2112604,CDM,L3807,HCPCS,0274,RC,,,,both,,,148.43,96.48,,,,,,,,,,,,,
GRAFT HUM TISS CORNEAL,SUP-2427794,CDM,V2785,HCPCS,0810,RC,,,,both,,,8242.50,5357.62,,,,,,,,,,,,,
THORACOLUMBAR STPL SYS GRPHC CA,SUP-2232367,CDM,C1713,HCPCS,0278,RC,,,,both,,,8845.38,5749.50,,,,,,,,,,,,,
GRAFT BNE W6-21XL14-25MM THK19-21MM TRICORT IL FRZ DRY,SUP-2307145,CDM,C1713,HCPCS,0278,RC,,,,both,,,2518.28,1636.88,,,,,,,,,,,,,
PROGRAMMER PT 128GM H6.8XL10.77CM THK2.6CM SPNL CRD W/,SUP-2355983,CDM,C1787,HCPCS,0278,RC,,,,both,,,5102.50,3316.62,,,,,,,,,,,,,
CATHETER ANGIOPLSTY L 200 CM BALLOON L 250 MM DIA 7 MM SHTH,SUP-2937101,CDM,C1725,HCPCS,0272,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
KIT PICC 5FR L40CM DBL LUMN PRSS INJ CATHETER W BLU FLEXTIP,SUP-2383369,CDM,C1751,HCPCS,0278,RC,,,,both,,,422.80,274.82,,,,,,,,,,,,,
CATHETER ETER OCCL 24 34FR L135CM COR CTO CROSSING CROSSBOSS,SUP-2140965,CDM,C1725,HCPCS,0272,RC,,,,both,,,3782.44,2458.59,,,,,,,,,,,,,
BIT DRL 3.2X140 MM QC TIN COAT,SUP-2644587,CDM,2720000010,LOCAL,0272,RC,,,,both,,,399.09,259.41,,,,,,,,,,,,,
SAW HAND STTRLEE 11 12NL 8NL BLADE BONE JARIT NON ST,SUP-2702377,CDM,2720000010,LOCAL,0272,RC,,,,both,,,607.72,395.02,,,,,,,,,,,,,
TRASTUZUMAB-STRF 150 MG IV SOLR,RX-170230,CDM,J3376,HCPCS,0636,RC,69448-0015-05,NDC,,both,1,UN,3840.80,2496.52,,,,,,,,,,,,,
HC Whfo Ridig W/O Custom Fit,PX-2740380801,CDM,L3808,HCPCS,0272,RC,,,,inpatient,,,1110.00,721.50,,,,,,,,,,,,,
CAST ORTHOT ANK KNEE TIB CUST FRAC MOLD TO PT,SUP-2435647,CDM,L0220,HCPCS,0274,RC,,,,both,,,3254.80,2115.62,,,,,,,,,,,,,
SLEEVE DRL 3.7 MM,SUP-2473948,CDM,2720000010,LOCAL,0272,RC,,,,both,,,507.42,329.82,,,,,,,,,,,,,
ARCOS 15X250MM CYL DIST,SUP-2506084,CDM,C1776,CPT,0278,RC,,,,both,,,7812.32,5078.01,,,,,,,,,,,,,
PLATE BNE ORBIT FLR LG 0.4 MM LT SMRT GRV 3D TI NS LEVEL 1,SUP-2462546,CDM,C1713,HCPCS,0278,RC,,,,both,,,3597.09,2338.11,,,,,,,,,,,,,
FIBER LASER KIT OMNIGUIDE,SUP-2225640,CDM,2720000010,LOCAL,0272,RC,,,,both,,,353.25,229.61,,,,,,,,,,,,,
MESH SURG 20X16 CM BIOMATERIAL INTRAPERITONEAL ENFORM,SUP-2435396,CDM,C1781,HCPCS,0278,RC,,,,both,,,18582.52,12078.64,,,,,,,,,,,,,
HOOK SPNL 55MM DIA 8MML STNLSS STEEL LMNR THRCC CLSD F/475,SUP-2720444,CDM,C1713,HCPCS,0278,RC,,,,both,,,1210.91,787.09,,,,,,,,,,,,,
EASYFUSE STAPLE 15X20 NITINOL 2-LEG,SUP-2830230,CDM,C1713,HCPCS,0278,RC,,,,both,,,5102.50,3316.62,,,,,,,,,,,,,
HC Car-T Therapy Autologous Cell Admin,PX-8723822800,CDM,38228,CPT,0874,RC,,,,both,,,926.00,601.90,,,,,,,,,,,,,
CATHETER EP 5-3-8 MM 5 FRX115 CM WOVENFLEXIE,SUP-2424761,CDM,C1730,HCPCS,0272,RC,,,,both,,,847.80,551.07,,,,,,,,,,,,,
COUNTERSINK SURG CANN W/ S CPLR FOR SM FRAG PLATING SYS,SUP-2211520,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1094.29,711.29,,,,,,,,,,,,,
FORCEPS SURG NK TRL ACCOLADE,SUP-2361691,CDM,C1776,CPT,0278,RC,,,,both,,,2539.00,1650.35,,,,,,,,,,,,,
REAMER SURG OD10MM IM MOD HD FWD SIDE CUT DBL WND SHFT,SUP-2368230,CDM,2720000010,LOCAL,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
ENDOPROSTHESIS VASC VIABAHN L 2.5 CM DIA11 MM CATH L 110 CM,SUP-2396465,CDM,C1874,HCPCS,0278,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
HC Sleep Study Unattended,PX-9209580000,CDM,95800,CPT,0920,RC,,,,both,,,898.00,583.70,,,,,,,,,,,,,
DEVICE BX NDL 9GA L13CM APER 20MM FOR BRST SYS -SEE COMMENT,SUP-2240015,CDM,2720000010,LOCAL,0272,RC,,,,both,,,675.95,439.37,,,,,,,,,,,,,
DISSECTOR ENDOSCP 5 MM W/ MONOPOLAR CAUT,SUP-2787741,CDM,2720000010,LOCAL,0272,RC,,,,both,,,699.31,454.55,,,,,,,,,,,,,
IRRIGATION SET CTRL DISTENTION,SUP-2208441,CDM,C1894,HCPCS,0272,RC,,,,both,,,2900.64,1885.42,,,,,,,,,,,,,
SOL SYS 8/16.5 L LRG STAT,SUP-2513056,CDM,C1776,CPT,0278,RC,,,,both,,,19354.96,12580.72,,,,,,,,,,,,,
"HC Post.Drain/Percussion,Initial",PX-4109466700,CDM,94667,CPT,0410,RC,,,,inpatient,,,247.00,160.55,,,,,,,,,,,,,
CATHETER MNOMTR AIR CHARGED ANORECT,SUP-2265006,CDM,C1713,HCPCS,0278,RC,,,,both,,,885.48,575.56,,,,,,,,,,,,,
STAPLE SPNL 10-10X10X1.5X1.2 MM,SUP-2365483,CDM,C1713,HCPCS,0278,RC,,,,both,,,5699.10,3704.41,,,,,,,,,,,,,
BOOT FT FLEECE X LG ANK CONTRACTURE W/ OUT SOLE,SUP-2336235,CDM,L4396,HCPCS,0274,RC,,,,both,,,120.20,78.13,,,,,,,,,,,,,
PLATE BNE METATARSOPHALANGEAL LNG LT RECON CROSSCHECK NX,SUP-2486196,CDM,C1713,HCPCS,0278,RC,,,,both,,,5677.12,3690.13,,,,,,,,,,,,,
HC So Anti-Hbs,PX-3028670666,CDM,86706,CPT,0302,RC,,,,both,,,21.00,13.65,,,,,,,,,,,,,
BLOCK CUT W10XL69MM TIB CONSTRN CNDYL KNEE INSALL-BURSTEIN,SUP-2205968,CDM,C1776,CPT,0278,RC,,,,both,,,5875.57,3819.12,,,,,,,,,,,,,
HC So Estrogens Total,PX-3018267266,CDM,82672,CPT,0301,RC,,,,inpatient,,,366.00,237.90,,,,,,,,,,,,,
SPINDLE TOT FEM 12MM DIA INTFACE MED FORC SM POR COAT COMPR,SUP-2406895,CDM,C1776,CPT,0278,RC,,,,both,,,11143.86,7243.51,,,,,,,,,,,,,
GRAFT HUM TISS W13XL15CM PROC DERM CLLGN RECTANG ALLOMAX,SUP-2125859,CDM,C1781,HCPCS,0278,RC,,,,both,,,19342.40,12572.56,,,,,,,,,,,,,
CATHETER CARD ABLATION EZ STEER L 115 CM 8 FR 4 MM D-F CRV,SUP-2248504,CDM,C1732,HCPCS,0272,RC,,,,both,,,2392.68,1555.24,,,,,,,,,,,,,
PLATE BNE L 2-2.5X44X1 MM 28 MM RT 2X2 HOLE TLTS BSSO TI,SUP-2463273,CDM,C1713,HCPCS,0278,RC,,,,both,,,1292.90,840.38,,,,,,,,,,,,,
HC Whfo Ridig W/O Custom Fit,PX-2740380801,CDM,L3808,HCPCS,0274,RC,,,,inpatient,,,1110.00,721.50,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED UPLR CEM ENDO HD ST LD/FX,SUP-2212085,CDM,C1776,CPT,0278,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
GRAFT VASC GORTX L 10 CM DIA 5 MM RNG L 2.5 CM EPTFE STR TW,SUP-2396148,CDM,C1768,CPT,0278,RC,,,,both,,,1234.02,802.11,,,,,,,,,,,,,
PACK NEUROSURGICAL SHTH L 50 X W 13.5 MM MYRIAD HNDPC L 13 NN-3003,SUP-2930299,CDM,2720000010,LOCAL,0272,RC,,,,both,,,22302.92,14496.90,,,,,,,,,,,,,
CATHETER DRNGE 10FR L25CM HYDRPHLC ORIGIN STIFFNESS W/ LCK,SUP-2391577,CDM,C1729,HCPCS,0272,RC,,,,both,,,273.18,177.57,,,,,,,,,,,,,
GRAFT BNE SUB 5ML DBM PSTE GRFTON,SUP-2281667,CDM,C1713,HCPCS,0278,RC,,,,both,,,2716.10,1765.46,,,,,,,,,,,,,
CLIP ANEURYSM SUNDT MINI #7 BAYONET 9MM 201833,SUP-2844635,CDM,C1889,HCPCS,0278,RC,,,,both,,,775.58,504.13,,,,,,,,,,,,,
CATHETER EP MED SWP 2-5-2 MM 2 MM 6 FRX115 CM,SUP-2867397,CDM,C1730,HCPCS,0272,RC,,,,both,,,2804.02,1822.61,,,,,,,,,,,,,
FENTANYL 25 MCG/HR TD PT72,RX-27905,CDM,6370000000,HCPCS,0637,RC,50742-0550-05,NDC,,both,1,UN,22.50,14.62,,,,,,,,,,,,,
SET INTRO MICROPUNCTURE CATH L 10 CM 4 FR L 7 CM SS PLAT,SUP-2170553,CDM,C1894,HCPCS,0272,RC,,,,both,,,77.72,50.52,,,,,,,,,,,,,
NAIL IM L130MM DIA8MM MIDFOOT CANN SALVATION 2,SUP-2417598,CDM,C1713,HCPCS,0278,RC,,,,both,,,5717.94,3716.66,,,,,,,,,,,,,
PLATE BNE TBLR 2.7X33 MM 4 HOLE 1/4 TI,SUP-2536104,CDM,C1713,HCPCS,0278,RC,,,,both,,,349.48,227.16,,,,,,,,,,,,,
PLATE BNE L118MM 6 H ST L LAT PROX TIB S STL LOK COMPR LO,SUP-2185714,CDM,C1713,HCPCS,0278,RC,,,,both,,,4593.82,2985.98,,,,,,,,,,,,,
TUBE VENT ID1MM INNR FLNG 1MM FLROPLAS W/O H FOR MYR REUT,SUP-2312596,CDM,L8699,HCPCS,0278,RC,,,,both,,,15.89,10.33,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 80 CM DIA 6 MM RNG L 20 CM EPTFE,SUP-2396310,CDM,C1768,CPT,0278,RC,,,,both,,,3821.38,2483.90,,,,,,,,,,,,,
DEVICE SUT W/ DEL TOOL KNOT PUSH DISP FIXATE,SUP-2138771,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
PLATE BNE 2/2.4X49X1.7 MM 6 HOLE SS LC-DCP,SUP-2569205,CDM,C1713,HCPCS,0278,RC,,,,both,,,290.14,188.59,,,,,,,,,,,,,
GRAFT BONE 5CC HCT/P REGULATED VIABLE CELLULAR,SUP-2718753,CDM,C1713,HCPCS,0278,RC,,,,both,,,9891.00,6429.15,,,,,,,,,,,,,
GRAFT TISS FRZ DRY ALLGRFT CANC OR CORT DWL BONE 14MM,SUP-2307026,CDM,C1713,HCPCS,0278,RC,,,,both,,,1409.86,916.41,,,,,,,,,,,,,
CATHETER ANGIOPLSTY AGNT L 144 MM BALLOON L 12 MM DIA2.25 MM,SUP-2892819,CDM,C2623,HCPCS,0278,RC,,,,both,,,19389.50,12603.17,,,,,,,,,,,,,
"HC So1 Quantation of Therapuetic Drug, Nes",PX-3018029967,CDM,80299,CPT,0301,RC,,,,both,,,192.00,124.80,,,,,,,,,,,,,
GRAFT AMNIOFIX AMNIOTIC MEMBRANE 40MG,SUP-2866797,CDM,C1762,CPT,0278,RC,,,,both,,,1051.90,683.73,,,,,,,,,,,,,
BLADE SURG EXTRACTOR SPACER,SUP-2653712,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1642.85,1067.85,,,,,,,,,,,,,
CANNULA ENDOSCP LL 11 MMX6.5 CM STOPCOCK ANGLED N THRD GRN,SUP-2771889,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1125.34,731.47,,,,,,,,,,,,,
ANCHOR SUT OD5.5MM LACTOSORB L15 COPOLYMER 2 TWO MAXBRAID 905942] ZIMMER BIOMET SPORTS MEDICINE],SUP-2212878,CDM,C1713,HCPCS,0278,RC,,,,both,,,1036.20,673.53,,,,,,,,,,,,,
BASKET RETRV HELI BGLY 10MM BSKT 1.9 FR X 90 CM,SUP-2139260,CDM,2720000010,LOCAL,0272,RC,,,,both,,,456.68,296.84,,,,,,,,,,,,,
NAIL IM L340MM OD11MM 135DEG BLU TI LT PROX HIP BEND NK,SUP-2371012,CDM,C1713,HCPCS,0278,RC,,,,both,,,4765.26,3097.42,,,,,,,,,,,,,
PLATE BNE L197MM THK38MM 10 H L MED DST TIB S STL NEUT,SUP-2185221,CDM,C1713,HCPCS,0278,RC,,,,both,,,4154.28,2700.28,,,,,,,,,,,,,
SYSTEM SACRALCOLPOPEXY PROLAPSE REP STRAIGHT-IN INTEPRO,SUP-2140285,CDM,C1771,HCPCS,0278,RC,,,,both,,,5538.96,3600.32,,,,,,,,,,,,,
CODMAN DISPOSABLE FRCP 8 20 CM 05 MM VERSATRU,SUP-2243825,CDM,C1713,HCPCS,0278,RC,,,,both,,,894.90,581.68,,,,,,,,,,,,,
HC Cath/Intro Sal Cont Hyst,PX-3615834000,CDM,58340,CPT,0361,RC,,,,outpatient,,,445.00,289.25,,,,,,,,,,,,,
BLADE SAW L 51 X W 15 MM D 20 MM THK MATERIAL 0.5 MM CUT 6,SUP-2928910,CDM,2720000010,LOCAL,0272,RC,,,,both,,,449.27,292.03,,,,,,,,,,,,,
COIL NEUROVASCULAR TRUFILL DCS ORBIT L 12 CM SHP DIA 5 MM,SUP-2458341,CDM,C1889,HCPCS,0278,RC,,,,both,,,3243.37,2108.19,,,,,,,,,,,,,
SPACER KNEE DRL TIP 8 MM PATELLAR 1 PEG VANGUARD,SUP-2446515,CDM,C1776,CPT,0278,RC,,,,both,,,649.98,422.49,,,,,,,,,,,,,
PIN FIX DBL DIAMOND 0.125X9 IN THRD SS NS STEINMANN,SUP-2791304,CDM,C1713,HCPCS,0278,RC,,,,both,,,80.64,52.42,,,,,,,,,,,,,
NAIL IM L340MM DIA9MM 130DEG LNG GRN L PROX FEM TI,SUP-2180696,CDM,C1713,HCPCS,0278,RC,,,,both,,,6805.60,4423.64,,,,,,,,,,,,,
STAPLER INT L60MM DIA12MM STD TISS TI LNAR CUT LN 6 ROW,SUP-2218984,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1304.32,847.81,,,,,,,,,,,,,
PIN PERC 150MM PACKED IN BLISTER,SUP-2739164,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
PROBE DOPP MIC 20MHZ L231MM TIP 0.8MM BAYONETED DISP,SUP-2305982,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1714.44,1114.39,,,,,,,,,,,,,
SET INTRO PERFRMR L 13 CM OD 5 FR ID 1.7 MM GUIDEWIRE L 40,SUP-2168551,CDM,C1894,HCPCS,0272,RC,,,,both,,,104.09,67.66,,,,,,,,,,,,,
SHELL ACET PRESSFIT PRI 40 MM OD UNIV NO H CERAMIC COAT TI,SUP-2210213,CDM,C1776,CPT,0278,RC,,,,both,,,5306.60,3449.29,,,,,,,,,,,,,
PROSTHESIS VOICE SIL L6 MM OD16 FR TRACHEOESOPHAGEAL 1W SLT,SUP-2242327,CDM,L8507,HCPCS,0274,RC,,,,both,,,188.40,122.46,,,,,,,,,,,,,
IMPLANT HUM TISS L 3 X W 3 CM PLCNTA MTRX MEMBRN DEHYDR ASEP,SUP-2905530,CDM,Q4184,HCPCS,0636,RC,,,,both,,,7065.00,4592.25,,,,,,,,,,,,,
SCREW BNE CANN 7.3X50 MM PERI ARTC CONCL FT SS NS LCP,SUP-2184772,CDM,C1713,HCPCS,0278,RC,,,,both,,,685.40,445.51,,,,,,,,,,,,,
INDOCYANINE GREEN 25 MG IJ SOLR,RX-164944,CDM,2500000003,HCPCS,0250,RC,70100-0825-02,NDC,,both,1,UN,1643.60,1068.34,,,,,,,,,,,,,
STRUT SPNL W6XL200MM THK3-15MM TIB CORT THIRDS ALLGRFT FRZN,SUP-2307374,CDM,C1713,HCPCS,0278,RC,,,,both,,,2288.71,1487.66,,,,,,,,,,,,,
GUIDEWIRE ORTH 1ST METATRSL LAPIDUS CLMP SYS NS LF,SUP-2881124,CDM,C1769,HCPCS,0272,RC,,,,both,,,2402.10,1561.36,,,,,,,,,,,,,
BLADE RTRCTR 14MMW X 45MML SPNL BALL SNAP CNTR F/MCRO LMBR D,SUP-2492000,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1040.50,676.32,,,,,,,,,,,,,
STENT URET OPN END 6 FRX24 CM KID CURL TAPR SIL MULTI-FLEX,SUP-2313765,CDM,C2617,HCPCS,0278,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
HC Open/Perq Place Stent Ea Add A,PX-3603723700,CDM,37237,CPT,0360,RC,,,,both,,,15457.00,10047.05,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED ULTRA HI DEMAND 1 FIX BEAR STRYKERK1FIX] STRYKER CORP],SUP-2365982,CDM,C1776,CPT,0278,RC,,,,both,,,19405.20,12613.38,,,,,,,,,,,,,
NAIL IM TIB LNG W/ HNDL OXFORD,SUP-2445267,CDM,C1713,HCPCS,0278,RC,,,,both,,,466.29,303.09,,,,,,,,,,,,,
DEXTROSE 5% IV SOLN NEONATE|DISCARDED DRUG NOT ADMINISTE,RX-40840076,CDM,2580000003,HCPCS,0258,RC,00264-7510-20,NDC,JW,both,250,ML,31.90,20.73,,,,,,,,,,,,,
PLATE BNE LG NON-BIOASORB STRL X-PLATE STRATUM,SUP-2656715,CDM,C1713,HCPCS,0278,RC,,,,both,,,3221.26,2093.82,,,,,,,,,,,,,
BUR SURG ACORN MED 3.7 MM 67 MM ENT FLUT HI SPD SS,SUP-2628876,CDM,2720000010,LOCAL,0272,RC,,,,both,,,179.55,116.71,,,,,,,,,,,,,
BODY RAD SZ 1 12MM RT WR FOR FX SYS MAESTRO,SUP-2407361,CDM,C1776,CPT,0278,RC,,,,both,,,11282.02,7333.31,,,,,,,,,,,,,
SCREW BONE L30MM DIA4.5MM PARTIALLY THRD HD M CANN,SUP-2225342,CDM,C1713,HCPCS,0278,RC,,,,both,,,772.22,501.94,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.440,SUP-2860004,CDM,C1713,HCPCS,0278,RC,,,,both,,,45146.92,29345.50,,,,,,,,,,,,,
PORT IMPL INFUSION SINGLE LUMEN 9.6 FR DETACHED SIL CATH TI,SUP-2118760,CDM,C1788,HCPCS,0278,RC,,,,both,,,957.70,622.50,,,,,,,,,,,,,
WIRE PACE MYO/WIRE L 61 CM SZ 2-0 NDL L 89 MM SS TEMP ORN,SUP-2101188,CDM,2720000010,LOCAL,0272,RC,,,,both,,,86.10,55.96,,,,,,,,,,,,,
KIT BNE FIX 35MM CRKSCR FULL THRD SUT ANCHR NO0 48IN BLU,SUP-2122810,CDM,C1713,HCPCS,0278,RC,,,,both,,,1978.20,1285.83,,,,,,,,,,,,,
DRILL SURG L 185 MM DIA 3.5 MM FREE HND STRL DISP T2 ALPHA,SUP-2902355,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1103.11,717.02,,,,,,,,,,,,,
GRAFT DURA W1XL1IN REABSORBABLE MTRX SUB FOR SFT TISS REP ID1101] INTEGRA LIFESCIENCES CORP],SUP-2244077,CDM,C1763,HCPCS,0278,RC,,,,both,,,648.91,421.79,,,,,,,,,,,,,
PROBE LASER CYCLOPHOTOCOAGULATION FOR GLAUCOMA PROC MICROPULSE,SUP-2247220,CDM,2720000010,LOCAL,0272,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
LOCKING SCREW TKA TIBIAL AUGMENT 5MM,SUP-2813238,CDM,C1713,HCPCS,0278,RC,,,,both,,,301.44,195.94,,,,,,,,,,,,,
ANCHOR SUTURE SCR IN 1-0 6.5 MM TWST AP BLU,SUP-2761993,CDM,C1713,HCPCS,0278,RC,,,,both,,,1321.94,859.26,,,,,,,,,,,,,
REAMER SURG ACORN 11MM,SUP-2249539,CDM,2720000010,LOCAL,0272,RC,,,,both,,,797.56,518.41,,,,,,,,,,,,,
SET INT FIX DIA18.5 MM TI NEURO 1 PK STRL DISP LORENZ,SUP-2935547,CDM,C1713,HCPCS,0278,RC,,,,both,,,1968.78,1279.71,,,,,,,,,,,,,
HC So Osmolality Serum,PX-3018393066,CDM,83930,CPT,0301,RC,,,,inpatient,,,26.00,16.90,,,,,,,,,,,,,
GUIDEWIRE ORTH 2X200 MM SS,SUP-2646004,CDM,C1769,HCPCS,0272,RC,,,,both,,,93.51,60.78,,,,,,,,,,,,,
INVISION  TIBIAL TRAY SZ 4 8MM UNIVERSAL LNG,SUP-2458083,CDM,C1776,CPT,0278,RC,,,,both,,,18199.44,11829.64,,,,,,,,,,,,,
STENT COR 15MM 2.5MM CO CHROM ALLOY EVEROLIMUS DRUG,SUP-2139513,CDM,C1874,HCPCS,0278,RC,,,,both,,,6123.00,3979.95,,,,,,,,,,,,,
BOOT WALKING SURG,SUP-2265017,CDM,L3260,HCPCS,0274,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
LINER ACET NEUT HIP METASUL EPSILON,SUP-2448623,CDM,C1776,CPT,0278,RC,,,,both,,,50995.17,33146.86,,,,,,,,,,,,,
PERMETHRIN 1 % EX LIQD,RX-10918,CDM,6370000000,HCPCS,0637,RC,63736-0120-02,NDC,,both,59,ML,40.10,26.06,,,,,,,,,,,,,
HC CT Abdomen W/O Cont,PX-3527415000,CDM,74150,CPT,0352,RC,,,,both,,,1973.00,1282.45,,,,,,,,,,,,,
BRACE ORTH CORSET FRONT,SUP-2388154,CDM,L0972,HCPCS,0272,RC,,,,both,,,297.99,193.69,,,,,,,,,,,,,
MESH SPNL H7XL10MM TI RND,SUP-2254462,CDM,C1713,HCPCS,0278,RC,,,,both,,,4207.60,2734.94,,,,,,,,,,,,,
SHEATH GUID 0.018 IN 5 FRX10 CM THN WALLED HYDRPHLC HALO 1,SUP-2719762,CDM,C1887,HCPCS,0272,RC,,,,both,,,266.90,173.48,,,,,,,,,,,,,
KIT PRB 17GA L50MM ACT TIP 4MM COOLED RF COOLIEF,SUP-2237175,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
PROTECTOR TISS 1X2 IN 1 CC FLAT DRY SHT TRNSLUC VERSAWRAP,SUP-2740207,CDM,C1889,HCPCS,0278,RC,,,,both,,,5008.30,3255.39,,,,,,,,,,,,,
GRAFT BNE SUB 30CC SZ 01 4MM CRUSH CANC CHIP FRZN,SUP-2307400,CDM,C1713,HCPCS,0278,RC,,,,both,,,2028.69,1318.65,,,,,,,,,,,,,
SCREW SPNL L60MM OD7.5MM S STL PEDCL IL CDH LEG,SUP-2286974,CDM,C1713,HCPCS,0278,RC,,,,both,,,2847.20,1850.68,,,,,,,,,,,,,
PLATE BNE 8 H TI ALLOY RT 1ST-2ND TMT NS LEOS,SUP-2933214,CDM,C1713,HCPCS,0278,RC,,,,both,,,5666.13,3682.98,,,,,,,,,,,,,
NAIL IM L90MM OD11MM HIP SUBTROCHANTERIC ZCKL II,SUP-2364782,CDM,C1713,HCPCS,0278,RC,,,,both,,,852.20,553.93,,,,,,,,,,,,,
INSERT TIB H16MM M/M+ DURAMER ADVTM LSI,SUP-2304384,CDM,C1776,CPT,0278,RC,,,,both,,,6559.77,4263.85,,,,,,,,,,,,,
PROSTHESIS OSS 6 MM 1.12 MM 3 MM CENTERED PART TILT OTOSIL,SUP-2468981,CDM,L8613,CPT,0278,RC,,,,both,,,1235.24,802.91,,,,,,,,,,,,,
INSERT TIBIAL REVISION XXSMALL 18 MM KNEE AOX ATTUNE LPS,SUP-2838627,CDM,C1776,CPT,0278,RC,,,,both,,,9211.35,5987.38,,,,,,,,,,,,,
PLATE BNE L STD CALCNL POLYAX PERIMETER TAB LOK ORTHOLOC,SUP-2398085,CDM,C1713,HCPCS,0278,RC,,,,both,,,3994.08,2596.15,,,,,,,,,,,,,
HC Rep Lac Smp Face 12.6-20cm,PX-4501201600,CDM,12016,CPT,0450,RC,,,,both,,,1216.00,790.40,,,,,,,,,,,,,
REAMER RMR 22MM CONCV HD,SUP-2390566,CDM,2720000010,LOCAL,0272,RC,,,,both,,,596.60,387.79,,,,,,,,,,,,,
SCREW BONE L11MM DIA2MM MAND TI SELF DRL INTRAMAXILLARY FIX,SUP-2137237,CDM,C1713,HCPCS,0278,RC,,,,both,,,335.98,218.39,,,,,,,,,,,,,
PUMP INFUS 40ML 0.048ML/DAY DIA87.5MM THK19.5MM ITH TI,SUP-2284622,CDM,C1772,HCPCS,0278,RC,,,,both,,,37230.98,24200.14,,,,,,,,,,,,,
SCREW SPNL MULTAXL 4X40 MM OCCIPITOCERVICAL UPPER THOR,SUP-2632002,CDM,C1713,HCPCS,0278,RC,,,,both,,,1789.80,1163.37,,,,,,,,,,,,,
CATHETER GUID FLOWGATE L 95 CM OD 8 FR ID 0.084 IN 60 CC SYR,SUP-2367796,CDM,C2628,HCPCS,0272,RC,,,,both,,,3689.50,2398.17,,,,,,,,,,,,,
HC Bil Niv Arterial With Stress Tc,PX-9219392400,CDM,93924,CPT,0921,RC,,,,outpatient,,,1868.00,1214.20,,,,,,,,,,,,,
THREADLOCK TRANSPORT DIST 50MM PREBENT RIGHT TI 6AL 4V,SUP-2669833,CDM,C1713,HCPCS,0278,RC,,,,both,,,17792.37,11565.04,,,,,,,,,,,,,
PUMP PAIN 400ML 1 PRT 1 FIX HUB PROGRAMMABLE PRTABLE RESVR,SUP-2361479,CDM,C2626,HCPCS,0278,RC,,,,both,,,769.30,500.04,,,,,,,,,,,,,
CATHETER GUID VISTA BRT TIP L 100 CM OD 5 FR ID 0.056 IN LNG,SUP-2155873,CDM,C1887,HCPCS,0272,RC,,,,both,,,94.95,61.72,,,,,,,,,,,,,
HEAD SPNL SCREW ROD DIA 5.5/6 MM MULTAXL STRL CD HORZ 4PK,SUP-2928657,CDM,C1713,HCPCS,0278,RC,,,,both,,,6656.80,4326.92,,,,,,,,,,,,,
HEAD FEM MOD 3+ MM 12/14 32 MM CONSTRN TAPR COCR FRDM,SUP-2441358,CDM,C1776,CPT,0278,RC,,,,both,,,3152.56,2049.16,,,,,,,,,,,,,
CANNULA ART 1/4 IN 10 CM PEDIATRIC 10 FRX22.9 CM BIO-MEDICUS,SUP-2473526,CDM,2720000010,LOCAL,0272,RC,,,,both,,,932.58,606.18,,,,,,,,,,,,,
PLATE BNE NAR 3.5X251 MM 14 HOLE SS LCP,SUP-2569357,CDM,C1713,HCPCS,0278,RC,,,,both,,,657.99,427.69,,,,,,,,,,,,,
CHOLANGIOGRAPHY SET FRANK 0.025 IN 4 FRX60 CM,SUP-2737155,CDM,C1769,HCPCS,0272,RC,,,,both,,,172.70,112.25,,,,,,,,,,,,,
CEMENT FEM/ CEM TIBIA/ PRLNGART SURF/ NO PAT,SUP-2212172,CDM,C1776,CPT,0278,RC,,,,both,,,10451.65,6793.57,,,,,,,,,,,,,
PROBE COAG BPLR 7 FRX350 MM SINGLE PRNG ROUNDED PUR BRIGHTON,SUP-2487039,CDM,2720000010,LOCAL,0272,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
PROSTHESIS PENILE L25CM DIA11MM HYDRPHLC MAL TAIL CAP TRIM,SUP-2165370,CDM,C1813,HCPCS,0278,RC,,,,both,,,30147.14,19595.64,,,,,,,,,,,,,
PLATE FUSION VA LCP 1ST MTP 2.4/2.7MM REV 0 DEG LT TI STRL,SUP-2546981,CDM,C1713,HCPCS,0278,RC,,,,both,,,4865.43,3162.53,,,,,,,,,,,,,
BLADE RETRACTOR ABH 3X1 IN RENAL ALUM,SUP-2458343,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1330.10,864.56,,,,,,,,,,,,,
SEATING CHISEL FOR ADULT ANGLED BLADE PLATES 320MM,SUP-2548620,CDM,C1713,HCPCS,0278,RC,,,,both,,,2280.64,1482.42,,,,,,,,,,,,,
SURGICAL PROCEDURE KIT HIP CONSUM,SUP-2378875,CDM,C1776,CPT,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
GUIDEWIRE VASC ARW L 14 CM DIA 0.025 IN PERIPH AV SWG POS,SUP-2826706,CDM,C1769,HCPCS,0272,RC,,,,both,,,21.73,14.12,,,,,,,,,,,,,
SLEEVE PROTEC E51 V52 FLEX LG FOR NL 8-11 ST,SUP-2718100,CDM,2720000010,LOCAL,0272,RC,,,,both,,,718.43,466.98,,,,,,,,,,,,,
SCREW BNE L17MM DIA2.4MM LNG THRD L6MM CANC TI CANN ST SELF,SUP-2181373,CDM,C1713,HCPCS,0278,RC,,,,both,,,880.46,572.30,,,,,,,,,,,,,
TITANIUM 3D MESH 120MM X 120MM 3MM 15MM SSTM CP TTNM,SUP-2681401,CDM,C1713,HCPCS,0278,RC,,,,both,,,7699.66,5004.78,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC SV MAXBARR 3FR 45CM 1 LUMAN RVRSE T,SUP-2613430,CDM,C1751,HCPCS,0278,RC,,,,both,,,709.61,461.25,,,,,,,,,,,,,
GRAFT HUM TISS 20ML DEMIN MTRX PASTE OSTEOFIL RT,SUP-2293737,CDM,C1713,HCPCS,0278,RC,,,,both,,,6245.46,4059.55,,,,,,,,,,,,,
GRAFT BONE SUBSTITUTE 10CC DEMINERALIZED BONE MATRIX PUTTY REVERSE PHASE M STIMUBLAST CB,SUP-2120750,CDM,C1713,HCPCS,0278,RC,,,,both,,,3659.67,2378.79,,,,,,,,,,,,,
BRACE KNEE L FOR 21 24IN THGH UNIV NEOPRENE PUL ON ACL PLC,SUP-2151024,CDM,L1810,HCPCS,0272,RC,,,,both,,,162.02,105.31,,,,,,,,,,,,,
CATHETER NINJA FX JAPAN 2.25X10,SUP-2157897,CDM,C1725,HCPCS,0272,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
GUIDEWIRE VASC ARW L 68 CM DIA 0.018 IN SS PERIPH J/STRAIGHT,SUP-2383972,CDM,C1769,HCPCS,0272,RC,,,,both,,,33.91,22.04,,,,,,,,,,,,,
MOLD FEM SPCR M AP44MM ML67MM PMMA URETHANE GENT KASM,SUP-2315775,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5024.00,3265.60,,,,,,,,,,,,,
SHELL ACET OD62MM ID56MM UNIV HIP TI POR PRI PRESSFIT DUROM,SUP-2204676,CDM,C1776,CPT,0278,RC,,,,both,,,11699.64,7604.77,,,,,,,,,,,,,
BUTTERFLY WASHER LENGTH 21.7MM,SUP-2818892,CDM,C1713,HCPCS,0278,RC,,,,both,,,335.04,217.78,,,,,,,,,,,,,
PLATE BNE L 100 DEG 1.7X12 MM RT 6 HOLE BAR TI GLD NS,SUP-2366311,CDM,C1713,HCPCS,0278,RC,,,,both,,,683.67,444.39,,,,,,,,,,,,,
PLATE BNE BADIE 7X13X0.6 MM RESORB X STRL,SUP-2461165,CDM,C1713,HCPCS,0278,RC,,,,both,,,1163.87,756.52,,,,,,,,,,,,,
ALLOGRAFT BNE PLATE 150-20 MM FRZN IRRADIATED FEM,SUP-2866858,CDM,C1762,CPT,0278,RC,,,,both,,,1900.17,1235.11,,,,,,,,,,,,,
LONG CALCNL DRL 4.1MM,SUP-2244337,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1230.19,799.62,,,,,,,,,,,,,
GRAFT VASC ARTEGRAFT L 15 CM DIA 8 MM CLLGN BOV CAR ART,SUP-2880942,CDM,C1768,CPT,0278,RC,,,,both,,,10311.76,6702.64,,,,,,,,,,,,,
CATHETER HD 14 FRX28 CM CV,SUP-2159459,CDM,C1750,HCPCS,0278,RC,,,,both,,,1303.10,847.01,,,,,,,,,,,,,
STENT BILI UNCOVERED 0.035 IN 3.2 MM 8X60 MM 7.5 FRX1900 MM,SUP-2463295,CDM,C1876,HCPCS,0278,RC,,,,both,,,3611.00,2347.15,,,,,,,,,,,,,
BIT DRL L145MM DIA4.2MM TI 3 FLUT NDL PNT USED W/ RADLUC,SUP-2187055,CDM,2720000010,LOCAL,0272,RC,,,,both,,,745.75,484.74,,,,,,,,,,,,,
PASSER CATH L65CM X LNG MALL STR UNI SHUNT KT DISP FOR,SUP-2243783,CDM,C1713,HCPCS,0278,RC,,,,both,,,388.89,252.78,,,,,,,,,,,,,
CATHETER KIT SINGLE LUMEN 3 FR PICC,SUP-2118362,CDM,C1751,HCPCS,0278,RC,,,,both,,,204.10,132.66,,,,,,,,,,,,,
BIT DRL L50MM DIA1.6MM 5MM STP FOR 2/2.3MM SCR LEIBINGER,SUP-2366415,CDM,2720000010,LOCAL,0272,RC,,,,both,,,385.94,250.86,,,,,,,,,,,,,
PLATE BNE H 3.5/4X30 MM NS LTX,SUP-2857048,CDM,C1713,HCPCS,0278,RC,,,,both,,,6091.60,3959.54,,,,,,,,,,,,,
CATHETER CV 1 LUMEN 4 FR FULL W/ MI DOT POWERPICC SOLO 2,SUP-2126372,CDM,C1751,HCPCS,0278,RC,,,,both,,,503.84,327.50,,,,,,,,,,,,,
SPACER SPNL LAT 10X11X11 MM PRT VERTE-STACK CORNERSTONE PSR,SUP-2286381,CDM,C1821,HCPCS,0278,RC,,,,both,,,2009.60,1306.24,,,,,,,,,,,,,
CANISTER SUCTION ASPIR NS DISP ZOOM DUOPORT,SUP-2930264,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1114.70,724.55,,,,,,,,,,,,,
BOOT CHARCOT TCC EZ EXTRA L,SUP-2194343,CDM,L4387,HCPCS,0272,RC,,,,both,,,312.27,202.98,,,,,,,,,,,,,
PLATE BNE 2.7X52 MM 6 HOLE SS DCP,SUP-2569128,CDM,C1713,HCPCS,0278,RC,,,,both,,,272.87,177.37,,,,,,,,,,,,,
GUIDEWIRE VASC L190CM SPR COIL L17CM TIP DIA0014IN S STL COR,SUP-2140861,CDM,C1769,HCPCS,0272,RC,,,,both,,,244.92,159.20,,,,,,,,,,,,,
GRAFT NERVE REP 4X2 CM SFT TISS MEMBRN AVIVE,SUP-2424161,CDM,C1762,CPT,0278,RC,,,,both,,,6672.50,4337.12,,,,,,,,,,,,,
KIT INSTR DIA15MM CRV GUID W DRL CNTR SL FOR SFT ANCHR SYS,SUP-2212963,CDM,C1713,HCPCS,0278,RC,,,,both,,,1271.70,826.60,,,,,,,,,,,,,
CATHETERIZATION KIT 16 GAX20 CM CV PRB NDL FAST,SUP-2383266,CDM,C1751,HCPCS,0278,RC,,,,both,,,83.52,54.29,,,,,,,,,,,,,
LINER ACET OD36MM HIP RNG RECON COMP HK ROOF IMP GANZ,SUP-2212025,CDM,C1776,CPT,0278,RC,,,,both,,,5592.34,3635.02,,,,,,,,,,,,,
RING DIA155MM ALUM,SUP-2463278,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4031.76,2620.64,,,,,,,,,,,,,
SEALER BPLR DIA2.3MM DISP AQUAMANTYS,SUP-2281803,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1411.56,917.51,,,,,,,,,,,,,
DEVICE HYSTEROSCOPIC ROTARY STYL USE W/ 5C SYS TRUCLEAR,SUP-2172309,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2014.40,1309.36,,,,,,,,,,,,,
HC Assay of Lactate,PX-3018360500,CDM,83605,CPT,0301,RC,,,,both,,,231.00,150.15,,,,,,,,,,,,,
BRACE KNEE AD UNIV FOAM POSTOP 1 SZ FIT MOST AVG LEN FASTEN,SUP-2195290,CDM,L1810,HCPCS,0272,RC,,,,both,,,310.23,201.65,,,,,,,,,,,,,
GUIDEWIRE ORTH MULT HOLE PERC NS TFN-ADVANCED,SUP-2799743,CDM,C1769,HCPCS,0272,RC,,,,both,,,3435.60,2233.14,,,,,,,,,,,,,
PLATE BNE L69MM 3 H L SUP ANT CLAV S STL LOK COMPR W/ LAT,SUP-2184128,CDM,C1713,HCPCS,0278,RC,,,,both,,,2552.95,1659.42,,,,,,,,,,,,,
GRAFT BNE CHIP FRZN CRUSH CANC 01MM 4MM RANG 90CC,SUP-2307402,CDM,C1713,HCPCS,0278,RC,,,,both,,,5720.67,3718.44,,,,,,,,,,,,,
BUR DENT DIAMOND 0.6X70 MM STRL PM2 80K,SUP-2134820,CDM,2720000010,LOCAL,0272,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
DEVICE KNEE ALIGN,SUP-2237247,CDM,C1713,HCPCS,0278,RC,,,,both,,,4867.00,3163.55,,,,,,,,,,,,,
SET BILI STENT COTTON-HUIBREGTSE L 5 CM DIA10 FR PUSH L 170,SUP-2169034,CDM,C2617,HCPCS,0278,RC,,,,both,,,405.06,263.29,,,,,,,,,,,,,
ANCHOR SUTURE 2-0 LNG 1.5 MM SINGLE LD BLK WHT JUGGERKNOT,SUP-2745520,CDM,C1776,CPT,0278,RC,,,,both,,,918.45,596.99,,,,,,,,,,,,,
GUIDEWIRE VASC L180CM DIA0035IN TAPR L7CM FLPY TIP L3CM HEP,SUP-2167921,CDM,C1769,HCPCS,0272,RC,,,,both,,,65.19,42.37,,,,,,,,,,,,,
PLATE BONE W15XL136MM THK2MM 6 H BILAT TI THN BLDE RIG,SUP-2190984,CDM,C1713,HCPCS,0278,RC,,,,both,,,1464.24,951.76,,,,,,,,,,,,,
COMPONENT TIB TY PROX PLATE NS OPTILOCK LTX,SUP-2861371,CDM,C1776,CPT,0278,RC,,,,both,,,7315.76,4755.24,,,,,,,,,,,,,
TUBE FEED NG RADPQ POLYUR AD W OUT CO2 CONN DBL LUMN,SUP-2172146,CDM,2720000010,LOCAL,0272,RC,,,,both,,,59.09,38.41,,,,,,,,,,,,,
CATHETER ANGIOPLSTY ADV ENFORCER 35 L 80 CM L 4 CM DIA 10 MM,SUP-2635410,CDM,C1725,HCPCS,0272,RC,,,,both,,,621.72,404.12,,,,,,,,,,,,,
LASER FBR ANG DEL DEV GREENLIGHT HPS,SUP-2138863,CDM,C1713,HCPCS,0278,RC,,,,both,,,3611.00,2347.15,,,,,,,,,,,,,
BRACE WLK M M 7 10 WOM 8 11 EXTRA PNEUMAT LTWT DURABLE SEMI,SUP-2196364,CDM,L4361,HCPCS,0272,RC,,,,both,,,184.22,119.74,,,,,,,,,,,,,
KIT FEED TB 18FR L45CM STOMA L2CM TRANSGASTRIC JEJU SIL LO,SUP-2236573,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1102.27,716.48,,,,,,,,,,,,,
BUR SURG DIA 3 MM HUB I NEURO 1 RNG CUT STRL DISP ELAN 4,SUP-2929199,CDM,2720000010,LOCAL,0272,RC,,,,both,,,359.97,233.98,,,,,,,,,,,,,
GRAFT BNE SUB W1XL20CM SPNL DEFORMITY MAGNIFUSE,SUP-2293964,CDM,C1713,HCPCS,0278,RC,,,,both,,,12089.00,7857.85,,,,,,,,,,,,,
CATHETER BAL 5.3FR 3MM BAL DIAM 4MM BAL LEN .035IN WIRE SZ,SUP-2141045,CDM,C1725,HCPCS,0272,RC,,,,both,,,563.13,366.03,,,,,,,,,,,,,
SHEATH INTRO L 81 CM DIA 9.5 FR AD STRL,SUP-2141175,CDM,C1753,HCPCS,0278,RC,,,,both,,,288.88,187.77,,,,,,,,,,,,,
STENT COR 30MM 4MM CO CHROM ALLY RX BARE MTL LO,SUP-2295436,CDM,C1876,HCPCS,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
COMPONENT HUM SHLDR POLY CONSTRUCT COMPHSVE,SUP-2212461,CDM,C1776,CPT,0278,RC,,,,both,,,17898.00,11633.70,,,,,,,,,,,,,
CUP GLEN SUCTION AS INVERSE,SUP-2440764,CDM,C1776,CPT,0278,RC,,,,both,,,3052.08,1983.85,,,,,,,,,,,,,
COMPONENT TIB TY REV 3 LT KNEE,SUP-2392622,CDM,C1776,CPT,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
OCCLUDER CV HELEX L 75 CM DIA 30 MM NIT EPTFE HYDRPHLC DBL,SUP-2395830,CDM,C1817,HCPCS,0278,RC,,,,both,,,20218.46,13142.00,,,,,,,,,,,,,
GRAFT BNE 5 CC VOID FILL CERAMENT,SUP-2138669,CDM,C1713,HCPCS,0278,RC,,,,both,,,3264.03,2121.62,,,,,,,,,,,,,
PLATE BONE 1.7MM SCR H DIA N COMPR L PLT BILAT 7 H RIG RESRB,SUP-2364974,CDM,C1713,HCPCS,0278,RC,,,,both,,,470.69,305.95,,,,,,,,,,,,,
NEEDLE SUTURE L11IN BLUNT LIGATURE FOR LEFT HAND DESCHAMPS,SUP-2803432,CDM,2720000010,LOCAL,0272,RC,,,,both,,,386.44,251.19,,,,,,,,,,,,,
STEM FEM SZ 1 STD HIP TI PLSM SPR OVATION,SUP-2314387,CDM,C1776,CPT,0278,RC,,,,both,,,9696.32,6302.61,,,,,,,,,,,,,
HC Anesthesia Attended Care,PX-3700000000,CDM,3700000000,LOCAL,0370,RC,,,,both,,,1048.00,681.20,,,,,,,,,,,,,
PLATE BNE THK 0.75 MM PANEL 1.7 MM 1 X 21 H MAXILLOFCL PART,SUP-2909605,CDM,C1713,HCPCS,0278,RC,,,,both,,,7925.17,5151.36,,,,,,,,,,,,,
TUBE TRACH BLUE RHINO G2-MULTI TRAY W/ SHILEY FLEX 8.5,SUP-2714086,CDM,C1769,HCPCS,0272,RC,,,,both,,,2001.75,1301.14,,,,,,,,,,,,,
PLATE BNE THK 2 MM SCREW DIA2/2.3 MM LG GRD IV TI MANDIBULAR,SUP-2935785,CDM,C1713,HCPCS,0278,RC,,,,both,,,4713.14,3063.54,,,,,,,,,,,,,
SET ORTH GRPHC CA W/ K WIRE FOR MOD MINI FRAG INSTR AND,SUP-2177067,CDM,C1713,HCPCS,0278,RC,,,,both,,,128032.09,83220.86,,,,,,,,,,,,,
GRAFT BTM THK 20X16CM NO CL SCAF NAT OCC PRCN STRL GNTRX DSP,SUP-2106500,CDM,Q4166,HCPCS,0636,RC,,,,both,,,25953.98,16870.09,,,,,,,,,,,,,
GRAFT VASC L 50 CM DIA 8 MM PVC GEL EPTFE CARDPULM BYPS STRL,SUP-2385090,CDM,C1768,CPT,0278,RC,,,,both,,,2449.20,1591.98,,,,,,,,,,,,,
PACEMAKER CARD PHILOS SR-B SINGLE CHMBR 6 CONN UPLR SSIR,SUP-2137962,CDM,C1786,HCPCS,0275,RC,,,,both,,,8647.56,5620.91,,,,,,,,,,,,,
HEPARIN NA (PORK) LOCK FLSH PF 10 UNIT/ML IV SOLN,RX-162827,CDM,J1642,HCPCS,0636,RC,64253-0222-35,NDC,,both,3,ML,54.10,35.16,,,,,,,,,,,,,
ALLODERM DERMAL X THICK 16CM X 20CM MATRIX,SUP-2866786,CDM,Q4116,HCPCS,0636,RC,,,,both,,,33225.91,21596.84,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9 % IV SOLN 1000 ML,RX-40861025,CDM,J7030,HCPCS,0258,RC,00338-9793-01,NDC,,both,1000,ML,42.50,27.62,,,,,,,,,,,,,
ROD EXT FIX L638MM DIA8MM SPAN L499MM 135DEG C FBR CVD,SUP-2188723,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1510.69,981.95,,,,,,,,,,,,,
PLATE BONE L 4X4 H MAND TI ANG FOR 2MM SCR FIX LCKING SYS,SUP-2191241,CDM,C1713,HCPCS,0278,RC,,,,both,,,4374.02,2843.11,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9 % IV SOLN 1000 ML,RX-40861025,CDM,J7030,HCPCS,0250,RC,00338-9793-01,NDC,,both,1000,ML,42.50,27.62,,,,,,,,,,,,,
HC JONES BOLT STERILE 4.5MMX47MM,SUP-2841255,CDM,C1713,HCPCS,0278,RC,,,,both,,,7834.30,5092.29,,,,,,,,,,,,,
BLADE SHAVER CRV SUCTION 65 DEG 4 MMX12 CM SERRATED YEL STRL,SUP-2602791,CDM,2720000010,LOCAL,0272,RC,,,,both,,,670.33,435.71,,,,,,,,,,,,,
PROBE ABLATION INTERCEPT BIPOLAR L3 BASIVERTEBRAL NERVE RADIOFREQUENCY,SUP-2757212,CDM,C1889,HCPCS,0278,RC,,,,both,,,13878.80,9021.22,,,,,,,,,,,,,
CLAMP CRAN DIA18MM TI FLAP TUBE,SUP-2192429,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1530.12,994.58,,,,,,,,,,,,,
HC So Hepatitis B Core Antibody|NOT REASONABLE AND NECESSARY,PX-3028670466,CDM,86704,CPT,0302,RC,,,GZ,outpatient,,,59.00,38.35,,,,,,,,,,,,,
BRACE WR AD UNIV LT AND RT ELAS SUPP STRP FOAM CUSH WRP ARND,SUP-2309133,CDM,L3931,HCPCS,0274,RC,,,,both,,,52.09,33.86,,,,,,,,,,,,,
TIP HNDPC BARRACUDA SONOPET IQ,SUP-2423053,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2895.14,1881.84,,,,,,,,,,,,,
GRAFT HUM TISS SM W10XL17CM THK15 22MM THCK PERF FLEXHD,SUP-2307602,CDM,Q4126,HCPCS,0636,RC,,,,both,,,9044.52,5878.94,,,,,,,,,,,,,
SLEEVE DRL 6+ MM PIN APEX,SUP-2465611,CDM,C1713,HCPCS,0278,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
ALLOGRAFT BNE DBM + CORTICAL 5 CC FD,SUP-2717769,CDM,C1713,HCPCS,0278,RC,,,,both,,,3168.73,2059.67,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC MAXBARR 5FR 55CM 1 LUMAN RVS TAPR P,SUP-2613367,CDM,C1751,HCPCS,0278,RC,,,,both,,,787.51,511.88,,,,,,,,,,,,,
PLATE BNE 3X5 H L DST RAD VOLAR S STL LO PROF RIG,SUP-2186103,CDM,C1713,HCPCS,0278,RC,,,,both,,,2736.26,1778.57,,,,,,,,,,,,,
CUFF URETH L6CM OCCL W/ INHIBZN FOR URIN CTRL SYS AMS 800,SUP-2138953,CDM,C1815,HCPCS,0278,RC,,,,both,,,19739.61,12830.75,,,,,,,,,,,,,
HC Drain/Inj Joint/Bursa W/US,PX-3612060600,CDM,20606,CPT,0361,RC,,,,outpatient,,,3707.00,2409.55,,,,,,,,,,,,,
SCREW BNE L36MM DIA4.5MM CORT DST FEM TI ST NONLOCKING FULL,SUP-2413522,CDM,C1713,HCPCS,0278,RC,,,,both,,,144.44,93.89,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY LIVEWIRE L 115 CM 5 FR 2-5-2MM XL,SUP-2538070,CDM,C1730,HCPCS,0272,RC,,,,both,,,677.99,440.69,,,,,,,,,,,,,
HC Surgery Robot Base,PX-3600000009,CDM,3600000009,LOCAL,0360,RC,,,,both,,,9659.00,6278.35,,,,,,,,,,,,,
HC Drain/Inj Joint/Bursa W/US,PX-3612060400,CDM,20604,CPT,0361,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
PLATE BONE CRANIAL 5 HOLE Y-PLATE 20.1X9.8MM TITANIUM NEURO,SUP-2825991,CDM,C1713,HCPCS,0278,RC,,,,both,,,266.27,173.08,,,,,,,,,,,,,
CLIP ANEURYSM TITANIUM FENESTRATED PERMANENT 90DEG ANGLED 3.,SUP-2825571,CDM,C1889,HCPCS,0278,RC,,,,both,,,1242.09,807.36,,,,,,,,,,,,,
GUIDEWIRE VASC SPECTRE L 200 CM DIA 0.014 IN RADIOPAQUE TIP,SUP-2383180,CDM,C1769,HCPCS,0272,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
FIBER LASER 200 MH HOLM 10493] FORTEC MEDICAL INC],SUP-2225589,CDM,2720000010,LOCAL,0272,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
BUR SURG DIA5MM RND TWO FLUT RIM GLDE TECHNOLOGY PRECIS,SUP-2367542,CDM,2720000010,LOCAL,0272,RC,,,,both,,,580.90,377.58,,,,,,,,,,,,,
PLATE BNE 3X6 H 2 23MM LOK GRID T SHP TRILOK,SUP-2267940,CDM,C1713,HCPCS,0278,RC,,,,both,,,2762.57,1795.67,,,,,,,,,,,,,
SCREW CADDY 2.7MM,SUP-2841456,CDM,C1713,HCPCS,0278,RC,,,,both,,,4647.20,3020.68,,,,,,,,,,,,,
HC L-Spine Min 4 Views,PX-3207211000,CDM,72110,CPT,0320,RC,,,,both,,,825.00,536.25,,,,,,,,,,,,,
CATHETER SPEC RETRV 2 MM SINGLE LUMEN W/O VOL CAP,SUP-2312956,CDM,2720000010,LOCAL,0272,RC,,,,both,,,504.13,327.68,,,,,,,,,,,,,
"HC Est Pt, E/M Level 3",PX-5109921300,CDM,99213,CPT,0510,RC,,,,both,,,257.00,167.05,,,,,,,,,,,,,
DRILL MEASURING SLEEVE 4.5MM,SUP-2587232,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1090.71,708.96,,,,,,,,,,,,,
SCREW BNE L6MM OD3.8MM BLU TI CORT IM FUS LOK HEX HD ST,SUP-2388908,CDM,C1713,HCPCS,0278,RC,,,,both,,,738.53,480.04,,,,,,,,,,,,,
VALVE HEMOSTAS HONOR DIA 7.2 FR POLYCARB SIL SM BOR STRL,SUP-2303047,CDM,C1713,HCPCS,0278,RC,,,,both,,,49.46,32.15,,,,,,,,,,,,,
HC So1 Immunoglobulinige,PX-3018278567,CDM,82785,CPT,0301,RC,,,,inpatient,,,48.00,31.20,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH L 76 MM LEG L 45 MM IPSILATERAL DIA20,SUP-2170132,CDM,C1768,CPT,0278,RC,,,,both,,,12132.96,7886.42,,,,,,,,,,,,,
HEAD FEM DIA26MM NK L0MM STD CERAMIC ZIRCONIA 12/14 TAPR PRI,SUP-2344550,CDM,C1776,CPT,0278,RC,,,,both,,,4684.10,3044.66,,,,,,,,,,,,,
SCALPEL SURG SAFETY SZ 10 STAINLES STL W/LNG LCK BARD PARKER,SUP-2605891,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4.99,3.24,,,,,,,,,,,,,
COMPONENT GLEN SHLDR HEMI TO RVS TRABECULAR MTL,SUP-2212298,CDM,C1776,CPT,0278,RC,,,,both,,,23550.00,15307.50,,,,,,,,,,,,,
CARBIDOPA-LEVODOPA 10-100 MG PO TABS,RX-9406,CDM,6370000000,HCPCS,0637,RC,00093-9701-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
VALVE MITRL BIOCOR STENTED TISS PERICARD SHLD FLEXFIT HLDR,SUP-2355766,CDM,C1889,HCPCS,0278,RC,,,,both,,,14130.00,9184.50,,,,,,,,,,,,,
WIRE TEMP FIX 48 MM DIAM S STL DBL END SMOOTH DBL SHRP TIP,SUP-2342728,CDM,C1713,HCPCS,0278,RC,,,,both,,,274.12,178.18,,,,,,,,,,,,,
SYSTEM DELIVERY 34 MM  EVOLUT FX,SUP-2854100,CDM,2720000010,LOCAL,0272,RC,,,,both,,,9765.40,6347.51,,,,,,,,,,,,,
VALVE AORT CARP EDW PERIMT DIA29 MM BOV PERICARD COCR,SUP-2214059,CDM,C1889,HCPCS,0278,RC,,,,both,,,19436.60,12633.79,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.540,SUP-2860057,CDM,C1713,HCPCS,0278,RC,,,,both,,,48793.40,31715.71,,,,,,,,,,,,,
COMPONENT RADIAL CRPL XS LT WRST UNIV 2,SUP-2610331,CDM,C1776,CPT,0278,RC,,,,both,,,21325.44,13861.54,,,,,,,,,,,,,
SCREW BNE L16MM DIA2.7MM TI ST VAR ANG NONCANNULATED LOK,SUP-2181185,CDM,C1713,HCPCS,0278,RC,,,,both,,,479.32,311.56,,,,,,,,,,,,,
PROBE ELECSURG MIC ANG TEMP CTRL TACS,SUP-2341610,CDM,C1713,HCPCS,0278,RC,,,,both,,,1167.14,758.64,,,,,,,,,,,,,
CANNULA SURG FOR DRL GUIDE,SUP-2762143,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1061.32,689.86,,,,,,,,,,,,,
STENT PERIPH SMRT RADIANZ L 20 MM DIA 8 MM DEL SYS L 190 CM,SUP-2866177,CDM,C1876,HCPCS,0278,RC,,,,both,,,3422.88,2224.87,,,,,,,,,,,,,
T2 PROX HUM NAIL 8MMX150MM LT STRL,SUP-2361808,CDM,C1713,HCPCS,0278,RC,,,,both,,,5840.40,3796.26,,,,,,,,,,,,,
ANCHOR FIX OCPTL SHT 11 MM SPINAL SYSTEM CASPIAN,SUP-2734710,CDM,C1713,HCPCS,0278,RC,,,,both,,,4553.00,2959.45,,,,,,,,,,,,,
DRAINAGE KIT PLEURAL ESSENTIAL INSRTN TY CATH ASPIRA,SUP-2301576,CDM,C1729,HCPCS,0272,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
WIRE FIX L150MM DIA1.6MM THRD L20MM TI PARTIALLY THRDED FOR,SUP-2179086,CDM,C1713,HCPCS,0278,RC,,,,both,,,144.63,94.01,,,,,,,,,,,,,
PLATE BONE 8 H DBL Y FOR 1.7MM SCR,SUP-2365074,CDM,C1713,HCPCS,0278,RC,,,,both,,,1822.68,1184.74,,,,,,,,,,,,,
ANKLE FUSION PLATE LATERAL TTC 5H STRL,SUP-2815100,CDM,C1713,HCPCS,0278,RC,,,,both,,,7693.00,5000.45,,,,,,,,,,,,,
CATHETER ATHRCTMY TURBOHAWK L 133 CM SHTH 6 FR RVD 2-4 MM,SUP-2281688,CDM,C1714,HCPCS,0272,RC,,,,both,,,10032.30,6520.99,,,,,,,,,,,,,
"HC Culture, Aerobic",PX-3008707000,CDM,87070,CPT,0300,RC,,,,both,,,207.00,134.55,,,,,,,,,,,,,
HC Holter Scan Analysis,PX-7319322600,CDM,93226,CPT,0731,RC,,,,both,,,1348.00,876.20,,,,,,,,,,,,,
PLATE BNE XLN L VOLAR DST RAD WRST LOK ACU LOC,SUP-2107774,CDM,C1713,HCPCS,0278,RC,,,,both,,,2970.44,1930.79,,,,,,,,,,,,,
KIT EXP NDL L8IN SOAK CATH L10IN T PEEL ON-Q PAINBUSTER,SUP-2236845,CDM,C1751,HCPCS,0278,RC,,,,both,,,304.58,197.98,,,,,,,,,,,,,
BLADE SAW OSCILLATING CLSSC 13MMW X90MML 1.37MM THK INNVTVE,SUP-2605814,CDM,2720000010,LOCAL,0272,RC,,,,both,,,139.32,90.56,,,,,,,,,,,,,
JOINT TOE CANN PHLANG HEMI SYS BIOMOTION,SUP-2664033,CDM,C1776,CPT,0278,RC,,,,both,,,14016.96,9111.02,,,,,,,,,,,,,
SCREW BNE L76MM DIA4.5MM CORT TI ST NONCANNULATED,SUP-2190484,CDM,C1713,HCPCS,0278,RC,,,,both,,,125.79,81.76,,,,,,,,,,,,,
ALLOGRAFT BNE BLOCK 2X2X3 CM PRESERVON CANC READIGRAFT,SUP-2740812,CDM,C1713,HCPCS,0278,RC,,,,both,,,1240.93,806.60,,,,,,,,,,,,,
HEAD FEM DIA28MM +0MM OFFSET 14/16 TAPR CO CHROM MTL ON,SUP-2249722,CDM,C1776,CPT,0278,RC,,,,both,,,2072.40,1347.06,,,,,,,,,,,,,
CAGE SPNL FACEPLT 14 MM 2 HOLE NO PROF,SUP-2750635,CDM,C1889,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
INTRODUCER 4FRX25CM SHTH W/ .035IN GWIRE ENGAGE,SUP-2355798,CDM,C1894,HCPCS,0272,RC,,,,both,,,65.94,42.86,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL PEEK SD800.536,SUP-2860217,CDM,C1713,HCPCS,0278,RC,,,,both,,,43305.00,28148.25,,,,,,,,,,,,,
DEVICE FIX KNOTLESS 3 MM HIP ARTHCARE PEEK IMPL SPEEDLOCK,SUP-2848538,CDM,C1713,HCPCS,0278,RC,,,,both,,,1417.71,921.51,,,,,,,,,,,,,
FEEDING TUBE KIT LP 20 FRX2 CM BLLN BUTTON SIL CLR MINI 1,SUP-2754579,CDM,2720000010,LOCAL,0272,RC,,,,both,,,660.22,429.14,,,,,,,,,,,,,
GRAFT BNE SUB 3CC CA PHSPTE HYALURONIC ACID CEM VOID FILL,SUP-2365202,CDM,C1713,HCPCS,0278,RC,,,,both,,,2540.26,1651.17,,,,,,,,,,,,,
COMPONENT PAT 28MM INSET SAMP PFC SIG,SUP-2253515,CDM,C1776,CPT,0278,RC,,,,both,,,379.94,246.96,,,,,,,,,,,,,
STENT CORONARY MULTLNK TRI L 8 MM DIA2.5 MM GUIDE CATH 0.064,SUP-2101447,CDM,C1876,HCPCS,0278,RC,,,,both,,,4254.70,2765.55,,,,,,,,,,,,,
CATHETER KIT 0.018 INX17.75 IN AD 4 FRX50 CM BLU FLEXTIP,SUP-2384053,CDM,C1751,HCPCS,0278,RC,,,,both,,,145.26,94.42,,,,,,,,,,,,,
CUTTER BNE 2.5MM AGG SM JT J LOK JTCUT,SUP-2366551,CDM,2720000010,LOCAL,0272,RC,,,,both,,,128.14,83.29,,,,,,,,,,,,,
ACETAMINOPHEN 120 MG RE SUPP,RX-103,CDM,6370000000,HCPCS,0637,RC,45802-0732-30,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
MARKER FIDUCIAL 0.35 MMX1 CM PRELD NDL CARR COIL VISICOIL,SUP-2430920,CDM,A4648,CPT,0278,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
ALLOGRAFT BNE FRZN ASEP ANTR TIBIALIS,SUP-2867227,CDM,C1762,CPT,0278,RC,,,,both,,,6828.09,4438.26,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA PLU MAXBARR 3FR S1173108D3,SUP-2632787,CDM,C1751,HCPCS,0278,RC,,,,both,,,1059.75,688.84,,,,,,,,,,,,,
HC So Fructosamine,PX-3018298566,CDM,82985,CPT,0301,RC,,,,inpatient,,,274.00,178.10,,,,,,,,,,,,,
CURETTE SURG BAYNT STR 36MM,SUP-2293073,CDM,C1713,HCPCS,0278,RC,,,,both,,,901.40,585.91,,,,,,,,,,,,,
PLATE BNE L 246 X W 12 MM THK 3 MM SCREW DIA 3.5 MM 18 H SS 72467118,SUP-2933409,CDM,C1713,HCPCS,0278,RC,,,,both,,,7245.55,4709.61,,,,,,,,,,,,,
PLATE BNE STR 5 HOLE THRD FIX FOR R.E.D II DEV TI,SUP-2467444,CDM,C1713,HCPCS,0278,RC,,,,both,,,404.18,262.72,,,,,,,,,,,,,
HC Mandible Partial Less Than 4 Views,PX-3207010000,CDM,70100,CPT,0320,RC,,,,both,,,759.00,493.35,,,,,,,,,,,,,
PLATE BNE BROAD 4.5X107 MM 6 HOLE SS LCP,SUP-2569359,CDM,C1713,HCPCS,0278,RC,,,,both,,,533.64,346.87,,,,,,,,,,,,,
SUBSTITUTE BNE GRFT 3ML CA PHSPTE HA INJ CEM CRANIO,SUP-2366469,CDM,C1713,HCPCS,0278,RC,,,,both,,,2956.18,1921.52,,,,,,,,,,,,,
GRAFT BNE 40CC W/ BIOACTIVE GLS MOLD MTRX PLATFORM,SUP-2719785,CDM,C1713,HCPCS,0278,RC,,,,both,,,39187.20,25471.68,,,,,,,,,,,,,
PLATE BNE THK0.8MM 8 H HND T SHP TRILOK FOR 1.5MM SCR APTUS,SUP-2267904,CDM,C1713,HCPCS,0278,RC,,,,both,,,1748.98,1136.84,,,,,,,,,,,,,
SET ACCS L 38.5 CM DIA 9 FR NDL L 50.5 CM DIA16 GA TRNSJUG,SUP-2168168,CDM,C1894,HCPCS,0272,RC,,,,both,,,1789.96,1163.47,,,,,,,,,,,,,
GRAFT VASC GORTX L 70 CM DIA 6 MM RNG L 70 CM EPTFE STR TW,SUP-2396161,CDM,C1768,CPT,0278,RC,,,,both,,,4135.38,2688.00,,,,,,,,,,,,,
CANNULA OPHTH LAMBERT 33 GAX1-5/32 IN SUBRETINAL BLNT TIP,SUP-2457158,CDM,2720000010,LOCAL,0272,RC,,,,both,,,318.30,206.89,,,,,,,,,,,,,
CATHETER VASC 7FR L100CM FEM GUID VODA LT 3 COR W/O HYDRPHLC,SUP-2144029,CDM,C1887,HCPCS,0272,RC,,,,both,,,160.14,104.09,,,,,,,,,,,,,
CATHETER HD DL 11.5 FRX20 CM RAULERSON INT JUG DUOFLO,SUP-2269578,CDM,C1752,HCPCS,0278,RC,,,,both,,,109.90,71.43,,,,,,,,,,,,,
PLATE BNE LOK L CRV L 7 H TI PROX TIB PLATING SYS ALPS,SUP-2413715,CDM,C1713,HCPCS,0278,RC,,,,both,,,3884.18,2524.72,,,,,,,,,,,,,
PLATE BNE L210MM 13 H NAR 2 COMPR FOR 45MM SCR L FRAG SYS,SUP-2411428,CDM,C1713,HCPCS,0278,RC,,,,both,,,600.27,390.18,,,,,,,,,,,,,
CATHETER KIT HYBRID PICC 6 FRX55 CM 145 CM WIRE W/ ENDEXO,SUP-2117130,CDM,C1751,HCPCS,0278,RC,,,,both,,,492.98,320.44,,,,,,,,,,,,,
GRAFT BNE SUB 7GA 8CC CA PHSPTE SYR DISPENSER GUN CANN,SUP-2348206,CDM,C1713,HCPCS,0278,RC,,,,both,,,7762.49,5045.62,,,,,,,,,,,,,
BIT DRL L 140/45 MM DIA2.8 MM CALIB AO QC STRL DISP V,SUP-2908348,CDM,2720000010,LOCAL,0272,RC,,,,both,,,741.83,482.19,,,,,,,,,,,,,
LINER ACET OD64MM ID40MM +4MM OFFSET HIP GVF POLYETH TI,SUP-2250283,CDM,C1776,CPT,0278,RC,,,,both,,,11224.87,7296.17,,,,,,,,,,,,,
CATHETER CTRL VEN L65CM OD9FR SIL DBL LUMN TUNNELED N COAT N,SUP-2126155,CDM,C1751,HCPCS,0278,RC,,,,both,,,356.39,231.65,,,,,,,,,,,,,
PROBE ES L230CM CHN 28MM STR HEMSTAS REUSE HEATPRBS,SUP-2436501,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1342.10,872.36,,,,,,,,,,,,,
BIT DRILL DIA26MM STAINLESS STEEL FOR 4MM HALF PIN,SUP-2586489,CDM,2720000010,LOCAL,0272,RC,,,,both,,,724.05,470.63,,,,,,,,,,,,,
PLATE SPNL L26MM 6 H STD ANT CERV TI LEV 2 FIX LOK MAXAN,SUP-2414939,CDM,C1713,HCPCS,0278,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
STAPLE CART RELD ENDOSCP VASC THCK TISS 6 ROW CUT TI N ABSRB,SUP-2219723,CDM,C1713,HCPCS,0278,RC,,,,both,,,989.10,642.91,,,,,,,,,,,,,
BISMUTH SUBSALICYLATE 262 MG PO CHEW,RX-9284,CDM,6370000000,HCPCS,0637,RC,01490-0039-78,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
SET INTRO L2IN OD6FR PERC HEMSTAS VLV PRT TIP MRK DUST CAP,SUP-2383422,CDM,C1894,HCPCS,0272,RC,,,,both,,,865.48,562.56,,,,,,,,,,,,,
TOPOTECAN HCL 4 MG/4ML IV SOLN,RX-104079,CDM,J9351,HCPCS,0636,RC,00409-0302-01,NDC,,both,4,ML,399.10,259.41,,,,,,,,,,,,,
SCREW BNE CORT ST W T8 STARDRV RECESS TI IN ST TB 24MM X,SUP-2418148,CDM,C1713,HCPCS,0278,RC,,,,both,,,207.77,135.05,,,,,,,,,,,,,
MARKER TISS BIOMARC 1X3MM 18G,SUP-2152633,CDM,A4648,CPT,0278,RC,,,,both,,,303.54,197.30,,,,,,,,,,,,,
BUR SURGICAL DIAMETER 15MM PERFORATING FOR SKULL OPENING NEU,SUP-2804979,CDM,2720000010,LOCAL,0272,RC,,,,both,,,423.21,275.09,,,,,,,,,,,,,
CEFEPIME HCL 1 G IJ SOLR,RX-16369,CDM,J0692,HCPCS,0636,RC,60505-6146-04,NDC,,both,1,UN,54.10,35.16,,,,,,,,,,,,,
CLAMP EXT FIX L6IN TI ALLY MULTIPIN 6 POS,SUP-2188486,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1977.32,1285.26,,,,,,,,,,,,,
"HC Growth Hormone, Serum (5 Spec)",PX-3018300367,CDM,83003,CPT,0301,RC,,,,both,,,46.00,29.90,,,,,,,,,,,,,
GRAFT BNE STRP 100X20X5 MM DBM FIBER,SUP-2860952,CDM,C1713,HCPCS,0278,RC,,,,both,,,10409.10,6765.91,,,,,,,,,,,,,
SCREW BNE L10MM OD2.7MM S STL CORT ST NONCANNULATED LOK,SUP-2348635,CDM,C1713,HCPCS,0278,RC,,,,both,,,776.68,504.84,,,,,,,,,,,,,
BRACE ANK SWVL STRP STD 10 IN AIR/GEL BLDR LP BLK STIRRUP,SUP-2336325,CDM,L4350,HCPCS,0274,RC,,,,both,,,28.79,18.71,,,,,,,,,,,,,
BIT DRILL SURG DIA 3.5 MM MINI FOOTPRINT,SUP-2882964,CDM,2720000010,LOCAL,0272,RC,,,,both,,,492.89,320.38,,,,,,,,,,,,,
SCREW BNE L16MM DIA13MM GRN CORT TI ALLY ST SELF RET W T4,SUP-2180983,CDM,C1713,HCPCS,0278,RC,,,,both,,,309.45,201.14,,,,,,,,,,,,,
VALVE CSF PROGRAMMABLE W/ SIPHONGUARD BACTISEAL CERTAS +,SUP-2666587,CDM,C1889,HCPCS,0278,RC,,,,both,,,15969.54,10380.20,,,,,,,,,,,,,
PLATE BNE W12XL140MM THK25MM LNG 5 H NONSTERILE BILAT PROX,SUP-2190990,CDM,C1713,HCPCS,0278,RC,,,,both,,,4817.33,3131.26,,,,,,,,,,,,,
DEVICE THROMCTMY TIGERTRIEVER 13 L 20.5 MM DIA 0.5-2.5 MM,SUP-2864551,CDM,C1757,HCPCS,0272,RC,,,,both,,,19468.00,12654.20,,,,,,,,,,,,,
QUARTEX PARA CONNECTOR4.0MM ROD TO4.0MM ROD,SUP-2229082,CDM,C1713,HCPCS,0278,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
SHEATH INTRO PRELUDE L 11 CM DIA 5 FR POLYPRO TBNG SS,SUP-2740710,CDM,C1894,HCPCS,0272,RC,,,,both,,,65.28,42.43,,,,,,,,,,,,,
EPINEPHRINE (ANAPHYLAXIS) 1 MG/ML IJ SOLN,RX-140028,CDM,J0169,HCPCS,0636,RC,42023-0159-25,NDC,,both,0.1,ML,54.10,35.16,,,,,,,,,,,,,
ALLOGRAFT BNE WDG 10 MM INFRASPINATUS CORTICAL,SUP-2787781,CDM,C1713,HCPCS,0278,RC,,,,both,,,8883.97,5774.58,,,,,,,,,,,,,
KIT INFUS PMP 400ML 5IN SOAK CATH NONNARCOTIC ELASTOMERIC,SUP-2236781,CDM,E0783,HCPCS,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
KIT LEAD TINED 4 CYL ELECTRODE,SUP-2563685,CDM,C1897,HCPCS,0278,RC,,,,both,,,10223.84,6645.50,,,,,,,,,,,,,
TAP SURG DIA 4 MM SINGLE LD AO QC FOR FIBULAR NAIL NS DISP,SUP-2909095,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1295.25,841.91,,,,,,,,,,,,,
DEXMEDETOMIDINE HCL 200 MCG/2ML IV SOLN,RX-123832,CDM,2500000003,HCPCS,0250,RC,16729-0239-93,NDC,,both,2,ML,54.10,35.16,,,,,,,,,,,,,
BRACE ANK SWVL STRP STD 10 IN AIR/GEL BLDR LP BLK STIRRUP,SUP-2336325,CDM,L4350,HCPCS,0272,RC,,,,both,,,28.79,18.71,,,,,,,,,,,,,
BLADE SURG ULTRA AGGRESSIVE 3.5 MM + STRL FMS VUE DISP,SUP-2637146,CDM,2720000010,LOCAL,0272,RC,,,,both,,,234.87,152.67,,,,,,,,,,,,,
PLATE BNE 110 DEG MINI LNG LT 6 HOLE BAR TURNED TI,SUP-2468566,CDM,C1713,HCPCS,0278,RC,,,,both,,,497.06,323.09,,,,,,,,,,,,,
HEAD REAMER 14.5 MM KT FOR RIA 2 STRL,SUP-2432238,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2478.59,1611.08,,,,,,,,,,,,,
BRACE KNEE HNG WRP L,SUP-2276700,CDM,L1820,HCPCS,0274,RC,,,,both,,,56.68,36.84,,,,,,,,,,,,,
LEUCOVORIN CALCIUM 100 MG IJ SOLR,RX-4392,CDM,J0640,HCPCS,0636,RC,00143-9554-01,NDC,,both,1,UN,54.10,35.16,,,,,,,,,,,,,
BRACE SHLDR SM FA L115 13IN UNIV AIRMESH BRTH SLNG 15DEG,SUP-2150867,CDM,L3650,HCPCS,0274,RC,,,,both,,,171.16,111.25,,,,,,,,,,,,,
LINER ACET NON-HOODED 36X54-56 MM HIP CLUS XLPE POLYETH EXP,SUP-2390423,CDM,C1776,CPT,0278,RC,,,,both,,,8242.50,5357.62,,,,,,,,,,,,,
TM FEM METAPHYSEAL CONE 35 SMALL LEFT,SUP-2502264,CDM,C1776,CPT,0278,RC,,,,both,,,11618.00,7551.70,,,,,,,,,,,,,
SET HAD CATH 12.5FR L28CM W/ INJ CAP SCALP SHTH NDL GWIRE,SUP-2267082,CDM,C1752,HCPCS,0278,RC,,,,both,,,533.80,346.97,,,,,,,,,,,,,
CATHETER CV DL 5 FRX55 CM STD BASIC KT POWERPICC,SUP-2126384,CDM,C1751,HCPCS,0278,RC,,,,both,,,279.77,181.85,,,,,,,,,,,,,
HC Cholecystostomy,PX-3614749000,CDM,47490,CPT,0361,RC,,,,outpatient,,,6875.00,4468.75,,,,,,,,,,,,,
SCREW BONE LOCKING 3.5MM DIA 85MML,SUP-2588247,CDM,C1713,HCPCS,0278,RC,,,,both,,,397.21,258.19,,,,,,,,,,,,,
GUIDEWIRE VASC SYNCHRO 2 215CM 0.014IN SEG 35CM STR PLAT,SUP-2716233,CDM,C1769,HCPCS,0272,RC,,,,both,,,1733.28,1126.63,,,,,,,,,,,,,
GRAFT HUM TISS W6XL12CM PROC DERM CLLGN RECTANG ALLOMAX,SUP-2125861,CDM,C1781,HCPCS,0278,RC,,,,both,,,7159.20,4653.48,,,,,,,,,,,,,
HC Cardiac Rehab Phase 3 - Monthly,PX-9900000038,CDM,9900000038,LOCAL,0990,RC,,,,both,,,30.00,19.50,,,,,,,,,,,,,
HC Biopsy Soft Tissue Thigh/Knee Area Deep,PX-5102732400,CDM,27324,CPT,0510,RC,,,,both,,,8784.00,5709.60,,,,,,,,,,,,,
CAP ORTH FEM LCK TAPR COMPR,SUP-2406937,CDM,C1713,HCPCS,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
MESH SURG W20XL30CM SKIRTED FOR OPN VENTRAL PCOX,SUP-2752147,CDM,C1781,HCPCS,0278,RC,,,,both,,,7244.77,4709.10,,,,,,,,,,,,,
DEVICE COMPR PLASMAFLOW,SUP-2787593,CDM,2720000010,LOCAL,0272,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
SYSTEM RETRV 15/15MM 12MM PRT INZII,SUP-2119646,CDM,2720000010,LOCAL,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
SCREW BNE L40MM OD4MM CANN HD SHT THRD MINI-MONSTER,SUP-2320559,CDM,C1713,HCPCS,0278,RC,,,,both,,,554.21,360.24,,,,,,,,,,,,,
CATHETER EP LG CRV 2-5-2 MM 6 FRX110 CM STEER,SUP-2126972,CDM,C1730,HCPCS,0272,RC,,,,both,,,463.81,301.48,,,,,,,,,,,,,
CEMENT BONE 10CC CA PHOS HA INJ FAST SET ISOTHERMIC RADPQ,SUP-2365156,CDM,C1713,HCPCS,0278,RC,,,,both,,,12075.06,7848.79,,,,,,,,,,,,,
IMPLANT NSL CART LAT ABSORB,SUP-2217800,CDM,C1889,HCPCS,0278,RC,,,,both,,,3124.30,2030.79,,,,,,,,,,,,,
PIN EXT FIX HALF 3X80 MM 25MM TI NITRIDE COAT CORETRAK,SUP-2473799,CDM,2720000010,LOCAL,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
PSN REV TM TIB CENTRAL CONE FIX TIB,SUP-2508664,CDM,C1776,CPT,0278,RC,,,,both,,,12874.00,8368.10,,,,,,,,,,,,,
HC So Testosterone Free,PX-3018440266,CDM,84402,CPT,0301,RC,,,,inpatient,,,98.00,63.70,,,,,,,,,,,,,
CATHETER CARD ABLATION FREEZOR L 108 CM 7 FR L 4 MM SHRT RED,SUP-2175197,CDM,C1733,HCPCS,0272,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
PLATE BONE DUAL CMPRSSN HLX9 TTNM CNTRD F3.5MM LOK SCREW ST,SUP-2724127,CDM,C1713,HCPCS,0278,RC,,,,both,,,1785.28,1160.43,,,,,,,,,,,,,
SET INSTR IMPL S STL W/ 2.4MM DSTL RAD PLT LCP,SUP-2183074,CDM,C1713,HCPCS,0278,RC,,,,both,,,112258.14,72967.79,,,,,,,,,,,,,
STENT BILI ZILVER 635 L 60 MM DIA12 MM DEL SYS L 40 CM SHTH,SUP-2647170,CDM,C1876,HCPCS,0278,RC,,,,both,,,2480.60,1612.39,,,,,,,,,,,,,
PLATE BONE LNG THK0.6MM 100DEG 4X6 H MIDFACE SLV TI LT L SHP,SUP-2135896,CDM,C1713,HCPCS,0278,RC,,,,both,,,684.52,444.94,,,,,,,,,,,,,
PLATE BNE HUM 202 MM RT PROX LAT 12 HOLE,SUP-2365891,CDM,C1713,HCPCS,0278,RC,,,,both,,,5034.99,3272.74,,,,,,,,,,,,,
CATHETER GUID SKR L 135 CM SHTH 4 FR GUIDEWIRE 0.014 IN,SUP-2128481,CDM,C1887,HCPCS,0272,RC,,,,both,,,580.90,377.58,,,,,,,,,,,,,
SYMALIGN EVANS OSTEOTMY WDG HEIGHT18MM LENGTH18MM,SUP-2264625,CDM,C1713,HCPCS,0278,RC,,,,both,,,5918.77,3847.20,,,,,,,,,,,,,
PLATE BNE L137MM 10 H NONSTERILE R PROX TIB S STL LO PROF,SUP-2185815,CDM,C1713,HCPCS,0278,RC,,,,both,,,3659.86,2378.91,,,,,,,,,,,,,
NAIL IM L440MM DIA12MM FEM TI CANN LCK AG RG T2,SUP-2361800,CDM,C1713,HCPCS,0278,RC,,,,both,,,6893.71,4480.91,,,,,,,,,,,,,
PORT BURR HOLE RESERVOIR VENTRICULAR DRAINAGE 18CM CATHETER,SUP-2830491,CDM,C1889,HCPCS,0278,RC,,,,both,,,1460.95,949.62,,,,,,,,,,,,,
SCREW BNE ST 3.5X50 MM LCK SS NS,SUP-2184252,CDM,C1713,HCPCS,0278,RC,,,,both,,,424.40,275.86,,,,,,,,,,,,,
MESH CRAN L 12 X W 9 IN THK 0.6 MM SCREW DIA1.5 MM TI,SUP-2936844,CDM,C1713,HCPCS,0278,RC,,,,both,,,9250.44,6012.79,,,,,,,,,,,,,
SPLINT ORTH HND M 80DEG PLAS R MTCRPL JT W O STRP BRN,SUP-2112605,CDM,L3807,HCPCS,0272,RC,,,,both,,,167.71,109.01,,,,,,,,,,,,,
PLATE BONE 3 H STRL BILAT 1/4 TBLR COMPR FOR 2.7MM SCR VLP,SUP-2349935,CDM,C1713,HCPCS,0278,RC,,,,both,,,4294.58,2791.48,,,,,,,,,,,,,
DEFIBRILLATOR IMPL PROTEGO TD W 5 X L 65 CM D 1.3 CM DIA2.6,SUP-2138099,CDM,C1895,HCPCS,0275,RC,,,,both,,,8792.00,5714.80,,,,,,,,,,,,,
INTRODUCER SHTH 0.038 IN 8 FRX23 CM GUIDEWIRE BLU PRELUDE,SUP-2303305,CDM,C1893,HCPCS,0272,RC,,,,both,,,37.93,24.65,,,,,,,,,,,,,
TEMPLATE SPNL 14MM LUM TAPR FUS L CAGE DISCECTOMY,SUP-2291602,CDM,C1713,HCPCS,0278,RC,,,,both,,,208.81,135.73,,,,,,,,,,,,,
SYSTEM TKR FEM PAT TIB STD GENDER SOL,SUP-2212276,CDM,C1776,CPT,0278,RC,,,,both,,,14130.00,9184.50,,,,,,,,,,,,,
CONNECTOR SHFT FLX CANN QUIK CPL FOR JCBS CHK,SUP-2188078,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2012.74,1308.28,,,,,,,,,,,,,
SCREW BNE PART THRD 2.7X34 MM TI MINICAN,SUP-2534675,CDM,C1713,HCPCS,0278,RC,,,,both,,,636.57,413.77,,,,,,,,,,,,,
BASEPLATE TIB REV KNEE,SUP-2366000,CDM,C1776,CPT,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
SEED BRACHYTHERAPY 1-2MCI I-125 LD IN EYE PHYSICS PLAQ,SUP-2247260,CDM,C2642,HCPCS,0278,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
PLATE BONE L109MM 8 HOLE RIGHT LTRL DST PRRTCLR TBL,SUP-2485430,CDM,C1713,HCPCS,0278,RC,,,,both,,,2256.18,1466.52,,,,,,,,,,,,,
TRAY CATH MIDLN PROVENA MAXBARR 4FR 20CM 2 LUMAN S4254108BDP,SUP-2632865,CDM,C1751,HCPCS,0278,RC,,,,both,,,682.35,443.53,,,,,,,,,,,,,
PACEMAKER PERM 2 CHMBR DDDR NON MRI S404 ALTRUA 40,SUP-2149276,CDM,C1785,HCPCS,0275,RC,,,,both,,,12792.36,8315.03,,,,,,,,,,,,,
GADOBUTROL 1 MMOL/ML IV SOLN,RX-104340,CDM,A9585,HCPCS,0636,RC,50419-0325-12,NDC,,both,10,ML,45.70,29.70,,,,,,,,,,,,,
SCREW BNE SELF DRILLING 2.3X14 MM LCK,SUP-2435293,CDM,C1713,HCPCS,0278,RC,,,,both,,,164.07,106.65,,,,,,,,,,,,,
CATHETER HD LT 10 FRX52 CM 22-25 CM ART CUF BASIC SET TESIO,SUP-2627149,CDM,C1750,HCPCS,0278,RC,,,,both,,,1070.11,695.57,,,,,,,,,,,,,
STEM RADIAL SM 6.5 ULN WRST MOD COCR 1ST CHOICE,SUP-2852823,CDM,C1776,CPT,0278,RC,,,,both,,,11398.20,7408.83,,,,,,,,,,,,,
CATHETER PTCA L135CM BLLN L20MM DIA4MM XCELON HYDROPHOBIC,SUP-2104226,CDM,C1725,HCPCS,0272,RC,,,,both,,,643.70,418.40,,,,,,,,,,,,,
CATHETER ABLAT 7FR L115CM 5MM TIP 2-5-2MM SPC M CURL QPLR,SUP-2421255,CDM,C1733,HCPCS,0272,RC,,,,both,,,2230.97,1450.13,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 40 CM DIA 4 MM STR STD WALL HELIX,SUP-2491640,CDM,C1768,CPT,0278,RC,,,,both,,,928.50,603.52,,,,,,,,,,,,,
INSERT HUM OD36MM STD ARW,SUP-2224533,CDM,C1776,CPT,0278,RC,,,,both,,,5181.00,3367.65,,,,,,,,,,,,,
HC So Gastrin,PX-3018294166,CDM,82941,CPT,0301,RC,,,,inpatient,,,341.00,221.65,,,,,,,,,,,,,
CABLE NERVE STIM ELECTRD MIC 3 IN LEADPOINT,SUP-2661733,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1036.20,673.53,,,,,,,,,,,,,
PLATE BNE L140MM 7 H R PROX HUM HI ALPS,SUP-2411643,CDM,C1713,HCPCS,0278,RC,,,,both,,,7360.16,4784.10,,,,,,,,,,,,,
HC I&D Abscess Peritonsillar,PX-4504270000,CDM,42700,CPT,0450,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
INSTRUMENT KIT 7 MM DISP,SUP-2200252,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2358.14,1532.79,,,,,,,,,,,,,
GRAFT BONE SUB 16X14MM DWL CANC AND CORT FRZ DRY,SUP-2294050,CDM,C1713,HCPCS,0278,RC,,,,both,,,1626.52,1057.24,,,,,,,,,,,,,
TBO-FILGRASTIM 480 MCG/0.8ML SC SOSY,RX-124232,CDM,J1447,HCPCS,0636,RC,63459-0912-11,NDC,,both,0.8,ML,1179.70,766.80,,,,,,,,,,,,,
BLADE SAW OSCLLTNG 13MMW X90MML 1.37MM THK COARSE MIDMIDDLEB,SUP-2605770,CDM,2720000010,LOCAL,0272,RC,,,,both,,,202.28,131.48,,,,,,,,,,,,,
"HC So Culture, Chlamydia, Any Source",PX-3008711066,CDM,87110,CPT,0300,RC,,,,inpatient,,,185.00,120.25,,,,,,,,,,,,,
PIN EXT FIX TRANSFIX 5X300 MM W/ WIRE HOLE TIP TIN SIDEKCK,SUP-2476923,CDM,2720000010,LOCAL,0272,RC,,,,both,,,715.92,465.35,,,,,,,,,,,,,
VANCOMYCIN 50 MG/ML ORAL SOLUTION,RX-40850042,CDM,J3370,HCPCS,0637,RC,09999-9900-34,NDC,,both,2.5,ML,22.50,14.62,,,,,,,,,,,,,
HC So Gastrin,PX-3018294166,CDM,82941,CPT,0301,RC,,,,outpatient,,,341.00,221.65,,,,,,,,,,,,,
COLLAR CERV MOTN CTRL STOUT W/ REPL PD MIAMI J XTRA,SUP-2270252,CDM,L0174,HCPCS,0272,RC,,,,both,,,120.23,78.15,,,,,,,,,,,,,
SCREW BNE LCK 3.5X10 MM DBL STRT THRD SS JPS,SUP-2645521,CDM,C1713,HCPCS,0278,RC,,,,both,,,1097.74,713.53,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 50 CM DIA 6MM STR STD WALL SLDE GDS,SUP-2479677,CDM,C1768,CPT,0278,RC,,,,both,,,1385.68,900.69,,,,,,,,,,,,,
CUP ACET SZ 6 DIA54MM HIP CO CHROM RESURF CORMET PRECIS,SUP-2363892,CDM,C1776,CPT,0278,RC,,,,both,,,10472.90,6807.38,,,,,,,,,,,,,
GRAFT VASC FLX 6 MMX50 CM STD WALL N RING EPTFE CARBOFLO,SUP-2761452,CDM,C1768,CPT,0278,RC,,,,both,,,2491.94,1619.76,,,,,,,,,,,,,
PLATE BNE L45MM THK12MM 0DEG 7 H BILAT S STL STR RIG LIMIT,SUP-2186170,CDM,C1713,HCPCS,0278,RC,,,,both,,,1212.10,787.86,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED UPCHARGE GENDER SPEC,SUP-2212679,CDM,C1776,CPT,0278,RC,,,,both,,,1761.54,1145.00,,,,,,,,,,,,,
SCREW BNE L8MM DIA2MM CRANIOMAXILLOFACIAL TI SELF DRL LOK 5PK,SUP-2366137,CDM,C1713,HCPCS,0278,RC,,,,both,,,456.68,296.84,,,,,,,,,,,,,
PAD CERV CLLR REPL FOR VISTA,SUP-2123902,CDM,L0190,HCPCS,0274,RC,,,,both,,,23.20,15.08,,,,,,,,,,,,,
ENDCAP SPNL DIA20MM 5DEG SM H1.5MM TEETH THORLUM GRY TI,SUP-2390811,CDM,C1889,HCPCS,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
BENDER PLT CERV MSPAN X10 XLNK,SUP-2289443,CDM,C1713,HCPCS,0278,RC,,,,both,,,1183.18,769.07,,,,,,,,,,,,,
SHEATH INTRO OPTISEAL L 25 CM OD 9 FR ID 0.125 IN DIL L 13,SUP-2281853,CDM,C1892,HCPCS,0272,RC,,,,both,,,188.40,122.46,,,,,,,,,,,,,
INTRODUCER HOWELL BILI PUR 6FRX200CM,SUP-2169442,CDM,C1894,HCPCS,0272,RC,,,,both,,,266.90,173.48,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED CMNTLS TRIATHLON,SUP-2365949,CDM,C1776,CPT,0278,RC,,,,both,,,17188.36,11172.43,,,,,,,,,,,,,
BRACE ORTHOPEDIC POST OPERATIVE LG XL 28 IN BLK LTX,SUP-2421706,CDM,L1833,HCPCS,0274,RC,,,,both,,,228.18,148.32,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE 10 CC CALCIUM SULF CALCIUM PHOSPHATE LO,SUP-2890197,CDM,C1713,HCPCS,0278,RC,,,,both,,,21050.56,13682.86,,,,,,,,,,,,,
SD BLADE 1.5MM XD 80MM 1.5MM DRIVER WIDE DIA,SUP-2676717,CDM,2720000010,LOCAL,0272,RC,,,,both,,,720.69,468.45,,,,,,,,,,,,,
CATHETER PERITONEAL OPN END 90 CM W/ SLT BA IMPREG,SUP-2851431,CDM,C1729,HCPCS,0272,RC,,,,both,,,540.61,351.40,,,,,,,,,,,,,
STENT PANCREATIC GEENEN L 7CM 5 FR 0.035IN SOFFLX OFFSET,SUP-2170683,CDM,C2617,HCPCS,0278,RC,,,,both,,,197.82,128.58,,,,,,,,,,,,,
CEMENT BNE 5 GM 3.45 CC HA ALPHA TCP RADIOPAQUE STRL MIMIX,SUP-2883758,CDM,C1713,HCPCS,0278,RC,,,,both,,,2081.82,1353.18,,,,,,,,,,,,,
KIT LD INTRO SAFSHTH L 13 CM DIA 9 FR NDL 18 GA GUIDEWIRE,SUP-2148862,CDM,C1892,HCPCS,0272,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
CATHETER INTRAUTERINE BALLOON L 4 CM DIA 9 FR 5 ML SYR SIL,SUP-2168944,CDM,C2628,HCPCS,0272,RC,,,,both,,,118.41,76.97,,,,,,,,,,,,,
DISTRACTION INTRNL DIST MNDBLE ZRCH 2 NYU END DRV RTCH 1.5 1,SUP-2495564,CDM,C1713,HCPCS,0278,RC,,,,both,,,16969.66,11030.28,,,,,,,,,,,,,
NAIL IM FEM SLD TI NS,SUP-2192569,CDM,C1713,HCPCS,0278,RC,,,,both,,,2059.84,1338.90,,,,,,,,,,,,,
SPLINT WRST L L THMB SPICA COT POLY FAB LTHR WRKHRD ORIG BGE,SUP-2326138,CDM,L3908,HCPCS,0272,RC,,,,both,,,63.05,40.98,,,,,,,,,,,,,
STENT URET 4.5FR L26CM CLASS DBL PGTL COAT OPN END TECOFLEX,SUP-2313803,CDM,C2617,HCPCS,0278,RC,,,,both,,,172.39,112.05,,,,,,,,,,,,,
JOINT SACROILIAC 7X80 MM IFUSE-3D,SUP-2423223,CDM,C1889,HCPCS,0278,RC,,,,both,,,10440.50,6786.32,,,,,,,,,,,,,
GRAFT BONE CLOWARD DWL FRZ DRY,SUP-2165558,CDM,C1713,HCPCS,0278,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
WASHER ORTH FOR 2.0 SCR VLP,SUP-2350903,CDM,C1713,HCPCS,0278,RC,,,,both,,,310.67,201.94,,,,,,,,,,,,,
PIN GUIDE L 2.5 IN DIA 0.101 IN METATRSL K WIRE REAMER NS,SUP-2913228,CDM,2720000010,LOCAL,0272,RC,,,,both,,,160.14,104.09,,,,,,,,,,,,,
HC Fna Bx W/US Gdn 1st Les|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE PRIOR TO THE ADMINISTRATION OF ANESTHESIA,PX-3611000500,CDM,10005,CPT,0361,RC,,,73,both,,,3993.00,2595.45,,,,,,,,,,,,,
BLADE SAW WIDE MICROAIRE STRYKR STRL INBONE,SUP-2463497,CDM,2720000010,LOCAL,0272,RC,,,,both,,,364.24,236.76,,,,,,,,,,,,,
ALLOGRAFT HUM TISS GRAFIX PRIME 16MM DISC CYROPRESERVED,SUP-2319187,CDM,Q4133,HCPCS,0636,RC,,,,both,,,1398.87,909.27,,,,,,,,,,,,,
CATHETER EP D 2-5-2 MM 7 FRX95 CM ORBITER ST,SUP-2142352,CDM,C1731,HCPCS,0278,RC,,,,both,,,2405.24,1563.41,,,,,,,,,,,,,
GRAFT BNE DWL 13X12 MM PATELLAR,SUP-2860933,CDM,C1713,HCPCS,0278,RC,,,,both,,,3871.62,2516.55,,,,,,,,,,,,,
SYSTEM SLNG SGL INCIS W/ INTRO ANCHR TENSIONING SUT ALTIS,SUP-2165319,CDM,C1781,HCPCS,0278,RC,,,,both,,,4851.30,3153.34,,,,,,,,,,,,,
MATRIX BIO SZ 19 SQCM FISH SKIN DERMAL MIC INTACT STRL,SUP-2909234,CDM,Q4158,HCPCS,0636,RC,,,,both,,,2794.60,1816.49,,,,,,,,,,,,,
HC Pain Combination,PX-3600007517,CDM,3600007517,LOCAL,0360,RC,,,,inpatient,,,3954.00,2570.10,,,,,,,,,,,,,
FILTER VASC GRNFLD L 28 MM DIA12 FR TI VENA CAVA FEM SHTH N,SUP-2148340,CDM,C1880,HCPCS,0278,RC,,,,both,,,3450.86,2243.06,,,,,,,,,,,,,
SHEATH UROLOGICAL 1 STP TROCAR L 20 CM L 17 CM CATH 12 FR,SUP-2835963,CDM,C1894,HCPCS,0272,RC,,,,both,,,248.69,161.65,,,,,,,,,,,,,
GUIDEPIN ORTH FLX VERSITOMIC,SUP-2366528,CDM,2720000010,LOCAL,0272,RC,,,,both,,,828.96,538.82,,,,,,,,,,,,,
PLATE BONE L27MM 100DEG 3X4 H LT CRANIOMAXILLOFACIAL TEAL TI,SUP-2191160,CDM,C1713,HCPCS,0278,RC,,,,both,,,1081.42,702.92,,,,,,,,,,,,,
COIL VASC AZUR CX L 39 CM DIA16 MM MICROCATHETER 0.018 IN,SUP-2385242,CDM,C1889,HCPCS,0278,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
MESH BIOLOGIC OVINE RUMEN PERM OVITEX 1S 25X40 CM,SUP-2383099,CDM,C1781,HCPCS,0278,RC,,,,both,,,39250.00,25512.50,,,,,,,,,,,,,
SCREW BNE COMPR 4.5X20 MM ANK FUSION CONSTRUCT,SUP-2609762,CDM,C1713,HCPCS,0278,RC,,,,both,,,935.78,608.26,,,,,,,,,,,,,
DEXTROSE 5 % AND 0.9 % NACL IV BOLUS,RX-40840054,CDM,J7042,HCPCS,0258,RC,00264-7610-00,NDC,,both,250,ML,8.50,5.52,,,,,,,,,,,,,
BLADE RETRACTOR HOHMN 11 CMX29 MM WIDE OLIF,SUP-2629247,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1431.24,930.31,,,,,,,,,,,,,
PLATE BNE SELLA RECON 20X20X0.3 MM MXLFCL W/ TAB PDLLA STRL,SUP-2466202,CDM,C1713,HCPCS,0278,RC,,,,both,,,2112.00,1372.80,,,,,,,,,,,,,
COUNTERSINK DRL SCREW DIA 3 MM NS DISP PRECIS MIS,SUP-2899150,CDM,2720000010,LOCAL,0272,RC,,,,both,,,584.04,379.63,,,,,,,,,,,,,
PACEMAKER CARD VISIONIST X4 W 4.45 X H 6.17 MM THK 0.75 MM,SUP-2432111,CDM,C2621,HCPCS,0275,RC,,,,both,,,19766.30,12848.09,,,,,,,,,,,,,
KIT PACE STYL L 46 CM STR STD WIDE NAR J CLP ON/IMPLANT TOOL,SUP-2356345,CDM,C1713,HCPCS,0278,RC,,,,both,,,339.12,220.43,,,,,,,,,,,,,
ANCHOR SUTURE L 14.7 MM DIA 5.5 MM PEEK SUTURETAPE FT STRL,SUP-2930462,CDM,C1713,HCPCS,0278,RC,,,,both,,,1038.56,675.06,,,,,,,,,,,,,
PACEMAKER CARD W44XH43MM THK6MM PERM 2 CHMBR STD,SUP-2357345,CDM,C1785,HCPCS,0275,RC,,,,both,,,12560.00,8164.00,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY INSRTN L 115 CM DIA 5 FR SPC,SUP-2475199,CDM,C1730,HCPCS,0272,RC,,,,both,,,2367.56,1538.91,,,,,,,,,,,,,
HC Spirometry / Tvc / Mvv,PX-4609401000,CDM,94010,CPT,0460,RC,,,,outpatient,,,347.00,225.55,,,,,,,,,,,,,
BASEPLATE KNEE MG II PC PEG TIB A/PURPLE,SUP-2199595,CDM,C1713,HCPCS,0278,RC,,,,both,,,11354.24,7380.26,,,,,,,,,,,,,
PLATE BNE W9XL33MM THK1MM 3 H TI 1 3 TBLR W CLLR LOK COMPR,SUP-2190946,CDM,C1713,HCPCS,0278,RC,,,,both,,,448.42,291.47,,,,,,,,,,,,,
PLATE BNE FEM 3.5/4.5X354 MM LT PROX 11 HOLE STRL VALCP,SUP-2789592,CDM,C1713,HCPCS,0278,RC,,,,both,,,9098.84,5914.25,,,,,,,,,,,,,
PORT IMPL INFUSION 9.6 FR PREATTACH CATH POWERPORT MRI,SUP-2126336,CDM,C1788,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
KIT THROMCTMY STROKE FAST PK L 32 MM DIA 3 MM MICROCATHETER,SUP-2551059,CDM,C1757,HCPCS,0272,RC,,,,both,,,11547.98,7506.19,,,,,,,,,,,,,
CURETTE ENDOSCP CUP 7 CM NANO ARTHSCP STRL BONESYNC LTX,SUP-2859817,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
TOURNIQUET PNEUMAT W HOSES ATS 2200,SUP-2208753,CDM,2720000010,LOCAL,0272,RC,,,,both,,,18608.27,12095.38,,,,,,,,,,,,,
SCREW BNE L46MM DIA5MM CORT TI ST DBL LD THRD FOR PHOENIX,SUP-2412126,CDM,C1713,HCPCS,0278,RC,,,,both,,,1067.60,693.94,,,,,,,,,,,,,
SCREW BONE L100MM D105MM CRTCL TTNM ALLOY NNCNNLTD LAG NNLCK,SUP-2495133,CDM,C1713,HCPCS,0278,RC,,,,both,,,1614.53,1049.44,,,,,,,,,,,,,
PACEMAKER CARD EVIA DR-T TI 2 CHMBR PREM DDDR IS1 UPLR BPLR,SUP-2138284,CDM,C1785,HCPCS,0275,RC,,,,both,,,14412.60,9368.19,,,,,,,,,,,,,
PLATE BNE R MT SLIM FUS OMNI,SUP-2223994,CDM,C1713,HCPCS,0278,RC,,,,both,,,5275.20,3428.88,,,,,,,,,,,,,
DEVICE ABLAT BPLR LO PROF STD ALONE ELECTRD CARDIOBLATE,SUP-2278866,CDM,2720000010,LOCAL,0272,RC,,,,both,,,9718.30,6316.89,,,,,,,,,,,,,
GUIDEROD ORTH BALL TIPPED 3X550 MM HINDFOOT FOR NAIL PHANTOM,SUP-2749692,CDM,C1713,HCPCS,0278,RC,,,,both,,,847.80,551.07,,,,,,,,,,,,,
DRILL TWST L 87 MM DIA1.1 MM STP 3 MM HALL FOR 1.5 SYS NS,SUP-2934790,CDM,2720000010,LOCAL,0272,RC,,,,both,,,524.38,340.85,,,,,,,,,,,,,
ROD EXT FIX L400MM THRD STR SIDEKCK FREE CIR FIX,SUP-2400600,CDM,2720000010,LOCAL,0272,RC,,,,both,,,200.96,130.62,,,,,,,,,,,,,
CAGE SPNL 10 DEG 12X22X60 MM LAT COROENT XL-W+ LF,SUP-2560504,CDM,C1889,HCPCS,0278,RC,,,,both,,,13979.28,9086.53,,,,,,,,,,,,,
SCREW BONE L33MM OD28MM LCTSRB CPLMR SHLDR SOLID FLLY THRDD,SUP-2724042,CDM,C1725,HCPCS,0272,RC,,,,both,,,649.98,422.49,,,,,,,,,,,,,
HC Chem Cautery Granulatn Tissue,PX-4501725000,CDM,17250,CPT,0450,RC,,,,both,,,280.00,182.00,,,,,,,,,,,,,
COMPONENT FEM SZ 3 NAR L KNEE CO CHROM CEM POST STBL CRUCE,SUP-2206157,CDM,C1776,CPT,0278,RC,,,,both,,,25559.60,16613.74,,,,,,,,,,,,,
STENT COR 15MM 35MM CATHETER L140CM 0014IN CO CHROME RAP,SUP-2138319,CDM,C1876,HCPCS,0278,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
CPT SPNL W/Q NDL,SUP-2125210,CDM,C1713,HCPCS,0278,RC,,,,both,,,427.04,277.58,,,,,,,,,,,,,
PLATE BNE CLAV CS1 2.7 MM LT VA LCK COMPR SS STRL VA-LCP,SUP-2750791,CDM,C1713,HCPCS,0278,RC,,,,both,,,3502.36,2276.53,,,,,,,,,,,,,
PLATE BNE L52MM 6 H S STL COMPR FOR 27MM SCR MINI FRAG SYS,SUP-2199360,CDM,C1713,HCPCS,0278,RC,,,,both,,,424.34,275.82,,,,,,,,,,,,,
BRACE ORTHOPEDIC ADJ SAG RIGID PANEL PREFABRICATED LO,SUP-2124234,CDM,L1810,HCPCS,0272,RC,,,,both,,,1585.70,1030.70,,,,,,,,,,,,,
STIMULATOR NEUROMUSCULAR TRL PRECIS SPECTR,SUP-2148535,CDM,C1897,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
FELT PTFE LO POROSITY NOM THICKNESS 1.85MM 4INX4IN DIAM,SUP-2127685,CDM,C1768,CPT,0278,RC,,,,both,,,355.98,231.39,,,,,,,,,,,,,
INBONE  POLY SZ 1 10MM SULCUS TOTAL ANKLE,SUP-2476135,CDM,C1776,CPT,0278,RC,,,,both,,,5221.82,3394.18,,,,,,,,,,,,,
LASER SURG VISION 1/SMART 532 FC SMRT LIO,SUP-2713732,CDM,2720000010,LOCAL,0272,RC,,,,both,,,38370.80,24941.02,,,,,,,,,,,,,
SPACER TIB SMALL/SMALL + 17.5 MM LCS,SUP-2453975,CDM,C1776,CPT,0278,RC,,,,both,,,1808.64,1175.62,,,,,,,,,,,,,
FULVESTRANT 250 MG/5ML IM SOSY,RX-159677,CDM,J9395,HCPCS,0636,RC,16714-0070-02,NDC,,both,5,ML,2336.50,1518.72,,,,,,,,,,,,,
GUIDEWIRE ORTH SUPER STIFF 2.2X500 MM SHLDR MARKER AEQUALIS,SUP-2715408,CDM,C1769,HCPCS,0272,RC,,,,both,,,477.28,310.23,,,,,,,,,,,,,
NAIL IM L440MM DIA3MM 85DEG UNIV ST G L FEM TI CANN LOK CRV,SUP-2192730,CDM,C1713,HCPCS,0278,RC,,,,both,,,932.39,606.05,,,,,,,,,,,,,
BOOT M SZ GREATER THAN 10.5 WOM GREATER THAN 11.5 CALF CIRC,SUP-2197116,CDM,L4396,HCPCS,0274,RC,,,,both,,,108.08,70.25,,,,,,,,,,,,,
SCREW SPNL IL 7.5X80 MM ARM15T ARMDA,SUP-2561820,CDM,C1713,HCPCS,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
GRAFT BNE PTTY 2.5 CC OSTEOSPARX,SUP-2641788,CDM,C1713,HCPCS,0278,RC,,,,both,,,606.02,393.91,,,,,,,,,,,,,
DEVICE TISS FIX PUSHLOCK ANCHR DIA2.9 MM LNT SYS STRL HD,SUP-2910497,CDM,C1713,HCPCS,0278,RC,,,,both,,,2818.94,1832.31,,,,,,,,,,,,,
SHELL ACET OD62MM LNR SZ G NO H MPACT,SUP-2267386,CDM,C1776,CPT,0278,RC,,,,both,,,3390.10,2203.56,,,,,,,,,,,,,
STAPLER INT 3.4 MMX35 MM RELD SS STRL MULTFI PREM DISP,SUP-2787675,CDM,2720000010,LOCAL,0272,RC,,,,both,,,313.50,203.77,,,,,,,,,,,,,
GRAFT HUM TISS L23CM FLD DIA6MM FRZN DBL STRND POST,SUP-2113923,CDM,C1713,HCPCS,0278,RC,,,,both,,,9326.74,6062.38,,,,,,,,,,,,,
STRIP FNGR ALUM W/ FOAM 1INX18IN XL,SUP-2194457,CDM,L3933,HCPCS,0272,RC,,,,both,,,3.86,2.51,,,,,,,,,,,,,
CHLORDIAZEPOXIDE HCL 25 MG PO CAPS,RX-1623,CDM,6370000000,HCPCS,0637,RC,51079-0141-20,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
TUBE ET L40CM DIA4MM FOAM SURROUND MAGILL CUF LSR RESIST,SUP-2383546,CDM,2720000010,LOCAL,0272,RC,,,,both,,,290.45,188.79,,,,,,,,,,,,,
DEVICE ELECSURG CORECATH 2.7S DISP,SUP-2381722,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4317.50,2806.37,,,,,,,,,,,,,
SCREW BONE L38MM DIA2MM STD CORT S STL NONCANNULATED FULL,SUP-2248962,CDM,C1713,HCPCS,0278,RC,,,,both,,,157.22,102.19,,,,,,,,,,,,,
STRIP FNGR ALUM W/ FOAM 1INX18IN XL,SUP-2194457,CDM,L3933,HCPCS,0274,RC,,,,both,,,3.86,2.51,,,,,,,,,,,,,
BOLT FIX 3 H M,SUP-2197277,CDM,2720000010,LOCAL,0272,RC,,,,both,,,353.25,229.61,,,,,,,,,,,,,
CATHETER SUPRAPUBIC SET 8 FRX30 CM PERC MCOT UNIVERSA,SUP-2836205,CDM,C2627,HCPCS,0272,RC,,,,both,,,142.59,92.68,,,,,,,,,,,,,
PLATE BONE NARROW 4.5X39 MM 2 HOLE FOR SCREW STERILE TC100,SUP-2836674,CDM,C1713,HCPCS,0278,RC,,,,both,,,1023.39,665.20,,,,,,,,,,,,,
PLATE BNE L79MM 2 H ST POST MED PROX TIB S STL LOK COMPR,SUP-2177793,CDM,C1713,HCPCS,0278,RC,,,,both,,,3381.72,2198.12,,,,,,,,,,,,,
SHEATH RENAL L17CM ID24 30FR AMPLATZ SET PTFE,SUP-2141696,CDM,C1894,HCPCS,0272,RC,,,,both,,,89.84,58.40,,,,,,,,,,,,,
FIXATION KIT SELFDRILLING LARGE 12 MM STERNAL H TYPE PRECONT,SUP-2838436,CDM,C1713,HCPCS,0278,RC,,,,both,,,6158.80,4003.22,,,,,,,,,,,,,
VALVE HEMOSTAS DBL PLAY LUMEN DIA 9 FR POLYCARB INSRTN TOOL,SUP-2303045,CDM,C1713,HCPCS,0278,RC,,,,both,,,62.05,40.33,,,,,,,,,,,,,
ELECTRODE ELECSURG THERMOPAD DISPER RITA,SUP-2752472,CDM,2720000010,LOCAL,0272,RC,,,,both,,,606.02,393.91,,,,,,,,,,,,,
STENT PANCREATIC GEENEN L 13 CM DIA 3 FR GUIDEWIRE 0.018 IN,SUP-2737457,CDM,C2617,HCPCS,0278,RC,,,,both,,,182.12,118.38,,,,,,,,,,,,,
GRAFT HUM TISS W5XL5CM THK1.8-3.9MM ULT THCK HYDRATED,SUP-2307495,CDM,Q4128,HCPCS,0636,RC,,,,both,,,4697.44,3053.34,,,,,,,,,,,,,
COMPONENT FEM E AP51.5MM ML24MM UNI PC PRI CEM STEMLESS R 584201501] ZIMMER BIOMET INC],SUP-2208539,CDM,C1776,CPT,0278,RC,,,,both,,,11498.21,7473.84,,,,,,,,,,,,,
KIT INTRO VAXCEL MINI-STICK SHTH 15 CM 6 FR SS PLAT TIP,SUP-2118969,CDM,C1894,HCPCS,0272,RC,,,,both,,,12.09,7.86,,,,,,,,,,,,,
GUIDEWIRE ORTH 3.2 MM FOR PFNA BLADE,SUP-2851917,CDM,C1769,HCPCS,0272,RC,,,,both,,,659.40,428.61,,,,,,,,,,,,,
INSULIN GLARGINE-YFGN 100 UNIT/ML SC SOLN,RX-155721,CDM,S5553,HCPCS,0637,RC,83257-0014-11,NDC,,both,10,ML,50.40,32.76,,,,,,,,,,,,,
GRAFT HUM TISS DERM ACELLULAR ULT THCK ALLGRFT 12CM WX12CM L,SUP-2307481,CDM,Q4128,HCPCS,0636,RC,,,,both,,,13873.93,9018.05,,,,,,,,,,,,,
PLATE BNE TIB 4.5/6.5X165 MM LT PROX LAT 8 HOLE SS EPI UNION,SUP-2472819,CDM,C1713,HCPCS,0278,RC,,,,both,,,1321.00,858.65,,,,,,,,,,,,,
PLATE BNE THK0MM 4 H TI BILAT LOK COMPR FOR 27 35MM SCR COT,SUP-2398182,CDM,C1713,HCPCS,0278,RC,,,,both,,,3925.00,2551.25,,,,,,,,,,,,,
HEPARIN NA (PORK) LOCK FLSH PF 1 UNIT/ML IV SOLN,RX-162826,CDM,J1642,HCPCS,0636,RC,64253-0444-22,NDC,,both,1,ML,54.10,35.16,,,,,,,,,,,,,
PLATE BNE L142MM 6 H L MED DST TIB S STL VAR ANG LOK COMPR,SUP-2177635,CDM,C1713,HCPCS,0278,RC,,,,both,,,4823.35,3135.18,,,,,,,,,,,,,
DRIVER NDL ST GRAV,SUP-2399114,CDM,C1713,HCPCS,0278,RC,,,,both,,,876.06,569.44,,,,,,,,,,,,,
STENT URET L22CM DIA5FR URETEROPELVIC JUNCTION BRAID TETH,SUP-2171028,CDM,C2617,HCPCS,0278,RC,,,,both,,,349.80,227.37,,,,,,,,,,,,,
HINGE EXT FIX MONOTUBE,SUP-2480614,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1101.20,715.78,,,,,,,,,,,,,
ALLOGRAFT HUM TISS STRUT FRZN IRRADIATED ACHILLES TEND,SUP-2867083,CDM,C1762,CPT,0278,RC,,,,both,,,4939.85,3210.90,,,,,,,,,,,,,
SCREW SPNL L35MM OD5MM TI CORT PEDCL NONCANNULATED TOP LD,SUP-2288104,CDM,C1713,HCPCS,0278,RC,,,,both,,,4377.47,2845.36,,,,,,,,,,,,,
STENT NEPHURET COPE L 22 CM DIA 8.5 FR GUIDEWIRE 0.038 IN,SUP-2170578,CDM,C2625,HCPCS,0278,RC,,,,both,,,284.17,184.71,,,,,,,,,,,,,
STEM FEM HIP CEM PRIMARY,SUP-2249583,CDM,C1776,CPT,0278,RC,,,,both,,,11147.00,7245.55,,,,,,,,,,,,,
IMMOBILIZER KNEE AD L22IN FOAM WRP ARND UNIV CLS PAT,SUP-2195242,CDM,L1830,CPT,0274,RC,,,,both,,,23.99,15.59,,,,,,,,,,,,,
GUIDEWIRE ORTH THRD 2.8X230 MM NS EXTRIMIFIX LTX,SUP-2856033,CDM,C1769,HCPCS,0272,RC,,,,both,,,116.18,75.52,,,,,,,,,,,,,
CUP ACET 28X52 MM W/ SULMESH,SUP-2442449,CDM,C1776,CPT,0278,RC,,,,both,,,3150.99,2048.14,,,,,,,,,,,,,
SHEATH INTRO SOLOPATH WORKING L 25 CM EXPANDABLE L 20CM 18FR,SUP-2385696,CDM,C1894,HCPCS,0272,RC,,,,both,,,211.95,137.77,,,,,,,,,,,,,
LENGTHENER EXT FIX L 50 MM MINI KT,SUP-2885172,CDM,C1713,HCPCS,0278,RC,,,,both,,,6850.04,4452.53,,,,,,,,,,,,,
IMPLANT HUM TISS L 7 X W 7 CM AMNIO MEMBRN LYOPRESERVED,SUP-2905520,CDM,Q4133,HCPCS,0636,RC,,,,both,,,15700.00,10205.00,,,,,,,,,,,,,
CURETTE SRGCL BRUN SIZE 0000 CUP 22.9CML 2.6MMW X 3MML CUP S,SUP-2494962,CDM,2720000010,LOCAL,0272,RC,,,,both,,,393.29,255.64,,,,,,,,,,,,,
COLLAR CERV LG BLK,SUP-2414450,CDM,L0120,HCPCS,0274,RC,,,,both,,,34.85,22.65,,,,,,,,,,,,,
DEVICE BNE COLLCTN STRL DISP GRAFTNET XL,SUP-2930403,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1491.50,969.47,,,,,,,,,,,,,
SCREW ST 120MM 3.5MM CRTX,SUP-2183609,CDM,C1713,HCPCS,0278,RC,,,,both,,,78.12,50.78,,,,,,,,,,,,,
PROSTHESIS OSS L4MM OD0.4X1MM TI PIST BCKT HNDL 2,SUP-2312801,CDM,L8613,CPT,0278,RC,,,,both,,,653.53,424.79,,,,,,,,,,,,,
PLATE BNE STR MIC 1.5X1 MM 24 HOLE TI,SUP-2472729,CDM,C1713,HCPCS,0278,RC,,,,both,,,838.95,545.32,,,,,,,,,,,,,
SCREW BNE L 26 MM DIA2.7 MM TI NLCK T15 DRV NS LEOS,SUP-2931540,CDM,C1713,HCPCS,0278,RC,,,,both,,,332.53,216.14,,,,,,,,,,,,,
PAROXETINE HCL 10 MG PO TABS,RX-16632,CDM,6370000000,HCPCS,0637,RC,50268-0640-11,NDC,,both,1,UN,3.00,1.95,,,,,,,,,,,,,
WRAP WR UNIV LT COMPR GEL,SUP-2324362,CDM,L3931,HCPCS,0274,RC,,,,both,,,99.91,64.94,,,,,,,,,,,,,
KIT BNE CEM PREP FEM W O RESTRIC BRSH CURET NOZ AND SPNG,SUP-2257057,CDM,2720000010,LOCAL,0272,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
ROD SPNL CAPPED 4.75X35 MM CCM CD HORZ SOLERA VOYAGER,SUP-2278971,CDM,C1713,HCPCS,0278,RC,,,,both,,,1108.42,720.47,,,,,,,,,,,,,
STENT ESOPH OTW 19X150 MM 24 FRX90 CM FULL CVR ENDOMAXX,SUP-2467319,CDM,C1874,HCPCS,0278,RC,,,,both,,,6908.00,4490.20,,,,,,,,,,,,,
FEATHERVAC DISPOSABLE STAPES SEAT,SUP-2680416,CDM,L8613,CPT,0278,RC,,,,both,,,120.11,78.07,,,,,,,,,,,,,
KIT IMPL NEUROSTIMULATOR THK 10.7 MM BATTERY 200 MAH REMOT,SUP-2899871,CDM,C1767,HCPCS,0278,RC,,,,both,,,56520.00,36738.00,,,,,,,,,,,,,
NAIL IM L180MM DIA9MM 130DEG SHT TROCHANTERIC FEM HIP CANN,SUP-2253388,CDM,C1713,HCPCS,0278,RC,,,,both,,,2857.40,1857.31,,,,,,,,,,,,,
GRAFT VASC GORTX L 15 CM DIA 6 MM RNG L 5 CM EPTFE STR TW,SUP-2396149,CDM,C1768,CPT,0278,RC,,,,both,,,1221.46,793.95,,,,,,,,,,,,,
GRAFT VASC STR 7 MMX70 CM TW N RING HD ACCS EPTFE CARBOFLO,SUP-2761329,CDM,C1768,CPT,0278,RC,,,,both,,,2790.11,1813.57,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY INQUIRY DIA 7 FR SPC 1-3 MM TIP 1,SUP-2357673,CDM,C1730,HCPCS,0272,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
STENT COLON SELF EXPND 0.035 IN 25 MMX12 CM HANAROSTENT,SUP-2469989,CDM,C1876,HCPCS,0278,RC,,,,both,,,9843.90,6398.53,,,,,,,,,,,,,
PASSER SUT FOR OMNISPAN MENIS REP SYS CHIA PERCPASS,SUP-2249384,CDM,2720000010,LOCAL,0272,RC,,,,both,,,633.02,411.46,,,,,,,,,,,,,
SET VASC ACCS 4FR L10CM S STL PLAT TIP 0018IN NDL 21GA,SUP-2170554,CDM,C1894,HCPCS,0272,RC,,,,both,,,117.28,76.23,,,,,,,,,,,,,
HC Clsd Tx Mcp IP Fx W Manip,PX-4502674200,CDM,26742,CPT,0450,RC,,,,both,,,1633.00,1061.45,,,,,,,,,,,,,
SUBSTITUTE BONE GRFT 2.5CC PUTTY GRFTON,SUP-2307527,CDM,C9359,HCPCS,0278,RC,,,,both,,,1246.58,810.28,,,,,,,,,,,,,
LO PLATE ORBTL RIGID BLUE 12 HOLE 10MM 20 TRMA SSTM T 6L 4,SUP-2682190,CDM,C1713,HCPCS,0278,RC,,,,both,,,672.27,436.98,,,,,,,,,,,,,
BLADE SAW OSCLLTNG 19MM CUT EDGE 95MM CUT DEPTH 0.9MM CUT TH,SUP-2605460,CDM,2720000010,LOCAL,0272,RC,,,,both,,,63.68,41.39,,,,,,,,,,,,,
FORCEPS BX ALGTR JAW W BSKT BITE 11 CM X 3 MM WIDE 360 ROT,SUP-2161771,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3212.69,2088.25,,,,,,,,,,,,,
IMPLANT HUM TISS L 30-80 MM W 25-50 MM PA PTCH BRANCH REDUC,SUP-2932857,CDM,C1762,CPT,0278,RC,,,,both,,,17121.32,11128.86,,,,,,,,,,,,,
CATHETER DRAINAGE SLIP FIT 4 FRX7 CM 20 GA 4 SH 1 STP,SUP-2303166,CDM,C1729,HCPCS,0272,RC,,,,both,,,49.64,32.27,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 7X2 CM PROC SUSPEND FASC LATA TUTOPLAST,SUP-2165387,CDM,C1762,CPT,0278,RC,,,,both,,,2276.50,1479.72,,,,,,,,,,,,,
TRAY TIB SZ 3 KNEE CEM KEELED MOB BEAR REV LCS COMPLT,SUP-2250907,CDM,C1776,CPT,0278,RC,,,,both,,,3218.50,2092.02,,,,,,,,,,,,,
ADJUSTER SPNL 14MM STR,SUP-2292678,CDM,C1713,HCPCS,0278,RC,,,,both,,,1452.60,944.19,,,,,,,,,,,,,
PLATE BNE L 28 MM SCREW DIA2.8 MM SM CP TI MANDIBULAR FULL,SUP-2883711,CDM,C1713,HCPCS,0278,RC,,,,both,,,18327.05,11912.58,,,,,,,,,,,,,
SET PICC L 55 CM DIA 5.5 FR SHTH L 7 CM DIA 5.5 FR,SUP-2887067,CDM,C1751,HCPCS,0278,RC,,,,both,,,679.28,441.53,,,,,,,,,,,,,
BIT DRL UNIV 24 MM SL INTER-LOCK CROSS PIN FOR SCREW INTLOK,SUP-2608241,CDM,2720000010,LOCAL,0272,RC,,,,both,,,427.26,277.72,,,,,,,,,,,,,
PIN SKULL DISPOSIBLE CH STL 36/BX,SUP-2243874,CDM,C1713,HCPCS,0278,RC,,,,both,,,35.20,22.88,,,,,,,,,,,,,
HC Ot Ther Ex per 15 Min|OP OCCUPATIONAL THERAPY SERV|DOCUMENTATION ON FILE|SERVICES PROVIDED IN WHOLE OR IN PARTY BY AN OTA FOR MEDICARE PATIENTS,PX-4309711000,CDM,97110,CPT,0430,RC,,,GO|KX|CO,both,,,195.00,126.75,,,,,,,,,,,,,
NAIL IM L30CM DIA1.5MM S STL TAPR TIP ELAS PEDIFLEX,SUP-2318623,CDM,C1713,HCPCS,0278,RC,,,,both,,,1804.43,1172.88,,,,,,,,,,,,,
HC So Antibody ID; Leukocyte Antibodies,PX-3028602166,CDM,86021,CPT,0302,RC,,,,both,,,347.00,225.55,,,,,,,,,,,,,
BLADE ENDO L10CM DIA5MM HK TIP ELECTRD SCALP OPN DISECT,SUP-2218961,CDM,C1713,HCPCS,0278,RC,,,,both,,,424.34,275.82,,,,,,,,,,,,,
PLATE BNE W17.5XL206MM THK5.2MM 8 H L CNDYL FEM S STL LOK,SUP-2185020,CDM,C1713,HCPCS,0278,RC,,,,both,,,4179.43,2716.63,,,,,,,,,,,,,
SET TBNG FOR AFFERA SPHR 9 HEXAFLOW IRRIGATION PMP STRL,SUP-2911942,CDM,2720000010,LOCAL,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
RESORB X TAP FRCTN STOP STYLE 100MM LGTH 24MM F0R 15MM DRV,SUP-2679317,CDM,2720000010,LOCAL,0272,RC,,,,both,,,665.52,432.59,,,,,,,,,,,,,
PREM ST/MOM CP/LG E1 LN/CER HD,SUP-2212355,CDM,C1776,CPT,0278,RC,,,,both,,,15115.96,9825.37,,,,,,,,,,,,,
IMPLANT BRST SIL SIENTRA SMOOTH RND MOD PROJCT 350CC,SUP-2264567,CDM,C1789,HCPCS,0278,RC,,,,both,,,2119.50,1377.67,,,,,,,,,,,,,
HC X-Ray Spine 1 View,PX-3207202000,CDM,72020,CPT,0320,RC,,,,inpatient,,,233.00,151.45,,,,,,,,,,,,,
CANNULA ENDOSCP TERMANIAN ENDOTIP 6 MMX10.5 CM W/SIL LEAFLET,SUP-2767564,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2012.77,1308.30,,,,,,,,,,,,,
VALVULOTOME ANGIOSCOPIC EZE-SIT TRU-INCISE CATH L 91 CM CUT,SUP-2390667,CDM,C1726,HCPCS,0272,RC,,,,both,,,11928.86,7753.76,,,,,,,,,,,,,
GRAFT HUM TISS TEND SEMITENDINOSUS,SUP-2165549,CDM,C1713,HCPCS,0278,RC,,,,both,,,4333.20,2816.58,,,,,,,,,,,,,
BIT DRL 2.5 MM PERC FOR UNIV LCK SYS,SUP-2199256,CDM,2720000010,LOCAL,0272,RC,,,,both,,,321.54,209.00,,,,,,,,,,,,,
DRESSING BIO W4XL10IN BOV CLLGN AND GLYCOSAMINOGLYCAN,SUP-2243933,CDM,Q4104,HCPCS,0636,RC,,,,both,,,9624.10,6255.66,,,,,,,,,,,,,
GUIDEWIRE ORTH 15MMX14IN NIT,SUP-2137207,CDM,C1769,HCPCS,0272,RC,,,,both,,,203.97,132.58,,,,,,,,,,,,,
CANNULA SUCTION MONOPOLAR 5 MMX28 CM COAG TUBE DSTL ANGLED,SUP-2775812,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1069.42,695.12,,,,,,,,,,,,,
COIL EMB L12CM DIA6MM 0020IN PERIPH L VOL COMPLX STD FRME,SUP-2323663,CDM,C1889,HCPCS,0278,RC,,,,both,,,3108.60,2020.59,,,,,,,,,,,,,
LENS INTOCU +10.5 DIOPT L13MM DIA5.5MM D3.39MM 0.5DEG,SUP-2110782,CDM,V2630,CPT,0276,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
COMPONENT CRPL LG STD WRST POLYETH,SUP-2610307,CDM,C1776,CPT,0278,RC,,,,both,,,8989.95,5843.47,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY LIVEWIRE L 115 CM DIA 5 FR SPC 2,SUP-2356876,CDM,C1730,HCPCS,0272,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
GRAFT VASC IMPRA L 60 CM DIA 6 MM EPTFE STR TW N RING HEMO,SUP-2761313,CDM,C1768,CPT,0278,RC,,,,both,,,2504.12,1627.68,,,,,,,,,,,,,
TREPHINE ORTH SZ 65MM STR SCR REM CRWN DRL,SUP-2368627,CDM,C1713,HCPCS,0278,RC,,,,both,,,2240.39,1456.25,,,,,,,,,,,,,
SHEATH INTRO FAST-CATH L 30 CM DIA 9.5 FR GUIDEWIRE 0.038 IN,SUP-2355546,CDM,C1894,HCPCS,0272,RC,,,,both,,,58.88,38.27,,,,,,,,,,,,,
HC Treat Fibula Fx,PX-4502778100,CDM,27781,CPT,0450,RC,,,,both,,,1633.00,1061.45,,,,,,,,,,,,,
PIN BNE FIX DIA 5 MM CANC THRD REDUCTION STRL VARIAX,SUP-2900652,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1281.87,833.22,,,,,,,,,,,,,
ADAPTER HEAD FEMORAL UNIPOLAR 12/14 +14.0MM,SUP-2504176,CDM,C1776,CPT,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
DEFIBRILLATOR IMPL VITALITY AVT 31 J 30 CC TI 2 CHMBR A IS1,SUP-2149155,CDM,C1721,HCPCS,0275,RC,,,,both,,,58247.00,37860.55,,,,,,,,,,,,,
GRAFT BNE SPNG 10X10X10 MM DBM CANC,SUP-2641779,CDM,C1713,HCPCS,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
IMMOBILIZER SHLDR XL L9X22.5IN R/L CANVS W/ WAIST STRP THMB,SUP-2336107,CDM,L3660,HCPCS,0272,RC,,,,both,,,14.60,9.49,,,,,,,,,,,,,
BLADE SAW OSTEOTMY 12.5X12X0.38 MM MAND OFFSET STRL LTX,SUP-2862476,CDM,2720000010,LOCAL,0272,RC,,,,both,,,327.47,212.86,,,,,,,,,,,,,
BEARING HUM DIA36-44MM +3MM OFFSET ARCOMXL RETENTIVE FOR,SUP-2409555,CDM,C1776,CPT,0278,RC,,,,both,,,2037.86,1324.61,,,,,,,,,,,,,
WIRE EXT FIX L 400 MM DIA2 MM SPD,SUP-2898547,CDM,C1713,HCPCS,0278,RC,,,,both,,,433.32,281.66,,,,,,,,,,,,,
COAGULATOR ELECSURG MONOPOLAR 5 MMX33 CM OPN END DSTL TIP,SUP-2490488,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1242.06,807.34,,,,,,,,,,,,,
CATHETER ETER EP 4FR L110CM ELECTRD SPC 2 5 2MM BND ELECTRD 1MM L,SUP-2357650,CDM,C1730,HCPCS,0272,RC,,,,both,,,1654.00,1075.10,,,,,,,,,,,,,
SET SCR SPNL L50MM DIA7.2MM PEDCL TI ALLOY FUS FOR DYN STBL,SUP-2414270,CDM,C1713,HCPCS,0278,RC,,,,both,,,9796.80,6367.92,,,,,,,,,,,,,
PUTTY BNE MORPHOGENETIC PROT OP 1,SUP-2282592,CDM,C1713,HCPCS,0278,RC,,,,both,,,80.38,52.25,,,,,,,,,,,,,
WEDGE EVANS 3D PRNT TI SM 17X6MM,SUP-2320322,CDM,C1713,HCPCS,0278,RC,,,,both,,,9812.50,6378.12,,,,,,,,,,,,,
KIT GUIDEWIRE DIA 0.096 IN CORONARY ROTATING HEMOSTATIC VLV,SUP-2101941,CDM,C1769,HCPCS,0272,RC,,,,both,,,122.46,79.60,,,,,,,,,,,,,
IMMOBILIZER SHLDR XL L9X22.5IN R/L CANVS W/ WAIST STRP THMB,SUP-2336107,CDM,L3660,HCPCS,0274,RC,,,,both,,,14.60,9.49,,,,,,,,,,,,,
CENTRALIZER STEM L120MM DIA16.5MM DSTL FEM HIP CEM MOLD FOR,SUP-2251182,CDM,C1776,CPT,0278,RC,,,,both,,,414.48,269.41,,,,,,,,,,,,,
PLATE BONE L110MM 7 H RT ANTR LAT DSTL TIB TI FOR,SUP-2225375,CDM,C1713,HCPCS,0278,RC,,,,both,,,5546.50,3605.22,,,,,,,,,,,,,
ELECTRODE CORTICAL 1 X 4 KT STRL DISP EVO,SUP-2935104,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2081.82,1353.18,,,,,,,,,,,,,
GRAFT HUM TISS 30 MG MICRONIZED PARTIC MICROMATRIX,SUP-2106469,CDM,Q4118,HCPCS,0636,RC,,,,both,,,305.49,198.57,,,,,,,,,,,,,
SHEATH INTRO PRELUDE IDEAL L 23 CM DIA 6 FR STIFF STR,SUP-2740609,CDM,C1892,HCPCS,0272,RC,,,,both,,,244.92,159.20,,,,,,,,,,,,,
CATHETER KIT 4 FRX20 CM MIDLN TRIM,SUP-2384035,CDM,C1751,HCPCS,0278,RC,,,,both,,,110.53,71.84,,,,,,,,,,,,,
PLATE BONE 12 H TI BROAD HYBRID COMPR FOR 4.5MM SCR ALPS,SUP-2413755,CDM,C1713,HCPCS,0278,RC,,,,both,,,1471.15,956.25,,,,,,,,,,,,,
PROBE LASER 20GA STD STR TAPR TIP DISP ENDOPRB,SUP-2247212,CDM,C1713,HCPCS,0278,RC,,,,both,,,422.86,274.86,,,,,,,,,,,,,
SYSTEM CLOSURE VASC KNOT TYNG PER CLOSE CLINCH,SUP-2241108,CDM,C1760,HCPCS,0278,RC,,,,both,,,62.80,40.82,,,,,,,,,,,,,
SYSTEM MIX BNE CEM ACCUMIX,SUP-2414254,CDM,2720000010,LOCAL,0272,RC,,,,both,,,775.58,504.13,,,,,,,,,,,,,
RING OPEN ALUM DIA155MM,SUP-2701756,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4233.35,2751.68,,,,,,,,,,,,,
SET HAD CATHETER 9FR L12CM STR INTRO NDL GWIRE DIL BASIC,SUP-2269568,CDM,C1752,HCPCS,0278,RC,,,,both,,,138.47,90.01,,,,,,,,,,,,,
WAND ABLAT DIA2.9MM ANG TIP TURB REDUC W/ SUCT COBLATION,SUP-2342044,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1044.74,679.08,,,,,,,,,,,,,
ANCHOR SUT FOR ARTHSCP INSTABILITY REP LUPINE BR ORTHOCORD,SUP-2256590,CDM,C1713,HCPCS,0278,RC,,,,both,,,2552.82,1659.33,,,,,,,,,,,,,
PIN REINFORCEMENT LARGE 16MM,SUP-2890769,CDM,C1713,HCPCS,0278,RC,,,,both,,,4493.34,2920.67,,,,,,,,,,,,,
INTRODUCER MIC KT 4FRX40CM WIRE S STL SFT TIP,SUP-2120523,CDM,C1894,HCPCS,0272,RC,,,,both,,,72.22,46.94,,,,,,,,,,,,,
SCREW SPNL TAPR 5X10 MM OCCIPITOCERVICAL UPPER THOR,SUP-2632009,CDM,C1713,HCPCS,0278,RC,,,,both,,,1664.20,1081.73,,,,,,,,,,,,,
BASEPLATE TIB LIMB SALV LO BODY ELEOS SZ 3 70MM M/L,SUP-2314044,CDM,C1776,CPT,0278,RC,,,,both,,,20918.68,13597.14,,,,,,,,,,,,,
PATCH CV HEMSHLD L 3 X W 0.2 IN THK 0.76 MM POLYESTER BOV,SUP-2227620,CDM,C1768,CPT,0278,RC,,,,both,,,364.33,236.81,,,,,,,,,,,,,
CATHETER GUID 6FR L100CM DIA0.071IN NYL SHFT EBU3.5,SUP-2295685,CDM,C1887,HCPCS,0272,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
BIT DRL 1.5X107 MM 20 MM END NS LTX,SUP-2862797,CDM,2720000010,LOCAL,0272,RC,,,,both,,,915.15,594.85,,,,,,,,,,,,,
STENT COR RX 2.75X23 MM 6 FRX145 CM COCR XIENCE ALPINE,SUP-2516975,CDM,C1874,HCPCS,0278,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
TIP ASPIR L4.6IN OD2.46MM ID2.01MM SFT TISS CUT ABLAT DISP,SUP-2367530,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1681.47,1092.96,,,,,,,,,,,,,
ROD IM L345MM OD10.7MM 10DEG AG TIB FOR LIMB LENGTHENING,SUP-2312268,CDM,C1713,HCPCS,0278,RC,,,,both,,,56598.50,36789.02,,,,,,,,,,,,,
SUPPORT ORTHOT WRST ELBW HND FNGR W/JT ELASTIC FABRICATED,SUP-2435765,CDM,L3766,HCPCS,0272,RC,,,,both,,,3498.56,2274.06,,,,,,,,,,,,,
PLATE BONE L45MM THK1.4MM SHFT W6MM HD 12.9MM 5 H STRL Y SHP,SUP-2349686,CDM,C1713,HCPCS,0278,RC,,,,both,,,5193.09,3375.51,,,,,,,,,,,,,
SCREW BNE ST 2.4X22 MM LCK W/ CRUCFRM RECESS TI,SUP-2570001,CDM,C1713,HCPCS,0278,RC,,,,both,,,108.80,70.72,,,,,,,,,,,,,
BAG SPEC LAP 9X7.5 IN 12 MM 1500 CC MEM WIRE CANN NYL,SUP-2166300,CDM,2720000010,LOCAL,0272,RC,,,,both,,,173.67,112.89,,,,,,,,,,,,,
MICROCATHETER DIAG DIREXION HI FLO L 105 CM DIA,SUP-2652836,CDM,C1887,HCPCS,0272,RC,,,,both,,,1695.60,1102.14,,,,,,,,,,,,,
ANTERIOR ANKLE FUSION PLATE SLIM LEFT,SUP-2604351,CDM,C1713,HCPCS,0278,RC,,,,both,,,7287.94,4737.16,,,,,,,,,,,,,
TRAY TIB SZ 1 NEUT MOD BAL REV SYS,SUP-2315544,CDM,C1776,CPT,0278,RC,,,,both,,,6280.00,4082.00,,,,,,,,,,,,,
SCREW SZ 30MMX26MM CANN,SUP-2243601,CDM,C1713,HCPCS,0278,RC,,,,both,,,1079.50,701.67,,,,,,,,,,,,,
SPLINT WR UNIV PED LT HND COCKUP ALUM STAY INSTABILITY INJ,SUP-2203821,CDM,L3908,HCPCS,0274,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
PROSTHESIS VOICE LO PRSS 16FR SZ 18MM BLOM SINGER,SUP-2242312,CDM,L8509,HCPCS,0272,RC,,,,both,,,266.90,173.48,,,,,,,,,,,,,
STAPLER INT 60 UNIV BLK W TRI STAPLE TECHNOLOGY ULT FOR 4,SUP-2395285,CDM,C1781,HCPCS,0278,RC,,,,both,,,550.29,357.69,,,,,,,,,,,,,
SCREW BNE CANN 2.5X8 MM LP TI CAPTURE,SUP-2609528,CDM,C1713,HCPCS,0278,RC,,,,both,,,825.41,536.52,,,,,,,,,,,,,
KIT INSRTN INTRO L 6 IN CATH DIA 7 FR 34/40 CC PACKAGED STRL,SUP-2908751,CDM,C1894,HCPCS,0272,RC,,,,both,,,455.17,295.86,,,,,,,,,,,,,
INSERT TIB SZ 1 THK6MM LT ANK FIX BEAR VANTAGE,SUP-2223483,CDM,C1776,CPT,0278,RC,,,,both,,,3689.50,2398.17,,,,,,,,,,,,,
IMPLANT NSL L 25 X W 11 MM THK 0.60 MM POLYETHYL THN,SUP-2883470,CDM,C1889,HCPCS,0278,RC,,,,both,,,1250.57,812.87,,,,,,,,,,,,,
HEAD REAMER 11.5 MM FOR RIA 2 STRL,SUP-2563903,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2478.59,1611.08,,,,,,,,,,,,,
BLADE SURG FASCIAL PRECEPT,SUP-2312035,CDM,C1713,HCPCS,0278,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
GUIDEWIRE ORTH TROCAR PT 1 END 1.4X150 MM NS,SUP-2789083,CDM,C1769,HCPCS,0272,RC,,,,both,,,956.82,621.93,,,,,,,,,,,,,
PLATE BNE FEM 90 18 DEG 3.5 MM 18 MM DSTL 6 HOLE SS STRL JPS,SUP-2645612,CDM,C1713,HCPCS,0278,RC,,,,both,,,14444.00,9388.60,,,,,,,,,,,,,
COIL NEUROVASCULAR MICRUSPHERE 18 L 24.3 CM DIA14 MM PRIMARY,SUP-2461161,CDM,C1889,HCPCS,0278,RC,,,,both,,,5806.68,3774.34,,,,,,,,,,,,,
SCREW BNE DIA1.5 MM HI TORQUE XLOCK SHRT BLADE NS,SUP-2934126,CDM,C1713,HCPCS,0278,RC,,,,both,,,1522.90,989.88,,,,,,,,,,,,,
POST EXT FIX WIRE TALL MR SAFE,SUP-2179142,CDM,2720000010,LOCAL,0272,RC,,,,both,,,671.90,436.73,,,,,,,,,,,,,
HC Elbow Min 3 Views,PX-3207308000,CDM,73080,CPT,0320,RC,,,,both,,,660.00,429.00,,,,,,,,,,,,,
ASSEMBLY KIT PENILE PROS,SUP-2300751,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1224.60,795.99,,,,,,,,,,,,,
NEEDLE VENTRICULAR MIXTER 16 GAX3-5/8 IN 2 HOLE SLV,SUP-2666378,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1126.63,732.31,,,,,,,,,,,,,
PLATE BONE THK1MM 16 H MINI STR FOR 2/2.3MM SCR,SUP-2418321,CDM,C1713,HCPCS,0278,RC,,,,both,,,2774.72,1803.57,,,,,,,,,,,,,
COLLAR CERV SFT DENS UNIV 24X4.5 IN HK LOOP CLOSURE,SUP-2336316,CDM,L0120,HCPCS,0272,RC,,,,both,,,10.46,6.80,,,,,,,,,,,,,
CHOLANGIOGRAM KIT RX AUTOTOME UTOM XL SPHINTOM JAGWIRE 7116,SUP-2484389,CDM,2720000010,LOCAL,0272,RC,,,,both,,,750.46,487.80,,,,,,,,,,,,,
GRAFT VASC IMPRA L 15 CM DIA 5 MM EPTFE FLX TW SM BEAD RING,SUP-2761430,CDM,C1768,CPT,0278,RC,,,,both,,,1271.83,826.69,,,,,,,,,,,,,
GUIDEWIRE SM PASS R ANG,SUP-2286521,CDM,C1769,HCPCS,0272,RC,,,,both,,,184.10,119.66,,,,,,,,,,,,,
BIT DRL OD10.5MM SACROILIAC CANN SI-LOK,SUP-2232173,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
VALVE MITRL OPN PVT DIA25 MM TISS ANNULUS 25.5 MM ORIFICE,SUP-2124484,CDM,C1889,HCPCS,0278,RC,,,,both,,,17270.00,11225.50,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE L 10 MM DIA 7.5 MM CART ARAGONITE 1PK,SUP-2913427,CDM,C1763,HCPCS,0278,RC,,,,both,,,18212.00,11837.80,,,,,,,,,,,,,
HC So1 Immunoassay Quant,PX-3018351967,CDM,83519,CPT,0301,RC,,,,outpatient,,,264.00,171.60,,,,,,,,,,,,,
PLATE BURR H DIA22 CTR H 8 MM THK 1.73 MM SCREW DIA1.5 MM TI,SUP-2937007,CDM,C1713,HCPCS,0278,RC,,,,both,,,3742.88,2432.87,,,,,,,,,,,,,
SCREW BNE SEMICONSTRAINED 4.5X17.5 MM WRST LCK CAP STRL FRDM,SUP-2852810,CDM,C1713,HCPCS,0278,RC,,,,both,,,1500.04,975.03,,,,,,,,,,,,,
PLATE BNE L 48 X W 8 MM THK 3.3 MM SCREW DIA2.7 MM DISTANCE,SUP-2908131,CDM,C1713,HCPCS,0278,RC,,,,both,,,1031.99,670.79,,,,,,,,,,,,,
PLATE FOOT LK L PLT LT,SUP-2701953,CDM,C1713,HCPCS,0278,RC,,,,both,,,1688.06,1097.24,,,,,,,,,,,,,
PLATE BNE PROX 3.5 MM MEDL SS STRL,SUP-2185354,CDM,C1713,HCPCS,0278,RC,,,,both,,,4684.88,3045.17,,,,,,,,,,,,,
KIT ELBW JT HUM PIN BUSHING COONRAD/MORREY,SUP-2205922,CDM,C1776,CPT,0278,RC,,,,both,,,2317.32,1506.26,,,,,,,,,,,,,
WIRE ORTH SMOOTH DBL SHRP TIP S STL 2.0MM DIA 60MM K,SUP-2204886,CDM,C1769,HCPCS,0272,RC,,,,both,,,25.12,16.33,,,,,,,,,,,,,
MARKER BX SITE TI CORK SHP US GUID MAG ATEC TRIMARK,SUP-2240071,CDM,A4648,CPT,0278,RC,,,,both,,,203.75,132.44,,,,,,,,,,,,,
PLATE BNE STR 3.5X66 MM 5 HOLE RECON LCK SS STRL,SUP-2464583,CDM,C1713,HCPCS,0278,RC,,,,both,,,1200.55,780.36,,,,,,,,,,,,,
COMPONENT FEM SZ 4 LT CO CHROM CRUC RET CEM PRI NP UNISX,SUP-2350332,CDM,C1776,CPT,0278,RC,,,,both,,,10205.00,6633.25,,,,,,,,,,,,,
TIP DRVR AO SHFT 1.5 MM SLD HEX NS ACU-LOC 2 LF DISP,SUP-2518463,CDM,2720000010,LOCAL,0272,RC,,,,both,,,602.88,391.87,,,,,,,,,,,,,
CATHETER URETH 18 FR 5 CM BLLN W/ INFLATION DRUG OPTILUME,SUP-2863021,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6578.30,4275.89,,,,,,,,,,,,,
LINER ACET OD52MM ID28MMXLPE HIP CEM ANTEVERTED REDAPT,SUP-2345493,CDM,C1776,CPT,0278,RC,,,,both,,,3292.29,2139.99,,,,,,,,,,,,,
DRILL SURG CRTX STD 4.2 MM PROX AO QR NS LTX,SUP-2856022,CDM,2720000010,LOCAL,0272,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
PLATE BNE L86MM 4 H L TIB BILAT TI L BTTRS LO PROF RIG,SUP-2190897,CDM,C1713,HCPCS,0278,RC,,,,both,,,1555.34,1010.97,,,,,,,,,,,,,
ALLOGRAFT BNE CUBE 10X10X10 MM DEMINERALIZED CANC LIFEFLEX,SUP-2866837,CDM,C1762,CPT,0278,RC,,,,both,,,939.65,610.77,,,,,,,,,,,,,
BLADE RTRCTR MCCLLCH 3CMD SPNL MSCLE MULTI TTHD BLACK FNSH U,SUP-2459197,CDM,2720000010,LOCAL,0272,RC,,,,both,,,610.51,396.83,,,,,,,,,,,,,
PLATE BNE THK0.6MM 2MM BAR 5 H 100DEG UNIV,SUP-2366304,CDM,C1713,HCPCS,0278,RC,,,,both,,,625.68,406.69,,,,,,,,,,,,,
SCREW BONE L5MM DIA1.7MM ST LO PROF 5PK,SUP-2418784,CDM,C1713,HCPCS,0278,RC,,,,both,,,278.86,181.26,,,,,,,,,,,,,
BIT DRILL RADLUC 4 MM,SUP-2632387,CDM,2720000010,LOCAL,0272,RC,,,,both,,,388.61,252.60,,,,,,,,,,,,,
CATHETER GUID ARMADILLO 95CM 7FR 0.072IN L22CM 0.035-0.038IN,SUP-2759488,CDM,C1887,HCPCS,0272,RC,,,,both,,,5495.00,3571.75,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL PEEK SD800.551,SUP-2860232,CDM,C1713,HCPCS,0278,RC,,,,both,,,55837.99,36294.69,,,,,,,,,,,,,
ALLOGRAFT BNE DWL 20X20 MM FRZN THRD SVC FEE MDII,SUP-2791141,CDM,C1713,HCPCS,0278,RC,,,,both,,,9772.81,6352.33,,,,,,,,,,,,,
PROBE VITRCTMY ODSEC20GA ACCURUS 2500,SUP-2109872,CDM,C1713,HCPCS,0278,RC,,,,both,,,584.04,379.63,,,,,,,,,,,,,
FILLER BNE VOID SZ 1-4 MM 10 CC DBM CANC SPNG FIL STRL APEX,SUP-2913403,CDM,C1713,HCPCS,0278,RC,,,,both,,,3730.32,2424.71,,,,,,,,,,,,,
SET VASC FILTER SHTH 10 FR JUG 6 MM PHYNOX VENA CAVA,SUP-2124925,CDM,C1880,HCPCS,0278,RC,,,,both,,,3447.25,2240.71,,,,,,,,,,,,,
STENT BILI PALMAZ GEN L 39 MM EXPANSION DIA10-12 MM SHTH 8,SUP-2159261,CDM,C1877,HCPCS,0278,RC,,,,both,,,3975.24,2583.91,,,,,,,,,,,,,
LINER ACET NEUT 28 MM HIP GRP 0 XLPE YEL NOVATION,SUP-2222011,CDM,C1776,CPT,0278,RC,,,,both,,,5298.75,3444.19,,,,,,,,,,,,,
HC Treat Elbow Dislocation W Anes,PX-4502460500,CDM,24605,CPT,0450,RC,,,,both,,,1633.00,1061.45,,,,,,,,,,,,,
CATHETER LD DEL AVEIR VR L 105 CM DIA 6.8 MM SINGLE CHMBR,SUP-2880902,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5495.00,3571.75,,,,,,,,,,,,,
VEST HOLSTER POCKET BATTERY CTRL,SUP-2356017,CDM,C1713,HCPCS,0278,RC,,,,both,,,1339.52,870.69,,,,,,,,,,,,,
SPLINT UP EXTRM MTL SPLNTS MTCRPL,SUP-2124890,CDM,L3913,HCPCS,0272,RC,,,,both,,,35.33,22.96,,,,,,,,,,,,,
ANCHOR SUTXL DIA1.7MM W/ SZ 2 BLU COBRAID ULTBRAID POLY SUT,SUP-2341891,CDM,C1713,HCPCS,0278,RC,,,,both,,,1180.33,767.21,,,,,,,,,,,,,
COLLAR CERV ADJ MED 20X3 IN COTTON FOAM PREMIERPRO REUSE,SUP-2424885,CDM,L0120,HCPCS,0272,RC,,,,both,,,12.78,8.31,,,,,,,,,,,,,
CLONIDINE 0.02 MG/ML PO SUSP,RX-4081830,CDM,6370000000,HCPCS,0637,RC,09999-9914-70,NDC,,both,1,ML,2.70,1.75,,,,,,,,,,,,,
EXTENSION STEM L140MM OD21MM FEM HIP CEMENTLESS CNL FILL,SUP-2304776,CDM,C1776,CPT,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
ANCHOR SUT KNOTLESS BIORAPTOR,SUP-2341830,CDM,C1713,HCPCS,0278,RC,,,,both,,,1361.76,885.14,,,,,,,,,,,,,
PLATE EXT FIX L180MM FT DBL H FOR SIDEKCK FREE CIR FIX,SUP-2400658,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4034.90,2622.68,,,,,,,,,,,,,
SYSTEM ROD BONE 150MML TTNM WGRVE FRGD EXTRNL DISTR LATEX,SUP-2679223,CDM,C1713,HCPCS,0278,RC,,,,both,,,1221.62,794.05,,,,,,,,,,,,,
CATHETER DRNGE L120CM DIA2.5MM PERI KINK RESIST SLT WALLED,SUP-2308216,CDM,C1729,HCPCS,0272,RC,,,,both,,,895.06,581.79,,,,,,,,,,,,,
PROSTHESIS OSS L 7 MM SHFT DIA 0.8 MM HD DIA 4 MM TI HA TOT,SUP-2901996,CDM,L8613,CPT,0278,RC,,,,both,,,1366.53,888.24,,,,,,,,,,,,,
GRAFT HUM TISS 7X4 CM 4 LAYR CLLGN MTRX BIODESIGN,SUP-2423403,CDM,C1763,HCPCS,0278,RC,,,,both,,,2596.15,1687.50,,,,,,,,,,,,,
PLATE BNE L 259 X W 11 MM THK 3.3 MM SCREW DIA 3.5 MM,SUP-2907870,CDM,C1713,HCPCS,0278,RC,,,,both,,,2771.43,1801.43,,,,,,,,,,,,,
CATHETER VENTRICULAR STYL LUER CONN CAP ANCHR CLP BACTISEAL,SUP-2666820,CDM,C1729,HCPCS,0272,RC,,,,both,,,1830.65,1189.92,,,,,,,,,,,,,
SHUNT SUNDT INT AND EXT CAR EAE,SUP-2308228,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2350.04,1527.53,,,,,,,,,,,,,
BLADE SURG FASCIAL RELINE MAS,SUP-2557551,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
EVOS 3.5MM LCK 1/3 TUBULAR PL 2H 22MM,SUP-2931423,CDM,C1713,HCPCS,0278,RC,,,,both,,,715.64,465.17,,,,,,,,,,,,,
CONNECTOR SPNL CROSS 24 MM FIX,SUP-2175299,CDM,C1713,HCPCS,0278,RC,,,,both,,,4474.50,2908.42,,,,,,,,,,,,,
ADVANCED LOCKING SCREW DIA 4X37.5MM,SUP-2900554,CDM,C1713,HCPCS,0278,RC,,,,both,,,1200.74,780.48,,,,,,,,,,,,,
PLATE BNE LAT LNG 95 MM RT 11 HOLE EVOLVE EPS ORTHOLOC,SUP-2535928,CDM,C1713,HCPCS,0278,RC,,,,both,,,3796.26,2467.57,,,,,,,,,,,,,
HC Drainage of Eyelid Abscess,PX-4506770000,CDM,67700,CPT,0450,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
TRAY CATH HEMODIALYSI 400XL ACTE 14FR DIA 15CM INTRNL JUG PC,SUP-2610525,CDM,C1752,HCPCS,0278,RC,,,,both,,,288.88,187.77,,,,,,,,,,,,,
HC X-Ray Exam Chest 4+ Views,PX-3247104800,CDM,71048,CPT,0324,RC,,,,inpatient,,,1066.00,692.90,,,,,,,,,,,,,
CLAMP EXT FIX BAR TO RNG FOR JETXSYSTEM,SUP-2342864,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3670.19,2385.62,,,,,,,,,,,,,
SODIUM CHLORIDE 3% IV BOLUS|DISCARDED DRUG NOT ADMINISTE,RX-4082505,CDM,2580000003,HCPCS,0258,RC,00264-7805-10,NDC,JW,both,100,ML,9.40,6.11,,,,,,,,,,,,,
BLADE IM L105MM DIA12.5MM NSTERILE LT BLU CANC TI SPRL,SUP-2191886,CDM,C1713,HCPCS,0278,RC,,,,both,,,2201.83,1431.19,,,,,,,,,,,,,
CATHETER THRMDIL 7FR L110CM 4 LUMN S TIP FOR FEM VEIN INSRT,SUP-2214034,CDM,C1751,HCPCS,0278,RC,,,,both,,,371.93,241.75,,,,,,,,,,,,,
PLATE BNE L315MM 2 H ST BILAT S STL SPR LO PROF RIG,SUP-2177156,CDM,C1713,HCPCS,0278,RC,,,,both,,,1179.54,766.70,,,,,,,,,,,,,
SCREW BONE DIA1.8MM L5MM EMER TITANIUMXDRIVE TIMESH CRAN,SUP-2277541,CDM,C1713,HCPCS,0278,RC,,,,both,,,134.64,87.52,,,,,,,,,,,,,
PLATE BNE SQ MINI 2 MM 6X2 HOLE MESH STRP LADDER TI NS,SUP-2475662,CDM,C1713,HCPCS,0278,RC,,,,both,,,732.62,476.20,,,,,,,,,,,,,
BOLT EXT FIX HALF PIN FOR SIDEKCK FREE CIR FIX,SUP-2400704,CDM,C1713,HCPCS,0278,RC,,,,both,,,558.92,363.30,,,,,,,,,,,,,
GRAFT BNE SUB 5ML DBM HA PTTY W/ GRAN BONUS SYN RESRB,SUP-2402609,CDM,C1713,HCPCS,0278,RC,,,,both,,,3180.82,2067.53,,,,,,,,,,,,,
REGULATOR CARBON DIOX 90 DEG 50 LB SINGLE STG,SUP-2389347,CDM,2720000010,LOCAL,0272,RC,,,,both,,,565.17,367.36,,,,,,,,,,,,,
COMPRESSOR SURG CERV REUSE PLT COMPR,SUP-2279320,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1142.77,742.80,,,,,,,,,,,,,
CABLE VENT ASST MOD HEARTMATE 3,SUP-2356027,CDM,C1713,HCPCS,0278,RC,,,,both,,,16786.44,10911.19,,,,,,,,,,,,,
ANCHOR SUTURE MORPHIX XT 3.5MM W/2-USP #2 DOUBLE-ARMED,SUP-2878657,CDM,C1713,HCPCS,0278,RC,,,,both,,,2213.70,1438.90,,,,,,,,,,,,,
BUR SURG OD20MM M DMND RND N FLUT ST TPS,SUP-2367429,CDM,C1713,HCPCS,0278,RC,,,,both,,,322.35,209.53,,,,,,,,,,,,,
HEAD ELBW 16 MM 4.5 MM ULN STEM FOR PART REPL 1ST CHOICE,SUP-2852832,CDM,C1776,CPT,0278,RC,,,,both,,,18473.34,12007.67,,,,,,,,,,,,,
MENISCAL ALLOGRAFT DISPOSABLE KIT,SUP-2812465,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2062.98,1340.94,,,,,,,,,,,,,
SCREW BONE L45MM OD6.5MM STD NONSTERILE TI CANC CORT ST SELF,SUP-2374387,CDM,C1713,HCPCS,0278,RC,,,,both,,,771.50,501.47,,,,,,,,,,,,,
SLEEVE KNEE RIGID SUPP ADJ JT,SUP-2388160,CDM,L1832,HCPCS,0274,RC,,,,both,,,2659.58,1728.73,,,,,,,,,,,,,
DRILL SURG 1/8 SHLDR PATELLAR S-ROM,SUP-2455984,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2474.32,1608.31,,,,,,,,,,,,,
PLATE FRACTURE 6H 2MM PROF,SUP-2740124,CDM,C1713,HCPCS,0278,RC,,,,both,,,2123.17,1380.06,,,,,,,,,,,,,
BASKET RETRV BILI STONE HELCL 3FR SHTH 16MM OPN DIAM 240CM,SUP-2141354,CDM,2720000010,LOCAL,0272,RC,,,,both,,,624.86,406.16,,,,,,,,,,,,,
IMPLANT OTO 4MM W/ 9MM ABUTMENT FOR BAHA FAST SURG,SUP-2164972,CDM,L8614,HCPCS,0278,RC,,,,both,,,9090.30,5908.69,,,,,,,,,,,,,
ATORVASTATIN CALCIUM 40 MG PO TABS,RX-19177,CDM,6370000000,HCPCS,0637,RC,00904-6292-61,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
SLING ORTHOT CUST TRAPEZIUS,SUP-2435577,CDM,L1070,HCPCS,0274,RC,,,,both,,,317.61,206.45,,,,,,,,,,,,,
FUROSEMIDE 40 MG PO TABS,RX-3295,CDM,6370000000,HCPCS,0637,RC,00904-7178-61,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
AMITRIPTYLINE HCL 50 MG PO TABS,RX-436,CDM,6370000000,HCPCS,0637,RC,60687-0444-11,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PLATE BNE L 70 X W 9.5 MM THK 1.5 MM SCREW DIA 3.5 MM 6 H SS,SUP-2933006,CDM,C1713,HCPCS,0278,RC,,,,both,,,350.02,227.51,,,,,,,,,,,,,
ROD EXT FIX THRD 25 MM DNETR25] DNE LLC],SUP-2197314,CDM,C1713,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
COUPLER FIX OFFSET +2MM FEM KNEE LEGION,SUP-2346815,CDM,C1776,CPT,0278,RC,,,,both,,,3811.96,2477.77,,,,,,,,,,,,,
OSTEOTOME SURG STRL DISP TRITOME,SUP-2893054,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
STEM FEM L180MM OD22.5MM S-5 TI HX COAT HIP CEMENTLESS 03,SUP-2397012,CDM,C1776,CPT,0278,RC,,,,both,,,13188.00,8572.20,,,,,,,,,,,,,
EVOS 2.7/3.5MM EA-D HUM PL 16H L 195MM,SUP-2819909,CDM,C1713,HCPCS,0278,RC,,,,both,,,9594.27,6236.28,,,,,,,,,,,,,
"HC Pt Therapeutic Exercise,Ea 15 Min|DOCUMENTATION ON FILE|UNUSUAL NON-OVERLAPPING SERVICE",PX-4209711000,CDM,97110,CPT,0420,RC,,,KX|XU,both,,,195.00,126.75,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 50 CM DIA 6 MM STR STD WALL REINF,SUP-2525434,CDM,C1768,CPT,0278,RC,,,,both,,,959.90,623.93,,,,,,,,,,,,,
PLATE BONE W10MM ASMBLY SPINOUS PROC SYS ASPN,SUP-2209056,CDM,C1713,HCPCS,0278,RC,,,,both,,,7536.00,4898.40,,,,,,,,,,,,,
TUNNELER INFUS 16GA L12IN SHTH DISP ON-Q,SUP-2236855,CDM,C1894,HCPCS,0272,RC,,,,both,,,65.94,42.86,,,,,,,,,,,,,
ROD IM SPEC KNEE LNG LNG,SUP-2254015,CDM,C1713,HCPCS,0278,RC,,,,both,,,838.38,544.95,,,,,,,,,,,,,
TOOL DIL L18MM DIA7MM MALL MULT BAL COMPATIBLE EZ TO USE,SUP-2217798,CDM,C1713,HCPCS,0278,RC,,,,both,,,4553.00,2959.45,,,,,,,,,,,,,
SODIUM POLYSTYRENE SULFONATE 15 GM/60ML PO SUSP (WRAPPER),RX-430083,CDM,340b,HCPCS,0637,RC,46287-0006-60,NDC,,both,60,ML,111.60,72.54,,,,,,,,,,,,,
IMPLANT BRST M W12.3-11.9XH10.5-10.1CM P5.3-6.9CM 350-420CC,SUP-2300537,CDM,C1789,HCPCS,0278,RC,,,,both,,,3877.90,2520.63,,,,,,,,,,,,,
TRIAL NERVE STIM LD 60 CM KT OCTRODE,SUP-2615496,CDM,C1897,HCPCS,0278,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
ALLOGRAFT BNE BLOCK TRICORT 800123,SUP-2743388,CDM,C1713,HCPCS,0278,RC,,,,both,,,4138.52,2690.04,,,,,,,,,,,,,
SCREW ACET TI PPS HIP FLNG MOD IMP PAR-5,SUP-2403457,CDM,C1713,HCPCS,0278,RC,,,,both,,,662.54,430.65,,,,,,,,,,,,,
STENT BILI SELF SELF EXP 8FR CATH 194CM CATH LEN 10MM DIA,SUP-2149335,CDM,C1874,HCPCS,0278,RC,,,,both,,,5141.62,3342.05,,,,,,,,,,,,,
GRAFT HUM TISS W1XL2CM THK1.04-2.28MM THCK REGENERATIVE TISS,SUP-2113073,CDM,Q4116,HCPCS,0636,RC,,,,both,,,593.46,385.75,,,,,,,,,,,,,
STENT PERIPH ZILVER PTX L 140 MM DIA 7 MM CATH L 125 CM SHTH,SUP-2170407,CDM,C1874,HCPCS,0278,RC,,,,both,,,7520.30,4888.19,,,,,,,,,,,,,
SCREW SPNL THN LNG 4.5X50 MM TSRH 3DX OSTEOGRIP,SUP-2631147,CDM,C1713,HCPCS,0278,RC,,,,both,,,1491.50,969.47,,,,,,,,,,,,,
PLATE BNE CRV 6 HOLE TI,SUP-2402951,CDM,C1713,HCPCS,0278,RC,,,,both,,,386.22,251.04,,,,,,,,,,,,,
KIT CATH REPERFUSION 6FR L132CM 0.072IN W/ HI FLO ASPIR,SUP-2323555,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8635.00,5612.75,,,,,,,,,,,,,
BEAM FIX L135MM DIA4.5MM ARTH,SUP-2223934,CDM,C1713,HCPCS,0278,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
SUPPORT ORTHOT WRST HND FNGR CUST W/O JT PREFABRICATED,SUP-2435768,CDM,L3809,HCPCS,0272,RC,,,,both,,,644.23,418.75,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 45 CM DIA 4-7 MM SHRT TAPR SLDE GDS,SUP-2681787,CDM,C1768,CPT,0278,RC,,,,both,,,1541.61,1002.05,,,,,,,,,,,,,
HUMERAL NAIL 11/9.5MMX24CM,SUP-2818963,CDM,C1713,HCPCS,0278,RC,,,,both,,,7386.07,4800.95,,,,,,,,,,,,,
PLATE CRAN 60X20X20 MM PT SPEC IMPL PEEK,SUP-2860167,CDM,C1713,HCPCS,0278,RC,,,,both,,,21795.37,14166.99,,,,,,,,,,,,,
COIL NEUROVASCULAR PENUMBRA COIL 400 L 6 CM DIA 3 MM STD,SUP-2323353,CDM,C1889,HCPCS,0278,RC,,,,both,,,6832.64,4441.22,,,,,,,,,,,,,
WIRE PACE MYO/WIRE L 61 CM SZ 2-0 CRV 37 MM STR 89 MM SS WNG,SUP-2101192,CDM,2720000010,LOCAL,0272,RC,,,,both,,,59.91,38.94,,,,,,,,,,,,,
STAPLE BNE RELIABLE 3 20X20X25 MM COMPR STRL EXPRESS XL,SUP-2223983,CDM,C1713,HCPCS,0278,RC,,,,both,,,4314.36,2804.33,,,,,,,,,,,,,
END CAP ORTH STD HINDFOOT NS DUALCOMPRESSION,SUP-2930411,CDM,C1889,HCPCS,0278,RC,,,,both,,,1472.66,957.23,,,,,,,,,,,,,
PLATE SPNL 60 MM STRL ATLNTS ESSENTIALS,SUP-2632021,CDM,C1713,HCPCS,0278,RC,,,,both,,,2386.40,1551.16,,,,,,,,,,,,,
SCREW BONE L26MM DIA5.5MM THRD L8MM STD CORT S STL PARTIALLY,SUP-2343632,CDM,C1713,HCPCS,0278,RC,,,,both,,,389.52,253.19,,,,,,,,,,,,,
CANNULA SURG LAG SCREW SHT CEPHALOMEDULLARY,SUP-2471456,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1055.67,686.19,,,,,,,,,,,,,
GRAFT VASC VLV 27 MM AORT ROTATABLE STENT MSTR SER,SUP-2356715,CDM,C1889,HCPCS,0278,RC,,,,both,,,20045.76,13029.74,,,,,,,,,,,,,
SLING GYN L 12 X W 1.1 CM POLYPRO MONOFILAMENT SHRT CAL-DS01BSL,SUP-2929667,CDM,C1771,HCPCS,0278,RC,,,,both,,,4006.64,2604.32,,,,,,,,,,,,,
INTRODUCER HEMSTAS ULTIMUM 5FRX23CM SHTH W/ .038IN GWIRE,SUP-2355647,CDM,C1894,HCPCS,0272,RC,,,,both,,,384.65,250.02,,,,,,,,,,,,,
CATHETER INFSN 5FR DIA 135CML 5CML PEBAX OCCLDNG WIRE FNTN L,SUP-2701664,CDM,C1751,HCPCS,0278,RC,,,,both,,,266.90,173.48,,,,,,,,,,,,,
BEARING TIB L71/75MM THK18MM KNEE ARCM CONSTRN DIR COMPR,SUP-2404160,CDM,C1776,CPT,0278,RC,,,,both,,,4295.52,2792.09,,,,,,,,,,,,,
GRAFT BNE WDG 12X11X10-12 MM TRICORT PUROS,SUP-2335231,CDM,C1713,HCPCS,0278,RC,,,,both,,,4835.60,3143.14,,,,,,,,,,,,,
KYPHOPLASTY TRAY 10/2 OSTEO INTRO CDS SYS KYPHOPAK EXPRESS,SUP-2665110,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8499.98,5524.99,,,,,,,,,,,,,
OCCLUDER CV WATCHMAN TRUSEAL ERGO HUB 2 STRT THRD ACCS SYS,SUP-2892941,CDM,C1894,HCPCS,0272,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
CATHETER IRRIG 3FR L40CM 6MM DST 2 LUMN 230234] LEMAITRE VASCULAR INC],SUP-2264228,CDM,C1751,HCPCS,0278,RC,,,,both,,,244.92,159.20,,,,,,,,,,,,,
PLATE BNE L 294 X W 12 MM THK 4 MM SCREW DIA2.7/3.5 MM 25 H 72469225N,SUP-2933616,CDM,C1713,HCPCS,0278,RC,,,,both,,,7222.63,4694.71,,,,,,,,,,,,,
BIT DRL DIA2MM FAST W/ MINI QUIK CONN DISP FOR HND FRAC SYS,SUP-2412645,CDM,2720000010,LOCAL,0272,RC,,,,both,,,128.11,83.27,,,,,,,,,,,,,
IODINE STRONG 5 % PO SOLN,RX-3961,CDM,6370000000,HCPCS,0637,RC,48433-0230-15,NDC,,both,14,ML,167.60,108.94,,,,,,,,,,,,,
BIT DRILL 2.9 MM INLINE SPADE W/ DEPTH STP FOR 2.7 MM,SUP-2849140,CDM,2720000010,LOCAL,0272,RC,,,,both,,,580.90,377.58,,,,,,,,,,,,,
SCREW BONE L100MM DIA6.5MM UNIV CORT FEM ST FT DRV END,SUP-2411524,CDM,C1713,HCPCS,0278,RC,,,,both,,,587.18,381.67,,,,,,,,,,,,,
PROSTHESIS OSS PISTON 0.6X6 MM SCHKNT MALL ATTCH SS FLROPLAS,SUP-2637750,CDM,L8613,CPT,0278,RC,,,,both,,,351.30,228.34,,,,,,,,,,,,,
SNARE RETRV L286CM WRK CHN 1.2MM CBL DIA1MM DIR VIS DISP,SUP-2418488,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1641.53,1066.99,,,,,,,,,,,,,
TRAY CHST TB CATH 12FR L22CM 3 SIDEPRT THAL-QUICK,SUP-2168086,CDM,C1729,HCPCS,0272,RC,,,,both,,,691.74,449.63,,,,,,,,,,,,,
CONNECTOR SPNL TOP SIDE 4.5-5 MM CORTICAL CD HORZ MODULEX,SUP-2854491,CDM,C1713,HCPCS,0278,RC,,,,both,,,1868.30,1214.39,,,,,,,,,,,,,
BASEPLATE TIB SZ 1 L LAT MOD CEM NTRL KN II,SUP-2210157,CDM,C1776,CPT,0278,RC,,,,both,,,10644.60,6918.99,,,,,,,,,,,,,
SHELL ACET NEUT 28X42 MM HIP,SUP-2315329,CDM,C1776,CPT,0278,RC,,,,both,,,2863.68,1861.39,,,,,,,,,,,,,
SENSOR OXMTR PTCH TISS DISP,SUP-2392934,CDM,C1713,HCPCS,0278,RC,,,,both,,,4631.50,3010.47,,,,,,,,,,,,,
CATHETER HD STR 55 CM 50 CM 2 VLV BASIC KT BIOFLO DURAMAX,SUP-2457543,CDM,C1750,HCPCS,0278,RC,,,,both,,,1130.40,734.76,,,,,,,,,,,,,
SMALL CURVE BX5,SUP-2573317,CDM,C1769,HCPCS,0272,RC,,,,both,,,1036.20,673.53,,,,,,,,,,,,,
SURGICAL PROCEDURE PACK ORTHOGNATHIC PLN IPS,SUP-2433937,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3281.30,2132.84,,,,,,,,,,,,,
WRENCH EXT FIX 10MM FLX FOR SIDEKCK EZ FRME FREE CIR FIX,SUP-2401155,CDM,2720000010,LOCAL,0272,RC,,,,both,,,872.92,567.40,,,,,,,,,,,,,
BIT DRILL QUICK COUPLING 3.5X85/110 MM STERILE TC100 DISPOSA,SUP-2837034,CDM,2720000010,LOCAL,0272,RC,,,,both,,,801.05,520.68,,,,,,,,,,,,,
SLEEVE CANN DIA15 MM RADIALLY EXPANDABLE STRL DISP VERSASTEP,SUP-2896204,CDM,2720000010,LOCAL,0272,RC,,,,both,,,359.84,233.90,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 70 CM DIA 7 MM STR REINF SLDE GDS,SUP-2681173,CDM,C1768,CPT,0278,RC,,,,both,,,1942.72,1262.77,,,,,,,,,,,,,
BEARING HUM +3MM 3X44-41MM RETENTIVE REV SHLDR COMPHSVE,SUP-2409558,CDM,C1776,CPT,0278,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
GORE TAG THORACIC BRANCH ENDOPROSTHESIS 17MMX8MMX6CM,SUP-2855633,CDM,C1768,CPT,0278,RC,,,,both,,,24492.00,15919.80,,,,,,,,,,,,,
STEM FEM L177MM DIA13.5MM STD OFFSET CALCAR HIP CO CHROM,SUP-2203190,CDM,C1776,CPT,0278,RC,,,,both,,,20226.31,13147.10,,,,,,,,,,,,,
COMPONENT FEM REV 5 LT KNEE CEM PERSONA,SUP-2435457,CDM,C1776,CPT,0278,RC,,,,both,,,26336.75,17118.89,,,,,,,,,,,,,
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-112652,CDM,J1953,HCPCS,0636,RC,67457-0265-10,NDC,,both,50,ML,61.90,40.23,,,,,,,,,,,,,
MESH CRAN W40XL40MM THK0.6MM SLV TI ULT PRECONTOURED FOR,SUP-2402862,CDM,C1781,HCPCS,0278,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
SCREW BNE FOR GALAXY FIX SYS 35MMX80MM 4MM,SUP-2316042,CDM,C1713,HCPCS,0278,RC,,,,both,,,314.13,204.18,,,,,,,,,,,,,
SPONGE SCLER BCKL L80MM DIA3MM RND STYL 503,SUP-2213492,CDM,C1784,HCPCS,0278,RC,,,,both,,,146.32,95.11,,,,,,,,,,,,,
CATHETER CARD ABLATION NAVISTAR L 115CM 7FR 4MM B CRV UNIDIR,SUP-2248936,CDM,C1732,HCPCS,0272,RC,,,,both,,,5567.22,3618.69,,,,,,,,,,,,,
GRAFT BIO TISS W15XL10CM THK0.6MM NONDENATURED CLLGN BOV OVL,SUP-2383081,CDM,C9356,HCPCS,0278,RC,,,,both,,,9891.00,6429.15,,,,,,,,,,,,,
PLATE BONE L199MM 12 H BILAT COMPR STR BROAD FOR 4.5MM SCR,SUP-2343800,CDM,C1713,HCPCS,0278,RC,,,,both,,,2464.05,1601.63,,,,,,,,,,,,,
NAIL IM L300MM DIA9MM NONSTERILE DK BLU TIB TI LCK UNREAMED,SUP-2192774,CDM,C1713,HCPCS,0278,RC,,,,both,,,3778.55,2456.06,,,,,,,,,,,,,
PIN EXT FIX FT 7X125 MM BEAM SALVATION,SUP-2852135,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4892.12,3179.88,,,,,,,,,,,,,
AMK TIB TY SZ 3+,SUP-2251229,CDM,C1776,CPT,0278,RC,,,,both,,,7991.30,5194.34,,,,,,,,,,,,,
FOUNDATION ALL POLY PAT W/ CTRL PEG 29 MM ** SPEC ORD ONLY,SUP-2215523,CDM,C1776,CPT,0278,RC,,,,both,,,2581.08,1677.70,,,,,,,,,,,,,
HC So Lead,PX-3018365566,CDM,83655,CPT,0301,RC,,,,both,,,102.00,66.30,,,,,,,,,,,,,
STENT URTRL 48FR DIA 22 30CML FLXMA STRGHT TIP W/0035N 150,SUP-2724948,CDM,C2617,HCPCS,0278,RC,,,,both,,,469.65,305.27,,,,,,,,,,,,,
STIMULATOR NERVE SURESCAN MRI CLOSED LOOP TECHNOLOGY RECHRG,SUP-2889722,CDM,C1826,HCPCS,0278,RC,,,,both,,,69080.00,44902.00,,,,,,,,,,,,,
CLAMP EXT FIX M 4 POS PIN,SUP-2188512,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1244.66,809.03,,,,,,,,,,,,,
HC Plcmt Interstit Prostate Rx Tx,PX-3615587600,CDM,55876,CPT,0361,RC,,,,both,,,8583.00,5578.95,,,,,,,,,,,,,
GRAFT BONE SUB 2CC VIABLE BONE MTRX BIOFUSE,SUP-2224015,CDM,C1762,CPT,0278,RC,,,,both,,,3711.48,2412.46,,,,,,,,,,,,,
PIN FIX L150MM SPNL PERC DISP O ARM,SUP-2280202,CDM,C1713,HCPCS,0278,RC,,,,both,,,963.98,626.59,,,,,,,,,,,,,
ELECTRODE SUBDERM NDL L 12 MM SET 8 CHANNEL PR GRN WHT STRL,SUP-2902105,CDM,2720000010,LOCAL,0272,RC,,,,both,,,915.47,595.06,,,,,,,,,,,,,
INSERT TIB SZ 2-3 THK11MM KNEE HNG ROT PLATFRM LEGION,SUP-2346655,CDM,C1776,CPT,0278,RC,,,,both,,,6493.52,4220.79,,,,,,,,,,,,,
PLATE BONE LOCKING HOLEX6 T SHAPED RIGHT DORSAL DISTAL,SUP-2725612,CDM,C1713,HCPCS,0278,RC,,,,both,,,3066.02,1992.91,,,,,,,,,,,,,
PLATE 4.5MM TI LCP MEDIAL PROXIMAL TIBIA 16H LT 322MM STER,SUP-2549627,CDM,C1713,HCPCS,0278,RC,,,,both,,,3659.95,2378.97,,,,,,,,,,,,,
SYSTEM PRT CLOSURE 15 MM SUTURE GUIDE CARTER-THOMASON,SUP-2756022,CDM,2720000010,LOCAL,0272,RC,,,,both,,,485.29,315.44,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 50 CM DIA 4 MM EPTFE STR STD WALL,SUP-2681083,CDM,C1768,CPT,0278,RC,,,,both,,,1337.70,869.50,,,,,,,,,,,,,
PLATE BNE 4.5MM ANAT REPLICATOR O/S EQUINOXE,SUP-2223285,CDM,C1713,HCPCS,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
UROGESIC-BLUE 81.6 MG PO TABS,RX-106258,CDM,6370000000,HCPCS,0637,RC,00485-0151-30,NDC,,both,1,UN,23.40,15.21,,,,,,,,,,,,,
DRILL CANN 2.75MM,SUP-2321075,CDM,2720000010,LOCAL,0272,RC,,,,both,,,681.38,442.90,,,,,,,,,,,,,
STENT URET L 22 CM DIA 8 FR FLEXIMA GLDEX DBL PIGTL THRD,SUP-2147878,CDM,C2617,HCPCS,0278,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
IMPLANT OP RM TISS 10 X 5MM CALCANEO CUBOID JT WDG,SUP-2321656,CDM,C1776,CPT,0278,RC,,,,both,,,6154.40,4000.36,,,,,,,,,,,,,
RX MESH 50 X 50 X 10MM LG GRID,SUP-2669320,CDM,C1713,HCPCS,0278,RC,,,,both,,,2841.32,1846.86,,,,,,,,,,,,,
GRAFT BNE 10X20X8MM DEMIN CANC SPNG STRP FLEXIGRFT,SUP-2264613,CDM,C9362,HCPCS,0278,RC,,,,both,,,2283.97,1484.58,,,,,,,,,,,,,
EXTRACTOR SURG L5 MMXTRACT ALL DISP FOR 4.5-6 MM BROKEN SCR,SUP-2337707,CDM,C1713,HCPCS,0278,RC,,,,both,,,737.90,479.63,,,,,,,,,,,,,
SCREW INTFR L30MM DIA9MM BIOSURE REGENESORB,SUP-2341923,CDM,C1713,HCPCS,0278,RC,,,,both,,,1157.31,752.25,,,,,,,,,,,,,
COMPONENT FEM C- KNEE FEMALE NXGN LPS-FLEX GENDER SOL 00572401351] ZIMMER BIOMET INC],SUP-2200264,CDM,C1776,CPT,0278,RC,,,,both,,,18309.34,11901.07,,,,,,,,,,,,,
PLATE BONE W8XL112MM THK3.3MM 14 H STRL BILAT PELV S STL,SUP-2186242,CDM,C1713,HCPCS,0278,RC,,,,both,,,1557.13,1012.13,,,,,,,,,,,,,
COIL VASC AZUR HYDROCOIL L 6 CM DIA 4 MM MICROCATHETER 0.018,SUP-2385384,CDM,C1889,HCPCS,0278,RC,,,,both,,,785.03,510.27,,,,,,,,,,,,,
BUR SURG SM L18.3MM DIA3.2MM HELICOIDAL SGL END ANG TAPR,SUP-2363319,CDM,2720000010,LOCAL,0272,RC,,,,both,,,414.57,269.47,,,,,,,,,,,,,
PLATE BNE 3 H L DST VOLAR RAD TI NAR GEMINUS,SUP-2340196,CDM,C1713,HCPCS,0278,RC,,,,both,,,2187.01,1421.56,,,,,,,,,,,,,
MESH HERN L W14XL18CM INGUINAL OVL SELF EXP PTCH KUGEL,SUP-2125976,CDM,C1781,HCPCS,0278,RC,,,,both,,,450.59,292.88,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC IR 4FR 55CM 1 LUMAN RVS TAP 3174155,SUP-2632653,CDM,C1751,HCPCS,0278,RC,,,,both,,,202.06,131.34,,,,,,,,,,,,,
PLATE BNE RND 1.5X30 MM CRANIOFACIAL MESH MALL CONTOURABLE,SUP-2191123,CDM,C1713,HCPCS,0278,RC,,,,both,,,2631.32,1710.36,,,,,,,,,,,,,
SET URET STENT SALLE L 12-18 CM DIA 4.0 FR GUIDEWIRE L 145,SUP-2171180,CDM,C2625,HCPCS,0278,RC,,,,both,,,488.58,317.58,,,,,,,,,,,,,
STENT PERIPH LIFESTENT L 170 MM DIA 6 MM CATH L 130 CM DIA 6,SUP-2128187,CDM,C1876,HCPCS,0278,RC,,,,both,,,10346.30,6725.09,,,,,,,,,,,,,
HC Custom Finger Static,PX-2740393301,CDM,L3933,HCPCS,0272,RC,,,,inpatient,,,710.00,461.50,,,,,,,,,,,,,
ALLOGRAFT BNE STRP 50X20X7 MM FD ILIUM TRICORT,SUP-2717880,CDM,C1762,CPT,0278,RC,,,,both,,,12217.05,7941.08,,,,,,,,,,,,,
HC Pt Therapeutic Activities 15 Min|DOCUMENTATION ON FILE|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS,PX-4209753000,CDM,97530,CPT,0420,RC,,,KX|CQ,both,,,144.00,93.60,,,,,,,,,,,,,
BONESYNC PUTTY 2.5CC,SUP-2816385,CDM,C1713,HCPCS,0278,RC,,,,both,,,847.80,551.07,,,,,,,,,,,,,
STEM HUM L130MM DIA12MM NK 130DEG ANG UNIV SHLDR CO CHROM,SUP-2388623,CDM,C1776,CPT,0278,RC,,,,both,,,12156.51,7901.73,,,,,,,,,,,,,
CATHETER INFUSION PULSE SPRY L 135 CM DIA 5 FR SLT PAT L 20,SUP-2118495,CDM,C1751,HCPCS,0278,RC,,,,both,,,832.10,540.86,,,,,,,,,,,,,
RESERVOIR VENT DRNGE 0.68ML DIA1.5CM STD BUR H STYL W/ SM,SUP-2308213,CDM,C1889,HCPCS,0278,RC,,,,both,,,1343.83,873.49,,,,,,,,,,,,,
OXYCODONE HCL ER 10 MG PO T12A,RX-123648,CDM,6370000000,HCPCS,0637,RC,59011-0410-10,NDC,,both,1,UN,25.50,16.57,,,,,,,,,,,,,
COMPONENT PAT L+ 3PEG RND REV ROT CEM POR WITHOUTXRAY WIRE,SUP-2252417,CDM,C1776,CPT,0278,RC,,,,both,,,5542.10,3602.36,,,,,,,,,,,,,
PLATE BNE L421MM 18 H ST PROX FEM S STL HK LO PROF LOK COMPR,SUP-2186069,CDM,C1713,HCPCS,0278,RC,,,,both,,,5925.78,3851.76,,,,,,,,,,,,,
CATHETER PERITONEAL 110 CM RADIOPAQUE W/ 16 SLT,SUP-2851310,CDM,C1729,HCPCS,0272,RC,,,,both,,,397.05,258.08,,,,,,,,,,,,,
CATHETER VENT DRNGE L91CM OD2.54MM ID1.27CM 90DEG CLS PRSS,SUP-2243779,CDM,C1729,HCPCS,0272,RC,,,,both,,,843.94,548.56,,,,,,,,,,,,,
PLATE BNE L94MM 6 H L SUP ANT CLAV S STL LOK COMPR,SUP-2184140,CDM,C1713,HCPCS,0278,RC,,,,both,,,2668.37,1734.44,,,,,,,,,,,,,
GUIDEWIRE VASC GLIDEWIRE 350CM 0.035IN NIT POLYUR 45 ANGLED,SUP-2535550,CDM,C1769,HCPCS,0272,RC,,,,both,,,245.86,159.81,,,,,,,,,,,,,
BALL TIP PRB DBL END,SUP-2232071,CDM,2720000010,LOCAL,0272,RC,,,,both,,,599.74,389.83,,,,,,,,,,,,,
PLATE BNE THK1.3MM 6 H HND T SHP LOK TRILOK FOR 2MM SCR,SUP-2267936,CDM,C1713,HCPCS,0278,RC,,,,both,,,2744.36,1783.83,,,,,,,,,,,,,
SPLINT WRST LOOP LCK CLOSURE SM 10 IN RT VELCRO PROCARE,SUP-2196996,CDM,L3809,HCPCS,0274,RC,,,,both,,,19.44,12.64,,,,,,,,,,,,,
PLATE BONE ORBITAL FLOOR LARGE 0.4 MM LEFT SUBCONDYLAR PRECO,SUP-2837771,CDM,C1713,HCPCS,0278,RC,,,,both,,,6143.41,3993.22,,,,,,,,,,,,,
COLLAR CERV ADJ SM AD 10-20 IN 2 IN W/ PD MIAMI J,SUP-2196886,CDM,L0174,HCPCS,0272,RC,,,,both,,,143.56,93.31,,,,,,,,,,,,,
PLATE SPNL W27.5MM ANT CERV ATLNTS VISN ELITE,SUP-2287284,CDM,C1713,HCPCS,0278,RC,,,,both,,,1789.80,1163.37,,,,,,,,,,,,,
SUPPORT ORTHOT LOWER EXTREMITY PELV,SUP-2435690,CDM,L2650,HCPCS,0274,RC,,,,both,,,391.78,254.66,,,,,,,,,,,,,
SYSTEM INTRO ACUSTK II L 60 CM DIA 0.018 IN TIP L 7.5 CM SS,SUP-2147726,CDM,C1887,HCPCS,0272,RC,,,,both,,,84.78,55.11,,,,,,,,,,,,,
LINER ACET OD37MM ID28MM M2A RINGLOK,SUP-2405939,CDM,C1776,CPT,0278,RC,,,,both,,,5366.26,3488.07,,,,,,,,,,,,,
PLATE BNE CRV 4.5X439 MM RT CNDYL 22 HOLE VA LCK STRL VALCP,SUP-2789400,CDM,C1713,HCPCS,0278,RC,,,,both,,,9063.14,5891.04,,,,,,,,,,,,,
KIT DRAINAGE VONSONNENBERG SUMP L 30 CM DIA12 FR GUIDEWIRE,SUP-2142256,CDM,C1729,HCPCS,0272,RC,,,,both,,,323.45,210.24,,,,,,,,,,,,,
"HC New Pt, Outpt Visit Level 2|MULTIPLE OUTPATIENT HOSPITAL E/M ENCOUNTERS ON THE SAME DATE",PX-7619920200,CDM,99202,CPT,0761,RC,,,27,outpatient,,,363.00,235.95,,,,,,,,,,,,,
GUIDEWIRE ORTH L 16 IN DIA2.5 MM LG TROCAR TIP STRL DISP,SUP-2934627,CDM,C1769,HCPCS,0272,RC,,,,both,,,354.82,230.63,,,,,,,,,,,,,
FIBER LASER HOLMIUM 1000 OLYMPUS,SUP-2885433,CDM,2720000010,LOCAL,0272,RC,,,,both,,,587.18,381.67,,,,,,,,,,,,,
SET TUBING THERMOABLATION GENESYS HTA PROCERVA HYSTEROSCOPIC ENDOMETRIAL W/CASSETTE DRAIN BAG SHEATH 5ST/BX,SUP-2138889,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4828.69,3138.65,,,,,,,,,,,,,
CAGE SPNL LORDTC 10-30 DEG 22X50X16 MM STAND-ALONE SAHARA,SUP-2520312,CDM,C1889,HCPCS,0278,RC,,,,both,,,44854.90,29155.68,,,,,,,,,,,,,
INTRODUCER HEMSTAS 8FR L85CM GWIRE 0.038IN 7CM J W/ DIL FAST,SUP-2355579,CDM,C1894,HCPCS,0272,RC,,,,both,,,167.99,109.19,,,,,,,,,,,,,
PLATE BNE L267MM THK3.4MM 20 H BILAT S STL STR LOK COMPR,SUP-2185158,CDM,C1713,HCPCS,0278,RC,,,,both,,,2262.87,1470.87,,,,,,,,,,,,,
DEFIBRILLATOR CARD W5.37XH7.79CM D0.99CM 2 CHMBR DR IS-1,SUP-2149169,CDM,C1721,HCPCS,0275,RC,,,,both,,,53361.16,34684.75,,,,,,,,,,,,,
DIST LAT HUM LCK PLATE 7H,SUP-2464842,CDM,C1713,HCPCS,0278,RC,,,,both,,,2545.97,1654.88,,,,,,,,,,,,,
ONDANSETRON HCL 4 MG PO TABS,RX-10778,CDM,Q0162,HCPCS,0637,RC,57237-0075-30,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
HC Eosinophil Smear Sputum,PX-3008599966,CDM,85999,CPT,0300,RC,,,,both,,,237.00,154.05,,,,,,,,,,,,,
ADAPTER FEM TI FEM LUERLOCK COMPR OSS,SUP-2406934,CDM,C1776,CPT,0278,RC,,,,both,,,2062.98,1340.94,,,,,,,,,,,,,
ANCHOR SUT L14.5MM OD3MM 2 INSRTR HNDL SHLDR PLDLA,SUP-2121581,CDM,C1713,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
BRACE ORTH SH UNIV KNEE FAST HNG ROM STRP CLSR FOAM AD UNISX,SUP-2196518,CDM,L1810,HCPCS,0274,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
CAGE SPNL 27X11X9 IN CONCORDE BULL,SUP-2255187,CDM,C1889,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
CRYOABLATION KIT PROST HE-THAW ICEROD,SUP-2225659,CDM,C2618,HCPCS,0272,RC,,,,both,,,11480.63,7462.41,,,,,,,,,,,,,
HC Sed Rate,PX-3058565200,CDM,85652,CPT,0305,RC,,,,both,,,161.00,104.65,,,,,,,,,,,,,
PLATE BNE 2 Y 1.4 MM 18 HOLE LCK 6-6-6 TI BABY GORILLA,SUP-2750964,CDM,C1713,HCPCS,0278,RC,,,,both,,,3725.61,2421.65,,,,,,,,,,,,,
PLATE BONE L THK1.5MM 6X24X6 H MAND TI LCKING DBL ANG FOR,SUP-2191270,CDM,C1713,HCPCS,0278,RC,,,,both,,,9466.79,6153.41,,,,,,,,,,,,,
GRAFT VASC FLIXENE L 30 CM DIA 7 MM EPTFE GRAD REINF 3 LAYR,SUP-2669712,CDM,C1768,CPT,0278,RC,,,,both,,,3448.44,2241.49,,,,,,,,,,,,,
BAND CIR L125MM 2X0.75MM 4.0,SUP-2129433,CDM,C1784,HCPCS,0278,RC,,,,both,,,200.18,130.12,,,,,,,,,,,,,
SUPPORT ORTHOT FT HEEL STBL PLAS SIL,SUP-2435713,CDM,L3170,HCPCS,0274,RC,,,,both,,,144.00,93.60,,,,,,,,,,,,,
COMPONENT TOT SHLDR RT GUIDE BNE MODEL COMPHSVE,SUP-2435449,CDM,C1776,CPT,0278,RC,,,,both,,,4239.00,2755.35,,,,,,,,,,,,,
PROSTHESIS PENILE SCROT ALPHA 1 CYL,SUP-2300754,CDM,C1813,HCPCS,0278,RC,,,,both,,,18196.30,11827.59,,,,,,,,,,,,,
DOXYCYCLINE HYCLATE 100 MG PO CAPS,RX-2623,CDM,6370000000,HCPCS,0637,RC,60687-0513-65,NDC,,both,1,UN,7.60,4.94,,,,,,,,,,,,,
PLATE BNE L74MM 9 H L LAT POST HUM TIM LO PROF RIG ALPS,SUP-2411721,CDM,C1713,HCPCS,0278,RC,,,,both,,,4227.70,2748.00,,,,,,,,,,,,,
SUPPORT ORTHOT FT HEEL STBL PLAS SIL,SUP-2435713,CDM,L3170,HCPCS,0272,RC,,,,both,,,144.00,93.60,,,,,,,,,,,,,
COMPONENT TOT HIP MH GRIPTION,SUP-2257833,CDM,C1776,CPT,0278,RC,,,,both,,,722.20,469.43,,,,,,,,,,,,,
SUPPORT ORTHOT HND CUST STRP W/O JT FABRICATED SFT INTFACE,SUP-2435780,CDM,L3919,HCPCS,0272,RC,,,,both,,,697.80,453.57,,,,,,,,,,,,,
GRAFT HUM TISS W4XL4CM THK.4-.8MM ACELLULAR DERM MTRX MESH,SUP-2402503,CDM,Q4126,HCPCS,0636,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
ALLOGRAFT BNE FEM SHFT 160-200 MMX0.3 CM FD,SUP-2717849,CDM,C1762,CPT,0278,RC,,,,both,,,6319.16,4107.45,,,,,,,,,,,,,
SCREW SPNL L35MM DIA5MM TI UNIAXIAL FOR 5.5MM ROD CDH LEG,SUP-2288039,CDM,C1713,HCPCS,0278,RC,,,,both,,,1940.52,1261.34,,,,,,,,,,,,,
KNIFE SINGLE-PIECE ANNULOTOMY,SUP-2889567,CDM,2720000010,LOCAL,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
COMPONENT FEM DSTL E 8.5 CM RT KNEE POROUS MAK RS OSS,SUP-2449861,CDM,C1776,CPT,0278,RC,,,,both,,,18128.79,11783.71,,,,,,,,,,,,,
KIT INSRT AD PED VEN GWIRE L180CM DIA0038IN STP VES DIL 8FR,SUP-2282870,CDM,C1769,HCPCS,0272,RC,,,,both,,,276.32,179.61,,,,,,,,,,,,,
STENT BILI PRECIS L 30 MM DIA 9 MM CATH L 135 CM DIA 6 FR,SUP-2155713,CDM,C1876,HCPCS,0278,RC,,,,both,,,5829.10,3788.91,,,,,,,,,,,,,
HC E/M Crit Care Each Addit 30min,PX-4509929200,CDM,99292,CPT,0450,RC,,,,inpatient,,,362.00,235.30,,,,,,,,,,,,,
BRIMONIDINE TARTRATE 0.15 % OP SOLN,RX-31158,CDM,6370000000,HCPCS,0637,RC,61314-0144-05,NDC,,both,5,ML,690.10,448.56,,,,,,,,,,,,,
SUPPORT ORTHOT HND FNGR W/ELASTIC FNGR CTRL PREFABRICATED,SUP-2435774,CDM,L3912,HCPCS,0274,RC,,,,both,,,271.45,176.44,,,,,,,,,,,,,
SUPPORT ORTHOT HIP JT LOWER EXTREMITY PELV CTRL FREE,SUP-2435682,CDM,L2600,HCPCS,0272,RC,,,,both,,,603.82,392.48,,,,,,,,,,,,,
DECITABINE 50 MG/10ML IV (WET SOLR VIAL),RX-43076364,CDM,J0894,HCPCS,0636,RC,67457-0316-25,NDC,,both,1,UN,1137.60,739.44,,,,,,,,,,,,,
BUR SURG L7.6MM DIA6MM LNG FLUT DR CUT TPS,SUP-2363386,CDM,2720000010,LOCAL,0272,RC,,,,both,,,222.00,144.30,,,,,,,,,,,,,
BRACE ORTH LACE CLOSURE SM 5.5X6.25 IN WRST RT SPECTR,SUP-2319268,CDM,L3931,HCPCS,0272,RC,,,,both,,,26.75,17.39,,,,,,,,,,,,,
BLADE SCRDRVR 2.5/2.8 HD7 AO,SUP-2267811,CDM,2720000010,LOCAL,0272,RC,,,,both,,,685.46,445.55,,,,,,,,,,,,,
PLATE BNE 6 H TI ALLOY 2ND-3RD TMT NS LEOS,SUP-2933476,CDM,C1713,HCPCS,0278,RC,,,,both,,,5840.40,3796.26,,,,,,,,,,,,,
SCREW BNE ST 2X20 MM CRTX FT W/ FLUT TIP TI NS,SUP-2189376,CDM,C1713,HCPCS,0278,RC,,,,both,,,196.25,127.56,,,,,,,,,,,,,
PROSTHESIS 16F 5MM SPEC LEN INDWL VOICE,SUP-2242346,CDM,L8509,HCPCS,0272,RC,,,,both,,,916.88,595.97,,,,,,,,,,,,,
TUBE VENT SHEEHY 1.27 MM PHOSPHORYLCHOLINE COAT SIL 510132C,SUP-2535101,CDM,L8699,HCPCS,0278,RC,,,,both,,,37.55,24.41,,,,,,,,,,,,,
CONNECTOR XLNK 40-50MM SPNL POST ADJ ST360,SUP-2212637,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
CATHETER HD SHT TERM 14 FRX20 CM MAX BARR TY 400XL STR TAPR,SUP-2550545,CDM,C1752,HCPCS,0278,RC,,,,both,,,449.02,291.86,,,,,,,,,,,,,
PLATE BONE CRANIAL 2 HOLE STRAIGHT 15.4X3.4MM TITANIUM NEURO,SUP-2821913,CDM,C1713,HCPCS,0278,RC,,,,both,,,79.76,51.84,,,,,,,,,,,,,
PROSTHESIS OTO L4.25MM SHFT OD0.4MM TI BILAT MID EAR STAP,SUP-2312802,CDM,L8613,CPT,0278,RC,,,,both,,,757.87,492.62,,,,,,,,,,,,,
PLATE BNE L230MM 10 H NONSTERILE L DST FEM LOK FOR 4.5MM,SUP-2348456,CDM,C1713,HCPCS,0278,RC,,,,both,,,10797.36,7018.28,,,,,,,,,,,,,
NITROGLYCERIN IV BOLUS,RX-4081329,CDM,J2305,HCPCS,0636,RC,00338-1049-02,NDC,,both,250,ML,129.40,84.11,,,,,,,,,,,,,
HC X-Ray Specimen,PX-3207609800,CDM,76098,CPT,0320,RC,,,,inpatient,,,566.00,367.90,,,,,,,,,,,,,
FOOTPLATE EXT FIX 180 MM FULL DBL ROW STRL TRUELOK TL-HEX,SUP-2875382,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6084.38,3954.85,,,,,,,,,,,,,
CYCLOSPORINE 0.05 % OP EMUL,RX-35209,CDM,6370000000,HCPCS,0637,RC,00378-8760-98,NDC,,both,1,UN,17.30,11.24,,,,,,,,,,,,,
CABLE ORTH SWAGE 2 MM RCS COCR 745320,SUP-2450891,CDM,C1713,HCPCS,0278,RC,,,,both,,,841.52,546.99,,,,,,,,,,,,,
SUPPORT ORTHOT HND FNGR W/ELASTIC FNGR CTRL PREFABRICATED,SUP-2435774,CDM,L3912,HCPCS,0272,RC,,,,both,,,271.45,176.44,,,,,,,,,,,,,
METHYLNALTREXONE BROMIDE 12 MG/0.6ML SC SOLN,RX-91651,CDM,J2212,HCPCS,0636,RC,65649-0551-02,NDC,,both,0.4,ML,651.40,423.41,,,,,,,,,,,,,
STEM FEM TRI-SLOT 8 LNG 12X255 MM LT HIP BOW REV PRSS FT,SUP-2374196,CDM,C1776,CPT,0278,RC,,,,both,,,17751.05,11538.18,,,,,,,,,,,,,
INSERT TIBIALXSM THK21MM UNIV KNEE HNG POST STBL BEAR PRI,SUP-2252653,CDM,C1776,CPT,0278,RC,,,,both,,,7520.30,4888.19,,,,,,,,,,,,,
SCREW BNE L35MM THRD 3.5MM HD 4.5MM TI LNG THRD CANN HDLESS,SUP-2389530,CDM,C1713,HCPCS,0278,RC,,,,both,,,973.40,632.71,,,,,,,,,,,,,
CONN PL W/THD ED 5HLS 135,SUP-2818042,CDM,C1713,HCPCS,0278,RC,,,,both,,,2049.82,1332.38,,,,,,,,,,,,,
RETROGRADE FEMORAL NAIL 11MMX26CM,SUP-2829134,CDM,C1713,HCPCS,0278,RC,,,,both,,,7520.30,4888.19,,,,,,,,,,,,,
LEUPROLIDE ACETATE (PED) 7.5 MG IM KIT,RX-27123,CDM,J1950,HCPCS,0636,RC,00074-2108-03,NDC,,both,1,UN,12458.90,8098.28,,,,,,,,,,,,,
TUBE SCTN 6FR DIA 8INL TRDRP TPRD STRGHT MAL,SUP-2484865,CDM,C1713,HCPCS,0278,RC,,,,both,,,454.42,295.37,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC MAXBARR 5FR 55CM 1 LUMAN R 9175108D,SUP-2632695,CDM,C1751,HCPCS,0278,RC,,,,both,,,649.98,422.49,,,,,,,,,,,,,
TM TIBIAL CONE LARGE 55 X 36 LEFT,SUP-2502241,CDM,C1776,CPT,0278,RC,,,,both,,,9558.16,6212.80,,,,,,,,,,,,,
SPLINT WR AD SM FOR 5.5-6.5IN STRP L4IN VENT ELAS,SUP-2324483,CDM,L3908,HCPCS,0272,RC,,,,both,,,43.27,28.13,,,,,,,,,,,,,
GRAFT BNE SUB 15CC 01 2MM CORT CANC MIX MORSELIZED GRAN FRZ,SUP-2307060,CDM,C1713,HCPCS,0278,RC,,,,both,,,965.80,627.77,,,,,,,,,,,,,
CRANIAL ACCESS KIT 5.31 MM W/ DRUG DRL BIT NO RAZOR,SUP-2852686,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1231.98,800.79,,,,,,,,,,,,,
PLATE BNE SM T SHP REDUC FOR TEMP FIX,SUP-2315956,CDM,C1713,HCPCS,0278,RC,,,,both,,,2108.51,1370.53,,,,,,,,,,,,,
BIT REPROC DRL CANN TAP AO CPL 2.1MM,SUP-2653150,CDM,2720000010,LOCAL,0272,RC,,,,both,,,409.24,266.01,,,,,,,,,,,,,
GUIDEWIRE SURG PED DIA1.6MM CO CHROM THRD TRCR TIP,SUP-2318875,CDM,C1769,HCPCS,0272,RC,,,,both,,,155.62,101.15,,,,,,,,,,,,,
PLATE BONE W10XL58MM THK3.3MM HK D15MM 6 H LT CLAV S STL LCK,SUP-2185831,CDM,C1713,HCPCS,0278,RC,,,,both,,,2294.71,1491.56,,,,,,,,,,,,,
SET FUS NAIL RT FEM TIB KNEE CO CHROM MOLYBDENUM UHMWPE MOD,SUP-2265070,CDM,C1776,CPT,0278,RC,,,,both,,,17785.59,11560.63,,,,,,,,,,,,,
PLATE BONE L146MM BLDE W4.8XL25MM 95DEG 8 H STRL HIP S STL,SUP-2186774,CDM,C1713,HCPCS,0278,RC,,,,both,,,55.80,36.27,,,,,,,,,,,,,
CATHETER ABLAT 7FR L110CM 2-5-2MM SPC 8MM TIP 1MM BND QPLR,SUP-2357037,CDM,C1733,HCPCS,0272,RC,,,,both,,,2904.50,1887.92,,,,,,,,,,,,,
CATHETER PTA BAL 0.035 IN OTW CATH LEN 80CM BAL SZ 10MMX20MM,SUP-2265999,CDM,C1725,HCPCS,0272,RC,,,,both,,,413.70,268.90,,,,,,,,,,,,,
OSTEOTOME ACET 66MM CVD STRL FOR GRY SYS,SUP-2364387,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1142.96,742.92,,,,,,,,,,,,,
DEVICE DCOMPR 8MM GRY ALUM TI VANADIUM INTERLAMINAR,SUP-2320315,CDM,C1889,HCPCS,0278,RC,,,,both,,,14915.00,9694.75,,,,,,,,,,,,,
ROD SPNL L35MM POST PEDCL TI LORDOSED VIPER 2,SUP-2255064,CDM,C1713,HCPCS,0278,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
SCREW BNE LCK FIX BOLT,SUP-2609714,CDM,C1713,HCPCS,0278,RC,,,,both,,,2061.66,1340.08,,,,,,,,,,,,,
HC Labor and Delivery Epidural,PX-3700000025,CDM,3700000025,LOCAL,0370,RC,,,,inpatient,,,641.00,416.65,,,,,,,,,,,,,
APPLIER INT CLP MULT FIRE SM MED 5 MMX31 CM CHALLENGER TIP,SUP-2852455,CDM,C1889,HCPCS,0278,RC,,,,both,,,6200.43,4030.28,,,,,,,,,,,,,
PLATE BNE H0.6MM BAR L12MM 100DEG 6 H R MID FACE G TI L,SUP-2366302,CDM,C1713,HCPCS,0278,RC,,,,both,,,624.23,405.75,,,,,,,,,,,,,
NAIL INT FIX L20MM DIA3.5MM 8MM OFFSET HD 96L/4D PLA,SUP-2166735,CDM,C1713,HCPCS,0278,RC,,,,both,,,662.76,430.79,,,,,,,,,,,,,
KIT RF MULT COOLED INCL PRB INTRO BURET DISP COOLIEF,SUP-2236768,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4176.20,2714.53,,,,,,,,,,,,,
SHEATH LD INTRO SAFSHTH L 25 CM DIA 9 FR GUIDEWIRE L 80 CM,SUP-2329848,CDM,C1894,HCPCS,0272,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
PLATE BONE W18XL30MM 5 H MIDFOOT TITANIUMXCOMPRESSION FOR,SUP-2225438,CDM,C1713,HCPCS,0278,RC,,,,both,,,4775.94,3104.36,,,,,,,,,,,,,
PLATE BONE ANGLED 1.5 MM 3X3 HOLE PRECONTOURED TITANIUM SILV,SUP-2837750,CDM,C1713,HCPCS,0278,RC,,,,both,,,3661.87,2380.22,,,,,,,,,,,,,
PLATE BNE THK 2 MM SCREW DIA2/2.3 MM MED GRD IV TI DBL,SUP-2936816,CDM,C1713,HCPCS,0278,RC,,,,both,,,6791.82,4414.68,,,,,,,,,,,,,
MEMBRANE DURA 4X5IN REP SUTURABLE DURAMATRIX,SUP-2165132,CDM,C1763,HCPCS,0278,RC,,,,both,,,2998.45,1948.99,,,,,,,,,,,,,
SCREW BONE L65MM THRD DIA2.7MM HD DIA4.3MM COR DIA2MM PITCH,SUP-2349470,CDM,C1713,HCPCS,0278,RC,,,,both,,,761.45,494.94,,,,,,,,,,,,,
KWIRE THRD RECON 3.2X400MM,SUP-2465619,CDM,2720000010,LOCAL,0272,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
NEEDLE CENTESIS 19GA CATH 5FR 10CM 4 SIDEPRT FOR,SUP-2168453,CDM,C1729,HCPCS,0272,RC,,,,both,,,46.41,30.17,,,,,,,,,,,,,
SHEET THERMOPLASTIC SPLNT 1/16X12X18IN 4 PER CA SLD BLUSH,SUP-2324644,CDM,L4350,HCPCS,0274,RC,,,,both,,,85.00,55.25,,,,,,,,,,,,,
CATHETER THROMCTMY ANGIOJET ULTRA SOLENT OMNI L 120 CM DIA 6,SUP-2142039,CDM,C1757,HCPCS,0272,RC,,,,both,,,13140.90,8541.58,,,,,,,,,,,,,
ROD SPNL POST CRV PREBENT SMOOTH TI ALLY OD5.5MM L40MM EBI,SUP-2415868,CDM,C1713,HCPCS,0278,RC,,,,both,,,1019.62,662.75,,,,,,,,,,,,,
DRILL ARTHSCP TOP HAT CORACOID,SUP-2256888,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1946.80,1265.42,,,,,,,,,,,,,
CATHETER DRNGE 8.5FR L25CM UTHANE DAWSON MUELLER 5 SIDEPRT,SUP-2168489,CDM,C1729,HCPCS,0272,RC,,,,both,,,200.46,130.30,,,,,,,,,,,,,
CENTRALIZER STEM DIA14MM DST FEM HIP NP CEM PFC SIG,SUP-2253267,CDM,C1776,CPT,0278,RC,,,,both,,,422.02,274.31,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9% INTERMITTENT INFUSION,RX-40840102,CDM,2580000003,HCPCS,0250,RC,00338-0049-11,NDC,,both,250,ML,123.30,80.14,,,,,,,,,,,,,
PLATE BONE L146MM 6 H NONSTERILE RT MEDL DSTL TIB LCK FOR,SUP-2348486,CDM,C1713,HCPCS,0278,RC,,,,both,,,12868.51,8364.53,,,,,,,,,,,,,
IMMUNE GLOBULIN (HUMAN) 5 GM/50ML IV SOLN,RX-104396,CDM,J1459,HCPCS,0636,RC,44206-0436-05,NDC,,both,50,ML,2830.00,1839.50,,,,,,,,,,,,,
SHEATH INTRO DIA10 FR VLV SET STRL,SUP-2118983,CDM,C1894,HCPCS,0272,RC,,,,both,,,103.62,67.35,,,,,,,,,,,,,
SYSTEM DRAINAGE 85-125 MM H2O 325-445 MM H2O TALL AD GRN,SUP-2851476,CDM,C1729,HCPCS,0272,RC,,,,both,,,4289.27,2788.03,,,,,,,,,,,,,
STEM FEM SZ 1 L115MM DIA11MM NK L31MM 34 OFFSET 132DEG ANG 62610003] STRYKER ORTHOPEDICS HOWM],SUP-2375304,CDM,C1776,CPT,0278,RC,,,,both,,,13455.53,8746.09,,,,,,,,,,,,,
PLATE BNE TIB 3.5 MM LAT PROX SET PERI-LOC,SUP-2351408,CDM,C1713,HCPCS,0278,RC,,,,both,,,5809.00,3775.85,,,,,,,,,,,,,
SCREW BNE L16MM TIP DIA32MM BK END DIA35MM GWIRE 0035IN,SUP-2106857,CDM,C1713,HCPCS,0278,RC,,,,both,,,1821.20,1183.78,,,,,,,,,,,,,
RECON PLATE 4X61MM 4.5MM,SUP-2820860,CDM,C1713,HCPCS,0278,RC,,,,both,,,2847.82,1851.08,,,,,,,,,,,,,
SCREW BONE LOCKING 3.5MM DIA 46MML CORTICAL STERILE,SUP-2588150,CDM,C1713,HCPCS,0278,RC,,,,both,,,115.93,75.35,,,,,,,,,,,,,
MATRIX WOUND THERAGENESIS MESHED 4X6CM,SUP-2738095,CDM,A2008,HCPCS,0636,RC,,,,both,,,7173.17,4662.56,,,,,,,,,,,,,
PRELUDE SHRT SHTH INTRDCR 8FR 4CM .035X50CM STNLSS STEEL 3MM,SUP-2463174,CDM,C1894,HCPCS,0272,RC,,,,both,,,75.36,48.98,,,,,,,,,,,,,
SCREW BNE OP LOK 55 X 36MM,SUP-2401214,CDM,C1713,HCPCS,0278,RC,,,,both,,,722.20,469.43,,,,,,,,,,,,,
PIN DRL L75MM DIA3.2MM HEX 2.5MM TRCR TIP DISP FOR PERSONA,SUP-2342258,CDM,2720000010,LOCAL,0272,RC,,,,both,,,70.65,45.92,,,,,,,,,,,,,
PIN GUIDE TILINK-P,SUP-2937175,CDM,C1713,HCPCS,0278,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
GRAFT ALLODERM DERMAL MATRIX 16CM X 20CM EXTRA THICK,SUP-2848898,CDM,Q4116,HCPCS,0636,RC,,,,both,,,32260.36,20969.23,,,,,,,,,,,,,
BIT DRL CANN 6 MM KNEE FOR ACL/PCL STRL DISP,SUP-2849068,CDM,2720000010,LOCAL,0272,RC,,,,both,,,851.63,553.56,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA PLU MAXBARR 5FR S1385108D4,SUP-2632823,CDM,C1751,HCPCS,0278,RC,,,,both,,,884.54,574.95,,,,,,,,,,,,,
SCREW BONE L95MM DIA5MM PARTIALLY THRD FOR ARTH NAIL SYS,SUP-2244343,CDM,C1713,HCPCS,0278,RC,,,,both,,,1770.52,1150.84,,,,,,,,,,,,,
PLATE BNE L58MM 5 H BILAT S STL STR RECON NONLOCKING,SUP-2197670,CDM,C1713,HCPCS,0278,RC,,,,both,,,869.37,565.09,,,,,,,,,,,,,
TUBE TRACH 8X120 MM CUST SHILEY,SUP-2264411,CDM,A7521,HCPCS,0278,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
BLOCK VERSYS CEM/REV/CALCAR BUILD-UP 13/15X20MM,SUP-2504502,CDM,C1776,CPT,0278,RC,,,,both,,,1172.79,762.31,,,,,,,,,,,,,
CATHETER INFUSION OCCL 4 FRX135 CM 30 CM 1 CC 20 CC FOUNTAIN,SUP-2302565,CDM,C1751,HCPCS,0278,RC,,,,both,,,379.63,246.76,,,,,,,,,,,,,
STAPLER INT CIR XLN MED THCK 25 MM 3/3.5/4 MM TRI-STAPLE EEA,SUP-2858015,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4865.84,3162.80,,,,,,,,,,,,,
PLATE BNE ANGLED BLADE 130 DEG SM 4.5X104 MM 50 MM 6 NS,SUP-2653580,CDM,C1713,HCPCS,0278,RC,,,,both,,,2073.40,1347.71,,,,,,,,,,,,,
COUPLING REPROC EXT FIX 5/8/11 MM 4/5/6 MM PIN TO ROD,SUP-2516723,CDM,2720000010,LOCAL,0272,RC,,,,both,,,685.31,445.45,,,,,,,,,,,,,
PLATE CRAN 100X80X40 MM PT SPEC IMPL PEEK,SUP-2860139,CDM,C1713,HCPCS,0278,RC,,,,both,,,32398.52,21059.04,,,,,,,,,,,,,
MEMBRANE CLLGN DURA REP DURAMATRIX ONLAY + 1IN X 3IN,SUP-2165124,CDM,C1763,HCPCS,0278,RC,,,,both,,,1320.87,858.57,,,,,,,,,,,,,
CLAMP EXT FIX MULTIPIN UNIV GEM FIX NS GALAXY LTX,SUP-2875228,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4361.93,2835.25,,,,,,,,,,,,,
SCREW BONE L8MM OD1.9MM TI CANC ST FULL THRD CROSS FIT SM,SUP-2364076,CDM,C1713,HCPCS,0278,RC,,,,both,,,204.41,132.87,,,,,,,,,,,,,
GRAFT BNE CAP ADAPT MIS,SUP-2430777,CDM,2720000010,LOCAL,0272,RC,,,,both,,,433.32,281.66,,,,,,,,,,,,,
CATHETER THOR STR 32F FIRM PVC,SUP-2227341,CDM,C1729,HCPCS,0272,RC,,,,both,,,24.46,15.90,,,,,,,,,,,,,
FIBER LASER SURG FIBER 1000 MH RND TIP HOLM SMARTSCOPE DISP,SUP-2337025,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1133.54,736.80,,,,,,,,,,,,,
TRAY PICC SUBCL 1/L 5FR 55CML SIL PWR INJ RADPQ PEEL 9918518,SUP-2632711,CDM,C1751,HCPCS,0278,RC,,,,both,,,651.24,423.31,,,,,,,,,,,,,
PLATE BNE L 76 MM SCREW DIA2.4 MM 10 H T SHP LCK NAR NS,SUP-2900512,CDM,C1713,HCPCS,0278,RC,,,,both,,,4046.83,2630.44,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 70 CM DIA 6MM STR STD WALL SLDE GDS,SUP-2525440,CDM,C1768,CPT,0278,RC,,,,both,,,1801.61,1171.05,,,,,,,,,,,,,
NAIL IM L340MM DIA13MM FEM NONLOCKING CANN,SUP-2205960,CDM,C1713,HCPCS,0278,RC,,,,both,,,14312.12,9302.88,,,,,,,,,,,,,
HC Smoke/Tobac Counsel 3-10,PX-9429940600,CDM,99406,CPT,0942,RC,,,,inpatient,,,29.00,18.85,,,,,,,,,,,,,
GRAFT BNE CHIP CRUSH FRZN CANC 1MM 8MM RANG 160CC READIGRFT,SUP-2264734,CDM,C1713,HCPCS,0278,RC,,,,both,,,5584.11,3629.67,,,,,,,,,,,,,
INSERT TIB SZ 9 THICKNESS 21MM UHMWPE KNEE PRI NEUT UNIV,SUP-2365107,CDM,C1776,CPT,0278,RC,,,,both,,,2043.51,1328.28,,,,,,,,,,,,,
PLATE BNE L 38 MM SCREW DIA2 MM 7 SHFT H TI STR COMPACT MINI,SUP-2907840,CDM,C1713,HCPCS,0278,RC,,,,both,,,2629.37,1709.09,,,,,,,,,,,,,
SCREW BONE L8MM DIA2MM TI ST GRY MATRIXMANDIBLE,SUP-2181721,CDM,C1713,HCPCS,0278,RC,,,,both,,,254.09,165.16,,,,,,,,,,,,,
ADAPTER ASPRTN ENDSCPC ULTRSND NDLE RX LOK DVCE CMPTBLE FPL,SUP-2676537,CDM,2720000010,LOCAL,0272,RC,,,,both,,,54.92,35.70,,,,,,,,,,,,,
STAPLE INT L18XW14XH14MM NIT MEMOFIX,SUP-2244265,CDM,C1713,HCPCS,0278,RC,,,,both,,,4586.63,2981.31,,,,,,,,,,,,,
PLATE BONE DUAL CMPRSSN HLX16 TTNM RCNSTRCTN F2.7MM LOK SCR,SUP-2721057,CDM,C1713,HCPCS,0278,RC,,,,both,,,1552.42,1009.07,,,,,,,,,,,,,
COMPONENT TIB SZ 2 RT MEDL LT LAT FIX BEAR CEM PRESERVATION,SUP-2251282,CDM,C1776,CPT,0278,RC,,,,both,,,5268.92,3424.80,,,,,,,,,,,,,
BONE VOID FILLERS MORSELIZED ALLOGRAFTS CORT CANC SPIERINGS,SUP-2307432,CDM,C1713,HCPCS,0278,RC,,,,both,,,3265.13,2122.33,,,,,,,,,,,,,
INSERT TIB SZ 9 THICKNESS 10MM UHMWPE KNEE PRI NEUT UNIV,SUP-2365106,CDM,C1776,CPT,0278,RC,,,,both,,,1997.42,1298.32,,,,,,,,,,,,,
PLATE BNE L 329 MM SCREW DIA 3.5/4.5 MM H 16 LT PROX FEM,SUP-2931257,CDM,C1713,HCPCS,0278,RC,,,,both,,,20318.16,13206.80,,,,,,,,,,,,,
BAR XTRAFIX 11MM CRBN 250,SUP-2495831,CDM,2720000010,LOCAL,0272,RC,,,,both,,,652.02,423.81,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY L 92 CM DIA 6 FR TIP DIA1 MM SPC,SUP-2526801,CDM,C1730,HCPCS,0272,RC,,,,both,,,359.15,233.45,,,,,,,,,,,,,
LEAD DEFIB LINOXSMART S L 60 CM SIL INSUL IRIDIUM OXIDE TIP,SUP-2138278,CDM,C1777,HCPCS,0275,RC,,,,both,,,8792.00,5714.80,,,,,,,,,,,,,
HC Rfa 1 or More Liver Tumors,PX-3614738200,CDM,47382,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
SPLINT ANK STRRP AIR AND FOAM S,SUP-2276706,CDM,L4350,HCPCS,0272,RC,,,,both,,,38.18,24.82,,,,,,,,,,,,,
PLATE BNE TIBIOTALOCALCANEAL RT 7 HOLE,SUP-2609040,CDM,C1713,HCPCS,0278,RC,,,,both,,,6494.65,4221.52,,,,,,,,,,,,,
NEOMYCIN-POLYMYXIN-HC 1 % OT SOLN,RX-19632,CDM,6370000000,HCPCS,0637,RC,24208-0631-10,NDC,,both,10,ML,377.60,245.44,,,,,,,,,,,,,
SCREW BONE LNG W/ FRE SPINNING WSHR RESRB TIB FIX INTRF,SUP-2212867,CDM,C1713,HCPCS,0278,RC,,,,both,,,1186.92,771.50,,,,,,,,,,,,,
KIT SLNG NDL PASS PERC RETRCT RNG BLNT STAY HK FOR STRESS,SUP-2138903,CDM,C1771,HCPCS,0278,RC,,,,both,,,20978.34,13635.92,,,,,,,,,,,,,
SPACER FEM NS TRAC FLX,SUP-2445536,CDM,C1776,CPT,0278,RC,,,,both,,,2303.19,1497.07,,,,,,,,,,,,,
FILLER BONE VOID 3ML CA PHOS CEM STRL IMP HYDROSET,SUP-2364371,CDM,C1713,HCPCS,0278,RC,,,,both,,,2307.90,1500.13,,,,,,,,,,,,,
LORAZEPAM 1 MG PO TABS,RX-4573,CDM,6370000000,HCPCS,0637,RC,69315-0905-05,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
CAGE VERT 37X10X6 MM MIDLN FOR VBR SYS,SUP-2320299,CDM,C1889,HCPCS,0278,RC,,,,both,,,23.02,14.96,,,,,,,,,,,,,
COMPONENT HIP CMNTLS UPLR HA LD/FX,SUP-2212770,CDM,C1776,CPT,0278,RC,,,,both,,,4082.00,2653.30,,,,,,,,,,,,,
PROSTHESIS OSS TOT L 7 MM PART L 3.65 MM DIA1.14 MM HD DIA 3,SUP-2902042,CDM,L8613,CPT,0278,RC,,,,both,,,1602.19,1041.42,,,,,,,,,,,,,
LOWER EXTREMITY KIT DISP,SUP-2365639,CDM,2720000010,LOCAL,0272,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
PLATE BONE LOCKING HOLEX2 T SHAPED LEFT DORSAL DISTAL,SUP-2723523,CDM,C1713,HCPCS,0278,RC,,,,both,,,2658.51,1728.03,,,,,,,,,,,,,
STEM TIB MID 12 MM R/L TOT ANK PLASMA COAT INBONE II,SUP-2850811,CDM,C1776,CPT,0278,RC,,,,both,,,1428.70,928.65,,,,,,,,,,,,,
GRAFT BNE SUB 10CC 50X15X7MM DEMIN BNE MTRX 3D SCFLD STRP,SUP-2335645,CDM,C9362,HCPCS,0278,RC,,,,both,,,14130.00,9184.50,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 40 CM DIA 5-8 MM EPTFE LNG TAPR STD,SUP-2669627,CDM,C1768,CPT,0278,RC,,,,both,,,528.18,343.32,,,,,,,,,,,,,
DRIVER SURG TORQUE STRL DISP STERNALOCK XP,SUP-2894509,CDM,2720000010,LOCAL,0272,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
SCREW BONE L45MM D6MM HEAD D35MM CRTCL TTNM ALLOY FIXED ANGL,SUP-2463415,CDM,C1713,HCPCS,0278,RC,,,,both,,,600.27,390.18,,,,,,,,,,,,,
KIT INTRO SHTH 6FR L10CM NDL 22GA L1.25IN 0.021IN NIT FLPY,SUP-2384833,CDM,C1894,HCPCS,0272,RC,,,,both,,,266.27,173.08,,,,,,,,,,,,,
PLATE BNE L14MM THK2MM TARSAL TI ISOLATED FUS AFP DARCO MRS,SUP-2399641,CDM,C1713,HCPCS,0278,RC,,,,both,,,2621.90,1704.23,,,,,,,,,,,,,
SET INTRO L 30 CM DIA 6 FR GUIDEWIRE 0.038 IN PTFE TEARWY,SUP-2226015,CDM,C1892,HCPCS,0272,RC,,,,both,,,143.18,93.07,,,,,,,,,,,,,
HC Placement of J-Tube,PX-3614401500,CDM,44015,CPT,0361,RC,,,,both,,,10303.00,6696.95,,,,,,,,,,,,,
SET GJ 16FR GAST 102FR JEJU 80CM MCOT DST END 100CM FULL,SUP-2167893,CDM,C1713,HCPCS,0278,RC,,,,both,,,832.07,540.85,,,,,,,,,,,,,
TAMP SURG OD6MM FOR BNE GRFT,SUP-2285247,CDM,C1713,HCPCS,0278,RC,,,,both,,,799.26,519.52,,,,,,,,,,,,,
"HC So Dihydroxyvitamin D, 1 25",PX-3018265266,CDM,82652,CPT,0301,RC,,,,both,,,229.00,148.85,,,,,,,,,,,,,
TREPHINE ORTH SZ 4MM STR SCR REM CRWN DRL,SUP-2368625,CDM,C1713,HCPCS,0278,RC,,,,both,,,2219.98,1442.99,,,,,,,,,,,,,
RING FT ID150MM EXT FIX SYS,SUP-2316277,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3463.11,2251.02,,,,,,,,,,,,,
KNIFE 3722022 FLAP 2X5MM BLADE,SUP-2702664,CDM,2720000010,LOCAL,0272,RC,,,,both,,,442.80,287.82,,,,,,,,,,,,,
WIRE FIX THRD 1.6X150 MM KIRSCHNER,SUP-2316487,CDM,C1713,HCPCS,0278,RC,,,,both,,,141.30,91.84,,,,,,,,,,,,,
VALVE SHUNT L23.7MM 20CM H2O PRSS TI 2.0 CONN GRAVITATIONAL,SUP-2711652,CDM,C1889,HCPCS,0278,RC,,,,both,,,4501.28,2925.83,,,,,,,,,,,,,
SCREW BNE L 3.5 MM DIA1.5 MM STRL DISP LORENZ STRL TRAC,SUP-2934950,CDM,C1713,HCPCS,0278,RC,,,,both,,,3111.74,2022.63,,,,,,,,,,,,,
EXTENDER BNE GRFT 2 MM 10 CC GRAN GROWTH FACTOR OSTEOAMP,SUP-2138492,CDM,C1713,HCPCS,0278,RC,,,,both,,,5548.69,3606.65,,,,,,,,,,,,,
CATHETER IV DL 5 FR DOT KT MBP BIOP PC NG POWERMIDLINE,SUP-2626740,CDM,C1751,HCPCS,0278,RC,,,,both,,,540.08,351.05,,,,,,,,,,,,,
CATHETER CV SET 025 5 FRX12 CM 3L CUTLM501JRSCABRMHC,SUP-2759859,CDM,C1751,HCPCS,0278,RC,,,,both,,,362.86,235.86,,,,,,,,,,,,,
INTRODUCER SHTH 16 FRX14 CM SET CS ACCS W/O CRV PEELWY,SUP-2357073,CDM,C1892,HCPCS,0272,RC,,,,both,,,25.12,16.33,,,,,,,,,,,,,
STENT PIPELINE FLEX EMBOL DEVICE W/ SHIELD TECH 2.5MMX10MM,SUP-2854137,CDM,C2625,HCPCS,0278,RC,,,,both,,,43925.46,28551.55,,,,,,,,,,,,,
GRAFT BONE CRUSH FRZ DRY DEMIN CANC 0.1MM-4MM RANG 30CC,SUP-2294025,CDM,C1713,HCPCS,0278,RC,,,,both,,,1343.92,873.55,,,,,,,,,,,,,
SPLINT ORTH AD W21XL80CM PVC DURABLE SGL CHMBR LNG ARM FOR,SUP-2309123,CDM,L3908,HCPCS,0274,RC,,,,both,,,149.43,97.13,,,,,,,,,,,,,
HC Nasotracheal Catheter Aspiration,PX-7613172000,CDM,31720,CPT,0761,RC,,,,inpatient,,,99.00,64.35,,,,,,,,,,,,,
TUBE VNTLTN SHHY CLLR BTTN 127MM ID 15MML FLRPLSTC EAR F/M,SUP-2681455,CDM,L8699,HCPCS,0278,RC,,,,both,,,22.04,14.33,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED UPLR CHIPZIMUNI] ZIMMER BIOMET INC],SUP-2212526,CDM,C1776,CPT,0278,RC,,,,both,,,4042.75,2627.79,,,,,,,,,,,,,
RELOAD STPL L60MM THCK TISS GRN W/ GRIPPING SURF TECHNOLOGY,SUP-2283358,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1410.43,916.78,,,,,,,,,,,,,
SCREW BNE L 44 MM DIA 3 MM THRD L 11 MM TI CANN COMPR HDLSS,SUP-2905718,CDM,C1713,HCPCS,0278,RC,,,,both,,,1486.54,966.25,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 40 CM DIA 6 MM STR STD WALL STRL,SUP-2396266,CDM,C1768,CPT,0278,RC,,,,both,,,2505.72,1628.72,,,,,,,,,,,,,
NAIL IM FEM 15X270 MM RETROGRADE PHOENIX,SUP-2606411,CDM,C1713,HCPCS,0278,RC,,,,both,,,6672.50,4337.12,,,,,,,,,,,,,
PLATE BNE L 241 MM SCREW DIA 3.5/4.5 MM 9 H LT TROCHANTERIC 72586109N,SUP-2933435,CDM,C1713,HCPCS,0278,RC,,,,both,,,21121.21,13728.79,,,,,,,,,,,,,
CATHETER ETER CTRL VEN L15CM OD5FR SGL LUMN POLYUR STD SET,SUP-2167835,CDM,C1751,HCPCS,0278,RC,,,,both,,,207.71,135.01,,,,,,,,,,,,,
TUBE VENT 1.14 MM 0.76 MM 2.3 MM DONALDSON W/ TAB PC SIL,SUP-2535072,CDM,L8699,HCPCS,0278,RC,,,,both,,,37.15,24.15,,,,,,,,,,,,,
PLATE BNE L47MM 6 H TI RIG DYN LOK COMPR FOR 2.4MM SCR MOD,SUP-2191477,CDM,C1713,HCPCS,0278,RC,,,,both,,,1846.98,1200.54,,,,,,,,,,,,,
TRAY CATH HEMODIALYSI T 3 CT ACTE 15.5FR DIA 24CM MC013523MB,SUP-2633010,CDM,C1752,HCPCS,0278,RC,,,,both,,,675.10,438.81,,,,,,,,,,,,,
PANTOPRAZOLE SODIUM 40 MG IV SOLR,RX-26226,CDM,J2470,HCPCS,0636,RC,71288-0600-11,NDC,,both,1,UN,54.10,35.16,,,,,,,,,,,,,
DEFIBRILLATOR CARD 38CC W41XH76MM THK14MM L VENT DF-4 IS-4,SUP-2356330,CDM,C1882,HCPCS,0275,RC,,,,both,,,54950.00,35717.50,,,,,,,,,,,,,
PLATE BNE W23XL44MM THK1.6MM 10 H SHT L DST RAD VOLAR TI,SUP-2267967,CDM,C1713,HCPCS,0278,RC,,,,both,,,3058.36,1987.93,,,,,,,,,,,,,
GRAFT VASC W1XL10CM THK6 PLY SYNTH CROSSLINKED ELAS FOR VASC - ORDER UOM BX,SUP-2172044,CDM,C1768,CPT,0278,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
WASHER ORTH DIA 9 MM THK 2 MM TI NS RIBFIX TITAN,SUP-2905461,CDM,C1713,HCPCS,0278,RC,,,,both,,,1343.92,873.55,,,,,,,,,,,,,
ROD EXT FIX W239XL190MM DIA11MM LNG C FBR BRDG,SUP-2420186,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2154.83,1400.64,,,,,,,,,,,,,
SPLINT WRST XSM AD L8IN FOR 5 65IN L NYL LN FOAM PUL ON,SUP-2276661,CDM,L3908,HCPCS,0272,RC,,,,both,,,20.41,13.27,,,,,,,,,,,,,
PIN FIX L254MM OD3MM S STL BLNT TIP RND BVL PT SMOOTH,SUP-2342643,CDM,C1713,HCPCS,0278,RC,,,,both,,,279.46,181.65,,,,,,,,,,,,,
PLATE BNE LP 14X0.6 MM NEURO 2X2 HOLE LADDER SQ FOR SCR TI,SUP-2480794,CDM,C1713,HCPCS,0278,RC,,,,both,,,702.01,456.31,,,,,,,,,,,,,
PLATE BNE CLAV SUP,SUP-2846075,CDM,C1713,HCPCS,0278,RC,,,,both,,,6088.46,3957.50,,,,,,,,,,,,,
KIT CATH PARENCHYMA W/ TRNSDUC TIP CATH THRMSTER CAMINO BOLT,SUP-2242792,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2807.07,1824.60,,,,,,,,,,,,,
HC Treat Foot Disloc,PX-4502854000,CDM,28540,CPT,0450,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
HC Abdominal Aortogram,PX-3237562500,CDM,75625,CPT,0323,RC,,,,outpatient,,,2979.00,1936.35,,,,,,,,,,,,,
COMP FEM AUG BTN SM/LG+ 5 POS,SUP-2513640,CDM,C1776,CPT,0278,RC,,,,both,,,693.94,451.06,,,,,,,,,,,,,
"HC Exchange Nephrostomy Cath, Perc",PX-3615043500,CDM,50435,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
ALLOGRAFT BNE CHIP 4-10 MM 30 CC FD CRUSH CANC READIGRAFT,SUP-2741026,CDM,C1713,HCPCS,0278,RC,,,,both,,,1204.10,782.66,,,,,,,,,,,,,
SYSTEM SURG ABLATION ISOLATOR SYNERGY RT CRV GLIDEPATH TAPE,SUP-2124422,CDM,2720000010,LOCAL,0272,RC,,,,both,,,9420.00,6123.00,,,,,,,,,,,,,
BUR SURG L75MM DIA2MM S STL RND CUT,SUP-2284224,CDM,C1713,HCPCS,0278,RC,,,,both,,,168.12,109.28,,,,,,,,,,,,,
CLIP ANEURYSM T BAR 5MM FENESTRATED STANDARD 60 DEGREE ANGLE,SUP-2821640,CDM,C1889,HCPCS,0278,RC,,,,both,,,5892.87,3830.37,,,,,,,,,,,,,
REGULATOR SUCTION ADAPTOR TBNG,SUP-2226272,CDM,2720000010,LOCAL,0272,RC,,,,both,,,907.62,589.95,,,,,,,,,,,,,
SCREW BNE L 140 MM DIA 6.5 MM TI ST SD CANN FULL THRD RVS,SUP-2900916,CDM,C1713,HCPCS,0278,RC,,,,both,,,1250.44,812.79,,,,,,,,,,,,,
GRAFT BNE L50MM W20-24MM THICKNESS 5-30MM ILIUM TRICORT,SUP-2307165,CDM,C1713,HCPCS,0278,RC,,,,both,,,4895.26,3181.92,,,,,,,,,,,,,
GUIDEWIRE VASC L 60 CM DIA 0.018 IN TAPR L 5 CM FLX TIP 2 CM,SUP-2167573,CDM,C1769,HCPCS,0272,RC,,,,both,,,23.24,15.11,,,,,,,,,,,,,
BIT DRL L 2.09 IN DIA1.1 MM STP 5 MM SS NS DISP TRAUMAONE IQ,SUP-2935223,CDM,2720000010,LOCAL,0272,RC,,,,both,,,646.84,420.45,,,,,,,,,,,,,
PLATE BNE CALCANEAL 3.5/4X58 MM LT NS LTX,SUP-2857056,CDM,C1713,HCPCS,0278,RC,,,,both,,,6590.86,4284.06,,,,,,,,,,,,,
HALF PIN 5MMX55MM,SUP-2818216,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1663.01,1080.96,,,,,,,,,,,,,
GRAFT BNE 4X4 CM XPLUS HYDROMEMBRANE PALINGEN,SUP-2164365,CDM,C1713,HCPCS,0278,RC,,,,both,,,5024.00,3265.60,,,,,,,,,,,,,
CUP ACET M28MM DIA50MM HIP ZTT 2 S-ROM,SUP-2253171,CDM,C1776,CPT,0278,RC,,,,both,,,5887.50,3826.87,,,,,,,,,,,,,
SYSTEM MCRCTHTR INTRVNTNL 3/2.4FR OD P/D 155CML 0.021N ID PT,SUP-2652839,CDM,C1887,HCPCS,0272,RC,,,,both,,,2653.30,1724.64,,,,,,,,,,,,,
COMPONENT FEM PRIMARY X SM RT KNEE POROUS ASCNT,SUP-2407166,CDM,C1776,CPT,0278,RC,,,,both,,,10550.40,6857.76,,,,,,,,,,,,,
HC So Acetylcholn Rcptr Blckg Antb,PX-3028604266,CDM,86042,CPT,0302,RC,,,,both,,,256.00,166.40,,,,,,,,,,,,,
FOOTPLATE EXT FIX DBL HOLE 200 MM,SUP-2197269,CDM,C1713,HCPCS,0278,RC,,,,both,,,4804.20,3122.73,,,,,,,,,,,,,
PATCH DURA BIOABSRB SUB PLIABLE N IMMUNOGENIC LOOSE FIBROUS,SUP-2108184,CDM,C1763,HCPCS,0278,RC,,,,both,,,877.25,570.21,,,,,,,,,,,,,
BASEPLATE TIB SZ 4 RT W/ LCK JOURNEY LEGION,SUP-2340960,CDM,C1776,CPT,0278,RC,,,,both,,,9633.52,6261.79,,,,,,,,,,,,,
SCREW BNE L34MM DIA3.5MM PROX HUM NONLOCKING T15 LO PROF 110017734] ZIMMER BIOMET TRAUMA],SUP-2411570,CDM,C1713,HCPCS,0278,RC,,,,both,,,156.37,101.64,,,,,,,,,,,,,
TUBE ENDOTRACHEAL CONT MONITORING 8X11X323 MM VIVASIGHT-SL,SUP-2752999,CDM,2720000010,LOCAL,0272,RC,,,,both,,,543.22,353.09,,,,,,,,,,,,,
CHUCK HOFF 3 FOR PIN INSTR,SUP-2363108,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2142.74,1392.78,,,,,,,,,,,,,
KIT INSTR W/ 2.4MM GUIDEPIN SUT PASS WIRE NO2 FIBERWIRE(ORDER MULTIPLES OF 5 EA),SUP-2121448,CDM,2720000010,LOCAL,0272,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
BIT DRL QC 4.3 MM SS,SUP-2646003,CDM,2720000010,LOCAL,0272,RC,,,,both,,,329.79,214.36,,,,,,,,,,,,,
CATHETER NEPHROSTOMY SET 7/22 FRX20 CM MCOT STENT,SUP-2835671,CDM,C1729,HCPCS,0272,RC,,,,both,,,262.69,170.75,,,,,,,,,,,,,
DRILL SURG HD DIA2MM LOCON-T,SUP-2397216,CDM,2720000010,LOCAL,0272,RC,,,,both,,,593.93,386.05,,,,,,,,,,,,,
SCREW SPNL CORTICAL 5X40 MM FIX FEN X-TAB STRL VIPER PRIM,SUP-2590945,CDM,C1713,HCPCS,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
ALLOGRAFT BNE INSRT SM 11X5.5X11 MM FD DBM XPANSE,SUP-2787772,CDM,C1713,HCPCS,0278,RC,,,,both,,,2396.45,1557.69,,,,,,,,,,,,,
"HC NM Lymphatics,Lymph Gland Imaging",PX-3417819500,CDM,78195,CPT,0341,RC,,,,inpatient,,,2453.00,1594.45,,,,,,,,,,,,,
BENDING TEMPLATE FOR CALCANEAL PLATES 60MM,SUP-2548479,CDM,C1713,HCPCS,0278,RC,,,,both,,,116.90,75.98,,,,,,,,,,,,,
SCREW BNE L 26 MM DIA 3.5 MM LCK FOR PLATE NS ORTHOLOC 3DI,SUP-2900505,CDM,C1713,HCPCS,0278,RC,,,,both,,,1268.56,824.56,,,,,,,,,,,,,
SCREW BNE L85MM DIA3.7MM THRD L25MM S STL CANN CONIC,SUP-2185199,CDM,C1713,HCPCS,0278,RC,,,,both,,,430.81,280.03,,,,,,,,,,,,,
OCTREOTIDE ACETATE 10 MG IM KIT,RX-24434,CDM,J2353,HCPCS,0636,RC,00078-0811-81,NDC,,both,1,UN,10147.50,6595.87,,,,,,,,,,,,,
SYSTEM IV PRT ACC NDL 16GA APHERESIS POWERFLOW,SUP-2126744,CDM,C1788,HCPCS,0278,RC,,,,both,,,94.20,61.23,,,,,,,,,,,,,
CAP HEALING H30MM DIA30MM W/ PLUG BAHA,SUP-2165000,CDM,L8614,HCPCS,0278,RC,,,,both,,,53.38,34.70,,,,,,,,,,,,,
ALLOGRAFT BNE FEM 13 MMX0.4 CM FD CROSS SECT,SUP-2717813,CDM,C1762,CPT,0278,RC,,,,both,,,2983.00,1938.95,,,,,,,,,,,,,
STENT CAR PRECIS L 20 MM DIA 5 MM CATH L 135 CM SHTH 6 FR,SUP-2158935,CDM,C1876,HCPCS,0278,RC,,,,both,,,6217.20,4041.18,,,,,,,,,,,,,
TUBE GASTSTMY 18FR L3.4CM 1 STP BTTN,SUP-2149754,CDM,C1713,HCPCS,0278,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
SYSTEM TKR SZ 2-5 HNG LINK ASMBLY LEGION,SUP-2346313,CDM,C1776,CPT,0278,RC,,,,both,,,3541.92,2302.25,,,,,,,,,,,,,
RING EXT FIX FULL 160 MM CARBON FIBER NS,SUP-2800125,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3174.51,2063.43,,,,,,,,,,,,,
CUBE EXT FIX 5 HOLE RANCHO,SUP-2749950,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1394.16,906.20,,,,,,,,,,,,,
GRAFT HUM TISS W4XL16CM THK1MM PROC DERM CLLGN RECTANG,SUP-2126256,CDM,C1781,HCPCS,0278,RC,,,,both,,,4485.80,2915.77,,,,,,,,,,,,,
SYSTEM IMPL SZ 4 MM SUTURE SZ 2-0 BTB-IB FLX PIN STRL DISP,SUP-2882297,CDM,C1713,HCPCS,0278,RC,,,,both,,,2904.50,1887.92,,,,,,,,,,,,,
GRAFT BNE 25X25X8 MM 5 CC POROUS COLLAGEN MATRIX SIGNAFUSE,SUP-2731800,CDM,C1713,HCPCS,0278,RC,,,,both,,,2896.65,1882.82,,,,,,,,,,,,,
DARATUMUMAB 400 MG/20ML IV SOLN,RX-132052,CDM,J9145,HCPCS,0636,RC,57894-0505-20,NDC,,both,20,ML,8935.20,5807.88,,,,,,,,,,,,,
FILTER PERF ART PED AFFIN PIXIE,SUP-2500380,CDM,2720000010,LOCAL,0272,RC,,,,both,,,306.15,199.00,,,,,,,,,,,,,
CATHETER ANGIOPLSTY L130CM BAL L250MM DIA4MM GWIRE 0.035IN,SUP-2280384,CDM,C2623,HCPCS,0278,RC,,,,both,,,6374.20,4143.23,,,,,,,,,,,,,
GRAFT DERMAL STRUCTURAL THCK 7X3 CMX0.8-1.7 MM FLEXHD,SUP-2307465,CDM,Q4128,HCPCS,0636,RC,,,,both,,,2140.29,1391.19,,,,,,,,,,,,,
GUIDEWIRE ORTH L230MM DIA2MM S STL NTHRD SPADE PNT,SUP-2186892,CDM,C1769,HCPCS,0272,RC,,,,both,,,94.39,61.35,,,,,,,,,,,,,
KIT VENTRICULAR DRAINAGE W/ NL850500V 951303 CATH,SUP-2883567,CDM,2720000010,LOCAL,0272,RC,,,,both,,,899.89,584.93,,,,,,,,,,,,,
PLATE BNE BROAD 3.5X185 MM 14 HOLE SS LCP,SUP-2569340,CDM,C1713,HCPCS,0278,RC,,,,both,,,528.46,343.50,,,,,,,,,,,,,
CATHETER ANGIOPLSTY L90CM BAL L20MM OD4MM DIL RX MRAIL,SUP-2140565,CDM,C1725,HCPCS,0272,RC,,,,both,,,1089.58,708.23,,,,,,,,,,,,,
STEM FEM SZ 2 L KNEE POST STBL CONGRUENCY 121928160] JNJ DEPUY SYNTHES ORTHOPEDICS],SUP-2250362,CDM,C1776,CPT,0278,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
BUR SURG DIA25.4 MM CARBIDE 3MC FOR MTL CUT HNDPC STRL DISP,SUP-2937257,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
PIN GUID SQ 3.2X89.5,SUP-2263117,CDM,C1713,HCPCS,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
ROD CONN 0 DEG LG 4.5-5.5/6 MM,SUP-2517437,CDM,C1713,HCPCS,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
BUR DENT NO 369/025 FOOTBALL COARSE FRIC GRP MAXIMA DMND,SUP-2238963,CDM,2720000010,LOCAL,0272,RC,,,,both,,,137.94,89.66,,,,,,,,,,,,,
PLATE BNE TIB SHT RT MEDL DSTL 6 HOLE TRIBRID TECHNOLOGY TI,SUP-2399844,CDM,C1776,CPT,0278,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
COLLAR CERV ADJ CHIN CUP THERMOPLASTIC,SUP-2388133,CDM,L0150,HCPCS,0272,RC,,,,both,,,295.82,192.28,,,,,,,,,,,,,
ROD SPNL 4+ LEVEL 2 5.5 MM COCR UNID,SUP-2730615,CDM,C1713,HCPCS,0278,RC,,,,both,,,10990.00,7143.50,,,,,,,,,,,,,
CATHETER OCCL SNIPER WORKING L 150 CM PROX/DSTL OD,SUP-2164817,CDM,C2628,HCPCS,0272,RC,,,,both,,,5008.30,3255.39,,,,,,,,,,,,,
SET ACCS SHTH 4X7FR L18CM NDL 22GA L15CM 0.018IN PLAT TIP S,SUP-2168002,CDM,C1894,HCPCS,0272,RC,,,,both,,,195.90,127.33,,,,,,,,,,,,,
LEAD DEFIB RELIANCE SG L 70 CM SIL EPTFE STEROID ENDOCARD RT,SUP-2863480,CDM,C1777,HCPCS,0275,RC,,,,both,,,8518.82,5537.23,,,,,,,,,,,,,
IMPLANT GYN TENS FREE SUPP UROLOGICAL GYNECARE TVT,SUP-2383005,CDM,C1771,HCPCS,0278,RC,,,,both,,,2653.30,1724.64,,,,,,,,,,,,,
GRAFT HUM TISS M W40XL40MM PERICARD FRZ DRY READIGRFT,SUP-2264833,CDM,C1713,HCPCS,0278,RC,,,,both,,,1200.08,780.05,,,,,,,,,,,,,
CATHETER ANGIO AD 4FR L65CM COBRA 1 HYDRPHLC RADPQ,SUP-2139772,CDM,C1725,HCPCS,0272,RC,,,,both,,,158.10,102.76,,,,,,,,,,,,,
CLONIDINE HCL (ANALGESIA) 100 MCG/ML EP SOLN,RX-19333,CDM,J0735,HCPCS,0636,RC,67457-0218-10,NDC,,both,1.5,ML,54.10,35.16,,,,,,,,,,,,,
WASHER ORTHPDC CNNLTD STNLSS STEEL SPHRCL F3.5MM SCREW NON,SUP-2727190,CDM,C1713,HCPCS,0278,RC,,,,both,,,128.36,83.43,,,,,,,,,,,,,
STEM HUM CEM STD UNIV 15X115 MM REV W/ ALIGN HOLE TI PLASMA,SUP-2431683,CDM,C1776,CPT,0278,RC,,,,both,,,5972.28,3881.98,,,,,,,,,,,,,
PLATE BNE L44MM THK13MM 2X6 H NONSTERILE PHLANG BASE HND TI,SUP-2176871,CDM,C1713,HCPCS,0278,RC,,,,both,,,1984.51,1289.93,,,,,,,,,,,,,
TRIAMCINOLONE ACETONIDE 0.025 % EX CREA,RX-8112,CDM,6370000000,HCPCS,0637,RC,45802-0063-35,NDC,,both,15,GR,16.20,10.53,,,,,,,,,,,,,
GUIDEWIRE VASC L 145 CM DIA 0.045 MM PERIPH AMPLTZ DEV DEL,SUP-2167809,CDM,C1769,HCPCS,0272,RC,,,,both,,,40.57,26.37,,,,,,,,,,,,,
TRILOGY PROV LNR 20 DEG 50/52/54X32,SUP-2202552,CDM,C1776,CPT,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
CATHETER VENTRICULAR L25CM OD2.5MM GRADUATED WITH STYLET WIT,SUP-2825903,CDM,C1729,HCPCS,0272,RC,,,,both,,,749.24,487.01,,,,,,,,,,,,,
DISTRACTOR 30MM TLSCPNG LFT 20MM SCRWS MAX DRIVE BRSTN BODY,SUP-2669776,CDM,C1713,HCPCS,0278,RC,,,,both,,,15042.20,9777.43,,,,,,,,,,,,,
SCREW BNE L42MM DIA3.5MM CORT S STL ST FULL THRD T15 DRV,SUP-2178224,CDM,C1713,HCPCS,0278,RC,,,,both,,,109.33,71.06,,,,,,,,,,,,,
GRAFT HUM TISS THK13 15MM CALCANEUS CRSS SECT FRZ DRY,SUP-2307162,CDM,C1713,HCPCS,0278,RC,,,,both,,,2299.33,1494.56,,,,,,,,,,,,,
ENDOILLUMINATOR OPHTH 25GA STR STIFF SHFT N RFID DISPOSABLE,SUP-2109929,CDM,C1713,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
TR PN W/CV PT 250X50X5 FP,SUP-2818094,CDM,C1713,HCPCS,0278,RC,,,,both,,,1854.89,1205.68,,,,,,,,,,,,,
SHELL ACET SZ G DIA64MM HIP TRITANIUM X3 MH HMSPHR MOD 2,SUP-2372558,CDM,C1776,CPT,0278,RC,,,,both,,,7117.75,4626.54,,,,,,,,,,,,,
BIT DRILL SURG CANN 4.7 MM PERC ELBW TRINKLE COMP SS,SUP-2198524,CDM,C1776,CPT,0278,RC,,,,both,,,869.37,565.09,,,,,,,,,,,,,
STENT COR OTW 0.014 IN 3X28 MM 135 CM TAXUS,SUP-2140724,CDM,C1874,HCPCS,0278,RC,,,,both,,,8258.20,5367.83,,,,,,,,,,,,,
TRIAL BONE PLT 4 H CLVRLF TC-100 SM FRAG SYS,SUP-2343733,CDM,C1713,HCPCS,0278,RC,,,,both,,,2975.75,1934.24,,,,,,,,,,,,,
WASHER ORTH DOME 4.5 MM MONSTER,SUP-2742351,CDM,C1713,HCPCS,0278,RC,,,,both,,,313.22,203.59,,,,,,,,,,,,,
HC Sinuses Min 3 Views,PX-3207022000,CDM,70220,CPT,0320,RC,,,,both,,,664.00,431.60,,,,,,,,,,,,,
PLASMA-LYTE A IV SOLN,RX-6331,CDM,2580000003,HCPCS,0250,RC,65219-0389-00,NDC,,both,500,ML,77.70,50.50,,,,,,,,,,,,,
URETEROSCOPE FLX DIGITAL 3.1X650 MM 1.2 MM AXIS DISP,SUP-2432367,CDM,C1747,HCPCS,0272,RC,,,,both,,,2471.18,1606.27,,,,,,,,,,,,,
PIN FIX L 60 MM DIA2.5 MM PROV SM TARGETER SYS STRL EVOS,SUP-2933430,CDM,C1713,HCPCS,0278,RC,,,,both,,,1867.52,1213.89,,,,,,,,,,,,,
CATHETER ANGIOPLSTY OTW 0.035 IN 120 CM 6X80 MM POLARCATH,SUP-2141212,CDM,C1725,HCPCS,0272,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
PROSTHESIS OSS 2X1.32 MM FTPLT,SUP-2465816,CDM,L8613,CPT,0278,RC,,,,both,,,329.98,214.49,,,,,,,,,,,,,
CITRELOCK XPRESS IMPLANT SYSTEM 6MM X 23MM,SUP-2900572,CDM,C1713,HCPCS,0278,RC,,,,both,,,5127.62,3332.95,,,,,,,,,,,,,
SCREW BNE L22MM DIA3.5MM CORT FOR VERSANAIL UNIV HUM,SUP-2412538,CDM,C1713,HCPCS,0278,RC,,,,both,,,113.04,73.48,,,,,,,,,,,,,
FLUOROMETHOLONE 0.1 % OP SUSP,RX-3208,CDM,6370000000,HCPCS,0637,RC,60219-1585-03,NDC,,both,5,ML,348.50,226.52,,,,,,,,,,,,,
GRAFT HUM TISS W4XL4CM THK200UM AMNIO MEMBRN DEHYDR CHORION,SUP-2421218,CDM,C1762,CPT,0278,RC,,,,both,,,13530.26,8794.67,,,,,,,,,,,,,
PLATE BONE 13 H LT OLECRANON S STL LCK PERI-LOC,SUP-2350886,CDM,C1713,HCPCS,0278,RC,,,,both,,,1957.16,1272.15,,,,,,,,,,,,,
GRAFT HUM TISS ACELLULAR DERM THK.4-.8 MM OD4 CM X 8 CM N,SUP-2366753,CDM,Q4126,HCPCS,0636,RC,,,,both,,,9815.55,6380.11,,,,,,,,,,,,,
PLATE BONE ULTRA LOW PRFLE HLX2X3 03MM THK TTNM BOX STYLE C,SUP-2676587,CDM,C1713,HCPCS,0278,RC,,,,both,,,1010.61,656.90,,,,,,,,,,,,,
PLATE BNE L145MM 5 H NONSTERILE L PERIARTC PROX HUM S STL,SUP-2177822,CDM,C1713,HCPCS,0278,RC,,,,both,,,4928.32,3203.41,,,,,,,,,,,,,
GRAFT BNE CHIP CRUSH FRZN CANC 1MM 8MM RANG 40CC READIGRFT,SUP-2264730,CDM,C1713,HCPCS,0278,RC,,,,both,,,1492.00,969.80,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY SUP CS L 60 CM DIA 6 FR SPC 2-8-2,SUP-2700001,CDM,C1730,HCPCS,0272,RC,,,,both,,,143.84,93.50,,,,,,,,,,,,,
MESH HERN W10XL14IN RECT PROCEED,SUP-2219769,CDM,C1781,HCPCS,0278,RC,,,,both,,,7290.14,4738.59,,,,,,,,,,,,,
GRAFT BNE SUB W12XL30MM SPCR EXTENSURE H2,SUP-2310519,CDM,C1713,HCPCS,0278,RC,,,,both,,,6280.00,4082.00,,,,,,,,,,,,,
CIPROFLOXACIN IN D5W 400 MG/200ML IV SOLN,RX-104409,CDM,J0744,HCPCS,0636,RC,25021-0114-87,NDC,,both,100,ML,54.10,35.16,,,,,,,,,,,,,
CLIP ENDSCPC 28MM DIA 165CML CHNNL RTTBLE LATEX NON RDLCNT,SUP-2679369,CDM,C1889,HCPCS,0278,RC,,,,both,,,648.98,421.84,,,,,,,,,,,,,
NAIL IM L420MM OD13MM UNIV TI FEM CANN LCK VERSANAIL,SUP-2412455,CDM,C1713,HCPCS,0278,RC,,,,both,,,5398.01,3508.71,,,,,,,,,,,,,
SET CBL SL SM DIA2MM S STL FOR RECON TRAUM SYS DALL-M,SUP-2371517,CDM,C1713,HCPCS,0278,RC,,,,both,,,790.02,513.51,,,,,,,,,,,,,
CATHETER CARD ABLATION ISOLATOR SYNERGY L 64 CM SS ABS RT,SUP-2124448,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8792.00,5714.80,,,,,,,,,,,,,
HC Doppler Color Flow Mapping,PX-4839332500,CDM,93325,CPT,0483,RC,,,,both,,,1015.00,659.75,,,,,,,,,,,,,
RELOAD STPL 35MM THN VASC TISS WHT,SUP-2283262,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1624.86,1056.16,,,,,,,,,,,,,
BIORESORBABLE PIN 22MM,SUP-2467625,CDM,C1713,HCPCS,0278,RC,,,,both,,,1918.85,1247.25,,,,,,,,,,,,,
SHEATH INTRO 16FR L28CM 0.035IN GWIRE HYDRPHLC LOK,SUP-2298362,CDM,C1894,HCPCS,0272,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
SCREW BONE L60MM DIA7.3MM CORT S STL ST CANN LCK PARTIALLY,SUP-2185011,CDM,C1713,HCPCS,0278,RC,,,,both,,,370.52,240.84,,,,,,,,,,,,,
EXTRACTOR SALIVARY STONE CATH 1.5FR L115CM BSKT DIA10MM,SUP-2169475,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1397.30,908.24,,,,,,,,,,,,,
SHAFT SCRDRVR SELF RET T15 FRAG PLATING SYS 120MM SM,SUP-2344016,CDM,C1713,HCPCS,0278,RC,,,,both,,,561.43,364.93,,,,,,,,,,,,,
PLATE BNE L20MM 2 H LOK FOR 15MM SCR,SUP-2321432,CDM,C1713,HCPCS,0278,RC,,,,both,,,3532.50,2296.12,,,,,,,,,,,,,
TRAY CATH PICC POLY Q CATH BSC 5FR 0.034IN 60CM 2 LU 3255105,SUP-2632660,CDM,C1751,HCPCS,0278,RC,,,,both,,,213.77,138.95,,,,,,,,,,,,,
SCREW BNE CORTICAL 3.5X24 MM TOT WR SS STRL,SUP-2610371,CDM,C1713,HCPCS,0278,RC,,,,both,,,429.61,279.25,,,,,,,,,,,,,
DEVICE PROSTHETIC GRAPHITE LAMINATED CARBON,SUP-2388185,CDM,L2755,HCPCS,0272,RC,,,,both,,,336.45,218.69,,,,,,,,,,,,,
CATHETER VENTRICULAR 1.5X3.1X15.7X4X6 MM STRL HOLTER,SUP-2666419,CDM,C1729,HCPCS,0272,RC,,,,both,,,1614.87,1049.67,,,,,,,,,,,,,
SET INTRO SUP ARW FLX SHTH L 45 CM DIA 6 FR HYDRPHLC,SUP-2383404,CDM,C1894,HCPCS,0272,RC,,,,both,,,528.15,343.30,,,,,,,,,,,,,
UNIT DISTRACTOR 4CM COMPR STD FOR EL FIX,SUP-2315961,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1105.28,718.43,,,,,,,,,,,,,
SCREW BONE L90MM DIA4MM PROX HUM S STL ST NONCANNULATED LCK,SUP-2371545,CDM,C1713,HCPCS,0278,RC,,,,both,,,400.04,260.03,,,,,,,,,,,,,
GUIDEWIRE ORTH L19IN DIA1.6MM NIT BLNT TIP SNIPER,SUP-2354677,CDM,C1769,HCPCS,0272,RC,,,,both,,,489.84,318.40,,,,,,,,,,,,,
ANCHOR SUT BIOCRYL RAPIDE ORTHOCORD RADLUC BRAID OD4.5MM 222229] DEPUY SYNTHES USA],SUP-2184886,CDM,C1713,HCPCS,0278,RC,,,,both,,,4151.33,2698.36,,,,,,,,,,,,,
INSERT TIB M THK11MM AP48MM ML72MM L R ANT POST ARTC KNEE,SUP-2377436,CDM,C1776,CPT,0278,RC,,,,both,,,1975.69,1284.20,,,,,,,,,,,,,
TUBE JEJUNOSTOMY FEED 16 FRX30 CM 2 CM 3-5 CC MIC-KEY,SUP-2764813,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1113.29,723.64,,,,,,,,,,,,,
GRAFT VASC EXCLUDER 23 X 14.5 X 12CM,SUP-2395973,CDM,C1768,CPT,0278,RC,,,,both,,,22915.72,14895.22,,,,,,,,,,,,,
TRAY KYPHOPLASTY SZ 2 BLLN L15MM IBT 1ST FRAC OSTEO INTRO,SUP-2293626,CDM,C1894,HCPCS,0272,RC,,,,both,,,8415.20,5469.88,,,,,,,,,,,,,
TISSUE BIO MATRIDERM 10.5 X 14.8CM 2MM MED,SUP-2866497,CDM,A2027,HCPCS,0636,RC,,,,both,,,18162.20,11805.43,,,,,,,,,,,,,
DEVICE PROSTHETIC GRAPHITE LAMINATED CARBON,SUP-2388185,CDM,L2755,HCPCS,0274,RC,,,,both,,,336.45,218.69,,,,,,,,,,,,,
TRAY THORCENT 11FR L13MM TRCR ASPIR CANN SUCT TBNG NDL SYR,SUP-2391583,CDM,C1729,HCPCS,0272,RC,,,,both,,,703.36,457.18,,,,,,,,,,,,,
RAIL EXT FIX STRL,SUP-2875233,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7975.60,5184.14,,,,,,,,,,,,,
GRAFT BNE 5CC DBM SHP,SUP-2364718,CDM,C1713,HCPCS,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
CATHETER CV 3L 12 FRX20 CM N TUNNELED FULL KT,SUP-2120610,CDM,C1751,HCPCS,0278,RC,,,,both,,,448.39,291.45,,,,,,,,,,,,,
WASHER SPNL LT OCCIPITAL CERV THOR TI HI ANG LCK DEV FOR TIB,SUP-2254386,CDM,C1713,HCPCS,0278,RC,,,,both,,,351.68,228.59,,,,,,,,,,,,,
HC Humerus Min 2 View,PX-3207306000,CDM,73060,CPT,0320,RC,,,,both,,,386.00,250.90,,,,,,,,,,,,,
DEVICE FN NDL BX 22GA ENDOBRONCH US,SUP-2418159,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1148.14,746.29,,,,,,,,,,,,,
TUBE VENT ARMSTR 1.14 MM STR FLROPLAS,SUP-2458645,CDM,L8699,HCPCS,0278,RC,,,,both,,,23.58,15.33,,,,,,,,,,,,,
MENISCAL ROOT REP PK W/ ULTRATAPE,SUP-2341434,CDM,C1713,HCPCS,0278,RC,,,,both,,,2926.48,1902.21,,,,,,,,,,,,,
MALLET 3714105 NYLON SURFACE,SUP-2705131,CDM,C1713,HCPCS,0278,RC,,,,both,,,528.09,343.26,,,,,,,,,,,,,
STENT GRFT VASC POWERLINK INTUITRAK L 55 MM DIA25 MM DEL SYS,SUP-2217568,CDM,C1768,CPT,0278,RC,,,,both,,,7206.30,4684.09,,,,,,,,,,,,,
PLATE STRNL CLOSURE THK 1.5 MM 16 H TI STR LP NS STERNALOCK,SUP-2894451,CDM,C1713,HCPCS,0278,RC,,,,both,,,5181.00,3367.65,,,,,,,,,,,,,
KIT INFUS PMP PAINBUSTER W/ ON Q SILVERSOAK 65MLX0.5ML PER,SUP-2236782,CDM,E0783,HCPCS,0278,RC,,,,both,,,348.54,226.55,,,,,,,,,,,,,
SPACER SPNL W10XH11XL11MM PEEK CERV INTBDY FUS TANT MRK,SUP-2278919,CDM,C1889,HCPCS,0278,RC,,,,both,,,1789.80,1163.37,,,,,,,,,,,,,
BOOT WALKING PNEUMATIC LG HI TOP AIR LIFESTRIDE,SUP-2108147,CDM,L4386,HCPCS,0272,RC,,,,both,,,112.73,73.27,,,,,,,,,,,,,
SET INTRO CATH 5FR L10CM NDL 21GA L7CM 0.018IN S STL,SUP-2170558,CDM,C1894,HCPCS,0272,RC,,,,both,,,72.66,47.23,,,,,,,,,,,,,
SHELL ACET SLD BK COCR ALLOY 52MM VITALOCK,SUP-2364626,CDM,C1776,CPT,0278,RC,,,,both,,,3980.33,2587.21,,,,,,,,,,,,,
PLATE BONE 5 H 5 PEG W LT VOLAR S STL BEAR,SUP-2389749,CDM,C1713,HCPCS,0278,RC,,,,both,,,3956.40,2571.66,,,,,,,,,,,,,
SCREW BONE CANNULATED 55MM DIA 95MML,SUP-2721042,CDM,C1713,HCPCS,0278,RC,,,,both,,,601.56,391.01,,,,,,,,,,,,,
STENT BILI PALMAZ GEN L 15 MM EXPANSION DIA 5-8 MM SHTH 6 FR,SUP-2159109,CDM,C1877,HCPCS,0278,RC,,,,both,,,3334.68,2167.54,,,,,,,,,,,,,
KIT BONE GRFT SUB SIDE DEL CANN COMPLT KNEE FOR,SUP-2207870,CDM,C1713,HCPCS,0278,RC,,,,both,,,8949.00,5816.85,,,,,,,,,,,,,
STENT BILI WALLFLEX L 60 MM DIA 8 MM CVR L 48 MM CATH L 75,SUP-2149821,CDM,C1874,HCPCS,0278,RC,,,,both,,,7065.00,4592.25,,,,,,,,,,,,,
TUNNELER NERVE STIM,SUP-2225542,CDM,C1894,HCPCS,0272,RC,,,,both,,,188.40,122.46,,,,,,,,,,,,,
PLATE LOK STRGHT LRG4H T10MM 1MM MARKS W/TAB CP TTNM,SUP-2679030,CDM,C1713,HCPCS,0278,RC,,,,both,,,1712.46,1113.10,,,,,,,,,,,,,
BUR SURG L13CM DIA3MM RND PRECIS LILAC BND,SUP-2365189,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1618.86,1052.26,,,,,,,,,,,,,
KIT DISECT 6 7 8.5 10 12MM MOD RNG HNDL VOLLMAR,SUP-2264255,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7834.30,5092.29,,,,,,,,,,,,,
PLATE BNE L92MM 4 H ST R DST LAT FIBULAR S STL VAR ANG LOK,SUP-2177715,CDM,C1713,HCPCS,0278,RC,,,,both,,,2527.73,1643.02,,,,,,,,,,,,,
BUTTON FIX 6MM ENDOBTTN DIR,SUP-2341084,CDM,C1713,HCPCS,0278,RC,,,,both,,,3344.29,2173.79,,,,,,,,,,,,,
PERFORATOR SURG 14X11X3 MM CRAN EASYDRILL,SUP-2432050,CDM,2720000010,LOCAL,0272,RC,,,,both,,,920.02,598.01,,,,,,,,,,,,,
STENT PERIPH SMRT RADIANZ L 150 MM DIA 8 MM DEL SYS L 150 CM,SUP-2866193,CDM,C1876,HCPCS,0278,RC,,,,both,,,5704.81,3708.13,,,,,,,,,,,,,
COIL VASC AZUR HYDROPACK L 20 CM SZ 18 MICROCATHETER 2.4/2.8,SUP-2896811,CDM,C1889,HCPCS,0278,RC,,,,both,,,3626.70,2357.35,,,,,,,,,,,,,
KIT CATH ACCS PRT CONTAIN SYR EXTN TBNG CLMP NONCORING NDL,SUP-2284604,CDM,C1751,HCPCS,0278,RC,,,,both,,,94.20,61.23,,,,,,,,,,,,,
HC Pt Iontophoresis per 15 Min|OP PT SERVICES|DOCUMENTATION ON FILE|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS,PX-4209703300,CDM,97033,CPT,0420,RC,,,GP|KX|CQ,outpatient,,,221.00,143.65,,,,,,,,,,,,,
CATHETER CV MAXIMAL BARR TY 7 FRX15 CM 3L DRY SPECTRUM,SUP-2759883,CDM,C1751,HCPCS,0278,RC,,,,both,,,533.74,346.93,,,,,,,,,,,,,
PLATE BNE STR MED 1.5X28X0.8 MM MIDFACE 6 HOLE W/ TAB TI NS,SUP-2471286,CDM,C1713,HCPCS,0278,RC,,,,both,,,502.81,326.83,,,,,,,,,,,,,
DILTIAZEM HCL 25 MG/5ML IV SOLN,RX-97166,CDM,J1163,HCPCS,0636,RC,00641-6013-10,NDC,,both,1,ML,54.10,35.16,,,,,,,,,,,,,
SUPPORT ORTHOT ANK KNEE CUST W/ADJ STP SINGLE UPR,SUP-2435627,CDM,L1920,HCPCS,0272,RC,,,,both,,,1163.06,755.99,,,,,,,,,,,,,
DISC CERV H6MM DIA14MM TI CERAMIC PROS PRESTIGE LP,SUP-2286936,CDM,C1889,HCPCS,0278,RC,,,,both,,,12560.00,8164.00,,,,,,,,,,,,,
SCREW BNE L44MM DIA5MM HD DIA8MM CORT GRN TI ALLY ST,SUP-2192323,CDM,C1713,HCPCS,0278,RC,,,,both,,,658.74,428.18,,,,,,,,,,,,,
SCREW BNE NLCK 4X14 MM,SUP-2315904,CDM,C1713,HCPCS,0278,RC,,,,both,,,615.44,400.04,,,,,,,,,,,,,
NAIL IM L440MM DIA4MM FEM TIB TI CANN RG BENT E FLX DSGN,SUP-2192734,CDM,C1713,HCPCS,0278,RC,,,,both,,,1040.41,676.27,,,,,,,,,,,,,
SCREW INTFR L24MM DIA3MM PLLA BIO-COMPRESSION,SUP-2121891,CDM,C1713,HCPCS,0278,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
SHEATH INTRO FAST-CATH L 12 CM DIA11 FR GUIDEWIRE 0.038 IN,SUP-2355540,CDM,C1894,HCPCS,0272,RC,,,,both,,,48.67,31.64,,,,,,,,,,,,,
PLATE 4.5MM TI CURVED NARROW LCP PLATE 16 HOLE STERILE,SUP-2546928,CDM,C1713,HCPCS,0278,RC,,,,both,,,2894.83,1881.64,,,,,,,,,,,,,
SCREW BNE L 135 MM DIA 3.5 MM SS CORTICAL ST STRL EVOS,SUP-2931584,CDM,C1713,HCPCS,0278,RC,,,,both,,,212.08,137.85,,,,,,,,,,,,,
AWL ASSY STARTER AWL,SUP-2472912,CDM,2720000010,LOCAL,0272,RC,,,,both,,,547.62,355.95,,,,,,,,,,,,,
PLATE BNE L 118 MM SCREW DIA 3.5 MM 10 H SS 1/3 TUBLR LCK LP,SUP-2931342,CDM,C1713,HCPCS,0278,RC,,,,both,,,1226.17,797.01,,,,,,,,,,,,,
SPLINT ORTHOPEDIC BOUTONNIERE 4 FNGR BEAUTY STRENGTH,SUP-2325004,CDM,L3927,HCPCS,0274,RC,,,,both,,,250.76,162.99,,,,,,,,,,,,,
SYSTEM PT MON W WIRELESS COMMUNICATOR LATITUDE,SUP-2140198,CDM,2720000010,LOCAL,0272,RC,,,,both,,,624.86,406.16,,,,,,,,,,,,,
GRAFT VASC EXXCEL SFT L 70 CM SUPP L 70 CM DIA 7 MM EPTFE,SUP-2227658,CDM,C1768,CPT,0278,RC,,,,both,,,2688.97,1747.83,,,,,,,,,,,,,
PLATE BNE W101XL196MM THK35MM 14 H BILAT TI STR RIG LOK,SUP-2191089,CDM,C1713,HCPCS,0278,RC,,,,both,,,2080.85,1352.55,,,,,,,,,,,,,
SCREW BONE 5X50MM LCK FT,SUP-2364651,CDM,C1713,HCPCS,0278,RC,,,,both,,,448.39,291.45,,,,,,,,,,,,,
TUBE ET DIA7MM REINF SUBDERM NDL KT EMG MON,SUP-2310415,CDM,2720000010,LOCAL,0272,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
WIRE EXT FIX L400MM DIA18MM ANK FT BAYNT W STPR FOR,SUP-2316136,CDM,2720000010,LOCAL,0272,RC,,,,both,,,538.38,349.95,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED PRIMARY HI DEMAND K5SN] SMITH AND NEPHEW ORTHOPAEDICS],SUP-2351383,CDM,C1776,CPT,0278,RC,,,,both,,,16014.00,10409.10,,,,,,,,,,,,,
NAIL IM CANN 135 DEG 10 MM FIX TI STRL,SUP-2192104,CDM,C1713,HCPCS,0278,RC,,,,both,,,3617.28,2351.23,,,,,,,,,,,,,
PLATE BNE FEM LNG 3.5X152 MM LT DSTL PROX 4 HOLE NS VA-LCP,SUP-2757673,CDM,C1713,HCPCS,0278,RC,,,,both,,,3779.84,2456.90,,,,,,,,,,,,,
SIZER BRST 325CC DIA115CM P48CM COHESIVE I SIL GEL SMOOTH,SUP-2300854,CDM,2720000010,LOCAL,0272,RC,,,,both,,,957.70,622.50,,,,,,,,,,,,,
HC Ribs Unilateral 2 Views,PX-3207110000,CDM,71100,CPT,0320,RC,,,,both,,,497.00,323.05,,,,,,,,,,,,,
CLIP SURG LG 25X21X14 MM LAT PEEK SANTORINI,SUP-2517398,CDM,C1889,HCPCS,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
DEFEROXAMINE MESYLATE 2 G IJ SOLR,RX-9722,CDM,J0895,HCPCS,0636,RC,63323-0599-30,NDC,,both,1,UN,236.90,153.98,,,,,,,,,,,,,
ENDCAP ORTH DIA8MM 5MM EXTN NONSTERILE DK PUR TI ALLY CANN,SUP-2180315,CDM,C1713,HCPCS,0278,RC,,,,both,,,445.47,289.56,,,,,,,,,,,,,
SUPPORT ORTHOPEDIC LOWER SPINE ADJUSTABLE VISTA 637 LSO,SUP-2427925,CDM,L0637,HCPCS,0274,RC,,,,both,,,679.12,441.43,,,,,,,,,,,,,
HC So Calprotectin Fecal,PX-3018399366,CDM,83993,CPT,0301,RC,,,,both,,,480.00,312.00,,,,,,,,,,,,,
STEM WR JT ULN PRI N COAT CO CHROM PRSS FIT BILAT 14.5 MM,SUP-2244021,CDM,C1776,CPT,0278,RC,,,,both,,,14130.00,9184.50,,,,,,,,,,,,,
MENINGOCOCCAL A C Y&W-135 OLIG IM SOLN,RX-160837,CDM,90734,HCPCS,0636,RC,58160-0827-03,NDC,,both,.5,ML,750.40,487.76,,,,,,,,,,,,,
SYSTEM BNE CEMENT SYR 5 ML SEMIMANUAL MX CLOSED SPATULA,SUP-2917178,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1522.90,989.88,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 120 MM DIA13/10 MM DEL,SUP-2934294,CDM,C1713,HCPCS,0278,RC,,,,both,,,16932.95,11006.42,,,,,,,,,,,,,
CATHETER GUID L 100 CM OD 6 FR ID 0.070 IN HYDRPHLC PERIPH,SUP-2154305,CDM,C1887,HCPCS,0272,RC,,,,both,,,106.76,69.39,,,,,,,,,,,,,
COLLAR CERV L AD H5XL21.5IN M DENS CNTCT CLSR FOAM W/ STOCK,SUP-2198741,CDM,L0120,HCPCS,0274,RC,,,,both,,,28.26,18.37,,,,,,,,,,,,,
NAIL IM FEM ADOL 10X240 MM RT LAT ENTRY TI STRL NAIL-EX,SUP-2546423,CDM,C1713,HCPCS,0278,RC,,,,both,,,4308.21,2800.34,,,,,,,,,,,,,
COMPONENT FEM SM RT KNEE ZNK LIBRA,SUP-2442387,CDM,C1776,CPT,0278,RC,,,,both,,,748.89,486.78,,,,,,,,,,,,,
SUPPORT ORTHOT CUST SOLE WDG BTWN,SUP-2435723,CDM,L3370,HCPCS,0274,RC,,,,both,,,140.42,91.27,,,,,,,,,,,,,
COIL EMB L40CM DIA10MM 360DEG STD DETACH TARGET XL,SUP-2367728,CDM,C1889,HCPCS,0278,RC,,,,both,,,6685.53,4345.59,,,,,,,,,,,,,
INTRODUCER TUBE 14FR L65CM ID3MM RADPQ RAPI FIT ADPT,SUP-2168837,CDM,C1894,HCPCS,0272,RC,,,,both,,,197.82,128.58,,,,,,,,,,,,,
CATHETER ANGIOPLSTY SAVVY L 150 CM DIA 3-3.5 FR BALLOON L 10,SUP-2153845,CDM,C1725,HCPCS,0272,RC,,,,both,,,962.72,625.77,,,,,,,,,,,,,
SCREW BNE L80MM DIA7.3MM THRD L32MM TI CANN PARTIALLY,SUP-2190165,CDM,C1713,HCPCS,0278,RC,,,,both,,,676.17,439.51,,,,,,,,,,,,,
RING EXT FIX ID180MM 2/3 W/ FT ADD H FOR SPAT FRME,SUP-2343033,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6228.66,4048.63,,,,,,,,,,,,,
"HC Post.Drain/Percussion,Initial",PX-4109466700,CDM,94667,CPT,0410,RC,,,,outpatient,,,247.00,160.55,,,,,,,,,,,,,
PLATE BNE 1.5/2X49X1.5 MM 8 HOLE SS LC-DCP,SUP-2569198,CDM,C1713,HCPCS,0278,RC,,,,both,,,283.23,184.10,,,,,,,,,,,,,
SPLINT WRST R INSTABILITY INJ LOOP LOK W STAY FIRM SUPP,SUP-2276663,CDM,L3908,HCPCS,0274,RC,,,,both,,,16.36,10.63,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 70 CM DIA 7 MM STR HELIX SLDE GDS,SUP-2482765,CDM,C1768,CPT,0278,RC,,,,both,,,2529.84,1644.40,,,,,,,,,,,,,
BLADE RTRCTR BLFR 2 34NW X 9 12NL X 2 34ND SPRPBC CNTR,SUP-2706029,CDM,2720000010,LOCAL,0272,RC,,,,both,,,205.83,133.79,,,,,,,,,,,,,
"HC So Albumin Other Source, Quan Ea",PX-3078204266,CDM,82042,CPT,0307,RC,,,,both,,,37.00,24.05,,,,,,,,,,,,,
STAPLE SPNL ANTR ANTR SYS TI COLORADO 2,SUP-2290620,CDM,C1713,HCPCS,0278,RC,,,,both,,,1880.86,1222.56,,,,,,,,,,,,,
HC Whfo Ridig W/O Custom Fit,PX-2740380801,CDM,L3808,HCPCS,0274,RC,,,,outpatient,,,1110.00,721.50,,,,,,,,,,,,,
KIT INTRO DIL DIA24 FR LAPSCP FOR GASTMY FEED TUBE STRL,SUP-2764615,CDM,2720000010,LOCAL,0272,RC,,,,both,,,725.94,471.86,,,,,,,,,,,,,
COMPONENT TIB L150MM L5CM THK9MM PROX N MOD CEM STEM 1 PC,SUP-2405786,CDM,C1776,CPT,0278,RC,,,,both,,,20135.25,13087.91,,,,,,,,,,,,,
GUIDEWIRE VASC SHORTY L 180 CM DIA 0.018 IN TAPR L 6 CM FLPY,SUP-2168621,CDM,C1769,HCPCS,0272,RC,,,,both,,,228.34,148.42,,,,,,,,,,,,,
PLATE BNE L 81 X W 8.5 MM THK 2.4 MM SCREW DIA2.7 MM 3 H SS 72468703,SUP-2932782,CDM,C1713,HCPCS,0278,RC,,,,both,,,2550.31,1657.70,,,,,,,,,,,,,
PIN FIX L200MM DIA5MM S STL MRI CONDITIONAL FOR TRAC STNMN,SUP-2186923,CDM,C1713,HCPCS,0278,RC,,,,both,,,208.03,135.22,,,,,,,,,,,,,
AUGMENT TIB SZ B KNEE TRITANIUM SYMMETRICAL CONE REV,SUP-2373578,CDM,C1776,CPT,0278,RC,,,,both,,,11065.36,7192.48,,,,,,,,,,,,,
HC Repair Enteroctaneous Fistula Small Intestine or Colon,PX-3610979600,CDM,C9796,CPT,0361,RC,,,,inpatient,,,8689.00,5647.85,,,,,,,,,,,,,
PLATE BNE RECON 2-2.5X190X2.5 MM LT MAND 26 HOLE ANGLED STRL,SUP-2539585,CDM,C1713,HCPCS,0278,RC,,,,both,,,6372.82,4142.33,,,,,,,,,,,,,
T2 EXTRACION NUT,SUP-2823765,CDM,C1713,HCPCS,0278,RC,,,,both,,,711.21,462.29,,,,,,,,,,,,,
DRILL SURG CALIB 4.8 MM STP,SUP-2766149,CDM,2720000010,LOCAL,0272,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
LEAD DEFIB L58CM INTRO 7FR PROX TIP 17CM BPLR 2 COIL TINES,SUP-2357381,CDM,C1895,HCPCS,0275,RC,,,,both,,,18055.00,11735.75,,,,,,,,,,,,,
GRAFT VASC INTERGARD L 100 CM DIA 8 MM THK 0.49 MM POLYESTER,SUP-2227571,CDM,C1768,CPT,0278,RC,,,,both,,,1927.11,1252.62,,,,,,,,,,,,,
CANNULA SUCTION COAG 3 MMX17 CM ANGULAR,SUP-2776833,CDM,2720000010,LOCAL,0272,RC,,,,both,,,530.75,344.99,,,,,,,,,,,,,
SCREW SPNL L13MM DIA4.6MM ANT CERV VLT TI SELF DRL LOK FOR,SUP-2255539,CDM,C1713,HCPCS,0278,RC,,,,both,,,266.90,173.48,,,,,,,,,,,,,
BUR SURG COARSE DIAMOND 5 MM RND UPWR,SUP-2166788,CDM,2720000010,LOCAL,0272,RC,,,,both,,,158.26,102.87,,,,,,,,,,,,,
ROD EXT FIX SHT 11X220 MM NS BRDG,SUP-2422224,CDM,C1713,HCPCS,0278,RC,,,,both,,,2154.83,1400.64,,,,,,,,,,,,,
PLATE BNE L155MM 9 H ST R DST RAD VOLAR DPHSEAL MTPHSEAL S,SUP-2177217,CDM,C1713,HCPCS,0278,RC,,,,both,,,4793.62,3115.85,,,,,,,,,,,,,
SCREW BNE COMPARTMENT ALLOFIT,SUP-2448650,CDM,C1713,HCPCS,0278,RC,,,,both,,,1511.91,982.74,,,,,,,,,,,,,
COVER BURR HOLE 03MM 26MM DIA CMMRCLLY PURE TTNM CNTRD LOW,SUP-2694728,CDM,C1713,HCPCS,0278,RC,,,,both,,,951.26,618.32,,,,,,,,,,,,,
SET ENDOSCP ELECTROCAUTERY L 220 CM DIA2.8 MM BALLOON L 180,SUP-2881766,CDM,C1769,HCPCS,0272,RC,,,,both,,,5240.66,3406.43,,,,,,,,,,,,,
PAD ORTHOT LUMBAR CUST BOLSTER,SUP-2435573,CDM,L1030,HCPCS,0272,RC,,,,both,,,221.68,144.09,,,,,,,,,,,,,
HC Bil Duct Dila W/ W/O Stent S&I,PX-3207436300,CDM,74363,CPT,0320,RC,,,,outpatient,,,2584.00,1679.60,,,,,,,,,,,,,
PLATE BNE CALCANEAL 2.4/2.7/3.5 MM LT,SUP-2653733,CDM,C1713,HCPCS,0278,RC,,,,both,,,2385.55,1550.61,,,,,,,,,,,,,
SCALPEL SURG JACKSON 2 IN 6.5 IN TRACH PRB TIP CRV BLADE,SUP-2478298,CDM,2720000010,LOCAL,0272,RC,,,,both,,,341.82,222.18,,,,,,,,,,,,,
SACITUZUMAB GOVITECAN-HZIY 180 MG IV SOLR,RX-150405,CDM,J9317,HCPCS,0636,RC,55135-0132-01,NDC,,both,1,UN,7382.90,4798.88,,,,,,,,,,,,,
PLATE BNE RECON 3.5X178 MM 15 HOLE SS,SUP-2569090,CDM,C1713,HCPCS,0278,RC,,,,both,,,476.65,309.82,,,,,,,,,,,,,
PLATE BNE COMPR BROAD 137 MM 7 HOLE,SUP-2362722,CDM,C1713,HCPCS,0278,RC,,,,both,,,532.23,345.95,,,,,,,,,,,,,
SCREW LK ADV IMN SYS 5X525MM,SUP-2701136,CDM,C1713,HCPCS,0278,RC,,,,both,,,1200.74,780.48,,,,,,,,,,,,,
DRILL SURG TIB POROUS ATTUNE RP,SUP-2454828,CDM,2720000010,LOCAL,0272,RC,,,,both,,,364.24,236.76,,,,,,,,,,,,,
POST EXT FIX ANK FT 2 H FOR TRUELOK FRME ASSEMB HEXAPOD SYS,SUP-2316130,CDM,2720000010,LOCAL,0272,RC,,,,both,,,477.97,310.68,,,,,,,,,,,,,
PLATE BONE RT DSTL DORS RAD TI FOR 1.8/2.4/2.7MM SCR,SUP-2191013,CDM,C1713,HCPCS,0278,RC,,,,both,,,2628.81,1708.73,,,,,,,,,,,,,
SCREW BONE LOK 5.5MM DIA 100MML TTNM CRTCL FLLY THRDD SOLID,SUP-2587389,CDM,C1713,HCPCS,0278,RC,,,,both,,,459.32,298.56,,,,,,,,,,,,,
HC Whfo Ridig W/O Custom Fit,PX-2740380801,CDM,L3808,HCPCS,0272,RC,,,,outpatient,,,1110.00,721.50,,,,,,,,,,,,,
CATH REPROC EP STRBL DECAPLR 2-5-2MM MED CRV 5FR 110CM,SUP-2526275,CDM,C1730,HCPCS,0272,RC,,,,both,,,865.67,562.69,,,,,,,,,,,,,
BIT DRL DIA2.5MM FLUT SH NAVIGATED,SUP-2364163,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1806.63,1174.31,,,,,,,,,,,,,
GRAFT BNE BLOCK 15-18 MM TRICORT,SUP-2766768,CDM,C1713,HCPCS,0278,RC,,,,both,,,3039.99,1975.99,,,,,,,,,,,,,
BLADE SHV DIA4MM STR IRRIG DISECT SERR FOR DIEGO,SUP-2313823,CDM,2720000010,LOCAL,0272,RC,,,,both,,,348.70,226.65,,,,,,,,,,,,,
PORT INFUS CATH DIA6FR TI ATTACH POLYUR PEEL APART INTRO SGL,SUP-2126576,CDM,C1788,HCPCS,0278,RC,,,,both,,,1723.23,1120.10,,,,,,,,,,,,,
BUR SURG OD7.5MM S STL RND TWO FLUT ELITE SABER SHANK,SUP-2367544,CDM,2720000010,LOCAL,0272,RC,,,,both,,,786.32,511.11,,,,,,,,,,,,,
PLATE SPNL W9XL112MM 7 H ANTR BILAT TI CHANNELED SUMMIT FIX,SUP-2254412,CDM,C1713,HCPCS,0278,RC,,,,both,,,2505.72,1628.72,,,,,,,,,,,,,
DOME TALAR SZ 1 CO CHROM MO RT ANK TOT ANAT STRL CADENCE,SUP-2931374,CDM,C1776,CPT,0278,RC,,,,both,,,23391.90,15204.73,,,,,,,,,,,,,
KNEE ORTHOLOC II PAT POLYETH 35MM MED-LRG-XLG,SUP-2397043,CDM,C1776,CPT,0278,RC,,,,both,,,1582.56,1028.66,,,,,,,,,,,,,
STENT GRFT VASC BIFURCATE 1 AORT LIMB EXT,SUP-2777589,CDM,C1768,CPT,0278,RC,,,,both,,,31525.60,20491.64,,,,,,,,,,,,,
KIT 2.7MM 2.4MM DRL TIP GWIRE 4.5MM CANN ACL BONE FIX PLUG,SUP-2341041,CDM,C1769,HCPCS,0272,RC,,,,both,,,1526.04,991.93,,,,,,,,,,,,,
HEAD FEM BPLR CO CHROM BPLR SYS 28MMX45MM,SUP-2359154,CDM,C1776,CPT,0278,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
PLATE BONE L38MM THK1.4MM SHFT W7.5MM 5 H STRL STR TINE FOR,SUP-2349703,CDM,C1713,HCPCS,0278,RC,,,,both,,,4873.28,3167.63,,,,,,,,,,,,,
ANCHOR SUTURE DIAMETER 1.8MM WITH TWO 1.3MM WHITE/BLUE AND W,SUP-2824773,CDM,C1713,HCPCS,0278,RC,,,,both,,,1588.84,1032.75,,,,,,,,,,,,,
KIT SHIM FIX MAXCESS IV SYS,SUP-2310432,CDM,C1713,HCPCS,0278,RC,,,,both,,,4033.02,2621.46,,,,,,,,,,,,,
INQUIRY STEER 5F DEC 1110 5 2303 M,SUP-2698826,CDM,C1730,HCPCS,0272,RC,,,,both,,,1259.14,818.44,,,,,,,,,,,,,
DEVICE BNE MAR EXTR AUTOLGS CELL 45S CELLXTRACT,SUP-2138516,CDM,C1713,HCPCS,0278,RC,,,,both,,,3061.50,1989.97,,,,,,,,,,,,,
BIT DRL 4.5X300 MM FITBONE TAA,SUP-2645728,CDM,2720000010,LOCAL,0272,RC,,,,both,,,519.98,337.99,,,,,,,,,,,,,
ANCHOR SUT DIA2.3MM CRV COBRAID SZ 2 ULTRABRAID BLK SUT,SUP-2341873,CDM,C1713,HCPCS,0278,RC,,,,both,,,1648.50,1071.52,,,,,,,,,,,,,
CATHETER HAD AD 14.5FR L50CM INSRT L33CM POLYUR CARBOTHANE,SUP-2283943,CDM,C1881,HCPCS,0278,RC,,,,both,,,768.67,499.64,,,,,,,,,,,,,
GRAFT VASC L50CM DIA8MM RNG L40CM EPTFE THN WALLED CBAS HEP,SUP-2395823,CDM,C1768,CPT,0278,RC,,,,both,,,5670.84,3686.05,,,,,,,,,,,,,
HAGIE PIN 3/16X6X11.4,SUP-2818340,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1099.53,714.69,,,,,,,,,,,,,
KIT AORT VLV SAPIEN 3 ULTRA RESILIA DIA29 MM BOV PERICARD,SUP-2882185,CDM,C1889,HCPCS,0278,RC,,,,both,,,106760.00,69394.00,,,,,,,,,,,,,
LEAD DEFIB LINOX S L 65 CM DIA2.6 MM SIL INSUL IRIDIUM OXIDE,SUP-2138049,CDM,C1777,HCPCS,0275,RC,,,,both,,,11618.00,7551.70,,,,,,,,,,,,,
PLATE BNE L 66 X W 10.2 MM THK 2.8 MM SCREW DIA 3.5 MM 6 H 72440606N,SUP-2932770,CDM,C1713,HCPCS,0278,RC,,,,both,,,2144.68,1394.04,,,,,,,,,,,,,
RETRIEVER THROMCTMY TREVO XP PROVUE L 20 MM DIA 4 MM NIT,SUP-2367790,CDM,C1757,HCPCS,0272,RC,,,,both,,,22518.20,14636.83,,,,,,,,,,,,,
ENDOPROSTHESIS TRACHBRONCH VIABAHN L 5 CM DIA 9 MM CATH L,SUP-2396460,CDM,C1874,HCPCS,0278,RC,,,,both,,,7159.20,4653.48,,,,,,,,,,,,,
TUBE ET ID5MM ORAL UNCUF MURPHY EYE PREFRM BOLD MRK AT CNTR,SUP-2383863,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7.69,5.00,,,,,,,,,,,,,
PLATE BNE THK0.6MM 10 H STD CRANIOMAXILLOFACIAL G TI CRV,SUP-2366293,CDM,C1713,HCPCS,0278,RC,,,,both,,,836.21,543.54,,,,,,,,,,,,,
WALKER LEG DLX BLK SHT L,SUP-2276713,CDM,L4387,HCPCS,0272,RC,,,,both,,,87.64,56.97,,,,,,,,,,,,,
STEM FEM L167MM OD11MM BOW FLUT TI ALLY HA DST HIP REV MOD,SUP-2375745,CDM,C1776,CPT,0278,RC,,,,both,,,8140.14,5291.09,,,,,,,,,,,,,
INSERT ACET SZ E DIA44.4MM HD OD36MM ID22MM THK7.9MM 10DEG,SUP-2377727,CDM,C1776,CPT,0278,RC,,,,both,,,6860.27,4459.18,,,,,,,,,,,,,
STEM FEM SZ 13 L195MM HIP TI HA STD OFFSET CEMENTLESS REV,SUP-2257652,CDM,C1776,CPT,0278,RC,,,,both,,,19061.06,12389.69,,,,,,,,,,,,,
PACEMAKER CARD ESTELLA DR-T 2 CHMBR HOME MONITORING,SUP-2138294,CDM,C1785,HCPCS,0275,RC,,,,both,,,16328.00,10613.20,,,,,,,,,,,,,
HEAD RADIAL LNG STEM 4 ELBW MOD,SUP-2852853,CDM,C1776,CPT,0278,RC,,,,both,,,10237.19,6654.17,,,,,,,,,,,,,
GUIDEWIRE FEM CENTRONAIL STRL PACKAGED INSTRMT W/O OLV DIAM,SUP-2316304,CDM,C1769,HCPCS,0272,RC,,,,both,,,599.93,389.95,,,,,,,,,,,,,
PLATE M L PAT PROTCT TRIATHLON,SUP-2364730,CDM,C1776,CPT,0278,RC,,,,both,,,850.94,553.11,,,,,,,,,,,,,
PLATE BNE TBLR 3.5X159 MM 12 HOLE 1/3 2 COMPR LCK FOR SCR TI,SUP-2490037,CDM,C1713,HCPCS,0278,RC,,,,both,,,589.94,383.46,,,,,,,,,,,,,
SCREW BNE L3MM DIA1MM MIC CORT TI ST SELF DRL SELF RET,SUP-2262772,CDM,C1713,HCPCS,0278,RC,,,,both,,,222.00,144.30,,,,,,,,,,,,,
SUPPORT ORTH H8XL13IN D2 1/2IN CUSH MCKENZ SLM LN,SUP-2324239,CDM,L0642,HCPCS,0274,RC,,,,both,,,52.00,33.80,,,,,,,,,,,,,
SHELL ACET OD50MM ID28MM HIP TI POR CLUS H DURALOC OPT,SUP-2252355,CDM,C1776,CPT,0278,RC,,,,both,,,5621.86,3654.21,,,,,,,,,,,,,
SIMETHICONE 40 MG/0.6ML PO SUSP,RX-7228,CDM,340b,HCPCS,0637,RC,00536-1303-75,NDC,,both,30,ML,9.90,6.43,,,,,,,,,,,,,
PLATE BNE FIBULAR 3.5X178 MM LT DSTL PL PERI ARTC 14 HOLE SS,SUP-2422116,CDM,C1713,HCPCS,0278,RC,,,,both,,,1966.39,1278.15,,,,,,,,,,,,,
TUBE VENT MOD 1.27 MM CLLR BUTTON SIL,SUP-2480682,CDM,L8699,HCPCS,0278,RC,,,,both,,,27.26,17.72,,,,,,,,,,,,,
PUSHER SURG ANT,SUP-2292673,CDM,C1713,HCPCS,0278,RC,,,,both,,,1452.60,944.19,,,,,,,,,,,,,
PIN FIX L50MM ANCHR DISPOSABLE AERO LL,SUP-2381022,CDM,C1713,HCPCS,0278,RC,,,,both,,,219.80,142.87,,,,,,,,,,,,,
DEXTROSE-SODIUM CHLORIDE 5-0.225 % IV SOLN,RX-17858,CDM,J7042,HCPCS,0258,RC,00990-7924-03,NDC,,both,500,ML,55.30,35.94,,,,,,,,,,,,,
APPLICATOR SURG FARRELL 5.5 IN 18 MM TRIANG END SS,SUP-2501259,CDM,2720000010,LOCAL,0272,RC,,,,both,,,58.75,38.19,,,,,,,,,,,,,
SCREW BONE L6MM DIA2MM CORT CRANIOMAXILLOFACIAL TI ST FULL,SUP-2189425,CDM,C1713,HCPCS,0278,RC,,,,both,,,180.55,117.36,,,,,,,,,,,,,
PROBE RF L75MM OD17GA 4MM PAIN MGMT SINERGY,SUP-2237202,CDM,C1713,HCPCS,0278,RC,,,,both,,,1193.20,775.58,,,,,,,,,,,,,
REAMER SURG 3 MM,SUP-2175004,CDM,2720000010,LOCAL,0272,RC,,,,both,,,775.58,504.13,,,,,,,,,,,,,
PLATE BNE LADDER MED 1.5X0.8 MM MIDFACE 16 HOLE W/ TAB NS,SUP-2498095,CDM,C1713,HCPCS,0278,RC,,,,both,,,879.17,571.46,,,,,,,,,,,,,
PEG SUBTALAR FT DEFORMITY STA PEG SM,SUP-2397143,CDM,C1713,HCPCS,0278,RC,,,,both,,,6926.84,4502.45,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 70 CM DIA 4-7 MM EPTFE TAPR STD,SUP-2396217,CDM,C1768,CPT,0278,RC,,,,both,,,3133.72,2036.92,,,,,,,,,,,,,
CARRIER LT L16CM FBR OPT FOR DST ILLUMINATION LARYNSCP,SUP-2261375,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2116.30,1375.59,,,,,,,,,,,,,
PLATE BONE L74MM 6 H DSTL ANTR TIB VAR ANG LCK FOR 3.5MM SCR,SUP-2349813,CDM,C1713,HCPCS,0278,RC,,,,both,,,8695.76,5652.24,,,,,,,,,,,,,
SCREW BNE ST 1.85X18 MM CRUCFRM HD EMGCY TI LT BLU NS,SUP-2181652,CDM,C1713,HCPCS,0278,RC,,,,both,,,330.14,214.59,,,,,,,,,,,,,
PIN 12 APEX SELF DRILL SS 2X45MM,SUP-2695709,CDM,C1713,HCPCS,0278,RC,,,,both,,,347.60,225.94,,,,,,,,,,,,,
STENT URET L 95 CM DIA 7 FR PTFE GUIDEWIRE 0.038 IN ADPT,SUP-2141655,CDM,C2617,HCPCS,0278,RC,,,,both,,,254.34,165.32,,,,,,,,,,,,,
COLLAR CERV M H4.25IN POLYETH FOAM CA,SUP-2196884,CDM,L0120,HCPCS,0274,RC,,,,both,,,43.05,27.98,,,,,,,,,,,,,
WIRE GUID SET EXCHG 6.3FR AND 8.0FR 20CM 21CM AND 15CM,SUP-2168700,CDM,C1769,HCPCS,0272,RC,,,,both,,,268.34,174.42,,,,,,,,,,,,,
WASHER ORTH HD FOR 2.7/3.5MM SCR DARCO,SUP-2401363,CDM,C1713,HCPCS,0278,RC,,,,both,,,62.80,40.82,,,,,,,,,,,,,
GRAFT BNE PTTY 1 CC CHIP DBM PUROS,SUP-2335247,CDM,C9359,HCPCS,0278,RC,,,,both,,,1067.60,693.94,,,,,,,,,,,,,
MESH SURG W18XL24CM THK1MM EPTFE BIOMATERIAL ANTIMIC FOR,SUP-2395342,CDM,C1781,HCPCS,0278,RC,,,,both,,,3915.58,2545.13,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 40 CM DIA 6 MM EPTFE STR TW N RING,SUP-2396340,CDM,C1768,CPT,0278,RC,,,,both,,,1997.04,1298.08,,,,,,,,,,,,,
BIT DRILL SURG 4 MM ALPS DISP,SUP-2607159,CDM,2720000010,LOCAL,0272,RC,,,,both,,,591.73,384.62,,,,,,,,,,,,,
RESERVOIR SHUNT RICKHAM STYL SM,SUP-2851447,CDM,C1889,HCPCS,0278,RC,,,,both,,,939.36,610.58,,,,,,,,,,,,,
PLATE BNE 3 H 7 PEG STD L VOLAR S STL FIX ANG,SUP-2389779,CDM,C1713,HCPCS,0278,RC,,,,both,,,1836.90,1193.98,,,,,,,,,,,,,
STAPLE BNE L 12 X W 12 X H 12 MM STRL MOTOCLIP MAX,SUP-2908414,CDM,C1713,HCPCS,0278,RC,,,,both,,,3620.42,2353.27,,,,,,,,,,,,,
SCISSORS 4.5IN CVD SUP CUT STEVENS,SUP-2162150,CDM,2720000010,LOCAL,0272,RC,,,,both,,,776.96,505.02,,,,,,,,,,,,,
SCREW BNE L14MM DIA2.7MM S STL LOK HEX MTP CHARLOTTE CLAW,SUP-2397524,CDM,C1713,HCPCS,0278,RC,,,,both,,,207.24,134.71,,,,,,,,,,,,,
PLATE BNE STR MINI REG 2X0.6 MM 6 HOLE LP FOR SCR TI STRL,SUP-2458636,CDM,C1713,HCPCS,0278,RC,,,,both,,,287.31,186.75,,,,,,,,,,,,,
GAUGE DIAMETER ZIMMER BIOMET,SUP-2488095,CDM,2720000010,LOCAL,0272,RC,,,,both,,,714.13,464.18,,,,,,,,,,,,,
PORT GAST INJ SUTURELESS REPL W/ APPL REALIZE,SUP-2219871,CDM,C1788,HCPCS,0278,RC,,,,both,,,2684.70,1745.05,,,,,,,,,,,,,
SPLINT FA WRST PED 6 IN L,SUP-2336053,CDM,L3908,HCPCS,0272,RC,,,,both,,,14.79,9.61,,,,,,,,,,,,,
PLEDGET VASCULAR 45X6MM OVAL FIRM,SUP-2427114,CDM,C1768,CPT,0278,RC,,,,both,,,119.57,77.72,,,,,,,,,,,,,
HC N-Invas Est C Ffr Sw Aly Cta,PX-3297558000,CDM,75580,CPT,0480,RC,,,,both,,,5678.00,3690.70,,,,,,,,,,,,,
BOLT EXT FIX L10MM S STL CONN FOR ILIZ TAY SPAT FRME EXT,SUP-2342323,CDM,C1713,HCPCS,0278,RC,,,,both,,,913.74,593.93,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.438,SUP-2860002,CDM,C1713,HCPCS,0278,RC,,,,both,,,47437.24,30834.21,,,,,,,,,,,,,
COMPONENT 6X200MM HUMERAL ELBOW FLANGED C RIGHT DISCOVERY,SUP-2879138,CDM,C1776,CPT,0278,RC,,,,both,,,17091.02,11109.16,,,,,,,,,,,,,
BIT DRL L 295 MM DIA 5 MM LNG CANN QC STRL REUSE,SUP-2905576,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2429.76,1579.34,,,,,,,,,,,,,
ALLOGRAFT DERMAL N MESHED MED STD 2X4 CM FLOWERDERM,SUP-2225419,CDM,C1713,HCPCS,0278,RC,,,,both,,,2974.21,1933.24,,,,,,,,,,,,,
CATHETER EDI 6FR L49CM PHT FRE,SUP-2266012,CDM,2720000010,LOCAL,0272,RC,,,,both,,,746.06,484.94,,,,,,,,,,,,,
COMPONENT PATELLAR 25 MM KNEE ARCM POLYETH,SUP-2449779,CDM,C1776,CPT,0278,RC,,,,both,,,1904.72,1238.07,,,,,,,,,,,,,
MATRIX BIO SZ 300 SQCM FISH SKIN DERMAL MESHED 21 INTACT,SUP-2909230,CDM,Q4158,HCPCS,0636,RC,,,,both,,,30049.80,19532.37,,,,,,,,,,,,,
SCREW SPNL L14MM OD4MM 0DEG FIX SELF DRL CANN TI SNOWCAP,SUP-2207843,CDM,C1713,HCPCS,0278,RC,,,,both,,,776.21,504.54,,,,,,,,,,,,,
COMPONENT PAT DIA41MM THK10MM STD TI POLY TRABECULAR MTL,SUP-2200605,CDM,C1776,CPT,0278,RC,,,,both,,,9796.80,6367.92,,,,,,,,,,,,,
GRAFT VASC GORTX L 40 CM DIA 3 MM EPTFE STR TW N RING STRL,SUP-2396678,CDM,C1768,CPT,0278,RC,,,,both,,,1328.22,863.34,,,,,,,,,,,,,
ANCHOR SUT DIA1.5MM SGL LD JUGGERKNOT,SUP-2212949,CDM,C1713,HCPCS,0278,RC,,,,both,,,1160.54,754.35,,,,,,,,,,,,,
PLATE BONE L30MM MAXILLOFACIAL DBL T NONCOMPRESSION FOR MINI,SUP-2364907,CDM,C1713,HCPCS,0278,RC,,,,both,,,574.24,373.26,,,,,,,,,,,,,
GRAFT HUM TISS W50 55XL15MM FASC LATA,SUP-2307108,CDM,C1762,CPT,0278,RC,,,,both,,,2088.13,1357.28,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA MAXBARR 5FR 55CM S3385108D,SUP-2632850,CDM,C1751,HCPCS,0278,RC,,,,both,,,637.92,414.65,,,,,,,,,,,,,
STIMULATOR BNE GROWTH SZ 1 2 COIL,SUP-2196348,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7959.90,5173.93,,,,,,,,,,,,,
LENS IOL BCNVX 0+ DIOPT 6X12.5 MM ACRYL ENVISTA,SUP-2129601,CDM,V2632,HCPCS,0276,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
SPLINT WRST FOAM PADDING YTH FOREARM RT PERF DESIGN ALUM,SUP-2336021,CDM,L3908,HCPCS,0272,RC,,,,both,,,11.43,7.43,,,,,,,,,,,,,
ALLOGRAFT BNE FEM SHFT 210 MMX0.3 CM FD,SUP-2717850,CDM,C1762,CPT,0278,RC,,,,both,,,7191.79,4674.66,,,,,,,,,,,,,
CONNECTOR SPNL TI STR SLT W/ WSHR FOR 6.35MM ROD MNRCH,SUP-2254511,CDM,C1713,HCPCS,0278,RC,,,,both,,,2857.40,1857.31,,,,,,,,,,,,,
BRACE ANK LACE UP X LG ELASTIC CUF CLOSURE SPRT ORTHOSIS NYL,SUP-2336333,CDM,L4350,HCPCS,0274,RC,,,,both,,,33.69,21.90,,,,,,,,,,,,,
TIROFIBAN HCL IN NACL 12.5-0.9 MG/250ML-% IV SOLN,RX-135453,CDM,J3246,HCPCS,0636,RC,14789-0102-05,NDC,,both,250,ML,920.00,598.00,,,,,,,,,,,,,
ADAPTER TIB TY 3MM OFFSET BAL REV SYS,SUP-2315558,CDM,C1776,CPT,0278,RC,,,,both,,,1783.52,1159.29,,,,,,,,,,,,,
SYSTEM AIRWAY NASAL CLEAR FLOW RELTOK,SUP-2707513,CDM,2720000010,LOCAL,0272,RC,,,,both,,,562.06,365.34,,,,,,,,,,,,,
GRAFT DERMAL RECT 7.9X15.7 IN ANTIBACT XENMATRIX AB,SUP-2855243,CDM,C1781,HCPCS,0278,RC,,,,both,,,84780.00,55107.00,,,,,,,,,,,,,
SCREW BONE LOK 3.5MM DIA UNVRSL 80MML TTNM CRTCL SELF TPPNG,SUP-2588595,CDM,C1713,HCPCS,0278,RC,,,,both,,,70.40,45.76,,,,,,,,,,,,,
DRILL TWST L87MM OD21MM CANN AO QUIK CPL SHFT END FOR K WIRE,SUP-2267871,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1701.25,1105.81,,,,,,,,,,,,,
DRILL DISK DIA7MM 3 ULTSONIC DISP ULT DRV,SUP-2408562,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2935.90,1908.33,,,,,,,,,,,,,
SUPPORT ORTHOT FT CUST INSRT MOLD TO PT MODEL SPENCO,SUP-2435701,CDM,L3001,HCPCS,0274,RC,,,,both,,,374.48,243.41,,,,,,,,,,,,,
SPADE TIP DRILL FOR 3.9MM SWIVELOCK,SUP-2812532,CDM,2720000010,LOCAL,0272,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
STEM FEM L150MM DIA13MM HIP TI HI OFFSET PRESSFIT NEUT PRI,SUP-2344348,CDM,C1776,CPT,0278,RC,,,,both,,,11021.40,7163.91,,,,,,,,,,,,,
ENDCAP SCR SPNL TITLE 2,SUP-2211411,CDM,2780000010,LOCAL,0278,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
PLUG VASC DIA 9 MM AMPLTZ DEL STRL,SUP-2167792,CDM,C1757,HCPCS,0272,RC,,,,both,,,496.12,322.48,,,,,,,,,,,,,
TOOL VLV BYPS FOR SLITTABLE INNR GUID CATH CPS AIM SL,SUP-2356360,CDM,C1893,HCPCS,0272,RC,,,,both,,,50.24,32.66,,,,,,,,,,,,,
STENT CAR PRECIS L 40 MM DIA 8 MM CATH L 135 CM SHTH 8 FR,SUP-2158965,CDM,C1876,HCPCS,0278,RC,,,,both,,,4144.80,2694.12,,,,,,,,,,,,,
SPHERE EMB ONCOZENE DIA 40 UM 2 ML HYDRGEL POLYZENE MIC WHT,SUP-2139503,CDM,C1889,HCPCS,0278,RC,,,,both,,,10048.00,6531.20,,,,,,,,,,,,,
NEURO MD SCREW 15MM DIA X 4MM TI 6AL 4V TITANIUM ALLOY,SUP-2677102,CDM,C1713,HCPCS,0278,RC,,,,both,,,192.64,125.22,,,,,,,,,,,,,
SCREW BNE SD 3-2.5X60/20 MM CORTICAL STRL SOLE LTX,SUP-2875653,CDM,C1713,HCPCS,0278,RC,,,,both,,,454.11,295.17,,,,,,,,,,,,,
CROWN DENT SZ DLR3 LO RT 1ST M S STL REFIL PRI,SUP-2322186,CDM,D6783,CPT,0278,RC,,,,both,,,28.13,18.28,,,,,,,,,,,,,
GUIDEWIRE VASC GLIDEWIRE GT L 180CM 0.018IN 90/60 DEG,SUP-2385632,CDM,C1769,HCPCS,0272,RC,,,,both,,,619.08,402.40,,,,,,,,,,,,,
GRAFT BONE SUB 5CC CA PHOS VIT E ACETT HEMSTAT COHESIVE,SUP-2106300,CDM,C1713,HCPCS,0278,RC,,,,both,,,5491.86,3569.71,,,,,,,,,,,,,
CONNECTOR SPNL SM SZ 4 L26-27MM STD POST LUM THOR TI SCR,SUP-2254359,CDM,C1713,HCPCS,0278,RC,,,,both,,,3546.63,2305.31,,,,,,,,,,,,,
IBAL TKA FEM IMP PS CEMENTED SZ 5 LFT,SUP-2813066,CDM,C1776,CPT,0278,RC,,,,both,,,4396.00,2857.40,,,,,,,,,,,,,
ALLOGRAFT HUM TISS MED 5 CC OSTEOCONDUCTIVE MTRX + NUCEL,SUP-2716038,CDM,C1762,CPT,0278,RC,,,,both,,,6609.70,4296.30,,,,,,,,,,,,,
DRIVER SURG T10 HEXALOBE CALIB AO QC NS REUSE PHANTOM,SUP-2909077,CDM,C1713,HCPCS,0278,RC,,,,both,,,1036.20,673.53,,,,,,,,,,,,,
GUIDEWIRE ORTH DIA2.8MM BITE 6.5-8MM COMPR SCR,SUP-2315942,CDM,C1769,HCPCS,0272,RC,,,,both,,,499.10,324.41,,,,,,,,,,,,,
CAGE SPNL SPIKLS 3.5 DEG 14X16 MM 12 MM UPPER LOWER ENDPLATE,SUP-2420875,CDM,C1889,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
SCREW LCKNG MATRIXRIB TI SLF DRL 2.7X11MM,SUP-2752103,CDM,C1713,HCPCS,0278,RC,,,,both,,,843.09,548.01,,,,,,,,,,,,,
LEAD PACE L86CM 7.5CM ELECTRD SPACE L VENT QPLR TINES 3D,SUP-2148718,CDM,C1900,HCPCS,0275,RC,,,,both,,,4816.76,3130.89,,,,,,,,,,,,,
AUG PAT 3-PEG ROT POR LCS 177974000] JNJ DEPUY SYNTHES ORTHOPEDICS],SUP-2252415,CDM,C1776,CPT,0278,RC,,,,both,,,4345.76,2824.74,,,,,,,,,,,,,
CATHETER HD 7.5 FRX18 CM LT VLV INTRO GLIDEPATH AIRGUARD,SUP-2627025,CDM,C1750,HCPCS,0278,RC,,,,both,,,2093.60,1360.84,,,,,,,,,,,,,
BIT DRL DIA6.5MM NONSTERILE COUNTSINK CONIC STP,SUP-2178941,CDM,2720000010,LOCAL,0272,RC,,,,both,,,992.11,644.87,,,,,,,,,,,,,
STEM HUM SZ 7 L130MM 135DEG CO CHROM MOLYBDENUM CEM,SUP-2204817,CDM,C1776,CPT,0278,RC,,,,both,,,11285.16,7335.35,,,,,,,,,,,,,
INTRAAORTIC PUMP KIT 34 CC 40 CC INSRTN SENS,SUP-2534219,CDM,C1894,HCPCS,0272,RC,,,,both,,,414.35,269.33,,,,,,,,,,,,,
DOXORUBICIN HCL LIPOSOMAL 2 MG/ML IV SUSP,RX-169094,CDM,Q2050,HCPCS,0636,RC,47335-0050-40,NDC,,both,25,ML,1669.30,1085.04,,,,,,,,,,,,,
LASER SURG CRV 23 GA ILL,SUP-2713794,CDM,2720000010,LOCAL,0272,RC,,,,both,,,513.70,333.90,,,,,,,,,,,,,
HC Paracentesis W/O Imaging,PX-7614908200,CDM,49082,CPT,0761,RC,,,,outpatient,,,2844.00,1848.60,,,,,,,,,,,,,
CATHETER ANGIOPLSTY L75CM BAL L100MM DIA10MM RBP 18ATM GWIRE,SUP-2117081,CDM,C1725,HCPCS,0272,RC,,,,both,,,741.04,481.68,,,,,,,,,,,,,
DRILL SURG OFFSET KNEE FOR REV SYS ATTUNE,SUP-2454562,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1510.34,981.72,,,,,,,,,,,,,
NEEDLE ENDO NON STRL ELITE REUSE,SUP-2747578,CDM,2720000010,LOCAL,0272,RC,,,,both,,,905.54,588.60,,,,,,,,,,,,,
TROCAR SURG TRANSBUCCAL 71 MM MOD,SUP-2477313,CDM,2720000010,LOCAL,0272,RC,,,,both,,,680.12,442.08,,,,,,,,,,,,,
SCREW BNE LCK 3.5X36 MM PERIARTICULAR STRL,SUP-2459159,CDM,C1713,HCPCS,0278,RC,,,,both,,,331.21,215.29,,,,,,,,,,,,,
PIN EXT FIX L 50 MM DIA 5 MM SHRT TIN TRACTION STRL DISP,SUP-2932905,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1240.27,806.18,,,,,,,,,,,,,
CAP PROTCT 4MM RED FOR THRD PIN JETX,SUP-2342834,CDM,C1713,HCPCS,0278,RC,,,,both,,,182.75,118.79,,,,,,,,,,,,,
BLOCK CANC TRAD ALLGRFT 30 MM LX13 MM WX13 MM H FRZ DRY,SUP-2294053,CDM,C1713,HCPCS,0278,RC,,,,both,,,2260.80,1469.52,,,,,,,,,,,,,
SPACER SPNL H13MM 8DEG M ANTR LUM INTBDY FUS LORDTC INTEGR,SUP-2231341,CDM,C1821,HCPCS,0278,RC,,,,both,,,17584.00,11429.60,,,,,,,,,,,,,
CEMENT BNE ARTHRPLSTY ORTHOPEDIC N MEDICATED GENTAMICIN,SUP-2156016,CDM,C1713,HCPCS,0278,RC,,,,both,,,554.65,360.52,,,,,,,,,,,,,
SUPPORT ORTHOT HIP JT LOWER EXTREMITY PELV CTRL LCK,SUP-2435683,CDM,L2610,HCPCS,0272,RC,,,,both,,,667.25,433.71,,,,,,,,,,,,,
PLATE BNE CERV SM 2.7X60 MM 7 HOLE TI,SUP-2536116,CDM,C1713,HCPCS,0278,RC,,,,both,,,402.23,261.45,,,,,,,,,,,,,
SCREW BONE L45MM DIA6.4MM STD CORT LCK RECON FOR FEM NAIL,SUP-2342526,CDM,C1713,HCPCS,0278,RC,,,,both,,,259.02,168.36,,,,,,,,,,,,,
SCREW BNE L70MM DIA5.5MM LNG PERIARTC CORT S STL ST CANN,SUP-2410842,CDM,C1713,HCPCS,0278,RC,,,,both,,,527.83,343.09,,,,,,,,,,,,,
HC Drug Tst Prsmv Instrmnt Chem Analyzers PR Date|NOT REASONABLE AND NECESSARY,PX-3018030700,CDM,80307,CPT,0301,RC,,,GZ,both,,,400.00,260.00,,,,,,,,,,,,,
ANCHOR SUT 3.4 MM DIA SGL ARMED BIOCRYL RAPIDE ABSRB 2 SUT,SUP-2256654,CDM,C1713,HCPCS,0278,RC,,,,both,,,2957.88,1922.62,,,,,,,,,,,,,
STEM FEM L220MM DIA15MM CALCAR HIP ZMLY CLLRD FOR VERSYS 78711561] ZIMMER BIOMET INC],SUP-2211407,CDM,C1776,CPT,0278,RC,,,,both,,,14068.61,9144.60,,,,,,,,,,,,,
CONNECTOR SPNL W55XH45MM TI SIDE LD,SUP-2279796,CDM,C1713,HCPCS,0278,RC,,,,both,,,2539.13,1650.43,,,,,,,,,,,,,
WASHER SPNL 15MM TI BNE GRFT,SUP-2292219,CDM,C1713,HCPCS,0278,RC,,,,both,,,920.02,598.01,,,,,,,,,,,,,
HC So1 Fluor Anti Titer,PX-3028625667,CDM,86256,CPT,0302,RC,,,,both,,,196.00,127.40,,,,,,,,,,,,,
GRAFT HUM TISS 2X2 CM AMNIO MEMBRN MTRX,SUP-2225380,CDM,2780000010,LOCAL,0278,RC,,,,both,,,4458.80,2898.22,,,,,,,,,,,,,
PLATE BONE PREBENT 2MM STP RT MAX 1.6MM SCR OSA SYS,SUP-2319382,CDM,C1713,HCPCS,0278,RC,,,,both,,,1133.54,736.80,,,,,,,,,,,,,
HOLDER SPNL PLT FOR FIX,SUP-2287267,CDM,C1713,HCPCS,0278,RC,,,,both,,,216.66,140.83,,,,,,,,,,,,,
GRAFT VASC STD WALL 6 MMX40 CM STR RNG REINF ADVANTA VXT,SUP-2469303,CDM,C1768,CPT,0278,RC,,,,both,,,1738.84,1130.25,,,,,,,,,,,,,
PLATE BNE TBLR 159 MM 12 HOLE 1/3 LCK SS STRL,SUP-2499651,CDM,C1713,HCPCS,0278,RC,,,,both,,,548.53,356.54,,,,,,,,,,,,,
TRIPTORELIN PAMOATE 3.75 MG IM SUSR,RX-28558,CDM,J3315,HCPCS,0636,RC,74676-5902-01,NDC,,both,1,UN,2631.60,1710.54,,,,,,,,,,,,,
DEVICE FIX MTO N ABSRB STRL ENDOBUTTON,SUP-2849141,CDM,C1713,HCPCS,0278,RC,,,,both,,,2791.46,1814.45,,,,,,,,,,,,,
SYSTEM BX L114MM DIA1.9MM COR PROPRIETARY BLDE DSGN FOR,SUP-2281537,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1579.42,1026.62,,,,,,,,,,,,,
STREAMER OTOLOGICAL WHT,SUP-2430286,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
GRAFT BNE FIBER SM 2.5 CC SYR DBM,SUP-2431096,CDM,C1889,HCPCS,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
PACK INSTR CONVENIENCE W/ MPFL TMPLT 4.75 BIO SWIVELOCK,SUP-2121120,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4330.06,2814.54,,,,,,,,,,,,,
SCREW BONE 2.8X14MM CANN PART THRD BIODRIVE,SUP-2408399,CDM,C1713,HCPCS,0278,RC,,,,both,,,663.80,431.47,,,,,,,,,,,,,
RASP SURG RND SHANK 73X5.5 MM RECIP,SUP-2607480,CDM,2720000010,LOCAL,0272,RC,,,,both,,,109.90,71.43,,,,,,,,,,,,,
SCREW ABSRBBLE 50MM DIA 40MML LOW PRFLE DRCT DRIVE ARTHRTK,SUP-2724043,CDM,C1725,HCPCS,0272,RC,,,,both,,,916.88,595.97,,,,,,,,,,,,,
NEEDLE MAYO 1/2 CIRCLE SIZE 4 TAPER POINT 212613,SUP-2845002,CDM,C1713,HCPCS,0278,RC,,,,both,,,18.68,12.14,,,,,,,,,,,,,
NAIL IM L350MM OD13MM SUBTROCHANTERIC ROD LT ZCKL II,SUP-2364772,CDM,C1713,HCPCS,0278,RC,,,,both,,,4354.40,2830.36,,,,,,,,,,,,,
ALLOGRAFT BNE CUBE 13X13X13 MM 2.2 CC CANC CONFORM Q-PACK,SUP-2737082,CDM,C1713,HCPCS,0278,RC,,,,both,,,2129.86,1384.41,,,,,,,,,,,,,
HC So1 Infliximab Level,PX-3018023067,CDM,80230,CPT,0301,RC,,,,both,,,1477.00,960.05,,,,,,,,,,,,,
GUIDEWIRE VASC L 180 CM DIA 0.035 IN TIP L 3 MM SS PTFE J,SUP-2733979,CDM,C1769,HCPCS,0272,RC,,,,both,,,22.17,14.41,,,,,,,,,,,,,
SCREW SPINAL RETAIN 3.5X14MM,SUP-2256930,CDM,C1713,HCPCS,0278,RC,,,,both,,,1676.76,1089.89,,,,,,,,,,,,,
LINER CROSS LINK LNR NEUT 22X44MM,SUP-2267710,CDM,C1776,CPT,0278,RC,,,,both,,,2970.44,1930.79,,,,,,,,,,,,,
MICROSPHERE EMB THERASPHERE 5 GBQ YTTRIUM-90 GLS DOSE VI,SUP-2135306,CDM,C1889,HCPCS,0278,RC,,,,both,,,54322.00,35309.30,,,,,,,,,,,,,
SCREW BONE 32MM 6.5MM CANC LCK EQUINOXE,SUP-2223450,CDM,C1713,HCPCS,0278,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
HC Med Nutr Ther Group Init/Fu 30 Min,PX-9429780400,CDM,97804,CPT,0940,RC,,,,both,,,37.00,24.05,,,,,,,,,,,,,
PLATE STRNL 8 H TI PI NS MATRIXSTERNUM,SUP-2904258,CDM,C1713,HCPCS,0278,RC,,,,both,,,2009.32,1306.06,,,,,,,,,,,,,
GUANFACINE HCL 1 MG PO TABS,RX-10149,CDM,6370000000,HCPCS,0637,RC,00591-0444-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE 2.5 CC DEMINERALIZED CORTICAL BNE FIBER,SUP-2932935,CDM,C1762,CPT,0278,RC,,,,both,,,1927.58,1252.93,,,,,,,,,,,,,
POST GLENOID 20 MM SHOULDER MODULAR CENTRAL STERILE UNIVERS,SUP-2836551,CDM,C1776,CPT,0278,RC,,,,both,,,832.10,540.86,,,,,,,,,,,,,
PREDNISONE 5 MG PO TABS,RX-6497,CDM,J7512,HCPCS,0637,RC,00054-8724-25,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
GUIDEWIRE VASC L 260 CM DIA 0.018 IN TAPR L 7 CM FLX TIP L 2,SUP-2167643,CDM,C1769,HCPCS,0272,RC,,,,both,,,53.66,34.88,,,,,,,,,,,,,
HC US Fetal Evaluation-Limited,PX-4027681500,CDM,76815,CPT,0402,RC,,,,both,,,744.00,483.60,,,,,,,,,,,,,
HC So Buprenorphine,PX-3018034866,CDM,G0480,CPT,0301,RC,,,,both,,,169.00,109.85,,,,,,,,,,,,,
SCREW BNE CORTICAL 3.5X16 MM FUSION HEX DRV YEL WRST SS NS,SUP-2852074,CDM,C1713,HCPCS,0278,RC,,,,both,,,456.56,296.76,,,,,,,,,,,,,
POLYVINYL ALCOHOL-POVIDONE PF 1.4-0.6 % OP SOLN,RX-141221,CDM,6370000000,HCPCS,0637,RC,00023-0506-50,NDC,,both,0.05,ML,1.00,0.65,,,,,,,,,,,,,
GRAFT BNE 10 CC CELLULAR BNE MTRX OSSEOGEN,SUP-2858501,CDM,C1713,HCPCS,0278,RC,,,,both,,,10205.00,6633.25,,,,,,,,,,,,,
BUR SURG RND 6 MM 51 MM FLUT FOR DRL SYS SS,SUP-2628956,CDM,2720000010,LOCAL,0272,RC,,,,both,,,211.26,137.32,,,,,,,,,,,,,
ECH STRAIGHT 190MM SZ 20 STD COLLAR,SUP-2822792,CDM,C1776,CPT,0278,RC,,,,both,,,19059.80,12388.87,,,,,,,,,,,,,
PROSTHESIS OSS PISTON 0.8X3.75 MM RICHARD PLAT FLROPLAS,SUP-2637849,CDM,L8613,CPT,0278,RC,,,,both,,,546.01,354.91,,,,,,,,,,,,,
COLLAR CERV 9-24 MO PEDIATRIC 29-37 IN FLEXTABS HK,SUP-2427924,CDM,L0172,HCPCS,0272,RC,,,,both,,,103.87,67.52,,,,,,,,,,,,,
BUR SURG L48MM DIA2MM 150 200 GRIT DMND RND FOR OTO OSTEON,SUP-2166382,CDM,2720000010,LOCAL,0272,RC,,,,both,,,311.08,202.20,,,,,,,,,,,,,
GUIDE SURG SZ 04-02 MOD SET FOR TOT KNEE ARTHROPLASTY SIGN,SUP-2408585,CDM,C1713,HCPCS,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
STENT CORONARY ORSIRO L 15 MM DIA 3.5 MM DEL SYS L 140 CM,SUP-2501377,CDM,C1874,HCPCS,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
PROBE NERVE STIM BALL TIP STRL DISP,SUP-2517604,CDM,2720000010,LOCAL,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
ANCHOR SFT TISS 2.8 MM SINGLE W/O SUTURE OR NDL TI TWINFIX,SUP-2877961,CDM,C1713,HCPCS,0278,RC,,,,both,,,619.84,402.90,,,,,,,,,,,,,
HC Scs Analysis W/O Program,PX-9209597000,CDM,95970,CPT,0920,RC,,,,both,,,418.00,271.70,,,,,,,,,,,,,
VERAPAMIL HCL ER 120 MG PO TBCR,RX-13184,CDM,6370000000,HCPCS,0637,RC,68462-0292-01,NDC,,both,1,UN,2.80,1.82,,,,,,,,,,,,,
STEM FEM STD OFFSET 133 DEG 18-24 MM TYPE1 TRUNNION TAPRLOK,SUP-2448381,CDM,C1776,CPT,0278,RC,,,,both,,,1102.14,716.39,,,,,,,,,,,,,
MATRIX HEMOSTATIC BOV DERIVED 10 CC GEL APPL TIP FLOSEAL,SUP-2424551,CDM,C1713,HCPCS,0278,RC,,,,both,,,814.80,529.62,,,,,,,,,,,,,
DEVICE FIX 15MM LOOP DYNEEMA PURITY BRAID CONT FOR ACL PCL,SUP-2366632,CDM,C1713,HCPCS,0278,RC,,,,both,,,1284.26,834.77,,,,,,,,,,,,,
ALLOGRAFT BNE 20X45X5 MM DBM STRP INCITE,SUP-2517583,CDM,C1713,HCPCS,0278,RC,,,,both,,,8116.90,5275.98,,,,,,,,,,,,,
RESERVOIR VENTRICULAR 14 MM ACCU-FLO,SUP-2666408,CDM,C1889,HCPCS,0278,RC,,,,both,,,1301.78,846.16,,,,,,,,,,,,,
SCREW BONE L5MM DIA2MM CORT CRANIOMAXILLOFACIAL TI ST,SUP-2188962,CDM,C1713,HCPCS,0278,RC,,,,both,,,177.72,115.52,,,,,,,,,,,,,
GUIDEWIRE ORTHOPEDIC INSTRUMENT 1.1 MMX31.49 CM INTRAFIX ADV,SUP-2257894,CDM,C1769,HCPCS,0272,RC,,,,both,,,241.25,156.81,,,,,,,,,,,,,
SYSTEM 1 DEL DEV AND 1 MESH ASMBLY PREFYX PPS,SUP-2141797,CDM,C1771,HCPCS,0278,RC,,,,both,,,3554.17,2310.21,,,,,,,,,,,,,
MINERAL OIL PO OIL,RX-5086,CDM,340b,HCPCS,0637,RC,48433-0202-30,NDC,,both,15,ML,8.60,5.59,,,,,,,,,,,,,
SCREW BNE L12MM DIA3.5MM NONLOCKING FOR TUFFNEK TECHNOLOGY,SUP-2321194,CDM,C1713,HCPCS,0278,RC,,,,both,,,529.88,344.42,,,,,,,,,,,,,
CATHETER EMB FOGARTY L 60 CM DIA2 FR BALLOON DIA 4 MM,SUP-2214007,CDM,C1757,HCPCS,0272,RC,,,,both,,,245.30,159.44,,,,,,,,,,,,,
PLATE BNE BROAD 3.5X170 MM 14 HOLE SS DCP,SUP-2569156,CDM,C1713,HCPCS,0278,RC,,,,both,,,379.94,246.96,,,,,,,,,,,,,
GRAFT SFT TISS W6X16CM NAT BARR OPTIMIZE SURG PERF AMNIOFIX,SUP-2305727,CDM,V2790,HCPCS,0274,RC,,,,both,,,12443.82,8088.48,,,,,,,,,,,,,
SPACER SCREW SELF RET 2 MM MAND X DRV TI THREADLOCK TS,SUP-2493717,CDM,C1713,HCPCS,0278,RC,,,,both,,,280.62,182.40,,,,,,,,,,,,,
COMPONENT FEM L35MM SEG CLLR FOR 17-19MM STEM TRABECULAR,SUP-2200567,CDM,C1776,CPT,0278,RC,,,,both,,,6231.33,4050.36,,,,,,,,,,,,,
CATHETER THROMCTMY 7FR L145CM STD ALONE EXPORT,SUP-2295351,CDM,C1769,HCPCS,0272,RC,,,,both,,,1114.70,724.55,,,,,,,,,,,,,
BIT DRL DIA4MM S STL CANN,SUP-2290857,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1456.46,946.70,,,,,,,,,,,,,
STENT URET L80CM DIA6FR STR FIRM OPN PERCFLX LUERLOCK ADPT,SUP-2139080,CDM,C2617,HCPCS,0278,RC,,,,both,,,65.28,42.43,,,,,,,,,,,,,
PEG BNE FIX DST FEM MOD TRIATHLON,SUP-2373755,CDM,C1776,CPT,0278,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
PLATE BNE Y 2.3X1.5 MM THOR RIB 40 HOLE LCK LEVEL 1,SUP-2869166,CDM,C1713,HCPCS,0278,RC,,,,both,,,5915.76,3845.24,,,,,,,,,,,,,
PLATE BNE L 44.45 X W 6.99 MM THK 2 MM SCREW DIA2/2.3 MM 6 H,SUP-2937040,CDM,C1713,HCPCS,0278,RC,,,,both,,,1927.96,1253.17,,,,,,,,,,,,,
PLATE BNE W24XL31MM 5 H ST BILAT MIDFOOT HINDFOOT TI RIG LOK,SUP-2191456,CDM,C1713,HCPCS,0278,RC,,,,both,,,2874.07,1868.15,,,,,,,,,,,,,
PLATE CRAN 120X40X20 MM PT SPEC IMPL PEEK,SUP-2860178,CDM,C1713,HCPCS,0278,RC,,,,both,,,25639.67,16665.79,,,,,,,,,,,,,
COLLAR EXTRIC AD 2IN 17IN XSH TWO PC TRACH OPN VELC CLSR W,SUP-2194464,CDM,L0172,HCPCS,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
PEN ISOLATOR ELECTRD L7MM BPLR TRANSPOLAR UNIDIR LESION MAX1] ATRICURE INC],SUP-2124459,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5809.00,3775.85,,,,,,,,,,,,,
MESH MXLFCL 126.2X11 MM 1 MM FOIL PLLA-PGA STRL RESORB XG,SUP-2487956,CDM,C1713,HCPCS,0278,RC,,,,both,,,1741.26,1131.82,,,,,,,,,,,,,
PROBE ELECTRD SINGLE 25 CM IRREVERSIBLE NANOKNIFE,SUP-2752604,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7222.00,4694.30,,,,,,,,,,,,,
LINER ACET CUP NEUT PRI SNAP IN MTL ON POLY POLYETH 0DEG,SUP-2202228,CDM,C1776,CPT,0278,RC,,,,both,,,2989.28,1943.03,,,,,,,,,,,,,
PROBE CHNDLR TRNSLUMN V PACE 2.4X135CM SWAN GANZ,SUP-2214433,CDM,2720000010,LOCAL,0272,RC,,,,both,,,358.62,233.10,,,,,,,,,,,,,
RESERVOIR PERF BG 800 ML VEN CORTIVA COAT MVR,SUP-2494155,CDM,2720000010,LOCAL,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
RESERVOIR VENT DRNGE NEO 01ML INTCRAN L75CM DIA4CM,SUP-2277914,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1006.68,654.34,,,,,,,,,,,,,
PLATE BNE L69MM 3 H ST R SUP ANT CLAV TI LOK COMPR W LAT,SUP-2180853,CDM,C1713,HCPCS,0278,RC,,,,both,,,3063.51,1991.28,,,,,,,,,,,,,
ALLOGRAFT BNE CHIP 1-4 MM FRZN CRUSH CANC 800116,SUP-2743365,CDM,C1713,HCPCS,0278,RC,,,,both,,,6050.78,3933.01,,,,,,,,,,,,,
INSERT SHOE ANK JT,SUP-2388172,CDM,L2180,HCPCS,0274,RC,,,,both,,,295.98,192.39,,,,,,,,,,,,,
PROSTHESIS VOICE 17FR 6MM LESS STRAINED SPEAK VLV PROVOX,SUP-2124379,CDM,L8509,HCPCS,0272,RC,,,,both,,,940.08,611.05,,,,,,,,,,,,,
PLATE BNE THK 0.8 MM SCREW DIA2 MM 6 H MED CRV NS DISP,SUP-2934840,CDM,C1713,HCPCS,0278,RC,,,,both,,,1164.94,757.21,,,,,,,,,,,,,
CONNECTOR SPNL ROD LNG 100 MM CLOSED AX MARINER OUTRIG,SUP-2709810,CDM,C1713,HCPCS,0278,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
DEVICE FIX L36MM 5MM 30 TACKS ABSRB POLY COPOLYMER ERGO,SUP-2283225,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1273.11,827.52,,,,,,,,,,,,,
PLATE CRAN 60X40X20 MM PT SPEC IMPL PEEK,SUP-2860175,CDM,C1713,HCPCS,0278,RC,,,,both,,,26356.22,17131.54,,,,,,,,,,,,,
COLLAR EXTRIC AD 2IN 17IN XSH TWO PC TRACH OPN VELC CLSR W,SUP-2194464,CDM,L0172,HCPCS,0274,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
HC Level VI Surg Pathology Gross&Microscopic Exam,PX-3128830900,CDM,88309,CPT,0312,RC,,,,both,,,1380.00,897.00,,,,,,,,,,,,,
DEVICE FIX 8MM DIR ENDOBUTTON,SUP-2341086,CDM,C1713,HCPCS,0278,RC,,,,both,,,938.86,610.26,,,,,,,,,,,,,
COMPONENT TIB TY MOD REV PROVEN SZ 3T3F,SUP-2359296,CDM,C1776,CPT,0278,RC,,,,both,,,8666.40,5633.16,,,,,,,,,,,,,
CATHETER GUID 5 FRX135 CM MULTLYR TURNPIKE,SUP-2383150,CDM,C1887,HCPCS,0272,RC,,,,both,,,2461.76,1600.14,,,,,,,,,,,,,
PLATE BONE L155MM 11 H LT DSTL LAT FIBULAR VAR ANG LCK FOR,SUP-2349831,CDM,C1713,HCPCS,0278,RC,,,,both,,,6837.82,4444.58,,,,,,,,,,,,,
WIRE FIX L200MM DIA2.5MM S STL DBL SHRP TIP SMOOTH TIBIAXYS,SUP-2242888,CDM,C1769,HCPCS,0272,RC,,,,both,,,224.89,146.18,,,,,,,,,,,,,
SPIRONOLACTONE 25 MG PO TABS,RX-7437,CDM,6370000000,HCPCS,0637,RC,00904-6927-61,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PLATE BNE W10.2XL156MM THK2.7MM 12 H BILAT S STL STR LO,SUP-2186199,CDM,C1713,HCPCS,0278,RC,,,,both,,,1620.55,1053.36,,,,,,,,,,,,,
CATHETER DEL AMPLATZER TORQVUE LP TIP 90 DEG L 80 CM DIA 4,SUP-2904230,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2311.04,1502.18,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED UPCHARGE BIOMETKNEUP] ZIMMER BIOMET INC],SUP-2137344,CDM,C1776,CPT,0278,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
PLATE BONE COMPRESSION SMALL 195 MM PELVIC 15 HOLE CONTOURED,SUP-2837526,CDM,C1713,HCPCS,0278,RC,,,,both,,,4142.29,2692.49,,,,,,,,,,,,,
CATHETER VALVULOPLASTY COEFFICIENT L 75 CM 3.5 FR 4 CM 4 MM,SUP-2659438,CDM,C1725,HCPCS,0272,RC,,,,both,,,1466.38,953.15,,,,,,,,,,,,,
CATHETER CARD ABLATION CHILLI II L 120 CM DIA 7 FR SPC 2.5,SUP-2139755,CDM,C1730,HCPCS,0272,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
STEM FEM PRSS FIT COCR HA COAT SZ 5/15MM MERID PA,SUP-2375312,CDM,C1776,CPT,0278,RC,,,,both,,,9037.99,5874.69,,,,,,,,,,,,,
GRAFT BNE RND 7X0.6 CM DBM ACCELL TBM,SUP-2641758,CDM,C1713,HCPCS,0278,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
ROD REPROC EXT FIX CRV 90 DEG 11X382 MM MR NS,SUP-2188644,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1359.62,883.75,,,,,,,,,,,,,
MATRIX WOUND THERAGENESIS MESHED BILYR 12X24CM,SUP-2737593,CDM,A2008,HCPCS,0636,RC,,,,both,,,19782.00,12858.30,,,,,,,,,,,,,
SHELL ACET SZ D DIA48MM STD TI POR SPIK REFLCT,SUP-2345040,CDM,C1776,CPT,0278,RC,,,,both,,,6320.82,4108.53,,,,,,,,,,,,,
ACETAZOLAMIDE 25 MG/ML PO SUSP,RX-4081112,CDM,6370000000,HCPCS,0637,RC,09999-9904-13,NDC,,both,5,ML,30.00,19.50,,,,,,,,,,,,,
GRAFT BONE SUB 25X100X4MM 10ML STRP BIOLOGIC SPINE SURG,SUP-2232308,CDM,C1713,HCPCS,0278,RC,,,,both,,,4490.20,2918.63,,,,,,,,,,,,,
IMPERIUM 300 OTO FIBER,SUP-2885249,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2110.08,1371.55,,,,,,,,,,,,,
CANNULA SUCTION 3MM SINUS ANGLED,SUP-2667540,CDM,2720000010,LOCAL,0272,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
SPACER SPNL PARL 0 DEG 21X15X9 MM VALEO PL,SUP-2175328,CDM,C1713,HCPCS,0278,RC,,,,both,,,10048.00,6531.20,,,,,,,,,,,,,
POST HUM L32MM DIA12MM SHLDR TAPR HEMICAPOVO,SUP-2123537,CDM,C1776,CPT,0278,RC,,,,both,,,2841.70,1847.10,,,,,,,,,,,,,
COIL EMB L4CM LOOP OD2MM OD0.020IN NIT STRTCH RESIST CRV,SUP-2323441,CDM,C1889,HCPCS,0278,RC,,,,both,,,5865.52,3812.59,,,,,,,,,,,,,
GRAFT BNE MORSELS MINI 1.5 CC MOLD GRAN CUBE ISOTIS MOZAIK,SUP-2427675,CDM,C1713,HCPCS,0278,RC,,,,both,,,580.90,377.58,,,,,,,,,,,,,
PACEMAKER CARD 20GM 10.4CC W50XH47MM THK6MM SGL CHMBR IS1,SUP-2356457,CDM,C1786,HCPCS,0275,RC,,,,both,,,9734.00,6327.10,,,,,,,,,,,,,
STEM FEM L260MM DIA19MM STD CLLR L HIP CO CHROME POR REV,SUP-2345240,CDM,C1776,CPT,0278,RC,,,,both,,,24713.37,16063.69,,,,,,,,,,,,,
CONNECTOR ROD DIA6.35MM TI TRNSVRS SPINE W/ CNTR NUT ISOLA,SUP-2255603,CDM,C1713,HCPCS,0278,RC,,,,both,,,3275.02,2128.76,,,,,,,,,,,,,
BIT DRILL L220MM DIA44MM CS 65 CANNULATED HUDSON,SUP-2586586,CDM,2720000010,LOCAL,0272,RC,,,,both,,,771.06,501.19,,,,,,,,,,,,,
PLATE EXT FIX SHT 100 MM FT RNG CARBON FIBER NS,SUP-2800194,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1920.99,1248.64,,,,,,,,,,,,,
PI PICC 3-L: 6FRX55CM WITH 80CM HYDRO NI,SUP-2822096,CDM,C1751,HCPCS,0278,RC,,,,both,,,472.26,306.97,,,,,,,,,,,,,
SCREW SPNL 5.5X35 MM SHANK OSTEOGRIP NS CD HORIZON,SUP-2737981,CDM,C1713,HCPCS,0278,RC,,,,both,,,1033.06,671.49,,,,,,,,,,,,,
SCREW BNE ST STD 2X15 MM CORTICAL COMPR TI,SUP-2189448,CDM,C1713,HCPCS,0278,RC,,,,both,,,159.79,103.86,,,,,,,,,,,,,
SPLINT ARM SM L7IN L ALUMINUM FOAM PD MAL COLLES,SUP-2276768,CDM,L3809,HCPCS,0274,RC,,,,both,,,17.80,11.57,,,,,,,,,,,,,
REDUCTION TWR,SUP-2232138,CDM,2780000010,LOCAL,0278,RC,,,,both,,,7027.32,4567.76,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL PEEK SD800.545,SUP-2860226,CDM,C1713,HCPCS,0278,RC,,,,both,,,50499.05,32824.38,,,,,,,,,,,,,
ROD SPNL 6X300 MM INVICTUS 152705560300,SUP-2724629,CDM,C1713,HCPCS,0278,RC,,,,both,,,1262.28,820.48,,,,,,,,,,,,,
FOOTSWITCH ELECSURG BPLR SINGLE FT NS LTX,SUP-2859252,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3889.99,2528.49,,,,,,,,,,,,,
DRILL 12MMX2.0MM,SUP-2841897,CDM,2720000010,LOCAL,0272,RC,,,,both,,,844.66,549.03,,,,,,,,,,,,,
HC US Duplex Scan of Aorta Complt,PX-9219397800,CDM,93978,CPT,0921,RC,,,,both,,,2518.00,1636.70,,,,,,,,,,,,,
CUP ACET CMNTLS FEM HIP PREMIER POROUS,SUP-2379160,CDM,C1776,CPT,0278,RC,,,,both,,,15700.00,10205.00,,,,,,,,,,,,,
EXPANDER TISS 12X17CM P12CM 1600CC RECT SMOOTH 2 STG INTEGRA,SUP-2328139,CDM,C1789,HCPCS,0278,RC,,,,both,,,3061.50,1989.97,,,,,,,,,,,,,
KIT ACC ANCHR W DISPENSER TOOL CATHETER CONN 2 ATTCH CLLT,SUP-2280047,CDM,C1755,HCPCS,0278,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
HC CT Chest Screening Low Dose Wout Cont,PX-3527127100,CDM,71271,CPT,0352,RC,,,,both,,,529.00,343.85,,,,,,,,,,,,,
REAMER CONE METATARSOPHALANGEAL FUS GEN II 20 MM,SUP-2398339,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1394.16,906.20,,,,,,,,,,,,,
PLATE BONE W10XL63MM THK1.5MM 3X4 H BILAT S STL T SHP OBLQ,SUP-2185886,CDM,C1713,HCPCS,0278,RC,,,,both,,,838.76,545.19,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.512,SUP-2860029,CDM,C1713,HCPCS,0278,RC,,,,both,,,35587.82,23132.08,,,,,,,,,,,,,
GRAFT VASC 6 MMX70 CM 30 CM RNG GORTX,SUP-2396006,CDM,C1768,CPT,0278,RC,,,,both,,,2712.96,1763.42,,,,,,,,,,,,,
PLATE CRAN 200X80X40 MM PT SPEC IMPL PEEK,SUP-2860144,CDM,C1713,HCPCS,0278,RC,,,,both,,,36524.17,23740.71,,,,,,,,,,,,,
CATHETER CV SET 032 8 FRX15 CM DL J TIP POLYURETHANE,SUP-2759960,CDM,C1751,HCPCS,0278,RC,,,,both,,,229.09,148.91,,,,,,,,,,,,,
PLATE BONE L20MM THK0.9MM 8MM OFFSET 0DEG 4 H BILAT CHIN,SUP-2191216,CDM,C1713,HCPCS,0278,RC,,,,both,,,1024.27,665.78,,,,,,,,,,,,,
BUR SURG TAPR 2.4 MMX16 CM MIDAS REX LEGEND,SUP-2627869,CDM,2720000010,LOCAL,0272,RC,,,,both,,,332.68,216.24,,,,,,,,,,,,,
FIBER LASER SINGLE 200 MH TRAC TIP FLEXIVA ID,SUP-2462861,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1325.61,861.65,,,,,,,,,,,,,
CONNECTOR SPNL SZ A5 L41-49MM MED TI CRSS FOR 5.5MM ROD,SUP-2255518,CDM,C1713,HCPCS,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
SET PIN MOD GLEN SYS,SUP-2418458,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
COMPONENT FEM PS 3 UNISX LT KNEE CEM STEMLESS SINGLE AXIS,SUP-2378102,CDM,C1776,CPT,0278,RC,,,,both,,,7245.86,4709.81,,,,,,,,,,,,,
USTEKINUMAB-AUUB 130 MG/26ML IV SOLN,RX-170236,CDM,Q5138,HCPCS,0636,RC,84612-0066-01,NDC,,both,52,ML,8361.30,5434.84,,,,,,,,,,,,,
STENT BILI WALLFLEX L 40 MM DIA 8 MM CATH L 194 CM DIA 8 FR,SUP-2148505,CDM,C1876,HCPCS,0278,RC,,,,both,,,5427.84,3528.10,,,,,,,,,,,,,
GENERATOR NEUROSTIM SPNL CRD PLSE STIM SYS PRECISION SPECTRA,SUP-2138776,CDM,C1820,HCPCS,0278,RC,,,,both,,,62580.55,40677.36,,,,,,,,,,,,,
TUNNELER MTL MALL TAPR FOR HEMOSPLIT AND HEMOSPLITXK,SUP-2126521,CDM,C1894,HCPCS,0272,RC,,,,both,,,128.74,83.68,,,,,,,,,,,,,
WASHER ORTH OD13.5MM ID4MM PEEK 6% BASO4 SPIK FOR 3.5/4MM,SUP-2184671,CDM,C1713,HCPCS,0278,RC,,,,both,,,327.09,212.61,,,,,,,,,,,,,
COMPONENT TIB SZ 2 CO CHROM FOR CEM USE SALTO TALARIS,SUP-2123857,CDM,C1776,CPT,0278,RC,,,,both,,,21925.05,14251.28,,,,,,,,,,,,,
HEAD FEM DIA40MM +5MM OFFSET 12/14 TAPR HIP CERAMIC TI SL,SUP-2251123,CDM,C1776,CPT,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
SCREW BNE CRTX 1.5X4 MM RAPID RESRB W/PLATE STRL 80560420S,SUP-2859930,CDM,C1713,HCPCS,0278,RC,,,,both,,,316.39,205.65,,,,,,,,,,,,,
GUIDEWIRE ORTH L150MM DIA1.6MM S STL THRD FOR 4.5MM CANN,SUP-2186898,CDM,C1769,HCPCS,0272,RC,,,,both,,,82.17,53.41,,,,,,,,,,,,,
STEM FEM HIP COXA VARA NK SEG AMT CORAIL,SUP-2456922,CDM,C1776,CPT,0278,RC,,,,both,,,2398.96,1559.32,,,,,,,,,,,,,
PLATE BNE L 75 MM SCREW DIA2 MM 2 HD 10 SHFT H SS TINE VA,SUP-2907851,CDM,C1713,HCPCS,0278,RC,,,,both,,,3334.93,2167.70,,,,,,,,,,,,,
NEEDLE BX BRST LOC KOPANS-STYLE STRL DISP 20GX10CM,SUP-2331833,CDM,C1819,HCPCS,0278,RC,,,,both,,,49.74,32.33,,,,,,,,,,,,,
PIN FIX L25MM DIA2.7MM PROV FOR LCK DRL GUID,SUP-2344008,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1717.83,1116.59,,,,,,,,,,,,,
BIT DRL CANN 4.9 MM ASNS III,SUP-2365004,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2634.46,1712.40,,,,,,,,,,,,,
DEFIBRILLATOR IMPL INOGEN MINI TI 2 CHMBR DF4 CONN 2 LD CLR,SUP-2140377,CDM,C1722,HCPCS,0275,RC,,,,both,,,57462.00,37350.30,,,,,,,,,,,,,
SCREW BONE ST OMEGA 21 FIX TI 5.5 X45 MM,SUP-2414706,CDM,C1713,HCPCS,0278,RC,,,,both,,,1801.48,1170.96,,,,,,,,,,,,,
"HC Inj Proc Nfrosgrm/Urtrgrm, Complete",PX-3615043100,CDM,50431,CPT,0361,RC,,,,inpatient,,,6875.00,4468.75,,,,,,,,,,,,,
HC Place Xrt Guide Percu-Thoracic,PX-3613255300,CDM,32553,CPT,0361,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
HC So Complement C-3/C-4,PX-3028616066,CDM,86160,CPT,0302,RC,,,,both,,,148.00,96.20,,,,,,,,,,,,,
COMPONENT TOT SHLDR CAPPED GLEN TOT STBL PERFORM +,SUP-2388596,CDM,C1776,CPT,0278,RC,,,,both,,,19468.00,12654.20,,,,,,,,,,,,,
CLAMP REPROC JETX 6 HL PIN,SUP-2700485,CDM,2720000010,LOCAL,0272,RC,,,,both,,,544.48,353.91,,,,,,,,,,,,,
HEAD FEM CEM 47 MM HIP RESURF RECAP,SUP-2441777,CDM,C1776,CPT,0278,RC,,,,both,,,10126.50,6582.22,,,,,,,,,,,,,
TROCAR TIP PLN GUIDWIRE,SUP-2243875,CDM,C1769,HCPCS,0272,RC,,,,both,,,141.30,91.84,,,,,,,,,,,,,
THERASKIN 2.5X2.5CM 6SQ CM,SUP-2264656,CDM,Q4121,HCPCS,0636,RC,,,,both,,,2574.80,1673.62,,,,,,,,,,,,,
SURFACE ARTC TIB 3-4 FEM C-H THK10MM 6DEG RT KNEE YEL UHMWPE,SUP-2201406,CDM,C1776,CPT,0278,RC,,,,both,,,3367.65,2188.97,,,,,,,,,,,,,
COLLAR CERV PHILLY LG 4.25 IN 16-19 IN REHAB FOAM PROCARE,SUP-2196880,CDM,L0120,HCPCS,0272,RC,,,,both,,,28.39,18.45,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC SL2 4FR 55CM 1 LUMAN RVS TAPR PWR I,SUP-2613368,CDM,C1751,HCPCS,0278,RC,,,,both,,,629.60,409.24,,,,,,,,,,,,,
PLATE BNE L 405 MM SCREW DIA 3.5/4.5 MM 20 H SS RT DSTL FEM 72585220N,SUP-2932787,CDM,C1713,HCPCS,0278,RC,,,,both,,,21907.00,14239.55,,,,,,,,,,,,,
TUBE ET L295MM OD10.8MM ID7.5MM NSL IVRY PVC DIR NORTH,SUP-2351741,CDM,2720000010,LOCAL,0272,RC,,,,both,,,33.66,21.88,,,,,,,,,,,,,
SET NDL 15GA L45MM STBL KT FOR IO VASC ACCS SYS EZ-IO,SUP-2383226,CDM,2720000010,LOCAL,0272,RC,,,,both,,,447.76,291.04,,,,,,,,,,,,,
BIT DRL L 229 MM DIA 3 MM LG AO NS DISP LEOS,SUP-2932790,CDM,2720000010,LOCAL,0272,RC,,,,both,,,859.73,558.82,,,,,,,,,,,,,
SET GASTROSTMY 14FR L30CM 6 SIDEPRT PERC LOK PGTL,SUP-2168334,CDM,C1713,HCPCS,0278,RC,,,,both,,,502.62,326.70,,,,,,,,,,,,,
SYSTEM DRAINAGE SFOR DRAINAGE,SUP-2666843,CDM,C1729,HCPCS,0272,RC,,,,both,,,589.54,383.20,,,,,,,,,,,,,
BASEPLATE TIB MOD 71 MM KNEE POROUS OSS,SUP-2449767,CDM,C1776,CPT,0278,RC,,,,both,,,8435.61,5483.15,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY EPSTAR L 130 CM DIA2 FR SPC 5-5-5,SUP-2641907,CDM,C1730,HCPCS,0272,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
GRAFT BNE SUB 30ML TRICALCIUM PHSPTE GRAN CONT RESRB,SUP-2255617,CDM,C1763,HCPCS,0278,RC,,,,both,,,4060.02,2639.01,,,,,,,,,,,,,
MESH DERM REP W10XL20CM SURGIMEND PRS,SUP-2243678,CDM,C9360,HCPCS,0278,RC,,,,both,,,22294.00,14491.10,,,,,,,,,,,,,
HC Renal Arteriogram,PX-3233625100,CDM,36251,CPT,0323,RC,,,,both,,,10063.00,6540.95,,,,,,,,,,,,,
SCREW BNE LCK 3X44 MM DBL STRT THRD STRL JPS LTX,SUP-2875324,CDM,C1713,HCPCS,0278,RC,,,,both,,,1341.41,871.92,,,,,,,,,,,,,
CATHETER HD FULL SAFETY TY 12 FRX15 CM DL TURBO-FLO HD,SUP-2759884,CDM,C1752,HCPCS,0278,RC,,,,both,,,851.76,553.64,,,,,,,,,,,,,
DRESSING WND SURG MTRX THCK 7X10 CM MATRISTEM,SUP-2106496,CDM,Q4166,HCPCS,0636,RC,,,,both,,,5934.60,3857.49,,,,,,,,,,,,,
STEM FEM STR 12/14 SM LNG 165 MM REV TAPR COCR SPECTRN EF,SUP-2434573,CDM,C1776,CPT,0278,RC,,,,both,,,12277.40,7980.31,,,,,,,,,,,,,
MESH HERN CIR 6 IN W/ ECHO 2 POS SYS PHASIX ST,SUP-2421795,CDM,C1781,HCPCS,0278,RC,,,,both,,,11555.20,7510.88,,,,,,,,,,,,,
BIT DRL DIA2.9MM CANN DISP FOR PEDILOC LOK PROX FEM SYS,SUP-2318866,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1073.88,698.02,,,,,,,,,,,,,
COLLAR CERV PED H1.5/1.75/2IN FOR 8-18IN NK HDPE FOAM 1 PC,SUP-2196873,CDM,L0150,HCPCS,0274,RC,,,,both,,,16.20,10.53,,,,,,,,,,,,,
PROCEDURE KIT HAMRTOE 3.5 MM SAW CUT STRL NEXTRA,SUP-2137576,CDM,C1713,HCPCS,0278,RC,,,,both,,,3460.53,2249.34,,,,,,,,,,,,,
GRAFT HUM TISS IL 12-14X10-12X7 MM CREST WDG IL STRL LF DISP,SUP-2632287,CDM,C1762,CPT,0278,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
HC Receptor Assay Non-Endocrine Specify Receptor,PX-3018423800,CDM,84238,CPT,0301,RC,,,,both,,,213.00,138.45,,,,,,,,,,,,,
PLATE BNE SM W10.1XL82MM THK3.5MM 6 H BILAT S STL CRV RIG,SUP-2186261,CDM,C1713,HCPCS,0278,RC,,,,both,,,1921.11,1248.72,,,,,,,,,,,,,
CEMENT BNE 10 CC DEMINERALIZED BONE MATRIX STRL TRABEXUS LTX,SUP-2855700,CDM,C1713,HCPCS,0278,RC,,,,both,,,28115.56,18275.11,,,,,,,,,,,,,
PLATE BONE L155MM RIB RIBLOC U+,SUP-2107919,CDM,C1713,HCPCS,0278,RC,,,,both,,,5394.52,3506.44,,,,,,,,,,,,,
PLATE BONE CRESCENT 2 MM MANDIBULAR 7 HOLE INTERMEDIATE TITA,SUP-2838412,CDM,C1713,HCPCS,0278,RC,,,,both,,,2085.90,1355.83,,,,,,,,,,,,,
INSERT TALAR SZ 4 THK11MM ANK POLYETH FOR PROPHECY INBONE 2,SUP-2397177,CDM,C1776,CPT,0278,RC,,,,both,,,3865.34,2512.47,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 20 CM DIA16 MM EPTFE STR STD WALL,SUP-2396221,CDM,C1768,CPT,0278,RC,,,,both,,,1384.74,900.08,,,,,,,,,,,,,
SET TRACH 26-28FR LD DIL EXCHG WEINMANN,SUP-2170062,CDM,C1713,HCPCS,0278,RC,,,,both,,,646.84,420.45,,,,,,,,,,,,,
LEAD PACE SELECTSECURE L 59 CM DIA 4.1 FR POLYUR SIL INSUL,SUP-2281896,CDM,C1898,HCPCS,0275,RC,,,,both,,,1130.40,734.76,,,,,,,,,,,,,
GUIDE SURG FOR TIB TALUS ALIGN PROPHECY INBONE,SUP-2400573,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2361.28,1534.83,,,,,,,,,,,,,
SCREW BNE L15MM DIA2.5MM CO CHROM MULTDIR LOK THRD PEGGED,SUP-2411661,CDM,C1713,HCPCS,0278,RC,,,,both,,,464.72,302.07,,,,,,,,,,,,,
SPLINT WRST XL L7IN FOR 85 95IN COT R SLIP ON SFT DURABLE,SUP-2276656,CDM,L3809,HCPCS,0272,RC,,,,both,,,9.73,6.32,,,,,,,,,,,,,
BETHANECHOL CHLORIDE 10 MG PO TABS,RX-1043,CDM,6370000000,HCPCS,0637,RC,00832-0511-89,NDC,,both,1,UN,2.90,1.88,,,,,,,,,,,,,
HEAD HUM 50X16 MM SHLDR TI AEQUALIS,SUP-2715525,CDM,C1776,CPT,0278,RC,,,,both,,,8994.53,5846.44,,,,,,,,,,,,,
ALLOGRAFT BNE 5 CC VIABLE BNE MTRX VIBONE,SUP-2731788,CDM,C1762,CPT,0278,RC,,,,both,,,6280.00,4082.00,,,,,,,,,,,,,
EXTRACTOR STONE 1.7FR L115CM BSKT DIA1CM NIT TIPLSS UNIDEX,SUP-2170509,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1024.90,666.18,,,,,,,,,,,,,
PIN FIX HABAL TYP 2X8 MM 5 MM RED II,SUP-2463190,CDM,C1713,HCPCS,0278,RC,,,,both,,,361.63,235.06,,,,,,,,,,,,,
PLATE EXT FIX SHT 180 MM FT ALUM NS MAXFRAME,SUP-2799583,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4164.61,2707.00,,,,,,,,,,,,,
PLATE BNE W12XL71MM THK1MM 4 H BILAT S STL SEMI TBLR LO,SUP-2184865,CDM,C1713,HCPCS,0278,RC,,,,both,,,87.92,57.15,,,,,,,,,,,,,
HC MRI Face Neck Eye WO Contrast,PX-6107054000,CDM,70540,CPT,0610,RC,,,,inpatient,,,4451.00,2893.15,,,,,,,,,,,,,
EXTRACTOR STONE BSKT 0.4 MM 4 WIR HNDL ENDOSCP STRL DISP,SUP-2773255,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1060.10,689.06,,,,,,,,,,,,,
RESERVOIR VENTRICULAR L18CM OD60FR ODSEC2.5MM D.56CM 20MM L,SUP-2825885,CDM,C1729,HCPCS,0272,RC,,,,both,,,1393.53,905.79,,,,,,,,,,,,,
LIOTHYRONINE SODIUM 25 MCG PO TABS,RX-4504,CDM,6370000000,HCPCS,0637,RC,70377-0115-12,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
Z DISCONTINUED USE 2284564 SET VENT DRNGE HYDROPHOBIC VENT BLU STRP TBNG CRD LOK GRAD,SUP-2284542,CDM,C1729,HCPCS,0272,RC,,,,both,,,594.21,386.24,,,,,,,,,,,,,
PLATE BONE WEB LCK FOR 1.5MM SCR ALPS HND FX SYS,SUP-2411743,CDM,C1713,HCPCS,0278,RC,,,,both,,,1780.38,1157.25,,,,,,,,,,,,,
PLATE BONE RECONSTRUCTION 3.5X118 MM 10 HOLE FOR SCREW STERI,SUP-2836655,CDM,C1713,HCPCS,0278,RC,,,,both,,,3502.67,2276.74,,,,,,,,,,,,,
IMMUNE GLOBULIN (GAMUNEX-C) 10%,RX-4081759,CDM,J1561,HCPCS,0636,RC,13533-0800-15,NDC,,both,25,ML,1316.40,855.66,,,,,,,,,,,,,
GRAFT VASC HEMSHLD GLD L 30 CM 12 MM POLYESTER BOV CLLGN STR,SUP-2265895,CDM,C1768,CPT,0278,RC,,,,both,,,48.61,31.60,,,,,,,,,,,,,
BAND ANNULPLSTY SIMPLICI-T L 100 MM FLX STRL,SUP-2429903,CDM,C1713,HCPCS,0278,RC,,,,both,,,7755.80,5041.27,,,,,,,,,,,,,
CHECKMATE VALVE ADJUSTMENT SYSTEM PROSA,SUP-2821806,CDM,C1889,HCPCS,0278,RC,,,,both,,,1254.62,815.50,,,,,,,,,,,,,
MESH HERN OVL 5X3 IN POCKETED BIORESORBABLE PHASIX ST,SUP-2855269,CDM,C1781,HCPCS,0278,RC,,,,both,,,5856.10,3806.46,,,,,,,,,,,,,
HC Initiate Prolonged Chemo Pump,PX-3359641600,CDM,96416,CPT,0335,RC,,,,both,,,1112.00,722.80,,,,,,,,,,,,,
GRAFT EVAR L199MM DIA16X10MM CATH 16FR LIMB DST DSGN C DEL,SUP-2295242,CDM,C1768,CPT,0278,RC,,,,both,,,20394.30,13256.29,,,,,,,,,,,,,
CATHETER CARD ABLATION THERMOCOOL SMARTTOUCH SF L115CM 8FR D,SUP-2248617,CDM,C1732,HCPCS,0278,RC,,,,both,,,8983.54,5839.30,,,,,,,,,,,,,
LEAD PACE BPLR 40 CM ATRICLE VENTRIC ISOFLEX-S,SUP-2356086,CDM,C1898,HCPCS,0275,RC,,,,both,,,1218.32,791.91,,,,,,,,,,,,,
BLADE RETRCT W2XL4CM BLK FINISH NAR MUSC 1 PR SPNL MED LAT,SUP-2382490,CDM,2720000010,LOCAL,0272,RC,,,,both,,,701.92,456.25,,,,,,,,,,,,,
ANCHOR SUT 4.5MM PEEK KNOTLESS INSITE FT,SUP-2388895,CDM,C1713,HCPCS,0278,RC,,,,both,,,2223.12,1445.03,,,,,,,,,,,,,
PLATE BONE DUAL CMPRSSN HLX4 TTNM CNTRD F2.7MM LOK SCREW ST,SUP-2724125,CDM,C1713,HCPCS,0278,RC,,,,both,,,873.23,567.60,,,,,,,,,,,,,
INSERT TIB SZ 2 THK12.5MM UNIV KNEE POLYETH CRUC RET POST,SUP-2253784,CDM,C1776,CPT,0278,RC,,,,both,,,3214.10,2089.16,,,,,,,,,,,,,
PIN SPNL CASPR 11 MM ALTA,SUP-2692984,CDM,C1713,HCPCS,0278,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
PLUG H APCL FOR LEGEND ACET SHELL,SUP-2314464,CDM,C1776,CPT,0278,RC,,,,both,,,213.52,138.79,,,,,,,,,,,,,
TRAY CATH MIDLN POWERGLIDE PRO 22GA 8CM WNG 1 LUMAN F322088T,SUP-2632776,CDM,C1751,HCPCS,0278,RC,,,,both,,,332.84,216.35,,,,,,,,,,,,,
STEM HUM H120MM DIA8MM 135DEG TI PRI CEM AND PRSS FIT UNIV,SUP-2224494,CDM,C1776,CPT,0278,RC,,,,both,,,6280.00,4082.00,,,,,,,,,,,,,
GRAFT VASC IMPRA L 70 CM DIA 7-4 MM EPTFE TAPR STD WALL N,SUP-2761335,CDM,C1768,CPT,0278,RC,,,,both,,,2318.51,1507.03,,,,,,,,,,,,,
COLLAR FEM L30MM KNEE TRABECULAR MTL SEG FOR 9-16MM STEM,SUP-2200564,CDM,C1776,CPT,0278,RC,,,,both,,,6231.33,4050.36,,,,,,,,,,,,,
CATHETER CV SINGLE LUMEN 5 FRX20 CM BASIC KT ARROWG+ARD,SUP-2383313,CDM,C1751,HCPCS,0278,RC,,,,both,,,170.19,110.62,,,,,,,,,,,,,
ANCHOR SUTURE DIA 4.5 MM PEEK KNOTLESS BRIDGELINE ADAPTIVE,SUP-2899265,CDM,C1713,HCPCS,0278,RC,,,,both,,,3618.07,2351.75,,,,,,,,,,,,,
GUIDEWIRE URO X STIFF 0.038INX145CM AMPLTZ,SUP-2168893,CDM,C1769,HCPCS,0272,RC,,,,both,,,90.24,58.66,,,,,,,,,,,,,
SCREW BNE L14MM DIA2MM QUIK SNAP CAPTURE,SUP-2243914,CDM,C1713,HCPCS,0278,RC,,,,both,,,1124.47,730.91,,,,,,,,,,,,,
GRAFT BIO TISS W3XL3CM MTRX CLLGN TISSMEND,SUP-2376568,CDM,C1768,CPT,0278,RC,,,,both,,,13649.58,8872.23,,,,,,,,,,,,,
PAD CERV CLLR REPL FOR VISTA,SUP-2123902,CDM,L0190,HCPCS,0272,RC,,,,both,,,23.20,15.08,,,,,,,,,,,,,
PLATE BONE L242MM BLDE W4.8XL25MM 95DEG 14 H STRL HIP S STL,SUP-2186761,CDM,C1713,HCPCS,0278,RC,,,,both,,,4679.86,3041.91,,,,,,,,,,,,,
SPLINT FNGR AD M JT EXTN TUBE DGT DYN,SUP-2325054,CDM,L3933,HCPCS,0274,RC,,,,both,,,46.91,30.49,,,,,,,,,,,,,
CATHETER DRNGE 26FR 2 EYE PROPORTIONATE HD DISP FOR,SUP-2128981,CDM,C1729,HCPCS,0272,RC,,,,both,,,23.17,15.06,,,,,,,,,,,,,
STYLET LD POS L75/86CM OD0.014IN ID0.012IN LV LD LUMN,SUP-2357579,CDM,C1769,HCPCS,0272,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
DRILL SURG TORQUE LIMITING ATTCH,SUP-2497856,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3446.37,2240.14,,,,,,,,,,,,,
MODEL ANAT PLN CASE BNDL MANDIBULAR MAX VSP,SUP-2883956,CDM,2720000010,LOCAL,0272,RC,,,,both,,,27819.46,18082.65,,,,,,,,,,,,,
KIT TMPLT STRL DISP MOTOBAND CP DYNAMET,SUP-2893259,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
COMPONENT TOT SHLDR ONCOLOGY B-O3,SUP-2137348,CDM,C1776,CPT,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
LINER ACET OD54MM ID32MM +4MM OFFSET 10DEG HIP GVF POLYETH,SUP-2250263,CDM,C1776,CPT,0278,RC,,,,both,,,10203.74,6632.43,,,,,,,,,,,,,
GRAFT HUM TISS W1 3-40MMXL13-20CM 30-80MM SPC PAT TEND HEMI,SUP-2307271,CDM,C1713,HCPCS,0278,RC,,,,both,,,15176.47,9864.71,,,,,,,,,,,,,
PLATE BNE CNDYL 2.7X66 MM 7 HOLE LP RIGID LCK COMPR TI,SUP-2191449,CDM,C1713,HCPCS,0278,RC,,,,both,,,1894.36,1231.33,,,,,,,,,,,,,
SET PUTTY BONE SYNTH CARB APATITE 5CC PRELD SYR DILUTANT,SUP-2316472,CDM,C1713,HCPCS,0278,RC,,,,both,,,1931.10,1255.21,,,,,,,,,,,,,
TUBE NSL 3 LUMN,SUP-2306843,CDM,2720000010,LOCAL,0272,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
PLATE BONE L234MM 9 H LT PROX FEM LCK FOR 4.5MM SCR PERI-LOC,SUP-2351170,CDM,C1713,HCPCS,0278,RC,,,,both,,,12076.60,7849.79,,,,,,,,,,,,,
CATHETER EP XL 2-2-2-3 1 MM 5 FRX110 INQUIRY,SUP-2462097,CDM,C1730,HCPCS,0272,RC,,,,both,,,1315.66,855.18,,,,,,,,,,,,,
PLATE BNE TBLR 97 MM 8 HOLE 1/3 STRL,SUP-2518443,CDM,C1713,HCPCS,0278,RC,,,,both,,,1956.22,1271.54,,,,,,,,,,,,,
NEEDLE BRST LOC L10CM OD20GA HAWK II,SUP-2120049,CDM,C1819,HCPCS,0278,RC,,,,both,,,109.21,70.99,,,,,,,,,,,,,
DEVICE ELECSURG TIPTOOL SONICFUSION 19101020,SUP-2499743,CDM,C1776,CPT,0278,RC,,,,both,,,1740.82,1131.53,,,,,,,,,,,,,
FENTANYL 50 MCG/HR TD PT72,RX-27906,CDM,6370000000,HCPCS,0637,RC,00378-9122-16,NDC,,both,1,UN,57.10,37.11,,,,,,,,,,,,,
TUBE ORTHOPEDIC MEDULLARY INSTR STRL,SUP-2188169,CDM,2720000010,LOCAL,0272,RC,,,,both,,,910.60,591.89,,,,,,,,,,,,,
CROWN DRILL 010X195 M,SUP-2701846,CDM,2720000010,LOCAL,0272,RC,,,,both,,,931.01,605.16,,,,,,,,,,,,,
GRAFT VASC STR 7 MMX80 CM TW N RING HD ACCS EPTFE CARBOFLO,SUP-2761366,CDM,C1768,CPT,0278,RC,,,,both,,,7629.67,4959.29,,,,,,,,,,,,,
GUIDEWIRE ENDO L450CM OD0.035IN NIT HYDRPHLC TORQUEABLE,SUP-2141513,CDM,C1769,HCPCS,0272,RC,,,,both,,,337.55,219.41,,,,,,,,,,,,,
SCREW SPNL LCK 4.5 MM GROWTH DIRECTING CLLRD SS SHILLA,SUP-2630596,CDM,C1713,HCPCS,0278,RC,,,,both,,,1108.42,720.47,,,,,,,,,,,,,
CLIP SURG INT USE TI HEMSTAT MICROCLP,SUP-2382611,CDM,C1760,HCPCS,0278,RC,,,,both,,,36.64,23.82,,,,,,,,,,,,,
GRAFT DERMAL STRUCTURAL THCK 16X4 CMX0.8-1.7 MM BRST FLEXHD,SUP-2307508,CDM,Q4128,HCPCS,0636,RC,,,,both,,,10649.09,6921.91,,,,,,,,,,,,,
ATEZOLIZUMAB 1200 MG/20ML IV SOLN,RX-1150423,CDM,J9022,HCPCS,0636,RC,50242-0917-01,NDC,,both,20,ML,33377.40,21695.31,,,,,,,,,,,,,
SEALER LAPAROSCOPIC L 20 CM DIA 3 MM,SUP-2904182,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2302.66,1496.73,,,,,,,,,,,,,
SWITCH PERF L13IN EQL LEG TBL MT MOD ARISS,SUP-2282550,CDM,C1713,HCPCS,0278,RC,,,,both,,,131.97,85.78,,,,,,,,,,,,,
KNIFE BALLENGER SWIVEL BAYONET 4MM BLADE 20CM 8IN,SUP-2677477,CDM,2720000010,LOCAL,0272,RC,,,,both,,,659.90,428.93,,,,,,,,,,,,,
CATHETER GUID EASYTRAK L 54 CM OD 2.7 MM ID 2.21 MM CORONARY,SUP-2148981,CDM,C1887,HCPCS,0272,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
GRAFT HUMAN TSSUE W2XL4CM THK0.33 0.76MM THIN RGNRTVE TSSUE,SUP-2470381,CDM,Q4116,HCPCS,0636,RC,,,,both,,,1610.82,1047.03,,,,,,,,,,,,,
SCREW SPNL L45MM DIA6MM TI POLYAX EXT TAB FOR MINIMALLY,SUP-2255023,CDM,C1713,HCPCS,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
GRAFT SKIN 4X2CM DERMAMTRX ACELLULAR DERM MTRX REHYDRATED,SUP-2306891,CDM,Q4126,HCPCS,0636,RC,,,,both,,,469.37,305.09,,,,,,,,,,,,,
BLADE SHV L11CM OD3.5MM S STL STR SHFT IRRIG TBNG REUSE FOR,SUP-2284132,CDM,2720000010,LOCAL,0272,RC,,,,both,,,705.87,458.82,,,,,,,,,,,,,
GUIDEWIRE VASC GLIDEWIRE 180CM 0.038IN TIP L 3 CM STIFF STR,SUP-2385594,CDM,C1769,HCPCS,0272,RC,,,,both,,,158.48,103.01,,,,,,,,,,,,,
PUTTY BONE 5 CC REINFORCED FAST SET STERILE CRANIOS,SUP-2838512,CDM,C1713,HCPCS,0278,RC,,,,both,,,6167.59,4008.93,,,,,,,,,,,,,
HC Tissue Level IV,PX-3128830500,CDM,88305,CPT,0312,RC,,,,both,,,352.00,228.80,,,,,,,,,,,,,
GRAFT HUM TISS NRML THK230-320UM CLR PRE HYDRATION CORNEA W/,SUP-2261409,CDM,V2785,HCPCS,0278,RC,,,,both,,,1271.70,826.60,,,,,,,,,,,,,
DRILL HAND BUNNELL,SUP-2702381,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2515.33,1634.96,,,,,,,,,,,,,
BOLT FIX L50MM DIA65MM ST MIDFOOT FUS S STL,SUP-2177259,CDM,C1713,HCPCS,0278,RC,,,,both,,,1622.06,1054.34,,,,,,,,,,,,,
STEM HUM L145MM DIA10MM STD SHLDR CO CHROM COFIELD2,SUP-2344289,CDM,C1776,CPT,0278,RC,,,,both,,,6790.25,4413.66,,,,,,,,,,,,,
ALLOGRAFT BNE DEMINERALIZED CORTICAL 125-710 MIC 15 CC FD,SUP-2717750,CDM,C1713,HCPCS,0278,RC,,,,both,,,2276.31,1479.60,,,,,,,,,,,,,
ENDCAP IM NAIL 0MM OFFSET FEM LO PROF FOR PHOENIX SYS,SUP-2412152,CDM,C1713,HCPCS,0278,RC,,,,both,,,678.24,440.86,,,,,,,,,,,,,
HC Extrem Up Elbow Arthrogram,PX-3227308500,CDM,73085,CPT,0322,RC,,,,inpatient,,,3707.00,2409.55,,,,,,,,,,,,,
STENT PANCREATIC ZMMN L 120 MM DIA 7 FR CHANNEL 3.2 MM,SUP-2480092,CDM,C1877,HCPCS,0278,RC,,,,both,,,172.70,112.25,,,,,,,,,,,,,
PLATE BONE L94MM 8 H STRL S STL 1/3 TBLR FOR 3.5MM SCR EVOS,SUP-2349635,CDM,C1713,HCPCS,0278,RC,,,,both,,,581.75,378.14,,,,,,,,,,,,,
HC Thromb Mech Vein,PX-3613718700,CDM,37187,CPT,0361,RC,,,,inpatient,,,7160.00,4654.00,,,,,,,,,,,,,
BLADE EXPLANT FULL 42MM,SUP-2210645,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
GUIDEWIRE MOVABLE COR W/ STR TIP STD .035INX150CM GUIDERIGHT,SUP-2355317,CDM,C1769,HCPCS,0272,RC,,,,both,,,25.12,16.33,,,,,,,,,,,,,
GRAFT WND BURN 10X15 CM EXTRACELLULAR MTRX MATRISTEM,SUP-2106464,CDM,Q4166,HCPCS,0636,RC,,,,both,,,6641.10,4316.71,,,,,,,,,,,,,
STEM FEM CMNTLS 24/20X130 MM MOD W/ M TAPR FOR 6 MM NOSE,SUP-2423702,CDM,C1776,CPT,0278,RC,,,,both,,,7051.91,4583.74,,,,,,,,,,,,,
ROD EXT FIX 25X250 MM CARBON LIGHTWEIGHT RADLUC,SUP-2372614,CDM,C1713,HCPCS,0278,RC,,,,both,,,675.10,438.81,,,,,,,,,,,,,
ANCHOR SUT 5.5MM W/ NDL,SUP-2366676,CDM,C1713,HCPCS,0278,RC,,,,both,,,721.51,468.98,,,,,,,,,,,,,
STRM LOCKING SCREW 3.5X14MM ST,SUP-2483503,CDM,C1713,HCPCS,0278,RC,,,,both,,,504.54,327.95,,,,,,,,,,,,,
PROSTHESIS PENILE L18CM TBNG L10CM IFP PARYLENE INFL,SUP-2138991,CDM,C1813,HCPCS,0278,RC,,,,both,,,39969.69,25980.30,,,,,,,,,,,,,
PLATE BNE L 90 MM SCREW DIA2.7/3.5 MM 7 H LL DSTL HUM STRL,SUP-2931162,CDM,C1713,HCPCS,0278,RC,,,,both,,,5042.21,3277.44,,,,,,,,,,,,,
PLATE SPNL 17 MM ZEVO,SUP-2278039,CDM,C1713,HCPCS,0278,RC,,,,both,,,5081.78,3303.16,,,,,,,,,,,,,
SCREW BNE L105MM DIA10.5MM LAG FOR AFFIXUS HIP FRAC NAIL,SUP-2413330,CDM,C1713,HCPCS,0278,RC,,,,both,,,1968.78,1279.71,,,,,,,,,,,,,
CAGE SPNL H5.5MM AP D12MM 6DEG TAPR LORDOSIS ANTR CERV PEEK,SUP-2163178,CDM,C1889,HCPCS,0278,RC,,,,both,,,8478.00,5510.70,,,,,,,,,,,,,
PEGFILGRASTIM-APGF 6 MG/0.6ML SC SOSY,RX-152864,CDM,Q5122,HCPCS,0636,RC,00069-0324-01,NDC,,both,0.6,ML,11578.80,7526.22,,,,,,,,,,,,,
NAIL IM L 22 CM DIA 3.5 MM SS FOREARM,SUP-2885030,CDM,C1713,HCPCS,0278,RC,,,,both,,,4288.55,2787.56,,,,,,,,,,,,,
GRAFT VASC IMPRA L 80 CM DIA 4 MM EPTFE STR STD WALL N RING,SUP-2761360,CDM,C1768,CPT,0278,RC,,,,both,,,2601.49,1690.97,,,,,,,,,,,,,
VALVE PRESSURE PROGRAMMABLE 70MM H2O + OR MINUS 10MM H2O,SUP-2666797,CDM,C1889,HCPCS,0278,RC,,,,both,,,3288.49,2137.52,,,,,,,,,,,,,
L PLATE RIGHT 2.0MM,SUP-2819059,CDM,C1713,HCPCS,0278,RC,,,,both,,,408.14,265.29,,,,,,,,,,,,,
TROCAR FOR 6.5MM AND 7.3MM CANNULATED SCREWS,SUP-2548323,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1772.06,1151.84,,,,,,,,,,,,,
HC So Anaerobic Culture,PX-3008707566,CDM,87075,CPT,0300,RC,,,,both,,,50.00,32.50,,,,,,,,,,,,,
GRAFT VASC IMPRA L 50 CM DIA 6 MM EPTFE STR TW N RING HEMO,SUP-2761301,CDM,C1768,CPT,0278,RC,,,,both,,,2176.02,1414.41,,,,,,,,,,,,,
GUIDEWIRE ORTH BALL NOSE HUM STRL AFFIXUS,SUP-2606191,CDM,C1769,HCPCS,0272,RC,,,,both,,,1183.78,769.46,,,,,,,,,,,,,
PLATE BNE L34MM 2 H L RAD HD RIM S STL RIG LOK COMPR FOR,SUP-2185997,CDM,C1713,HCPCS,0278,RC,,,,both,,,1750.83,1138.04,,,,,,,,,,,,,
BIT DRL CANN LNG 12 MM FLX STRL,SUP-2789625,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3274.61,2128.50,,,,,,,,,,,,,
PLATE BNE L 30.5 MM THK 1 MM SCREW DIA2 MM 6 H SHRT TI,SUP-2936955,CDM,C1713,HCPCS,0278,RC,,,,both,,,1070.74,695.98,,,,,,,,,,,,,
PLATE 3.5MM TI LCP PROXIMAL TIBIA 8 HOLES 133MM RIGHT,SUP-2549545,CDM,C1713,HCPCS,0278,RC,,,,both,,,3624.47,2355.91,,,,,,,,,,,,,
INSERT TIB SZ 2 L11MM UHMWPE ANK INBONE,SUP-2397096,CDM,C1776,CPT,0278,RC,,,,both,,,4634.64,3012.52,,,,,,,,,,,,,
DEFIBRILLATOR IMPL VENTAK PRIZM 2 DR W 6.5 X H 6.5 CM D 1.2,SUP-2148621,CDM,C1721,HCPCS,0275,RC,,,,both,,,74104.00,48167.60,,,,,,,,,,,,,
CONTAINER SPEC PRESERV NS DISP MYRIAD,SUP-2930214,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4775.69,3104.20,,,,,,,,,,,,,
LEVEL NEURO ST MESH 3D ULTRNE NEURO SCRW75 MM DIA T06 MM CP,SUP-2676604,CDM,C1713,HCPCS,0278,RC,,,,both,,,3348.81,2176.73,,,,,,,,,,,,,
HC So Protein Electrophoresis Serum,PX-3018416566,CDM,84165,CPT,0301,RC,,,,both,,,369.00,239.85,,,,,,,,,,,,,
PLATE BNE W10XL96MM THK1.5MM 3X7 H S STL R OBLQ T SHP LOK,SUP-2185839,CDM,C1713,HCPCS,0278,RC,,,,both,,,1126.29,732.09,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 45 CM DIA 6 MM STR TW STRL,SUP-2396307,CDM,C1768,CPT,0278,RC,,,,both,,,2521.42,1638.92,,,,,,,,,,,,,
GUIDEWIRE NEUROSTIMULATOR LD STRL,SUP-2356623,CDM,C1769,HCPCS,0272,RC,,,,both,,,13345.00,8674.25,,,,,,,,,,,,,
GUIDEWIRE VASC VISTA BRT TIP L 55 CM DIA 8 FR SS PTFE IM,SUP-2155547,CDM,C1769,HCPCS,0272,RC,,,,both,,,444.31,288.80,,,,,,,,,,,,,
PIN REINF L 12 MM LG FOR TIB INSRT STRL,SUP-2929676,CDM,C1776,CPT,0278,RC,,,,both,,,3924.75,2551.09,,,,,,,,,,,,,
LIDOCAINE HCL 1 % IJ SOLN,RX-4452,CDM,J2003,HCPCS,0636,RC,63323-0485-01,NDC,,both,5,ML,54.10,35.16,,,,,,,,,,,,,
POST SURG ANK INTOSS FIX L18MM OD4.6MM 60DEG IOFIX,SUP-2223852,CDM,C1713,HCPCS,0278,RC,,,,both,,,3925.00,2551.25,,,,,,,,,,,,,
PLATE BNE STR 20X0.6 MM NEURO 4 HOLE TI STRL LEVEL 1,SUP-2500874,CDM,C1713,HCPCS,0278,RC,,,,both,,,494.42,321.37,,,,,,,,,,,,,
CATHETER GUID MP1 8 FR CORONARY LAUNCHER,SUP-2281133,CDM,C1887,HCPCS,0272,RC,,,,both,,,141.30,91.84,,,,,,,,,,,,,
STENT URET 14/7FR L26CM PERCFLX HYDR+ TAPR TIP SMOOTH,SUP-2139061,CDM,C2617,HCPCS,0278,RC,,,,both,,,641.69,417.10,,,,,,,,,,,,,
SCREW SPNL TRANSITION RAIL 4.5X500 MM COCR MESA RAIL 4D,SUP-2538578,CDM,C1713,HCPCS,0278,RC,,,,both,,,7338.18,4769.82,,,,,,,,,,,,,
PLATE BNE L 55 MM SCREW DIA2.4/2.7 MM 6 HD 3 SHFT H RT DSTL,SUP-2913635,CDM,C1713,HCPCS,0278,RC,,,,both,,,4373.49,2842.77,,,,,,,,,,,,,
POST EXT FIX 1 H M,SUP-2898407,CDM,C1713,HCPCS,0278,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
CATHETER CV SINGLE LUMEN 2 FRX30 CM INTERMED TY PER-Q-CATH,SUP-2125570,CDM,C1751,HCPCS,0278,RC,,,,both,,,177.41,115.32,,,,,,,,,,,,,
IMPLANT HUM TISS RT ANK WHL OSTEOARTICULAR CUST MATCHED FRZN,SUP-2932942,CDM,C1762,CPT,0278,RC,,,,both,,,25586.92,16631.50,,,,,,,,,,,,,
METHOCARBAMOL 1000 MG/10ML IJ SOLN,RX-129226,CDM,J2800,HCPCS,0636,RC,71288-0716-11,NDC,,both,5,ML,54.10,35.16,,,,,,,,,,,,,
PLATE HEAD LCKNG PHALANGEAL 1.3MM RIGHT-STERILE,SUP-2546065,CDM,C1713,HCPCS,0278,RC,,,,both,,,1621.24,1053.81,,,,,,,,,,,,,
GRAFT BONE GEL IRRADIATED DEMINERLIZED BONE MTRX 10CC GRFTON,SUP-2307525,CDM,C1713,HCPCS,0278,RC,,,,both,,,3114.88,2024.67,,,,,,,,,,,,,
CLIP ENDOSCP 235CM RESOL 360 ORDER UOM IS EACH,SUP-2149428,CDM,C1889,HCPCS,0278,RC,,,,both,,,750.46,487.80,,,,,,,,,,,,,
SPACER SPNL W9XH26MM EXP 8-13MM TI CONVX SELF EXP CONCORDE,SUP-2257837,CDM,C1889,HCPCS,0278,RC,,,,both,,,18526.00,12041.90,,,,,,,,,,,,,
DEFIBRILLATOR IMPL MOMENTUM W 5.37 X H 8.18 CM D 0.99 CM,SUP-2149205,CDM,C1882,HCPCS,0275,RC,,,,both,,,63208.20,41085.33,,,,,,,,,,,,,
CATHETER URET WHSTL TIP 6FRX70CM FLEXIMA,SUP-2139296,CDM,C1758,HCPCS,0278,RC,,,,both,,,607.65,394.97,,,,,,,,,,,,,
TUBE FEED NG 10 FR 109 CM SGL LUMN POLYUR LTX FREE PED W OUT,SUP-2124654,CDM,2720000010,LOCAL,0272,RC,,,,both,,,50.77,33.00,,,,,,,,,,,,,
PLATE BONEXL L120MM HD W22MM 11 H RT DSTL VOLAR RAD TI NAR,SUP-2101272,CDM,C1713,HCPCS,0278,RC,,,,both,,,5149.60,3347.24,,,,,,,,,,,,,
CATHETER HEMO DYLS OR HD AD L36CM INSRTN L19CM DIA14.5FR,SUP-2174215,CDM,C1750,HCPCS,0278,RC,,,,both,,,1475.80,959.27,,,,,,,,,,,,,
MESH SURG VERTESSA LITE Y 26X5X4CM,SUP-2716340,CDM,C1781,HCPCS,0278,RC,,,,both,,,3293.86,2141.01,,,,,,,,,,,,,
HC Perq Dev Breast 1st US Image,PX-3611928500,CDM,19285,CPT,0361,RC,,,,outpatient,,,2124.00,1380.60,,,,,,,,,,,,,
BARRIER ADH L 2 X W 2 CM AMNIO MEMBRN DBL SIDE LAYR PROTCT,SUP-2904076,CDM,C1762,CPT,0278,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
SNARE VASC ENSNARE L 120 CM DIA18-30 MM CATH L 100 CM DIA 7,SUP-2217698,CDM,C1773,HCPCS,0272,RC,,,,both,,,1055.04,685.78,,,,,,,,,,,,,
PLATE BNE CRV BROAD PEDIATRIC 3.5 MM 30 HOLE SS NS LCP,SUP-2799226,CDM,C1713,HCPCS,0278,RC,,,,both,,,3890.84,2529.05,,,,,,,,,,,,,
TRIAL GREAT TOE HEMI MED MTL,SUP-2319051,CDM,C1776,CPT,0278,RC,,,,both,,,2559.10,1663.41,,,,,,,,,,,,,
T-PLT OBLQ 73MM STER HEAD 5HL SHAFT 4HL,SUP-2818408,CDM,C1713,HCPCS,0278,RC,,,,both,,,1854.89,1205.68,,,,,,,,,,,,,
WIRE FIX 1.2X150 MM KIRSCHNER,SUP-2316473,CDM,C1713,HCPCS,0278,RC,,,,both,,,62.80,40.82,,,,,,,,,,,,,
PLATE BNE 1/3 TBLR 61 MM 5 HOLE NS LTX,SUP-2861941,CDM,C1713,HCPCS,0278,RC,,,,both,,,194.05,126.13,,,,,,,,,,,,,
SUPPORT ORTHOPEDIC STRP LG ELBW TENNNIS NEOPRNE,SUP-2136949,CDM,L3702,HCPCS,0272,RC,,,,both,,,27.48,17.86,,,,,,,,,,,,,
ALLOGRAFT BNE FRZN MEDL TO LAT HALF FEM CONDYLE,SUP-2866852,CDM,C1762,CPT,0278,RC,,,,both,,,3758.58,2443.08,,,,,,,,,,,,,
MICROCATHETER GUID SNIPER L 130 CM DIA PROX/DSTL,SUP-2431937,CDM,C2628,HCPCS,0272,RC,,,,both,,,20410.00,13266.50,,,,,,,,,,,,,
CATHETER ABLAT 8FR L CRV INTELLATIP MIFI XP,SUP-2148491,CDM,C1733,HCPCS,0272,RC,,,,both,,,5024.00,3265.60,,,,,,,,,,,,,
DRESSING WND SURG MTRX 8X16 CM THCK MATRISTEM,SUP-2106497,CDM,Q4166,HCPCS,0636,RC,,,,both,,,10881.98,7073.29,,,,,,,,,,,,,
BIT DRL L330MM DIA4.2MM CALIB 100MM 3 FLUT QUIK CPL,SUP-2178854,CDM,2720000010,LOCAL,0272,RC,,,,both,,,696.23,452.55,,,,,,,,,,,,,
CATHETER ATHRCTMY L 135 CM BUR DIA1.75 MM CORONARY ADVANCING,SUP-2140972,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2612.48,1698.11,,,,,,,,,,,,,
OBLONG WASHER 12.7MMX21.7MM,SUP-2818891,CDM,C1713,HCPCS,0278,RC,,,,both,,,371.59,241.53,,,,,,,,,,,,,
SEGMENT FEM OD23MM 5DEG M TRAPEZOIDAL FLARE COMP SCR FORGED,SUP-2222176,CDM,C1713,HCPCS,0278,RC,,,,both,,,6004.94,3903.21,,,,,,,,,,,,,
PLATE BNE L56MM 4X4 H T SHP FOR 3.5MM SCR,SUP-2411365,CDM,C1713,HCPCS,0278,RC,,,,both,,,341.54,222.00,,,,,,,,,,,,,
PROSTHESIS CNTR HD TOT OSS HA STRL 4MM DIA 7MM LEN TORP FLX,SUP-2277544,CDM,L8613,CPT,0278,RC,,,,both,,,1670.48,1085.81,,,,,,,,,,,,,
MARKER BRST BX 12 CM NDL MAGSEED,SUP-2427297,CDM,A4648,CPT,0278,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
DHHS HELIX BLADE 150MM-STERILE,SUP-2547641,CDM,C1713,HCPCS,0278,RC,,,,both,,,1216.53,790.74,,,,,,,,,,,,,
SET REMEEX FOR FEM URIN INCONT,SUP-2308305,CDM,C1771,HCPCS,0278,RC,,,,both,,,6123.00,3979.95,,,,,,,,,,,,,
OLANZAPINE 5 MG PO TABS,RX-17936,CDM,6370000000,HCPCS,0637,RC,60505-3111-00,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
SHEATH INTRO PERFRMR L 85 CM OD 10 FR ID 3.3 MM GUIDEWIRE,SUP-2168404,CDM,C1894,HCPCS,0272,RC,,,,both,,,264.98,172.24,,,,,,,,,,,,,
CUP 32MM ID/44MM OD MUELLER FULL PROF ALL POLY,SUP-2209462,CDM,C1776,CPT,0278,RC,,,,both,,,2265.82,1472.78,,,,,,,,,,,,,
KIT CATH HEMODIALYSI EQUISTREAM CHRONIC MICROINTRODU 5904310,SUP-2632976,CDM,C1750,HCPCS,0278,RC,,,,both,,,1717.58,1116.43,,,,,,,,,,,,,
ALUMINUM RENAL ABH BLADE 1 X 7 25CM X 178CM,SUP-2702015,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1423.39,925.20,,,,,,,,,,,,,
PLATE BONE LT DSTL RAD STD SGL PT USE,SUP-2225425,CDM,C1713,HCPCS,0278,RC,,,,both,,,3265.60,2122.64,,,,,,,,,,,,,
STENT URET DBL PGTL 0.035 IN 3 CM 5 FRX14 CM STIFF SHFT,SUP-2463614,CDM,C2617,HCPCS,0278,RC,,,,both,,,589.44,383.14,,,,,,,,,,,,,
SUPPORT EL NEOPRENE 7 9IN SM,SUP-2276612,CDM,L3702,HCPCS,0272,RC,,,,both,,,9.36,6.08,,,,,,,,,,,,,
CATHETER GUID ENVOY DA XB L 95 CM DIA 6 FR ID 0.071 IN NYL,SUP-2257101,CDM,C1887,HCPCS,0272,RC,,,,both,,,2957.00,1922.05,,,,,,,,,,,,,
HC X-Ray Spine 1 View,PX-3207202000,CDM,72020,CPT,0320,RC,,,,outpatient,,,233.00,151.45,,,,,,,,,,,,,
SYSTEM DEL 8 GAX10 CM,SUP-2194168,CDM,C1713,HCPCS,0278,RC,,,,both,,,15700.00,10205.00,,,,,,,,,,,,,
EXTENSION STEM L100MM OD12MM STABILIZING FEM PRI REV,SUP-2215638,CDM,C1776,CPT,0278,RC,,,,both,,,2651.32,1723.36,,,,,,,,,,,,,
ALLOGRAFT DERMAL PTCH MED 5X10 CM ACELLULAR HYDRATED DERM,SUP-2321754,CDM,C1713,HCPCS,0278,RC,,,,both,,,8148.30,5296.39,,,,,,,,,,,,,
CATHETER SNUS BLLN L16MM DIA5MM HI PERF DIL INT SNUS IRRIG,SUP-2106310,CDM,C1726,HCPCS,0272,RC,,,,both,,,2452.34,1594.02,,,,,,,,,,,,,
WAND ABLAT DIA3MM TIP DIA4.5MM 15DEG ANG INTEGR CBL PARAGON,SUP-2341986,CDM,2720000010,LOCAL,0272,RC,,,,both,,,665.68,432.69,,,,,,,,,,,,,
"HC Blood Smear,Microscopic W/Diff",PX-3058500700,CDM,85007,CPT,0305,RC,,,,both,,,12.00,7.80,,,,,,,,,,,,,
KIT LD INTRO SAFSHTH L 13 CM DIA 8 FR GUIDEWIRE L 45 CM DIA,SUP-2329858,CDM,C1892,HCPCS,0272,RC,,,,both,,,174.62,113.50,,,,,,,,,,,,,
GRAFT BIO TISS W6XL16CM DERM PORCINE ABD RECON FIRM,SUP-2112976,CDM,Q4130,HCPCS,0636,RC,,,,both,,,9228.46,5998.50,,,,,,,,,,,,,
SCREW BNE L18MM OD6.5MM VIT ST HEX DRV,SUP-2376067,CDM,C1713,HCPCS,0278,RC,,,,both,,,261.25,169.81,,,,,,,,,,,,,
SET INTRO NEFF SHTH L 18 CM OD 7 FR ID 4 FR GUIDEWIRE 0.018,SUP-2168339,CDM,C1894,HCPCS,0272,RC,,,,both,,,214.74,139.58,,,,,,,,,,,,,
IMMOBILIZER ORTH CLOSED PAT UNIV AD 12 IN 24 IN CANVS,SUP-2194466,CDM,L1830,CPT,0272,RC,,,,both,,,59.66,38.78,,,,,,,,,,,,,
HC Control Throat Bleeding,PX-4504296000,CDM,42960,CPT,0450,RC,,,,both,,,706.00,458.90,,,,,,,,,,,,,
PLATE BNE L39MM THK3.8MM 2 H BILAT S STL NAR DYN COMPR FOR,SUP-2185180,CDM,C1713,HCPCS,0278,RC,,,,both,,,1013.78,658.96,,,,,,,,,,,,,
IMPLANT FACE L 95 X H 98 MM THK 18 MM LG POLYETHYL TEMPORAL,SUP-2883655,CDM,C1713,HCPCS,0278,RC,,,,both,,,5200.97,3380.63,,,,,,,,,,,,,
HC Cta Neck/Carotid W & W/O Cont,PX-3517049800,CDM,70498,CPT,0351,RC,,,,both,,,2630.00,1709.50,,,,,,,,,,,,,
HC Trluml Balo Angiop 1st Art,PX-3613724600,CDM,37246,CPT,0361,RC,,,,both,,,8583.00,5578.95,,,,,,,,,,,,,
KIT CATH HYDRPHLC CO2 CVD ATTAIN COMMND SYS,SUP-2282194,CDM,C1887,HCPCS,0272,RC,,,,both,,,1993.43,1295.73,,,,,,,,,,,,,
STENT DUODENAL L120MM DIA22MM CATH L230CM 10FR 0.035IN NIT,SUP-2149875,CDM,C1876,HCPCS,0278,RC,,,,both,,,7716.80,5015.92,,,,,,,,,,,,,
WIRE FIX DIA062IN REUNITE K,SUP-2137299,CDM,C1713,HCPCS,0278,RC,,,,both,,,203.97,132.58,,,,,,,,,,,,,
CATHETER PUSH STENT CONN CLR PUR 11FR LEN 170CM,SUP-2169264,CDM,C1729,HCPCS,0272,RC,,,,both,,,119.32,77.56,,,,,,,,,,,,,
TROCAR SURG STRUCTURAL OVL DISECT BLLN SPCMKR +,SUP-2283394,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1379.25,896.51,,,,,,,,,,,,,
CATHETERIZATION KIT 17.75 IN 7 FRX16 CM ARROWG+ARD +,SUP-2383331,CDM,C1751,HCPCS,0278,RC,,,,both,,,206.08,133.95,,,,,,,,,,,,,
STAPLER INTERNAL TITAN SGS LINEAR POWERED ENDOSCOPIC 1.2-2.2MM 23CM JAW,SUP-2902725,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6594.00,4286.10,,,,,,,,,,,,,
BASKET STONE RETRV L120CM DIA12MM SHTH 1.9FR NIT POLYAMIDE,SUP-2139280,CDM,2720000010,LOCAL,0272,RC,,,,both,,,695.16,451.85,,,,,,,,,,,,,
DRILL SURG BUNNELL 5/32 IN HND,SUP-2795266,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1583.00,1028.95,,,,,,,,,,,,,
GRAFT HUM AMNION L FLD MTRX,SUP-2309717,CDM,C1713,HCPCS,0278,RC,,,,both,,,8368.10,5439.26,,,,,,,,,,,,,
KNIFE SURG BLDE L220MM DBL CUT FOR AMPUTATION LISTON,SUP-2108449,CDM,C1713,HCPCS,0278,RC,,,,both,,,548.87,356.77,,,,,,,,,,,,,
INTRODUCER ORTHOPEDIC BLNT,SUP-2265698,CDM,C1894,HCPCS,0272,RC,,,,both,,,807.92,525.15,,,,,,,,,,,,,
ELECTRODE ABLAT TUMOR RF RITA UNIBLATE CT COMPATIBLE 17 GA 5,SUP-2118725,CDM,C1713,HCPCS,0278,RC,,,,both,,,6578.30,4275.89,,,,,,,,,,,,,
HC So1 Fluorescent Antibody Screen,PX-3028625567,CDM,86255,CPT,0302,RC,,,,outpatient,,,588.00,382.20,,,,,,,,,,,,,
STIMULATOR NERVE IMPL PULSE GENRTR KT PRECIS MONTAGE MRI,SUP-2138778,CDM,C1820,HCPCS,0278,RC,,,,both,,,66863.16,43461.05,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED PRSS FT STEM EPOCH,SUP-2212732,CDM,C1776,CPT,0278,RC,,,,both,,,15029.61,9769.25,,,,,,,,,,,,,
CATHETER VENTRICULAR 1.3X2.5 MMX15 CM IMPREG STRIPE TRNSLUC,SUP-2631853,CDM,C1729,HCPCS,0272,RC,,,,both,,,693.28,450.63,,,,,,,,,,,,,
SYSTEM BOOT TOT CNTCT CAST REG FOR MEDE-KAST TCC-EZ,SUP-2194356,CDM,L4386,HCPCS,0274,RC,,,,both,,,213.52,138.79,,,,,,,,,,,,,
KIT NEUROSTIMULATOR CHRG SENZA,SUP-2308584,CDM,2720000010,LOCAL,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
BLADE SAW OSCLLTNG 25.4MMW X90MML 1.5MM THK 1.5MM THK CUT ME,SUP-2605471,CDM,2720000010,LOCAL,0272,RC,,,,both,,,102.21,66.44,,,,,,,,,,,,,
IMPL CAPPED KNEE LPS FXTICMFMTBPRLNOPATPLG,SUP-2212335,CDM,C1776,CPT,0278,RC,,,,both,,,14359.69,9333.80,,,,,,,,,,,,,
LENS INTOCU +5.0 DIOPT L13MM DIA5.5MM D3.39MM 0.5DEG HAPTIC,SUP-2110858,CDM,V2630,CPT,0276,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
TRAY CATH HEMODIALYSI BREVIA ACUTE 11FR DIA 12.5CML 5496120,SUP-2632894,CDM,C1752,HCPCS,0278,RC,,,,both,,,624.55,405.96,,,,,,,,,,,,,
BLADE SCREWDRIVER 15MM DIA 80MML CROSS DRIVE W/SLEEVE,SUP-2681047,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1143.09,743.01,,,,,,,,,,,,,
SCREW BONE CNNLTD 45MM DIA W/INSTRMNT CASE NON ST,SUP-2721263,CDM,C1713,HCPCS,0278,RC,,,,both,,,7596.51,4937.73,,,,,,,,,,,,,
DRESSING BIO W5XL5CM CLLGN SH 0.1% POLYHEXMETHYLENEBIGUANIDE,SUP-2314086,CDM,Q4196,HCPCS,0636,RC,,,,both,,,8164.00,5306.60,,,,,,,,,,,,,
HC Dx Breast Tomo Uni,PX-4017706100,CDM,G0279,HCPCS,0401,RC,,,,outpatient,,,153.00,99.45,,,,,,,,,,,,,
NAIL IM L320MM DIA10.5MM UNIV TIB TI ALLOY CANN LCK,SUP-2412955,CDM,C1713,HCPCS,0278,RC,,,,both,,,6468.40,4204.46,,,,,,,,,,,,,
INTRODUCER TUBE SET PERC ADV CIAGLIA BLU RHINO G2,SUP-2759751,CDM,C1769,HCPCS,0272,RC,,,,both,,,1147.07,745.60,,,,,,,,,,,,,
HC Cytp Smrs Any Oth Src Scr&Interpj,PX-3118816000,CDM,88160,CPT,0311,RC,,,,both,,,149.00,96.85,,,,,,,,,,,,,
NAIL CPHLMDLLRY SM L38CM D10MM 130DG LNG TTNM LEFT CCD ANGLE,SUP-2468352,CDM,C1776,CPT,0278,RC,,,,both,,,6685.75,4345.74,,,,,,,,,,,,,
TUNNELER SURG VAGUS NRV S STL HAFT BULL TIP SL FLUOROCARBON,SUP-2265175,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1814.92,1179.70,,,,,,,,,,,,,
HC So F2 Gene Analysis,PX-3108124066,CDM,81240,CPT,0310,RC,,,,both,,,330.00,214.50,,,,,,,,,,,,,
STENT ENDOVASCULAR L50MM DIA9MM CATHETER 9FR L80CM GUIDEWIRE 0.035IN EPTFE GRAFT FLARED OUTFLOW CONFIGURATION ENCAPSULATED CARBON IMPREGNATION FLAIR,SUP-2128224,CDM,C1874,HCPCS,0278,RC,,,,both,,,7065.00,4592.25,,,,,,,,,,,,,
LARYNGECTOMY KIT PULM 9/36 9/55 STD W/ PROVOX LARYTUBE,SUP-2424442,CDM,C1713,HCPCS,0278,RC,,,,both,,,2228.58,1448.58,,,,,,,,,,,,,
IMPLANT HUM TISS L 2 X W 1 CM PLCNTA MEMBRN TRILAYER,SUP-2905503,CDM,Q4278,HCPCS,0636,RC,,,,both,,,3176.17,2064.51,,,,,,,,,,,,,
PACK PROC TOT SHLDR PROMOS,SUP-2347962,CDM,C1776,CPT,0278,RC,,,,both,,,19243.49,12508.27,,,,,,,,,,,,,
SCREW CRTX FT ST HEX HD 4.5MM DIA 38MML,SUP-2342658,CDM,C1713,HCPCS,0278,RC,,,,both,,,310.67,201.94,,,,,,,,,,,,,
BASKET RETRV L2700MM DIA16MM MIN WRK CHN 2.8MM ROT 6 WIR TO,SUP-2313142,CDM,2720000010,LOCAL,0272,RC,,,,both,,,632.74,411.28,,,,,,,,,,,,,
ALLOGRAFT BNE FEM HD 4.8 CM FRZN W/O CART,SUP-2717885,CDM,C1762,CPT,0278,RC,,,,both,,,6931.02,4505.16,,,,,,,,,,,,,
GUIDEWIRE ORTH L152MM DIA32MM SMOOTH SHRP TIP,SUP-2251211,CDM,C1769,HCPCS,0272,RC,,,,both,,,87.92,57.15,,,,,,,,,,,,,
SCREW SPNL MULTAXL 5.5X60 MM CANN EXT TAB VOYAGER 4.75,SUP-2629435,CDM,C1713,HCPCS,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
KIT SUTURING DEVICE M-CLOSE,SUP-2707531,CDM,2720000010,LOCAL,0272,RC,,,,both,,,282.57,183.67,,,,,,,,,,,,,
SYSTEM SPNL CEMENT FOR VERTEBROPLASTY STRL DISP HI V,SUP-2883108,CDM,C1713,HCPCS,0278,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
GRAFT BIO TISS W3.1XL3.1IN PORCINE DERM RIFAMPIN,SUP-2125833,CDM,C1781,HCPCS,0278,RC,,,,both,,,6782.40,4408.56,,,,,,,,,,,,,
INSERT TIB L79/83MM THK10MM UNIV KNEE UHMWPE PRI POST STBL,SUP-2407050,CDM,C1776,CPT,0278,RC,,,,both,,,2775.76,1804.24,,,,,,,,,,,,,
MARKER RAD L20MM DIA0.9MM NIT LUNG COIL FIDUCIAL SUPERLOCK,SUP-2381755,CDM,A4648,CPT,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
WIRE K THRD GRV 23 X 230MM,SUP-2321631,CDM,C1713,HCPCS,0278,RC,,,,both,,,417.62,271.45,,,,,,,,,,,,,
LENS INTOCU +12.5 DIOPT L12.5MM DIA5.5MM D3.39MM 0.5DEG,SUP-2110698,CDM,V2630,CPT,0276,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
ECLIPSE CAGE SCREW X-LARGE 45MM,SUP-2817810,CDM,C1713,HCPCS,0278,RC,,,,both,,,9420.00,6123.00,,,,,,,,,,,,,
ADAPTER AUDIO,SUP-2430340,CDM,2720000010,LOCAL,0272,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
CATHETER ANGIOPLSTY POLARCATH L 80 CM BALLOON L 100 MM DIA 5,SUP-2141855,CDM,C1725,HCPCS,0272,RC,,,,both,,,2260.80,1469.52,,,,,,,,,,,,,
PACEMAKER CARD W44XH43MM THK6MM 18GM 2 CHMBR SYS W/ LD,SUP-2356217,CDM,C1785,HCPCS,0275,RC,,,,both,,,21524.70,13991.05,,,,,,,,,,,,,
SCREW BONE LOCKING 2.9X14 MM SELFTAPPING TITANIUM NON STERIL,SUP-2837689,CDM,C1713,HCPCS,0278,RC,,,,both,,,754.07,490.15,,,,,,,,,,,,,
ALISKIREN FUMARATE 150 MG PO TABS,RX-78653,CDM,6370000000,HCPCS,0637,RC,70839-0150-30,NDC,,both,1,UN,51.80,33.67,,,,,,,,,,,,,
REVERS CA HUM HD 50/19,SUP-2123387,CDM,C1776,CPT,0278,RC,,,,both,,,7379.00,4796.35,,,,,,,,,,,,,
FILTER VASC 4 MM EMBOLC PROTCT FLPY TIP MED NIT ANGIOGUARD,SUP-2865935,CDM,C1725,HCPCS,0272,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
DEVICE SUTURING N ABSRB 3-0 8 IN LD UNIT ENDOSTCH DISP,SUP-2787734,CDM,2720000010,LOCAL,0272,RC,,,,both,,,239.61,155.75,,,,,,,,,,,,,
HC Inj/Asp Maj Jnt or Bursa|BILATERAL PROCEDURE,PX-7612061000,CDM,20610,CPT,0761,RC,,,50,outpatient,,,1092.00,709.80,,,,,,,,,,,,,
PANCRELIPASE (LIP-PROT-AMYL) 10000-32000 UNITS PO CPEP,RX-142032,CDM,6370000000,HCPCS,0637,RC,73562-0110-01,NDC,,both,1,UN,19.00,12.35,,,,,,,,,,,,,
TUBE GAST JEJU 14FR L15CM STOMA L1CM G GRN TECHNOLOGY LO,SUP-2119808,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1293.68,840.89,,,,,,,,,,,,,
CATHETER NEPHROSTOMY LCK PIG 0.035 IN 6 FRX25 CM SKATER,SUP-2269626,CDM,C1729,HCPCS,0272,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
HC So1 Immunoassay Quant,PX-3018351967,CDM,83519,CPT,0301,RC,,,,inpatient,,,264.00,171.60,,,,,,,,,,,,,
STRIPPER TENDON QUADPRO HARVESTER 10MM,SUP-2660682,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
AUGMENT TIB SZ 6 THK5MM R MED L LAT KNEE CO CHROM REV,SUP-2373556,CDM,C1776,CPT,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
KIT CVC L 16 CM DIA12 FR TL BIOPATCH DRSG LG BOR FOR HI VOL,SUP-2909932,CDM,C1751,HCPCS,0278,RC,,,,both,,,547.62,355.95,,,,,,,,,,,,,
SCREW CANN MINI COMP 12MM,SUP-2321406,CDM,C1713,HCPCS,0278,RC,,,,both,,,753.91,490.04,,,,,,,,,,,,,
PLATE BNE LCK 217 MM RT DSTL LAT HUM PERIARTICULAR 15 HOLE,SUP-2525156,CDM,C1713,HCPCS,0278,RC,,,,both,,,3146.25,2045.06,,,,,,,,,,,,,
BUR SURGICAL TRABECULAR METAL TOTAL ANKLE SYSTEM,SUP-2471018,CDM,2720000010,LOCAL,0272,RC,,,,both,,,941.34,611.87,,,,,,,,,,,,,
IMPLANT MID PHALANX 55MM NEXTRA HAMRTOE CORR SYS,SUP-2137583,CDM,C1713,HCPCS,0278,RC,,,,both,,,1209.78,786.36,,,,,,,,,,,,,
SCREW SPNL OD5.5MM LCK CLOSE LAT COLORADO 2,SUP-2290609,CDM,C1713,HCPCS,0278,RC,,,,both,,,606.02,393.91,,,,,,,,,,,,,
KIT PERI DRNGE STRT W/ 1 INSRTN TY 15.5FR CATH 1L BG WIPE,SUP-2416418,CDM,C1729,HCPCS,0272,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
S-T CORTEX SCREW 50MM 2.5MM,SUP-2844048,CDM,C1713,HCPCS,0278,RC,,,,both,,,193.27,125.63,,,,,,,,,,,,,
BASKET STONE RETRIVAL 22 MMX195 CM BILI BULL SHP TIP,SUP-2493853,CDM,2720000010,LOCAL,0272,RC,,,,both,,,701.01,455.66,,,,,,,,,,,,,
MESH HERN W20XL30CM POLY SYN REABSORBABLE CLLGN BARR 3D,SUP-2174723,CDM,C1781,HCPCS,0278,RC,,,,both,,,4061.56,2640.01,,,,,,,,,,,,,
SCREW SPNL L25MM OD4MM 0DEG TI POST MONOAX DBL LD THRD LO,SUP-2229293,CDM,C1713,HCPCS,0278,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
BLADE ELECSURG SHV 4.5MM RESECT ELECTROSHV ELITE VULCAN,SUP-2341031,CDM,2720000010,LOCAL,0272,RC,,,,both,,,732.66,476.23,,,,,,,,,,,,,
LINER ACET NEUT 28X66 MM HIP ENDRN,SUP-2342576,CDM,C1713,HCPCS,0278,RC,,,,both,,,3639.73,2365.82,,,,,,,,,,,,,
HEAD HUM ANAT 3.5 MM 37X13.5 MM SHLDR HIGH OFFSET COCR,SUP-2715717,CDM,C1776,CPT,0278,RC,,,,both,,,10484.46,6814.90,,,,,,,,,,,,,
ENDCAP ORTH RESRB C STEM,SUP-2253662,CDM,C1776,CPT,0278,RC,,,,both,,,258.74,168.18,,,,,,,,,,,,,
RING EXT FIX DIA220 MM FULL SINGLE ROW MONK RING,SUP-2899177,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4308.87,2800.77,,,,,,,,,,,,,
COVER BUR H DIA24MM 6 H TI BENT W/O TAB NONCOMPRESSION LO,SUP-2136517,CDM,C1713,HCPCS,0278,RC,,,,both,,,800.70,520.45,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 201-250 CM FASC,SUP-2321783,CDM,C1762,CPT,0278,RC,,,,both,,,7206.30,4684.09,,,,,,,,,,,,,
IMPLANT BIO TISS L25CM ID4MM PERIPH NRV CLLGN CONDUIT,SUP-2378814,CDM,C1713,HCPCS,0278,RC,,,,both,,,3441.44,2236.94,,,,,,,,,,,,,
PLATE BNE W4XL50MM THK1MM 3X9 H BILAT TI T SHP RIG,SUP-2191142,CDM,C1713,HCPCS,0278,RC,,,,both,,,1329.13,863.93,,,,,,,,,,,,,
SCREW BNE L 3 MM DIA1.4 MM TI CRANIOMAXILLOFACIAL EMER ST,SUP-2884140,CDM,C1713,HCPCS,0278,RC,,,,both,,,232.67,151.24,,,,,,,,,,,,,
PROSTHESIS OSS DE LA CRUZ 0.6X4.25 MM PISTON NIT SMRT,SUP-2651569,CDM,L8613,CPT,0278,RC,,,,both,,,1141.11,741.72,,,,,,,,,,,,,
DICYCLOMINE HCL 10 MG PO CAPS,RX-2418,CDM,6370000000,HCPCS,0637,RC,60687-0369-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
HC NM Acute GI Bleed Study,PX-3417827800,CDM,78278,CPT,0341,RC,,,,inpatient,,,2106.00,1368.90,,,,,,,,,,,,,
BRACE ORTH CUST ANK FT,SUP-2388163,CDM,L1940,HCPCS,0274,RC,,,,both,,,1220.14,793.09,,,,,,,,,,,,,
STEM HUM H130MM DIA9MM GRN CO CHROM ALLY HA CEM FOR,SUP-2388687,CDM,C1776,CPT,0278,RC,,,,both,,,15707.85,10210.10,,,,,,,,,,,,,
FORCEPS ENDO L45CM TIP L23MM DIA10MM DEBAKEY TEETH PRSS LCK,SUP-2382314,CDM,2720000010,LOCAL,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
TIP ASPIR 23GA ADV BACKFLUSH SFT PASS OR ACT DISP,SUP-2109650,CDM,C1713,HCPCS,0278,RC,,,,both,,,318.49,207.02,,,,,,,,,,,,,
DAKINS (FULL STRENGTH) 0.5 % EX SOLN,RX-148149,CDM,6370000000,HCPCS,0637,RC,00436-0946-16,NDC,,both,473,ML,51.10,33.21,,,,,,,,,,,,,
PROSTHESIS VOICE LO PRSS 16FR SZ 18MM BLOM SINGER,SUP-2242312,CDM,L8509,HCPCS,0274,RC,,,,both,,,266.90,173.48,,,,,,,,,,,,,
ARROWGARD BLUE PSI KIT CATH GARD 7.5-8 FR CATH 8.5FRX10CM,SUP-2660676,CDM,C1894,HCPCS,0272,RC,,,,both,,,385.84,250.80,,,,,,,,,,,,,
HEAD HUM DIA45MM THK18MM SHLDR CO CHROM PRI STD OFFSET NK 53504518] STRYKER ORTHOPEDICS HOWM],SUP-2372837,CDM,C1776,CPT,0278,RC,,,,both,,,4468.19,2904.32,,,,,,,,,,,,,
PLATE SPNL LG MINI 12X23 MM TITAN NANOLOCK STRL ANTERALIGN,SUP-2859405,CDM,C1713,HCPCS,0278,RC,,,,both,,,8242.50,5357.62,,,,,,,,,,,,,
GUIDEWIRE VASC L150CM 0.035IN BENT PTFE FIX COR INQWIRE,SUP-2302700,CDM,C1769,HCPCS,0272,RC,,,,both,,,31.40,20.41,,,,,,,,,,,,,
SPLINT ORTH M LT ANTI SPASMOTIC NEUROLOGIC CONTRACTURES REG,SUP-2324561,CDM,L3906,HCPCS,0272,RC,,,,both,,,77.93,50.65,,,,,,,,,,,,,
PLATE BNE ARNETT MINI XL 1X1 MM 4 HOLE STR RIGID SIDE TI NS,SUP-2472701,CDM,C1713,HCPCS,0278,RC,,,,both,,,1113.57,723.82,,,,,,,,,,,,,
ALLOGRAFT BNE FEM 210X13X3 MM FRZN STRUT,SUP-2717901,CDM,C1762,CPT,0278,RC,,,,both,,,4212.78,2738.31,,,,,,,,,,,,,
FIBER LASER HOLM DISP SU555RT] LEONI FIBER OPTICS INC],SUP-2264316,CDM,2720000010,LOCAL,0272,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
PLATE BNE L106MM 6 H L LAT DST PERIARTC FIBULAR S STL LOK,SUP-2410716,CDM,C1713,HCPCS,0278,RC,,,,both,,,2069.89,1345.43,,,,,,,,,,,,,
COIL EMB L30CM OD10MM 0010IN 360DEG STD STRTCH RESIST,SUP-2365676,CDM,C1889,HCPCS,0278,RC,,,,both,,,5829.10,3788.91,,,,,,,,,,,,,
SYSTEM KNEE LNG REINF FINN,SUP-2406069,CDM,C1776,CPT,0278,RC,,,,both,,,2752.52,1789.14,,,,,,,,,,,,,
CATHETER CARD ABLATION SPHERE-9 L 115 CM DIA 8 FR ELECTRD,SUP-2911943,CDM,C1733,HCPCS,0272,RC,,,,both,,,34540.00,22451.00,,,,,,,,,,,,,
GENERATOR PULSE IMPL V1 INTEGR RESP SENS STRL,SUP-2937408,CDM,2720000010,LOCAL,0272,RC,,,,both,,,69858.72,45408.17,,,,,,,,,,,,,
"HC Est Pt, E/M Level 4",PX-5109921400,CDM,99214,CPT,0510,RC,,,,both,,,313.00,203.45,,,,,,,,,,,,,
BIT DRL L100MM DIA2MM ST 3 FLUT QUIK CPL NONRADIOPAQUE W O,SUP-2187579,CDM,2720000010,LOCAL,0272,RC,,,,both,,,451.41,293.42,,,,,,,,,,,,,
SCREW BNE STD 2.3X15 MM TI NS MAXDRIVE LEVEL 1,SUP-2464155,CDM,C1713,HCPCS,0278,RC,,,,both,,,204.85,133.15,,,,,,,,,,,,,
SPACER SPNL STRL TRANSFORAMINAL LUM SHIM HOOP DISP MAS,SUP-2310434,CDM,C1713,HCPCS,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
SPLINT ORTH M LT ANTI SPASMOTIC NEUROLOGIC CONTRACTURES REG,SUP-2324561,CDM,L3906,HCPCS,0274,RC,,,,both,,,77.93,50.65,,,,,,,,,,,,,
MESH BONE SIZE 11 0.6MM THK TTNM CNTRD STNDRD LATEX FREE ST,SUP-2496702,CDM,C1713,HCPCS,0278,RC,,,,both,,,16876.12,10969.48,,,,,,,,,,,,,
INSERT TIB ROTATING HINGE 10 MM,SUP-2452028,CDM,C1776,CPT,0278,RC,,,,both,,,1535.93,998.35,,,,,,,,,,,,,
PLATE BONE L184MM BLDE W11.7XL30MM 90DEG 10 H STRL BILAT TI,SUP-2190868,CDM,C1713,HCPCS,0278,RC,,,,both,,,3838.18,2494.82,,,,,,,,,,,,,
SPACER SPNL L8MM PEEK TI SPINOUS PROC FUS AXLE,SUP-2401502,CDM,C1889,HCPCS,0278,RC,,,,both,,,4082.00,2653.30,,,,,,,,,,,,,
PLATE BNE NAR 3.5X287 MM 16 HOLE SS LCP,SUP-2569358,CDM,C1713,HCPCS,0278,RC,,,,both,,,709.80,461.37,,,,,,,,,,,,,
CAGE SPNL W8XL36MM PEEK MECH CAPSTONE,SUP-2293986,CDM,C1889,HCPCS,0278,RC,,,,both,,,17298.26,11243.87,,,,,,,,,,,,,
SUPPORT ORTHOT LUMBAR SACR CUST SAGITTAL-CORONAL CTRL LAT,SUP-2435554,CDM,L0635,HCPCS,0272,RC,,,,both,,,2828.95,1838.82,,,,,,,,,,,,,
BIT DRL DIA4MM FOR 55MM CANN SCR,SUP-2343598,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2793.00,1815.45,,,,,,,,,,,,,
BLADE SHAVER BPLR STD 40 DEG 4 MM ANGLE SERRATED EDGE FRM,SUP-2638394,CDM,2720000010,LOCAL,0272,RC,,,,both,,,566.77,368.40,,,,,,,,,,,,,
SPLINT RST PAN MIT SP S RT,SUP-2163831,CDM,L3807,HCPCS,0272,RC,,,,both,,,81.29,52.84,,,,,,,,,,,,,
SYSTEM BNE BX PERF 11 GAX6.5 CM W/ DRL MADISON,SUP-2489550,CDM,2720000010,LOCAL,0272,RC,,,,both,,,753.60,489.84,,,,,,,,,,,,,
GRAFT BIO TISS W8XL16CM THK1MM CLLGN MTRX FEN SEMI OVL FOR,SUP-2243672,CDM,C9360,HCPCS,0278,RC,,,,both,,,8440.32,5486.21,,,,,,,,,,,,,
PLATE BNE L52MM 3X3 H T SHP FOR 3.5MM SCR,SUP-2411362,CDM,C1713,HCPCS,0278,RC,,,,both,,,538.20,349.83,,,,,,,,,,,,,
SUPPORT ORTHOT PIP FNGR DSTL INTERPHALANGEAL CUST W/O JT,SUP-2435785,CDM,L3927,HCPCS,0272,RC,,,,both,,,90.21,58.64,,,,,,,,,,,,,
DOCUSATE SODIUM 50 MG/5ML PO LIQD,RX-36962,CDM,6370000000,HCPCS,0637,RC,00121-1870-00,NDC,,both,5,ML,4.20,2.73,,,,,,,,,,,,,
PLATE EXT FIX L 95 MM 8 H SHRT CONN OVL SLOT NS DISP ILIZ,SUP-2933403,CDM,2720000010,LOCAL,0272,RC,,,,both,,,786.85,511.45,,,,,,,,,,,,,
INTRODUCER HEMSTAS 6FRX5CM SHTH W/ .035IN GWIRE ULTIMUM EV 407649] ST JUDE MED CARDIOVASCULAR DIV],SUP-2355603,CDM,C1894,HCPCS,0272,RC,,,,both,,,31.40,20.41,,,,,,,,,,,,,
ANCHOR SUT MINI MAG KNOTLESS W/ INSRT HNDL,SUP-2342078,CDM,C1776,CPT,0278,RC,,,,both,,,1444.40,938.86,,,,,,,,,,,,,
SUTURE N ABSRB BRAIDED 5-0 24 IN 49 MM GRN NICELOOP SMSL50101,SUP-2401165,CDM,C1713,HCPCS,0278,RC,,,,both,,,391.84,254.70,,,,,,,,,,,,,
HC CT Guide for Stereotactic Loca,PX-3507701100,CDM,77011,CPT,0350,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
SCREW INTRF L25MM DIA10MM KNEE PLLA HA BIOABSRB FOR ACL PCL,SUP-2341580,CDM,C1713,HCPCS,0278,RC,,,,both,,,762.61,495.70,,,,,,,,,,,,,
SET PANCREATIC STENT GEENEN L 9 CM DIA 7 FR NO INT FLAP,SUP-2169207,CDM,C2625,HCPCS,0278,RC,,,,both,,,445.88,289.82,,,,,,,,,,,,,
ALLOGRAFT HUMAN TISSUE AMNIOBAND 3CM X 8CM,SUP-2907551,CDM,Q4151,HCPCS,0636,RC,,,,both,,,7634.47,4962.41,,,,,,,,,,,,,
SYSTEM INTRO SHTH 9FR L25CM BLK HUB W O SIDEPRT SPLITTABLE,SUP-2303232,CDM,C1892,HCPCS,0272,RC,,,,both,,,131.88,85.72,,,,,,,,,,,,,
ABLATOR ENDOSCOPIC ELECTROCAUTERY 90 DEG RF ASPIRATING STERILE DISPOSABLE APOLLORF I90,SUP-2895201,CDM,C1713,HCPCS,0278,RC,,,,both,,,675.10,438.81,,,,,,,,,,,,,
ROD ORTH THRD 200 MM PILLAR,SUP-2749920,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1667.34,1083.77,,,,,,,,,,,,,
HC in Situ Hybridization Ea Addl Probe Stain,PX-3128836400,CDM,88364,CPT,0312,RC,,,,both,,,184.00,119.60,,,,,,,,,,,,,
FORCEPS BX 2.4FR L115CM BACKLOADING TO OBTAIN SAMP FOR,SUP-2171429,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1951.20,1268.28,,,,,,,,,,,,,
RING EXT FIX 2/3 220 MM CARBON DFS DYNAFIX,SUP-2534572,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1312.52,853.14,,,,,,,,,,,,,
GUIDEWIRE SURG SMOOTH 2.5X800 MM,SUP-2644703,CDM,C1769,HCPCS,0272,RC,,,,both,,,416.36,270.63,,,,,,,,,,,,,
BRA SURG 3XL WHT POST SURG MAMM COMPR DSG W/ REM STRP FR HK,SUP-2276930,CDM,L8000,HCPCS,0272,RC,,,,both,,,50.08,32.55,,,,,,,,,,,,,
WASHER ORTH OD6MM TI RND,SUP-2122406,CDM,C1713,HCPCS,0278,RC,,,,both,,,109.90,71.43,,,,,,,,,,,,,
PACK KNE SCR W/INSTR CONVENIENCE W/ MPFL RECON TMPLT 4.75MM,SUP-2121122,CDM,C1713,HCPCS,0278,RC,,,,both,,,4669.18,3034.97,,,,,,,,,,,,,
CATHETER DRNAGE 10FR L35CM POLYUR HYDRPHLC W/ LCK PGTL M DRN,SUP-2303557,CDM,C1729,HCPCS,0272,RC,,,,both,,,244.92,159.20,,,,,,,,,,,,,
GRAFT VASC INTERGARD L 50 CM DIA16 X 8 MM THK 0.49 MM,SUP-2227598,CDM,L8670,HCPCS,0278,RC,,,,both,,,2567.70,1669.00,,,,,,,,,,,,,
HC Microsomal Antibodies Each,PX-3028637600,CDM,86376,CPT,0302,RC,,,,both,,,79.00,51.35,,,,,,,,,,,,,
CATHETER HD SET 14 FRX20 CM DL N COAT BLU FLEXTIP,SUP-2763025,CDM,C1752,HCPCS,0278,RC,,,,both,,,177.19,115.17,,,,,,,,,,,,,
STAPLER INT STPL L53MM 4X6.6MM 4.3MM CLSR TAN LACTOMER STD,SUP-2283019,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1701.63,1106.06,,,,,,,,,,,,,
SCREW BNE NLCK 5X40 MM OSTEOPENIA PARTIALLY THRD NS PERI-LOC,SUP-2348498,CDM,C1713,HCPCS,0278,RC,,,,both,,,220.74,143.48,,,,,,,,,,,,,
TUBE INNR EAR MYR VENT CLLR BTTN FLNG L 2.1 MM LEN 1.27 MM,SUP-2381507,CDM,L8699,HCPCS,0278,RC,,,,both,,,76.93,50.00,,,,,,,,,,,,,
ETHAMBUTOL HCL 100 MG PO TABS,RX-9982,CDM,6370000000,HCPCS,0637,RC,68180-0280-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
TIP CATHETER 110DEG MAX SNUS GUID FOR BLLN SINUPLASTY SYS,SUP-2106366,CDM,C1887,HCPCS,0272,RC,,,,both,,,546.39,355.15,,,,,,,,,,,,,
STEM TIB SMOOTH TOP 16 MM R/L TOT ANK COAT INBONE II,SUP-2475073,CDM,C1776,CPT,0278,RC,,,,both,,,1337.64,869.47,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL PEEK SD800.505,SUP-2860187,CDM,C1713,HCPCS,0278,RC,,,,both,,,25477.02,16560.06,,,,,,,,,,,,,
CAGE SPNL L14MM W10MM H50MM TI INTBDY ANT THORLUM OVL,SUP-2291981,CDM,C1889,HCPCS,0278,RC,,,,both,,,17301.40,11245.91,,,,,,,,,,,,,
CLAV ANT NRW 11H 90MM NS,SUP-2721206,CDM,C1713,HCPCS,0278,RC,,,,both,,,4248.42,2761.47,,,,,,,,,,,,,
WIRE BNE FIX DIA2 MM NS LEOS KIRSCHNER,SUP-2933365,CDM,C1713,HCPCS,0278,RC,,,,both,,,151.66,98.58,,,,,,,,,,,,,
PROSTHESIS VOICE 22.5FR 4MM PRELD W/ SMRT INSRTR AND BRSH,SUP-2124407,CDM,L8509,HCPCS,0274,RC,,,,both,,,1029.35,669.08,,,,,,,,,,,,,
DRILL ENDOSCP 9.5 MM,SUP-2849106,CDM,2720000010,LOCAL,0272,RC,,,,both,,,750.46,487.80,,,,,,,,,,,,,
PLATE BNE 4 SLOT 120 DEG PEDIATRIC,SUP-2535994,CDM,C1713,HCPCS,0278,RC,,,,both,,,2201.93,1431.25,,,,,,,,,,,,,
SCREW BNE L50MM DIA4.5MM HD DIA6.5MM S STL ST SELF DRL CANN,SUP-2184493,CDM,C1713,HCPCS,0278,RC,,,,both,,,504.06,327.64,,,,,,,,,,,,,
MESH CS LEFT EXTRA-LARGE 12CM X 17CM,SUP-2655638,CDM,C1781,HCPCS,0278,RC,,,,both,,,737.90,479.63,,,,,,,,,,,,,
STEM HUM SZ 5 L100MM NEXEL,SUP-2402659,CDM,C1776,CPT,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
SET ART LN CATH 4FR L15CM STR BASEPLT W/ GWIRE INTRO AND,SUP-2167823,CDM,C1751,HCPCS,0278,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
PLATE BNE L48MM 4X3 H L DST RAD VOLAR EXTRA ARTC S STL VAR,SUP-2184070,CDM,C1713,HCPCS,0278,RC,,,,both,,,2329.35,1514.08,,,,,,,,,,,,,
LIFT HEEL MED ADJLFT,SUP-2394117,CDM,L3334,HCPCS,0274,RC,,,,both,,,38.31,24.90,,,,,,,,,,,,,
KIT FIX DEV KNEE AC JT TOGGLELOC PUSH PLUNG BRTH PIN CANN,SUP-2212834,CDM,C1776,CPT,0278,RC,,,,both,,,2851.12,1853.23,,,,,,,,,,,,,
CATHETER EXT VENT L33CM OD2.8MM ID1.5MM TRNSLUC W/ BA STRP,SUP-2284571,CDM,C1729,HCPCS,0272,RC,,,,both,,,737.81,479.58,,,,,,,,,,,,,
ENDOPROSTHESIS VASC VIABAHN L 5 CM DIA10 MM CATH L 75 CM NIT,SUP-2396461,CDM,C1876,HCPCS,0278,RC,,,,both,,,6437.00,4184.05,,,,,,,,,,,,,
WRE FX 6IN .028IN KRSH ORTH SS,SUP-2361608,CDM,C1713,HCPCS,0278,RC,,,,both,,,24.18,15.72,,,,,,,,,,,,,
SHUNT PERI 7FR 90CM HI REG W/O RESVR CSF ASSEMB FLO CTRL,SUP-2284551,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2447.66,1590.98,,,,,,,,,,,,,
PIN BONE FIX L40MM OD4MM LACTOSORB L15 BIOABSRB ACL,SUP-2212875,CDM,C1713,HCPCS,0278,RC,,,,both,,,1607.68,1044.99,,,,,,,,,,,,,
GRAFT HUM TISS W3XL7CM THK1.04-2.28MM THCK REGEN TISS MTRX,SUP-2112990,CDM,Q4116,HCPCS,0636,RC,,,,both,,,2945.32,1914.46,,,,,,,,,,,,,
PLATE BONE 95DEG 8 HOLE SUPRACONDYLAR VERSAFX II,SUP-2490642,CDM,C1713,HCPCS,0278,RC,,,,both,,,1914.65,1244.52,,,,,,,,,,,,,
EPOETIN ALFA-EPBX 2000 UNIT/ML IJ SOLN,RX-142361,CDM,Q5106,HCPCS,0636,RC,00069-1305-10,NDC,,both,1,ML,65.10,42.31,,,,,,,,,,,,,
COVER KIT 8X2 IN W/ 20 ML GEL FOR ULTRASOUND PRB SHEATHES,SUP-2417988,CDM,2720000010,LOCAL,0272,RC,,,,both,,,327.97,213.18,,,,,,,,,,,,,
HC So Sex Hormone Binding Globulin,PX-3018427066,CDM,84270,CPT,0301,RC,,,,both,,,50.00,32.50,,,,,,,,,,,,,
PIN DRL RND END 3.1X76.2 MM FIX TRCR PT,SUP-2760729,CDM,2720000010,LOCAL,0272,RC,,,,both,,,576.98,375.04,,,,,,,,,,,,,
CATHETER CARD ABLATION NAVISTAR RMT THERMOCOOL L 130 CM DIA,SUP-2248934,CDM,C1732,HCPCS,0278,RC,,,,both,,,7831.16,5090.25,,,,,,,,,,,,,
EARPHONE HEARING MINI WIRELESS MICROPHONE USER MNL JACK CBL,SUP-2164999,CDM,L8616,HCPCS,0278,RC,,,,both,,,926.30,602.09,,,,,,,,,,,,,
HC So Factor Inhibitor Test,PX-3058533566,CDM,85335,CPT,0305,RC,,,,outpatient,,,385.00,250.25,,,,,,,,,,,,,
TIBIAL NAIL TRAY,SUP-2811218,CDM,C1713,HCPCS,0278,RC,,,,both,,,9404.30,6112.79,,,,,,,,,,,,,
STEM HUM L200 MM OD6.5 MM LT LNG EQUINOXE,SUP-2223307,CDM,C1776,CPT,0278,RC,,,,both,,,13707.98,8910.19,,,,,,,,,,,,,
HC Ot Therapeutic Activities 15 Min|OP PT SERVICES|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS,PX-4309753000,CDM,97530,CPT,0430,RC,,,GP|CQ,both,,,144.00,93.60,,,,,,,,,,,,,
HC Ot Eval Mod Complex,PX-4349716600,CDM,97166,CPT,0434,RC,,,,both,,,239.00,155.35,,,,,,,,,,,,,
GRAFT VASC GORTX 80 CM 10MM RNG L 70 CM STR TW REMOVABLE RNG,SUP-2396143,CDM,C1768,CPT,0278,RC,,,,both,,,4333.20,2816.58,,,,,,,,,,,,,
DRILL SURG BI-DIAMETER 1.8/2.3 MM 40 MM AO SHFT,SUP-2472981,CDM,2720000010,LOCAL,0272,RC,,,,both,,,364.87,237.17,,,,,,,,,,,,,
GUIDEWIRE ORTH DIA2MM S STL BALL NOSE DISP,SUP-2412815,CDM,C1769,HCPCS,0272,RC,,,,both,,,690.80,449.02,,,,,,,,,,,,,
FIBER LASER 200 MH SOLTIVE DISP,SUP-2540082,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1193.67,775.89,,,,,,,,,,,,,
PLATE BONE L62MM 6 H LCK COMPR FOR 2.7MM SCR PEDIFRAG,SUP-2318663,CDM,C1713,HCPCS,0278,RC,,,,both,,,2252.76,1464.29,,,,,,,,,,,,,
GUIDEWIRE VASC L 180 CM DIA 0.021 IN TAPR L 7 CM FLPY TIP,SUP-2167812,CDM,C1769,HCPCS,0272,RC,,,,both,,,37.84,24.60,,,,,,,,,,,,,
ALLOGRAFT BNE CRUSH 90 CC FD IRRADIATED CANC,SUP-2867147,CDM,C1762,CPT,0278,RC,,,,both,,,3221.64,2094.07,,,,,,,,,,,,,
PROSTHESES BTTN SEPT OD.06MM 20FR OESOPHAGUS TRACH LARYN,SUP-2242394,CDM,L8509,HCPCS,0272,RC,,,,both,,,778.72,506.17,,,,,,,,,,,,,
PLATE BONE L160MM 9 H S STL T SHP BTTRS LO PROF RIG,SUP-2185760,CDM,C1713,HCPCS,0278,RC,,,,both,,,1912.39,1243.05,,,,,,,,,,,,,
BIT DRL L L90 120MM CANN DENS FOR HDLSS COMPR SCR ACUTRK,SUP-2107245,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3045.80,1979.77,,,,,,,,,,,,,
CATHETER INFUSION UNI-FUSE L 90 CM DIA 5 FR SLT PAT 5 CM,SUP-2118474,CDM,C1751,HCPCS,0278,RC,,,,both,,,356.70,231.85,,,,,,,,,,,,,
BIT DRL SHT 2.8 MM BLNT SHFT POLARUS 3 SURGIBIT,SUP-2518565,CDM,2720000010,LOCAL,0272,RC,,,,both,,,335.98,218.39,,,,,,,,,,,,,
STEM FEM CEMENTLESS MOD R HIP HA COAT IMPL SZ 1 ABG II,SUP-2372187,CDM,C1776,CPT,0278,RC,,,,both,,,13553.50,8809.77,,,,,,,,,,,,,
BAR EXT FIX L 150 MM DIA11 MM NS MAV,SUP-2931172,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1810.52,1176.84,,,,,,,,,,,,,
PROSTHESES BTTN SEPT OD.06MM 20FR OESOPHAGUS TRACH LARYN,SUP-2242394,CDM,L8509,HCPCS,0274,RC,,,,both,,,778.72,506.17,,,,,,,,,,,,,
"HC Wbc,Dialysate Fluid",PX-3008905000,CDM,89050,CPT,0300,RC,,,,inpatient,,,186.00,120.90,,,,,,,,,,,,,
SCREW INTFR BIOSURE REGENESORB 12MM X 35MM,SUP-2341932,CDM,C1713,HCPCS,0278,RC,,,,both,,,1083.74,704.43,,,,,,,,,,,,,
ALLOGRAFT BNE INJ 20 CC IGNITE PWR MIX,SUP-2759597,CDM,C1713,HCPCS,0278,RC,,,,both,,,7910.13,5141.58,,,,,,,,,,,,,
PLATE SPNL Z 8 MM CLUTCH,SUP-2762333,CDM,C1713,HCPCS,0278,RC,,,,both,,,11932.00,7755.80,,,,,,,,,,,,,
MONITOR CRD 1.4 CC 3.4 GM INSERTABLE LINQ,SUP-2665248,CDM,C1764,HCPCS,0278,RC,,,,both,,,14130.00,9184.50,,,,,,,,,,,,,
LENS IOL 12.0 DIOPT CYL 1.5 DIOPT L 13 MM DIA 6 MM,SUP-2881506,CDM,V2787,HCPCS,0276,RC,,,,both,,,505.00,328.25,,,,,,,,,,,,,
HAGIE PIN 3.16X6X11.2,SUP-2818443,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1035.57,673.12,,,,,,,,,,,,,
ALLOGRAFT BNE FRZN LT SCAPULA,SUP-2740913,CDM,C1762,CPT,0278,RC,,,,both,,,15177.50,9865.37,,,,,,,,,,,,,
BLADE ULTRASONIC L20MM BLNT W/ SIL SL SHT EXTN DISP FOR HRD,SUP-2305941,CDM,C1713,HCPCS,0278,RC,,,,both,,,1185.66,770.68,,,,,,,,,,,,,
STENT DUODENAL 0.035 IN 22 MMX230 CM 27 MMX6 CM NIT WALLFLEX,SUP-2485759,CDM,C1874,HCPCS,0278,RC,,,,both,,,7968.44,5179.49,,,,,,,,,,,,,
PORT INFUS 9.6FR CATH SIL POLYUR PRT PLAS SGL LUMN INTERMED,SUP-2127751,CDM,C1788,HCPCS,0278,RC,,,,both,,,920.02,598.01,,,,,,,,,,,,,
COIL NEUROVASCULAR V-TRAK HYDROFRAME 10 L 12 CM LOOP DIA 4,SUP-2430110,CDM,C1713,HCPCS,0278,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
HC Treatment of Miscarriage,PX-4505981200,CDM,59812,CPT,0450,RC,,,,both,,,3074.00,1998.10,,,,,,,,,,,,,
PIN ANCHR L45MM DIA2MM SMOOTH SHRP TIP,SUP-2249400,CDM,C1713,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
GUIDEWIRE ORTH 0.94X9.25 IN,SUP-2857702,CDM,C1769,HCPCS,0272,RC,,,,both,,,56.52,36.74,,,,,,,,,,,,,
SAW SURGICAL 800MM 0.81/0.91MM THK DIAMOND,SUP-2627607,CDM,2720000010,LOCAL,0272,RC,,,,both,,,381.48,247.96,,,,,,,,,,,,,
CATHETER ANGIO SOFT-VU DIA 5 FR NYL TUNGSTEN PERIPH BERN SFT,SUP-2117963,CDM,C1887,HCPCS,0272,RC,,,,both,,,37.68,24.49,,,,,,,,,,,,,
PIN DRL L LNG DISP FOR 4.5/8.5MM BEAMING SYS,SUP-2223925,CDM,2720000010,LOCAL,0272,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
PLATE BONE TRAPEZOIDAL SMALL 1 MM RIGHT SUBCONDYLAR 4 HOLE M,SUP-2837776,CDM,C1713,HCPCS,0278,RC,,,,both,,,3129.95,2034.47,,,,,,,,,,,,,
MESH TISS L 20 X W 25 MM HYAFF-11 P100 TBA MULTIFILAMENT PET,SUP-2901902,CDM,C1781,HCPCS,0278,RC,,,,both,,,5495.00,3571.75,,,,,,,,,,,,,
GUIDEWIRE ORTH L 50 MM DIA1.1 MM N THRD NS PENDING,SUP-2896855,CDM,C1769,HCPCS,0272,RC,,,,both,,,91.06,59.19,,,,,,,,,,,,,
PACEMAKER CARD INGENIO TI 2 CHMBR 2 LD CONN BATTERY PWR STRL,SUP-2149153,CDM,C1785,HCPCS,0275,RC,,,,both,,,16014.00,10409.10,,,,,,,,,,,,,
GUIDEWIRE VASC ANGLED 3 CM 035X150 STD COR CANALIZER,SUP-2120018,CDM,C1769,HCPCS,0272,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
SCREW BONE PARTIAL THREADED 3.5X16 MM 6 MM SHAFT SMALL FRAGM,SUP-2837068,CDM,C1713,HCPCS,0278,RC,,,,both,,,199.52,129.69,,,,,,,,,,,,,
NEEDLE PROC TRANSSEPTAL,SUP-2535511,CDM,2720000010,LOCAL,0272,RC,,,,both,,,480.42,312.27,,,,,,,,,,,,,
SUBSTITUTE BONE GRFT VOID FIL 3D LD SYR DEL 5CC NANOSS,SUP-2335284,CDM,C1713,HCPCS,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
GUIDEWIRE ORTH L460CM DIA3.2MM CO CHROM THRD TIP FOR,SUP-2412148,CDM,C1769,HCPCS,0272,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
"HC Wbc,Dialysate Fluid",PX-3008905000,CDM,89050,CPT,0300,RC,,,,outpatient,,,186.00,120.90,,,,,,,,,,,,,
HC Ammonia,PX-3018214000,CDM,82140,CPT,0301,RC,,,,both,,,301.00,195.65,,,,,,,,,,,,,
CABLE SURG L750MM DIA1.7MM S STL W/ CRMP,SUP-2187031,CDM,C1776,CPT,0278,RC,,,,both,,,13282.73,8633.77,,,,,,,,,,,,,
PLATE BNE L64MM 3 H ST DST TIB S STL T LOK COMPR FOR 35MM,SUP-2177433,CDM,C1713,HCPCS,0278,RC,,,,both,,,2209.62,1436.25,,,,,,,,,,,,,
PIN NAVIGATION L100MM OD3MM S STL STRL DISP,SUP-2364170,CDM,C1713,HCPCS,0278,RC,,,,both,,,1526.04,991.93,,,,,,,,,,,,,
PLATE BNE DSTL C2 STD RT VOLAR RAD TI,SUP-2646875,CDM,C1713,HCPCS,0278,RC,,,,both,,,1532.23,995.95,,,,,,,,,,,,,
GRAFT BNE SUB CANC CORT DEMIN 1/2 FILL TB STR AFT G2,SUP-2307038,CDM,C1713,HCPCS,0278,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
DEVICE FIX SGL SUT CVD INTRO FOR MENIS REP SYS FAST-FIX,SUP-2341342,CDM,C1713,HCPCS,0278,RC,,,,both,,,392.34,255.02,,,,,,,,,,,,,
PLATE BNE L65MM THK1.2MM 3X10 H S STL T SHP ADPT FOR 2MM,SUP-2186154,CDM,C1713,HCPCS,0278,RC,,,,both,,,1352.68,879.24,,,,,,,,,,,,,
MESH HERN L W1.5XL1.9IN SYN POLY-4-HYDROXYBUTYRATE PLUG AND,SUP-2125875,CDM,C1781,HCPCS,0278,RC,,,,both,,,1412.84,918.35,,,,,,,,,,,,,
RASP SURG GLEN HANDHELD SGL END COARSE CRSS CUT ANG TAPR,SUP-2120944,CDM,C1776,CPT,0278,RC,,,,both,,,1083.30,704.14,,,,,,,,,,,,,
SCREW BNE CANC 4.5X25 MM CRPL PLATE TI NS UNIV 2,SUP-2851987,CDM,C1713,HCPCS,0278,RC,,,,both,,,706.22,459.04,,,,,,,,,,,,,
HC Myelogram Lumbar|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE PRIOR TO THE ADMINISTRATION OF ANESTHESIA,PX-3616230400,CDM,62304,CPT,0361,RC,,,73,outpatient,,,3892.00,2529.80,,,,,,,,,,,,,
PLATE BNE SM 2 H 5DEG SHT L DST MTP,SUP-2321454,CDM,C1713,HCPCS,0278,RC,,,,both,,,3713.05,2413.48,,,,,,,,,,,,,
HC Repair Tongue Laceration,PX-4504125100,CDM,41251,CPT,0450,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
BUR SURG DIAMOND LNG 1.2 MM 7.5 CM BALL MIDAS REX LEGEND,SUP-2630503,CDM,2720000010,LOCAL,0272,RC,,,,both,,,403.11,262.02,,,,,,,,,,,,,
WIRE FIX DIAMOND PT 2 END 0.045X5 IN SS NS KIRSCHNER,SUP-2791344,CDM,C1713,HCPCS,0278,RC,,,,both,,,8.42,5.47,,,,,,,,,,,,,
STEM FEM L127MM DIA13MM KNEE TI POR BODY STR CEM GMRS,SUP-2376422,CDM,C1776,CPT,0278,RC,,,,both,,,9248.09,6011.26,,,,,,,,,,,,,
PREM ST/LG HD,SUP-2212356,CDM,C1776,CPT,0278,RC,,,,both,,,8792.00,5714.80,,,,,,,,,,,,,
SCREW BONE CORTICAL 1X2 MM SELFTAPPING PLUSDRIVE RECESS TITA,SUP-2838136,CDM,C1713,HCPCS,0278,RC,,,,both,,,356.08,231.45,,,,,,,,,,,,,
GRAFT BNE FRZ DRY STRUT CORT FEM IMPL ALLGRFT L100MM OD15MM,SUP-2264712,CDM,C1713,HCPCS,0278,RC,,,,both,,,1251.54,813.50,,,,,,,,,,,,,
BRACE OPN POPLITEAL 28IN 305IN SZ 3XL FREDDIE,SUP-2196843,CDM,L1810,HCPCS,0274,RC,,,,both,,,66.13,42.98,,,,,,,,,,,,,
CLIP ENDOSCP 2.6X230 MM HEMSTAT,SUP-2313195,CDM,C1713,HCPCS,0278,RC,,,,both,,,709.64,461.27,,,,,,,,,,,,,
AUGMENT ACET OD50MM ID52MM THK15MM GRIPTION TF REV PINN,SUP-2250126,CDM,C1776,CPT,0278,RC,,,,both,,,5181.00,3367.65,,,,,,,,,,,,,
PLATE BNE L75MM THK1.5MM 5X3 H BILAT S STL T SHP OBLQ ANG,SUP-2185888,CDM,C1713,HCPCS,0278,RC,,,,both,,,714.29,464.29,,,,,,,,,,,,,
STENT BILI S.M.A.R.T. CTRL L 100 MM DIA 6 MM DEL SYS L 120,SUP-2158568,CDM,C1876,HCPCS,0278,RC,,,,both,,,2009.60,1306.24,,,,,,,,,,,,,
PLATE BONE L10MM 1LEVEL NONSTERILE TEMPUS SPINE,SUP-2879276,CDM,C1713,HCPCS,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
MATRIX BIO L 7 X W 10 CM SZ 126 SQCM FISH SKIN DERMAL MESHED 10/BX,SUP-2909436,CDM,Q4158,HCPCS,0636,RC,,,,both,,,8151.44,5298.44,,,,,,,,,,,,,
TRIAMTERENE-HCTZ 75-50 MG PO TABS,RX-8134,CDM,6370000000,HCPCS,0637,RC,60505-2657-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
GRAFT BNE ANT H10MM DIA8 15MM PARA FIBULAR CRSS SECT FRZ DRY,SUP-2264871,CDM,C1713,HCPCS,0278,RC,,,,both,,,2348.50,1526.52,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 2X2 CM TERMINALLY STRL WND NEOX CRD RT,SUP-2648695,CDM,Q4148,HCPCS,0636,RC,,,,both,,,1444.40,938.86,,,,,,,,,,,,,
PROBE LITHOTRIPSY DISPOSABLE 9FR PNEUMATIC AUTOLITH IEHL,SUP-2722576,CDM,2720000010,LOCAL,0272,RC,,,,both,,,633.24,411.61,,,,,,,,,,,,,
GRAFT VASC PROPATEN L 10 CM DIA 3 MM EPTFE CBAS HEPARIN TW,SUP-2655621,CDM,C1768,CPT,0278,RC,,,,both,,,2895.08,1881.80,,,,,,,,,,,,,
COMPONENT PAT DIA38MM THK9.5MM KNEE POLY CEM CONVENTIONAL,SUP-2207286,CDM,C1776,CPT,0278,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
STRUT EXTERNAL FIXATION L163300MM LONG RAPID,SUP-2874152,CDM,C1713,HCPCS,0278,RC,,,,both,,,3191.34,2074.37,,,,,,,,,,,,,
COMPONENT FEM CEM UNISX LT ANTR POST PRIMARY STEMLESS N BEAD,SUP-2376273,CDM,C1776,CPT,0278,RC,,,,both,,,12129.19,7883.97,,,,,,,,,,,,,
OYSTER SHELL CALCIUM W/D 500-5 MG-MCG PO TABS,RX-160103,CDM,6370000000,HCPCS,0637,RC,10006-0700-38,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 50 CM DIA 6 MM STR TW HELIX,SUP-2525453,CDM,C1768,CPT,0278,RC,,,,both,,,1340.37,871.24,,,,,,,,,,,,,
IDENTIFIER BX SITE 12GA ATEC TRIMARK3612] SUROS SURGICAL SYSTEMS],SUP-2382014,CDM,A4648,CPT,0278,RC,,,,both,,,243.66,158.38,,,,,,,,,,,,,
CATHETER INFUSION CLEARWAY BALLOON L 50 MM DIA2 MM PERIPH,SUP-2227354,CDM,C1725,HCPCS,0272,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
SHEATH INTRO PERFRMR L 30 CM DIA12 FR GUIDEWIRE 0.038 IN,SUP-2168409,CDM,C1894,HCPCS,0272,RC,,,,both,,,190.06,123.54,,,,,,,,,,,,,
SET CBL SL SM DIA2MM VIT BEAD DALL-M,SUP-2377566,CDM,C1776,CPT,0278,RC,,,,both,,,790.02,513.51,,,,,,,,,,,,,
ALLOGRAFT BNE FRZN ASEP LT DSTL FEM NO CART,SUP-2867023,CDM,C1762,CPT,0278,RC,,,,both,,,12349.62,8027.25,,,,,,,,,,,,,
PLATE BNE LCK 3.5X130 MM LT DSTL MEDL HUM 7 HOLE FIX ANGLE,SUP-2468169,CDM,C1713,HCPCS,0278,RC,,,,both,,,2918.57,1897.07,,,,,,,,,,,,,
ANCHOR SUT DIA5MM W/ HNDL INSRT 2 FIBERWIRE 1/2 CIR NDL,SUP-2121498,CDM,C1713,HCPCS,0278,RC,,,,both,,,737.90,479.63,,,,,,,,,,,,,
EXPANDER TISS BRST 6-7.3 CM 14X11.2 460-550 DERMASPAN LPP14R,SUP-2749165,CDM,C1889,HCPCS,0278,RC,,,,both,,,4066.30,2643.09,,,,,,,,,,,,,
WALKER ANK L SHT STD BLK COMP SHELL NONSKID HK LO CLSR,SUP-2276717,CDM,L4387,HCPCS,0272,RC,,,,both,,,78.12,50.78,,,,,,,,,,,,,
GUIDE PIN ORTH 2.4X450 MM,SUP-2766035,CDM,2720000010,LOCAL,0272,RC,,,,both,,,769.30,500.04,,,,,,,,,,,,,
CATHETER CV SINGLE LUMEN 6 FRX45 CM 17 GA INTERMED XCELA,SUP-2118814,CDM,C1751,HCPCS,0278,RC,,,,both,,,574.62,373.50,,,,,,,,,,,,,
TUBE TRACHEOSTOMY FENESTRATED ADULT 7  UNCUFFED ADAPTER OBTU,SUP-2793425,CDM,2720000010,LOCAL,0272,RC,,,,both,,,146.92,95.50,,,,,,,,,,,,,
SPLINT KNEE L24IN FOR 32IN THGH UNIV FOAM 3 PC DSGN TRIMMED,SUP-2196755,CDM,L1830,CPT,0272,RC,,,,both,,,46.69,30.35,,,,,,,,,,,,,
GRIP CBL L265MM STD TROCHANTERIC HIP 11 CBL ACCORD,SUP-2345209,CDM,C1776,CPT,0278,RC,,,,both,,,9683.76,6294.44,,,,,,,,,,,,,
ALLOGRAFT HUMAN TISSUE PUROS 12X12MM 9MM THK WEDGE FD,SUP-2863659,CDM,C1713,HCPCS,0278,RC,,,,both,,,4835.60,3143.14,,,,,,,,,,,,,
HC Porphobolinogen Urine Qual,PX-3008410666,CDM,84106,CPT,0300,RC,,,,inpatient,,,396.00,257.40,,,,,,,,,,,,,
PLATE BNE SM W10XL56MM THK1.2MM 90DEG 4X4 H TI T SHP R ANG,SUP-2190928,CDM,C1713,HCPCS,0278,RC,,,,both,,,498.60,324.09,,,,,,,,,,,,,
DRILL TWST DIA1.7MM DISP FOR SUTUREFIX ULT SYS,SUP-2341896,CDM,C1713,HCPCS,0278,RC,,,,both,,,708.26,460.37,,,,,,,,,,,,,
PLATE BNE L135MM 10 H L LAT DST PERIARTC FIBULAR S STL,SUP-2410568,CDM,C1713,HCPCS,0278,RC,,,,both,,,1686.97,1096.53,,,,,,,,,,,,,
SYSTEM TKR VERILAST OXI FEM TIB CEM PS HIFLEX,SUP-2348027,CDM,C1776,CPT,0278,RC,,,,both,,,13816.00,8980.40,,,,,,,,,,,,,
RETROBUTTON LONG 15MMX20MM LOOP,SUP-2811847,CDM,C1713,HCPCS,0278,RC,,,,both,,,737.90,479.63,,,,,,,,,,,,,
HC Gbl Iop Tx 30 Min,PX-9829083200,CDM,90832,CPT,0982,RC,,,,both,,,1103.00,716.95,,,,,,,,,,,,,
CAGE SPNL THRD 21X12 MM RAY TFC UNITE,SUP-2381380,CDM,C1889,HCPCS,0278,RC,,,,both,,,10880.10,7072.06,,,,,,,,,,,,,
PLATE S PROFYLE CONDYLAR 5 HL 17MM,SUP-2703007,CDM,C1713,HCPCS,0278,RC,,,,both,,,1043.27,678.13,,,,,,,,,,,,,
PLATE BONE 4 H COMPR LCK FOR 2.7MM SCR,SUP-2318661,CDM,C1713,HCPCS,0278,RC,,,,both,,,2171.25,1411.31,,,,,,,,,,,,,
TRIAL HD 28MM -4MM OFFSET SH FEM TAPR LFIT HMSPHR V40,SUP-2364470,CDM,C1776,CPT,0278,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
TENOFOVIR DISOPROXIL FUMARATE 300 MG PO TABS,RX-31684,CDM,6370000000,HCPCS,0637,RC,61958-0401-01,NDC,,both,1,UN,188.10,122.26,,,,,,,,,,,,,
NAIL IM L190MM DIA7.5MM 120DEG NONSTERILE BLU L/R HUM TI,SUP-2192482,CDM,C1713,HCPCS,0278,RC,,,,both,,,5515.50,3585.07,,,,,,,,,,,,,
CATHETER CV FULL SAFETY TY 7 FRX20 CM 3L DRY SPECTRUM,SUP-2759881,CDM,C1751,HCPCS,0278,RC,,,,both,,,506.92,329.50,,,,,,,,,,,,,
CATHETER ANGIOPLSTY 0.018 IN 130 CM 6X300 MM LUTONIX,SUP-2431946,CDM,C1725,HCPCS,0272,RC,,,,both,,,10362.00,6735.30,,,,,,,,,,,,,
GRAFT VASC FLIXENE L 30 CM DIA 6 MM EPTFE GRAD REINF 3 LAYR,SUP-2474583,CDM,C1768,CPT,0278,RC,,,,both,,,3448.44,2241.49,,,,,,,,,,,,,
PUSHER KNOT L12.9IN FOR EXCORP TYNG HEARTPORT,SUP-2219525,CDM,C1713,HCPCS,0278,RC,,,,both,,,530.66,344.93,,,,,,,,,,,,,
STENT GRFT VASC AFX2 BODY L 80 MM DIA22 MM LIMB 40 MM 20 MM,SUP-2541371,CDM,C1768,CPT,0278,RC,,,,both,,,37441.36,24336.88,,,,,,,,,,,,,
LORAZEPAM 2 MG/ML IJ SOLN,RX-10467,CDM,J2060,HCPCS,0636,RC,00641-6044-01,NDC,,both,0.25,ML,54.10,35.16,,,,,,,,,,,,,
INSERT TIB 0 THK8MM UHMWPE RT SALTO TALARIS,SUP-2400120,CDM,C1776,CPT,0278,RC,,,,both,,,5344.28,3473.78,,,,,,,,,,,,,
STRUT EXT FIX QUIK ADJ LG 160-250 MM MOD CONN,SUP-2749905,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4323.78,2810.46,,,,,,,,,,,,,
EXTRACTOR SURG L2.5-3.5 MMXTRACT ALL DISP FOR 2.5-3.5 MM,SUP-2337711,CDM,C1713,HCPCS,0278,RC,,,,both,,,753.60,489.84,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY L 92 CM 6FR 4MM A CRV QPLR UNIDIR,SUP-2248663,CDM,C1733,HCPCS,0272,RC,,,,both,,,2241.96,1457.27,,,,,,,,,,,,,
HC Porphobolinogen Urine Qual,PX-3008410666,CDM,84106,CPT,0300,RC,,,,outpatient,,,396.00,257.40,,,,,,,,,,,,,
HC OP Family Tx WO Pt Ppresent 50min,PX-9169084602,CDM,90846,CPT,0916,RC,,,,both,,,916.00,595.40,,,,,,,,,,,,,
SET CHOLANGIOGRAPHY 4FR L60CM W/ ARW KARLAN BLLN CATH CRV,SUP-2383432,CDM,C1726,HCPCS,0272,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
GAUGE WIRE 0.045,SUP-2480299,CDM,C1769,HCPCS,0272,RC,,,,both,,,31.40,20.41,,,,,,,,,,,,,
CATHETER EP MED SWP 2-5-2 DECAPOLAR LIVEWIRE,SUP-2465588,CDM,C1730,HCPCS,0272,RC,,,,both,,,1673.62,1087.85,,,,,,,,,,,,,
ANCHOR SUT OD65MM 2 TWO MAXBRAID TI SCR SP CUT NDL PERM DBL,SUP-2212812,CDM,C1713,HCPCS,0278,RC,,,,both,,,1001.66,651.08,,,,,,,,,,,,,
CATHETER EXT M SZ 29MM CLR SELF ADH POLYTECH,SUP-2239736,CDM,C1758,HCPCS,0278,RC,,,,both,,,9.42,6.12,,,,,,,,,,,,,
GRAFT BNE INJ 20 CC INDUCTIVE PRO-STIM,SUP-2759469,CDM,C1713,HCPCS,0278,RC,,,,both,,,13979.28,9086.53,,,,,,,,,,,,,
SCREW BNE 2.7X24 MM FOR THRD STP SS STRL,SUP-2178276,CDM,C1713,HCPCS,0278,RC,,,,both,,,496.87,322.97,,,,,,,,,,,,,
ANCHOR SUTURE L 16.3 MM DIA 5.5 MM TI SUTURETAPEN FT STRL,SUP-2930502,CDM,C1713,HCPCS,0278,RC,,,,both,,,956.13,621.48,,,,,,,,,,,,,
CANNULA ENDOSCP 6.5 MM HIP MTL,SUP-2845561,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1092.15,709.90,,,,,,,,,,,,,
BEARING TIB L59MM THK10MM UHMWPE KNEE PRI NEUT HI POST POST,SUP-2405892,CDM,C1776,CPT,0278,RC,,,,both,,,2449.20,1591.98,,,,,,,,,,,,,
MOLD CEMENT SPACER SHLDR CUST MOD EXT,SUP-2898665,CDM,C1713,HCPCS,0278,RC,,,,both,,,1507.20,979.68,,,,,,,,,,,,,
PLATE BNE ST 2.4X90 MM RT CORTICAL W/ T8 STARDRV RECESS SS,SUP-2757641,CDM,C1713,HCPCS,0278,RC,,,,both,,,181.05,117.68,,,,,,,,,,,,,
TRIAL TIB 11MM ANTR POST LIP,SUP-2364861,CDM,C1776,CPT,0278,RC,,,,both,,,463.31,301.15,,,,,,,,,,,,,
"HC New Pt, Outpt Visit Level 2|UNUSUAL NON-OVERLAPPING SERVICE",PX-7619920200,CDM,99202,CPT,0761,RC,,,XU,outpatient,,,363.00,235.95,,,,,,,,,,,,,
CEMENT BNE 5 CC STRL FORTERA LTX,SUP-2855702,CDM,C1713,HCPCS,0278,RC,,,,both,,,9143.68,5943.39,,,,,,,,,,,,,
IMPLANT OSS L6MM PIST DIA04MM LOOP DIA 06MM STAP FLROPLAS,SUP-2313665,CDM,L8613,CPT,0278,RC,,,,both,,,254.78,165.61,,,,,,,,,,,,,
HC 2d Echo W Contrast - W Dop/Color Flow,PX-4839330600,CDM,C8929,HCPCS,0483,RC,,,,both,,,3299.00,2144.35,,,,,,,,,,,,,
CANNULA SUCTION CONNOR 23GA 19MML STAINLESS STEEL,SUP-2487901,CDM,2720000010,LOCAL,0272,RC,,,,both,,,469.43,305.13,,,,,,,,,,,,,
TUBE GAST JEJU 14FR L15CM STOMA L1.5CM G GRN TECHNOLOGY LO,SUP-2119813,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1730.14,1124.59,,,,,,,,,,,,,
SET DIL 6/8/10/12/14/16FR GWIRE 0.038IN URET PTFE HYDR+ C,SUP-2139212,CDM,2720000010,LOCAL,0272,RC,,,,both,,,514.43,334.38,,,,,,,,,,,,,
GRAFT BONE PASTE DEMIN BONE MTRX 1CC GRFTON +,SUP-2281283,CDM,C9359,HCPCS,0278,RC,,,,both,,,480.42,312.27,,,,,,,,,,,,,
HEAD HUM RESURF 1 SHLDR,SUP-2267804,CDM,C1776,CPT,0278,RC,,,,both,,,10205.00,6633.25,,,,,,,,,,,,,
HC Implant Spinal Cord Stim,PX-3600007518,CDM,3600007518,LOCAL,0360,RC,,,,inpatient,,,6232.00,4050.80,,,,,,,,,,,,,
PLATE BNE L37MM SHT 2X2 H NONSTERILE R BILAT 1ST MTP FUS TI,SUP-2177010,CDM,C1713,HCPCS,0278,RC,,,,both,,,3141.57,2042.02,,,,,,,,,,,,,
BLADE SAW SAG 20X12X0.4 MM STD TOOTH STRL,SUP-2432341,CDM,2720000010,LOCAL,0272,RC,,,,both,,,370.52,240.84,,,,,,,,,,,,,
CATHETER ANGIO AD PED 5FR L100CM GWIRE 0.038IN PERIPH PGTL,SUP-2139761,CDM,C1758,HCPCS,0278,RC,,,,both,,,30.71,19.96,,,,,,,,,,,,,
HC CT Cologrph Dx W/O Cont,PX-3507426100,CDM,74261,CPT,0350,RC,,,,outpatient,,,2630.00,1709.50,,,,,,,,,,,,,
PROSTHESIS OTO L12MM OD0.4MM MALL CAUSSE LOOP FLROPLAS,SUP-2284064,CDM,L8613,CPT,0278,RC,,,,both,,,339.50,220.67,,,,,,,,,,,,,
HC Eval C/V Amniotic Fluid Protein Qual Ea Specimen,PX-3018411200,CDM,84112,CPT,0301,RC,,,,inpatient,,,193.00,125.45,,,,,,,,,,,,,
SPACER SPNL W14XH7XL16MM PEEK CERV INTBDY FUS SET TYP 2096,SUP-2278331,CDM,C1889,HCPCS,0278,RC,,,,both,,,8635.00,5612.75,,,,,,,,,,,,,
MARKER FIDUCIAL 0.75 MMX1 CM 18 GA PRELD GLD VISICOIL,SUP-2430921,CDM,A4648,CPT,0278,RC,,,,both,,,381.51,247.98,,,,,,,,,,,,,
CYCLOSPORINE MODIFIED 25 MG PO CAPS,RX-28842,CDM,J7515,HCPCS,0636,RC,00078-0246-15,NDC,,both,1,UN,13.30,8.64,,,,,,,,,,,,,
PLATE BNE L33MM PROF 15MM 4 H TI MINI PATTEN THREADLOCK TS,SUP-2262962,CDM,C1713,HCPCS,0278,RC,,,,both,,,1117.65,726.47,,,,,,,,,,,,,
SCREW BNE 2X28 MM FUSION NS LTX,SUP-2856973,CDM,C1713,HCPCS,0278,RC,,,,both,,,1023.64,665.37,,,,,,,,,,,,,
CATHETER CV SET 032 10 FRX15 CM 11 GA 5 LUMEN QUINT,SUP-2759729,CDM,C1751,HCPCS,0278,RC,,,,both,,,408.80,265.72,,,,,,,,,,,,,
STENT PANCREATIC FREEMAN L 5 CM DIA 5 FR GUIDEWIRE 0.035 IN,SUP-2319809,CDM,C2617,HCPCS,0278,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9% INTERMITTENT INFUSION,RX-40840102,CDM,J7040,HCPCS,0250,RC,00264-7800-10,NDC,,both,250,ML,14.90,9.68,,,,,,,,,,,,,
KIT FIX DIA10 MM ALL INSIDE STRL QUADLINK,SUP-2930405,CDM,C1713,HCPCS,0278,RC,,,,both,,,8964.70,5827.05,,,,,,,,,,,,,
SCREW SET HD 1.5/2/2.5 MM,SUP-2607262,CDM,C1713,HCPCS,0278,RC,,,,both,,,9970.66,6480.93,,,,,,,,,,,,,
PLATE BONE W5.4XL30MM THK1.5MM 6 H RT FOREFOOT TI T FOR,SUP-2225450,CDM,C1713,HCPCS,0278,RC,,,,both,,,2157.81,1402.58,,,,,,,,,,,,,
SPLINT WR AD M L6.25IN FOR 6.5-7.5IN LT REG W/ STAY ELAS,SUP-2309139,CDM,L3808,HCPCS,0274,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
LEAD NERVE STIM 2.16 MM INTERSTIM SURESCAN,SUP-2550570,CDM,C1778,HCPCS,0278,RC,,,,both,,,12305.66,7998.68,,,,,,,,,,,,,
GRAFT HUM TISS H 18 MM TRICORT IL CREST WDG PARALLEL FD STRL,SUP-2913421,CDM,C1762,CPT,0278,RC,,,,both,,,5626.88,3657.47,,,,,,,,,,,,,
BRACE KNEE AD L23 17IN UNIV COOL FOAM UNISX TRANSITION,SUP-2195291,CDM,L1810,HCPCS,0274,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
SPLINT WR AD SM FOR 5.5-6.5IN STRP L4IN VENT ELAS,SUP-2324483,CDM,L3908,HCPCS,0274,RC,,,,both,,,43.27,28.13,,,,,,,,,,,,,
WASHER ORTH STP 3.5 MM FOR LAG SCREW IO FRDM DISP,SUP-2864895,CDM,C1713,HCPCS,0278,RC,,,,both,,,546.36,355.13,,,,,,,,,,,,,
KNIFE 3714165 BALLENGER SWIVEL 4MM BAYO,SUP-2706947,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1645.45,1069.54,,,,,,,,,,,,,
CATHETER ANGIO AD L80CM DIA5FR 0.038IN HYDRPHLC SOS OMNI 2,SUP-2117797,CDM,C1887,HCPCS,0272,RC,,,,both,,,47.73,31.02,,,,,,,,,,,,,
HC Surgery Level 3 Addtl 15min,PX-3600000013,CDM,3600000013,LOCAL,0360,RC,,,,both,,,2666.00,1732.90,,,,,,,,,,,,,
MESH HERN ANAT 12X8 CM LT SELF GRIPPING BASE POLYPR PROGRIP,SUP-2752182,CDM,C1781,HCPCS,0278,RC,,,,both,,,1276.66,829.83,,,,,,,,,,,,,
SUPPORT ORTHOT ANK KNEE CUST SINGLE DBL MECH ACT,SUP-2435632,CDM,L2005,HCPCS,0274,RC,,,,both,,,11601.23,7540.80,,,,,,,,,,,,,
NAIL IM NONSTERILE S STL END OLECRANON FOR OSTEOTMY,SUP-2183155,CDM,C1713,HCPCS,0278,RC,,,,both,,,1469.90,955.43,,,,,,,,,,,,,
BIT DRILL 2.5MM DIA WRIST LATEXFREEDOM,SUP-2605906,CDM,2720000010,LOCAL,0272,RC,,,,both,,,801.64,521.07,,,,,,,,,,,,,
INSERT HUM DIA36/16MM RVS BODY MOD SYS PROMOS,SUP-2351189,CDM,C1776,CPT,0278,RC,,,,both,,,3069.35,1995.08,,,,,,,,,,,,,
SUPPORT ORTHOT ANK KNEE CUST SINGLE DBL MECH ACT,SUP-2435632,CDM,L2005,HCPCS,0272,RC,,,,both,,,11601.23,7540.80,,,,,,,,,,,,,
IMPLANT BRST 450-470ML W13XH13.5CM P5.3CM NACL STYL 468,SUP-2113304,CDM,C1789,HCPCS,0278,RC,,,,both,,,2041.00,1326.65,,,,,,,,,,,,,
WIRE FIX 3X400 MM KIRSCHNER,SUP-2316010,CDM,C1713,HCPCS,0278,RC,,,,both,,,149.15,96.95,,,,,,,,,,,,,
RING PESSARY 6 3.25 IN W/ SUPP SIL,SUP-2171734,CDM,A4562,HCPCS,0272,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9% INTERMITTENT INFUSION,RX-40840102,CDM,2580000003,HCPCS,0250,RC,00264-1800-32,NDC,,both,250,ML,57.40,37.31,,,,,,,,,,,,,
BASKET STONE REM L350CM OD2.5MM 3X6CM DISP ROTH NET,SUP-2391610,CDM,2720000010,LOCAL,0272,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
INBONE EVERLAST SZ 2 6MM TOTAL ANKLE,SUP-2822304,CDM,C1776,CPT,0278,RC,,,,both,,,4637.78,3014.56,,,,,,,,,,,,,
NAIL FEM CHILD RIGHT 8MMX 360MM,SUP-2750026,CDM,C1713,HCPCS,0278,RC,,,,both,,,12246.00,7959.90,,,,,,,,,,,,,
MESH SURG 25X33CM W/ POS SYS ECHO 2 VENTRALIGHT ST,SUP-2125931,CDM,C1781,HCPCS,0278,RC,,,,both,,,6421.30,4173.84,,,,,,,,,,,,,
WASHER SPNL OD5.5MM FOR STPL SYS REVERE ANTR,SUP-2229628,CDM,C1713,HCPCS,0278,RC,,,,both,,,188.40,122.46,,,,,,,,,,,,,
DOUBLE DRILL GUIDE COMPR/NEUTR 32MM,SUP-2705030,CDM,C1713,HCPCS,0278,RC,,,,both,,,2924.22,1900.74,,,,,,,,,,,,,
BIT DRL DIA2.4MM DISP FOR GRIDLOCK SCR,SUP-2390570,CDM,2720000010,LOCAL,0272,RC,,,,both,,,675.10,438.81,,,,,,,,,,,,,
SCREW BN MTRXMDF 2X6MM SLFTP,SUP-2837732,CDM,C1713,HCPCS,0278,RC,,,,both,,,263.76,171.44,,,,,,,,,,,,,
STRUT FX MAXIFRAME POLYAX STRUT LONG,SUP-2737907,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3849.36,2502.08,,,,,,,,,,,,,
NEEDLE ENDOSCP 21 MMX10 CM VERES LL SPRING LD BLNT INNR CANN,SUP-2766955,CDM,2720000010,LOCAL,0272,RC,,,,both,,,679.78,441.86,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC SOLO2 HF IR 5FR 55CM 3 LUMAN RVRSE,SUP-2613400,CDM,C1751,HCPCS,0278,RC,,,,both,,,666.84,433.45,,,,,,,,,,,,,
GRAFT VASC STR 6 MMX50 CM STD WALL EPTFE CARBOFLO CENTERFLEX,SUP-2761402,CDM,C1768,CPT,0278,RC,,,,both,,,2351.99,1528.79,,,,,,,,,,,,,
SYSTEM DRAINAGE MONITORR SP0042,SUP-2666839,CDM,C1729,HCPCS,0272,RC,,,,both,,,634.25,412.26,,,,,,,,,,,,,
BIT DRL OD4MM CANN FOR SFT TISS FIX,SUP-2399125,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1321.94,859.26,,,,,,,,,,,,,
PINN CAN BONE SCREW 6.5MMX8MM,SUP-2512745,CDM,C1713,HCPCS,0278,RC,,,,both,,,188.40,122.46,,,,,,,,,,,,,
FEEDING TUBE KIT LP 20 FRX2.5 CM BLLN BUTTON,SUP-2754599,CDM,2720000010,LOCAL,0272,RC,,,,both,,,638.42,414.97,,,,,,,,,,,,,
LIDOCAINE-EPINEPHRINE (PF) 1.5 %-1:200000 IJ SOLN,RX-169109,CDM,J2004,HCPCS,0636,RC,00409-1209-01,NDC,,both,5,ML,54.10,35.16,,,,,,,,,,,,,
CATHETER GUID SUPER BKUP SUPP 3.75 8 FRX100 CM CONCIERGE,SUP-2798622,CDM,C1887,HCPCS,0272,RC,,,,both,,,122.90,79.88,,,,,,,,,,,,,
BIT DRL TWST 1.2X4 MM 7 CM SM BOR MIDAS REX 8,SUP-2664817,CDM,2720000010,LOCAL,0272,RC,,,,both,,,293.65,190.87,,,,,,,,,,,,,
GUIDEWIRE ORTH TRCR PT 1 END 2.8X220 MM STRL,SUP-2789093,CDM,C1769,HCPCS,0272,RC,,,,both,,,1796.08,1167.45,,,,,,,,,,,,,
HC So Androstenedione,PX-3018215766,CDM,82157,CPT,0301,RC,,,,both,,,1352.00,878.80,,,,,,,,,,,,,
HC Auto Cryo Pbpc Infusion,PX-3623824100,CDM,38241,CPT,0362,RC,,,,both,,,1752.00,1138.80,,,,,,,,,,,,,
NAIL IM 1/8 IN HOOKED FIX,SUP-2364712,CDM,C1713,HCPCS,0278,RC,,,,both,,,133.14,86.54,,,,,,,,,,,,,
ELECTRODE ENDO MPLR NDL ELECTRD DISP 15CM,SUP-2139746,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3846.50,2500.22,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED FEM TIB FLX CEM TAP PLUG SURF,SUP-2212253,CDM,C1776,CPT,0278,RC,,,,both,,,15022.23,9764.45,,,,,,,,,,,,,
MANIFOLD IV 2 PRT 200PSI BLOCK BODY RT ORIENTATION DISP,SUP-2301354,CDM,C1713,HCPCS,0278,RC,,,,both,,,14.70,9.55,,,,,,,,,,,,,
IMPLANT OP RM 28 PLTS 28 PLT 20MM,SUP-2321429,CDM,C1713,HCPCS,0278,RC,,,,both,,,3355.88,2181.32,,,,,,,,,,,,,
MESH SURG L15XW10CM POLYFORM MACROPOROUS POLYPR SYN,SUP-2139413,CDM,C1781,HCPCS,0278,RC,,,,both,,,1867.70,1214.00,,,,,,,,,,,,,
PI PICC KIT 1-L 4 FR X 55 CM TIPTRACKER,SUP-2565189,CDM,C1751,HCPCS,0278,RC,,,,both,,,539.04,350.38,,,,,,,,,,,,,
CATHETER DRAINAGE INTRO 25 FRX38 CM MULT BIO-MEDICUS LS,SUP-2745345,CDM,C1729,HCPCS,0272,RC,,,,both,,,1678.64,1091.12,,,,,,,,,,,,,
IMPLANT HUM TISS 20CML TISS FRZN TIBIALIS ANTR TEND,SUP-2307034,CDM,C1713,HCPCS,0278,RC,,,,both,,,5026.36,3267.13,,,,,,,,,,,,,
SPACER SPNL 6-45MM FUS UNIV DYNESYS,SUP-2414261,CDM,C1889,HCPCS,0278,RC,,,,both,,,7363.30,4786.14,,,,,,,,,,,,,
PLATE BNE STR 3.5X131 MM 10 HOLE RECON LCK SS STRL,SUP-2477073,CDM,C1713,HCPCS,0278,RC,,,,both,,,1521.39,988.90,,,,,,,,,,,,,
KIT SUTURE ANCHR L 15 MM DIA 4.5 MM TI PRELD 1.5 MM PASS,SUP-2899082,CDM,C1713,HCPCS,0278,RC,,,,both,,,1200.27,780.18,,,,,,,,,,,,,
PLATE BONE L29MM MINI STR,SUP-2364910,CDM,C1713,HCPCS,0278,RC,,,,both,,,210.38,136.75,,,,,,,,,,,,,
DEVICE FIX HELCL 5 MM FOR LAP FIX OF MESH IN HERN REP TI TRK,SUP-2752179,CDM,C1713,HCPCS,0278,RC,,,,both,,,363.74,236.43,,,,,,,,,,,,,
CATHETER IV SINGLE LEMEN 4 FR DOT KT BIOP PC NG POWERMIDLINE,SUP-2626735,CDM,C1751,HCPCS,0278,RC,,,,both,,,514.96,334.72,,,,,,,,,,,,,
SYSTEM MIXER BONE CEMENT W/SHORT EXT TUBE PCD VERTAPLEX,SUP-2875968,CDM,C1713,HCPCS,0278,RC,,,,both,,,1731.90,1125.73,,,,,,,,,,,,,
MESH BIO PORCINE MTRX BRST TISS RECON 14CM LEN 3CM W,SUP-2113067,CDM,Q4130,HCPCS,0636,RC,,,,both,,,3275.02,2128.76,,,,,,,,,,,,,
INSERT TIB THK 16 MM SZ 6 X3 REV STRL TRIATHLON,SUP-2889775,CDM,C1776,CPT,0278,RC,,,,both,,,11429.60,7429.24,,,,,,,,,,,,,
CATHETER EMB L 80 CM DIA 7 FR BALLOON DIA14 MM 1.75 CC 1 YEL,SUP-2589454,CDM,C1757,HCPCS,0272,RC,,,,both,,,232.36,151.03,,,,,,,,,,,,,
SENSOR SHUNT HEP TREAT DISP FOR CDI SYS 500,SUP-2385082,CDM,2720000010,LOCAL,0272,RC,,,,both,,,486.35,316.13,,,,,,,,,,,,,
HC Thrombolytic Ther Stroke,PX-4503719500,CDM,37195,CPT,0450,RC,,,,both,,,1088.00,707.20,,,,,,,,,,,,,
SHEATH INTRO L 80 CM DIA 6 FR STRL,SUP-2383980,CDM,C1894,HCPCS,0272,RC,,,,both,,,580.90,377.58,,,,,,,,,,,,,
ANCHOR SUTURE BIOWIRE 4 IN KNOTLESS WHT SUTURETAK,SUP-2122130,CDM,C1713,HCPCS,0278,RC,,,,both,,,69.08,44.90,,,,,,,,,,,,,
PLATE BNE 1/3 TBLR 31 MM 4 HOLE NS LTX,SUP-2861928,CDM,C1713,HCPCS,0278,RC,,,,both,,,155.24,100.91,,,,,,,,,,,,,
TRAY TIB SZ 0F/0T CEM FIN OPTETRAK LOGIC,SUP-2220920,CDM,C1776,CPT,0278,RC,,,,both,,,6970.80,4531.02,,,,,,,,,,,,,
PLATE BNE T 2.7/3.5X85 MM 7 HOLE SS,SUP-2569104,CDM,C1713,HCPCS,0278,RC,,,,both,,,385.12,250.33,,,,,,,,,,,,,
NEEDLE SUT C-13 L36.6MM 1/2 CIR REV CUT W/ NIT LOOP FOR,SUP-2122138,CDM,2720000010,LOCAL,0272,RC,,,,both,,,715.92,465.35,,,,,,,,,,,,,
TEMPLATE SURG M W5XL14MM 0DEG IM CHT FIX SYS PET ANG SZ NIT,SUP-2194205,CDM,C1713,HCPCS,0278,RC,,,,both,,,2983.00,1938.95,,,,,,,,,,,,,
BLADE LARYNSCP UNIV EMER CLD LT DORGES,SUP-2261361,CDM,2720000010,LOCAL,0272,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
BOOT ANK AD L8 13IN FOR 16IN CALF UNIV DK BLU FLEECE LN,SUP-2165483,CDM,L4631,HCPCS,0272,RC,,,,both,,,145.38,94.50,,,,,,,,,,,,,
ALLOGRAFT BNE 15 CC PRIMAGEN ADV,SUP-2693647,CDM,C1713,HCPCS,0278,RC,,,,both,,,10782.76,7008.79,,,,,,,,,,,,,
NUT REDUC SPNL VERT BODY EXT TSRH 3D,SUP-2289810,CDM,C1713,HCPCS,0278,RC,,,,both,,,1043.01,677.96,,,,,,,,,,,,,
MIDLINE APPRCH 42MMX17MMX8DEG,SUP-2320310,CDM,C1889,HCPCS,0278,RC,,,,both,,,25434.00,16532.10,,,,,,,,,,,,,
CATHETER SET CECOSTOMY 10.2 FRX20 CM 0.6 CM CHAIT NDL CANN,SUP-2168770,CDM,C1729,HCPCS,0272,RC,,,,both,,,1225.42,796.52,,,,,,,,,,,,,
PLATE BNE MED,SUP-2101217,CDM,C1713,HCPCS,0278,RC,,,,both,,,2411.71,1567.61,,,,,,,,,,,,,
PLATE BONE L78MM NONSTERILE RT MEDL S STL CLMN FUS VAR ANG,SUP-2420165,CDM,C1713,HCPCS,0278,RC,,,,both,,,4803.16,3122.05,,,,,,,,,,,,,
BASKET UROLOGY STONE SEGR MULT WIRE 70CML DISP GUIDWIRE,SUP-2141084,CDM,C1713,HCPCS,0278,RC,,,,both,,,428.61,278.60,,,,,,,,,,,,,
HC Iadna Sarscov2& Inf a&B Mult Amp Probe|NOT REASONABLE AND NECESSARY,PX-3068763600,CDM,87636,CPT,0306,RC,,,GZ,both,,,170.00,110.50,,,,,,,,,,,,,
PLATE RECON 3.5MM 8HL,SUP-2717532,CDM,C1713,HCPCS,0278,RC,,,,both,,,3296.25,2142.56,,,,,,,,,,,,,
ANCHOR SUT BRAID 2 SUT W/ ORTHOCORD GRYPHON T,SUP-2256591,CDM,C1713,HCPCS,0278,RC,,,,both,,,1155.52,751.09,,,,,,,,,,,,,
BASKET RETRIEVAL DISCOVER SPYGLASS,SUP-2713870,CDM,2720000010,LOCAL,0272,RC,,,,both,,,776.21,504.54,,,,,,,,,,,,,
SPLINT ANK STRRP AIR AND FOAM S,SUP-2276706,CDM,L4350,HCPCS,0274,RC,,,,both,,,38.18,24.82,,,,,,,,,,,,,
CLOVERLEAF PLT STERILIZER 104 MM 4 HL,SUP-2818114,CDM,C1713,HCPCS,0278,RC,,,,both,,,2430.55,1579.86,,,,,,,,,,,,,
PLATE BONE LOK CMPRSSN 199MML HLX12 TIMAX CRTCL BROAD PRE CN,SUP-2588751,CDM,C1713,HCPCS,0278,RC,,,,both,,,3920.92,2548.60,,,,,,,,,,,,,
PLATE BONE W7XL57MM THK1.4MM 7 H RT CNDYL S STL,SUP-2343848,CDM,C1713,HCPCS,0278,RC,,,,both,,,2415.32,1569.96,,,,,,,,,,,,,
STENT TRACHBRONCH HANAROSTENT L 60 MM DIA18 MM DEL SYS L 900,SUP-2865673,CDM,C1874,HCPCS,0278,RC,,,,both,,,12638.50,8215.02,,,,,,,,,,,,,
DEVICE PESSARY NO4 DIA2.75IN RNG FLD KITTED W/ SUPP PROLAPSE,SUP-2171799,CDM,A4562,HCPCS,0272,RC,,,,both,,,173.30,112.64,,,,,,,,,,,,,
PLATE BNE SM W11XL202MM THK34MM 15 H BILAT TI RIG NEUT LOK,SUP-2190794,CDM,C1713,HCPCS,0278,RC,,,,both,,,1909.18,1240.97,,,,,,,,,,,,,
BIT DRL N CANN 4 MM TWST,SUP-2389445,CDM,2720000010,LOCAL,0272,RC,,,,both,,,486.70,316.35,,,,,,,,,,,,,
HARVESTING SET 6.5 MM MOSAICPLASTY DISP,SUP-2849112,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1190.06,773.54,,,,,,,,,,,,,
SET INTRO SUP ARW FLX SHTH L 24 CM DIA 7 FR HYDRPHLC,SUP-2383407,CDM,C1894,HCPCS,0272,RC,,,,both,,,963.98,626.59,,,,,,,,,,,,,
GRAFT EVAR L10CM DIA12MM NIT EPTFE FEP BIFUR EXT LEG INT,SUP-2395717,CDM,C1768,CPT,0278,RC,,,,both,,,30957.26,20122.22,,,,,,,,,,,,,
DEFIBRILLATOR CARD W5.90CM D1.30CM 40J 20SEC 5YR STD 2 CHMBR,SUP-2138074,CDM,C1721,HCPCS,0275,RC,,,,both,,,46891.16,30479.25,,,,,,,,,,,,,
SHEATH INTRO CATAPULT L 60 CM DIA 5 FR GUIDEWIRE 0.035 IN,SUP-2913627,CDM,C1894,HCPCS,0272,RC,,,,both,,,373.66,242.88,,,,,,,,,,,,,
SHUNT SURG L 11.8 MM VENTRICULAR CATH L 180 MM PRESSURE 0 CM,SUP-2929123,CDM,C1889,HCPCS,0278,RC,,,,both,,,2761.88,1795.22,,,,,,,,,,,,,
GRAFT VASC GORTX L 10 CM DIA 7 MM EPTFE STR STD WALL N RING,SUP-2396427,CDM,C1768,CPT,0278,RC,,,,both,,,474.14,308.19,,,,,,,,,,,,,
CATHETER 6-2X5.3X135 SYNERGY,SUP-2147627,CDM,C1725,HCPCS,0272,RC,,,,both,,,562.06,365.34,,,,,,,,,,,,,
TIP ASPIR L03MM BENT MIC COAX INTREPID,SUP-2109920,CDM,C1713,HCPCS,0278,RC,,,,both,,,747.32,485.76,,,,,,,,,,,,,
EXTENSION STEM L100MM DIA14MM FEM HIP CEMENTLESS CNL FILL,SUP-2304763,CDM,C1776,CPT,0278,RC,,,,both,,,3089.76,2008.34,,,,,,,,,,,,,
GRAFT HUM TISS W6XL12CM THK0.9-1.99MM ACELLULAR DERM MTRX,SUP-2402511,CDM,Q4126,HCPCS,0636,RC,,,,both,,,11932.00,7755.80,,,,,,,,,,,,,
GENERATOR CARD Q TRAK ELECTRD SUBQ ICD STRL,SUP-2140374,CDM,C1882,HCPCS,0275,RC,,,,both,,,78500.00,51025.00,,,,,,,,,,,,,
PLATE BONE LOK 185MML HLX14 STNLSS STEEL 1/3 TBLR ST,SUP-2588608,CDM,C1713,HCPCS,0278,RC,,,,both,,,656.26,426.57,,,,,,,,,,,,,
ALLOGRAFT BNE 2.5 ML BIOACTIVE FOAM PK VITOSS BA BIMODAL,SUP-2637054,CDM,C1889,HCPCS,0278,RC,,,,both,,,1968.78,1279.71,,,,,,,,,,,,,
SPLINT ORTH COTATION HUM ARM,SUP-2388194,CDM,L3980,HCPCS,0272,RC,,,,both,,,1736.42,1128.67,,,,,,,,,,,,,
IMPLANT CAPPED SHOULDER S9 CONVERTIBLE GLENOID BASEPLATE SCREWS,SUP-2903941,CDM,C1776,CPT,0278,RC,,,,both,,,5809.00,3775.85,,,,,,,,,,,,,
HEAD FEM EXT 5+ MM 10/12 26 MM HIP TAPR OXIN,SUP-2434569,CDM,C1776,CPT,0278,RC,,,,both,,,4854.44,3155.39,,,,,,,,,,,,,
BUR SURG WIRE PASS MED 2X19 MM SS MICROPOWER MIC 100,SUP-2166419,CDM,2720000010,LOCAL,0272,RC,,,,both,,,87.92,57.15,,,,,,,,,,,,,
JIG TIBIAL LOCKING NAIL,SUP-2588064,CDM,C1713,HCPCS,0278,RC,,,,both,,,46795.86,30417.31,,,,,,,,,,,,,
PLATE BNE L 3.5X60 MM RT PROX TIB 4 HOLE SS STRL,SUP-2421869,CDM,C1713,HCPCS,0278,RC,,,,both,,,4186.81,2721.43,,,,,,,,,,,,,
IMPLANT TOE JT METATRSL CO CHROM N POR 12.5MM BIOPRO,SUP-2137765,CDM,C1776,CPT,0278,RC,,,,both,,,4553.00,2959.45,,,,,,,,,,,,,
SCREW BNE GLENOSPHERE SHLDR PRI LOK REV EQUINOXE,SUP-2223384,CDM,C1713,HCPCS,0278,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
STRYKER REPLACEMENT BLADE 13X90X0.89MM,SUP-2605749,CDM,2720000010,LOCAL,0272,RC,,,,both,,,101.48,65.96,,,,,,,,,,,,,
PLATE 8 H RECON 3.5MM INA,SUP-2186268,CDM,C1713,HCPCS,0278,RC,,,,both,,,3789.67,2463.29,,,,,,,,,,,,,
LINER ACETABULARXL OD68MM ID32MM THK12.4MM 0DEG STD,SUP-2209703,CDM,C1776,CPT,0278,RC,,,,both,,,2024.83,1316.14,,,,,,,,,,,,,
"HC So Herpes Simplex, Type 2",PX-3028669666,CDM,86696,CPT,0302,RC,,,,both,,,109.00,70.85,,,,,,,,,,,,,
CATHETER VLV MAPPER STD CRV EXT DSTL SHFT QPLR 2.5MM SPC 8MM,SUP-2139726,CDM,C1733,HCPCS,0272,RC,,,,both,,,2339.30,1520.54,,,,,,,,,,,,,
CATHETER CARD ABLATION THERMOCOOL SMARTTOUCH L 115 CM 8FR FJ,SUP-2248607,CDM,C1732,HCPCS,0272,RC,,,,both,,,9730.86,6325.06,,,,,,,,,,,,,
GRAFT DERM MTRX HUM TISS FLD HYDRATED THN KT BILAT BRST,SUP-2307579,CDM,Q4128,HCPCS,0636,RC,,,,both,,,4403.85,2862.50,,,,,,,,,,,,,
SUBSTITUTE BONE GRFT 15ML CANC CUBE,SUP-2212019,CDM,C1713,HCPCS,0278,RC,,,,both,,,857.22,557.19,,,,,,,,,,,,,
HC Njx Dx/Ther Sbst W/Indwelling Cath Intrlmnr Crv/Thrc W/Img Gdn,PX-3606232500,CDM,62325,CPT,0360,RC,,,,outpatient,,,2895.00,1881.75,,,,,,,,,,,,,
ELECTRODE BPLR CUT 21FR,SUP-2332802,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1236.85,803.95,,,,,,,,,,,,,
STEM FEM PRSS FT 13 HIP SYNERGY,SUP-2344424,CDM,C1776,CPT,0278,RC,,,,both,,,8135.30,5287.94,,,,,,,,,,,,,
BUR SURG L 12 CM DIA 5 MM SHRT BALL DISECT TOOL STRL DISP,SUP-2929985,CDM,2720000010,LOCAL,0272,RC,,,,both,,,437.28,284.23,,,,,,,,,,,,,
QUINAPRIL HCL 10 MG PO TABS,RX-11251,CDM,6370000000,HCPCS,0637,RC,65862-0618-90,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
"HC OB ER Level 3|SIGNIFICANT, SEPARATELY IDENTIFIABLE EVALUATION AND MANAGEMENT SERVICE BY THE SAME PHYSICIAN ON THE SAME DAY OF THE PROCEDURE OR OTHER SERVICE|MULTIPLE OUTPATIENT HOSPITAL E/M ENCOUNTERS ON THE SAME DATE",PX-4509928301,CDM,99283,CPT,0450,RC,,,25|27,outpatient,,,1556.00,1011.40,,,,,,,,,,,,,
GRAFT BIO TISS W18XL28MM THK1MM PORCINE DERM CLLGN FOR HERN,SUP-2174698,CDM,C9364,HCPCS,0278,RC,,,,both,,,30856.78,20056.91,,,,,,,,,,,,,
IMPLANT NSL L 70 X W 13 MM THK 2 MM SM POLYETHYL ARCH TRIM,SUP-2883445,CDM,C1889,HCPCS,0278,RC,,,,both,,,1300.53,845.34,,,,,,,,,,,,,
HC Drug Screen Quantitative Amikacin,PX-3018015000,CDM,80150,CPT,0301,RC,,,,both,,,467.00,303.55,,,,,,,,,,,,,
ALLOGRAFT BNE PTTY 0.25 CC FD SYR DBM GRFT,SUP-2787765,CDM,C1713,HCPCS,0278,RC,,,,both,,,188.40,122.46,,,,,,,,,,,,,
PLATE BNE L286MM 13 H NONSTERILE L DST FEM LOK FOR 4.5MM,SUP-2348457,CDM,C1713,HCPCS,0278,RC,,,,both,,,11284.69,7335.05,,,,,,,,,,,,,
HC Gbl Smoke/Tobac Counsel 3-10,PX-9829940601,CDM,99406,CPT,0982,RC,,,,both,,,70.00,45.50,,,,,,,,,,,,,
PIN GUIDE L 358 MM DIA 3.2 MM COCR FLUT TIP STRL DISP,SUP-2932801,CDM,2720000010,LOCAL,0272,RC,,,,both,,,918.01,596.71,,,,,,,,,,,,,
SET PICC 2L 5FR X 55CM W TEG CHG,SUP-2887044,CDM,C1751,HCPCS,0278,RC,,,,both,,,2662.72,1730.77,,,,,,,,,,,,,
BLADE REPROC SHV 4.5MM YEL STR FULL RAD,SUP-2652902,CDM,2720000010,LOCAL,0272,RC,,,,both,,,103.56,67.31,,,,,,,,,,,,,
HC So T Cell Total,PX-3028635966,CDM,86359,CPT,0302,RC,,,,both,,,64.00,41.60,,,,,,,,,,,,,
CASE TRAVEL,SUP-2356034,CDM,C1713,HCPCS,0278,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
ALLOGRAFT PROVENDA-FLO 2.0ML,SUP-2653995,CDM,C1762,CPT,0278,RC,,,,both,,,12560.00,8164.00,,,,,,,,,,,,,
SPLINT WRST XSM AD L8IN FOR 5 65IN L NYL LN FOAM PUL ON,SUP-2276661,CDM,L3908,HCPCS,0274,RC,,,,both,,,20.41,13.27,,,,,,,,,,,,,
PLATE BNE CNDYL 1.5 MM FRAC TI,SUP-2462853,CDM,C1713,HCPCS,0278,RC,,,,both,,,769.99,500.49,,,,,,,,,,,,,
BREXUCABTAGENE AUTOLEUCEL 100000000 CELLS IV SUSP,RX-156489,CDM,Q2053,HCPCS,0891,RC,71287-0220-01,NDC,,both,1,UN,3234000.00,2102100.00,,,,,,,,,,,,,
STENT PERIPH ELUVIA L 100 MM DIA 6 MM CATH L 130 CM DIA 6 FR,SUP-2140847,CDM,C1874,HCPCS,0278,RC,,,,both,,,8776.30,5704.59,,,,,,,,,,,,,
GRAFT VASC ALBOGRAFT L 30 CM DIA20 MM POLYESTER STR KNITTED,SUP-2264281,CDM,C1768,CPT,0278,RC,,,,both,,,1491.50,969.47,,,,,,,,,,,,,
ALLOGRAFT BNE CHIP CANC 800107,SUP-2743332,CDM,C1713,HCPCS,0278,RC,,,,both,,,976.54,634.75,,,,,,,,,,,,,
SET ORTH SM/L 0-1DEG PRO-TOE VO,SUP-2397813,CDM,C1776,CPT,0278,RC,,,,both,,,618.58,402.08,,,,,,,,,,,,,
DEVICE DEFCT CLOSURE PRELD SELF GRASPING FOR GI TRACT PDLOK,SUP-2913711,CDM,C1889,HCPCS,0278,RC,,,,both,,,6280.00,4082.00,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 10 CM DIA 7 MM EPTFE STR STD WALL,SUP-2525430,CDM,C1768,CPT,0278,RC,,,,both,,,345.84,224.80,,,,,,,,,,,,,
COLLAR CERV M H3XL17IN HK AND LOOP CLSR W/ STOCK,SUP-2194569,CDM,L0180,HCPCS,0272,RC,,,,both,,,45.50,29.57,,,,,,,,,,,,,
BUR SURG BALL 4 MMX10 CM SPEC MIDAS REX LEGEND,SUP-2627617,CDM,2720000010,LOCAL,0272,RC,,,,both,,,403.62,262.35,,,,,,,,,,,,,
SPLINT ORTHOPEDIC SPICA MED LG LT THMB HK LOOP CLOSURE VLY 0005785000000] ALIMED INC],SUP-2112560,CDM,L3924,HCPCS,0274,RC,,,,both,,,96.56,62.76,,,,,,,,,,,,,
TAP ORTH OD7MM CANN FOR DARCO 7MM HDLSS COMPR SCR,SUP-2399605,CDM,C1713,HCPCS,0278,RC,,,,both,,,477.28,310.23,,,,,,,,,,,,,
STEM FEM CLLRLSS 11-14 STD 131.5 DEG PROX W/ TRUNION,SUP-2450444,CDM,C1776,CPT,0278,RC,,,,both,,,748.89,486.78,,,,,,,,,,,,,
COIL EMB L8CM OD4MM 360DEG USFT STRTCH RESIST BIG LOOP,SUP-2365791,CDM,C1889,HCPCS,0278,RC,,,,both,,,7762.71,5045.76,,,,,,,,,,,,,
BIT DRL CALIB 3.3 MM HUM C LBL INSTRUMENT CASE NS AFFIXUS,SUP-2606174,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1406.72,914.37,,,,,,,,,,,,,
INSERT TIB SZ 1-2 THK18MM R KNEE BI CRUCE STBL CONSTRN ARTC,SUP-2350781,CDM,C1776,CPT,0278,RC,,,,both,,,8547.08,5555.60,,,,,,,,,,,,,
CATHETER DRAINAGE 8 FRX40 CM BILI,SUP-2303541,CDM,C1729,HCPCS,0272,RC,,,,both,,,226.08,146.95,,,,,,,,,,,,,
HC Srs Linear Based,PX-3337737200,CDM,77372,CPT,0333,RC,,,,outpatient,,,21769.00,14149.85,,,,,,,,,,,,,
PLATE BONE TIBIAL 2.7X32 MM MEDIAL DISTAL 4 HOLE STRAIGHT LO,SUP-2836534,CDM,C1713,HCPCS,0278,RC,,,,both,,,894.90,581.68,,,,,,,,,,,,,
WAND ABLAT 70DEG 3 WIRE ACT ELECTRD FOR ADENOTONSILLECTOMY,SUP-2342042,CDM,2720000010,LOCAL,0272,RC,,,,both,,,690.80,449.02,,,,,,,,,,,,,
DISULFIRAM 250 MG PO TABS,RX-2540,CDM,6370000000,HCPCS,0637,RC,47781-0607-30,NDC,,both,1,UN,12.80,8.32,,,,,,,,,,,,,
HC So Immunoglobulin,PX-3018278466,CDM,82784,CPT,0301,RC,,,,both,,,109.00,70.85,,,,,,,,,,,,,
CATHETER ATHRCTMY ROTLNK L 135 CM DIA 0.058 IN BUR SZ 1.25,SUP-2142284,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4034.90,2622.68,,,,,,,,,,,,,
PLATE BONE ADAPTION 0.5 MM 5 HOLE TITANIUM NON STERILE LOW P,SUP-2838361,CDM,C1713,HCPCS,0278,RC,,,,both,,,828.96,538.82,,,,,,,,,,,,,
GRAFT BONE CRUSH FRZN CANC STRL 1-10MM 30CC,SUP-2165556,CDM,C1762,CPT,0278,RC,,,,both,,,1095.86,712.31,,,,,,,,,,,,,
DRILL TWST OD5MM ADPT TARGETING DEV RADLUC,SUP-2413010,CDM,2720000010,LOCAL,0272,RC,,,,both,,,386.22,251.04,,,,,,,,,,,,,
MUELLER FULL PROF ALL POLY CUP 32MM ID/46MM OD,SUP-2209463,CDM,C1776,CPT,0278,RC,,,,both,,,2265.82,1472.78,,,,,,,,,,,,,
GUIDE WIRE THRDED 2.4 MMX203 MM STR,SUP-2815257,CDM,C1769,HCPCS,0272,RC,,,,both,,,94.20,61.23,,,,,,,,,,,,,
PSN REV 6MM OFFSET STEM EXT 18X135MM,SUP-2508831,CDM,C1776,CPT,0278,RC,,,,both,,,6531.20,4245.28,,,,,,,,,,,,,
COUNTERSINK DRL DIA4MM G,SUP-2400357,CDM,2720000010,LOCAL,0272,RC,,,,both,,,486.70,316.35,,,,,,,,,,,,,
PLATE BNE L34MM 4X4 H BILAT MAND ORAL MAXILLOFACIAL TI ANG,SUP-2191466,CDM,C1713,HCPCS,0278,RC,,,,both,,,4648.77,3021.70,,,,,,,,,,,,,
RESORB X ST TMPLTE CRNL MRKNG GUIDE CP TTNM QT001 EA,SUP-2500222,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2486.31,1616.10,,,,,,,,,,,,,
GRAFT HUM TISS 21MM AORT VLV CRYOPRESERVED CARDIOGRFT,SUP-2264801,CDM,C1762,CPT,0278,RC,,,,both,,,61470.68,39955.94,,,,,,,,,,,,,
PLATE BNE L 107 MM SCREW DIA2.4 MM 12 SHFT H TI ADPT COMB,SUP-2907636,CDM,C1713,HCPCS,0278,RC,,,,both,,,2848.61,1851.60,,,,,,,,,,,,,
HC TB Cell Mediated Antign Respnse Gamma Interferon,PX-3028648000,CDM,86480,CPT,0302,RC,,,,both,,,163.00,105.95,,,,,,,,,,,,,
NAIL IM HUM 9.5X200 MM AG RETROGRADE AFFIXUS NAT NAIL,SUP-2606981,CDM,C1713,HCPCS,0278,RC,,,,both,,,5504.42,3577.87,,,,,,,,,,,,,
SET URET STENT STRTCH VL L 22-30 CM DIA 6 FR TIP L 3 CM PTFE,SUP-2481642,CDM,C2617,HCPCS,0278,RC,,,,both,,,440.64,286.42,,,,,,,,,,,,,
PLATE BNE CRV 4.5X336 MM LT CNDYL 16 HOLE VA LCK STRL VALCP,SUP-2789644,CDM,C1713,HCPCS,0278,RC,,,,both,,,7090.40,4608.76,,,,,,,,,,,,,
NAIL IM L 120 MM DIA 8 MM COMPR SCREW STRL T2,SUP-2900534,CDM,C1713,HCPCS,0278,RC,,,,both,,,10738.80,6980.22,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY PENTARAY NAV INSRTN 115CM 4-4-4 F,SUP-2492016,CDM,C1731,HCPCS,0278,RC,,,,both,,,5425.92,3526.85,,,,,,,,,,,,,
GUIDEWIRE VASC L 80CM 0.035IN L7CM L 3CM AMPLTZ STR X STIFF,SUP-2167977,CDM,C1769,HCPCS,0272,RC,,,,both,,,57.96,37.67,,,,,,,,,,,,,
SUPPORT SHLDR M L36-40IN UNIV CHST NEOPRENE BLK HUM CUF 61460601] PERFORMANCE HEALTH INC],SUP-2324516,CDM,L3675,HCPCS,0272,RC,,,,both,,,160.45,104.29,,,,,,,,,,,,,
PROSTHESIS PENILE L15CM TBNG L9CM PS PARYLENE INFL PRECONN,SUP-2138986,CDM,C1813,HCPCS,0278,RC,,,,both,,,39969.69,25980.30,,,,,,,,,,,,,
MODIFIED KLS MRTN RD II PRPLE SCRWS O/R S/D SNGLE USE,SUP-2681290,CDM,C1713,HCPCS,0278,RC,,,,both,,,22563.32,14666.16,,,,,,,,,,,,,
GUIDE WIRE BALL TIP 2.7/3.75MM X800MM,SUP-2750033,CDM,C1769,HCPCS,0272,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
GUIDEWIRE VASC HIWIRE L 260 CM DIA 0.018 IN TAPR L 15 CM,SUP-2170335,CDM,C1769,HCPCS,0272,RC,,,,both,,,168.65,109.62,,,,,,,,,,,,,
PLATE BNE L64MM THK2MM L CALCNL S STL LOK COMPR FOR,SUP-2185986,CDM,C1713,HCPCS,0278,RC,,,,both,,,1765.62,1147.65,,,,,,,,,,,,,
IMPLANT NSL DORSUM SM 53X5 MM DESIGN A STRL MEDPOR LF,SUP-2366462,CDM,C1889,HCPCS,0278,RC,,,,both,,,1191.66,774.58,,,,,,,,,,,,,
DARBEPOETIN ALFA 500 MCG/ML IJ SOSY,RX-131234,CDM,J0881,HCPCS,0636,RC,55513-0032-01,NDC,,both,1,ML,11416.50,7420.72,,,,,,,,,,,,,
GRAFT BIO TISS W3.9XL11IN PORCINE DERM RIFAMPIN MINOCYCLINE,SUP-2125837,CDM,C1781,HCPCS,0278,RC,,,,both,,,29842.56,19397.66,,,,,,,,,,,,,
HC Blood Count Hemoglobin,PX-3058501800,CDM,85018,CPT,0305,RC,,,,both,,,59.00,38.35,,,,,,,,,,,,,
SCREW BNE ST 2.7X22 MM CRTX,SUP-2364671,CDM,C1713,HCPCS,0278,RC,,,,both,,,68.30,44.39,,,,,,,,,,,,,
TRAY TK2 INSTRUMENT,SUP-2724037,CDM,C1725,HCPCS,0272,RC,,,,both,,,4125.96,2681.87,,,,,,,,,,,,,
IDARUBICIN HCL 10 MG/10ML IV SOLN,RX-88242,CDM,J9211,HCPCS,0636,RC,00013-2586-10,NDC,,both,10,ML,310.50,201.82,,,,,,,,,,,,,
POST EXT FIX 2 H WIRE,SUP-2176966,CDM,2720000010,LOCAL,0272,RC,,,,both,,,671.90,436.73,,,,,,,,,,,,,
RETRACTOR ESPOPHAGEAL ESOSURE,SUP-2877141,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1193.20,775.58,,,,,,,,,,,,,
BRACE UNIV WRST UNI L 8IN 45IN 95IN FRM FIT,SUP-2319285,CDM,L3809,HCPCS,0274,RC,,,,both,,,28.32,18.41,,,,,,,,,,,,,
CATHETER ETER EP MAP RESPON 6FR HEXAPOLAR 2 2 2MM ELECTRD SPC CRD,SUP-2356804,CDM,C1730,HCPCS,0272,RC,,,,both,,,813.26,528.62,,,,,,,,,,,,,
WIRE FIX L10MM DIA1MM CERCLAGE S STL PRECUT SMOOTH W/,SUP-2186840,CDM,C1713,HCPCS,0278,RC,,,,both,,,193.86,126.01,,,,,,,,,,,,,
CATHETER ABLAT 7FR TIP L4MM 2.5MM SPC QPLR SM CRV STD LEN,SUP-2140147,CDM,C1733,HCPCS,0272,RC,,,,both,,,2798.37,1818.94,,,,,,,,,,,,,
CARTILAGINATOR SURG FLAT SINGLE SIDE SAW RASP STRL,SUP-2898459,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2289.06,1487.89,,,,,,,,,,,,,
GRAFT BONE SUB 5ML TRICALCIUM PHOS GRAN CONT RESRB CONDUIT,SUP-2256851,CDM,C1713,HCPCS,0278,RC,,,,both,,,1130.40,734.76,,,,,,,,,,,,,
SYSTEM VAC MIX SGL DBL CLEARMIX 1 PER CA,SUP-2408543,CDM,2720000010,LOCAL,0272,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
SPLINT WRST SM L6IN R CANVS LACE UP FIRM SUPP REM MAL PALMAR,SUP-2194831,CDM,L3908,HCPCS,0274,RC,,,,both,,,29.36,19.08,,,,,,,,,,,,,
SHUNT SURG 1X20.25 MM,SUP-2266071,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
HC Assay of Total Estradiol,PX-3018267000,CDM,82670,CPT,0301,RC,,,,outpatient,,,638.00,414.70,,,,,,,,,,,,,
GUIDE NERVE REP MTRX 1.5 MMX2 CM STRL NEURAGEN 3D LF,SUP-2877623,CDM,C9352,HCPCS,0278,RC,,,,both,,,7681.32,4992.86,,,,,,,,,,,,,
STEM FEM L8IN DIA15MM PLATFRM 15CM CALCAR HIP POR STR,SUP-2252183,CDM,C1776,CPT,0278,RC,,,,both,,,22323.52,14510.29,,,,,,,,,,,,,
PATCH HEMOSTAS SYVEK POLY-N GLUCOSAMINE EXT FOR 4-10 FEM,SUP-2266133,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1224.60,795.99,,,,,,,,,,,,,
MELPHALAN HCL 50 MG IV SOLR,RX-10522,CDM,J9245,HCPCS,0636,RC,43598-0392-48,NDC,,both,1,UN,289.40,188.11,,,,,,,,,,,,,
LEVEL CMF PLATE ORTHG TLTS BSSO L SHP W/TAB LFT 20 MM BRG 2.,SUP-2496300,CDM,C1713,HCPCS,0278,RC,,,,both,,,1198.00,778.70,,,,,,,,,,,,,
BUR SURG DIA1MM EXT FN DMND RIM GLDE TECHNOLOGY RAP SMOOTH,SUP-2363789,CDM,2720000010,LOCAL,0272,RC,,,,both,,,763.02,495.96,,,,,,,,,,,,,
PLATE 4.5MM 3.5MM TI LCP METAPHYSEAL 20 HOLES,SUP-2549480,CDM,C1713,HCPCS,0278,RC,,,,both,,,3363.94,2186.56,,,,,,,,,,,,,
DEFIBRILLATOR CRD SINGLE CHMBR 30 J CURRENT VR,SUP-2356048,CDM,C1722,HCPCS,0275,RC,,,,both,,,70336.00,45718.40,,,,,,,,,,,,,
PLATE BNE L80MM 4 H R LAT DST PERIARTC FIBULAR S STL LOK,SUP-2410713,CDM,C1713,HCPCS,0278,RC,,,,both,,,1812.06,1177.84,,,,,,,,,,,,,
GUIDEWIRE VASC VASSALLO GT L 190 CM DIA 0.014 IN TIP LOAD 1,SUP-2909310,CDM,C1769,HCPCS,0272,RC,,,,both,,,51.78,33.66,,,,,,,,,,,,,
ALLOGRAFT BNE INSRT MED 9 8X6X9 MM FD CYL DBM XPANSE,SUP-2787771,CDM,C1713,HCPCS,0278,RC,,,,both,,,1597.63,1038.46,,,,,,,,,,,,,
MORCELLATOR HYSTEROSCOPIC 10MM CUT WIND 5MM DST FOR 80 SYS,SUP-2172310,CDM,C1782,HCPCS,0272,RC,,,,both,,,2383.95,1549.57,,,,,,,,,,,,,
PLUG MESH SM ANCHR 3CM RIM 5CM SYN POLYPR POLIGLECAPRONE 25,SUP-2220114,CDM,C1781,HCPCS,0278,RC,,,,both,,,624.99,406.24,,,,,,,,,,,,,
BLADE RETRACTOR INSTRUMENT,SUP-2242480,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1111.87,722.72,,,,,,,,,,,,,
SHEATH INTRO AVNT + DIA 9 FR CANN L 11 CM GUIDEWIRE 0.038 IN,SUP-2157380,CDM,C1894,HCPCS,0272,RC,,,,both,,,19.63,12.76,,,,,,,,,,,,,
ANCHOR SUTURE WITH TWO NO 2 HI FI SUTURES WITH NEEDLES 5.0MM,SUP-2828568,CDM,C1713,HCPCS,0278,RC,,,,both,,,1110.46,721.80,,,,,,,,,,,,,
KIT INTRO DIA 6 FR TUOHY BORST ADPT STRL,SUP-2877845,CDM,C1894,HCPCS,0272,RC,,,,both,,,219.80,142.87,,,,,,,,,,,,,
ALLOGRAFT BNE CHIP 1.7-10 MM 15 CC FD CANC,SUP-2743407,CDM,C1713,HCPCS,0278,RC,,,,both,,,1073.88,698.02,,,,,,,,,,,,,
BUR SURG HUDSON END 14 MMX4 IN CRAN BRAC CUSHING,SUP-2499470,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1031.52,670.49,,,,,,,,,,,,,
HC So1 H.Pylori. Serum,PX-3028667767,CDM,86677,CPT,0302,RC,,,,both,,,192.00,124.80,,,,,,,,,,,,,
TUBE SURG NOSE 13 CM CRV MIS NS LTX,SUP-2859727,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5216.64,3390.82,,,,,,,,,,,,,
PLATE BONE CRANIAL 5 HOLE STRAIGHT 21.4X3.4MM TITANIUM NEURO,SUP-2825989,CDM,C1713,HCPCS,0278,RC,,,,both,,,109.90,71.43,,,,,,,,,,,,,
GRAFT BONE PUTTY SYR DEMINERALISED BONE MTRX 5CC TREL-XPRESS,SUP-2244477,CDM,C9359,HCPCS,0278,RC,,,,both,,,2365.99,1537.89,,,,,,,,,,,,,
CATHETER HD 55 CM 50 CM CHRONIC DLYS COMPLETE KT SH,SUP-2484233,CDM,C1750,HCPCS,0278,RC,,,,both,,,753.60,489.84,,,,,,,,,,,,,
IMPLANT CAPSULAR TENS RNG COMPR 13-11 MM PMMA PRELD INJ FLX,SUP-2884219,CDM,L8699,HCPCS,0278,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
ESTRADIOL 0.05 MG/24HR TD PTWK,RX-28408,CDM,6370000000,HCPCS,0637,RC,00378-3350-16,NDC,,both,1,UN,83.60,54.34,,,,,,,,,,,,,
PLATE BNE LCK UNIV 3.5 MM 9 HOLE CONTOURED 2 COMPR RECON,SUP-2468353,CDM,C1713,HCPCS,0278,RC,,,,both,,,1459.28,948.53,,,,,,,,,,,,,
SCREW BNE L HIP TI LOK SM HD,SUP-2405826,CDM,C1713,HCPCS,0278,RC,,,,both,,,593.46,385.75,,,,,,,,,,,,,
ANKLE ARTHRODESIS CYLINDRICAL PIN,SUP-2701071,CDM,C1713,HCPCS,0278,RC,,,,both,,,230.79,150.01,,,,,,,,,,,,,
STENT BILI WALLFLEX L 60 MM DIA 8 MM CVR L 48 MM CATH L 194,SUP-2141594,CDM,C1874,HCPCS,0278,RC,,,,both,,,7785.63,5060.66,,,,,,,,,,,,,
ROD EXT FIX L100MM GRAD TELSCP FOR ILIZ SYS,SUP-2342266,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6715.99,4365.39,,,,,,,,,,,,,
SCREW BONE EMERGENCY 2X18 MM WITH PLUSDRIVE RECESS TITANIUM,SUP-2838135,CDM,C1713,HCPCS,0278,RC,,,,both,,,246.18,160.02,,,,,,,,,,,,,
SHEATH INTRO DRNGE CATH BAN PEEL 12FR 15MM,SUP-2141070,CDM,C1894,HCPCS,0272,RC,,,,both,,,131.41,85.42,,,,,,,,,,,,,
CONDYLAR PLATE RIGHT 7X158MM,SUP-2818527,CDM,C1713,HCPCS,0278,RC,,,,both,,,7218.55,4692.06,,,,,,,,,,,,,
SCREW BNE CANN 2.8X28 MM PARTIALLY THRD STRL BIODRIVE LTX,SUP-2861399,CDM,C1713,HCPCS,0278,RC,,,,both,,,853.83,554.99,,,,,,,,,,,,,
GRAFT VASC IMPRA L 10 CM DIA 8 MM EPTFE FLX STD WALL RING,SUP-2126873,CDM,C1768,CPT,0278,RC,,,,both,,,701.29,455.84,,,,,,,,,,,,,
SHUNT NEUROSURGICAL 10/40CM WATER WITH SPRUNG RESERVOIR NON,SUP-2825676,CDM,C1889,HCPCS,0278,RC,,,,both,,,7222.35,4694.53,,,,,,,,,,,,,
STEM HUM L90MM DIA9MM SHLDR TI PLSM SPRY AEQUALIS FLX,SUP-2417742,CDM,C1776,CPT,0278,RC,,,,both,,,12140.81,7891.53,,,,,,,,,,,,,
HC US Pelvis Complete,PX-4027685600,CDM,76856,CPT,0402,RC,,,,both,,,1227.00,797.55,,,,,,,,,,,,,
STAPLER INT STR 4.8X45 MM RT BIOABSORBABLE GRN SEAMGRD,SUP-2468455,CDM,2720000010,LOCAL,0272,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
PLATE BONE LOW PROFILE 100X0.4 MM CONTOURABLE MESH MALLEABLE,SUP-2838373,CDM,C1713,HCPCS,0278,RC,,,,both,,,6418.79,4172.21,,,,,,,,,,,,,
AMIODARONE HCL 450 MG/9ML IV SOLN,RX-97603,CDM,J0282,HCPCS,0636,RC,67457-0153-99,NDC,,both,3,ML,54.10,35.16,,,,,,,,,,,,,
COIL DETACH 4MM DIA 12CM COIL OUTER DIA 0125IN VOL 950MM,SUP-2173106,CDM,C1889,HCPCS,0278,RC,,,,both,,,6396.18,4157.52,,,,,,,,,,,,,
CATHETERIZATION KIT 0.032 IN 7 FRX20 CM BLU FLEXTIP,SUP-2120588,CDM,C1751,HCPCS,0278,RC,,,,both,,,85.41,55.52,,,,,,,,,,,,,
GRAFT BONE SUB M 6CC BIOACTIVE GLS PUTTY FIBERGRFT,SUP-2330556,CDM,C1713,HCPCS,0278,RC,,,,both,,,7347.60,4775.94,,,,,,,,,,,,,
SPACER TIB H5MM SM PROX ENDO MOD M IMPL,SUP-2265091,CDM,C1776,CPT,0278,RC,,,,both,,,6524.92,4241.20,,,,,,,,,,,,,
CATHETER THROMCTMY L 135 CM DIA 4.3 FR THROMBOLYTIC INFUSION,SUP-2117142,CDM,C1751,HCPCS,0278,RC,,,,both,,,712.78,463.31,,,,,,,,,,,,,
NEEDLE SPNL Y 400 MM ES2 LT,SUP-2532845,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1841.99,1197.29,,,,,,,,,,,,,
DEXTROSE 70 % IV SOLN,RX-2367,CDM,2580000003,HCPCS,0258,RC,00338-0719-06,NDC,,both,2000,ML,170.00,110.50,,,,,,,,,,,,,
BLADE RETRACTOR BALFOUR 9.75 IN 3.5X1.75 IN ABD CENTER STD,SUP-2472667,CDM,2720000010,LOCAL,0272,RC,,,,both,,,205.83,133.79,,,,,,,,,,,,,
PPICC PROV PED 3F SLEEVE DELTA,SUP-2613521,CDM,C1751,HCPCS,0278,RC,,,,both,,,735.67,478.19,,,,,,,,,,,,,
GUIDEWIRE SURG BALL TIP 3X800 MM,SUP-2644702,CDM,C1769,HCPCS,0272,RC,,,,both,,,498.00,323.70,,,,,,,,,,,,,
CATHETER INFUSION FASTRACKER 325 L 105 CM OD PROX/DSTL,SUP-2147318,CDM,C1887,HCPCS,0272,RC,,,,both,,,1270.88,826.07,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED PRIMARY POLYETH,SUP-2365629,CDM,C1776,CPT,0278,RC,,,,both,,,15386.00,10000.90,,,,,,,,,,,,,
SET INT FIX SCREW DIA1.5 MM 2 H TI NEURO STR PLT XDRV 12 PK,SUP-2935648,CDM,C1713,HCPCS,0278,RC,,,,both,,,8883.06,5773.99,,,,,,,,,,,,,
RAIL EXT FIX MINI BODY,SUP-2197292,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
ZIDOVUDINE 10 MG/ML IV SOLN,RX-11691,CDM,J3485,HCPCS,0636,RC,49702-0213-26,NDC,,both,20,ML,167.90,109.13,,,,,,,,,,,,,
DEXTROSE 70 % IV SOLN,RX-2367,CDM,2580000003,HCPCS,0250,RC,00338-0719-06,NDC,,both,2000,ML,170.00,110.50,,,,,,,,,,,,,
HC Urine Cult./Colony Count|NOT REASONABLE AND NECESSARY,PX-3008708600,CDM,87086,CPT,0300,RC,,,GZ,both,,,150.00,97.50,,,,,,,,,,,,,
BUR SURG L12CM DIA2.5MM MTCH HD TELSCP LNG MIDAS REX LEGEND,SUP-2281644,CDM,2720000010,LOCAL,0272,RC,,,,both,,,672.71,437.26,,,,,,,,,,,,,
RESERVOIR VENT STD S STL BASE FOR 6MM BUR H HOLTER RICKHAM,SUP-2243788,CDM,C1713,HCPCS,0278,RC,,,,both,,,1314.28,854.28,,,,,,,,,,,,,
TRASTUZUMAB 150 MG IV SOLR|DISCARDED DRUG NOT ADMINISTE,RX-138289,CDM,J9355,HCPCS,0636,RC,50242-0132-01,NDC,JW,both,1,UN,4519.70,2937.80,,,,,,,,,,,,,
PIN HALF FIXATION M5 L200MM THREAD L30MM STAINLESS STEEL,SUP-2586487,CDM,2720000010,LOCAL,0272,RC,,,,both,,,564.38,366.85,,,,,,,,,,,,,
PLATE BONE SM LT EPIPHYSIS OBLQ,SUP-2198586,CDM,C1713,HCPCS,0278,RC,,,,both,,,59.66,38.78,,,,,,,,,,,,,
SYSTEM SFT TISS FIX PEEK ACHILLES JUMPSTART SPEEDBRIDGE,SUP-2122835,CDM,C1713,HCPCS,0278,RC,,,,both,,,6264.30,4071.79,,,,,,,,,,,,,
HINGE EXT FIX INLINE 100 MM NS TRUELOK LTX,SUP-2875015,CDM,2720000010,LOCAL,0272,RC,,,,both,,,869.31,565.05,,,,,,,,,,,,,
PIN MXLFCL 1.6X4 MM PDLLA STRL SONICPIN RX,SUP-2466544,CDM,C1713,HCPCS,0278,RC,,,,both,,,256.79,166.91,,,,,,,,,,,,,
SCREW BNE L 65 MM DIA 6.5 MM SS CANN LCK NS EVOS,SUP-2931536,CDM,C1713,HCPCS,0278,RC,,,,both,,,1385.05,900.28,,,,,,,,,,,,,
FEBUXOSTAT 40 MG PO TABS,RX-97047,CDM,6370000000,HCPCS,0637,RC,60687-0538-21,NDC,,both,1,UN,11.30,7.34,,,,,,,,,,,,,
GRAFT HUM TISS FRZN ACHILLES TEND W/ BONE BLK FOR LIGMNT REP,SUP-2113891,CDM,C1713,HCPCS,0278,RC,,,,both,,,9842.74,6397.78,,,,,,,,,,,,,
COMPONENT 6X100MM HUMERAL ELBOW FLANGED C LEFT DISCOVERY,SUP-2879152,CDM,C1776,CPT,0278,RC,,,,both,,,15002.92,9751.90,,,,,,,,,,,,,
KIT INTRO ACCS 4FR L10CM GWIRE 0018IN NDL 21GA L7CM STD,SUP-2302999,CDM,C1894,HCPCS,0272,RC,,,,both,,,81.48,52.96,,,,,,,,,,,,,
PREDNISONE 20 MG PO TABS,RX-6496,CDM,J7512,HCPCS,0637,RC,00591-5443-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
MODULAR CUP REPLACEMENT LOCK RING 60MM,SUP-2503596,CDM,C1776,CPT,0278,RC,,,,both,,,204.10,132.66,,,,,,,,,,,,,
AMNION THICK 2X2,SUP-2811351,CDM,C1762,CPT,0278,RC,,,,both,,,2784.80,1810.12,,,,,,,,,,,,,
CATHETER CV SET 12 FRX16 CM 3L LG BOR ARW HWS,SUP-2763395,CDM,C1751,HCPCS,0278,RC,,,,both,,,280.72,182.47,,,,,,,,,,,,,
SCREW DISTRCTN L14MM QUIK STRT CASPR,SUP-2390670,CDM,C1713,HCPCS,0278,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
SCREW DISTRCTN CASPR 16MM 2 3/4IN - 16MM,SUP-2106568,CDM,C1713,HCPCS,0278,RC,,,,both,,,122.46,79.60,,,,,,,,,,,,,
PLATE BONE L36MM THK1.2MM SHFT W5MM HD 10.2MM 2X6 H STRL T,SUP-2349645,CDM,C1713,HCPCS,0278,RC,,,,both,,,3228.55,2098.56,,,,,,,,,,,,,
MESH CRAN CUSTOMIZED LG PRIORITY STRL MEDPOR,SUP-2862752,CDM,C1713,HCPCS,0278,RC,,,,both,,,61889.43,40228.13,,,,,,,,,,,,,
CATHETER EP D 6 MM 20 MMX7 FRX115 CM DUO,SUP-2465282,CDM,C1732,HCPCS,0278,RC,,,,both,,,8245.64,5359.67,,,,,,,,,,,,,
DRIVER SHFT SURG FLAT BLDE NONCANNULATED SPARE MMF LEIBINGER,SUP-2361548,CDM,2720000010,LOCAL,0272,RC,,,,both,,,824.97,536.23,,,,,,,,,,,,,
DEVICE CRPL TUNN RELEASE SEC GENERATION ULTRAGUIDECTR,SUP-2928366,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3293.86,2141.01,,,,,,,,,,,,,
PLATE BONE 12MM BAR 2 H CRANIOFACIAL FIX LO PROF W/ TAB UNIV,SUP-2365221,CDM,C1713,HCPCS,0278,RC,,,,both,,,504.85,328.15,,,,,,,,,,,,,
CARTRIDGE GRFT DEL 5 CC DBM INSTAFILL,SUP-2865333,CDM,C1713,HCPCS,0278,RC,,,,both,,,4402.28,2861.48,,,,,,,,,,,,,
LEAD NEUROSTIMULATOR L60CM 16 ELECTRD PADDLE TRIPOLE,SUP-2356735,CDM,C1778,HCPCS,0278,RC,,,,both,,,15067.70,9794.00,,,,,,,,,,,,,
SPHERE GLEN DIA38MM SHLDR ECC FOR DELT XTEND REV SYS,SUP-2251011,CDM,C1776,CPT,0278,RC,,,,both,,,4396.00,2857.40,,,,,,,,,,,,,
KIT BNE CEMENT MIXING SYS FEM BRKWY NOZ MED PRESSURIZER STRL,SUP-2884225,CDM,2720000010,LOCAL,0272,RC,,,,both,,,388.86,252.76,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.504,SUP-2860021,CDM,C1713,HCPCS,0278,RC,,,,both,,,34365.73,22337.72,,,,,,,,,,,,,
ALLOGRAFT GEL DBM PUTTY 5CC,SUP-2307528,CDM,C9359,HCPCS,0278,RC,,,,both,,,2427.22,1577.69,,,,,,,,,,,,,
GRAFT BNE SUB 10ML POLYMER HYALURONIC ACID BASE PSTE MIX,SUP-2247322,CDM,C1713,HCPCS,0278,RC,,,,both,,,6458.98,4198.34,,,,,,,,,,,,,
CATHETER EP SM CRV INQUIRY,SUP-2357441,CDM,C1730,HCPCS,0272,RC,,,,both,,,1868.30,1214.39,,,,,,,,,,,,,
STENT BILI AD L100MM DIA6MM CATH 6FR L80CM SHTH 0.035IN,SUP-2170730,CDM,C1876,HCPCS,0278,RC,,,,both,,,2785.18,1810.37,,,,,,,,,,,,,
PLUG ORTH HIP HNG AXLE LEGION,SUP-2346399,CDM,C1776,CPT,0278,RC,,,,both,,,511.19,332.27,,,,,,,,,,,,,
STENT CAR NEXSTENT L 30 MM DIA 4-9 MM NIT OTW SELF,SUP-2140174,CDM,C1876,HCPCS,0278,RC,,,,both,,,7834.30,5092.29,,,,,,,,,,,,,
GUIDEWIRE VASC MAGIC TORQUE DLVR L 315 CM DIA 0.035 IN TIP 5,SUP-2653352,CDM,C1769,HCPCS,0272,RC,,,,both,,,317.14,206.14,,,,,,,,,,,,,
CATHETER EP MED CRV 2-5-2 MM 6 FRX110 CM QPLR,SUP-2357433,CDM,C1730,HCPCS,0272,RC,,,,both,,,618.58,402.08,,,,,,,,,,,,,
SCREW BNE L12MM DIA5MM ST UNICORTICAL TI ST NONCANNULATED,SUP-2255847,CDM,C1713,HCPCS,0278,RC,,,,both,,,771.06,501.19,,,,,,,,,,,,,
SPLINT REST HND ADL R DRBLUE BROAD,SUP-2165489,CDM,L3807,HCPCS,0274,RC,,,,both,,,124.82,81.13,,,,,,,,,,,,,
WEDGE FEM SZ 1 DIA4MM DST GMK,SUP-2267560,CDM,C1776,CPT,0278,RC,,,,both,,,3854.35,2505.33,,,,,,,,,,,,,
GRAFT BNE SUB 1CC DBM FRZ DRY PTTY GRFTON,SUP-2294014,CDM,C1713,HCPCS,0278,RC,,,,both,,,678.24,440.86,,,,,,,,,,,,,
GRAFT BNE SUB W20XH7XL50MM POSTEROLATERAL STRP,SUP-2138514,CDM,C1713,HCPCS,0278,RC,,,,both,,,9080.28,5902.18,,,,,,,,,,,,,
PLATE X LCK 2.4/2.7MM SM 24X18MM TI STRL,SUP-2549725,CDM,C1713,HCPCS,0278,RC,,,,both,,,2290.98,1489.14,,,,,,,,,,,,,
COLLAR CERV EXTRIC COMB PK PERFIT ACE,SUP-2115130,CDM,L0120,HCPCS,0274,RC,,,,both,,,45.81,29.78,,,,,,,,,,,,,
SLING GYN POLYPR MFIL WRP KNIT MESH T FOR GENUINE STRESS,SUP-2152275,CDM,C1771,HCPCS,0278,RC,,,,both,,,3048.94,1981.81,,,,,,,,,,,,,
PLATE BNE 2X32X1 MM 6 HOLE SS DCP,SUP-2569121,CDM,C1713,HCPCS,0278,RC,,,,both,,,281.50,182.97,,,,,,,,,,,,,
SCREW BNE L12MM DIA2.7MM NONLOCKING TI 2 PK,SUP-2399692,CDM,C1713,HCPCS,0278,RC,,,,both,,,78.50,51.02,,,,,,,,,,,,,
ALLOGRAFT BNE PWD 10 CC FD ASEP CORTICAL,SUP-2867134,CDM,C1762,CPT,0278,RC,,,,both,,,536.94,349.01,,,,,,,,,,,,,
GUIDEWIRE HEP COAT FIX COR DBL END STR J TIP 3MM 035INX150CM,SUP-2302743,CDM,C1769,HCPCS,0272,RC,,,,both,,,27.00,17.55,,,,,,,,,,,,,
PLATE BNE STR 8 HOLE OMNI,SUP-2610113,CDM,C1713,HCPCS,0278,RC,,,,both,,,3720.90,2418.58,,,,,,,,,,,,,
AUGMENT FEM SZ 5 THK10MM L DST KNEE CO CHROM TOT STBL FULL,SUP-2373503,CDM,C1776,CPT,0278,RC,,,,both,,,2696.63,1752.81,,,,,,,,,,,,,
PLATE BNE SM W11XL78MM THK1.2MM 90DEG 4X6 H TI T SHP R ANG,SUP-2190934,CDM,C1713,HCPCS,0278,RC,,,,both,,,506.67,329.34,,,,,,,,,,,,,
TUBE VENT SHEEHY 1.27 MM PHOSPHORYLCHOLINE COAT SIL 510133C,SUP-2535103,CDM,L8699,HCPCS,0278,RC,,,,both,,,37.37,24.29,,,,,,,,,,,,,
KIT BONE CEM HNDL W/ 11GA L12CM NDL N BVL AVATEX,SUP-2155333,CDM,2720000010,LOCAL,0272,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
POLY-VI-SOL/IRON 11 MG/ML PO SOLN,RX-151312,CDM,340b,HCPCS,0637,RC,09999-9904-67,NDC,,both,1,ML,2.70,1.75,,,,,,,,,,,,,
KIT KYPHOPLASTY FULL DOSE PMMA RADPQ HI VISC W/O ANTIBIO,SUP-2293484,CDM,C1713,HCPCS,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
GRAFT HUM TISS W4XL4CM GRAFIX COR,SUP-2319168,CDM,Q4132,HCPCS,0636,RC,,,,both,,,6908.00,4490.20,,,,,,,,,,,,,
CATHETER ANGIO SOFT-VU L 90 CM 5 FR 0.035 IN RACKET SFT,SUP-2116615,CDM,C1887,HCPCS,0272,RC,,,,both,,,99.35,64.58,,,,,,,,,,,,,
PLATE BNE THK1MM 4X2 H BLU MAND TI 3D SQ FOR LEIBINGER,SUP-2366347,CDM,C1713,HCPCS,0278,RC,,,,both,,,1113.98,724.09,,,,,,,,,,,,,
SOLUTION IV 250ML 0.9% SODIUM CHLORIDE INJ USP,SUP-2900294,CDM,C1713,HCPCS,0278,RC,,,,both,,,6.91,4.49,,,,,,,,,,,,,
SCREW BNE L22MM DIA15MM PUR TI ALLY THRD AND ROUNDED HD LOK,SUP-2255843,CDM,C1713,HCPCS,0278,RC,,,,both,,,348.13,226.28,,,,,,,,,,,,,
PLATE BNE 110 DEG PEDIATRIC 5X90 MM 23/15 MM HIP 3 HOLE LCP,SUP-2799110,CDM,C1713,HCPCS,0278,RC,,,,both,,,2459.72,1598.82,,,,,,,,,,,,,
SCREW BNE L10MM OD2MM THRD L5MM TI BRK OFF MONSTER BITE,SUP-2320987,CDM,C1713,HCPCS,0278,RC,,,,both,,,977.33,635.26,,,,,,,,,,,,,
"HC OB ER Level 5|SIGNIFICANT, SEPARATELY IDENTIFIABLE EVALUATION AND MANAGEMENT SERVICE BY THE SAME PHYSICIAN ON THE SAME DAY OF THE PROCEDURE OR OTHER SERVICE|MULTIPLE OUTPATIENT HOSPITAL E/M ENCOUNTERS ON THE SAME DATE",PX-4509928501,CDM,99285,CPT,0450,RC,,,25|27,outpatient,,,3911.00,2542.15,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC HF 5FR 55CM 3 LUMAN RVRSE 9385108Q,SUP-2632704,CDM,C1751,HCPCS,0278,RC,,,,both,,,695.64,452.17,,,,,,,,,,,,,
PLATE BNE L151MM 11 H BILAT MTPHSEAL S STL LOK COMPR LO,SUP-2185104,CDM,C1713,HCPCS,0278,RC,,,,both,,,2597.35,1688.28,,,,,,,,,,,,,
BIT DRL BNE VERTECO R,SUP-2470883,CDM,2720000010,LOCAL,0272,RC,,,,both,,,453.42,294.72,,,,,,,,,,,,,
SLEEVE CNTR L14MM PMMA FOR FEM HIP FRAC,SUP-2406641,CDM,C1776,CPT,0278,RC,,,,both,,,973.40,632.71,,,,,,,,,,,,,
PLUG FIST DIA0.4CM ANAL/RECTOVAGINAL BTTN BIODESIGN,SUP-2171042,CDM,C1781,HCPCS,0278,RC,,,,both,,,4185.62,2720.65,,,,,,,,,,,,,
BUTTON GAST 18FR STOMA L3.4CM OBT ANTIREFLX VLV NONBLLN,SUP-2125954,CDM,C1713,HCPCS,0278,RC,,,,both,,,411.34,267.37,,,,,,,,,,,,,
CATHETER ANGIO L135CM DIA0.044X.038IN DIA2.1FR GWIRE,SUP-2353151,CDM,C1887,HCPCS,0272,RC,,,,both,,,587.18,381.67,,,,,,,,,,,,,
DRILL SURG TRINKLE TORQUE LIMITING ATTCH,SUP-2475270,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3498.12,2273.78,,,,,,,,,,,,,
INFINITY EVERLAST SZ 2 12MM TOTAL ANKLE,SUP-2822275,CDM,C1776,CPT,0278,RC,,,,both,,,7944.20,5163.73,,,,,,,,,,,,,
GENERATOR NEUROSTIMULATOR 16 CHAN RECHRG ECON MINI,SUP-2356760,CDM,C1820,HCPCS,0278,RC,,,,both,,,40820.00,26533.00,,,,,,,,,,,,,
KNIFE ARTHSCP 5MM HK SERR REUSE STR S STL STRL,SUP-2340708,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1004.80,653.12,,,,,,,,,,,,,
IMPL CAP END NAIL 12MM 10,SUP-2704173,CDM,C1889,HCPCS,0278,RC,,,,both,,,611.83,397.69,,,,,,,,,,,,,
COMPONENT FEM SZ 1 LT KNEE CONV MOD TAPR GEN II,SUP-2345982,CDM,C1776,CPT,0278,RC,,,,both,,,5929.11,3853.92,,,,,,,,,,,,,
SCREW SPNL L55MM DIA5.5MM TI ST VAR TIMBERLINE MPF,SUP-2415819,CDM,C1713,HCPCS,0278,RC,,,,both,,,894.90,581.68,,,,,,,,,,,,,
LENS INTOCU L13.75MM OD6.0MM A-CONSTANT 115.8 DIOPT DIOPT,SUP-2129493,CDM,V2630,CPT,0276,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
SHEARS REPROC HARMONIC FOCUS+ W/O ADAP,SUP-2527351,CDM,2720000010,LOCAL,0272,RC,,,,both,,,438.47,285.01,,,,,,,,,,,,,
EAR POSITIONING TEMPLATE YAMADA HARADA PPSU,SUP-2677944,CDM,2720000010,LOCAL,0272,RC,,,,both,,,607.40,394.81,,,,,,,,,,,,,
COLLAR CERV L AD H5XL21.5IN M DENS CNTCT CLSR FOAM W/ STOCK,SUP-2198741,CDM,L0120,HCPCS,0272,RC,,,,both,,,28.26,18.37,,,,,,,,,,,,,
GRAFT HUM TISS 2X4CM 0.4-1MM THN REGENERATIVE TISS MTRX,SUP-2399078,CDM,C1713,HCPCS,0278,RC,,,,both,,,3275.33,2128.96,,,,,,,,,,,,,
KIT NEUROSTIMULATOR PT PRGMR INCLUDE REMOT CTRL HOLSTER,SUP-2141948,CDM,C1787,HCPCS,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
TRANSDUCER 15 MM 2 MHZ MON,SUP-2162528,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1303.10,847.01,,,,,,,,,,,,,
"HC Unlisted Procedure, Nervous System",PX-3606499900,CDM,64999,CPT,0360,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
"HC New Pt, Outpt Visit Level 2",PX-7619920200,CDM,99202,CPT,0761,RC,,,,outpatient,,,363.00,235.95,,,,,,,,,,,,,
IMPLANT SACROILIAC JT L 40 MM DIA 9.5 MM TI STRL IFUSE,SUP-2889903,CDM,C1737,HCPCS,0278,RC,,,,both,,,11147.00,7245.55,,,,,,,,,,,,,
PLATE BNE CALCANEAL 90X22 MM LAT TIBIOTALAR ANK HI MODEL,SUP-2399179,CDM,C1713,HCPCS,0278,RC,,,,both,,,3802.54,2471.65,,,,,,,,,,,,,
BRONCHOSCOPES MONARCH,SUP-2736193,CDM,C1601,HCPCS,0272,RC,,,,both,,,9734.00,6327.10,,,,,,,,,,,,,
KIT SPNL 4 DEG L 26 X W 20 MM SM BLACKARMOR CARBON PEEK,SUP-2917102,CDM,C1889,HCPCS,0278,RC,,,,both,,,7536.00,4898.40,,,,,,,,,,,,,
FLECAINIDE ACETATE 100 MG PO TABS,RX-10041,CDM,6370000000,HCPCS,0637,RC,00054-0011-20,NDC,,both,1,UN,4.30,2.79,,,,,,,,,,,,,
GRAFT VASC HEMSHLD PLAT L 60 CM 38MM POLYESTER BOV CLLGN STR,SUP-2227241,CDM,C1768,CPT,0278,RC,,,,both,,,2575.18,1673.87,,,,,,,,,,,,,
CATHETER ETER DIL 75FR L180CM BLLN L3CM DIA10 11 12MM 0035IN,SUP-2141556,CDM,C1726,HCPCS,0272,RC,,,,both,,,873.23,567.60,,,,,,,,,,,,,
KIT CATH HEMODIALYSI ZENYSI DL ACUTE 11FR DIA 20CM PCED 2LUM,SUP-2613269,CDM,C1752,HCPCS,0278,RC,,,,both,,,715.14,464.84,,,,,,,,,,,,,
BASKET STONE RETRV L120CM DIA8MM SHTH 1.9FR NIT OPENSURE,SUP-2139284,CDM,2720000010,LOCAL,0272,RC,,,,both,,,712.12,462.88,,,,,,,,,,,,,
CATHETER DRNGE 18FR PROPORTIONATE HD 2 EYE FOR NEPHSTMY,SUP-2128977,CDM,C1729,HCPCS,0272,RC,,,,both,,,53.98,35.09,,,,,,,,,,,,,
CAGE SPNL H30XL10MM ANT THORLUM INTBDY TI RND PYRAMESH,SUP-2291997,CDM,C1889,HCPCS,0278,RC,,,,both,,,6452.61,4194.20,,,,,,,,,,,,,
"HC So1 Amino Acids, 6 or < Ea Spec",PX-3018213967,CDM,82139,CPT,0301,RC,,,,both,,,194.00,126.10,,,,,,,,,,,,,
STAPLE BNE FIX L 18 X W 14 MM TI ALLOY TOE COMPR LCK RAPID,SUP-2893051,CDM,C1713,HCPCS,0278,RC,,,,both,,,9533.04,6196.48,,,,,,,,,,,,,
HC So Lyme Disease Total Anitbodies,PX-3028661866,CDM,86618,CPT,0302,RC,,,,both,,,200.00,130.00,,,,,,,,,,,,,
CLAMP EXT FIX SM ADJ NONSPANNING MAG RESONANCE SAFE FOR,SUP-2188537,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2266.45,1473.19,,,,,,,,,,,,,
SPACER FEM M/L THK5MM POST HALF DURAC,SUP-2377251,CDM,C1776,CPT,0278,RC,,,,both,,,182.31,118.50,,,,,,,,,,,,,
BUR SURG RND 1.8X1 MM CARBIDE BRN S2 MINI,SUP-2859298,CDM,2720000010,LOCAL,0272,RC,,,,both,,,625.86,406.81,,,,,,,,,,,,,
SCREW BNE ST 5X48 MM LCK T25 STARDRV RECESS TI STRL,SUP-2569912,CDM,C1713,HCPCS,0278,RC,,,,both,,,122.62,79.70,,,,,,,,,,,,,
GUIDEWIRE HYBRID .008 DOUBLE ANGLE,SUP-2854078,CDM,C1769,HCPCS,0272,RC,,,,both,,,1993.90,1296.03,,,,,,,,,,,,,
HEAD HUM STD OFFSET 40X15 MM SHLDR PRIMARY NECKLESS COCR,SUP-2249977,CDM,C1776,CPT,0278,RC,,,,both,,,4909.70,3191.30,,,,,,,,,,,,,
WALKER L SHT LEG NONSKID,SUP-2276710,CDM,L4387,HCPCS,0274,RC,,,,both,,,83.56,54.31,,,,,,,,,,,,,
NEEDLE PLCMNT 18 GAX20 CM FUSIONCOIL MARKER STRL,SUP-2164570,CDM,A4648,CPT,0278,RC,,,,both,,,1130.40,734.76,,,,,,,,,,,,,
HC Pt Ultrasound Each 15 Min|OP PT SERVICES|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS,PX-4209703500,CDM,97035,CPT,0420,RC,,,GP|CQ,outpatient,,,194.00,126.10,,,,,,,,,,,,,
COMPONENT GLEN OD23MM SZ 1 REG POLYETH SHLDR CEM PEGGED ULT,SUP-2351227,CDM,C1776,CPT,0278,RC,,,,both,,,3815.10,2479.81,,,,,,,,,,,,,
GUIDEWIRE VASC L150CM OD0038IN TAPR L3CM J TIP ZIPWIRE,SUP-2148214,CDM,C1769,HCPCS,0272,RC,,,,both,,,83.18,54.07,,,,,,,,,,,,,
RESERVOIR PENILE PROSTHESIS BIOFLEX 75CC,SUP-2300750,CDM,C1813,HCPCS,0278,RC,,,,both,,,3972.10,2581.86,,,,,,,,,,,,,
STAPLE BNE FIX 10X10X10MM FOR HND AND FT BNE FRAG SURG,SUP-2175096,CDM,C1713,HCPCS,0278,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
HC Repair Enteroctaneous Fistula Small Intestine or Colon,PX-3610979600,CDM,C9796,CPT,0361,RC,,,,outpatient,,,8689.00,5647.85,,,,,,,,,,,,,
CABLE ORTH HIP MINI CLEAT DALL M,SUP-2377583,CDM,C1713,HCPCS,0278,RC,,,,both,,,592.83,385.34,,,,,,,,,,,,,
PIN FIX N THRD 3.5X508 MM ZNN,SUP-2517811,CDM,2720000010,LOCAL,0272,RC,,,,both,,,372.59,242.18,,,,,,,,,,,,,
PLATE BNE L84MM 6 H TIB S STL LOK COMPR WAISTED FOR 4MM SCR,SUP-2371949,CDM,C1713,HCPCS,0278,RC,,,,both,,,1444.40,938.86,,,,,,,,,,,,,
SET VITRCTMY 25GA PRB STANDALONE ACCURUS,SUP-2109888,CDM,C1713,HCPCS,0278,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
PLATE BNE STR MIC SHT 2 HOLE RIGID BLU,SUP-2462806,CDM,C1713,HCPCS,0278,RC,,,,both,,,195.37,126.99,,,,,,,,,,,,,
GRAFT HUM TISS 2X2CM AMNIO MEM VERSASHIELD,SUP-2316033,CDM,C1762,CPT,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
STAPLER INT AD L30MM STPL SZ 2.5MM 1MM CLSR WHT TI STD TISS,SUP-2283032,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2081.85,1353.20,,,,,,,,,,,,,
DRILL SURG 4.5MM CANN DISP FOR 4.5/8.5MM BEAMING SYS,SUP-2223914,CDM,2720000010,LOCAL,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
PROSTHESIS OTO L 3X5MM PART MALL FLX H/A,SUP-2277549,CDM,L8613,CPT,0278,RC,,,,both,,,2634.65,1712.52,,,,,,,,,,,,,
SCREW INTRF L 23 MM DIA 6 MM CITREGEN ANK FT TEND FIX RESRB,SUP-2900582,CDM,C1713,HCPCS,0278,RC,,,,both,,,2565.38,1667.50,,,,,,,,,,,,,
SHEATH INTRO PRELUDE SNAP L 13CM DIA10FR HYDRPHLC NO SIDEPRT,SUP-2743277,CDM,C1769,HCPCS,0272,RC,,,,both,,,195.94,127.36,,,,,,,,,,,,,
HC Ot Ther Ex per 15 Min|OP PT SERVICES|DOCUMENTATION ON FILE|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS,PX-4309711000,CDM,97110,CPT,0430,RC,,,GP|KX|CQ,both,,,195.00,126.75,,,,,,,,,,,,,
SET INTRO ARW SHTH L 4 IN DIA 6 FR GUIDEWIRE L 45 CM DIA,SUP-2384381,CDM,C1894,HCPCS,0272,RC,,,,both,,,72.16,46.90,,,,,,,,,,,,,
SCREW BNE CANN 2X6 MM LAG PARTIALLY THRD TI DK BLU,SUP-2392831,CDM,C1713,HCPCS,0278,RC,,,,both,,,438.03,284.72,,,,,,,,,,,,,
BALLOON SIL 9FR W/ CHECKVALVE T3103A,SUP-2214693,CDM,2720000010,LOCAL,0272,RC,,,,both,,,511.82,332.68,,,,,,,,,,,,,
HC Gbl Anl Sp Inf Pmp W/Mdreprg&Fil,PX-9826237000,CDM,62370,CPT,0982,RC,,,,both,,,1214.00,789.10,,,,,,,,,,,,,
PACK ORTH INSTR OVR DRL COMPR SLV RECTANGULAR DRVR FOR 4 MM,SUP-2902446,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1624.64,1056.02,,,,,,,,,,,,,
COIL VASC I-ED COIL L 40 CM DIA 0.014 IN SECONDARY 10 MM,SUP-2865314,CDM,C1889,HCPCS,0278,RC,,,,both,,,6594.00,4286.10,,,,,,,,,,,,,
SHEATH GUID R2P DESTINATION SLENDER L 80 CM WORKING L 75 CM,SUP-2615637,CDM,C1894,HCPCS,0272,RC,,,,both,,,1003.23,652.10,,,,,,,,,,,,,
PORT IMPL INFUSION OPN END 9.6 FR 1 LUMEN VEN CATH X-PORT,SUP-2127752,CDM,C1751,HCPCS,0278,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
TUBE VENT L5MM FLNG L2MM LUMN DIA135MM INNR EAR PC SIL FOR,SUP-2232492,CDM,L8699,HCPCS,0278,RC,,,,both,,,93.57,60.82,,,,,,,,,,,,,
STIMULATOR NERVE PT PRGMR EON,SUP-2355981,CDM,C1787,HCPCS,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
CANNULA DRNGE 20DEG W/ DIL ANGIOVAC,SUP-2420159,CDM,2720000010,LOCAL,0272,RC,,,,both,,,40820.00,26533.00,,,,,,,,,,,,,
BLADE SURG 7 LT MIDLN MAST MIDLF,SUP-2631589,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2132.85,1386.35,,,,,,,,,,,,,
PLATE BNE L MED 1 MM RT LCK TI,SUP-2477583,CDM,C1713,HCPCS,0278,RC,,,,both,,,919.17,597.46,,,,,,,,,,,,,
JOINT EXT FIX UNIV NS DISP MONK RING,SUP-2899260,CDM,2720000010,LOCAL,0272,RC,,,,both,,,854.87,555.67,,,,,,,,,,,,,
PASSER SUT RT CVD FIRSTPASS MINI,SUP-2419530,CDM,2720000010,LOCAL,0272,RC,,,,both,,,906.68,589.34,,,,,,,,,,,,,
MIDAZOLAM 100 MG/100ML IV SOLN,RX-151967,CDM,J2250,HCPCS,0636,RC,69374-0314-10,NDC,,both,100,ML,121.40,78.91,,,,,,,,,,,,,
GRAFT BNE SPNG 14X14X14 MM BLOCK CANC DBM,SUP-2354411,CDM,C1713,HCPCS,0278,RC,,,,both,,,6210.92,4037.10,,,,,,,,,,,,,
GRAFT VASC HEMSHLD PLAT L 60 CM 28MM POLYESTER BOV CLLGN STR,SUP-2265931,CDM,C1768,CPT,0278,RC,,,,both,,,2342.44,1522.59,,,,,,,,,,,,,
NEEDLE INSUFFLATION VERES 2.1X150 MM 1.6 MM DSTL TIP,SUP-2850590,CDM,2720000010,LOCAL,0272,RC,,,,both,,,351.93,228.75,,,,,,,,,,,,,
HINGE EXT FIX STD S STL FEM FOR ILIZ TAY SPAT FRME EXT FIX,SUP-2342292,CDM,2720000010,LOCAL,0272,RC,,,,both,,,791.91,514.74,,,,,,,,,,,,,
SUPPORT ORTHOT FT CUST INSRT REMOVABLE UCB TYP BERK SHELL,SUP-2435700,CDM,L3000,HCPCS,0274,RC,,,,both,,,889.37,578.09,,,,,,,,,,,,,
ANCHOR SUT DIA5MM DRL 28MM BLK HNDL SELF PUNCHING W TWO,SUP-2167268,CDM,C1713,HCPCS,0278,RC,,,,both,,,2135.20,1387.88,,,,,,,,,,,,,
NAIL IM L360MM DIA13MM FEM TIB KNEE G TI CANN LOK AG RG,SUP-2347118,CDM,C1713,HCPCS,0278,RC,,,,both,,,2877.34,1870.27,,,,,,,,,,,,,
SITAGLIPTIN PHOSPHATE 50 MG PO TABS,RX-77616,CDM,6370000000,HCPCS,0637,RC,00006-0112-28,NDC,,both,1,UN,49.50,32.17,,,,,,,,,,,,,
PLATE BNE ANGLED 2 MM LT 7X23 HOLE RECON PT SPEC,SUP-2860074,CDM,C1713,HCPCS,0278,RC,,,,both,,,23122.96,15029.92,,,,,,,,,,,,,
BLOCK TIB AUG CONSTRN 64X5 MM CNDYL KNEE,SUP-2205993,CDM,C1776,CPT,0278,RC,,,,both,,,5875.57,3819.12,,,,,,,,,,,,,
GRAFT HUM TISS FRZN HEMI PAT LIGMNT,SUP-2113903,CDM,C1713,HCPCS,0278,RC,,,,both,,,8870.50,5765.82,,,,,,,,,,,,,
KIT CAGE SPINAL APREVO 5-LEVEL,SUP-2912826,CDM,C1889,HCPCS,0278,RC,,,,both,,,157000.00,102050.00,,,,,,,,,,,,,
KNEE IMMOB 22IN QUAL + M,SUP-2195532,CDM,L1830,CPT,0272,RC,,,,both,,,60.92,39.60,,,,,,,,,,,,,
BELT RIB ELAS FOAM FEM UNIV 6IN,SUP-2194538,CDM,L0220,HCPCS,0274,RC,,,,both,,,30.21,19.64,,,,,,,,,,,,,
SCREW BONE LOCKING 2X12 MM MANDIBULAR SELFTAPPING 20/PK TITA,SUP-2842331,CDM,C1713,HCPCS,0278,RC,,,,both,,,475.52,309.09,,,,,,,,,,,,,
HC MRI-Pelvis WO & W Contrast,PX-6147219700,CDM,72197,CPT,0614,RC,,,,both,,,5187.00,3371.55,,,,,,,,,,,,,
HYPERFORM 7X15 MM BLLN SYSTEM,SUP-2676312,CDM,C2628,HCPCS,0272,RC,,,,both,,,5630.02,3659.51,,,,,,,,,,,,,
TUNNELER NEUROSTIMULATOR L28CM FOR SPNL CRD STIM SYS,SUP-2138849,CDM,2720000010,LOCAL,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
BRONCHOSCOPE RIGID THE GALAXY SYS,SUP-2885099,CDM,C1601,HCPCS,0272,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
PLATE BNE W8XL36MM THK2MM 0DEG 4 H BILAT S STL STR RIG DYN,SUP-2186175,CDM,C1713,HCPCS,0278,RC,,,,both,,,435.02,282.76,,,,,,,,,,,,,
HC NM Peritoneal Venous Shunt Paten,PX-3407829100,CDM,78291,CPT,0340,RC,,,,both,,,2204.00,1432.60,,,,,,,,,,,,,
WIRE FIX 1.5X20 MM KIT SIMP SAFE RESRB SOL K,SUP-2166910,CDM,C1713,HCPCS,0278,RC,,,,both,,,582.97,378.93,,,,,,,,,,,,,
CEMENT BNE FULL DOSE 20 CC TOBRA SIMPLEX P -SINGLE PK,SUP-2636351,CDM,C1713,HCPCS,0278,RC,,,,both,,,832.10,540.86,,,,,,,,,,,,,
SCREW BNE L20MM DIA3.5MM CORT FT ANK TI NONLOCKING FULL,SUP-2398303,CDM,C1713,HCPCS,0278,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
BINDER ABD XL W15IN 62 74IN CIRC UNISX 5 PNL E CNTCT CLSR,SUP-2197130,CDM,L3650,HCPCS,0272,RC,,,,both,,,70.18,45.62,,,,,,,,,,,,,
PLATE BNE L73MM THK3.3MM 6 H BILAT S STL RIG STR DYN COMPR,SUP-2186330,CDM,C1713,HCPCS,0278,RC,,,,both,,,937.79,609.56,,,,,,,,,,,,,
CURETTE KYPHOPLASTY SZ 3 DIA6.5MM WDG TIP FOR VERTPLSTY,SUP-2293447,CDM,2720000010,LOCAL,0272,RC,,,,both,,,607.90,395.13,,,,,,,,,,,,,
PATCH CV IMPRA L 30 X W 30 MM THK 0.6 MM EPTFE RECTANGULAR,SUP-2761260,CDM,C1768,CPT,0278,RC,,,,both,,,857.22,557.19,,,,,,,,,,,,,
BOOT WALKING SURG,SUP-2265017,CDM,L3260,HCPCS,0272,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
PLEDGET CV L 1 X W 15.2 CM THK 2.87 MM PTFE FELT LO POROSITY,SUP-2761314,CDM,C1768,CPT,0278,RC,,,,both,,,88.23,57.35,,,,,,,,,,,,,
CUP ACET OD56MM ID36MM 0DEG HIP UHMWPE CONSTRN STD FACE,SUP-2403895,CDM,C1776,CPT,0278,RC,,,,both,,,5400.80,3510.52,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 70 CM DIA 8 MM STR STD WALL REINF,SUP-2695225,CDM,C1768,CPT,0278,RC,,,,both,,,1236.25,803.56,,,,,,,,,,,,,
SCREW BNE ST 2.7X18 MM CORTICAL W/ T8 SS NS,SUP-2183600,CDM,C1713,HCPCS,0278,RC,,,,both,,,63.08,41.00,,,,,,,,,,,,,
GRAFT VASC HEMSHLD PLAT L 50 CM DIA26 MM BRANCH SZ 10 MM,SUP-2227364,CDM,C1768,CPT,0278,RC,,,,both,,,4510.42,2931.77,,,,,,,,,,,,,
KNIFE SURG 10MM GRFT DISP FOR ACL RECON,SUP-2249532,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1155.21,750.89,,,,,,,,,,,,,
PLATE BONE 90MM STR PAN FIX COND VIT,SUP-2364699,CDM,C1713,HCPCS,0278,RC,,,,both,,,715.92,465.35,,,,,,,,,,,,,
ELECTRODE ELECSURG 24 FR CUT LOOP RT ANGLED,SUP-2313975,CDM,C1713,HCPCS,0278,RC,,,,both,,,2292.20,1489.93,,,,,,,,,,,,,
HC So Osmolality Serum,PX-3018393066,CDM,83930,CPT,0301,RC,,,,outpatient,,,26.00,16.90,,,,,,,,,,,,,
STAPLE SPNL ANTR ANTR SYS S STL COLORADO 2,SUP-2290569,CDM,C1713,HCPCS,0278,RC,,,,both,,,1661.06,1079.69,,,,,,,,,,,,,
GRAFT VASC INTERGARD BODY/BRANCH L 100/60 CM DIA10 X 10 MM,SUP-2914832,CDM,C1762,CPT,0278,RC,,,,both,,,3015.34,1959.97,,,,,,,,,,,,,
BLADE SAW 296 37 133S4 W TPS RECIP NOTCH,SUP-2363310,CDM,2720000010,LOCAL,0272,RC,,,,both,,,508.68,330.64,,,,,,,,,,,,,
CLAMP REPROC EXT FIX L DIA11MM C FBR CLP ON SELF HLD MRI COMPATIBLE,SUP-2188496,CDM,2720000010,LOCAL,0272,RC,,,,both,,,466.48,303.21,,,,,,,,,,,,,
PLATE SPNL OCC SM EL CAPITAN NORTHSTAR,SUP-2710863,CDM,C1713,HCPCS,0278,RC,,,,both,,,5730.50,3724.82,,,,,,,,,,,,,
GRAFT DERMAL PLIABLE THN XL 24X15 CMX0.7-1.4 MM KT FLEXHD,SUP-2307609,CDM,C1713,HCPCS,0278,RC,,,,both,,,37233.49,24201.77,,,,,,,,,,,,,
INSERT TIB OFFSET,SUP-2405432,CDM,C1776,CPT,0278,RC,,,,both,,,464.72,302.07,,,,,,,,,,,,,
PLATE BNE THK13MM DORS HND TI 6 H LOK COMPR MAL FOR 23MM,SUP-2107089,CDM,C1713,HCPCS,0278,RC,,,,both,,,1403.58,912.33,,,,,,,,,,,,,
GRAFT 10MM WDG,SUP-2244474,CDM,C1713,HCPCS,0278,RC,,,,both,,,6006.73,3904.37,,,,,,,,,,,,,
COMPONENT FEM 10X35 MM KNEE W/ INSRTR APERFIX,SUP-2431667,CDM,C1776,CPT,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
KIT INFL SYR TBNG L13IN 20ML PRSS 30ATM BAR CLR POLYCARB,SUP-2257637,CDM,C1894,HCPCS,0272,RC,,,,both,,,163.22,106.09,,,,,,,,,,,,,
PLATE BNE L W13.5XL160MM THK4.2MM 9 H BILAT TI STR RIG,SUP-2190817,CDM,C1713,HCPCS,0278,RC,,,,both,,,622.85,404.85,,,,,,,,,,,,,
GRAFT SPNL ALLGRFT,SUP-2293972,CDM,C1713,HCPCS,0278,RC,,,,both,,,2041.00,1326.65,,,,,,,,,,,,,
HC Rcnstj Polydactylous Digit Soft Tissue & Bone,PX-3602658700,CDM,26587,CPT,0360,RC,,,,outpatient,,,9955.00,6470.75,,,,,,,,,,,,,
SHEATH INTRO L81CM DIA8FR 0.032IN SL1 CRV TRANSSEPTAL BRAID,SUP-2357253,CDM,C1893,HCPCS,0272,RC,,,,both,,,806.98,524.54,,,,,,,,,,,,,
PROBE LASER ASPIR 25 GA CRV PRECIS FIBER CENTERING,SUP-2466730,CDM,2720000010,LOCAL,0272,RC,,,,both,,,352.68,229.24,,,,,,,,,,,,,
ALLOGRAFT DERMAL THN 4X4 CM MTRX MIAMI,SUP-2321687,CDM,C1713,HCPCS,0278,RC,,,,both,,,5731.13,3725.23,,,,,,,,,,,,,
GUIDEWIRE VASC L145CM DIA0.014IN EXTN ADDWIRE 5 PK,SUP-2143722,CDM,C1769,HCPCS,0272,RC,,,,both,,,229.85,149.40,,,,,,,,,,,,,
SCREW MTO SFT SLK STRL 11MM X 25MM,SUP-2754805,CDM,C1713,HCPCS,0278,RC,,,,both,,,1519.92,987.95,,,,,,,,,,,,,
PLATE BNE W102XL130MM THK27MM 10 H BILAT S STL STR LO PROF,SUP-2420784,CDM,C1713,HCPCS,0278,RC,,,,both,,,1478.50,961.02,,,,,,,,,,,,,
HC Rheumatoid Factor Quantitative,PX-3028643100,CDM,86431,CPT,0302,RC,,,,both,,,347.00,225.55,,,,,,,,,,,,,
BLOCK CUT TIB MYKNEE R MED SZ 4 ST,SUP-2267765,CDM,2720000010,LOCAL,0272,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
WASHER ORTH CANN 4.6X10 MM FOR BNE SCR,SUP-2657750,CDM,C1713,HCPCS,0278,RC,,,,both,,,357.96,232.67,,,,,,,,,,,,,
PIN EXT FIX L120MM DIA5MM THRD L35MM CORT S STL ST SELF DRL,SUP-2372356,CDM,C1713,HCPCS,0278,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
OBTURATOR ENDOSCP BOAT NOSE NS ECTRA II LTX,SUP-2877787,CDM,2720000010,LOCAL,0272,RC,,,,both,,,412.13,267.88,,,,,,,,,,,,,
CATHETER LA6JR405 LA 6F 5PK 100 JR40,SUP-2429762,CDM,C1887,HCPCS,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
VALVE AORT PORCINE BIOPROSTHESIS 25MM CARPENTIER,SUP-2214049,CDM,C1713,HCPCS,0278,RC,,,,both,,,13973.00,9082.45,,,,,,,,,,,,,
PLATE BNE W12XL232MM THK3.7MM LNG 10 H ST PROX HUM S STL,SUP-2186022,CDM,C1713,HCPCS,0278,RC,,,,both,,,5046.70,3280.35,,,,,,,,,,,,,
TAP SURG UNIV 13 MM BIT HELIX ACP,SUP-2434167,CDM,2720000010,LOCAL,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
PLATE SPNL 60 MM INVIZIA,SUP-2414425,CDM,C1713,HCPCS,0278,RC,,,,both,,,6964.52,4526.94,,,,,,,,,,,,,
CLAMP EXT FIX PIN UNIV,SUP-2749970,CDM,2720000010,LOCAL,0272,RC,,,,both,,,649.98,422.49,,,,,,,,,,,,,
K WIRE FIX L8IN DIA1.1MM BVL TIP SMOOTH SPADE PNT SPHERX,SUP-2311267,CDM,C1713,HCPCS,0278,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
VEST PT SURG ASST CERV HALO,SUP-2265013,CDM,L0810,HCPCS,0274,RC,,,,both,,,21195.00,13776.75,,,,,,,,,,,,,
PLATE POLYAXIAL LK CUBOID T8,SUP-2704973,CDM,C1713,HCPCS,0278,RC,,,,both,,,4611.40,2997.41,,,,,,,,,,,,,
HC So2 Detect Agent Nos Dna Amp,PX-3068779868,CDM,87798,CPT,0306,RC,,,,inpatient,,,855.00,555.75,,,,,,,,,,,,,
PACK EYE CUST 23GA PPK571802] ALCON LABORATORIES INC],SUP-2110964,CDM,C1713,HCPCS,0278,RC,,,,both,,,1836.24,1193.56,,,,,,,,,,,,,
GUIDEWIRE VASC L145CM L95MM OD0038IN L3CM 3MM RAD S STL PTFE,SUP-2167908,CDM,C1769,HCPCS,0272,RC,,,,both,,,66.47,43.21,,,,,,,,,,,,,
CHOLANGIOGRAM KIT RX AUTOTOME UTOM XL SPHINTOM JAGWIRE 7148,SUP-2525313,CDM,C1769,HCPCS,0272,RC,,,,both,,,813.26,528.62,,,,,,,,,,,,,
ROD SPNL POST RT CVD SMOOTH 3.5MM DIA 60MM LEN,SUP-2317561,CDM,C1713,HCPCS,0278,RC,,,,both,,,668.82,434.73,,,,,,,,,,,,,
GRAFT BNE GRAN 4 CC CORTICAL CANC,SUP-2307035,CDM,2780000010,LOCAL,0278,RC,,,,both,,,1538.60,1000.09,,,,,,,,,,,,,
CATHETER CV FULL TY 025 5 FRX5 CM 16 GA 3L STR NDL SPECTRUM,SUP-2759862,CDM,C1751,HCPCS,0278,RC,,,,both,,,522.34,339.52,,,,,,,,,,,,,
SHUNT VENTRICULOPERITONEAL 120CM L VLV CEREB SPNL FLD,SUP-2244313,CDM,C1889,HCPCS,0278,RC,,,,both,,,16069.58,10445.23,,,,,,,,,,,,,
PENICILLIN G POTASSIUM 5000000 UNITS IJ SOLR|DISCARDED DRUG NOT ADMINISTE,RX-6086,CDM,J2540,HCPCS,0636,RC,00049-0520-22,NDC,JW,both,1,UN,54.10,35.16,,,,,,,,,,,,,
CATHETER INTRAAORTIC BLLN 75 FR 25 CC W/ KONTRON LINEAR,SUP-2227230,CDM,C1725,HCPCS,0272,RC,,,,both,,,2543.31,1653.15,,,,,,,,,,,,,
TUBE FEED 18FR CLR SIL GASTRO ENTERIC EXT RETEN RNG JEJU,SUP-2124601,CDM,2720000010,LOCAL,0272,RC,,,,both,,,564.92,367.20,,,,,,,,,,,,,
VALVE CSF PROGRAMMABLE 70 MM PRECIS REG CATH W/ SIPHONGUARD,SUP-2666507,CDM,C1889,HCPCS,0278,RC,,,,both,,,3866.91,2513.49,,,,,,,,,,,,,
GRAFT BNE SUB 5ML SIL SOD CA PHOS OXIDE FOAM PK RECT CONT,SUP-2368183,CDM,C1713,HCPCS,0278,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
CATHETER KIT OPN TIP 84 CM LUMBAR IMPREG TUOHY NDL HUBER,SUP-2664453,CDM,C1729,HCPCS,0272,RC,,,,both,,,1491.44,969.44,,,,,,,,,,,,,
METRONIDAZOLE (FLAGYL) IVPB (PEDS),RX-4085042,CDM,J1836,HCPCS,0636,RC,99999-9913-19,NDC,,both,50,ML,54.10,35.16,,,,,,,,,,,,,
NEEDLE SPNL TUOHY 14 GAX15.2 CM STRL,SUP-2851434,CDM,2720000010,LOCAL,0272,RC,,,,both,,,347.69,226.00,,,,,,,,,,,,,
VALVE CSF PROGRAMMABLE REG RT ANGLE W/ SIPHONGUARD HAKIM,SUP-2666511,CDM,C1889,HCPCS,0278,RC,,,,both,,,16468.70,10704.65,,,,,,,,,,,,,
GUIDEWIRE VASC L150CM OD.038IN NIT HYDRPHLC ANG STIFF TAPR,SUP-2139350,CDM,C1769,HCPCS,0272,RC,,,,both,,,165.60,107.64,,,,,,,,,,,,,
PLATE BNE STR MINI XL 2-2.5X1 MM 22 MM 4 HOLE LCK TLTS TI,SUP-2481118,CDM,C1713,HCPCS,0278,RC,,,,both,,,1712.46,1113.10,,,,,,,,,,,,,
GRAFT BONE SUB 2CC DEMIN BONE MTRX PASTE STAGRFT,SUP-2137252,CDM,C1713,HCPCS,0278,RC,,,,both,,,1584.76,1030.09,,,,,,,,,,,,,
GRAFT BNE 15 CC CELLULAR BNE MTRX OSSEOGEN,SUP-2858502,CDM,C1713,HCPCS,0278,RC,,,,both,,,12446.18,8090.02,,,,,,,,,,,,,
SCREW BONE L90MM OD10.5MM TI HIP U BLDE LAG FOR GAMMA3 NAIL,SUP-2362205,CDM,C1713,HCPCS,0278,RC,,,,both,,,3035.60,1973.14,,,,,,,,,,,,,
CAP NERVE AXOGUARD 2MM X 15MM,SUP-2707506,CDM,C1763,HCPCS,0278,RC,,,,both,,,6568.88,4269.77,,,,,,,,,,,,,
CYSTOSCOPE ASCOPE 4 CYSTO REVERSE SINGLE USE,SUP-2884333,CDM,2720000010,LOCAL,0272,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
IMPLANT L9MM OD4MM ABUTMENT FIX CONN SCR BONE ANCHORED,SUP-2319881,CDM,L8690,HCPCS,0278,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
BEARING TOE SM PHLANG MTL BK IMPL,SUP-2404750,CDM,C1713,HCPCS,0278,RC,,,,both,,,2449.20,1591.98,,,,,,,,,,,,,
MESH SURG 20 X 20.5 CM SUTURE SZ 6-0 OVINE PGA REINF TISS,SUP-2914816,CDM,C1781,HCPCS,0278,RC,,,,both,,,23179.48,15066.66,,,,,,,,,,,,,
ENDOSCOPIC KIT SIDP,SUP-2121761,CDM,2720000010,LOCAL,0272,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
PACEMAKER CARD ALTURA 40 TI 2 CHMBR 1 LD BATTERY PWR STRL,SUP-2149116,CDM,C1785,HCPCS,0275,RC,,,,both,,,14444.00,9388.60,,,,,,,,,,,,,
ENDCAP SPINAL 5MM PHOENIX,SUP-2497351,CDM,C1713,HCPCS,0278,RC,,,,both,,,483.56,314.31,,,,,,,,,,,,,
HC Endo Level 1 Base 15 Min,PX-3600007501,CDM,3600007501,LOCAL,0360,RC,,,,both,,,3939.00,2560.35,,,,,,,,,,,,,
KIT SCR L25MM DIA9MM W/ BICEPTOR BIOSURE,SUP-2341828,CDM,C1713,HCPCS,0278,RC,,,,both,,,1186.92,771.50,,,,,,,,,,,,,
BOLT FIX HALF PIN UNIV,SUP-2197244,CDM,C1713,HCPCS,0278,RC,,,,both,,,847.80,551.07,,,,,,,,,,,,,
SCREW SPNL MONOAX 6.5X35 MM PEDCL,SUP-2175442,CDM,C1713,HCPCS,0278,RC,,,,both,,,3579.60,2326.74,,,,,,,,,,,,,
DISTRACTOR SURG L 35 MM INTRAORAL MANDIBULAR FRME NS,SUP-2883457,CDM,C1713,HCPCS,0278,RC,,,,both,,,15299.40,9944.61,,,,,,,,,,,,,
BRACE KNEE AD UNIV FOAM POSTOP 1 SZ FIT MOST AVG LEN FASTEN,SUP-2195290,CDM,L1810,HCPCS,0274,RC,,,,both,,,310.23,201.65,,,,,,,,,,,,,
PLATE BNE CERV SM 2.7X84 MM 10 HOLE TI,SUP-2536119,CDM,C1713,HCPCS,0278,RC,,,,both,,,474.77,308.60,,,,,,,,,,,,,
PILLAR EXT FIX L 400 MM THRD MONK RING,SUP-2899175,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1856.53,1206.74,,,,,,,,,,,,,
TUBE JEJUNOSTOMY FEED 18 FR 2.7 CM 5 CC EXTN SET LP MIC-KEY,SUP-2764478,CDM,2720000010,LOCAL,0272,RC,,,,both,,,545.95,354.87,,,,,,,,,,,,,
CATHETER BLLN 95 CM GUIDE EMBOGUARD,SUP-2854947,CDM,C1725,HCPCS,0272,RC,,,,both,,,8042.51,5227.63,,,,,,,,,,,,,
STEM FEM SZ 10.5 LT L BODY FULL TEXT APR,SUP-2210949,CDM,C1776,CPT,0278,RC,,,,both,,,10389.63,6753.26,,,,,,,,,,,,,
LEAD PACE AJ ENDO RA IS-1 CONN UPLR SIL INSUL SELUTE,SUP-2148641,CDM,C1898,HCPCS,0275,RC,,,,both,,,2555.96,1661.37,,,,,,,,,,,,,
CATHETER DRAINAGE VLV 5 FRX15 CM 1 STP,SUP-2303184,CDM,C1729,HCPCS,0272,RC,,,,both,,,54.17,35.21,,,,,,,,,,,,,
ENDO FUSE  FUSION ROD 3 X 30MM,SUP-2469817,CDM,C1713,HCPCS,0278,RC,,,,both,,,4016.06,2610.44,,,,,,,,,,,,,
LINER ACET CUP 26 MM ID 0 DEG CERAMIC ON POLY SZ E LTX FRE,SUP-2202729,CDM,C1776,CPT,0278,RC,,,,both,,,3422.60,2224.69,,,,,,,,,,,,,
SCREW C806 CCD CL IMP 6MM PLG C806,SUP-2280605,CDM,C1713,HCPCS,0278,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
TRIAL KNEE SZ 3 L FEM TRIATHLON PS,SUP-2363725,CDM,C1776,CPT,0278,RC,,,,both,,,1908.34,1240.42,,,,,,,,,,,,,
NEEDLE KIT SR061123,SUP-2737858,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
HC Ph Body Fluid Not Elsewhere Specified,PX-3018398600,CDM,83986,CPT,0301,RC,,,,both,,,86.00,55.90,,,,,,,,,,,,,
BIT DRL DIA5.2MM FOR 7MM CANN SCR,SUP-2343599,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3259.01,2118.36,,,,,,,,,,,,,
GUIDE BLOCK FOR LCP(TM) DISTAL FEMUR PLATES-RIGHT,SUP-2548289,CDM,C1713,HCPCS,0278,RC,,,,both,,,1530.28,994.68,,,,,,,,,,,,,
DISTRACTOR EXT FIX 20 MM 1 - 1.2 MM 9 MM END DRIVEN SQ MESH,SUP-2477760,CDM,C1713,HCPCS,0278,RC,,,,both,,,19739.26,12830.52,,,,,,,,,,,,,
PLATE BNE L44MM THK1.3MM 2X6 H CNDYL HND 316L S STL VAR ANG,SUP-2178038,CDM,C1713,HCPCS,0278,RC,,,,both,,,1784.40,1159.86,,,,,,,,,,,,,
PLATE BNE L168MM THK3.7MM 8 H NONSTERILE R DST MED TIB S,SUP-2185529,CDM,C1713,HCPCS,0278,RC,,,,both,,,3820.88,2483.57,,,,,,,,,,,,,
KIT REP HAD BLNT TRCR TUNN X L,SUP-2116793,CDM,C1713,HCPCS,0278,RC,,,,both,,,69.08,44.90,,,,,,,,,,,,,
KIT INSTR APREVO,SUP-2912093,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
TITANIUM MESH PANEL ROUND CNTRD 100MM DIA 6MM 15MM SSTM CP,SUP-2681384,CDM,C1713,HCPCS,0278,RC,,,,both,,,5711.97,3712.78,,,,,,,,,,,,,
SHEATH INTRO FAST-CATH DIA 7 FR LNG HEMOSTATIC VLV SIDEPRT,SUP-2355556,CDM,C1894,HCPCS,0272,RC,,,,both,,,43.18,28.07,,,,,,,,,,,,,
SCREW BNE L5MM DIA2MM CRANIOMAXILLOFACIAL TI SELF RET,SUP-2262831,CDM,C1713,HCPCS,0278,RC,,,,both,,,333.59,216.83,,,,,,,,,,,,,
SCREW BONE L36MM DIA5MM ST LCK W/ T25 STARDRV,SUP-2190248,CDM,C1713,HCPCS,0278,RC,,,,both,,,531.32,345.36,,,,,,,,,,,,,
PLATE 3 HL TWST RINGFIX SYS,SUP-2704820,CDM,C1713,HCPCS,0278,RC,,,,both,,,414.48,269.41,,,,,,,,,,,,,
SPHINCTEROTOME ENDOSCP DOME 5.5 FR 0.021 IN 2.8 MM OMNI,SUP-2737409,CDM,2720000010,LOCAL,0272,RC,,,,both,,,766.16,498.00,,,,,,,,,,,,,
SET ORTH EXT FIX FOR SELF DRL SCHNZ SCR,SUP-2177077,CDM,2720000010,LOCAL,0272,RC,,,,both,,,56329.34,36614.07,,,,,,,,,,,,,
PLATE BONE LOCKING STERNAL 8 HOLE PRECONTOURED TITANIUM STER,SUP-2838433,CDM,C1713,HCPCS,0278,RC,,,,both,,,3123.67,2030.39,,,,,,,,,,,,,
GRAFT SFT TISS 13X6 CM PLIABLE PORCINE TISS MTRX STRATTICE,SUP-2488520,CDM,Q4130,HCPCS,0636,RC,,,,both,,,4650.34,3022.72,,,,,,,,,,,,,
BASKET EXTR STONE REM .021IN MULTIFILAMENT DBL LUMN 4W L4CM,SUP-2169335,CDM,2720000010,LOCAL,0272,RC,,,,both,,,486.70,316.35,,,,,,,,,,,,,
PLATE BNE 12 H BILAT ORBIT RIM TI LO PROF RIG NEUT,SUP-2191242,CDM,C1713,HCPCS,0278,RC,,,,both,,,1059.44,688.64,,,,,,,,,,,,,
DEVICE FILTRATION GLAUCOMA MINI SHUNT EX-PRESS,SUP-2110073,CDM,C1783,HCPCS,0278,RC,,,,both,,,3124.30,2030.79,,,,,,,,,,,,,
BIT DRL DIA4.5/3.2MM STP TAPR FOR SALVATION SYS,SUP-2400807,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1237.16,804.15,,,,,,,,,,,,,
BLOCK CANC TRAD ALLGRFT 30 MM LX20 MM WX20 MM H FRZ DRY,SUP-2294054,CDM,C1713,HCPCS,0278,RC,,,,both,,,2474.32,1608.31,,,,,,,,,,,,,
HC Mra Chest W&W/O Contrast,PX-6107155502,CDM,C8911,CPT,0610,RC,,,,inpatient,,,4146.00,2694.90,,,,,,,,,,,,,
WIRE BNE FIX L 23 MM SHRT FT COMPR NS A.L.P.S.,SUP-2211521,CDM,C1713,HCPCS,0278,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
ROTH NET RETRIEVER 360,SUP-2720127,CDM,2720000010,LOCAL,0272,RC,,,,both,,,324.99,211.24,,,,,,,,,,,,,
DEFIBRILLATOR CARD SGL CHMBR C HD ATLS + VR,SUP-2357746,CDM,C1722,HCPCS,0275,RC,,,,both,,,37366.00,24287.90,,,,,,,,,,,,,
GRAFT BNE SUB 15ML GROWTH FACT GRAN OSTEOAMP,SUP-2138499,CDM,C1713,HCPCS,0278,RC,,,,both,,,7755.80,5041.27,,,,,,,,,,,,,
MESH HERN SQ 1 50X50 CM MONOFILAMENT 3D TEXTILE VERSATEX,SUP-2752221,CDM,C1781,HCPCS,0278,RC,,,,both,,,3172.15,2061.90,,,,,,,,,,,,,
DEVICE VASC DISC BRTRC PT COMFORT COMPRESSAR,SUP-2337148,CDM,2720000010,LOCAL,0272,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
KIT REP PELV FLR ANTR APCL PINN,SUP-2141761,CDM,C1771,HCPCS,0278,RC,,,,both,,,5843.54,3798.30,,,,,,,,,,,,,
PLATE BNE W16XL267MM BLDE L70MM THK48MM 95DEG 16 H ST BILAT,SUP-2185493,CDM,C1713,HCPCS,0278,RC,,,,both,,,5623.90,3655.53,,,,,,,,,,,,,
ALLOGRAFT DISC PART DBM AND CORT CANC BONE CHIP FRZN,SUP-2223557,CDM,C1762,CPT,0278,RC,,,,both,,,6374.20,4143.23,,,,,,,,,,,,,
GRAFT BONE SUB 20ML LESS THAN 2MM GROWTH FACT GRAN OSTEOAMP,SUP-2138494,CDM,C1713,HCPCS,0278,RC,,,,both,,,8792.00,5714.80,,,,,,,,,,,,,
BOLT SURG 3.5X30 MM ANTI-DRIFT,SUP-2610689,CDM,C1713,HCPCS,0278,RC,,,,both,,,777.15,505.15,,,,,,,,,,,,,
HC Drain/Inj Joint/Bursa W/US,PX-5102060600,CDM,20606,CPT,0510,RC,,,,inpatient,,,1818.00,1181.70,,,,,,,,,,,,,
SYSTEM DELIVERY MEDICATION CATHETER MACY,SUP-2240139,CDM,C1751,HCPCS,0278,RC,,,,both,,,174.62,113.50,,,,,,,,,,,,,
PLATE BONE L71MM 5 H T SHP LCK 2 HD FOR 3.5MM SCR,SUP-2318680,CDM,C1713,HCPCS,0278,RC,,,,both,,,1860.01,1209.01,,,,,,,,,,,,,
HC Mra Chest W&W/O Contrast,PX-6107155502,CDM,C8911,CPT,0610,RC,,,,outpatient,,,4146.00,2694.90,,,,,,,,,,,,,
NAIL INTRMDLLRY 9MM DIA 320MML TTNM ALLOY FMRL RTRGRDE TRGTN,SUP-2587317,CDM,C1713,HCPCS,0278,RC,,,,both,,,5446.74,3540.38,,,,,,,,,,,,,
ELECTRODE ABLAT STARBURST 15,SUP-2118717,CDM,C1819,HCPCS,0278,RC,,,,both,,,5818.42,3781.97,,,,,,,,,,,,,
ELECTRODE ENDOSCP PLASMA NDL 12-30 DEG 24 FR LNG ESG TCRIS,SUP-2485562,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1627.12,1057.63,,,,,,,,,,,,,
HC Drain/Inj Joint/Bursa W/US,PX-4502060600,CDM,20606,CPT,0450,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
PLATE BONE THK1.5MM TI MAND 11 H PRI STR,SUP-2363731,CDM,C1713,HCPCS,0278,RC,,,,both,,,1889.59,1228.23,,,,,,,,,,,,,
STRIP TST 10X40 CM 35 GM FOR HERN TILENE,SUP-2402502,CDM,C1781,HCPCS,0278,RC,,,,both,,,1296.82,842.93,,,,,,,,,,,,,
SCREW BONE L65MM DIA4MM CANC T20 FULL THRD SM FRAG PLATING,SUP-2350003,CDM,C1713,HCPCS,0278,RC,,,,both,,,284.17,184.71,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.430,SUP-2859994,CDM,C1713,HCPCS,0278,RC,,,,both,,,42540.09,27651.06,,,,,,,,,,,,,
AMOXICILLIN-POT CLAVULANATE 875-125 MG PO TABS,RX-33228,CDM,6370000000,HCPCS,0637,RC,65862-0503-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
CUTTER SUTURE ARTHROSCOPY DISPOSABLE,SUP-2828668,CDM,2720000010,LOCAL,0272,RC,,,,both,,,315.66,205.18,,,,,,,,,,,,,
SYSTEM PRP 60ML FOR GENTLE CENTRIFUGATION ACT HI YLD,SUP-2223569,CDM,C1713,HCPCS,0278,RC,,,,both,,,2527.70,1643.00,,,,,,,,,,,,,
FILTER VASC TRAPEASE L 55 CM DIA 6 FR CAVA DIA 30 MM NIT JUG,SUP-2865606,CDM,C1880,HCPCS,0278,RC,,,,both,,,3372.36,2192.03,,,,,,,,,,,,,
ALLOGRAFT BNE CHIP 1-8 MM 30 CC CANC DBM POWER BIO,SUP-2718029,CDM,C1713,HCPCS,0278,RC,,,,both,,,8388.67,5452.64,,,,,,,,,,,,,
SCREW BONE L20MM DIA4.5MM CORT TI N ST N SELF DRL,SUP-2190345,CDM,C1713,HCPCS,0278,RC,,,,both,,,53.25,34.61,,,,,,,,,,,,,
ARM EXT FIX ACTIVATION 20 MM EMGCY EXTN RIGID REMOT DETACH,SUP-2499781,CDM,C1713,HCPCS,0278,RC,,,,both,,,2732.18,1775.92,,,,,,,,,,,,,
PLATE BNE L41MM +20DEG 3X3 H NONSTERILE DST DORS RAD S STL,SUP-2177506,CDM,C1713,HCPCS,0278,RC,,,,both,,,1917.22,1246.19,,,,,,,,,,,,,
SD BLADE15MM DRIVER XD58MM1SIDE BEVD,SUP-2676841,CDM,2720000010,LOCAL,0272,RC,,,,both,,,596.60,387.79,,,,,,,,,,,,,
PLATE BNE L85MM 7 H BILAT S STL COMPR FOR 3.5MM SCR,SUP-2411341,CDM,C1713,HCPCS,0278,RC,,,,both,,,393.29,255.64,,,,,,,,,,,,,
BRACE ANK OR FT L7-8IN CALF CIRC 15IN SM AD UNISX ACT W/ AMB,SUP-2332640,CDM,L4396,HCPCS,0274,RC,,,,both,,,202.53,131.64,,,,,,,,,,,,,
BIT DRL L125MM OD3.6MM GRY TIP W/O STP NONRADIOLUCENT BI,SUP-2373944,CDM,2720000010,LOCAL,0272,RC,,,,both,,,445.10,289.31,,,,,,,,,,,,,
BIT DRL TWST 1.5X20 MM 6 MM W/ STP DENT LATCH LEVEL 1 DISP,SUP-2475244,CDM,2720000010,LOCAL,0272,RC,,,,both,,,489.24,318.01,,,,,,,,,,,,,
PLATE BNE W16XL71MM 3 H L PROX HUM SHLDR S STL S3,SUP-2254093,CDM,C1713,HCPCS,0278,RC,,,,both,,,3815.10,2479.81,,,,,,,,,,,,,
PLATE SPNL ANCHR 50 MM OCPTL ASCNT POCT,SUP-2601973,CDM,C1713,HCPCS,0278,RC,,,,both,,,4038.04,2624.73,,,,,,,,,,,,,
PLATE BNE 24 DEG L 78 X W 8.5 MM THK 1.6 MM 5 H SS RT DSTL,SUP-2933082,CDM,C1713,HCPCS,0278,RC,,,,both,,,5110.35,3321.73,,,,,,,,,,,,,
PORT INFUS 14.3FR PERI TI ATTCH BASIC TY 2 SURECUF TISS,SUP-2127734,CDM,C1788,HCPCS,0278,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
OSSEON 10 GAUGE VERTEBROPLASTY CONVENIENCE PACK,SUP-2702139,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1161.80,755.17,,,,,,,,,,,,,
DEVICE SUCTION DIR BIOVAC,SUP-2736674,CDM,2720000010,LOCAL,0272,RC,,,,both,,,354.54,230.45,,,,,,,,,,,,,
BRACE ELBW TENNIS 1 SZ BLK INT FOAM PD LTWT HG80,SUP-2324093,CDM,L3702,HCPCS,0274,RC,,,,both,,,37.93,24.65,,,,,,,,,,,,,
HC So Assay of Volatiles,PX-3018460066,CDM,84600,CPT,0301,RC,,,,both,,,101.00,65.65,,,,,,,,,,,,,
BLADE SURG SAW SAG S STL 85MM LEN 19.5MM W 1.27MM THCK 85MM,SUP-2150770,CDM,2720000010,LOCAL,0272,RC,,,,both,,,642.76,417.79,,,,,,,,,,,,,
ALPROSTADIL 500 MCG/ML IJ SOLN,RX-9001,CDM,J0270,HCPCS,0636,RC,00009-3169-06,NDC,,both,1,ML,973.80,632.97,,,,,,,,,,,,,
HEAD HUM H21MM OD64MM ID54MM SHLDR CO CHROM MOD NECKLESS,SUP-2404506,CDM,C1776,CPT,0278,RC,,,,both,,,4684.88,3045.17,,,,,,,,,,,,,
GRAFT SCFLD W3XL3CM DERM REP MESHED PRIMATRIX,SUP-2243702,CDM,Q4110,HCPCS,0636,RC,,,,both,,,1632.80,1061.32,,,,,,,,,,,,,
PLATE BONE L W13.5XL178MM THK4.2MM 10 H BILAT TI STR RIG,SUP-2190819,CDM,C1713,HCPCS,0278,RC,,,,both,,,794.95,516.72,,,,,,,,,,,,,
BIT DRL 2.2X16 MM JCBS ANTR CERV PLATE SYS SKYLINE,SUP-2591625,CDM,2720000010,LOCAL,0272,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
BIT DRL L40MM DIA2MM SLD SIDE CUT FOR GEMINUS VOLAR DST RAD,SUP-2340179,CDM,2720000010,LOCAL,0272,RC,,,,both,,,200.96,130.62,,,,,,,,,,,,,
PAIN PMP,SUP-2363223,CDM,2720000010,LOCAL,0272,RC,,,,both,,,467.86,304.11,,,,,,,,,,,,,
SPACER TIB L12MM SM DURAMER SL GRDIAN,SUP-2304390,CDM,C1776,CPT,0278,RC,,,,both,,,4144.80,2694.12,,,,,,,,,,,,,
BIT DRL L58MM DIA1.9MM CRANIOMAXILLOFACIAL FOR 20MM,SUP-2366430,CDM,2720000010,LOCAL,0272,RC,,,,both,,,514.11,334.17,,,,,,,,,,,,,
PLATE BONE L15MM MAXILLOFACIAL DBL T NONCOMPRESSION FOR MINI,SUP-2364905,CDM,C1713,HCPCS,0278,RC,,,,both,,,437.72,284.52,,,,,,,,,,,,,
SCREW INTFR L25MM DIA7MM KT LOT BICEPTOR,SUP-2341826,CDM,C1713,HCPCS,0278,RC,,,,both,,,1152.38,749.05,,,,,,,,,,,,,
CATHETER ANGIO GLIDECATH L 100 CM DIA 4 FR DIA1.05 MM ANGLED,SUP-2385513,CDM,C1887,HCPCS,0272,RC,,,,both,,,88.71,57.66,,,,,,,,,,,,,
SHUNT SURG L 8.9 MM VENTRICULAR CATH L 250 MM PRESSURE 15 CM FV677T,SUP-2928851,CDM,C1889,HCPCS,0278,RC,,,,both,,,2992.04,1944.83,,,,,,,,,,,,,
COMPONENT FEM 5 CO CHROM LT KNEE UNISX PRI CEM,SUP-2346571,CDM,C1776,CPT,0278,RC,,,,both,,,10000.90,6500.58,,,,,,,,,,,,,
HC Cta Abdominal Aorta W Runoffs,PX-3527563500,CDM,75635,CPT,0352,RC,,,,both,,,1973.00,1282.45,,,,,,,,,,,,,
COUPLING ABUTMENT SNAP 5.5MM BAHA,SUP-2164928,CDM,L8614,HCPCS,0278,RC,,,,both,,,3846.50,2500.22,,,,,,,,,,,,,
HANDLE DETACH PENUMBRA COIL DH1] PENUMBRA INC],SUP-2323581,CDM,2720000010,LOCAL,0272,RC,,,,both,,,747.32,485.76,,,,,,,,,,,,,
ALLOGRAFT BNE CHIP 1.7-10 MM 90 CC FD CANC READIGRAFT,SUP-2740804,CDM,C1713,HCPCS,0278,RC,,,,both,,,3194.20,2076.23,,,,,,,,,,,,,
IMP SYS T-ROPE BTB-J W/10.5MM FLPCTR IIS,SUP-2811806,CDM,C1713,HCPCS,0278,RC,,,,both,,,2417.80,1571.57,,,,,,,,,,,,,
ALLOGRAFT BNE CHIP 4-9.5 MM 90 CC FD CANC,SUP-2717773,CDM,C1713,HCPCS,0278,RC,,,,both,,,2733.65,1776.87,,,,,,,,,,,,,
PLATE BNE L48MM THK075MM 12 H NONSTERILE HND TI STR LOK FOR,SUP-2180986,CDM,C1713,HCPCS,0278,RC,,,,both,,,1411.02,917.16,,,,,,,,,,,,,
CATHETER CV KT 7 FRX16 CM 20 GA 3L PRESSURE INJ RW INTRO,SUP-2763403,CDM,C1751,HCPCS,0278,RC,,,,both,,,219.17,142.46,,,,,,,,,,,,,
PORT IMPL INFUSION SINGLE LUMEN 8 FR AIRGUARD POWERPORT ISP,SUP-2126309,CDM,C1788,HCPCS,0278,RC,,,,both,,,910.60,591.89,,,,,,,,,,,,,
NAIL IM L200MM OD11.5MM 130DEG AG FOR INTERTROCHANTERIC FX,SUP-2347569,CDM,C1713,HCPCS,0278,RC,,,,both,,,5581.35,3627.88,,,,,,,,,,,,,
ANCHOR SUT DIA5MM PLLA W/ PRELD ULTRABRAID SUT TWINFIX,SUP-2341744,CDM,C1713,HCPCS,0278,RC,,,,both,,,824.91,536.19,,,,,,,,,,,,,
INBONE EVERLAST SZ 2+ 14MM TOTAL ANKLE,SUP-2822258,CDM,C1776,CPT,0278,RC,,,,both,,,6264.30,4071.79,,,,,,,,,,,,,
STENT ENDOPROS L15CM DIA8MM CATH 8FR L120CM 0.035IN VES,SUP-2396623,CDM,C1874,HCPCS,0278,RC,,,,both,,,12261.70,7970.10,,,,,,,,,,,,,
PLATE BNE FUSION LG CLOSED ALPS,SUP-2413841,CDM,C1713,HCPCS,0278,RC,,,,both,,,2015.13,1309.83,,,,,,,,,,,,,
CANNULA SUCTION KLEINSASSER 5 MMX26 CM COAG UPLR INSUL,SUP-2775055,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1106.10,718.96,,,,,,,,,,,,,
STENT CORONARY CYPHER L 23 MM DIA2.5 MM DEL SYS L 145 CM,SUP-2158698,CDM,C1874,HCPCS,0278,RC,,,,both,,,5589.20,3632.98,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL PEEK SD800.510,SUP-2860192,CDM,C1713,HCPCS,0278,RC,,,,both,,,28622.36,18604.53,,,,,,,,,,,,,
CATHETER CHRONIC TOT OCCL 180DEG 0.066INX150CM 20X2.75X1MM,SUP-2280835,CDM,C1887,HCPCS,0272,RC,,,,both,,,6594.00,4286.10,,,,,,,,,,,,,
PLATE BNE W12XL200MM THK25MM LNG 8 H NONSTERILE BILAT PROX,SUP-2190992,CDM,C1713,HCPCS,0278,RC,,,,both,,,5200.59,3380.38,,,,,,,,,,,,,
BIT DRL L266MM DIA16MM CANN L QUIK CPL FOR PROX FEM NAILING,SUP-2418559,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2369.85,1540.40,,,,,,,,,,,,,
BAR EXT FIX 6MM OFFSET FOR JET-X EXT FIX,SUP-2342917,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1385.84,900.80,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED CEM SCREW PIN HI FLX M HXLPE,SUP-2212708,CDM,C1776,CPT,0278,RC,,,,both,,,13073.77,8497.95,,,,,,,,,,,,,
CLIP HEMSTAS W11MMXL230CM WRK CHAN 2.8MM W/ 360DEG ROT,SUP-2418561,CDM,2720000010,LOCAL,0272,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 10X10X10 MM FUSIONFLEX,SUP-2759587,CDM,C1713,HCPCS,0278,RC,,,,both,,,1962.50,1275.62,,,,,,,,,,,,,
PLATE BNE 18 H NONSTERILE BILAT S STL NAR CRV LOK COMPR FOR,SUP-2178049,CDM,C1713,HCPCS,0278,RC,,,,both,,,2730.54,1774.85,,,,,,,,,,,,,
VALPROIC ACID 250 MG/5ML PO SOLN,RX-107385,CDM,6370000000,HCPCS,0637,RC,00121-4675-40,NDC,,both,5,ML,9.80,6.37,,,,,,,,,,,,,
POST EXT FIX 3 HOLE W/ THRD ATTCH,SUP-2749945,CDM,2720000010,LOCAL,0272,RC,,,,both,,,970.26,630.67,,,,,,,,,,,,,
TUBE ENTRL FEED GASTRO-JEJUNAL 18 FRX30 CM 7-10 CC MIC-KEY,SUP-2764492,CDM,2720000010,LOCAL,0272,RC,,,,both,,,737.62,479.45,,,,,,,,,,,,,
BRACE CLAV INTO JACKET VEST HALO,SUP-2388153,CDM,L0810,HCPCS,0272,RC,,,,both,,,6444.03,4188.62,,,,,,,,,,,,,
PLATE BNE L67MM 8 H BILAT S STL STR MINI FRAG ST LO PROF,SUP-2186377,CDM,C1713,HCPCS,0278,RC,,,,both,,,1632.42,1061.07,,,,,,,,,,,,,
DRESSING NSL L4CM SYN PROPRIETARY POLYMER FOAM STD,SUP-2367516,CDM,2720000010,LOCAL,0272,RC,,,,both,,,373.28,242.63,,,,,,,,,,,,,
PLATE BNE L212MM THK3.4MM 16 H BILAT S STL STR LOK COMPR,SUP-2185155,CDM,C1713,HCPCS,0278,RC,,,,both,,,1817.40,1181.31,,,,,,,,,,,,,
COIL EMB L40CM OD0.020IN LOOP OD14MM NIT STRTCH RESIST FILL,SUP-2323418,CDM,C1889,HCPCS,0278,RC,,,,both,,,7944.20,5163.73,,,,,,,,,,,,,
SCREW BNE LCK STD 4.5X25 MM,SUP-2875148,CDM,C1713,HCPCS,0278,RC,,,,both,,,1061.95,690.27,,,,,,,,,,,,,
MATRIX WND W7XL10CM TRI LAYR OASIS ULT,SUP-2341245,CDM,Q4124,HCPCS,0636,RC,,,,both,,,2559.23,1663.50,,,,,,,,,,,,,
SET SCR SPNL L3.17MM DIA0.25IN S STL DEV ISOLA,SUP-2255702,CDM,C1713,HCPCS,0278,RC,,,,both,,,263.76,171.44,,,,,,,,,,,,,
COMPONENT FEM SM RT KNEE ZPU LIBRA,SUP-2442381,CDM,C1776,CPT,0278,RC,,,,both,,,607.59,394.93,,,,,,,,,,,,,
SCREW BNE L115MM DIA9MM THRD L21MM DIA14.3MM SUP LAG CLASS,SUP-2342460,CDM,C1713,HCPCS,0278,RC,,,,both,,,2464.05,1601.63,,,,,,,,,,,,,
HEAD HUM DXTEND CTA D48 X 26MM,SUP-2512996,CDM,C1776,CPT,0278,RC,,,,both,,,7105.82,4618.78,,,,,,,,,,,,,
SCREW SPNL TI BRK OFF CLOSE CD HORZ ENGAGE,SUP-2293323,CDM,C1713,HCPCS,0278,RC,,,,both,,,527.52,342.89,,,,,,,,,,,,,
SYSTEM WST MGMT AVETA,SUP-2739119,CDM,2720000010,LOCAL,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
KIT INSTR DIA1.4MM INCL GUID DRL AND OBT DISP JUGGERKNOT,SUP-2212952,CDM,C1713,HCPCS,0278,RC,,,,both,,,946.02,614.91,,,,,,,,,,,,,
SEED BRACHYTHERAPY PALLADIUM 103 LOOSE VI THERASEED ST,SUP-2129127,CDM,C2641,HCPCS,0278,RC,,,,both,,,131.88,85.72,,,,,,,,,,,,,
LOOP ENDOSCP BPLR LG 200X100 MM FOR SUPRACERVICAL HYS STRL,SUP-2423020,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
KIT ENDO L15MM DIA9MM GUIDPIN GUID ROD INTRF SCR FOR,SUP-2341123,CDM,C1713,HCPCS,0278,RC,,,,both,,,1186.92,771.50,,,,,,,,,,,,,
PLATE BNE 130 DEG SHFT L 60 MM BLADE L 100 MM 4 H SS PROX,SUP-2907696,CDM,C1713,HCPCS,0278,RC,,,,both,,,2669.88,1735.42,,,,,,,,,,,,,
GUIDEWIRE ORTH FLUT 2.8X450 MM SLIPPED EPIPHYSIS SS NS LCP,SUP-2863441,CDM,C1769,HCPCS,0272,RC,,,,both,,,247.15,160.65,,,,,,,,,,,,,
BIT DRL DIA13 MM CANN REMOVAL NS REUSE,SUP-2905317,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5397.66,3508.48,,,,,,,,,,,,,
HC Chemo Infusion Concurrent,PX-3359654900,CDM,96549,CPT,0335,RC,,,,both,,,142.00,92.30,,,,,,,,,,,,,
NAIL IM 9X360MM TIB HUM N LCK SLD PROX BEND TI ALTA,SUP-2363492,CDM,C1713,HCPCS,0278,RC,,,,both,,,2153.73,1399.92,,,,,,,,,,,,,
BUTTON SUTURE DST CLAV PLT KNOTLESS PRELD ON INSRT TIGHTROPE,SUP-2121740,CDM,C1713,HCPCS,0278,RC,,,,both,,,3092.90,2010.38,,,,,,,,,,,,,
DISC INTERVERTEBRAL 5X12 MM CERV PRESTIGE LP,SUP-2630296,CDM,C1889,HCPCS,0278,RC,,,,both,,,12560.00,8164.00,,,,,,,,,,,,,
GRAFT VASC GORTX L 60 CM DIA 4-7 MM EPTFE TAPR STD WALL N,SUP-2396453,CDM,C1768,CPT,0278,RC,,,,both,,,2019.02,1312.36,,,,,,,,,,,,,
TOTAL KNEE REPLACEMENT KIT END-DELIVERY 11 GAX120 MM 3 CC,SUP-2866889,CDM,C1713,HCPCS,0278,RC,,,,both,,,8138.88,5290.27,,,,,,,,,,,,,
WIRE FIX L200MM OD2MM K,SUP-2417736,CDM,C1713,HCPCS,0278,RC,,,,both,,,122.46,79.60,,,,,,,,,,,,,
PLATE BNE MESHED 52X31X1 MM SM GRID PLLA-PGA STRL RESORB XG,SUP-2487491,CDM,C1713,HCPCS,0278,RC,,,,both,,,2537.43,1649.33,,,,,,,,,,,,,
VALVULOTOME ANGIOSCOPIC L 3 1/2 IN DIA 3 MM,SUP-2264159,CDM,C1713,HCPCS,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
BASEPLATE TIB XSM SZ 2 AP39MM ML64MM UNIV KNEE CEM NONBEADED,SUP-2377183,CDM,C1776,CPT,0278,RC,,,,both,,,4376.53,2844.74,,,,,,,,,,,,,
SUPPORT WRST PUL LACE CLOSURE UNIV LT PROCARE QUICK-FIT,SUP-2195780,CDM,L3931,HCPCS,0274,RC,,,,both,,,34.32,22.31,,,,,,,,,,,,,
GRAFT DURA W4XL5IN ULTRAPURE DURAGN +,SUP-2244008,CDM,C1763,HCPCS,0278,RC,,,,both,,,3927.42,2552.82,,,,,,,,,,,,,
GRAFT BONE MAR SM + CONC,SUP-2163084,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7536.00,4898.40,,,,,,,,,,,,,
SUPPORT ORTHOT FT METATRSL ARCH PREMOLDED LONGITUDINAL,SUP-2435706,CDM,L3060,HCPCS,0274,RC,,,,both,,,208.81,135.73,,,,,,,,,,,,,
PACK GUIDE DRILL MORPHIX 4.5MM SINGLE-USE,SUP-2878757,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1318.80,857.22,,,,,,,,,,,,,
SET INT FIX SCREW DIA1.5 MM 4 H TI NEURO SQ PLATE XDRV 1 PK,SUP-2935486,CDM,C1713,HCPCS,0278,RC,,,,both,,,1723.86,1120.51,,,,,,,,,,,,,
HC Level I Surg Pathology Gross Examination Only,PX-3128830000,CDM,88300,CPT,0312,RC,,,,both,,,219.00,142.35,,,,,,,,,,,,,
DEFIBRILLATOR IMPL LUMOS VR-T W 67 X H 55 MM D 12 MM 32 CC,SUP-2138086,CDM,C1722,HCPCS,0275,RC,,,,both,,,53163.34,34556.17,,,,,,,,,,,,,
GRAFT BNE CHIP FRZ DRY CANC CORT 1MM 8MM RANG 30CC READIGRFT,SUP-2264695,CDM,C1713,HCPCS,0278,RC,,,,both,,,1109.14,720.94,,,,,,,,,,,,,
INSERT TIB SZ 4 THK20MM KNEE GVF POLYETH STBL ROT PLATFRM,SUP-2253721,CDM,C1713,HCPCS,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
DISTRACTION INTRNL DIST LFRT 1 ZRCH 2 LFT 1.5 1.8 MM SCRW20,SUP-2499089,CDM,C1713,HCPCS,0278,RC,,,,both,,,15052.19,9783.92,,,,,,,,,,,,,
HC Flow Cytometry Cell Surf Marker Techl Only 1st,PX-3118818400,CDM,88184,CPT,0311,RC,,,,both,,,246.00,159.90,,,,,,,,,,,,,
PROSTHESIS TEMP LT CNDYL RIG LEIBINGER,SUP-2363871,CDM,C1713,HCPCS,0278,RC,,,,both,,,3157.71,2052.51,,,,,,,,,,,,,
IMPLANT W/ HIFOCUS HELIX ELECTRD DIAM 0.66MM-1.16MM OR,SUP-2140410,CDM,L8614,HCPCS,0278,RC,,,,both,,,80855.00,52555.75,,,,,,,,,,,,,
LEAD NERVE STIM 33 CM MRI INTERSTIM SURESCAN,SUP-2641996,CDM,C1778,HCPCS,0278,RC,,,,both,,,12089.00,7857.85,,,,,,,,,,,,,
MATRIX PLCNTA FLOWABLE CYROPRESERVED CRYOMTRX 2.0CC,SUP-2340462,CDM,C1762,CPT,0278,RC,,,,both,,,6280.00,4082.00,,,,,,,,,,,,,
PROSTHESIS OSS DE LA CRUZ PISTON 0.6X4.5 MM SHORTENED SMRT,SUP-2638168,CDM,L8613,CPT,0278,RC,,,,both,,,1130.24,734.66,,,,,,,,,,,,,
K WIRE FIX L80MM DIA0.9MM S STL AUTOFIX,SUP-2372156,CDM,C1713,HCPCS,0278,RC,,,,both,,,141.30,91.84,,,,,,,,,,,,,
RING ANNULPLSTY DIA26MM MI VLV TI CLASS KID SHP,SUP-2214148,CDM,C1713,HCPCS,0278,RC,,,,both,,,5024.00,3265.60,,,,,,,,,,,,,
RILPIVIRINE HCL 25 MG PO TABS,RX-108761,CDM,6370000000,HCPCS,0637,RC,59676-0278-01,NDC,,both,1,UN,222.60,144.69,,,,,,,,,,,,,
BUR SURG X COARSE DIAMOND 4 MM 10 CM BALL SM BOR MIDAS REX 8,SUP-2664492,CDM,2720000010,LOCAL,0272,RC,,,,both,,,422.02,274.31,,,,,,,,,,,,,
RING EXT FIX DIA180MM HALF FOR RNG FIX SYS TRUELOK,SUP-2316181,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1722.86,1119.86,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA BSC 5FR 55CM 3 LUMAN RVS TA,SUP-2613544,CDM,C1751,HCPCS,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
CATHETER DRAINAGE WHSTL TIP 4 FRX70 CM URET RT FOR PYELOGRAM,SUP-2168870,CDM,C1758,HCPCS,0278,RC,,,,both,,,166.73,108.37,,,,,,,,,,,,,
HC Thrombin Time Plasma,PX-3058567000,CDM,85670,CPT,0305,RC,,,,both,,,122.00,79.30,,,,,,,,,,,,,
MARKER RAD L3MM DIA1MM W/ 17GA L20CM PLCMNT NDL X THN WALL,SUP-2164649,CDM,A4648,CPT,0278,RC,,,,both,,,1073.88,698.02,,,,,,,,,,,,,
SCREW BNE SZ 25MMX26MM CANN,SUP-2243603,CDM,C1713,HCPCS,0278,RC,,,,both,,,1004.20,652.73,,,,,,,,,,,,,
HC Galactogram Multi S&I,PX-3207705400,CDM,77054,CPT,0320,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
GRAFT SURG 1MM PROC HUM DERM CLLGN RECTANG 10CMX15CM ALLOMAX,SUP-2126263,CDM,C1781,HCPCS,0278,RC,,,,both,,,10406.59,6764.28,,,,,,,,,,,,,
CEMENT BNE 51 GM GENTAMICIN PALACOS,SUP-2601061,CDM,C1713,HCPCS,0278,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
PLATE BONE L188MM 12 HOLE LEFT LTRL PRXML PRRTCLR HMRL 35MM,SUP-2478257,CDM,C1713,HCPCS,0278,RC,,,,both,,,2442.48,1587.61,,,,,,,,,,,,,
GENTAMICIN SULFATE 40 MG/ML IJ SOLN,RX-3426,CDM,J1580,HCPCS,0636,RC,63323-0010-02,NDC,,both,2,ML,54.10,35.16,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE SM 1.3 CC CORTICOCANCELLOUS VIABLE,SUP-2933521,CDM,C1762,CPT,0278,RC,,,,both,,,1585.07,1030.30,,,,,,,,,,,,,
DEVICE BX L15CM OD18GA DISP EZ COR,SUP-2140105,CDM,2720000010,LOCAL,0272,RC,,,,both,,,600.05,390.03,,,,,,,,,,,,,
EXTRACTOR STONE 2.2FR L115CM BSKT DIA1CM NIT TIPLSS UNIDEX,SUP-2171315,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1032.12,670.88,,,,,,,,,,,,,
KIT CATH BA SIL RIFAMPICIN CLINDAMYCIN HCI SHUNT RADPQ W/,SUP-2243804,CDM,C1729,HCPCS,0272,RC,,,,both,,,2684.61,1745.00,,,,,,,,,,,,,
COMPONENT FEM CEM 15 DEG STD UNIV UNISX RT PROX CR PRIMARY,SUP-2376508,CDM,C1776,CPT,0278,RC,,,,both,,,12975.11,8433.82,,,,,,,,,,,,,
KIT HEMO DYLS OR HD 15.5FR L24CM BASIC LNG TERM ADMIN POLYUR,SUP-2354971,CDM,C1750,HCPCS,0278,RC,,,,both,,,904.32,587.81,,,,,,,,,,,,,
HEAD FEM OD36MM +0 NK CERAMIC ALUMINA V40,SUP-2364458,CDM,C1776,CPT,0278,RC,,,,both,,,4592.25,2984.96,,,,,,,,,,,,,
PLATE BNE STR 3.5X213 MM 18 HOLE RECON FOR SCR SS NS,SUP-2458666,CDM,C1713,HCPCS,0278,RC,,,,both,,,1500.67,975.44,,,,,,,,,,,,,
HEAD RADIAL STD 28X14 MM ELBW COCR STRL,SUP-2564450,CDM,C1776,CPT,0278,RC,,,,both,,,4861.82,3160.18,,,,,,,,,,,,,
PLATE BNE L 48 MM 3 H RT DSTL VOLAR RADIAL WIDE STRL VARIAX,SUP-2902226,CDM,C1713,HCPCS,0278,RC,,,,both,,,4981.83,3238.19,,,,,,,,,,,,,
SET URET STENT UNIVERSA L 20 CM DIA 5 FR HYDRPHLC SFT,SUP-2169453,CDM,C2617,HCPCS,0278,RC,,,,both,,,155.43,101.03,,,,,,,,,,,,,
TUBE SET DECOMPRESSION BLADE SHAVER BONESCALPEL MIS,SUP-2748601,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
PLATE BNE L90MM 5 H L DST POSTEROLATERAL HUM S STL LOK,SUP-2185894,CDM,C1713,HCPCS,0278,RC,,,,both,,,2555.93,1661.35,,,,,,,,,,,,,
COMPONENT FEM KNEE REV THRD SHFT LCS COMPLETE,SUP-2453523,CDM,C1776,CPT,0278,RC,,,,both,,,2562.24,1665.46,,,,,,,,,,,,,
PLATE BNE L 31 MM SCREW DIA2.4 MM 4 SHFT H SS COMPACT STR VA NS,SUP-2910644,CDM,C1713,HCPCS,0278,RC,,,,both,,,2790.93,1814.10,,,,,,,,,,,,,
CATHETER EP 4FR L110CM SPC 2MM M CRV DECAPOLAR STEER,SUP-2357444,CDM,C1730,HCPCS,0272,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
GRAFT VASC GELWEAVE L 30 CM DIA10 MM POLYESTER GEL,SUP-2385013,CDM,L8670,HCPCS,0278,RC,,,,both,,,3108.60,2020.59,,,,,,,,,,,,,
SLEEVE TIB L5CM PROX KNEE FOR ORTH SALV SYS,SUP-2406464,CDM,C1776,CPT,0278,RC,,,,both,,,8463.87,5501.52,,,,,,,,,,,,,
KIT SHTH DESTINO REACH L 75 CM DIA12 FR CRV BEND 50 MM DIL,SUP-2616173,CDM,C1766,CPT,0272,RC,,,,both,,,2496.30,1622.59,,,,,,,,,,,,,
MESH HERN VENTRAL MED 2.5X2.5 IN O3FA COAT C-QUR V-PATCH,SUP-2227252,CDM,C1781,HCPCS,0278,RC,,,,both,,,1384.11,899.67,,,,,,,,,,,,,
SEALANT HEMSTAT 4 CC TISSEEL,SUP-2430137,CDM,C1713,HCPCS,0278,RC,,,,both,,,3849.64,2502.27,,,,,,,,,,,,,
MARKER BRST BX 18 GAX13.3 CM VISION NIT TUMARK EVIVA,SUP-2716299,CDM,A4648,CPT,0278,RC,,,,both,,,301.44,195.94,,,,,,,,,,,,,
PLATE BNE L20MM 4 H FT COMPR INTERAXIAL UNI-CP,SUP-2243488,CDM,C1713,HCPCS,0278,RC,,,,both,,,6387.23,4151.70,,,,,,,,,,,,,
SCREW 2 THRD. 8.0X70 TI ST,SUP-2392806,CDM,C1713,HCPCS,0278,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
PLATE BNE L41MM -90DEG 2X3 H NONSTERILE L DST DORS RAD R,SUP-2184184,CDM,C1713,HCPCS,0278,RC,,,,both,,,2065.24,1342.41,,,,,,,,,,,,,
GADOBUTROL 1 MMOL/ML IV SOLN,RX-104340,CDM,A9585,HCPCS,0636,RC,50419-0325-37,NDC,,both,2,ML,9.20,5.98,,,,,,,,,,,,,
ENALAPRIL MALEATE 5 MG PO TABS,RX-9927,CDM,6370000000,HCPCS,0637,RC,16714-0443-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
KIT KYPHOPLASTY 10CC L9IN W/ STR SH EXTN TUBE MX AND DEL,SUP-2367030,CDM,C1713,HCPCS,0278,RC,,,,both,,,533.80,346.97,,,,,,,,,,,,,
REAMER SURG SZ 40/44MM CTRL LO PROF GLOB APG+,SUP-2252721,CDM,C1776,CPT,0278,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP MARKED SPRING TIP 210 CM SAFEGUIDE DISP,SUP-2423867,CDM,C1769,HCPCS,0272,RC,,,,both,,,23.55,15.31,,,,,,,,,,,,,
CATHETER CV KT 12 FRX16 CM 3L LG BOR FOR HI VOL INFUSION,SUP-2763356,CDM,C1751,HCPCS,0278,RC,,,,both,,,413.22,268.59,,,,,,,,,,,,,
GRAFT GRAN PRO OSTEON 500 30CC,SUP-2413081,CDM,C1713,HCPCS,0278,RC,,,,both,,,4235.86,2753.31,,,,,,,,,,,,,
SHEATH INTRO PINNACLE L 10 CM 10FR SS HYDRPHLC CORONARY,SUP-2385285,CDM,C1894,HCPCS,0272,RC,,,,both,,,306.15,199.00,,,,,,,,,,,,,
CATHETER ETER ANGIO AD 7FR L80CM 0035IN XL CURL PLCMNT,SUP-2357043,CDM,C1730,HCPCS,0272,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
SCREW INTFR L28MM DIA8MM KNEE PLLA WDG SHP ROUNDED THRD,SUP-2366520,CDM,C1713,HCPCS,0278,RC,,,,both,,,711.52,462.49,,,,,,,,,,,,,
SPACER SPNL ALIF TI STALIF,SUP-2163224,CDM,C1889,HCPCS,0278,RC,,,,both,,,21195.00,13776.75,,,,,,,,,,,,,
BASKET STONE RETRIVAL 10 MMX250 CM SFT WIRE LL CONN STRL,SUP-2480878,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1864.38,1211.85,,,,,,,,,,,,,
BLADE RETRACTOR CASPR 50X23 MM CERV BALL SNAP MEDL ULTRA,SUP-2458700,CDM,2720000010,LOCAL,0272,RC,,,,both,,,576.47,374.71,,,,,,,,,,,,,
GRAFT HUM TISS BIDIR 5X5 CM GRID PAT AMNIO MEMBRN BIOVANCE,SUP-2651378,CDM,Q4154,HCPCS,0636,RC,,,,both,,,10205.00,6633.25,,,,,,,,,,,,,
HC Simulation Intermediate,PX-3337728500,CDM,77285,CPT,0333,RC,,,,both,,,1230.00,799.50,,,,,,,,,,,,,
CANNULA ENDOSCP W/O VLV 11 MMX8.5 CM W/ INSUFFLATION GRN WHT,SUP-2767244,CDM,2720000010,LOCAL,0272,RC,,,,both,,,934.72,607.57,,,,,,,,,,,,,
CATHETER ANGIO PERFORMA 100 CM 4 FR 0.042 IN ULT1 1 SIDE H,SUP-2301467,CDM,C1713,HCPCS,0278,RC,,,,both,,,74.29,48.29,,,,,,,,,,,,,
GUIDEWIRE SOLO PLUS 0.035IN STRAIGHT TIP,SUP-2655881,CDM,C1769,HCPCS,0272,RC,,,,both,,,81.64,53.07,,,,,,,,,,,,,
BOLT ORTH L75MM LOK FOR MOD REV HIP SYS RECLAIM,SUP-2252536,CDM,C1776,CPT,0278,RC,,,,both,,,621.72,404.12,,,,,,,,,,,,,
HC MRI Face Neck Eye WO Contrast,PX-6107054000,CDM,70540,CPT,0610,RC,,,,outpatient,,,4451.00,2893.15,,,,,,,,,,,,,
PACEMAKER CARD ACCOLADE MRI W 4.45 X H 5.88 CM THK 0.75 CM,SUP-2149253,CDM,C1785,HCPCS,0275,RC,,,,both,,,8854.80,5755.62,,,,,,,,,,,,,
CATHETER EP DIAG MAP HISSER CRV QPLR 5MM SPC 1MM TIP UNI M004814830] ABBOTT],SUP-2102301,CDM,C1730,HCPCS,0272,RC,,,,both,,,1461.67,950.09,,,,,,,,,,,,,
PLATE BNE L 100 DEG 1.7X2 MM RT 6 HOLE BAR TI GLD NS,SUP-2366305,CDM,C1713,HCPCS,0278,RC,,,,both,,,625.68,406.69,,,,,,,,,,,,,
BRACE WLK SM SHOE MAN 4 7 WOMAN 5 8 SHT PNEUMAT SEMI RIG,SUP-2196357,CDM,L4361,HCPCS,0272,RC,,,,both,,,113.35,73.68,,,,,,,,,,,,,
NEEDLE BRST LOC 20 GAX15 CM 28.9 CM D WIRE ACCURA,SUP-2876722,CDM,C1819,HCPCS,0278,RC,,,,both,,,144.75,94.09,,,,,,,,,,,,,
FIBER LASER END FIRE REVOLIX,SUP-2225647,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2943.75,1913.44,,,,,,,,,,,,,
HC So Hepatitis B Core Igm Antibody,PX-3028670566,CDM,86705,CPT,0302,RC,,,,both,,,45.00,29.25,,,,,,,,,,,,,
SLING TRNSVAG IN FAST ULT SYS INTEXEN,SUP-2140293,CDM,C1771,HCPCS,0278,RC,,,,both,,,5294.83,3441.64,,,,,,,,,,,,,
TICAGRELOR 90 MG PO TABS,RX-110035,CDM,6370000000,HCPCS,0637,RC,67877-0491-60,NDC,,both,1,UN,3.50,2.27,,,,,,,,,,,,,
ANCHOR SUT OD6.5MM BIOCRYL RAPIDE ORTHOCORD HEALIX ADV BR,SUP-2256660,CDM,C1713,HCPCS,0278,RC,,,,both,,,1522.90,989.88,,,,,,,,,,,,,
HC CT Abd/Pelvis W W/O Contrast,PX-3527417800,CDM,74178,CPT,0352,RC,,,,both,,,3757.00,2442.05,,,,,,,,,,,,,
SHEATH INTRO 17GA L8IN TUNN DISP ON-Q,SUP-2236802,CDM,C1892,HCPCS,0272,RC,,,,both,,,85.09,55.31,,,,,,,,,,,,,
PLATE BONE W10XL142MM THK2.8MM 12 H S STL STR NONCOMPRESSION,SUP-2343767,CDM,C1713,HCPCS,0278,RC,,,,both,,,4248.89,2761.78,,,,,,,,,,,,,
HC So Legionnaires Titer,PX-3028671366,CDM,86713,CPT,0302,RC,,,,both,,,668.00,434.20,,,,,,,,,,,,,
PLATE FT 180 DBL H IMP,SUP-2197261,CDM,C1713,HCPCS,0278,RC,,,,both,,,4662.90,3030.88,,,,,,,,,,,,,
PLATE BONE L51MM 6 H MAND TI STR ECC LIMIT CNTCT DYN COMPR,SUP-2191400,CDM,C1713,HCPCS,0278,RC,,,,both,,,2956.31,1921.60,,,,,,,,,,,,,
SCISSORS OPHTH 41IN KERATOPLASTY CRV R DEL BLNT CASTRO,SUP-2129397,CDM,2720000010,LOCAL,0272,RC,,,,both,,,798.03,518.72,,,,,,,,,,,,,
PLATE BNE 15MM INTERAXIS COMPR FOR 2.7MM SCR CHARLOTTE CLAW,SUP-2397350,CDM,C1713,HCPCS,0278,RC,,,,both,,,2289.06,1487.89,,,,,,,,,,,,,
PLATE BONE AD PED L135MM 8 H LT FIBULAR TI ANAT PRECONTOURED,SUP-2319686,CDM,C1713,HCPCS,0278,RC,,,,both,,,6603.42,4292.22,,,,,,,,,,,,,
SCREW SPNL L60MM OD6.5MM 0DEG TI CANC PEDCL IL FIX ANG HD,SUP-2287135,CDM,C1713,HCPCS,0278,RC,,,,both,,,3032.93,1971.40,,,,,,,,,,,,,
ROD SPNL L60MM TOP LD FOR DYN STBL SYS DYNESYS,SUP-2414280,CDM,C1713,HCPCS,0278,RC,,,,both,,,9702.60,6306.69,,,,,,,,,,,,,
STENT CORONARY XIENCE PRIM LL L 28 MM DIA2.75 MM SYS L 143,SUP-2104689,CDM,C1874,HCPCS,0278,RC,,,,both,,,4615.80,3000.27,,,,,,,,,,,,,
HC Endovasc Tempory Vessel Occl,PX-3616162300,CDM,61623,CPT,0361,RC,,,,both,,,11772.00,7651.80,,,,,,,,,,,,,
KIT LASER L65CM 0.035IN NDL 21GA GRP G TIP FRS FBR NEVERTOUCH,SUP-2118073,CDM,C1894,HCPCS,0272,RC,,,,both,,,921.75,599.14,,,,,,,,,,,,,
VALVE 0 WITH BURRHOLE RESERVOIR MININAV,SUP-2821809,CDM,C1889,HCPCS,0278,RC,,,,both,,,2018.20,1311.83,,,,,,,,,,,,,
CATHETER THROMCTMY PRONTO V4 L 138 CM DIA 7 FR INTRO 6 FR,SUP-2120489,CDM,C1757,HCPCS,0272,RC,,,,both,,,1252.86,814.36,,,,,,,,,,,,,
ALLOGRAFT HUM TISS LG FD IRRADIATED FASC LATA 920428,SUP-2867046,CDM,C1762,CPT,0278,RC,,,,both,,,2505.72,1628.72,,,,,,,,,,,,,
WAND ARTHSCP ENT 45 DEG REFLX ULT COBLATOR II,SUP-2342028,CDM,C1713,HCPCS,0278,RC,,,,both,,,840.89,546.58,,,,,,,,,,,,,
SHUNT SURG VENTRICULOPERITONEAL UNI-SHUNT NS0172,SUP-2666779,CDM,C1889,HCPCS,0278,RC,,,,both,,,2304.23,1497.75,,,,,,,,,,,,,
IMPLANT FEM L29MM DIA10MM INSRT APERFIX AM,SUP-2402621,CDM,C1776,CPT,0278,RC,,,,both,,,3175.67,2064.19,,,,,,,,,,,,,
ALLOGRAFT BNE FRZN ASEP POST TIBIALIS,SUP-2867037,CDM,C1762,CPT,0278,RC,,,,both,,,5273.94,3428.06,,,,,,,,,,,,,
INSERT TIB 10X75 MM BASE AXIOM,SUP-2397003,CDM,C1776,CPT,0278,RC,,,,both,,,10091.96,6559.77,,,,,,,,,,,,,
PLATE BNE W5XL100MM THK1MM 20 H TI STR FOR 2MM SCR,SUP-2191056,CDM,C1713,HCPCS,0278,RC,,,,both,,,940.15,611.10,,,,,,,,,,,,,
NEEDLE BRST LOC L7.5CM OD20GA REPOSIT H STYL,SUP-2174909,CDM,C1819,HCPCS,0278,RC,,,,both,,,150.72,97.97,,,,,,,,,,,,,
PLATE BNE STR 1.3 MM HND 10 HOLE STRL,SUP-2518390,CDM,C1713,HCPCS,0278,RC,,,,both,,,1551.16,1008.25,,,,,,,,,,,,,
DEFIBRILLATOR IMPL VITALITY 2 EL VR W 6.3 X H 7.1 CM D 1.1,SUP-2149287,CDM,C1722,HCPCS,0275,RC,,,,both,,,40035.00,26022.75,,,,,,,,,,,,,
CATHETER CV DL 5 FRX55 CM FULL TY PWR INJ POWERPICC,SUP-2126386,CDM,C1751,HCPCS,0278,RC,,,,both,,,633.46,411.75,,,,,,,,,,,,,
PLATE BNE FEM 120 DEG 180 MM ARCHED MR SAFE NS,SUP-2863458,CDM,C1713,HCPCS,0278,RC,,,,both,,,2937.72,1909.52,,,,,,,,,,,,,
SYSTEM DRAINAGE 20 CC BG,SUP-2666736,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1262.85,820.85,,,,,,,,,,,,,
PLATE VARIAX COMP NAR STRAIGHT 9HL,SUP-2703713,CDM,C1713,HCPCS,0278,RC,,,,both,,,2670.57,1735.87,,,,,,,,,,,,,
SYSTEM GLAUCOMA TREAT INCLUDES XEN 45 PORCINE DERM GEL STENT,SUP-2113356,CDM,L8612,HCPCS,0278,RC,,,,both,,,8013.28,5208.63,,,,,,,,,,,,,
SPLINT FNGR AD M JT EXTN TUBE DGT DYN,SUP-2325054,CDM,L3933,HCPCS,0272,RC,,,,both,,,46.91,30.49,,,,,,,,,,,,,
SCREW BNE L11MM DIA1.2MM TI ST CRSS FIT MOD PROFYLE,SUP-2366389,CDM,C1713,HCPCS,0278,RC,,,,both,,,1828.27,1188.38,,,,,,,,,,,,,
GUIDEWIRE VASC KATZN L 145 CM TIP L 9 CM DIA 0.035 IN SS,SUP-2148178,CDM,C1769,HCPCS,0272,RC,,,,both,,,537.82,349.58,,,,,,,,,,,,,
PLATE BNE CRV 4.5X195 MM LT CNDYL 8 HOLE VA LCK STRL VALCP,SUP-2789395,CDM,C1713,HCPCS,0278,RC,,,,both,,,6098.16,3963.80,,,,,,,,,,,,,
EXTERNAL FIXATION KIT META DPHSEAL XCALIBER PVC FREE STRL,SUP-2646342,CDM,C1713,HCPCS,0278,RC,,,,both,,,13149.50,8547.17,,,,,,,,,,,,,
FIBER LASER 550 MH 100 W FLEXSHIELD OUTPT TIP ETFE SIL,SUP-2141812,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1285.05,835.28,,,,,,,,,,,,,
SCREW BNE L44MM DIA5MM CORT TI ST DBL LD THRD FOR PHOENIX,SUP-2412125,CDM,C1713,HCPCS,0278,RC,,,,both,,,835.24,542.91,,,,,,,,,,,,,
TRAY CATH HEMODIALYSI NIAG SLIM CATH ACTE 12FR DIA 1 5436150,SUP-2632891,CDM,C1752,HCPCS,0278,RC,,,,both,,,656.57,426.77,,,,,,,,,,,,,
MELATONIN 5 MG PO TABS,RX-17427,CDM,6370000000,HCPCS,0637,RC,77333-0520-25,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
HC Drug Tst Prsmv Instrmnt Chem Analyzers PR Date,PX-3018030700,CDM,80307,CPT,0301,RC,,,,both,,,400.00,260.00,,,,,,,,,,,,,
LENS INTOCU BI CONVX TORIC NO HAPTIC ANG SGL PC POST CHMBR,SUP-2111273,CDM,V2787,HCPCS,0276,RC,,,,both,,,395.00,256.75,,,,,,,,,,,,,
SCREW BNE L 24 MM DIA2.5 MM TI CANN HD NS LEOS,SUP-2932584,CDM,C1713,HCPCS,0278,RC,,,,both,,,679.65,441.77,,,,,,,,,,,,,
FEEDING TUBE KIT LP 14 FRX1.2 CM BLLN BUTTON SIL MINI 1,SUP-2754572,CDM,2720000010,LOCAL,0272,RC,,,,both,,,509.81,331.38,,,,,,,,,,,,,
FEMORAL VG POR POR TIB/E1/STD,SUP-2137310,CDM,C1713,HCPCS,0278,RC,,,,both,,,16682.82,10843.83,,,,,,,,,,,,,
ALLOGRAFT BNE DEMINERALIZED CORTICAL 125-710 MIC 30 CC FD,SUP-2717751,CDM,C1713,HCPCS,0278,RC,,,,both,,,3647.93,2371.15,,,,,,,,,,,,,
DEFIBRILLATOR IMPL AMPLIA MRI SURESCAN W 51 X H 71 MM D 13,SUP-2282413,CDM,C1882,HCPCS,0275,RC,,,,both,,,58137.35,37789.28,,,,,,,,,,,,,
SHUNT SURG SM PERF LEVEL 1.0 DELT,SUP-2628313,CDM,C1729,HCPCS,0272,RC,,,,both,,,1088.95,707.82,,,,,,,,,,,,,
DOXYCYCLINE HYCLATE 100 MG IV SOLR,RX-2622,CDM,J1271,HCPCS,0636,RC,63323-0130-11,NDC,,both,1,UN,151.40,98.41,,,,,,,,,,,,,
SYSTEM TKR L MED LUNI KNEE UNI UNI KT,SUP-2165954,CDM,C1776,CPT,0278,RC,,,,both,,,20410.00,13266.50,,,,,,,,,,,,,
PLATE BONE L12MM 12 H MAND TI LCK FOR 2MM SCR,SUP-2191230,CDM,C1713,HCPCS,0278,RC,,,,both,,,2916.75,1895.89,,,,,,,,,,,,,
SCREW BONE SELFDRILLING 6 MM TITANIUM SILVER NON STERILE MAT,SUP-2837723,CDM,C1713,HCPCS,0278,RC,,,,both,,,326.75,212.39,,,,,,,,,,,,,
HOOK SPNL REDUC HELCL FLNG 4.5MM ALTIUS MINI OCT,SUP-2414670,CDM,C1713,HCPCS,0278,RC,,,,both,,,1444.40,938.86,,,,,,,,,,,,,
PIN FIX STD SPNL TEMP FOR SCR H,SUP-2255662,CDM,C1713,HCPCS,0278,RC,,,,both,,,224.51,145.93,,,,,,,,,,,,,
HC Clotting Inhibitors Antithrombin III Activity,PX-3058530000,CDM,85300,CPT,0305,RC,,,,both,,,496.00,322.40,,,,,,,,,,,,,
LAPAROSCOPE RIGID L330MM OD10MM 30DEG DIRECT VIEW AUTOCLAVAB,SUP-2801945,CDM,C1776,CPT,0278,RC,,,,both,,,9539.10,6200.41,,,,,,,,,,,,,
POUCH PIN TUBERCLE STRL,SUP-2223542,CDM,C1713,HCPCS,0278,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
ROD SPNL POST BILAT SMOOTH TI ALLOY 4.5MM DIA 16MM LEN,SUP-2290272,CDM,C1713,HCPCS,0278,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
MESH SRGCL 06MM THK TTNM ALLOY LEFT FRNTTMPRL PRTL CRNL CNT,SUP-2676602,CDM,C1713,HCPCS,0278,RC,,,,both,,,16876.12,10969.48,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 3X220 MM GRACILIS TEND,SUP-2866885,CDM,C1762,CPT,0278,RC,,,,both,,,2171.62,1411.55,,,,,,,,,,,,,
HA CONT ACT RECON RG 46MM LT,SUP-2822562,CDM,C1776,CPT,0278,RC,,,,both,,,6393.04,4155.48,,,,,,,,,,,,,
SHUNT SURG SM 90 CM PERF LEVEL 1.0 SNAP DELT,SUP-2665033,CDM,C1729,HCPCS,0272,RC,,,,both,,,5954.54,3870.45,,,,,,,,,,,,,
PLATE BNE W33XL95MM 6 H R DST MED TIB S STL LOK COMPR NEUT,SUP-2185109,CDM,C1713,HCPCS,0278,RC,,,,both,,,2925.91,1901.84,,,,,,,,,,,,,
SHEATH INTRO HEARTSPAN L 74 CM DIA 8.5 FR CRV ANGLE 36 MM,SUP-2492434,CDM,C1893,HCPCS,0272,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
BLADE SAW OSC DISP STABLECUT,SUP-2408657,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1401.23,910.80,,,,,,,,,,,,,
PLATE BNE L 225 MM SCREW DIA 3.5 MM 15 H SS PROX HUM STR,SUP-2932923,CDM,C1713,HCPCS,0278,RC,,,,both,,,9247.30,6010.74,,,,,,,,,,,,,
ESMOLOL HCL-SODIUM CHLORIDE 2500 MG/250ML IV SOLN,RX-29805,CDM,J1805,HCPCS,0636,RC,10019-0055-61,NDC,,both,250,ML,744.70,484.05,,,,,,,,,,,,,
PROSTHESIS VOICE 20FR L6MM L FLNG INDWL 2 VLV BLOM-SINGER,SUP-2242330,CDM,L8509,HCPCS,0274,RC,,,,both,,,1378.46,896.00,,,,,,,,,,,,,
CAGE SPNL H6.5MM AP D12MM 6DEG TAPR LORDOSIS ANTR CERV PEEK,SUP-2163179,CDM,C1889,HCPCS,0278,RC,,,,both,,,7379.00,4796.35,,,,,,,,,,,,,
GRAFT HUM TISS W7XL10CM PROC DERM CLLGN RECTANG ALLOMAX,SUP-2125856,CDM,C1781,HCPCS,0278,RC,,,,both,,,6939.40,4510.61,,,,,,,,,,,,,
ALLOGRAFT BNE CRUSH 1-4 MM 30 CC FRZN IRRADIATED CANC,SUP-2866925,CDM,C1762,CPT,0278,RC,,,,both,,,1055.04,685.78,,,,,,,,,,,,,
ELECTRODE NDL CANN L25CM ARRY DIA4CM FOR OPN AND PERC RF,SUP-2139751,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5259.50,3418.67,,,,,,,,,,,,,
SHEATH INTRO PRELUDE IDEAL L 11 CM DIA 4 FR IV CATH L 2.5 CM,SUP-2740573,CDM,C1892,HCPCS,0272,RC,,,,both,,,263.76,171.44,,,,,,,,,,,,,
IMPLANT SYNTH 13 X 38 MM THK 3 MM POLYETHYL CRANIOFACIAL,SUP-2883218,CDM,C1713,HCPCS,0278,RC,,,,both,,,1447.92,941.15,,,,,,,,,,,,,
PLATE BNE H06MM BAR L4MM 6 H CHIN TI ADV LEIBINGER UNIV 2,SUP-2366336,CDM,C1713,HCPCS,0278,RC,,,,both,,,761.14,494.74,,,,,,,,,,,,,
BUNDLE CASE MICROTIA CUST VSP,SUP-2862839,CDM,2720000010,LOCAL,0272,RC,,,,both,,,18463.20,12001.08,,,,,,,,,,,,,
BEARING TIB PS 11X71/75 MM ASCNT,SUP-2449791,CDM,C1776,CPT,0278,RC,,,,both,,,3014.40,1959.36,,,,,,,,,,,,,
AMLODIPINE BESYLATE-VALSARTAN 5-320 MG PO TABS,RX-82364,CDM,6370000000,HCPCS,0637,RC,00378-1723-93,NDC,,both,1,UN,54.10,35.16,,,,,,,,,,,,,
INTRODUCER TRANSSEPTAL GUID 8.5FR L63CM DIL 8.5FR L67CM,SUP-2357264,CDM,C1893,HCPCS,0272,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
GRAFT BNE 5 CC CELLULAR BNE MTRX OSSEOGEN,SUP-2858500,CDM,C1713,HCPCS,0278,RC,,,,both,,,5331.72,3465.62,,,,,,,,,,,,,
BLADE RETRACTOR RICHARDSON 0.75X1 IN BOOKWALTER,SUP-2490716,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1596.69,1037.85,,,,,,,,,,,,,
THIOTHIXENE 5 MG PO CAPS,RX-7906,CDM,6370000000,HCPCS,0637,RC,60219-1675-01,NDC,,both,1,UN,8.20,5.33,,,,,,,,,,,,,
SCREW BNE LP 5X82.5 MM TRIGEN,SUP-2347293,CDM,C1713,HCPCS,0278,RC,,,,both,,,561.62,365.05,,,,,,,,,,,,,
HC So Cmv Dna Quantitation by Pcr,PX-3068749766,CDM,87497,CPT,0306,RC,,,,both,,,387.00,251.55,,,,,,,,,,,,,
COMPONENT FEM 10X25 MM W/ INSRTR APERFIX II,SUP-2745500,CDM,C1776,CPT,0278,RC,,,,both,,,3472.84,2257.35,,,,,,,,,,,,,
PORT TI IMPL SIL FILL SUT H 6 FR ATTCH CHRONOFLEX POLYUR W/,SUP-2127781,CDM,C1788,HCPCS,0278,RC,,,,both,,,1444.40,938.86,,,,,,,,,,,,,
CANNULA LAP VERY LO PROF 3.5 MMX15 CM N THRD SMOOTH GRN,SUP-2767466,CDM,2720000010,LOCAL,0272,RC,,,,both,,,810.31,526.70,,,,,,,,,,,,,
GRAFT BONE SUB 10GM CA PHOS CLASS BONESOURCE,SUP-2365153,CDM,C1713,HCPCS,0278,RC,,,,both,,,3213.48,2088.76,,,,,,,,,,,,,
SCREW BONE L17MM OD3MM 0DEG CROSSTIE,SUP-2175108,CDM,C1713,HCPCS,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
SHEATH URO L35CM OD3FR ID12FR 2 LUMN FLX DL,SUP-2171425,CDM,C1894,HCPCS,0272,RC,,,,both,,,580.27,377.18,,,,,,,,,,,,,
BIT DRL CANN 6.5 MM SPRL UNDERCUT W/ ACORN TIP,SUP-2767127,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1544.72,1004.07,,,,,,,,,,,,,
CONTOURED MESH UNIV CENTER06MM PROFILE STERILE,SUP-2707382,CDM,C1713,HCPCS,0278,RC,,,,both,,,15619.93,10152.95,,,,,,,,,,,,,
FORCEPS ES AD PED L7IN DIA15MM STD BPLR NONSTICK DISPOSABLE,SUP-2364926,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1191.44,774.44,,,,,,,,,,,,,
COMPONENT FEM 2 LT PRI CEM RESURF UNISX GRDIAN,SUP-2304403,CDM,C1776,CPT,0278,RC,,,,both,,,9891.00,6429.15,,,,,,,,,,,,,
GRAFT HUMAN TISSUE BIOLOGICAL TISSUE MATRIX THICK 40X30 CM NON CROSSLINKED SCAFFOLD NATURALLY OCCURRING PORCINE STERILE GENTRIX DISPOSABLE,SUP-2106506,CDM,Q4166,HCPCS,0636,RC,,,,both,,,102018.60,66312.09,,,,,,,,,,,,,
FIBER LASER FOR YAG,SUP-2225711,CDM,2720000010,LOCAL,0272,RC,,,,both,,,508.68,330.64,,,,,,,,,,,,,
ENDCAP SPNL EXT 0 DEG 20X30 MM T2 STRATOSPHERE,SUP-2423277,CDM,C1889,HCPCS,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
ROD SPNL THRD LNG 350 MM MR SAFE NS,SUP-2863417,CDM,C1713,HCPCS,0278,RC,,,,both,,,239.77,155.85,,,,,,,,,,,,,
NEEDLE SURG 21GAX4 MM 0.8 MM MID BVL DISP,SUP-2430213,CDM,C1713,HCPCS,0278,RC,,,,both,,,176.15,114.50,,,,,,,,,,,,,
PLATE 3.5MM TI LCP TM PROX TIBIA PLATE 6H 107MM LEFT-STER,SUP-2549544,CDM,C1713,HCPCS,0278,RC,,,,both,,,4641.20,3016.78,,,,,,,,,,,,,
CATHETER CV 3L 6 FRX135 CM BASIC KT PWR INJ POWERPICC,SUP-2126401,CDM,C1751,HCPCS,0278,RC,,,,both,,,634.28,412.28,,,,,,,,,,,,,
CATHETER HD SPRT PK 14.5 FRX23 CM SYMMETRICAL TIP PALINDROME,SUP-2754729,CDM,C1750,HCPCS,0278,RC,,,,both,,,1229.28,799.03,,,,,,,,,,,,,
FIXATOR EXT W224MM HORZ ARTICULATED DBL SIDE MINIRAIL,SUP-2316471,CDM,2720000010,LOCAL,0272,RC,,,,both,,,9853.76,6404.94,,,,,,,,,,,,,
CATHETER INFUSION ANGLED 3 FRX150 CM 20 CM RENEGADE HIFLO,SUP-2147584,CDM,C1887,HCPCS,0272,RC,,,,both,,,1271.70,826.60,,,,,,,,,,,,,
PROCESSOR HEARING AID MOCCA BRN LT EAR SND PROC CHAN WIND,SUP-2319860,CDM,L8690,HCPCS,0278,RC,,,,both,,,11932.00,7755.80,,,,,,,,,,,,,
PLATE BNE COMPR 3 H 3D 25MM,SUP-2321434,CDM,C1713,HCPCS,0278,RC,,,,both,,,3979.95,2586.97,,,,,,,,,,,,,
SYSTEM CARD PACEMKR LEADLESS SINGLE CHMBR SURESCAN,SUP-2882758,CDM,C1786,HCPCS,0275,RC,,,,both,,,29547.40,19205.81,,,,,,,,,,,,,
CATHETER ABLATN F-J CRV 1-7-4 MM 8 MM 7 FRX115 CM EZ STEER,SUP-2248517,CDM,C1732,HCPCS,0278,RC,,,,both,,,7762.08,5045.35,,,,,,,,,,,,,
SUTURE ORTHOCORD SZ 2-0 VLT BLU MO-7 NDL MULTIPAK 223114,SUP-2249457,CDM,C1713,HCPCS,0278,RC,,,,both,,,245.17,159.36,,,,,,,,,,,,,
CATHETER KIT 2 LUMEN 5 FR 60M161562] ANGIODYNAMICS INC],SUP-2117190,CDM,C1751,HCPCS,0278,RC,,,,both,,,628.69,408.65,,,,,,,,,,,,,
BUR ENDOSCP SHAVER 40 DEG L 13 CM DIA 3 MM ENT FRONTAL,SUP-2901950,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1074.29,698.29,,,,,,,,,,,,,
GRAFT DURA PTCH LG 10X10 CM DURAMATER,SUP-2321734,CDM,C1713,HCPCS,0278,RC,,,,both,,,7520.30,4888.19,,,,,,,,,,,,,
POST EXTERNAL FIXATION SM STAINLESS STEEL SLOTTED,SUP-2586504,CDM,2720000010,LOCAL,0272,RC,,,,both,,,550.63,357.91,,,,,,,,,,,,,
PLATE BNE 5 H 7 PEG STD R VOLAR S STL BEAR,SUP-2389757,CDM,C1713,HCPCS,0278,RC,,,,both,,,3202.80,2081.82,,,,,,,,,,,,,
IMMOBILIZER KNEE 1 SZ FITS MOST WRP ARND ABV KNEE OPN PAT,SUP-2324216,CDM,L1830,CPT,0274,RC,,,,both,,,76.08,49.45,,,,,,,,,,,,,
HEAD FEM ADPT 0+ MM 12/14 HIP TAPR SEL,SUP-2449647,CDM,C1776,CPT,0278,RC,,,,both,,,621.72,404.12,,,,,,,,,,,,,
GUIDEWIRE VASC L 150 CM 0.035IN L 3 MM SS PTFE J FIX COR STD,SUP-2733978,CDM,C1769,HCPCS,0272,RC,,,,both,,,15.20,9.88,,,,,,,,,,,,,
HC Perq Dev Breast 1st US Image,PX-3611928500,CDM,19285,CPT,0361,RC,,,,inpatient,,,2124.00,1380.60,,,,,,,,,,,,,
BIT DRILL STRYKER 6015620,SUP-2855427,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1271.32,826.36,,,,,,,,,,,,,
ANCHOR SUT DIA1.4MM W/ NDL 1 STRND NO2 FORC FBR,SUP-2366689,CDM,C1713,HCPCS,0278,RC,,,,both,,,1828.52,1188.54,,,,,,,,,,,,,
TAP SURG DIA2.2 MM SD DELT,SUP-2883248,CDM,2720000010,LOCAL,0272,RC,,,,both,,,788.45,512.49,,,,,,,,,,,,,
SCREW INTFR L30MM DIA7-9MM TIB TAPR NONABSORBABLE FOR SFT,SUP-2249557,CDM,C1713,HCPCS,0278,RC,,,,both,,,800.70,520.45,,,,,,,,,,,,,
IMPLANT OPHTH 15MM MERIDIONAL,SUP-2213507,CDM,L8610,HCPCS,0278,RC,,,,both,,,69.71,45.31,,,,,,,,,,,,,
KIT EXT FIX DSTL RAD FOR MINI BAR JET-X,SUP-2342909,CDM,C1713,HCPCS,0278,RC,,,,both,,,15426.98,10027.54,,,,,,,,,,,,,
GRAFT BIO TISS W25XL40CM PORCINE REGEN TISS MTRX PLIABLE,SUP-2113042,CDM,Q4130,HCPCS,0636,RC,,,,both,,,86525.84,56241.80,,,,,,,,,,,,,
DISK ARTIFICIAL L H6MM CERV INTERVERTEBRAL CO CHROM 09820046S] CENTINEL SPINE INC],SUP-2163163,CDM,C1889,HCPCS,0278,RC,,,,both,,,16249.50,10562.17,,,,,,,,,,,,,
SCREW OPTILINK VA LCKING SLF -TP T25 SD 5.0X70MM,SUP-2653992,CDM,C1713,HCPCS,0278,RC,,,,both,,,570.13,370.58,,,,,,,,,,,,,
ELECTRODE SUCT 90DEG TPLR RF SYS W/ INTEGR HNDPIECE AND HND,SUP-2256714,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1130.40,734.76,,,,,,,,,,,,,
CATHETER CTRL VEN 24GAX3 1/2IN KT SGL LUMN STR J TIP GWIRE,SUP-2383272,CDM,C1751,HCPCS,0278,RC,,,,both,,,59.66,38.78,,,,,,,,,,,,,
SPACER FEM STD UNIV POST PRI PRESSFIT L 10MM THCK 66326440] STRYKER ORTHOPEDICS HOWM],SUP-2377238,CDM,C1776,CPT,0278,RC,,,,both,,,2347.65,1525.97,,,,,,,,,,,,,
GRAFT BNE 60CC 1 4MM CANC CRUSH CHIP READIGRFT,SUP-2264826,CDM,C1713,HCPCS,0278,RC,,,,both,,,2296.25,1492.56,,,,,,,,,,,,,
SUPPORT ORTHOT FT METATRSL CUST ARCH ATTCH TO SHOE,SUP-2435708,CDM,L3080,HCPCS,0272,RC,,,,both,,,90.02,58.51,,,,,,,,,,,,,
SET INTRO SUPER SHTH L 10 CM DIA 5 FR NIT WIRE TEARWY SUPER,SUP-2627264,CDM,C1894,HCPCS,0272,RC,,,,both,,,10.77,7.00,,,,,,,,,,,,,
CATHETER URET L70CM DIA5FR POLYUR SPRL OLV TIP W/ ADPT,SUP-2129012,CDM,C1758,HCPCS,0278,RC,,,,both,,,41.01,26.66,,,,,,,,,,,,,
ADAPTER PACE ADAP-2RL REMINGTON NS,SUP-2538009,CDM,2720000010,LOCAL,0272,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
MESH CRAN THK 0.2 MM SCREW DIA1/1.5 MM SM TRAP NS DISP,SUP-2937011,CDM,C1713,HCPCS,0278,RC,,,,both,,,788.14,512.29,,,,,,,,,,,,,
PLATE BNE THK15MM M 4 H TI LOK FOR 27MM SCR 2MM MINI SYS,SUP-2262961,CDM,C1713,HCPCS,0278,RC,,,,both,,,1346.53,875.24,,,,,,,,,,,,,
TAMP BNE BLLN 4CC L10MM 400 PRSS INFL FOR FRAC REDUC EXPR,SUP-2293621,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
TROCAR SURG PERC,SUP-2459398,CDM,2720000010,LOCAL,0272,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
SPHINCTEROTOME ENDOSCP 4.5 FRX170 CM 2.8X30 MM TRPL LUMEN,SUP-2313224,CDM,2720000010,LOCAL,0272,RC,,,,both,,,907.71,590.01,,,,,,,,,,,,,
ANCHOR SUTURE NO 2 L12MM DIAMETER 4MM POLYESTER PRETHREADED,SUP-2824801,CDM,C1713,HCPCS,0278,RC,,,,both,,,443.12,288.03,,,,,,,,,,,,,
KIT MIC INTRO 9.5FR 2 LUMN POLYUR CATH W/ SURECUF INGROWTH,SUP-2127769,CDM,C1751,HCPCS,0278,RC,,,,both,,,1246.58,810.28,,,,,,,,,,,,,
PLATE BNE 2X2 H PHLANG RECTANG GRID TI FOR 1.5MM SCR H,SUP-2267907,CDM,C1713,HCPCS,0278,RC,,,,both,,,1551.47,1008.46,,,,,,,,,,,,,
CROWN DENT LR2 SEC PRI M INDIV SPACE MAINTAINER,SUP-2176708,CDM,D6783,CPT,0278,RC,,,,both,,,23.33,15.16,,,,,,,,,,,,,
GRAFT HUM TISS W10XL36MM REV COR FRZ DRY LIG RECON,SUP-2307072,CDM,C1713,HCPCS,0278,RC,,,,both,,,3230.75,2099.99,,,,,,,,,,,,,
POST EXT FIX 4 H M,SUP-2898539,CDM,C1713,HCPCS,0278,RC,,,,both,,,606.02,393.91,,,,,,,,,,,,,
SUPPORT ORTHOPEDIC STRP LG ELBW TENNNIS NEOPRNE,SUP-2136949,CDM,L3702,HCPCS,0274,RC,,,,both,,,27.48,17.86,,,,,,,,,,,,,
AUGMENT FLNG ANTR FEM 3CM RESURF TI FINN,SUP-2406083,CDM,C1776,CPT,0278,RC,,,,both,,,2270.22,1475.64,,,,,,,,,,,,,
GRAFT VASC L80CM OD6MM PTFE NONRINGED THN WALL SM BEAD STR,SUP-2126888,CDM,C1768,CPT,0278,RC,,,,both,,,4468.22,2904.34,,,,,,,,,,,,,
GRAFT VASC BIFUR 16X8 MMX50 CM WOVEN POLYESTER INTERGARD,SUP-2246476,CDM,C1768,CPT,0278,RC,,,,both,,,1585.70,1030.70,,,,,,,,,,,,,
ANCHOR SUT DIA5.5MM W/ 2 3 COBRAID BLU BLK ULTRABRAID SUT,SUP-2341878,CDM,C1713,HCPCS,0278,RC,,,,both,,,1222.53,794.64,,,,,,,,,,,,,
SPHINCTEROTOME ENDOSCP 0.035 INX450 CM 6.5 FR DOME TIP DASH,SUP-2737238,CDM,C1769,HCPCS,0272,RC,,,,both,,,1234.02,802.11,,,,,,,,,,,,,
CATHETER ENDOBRONCHIAL BLK SET 9 FRX65 CM COHEN,SUP-2760001,CDM,2720000010,LOCAL,0272,RC,,,,both,,,970.39,630.75,,,,,,,,,,,,,
HC Adult Cpap Titration Study,PX-9209581100,CDM,95811,CPT,0920,RC,,,,both,,,5739.00,3730.35,,,,,,,,,,,,,
HC Fetal Eval 2-3 Trim Sgl Gest,PX-4027680500,CDM,76805,CPT,0402,RC,,,,outpatient,,,1288.00,837.20,,,,,,,,,,,,,
GUIDEWIRE ORTH 4.3X190 MM SS,SUP-2646008,CDM,C1769,HCPCS,0272,RC,,,,both,,,94.33,61.31,,,,,,,,,,,,,
GRAFT HUM TISS W3XL3CM CRYOPRESERVED AMNIO MEM LO PROF FOR,SUP-2116285,CDM,Q4148,HCPCS,0636,RC,,,,both,,,3124.30,2030.79,,,,,,,,,,,,,
SCREW VA LCK 2.4X8MM STARDRIVE STRL,SUP-2546111,CDM,C1713,HCPCS,0278,RC,,,,both,,,438.09,284.76,,,,,,,,,,,,,
SCREW BNE L90MM OD7MM THRD L17MM PUR HINDFOOT ANK CANN SHT,SUP-2320793,CDM,C1713,HCPCS,0278,RC,,,,both,,,1514.42,984.37,,,,,,,,,,,,,
SPLINT WRST ADJ 10 IN UNIV 7.5 IN LT COOL SFT QUIK FIT,SUP-2197068,CDM,L3908,HCPCS,0272,RC,,,,both,,,24.90,16.18,,,,,,,,,,,,,
DEVICE DCOMPR SM H12-17MM DIA12MM 0DEG THORLUM TI SIMP EZ,SUP-2390788,CDM,C1713,HCPCS,0278,RC,,,,both,,,23393.00,15205.45,,,,,,,,,,,,,
CANNULA SURG PERC FOR 3MM SCREW,SUP-2459884,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1024.61,666.00,,,,,,,,,,,,,
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-102314,CDM,J2003,HCPCS,0636,RC,00143-9595-25,NDC,,both,1,ML,54.10,35.16,,,,,,,,,,,,,
IMMOBILIZER SHLDR E M RIB MEAS 44-48IN SZ XL,SUP-2196923,CDM,L3650,HCPCS,0274,RC,,,,both,,,17.43,11.33,,,,,,,,,,,,,
BUTTON SUT LNG CORT ADJ RIGIDLOOP,SUP-2256784,CDM,C1713,HCPCS,0278,RC,,,,both,,,1683.04,1093.98,,,,,,,,,,,,,
BLADE RETRACTOR BALFOUR STD 3X2.75 IN ABD SWVL SQ SHFT NS,SUP-2477548,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1135.46,738.05,,,,,,,,,,,,,
HC Eo Dbl Upright W/Cuff Cus,PX-2740373001,CDM,L3730,HCPCS,0272,RC,,,,both,,,3165.00,2057.25,,,,,,,,,,,,,
BRACE WALKING POSTOP XS PEDI PROCARE MAXTRAX,SUP-2195785,CDM,L4360,HCPCS,0274,RC,,,,both,,,84.00,54.60,,,,,,,,,,,,,
ALLOGRAFT BNE CUBE 10X10X10 MM FD SPNG CANC READIGRAFT BLX,SUP-2741070,CDM,C1713,HCPCS,0278,RC,,,,both,,,1433.06,931.49,,,,,,,,,,,,,
SLING GYN TRANSOBTURATOR MID URETH HALO W/ PRECISIONBLUE,SUP-2139453,CDM,C1771,HCPCS,0278,RC,,,,both,,,5561.29,3614.84,,,,,,,,,,,,,
STEM FEM 14X30MM CEM ATTUNE,SUP-2251473,CDM,C1776,CPT,0278,RC,,,,both,,,2380.12,1547.08,,,,,,,,,,,,,
DEVICE ENDOSKELETAL SYS BK ALIGNABLE SYS,SUP-2388219,CDM,L5910,HCPCS,0274,RC,,,,both,,,958.74,623.18,,,,,,,,,,,,,
PLATE SPINE IMPL 3 LEV VUELOCK CERV TI 46 MM,SUP-2415779,CDM,C1713,HCPCS,0278,RC,,,,both,,,3956.40,2571.66,,,,,,,,,,,,,
MESH C-QUR EDGEXL OBLONG OVL 12 INX18 IN,SUP-2265972,CDM,C1781,HCPCS,0278,RC,,,,both,,,7856.28,5106.58,,,,,,,,,,,,,
SPACER SPNL PARL SM 5 MM COLONIAL,SUP-2598657,CDM,C1889,HCPCS,0278,RC,,,,both,,,932.58,606.18,,,,,,,,,,,,,
SUTURE FIBERTAPE W2MMXL17IN BLU STR NDL BRAID POLYBLEND AR723717LN (ORDER MULTIPLES OF 6  EACH),SUP-2122113,CDM,2720000010,LOCAL,0272,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
CATHETER THORACENTESIS SET 8.5 FRX15 CM 8 SIDEPRT,SUP-2760036,CDM,C1729,HCPCS,0272,RC,,,,both,,,801.77,521.15,,,,,,,,,,,,,
SYSTEM CARD DEFIB ATLS II VR,SUP-2356519,CDM,C1722,HCPCS,0275,RC,,,,both,,,68766.00,44697.90,,,,,,,,,,,,,
SPHINCTEROTOME ENDOSCP DST 3.9FR L20MM TIP L5MM GWIRE,SUP-2149819,CDM,C1769,HCPCS,0272,RC,,,,both,,,978.83,636.24,,,,,,,,,,,,,
TIP SONOPET IQ LARGE 12CM,SUP-2755027,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2747.53,1785.89,,,,,,,,,,,,,
BONE MACH BLK 7X15MM GIC58 TRICORT ILIUM,SUP-2293821,CDM,C1713,HCPCS,0278,RC,,,,both,,,1877.72,1220.52,,,,,,,,,,,,,
GUIDEWIRE ORTH PARL 2.8 MM,SUP-2657789,CDM,C1769,HCPCS,0272,RC,,,,both,,,3118.02,2026.71,,,,,,,,,,,,,
BUR SURG 3.1 MM STRT ORTHOSPHERE CMC,SUP-2521577,CDM,2720000010,LOCAL,0272,RC,,,,both,,,288.88,187.77,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.437,SUP-2860001,CDM,C1713,HCPCS,0278,RC,,,,both,,,45322.76,29459.79,,,,,,,,,,,,,
GRAFT BNE SUB W10 30MM SPL L50 130MM THK1 20MM RIB SEGMENTS,SUP-2307187,CDM,C1713,HCPCS,0278,RC,,,,both,,,888.43,577.48,,,,,,,,,,,,,
GRASPER ARTHSCP SHFT L15CM 15DEG GRY SUT MGMT IDEAL,SUP-2256808,CDM,2720000010,LOCAL,0272,RC,,,,both,,,923.16,600.05,,,,,,,,,,,,,
JIG SURG REDUC FX CAGE PH,SUP-2167383,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2041.00,1326.65,,,,,,,,,,,,,
SYRINGE IRRIGATION CONE TIP 150 CC FIX,SUP-2747413,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1571.82,1021.68,,,,,,,,,,,,,
SPACER SPNL 8MM LONESTAR,SUP-2317851,CDM,C1821,HCPCS,0278,RC,,,,both,,,8164.00,5306.60,,,,,,,,,,,,,
DEVICE THERM REG SIL ESOPH MLTI LUMEN CLIK-TITE CONN 5 DEG,SUP-2882141,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2668.22,1734.34,,,,,,,,,,,,,
SPACER SPNL 65X20X10-17 MM ELSA,SUP-2732362,CDM,C1889,HCPCS,0278,RC,,,,both,,,29202.00,18981.30,,,,,,,,,,,,,
HC Sc Ther Infusion Up to 1 Hr,PX-2609636900,CDM,96369,CPT,0260,RC,,,,both,,,267.00,173.55,,,,,,,,,,,,,
LOOP LENS GILLS-WELSH 4.75 IN 7X5 MM OLV TIP ON OPPOSITE END,SUP-2872025,CDM,2720000010,LOCAL,0272,RC,,,,both,,,651.27,423.33,,,,,,,,,,,,,
NUT SPNL W11MM UNIV PEDCL THORLUM TI ALLY FLAT SM STAT USS,SUP-2193398,CDM,C1713,HCPCS,0278,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
SLEEVE SURG DRL MICA MINIBUNION,SUP-2435410,CDM,2720000010,LOCAL,0272,RC,,,,both,,,417.62,271.45,,,,,,,,,,,,,
KIT SUT ANCHR DISPOSABLES FOR SH 2.9MM PUSHLOCKXL,SUP-2121758,CDM,C1713,HCPCS,0278,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
IMPL CAPITELLUM RADIO LT LG SBI,SUP-2701552,CDM,C1776,CPT,0278,RC,,,,both,,,9435.23,6132.90,,,,,,,,,,,,,
HC CT Angio Abdomen W & W/O Cont,PX-3527417500,CDM,74175,CPT,0352,RC,,,,outpatient,,,4683.00,3043.95,,,,,,,,,,,,,
CATHETER BLLN DIL PRESSURE MONITORING SET AD 5 FRX36 IN,SUP-2756350,CDM,C1725,HCPCS,0272,RC,,,,both,,,154.52,100.44,,,,,,,,,,,,,
KIT BNE CEM MIX W/ SHT EXTN TB HV W/OUT NDL PRECIS SYS,SUP-2367031,CDM,C1713,HCPCS,0278,RC,,,,both,,,1815.64,1180.17,,,,,,,,,,,,,
PLATE BNE 11 H ORBIT RIM TI FOR PLUSDRIVE SCR,SUP-2190575,CDM,C1713,HCPCS,0278,RC,,,,both,,,1103.40,717.21,,,,,,,,,,,,,
ALLOGRAFT BNE WDG 0 DEG 18 MM LORDTC ILLIAC CREST BIO,SUP-2637034,CDM,C1713,HCPCS,0278,RC,,,,both,,,4100.46,2665.30,,,,,,,,,,,,,
SUPPORT ORTHOT WRST ELBW HND FNGR W/JT ELASTIC FABRICATED,SUP-2435765,CDM,L3766,HCPCS,0274,RC,,,,both,,,3498.56,2274.06,,,,,,,,,,,,,
COLLAR CERV H325XL19IN M TRACH CLS VELC CLSR CNTOUR LO DENS,SUP-2196900,CDM,L0120,HCPCS,0274,RC,,,,both,,,8.54,5.55,,,,,,,,,,,,,
SHOE ORTHOT CALIP PLATE EXISTING TRANSFER,SUP-2435745,CDM,L3600,HCPCS,0272,RC,,,,both,,,216.03,140.42,,,,,,,,,,,,,
CATHETER SPEC RETRV BKSTP 3 FR GEL STONE ANTIRETROPULSION,SUP-2149867,CDM,C1713,HCPCS,0278,RC,,,,both,,,1186.92,771.50,,,,,,,,,,,,,
ALLOGRAFT BNE FRZN IRRADIATED COSTAL CART,SUP-2867161,CDM,C1762,CPT,0278,RC,,,,both,,,2789.11,1812.92,,,,,,,,,,,,,
DRILL SURG 6 MM GENDER SOL N-K FLX,SUP-2438081,CDM,2720000010,LOCAL,0272,RC,,,,both,,,367.38,238.80,,,,,,,,,,,,,
SPLINT KNEE L16IN FOR 29IN THGH UNIV NYL FBR LAM ALUM FOAM,SUP-2196753,CDM,L1830,CPT,0274,RC,,,,both,,,43.08,28.00,,,,,,,,,,,,,
CATHETER CV TY 7 FRX20 CM 3L CUTLMY701JABRMCUSTOM0018,SUP-2759903,CDM,C1751,HCPCS,0278,RC,,,,both,,,478.25,310.86,,,,,,,,,,,,,
SLING GYN TRANSOBTURATOR APPRCH GYNECARE TVT ABBREVO,SUP-2220076,CDM,C1771,HCPCS,0278,RC,,,,both,,,6812.29,4427.99,,,,,,,,,,,,,
SUPPORT ORTHOT CUST RNG MOL PLAS LTHR,SUP-2435582,CDM,L1110,HCPCS,0274,RC,,,,both,,,901.46,585.95,,,,,,,,,,,,,
ANCHOR FIX L 18 MM DIA 5.5 MM TI INLINE NS,SUP-2895467,CDM,C1713,HCPCS,0278,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
GRAFT BNE SUB 60CC 1.7MM-10MM CHIP FRZ DRY CANC,SUP-2307079,CDM,C1713,HCPCS,0278,RC,,,,both,,,2113.22,1373.59,,,,,,,,,,,,,
ALLOGRAFT BNE STRP SM FD ASEP IL CREST,SUP-2867019,CDM,C1762,CPT,0278,RC,,,,both,,,2201.45,1430.94,,,,,,,,,,,,,
CATHETER EXT INTMED SZ 32MM CLR SELF ADH POLYTECH,SUP-2239737,CDM,C1758,HCPCS,0278,RC,,,,both,,,3.14,2.04,,,,,,,,,,,,,
VALVE NEUROSURGICAL OD1.9MM CATHETERL90CM 40CM VERTICAL WATE,SUP-2825677,CDM,C1889,HCPCS,0278,RC,,,,both,,,6978.84,4536.25,,,,,,,,,,,,,
ACCESSORY KIT WEARABLE FOR PC HEARTMATE II GOGEAR,SUP-2356022,CDM,C1713,HCPCS,0278,RC,,,,both,,,533.80,346.97,,,,,,,,,,,,,
CATHETER HD STR 13 FRX24 CM SHT TERM DL KT DUOGLIDE,SUP-2431943,CDM,C1752,HCPCS,0278,RC,,,,both,,,375.54,244.10,,,,,,,,,,,,,
INTRODUCER SHTH GUID 0.038 IN 8.5 FRX60 CM DIL FAST-CATH,SUP-2357188,CDM,C1894,HCPCS,0272,RC,,,,both,,,527.52,342.89,,,,,,,,,,,,,
COIL EMB L3CM DST DIA2MM PROX DIA3MM FBR DETACH GDC-18,SUP-2367913,CDM,C1889,HCPCS,0278,RC,,,,both,,,6000.54,3900.35,,,,,,,,,,,,,
HC Xr Aortogram Thorac S&I,PX-3237560500,CDM,75605,CPT,0323,RC,,,,both,,,3892.00,2529.80,,,,,,,,,,,,,
BIT DRL L 13 CM DIA 3.5 MM TIB SQ TIP FOR TOT ANK REPL SYS,SUP-2899034,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1071.53,696.49,,,,,,,,,,,,,
HC Treat Humerus Fx,PX-4502450000,CDM,24500,CPT,0450,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
GRAFT BNE SUB 5CC DBM GEL FRZ DRY OPTIUM,SUP-2264857,CDM,C1713,HCPCS,0278,RC,,,,both,,,1698.30,1103.89,,,,,,,,,,,,,
WIRE FIX SMOOTH 400 MM KIRSCHNER,SUP-2162649,CDM,2720000010,LOCAL,0272,RC,,,,both,,,660.66,429.43,,,,,,,,,,,,,
TUBE JEJUNOSTOMY FEED 18 FRX2.5 CM 5 CC N ENFIT SIL MIC-KEY,SUP-2764777,CDM,2720000010,LOCAL,0272,RC,,,,both,,,535.24,347.91,,,,,,,,,,,,,
PLATE BNE W14XL115MM THK3.8MM 90DEG 6 H L TIB S STL L SHP,SUP-2185781,CDM,C1713,HCPCS,0278,RC,,,,both,,,1777.68,1155.49,,,,,,,,,,,,,
SPLINT KNEE L16IN FOR 29IN THGH UNIV FOAM LAM 3IN E CNTCT,SUP-2197153,CDM,L1810,HCPCS,0272,RC,,,,both,,,32.37,21.04,,,,,,,,,,,,,
CATHETER CV OXMTR 16 CM 3L SCVO2 MONITORING OLIGON,SUP-2480230,CDM,C1751,HCPCS,0278,RC,,,,both,,,957.70,622.50,,,,,,,,,,,,,
KIT CATHETER 3FR SGL LUMN POLY FULL MIDLN,SUP-2125576,CDM,C1751,HCPCS,0278,RC,,,,both,,,307.72,200.02,,,,,,,,,,,,,
SLEEVE CNTR DIA5MM S STL FOR TAY SPAT FRME ILIZ RANCHO,SUP-2342330,CDM,2720000010,LOCAL,0272,RC,,,,both,,,874.14,568.19,,,,,,,,,,,,,
PLATE BNE X 1.5X0.6 MM 6 MM C-TUBE BRIDGE TI NS LEVEL 1,SUP-2485813,CDM,C1713,HCPCS,0278,RC,,,,both,,,410.27,266.68,,,,,,,,,,,,,
BLADE SHV DIA4MM 75DEG CRV SERR DISECT CONCAVE WIND FOR,SUP-2313833,CDM,C1713,HCPCS,0278,RC,,,,both,,,400.76,260.49,,,,,,,,,,,,,
SCREW SPNL N CANN 8.5X35 MM FOR PEEK ROD HA CD HORZ,SUP-2630797,CDM,C1713,HCPCS,0278,RC,,,,both,,,2684.70,1745.05,,,,,,,,,,,,,
PATCH CV W3XL6CM THK05MM PTFE STR STD WALL NONTAPERED,SUP-2395325,CDM,C1768,CPT,0278,RC,,,,both,,,938.86,610.26,,,,,,,,,,,,,
PIN FIX STERILE L150MM DIA3.2MM FLUT,SUP-2877819,CDM,C1776,CPT,0278,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
PLATE BNE TIBIOTALAR ANTR AXSOS 3 630101,SUP-2613575,CDM,C1713,HCPCS,0278,RC,,,,both,,,9608.40,6245.46,,,,,,,,,,,,,
OBTURATOR ENDOSCP BLNT 10 MM SINGLE PRT DA VINCI REUSE,SUP-2246709,CDM,C1713,HCPCS,0278,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
DARBEPOETIN ALFA 200 MCG/0.4ML IJ SOSY,RX-131232,CDM,J0881,HCPCS,0636,RC,55513-0028-01,NDC,,both,0.4,ML,4566.60,2968.29,,,,,,,,,,,,,
PLATE BNE L 197 MM SCREW DIA 4.5 MM 9 H RT DSTL FEM ST LCK,SUP-2931330,CDM,C1713,HCPCS,0278,RC,,,,both,,,11070.07,7195.55,,,,,,,,,,,,,
CATHETER ANGIOPLSTY RANG L 150 CM BALLOON L 200 MM DIA 4 MM,SUP-2754424,CDM,C2623,HCPCS,0278,RC,,,,both,,,6578.30,4275.89,,,,,,,,,,,,,
TUBE CONN OUTER MID TELLURIDE FOR MIS SPNL FIX SYS,SUP-2211191,CDM,2780000010,LOCAL,0278,RC,,,,both,,,2115.73,1375.22,,,,,,,,,,,,,
STEM FEM 2 125 MM MOLD PROSTALAC,SUP-2454727,CDM,C1776,CPT,0278,RC,,,,both,,,23427.54,15227.90,,,,,,,,,,,,,
SUPPORT ORTHOT WRST HND FNGR CUST ADJ W/JT FABRICATED,SUP-2435766,CDM,L3806,HCPCS,0274,RC,,,,both,,,1170.37,760.74,,,,,,,,,,,,,
COUNTERSINK DRL SHT MINI EXTRM MTP PKT MASXLOCK,SUP-2400512,CDM,2720000010,LOCAL,0272,RC,,,,both,,,477.28,310.23,,,,,,,,,,,,,
PLATE BNE CRV MINI 28X14 MM CRANIOFACIAL 6 HOLE TRI SHP SAG,SUP-2460012,CDM,C1713,HCPCS,0278,RC,,,,both,,,629.22,408.99,,,,,,,,,,,,,
STENT URET TAIL + L 34 CM DIA PROX/DSTL 6/3 FR PERCFLX,SUP-2141647,CDM,C1874,HCPCS,0278,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
GRAFT BNE SUB W25XH4XL240MM THK4MM 24ML B TRICALCIUM PHSPTE,SUP-2368174,CDM,C1713,HCPCS,0278,RC,,,,both,,,7222.00,4694.30,,,,,,,,,,,,,
SCREW SPNL L15MM DIA4.5MM ST CANC ANT CERV TI FIX ANG,SUP-2293268,CDM,C1713,HCPCS,0278,RC,,,,both,,,1140.92,741.60,,,,,,,,,,,,,
GUIDEWIRE INTRMDLLRY NAIL 32MM SHAFT 60CML SMTH/BLNT TIPS,SUP-2726657,CDM,C1769,HCPCS,0272,RC,,,,both,,,496.78,322.91,,,,,,,,,,,,,
PROPHECY PATIENT SPEC GUIDES FOR INVISION WITH FOOTPRINT,SUP-2830301,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3852.78,2504.31,,,,,,,,,,,,,
GRAFT VASC FUSION BIOLINE L 60 CM DIA 6 MM AX COMPLIANCE,SUP-2477406,CDM,C1768,CPT,0278,RC,,,,both,,,4814.56,3129.46,,,,,,,,,,,,,
TRAY CATH HEMODIALYSI DUO SPLIT ACTE 13FR DIA 20CM INTRNL JU,SUP-2610514,CDM,C1752,HCPCS,0278,RC,,,,both,,,310.86,202.06,,,,,,,,,,,,,
DEFIBRILLATOR CARD W/ HM LUMAX 740 DX,SUP-2138277,CDM,C1722,HCPCS,0275,RC,,,,both,,,43018.00,27961.70,,,,,,,,,,,,,
CATHETER VENTRICULAR STR 1.3X2.5X23 CM LG HOLE SLT TIP,SUP-2851432,CDM,C1729,HCPCS,0272,RC,,,,both,,,510.56,331.86,,,,,,,,,,,,,
DEVICE ENDOSKELETAL SYS KNEE SHIN FRIC,SUP-2388218,CDM,L5812,HCPCS,0272,RC,,,,both,,,1485.85,965.80,,,,,,,,,,,,,
GRAFT HUM TISS 200MM TISS FRZN SEMITENDINOSIS AND GRACILIS,SUP-2137248,CDM,C1762,CPT,0278,RC,,,,both,,,5024.00,3265.60,,,,,,,,,,,,,
INTRODUCER SHTH 0.021 IN 6 FRX23 CM 21 GAX4 CM PRELUDE EASE,SUP-2798464,CDM,C1894,HCPCS,0272,RC,,,,both,,,230.79,150.01,,,,,,,,,,,,,
PLATE BNE L95MM 3 H TI R FIBULAR LOK COMPR PROX BULL TIP,SUP-2413692,CDM,C1713,HCPCS,0278,RC,,,,both,,,2125.97,1381.88,,,,,,,,,,,,,
GUIDEWIRE ORTH TROCAR PT 1 END 0.094X9.25 IN THRD STRL,SUP-2846265,CDM,C1769,HCPCS,0272,RC,,,,both,,,571.48,371.46,,,,,,,,,,,,,
BIT DRL DIA2.9MM DISP FOR VERSANAIL HUM UNIV NAILING SYS,SUP-2412817,CDM,2720000010,LOCAL,0272,RC,,,,both,,,571.48,371.46,,,,,,,,,,,,,
RETRACTOR SPNL L7CM DIA26MM D275IN S STL TB MED LAT DIL BLNT,SUP-2293060,CDM,C1713,HCPCS,0278,RC,,,,both,,,1109.68,721.29,,,,,,,,,,,,,
PLATE EXTN FOR SHEFFIELD STERILISATION TY SYS,SUP-2316257,CDM,C1713,HCPCS,0278,RC,,,,both,,,628.25,408.36,,,,,,,,,,,,,
HC Electron Microscopy Diagnostic,PX-3128834800,CDM,88348,CPT,0312,RC,,,,inpatient,,,1815.00,1179.75,,,,,,,,,,,,,
GRAFT HUM TISS 3X3 CM REP AMNIO TISS MEMBRN,SUP-2423431,CDM,C1762,CPT,0278,RC,,,,both,,,5375.68,3494.19,,,,,,,,,,,,,
GUIDEWIRE ORTH THRD 2.8X220 MM FOR CANN SCREW NS 03333014,SUP-2789095,CDM,C1769,HCPCS,0272,RC,,,,both,,,429.43,279.13,,,,,,,,,,,,,
VORICONAZOLE 40 MG/ML PO SUSR,RX-38103,CDM,340b,HCPCS,0637,RC,09999-9914-77,NDC,,both,5,ML,145.60,94.64,,,,,,,,,,,,,
SHEATH INTRO INPUT PS L 6 CM DIA 6 FR AD W/O HEMOSTATIC VLV,SUP-2141020,CDM,C1894,HCPCS,0272,RC,,,,both,,,35.95,23.37,,,,,,,,,,,,,
PIN FIX SINGLE DIAMOND 0.177X9 IN SHANK END SS NS STEINMANN,SUP-2791598,CDM,C1713,HCPCS,0278,RC,,,,both,,,55.08,35.80,,,,,,,,,,,,,
BIT DRL L150MM DIA2MM ST CANN QUIK CPL NONRADIOPAQUE W/O,SUP-2187218,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1180.26,767.17,,,,,,,,,,,,,
INTRODUCER CATHETER L32CM PERC SHLD,SUP-2133169,CDM,C1894,HCPCS,0272,RC,,,,both,,,119.92,77.95,,,,,,,,,,,,,
KIT VASC SNR AMPLTZ GOOSE NK 90 DEG L 120 MM LOOP DIA25 MM,SUP-2172948,CDM,C1773,HCPCS,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
NUT EXT FIX SPD NS DISP,SUP-2932766,CDM,2720000010,LOCAL,0272,RC,,,,both,,,251.23,163.30,,,,,,,,,,,,,
FIBERTAPE STERNAL CLOSURE WITH BLUNT NDL,SUP-2814067,CDM,2720000010,LOCAL,0272,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
KIT SUTURE LG HS FIBER SUTURE ORTH SURG NDL FOR OPN SFT TISS,SUP-2906617,CDM,C1713,HCPCS,0278,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
NEEDLE BRACHYTHERAPY L20CM DIA18GA APPL SEEDWITH ULT SHRP,SUP-2129081,CDM,C1715,HCPCS,0272,RC,,,,both,,,1089.58,708.23,,,,,,,,,,,,,
PLATE BNE W16XL235MM BLDE L50MM THK48MM 95DEG 14 H ST BILAT,SUP-2185475,CDM,C1713,HCPCS,0278,RC,,,,both,,,5316.05,3455.43,,,,,,,,,,,,,
SCREW BNE L90MM DIA3.5MM S STL CORT PERIARTC ST,SUP-2410854,CDM,C1713,HCPCS,0278,RC,,,,both,,,351.90,228.73,,,,,,,,,,,,,
CATHETER ANGIOPLSTY MAVERICK2 L 142 CM BALLOON L 9 MM DIA 3,SUP-2143670,CDM,C1725,HCPCS,0272,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
RING FIX SZ 5 8 180MM ALUMINUM MAXFRAME,SUP-2255814,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3378.80,2196.22,,,,,,,,,,,,,
RING ANNULPLSTY CARP EDW PHY DIA24 MM TI ALLOY POLYESTER SIL,SUP-2214260,CDM,C1889,HCPCS,0278,RC,,,,both,,,12874.00,8368.10,,,,,,,,,,,,,
INSERT TALAR SZ 4 THK13MM ANK POLYETH FOR PROPHECY INBONE 2,SUP-2397178,CDM,C1776,CPT,0278,RC,,,,both,,,5221.82,3394.18,,,,,,,,,,,,,
LORAZEPAM 2 MG/ML PO CONC,RX-4571,CDM,340b,HCPCS,0637,RC,09999-9905-54,NDC,,both,0.25,ML,2.70,1.75,,,,,,,,,,,,,
NAIL IM 2 L345MM OD12MM TI DST RAD MINIMALLY INVASIVE FIX,SUP-2398593,CDM,C1713,HCPCS,0278,RC,,,,both,,,6983.36,4539.18,,,,,,,,,,,,,
ONDANSETRON 8 MG PO TBDP,RX-27698,CDM,Q0162,HCPCS,0637,RC,65862-0391-10,NDC,,both,1,UN,3.90,2.53,,,,,,,,,,,,,
PORT 8FR PWR INJ MID SIZED TI DIGNITY W/ ATTACH CATH,SUP-2268425,CDM,C1788,HCPCS,0278,RC,,,,both,,,1146.10,744.96,,,,,,,,,,,,,
NAIL IM L300MM DIA16MM R LAT FEM AQUA TI CANN LOK CRV ENTRY,SUP-2179787,CDM,C1713,HCPCS,0278,RC,,,,both,,,5361.99,3485.29,,,,,,,,,,,,,
MESH CRAN CUSTOMIZED + XL PRIORITY STRL MEDPOR,SUP-2862760,CDM,C1713,HCPCS,0278,RC,,,,both,,,75264.45,48921.89,,,,,,,,,,,,,
PLATE BNE L 202 MM 6 H SCREW DIA 3.5/4.5 MM LT TROCHANTERIC,SUP-2931428,CDM,C1713,HCPCS,0278,RC,,,,both,,,20637.65,13414.47,,,,,,,,,,,,,
PROSTHESIS EAR INCUS EXTENSIBLE 2.5-5 MM POR,SUP-2247167,CDM,L8613,CPT,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
PLATE BNE INFRAPECTINEAL SM RT QUADRILATERAL SURF NS,SUP-2461137,CDM,C1713,HCPCS,0278,RC,,,,both,,,5181.00,3367.65,,,,,,,,,,,,,
CANNULA BYPS ART 17FR VEN 24FR TANDEMHEART BLD PMP,SUP-2152649,CDM,C1889,HCPCS,0278,RC,,,,both,,,51810.00,33676.50,,,,,,,,,,,,,
COIL VASC AZUR HYDROCOIL L 6 CM DIA 4 MM MICROCATHETER 0.035,SUP-2385371,CDM,C1889,HCPCS,0278,RC,,,,both,,,926.33,602.11,,,,,,,,,,,,,
HC So Protein Western Blot Test,PX-3018418266,CDM,84182,CPT,0301,RC,,,,both,,,67.00,43.55,,,,,,,,,,,,,
SUPPORT ORTHOT KNEE ANTR CRUC LIGMNT CUST DEROTATION,SUP-2435612,CDM,L1840,HCPCS,0272,RC,,,,both,,,2662.44,1730.59,,,,,,,,,,,,,
LINER ACET 40X58-60 MM HIP FACE CHANGING UHMWPE VIT E,SUP-2308987,CDM,C1776,CPT,0278,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
ALLOGRAFT CUBE CANC IRRADIATED 60CC,SUP-2212021,CDM,C1889,HCPCS,0278,RC,,,,both,,,3617.28,2351.23,,,,,,,,,,,,,
STENT PERIPH ABRE L 100 MM DIA10 MM CATH WORKING L 90 CM,SUP-2665373,CDM,C1876,HCPCS,0278,RC,,,,both,,,4694.30,3051.29,,,,,,,,,,,,,
SPACER HIP LG PMMA INNR SS GENTAMICIN TEMP RADIOPAQUE STRL,SUP-2905387,CDM,C1776,CPT,0278,RC,,,,both,,,12089.00,7857.85,,,,,,,,,,,,,
CLONIDINE 0.02 MG/ML PO SUSP,RX-4081830,CDM,6370000000,HCPCS,0637,RC,99999-9915-00,NDC,,both,1,ML,2.70,1.75,,,,,,,,,,,,,
APPLIER ANEURYSM CLIP YASARGIL MINI FINGER TIP GRIP STRAIGHT,SUP-2821561,CDM,C1889,HCPCS,0278,RC,,,,both,,,4716.91,3065.99,,,,,,,,,,,,,
STENT LACR L 28 MM DIA 3.5 MM MEDPOR TRIM STRL,SUP-2883451,CDM,2720000010,LOCAL,0272,RC,,,,both,,,932.11,605.87,,,,,,,,,,,,,
CANNULA ENDOSCP N THRD KII SHLD ACCES,SUP-2119605,CDM,2720000010,LOCAL,0272,RC,,,,both,,,483.25,314.11,,,,,,,,,,,,,
PLATE BONE L152MM 12 H STRL S STL COMPR FOR 3.5MM SCR EVOS,SUP-2349640,CDM,C1713,HCPCS,0278,RC,,,,both,,,1358.43,882.98,,,,,,,,,,,,,
HC Ot Ther Ex per 15 Min|OP OCCUPATIONAL THERAPY SERV|DOCUMENTATION ON FILE|SERVICES PROVIDED IN WHOLE OR IN PARTY BY AN OTA FOR MEDICARE PATIENTS|UNUSUAL NON-OVERLAPPING SERVICE,PX-4309711000,CDM,97110,CPT,0430,RC,,,GO|KX|CO|XU,both,,,195.00,126.75,,,,,,,,,,,,,
PLATE BNE L46MM 5 H ST DST DORS RAD S STL CLMN LOK COMPR,SUP-2420768,CDM,C1713,HCPCS,0278,RC,,,,both,,,2070.30,1345.69,,,,,,,,,,,,,
HEAD RADIAL 2 FLEXSPAN,SUP-2538173,CDM,C1776,CPT,0278,RC,,,,both,,,9052.62,5884.20,,,,,,,,,,,,,
GUIDEWIRE ORTHOPEDIC 0.059 MM TROCAR PT 1 END,SUP-2107891,CDM,C1769,HCPCS,0272,RC,,,,both,,,47.10,30.61,,,,,,,,,,,,,
MICROCATHETER INFUSION MARKSMAN L 160 CM OD PROX/DSTL,SUP-2280932,CDM,C1887,HCPCS,0272,RC,,,,both,,,3375.50,2194.07,,,,,,,,,,,,,
NEEDLE TRANSSEPTAL 22GA L56CM 50DEG TRNSLUC HUB HEARTSPAN,SUP-2302569,CDM,C1713,HCPCS,0278,RC,,,,both,,,412.13,267.88,,,,,,,,,,,,,
PLATE BNE L 131 MM SCREW DIA 4.5 MM 7 H NAR COMPR NLCK NS,SUP-2932891,CDM,C1713,HCPCS,0278,RC,,,,both,,,1597.48,1038.36,,,,,,,,,,,,,
SCREW BONE L30MM DIA3MM CO CHROM POLYAX LCK CANN FOR PROX,SUP-2340276,CDM,C1713,HCPCS,0278,RC,,,,both,,,728.48,473.51,,,,,,,,,,,,,
IMETELSTAT SODIUM 31.4 MG/ML IV SOLN (MIXTURES ONLY),RX-4082818,CDM,J0870,HCPCS,0636,RC,82959-0112-01,NDC,,both,1.5,ML,11242.40,7307.56,,,,,,,,,,,,,
STEM FEM L138MM DIA13MM STD NK OFFSET HIP PROS TRABECULAR,SUP-2203543,CDM,C1776,CPT,0278,RC,,,,both,,,6280.00,4082.00,,,,,,,,,,,,,
HEAD FEM M 14/16 DIA36MM +5 OFFSET HIP CO CHROM TAPR PRI,SUP-2249728,CDM,C1776,CPT,0278,RC,,,,both,,,3671.29,2386.34,,,,,,,,,,,,,
PLATE BNE L28MM THK1MM 6 H NONSTERILE HND TI STR LOK VAR ANG,SUP-2181003,CDM,C1713,HCPCS,0278,RC,,,,both,,,1444.68,939.04,,,,,,,,,,,,,
TRIAL NERVE STIM EXT REFURB SPECTR WAVEWRITER,SUP-2141941,CDM,C1820,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
CAGE GLEN SM STD POLYETH ALPHA CEM OR PRSS FIT BILAT,SUP-2223363,CDM,C1776,CPT,0278,RC,,,,both,,,3925.00,2551.25,,,,,,,,,,,,,
FILTER VASC OPTEASE L 90 CM DIA 6 FR NIT AC JUG ACCS,SUP-2865605,CDM,C1880,HCPCS,0278,RC,,,,both,,,4615.80,3000.27,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH FLX L 56 MM DIA24 MM SHTH 16 FR SS,SUP-2170654,CDM,C1768,CPT,0278,RC,,,,both,,,9407.44,6114.84,,,,,,,,,,,,,
KNIFE NDLE ENDSCPC 5FR OD DST TIP 5MML 170CML WRKNG PRCRVD T,SUP-2675533,CDM,2720000010,LOCAL,0272,RC,,,,both,,,701.01,455.66,,,,,,,,,,,,,
STEM FEMORAL 115X17MM CONICAL TI DISTAL REVISION,SUP-2880911,CDM,C1776,CPT,0278,RC,,,,both,,,9185.44,5970.54,,,,,,,,,,,,,
IMMOBILIZER KNEE 3 PNL 19 IN,SUP-2336076,CDM,L1830,CPT,0272,RC,,,,both,,,37.65,24.47,,,,,,,,,,,,,
HC Biopsy of Salivary Gland,PX-3614240000,CDM,42400,CPT,0361,RC,,,,inpatient,,,3707.00,2409.55,,,,,,,,,,,,,
PLATE BNE L20MM UNICOMPRESSION INTERAXIS UNI CLIP,SUP-2243463,CDM,C1713,HCPCS,0278,RC,,,,both,,,3358.39,2182.95,,,,,,,,,,,,,
CUTTER FNGR RNG ECON NICKEL PLT,SUP-2382309,CDM,C1776,CPT,0278,RC,,,,both,,,100.01,65.01,,,,,,,,,,,,,
CATHETER CV FULL SAFETY TY 032 7 FRX15 CM 3L STD,SUP-2759917,CDM,C1751,HCPCS,0278,RC,,,,both,,,369.67,240.29,,,,,,,,,,,,,
LENS IOL 3 PC 22+ DIOPT 6 MM POST CHMBR MLPC TECNIS,SUP-2102332,CDM,V2632,HCPCS,0276,RC,,,,both,,,292.02,189.81,,,,,,,,,,,,,
GRAFT HUMAN TISSUE VIALIZE 4 X 4CM PLACENTAL MEMBRANE,SUP-2863009,CDM,C1762,CPT,0278,RC,,,,both,,,4223.30,2745.14,,,,,,,,,,,,,
PLATE BNE LCK 2.7 MM 5 HOLE CNTOUR 2 COMPR FOR SCR TI STRL,SUP-2459176,CDM,C1713,HCPCS,0278,RC,,,,both,,,827.96,538.17,,,,,,,,,,,,,
WRAP SURG W1.31XL1.34M CARD FOR PT 165-172CM THERMOWRP,SUP-2300140,CDM,C1713,HCPCS,0278,RC,,,,both,,,515.21,334.89,,,,,,,,,,,,,
PLATE BNE STR 3 H TARSALIS,SUP-2243237,CDM,C1713,HCPCS,0278,RC,,,,both,,,5351.94,3478.76,,,,,,,,,,,,,
GRAFT VASC ADVANTA SST L 80 CM DIA 8 MM EPTFE STR TW REINF 3,SUP-2265944,CDM,C1768,CPT,0278,RC,,,,both,,,4236.46,2753.70,,,,,,,,,,,,,
GRAFT VASC L40CM ID6MM THN WALLED CBAS HEP SURF PROPATEN,SUP-2395809,CDM,C1768,CPT,0278,RC,,,,both,,,3874.76,2518.59,,,,,,,,,,,,,
SUPPORT ORTHOT FT CUST ABDUCTN ROT BAR W/SHOE,SUP-2435711,CDM,L3140,HCPCS,0272,RC,,,,both,,,252.05,163.83,,,,,,,,,,,,,
KIT THROMCTMY STROKE FAST PK CATH AXS VECTA 46 CM VECTA 74,SUP-2878081,CDM,C1757,HCPCS,0272,RC,,,,both,,,13302.92,8646.90,,,,,,,,,,,,,
SCREW SPNL CANN 4.5X22 MM OCT FOR 4 MM REDUC NS SYM,SUP-2590159,CDM,C1713,HCPCS,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
BIT DRL SLD 2 MM SPIDER,SUP-2610408,CDM,2720000010,LOCAL,0272,RC,,,,both,,,661.06,429.69,,,,,,,,,,,,,
BUR SURG L 51 MM DIA2.35 MM HD L 4 MM DIA1.2 MM TUNGSTEN,SUP-2929084,CDM,2720000010,LOCAL,0272,RC,,,,both,,,139.29,90.54,,,,,,,,,,,,,
IMPLANT OSS L2.75MM DIA1.17MM SHT INCUS STAP HA FULL CANN,SUP-2313671,CDM,L8613,CPT,0278,RC,,,,both,,,1160.80,754.52,,,,,,,,,,,,,
WEDGE TIB M SZ 2 THK10MM KNEE PRI PRESSFIT FULL FLAT BLK,SUP-2377114,CDM,C1776,CPT,0278,RC,,,,both,,,3244.12,2108.68,,,,,,,,,,,,,
KEEL LARYNGEAL MONTGOMERY SZ 14 MM SIL UMBRELLA SHP N ADH,SUP-2139780,CDM,C1889,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
BIT DRL L50MM DIA1.8MM STP 22MM FOR LORENZ MAND PLATING SYS,SUP-2136818,CDM,2720000010,LOCAL,0272,RC,,,,both,,,477.28,310.23,,,,,,,,,,,,,
SCREW EXT FIX L260MM SHFT DIA6MM THRD L50MM DIA6 56MM HA,SUP-2316319,CDM,C1713,HCPCS,0278,RC,,,,both,,,424.84,276.15,,,,,,,,,,,,,
HC X-Ray Exam Chest 4+ Views,PX-3247104800,CDM,71048,CPT,0324,RC,,,,outpatient,,,1066.00,692.90,,,,,,,,,,,,,
PLUG BONE 9MM FD IRR,SUP-2875984,CDM,C1713,HCPCS,0278,RC,,,,both,,,1798.75,1169.19,,,,,,,,,,,,,
LENS INTOCU +10.0 DIOPT L12.5MM DIA5.5MM 5DEG HAPTIC ANG A,SUP-2110304,CDM,V2632,HCPCS,0276,RC,,,,both,,,389.36,253.08,,,,,,,,,,,,,
CONNECTOR SPNL 55X30 35MM TRNSVRS PROLIANT,SUP-2163946,CDM,C1713,HCPCS,0278,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
LEVEL CMF ST SIZER SET MDFCE TRMA ALMNM QT001 EA,SUP-2677520,CDM,2720000010,LOCAL,0272,RC,,,,both,,,317.08,206.10,,,,,,,,,,,,,
KIT STPL W20XL20MM BNE FIX BRDG 2 LEG CONT COMPR BME ELITE,SUP-2254042,CDM,C1713,HCPCS,0278,RC,,,,both,,,4490.67,2918.94,,,,,,,,,,,,,
CATHETER BLLN DIL 7.5 FRX180 CM 10-12 MMX5.5 CM CRE RX,SUP-2417342,CDM,C1726,HCPCS,0272,RC,,,,both,,,873.23,567.60,,,,,,,,,,,,,
KIT SURG DRL KT STRL DISP UDRV 3,SUP-2883772,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3343.16,2173.05,,,,,,,,,,,,,
CATHETER ANGIOPLSTY BLU MAX 20 L 75 CM BALLOON L 4 CM DIA 8,SUP-2147231,CDM,C1725,HCPCS,0272,RC,,,,both,,,313.97,204.08,,,,,,,,,,,,,
HC Endo Level 2 Base 15 Min,PX-3600007502,CDM,3600007502,LOCAL,0360,RC,,,,both,,,4270.00,2775.50,,,,,,,,,,,,,
SYSTEM FASCIAL CLSR UNIQUE SHLDED WNG SAFE UNIF CONSISTENT,SUP-2384365,CDM,2720000010,LOCAL,0272,RC,,,,both,,,351.68,228.59,,,,,,,,,,,,,
BASEPLATE TIB SZ 2 L MEDIAL/RIGHT LAT UNI KNEE TI ONLAY FOR,SUP-2368580,CDM,C1776,CPT,0278,RC,,,,both,,,2433.50,1581.77,,,,,,,,,,,,,
LEAD PACE L 52 CM SIL STEROID ENDOCARD RT VENTRICULAR PASS,SUP-2140102,CDM,C1898,HCPCS,0275,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
LEAD NEUROSTIMULATOR L43CM DIA2MM VAGUS NRV BPLR HELCL ELEC,SUP-2175908,CDM,C1778,HCPCS,0278,RC,,,,both,,,13310.46,8651.80,,,,,,,,,,,,,
SCREW +50MM L55MMCANNULATED COMPR,SUP-2364825,CDM,C1713,HCPCS,0278,RC,,,,both,,,4279.51,2781.68,,,,,,,,,,,,,
ROD SPNL L450MM DIA6.35MM R ANT TI STR SMOOTH MNRCH,SUP-2254522,CDM,C1713,HCPCS,0278,RC,,,,both,,,2057.33,1337.26,,,,,,,,,,,,,
GRAFT VASC GORTX L 90 CM DIA 6 MM EPTFE STR TW N RING STRL,SUP-2396700,CDM,C1768,CPT,0278,RC,,,,both,,,2370.70,1540.95,,,,,,,,,,,,,
PLATE CRAN PEEK CUST PATIENTMATCHED NS,SUP-2934133,CDM,C1713,HCPCS,0278,RC,,,,both,,,56520.00,36738.00,,,,,,,,,,,,,
SCREW BONE L40MM DIA4.5MM HD NONLOCKING LO PROF FOR INTOSS,SUP-2223847,CDM,C1713,HCPCS,0278,RC,,,,both,,,1808.64,1175.62,,,,,,,,,,,,,
HC CT Lower Ext W/O Cont|BILATERAL PROCEDURE,PX-3527370000,CDM,73700,CPT,0352,RC,,,50,both,,,2077.00,1350.05,,,,,,,,,,,,,
BUNDLE VLV REP MITRACLIP MITRL VLV 1 SGC0301,SUP-2106203,CDM,C1889,HCPCS,0278,RC,,,,both,,,94200.00,61230.00,,,,,,,,,,,,,
SHEATH INTRO MAX L 8.5 CM DIA 5 FR GUIDEWIRE 0.021 IN,SUP-2355462,CDM,C1894,HCPCS,0272,RC,,,,both,,,40.04,26.03,,,,,,,,,,,,,
PLATE BNE L57MM THK1MM 12 H NONSTERILE HND S STL STR LOK,SUP-2178006,CDM,C1713,HCPCS,0278,RC,,,,both,,,1449.71,942.31,,,,,,,,,,,,,
CATHETER GUID VISTA BRT TIP L 100 CM OD 6 FR ID 0.070 IN SS,SUP-2154312,CDM,C1887,HCPCS,0272,RC,,,,both,,,160.14,104.09,,,,,,,,,,,,,
PLATE BNE C MINI XL 1X0.8 MM CRANIOMAXILLOFACIAL 4 HOLE,SUP-2469954,CDM,C1713,HCPCS,0278,RC,,,,both,,,757.12,492.13,,,,,,,,,,,,,
HC Chemo Push Technique Arterial,PX-3619642000,CDM,96420,CPT,0361,RC,,,,both,,,10314.00,6704.10,,,,,,,,,,,,,
WASHER EXT FIX D SALVATION,SUP-2459036,CDM,2720000010,LOCAL,0272,RC,,,,both,,,480.42,312.27,,,,,,,,,,,,,
GRAFT AMNIOTIC MEMBRANE FLOWERAMNIOPATCH 10MM DISC SIZE,SUP-2866790,CDM,Q4178,HCPCS,0636,RC,,,,both,,,2943.75,1913.44,,,,,,,,,,,,,
FILLER BNE VOID 5 CC CORT CANC BNE SODIUM HYALURONATE,SUP-2927228,CDM,C1713,HCPCS,0278,RC,,,,both,,,2194.86,1426.66,,,,,,,,,,,,,
PLATE BNE RESECT + 1 MM NS VANGUARD MICROPLASTY SLIDEX,SUP-2446444,CDM,C1713,HCPCS,0278,RC,,,,both,,,593.46,385.75,,,,,,,,,,,,,
PLATE BNE 4 H ST S STL LOK COMPR ATTCH FOR 35 45MM SCR LCP,SUP-2177781,CDM,C1713,HCPCS,0278,RC,,,,both,,,1613.18,1048.57,,,,,,,,,,,,,
GRAFT HUM TISS W6XL150-200MM THK3-15MM TIB CORT FRZN STRUT,SUP-2307370,CDM,C1713,HCPCS,0278,RC,,,,both,,,2450.49,1592.82,,,,,,,,,,,,,
COMPONENT FEM 4 KNEE NXGN,SUP-2201240,CDM,C1776,CPT,0278,RC,,,,both,,,6286.28,4086.08,,,,,,,,,,,,,
TRANSITION BUMPER 15MM STRL,SUP-2231441,CDM,C1713,HCPCS,0278,RC,,,,both,,,1516.62,985.80,,,,,,,,,,,,,
PLATE BNE L50MM THK1.3MM 8 H HND TI STR LOK COMPR FOR 2MM,SUP-2267937,CDM,C1713,HCPCS,0278,RC,,,,both,,,2901.36,1885.88,,,,,,,,,,,,,
GRAFT HUM TISS 10ML FRMBL CELLULAR BNE MTRX CRYOPRESERVED,SUP-2264671,CDM,C1713,HCPCS,0278,RC,,,,both,,,11321.90,7359.23,,,,,,,,,,,,,
BOLT INSRT FOR TI SLD TIB NAIL,SUP-2188190,CDM,C1713,HCPCS,0278,RC,,,,both,,,473.57,307.82,,,,,,,,,,,,,
PLATE BNE THK08MM ORBIT PUR TI REINF FAN SMOOTH W EXPOSED,SUP-2182845,CDM,C1713,HCPCS,0278,RC,,,,both,,,4763.07,3096.00,,,,,,,,,,,,,
CAP PROTCT GRN FOR 6MM EXT FIX PIN,SUP-2188686,CDM,C1713,HCPCS,0278,RC,,,,both,,,167.24,108.71,,,,,,,,,,,,,
TUBING CT L60IN Y W DUAL CK VLV FOR OPTIVANTAGE 2,SUP-2858154,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5.43,3.53,,,,,,,,,,,,,
BRACE KNEE AD ALUM FOAM FULL UNIV HNG STRP CLSR ADJ X-ACT,SUP-2196492,CDM,L1833,HCPCS,0274,RC,,,,both,,,315.07,204.80,,,,,,,,,,,,,
HC Ther Ivntj Cog Funcj Cntct 1st 15 Mins,PX-4409712900,CDM,97129,CPT,0440,RC,,,,outpatient,,,186.00,120.90,,,,,,,,,,,,,
COLLAR CERV H3XL15IN SM AD TRACH CLS HK AND LOOP CLSR W CHIN,SUP-2276593,CDM,L0120,HCPCS,0274,RC,,,,both,,,6.56,4.26,,,,,,,,,,,,,
CONTROLLER DETACHMENT FOR ANEURYSM EMBOLIZATION SYSTEM WEB W,SUP-2836320,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2904.50,1887.92,,,,,,,,,,,,,
GUIDEWIRE GLDEWIRE STIFF SHFT ANG FLEX TIP 0.025INX150CM,SUP-2141741,CDM,C1769,HCPCS,0272,RC,,,,both,,,172.51,112.13,,,,,,,,,,,,,
BLADE STRPR L10MM KNEE FOR QUAD TEND GRFT CUT GUID DISP,SUP-2121715,CDM,2720000010,LOCAL,0272,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
ROD SPNL L480MM DIA5.5MM RT ANTR TI ALLOY SMOOTH MOSS MIAMI,SUP-2254454,CDM,C1713,HCPCS,0278,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
PLATE BNE W21XL25MM 10 H RAD HD EL SYS BTTRS FOR 2MM SCR,SUP-2267954,CDM,C1713,HCPCS,0278,RC,,,,both,,,1748.35,1136.43,,,,,,,,,,,,,
PLATE BONE 2 H UNIV COMPR,SUP-2243483,CDM,C1713,HCPCS,0278,RC,,,,both,,,3626.70,2357.35,,,,,,,,,,,,,
ANCHOR NEUROSTIMULATOR 2CM SPNL CRD PERC LD LOK SYS FOR,SUP-2141929,CDM,C1889,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
MESH SURG W12XL14IN UNCOATED MFIL POLYPR ABSRB HYDRGEL LO,SUP-2125904,CDM,C1781,HCPCS,0278,RC,,,,both,,,4967.48,3228.86,,,,,,,,,,,,,
SCREW BNE LAG 2.4X12 MM CARNIO MXLFCL HPS,SUP-2319410,CDM,C1713,HCPCS,0278,RC,,,,both,,,260.62,169.40,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 45 CM DIA 6MM STR STD WALL SLDE GDS,SUP-2485219,CDM,C1768,CPT,0278,RC,,,,both,,,1810.52,1176.84,,,,,,,,,,,,,
PLATE BNE L THK0.8MM 4X6 H L BILAT CRANIOMAXILLOFACIAL G TI,SUP-2181713,CDM,C1713,HCPCS,0278,RC,,,,both,,,1197.91,778.64,,,,,,,,,,,,,
GRAFT HUMAN TISSUE 35X25 CM BIOLOGIC TISSUE MATRIX STERILE X,SUP-2838621,CDM,C1763,HCPCS,0278,RC,,,,both,,,43740.20,28431.13,,,,,,,,,,,,,
COMPONENT FEM ROTATIONAL ENDOMODEL M 145,SUP-2265096,CDM,C1776,CPT,0278,RC,,,,both,,,30360.66,19734.43,,,,,,,,,,,,,
ENDCAP ORTH L4MM DIA8MM L ANK TI EXTN,SUP-2369013,CDM,C1713,HCPCS,0278,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
BINDER BRST SM,SUP-2223739,CDM,L4386,HCPCS,0272,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
GRAFT BNE SUB 15CC 15% HYDROXYAPATITE/85% B-TCP GRAN POR,SUP-2288533,CDM,C1713,HCPCS,0278,RC,,,,both,,,1766.25,1148.06,,,,,,,,,,,,,
INSERT TIB SZ 4 THK8MM ALL POLYETH STBL CEM PFC SIG,SUP-2253818,CDM,C1776,CPT,0278,RC,,,,both,,,4082.00,2653.30,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 80 CM DIA 6-8 MM EPTFE LNG TAPR TW,SUP-2485305,CDM,C1768,CPT,0278,RC,,,,both,,,3442.35,2237.53,,,,,,,,,,,,,
SLEEVE TIB SZ 29 H40MM AP26MM ML29MM MTPHSEAL TI PORCOAT,SUP-2250947,CDM,C1776,CPT,0278,RC,,,,both,,,6886.65,4476.32,,,,,,,,,,,,,
BIT DRL GRAD 10-12 MM 177665] ORTHOFIX INC],SUP-2316013,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2119.50,1377.67,,,,,,,,,,,,,
CATHETER THORACENTESIS SET 8.5 FRX22 CM 4 SIDEPRT,SUP-2760151,CDM,C1729,HCPCS,0272,RC,,,,both,,,439.07,285.40,,,,,,,,,,,,,
HYDROCORTISONE SOD SUC (PF) 250 MG IJ SOLR,RX-159345,CDM,J1720,HCPCS,0636,RC,00009-0013-05,NDC,,both,1,UN,256.10,166.46,,,,,,,,,,,,,
FIBER LASER ORTHOPEDIC 0 DEG HOLM DISP,SUP-2225604,CDM,2720000010,LOCAL,0272,RC,,,,both,,,824.25,535.76,,,,,,,,,,,,,
GRAFT BONE SUB 20ML CANC CORT DBM CHIP RM TEMP FRZ DRY,SUP-2223564,CDM,C1762,CPT,0278,RC,,,,both,,,8713.50,5663.77,,,,,,,,,,,,,
Z DISCONTINUED USE 2283564 DEVICE TISS SEAL L35CM BPLR CRV TIP ENSEAL TRIO,SUP-2257600,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1362.10,885.36,,,,,,,,,,,,,
INTRODUCER DIAG PEEL-APART L 15 CM DIA10 FR PTFE PERC LNG T,SUP-2126180,CDM,C1894,HCPCS,0272,RC,,,,both,,,488.30,317.39,,,,,,,,,,,,,
CATHETER REPERFUSION 138 CM KT TBNG RED62,SUP-2716393,CDM,C1757,HCPCS,0272,RC,,,,both,,,8635.00,5612.75,,,,,,,,,,,,,
BUTTON FIX OVL MED 11X18 MM 7.5 MM PEG STRL XTENDOBUTTON LTX,SUP-2877815,CDM,C1713,HCPCS,0278,RC,,,,both,,,659.40,428.61,,,,,,,,,,,,,
PLATE BNE STR 3.5X237 MM 20 HOLE RECON FOR SCR SS NS,SUP-2480321,CDM,C1713,HCPCS,0278,RC,,,,both,,,1811.15,1177.25,,,,,,,,,,,,,
NEEDLE EPIDURAL L 4 IN STRL DISP PHARM COUD,SUP-2917079,CDM,2720000010,LOCAL,0272,RC,,,,both,,,737.90,479.63,,,,,,,,,,,,,
CATHETER CARD ABLATION NAVISTAR L 115CM 7FR 4MM B CRV UNIDIR,SUP-2248936,CDM,C1732,HCPCS,0278,RC,,,,both,,,5567.22,3618.69,,,,,,,,,,,,,
GRAFT BNE 10 CC VIABLE TRIFECTA 81370010S,SUP-2740428,CDM,C1713,HCPCS,0278,RC,,,,both,,,12874.00,8368.10,,,,,,,,,,,,,
STAPLE BONE FIX BRDG W11MM LEG L7X15MM WIRE DIA1.5MM NIT,SUP-2135431,CDM,C1713,HCPCS,0278,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
CATHETER CV 1 LUMEN 4 FR BASIC MI TY ORNG POWERPICC SOLO 2,SUP-2126374,CDM,C1751,HCPCS,0278,RC,,,,both,,,440.86,286.56,,,,,,,,,,,,,
SCREW SPNL MULTAXL 7.5X65 MM CANN EXT TAB VOYAGER 4.75,SUP-2629443,CDM,C1713,HCPCS,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
PLATE BONE 2.7MM 10 H LCK COMPR FRAG SYS PEDILOC,SUP-2318666,CDM,C1713,HCPCS,0278,RC,,,,both,,,2373.06,1542.49,,,,,,,,,,,,,
SYSTEM KNEE FLX CEM,SUP-2212147,CDM,C1776,CPT,0278,RC,,,,both,,,10343.16,6723.05,,,,,,,,,,,,,
HC Custom Finger Static,PX-2740393301,CDM,L3933,HCPCS,0274,RC,,,,outpatient,,,710.00,461.50,,,,,,,,,,,,,
PROSTHESIS VOICE 20FR L6MM INDWL 2 VLV BLOM-SINGER,SUP-2242331,CDM,L8509,HCPCS,0272,RC,,,,both,,,1284.26,834.77,,,,,,,,,,,,,
SPLINT SWEDISH AFO M RT WHT,SUP-2324310,CDM,L4350,HCPCS,0272,RC,,,,both,,,67.70,44.00,,,,,,,,,,,,,
Z DUPLICATE USE 2293484 KIT BONE CEMENT SIZE 2 MIXER MULTI TAP ADAPTER XPEDE KYPHON,SUP-2429496,CDM,C1713,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
GUIDEWIRE VASC L150CM DIA0.035IN S STL PTFE J TIP FIX COR,SUP-2120088,CDM,C1769,HCPCS,0272,RC,,,,both,,,53.38,34.70,,,,,,,,,,,,,
PLATE BNE STR 1 MM 22 HOLE STRL RESORB X,SUP-2487123,CDM,C1713,HCPCS,0278,RC,,,,both,,,957.26,622.22,,,,,,,,,,,,,
ANCHOR SUT DIA2.3MM 2 COBRAID BLK ULTRABRAID SUT OSTEORAPTOR,SUP-2341804,CDM,C1713,HCPCS,0278,RC,,,,both,,,943.60,613.34,,,,,,,,,,,,,
GENERATOR PULSE REACTIV8,SUP-2877966,CDM,C1730,HCPCS,0272,RC,,,,both,,,43140.46,28041.30,,,,,,,,,,,,,
CATHETER ANGIOPLSTY SABER L 150 CM BALLOON L 250 MM DIA 4.5,SUP-2909664,CDM,C1725,HCPCS,0272,RC,,,,both,,,807.77,525.05,,,,,,,,,,,,,
HC Removal Biliary Drng Cath,PX-3614753700,CDM,47537,CPT,0361,RC,,,,inpatient,,,6875.00,4468.75,,,,,,,,,,,,,
KIT DRNGE CATH DIA8FR VAC EXTN SET W/ HNDL SFTY SCALP PNT,SUP-2133895,CDM,C1729,HCPCS,0272,RC,,,,both,,,152.51,99.13,,,,,,,,,,,,,
CLARITHROMYCIN 125 MG/5ML PO SUSR,RX-12885,CDM,340b,HCPCS,0637,RC,09999-9917-94,NDC,,both,5,ML,28.00,18.20,,,,,,,,,,,,,
GRAFT MTRX DERM HUM TISS ACELLULAR FRZN 4CMX5CM M HMTRX,SUP-2125441,CDM,Q4134,HCPCS,0636,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
CONNECTOR ROD LG CROSSBAR AX SS,SUP-2245533,CDM,C1713,HCPCS,0278,RC,,,,both,,,1224.60,795.99,,,,,,,,,,,,,
STAPLE BNE SUPER ELASTIC 20X20X20 MM RELD HIMAX DYNA,SUP-2748446,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
PRAVASTATIN SODIUM 20 MG PO TABS,RX-11111,CDM,6370000000,HCPCS,0637,RC,00904-5892-61,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PEG BONE FXTN 2.5MM DIA 14MML CBLT CHRMM THRDD LOK F/DVR PLT,SUP-2588999,CDM,C1713,HCPCS,0278,RC,,,,both,,,259.05,168.38,,,,,,,,,,,,,
FERUMOXYTOL 510 MG/17ML IV SOLN,RX-98222,CDM,Q0138,HCPCS,0636,RC,59338-0775-01,NDC,,both,17,ML,1576.90,1024.98,,,,,,,,,,,,,
CAGE SPNL L14XW14XH17MM 4 LOBE MESH NGAGE,SUP-2317738,CDM,C1889,HCPCS,0278,RC,,,,both,,,8258.20,5367.83,,,,,,,,,,,,,
BURR MED 51MM RND 6 FLUTED CARB 3MM,SUP-2586354,CDM,2720000010,LOCAL,0272,RC,,,,both,,,26.12,16.98,,,,,,,,,,,,,
SHEATH INTRO GLIDESHEATH L 10 CM OD 5FR ID 0.074IN FLPY TIP,SUP-2384810,CDM,C1894,HCPCS,0272,RC,,,,both,,,232.74,151.28,,,,,,,,,,,,,
PLATE BNE STR 2.4 MM 6 HOLE TI GLD NS LTX,SUP-2856964,CDM,C1713,HCPCS,0278,RC,,,,both,,,4176.20,2714.53,,,,,,,,,,,,,
SUPPORT ORTHOT RIB CUST GUSSET ELASTIC,SUP-2435591,CDM,L1280,HCPCS,0272,RC,,,,both,,,247.37,160.79,,,,,,,,,,,,,
PLATE BNE L 96 X W 10.9 MM THK 1.5 MM SCREW DIA 3.5 MM 6 H 72454506N,SUP-2932983,CDM,C1713,HCPCS,0278,RC,,,,both,,,2887.07,1876.60,,,,,,,,,,,,,
DEVICE INT FIX ENDOBUTTON,SUP-2341633,CDM,C1713,HCPCS,0278,RC,,,,both,,,401.92,261.25,,,,,,,,,,,,,
PLATE BNE LCK 2.7X118 MM 10 HOLE CNTOUR 2 COMPR SS STRL,SUP-2497102,CDM,C1713,HCPCS,0278,RC,,,,both,,,1014.25,659.26,,,,,,,,,,,,,
SPLINT ORTHOPEDIC BOUTONNIERE 10 FNGR BEAUTY STRENGTH,SUP-2325010,CDM,L3927,HCPCS,0274,RC,,,,both,,,253.27,164.63,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA FT PLU MAXBARR S1275108FD1,SUP-2632804,CDM,C1751,HCPCS,0278,RC,,,,both,,,714.04,464.13,,,,,,,,,,,,,
ANCHOR ABSORBABLE 14 MM MENIS,SUP-2166730,CDM,C1713,HCPCS,0278,RC,,,,both,,,816.40,530.66,,,,,,,,,,,,,
SET SHTH DESTINO L 87 CM L 67 CM 12FR CRV BEND 22 MM 50 DEG,SUP-2616110,CDM,C1766,CPT,0272,RC,,,,both,,,2402.10,1561.36,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 220 MM DIA11 MM DEL SHTH,SUP-2934261,CDM,C1713,HCPCS,0278,RC,,,,both,,,13897.64,9033.47,,,,,,,,,,,,,
HEAD FEM BPLR 28X49 MM HIP,SUP-2340085,CDM,C1776,CPT,0278,RC,,,,both,,,5262.64,3420.72,,,,,,,,,,,,,
PLATE BONE LOCKING LARGE STERNAL 8 HOLE PRECONTOURED TITANIU,SUP-2838430,CDM,C1713,HCPCS,0278,RC,,,,both,,,3292.60,2140.19,,,,,,,,,,,,,
PISTON OTOLARYN L4MM OD0.8MM S STL FLROPLAS STAP WIRE LOOP,SUP-2312533,CDM,L8613,CPT,0278,RC,,,,both,,,334.98,217.74,,,,,,,,,,,,,
LEVETIRACETAM 500 MG/5ML IV SOLN,RX-77195,CDM,J1953,HCPCS,0636,RC,00409-1886-02,NDC,,both,5,ML,54.10,35.16,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY PENTARAY NAV INSRTN L 115CM 4-4-4,SUP-2248592,CDM,C1732,HCPCS,0272,RC,,,,both,,,5425.92,3526.85,,,,,,,,,,,,,
PERFORATOR SURG AD AND PED OD13MM ID9MM DISP DGR-II,SUP-2106555,CDM,2720000010,LOCAL,0272,RC,,,,both,,,540.08,351.05,,,,,,,,,,,,,
MESH GYN L 30 X W 30 IN XL POLYPRO OR PPL FLAT CNTOUR PORE,SUP-2896108,CDM,C1781,HCPCS,0278,RC,,,,both,,,5155.88,3351.32,,,,,,,,,,,,,
CARTRIDGE SUT WHT MAG WIRE AND COBRAID SPEEDSTITCH,SUP-2342096,CDM,C1713,HCPCS,0278,RC,,,,both,,,543.22,353.09,,,,,,,,,,,,,
MARKER BREAST VISION TUMARK FOR BREVERA STD,SUP-2662949,CDM,A4648,CPT,0278,RC,,,,both,,,326.40,212.16,,,,,,,,,,,,,
TRIAL WEDGEXXL 5MM FEM POST,SUP-2364867,CDM,C1776,CPT,0278,RC,,,,both,,,1310.32,851.71,,,,,,,,,,,,,
GRAFT HUM TISS FRZN ALLGRFT ULNA WHL STRUCTURAL L,SUP-2307317,CDM,C1713,HCPCS,0278,RC,,,,both,,,7937.70,5159.50,,,,,,,,,,,,,
SYSTEM BONE CEMENT PCD W/VERTAPLEX HV LONG 90DEG EXT TUBE,SUP-2875969,CDM,C1713,HCPCS,0278,RC,,,,both,,,2222.05,1444.33,,,,,,,,,,,,,
DRILL SURG XL 1.7 MM SUTUREFIX ULTRA DISP,SUP-2848657,CDM,2720000010,LOCAL,0272,RC,,,,both,,,537.41,349.32,,,,,,,,,,,,,
KIT PROC 2 CP910 AND CP920 NUCLS 6 SYS,SUP-2165007,CDM,L8614,HCPCS,0278,RC,,,,both,,,39250.00,25512.50,,,,,,,,,,,,,
HOOK RETRCT 7CM BLDE MCCULLOCH,SUP-2161662,CDM,2720000010,LOCAL,0272,RC,,,,both,,,302.73,196.77,,,,,,,,,,,,,
BUTTON CERCLAGE DIA3.5MM S STL T25 STARDRV RECESS HEX FOR,SUP-2178462,CDM,2720000010,LOCAL,0272,RC,,,,both,,,498.76,324.19,,,,,,,,,,,,,
SLEEVE TIB L9CM PROX KNEE FOR ORTH SALV SYS,SUP-2406466,CDM,C1776,CPT,0278,RC,,,,both,,,14101.74,9166.13,,,,,,,,,,,,,
LIGHT CURING LED COLTOLUX,SUP-2322060,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1445.50,939.57,,,,,,,,,,,,,
PEG BNE FIX L11MM DIA2.5MM LOK FULL THRD FOR HND FRAC SYS,SUP-2414058,CDM,C1713,HCPCS,0278,RC,,,,both,,,346.97,225.53,,,,,,,,,,,,,
STENT URET INLAY OPTMA L 26 CM DIA 6 FR POLYMER BLEND,SUP-2126657,CDM,C2617,HCPCS,0278,RC,,,,both,,,782.68,508.74,,,,,,,,,,,,,
GUIDEWIRE VASC SENTAI FIGHTER L 190 CM SPRING COIL L 18 CM,SUP-2140868,CDM,C1769,HCPCS,0272,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
PLATE BONE L 2X2 H BX LO PROF W/ TAB FOR 1.5MM SCR CRAN FIX,SUP-2363625,CDM,C1713,HCPCS,0278,RC,,,,both,,,1025.02,666.26,,,,,,,,,,,,,
SHEARS ULTRSNC SHFT L 23 CM DIA 5 MM JAW L 14 MM APER 15 MM,SUP-2889594,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1206.98,784.54,,,,,,,,,,,,,
CATHETER ART L16CM DIA18GA 0.025IN FEM SFTY SET W/ SHRP,SUP-2383350,CDM,C1894,HCPCS,0272,RC,,,,both,,,168.62,109.60,,,,,,,,,,,,,
CUP HUM DIA36MM +6MM OFFSET SHLDR POLYETH REV LAT DELT CTA,SUP-2252976,CDM,C1776,CPT,0278,RC,,,,both,,,4264.12,2771.68,,,,,,,,,,,,,
BLADE RETRCT PED WIRE HND MAL DENIS BROWNE,SUP-2162011,CDM,C1713,HCPCS,0278,RC,,,,both,,,616.16,400.50,,,,,,,,,,,,,
GRAFT HUM TISS W3XL6CM MTRX CRD AMNION,SUP-2418326,CDM,C1762,CPT,0278,RC,,,,both,,,8713.50,5663.77,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE 1 CC ALLGRFT FLOWABLE OSTEOAMP SEL,SUP-2931046,CDM,C1762,CPT,0278,RC,,,,both,,,1921.62,1249.05,,,,,,,,,,,,,
COMPONENT HUM SHLDR CONSTRUCT COMPHSVE,SUP-2212467,CDM,C1776,CPT,0278,RC,,,,both,,,13188.00,8572.20,,,,,,,,,,,,,
PLATE BONE LAPIDUS RIGHT PETITE TITANIUM ARSENAL FOOT PLATING SYSTEM FOR 2.2/2.7/3.5MM SCREW,SUP-2878149,CDM,C1713,HCPCS,0278,RC,,,,both,,,6248.60,4061.59,,,,,,,,,,,,,
SAW BLDE W7XL12.7MM L TEAR RECIP FOR TOT PERF SYS COR,SUP-2367378,CDM,2720000010,LOCAL,0272,RC,,,,both,,,329.57,214.22,,,,,,,,,,,,,
SCREW BNE COMPR 6.5X90 MM 16 MM CANN HDLSS THRD NS LTX,SUP-2856182,CDM,C1713,HCPCS,0278,RC,,,,both,,,3058.36,1987.93,,,,,,,,,,,,,
CONNECTOR SPNL L10MM LAT OFFSET OPN VERTEX MAX,SUP-2286781,CDM,C1713,HCPCS,0278,RC,,,,both,,,1320.53,858.34,,,,,,,,,,,,,
STEM TOE SM CO CHROM METATRSL IMP,SUP-2404753,CDM,C1776,CPT,0278,RC,,,,both,,,4797.92,3118.65,,,,,,,,,,,,,
SYSTEM RETROPUBIC TENS FREE SUPP UTER PELV GYNECARE TVT,SUP-2717349,CDM,C1771,HCPCS,0278,RC,,,,both,,,5906.15,3839.00,,,,,,,,,,,,,
SCREW SET KNEE REPL MG II,SUP-2437015,CDM,C1713,HCPCS,0278,RC,,,,both,,,98.91,64.29,,,,,,,,,,,,,
PLATE BONE 7 H FIBULAR STR FOR ANK FX GORILLA,SUP-2321558,CDM,C1713,HCPCS,0278,RC,,,,both,,,2747.50,1785.87,,,,,,,,,,,,,
HC Implant Spinal Cord Stim,PX-3600007518,CDM,3600007518,LOCAL,0360,RC,,,,outpatient,,,6232.00,4050.80,,,,,,,,,,,,,
SCREW BNE CORTICAL 3.5X36 MM ST T15 FOR GRID LCK TI LOQTEQ,SUP-2539611,CDM,C1713,HCPCS,0278,RC,,,,both,,,758.62,493.10,,,,,,,,,,,,,
PLATE L FUSION VA LCP 2.4/2.7MM SHRT LT TI STRL,SUP-2546991,CDM,C1713,HCPCS,0278,RC,,,,both,,,3334.99,2167.74,,,,,,,,,,,,,
PLATE BONE L109MM 6 H RT SUP DSTL CLAV LCK FOR 3.5MM SCR,SUP-2348749,CDM,C1713,HCPCS,0278,RC,,,,both,,,6685.53,4345.59,,,,,,,,,,,,,
PLATE BNE W6XL30MM 16 H CRANIOMAXILLOFACIAL TI STRUT FOR,SUP-2190566,CDM,C1713,HCPCS,0278,RC,,,,both,,,2024.36,1315.83,,,,,,,,,,,,,
SUPPORT ORTHOT KNEE CUST POS LCK,SUP-2435609,CDM,L1831,HCPCS,0272,RC,,,,both,,,833.23,541.60,,,,,,,,,,,,,
MOUNT VERT FOR RADIOGRAPHIC MRK MAXFRAME,SUP-2255818,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1016.73,660.87,,,,,,,,,,,,,
GRAFT BNE SUB 10CC VI DIA4.8MM CA SULF PELLET RESRB PRELD,SUP-2399032,CDM,C1713,HCPCS,0278,RC,,,,both,,,2285.70,1485.70,,,,,,,,,,,,,
NAIL IM L400MM OD11MM 135DEG 2MM RAD TI L TROCHANTERIC,SUP-2370335,CDM,C1713,HCPCS,0278,RC,,,,both,,,4490.20,2918.63,,,,,,,,,,,,,
SHEET THERMOPLASTIC SPLNT 1/16X12X18IN 4 PER CA SLD BLUSH,SUP-2324644,CDM,L4350,HCPCS,0272,RC,,,,both,,,85.00,55.25,,,,,,,,,,,,,
COLLAR CERV TRACHEOTOMY SM AD 4.25 IN 10-13 IN PHILADELPHIA,SUP-2319297,CDM,L0172,HCPCS,0272,RC,,,,both,,,30.52,19.84,,,,,,,,,,,,,
BRACE KNEE AD L23 17IN UNIV COOL FOAM UNISX TRANSITION,SUP-2195291,CDM,L1810,HCPCS,0272,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
CATHETER ART PRESSURE MONITORING SET 018 3 FRX5 CM CPMS300RA,SUP-2760096,CDM,C1751,HCPCS,0278,RC,,,,both,,,146.64,95.32,,,,,,,,,,,,,
PLATE BNE L32MM THK1.3MM 2X4 H HND TI T SHP TRILOK FOR 2MM,SUP-2267938,CDM,C1713,HCPCS,0278,RC,,,,both,,,3025.70,1966.70,,,,,,,,,,,,,
HC So Myelin Basic Protein,PX-3018387366,CDM,83873,CPT,0301,RC,,,,inpatient,,,992.00,644.80,,,,,,,,,,,,,
FAMCICLOVIR 500 MG PO TABS,RX-13358,CDM,6370000000,HCPCS,0637,RC,42291-0416-30,NDC,,both,1,UN,2.90,1.88,,,,,,,,,,,,,
CATHETER VENTRICULAR TYP E 48 CM SHUNT ATR IFU BA HOLTER,SUP-2423585,CDM,C1729,HCPCS,0272,RC,,,,both,,,745.78,484.76,,,,,,,,,,,,,
SCREW BNE 2/PK L 10 MM DIA2.2 MM PLA GLYCOLIDE,SUP-2884154,CDM,C1713,HCPCS,0278,RC,,,,both,,,980.87,637.57,,,,,,,,,,,,,
RITUXIMAB 500 MG/50ML IV SOLN,RX-131190,CDM,J9312,HCPCS,0636,RC,50242-0053-06,NDC,,both,50,ML,13529.10,8793.91,,,,,,,,,,,,,
SHELL ACET MH 40 MM HIP LEGEND,SUP-2434196,CDM,C1776,CPT,0278,RC,,,,both,,,6145.61,3994.65,,,,,,,,,,,,,
LEVEL TWIST DRILL J NOTCH MRRSN 20 MM STOP USE W/25 471 05 0,SUP-2497037,CDM,2720000010,LOCAL,0272,RC,,,,both,,,477.97,310.68,,,,,,,,,,,,,
PEMBROLIZUMAB-BERAHYALUR-PMPH 395-4800 MG -UNT/2.4ML SC SOLN,RX-173861,CDM,J9999,HCPCS,0636,RC,00006-3083-01,NDC,,both,2.4,ML,34650.40,22522.76,,,,,,,,,,,,,
SCREW BNE L7MM OD23MM TI CRANIOMAXILLOFACIAL CROSSDRIVE SELF,SUP-2262805,CDM,C1713,HCPCS,0278,RC,,,,both,,,187.65,121.97,,,,,,,,,,,,,
STAPLER INT LN 75 MM ENDO GIA II,SUP-2129895,CDM,2720000010,LOCAL,0272,RC,,,,both,,,726.72,472.37,,,,,,,,,,,,,
COMPONENT TALAR SZ 4 UNIV POST PROX ANK JT CO CHROM POR SEMI,SUP-2252062,CDM,C1776,CPT,0278,RC,,,,both,,,8638.14,5614.79,,,,,,,,,,,,,
PLATE BNE CRANIOMAXILLOFACIAL THK06MM 6 H STR PROF MIDFACE,SUP-2262675,CDM,C1713,HCPCS,0278,RC,,,,both,,,502.81,326.83,,,,,,,,,,,,,
PLATE BONE L147MM 8 H S STL T SHP,SUP-2198575,CDM,C1713,HCPCS,0278,RC,,,,both,,,664.74,432.08,,,,,,,,,,,,,
ALLOGRAFT BNE PLUG 16 MM FD ASEP,SUP-2867010,CDM,C1762,CPT,0278,RC,,,,both,,,1959.83,1273.89,,,,,,,,,,,,,
MESH SURG L8XW6IN IMPL SEPRAMESH,SUP-2125924,CDM,C1781,HCPCS,0278,RC,,,,both,,,1880.55,1222.36,,,,,,,,,,,,,
CATHETER VENTRICULAR SUBDURAL F8 TBNG W/ A FLATTENED EXAFLOW,SUP-2666676,CDM,C1729,HCPCS,0272,RC,,,,both,,,565.23,367.40,,,,,,,,,,,,,
SCREW BNE 4 MM HD KT,SUP-2175155,CDM,C1713,HCPCS,0278,RC,,,,both,,,2811.87,1827.72,,,,,,,,,,,,,
SPACER SPNL 9X11X26MM 15DEG TI TLX,SUP-2431846,CDM,C1821,HCPCS,0278,RC,,,,both,,,12717.00,8266.05,,,,,,,,,,,,,
HALF PIN 6MMX75MM,SUP-2818664,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1535.08,997.80,,,,,,,,,,,,,
CATHETER EP 7FR L4MM STR TIP 2.5MM ASYM CRV QPLR BLZR PRIM,SUP-2141853,CDM,C1725,HCPCS,0272,RC,,,,both,,,2859.91,1858.94,,,,,,,,,,,,,
NIKO CORPECTOMY CAGE 29MM,SUP-2228346,CDM,C1713,HCPCS,0278,RC,,,,both,,,9106.00,5918.90,,,,,,,,,,,,,
PROBE LITHO 2.4FR L668MM RIG LNG FOR PNEUMAT SWISS,SUP-2140352,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1874.58,1218.48,,,,,,,,,,,,,
RELOAD STPL SZ 2.3MM L60MM 0DEG UNIV WHT TI NONARTICULATING,SUP-2283061,CDM,2720000010,LOCAL,0272,RC,,,,both,,,984.04,639.63,,,,,,,,,,,,,
COIL NEUROVASCULAR L 12 MM DIA 4 MM COMPLX SUPERSOFT XCEL,SUP-2895476,CDM,C1889,HCPCS,0278,RC,,,,both,,,5730.50,3724.82,,,,,,,,,,,,,
SHUNT VENTRICULAR L1.5CM DIAMETER 2.5MM CATHETER L18X120CM 1,SUP-2825944,CDM,C1889,HCPCS,0278,RC,,,,both,,,2727.75,1773.04,,,,,,,,,,,,,
STENT TRACHBRONCH 9X20 MM NOVATECH BD DUMON,SUP-2309496,CDM,C1875,HCPCS,0278,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
BRUSH NAVIGATION SYS L15MM DIA1.8MM ALWAYS ON TIP TRACKED,SUP-2392610,CDM,C1713,HCPCS,0278,RC,,,,both,,,1780.38,1157.25,,,,,,,,,,,,,
GUIDEROD L950MM DIA3MM W SMOOTH TIP FOR TI DST FEM NAIL,SUP-2188170,CDM,C1713,HCPCS,0278,RC,,,,both,,,394.98,256.74,,,,,,,,,,,,,
PLATE BONE L16MM THK0.6MM REG 4 H MIDFACE SLV TI STR FOR,SUP-2402870,CDM,C1713,HCPCS,0278,RC,,,,both,,,222.94,144.91,,,,,,,,,,,,,
PIN GUIDE L 360 MM DIA 3.2 MM THRD TIP TRIGEN MAX,SUP-2933183,CDM,2720000010,LOCAL,0272,RC,,,,both,,,546.36,355.13,,,,,,,,,,,,,
DRILL TWST L105MM DIA1.9MM ADD ON SHFT END DISP FOR DST RAD,SUP-2374317,CDM,2720000010,LOCAL,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
BUSHING FEM KNEE POLY REDUC SZ ORTH SALV SYS,SUP-2406496,CDM,C1776,CPT,0278,RC,,,,both,,,1045.62,679.65,,,,,,,,,,,,,
IMPLANT DSTL RAD SZ 1,SUP-2418016,CDM,C1776,CPT,0278,RC,,,,both,,,6983.36,4539.18,,,,,,,,,,,,,
TAP SURG SZ 4.75 MM PEEK STRL ALPHAVENT,SUP-2882662,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1978.20,1285.83,,,,,,,,,,,,,
DIVALPROEX SODIUM 250 MG PO TBEC,RX-2552,CDM,6370000000,HCPCS,0637,RC,62756-0797-88,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
ANCHOR SUTURE L12MM OD4MM ID1.8MM PRE THREADED WITH SINGLE N,SUP-2828526,CDM,C1713,HCPCS,0278,RC,,,,both,,,605.99,393.89,,,,,,,,,,,,,
BLADE SHAVER CRV 15 DEG 4 MM SERRATED CONVX WINDOW DIEGO,SUP-2638087,CDM,2720000010,LOCAL,0272,RC,,,,both,,,423.77,275.45,,,,,,,,,,,,,
CATHETER HD STR EXTN 13.5 FRX13 CM DL HI FLO KT MAHRK ELITE,SUP-2626880,CDM,C1752,HCPCS,0278,RC,,,,both,,,223.82,145.48,,,,,,,,,,,,,
ROD EXT FIX CRV 180 DEG 8X540 MM SPAN CARBON FIBER,SUP-2188574,CDM,C1713,HCPCS,0278,RC,,,,both,,,1213.11,788.52,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY WEBST COMPLI L 115 CM DIA 5 FR,SUP-2248851,CDM,C1733,HCPCS,0272,RC,,,,both,,,342.26,222.47,,,,,,,,,,,,,
SCREW BNE L22MM THRD 3.5MM HD 4.5MM TI LNG THRD CANN HDLESS,SUP-2389524,CDM,C1713,HCPCS,0278,RC,,,,both,,,923.16,600.05,,,,,,,,,,,,,
BIT DRL 4.2 MM DSTL,SUP-2644797,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1692.05,1099.83,,,,,,,,,,,,,
ONDANSETRON HCL 8 MG PO TABS,RX-10779,CDM,Q0162,HCPCS,0637,RC,68084-0221-11,NDC,,both,1,UN,4.40,2.86,,,,,,,,,,,,,
HC Iadna Human Papillomavirus Hi-Rsk Typ Poold Rslt,PX-3068762400,CDM,87624,CPT,0306,RC,,,,both,,,226.00,146.90,,,,,,,,,,,,,
SHUNT CAR 2 SWCH W/O RESVR N PROGRAMMABLE 9FR 15CM,SUP-2264207,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1472.66,957.23,,,,,,,,,,,,,
STENT URET ILLUMINATOR,SUP-2242456,CDM,C2617,HCPCS,0278,RC,,,,both,,,47.10,30.61,,,,,,,,,,,,,
MATRIX BIO L 20 X W 7 CM FISH SKIN DERMAL INTACT MARIGEN,SUP-2909236,CDM,Q4158,HCPCS,0636,RC,,,,both,,,24181.14,15717.74,,,,,,,,,,,,,
TIP SACROCERVICOPEXY SM HOYTE DISP,SUP-2755961,CDM,2720000010,LOCAL,0272,RC,,,,both,,,527.93,343.15,,,,,,,,,,,,,
BRENTUXIMAB VEDOTIN 50 MG IV SOLR|DISCARDED DRUG NOT ADMINISTE,RX-110553,CDM,J9042,HCPCS,0636,RC,51144-0050-01,NDC,JW,both,1,UN,36506.40,23729.16,,,,,,,,,,,,,
SHEATH INTRO FAST-CATH SWARTZ SR L 60 CM DIA 8 FR GUIDEWIRE,SUP-2357154,CDM,C1893,HCPCS,0272,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
GUIDEPIN FIX L9IN DIA2.4MM TRCR TIP SMOOTH SHFT,SUP-2410083,CDM,2720000010,LOCAL,0272,RC,,,,both,,,70.37,45.74,,,,,,,,,,,,,
PLATE BNE 2 HOLE STR SM BNE ORTHOLOC 3DI,SUP-2517176,CDM,C1713,HCPCS,0278,RC,,,,both,,,1243.44,808.24,,,,,,,,,,,,,
ROD SPNL PREBENT 5.5X95 MM,SUP-2256250,CDM,C1713,HCPCS,0278,RC,,,,both,,,1271.70,826.60,,,,,,,,,,,,,
HANDPIECE PULSED LAV 5 MM L7 CM ABD OPN SURG GEN CUT COAG,SUP-2328050,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1723.86,1120.51,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA 4FR 55CM 2 LUMAN RVS TAPR S,SUP-2613539,CDM,C1751,HCPCS,0278,RC,,,,both,,,557.32,362.26,,,,,,,,,,,,,
PLATE BNE W4.3XL61.7MM THK1.1MM 12 H TI STR LOK LO PROF FOR,SUP-2411739,CDM,C1713,HCPCS,0278,RC,,,,both,,,1783.52,1159.29,,,,,,,,,,,,,
CANNULA IRRIGATION SUCTION 3.5 MM 240 MM,SUP-2537817,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1887.33,1226.76,,,,,,,,,,,,,
PROCEDURE KIT CLOSUREFAST,SUP-2393088,CDM,C1888,HCPCS,0272,RC,,,,both,,,2574.80,1673.62,,,,,,,,,,,,,
BLADE SURG CRV SHFT LNG 2.9 MM 60 MM OSCILLATE TBNG RAD,SUP-2570715,CDM,2720000010,LOCAL,0272,RC,,,,both,,,914.37,594.34,,,,,,,,,,,,,
GRAFT HUM TISS L 60-120 MM DIA25 MM CORTICAL FEM SHFT FD 1PC,SUP-2913407,CDM,C1762,CPT,0278,RC,,,,both,,,4182.48,2718.61,,,,,,,,,,,,,
COMPONENT SHLDR CAPPED SHT GLEN HYBRID ST HD 1ST GLD,SUP-2212463,CDM,C1776,CPT,0278,RC,,,,both,,,17898.00,11633.70,,,,,,,,,,,,,
PIN FIX SINGLE DIAMOND 0.177X9 IN RND END SS NS STEINMANN,SUP-2791371,CDM,C1713,HCPCS,0278,RC,,,,both,,,43.65,28.37,,,,,,,,,,,,,
NAIL IM 8X285 MM TIB TI STRL EXPERT,SUP-2179811,CDM,C1713,HCPCS,0278,RC,,,,both,,,4001.62,2601.05,,,,,,,,,,,,,
PLATE BONE L68MM 3 H BILAT S STL T SHP LO PROF NEUT,SUP-2185751,CDM,C1713,HCPCS,0278,RC,,,,both,,,857.79,557.56,,,,,,,,,,,,,
SHEATH INTRO AIRGUARD L 15 CM DIA13 FR POLYUR VLV LCK CLLR,SUP-2127827,CDM,C1894,HCPCS,0272,RC,,,,both,,,1544.88,1004.17,,,,,,,,,,,,,
SCREW MYOMA L7.5IN DOYEN,SUP-2804355,CDM,C1713,HCPCS,0278,RC,,,,both,,,217.98,141.69,,,,,,,,,,,,,
TRANS1 FACET SCR SYS,SUP-2389071,CDM,C1713,HCPCS,0278,RC,,,,both,,,6280.00,4082.00,,,,,,,,,,,,,
STEM FNGR JT SZ 50 MP SIL CEMENTLESS PRI PRESSFIT NEUFLEX,SUP-2250688,CDM,C1776,CPT,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
HC Urinalysis Qual/Semiquant Except Immunoassays,PX-3078100500,CDM,81005,CPT,0307,RC,,,,both,,,113.00,73.45,,,,,,,,,,,,,
PATCH EXT REF SZ 100 MM FOR CARTO 3 PMP SYS NS,SUP-2248584,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1168.08,759.25,,,,,,,,,,,,,
PLATE BNE L199MM 12 H BROAD COMPR RIG FOR 4.5MM SCR L FRAG,SUP-2411424,CDM,C1713,HCPCS,0278,RC,,,,both,,,714.13,464.18,,,,,,,,,,,,,
GUIDEWIRE VASC EMERALD L 150 CM DIA 0.035 IN RAD DIA1.5 MM,SUP-2153999,CDM,C1769,HCPCS,0272,RC,,,,both,,,71.22,46.29,,,,,,,,,,,,,
DRESSING NSL 8CM NASOPORE FD,SUP-2367695,CDM,C1713,HCPCS,0278,RC,,,,both,,,723.02,469.96,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY LASSO NAV ECO L 115CM 7FR 20 POLE,SUP-2460618,CDM,C1731,HCPCS,0278,RC,,,,both,,,2816.27,1830.58,,,,,,,,,,,,,
TRASTUZUMAB-PKRB 150 MG IV SOLR,RX-149777,CDM,Q5113,HCPCS,0636,RC,63459-0303-43,NDC,,both,1,UN,3163.40,2056.21,,,,,,,,,,,,,
CONNECTOR SPNL MULTIAXIAL SCR XLNK CLP VERTEX,SUP-2279733,CDM,C1713,HCPCS,0278,RC,,,,both,,,984.39,639.85,,,,,,,,,,,,,
DRILL TWST L 48 MM WORKING L 4 MM DIA1.2 MM HEX SHFT NS DISP,SUP-2883376,CDM,2720000010,LOCAL,0272,RC,,,,both,,,645.02,419.26,,,,,,,,,,,,,
HC So Dna/Rna Amplified Probe,PX-3008715066,CDM,87150,CPT,0300,RC,,,,outpatient,,,173.00,112.45,,,,,,,,,,,,,
PLATE BNE LISFRANC SM LT OMNI,SUP-2610163,CDM,C1713,HCPCS,0278,RC,,,,both,,,4898.40,3183.96,,,,,,,,,,,,,
ANCHOR SUTURE UHMWPE POLYESTER POLYPRO OR PPL TI BTTN WASHER,SUP-2905453,CDM,C1713,HCPCS,0278,RC,,,,both,,,5809.00,3775.85,,,,,,,,,,,,,
PIN FIX L40MM DIA2MM PROV FOR EVOS SM PLATING SYS,SUP-2344054,CDM,C1713,HCPCS,0278,RC,,,,both,,,968.56,629.56,,,,,,,,,,,,,
IMPLANT HUMAN TSSUE W107XH104 228XL215MM ACLLLR DRML TSSUE,SUP-2676575,CDM,Q4116,HCPCS,0636,RC,,,,both,,,18299.92,11894.95,,,,,,,,,,,,,
STENT URET DBL PGTL 0.035 IN 3 CM 4.8 FRX22-30 CM 6 FR,SUP-2537694,CDM,C2617,HCPCS,0278,RC,,,,both,,,417.59,271.43,,,,,,,,,,,,,
ROD EXT FIX L100MM DIA11MM UNIV C FBR NONRADIOPAQUE REUSE 39480R] DEPUY SYNTHES USA],SUP-2188648,CDM,2720000010,LOCAL,0272,RC,,,,both,,,758.62,493.10,,,,,,,,,,,,,
CATHETER GUID SUPP 018 2.2-3.4 FRX150 CM QUIK CROSS SEL,SUP-2353127,CDM,C1887,HCPCS,0272,RC,,,,both,,,501.62,326.05,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED PRIMARY CAT EXCEPTION K3ZIMMER] ZIMMER BIOMET INC],SUP-2212591,CDM,C1776,CPT,0278,RC,,,,both,,,14522.50,9439.62,,,,,,,,,,,,,
STENT BILI L80MM 120CM CATH LEN 9MM DIAM AD SMRT,SUP-2155438,CDM,C1876,HCPCS,0278,RC,,,,both,,,4770.26,3100.67,,,,,,,,,,,,,
CATHETER ETER URET OD8FR OPN END,SUP-2141718,CDM,C1758,HCPCS,0278,RC,,,,both,,,118.66,77.13,,,,,,,,,,,,,
CATHETER EP DIAG VIK JOSEPHSON CRV 2MM OCTAPOLAR POLE 6FR,SUP-2142593,CDM,C1730,HCPCS,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
SUTURE ANCHR 65 MM CROSSFT SUT ANCHR W TWO NUMBER 2 HI FI,SUP-2167101,CDM,C1713,HCPCS,0278,RC,,,,both,,,1509.37,981.09,,,,,,,,,,,,,
WIRE FIX BNE TO BNE ANTR CERV LIGMNT KIRSCHNER,SUP-2362046,CDM,C1713,HCPCS,0278,RC,,,,both,,,1041.60,677.04,,,,,,,,,,,,,
PARTICLE EMB EMBOCUBE HYDRATED SZ 5 MM CATH 0.04 IN 100MG,SUP-2701310,CDM,C1889,HCPCS,0278,RC,,,,both,,,172.70,112.25,,,,,,,,,,,,,
SCREW INTRF L30MM DIA8-10MM TIB PEEK TAPR INTRAFIX,SUP-2256822,CDM,C1713,HCPCS,0278,RC,,,,both,,,847.80,551.07,,,,,,,,,,,,,
BLADE US CRV LNG 20 MM RIGID SHTH TISS REMOVAL BONESCALPEL,SUP-2305945,CDM,C1713,HCPCS,0278,RC,,,,both,,,1964.07,1276.65,,,,,,,,,,,,,
DEVICE PESSARY NO4 DIA2.75IN RNG FLD KITTED W/ SUPP PROLAPSE,SUP-2171799,CDM,A4562,HCPCS,0274,RC,,,,both,,,173.30,112.64,,,,,,,,,,,,,
HC So Antibody Titer,PX-3028688666,CDM,86886,CPT,0302,RC,,,,both,,,281.00,182.65,,,,,,,,,,,,,
KIT CATH HEMODIALYSI HICKMAN CHRONIC 13.5FR DIA 23CM 40CML I,SUP-2613307,CDM,C1751,HCPCS,0278,RC,,,,both,,,837.44,544.34,,,,,,,,,,,,,
BIT DRL L 140/45 MM DIA2.5 MM CALIB AO QC STRL DISP V,SUP-2907613,CDM,2720000010,LOCAL,0272,RC,,,,both,,,753.35,489.68,,,,,,,,,,,,,
Z DISCONTINUED NO SUB IDED CONNECTOR SHUNT OD1.8-1.5MM ID0.8MM S STL F8-F5 STEPDOWN,SUP-2243839,CDM,2720000010,LOCAL,0272,RC,,,,both,,,699.84,454.90,,,,,,,,,,,,,
HC Replace G-J Tube,PX-3614945200,CDM,49452,CPT,0361,RC,,,,both,,,8583.00,5578.95,,,,,,,,,,,,,
IMPLANT FACE L 100 X W 76 MM THK 1.5 MM POLYETHYL EMBEDDED,SUP-2883632,CDM,C1713,HCPCS,0278,RC,,,,both,,,8977.92,5835.65,,,,,,,,,,,,,
WIRE FIX TRCR PT 1.4X150 MM RND KIRSCHNER,SUP-2321689,CDM,C1713,HCPCS,0278,RC,,,,both,,,54.95,35.72,,,,,,,,,,,,,
STAPLER INT 12MM 60MM CART SHT NEW KNF BLDE W/ EVERY FIRING,SUP-2283269,CDM,2720000010,LOCAL,0272,RC,,,,both,,,385.87,250.82,,,,,,,,,,,,,
PLATE BONE L107MM 8 H LT POSTEROLATERAL DSTL HUM FOR,SUP-2349771,CDM,C1713,HCPCS,0278,RC,,,,both,,,7888.62,5127.60,,,,,,,,,,,,,
ROD EXT FIX L 400 MM THRD P45-310-0400,SUP-2900178,CDM,2720000010,LOCAL,0272,RC,,,,both,,,388.58,252.58,,,,,,,,,,,,,
POST EXT FIX 5 HOLE WIRE NS,SUP-2548518,CDM,2720000010,LOCAL,0272,RC,,,,both,,,744.43,483.88,,,,,,,,,,,,,
KIT CATH HEMODIALYSI NIAG ACUTE 13.5FR DIA 15CML INS 5593150,SUP-2632907,CDM,C1752,HCPCS,0278,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
NEEDLE INJ LL 18 GA 5 MMX43 CM,SUP-2767580,CDM,2720000010,LOCAL,0272,RC,,,,both,,,649.95,422.47,,,,,,,,,,,,,
BLADE RETRACTOR KOCHER 9 IN 38X20 MM SLIGHTLY CRV,SUP-2458460,CDM,2720000010,LOCAL,0272,RC,,,,both,,,349.39,227.10,,,,,,,,,,,,,
FILTER VASC CATH L48CM INTRO 7FR VENA CAVA NIT SNF/SL FEM,SUP-2127809,CDM,C1880,HCPCS,0278,RC,,,,both,,,2904.50,1887.92,,,,,,,,,,,,,
HC Ot Orthotic Fit/Train Subsq per 15 Min,PX-4309776300,CDM,97763,CPT,0430,RC,,,,outpatient,,,160.00,104.00,,,,,,,,,,,,,
MESH SURG SYN UNCOATED MFIL POLYFORM MACROPOROUS POLYPR,SUP-2139414,CDM,C1781,HCPCS,0278,RC,,,,both,,,1468.42,954.47,,,,,,,,,,,,,
MESH BONE HOLEX12 07MM THK LATEX FREE MAXILLOFACIAL,SUP-2707283,CDM,C1713,HCPCS,0278,RC,,,,both,,,5111.32,3322.36,,,,,,,,,,,,,
MICROCATHETER GUID FINECROSS M3 L 150 CM PROX/DSTL OD,SUP-2892551,CDM,C1887,HCPCS,0272,RC,,,,both,,,1821.20,1183.78,,,,,,,,,,,,,
COMPONENT TIBIAL STERILE LATEX MEDIUM VERSION STAR,SUP-2879177,CDM,C1776,CPT,0278,RC,,,,both,,,18197.24,11828.21,,,,,,,,,,,,,
INSERT TIB THK 6 MM SZ 2 UHMWPE RT ANK ANTR BIASED STRL,SUP-2932744,CDM,C1776,CPT,0278,RC,,,,both,,,11770.45,7650.79,,,,,,,,,,,,,
PLATE BNE 44 CM,SUP-2136805,CDM,C1713,HCPCS,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
SCREW INTRF L30MM DIA9MM PLLA KNEE BIOABSRB BLNT THRD ENLD,SUP-2340995,CDM,C1713,HCPCS,0278,RC,,,,both,,,640.56,416.36,,,,,,,,,,,,,
FORCEPS SPEC RETRV L135CM OD3FR S STL VASC BRAID,SUP-2168281,CDM,C1773,HCPCS,0272,RC,,,,both,,,1921.52,1248.99,,,,,,,,,,,,,
STENT URET 0.035 IN 7 FRX28 CM 6 FR MOVABLE FIRM PERC+,SUP-2470090,CDM,C1758,HCPCS,0278,RC,,,,both,,,365.21,237.39,,,,,,,,,,,,,
HC Ot Iontophoresis per 15 Min|OP PT SERVICES|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS,PX-4309703300,CDM,97033,CPT,0430,RC,,,GP|CQ,outpatient,,,221.00,143.65,,,,,,,,,,,,,
HC Image Cath Fluid Trns/Vgnl,PX-3614940700,CDM,49407,CPT,0361,RC,,,,inpatient,,,6875.00,4468.75,,,,,,,,,,,,,
HUMERAL SUTURE PLATE 5 HOLE STRL,SUP-2816581,CDM,C1713,HCPCS,0278,RC,,,,both,,,5008.30,3255.39,,,,,,,,,,,,,
CATHETER EP L115CM OD7FR SPC 2-8-2MM BLU D CRV DECAPOLAR,SUP-2248704,CDM,C1732,HCPCS,0272,RC,,,,both,,,1447.54,940.90,,,,,,,,,,,,,
MESH BONE 50MMW X 50MML 03MM THK TTNM 3D LATEX FREE MXLFCL,SUP-2681428,CDM,C1713,HCPCS,0278,RC,,,,both,,,4279.76,2781.84,,,,,,,,,,,,,
PLATE BNE TIB LT DSTL POSTEROMEDIAL ANK 3 HOLE NS,SUP-2518425,CDM,C1713,HCPCS,0278,RC,,,,both,,,5005.16,3253.35,,,,,,,,,,,,,
ALLOGRAFT BNE CUBE 12X12X12 MM FD SPNG CANC READIGRAFT BLX,SUP-2740971,CDM,C1713,HCPCS,0278,RC,,,,both,,,1671.92,1086.75,,,,,,,,,,,,,
SPLINT HND RT REG FUNC POS ABDUCTN OPPOS THMB FIRM SUPP,SUP-2324560,CDM,L3906,HCPCS,0274,RC,,,,both,,,81.33,52.86,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP J 0.038 INX145 CM SUPER STIFF PTFE AMPLATZ,SUP-2139355,CDM,C1769,HCPCS,0272,RC,,,,both,,,99.13,64.43,,,,,,,,,,,,,
"HC Peripheral Art Disease Rehab, Ea",PX-9409366800,CDM,93668,CPT,0940,RC,,,,both,,,336.00,218.40,,,,,,,,,,,,,
HC Cardiac Rehab Outpatient,PX-9439379800,CDM,93798,CPT,0943,RC,,,,both,,,412.00,267.80,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP LOOP TIP STRL LTX DISP,SUP-2877793,CDM,C1769,HCPCS,0272,RC,,,,both,,,642.92,417.90,,,,,,,,,,,,,
IMPLANT TOE SZ 30 FOREFOOT CLASS GREAT KT FUTURA,SUP-2388611,CDM,C1776,CPT,0278,RC,,,,both,,,3907.20,2539.68,,,,,,,,,,,,,
HC Nasotracheal Catheter Aspiration,PX-7613172000,CDM,31720,CPT,0761,RC,,,,outpatient,,,99.00,64.35,,,,,,,,,,,,,
ABLATOR ENDOSCP COAG TEF BALL TIP 23 MM DIAM 300 CM LEN 1 PC,SUP-2360707,CDM,C1713,HCPCS,0278,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
CUP ACET MULT H 48MM ACUMATCH A SER,SUP-2221817,CDM,C1776,CPT,0278,RC,,,,both,,,6028.80,3918.72,,,,,,,,,,,,,
BUR SURG OD7MM DMND STRL CORNERSTONE MAESTRO,SUP-2363389,CDM,2720000010,LOCAL,0272,RC,,,,both,,,302.54,196.65,,,,,,,,,,,,,
IMPLANT OP RM TUFFNEK SCR 2.7 X 34MM,SUP-2321189,CDM,C1713,HCPCS,0278,RC,,,,both,,,506.33,329.11,,,,,,,,,,,,,
BLADE IM L75MM DIA12.5MM ST TI CANN FR CUT EDGE SPRL FOR RG,SUP-2180044,CDM,C1713,HCPCS,0278,RC,,,,both,,,1719.15,1117.45,,,,,,,,,,,,,
BIT DRL L110MM DIA16MM SLD ADD ON,SUP-2321583,CDM,2720000010,LOCAL,0272,RC,,,,both,,,369.89,240.43,,,,,,,,,,,,,
CATHETER HD DL 11.5 FRX15 CM FULL KT PRECRV DUOFLO,SUP-2267010,CDM,C1752,HCPCS,0278,RC,,,,both,,,232.36,151.03,,,,,,,,,,,,,
STEM HUM 6MM MINI SHLDR CO CHROM COMPHSVE REV PRI CEM,SUP-2404559,CDM,C1776,CPT,0278,RC,,,,both,,,14952.68,9719.24,,,,,,,,,,,,,
STENT BILI ZILVER 635 L 40 MM DIA 8 MM DEL SYS L 40 CM SHTH,SUP-2647163,CDM,C1876,HCPCS,0278,RC,,,,both,,,2088.10,1357.26,,,,,,,,,,,,,
PLATE BNE L189MM THK3MM 10 H BILAT S STL STR LOK COMPR RECON,SUP-2185343,CDM,C1713,HCPCS,0278,RC,,,,both,,,1712.30,1112.99,,,,,,,,,,,,,
SCREW ENDPLATE MED STRL XRL,SUP-2602232,CDM,C1713,HCPCS,0278,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
EXTRACTOR SURG FEM STEM RAM,SUP-2885049,CDM,2720000010,LOCAL,0272,RC,,,,both,,,601.56,391.01,,,,,,,,,,,,,
PLATE BONE REG THK0.6MM 2X2 H MIDFACE SLV TI LT L SHP FOR,SUP-2135912,CDM,C1713,HCPCS,0278,RC,,,,both,,,675.10,438.81,,,,,,,,,,,,,
SUTURE NONABSORBABLE WHT CART FOR SMARTSTITCH PERFECT PASS OM8178,SUP-2342099,CDM,C1713,HCPCS,0278,RC,,,,both,,,543.22,353.09,,,,,,,,,,,,,
KIT SPNL IMPL FIX SHIM MAXCESS,SUP-2310425,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
HC Glb Donor Lymphocyte Infusion,PX-9823824200,CDM,38242,CPT,0982,RC,,,,both,,,1957.00,1272.05,,,,,,,,,,,,,
SPACER HIP 80MM LNG 70MM DIA L 1.7GM ANTIBIO ENDOPROSTESIS,SUP-2223695,CDM,C1776,CPT,0278,RC,,,,both,,,9388.60,6102.59,,,,,,,,,,,,,
HC So Renin,PX-3018424466,CDM,84244,CPT,0301,RC,,,,both,,,602.00,391.30,,,,,,,,,,,,,
STAPLE BNE FIX W13XL10MM NIT W/ INSTR LO PROF COMPRESSIVE,SUP-2122343,CDM,C1713,HCPCS,0278,RC,,,,both,,,5950.30,3867.69,,,,,,,,,,,,,
CATHETER HAD 11.5FR L20CM STR SIL DBL LUMN HEM CATH ST,SUP-2267079,CDM,C1881,HCPCS,0278,RC,,,,both,,,109.90,71.43,,,,,,,,,,,,,
PATCH VASC W6XL75MM KNIT POLY CAR ULT THN WALL N TAPR N RING,SUP-2395789,CDM,C1768,CPT,0278,RC,,,,both,,,425.53,276.59,,,,,,,,,,,,,
KIT INTRO ARW DIA 9 FR GUIDEWIRE 0.035 IN POLYUR PERC SHRP,SUP-2383944,CDM,C1894,HCPCS,0272,RC,,,,both,,,119.89,77.93,,,,,,,,,,,,,
CAGE SPNL L50XH12MM 6DEG PEEK LORD CLYDESDALE,SUP-2285049,CDM,C1889,HCPCS,0278,RC,,,,both,,,11514.38,7484.35,,,,,,,,,,,,,
CHLOROPROCAINE HCL (PF) 3 % IJ SOLN,RX-135449,CDM,J2401,HCPCS,0636,RC,63323-0478-27,NDC,,both,20,ML,128.70,83.65,,,,,,,,,,,,,
STAPLE BNE FIX W20XL20MM S STL FOREFOOT NTHRD COMPR,SUP-2397616,CDM,C1713,HCPCS,0278,RC,,,,both,,,1023.64,665.37,,,,,,,,,,,,,
COMPONENT ARTC SURF 1 12 MM KNEE VIVACIT-E,SUP-2450541,CDM,C1776,CPT,0278,RC,,,,both,,,3102.32,2016.51,,,,,,,,,,,,,
"HC NM Lymphatics,Lymph Gland Imaging",PX-3417819500,CDM,78195,CPT,0341,RC,,,,outpatient,,,2453.00,1594.45,,,,,,,,,,,,,
ANCHOR SUT TWINLOOP PEEK SGL STRND 2 EYELET UP EXT W NUMBER,SUP-2366681,CDM,C1713,HCPCS,0278,RC,,,,both,,,508.68,330.64,,,,,,,,,,,,,
PLATE DSTL RAD 2 CLMN 2.4MM 7H HD 3H SHFT RT SS VA LCP STRL,SUP-2546051,CDM,C1713,HCPCS,0278,RC,,,,both,,,4148.94,2696.81,,,,,,,,,,,,,
CATHETER URTRL 48FR DIA 70CML PLSTC OPEN ENDED FLXBLE TIP W,SUP-2730109,CDM,C1758,HCPCS,0278,RC,,,,both,,,132.16,85.90,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 80 CM DIA 7 MM STR STD WALL HELIX,SUP-2525444,CDM,C1768,CPT,0278,RC,,,,both,,,1928.49,1253.52,,,,,,,,,,,,,
SHEATH INTRO HEARTSPAN 55 DEG L 79.4 CM DIA 8.5 FR BRAIDED,SUP-2880097,CDM,C1893,HCPCS,0272,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
SUPPORT SHLDR M L36-40IN UNIV CHST NEOPRENE BLK HUM CUF 61460601] PERFORMANCE HEALTH INC],SUP-2324516,CDM,L3675,HCPCS,0274,RC,,,,both,,,160.45,104.29,,,,,,,,,,,,,
KIT LAP BND DISECT ADJ,SUP-2257755,CDM,2780000010,LOCAL,0278,RC,,,,both,,,9071.46,5896.45,,,,,,,,,,,,,
ELECTRODE ENDOSCP HF-RESECTION SM 12-30 DEG WA22705S,SUP-2482278,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1598.10,1038.76,,,,,,,,,,,,,
PLATE BNE 1.5/2X48X1.2 MM 7 HOLE SS LCP,SUP-2569287,CDM,C1713,HCPCS,0278,RC,,,,both,,,341.95,222.27,,,,,,,,,,,,,
SCREW BNE CORTICAL 3.5X18 MM FUSION HEX DRV YEL WRST SS NS,SUP-2852117,CDM,C1713,HCPCS,0278,RC,,,,both,,,710.93,462.10,,,,,,,,,,,,,
KIT TRACH AD TB L70MM OD8.7MM ID6MM SIL W/ OBT SIDEPRT,SUP-2352455,CDM,2720000010,LOCAL,0272,RC,,,,both,,,321.13,208.73,,,,,,,,,,,,,
KIT FIX W/ K WIRE GRFT PASS PIN 2 DRL BIT BNE PLUG MRK PEN,SUP-2212938,CDM,C1713,HCPCS,0278,RC,,,,both,,,2797.74,1818.53,,,,,,,,,,,,,
WAND ARTHSCP DIA3.75MM TIP DIA3MM 50DEG W/ INTEGR FNGR SWCH,SUP-2342011,CDM,2720000010,LOCAL,0272,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
CATHETER URET 6FR L70CM SFT PERCFLX SGL LUMN OPN END TAPR,SUP-2139286,CDM,C1758,HCPCS,0278,RC,,,,both,,,37.18,24.17,,,,,,,,,,,,,
PROSTHESIS OSS L5MM HD OD3MM CANN OD117MM HA PART CNTR,SUP-2436524,CDM,L8613,CPT,0278,RC,,,,both,,,966.59,628.28,,,,,,,,,,,,,
PATCH EP CATH REFSTAR QWIKPATCH DIA 6 FR EXT REF HYPR NS,SUP-2248956,CDM,C1730,HCPCS,0272,RC,,,,both,,,1164.94,757.21,,,,,,,,,,,,,
SCREW PEDCL 6.5X50MM 2105-6550,SUP-2415320,CDM,C1713,HCPCS,0278,RC,,,,both,,,5451.04,3543.18,,,,,,,,,,,,,
SCREW 5.0MM TI DUAL CORE LCKNG T25 STRDRV 28MM F IM NAIL STE,SUP-2546343,CDM,C1713,HCPCS,0278,RC,,,,both,,,697.55,453.41,,,,,,,,,,,,,
GRAFT BNE FIBER MED 5 CC SYR DBM,SUP-2431097,CDM,C1889,HCPCS,0278,RC,,,,both,,,4239.00,2755.35,,,,,,,,,,,,,
PISTON L4MM SHFT L1.25MM OD0.5MM STR PLAT TI KARTUSH,SUP-2284070,CDM,L8613,CPT,0278,RC,,,,both,,,741.04,481.68,,,,,,,,,,,,,
PLASMA-LYTE A IV SOLN,RX-6331,CDM,2580000003,HCPCS,0258,RC,65219-0389-10,NDC,,both,1000,ML,80.50,52.32,,,,,,,,,,,,,
OSSEOFLEX SN STRBLE NDLE 10 G INCL CNNLSSTLTSBPSY NDLE,SUP-2701996,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4279.98,2781.99,,,,,,,,,,,,,
COMPONENT TALAR SZ 2 COCR POROUS TI LT ANK FLAT CUT STRL,SUP-2933408,CDM,C1776,CPT,0278,RC,,,,both,,,35781.24,23257.81,,,,,,,,,,,,,
BRACE UNIV WRST UNI L 8IN 45IN 95IN FRM FIT,SUP-2319285,CDM,L3809,HCPCS,0272,RC,,,,both,,,28.32,18.41,,,,,,,,,,,,,
SCREW BNE L50MM DIA4MM S STL CANN LNG HALF THRD SM HEX SOCK,SUP-2183792,CDM,C1713,HCPCS,0278,RC,,,,both,,,466.32,303.11,,,,,,,,,,,,,
SCREW INTFR BIOSURE REGENESORB 10MM X 35MM,SUP-2341930,CDM,C1713,HCPCS,0278,RC,,,,both,,,1121.89,729.23,,,,,,,,,,,,,
SEALER LAP L37CM MARYLAND JAW OPN NANO COAT MULTIFUNCTIONAL,SUP-2283564,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1494.83,971.64,,,,,,,,,,,,,
ELECTRODE KIT ENSITE PRECIS,SUP-2357587,CDM,C1713,HCPCS,0278,RC,,,,both,,,2983.00,1938.95,,,,,,,,,,,,,
CEMENT BNE 10ML 20GM HALF DOSE PMMA W/O ANTIBIO M VISC,SUP-2374940,CDM,C1713,HCPCS,0278,RC,,,,both,,,94.20,61.23,,,,,,,,,,,,,
PLATE BNE L 75 MM SCREW DIA2 MM HD 2 SHFT 10 H SS TINE SLV,SUP-2905644,CDM,C1713,HCPCS,0278,RC,,,,both,,,3031.61,1970.55,,,,,,,,,,,,,
INSERT ACET OD44MM THK7.3MM BPLR HD 22MM OD36MM 0DEG UHMWPE,SUP-2377733,CDM,C1776,CPT,0278,RC,,,,both,,,7075.05,4598.78,,,,,,,,,,,,,
DRILL TWST 25MMDIA 4INL J LATCH DISPOSABLE,SUP-2262904,CDM,C1713,HCPCS,0278,RC,,,,both,,,504.44,327.89,,,,,,,,,,,,,
GUIDEWIRE WITH OLIVE,SUP-2714104,CDM,C1769,HCPCS,0272,RC,,,,both,,,596.60,387.79,,,,,,,,,,,,,
DRILL SURG 1.5MM LNG MINI QUIK CONN VLP MINI-MOD,SUP-2351109,CDM,2720000010,LOCAL,0272,RC,,,,both,,,721.85,469.20,,,,,,,,,,,,,
ROD EXT FIX L200MM DIA8MM C CONN HOFF III,SUP-2372456,CDM,C1713,HCPCS,0278,RC,,,,both,,,596.60,387.79,,,,,,,,,,,,,
PLATE BNE MED IMPL 13 H R TI EL FRAC SYS DST FIB 127MM LNG,SUP-2411734,CDM,C1713,HCPCS,0278,RC,,,,both,,,3689.50,2398.17,,,,,,,,,,,,,
SCREW BNE L8MM DIA2.7MM LOK FOR R3CON PLATING SYS GORILLA,SUP-2321270,CDM,C1713,HCPCS,0278,RC,,,,both,,,635.22,412.89,,,,,,,,,,,,,
ROD SPNL CRV 5.5X30 MM TITLE,SUP-2415475,CDM,C1713,HCPCS,0278,RC,,,,both,,,989.10,642.91,,,,,,,,,,,,,
PLATE BNE EXTRA-ARTICULAR 3.5X266 MM DSTL HUM 12 HOLE TI LCP,SUP-2432241,CDM,C1713,HCPCS,0278,RC,,,,both,,,5743.75,3733.44,,,,,,,,,,,,,
ELECTRODE ENDO MPLR BALL ELECTRD DISP 22FR,SUP-2361453,CDM,2720000010,LOCAL,0272,RC,,,,both,,,420.45,273.29,,,,,,,,,,,,,
INSERT TIB SZ 5 THK14MM HNG GMK,SUP-2267633,CDM,C1776,CPT,0278,RC,,,,both,,,8113.76,5273.94,,,,,,,,,,,,,
DEVICE REATTACHMENT L50MM DIA1MM STD TROCHANTERIC TI W/ CO,SUP-2193591,CDM,C1713,HCPCS,0278,RC,,,,both,,,5279.03,3431.37,,,,,,,,,,,,,
NAIL INTRAMEDULLARY TIBIOTALOCALCANEAL 12MM X 30CM NITINOL DYNANAIL XL,SUP-2878955,CDM,C1713,HCPCS,0278,RC,,,,both,,,58859.30,38258.54,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL PEEK SD800.502,SUP-2860184,CDM,C1713,HCPCS,0278,RC,,,,both,,,26747.46,17385.85,,,,,,,,,,,,,
BRACE ANK SM AD FOR 7-8.5IN UNIV VLY CNTOUR STL STAY CNTCT,SUP-2197932,CDM,L4350,HCPCS,0272,RC,,,,both,,,110.21,71.64,,,,,,,,,,,,,
NERVE STIMULATOR KIT 90 CM 1X8 SUBCOMPACT VECTRIS SURESCAN,SUP-2280219,CDM,C1778,HCPCS,0278,RC,,,,both,,,7529.72,4894.32,,,,,,,,,,,,,
PLATE BONE L LT GLD 3D ORBIT FLR FOR 1.2MM SCR,SUP-2363679,CDM,C1713,HCPCS,0278,RC,,,,both,,,4038.73,2625.17,,,,,,,,,,,,,
BIT DRL L95MM DIA3.5MM ST JCBS CHK NONRADIOPAQUE W/O STP,SUP-2187265,CDM,2720000010,LOCAL,0272,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
HC So Muscle-Specific Kinase Antibody,PX-3028636666,CDM,86366,CPT,0302,RC,,,,both,,,513.00,333.45,,,,,,,,,,,,,
PLATE BONE W14.9XL200MM THK1.2MM 12 H DSTL TIB S STL,SUP-2185741,CDM,C1713,HCPCS,0278,RC,,,,both,,,1374.10,893.16,,,,,,,,,,,,,
GRAFT BNE SUB 15CC SZ 05 5MM CORT CANC GRAN FRZ DRY,SUP-2307055,CDM,C1713,HCPCS,0278,RC,,,,both,,,968.34,629.42,,,,,,,,,,,,,
SCREWDRIVER BLADE 2.7 MM QUIK CPL CENTRE DRV SS 500189807,SUP-2525661,CDM,2720000010,LOCAL,0272,RC,,,,both,,,431.94,280.76,,,,,,,,,,,,,
PLATE BNE GRP MED 200 MM TROCHANTERIC SS DALL-M,SUP-2451635,CDM,C1713,HCPCS,0278,RC,,,,both,,,4856.95,3157.02,,,,,,,,,,,,,
COLLAR CERV LO DENS LG 15-20 IN,SUP-2197207,CDM,L0120,HCPCS,0272,RC,,,,both,,,17.18,11.17,,,,,,,,,,,,,
PLATE BNE BROAD 3.5X120 MM 9 HOLE SS LCP,SUP-2569335,CDM,C1713,HCPCS,0278,RC,,,,both,,,452.47,294.11,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE L 10 MM DIA 7.5 MM SZ 4 CART ARAGONITE,SUP-2913320,CDM,C1763,HCPCS,0278,RC,,,,both,,,25591.00,16634.15,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY WEBST INSRTN L 115 CM DIA 5 FR,SUP-2248588,CDM,C1730,HCPCS,0272,RC,,,,both,,,530.66,344.93,,,,,,,,,,,,,
SIDEPLATE STD BARL 150 DEG 3H STRL LCP DHHS,SUP-2547682,CDM,C1713,HCPCS,0278,RC,,,,both,,,1641.28,1066.83,,,,,,,,,,,,,
PEG BNE FIX L24MM DIA2.5MM DST VOLAR RAD PARTIALLY THRD FOR,SUP-2414246,CDM,C1713,HCPCS,0278,RC,,,,both,,,259.05,168.38,,,,,,,,,,,,,
COMPONENT ARTC SURF CR 3-4 CH 14 MM TIB KNEE YEL NXGN,SUP-2201356,CDM,C1776,CPT,0278,RC,,,,both,,,6437.00,4184.05,,,,,,,,,,,,,
PLATE BNE L STD 2.4/2.7X44 MM RT 1ST MTP 2X2 HOLE VA LP LCK,SUP-2181249,CDM,C1713,HCPCS,0278,RC,,,,both,,,3224.00,2095.60,,,,,,,,,,,,,
IMPLANT BIOINDUCTIVE M BOV ACHILLES TEND W/ ARTHSCP DEL SYS,SUP-2419470,CDM,C1763,HCPCS,0278,RC,,,,both,,,8341.41,5421.92,,,,,,,,,,,,,
DILATOR ENDO L180CM BAL L3CM OD8MM GWIRE OD0.035IN,SUP-2169413,CDM,C1726,HCPCS,0272,RC,,,,both,,,681.38,442.90,,,,,,,,,,,,,
INTRODUCER INFUSION PMP SHT 14 FR IMPELLA,SUP-2431911,CDM,C1892,HCPCS,0272,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
SPLINT THUMB WRIST L AD L8IN L D RNG ABD FIRM SUPP W STAY,SUP-2194734,CDM,L3807,HCPCS,0274,RC,,,,both,,,56.52,36.74,,,,,,,,,,,,,
SET SCR SPNL L32MM DIA6.35MM TI LOK BRK OFF DBL HEX SOCK,SUP-2289649,CDM,C1713,HCPCS,0278,RC,,,,both,,,349.01,226.86,,,,,,,,,,,,,
ORTHO ANCHRGE C TUBE PLATE CROSS SHPD RNDD LG TB3T1.5MM CP T,SUP-2492285,CDM,C1713,HCPCS,0278,RC,,,,both,,,1391.77,904.65,,,,,,,,,,,,,
TRAY KYPHOPLASTY SZ 2 BLLN L20MM BNE FILL DEV SYR IBT KYPHON,SUP-2293628,CDM,C1713,HCPCS,0278,RC,,,,both,,,8164.00,5306.60,,,,,,,,,,,,,
BUR ENDOSCP SHAVER 12 DEG L 11 CM DIA 3.2 MM SPD 12000 RPM,SUP-2902096,CDM,2720000010,LOCAL,0272,RC,,,,both,,,829.81,539.38,,,,,,,,,,,,,
SET BILI STENT ZMMN L 5 CM DIA11.5 FR PUSH L 170 CM,SUP-2169030,CDM,C2625,HCPCS,0278,RC,,,,both,,,398.78,259.21,,,,,,,,,,,,,
ALLOGRAFT CELLULAR ALLOFUSE SELECT  CM 10CC,SUP-2653973,CDM,C1713,HCPCS,0278,RC,,,,both,,,16663.98,10831.59,,,,,,,,,,,,,
DRILL SURG DIA4.5MM CANN ENDOBUTTON,SUP-2342262,CDM,2720000010,LOCAL,0272,RC,,,,both,,,263.70,171.40,,,,,,,,,,,,,
PROPHECY INVISION PATIENT SPECIFIC GUIDES,SUP-2853187,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3205.94,2083.86,,,,,,,,,,,,,
COLLAR CERV LO DENS LG 15-20 IN,SUP-2197207,CDM,L0120,HCPCS,0274,RC,,,,both,,,17.18,11.17,,,,,,,,,,,,,
GUIDEWIRE VASC HI TORQ WINN 200T L 300 CM DIA 0.014 IN TIP,SUP-2105136,CDM,C1769,HCPCS,0272,RC,,,,both,,,536.94,349.01,,,,,,,,,,,,,
KIT VENTRICULAR DRAINAGE W/ INS8302 SYS INS4500 CATH SET,SUP-2883669,CDM,C1729,HCPCS,0272,RC,,,,both,,,905.95,588.87,,,,,,,,,,,,,
BUR ORTH L 13 MM DIA2.9 MM WDG 3 STRL DISP,SUP-2896776,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1522.90,989.88,,,,,,,,,,,,,
KIT SURG PROC STD COR KNOT DEV,SUP-2265303,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
DEFIBRILLATOR IMPL VITALITY DS DR TI 2 CHMBR STD BPLR REMOT,SUP-2149064,CDM,C1721,HCPCS,0275,RC,,,,both,,,52438.00,34084.70,,,,,,,,,,,,,
ENDOPROSTHESIS VASC WSTNT RP L 90 MM DIA 6 MM CATH TOT L 100,SUP-2148369,CDM,C1876,HCPCS,0278,RC,,,,both,,,5730.50,3724.82,,,,,,,,,,,,,
CATHETER DRAINAGE NAGARAJA 7 FR NSL BILI,SUP-2737323,CDM,C1729,HCPCS,0272,RC,,,,both,,,226.08,146.95,,,,,,,,,,,,,
SCREW BNE THERMO SCARF 3 MM EMP BX BAROUK,SUP-2486548,CDM,C1713,HCPCS,0278,RC,,,,both,,,1239.64,805.77,,,,,,,,,,,,,
SET SHTH DESTINO L 87 CM L 67 CM 10FR CRV BEND 50 MM 50 DEG,SUP-2616102,CDM,C1766,CPT,0272,RC,,,,both,,,2088.10,1357.26,,,,,,,,,,,,,
KIT VASC CLOSURE VASOSEAL CLLGN MEDIATED EXTRAVASCULAR STRL,SUP-2227422,CDM,C1760,HCPCS,0278,RC,,,,both,,,551.07,358.20,,,,,,,,,,,,,
KIT CATH HEMODIALYSI EQUISTREAM CHRONIC MICROINTRODU 5904270,SUP-2632975,CDM,C1750,HCPCS,0278,RC,,,,both,,,1803.46,1172.25,,,,,,,,,,,,,
GRAFT HUM TISS L 240 MM ACHILLES TEND FRZN STRL STERIGRAFT,SUP-2913197,CDM,C1762,CPT,0278,RC,,,,both,,,6462.12,4200.38,,,,,,,,,,,,,
PLATE BNE DIA 35 MM THK 0.5 MM SCREW DIA1.7 MM MAXILLOFCL,SUP-2909620,CDM,C1713,HCPCS,0278,RC,,,,both,,,5740.96,3731.62,,,,,,,,,,,,,
PLATE BNE L79MM 10 H OLECRANON TIM LO PROF MULTIPLANAR ARM,SUP-2411728,CDM,C1713,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
INTRODUCER SET CARD LD PLCMNT STR 13CM LEN 10.5FR HEMSTAT,SUP-2280993,CDM,C1894,HCPCS,0272,RC,,,,both,,,141.30,91.84,,,,,,,,,,,,,
KIT CATHETER 6FR POLYUR PORTAL SGL LUMN PORT A CATHETER,SUP-2351857,CDM,C1788,HCPCS,0278,RC,,,,both,,,1310.23,851.65,,,,,,,,,,,,,
TAP BNE S STL HOAR TAP CANN W/ CLLR FOR 6 MM SCR CDH LEG,SUP-2290332,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1470.56,955.86,,,,,,,,,,,,,
SUPPORT ORTHOT SHLDR CUST FIG OF EIGHT DESIGN ABDUCTN,SUP-2435750,CDM,L3650,HCPCS,0272,RC,,,,both,,,185.67,120.69,,,,,,,,,,,,,
MESH HERN RECT 6.3X2.4 IN MONOFILAMENT SCAFFOLD PHASIX,SUP-2736740,CDM,C1781,HCPCS,0278,RC,,,,both,,,4885.84,3175.80,,,,,,,,,,,,,
BIT DRL DIA2.1MM CANN ADD ON CPL DISP FOR ASNS MIC SCR SYS,SUP-2372170,CDM,2720000010,LOCAL,0272,RC,,,,both,,,753.60,489.84,,,,,,,,,,,,,
BLADE SHAVER RESECT 4.5X120 MM FULL RAD LIGHT GRN UNIDRIVE,SUP-2585907,CDM,2720000010,LOCAL,0272,RC,,,,both,,,373.94,243.06,,,,,,,,,,,,,
PLATE BNE THK 0.75 MM SCREW DIA1.7 MM 49 H PLL POLYGLYCOLIDE,SUP-2883152,CDM,C1713,HCPCS,0278,RC,,,,both,,,11940.98,7761.64,,,,,,,,,,,,,
SPACER SPNL W11XH5XL11MM PEEK OPTMA ANT CERV INTBDY FUS,SUP-2286332,CDM,C1889,HCPCS,0278,RC,,,,both,,,2009.60,1306.24,,,,,,,,,,,,,
CATHETER CV SET 032 7 FRX25 CM 13 GA 3L CUTLM701JLSCABRMHCRD,SUP-2759886,CDM,C1751,HCPCS,0278,RC,,,,both,,,240.37,156.24,,,,,,,,,,,,,
PLATE BNE CERV SM 2.7X36 MM 4 HOLE TI,SUP-2474353,CDM,C1713,HCPCS,0278,RC,,,,both,,,349.48,227.16,,,,,,,,,,,,,
DEFEROXAMINE MESYLATE 500 MG IJ SOLR,RX-9723,CDM,J0895,HCPCS,0636,RC,60505-6236-00,NDC,,both,1,UN,74.50,48.42,,,,,,,,,,,,,
SCREW BNE L16MM DIA2.7MM CORT DST RAD LOK FULL THRD SQ DRV,SUP-2411811,CDM,C1713,HCPCS,0278,RC,,,,both,,,178.98,116.34,,,,,,,,,,,,,
PLATE BNE L74MM 3X5 H S STL T LOK COMPR OBLQ L ANG FOR,SUP-2186027,CDM,C1713,HCPCS,0278,RC,,,,both,,,1040.41,676.27,,,,,,,,,,,,,
GUIDEWIRE VASC ARISTOTLE 24 L 200 CM DIA 0.024 IN SFT,SUP-2656738,CDM,C1769,HCPCS,0272,RC,,,,both,,,2339.30,1520.54,,,,,,,,,,,,,
HC So Histamine,PX-3018308866,CDM,83088,CPT,0301,RC,,,,both,,,138.00,89.70,,,,,,,,,,,,,
GRAFT BONE SUB 11MM DWL ILIUM BICORTICAL,SUP-2307095,CDM,C1713,HCPCS,0278,RC,,,,both,,,2185.91,1420.84,,,,,,,,,,,,,
WEDGE TIB FULL 10MM 67MM RT LATERAL/LT MEDL FINN - 10MM 67MM,SUP-2406071,CDM,C1776,CPT,0278,RC,,,,both,,,2772.62,1802.20,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE 1 CC CORTICOCANCELLOUS ALLGRFT,SUP-2933719,CDM,C1762,CPT,0278,RC,,,,both,,,5526.40,3592.16,,,,,,,,,,,,,
NAIL ORTH 1.5IN LNG HD GMRS,SUP-2364863,CDM,C1713,HCPCS,0278,RC,,,,both,,,188.40,122.46,,,,,,,,,,,,,
PLUG VASC UNCONSTRAINED L13.5MM DIA8MM GWIRE 0.038IN W/,SUP-2355707,CDM,C1889,HCPCS,0278,RC,,,,both,,,3281.30,2132.84,,,,,,,,,,,,,
BLADE SAW SAG 6.5MMW X30MML 0.4MM THK 0.6MM THK CUT ANTR CRU,SUP-2605390,CDM,2720000010,LOCAL,0272,RC,,,,both,,,79.35,51.58,,,,,,,,,,,,,
CATHETER EP MCXL 2-5-2 MM SPC 110CM MARINR SC,SUP-2277552,CDM,C1887,HCPCS,0272,RC,,,,both,,,1915.40,1245.01,,,,,,,,,,,,,
GRAFT HUM TISS TEND GRACILIS,SUP-2165546,CDM,C1713,HCPCS,0278,RC,,,,both,,,4044.32,2628.81,,,,,,,,,,,,,
SCREW 65 L90 FT CANN,SUP-2243588,CDM,C1713,HCPCS,0278,RC,,,,both,,,1334.37,867.34,,,,,,,,,,,,,
GUIDEWIRE ORTH TROCAR PT 1 END MULTIPLE NS,SUP-2789119,CDM,C1769,HCPCS,0272,RC,,,,both,,,610.67,396.94,,,,,,,,,,,,,
VALVE PULM HOMOGRAFT SZ 23 MM CONDUIT STRL,SUP-2175243,CDM,2720000010,LOCAL,0272,RC,,,,both,,,31384.30,20399.79,,,,,,,,,,,,,
VEST ORTHOPEDIC HALO XL 42-58 IN CLASS II,SUP-2255768,CDM,C1713,HCPCS,0278,RC,,,,both,,,2951.60,1918.54,,,,,,,,,,,,,
STRAP ELBW TENNIS UNIV FOAM D RNG,SUP-2336255,CDM,L3702,HCPCS,0272,RC,,,,both,,,9.70,6.30,,,,,,,,,,,,,
PROSTHESIS PENILE 15CM PRECONN PENOSCROTAL APPRCH LGX MS,SUP-2139021,CDM,C1813,HCPCS,0278,RC,,,,both,,,26523.58,17240.33,,,,,,,,,,,,,
ALLOGRAFT HUMAN TISS MAXXEUS SEMIT W GRACLIS FZ,SUP-2875992,CDM,C1762,CPT,0278,RC,,,,both,,,5055.40,3286.01,,,,,,,,,,,,,
Z DISCONTINUED NO SUB IDED KIT INSRT 18GA 8CM CATH BASIC PWR GLDE PRO,SUP-2125659,CDM,C1751,HCPCS,0278,RC,,,,both,,,204.10,132.66,,,,,,,,,,,,,
HC Perq Device Breast Add Image,PX-3611928200,CDM,19282,CPT,0361,RC,,,,inpatient,,,1593.00,1035.45,,,,,,,,,,,,,
PLATE BONE W17.5XL314MM THK5.2MM 17 H BILAT S STL BROAD LCK,SUP-2185313,CDM,C1713,HCPCS,0278,RC,,,,both,,,3382.78,2198.81,,,,,,,,,,,,,
DRILL SURG 4.5X12 MM,SUP-2391410,CDM,2720000010,LOCAL,0272,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.449,SUP-2860013,CDM,C1713,HCPCS,0278,RC,,,,both,,,55824.80,36286.12,,,,,,,,,,,,,
KNEE IMMOB 22IN QUAL + L,SUP-2195533,CDM,L1830,CPT,0272,RC,,,,both,,,61.32,39.86,,,,,,,,,,,,,
PLATE BNE STR 12X0.6 MM NEURO 2 HOLE TI STRL LEVEL 1,SUP-2518093,CDM,C1713,HCPCS,0278,RC,,,,both,,,288.69,187.65,,,,,,,,,,,,,
SHELL ACET SZ 23 OD52MM HIP LIMIT H LOK RNG RANAWAT,SUP-2403845,CDM,C1776,CPT,0278,RC,,,,both,,,4710.63,3061.91,,,,,,,,,,,,,
IMPLANT COSMETIC SZ 20 X 20 X 2.45 X 0.45 MM POLYETHYL SELLA,SUP-2935353,CDM,C1713,HCPCS,0278,RC,,,,both,,,2455.48,1596.06,,,,,,,,,,,,,
PIN EXT FIX HALF 6X45 MM 160 MM BLNT SHANK P451966045,SUP-2749895,CDM,2720000010,LOCAL,0272,RC,,,,both,,,744.18,483.72,,,,,,,,,,,,,
ENDCAP ORTH 10 MM EXTN FOR TIB NAIL ADV TI STRL,SUP-2789370,CDM,C1889,HCPCS,0278,RC,,,,both,,,590.54,383.85,,,,,,,,,,,,,
PLATE BNE CUT SUP LAT SHLDR DELTA-XTEND,SUP-2454178,CDM,C1713,HCPCS,0278,RC,,,,both,,,2986.14,1940.99,,,,,,,,,,,,,
STENT URET 6FR L24CM LUBRICIOUS HYDRPHLC TAPR TIP SMOOTH,SUP-2126625,CDM,C2617,HCPCS,0278,RC,,,,both,,,685.71,445.71,,,,,,,,,,,,,
PLATE BONE H2.8MM 11 H MAND TI STR SEC RECON LEIBINGER,SUP-2363748,CDM,C1713,HCPCS,0278,RC,,,,both,,,2575.80,1674.27,,,,,,,,,,,,,
STIMULATOR SPNL CRD W 47 X H 57 MM D 6 MM SPC 2.8 MM 29 GM,SUP-2913244,CDM,C1820,HCPCS,0278,RC,,,,both,,,62172.00,40411.80,,,,,,,,,,,,,
PORT IMPL INFUSION STR 26X70 MM SS,SUP-2232157,CDM,2720000010,LOCAL,0272,RC,,,,both,,,722.20,469.43,,,,,,,,,,,,,
HC M/Phmtrc Alys Ish Quant/Semiq Mnl Each Multiprb|NOT REASONABLE AND NECESSARY,PX-3128837700,CDM,88377,CPT,0312,RC,,,GZ,both,,,1050.00,682.50,,,,,,,,,,,,,
PLATE COMPRSS BROAD CRVD 9 HL 115MM,SUP-2705336,CDM,C1713,HCPCS,0278,RC,,,,both,,,2591.60,1684.54,,,,,,,,,,,,,
GRAFT HUM TISS CORNEAL,SUP-2427794,CDM,V2785,HCPCS,0278,RC,,,,both,,,8242.50,5357.62,,,,,,,,,,,,,
DRILL SURG FLX FOR 2.3MM CRV SUT ANCHR SYS,SUP-2341871,CDM,2720000010,LOCAL,0272,RC,,,,both,,,563.72,366.42,,,,,,,,,,,,,
SCREW SPNL IL SACR AND SACROIL S STL 7.0MMX55MM COLORADO 2,SUP-2290484,CDM,C1713,HCPCS,0278,RC,,,,both,,,3215.36,2089.98,,,,,,,,,,,,,
ALLOGRAFT HUM TISS PTCH THN 7X7 CM AMNIO TISS MEMBRN CYGNUS,SUP-2422825,CDM,Q4170,HCPCS,0636,RC,,,,both,,,5777.60,3755.44,,,,,,,,,,,,,
SHELL ACET OD55MM UNIV CSTI HIP PROTRUSIO REV PRESSFIT,SUP-2208508,CDM,C1776,CPT,0278,RC,,,,both,,,6674.07,4338.15,,,,,,,,,,,,,
SYSTEM REPAIR MENISCAL NOVOSTITCH PRO,SUP-2665298,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2094.41,1361.37,,,,,,,,,,,,,
MESH SURG 10 X 18.5 CM SUTURE SZ 5-0 OVINE POLYPRO,SUP-2914806,CDM,C1781,HCPCS,0278,RC,,,,both,,,9781.10,6357.71,,,,,,,,,,,,,
GRAFT VASC RESTOREFLOW SZ 30 CM FEM VEIN BLD TYP A B AB O,SUP-2884030,CDM,C1768,CPT,0278,RC,,,,both,,,24551.66,15958.58,,,,,,,,,,,,,
VALVE VENT SM ADJ W/O RESVR STRATA II,SUP-2284520,CDM,C1889,HCPCS,0278,RC,,,,both,,,12366.20,8038.03,,,,,,,,,,,,,
PLATE BONE L50MM 9 H GRN S 1 RT LO EXTRM TI NONCOMPRESSION,SUP-2242904,CDM,C1713,HCPCS,0278,RC,,,,both,,,2311.04,1502.18,,,,,,,,,,,,,
DSG WND MICRONIZED PARTIC 20 MG MATRISTEM MICROMATRIX,SUP-2106466,CDM,Q4118,HCPCS,0636,RC,,,,both,,,144.53,93.94,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP L150CM OD.025IN 14FR INTRO FLX TIP FIX,SUP-2139323,CDM,C1769,HCPCS,0272,RC,,,,both,,,36.86,23.96,,,,,,,,,,,,,
ENDOPROSTHESIS VASC VIABAHN L 7.5CM 8MM 120CM 7FR RADIOPAQUE,SUP-2396658,CDM,C1874,HCPCS,0278,RC,,,,both,,,11093.62,7210.85,,,,,,,,,,,,,
STABILIZER PELV TPOD ORNG TRAUM ORTHOT DEV TPODOR,SUP-2150009,CDM,L0469,HCPCS,0272,RC,,,,both,,,423.87,275.52,,,,,,,,,,,,,
SCREW BNE ST 1.5X12 MM LCK VA W/ T4 STARDRV TI NS,SUP-2181045,CDM,C1713,HCPCS,0278,RC,,,,both,,,378.18,245.82,,,,,,,,,,,,,
GRAFT BNE CRUSH 1-10 MM 5 CC CANC,SUP-2766760,CDM,C1713,HCPCS,0278,RC,,,,both,,,494.55,321.46,,,,,,,,,,,,,
MESH SPNL W17XH50XL22MM TI OVL,SUP-2254371,CDM,2780000010,LOCAL,0278,RC,,,,both,,,12289.96,7988.47,,,,,,,,,,,,,
PLATE BONE LOCKING LARGE 3.5X68 MM LEFT CALCANEAL FOR SCREW,SUP-2837156,CDM,C1713,HCPCS,0278,RC,,,,both,,,6959.65,4523.77,,,,,,,,,,,,,
KIT CHOLGM PROC W SPHINTOM GWIRE JAGWIRE RX,SUP-2148976,CDM,C1769,HCPCS,0272,RC,,,,both,,,15.70,10.20,,,,,,,,,,,,,
SHUNT CAR OUTLYING 9FX31CM,SUP-2264211,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1566.86,1018.46,,,,,,,,,,,,,
SET SCR SPNL SM SILVERTON-D,SUP-2415754,CDM,C1713,HCPCS,0278,RC,,,,both,,,505.54,328.60,,,,,,,,,,,,,
DRILL SURG 3.9 MM FOR 5 MM PIN SALVATION 2,SUP-2521581,CDM,2720000010,LOCAL,0272,RC,,,,both,,,486.70,316.35,,,,,,,,,,,,,
ASSEMBLY SHUNT 120 CM NSC BURR HOLE OPN END WALL SLT STRATA,SUP-2664455,CDM,C1889,HCPCS,0278,RC,,,,both,,,15818.69,10282.15,,,,,,,,,,,,,
CATHETER HD LT 10 FRX52 CM 30 CM ART CUF SINGLE SET TESIO,SUP-2627147,CDM,C1750,HCPCS,0278,RC,,,,both,,,472.57,307.17,,,,,,,,,,,,,
SULFAMETHOXAZOLE-TRIMETHOPRIM 200-40 MG/5ML PO SUSP,RX-22560,CDM,340b,HCPCS,0637,RC,65862-0496-47,NDC,,both,10,ML,4.10,2.66,,,,,,,,,,,,,
DISTRACTION INTRNL ST SIZER 51 423 21 7120 MM 36 HOLE T 6L 4,SUP-2669792,CDM,2720000010,LOCAL,0272,RC,,,,both,,,350.80,228.02,,,,,,,,,,,,,
ALLOGRAFT HUM TISS FEN 9X9 CM SHT AMNION/CHORION AMNIOFIX,SUP-2871494,CDM,C1762,CPT,0278,RC,,,,both,,,18730.10,12174.56,,,,,,,,,,,,,
GRAFT STRUT CORT FEM QTR FRZN ALLGRFT 210MM MATRIGRFT,SUP-2264747,CDM,C1713,HCPCS,0278,RC,,,,both,,,1376.01,894.41,,,,,,,,,,,,,
ANCHOR SUT DIA4.5MM PEEK OPTMA LINK KNOTLESS CLEAT EYELET,SUP-2402633,CDM,C1713,HCPCS,0278,RC,,,,both,,,1484.09,964.66,,,,,,,,,,,,,
MESH HERN L W10.8XL16CM L INGUINAL WHT POLYPR MFIL,SUP-2125772,CDM,C1781,HCPCS,0278,RC,,,,both,,,499.26,324.52,,,,,,,,,,,,,
GUIDEPIN ORTH L343MM DIA3.2MM BRAD PNT TIP INSTR FOR OPN,SUP-2347574,CDM,2720000010,LOCAL,0272,RC,,,,both,,,883.28,574.13,,,,,,,,,,,,,
CATHETER PERITONEAL DLYS 2 CUF STD AD 62 CM 6 CM 6 CC ARC,SUP-2302486,CDM,C1750,HCPCS,0278,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
BIT DRL L8MM DIA1.8MM W/O STP FOR LAMINOPLASTY SYS,SUP-2186835,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1036.20,673.53,,,,,,,,,,,,,
BEAM FIX L75MM DIA6.5MM ARTH FOR CHARCOT DEFORMITY AXIS,SUP-2223945,CDM,C1713,HCPCS,0278,RC,,,,both,,,4239.00,2755.35,,,,,,,,,,,,,
PATCH VASC HEMGRD L 100 X W 100 MM THK 0.65 MM POLYESTER BOV,SUP-2535415,CDM,C1768,CPT,0278,RC,,,,both,,,790.34,513.72,,,,,,,,,,,,,
PLATE BNE L109MM 4 H ST L MED DST TIB S STL LO BEND LOK,SUP-2177444,CDM,C1713,HCPCS,0278,RC,,,,both,,,4065.48,2642.56,,,,,,,,,,,,,
PLATE BNE H1.5MM 6 H 140DEG MAND G TI FULL AND HALF FRAC,SUP-2366369,CDM,C1713,HCPCS,0278,RC,,,,both,,,2023.38,1315.20,,,,,,,,,,,,,
PROBE ES TEMP HOT AND CLD FAST ACCURATE SFT FLX CIRCA S CATH,SUP-2164521,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2009.60,1306.24,,,,,,,,,,,,,
PLATE BONE W24XL24MM THK0.5MM CRAN ORBIT FLR RAP RESRB W/,SUP-2194080,CDM,C1713,HCPCS,0278,RC,,,,both,,,2890.37,1878.74,,,,,,,,,,,,,
PLATE BNE W25.5XL77MM WIDE 7X5 H NONSTERILE R DST RAD VOLAR,SUP-2184126,CDM,C1713,HCPCS,0278,RC,,,,both,,,2368.22,1539.34,,,,,,,,,,,,,
NAIL INTRMDLLRY LOK CNNLTD UNVRSL 9MM DIA 285MML TTNM ALLOY,SUP-2587455,CDM,C1713,HCPCS,0278,RC,,,,both,,,3587.14,2331.64,,,,,,,,,,,,,
WIRE FIX L102MM OD1.6MM S STL TRCR PT SMOOTH SGL SHRP TIP K,SUP-2361625,CDM,C1713,HCPCS,0278,RC,,,,both,,,11.24,7.31,,,,,,,,,,,,,
OSS SEG DSTL FEM 8.5CM LT,SUP-2506417,CDM,C1776,CPT,0278,RC,,,,both,,,20064.60,13041.99,,,,,,,,,,,,,
GUIDEWIRE VASC AQUALINER 150CM 0.035IN TIP 3CM ANGLED REG,SUP-2118709,CDM,C1769,HCPCS,0272,RC,,,,both,,,173.33,112.66,,,,,,,,,,,,,
CUBE EXT FIX POST 1 H THRD ATTACH NS DISP MONK RING,SUP-2899072,CDM,2720000010,LOCAL,0272,RC,,,,both,,,682.17,443.41,,,,,,,,,,,,,
SCREW BNE COMPR 3-4.3 MM MULTI-USE CHARLOTTE,SUP-2397725,CDM,C1713,HCPCS,0278,RC,,,,both,,,105774.04,68753.13,,,,,,,,,,,,,
PLATE BONE OD20MM 6 HOLE TITANIUM CONTOURED NONCOMPRESSION W,SUP-2826366,CDM,C1713,HCPCS,0278,RC,,,,both,,,254.25,165.26,,,,,,,,,,,,,
SCREW BONE VARIAX 2.3MM 9MM LK TI T6 DRIVE,SUP-2695766,CDM,C1713,HCPCS,0278,RC,,,,both,,,402.23,261.45,,,,,,,,,,,,,
NAIL IM L180MM DIA17-11MM PROX FEM COMP FOR THE STBL UNSTBL,SUP-2152594,CDM,C1713,HCPCS,0278,RC,,,,both,,,3717.13,2416.13,,,,,,,,,,,,,
PLATE BNE HK 4.5/5X169 MM PROX FEM 4 HOLE LP LCK COMPR SS,SUP-2186054,CDM,C1713,HCPCS,0278,RC,,,,both,,,4367.39,2838.80,,,,,,,,,,,,,
BEARING MOD LM RL 8MM REPICCI II,SUP-2136601,CDM,C1713,HCPCS,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
CLIP LIG MIC TI TRNSVRS GRV NONABSORBABLE ADH BK PRECIS EZ 6CLIPS/CT,SUP-2383133,CDM,C1751,HCPCS,0278,RC,,,,both,,,12.65,8.22,,,,,,,,,,,,,
BOLT IM L90MM DIA4.9MM HD DIA8MM CORT TI ST CANN LOK FULL,SUP-2192420,CDM,C1713,HCPCS,0278,RC,,,,both,,,720.06,468.04,,,,,,,,,,,,,
STEM HUM DIA13MM 132.5DEG STD SHLDR PROX BODY AEQUALIS FLX,SUP-2419077,CDM,C1776,CPT,0278,RC,,,,both,,,12140.50,7891.32,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 50 CM DIA 6 MM 5 CM STR TW STRL,SUP-2396308,CDM,C1768,CPT,0278,RC,,,,both,,,2659.58,1728.73,,,,,,,,,,,,,
PROSTHESIS OSS 2.5X3.5 MM 0.8X37 MM DSTL TI SILVERSTEIN ALTO,SUP-2232495,CDM,L8613,CPT,0278,RC,,,,both,,,1151.12,748.23,,,,,,,,,,,,,
FIBER LASER E6783898] FORTEC MEDICAL INC],SUP-2225706,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2804.02,1822.61,,,,,,,,,,,,,
GEMCITABINE HCL 1 GM/26.3ML IV SOLN,RX-111497,CDM,J9184,HCPCS,0636,RC,71288-0117-28,NDC,,both,26.3,ML,63.40,41.21,,,,,,,,,,,,,
HC Finger Splint Application,PX-4502913000,CDM,29130,CPT,0450,RC,,,,both,,,363.00,235.95,,,,,,,,,,,,,
PLANER SURG M PAT BLDE BIT PFC SIG SPEC 2,SUP-2253953,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
CYGNUS ANTR CERV 32MM PLTE MTI LVL,SUP-2664167,CDM,C1713,HCPCS,0278,RC,,,,both,,,2480.60,1612.39,,,,,,,,,,,,,
SCREW BONE CRTX CRANIO MAXILLOFACIAL TI ALLOY SELF DRL TAP,SUP-2363331,CDM,C1713,HCPCS,0278,RC,,,,both,,,133.45,86.74,,,,,,,,,,,,,
SCREW BNE L6MM DIA2.7MM HD DIA5MM SM STD CORT TI ST,SUP-2189690,CDM,C1713,HCPCS,0278,RC,,,,both,,,102.84,66.85,,,,,,,,,,,,,
BUR SHAVER L19CM OD5.5/6MM STRAIGHT HPS SHEATH,SUP-2825161,CDM,2720000010,LOCAL,0272,RC,,,,both,,,472.51,307.13,,,,,,,,,,,,,
KNIFE ENDOSCP CORR SERRATED EDGE URETHROTOMY LF,SUP-2472077,CDM,2720000010,LOCAL,0272,RC,,,,both,,,931.29,605.34,,,,,,,,,,,,,
PLATE BNE MESHED 126X11X0.8 MM SM GRID PLLA-PGA STRL,SUP-2477191,CDM,C1713,HCPCS,0278,RC,,,,both,,,2112.00,1372.80,,,,,,,,,,,,,
PLATE BONE W13.5XL34MM THK4.2MM 2 H BILAT S STL NAR LIMIT,SUP-2185226,CDM,C1713,HCPCS,0278,RC,,,,both,,,540.90,351.58,,,,,,,,,,,,,
SUPPORT ORTH H8XL13IN D2 1/2IN CUSH MCKENZ SLM LN,SUP-2324239,CDM,L0642,HCPCS,0272,RC,,,,both,,,52.00,33.80,,,,,,,,,,,,,
CANNULA ENDO L195CM OD2.5FR CHAN 3.2MM GWIRE OD0.018IN MTL,SUP-2313499,CDM,C1713,HCPCS,0278,RC,,,,both,,,900.08,585.05,,,,,,,,,,,,,
PLATE BONE 2.7/3MM SCR H DIA 45MM LEN YEL N COMPR C RT 5 H,SUP-2242906,CDM,C1713,HCPCS,0278,RC,,,,both,,,2180.01,1417.01,,,,,,,,,,,,,
BUR SURG TAPR 1.7X16 MM ROUTER M ATTCH MIDAS REX UPWR TPS,SUP-2363340,CDM,2720000010,LOCAL,0272,RC,,,,both,,,238.42,154.97,,,,,,,,,,,,,
GRAFT BONE PRO DENS 7CC,SUP-2399147,CDM,C1713,HCPCS,0278,RC,,,,both,,,6762.46,4395.60,,,,,,,,,,,,,
ALTIUS CROSS CONN 20MM,SUP-2414612,CDM,C1713,HCPCS,0278,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
ENDOPROSTHESIS VASC FLUENCY + L 40 MM DIA10 MM CATH L 80 CM,SUP-2128267,CDM,C1874,HCPCS,0278,RC,,,,both,,,23747.82,15436.08,,,,,,,,,,,,,
HINGE EXT FIX ROTATING F FEM SVC PART,SUP-2437346,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3391.20,2204.28,,,,,,,,,,,,,
EXPANDER TISSUE MED HEIGHT TE SMOOTH 800CC,SUP-2718064,CDM,C1889,HCPCS,0278,RC,,,,both,,,5024.00,3265.60,,,,,,,,,,,,,
CABLE EXT FIX L 1200 MM DIA1.8 MM SS NS DISP ILIZ,SUP-2933559,CDM,2720000010,LOCAL,0272,RC,,,,both,,,737.65,479.47,,,,,,,,,,,,,
CATHETER VENTRICULAR FIN 15 CM STR CONN RT ANGLE GUIDE,SUP-2851484,CDM,C1729,HCPCS,0272,RC,,,,both,,,570.26,370.67,,,,,,,,,,,,,
HC So2 Ptt / Thromboplastin Subs,PX-3058573268,CDM,85732,CPT,0305,RC,,,,both,,,11.00,7.15,,,,,,,,,,,,,
DILTIAZEM HCL-SODIUM CHLORIDE 100-0.72 MG/100ML-% IV SOLN,RX-171777,CDM,2500000003,HCPCS,0250,RC,44567-0662-01,NDC,,both,100,ML,220.80,143.52,,,,,,,,,,,,,
GUIDEWIRE ORTH L950MM DIA2.4MM NIT ROUNDED TIP DISP PICCOLO,SUP-2152522,CDM,C1769,HCPCS,0272,RC,,,,both,,,125.10,81.31,,,,,,,,,,,,,
Z DUP USE 2676487 STENT ES L15CM DIA18MM CATH 18.5FR L120CM MTL PARTIALLY CVR,SUP-2149873,CDM,C1874,HCPCS,0278,RC,,,,both,,,7104.60,4617.99,,,,,,,,,,,,,
GUIDEWIRE VASC L180CM DIA0.035IN 3MM PTFE J TIP EXCHG FIX,SUP-2302717,CDM,C1769,HCPCS,0272,RC,,,,both,,,23.55,15.31,,,,,,,,,,,,,
VALVE MITRL ON-X TISS ANNULUS 27-29 MM ORIFICE 23.4 MM SZ,SUP-2175263,CDM,C1889,HCPCS,0278,RC,,,,both,,,15696.86,10202.96,,,,,,,,,,,,,
GRAFT BNE SUB 2ML DBM PTTY W/ GRAN BONUS SYN RESRB STAGRFT,SUP-2402608,CDM,C1713,HCPCS,0278,RC,,,,both,,,1362.76,885.79,,,,,,,,,,,,,
PLATE BNE HK SM 3.5/4.5X211 MM RT FEM PROX 5 HOLE NS VA-LCP,SUP-2750910,CDM,C1713,HCPCS,0278,RC,,,,both,,,7083.15,4604.05,,,,,,,,,,,,,
SYSTEM URIN CTRL W2XL4CM W/O INHIBZN OCCL CUF BELT M AMS,SUP-2138919,CDM,C1815,HCPCS,0278,RC,,,,both,,,12560.00,8164.00,,,,,,,,,,,,,
STENT URTRL 45FR DIA 28CML TCFLX DBLE PGTL ST SNGLE USE,SUP-2722037,CDM,C2617,HCPCS,0278,RC,,,,both,,,189.25,123.01,,,,,,,,,,,,,
NEEDLE BX BRST LOC MAMMALOK + 20 G X 7.5 CM,SUP-2120044,CDM,C1819,HCPCS,0278,RC,,,,both,,,1067.60,693.94,,,,,,,,,,,,,
BAR EXT FIX L 380 MM DIA11 MM CRV NS DISP MAV,SUP-2933083,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5859.24,3808.51,,,,,,,,,,,,,
MOLD SURG 10-1/2 IN FOR ACRYL SPLNT X-FIX 51-671-27-07,SUP-2478537,CDM,2720000010,LOCAL,0272,RC,,,,both,,,388.95,252.82,,,,,,,,,,,,,
TR3100-L/R OTIS KNEE FEMORAL/TIBIA CUT GIDE SET FOR STRYKR,SUP-2366016,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3014.40,1959.36,,,,,,,,,,,,,
KIT HIP PREP W/ PLUG INSRT BRSH SPNG PRSSZR,SUP-2408589,CDM,C1713,HCPCS,0278,RC,,,,both,,,371.46,241.45,,,,,,,,,,,,,
TRAY EPIDURAL CATH DIA20 GA NDL DIA18 GA CE18HKN ACCU BLOC,SUP-2936632,CDM,2720000010,LOCAL,0272,RC,,,,both,,,73.44,47.74,,,,,,,,,,,,,
KIT PROC W DRP AND DRUG COMP FOR PRTBL HANDHELD IMAGER,SUP-2419056,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2028.47,1318.51,,,,,,,,,,,,,
CABLE ADPT CARRG ADAPTOR LT VENTRICULAR ASST DEV,SUP-2356042,CDM,C1713,HCPCS,0278,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
TROCAR ENDOSCP BLNT TIP W/ RND DISECT BLLN DISP ACCS AND,SUP-2421063,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1275.03,828.77,,,,,,,,,,,,,
FIBER LASER FLEXIVA ID 550 SINGLE,SUP-2721827,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1189.87,773.42,,,,,,,,,,,,,
NYSTATIN 100000 UNIT/ML MT SUSP,RX-5751,CDM,340b,HCPCS,0637,RC,09999-9902-64,NDC,,both,.5,ML,2.70,1.75,,,,,,,,,,,,,
TM MODULAR CUP 60MM MULTI-HOLE REVISION,SUP-2503640,CDM,C1776,CPT,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
SYSTEM PRP DBL SYR W/ CAP FOR AUTOLGS PLSM SYS ACP,SUP-2120720,CDM,2720000010,LOCAL,0272,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
CATHETER ETER OCCL 22 28FR L150CM BLLN L15MM DIA5MM TIP L4MM,SUP-2172477,CDM,C2628,HCPCS,0272,RC,,,,both,,,4772.80,3102.32,,,,,,,,,,,,,
CATHETER DIAG L135CM OD0.059X0.052IN TIP OD3.2FR 50MM SPC,SUP-2353140,CDM,C1887,HCPCS,0272,RC,,,,both,,,587.18,381.67,,,,,,,,,,,,,
ADAPTER LD L 10 CM UPLR RECEPTACLE QUADRIFILAR COIL SIL,SUP-2282472,CDM,C1883,HCPCS,0278,RC,,,,both,,,1384.30,899.79,,,,,,,,,,,,,
ALLOGRAFT BNE SHFT PEDIATRIC LT RT FEM,SUP-2321797,CDM,C1713,HCPCS,0278,RC,,,,both,,,8572.20,5571.93,,,,,,,,,,,,,
BLADE SAW RCPRCTNG 9.4MMW X54.5MML 1.5MM THK 1.5MM THK CUT L,SUP-2605423,CDM,2720000010,LOCAL,0272,RC,,,,both,,,63.93,41.55,,,,,,,,,,,,,
GRAFT VASC 8 MMX35/15X70 CMX0.35 MM 20 CM STR HEMGRD,SUP-2471001,CDM,C1768,CPT,0278,RC,,,,both,,,3149.58,2047.23,,,,,,,,,,,,,
KIT GRFT SUB 2XSM 0.7ML 1.05MG RHBMP-2 FRZ DRY ST H2O CLLGN,SUP-2287846,CDM,C1713,HCPCS,0278,RC,,,,both,,,2998.70,1949.15,,,,,,,,,,,,,
GRAFT BNE SUB W30XL35MM THK12 16MM ILIUM BICORT STRP FRZ DRY,SUP-2307133,CDM,C1713,HCPCS,0278,RC,,,,both,,,2408.07,1565.25,,,,,,,,,,,,,
PLATE BONE MINI L37MM STR,SUP-2364911,CDM,C1713,HCPCS,0278,RC,,,,both,,,284.52,184.94,,,,,,,,,,,,,
SHEATH INTRO FUBUKI XF L 80 CM 2.70 MM 2.28 MM L 8 CM STR,SUP-2879073,CDM,C1887,HCPCS,0272,RC,,,,both,,,1723.86,1120.51,,,,,,,,,,,,,
STAPLER INT W25MM WHT TRNSOR CIR ANVIL W/ ADVANCING PROX,SUP-2283248,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1119.63,727.76,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.402,SUP-2859966,CDM,C1713,HCPCS,0278,RC,,,,both,,,30009.29,19506.04,,,,,,,,,,,,,
KIT CATH AD CTRL VEN CATH 7FR L6IN GWIRE 0.025IN POLYUR 3,SUP-2383292,CDM,C1751,HCPCS,0278,RC,,,,both,,,132.13,85.88,,,,,,,,,,,,,
TAP BNE 4.5 MM FOR IMAGE GUID TSRH 3D,SUP-2290727,CDM,C1713,HCPCS,0278,RC,,,,both,,,2035.00,1322.75,,,,,,,,,,,,,
KNIFE SURG BLDE L190MM DBL CUT FOR AMPUTATION LISTON,SUP-2108448,CDM,2720000010,LOCAL,0272,RC,,,,both,,,484.53,314.94,,,,,,,,,,,,,
SCREW DISTRCTN 12MM TI STRL ULTRA LF,SUP-2489624,CDM,C1713,HCPCS,0278,RC,,,,both,,,124.25,80.76,,,,,,,,,,,,,
SYSTEM NERVESTIMULATOR W48XH65CM THK11CM 32CUCM SPNL CLMN,SUP-2357674,CDM,C1767,HCPCS,0278,RC,,,,both,,,60999.24,39649.51,,,,,,,,,,,,,
ALLOGRAFT BNE SPACER SHT 25X9X9 MM PLIF BIO AVS UNILIF,SUP-2632328,CDM,C1713,HCPCS,0278,RC,,,,both,,,6829.50,4439.17,,,,,,,,,,,,,
PLATE BNE W10.1XL190MM THK3.5MM 18 H S STL CRV LOK COMPR,SUP-2186267,CDM,C1713,HCPCS,0278,RC,,,,both,,,2958.51,1923.03,,,,,,,,,,,,,
SCREW BONE PROX LCK S STL CONQ FN 7.5MMX95MM,SUP-2341201,CDM,C1713,HCPCS,0278,RC,,,,both,,,2165.56,1407.61,,,,,,,,,,,,,
HEAD HUM H17MM DIA44MM 4MM OFFSET SHLDR CO CHROM PRI TOT,SUP-2404660,CDM,C1776,CPT,0278,RC,,,,both,,,5256.36,3416.63,,,,,,,,,,,,,
BIT DRL CANN STD 2.5 MM 4.7 MM TAPR ACUTRK,SUP-2107356,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2493.16,1620.55,,,,,,,,,,,,,
CATHETER SUPP TRAILBLAZER L 90 CM DIA 0.034 IN SHTH 4 FR,SUP-2720107,CDM,C1887,HCPCS,0272,RC,,,,both,,,477.28,310.23,,,,,,,,,,,,,
PIN GUIDE L 8.5 MM SHLDR TRANSITION STRL DISP PERFORM,SUP-2912575,CDM,2720000010,LOCAL,0272,RC,,,,both,,,624.86,406.16,,,,,,,,,,,,,
BLADE SURG SAW GRFT HARV S STL ACL 20MM LEN 8.0MM W,SUP-2236515,CDM,2720000010,LOCAL,0272,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
REGULATOR ENDO AERO W/O VENT,SUP-2402575,CDM,C1713,HCPCS,0278,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
TESTOSTERONE CYPIONATE 100 MG/ML IM SOLN,RX-127407,CDM,J1071,HCPCS,0636,RC,00009-0347-02,NDC,,both,0.5,ML,54.10,35.16,,,,,,,,,,,,,
CATHETER DLYS PALINDROME,SUP-2283921,CDM,C1750,HCPCS,0278,RC,,,,both,,,1014.66,659.53,,,,,,,,,,,,,
BRONCHOSCOPE FLX L 600 MM OD 5 MM ID 2.2 MM SAMP SET STRL,SUP-2882950,CDM,C1601,HCPCS,0272,RC,,,,both,,,1014.22,659.24,,,,,,,,,,,,,
PLATE BONE THK0.5MM 10 H RESRB POLYMER CRANIOMAXILLOFACIAL,SUP-2365071,CDM,C1713,HCPCS,0278,RC,,,,both,,,1629.38,1059.10,,,,,,,,,,,,,
TUBING CONN L10FT VASC COMPR ASSEMB FLOTRN,SUP-2240678,CDM,C1713,HCPCS,0278,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
OCCLUDER CV AMPLATZER AMULET IDE LOBE DIA28 MM NIT LAA PERC,SUP-2866213,CDM,C1889,HCPCS,0278,RC,,,,both,,,37680.00,24492.00,,,,,,,,,,,,,
BIT DRL TWST SUT ANCHR 1.9MM DBL LD DISP SUTFIX ULT,SUP-2341897,CDM,2720000010,LOCAL,0272,RC,,,,both,,,729.67,474.29,,,,,,,,,,,,,
DEVICE FIX MED MIS BUNION MAX SHIFT PROSTEP TBC,SUP-2435406,CDM,C1713,HCPCS,0278,RC,,,,both,,,4012.92,2608.40,,,,,,,,,,,,,
PLATE BNE OSTEOTMY 110 DEG AD 4.5X116 MM TI NS DCP,SUP-2569053,CDM,C1713,HCPCS,0278,RC,,,,both,,,3381.53,2197.99,,,,,,,,,,,,,
GRAFT BNE SUB 5CC DEMIN BNE MTRX INJ FRZ DRY,SUP-2307005,CDM,C9359,HCPCS,0278,RC,,,,both,,,2623.60,1705.34,,,,,,,,,,,,,
PLATE BNE LO BEND 3.5X135 MM RT DSTL MEDL TIB 6 HOLE SS NS,SUP-2184171,CDM,C1713,HCPCS,0278,RC,,,,both,,,3736.91,2428.99,,,,,,,,,,,,,
HEPARIN (PORCINE) IN NACL 1000-0.9 UT/500ML-% IV SOLN,RX-145150,CDM,J1644,HCPCS,0636,RC,00264-9872-10,NDC,,both,500,ML,54.10,35.16,,,,,,,,,,,,,
PLATE BNE L244MM 90DEG 12 H BILAT S STL SUPCNDYL TB STD BRL,SUP-2342591,CDM,C1713,HCPCS,0278,RC,,,,both,,,6182.97,4018.93,,,,,,,,,,,,,
TROCAR VERSPRT + W/SHLD 5-10MM,SUP-2283195,CDM,2720000010,LOCAL,0272,RC,,,,both,,,434.04,282.13,,,,,,,,,,,,,
DEVICE COMPR PRELUDESYNC EVO L 24 CM 30 CC POLYCARB RADIAL,SUP-2430077,CDM,C1713,HCPCS,0278,RC,,,,both,,,59.35,38.58,,,,,,,,,,,,,
PROSOURCE TF PO LIQD,RX-126124,CDM,6370000000,HCPCS,0637,RC,94688-0114-44,NDC,,both,45,ML,5.70,3.70,,,,,,,,,,,,,
DEVICE REP SZ 30 MEMO 3D RECHORD,SUP-2352769,CDM,C1889,HCPCS,0278,RC,,,,both,,,7520.30,4888.19,,,,,,,,,,,,,
HC N-Invas Est C Ffr Sw Aly Cta,PX-4807558000,CDM,75580,CPT,0480,RC,,,,both,,,7572.00,4921.80,,,,,,,,,,,,,
IMPLANT MIDFACE PT SPEC CUSTOMIZED MEDPOR,SUP-2363698,CDM,C1713,HCPCS,0278,RC,,,,both,,,50090.88,32559.07,,,,,,,,,,,,,
COMPONENT FEM SZ C L DST KNEE SEG,SUP-2200502,CDM,C1776,CPT,0278,RC,,,,both,,,31029.48,20169.16,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED CMNTLS CERM X3,SUP-2365523,CDM,C1776,CPT,0278,RC,,,,both,,,15623.82,10155.48,,,,,,,,,,,,,
PLATE BONE L2MM THK0.8MM LT MAX GLD TI PREBENT OFFSET,SUP-2181827,CDM,C1713,HCPCS,0278,RC,,,,both,,,1672.68,1087.24,,,,,,,,,,,,,
GRAFT TUBE 7MM,SUP-2812116,CDM,2720000010,LOCAL,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
REAMER SURG 11 MM FEM,SUP-2121313,CDM,2720000010,LOCAL,0272,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
REAMER SURG FLX KNEE VERSITOMIC OD4.5MM,SUP-2366801,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4518.46,2937.00,,,,,,,,,,,,,
ANCHOR SOFT TISSUE 11X21MM FEMORAL WITH DISPOSABLE GUN EXOSH,SUP-2824100,CDM,C1713,HCPCS,0278,RC,,,,both,,,2677.79,1740.56,,,,,,,,,,,,,
HEAD FEM DIA32MM +9MM OFFSET 12/14 TAPR HIP CERAMIC TI SL,SUP-2251105,CDM,C1776,CPT,0278,RC,,,,both,,,5646.98,3670.54,,,,,,,,,,,,,
CURETTE SZ 6 MCELROY,SUP-2342356,CDM,C1713,HCPCS,0278,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
ADAPTER STEM 2MM OFFSET FEM FOR KNEE SYS REV ATTUNE,SUP-2251479,CDM,C1776,CPT,0278,RC,,,,both,,,2009.60,1306.24,,,,,,,,,,,,,
K WIRE FIXATION L400MM STAINLESS STEEL OLIVE,SUP-2586484,CDM,C1713,HCPCS,0278,RC,,,,both,,,821.52,533.99,,,,,,,,,,,,,
CAGE SPNL W17XH7IN D14IN 7DEG LORDTC CERV HI STRENGTH FOR,SUP-2101161,CDM,C1889,HCPCS,0278,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
PLATE BONE THK0.5MM 2 H STR FOR 1.7MM SCR DELT,SUP-2365073,CDM,C1713,HCPCS,0278,RC,,,,both,,,1262.06,820.34,,,,,,,,,,,,,
ALUMINUM RENAL ABH BLADE 1 X 4,SUP-2703358,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1419.31,922.55,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY L 80 CM DIA 5 FR TIP 3 MM SPC YEL,SUP-2248650,CDM,C1730,HCPCS,0272,RC,,,,both,,,1136.68,738.84,,,,,,,,,,,,,
COIL EMB 2MMX4CM HELI MIC NEUROVASC XSFT MIC NEUROVASC,SUP-2249161,CDM,C1889,HCPCS,0278,RC,,,,both,,,5700.26,3705.17,,,,,,,,,,,,,
ESTRADIOL 0.1 MG/24HR TD PTWK,RX-28409,CDM,6370000000,HCPCS,0637,RC,00378-3352-16,NDC,,both,1,UN,83.60,54.34,,,,,,,,,,,,,
CATHETER PICC L130CM OD5FR 2 LUMN W/ CLMP IR KT W/ WIRE,SUP-2118952,CDM,C1751,HCPCS,0278,RC,,,,both,,,260.37,169.24,,,,,,,,,,,,,
HC So Parvo,PX-3028674766,CDM,86747,CPT,0302,RC,,,,both,,,223.00,144.95,,,,,,,,,,,,,
BRACE ANK LACE UP X LG ELASTIC CUF CLOSURE SPRT ORTHOSIS NYL,SUP-2336333,CDM,L4350,HCPCS,0272,RC,,,,both,,,33.69,21.90,,,,,,,,,,,,,
NEOMYCIN-POLYMYXIN-GRAMICIDIN 1.75-10000-.025 OP SOLN,RX-5474,CDM,6370000000,HCPCS,0637,RC,24208-0790-62,NDC,,both,10,ML,229.80,149.37,,,,,,,,,,,,,
FORCEPS ES L23CM DIA1MM SLIM BPLR NONSTICK DISPOSABLE,SUP-2364938,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1337.61,869.45,,,,,,,,,,,,,
SET INTRODUCER BREAST BIOPSY 9GA 12CML LOCALIZATION W/PETIT,SUP-2240022,CDM,C1894,HCPCS,0272,RC,,,,both,,,452.79,294.31,,,,,,,,,,,,,
BUNDLE CASE DISTRCTN CRAN MXLFCL 4 FULL SKULL RECON VSP,SUP-2862828,CDM,2720000010,LOCAL,0272,RC,,,,both,,,34414.49,22369.42,,,,,,,,,,,,,
DESILETS-HOFFMAN INTRODUCER SET,SUP-2827464,CDM,C1894,HCPCS,0272,RC,,,,both,,,203.75,132.44,,,,,,,,,,,,,
HC CT Lower Ext W/ Cont,PX-3527370100,CDM,73701,CPT,0352,RC,,,,both,,,2769.00,1799.85,,,,,,,,,,,,,
CONNECTOR CSF STEPDOWN 0.8X1.8-1.5 MM SS STRL,SUP-2851468,CDM,C1889,HCPCS,0278,RC,,,,both,,,2894.48,1881.41,,,,,,,,,,,,,
ALLOGRAFT HUM TISS STRUT FRZN ASEP HEMI PATELLAR TEND,SUP-2867218,CDM,C1762,CPT,0278,RC,,,,both,,,9292.05,6039.83,,,,,,,,,,,,,
CAGE SPNL H16-25MM OD12MM 6DEG SM TI ANT THORLUM INTBDY FUS,SUP-2390790,CDM,C1889,HCPCS,0278,RC,,,,both,,,15700.00,10205.00,,,,,,,,,,,,,
VEST PT SURG ASST CERV HALO,SUP-2265013,CDM,L0810,HCPCS,0272,RC,,,,both,,,21195.00,13776.75,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 40 MM DIA 5 MM DEL SHTH 1.8ML,SUP-2937070,CDM,C1713,HCPCS,0278,RC,,,,both,,,5030.28,3269.68,,,,,,,,,,,,,
GUIDEWIRE ORTH 2 MMX9 IN FOR HDLSS SCR SYS NS LTX,SUP-2862167,CDM,C1769,HCPCS,0272,RC,,,,both,,,194.05,126.13,,,,,,,,,,,,,
GRAFT VASC L80CM DIA8MM RAD L80CM EPTFE HEP THN WALLED,SUP-2395862,CDM,C1768,CPT,0278,RC,,,,both,,,9247.30,6010.74,,,,,,,,,,,,,
PLATE BNE STR 2X29 MM 5 HOLE,SUP-2569072,CDM,C1713,HCPCS,0278,RC,,,,both,,,150.25,97.66,,,,,,,,,,,,,
GUIDEWIRE VASC L300CM DST SEG L45CM DIA0.014IN S STL NIT,SUP-2367846,CDM,C1769,HCPCS,0272,RC,,,,both,,,695.20,451.88,,,,,,,,,,,,,
MARKER BRST BX XR TISS SS MICROMARK II,SUP-2195630,CDM,A4648,CPT,0278,RC,,,,both,,,276.32,179.61,,,,,,,,,,,,,
SCREW BNE ST 2X5 MM EMGCY W/ PLUSDRIVE RECESS TI MTRX TEAL,SUP-2188976,CDM,C1713,HCPCS,0278,RC,,,,both,,,246.18,160.02,,,,,,,,,,,,,
HC So Ihc Ea Addl Single Ab Stain,PX-3128834166,CDM,88341,CPT,0312,RC,,,,both,,,495.00,321.75,,,,,,,,,,,,,
OCCLUDER CV WAIST L7MM DIA4MM 45X180DEG SHTH 5X6FR NIT,SUP-2357483,CDM,C1817,HCPCS,0278,RC,,,,both,,,26036.63,16923.81,,,,,,,,,,,,,
SCREW BNE SD 150 MM 6-5.6X30 MM CORTICAL FLUT NS XCALIBER,SUP-2645910,CDM,C1713,HCPCS,0278,RC,,,,both,,,383.65,249.37,,,,,,,,,,,,,
HEAD HUM STD PRI NECKLESS CO CHROM TOT 38MM OD 17MM HT,SUP-2217314,CDM,C1776,CPT,0278,RC,,,,both,,,4082.00,2653.30,,,,,,,,,,,,,
SPLINT THMB STRTCH LOOP STRP MED LG RT LIGHTWEIGHT SPICA BLK,SUP-2336216,CDM,L3931,HCPCS,0272,RC,,,,both,,,36.27,23.58,,,,,,,,,,,,,
OCCLUDER CV HEMOCOAT LT ATR APPENDAGE CLOSURE RADIOPAQUE,SUP-2905475,CDM,C1889,HCPCS,0278,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
CATHETER CV DL 7 FRX16 CM BASIC KT ARROWG+ARD,SUP-2383329,CDM,C1751,HCPCS,0278,RC,,,,both,,,172.39,112.05,,,,,,,,,,,,,
COVER BUR H DIA15MM TI SHUNT FOR CRAN CLSR SYS,SUP-2243978,CDM,C1713,HCPCS,0278,RC,,,,both,,,272.90,177.38,,,,,,,,,,,,,
PLATE BONE W3.5XL36MM THK0.9MM 7 H RT CNDYL S STL,SUP-2343830,CDM,C1713,HCPCS,0278,RC,,,,both,,,2384.86,1550.16,,,,,,,,,,,,,
STENT GRFT 17.5FR STNT L35MM DIA24MM OCCL CV FOR HYDR DEL,SUP-2296680,CDM,C1768,CPT,0278,RC,,,,both,,,8399.50,5459.67,,,,,,,,,,,,,
SYSTEM LSR INDIGO 830E,SUP-2257670,CDM,C1713,HCPCS,0278,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
NAIL FEM RG 10.5MM 260MM,SUP-2405537,CDM,C1713,HCPCS,0278,RC,,,,both,,,9325.80,6061.77,,,,,,,,,,,,,
SUBSTITUTE BONE GRFT 6X6X6MM DEMIN CANC CNFRM FLX,SUP-2307024,CDM,C1713,HCPCS,0278,RC,,,,both,,,1477.94,960.66,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE 30 CC DEMINERALIZED CORT CANC BNE FIBER,SUP-2905203,CDM,C1713,HCPCS,0278,RC,,,,both,,,9264.57,6021.97,,,,,,,,,,,,,
TUBE VENT 1.14 MM 1 MM 2.7 MM BOB FLROPLAS STRL,SUP-2535122,CDM,L8699,HCPCS,0278,RC,,,,both,,,22.45,14.59,,,,,,,,,,,,,
CENTESIS CATH 4F 12CM PGTL SLIP FIT 20GA INTRDCR NDLE 4 HOLE,SUP-2702112,CDM,C1729,HCPCS,0272,RC,,,,both,,,119.32,77.56,,,,,,,,,,,,,
HALF RING 220 MM INT DIAM,SUP-2818152,CDM,2720000010,LOCAL,0272,RC,,,,both,,,11619.73,7552.82,,,,,,,,,,,,,
ANCHOR SUT SZ 2-0 ULTRABRAID BLU COBRAID SUT PRELD,SUP-2341136,CDM,C1713,HCPCS,0278,RC,,,,both,,,178.98,116.34,,,,,,,,,,,,,
CATHETER IV MIDLN 3 FR,SUP-2133383,CDM,C1751,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
PLATE BONE L105MM 8 HOLE RCNSTRCTN 35MM SCREW UNVRSL LOK SST,SUP-2460268,CDM,C1713,HCPCS,0278,RC,,,,both,,,1500.67,975.44,,,,,,,,,,,,,
DRILL SURG 3.5 MM STRL LINEUM OCT,SUP-2683055,CDM,2720000010,LOCAL,0272,RC,,,,both,,,562.06,365.34,,,,,,,,,,,,,
CAGE SPINL EXCEED INTERBODY DEVICE 25 MM L X 10 MM W X 13 MM H,SUP-2934655,CDM,C1889,HCPCS,0278,RC,,,,both,,,15684.30,10194.79,,,,,,,,,,,,,
STENT TRACH POLYFLEX L 60 MM DIA14 MM DEL SYS DIA 9 MM,SUP-2675315,CDM,C1874,HCPCS,0278,RC,,,,both,,,6001.11,3900.72,,,,,,,,,,,,,
ALLOGRAFT BNE WDG 10X11-16 MM PRESERVON TRICORT CANC,SUP-2740823,CDM,C1713,HCPCS,0278,RC,,,,both,,,1941.40,1261.91,,,,,,,,,,,,,
DISC ARTIFICIAL M W27XL34.5MM INTERVERTEBRAL LUMSACR CO,SUP-2163215,CDM,C1713,HCPCS,0278,RC,,,,both,,,10990.00,7143.50,,,,,,,,,,,,,
COMPLETION REV FEM AP BLCK STD,SUP-2513649,CDM,C1776,CPT,0278,RC,,,,both,,,7523.44,4890.24,,,,,,,,,,,,,
PROSTHESIS HIPXSM 12/14 MAYO,SUP-2203724,CDM,C1776,CPT,0278,RC,,,,both,,,15164.63,9857.01,,,,,,,,,,,,,
KIT ARTHSCP INCLUDE 1.1MM MINI TIGHTROPE ANCHR S STL 2.6MM,SUP-2122787,CDM,C1713,HCPCS,0278,RC,,,,both,,,2182.30,1418.49,,,,,,,,,,,,,
COVERLOC VOLAR PLATE 22MM 3 HOLE RIGHT,SUP-2830148,CDM,C1713,HCPCS,0278,RC,,,,both,,,2050.42,1332.77,,,,,,,,,,,,,
SCREW BONE L3MM DIA1.7MM STD CORT NONLOCKING LO PROF RESRB 4/EA,SUP-2364991,CDM,C1713,HCPCS,0278,RC,,,,both,,,1194.83,776.64,,,,,,,,,,,,,
MESH HERN XL W1.4XL2IN SYN POLY-4-HYDROXYBUTYRATE PLUG AND,SUP-2125876,CDM,C1781,HCPCS,0278,RC,,,,both,,,1444.43,938.88,,,,,,,,,,,,,
PLATE SPNL 5 LEVEL WIDE 108 MM ANTR CERV ARCHON,SUP-2563466,CDM,C1713,HCPCS,0278,RC,,,,both,,,2590.50,1683.82,,,,,,,,,,,,,
SYSTEM PAIN PMP 270MLX2ML HR 5ML CTRL ADMIN CATHETER ONDEMAND BOL,SUP-2236852,CDM,C1713,HCPCS,0278,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
EVOS 2.7/3.5 OLCRNN PL W/TNS 4H L 82MM,SUP-2819863,CDM,C1713,HCPCS,0278,RC,,,,both,,,8436.87,5483.97,,,,,,,,,,,,,
CATHETER THORACENTESIS STR 28 FRX23 IN 6 EYELET TAPR TIP LF,SUP-2227432,CDM,C1729,HCPCS,0272,RC,,,,both,,,21.10,13.71,,,,,,,,,,,,,
MESH HERN W20XL25CM PTFE PGA TMC RECT NONABSORBABLE,SUP-2395756,CDM,C1781,HCPCS,0278,RC,,,,both,,,9834.48,6392.41,,,,,,,,,,,,,
BURR SHVR RPRCSSD ARTHSCP 5.5MM DIA STNDRD ROUND FLTDX12 CYA,SUP-2589372,CDM,2720000010,LOCAL,0272,RC,,,,both,,,179.17,116.46,,,,,,,,,,,,,
GRAFT VASC L50CM DIA6MM EPTFE STD WALL NONRINGED STR,SUP-2126471,CDM,C1768,CPT,0278,RC,,,,both,,,1770.96,1151.12,,,,,,,,,,,,,
FIXATOR EXT FIX D40MM STD CORETRAK STERIPACK,SUP-2401435,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5482.44,3563.59,,,,,,,,,,,,,
CATHETER INFUSION 0.018 IN 2.4 FRX150 CM PROGREAT GLIDEWIRE,SUP-2423783,CDM,C1887,HCPCS,0272,RC,,,,both,,,1858.88,1208.27,,,,,,,,,,,,,
GUIDEWIRE VASC L180CM DIA0.035IN L15CM STR TIP PTFE S STL,SUP-2142705,CDM,C1769,HCPCS,0272,RC,,,,both,,,48.36,31.43,,,,,,,,,,,,,
PLATE BNE Z LG 1.7 MM RT MIDFACE 4 HOLE GSP GLD NS LTX,SUP-2862764,CDM,C1713,HCPCS,0278,RC,,,,both,,,750.84,488.05,,,,,,,,,,,,,
NEEDLE SUT SHUTTLE FLEX STRL REUSE ELITE PASS,SUP-2341667,CDM,2720000010,LOCAL,0272,RC,,,,both,,,406.32,264.11,,,,,,,,,,,,,
ADAPTER TBNG W/ STPCOCK AND LUERLOCK FOR CUT CANN,SUP-2361364,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1150.65,747.92,,,,,,,,,,,,,
IMPLANT KNEE TOT SYS VANGUARD,SUP-2212592,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
HC Additional Vessel Selection,PX-3237577400,CDM,75774,CPT,0323,RC,,,,both,,,7130.00,4634.50,,,,,,,,,,,,,
ROD EXT FIX END CAP INSRTN,SUP-2478677,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1240.93,806.60,,,,,,,,,,,,,
INSERT TROCAR FOR PEDCL ACCS NDL STRL DISP,SUP-2910299,CDM,C1776,CPT,0278,RC,,,,both,,,579.02,376.36,,,,,,,,,,,,,
ANCHOR SUTURE KINSA,SUP-2341738,CDM,C1713,HCPCS,0278,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
BRACE WLK M M 7 10 WOM 8 11 EXTRA PNEUMAT LTWT DURABLE SEMI,SUP-2196364,CDM,L4361,HCPCS,0274,RC,,,,both,,,184.22,119.74,,,,,,,,,,,,,
INTRODUCER CATH CANN L 10 CM WIRE L 45 CM DIA 0.021 IN SHTH,SUP-2909808,CDM,C1894,HCPCS,0272,RC,,,,both,,,145.07,94.30,,,,,,,,,,,,,
SCREW BONE 24X16MM SS,SUP-2699088,CDM,C1713,HCPCS,0278,RC,,,,both,,,214.78,139.61,,,,,,,,,,,,,
CONNECTOR SPNL L20MM DIA5.5MM TI IL LAT CONN CLS CDH LEG,SUP-2287161,CDM,C1713,HCPCS,0278,RC,,,,both,,,2314.18,1504.22,,,,,,,,,,,,,
CUP ACET OD56MM ID50MM CO CHROM HA POR HIP PRI CEMENTLESS,SUP-2350848,CDM,C1776,CPT,0278,RC,,,,both,,,10205.00,6633.25,,,,,,,,,,,,,
MOUNT EXT FIX BEAC NS DISP SMRT TSF,SUP-2933057,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3536.14,2298.49,,,,,,,,,,,,,
PLATE BNE L 1 MM RT LCK TI,SUP-2459892,CDM,C1713,HCPCS,0278,RC,,,,both,,,919.17,597.46,,,,,,,,,,,,,
RING ANNULPLSTY CARP EDW PHY II DIA 36 MM COCR POLYESTER SIL,SUP-2214251,CDM,C1889,HCPCS,0278,RC,,,,both,,,9090.30,5908.69,,,,,,,,,,,,,
MODEL ANAT FULL SKULL AD 3D CT BASE SEL CLR VITAL STRUCT,SUP-2883375,CDM,2720000010,LOCAL,0272,RC,,,,both,,,17974.68,11683.54,,,,,,,,,,,,,
PLATE BNE SZ 2 R TIB FIX BEAR CEM,SUP-2420824,CDM,C1713,HCPCS,0278,RC,,,,both,,,16102.55,10466.66,,,,,,,,,,,,,
PROSTHESIS OSS 7 MM 4/3.25 MM 0.8 MM BOJRAB UNIV FLROPLAS,SUP-2464978,CDM,L8613,CPT,0278,RC,,,,both,,,1264.45,821.89,,,,,,,,,,,,,
SHEATH URET ACCS L45CM DIA107FR HYDRPHLC FLX,SUP-2170222,CDM,C1894,HCPCS,0272,RC,,,,both,,,603.51,392.28,,,,,,,,,,,,,
FORCEP SURG RATCH 8 IN 5X15 MM LAUFE LCK FNGR RNG HNDL CRV,SUP-2245498,CDM,C1713,HCPCS,0278,RC,,,,both,,,192.04,124.83,,,,,,,,,,,,,
SET IMPL SCR DISK SELF DRL 1.5MM DIA 5MML,SUP-2362179,CDM,C1713,HCPCS,0278,RC,,,,both,,,128.74,83.68,,,,,,,,,,,,,
MARKER BX BRST F/ULTRASOUND GUID W/ 14 G SYS V-MARK 15 GX10,SUP-2120152,CDM,A4648,CPT,0278,RC,,,,both,,,259.05,168.38,,,,,,,,,,,,,
SCREW BONE L12MM OD2.4MM TI CORT VOLAR ST T7 SET D RAD,SUP-2351124,CDM,C1713,HCPCS,0278,RC,,,,both,,,291.33,189.36,,,,,,,,,,,,,
SUPPORT ORTHOT ANK KNEE CALF SPRING WIRE DORSIFLEXION BND,SUP-2435621,CDM,L1900,HCPCS,0274,RC,,,,both,,,807.73,525.02,,,,,,,,,,,,,
HC Telethx Isodose Plan Cplx,PX-3337730700,CDM,77307,CPT,0333,RC,,,,inpatient,,,3311.00,2152.15,,,,,,,,,,,,,
GRAFT 10ML PUTTY NOVABONE,SUP-2307534,CDM,C9359,HCPCS,0278,RC,,,,both,,,3281.30,2132.84,,,,,,,,,,,,,
GUIDE SURG PLN NYL LP CUSTOMIZABLE BNDL RECON VSP,SUP-2883952,CDM,2720000010,LOCAL,0272,RC,,,,both,,,23864.00,15511.60,,,,,,,,,,,,,
ESUCTION COLONIC 3BOX,SUP-2677575,CDM,2720000010,LOCAL,0272,RC,,,,both,,,829.18,538.97,,,,,,,,,,,,,
GYN ESG PLASMABUTTON 12 30 DEG,SUP-2497213,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1688.25,1097.36,,,,,,,,,,,,,
HYDROMORPHONE HCL PF 50 MG/5ML IJ SOLN,RX-118275,CDM,J1171,HCPCS,0636,RC,00409-2634-50,NDC,,both,50,ML,950.80,618.02,,,,,,,,,,,,,
SCREW BNE OSTEOPENIA 4X65 MM PART THRD T8 DRVR EVOS,SUP-2349588,CDM,C1713,HCPCS,0278,RC,,,,both,,,566.52,368.24,,,,,,,,,,,,,
PLATE BONE W16XL124MM BLDE L50MM THK4.8MM 95DEG 7 H STRL,SUP-2185499,CDM,C1713,HCPCS,0278,RC,,,,both,,,3112.37,2023.04,,,,,,,,,,,,,
STEM FEM SEG 23 CM DPHSEAL KNEE TAPR OSS,SUP-2441757,CDM,C1776,CPT,0278,RC,,,,both,,,15119.10,9827.41,,,,,,,,,,,,,
MESH SURG L3.5XW3.5IN POLYPR ABD NONABSORBABLE CIR IMP,SUP-2265973,CDM,C1781,HCPCS,0278,RC,,,,both,,,847.80,551.07,,,,,,,,,,,,,
PLATE BONE FOIL 11MMW X 1262MML 1MM THK RSRB X LATEX FREE,SUP-2681108,CDM,C1713,HCPCS,0278,RC,,,,both,,,1844.56,1198.96,,,,,,,,,,,,,
SUPPORT ORTHOPEDIC ANK MED,SUP-2330426,CDM,L4350,HCPCS,0274,RC,,,,both,,,59.66,38.78,,,,,,,,,,,,,
CATHETER VENTRICULAR DRAINAGE TIP L 15 MM DIA 0.021 IN FLX,SUP-2910013,CDM,C1729,HCPCS,0272,RC,,,,both,,,6110.44,3971.79,,,,,,,,,,,,,
HC Mra Chest W Contrast,PX-6107155500,CDM,C8909,CPT,0610,RC,,,,both,,,4146.00,2694.90,,,,,,,,,,,,,
HC Drain/Inj Joint/Bursa W/US,PX-5102060400,CDM,20604,CPT,0510,RC,,,,inpatient,,,3707.00,2409.55,,,,,,,,,,,,,
CATHETER GUID AD 6FR L100CM COR PERIPH GRN NYL PTFE JL 5,SUP-2158129,CDM,C1887,HCPCS,0272,RC,,,,both,,,112.10,72.86,,,,,,,,,,,,,
GUIDEWIRE ORTH DIA2.8MM 300/150MM CALIB W/ FLUT FOR 6.5MM,SUP-2186907,CDM,C1769,HCPCS,0272,RC,,,,both,,,246.49,160.22,,,,,,,,,,,,,
DRILL SURG PNEUMATIC 6000 RPM ELEC RT HND NS SABER,SUP-2898898,CDM,2720000010,LOCAL,0272,RC,,,,both,,,973.87,633.02,,,,,,,,,,,,,
BRACE WR AD UNIV LT AND RT ELAS SUPP STRP FOAM CUSH WRP ARND,SUP-2309133,CDM,L3931,HCPCS,0272,RC,,,,both,,,52.09,33.86,,,,,,,,,,,,,
STIMULATOR NERVE CHARGING SYSTEM VERCISE,SUP-2836334,CDM,C1820,HCPCS,0278,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
HC Bx Breast 1st Lesion Strtctc|RIGHT SIDE|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE PRIOR TO THE ADMINISTRATION OF ANESTHESIA,PX-3611908100,CDM,19081,CPT,0361,RC,,,RT|73,outpatient,,,6190.00,4023.50,,,,,,,,,,,,,
BUR SURG DIA 4 MM HUB II BRL SOFTCUT STRL DISP HI-LINE XS,SUP-2929245,CDM,2720000010,LOCAL,0272,RC,,,,both,,,423.55,275.31,,,,,,,,,,,,,
VALVE SHUNT RIGHT ANGLE GUIDE,SUP-2711647,CDM,C1889,HCPCS,0278,RC,,,,both,,,292.15,189.90,,,,,,,,,,,,,
SCREW IM HEX DIA 3.5 MM COMPR SET STRL TRIGEN MAX,SUP-2931570,CDM,C1713,HCPCS,0278,RC,,,,both,,,1102.14,716.39,,,,,,,,,,,,,
PLATE BNE THK07MM 4X4 H BILAT ORAL MAXILLOFACIAL MAND TI DBL,SUP-2262953,CDM,C1713,HCPCS,0278,RC,,,,both,,,565.99,367.89,,,,,,,,,,,,,
GUIDEROD ORTH BALL TIPPED 3X800 MM HINDFOOT FOR NAIL PHANTOM,SUP-2749693,CDM,2720000010,LOCAL,0272,RC,,,,both,,,847.80,551.07,,,,,,,,,,,,,
HC So Factor X,PX-3058526066,CDM,85260,CPT,0305,RC,,,,both,,,842.00,547.30,,,,,,,,,,,,,
HEAD HUM 56X24 MM SHLDR COCR BIO MOD,SUP-2449915,CDM,C1776,CPT,0278,RC,,,,both,,,2402.10,1561.36,,,,,,,,,,,,,
PLATE BONE COMPRESSION 2 MM MANDIBULAR 4 HOLE INTERMEDIATE L,SUP-2838406,CDM,C1713,HCPCS,0278,RC,,,,both,,,1481.45,962.94,,,,,,,,,,,,,
SURGICAL LSR FBR 600/300 CONCL TIP W/ HNDPC W/ 2.5 CM EXTN,SUP-2164903,CDM,2720000010,LOCAL,0272,RC,,,,both,,,580.90,377.58,,,,,,,,,,,,,
INSERT SHOE ANK JT,SUP-2388172,CDM,L2180,HCPCS,0272,RC,,,,both,,,295.98,192.39,,,,,,,,,,,,,
SHEATH LD INTRO WORLEY ADV L 66 CM DIA 5.5 FR PEBAX HS,SUP-2497056,CDM,C1893,HCPCS,0272,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
MESH CRANIAL STRAIGHT 1.5X50X50X0.5 MM RAPID RESORBABLE STER,SUP-2838582,CDM,C1713,HCPCS,0278,RC,,,,both,,,4642.18,3017.42,,,,,,,,,,,,,
KIT DRL BIT DIA2MM DRL GUID HNDL LOC PIN TAMP CORRESPONDING,SUP-2194161,CDM,2720000010,LOCAL,0272,RC,,,,both,,,786.35,511.13,,,,,,,,,,,,,
GRAFT HUM TISS W4XL8CM 200M HUM AMNIO MEMBRN BIOFIX +,SUP-2417047,CDM,C1762,CPT,0278,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
VALVE SHUNT PROGRAMMABLE CEREB SPNL CONN SIPHONGUARD DEV,SUP-2194062,CDM,C1729,HCPCS,0272,RC,,,,both,,,16435.14,10682.84,,,,,,,,,,,,,
IMPLANT STAP 0.6MM DIAM 4MM LEN PIST LOOP FLROPLAS S STL,SUP-2312535,CDM,L8613,CPT,0278,RC,,,,both,,,257.73,167.52,,,,,,,,,,,,,
ANCHOR SUTURE DIA 3.9 MM PEEK STRL FIBERTAK ACHILLES,SUP-2910480,CDM,C1713,HCPCS,0278,RC,,,,both,,,9215.12,5989.83,,,,,,,,,,,,,
GRAFT BNE SUB W25XL100MM THK6MM CHRONOS SYN TISS STRP,SUP-2182834,CDM,C1713,HCPCS,0278,RC,,,,both,,,6565.74,4267.73,,,,,,,,,,,,,
CATHETER ANGIOPLSTY L130CM BAL L200MM DIA4MM GWIRE 0.035IN,SUP-2280383,CDM,C2623,HCPCS,0278,RC,,,,both,,,5793.30,3765.64,,,,,,,,,,,,,
STAPLE BONE FIX W9XL12MM LEG L10MM SPD TI FOR IMPL SELECTION,SUP-2135442,CDM,C1776,CPT,0278,RC,,,,both,,,4396.00,2857.40,,,,,,,,,,,,,
CATHETER INTCRAN L105CM OD6FR NIT STR TIP REFLX,SUP-2421067,CDM,C1887,HCPCS,0272,RC,,,,both,,,3846.50,2500.22,,,,,,,,,,,,,
CROSSLINK MECH GIC55 TRNSVRS LINK W/ 60MM BAR 806LT55L60T,SUP-2289278,CDM,C1713,HCPCS,0278,RC,,,,both,,,2141.48,1391.96,,,,,,,,,,,,,
PLATE BNE STR 2.7X81 MM 10 HOLE RECON LCK SS STRL,SUP-2469656,CDM,C1713,HCPCS,0278,RC,,,,both,,,1435.98,933.39,,,,,,,,,,,,,
STEM HUM CEM 2C STD 137.5 DEG 66 MM SHLDR AEQUALIS ASCEND,SUP-2715765,CDM,C1776,CPT,0278,RC,,,,both,,,11062.22,7190.44,,,,,,,,,,,,,
SPACER SPNL LORDTC 50X14 MM DUO,SUP-2423847,CDM,C1821,HCPCS,0278,RC,,,,both,,,23550.00,15307.50,,,,,,,,,,,,,
CEMENT BNE 10 CC DRILLABLE CALCIUM PHOSPHATE BONESYNC,SUP-2845381,CDM,C1713,HCPCS,0278,RC,,,,both,,,7050.87,4583.07,,,,,,,,,,,,,
STIMULATOR BONE GROWTH EXT ELECTROMAGNETIC CLAV SHLDR PRTBL,SUP-2316217,CDM,E0749,HCPCS,0278,RC,,,,both,,,11602.30,7541.49,,,,,,,,,,,,,
SYSTEM GRFT PREP 30MM LNG GRN WHT W HI STRENGTH SUT FOR KNEE,SUP-2256713,CDM,2720000010,LOCAL,0272,RC,,,,both,,,364.24,236.76,,,,,,,,,,,,,
CUTTER PACE LD ACUITY UNIV STRL,SUP-2148943,CDM,C1876,HCPCS,0278,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
CANNULA KIT OBLQ 7.5 CMX3 MM W/ TROCAR,SUP-2774114,CDM,2720000010,LOCAL,0272,RC,,,,both,,,619.96,402.97,,,,,,,,,,,,,
MESH HERN PROGRIP ANAT 15X15 CM SELF GRIPPING BASE POLYPR,SUP-2752184,CDM,C1781,HCPCS,0278,RC,,,,both,,,724.74,471.08,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE L 10 MM DIA 7.5 MM SZ 5 CART ARAGONITE,SUP-2913176,CDM,C1763,HCPCS,0278,RC,,,,both,,,26219.00,17042.35,,,,,,,,,,,,,
LEAD PACE L 64 CM DIA11 FR ENDOCARD 2 COIL STRL,SUP-2139604,CDM,C1895,HCPCS,0275,RC,,,,both,,,21116.50,13725.72,,,,,,,,,,,,,
SCREW LAG FRE LCK 15.8 MM DIAMETERX75 MM L THRD,SUP-2197712,CDM,C1713,HCPCS,0278,RC,,,,both,,,942.09,612.36,,,,,,,,,,,,,
HC Assay of Phosphorus Inorganic Urine,PX-3018410500,CDM,84105,CPT,0301,RC,,,,both,,,193.00,125.45,,,,,,,,,,,,,
DEFIBRILLATOR IMPL CLARIA MRI SURESCAN W 51 X H 73 MM D 13,SUP-2282410,CDM,C1882,HCPCS,0275,RC,,,,both,,,51012.44,33158.09,,,,,,,,,,,,,
BUR SURG COARSE DIAMOND 3 MM RND UPWR,SUP-2166786,CDM,2720000010,LOCAL,0272,RC,,,,both,,,140.11,91.07,,,,,,,,,,,,,
PLATE BNE STR 4 HOLE STRATUM,SUP-2475976,CDM,C1713,HCPCS,0278,RC,,,,both,,,3077.20,2000.18,,,,,,,,,,,,,
ACETAMINOPHEN 160 MG/5ML PO SOLN,RX-100,CDM,340b,HCPCS,0637,RC,00904-7321-76,NDC,,both,10.15,ML,6.80,4.42,,,,,,,,,,,,,
PLATE BNE LCK 324 MM LT PROX FEM 15 HOLE BRIDGE N CONTACT,SUP-2470912,CDM,C1713,HCPCS,0278,RC,,,,both,,,4346.76,2825.39,,,,,,,,,,,,,
CIDOFOVIR 75 MG/ML IV SOLN,RX-17378,CDM,J0740,HCPCS,0636,RC,23155-0216-31,NDC,,both,5,ML,2183.00,1418.95,,,,,,,,,,,,,
PLATE BNE L182MM THK37MM 14 H R J S STL LO PROF RIG RECON,SUP-2177163,CDM,C1713,HCPCS,0278,RC,,,,both,,,2697.98,1753.69,,,,,,,,,,,,,
SET URET STENT SOFFLX L 26 CM DIA10 FR INSRTR L 40 CM DIA10,SUP-2171244,CDM,C2617,HCPCS,0278,RC,,,,both,,,350.93,228.10,,,,,,,,,,,,,
RING ACET SZ 21 HIP UHMWPE MOD PRI REPL RNGLOC +,SUP-2403377,CDM,C1776,CPT,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
SPACER SPNL H14MM PEEK OPTMA POST LUM INTBDY FUS ESL,SUP-2415500,CDM,C1821,HCPCS,0278,RC,,,,both,,,12625.94,8206.86,,,,,,,,,,,,,
IMPLANT OP RM UNIV PLTS TED BEAR PLT SM,SUP-2321553,CDM,C1713,HCPCS,0278,RC,,,,both,,,4462.73,2900.77,,,,,,,,,,,,,
ANCHOR SUTXL CVD W/ 1 SZ 2 ULTRABRAID BLU COBRAID SUT SUTFIX,SUP-2341938,CDM,C1713,HCPCS,0278,RC,,,,both,,,1251.23,813.30,,,,,,,,,,,,,
"HC So Hepatitis, a Igm Anitbody",PX-3028670966,CDM,86709,CPT,0302,RC,,,,both,,,44.00,28.60,,,,,,,,,,,,,
PLATE BNE MIDSHAFT 180 MM FOREARM ULN 14 HOLE STRL,SUP-2518374,CDM,C1713,HCPCS,0278,RC,,,,both,,,2417.80,1571.57,,,,,,,,,,,,,
BRACE CLAV INTO JACKET VEST HALO,SUP-2388153,CDM,L0810,HCPCS,0274,RC,,,,both,,,6444.03,4188.62,,,,,,,,,,,,,
GUIDEWIRE VASC L108CM SL POLYMER TIP S STL STR ATRAUM TIP,SUP-2282440,CDM,C1769,HCPCS,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
AGENT HEMOSTATIC SYR KT ABSORBABLE GEL PWD GEL-FLOW NT,SUP-2326435,CDM,C1713,HCPCS,0278,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
BIT DRL DIA 4 MM MARKING 0 MM LNG PILOT AO CONN STRL TRIGEN,SUP-2933880,CDM,2720000010,LOCAL,0272,RC,,,,both,,,979.21,636.49,,,,,,,,,,,,,
GRAFT SURG PROC HUM DERM CLLGN RECTANG 1MM 16CMX20CM,SUP-2125867,CDM,C1781,HCPCS,0278,RC,,,,both,,,36832.20,23940.93,,,,,,,,,,,,,
SEVELAMER CARBONATE 800 MG PO TABS,RX-89201,CDM,J0601,HCPCS,0637,RC,65862-0921-27,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PLATE BONE BAR L2.9MM THK1.5MM 4 H MINI,SUP-2365231,CDM,C1713,HCPCS,0278,RC,,,,both,,,2080.28,1352.18,,,,,,,,,,,,,
MESH SURG L 4 X W 1 CM D 1 MM PORCINE DERMAL CLLGN ABD HERN,SUP-2901701,CDM,C9364,HCPCS,0278,RC,,,,both,,,327.53,212.89,,,,,,,,,,,,,
PLATE BONE TUBULAR BROAD 4.5 MM 9 HOLE PROVISIONAL FIXATION,SUP-2836965,CDM,C1713,HCPCS,0278,RC,,,,both,,,2668.12,1734.28,,,,,,,,,,,,,
BUDESONIDE 0.5 MG/2ML IN SUSP,RX-28775,CDM,J7626,HCPCS,0636,RC,00487-9701-01,NDC,,both,2,ML,41.90,27.23,,,,,,,,,,,,,
PLATE BNE TRAP LNG 20 MM GORILLA,SUP-2751129,CDM,C1713,HCPCS,0278,RC,,,,both,,,3730.32,2424.71,,,,,,,,,,,,,
CATHETER DRAINAGE PLUG 5 FRX9 CM 19 GAX11 CM DRAINER,SUP-2763481,CDM,C1729,HCPCS,0272,RC,,,,both,,,59.66,38.78,,,,,,,,,,,,,
ALLOGRAFT BNE FRZN W/ ROT CUF RT PROX HUM,SUP-2740790,CDM,C1762,CPT,0278,RC,,,,both,,,16603.38,10792.20,,,,,,,,,,,,,
INEBILIZUMAB-CDON 100 MG/10ML IV SOLN,RX-151014,CDM,J1823,HCPCS,0636,RC,75987-0150-03,NDC,,both,10,ML,137911.10,89642.21,,,,,,,,,,,,,
LEAD PACE L86CM CRV H16MM INTRO 5FR L HRT LO PROF STEER TIP,SUP-2356059,CDM,C1900,HCPCS,0275,RC,,,,both,,,6594.00,4286.10,,,,,,,,,,,,,
POST EXT FIX SHT WIRE PREASSEMBLED FOR SALVATION EXT FIX,SUP-2401120,CDM,2720000010,LOCAL,0272,RC,,,,both,,,951.42,618.42,,,,,,,,,,,,,
LEAD DEFIB L65/18CM SD PLEXA PROMRI,SUP-2138441,CDM,C1895,HCPCS,0275,RC,,,,both,,,8164.00,5306.60,,,,,,,,,,,,,
PLATE BNE L132MM 9 H R ANTLAT DST TIB S STL LOK COMPR LO,SUP-2185950,CDM,C1713,HCPCS,0278,RC,,,,both,,,4096.57,2662.77,,,,,,,,,,,,,
SOLE EXT FIX WALKING ATTACH,SUP-2898587,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
KIT INTRO VSI L 10 CM DIA 4 FR GUIDEWIRE L 60 CM DIA 0.018,SUP-2383171,CDM,C1894,HCPCS,0272,RC,,,,both,,,59.66,38.78,,,,,,,,,,,,,
HC Fna Bx W/CT Gdn 1st Les,PX-3611000900,CDM,10009,CPT,0361,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
DRESSING WND MICRONIZED PARTIC 1000 MG MATRISTEM MICROMATRIX,SUP-2106479,CDM,Q4118,HCPCS,0636,RC,,,,both,,,8330.42,5414.77,,,,,,,,,,,,,
DISTRACTOR SURG L 20 MM INTRAORAL MANDIBULAR FRME NS,SUP-2883442,CDM,C1713,HCPCS,0278,RC,,,,both,,,14539.77,9450.85,,,,,,,,,,,,,
CALCIUM ACETATE (PHOS BINDER) 667 MG PO CAPS,RX-131745,CDM,J0615,HCPCS,0250,RC,00054-0088-26,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
SHANK SPNL SCREW L 30 MM DIA 4.5 MM OSTEOGRIP STRL CD HORZ 5PK,SUP-2928659,CDM,C1713,HCPCS,0278,RC,,,,both,,,7222.00,4694.30,,,,,,,,,,,,,
GRAFT HUM TISS SZ 12 MM BICORTICAL FT WDG PRESHAPED EVANS,SUP-2913204,CDM,C1713,HCPCS,0278,RC,,,,both,,,8182.84,5318.85,,,,,,,,,,,,,
GRAFT BNE 12X12X12MM DEMIN CANC SPNG CUBE FLEXIGRFT,SUP-2264608,CDM,C1713,HCPCS,0278,RC,,,,both,,,1880.89,1222.58,,,,,,,,,,,,,
GRAFT HUM TISS 17MM 200MM CORT STRUT FRZN,SUP-2115987,CDM,C1713,HCPCS,0278,RC,,,,both,,,1227.74,798.03,,,,,,,,,,,,,
BUR SURG BORING TOOL 9.5MMDIA 10.4MML FOR TPS MIDAS REX,SUP-2363377,CDM,2720000010,LOCAL,0272,RC,,,,both,,,247.12,160.63,,,,,,,,,,,,,
SPLINT ORTH M WRST FA HND R FRAC FIRM SUPP ALUMINUM POLY,SUP-2276769,CDM,L3809,HCPCS,0274,RC,,,,both,,,14.48,9.41,,,,,,,,,,,,,
BIT DRL DIA4MM CALIB GRAD DEPTH MRK FOR ENCORE SYS,SUP-2197203,CDM,2720000010,LOCAL,0272,RC,,,,both,,,489.84,318.40,,,,,,,,,,,,,
PLATE BNE L61MM THK3MM 4 H BILAT S STL STR LIMIT CNTCT DYN,SUP-2185330,CDM,C1713,HCPCS,0278,RC,,,,both,,,1372.21,891.94,,,,,,,,,,,,,
CATHETER URET OPN END 038 5 FRX85 CM MOD FLEXI-TIP,SUP-2835781,CDM,C1758,HCPCS,0278,RC,,,,both,,,51.78,33.66,,,,,,,,,,,,,
DEVICE FAT PROC TISS COLLCTN REVOLVE RV0002] ALLERGAN USA - LIFECELL],SUP-2113063,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2797.74,1818.53,,,,,,,,,,,,,
PLATE BNE L20MM M L HEVANS,SUP-2321480,CDM,C1713,HCPCS,0278,RC,,,,both,,,4835.60,3143.14,,,,,,,,,,,,,
SCREW BNE CANC 4.5X15 MM TOT WR UNIV 2,SUP-2610339,CDM,C1713,HCPCS,0278,RC,,,,both,,,655.22,425.89,,,,,,,,,,,,,
STAPLE BONE FIX L21/21MM ARTH MEM,SUP-2137596,CDM,C1713,HCPCS,0278,RC,,,,both,,,1183.72,769.42,,,,,,,,,,,,,
SET INT FIX LEG L8MM DRL 1.5MM WIRE 1.2MM BACKSPAN 8MM,SUP-2418147,CDM,C1713,HCPCS,0278,RC,,,,both,,,2672.14,1736.89,,,,,,,,,,,,,
PLATE BNE 1/3 TBLR 23 MM 3 HOLE NS LTX,SUP-2861927,CDM,C1713,HCPCS,0278,RC,,,,both,,,135.84,88.30,,,,,,,,,,,,,
HC ED Clsd Manip Tibial Shaft Fx,PX-4502775200,CDM,27752,CPT,0450,RC,,,,both,,,1633.00,1061.45,,,,,,,,,,,,,
CROWN DENT STRP L3 PEDIATRIC LOWER CUSPID,SUP-2119364,CDM,D6783,CPT,0278,RC,,,,both,,,13.78,8.96,,,,,,,,,,,,,
SCREW BNE ST 2.4X8 MM CRTX MXLFCL,SUP-2189489,CDM,C1713,HCPCS,0278,RC,,,,both,,,349.48,227.16,,,,,,,,,,,,,
PLATE BONE 6 H T SHP BTTRS ECT,SUP-2198572,CDM,C1713,HCPCS,0278,RC,,,,both,,,667.03,433.57,,,,,,,,,,,,,
KIT GASTSTMY TUBE DIA20FR PEG SYS SAFT PUSH TECH ENTAKE,SUP-2167137,CDM,2720000010,LOCAL,0272,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
SCREW BONE L10MM DIA3MM STRNL TI SELF DRL LCK FOR STBL INT,SUP-2181529,CDM,C1713,HCPCS,0278,RC,,,,both,,,550.13,357.58,,,,,,,,,,,,,
GRAFT ENDOVASC L7X2CM ID8-10MM INTRO SHTH 10FR 0.035IN,SUP-2395927,CDM,C1874,HCPCS,0278,RC,,,,both,,,9332.08,6065.85,,,,,,,,,,,,,
CATHETER GUID AR1 XLG 8 FRX100 CM VISTA BRT TIP,SUP-2157984,CDM,C1887,HCPCS,0272,RC,,,,both,,,111.47,72.46,,,,,,,,,,,,,
HC Cholecystostomy,PX-3614749000,CDM,47490,CPT,0361,RC,,,,inpatient,,,6875.00,4468.75,,,,,,,,,,,,,
TUBE ET 34FR OD11.5MM ID8MM CUF EMG MON ACT REINF FULL ROT,SUP-2284331,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1247.58,810.93,,,,,,,,,,,,,
GRAFT VASC GRAD WALL 8 MMX40 CM STR REINF SLDE GDS FLIXENE,SUP-2471417,CDM,C1768,CPT,0278,RC,,,,both,,,2357.29,1532.24,,,,,,,,,,,,,
CUP ACET HIP RESURF BIRMINGHAM,SUP-2348009,CDM,C1776,CPT,0278,RC,,,,both,,,23550.00,15307.50,,,,,,,,,,,,,
SEALER TISS L25CM SHFT DIA5MM 360DEG ROT CVD JAW TAPR TIP,SUP-2219739,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1424.87,926.17,,,,,,,,,,,,,
HC Carcinoembryonic Antigen Cea|NOT REASONABLE AND NECESSARY,PX-3018237800,CDM,82378,CPT,0301,RC,,,GZ,both,,,334.00,217.10,,,,,,,,,,,,,
ALLOGRAFT BNE CRYOPRESERVED 20X1 MM PROCHONDRIX,SUP-2361155,CDM,C1889,HCPCS,0278,RC,,,,both,,,21666.00,14082.90,,,,,,,,,,,,,
BIT DRL DIA2.4 MM PIN DIA 3 MM STP NS DISP MAV MINI,SUP-2933866,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1131.97,735.78,,,,,,,,,,,,,
OSTEOTOME SURG OD20MM BLDE THN FLX,SUP-2408596,CDM,C1713,HCPCS,0278,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
SCREW BNE 4.5X30 MM,SUP-2243199,CDM,C1713,HCPCS,0278,RC,,,,both,,,584.26,379.77,,,,,,,,,,,,,
TAP SURG DIA7MM 2 LD SCR,SUP-2256861,CDM,2720000010,LOCAL,0272,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
DEXMEDETOMIDINE HCL IN NACL 400 MCG/100ML IV SOLN,RX-121454,CDM,2500000003,HCPCS,0250,RC,00143-9525-01,NDC,,both,100,ML,184.00,119.60,,,,,,,,,,,,,
GRAFT 25-49SQCM FASC FRZ DRY ALLGRFT,SUP-2165568,CDM,C1713,HCPCS,0278,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
DEVICE PROSTHETIC TYP BK SOCKET MOLD,SUP-2388180,CDM,L2350,HCPCS,0274,RC,,,,both,,,2452.91,1594.39,,,,,,,,,,,,,
HC Ot Adl Training 15 Min,PX-4309753500,CDM,97535,CPT,0430,RC,,,,both,,,131.00,85.15,,,,,,,,,,,,,
KIT INTRO SHTH 5 CM GUIDEWIRE L 30 CM DIA 6 FR NDL L 1.5 IN,SUP-2734926,CDM,C1894,HCPCS,0272,RC,,,,both,,,10.68,6.94,,,,,,,,,,,,,
SCREW INTFR L23MM DIA10MM BIOCOMPOSITE TAPR TIP W/ DISP,SUP-2121208,CDM,C1713,HCPCS,0278,RC,,,,both,,,737.90,479.63,,,,,,,,,,,,,
SCREW BNE L6MM DIA1.2MM CORT TI ALLY ST SELF DRL LO PROF,SUP-2268004,CDM,C1713,HCPCS,0278,RC,,,,both,,,271.83,176.69,,,,,,,,,,,,,
BASEPLATE TIB SZ 2+ THK10MM STD UNIV KNEE CO CHROM NP CRUC,SUP-2252435,CDM,C1713,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
GUIDEWIRE VASC 0.18X300 CM CROSSING VICTORY,SUP-2140076,CDM,C1769,HCPCS,0272,RC,,,,both,,,543.22,353.09,,,,,,,,,,,,,
WALKER PT STD XL 11-16 13 + CLOSED HEEL SHOE PACESETTER II,SUP-2195219,CDM,L4386,HCPCS,0272,RC,,,,both,,,84.78,55.11,,,,,,,,,,,,,
DEVICE GRSP L230CM SHTH DIA2.4MM HYBRID JAW FLX DST WIRE,SUP-2391614,CDM,2720000010,LOCAL,0272,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
ALLOGRAFT DRML MED THICK CNTR READY USE RGNRTVE TSSUE MTRX A,SUP-2460967,CDM,Q4116,HCPCS,0636,RC,,,,both,,,14302.70,9296.75,,,,,,,,,,,,,
HC So Candida Antibody,PX-3028662866,CDM,86628,CPT,0302,RC,,,,both,,,67.00,43.55,,,,,,,,,,,,,
MOST CNDYL END R,SUP-2208259,CDM,C1776,CPT,0278,RC,,,,both,,,26649.18,17321.97,,,,,,,,,,,,,
SPLINT WRST PADDED LG MTCRPL RT,SUP-2195719,CDM,L3809,HCPCS,0274,RC,,,,both,,,17.46,11.35,,,,,,,,,,,,,
DEVICE PROSTHETIC FT KNEELING EXT,SUP-2388222,CDM,L5970,HCPCS,0272,RC,,,,both,,,577.04,375.08,,,,,,,,,,,,,
GRAFT HUM TISS W4XL8CM AMNIO MEMBRN AMNIOEXCEL,SUP-2243186,CDM,Q4137,HCPCS,0636,RC,,,,both,,,6107.30,3969.74,,,,,,,,,,,,,
PLATE BNE W13XL109MM THK2MM 6 H S STL CLVRLF BTTRS BILAT,SUP-2362732,CDM,C1713,HCPCS,0278,RC,,,,both,,,1927.65,1252.97,,,,,,,,,,,,,
PIN FIX ANCHR 4X55 MM DISP,SUP-2657180,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1487.45,966.84,,,,,,,,,,,,,
GUIDEWIRE SURG PARL 6.5-8 MM SCR RIVAL,SUP-2644850,CDM,C1769,HCPCS,0272,RC,,,,both,,,2408.19,1565.32,,,,,,,,,,,,,
DEVICE COIL DETACH EDG V4 ELECTRO DETACH GENRTR RET ELECTRD,SUP-2865280,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
BRACE SHLDR SM FA L115 13IN UNIV AIRMESH BRTH SLNG 15DEG,SUP-2150867,CDM,L3650,HCPCS,0272,RC,,,,both,,,171.16,111.25,,,,,,,,,,,,,
DUTASTERIDE 0.5 MG PO CAPS,RX-34089,CDM,6370000000,HCPCS,0637,RC,31722-0131-30,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
SCREW SPNL G4 POST THORLUM CANN BRK OFF INT HEX SET CDH LEG,SUP-2288455,CDM,C1713,HCPCS,0278,RC,,,,both,,,178.98,116.34,,,,,,,,,,,,,
KIT KYPHOPLASTY SZ 3 CEM GUN W/ BNE FILL INJ KYPHON,SUP-2293483,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1369.04,889.88,,,,,,,,,,,,,
GUIDEWIRE VASC L 100 CM DIA 0.025 IN CRV RAD 5 MM SS REUT,SUP-2638688,CDM,C1769,HCPCS,0272,RC,,,,both,,,210.16,136.60,,,,,,,,,,,,,
DEVICE PROSTHETIC FT KNEELING EXT,SUP-2388222,CDM,L5970,HCPCS,0274,RC,,,,both,,,577.04,375.08,,,,,,,,,,,,,
INTRODUCER SHTH GRY HUB 5FRX23CM PRELUDE,SUP-2303275,CDM,C1894,HCPCS,0272,RC,,,,both,,,37.93,24.65,,,,,,,,,,,,,
HEAD RAD DIA20MM +4MM OFFSET 2499KITA EVOLVE PROLINE,SUP-2397970,CDM,C1776,CPT,0278,RC,,,,both,,,5915.76,3845.24,,,,,,,,,,,,,
HYDRALAZINE HCL 50 MG PO TABS,RX-3701,CDM,6370000000,HCPCS,0637,RC,50111-0328-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
DILTIAZEM HCL ER 60 MG PO CP12,RX-14100,CDM,6370000000,HCPCS,0637,RC,51079-0924-01,NDC,,both,1,UN,14.90,9.68,,,,,,,,,,,,,
CATHETER GUID GUIDELINER V3 L 150 CM DIA 6 FR RX L 25 CM,SUP-2383144,CDM,C1887,HCPCS,0272,RC,,,,both,,,1221.46,793.95,,,,,,,,,,,,,
CLIP HEMOSTAS L 235 CM X W 22 MM SHTH DIA2.6 MM CHANNEL,SUP-2909405,CDM,C1889,HCPCS,0278,RC,,,,both,,,508.68,330.64,,,,,,,,,,,,,
HB Gbl Visit to Discuss Lung Ca Screen W Ldct,PX-9820029600,CDM,G0296,CPT,0982,RC,,,,both,,,363.00,235.95,,,,,,,,,,,,,
SHEATH DIL SM 12FR L43CM OD5.5MM ID4.2MM PEBAX TEF ROBUST,SUP-2353112,CDM,C1893,HCPCS,0272,RC,,,,both,,,910.60,591.89,,,,,,,,,,,,,
SHOULDER IMMOB ELAS XLG,SUP-2195042,CDM,L3650,HCPCS,0272,RC,,,,both,,,28.26,18.37,,,,,,,,,,,,,
TROCAR DIA3.2MM TIP TRIGEN,SUP-2348120,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1148.27,746.38,,,,,,,,,,,,,
HC Egd Diagnostic Brush Wash,PX-4504323500,CDM,43235,CPT,0450,RC,,,,both,,,2447.00,1590.55,,,,,,,,,,,,,
MESH SYNTH ABD N ABSRB BIOMATERIAL EXP,SUP-2395365,CDM,C1781,HCPCS,0278,RC,,,,both,,,920.02,598.01,,,,,,,,,,,,,
HC Chest Tube Insertion,PX-7613255100,CDM,32551,CPT,0761,RC,,,,both,,,4942.00,3212.30,,,,,,,,,,,,,
SHUNT L250MM 0-20CM H2O CEREBROSPINAL FLUID WITH PEDIATRIC C,SUP-2843223,CDM,C1889,HCPCS,0278,RC,,,,both,,,18708.65,12160.62,,,,,,,,,,,,,
GRAFT BONE SUB 5ML HUM CORT DEMIN FBR STAGRFT,SUP-2136831,CDM,C1713,HCPCS,0278,RC,,,,both,,,2881.20,1872.78,,,,,,,,,,,,,
SYSTEM DEL FLEXNAV L 107 CM SHTH L 30 DIA15 FR VLV CAPSULE,SUP-2892348,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
GRAFT BNE SUB 5CC CA SULF STIMULAN RAP CURE,SUP-2135333,CDM,C1713,HCPCS,0278,RC,,,,both,,,2983.00,1938.95,,,,,,,,,,,,,
VALVE CSF MULTPURP HI PRESSURE ON-OFF FLSH W/O ANTI SIPHON,SUP-2852569,CDM,C1889,HCPCS,0278,RC,,,,both,,,4204.21,2732.74,,,,,,,,,,,,,
GRAFT VASC GELWEAVE L 30 CM DIA12 MM POLYESTER GEL,SUP-2385015,CDM,C1768,CPT,0278,RC,,,,both,,,1404.71,913.06,,,,,,,,,,,,,
GRAFT BNE DWL 14X13 MM FD CORTICAL CANC,SUP-2294047,CDM,C1713,HCPCS,0278,RC,,,,both,,,1243.44,808.24,,,,,,,,,,,,,
PLATE BONE W12XL55MM THK1MM 3 H BILAT TI SEMI TBLR LO PROF,SUP-2190701,CDM,C1713,HCPCS,0278,RC,,,,both,,,226.74,147.38,,,,,,,,,,,,,
SHEATH TRANSSEPTAL 45 DEG L 63 CM DIA 8.5 FR GUIDEWIRE L 180,SUP-2913151,CDM,C1893,HCPCS,0272,RC,,,,both,,,3042.66,1977.73,,,,,,,,,,,,,
BEARING TIB 2XSM THK14MM UNIV KNEE CO CHROM HNG FLAT ANT,SUP-2252665,CDM,C1776,CPT,0278,RC,,,,both,,,8160.08,5304.05,,,,,,,,,,,,,
SHEATH INTRO L28CM DIA12FR POLYETH HYDRPHLC W/O CRV HEMSTAT,SUP-2396254,CDM,C1894,HCPCS,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
HEAD HUM H27MM DIA46MM CURVATURE DIA46MM SHLDR CO CHROM,SUP-2404502,CDM,C1776,CPT,0278,RC,,,,both,,,5617.46,3651.35,,,,,,,,,,,,,
CATHETER CARD ABLATION THERMOCOOL SMARTTOUCH SF L115CM 8FR D,SUP-2248617,CDM,C1732,HCPCS,0272,RC,,,,both,,,8983.54,5839.30,,,,,,,,,,,,,
CABLE ORTH DIA2MM HIP S STL W/ CLMP ACCORD,SUP-2345205,CDM,C1776,CPT,0278,RC,,,,both,,,1129.14,733.94,,,,,,,,,,,,,
SPLINT WRST XL L7IN FOR 85 95IN COT R SLIP ON SFT DURABLE,SUP-2276656,CDM,L3809,HCPCS,0274,RC,,,,both,,,9.73,6.32,,,,,,,,,,,,,
TUBE JEJUSTMY 12FR BLLN 2-3ML SIL SECURELOK R ANG CONN 2,SUP-2124593,CDM,2720000010,LOCAL,0272,RC,,,,both,,,426.26,277.07,,,,,,,,,,,,,
GRAFT BNE STRUT 50X19X3 MM FRZN FEM CORTICAL,SUP-2294172,CDM,C1713,HCPCS,0278,RC,,,,both,,,2543.40,1653.21,,,,,,,,,,,,,
CENTRALIZER VERSYS HERITAGE PROX 15MM EXT,SUP-2504424,CDM,C1776,CPT,0278,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
ANCHOR SUT RIGIDLOOP FIXED 60MM,SUP-2749356,CDM,C1713,HCPCS,0278,RC,,,,both,,,2515.14,1634.84,,,,,,,,,,,,,
PLATE BNE L314MM 14 H ST R CNDYL S STL LOK COMPR CRV FOR,SUP-2177090,CDM,C1713,HCPCS,0278,RC,,,,both,,,5018.57,3262.07,,,,,,,,,,,,,
BOOT CAST L AD UNISX OPN TOE VELC CLSR TCC-EZ,SUP-2194357,CDM,L4386,HCPCS,0272,RC,,,,both,,,259.33,168.56,,,,,,,,,,,,,
CONE TIB SHT 18 KNEE LEGION,SUP-2349172,CDM,C1776,CPT,0278,RC,,,,both,,,11932.00,7755.80,,,,,,,,,,,,,
SYSTEM SEAL W/ DEL DEV LOADER 3.8MM AORT CUT HEARTSTRING,SUP-2227561,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1750.83,1138.04,,,,,,,,,,,,,
SUPPORT ORTHOT FT METATRSL ARCH REMOVABLE PREMOLDED,SUP-2435705,CDM,L3050,HCPCS,0274,RC,,,,both,,,133.26,86.62,,,,,,,,,,,,,
PILLAR EXT FIX L 350 MM THRD MONK RING,SUP-2899149,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1770.18,1150.62,,,,,,,,,,,,,
SCREW BNE ST FIX FRAMELESS GUID NAVIGATION SYS,SUP-2365166,CDM,C1713,HCPCS,0278,RC,,,,both,,,158.26,102.87,,,,,,,,,,,,,
COLLAR CERV SFT 4X22IN UNIV,SUP-2276584,CDM,L0120,HCPCS,0274,RC,,,,both,,,7.79,5.06,,,,,,,,,,,,,
BRACE ORTHOPEDIC POST OPERATIVE LG XL 28 IN BLK LTX,SUP-2421706,CDM,L1833,HCPCS,0272,RC,,,,both,,,228.18,148.32,,,,,,,,,,,,,
PLATE BNE L275MM 18 H ST R MED PROX TIB S STL LOK COMPR LO,SUP-2185659,CDM,C1713,HCPCS,0278,RC,,,,both,,,4885.37,3175.49,,,,,,,,,,,,,
HC Pt Therapeutic Activities 15 Min|OP PT SERVICES|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS,PX-4209753000,CDM,97530,CPT,0420,RC,,,GP|CQ,both,,,144.00,93.60,,,,,,,,,,,,,
CATHETER CTRL VEN OD4.2FR 1 LUMN SURCUF BASIC TY STYL NDL,SUP-2126548,CDM,C1751,HCPCS,0278,RC,,,,both,,,270.04,175.53,,,,,,,,,,,,,
BLADE RETRACTOR ABD 4 IN BALFOUR FEN WIRE BLDE,SUP-2462089,CDM,2720000010,LOCAL,0272,RC,,,,both,,,510.25,331.66,,,,,,,,,,,,,
FEEDING TUBE KIT LP 12 FRX1.2 CM BLLN BUTTON SIL MINI 1,SUP-2754569,CDM,2720000010,LOCAL,0272,RC,,,,both,,,704.62,458.00,,,,,,,,,,,,,
HEAD PLT PHLANG THK075MM R HND 316L S STL LOK FOR 13MM SCR,SUP-2177986,CDM,C1713,HCPCS,0278,RC,,,,both,,,1483.34,964.17,,,,,,,,,,,,,
GRAFT BNE BIPHASIC 18 CC 2 STRP OSTEOMATRIX +,SUP-2499102,CDM,C1713,HCPCS,0278,RC,,,,both,,,6005.85,3903.80,,,,,,,,,,,,,
CATHETER THERMODILUTION LUMENX7 8FRX110CM COMB SWN GZ,SUP-2214322,CDM,C1751,HCPCS,0278,RC,,,,both,,,815.14,529.84,,,,,,,,,,,,,
HEAD HUM SEG 48X19 MM SHLDR REV SUPER EAS COMPHSVE,SUP-2442441,CDM,C1776,CPT,0278,RC,,,,both,,,5736.78,3728.91,,,,,,,,,,,,,
BIT DRL 2.4MM S STL DISP CINCHLOCK,SUP-2378804,CDM,2720000010,LOCAL,0272,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
SCREW BNE L20MM DIA2.3MM STD CORT TI ST NONCANNULATED,SUP-2372652,CDM,C1713,HCPCS,0278,RC,,,,both,,,189.50,123.17,,,,,,,,,,,,,
ROD EXT FIX L 550 MM DIA 11 MM CARBON FIBER NS DISP,SUP-2908933,CDM,2720000010,LOCAL,0272,RC,,,,both,,,437.81,284.58,,,,,,,,,,,,,
SHELL ACET CLUS H ACUMATCH A SER 46,SUP-2221838,CDM,C1776,CPT,0278,RC,,,,both,,,6405.60,4163.64,,,,,,,,,,,,,
PLATE M PROFYLE STR 4 HL 2.3MM,SUP-2466867,CDM,C1713,HCPCS,0278,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
GRAFT NRV L30MM DIA4-5MM PERIPH NAT CONN CBL PROC FOR RECON,SUP-2124854,CDM,C1762,CPT,0278,RC,,,,both,,,14035.80,9123.27,,,,,,,,,,,,,
PLATE BNE L 333 MM SCREW DIA 4.5 MM 20 H COMPR LCK NS EVOS,SUP-2933272,CDM,C1713,HCPCS,0278,RC,,,,both,,,3686.89,2396.48,,,,,,,,,,,,,
CLIP 9MM T BAR STANDARD PERMANENT JAWS KONKAV,SUP-2821765,CDM,C1889,HCPCS,0278,RC,,,,both,,,5952.40,3869.06,,,,,,,,,,,,,
SCREW BNE L4MM DIA1.7MM CORT CRANIOMAXILLOFACIAL MIDFACE TI 5PK,SUP-2366101,CDM,C1713,HCPCS,0278,RC,,,,both,,,227.34,147.77,,,,,,,,,,,,,
SCREW BONE L7MM DIA1.3MM CORT CRANIOMAXILLOFACIAL TI ST FULL,SUP-2189054,CDM,C1713,HCPCS,0278,RC,,,,both,,,1326.65,862.32,,,,,,,,,,,,,
PLATE BNE L1865MM THK25MM 12 H PELV S STL STR,SUP-2362702,CDM,C1713,HCPCS,0278,RC,,,,both,,,2635.40,1713.01,,,,,,,,,,,,,
PLATE BONE THK1.5MM 6 H MINI STR FOR 2/2.3MM SCR,SUP-2365232,CDM,C1713,HCPCS,0278,RC,,,,both,,,2535.11,1647.82,,,,,,,,,,,,,
GRAFT HUM TISS 10X14MM THK2MM ACELLULAR DERM MTRX BIOWASHER,SUP-2120780,CDM,Q4125,HCPCS,0636,RC,,,,both,,,1723.86,1120.51,,,,,,,,,,,,,
ADAPTER SL +4MM OFFSET UNIV HIP TI V40 TAPR ACCOLADE II,SUP-2376608,CDM,C1713,HCPCS,0278,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
PLUG BONE INSRTR CALIB W/ DEPTH MRK RETRCT PCL PUSH CEM,SUP-2364406,CDM,C1713,HCPCS,0278,RC,,,,both,,,1083.77,704.45,,,,,,,,,,,,,
GRAFT HUM TISS W4XL4CM THN MTRX ANAT BARR FOR ORTH APPL,SUP-2120774,CDM,C1762,CPT,0278,RC,,,,both,,,5239.88,3405.92,,,,,,,,,,,,,
CATHETER HEMODIALYSI SLXACUTE 14FR DIA LG 15CM STRGHT TAPR T,SUP-2610567,CDM,C1752,HCPCS,0278,RC,,,,both,,,226.08,146.95,,,,,,,,,,,,,
BIT DRL DIA 4.15 MM RT ANGLE FOR TOT ANK REPL SYS NS DISP,SUP-2899211,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1122.55,729.66,,,,,,,,,,,,,
SET INT FIX SCREW DIA1.5 MM 4 H TI NEURO 2 SQ PLATE 1 PK,SUP-2936742,CDM,C1713,HCPCS,0278,RC,,,,both,,,3846.50,2500.22,,,,,,,,,,,,,
RASP SURG CRV TN SAW CONCV R25 STRYKR STRL,SUP-2898443,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2289.06,1487.89,,,,,,,,,,,,,
COIL EMB L3CM LOOP OD2MM OD0.020IN NIT STRTCH RESIST CRV,SUP-2323440,CDM,C1889,HCPCS,0278,RC,,,,both,,,5560.94,3614.61,,,,,,,,,,,,,
RESERVOIR CSF 0.23ML MINI SIDE INLET,SUP-2244283,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1254.21,815.24,,,,,,,,,,,,,
STENT CAR ART 10MM DIA 30MML .018 WIRE SZ NIT,SUP-2158978,CDM,C1876,HCPCS,0278,RC,,,,both,,,6264.30,4071.79,,,,,,,,,,,,,
HC So Hepatitis B Surface Ag,PX-3068734066,CDM,87340,CPT,0306,RC,,,,outpatient,,,57.00,37.05,,,,,,,,,,,,,
PLATE BNE 4 H R 1ST MP TI FUS PRECONTOURED POLISHED ROUNDED,SUP-2107819,CDM,C1713,HCPCS,0278,RC,,,,both,,,1566.86,1018.46,,,,,,,,,,,,,
SLING GYN UNIV MESH ASMBLY HALO NDL MID URETH POLYPR IMP,SUP-2141793,CDM,C1771,HCPCS,0278,RC,,,,both,,,2273.67,1477.89,,,,,,,,,,,,,
SCREW BNE L 8 MM DIA 3.2 MM MANDIBULAR XDRV EMER DISP,SUP-2935135,CDM,C1713,HCPCS,0278,RC,,,,both,,,3733.46,2426.75,,,,,,,,,,,,,
HC Apply Short Leg Cast,PX-4502942500,CDM,29425,CPT,0450,RC,,,,both,,,848.00,551.20,,,,,,,,,,,,,
SCREW BNE 40X120MM SELF DRL QUIK CONN CYL SHFT AO XCALIBER,SUP-2316302,CDM,C1713,HCPCS,0278,RC,,,,both,,,463.46,301.25,,,,,,,,,,,,,
PLATE BNE L W135XL188MM THK42MM 10 H BILAT TI NAR RIG NEUT,SUP-2190820,CDM,C1713,HCPCS,0278,RC,,,,both,,,1610.19,1046.62,,,,,,,,,,,,,
BIT DRL L190MM DIA2MM LNG QUIK CONN DISP FOR PERI-LOC L,SUP-2343993,CDM,2720000010,LOCAL,0272,RC,,,,both,,,807.14,524.64,,,,,,,,,,,,,
COIL MICRUSFRAME 6MMX122CM,SUP-2249237,CDM,C1889,HCPCS,0278,RC,,,,both,,,6409.81,4166.38,,,,,,,,,,,,,
SCREW SPNL MULTAXL 10.5X70 MM CANC CD HORZ TCS,SUP-2628343,CDM,C1713,HCPCS,0278,RC,,,,both,,,3355.88,2181.32,,,,,,,,,,,,,
COMPONENT FEM SZ C KNEE POLYETH SEG SYS,SUP-2200505,CDM,C1776,CPT,0278,RC,,,,both,,,847.80,551.07,,,,,,,,,,,,,
PLATE BNE L91MM 2 H NONSTERILE L PROX PERIARTC HUM S STL,SUP-2184283,CDM,C1713,HCPCS,0278,RC,,,,both,,,4666.35,3033.13,,,,,,,,,,,,,
STENT GRFT VASC AFX L 88 MM DIA 16 MM IL LIMB EXT AAA,SUP-2217705,CDM,C1768,CPT,0278,RC,,,,both,,,10032.30,6520.99,,,,,,,,,,,,,
SET LD INTRO FLOWGUARD L 20 CM DIA 7 FR 12 ML ART VLV,SUP-2281862,CDM,C1894,HCPCS,0272,RC,,,,both,,,105.35,68.48,,,,,,,,,,,,,
GUIDEWIRE VASC THRUWAY L 300 CM DIA 0.018 IN SS SIL STR SHRT,SUP-2148323,CDM,C1769,HCPCS,0272,RC,,,,both,,,285.74,185.73,,,,,,,,,,,,,
TRAY 3.5MM PLATE LCP HOOK PL RETROFIT KIT FOR OLECRANON,SUP-2549794,CDM,C1713,HCPCS,0278,RC,,,,both,,,46.97,30.53,,,,,,,,,,,,,
SHELL ACET OD46MM FF UNIV TI HIP PRESSFIT CEMENTLESS,SUP-2206146,CDM,C1776,CPT,0278,RC,,,,both,,,5245.37,3409.49,,,,,,,,,,,,,
STEM FEM SZ 1 STD OFFSET TAPR HIP REV CLP,SUP-2216934,CDM,C1776,CPT,0278,RC,,,,both,,,11822.10,7684.36,,,,,,,,,,,,,
GENERATOR PLSE PT PRGMR EON,SUP-2355980,CDM,C1787,HCPCS,0278,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
PLATE BONE M THK1MM 4 H MIDFACE SLV TI STR COMPR FOR 2MM SCR,SUP-2402955,CDM,C1713,HCPCS,0278,RC,,,,both,,,876.06,569.44,,,,,,,,,,,,,
NAIL IM L 130 MM DIA 4 MM TI RT FIBULAR STRL PHANTOM,SUP-2908995,CDM,C1713,HCPCS,0278,RC,,,,both,,,9239.45,6005.64,,,,,,,,,,,,,
PLATE BNE L164MM BRL L1IN 90DEG SUPCNDYL BILAT S STL SHT 8,SUP-2342447,CDM,C1713,HCPCS,0278,RC,,,,both,,,4995.11,3246.82,,,,,,,,,,,,,
BIT DRL DIA2.5MM CANN PROF FOR 2.5MM INSTR MAX VPC SCR SYS,SUP-2402760,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1130.40,734.76,,,,,,,,,,,,,
DISCHARGE KIT COPD,SUP-2389143,CDM,2720000010,LOCAL,0272,RC,,,,both,,,800.70,520.45,,,,,,,,,,,,,
CAP ORTH KNEE TAPR REGENEREX,SUP-2136302,CDM,C1776,CPT,0278,RC,,,,both,,,1789.80,1163.37,,,,,,,,,,,,,
GRAFT HUM TISS L W4XL16CM THK0.53-1.02MM DERM TISS MTRX M,SUP-2112996,CDM,Q4116,HCPCS,0636,RC,,,,both,,,6951.96,4518.77,,,,,,,,,,,,,
TRIAL KNEE DIA38MM PAT CONVENTIONAL MEDIALIZED DOME DRL,SUP-2436174,CDM,2720000010,LOCAL,0272,RC,,,,both,,,452.16,293.90,,,,,,,,,,,,,
SLITTER PACE SELECTRA CORONARY SINUS FOR TELSCP LD DEL SYS,SUP-2699211,CDM,2720000010,LOCAL,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
MESH SURGICAL 5CM X 5CM RESTRATA,SUP-2874125,CDM,A2007,HCPCS,0636,RC,,,,both,,,9671.20,6286.28,,,,,,,,,,,,,
GRIP CBL SM L75MM TROCHANTERIC HIP 3 CBL ACCORD,SUP-2345200,CDM,C1776,CPT,0278,RC,,,,both,,,4006.64,2604.32,,,,,,,,,,,,,
GRAFT BNE SUB 10ML HA CLLGN INJ FILL RESRB HEALOS FX,SUP-2255630,CDM,C1713,HCPCS,0278,RC,,,,both,,,5595.48,3637.06,,,,,,,,,,,,,
SPACER SPNL 10 DEG L 14 X W 11 X H 6 MM PEEK TI ANTR CERV,SUP-2925361,CDM,C1889,HCPCS,0278,RC,,,,both,,,5840.40,3796.26,,,,,,,,,,,,,
SHOE ORTHOT ADDITION TOE TAP HRS,SUP-2435740,CDM,L3560,HCPCS,0274,RC,,,,both,,,64.75,42.09,,,,,,,,,,,,,
SHOE ORTHOT ADDITION TOE TAP HRS,SUP-2435740,CDM,L3560,HCPCS,0272,RC,,,,both,,,64.75,42.09,,,,,,,,,,,,,
BIT DRL L195MM DIA3.3MM S STL FOR NCB SYS,SUP-2411440,CDM,2720000010,LOCAL,0272,RC,,,,both,,,351.90,228.73,,,,,,,,,,,,,
TAMP BNE GRFT SPNL STR,SUP-2292627,CDM,C1713,HCPCS,0278,RC,,,,both,,,1382.98,898.94,,,,,,,,,,,,,
SALVATION  6X35MM HALF PIN HA STERILE,SUP-2488401,CDM,C1713,HCPCS,0278,RC,,,,both,,,901.18,585.77,,,,,,,,,,,,,
TAMP BNE INFLATABLE 2 15 MM KYPHON EXPRESS II,SUP-2664464,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2684.70,1745.05,,,,,,,,,,,,,
PLATE BONE L20MM THK0.3MM 6 H CRANIOMAXILLOFACIAL TI Y FOR,SUP-2136525,CDM,C1713,HCPCS,0278,RC,,,,both,,,486.70,316.35,,,,,,,,,,,,,
COVER BUR H DIA12MM 6 H TI FOR 1.3MM PLUSDRIVE SCR,SUP-2190677,CDM,C1713,HCPCS,0278,RC,,,,both,,,882.34,573.52,,,,,,,,,,,,,
BAR EXT FIX 11X500 MM CARBON,SUP-2750001,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1742.70,1132.75,,,,,,,,,,,,,
GRAFT BIO TISS W2XL4CM THK02 04MM ACELLULAR DERM MTRX ULT,SUP-2307505,CDM,Q4128,HCPCS,0636,RC,,,,both,,,602.53,391.64,,,,,,,,,,,,,
GUIDEWIRE SURG L14IN DIA2.4MM CALIB DRL TIP DISP APERFIX,SUP-2416415,CDM,C1769,HCPCS,0272,RC,,,,both,,,753.60,489.84,,,,,,,,,,,,,
SYSTEM EMB 36 FR SZ 20 CM LEN PERIPH HYDRGEL HYDROLYSER,SUP-2385405,CDM,C1889,HCPCS,0278,RC,,,,both,,,4281.39,2782.90,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH ALPHA2 161 MM 36 MM SHTH 18 FR TAPR,SUP-2911984,CDM,C1889,HCPCS,0278,RC,,,,both,,,66894.56,43481.46,,,,,,,,,,,,,
GRAFT HUMAN TISSUE PELVIC FLOOR MATRIX 10X7 CM MATRISTEM,SUP-2106486,CDM,C1763,HCPCS,0278,RC,,,,both,,,6923.70,4500.40,,,,,,,,,,,,,
ENDCAP ORTH 10+ MM FOR FIB,SUP-2857590,CDM,C1889,HCPCS,0278,RC,,,,both,,,957.70,622.50,,,,,,,,,,,,,
BUTTON NSL SEPT DIA3CM SIL FOR OUTPT PROC,SUP-2277734,CDM,C1889,HCPCS,0278,RC,,,,both,,,687.82,447.08,,,,,,,,,,,,,
BUNDLE CASE DISTRCTN CRAN MXLFCL 3 FULL SKULL RECON VSP,SUP-2862827,CDM,2720000010,LOCAL,0272,RC,,,,both,,,24538.38,15949.95,,,,,,,,,,,,,
COMPONENT FEM CR 67.5 MM RT KNEE POROUS COCR AGC,SUP-2406027,CDM,C1776,CPT,0278,RC,,,,both,,,5966.00,3877.90,,,,,,,,,,,,,
CEMENT BNE PMMA FOR FEN SCR HV R,SUP-2279567,CDM,C1713,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
CARTRIDGE BLADE PRECIS,SUP-2364807,CDM,2720000010,LOCAL,0272,RC,,,,both,,,775.58,504.13,,,,,,,,,,,,,
CATHETER ABLATN F-J CRV 1-7-4 MM 8 MM 7 FRX115 CM EZ STEER,SUP-2248517,CDM,C1732,HCPCS,0272,RC,,,,both,,,7762.08,5045.35,,,,,,,,,,,,,
PLATE BNE PUBIC SYMPHYSIS PELV 6 HOLE,SUP-2518370,CDM,C1713,HCPCS,0278,RC,,,,both,,,3494.82,2271.63,,,,,,,,,,,,,
ANCHOR SUTURE 4.75 MM W/ 1MM HI-FI RIBBON ARGO KNOTLESS,SUP-2846775,CDM,C1713,HCPCS,0278,RC,,,,both,,,2534.39,1647.35,,,,,,,,,,,,,
WIRE FIX BOLT,SUP-2197304,CDM,2720000010,LOCAL,0272,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
KNOTLESS MINI TR IMPLANT AR8906DS,SUP-2843916,CDM,C1713,HCPCS,0278,RC,,,,both,,,4694.30,3051.29,,,,,,,,,,,,,
SPACER SPNL LORDTC 6 DEG 30X11X7 MM VALEO TL,SUP-2175318,CDM,C1713,HCPCS,0278,RC,,,,both,,,12246.00,7959.90,,,,,,,,,,,,,
STEM FEM L200MM DIA10MM KNEE EXTN OPTETRAK,SUP-2222911,CDM,C1776,CPT,0278,RC,,,,both,,,2420.00,1573.00,,,,,,,,,,,,,
DEVICE SUT L26CM DIA5MM TI KNOT TYNG CRMP STD HNDL DISP,SUP-2265298,CDM,C1889,HCPCS,0278,RC,,,,both,,,624.86,406.16,,,,,,,,,,,,,
STENT BILI S.M.A.R.T. CTRL L 40 MM DIA14 MM NIT SELF,SUP-2158900,CDM,C1876,HCPCS,0278,RC,,,,both,,,3868.48,2514.51,,,,,,,,,,,,,
DEFIBRILLATOR IMPL ILESTO 7 DR-T W 56 X H 65 MM D 11 MM 32,SUP-2138454,CDM,C1721,HCPCS,0275,RC,,,,both,,,41605.00,27043.25,,,,,,,,,,,,,
IMPLANT ORBIT COMPLT L IMPLABLE L93XW75MM MEDPOR,SUP-2366500,CDM,C1713,HCPCS,0278,RC,,,,both,,,14018.69,9112.15,,,,,,,,,,,,,
ELECTRODE ELECSURG UROLOGY 12-30 DEG BPLR CURET 24-28FR,SUP-2474315,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3405.61,2213.65,,,,,,,,,,,,,
INSERTER SURG FOR ABUTMENT BAHA,SUP-2164942,CDM,2720000010,LOCAL,0272,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
CATHETER HD 11.5 FRX15 CM FULL TY KINK RESISTANCE 5/BX,SUP-2267019,CDM,C1750,HCPCS,0278,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
HC So Assay of Manganese,PX-3018378566,CDM,83785,CPT,0301,RC,,,,both,,,108.00,70.20,,,,,,,,,,,,,
HC Immunization Administration,PX-7719047100,CDM,90471,CPT,0771,RC,,,,both,,,85.00,55.25,,,,,,,,,,,,,
GRAFT HUM TISS 4X4CM AMNION PTCH CYGNUS SOLO,SUP-2393056,CDM,Q4170,HCPCS,0636,RC,,,,both,,,4785.36,3110.48,,,,,,,,,,,,,
DOPAMINE-DEXTROSE 1.6-5 MG/ML-% IV SOLN,RX-14845,CDM,J1265,HCPCS,0636,RC,00338-1007-02,NDC,,both,250,ML,82.00,53.30,,,,,,,,,,,,,
STEM FEM L200MM OD11MM CVD MOD SEG FORGED HIP TI ACUMATCH,SUP-2222150,CDM,C1776,CPT,0278,RC,,,,both,,,6358.50,4133.02,,,,,,,,,,,,,
PLATE BNE PARASYMPHYSIS 2/2.5X27X12X1 MM 8 HOLE NS LEVEL 1,SUP-2469043,CDM,C1713,HCPCS,0278,RC,,,,both,,,1447.48,940.86,,,,,,,,,,,,,
PATCH DURA REGEN MTRX CLLGN BASE ST 1 IN X 3 IN DURAGN +,SUP-2244010,CDM,C1713,HCPCS,0278,RC,,,,both,,,1124.47,730.91,,,,,,,,,,,,,
BIT DRL L160MM DIA3.5MM CANN QUIK CPL NONRADIOLUCENT W/ ADJ,SUP-2187339,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1098.09,713.76,,,,,,,,,,,,,
CLIP HEMSTAS ROTATABLE 11 MM REPOSITIONABLE COAT STRL DISP,SUP-2791191,CDM,C1889,HCPCS,0278,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
SCREW BONE L45MM DIA4MM HDLSS COMPR M CANN FLOWERCUBE,SUP-2225513,CDM,C1713,HCPCS,0278,RC,,,,both,,,1178.13,765.78,,,,,,,,,,,,,
WASHER RESRB M CLOVER CENTRALOC RESRB TIB FIX,SUP-2212865,CDM,C1713,HCPCS,0278,RC,,,,both,,,634.28,412.28,,,,,,,,,,,,,
CATHETER ANGIO IMPRESS L 110 CM 5 FR 0.046 IN 0.038 IN IM,SUP-2665520,CDM,C1887,HCPCS,0272,RC,,,,both,,,75.11,48.82,,,,,,,,,,,,,
SCREW COMPR 4.5X40MM HEADLESS TI SHRT THRD STRL,SUP-2547070,CDM,C1713,HCPCS,0278,RC,,,,both,,,1038.15,674.80,,,,,,,,,,,,,
AGENT VISCOELASTIC REG 0.55 CC COHESIVE HEALON PRO,SUP-2753858,CDM,C1814,HCPCS,0278,RC,,,,both,,,84.78,55.11,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 60 CM DIA 6 MM EPTFE STR STD WALL,SUP-2396188,CDM,C1768,CPT,0278,RC,,,,both,,,2172.88,1412.37,,,,,,,,,,,,,
HC G Tube Plcmt,PX-3614944000,CDM,49440,CPT,0361,RC,,,,both,,,17165.00,11157.25,,,,,,,,,,,,,
PLATE BNE L MINI 2X29 MM OBLQ ANGLED SS,SUP-2479038,CDM,C1713,HCPCS,0278,RC,,,,both,,,272.55,177.16,,,,,,,,,,,,,
STEM FEM L25MM OD12MM UNIV CSTI POR KNEE PRI CEM FLUT STR,SUP-2208273,CDM,C1776,CPT,0278,RC,,,,both,,,13621.32,8853.86,,,,,,,,,,,,,
BIT DRL L110MM DIA2.5MM 3 FLUT QUIK CPL NONRADIOPAQUE W/O,SUP-2187584,CDM,2720000010,LOCAL,0272,RC,,,,both,,,331.52,215.49,,,,,,,,,,,,,
BIT DRL L91MM DIA2MM STP 40MM AO QUIK CPL TWST,SUP-2267864,CDM,2720000010,LOCAL,0272,RC,,,,both,,,364.24,236.76,,,,,,,,,,,,,
GRAFT BNE SUB 30CC 4 10MM CORT CANC CHIP COARSE FRZN,SUP-2307430,CDM,C1713,HCPCS,0278,RC,,,,both,,,3824.87,2486.17,,,,,,,,,,,,,
HC Thromb Mech Vein Sub Day,PX-3613718800,CDM,37188,CPT,0361,RC,,,,both,,,15457.00,10047.05,,,,,,,,,,,,,
CUP HUM BEAR 3+ MM STD 40 MM COMPHSVE VIVACIT-E,SUP-2441526,CDM,C1776,CPT,0278,RC,,,,both,,,3730.32,2424.71,,,,,,,,,,,,,
GRAFT HUM TISS PTCH 10X1 CM TAPR BOV PERICARD PHOTOFIX LTX,SUP-2859713,CDM,C1768,CPT,0278,RC,,,,both,,,1004.80,653.12,,,,,,,,,,,,,
PAD ORTHOT LAT TROCHANTERIC CUST,SUP-2435592,CDM,L1290,HCPCS,0272,RC,,,,both,,,219.99,142.99,,,,,,,,,,,,,
SYSTEM SPINAL CORUS X,SUP-2859206,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3611.00,2347.15,,,,,,,,,,,,,
LIDOCAINE HCL (CARDIAC) PF 100 MG/5ML IV SOLN,RX-145135,CDM,J2003,HCPCS,0636,RC,63323-0208-05,NDC,,both,1,ML,54.10,35.16,,,,,,,,,,,,,
PIN INT FIX GRFT PASS,SUP-2212873,CDM,C1713,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
COMPONENT FEM SZ 10 PRI ECH,SUP-2345288,CDM,C1776,CPT,0278,RC,,,,both,,,14287.00,9286.55,,,,,,,,,,,,,
PLATE BNE PROF H 1.5 MM 8 H SCREW DIA2 MM TI MANDIBULAR STR,SUP-2883150,CDM,C1713,HCPCS,0278,RC,,,,both,,,916.03,595.42,,,,,,,,,,,,,
HC Fetal Eval 2-3 Trim Sgl Gest,PX-4027680500,CDM,76805,CPT,0402,RC,,,,inpatient,,,1288.00,837.20,,,,,,,,,,,,,
COMPONENT TOT SHLDR CAPPED REVERSED SHOULDERCAP79000] STRYKER CORP],SUP-2365913,CDM,C1776,CPT,0278,RC,,,,both,,,24806.00,16123.90,,,,,,,,,,,,,
HC Venography Svc,PX-3207582700,CDM,75827,CPT,0320,RC,,,,outpatient,,,3006.00,1953.90,,,,,,,,,,,,,
PLATE 4.5MM TI CURVED NARROW LCP PLATE 18 HOLE STERILE,SUP-2546929,CDM,C1713,HCPCS,0278,RC,,,,both,,,3497.18,2273.17,,,,,,,,,,,,,
IMPLANT CRAN THK 5 MM SZ 174 X 133 MM HDPE POROUS RT HMSPHR,SUP-2934326,CDM,C1713,HCPCS,0278,RC,,,,both,,,27252.06,17713.84,,,,,,,,,,,,,
TUBE ENDOTRACHEAL 7 MM EVOKE,SUP-2137892,CDM,2720000010,LOCAL,0272,RC,,,,both,,,847.80,551.07,,,,,,,,,,,,,
SADDLE CBL ORTH SHT AND TY HEX PERI-LOC,SUP-2351133,CDM,C1713,HCPCS,0278,RC,,,,both,,,1324.92,861.20,,,,,,,,,,,,,
DRILL SURG STR SELF CNTR FORTIFY I LF,SUP-2598889,CDM,2720000010,LOCAL,0272,RC,,,,both,,,907.46,589.85,,,,,,,,,,,,,
SEALANT HEMOSTATIC 10 CC GEL MTRX PTCH THROM CACL2 FLOSEAL,SUP-2129855,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1080.51,702.33,,,,,,,,,,,,,
BUR SURG DIAMOND 70 DEG 4 MM TAPR SUCTION IRRIGATING,SUP-2638218,CDM,2720000010,LOCAL,0272,RC,,,,both,,,669.39,435.10,,,,,,,,,,,,,
KNIFE SURG CLD STR DISP SACHSE,SUP-2717639,CDM,2720000010,LOCAL,0272,RC,,,,both,,,907.46,589.85,,,,,,,,,,,,,
CATHETER DIL PASSPRT L 150 CM DIA 3 FR BALLOON 4 CM DIA 4 MM,SUP-2139182,CDM,C1726,HCPCS,0272,RC,,,,both,,,849.68,552.29,,,,,,,,,,,,,
DRILL SURG 4/5 SLD DENS ACUTRK,SUP-2107226,CDM,2720000010,LOCAL,0272,RC,,,,both,,,395.64,257.17,,,,,,,,,,,,,
CATHETER DRAINAGE VENTRICULAR 10 FRX1.9 MMX35 CM CEREBROFLO,SUP-2427663,CDM,C1713,HCPCS,0278,RC,,,,both,,,2392.08,1554.85,,,,,,,,,,,,,
CATHETER DIAG 2.9X2.7FR L135CM DSTL L6CM ID0.027IN 0.018IN,SUP-2368151,CDM,C1887,HCPCS,0272,RC,,,,both,,,2833.85,1842.00,,,,,,,,,,,,,
INSULIN NPH (HUMAN) (ISOPHANE) 100 UNIT/ML SC SUSP,RX-10284,CDM,J1815,HCPCS,0637,RC,00002-8315-01,NDC,,both,10,ML,35.70,23.20,,,,,,,,,,,,,
KIT LD INTRO OPTISEAL L 25 CM OD 8 FR ID 0.112 IN GUIDEWIRE,SUP-2763416,CDM,C1894,HCPCS,0272,RC,,,,both,,,170.19,110.62,,,,,,,,,,,,,
SPACER SPNL W22XH10XL60MM 8DEG 4.2CC STD LAT LUM PEEK OPTMA,SUP-2137134,CDM,C1821,HCPCS,0278,RC,,,,both,,,10362.00,6735.30,,,,,,,,,,,,,
CATHETER INFUS 5FR 10CM INFUS LEN 90CM LEN - 5FR 10CM INFUS,SUP-2117006,CDM,C1751,HCPCS,0278,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
SPACER SPNL SM W8.5XH7MM D20MM 5DEG LORDOSIS POST RAMP,SUP-2279965,CDM,C1889,HCPCS,0278,RC,,,,both,,,7065.00,4592.25,,,,,,,,,,,,,
SCREW BNE L22MM DIA2.7MM FULL THRD STP FOR OLECRANON,SUP-2177107,CDM,C1713,HCPCS,0278,RC,,,,both,,,521.62,339.05,,,,,,,,,,,,,
CLAMP EXT FIX DIA8-8MM OPN ROD TO ROD FOR TRANSFX,SUP-2199163,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1195.71,777.21,,,,,,,,,,,,,
HC Adult Sleep Study (Polysomnogram),PX-9209581000,CDM,95810,CPT,0920,RC,,,,both,,,5628.00,3658.20,,,,,,,,,,,,,
PLATE BNE LCK 3.5 MM 5 HOLE COMPR STRL ALPS LTX,SUP-2861814,CDM,C1713,HCPCS,0278,RC,,,,both,,,815.02,529.76,,,,,,,,,,,,,
IMMOBILIZER ORTH CLOSED PAT UNIV AD 12 IN 24 IN CANVS,SUP-2194466,CDM,L1830,CPT,0274,RC,,,,both,,,59.66,38.78,,,,,,,,,,,,,
BRACE WALKING POSTOP XS PEDI PROCARE MAXTRAX,SUP-2195785,CDM,L4360,HCPCS,0272,RC,,,,both,,,84.00,54.60,,,,,,,,,,,,,
BRACE ORTHOPEDIC LSO BK POST OPERATIVE RIGID PANEL,SUP-2138675,CDM,L0630,HCPCS,0272,RC,,,,both,,,480.42,312.27,,,,,,,,,,,,,
BIT DRL L 296 MM DIA 3.2 MM THK 5 MM DSTL MEDL FEM NS REUSE,SUP-2902361,CDM,2720000010,LOCAL,0272,RC,,,,both,,,595.03,386.77,,,,,,,,,,,,,
INTRODUCER SHTH 0.018 IN 21 GAX7 CM TRANSCAROTID ACCS KT,SUP-2431177,CDM,C1894,HCPCS,0272,RC,,,,both,,,436.46,283.70,,,,,,,,,,,,,
CAGE SPNL W14XH9XL14MM PEEK ANTR CERV INTBDY FUS LORDTC,SUP-2415976,CDM,C1889,HCPCS,0278,RC,,,,both,,,5181.00,3367.65,,,,,,,,,,,,,
WIRE SURG L175MM DIA0.6MM S STL CERCLAGE PRECUT SMOOTH W/,SUP-2186849,CDM,C1713,HCPCS,0278,RC,,,,both,,,34.73,22.57,,,,,,,,,,,,,
IMMOBILIZER SHLDR E M RIB MEAS 44-48IN SZ XL,SUP-2196923,CDM,L3650,HCPCS,0272,RC,,,,both,,,17.43,11.33,,,,,,,,,,,,,
PIN EXTERNAL FIXATION HALF 5X25 MM ARROW STAINLESS STEEL NON,SUP-2836752,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1793.98,1166.09,,,,,,,,,,,,,
NAIL IM TROCH ENTRY 130 DEG 11 MMX40 CM LT FEM TI STRL,SUP-2412491,CDM,C1713,HCPCS,0278,RC,,,,both,,,6889.16,4477.95,,,,,,,,,,,,,
TUBING SET SUC IRR FOR ROSI SYS STRL LTX,SUP-2865324,CDM,2720000010,LOCAL,0272,RC,,,,both,,,461.58,300.03,,,,,,,,,,,,,
PLATE BNE L393MM 21 H ST PERIPROSTHETIC R DST FEM TI NCB,SUP-2411451,CDM,C1713,HCPCS,0278,RC,,,,both,,,5009.15,3255.95,,,,,,,,,,,,,
BIT DRL CANN LNG 2.3X120 MM AO,SUP-2321603,CDM,2720000010,LOCAL,0272,RC,,,,both,,,648.41,421.47,,,,,,,,,,,,,
STEM EXT 10X120MM,SUP-2221189,CDM,C1776,CPT,0278,RC,,,,both,,,2492.53,1620.14,,,,,,,,,,,,,
GUIDEWIRE URO STD COAT FIX COR STR FLX BENT TYP TIP,SUP-2141735,CDM,C1769,HCPCS,0272,RC,,,,both,,,91.81,59.68,,,,,,,,,,,,,
BAXTER BEVELED BOBBIN VT 097MM FLPL,SUP-2680302,CDM,L8699,HCPCS,0278,RC,,,,both,,,33.28,21.63,,,,,,,,,,,,,
PLATE DISPLAY PORTFOLIO,SUP-2550456,CDM,C1713,HCPCS,0278,RC,,,,both,,,181.40,117.91,,,,,,,,,,,,,
PLATE BNE L 100.33 X W 5.08 MM THK 0.6 MM SCREW DIA2 MM 16 H,SUP-2936893,CDM,C1713,HCPCS,0278,RC,,,,both,,,1482.08,963.35,,,,,,,,,,,,,
NAIL IM 130DEG 13X380MM RT STER,SUP-2137255,CDM,C1713,HCPCS,0278,RC,,,,both,,,6287.69,4087.00,,,,,,,,,,,,,
BLADE SURG OPHTH 20 GAX1.2 MM 23 MM MVR DISP,SUP-2458241,CDM,2720000010,LOCAL,0272,RC,,,,both,,,68.55,44.56,,,,,,,,,,,,,
WEDGE ACF ILIUM CREST TRADITION ALLGRFT 10 - 12 MM FRZ DRY,SUP-2294064,CDM,C1713,HCPCS,0278,RC,,,,both,,,2612.48,1698.11,,,,,,,,,,,,,
CATHETER ENDOSCP L135CM W7.5XL15.7MM DIA2.8MM FLX RFA,SUP-2172452,CDM,C1888,HCPCS,0272,RC,,,,both,,,6327.10,4112.61,,,,,,,,,,,,,
PLATE BNE L112MM 5 H R PROX LAT HUM S STL LOK FOR 4MM SCR,SUP-2372104,CDM,C1713,HCPCS,0278,RC,,,,both,,,4317.50,2806.37,,,,,,,,,,,,,
DRIVER POWER CANN 1.8MM,SUP-2489130,CDM,2720000010,LOCAL,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
PATCH CV HEMACAROTID L 120 X W 8 MM THK 0.41 MM POLYESTER,SUP-2525482,CDM,C1768,CPT,0278,RC,,,,both,,,827.11,537.62,,,,,,,,,,,,,
PROBE LITHO L330MM DIA3.8MM KID URETER BLDR ULTSOUND,SUP-2139434,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1725.62,1121.65,,,,,,,,,,,,,
ANCHOR SUT L14.7MM DIA5.5MM PEEK W/ 3 SZ 2 FIBERWIRE CRKSCR,SUP-2121566,CDM,C1713,HCPCS,0278,RC,,,,both,,,659.40,428.61,,,,,,,,,,,,,
INLAY SPNL LG 10 MM W/ TANTALUM MARKER POLYETH PRODISC,SUP-2163210,CDM,C1889,HCPCS,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
STENT COR DRUG ELUT RX PACLITAXEL S STL 2.25MM TAXUS EXPRESS,SUP-2139982,CDM,C1874,HCPCS,0278,RC,,,,both,,,5809.00,3775.85,,,,,,,,,,,,,
CATHETER THRMDIL 7.5FR L110CM PROXIMAL/DISTAL PRT L30CM STD,SUP-2214335,CDM,C1751,HCPCS,0278,RC,,,,both,,,596.60,387.79,,,,,,,,,,,,,
RELOAD FIX DEV ARTC 5 TACK STD PURCH FOR RELIATACK,SUP-2283331,CDM,2720000010,LOCAL,0272,RC,,,,both,,,459.48,298.66,,,,,,,,,,,,,
SCREW BNE L52MM DIA3.5MM CORT FULL FOR ANK FRAC LP PLT SYS,SUP-2398443,CDM,C1713,HCPCS,0278,RC,,,,both,,,75.36,48.98,,,,,,,,,,,,,
PLATE BNE LT 6 HOLE,SUP-2321648,CDM,C1713,HCPCS,0278,RC,,,,both,,,4341.05,2821.68,,,,,,,,,,,,,
PLATE BNE SM L79MM 12 H MED DST PERIARTC HUM,SUP-2410659,CDM,C1713,HCPCS,0278,RC,,,,both,,,1428.23,928.35,,,,,,,,,,,,,
VEST HOLSTER POCKET SM CTRL,SUP-2356012,CDM,Q0499,HCPCS,0274,RC,,,,both,,,1339.52,870.69,,,,,,,,,,,,,
IMPLANT BEDROCK GRANITE INFUSE,SUP-2858214,CDM,C1737,HCPCS,0278,RC,,,,both,,,10990.00,7143.50,,,,,,,,,,,,,
GENTAMICIN IN SALINE 1.2-0.9 MG/ML-% IV SOLN|DISCARDED DRUG NOT ADMINISTE,RX-15909,CDM,J1580,HCPCS,0636,RC,00338-0507-48,NDC,JW,both,100,ML,54.10,35.16,,,,,,,,,,,,,
SUPPORT ORTHOT CUST RNG MOL PLAS LTHR,SUP-2435582,CDM,L1110,HCPCS,0272,RC,,,,both,,,901.46,585.95,,,,,,,,,,,,,
PLATE BNE S 3 5 DEG 55 MM RT HALLU-LOCK,SUP-2609238,CDM,C1713,HCPCS,0278,RC,,,,both,,,5009.02,3255.86,,,,,,,,,,,,,
SPHINCTEROTOME ENDOSCP CUT WIRE 20MM TIP L5MM 4.4FR 0.035IN,SUP-2149568,CDM,2720000010,LOCAL,0272,RC,,,,both,,,673.75,437.94,,,,,,,,,,,,,
LINER ACET OD48MM ID28MM 0DEG NEUT HIP MARATHON PINN,SUP-2250339,CDM,C1776,CPT,0278,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
PLATE BNE STR MINI 2X1 MM 5 HOLE COMPR FOR SCR TI LEVEL 1,SUP-2500999,CDM,C1713,HCPCS,0278,RC,,,,both,,,847.55,550.91,,,,,,,,,,,,,
STRAIGHT PLATE VARIAX FIBULA 4 HOLE L60MM STERILE,SUP-2703555,CDM,C1713,HCPCS,0278,RC,,,,both,,,1836.27,1193.58,,,,,,,,,,,,,
ELECTRODE COAG PT 22FR,SUP-2261119,CDM,2720000010,LOCAL,0272,RC,,,,both,,,533.80,346.97,,,,,,,,,,,,,
GRAFT VASC DISTAFLO L 50 CM DIA 7 MM EPTFE CARBON PERIPH,SUP-2761420,CDM,C1768,CPT,0278,RC,,,,both,,,5014.30,3259.29,,,,,,,,,,,,,
CYSTOTOME ENDOSCP ELECTROCAUTERY L 185 CM DIA 8.5 FR ELECTRD,SUP-2900079,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
SAW SURG JOS 190 LT BAYNT SHP CRV,SUP-2649605,CDM,2720000010,LOCAL,0272,RC,,,,both,,,461.39,299.90,,,,,,,,,,,,,
PIN EXTERNAL FIXATION HALF XSHORT 5X40 MM TITANIUM NITRIDE S,SUP-2836780,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1157.40,752.31,,,,,,,,,,,,,
FLUTEMETAMOL F 18 4.05 MCI/ML IV SOLN,RX-130987,CDM,Q9982,HCPCS,0343,RC,17156-0067-30,NDC,,both,1,UN,3585.10,2330.31,,,,,,,,,,,,,
HEAD RADIAL 18 MM LT ANAT SOL STRL SLIDE-LOC,SUP-2657732,CDM,C1776,CPT,0278,RC,,,,both,,,9944.38,6463.85,,,,,,,,,,,,,
SHELL ACET SZ A DIA42MM 3 CLUS H TRITANIUM PRESSFIT PRI,SUP-2377890,CDM,C1776,CPT,0278,RC,,,,both,,,7156.69,4651.85,,,,,,,,,,,,,
PACK ARTHRO HIP DISP,SUP-2758960,CDM,2720000010,LOCAL,0272,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
PLATE BNE L103MM 8 H TI FIBULAR COMP LOK COMPR FOR,SUP-2413683,CDM,C1713,HCPCS,0278,RC,,,,both,,,804.09,522.66,,,,,,,,,,,,,
MESH CRAN DIA100MM THK0.4MM BLU TI MALL PLT CNTOUR LO PROF,SUP-2190697,CDM,C1713,HCPCS,0278,RC,,,,both,,,6249.23,4062.00,,,,,,,,,,,,,
CATHETER CV SINGLE LUMEN 5 FR FULL TY NURSING PER-Q-CATH,SUP-2126364,CDM,C1894,HCPCS,0272,RC,,,,both,,,411.34,267.37,,,,,,,,,,,,,
CATHETER HD SET 15 FRX27 CM DL RETROGRADE STP TIP NEXTSTEP,SUP-2762966,CDM,C1750,HCPCS,0278,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
PLATE PROX MEDIAL TIB 3.5 RT 3H,SUP-2854928,CDM,C1713,HCPCS,0278,RC,,,,both,,,6999.44,4549.64,,,,,,,,,,,,,
CHOLANGIOGRAM KIT RX AUTOTOME UTOM XL SPHINTOM JAGWIRE 7184,SUP-2499897,CDM,C1769,HCPCS,0272,RC,,,,both,,,905.58,588.63,,,,,,,,,,,,,
PLUG BNE VIT APCL ACET CUP,SUP-2376078,CDM,C1713,HCPCS,0278,RC,,,,both,,,314.63,204.51,,,,,,,,,,,,,
BIT DRL CANN 2.5 MM FOR FRDM WRST ARTHROPLAST,SUP-2852121,CDM,2720000010,LOCAL,0272,RC,,,,both,,,863.97,561.58,,,,,,,,,,,,,
SHEATH ENDOSCP 3.5 MMX20 CM OUTER INSUL FOR CLN 31100,SUP-2768531,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1181.58,768.03,,,,,,,,,,,,,
CATHETER ABLAT 7FR L110CM TIP L8MM 2.5MM SPC QPLR L CRV,SUP-2141344,CDM,C1732,HCPCS,0272,RC,,,,both,,,7536.00,4898.40,,,,,,,,,,,,,
STEM FEM MOD 12/14 TAPR NK 35MM 8 CERASIV,SUP-2216774,CDM,C1776,CPT,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
EPHEDRINE SULFATE (PRESSORS) 50 MG/ML IV SOLN,RX-134058,CDM,2500000003,HCPCS,0250,RC,43598-0725-25,NDC,,both,0.1,ML,54.10,35.16,,,,,,,,,,,,,
CATHETER VENTRICULAR 120 CM DSTL BA STRP CLR,SUP-2666785,CDM,C1729,HCPCS,0272,RC,,,,both,,,760.76,494.49,,,,,,,,,,,,,
SHELL ACET 64 MM HIP 3 HOLE HA REFLECTION INTERFIT,SUP-2434632,CDM,C1776,CPT,0278,RC,,,,both,,,6663.08,4331.00,,,,,,,,,,,,,
REAMER SURG OD14.5MM PAT INTERCHANGEABLE HD W/ PILOT NOSE,SUP-2343591,CDM,2720000010,LOCAL,0272,RC,,,,both,,,835.24,542.91,,,,,,,,,,,,,
URETEROSCOPE FLX DIGITAL AXIS DISP,SUP-2432369,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2471.18,1606.27,,,,,,,,,,,,,
RESECTOR PHLEBECTOMY DEV DIA 4.5 MM DISP PHASTIPP,SUP-2908876,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5020.86,3263.56,,,,,,,,,,,,,
ALLOGRAFT HUM TISS RT WHL BONE-PATELLAR TENDON-BONE,SUP-2867063,CDM,C1762,CPT,0278,RC,,,,both,,,10309.25,6701.01,,,,,,,,,,,,,
KIT INFUS PMP 270ML 2M/HR SOAK CATH L5IN N NARC ON-Q,SUP-2420884,CDM,C9804,HCPCS,0272,RC,,,,both,,,373.66,242.88,,,,,,,,,,,,,
SCREW BNE L30MM DIA35MM S STL LOK SURFIX,SUP-2243400,CDM,C1713,HCPCS,0278,RC,,,,both,,,1128.92,733.80,,,,,,,,,,,,,
PLATE BNE REARFOOT INTERPOSITION W O STEM,SUP-2243221,CDM,C1713,HCPCS,0278,RC,,,,both,,,4223.05,2744.98,,,,,,,,,,,,,
MICROSPHERE EMB CNTOUR SE DIA100-300 UN 20 ML PVA STRL,SUP-2140324,CDM,C1889,HCPCS,0278,RC,,,,both,,,825.41,536.52,,,,,,,,,,,,,
GUIDEWIRE VASC BENT L 180 CM DIA 0.018 IN TAPR L 16 CM FLPY,SUP-2167993,CDM,C1769,HCPCS,0272,RC,,,,both,,,41.73,27.12,,,,,,,,,,,,,
ALLOGRAFT BNE SPACER 12.5X15X11 MM FD PARL ADV ACF,SUP-2736838,CDM,C1713,HCPCS,0278,RC,,,,both,,,4414.31,2869.30,,,,,,,,,,,,,
GRAFT BNE SUB 3CC FILL CALLOS INJ,SUP-2106907,CDM,C1713,HCPCS,0278,RC,,,,both,,,3548.20,2306.33,,,,,,,,,,,,,
SPACER SPNL L20XW9XH7MM 4DEG PEEK POST THORLUM INTBDY FUS,SUP-2380559,CDM,C1713,HCPCS,0278,RC,,,,both,,,7614.50,4949.42,,,,,,,,,,,,,
PLATE CRAN 60X20X40 MM PT SPEC IMPL PEEK,SUP-2860114,CDM,C1713,HCPCS,0278,RC,,,,both,,,24487.92,15917.15,,,,,,,,,,,,,
DEFIBRILLATOR CRD BPLR 12.9 MM 33 CC 70 GM ATR EPIC DR V235SYS] ST JUDE MED CARDIAC RHYM MGMT],SUP-2356541,CDM,C1721,HCPCS,0275,RC,,,,both,,,74575.00,48473.75,,,,,,,,,,,,,
GRAFT HUM TISS REGENERATIVE THCK 5X7 CM  GRAFTJACKET NOW,SUP-2858158,CDM,Q4107,HCPCS,0636,RC,,,,both,,,31396.86,20407.96,,,,,,,,,,,,,
GASTROSCOPE FLEXIBLE ASCOPE  210DEG AUXILIARY,SUP-2844707,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
TUBE TYMPANOSTOMY DIA1.14 MM INNR FLANGE DIA 3.5 MM MICROGEL,SUP-2902004,CDM,L8699,HCPCS,0278,RC,,,,both,,,82.08,53.35,,,,,,,,,,,,,
BIT DRL 2.7X127 MM KT DRL STP 3MM ALLEN WRNCH DYN WRST FIX,SUP-2644600,CDM,2720000010,LOCAL,0272,RC,,,,both,,,417.12,271.13,,,,,,,,,,,,,
SPLINT FNGR SZ 2 OPN TIP FOR FNGRTIP NAILBED INJ STAX,SUP-2195098,CDM,L3933,HCPCS,0272,RC,,,,both,,,7.03,4.57,,,,,,,,,,,,,
PLATE BNE SCREW DIA2.6 MM MED TI CRANIOMAXILLOFACIAL DBL,SUP-2937052,CDM,C1713,HCPCS,0278,RC,,,,both,,,9316.38,6055.65,,,,,,,,,,,,,
GUIDEWIRE VASC NITINOL HYDROPHIL STR 3 CM 0.035 INX150 CM STD NIT ZIPWIRE,SUP-2139333,CDM,C1769,HCPCS,0272,RC,,,,both,,,168.56,109.56,,,,,,,,,,,,,
PLATE BNE L71MM THK13MM 12 H NONSTERILE HND TI STR LOK VAR,SUP-2181037,CDM,C1713,HCPCS,0278,RC,,,,both,,,1809.61,1176.25,,,,,,,,,,,,,
SYSTEM SPNL TETHERING DISPOSABLE TRANSLACE,SUP-2417657,CDM,C1713,HCPCS,0278,RC,,,,both,,,1802.36,1171.53,,,,,,,,,,,,,
SIZER SURG GEL 5.3 CM PROJCT 10.5X10.9 CM 290 CC MEMORYSHAPE,SUP-2758644,CDM,2720000010,LOCAL,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
ROD SPNL L480MM DIA5.5MM RT POST S STL SMOOTH STR PRE CUT,SUP-2256373,CDM,C1713,HCPCS,0278,RC,,,,both,,,2340.87,1521.57,,,,,,,,,,,,,
HC ED Avulsion Nail Plate Single,PX-4501173000,CDM,11730,CPT,0450,RC,,,,both,,,632.00,410.80,,,,,,,,,,,,,
TAP SURG 4.5 MM OCPTL VERTEX SEL,SUP-2432048,CDM,2720000010,LOCAL,0272,RC,,,,both,,,370.46,240.80,,,,,,,,,,,,,
MESH 16X12 R ANAT,SUP-2172955,CDM,C1781,HCPCS,0278,RC,,,,both,,,1490.50,968.82,,,,,,,,,,,,,
SCREW BNE LCK 5X18 MM PERIPROSTHETIC ST OPTILINK NS VALCP,SUP-2789486,CDM,C1713,HCPCS,0278,RC,,,,both,,,590.32,383.71,,,,,,,,,,,,,
PROGUIDE CHRNC DLSS CATH HOLES 2 24CM TIP HUB 2 28CM TIP HUB,SUP-2676388,CDM,C1894,HCPCS,0272,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
PLATE BONE L115MM 5 H RT PROX HUM LCK FOR 3.5MM SCR PERI-LOC,SUP-2348552,CDM,C1713,HCPCS,0278,RC,,,,both,,,13036.02,8473.41,,,,,,,,,,,,,
NEEDLE ENDOSCP LARYNGEAL 23 CM CRV RT KLEINSASSER F8597 HNDL,SUP-2775006,CDM,2720000010,LOCAL,0272,RC,,,,both,,,677.93,440.65,,,,,,,,,,,,,
GRAFT SPNL SPCR W14.5XH8XL12MM 7DEG CERV LORDOSIS FRZ DRY,SUP-2264910,CDM,C1713,HCPCS,0278,RC,,,,both,,,2919.89,1897.93,,,,,,,,,,,,,
KIT INSTR DRL STRL DISP MINIBUNION,SUP-2893454,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
CATHETER BAL DBL LUMN,SUP-2169611,CDM,C1726,HCPCS,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
BLADE SAW COARSE TOOTH MIC 55X27X0.4 MM SAG,SUP-2607441,CDM,2720000010,LOCAL,0272,RC,,,,both,,,197.82,128.58,,,,,,,,,,,,,
DAPTOMYCIN 500 MG IV SOLR,RX-36989,CDM,J0878,HCPCS,0636,RC,71288-0016-15,NDC,,both,1,UN,88.50,57.52,,,,,,,,,,,,,
BLADE SHAVER BPLR 4 MM CONVX FOR DIEGO ELITE TURB,SUP-2648962,CDM,2720000010,LOCAL,0272,RC,,,,both,,,555.91,361.34,,,,,,,,,,,,,
SHELL ACET SZ F DIA56MM LNR POR REFLCT I,SUP-2350897,CDM,C1776,CPT,0278,RC,,,,both,,,6563.86,4266.51,,,,,,,,,,,,,
PLATE BONE LOW PROFILE 17 MM PRECONTOURED FOR SHUNT TITANIUM,SUP-2842240,CDM,C1713,HCPCS,0278,RC,,,,both,,,860.99,559.64,,,,,,,,,,,,,
CATHETER EP MED SWP 4 MM 2-5-2 MM 7 FRX115 CM,SUP-2356860,CDM,C1730,HCPCS,0272,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
NAIL IM CORTICAL 4X20 MM HUM STRL AFFIXUS NAT NAIL,SUP-2606859,CDM,C1713,HCPCS,0278,RC,,,,both,,,599.74,389.83,,,,,,,,,,,,,
SAW HAND JSPH 6 7/8NL 38MML BLADE STRGHT W/THMB REST PDGTT N,SUP-2492156,CDM,2720000010,LOCAL,0272,RC,,,,both,,,394.45,256.39,,,,,,,,,,,,,
STEM HUM L115MM OD9MM UNIV CO CHROM SHLDR MOD PRI BODY CEM,SUP-2376484,CDM,C1776,CPT,0278,RC,,,,both,,,8671.58,5636.53,,,,,,,,,,,,,
PLATE LOQTEQ VA VOLAR DISTAL RADIUS 2.5 NARROW XL L,SUP-2713861,CDM,C1713,HCPCS,0278,RC,,,,both,,,8138.88,5290.27,,,,,,,,,,,,,
CONNECTOR SPINE SPNL SYS TI TSRH 3D ROD 635MM M,SUP-2290000,CDM,C1713,HCPCS,0278,RC,,,,both,,,4107.12,2669.63,,,,,,,,,,,,,
BLOOD PUMP KIT CANN 31 FRX28 CM 18 FRX51 CM OXGNTR LIFESPARC,SUP-2570701,CDM,C1889,HCPCS,0278,RC,,,,both,,,75360.00,48984.00,,,,,,,,,,,,,
ANCHOR SUTURE 25 DEG LT TIGHT CRV QUICKPASS LASSO,SUP-2121951,CDM,C1713,HCPCS,0278,RC,,,,both,,,533.80,346.97,,,,,,,,,,,,,
SPLINT RST PAN MIT SP S RT,SUP-2163831,CDM,L3807,HCPCS,0274,RC,,,,both,,,81.29,52.84,,,,,,,,,,,,,
PLATE BNE W10.2XL208MM THK2.7MM 16 H BILAT S STL STR LO,SUP-2186203,CDM,C1713,HCPCS,0278,RC,,,,both,,,1932.86,1256.36,,,,,,,,,,,,,
PLATE SPNL W16XL106MM STD 2.5 H XLNK POST LUM S STL FIX CONN,SUP-2255574,CDM,C1713,HCPCS,0278,RC,,,,both,,,5044.41,3278.87,,,,,,,,,,,,,
GRAFT VASC VENAFLO II L 50 CM DIA 6 MM EPTFE CARBON STR N,SUP-2127058,CDM,C1768,CPT,0278,RC,,,,both,,,2540.26,1651.17,,,,,,,,,,,,,
GRAFT VASC W5XL6CM EPTFE PTCH DURA SUB NONBIOLOGICAL PRECL,SUP-2395355,CDM,C1713,HCPCS,0278,RC,,,,both,,,1403.58,912.33,,,,,,,,,,,,,
STEM RADIAL BPLR 7.5 MM ELBW ASMBLY SHFT KATALYST,SUP-2610315,CDM,C1776,CPT,0278,RC,,,,both,,,9237.00,6004.05,,,,,,,,,,,,,
PLATE BNE L 14.86 X W 9.35 MM THK 0.6 MM SCREW DIA1.5 MM 6 H,SUP-2936944,CDM,C1713,HCPCS,0278,RC,,,,both,,,756.74,491.88,,,,,,,,,,,,,
COLLAR CERV ADJ MED 20X3 IN COTTON FOAM PREMIERPRO REUSE,SUP-2424885,CDM,L0120,HCPCS,0274,RC,,,,both,,,12.78,8.31,,,,,,,,,,,,,
GRAFT PERICARD PROC TUTOPLAST 6X6CM,SUP-2165388,CDM,C1762,CPT,0278,RC,,,,both,,,8449.74,5492.33,,,,,,,,,,,,,
METAL CANNULA 5.0MM,SUP-2812609,CDM,2720000010,LOCAL,0272,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
HC CT Upper Extremity W/ Contrast,PX-3527320100,CDM,73201,CPT,0352,RC,,,,both,,,4472.00,2906.80,,,,,,,,,,,,,
DEVICE FIX 5.5X20MM XTENDOBUTTON,SUP-2341700,CDM,C1776,CPT,0278,RC,,,,both,,,511.82,332.68,,,,,,,,,,,,,
GRAFT BNE SUB COMPRESSIBLE SPNG SM TALL GROWTH FACT OSTEOAMP,SUP-2138506,CDM,C1713,HCPCS,0278,RC,,,,both,,,3406.90,2214.48,,,,,,,,,,,,,
HC Compatibility Test Electric,PX-3008692300,CDM,86923,CPT,0300,RC,,,,both,,,172.00,111.80,,,,,,,,,,,,,
PLATE 4.5MM TI LCP MEDIAL PROXIMAL TIBIA 6H LT 142MM STER,SUP-2549607,CDM,C1713,HCPCS,0278,RC,,,,both,,,3470.52,2255.84,,,,,,,,,,,,,
SCREW BNE 45X66MM LO PROF CORT TI ALLY CORT,SUP-2166944,CDM,C1713,HCPCS,0278,RC,,,,both,,,302.66,196.73,,,,,,,,,,,,,
ALLOPURINOL 100 MG PO TABS,RX-310,CDM,6370000000,HCPCS,0637,RC,00904-7041-61,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
NUT ORTH CO CHROM MOLYBDENUM ALLOY AUX MINI COMPR,SUP-2406902,CDM,C1713,HCPCS,0278,RC,,,,both,,,819.54,532.70,,,,,,,,,,,,,
SPLINT REST HND ADL L S DRBLUE BROAD,SUP-2165486,CDM,L3807,HCPCS,0272,RC,,,,both,,,140.26,91.17,,,,,,,,,,,,,
SCREW CANN COMPR HDLSS 2 THRD TI 3.0MMX20MM,SUP-2392761,CDM,C1713,HCPCS,0278,RC,,,,both,,,782.65,508.72,,,,,,,,,,,,,
SHEATH INTRO FAST-CATH L 30 CM DIA12 FR GUIDEWIRE 0.038 IN,SUP-2355550,CDM,C1894,HCPCS,0272,RC,,,,both,,,60.45,39.29,,,,,,,,,,,,,
APPLIER CLP LG 10 MMX34 CM MANUAL LOAD HEM-O-LOK ENDO10,SUP-2656818,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3595.30,2336.94,,,,,,,,,,,,,
TM FEM DIAPHYSEAL CONE 30 LARGE RIGHT,SUP-2502263,CDM,C1776,CPT,0278,RC,,,,both,,,10605.04,6893.28,,,,,,,,,,,,,
CATHETER PTCA BLLN DIL COR SNUS LV LD PLCMNT ATTAIN PERIPH,SUP-2282150,CDM,C1887,HCPCS,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
SUPPORT ORTHOT HEEL METATRSL CUST LIFT ELEVATION PER INCH,SUP-2435716,CDM,L3300,HCPCS,0272,RC,,,,both,,,147.64,95.97,,,,,,,,,,,,,
ANCHOR SUTURE DIA 4.75 MM REGENESORB OPN ARCHITECTURE DESIGN,SUP-2882958,CDM,C1713,HCPCS,0278,RC,,,,both,,,1805.50,1173.57,,,,,,,,,,,,,
STAPLER INT 5MM POLY COPOLYMER TACK FIX DEV PNT AND SHOOT,SUP-2283222,CDM,2720000010,LOCAL,0272,RC,,,,both,,,935.56,608.11,,,,,,,,,,,,,
SHEATH INTRO SUPER SHTH L 11 CM DIA 6 FR GUIDEWIRE 0.035 IN,SUP-2147280,CDM,C1894,HCPCS,0272,RC,,,,both,,,30.46,19.80,,,,,,,,,,,,,
OVERTUBE ENDOSCP L25CM OD19.5MM ID16.7MM SCP DIA8.6-10MM,SUP-2360645,CDM,2720000010,LOCAL,0272,RC,,,,both,,,528.09,343.26,,,,,,,,,,,,,
ALLOGRAFT BNE GRND 15 CC FD IRRADIATED CORTICAL CANC,SUP-2867209,CDM,C1762,CPT,0278,RC,,,,both,,,751.72,488.62,,,,,,,,,,,,,
ROD EXT FIX L350MM S STL THRD TELSCP ORIG CIR FOR TAY SPAT,SUP-2342307,CDM,2720000010,LOCAL,0272,RC,,,,both,,,456.87,296.97,,,,,,,,,,,,,
GRAFT VASC RESTOREFLOW SZ 19-24 MM PA COMPETENT VLV STRL,SUP-2884023,CDM,C1768,CPT,0278,RC,,,,both,,,47881.86,31123.21,,,,,,,,,,,,,
HC Biopsy of Salivary Gland,PX-3614240000,CDM,42400,CPT,0361,RC,,,,outpatient,,,3707.00,2409.55,,,,,,,,,,,,,
SHEATH INTRO 9FR L10CM DIL PROTRUDING L2.5CM 0.038IN GWIRE,SUP-2385201,CDM,C1894,HCPCS,0272,RC,,,,both,,,189.34,123.07,,,,,,,,,,,,,
BRACE WR THMB LT MCP CMC JT ELAS SUPP NEOPRNE WRP AD 1 SZ,SUP-2309135,CDM,L3908,HCPCS,0274,RC,,,,both,,,81.33,52.86,,,,,,,,,,,,,
PLATE BONE L125MM 9 H STRL LT LAT DSTL FIBULAR S STL FOR,SUP-2349758,CDM,C1713,HCPCS,0278,RC,,,,both,,,5330.15,3464.60,,,,,,,,,,,,,
COMPONENT ARTC SURF TIB 5-6 EF 20 MM KNEE GRN NXGN LPS,SUP-2208736,CDM,C1776,CPT,0278,RC,,,,both,,,3679.45,2391.64,,,,,,,,,,,,,
PLATE BNE LCK 34 MM LT RADIAL PERIARTICULAR 3 HOLE STYLOID,SUP-2461202,CDM,C1713,HCPCS,0278,RC,,,,both,,,1465.09,952.31,,,,,,,,,,,,,
SET URET STENT KWART RETRO INJ SOFFLX L 22-32 CM DIA 4.7 FR,SUP-2168903,CDM,C2617,HCPCS,0278,RC,,,,both,,,396.39,257.65,,,,,,,,,,,,,
BLADE RETRACTOR ANKENEY AD 1-3/8X2 IN STRNL SUTURE HOLDING,SUP-2485540,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3237.91,2104.64,,,,,,,,,,,,,
KIT SPNL DISP MAXCESS,SUP-2310426,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3758.58,2443.08,,,,,,,,,,,,,
GRAFT BNE W10XL250MM THK3 12MM CORT FEM FRZN HALVED STRUT 2,SUP-2307352,CDM,C1713,HCPCS,0278,RC,,,,both,,,3837.52,2494.39,,,,,,,,,,,,,
ERYTHROMYCIN 5 MG/GM OP OINT,RX-2888,CDM,6370000000,HCPCS,0637,RC,72485-0670-31,NDC,,both,1,GR,35.70,23.20,,,,,,,,,,,,,
PLATE BONE L W13.5XL116MM THK4.2MM 6 H BILAT TI STR RIG,SUP-2190811,CDM,C1713,HCPCS,0278,RC,,,,both,,,611.92,397.75,,,,,,,,,,,,,
DESMOPRESSIN ACETATE SPRAY 0.01 % NA SOLN,RX-21135,CDM,6370000000,HCPCS,0637,RC,60505-0815-00,NDC,,both,5,ML,554.10,360.16,,,,,,,,,,,,,
LIFT HEEL MED ADJLFT,SUP-2394117,CDM,L3334,HCPCS,0272,RC,,,,both,,,38.31,24.90,,,,,,,,,,,,,
COIL VASC AZUR HYDROCOIL L 2 CM DIA 2MM 0.018IN PLAT HYDRGEL,SUP-2384875,CDM,C1889,HCPCS,0278,RC,,,,both,,,2661.15,1729.75,,,,,,,,,,,,,
SHELL ACET DIA60MM LNR SZ DMI BRN VERSAFITCUP DM,SUP-2267333,CDM,C1776,CPT,0278,RC,,,,both,,,4662.90,3030.88,,,,,,,,,,,,,
GRAFT HUM TISS W20XL15MM THK10MM FRZ DRY ALLGRFT BLK CANC,SUP-2307118,CDM,C1713,HCPCS,0278,RC,,,,both,,,2453.16,1594.55,,,,,,,,,,,,,
CRVD INSERT KIT 2.0MM S-TAK 1.7,SUP-2812339,CDM,2720000010,LOCAL,0272,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
SLEEVE COMPR SCR FIX DRL FRAG LOC,SUP-2106752,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1359.62,883.75,,,,,,,,,,,,,
SYSTEM FIX 30 ABSRB FAST OPTIFIX,SUP-2125764,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1224.60,795.99,,,,,,,,,,,,,
SYSTEM OCCL DEL L60CM CATHETER 160CM SHTH 4FR 90DEG CRV CBL,SUP-2357479,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2524.31,1640.80,,,,,,,,,,,,,
DEFIBRILLATOR CRD 5.37X7.36X0.99 CM DF4 CONN RESONATE EL VR,SUP-2424813,CDM,C1722,HCPCS,0275,RC,,,,both,,,43768.46,28449.50,,,,,,,,,,,,,
SCREW BNE L18MM DIA2.3MM CORT CRANIOMAXILLOFACIAL G TI ST 5PK,SUP-2366159,CDM,C1713,HCPCS,0278,RC,,,,both,,,200.77,130.50,,,,,,,,,,,,,
TRAY CATH MIDLN POWERGLIDE PRO MAXBARR 20GA 8CM WNG 1 LUMAN,SUP-2613478,CDM,C1751,HCPCS,0278,RC,,,,both,,,442.74,287.78,,,,,,,,,,,,,
SCREW BONE L14MM THRD DIA2.7MM HD DIA4.3MM COR DIA2MM PITCH,SUP-2349442,CDM,C1713,HCPCS,0278,RC,,,,both,,,443.49,288.27,,,,,,,,,,,,,
ALLOGRAFT BNE 10CC MTRX VIABLE BIO4,SUP-2370454,CDM,C1713,HCPCS,0278,RC,,,,both,,,12151.80,7898.67,,,,,,,,,,,,,
PIN FEM 2 LT RESURF KT GRDIAN,SUP-2304395,CDM,C1713,HCPCS,0278,RC,,,,both,,,5463.60,3551.34,,,,,,,,,,,,,
PLATE BNE CRV 4.5X159 MM LT CNDYL 6 HOLE VA LCK STRL VALCP,SUP-2789398,CDM,C1713,HCPCS,0278,RC,,,,both,,,5980.41,3887.27,,,,,,,,,,,,,
WIRE FIX TROCAR PT 1 END 1.4X18 MM THRD KIRSCHNER 108319418,SUP-2740220,CDM,2720000010,LOCAL,0272,RC,,,,both,,,486.70,316.35,,,,,,,,,,,,,
PROBE ARTHSCP OD3MM GRN MALL SHFT RF LIGMNT CHSL EFLEX,SUP-2341621,CDM,C1713,HCPCS,0278,RC,,,,both,,,1566.86,1018.46,,,,,,,,,,,,,
ALLOGRAFT BNE CHIP 30 CC CANC PUROS,SUP-2687382,CDM,C1713,HCPCS,0278,RC,,,,both,,,2700.40,1755.26,,,,,,,,,,,,,
ROD SPNL TOP LD 5.5X24 MM,SUP-2414400,CDM,C1713,HCPCS,0278,RC,,,,both,,,4851.30,3153.34,,,,,,,,,,,,,
STENT URET INLAY OPTMA L 30 CM DIA 6 FR POLYMER BLEND,SUP-2126659,CDM,C2617,HCPCS,0278,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
GUIDEPIN ORTH EXT CUT DISP FOR 2 PLATFRM SHLDR ARTHROPLASTY,SUP-2224556,CDM,C1713,HCPCS,0278,RC,,,,both,,,398.47,259.01,,,,,,,,,,,,,
HC So1 Islet Cell Antibody,PX-3028634167,CDM,86341,CPT,0302,RC,,,,both,,,187.00,121.55,,,,,,,,,,,,,
OCTREOTIDE ACETATE 20 MG IM KIT,RX-24435,CDM,J2353,HCPCS,0636,RC,00078-0818-81,NDC,,both,1,UN,13295.00,8641.75,,,,,,,,,,,,,
SCREW BNE 5X44 MM,SUP-2205580,CDM,C1713,HCPCS,0278,RC,,,,both,,,472.26,306.97,,,,,,,,,,,,,
BOLT FIX L125MM DIA65MM MIDFOOT S STL LOK CANN SHT THRD,SUP-2177275,CDM,C1713,HCPCS,0278,RC,,,,both,,,1681.25,1092.81,,,,,,,,,,,,,
STEM FEM REV 0+ MM SHT 17 MM HIP POLISHED EMPERION,SUP-2434539,CDM,C1776,CPT,0278,RC,,,,both,,,12490.92,8119.10,,,,,,,,,,,,,
INSERT TIB SZ 5 THICKNESS 12MM CO CHROM UHMWPE KNEE PRI POST,SUP-2365100,CDM,C1776,CPT,0278,RC,,,,both,,,2121.86,1379.21,,,,,,,,,,,,,
SCREW BNE L30MM DIA4.5MM LNG THRD L12MM S STL SELF DRL CANN,SUP-2185056,CDM,C1713,HCPCS,0278,RC,,,,both,,,861.58,560.03,,,,,,,,,,,,,
CATHETER GUID R2P SLENGUIDE L 120 CM COAT L 300 MM OD 7 FR,SUP-2761864,CDM,C1887,HCPCS,0272,RC,,,,both,,,1003.23,652.10,,,,,,,,,,,,,
ALLOGRAFT BNE PTTY 100 MM 10 CC DBM VESUVIUS,SUP-2717999,CDM,C1713,HCPCS,0278,RC,,,,both,,,2521.42,1638.92,,,,,,,,,,,,,
DEFIBRILLATOR CRD SINGLE CHMBR 13 MM 33 CC 71 GM EPIC II VR V158SYS] ST JUDE MED CARDIAC RHYM MGMT],SUP-2356514,CDM,C1722,HCPCS,0275,RC,,,,both,,,46220.80,30043.52,,,,,,,,,,,,,
SCREW BNE SZ 4/3.7 MM TAPR,SUP-2896673,CDM,C1713,HCPCS,0278,RC,,,,both,,,2037.86,1324.61,,,,,,,,,,,,,
HEAD RADIAL DIA20 MM MED COCR LATITUDE EV,SUP-2902144,CDM,C1776,CPT,0278,RC,,,,both,,,7386.38,4801.15,,,,,,,,,,,,,
FOOTPLATE EXT FIX L 180 MM LNG GRN NS DISP SPAT FRME TSF,SUP-2933241,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4914.10,3194.16,,,,,,,,,,,,,
NAIL IM L24CM OD9MM 20DEG HUM CANN LCK RUSS TAY,SUP-2342553,CDM,C1713,HCPCS,0278,RC,,,,both,,,8339.84,5420.90,,,,,,,,,,,,,
BLADE SHV DIA4MM 60DEG CRV SERR DISECT CONCAVE WIND FOR,SUP-2313829,CDM,2720000010,LOCAL,0272,RC,,,,both,,,377.90,245.63,,,,,,,,,,,,,
GRAFT HUM TISS SPACER 22X8X13/10.6 MM FRZN POST LUMBAR,SUP-2306881,CDM,C1713,HCPCS,0278,RC,,,,both,,,8193.92,5326.05,,,,,,,,,,,,,
PLATE BNE DBL Y 1.5X0.6 MM MIDFACE 6 HOLE W/ TAB TI STRL,SUP-2489704,CDM,C1713,HCPCS,0278,RC,,,,both,,,840.26,546.17,,,,,,,,,,,,,
PLATE BONE THK2MM 14 H CP TI LCK STRNL MANUBRIUM,SUP-2262565,CDM,C1713,HCPCS,0278,RC,,,,both,,,1792.94,1165.41,,,,,,,,,,,,,
GUIDEWIRE VASC 3 CM 014X190 CORONARY HI TORQ BAL HVYWT,SUP-2101875,CDM,C1769,HCPCS,0272,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
GRAFT TEND SEMI TENDOSIS ALLGRFT FRZ DRY 26CM L,SUP-2307098,CDM,C1762,CPT,0278,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
BUR SURG DIAMOND 6 MM 10 CM BALL SM BOR MIDAS REX 8 LEGEND,SUP-2664503,CDM,2720000010,LOCAL,0272,RC,,,,both,,,395.64,257.17,,,,,,,,,,,,,
PLATE BONE L265MM 14 H S STL LCK COMPR FOR 4.5MM SCR,SUP-2348945,CDM,C1713,HCPCS,0278,RC,,,,both,,,7233.78,4701.96,,,,,,,,,,,,,
PLATE BNE LEFORT 2X7 MM RT LINDORF TI,SUP-2466454,CDM,C1713,HCPCS,0278,RC,,,,both,,,867.68,563.99,,,,,,,,,,,,,
SHEATH INTRO DIA 4 FR GUIDEWIRE L 40 CM DIA 0.018 IN NDL L 7,SUP-2120521,CDM,C1894,HCPCS,0272,RC,,,,both,,,74.39,48.35,,,,,,,,,,,,,
DILATOR RENAL AMPLATZ TYP 20 FR X 35CM,SUP-2139233,CDM,C1726,HCPCS,0272,RC,,,,both,,,145.98,94.89,,,,,,,,,,,,,
COMPONENT PART KNEE CAPPED K1ZIMMER] ZIMMER BIOMET INC],SUP-2212585,CDM,C1776,CPT,0278,RC,,,,both,,,11618.00,7551.70,,,,,,,,,,,,,
PIN EXT FIX L60MM OD20MM RX FIX MINIRAIL,SUP-2396845,CDM,C1713,HCPCS,0278,RC,,,,both,,,530.66,344.93,,,,,,,,,,,,,
TRAY KYPHOPLASTY SZ 3 BLLN L20MM IBT ADD FRAC KYPHON,SUP-2293663,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6437.00,4184.05,,,,,,,,,,,,,
MESH SYNTH ABD N ABSRB RECT POLYPR OBLONG OVL 12CM LEN 8CM,SUP-2265963,CDM,C1781,HCPCS,0278,RC,,,,both,,,1102.14,716.39,,,,,,,,,,,,,
HANDPIECE SURG PWR MINIMALLY INVASIVE HNDPC AO CONN STRL LF,SUP-2881083,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3384.92,2200.20,,,,,,,,,,,,,
PLATE BNE L208MM 14 H NONSTERILE R POSTEROLAT DST HUM S STL,SUP-2185918,CDM,C1713,HCPCS,0278,RC,,,,both,,,3298.85,2144.25,,,,,,,,,,,,,
HC External Ecg Rec>7d<15d Recording,PX-7309324600,CDM,93246,CPT,0731,RC,,,,both,,,381.00,247.65,,,,,,,,,,,,,
PLATE BONE METACARPAL MINI 2.7X60X8X2.5 MM METATARSAL PHALAN,SUP-2836996,CDM,C1713,HCPCS,0278,RC,,,,both,,,1519.85,987.90,,,,,,,,,,,,,
PLATE BNE L76MM 4 H R PROX TIB S STL LO BEND LOK COMPR NEUT,SUP-2184301,CDM,C1713,HCPCS,0278,RC,,,,both,,,3790.23,2463.65,,,,,,,,,,,,,
NUT DISTR TTNM MXLFCL LOK FRGD EXTRNL DISTR DVCE RED II 51,SUP-2679225,CDM,C1713,HCPCS,0278,RC,,,,both,,,452.16,293.90,,,,,,,,,,,,,
PLATE BONE REG THK0.6MM 2X2 H MIDFACE SLV TI RT L SHP FOR,SUP-2135911,CDM,C1713,HCPCS,0278,RC,,,,both,,,477.28,310.23,,,,,,,,,,,,,
PLATE BNE L 20 MM SCREW DIA2 MM LG CP TI RT MANDIBULAR HEMI,SUP-2883706,CDM,C1713,HCPCS,0278,RC,,,,both,,,14994.88,9746.67,,,,,,,,,,,,,
CATHETER EP 7FR L99CM 1-4-1MM SPC 20 POLE MAP DUO DECAPOLAR,SUP-2357021,CDM,C1731,HCPCS,0278,RC,,,,both,,,5466.74,3553.38,,,,,,,,,,,,,
SHELL ACET REV 56 MM HIP HEMI ANAT,SUP-2363244,CDM,C1776,CPT,0278,RC,,,,both,,,12735.84,8278.30,,,,,,,,,,,,,
CATHETER GUID TRAPLINER DIA 6 FR RX L 13 CM PUSH ROD 0.02,SUP-2558715,CDM,C1887,HCPCS,0272,RC,,,,both,,,1912.26,1242.97,,,,,,,,,,,,,
BLADE SURG SAW GRFT HARV STRL S STL 20MM LEN 6MM W .4MM THCK,SUP-2166600,CDM,2720000010,LOCAL,0272,RC,,,,both,,,401.92,261.25,,,,,,,,,,,,,
GRAFT BNE SUB 40CC 125 1000U DEMIN CORT PARTICULATE FRZ DRY,SUP-2264722,CDM,C1713,HCPCS,0278,RC,,,,both,,,1878.13,1220.78,,,,,,,,,,,,,
CATHETER PICC AD 6FR L55CM 3 LUMN NRS PWR INJ N COAT CT,SUP-2125646,CDM,C1751,HCPCS,0278,RC,,,,both,,,854.08,555.15,,,,,,,,,,,,,
PIN POS DIA5MM S STL LOK CRMP SEAT FOR 4.5MM LCP PLATING,SUP-2178464,CDM,C1713,HCPCS,0278,RC,,,,both,,,750.33,487.71,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY L 115 CM 7 FR 1-3-1 MM TIP 3 MM,SUP-2702613,CDM,C1730,HCPCS,0272,RC,,,,both,,,1414.07,919.15,,,,,,,,,,,,,
PLATE BONE MESH SCREEN 1.3X15X25X0.2 MM TITANIUM,SUP-2838348,CDM,C1713,HCPCS,0278,RC,,,,both,,,571.48,371.46,,,,,,,,,,,,,
STAPLE SPNL L24MM ANT MTL ALLY CRV BTTRS BOWTI,SUP-2254344,CDM,C1713,HCPCS,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
PLATE BONE WITHOUT ANGLE THICK 2.5 MM MANDIBLE PATIENT SPECI,SUP-2838603,CDM,C1713,HCPCS,0278,RC,,,,both,,,18588.49,12082.52,,,,,,,,,,,,,
PLATE BNE L 193 MM 16 H SS RADIAL SHFT STRL EVOS,SUP-2933262,CDM,C1713,HCPCS,0278,RC,,,,both,,,4497.11,2923.12,,,,,,,,,,,,,
CONE TIB DIA24MM SHT LEGION,SUP-2349175,CDM,C1776,CPT,0278,RC,,,,both,,,11932.00,7755.80,,,,,,,,,,,,,
HC Perq Device Breast 1st Image,PX-3611928100,CDM,19281,CPT,0361,RC,,,,inpatient,,,5152.00,3348.80,,,,,,,,,,,,,
HOLDER NDL W5MMXL30CM W/O SUT STR REUSE ENDOPATH,SUP-2218975,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1930.79,1255.01,,,,,,,,,,,,,
SCREW CONN HIP HNG KNEE GUID LCK INSRT LEGION,SUP-2346398,CDM,C1713,HCPCS,0278,RC,,,,both,,,403.18,262.07,,,,,,,,,,,,,
DEVICE ENDOSKELETAL SYS PROSTHETIC BK FLX INNR SOCKET,SUP-2388208,CDM,L5645,HCPCS,0274,RC,,,,both,,,2097.24,1363.21,,,,,,,,,,,,,
SCREW BNE L20MM OD3.5MM STD TI REARFT NONLOCKING TOT FT SYS,SUP-2243259,CDM,C1713,HCPCS,0278,RC,,,,both,,,519.61,337.75,,,,,,,,,,,,,
SCREW BNE L 28 MM DIA2 MM TI CANN HD NS LEOS,SUP-2932596,CDM,C1713,HCPCS,0278,RC,,,,both,,,618.08,401.75,,,,,,,,,,,,,
SCREW SPNL POLYAX 50 MM,SUP-2175448,CDM,C1713,HCPCS,0278,RC,,,,both,,,5968.51,3879.53,,,,,,,,,,,,,
CATHETER ABLAT 7FR L60CM ENDOVENOUS RF HEAT ELEMENT,SUP-2393076,CDM,C1888,HCPCS,0272,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
HC Spectrophotometry Analyt Not Elsewhere Specified,PX-3018431100,CDM,84311,CPT,0301,RC,,,,both,,,203.00,131.95,,,,,,,,,,,,,
CYLINDER PENILE PROS L20CM DIA14MM CONCEALABLE SPECTR,SUP-2138898,CDM,C2622,HCPCS,0278,RC,,,,both,,,36101.21,23465.79,,,,,,,,,,,,,
SCREW BNE CANN 60 MM CANC SCFE NS LTX,SUP-2861118,CDM,C1713,HCPCS,0278,RC,,,,both,,,834.42,542.37,,,,,,,,,,,,,
KNIFE SURG FOR APCL COR,SUP-2356018,CDM,C1713,HCPCS,0278,RC,,,,both,,,1865.16,1212.35,,,,,,,,,,,,,
COMPONENT HIP 24 MM LT TRIFLANGE,SUP-2212615,CDM,C1776,CPT,0278,RC,,,,both,,,34226.00,22246.90,,,,,,,,,,,,,
GRAFT BNE MED 5 CC DBM STRND +,SUP-2641768,CDM,C1713,HCPCS,0278,RC,,,,both,,,7159.20,4653.48,,,,,,,,,,,,,
SUPPORT ORTHOT LOWER EXTREMITY PELV,SUP-2435690,CDM,L2650,HCPCS,0272,RC,,,,both,,,391.78,254.66,,,,,,,,,,,,,
GRAFT HUM TISS L THK2 279MM RDY TO USE CNTOUR ALLDERM,SUP-2416980,CDM,Q4116,HCPCS,0636,RC,,,,both,,,19169.70,12460.30,,,,,,,,,,,,,
CONNECTOR SPNL S STL THORLUM LO PROF PARA FOR 5.5/5.5MM ROD,SUP-2230977,CDM,C1713,HCPCS,0278,RC,,,,both,,,920.02,598.01,,,,,,,,,,,,,
GRAFT DECELLULARIZED DERM 1.25-2.00MM 16X20CM RM TEMP,SUP-2264624,CDM,Q4122,HCPCS,0636,RC,,,,both,,,29202.00,18981.30,,,,,,,,,,,,,
STEM HUM LNG 8 MM SHLDR AFFINITI PC,SUP-2715293,CDM,C1776,CPT,0278,RC,,,,both,,,17668.78,11484.71,,,,,,,,,,,,,
COUNTERSINK DRL M3X SYS,SUP-2422266,CDM,2720000010,LOCAL,0272,RC,,,,both,,,690.80,449.02,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY LIVEWIRE L 115 CM DIA 7 MM SPC,SUP-2489510,CDM,C1731,HCPCS,0278,RC,,,,both,,,963.10,626.01,,,,,,,,,,,,,
TISSUE HUM IMPL W5XL5CM AMNIO MEMBRN ALLGRFT BIOVANCE,SUP-2113888,CDM,Q4154,HCPCS,0636,RC,,,,both,,,8901.90,5786.23,,,,,,,,,,,,,
PLATE BNE SM L93MM 3X6X2 H POST TIBIOTALOCALCANEAL ANK TI,SUP-2398511,CDM,C1713,HCPCS,0278,RC,,,,both,,,6794.96,4416.72,,,,,,,,,,,,,
OCCLUDER CV FLO RST L 12 MM BLB DIA2 MM SIL RUBBER CORONARY,SUP-2130327,CDM,C1760,HCPCS,0278,RC,,,,both,,,236.54,153.75,,,,,,,,,,,,,
GRAFT BONE OSTEOARTICULAR STRUCTURAL CUF L SEG RECON TISS,SUP-2307435,CDM,C1762,CPT,0278,RC,,,,both,,,16908.90,10990.78,,,,,,,,,,,,,
HALF PIN 4MMX45MM,SUP-2818302,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1002.07,651.35,,,,,,,,,,,,,
PIN FIX TROCAR PT 1 END 4.8X229 MM STYL 5 THRD PLN SHANK SS,SUP-2466827,CDM,C1713,HCPCS,0278,RC,,,,both,,,82.80,53.82,,,,,,,,,,,,,
HC So1 Chylmd Trach Dna Amp Probe,PX-3068749167,CDM,87491,CPT,0306,RC,,,,both,,,44.00,28.60,,,,,,,,,,,,,
PIN SURG FOR 0.078-0.126IN DRL CHK CLLT,SUP-2362644,CDM,C1713,HCPCS,0278,RC,,,,both,,,2466.72,1603.37,,,,,,,,,,,,,
SCREW BNE T6 DRV 2X20 MM VARIAX,SUP-2435328,CDM,C1713,HCPCS,0278,RC,,,,both,,,406.63,264.31,,,,,,,,,,,,,
CARBOPROST TROMETHAMINE 250 MCG/ML IM SOLN,RX-9413,CDM,J0675,HCPCS,0636,RC,43598-0698-58,NDC,,both,1,ML,1834.20,1192.23,,,,,,,,,,,,,
NUT ORTH DIA5/16IN RT HND FOR SPNL FIX DEV,SUP-2255599,CDM,C1713,HCPCS,0278,RC,,,,both,,,263.76,171.44,,,,,,,,,,,,,
GUIDEWIRE SYNCHRO SELECT SOFT PRE-SHAPED 0.014IN X 300 CM,SUP-2855165,CDM,C1769,HCPCS,0272,RC,,,,both,,,2907.64,1889.97,,,,,,,,,,,,,
SCREW BNE NLCK 3.5X44 MM STRL MOTOBAND CP,SUP-2427190,CDM,C1713,HCPCS,0278,RC,,,,both,,,516.53,335.74,,,,,,,,,,,,,
SET SPEC RETRV L 220 CM OD 2.2 MM ID 1.9 MM CAP OD 19.5 MM,SUP-2881870,CDM,C1889,HCPCS,0278,RC,,,,both,,,4361.46,2834.95,,,,,,,,,,,,,
STAPLE CARTRIDGE STR 10X7 MM TI,SUP-2166818,CDM,C1713,HCPCS,0278,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
OSSEOFLEX SB STRAIGHT BLLN 10GA2ML,SUP-2702114,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2705.64,1758.67,,,,,,,,,,,,,
BIT DRL PED DIA3.2MM AO QUIK CPL CANN DISP PEDIPLATES,SUP-2318876,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1482.08,963.35,,,,,,,,,,,,,
PLATE BNE L180MM 7 H NONSTERILE R LAT PROX TIB TI LOK COMPR,SUP-2190713,CDM,C1713,HCPCS,0278,RC,,,,both,,,4303.78,2797.46,,,,,,,,,,,,,
ONDANSETRON HCL 4 MG/2ML IJ SOLN,RX-103562,CDM,J2405,HCPCS,0636,RC,00641-6078-25,NDC,,both,1,ML,54.10,35.16,,,,,,,,,,,,,
PLATE BNE GRIFFIN MOD LINDORF 11 MM CHIN FOR 2.0 MM CP TI,SUP-2496758,CDM,C1713,HCPCS,0278,RC,,,,both,,,646.46,420.20,,,,,,,,,,,,,
CAGE SPNL LORDTC 7 DEG LG 36X24X16 MM ENDOSKELETON TAS,SUP-2431464,CDM,C1889,HCPCS,0278,RC,,,,both,,,23236.00,15103.40,,,,,,,,,,,,,
CATHETER ANGIO L70CM OD6FR GWIRE OD0.014IN 90DEG CRV PLCMNT,SUP-2356638,CDM,C1751,HCPCS,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
HARVESTING SET 4.5 MM CHSL TAMP DRL BIT GRN MOSAICPLASTY DP,SUP-2878033,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1391.33,904.36,,,,,,,,,,,,,
DHHS HELIX BLADE 130MM-STERILE,SUP-2547637,CDM,C1713,HCPCS,0278,RC,,,,both,,,1155.52,751.09,,,,,,,,,,,,,
SET SCR SPNL POST THORACOLUMBOSACRAL TI MULTIAXIAL REDUC,SUP-2287854,CDM,C1713,HCPCS,0278,RC,,,,both,,,528.62,343.60,,,,,,,,,,,,,
GRAFT BNE SHFT HUM IMPL ALLGRFT L120MM MATRIGRFT,SUP-2264765,CDM,C1713,HCPCS,0278,RC,,,,both,,,2374.59,1543.48,,,,,,,,,,,,,
SPLINT WRST LOOP LCK CLOSURE SM 10 IN RT VELCRO PROCARE,SUP-2196996,CDM,L3809,HCPCS,0272,RC,,,,both,,,19.44,12.64,,,,,,,,,,,,,
GRAFT BONE SUB 10CC DEMIN BONE MTRX GEL GRFTON,SUP-2293897,CDM,C1713,HCPCS,0278,RC,,,,both,,,2873.10,1867.51,,,,,,,,,,,,,
ROD IM UNIV 5 DEG PFC,SUP-2456051,CDM,C1713,HCPCS,0278,RC,,,,both,,,1353.34,879.67,,,,,,,,,,,,,
CATHETER PICC ARROWG+ARD BLU ADV L 55 CM DIA 4.5 FR,SUP-2827500,CDM,C1751,HCPCS,0278,RC,,,,both,,,310.23,201.65,,,,,,,,,,,,,
TRAY CATH MIDLN POWERGLIDE PRO 22GA 8CM WNG 1 LUMA F122088PT,SUP-2632747,CDM,C1751,HCPCS,0278,RC,,,,both,,,342.26,222.47,,,,,,,,,,,,,
KIT BNE PLATE SCREW DIA2 MM TI MANDIBULAR PRIMARY RECON HEMI,SUP-2883331,CDM,C1713,HCPCS,0278,RC,,,,both,,,30991.80,20144.67,,,,,,,,,,,,,
PLATE BNE L233MM 15 H ST R POSTEROLATERAL DST FIBULAR S STL,SUP-2177407,CDM,C1713,HCPCS,0278,RC,,,,both,,,2165.19,1407.37,,,,,,,,,,,,,
TISSUE T00247 ILIUMTRICORTSTRIP22MMX55MM,SUP-2281641,CDM,C1762,CPT,0278,RC,,,,both,,,7824.88,5086.17,,,,,,,,,,,,,
DAUNORUBICIN-CYTARABINE LIPO 44-100 MG IV SUSR,RX-139664,CDM,J9153,HCPCS,0636,RC,68727-0745-02,NDC,,both,1,UN,31622.40,20554.56,,,,,,,,,,,,,
PIFLUFOLASTAT F 18 9 MCI IV SOSY,RX-155146,CDM,A9595,HCPCS,0343,RC,71258-0022-00,NDC,,both,.1,UN,1363.00,885.95,,,,,,,,,,,,,
PLATE BNE L26MM THK075MM 2X5 H NONSTERILE PHLANG BASE HND TI,SUP-2180989,CDM,C1713,HCPCS,0278,RC,,,,both,,,1607.77,1045.05,,,,,,,,,,,,,
LONG CALI DRILL 49 MM CANN,SUP-2726665,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1780.13,1157.08,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 30 CM DIA 5 MM EPTFE STR STD WALL,SUP-2695231,CDM,C1768,CPT,0278,RC,,,,both,,,444.66,289.03,,,,,,,,,,,,,
BUR SURG DIA3MM CUT RND FLUT ZYPHR ELITE,SUP-2367562,CDM,C1713,HCPCS,0278,RC,,,,both,,,332.12,215.88,,,,,,,,,,,,,
IMPLANT KNEE ANTERIOR CRUCIATE BEAR,SUP-2857997,CDM,C1763,HCPCS,0278,RC,,,,both,,,15778.50,10256.02,,,,,,,,,,,,,
GRAFT HUM TISS M THK2-2.79MM RDY TO USE CNTOUR ALLDERM,SUP-2113440,CDM,C1713,HCPCS,0278,RC,,,,both,,,15429.96,10029.47,,,,,,,,,,,,,
HC Endo Level 1 Addl 15 Min,PX-3600007511,CDM,3600007511,LOCAL,0360,RC,,,,both,,,1968.00,1279.20,,,,,,,,,,,,,
BUNDLE GRFT ENDURANT II NIT POLYESTER 3 PC HELI-FX,SUP-2873747,CDM,C1768,CPT,0278,RC,,,,both,,,75360.00,48984.00,,,,,,,,,,,,,
CAGE SPNL INTBDY 7 DEG 18X15X12 MM NS SHORELINE ACS,SUP-2245768,CDM,C1889,HCPCS,0278,RC,,,,both,,,2151.31,1398.35,,,,,,,,,,,,,
PIN FIX DBL TROCAR 0.093X9 IN THRD SS NS STEINMANN,SUP-2791383,CDM,C1713,HCPCS,0278,RC,,,,both,,,70.56,45.86,,,,,,,,,,,,,
GRAFT BNE 10CC W/ BIOACTIVE GLS MOLD MTRX PLATFORM,SUP-2719783,CDM,C1713,HCPCS,0278,RC,,,,both,,,11618.00,7551.70,,,,,,,,,,,,,
NEXGEN LPS ART SURF EF 3-4/STR YEL 20MM,SUP-2201952,CDM,C1776,CPT,0278,RC,,,,both,,,4041.18,2626.77,,,,,,,,,,,,,
PLATE BONE 6 H TI STR FOR CRAN CLSR SYS,SUP-2243971,CDM,C1713,HCPCS,0278,RC,,,,both,,,200.99,130.64,,,,,,,,,,,,,
PLATE BNE L44MM 5 H S STL COMPR FOR 27MM SCR MINI FRAG SYS,SUP-2199359,CDM,C1713,HCPCS,0278,RC,,,,both,,,403.65,262.37,,,,,,,,,,,,,
KIT CATH HEMODIALYSI RELIANCE XK CHRONIC STD 16FR DIA 40CM 3,SUP-2613281,CDM,C1750,HCPCS,0278,RC,,,,both,,,7418.25,4821.86,,,,,,,,,,,,,
CATHETER PERI DLYS L13.5CM PRESTRNL POLYUR PRECRV SHFT KT,SUP-2283917,CDM,C1750,HCPCS,0278,RC,,,,both,,,1629.60,1059.24,,,,,,,,,,,,,
HC Rm Private,PX-1100000000,CDM,1100000000,LOCAL,0110,RC,,,,inpatient,,,2515.00,1634.75,,,,,,,,,,,,,
VALVE ANGIO Y VLV HEMSTAT 75FR W INSRT TOOL PASS,SUP-2303030,CDM,C1713,HCPCS,0278,RC,,,,both,,,43.43,28.23,,,,,,,,,,,,,
CATHETER HD STR 11.5 FRX24 CM SHT TERM DL BASIC SET DUOFLO,SUP-2627396,CDM,C1752,HCPCS,0278,RC,,,,both,,,54.95,35.72,,,,,,,,,,,,,
CATHETER CV SET 018 PEDIATRIC 4 FRX5 CM DL J TIP SPECTRUM,SUP-2759964,CDM,C1751,HCPCS,0278,RC,,,,both,,,337.93,219.65,,,,,,,,,,,,,
CATHETER INFUSION UNI-FUSE L 135 CM DIA 4 FR SLT PAT L 40 CM,SUP-2117042,CDM,C1751,HCPCS,0278,RC,,,,both,,,1303.10,847.01,,,,,,,,,,,,,
HC Thromb Mech W/Oth Interv,PX-3613718600,CDM,37186,CPT,0361,RC,,,,both,,,15457.00,10047.05,,,,,,,,,,,,,
PLUG FEN HIP STEM NO 4,SUP-2377822,CDM,C1776,CPT,0278,RC,,,,both,,,295.79,192.26,,,,,,,,,,,,,
PLATE LOCKING STRAIGHT 1.3MM 6 HOLES-STERILE,SUP-2546060,CDM,C1713,HCPCS,0278,RC,,,,both,,,1247.90,811.13,,,,,,,,,,,,,
SET DIL 8-30FR L35CM RENAL SHTH AMPLATZ,SUP-2139238,CDM,C1894,HCPCS,0272,RC,,,,both,,,752.41,489.07,,,,,,,,,,,,,
IMPLANT ARTHROPLASTY SZ 1 CMC STABYLX,SUP-2419550,CDM,C1776,CPT,0278,RC,,,,both,,,9891.00,6429.15,,,,,,,,,,,,,
GRAFT HUM TISS W8XL16CM THK0.8-1.7MM MESHED SKIN TISS PERF,SUP-2307575,CDM,C1781,HCPCS,0278,RC,,,,both,,,10132.15,6585.90,,,,,,,,,,,,,
INTRODUCER SHTH 0.021 IN 6 FRX23 CM 21 GAX4 CM PRELUDEEASE,SUP-2464429,CDM,C1894,HCPCS,0272,RC,,,,both,,,126.60,82.29,,,,,,,,,,,,,
IMPLANT TISSUE CONNECTIVE FLOW 4CC,SUP-2880217,CDM,C1762,CPT,0278,RC,,,,both,,,12874.00,8368.10,,,,,,,,,,,,,
PLATE BNE L391MM 16 H ST L PROX FEM S STL LO PROF LOK COMPR,SUP-2186052,CDM,C1713,HCPCS,0278,RC,,,,both,,,5632.78,3661.31,,,,,,,,,,,,,
SHUNT SURG ADJ L 17 MM GRAVITATIONAL L 12 MM CATH DSTL L FX578T,SUP-2928865,CDM,C1889,HCPCS,0278,RC,,,,both,,,16003.92,10402.55,,,,,,,,,,,,,
SET SCR SPNL L55MM DIA6.4MM PEDCL HA TI ALLOY FOR DYN STBL,SUP-2414277,CDM,C1713,HCPCS,0278,RC,,,,both,,,10596.24,6887.56,,,,,,,,,,,,,
BRACE KNEE FOR 26IN FOAM TELSCP FULL TECHNOLOGY QUIK LOK,SUP-2196499,CDM,L1832,HCPCS,0274,RC,,,,both,,,346.37,225.14,,,,,,,,,,,,,
GUIDEWIRE VASC STRT L 150 CM DIA 0.038 IN TAPR 0 CM SS PTFE,SUP-2148262,CDM,C1769,HCPCS,0272,RC,,,,both,,,22.89,14.88,,,,,,,,,,,,,
SUPPORT ORTHOT HND CUST STRP W/O JT FABRICATED SFT INTFACE,SUP-2435780,CDM,L3919,HCPCS,0274,RC,,,,both,,,697.80,453.57,,,,,,,,,,,,,
PLATE BNE L159MM 6 H R LAT DST FEM S STL LOK COMPR FOR,SUP-2410718,CDM,C1713,HCPCS,0278,RC,,,,both,,,4077.70,2650.50,,,,,,,,,,,,,
COIL NEUROVASCULAR CEREPAK HELIFORM XL L 45 CM DIA14 MM SLV,SUP-2865255,CDM,C1889,HCPCS,0278,RC,,,,both,,,7433.35,4831.68,,,,,,,,,,,,,
CATHETER EP JSN 10 MM SPC 6 FRX125 CM WOVEN,SUP-2142181,CDM,C1733,HCPCS,0272,RC,,,,both,,,722.20,469.43,,,,,,,,,,,,,
CATHETER DRAINAGE SET 5 FRX8 CM FURMAN CPPD500WOODIMH,SUP-2759774,CDM,C1729,HCPCS,0272,RC,,,,both,,,402.86,261.86,,,,,,,,,,,,,
GRAFT HUMAN TSSUE W2XL4CM THK023 051MM GRFTBLE RGNRTVE TSS,SUP-2707154,CDM,Q4116,HCPCS,0636,RC,,,,both,,,813.26,528.62,,,,,,,,,,,,,
ECLIPSE CAGE SCREW L 40MM,SUP-2815662,CDM,C1776,CPT,0278,RC,,,,both,,,9420.00,6123.00,,,,,,,,,,,,,
WIRE FIX L150MM OD0.9MM FOR FT RECON MIDFT FUS PLT K DARCO,SUP-2398609,CDM,C1776,CPT,0278,RC,,,,both,,,56.52,36.74,,,,,,,,,,,,,
STENT BILI NITI-S D L 6 CM DIA 8 MM DEL SYS L 180 CM DIA 8,SUP-2737106,CDM,C2617,HCPCS,0278,RC,,,,both,,,4788.50,3112.52,,,,,,,,,,,,,
SYSTEM IMPL DEL GRFT ANCHR,SUP-2122601,CDM,C1713,HCPCS,0278,RC,,,,both,,,3925.00,2551.25,,,,,,,,,,,,,
IMPLANT FNGR JT SZ 3 PROX INTERPHALANGEAL PRI SWNSN,SUP-2397895,CDM,C1776,CPT,0278,RC,,,,both,,,3488.54,2267.55,,,,,,,,,,,,,
CATHETER ANGIOPLSTY PFLX PRO L 80 CM BALLOON L 100 MM DIA 6,SUP-2156791,CDM,C1725,HCPCS,0272,RC,,,,both,,,561.43,364.93,,,,,,,,,,,,,
PENICILLIN V POTASSIUM 500 MG PO TABS,RX-6093,CDM,6370000000,HCPCS,0637,RC,65862-0176-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PATCH CV FLUOROPASSIV L 120 X W 25 MM POLYESTER,SUP-2385075,CDM,C1768,CPT,0278,RC,,,,both,,,448.02,291.21,,,,,,,,,,,,,
BIT DRL L65MM DIA1.1MM ST S STL J LATCH NONRADIOPAQUE W/O,SUP-2187176,CDM,2720000010,LOCAL,0272,RC,,,,both,,,408.55,265.56,,,,,,,,,,,,,
PLATE BNE LG LT MEDL CLMN FUSION STRATUM,SUP-2607235,CDM,C1713,HCPCS,0278,RC,,,,both,,,5276.61,3429.80,,,,,,,,,,,,,
SCREW BONE L20MM OD3.5MM TI CORT T15 ST LOQTEQ,SUP-2101294,CDM,C1713,HCPCS,0278,RC,,,,both,,,379.31,246.55,,,,,,,,,,,,,
GRAFT DERMAL SQ 11.8X11.8 IN ANTIBACT XENMATRIX AB,SUP-2855246,CDM,C1781,HCPCS,0278,RC,,,,both,,,93766.68,60948.34,,,,,,,,,,,,,
STEM FEM 60MM LNG WDG HIP INTERSPACE,SUP-2223688,CDM,C1776,CPT,0278,RC,,,,both,,,8478.00,5510.70,,,,,,,,,,,,,
GRAFT 10CMX15CM 300CMSQ SLNT CLLGN MTRX SEMIOVAL SURGIMEND,SUP-2243675,CDM,C9360,HCPCS,0278,RC,,,,both,,,7517.16,4886.15,,,,,,,,,,,,,
CATHETER NEPHROSTOMY LCK LOOP 8 FRX26 CM TAPR TIP PERCFLX,SUP-2481343,CDM,C1729,HCPCS,0272,RC,,,,both,,,266.71,173.36,,,,,,,,,,,,,
HC So Lysozyme,PX-3058554966,CDM,85549,CPT,0305,RC,,,,both,,,614.00,399.10,,,,,,,,,,,,,
HC X-Ray Specimen,PX-3207609800,CDM,76098,CPT,0320,RC,,,,outpatient,,,566.00,367.90,,,,,,,,,,,,,
PLATE BNE LCK UNIV 2.7X187 MM 16 HOLE CONTOURED 2 COMPR,SUP-2458326,CDM,C1713,HCPCS,0278,RC,,,,both,,,1231.60,800.54,,,,,,,,,,,,,
HC Canalith Repositioning Proc|OP PT SERVICES|DOCUMENTATION ON FILE,PX-4209599200,CDM,95992,CPT,0420,RC,,,GP|KX,both,,,333.00,216.45,,,,,,,,,,,,,
STEM FEM SZ 8 STD HIP HA AMISTEM-H,SUP-2267266,CDM,C1776,CPT,0278,RC,,,,both,,,12434.40,8082.36,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH ALPHA2 L 112 MM DIA 34 MM SHTH 18 FR,SUP-2912008,CDM,C1768,CPT,0278,RC,,,,both,,,41218.78,26792.21,,,,,,,,,,,,,
PARTICLE EMB BNDL S220PRO MIV-20500 SWIFTNINJA EMBOSPHEREPRO,SUP-2798603,CDM,C1889,HCPCS,0278,RC,,,,both,,,6892.30,4479.99,,,,,,,,,,,,,
COMPONENT FEM INTERCALARY 55 MM KNEE SEG,SUP-2437245,CDM,C1776,CPT,0278,RC,,,,both,,,8944.29,5813.79,,,,,,,,,,,,,
PLATE BNE L208MM THK3MM 11 H BILAT S STL STR LOK COMPR RECON,SUP-2185345,CDM,C1713,HCPCS,0278,RC,,,,both,,,1768.54,1149.55,,,,,,,,,,,,,
BRACE KNEE L FOR 205 23IN NEOPRENE OPN POPLITEAL WRP ARND,SUP-2196840,CDM,L1810,HCPCS,0274,RC,,,,both,,,64.87,42.17,,,,,,,,,,,,,
CATHETER INFUSION 0.038 IN 5 FRX65 CM 5 CM 10 SH MEWISSEN,SUP-2141150,CDM,C1751,HCPCS,0278,RC,,,,both,,,237.16,154.15,,,,,,,,,,,,,
COMPONENT FEM POST STBL LEGION OXINIUM,SUP-2348026,CDM,C1776,CPT,0278,RC,,,,both,,,13816.00,8980.40,,,,,,,,,,,,,
BUR SURG L92MM DIA2MM S STL RND FN DMND NONFLUTED VISAO,SUP-2284235,CDM,C1713,HCPCS,0278,RC,,,,both,,,837.94,544.66,,,,,,,,,,,,,
BIT DRL L110MM DIA4MM SLD,SUP-2321597,CDM,2720000010,LOCAL,0272,RC,,,,both,,,458.44,297.99,,,,,,,,,,,,,
WAND ABLAT BVL 60DEG 3MM,SUP-2341965,CDM,C1713,HCPCS,0278,RC,,,,both,,,577.76,375.54,,,,,,,,,,,,,
PLATE BNE L MINI MED 3X3 MM RT FOR SCR TI LEVEL 1,SUP-2466439,CDM,C1713,HCPCS,0278,RC,,,,both,,,476.93,310.00,,,,,,,,,,,,,
CUTTER TIP VITRCTMY POST DISPOSABLE,SUP-2129359,CDM,2720000010,LOCAL,0272,RC,,,,both,,,424.90,276.18,,,,,,,,,,,,,
PATCH CV CARDIOCEL L 8 X W 5 CM THK 0.5 MM BOV PERICARD,SUP-2433944,CDM,C1768,CPT,0278,RC,,,,both,,,6214.06,4039.14,,,,,,,,,,,,,
BRACE KNEE L FOR 205 23IN NEOPRENE OPN POPLITEAL WRP ARND,SUP-2196840,CDM,L1810,HCPCS,0272,RC,,,,both,,,64.87,42.17,,,,,,,,,,,,,
COMPONENT HIP PRIMARY 1,SUP-2212582,CDM,C1776,CPT,0278,RC,,,,both,,,11304.00,7347.60,,,,,,,,,,,,,
SHUNT NEUROSURGICAL 0-20CM H2O TI 2 CONN ADJ VLV BUR H,SUP-2108728,CDM,C1889,HCPCS,0278,RC,,,,both,,,10082.73,6553.77,,,,,,,,,,,,,
PLATE BONE L W12XL103MM THK1MM 6 H BILAT TI SEMI TBLR LO,SUP-2190704,CDM,C1713,HCPCS,0278,RC,,,,both,,,275.91,179.34,,,,,,,,,,,,,
SCREW INTFR L20MM DIA9MM TI CANN NONABSORBABLE TAPR HD,SUP-2341313,CDM,C1713,HCPCS,0278,RC,,,,both,,,540.71,351.46,,,,,,,,,,,,,
ENDOPROSTHESIS VASC WSTNT RP L 90 MM DIA 6 MM CATH TOT L 160,SUP-2148370,CDM,C1876,HCPCS,0278,RC,,,,both,,,6063.34,3941.17,,,,,,,,,,,,,
NAIL IM L420MM DIA13MM 130DEG LNG R HIP TIM CANN LOK FOR AG,SUP-2211489,CDM,C1713,HCPCS,0278,RC,,,,both,,,10059.37,6538.59,,,,,,,,,,,,,
CATHETER CV SET 025 PEDIATRIC 5 FRX5 CM 3L POLYETH,SUP-2760047,CDM,C1751,HCPCS,0278,RC,,,,both,,,233.93,152.05,,,,,,,,,,,,,
HC CT Cologrph Dx W/O Cont,PX-3507426100,CDM,74261,CPT,0350,RC,,,,inpatient,,,2630.00,1709.50,,,,,,,,,,,,,
DEFIBRILLATOR CARD 2 CHMBR ATLS + DR,SUP-2357755,CDM,C1721,HCPCS,0275,RC,,,,both,,,53380.00,34697.00,,,,,,,,,,,,,
ADAPTER LD L 16 CM 4.75 MM TO IS1 BPLR CONN,SUP-2148783,CDM,C1883,HCPCS,0278,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
ALLOGRAFT BNE PTTY 5 CC OSTEOINDUCTIVE DBM REFICIO,SUP-2731793,CDM,C1713,HCPCS,0278,RC,,,,both,,,1632.80,1061.32,,,,,,,,,,,,,
INTRODUCER PACE LD APEEL CS 60 DEG L 47 CM DIA 8 FR CATH DEL,SUP-2357275,CDM,C1894,HCPCS,0272,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
HANDLE ADV RENAISSANCE,SUP-2109715,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1142.96,742.92,,,,,,,,,,,,,
ALLODERM SELECT 2X12CM XTHICK 2.8-4.0,SUP-2822078,CDM,Q4116,HCPCS,0636,RC,,,,both,,,2581.08,1677.70,,,,,,,,,,,,,
T8 HLD SL,SUP-2344041,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2311.04,1502.18,,,,,,,,,,,,,
SCREW SPNL L12MM S STL ST THRD UNIV BULL SHP HD DISTR PIN,SUP-2274176,CDM,C1713,HCPCS,0278,RC,,,,both,,,65.75,42.74,,,,,,,,,,,,,
CATHETER PICC 3FR L45CM SGL LUMN SHERLOCK STYL MAXIMAL BARR,SUP-2125506,CDM,C1751,HCPCS,0278,RC,,,,both,,,838.38,544.95,,,,,,,,,,,,,
TOBRAMYCIN 0.3 % OP SOLN,RX-7995,CDM,6370000000,HCPCS,0637,RC,70069-0131-01,NDC,,both,5,ML,22.50,14.62,,,,,,,,,,,,,
WIRE FIX THRD OLV MAXLOCK EXTRM,SUP-2315908,CDM,C1769,HCPCS,0272,RC,,,,both,,,146.80,95.42,,,,,,,,,,,,,
INSERT TIB + + 9MM SZ 3 OPTETRAK CR SLOPE,SUP-2222737,CDM,C1776,CPT,0278,RC,,,,both,,,4088.28,2657.38,,,,,,,,,,,,,
LINER ACET OBLQ POLYETH 22MMX38MM TRIL LONGEVITY,SUP-2202299,CDM,C1776,CPT,0278,RC,,,,both,,,3469.70,2255.30,,,,,,,,,,,,,
PLATE BNE OSTEOTMY MAND SLIDING SAG MALL NS LTX,SUP-2862766,CDM,C1713,HCPCS,0278,RC,,,,both,,,1015.26,659.92,,,,,,,,,,,,,
TW DRL F/COLE RAD DRL 3.2MM,SUP-2819559,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1760.47,1144.31,,,,,,,,,,,,,
CATHETER NEPHROSTOMY SET 20 FRX30 CM MCOT EXCHANGE UNIVERSA,SUP-2836212,CDM,C1729,HCPCS,0272,RC,,,,both,,,142.59,92.68,,,,,,,,,,,,,
GRAFT BIOLOGICAL MESH TISSUE TEMPLATE 4IN X 5IN SHEET 2-LAYER REGENERATIVE COLLAGEN DERMAL MATRIX SILICONE DOMESTIC,SUP-2243491,CDM,Q4105,HCPCS,0636,RC,,,,both,,,20935.32,13607.96,,,,,,,,,,,,,
SYSTEM W/FLUSHING RESV 4/24,SUP-2821790,CDM,C1729,HCPCS,0272,RC,,,,both,,,6315.83,4105.29,,,,,,,,,,,,,
SCREW BNE L18MM DIA3.5MM TOT WRST FUS SYS SURFIX,SUP-2243389,CDM,C1713,HCPCS,0278,RC,,,,both,,,1217.63,791.46,,,,,,,,,,,,,
GRAFT BNE GRAN 1 CC VI RESRB CERM MASTERGRAFT,SUP-2743369,CDM,C1713,HCPCS,0278,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
PLATE BNE 3.5X27 MM 2 HOLE SS LCP,SUP-2569315,CDM,C1713,HCPCS,0278,RC,,,,both,,,309.13,200.93,,,,,,,,,,,,,
TRAY HAD FULL SHT TERM 3 LUMN 15.5FRX20CM T-3,SUP-2266986,CDM,C1751,HCPCS,0278,RC,,,,both,,,449.02,291.86,,,,,,,,,,,,,
VALVE SHUNT SYSTEM WITH NO DIFFERENTIAL PRESSURE UNIT WITH D,SUP-2821803,CDM,C1889,HCPCS,0278,RC,,,,both,,,11035.56,7173.11,,,,,,,,,,,,,
TRAY EPIDURAL TUOHY NDL L 3.5 IN DIA22 GA SGL SHT LIDO NACL,SUP-2936602,CDM,2720000010,LOCAL,0272,RC,,,,both,,,52.72,34.27,,,,,,,,,,,,,
SET BRUSHING L26MM DIA3MM FEM POLY KNEE ROT HNG TOT FINN,SUP-2406067,CDM,C1776,CPT,0278,RC,,,,both,,,1015.95,660.37,,,,,,,,,,,,,
OATS KIT FOR 16MM ALLOGRAFT PLUGS,SUP-2816374,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2190.15,1423.60,,,,,,,,,,,,,
COIL EMB 3 DIM 8 MMX25 CM GDC 18,SUP-2365730,CDM,C1889,HCPCS,0278,RC,,,,both,,,7897.73,5133.52,,,,,,,,,,,,,
FORCEPS ENDOMYOCARDIAMETERL BX 2.2MM JAW PRECRV 7FRX50CM,SUP-2120027,CDM,C1713,HCPCS,0278,RC,,,,both,,,957.70,622.50,,,,,,,,,,,,,
PLATE BNE PROX RAD TRL,SUP-2606623,CDM,C1713,HCPCS,0278,RC,,,,both,,,937.23,609.20,,,,,,,,,,,,,
PERTUZ-TRASTUZ-HYALURON-ZZXF 80-40-2000 MG-MG-U/ML SC SOLN,RX-151269,CDM,J9316,HCPCS,0636,RC,50242-0245-01,NDC,,both,15,ML,40079.70,26051.80,,,,,,,,,,,,,
K WIRE FIX L150MM DIA2.5MM FOR ORTHOLOC 3DI SYS,SUP-2398333,CDM,C1713,HCPCS,0278,RC,,,,both,,,78.50,51.02,,,,,,,,,,,,,
SCREW BNE L20MM DIA7MM ANT POST KNEE TI HEX DRV RND HD FOR,SUP-2341527,CDM,C1713,HCPCS,0278,RC,,,,both,,,431.91,280.74,,,,,,,,,,,,,
BIT DRILL CANN 24X14MM F/26MM PIN,SUP-2700935,CDM,2720000010,LOCAL,0272,RC,,,,both,,,386.85,251.45,,,,,,,,,,,,,
GUIDEWIRE VASC L180CM DIA0018IN TIP L20CM SIL NIT IMAG ANG,SUP-2172971,CDM,C1769,HCPCS,0272,RC,,,,both,,,225.04,146.28,,,,,,,,,,,,,
CATHETER GUID AD L45CM DIA7FR PERIPH W/O HYDRPHLC HOCK STK,SUP-2139612,CDM,C1894,HCPCS,0272,RC,,,,both,,,357.18,232.17,,,,,,,,,,,,,
PLATE BONE W9XL25MM THK1.1MM 2 H DSTL ULN FIBULAR S STL 1/3,SUP-2343773,CDM,C1713,HCPCS,0278,RC,,,,both,,,560.43,364.28,,,,,,,,,,,,,
KIT CATH HEMODIALYSI DUOGLIDE ACUTE 13FR DIA 12.5CML INSER 4,SUP-2613241,CDM,C1752,HCPCS,0278,RC,,,,both,,,750.90,488.08,,,,,,,,,,,,,
IMPLANT TOE JT GREAT MP CO CHROM N POR SM 17MM,SUP-2137755,CDM,C1776,CPT,0278,RC,,,,both,,,4587.54,2981.90,,,,,,,,,,,,,
SUP MED CLAV LCK PL 10H L SMP,SUP-2818689,CDM,C1713,HCPCS,0278,RC,,,,both,,,1501.58,976.03,,,,,,,,,,,,,
EVOS VOL PLATE 7H LEFT STD TI 105MM NS,SUP-2818636,CDM,C1713,HCPCS,0278,RC,,,,both,,,8223.66,5345.38,,,,,,,,,,,,,
DEVICE ANTI SIPHON W/ PUDENZ STR CONN,SUP-2244286,CDM,C1729,HCPCS,0272,RC,,,,both,,,1275.00,828.75,,,,,,,,,,,,,
GRAFT BNE BIPHASIC 9 CC 1 STRP OSTEOMATRIX +,SUP-2517943,CDM,C1713,HCPCS,0278,RC,,,,both,,,4270.78,2776.01,,,,,,,,,,,,,
TUBE VENT L7.6MM DIA1.14MM FLROPLAS PLN END BVL FOR MYR,SUP-2313661,CDM,L8699,HCPCS,0278,RC,,,,both,,,53.22,34.59,,,,,,,,,,,,,
KIT ENDSCPC INSTRMNT 112 118MM DIA 18MM OD CAP 165CML WRKN,SUP-2675481,CDM,2720000010,LOCAL,0272,RC,,,,both,,,658.05,427.73,,,,,,,,,,,,,
SPACER SPNL W10XH8XL25MM 4DEG PEEK POST LUM INTBDY FUS LORD,SUP-2380591,CDM,C1821,HCPCS,0278,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
ROD EXT FIX BIPHASE SYS,SUP-2136046,CDM,2720000010,LOCAL,0272,RC,,,,both,,,734.76,477.59,,,,,,,,,,,,,
SCREW BNE 2.1X4 MM PDLLA STRL RESORB RX,SUP-2457766,CDM,C1713,HCPCS,0278,RC,,,,both,,,203.00,131.95,,,,,,,,,,,,,
INSERT TIB SZ 4 POLYETH NONCOATED CEM REV COMP PRI NEUT FOR,SUP-2252064,CDM,C1776,CPT,0278,RC,,,,both,,,2800.25,1820.16,,,,,,,,,,,,,
SCREW BONE L65MM DIA6.5MM UNIV CORT FEM ST FT DRV END,SUP-2411531,CDM,C1713,HCPCS,0278,RC,,,,both,,,568.34,369.42,,,,,,,,,,,,,
SET BNE BX NDL W DMND TIP INTRO REDUC TRAUM MULT SPEC COLL,SUP-2168280,CDM,C1713,HCPCS,0278,RC,,,,both,,,970.07,630.55,,,,,,,,,,,,,
PLATE STRNL CLOSURE THK 1.5 MM 6 H TI O LP NS STERNALOCK EZ,SUP-2894444,CDM,C1713,HCPCS,0278,RC,,,,both,,,1381.60,898.04,,,,,,,,,,,,,
HC Iadna Sarscov2 & Inf a&B & Rsv Mult Amp Probe Tq,PX-3068763700,CDM,87637,CPT,0306,RC,,,,inpatient,,,300.00,195.00,,,,,,,,,,,,,
STEM HUM L100MM DIA8MM IM SHLDR MOD SEG REV SYS W/ SCR,SUP-2402759,CDM,C1776,CPT,0278,RC,,,,both,,,9184.50,5969.92,,,,,,,,,,,,,
SET SUT ANCHR 17GA INTRO NDL L12CM GI CART SPEC STR 0.035IN,SUP-2168016,CDM,C1713,HCPCS,0278,RC,,,,both,,,285.74,185.73,,,,,,,,,,,,,
SUPPORT ORTHOT ELBW CUST ADJ ACTIVE CTRL DBL UPR FABRICATED,SUP-2435759,CDM,L3740,HCPCS,0272,RC,,,,both,,,2768.51,1799.53,,,,,,,,,,,,,
PLATE BONE L53MM 3X3 H MAND TI LCK FOR 2MM SCR,SUP-2191231,CDM,C1713,HCPCS,0278,RC,,,,both,,,2936.53,1908.74,,,,,,,,,,,,,
SUPPORT ORTHOT ELBW CUST ADJ ACTIVE CTRL DBL UPR FABRICATED,SUP-2435759,CDM,L3740,HCPCS,0274,RC,,,,both,,,2768.51,1799.53,,,,,,,,,,,,,
LIGATOR ENDOSCP L122CM DIA9.5-13MM 4 BND SAEED 6 SHOT,SUP-2169398,CDM,2720000010,LOCAL,0272,RC,,,,both,,,624.86,406.16,,,,,,,,,,,,,
SUTURE ETHIBOND N ABSRB L 30 IN SZ 3-0 NDL L 17 MM POLYESTER GRN,SUP-2881365,CDM,2720000010,LOCAL,0272,RC,,,,both,,,144.60,93.99,,,,,,,,,,,,,
BLADE RETRACTOR 17 CMX20 MM VES THN OLIF,SUP-2627586,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1933.05,1256.48,,,,,,,,,,,,,
BIT DRL L216MM OD32MM ST SHT NONLOCKING,SUP-2365047,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1252.86,814.36,,,,,,,,,,,,,
STEM FEM SZ 8 L205MM DIA14MM L HIP TI ALLY HA BOW REV RESTR,SUP-2374213,CDM,C1776,CPT,0278,RC,,,,both,,,17148.17,11146.31,,,,,,,,,,,,,
HC So Hepatitis C Virus Antibody,PX-3028680366,CDM,86803,CPT,0302,RC,,,,both,,,64.00,41.60,,,,,,,,,,,,,
GRAFT BNE INJ 1.5 CC AUG,SUP-2759481,CDM,C1734,HCPCS,0278,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
PLATE BNE STR 2-2.5X159X2.5 MM MAND 20 HOLE RECON TI STRL,SUP-2485016,CDM,C1713,HCPCS,0278,RC,,,,both,,,4869.01,3164.86,,,,,,,,,,,,,
DEVICE FIX 7MM DIR ENDOBUTTON,SUP-2341085,CDM,C1713,HCPCS,0278,RC,,,,both,,,910.60,591.89,,,,,,,,,,,,,
ROD ORTH THRD COMPR OLECRANON IMP STRL L89.5MM OD4.5MM,SUP-2106883,CDM,C1713,HCPCS,0278,RC,,,,both,,,2810.30,1826.69,,,,,,,,,,,,,
GUIDEPIN SURG TIB PC CR-FLEX FIX NXGN,SUP-2201241,CDM,2720000010,LOCAL,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
FLUOXETINE HCL 20 MG/5ML PO SOLN,RX-38488,CDM,340b,HCPCS,0637,RC,00121-4721-05,NDC,,both,2.5,ML,12.90,8.38,,,,,,,,,,,,,
DEVICE BNE ACCS SZ 2 10GA DIA3.4MM DMND AND BVL OSTEO INTRO,SUP-2293707,CDM,C1894,HCPCS,0272,RC,,,,both,,,2904.50,1887.92,,,,,,,,,,,,,
HEAD RMR MINI WRST FUS PLT,SUP-2107837,CDM,C1713,HCPCS,0278,RC,,,,both,,,1190.06,773.54,,,,,,,,,,,,,
ROD DOLPHIX DELTA KIT TITANIUM,SUP-2717567,CDM,C1713,HCPCS,0278,RC,,,,both,,,26062.00,16940.30,,,,,,,,,,,,,
DEFIBRILLATOR IMPL COMPIA MRI SURESCAN W 51 X H 71 MM D 13,SUP-2421029,CDM,C1882,HCPCS,0275,RC,,,,both,,,43646.00,28369.90,,,,,,,,,,,,,
CATHETER ABLAT 7FR L110CM TIP L10MM 2.5MM SPC QPLR STD CRV,SUP-2148480,CDM,C1733,HCPCS,0272,RC,,,,both,,,4794.78,3116.61,,,,,,,,,,,,,
SET URET STENT UTHANE L 26 CM POS L 46 CM DIA 7.0 FR SLV L,SUP-2168927,CDM,C2617,HCPCS,0278,RC,,,,both,,,745.75,484.74,,,,,,,,,,,,,
HC Ventilator Initial Day,PX-4109400200,CDM,94002,CPT,0410,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
SCREW INTFR L25MM DIA8MM CANN W/ DISP SHTH,SUP-2121170,CDM,C1713,HCPCS,0278,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
BIT DRL OD2.5MM CANN INTOSS FIX SYS,SUP-2315899,CDM,2720000010,LOCAL,0272,RC,,,,both,,,555.78,361.26,,,,,,,,,,,,,
SYRINGE ANGIO 8ML CONTROLED PALM PLUNG FIX M CONN RNG GRP,SUP-2302472,CDM,C1713,HCPCS,0278,RC,,,,both,,,14.38,9.35,,,,,,,,,,,,,
SPACER SPNL H33-53MM 12MM COR VERT BODY REPL LORD,SUP-2229956,CDM,C1821,HCPCS,0278,RC,,,,both,,,21980.00,14287.00,,,,,,,,,,,,,
SLEEVE CNTR L38.1MM OD12.7MM ID9MM FOR IM HIP SCR,SUP-2351365,CDM,C1713,HCPCS,0278,RC,,,,both,,,715.73,465.22,,,,,,,,,,,,,
HC So Aquaporin-4 Antibody Cell-Based Imfluor Assay Ea,PX-3028605266,CDM,86052,CPT,0302,RC,,,,both,,,858.00,557.70,,,,,,,,,,,,,
WSHR ORTH 8MM POLARUS 3 LOCK STRL,SUP-2639524,CDM,C1713,HCPCS,0278,RC,,,,both,,,844.66,549.03,,,,,,,,,,,,,
HC So Dna/Rna Amplified Probe,PX-3008715066,CDM,87150,CPT,0300,RC,,,,inpatient,,,173.00,112.45,,,,,,,,,,,,,
HC Needle Bx Abd/Retroper Mass,PX-3614918000,CDM,49180,CPT,0361,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
STEM FEM L127MM DIA15MM PROX HIP STR CEM W/O POR BODY GMRS,SUP-2376429,CDM,C1776,CPT,0278,RC,,,,both,,,6699.03,4354.37,,,,,,,,,,,,,
PLATE BONE METATARSOPHALANGEAL LEFT STANDARD TITANIUM ARSENAL FOOT PLATING SYSTEM FOR 2.2/2.7/3.5MM SCREW,SUP-2878468,CDM,C1713,HCPCS,0278,RC,,,,both,,,7237.70,4704.50,,,,,,,,,,,,,
PLATE BONE LOCKING HOLEX4 LEFT LATERAL PROXIMAL TIBIAL,SUP-2588167,CDM,C1713,HCPCS,0278,RC,,,,both,,,3808.60,2475.59,,,,,,,,,,,,,
GRAFT VASC GORTX L 40 CM DIA 4 MM EPTFE STR STD WALL N RING,SUP-2396414,CDM,C1768,CPT,0278,RC,,,,both,,,1142.96,742.92,,,,,,,,,,,,,
PLATE BNE W16XL158MM THK5MM 7 H R CNDYL FEM S STL BTTRS DYN,SUP-2185805,CDM,C1713,HCPCS,0278,RC,,,,both,,,2366.05,1537.93,,,,,,,,,,,,,
SPACER SPNL 9X9X26MM 4 DEG L NAR IMPACTED PEEK COROENT,SUP-2310782,CDM,C1821,HCPCS,0278,RC,,,,both,,,7614.50,4949.42,,,,,,,,,,,,,
GUIDEWIRE STR BENT TYP STIFF 0038INX150CM ZIPWIRE,SUP-2139351,CDM,C1769,HCPCS,0272,RC,,,,both,,,168.56,109.56,,,,,,,,,,,,,
MATRIX HUM TISS L 5 X W 7 CM THK 0.2-1 MM ACELLULAR DERMAL,SUP-2909229,CDM,Q4122,HCPCS,0636,RC,,,,both,,,7682.01,4993.31,,,,,,,,,,,,,
SCREW BNE CANN 8X80 MM TI ASNS III,SUP-2559089,CDM,C1713,HCPCS,0278,RC,,,,both,,,1186.92,771.50,,,,,,,,,,,,,
SET CATH HEMODIALYSI ESCHLN CHRONIC BASIC 15FR DIA 32CM STRG,SUP-2610558,CDM,C1750,HCPCS,0278,RC,,,,both,,,910.60,591.89,,,,,,,,,,,,,
SCREW BONE L80MM D35MM STNLSS STEEL CRTCL PRRTCLR SELF TPPNG,SUP-2460904,CDM,C1713,HCPCS,0278,RC,,,,both,,,93.16,60.55,,,,,,,,,,,,,
STEM HUM L83MM DIA15MM MINI UNIV CO CHROM POR PRI PRESSFIT,SUP-2404568,CDM,C1776,CPT,0278,RC,,,,both,,,12560.00,8164.00,,,,,,,,,,,,,
SCREW CRTX FT SELF TAP HEX HD 4.5MM DIA 42MML,SUP-2342660,CDM,C1713,HCPCS,0278,RC,,,,both,,,46.63,30.31,,,,,,,,,,,,,
BASEPLATE TIB L STD UNIV KNEE PRESSFIT STEM PRI POR W/ SCR H,SUP-2397050,CDM,C1776,CPT,0278,RC,,,,both,,,16390.80,10654.02,,,,,,,,,,,,,
GRAFT BIO TISS W2XL2CM DISC DERM MESHED SCAFFOLD PRIMATRIX,SUP-2243701,CDM,Q4110,HCPCS,0636,RC,,,,both,,,1507.20,979.68,,,,,,,,,,,,,
WASHER SPNL 1MM FIX BNE POLYAX TI MNRCH,SUP-2254525,CDM,C1713,HCPCS,0278,RC,,,,both,,,306.68,199.34,,,,,,,,,,,,,
K WIRE FIX L150MM DIA1.6MM S STL DBL END SMOOTH DBL SHRP,SUP-2316403,CDM,C1769,HCPCS,0272,RC,,,,both,,,102.99,66.94,,,,,,,,,,,,,
PIN GIC64 15X50MM RESRB NEXFIX RFS,SUP-2388884,CDM,C1713,HCPCS,0278,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
SET INTRO TRIFORCE CATH L 65 CM DIA 4 FR SHTH L 55 CM ID 5,SUP-2171151,CDM,C1894,HCPCS,0272,RC,,,,both,,,1117.84,726.60,,,,,,,,,,,,,
SURGICAL PROCEDURE PACK 25 MM SCAPHOLUNATE INT CRPL SLIC,SUP-2106425,CDM,C1713,HCPCS,0278,RC,,,,both,,,3896.74,2532.88,,,,,,,,,,,,,
POSTERIOR FEMORAL AUGMENT - UNIVERSAL SZ 4/5 5MM,SUP-2890722,CDM,C1776,CPT,0278,RC,,,,both,,,6594.00,4286.10,,,,,,,,,,,,,
CANNULATED IMPLANTS FOR FOREFOOT JOINTS CO CHROM MET HD SZ,SUP-2392728,CDM,L8642,HCPCS,0278,RC,,,,both,,,5338.00,3469.70,,,,,,,,,,,,,
SCREW DARTFIRE EDGE SNAP OFF D2420012,SUP-2849011,CDM,C1713,HCPCS,0278,RC,,,,both,,,2116.36,1375.63,,,,,,,,,,,,,
CANNULA SURG BNE CEMENT L 60 MM DIA15 GA SUBCHONDRAL DRL,SUP-2893168,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
COMPONENT HIP PRSS FT BPLR HD PART,SUP-2379205,CDM,C1776,CPT,0278,RC,,,,both,,,12246.00,7959.90,,,,,,,,,,,,,
VALVE TRACH WHT SPEAK VENT PASSY MUIR,SUP-2322021,CDM,L8501,HCPCS,0274,RC,,,,both,,,231.10,150.21,,,,,,,,,,,,,
CATHETER GUID 6FR L140CM WIRE CTRL VENTURE,SUP-2356606,CDM,C1887,HCPCS,0272,RC,,,,both,,,1993.90,1296.03,,,,,,,,,,,,,
SHELL BPLR DIA42MM ACET HIP HMSPHR SLR,SUP-2304365,CDM,C1776,CPT,0278,RC,,,,both,,,3469.70,2255.30,,,,,,,,,,,,,
GRAFT DURA W3XL3IN REGEN MTRX CLLGN BILAYER SUTURABLE,SUP-2244025,CDM,C1763,HCPCS,0278,RC,,,,both,,,3061.75,1990.14,,,,,,,,,,,,,
LINER HUM 0+ MM 60 DEG 40 MM VIVACIT-E,SUP-2436931,CDM,C1776,CPT,0278,RC,,,,both,,,4521.60,2939.04,,,,,,,,,,,,,
HC Njx Dx/Ther Sbst W/Indwelling Cath Intrlmnr Crv/Thrc W/Img Gdn,PX-3606232500,CDM,62325,CPT,0360,RC,,,,inpatient,,,2895.00,1881.75,,,,,,,,,,,,,
TEMPLATE DERM REGEN W4XL10IN BOV TEND CLLGN,SUP-2244244,CDM,Q4105,HCPCS,0636,RC,,,,both,,,35400.36,23010.23,,,,,,,,,,,,,
SUPPORT ORTHOT HIP JT LOWER EXTREMITY PELV CTRL ADJ FLX,SUP-2435685,CDM,L2622,HCPCS,0274,RC,,,,both,,,900.87,585.57,,,,,,,,,,,,,
CUBE EXT FIX 40 MM UBER,SUP-2898449,CDM,2720000010,LOCAL,0272,RC,,,,both,,,690.80,449.02,,,,,,,,,,,,,
PROBE OPHTH LASER STR STRL 25GA,SUP-2129219,CDM,2720000010,LOCAL,0272,RC,,,,both,,,369.83,240.39,,,,,,,,,,,,,
GRAFT BNE SHFT SM 100-125 MM FD CORTICAL,SUP-2264581,CDM,C1713,HCPCS,0278,RC,,,,both,,,3124.30,2030.79,,,,,,,,,,,,,
CATHETER ETER PERI DLYS COILED W DBL CUF SET 63CM,SUP-2269530,CDM,C1750,HCPCS,0278,RC,,,,both,,,335.98,218.39,,,,,,,,,,,,,
MESH HERN W10XL13CM POLYPR POLYDIOXANONE POLYMER OVL THN,SUP-2219768,CDM,C1781,HCPCS,0278,RC,,,,both,,,7378.69,4796.15,,,,,,,,,,,,,
HC Icu R&B,PX-2000000000,CDM,2000000000,LOCAL,0200,RC,,,,inpatient,,,4935.00,3207.75,,,,,,,,,,,,,
RING FOOT LNG 155MM,SUP-2481005,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5950.93,3868.10,,,,,,,,,,,,,
GRAFT VASC GORTX L 50 CM DIA 6 MM EPTFE STR TW N RING STRL,SUP-2396696,CDM,C1768,CPT,0278,RC,,,,both,,,1899.70,1234.80,,,,,,,,,,,,,
PLATE BNE LCK 189 MM LT DSTL LAT TIB PERIARTICULAR 14 HOLE,SUP-2492343,CDM,C1713,HCPCS,0278,RC,,,,both,,,4491.68,2919.59,,,,,,,,,,,,,
SPLINT ORTH AD W21XL80CM PVC DURABLE SGL CHMBR LNG ARM FOR,SUP-2309123,CDM,L3908,HCPCS,0272,RC,,,,both,,,149.43,97.13,,,,,,,,,,,,,
GRAFT WEDGE BNE COTTON 8MM 30X16MM BONUS,SUP-2656709,CDM,C1713,HCPCS,0278,RC,,,,both,,,1485.85,965.80,,,,,,,,,,,,,
GRAFT BNE SUB W14XH8XL14MM CORT INTBDY FUS FRZ DRY BLK SPCR,SUP-2293782,CDM,C1713,HCPCS,0278,RC,,,,both,,,2650.16,1722.60,,,,,,,,,,,,,
PLUG VASC AMPLATZER UNCONSTRAINED L 7 MM DIA 6 MM DEL SYS L,SUP-2892937,CDM,C1889,HCPCS,0278,RC,,,,both,,,2515.14,1634.84,,,,,,,,,,,,,
CATHETER GUID 6FR L150CM GUID SEG L25CM PLAT IRIDIUM HELCL,SUP-2140875,CDM,C1887,HCPCS,0272,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
DEVICE ANNULAR CLOSURE 8 MM STRL BARRICAID LTX,SUP-2858409,CDM,C1713,HCPCS,0278,RC,,,,both,,,17898.00,11633.70,,,,,,,,,,,,,
SYSTEM DEL 14FR L107CM REPL W/ INTEGR HNDL FOR 23/26/29MM,SUP-2282430,CDM,2780000006,LOCAL,0278,RC,,,,both,,,6625.40,4306.51,,,,,,,,,,,,,
CATHETER REPROC EP SUPER LG 2-5 INQUIRY,SUP-2473347,CDM,C1731,HCPCS,0278,RC,,,,both,,,1226.20,797.03,,,,,,,,,,,,,
HC Sacroplasty,PX-3610200000,CDM,0200T,CPT,0361,RC,,,,both,,,7342.00,4772.30,,,,,,,,,,,,,
GUIDEPIN ORTH L230MM OD3.2MM S STL THRD,SUP-2340798,CDM,C1713,HCPCS,0278,RC,,,,both,,,362.45,235.59,,,,,,,,,,,,,
OPES 90 ASPIRATING ABLATOR,SUP-2815984,CDM,2720000010,LOCAL,0272,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
SCREW BNE LCK 6.5X26 MM ANK FUSION CONSTRUCT,SUP-2609803,CDM,C1713,HCPCS,0278,RC,,,,both,,,1097.96,713.67,,,,,,,,,,,,,
ALLOGRAFT HUM TISS SHT 4X4 CM PLCNTA BASE MEMBRN AMNIOEFFECT,SUP-2871499,CDM,C1762,CPT,0278,RC,,,,both,,,7162.34,4655.52,,,,,,,,,,,,,
PIN CNTR SPARE FOR HLLW RMR EXT FIX,SUP-2187149,CDM,C1713,HCPCS,0278,RC,,,,both,,,356.67,231.84,,,,,,,,,,,,,
ALLODERM SELECT RESTORE X-LARGE PERFORATED - MEDIUM 1.6 0.4M,SUP-2827047,CDM,Q4116,HCPCS,0636,RC,,,,both,,,55336.22,35968.54,,,,,,,,,,,,,
HC Car Seat / Bed Test 60 Min,PX-4109478000,CDM,94780,CPT,0410,RC,,,,outpatient,,,124.00,80.60,,,,,,,,,,,,,
CATHETER DRNGE PERI L120CM VENT L14CM ENDOMYOCARD RT ANG,SUP-2243807,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2894.70,1881.55,,,,,,,,,,,,,
GRAFT ALLGRFT TYP ANTIMIGRATION CORT DWL,SUP-2309707,CDM,C1713,HCPCS,0278,RC,,,,both,,,5966.00,3877.90,,,,,,,,,,,,,
PIN FIX L9IN DIA24MM ST S STL 2 SIDE SGL DMND 1 END PNT,SUP-2150478,CDM,C1713,HCPCS,0278,RC,,,,both,,,13.22,8.59,,,,,,,,,,,,,
RESERVOIR VENT 0.3ML DIA18MM CATH SM L23CM CSF BA IMPREG RT,SUP-2284525,CDM,C1713,HCPCS,0278,RC,,,,both,,,894.62,581.50,,,,,,,,,,,,,
CATHETER PULM ART 5FR L60CM INTRO 5FR INFLATED BAL 0.75CC,SUP-2383930,CDM,C1725,HCPCS,0272,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
GRAFT BNE PTTY 5 CC DBM GRFT,SUP-2294011,CDM,C1713,HCPCS,0278,RC,,,,both,,,1921.68,1249.09,,,,,,,,,,,,,
CATHETER INT THCL 110 CM,SUP-2225534,CDM,C1755,HCPCS,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
RESTRICTOR CEM L25MM FEM FOR TOT PREP-IM KT BUCK,SUP-2342753,CDM,C1713,HCPCS,0278,RC,,,,both,,,141.30,91.84,,,,,,,,,,,,,
HEAD HUM DIA40MM THK20MM 4MM OFFSET SHOULDERX3 ECC SGL RAD,SUP-2373624,CDM,C1776,CPT,0278,RC,,,,both,,,4787.24,3111.71,,,,,,,,,,,,,
PIN POS KRENKEL FIG 11 9.5 IN CNDYL,SUP-2472331,CDM,C1713,HCPCS,0278,RC,,,,both,,,457.03,297.07,,,,,,,,,,,,,
SCREW ACET LP 6.5X100 MM HIP SYS TI RINGLOK,SUP-2449907,CDM,C1713,HCPCS,0278,RC,,,,both,,,536.94,349.01,,,,,,,,,,,,,
GUIDEWIRE VASC LUNDERQUIST L260CM 0.035IN 11CM 7.5/7.5MM DBL,SUP-2170507,CDM,C1769,HCPCS,0272,RC,,,,both,,,368.01,239.21,,,,,,,,,,,,,
CATHETER THORACENTESIS DRY SET 8.5 FRX8.7 CM 15 GA EMGCY,SUP-2759771,CDM,C1729,HCPCS,0272,RC,,,,both,,,356.01,231.41,,,,,,,,,,,,,
MESH HERN MED 3.5X5.7 IN ANAT O3FA FIL COAT C-QUR CENTRIFX,SUP-2227253,CDM,C1781,HCPCS,0278,RC,,,,both,,,461.58,300.03,,,,,,,,,,,,,
PROBE COAG L330CM DIA2.3MM STR FIRE ARC SMRT,SUP-2360708,CDM,C1713,HCPCS,0278,RC,,,,both,,,692.37,450.04,,,,,,,,,,,,,
BOOT CAST SM W5XL11 1 4IN OPN TOE AND HEEL MOLD ROCK,SUP-2276728,CDM,L4386,HCPCS,0274,RC,,,,both,,,16.17,10.51,,,,,,,,,,,,,
STEM FEM SZ 3 8DEG STR HIP CLASS PROFEMUR PRESERVE,SUP-2304851,CDM,C1776,CPT,0278,RC,,,,both,,,7222.00,4694.30,,,,,,,,,,,,,
PLATE RAD HD RIM 2.4MM 2H LT TI LCP,SUP-2549707,CDM,C1713,HCPCS,0278,RC,,,,both,,,1926.92,1252.50,,,,,,,,,,,,,
GRAFT BNE CORT STRUT ALLGRFT FRZN IMPL L200XW20MM MATRIGRFT,SUP-2264744,CDM,C1713,HCPCS,0278,RC,,,,both,,,1440.51,936.33,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED PRICE,SUP-2212488,CDM,C1776,CPT,0278,RC,,,,both,,,13816.00,8980.40,,,,,,,,,,,,,
SET INTRO 4FR L10CM NDL 21GA L7CM GWIRE 0018IN NIT COR,SUP-2302995,CDM,C1713,HCPCS,0278,RC,,,,both,,,94.04,61.13,,,,,,,,,,,,,
NEUROSTIMULATOR INTERSTIM X RECHRGE FREE TORQ WRNCH PROD,SUP-2738996,CDM,C1767,HCPCS,0278,RC,,,,both,,,29845.70,19399.70,,,,,,,,,,,,,
ORTHOPEDIC KIT GLENOSPHERE 38 MM EXT LCK CAP,SUP-2451417,CDM,C1776,CPT,0278,RC,,,,both,,,3611.00,2347.15,,,,,,,,,,,,,
WEDGE FEM SZ 5 THK5MM STD UNIV DST KNEE PRI PRESSFIT CEM,SUP-2346329,CDM,C1776,CPT,0278,RC,,,,both,,,3774.28,2453.28,,,,,,,,,,,,,
PLATE BONE L64MM THK0.5-1.6MM 7 H LCK COMPR RT SH MALL TI,SUP-2267981,CDM,C1713,HCPCS,0278,RC,,,,both,,,2841.70,1847.10,,,,,,,,,,,,,
SCREW DISTRCTN ST 14 MM DISP,SUP-2106567,CDM,C1713,HCPCS,0278,RC,,,,both,,,166.42,108.17,,,,,,,,,,,,,
ALLOGRAFT BNE PLATE SM FD IRRADIATED TIB,SUP-2867175,CDM,C1762,CPT,0278,RC,,,,both,,,2094.07,1361.15,,,,,,,,,,,,,
STEM FEM SPLINED KNEE TAPR MICROPLASTY,SUP-2446370,CDM,C1776,CPT,0278,RC,,,,both,,,876.06,569.44,,,,,,,,,,,,,
PLATE SPNL SZ 10 2 H ANT LAT LUM XLP,SUP-2311329,CDM,C1713,HCPCS,0278,RC,,,,both,,,5024.00,3265.60,,,,,,,,,,,,,
SCREW IM LCK CORT TI DIAM 5.0MM LEN 70MM,SUP-2363498,CDM,C1713,HCPCS,0278,RC,,,,both,,,322.16,209.40,,,,,,,,,,,,,
STABILIZER FEM 2XL DURAC LT KNEE MOD MONO IMP,SUP-2364848,CDM,C1776,CPT,0278,RC,,,,both,,,6506.08,4228.95,,,,,,,,,,,,,
PROSTHESIS OSS MIC 2-10 MM OFF CENTERED ADJ TI TORP,SUP-2638132,CDM,L8613,CPT,0278,RC,,,,both,,,1086.66,706.33,,,,,,,,,,,,,
WIRE FIX 1.6 MM KIRSCHNER,SUP-2400530,CDM,C1713,HCPCS,0278,RC,,,,both,,,78.50,51.02,,,,,,,,,,,,,
PLATE BNE L THK0.8MM 3X4 H L BILAT CRANIOMAXILLOFACIAL G TI,SUP-2181706,CDM,C1713,HCPCS,0278,RC,,,,both,,,1158.35,752.93,,,,,,,,,,,,,
CUP ACET DIA 41 MM SS TI SPRY HA HIP 2 MOBILITY CMTLS PF 3,SUP-2913774,CDM,C1776,CPT,0278,RC,,,,both,,,29030.68,18869.94,,,,,,,,,,,,,
CAGE SPNL SM 12 MM PEEK,SUP-2136812,CDM,C1889,HCPCS,0278,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
IMPL KWIRE SMTH VARIAX 1.4X100MM,SUP-2492765,CDM,2720000010,LOCAL,0272,RC,,,,both,,,31.40,20.41,,,,,,,,,,,,,
MESH SURG L 15 X W 10 CM D 1.5 MM PORCINE DERMAL CLLGN ABD,SUP-2901807,CDM,C9364,HCPCS,0278,RC,,,,both,,,10317.60,6706.44,,,,,,,,,,,,,
HC US Breast Ltd,PX-4027664200,CDM,76642,CPT,0402,RC,,,,both,,,1221.00,793.65,,,,,,,,,,,,,
HC Plc Brst Dvc 1st Lesion Mam,PX-3201928100,CDM,19281,CPT,0320,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
GRAFT HUM TISS L23CM PERONEUS LONGUS FRZN DBL STRND,SUP-2257906,CDM,C1762,CPT,0278,RC,,,,both,,,7855.56,5106.11,,,,,,,,,,,,,
HC Suture Tongue > 2.6 Cm,PX-4504125200,CDM,41252,CPT,0450,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
HC Continous Inhale Tx 1st Hour,PX-4109464400,CDM,94644,CPT,0410,RC,,,,outpatient,,,660.00,429.00,,,,,,,,,,,,,
GRAFT HUM TISS 2X6CM AMNIOFIX,SUP-2305725,CDM,V2790,HCPCS,0274,RC,,,,both,,,1796.08,1167.45,,,,,,,,,,,,,
TUBE SET ASPIR PRECIS TIP CYL SHAVER NEXUS SONASTAR,SUP-2748596,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4217.52,2741.39,,,,,,,,,,,,,
HC Blood Count Hematocrit,PX-3058501400,CDM,85014,CPT,0305,RC,,,,both,,,66.00,42.90,,,,,,,,,,,,,
COMPONENT FEM F LT KNEE OPT NXGN LPS-FLEX,SUP-2437984,CDM,C1776,CPT,0278,RC,,,,both,,,10141.51,6591.98,,,,,,,,,,,,,
CATH 6F 125CMS 8E 40 3MM EMC,SUP-2424787,CDM,C1730,HCPCS,0272,RC,,,,both,,,973.40,632.71,,,,,,,,,,,,,
BIT DRL FLX ANAT LABRUM RESTR SYS DISP NANOTACK,SUP-2366742,CDM,2720000010,LOCAL,0272,RC,,,,both,,,696.39,452.65,,,,,,,,,,,,,
BIT DRL DIA65MM CONIC W STP FOR MULTILOC PROX HUM NAIL,SUP-2178942,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1147.42,745.82,,,,,,,,,,,,,
PLATE CRAN 140X80X40 MM PT SPEC IMPL PEEK,SUP-2860141,CDM,C1713,HCPCS,0278,RC,,,,both,,,36009.83,23406.39,,,,,,,,,,,,,
COMPONENT TIB AUG 360 DEG 10 MM W/ BOLT,SUP-2441915,CDM,C1776,CPT,0278,RC,,,,both,,,141.30,91.84,,,,,,,,,,,,,
STEM TALAR 2 L14MM ANK PROPHECY INBONE,SUP-2397139,CDM,C1776,CPT,0278,RC,,,,both,,,2744.36,1783.83,,,,,,,,,,,,,
CAGE SPNL PARL 17X14X8 MM MP DIVERGENCE,SUP-2632023,CDM,C1889,HCPCS,0278,RC,,,,both,,,2433.50,1581.77,,,,,,,,,,,,,
COLLAR CERV AND PD SET CAPITAL ENH,SUP-2336001,CDM,L0174,HCPCS,0272,RC,,,,both,,,112.88,73.37,,,,,,,,,,,,,
GUIDEWIRE VASC GLIDEWIRE 180CM 0.035IN TIP L 1 CM ANGLED,SUP-2385107,CDM,C1769,HCPCS,0272,RC,,,,both,,,130.31,84.70,,,,,,,,,,,,,
NEEDLE INTRO BX COAX 15 GX10.6 CM W/INTRO,SUP-2120162,CDM,C1894,HCPCS,0272,RC,,,,both,,,56.52,36.74,,,,,,,,,,,,,
ROCKER BOTTOM EXTERNAL FIXATION ALUMINUM SILICONE RUBBER,SUP-2586509,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4625.16,3006.35,,,,,,,,,,,,,
PROBE LASER 25GA DIR FOR VISION,SUP-2129222,CDM,2720000010,LOCAL,0272,RC,,,,both,,,556.63,361.81,,,,,,,,,,,,,
BLOCK DISTRCTN 75 MM STRUT RIGID COMPR 66,SUP-2197303,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1071.53,696.49,,,,,,,,,,,,,
DESMOPRESSIN ACETATE 0.1 MG PO TABS,RX-16052,CDM,6370000000,HCPCS,0637,RC,60505-0257-01,NDC,,both,1,UN,3.40,2.21,,,,,,,,,,,,,
HC Bx Breast 1st Les MR Image|RIGHT SIDE|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE PRIOR TO THE ADMINISTRATION OF ANESTHESIA,PX-3611908500,CDM,19085,CPT,0361,RC,,,RT|73,outpatient,,,6672.00,4336.80,,,,,,,,,,,,,
HC Endoven Ther Chem Adhes Sbsq,PX-3613648300,CDM,36483,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
SUPPORT ORTHOT CUST OUTRIG,SUP-2435578,CDM,L1080,HCPCS,0272,RC,,,,both,,,148.15,96.30,,,,,,,,,,,,,
LEVOFLOXACIN IN D5W 250 MG/50ML IV SOLN,RX-104433,CDM,J1956,HCPCS,0636,RC,25021-0132-81,NDC,,both,50,ML,54.10,35.16,,,,,,,,,,,,,
FIXATOR EXT GUID DORS PIN PREDRILLED TRNSVRS CAP APPL CUT,SUP-2237248,CDM,C1713,HCPCS,0278,RC,,,,both,,,4396.00,2857.40,,,,,,,,,,,,,
BOOT CAST W/ CUF SM BLK,SUP-2277488,CDM,L4386,HCPCS,0272,RC,,,,both,,,238.45,154.99,,,,,,,,,,,,,
HEAD RMR DIA9.5MM PILOT NOSE FOR CLINICALLY PROVEN IM HIP,SUP-2343581,CDM,2720000010,LOCAL,0272,RC,,,,both,,,801.33,520.86,,,,,,,,,,,,,
BOOT CAST W/ CUF SM BLK,SUP-2277488,CDM,L4386,HCPCS,0274,RC,,,,both,,,238.45,154.99,,,,,,,,,,,,,
SCREW BNE L24MM DIA4.5MM GLEN SHLDR METAGLENE LOK FOR DELT,SUP-2251020,CDM,C1713,HCPCS,0278,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
SCREW SPNL L30MM DIA4.75MM PEDCL TI POLYAX MNRCH SYS,SUP-2254485,CDM,C1713,HCPCS,0278,RC,,,,both,,,3441.44,2236.94,,,,,,,,,,,,,
SET PERICARDCENT L 22 CM DIA 7 FR GUIDEWIRE L 70 CM DIA,SUP-2760017,CDM,C1729,HCPCS,0272,RC,,,,both,,,482.40,313.56,,,,,,,,,,,,,
CONNECTOR SPNL D SHP BAR 5.5 MM SACR STD ASMBLY OPN EXPEDIUM,SUP-2590528,CDM,C1713,HCPCS,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
GRAFT BONE SUB BONE GRFT 1ML GEL TRANZGRFT,SUP-2353937,CDM,C1713,HCPCS,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
PLATE BONE L 40X65MM THK0.4MM SUBOCCIPITAL RIG FOR 1.5MM SCR,SUP-2363579,CDM,C1713,HCPCS,0278,RC,,,,both,,,3154.82,2050.63,,,,,,,,,,,,,
STENT GRFT VASC AFX L 95 MM DIA PROX/DSTL 25 MM COCR,SUP-2217594,CDM,C1768,CPT,0278,RC,,,,both,,,11570.90,7521.08,,,,,,,,,,,,,
GRAFT ENDOVASC L18CM AORT DIA26MM IL DIA12MM ABD EXCLUDER,SUP-2396076,CDM,C1768,CPT,0278,RC,,,,both,,,34540.00,22451.00,,,,,,,,,,,,,
COMPONENT FEM SZ 6 KNEE HNG AXLE LEGION,SUP-2346403,CDM,C1776,CPT,0278,RC,,,,both,,,1540.96,1001.62,,,,,,,,,,,,,
ENDOPROSTHESIS VASC VIABAHN L 10 CM DIA13 MM CATH L 110 CM,SUP-2396473,CDM,C1874,HCPCS,0278,RC,,,,both,,,9263.00,6020.95,,,,,,,,,,,,,
SCREW BONE L26MM DIA2.7MM FT TI LCK T8 DBL LD EXTREMILOCK,SUP-2319729,CDM,C1713,HCPCS,0278,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
TUBE FEED NSL 8 FR SIL WHT BRIDLE PRO LF,SUP-2754580,CDM,2720000010,LOCAL,0272,RC,,,,both,,,604.92,393.20,,,,,,,,,,,,,
PLATE KNEE MG II OPT STEM TIB C/YELLOW,SUP-2199657,CDM,C1776,CPT,0278,RC,,,,both,,,10691.07,6949.20,,,,,,,,,,,,,
VITAMIN D 25 MCG (1000 UT) PO TABS,RX-147710,CDM,6370000000,HCPCS,0637,RC,54629-0050-24,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
LINER ACET OD68MM ID28MM +4MM OFFSET 10DEG HIP MARATHON,SUP-2250366,CDM,C1776,CPT,0278,RC,,,,both,,,4722.56,3069.66,,,,,,,,,,,,,
ELECTRODE SPATULA WITH MOVABLE SHEATH LAPAROSCOPIC REUSABLE,SUP-2843214,CDM,2720000010,LOCAL,0272,RC,,,,both,,,709.39,461.10,,,,,,,,,,,,,
SHUNT VENTRICULAR L2.3CM OD13.8FR ODSEC4.6MM VERTICAL 40CM H,SUP-2825656,CDM,C1889,HCPCS,0278,RC,,,,both,,,6701.64,4356.07,,,,,,,,,,,,,
ENDCAP SPNL 8 DEG 30 MM FOR PLATE T2 STRATOSPHERE,SUP-2423826,CDM,C1889,HCPCS,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
GRAFT BIO TISS W7XL10CM 4 LAYR PORCINE MTRX ABD HERN,SUP-2168772,CDM,C1781,HCPCS,0278,RC,,,,both,,,3375.50,2194.07,,,,,,,,,,,,,
DECITABINE 50 MG IV SOLR,RX-76364,CDM,J0894,HCPCS,0636,RC,67457-0316-25,NDC,,both,1,UN,1137.60,739.44,,,,,,,,,,,,,
SCREW EXT FIX L60MM DIA4MM THRD L20MM CORT TI SELF DRL SCHNZ,SUP-2193159,CDM,C1713,HCPCS,0278,RC,,,,both,,,483.84,314.50,,,,,,,,,,,,,
PURAPLY AM 8X16 128SQ CM,SUP-2314120,CDM,Q4196,HCPCS,0636,RC,,,,both,,,9263.00,6020.95,,,,,,,,,,,,,
ALLOGRAFT DERMAL UNMESHED 8X20 CMX0.75-1.5 MM SFT DERMACELL,SUP-2427792,CDM,Q4122,HCPCS,0636,RC,,,,both,,,39935.96,25958.37,,,,,,,,,,,,,
SUPPORT ORTHOT LOWER EXTREMITY CUST EXT STL SHANK,SUP-2435661,CDM,L2360,HCPCS,0272,RC,,,,both,,,145.98,94.89,,,,,,,,,,,,,
GRAFT NRV L2CM ID3MM CLLGN PERIPH SEMI PERM BIOCOMPATIBLE,SUP-2244350,CDM,C9352,HCPCS,0278,RC,,,,both,,,3358.39,2182.95,,,,,,,,,,,,,
GRAFT HUMAN TSSUE SGMNT SM 8MML BRCHMTTRSL FRZE DRIED IRRDTD,SUP-2727663,CDM,C1713,HCPCS,0278,RC,,,,both,,,3733.15,2426.55,,,,,,,,,,,,,
SCREW BNE 4 MM 71823212] SMITH AND NEPHEW ORTHOPAEDICS],SUP-2348745,CDM,C1713,HCPCS,0278,RC,,,,both,,,62.64,40.72,,,,,,,,,,,,,
TROCAR SURGICAL 60MML TRANSBUCCAL,SUP-2695259,CDM,2720000010,LOCAL,0272,RC,,,,both,,,369.89,240.43,,,,,,,,,,,,,
ALLOGRAFT DERMAL 25X30X2 MM ACELLULAR DERMAL MTRX ARTHROFLEX,SUP-2740935,CDM,Q4125,HCPCS,0636,RC,,,,both,,,4747.68,3085.99,,,,,,,,,,,,,
SET DIL DIA4 5 6 7FR SALIVARY ACC OTOLARYN,SUP-2169479,CDM,2720000010,LOCAL,0272,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
SCREW BNE L10MM DIA2.7MM S STL CORT MIDFOOT FOREFOOT ST VAR,SUP-2348710,CDM,C1713,HCPCS,0278,RC,,,,both,,,198.13,128.78,,,,,,,,,,,,,
WASHER ORTH SCREW DIA 5.5 MM HD NS,SUP-2896692,CDM,C1713,HCPCS,0278,RC,,,,both,,,153.86,100.01,,,,,,,,,,,,,
GUIDEWIRE VASC L 150 CM DIA 0.021 IN TIP L 6 MM PTFE J FIX,SUP-2301926,CDM,C1769,HCPCS,0272,RC,,,,both,,,28.42,18.47,,,,,,,,,,,,,
HC Pulse Ox Multiple Determine,PX-4609476100,CDM,94761,CPT,0460,RC,,,,inpatient,,,406.00,263.90,,,,,,,,,,,,,
KIT CATH ARROWG+ARD BLU + L 16 CM DIA 7 FR GUIDEWIRE L 45 CM,SUP-2745250,CDM,C1751,HCPCS,0278,RC,,,,both,,,441.48,286.96,,,,,,,,,,,,,
SYSTEM MIXER BONE CEMENT W/90DEG LONG EXT TUBE PCD VERTAPLEX,SUP-2875967,CDM,C1713,HCPCS,0278,RC,,,,both,,,2193.04,1425.48,,,,,,,,,,,,,
PLATE BONE CURVED 3.5X94 MM 8 HOLE RECONSTRUCTION FOR SCREW,SUP-2836669,CDM,C1713,HCPCS,0278,RC,,,,both,,,3456.98,2247.04,,,,,,,,,,,,,
TUBE GAST VISIGI 3D 32FR,SUP-2138630,CDM,2720000010,LOCAL,0272,RC,,,,both,,,750.46,487.80,,,,,,,,,,,,,
STENT NEPHURETSTMY L24CM OD10.2FR .038IN UTHANE COPE,SUP-2170573,CDM,C2617,HCPCS,0278,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
CABLE SURG L229MM DIA18MM HIP S STL BNE PLT SMOOTH SL,SUP-2252406,CDM,C1713,HCPCS,0278,RC,,,,both,,,1360.25,884.16,,,,,,,,,,,,,
BUR SURG RND CUT NONFLUTED CARB L54.0MM OD3.0MM,SUP-2284205,CDM,C1713,HCPCS,0278,RC,,,,both,,,631.14,410.24,,,,,,,,,,,,,
COMPONENT TOE L13MM DIA7MM MT CE TAPR POST HEMICAP,SUP-2123592,CDM,C1776,CPT,0278,RC,,,,both,,,1620.24,1053.16,,,,,,,,,,,,,
NAIL IM L170MM DIA12MM 125DEG SHT TROCHANTERIC FEM GRN TI,SUP-2191927,CDM,C1713,HCPCS,0278,RC,,,,both,,,3637.78,2364.56,,,,,,,,,,,,,
ELECTRODE ES VPR FOR USA ELITE SYS,SUP-2314003,CDM,2720000010,LOCAL,0272,RC,,,,both,,,695.67,452.19,,,,,,,,,,,,,
GRAFT HUM TISS W2XL2CM THK200UM AMNIO MEMBRN DEHYDR CHORION,SUP-2340447,CDM,C1762,CPT,0278,RC,,,,both,,,6732.16,4375.90,,,,,,,,,,,,,
DRIVER SURG CANN PARTIALLY THRD T15 AO QC,SUP-2898130,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1566.86,1018.46,,,,,,,,,,,,,
SET ORTH GRPHC CA W/ DRL BIT GUID CONCL SCR WRNCH BEND FE,SUP-2177073,CDM,C1713,HCPCS,0278,RC,,,,both,,,85952.10,55868.86,,,,,,,,,,,,,
COMP FEM AUG BTN STD/LG+ 10DTL,SUP-2513645,CDM,C1776,CPT,0278,RC,,,,both,,,1786.66,1161.33,,,,,,,,,,,,,
TRIAL FIX PIN MOB BEAR TIB TY,SUP-2252717,CDM,C1713,HCPCS,0278,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
CLIP ANEURYSM OPENING W2.3MM BLADE L5MM MICRO PHYNOX STRAIGH,SUP-2825388,CDM,C1889,HCPCS,0278,RC,,,,both,,,801.05,520.68,,,,,,,,,,,,,
HC So Hbv Dna W/Reflex to Geno,PX-3068751767,CDM,87517,CPT,0306,RC,,,,both,,,144.00,93.60,,,,,,,,,,,,,
DEFIBRILLATOR IMPL LUMAX 300 HF-T 55 X 66MM 12MM 30J BPLR,SUP-2138112,CDM,C1882,HCPCS,0275,RC,,,,both,,,84962.12,55225.38,,,,,,,,,,,,,
PLATE BNE L 75 MM 7 H RT VOLAR DSTL RADIAL STD NS VARIAX,SUP-2902194,CDM,C1713,HCPCS,0278,RC,,,,both,,,5202.76,3381.79,,,,,,,,,,,,,
SPLINT REST HND ADL R DRBLUE BROAD,SUP-2165489,CDM,L3807,HCPCS,0272,RC,,,,both,,,124.82,81.13,,,,,,,,,,,,,
CATHETER GUID L90CM DIA7FR 0.078IN S STL NYL PTFE COR AR1,SUP-2158414,CDM,C1887,HCPCS,0272,RC,,,,both,,,116.18,75.52,,,,,,,,,,,,,
HC So Esterase Inhibitor,PX-3028616166,CDM,86161,CPT,0302,RC,,,,both,,,289.00,187.85,,,,,,,,,,,,,
CLAMP EXT FIX MULTI PIN HII 2080 MRI 10HL,SUP-2732231,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3196.21,2077.54,,,,,,,,,,,,,
PLATE BNE ORTHOGNATHIC 2 PLATE NS FACE ID,SUP-2883353,CDM,C1713,HCPCS,0278,RC,,,,both,,,24833.16,16141.55,,,,,,,,,,,,,
CATHETER ABLAT 7FR L115CM TIP 4MM 2-5-2MM SPC 4 ELECTRD F,SUP-2248808,CDM,C1730,HCPCS,0272,RC,,,,both,,,2367.56,1538.91,,,,,,,,,,,,,
SUPPORT ORTHOT SHLDR CUST FIG OF EIGHT DESIGN ABDUCTN,SUP-2435750,CDM,L3650,HCPCS,0274,RC,,,,both,,,185.67,120.69,,,,,,,,,,,,,
REDUCER ORTH RADLUC STRL DISP DYNABUNION,SUP-2907568,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3759.90,2443.93,,,,,,,,,,,,,
SCREW BNE L4MM DIA1.5MM CORT TI ST FULL THRD W/ FLUT TIP,SUP-2189222,CDM,C1713,HCPCS,0278,RC,,,,both,,,228.59,148.58,,,,,,,,,,,,,
SUPPORT ORTHOT ANK KNEE TIB CUST FRAC RIGID,SUP-2435650,CDM,L2116,HCPCS,0274,RC,,,,both,,,2182.11,1418.37,,,,,,,,,,,,,
TUBE VENT 1.02 MM 1 MM 2.44/2.16 MM PAPARELLA TAB SIL 510041,SUP-2535081,CDM,L8699,HCPCS,0278,RC,,,,both,,,44.84,29.15,,,,,,,,,,,,,
PLATE BNE FIBULAR 2.7/3.5X219 MM LT LAT 18 HOLE BUTTRESS SS,SUP-2459691,CDM,C1713,HCPCS,0278,RC,,,,both,,,2297.60,1493.44,,,,,,,,,,,,,
COVER BURR HOLE CONTOURED 18X0.6 MM W/ 3 MM DRN LO PROF,SUP-2475663,CDM,C1713,HCPCS,0278,RC,,,,both,,,785.97,510.88,,,,,,,,,,,,,
INTRODUCER SHTH L90CM OD6FR .038IN PTFE S STL HYDRPHLC,SUP-2385649,CDM,C1894,HCPCS,0272,RC,,,,both,,,400.35,260.23,,,,,,,,,,,,,
DRESSING WND MICRONIZED PARTIC 200 MG MATRISTEM MICROMATRIX,SUP-2106475,CDM,Q4118,HCPCS,0636,RC,,,,both,,,1927.02,1252.56,,,,,,,,,,,,,
PIN HOLDING HDLSS 3.2X75 MM TROCAR ZUK,SUP-2853446,CDM,2720000010,LOCAL,0272,RC,,,,both,,,70.65,45.92,,,,,,,,,,,,,
PLATE BNE L208MM 14 H L DST POSTEROLATERAL HUM S STL LOK,SUP-2185917,CDM,C1713,HCPCS,0278,RC,,,,both,,,3121.25,2028.81,,,,,,,,,,,,,
SYSTEM FIX MED 4.5X2.2X7.5 MM FEMALE SFT TISS TENOTAC,SUP-2749807,CDM,C1713,HCPCS,0278,RC,,,,both,,,1478.94,961.31,,,,,,,,,,,,,
GUIDEWIRE VASC L185CM DIA0.014IN TIP L35CM HYDRPHLC STR LT,SUP-2142048,CDM,C1769,HCPCS,0272,RC,,,,both,,,210.38,136.75,,,,,,,,,,,,,
PIN FIX 50MM TRANSFIX QUIK CPL,SUP-2316016,CDM,C1713,HCPCS,0278,RC,,,,both,,,489.21,317.99,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC SOLO2 FT MAXBARR 5FR 55CM 3295108FD,SUP-2632676,CDM,C1751,HCPCS,0278,RC,,,,both,,,552.64,359.22,,,,,,,,,,,,,
PLATE BNE 3D PRNT MED MIDFACE MAND TI TRUMATCH,SUP-2860367,CDM,C1713,HCPCS,0278,RC,,,,both,,,23175.71,15064.21,,,,,,,,,,,,,
ENDOPROSTHESIS VASC WSTNT RP L 18 MM DIA 9 MM CATH TOT L 100,SUP-2142750,CDM,C1876,HCPCS,0278,RC,,,,both,,,3375.50,2194.07,,,,,,,,,,,,,
ROD SPNL PRECUT 40 MM LUMBAR,SUP-2256248,CDM,C1713,HCPCS,0278,RC,,,,both,,,1271.89,826.73,,,,,,,,,,,,,
HC Reprogramming Implanted Pump,PX-7616236800,CDM,62368,CPT,0761,RC,,,,both,,,961.00,624.65,,,,,,,,,,,,,
CATHETER URET L70CM OD10FR HYDR+,SUP-2139214,CDM,C1726,HCPCS,0272,RC,,,,both,,,172.95,112.42,,,,,,,,,,,,,
SCREW BNE THRD 6X180 MM 40 MM,SUP-2315870,CDM,C1713,HCPCS,0278,RC,,,,both,,,489.21,317.99,,,,,,,,,,,,,
CATHETER LD RETRV AVEIR VR L 105 CM DIA25 FR TRI LOOP 2,SUP-2880903,CDM,2720000010,LOCAL,0272,RC,,,,both,,,9420.00,6123.00,,,,,,,,,,,,,
WIRE SURG FLX INSTR NIT,SUP-2608587,CDM,C1713,HCPCS,0278,RC,,,,both,,,625.99,406.89,,,,,,,,,,,,,
GRAFT BONE 1ML MULT POTENT CELLULAR SUSP TISS OVATION REP,SUP-2319176,CDM,C1762,CPT,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
PLATE BNE W8XL52MM THK2MM 0DEG 6 H BILAT S STL STR RIG DYN,SUP-2186177,CDM,C1713,HCPCS,0278,RC,,,,both,,,538.26,349.87,,,,,,,,,,,,,
SPLINT ORTHOPEDIC BOUTONNIERE 4 FNGR BEAUTY STRENGTH,SUP-2325004,CDM,L3927,HCPCS,0272,RC,,,,both,,,250.76,162.99,,,,,,,,,,,,,
HC Assay of Triglycerides,PX-3018447800,CDM,84478,CPT,0301,RC,,,,both,,,146.00,94.90,,,,,,,,,,,,,
SCREW BONE L105MM DIA6.5MM CANC TI FULL THRD PLATING SYS,SUP-2413553,CDM,C1713,HCPCS,0278,RC,,,,both,,,131.88,85.72,,,,,,,,,,,,,
HC MRI-Myocardium W/WO Contrast,PX-6107556100,CDM,75561,CPT,0610,RC,,,,both,,,4647.00,3020.55,,,,,,,,,,,,,
PLATE BNE W255XL55MM WIDE 7X3 H NONSTERILE L DST RAD VOLAR,SUP-2180851,CDM,C1713,HCPCS,0278,RC,,,,both,,,2410.52,1566.84,,,,,,,,,,,,,
SCREW INTFR L23MM DIA10MM SHTH L L23MM TIB BIOCRYL RAPIDE,SUP-2249569,CDM,C1713,HCPCS,0278,RC,,,,both,,,2885.66,1875.68,,,,,,,,,,,,,
BOLT ORTHOPEDIC FUSION 6.5X145 MM MIDFOOT SS NS,SUP-2184104,CDM,C1713,HCPCS,0278,RC,,,,both,,,1521.42,988.92,,,,,,,,,,,,,
PROBE ARTHSCP MINI TIP DIA35MM 5MM GRADUATIONS STR FIRM GRP,SUP-2166512,CDM,2720000010,LOCAL,0272,RC,,,,both,,,432.32,281.01,,,,,,,,,,,,,
PLATE POS TRIANG 110 DEG/60 DEG/10 DEG,SUP-2548633,CDM,C1713,HCPCS,0278,RC,,,,both,,,179.07,116.40,,,,,,,,,,,,,
STRUT TRANSPORT 402X43X24,SUP-2481481,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5024.00,3265.60,,,,,,,,,,,,,
SCREW BNE L 20 MM DIA2 MM TI MAND ST AXS NS UNIV,SUP-2909553,CDM,C1713,HCPCS,0278,RC,,,,both,,,327.97,213.18,,,,,,,,,,,,,
RAIL EXT FIX LNG BODY COMPLT,SUP-2197293,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
PACK NEUROSURGICAL SHTH L 60 X W 11 MM MYRIAD HNDPC L 13 CM NN-3001,SUP-2930298,CDM,2720000010,LOCAL,0272,RC,,,,both,,,22103.37,14367.19,,,,,,,,,,,,,
HC So1 Immunofluor per Spec Ea Add Ab,PX-3128835067,CDM,88350,CPT,0312,RC,,,,both,,,96.00,62.40,,,,,,,,,,,,,
NAIL INTRMDLLRY 130 DGREE LNG 9X380 MM RIGHT HNDFT HIP FSN A,SUP-2495553,CDM,C1713,HCPCS,0278,RC,,,,both,,,6992.78,4545.31,,,,,,,,,,,,,
BLADE RETRCT W23MM D40MM M LEN SELF RET LNG TEETH BALL SNAP,SUP-2244383,CDM,2720000010,LOCAL,0272,RC,,,,both,,,404.59,262.98,,,,,,,,,,,,,
AXLE TIB FOR SM DST FEM GMRS,SUP-2376515,CDM,C1776,CPT,0278,RC,,,,both,,,2465.69,1602.70,,,,,,,,,,,,,
COIL EMB MIC EXT EMBOLUS L14CM COILED DIA12MM CATH 0.035IN,SUP-2169685,CDM,C1889,HCPCS,0278,RC,,,,both,,,395.61,257.15,,,,,,,,,,,,,
COMPONENT PATELLAR CEM 3 LT KNEE GENDER SOL,SUP-2437876,CDM,C1776,CPT,0278,RC,,,,both,,,6594.00,4286.10,,,,,,,,,,,,,
DRILL TWST L19MM DIA1.6MM WRK L8MM FOR 2/2.3MM SCR,SUP-2364189,CDM,2720000010,LOCAL,0272,RC,,,,both,,,866.70,563.35,,,,,,,,,,,,,
GRAFT VASC IMPRA L 60 CM DIA10 MM EPTFE FLX STD WALL RING,SUP-2126882,CDM,C1768,CPT,0278,RC,,,,both,,,2559.70,1663.80,,,,,,,,,,,,,
CLINIMIX E/DEXTROSE (5/15) 5 % IV SOLN,RX-23165,CDM,2500000003,HCPCS,0250,RC,00338-1123-04,NDC,,both,2000,ML,494.50,321.42,,,,,,,,,,,,,
ALLOGRAFT BNE WDG 9-13 MM FD ILIUM TRICORT,SUP-2717913,CDM,C1713,HCPCS,0278,RC,,,,both,,,3661.11,2379.72,,,,,,,,,,,,,
DEFIBRILLATOR IMPL VITALITY DS VR W 6.1 X H 6.6 CM D 1.1 CM,SUP-2149283,CDM,C1722,HCPCS,0275,RC,,,,both,,,49665.38,32282.50,,,,,,,,,,,,,
PLATE BNE L L 1ST 2ND 4 TMT CORNER GORILLA,SUP-2321518,CDM,C1713,HCPCS,0278,RC,,,,both,,,9090.30,5908.69,,,,,,,,,,,,,
PIN EXT FIX 6 H JET-X,SUP-2342953,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4142.29,2692.49,,,,,,,,,,,,,
FIBER LASER 550UM 6J 80HZ 120W D F L FOR LITHO MOSES,SUP-2417491,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1780.07,1157.05,,,,,,,,,,,,,
SUPPORT ORTH L8IN M NEOPRENE EL CNTCT CLSR STRP D RNG GOLFER,SUP-2196836,CDM,L3702,HCPCS,0272,RC,,,,both,,,20.85,13.55,,,,,,,,,,,,,
IMPLANT OTO PART POLYCEL CLASS DSGN SHEEHY,SUP-2284067,CDM,L8613,CPT,0278,RC,,,,both,,,715.42,465.02,,,,,,,,,,,,,
SCREW SPNL MULTAXL 7.5X40 MM ESSENCE TI CD HORZ ESSENTIALS,SUP-2631916,CDM,C1713,HCPCS,0278,RC,,,,both,,,8102.77,5266.80,,,,,,,,,,,,,
PLATE BONE 12 HOLE LEFT LTRL PRXML PRRTCLR TBL TTNM LOK CMPR,SUP-2494701,CDM,C1713,HCPCS,0278,RC,,,,both,,,4036.28,2623.58,,,,,,,,,,,,,
MATRIX HUM TISS DIA20 MM DECELL PLCNTA MEMBRN TROPHOBLAST,SUP-2909227,CDM,Q4201,HCPCS,0636,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
PAD ORTHOT LUMBAR CUST BOLSTER,SUP-2435573,CDM,L1030,HCPCS,0274,RC,,,,both,,,221.68,144.09,,,,,,,,,,,,,
HC Inject Sacroiliac Joint,PX-3612709600,CDM,27096,CPT,0361,RC,,,,outpatient,,,3707.00,2409.55,,,,,,,,,,,,,
COLLAR CERV SM H425IN POLY FOAM PLAS SUPP TWO PC CA PROCARE,SUP-2196883,CDM,L0172,HCPCS,0272,RC,,,,both,,,42.42,27.57,,,,,,,,,,,,,
PIN FIX L4MM DIA21MM RESORB X SONICPINS RX,SUP-2263018,CDM,C1713,HCPCS,0278,RC,,,,both,,,5082.88,3303.87,,,,,,,,,,,,,
CLIP SCALP UNIV NEURO SYS SGL MTL STR EDGE AD 1.5MM/1.7MM,SUP-2363680,CDM,C1889,HCPCS,0278,RC,,,,both,,,324.68,211.04,,,,,,,,,,,,,
ALLOGRAFT BNE BLOCK 8X8X8 MM SPNG FD CANC,SUP-2717778,CDM,C1713,HCPCS,0278,RC,,,,both,,,1442.26,937.47,,,,,,,,,,,,,
SCREW BNE LO PROF CANN SYS 25MMX16MM CAPTURE,SUP-2243886,CDM,C1713,HCPCS,0278,RC,,,,both,,,824.60,535.99,,,,,,,,,,,,,
HC Mra Abdomen W&W/O Contrast,PX-6187418502,CDM,C8902,CPT,0618,RC,,,,outpatient,,,2826.00,1836.90,,,,,,,,,,,,,
CATHETER HAD ADMIN BASIC KT SGL LUMN POLYUR PRECRV HYDRPHLC,SUP-2117396,CDM,C1750,HCPCS,0278,RC,,,,both,,,857.22,557.19,,,,,,,,,,,,,
STABILIT MX FRACTURE KIT LNG,SUP-2702136,CDM,2720000010,LOCAL,0272,RC,,,,both,,,9061.26,5889.82,,,,,,,,,,,,,
BUR SURG MTCH HD 3 MMX12 CM FLUT SM BOR MIDAS REX LEGEND,SUP-2627657,CDM,2720000010,LOCAL,0272,RC,,,,both,,,312.43,203.08,,,,,,,,,,,,,
IOBP KNEE OPEN TIP PROCEDURE KIT,SUP-2816371,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2402.10,1561.36,,,,,,,,,,,,,
GEMCITABINE HCL 200 MG IV SOLR,RX-17121,CDM,J9201,HCPCS,0636,RC,71288-0113-10,NDC,,both,1,UN,54.10,35.16,,,,,,,,,,,,,
SET INT FIX DIA18.5 MM TI NEURO XDRV 12 PK STRL DISP LORENZ,SUP-2935186,CDM,C1713,HCPCS,0278,RC,,,,both,,,26099.68,16964.79,,,,,,,,,,,,,
SET DCOMPR DRNGE CATH 10FR L350CM ACCSRY CHAN 3.7MM 0.035IN,SUP-2169320,CDM,C1713,HCPCS,0278,RC,,,,both,,,480.42,312.27,,,,,,,,,,,,,
PLATE BNE THK1.3MM 5 H MTCRPL TI STR COMPR FOR 2/2.3MM SCR,SUP-2267913,CDM,C1713,HCPCS,0278,RC,,,,both,,,821.42,533.92,,,,,,,,,,,,,
SHEATH GUID HALO 1 L 45 CM DIA 5 FR DIL L 52.5 CM GUIDEWIRE,SUP-2431945,CDM,2720000010,LOCAL,0272,RC,,,,both,,,989.10,642.91,,,,,,,,,,,,,
OXYGENATOR PERF 43ML FLO RATE 0.1-1.5LPMXCOATING HARDSHELL,SUP-2384817,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1805.50,1173.57,,,,,,,,,,,,,
PLATE BNE PROF THK 0.6 MM SCREW DIA1. 5 MM TI MIDFACE FLAT,SUP-2883893,CDM,C1713,HCPCS,0278,RC,,,,both,,,860.36,559.23,,,,,,,,,,,,,
PLATE BNE 2X2 H RECT FOR 15MM CRAN FIX UNIV NEURO III SYS,SUP-2363627,CDM,C1713,HCPCS,0278,RC,,,,both,,,954.47,620.41,,,,,,,,,,,,,
CATHETER DIAG 4FR L135CM 0.014IN S STL HYDRPHLC SPC BRAID,SUP-2353144,CDM,C1887,HCPCS,0272,RC,,,,both,,,59.35,38.58,,,,,,,,,,,,,
HYDROCORTISONE BUTYRATE 0.1 % EX CREA,RX-10214,CDM,6370000000,HCPCS,0637,RC,51672-4074-01,NDC,,both,15,GR,225.80,146.77,,,,,,,,,,,,,
DEFIBRILLATOR IMPL LUMAX 540 VR-T 55 X 66MM 13MM 40J REMOT,SUP-2138132,CDM,C1722,HCPCS,0275,RC,,,,both,,,29202.00,18981.30,,,,,,,,,,,,,
MESH SURG L 15 X W 10 CM GLYCOLIDE LACTIDE COPOLYMER,SUP-2931122,CDM,C1781,HCPCS,0278,RC,,,,both,,,5181.00,3367.65,,,,,,,,,,,,,
LOW PRFLE NEURO PLATE STRGHT 2 HOLE SHRT CP TTNM,SUP-2676764,CDM,C1713,HCPCS,0278,RC,,,,both,,,191.38,124.40,,,,,,,,,,,,,
CHANDELIER INFUS 25GA AWH,SUP-2129241,CDM,2720000010,LOCAL,0272,RC,,,,both,,,334.41,217.37,,,,,,,,,,,,,
ROCURONIUM BROMIDE 50 MG/5ML IV SOSY,RX-135030,CDM,2500000003,HCPCS,0250,RC,69374-0924-05,NDC,,both,5,ML,54.10,35.16,,,,,,,,,,,,,
SCREW LAG GAMMA 10.5X95MM,SUP-2854215,CDM,C1713,HCPCS,0278,RC,,,,both,,,2124.87,1381.17,,,,,,,,,,,,,
PLATE BNE THK07MM TI BILAT ORAL MAXILLOFACIAL NONCOMPRESSION,SUP-2262951,CDM,C1713,HCPCS,0278,RC,,,,both,,,526.45,342.19,,,,,,,,,,,,,
CATHETER CARD ABLATION THERMOCOOL SMARTTOUCH L 115 CM 8FR DD,SUP-2248604,CDM,C1732,HCPCS,0278,RC,,,,both,,,9730.86,6325.06,,,,,,,,,,,,,
CLAMP EXT FIX DIA4MM DSTL RAD TI ALLOY ADJ FOR SCHNZ SCR,SUP-2188540,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1588.84,1032.75,,,,,,,,,,,,,
HC Mra Abdomen W&W/O Contrast,PX-6187418502,CDM,C8902,CPT,0618,RC,,,,inpatient,,,2826.00,1836.90,,,,,,,,,,,,,
CATHETER DRNGE L120CM OD2.2MM ID1MM SIL PERI IMPREG BA,SUP-2243806,CDM,C1729,HCPCS,0272,RC,,,,both,,,1525.10,991.31,,,,,,,,,,,,,
INTRODUCER CARD LD PLCMNT STR 9FRX47CM W/O HEMSTAT VLV COR,SUP-2357292,CDM,C1887,HCPCS,0272,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
HYDROMORPHONE HCL 2 MG PO TABS,RX-3760,CDM,6370000000,HCPCS,0637,RC,00406-3243-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
BIT DRL DIA1.4MM DISP FOR ICONIX,SUP-2366696,CDM,2720000010,LOCAL,0272,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
PIN FIX TROCAR PT 1 END 9/64X9 IN 1 PT STYL SMOOTH PLN STRL,SUP-2150458,CDM,C1713,HCPCS,0278,RC,,,,both,,,15.73,10.22,,,,,,,,,,,,,
HC Cath/Intro Sal Cont Hyst,PX-3615834000,CDM,58340,CPT,0361,RC,,,,inpatient,,,445.00,289.25,,,,,,,,,,,,,
TI MATRIXMANDIBLE 3X3H,SUP-2823271,CDM,C1713,HCPCS,0278,RC,,,,both,,,1885.88,1225.82,,,,,,,,,,,,,
SUPPORT ORTHOT FT CUST INSRT REMOVABLE UCB TYP BERK SHELL,SUP-2435700,CDM,L3000,HCPCS,0272,RC,,,,both,,,889.37,578.09,,,,,,,,,,,,,
BEARING TIB XSM THK12MM UNIV KNEE CO CHROM HNG FLAT ANT,SUP-2252669,CDM,C1776,CPT,0278,RC,,,,both,,,8160.08,5304.05,,,,,,,,,,,,,
BLADE SHV L22CM OD32MM LARYN CONCAVE WIND SUPERFICIAL DIEGO,SUP-2313832,CDM,C1713,HCPCS,0278,RC,,,,both,,,915.75,595.24,,,,,,,,,,,,,
STENT LARYNGEAL MONTGOMERY L 15 X W 16 X H 47 MM LG SIL FIRM,SUP-2138743,CDM,C1875,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
SUPPORT FACE L FOR 27IN EAR CHEEK CHIN E FOR FACIOPLASTY,SUP-2151622,CDM,L0150,HCPCS,0272,RC,,,,both,,,61.80,40.17,,,,,,,,,,,,,
CATHETER GUID AR1.2 0.078 INX7 FR VASC BRAIDING ECOPAC BLU,SUP-2158418,CDM,C1887,HCPCS,0272,RC,,,,both,,,116.18,75.52,,,,,,,,,,,,,
KIT HEMO DYLS OR HD L50CM L33CM OD14.5FR ODSEC16FR,SUP-2174222,CDM,C1750,HCPCS,0278,RC,,,,both,,,1229.28,799.03,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED MOM CHIPBIOM2M] ZIMMER BIOMET INC],SUP-2137374,CDM,C1776,CPT,0278,RC,,,,both,,,20745.98,13484.89,,,,,,,,,,,,,
COVER US PRB L11.8IN DIA1.18IN ISOPRENE SEAMLESS STR RL X,SUP-2337625,CDM,C1894,HCPCS,0272,RC,,,,both,,,7.28,4.73,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 3 CC ADIPOSE MTRX RENUVA,SUP-2465397,CDM,C1762,CPT,0278,RC,,,,both,,,3040.15,1976.10,,,,,,,,,,,,,
WIRE BNE FIX REDUCTION NS DISP PRECIS MIS,SUP-2899213,CDM,2720000010,LOCAL,0272,RC,,,,both,,,555.78,361.26,,,,,,,,,,,,,
MESH HERN W5XL10CM SYNTH INGUINAL N ABSRB PRESHAPED KEYHOLE,SUP-2265907,CDM,C1781,HCPCS,0278,RC,,,,both,,,125.29,81.44,,,,,,,,,,,,,
STENT VASC OTW 3X9 MM 6 FRX135 CM WINGSPAN LF,SUP-2368132,CDM,C1876,HCPCS,0278,RC,,,,both,,,19766.30,12848.09,,,,,,,,,,,,,
HFN RH 130 DEG 15MM X 360MM,SUP-2588704,CDM,C1713,HCPCS,0278,RC,,,,both,,,7503.03,4876.97,,,,,,,,,,,,,
CIPROFLOXACIN (CIPRO) IV (PEDS),RX-4085029,CDM,J0744,HCPCS,0636,RC,00409-2300-01,NDC,,both,100,ML,54.10,35.16,,,,,,,,,,,,,
CLIP MED LD CROCODILE 122 CMX48 IN,SUP-2517526,CDM,2720000010,LOCAL,0272,RC,,,,both,,,596.60,387.79,,,,,,,,,,,,,
HC Inj Proc Ankle Arthrography,PX-3612764800,CDM,27648,CPT,0361,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
STENT BILI PALMAZ GEN L 15 MM BALLOON L 17 MM DIA 6.5 MM,SUP-2155764,CDM,C1876,HCPCS,0278,RC,,,,both,,,2606.20,1694.03,,,,,,,,,,,,,
VIEN HARVEST KIT VASCUCLEAR ENDOSCP SM RETRACTOR,SUP-2265220,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1831.66,1190.58,,,,,,,,,,,,,
LEAD DEFIB PROTEGO SD L 60 CM TIP DISTANCE 16 CM PTIR,SUP-2138427,CDM,C1895,HCPCS,0275,RC,,,,both,,,8792.00,5714.80,,,,,,,,,,,,,
RING EXT FIX CIR 5/8 120 MM SIDEKCK,SUP-2483229,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1114.70,724.55,,,,,,,,,,,,,
HC So Special Stain Grp 2,PX-3128831366,CDM,88313,CPT,0312,RC,,,,inpatient,,,239.00,155.35,,,,,,,,,,,,,
PLATE BNE MAXILLOFCL 3 MESH KT NS FACE ID,SUP-2909584,CDM,C1713,HCPCS,0278,RC,,,,both,,,39439.09,25635.41,,,,,,,,,,,,,
CONNECTOR SPNL SM TI FOR 6.35MM ROD TSRH-3D,SUP-2290003,CDM,C1713,HCPCS,0278,RC,,,,both,,,2877.81,1870.58,,,,,,,,,,,,,
PLATE LCK NAVICULAR 2.4/2.7MM TI STRL,SUP-2546616,CDM,C1713,HCPCS,0278,RC,,,,both,,,2835.61,1843.15,,,,,,,,,,,,,
HC Place Cath Carotd Art,PX-3613622400,CDM,36224,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
SCREW BNE L65MM OD5.5MM YEL TI LO EXT ST SELF DRL CANN FIX,SUP-2242848,CDM,C1713,HCPCS,0278,RC,,,,both,,,1484.31,964.80,,,,,,,,,,,,,
KIT HYSTEROSCOPIC PROC INFLO OUTFLO TUBE SET W/ SVC,SUP-2341625,CDM,C1713,HCPCS,0278,RC,,,,both,,,1105.28,718.43,,,,,,,,,,,,,
CATHETER ENDOSCP 1.9 MMX110 CM INSPECTION OPT USB CTRL SFTWR,SUP-2765097,CDM,2720000010,LOCAL,0272,RC,,,,both,,,9396.45,6107.69,,,,,,,,,,,,,
JOINT EXT FIX SPHR STRL TRUELOK LTX,SUP-2875240,CDM,2720000010,LOCAL,0272,RC,,,,both,,,11162.70,7255.75,,,,,,,,,,,,,
KIT INTRO L 10 CM 45 CM SS WIRE/TIP MIC B BVL STIFF,SUP-2752615,CDM,C1894,HCPCS,0272,RC,,,,both,,,101.86,66.21,,,,,,,,,,,,,
BLADE RTRCTR RVL 60MMW X 60MML TTNM LMBR 15DG ANGLD TTHD ULT,SUP-2674276,CDM,2720000010,LOCAL,0272,RC,,,,both,,,574.84,373.65,,,,,,,,,,,,,
KIT HEMTLGY 30ML PLT RICH PLSM DISP PEAK,SUP-2256856,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1155.52,751.09,,,,,,,,,,,,,
KIT BRST BX MRK WIRE,SUP-2240024,CDM,A4648,CPT,0278,RC,,,,both,,,2072.40,1347.06,,,,,,,,,,,,,
WAND ABLAT P 50 HND CTRL VAPR,SUP-2256752,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1526.04,991.93,,,,,,,,,,,,,
SPLINT ARM M L13IN FOR 5 17IN ARM POLY FAB MP MACH WSH,SUP-2274801,CDM,L3809,HCPCS,0274,RC,,,,both,,,29.99,19.49,,,,,,,,,,,,,
NEEDLE BX MENG LIV 16 GA 5 MMX36 CM LL,SUP-2767446,CDM,2720000010,LOCAL,0272,RC,,,,both,,,761.86,495.21,,,,,,,,,,,,,
STEM FEM VERSYS 7.5 INCH BEADED FC REV 13.5X190MM STRAIGHT,SUP-2504240,CDM,C1776,CPT,0278,RC,,,,both,,,13966.72,9078.37,,,,,,,,,,,,,
HC Insert Picc Cath|REDUCED SERVICES,PX-4503656900,CDM,36569,CPT,0450,RC,,,52,outpatient,,,4942.00,3212.30,,,,,,,,,,,,,
STEM FEM SZ 6 SH TAPR HIP TI POR PLSM SPRY STD OFFSET,SUP-2349072,CDM,C1776,CPT,0278,RC,,,,both,,,20700.45,13455.29,,,,,,,,,,,,,
HEAD CASS DIA14MM DISP FOR SELF EXP SM VERT BODY REPL,SUP-2390801,CDM,2720000010,LOCAL,0272,RC,,,,both,,,932.58,606.18,,,,,,,,,,,,,
STENT PERIPH SMRT RADIANZ L 20 MM DIA 6 MM DEL SYS L 190 CM,SUP-2866200,CDM,C1725,HCPCS,0272,RC,,,,both,,,3422.88,2224.87,,,,,,,,,,,,,
FOOTPLATE BONE ELEVATED RIGHT ANTERIOR MIDFACIAL FOR DISTRAC,SUP-2838453,CDM,C1713,HCPCS,0278,RC,,,,both,,,3382.72,2198.77,,,,,,,,,,,,,
GRAFT BNE SUB W25XH4XL100MM THK4MM 10ML B TRICALCIUM PHSPTE,SUP-2368173,CDM,C1713,HCPCS,0278,RC,,,,both,,,4333.20,2816.58,,,,,,,,,,,,,
NEEDLE LASER 90 DEG SIDE FIRE OMNITIP,SUP-2225653,CDM,2720000010,LOCAL,0272,RC,,,,both,,,659.40,428.61,,,,,,,,,,,,,
SCREW KNEE ARTHROPLASTY FEM DST VIT ST DURAC 5MML,SUP-2377212,CDM,C1713,HCPCS,0278,RC,,,,both,,,249.94,162.46,,,,,,,,,,,,,
BUR SURG OD2.1MM XCUT FISS RND N FLUT TPS ELITE,SUP-2419777,CDM,2720000010,LOCAL,0272,RC,,,,both,,,443.96,288.57,,,,,,,,,,,,,
BIT DRL TWST LNG 1.75 MM,SUP-2389423,CDM,2720000010,LOCAL,0272,RC,,,,both,,,151.72,98.62,,,,,,,,,,,,,
BLADE SHAVER XOMED STRAIGHTSHOT SYSTEM XPS ENDOSCOPIC 2.9MM 11CM PEDI,SUP-2902788,CDM,2720000010,LOCAL,0272,RC,,,,both,,,746.06,484.94,,,,,,,,,,,,,
SPLINT ARM M L13IN FOR 5 17IN ARM POLY FAB MP MACH WSH,SUP-2274801,CDM,L3809,HCPCS,0272,RC,,,,both,,,29.99,19.49,,,,,,,,,,,,,
HEAD FEM 54MM MOD ST REMEDY HIP SPCR,SUP-2319833,CDM,C1776,CPT,0278,RC,,,,both,,,5495.00,3571.75,,,,,,,,,,,,,
ELECTRODE LARYNGEAL MAGSTIM SIZE 6/7,SUP-2844648,CDM,2720000010,LOCAL,0272,RC,,,,both,,,357.96,232.67,,,,,,,,,,,,,
RESERVOIR PORT PEDIATRIC SMALL L14MM TITANIUM RADIOPAQUE CSF,SUP-2830490,CDM,C1889,HCPCS,0278,RC,,,,both,,,887.84,577.10,,,,,,,,,,,,,
PLATE CRAN 160X80X40 MM PT SPEC IMPL PEEK,SUP-2860142,CDM,C1713,HCPCS,0278,RC,,,,both,,,37796.81,24567.93,,,,,,,,,,,,,
BRACE KNEE AD LG UNISX R MED HNG FASTEN ON OPN,SUP-2196476,CDM,L1852,HCPCS,0272,RC,,,,both,,,1212.07,787.85,,,,,,,,,,,,,
BIT DRL L331MM DIA3.9X4.2MM CALIB 100MM 3 FLUT QUIK CPL,SUP-2176961,CDM,2720000010,LOCAL,0272,RC,,,,both,,,716.30,465.59,,,,,,,,,,,,,
"HC So Chlamydia, Ab, Igm",PX-3028663266,CDM,86632,CPT,0302,RC,,,,both,,,225.00,146.25,,,,,,,,,,,,,
BASEPLATE TIB MOD 75 MM KNEE OSS AVL,SUP-2441784,CDM,C1776,CPT,0278,RC,,,,both,,,9339.93,6070.95,,,,,,,,,,,,,
PLATE BONE L33MM THK0.7MM 4 H CRANIOMAXILLOFACIAL TI SAG SPL,SUP-2191237,CDM,C1713,HCPCS,0278,RC,,,,both,,,1718.84,1117.25,,,,,,,,,,,,,
COIL NEUROVASCULAR PENUMBRA COIL 400 L 8 CM PRIMARY DIA,SUP-2323355,CDM,C1889,HCPCS,0278,RC,,,,both,,,6443.28,4188.13,,,,,,,,,,,,,
GAMMATILE THERAPY DEVICE 5 PACK,SUP-2855639,CDM,C2642,HCPCS,0278,RC,,,,both,,,18212.00,11837.80,,,,,,,,,,,,,
IMPLANT COSMETIC SZ 38 X 50 X 3 MM POLYETHYL ORBIT FLR SHT,SUP-2936087,CDM,C1713,HCPCS,0278,RC,,,,both,,,4578.12,2975.78,,,,,,,,,,,,,
CATHETER GUID 7X5FR L68CM WRK L65CM 90DEG CRV PEBAX INNR,SUP-2356396,CDM,C1887,HCPCS,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
PLATE RINGFIX SYS 8 HL ALUM,SUP-2473058,CDM,C1713,HCPCS,0278,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
STEM FEM CONCL 20X195 MM DSTL HIP STR,SUP-2364560,CDM,C1776,CPT,0278,RC,,,,both,,,9185.44,5970.54,,,,,,,,,,,,,
CATHETER INFUSION PULSE SPRY L 90 CM DIA 5 FR SLT PAT L 10,SUP-2118492,CDM,C1751,HCPCS,0278,RC,,,,both,,,832.10,540.86,,,,,,,,,,,,,
ALLOGRAFT BNE SPACER 8 DEG 23-27X24-32X13 MM FD ANGLED FRA,SUP-2736752,CDM,C1713,HCPCS,0278,RC,,,,both,,,12317.91,8006.64,,,,,,,,,,,,,
SLEEVE DRL 9MM BLU DISP OSTEOCURE,SUP-2400544,CDM,2720000010,LOCAL,0272,RC,,,,both,,,926.30,602.09,,,,,,,,,,,,,
GRAFT VASC INTERGARD L 20 CM DIA 6 MM THK 0.49 MM POLYESTER,SUP-2227563,CDM,C1768,CPT,0278,RC,,,,both,,,1401.29,910.84,,,,,,,,,,,,,
PLATE OLECRANON 3.5MM 12H LT 216MM SS LCP STRL,SUP-2547490,CDM,C1713,HCPCS,0278,RC,,,,both,,,3674.77,2388.60,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE XLN 2.5 CC DBM FIBER INFLUENCER -RSFH,SUP-2881441,CDM,C1713,HCPCS,0278,RC,,,,both,,,3253.04,2114.48,,,,,,,,,,,,,
RAMIPRIL 5 MG PO CAPS,RX-11261,CDM,6370000000,HCPCS,0637,RC,65862-0476-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
SCOUT 5CM DEL NDL AND REFLECTOR PSA,SUP-2164408,CDM,C1819,HCPCS,0278,RC,,,,both,,,1868.30,1214.39,,,,,,,,,,,,,
GRAFT VASC FLIXENE 6MMX40CM,SUP-2470173,CDM,C1768,CPT,0278,RC,,,,both,,,3598.38,2338.95,,,,,,,,,,,,,
SLEEVE KNEE PROSTHETIC,SUP-2323332,CDM,L5685,LOCAL,0272,RC,,,,both,,,379.94,246.96,,,,,,,,,,,,,
HC Ther Infusion Addl Hr,PX-2609637000,CDM,96370,CPT,0260,RC,,,,both,,,87.00,56.55,,,,,,,,,,,,,
PLATE BNE L60MM THK1.2MM BILAT CALCNL S STL LOK COMPR FOR,SUP-2185984,CDM,C1713,HCPCS,0278,RC,,,,both,,,2866.69,1863.35,,,,,,,,,,,,,
PARTICLE EMB SZ 250-500UM POLYVI ALC N RADIOACTIVE CNTOUR 5,SUP-2148442,CDM,C1889,HCPCS,0278,RC,,,,both,,,398.78,259.21,,,,,,,,,,,,,
COMPONENT FNGR JT SZ 40 PROX MP PYROCARBON SIL SPCR,SUP-2244240,CDM,C1776,CPT,0278,RC,,,,both,,,7023.27,4565.13,,,,,,,,,,,,,
GRAFT VASC L70CM DIA8MM CLLGN POLY STR KNIT ULTRATHIN SM,SUP-2227536,CDM,C1768,CPT,0278,RC,,,,both,,,1839.04,1195.38,,,,,,,,,,,,,
TOOL TUNN L 35.5 CM DIA 9 FR INTRO L 19.13 CM DIA 9 FR SS,SUP-2891549,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
BLADE SURG VES 29 MMX10 CM WIDE,SUP-2629240,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1570.57,1020.87,,,,,,,,,,,,,
CATHETER GUID SOFIA + L 131 CM DIA 6 FR ID 0.070 IN OD,SUP-2538141,CDM,C1887,HCPCS,0272,RC,,,,both,,,7253.40,4714.71,,,,,,,,,,,,,
SCREW BNE EMGCY 2X4 MM TI NS,SUP-2188961,CDM,C1713,HCPCS,0278,RC,,,,both,,,177.41,115.32,,,,,,,,,,,,,
HC So Aso Titer,PX-3028606066,CDM,86060,CPT,0302,RC,,,,inpatient,,,129.00,83.85,,,,,,,,,,,,,
CATHETER CTRL VEN 12FR 16CM LEN 3 LUMN N TUNNELED BASIC SET,SUP-2120626,CDM,C1751,HCPCS,0278,RC,,,,both,,,192.80,125.32,,,,,,,,,,,,,
LASER SURG ULTRAPULSE DUO,SUP-2713804,CDM,2720000010,LOCAL,0272,RC,,,,both,,,468645.00,304619.25,,,,,,,,,,,,,
BUR SURG RND 1 MM ELITE,SUP-2361689,CDM,2720000010,LOCAL,0272,RC,,,,both,,,218.23,141.85,,,,,,,,,,,,,
DRILL CANNULATED 4.5 MM X 210 MM SONOMA CRX,SUP-2431212,CDM,2720000010,LOCAL,0272,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
STEM HUM L110MM DIA10.5MM 135DEG CO CHROM MOLYBDENUM,SUP-2204813,CDM,C1776,CPT,0278,RC,,,,both,,,9928.68,6453.64,,,,,,,,,,,,,
PIN DRL TRIANG END 3.1X76.2 MM FIX TRCR PT RND END,SUP-2760757,CDM,2720000010,LOCAL,0272,RC,,,,both,,,741.83,482.19,,,,,,,,,,,,,
STRIP RETIN SCLER BCKL 1.25X4 MM STYL 42 SIL,SUP-2213476,CDM,C1784,HCPCS,0278,RC,,,,both,,,54.64,35.52,,,,,,,,,,,,,
CATHETER INFUSION MISTIQUE L 135 CM DIA 5 FR SEG L 5 CM,SUP-2701991,CDM,C1751,HCPCS,0278,RC,,,,both,,,167.68,108.99,,,,,,,,,,,,,
CATHETER GUID HEARTRAIL III L 100 CM DIA 6 FR 700 PSI IL4,SUP-2384861,CDM,C1887,HCPCS,0272,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
PROBE NSL STR 90 DEG W/ RT HND MIRROR,SUP-2713679,CDM,2720000010,LOCAL,0272,RC,,,,both,,,743.80,483.47,,,,,,,,,,,,,
SCREW BONE L12MM OD2.6MM FULL THRD COMPR,SUP-2224034,CDM,C1713,HCPCS,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
SCREW BONE L25MM DIA5MM HD CORT DYNANAIL,SUP-2277461,CDM,C1713,HCPCS,0278,RC,,,,both,,,1774.10,1153.16,,,,,,,,,,,,,
BIT DRL TWST 3.2MMX310 COIL 50 QUIK CPL DISP,SUP-2101266,CDM,2720000010,LOCAL,0272,RC,,,,both,,,359.22,233.49,,,,,,,,,,,,,
GRAFT DERMAL RECT 3.1X6.3 IN ANTIBACT XENMATRIX AB,SUP-2855241,CDM,C1781,HCPCS,0278,RC,,,,both,,,13700.45,8905.29,,,,,,,,,,,,,
NEEDLE SPNL FIX 11 GA BVL FOR PEDCL ACCS SERENGETI,SUP-2869133,CDM,2720000010,LOCAL,0272,RC,,,,both,,,769.36,500.08,,,,,,,,,,,,,
MICROCATHETER GUID MIRAFLEX L 135 CM OD 2.5 FR ID 0.021 IN,SUP-2170451,CDM,C1887,HCPCS,0272,RC,,,,both,,,1067.60,693.94,,,,,,,,,,,,,
PATCH SURG FIBRIN SEAL 4.8X4.8 CM ABSORBABLE TACHOSIL,SUP-2130296,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1429.83,929.39,,,,,,,,,,,,,
ANCHOR SUT L19.1MM DIA4.75MM BIOCOMPOSITE FULL THRD,SUP-2121695,CDM,C1713,HCPCS,0278,RC,,,,both,,,1475.80,959.27,,,,,,,,,,,,,
FIBER LASER HOLM 10609] FORTEC MEDICAL INC],SUP-2225649,CDM,2720000010,LOCAL,0272,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
COUPLER ANAS DIA1.5MM VES RANG 1.3-1.7MM SGL DBL END DISP,SUP-2419428,CDM,C1889,HCPCS,0278,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
PATCH CV W0.8XL7.5CM THK0.5MM FOR RECON ACUSEAL,SUP-2395323,CDM,C1781,HCPCS,0278,RC,,,,both,,,558.92,363.30,,,,,,,,,,,,,
PIN GUID 3.2MM ORTH LNG FULL THRD FOR SUBTROCHANTERIC,SUP-2410484,CDM,2720000010,LOCAL,0272,RC,,,,both,,,413.98,269.09,,,,,,,,,,,,,
BUTTON FIXATION ENDOBUTTON CL BTB 45MM,SUP-2845208,CDM,C1730,HCPCS,0272,RC,,,,both,,,985.80,640.77,,,,,,,,,,,,,
MESH CRAN 105X60 MM 0.6 MM PLATE PROF PANEL OBLONG CP TI,SUP-2493671,CDM,C1713,HCPCS,0278,RC,,,,both,,,3645.95,2369.87,,,,,,,,,,,,,
IDARUBICIN HCL 10 MG/10ML IV SOLN|DISCARDED DRUG NOT ADMINISTE,RX-88242,CDM,J9211,HCPCS,0636,RC,00013-2586-10,NDC,JW,both,10,ML,310.50,201.82,,,,,,,,,,,,,
SNARE ENDOSCP OD25MM SHTH L50CM OD55FR DUCK BILL INSUL S STL,SUP-2171039,CDM,C1713,HCPCS,0278,RC,,,,both,,,378.02,245.71,,,,,,,,,,,,,
WASHER INSET N FORCE 73MM,SUP-2414094,CDM,C1713,HCPCS,0278,RC,,,,both,,,122.46,79.60,,,,,,,,,,,,,
PLATE BONE L180MM 135DEG 8 H PELVIS BILAT S STL STD BRL RIG,SUP-2342588,CDM,C1713,HCPCS,0278,RC,,,,both,,,4934.20,3207.23,,,,,,,,,,,,,
PLATE BONE LOK SHRT 74MML HLX3 PRPLE ST LEFT MED DST HMRL,SUP-2463028,CDM,C1713,HCPCS,0278,RC,,,,both,,,2401.10,1560.71,,,,,,,,,,,,,
IMPLANT COSMETIC SZ 76 X 61 X 19 MM SM POLYETHYL LT TEMPORAL,SUP-2934456,CDM,C1713,HCPCS,0278,RC,,,,both,,,6126.14,3981.99,,,,,,,,,,,,,
DEVICE ANTISIPH 2.2X1.2 MM FLAT BTM ASD PUDENZ STR CONN,SUP-2852571,CDM,C1889,HCPCS,0278,RC,,,,both,,,1467.07,953.60,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED FEM TIB FLX CEM SURF GENDER SOL,SUP-2212246,CDM,C1776,CPT,0278,RC,,,,both,,,11732.77,7626.30,,,,,,,,,,,,,
GRAFT BONE SUB W10XH10XL10MM CUBE SHP DEMIN CANC FIL MTRX,SUP-2307019,CDM,C1713,HCPCS,0278,RC,,,,both,,,1635.00,1062.75,,,,,,,,,,,,,
ALLOGRAFT HUM TISS LORDTC 7 DEG 12X14.5X7.22X5.75 MM,SUP-2264943,CDM,C1713,HCPCS,0278,RC,,,,both,,,2911.35,1892.38,,,,,,,,,,,,,
INTRO SAFESHEATH 7FR 25CM W/SIDEPORT,SUP-2478232,CDM,C1892,HCPCS,0272,RC,,,,both,,,148.52,96.54,,,,,,,,,,,,,
GRAFT BNE SUB 30ML 4-9.5MM CHIP CANC FRZ DRY ALLGRFT 27615030] ALLOSOURCE],SUP-2113908,CDM,C1713,HCPCS,0278,RC,,,,both,,,1634.50,1062.42,,,,,,,,,,,,,
COIL NEUROVASCULAR L 12 CM DIA2 MM BARE PLAT LG VOL COIL,SUP-2895596,CDM,C1889,HCPCS,0278,RC,,,,both,,,12230.30,7949.69,,,,,,,,,,,,,
STEM FEM SZ 2 STD SHT NK HIP HA QUADRA H,SUP-2267225,CDM,C1776,CPT,0278,RC,,,,both,,,8289.60,5388.24,,,,,,,,,,,,,
HC MRI-Spine Thoracic WO&W Cont,PX-6127215700,CDM,72157,CPT,0612,RC,,,,both,,,3486.00,2265.90,,,,,,,,,,,,,
TUBE VENT SHEP GRMMT 1.02 MM 1.6 MM 2.3 MM SIL,SUP-2469512,CDM,L8699,HCPCS,0278,RC,,,,both,,,29.20,18.98,,,,,,,,,,,,,
GRAFT BNE BLOCK 6.25X2X0.4 CM 5 CC PLATFORM CM,SUP-2691580,CDM,C1713,HCPCS,0278,RC,,,,both,,,4304.94,2798.21,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 50 CM DIA 6 MM STR STD WALL HELIX,SUP-2695227,CDM,C1768,CPT,0278,RC,,,,both,,,1196.94,778.01,,,,,,,,,,,,,
GRAFT ENDOVASC UNCVR L20MM CVR L95MM DIA28X28MM AFX,SUP-2217604,CDM,C1768,CPT,0278,RC,,,,both,,,13313.60,8653.84,,,,,,,,,,,,,
BARRIER ADH SHT 6X5 IN SODIUM HYALURONATE CMC SEPRAFILM,SUP-2227089,CDM,C1765,HCPCS,0278,RC,,,,both,,,1254.56,815.46,,,,,,,,,,,,,
CLIP APPL INT 5 MMX35 CM ENDOSCP AUTO HEMOLOCK TI,SUP-2384725,CDM,2720000010,LOCAL,0272,RC,,,,both,,,389.36,253.08,,,,,,,,,,,,,
WIRE FIX DIA13MM ANK FT SMOOTH OLV,SUP-2321632,CDM,2720000010,LOCAL,0272,RC,,,,both,,,351.68,228.59,,,,,,,,,,,,,
HC So Nuclear Antigen Antibody,PX-3028623566,CDM,86235,CPT,0302,RC,,,,both,,,71.00,46.15,,,,,,,,,,,,,
SLEEVE SURG SFT TISS WORKING CHANNEL,SUP-2460475,CDM,C1713,HCPCS,0278,RC,,,,both,,,2709.82,1761.38,,,,,,,,,,,,,
SCREW BNE AD PED L7MM DIA23MM CRANIOMAXILLOFACIAL TI SELF,SUP-2262835,CDM,C1713,HCPCS,0278,RC,,,,both,,,412.75,268.29,,,,,,,,,,,,,
SUPPORT INSTR PEDICULAR STPL COLORADO 2,SUP-2290548,CDM,C1713,HCPCS,0278,RC,,,,both,,,750.46,487.80,,,,,,,,,,,,,
PLATE BNE FIBULAR SHT LT DSTL,SUP-2315877,CDM,C1713,HCPCS,0278,RC,,,,both,,,3859.06,2508.39,,,,,,,,,,,,,
GRAFT HUM TISS DIA10 MM AMNION PLCNTA MEMBRN 2 LAYR PROTCT,SUP-2913307,CDM,C1762,CPT,0278,RC,,,,both,,,2405.24,1563.41,,,,,,,,,,,,,
IMPLANT ANK JT SZ 9 SNUS TARSI HYPROCURE,SUP-2236088,CDM,C1776,CPT,0278,RC,,,,both,,,4217.02,2741.06,,,,,,,,,,,,,
GRAFT SFT TISS FASC LATA MED 10 CM,SUP-2307536,CDM,C1762,CPT,0278,RC,,,,both,,,2088.10,1357.26,,,,,,,,,,,,,
CATHETER CV 3L 6 FR PASV VLV MAX BARR NURSING KT BIOFLO,SUP-2734869,CDM,C1751,HCPCS,0278,RC,,,,both,,,183.38,119.20,,,,,,,,,,,,,
PORT INFUS 8FR SIL PWR INJ ATTCH POLYUR CATH INTMED KT,SUP-2126306,CDM,C1788,HCPCS,0278,RC,,,,both,,,1208.90,785.78,,,,,,,,,,,,,
CATHETER INTVASC OCCL PRUITT L 24CM 12FR 43MM ABD LEAK ANEUR,SUP-2332927,CDM,C2628,HCPCS,0272,RC,,,,both,,,2037.86,1324.61,,,,,,,,,,,,,
CATHETER ART THERMODILUTION 6 FRX110 CM 4 LUMEN SWAN,SUP-2213978,CDM,C1725,HCPCS,0272,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
PLATE BNE SM W11XL67MM THK15MM 90DEG 4X5 H TI T SHP R ANG,SUP-2190933,CDM,C1713,HCPCS,0278,RC,,,,both,,,1089.27,708.03,,,,,,,,,,,,,
SPLINT ORTH W4IN RT HND BASE THMB SPICA ROLYAN,SUP-2324965,CDM,L3931,HCPCS,0274,RC,,,,both,,,102.74,66.78,,,,,,,,,,,,,
GRAFT BONE PUTTY W/ CHIP DEMIN BONE MTRX 2CC PUROS,SUP-2197454,CDM,C9359,HCPCS,0278,RC,,,,both,,,1679.90,1091.93,,,,,,,,,,,,,
DRESSING WND FEN 7X10 CM SHT EXTRACELLULAR MTRX MATRISTEM,SUP-2106522,CDM,Q4166,HCPCS,0636,RC,,,,both,,,1198.35,778.93,,,,,,,,,,,,,
HC Drain/Inj Joint/Bursa W/US,PX-3612061100,CDM,20611,CPT,0361,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
STAPLER INT SHFT L55MM STPL H1.5X1.8X2MM 6 ROW ENDO-SURGERY,SUP-2219742,CDM,C1713,HCPCS,0278,RC,,,,both,,,108.39,70.45,,,,,,,,,,,,,
CATHETER ANGIOPLSTY 035 IN 5 FRX130 CM 6X150 MM LP LUTONIX,SUP-2127981,CDM,C2623,HCPCS,0278,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
BRACE ORTH CIRC THGH 23.5-32 IN CTR 17-23 IN CALF 18-24 IN RT MED LT LAT,SUP-2916947,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1183.81,769.48,,,,,,,,,,,,,
CATHETER THROMCTMY PRONTO V3 L 140 CM DIA 6 FR SECT L 20 CM,SUP-2120491,CDM,C1757,HCPCS,0272,RC,,,,both,,,1045.62,679.65,,,,,,,,,,,,,
GRAFT BNE SUB W6-20X9-21XL25-35MM THK16-18MM IL CREST,SUP-2307147,CDM,C1776,CPT,0278,RC,,,,both,,,2518.28,1636.88,,,,,,,,,,,,,
KIT PRESSURE MONITOR VENTRICULAR CATH TUNN TROCAR ANCHR CLP,SUP-2883380,CDM,C1729,HCPCS,0272,RC,,,,both,,,2312.04,1502.83,,,,,,,,,,,,,
BOLT ORTHOPEDIC GUIDE,SUP-2196673,CDM,2720000010,LOCAL,0272,RC,,,,both,,,405.06,263.29,,,,,,,,,,,,,
GUIDEWIRE SURG 0.062X18.5 IN NIT HYPRFLX,SUP-2765928,CDM,C1769,HCPCS,0272,RC,,,,both,,,121.68,79.09,,,,,,,,,,,,,
PEG FIX VOLAR 22X51 MM RT DORS RADIAL NAR LCK W/ SMOOTH STRL,SUP-2861573,CDM,C1713,HCPCS,0278,RC,,,,both,,,6267.88,4074.12,,,,,,,,,,,,,
WASHER ORTH 4 MM FOR PROV TISS CRV TRABECULAR MTL,SUP-2437276,CDM,C1713,HCPCS,0278,RC,,,,both,,,1752.12,1138.88,,,,,,,,,,,,,
HC So Thiocyanate,PX-3018443066,CDM,84430,CPT,0301,RC,,,,both,,,417.00,271.05,,,,,,,,,,,,,
PLATE BNE LCK 233 MM LT DORS PROXIMAL ULNAR 15 HOLE STRL,SUP-2470065,CDM,C1713,HCPCS,0278,RC,,,,both,,,3001.34,1950.87,,,,,,,,,,,,,
HC Drain/Inj Joint/Bursa W/US,PX-5102060600,CDM,20606,CPT,0510,RC,,,,outpatient,,,1818.00,1181.70,,,,,,,,,,,,,
STAPLE INT CARTRIDGE 10X10 MM TI SS DISP,SUP-2166759,CDM,C1713,HCPCS,0278,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
SUPPORT ORTHOT ANK KNEE CALF SPRING WIRE DORSIFLEXION BND,SUP-2435621,CDM,L1900,HCPCS,0272,RC,,,,both,,,807.73,525.02,,,,,,,,,,,,,
PLATE BNE RECON 2-2.5X2.5 MM RT MAND 26 HOLE ANGLED LCK TI,SUP-2539580,CDM,C1713,HCPCS,0278,RC,,,,both,,,5614.54,3649.45,,,,,,,,,,,,,
HC Med Nutr Ther Group Init/Fu 30 Min,PX-9429780400,CDM,97804,CPT,0942,RC,,,,both,,,37.00,24.05,,,,,,,,,,,,,
PLATE BNE RADIAL XLN RT DSTL VOLAR LCK STRL DVR EPAK LTX,SUP-2861557,CDM,C1713,HCPCS,0278,RC,,,,both,,,8169.59,5310.23,,,,,,,,,,,,,
DEFIBRILLATOR IMPL LUMAX W 59 MM 27 J TI EPOXY RESIN SIL 2,SUP-2138108,CDM,C1721,HCPCS,0275,RC,,,,both,,,53122.52,34529.64,,,,,,,,,,,,,
HC MRI Lower Ext Jnt W/O Cont,PX-6107372100,CDM,73721,CPT,0610,RC,,,,both,,,3764.00,2446.60,,,,,,,,,,,,,
CITALOPRAM HYDROBROMIDE 10 MG PO TABS,RX-30264,CDM,6370000000,HCPCS,0637,RC,00904-6084-61,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
CANNULATED 8.0MM TWIST DRILL,SUP-2823744,CDM,2720000010,LOCAL,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
HC Telethx Isodose Plan Cplx,PX-3337730700,CDM,77307,CPT,0333,RC,,,,outpatient,,,3311.00,2152.15,,,,,,,,,,,,,
COLLAR SPNL DIA6MM UNIV TI 2 COR USS,SUP-2193399,CDM,C1713,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
CATHETER ASPIR 6FR L55IN 100% S STL BRAID KINK RESIST,SUP-2302443,CDM,C1757,HCPCS,0272,RC,,,,both,,,950.85,618.05,,,,,,,,,,,,,
SET BLD COLLCTN SPECTR 2 NDL LRS ISBT COBE,SUP-2162577,CDM,C1713,HCPCS,0278,RC,,,,both,,,832.10,540.86,,,,,,,,,,,,,
HC So Deoxycorticosterone,PX-3018263366,CDM,82633,CPT,0301,RC,,,,both,,,160.00,104.00,,,,,,,,,,,,,
DRESSING WND TALYMED L 3 X W 3 CM POLY-N-ACETYL GLUCOSAMINE,SUP-2266132,CDM,Q4127,HCPCS,0636,RC,,,,both,,,2590.50,1683.82,,,,,,,,,,,,,
STENT URTRL 6FR DIA 28CML SLCNE TCFLX OPEN END WPSH CATH UR,SUP-2727156,CDM,C2617,HCPCS,0278,RC,,,,both,,,429.90,279.43,,,,,,,,,,,,,
HC Cbc|NOT REASONABLE AND NECESSARY,PX-3058502500,CDM,85025,CPT,0305,RC,,,GZ,both,,,180.00,117.00,,,,,,,,,,,,,
GRAFT HUM TISS RT TALAR ASEP FRSH FOR ARTC CART SUBCHNDRL FT,SUP-2113921,CDM,C1713,HCPCS,0278,RC,,,,both,,,36643.80,23818.47,,,,,,,,,,,,,
NEEDLE INJ 5 6CM LARYN OROTRACHEAL DISPOSABLE,SUP-2243034,CDM,C1713,HCPCS,0278,RC,,,,both,,,96.08,62.45,,,,,,,,,,,,,
NEEDLE ASPIR 22 GA EZ SHOT 3,SUP-2434182,CDM,2720000010,LOCAL,0272,RC,,,,both,,,827.77,538.05,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE SZ 100 X 25 X 6 MM 15 CC CER GRAN,SUP-2930806,CDM,C1763,HCPCS,0278,RC,,,,both,,,10362.00,6735.30,,,,,,,,,,,,,
SCREW BNE FIX 8734100S] ZIMMER BIOMET INC],SUP-2137138,CDM,C1713,HCPCS,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
GRAFT VASC ARTEGRAFT L 45 CM DIA 6 MM CLLGN BOV CAR ART,SUP-2120670,CDM,C1768,CPT,0278,RC,,,,both,,,9982.06,6488.34,,,,,,,,,,,,,
STAPLE BONE FIX BRDG W11MM LEG L14X13MM WIRE DIA1.5X1.5MM,SUP-2135430,CDM,C1713,HCPCS,0278,RC,,,,both,,,1186.92,771.50,,,,,,,,,,,,,
NAIL IM L180MM DIA10MM R HINDFOOT TI CANN LOK LAT BEND RND,SUP-2180015,CDM,C1713,HCPCS,0278,RC,,,,both,,,5449.31,3542.05,,,,,,,,,,,,,
SLING URETH MONOARC,SUP-2140379,CDM,C1771,HCPCS,0278,RC,,,,both,,,3721.81,2419.18,,,,,,,,,,,,,
CATHETER PULM ART 10.5FR L100CM 0.038IN INTRAAORTIC 3 LUMN,SUP-2214546,CDM,C1713,HCPCS,0278,RC,,,,both,,,15072.00,9796.80,,,,,,,,,,,,,
HC Hemoglobin Glycosylated A1c,PX-3018303600,CDM,83036,CPT,0301,RC,,,,both,,,141.00,91.65,,,,,,,,,,,,,
GUIDEWIRE LD PERC,SUP-2615459,CDM,C1769,HCPCS,0272,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
IMPLANT BIO TISS W18 25XL450MM THCK CLLGN DERM MTRX XENMTRX,SUP-2126246,CDM,C1781,HCPCS,0278,RC,,,,both,,,125690.12,81698.58,,,,,,,,,,,,,
TORIPALIMAB-TPZI 240 MG/6ML IV SOLN,RX-165976,CDM,J3263,HCPCS,0636,RC,70114-0340-01,NDC,,both,6,ML,27424.90,17826.18,,,,,,,,,,,,,
FOOT ARCH EXT FIX D 180 MM RX STRL TRUELOK EVO LTX,SUP-2875622,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7054.01,4585.11,,,,,,,,,,,,,
GRAFT VASC GORTX L 100 CM DIA 6 MM RNG L 50 CM EPTFE STR TW,SUP-2396160,CDM,C1768,CPT,0278,RC,,,,both,,,4455.66,2896.18,,,,,,,,,,,,,
SCREW SPNL THN 7.5X55 MM TSRH 3DX OSTEOGRIP,SUP-2279941,CDM,C1713,HCPCS,0278,RC,,,,both,,,1491.50,969.47,,,,,,,,,,,,,
TROCH NAIL 10X15 BLUE,SUP-2818907,CDM,C1713,HCPCS,0278,RC,,,,both,,,8193.20,5325.58,,,,,,,,,,,,,
IMPLANT COSMETIC SZ 50 X 61 MM POLYETHYL RT HELCL RIM STRL,SUP-2935272,CDM,C1713,HCPCS,0278,RC,,,,both,,,2427.22,1577.69,,,,,,,,,,,,,
BIT DRL L150MM DIA4MM 3 FLUT QUIK CPL RADPQ BRAD PNT W/O,SUP-2193806,CDM,2720000010,LOCAL,0272,RC,,,,both,,,811.38,527.40,,,,,,,,,,,,,
IMPLANT COSMETIC SZ 102 X 10 X 4.7 X 0.6 MM POLYETHYL,SUP-2935666,CDM,C1713,HCPCS,0278,RC,,,,both,,,1381.60,898.04,,,,,,,,,,,,,
KIT KYPHOPLASTY NDL 11GA BAL L10MM VERT PROC AVAMAX,SUP-2361539,CDM,C1726,HCPCS,0272,RC,,,,both,,,4003.50,2602.27,,,,,,,,,,,,,
VALVE AORT CARP EDW PERIMT RSR THEON 25MM 32MM 17MM PERICARD,SUP-2214083,CDM,C1889,HCPCS,0278,RC,,,,both,,,14915.00,9694.75,,,,,,,,,,,,,
GUIDEWIRE VASC KATZN L 145 CM DIA 0.035 IN SS COR STRL,SUP-2148182,CDM,C1769,HCPCS,0272,RC,,,,both,,,66.44,43.19,,,,,,,,,,,,,
CAGE SPNL MED 11X14X7 MM TANTALUM TRABECULAR MTL,SUP-2414454,CDM,C1889,HCPCS,0278,RC,,,,both,,,6594.00,4286.10,,,,,,,,,,,,,
CLIP ANEURYSM SUNDTKEES 6MM REINFORCING O DEG 201740,SUP-2844622,CDM,C1889,HCPCS,0278,RC,,,,both,,,868.30,564.39,,,,,,,,,,,,,
GRAFT HUM TISS L 4 X W 4 CM LG AMNIO MEMBRN RESRB STRL,SUP-2913456,CDM,Q4173,HCPCS,0636,RC,,,,both,,,8807.70,5725.00,,,,,,,,,,,,,
PROSTHESIS OSS L 14 MM SHFT DIA1.14 MM HD DIA 3.25 MM TI HA,SUP-2902119,CDM,L8613,CPT,0278,RC,,,,both,,,1681.78,1093.16,,,,,,,,,,,,,
PLATE BNE L 25 MM SCREW DIA1.6 MM TI LT OFFSET GRID 2 COMPR,SUP-2912902,CDM,C1713,HCPCS,0278,RC,,,,both,,,1001.66,651.08,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH ALPHA L 157 MM DIA 46 MM NIT POLYPRO,SUP-2751294,CDM,C1874,HCPCS,0278,RC,,,,both,,,53955.97,35071.38,,,,,,,,,,,,,
MESH 2X4IN PROL SFT POLYPR SYN ABD NONABSORBABLE RECT SFT,SUP-2219920,CDM,C1781,HCPCS,0278,RC,,,,both,,,4600.82,2990.53,,,,,,,,,,,,,
ALLOGRAFT BNE MOLD 1 CC VIABLE BNE MTRX VIBONE,SUP-2731785,CDM,C1762,CPT,0278,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
GRAFT HUM TISS ANTR TIBIALIS TEND,SUP-2294000,CDM,C1762,CPT,0278,RC,,,,both,,,6751.00,4388.15,,,,,,,,,,,,,
STENT CORONARY ION MR L 8 MM DIA 4 MM CATH L 144 CM DIA,SUP-2144867,CDM,C1874,HCPCS,0278,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
COMPONENT PATELLAR XS KNEE,SUP-2361582,CDM,C1776,CPT,0278,RC,,,,both,,,1461.04,949.68,,,,,,,,,,,,,
GRAFT TISS FRZ DRY ALLGRFT WDG ACF FIB TRAD 10X9-13MM,SUP-2294097,CDM,C1713,HCPCS,0278,RC,,,,both,,,1086.44,706.19,,,,,,,,,,,,,
TUBING IRRGTN 0.125N ID 0.25N OD 19FR DIA 50FTL SLSTC SLCNE,SUP-2492891,CDM,2720000010,LOCAL,0272,RC,,,,both,,,567.40,368.81,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE 5 CC CANC CRUSH,SUP-2899239,CDM,C1713,HCPCS,0278,RC,,,,both,,,1467.95,954.17,,,,,,,,,,,,,
SCREW SPNL L10MM DIA4MM ANT CANC,SUP-2291051,CDM,C1713,HCPCS,0278,RC,,,,both,,,822.84,534.85,,,,,,,,,,,,,
TI NARROW 2 HOLE PLATE 26MM,SUP-2704879,CDM,C1713,HCPCS,0278,RC,,,,both,,,224.20,145.73,,,,,,,,,,,,,
REMIFENTANIL HCL 1 MG IV SOLR,RX-18398,CDM,2500000003,HCPCS,0250,RC,72078-0034-01,NDC,,both,1,UN,352.50,229.12,,,,,,,,,,,,,
NAIL IM FEM 13 MMX43 CM TRIGEN META-NAIL,SUP-2347433,CDM,C1713,HCPCS,0278,RC,,,,both,,,5295.92,3442.35,,,,,,,,,,,,,
GUIDE PIN FIX 2.5MM TRABECULAR REV SHLDR SYS,SUP-2199079,CDM,C1713,HCPCS,0278,RC,,,,both,,,847.80,551.07,,,,,,,,,,,,,
SPLINT ARM SM L7IN L ALUMINUM FOAM PD MAL COLLES,SUP-2276768,CDM,L3809,HCPCS,0272,RC,,,,both,,,17.80,11.57,,,,,,,,,,,,,
COMPONENT FEM KNEE CR KT STRL ITOTAL,SUP-2904534,CDM,C1776,CPT,0278,RC,,,,both,,,7339.75,4770.84,,,,,,,,,,,,,
TI MACHINE SCREW,SUP-2827975,CDM,C1713,HCPCS,0278,RC,,,,both,,,404.43,262.88,,,,,,,,,,,,,
SCREW BONE L100MM DIA7MM THRD L16MM S STL SELF DRL ST CANN,SUP-2343698,CDM,C1713,HCPCS,0278,RC,,,,both,,,1681.28,1092.83,,,,,,,,,,,,,
HALF PIN EXT FIX L50MM DIA5MM TI TRAC FOR JET-X EXT FIX,SUP-2342937,CDM,C1713,HCPCS,0278,RC,,,,both,,,2235.62,1453.15,,,,,,,,,,,,,
HC Renal Function Panel,PX-3018006900,CDM,80069,CPT,0301,RC,,,,both,,,109.00,70.85,,,,,,,,,,,,,
RETRACTOR SURG TBLR 20 MMX4 CM SPINE ANGLED COAT METRX REUSE,SUP-2292989,CDM,C1713,HCPCS,0278,RC,,,,both,,,2939.04,1910.38,,,,,,,,,,,,,
STEM RADIAL MORSE TAPR LNG 8 MM,SUP-2424148,CDM,C1776,CPT,0278,RC,,,,both,,,5692.82,3700.33,,,,,,,,,,,,,
IMPLANT HUM TISS 1 CC AMNIO STEM CELL ECT3 EXTRACELLULAR -RSFH,SUP-2881354,CDM,C1762,CPT,0278,RC,,,,both,,,14368.64,9339.62,,,,,,,,,,,,,
WAND ABLAT DIA3.5MM 90DEG SUCT TURBOVAC 90,SUP-2341988,CDM,C1713,HCPCS,0278,RC,,,,both,,,709.64,461.27,,,,,,,,,,,,,
PLATE BNE BSSO 2X40 MM SLIDING COLOGNE FOR SCR TI STRL,SUP-2477757,CDM,C1713,HCPCS,0278,RC,,,,both,,,1861.74,1210.13,,,,,,,,,,,,,
PLATE BNE L189MM THK3MM 12 H BILAT S STL STR LIMIT CNTCT,SUP-2185346,CDM,C1713,HCPCS,0278,RC,,,,both,,,2125.12,1381.33,,,,,,,,,,,,,
PROVEN SYMMETRICAL REV FEM SZ 1,SUP-2359204,CDM,C1776,CPT,0278,RC,,,,both,,,17898.00,11633.70,,,,,,,,,,,,,
SHELL ACET OD56MM ID53MM TI R HIP MH CEM RECON COMP RESTR,SUP-2370295,CDM,C1776,CPT,0278,RC,,,,both,,,7340.06,4771.04,,,,,,,,,,,,,
TAP BONE SPNL COLORADO 2 4.5MM DIA,SUP-2290560,CDM,C1713,HCPCS,0278,RC,,,,both,,,4502.76,2926.79,,,,,,,,,,,,,
SHEATH INTRO SENTRANT L 64 CM DIA16 FR GUIDEWIRE 0.035 IN,SUP-2749558,CDM,C1894,HCPCS,0272,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
CATHETER NEPHSTMY L25CM OD14FR DRNGE PGTL TIP RADPQ FLEXIMA,SUP-2139753,CDM,C1729,HCPCS,0272,RC,,,,both,,,264.70,172.05,,,,,,,,,,,,,
HEAD RMR DIA17MM S STL CONIC TIP SHRP CUT EDGE ATTACH W/,SUP-2188161,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2453.88,1595.02,,,,,,,,,,,,,
VALVE CSF PROGRAMMABLE 10 MM PRECIS CYL PRE-CHAMBER VERY LO,SUP-2666443,CDM,C1889,HCPCS,0278,RC,,,,both,,,3035.12,1972.83,,,,,,,,,,,,,
SCREW BNE L28MM DIA5MM TIB TI DBL LD FOR PHOENIX NAIL SYS,SUP-2412117,CDM,C1713,HCPCS,0278,RC,,,,both,,,888.78,577.71,,,,,,,,,,,,,
HC So1 Immunoglob G Subclasses Each,PX-3018278767,CDM,82787,CPT,0301,RC,,,,outpatient,,,5.00,3.25,,,,,,,,,,,,,
TUBE MYR L7MM POLY FOR VENT,SUP-2312523,CDM,L8699,HCPCS,0278,RC,,,,both,,,20.54,13.35,,,,,,,,,,,,,
SPLINT FNGR W1 2IN 3PP BUDDY LOOP,SUP-2112615,CDM,L3933,HCPCS,0272,RC,,,,both,,,8.35,5.43,,,,,,,,,,,,,
PORT INFUS CATH 6FR TI SGL LUMN INTMED KT W/ ATTCH OPN END,SUP-2127741,CDM,C1788,HCPCS,0278,RC,,,,both,,,1092.72,710.27,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED STD CEM N-K,SUP-2212609,CDM,C1776,CPT,0278,RC,,,,both,,,11597.31,7538.25,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 80 CM DIA 6MM STR STD WALL SLDE GDS,SUP-2681785,CDM,C1768,CPT,0278,RC,,,,both,,,2852.47,1854.11,,,,,,,,,,,,,
HC Visceral Arteriogram,PX-3237572600,CDM,75726,CPT,0323,RC,,,,both,,,9017.00,5861.05,,,,,,,,,,,,,
CATHETER LD DEL CPS AIM 90 DEG STD CRV SUBSELECTOR STRL,SUP-2357302,CDM,C1887,HCPCS,0272,RC,,,,both,,,753.60,489.84,,,,,,,,,,,,,
CATHETER HEMO DYLS OR HD ADMIN COMP ONLY DBL LUMN POLYUR STR,SUP-2116547,CDM,C1750,HCPCS,0278,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
PLATE BONE L164MM 12 H BILAT FIBULAR TIM LCK COMPR FOR,SUP-2413685,CDM,C1713,HCPCS,0278,RC,,,,both,,,1026.47,667.21,,,,,,,,,,,,,
KIT CAST TOT CONTACT SYS DUST VAC TCC-EZ,SUP-2909278,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2007.25,1304.71,,,,,,,,,,,,,
BOLT LOCKING RADIUS ULNA ROD F / IM ROD SYSTEM,SUP-2639989,CDM,2720000010,LOCAL,0272,RC,,,,both,,,580.90,377.58,,,,,,,,,,,,,
SLEEVE TIB 29MM KNEE PORCOAT PARTIALLY REV SYS ATTUNE,SUP-2251461,CDM,C1776,CPT,0278,RC,,,,both,,,8297.14,5393.14,,,,,,,,,,,,,
INSERT TIBIALXSM THK16MM UNIV KNEE HNG POST STBL BEAR PRI,SUP-2252652,CDM,C1776,CPT,0278,RC,,,,both,,,10833.00,7041.45,,,,,,,,,,,,,
BLADE SAW DIA9MM S STL CASPR,SUP-2363307,CDM,2720000010,LOCAL,0272,RC,,,,both,,,383.08,249.00,,,,,,,,,,,,,
ROD SPNL 5.5X85 MM CD HORZ LEG,SUP-2631281,CDM,C1713,HCPCS,0278,RC,,,,both,,,552.64,359.22,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 48 CM DIA 4-6 MM EPTFE TAPR STD,SUP-2396210,CDM,C1768,CPT,0278,RC,,,,both,,,1893.42,1230.72,,,,,,,,,,,,,
SYSTEM INTRO ACUSTK II GUIDEWIRE 0.038/0.018 IN SS WIRE STR,SUP-2147740,CDM,C1894,HCPCS,0272,RC,,,,both,,,263.76,171.44,,,,,,,,,,,,,
DISC ARTIFICIAL SZ 3 7.5DEG UNIV INTERVERTEBRAL LUM MTL ON,SUP-2257119,CDM,C1889,HCPCS,0278,RC,,,,both,,,18526.00,12041.90,,,,,,,,,,,,,
CATHETER HAD AD 14.5FR L27CM POLYUR STR TAPR TIP NO CUF,SUP-2127859,CDM,C1750,HCPCS,0278,RC,,,,both,,,1430.90,930.08,,,,,,,,,,,,,
HC Inj Proc Cysto or Void,PX-3615160000,CDM,51600,CPT,0361,RC,,,,outpatient,,,1485.00,965.25,,,,,,,,,,,,,
KNIFE ENDOSCP 9.5 FR HK BLADE SCKL TIP FOR OPT URETHROTM,SUP-2430220,CDM,C1713,HCPCS,0278,RC,,,,both,,,733.50,476.77,,,,,,,,,,,,,
PLATE BNE COMPR SM 2.7X84 MM 10 HOLE DYN NS DCP LTX,SUP-2861903,CDM,C1713,HCPCS,0278,RC,,,,both,,,504.54,327.95,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP L150CM DIA0.025IN 3CM PTFE COAT FLEXTIP,SUP-2313703,CDM,C1769,HCPCS,0272,RC,,,,both,,,71.15,46.25,,,,,,,,,,,,,
BLADE SCRWDRVR 74MML ULTRA LOW PRFLE F/NRO PLTNG SSTM,SUP-2500774,CDM,2720000010,LOCAL,0272,RC,,,,both,,,692.06,449.84,,,,,,,,,,,,,
ALLOGRAFT BNE 2 CC OSTEOCONDUCTIVE MTRX +,SUP-2716041,CDM,C1713,HCPCS,0278,RC,,,,both,,,31.40,20.41,,,,,,,,,,,,,
CAGE SPNL H88MM DIA12MM ANT THORLUM TI RND MESH INTBDY FUS,SUP-2193220,CDM,C1889,HCPCS,0278,RC,,,,both,,,13106.36,8519.13,,,,,,,,,,,,,
GRAFT BONE SUB 15CC CA PHOS VOID FIL PUTTY FOR CRS NORIAN,SUP-2193978,CDM,C1713,HCPCS,0278,RC,,,,both,,,14940.12,9711.08,,,,,,,,,,,,,
KAWAMOTO MIDFACE DIST CVD30MM4X4 MESH,SUP-2679181,CDM,C1713,HCPCS,0278,RC,,,,both,,,18810.36,12226.73,,,,,,,,,,,,,
CATHETER PTCA 8FR L100CM BLLN DIA10-46MM SHTH 12FR GWIRE,SUP-2296785,CDM,C1725,HCPCS,0272,RC,,,,both,,,1397.30,908.24,,,,,,,,,,,,,
CATHETER HD SHT TERM 11.5 FRX20 CM J HEMO-CATH,SUP-2627425,CDM,C1752,HCPCS,0278,RC,,,,both,,,384.65,250.02,,,,,,,,,,,,,
WIRE ORTH SMOOTH DBL SHRP TIP S STL NONSTERILE 3.0MM DIA,SUP-2362539,CDM,C1769,HCPCS,0272,RC,,,,both,,,339.12,220.43,,,,,,,,,,,,,
SPLINT WRST FA L INSTABILITY INJ 10IN LOOP LOK FIRM SUPP VYN,SUP-2276620,CDM,L3908,HCPCS,0272,RC,,,,both,,,16.01,10.41,,,,,,,,,,,,,
BRACE KNEE HNG WRP L,SUP-2276700,CDM,L1820,HCPCS,0272,RC,,,,both,,,56.68,36.84,,,,,,,,,,,,,
SPLINT ORTH M WRST FA HND R FRAC FIRM SUPP ALUMINUM POLY,SUP-2276769,CDM,L3809,HCPCS,0272,RC,,,,both,,,14.48,9.41,,,,,,,,,,,,,
LINER ACET ID28MM 20DEG GRP 2 ACS ENDRN,SUP-2249912,CDM,C1776,CPT,0278,RC,,,,both,,,3888.58,2527.58,,,,,,,,,,,,,
CANNULA SUBTLE L40CM WITH GUIDE KIT,SUP-2424450,CDM,C1713,HCPCS,0278,RC,,,,both,,,9420.00,6123.00,,,,,,,,,,,,,
PLATE BNE L 176 X W 10.2 MM THK 2.8 MM SCREW DIA 3.5 MM 16 HL NS LK,SUP-2937313,CDM,C1713,HCPCS,0278,RC,,,,both,,,3221.95,2094.27,,,,,,,,,,,,,
GRAFT HUM TISS W4XL7CM THK0.9-1.99MM ACELLULAR DERM MTRX,SUP-2402507,CDM,Q4126,HCPCS,0636,RC,,,,both,,,7222.00,4694.30,,,,,,,,,,,,,
GUIDEWIRE VASC INQWIRE L 150 CM DIA 0.035 IN PTFE PERIPH STR,SUP-2301931,CDM,C1769,HCPCS,0272,RC,,,,both,,,28.10,18.26,,,,,,,,,,,,,
SCREW BNE L 110 MM DIA 4.7 MM SS PARTIALLY THRD OSTEOPENIA,SUP-2931541,CDM,C1713,HCPCS,0278,RC,,,,both,,,287.59,186.93,,,,,,,,,,,,,
TAP SURG BONE SCR SELF DRL DELT SYS 1.7MM,SUP-2365068,CDM,2720000010,LOCAL,0272,RC,,,,both,,,573.49,372.77,,,,,,,,,,,,,
BUR SURG L21CM DIA6MM BALL FLUT L BOR MIDAS REX LEGEND,SUP-2284388,CDM,2720000010,LOCAL,0272,RC,,,,both,,,417.21,271.19,,,,,,,,,,,,,
COLLAR CERV UNIV AD L13-19IN TRACH OPN TWO PC RIG POLYETH,SUP-2124202,CDM,L0120,HCPCS,0272,RC,,,,both,,,115.05,74.78,,,,,,,,,,,,,
BLOCKER ENDOBRONCH SET W/ SPHR BAL DISP ARNDT,SUP-2170492,CDM,2720000010,LOCAL,0272,RC,,,,both,,,942.31,612.50,,,,,,,,,,,,,
FIBER LASER 940 MH SOLTIVE DISP,SUP-2540085,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2374.72,1543.57,,,,,,,,,,,,,
FIBER LASER 550 MH HD YAG,SUP-2835044,CDM,2720000010,LOCAL,0272,RC,,,,both,,,832.10,540.86,,,,,,,,,,,,,
PLATE BNE L322MM 16 H ST R MED PROX TIB S STL LOK COMPR LO,SUP-2185691,CDM,C1713,HCPCS,0278,RC,,,,both,,,5017.09,3261.11,,,,,,,,,,,,,
BUR SURG RND CUT SHT 3 MM ROSEN N FLUT HI-LINE XS DISP,SUP-2108764,CDM,C1713,HCPCS,0278,RC,,,,both,,,344.49,223.92,,,,,,,,,,,,,
PLATE CRAN 200X180X40 MM PT SPEC IMPL PEEK,SUP-2860164,CDM,C1713,HCPCS,0278,RC,,,,both,,,55743.48,36233.26,,,,,,,,,,,,,
PLATE BONE LOK NON CMPRSSN HLX24 15MM THK TTNM STRGHT LVLX1,SUP-2679059,CDM,C1713,HCPCS,0278,RC,,,,both,,,2725.30,1771.44,,,,,,,,,,,,,
WALKER PT STD XL 11-16 13 + CLOSED HEEL SHOE PACESETTER II,SUP-2195219,CDM,L4386,HCPCS,0274,RC,,,,both,,,84.78,55.11,,,,,,,,,,,,,
NAIL IM L280MM DIA12MM UNIV L R DST FEM TI CANN LOK RG DYN,SUP-2191777,CDM,C1713,HCPCS,0278,RC,,,,both,,,6847.40,4450.81,,,,,,,,,,,,,
GRAFT BNE TISS DBM SYNERGENT 6300001] EXACTECH INC],SUP-2223570,CDM,C1713,HCPCS,0278,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
PLATE BONE L149MM THK4MM 7 H LT LAT TIB HD BTTRS FOR,SUP-2343793,CDM,C1713,HCPCS,0278,RC,,,,both,,,6000.23,3900.15,,,,,,,,,,,,,
GRAFT ALLGRFT TEND TIBIALIS ANTR FRZN,SUP-2165551,CDM,C1713,HCPCS,0278,RC,,,,both,,,5014.58,3259.48,,,,,,,,,,,,,
FOOTSWITCH ELECSURG 10 MM FOR LAP,SUP-2225600,CDM,2720000010,LOCAL,0272,RC,,,,both,,,824.25,535.76,,,,,,,,,,,,,
PLATE BNE FIBULAR 2.7X183 MM RT LAT DSTL 11 HOLE STRL VALCP,SUP-2789399,CDM,C1713,HCPCS,0278,RC,,,,both,,,3592.16,2334.90,,,,,,,,,,,,,
CATH REPROC EP FIXED JSN 4POL 2-5-2 5FR,SUP-2526068,CDM,C1730,HCPCS,0272,RC,,,,both,,,185.29,120.44,,,,,,,,,,,,,
GRAFT HUM TISS W10XL200MM THK3-12MM CORT FEM STRUT 3RD FRZN,SUP-2307354,CDM,C1713,HCPCS,0278,RC,,,,both,,,2530.06,1644.54,,,,,,,,,,,,,
HC X-Ray Exam Bil Hips W/Pelvis 2 Views,PX-3207352100,CDM,73521,CPT,0320,RC,,,,both,,,676.00,439.40,,,,,,,,,,,,,
GUIDEWIRE ORTH L350MM DIA2.8MM S STL THRD TRCR PNT,SUP-2188202,CDM,C1769,HCPCS,0272,RC,,,,both,,,116.59,75.78,,,,,,,,,,,,,
BIT DRL DIA 4.8/1.8 MM SHRT CANN FOR HALF PIN NS DISP,SUP-2933734,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1653.78,1074.96,,,,,,,,,,,,,
PIN FIX THRD UNIV 3.2X67 MM HD FOR SYNTHES KNEE INSTR SYS SS,SUP-2877753,CDM,2720000010,LOCAL,0272,RC,,,,both,,,569.94,370.46,,,,,,,,,,,,,
PLATE BNE COMPR 95 DEG 299 MM FEM HIP 18 HOLE KEYED TUBE,SUP-2470679,CDM,C1713,HCPCS,0278,RC,,,,both,,,2566.67,1668.34,,,,,,,,,,,,,
PLATE BNE L1865MM THK25MM 12 H PELV S STL CRV,SUP-2362694,CDM,C1713,HCPCS,0278,RC,,,,both,,,2903.56,1887.31,,,,,,,,,,,,,
KIT ORTH INSTR GUIDEWIRE L 254 CM DIA1.6 X 0.8MM DEPTH GA,SUP-2882151,CDM,C1769,HCPCS,0272,RC,,,,both,,,1146.10,744.96,,,,,,,,,,,,,
IMPLANT SYNTH 13 X 38 MM THK 6 MM POLYETHYL CRANIOFACIAL,SUP-2883239,CDM,C1713,HCPCS,0278,RC,,,,both,,,1820.95,1183.62,,,,,,,,,,,,,
GRAFT BNE XS 1 CC DBM FIBER STRND +,SUP-2644300,CDM,C1713,HCPCS,0278,RC,,,,both,,,2684.70,1745.05,,,,,,,,,,,,,
SCREW BNE CORTICAL 1.5X10 MM,SUP-2462932,CDM,C1713,HCPCS,0278,RC,,,,both,,,67.01,43.56,,,,,,,,,,,,,
PROCESSOR SOUND PONTO 3 SUPER POWER RIGHT CHROMA BEIGE,SUP-2430359,CDM,L8690,HCPCS,0278,RC,,,,both,,,18212.00,11837.80,,,,,,,,,,,,,
GRAFT DURA W1XL1IN CLLGN DURAFOAM,SUP-2243763,CDM,C1713,HCPCS,0278,RC,,,,both,,,415.23,269.90,,,,,,,,,,,,,
BEVACIZUMAB 100 MG/4ML IV SOLN,RX-104374,CDM,J9035,HCPCS,0636,RC,50242-0060-01,NDC,,both,4,ML,2295.20,1491.88,,,,,,,,,,,,,
GUIDEWIRE ORTH L 220 MM DIA1.6 MM SCREW DIA 4.5/5.5 MM,SUP-2908198,CDM,C1769,HCPCS,0272,RC,,,,both,,,338.99,220.34,,,,,,,,,,,,,
SCREW SPNL L80MM DIA10MM CANC ANTR IL S STL CLOSE FOR 6.35MM,SUP-2255703,CDM,C1713,HCPCS,0278,RC,,,,both,,,2518.28,1636.88,,,,,,,,,,,,,
CATHETER GUID JCR3.5 0.066 INX8 FRX100 CM CORONARY VKG,SUP-2103236,CDM,C1887,HCPCS,0272,RC,,,,both,,,172.70,112.25,,,,,,,,,,,,,
CATHETER PICC 3FR POLYUR NCOATED MICROINTRODUCER TRIM LEN,SUP-2127455,CDM,C1751,HCPCS,0278,RC,,,,both,,,411.34,267.37,,,,,,,,,,,,,
COLLAR CERV PHILLY LG 4.25 IN 16-19 IN REHAB FOAM PROCARE,SUP-2196880,CDM,L0120,HCPCS,0274,RC,,,,both,,,28.39,18.45,,,,,,,,,,,,,
BLOCK CUT FEM MYKNEE SZ 4 R ST,SUP-2417454,CDM,C1776,CPT,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
PLATE BNE FIBULAR 2.7X183 MM RT LAT DSTL 11 HOLE NS VA-LCP,SUP-2758203,CDM,C1713,HCPCS,0278,RC,,,,both,,,3273.76,2127.94,,,,,,,,,,,,,
BATTERY SET 14 V CLP HEARTMATE,SUP-2356044,CDM,C1713,HCPCS,0278,RC,,,,both,,,1865.16,1212.35,,,,,,,,,,,,,
GRAFT DERMAL MESH 8X8 CM FEN + WND MTRX MIRODERM,SUP-2431552,CDM,Q4175,HCPCS,0636,RC,,,,both,,,12449.47,8092.16,,,,,,,,,,,,,
INSTRUMENT TEMP FIX 2X12 MM RIB THOR SCR TI LEVEL 1 MAXDRIVE,SUP-2869183,CDM,2720000010,LOCAL,0272,RC,,,,both,,,560.18,364.12,,,,,,,,,,,,,
PATCH LD TEMP TRNSVEN UPLR ACT FIX DF-1 CONN,SUP-2282237,CDM,C1896,HCPCS,0275,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
MESH CRAN L 84.33 X W 34.7 MM THK 0.3 MM SCREW DIA1.5 MM LG,SUP-2936583,CDM,C1713,HCPCS,0278,RC,,,,both,,,4289.24,2788.01,,,,,,,,,,,,,
TUBE VENT SHEEHY 1.27X3 MM 1.52 MM FLANGE CLLR BUTTON WHT,SUP-2284075,CDM,L8699,HCPCS,0278,RC,,,,both,,,28.83,18.74,,,,,,,,,,,,,
WASHER ORTHOPAEDIC ROUND 2.2X4.5 MM STAINLESS STEEL NON STER,SUP-2837002,CDM,C1713,HCPCS,0278,RC,,,,both,,,205.61,133.65,,,,,,,,,,,,,
ALLOGRAFT BNE CHIP 0.1-4 MM 15 CC FRZN CANC,SUP-2792182,CDM,C1713,HCPCS,0278,RC,,,,both,,,1407.35,914.78,,,,,,,,,,,,,
SCREW SPNL L20MM DIA5.5MM CANC ANTR THORLUM GRN TI ALLOY ST,SUP-2193078,CDM,C1713,HCPCS,0278,RC,,,,both,,,751.72,488.62,,,,,,,,,,,,,
SEALER TISS L45CM ADV BPLR STR RND TIP LAP APPRCH ENSEAL,SUP-2257695,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6725.94,4371.86,,,,,,,,,,,,,
GUIDEWIRE VASC L 45 CM DIA 0.032 IN STR TIP STRL,SUP-2214526,CDM,C1769,HCPCS,0272,RC,,,,both,,,25.43,16.53,,,,,,,,,,,,,
CLIP ANEURYSM L5MM BLADE L13MM 90DEG STANDARD PERMANENT ANGL,SUP-2821637,CDM,C1889,HCPCS,0278,RC,,,,both,,,6437.03,4184.07,,,,,,,,,,,,,
ROD SPNL L72-220MM DIA3.5-6.35MM POST OCCIPITOCERVICAL TI,SUP-2176891,CDM,C1713,HCPCS,0278,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH FLX L 82 MM DIA 30 MM SHTH 20 FR RVD,SUP-2170627,CDM,C1874,HCPCS,0278,RC,,,,both,,,24021.00,15613.65,,,,,,,,,,,,,
SET ORTH INSTR SHLDR PERC COR DECOMPRESSION SYS STRL DISP,SUP-2884256,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5510.70,3581.95,,,,,,,,,,,,,
COMPRESSOR EXT FIX OPN,SUP-2188620,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1747.85,1136.10,,,,,,,,,,,,,
CAGE IM SM 73MM NIT SELF EXP 3 DIM FX MGMT,SUP-2167473,CDM,C1889,HCPCS,0278,RC,,,,both,,,15370.30,9990.69,,,,,,,,,,,,,
SHOULDER IMMOB ELAS XLG,SUP-2195042,CDM,L3650,HCPCS,0274,RC,,,,both,,,28.26,18.37,,,,,,,,,,,,,
GADOBUTROL 1 MMOL/ML IV SOLN,RX-104340,CDM,A9585,HCPCS,0636,RC,50419-0325-11,NDC,,both,7.5,ML,34.30,22.29,,,,,,,,,,,,,
KIT THROMCTMY JETI L 120 CM DIA 6 FR PERIPH HYDRODYNAMIC,SUP-2753186,CDM,C1757,HCPCS,0272,RC,,,,both,,,11743.60,7633.34,,,,,,,,,,,,,
COLLAR CERV SFT 3X22IN UNIV,SUP-2276583,CDM,L0120,HCPCS,0272,RC,,,,both,,,6.59,4.28,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 70 CM DIA 6 MM EPTFE STR TW,SUP-2525470,CDM,C1768,CPT,0278,RC,,,,both,,,2677.51,1740.38,,,,,,,,,,,,,
HC X-Ray Exam Chest 2 Views,PX-3247104600,CDM,71046,CPT,0324,RC,,,,both,,,718.00,466.70,,,,,,,,,,,,,
KIT CATH 5FR L91CM GWIRE INTRO SHTH SET SYR STPCOCK BRDG,SUP-2353170,CDM,C2628,HCPCS,0272,RC,,,,both,,,926.30,602.09,,,,,,,,,,,,,
BLADE SHV DIA2MM STR SERR TURB DISECT FOR SNUS SURG DIEGO,SUP-2313836,CDM,2720000010,LOCAL,0272,RC,,,,both,,,425.72,276.72,,,,,,,,,,,,,
LENGTHENER FIX SHT FOR 32.5MM MINIRAIL SYS,SUP-2316437,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3115.51,2025.08,,,,,,,,,,,,,
IMMUNE GLOBULIN (GAMUNEX-C) 10%,RX-4081759,CDM,J1569,HCPCS,0636,RC,00944-2700-04,NDC,,both,50,ML,2575.50,1674.07,,,,,,,,,,,,,
LINER ACET OD68MM ID36MM 0DEG MARATHON HIP REV NEUT PINN,SUP-2250463,CDM,C1776,CPT,0278,RC,,,,both,,,4666.67,3033.34,,,,,,,,,,,,,
GRAFT HUM TISS W9XL20CM AMNIO MEM FEN EPIXL,SUP-2305735,CDM,Q4186,HCPCS,0636,RC,,,,both,,,37100.67,24115.44,,,,,,,,,,,,,
PIN EXT FIX TRANSFIX 5X300 MM W/ WIRE HOLE TIP SIDEKCK,SUP-2483147,CDM,2720000010,LOCAL,0272,RC,,,,both,,,715.92,465.35,,,,,,,,,,,,,
BIT DRL N CANN 2.7 MM FOR LAG TECH SMRTSCR II,SUP-2167109,CDM,2720000010,LOCAL,0272,RC,,,,both,,,540.08,351.05,,,,,,,,,,,,,
GRAFT SURG REGEN PORCINE CLLGN XENMATRIX RECT 20CM X 20CM,SUP-2125850,CDM,C1781,HCPCS,0278,RC,,,,both,,,38335.32,24917.96,,,,,,,,,,,,,
INSERT TIB SM THK16MM KNEE DUR CEM POST STBL LIP DURAC,SUP-2377660,CDM,C1776,CPT,0278,RC,,,,both,,,2297.22,1493.19,,,,,,,,,,,,,
APPLIER INT CLP MULT FIRE MED LG 10X370 MM CHALLENGER REUSE,SUP-2850165,CDM,C1889,HCPCS,0278,RC,,,,both,,,5265.59,3422.63,,,,,,,,,,,,,
PLATE BNE W11XL151MM THK33MM 11 H BILAT MTPHSEAL TI LOK,SUP-2190765,CDM,C1713,HCPCS,0278,RC,,,,both,,,2856.36,1856.63,,,,,,,,,,,,,
IMMUNE GLOBULIN (GAMUNEX-C) 10%,RX-4081759,CDM,J1561,HCPCS,0636,RC,13533-0800-24,NDC,,both,200,ML,8775.70,5704.20,,,,,,,,,,,,,
ROD SPNL L420MM DIA35 55MM OCCIPITOCERVICAL UP THOR TAPR,SUP-2285471,CDM,C1713,HCPCS,0278,RC,,,,both,,,3048.94,1981.81,,,,,,,,,,,,,
HOLDER NDLE CSTRVJO 8 1/2NL TNGSTN CRBDE STRGHT SRRTD JAW DL,SUP-2482021,CDM,2720000010,LOCAL,0272,RC,,,,both,,,439.47,285.66,,,,,,,,,,,,,
ROD SPNL ANTR RT SMOOTH S STL 5.0MM DIA 200MM LEN COLORADO,SUP-2290510,CDM,C1713,HCPCS,0278,RC,,,,both,,,2091.24,1359.31,,,,,,,,,,,,,
BIT DRL L100MM DIA2MM ST QUIK CPL NONRADIOPAQUE W/O STP,SUP-2187201,CDM,2720000010,LOCAL,0272,RC,,,,both,,,374.45,243.39,,,,,,,,,,,,,
BUR SURG RND CUT NONFLUTED S STL ULT LNG L710MM OD50MM,SUP-2278151,CDM,2720000010,LOCAL,0272,RC,,,,both,,,247.02,160.56,,,,,,,,,,,,,
INTRODUCER HEMSTAS 5FRX5CM WYSHAM SHTH .038IN GWIRE FAST,SUP-2355425,CDM,C1894,HCPCS,0272,RC,,,,both,,,35.33,22.96,,,,,,,,,,,,,
WASHER ORTH DIA 4 MM NS LEOS,SUP-2932986,CDM,C1713,HCPCS,0278,RC,,,,both,,,498.41,323.97,,,,,,,,,,,,,
PSN REV TIB FIXED KEEL CMT SZ D L,SUP-2508652,CDM,C1776,CPT,0278,RC,,,,both,,,6405.60,4163.64,,,,,,,,,,,,,
NAIL IM FEM 130 DEG UNIV 13 MMX44 CM RT LCK CANN VERSANAIL,SUP-2460878,CDM,C1713,HCPCS,0278,RC,,,,both,,,6889.16,4477.95,,,,,,,,,,,,,
WIRE PACE MYO/WIRE L 61 CM SZ 2-0 CRV 26 MM STR 89 MM SS ORN,SUP-2101190,CDM,2720000010,LOCAL,0272,RC,,,,both,,,50.37,32.74,,,,,,,,,,,,,
CLIP ANEUR NO51 L15.8MM OPN 9MM HNDL L7MM 0.69N STD TI T2,SUP-2306119,CDM,C1889,HCPCS,0278,RC,,,,both,,,1740.82,1131.53,,,,,,,,,,,,,
KIT BNE PLT L54MM HD DIA22MM 6X3 H L VOLAR DST RAD S STL VAR,SUP-2177300,CDM,C1713,HCPCS,0278,RC,,,,both,,,4148.94,2696.81,,,,,,,,,,,,,
NEEDLE INTOSS AD FAST L25MM OD15GA EZ-IO,SUP-2120556,CDM,2720000010,LOCAL,0272,RC,,,,both,,,160.14,104.09,,,,,,,,,,,,,
HC Pain Combination,PX-3600007517,CDM,3600007517,LOCAL,0360,RC,,,,outpatient,,,3954.00,2570.10,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.526,SUP-2860043,CDM,C1713,HCPCS,0278,RC,,,,both,,,39196.93,25478.00,,,,,,,,,,,,,
CATHETER ANGIOPLSTY FOX SV L 150 CM BALLOON L 100 MM DIA2.5,SUP-2105995,CDM,C1725,HCPCS,0272,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
TOOL TUNN ROD 12 IN,SUP-2496412,CDM,2720000010,LOCAL,0272,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
PLATE BNE MESH PANEL 2X10X1 MM MENARD SPEC SM GRID FOR SCR,SUP-2539594,CDM,C1713,HCPCS,0278,RC,,,,both,,,2008.28,1305.38,,,,,,,,,,,,,
MONITOR CO INSERTABLE LUXDX,SUP-2640130,CDM,C1764,HCPCS,0278,RC,,,,both,,,14130.00,9184.50,,,,,,,,,,,,,
ARSENIC TRIOXIDE 10 MG/10ML IV SOLN,RX-29071,CDM,J9017,HCPCS,0636,RC,70121-1483-07,NDC,,both,10,ML,195.70,127.20,,,,,,,,,,,,,
KIT INFUS PMP L 20GA L6.4CM VOL TBNG EPI CATH 2 DY NDL SYR,SUP-2363211,CDM,C2626,HCPCS,0278,RC,,,,both,,,420.85,273.55,,,,,,,,,,,,,
GUIDEWIRE UROLOGY STR 0.038 INX150 CM HYBRID MOTN,SUP-2835990,CDM,C1769,HCPCS,0272,RC,,,,both,,,200.65,130.42,,,,,,,,,,,,,
RESIN ORTHODONTIC 12 OZ LIQ PNK,SUP-2176745,CDM,C1713,HCPCS,0278,RC,,,,both,,,125.57,81.62,,,,,,,,,,,,,
ELECTRODE SUCT DIA23MM CBL L85MM SHT SIDE EFF RF SYS W,SUP-2256734,CDM,2720000010,LOCAL,0272,RC,,,,both,,,269.91,175.44,,,,,,,,,,,,,
BLADE ENDOSCP SHAVER 360 DEG L 11 CM DIA2.9 MM SPD 7500 RPM,SUP-2902025,CDM,2720000010,LOCAL,0272,RC,,,,both,,,756.11,491.47,,,,,,,,,,,,,
SCREW BNE L10MM DIA3.5MM TI BLNT TIP HEXALOBE DRV FOR,SUP-2321360,CDM,C1713,HCPCS,0278,RC,,,,both,,,525.32,341.46,,,,,,,,,,,,,
PLATE BONE W14.9XL232MM THK1.2MM 14 H DSTL TIB S STL,SUP-2185743,CDM,C1713,HCPCS,0278,RC,,,,both,,,1551.66,1008.58,,,,,,,,,,,,,
PLATE BNE OFFSET GRID 2 MM RT LCK NS LTX,SUP-2856943,CDM,C1713,HCPCS,0278,RC,,,,both,,,1001.66,651.08,,,,,,,,,,,,,
GUIDE SURG PLN TI LP RECON CUSTOMIZABLE VSP,SUP-2883951,CDM,2720000010,LOCAL,0272,RC,,,,both,,,9020.59,5863.38,,,,,,,,,,,,,
DEXTROSE 5 % AND 0.9 % NACL IV BOLUS,RX-40840054,CDM,2580000003,HCPCS,0258,RC,00338-0089-03,NDC,,both,250,ML,19.20,12.48,,,,,,,,,,,,,
PLATE BNE T NEURO ULTRA LO PROF W/ TAB TI LEVEL 1 LF,SUP-2462737,CDM,C1713,HCPCS,0278,RC,,,,both,,,753.76,489.94,,,,,,,,,,,,,
MESH SURG DIA20-25CM WHT POLY CLLGN FLM RECT MFIL BIOABSRB,SUP-2283402,CDM,C1781,HCPCS,0278,RC,,,,both,,,5338.44,3469.99,,,,,,,,,,,,,
HC So Hepatitis B Surface Ag,PX-3068734066,CDM,87340,CPT,0306,RC,,,,inpatient,,,57.00,37.05,,,,,,,,,,,,,
MESH HERN SM W5XL30CM POLYPR NONABSORBABLE SYN RECT PROL,SUP-2219802,CDM,C1781,HCPCS,0278,RC,,,,both,,,252.46,164.10,,,,,,,,,,,,,
BIT DRL L110MM DIA2.7MM STRL TI JCBS CHK NONRADIOPAQUE W/O,SUP-2187246,CDM,2720000010,LOCAL,0272,RC,,,,both,,,401.57,261.02,,,,,,,,,,,,,
MAND ANGLE PLATE T.S.LCKNG RT X LNG 3 X 3 2.3MM SSTM T 6L 4V,SUP-2496207,CDM,C1713,HCPCS,0278,RC,,,,both,,,1516.97,986.03,,,,,,,,,,,,,
RING EXT FIX CIR 5/8 200 MM SIDEKCK,SUP-2850514,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2006.46,1304.20,,,,,,,,,,,,,
SUPPORT ORTHOT ANK JT TORSION CTRL ANK JT HALF SLD STIRRUP,SUP-2435663,CDM,L2375,HCPCS,0274,RC,,,,both,,,348.35,226.43,,,,,,,,,,,,,
SPLINT WRST L L THMB SPICA COT POLY FAB LTHR WRKHRD ORIG BGE,SUP-2326138,CDM,L3908,HCPCS,0274,RC,,,,both,,,63.05,40.98,,,,,,,,,,,,,
PROSTHESIS VOICE 20FR L6MM L FLNG INDWL 2 VLV BLOM-SINGER,SUP-2242330,CDM,L8509,HCPCS,0272,RC,,,,both,,,1378.46,896.00,,,,,,,,,,,,,
NEEDLE SCLERO L4MM L200CM OD25GA ODSEC18MM 038IN LOK CLR HUB,SUP-2141385,CDM,2720000010,LOCAL,0272,RC,,,,both,,,488.43,317.48,,,,,,,,,,,,,
COIL VASC HELCL SFT 10MM ID 20CM LEN .0135IN GWIRE STRTCH,SUP-2173640,CDM,C1889,HCPCS,0278,RC,,,,both,,,3416.32,2220.61,,,,,,,,,,,,,
BLADE SAW SAG 16.5X10 MM 20 MM GRFT HARVESTING W/ STP SS,SUP-2166092,CDM,C1713,HCPCS,0278,RC,,,,both,,,341.51,221.98,,,,,,,,,,,,,
PLATE BONE SM 95MML HLX8 STNLSS STEEL BTTRSS ST LEFT DST VOL,SUP-2496870,CDM,C1713,HCPCS,0278,RC,,,,both,,,2007.81,1305.08,,,,,,,,,,,,,
KIT BNE CEM 80GM DBL MIX SHT CART EXT W/ BRKWY NOZ OPTVAC,SUP-2216858,CDM,C1713,HCPCS,0278,RC,,,,both,,,307.72,200.02,,,,,,,,,,,,,
GRAFT VASC GELSFT + L 45 CM DIA22 MM LEG DIA11 MM POLYESTER,SUP-2384942,CDM,C1768,CPT,0278,RC,,,,both,,,2128.20,1383.33,,,,,,,,,,,,,
RING EXT FIX FULL 200 MM TAB,SUP-2749874,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4700.58,3055.38,,,,,,,,,,,,,
BEARING TIB L63/67MM THK14MM KNEE SUP STBL POST STBL CNDYL 183864] ZIMMER BIOMET ORTHOPEDICS],SUP-2407724,CDM,C1776,CPT,0278,RC,,,,both,,,6571.24,4271.31,,,,,,,,,,,,,
HC Replac Central Tun Cath W/Port,PX-3613658200,CDM,36582,CPT,0361,RC,,,,outpatient,,,3707.00,2409.55,,,,,,,,,,,,,
BLADE SAW W13XL76MM THK089MM DBL SIDE RECIP,SUP-2205421,CDM,C1713,HCPCS,0278,RC,,,,both,,,109.90,71.43,,,,,,,,,,,,,
GRAFT TISS FRZ DRY ALLGRFT STRP ILIUM TRICORT TRAD 22X50MM,SUP-2294072,CDM,C1713,HCPCS,0278,RC,,,,both,,,5187.28,3371.73,,,,,,,,,,,,,
GRAFT SFT TISS 30X40 MM PERICARD MEMBRN COPIOS,SUP-2390690,CDM,C1713,HCPCS,0278,RC,,,,both,,,838.38,544.95,,,,,,,,,,,,,
CONNECTOR SPNL L200MM POST LAT TI OFFSET SACR EXT FIX XLNK,SUP-2254757,CDM,C1713,HCPCS,0278,RC,,,,both,,,2395.82,1557.28,,,,,,,,,,,,,
GRAFT SFT TISS PRE SAT 155 MM ANK LAT FRZN TEND,SUP-2427793,CDM,C1762,CPT,0278,RC,,,,both,,,4091.26,2659.32,,,,,,,,,,,,,
CATHETER ANGIO ZOOM L 137 CM DIA 6 FR DSTL OD 5 FR PROX ID,SUP-2913687,CDM,C1757,HCPCS,0272,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
DRESSING WND MULTLYR CLLGN MTRX 5X5 CM SHT MATRISTEM,SUP-2106525,CDM,Q4166,HCPCS,0636,RC,,,,both,,,2508.86,1630.76,,,,,,,,,,,,,
CAP NUT VLS ALIGNING TI,SUP-2415645,CDM,C1713,HCPCS,0278,RC,,,,both,,,738.53,480.04,,,,,,,,,,,,,
HC Spirometry / Tvc / Mvv,PX-4609401000,CDM,94010,CPT,0460,RC,,,,inpatient,,,347.00,225.55,,,,,,,,,,,,,
PLATE CNDYL 1.5MM 2H HD 6H SHFT STRL VAL,SUP-2546074,CDM,C1713,HCPCS,0278,RC,,,,both,,,1656.57,1076.77,,,,,,,,,,,,,
CATHETER HD STR 8 FRX12 CM SHT TERM DL BASIC SET SIL HEMCATH,SUP-2627300,CDM,C1752,HCPCS,0278,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
PLATE BONE DUAL CMPRSSN HLX7 TTNM F/2.7MM SCREW UNVRSL LOK S,SUP-2493084,CDM,C1713,HCPCS,0278,RC,,,,both,,,838.32,544.91,,,,,,,,,,,,,
STENT BILI L40MM 120CM CATH LEN 7MM DIAM AD XCEED,SUP-2105768,CDM,C1876,HCPCS,0278,RC,,,,both,,,4474.50,2908.42,,,,,,,,,,,,,
SPACER CERV 7MM HYDRATED LORD,SUP-2415953,CDM,C1889,HCPCS,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
STRUT EXT FIX SHRT STD NS DISP SMRT TSF,SUP-2933052,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4183.61,2719.35,,,,,,,,,,,,,
SCREW BNE L8MM DIA2MM STD CORT CRANIOMAXILLOFACIAL TI SELF,SUP-2189351,CDM,C1713,HCPCS,0278,RC,,,,both,,,281.34,182.87,,,,,,,,,,,,,
IMPLANT BIO TISS W25XL40MM THK3MM ABD BOV CLLGN SURGIMEND,SUP-2383082,CDM,C1781,HCPCS,0278,RC,,,,both,,,72220.00,46943.00,,,,,,,,,,,,,
PLATE BNE VOLAR DST RAD NEUT EXTN EXTRA ARTC ACU-LOC 2,SUP-2107045,CDM,C1713,HCPCS,0278,RC,,,,both,,,1975.06,1283.79,,,,,,,,,,,,,
KIT PICC OD5FR ID17.5/17.5GA RVS TAPR 7FR WIRE L70CM NIT 2,SUP-2118834,CDM,C1751,HCPCS,0278,RC,,,,both,,,486.70,316.35,,,,,,,,,,,,,
WIRE EXT FIX TIN TIP SIDEKCK EZ FRAME,SUP-2851086,CDM,C1713,HCPCS,0278,RC,,,,both,,,4060.02,2639.01,,,,,,,,,,,,,
BLADE RTRCTR JNNTTA 20MM X 95MMW SPNL MAL RGGLS RDMND,SUP-2465307,CDM,2720000010,LOCAL,0272,RC,,,,both,,,172.76,112.29,,,,,,,,,,,,,
CONN PL W/THD 9HOLES 215,SUP-2818122,CDM,C1713,HCPCS,0278,RC,,,,both,,,2622.43,1704.58,,,,,,,,,,,,,
RETRACTOR SINGLE USE CORDLESS ONETRAC LX 135MMX20MM,SUP-2740196,CDM,2720000010,LOCAL,0272,RC,,,,both,,,989.10,642.91,,,,,,,,,,,,,
GUIDEWIRE VASC L 50 CM DIA 0.035 IN TAPR L 10 CM FLPY TIP L,SUP-2167577,CDM,C1769,HCPCS,0272,RC,,,,both,,,64.02,41.61,,,,,,,,,,,,,
COMPONENT FEM SEG 8.5 CM RT KNEE REDUC RESECT OSS RS,SUP-2441808,CDM,C1776,CPT,0278,RC,,,,both,,,19287.45,12536.84,,,,,,,,,,,,,
HC Cold Agglutinin Titer,PX-3028615700,CDM,86157,CPT,0302,RC,,,,both,,,421.00,273.65,,,,,,,,,,,,,
COMPONENT PART SHLDR,SUP-2212641,CDM,C1776,CPT,0278,RC,,,,both,,,11932.00,7755.80,,,,,,,,,,,,,
PLATE BNE 5MM R CRANIOMAXILLOFACIAL CP TI 1 LEV FOR 2MM SCR,SUP-2262503,CDM,C1713,HCPCS,0278,RC,,,,both,,,867.68,563.99,,,,,,,,,,,,,
TOE IMPL INSRTN KT GREAT SIZE: 0 TO 4 CONTENTS: TI IMPL,SUP-2397201,CDM,C1776,CPT,0278,RC,,,,both,,,5102.50,3316.62,,,,,,,,,,,,,
PLATE BNE CRV 4.5X159 MM LT CNDYL 6 HOLE VA LCK NS VA-LCP,SUP-2758210,CDM,C1713,HCPCS,0278,RC,,,,both,,,5437.22,3534.19,,,,,,,,,,,,,
FIBER LASER 270UM DISP FLAT TIP HOLM SINGLEFLEX,SUP-2213046,CDM,C1713,HCPCS,0278,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
HC Transcatheter Biopsy,PX-3613720000,CDM,37200,CPT,0361,RC,,,,inpatient,,,6875.00,4468.75,,,,,,,,,,,,,
PLATE BNE Y 0.6 MM FACE,SUP-2262678,CDM,C1713,HCPCS,0278,RC,,,,both,,,784.56,509.96,,,,,,,,,,,,,
BUR SURG DIA05MM DMND RND FLUT FOR ELITE SABER SHANK,SUP-2367567,CDM,C1713,HCPCS,0278,RC,,,,both,,,369.55,240.21,,,,,,,,,,,,,
TUBE VENT 0.97 MM 2.3 MM BAXTER BVL BOB TAPR FLROPLAS,SUP-2535148,CDM,L8699,HCPCS,0278,RC,,,,both,,,33.06,21.49,,,,,,,,,,,,,
GRAFT BNE SUB W15 18XL80MM RAD ULN SHFT FRZ DRY,SUP-2307202,CDM,C1713,HCPCS,0278,RC,,,,both,,,2256.88,1466.97,,,,,,,,,,,,,
LINER ACET 36X58 MM HIP CERM BIOLOX FORTE R3,SUP-2434792,CDM,C1776,CPT,0278,RC,,,,both,,,5545.24,3604.41,,,,,,,,,,,,,
ALLOGRAFT HUM TISS MESHED 4X2 CMX0.3 MM PERITONEUM MTRX MESO,SUP-2491346,CDM,C1762,CPT,0278,RC,,,,both,,,1185.41,770.52,,,,,,,,,,,,,
HC Transcatheter Biopsy,PX-3613720000,CDM,37200,CPT,0361,RC,,,,outpatient,,,6875.00,4468.75,,,,,,,,,,,,,
CATHETER CV SINGLE LUMEN 5 FRX60 CM 5 CM BASIC KT PRO-LINE,SUP-2268423,CDM,C1751,HCPCS,0278,RC,,,,both,,,769.30,500.04,,,,,,,,,,,,,
MODEL ANAT MANDIBULAR/MAXILLARY RECON CASE BNDL VSP,SUP-2884205,CDM,2720000010,LOCAL,0272,RC,,,,both,,,21775.90,14154.33,,,,,,,,,,,,,
TRAB METAL TIB CONE SZ 48-15MM FULL XSMALL,SUP-2502270,CDM,C1776,CPT,0278,RC,,,,both,,,10198.72,6629.17,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 4.5X200-219 MM SEMITENDINOSUS,SUP-2866880,CDM,C1762,CPT,0278,RC,,,,both,,,2881.58,1873.03,,,,,,,,,,,,,
KIT PHLEB W/ 5.5MM BLDE AND TBNG TRANSILLUMINATED PWR SYS,SUP-2264271,CDM,C1713,HCPCS,0278,RC,,,,both,,,1252.86,814.36,,,,,,,,,,,,,
ALLOGRAFT HUM TISS FRZN IRRADIATED GRACILIS TEND,SUP-2867226,CDM,C1762,CPT,0278,RC,,,,both,,,3516.80,2285.92,,,,,,,,,,,,,
NOZZLE SPRY FOR GD450R GD455R GD465 NS REUSE MICRO-LINE,SUP-2929144,CDM,2720000010,LOCAL,0272,RC,,,,both,,,396.86,257.96,,,,,,,,,,,,,
PLATE STRNL CLOSURE 100 DEG 8 H TI X NS STERNALOCK BLU,SUP-2894475,CDM,C1713,HCPCS,0278,RC,,,,both,,,2219.98,1442.99,,,,,,,,,,,,,
LEVEL CMF ST PLATE ORTHG GNPLSTY FAB DBL Y SHP WTAB 2.0 2.5,SUP-2669082,CDM,C1713,HCPCS,0278,RC,,,,both,,,654.88,425.67,,,,,,,,,,,,,
PIN GUID L229MM OD2MM FOR FUTURA CSI SYS,SUP-2388544,CDM,2720000010,LOCAL,0272,RC,,,,both,,,144.44,93.89,,,,,,,,,,,,,
PIN FIX DBL TROCAR 0.078X9 IN SS NS STEINMANN,SUP-2791590,CDM,C1713,HCPCS,0278,RC,,,,both,,,10.30,6.69,,,,,,,,,,,,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,0636,RC,71288-0402-11,NDC,,both,1,ML,54.10,35.16,,,,,,,,,,,,,
GRAFT BNE 150X11 MM BLLST 021000000,SUP-2644294,CDM,C1713,HCPCS,0278,RC,,,,both,,,3956.40,2571.66,,,,,,,,,,,,,
PLATE 3.5MM TI LCP OLECRANON 6 HOLES LEFT 138MM-STERILE,SUP-2549526,CDM,C1713,HCPCS,0278,RC,,,,both,,,3717.70,2416.50,,,,,,,,,,,,,
CATHETER ART SET LN POLYETH FEM 0.028INX2 GWIRE 18GA 15CM,SUP-2167842,CDM,C1751,HCPCS,0278,RC,,,,both,,,130.66,84.93,,,,,,,,,,,,,
SCREW BONE L24MM DIA2MM TI CANC ST SELF DRL CANN LAG,SUP-2319500,CDM,C1713,HCPCS,0278,RC,,,,both,,,593.46,385.75,,,,,,,,,,,,,
PLATE BNE LAT IMPL 15 H TI L EL FRAC SYS DST FIB 142MM ALPS,SUP-2411718,CDM,C1713,HCPCS,0278,RC,,,,both,,,4708.12,3060.28,,,,,,,,,,,,,
WASHER ORTH FOR 6.5/7.3 MM SCR NS LTX,SUP-2855920,CDM,C1713,HCPCS,0278,RC,,,,both,,,631.14,410.24,,,,,,,,,,,,,
ENDCAP SPNL TI IMPL H19MM OD13MM 13B T2 ALTITUDE,SUP-2292774,CDM,C1889,HCPCS,0278,RC,,,,both,,,21477.60,13960.44,,,,,,,,,,,,,
WIRE FIX L150MM DIA1.6MM FT 2X TRCR TIP END FOR VAR ANG,SUP-2343050,CDM,C1769,HCPCS,0272,RC,,,,both,,,1096.49,712.72,,,,,,,,,,,,,
CENTRALIZER FEM L135MM DIA11MM HIP CO CHROM PMMA FORGED,SUP-2405078,CDM,C1776,CPT,0278,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
PLATE BNE DORS SM RT MID FT,SUP-2609048,CDM,C1713,HCPCS,0278,RC,,,,both,,,5112.30,3322.99,,,,,,,,,,,,,
PLATE BNE CRANIOMAXILLOFACIAL THK06MM DBL Y SHP PROF MIDFACE,SUP-2262677,CDM,C1713,HCPCS,0278,RC,,,,both,,,884.91,575.19,,,,,,,,,,,,,
PLATE BONE SM L104MM 8 H STD BILAT COMPR CNTOUR + FOR 3.5MM,SUP-2348995,CDM,C1713,HCPCS,0278,RC,,,,both,,,1504.63,978.01,,,,,,,,,,,,,
REAMER NC FUS,SUP-2321411,CDM,2720000010,LOCAL,0272,RC,,,,both,,,868.21,564.34,,,,,,,,,,,,,
BUR SURG 2 FLUT 2.2X16 MM SIDE CUT UPWR,SUP-2166802,CDM,2720000010,LOCAL,0272,RC,,,,both,,,188.40,122.46,,,,,,,,,,,,,
WIRE EXT FIX DLC,SUP-2473320,CDM,2720000010,LOCAL,0272,RC,,,,both,,,803.84,522.50,,,,,,,,,,,,,
SPACER FEM THK10MM POST HALF DURAC,SUP-2377240,CDM,C1776,CPT,0278,RC,,,,both,,,2483.11,1614.02,,,,,,,,,,,,,
CAGE SPINE VBR PEEK SMALL 9MM,SUP-2665180,CDM,C1889,HCPCS,0278,RC,,,,both,,,2590.50,1683.82,,,,,,,,,,,,,
GUIDEWIRE VASC L 50 CM DIA 0.018 IN SS SAFE-T-J STR FIX COR,SUP-2760105,CDM,C1769,HCPCS,0272,RC,,,,both,,,65.85,42.80,,,,,,,,,,,,,
BIT DRL TWST 3.8MMX310 COIL 50 QUIK CPL DISP,SUP-2101267,CDM,2720000010,LOCAL,0272,RC,,,,both,,,668.19,434.32,,,,,,,,,,,,,
GRAFT VASC VENAFLO II L 10 CM DIA 7 MM EPTFE CARBON STR STD,SUP-2128668,CDM,L8670,HCPCS,0278,RC,,,,both,,,1124.37,730.84,,,,,,,,,,,,,
PLATE SPNL L39MM SACR TI 1 LEV,SUP-2180806,CDM,C1713,HCPCS,0278,RC,,,,both,,,5024.00,3265.60,,,,,,,,,,,,,
WRAP WR UNIV LT COMPR GEL,SUP-2324362,CDM,L3931,HCPCS,0272,RC,,,,both,,,99.91,64.94,,,,,,,,,,,,,
ELEVEST PROC KT KT INCL E-Z PASS SUT PASS METRAPASS SUT,SUP-2171702,CDM,C1713,HCPCS,0278,RC,,,,both,,,3752.30,2438.99,,,,,,,,,,,,,
MITOXANTRONE HCL 20 MG/10ML IV CONC,RX-93748,CDM,J9293,HCPCS,0636,RC,61703-0343-18,NDC,,both,10,ML,509.10,330.91,,,,,,,,,,,,,
GRAFT BNE SUB 15ML 0.1-4MM CANC CRUSH CHIP MORSELIZED FRZ,SUP-2307064,CDM,C1713,HCPCS,0278,RC,,,,both,,,871.35,566.38,,,,,,,,,,,,,
"HC Uro/Pyelo, IV W/WO Kub, W/WO Tomography",PX-3207440000,CDM,74400,CPT,0320,RC,,,,both,,,930.00,604.50,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP L150CM DIA0032IN TIP L3CM STD FLX STR,SUP-2139339,CDM,C1769,HCPCS,0272,RC,,,,both,,,113.70,73.90,,,,,,,,,,,,,
PLATE BNE DPHSEAL-MTPHSEAL RT VOLAR DSTL RADIAL 9 HOLE STRL,SUP-2546639,CDM,C1713,HCPCS,0278,RC,,,,both,,,5228.76,3398.69,,,,,,,,,,,,,
STAPLE SKIN LN REINF 60 MM ECHELON ENDOPATH,SUP-2636323,CDM,C1781,HCPCS,0278,RC,,,,both,,,866.55,563.26,,,,,,,,,,,,,
PLATE 20MM SYS MINI L SHAPE 3X3 HOLE MED CP TTNM,SUP-2694756,CDM,C1713,HCPCS,0278,RC,,,,both,,,462.58,300.68,,,,,,,,,,,,,
STENT CORONARY CYPHER L 23 MM DIA2.75 MM DEL SYS L 137 CM,SUP-2158715,CDM,C1874,HCPCS,0278,RC,,,,both,,,4867.00,3163.55,,,,,,,,,,,,,
CAP HEALING DIA30MM W/ PLUG BAHA,SUP-2164967,CDM,L8690,HCPCS,0278,RC,,,,both,,,53.38,34.70,,,,,,,,,,,,,
ANCHOR SUT PEEK W/ FORC FBR GRYPHON,SUP-2249465,CDM,C1713,HCPCS,0278,RC,,,,both,,,1494.64,971.52,,,,,,,,,,,,,
METHENAMINE HIPPURATE 1 G PO TABS,RX-10549,CDM,6370000000,HCPCS,0637,RC,65862-0782-01,NDC,,both,1,UN,3.60,2.34,,,,,,,,,,,,,
HC Hiv Rapid Ag Ab,PX-3008780600,CDM,87806,CPT,0300,RC,,,,both,,,308.00,200.20,,,,,,,,,,,,,
RING EXT FIX DIA180 MM 2/3 PNK NS DISP TSF,SUP-2933080,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4161.50,2704.97,,,,,,,,,,,,,
BIT DRL L 150 MM DIA 3.5 MM AO QC STRL DISP V,SUP-2908409,CDM,2720000010,LOCAL,0272,RC,,,,both,,,994.06,646.14,,,,,,,,,,,,,
INTRODUCER SHTH 6FR L12CM 0.038IN L50CM W/ LUERLOK HEMSTAS,SUP-2355454,CDM,C1894,HCPCS,0272,RC,,,,both,,,37.68,24.49,,,,,,,,,,,,,
SYSTEM SURG HEMSTAT PWD 5 GM POLYSACCHARIDE HEMOSPHERES,SUP-2175235,CDM,2720000010,LOCAL,0272,RC,,,,both,,,737.90,479.63,,,,,,,,,,,,,
HC X-Ray Knee 3 Views,PX-3207356200,CDM,73562,CPT,0320,RC,,,,both,,,374.00,243.10,,,,,,,,,,,,,
CONNECTOR SHUNT OD1.9MM TITANIUM STEP DOWN L HYDROCEPHALUS M,SUP-2821782,CDM,C1889,HCPCS,0278,RC,,,,both,,,869.12,564.93,,,,,,,,,,,,,
PLATE 4.5MM TI CURVED BROAD LCP TM 26 HOLES 479MM STERILE,SUP-2549502,CDM,C1713,HCPCS,0278,RC,,,,both,,,5545.46,3604.55,,,,,,,,,,,,,
BASEPLATE TIB L71MM KNEE MOD OSS,SUP-2405773,CDM,C1776,CPT,0278,RC,,,,both,,,8802.99,5721.94,,,,,,,,,,,,,
PEG BNE FIX L14MM DIA2MM VOLAR SMOOTH LOK FOR ANAT PLATING,SUP-2414129,CDM,C1776,CPT,0278,RC,,,,both,,,307.72,200.02,,,,,,,,,,,,,
HC CT Angio Abdomen W & W/O Cont,PX-3527417500,CDM,74175,CPT,0352,RC,,,,inpatient,,,4683.00,3043.95,,,,,,,,,,,,,
BIT DRL DIA3.2MM CANN EIGHT-PLATE,SUP-2316399,CDM,2720000010,LOCAL,0272,RC,,,,both,,,579.33,376.56,,,,,,,,,,,,,
WASHER ORTH DIA7MM DOMED FOR CANN SCR SYS MAXTORQUE,SUP-2399472,CDM,C1713,HCPCS,0278,RC,,,,both,,,442.74,287.78,,,,,,,,,,,,,
SCREW INTFR 8MM 20MM KNEE CANN TAPR TIP N ABSRB TI GUARDSMAN,SUP-2167013,CDM,C1713,HCPCS,0278,RC,,,,both,,,414.29,269.29,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PLU MAXBARR 4FR 55CM 1 LU 1174108D2,SUP-2632626,CDM,C1751,HCPCS,0278,RC,,,,both,,,974.97,633.73,,,,,,,,,,,,,
IMPLANT TOE HEMI,SUP-2397200,CDM,C1776,CPT,0278,RC,,,,both,,,6829.50,4439.17,,,,,,,,,,,,,
MESH SURG DIA6IN UNCOATED M WT MFIL PROPYLENE CIR HYDRGEL,SUP-2126542,CDM,C1781,HCPCS,0278,RC,,,,both,,,1613.96,1049.07,,,,,,,,,,,,,
HC So Clot Inhibit Protein C Antigen,PX-3058530266,CDM,85302,CPT,0305,RC,,,,both,,,151.00,98.15,,,,,,,,,,,,,
HEAD FEM 12/14 TAPR ZIRCONIA 36MM + 0 NOVATION ELEMENT,SUP-2222117,CDM,C1776,CPT,0278,RC,,,,both,,,5086.80,3306.42,,,,,,,,,,,,,
SUPPORT EL NEOPRENE 7 9IN SM,SUP-2276612,CDM,L3702,HCPCS,0274,RC,,,,both,,,9.36,6.08,,,,,,,,,,,,,
SYSTEM CLOSURE 6-12 FR VEN VASC VASCADE MVP,SUP-2653507,CDM,C1760,HCPCS,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
PLATE BENDING PLIERS TRACK 15MM,SUP-2680408,CDM,C1713,HCPCS,0278,RC,,,,both,,,1334.06,867.14,,,,,,,,,,,,,
NEEDLE ASPIR 19GA HISTOLOGY FLX VIZISHOT 2,SUP-2313405,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1011.08,657.20,,,,,,,,,,,,,
"HC NM Tumor Localization,Whole Body",PX-3417880400,CDM,78804,CPT,0341,RC,,,,both,,,5060.00,3289.00,,,,,,,,,,,,,
INQUIRY AFOCUS II 1120 7 125 SM AF20,SUP-2699062,CDM,C1730,HCPCS,0272,RC,,,,both,,,4361.46,2834.95,,,,,,,,,,,,,
CATHETER EMB TUFTEX L 60 CM DIA2 FR BALLOON DIA 4.5 MM 0.05,SUP-2264174,CDM,C1757,HCPCS,0272,RC,,,,both,,,232.36,151.03,,,,,,,,,,,,,
EXTENDER EXT FIX HALO FOR RED II ALUM TI PUR,SUP-2459173,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2883.87,1874.52,,,,,,,,,,,,,
SPACER SPNL W22XH7-10XL50MM LAT LUM INTBDY FUS SELF EXP,SUP-2232010,CDM,C1821,HCPCS,0278,RC,,,,both,,,16485.00,10715.25,,,,,,,,,,,,,
PLATE BONE L64MM 8 H STRL S STL LCK RECON FOR 2.7MM SCR EVOS,SUP-2349614,CDM,C1713,HCPCS,0278,RC,,,,both,,,3959.54,2573.70,,,,,,,,,,,,,
CATHETER GUID BNCHMRK BMX96 L 80 CM OD 8 FR 0.096 IN DEL,SUP-2653461,CDM,C1887,HCPCS,0278,RC,,,,both,,,2998.70,1949.15,,,,,,,,,,,,,
SET INTRO 5F COAX MICRO STICK STIFF W NIT WIRE RADPQ DST,SUP-2267054,CDM,C1894,HCPCS,0272,RC,,,,both,,,8.16,5.30,,,,,,,,,,,,,
PLATE BONE DUAL CMPRSSN HLX3 TTNM L SHPD OBLQUE F2.7MM LOK,SUP-2721019,CDM,C1713,HCPCS,0278,RC,,,,both,,,1028.48,668.51,,,,,,,,,,,,,
RECON PLATE 22X263MM 3.5MM,SUP-2818797,CDM,C1713,HCPCS,0278,RC,,,,both,,,7675.42,4989.02,,,,,,,,,,,,,
BRACE ORTHOPEDIC LSO BK POST OPERATIVE RIGID PANEL,SUP-2138675,CDM,L0630,HCPCS,0274,RC,,,,both,,,480.42,312.27,,,,,,,,,,,,,
CATHETER KIT BUNDLED 16 CM CV,SUP-2214467,CDM,C1751,HCPCS,0278,RC,,,,both,,,349.07,226.90,,,,,,,,,,,,,
GUIDEWIRE ZBR ANG .035X450CM,SUP-2141514,CDM,C1769,HCPCS,0272,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
MESH BONE 30MM DIA 30MMW X 30MML 0.6MM THK RSRB X TRNGLR LAT,SUP-2496475,CDM,C1713,HCPCS,0278,RC,,,,both,,,2397.64,1558.47,,,,,,,,,,,,,
HC Eo Dbl Upright W/Cuff Cus,PX-2740373001,CDM,L3730,HCPCS,0274,RC,,,,both,,,3165.00,2057.25,,,,,,,,,,,,,
CATHETER ANGIOPLSTY OTW 5 FRX130 CM 4X100 MM LUTONIX BSLX3513041005F] BARD PERIPHERAL VASCULAR],SUP-2127967,CDM,C2623,HCPCS,0278,RC,,,,both,,,3925.00,2551.25,,,,,,,,,,,,,
BIT DRL FLXIBLE DISP FOR SUT TWIN LOOP FLX,SUP-2366680,CDM,2720000010,LOCAL,0272,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
GRAFT BIO TISS OASIS ULTRA 3LAYER MATRIX 7X20CM MESHED,SUP-2341244,CDM,Q4124,HCPCS,0636,RC,,,,both,,,5534.53,3597.44,,,,,,,,,,,,,
SPACER FEM STD UNIV POST PRI CEM SM 10MM THCK,SUP-2377233,CDM,C1776,CPT,0278,RC,,,,both,,,2366.30,1538.09,,,,,,,,,,,,,
SPLINT WRST ADJ 10 IN UNIV 7.5 IN LT COOL SFT QUIK FIT,SUP-2197068,CDM,L3908,HCPCS,0274,RC,,,,both,,,24.90,16.18,,,,,,,,,,,,,
ROD REPROC SPNL 11 MM CARBON FIBER,SUP-2558714,CDM,C1713,HCPCS,0278,RC,,,,both,,,405.03,263.27,,,,,,,,,,,,,
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 IJ SOLN,RX-106534,CDM,2500000003,HCPCS,0250,RC,63323-0468-37,NDC,,both,1,ML,54.10,35.16,,,,,,,,,,,,,
PROSTHESIS OSS MEGERIAN SRP 0.6X4.25 MM PISTON NIT PTFE,SUP-2467226,CDM,L8613,CPT,0278,RC,,,,both,,,1687.88,1097.12,,,,,,,,,,,,,
WIRE FIX TROCAR PT 2 END 0.054X9 IN SS NS KIRSCHNER,SUP-2791356,CDM,C1713,HCPCS,0278,RC,,,,both,,,10.11,6.57,,,,,,,,,,,,,
INSERT TIB SZ 2 THK11MM UNIV KNEE POST STBL CONSTRN REV NEUT,SUP-2216434,CDM,C1776,CPT,0278,RC,,,,both,,,3513.00,2283.45,,,,,,,,,,,,,
SHOE ORTHOT CALIP PLATE EXISTING TRANSFER,SUP-2435745,CDM,L3600,HCPCS,0274,RC,,,,both,,,216.03,140.42,,,,,,,,,,,,,
RESERVOIR VENTRICULAR L18CM OD20MM ODSEC2.5MM D5.65MM EXTERN,SUP-2825620,CDM,C1889,HCPCS,0278,RC,,,,both,,,1824.34,1185.82,,,,,,,,,,,,,
CARFILZOMIB 10 MG IV SOLR,RX-143086,CDM,J9047,HCPCS,0636,RC,76075-0103-21,NDC,,both,1,UN,1798.60,1169.09,,,,,,,,,,,,,
CEFUROXIME SODIUM 1.5 G IV SOLR,RX-27299,CDM,J0697,HCPCS,0636,RC,00143-9977-22,NDC,,both,1,UN,54.10,35.16,,,,,,,,,,,,,
DEVICE TISS REM FOR HYSTEROSCOPIC IU PROC MYOSURE XL,SUP-2239854,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
PLATE BNE L47MM 6 H S STL 1/4 TBLR CLLRD FOR 2.7MM SCR,SUP-2411324,CDM,C1713,HCPCS,0278,RC,,,,both,,,258.74,168.18,,,,,,,,,,,,,
TROCAR SURG TOT ANK SYS INFIN,SUP-2397260,CDM,2720000010,LOCAL,0272,RC,,,,both,,,527.52,342.89,,,,,,,,,,,,,
GRAFT SURG HUM CLLGN ACELLULAR RECT 6CMX12CM,SUP-2126258,CDM,C1781,HCPCS,0278,RC,,,,both,,,5046.29,3280.09,,,,,,,,,,,,,
SUPPORT ANK UNIV AIR FOAM STRRP,SUP-2276705,CDM,L4350,HCPCS,0272,RC,,,,both,,,33.28,21.63,,,,,,,,,,,,,
CATHETER DRNGE 10FR L25CM FLEXIMA KT ALL PURP LOOP REG,SUP-2147853,CDM,C1729,HCPCS,0272,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
SPACER SPNL W20XH8XL50MM 6DEG PEEK LUM INTBDY FUS LORDTC,SUP-2231319,CDM,C1821,HCPCS,0278,RC,,,,both,,,18526.00,12041.90,,,,,,,,,,,,,
IMPLANT HEARING 6MM THK3MM HA ABUTMENT IMPL HEARINGABLE,SUP-2164980,CDM,L8614,HCPCS,0278,RC,,,,both,,,10487.60,6816.94,,,,,,,,,,,,,
TESTER VENTILATOR CIRC LUNG 0.05 LT BABI +,SUP-2352862,CDM,C1713,HCPCS,0278,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
PACK VITRCTMY 25GA 5000CPM STR ENDOILLUMINATOR NONVALVED,SUP-2109942,CDM,C1713,HCPCS,0278,RC,,,,both,,,1818.06,1181.74,,,,,,,,,,,,,
CANNULA ENDOSCP INSUL 25 MMX23 CM MONOPOLAR LARYNGEAL,SUP-2776942,CDM,2720000010,LOCAL,0272,RC,,,,both,,,512.92,333.40,,,,,,,,,,,,,
PIN FIX SINGLE DIAMOND 0.125X9 IN RND END SS NS STEINMANN,SUP-2791620,CDM,C1713,HCPCS,0278,RC,,,,both,,,17.62,11.45,,,,,,,,,,,,,
SHOULDER AUGMENT IMPL STANDARD LEFT EXTENSION W/SCREW,SUP-2512468,CDM,C1776,CPT,0278,RC,,,,both,,,5581.66,3628.08,,,,,,,,,,,,,
HC T-Spine 2 Views,PX-3207207000,CDM,72070,CPT,0320,RC,,,,both,,,233.00,151.45,,,,,,,,,,,,,
CATHETER CV 3L 12.5 FRX90 CM LT KT,SUP-2626378,CDM,C1751,HCPCS,0278,RC,,,,both,,,533.80,346.97,,,,,,,,,,,,,
PLATE BNE L91MM 2 H ST R PERIARTC PROX HUM TI LOK LO PROF,SUP-2180957,CDM,C1713,HCPCS,0278,RC,,,,both,,,5600.22,3640.14,,,,,,,,,,,,,
GRAFT BNE IL CREST FD,SUP-2684141,CDM,C1762,CPT,0278,RC,,,,both,,,6936.26,4508.57,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 101-150 CM FASC,SUP-2321781,CDM,C1762,CPT,0278,RC,,,,both,,,6264.30,4071.79,,,,,,,,,,,,,
TIP CATH FRONTAL F-70 PRECIS SGL HND CTRL DIL IRRIG DURABLE,SUP-2106365,CDM,C1887,HCPCS,0272,RC,,,,both,,,530.38,344.75,,,,,,,,,,,,,
PACK SURG PROC KNEE USER GPS,SUP-2223588,CDM,C1713,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
WIRE SURG 0.062X6 IN TRCR PT NS KIRSCHNER LTX,SUP-2862422,CDM,C1713,HCPCS,0278,RC,,,,both,,,10.68,6.94,,,,,,,,,,,,,
PLATE BNE 2.7X108 MM 12 HOLE SS LCP,SUP-2569312,CDM,C1713,HCPCS,0278,RC,,,,both,,,426.57,277.27,,,,,,,,,,,,,
BUR SURG DIA1MM S STL STAP RND CUT REUSE FOR VIPER OTO DRL,SUP-2313878,CDM,C1713,HCPCS,0278,RC,,,,both,,,358.05,232.73,,,,,,,,,,,,,
ROD SPNL CLP 6.35 MM,SUP-2661696,CDM,C1713,HCPCS,0278,RC,,,,both,,,398.78,259.21,,,,,,,,,,,,,
TRAY PICC SUBCL 2/L 4FR 60CML PU RADPQ STYL SFTY EXC 3254107,SUP-2632659,CDM,C1751,HCPCS,0278,RC,,,,both,,,411.34,267.37,,,,,,,,,,,,,
ALLOGRAFT BNE 2.5 CC VIABLE BNE MTRX BIO4,SUP-2637050,CDM,C1713,HCPCS,0278,RC,,,,both,,,2945.32,1914.46,,,,,,,,,,,,,
SUPPORT ANK UNIV AIR FOAM STRRP,SUP-2276705,CDM,L4350,HCPCS,0274,RC,,,,both,,,33.28,21.63,,,,,,,,,,,,,
COMPONENT FEM SZ 1 KNEE POST STABILIZING UNIV UNISX PRI CEM,SUP-2223013,CDM,C1776,CPT,0278,RC,,,,both,,,18891.81,12279.68,,,,,,,,,,,,,
PLUG CEMENT MEDULLARY ALLEN,SUP-2205607,CDM,C1713,HCPCS,0278,RC,,,,both,,,205.73,133.72,,,,,,,,,,,,,
SCREW BNE L6MM DIA2.3MM MAND CRANIOMAXILLOFACIAL G ST CRSS 5PK,SUP-2366152,CDM,C1713,HCPCS,0278,RC,,,,both,,,200.74,130.48,,,,,,,,,,,,,
COMPONENT PATELLAR F 12 MM ARTC KNEE,SUP-2200799,CDM,C1776,CPT,0278,RC,,,,both,,,9200.20,5980.13,,,,,,,,,,,,,
DEVICE DCOMPR 16MM BLU ALUM TI VANADIUM INTERLAMINAR,SUP-2320314,CDM,C1889,HCPCS,0278,RC,,,,both,,,18055.00,11735.75,,,,,,,,,,,,,
ANCHOR SOFT TISSUE 7X30MM CARTRIDGE TIBIAL ANGLED KNURLED EX,SUP-2824094,CDM,C1713,HCPCS,0278,RC,,,,both,,,1387.88,902.12,,,,,,,,,,,,,
GRAFT VASC GORTX L 20 CM DIA 6 MM EPTFE STR TW N RING STRL,SUP-2396692,CDM,C1768,CPT,0278,RC,,,,both,,,719.06,467.39,,,,,,,,,,,,,
GRAFT BNE SUB 5CC INJ FOR BNE AUG CORTOSS,SUP-2379531,CDM,C1713,HCPCS,0278,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
SCREW BNE NAIL HOLDING SPI,SUP-2474223,CDM,C1713,HCPCS,0278,RC,,,,both,,,640.56,416.36,,,,,,,,,,,,,
MESH NEURO SQ RECT TI TIMESH CRAN FIX 1.5MM SCR DIA,SUP-2277535,CDM,C1713,HCPCS,0278,RC,,,,both,,,1862.02,1210.31,,,,,,,,,,,,,
PI AGBA PICC KIT: 3-L 6 FRX40 CM W/VPS,SUP-2822089,CDM,C1751,HCPCS,0278,RC,,,,both,,,1063.36,691.18,,,,,,,,,,,,,
ENDCAP ORTH 0MM EXTN G TI CANN T40 STARDRV RECESS FOR,SUP-2179788,CDM,C1713,HCPCS,0278,RC,,,,both,,,646.68,420.34,,,,,,,,,,,,,
PLATE BONE SM RT GLD 3D ORBIT FLR FOR 1.2MM SCR,SUP-2363676,CDM,C1713,HCPCS,0278,RC,,,,both,,,3998.76,2599.19,,,,,,,,,,,,,
"HC Gbl Est Pt, E/M Level 1",PX-9829921100,CDM,99211,CPT,0982,RC,,,,both,,,180.00,117.00,,,,,,,,,,,,,
HC So Trichomonas Vaginalis Amplif,PX-3068766166,CDM,87661,CPT,0306,RC,,,,both,,,120.00,78.00,,,,,,,,,,,,,
BLADE SURG TRIANG KT HK ENDOTRAC 20566,SUP-2530570,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1011.08,657.20,,,,,,,,,,,,,
PLATE BNE L207MM 13 H ST R POSTEROLATERAL DST FIBULAR S STL,SUP-2177403,CDM,C1713,HCPCS,0278,RC,,,,both,,,2140.04,1391.03,,,,,,,,,,,,,
LGN EXT FLT PRESSFIT STEM 18MMX160MM,SUP-2822621,CDM,C1776,CPT,0278,RC,,,,both,,,4370.88,2841.07,,,,,,,,,,,,,
LEUCOVORIN CALCIUM 50 MG IJ SOLR,RX-4394,CDM,J0640,HCPCS,0636,RC,00143-9555-01,NDC,,both,1,UN,54.10,35.16,,,,,,,,,,,,,
TIP IRR DIA0.3MM SM BOR THRD FOR USE W/ INFIN SER 20000 LEG,SUP-2109660,CDM,2720000010,LOCAL,0272,RC,,,,both,,,879.20,571.48,,,,,,,,,,,,,
STEM FEM SZ 3 L190MM HIP 12/14 TAPR ENDUR,SUP-2251941,CDM,C1776,CPT,0278,RC,,,,both,,,11994.80,7796.62,,,,,,,,,,,,,
SUPPORT ORTHOT WRST HND FNGR CUST ADJ W/JT FABRICATED,SUP-2435766,CDM,L3806,HCPCS,0272,RC,,,,both,,,1170.37,760.74,,,,,,,,,,,,,
ANCHOR SUT OD5.5MM PEEK ORTHOCORD NDL HEALIX,SUP-2249414,CDM,C1713,HCPCS,0278,RC,,,,both,,,1124.12,730.68,,,,,,,,,,,,,
HOOK SPNL 45DEG LT LUM TI S FOR 5MM ROD ALA,SUP-2193332,CDM,C1713,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
BIT DRL L10CM DIA11MM S STL STR SHANK,SUP-2410509,CDM,2720000010,LOCAL,0272,RC,,,,both,,,96.59,62.78,,,,,,,,,,,,,
PLATE BNE W5XL27MM THK1MM 0DEG 5 H BILAT S STL STR RIG DYN,SUP-2186163,CDM,C1713,HCPCS,0278,RC,,,,both,,,572.74,372.28,,,,,,,,,,,,,
CATHETER ABLAT 7FR L115CM TIP 8MM 1-6-2MM SPC 4 ELECTRD BLK,SUP-2248803,CDM,C1733,HCPCS,0272,RC,,,,both,,,3460.28,2249.18,,,,,,,,,,,,,
GUIDE DRL CERV SPNL PLT ANG LOK SGL W TISS PROTCT SL,SUP-2187796,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5519.18,3587.47,,,,,,,,,,,,,
SET INFUS L100CM OD5FR CATH SEG L7CM GWIRE OD0.035IN 14,SUP-2418550,CDM,C1751,HCPCS,0278,RC,,,,both,,,282.69,183.75,,,,,,,,,,,,,
BLOCK TIB AUG L67MM THK6MM KNEE TI ALLY CEM VANGUARD,SUP-2405486,CDM,C1776,CPT,0278,RC,,,,both,,,2323.60,1510.34,,,,,,,,,,,,,
CATHETER INFUSION MEWEISSEN L 100 CM DIA 5 FR SEG 15 CM,SUP-2141166,CDM,C1751,HCPCS,0278,RC,,,,both,,,257.48,167.36,,,,,,,,,,,,,
GRAFT VASC VECTRA L 50 CM DIA 5 MM WALL THK 1 MM POLYUR HEMO,SUP-2127770,CDM,C1768,CPT,0278,RC,,,,both,,,3686.36,2396.13,,,,,,,,,,,,,
UPCHARGE HIP TRITANIUM CUP STRYKER,SUP-2501355,CDM,C1776,CPT,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
ROD SPNL STR OD6.35MM L55MM BEAC,SUP-2230201,CDM,C1713,HCPCS,0278,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
SYSTEM EXT DRNGE MON EXACTA,SUP-2284552,CDM,C1713,HCPCS,0278,RC,,,,both,,,412.00,267.80,,,,,,,,,,,,,
DAPAGLIFLOZIN PROPANEDIOL 10 MG PO TABS,RX-124903,CDM,6370000000,HCPCS,0637,RC,66993-0457-30,NDC,,both,1,UN,56.80,36.92,,,,,,,,,,,,,
DEVICE PESSARY RNG 3 64 MM W/ SUPP,SUP-2273825,CDM,A4562,HCPCS,0274,RC,,,,both,,,108.39,70.45,,,,,,,,,,,,,
HC Electron Microscopy Diagnostic,PX-3128834800,CDM,88348,CPT,0312,RC,,,,outpatient,,,1815.00,1179.75,,,,,,,,,,,,,
CASSETTE ANCHR ANCIL W/ 5 IMPL FOR EVAR ENDOANCHR,SUP-2280763,CDM,C1713,HCPCS,0278,RC,,,,both,,,5008.30,3255.39,,,,,,,,,,,,,
FORCEP DISECT ENDOSCP 5 MMX45 CM STRL DISP,SUP-2313743,CDM,C1713,HCPCS,0278,RC,,,,both,,,659.40,428.61,,,,,,,,,,,,,
SPACER FEM SZ 4 THK12MM RT LAT ASYM REV CEM NP N-K II,SUP-2209182,CDM,C1776,CPT,0278,RC,,,,both,,,3253.04,2114.48,,,,,,,,,,,,,
GRAFT HUM TISS W4XL16CM THK1.04-2.28MM THCK REGEN TISS MTRX,SUP-2113019,CDM,Q4116,HCPCS,0636,RC,,,,both,,,6559.46,4263.65,,,,,,,,,,,,,
IMPLANT HUM TISS W5XL8CM THK1MM PROC DERM CLLGN RECTANG,SUP-2126257,CDM,C1781,HCPCS,0278,RC,,,,both,,,2803.71,1822.41,,,,,,,,,,,,,
CONNECTOR ROD DOMINO 6.35X6.35 IN,SUP-2280181,CDM,2780000010,LOCAL,0278,RC,,,,both,,,1716.07,1115.45,,,,,,,,,,,,,
SET GUID CATH GORE TIP L 49 CM DIA10 FR SHTH L 40 CM DIA10,SUP-2396408,CDM,C1894,HCPCS,0272,RC,,,,both,,,1792.94,1165.41,,,,,,,,,,,,,
ROD EXT FIX L600MM DIA11MM MRI C CONN FOR HOFFMANN III EXT,SUP-2372235,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1701.25,1105.81,,,,,,,,,,,,,
SCREW BNE L12MM DIA2.7MM STD LOK FOR HALLU-LOCK MTP ARTH,SUP-2243341,CDM,C1713,HCPCS,0278,RC,,,,both,,,1039.78,675.86,,,,,,,,,,,,,
HC Pt Iontophoresis per 15 Min,PX-4209703300,CDM,97033,CPT,0420,RC,,,,outpatient,,,221.00,143.65,,,,,,,,,,,,,
CYSTEINE HCL 50 MG/ML IV SOLN,RX-2034,CDM,2500000003,HCPCS,0250,RC,51754-1007-01,NDC,,both,10,ML,544.60,353.99,,,,,,,,,,,,,
HC Pt Iontophoresis per 15 Min,PX-4209703300,CDM,97033,CPT,0420,RC,,,,inpatient,,,221.00,143.65,,,,,,,,,,,,,
PROCEDURE KIT TARGETING SINGLE INSRTN ELECTRD D-ZAP SINGLE,SUP-2665071,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2304.76,1498.09,,,,,,,,,,,,,
CAGE SPNL H32MM DIA12MM ANT THORLUM TI RND MESH INTBDY FUS,SUP-2193219,CDM,C1889,HCPCS,0278,RC,,,,both,,,9018.08,5861.75,,,,,,,,,,,,,
SET INTRO SUP ARW FLX SHTH L 80 CM DIA11 FR HYDRPHLC,SUP-2383424,CDM,C1894,HCPCS,0272,RC,,,,both,,,315.57,205.12,,,,,,,,,,,,,
PLATE BONE X LNG L18MM THK0.6MM 6 H TI DBL Y SHP FOR 1.5MM,SUP-2402885,CDM,C1713,HCPCS,0278,RC,,,,both,,,546.36,355.13,,,,,,,,,,,,,
SYSTEM EMBOLIC PROTCT L190CM VASC BAREWIRE DSTL ACC FLTR DEL,SUP-2101961,CDM,C1769,HCPCS,0272,RC,,,,both,,,414.48,269.41,,,,,,,,,,,,,
HC Mod Sed Oth Phys/Qhp <5 Yrs Initial 15 Min,PX-3729915500,CDM,99155,CPT,0372,RC,,,,both,,,306.00,198.90,,,,,,,,,,,,,
ADAPTER PACEMKR CABLE TCH PRF IS1 FOR PK 67 S OR PK 67 L,SUP-2137933,CDM,C1883,HCPCS,0278,RC,,,,both,,,668.82,434.73,,,,,,,,,,,,,
GUIDEWIRE ENDSCPC 0.035N DIA RGLR 260CML 3CML HDRPHLC CTD BL,SUP-2483272,CDM,C1769,HCPCS,0272,RC,,,,both,,,461.58,300.03,,,,,,,,,,,,,
DEFIBRILLATOR IMPL LUMAX 27 J TI EPOXY RESIN SIL SINGLE,SUP-2138114,CDM,C1722,HCPCS,0275,RC,,,,both,,,49502.10,32176.36,,,,,,,,,,,,,
ANCHOR SUT NO 0 MINI DRL BIT QUICKANCHR + ORTHOCORD,SUP-2256599,CDM,C1713,HCPCS,0278,RC,,,,both,,,2782.04,1808.33,,,,,,,,,,,,,
BRACE KNEE AD SM SH UNIV FOAM POSTOP UNISX WRP ARND HNG T,SUP-2150853,CDM,L1845,HCPCS,0274,RC,,,,both,,,703.36,457.18,,,,,,,,,,,,,
SUPPORT ORTHOT LUMBAR SACR CUST SAGITTAL-CORONAL CTRL LAT,SUP-2435554,CDM,L0635,HCPCS,0274,RC,,,,both,,,2828.95,1838.82,,,,,,,,,,,,,
BUR SURG L 240 MM DIA 5 MM R DIAMOND FOR SLIM ATTACH STRL,SUP-2937165,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
GRAFT BONE SUB 16ML HA SYNTH TISS CLLGN MTRX STRP RESRB,SUP-2256854,CDM,C9362,HCPCS,0278,RC,,,,both,,,7764.72,5047.07,,,,,,,,,,,,,
SCREW BONE L16MM OD2.3MM TI CORT ST CROSS PIN NONLOCKING,SUP-2363448,CDM,C1713,HCPCS,0278,RC,,,,both,,,132.60,86.19,,,,,,,,,,,,,
CATHETER ANGIOPLSTY CROSSTELLA 150CM 80 MM 4 MM PERIPH RX,SUP-2384772,CDM,C1725,HCPCS,0272,RC,,,,both,,,584.04,379.63,,,,,,,,,,,,,
HC So Body Fluid Culture,PX-3008707066,CDM,87070,CPT,0300,RC,,,,both,,,43.00,27.95,,,,,,,,,,,,,
SYSTEM TARGETING 6MM PRECIS W/ PERPENDICULARITY ROD FOR GRFT,SUP-2256809,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6352.22,4128.94,,,,,,,,,,,,,
RIVAROXABAN 10 MG PO TABS,RX-110026,CDM,6370000000,HCPCS,0637,RC,50458-0580-01,NDC,,both,1,UN,89.80,58.37,,,,,,,,,,,,,
BOUGIE ESOPH 34FR TUNGSTEN FIL SIL HURST,SUP-2383703,CDM,2720000010,LOCAL,0272,RC,,,,both,,,390.46,253.80,,,,,,,,,,,,,
IMETELSTAT SODIUM 31.4 MG/ML IV SOLN (MIXTURES ONLY),RX-4082818,CDM,J0870,HCPCS,0636,RC,82959-0111-01,NDC,,both,6,ML,29979.60,19486.74,,,,,,,,,,,,,
STENT GRFT VASC POWERLINK XL INTUITRAK L 100 MM CVR L 80 MM,SUP-2217582,CDM,C1768,CPT,0278,RC,,,,both,,,11602.30,7541.49,,,,,,,,,,,,,
ROD SPNL 2 DIAMETER 1 3.5/5.5 MM OCT TI UNID,SUP-2730562,CDM,C1713,HCPCS,0278,RC,,,,both,,,5966.00,3877.90,,,,,,,,,,,,,
PLATE BNE L 70 X W 11.5 MM THK 3.6 MM SCREW DIA 3.5 MM 4 H 72463104,SUP-2933302,CDM,C1713,HCPCS,0278,RC,,,,both,,,6721.64,4369.07,,,,,,,,,,,,,
PIN BNE FIX L 60 MM DIA 3.5 MM LG TARGETER PROV COMPR STRL,SUP-2931376,CDM,C1713,HCPCS,0278,RC,,,,both,,,1026.03,666.92,,,,,,,,,,,,,
HC So Gc/Ms Quantitative,PX-3018378966,CDM,83789,CPT,0301,RC,,,,both,,,116.00,75.40,,,,,,,,,,,,,
STENT PIPELINE FLEX EMBOL DEVICE W/ SHIELD TECH 4MMX 30MM,SUP-2854170,CDM,C2625,HCPCS,0278,RC,,,,both,,,46982.25,30538.46,,,,,,,,,,,,,
ALLOGRAFT BNE CORTICAL 250X20 MM FD STRUT,SUP-2717908,CDM,C1762,CPT,0278,RC,,,,both,,,5882.85,3823.85,,,,,,,,,,,,,
DEFIBRILLATOR IMPL RIVACOR 7 HF-T PROMRI W 60 X H 67 MM D 10,SUP-2739235,CDM,C1898,HCPCS,0275,RC,,,,both,,,69529.02,45193.86,,,,,,,,,,,,,
SET CLLR STOUT SORBATEX PD BIOENGINEERED CMFRT ADJ BTTN,SUP-2247595,CDM,L0120,HCPCS,0274,RC,,,,both,,,174.84,113.65,,,,,,,,,,,,,
RELOAD STPLR MULTFI 30-25 MM LD UNIT TI STRL ENDO TA DISP,SUP-2787747,CDM,2720000010,LOCAL,0272,RC,,,,both,,,571.83,371.69,,,,,,,,,,,,,
HC Pericardiocentesis Including Imag Guid When Performed,PX-3613301600,CDM,33016,CPT,0361,RC,,,,both,,,3477.00,2260.05,,,,,,,,,,,,,
TILENE STRP 6CMX40CM LT 3PK,SUP-2402556,CDM,C1781,HCPCS,0278,RC,,,,both,,,800.70,520.45,,,,,,,,,,,,,
CLAMP EXT FIX W1.044XH1.63XL1.344IN ALUM TI S STL USED W/,SUP-2342862,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3152.40,2049.06,,,,,,,,,,,,,
IMPLANT SYS BIOCOMP ACHILLES SUTRBRIDGE,SUP-2122828,CDM,C1713,HCPCS,0278,RC,,,,both,,,5008.30,3255.39,,,,,,,,,,,,,
GRAFT HUMAN TSSUE W16XL20CM THK1.04 2.28MM HICK RGNRTVE TSSU,SUP-2485846,CDM,Q4116,HCPCS,0636,RC,,,,both,,,34675.02,22538.76,,,,,,,,,,,,,
HEAD FEM PRI MTL ON POLY VIT 28MM DIA +12 NK LEN ABG II V40,SUP-2364468,CDM,C1776,CPT,0278,RC,,,,both,,,1120.98,728.64,,,,,,,,,,,,,
SCREW SPNL ROD DIA 4.75/5 MM SS MULTAXL STRL CD HORZ MODULEX 2PK,SUP-2928043,CDM,C1713,HCPCS,0278,RC,,,,both,,,3799.40,2469.61,,,,,,,,,,,,,
LINER ACET OD48MM ID28MM GG METASUL HIP ALPHA UNCEMENTED STD,SUP-2204545,CDM,C1776,CPT,0278,RC,,,,both,,,5286.19,3436.02,,,,,,,,,,,,,
CATHETER GUID ZIPLINE ID 0.088 IN HYDRPHLC VAR STIFFNESS,SUP-2929970,CDM,C1757,HCPCS,0272,RC,,,,both,,,15684.30,10194.79,,,,,,,,,,,,,
ALLOGRAFT BNE SPACER 24X10X9/5.7 MM FD PLIF LUMINARY,SUP-2736798,CDM,C1713,HCPCS,0278,RC,,,,both,,,8535.43,5548.03,,,,,,,,,,,,,
COIL EMB L10CM OD2MM 360DEG HELCL USFT STRTCH RESIST BIG,SUP-2365766,CDM,C1889,HCPCS,0278,RC,,,,both,,,6464.00,4201.60,,,,,,,,,,,,,
INTRODUCER PACE LD WORLEY ADV CSG L 40 CM DIA 9 FR GUIDEWIRE,SUP-2357564,CDM,C1892,HCPCS,0272,RC,,,,both,,,1868.30,1214.39,,,,,,,,,,,,,
PEG BNE L 11 MM DIA1.8 MM SS WR LCK T7 DRV STRL EVOS,SUP-2931457,CDM,C1713,HCPCS,0278,RC,,,,both,,,393.25,255.61,,,,,,,,,,,,,
CONNECTOR SPNL SZ 5 L55MM STD POST S STL FIX TRNSVRS CONN,SUP-2254368,CDM,C1713,HCPCS,0278,RC,,,,both,,,3475.98,2259.39,,,,,,,,,,,,,
SHEATH INTCARD STEER 8.5FR DIREX 71CM L 50MM CRV 50DEG DIL,SUP-2140432,CDM,C1894,HCPCS,0272,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
BCG LIVE 50 MG IS SUSR,RX-21570,CDM,J9030,HCPCS,0636,RC,00052-0602-02,NDC,,both,1,UN,508.90,330.78,,,,,,,,,,,,,
PLATE BNE MAXILLOFCL 1 MESH NS FACE ID,SUP-2909646,CDM,C1713,HCPCS,0278,RC,,,,both,,,27516.26,17885.57,,,,,,,,,,,,,
COIL VASC INTERLOCK-35 L 20 CM DIA15 MM GUIDEWIRE 0.035 IN,SUP-2148117,CDM,C1889,HCPCS,0278,RC,,,,both,,,2433.50,1581.77,,,,,,,,,,,,,
BUR SURG STD MED 60 K 3 MM HI SPD STRL UNIDRIVE DISP,SUP-2599309,CDM,2720000010,LOCAL,0272,RC,,,,both,,,649.04,421.88,,,,,,,,,,,,,
STYLET NAVIGATION ELECTROMAGNETIC DISP,SUP-2910365,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2584.22,1679.74,,,,,,,,,,,,,
SCREW BNE L25MM OD10.5MM DISP ACL MULCH,SUP-2212889,CDM,C1713,HCPCS,0278,RC,,,,both,,,1312.52,853.14,,,,,,,,,,,,,
SHEATH INTRO PRELUDE IDEAL L 16 CM DIA 7 FR GUIDEWIRE L 80,SUP-2740618,CDM,C1892,HCPCS,0272,RC,,,,both,,,184.63,120.01,,,,,,,,,,,,,
PLATE BNE L203MM 13 H ST R LAT DST FIBULAR S STL LOK COMPR,SUP-2177427,CDM,C1713,HCPCS,0278,RC,,,,both,,,2199.26,1429.52,,,,,,,,,,,,,
PACK NEUROSURGICAL MYRIAD HNDPC L 10 CM DIA13 GA,SUP-2930237,CDM,2720000010,LOCAL,0272,RC,,,,both,,,46200.33,30030.21,,,,,,,,,,,,,
PLATE BNE 1 H POST RIM NAR NS PRO,SUP-2902296,CDM,C1713,HCPCS,0278,RC,,,,both,,,1832.35,1191.03,,,,,,,,,,,,,
LEAD CARD PACE PERM ATR LD PACE BPLR PASS FIX IS 1 CONN 46CM,SUP-2356655,CDM,C1898,HCPCS,0275,RC,,,,both,,,2041.00,1326.65,,,,,,,,,,,,,
SCREW BONE CANNULATED 6.5X70 MM FULLY THREADED CANNULATED LO,SUP-2837563,CDM,C1713,HCPCS,0278,RC,,,,both,,,1690.42,1098.77,,,,,,,,,,,,,
SPHERE ORBIT DIA20 MM SMTH POROUS ANTR SURF SUTURE TUNN,SUP-2909476,CDM,L8610,HCPCS,0278,RC,,,,both,,,2227.42,1447.82,,,,,,,,,,,,,
SCREW BNE L60MM DIA4.5MM CORT TI N ST N SELF DRL,SUP-2190393,CDM,C1713,HCPCS,0278,RC,,,,both,,,62.20,40.43,,,,,,,,,,,,,
PLATE BNE FEM 1 HOLE NK SYS TI NS,SUP-2181049,CDM,C1713,HCPCS,0278,RC,,,,both,,,3269.68,2125.29,,,,,,,,,,,,,
PLATE CRAN 80X20X20 MM PT SPEC IMPL PEEK,SUP-2860168,CDM,C1713,HCPCS,0278,RC,,,,both,,,22434.99,14582.74,,,,,,,,,,,,,
SHEATH INTRO ARW GLIDETHRU L 7 CM DIA 6 FR DIL 6 FR POLYUR,SUP-2887200,CDM,C1894,HCPCS,0272,RC,,,,both,,,44.90,29.18,,,,,,,,,,,,,
BLADE STERILE RADIUS,SUP-2574100,CDM,2720000010,LOCAL,0272,RC,,,,both,,,305.33,198.46,,,,,,,,,,,,,
"HC Estrogens, Fractionated, Assay of Estrone",PX-3018267967,CDM,82679,CPT,0301,RC,,,,both,,,43.00,27.95,,,,,,,,,,,,,
CEMENT DENT REFIL W/ TIP FUJI AUTOMX,SUP-2226109,CDM,C1713,HCPCS,0278,RC,,,,both,,,449.15,291.95,,,,,,,,,,,,,
IMPLANT PENILE L 16 CM INFPUB PRECONNECT INFLATABLE,SUP-2930708,CDM,C1813,HCPCS,0278,RC,,,,both,,,44202.88,28731.87,,,,,,,,,,,,,
GLYCOPYRROLATE-FORMOTEROL 9-4.8 MCG/ACT IN AERO,RX-134596,CDM,6370000000,HCPCS,0637,RC,00310-4600-12,NDC,,both,10.7,GR,2001.20,1300.78,,,,,,,,,,,,,
SCREW BNE SM L40MM DIA3.5MM HD DIA6MM CORT TI NONCANNULATED,SUP-2189877,CDM,C1713,HCPCS,0278,RC,,,,both,,,65.72,42.72,,,,,,,,,,,,,
CATHETER CV SET 018 4 FRX8 CM 18 GA DL J TIP SPECTRUM,SUP-2759746,CDM,C1751,HCPCS,0278,RC,,,,both,,,424.31,275.80,,,,,,,,,,,,,
KIT CATH HEMODIALYSI EQUISTREAM CHRONIC STD 14.5FR DIA 29CM,SUP-2613300,CDM,C1750,HCPCS,0278,RC,,,,both,,,1658.39,1077.95,,,,,,,,,,,,,
PUTTY BONE 3 CC REINFORCED FAST SET STERILE CRANIOS,SUP-2838511,CDM,C1713,HCPCS,0278,RC,,,,both,,,3758.58,2443.08,,,,,,,,,,,,,
GAUGE DEPTH STANDALONE FOR 5 MM SCREW STRL DISP PROSTEP MIS,SUP-2902371,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1430.74,929.98,,,,,,,,,,,,,
DEFIBRILLATOR CRD BPLR 74X50X14 MM VENTRIC CSYS ATLAS+ VR,SUP-2356525,CDM,C1722,HCPCS,0275,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
HC Peripheral Block - Brachial Plexus Single W/Img Gdn,PX-3606441500,CDM,64415,CPT,0360,RC,,,,both,,,2895.00,1881.75,,,,,,,,,,,,,
GRAFT HUM TISS W22XL45MM ILIUM BICORT STRP FRZ DRY,SUP-2307120,CDM,C1713,HCPCS,0278,RC,,,,both,,,1954.56,1270.46,,,,,,,,,,,,,
GRAFT VASC FUSION BIOLINE L 80 CM DIA10 MM EXTERNALLY SUPP,SUP-2478251,CDM,C1768,CPT,0278,RC,,,,both,,,8213.08,5338.50,,,,,,,,,,,,,
PLATE BNE L205MM THK3MM 13 H BILAT S STL STR LIMIT CNTCT DYN,SUP-2185348,CDM,C1713,HCPCS,0278,RC,,,,both,,,2263.06,1470.99,,,,,,,,,,,,,
KIT PICC XCELA CATH L 55 CM DIA 5 FR 2 LUMEN ANGIO CUST STRL,SUP-2118855,CDM,C1751,HCPCS,0278,RC,,,,both,,,587.18,381.67,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH TX2 L 120 MM DIA28 MM SHTH 20 FR RVD,SUP-2171017,CDM,C1874,HCPCS,0278,RC,,,,both,,,37975.16,24683.85,,,,,,,,,,,,,
WASHER ORTHOPEDIC 2/2.5 MM NS EPIC,SUP-2221462,CDM,C1713,HCPCS,0278,RC,,,,both,,,78.50,51.02,,,,,,,,,,,,,
WASHER EXT FIX OD12MM ID6.4MM THK1.5MM SPC FOR ILIZ TAY,SUP-2342312,CDM,2720000010,LOCAL,0272,RC,,,,both,,,548.24,356.36,,,,,,,,,,,,,
GRAFT BONE RT DSTL HUM TRAD FRZN,SUP-2294182,CDM,C1713,HCPCS,0278,RC,,,,both,,,3984.66,2590.03,,,,,,,,,,,,,
STENT VASC RX 6X100 MM 6 FRX200 CM SELF EXP R2P MISAGO,SUP-2422180,CDM,C1876,HCPCS,0278,RC,,,,both,,,2983.00,1938.95,,,,,,,,,,,,,
MESH HERN DIA5.12IN OMEGA 3 FATTY ACID POLYPR RND BLT ON,SUP-2265960,CDM,C1781,HCPCS,0278,RC,,,,both,,,1228.96,798.82,,,,,,,,,,,,,
SHEATH KIT NANONEEDLE 125 MM,SUP-2849269,CDM,2720000010,LOCAL,0272,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
STIMULATOR NERVE PENTA SYS PROCLAIM ELITE XR 5,SUP-2862943,CDM,C1767,HCPCS,0278,RC,,,,both,,,48670.00,31635.50,,,,,,,,,,,,,
NITROGLYCERIN 2 % TD OINT,RX-5606,CDM,6370000000,HCPCS,0637,RC,00281-0326-08,NDC,,both,1,GR,54.10,35.16,,,,,,,,,,,,,
HORIZONTAL CROSS BAR 160MM RED DEVICE,SUP-2707225,CDM,C1713,HCPCS,0278,RC,,,,both,,,1270.22,825.64,,,,,,,,,,,,,
ALLOGRAFT HUM TISS FRZN ASEP TEND FLX,SUP-2867090,CDM,C1762,CPT,0278,RC,,,,both,,,2839.82,1845.88,,,,,,,,,,,,,
KLS MARTIN RED III PED,SUP-2679246,CDM,C1713,HCPCS,0278,RC,,,,both,,,23523.56,15290.31,,,,,,,,,,,,,
GRAFT HUMAN TSSUE L W5XL10CM THK0.53 1.02MM DRML TSSUE MTRX,SUP-2496478,CDM,Q4116,HCPCS,0636,RC,,,,both,,,5045.98,3279.89,,,,,,,,,,,,,
PACEMAKER SGL CHMBR ADAPTIVE RATE PULSE GEN SGL DDDR RT A OR,SUP-2357336,CDM,C1785,HCPCS,0275,RC,,,,both,,,13502.00,8776.30,,,,,,,,,,,,,
IMMOBILIZER KNEE 3 PNL 19 IN,SUP-2336076,CDM,L1830,CPT,0274,RC,,,,both,,,37.65,24.47,,,,,,,,,,,,,
PLATE BNE BURR HOLE CVR 12X3X1.5 MM LP CONTOURED TI STRL,SUP-2472581,CDM,C1713,HCPCS,0278,RC,,,,both,,,768.55,499.56,,,,,,,,,,,,,
PLATE BNE L 100 DEG STD 1.7X2X0.55 MM RT 5 HOLE BAR MALL,SUP-2366243,CDM,C1713,HCPCS,0278,RC,,,,both,,,616.57,400.77,,,,,,,,,,,,,
HC Pt Vasopneumatic Device Therapy|OP OCCUPATIONAL THERAPY SERV|DOCUMENTATION ON FILE|SERVICES PROVIDED IN WHOLE OR IN PARTY BY AN OTA FOR MEDICARE PATIENTS,PX-4209701600,CDM,97016,CPT,0420,RC,,,GO|KX|CO,outpatient,,,206.00,133.90,,,,,,,,,,,,,
SINUS SCTN BURR ANGLD 40DGRS OBLONG BURR D3MM SHFT4MMX12CM5/,SUP-2574174,CDM,2720000010,LOCAL,0272,RC,,,,both,,,725.53,471.59,,,,,,,,,,,,,
STAPLE BONE FIX W20XL20MM NIT COMPR W/ INSTRMT LO PROF FOR,SUP-2418418,CDM,C1713,HCPCS,0278,RC,,,,both,,,7834.30,5092.29,,,,,,,,,,,,,
HC Rep Blood Vessel Direct Up Ext,PX-4503520600,CDM,35206,CPT,0450,RC,,,,both,,,3355.00,2180.75,,,,,,,,,,,,,
NEEDLE VENT 18GA 2 H CONE W/ LUERLOCK,SUP-2382315,CDM,2720000010,LOCAL,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
URETERORENOSCOPE FLX L 600 MM DIA 9 FR WORKING CHANNEL 6-65,SUP-2883367,CDM,C1747,HCPCS,0272,RC,,,,both,,,4396.00,2857.40,,,,,,,,,,,,,
HC C-Spine Complete W/ Flex/Ext,PX-3207205200,CDM,72052,CPT,0320,RC,,,,both,,,1157.00,752.05,,,,,,,,,,,,,
PLATE BNE L30MM BLDE W9.2XL80MM 90DEG 6 H BILAT S STL LOK,SUP-2185367,CDM,C1713,HCPCS,0278,RC,,,,both,,,3502.61,2276.70,,,,,,,,,,,,,
INSTRUMENT SET 2.7 MM IFP IMPL DRVR ASMBLY,SUP-2400027,CDM,C1776,CPT,0278,RC,,,,both,,,4543.58,2953.33,,,,,,,,,,,,,
SCREW BONE L8MM DIA2.5MM CORT WR TI TRILOK APTUS HEXADRIVE 7,SUP-2268222,CDM,C1713,HCPCS,0278,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
PLATE BNE L396MM 17 H R DST FEM S STL LOK COMPR FOR 45MM SCR,SUP-2177826,CDM,C1713,HCPCS,0278,RC,,,,both,,,5114.78,3324.61,,,,,,,,,,,,,
SCREW LCK 1.50X8MM APTUS HD4,SUP-2268076,CDM,C1713,HCPCS,0278,RC,,,,both,,,381.51,247.98,,,,,,,,,,,,,
KIT DIAG CATH ER-REBOA POLYMER CONVENIENCE W/ ACCS NDL INTRO,SUP-2417427,CDM,C1894,HCPCS,0272,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
IMPLANT CRPL SZ 2 PYROCARBON LUNATE,SUP-2244198,CDM,C1776,CPT,0278,RC,,,,both,,,11750.01,7637.51,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 100 MM DIA 9 MM DEL SHTH 4.5MM,SUP-2936837,CDM,C1713,HCPCS,0278,RC,,,,both,,,11661.96,7580.27,,,,,,,,,,,,,
BLADE IM L42MM TAN TI ALLY SPRL LOK FOR UHN/PHN HUM NAIL,SUP-2192460,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1492.88,970.37,,,,,,,,,,,,,
BLADE ENDOSCP CUBITAL TUNN RELEASE SYS ENDORELEASE LTXFRDM,SUP-2604359,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2353.40,1529.71,,,,,,,,,,,,,
KIT INTRO SHTH L 10 CM DIA 5.5 FR TEARWY ACCSRY STRL,SUP-2627294,CDM,C1894,HCPCS,0272,RC,,,,both,,,20.22,13.14,,,,,,,,,,,,,
BLADE URETHROTOME STR SACHSE,SUP-2261208,CDM,2720000010,LOCAL,0272,RC,,,,both,,,880.77,572.50,,,,,,,,,,,,,
CLAMP EXT FIX DIA56MM BAR TO PIN MINI FRDM,SUP-2342866,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4142.29,2692.49,,,,,,,,,,,,,
MATRIX BIO L 8 X W 10 CM SZ 144 SQCM FISH SKIN DERMAL BX/10,SUP-2909360,CDM,Q4158,HCPCS,0636,RC,,,,both,,,9316.07,6055.45,,,,,,,,,,,,,
PLATE CRAN 140X140X40 MM PT SPEC IMPL PEEK,SUP-2860156,CDM,C1713,HCPCS,0278,RC,,,,both,,,44496.31,28922.60,,,,,,,,,,,,,
SYSTEM ORTHOPEDIC 4.75 MM FDL,SUP-2431993,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4694.30,3051.29,,,,,,,,,,,,,
GRAFT BNE 2.5 CC CELLULAR BNE MTRX V92 FC+,SUP-2742068,CDM,C1713,HCPCS,0278,RC,,,,both,,,4749.25,3087.01,,,,,,,,,,,,,
PLATE SPNL L27MM 4MM SPC MINI TI DBL BEND FOR 2MM SCR,SUP-2191051,CDM,C1713,HCPCS,0278,RC,,,,both,,,2041.00,1326.65,,,,,,,,,,,,,
GRAFT VASC GELWEAVE L 60 CM DIA 30 MM POLYESTER GEL,SUP-2385055,CDM,C1768,CPT,0278,RC,,,,both,,,1988.62,1292.60,,,,,,,,,,,,,
TRAY CATH PICC POLY Q CATH BASIC 3FR 0.024IN 60CM 1 LUMAN RV,SUP-2613377,CDM,C1751,HCPCS,0278,RC,,,,both,,,161.77,105.15,,,,,,,,,,,,,
DEFIBRILLATOR IMPL EDORA PROMRI 8 HF-T W 52 X H 53 MM D 6.5,SUP-2739240,CDM,C2621,HCPCS,0275,RC,,,,both,,,25826.50,16787.22,,,,,,,,,,,,,
HC So Factor Inhibitor Test,PX-3058533566,CDM,85335,CPT,0305,RC,,,,inpatient,,,385.00,250.25,,,,,,,,,,,,,
BIT DRL L200MM DIA3.3MM 3/16 SQ CONN CANN FOR MEDL CLMN,SUP-2321608,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1483.65,964.37,,,,,,,,,,,,,
SPHINCTEROTOME ENDOSCP CUT WIRE SZ 20 MM SHRT,SUP-2889730,CDM,2720000010,LOCAL,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
PIN FIX KNEE S STL HEX HD HLD MG II,SUP-2342143,CDM,C1713,HCPCS,0278,RC,,,,both,,,94.20,61.23,,,,,,,,,,,,,
KNIFE SURG SCKL AD 7.5 IN SHRP CRV RT MICROFRANCE,SUP-2464568,CDM,2720000010,LOCAL,0272,RC,,,,both,,,709.61,461.25,,,,,,,,,,,,,
SYSTEM FLUID DEL STRL DISP MYRIAD,SUP-2930225,CDM,2720000010,LOCAL,0272,RC,,,,both,,,363.24,236.11,,,,,,,,,,,,,
APPLIER CLIP 725INL SPRING,SUP-2672287,CDM,2720000010,LOCAL,0272,RC,,,,both,,,356.77,231.90,,,,,,,,,,,,,
PLATE BNE L29MM THK075MM 14 H NONSTERILE HND TI WEB LOK FOR,SUP-2180994,CDM,C1713,HCPCS,0278,RC,,,,both,,,1485.03,965.27,,,,,,,,,,,,,
CUBE EXT FIX TWO HOLE SS,SUP-2162666,CDM,2720000010,LOCAL,0272,RC,,,,both,,,592.83,385.34,,,,,,,,,,,,,
CATHETER ABLAT IRRIG 4MM TIP THRMCPL 7FR QPLR,SUP-2357657,CDM,C1730,HCPCS,0272,RC,,,,both,,,3689.50,2398.17,,,,,,,,,,,,,
DEVICE OCCL CLP L45MM PLUNG GRP FLX SHFT FOR GILLINOV,SUP-2540328,CDM,C1889,HCPCS,0278,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
SYSTEM MIC ACCS GLIDEACCESS DIA 4 FR L 40 CM PLAT NIT WIRE,SUP-2385205,CDM,C1894,HCPCS,0272,RC,,,,both,,,94.20,61.23,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED CEM FLX GENDER SOL N-K,SUP-2212608,CDM,C1776,CPT,0278,RC,,,,both,,,15219.99,9892.99,,,,,,,,,,,,,
PLATE BONE W23XL68MM THK2MM LNG 15 H LT DSTL RAD TI ADAPTIVE,SUP-2267976,CDM,C1713,HCPCS,0278,RC,,,,both,,,4111.05,2672.18,,,,,,,,,,,,,
NEEDLE SUT SZ 2 SURG 3 FRE STRND SGL PASS MENIS LOOP W/ WIRE,SUP-2256747,CDM,C1713,HCPCS,0278,RC,,,,both,,,474.14,308.19,,,,,,,,,,,,,
HC Arthrocent/Aspiration Maj Jnt|BILATERAL PROCEDURE|PBB CHARGE,PX-3612061000,CDM,20610,CPT,0361,RC,,,50|PBB,both,,,1245.00,809.25,,,,,,,,,,,,,
PLATE BNE SM W11XL59MM THK34MM 4 H BILAT TI RIG NEUT LOK,SUP-2190775,CDM,C1713,HCPCS,0278,RC,,,,both,,,840.64,546.42,,,,,,,,,,,,,
SUPPORT ORTHOT WRST HND FNGR CUST W/O JT PREFABRICATED,SUP-2435768,CDM,L3809,HCPCS,0274,RC,,,,both,,,644.23,418.75,,,,,,,,,,,,,
CATHETER EPIDURAL 20 GAX40 IN SFT CLOSED TIP 3 SP PERIFIX,SUP-2125021,CDM,C1755,HCPCS,0278,RC,,,,both,,,22.77,14.80,,,,,,,,,,,,,
PLATE BONE 33MM 4 H 1 LEV THOR STRNL FIX DEV DISP,SUP-2262569,CDM,C1713,HCPCS,0278,RC,,,,both,,,1818.06,1181.74,,,,,,,,,,,,,
MESH GYNEMESH PS PROL SQ 25 CMX25 CM,SUP-2219080,CDM,C1781,HCPCS,0278,RC,,,,both,,,2294.99,1491.74,,,,,,,,,,,,,
PLATE BNE VA NAR XLN 2.4/2.7X105 MM RT RADIAL 6X7 TWO CLMN,SUP-2184115,CDM,C1713,HCPCS,0278,RC,,,,both,,,4622.14,3004.39,,,,,,,,,,,,,
GRAFT DURA W2XL2IN ULTRAPURE DURAGN+ 5PK/EA,SUP-2244011,CDM,C1713,HCPCS,0278,RC,,,,both,,,5792.42,3765.07,,,,,,,,,,,,,
NAIL IM L400MM OD11MM 130DEG LNG TI LT FEM CANN LCK GAMMA3,SUP-2362345,CDM,C1713,HCPCS,0278,RC,,,,both,,,3102.32,2016.51,,,,,,,,,,,,,
BOLT EXT FIX S STL LNG WIRE SLT FOR ILIZ TAY SPAT FRME SYS,SUP-2342847,CDM,C1713,HCPCS,0278,RC,,,,both,,,1934.08,1257.15,,,,,,,,,,,,,
BLADE LARYNSCP FBR OPT CLD LT SZ 4 MACINTOSH,SUP-2261366,CDM,2720000010,LOCAL,0272,RC,,,,both,,,537.57,349.42,,,,,,,,,,,,,
HC Pt Elec Stim Unattended|OP PT SERVICES|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS,PX-4209701400,CDM,G0283,HCPCS,0420,RC,,,GP|CQ,outpatient,,,206.00,133.90,,,,,,,,,,,,,
CATHETER DRAINAGE 10.2 FRX25 CM MP COOKCOPE TYP UTHANE,SUP-2168200,CDM,C1729,HCPCS,0272,RC,,,,both,,,231.29,150.34,,,,,,,,,,,,,
PLATE BNE L96MM 0DEG 8 H TI ANK BILAT 1 3 TBLR STR LOK COMPR,SUP-2398346,CDM,C1713,HCPCS,0278,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
GRAFT HUM TISS 20X6.5MM WDG COT FOR ANAT RECON ALLOSYNC,SUP-2120759,CDM,C1713,HCPCS,0278,RC,,,,both,,,4733.55,3076.81,,,,,,,,,,,,,
HC Pt Eval Mod Complex,PX-4249716200,CDM,97162,CPT,0424,RC,,,,both,,,227.00,147.55,,,,,,,,,,,,,
COMPONENT FEM DSTL E 8.5 CM RT KNEE POROUS MAK OSS,SUP-2449875,CDM,C1776,CPT,0278,RC,,,,both,,,18917.24,12296.21,,,,,,,,,,,,,
BIT DRL L 115 MM DIA1.5 MM STP 26 MM NS DISP,SUP-2936992,CDM,2720000010,LOCAL,0272,RC,,,,both,,,916.88,595.97,,,,,,,,,,,,,
CLAMP SURG PIN 8 MM 16 MM BEND BUTTRESS PIN,SUP-2389688,CDM,C1713,HCPCS,0278,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
MONO T1 NEUT STEM 6X18MM,SUP-2364449,CDM,C1776,CPT,0278,RC,,,,both,,,13345.00,8674.25,,,,,,,,,,,,,
CATHETER INTVASC OCCL ASCNT L 150 CM 2.9 FR 0.0170 IN 10 MM,SUP-2459180,CDM,C2628,HCPCS,0272,RC,,,,both,,,6208.72,4035.67,,,,,,,,,,,,,
BUR SHV DIA5.5MM BRN STR TIP FOR ARTHSCP RESECT DYONIC,SUP-2341736,CDM,2720000010,LOCAL,0272,RC,,,,both,,,113.04,73.48,,,,,,,,,,,,,
BIT DRL L110MM DIA2MM CANN W/ QUIK CONN FOR SM SCR,SUP-2344062,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1809.21,1175.99,,,,,,,,,,,,,
PLATE BONE L168MM THK3.7MM 8 H LT DSTL MEDL TIB TI LCK COMPR,SUP-2190883,CDM,C1713,HCPCS,0278,RC,,,,both,,,4564.30,2966.79,,,,,,,,,,,,,
COMPONENT PAT 3 STD PEG RND REV ROT CEM POR WITHOUTXRAY WIRE,SUP-2252413,CDM,C1776,CPT,0278,RC,,,,both,,,3830.80,2490.02,,,,,,,,,,,,,
COLLAR CERV H3XL15IN SM AD TRACH CLS HK AND LOOP CLSR W CHIN,SUP-2276593,CDM,L0120,HCPCS,0272,RC,,,,both,,,6.56,4.26,,,,,,,,,,,,,
HARVESTER TEND DIA 8 MM STRL DISP QUADPRO COR,SUP-2930461,CDM,2720000010,LOCAL,0272,RC,,,,both,,,741.83,482.19,,,,,,,,,,,,,
ANCHOR FIX INLINE 6X14 MM MERID,SUP-2711020,CDM,C1776,CPT,0278,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
LENS INTOCU +24.0 DIOPT L12.5MM DIA5.5MM D3.39MM 0.5DEG,SUP-2110745,CDM,V2630,CPT,0276,RC,,,,both,,,260.87,169.57,,,,,,,,,,,,,
GUIDEWIRE VASC NIT-VU L 300 CM DIA 0.014 IN TIP L 7 CM NIT,SUP-2117335,CDM,C1769,HCPCS,0272,RC,,,,both,,,220.74,143.48,,,,,,,,,,,,,
LENS IOL BCNVX 14+ DIOPT 6X13 MM TORIC,SUP-2102624,CDM,V2788,HCPCS,0276,RC,,,,both,,,984.00,639.60,,,,,,,,,,,,,
NAIL IM L360MM OD12MM TI R FEM RECON AG FLUT T2 R1.5,SUP-2369393,CDM,C1713,HCPCS,0278,RC,,,,both,,,4553.00,2959.45,,,,,,,,,,,,,
MICROFREE MED SPEED DRILL,SUP-2605744,CDM,2720000010,LOCAL,0272,RC,,,,both,,,19211.15,12487.25,,,,,,,,,,,,,
DONALDSON VENT TUBE 114MM ID BLUE FLUOROPLASTIC 10 PACK,SUP-2695104,CDM,L8699,HCPCS,0278,RC,,,,both,,,22.58,14.68,,,,,,,,,,,,,
RING ANNULPLSTY CARP EDW CLASSIC OD 26 MM ID 24.3 MM TI SIL,SUP-2214176,CDM,C1889,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
MESH HERN W18XL24CM THK2MM EPTFE PTCH RECT 2 SIDE FOR,SUP-2126080,CDM,C1781,HCPCS,0278,RC,,,,both,,,4882.70,3173.75,,,,,,,,,,,,,
CATHETER THROMCTMY SOLITAIRE X L 31 MM DIA 6 MM USABLE L 20,SUP-2432063,CDM,C1757,HCPCS,0272,RC,,,,both,,,21125.92,13731.85,,,,,,,,,,,,,
DISTRACTOR EXT FIX 30 MM 1.5 - 1.8 MM TELSCP W/O ACTIVATOR,SUP-2492291,CDM,C1713,HCPCS,0278,RC,,,,both,,,17506.69,11379.35,,,,,,,,,,,,,
KIT CATH HAD CHRNC LNG TERM LMNX2 155FR DIA 48CML RBST PLST,SUP-2729584,CDM,C1750,HCPCS,0278,RC,,,,both,,,1083.30,704.14,,,,,,,,,,,,,
GRAFT ILIAC CREST STRIP MED 70-90MM FD,SUP-2863663,CDM,C1762,CPT,0278,RC,,,,both,,,10418.52,6772.04,,,,,,,,,,,,,
KIT NEUROSTIM PASS ELEV ACC FOR INTERSTIM SPNL CRD STIM,SUP-2284445,CDM,2720000010,LOCAL,0272,RC,,,,both,,,747.32,485.76,,,,,,,,,,,,,
KIT CATH L58CM OD4FR W/ PEEL AWAY SHTH INTRO CTRL VEN PICC,SUP-2168400,CDM,C1751,HCPCS,0278,RC,,,,both,,,245.23,159.40,,,,,,,,,,,,,
GRAFT BIO TISS L5CMXW3.5CM PORCINE CLLGN 4 LAYR GEN,SUP-2168861,CDM,C1781,HCPCS,0278,RC,,,,both,,,959.43,623.63,,,,,,,,,,,,,
HEAD FEM HIP,SUP-2437030,CDM,C1776,CPT,0278,RC,,,,both,,,254.34,165.32,,,,,,,,,,,,,
GRAFT HUM TISS W10XL150MM THK3 12MM FEM CORT STRUT FRZN,SUP-2307353,CDM,C1713,HCPCS,0278,RC,,,,both,,,2683.88,1744.52,,,,,,,,,,,,,
AMBI SHORT PL 5SL 120MM 140,SUP-2818070,CDM,C1713,HCPCS,0278,RC,,,,both,,,3852.94,2504.41,,,,,,,,,,,,,
PLATE EXT FIX DIA160MM ANK FT FOR TRUELOK FRME ASSEMB,SUP-2316191,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1725.46,1121.55,,,,,,,,,,,,,
GRAFT BIO TISS OMEGA3 MARIGEN 5X7CM,SUP-2909170,CDM,Q4158,HCPCS,0636,RC,,,,both,,,4513.75,2933.94,,,,,,,,,,,,,
PATCH BIO L 10 X W 1.5 CM BOV PERICARD XENOSURE,SUP-2884043,CDM,C1768,CPT,0278,RC,,,,both,,,1158.66,753.13,,,,,,,,,,,,,
EXTRACTOR SURG EASYOUT 4 MM QR ACUTRK,SUP-2857694,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1331.36,865.38,,,,,,,,,,,,,
STIMULATOR NRV 386CC 583GM W502XH668CM THK135CM BRAIN DP,SUP-2357361,CDM,C1767,HCPCS,0278,RC,,,,both,,,78500.00,51025.00,,,,,,,,,,,,,
NAIL IM L240MM DIA9MM HUM TI NONLOCKING CANN AIM,SUP-2252403,CDM,C1713,HCPCS,0278,RC,,,,both,,,3912.44,2543.09,,,,,,,,,,,,,
GRAFT VASC IMPRA L 70 CM DIA 8-5 MM EPTFE TAPR STD WALL N,SUP-2761339,CDM,C1768,CPT,0278,RC,,,,both,,,2319.83,1507.89,,,,,,,,,,,,,
SPACER SPNL W12XH5XL14MM 5DEG PEEK OPTMA INTERVERTEBRAL,SUP-2211875,CDM,C1821,HCPCS,0278,RC,,,,both,,,3432.65,2231.22,,,,,,,,,,,,,
STEM FEM ARCOS 15X115MM CYL DIST,SUP-2506043,CDM,C1776,CPT,0278,RC,,,,both,,,9382.32,6098.51,,,,,,,,,,,,,
GUIDEWIRE VASC TAD II L 260 CM DIA 0.035 IN MICROGLIDE,SUP-2104859,CDM,C1769,HCPCS,0272,RC,,,,both,,,266.90,173.48,,,,,,,,,,,,,
BIT DRL CANN LG 14 MM QC NS,SUP-2799308,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1454.76,945.59,,,,,,,,,,,,,
STENT URET STR 0.038 IN 3 CM 7 FRX26 CM 6 FRX150 CM CNTOUR,SUP-2459842,CDM,C2617,HCPCS,0278,RC,,,,both,,,537.00,349.05,,,,,,,,,,,,,
GRAFT BONE 4-10MM 30ML CANC CUBE,SUP-2293754,CDM,C1713,HCPCS,0278,RC,,,,both,,,1909.12,1240.93,,,,,,,,,,,,,
GRAFT BNE INJ 2 CC INDUCTIVE PRO-STIM,SUP-2759437,CDM,C1713,HCPCS,0278,RC,,,,both,,,3491.68,2269.59,,,,,,,,,,,,,
SCR MD LCKNG EMERG31X17MM,SUP-2668812,CDM,C1713,HCPCS,0278,RC,,,,both,,,494.71,321.56,,,,,,,,,,,,,
PORT INFUS CATH OD9.6FR ID1.5MM TI SGL LUMN W/ DETACHED SIL,SUP-2332930,CDM,C1788,HCPCS,0278,RC,,,,both,,,675.10,438.81,,,,,,,,,,,,,
CATHETER CV FULL SAFETY TY 032 9 FRX25 CM 11 GA 3L SPECTRUM,SUP-2759740,CDM,C1751,HCPCS,0278,RC,,,,both,,,499.67,324.79,,,,,,,,,,,,,
SCREW BONE 2.7MM DIA 70MML STNLSS STEEL CRTCL SELF TPPNG,SUP-2588511,CDM,C1713,HCPCS,0278,RC,,,,both,,,72.47,47.11,,,,,,,,,,,,,
MIS LOCK CALC PLT SM EXD 2H LT,SUP-2586880,CDM,C1713,HCPCS,0278,RC,,,,both,,,2624.35,1705.83,,,,,,,,,,,,,
MESH CRANIOMAXILLOFACIAL STD L W120XL120MM THK0.6MM,SUP-2419460,CDM,C1713,HCPCS,0278,RC,,,,both,,,8443.08,5488.00,,,,,,,,,,,,,
ALLOGRAFT BNE PTTY 10 CC DBM FIBER NEVOS,SUP-2762319,CDM,C1713,HCPCS,0278,RC,,,,both,,,2645.14,1719.34,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED PRICING PERSONA,SUP-2212485,CDM,C1776,CPT,0278,RC,,,,both,,,13659.00,8878.35,,,,,,,,,,,,,
PLATE BNE L167MM 10 H BROAD COMPR RIG FOR 4.5MM SCR L FRAG,SUP-2411417,CDM,C1713,HCPCS,0278,RC,,,,both,,,672.71,437.26,,,,,,,,,,,,,
KIT THR R 15 TIB 15 FEM KNEE RESECT GUID SPEC 2 TRUMATCH,SUP-2252922,CDM,C1713,HCPCS,0278,RC,,,,both,,,4052.48,2634.11,,,,,,,,,,,,,
BETAMETHASONE VALERATE 0.1 % EX LOTN,RX-1032,CDM,6370000000,HCPCS,0637,RC,00168-0041-60,NDC,,both,60,ML,270.00,175.50,,,,,,,,,,,,,
GUIDEWIRE VASC L450CM TIP L5CM 025FR STR RND TIP TUNGSTEN FI,SUP-2436464,CDM,C1769,HCPCS,0272,RC,,,,both,,,549.81,357.38,,,,,,,,,,,,,
IMPLANT HUM TISS LT DSTL FIBULAR OSTEOARTICULAR CUST MATCHED,SUP-2933013,CDM,C1762,CPT,0278,RC,,,,both,,,11416.10,7420.46,,,,,,,,,,,,,
STENT PERIPH L17MM DIA7MM CATH L80CM BLLN L20MM SHTH 6FR,SUP-2173266,CDM,C1876,HCPCS,0278,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
BEARING TIB 1MAXIM VI ARCM CON BRNG 12X63MM,SUP-2841752,CDM,C1776,CPT,0278,RC,,,,both,,,4207.60,2734.94,,,,,,,,,,,,,
SPLINT KNEE L24IN FOR 32IN THGH UNIV FOAM 3 PC DSGN TRIMMED,SUP-2196755,CDM,L1830,CPT,0274,RC,,,,both,,,46.69,30.35,,,,,,,,,,,,,
SCREW BONE STD CANC FULL THRD CANN N LCK NSTERILE 4MM DIA,SUP-2348388,CDM,C1713,HCPCS,0278,RC,,,,both,,,266.96,173.52,,,,,,,,,,,,,
STENT ENTERPRISE VASC 2 TIP 4.0X16MM,SUP-2470070,CDM,C1874,HCPCS,0278,RC,,,,both,,,28918.83,18797.24,,,,,,,,,,,,,
TRAY PARACENT 5FR L10CM STR 1 STP CENTESIS CATHETER SLIP FIT,SUP-2303451,CDM,C1713,HCPCS,0278,RC,,,,both,,,100.48,65.31,,,,,,,,,,,,,
PLATE BNE STR 2 HOLE OMNI,SUP-2610109,CDM,C1713,HCPCS,0278,RC,,,,both,,,2260.80,1469.52,,,,,,,,,,,,,
BLADE SAW L 10 MM WORKING L 5 MM NAR RASP RECIP STRL DISP,SUP-2929131,CDM,2720000010,LOCAL,0272,RC,,,,both,,,655.19,425.87,,,,,,,,,,,,,
SPHINCTEROTOME ENDOSCP L20MM CATH L200CM DIA11.5MM BELOW,SUP-2149502,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1093.44,710.74,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 220 MM DIA15 MM DEL SHTH,SUP-2934254,CDM,C1713,HCPCS,0278,RC,,,,both,,,18920.29,12298.19,,,,,,,,,,,,,
GRAFT BIO TISS W7XL10CM 1 LAYR PORCINE MTRX SFT TISS REINF,SUP-2168773,CDM,C1763,HCPCS,0278,RC,,,,both,,,1639.08,1065.40,,,,,,,,,,,,,
ADJUST MAXILLARY DISTRACTOR BODY 15MM,SUP-2694294,CDM,C1713,HCPCS,0278,RC,,,,both,,,13275.92,8629.35,,,,,,,,,,,,,
FIBER LASER 365 MH SIDE FIRING FOR LUMENIS HOLM SLM LN EZ,SUP-2140361,CDM,2720000010,LOCAL,0272,RC,,,,both,,,904.89,588.18,,,,,,,,,,,,,
SPHERE GLEN DIA36MM THK11MM STD SHLDR POLY TRABECULAR MTL,SUP-2199137,CDM,C1776,CPT,0278,RC,,,,both,,,4521.29,2938.84,,,,,,,,,,,,,
POST EXT FIX MIAMI FOR HOFFMANN II SYS,SUP-2372206,CDM,2720000010,LOCAL,0272,RC,,,,both,,,352.31,229.00,,,,,,,,,,,,,
BIT DRILL ARTHROSCOPIC 2.4 MM DIAMETER FLUTED NON CANNULATED,SUP-2824795,CDM,2720000010,LOCAL,0272,RC,,,,both,,,699.69,454.80,,,,,,,,,,,,,
KIT PROC W IMPL STP DRL PHALANX REAMERS BNE HLDR IMPL HNDL,SUP-2137578,CDM,C1713,HCPCS,0278,RC,,,,both,,,4388.97,2852.83,,,,,,,,,,,,,
BLOCKER BRONCH AD 9FR 8ML L610MM POLYUR STL MESH SIL HI VOL,SUP-2115125,CDM,2720000010,LOCAL,0272,RC,,,,both,,,898.04,583.73,,,,,,,,,,,,,
STEM HUM LNG 44X21 MM SHLDR AFFINITI EH2,SUP-2715335,CDM,C1776,CPT,0278,RC,,,,both,,,8655.41,5626.02,,,,,,,,,,,,,
PLATE BONE L191MM 11 H LT PROX HUM LCK COMPR FOR 3.5MM SCR,SUP-2340928,CDM,C1776,CPT,0278,RC,,,,both,,,14345.72,9324.72,,,,,,,,,,,,,
HC Evacuation--Subungual Hematoma,PX-4501174000,CDM,11740,CPT,0450,RC,,,,both,,,396.00,257.40,,,,,,,,,,,,,
PLATE BONE STRAIGHT 1.5X240 MM 24 HOLE TITANIUM NON STERILE,SUP-2837695,CDM,C1713,HCPCS,0278,RC,,,,both,,,6603.42,4292.22,,,,,,,,,,,,,
CAP NAIL FEM RETRGRD 5MM,SUP-2467184,CDM,C1776,CPT,0278,RC,,,,both,,,589.94,383.46,,,,,,,,,,,,,
CATHETER ANGIOPLSTY OTW 135 CM 4.5X8 MM QUANTUM MAV,SUP-2144389,CDM,C1725,HCPCS,0272,RC,,,,both,,,938.86,610.26,,,,,,,,,,,,,
SYSTEM PRT CLOSURE 10/12 MM 15 MM XL CARTER-THOMASON II,SUP-2756023,CDM,2720000010,LOCAL,0272,RC,,,,both,,,662.29,430.49,,,,,,,,,,,,,
SHEATH INTRO TRANSSEPTAL MULLINS,SUP-2280906,CDM,C1894,HCPCS,0272,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
IMPLANT TIB H 12 MM DIA 9 MM LATTICE 3 MM SZ 1 SHRT LT ANK,SUP-2908998,CDM,C1776,CPT,0278,RC,,,,both,,,17270.00,11225.50,,,,,,,,,,,,,
PLATE BNE VOLAR LT GEMINUS,SUP-2340192,CDM,C1713,HCPCS,0278,RC,,,,both,,,5338.00,3469.70,,,,,,,,,,,,,
PHENYLEPHRINE HCL 1 MG/10ML IV SOSY,RX-143164,CDM,J7999,HCPCS,0636,RC,71266-9011-01,NDC,,both,1,ML,54.10,35.16,,,,,,,,,,,,,
PLATE BNE L 129 X W 11 MM THK 3.3 MM SCREW DIA 3.5 MM,SUP-2908399,CDM,C1713,HCPCS,0278,RC,,,,both,,,1204.35,782.83,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED PRSS FT XLPE CHIPZIMPRS] ZIMMER BIOMET INC],SUP-2212523,CDM,C1776,CPT,0278,RC,,,,both,,,14877.32,9670.26,,,,,,,,,,,,,
MARKER FIDUCIAL IMPLT G SFT TISS 12MM 1 NDL W 2 MRK SPC,SUP-2418128,CDM,A4648,CPT,0278,RC,,,,both,,,571.48,371.46,,,,,,,,,,,,,
BIT DRL L50MM DIA1.2MM WRK L6MM J NOTCH FOR UNIV NEURO 2 LO,SUP-2365217,CDM,2720000010,LOCAL,0272,RC,,,,both,,,362.67,235.74,,,,,,,,,,,,,
COMPONENT FEM KNEE POST STABILIZING UNI UNISX PRI PRESSFIT,SUP-2208911,CDM,C1776,CPT,0278,RC,,,,both,,,9327.37,6062.79,,,,,,,,,,,,,
ALLOGRAFT BNE W/ HD FRZN WHL FEM,SUP-2321809,CDM,C1713,HCPCS,0278,RC,,,,both,,,14327.82,9313.08,,,,,,,,,,,,,
WIRE FIX L6IN DIA0.08IN K,SUP-2167370,CDM,C1713,HCPCS,0278,RC,,,,both,,,50.24,32.66,,,,,,,,,,,,,
PLATE BNE CRV 1.5X0.8 MM MIDFACE 12 HOLE W/ TAB TI STRL,SUP-2474849,CDM,C1713,HCPCS,0278,RC,,,,both,,,921.28,598.83,,,,,,,,,,,,,
GRAFT BNE SUB 15GM GRN CA COMPND PTTY AND SILICATE BASE INJ,SUP-2138530,CDM,C9359,HCPCS,0278,RC,,,,both,,,5310.53,3451.84,,,,,,,,,,,,,
PLATE BNE HLS STR 1.0MM 6-HOLE LT,SUP-2247338,CDM,C1713,HCPCS,0278,RC,,,,both,,,1513.48,983.76,,,,,,,,,,,,,
TUBE FEEDING KANGAROO IRIS WITH IRIS TECHNOLOGY 12FR 43IN,SUP-2719883,CDM,2720000010,LOCAL,0272,RC,,,,both,,,686.94,446.51,,,,,,,,,,,,,
PIN PASS SPADE TIP 3MM STRL,SUP-2341131,CDM,2720000010,LOCAL,0272,RC,,,,both,,,788.14,512.29,,,,,,,,,,,,,
PLATE BNE BROAD 4.5X295 MM 18 HOLE SS DCP,SUP-2569182,CDM,C1713,HCPCS,0278,RC,,,,both,,,564.73,367.07,,,,,,,,,,,,,
GRAFT DERMAL MESH 3X3 CM FEN + WND MTRX MIRODERM,SUP-2431550,CDM,Q4175,HCPCS,0636,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
SCREW BONE L30MM DIA4MM TIB FEM BLU LCK FOR IM LIMB,SUP-2312231,CDM,C1713,HCPCS,0278,RC,,,,both,,,810.12,526.58,,,,,,,,,,,,,
KIT FIX ACL FEM ABSRB SL INTLOK TRCR FOR 2.7MM BNE TEND BNE,SUP-2249324,CDM,C1713,HCPCS,0278,RC,,,,both,,,1086.44,706.19,,,,,,,,,,,,,
CANNULA ENDOSCP 5MM SHT DIL MINI STP,SUP-2283295,CDM,2720000010,LOCAL,0272,RC,,,,both,,,356.23,231.55,,,,,,,,,,,,,
PIN BNE FIX LNG SHOULDERED CADENCE,SUP-2933705,CDM,C1713,HCPCS,0278,RC,,,,both,,,362.51,235.63,,,,,,,,,,,,,
CATHETER LA 6F 100CM RACAO,SUP-2429772,CDM,C1887,HCPCS,0272,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
COMPONENT FEM M L RT KNEE POST STABILIZING REV PRI STEMLESS,SUP-2364857,CDM,C1776,CPT,0278,RC,,,,both,,,13349.43,8677.13,,,,,,,,,,,,,
HC Preputial Stretching,PX-4505445000,CDM,54450,CPT,0450,RC,,,,both,,,790.00,513.50,,,,,,,,,,,,,
COMPONENT PATELLAR PEGGED SM STD 35 MM KNEE OVL MOD CEM REV,SUP-2253517,CDM,C1776,CPT,0278,RC,,,,both,,,2238.19,1454.82,,,,,,,,,,,,,
TUBE ENDOTRACHEAL LASER 6.5 MM SAFETY,SUP-2225686,CDM,2720000010,LOCAL,0272,RC,,,,both,,,506.33,329.11,,,,,,,,,,,,,
GRAFT VASC EXXCEL SFT L 50 CM DIA 6 MM EPTFE STR STD WALL,SUP-2227644,CDM,L8670,HCPCS,0278,RC,,,,both,,,1758.40,1142.96,,,,,,,,,,,,,
STENT COR 8MM 2.25MM CO ALLY ZOTAROLIMUS ELUT OTW,SUP-2296909,CDM,C1874,HCPCS,0278,RC,,,,both,,,2119.50,1377.67,,,,,,,,,,,,,
GUIDEWIRE VASC ANGLED 180 CM STIFF SHT TAPR AQUATRACK,SUP-2158675,CDM,C1769,HCPCS,0272,RC,,,,both,,,171.44,111.44,,,,,,,,,,,,,
BLADE RTRCTR SCVLLE MRDNG SM MED 2INW X 3 12ND SRRTD TIP UL,SUP-2667621,CDM,2720000010,LOCAL,0272,RC,,,,both,,,324.21,210.74,,,,,,,,,,,,,
BIT DRL MED 3 MM POWEREASE,SUP-2628248,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1248.40,811.46,,,,,,,,,,,,,
ACEBUTOLOL HCL 200 MG PO CAPS,RX-8939,CDM,6370000000,HCPCS,0637,RC,50268-0050-11,NDC,,both,1,UN,6.70,4.35,,,,,,,,,,,,,
BOLT SPNL 6X17.5 MM ALIF FIX MODULUS,SUP-2736299,CDM,C1713,HCPCS,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
SHEATH INTRO PINNACLE R/O II L 25 CM DIA 6 FR DIL PROTRUDING,SUP-2385641,CDM,C1894,HCPCS,0272,RC,,,,both,,,116.18,75.52,,,,,,,,,,,,,
TUBE VENT SHEEHY 1.27 MM 1.5 MM CLLR BUTTON SIL STRL 510132,SUP-2535100,CDM,L8699,HCPCS,0278,RC,,,,both,,,29.39,19.10,,,,,,,,,,,,,
GRAFT BONE L15CM FIBULAR SHFT FRZ DRY IMP,SUP-2113901,CDM,C1713,HCPCS,0278,RC,,,,both,,,2232.54,1451.15,,,,,,,,,,,,,
STENT CORONARY MULTLNK TRI L 28 MM DIA 3.5 MM GUIDE CATH,SUP-2101466,CDM,C1876,HCPCS,0278,RC,,,,both,,,6754.14,4390.19,,,,,,,,,,,,,
ELECTRODE ELECSURG PLUNG CLIP-ON DISP,SUP-2523883,CDM,2720000010,LOCAL,0272,RC,,,,both,,,745.75,484.74,,,,,,,,,,,,,
SHEATH INTRO PRELUDE PRO L 11 CM DIA 4 FR POLYPRO RED,SUP-2303250,CDM,C1894,HCPCS,0272,RC,,,,both,,,26.38,17.15,,,,,,,,,,,,,
GRAFT VASC RESTOREFLOW SZ 40-49 CM SAPH VEIN BLD TYP A B AB,SUP-2884061,CDM,C1768,CPT,0278,RC,,,,both,,,29983.86,19489.51,,,,,,,,,,,,,
HC Blood Patch,PX-4506227300,CDM,62273,CPT,0450,RC,,,,both,,,1586.00,1030.90,,,,,,,,,,,,,
CATHETER EMB 4FR 0.50ML L40CM BLLN DIA9MM 0.025IN S STL BA,SUP-2214016,CDM,C1757,HCPCS,0272,RC,,,,both,,,421.07,273.70,,,,,,,,,,,,,
SCREW BONE 35MM 4MM DIA SLEEVE HOLDING,SUP-2720253,CDM,C1713,HCPCS,0278,RC,,,,both,,,1200.55,780.36,,,,,,,,,,,,,
GRAFT VASC GORTX L 40 CM DIA 6-8 MM EPTFE TAPR TW N RING,SUP-2396729,CDM,C1768,CPT,0278,RC,,,,both,,,1359.62,883.75,,,,,,,,,,,,,
EXTERNAL FIXATION KIT MOTN ELBW,SUP-2645942,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4599.32,2989.56,,,,,,,,,,,,,
GUIDE SURG LT RVS SHLDR AUGMENTED COMPHSVE,SUP-2613651,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
HC Glb Remove Brain Cavity Fluid,PX-9826102000,CDM,61020,CPT,0982,RC,,,,both,,,3180.00,2067.00,,,,,,,,,,,,,
COMPONENT FEM SZ 4 NAR LT POST STBL CEM GMK,SUP-2267604,CDM,C1776,CPT,0278,RC,,,,both,,,8438.75,5485.19,,,,,,,,,,,,,
SUPPORT ORTHOT HIP JT LOWER EXTREMITY PELV CTRL FREE,SUP-2435682,CDM,L2600,HCPCS,0274,RC,,,,both,,,603.82,392.48,,,,,,,,,,,,,
SPACER SPNL H10XL10MM 8DEG M PEEK THORLUM INTBDY FUS LORD,SUP-2285328,CDM,C1821,HCPCS,0278,RC,,,,both,,,7457.50,4847.37,,,,,,,,,,,,,
ELECTRODE NDL CANN L15CM ARRY 3CM OPN AND PERC RF M001262220,SUP-2149341,CDM,C1713,HCPCS,0278,RC,,,,both,,,5918.90,3847.28,,,,,,,,,,,,,
PACEMAKER CARD ALTURA 60 TI 2 CHMBR 1 LD BATTERY PWR EXT,SUP-2149110,CDM,C1786,HCPCS,0275,RC,,,,both,,,15700.00,10205.00,,,,,,,,,,,,,
IMPLANT FACE L 45 X H 47 MM PROJCT 5 MM MED POLYETHYL CHIN,SUP-2883660,CDM,C1713,HCPCS,0278,RC,,,,both,,,1560.39,1014.25,,,,,,,,,,,,,
HC Assay of Osmolality Blood,PX-3018393000,CDM,83930,CPT,0301,RC,,,,both,,,216.00,140.40,,,,,,,,,,,,,
SHEATH URO L16CM OD16FR RENAL OPQ FOR NEPHSTMY TRACT AMPLTZ,SUP-2171312,CDM,C1894,HCPCS,0272,RC,,,,both,,,102.49,66.62,,,,,,,,,,,,,
CONFORMER OPHTH L W22XL25MM BILAT CLR VENT ACRYL CUP,SUP-2366503,CDM,L8610,HCPCS,0278,RC,,,,both,,,184.82,120.13,,,,,,,,,,,,,
BISOPROLOL-HYDROCHLOROTHIAZIDE 10-6.25 MG PO TABS,RX-18289,CDM,6370000000,HCPCS,0637,RC,42799-0922-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PLATE BNE 7 X 5 H CRANIOMAXILLOFACIAL REG DISTRCTN NS,SUP-2883330,CDM,C1713,HCPCS,0278,RC,,,,both,,,6458.67,4198.14,,,,,,,,,,,,,
PLATE BNE L 62 MM SCREW DIA2.7 MM 8 SHFT H TI STR COMPACT NS,SUP-2927308,CDM,C1713,HCPCS,0278,RC,,,,both,,,4788.91,3112.79,,,,,,,,,,,,,
WIRE FIX DIA1.6MM K,SUP-2267995,CDM,C1713,HCPCS,0278,RC,,,,both,,,67.82,44.08,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9% INTERMITTENT INFUSION,RX-40840102,CDM,J7050,HCPCS,0258,RC,00264-7800-20,NDC,,both,250,ML,23.40,15.21,,,,,,,,,,,,,
TRAY HAD 13FR L15CM 3 LUMN CATH SHT TERM CRV EXTN LEG,SUP-2125601,CDM,C1752,HCPCS,0278,RC,,,,both,,,996.13,647.48,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY LASSOSTAR NAV LOOP DIA25 MM SZ,SUP-2882598,CDM,C1730,HCPCS,0272,RC,,,,both,,,3541.92,2302.25,,,,,,,,,,,,,
ROD SPNL L600MM DIA3-5.5MM RT POST THORLUM TI ALLOY SMOOTH,SUP-2254422,CDM,C1713,HCPCS,0278,RC,,,,both,,,2681.56,1743.01,,,,,,,,,,,,,
ROD TOP LD 20-25 OFFSET SPC 5.5MM,SUP-2205149,CDM,C1713,HCPCS,0278,RC,,,,both,,,2590.50,1683.82,,,,,,,,,,,,,
HC Labor and Delivery Epidural,PX-3700000025,CDM,3700000025,LOCAL,0370,RC,,,,outpatient,,,641.00,416.65,,,,,,,,,,,,,
DIS HUM POSTLAT LT 25HOLE 250MM,SUP-2477945,CDM,C1713,HCPCS,0278,RC,,,,both,,,5422.78,3524.81,,,,,,,,,,,,,
GRAFT TISS FRZN ALLGRFT PELVIS HEMI STRUCTURAL L,SUP-2307413,CDM,C1713,HCPCS,0278,RC,,,,both,,,26063.13,16941.03,,,,,,,,,,,,,
CATHETER CHOLGM 5.5FR L200CM L100CM MTL CANN TIP STYL REUSE,SUP-2169156,CDM,C1725,HCPCS,0272,RC,,,,both,,,141.30,91.84,,,,,,,,,,,,,
GRAFT VASC RESTOREFLOW SZ 85 CM SAPH VEIN BLD TYP A B AB O,SUP-2884022,CDM,C1768,CPT,0278,RC,,,,both,,,43077.66,28000.48,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP KIT ACL DISP,SUP-2608756,CDM,C1769,HCPCS,0272,RC,,,,both,,,1072.62,697.20,,,,,,,,,,,,,
PLATE BNE STR 63X0.6 MM NEURO 16 HOLE TI STRL LEVEL 1,SUP-2486933,CDM,C1713,HCPCS,0278,RC,,,,both,,,909.85,591.40,,,,,,,,,,,,,
PLATE SPNL 1 LEVEL 26 MM ANTR CERV NEO-SL,SUP-2430718,CDM,C1713,HCPCS,0278,RC,,,,both,,,6217.20,4041.18,,,,,,,,,,,,,
PIN BNE FIX L3IN KNEE SMOOTH,SUP-2252734,CDM,C1713,HCPCS,0278,RC,,,,both,,,457.18,297.17,,,,,,,,,,,,,
GUIDEWIRE VASC VSI L 40 CM DIA 0.018 IN NIT MANDREL TUNGSTEN,SUP-2606006,CDM,C1769,HCPCS,0272,RC,,,,both,,,60.29,39.19,,,,,,,,,,,,,
COUNTERSINK SURG HDLSS 4 MM MINI-MONSTER,SUP-2320972,CDM,2720000010,LOCAL,0272,RC,,,,both,,,428.61,278.60,,,,,,,,,,,,,
HC So Myelin Basic Protein,PX-3018387366,CDM,83873,CPT,0301,RC,,,,outpatient,,,992.00,644.80,,,,,,,,,,,,,
SCREW BNE MULT DIR 2.7X28 MM STRL DVR,SUP-2606227,CDM,C1713,HCPCS,0278,RC,,,,both,,,500.83,325.54,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9% INTERMITTENT INFUSION,RX-40840102,CDM,2580000003,HCPCS,0258,RC,00338-0049-11,NDC,,both,250,ML,123.30,80.14,,,,,,,,,,,,,
GUIDEWIRE VASC L 80 CM DIA 0.038 IN TAPR L 9 CM FLPY TIP L 4,SUP-2638705,CDM,C1769,HCPCS,0272,RC,,,,both,,,34.35,22.33,,,,,,,,,,,,,
CATHETER DRNGE 12FR UNIV NIT LOK PGTL NAVARRE,SUP-2128419,CDM,C1729,HCPCS,0272,RC,,,,both,,,266.90,173.48,,,,,,,,,,,,,
NEEDLE EPI 22GA L2IN N STIMULATING ULTRAPLEX,SUP-2125036,CDM,C1713,HCPCS,0278,RC,,,,both,,,30.77,20.00,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9% INTERMITTENT INFUSION,RX-40840102,CDM,2580000003,HCPCS,0258,RC,00264-1800-32,NDC,,both,250,ML,57.40,37.31,,,,,,,,,,,,,
INSERT TIB 3 H8MM POLYETH ANK INFIN,SUP-2397294,CDM,C1776,CPT,0278,RC,,,,both,,,4898.40,3183.96,,,,,,,,,,,,,
PLATE BNE SCREW DIA2 MM TI MANDIBULAR PRIMARY RECON HEMI,SUP-2883261,CDM,C1713,HCPCS,0278,RC,,,,both,,,28778.10,18705.76,,,,,,,,,,,,,
HC So Vma,PX-3018458566,CDM,84585,CPT,0301,RC,,,,both,,,64.00,41.60,,,,,,,,,,,,,
INSERT LOK OD3MM S STL KNEE SM FRAG AXSOS,SUP-2371463,CDM,C1776,CPT,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
TI LCP DISTAL FEMUR PLATE 5 HOLES/156MM/LEFT-STERILE,SUP-2549448,CDM,C1713,HCPCS,0278,RC,,,,both,,,5169.54,3360.20,,,,,,,,,,,,,
NEEDLE 60DEG SLDE STR,SUP-2366706,CDM,C1713,HCPCS,0278,RC,,,,both,,,880.61,572.40,,,,,,,,,,,,,
DISSECTOR GLIDEPATH SYS FOR OPN CHST LUMITIP,SUP-2124451,CDM,C1713,HCPCS,0278,RC,,,,both,,,4185.62,2720.65,,,,,,,,,,,,,
PLATE BNE W7.5XL43MM THK1.6MM 5X3 H L DST VOLAR RAD S STL,SUP-2186106,CDM,C1713,HCPCS,0278,RC,,,,both,,,2293.96,1491.07,,,,,,,,,,,,,
HEAD HUM H27MM OD44MM 4MM OFFSET CO CHROM SHLDR PRI TOT,SUP-2404662,CDM,C1776,CPT,0278,RC,,,,both,,,4976.90,3234.98,,,,,,,,,,,,,
STEM FEM 135 NK 15X225 MM REV ANGLED,SUP-2204638,CDM,C1776,CPT,0278,RC,,,,both,,,24391.52,15854.49,,,,,,,,,,,,,
COMPONENT ARTC 2X3MM OFFSET PATELLOFEMORAL HEMICAP,SUP-2123657,CDM,C1776,CPT,0278,RC,,,,both,,,17411.30,11317.34,,,,,,,,,,,,,
DRILL TWST L 58 MM DIA1.5 MM STP 20 MM DENT SHFT NS DISP,SUP-2883284,CDM,2720000010,LOCAL,0272,RC,,,,both,,,398.47,259.01,,,,,,,,,,,,,
PACK PIP FUS ID2.7X4MM PROX MID PHALANX IMPL PEEK HAT-TRICK,SUP-2349219,CDM,C1713,HCPCS,0278,RC,,,,both,,,4995.11,3246.82,,,,,,,,,,,,,
SCREW SPNL L40MM OD5.5MM CO CHROM VAR ANG CANN MULTIAXIAL,SUP-2285899,CDM,C1713,HCPCS,0278,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
PLATE BNE L 55 MM SCREW DIA2.7 MM 7 SHFT H SS COMPACT STR VA,SUP-2907651,CDM,C1713,HCPCS,0278,RC,,,,both,,,3193.13,2075.53,,,,,,,,,,,,,
MICROCATHETER GUID CORSAIR ARMET L 60 CM SHFT OD,SUP-2480207,CDM,C1887,HCPCS,0272,RC,,,,both,,,2119.50,1377.67,,,,,,,,,,,,,
KIT SPNL ROD PT SPEC PROC CDH UNID,SUP-2926400,CDM,C1713,HCPCS,0278,RC,,,,both,,,5632.38,3661.05,,,,,,,,,,,,,
STAPLE FIX W9XH7-7MM WIRE W1.2XL1.2MM BARB OSSTPL BOSS,SUP-2190856,CDM,C1713,HCPCS,0278,RC,,,,both,,,1036.20,673.53,,,,,,,,,,,,,
SET ORTH INSTR DISP IDUO,SUP-2904896,CDM,2720000010,LOCAL,0272,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
INSERT TIB SZ 6 THK10MM RT KNEE CRUC SUB UHMWPE PRI FIX,SUP-2304586,CDM,C1776,CPT,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
PLATE BNE L193MM 10 H S STL LOK COMPR FOR 4.5MM SCR,SUP-2348943,CDM,C1713,HCPCS,0278,RC,,,,both,,,5695.65,3702.17,,,,,,,,,,,,,
CATHETER PICC AD 5FR L55CM GWIRE L135CM SGL LUMN BASIC KT,SUP-2125528,CDM,C1894,HCPCS,0272,RC,,,,both,,,293.02,190.46,,,,,,,,,,,,,
CONNECTOR SPNL THORLUM THRD POLYAX FOR 5.5MM ROD TULIP CREO,SUP-2228674,CDM,C1713,HCPCS,0278,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
RESTRICTOR CEMENT 12/13 MM PFC,SUP-2253283,CDM,C1713,HCPCS,0278,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
PLATE BONE LOK DUAL CMPRSSN 209MML HLX16 STNLSS STEEL CNTRD,SUP-2588609,CDM,C1713,HCPCS,0278,RC,,,,both,,,1744.27,1133.78,,,,,,,,,,,,,
GRAFT HUM TISS W8-17XH10-17XL14-20MM THK7MM IL CREST,SUP-2307137,CDM,C1762,CPT,0278,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
GUIDEWIRE VASC CENTURION L 60 CM DIA 0.032 IN TIP L 3 MM J,SUP-2764052,CDM,C1769,HCPCS,0272,RC,,,,both,,,47.29,30.74,,,,,,,,,,,,,
GRAFT DERM ULT THN ACELLULAR DERM IMP L2XW1CM THICKNESS .2,SUP-2307504,CDM,Q4128,HCPCS,0636,RC,,,,both,,,356.26,231.57,,,,,,,,,,,,,
MODULAR NAIL 9.0MMX44CM,SUP-2828713,CDM,C1713,HCPCS,0278,RC,,,,both,,,8101.20,5265.78,,,,,,,,,,,,,
PLATE BNE CALCANEOCUBOID SM LT STRATUM,SUP-2656714,CDM,C1713,HCPCS,0278,RC,,,,both,,,4599.03,2989.37,,,,,,,,,,,,,
ABRASOR DIAMOND COARSE 265MM X 3.5MM X 4.4MM BALL TIP JOIMAX,SUP-2848825,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1868.30,1214.39,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL PEEK SD800.506,SUP-2860188,CDM,C1713,HCPCS,0278,RC,,,,both,,,25855.07,16805.80,,,,,,,,,,,,,
PLATE LCK FOR STRNL APPRX WOLVEK,SUP-2383724,CDM,C1713,HCPCS,0278,RC,,,,both,,,175.90,114.33,,,,,,,,,,,,,
HC CT Ablation Bone,PX-3612098200,CDM,20982,CPT,0361,RC,,,,both,,,7342.00,4772.30,,,,,,,,,,,,,
SHEATH URET PROXIS L 45 CM OD 14 FR ID 12 FR ACCS SHRT DIL,SUP-2655867,CDM,C1894,HCPCS,0272,RC,,,,both,,,846.14,549.99,,,,,,,,,,,,,
CATHETER CV SET 018 4 FRX12 CM DL J TIP POLYURETHANE,SUP-2759958,CDM,C1751,HCPCS,0278,RC,,,,both,,,233.84,152.00,,,,,,,,,,,,,
CEMENT FLX FEM/CEM TIB/STD SURF/NO PT/TP PL,SUP-2212161,CDM,C1776,CPT,0278,RC,,,,both,,,13439.67,8735.79,,,,,,,,,,,,,
KIT INTRO GLIDESHEATH SLENDER L 10 CM DIA 5FR 0.021IN PLAS,SUP-2385463,CDM,C1894,HCPCS,0272,RC,,,,both,,,372.88,242.37,,,,,,,,,,,,,
PUMP CNTRFUG CONN SZ 3/8 IN BIOLINE COAT FLOWPR STRL DISP,SUP-2908663,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1147.36,745.78,,,,,,,,,,,,,
CONNECTOR CSF STR 1X2 MM RADIOPAQUE POLYPR STRL,SUP-2851297,CDM,C1889,HCPCS,0278,RC,,,,both,,,1242.75,807.79,,,,,,,,,,,,,
CATHETER GUID DIA 7 FR AL1 STRL,SUP-2154503,CDM,C1769,HCPCS,0272,RC,,,,both,,,144.44,93.89,,,,,,,,,,,,,
AGENT HEMSTAT 5ML BOV DERIVD GEL MTRX THROM COMP W NDL FREE,SUP-2130316,CDM,2720000010,LOCAL,0272,RC,,,,both,,,580.81,377.53,,,,,,,,,,,,,
NEEDLE BX 18GA L15CM ASAP DELT CUT,SUP-2141132,CDM,2720000010,LOCAL,0272,RC,,,,both,,,138.16,89.80,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 8X3 CM CRYOPRESERVED AMNIOX CLARIX CRD 1K,SUP-2648675,CDM,Q4148,HCPCS,0636,RC,,,,both,,,8478.00,5510.70,,,,,,,,,,,,,
GRAFT VASC GORTX L 45 CM DIA 4-7 MM RNG L 15 CM EPTFE TAPR,SUP-2396106,CDM,C1768,CPT,0278,RC,,,,both,,,2103.80,1367.47,,,,,,,,,,,,,
ANCHOR SUT SFT TISS NO 2 POLY SUT ABSRB GLEN 3MM DIA,SUP-2366663,CDM,C1713,HCPCS,0278,RC,,,,both,,,491.72,319.62,,,,,,,,,,,,,
RESERVOIR CSF RICKHAM STYL LG,SUP-2852578,CDM,C1889,HCPCS,0278,RC,,,,both,,,939.36,610.58,,,,,,,,,,,,,
TUBING SET INFL EXP ACCULIF TL ST,SUP-2381475,CDM,2720000010,LOCAL,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
KIT EMB LAVA 6 ML FOR MIXING W/ DMSO MANIFOLD STRL,SUP-2899724,CDM,2720000010,LOCAL,0272,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
STENT PERIPH L25MM DIA7MM CATH L120CM 0.018IN FEM IL ART,SUP-2396630,CDM,C1874,HCPCS,0278,RC,,,,both,,,9011.80,5857.67,,,,,,,,,,,,,
PLATE BNE L285MM 12 H R PROX PERIPROSTHETIC FEM TI NCB,SUP-2411490,CDM,C1713,HCPCS,0278,RC,,,,both,,,4098.39,2663.95,,,,,,,,,,,,,
PLATE BNE L211MM 6 H ST L PROX FEM S STL LO PROF LOK COMPR,SUP-2186042,CDM,C1713,HCPCS,0278,RC,,,,both,,,4254.92,2765.70,,,,,,,,,,,,,
SPHERE GLEN TI ECCENTER DSGN SHLDR EPOCA,SUP-2193867,CDM,C1776,CPT,0278,RC,,,,both,,,1868.36,1214.43,,,,,,,,,,,,,
GRAFT BIO TISS W8XL12CM SLD FET BOV ACELLULAR DERM MTRX,SUP-2243687,CDM,C1781,HCPCS,0278,RC,,,,both,,,9043.20,5878.08,,,,,,,,,,,,,
BLADE SAW L 73 X W 5 MM L 10 MM NAR RASP SM RECIP FOR GB130R,SUP-2929229,CDM,2720000010,LOCAL,0272,RC,,,,both,,,572.39,372.05,,,,,,,,,,,,,
GUIDEWIRE VASC ANGLED 35 DEG 1 CM 018X180 25 CM GLIDEWIRE,SUP-2851656,CDM,C1769,HCPCS,0272,RC,,,,both,,,1227.74,798.03,,,,,,,,,,,,,
STAPLE INT L15XW12MM S STL COMPR INTERAXIS NONSTERILE IMPL,SUP-2243121,CDM,C1713,HCPCS,0278,RC,,,,both,,,2983.57,1939.32,,,,,,,,,,,,,
LAMIVUDINE 10 MG/ML PO SOLN,RX-15881,CDM,6370000000,HCPCS,0637,RC,99999-9917-70,NDC,,both,15,ML,23.40,15.21,,,,,,,,,,,,,
VALVE TRACH WHT SPEAK VENT PASSY MUIR,SUP-2322021,CDM,L8501,HCPCS,0272,RC,,,,both,,,231.10,150.21,,,,,,,,,,,,,
CUP ACET OD48MM ID42MM HIP CO CHROM HA POR PRI CEMENTLESS,SUP-2350844,CDM,C1776,CPT,0278,RC,,,,both,,,15562.63,10115.71,,,,,,,,,,,,,
MATRIX BIO L 4 X W 4 CM BOV CLLGN CHONDROITIN-6-SULFATE,SUP-2909248,CDM,Q4105,HCPCS,0636,RC,,,,both,,,3968.90,2579.78,,,,,,,,,,,,,
PLATE BNE W13.5XL260MM THK4.2MM 14 H BILAT S STL NAR LOK,SUP-2185253,CDM,C1713,HCPCS,0278,RC,,,,both,,,1901.74,1236.13,,,,,,,,,,,,,
BUR SURG OD2 MM RND COARSE DMND F MOTORIZED RHINOSCOPIC,SUP-2363796,CDM,2720000010,LOCAL,0272,RC,,,,both,,,437.65,284.47,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS,SUP-2859965,CDM,C1713,HCPCS,0278,RC,,,,both,,,29662.01,19280.31,,,,,,,,,,,,,
DEVICE ANEUR NK RECON 4MM 10MM Y SHP ARCH PULSERIDER,SUP-2893543,CDM,C1876,HCPCS,0278,RC,,,,both,,,39250.00,25512.50,,,,,,,,,,,,,
SCREW BONE L6MM THRD DIA2MM HD DIA3MM COR DIA1.3MM PITCH,SUP-2349226,CDM,C1713,HCPCS,0278,RC,,,,both,,,193.86,126.01,,,,,,,,,,,,,
PLATE BONE L W13.5XL394MM THK4.2MM 22 H BILAT TI STR RIG,SUP-2190838,CDM,C1713,HCPCS,0278,RC,,,,both,,,2059.78,1338.86,,,,,,,,,,,,,
NAIL IM L75CM OD13MM RT KNEE FUS FAN,SUP-2349054,CDM,C1713,HCPCS,0278,RC,,,,both,,,9241.02,6006.66,,,,,,,,,,,,,
BLADE SURG FOR ADENOTOMES WT540602,SUP-2649905,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1582.81,1028.83,,,,,,,,,,,,,
VALVE AORT ON-X TISS ANNULUS 21 MM ORIFICE 19.4 MM CONFORM-X,SUP-2175255,CDM,C1889,HCPCS,0278,RC,,,,both,,,15696.86,10202.96,,,,,,,,,,,,,
BLOCK I/B II CCK AUG 59X15MM DIST,SUP-2205970,CDM,C1776,CPT,0278,RC,,,,both,,,7051.18,4583.27,,,,,,,,,,,,,
PROSTHESIS OSS CLASSIC STAP 4X1 MM 0.4 MM TI,SUP-2638170,CDM,L8613,CPT,0278,RC,,,,both,,,708.10,460.26,,,,,,,,,,,,,
BIT DRL 2.5 MM W/ MINI-QUICK CONN ALPS,SUP-2606626,CDM,2720000010,LOCAL,0272,RC,,,,both,,,165.29,107.44,,,,,,,,,,,,,
GRAFT BNE FRZN FEM CONDYLE IMPL ALLGRFT L50 TO 70MM,SUP-2264792,CDM,C1713,HCPCS,0278,RC,,,,both,,,8569.06,5569.89,,,,,,,,,,,,,
SCREW BONE L60MM DIA5MM TI CANN PARTIALLY THRD,SUP-2402711,CDM,C1713,HCPCS,0278,RC,,,,both,,,778.72,506.17,,,,,,,,,,,,,
STENT COR 0.014 IN 4.5X20 MM 6 FRX140 CM CVR PK PAPYRUS,SUP-2422138,CDM,C1874,HCPCS,0278,RC,,,,both,,,11398.20,7408.83,,,,,,,,,,,,,
CATHETER VENTRICULAR STYL 35X38 CM SS,SUP-2666713,CDM,C1729,HCPCS,0272,RC,,,,both,,,414.64,269.52,,,,,,,,,,,,,
HEALICOIL KNOTLESS RG ST,SUP-2823680,CDM,C1713,HCPCS,0278,RC,,,,both,,,1605.70,1043.70,,,,,,,,,,,,,
DUAL PKT 36MM ALPHA H PLATE,SUP-2400568,CDM,C1713,HCPCS,0278,RC,,,,both,,,4744.54,3083.95,,,,,,,,,,,,,
MESH HERN OVL 14X12 IN POCKETED BIORESORBABLE PHASIX ST,SUP-2855275,CDM,C1781,HCPCS,0278,RC,,,,both,,,57132.30,37135.99,,,,,,,,,,,,,
STENT BILI MGLNK L 18 MM DIA 6 FR EXP DIA 8 MM SS AD BALLOON,SUP-2103531,CDM,C1877,HCPCS,0278,RC,,,,both,,,2983.00,1938.95,,,,,,,,,,,,,
HC Office/OP Consltj New/Est Pt High Mdm 55 Minutes,PX-5109924500,CDM,99245,CPT,0510,RC,,,,both,,,439.00,285.35,,,,,,,,,,,,,
PLATE BNE L18MM THK03MM 2 H CRANIOMAXILLOFACIAL TI STR WIDE,SUP-2136515,CDM,C1713,HCPCS,0278,RC,,,,both,,,279.46,181.65,,,,,,,,,,,,,
KIT BNE CEM 180GM CART 200MM BRKWY FEM NOZ AND RESTRIC M,SUP-2366880,CDM,C1713,HCPCS,0278,RC,,,,both,,,471.16,306.25,,,,,,,,,,,,,
ISATUXIMAB-IRFC 500 MG/25ML IV SOLN,RX-149832,CDM,J9227,HCPCS,0636,RC,00024-0656-01,NDC,,both,25,ML,12526.90,8142.48,,,,,,,,,,,,,
HC Image Cath Fluid Trns/Vgnl,PX-3614940700,CDM,49407,CPT,0361,RC,,,,outpatient,,,6875.00,4468.75,,,,,,,,,,,,,
STENT GRFT ENDO 7MMX10CMX75CM,SUP-2396481,CDM,C1876,HCPCS,0278,RC,,,,both,,,7693.00,5000.45,,,,,,,,,,,,,
PLATE BNE W11XL298MM THK42MM 18 H MTPHSEAL S STL LOK COMPR,SUP-2185269,CDM,C1713,HCPCS,0278,RC,,,,both,,,3702.91,2406.89,,,,,,,,,,,,,
BLADE SAW L 11 MM D 7 MM THK MATERIAL 0.4 MM CUT 0.5 MM,SUP-2929143,CDM,2720000010,LOCAL,0272,RC,,,,both,,,549.47,357.16,,,,,,,,,,,,,
HC Remote 30 Day Ecg Tech Supp,PX-7319322900,CDM,93229,CPT,0731,RC,,,,outpatient,,,485.00,315.25,,,,,,,,,,,,,
NICOTINE POLACRILEX 4 MG MT LOZG,RX-34770,CDM,6370000000,HCPCS,0637,RC,43598-0487-24,NDC,,both,0.5,UN,3.40,2.21,,,,,,,,,,,,,
HC So2 Drg Scrn Class List A|NOT REASONABLE AND NECESSARY,PX-3018030768,CDM,80307,CPT,0301,RC,,,GZ,both,,,452.00,293.80,,,,,,,,,,,,,
HC Inj Aa&/Strd Greater Occipital Nerve,PX-4506440500,CDM,64405,CPT,0450,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
HC Mech Removal Intracath S&I,PX-3207590200,CDM,75902,CPT,0320,RC,,,,inpatient,,,3098.00,2013.70,,,,,,,,,,,,,
EXTRACTOR STONE L38CM DIA10FR BSKT DIA2CM TIPLSS NIT WIRE S,SUP-2171367,CDM,2720000010,LOCAL,0272,RC,,,,both,,,490.78,319.01,,,,,,,,,,,,,
SCREW BNE L 70 MM DIA 7 MM LG CANN HDLSS STRL,SUP-2931688,CDM,C1713,HCPCS,0278,RC,,,,both,,,957.17,622.16,,,,,,,,,,,,,
STENT BILI EXP L26MM BLLN L30MM DIA7MM SHFT L80CM 0.035IN,SUP-2159253,CDM,C1876,HCPCS,0278,RC,,,,both,,,4050.60,2632.89,,,,,,,,,,,,,
SUPPORT ORTHOT THOR LUMBAR SACR CUST TRIPLANAR CTRL SHELL,SUP-2435546,CDM,L0480,HCPCS,0272,RC,,,,both,,,4276.30,2779.59,,,,,,,,,,,,,
HC So Trb@ Gene Rearrange Amp,PX-3108134066,CDM,81340,CPT,0310,RC,,,,both,,,698.00,453.70,,,,,,,,,,,,,
TUBE TYMPLSTY PED L2MM DIA0.76MM TI VENT MORETZ TAB GRMMT,SUP-2284039,CDM,L8614,HCPCS,0278,RC,,,,both,,,117.12,76.13,,,,,,,,,,,,,
STENT BILI WSTNT L 24 MM DIA10 MM CATH L 155 MM SHTH 6 FR,SUP-2141197,CDM,C1876,HCPCS,0278,RC,,,,both,,,5177.86,3365.61,,,,,,,,,,,,,
ARROW COCR CNTR HUM HD .40 - 15,SUP-2224499,CDM,C1776,CPT,0278,RC,,,,both,,,5966.00,3877.90,,,,,,,,,,,,,
PROBE ABLAT 50DEG ASPIR MULTIPORT BPLR RF 1 PC ELECTRD ERGO,SUP-2123448,CDM,2720000010,LOCAL,0272,RC,,,,both,,,624.86,406.16,,,,,,,,,,,,,
CATHETER BLLN OCCL 2.8/2.5 FRX150 CM 4X7 MM HYPERFORM,SUP-2465947,CDM,C2628,HCPCS,0272,RC,,,,both,,,5630.02,3659.51,,,,,,,,,,,,,
CRANIAL ACCESS KIT 6.35 MM MULTIPLE DRL BITS,SUP-2666730,CDM,2720000010,LOCAL,0272,RC,,,,both,,,845.32,549.46,,,,,,,,,,,,,
SET INTRO PERFRMR L 7 CM OD 5 FR ID 1.7 MM GUIDEWIRE L 30 CM,SUP-2168553,CDM,C1894,HCPCS,0272,RC,,,,both,,,103.46,67.25,,,,,,,,,,,,,
HC Clsd Tx Nasal Bone Fracture,PX-4502131500,CDM,21315,CPT,0450,RC,,,,both,,,1586.00,1030.90,,,,,,,,,,,,,
ELECTRODE ES 6FR L53CM UPLR COAG BALL,SUP-2261253,CDM,2720000010,LOCAL,0272,RC,,,,both,,,590.73,383.97,,,,,,,,,,,,,
ANCHOR SUTURE 6.5MM WITH 3 NO 2 SUTURES HI-FI NEEDLE CROSSFT,SUP-2825119,CDM,C1713,HCPCS,0278,RC,,,,both,,,1545.29,1004.44,,,,,,,,,,,,,
STENT BILI RAPID EXCHANGE 0.035 IN 10X60 MM 8.5 FRX194 CM,SUP-2141242,CDM,C1874,HCPCS,0278,RC,,,,both,,,8132.60,5286.19,,,,,,,,,,,,,
WIRE PACE MYO/WIRE L 61 CM 2-0 CRV 37 MM STR 89 MM SS M-24,SUP-2101193,CDM,2720000010,LOCAL,0272,RC,,,,both,,,39.03,25.37,,,,,,,,,,,,,
VALVE AORT CARBOMEDICS DIA18.5 MM TAD 18.5 MM OH 7.3 MM SZ,SUP-2265216,CDM,C1889,HCPCS,0278,RC,,,,both,,,15904.10,10337.66,,,,,,,,,,,,,
"HC So Enterovirus,Amplified Probe",PX-3068749866,CDM,87498,CPT,0306,RC,,,,both,,,149.00,96.85,,,,,,,,,,,,,
BIT DRL KNOTLESS 4.75 MM LINK ANCHR STRL VENTIX DISP,SUP-2608607,CDM,2720000010,LOCAL,0272,RC,,,,both,,,443.12,288.03,,,,,,,,,,,,,
SCREW BNE LCK 5X30 MM CANN TI NS,SUP-2863427,CDM,C1713,HCPCS,0278,RC,,,,both,,,581.62,378.05,,,,,,,,,,,,,
IBUTILIDE FUMARATE 1 MG/10ML IV SOLN,RX-101486,CDM,J1742,HCPCS,0636,RC,00009-3794-01,NDC,,both,10,ML,695.30,451.94,,,,,,,,,,,,,
GRAFT HUM TISS OPN MED MINI 20X26 MM BIOINDUCTIVE REGENETEN,SUP-2848897,CDM,C1781,HCPCS,0278,RC,,,,both,,,6280.00,4082.00,,,,,,,,,,,,,
SHELL ACET MH 40 MM HIP GRP 0 CUP ALTEON,SUP-2432482,CDM,C1776,CPT,0278,RC,,,,both,,,5659.85,3678.90,,,,,,,,,,,,,
HC Srs Linear Based,PX-3337737200,CDM,77372,CPT,0333,RC,,,,inpatient,,,21769.00,14149.85,,,,,,,,,,,,,
VALVE AORT SZ 27MM STD CUF PERICARD BIOPROSTHESIS IMPL,SUP-2214058,CDM,C1713,HCPCS,0278,RC,,,,both,,,16312.30,10602.99,,,,,,,,,,,,,
STAPLE BNE COMPR 20 MM LG NOTCH STR STRL UNICLIP,SUP-2397150,CDM,C1713,HCPCS,0278,RC,,,,both,,,1533.76,996.94,,,,,,,,,,,,,
CATHETER CTRL VEN 4.2FR 0.3ML L71CM OD1.4MM ID0.7MM SIL SGL,SUP-2127697,CDM,C1751,HCPCS,0278,RC,,,,both,,,1111.94,722.76,,,,,,,,,,,,,
SCREW SPNL L45MM DIA6.5MM CANN SHANK SPHERX PPS,SUP-2311488,CDM,C1713,HCPCS,0278,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
IMPL SUBTALAR SUBFIX 8MM,SUP-2476855,CDM,C1713,HCPCS,0278,RC,,,,both,,,4396.00,2857.40,,,,,,,,,,,,,
SHELL ACET OD76MM TI POR PLSM SPR HIP LIMIT H RAD FIN,SUP-2406532,CDM,C1776,CPT,0278,RC,,,,both,,,4733.55,3076.81,,,,,,,,,,,,,
GRAFT BNE L230MM DIA4MM GRACILIS TEND HAMSTRING FRZN FOR,SUP-2264762,CDM,C1762,CPT,0278,RC,,,,both,,,3634.96,2362.72,,,,,,,,,,,,,
HC Continous Inhale Tx 1st Hour,PX-4109464400,CDM,94644,CPT,0410,RC,,,,inpatient,,,660.00,429.00,,,,,,,,,,,,,
CORD ELECSURG BPLR PWR IRRIGATOR NS LTX,SUP-2859250,CDM,2720000010,LOCAL,0272,RC,,,,both,,,385.47,250.56,,,,,,,,,,,,,
ALLOGRAFT BNE FD ASEP FIBULAR SHFT,SUP-2867016,CDM,C1762,CPT,0278,RC,,,,both,,,3248.49,2111.52,,,,,,,,,,,,,
LEAD NERVE STIM LNG 1.4 MMX60 CM 4 CHANNEL KT LAMITRODE S-4,SUP-2356738,CDM,C1778,HCPCS,0278,RC,,,,both,,,5809.00,3775.85,,,,,,,,,,,,,
CROWN DENT UP LT PRI M S STL REFIL,SUP-2322199,CDM,D6783,CPT,0278,RC,,,,both,,,37.37,24.29,,,,,,,,,,,,,
ALLOGRAFT BNE WHL MAND,SUP-2321827,CDM,C1713,HCPCS,0278,RC,,,,both,,,10399.68,6759.79,,,,,,,,,,,,,
PLATE BNE L44MM MINI 11 H TI T FOR 1.5MM SCR MOD HND SYS,SUP-2191143,CDM,C1713,HCPCS,0278,RC,,,,both,,,1281.65,833.07,,,,,,,,,,,,,
PLATE BNE L MINI 2-2.5X1 MM LT FOR SCR 9 HOLE TLTS LCK TI,SUP-2458650,CDM,C1713,HCPCS,0278,RC,,,,both,,,1009.92,656.45,,,,,,,,,,,,,
STENT URET OPN END 7 FRX24 CM KT TWO DUROMETER SOF-CURL,SUP-2313812,CDM,C2617,HCPCS,0278,RC,,,,both,,,241.78,157.16,,,,,,,,,,,,,
HC So Magnesium,PX-3018373566,CDM,83735,CPT,0301,RC,,,,outpatient,,,58.00,37.70,,,,,,,,,,,,,
ANCHOR SUT 2.2 MM CANNULINK TRUVIEW,SUP-2315892,CDM,C1713,HCPCS,0278,RC,,,,both,,,5243.80,3408.47,,,,,,,,,,,,,
MEDIA TRACER CONTRAST LIQ 1MG MAGTRACE,SUP-2427295,CDM,A4648,CPT,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
BIT DRL DIA2.4MM FOR VERTEX SEL OCCIPITAL RECON SYS,SUP-2289128,CDM,2720000010,LOCAL,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
PLATE SPNL FIX 28 MM 6.35 MM LP FOR ROD SS X10 CROSSLINK,SUP-2289429,CDM,C1713,HCPCS,0278,RC,,,,both,,,2386.40,1551.16,,,,,,,,,,,,,
ALLOGRAFT BNE WDG 15 MM IL CREST,SUP-2867100,CDM,C1762,CPT,0278,RC,,,,both,,,4295.52,2792.09,,,,,,,,,,,,,
PLATE BNE TWST 3 HOLE,SUP-2481591,CDM,C1713,HCPCS,0278,RC,,,,both,,,404.43,262.88,,,,,,,,,,,,,
EVOS 3.5MM LCK 1/3 TUBULAR PL 7H 82MM,SUP-2819632,CDM,C1713,HCPCS,0278,RC,,,,both,,,1599.05,1039.38,,,,,,,,,,,,,
CATHETER CV SET 025 5 FRX15 CM 3L POLYURETHANE,SUP-2759970,CDM,C1751,HCPCS,0278,RC,,,,both,,,240.96,156.62,,,,,,,,,,,,,
BUR SURG 10 FLUT MED 5 MM RND M ATTCH FOR CORE/TPS TOOL STL,SUP-2363426,CDM,2720000010,LOCAL,0272,RC,,,,both,,,274.53,178.44,,,,,,,,,,,,,
ALLOGRAFT DERMAL THCK 4X4 CMX0.8-1.7 MM DEHYDR ALLOPATCH HD,SUP-2489516,CDM,Q4128,HCPCS,0636,RC,,,,both,,,4123.61,2680.35,,,,,,,,,,,,,
PLATE BNE L62MM 6 H ST ULN S STL LOK COMPR FOR 27MM SCR,SUP-2177321,CDM,C1713,HCPCS,0278,RC,,,,both,,,3395.06,2206.79,,,,,,,,,,,,,
PLATE BNE FEM 130 MM LT DSTL LAT 4 HOLE SS NS AXSOS,SUP-2461830,CDM,C1713,HCPCS,0278,RC,,,,both,,,5844.48,3798.91,,,,,,,,,,,,,
TWIST DRILL 3.6MM,SUP-2818386,CDM,2720000010,LOCAL,0272,RC,,,,both,,,743.18,483.07,,,,,,,,,,,,,
PLATE BNE MESH PANEL 1X32X32X0.2 MM SCRN TI NS LEVEL 1,SUP-2468182,CDM,C1713,HCPCS,0278,RC,,,,both,,,735.51,478.08,,,,,,,,,,,,,
BUSPIRONE HCL 5 MG PO TABS,RX-9324,CDM,6370000000,HCPCS,0637,RC,00093-0053-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
CONNECTOR SPNL SCREW RNG,SUP-2316270,CDM,C1713,HCPCS,0278,RC,,,,both,,,172.51,112.13,,,,,,,,,,,,,
PROBE LASER 25GA ILLUMINATED FLX CRV W/ RFID,SUP-2109955,CDM,2720000010,LOCAL,0272,RC,,,,both,,,685.78,445.76,,,,,,,,,,,,,
BUR SURG BALL 3 MMX12 CM SYMMETRI MIDAS REX LEGEND,SUP-2627646,CDM,2720000010,LOCAL,0272,RC,,,,both,,,421.11,273.72,,,,,,,,,,,,,
HEAD FEM DIA50MM CO CHROM POR CEM HEMI RESURF BIRMINGHAM,SUP-2350876,CDM,C1776,CPT,0278,RC,,,,both,,,6311.40,4102.41,,,,,,,,,,,,,
ALLOGRAFT BNE SPNG 20X15X5 MM BLOCK DBM CANC H-GENIN,SUP-2225961,CDM,C1889,HCPCS,0278,RC,,,,both,,,3717.76,2416.54,,,,,,,,,,,,,
ANCHOR SUTURE T KUMAR TRNS FACE,SUP-2330506,CDM,C1713,HCPCS,0278,RC,,,,both,,,199.39,129.60,,,,,,,,,,,,,
BIT DRL DIA 3.1 MM MEDIALIZED MOD STRL DISP INVICTUS,SUP-2886560,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2041.00,1326.65,,,,,,,,,,,,,
BLADE SHV STR STD TYP A 4MM,SUP-2313524,CDM,C1713,HCPCS,0278,RC,,,,both,,,417.97,271.68,,,,,,,,,,,,,
CATHETER THROMCTMY ANGIOJET ULTRA SOLENT PROXI L 90 CM DIA 6,SUP-2142038,CDM,C1757,HCPCS,0272,RC,,,,both,,,13140.90,8541.58,,,,,,,,,,,,,
LNT IMPLANT SYSTEM 2.9 BC PUSHLOCK,SUP-2812050,CDM,C1713,HCPCS,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
GRAFT HUM TISS ACHILLES TEND W/ BONE FRZN,SUP-2165557,CDM,C1713,HCPCS,0278,RC,,,,both,,,4867.00,3163.55,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 50 CM DIA 7MM STR STD WALL SLDE GDS,SUP-2525458,CDM,C1768,CPT,0278,RC,,,,both,,,1511.66,982.58,,,,,,,,,,,,,
MINI PLATE LOK 4 HOLE MED T 6L 4V TTNM ALLOY,SUP-2678306,CDM,C1713,HCPCS,0278,RC,,,,both,,,1024.55,665.96,,,,,,,,,,,,,
PLATE BNE CRV NAR 4.5 MM 16 HOLE SS NS LCP,SUP-2178061,CDM,C1713,HCPCS,0278,RC,,,,both,,,2918.50,1897.02,,,,,,,,,,,,,
DEVICE MENIS CRV IMPL JUGGER STIT DISP,SUP-2421744,CDM,C1713,HCPCS,0278,RC,,,,both,,,934.46,607.40,,,,,,,,,,,,,
SPLINT WRST FA Y L W O FOAM PD ALUMINUM PERF PREMOLDED DSGN,SUP-2195056,CDM,L3908,HCPCS,0274,RC,,,,both,,,13.75,8.94,,,,,,,,,,,,,
SUPPORT ORTHOT CUST OUTRIG,SUP-2435578,CDM,L1080,HCPCS,0274,RC,,,,both,,,148.15,96.30,,,,,,,,,,,,,
ROD 350MM LNG FOR ORTHOFIX PREFIX FIX,SUP-2316293,CDM,2720000010,LOCAL,0272,RC,,,,both,,,610.23,396.65,,,,,,,,,,,,,
STENT PERIPH S.M.A.R.T. CTRL L 150 MM DIA 7 MM DEL SYS L 120,SUP-2158593,CDM,C1876,HCPCS,0278,RC,,,,both,,,4615.80,3000.27,,,,,,,,,,,,,
TUBE TRACH MONTGOMERY 14 MM SAFE T STD CLR,SUP-2140098,CDM,2720000010,LOCAL,0272,RC,,,,both,,,580.90,377.58,,,,,,,,,,,,,
HC Assay of Total Estradiol,PX-3018267000,CDM,82670,CPT,0301,RC,,,,inpatient,,,638.00,414.70,,,,,,,,,,,,,
TRIAL HIP OD45MM 127DEG NK C TAPR SGL PT USE FOR REST HA REV,SUP-2375986,CDM,C1713,HCPCS,0278,RC,,,,both,,,1049.39,682.10,,,,,,,,,,,,,
MALLET 3714104 LUCAE,SUP-2705130,CDM,C1713,HCPCS,0278,RC,,,,both,,,415.33,269.96,,,,,,,,,,,,,
PLATE BNE LO BEND 3.5X135 MM LT MEDL DSTL TIB 6 HOLE LCK TI,SUP-2180904,CDM,C1713,HCPCS,0278,RC,,,,both,,,4111.36,2672.38,,,,,,,,,,,,,
LINER ACET ID28MM HOOD,SUP-2359079,CDM,C1776,CPT,0278,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
PIN FIX TRCR PT 1 END 0.156X9 IN 3 SHANK END SS NS STEINMANN,SUP-2791607,CDM,C1713,HCPCS,0278,RC,,,,both,,,54.76,35.59,,,,,,,,,,,,,
APPLIER CLP CRV MED 14 IN OPN SURG HORZ MTL LIG SYS,SUP-2656767,CDM,2720000010,LOCAL,0272,RC,,,,both,,,342.26,222.47,,,,,,,,,,,,,
TRAY CATH L 24 CM DIA11.5 FR PRIMING ART 1.7 ML VEN 1.8 ML,SUP-2905033,CDM,C1752,HCPCS,0278,RC,,,,both,,,262.19,170.42,,,,,,,,,,,,,
DEVICE CLSR 6FR SUT MEDICATED SYS PERCLOSE AT,SUP-2105647,CDM,C1760,HCPCS,0278,RC,,,,both,,,624.86,406.16,,,,,,,,,,,,,
BRACE ANK SM AD FOR 7-8.5IN UNIV VLY CNTOUR STL STAY CNTCT,SUP-2197932,CDM,L4350,HCPCS,0274,RC,,,,both,,,110.21,71.64,,,,,,,,,,,,,
VALVE HYDROCEPHALUS 35 A WITH SHUNT ASSISTANT PRECHAMBER PRO,SUP-2825833,CDM,C1889,HCPCS,0278,RC,,,,both,,,9078.68,5901.14,,,,,,,,,,,,,
GRAFT DERMAL PLIABLE MED THN 20X11 CMX0.7-1.4 MM KT FLEXHD,SUP-2307615,CDM,Q4128,HCPCS,0636,RC,,,,both,,,37296.92,24243.00,,,,,,,,,,,,,
SNARE ENDOSCP POLYP SM 2.4 MM 195 CM 13 MM 2.8 MM CAPTIVATOR,SUP-2494995,CDM,2720000010,LOCAL,0272,RC,,,,both,,,61.45,39.94,,,,,,,,,,,,,
NAIL IM 11X300MM 125DEG LNG W/ 2MM SET SCR GAM SYS,SUP-2370024,CDM,C1713,HCPCS,0278,RC,,,,both,,,6097.25,3963.21,,,,,,,,,,,,,
HEAD FEM DIA50MM CO CHROM MTL POR HIP CEM FOR DYSPLASIA,SUP-2350857,CDM,C1776,CPT,0278,RC,,,,both,,,10833.00,7041.45,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 10X190 MM ACHILLES TEND,SUP-2866883,CDM,C1762,CPT,0278,RC,,,,both,,,5846.68,3800.34,,,,,,,,,,,,,
SPLINT THUMB WRIST L AD L8IN L D RNG ABD FIRM SUPP W STAY,SUP-2194734,CDM,L3807,HCPCS,0272,RC,,,,both,,,56.52,36.74,,,,,,,,,,,,,
PROBE ARTHSCP HK L5.4MM TIP W/ 5MM MRK,SUP-2120782,CDM,2720000010,LOCAL,0272,RC,,,,both,,,527.52,342.89,,,,,,,,,,,,,
TUBE OPHTH IMPL .305 MM DIAM 25 MM TUBE LEN SIL POLYPR,SUP-2308661,CDM,C1783,HCPCS,0278,RC,,,,both,,,1805.50,1173.57,,,,,,,,,,,,,
SYSTEM VENTRICULAR DRAINAGE W/ HERM VENT CATH SET ACCUDRAIN,SUP-2883383,CDM,C1729,HCPCS,0272,RC,,,,both,,,1025.40,666.51,,,,,,,,,,,,,
SCREW SFTAP HEX 3.5X100MM,SUP-2818585,CDM,C1713,HCPCS,0278,RC,,,,both,,,307.63,199.96,,,,,,,,,,,,,
STENT URET L 24 CM DIA 6 FR TIP L 3 CM STIFF SHFT PTFE,SUP-2522131,CDM,C2617,HCPCS,0278,RC,,,,both,,,410.34,266.72,,,,,,,,,,,,,
PLATE BNE TI TALONAVICULOCUNEIFORM EXT REV NS UNITE,SUP-2897094,CDM,C1713,HCPCS,0278,RC,,,,both,,,5805.86,3773.81,,,,,,,,,,,,,
PLATE BONE DUAL CMPRSSN HLX4 TTNM CNTRD F/2.7MM SCREW UNVRSL,SUP-2494025,CDM,C1713,HCPCS,0278,RC,,,,both,,,765.88,497.82,,,,,,,,,,,,,
ALLOGRAFT BNE BLOCK 14X12X10 MM PARL DENS CANC STERIGRAFT,SUP-2430765,CDM,C1889,HCPCS,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
HC Rfa Renal Tumor(S),PX-3615059200,CDM,50592,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
HC Perq Plmt Bile Duct Stent W/ Bili Cath Plmt,PX-3614754000,CDM,47540,CPT,0361,RC,,,,both,,,8583.00,5578.95,,,,,,,,,,,,,
ARH PARTIAL BLAST STEM 11.0MMX8.0MM,SUP-2841880,CDM,C1713,HCPCS,0278,RC,,,,both,,,4631.50,3010.47,,,,,,,,,,,,,
PRE 20MM 0035 VISIGLIDE 0025 ANG,SUP-2679396,CDM,C1769,HCPCS,0272,RC,,,,both,,,1745.24,1134.41,,,,,,,,,,,,,
GUIDEWIRE ORTH DIA0.053IN THRD W/ TRCR TIP LSR LN FOR,SUP-2122460,CDM,C1769,HCPCS,0272,RC,,,,both,,,47.10,30.61,,,,,,,,,,,,,
INTRODUCER SHTH WORLEY RT SIDE 9FR,SUP-2329879,CDM,C1894,HCPCS,0272,RC,,,,both,,,288.88,187.77,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED CEM TRIATHLON TRIATHLONKNEE] STRYKER CORP],SUP-2366017,CDM,C1776,CPT,0278,RC,,,,both,,,14758.00,9592.70,,,,,,,,,,,,,
PASSER SUT 45DEG RT W/ SM PUNC FOOTPRINT SGL PORTAL PVT,SUP-2366737,CDM,2720000010,LOCAL,0272,RC,,,,both,,,816.40,530.66,,,,,,,,,,,,,
PROBE ARTHSCP SUCT DIA2.5MM AARDVARK,SUP-2367324,CDM,C1713,HCPCS,0278,RC,,,,both,,,622.29,404.49,,,,,,,,,,,,,
CLIP BRAIDED 360 CATHETER RESOLUTION ULTRA – UOM BOX OF 10,SUP-2615605,CDM,2720000010,LOCAL,0272,RC,,,,both,,,772.97,502.43,,,,,,,,,,,,,
SPACER SPNL W11XH25XL14MM 4DEG PEEK ANT CERV INTBDY FUS,SUP-2286343,CDM,C1889,HCPCS,0278,RC,,,,both,,,7536.00,4898.40,,,,,,,,,,,,,
DISPENSER GUIDEWIRE 0.9 MMX6 IN,SUP-2607260,CDM,C1769,HCPCS,0272,RC,,,,both,,,506.89,329.48,,,,,,,,,,,,,
STIMULATOR COCHLEAR BILATERAL AD 1 STG BAHA,SUP-2165011,CDM,L8614,HCPCS,0278,RC,,,,both,,,27035.40,17573.01,,,,,,,,,,,,,
SCREW BNE L 19 MM DIA2 MM XDRV NS DISP LORENZ,SUP-2935133,CDM,C1713,HCPCS,0278,RC,,,,both,,,96.71,62.86,,,,,,,,,,,,,
GRAFT SFT TISS W5XL19.2CM SPNL HUM FRZN FASC LATA,SUP-2113899,CDM,C1762,CPT,0278,RC,,,,both,,,2176.02,1414.41,,,,,,,,,,,,,
CATHETER ANGIOPLSTY ANGIOSCULPT L 155 CM 100 MM 2 MM,SUP-2353226,CDM,C1725,HCPCS,0272,RC,,,,both,,,3972.10,2581.86,,,,,,,,,,,,,
SYSTEM PACEMKR PHILOS SINGLE CHMBR,SUP-2137965,CDM,C1786,HCPCS,0275,RC,,,,both,,,10060.56,6539.36,,,,,,,,,,,,,
SCREW AX MULT 3605535 55 X 35MM,SUP-2285536,CDM,C1713,HCPCS,0278,RC,,,,both,,,2535.55,1648.11,,,,,,,,,,,,,
CATHETER IVL SHOCKWAVE INTRAVACULAR LITHOTRIPSY M5+ 135CM 5.0X60MM,SUP-2850096,CDM,C1725,HCPCS,0272,RC,,,,both,,,108.33,70.41,,,,,,,,,,,,,
PLATE BNE W12XL160MM THK25MM LNG 6 H NONSTERILE BILAT PROX,SUP-2190991,CDM,C1713,HCPCS,0278,RC,,,,both,,,5006.76,3254.39,,,,,,,,,,,,,
LEVOBUNOLOL HCL 0.5 % OP SOLN,RX-10394,CDM,6370000000,HCPCS,0637,RC,24208-0505-05,NDC,,both,5,ML,80.60,52.39,,,,,,,,,,,,,
HC CSF Shunt Reprogram,PX-3606225200,CDM,62252,CPT,0360,RC,,,,both,,,961.00,624.65,,,,,,,,,,,,,
HC Hemoglobin Methemoglobin Quantitative,PX-3018305000,CDM,83050,CPT,0301,RC,,,,inpatient,,,89.00,57.85,,,,,,,,,,,,,
CONNECTOR SPNL IN-LINE 6.5MM TO 6.5MM,SUP-2228082,CDM,C1713,HCPCS,0278,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
DEVICE FIXATION 8MM IMPLANT ARTHROSCOPY BIOABSORBABLE STERIL,SUP-2824301,CDM,C1713,HCPCS,0278,RC,,,,both,,,270.20,175.63,,,,,,,,,,,,,
SYSTEM BLLN DIL L2.4CM OD5MM HI PRSS NONCOMPLIANT ENDOSCP,SUP-2106312,CDM,C1726,HCPCS,0272,RC,,,,both,,,411.34,267.37,,,,,,,,,,,,,
HYLAN G-F 20 48 MG/6ML IX SOSY,RX-125369,CDM,J7325,HCPCS,0636,RC,58468-0090-03,NDC,,both,6,ML,4040.40,2626.26,,,,,,,,,,,,,
SCREW BNE L12MM DIA2.5MM DST RAD VOLAR CO CHROM POLYAX LOK,SUP-2340265,CDM,C1713,HCPCS,0278,RC,,,,both,,,467.08,303.60,,,,,,,,,,,,,
PLATE BONE 6X17 H LT MAND HMSPHR TI RECON LEIBINGER,SUP-2363751,CDM,C1713,HCPCS,0278,RC,,,,both,,,4361.15,2834.75,,,,,,,,,,,,,
SCREW BONE LOCKING 2.4X14 MM MANDIBULAR SELFTAPPING 20/PK TI,SUP-2842339,CDM,C1713,HCPCS,0278,RC,,,,both,,,516.22,335.54,,,,,,,,,,,,,
PIN FIX L9IN DIA4MM ST S STL 3 SIDE SGL TRCR 1 END PNT STYL,SUP-2150452,CDM,C1713,HCPCS,0278,RC,,,,both,,,19.59,12.73,,,,,,,,,,,,,
NEXGEN ROTATING HINGE FULL TIB AGMT BLK 10MM SZ 3,SUP-2502524,CDM,C1776,CPT,0278,RC,,,,both,,,3899.88,2534.92,,,,,,,,,,,,,
HC Custom Hand Static,PX-2740391901,CDM,L3919,HCPCS,0272,RC,,,,both,,,900.00,585.00,,,,,,,,,,,,,
HOUSING EXT FIX SM BNE ASMBLY,SUP-2525824,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
SCREW BNE L30MM DIA5MM CORT CONIC S STL ST CANN LOK FULL,SUP-2184910,CDM,C1713,HCPCS,0278,RC,,,,both,,,678.87,441.27,,,,,,,,,,,,,
GRAFT BNE SUB W18XH3XL47MM ST CHRONOS STRP MX CUT T,SUP-2182835,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3047.06,1980.59,,,,,,,,,,,,,
BIT DRL L 280 MM DIA 4.5 MM COUNTERBORE MANUAL NS DISP,SUP-2902466,CDM,2720000010,LOCAL,0272,RC,,,,both,,,848.30,551.39,,,,,,,,,,,,,
HC Custom Hand Static,PX-2740391901,CDM,L3919,HCPCS,0274,RC,,,,both,,,900.00,585.00,,,,,,,,,,,,,
STEM RAD L22MM OD5MM UNIV TI POR PLSM SPR ANT DST EL STR,SUP-2404376,CDM,C1776,CPT,0278,RC,,,,both,,,4069.75,2645.34,,,,,,,,,,,,,
MESH TIPATCH 2.75 INX4 IN LT,SUP-2402540,CDM,C1781,HCPCS,0278,RC,,,,both,,,894.90,581.68,,,,,,,,,,,,,
GRAFT VASC INTERGARD L 70 CM DIA 6 MM RNG L 20 CM,SUP-2227608,CDM,C1768,CPT,0278,RC,,,,both,,,3244.09,2108.66,,,,,,,,,,,,,
CATHETER GUID VISTA BRT TIP L 55 CM OD 6 FR ID 0.07 IN TIP L,SUP-2158730,CDM,C1887,HCPCS,0272,RC,,,,both,,,444.31,288.80,,,,,,,,,,,,,
IMPLANT ANTIREFLX SZ 13 LAPSCP FUNDIC SPRNG MRI COMPATIBLE,SUP-2219559,CDM,C1889,HCPCS,0278,RC,,,,both,,,19405.20,12613.38,,,,,,,,,,,,,
DIHYDROERGOTAMINE MESYLATE 1 MG/ML IJ SOLN,RX-9859,CDM,J1110,HCPCS,0636,RC,81284-0411-05,NDC,,both,0.5,ML,224.30,145.79,,,,,,,,,,,,,
ULNAR STEM EXT ULN STEMS,SUP-2398597,CDM,C1776,CPT,0278,RC,,,,both,,,1671.58,1086.53,,,,,,,,,,,,,
METACARPAL NAIL 4.6MM / 7.6MMX60MM TI,SUP-2340240,CDM,C1713,HCPCS,0278,RC,,,,both,,,1813.35,1178.68,,,,,,,,,,,,,
PLATE BNE PROX 3.5X232 MM LT TIB 16 HOLE SS NS,SUP-2177844,CDM,C1713,HCPCS,0278,RC,,,,both,,,5315.71,3455.21,,,,,,,,,,,,,
METHYLPREDNISOLONE SODIUM SUCC 1000 MG IJ SOLR (MIXTURES ONLY),RX-430070,CDM,J2919,HCPCS,0636,RC,00009-0698-01,NDC,,both,1,UN,252.90,164.38,,,,,,,,,,,,,
SCREW BONE 1.5X3MM STERILE CROSS DRIVE SELF DRILLING TITANIU,SUP-2821670,CDM,C1713,HCPCS,0278,RC,,,,both,,,57.68,37.49,,,,,,,,,,,,,
GRAFT BIO TISS W15XL25CM PORCINE REGEN TISS MTRX PLIABLE,SUP-2113031,CDM,Q4130,HCPCS,0636,RC,,,,both,,,36053.48,23434.76,,,,,,,,,,,,,
PLATE BNE FUSION LNG 3.5/4 MM MEDL CLMN NS LTX,SUP-2857066,CDM,C1713,HCPCS,0278,RC,,,,both,,,8327.28,5412.73,,,,,,,,,,,,,
DEVICE SUTURE ADH RETENTION RIGID HEMI BRIDGE LAYR,SUP-2881029,CDM,2720000010,LOCAL,0272,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
BLADE RETRACTOR CASPR 60X23 MM CERV BALL SNAP MEDL ULTRA,SUP-2465498,CDM,2720000010,LOCAL,0272,RC,,,,both,,,560.52,364.34,,,,,,,,,,,,,
HC CSF Shunt Reprogram,PX-5106225200,CDM,62252,CPT,0510,RC,,,,both,,,961.00,624.65,,,,,,,,,,,,,
SCREW INTFR L25MM DIA8MM BIOSURE REGENESORB,SUP-2341917,CDM,C1713,HCPCS,0278,RC,,,,both,,,1155.39,751.00,,,,,,,,,,,,,
PLATE BNE MIC THK06MM 8 H R CRANIOMAXILLOFACIAL TI,SUP-2262724,CDM,C1713,HCPCS,0278,RC,,,,both,,,580.37,377.24,,,,,,,,,,,,,
GUIDEWIRE VASC COON L 180 CM DIA 0.038 IN TAPR L 15 CM FLPY,SUP-2167861,CDM,C1769,HCPCS,0272,RC,,,,both,,,67.07,43.60,,,,,,,,,,,,,
GRAFT SFT TISS 50 MG PARTICULATE IN VI TISS MTRX INTERFYL,SUP-2651383,CDM,Q4171,HCPCS,0636,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
SPACER SPNL W12XH8XL14MM FORTITUDE DUO,SUP-2414776,CDM,C1821,HCPCS,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
HC Gliadin Antibody Each Immunoglobulin Class,PX-3028625800,CDM,86258,CPT,0302,RC,,,,both,,,65.00,42.25,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY ADVISOR HD SENSOR ENABLED L 105,SUP-2102267,CDM,C1730,HCPCS,0272,RC,,,,both,,,7083.84,4604.50,,,,,,,,,,,,,
HC Eval Speech Sound Lang Comprhension|OP SPEECH LANGUAGE SERVICE|NOT REASONABLE AND NECESSARY,PX-4449252300,CDM,92523,CPT,0444,RC,,,GN|GZ,both,,,484.00,314.60,,,,,,,,,,,,,
INSERT VNGD 360 OTI TIB SLV SM FULL,SUP-2506506,CDM,C1776,CPT,0278,RC,,,,both,,,5765.04,3747.28,,,,,,,,,,,,,
VALVE CSF MULTPURP HI PRESSURE ON-OFF FLSH ANTISIPH DEV,SUP-2852567,CDM,C1889,HCPCS,0278,RC,,,,both,,,5226.22,3397.04,,,,,,,,,,,,,
CORT BONE SCW 4.5MMX22MM,SUP-2510198,CDM,C1776,CPT,0278,RC,,,,both,,,109.90,71.43,,,,,,,,,,,,,
PLATE BNE SM W11XL137MM THK34MM 10 H BILAT TI RIG NEUT LOK,SUP-2190785,CDM,C1713,HCPCS,0278,RC,,,,both,,,1080.38,702.25,,,,,,,,,,,,,
PLATE BNE L241MM THK3.4MM 18 H BILAT S STL STR LOK COMPR,SUP-2185156,CDM,C1713,HCPCS,0278,RC,,,,both,,,2039.40,1325.61,,,,,,,,,,,,,
GUIDEWIRE VASC LUNDERQUIST L 90 CM DIA 0.035 IN TAPR L 11 CM,SUP-2170672,CDM,C1769,HCPCS,0272,RC,,,,both,,,173.64,112.87,,,,,,,,,,,,,
SCREW SPNL L10MM OD4MM 18DEG VAR ANG N CANN THRD SELF DRL,SUP-2228496,CDM,C1713,HCPCS,0278,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
GRAFT BNE SUB 6MM IL CREST WDG TREAT W PRESERVON,SUP-2264835,CDM,C1713,HCPCS,0278,RC,,,,both,,,1862.68,1210.74,,,,,,,,,,,,,
CLAMP EXT FIX M SELF HLD CLP ON COMB,SUP-2188521,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1548.05,1006.23,,,,,,,,,,,,,
TRAY TIB SZ 2.5F/1.5T CEM OPTETRAK LOGIC,SUP-2220928,CDM,C1776,CPT,0278,RC,,,,both,,,6970.80,4531.02,,,,,,,,,,,,,
LEAD PACEMKR SOLIA S PROMRI L 45 CM DF1 CONN MR CONDITIONAL,SUP-2138279,CDM,C1898,HCPCS,0275,RC,,,,both,,,1161.80,755.17,,,,,,,,,,,,,
PLATE BNE L183MM 11 H ST R DST LAT FIBULAR S STL VAR ANG,SUP-2177734,CDM,C1713,HCPCS,0278,RC,,,,both,,,3198.75,2079.19,,,,,,,,,,,,,
CLAMP EXT FIX MULTIPIN STRL GALAXY FIX GEM LTX,SUP-2875642,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5547.28,3605.73,,,,,,,,,,,,,
SUPPORT ORTHOT CERV THOR LUMBAR SACR CUST MILWAUKEE INIT,SUP-2435568,CDM,L1000,HCPCS,0272,RC,,,,both,,,5740.92,3731.60,,,,,,,,,,,,,
SET URET STENT L 24 CM DIA 4.8 FR CATH 6 FR PTFE GUIDEWIRE,SUP-2139093,CDM,C2617,HCPCS,0278,RC,,,,both,,,406.82,264.43,,,,,,,,,,,,,
SUPPORT ORTHOPEDIC LOWER SPINE ADJUSTABLE VISTA 637 LSO,SUP-2427925,CDM,L0637,HCPCS,0272,RC,,,,both,,,679.12,441.43,,,,,,,,,,,,,
BIT DRL 4X130 MM MIDFOOT FOR 4.0 HD COMPR SCR SS DISP,SUP-2609255,CDM,2720000010,LOCAL,0272,RC,,,,both,,,671.11,436.22,,,,,,,,,,,,,
ANCHOR SUT DIA5.5MM TI W/ ORTHOCORD HEALIX,SUP-2249430,CDM,C1713,HCPCS,0278,RC,,,,both,,,1083.30,704.14,,,,,,,,,,,,,
GRAFT BONE SUB W2.5XL5CM DEMIN BONE MTRX PLF GRFTON,SUP-2281664,CDM,C1713,HCPCS,0278,RC,,,,both,,,4109.48,2671.16,,,,,,,,,,,,,
GRAFT VASC PTCH 7.6X0.8 CMX0.76 MM AORT TAPR END HEMSHLD GLD,SUP-2468641,CDM,C1768,CPT,0278,RC,,,,both,,,359.12,233.43,,,,,,,,,,,,,
STAPLER INT RELD LD UNIT SM DISP,SUP-2787674,CDM,2720000010,LOCAL,0272,RC,,,,both,,,324.33,210.81,,,,,,,,,,,,,
CATHETER SET TWO LUMEN 0.035 IN 12 FRX20 CM YOU-BEND LG BOR,SUP-2627065,CDM,C1752,HCPCS,0278,RC,,,,both,,,230.04,149.53,,,,,,,,,,,,,
HC NM Shuntogram,PX-3417864500,CDM,78645,CPT,0341,RC,,,,both,,,2031.00,1320.15,,,,,,,,,,,,,
NAIL IM FOR PROX FEM FRAC PICCOLO COMP,SUP-2422370,CDM,C1713,HCPCS,0278,RC,,,,both,,,4749.56,3087.21,,,,,,,,,,,,,
PLATE BONE L18MM THK0.8MM 0DEG 2 H CRAN ADPT STR RAP RESRB,SUP-2194070,CDM,C1713,HCPCS,0278,RC,,,,both,,,487.96,317.17,,,,,,,,,,,,,
DEVICE MARROW SHOT SMART,SUP-2707511,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
TROCAR SURG SM FOR 3 MM BLOCK,SUP-2458593,CDM,2720000010,LOCAL,0272,RC,,,,both,,,532.54,346.15,,,,,,,,,,,,,
MATRIX DERM ACELLULAR DERMAMTRX THCK 1.8 4 MMX6X16 CM,SUP-2307010,CDM,C1762,CPT,0278,RC,,,,both,,,16401.95,10661.27,,,,,,,,,,,,,
CATHETER CARD ABLATION EZ STEER L 115 CM 8 FR 4 MM D-F CRV,SUP-2248504,CDM,C1732,HCPCS,0278,RC,,,,both,,,2392.68,1555.24,,,,,,,,,,,,,
PLATE 4.5MM 3.5MM TI LCP METAPHYSEAL 13 HOLES,SUP-2549476,CDM,C1713,HCPCS,0278,RC,,,,both,,,3025.04,1966.28,,,,,,,,,,,,,
FIBER LASER 200 MH HOLM DISP,SUP-2430215,CDM,C1713,HCPCS,0278,RC,,,,both,,,1441.13,936.73,,,,,,,,,,,,,
CONNECTOR SPNL S STL END TO END FOR 6.35/6.35MM ROD ISOLA,SUP-2255713,CDM,C1713,HCPCS,0278,RC,,,,both,,,2593.64,1685.87,,,,,,,,,,,,,
MESH HERN W6XL8IN ELLIPSE W/ ECHO PS POS SYS VENTRALIGHT ST,SUP-2125917,CDM,C1781,HCPCS,0278,RC,,,,both,,,2891.94,1879.76,,,,,,,,,,,,,
MARKER SURG FIDUCIAL 2X1 CM SPACER CLP SFT TISS STRL BIOZORB,SUP-2716280,CDM,A4648,CPT,0278,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
RELOAD STPL H38XL60MM G REG THCK B FORM NAT ARTC ECHELON,SUP-2218990,CDM,2720000010,LOCAL,0272,RC,,,,both,,,401.73,261.12,,,,,,,,,,,,,
NEXGEN TIBIAL WEDGE ATTACHING SCREW,SUP-2503253,CDM,C1776,CPT,0278,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
WALKER L SHT LEG NONSKID,SUP-2276710,CDM,L4387,HCPCS,0272,RC,,,,both,,,83.56,54.31,,,,,,,,,,,,,
SUPPORT ORTH L8IN M NEOPRENE EL CNTCT CLSR STRP D RNG GOLFER,SUP-2196836,CDM,L3702,HCPCS,0274,RC,,,,both,,,20.85,13.55,,,,,,,,,,,,,
ENDPLATE SPNL DISK H6MM 11X12MM FOOTPRINT 6DEG CO CHROM,SUP-2232282,CDM,C1713,HCPCS,0278,RC,,,,both,,,15386.00,10000.90,,,,,,,,,,,,,
CROWN DENT PED NO7 SEC PRI M ANTR UP L CUSPID PREFABRICATED,SUP-2238929,CDM,D6783,CPT,0278,RC,,,,both,,,19.15,12.45,,,,,,,,,,,,,
BIT DRL 2MM SPNL,SUP-2400583,CDM,2720000010,LOCAL,0272,RC,,,,both,,,320.28,208.18,,,,,,,,,,,,,
PLATE BONE 10 H STR FOR 2MM SCR CRANIOMAXILLOFACIAL FX,SUP-2319363,CDM,C1713,HCPCS,0278,RC,,,,both,,,744.18,483.72,,,,,,,,,,,,,
LEAD DEFIB PERM VENT LD PACE BPLR PASS FIX IS 1 CONN 52CM,SUP-2356656,CDM,C1898,HCPCS,0275,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
PIN EXT FIX CIR HALF S STL RANCHO SYS 5 DIAM 25 THRD LEN,SUP-2342569,CDM,C1713,HCPCS,0278,RC,,,,both,,,1142.18,742.42,,,,,,,,,,,,,
AIRWAY LARYN MASK DISP UNIQUE + SZ 5 W/ SYR AND LUB,SUP-2384091,CDM,C1713,HCPCS,0278,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
ANCHOR SUT CRV FOR MENIS REP SYS ULT FAST-FIX,SUP-2341774,CDM,C1713,HCPCS,0278,RC,,,,both,,,1035.26,672.92,,,,,,,,,,,,,
HC Aspiration of Bladder,PX-3615110100,CDM,51101,CPT,0361,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
PROSTHESIS OSS L3.75MM SHFT OD0.5MM PLAT STAP FLROPLAS PIST,SUP-2419763,CDM,L8613,CPT,0278,RC,,,,both,,,592.80,385.32,,,,,,,,,,,,,
PROBE US AD DIA3/8IN STD FLAT PNCL,SUP-2321984,CDM,2720000010,LOCAL,0272,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
SCREW PERIIPR VA LCK OPTILINK 5.0X10MM,SUP-2720093,CDM,C1713,HCPCS,0278,RC,,,,both,,,813.98,529.09,,,,,,,,,,,,,
PROBE ELECSURG THERM MOD VULCAN,SUP-2848571,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1211.98,787.79,,,,,,,,,,,,,
KIT ARTHSCP MINI W/ INSRTR FOR HALLUX VALGUS MINI TIGHTROPE,SUP-2122786,CDM,C1713,HCPCS,0278,RC,,,,both,,,1899.70,1234.80,,,,,,,,,,,,,
IMPLANT METATRSL SHORTNG SLOT 4.2 NS,SUP-2899074,CDM,C1713,HCPCS,0278,RC,,,,both,,,1874.58,1218.48,,,,,,,,,,,,,
PLATE BNE THK 1 MM ADV 8 MM SCREW DIA2 MM MINI RT,SUP-2883140,CDM,C1713,HCPCS,0278,RC,,,,both,,,1896.65,1232.82,,,,,,,,,,,,,
SCREW BONE L115MM DIA4.5MM CORT TI N ST N SELF DRL,SUP-2190371,CDM,C1713,HCPCS,0278,RC,,,,both,,,90.12,58.58,,,,,,,,,,,,,
POLY-VI-SOL PO SOLN,RX-6374,CDM,340b,HCPCS,0637,RC,09999-9904-68,NDC,,both,1,ML,2.70,1.75,,,,,,,,,,,,,
GRAFT BNE SUB 2.5ML HA SYN TISS CLLGN MTRX STRP RESRB,SUP-2255625,CDM,C9362,HCPCS,0278,RC,,,,both,,,887.05,576.58,,,,,,,,,,,,,
PLATE BONE L97X47MM 5X13 H LT MAND ORAL MAXILLOFACIAL TI ANG,SUP-2191467,CDM,C1713,HCPCS,0278,RC,,,,both,,,5475.22,3558.89,,,,,,,,,,,,,
"HC Culture,Fungus Other",PX-3008710200,CDM,87102,CPT,0300,RC,,,,both,,,247.00,160.55,,,,,,,,,,,,,
BIT DRL L200MM DIA2.8MM CALIB L100MM FOR 3.5MM VA LCP PROX,SUP-2187853,CDM,2720000010,LOCAL,0272,RC,,,,both,,,476.56,309.76,,,,,,,,,,,,,
SUTURE ANCHOR CROSSFT KNOTLESS 4.0MM WITH WHITE BLACK HI-FI,SUP-2824386,CDM,C1713,HCPCS,0278,RC,,,,both,,,2116.67,1375.84,,,,,,,,,,,,,
PLATE BNE L194MM 8 H ST R DST HUM EXTRA ARTC S STL LOK,SUP-2177169,CDM,C1713,HCPCS,0278,RC,,,,both,,,4352.57,2829.17,,,,,,,,,,,,,
SCREW BNE CANN TI FIX 40MMX46MM TI6,SUP-2244446,CDM,C1713,HCPCS,0278,RC,,,,both,,,1124.34,730.82,,,,,,,,,,,,,
SHEATH URET ACCS 10.7 FRX20 CM DIL FLX PARL RAPID RELEASE,SUP-2835981,CDM,C1894,HCPCS,0272,RC,,,,both,,,431.06,280.19,,,,,,,,,,,,,
TREPHINE OPHTHALMIC TERRY 7.5MM W/GUARD LATEX FREE,SUP-2473112,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1369.51,890.18,,,,,,,,,,,,,
PLATE BONE L309MM 16 H LT LAT PROX TIB S STL LCK FOR 4.5MM,SUP-2348226,CDM,C1713,HCPCS,0278,RC,,,,both,,,15594.50,10136.42,,,,,,,,,,,,,
SCREW SET REPL,SUP-2610317,CDM,C1713,HCPCS,0278,RC,,,,both,,,736.61,478.80,,,,,,,,,,,,,
SUPPORT FACE L FOR 27IN EAR CHEEK CHIN E FOR FACIOPLASTY,SUP-2151622,CDM,L0150,HCPCS,0274,RC,,,,both,,,61.80,40.17,,,,,,,,,,,,,
CLAMP AD STR CTRL FOR LIMB RECON SYS,SUP-2316076,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2070.14,1345.59,,,,,,,,,,,,,
NAIL IM L260MM DIA8MM R PROX HUM TI CANN LOK BEND T2,SUP-2369271,CDM,C1713,HCPCS,0278,RC,,,,both,,,5102.50,3316.62,,,,,,,,,,,,,
GUIDEWIRE ORTH L150MM DIA1.6MM TIB DRL TIP LOK COMPR,SUP-2194143,CDM,C1769,HCPCS,0272,RC,,,,both,,,105.47,68.56,,,,,,,,,,,,,
INTRODUCER PACE LD APEEL 115 DEG L 47 CM DIA 8 FR CORONARY,SUP-2357276,CDM,C1894,HCPCS,0272,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
HC C-Spine 2-3 Views,PX-3207204000,CDM,72040,CPT,0320,RC,,,,both,,,530.00,344.50,,,,,,,,,,,,,
CATHETER THROMCTMY ANGIOJET ULTRA AVX L 50 CM DIA 6 FR SHTH,SUP-2142030,CDM,C1757,HCPCS,0272,RC,,,,both,,,5243.80,3408.47,,,,,,,,,,,,,
PLATE BNE L43MM 2X2 H ST BILAT TARSOMETATARSAL TI T SHP LO,SUP-2181257,CDM,C1713,HCPCS,0278,RC,,,,both,,,3504.84,2278.15,,,,,,,,,,,,,
GRAFT HUM TISS PERICARD 5X7 CM LT,SUP-2400554,CDM,C1713,HCPCS,0278,RC,,,,both,,,8478.00,5510.70,,,,,,,,,,,,,
IMPLANT BIO TISS W25XL40CM 1000SQCM PORCINE RECON PERF MTRX,SUP-2113247,CDM,C1781,HCPCS,0278,RC,,,,both,,,99016.76,64360.89,,,,,,,,,,,,,
KNIFE SURG OPT RND URETHROTM,SUP-2463253,CDM,2720000010,LOCAL,0272,RC,,,,both,,,733.50,476.77,,,,,,,,,,,,,
PACEMAKER CARD 12.8GM 5.9CC W33XH33IN THK6MM SGL CHMBR IS1,SUP-2356132,CDM,C1786,HCPCS,0275,RC,,,,both,,,7138.16,4639.80,,,,,,,,,,,,,
NAIL IM L460MM DIA9MM RT LAT FEM LT GRN TI CANN LCK CVD,SUP-2179694,CDM,C1713,HCPCS,0278,RC,,,,both,,,4967.48,3228.86,,,,,,,,,,,,,
"HC So1 Quantation of Therapuetic Drug, Nes",PX-3018037567,CDM,G0480,CPT,0301,RC,,,,both,,,225.00,146.25,,,,,,,,,,,,,
PROSTHESIS VOICE 20 FRX6 MM INDWL ESOPH FLANGE BLOM-SINGER,SUP-2242390,CDM,L8509,HCPCS,0272,RC,,,,both,,,904.32,587.81,,,,,,,,,,,,,
CATHETER CARD ABLATION FREEZOR MAX L 90 CM DIA 9 FR TIP 8 MM,SUP-2281879,CDM,C1733,HCPCS,0272,RC,,,,both,,,5966.00,3877.90,,,,,,,,,,,,,
CAFFEINE CITRATE 20 MG/ML PO SYRINGE (PED-NEO)|DISCARDED DRUG NOT ADMINISTE,RX-4090426,CDM,J0706,HCPCS,0636,RC,63323-0407-03,NDC,JW,both,3,ML,140.10,91.06,,,,,,,,,,,,,
SYSTEM BX NDL 19GA SHTH W/ MTL STIFFENER 7FR L60CM CATH STR,SUP-2120185,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2072.40,1347.06,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 30-50X10 MM 25X10 MM FRZN PATELLAR TEND,SUP-2866904,CDM,C1762,CPT,0278,RC,,,,both,,,7218.86,4692.26,,,,,,,,,,,,,
PLATE BONE W100XL100MM THK0.6MM TI DYN MESH FOR COMP CRAN,SUP-2243967,CDM,C1713,HCPCS,0278,RC,,,,both,,,1499.13,974.43,,,,,,,,,,,,,
SCREW BNE STD CORT FULL THRD N CANN ST N LOK SNAP OFF HD,SUP-2242899,CDM,C1713,HCPCS,0278,RC,,,,both,,,1138.34,739.92,,,,,,,,,,,,,
CATHETER ANGIOPLSTY MR L 135 CM BALLOON L 9 MM DIA 4 MM,SUP-2139714,CDM,C1725,HCPCS,0272,RC,,,,both,,,844.66,549.03,,,,,,,,,,,,,
COIL EMB L15CM OD5MM 360DEG SFT DETACH TARGET,SUP-2368026,CDM,C1889,HCPCS,0278,RC,,,,both,,,7269.10,4724.91,,,,,,,,,,,,,
CATHETER ANGIOPLSTY SLOM BALLOON L 24 MM DIA 7 MM DURALYN,SUP-2159226,CDM,C1876,HCPCS,0278,RC,,,,both,,,2370.70,1540.95,,,,,,,,,,,,,
GRAFT BONE SUB 25GM CA PHOS CRANIOMAXILLOFACIAL FULL DOSE HI,SUP-2365154,CDM,C1713,HCPCS,0278,RC,,,,both,,,7582.63,4928.71,,,,,,,,,,,,,
POST FIX 12MM PLNTR COMPR FOR PLATING SYS OMNI PLANTARFIX,SUP-2224009,CDM,C1713,HCPCS,0278,RC,,,,both,,,3014.40,1959.36,,,,,,,,,,,,,
GRAFT HUM TISS LR THAN 11CM FEM SHFT STRUCTURAL FRZ DRY,SUP-2165573,CDM,C1713,HCPCS,0278,RC,,,,both,,,3124.30,2030.79,,,,,,,,,,,,,
PLATE BNE L 134 X W 11 MM THK 3 MM SCREW DIA2.7/3.5 MM 11 H 72466011,SUP-2932754,CDM,C1713,HCPCS,0278,RC,,,,both,,,5616.52,3650.74,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9 % IN NEBU,RX-7325,CDM,6370000000,HCPCS,0637,RC,00487-9301-33,NDC,,both,3,ML,2.70,1.75,,,,,,,,,,,,,
BIT DRL CANN 3.5 MM AO FIT,SUP-2691432,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1250.66,812.93,,,,,,,,,,,,,
SCREW BNE L75MM DIA6MM TI CANC ST LOK PARTIALLY THRD LO,SUP-2282070,CDM,C1713,HCPCS,0278,RC,,,,both,,,110.75,71.99,,,,,,,,,,,,,
STAPLE BNE 12X12 MM FOREFOOT PK NIT DYNAFORCE MOTOCLIP MAX,SUP-2175167,CDM,C1713,HCPCS,0278,RC,,,,both,,,2041.00,1326.65,,,,,,,,,,,,,
CATHETER HD RT STR AD 62.5 CM SWAN NK CURL CATH KT ARYGLE,SUP-2283992,CDM,C1750,HCPCS,0278,RC,,,,both,,,816.71,530.86,,,,,,,,,,,,,
PLATE BNE STR 0.6 MM LT 4 HOLE C-TUBE HK FOR 6MM BRIDGE TI,SUP-2458997,CDM,C1713,HCPCS,0278,RC,,,,both,,,1154.77,750.60,,,,,,,,,,,,,
PLATE BONE 8 H TI PRECONTOURED FOR 8 AND 9 RT RIB MATRIXRIB,SUP-2181511,CDM,C1713,HCPCS,0278,RC,,,,both,,,4189.55,2723.21,,,,,,,,,,,,,
GUIDEWIRE VASC COON L 260 CM DIA 0.035 IN TAPR L 15 CM FLPY,SUP-2167872,CDM,C1769,HCPCS,0272,RC,,,,both,,,135.43,88.03,,,,,,,,,,,,,
TUBE VENT 7 MM 0.9 MM STR FLROPLAS,SUP-2461765,CDM,L8699,HCPCS,0278,RC,,,,both,,,19.63,12.76,,,,,,,,,,,,,
BIT DRILL L3.3MM OD2.8MM KNOTLESS SUTURE ANCHOR POPLOK,SUP-2828522,CDM,2720000010,LOCAL,0272,RC,,,,both,,,949.60,617.24,,,,,,,,,,,,,
PLATE BONE SQUARE SHEET 50X50X0.8 MM DEMO STERILE SYNPOR,SUP-2837792,CDM,C1713,HCPCS,0278,RC,,,,both,,,1417.71,921.51,,,,,,,,,,,,,
BEARING HUM DIA4441MM H+0MM STD ARCOMXL FOR COMPHSVE REV,SUP-2409556,CDM,C1776,CPT,0278,RC,,,,both,,,2951.60,1918.54,,,,,,,,,,,,,
CATHETER URET PIG 0.038 IN 8 FRX70 CM C FLX LF,SUP-2470446,CDM,C1758,HCPCS,0278,RC,,,,both,,,212.08,137.85,,,,,,,,,,,,,
SPACER ORTH HUM 18+ MM,SUP-2715616,CDM,C1776,CPT,0278,RC,,,,both,,,1472.66,957.23,,,,,,,,,,,,,
CATHETER KIT EXT LUMBAR CEREBROSPINAL FLUID II EDS 3,SUP-2851442,CDM,C1729,HCPCS,0272,RC,,,,both,,,1392.06,904.84,,,,,,,,,,,,,
COVER ORTHOT CUST FOR UPR,SUP-2435583,CDM,L1120,HCPCS,0274,RC,,,,both,,,107.67,69.99,,,,,,,,,,,,,
"HC Insert Picc Cath, 5/> Yrs|REDUCED SERVICES",PX-3613656900,CDM,36569,CPT,0361,RC,,,52,both,,,1231.00,800.15,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY RESPON L 120 CM 6FR 2-8-2MM FIX,SUP-2703680,CDM,C1730,HCPCS,0272,RC,,,,both,,,170.47,110.81,,,,,,,,,,,,,
ALLOGRAFT HUM TISS STRP FD IRRADIATED FASC LATA,SUP-2867199,CDM,C1762,CPT,0278,RC,,,,both,,,643.70,418.40,,,,,,,,,,,,,
BRACE ORTH CORSET FRONT,SUP-2388154,CDM,L0972,HCPCS,0274,RC,,,,both,,,297.99,193.69,,,,,,,,,,,,,
SET CNNLAOBTRTR LAP 12MM DIA THRCC THRDD BLUNT TIP JARIT RS,SUP-2675722,CDM,2720000010,LOCAL,0272,RC,,,,both,,,719.19,467.47,,,,,,,,,,,,,
GRAFT BNE SUB 1.2CC SIL SOD CA PHOS OXIDE FOAM PK RECT CONT,SUP-2368181,CDM,C1713,HCPCS,0278,RC,,,,both,,,859.17,558.46,,,,,,,,,,,,,
KYPHOPLASTY KIT ACCS 10 GA OSSEOFLEX,SUP-2500683,CDM,2720000010,LOCAL,0272,RC,,,,both,,,853.04,554.48,,,,,,,,,,,,,
GRAFT BONE 14X20 MECH GIC58 THR DWL FRO MDII,SUP-2293889,CDM,C1713,HCPCS,0278,RC,,,,both,,,11278.88,7331.27,,,,,,,,,,,,,
HC Lymphangiogram Bilat S&I,PX-3207580300,CDM,75803,CPT,0320,RC,,,,both,,,2550.00,1657.50,,,,,,,,,,,,,
SUBSTITUTE BONE GRAFT SM PROPEL PUTTY,SUP-2546000,CDM,C1713,HCPCS,0278,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
SULBACTAM SOD-DURLOBACTAM SOD 1-1 G IV SOLR,RX-165034,CDM,J3376,HCPCS,0636,RC,68547-0111-10,NDC,,both,1,UN,956.50,621.72,,,,,,,,,,,,,
RING EXT FIX ARCH 180 MM,SUP-2749882,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2251.38,1463.40,,,,,,,,,,,,,
HC So2 Detect Agent Nos Dna Amp,PX-3068779868,CDM,87798,CPT,0306,RC,,,,outpatient,,,855.00,555.75,,,,,,,,,,,,,
PLATE Y 2MM 3H HD 7H SHFT TI STRL VAL,SUP-2546910,CDM,C1713,HCPCS,0278,RC,,,,both,,,1693.56,1100.81,,,,,,,,,,,,,
BLADE SAW OSCILLATING MIC 12X9X0.38-0.53 MM CRESC W/O OFFSET,SUP-2862462,CDM,2720000010,LOCAL,0272,RC,,,,both,,,349.67,227.29,,,,,,,,,,,,,
"HC So2 Quantation of Therapuetic Drug, Nes",PX-3018029968,CDM,80299,CPT,0301,RC,,,,both,,,1562.00,1015.30,,,,,,,,,,,,,
PEG BNE HOLDING TOT KNEE SYS MG II,SUP-2437017,CDM,C1713,HCPCS,0278,RC,,,,both,,,56.52,36.74,,,,,,,,,,,,,
BIT DRL DIA3.2MM CANN FOR JONE FRAC SYS CHARLOTTE CAROLINA,SUP-2398089,CDM,2720000010,LOCAL,0272,RC,,,,both,,,273.18,177.57,,,,,,,,,,,,,
STEM HUM L125MM L9.5MM UNIV TI POR SHLDR PRI CEM IMP,SUP-2404705,CDM,C1776,CPT,0278,RC,,,,both,,,12503.48,8127.26,,,,,,,,,,,,,
ALLOGRAFT BNE STRP 15X20 MM PRESERVON STRUCTURAL ORAGRAFT,SUP-2740968,CDM,C1713,HCPCS,0278,RC,,,,both,,,1119.72,727.82,,,,,,,,,,,,,
PIN FIX L180MM DIA3.5MM S STL SGL END SHRP TIP CTRL THRD,SUP-2186930,CDM,C1713,HCPCS,0278,RC,,,,both,,,251.33,163.36,,,,,,,,,,,,,
PROSTHESIS OSS CNTR CONCISE PART,SUP-2420195,CDM,L8613,CPT,0278,RC,,,,both,,,1153.48,749.76,,,,,,,,,,,,,
HC Spinal Angiography/Selective,PX-3237570500,CDM,75705,CPT,0323,RC,,,,both,,,3269.00,2124.85,,,,,,,,,,,,,
PLATE BNE L319MM 12 H NONSTERILE L PROX FEM S STL LO PROF,SUP-2186047,CDM,C1713,HCPCS,0278,RC,,,,both,,,4602.71,2991.76,,,,,,,,,,,,,
COIL DETACH 3D SHP 7MM BIG LOOP OD 12CM INTRO GDC 10,SUP-2365674,CDM,C1889,HCPCS,0278,RC,,,,both,,,4900.44,3185.29,,,,,,,,,,,,,
EVOS 2.7/3.5MM OLECRANON PL 8H L 114MM,SUP-2819866,CDM,C1713,HCPCS,0278,RC,,,,both,,,9076.48,5899.71,,,,,,,,,,,,,
CITALOPRAM HYDROBROMIDE 20 MG PO TABS,RX-21062,CDM,6370000000,HCPCS,0637,RC,00904-6085-61,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PLATE BNE COMPR SM 2.7X44 MM 5 HOLE DYN NS DCP LTX,SUP-2861898,CDM,C1713,HCPCS,0278,RC,,,,both,,,310.48,201.81,,,,,,,,,,,,,
CATHETER ANGIO SOFT-VU L 65 CM 4 FR 0.035 IN C2 BRAIDED,SUP-2116588,CDM,C1887,HCPCS,0272,RC,,,,both,,,86.60,56.29,,,,,,,,,,,,,
CANNULA ENDOSCP LT 10X49 MM STRL MONTGOMERY DISP,SUP-2139784,CDM,2720000010,LOCAL,0272,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
BLADE SURG VES 29 MMX14 CM WIDE,SUP-2629242,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1347.06,875.59,,,,,,,,,,,,,
BRACE KNEE L FOR 21 24IN THGH UNIV NEOPRENE PUL ON ACL PLC,SUP-2151024,CDM,L1810,HCPCS,0274,RC,,,,both,,,162.02,105.31,,,,,,,,,,,,,
GRAFT BNE 8MM WDG ALLGRFT,SUP-2244473,CDM,C1713,HCPCS,0278,RC,,,,both,,,6614.06,4299.14,,,,,,,,,,,,,
PROSTHESIS OSS FISCH TYP PISTON 0.4X6 MM PLAT RIBBON,SUP-2637813,CDM,L8613,CPT,0278,RC,,,,both,,,491.57,319.52,,,,,,,,,,,,,
SPLINT WRST FOAM PADDING YTH FOREARM RT PERF DESIGN ALUM,SUP-2336021,CDM,L3908,HCPCS,0274,RC,,,,both,,,11.43,7.43,,,,,,,,,,,,,
EMPAGLIFLOZIN 10 MG PO TABS,RX-127132,CDM,6370000000,HCPCS,0637,RC,00597-0152-37,NDC,,both,1,UN,94.50,61.42,,,,,,,,,,,,,
GRAFT BNE SUB 5CC BOV TYP I SYN TISS CLLGN MTRX STRP RESRB,SUP-2255626,CDM,C9362,HCPCS,0278,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
PLATE BNE L 43 MM SCREW DIA2 MM 8 SHFT H SS COMPACT STR VA NS,SUP-2908859,CDM,C1713,HCPCS,0278,RC,,,,both,,,3944.88,2564.17,,,,,,,,,,,,,
SPACER SPNL 11X14X8MM 7 DEG CERV LORD CALIX,SUP-2402241,CDM,C1821,HCPCS,0278,RC,,,,both,,,4421.12,2873.73,,,,,,,,,,,,,
ROD SPNL 4 MM VIPER,SUP-2256283,CDM,C1713,HCPCS,0278,RC,,,,both,,,2472.75,1607.29,,,,,,,,,,,,,
SCREW BNE L40MM DIA5.5MM CORT PROX TIB SLD FULL THRD,SUP-2412189,CDM,C1713,HCPCS,0278,RC,,,,both,,,517.79,336.56,,,,,,,,,,,,,
GRAFT HUM TISS W6XL16CM THK15 22MM THCK ACELLULAR HYDRATED,SUP-2307568,CDM,Q4128,HCPCS,0636,RC,,,,both,,,8480.36,5512.23,,,,,,,,,,,,,
PROSTHESIS OSS STAP 0.8X4 MM 0.6 MM PISTON FLROPLAS,SUP-2478087,CDM,L8699,HCPCS,0278,RC,,,,both,,,286.18,186.02,,,,,,,,,,,,,
CEMENT DELIEVERY KIT 13 GA NDL PARALLAX EZ FLO,SUP-2342022,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
CATHETER ANGIOPLSTY ADV MIC 14 L 150 CM BALLOON L 3 CM DIA2,SUP-2633245,CDM,C1725,HCPCS,0272,RC,,,,both,,,1103.55,717.31,,,,,,,,,,,,,
DEVICE SUTURING 2 PK LD FIX KNOT PUSH FIXATE,SUP-2765584,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
OPES 90 ABLATOR TOOTHBRUSH,SUP-2815764,CDM,2720000010,LOCAL,0272,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
GRAFT HUM TISS W8XL16CM THK0.9-1.99MM ACELLULAR DERM MTRX,SUP-2402514,CDM,Q4126,HCPCS,0636,RC,,,,both,,,20410.00,13266.50,,,,,,,,,,,,,
HOOK SPNL SM W7.5XH6.4XL9.5MM S STL PEDCL LO PROF REVERE,SUP-2230933,CDM,C1713,HCPCS,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
FLUVOXAMINE MALEATE 100 MG PO TABS,RX-10084,CDM,6370000000,HCPCS,0637,RC,62559-0160-01,NDC,,both,1,UN,3.00,1.95,,,,,,,,,,,,,
HC Ultrasound Chest,PX-4027660400,CDM,76604,CPT,0402,RC,,,,both,,,1369.00,889.85,,,,,,,,,,,,,
RETRACTOR PEER 12.5IN 5MM,SUP-2243666,CDM,C1713,HCPCS,0278,RC,,,,both,,,5285.78,3435.76,,,,,,,,,,,,,
DEFIBRILLATOR IMPL CURRENT DR W 5 X H 7.6 CM 30 J 38 CC TI,SUP-2356699,CDM,C1721,HCPCS,0275,RC,,,,both,,,45530.00,29594.50,,,,,,,,,,,,,
STEM FEM L160MM DIA16MM STD UNIV KNEE STR CEM PRI LEGION,SUP-2346811,CDM,C1776,CPT,0278,RC,,,,both,,,4056.88,2636.97,,,,,,,,,,,,,
CATHETER ANGIOPLSTY RIVAL L 80 CM BALLOON L 4 CM DIA 6 MM,SUP-2128468,CDM,C1725,HCPCS,0272,RC,,,,both,,,722.20,469.43,,,,,,,,,,,,,
PLATE BNE THK 1 MM BAR 10 MM SCREW DIA2 MM 6 H MINI CRV,SUP-2883179,CDM,C1713,HCPCS,0278,RC,,,,both,,,923.63,600.36,,,,,,,,,,,,,
BIT DRL DIA1.6 MM FOR STD TECH LOWER EXTREMITY ANAT PLATING,SUP-2905655,CDM,2720000010,LOCAL,0272,RC,,,,both,,,552.51,359.13,,,,,,,,,,,,,
CATHETER ETER HAD 135FR 20CM CE PASS MAHRK ELITE,SUP-2613221,CDM,C1752,HCPCS,0278,RC,,,,both,,,417.81,271.58,,,,,,,,,,,,,
GRAFT HUM TISS L14MM CONE GRAFIX,SUP-2319160,CDM,Q4132,HCPCS,0636,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
SET PERICARDCENT L 40 CM DIA 8.3 FR GUIDEWIRE L 70 CM DIA,SUP-2759900,CDM,C1729,HCPCS,0272,RC,,,,both,,,349.58,227.23,,,,,,,,,,,,,
HC Endovenous Rf 1st Vein,PX-3613647500,CDM,36475,CPT,0361,RC,,,,both,,,10314.00,6704.10,,,,,,,,,,,,,
HC Place Percu-Abd/Plv-No Prost,PX-3334941100,CDM,49411,CPT,0333,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
HC Paracentesis W/O Imaging,PX-7614908200,CDM,49082,CPT,0761,RC,,,,inpatient,,,2844.00,1848.60,,,,,,,,,,,,,
SP PLASMALOOP ANGLED,SUP-2725840,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1600.83,1040.54,,,,,,,,,,,,,
ALLOGRAFT BNE SPACER 12X14X7 MM FD PARL ACF,SUP-2736817,CDM,C1713,HCPCS,0278,RC,,,,both,,,3378.33,2195.91,,,,,,,,,,,,,
BOLT EXT FIX UNIV FOR 4-6MM HALF PIN RNG FIX SYS TRUELOK,SUP-2316126,CDM,2720000010,LOCAL,0272,RC,,,,both,,,383.43,249.23,,,,,,,,,,,,,
BIT DRL CANN 16 MM HLLW PERC NS TFN-ADVANCED,SUP-2799412,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2800.97,1820.63,,,,,,,,,,,,,
NEEDLE NAVIGATION BX,SUP-2900080,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2766.31,1798.10,,,,,,,,,,,,,
TUBE CHST 24FR L20IN POLYVI CHL OPN TIP STR FIRM RADPQ ARGY,SUP-2154967,CDM,C1729,HCPCS,0272,RC,,,,both,,,26.25,17.06,,,,,,,,,,,,,
STENT BILI L 30 MM DIA2 MM CATH L 80 CM DIA 7 FR AD STRL,SUP-2155739,CDM,C1876,HCPCS,0278,RC,,,,both,,,3187.10,2071.61,,,,,,,,,,,,,
PLATE BNE FRAG NS MOD LTX,SUP-2861299,CDM,C1713,HCPCS,0278,RC,,,,both,,,1591.23,1034.30,,,,,,,,,,,,,
TISSUE BIO MATRIDERM 5.2 X 7.4CM 1MM SM,SUP-2866499,CDM,A2027,HCPCS,0636,RC,,,,both,,,9143.49,5943.27,,,,,,,,,,,,,
BLADE CANN SCRDRVR SELF HLD 2.2,SUP-2267812,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1997.35,1298.28,,,,,,,,,,,,,
CATHETER DRAINAGE SET 12 FRX15 CM PNEUMOPERICARDIAL FURMAN,SUP-2759780,CDM,C1729,HCPCS,0272,RC,,,,both,,,407.45,264.84,,,,,,,,,,,,,
TI WASHER 12.7MM OD {} 6.5 ID,SUP-2818893,CDM,C1713,HCPCS,0278,RC,,,,both,,,529.97,344.48,,,,,,,,,,,,,
SCREW INTFR L30MM DIA6-7MM TIB PLA BIOABSRB TAPR FOR SFT,SUP-2249559,CDM,C1713,HCPCS,0278,RC,,,,both,,,1582.56,1028.66,,,,,,,,,,,,,
PROBE ARTHROSCOPIC ENERGY 20DEG BIPOLAR ANGLED HOOK EDGE,SUP-2824215,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1002.29,651.49,,,,,,,,,,,,,
SYSTEM TRANSSEPTAL ACCESS ACQCROSS QX AG 71CM,SUP-2854451,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
HC Drain/Inj Joint/Bursa W/US,PX-3612060600,CDM,20606,CPT,0361,RC,,,,inpatient,,,3707.00,2409.55,,,,,,,,,,,,,
CATHETER NEPHROSTOMY INTRODUCTORY SET 8 FRX30 CM UNIVERSA,SUP-2836201,CDM,C1729,HCPCS,0272,RC,,,,both,,,1303.41,847.22,,,,,,,,,,,,,
SCREW BNE L20MM DIA7MM COMPR CANC FULL THRD CANN ST SELF,SUP-2409839,CDM,C1713,HCPCS,0278,RC,,,,both,,,693.31,450.65,,,,,,,,,,,,,
HC FB Removal From Ear,PX-4506920000,CDM,69200,CPT,0450,RC,,,,both,,,396.00,257.40,,,,,,,,,,,,,
BASEPLATE TIB LIMB SALV LO BODY ELEOS SZ 4 75MM M/L,SUP-2314045,CDM,C1776,CPT,0278,RC,,,,both,,,18456.92,11997.00,,,,,,,,,,,,,
CAGE SPNL W13XH6XL15MM 5DEG ANTR CERV PEEK DISCECTOMY FUS,SUP-2137095,CDM,C1889,HCPCS,0278,RC,,,,both,,,5966.00,3877.90,,,,,,,,,,,,,
PLATE BNE L112MM 6 H ST R LAT DST FIBULAR S STL LOK COMPR,SUP-2177418,CDM,C1713,HCPCS,0278,RC,,,,both,,,1953.55,1269.81,,,,,,,,,,,,,
SPLINT DENT OCCLUSAL IPS,SUP-2263024,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3030.57,1969.87,,,,,,,,,,,,,
PLATE BONE L W7XL34MM THK1MM 3 H LT TI OBLQ RIG,SUP-2191007,CDM,C1713,HCPCS,0278,RC,,,,both,,,203.50,132.27,,,,,,,,,,,,,
CATHETER DRNGE 20FR 4 WNG DISP FOR NEPHSTMY MALECOTS,SUP-2129075,CDM,C2627,HCPCS,0272,RC,,,,both,,,106.76,69.39,,,,,,,,,,,,,
SCREW CVR TI CONIC USED FOR BAHA TWO STG SURG BI300,SUP-2164965,CDM,2780000010,LOCAL,0278,RC,,,,both,,,580.90,377.58,,,,,,,,,,,,,
SCOPE ENDOSCP NANONEEDLE 125 MM,SUP-2849266,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1689.32,1098.06,,,,,,,,,,,,,
SPLINT ORTH W4IN RT HND BASE THMB SPICA ROLYAN,SUP-2324965,CDM,L3931,HCPCS,0272,RC,,,,both,,,102.74,66.78,,,,,,,,,,,,,
CONNECTOR OFFSET 5MM FOR GMK REV SYS,SUP-2267452,CDM,C1776,CPT,0278,RC,,,,both,,,8917.60,5796.44,,,,,,,,,,,,,
GRAFT BNE 1-2 MM 8 CC ACTIFUSE,SUP-2129859,CDM,C9362,HCPCS,0278,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
SCREW BNE L36MM L19MM OD4.5MM MONSTER LNG THRD,SUP-2320609,CDM,C1713,HCPCS,0278,RC,,,,both,,,758.31,492.90,,,,,,,,,,,,,
LENS INTOCU BI-CONVEX ASYMMETRICAL 0.0 - 4.0 IN 1.0 DIOPT A,SUP-2129500,CDM,V2632,HCPCS,0276,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
FOOT PLATE EXT FIX L 220 MM MONK RING,SUP-2899029,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5345.07,3474.30,,,,,,,,,,,,,
IMPLANT STAP L4.5MM DIA0.6MM PIST AND WIRE FLROPLAS S STL,SUP-2312792,CDM,L8613,CPT,0278,RC,,,,both,,,374.73,243.57,,,,,,,,,,,,,
LNT IMPLANT SYSTEM 4.75 PEEK SWIVELOCK,SUP-2816638,CDM,C1713,HCPCS,0278,RC,,,,both,,,2433.50,1581.77,,,,,,,,,,,,,
HYDROTENOTOMY SET PERC HNDPC STRL TENJET LTX DISP,SUP-2875923,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
MESH SURG W15XL15CM WHT POLYPR MACROPOROUS NONABSORABLE,SUP-2752157,CDM,C1781,HCPCS,0278,RC,,,,both,,,264.20,171.73,,,,,,,,,,,,,
PLATE BONE DUAL CMPRSSN 103MML HLX6 STNLSS STEEL STRGHT NRRW,SUP-2495950,CDM,C1713,HCPCS,0278,RC,,,,both,,,413.98,269.09,,,,,,,,,,,,,
GRAFT BNE SUB 5CC SPNG DEMIN CORT FBR FLEXIGRFT,SUP-2264607,CDM,C1713,HCPCS,0278,RC,,,,both,,,1979.42,1286.62,,,,,,,,,,,,,
MINIMAL INVASIVE CALCANEAL PLATE L S,SUP-2829383,CDM,C1713,HCPCS,0278,RC,,,,both,,,5133.90,3337.03,,,,,,,,,,,,,
HC Glb Reprogramming Implanted Pump,PX-9826236800,CDM,62368,CPT,0982,RC,,,,both,,,1086.00,705.90,,,,,,,,,,,,,
SUPPORT ORTHOT CUST RNG FLANGE PLAS LTHR,SUP-2435581,CDM,L1100,HCPCS,0274,RC,,,,both,,,537.66,349.48,,,,,,,,,,,,,
HC Pt Adl Training 15mn|OP OCCUPATIONAL THERAPY SERV|DOCUMENTATION ON FILE,PX-4209753500,CDM,97535,CPT,0420,RC,,,GO|KX,outpatient,,,174.00,113.10,,,,,,,,,,,,,
GRAFT HUM TISS LT RT WHL HUM STRUCTURAL FRZN,SUP-2165584,CDM,C1713,HCPCS,0278,RC,,,,both,,,3611.00,2347.15,,,,,,,,,,,,,
MATRIX SURGICAL WOUND 0.015OZ CONNEXT,SUP-2758895,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3532.50,2296.12,,,,,,,,,,,,,
TRAY CATH MIDLN POWERGLIDE PRO BASIC 18GA 10CM WNG F118100TX,SUP-2632724,CDM,C1751,HCPCS,0278,RC,,,,both,,,238.64,155.12,,,,,,,,,,,,,
HC Surgery Level 1 Addtl 15min,PX-3600000011,CDM,3600000011,LOCAL,0360,RC,,,,both,,,622.00,404.30,,,,,,,,,,,,,
HC Skull Less Than 4 Views,PX-3207025000,CDM,70250,CPT,0320,RC,,,,both,,,272.00,176.80,,,,,,,,,,,,,
DISTRACTOR EXT FIX 20 MM 1-1.2 MM 9 HOLE MID DRIVEN RATCH,SUP-2465567,CDM,C1713,HCPCS,0278,RC,,,,both,,,15966.27,10378.08,,,,,,,,,,,,,
COMPONENT EXT FIX FOOTING FOR THREADLOCK TRNSPRT,SUP-2459456,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2765.34,1797.47,,,,,,,,,,,,,
PLATE BONE 8 H Y SHP FOR 2MM SCR VLP MINI-MOD SM BONE SYS,SUP-2351080,CDM,C1713,HCPCS,0278,RC,,,,both,,,4949.43,3217.13,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA PLU MAXBARR 5FR S1385108D1,SUP-2632820,CDM,C1751,HCPCS,0278,RC,,,,both,,,853.14,554.54,,,,,,,,,,,,,
PLATE 4.5MM TI LCP TM PROX TIBIA 4H 82MM LEFT STERILE,SUP-2549631,CDM,C1713,HCPCS,0278,RC,,,,both,,,4950.49,3217.82,,,,,,,,,,,,,
SPLINT WRST FA L INSTABILITY INJ LOOP LOK W STAY E SUPP COT,SUP-2276650,CDM,L3809,HCPCS,0272,RC,,,,both,,,9.64,6.27,,,,,,,,,,,,,
ROD SPNL TAPR 3.5-5.5X420 MM TI VERTEX,SUP-2630726,CDM,C1713,HCPCS,0278,RC,,,,both,,,832.10,540.86,,,,,,,,,,,,,
RELOAD STPLR RADIAL EXTRA THICK 2 MM INTELLIGENT BLK,SUP-2787708,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2537.43,1649.33,,,,,,,,,,,,,
HC So Assay of Albumin,PX-3078204067,CDM,82040,CPT,0307,RC,,,,both,,,17.00,11.05,,,,,,,,,,,,,
NEEDLE LOC 21GA L7CM FOR PREOPERATIVE MRK OF NONPALPABLE,SUP-2167949,CDM,C1819,HCPCS,0278,RC,,,,both,,,77.56,50.41,,,,,,,,,,,,,
PROBE SURG STR BALL HNDL CD HORZ ENGAGE,SUP-2293399,CDM,C1713,HCPCS,0278,RC,,,,both,,,2113.22,1373.59,,,,,,,,,,,,,
BRACE ELBW TENNIS 1 SZ BLK INT FOAM PD LTWT HG80,SUP-2324093,CDM,L3702,HCPCS,0272,RC,,,,both,,,37.93,24.65,,,,,,,,,,,,,
SPLINT WRST FA L INSTABILITY INJ LOOP LOK W STAY E SUPP COT,SUP-2276650,CDM,L3809,HCPCS,0274,RC,,,,both,,,9.64,6.27,,,,,,,,,,,,,
MESH HERN W12XL15CM RECT PREPERI BIOMATERIAL COMP POLYPR,SUP-2395760,CDM,C1781,HCPCS,0278,RC,,,,both,,,2967.30,1928.74,,,,,,,,,,,,,
RING EXT FIX MED 180 MM SET RX STRUT STRL TRUELOK EVO LTX,SUP-2875588,CDM,2720000010,LOCAL,0272,RC,,,,both,,,29967.16,19478.65,,,,,,,,,,,,,
GRAFT BONE PUTTY SYR DEMINERALISED BONE MTRX 2.5CC,SUP-2244479,CDM,C9359,HCPCS,0278,RC,,,,both,,,1248.15,811.30,,,,,,,,,,,,,
COLLAR CERV 9-24 MO PEDIATRIC 29-37 IN FLEXTABS HK,SUP-2427924,CDM,L0172,HCPCS,0274,RC,,,,both,,,103.87,67.52,,,,,,,,,,,,,
BALLOON ANORECT MNOMTR AD KI ANO STIM FOR ANORECT COMPLIANCE,SUP-2336754,CDM,C1726,HCPCS,0272,RC,,,,both,,,141.30,91.84,,,,,,,,,,,,,
KIT IR SMRT CT PICC 3 FR SGL LUMN RVS TAPR .018X130 CM S STL,SUP-2118437,CDM,C1751,HCPCS,0278,RC,,,,both,,,266.90,173.48,,,,,,,,,,,,,
ENDPLATE SPNL 20MM 4DEG 22X40MM UP FORTIFY I,SUP-2230000,CDM,C1713,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
GUIDEWIRE VASC L 40 CM DIA 0.035 IN SS STR FIX COR STRL,SUP-2760015,CDM,C1769,HCPCS,0272,RC,,,,both,,,43.36,28.18,,,,,,,,,,,,,
SCREW COMPR 1.5X13MM HEADLESS TI STRL,SUP-2547163,CDM,C1713,HCPCS,0278,RC,,,,both,,,763.90,496.53,,,,,,,,,,,,,
COMPONENT GLEN FIX DIA40MM SHLDR XLPE POR ANCHR PEG FOR,SUP-2250030,CDM,C1776,CPT,0278,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
POTASSIUM IODIDE (EXPECTORANT) 1 GM/ML PO SOLN,RX-141223,CDM,340b,HCPCS,0637,RC,71740-0112-30,NDC,,both,30,ML,2126.60,1382.29,,,,,,,,,,,,,
STEM FEM SZ 12L L300MM STD CLLR REV CEM ECHELON,SUP-2344519,CDM,C1776,CPT,0278,RC,,,,both,,,15046.88,9780.47,,,,,,,,,,,,,
GRAFT BNE SUB 40CC 1 8MM CANC CRUSH CHIP READIGRFT,SUP-2264813,CDM,C1713,HCPCS,0278,RC,,,,both,,,1313.34,853.67,,,,,,,,,,,,,
GRAFT VASC GORTX L 30 CM DIA 8 MM RNG L 20 CM EPTFE STR STD,SUP-2396099,CDM,C1768,CPT,0278,RC,,,,both,,,1708.16,1110.30,,,,,,,,,,,,,
TRAY PACE ELECTRD L 110 CM DIA 5 FR TRNSVEN LIDO TEMP,SUP-2119989,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1799.22,1169.49,,,,,,,,,,,,,
HC Stent Plmt Ctr Dialysis Seg,PX-3613690800,CDM,36908,CPT,0361,RC,,,,both,,,8583.00,5578.95,,,,,,,,,,,,,
SET HEMO DYLS OR HD ADMIN ST100 HI PERM HEMDLYZR EXCORP CIRC,SUP-2885238,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4873.78,3167.96,,,,,,,,,,,,,
CLAV SUP PLT RT 8H 90MM NS,SUP-2720907,CDM,C1713,HCPCS,0278,RC,,,,both,,,4367.74,2839.03,,,,,,,,,,,,,
SCREW BNE L 20 MM DIA 3.5 MM MINERAL FIBER MTRX CANN COMPR,SUP-2904309,CDM,C1713,HCPCS,0278,RC,,,,both,,,3815.10,2479.81,,,,,,,,,,,,,
GUIDEWIRE ORTH L12IN DIA1.2MM NIT SMOOTH BLNT TIP FOR ACL,SUP-2341059,CDM,C1769,HCPCS,0272,RC,,,,both,,,127.01,82.56,,,,,,,,,,,,,
SET CATH PERITONEAL DIALYSI V SER BASIC 15FR DIA MC20VS43RS,SUP-2633016,CDM,C1752,HCPCS,0278,RC,,,,both,,,737.90,479.63,,,,,,,,,,,,,
TRAY CATH MIDLN PROVENA MAXBARR 4FR 20CM 2 LUMAN S4254108DGP,SUP-2632868,CDM,C1751,HCPCS,0278,RC,,,,both,,,675.57,439.12,,,,,,,,,,,,,
KIT INFUS PRT CATH L76CM OD9.6FR IMP LO PROF N INJ SGL LUMN,SUP-2127748,CDM,C1788,HCPCS,0278,RC,,,,both,,,1014.22,659.24,,,,,,,,,,,,,
NEEDLE SUT STR FOR DEL MENISCI REP SYS FAST-FIX 360,SUP-2341832,CDM,C1713,HCPCS,0278,RC,,,,both,,,1534.96,997.72,,,,,,,,,,,,,
GUIDEWIRE ORTH TROCAR 0.062X14 IN NIT DISP,SUP-2608183,CDM,C1769,HCPCS,0272,RC,,,,both,,,72.09,46.86,,,,,,,,,,,,,
CATHETER CV DL 13.5 FR HICKMAN,SUP-2627027,CDM,C1751,HCPCS,0278,RC,,,,both,,,837.44,544.34,,,,,,,,,,,,,
HC Transferase Aspartate Amino Ast Sgot,PX-3018445000,CDM,84450,CPT,0301,RC,,,,both,,,122.00,79.30,,,,,,,,,,,,,
GRAFT BNE SUB MACRO 15CC B TRICALCIUM PHSPTE SYN TISS BNE,SUP-2368161,CDM,C1713,HCPCS,0278,RC,,,,both,,,2003.32,1302.16,,,,,,,,,,,,,
PLATE BNE W135XL62MM THK42MM 3 H BILAT S STL NAR LOK COMPR,SUP-2185229,CDM,C1713,HCPCS,0278,RC,,,,both,,,882.06,573.34,,,,,,,,,,,,,
NEEDLE PUNC AUTO SPRING MECHANISM 15 MMX30 CM,SUP-2767360,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2849.49,1852.17,,,,,,,,,,,,,
PLATE BNE L33MM THK12MM 0DEG 5 H BILAT S STL STR RIG LIMIT,SUP-2186168,CDM,C1713,HCPCS,0278,RC,,,,both,,,1025.62,666.65,,,,,,,,,,,,,
CATHETER PTCA 5FR L80CM BLLN L100MM DIA6MM SHTH 6FR 0.035IN,SUP-2156359,CDM,C1725,HCPCS,0272,RC,,,,both,,,433.32,281.66,,,,,,,,,,,,,
SYSTEM INCISION MINI LAPIPLASTY,SUP-2652626,CDM,C1713,HCPCS,0278,RC,,,,both,,,16312.30,10602.99,,,,,,,,,,,,,
INTERTAN NAIL CAP 0.0MM,SUP-2821024,CDM,C1889,HCPCS,0278,RC,,,,both,,,928.97,603.83,,,,,,,,,,,,,
HC Rem/Rep Ex/in N-U Stent,PX-3615038700,CDM,50387,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
SCREW BNE NC 4.5X44 MM CORTICAL HIP POLARCUP,SUP-2418620,CDM,C1713,HCPCS,0278,RC,,,,both,,,233.15,151.55,,,,,,,,,,,,,
DRILL TWST 1X18X8MM,SUP-2364175,CDM,2720000010,LOCAL,0272,RC,,,,both,,,578.55,376.06,,,,,,,,,,,,,
MESH CRAN L 90 X W 80 MM THK 0.8 MM SCREW DIA1.5/1.7 MM MED,SUP-2883650,CDM,C1713,HCPCS,0278,RC,,,,both,,,6230.80,4050.02,,,,,,,,,,,,,
PACEMAKER CARD EVIA SR-T TI SINGLE CHMBR HOME MONITORING MOB,SUP-2138288,CDM,C1786,HCPCS,0275,RC,,,,both,,,10205.00,6633.25,,,,,,,,,,,,,
PLATE BNE L 56 MM 7 H TI LT DSTL DORS ULN STRL EVOS,SUP-2931301,CDM,C1713,HCPCS,0278,RC,,,,both,,,3835.20,2492.88,,,,,,,,,,,,,
SCREW BONE L30MM DIA4MM PARTIALLY THRD HDLSS M CANN COMPR,SUP-2418754,CDM,C1713,HCPCS,0278,RC,,,,both,,,675.23,438.90,,,,,,,,,,,,,
BB-TAK THREADED STRL,SUP-2811920,CDM,C1713,HCPCS,0278,RC,,,,both,,,266.90,173.48,,,,,,,,,,,,,
INTRODUCER DIAG PEEL-APART L 15 CM DIA10 FR PTFE PERC NO CRV,SUP-2127709,CDM,C1892,HCPCS,0272,RC,,,,both,,,488.30,317.39,,,,,,,,,,,,,
SHEATH INTRO FLX BLKN L 40 CM OD 7 FR ID 2.5 MM GUIDEWIRE,SUP-2168569,CDM,C1894,HCPCS,0272,RC,,,,both,,,141.87,92.22,,,,,,,,,,,,,
CLINDAMYCIN PALMITATE HCL 75 MG/5ML PO SOLR,RX-37642,CDM,340b,HCPCS,0637,RC,99999-5960-05,NDC,,both,5,ML,5.50,3.57,,,,,,,,,,,,,
VINBLASTINE SULFATE 1 MG/ML IV SOLN,RX-8594,CDM,J9360,HCPCS,0636,RC,63323-0278-10,NDC,,both,10,ML,154.90,100.68,,,,,,,,,,,,,
CATHETER CV MAXIMAL BARR TY 032 7 FRX15 CM 3L STRL,SUP-2759920,CDM,C1751,HCPCS,0278,RC,,,,both,,,557.35,362.28,,,,,,,,,,,,,
WIRE ORTH L102MM OD1.4MM S STL SMOOTH SGL SHRP TIP TRCR PLN,SUP-2384028,CDM,C1713,HCPCS,0278,RC,,,,both,,,63.71,41.41,,,,,,,,,,,,,
MESH SURG L 40 X W 28 CM D 1.5 MM PORCINE DERMAL CLLGN ABD,SUP-2901702,CDM,C9364,HCPCS,0278,RC,,,,both,,,84741.88,55082.22,,,,,,,,,,,,,
PLATE BNE SPLNT PT SPEC ORTHOGNATHIC FINAL,SUP-2194244,CDM,C1713,HCPCS,0278,RC,,,,both,,,3182.70,2068.75,,,,,,,,,,,,,
STEM HUM L100MM OD6.5MM UNIV TI SHLDR IM PROX BODY MOD REV,SUP-2403502,CDM,C1776,CPT,0278,RC,,,,both,,,6126.14,3981.99,,,,,,,,,,,,,
DRILL 4.75MM HEALICOIL KNOTLESS,SUP-2823681,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1097.05,713.08,,,,,,,,,,,,,
LINER MOBILITY CAPPED HIP LINER 50/43,SUP-2718085,CDM,C1776,CPT,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
PLATE BNE K 1.5X0.2 MM ORBIT FLR FOR SCREW TI NS LEVEL 1,SUP-2457682,CDM,C1713,HCPCS,0278,RC,,,,both,,,1917.60,1246.44,,,,,,,,,,,,,
KIT CATH HEMODIALYSI RELIANCE XK CHRONIC STD 16FR DIA 47CM 4,SUP-2613282,CDM,C1750,HCPCS,0278,RC,,,,both,,,7418.25,4821.86,,,,,,,,,,,,,
MARKER RAD 1X3 MM W/ PLCMNT NDL STRL POLYMARK,SUP-2164574,CDM,A4648,CPT,0278,RC,,,,both,,,232.36,151.03,,,,,,,,,,,,,
HOOK SPNL PEDCL NEUT OPN BILAT 5.5MM ROD DIA M THRT,SUP-2290617,CDM,C1713,HCPCS,0278,RC,,,,both,,,9398.02,6108.71,,,,,,,,,,,,,
CYSTOSCOPY KIT FLX CANN STRL DRP ENDOSEE,SUP-2755376,CDM,2720000010,LOCAL,0272,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
PERI-LOC 2.7MM S-T LOCK SCREW 28MM,SUP-2819441,CDM,C1713,HCPCS,0278,RC,,,,both,,,938.11,609.77,,,,,,,,,,,,,
AGBA PICC/DELTA KIT: 1-L 4.5 FRX40 CM,SUP-2822087,CDM,C1751,HCPCS,0278,RC,,,,both,,,981.78,638.16,,,,,,,,,,,,,
PLATE X LCK 2.4/2.7MM XS 22X14MM TI,SUP-2549730,CDM,C1713,HCPCS,0278,RC,,,,both,,,2570.72,1670.97,,,,,,,,,,,,,
LEVEL NEURO ST PLATE ULTRNE STR WTAB NEURO SCRW6 HOLE 27 MM,SUP-2707451,CDM,C1713,HCPCS,0278,RC,,,,both,,,776.96,505.02,,,,,,,,,,,,,
HC Ureteral Embolization/Occl W Img Guide/Si,PX-3615070500,CDM,50705,CPT,0361,RC,,,,both,,,15457.00,10047.05,,,,,,,,,,,,,
HC Dexa Axial Skeleton,PX-3207708000,CDM,77080,CPT,0320,RC,,,,both,,,541.00,351.65,,,,,,,,,,,,,
GRAFT OPHTH SZ B THK50-100UM W1.5XL2CM CONJUNCTIVOCHALASIS,SUP-2135256,CDM,V2790,HCPCS,0278,RC,,,,both,,,1868.30,1214.39,,,,,,,,,,,,,
GRAFT BNE PASTE 3 CC SYR DBM ORTHOBLAST II,SUP-2641747,CDM,C1713,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA 3FR 55CM 1 LUMAN R S1173108,SUP-2632783,CDM,C1751,HCPCS,0278,RC,,,,both,,,771.94,501.76,,,,,,,,,,,,,
LINER ACET TRIL SZ II 36 MM,SUP-2203897,CDM,C1776,CPT,0278,RC,,,,both,,,3893.25,2530.61,,,,,,,,,,,,,
ALLOGRAFT DERMAL MESH 12X12 CMX2.31-3.30 MM TISS ALLDERM,SUP-2113050,CDM,Q4116,HCPCS,0636,RC,,,,both,,,16880.64,10972.42,,,,,,,,,,,,,
PLATE BNE THK1.25MM 11 H BILAT MIDFOOT S STL CUBOID ST LO,SUP-2186374,CDM,C1713,HCPCS,0278,RC,,,,both,,,2357.61,1532.45,,,,,,,,,,,,,
SPLINT WRST FA L INSTABILITY INJ 10IN LOOP LOK FIRM SUPP VYN,SUP-2276620,CDM,L3908,HCPCS,0274,RC,,,,both,,,16.01,10.41,,,,,,,,,,,,,
IMPLANT HAMRTOE LG PEEK CANN FIX SYS STRL,SUP-2893058,CDM,C1713,HCPCS,0278,RC,,,,both,,,3532.50,2296.12,,,,,,,,,,,,,
CATHETER CV DL 7 FRX150 MM 16 GAX70 MM W/ EXTN TY CAREFLOW,SUP-2516614,CDM,C1751,HCPCS,0278,RC,,,,both,,,71.84,46.70,,,,,,,,,,,,,
COMPONENT FEM SM UNIV W1XL3MM OFFSET CO CHROM ARTC UNI,SUP-2123715,CDM,C1776,CPT,0278,RC,,,,both,,,21267.22,13823.69,,,,,,,,,,,,,
GRIP IT SHOES FRACTURE,SUP-2366437,CDM,C1713,HCPCS,0278,RC,,,,both,,,418.53,272.04,,,,,,,,,,,,,
SUPPORT ORTHOT FT METATRSL ARCH PREMOLDED LONGITUDINAL,SUP-2435706,CDM,L3060,HCPCS,0272,RC,,,,both,,,208.81,135.73,,,,,,,,,,,,,
ANCHOR SUT DIA5.5MM PEEK FULL THRD W/ FORC FBR INTRALINE,SUP-2366675,CDM,C1713,HCPCS,0278,RC,,,,both,,,750.37,487.74,,,,,,,,,,,,,
SCREW BNE CANC 150MM THRD LEN 30MM OD 6MM XCALIBER ST,SUP-2316314,CDM,C1713,HCPCS,0278,RC,,,,both,,,424.84,276.15,,,,,,,,,,,,,
STEM FEM SZ 2 135DEG TI HA HIP POR PLSM SPR PROX REV,SUP-2408341,CDM,C1776,CPT,0278,RC,,,,both,,,16252.64,10564.22,,,,,,,,,,,,,
SIZER BRST 325CC DIA11.9CM P4.1CM SIL GEL RND SMOOTH MOD +,SUP-2300937,CDM,2720000010,LOCAL,0272,RC,,,,both,,,753.60,489.84,,,,,,,,,,,,,
GRAFT CERV ALLOGRAFT 6MM,SUP-2490652,CDM,C1713,HCPCS,0278,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
POST HUM L30MM DIA9MM SHLDR TAPR HEMICAP,SUP-2123525,CDM,C1713,HCPCS,0278,RC,,,,both,,,1792.94,1165.41,,,,,,,,,,,,,
SHUNT CAR 9FR L31CM W/ T PRT REG TEMP W/OUT RESVR,SUP-2264217,CDM,C1889,HCPCS,0278,RC,,,,both,,,1692.46,1100.10,,,,,,,,,,,,,
STENT TRACHBRONCH WSTNT L 45 MM DIA22 MM SHTH 11 FR CATH L,SUP-2142679,CDM,C1876,HCPCS,0278,RC,,,,both,,,5887.50,3826.87,,,,,,,,,,,,,
HC Bilirubin Total,PX-3018224700,CDM,82247,CPT,0301,RC,,,,both,,,252.00,163.80,,,,,,,,,,,,,
GUIDEWIRE ORTH SMOOTH 3.2X300 MM,SUP-2693950,CDM,C1769,HCPCS,0272,RC,,,,both,,,4835.60,3143.14,,,,,,,,,,,,,
TRAY TRACH INTRO GUID CATH NDL SYR CONN HEMSTAT HYDRPHLC,SUP-2171014,CDM,C1769,HCPCS,0272,RC,,,,both,,,1395.76,907.24,,,,,,,,,,,,,
PLATE BONE X LNG OLECRANON ELBW NONCOMPRESSION,SUP-2107789,CDM,C1713,HCPCS,0278,RC,,,,both,,,4069.44,2645.14,,,,,,,,,,,,,
CLINIMIX E/DEXTROSE (4.25/5) 4.25 % IV SOLN,RX-23162,CDM,2500000003,HCPCS,0250,RC,00338-7022-01,NDC,,both,1000,ML,247.30,160.74,,,,,,,,,,,,,
TUBE EXT FIX 20X640 MM MONOTUBE TRIAX,SUP-2480847,CDM,2720000010,LOCAL,0272,RC,,,,both,,,9091.24,5909.31,,,,,,,,,,,,,
KNIFE SRGCL GLDMN 7INL 3MM GUIDE LEFT ANGLD LATEX FREE,SUP-2705498,CDM,2720000010,LOCAL,0272,RC,,,,both,,,445.38,289.50,,,,,,,,,,,,,
BIT DRL TWST 1.1X61 MM 12 MM W/ STP O-SHANK CYL SS LEVEL 1,SUP-2457787,CDM,2720000010,LOCAL,0272,RC,,,,both,,,474.08,308.15,,,,,,,,,,,,,
PLATE BONE LUHR STR 40MM,SUP-2364679,CDM,C1713,HCPCS,0278,RC,,,,both,,,671.96,436.77,,,,,,,,,,,,,
SYSTEM MENIS REP VERSATILE LO PROF ROBUST W/ PEEK IMPL,SUP-2249485,CDM,C1713,HCPCS,0278,RC,,,,both,,,2681.56,1743.01,,,,,,,,,,,,,
ENDCAP ORTH TIB NAIL STRL LTX,SUP-2861517,CDM,C1889,HCPCS,0278,RC,,,,both,,,368.70,239.65,,,,,,,,,,,,,
FAMOTIDINE 2 MG/ML IN NS INJ SOLN (PED-NEO),RX-4090131,CDM,J1308,HCPCS,0636,RC,09999-9906-54,NDC,,both,1,UN,54.10,35.16,,,,,,,,,,,,,
HC Carboxyhemoglobin Quantitative,PX-3018237500,CDM,82375,CPT,0301,RC,,,,inpatient,,,120.00,78.00,,,,,,,,,,,,,
SET CATH CATH L 15 CM DIA 5.5 FR GUIDEWIRE 0.018 IN NDL L 7,SUP-2884239,CDM,C1751,HCPCS,0278,RC,,,,both,,,524.38,340.85,,,,,,,,,,,,,
DEVICE FIX ARTICULATING RELD W/ 3X 8 DP RELIATACK,SUP-2752196,CDM,C1713,HCPCS,0278,RC,,,,both,,,1589.72,1033.32,,,,,,,,,,,,,
DEVICE FIX DIA8MM TIB PRELD TUNNELOC,SUP-2137203,CDM,C1713,HCPCS,0278,RC,,,,both,,,1874.45,1218.39,,,,,,,,,,,,,
DEVICE ENDOSKELETAL SYS PROSTHETIC BELOW LIMB PREPARATORY,SUP-2388205,CDM,L5530,HCPCS,0274,RC,,,,both,,,4784.51,3109.93,,,,,,,,,,,,,
CATHETER CARD ABLATION RF ENH II L 90 CM DIA 7 FR TIP L 65,SUP-2281900,CDM,C1733,HCPCS,0272,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
RING EXT FIX FULL D 140 MM RX STRL TRUELOK EVO LTX,SUP-2875599,CDM,2720000010,LOCAL,0272,RC,,,,both,,,9369.32,6090.06,,,,,,,,,,,,,
KIT EVAC BLB 7MM 100CC SIL FLAT LO LEV SUCT DISPOSABLE,SUP-2126599,CDM,C1729,HCPCS,0272,RC,,,,both,,,27.00,17.55,,,,,,,,,,,,,
SINGLE USE RETRIEVAL NITINOL BASKET V,SUP-2675476,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1200.27,780.18,,,,,,,,,,,,,
CAP NAIL HUM 8.5X10 MM AG RETROGRADE STRL AFFIXUS NAT NAIL,SUP-2606874,CDM,C1713,HCPCS,0278,RC,,,,both,,,273.18,177.57,,,,,,,,,,,,,
MESH BIO PORCINE MTRX BRST TISS RECON 16CM LEN 4CM W,SUP-2113068,CDM,Q4130,HCPCS,0636,RC,,,,both,,,4989.46,3243.15,,,,,,,,,,,,,
SCREW SCHANZ SD 5X200MM HA COAT TI STRL,SUP-2549742,CDM,C1713,HCPCS,0278,RC,,,,both,,,963.45,626.24,,,,,,,,,,,,,
PACK ARTHSCP ACL PCL RAP PAC C,SUP-2341855,CDM,C1769,HCPCS,0272,RC,,,,both,,,869.34,565.07,,,,,,,,,,,,,
SPACER SPNL W40XH12MM 6DEG WIDE TI ANT INTBDY FUS LORD,SUP-2414751,CDM,C1713,HCPCS,0278,RC,,,,both,,,12560.00,8164.00,,,,,,,,,,,,,
BUR SURG DIA 3.1 MM HUB XLII ROSEN STRL REUSE HI-LINE,SUP-2929086,CDM,2720000010,LOCAL,0272,RC,,,,both,,,744.09,483.66,,,,,,,,,,,,,
DRESSING BIO L 2 X W 4 CM PORCINE CLLGN SINGLE LAYR FEN SHT,SUP-2909412,CDM,Q4195,HCPCS,0636,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.506,SUP-2860023,CDM,C1713,HCPCS,0278,RC,,,,both,,,35308.67,22950.64,,,,,,,,,,,,,
PLATE BONE SM W11XL208MM THK3.3MM 0DEG 16 H BILAT TI STR RIG,SUP-2190795,CDM,C1713,HCPCS,0278,RC,,,,both,,,1360.44,884.29,,,,,,,,,,,,,
COMPONENT TIB BASEPLT UNI 37MM X 6.5MM REPICCI II,SUP-2403267,CDM,C1776,CPT,0278,RC,,,,both,,,2241.96,1457.27,,,,,,,,,,,,,
CATHETER TRAY 6 FR 3L MAXIMAL BARR POWERHOHN,SUP-2126753,CDM,C1751,HCPCS,0278,RC,,,,both,,,851.51,553.48,,,,,,,,,,,,,
WIRE SPNL L30CM DIA0.97MM BEAD LOOP LUQ,SUP-2410237,CDM,C1713,HCPCS,0278,RC,,,,both,,,116.97,76.03,,,,,,,,,,,,,
COMPONENT HUM DIA10.5MM HEMI CAP,SUP-2123524,CDM,C1713,HCPCS,0278,RC,,,,both,,,1796.08,1167.45,,,,,,,,,,,,,
HC Fetal Eval 1st Tri Sgl Gest,PX-4027680100,CDM,76801,CPT,0402,RC,,,,outpatient,,,1288.00,837.20,,,,,,,,,,,,,
CATHETER PERITONEAL POS XR ID 1.2X2.5 MMX90 CM DSTL HOLTER,SUP-2666429,CDM,C1729,HCPCS,0272,RC,,,,both,,,760.76,494.49,,,,,,,,,,,,,
SET INTRO MICROEZ L 50 CM CATH 5 FR NDL L 7 CM FLEXURA RED,SUP-2125503,CDM,C1769,HCPCS,0272,RC,,,,both,,,140.92,91.60,,,,,,,,,,,,,
DEVICE ENDOSKELETAL SYS PROSTHETIC BELOW LIMB PREPARATORY,SUP-2388205,CDM,L5530,HCPCS,0272,RC,,,,both,,,4784.51,3109.93,,,,,,,,,,,,,
PLATE BONE COMPRESSION SMALL 3.5X158 MM CORTICAL 11 HOLE PER,SUP-2837382,CDM,C1713,HCPCS,0278,RC,,,,both,,,1681.28,1092.83,,,,,,,,,,,,,
SCREW DENT 4.3X11.5 MM CONCL CONN RP NOBELREPLACE,SUP-2430155,CDM,C1713,HCPCS,0278,RC,,,,both,,,1000.88,650.57,,,,,,,,,,,,,
HYDROCORT-PRAMOXINE (PERIANAL) 1-1 % EX FOAM,RX-150023,CDM,6370000000,HCPCS,0637,RC,00037-6822-10,NDC,,both,10,GR,874.80,568.62,,,,,,,,,,,,,
GUIDEWIRE ORTH 3.2MM DIA 230MM SMOOTH SHRP TIP S STL W/ LEN,SUP-2412995,CDM,C1713,HCPCS,0278,RC,,,,both,,,66.25,43.06,,,,,,,,,,,,,
STENT BILI 7FR L5CM PLAS CNTR BEND SGL ADVANIX,SUP-2141416,CDM,C2617,HCPCS,0278,RC,,,,both,,,173.64,112.87,,,,,,,,,,,,,
SEALANT TISS 2 CC FIBRIN VISTASEAL,SUP-2427766,CDM,C1713,HCPCS,0278,RC,,,,both,,,369.08,239.90,,,,,,,,,,,,,
SPACER SPNL BLK W6XH14XL14MM ANTR CERV INTBDY FUS,SUP-2293956,CDM,C1713,HCPCS,0278,RC,,,,both,,,3764.86,2447.16,,,,,,,,,,,,,
PLATE BNE STR NAR NS NCB,SUP-2862093,CDM,C1713,HCPCS,0278,RC,,,,both,,,8926.39,5802.15,,,,,,,,,,,,,
VICI STENT SYS 14X120MM 100CM,SUP-2419658,CDM,C1876,HCPCS,0278,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
FILLER BNE GRFT L 9 X W 9 X H 9 MM DEMINERALIZED CANC CUBE,SUP-2894885,CDM,C1713,HCPCS,0278,RC,,,,both,,,1475.80,959.27,,,,,,,,,,,,,
GRAFT BNE 50X10X2 MM 2 CC DBM BI-OSTETIC FOAM,SUP-2225965,CDM,C1713,HCPCS,0278,RC,,,,both,,,7193.74,4675.93,,,,,,,,,,,,,
GRAFT VSCLR L50CM D26MM BRNCH D10MM THRCC CLLGN BFRCTD WOVEN,SUP-2463393,CDM,C1768,CPT,0278,RC,,,,both,,,4459.93,2898.95,,,,,,,,,,,,,
SCREW BONE L14MM DIA2.7MM MIDFOOT VAR ANG COMPR 1ST RAY,SUP-2417629,CDM,C1713,HCPCS,0278,RC,,,,both,,,298.93,194.30,,,,,,,,,,,,,
PIN FIX LNG FOR ANT FIX SYS ANTEGRA-T,SUP-2179473,CDM,C1713,HCPCS,0278,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
PLATE BNE L 76 MM 5 H SS RT DSTL RADIAL VOLAR STD STRL EVOS,SUP-2931167,CDM,C1713,HCPCS,0278,RC,,,,both,,,4983.81,3239.48,,,,,,,,,,,,,
SHEATH INTRO BAN PEEL L 15 CM DIA16 FR STRL,SUP-2141072,CDM,C1892,HCPCS,0272,RC,,,,both,,,131.41,85.42,,,,,,,,,,,,,
COLLAR CERV SFT 3X22IN UNIV,SUP-2276583,CDM,L0120,HCPCS,0274,RC,,,,both,,,6.59,4.28,,,,,,,,,,,,,
MESH SURG DIA6.6CM POLY PGLA CLLGN FLM RIG ABSRB EXP SEMI,SUP-2283994,CDM,C1781,HCPCS,0278,RC,,,,both,,,1960.68,1274.44,,,,,,,,,,,,,
TREMELIMUMAB-ACTL 300 MG/15ML IV SOLN,RX-160346,CDM,J9347,HCPCS,0636,RC,00310-4535-30,NDC,,both,3.75,ML,30196.10,19627.46,,,,,,,,,,,,,
CATHETER ELECHEMSTAS 7FR L300CM WRK CHN 2.8MM G PRB STD,SUP-2149698,CDM,2720000010,LOCAL,0272,RC,,,,both,,,504.22,327.74,,,,,,,,,,,,,
RIB PLATE 14MMX46MM,SUP-2841907,CDM,C1713,HCPCS,0278,RC,,,,both,,,3683.22,2394.09,,,,,,,,,,,,,
NEEDLE NERVE STIM TROCAR PEDCL ACCS NAV PK NIM,SUP-2792159,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2552.25,1658.96,,,,,,,,,,,,,
SHEATH INTRO PRELUDE IDEAL L 11 CM DIA 5 FR IV CATH L 2.5 CM,SUP-2740585,CDM,C1892,HCPCS,0272,RC,,,,both,,,197.82,128.58,,,,,,,,,,,,,
HC Group Exercise Pt,PX-4209715000,CDM,97150,CPT,0420,RC,,,,both,,,135.00,87.75,,,,,,,,,,,,,
PLATE BONE LOCKING 4.5X336 MM 18 HOLE COMPRESSION,SUP-2837369,CDM,C1713,HCPCS,0278,RC,,,,both,,,9137.40,5939.31,,,,,,,,,,,,,
PLATE BNE W5XL42MM THK1.5MM 8 H BILAT TI STR RIG NEUT DYN,SUP-2191045,CDM,C1713,HCPCS,0278,RC,,,,both,,,1168.36,759.43,,,,,,,,,,,,,
NAIL IM DSTL TIB GRY 10MMX26CM,SUP-2347126,CDM,C1713,HCPCS,0278,RC,,,,both,,,4065.20,2642.38,,,,,,,,,,,,,
SET PLUG 0.6X9.5CM FOR ANORECT FIST BIODESIGN,SUP-2171027,CDM,C1763,HCPCS,0278,RC,,,,both,,,4370.88,2841.07,,,,,,,,,,,,,
PLATE BNE HUM 94 MM RT DSTL POSTEROLATERAL 11 HOLE STRL LTX,SUP-2861608,CDM,C1713,HCPCS,0278,RC,,,,both,,,3861.63,2510.06,,,,,,,,,,,,,
SUPPORT ORTHOT FT METATRSL ARCH REMOVABLE PREMOLDED,SUP-2435705,CDM,L3050,HCPCS,0272,RC,,,,both,,,133.26,86.62,,,,,,,,,,,,,
MESH BONE 262MMW X 262MML 03MM THK RSRB X SM GRID LATEX F,SUP-2681446,CDM,C1713,HCPCS,0278,RC,,,,both,,,1327.97,863.18,,,,,,,,,,,,,
SPACER SPNL W18XH10XL60MM PEEK LAT LUM INTBDY FUS,SUP-2310914,CDM,C1821,HCPCS,0278,RC,,,,both,,,12120.40,7878.26,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9 % IV SOLN,RX-27838,CDM,J7050,HCPCS,0258,RC,00338-0049-02,NDC,,both,250,ML,36.20,23.53,,,,,,,,,,,,,
K WIRE FIX L4IN DIA0.062IN SMOOTH DBL TRCR PT,SUP-2304019,CDM,C1713,HCPCS,0278,RC,,,,both,,,16.33,10.61,,,,,,,,,,,,,
ROD EXT FIX L250MM S STL THRD TELSCP ORIG CIR FOR TAY SPAT,SUP-2342305,CDM,2720000010,LOCAL,0272,RC,,,,both,,,365.50,237.57,,,,,,,,,,,,,
ROD SPNL 72205510] ZIMMER SPINE],SUP-2415700,CDM,C1713,HCPCS,0278,RC,,,,both,,,474.14,308.19,,,,,,,,,,,,,
SUPPORT MAMM SURG 48-50 IN 2XL BRA,SUP-2336341,CDM,L8000,HCPCS,0274,RC,,,,both,,,123.50,80.27,,,,,,,,,,,,,
GUIDEWIRE VASC L 65 CM UNIV,SUP-2148724,CDM,C1769,HCPCS,0272,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
CATHETER ANGIOPLSTY DORADO L 120 CM BALLOON L 4 CM DIA 9 MM,SUP-2128101,CDM,C1725,HCPCS,0272,RC,,,,both,,,580.90,377.58,,,,,,,,,,,,,
CATHETER ANGIOPLSTY L 90 CM DIA 5.3 FR BALLOON L 20 MM DIA 4,SUP-2141832,CDM,C1725,HCPCS,0272,RC,,,,both,,,662.54,430.65,,,,,,,,,,,,,
SCREW BNE L75MM DIA4.5MM LNG THRD L30MM TAN CANN SELF DRL,SUP-2181437,CDM,C1713,HCPCS,0278,RC,,,,both,,,951.55,618.51,,,,,,,,,,,,,
PLATE BONE L62MM 5 H POST LAT S STL 1/3 TBLR LCK COMPR FOR,SUP-2349794,CDM,C1713,HCPCS,0278,RC,,,,both,,,1876.21,1219.54,,,,,,,,,,,,,
STENT URET DBL PGTL 0.035 INX150 CM 3 CM 6 FRX30 CM POLARIS,SUP-2465195,CDM,C2617,HCPCS,0278,RC,,,,both,,,681.82,443.18,,,,,,,,,,,,,
"HC Pt Therapeutic Exercise,Ea 15 Min|OP PT SERVICES|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS",PX-4209711000,CDM,97110,CPT,0420,RC,,,GP|CQ,both,,,195.00,126.75,,,,,,,,,,,,,
HYDROCORTISONE-ACETIC ACID 1-2 % OT SOLN,RX-24385,CDM,6370000000,HCPCS,0637,RC,51672-3007-01,NDC,,both,10,ML,609.60,396.24,,,,,,,,,,,,,
CABLE ORTH L750MM DIA2MM HIP VIT DALL-M,SUP-2377585,CDM,C1776,CPT,0278,RC,,,,both,,,649.35,422.08,,,,,,,,,,,,,
PLATE BNE L 90 X W 10.7 MM THK 3.4 MM SCREW DIA 3.5 MM 7 H,SUP-2936380,CDM,C1713,HCPCS,0278,RC,,,,both,,,731.78,475.66,,,,,,,,,,,,,
KIT INT FIX ACL GUID PIN K WIRE DRL BIT SUT LOOP PASS BNE,SUP-2212934,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1507.20,979.68,,,,,,,,,,,,,
KIT REP DISP ASPIRA,SUP-2301572,CDM,C1729,HCPCS,0272,RC,,,,both,,,69.08,44.90,,,,,,,,,,,,,
TRACKER SURG NAVIGATION PT TRUDI,SUP-2883970,CDM,2720000010,LOCAL,0272,RC,,,,both,,,659.40,428.61,,,,,,,,,,,,,
GRAFT BNE STRP 50X10X7 MM COMPRESSIBLE BNE MTRX,SUP-2644322,CDM,C1713,HCPCS,0278,RC,,,,both,,,4621.77,3004.15,,,,,,,,,,,,,
HOOK SPNL L S STL PEDCL NEUT BILAT OPN THRT TOP LD WIDE,SUP-2288835,CDM,C1713,HCPCS,0278,RC,,,,both,,,2379.81,1546.88,,,,,,,,,,,,,
HC 2d Echo W Contrast - WO Dop/Color Flow,PX-4839330700,CDM,C8923,CPT,0483,RC,,,,inpatient,,,1075.00,698.75,,,,,,,,,,,,,
CATHETER HD 16 FRX21 CM TIP TO CUF HEMOSPLIT,SUP-2269495,CDM,C1881,HCPCS,0278,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
DRESSING NSL L 8 CM POLYMER X FIRM BIORESORBABLE STRL DISP,SUP-2900113,CDM,2720000010,LOCAL,0272,RC,,,,both,,,675.38,439.00,,,,,,,,,,,,,
HEAD UPLR DIA47MM HIP BALL MOD CATHCART SELF CNTR,SUP-2251039,CDM,C1776,CPT,0278,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
PLATE BNE L131MM 7 H ST L DST LAT FIBULAR S STL VAR ANG LOK,SUP-2177728,CDM,C1713,HCPCS,0278,RC,,,,both,,,2919.57,1897.72,,,,,,,,,,,,,
CANNULA ENDOSCP W/O VLV 11 MMX13 CM W/ 2 FLNG ADJ CONE,SUP-2767245,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1088.58,707.58,,,,,,,,,,,,,
COLLAR CERV SFT 4X22IN UNIV,SUP-2276584,CDM,L0120,HCPCS,0272,RC,,,,both,,,7.79,5.06,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL 20 ML MONOMER VI PCH STRL,SUP-2934646,CDM,C1713,HCPCS,0278,RC,,,,both,,,1786.66,1161.33,,,,,,,,,,,,,
CATHETER DLYS AD L62.5CM SWAN NK CURL DBL CUF R COILED ARGY,SUP-2283990,CDM,C1750,HCPCS,0278,RC,,,,both,,,595.41,387.02,,,,,,,,,,,,,
CLAMP EXT FIX M DSTL RAD S STL SELF HLD CLP ON COMB REPROC,SUP-2188522,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1673.65,1087.87,,,,,,,,,,,,,
GRAFT ALLODERM SELECT REGENERATIVE TISSUE MATRIX 4X7,SUP-2665174,CDM,Q4116,HCPCS,0636,RC,,,,both,,,3105.46,2018.55,,,,,,,,,,,,,
GRAFT BIO TISS OMEGA3 MARIGEN 1.75X1.75CM,SUP-2261683,CDM,Q4158,HCPCS,0636,RC,,,,both,,,1667.34,1083.77,,,,,,,,,,,,,
BIT DRL L125MM DIA1.8MM QUIK CPL NONRADIOLUCENT W/O STP,SUP-2187303,CDM,2720000010,LOCAL,0272,RC,,,,both,,,573.68,372.89,,,,,,,,,,,,,
DEXTROSE 5 % AND 0.9 % NACL IV BOLUS,RX-40840054,CDM,J7042,HCPCS,0250,RC,00264-7610-00,NDC,,both,250,ML,8.50,5.52,,,,,,,,,,,,,
ANCHOR SUT 3 STRND INTELLIBRAID TECHNOLOGY W/ NO2 FORC FBR,SUP-2366695,CDM,C1713,HCPCS,0278,RC,,,,both,,,1353.56,879.81,,,,,,,,,,,,,
STEM RAD L40MM OD9MM WRST IMPL MAESTRO,SUP-2407299,CDM,C1776,CPT,0278,RC,,,,both,,,4049.34,2632.07,,,,,,,,,,,,,
PLATE BNE W3.8XL100MM 20 H BILAT S STL STR LO PROF NEUT LOK,SUP-2186287,CDM,C1713,HCPCS,0278,RC,,,,both,,,781.26,507.82,,,,,,,,,,,,,
KIT CATH HEMODIALYSI NIAG SLIM CATH ACTE 12FR DIA 12.5CML IN,SUP-2613232,CDM,C1752,HCPCS,0278,RC,,,,both,,,405.06,263.29,,,,,,,,,,,,,
PLATE BONE DUAL CMPRSSN HLX6 TTNM CNTRD F/3.5MM LOK SCREW ST,SUP-2488123,CDM,C1713,HCPCS,0278,RC,,,,both,,,1610.63,1046.91,,,,,,,,,,,,,
KIT PROCEDURE 16X13MM STAPLE SYSTEM PROCEDURE ARCUS,SUP-2477375,CDM,C1713,HCPCS,0278,RC,,,,both,,,2649.85,1722.40,,,,,,,,,,,,,
BASEPLATE TIB L62XW37MM UNIV DURAC KNEE CRUCFRM BEAD IMPL,SUP-2377157,CDM,C1776,CPT,0278,RC,,,,both,,,9077.74,5900.53,,,,,,,,,,,,,
HC So Ehrlichia Chaffeensis Igg /Igm,PX-3028666666,CDM,86666,CPT,0302,RC,,,,inpatient,,,132.00,85.80,,,,,,,,,,,,,
K WIRE FIX L150MM DIA1.6MM S STL SGL END SMOOTH SGL SHRP,SUP-2371657,CDM,C1713,HCPCS,0278,RC,,,,both,,,31.40,20.41,,,,,,,,,,,,,
DEXTROSE 5 % AND 0.9 % NACL IV BOLUS,RX-40840054,CDM,2580000003,HCPCS,0250,RC,00338-0089-03,NDC,,both,250,ML,19.20,12.48,,,,,,,,,,,,,
CLAMP SPNL DEV 2 5.5MM DIA ROD TENOR SPNL SYS,SUP-2289283,CDM,C1713,HCPCS,0278,RC,,,,both,,,2100.66,1365.43,,,,,,,,,,,,,
SCREW INTFR L30MM DIA11MM KNEE PLLA CANN ABSRB RND HD,SUP-2249527,CDM,C1713,HCPCS,0278,RC,,,,both,,,1438.12,934.78,,,,,,,,,,,,,
KIT SHRP FOR GEN STPL PLATE STRL DISP MOTOBAND CP DYNAFORCE,SUP-2893436,CDM,2720000010,LOCAL,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
SCREW BONE L45MM DIA5MM CORT VOLAR S ST NONCANNULATED LCK,SUP-2348625,CDM,C1713,HCPCS,0278,RC,,,,both,,,154.49,100.42,,,,,,,,,,,,,
IMPLANT HUM TISS L 8 X W 4 CM DECELL PLCNTA MEMBRN TEND NEVE,SUP-2881935,CDM,C1762,CPT,0278,RC,,,,both,,,14115.87,9175.32,,,,,,,,,,,,,
PLATE BONE L73MM 5 H OBLQ T SHP PERI-LOC SM FRAG SYS,SUP-2348452,CDM,C1713,HCPCS,0278,RC,,,,both,,,2068.10,1344.26,,,,,,,,,,,,,
SCREW BNE LCK 3.5X48 MM PERIARTICULAR N CANN SS NS,SUP-2410817,CDM,C1713,HCPCS,0278,RC,,,,both,,,310.48,201.81,,,,,,,,,,,,,
BAR SPNL S STL INTEGR CRMP ATLS,SUP-2289630,CDM,C1713,HCPCS,0278,RC,,,,both,,,248.06,161.24,,,,,,,,,,,,,
PLATE BNE L184MM BLDE W11.7XL30MM 90DEG 10 H ST BILAT S STL,SUP-2185446,CDM,C1713,HCPCS,0278,RC,,,,both,,,4408.03,2865.22,,,,,,,,,,,,,
CLAMP ROD CLP FOR ORTHOFIX PREFIX FIX,SUP-2316286,CDM,2720000010,LOCAL,0272,RC,,,,both,,,906.33,589.11,,,,,,,,,,,,,
PUMP CNTRFUG PED BLD 50ML PRIMING 4500RPM CONE BP50 BIO PMP,SUP-2280159,CDM,2720000010,LOCAL,0272,RC,,,,both,,,427.89,278.13,,,,,,,,,,,,,
STEM FEM CEM -5 MM 5 9X175 MM 25 MM HIP CRV REDUC NK TAPR,SUP-2376613,CDM,C1776,CPT,0278,RC,,,,both,,,15848.21,10301.34,,,,,,,,,,,,,
HOLDER INSTRUMENT LG 7.5 MM MT TYP B SIL,SUP-2484760,CDM,C1713,HCPCS,0278,RC,,,,both,,,60.82,39.53,,,,,,,,,,,,,
HALF PIN 4X150MM 35MM THR,SUP-2818388,CDM,2720000010,LOCAL,0272,RC,,,,both,,,895.47,582.06,,,,,,,,,,,,,
CLAMP RING HOFFMAN II HYBRID,SUP-2678698,CDM,2720000010,LOCAL,0272,RC,,,,both,,,332.02,215.81,,,,,,,,,,,,,
BIT DRL 4.75/5.5 MM ARGO KNOTLESS DISP,SUP-2846776,CDM,2720000010,LOCAL,0272,RC,,,,both,,,864.10,561.66,,,,,,,,,,,,,
STENT URET 45FR L8CM NYL COAT DBL PGTL BRAID HYDRPHLC OPN,SUP-2313796,CDM,C2617,HCPCS,0278,RC,,,,both,,,245.80,159.77,,,,,,,,,,,,,
CATHETER INFUSION,SUP-2305457,CDM,C1887,HCPCS,0272,RC,,,,both,,,2920.20,1898.13,,,,,,,,,,,,,
STEM FEM L250MM OD12MM 80% POR PLSM SPRY DSTL HIP BOW RL,SUP-2408822,CDM,C1776,CPT,0278,RC,,,,both,,,7887.68,5126.99,,,,,,,,,,,,,
HC CT Chest W/ Contrast,PX-3527126000,CDM,71260,CPT,0352,RC,,,,both,,,1973.00,1282.45,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY LIVEWIRE L115CM 6FR 4MM QPLR CURL,SUP-2494656,CDM,C1730,HCPCS,0272,RC,,,,both,,,504.32,327.81,,,,,,,,,,,,,
HC Thromb Mech Vein,PX-3613718700,CDM,37187,CPT,0361,RC,,,,outpatient,,,7160.00,4654.00,,,,,,,,,,,,,
CATHETER SPNL OD1MM ODSEC17GA ID.5MM TI POLYUR KT INTEGR,SUP-2257114,CDM,C1889,HCPCS,0278,RC,,,,both,,,2439.78,1585.86,,,,,,,,,,,,,
PROSTHESIS OSS PISTON 0.6X3.50 MM ARMSTR STYL PLASTI PORE,SUP-2637835,CDM,L8613,CPT,0278,RC,,,,both,,,514.71,334.56,,,,,,,,,,,,,
HC Replac Central Tun Cath W/Port,PX-3613658200,CDM,36582,CPT,0361,RC,,,,inpatient,,,3707.00,2409.55,,,,,,,,,,,,,
PPICC PROV PED 3F SLEEVE MAXDELTA,SUP-2613522,CDM,C1751,HCPCS,0278,RC,,,,both,,,799.63,519.76,,,,,,,,,,,,,
CATHETER ANGIO RAVI MG1 038 4 FRX125 CM SS GLIDECATH,SUP-2852405,CDM,C1887,HCPCS,0272,RC,,,,both,,,166.99,108.54,,,,,,,,,,,,,
CATH EP ABLATION VARIPULSE BIDIR 8.5FR,SUP-2928125,CDM,C1733,HCPCS,0272,RC,,,,both,,,19383.22,12599.09,,,,,,,,,,,,,
HC MRI Breast W&WO Cont Incl Cad Bilateral,PX-6107704900,CDM,C8908,CPT,0610,RC,,,,outpatient,,,5627.00,3657.55,,,,,,,,,,,,,
GUIDEWIRE SURGICAL L12IN DIA24MM REUSABLE APERFIX,SUP-2589282,CDM,C1769,HCPCS,0272,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
GRAFT BIO TISS W12XL6CM THK2MM NONDENATURED BOV CLLGN,SUP-2243680,CDM,C9360,HCPCS,0278,RC,,,,both,,,4069.44,2645.14,,,,,,,,,,,,,
KIT INSRTN INTRO L 6 IN CATH DIA 7.5 FR 34/40 CC PACKAGED,SUP-2908583,CDM,C1769,HCPCS,0272,RC,,,,both,,,379.31,246.55,,,,,,,,,,,,,
SCREW BONE L5MM DIA1.5MM GRN TI CRANIOMAXILLOFACIAL SELF DRL,SUP-2403085,CDM,C1713,HCPCS,0278,RC,,,,both,,,256.85,166.95,,,,,,,,,,,,,
PLATE BONE GORILLA GRIP 20MM THICKNESS LEFT M,SUP-2741754,CDM,C1713,HCPCS,0278,RC,,,,both,,,5487.15,3566.65,,,,,,,,,,,,,
PLATE BNE L145MM 12 H S STL 1/3 TBLR W/ CLLR LIMIT CNTCT,SUP-2185940,CDM,C1713,HCPCS,0278,RC,,,,both,,,531.32,345.36,,,,,,,,,,,,,
SCREW LANCER SET MT20 001,SUP-2164311,CDM,C1713,HCPCS,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
INFLIXIMAB-ABDA 100 MG IV SOLR,RX-139340,CDM,Q5104,HCPCS,0636,RC,78206-0162-01,NDC,,both,1,UN,2222.60,1444.69,,,,,,,,,,,,,
BLADE SAW 11.5X7 MM INT ORAL,SUP-2632407,CDM,2720000010,LOCAL,0272,RC,,,,both,,,328.41,213.47,,,,,,,,,,,,,
CONNECTOR SPNL EXT AX 3X90 MM 2 SCREW DAYTONA OZAT,SUP-2709258,CDM,C1713,HCPCS,0278,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
HC Behavral Qualit Analys Voice,PX-4449252400,CDM,92524,CPT,0444,RC,,,,both,,,719.00,467.35,,,,,,,,,,,,,
DISC SPNL 6 DEG 18X15 MM ENDPLATE ASMBLY ANGLED SECURE-C,SUP-2602758,CDM,C1889,HCPCS,0278,RC,,,,both,,,10990.00,7143.50,,,,,,,,,,,,,
PLATE BONE L358MM 22 H BILAT S STL BROAD LO PROF RIG DYN,SUP-2185282,CDM,C1713,HCPCS,0278,RC,,,,both,,,1699.18,1104.47,,,,,,,,,,,,,
PLATE BONE SM THK0.4MM NONSTERILE RT ORBIT DK PUR TI PREFRM,SUP-2181781,CDM,C1713,HCPCS,0278,RC,,,,both,,,5939.00,3860.35,,,,,,,,,,,,,
GRAFT BNE CORTICAL 22X1 CM,SUP-2165532,CDM,C1713,HCPCS,0278,RC,,,,both,,,10453.06,6794.49,,,,,,,,,,,,,
CATHETER URET 5FR L70CM LT WHSTL TIP FOR DRNGE RG PYELOGRAM,SUP-2168873,CDM,C1758,HCPCS,0278,RC,,,,both,,,52.60,34.19,,,,,,,,,,,,,
ALLOGRAFT BNE SM 100-125 MM FRZN IRRADIATED CORTICAL SHFT,SUP-2866975,CDM,C1762,CPT,0278,RC,,,,both,,,2076.17,1349.51,,,,,,,,,,,,,
COIL DELTAPLUSH STRETCH RESIST 1.5MMX1CM,SUP-2466226,CDM,C1889,HCPCS,0278,RC,,,,both,,,5209.70,3386.30,,,,,,,,,,,,,
CATHETER NEPHSTMY 24-8FR L52CM PERCFLX STENTING N COAT PGTL,SUP-2147762,CDM,C1729,HCPCS,0272,RC,,,,both,,,207.24,134.71,,,,,,,,,,,,,
ENDO FUSE  FUSION BEAM 30X20MM,SUP-2469973,CDM,C1713,HCPCS,0278,RC,,,,both,,,5601.76,3641.14,,,,,,,,,,,,,
GRAFT BNE PTTY 10 CC SYR DBM ACCELL EVO3C,SUP-2641765,CDM,C1713,HCPCS,0278,RC,,,,both,,,6612.84,4298.35,,,,,,,,,,,,,
GRAFT BONE CORT STRUT ALLGRFT FRZN,SUP-2165593,CDM,C1713,HCPCS,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
GUIDEWIRE ORTHOPEDIC FLUT TIP 2.8X220 MM,SUP-2423242,CDM,C1769,HCPCS,0272,RC,,,,both,,,326.56,212.26,,,,,,,,,,,,,
WASHER OD7MM BLU FLAT MAXTORQUE,SUP-2399471,CDM,C1713,HCPCS,0278,RC,,,,both,,,295.16,191.85,,,,,,,,,,,,,
COMPONENT PAT SZ 1 10MM POLYETH N-K FLX,SUP-2200040,CDM,C1776,CPT,0278,RC,,,,both,,,2408.38,1565.45,,,,,,,,,,,,,
GUIDEWIRE VASC BLNT 350 MM NIT,SUP-2630450,CDM,C1769,HCPCS,0272,RC,,,,both,,,221.94,144.26,,,,,,,,,,,,,
BIT DRL L46MM DIA1MM 4MM STP STRYKR END DISP FOR 1.2MM SCR,SUP-2366398,CDM,2720000010,LOCAL,0272,RC,,,,both,,,397.68,258.49,,,,,,,,,,,,,
IB KIT PEEK NON-COLLAGEN COATED,SUP-2812060,CDM,C1713,HCPCS,0278,RC,,,,both,,,4694.30,3051.29,,,,,,,,,,,,,
COMPONENT TIB L150MM L7CM THK9MM PROX N MOD CEM STEM 1 PC,SUP-2405790,CDM,C1776,CPT,0278,RC,,,,both,,,21463.47,13951.26,,,,,,,,,,,,,
HC Bedside Swallowing Eval|OP SPEECH LANGUAGE SERVICE,PX-4449261000,CDM,92610,CPT,0444,RC,,,GN,both,,,355.00,230.75,,,,,,,,,,,,,
BLADE DISP MILLER CH FBR OPT SZ 2 153MMX12MM GRNLN,SUP-2381518,CDM,2720000010,LOCAL,0272,RC,,,,both,,,30.08,19.55,,,,,,,,,,,,,
SCREW BONE L16MM DIA3MM GRN TI ALLOY ST SELF DRL CANN,SUP-2399806,CDM,C1713,HCPCS,0278,RC,,,,both,,,788.14,512.29,,,,,,,,,,,,,
GAUGE DEPTH FOR RECON SYS VERTEX MAX,SUP-2286802,CDM,C1713,HCPCS,0278,RC,,,,both,,,1176.43,764.68,,,,,,,,,,,,,
JOINT TOE METATARSOPHALANGEAL 10 MM CARTIVA,SUP-2519595,CDM,C1776,CPT,0278,RC,,,,both,,,11972.82,7782.33,,,,,,,,,,,,,
SCREW BNE ST 3.5X65 MM CONCL PARTIAL THRD W/ STARDRV RECESS,SUP-2184318,CDM,C1713,HCPCS,0278,RC,,,,both,,,368.51,239.53,,,,,,,,,,,,,
DEVICE SIZING GRAFT FIX 0 1.3 MM KT TENODESIS SUTURETAPE W/ NDL,SUP-2423012,CDM,2720000010,LOCAL,0272,RC,,,,both,,,926.30,602.09,,,,,,,,,,,,,
ALLOGRAFT TISS 8 MM CORNERSTONE,SUP-2113943,CDM,C1713,HCPCS,0278,RC,,,,both,,,2662.34,1730.52,,,,,,,,,,,,,
PLATE BNE CRV 2.3X30 MM FRAC COMPR FOR SCR TI LEVEL 1,SUP-2475936,CDM,C1713,HCPCS,0278,RC,,,,both,,,948.09,616.26,,,,,,,,,,,,,
POST PLT WRST TI LOK HUB CAP,SUP-2107845,CDM,C1713,HCPCS,0278,RC,,,,both,,,464.72,302.07,,,,,,,,,,,,,
WIRE EXT FIX BAYNT 1.8 MM,SUP-2197297,CDM,2720000010,LOCAL,0272,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
PLATE BNE SM 2X5 H TI MED MALL LOK COMPR FOR 35 4MM SCR,SUP-2398387,CDM,C1713,HCPCS,0278,RC,,,,both,,,1551.16,1008.25,,,,,,,,,,,,,
COUNTERSINK DRL CANN FOR 7MM CHARLOTTE MULT USE COMPR SCR,SUP-2397750,CDM,2720000010,LOCAL,0272,RC,,,,both,,,602.88,391.87,,,,,,,,,,,,,
PLATE BNE 4 H XS ORBIT FLR NS DISP,SUP-2934900,CDM,C1713,HCPCS,0278,RC,,,,both,,,8813.98,5729.09,,,,,,,,,,,,,
PLATE BONE L29MM 4 H BILAT MAXILLOFACIAL MAND ORAL TI STR,SUP-2191324,CDM,C1713,HCPCS,0278,RC,,,,both,,,1303.41,847.22,,,,,,,,,,,,,
PLATE BONE LOW PROFILE MEDIUM 1.6X0.4 MM CONTOURABLE MESH MA,SUP-2838374,CDM,C1713,HCPCS,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
PLATE BONE MINI L L37MM 110DEG RT,SUP-2364918,CDM,C1713,HCPCS,0278,RC,,,,both,,,270.83,176.04,,,,,,,,,,,,,
GRAFT MTRX DERM HUM TISS ACELLULAR FRZ DRY THN 1CMX2CM,SUP-2306888,CDM,C1762,CPT,0278,RC,,,,both,,,356.26,231.57,,,,,,,,,,,,,
STENT PERIPH LIFESTENT L 20 MM DIA 6 MM CATH L 130 CM DIA 6,SUP-2420389,CDM,C1876,HCPCS,0278,RC,,,,both,,,3124.30,2030.79,,,,,,,,,,,,,
CATH REBAR MICRO 027,SUP-2469113,CDM,C1887,HCPCS,0272,RC,,,,both,,,888.62,577.60,,,,,,,,,,,,,
HC Psa Screening|NOT REASONABLE AND NECESSARY,PX-3010010300,CDM,G0103,HCPCS,0301,RC,,,GZ,both,,,343.00,222.95,,,,,,,,,,,,,
BLOOD PUMP KIT CANN 31 FRX28 CM 18 FRX51 CM VENOUS LIFESPARC,SUP-2570700,CDM,C1889,HCPCS,0278,RC,,,,both,,,67510.00,43881.50,,,,,,,,,,,,,
STAPLE BNE FIX W9XL7MM DIA1.5MM WIRE OSSTPL,SUP-2194212,CDM,C1713,HCPCS,0278,RC,,,,both,,,1004.80,653.12,,,,,,,,,,,,,
ALLOGRAFT BNE GRND 60 CC FRZN IRRADIATED CANC,SUP-2867072,CDM,C1762,CPT,0278,RC,,,,both,,,2765.24,1797.41,,,,,,,,,,,,,
GUIDEWIRE VASC L 260 CM DIA 0.025 IN L 7 CM FLPY TIP L 2.5,SUP-2167594,CDM,C1769,HCPCS,0272,RC,,,,both,,,55.17,35.86,,,,,,,,,,,,,
PLATE BNE L435MM 3 H ST BILAT S STL SPR LO PROF RIG,SUP-2177157,CDM,C1713,HCPCS,0278,RC,,,,both,,,1274.27,828.28,,,,,,,,,,,,,
PLATE BNE BURR HOLE CVR 12X1X0.3 MM CONTOURED FOR SCR TI NS,SUP-2459375,CDM,C1713,HCPCS,0278,RC,,,,both,,,672.84,437.35,,,,,,,,,,,,,
COMPONENT TIB CR 5 UNIV 10 MM NP PRIMARY CEM STEM MONOBLOCK,SUP-2378461,CDM,C1776,CPT,0278,RC,,,,both,,,2859.91,1858.94,,,,,,,,,,,,,
PLATE BONE 4 H N COMPR MAND BILAT TI 2.3MM SCR L 30MM,SUP-2262996,CDM,C1713,HCPCS,0278,RC,,,,both,,,596.60,387.79,,,,,,,,,,,,,
BIT DRL DIA3.2MM MID FOR PHALINX SYS,SUP-2397839,CDM,2720000010,LOCAL,0272,RC,,,,both,,,527.52,342.89,,,,,,,,,,,,,
SET INTRO SHTH L 68.6 CM OD 16 FR GUIDEWIRE 0.038 IN FEM CRV,SUP-2169595,CDM,C1894,HCPCS,0272,RC,,,,both,,,1890.25,1228.66,,,,,,,,,,,,,
STAPLER INT L37CM STPL 21MM CIR ENDOSCP CRV INTLUMN B FRM,SUP-2218993,CDM,2720000010,LOCAL,0272,RC,,,,both,,,772.35,502.03,,,,,,,,,,,,,
INTRODUCER PACE LD SHTH L 14.2 CM DIL L 17.7 CM DIA 9 FR STD,SUP-2148967,CDM,C1894,HCPCS,0272,RC,,,,both,,,172.70,112.25,,,,,,,,,,,,,
BODY FEM L75MM DIA20MM 135DEG 40MM OFFSET PROX TI ALLY,SUP-2252540,CDM,C1776,CPT,0278,RC,,,,both,,,11006.33,7154.11,,,,,,,,,,,,,
IMPLANT ANK JT TALAR COMP R FLAT CUT CO CHROM SALTO TALARIS,SUP-2244182,CDM,C1776,CPT,0278,RC,,,,both,,,31045.18,20179.37,,,,,,,,,,,,,
PLATE BNE 2.7X63 MM 7 HOLE SS LCP,SUP-2569308,CDM,C1713,HCPCS,0278,RC,,,,both,,,371.31,241.35,,,,,,,,,,,,,
GUIDEWIRE ORTH L 150 MM DIA1.1 MM SCREW DIA2.5/3 MM TROCAR,SUP-2907653,CDM,C1769,HCPCS,0272,RC,,,,both,,,270.54,175.85,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED FRAC,SUP-2212723,CDM,C1776,CPT,0278,RC,,,,both,,,4549.86,2957.41,,,,,,,,,,,,,
CATHETER CV SINGLE LUMEN 3 FR BASIC TY W/ SAFETY INTRO GROSH,SUP-2126613,CDM,C1751,HCPCS,0278,RC,,,,both,,,232.99,151.44,,,,,,,,,,,,,
GRAFT BNE W14.5XH6X8XL12MM 7DEG CERV INTBDY FUS LORD,SUP-2264946,CDM,C1713,HCPCS,0278,RC,,,,both,,,3665.32,2382.46,,,,,,,,,,,,,
SPLINT WRST FA UNIV R 8 IN,SUP-2276644,CDM,L3809,HCPCS,0274,RC,,,,both,,,14.63,9.51,,,,,,,,,,,,,
PROBE BRST BX 11GA HANDHELD MAMTOM,SUP-2195648,CDM,2720000010,LOCAL,0272,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE 15 CC VIABLE MTRX NEO MTX,SUP-2901736,CDM,C1713,HCPCS,0278,RC,,,,both,,,19775.72,12854.22,,,,,,,,,,,,,
AGENT HEMSTAT W4XL4IN OXIDIZED REGENERATED CELOS ABSRB SFT,SUP-2218197,CDM,2720000010,LOCAL,0272,RC,,,,both,,,358.93,233.30,,,,,,,,,,,,,
HYDROMORPHONE HCL 2 MG/ML IJ SOLN,RX-3758,CDM,J1171,HCPCS,0636,RC,00641-6151-25,NDC,,both,0.5,ML,54.10,35.16,,,,,,,,,,,,,
MESH HERN LG 15.7X10.2 CM W/ POCKET STRP,SUP-2858045,CDM,C1781,HCPCS,0278,RC,,,,both,,,879.17,571.46,,,,,,,,,,,,,
CATHETER URET 6FR L70CM GWIRE L145CM 0.035IN 20DEG TAPR ANG,SUP-2171227,CDM,C1758,HCPCS,0278,RC,,,,both,,,172.07,111.85,,,,,,,,,,,,,
SCREW BNE L 30 MM DIA 5 MM INTLOK,SUP-2898515,CDM,C1713,HCPCS,0278,RC,,,,both,,,951.42,618.42,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED CERM ON POLYETH STEJH6] STRYKER CORP],SUP-2365940,CDM,C1776,CPT,0278,RC,,,,both,,,15367.16,9988.65,,,,,,,,,,,,,
SCREW BONE L3MM DIA1.5MM SELF DRL SELF CNTR AX STBL FOR CRAN 5PK,SUP-2363858,CDM,C1713,HCPCS,0278,RC,,,,both,,,202.06,131.34,,,,,,,,,,,,,
SCREW BNE ASMBLY 50 MM SHLDR ADJ REVERSED AEQUALIS,SUP-2715362,CDM,C1713,HCPCS,0278,RC,,,,both,,,2168.17,1409.31,,,,,,,,,,,,,
GRAFT BNE SQ 5X5X0.5 CM DBM ACCELL TBM,SUP-2641757,CDM,C1713,HCPCS,0278,RC,,,,both,,,6074.33,3948.31,,,,,,,,,,,,,
SPACER CEM M SHT L94MM DIA54MM PMMA HI REL GENT IMPREG TEMP,SUP-2223676,CDM,C1776,CPT,0278,RC,,,,both,,,13156.60,8551.79,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 80 CM DIA10 MM STR STD WALL HELIX,SUP-2476734,CDM,C1768,CPT,0278,RC,,,,both,,,2791.99,1814.79,,,,,,,,,,,,,
SYSTEM THROMCTMY CLN XT L 65 CM DIA 6 FR GUIDEWIRE 0.035 IN,SUP-2120124,CDM,C1724,HCPCS,0278,RC,,,,both,,,2141.48,1391.96,,,,,,,,,,,,,
COMPONENT HIP CEM UPLR HA LD/FX,SUP-2212771,CDM,C1776,CPT,0278,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
SCREW BONE L14MM DIA3.5MM CORT ANK FT TI ST NONLOCKING FULL,SUP-2362632,CDM,C1713,HCPCS,0278,RC,,,,both,,,257.17,167.16,,,,,,,,,,,,,
PLATE BNE ORBIT FLR LG 1.5X40X35X0.5 MM RT SMRT TI STRL,SUP-2484584,CDM,C1713,HCPCS,0278,RC,,,,both,,,4579.34,2976.57,,,,,,,,,,,,,
FIBER LASER ACCUSTAT,SUP-2225641,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
IMMOBILIZER KNEE AD L22IN FOAM WRP ARND UNIV CLS PAT,SUP-2195242,CDM,L1830,CPT,0272,RC,,,,both,,,23.99,15.59,,,,,,,,,,,,,
STENT ESOPH NITI-S L 6 CM 18 MM 180 CM 10.5 FR FULL CVR,SUP-2425038,CDM,C1874,HCPCS,0278,RC,,,,both,,,8336.70,5418.85,,,,,,,,,,,,,
SCREW LAG FOR AFFIXUS HIP FX NAIL SYS IMP L80MM OD10.5MM,SUP-2211483,CDM,C1713,HCPCS,0278,RC,,,,both,,,1976.32,1284.61,,,,,,,,,,,,,
IMMOBILIZER KNEE 1 SZ FITS MOST WRP ARND ABV KNEE OPN PAT,SUP-2324216,CDM,L1830,CPT,0272,RC,,,,both,,,76.08,49.45,,,,,,,,,,,,,
BLADE SCREWDRVR DIA1.5MM SH CNTR DRV FOR 1.5/2MM MIDFACE,SUP-2402899,CDM,2720000010,LOCAL,0272,RC,,,,both,,,543.22,353.09,,,,,,,,,,,,,
BLADE RTRCTR SM 24MMW X 110MML TTNM SPNL TTHX3 THIN PRPLE LM,SUP-2478743,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1018.02,661.71,,,,,,,,,,,,,
LEAD DEFIB SPRNT QUATTRO SECUR S MRI SURESCAN L 58 CM DIA,SUP-2282262,CDM,C1895,HCPCS,0275,RC,,,,both,,,9744.24,6333.76,,,,,,,,,,,,,
PORT INFUS OD2.7MM ID1.5MM INTRO 8FR TI POLYUR CATH DETACH CT80STPD] ANGIODYNAMICS INC],SUP-2117292,CDM,C1788,HCPCS,0278,RC,,,,both,,,985.96,640.87,,,,,,,,,,,,,
DEVICE VASC HEARTSTRING II DIA 4.3 MM PROX SEAL AORT ANAS,SUP-2227560,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1756.77,1141.90,,,,,,,,,,,,,
IMPLANT BRST 425CC P5.2CM DIA12CM SFT COHESIVE SIL GEL STYL,SUP-2113229,CDM,C1789,HCPCS,0278,RC,,,,both,,,2678.42,1740.97,,,,,,,,,,,,,
GRAFT BNE VIABLE 5 CC BIO4,SUP-2319183,CDM,C1713,HCPCS,0278,RC,,,,both,,,9106.00,5918.90,,,,,,,,,,,,,
HC Electrolyte Panel,PX-3018005100,CDM,80051,CPT,0301,RC,,,,both,,,317.00,206.05,,,,,,,,,,,,,
GRAFT HUM TISS L 8 X W 4 CM 2XL AMNIO MEMBRN RESRB STRL,SUP-2913438,CDM,Q4173,HCPCS,0636,RC,,,,both,,,11250.62,7312.90,,,,,,,,,,,,,
ETOPOSIDE PHOSPHATE 100 MG IV SOLR,RX-17451,CDM,J9181,HCPCS,0636,RC,61269-0410-20,NDC,,both,1,UN,490.70,318.95,,,,,,,,,,,,,
PLATE BONE 6 H T SHP FOR SM BONES ORTHOLOC 3DI,SUP-2398058,CDM,C1713,HCPCS,0278,RC,,,,both,,,1862.02,1210.31,,,,,,,,,,,,,
COMPONENT FEM L4CM KNEE TI DPHSEAL SEG OSS,SUP-2405833,CDM,C1776,CPT,0278,RC,,,,both,,,15288.66,9937.63,,,,,,,,,,,,,
DRILL SURG 0.25 IN DSTL W/ STP MAXM,SUP-2444379,CDM,2720000010,LOCAL,0272,RC,,,,both,,,339.12,220.43,,,,,,,,,,,,,
VLP 2.7MM S-T LOCK SCREW 46MM STER,SUP-2819997,CDM,C1713,HCPCS,0278,RC,,,,both,,,849.78,552.36,,,,,,,,,,,,,
HEAD FEM 17X35X160 MM BIMTRC,SUP-2791017,CDM,C1776,CPT,0278,RC,,,,both,,,9834.48,6392.41,,,,,,,,,,,,,
PLATE BONE L18MM 6 H CRANIOFACIAL VIT STR COND FOR 1.3MM SCR,SUP-2364697,CDM,C1713,HCPCS,0278,RC,,,,both,,,263.76,171.44,,,,,,,,,,,,,
CAP END 5X12MM,SUP-2494165,CDM,C1889,HCPCS,0278,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
GRAFT TISS MATRIX REGEN 4X8CM GRAFTJACKET,SUP-2262294,CDM,Q4107,HCPCS,0636,RC,,,,both,,,9508.17,6180.31,,,,,,,,,,,,,
GUIDEWIRE ORTH 2 HOLE 3.2X12 MM NS,SUP-2799385,CDM,C1769,HCPCS,0272,RC,,,,both,,,2131.53,1385.49,,,,,,,,,,,,,
INTRODUCER LD 0.032 IN 8.5 FRX40 CM SINUS ACCS VLV AGILIS,SUP-2357589,CDM,C1894,HCPCS,0272,RC,,,,both,,,4348.90,2826.78,,,,,,,,,,,,,
CATHETER CV SET 032 8 FRX15 CM DL J TIP RIFAMPIN SPECTRUM,SUP-2759760,CDM,C1751,HCPCS,0278,RC,,,,both,,,111.91,72.74,,,,,,,,,,,,,
GUIDEWIRE UROLOGICAL ANGLED 3 CM 0.038 INX150 CM 66802091,SUP-2862344,CDM,C1769,HCPCS,0272,RC,,,,both,,,115.71,75.21,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 10 CM DIA 8 MM EPTFE STR TW N RING,SUP-2396350,CDM,C1768,CPT,0278,RC,,,,both,,,618.58,402.08,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP L150CM DIA0.038IN INTRO 14FR URIN TRACT,SUP-2139322,CDM,C1769,HCPCS,0272,RC,,,,both,,,50.96,33.12,,,,,,,,,,,,,
SHEATH INTRO FLEXCATH CNTOUR L 65.5 CM DIA10 FR TIP SZ 13 MM,SUP-2882554,CDM,C1766,CPT,0272,RC,,,,both,,,3925.00,2551.25,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 9X9 CM SHT AMNION/CHORION AMNIOFIX,SUP-2872718,CDM,C1762,CPT,0278,RC,,,,both,,,19675.24,12788.91,,,,,,,,,,,,,
COMPONENT TOT KNEE UNIV 45X22 MM 9 MM,SUP-2222198,CDM,C1776,CPT,0278,RC,,,,both,,,6813.80,4428.97,,,,,,,,,,,,,
MAGNESIUM SULFATE 4 GM/100ML IV SOLN,RX-131193,CDM,J3475,HCPCS,0636,RC,00409-6729-23,NDC,,both,100,ML,54.10,35.16,,,,,,,,,,,,,
GUIDEWIRE PC STR TIP 035INX145CM RDRUN THE FIRM LT,SUP-2168205,CDM,C1769,HCPCS,0272,RC,,,,both,,,82.90,53.88,,,,,,,,,,,,,
LENS INTOCU L13MM DIA6MM HYDROPHOBIC ACRYL POST CHMBR,SUP-2102344,CDM,V2632,HCPCS,0276,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH TX2 L 202 MM DIA 30 MM SHTH 20 FR RVD,SUP-2423375,CDM,C1768,CPT,0278,RC,,,,both,,,55829.20,36288.98,,,,,,,,,,,,,
STEM FEM L L60MM NK L35MM SH CEMEX GENTMYCN HI REL IMPREG,SUP-2223679,CDM,C1776,CPT,0278,RC,,,,both,,,9693.18,6300.57,,,,,,,,,,,,,
HC MRI-Upper Ext WO Cont,PX-6107321800,CDM,73218,CPT,0610,RC,,,,inpatient,,,4976.00,3234.40,,,,,,,,,,,,,
PLATE SPNL L118MM ANT BILAT THORLUM TI LOK,SUP-2193105,CDM,C1713,HCPCS,0278,RC,,,,both,,,7595.66,4937.18,,,,,,,,,,,,,
SAW SURG IM SPOOL DRV,SUP-2448361,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1949.94,1267.46,,,,,,,,,,,,,
COUNTERBORE DRILL BIO-POST,SUP-2811826,CDM,2720000010,LOCAL,0272,RC,,,,both,,,907.46,589.85,,,,,,,,,,,,,
ALLOGRAFT BNE BLOCK 30X13X13 MM FD CANC,SUP-2792177,CDM,C1713,HCPCS,0278,RC,,,,both,,,2811.87,1827.72,,,,,,,,,,,,,
GUIDEWIRE VASC STR 035X150 N LT,SUP-2264475,CDM,C1769,HCPCS,0272,RC,,,,both,,,35.33,22.96,,,,,,,,,,,,,
PLATE BONE SM 47MM THK0.3MM SKULL BASE RND MALL FOR 1.5MM,SUP-2363577,CDM,C1713,HCPCS,0278,RC,,,,both,,,2892.32,1880.01,,,,,,,,,,,,,
ALLOGRAFT BNE WDG LG FD IRRADIATED IL CREST,SUP-2867214,CDM,C1762,CPT,0278,RC,,,,both,,,2550.47,1657.81,,,,,,,,,,,,,
INSERTER SPNL CATLYST ALLGRFT,SUP-2285270,CDM,C1713,HCPCS,0278,RC,,,,both,,,479.32,311.56,,,,,,,,,,,,,
GRAFT BNE 5 ML SUBSTITUTE VIABLE OSSIGRAFT,SUP-2901522,CDM,C1713,HCPCS,0278,RC,,,,both,,,8204.82,5333.13,,,,,,,,,,,,,
ARTHROSCOPE VID L 250 MM HF SHTH,SUP-2930423,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1829.84,1189.40,,,,,,,,,,,,,
GRAFT HUM TISS L 2 X W 3 CM THK 0.2 MM HUM AMNIO MEMBRN,SUP-2909418,CDM,Q4282,HCPCS,0636,RC,,,,both,,,5338.00,3469.70,,,,,,,,,,,,,
MESH HERN SM W1XL1.4IN SYN POLY-4-HYDROXYBUTYRATE PLUG AND,SUP-2125873,CDM,C1781,HCPCS,0278,RC,,,,both,,,1349.35,877.08,,,,,,,,,,,,,
BUR SURG L21CM HD L79MM DIA9MM CYL FLUT L BOR MIDAS REX,SUP-2277908,CDM,2720000010,LOCAL,0272,RC,,,,both,,,349.29,227.04,,,,,,,,,,,,,
PREPARATION KIT BNE CEMENT SM 14 FR FEM BOWL SPATULA STRL,SUP-2408545,CDM,2720000010,LOCAL,0272,RC,,,,both,,,514.96,334.72,,,,,,,,,,,,,
VALVE AORT EVOLUT FX + DIA26 MM ANNULUS 20-23 MM PORCINE,SUP-2898735,CDM,C1889,HCPCS,0278,RC,,,,both,,,100480.00,65312.00,,,,,,,,,,,,,
NEEDLE BRST LOC BLNT 20 GAX3 CM W/ ECHOGENIC TIP STRL HAWK3,SUP-2876185,CDM,C1819,HCPCS,0278,RC,,,,both,,,151.03,98.17,,,,,,,,,,,,,
CATHETER CV 1 LUMEN 16 GAX30 CM STYL,SUP-2133136,CDM,C1751,HCPCS,0278,RC,,,,both,,,11.74,7.63,,,,,,,,,,,,,
Cysto W/Ureteroscopy W/Rmvl/Manj Stones|LEFT SIDE,CASE-52352,LOCAL,52352,CPT,0360,RC,,,LT,outpatient,,,23156.35,13893.81,,,,,,,,,,,,,
Replacement Tissue Expander W/Permanent Implant|LEFT SIDE,CASE-11970,LOCAL,11970,CPT,0360,RC,,,LT,outpatient,,,68495.68,41097.41,,,,,,,,,,,,,
Cysto W/Ureteroscopy W/Rmvl/Manj Stones|LEFT SIDE,CASE-52352,LOCAL,52352,CPT,,,,,LT,outpatient,,,23156.35,13893.81,,,,,,,,,,,,,
Replacement Tissue Expander W/Permanent Implant|LEFT SIDE,CASE-11970,LOCAL,11970,CPT,,,,,LT,outpatient,,,68495.68,41097.41,,,,,,,,,,,,,
ALLOGRAFT BNE STRP 22X60 MM PRESERVON TRICORT MATRIGRAFT,SUP-2741052,CDM,C1713,HCPCS,0278,RC,,,,both,,,7138.19,4639.82,,,,,,,,,,,,,
CATHETER HD STR 13 FRX30 CM SHT TERM BASIC SET DUO-SPLIT,SUP-2627180,CDM,C1752,HCPCS,0278,RC,,,,both,,,288.88,187.77,,,,,,,,,,,,,
GRAFT BNE PTTY 5 CC SYR DBM ACCELL EVO3C,SUP-2641764,CDM,C1713,HCPCS,0278,RC,,,,both,,,3560.76,2314.49,,,,,,,,,,,,,
CATHETER DRN GEN W/ RO MRK TOT ABCESSIONGEN DRNAGE 10FRX30CM,SUP-2117068,CDM,C1729,HCPCS,0272,RC,,,,both,,,1095.86,712.31,,,,,,,,,,,,,
COMPONENT CTRL BODY EXT FIX SH FOR JET-X,SUP-2342857,CDM,C1776,CPT,0278,RC,,,,both,,,6538.11,4249.77,,,,,,,,,,,,,
GRAFT BNE GEL 10 CC SYR DBM DYNAGRAFT II,SUP-2641740,CDM,C1713,HCPCS,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
BASEPLATE TIB SZ 6 RT PRI NP CEM FIX COMPARTMENTAL CA KEELED,SUP-2304601,CDM,C1776,CPT,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
CATHETER INTVASC OCCL EQL L 100 CM DIA 7 FR BALLOON DIA 33,SUP-2147471,CDM,C2628,HCPCS,0272,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
CATHETER CTRL VEN 3 LUMN N TUNNELED BASIC KT POLYUR N COAT,SUP-2120589,CDM,C1751,HCPCS,0278,RC,,,,both,,,124.34,80.82,,,,,,,,,,,,,
NAIL IM TROCHANTERIC TI NS,SUP-2180364,CDM,C1713,HCPCS,0278,RC,,,,both,,,1874.58,1218.48,,,,,,,,,,,,,
Marsupialization Bartholins Gland Cyst,CASE-56440,LOCAL,56440,CPT,,,,,,outpatient,,,19234.90,11540.94,,,,,,,,,,,,,
Exc Tum/Vasc Mal Sft Tiss Hand/Fngr Subq <1.5cm|RIGHT SIDE,CASE-26115,LOCAL,26115,CPT,,,,,RT,outpatient,,,13722.23,8233.34,,,,,,,,,,,,,
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level|RIGHT SIDE,CASE-64483,LOCAL,64483,CPT,,,,,RT,outpatient,,,3975.62,2385.37,,,,,,,,,,,,,
Exc Tum/Vasc Mal Sft Tiss Hand/Fngr Subq <1.5cm|RIGHT SIDE,CASE-26115,LOCAL,26115,CPT,0360,RC,,,RT,outpatient,,,13722.23,8233.34,,,,,,,,,,,,,
Marsupialization Bartholins Gland Cyst,CASE-56440,LOCAL,56440,CPT,0360,RC,,,,outpatient,,,19234.90,11540.94,,,,,,,,,,,,,
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level|RIGHT SIDE,CASE-64483,LOCAL,64483,CPT,0360,RC,,,RT,outpatient,,,3975.62,2385.37,,,,,,,,,,,,,
NAIL IM L400MM DIA10MM 130DEG STD R FEM KNEE ROSE TI CANN,SUP-2347364,CDM,C1713,HCPCS,0278,RC,,,,both,,,13066.48,8493.21,,,,,,,,,,,,,
NEEDLE SET CHESBROUGH 19 GAX2.75 IN 5 CM,SUP-2242570,CDM,C1819,HCPCS,0278,RC,,,,both,,,138.16,89.80,,,,,,,,,,,,,
BLADE ARTHSCP STR HIP BLNT TIP,SUP-2608320,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1047.94,681.16,,,,,,,,,,,,,
ALLOGRAFT HUM TISS INJ LG 1 CC STRL ALLOGEN AMINON,SUP-2393046,CDM,Q4139,HCPCS,0636,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
"HC So Enzyme Activity,Cells/Tissue",PX-3018265766,CDM,82657,CPT,0301,RC,,,,outpatient,,,223.00,144.95,,,,,,,,,,,,,
EVOS LG TGTR 3.7MM R DRL,SUP-2931387,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1549.59,1007.23,,,,,,,,,,,,,
PLATE RINGFIX SYS 90DEG 1X2,SUP-2500596,CDM,C1713,HCPCS,0278,RC,,,,both,,,381.51,247.98,,,,,,,,,,,,,
BLADE SAW RCPRCTNG 12MMW X76MML 1.3MM THK 1.3MM THK CUT LG B,SUP-2605425,CDM,2720000010,LOCAL,0272,RC,,,,both,,,71.69,46.60,,,,,,,,,,,,,
GRAFT HUMAN TISSUE 3X4CM THICK AMNIOTIC UMBILICAL CORD PRO3C,SUP-2880640,CDM,C1762,CPT,0278,RC,,,,both,,,6778.48,4406.01,,,,,,,,,,,,,
Laps Surg Rpr Recurrent Inguinal Hernia|LEFT SIDE,CASE-49651,LOCAL,49651,CPT,0360,RC,,,LT,outpatient,,,42988.98,25793.39,,,,,,,,,,,,,
HC Peripheral Block - Femoral Single or Saphenous W/Img Gdn|LEFT SIDE,CASE-64447,LOCAL,64447,CPT,0360,RC,,,LT,outpatient,,,4274.93,2564.96,,,,,,,,,,,,,
Vag Hyst > 250 Gm Rmvl Tube&/Ovary,CASE-58291,LOCAL,58291,CPT,,,,,,outpatient,,,41402.72,24841.63,,,,,,,,,,,,,
Vag Hyst > 250 Gm Rmvl Tube&/Ovary,CASE-58291,LOCAL,58291,CPT,0360,RC,,,,outpatient,,,41402.72,24841.63,,,,,,,,,,,,,
Laps Surg Rpr Recurrent Inguinal Hernia|LEFT SIDE,CASE-49651,LOCAL,49651,CPT,,,,,LT,outpatient,,,42988.98,25793.39,,,,,,,,,,,,,
Rpr Ingun Hernia Sliding Any Age,CASE-49525,LOCAL,49525,CPT,,,,,,outpatient,,,31194.02,18716.41,,,,,,,,,,,,,
HC Drain/Inj Joint/Bursa W/US Large|RIGHT SIDE,CASE-20611,LOCAL,20611,CPT,0510,RC,,,RT,outpatient,,,4204.63,2522.78,,,,,,,,,,,,,
Rpr Ingun Hernia Sliding Any Age,CASE-49525,LOCAL,49525,CPT,0360,RC,,,,outpatient,,,31194.02,18716.41,,,,,,,,,,,,,
MESH HERN M W8.5XL13.7CM L INGUINAL WHT POLYPR MFIL,SUP-2125771,CDM,C1781,HCPCS,0278,RC,,,,both,,,458.44,297.99,,,,,,,,,,,,,
ANCHOR SUT W/ ETHBND SZ 2-0 L18IN GRN POLY BRAID V5 DBL,SUP-2249347,CDM,C1713,HCPCS,0278,RC,,,,both,,,2267.08,1473.60,,,,,,,,,,,,,
CATHETER ETER DRNGE NEPHSTMY MCOT 16FRX35CM,SUP-2141725,CDM,C1729,HCPCS,0272,RC,,,,both,,,196.47,127.71,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 45 CM DIA 4-7 MM SHRT TAPR REINF,SUP-2681781,CDM,C1768,CPT,0278,RC,,,,both,,,950.70,617.95,,,,,,,,,,,,,
DEFIBRILLATOR IMPL IPERIA 7 HF-T W58.5XH65MM D11MM 40J 3.2MM,SUP-2138439,CDM,C1882,HCPCS,0275,RC,,,,both,,,54165.00,35207.25,,,,,,,,,,,,,
SCREW SET BREAK-OFF INSTRUMENT IPC,SUP-2628257,CDM,C1713,HCPCS,0278,RC,,,,both,,,7112.48,4623.11,,,,,,,,,,,,,
BUR SURG L125MM DIA2.7MM RND CUT NONFLUTED DMND END STR,SUP-2108950,CDM,C1713,HCPCS,0278,RC,,,,both,,,544.63,354.01,,,,,,,,,,,,,
CLIP INT LIG SM WIDE TI RED VESOCCLUDE DISP,SUP-2757589,CDM,C1889,HCPCS,0278,RC,,,,both,,,7.22,4.69,,,,,,,,,,,,,
ALLOGRAFT HUM TISS DISC 15 MM AMNIO WND MTRX BIOSKIN,SUP-2759608,CDM,C1762,CPT,0278,RC,,,,both,,,2006.30,1304.09,,,,,,,,,,,,,
BUR SURG DIAMOND 1.3 MM FOR STAP NS REUSE,SUP-2638252,CDM,2720000010,LOCAL,0272,RC,,,,both,,,341.26,221.82,,,,,,,,,,,,,
PLATE BNE ORBIT RIM 47X40 MM RT SIDE EXTN MEDPOR,SUP-2328473,CDM,C1713,HCPCS,0278,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
PEG BONE FXTN L525MM OD4MM STNLSS STEEL PRXML HMRL LOK THRD,SUP-2721540,CDM,C1713,HCPCS,0278,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
FORCEPS BPLR L33MM DIA5MM INSUL CUT COAGULATE PRB RF DISP,SUP-2313949,CDM,C1713,HCPCS,0278,RC,,,,both,,,1212.04,787.83,,,,,,,,,,,,,
"Arthrodesis Great Toe Metatarsophalangeal Joint|LEFT FOOT, GREAT TOE",CASE-28750,LOCAL,28750,CPT,,,,,TA,outpatient,,,62044.37,37226.62,,,,,,,,,,,,,
HC Joint Injection/Aspir Large WO US|RIGHT SIDE|PBB CHARGE,CASE-20610,LOCAL,20610,CPT,0510,RC,,,RT|PBB,outpatient,,,1445.17,867.10,,,,,,,,,,,,,
"Arthrodesis Great Toe Metatarsophalangeal Joint|LEFT FOOT, GREAT TOE",CASE-28750,LOCAL,28750,CPT,0360,RC,,,TA,outpatient,,,62044.37,37226.62,,,,,,,,,,,,,
Mastopexy|BILATERAL PROCEDURE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-19316,LOCAL,19316,CPT,0360,RC,,,50|XU,outpatient,,,71967.40,43180.44,,,,,,,,,,,,,
Mastopexy|BILATERAL PROCEDURE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-19316,LOCAL,19316,CPT,,,,,50|XU,outpatient,,,71967.40,43180.44,,,,,,,,,,,,,
WASHER ORTH DIA3.5/4.5MM FOR PROX TIB PLT,SUP-2185708,CDM,C1713,HCPCS,0278,RC,,,,both,,,158.35,102.93,,,,,,,,,,,,,
DEVICE CLSR ANGIO-SEAL VIP 6FR 0.035IN V TWST INTEGR PLATFRM,SUP-2385247,CDM,C1760,HCPCS,0278,RC,,,,both,,,1359.62,883.75,,,,,,,,,,,,,
ALLOGRAFT DERMAL MED 4X16 CMX1.6/0.4 MM RDY TO USE ALLDERM,SUP-2474753,CDM,Q4116,HCPCS,0636,RC,,,,both,,,7077.56,4600.41,,,,,,,,,,,,,
STEM FEM SZ 002 PROX STEM DIA 16MM DIST STEM DIA 14MM,SUP-2265098,CDM,C1776,CPT,0278,RC,,,,both,,,11018.26,7161.87,,,,,,,,,,,,,
HEAD FEM 28MM +0 CO CHROM,SUP-2359067,CDM,C1776,CPT,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
LINER ACET SZ 6 ID28MM 0DEG ARCM HIP LCK RNG HI RIM WALL SUP,SUP-2405917,CDM,C1776,CPT,0278,RC,,,,both,,,4684.88,3045.17,,,,,,,,,,,,,
INSERT TIB SM THK9MM AP42MM ML67MM STD L KNEE PCA ARTC CRUCE,SUP-2377290,CDM,C1776,CPT,0278,RC,,,,both,,,5685.91,3695.84,,,,,,,,,,,,,
Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq,CASE-45385,LOCAL,45385,CPT,0360,RC,,,,outpatient,,,13998.28,8398.97,,,,,,,,,,,,,
Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq,CASE-45385,LOCAL,45385,CPT,,,,,,outpatient,,,13998.28,8398.97,,,,,,,,,,,,,
Ligamentous Reconstruction Knee Extra-Articular|LEFT SIDE,CASE-27427,LOCAL,27427,CPT,,,,,LT,outpatient,,,76007.77,45604.66,,,,,,,,,,,,,
Insj/Rplcmt Breast Implant Sep Day Mastectomy|LEFT SIDE,CASE-19342,LOCAL,19342,CPT,,,,,LT,outpatient,,,73439.58,44063.75,,,,,,,,,,,,,
Dstr Nrolytc Agnt Parverteb Fct Addl Lmbr/Sacral,CASE-64636,LOCAL,64636,CPT,0360,RC,,,,outpatient,,,11983.28,7189.97,,,,,,,,,,,,,
HC Biopsy of Vulva/Perineum,CASE-56605,LOCAL,56605,CPT,0361,RC,,,,outpatient,,,11324.40,6794.64,,,,,,,,,,,,,
Exc Tumor Soft Tis Neck/Ant Thorax Subq 3 Cm/>,CASE-21552,LOCAL,21552,CPT,,,,,,outpatient,,,19696.30,11817.78,,,,,,,,,,,,,
Dstr Nrolytc Agnt Parverteb Fct Addl Lmbr/Sacral,CASE-64636,LOCAL,64636,CPT,,,,,,outpatient,,,11983.28,7189.97,,,,,,,,,,,,,
Exc Tumor Soft Tis Neck/Ant Thorax Subq 3 Cm/>,CASE-21552,LOCAL,21552,CPT,0360,RC,,,,outpatient,,,19696.30,11817.78,,,,,,,,,,,,,
Insj/Rplcmt Breast Implant Sep Day Mastectomy|LEFT SIDE,CASE-19342,LOCAL,19342,CPT,0360,RC,,,LT,outpatient,,,73439.58,44063.75,,,,,,,,,,,,,
Ligamentous Reconstruction Knee Extra-Articular|LEFT SIDE,CASE-27427,LOCAL,27427,CPT,0360,RC,,,LT,outpatient,,,76007.77,45604.66,,,,,,,,,,,,,
NAIL INTRMDLLRY CNNLTD 30MM DIA 100 POLY L LCTC ACID HELI RS,SUP-2639523,CDM,C1713,HCPCS,0278,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
SET INT FIX SCREW DIA1.5 MM TI NEURO Y DBL PLATE XDRV 12 PK,SUP-2935181,CDM,C1713,HCPCS,0278,RC,,,,both,,,27905.18,18138.37,,,,,,,,,,,,,
ALLOGRAFT BNE 5 CC DEMINERALIZED BONE MTRX ALLOCRAFT,SUP-2636996,CDM,C1713,HCPCS,0278,RC,,,,both,,,2627.55,1707.91,,,,,,,,,,,,,
UNIT PWR MOB W/ CRD,SUP-2356032,CDM,C1713,HCPCS,0278,RC,,,,both,,,27129.60,17634.24,,,,,,,,,,,,,
PLATE BONE L RT 1ST MTP FUS TI ALPS,SUP-2211519,CDM,C1713,HCPCS,0278,RC,,,,both,,,3617.28,2351.23,,,,,,,,,,,,,
SCREW BNE HD 2X10 MM DART-FIRE,SUP-2399800,CDM,C1713,HCPCS,0278,RC,,,,both,,,712.78,463.31,,,,,,,,,,,,,
ROD EXT FIX L500MM DIA11MM C CONN MOD MRI SAFE FOR HOFFMANN,SUP-2372233,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1490.24,968.66,,,,,,,,,,,,,
HC Car Seat Study Add 30 Min,PX-4109478100,CDM,94781,CPT,0410,RC,,,,outpatient,,,63.00,40.95,,,,,,,,,,,,,
HC Specific Gravity Except Urine,PX-3018431500,CDM,84315,CPT,0301,RC,,,,both,,,70.00,45.50,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH L 37 MM DIA DSTL 22 MM SHTH 16 FR SS,SUP-2168746,CDM,C1874,HCPCS,0278,RC,,,,both,,,8992.96,5845.42,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 100 MM DIA 8 MM DEL SHTH,SUP-2934346,CDM,C1713,HCPCS,0278,RC,,,,both,,,15049.77,9782.35,,,,,,,,,,,,,
PIN EXT FIX HALF 4X100X35 MM BLU XTRAFIX,SUP-2435434,CDM,C1713,HCPCS,0278,RC,,,,both,,,403.65,262.37,,,,,,,,,,,,,
Rpr Aa Hernia 1st < 3 Cm Ncrc8/Strangulated,CASE-49592,LOCAL,49592,CPT,0360,RC,,,,outpatient,,,52329.65,31397.79,,,,,,,,,,,,,
Rpr Aa Hernia 1st < 3 Cm Ncrc8/Strangulated,CASE-49592,LOCAL,49592,CPT,,,,,,outpatient,,,52329.65,31397.79,,,,,,,,,,,,,
DRILL SURG 1.6 MM STRL MICRORAPTOR LTX,SUP-2879935,CDM,2720000010,LOCAL,0272,RC,,,,both,,,659.40,428.61,,,,,,,,,,,,,
GRAFT DURA W2XL2IN WHT ABSRB POR NONFRIABLE DBL PEEL CLLGN,SUP-2244082,CDM,C1763,HCPCS,0278,RC,,,,both,,,770.15,500.60,,,,,,,,,,,,,
WASHER ORTH PICKUP STAND PELVIS II,SUP-2496221,CDM,C1713,HCPCS,0278,RC,,,,both,,,1018.11,661.77,,,,,,,,,,,,,
KIT INTRO MAK-NV TROCAR L 15 CM DIA21 GA NONVASCULAR,SUP-2492733,CDM,C1894,HCPCS,0272,RC,,,,both,,,30.62,19.90,,,,,,,,,,,,,
SLEEVE IRRIGATION FOR PM2 STRL LF DISP,SUP-2900576,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1557.28,1012.23,,,,,,,,,,,,,
STAPLER INT AD L31MM DIA5MM STD GI GRN TI CIR CUT 2 ROW,SUP-2421064,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2301.65,1496.07,,,,,,,,,,,,,
ROD ALIGN L165MM CO CHROME FOR SUBTALAR IMPL SYS BIOARCH,SUP-2401367,CDM,C1713,HCPCS,0278,RC,,,,both,,,175.84,114.30,,,,,,,,,,,,,
PLATE BNE 7 H MED EL LOK CONG,SUP-2107808,CDM,C1713,HCPCS,0278,RC,,,,both,,,3136.86,2038.96,,,,,,,,,,,,,
BIT DRL OLECRANON CANN ROD,SUP-2107106,CDM,2720000010,LOCAL,0272,RC,,,,both,,,976.54,634.75,,,,,,,,,,,,,
SEMI-TUB PLT STERILIZER 103 MM LENGTH 6 HL,SUP-2818491,CDM,C1713,HCPCS,0278,RC,,,,both,,,539.11,350.42,,,,,,,,,,,,,
BRACE OPN POPLITEAL 28IN 305IN SZ 3XL FREDDIE,SUP-2196843,CDM,L1810,HCPCS,0272,RC,,,,both,,,66.13,42.98,,,,,,,,,,,,,
HC Custom Finger Static,PX-2740393301,CDM,L3933,HCPCS,0274,RC,,,,inpatient,,,710.00,461.50,,,,,,,,,,,,,
HC So Candida Dna Amp Probe,PX-3068748166,CDM,87481,CPT,0306,RC,,,,both,,,101.00,65.65,,,,,,,,,,,,,
GRAFT BNE PTTY DEMIN BNE MTRX 1CC TREL-XC,SUP-2244466,CDM,C1713,HCPCS,0278,RC,,,,both,,,1114.70,724.55,,,,,,,,,,,,,
GRAFT VASC GORTX L 50 CM DIA 7 MM EPTFE STR TW N RING STRL,SUP-2396704,CDM,C1768,CPT,0278,RC,,,,both,,,1698.74,1104.18,,,,,,,,,,,,,
Posterior Segmental Instrumentation 3-6 Vrt Seg,CASE-22842,LOCAL,22842,CPT,,,,,,outpatient,,,92332.10,55399.26,,,,,,,,,,,,,
Posterior Segmental Instrumentation 3-6 Vrt Seg,CASE-22842,LOCAL,22842,CPT,0360,RC,,,,outpatient,,,92332.10,55399.26,,,,,,,,,,,,,
Ligamentous Reconstruction Knee Extra-Articular|LEFT SIDE|SEPARATE STRUCTURE,CASE-27427,LOCAL,27427,CPT,0360,RC,,,LT|XS,outpatient,,,77952.75,46771.65,,,,,,,,,,,,,
Ligamentous Reconstruction Knee Extra-Articular|LEFT SIDE|SEPARATE STRUCTURE,CASE-27427,LOCAL,27427,CPT,,,,,LT|XS,outpatient,,,77952.75,46771.65,,,,,,,,,,,,,
GRAFT BNE SUB SM 5CC DBM BIOCOMPOSITE OSTEOSET CANC CHIP,SUP-2399073,CDM,C9359,HCPCS,0278,RC,,,,both,,,2420.94,1573.61,,,,,,,,,,,,,
NAIL IM UNIV 11.5 MMX32 CM,SUP-2208238,CDM,C1713,HCPCS,0278,RC,,,,both,,,6129.28,3984.03,,,,,,,,,,,,,
EXTERNAL FIXATION KIT DAMAGE CTRL FASTFRAME,SUP-2493135,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7598.80,4939.22,,,,,,,,,,,,,
SHEATH INTRO HEARTSPAN L 60 CM DIA 8.5 FR NDL L 71 CM MP18,SUP-2516625,CDM,C1893,HCPCS,0272,RC,,,,both,,,555.15,360.85,,,,,,,,,,,,,
PLATE BNE L317MM 15 H L DST PERIPROSTHETIC FEM TI NCB,SUP-2411492,CDM,C1713,HCPCS,0278,RC,,,,both,,,4346.76,2825.39,,,,,,,,,,,,,
CATHETER INTVASC ULTRASOUND ICROSS L 135 CM DIA 3.6 FR FREQ,SUP-2146959,CDM,C1753,HCPCS,0278,RC,,,,both,,,3086.43,2006.18,,,,,,,,,,,,,
PASSER ACL RECON 2 PIN,SUP-2166843,CDM,2720000010,LOCAL,0272,RC,,,,both,,,638.55,415.06,,,,,,,,,,,,,
RING EXT FIX HALF 100 MM TI NS,SUP-2799568,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1047.82,681.08,,,,,,,,,,,,,
HC Injection Small Joint/Bursa,PX-3612060000,CDM,20600,CPT,0361,RC,,,,both,,,358.00,232.70,,,,,,,,,,,,,
SCREW BNE L12MM DIA3.5MM CORT DST RAD VOLAR TI NONLOCKING,SUP-2340287,CDM,C1713,HCPCS,0278,RC,,,,both,,,239.58,155.73,,,,,,,,,,,,,
ARCH EXT FIX FT 100 MM,SUP-2497487,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5375.68,3494.19,,,,,,,,,,,,,
Nasal/Sinus Ndsc W/Rmvl Tiss From Frontal Sinus,CASE-31276,LOCAL,31276,CPT,0360,RC,,,,outpatient,,,98006.38,58803.83,,,,,,,,,,,,,
HC Injection Small Joint/Bursa,CASE-20600,LOCAL,20600,CPT,0361,RC,,,,outpatient,,,5130.12,3078.07,,,,,,,,,,,,,
HC Inj Tendon Sheath/Ligament,CASE-20550,LOCAL,20550,CPT,0510,RC,,,,outpatient,,,3602.73,2161.64,,,,,,,,,,,,,
HC Rm Private,PX-1100000000,CDM,1100000000,LOCAL,,,,,,outpatient,,,2724.58,1634.75,,,,,,,,,,,,,
Nasal/Sinus Ndsc W/Rmvl Tiss From Frontal Sinus,CASE-31276,LOCAL,31276,CPT,,,,,,outpatient,,,98006.38,58803.83,,,,,,,,,,,,,
BUR SURG L3.8MM OD3MM LESS AGG NEURO DRL NONFLUTED ELITE,SUP-2367601,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1190.47,773.81,,,,,,,,,,,,,
GUIDEWIRE SURG 0.032X14 IN INTRF SCR NIT,SUP-2765771,CDM,C1769,HCPCS,0272,RC,,,,both,,,91.19,59.27,,,,,,,,,,,,,
CANNULA SURG L12MM OD10MM ELP BLLN ATRAUM SURF DISK,SUP-2171752,CDM,C1713,HCPCS,0278,RC,,,,both,,,374.04,243.13,,,,,,,,,,,,,
NEEDLE BX DIAMOND TIP 11 GA ACCS STRL DISP,SUP-2849292,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3843.36,2498.18,,,,,,,,,,,,,
GUIDEWIRE VASC L 80 CM DIA 0.035 IN TAPR L 15 CM FLX TIP L 6,SUP-2167759,CDM,C1769,HCPCS,0272,RC,,,,both,,,48.20,31.33,,,,,,,,,,,,,
SET STONE EXTR L75CM EXPLORATION CATH 5.5FR L70CM 4W FOR,SUP-2167922,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1585.70,1030.70,,,,,,,,,,,,,
PLATE BNE 2.7X148 MM 16 HOLE TI STRL LCP,SUP-2789464,CDM,C1713,HCPCS,0278,RC,,,,both,,,1523.09,990.01,,,,,,,,,,,,,
COMPONENT PAT OD32MM THICKNESS 7MM STD UHMWPE NP PRI REV CEM,SUP-2199752,CDM,C1776,CPT,0278,RC,,,,both,,,4755.53,3091.09,,,,,,,,,,,,,
BASKET STONE HELCL 3 FR 16 MMX120 CM 4 WIR W/ TIP NIT STRL,SUP-2769752,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1225.51,796.58,,,,,,,,,,,,,
PLATE BNE L25MM 2 H S STL 1/3 TBLR W/ CLLR LIMIT CNTCT DYN,SUP-2185922,CDM,C1713,HCPCS,0278,RC,,,,both,,,387.76,252.04,,,,,,,,,,,,,
BIT DRILL 3.8MM 50MM,SUP-2514440,CDM,C1776,CPT,0278,RC,,,,both,,,364.24,236.76,,,,,,,,,,,,,
GRAFT BNE SUB 5CC DEMIN BNE MTRX EXPONENT,SUP-2138518,CDM,C1713,HCPCS,0278,RC,,,,both,,,1707.47,1109.86,,,,,,,,,,,,,
SCREW BNE L3MM DIA1.5MM SIL TI SELF DRL FULL THRD,SUP-2760173,CDM,C1713,HCPCS,0278,RC,,,,both,,,259.99,168.99,,,,,,,,,,,,,
PLATE BNE L 1.5X0.6 MM MIDFACE 10 HOLE W/ TAB FOR SCREW STRL,SUP-2518098,CDM,C1713,HCPCS,0278,RC,,,,both,,,879.83,571.89,,,,,,,,,,,,,
Vag Hyst 250 Gm/< W/Rmvl Tube&/Ovary,CASE-58262,LOCAL,58262,CPT,,,,,,outpatient,,,37248.23,22348.94,,,,,,,,,,,,,
Open Biopsy/Excision Inguinofemoral Nodes|RIGHT SIDE,CASE-38531,LOCAL,38531,CPT,,,,,RT,outpatient,,,21935.45,13161.27,,,,,,,,,,,,,
Open Biopsy/Excision Inguinofemoral Nodes|RIGHT SIDE,CASE-38531,LOCAL,38531,CPT,0360,RC,,,RT,outpatient,,,21935.45,13161.27,,,,,,,,,,,,,
HC Bx Breast 1st Lesion US Img|LEFT SIDE,CASE-19083,LOCAL,19083,CPT,0361,RC,,,LT,outpatient,,,10372.50,6223.50,,,,,,,,,,,,,
Dilation & Curettage Dx&/Ther Nonobstetric,CASE-58120,LOCAL,58120,CPT,0360,RC,,,,outpatient,,,20556.90,12334.14,,,,,,,,,,,,,
Sigmoidoscopy Flx W/Biopsy Single/Multiple|COLORECTAL CANCER SCREEN,CASE-45331,LOCAL,45331,CPT,0360,RC,,,PT,outpatient,,,10021.15,6012.69,,,,,,,,,,,,,
Rpr Aa Hernia 1st < 3 Cm Reducible,CASE-49591,LOCAL,49591,CPT,,,,,,outpatient,,,44936.12,26961.67,,,,,,,,,,,,,
Dilation & Curettage Dx&/Ther Nonobstetric,CASE-58120,LOCAL,58120,CPT,,,,,,outpatient,,,20556.90,12334.14,,,,,,,,,,,,,
Rpr Aa Hernia 1st < 3 Cm Reducible,CASE-49591,LOCAL,49591,CPT,0360,RC,,,,outpatient,,,44936.12,26961.67,,,,,,,,,,,,,
Vag Hyst 250 Gm/< W/Rmvl Tube&/Ovary,CASE-58262,LOCAL,58262,CPT,0360,RC,,,,outpatient,,,37248.23,22348.94,,,,,,,,,,,,,
Sigmoidoscopy Flx W/Biopsy Single/Multiple|COLORECTAL CANCER SCREEN,CASE-45331,LOCAL,45331,CPT,,,,,PT,outpatient,,,10021.15,6012.69,,,,,,,,,,,,,
RASP SURG FEATHERTOUCH NSL HANDHELD SGL END STR TAPR FLAT,SUP-2284175,CDM,C1713,HCPCS,0278,RC,,,,both,,,899.30,584.54,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 5 CC ADIPOSE MTRX RENUVA,SUP-2479658,CDM,C1762,CPT,0278,RC,,,,both,,,5168.25,3359.36,,,,,,,,,,,,,
LEAD DEFIB SPRNT QUATTRO SECUR S L 58 CM DIA 8.6 FR SIL,SUP-2282247,CDM,C1777,HCPCS,0275,RC,,,,both,,,9744.24,6333.76,,,,,,,,,,,,,
DILATOR PK ADVNTG ESOPH BAL 15MMX8CM BAL 180CM CATH,SUP-2166054,CDM,C1726,HCPCS,0272,RC,,,,both,,,229.22,148.99,,,,,,,,,,,,,
HC 3rd Order Sel Abd/Lower Ext,PX-3613624700,CDM,36247,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
CATHETER CARD ABLATION THERMOCOOL SF L 115 CM 8 FR D-D CRV,SUP-2516525,CDM,C2630,CPT,0272,RC,,,,both,,,4920.38,3198.25,,,,,,,,,,,,,
CATHETER PICC L 55 CM DIA 4.5 FR 1 LUMEN PRELD VPS STYL BLU,SUP-2886214,CDM,C1751,HCPCS,0278,RC,,,,both,,,1013.18,658.57,,,,,,,,,,,,,
SLEEVE FEM +3.5MM LNG NK TI HIP DYNASTY,SUP-2304514,CDM,C1776,CPT,0278,RC,,,,both,,,2245.10,1459.31,,,,,,,,,,,,,
ALLOGRAFT BNE CHIP 1-9.5 MM 25 CC FRZN N PURGED ASEP CANC,SUP-2717933,CDM,C1713,HCPCS,0278,RC,,,,both,,,2158.75,1403.19,,,,,,,,,,,,,
SPACER SPNL C RNG FOR 55MM SCR CDH LEG,SUP-2292826,CDM,C1713,HCPCS,0278,RC,,,,both,,,766.16,498.00,,,,,,,,,,,,,
Exc Tumor Soft Tissue Abdl Wall Subfascial 5cm/>,CASE-22901,LOCAL,22901,CPT,0360,RC,,,,outpatient,,,19288.97,11573.38,,,,,,,,,,,,,
"Suture Digital Nerve Hand/Foot 1 Nerve|RIGHT HAND, SECOND DIGIT",CASE-64831,LOCAL,64831,CPT,0360,RC,,,F6,outpatient,,,25789.52,15473.71,,,,,,,,,,,,,
Cysto W/Ureteroscopy W/Lithotripsy|RIGHT SIDE,CASE-52353,LOCAL,52353,CPT,0360,RC,,,RT,outpatient,,,27952.95,16771.77,,,,,,,,,,,,,
Arthrodesis Pst/Pstlat Tq 1ntrspc Ea Addl Ntrspc,CASE-22614,LOCAL,22614,CPT,,,,,,outpatient,,,67786.80,40672.08,,,,,,,,,,,,,
HC Joint Injection/Aspir Large WO US|UNUSUAL NON-OVERLAPPING SERVICE|RIGHT SIDE,CASE-20610,LOCAL,20610,CPT,0510,RC,,,XU|RT,outpatient,,,5567.03,3340.22,,,,,,,,,,,,,
Exc Tumor Soft Tissue Abdl Wall Subfascial 5cm/>,CASE-22901,LOCAL,22901,CPT,,,,,,outpatient,,,19288.97,11573.38,,,,,,,,,,,,,
Dstr Nrolytc Agnt Parverteb Fct Addl Lmbr/Sacral|LEFT SIDE,CASE-64636,LOCAL,64636,CPT,,,,,LT,outpatient,,,11924.68,7154.81,,,,,,,,,,,,,
Tissue Expander Placement Breast Reconstruction|BILATERAL PROCEDURE,CASE-19357,LOCAL,19357,CPT,0360,RC,,,50,outpatient,,,241867.90,145120.74,,,,,,,,,,,,,
Dstr Nrolytc Agnt Parverteb Fct Addl Lmbr/Sacral|LEFT SIDE,CASE-64636,LOCAL,64636,CPT,0360,RC,,,LT,outpatient,,,11924.68,7154.81,,,,,,,,,,,,,
"Suture Digital Nerve Hand/Foot 1 Nerve|RIGHT HAND, SECOND DIGIT",CASE-64831,LOCAL,64831,CPT,,,,,F6,outpatient,,,25789.52,15473.71,,,,,,,,,,,,,
Laps Surg Prst8ect Rpbic Rad W/Nrv Sparing Robot,CASE-55866,LOCAL,55866,CPT,0360,RC,,,,outpatient,,,107538.48,64523.09,,,,,,,,,,,,,
Tissue Expander Placement Breast Reconstruction|BILATERAL PROCEDURE,CASE-19357,LOCAL,19357,CPT,,,,,50,outpatient,,,241867.90,145120.74,,,,,,,,,,,,,
Laps Surg Prst8ect Rpbic Rad W/Nrv Sparing Robot,CASE-55866,LOCAL,55866,CPT,,,,,,outpatient,,,107538.48,64523.09,,,,,,,,,,,,,
Cysto W/Ureteroscopy W/Lithotripsy|RIGHT SIDE,CASE-52353,LOCAL,52353,CPT,,,,,RT,outpatient,,,27952.95,16771.77,,,,,,,,,,,,,
Arthrodesis Pst/Pstlat Tq 1ntrspc Ea Addl Ntrspc,CASE-22614,LOCAL,22614,CPT,0360,RC,,,,outpatient,,,67786.80,40672.08,,,,,,,,,,,,,
PLATE BNE L96MM THK1.5MM 3X7 H L S STL OBLQ T SHP LOK COMPR,SUP-2186029,CDM,C1713,HCPCS,0278,RC,,,,both,,,1127.73,733.02,,,,,,,,,,,,,
SCREW BONE LOCKING 2.9X20 MM SELFTAPPING 5/pk TITANIUM NONST,SUP-2842216,CDM,C1713,HCPCS,0278,RC,,,,both,,,768.67,499.64,,,,,,,,,,,,,
HC Smoke/Tobac Counsel 3-10,PX-9429940600,CDM,99406,CPT,0942,RC,,,,outpatient,,,29.00,18.85,,,,,,,,,,,,,
OCD DISPOSABLES KIT,SUP-2812881,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4066.30,2643.09,,,,,,,,,,,,,
SCREW BNE L20MM DIA3.5MM STD CORT DST TIB TI ST LOK FULL,SUP-2413565,CDM,C1713,HCPCS,0278,RC,,,,both,,,414.48,269.41,,,,,,,,,,,,,
Tnot Elbow Lateral/Medial Debride Open Tdn Rpr|RIGHT SIDE,CASE-24359,LOCAL,24359,CPT,,,,,RT,outpatient,,,13020.17,7812.10,,,,,,,,,,,,,
Tnot Elbow Lateral/Medial Debride Open Tdn Rpr|RIGHT SIDE,CASE-24359,LOCAL,24359,CPT,0360,RC,,,RT,outpatient,,,13020.17,7812.10,,,,,,,,,,,,,
SHEATH INTRO OPTISEAL L 25 CM OD 8 FR ID 0.112 IN DIL L 13,SUP-2281852,CDM,C1892,HCPCS,0272,RC,,,,both,,,188.40,122.46,,,,,,,,,,,,,
DEFIBRILLATOR IMPL DYNAGEN MINI W 5.23 X H 7.03 CM D 0.99 CM,SUP-2149166,CDM,C1721,HCPCS,0275,RC,,,,both,,,34408.12,22365.28,,,,,,,,,,,,,
CATHETER EP 7 MM 7 FRX110 CM 1525 MM INQUIRY,SUP-2538004,CDM,C1730,HCPCS,0272,RC,,,,both,,,4458.80,2898.22,,,,,,,,,,,,,
PLATE BONE FEMORAL 4.5X99 MM RIGHT PROXIMAL 2 HOLE LOCKING F,SUP-2837600,CDM,C1713,HCPCS,0278,RC,,,,both,,,10903.96,7087.57,,,,,,,,,,,,,
BLADE SAW SM BNE 90X12.5 MM RASP,SUP-2661990,CDM,2720000010,LOCAL,0272,RC,,,,both,,,76.24,49.56,,,,,,,,,,,,,
BIT DRL L 1.33 IN OD 12 MM ID 2.7 MM TROCAR TIP NS DISP,SUP-2905455,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1921.68,1249.09,,,,,,,,,,,,,
GRAFT HUM TISS SAPH VEIN 5X6 MMX58 CM,SUP-2175204,CDM,C1768,CPT,0278,RC,,,,both,,,22608.00,14695.20,,,,,,,,,,,,,
CATHETER CARD ABLATION THERMOCOOL SMARTTOUCH SF L115CM 8FR F,SUP-2248618,CDM,C1732,HCPCS,0278,RC,,,,both,,,9410.58,6116.88,,,,,,,,,,,,,
INTRODUCER SHTH 18FRX30CM GORE,SUP-2395872,CDM,C1894,HCPCS,0272,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
SYSTEM BX NDL 18GA SHTH W/ MTL STIFFENER 7FR L60CM CATH STR,SUP-2120183,CDM,C1894,HCPCS,0272,RC,,,,both,,,1978.20,1285.83,,,,,,,,,,,,,
THE CROSSROADS SCR SYS IS INDICATED FOR FRAC REP AND FIX,SUP-2175127,CDM,C1776,CPT,0278,RC,,,,both,,,2811.87,1827.72,,,,,,,,,,,,,
RING EXT FIX 5/8 160 MM SALVATION,SUP-2850370,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3529.36,2294.08,,,,,,,,,,,,,
PLATE BNE LCK 32 MM LT DSTL RADIAL VOLAR MEDL 2 HOLE CLMN,SUP-2462600,CDM,C1713,HCPCS,0278,RC,,,,both,,,2152.69,1399.25,,,,,,,,,,,,,
MESH HERN 30.5X30.5CM POLYPR W/ POLYDIOXANONE PROCEED RECT,SUP-2219764,CDM,C1781,HCPCS,0278,RC,,,,both,,,7046.60,4580.29,,,,,,,,,,,,,
CLOZAPINE 100 MG PO TABS,RX-9647,CDM,6370000000,HCPCS,0637,RC,51079-0922-01,NDC,,both,1,UN,7.50,4.87,,,,,,,,,,,,,
Excision Malignant Lesion Trunk/Arm/Leg > 4.0 Cm,CASE-11606,LOCAL,11606,CPT,,,,,,outpatient,,,21935.45,13161.27,,,,,,,,,,,,,
Septoplasty/Submucous Resecj W/WO Cartilage Grf|BILATERAL PROCEDURE,CASE-30520,LOCAL,30520,CPT,0360,RC,,,50,outpatient,,,53466.13,32079.68,,,,,,,,,,,,,
Septoplasty/Submucous Resecj W/WO Cartilage Grf|BILATERAL PROCEDURE,CASE-30520,LOCAL,30520,CPT,,,,,50,outpatient,,,53466.13,32079.68,,,,,,,,,,,,,
Excision Malignant Lesion Trunk/Arm/Leg > 4.0 Cm,CASE-11606,LOCAL,11606,CPT,0360,RC,,,,outpatient,,,21935.45,13161.27,,,,,,,,,,,,,
KEEL LARYNGEAL MONTGOMERY SZ 12 MM SIL UMBRELLA SHP N ADH,SUP-2139779,CDM,C1889,HCPCS,0278,RC,,,,both,,,276.32,179.61,,,,,,,,,,,,,
HC So Pml/Rar Alpha Translocation,PX-3108131566,CDM,81315,CPT,0310,RC,,,,both,,,384.00,249.60,,,,,,,,,,,,,
INSTRUMENT KIT HIP CRV KNOTLESS FIBERTAK DISP,SUP-2423107,CDM,C1713,HCPCS,0278,RC,,,,both,,,926.30,602.09,,,,,,,,,,,,,
HC Remote 30 Day Ecg Tech Supp,PX-7319322900,CDM,93229,CPT,0731,RC,,,,inpatient,,,485.00,315.25,,,,,,,,,,,,,
ALLOGRAFT TISS AMNIO NUCEL SM W/ FIBEROS,SUP-2314100,CDM,C1713,HCPCS,0278,RC,,,,both,,,3532.50,2296.12,,,,,,,,,,,,,
APPLIER CLP M-L DIA5MM ENDOSCP LIG SGL SITE DA VINCI,SUP-2246691,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2088.10,1357.26,,,,,,,,,,,,,
TUBE FEED GASTRO ENTERIC BLLN 3 5ML 18FR 254CM MIC,SUP-2124602,CDM,2720000010,LOCAL,0272,RC,,,,both,,,559.33,363.56,,,,,,,,,,,,,
SUPPORT ORTHOT HIP JT LOWER EXTREMITY PELV CTRL ADJ FLX,SUP-2435685,CDM,L2622,HCPCS,0272,RC,,,,both,,,900.87,585.57,,,,,,,,,,,,,
CANNULA LAP SMOOTH 13.5 MMX15 CM N THRD STOPCOCK BLU RED,SUP-2776627,CDM,2720000010,LOCAL,0272,RC,,,,both,,,992.11,644.87,,,,,,,,,,,,,
CATHETER EP L115CM OD7FR SPC 2-8-2MM BLU D CRV DECAPOLAR,SUP-2248704,CDM,C1732,HCPCS,0278,RC,,,,both,,,1447.54,940.90,,,,,,,,,,,,,
SPHERE GLEN +3 MM 42 MM SHLDR REVERSED LAT AEQUALIS PERFORMA,SUP-2421800,CDM,C1776,CPT,0278,RC,,,,both,,,8437.02,5484.06,,,,,,,,,,,,,
CATHETER URET 5FR L70CM OPN END SGL LUMN INJ HUB FLEXIMA,SUP-2139290,CDM,C1758,HCPCS,0278,RC,,,,both,,,32.81,21.33,,,,,,,,,,,,,
SHAFT CUP REM 52MM STRT FIX HNDL W/ BLDE,SUP-2242466,CDM,2720000010,LOCAL,0272,RC,,,,both,,,737.90,479.63,,,,,,,,,,,,,
COLLAR CERV M H3XL17IN HK AND LOOP CLSR W/ STOCK,SUP-2194569,CDM,L0180,HCPCS,0274,RC,,,,both,,,45.50,29.57,,,,,,,,,,,,,
STAPLE FRACTURE 7/8X7/8IN,SUP-2695768,CDM,C1713,HCPCS,0278,RC,,,,both,,,537.57,349.42,,,,,,,,,,,,,
TOURNIQUET RED 18 X 4 DISP,SUP-2719743,CDM,2720000010,LOCAL,0272,RC,,,,both,,,40.82,26.53,,,,,,,,,,,,,
Perq Drainage Pleura Insert Cath W/O Imaging|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-32556,LOCAL,32556,CPT,0360,RC,,,LT|XU,outpatient,,,34308.52,20585.11,,,,,,,,,,,,,
Egd Flexible Foreign Body Removal,CASE-43247,LOCAL,43247,CPT,0360,RC,,,,outpatient,,,10667.58,6400.55,,,,,,,,,,,,,
Bronchoscopy Bronchial/Endobrncl Bx 1+ Sites|UNUSUAL NON-OVERLAPPING SERVICE,CASE-31625,LOCAL,31625,CPT,,,,,XU,outpatient,,,34163.40,20498.04,,,,,,,,,,,,,
Laparoscopy Colpopexy Suspension Vaginal Apex,CASE-57425,LOCAL,57425,CPT,0360,RC,,,,outpatient,,,88549.42,53129.65,,,,,,,,,,,,,
Perq Drainage Pleura Insert Cath W/O Imaging|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-32556,LOCAL,32556,CPT,,,,,LT|XU,outpatient,,,34308.52,20585.11,,,,,,,,,,,,,
Egd Flexible Foreign Body Removal,CASE-43247,LOCAL,43247,CPT,,,,,,outpatient,,,10667.58,6400.55,,,,,,,,,,,,,
Laparoscopy Colpopexy Suspension Vaginal Apex,CASE-57425,LOCAL,57425,CPT,,,,,,outpatient,,,88549.42,53129.65,,,,,,,,,,,,,
Bronchoscopy Bronchial/Endobrncl Bx 1+ Sites|UNUSUAL NON-OVERLAPPING SERVICE,CASE-31625,LOCAL,31625,CPT,0360,RC,,,XU,outpatient,,,34163.40,20498.04,,,,,,,,,,,,,
HC Icu R&B,PX-2000000000,CDM,2000000000,LOCAL,,,,,,outpatient,,,5346.25,3207.75,,,,,,,,,,,,,
Egd Insert Guide Wire Dilator Passage Esophagus,CASE-43248,LOCAL,43248,CPT,0360,RC,,,,outpatient,,,10346.32,6207.79,,,,,,,,,,,,,
Egd Insert Guide Wire Dilator Passage Esophagus,CASE-43248,LOCAL,43248,CPT,,,,,,outpatient,,,10346.32,6207.79,,,,,,,,,,,,,
STIMULATOR NERVE IMPL PULSE GENRTR KT SPECTR WAVEWRITER,SUP-2141898,CDM,C1820,HCPCS,0278,RC,,,,both,,,53380.00,34697.00,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.511,SUP-2860028,CDM,C1713,HCPCS,0278,RC,,,,both,,,34884.46,22674.90,,,,,,,,,,,,,
GUIDEWIRE ORTH 2.8X980 MM,SUP-2646016,CDM,C1769,HCPCS,0272,RC,,,,both,,,742.61,482.70,,,,,,,,,,,,,
PLATE BONE L207MM 14 H RT DSTL LAT FEM TI FOR 4.5MM SCR,SUP-2101269,CDM,C1713,HCPCS,0278,RC,,,,both,,,4815.50,3130.07,,,,,,,,,,,,,
TRAY PROVEN REV MOD TIB 3T2F,SUP-2359295,CDM,C1776,CPT,0278,RC,,,,both,,,8666.40,5633.16,,,,,,,,,,,,,
COUPLER EXT FIX DIA5/8/11MM PIN DIA5MM ROD TO ROD DELT,SUP-2372218,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2890.37,1878.74,,,,,,,,,,,,,
ANCHOR SUTURE BRAID 2-0 6.5 MM TWST W/ TAPE 1 WHT 11083T,SUP-2762109,CDM,C1713,HCPCS,0278,RC,,,,both,,,1142.96,742.92,,,,,,,,,,,,,
SCREW BNE L12MM DIA2MM SNAP OFF FOR FRAC REP AND FIX,SUP-2175086,CDM,C1713,HCPCS,0278,RC,,,,both,,,1201.05,780.68,,,,,,,,,,,,,
BIT DRL L279MM DIA3.5MM LNG HIP GRAD BRAD PNT,SUP-2347931,CDM,2720000010,LOCAL,0272,RC,,,,both,,,367.88,239.12,,,,,,,,,,,,,
COIL EMB L6CM OD0.020IN LOOP OD3MM NIT STRTCH RESIST FILL,SUP-2323431,CDM,C1889,HCPCS,0278,RC,,,,both,,,6760.42,4394.27,,,,,,,,,,,,,
PLATE BNE L56MM 4 H L DST DORS PERIARTC RAD S STL T SHP LOK,SUP-2198467,CDM,C1713,HCPCS,0278,RC,,,,both,,,2463.17,1601.06,,,,,,,,,,,,,
COMPONENT FEM L7CM R DST KNEE RESURF ORTH SALV SYS,SUP-2405705,CDM,C1776,CPT,0278,RC,,,,both,,,19287.45,12536.84,,,,,,,,,,,,,
SUPPORT ORTHOT THOR ANTR CUST DEROTATION,SUP-2435589,CDM,L1260,HCPCS,0274,RC,,,,both,,,267.03,173.57,,,,,,,,,,,,,
PLATE BNE L W10.1XL140MM THK3.5MM 10 H BILAT S STL STR LOK,SUP-2186217,CDM,C1713,HCPCS,0278,RC,,,,both,,,1519.95,987.97,,,,,,,,,,,,,
HC Inj Anes/Steroid C/D Facet Sg|LEFT SIDE|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-64490,LOCAL,64490,CPT,0361,RC,,,LT|74,outpatient,,,4509.37,2705.62,,,,,,,,,,,,,
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|LEFT HAND, SECOND DIGIT",CASE-26160,LOCAL,26160,CPT,0360,RC,,,F1,outpatient,,,11193.95,6716.37,,,,,,,,,,,,,
Nsl/Sinus Ndsc Max Antrost W/Rmvl Tiss Max Sinus|BILATERAL PROCEDURE,CASE-31267,LOCAL,31267,CPT,0360,RC,,,50,outpatient,,,60525.53,36315.32,,,,,,,,,,,,,
Nsl/Sinus Ndsc Max Antrost W/Rmvl Tiss Max Sinus|BILATERAL PROCEDURE,CASE-31267,LOCAL,31267,CPT,,,,,50,outpatient,,,60525.53,36315.32,,,,,,,,,,,,,
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|LEFT HAND, SECOND DIGIT",CASE-26160,LOCAL,26160,CPT,,,,,F1,outpatient,,,11193.95,6716.37,,,,,,,,,,,,,
TRAY PROC SZ 3 6DEG TAPR FEM HIP LNG STEM CUST,SUP-2205956,CDM,C1776,CPT,0278,RC,,,,both,,,10301.71,6696.11,,,,,,,,,,,,,
HC Creatinine Urine/Other,PX-3018257000,CDM,82570,CPT,0301,RC,,,,both,,,134.00,87.10,,,,,,,,,,,,,
SYSTEM THR HI DEMAND DOCTOR P 2C,SUP-2212120,CDM,C1776,CPT,0278,RC,,,,both,,,18315.62,11905.15,,,,,,,,,,,,,
STENT BILI L38MM DIA7MM CATH L135CM 0.018IN S STEELXCELON,SUP-2101524,CDM,C1876,HCPCS,0278,RC,,,,both,,,4160.50,2704.32,,,,,,,,,,,,,
BIT DRL TWST 1.8X70 MM 6 MM W/ STP RESORB-X DISP,SUP-2457083,CDM,2720000010,LOCAL,0272,RC,,,,both,,,446.70,290.35,,,,,,,,,,,,,
DEVICE FIX CL BTB 15 MM STRL ENDOBUTTON,SUP-2849159,CDM,C1713,HCPCS,0278,RC,,,,both,,,1015.38,660.00,,,,,,,,,,,,,
STENT URET L 24 CM DIA 4.8 FR TIP L 3 CM STIFF SHFT PTFE,SUP-2141639,CDM,C2617,HCPCS,0278,RC,,,,both,,,374.82,243.63,,,,,,,,,,,,,
BUR SURG DIAMOND MIC XLN 2 MM HVY GRIT MICROPOWER MIC 100,SUP-2607498,CDM,2720000010,LOCAL,0272,RC,,,,both,,,285.74,185.73,,,,,,,,,,,,,
PLATE BONE 135DEG 10 H SUPCNDYL S STL COMPR FRELOK,SUP-2205403,CDM,C1713,HCPCS,0278,RC,,,,both,,,1376.26,894.57,,,,,,,,,,,,,
TARGETING SLEEVE KNOB,SUP-2900823,CDM,C1713,HCPCS,0278,RC,,,,both,,,5798.95,3769.32,,,,,,,,,,,,,
KIT THROMCTMY TREVO XP PROVUE L 190 CM RETRV L 36 MM DIA 3,SUP-2367763,CDM,C1713,HCPCS,0278,RC,,,,both,,,23534.30,15297.29,,,,,,,,,,,,,
ANCHOR SUTURE DIA1.4 MM SUTURE SZ 1 1 STRND XBRAID S WHT BLU,SUP-2908825,CDM,C1713,HCPCS,0278,RC,,,,both,,,1127.26,732.72,,,,,,,,,,,,,
TI CONNECTING SCREW F/LCKNG ATTACHMENT PL/STARDRIVE-STER,SUP-2546836,CDM,C1713,HCPCS,0278,RC,,,,both,,,778.47,506.01,,,,,,,,,,,,,
Cysto/Uretero W/Lithotripsy &Indwell Stent Insrt|SEPARATE STRUCTURE|RIGHT SIDE,CASE-52356,LOCAL,52356,CPT,,,,,XS|RT,outpatient,,,34725.05,20835.03,,,,,,,,,,,,,
Cysto W/Urtroscopy&/Pyeloscopy Dx|UNUSUAL NON-OVERLAPPING SERVICE|LEFT SIDE,CASE-52351,LOCAL,52351,CPT,0360,RC,,,XU|LT,outpatient,,,25914.87,15548.92,,,,,,,,,,,,,
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 2nd Level|RIGHT SIDE,CASE-64494,LOCAL,64494,CPT,0360,RC,,,RT,outpatient,,,3988.28,2392.97,,,,,,,,,,,,,
Cysto W/Urtroscopy&/Pyeloscopy Dx|UNUSUAL NON-OVERLAPPING SERVICE|LEFT SIDE,CASE-52351,LOCAL,52351,CPT,,,,,XU|LT,outpatient,,,25914.87,15548.92,,,,,,,,,,,,,
Cysto/Uretero W/Lithotripsy &Indwell Stent Insrt|SEPARATE STRUCTURE|RIGHT SIDE,CASE-52356,LOCAL,52356,CPT,0360,RC,,,XS|RT,outpatient,,,34725.05,20835.03,,,,,,,,,,,,,
CATHETER DLYS AD ADMIN SET STYL CONN TB,SUP-2125395,CDM,C1750,HCPCS,0278,RC,,,,both,,,48.17,31.31,,,,,,,,,,,,,
STAPLE INT BIOABSRB FOR PROX 75 ILA 75 MULTFI GIA 80,SUP-2395619,CDM,2720000010,LOCAL,0272,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
SCREW IM NAIL L65MM DIA5MM CALCNL TI THRD HD FOR ANK COMPR,SUP-2316351,CDM,C1713,HCPCS,0278,RC,,,,both,,,853.55,554.81,,,,,,,,,,,,,
MESH SURG L MED HIP TI WALL X CHANGE,SUP-2368355,CDM,C1781,HCPCS,0278,RC,,,,both,,,567.52,368.89,,,,,,,,,,,,,
PLATE BNE M 5DEG L MT GORILLA,SUP-2321452,CDM,C1713,HCPCS,0278,RC,,,,both,,,4388.15,2852.30,,,,,,,,,,,,,
IMPLANT RADIAL SIZE 2 LEFT WRIST FREEDOM,SUP-2586703,CDM,C1776,CPT,0278,RC,,,,both,,,23457.15,15247.15,,,,,,,,,,,,,
DISTRACTOR EXT FIX ROZELLE 15 MM 1 - 1.2 MM 9 HOLE MESH,SUP-2471260,CDM,C1713,HCPCS,0278,RC,,,,both,,,16631.51,10810.48,,,,,,,,,,,,,
SHEATH INTRO FLEXCATH ADV TOT L 81 CM L 65 CM OD 15 FR ID 12,SUP-2281956,CDM,C1766,CPT,0272,RC,,,,both,,,3925.00,2551.25,,,,,,,,,,,,,
BLADE SHV OD3.5MM 15DEG FULL RAD RESECT CUT PREBENT DISP,SUP-2341388,CDM,2720000010,LOCAL,0272,RC,,,,both,,,188.40,122.46,,,,,,,,,,,,,
MESH HERN W3XL6IN POLYPR MFIL RECTANG,SUP-2125747,CDM,C1781,HCPCS,0278,RC,,,,both,,,161.08,104.70,,,,,,,,,,,,,
BOLT EXT FIX L6MM HALF PIN FOR TAY SPAT FRME ILIZ,SUP-2342272,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7690.65,4998.92,,,,,,,,,,,,,
STRIP SUTURE STRL DISP ZIPSEAL 24,SUP-2904128,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1476.37,959.64,,,,,,,,,,,,,
SCREW BONE 4.5X12MM CANC ST,SUP-2202663,CDM,C1713,HCPCS,0278,RC,,,,both,,,404.43,262.88,,,,,,,,,,,,,
Open Tx Clavicular Fracture Internal Fixation|RIGHT SIDE,CASE-23515,LOCAL,23515,CPT,,,,,RT,outpatient,,,65590.45,39354.27,,,,,,,,,,,,,
Brnchsc Removal Bronchial Valve Initial,CASE-31648,LOCAL,31648,CPT,,,,,,outpatient,,,21058.05,12634.83,,,,,,,,,,,,,
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral Ea Addl|LEFT SIDE,CASE-64484,LOCAL,64484,CPT,0360,RC,,,LT,outpatient,,,4037.58,2422.55,,,,,,,,,,,,,
HC Drain/Inj Joint/Bursa W/US Large|PBB CHARGE|RIGHT SIDE,CASE-20611,LOCAL,20611,CPT,0510,RC,,,PBB|RT,outpatient,,,4278.08,2566.85,,,,,,,,,,,,,
Orchiectomy Radical Tumor Inguinal Approach|LEFT SIDE,CASE-54530,LOCAL,54530,CPT,0360,RC,,,LT,outpatient,,,24582.80,14749.68,,,,,,,,,,,,,
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral Ea Addl|LEFT SIDE,CASE-64484,LOCAL,64484,CPT,,,,,LT,outpatient,,,4037.58,2422.55,,,,,,,,,,,,,
Open Tx Clavicular Fracture Internal Fixation|RIGHT SIDE,CASE-23515,LOCAL,23515,CPT,0360,RC,,,RT,outpatient,,,65590.45,39354.27,,,,,,,,,,,,,
Orchiectomy Radical Tumor Inguinal Approach|LEFT SIDE,CASE-54530,LOCAL,54530,CPT,,,,,LT,outpatient,,,24582.80,14749.68,,,,,,,,,,,,,
Brnchsc Removal Bronchial Valve Initial,CASE-31648,LOCAL,31648,CPT,0360,RC,,,,outpatient,,,21058.05,12634.83,,,,,,,,,,,,,
PACEMAKER CARD D6MM PERM 3 CHMBR STD UNIPOLAR/BIPOLAR W/,SUP-2357348,CDM,C2621,HCPCS,0275,RC,,,,both,,,25120.00,16328.00,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED RESURF H6MEDACTA] MEDACTA USA],SUP-2267791,CDM,C1776,CPT,0278,RC,,,,both,,,23550.00,15307.50,,,,,,,,,,,,,
HC So Fluor Anti Titer,PX-3028625666,CDM,86256,CPT,0302,RC,,,,both,,,76.00,49.40,,,,,,,,,,,,,
GRAFT BNE CRUSH 10 CC PREHYDRATED PTTY CHIP DBM TENSIX,SUP-2477938,CDM,C1713,HCPCS,0278,RC,,,,both,,,8415.20,5469.88,,,,,,,,,,,,,
STAPLER ENDOSCP 45MM L34CM STD NAT ARTC LIN CUT ECHELON FLX,SUP-2218982,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1139.44,740.64,,,,,,,,,,,,,
CATHETER GUID ADV EH 52CM,SUP-2149008,CDM,C1887,HCPCS,0272,RC,,,,both,,,926.30,602.09,,,,,,,,,,,,,
PLATE BNE STR 1.7X119 MM FIBULAR 10 HOLE LCK,SUP-2520875,CDM,C1713,HCPCS,0278,RC,,,,both,,,3639.89,2365.93,,,,,,,,,,,,,
ROD IM VANGUARD GLOB,SUP-2441397,CDM,C1713,HCPCS,0278,RC,,,,both,,,692.37,450.04,,,,,,,,,,,,,
Rmvl Noninfct Mesh/Prosth Aa/Parastomal Hrna Rpr,CASE-49623,LOCAL,49623,CPT,,,,,,outpatient,,,109529.25,65717.55,,,,,,,,,,,,,
Bronchoscopy W/Transbroncl Ndl Aspir Bx Ea Lobe,CASE-31633,LOCAL,31633,CPT,,,,,,outpatient,,,42778.25,25666.95,,,,,,,,,,,,,
Bronchoscopy W/Transbroncl Ndl Aspir Bx Ea Lobe,CASE-31633,LOCAL,31633,CPT,0360,RC,,,,outpatient,,,42778.25,25666.95,,,,,,,,,,,,,
Rmvl Noninfct Mesh/Prosth Aa/Parastomal Hrna Rpr,CASE-49623,LOCAL,49623,CPT,0360,RC,,,,outpatient,,,109529.25,65717.55,,,,,,,,,,,,,
SUTURE ARTHSCP 90 DEG STR SUTSNARE,SUP-2121952,CDM,C1713,HCPCS,0278,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
SUPPORT ORTHOT ANK KNEE CUST W/ADJ STP SINGLE UPR,SUP-2435627,CDM,L1920,HCPCS,0274,RC,,,,both,,,1163.06,755.99,,,,,,,,,,,,,
TRIAL TIB 11MMXL M2 A/P LIP CONSTRN DURAC,SUP-2364862,CDM,C1776,CPT,0278,RC,,,,both,,,483.72,314.42,,,,,,,,,,,,,
HC Antibody Elution RBC Each Elution,PX-3028686000,CDM,86860,CPT,0302,RC,,,,both,,,656.00,426.40,,,,,,,,,,,,,
TROCAR LONG F/NAILS 8-13 SILE,SUP-2720071,CDM,2720000010,LOCAL,0272,RC,,,,both,,,326.18,212.02,,,,,,,,,,,,,
STABILIZER PELV TPOD ORNG TRAUM ORTHOT DEV TPODOR,SUP-2150009,CDM,L0469,HCPCS,0274,RC,,,,both,,,423.87,275.52,,,,,,,,,,,,,
SHEETING SILAS W2XL2IN THK0.20IN BIOCOMPATIBLE SIL,SUP-2284111,CDM,C1781,HCPCS,0278,RC,,,,both,,,61.92,40.25,,,,,,,,,,,,,
"Prq Skel Fixj Dstl Phlngl Fx Fngr/Thmb Ea|LEFT HAND, FOURTH DIGIT",CASE-26756,LOCAL,26756,CPT,,,,,F3,outpatient,,,13106.78,7864.07,,,,,,,,,,,,,
Laparoscopy Tot Hysterectomy >250 G W/Tube/Ovar,CASE-58573,LOCAL,58573,CPT,0360,RC,,,,outpatient,,,98957.78,59374.67,,,,,,,,,,,,,
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|RIGHT HAND, THIRD DIGIT",CASE-26160,LOCAL,26160,CPT,,,,,F7,outpatient,,,13729.48,8237.69,,,,,,,,,,,,,
Hallux Rigidus W/Cheilectomy 1st Mp Jt W/O Implt,CASE-28289,LOCAL,28289,CPT,,,,,,outpatient,,,31261.22,18756.73,,,,,,,,,,,,,
"Prq Skel Fixj Dstl Phlngl Fx Fngr/Thmb Ea|LEFT HAND, FOURTH DIGIT",CASE-26756,LOCAL,26756,CPT,0360,RC,,,F3,outpatient,,,13106.78,7864.07,,,,,,,,,,,,,
Laparoscopy Tot Hysterectomy >250 G W/Tube/Ovar,CASE-58573,LOCAL,58573,CPT,,,,,,outpatient,,,98957.78,59374.67,,,,,,,,,,,,,
Hallux Rigidus W/Cheilectomy 1st Mp Jt W/O Implt,CASE-28289,LOCAL,28289,CPT,0360,RC,,,,outpatient,,,31261.22,18756.73,,,,,,,,,,,,,
Ostc Prtl Exostc/Condylc Metar Head|RIGHT SIDE|SEPARATE STRUCTURE,CASE-28288,LOCAL,28288,CPT,,,,,RT|XS,outpatient,,,28867.77,17320.66,,,,,,,,,,,,,
Ostc Prtl Exostc/Condylc Metar Head|RIGHT SIDE|SEPARATE STRUCTURE,CASE-28288,LOCAL,28288,CPT,0360,RC,,,RT|XS,outpatient,,,28867.77,17320.66,,,,,,,,,,,,,
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|RIGHT HAND, THIRD DIGIT",CASE-26160,LOCAL,26160,CPT,0360,RC,,,F7,outpatient,,,13729.48,8237.69,,,,,,,,,,,,,
HC Inj Tendon Sheath/Ligament|PBB CHARGE,CASE-20550,LOCAL,20550,CPT,0510,RC,,,PBB,outpatient,,,1930.50,1158.30,,,,,,,,,,,,,
PROBE ARTHSCP 90DEG 3.0MM WAND ABLAT BPLR RF SAPHYRE VULCAN,SUP-2341029,CDM,2720000010,LOCAL,0272,RC,,,,both,,,546.36,355.13,,,,,,,,,,,,,
NAIL INTRMDLLRY L340MM D11MM 125DG LNG RIGHT HIP TIMAX CNNLT,SUP-2475691,CDM,C1713,HCPCS,0278,RC,,,,both,,,6992.78,4545.31,,,,,,,,,,,,,
WASHER ORTH FOR IMPCT FOR SEG SYS TRABECULAR MTL,SUP-2437280,CDM,C1713,HCPCS,0278,RC,,,,both,,,1243.44,808.24,,,,,,,,,,,,,
SCREW SPNL L25MM OD8MM TI CANC ANT THORLUM PEDCL ST FIX ANG,SUP-2292731,CDM,C1713,HCPCS,0278,RC,,,,both,,,4736.69,3078.85,,,,,,,,,,,,,
PLATE BNE PROF THK 1 MM 40 H SCREW DIA2 MM TI MIDFACE NS,SUP-2883813,CDM,C1713,HCPCS,0278,RC,,,,both,,,1142.96,742.92,,,,,,,,,,,,,
SHEATH INTRO L 98 CM CATH 8 FR STR AD W/O HYDRPHLC COAT,SUP-2157192,CDM,C1894,HCPCS,0272,RC,,,,both,,,51.81,33.68,,,,,,,,,,,,,
CANNULA SUCTION WORKING L140MM OD2.7MM MICRO GREEN OBTURATOR,SUP-2805826,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1114.20,724.23,,,,,,,,,,,,,
HC Inject Sacroiliac Joint,PX-3612709600,CDM,27096,CPT,0361,RC,,,,inpatient,,,3707.00,2409.55,,,,,,,,,,,,,
STEM HUM SZ 1 DIA20MM R SHLDR HA CEMENTLESS MOD ECC,SUP-2250997,CDM,C1776,CPT,0278,RC,,,,both,,,5338.00,3469.70,,,,,,,,,,,,,
LINER ACET E1 2 MOBILITY ACT ARTC CP G7 SYS,SUP-2417506,CDM,C1776,CPT,0278,RC,,,,both,,,11344.82,7374.13,,,,,,,,,,,,,
NEURO MD SCRWS 15MM DIA X 4MM 5/PKG T 6L 4V TTNM ALLOY,SUP-2682079,CDM,C1713,HCPCS,0278,RC,,,,both,,,188.71,122.66,,,,,,,,,,,,,
PLATE BNE HK 4.5X128 MM 4 HOLE SS NS DCP,SUP-2185800,CDM,C1713,HCPCS,0278,RC,,,,both,,,2204.56,1432.96,,,,,,,,,,,,,
PLATE BNE L190MM 10 H ST L LAT PROX TIB S STL LOK COMPR LO,SUP-2185721,CDM,C1713,HCPCS,0278,RC,,,,both,,,4695.93,3052.35,,,,,,,,,,,,,
ALLOGRAFT BNE STRP IRRADIATED TRICORT IL CREST,SUP-2867130,CDM,C1762,CPT,0278,RC,,,,both,,,6174.81,4013.63,,,,,,,,,,,,,
CATHETER INFUS 5FR L135CM INFUS L50CM 0.038IN SGL LUMN VLV,SUP-2172526,CDM,C1751,HCPCS,0278,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
SCREW BONE L5MM DIA1.85MM TI ST MATRIXORTHOGNATHIC 1 PER PK,SUP-2181786,CDM,C1713,HCPCS,0278,RC,,,,both,,,314.31,204.30,,,,,,,,,,,,,
SCREW BNE CANC 4X10 MM DSTL RADIAL FORTE,SUP-2462778,CDM,C1713,HCPCS,0278,RC,,,,both,,,194.59,126.48,,,,,,,,,,,,,
HC So1 Sgpt (Alt),PX-3018446067,CDM,84460,CPT,0301,RC,,,,both,,,15.00,9.75,,,,,,,,,,,,,
Egd Intrmural US Needle Aspirate/Biopsy Esophags,CASE-43238,LOCAL,43238,CPT,,,,,,outpatient,,,14121.23,8472.74,,,,,,,,,,,,,
Exc Breast Les Preop Plmt Rad Marker Open 1 Les|LEFT SIDE,CASE-19125,LOCAL,19125,CPT,0360,RC,,,LT,outpatient,,,24306.47,14583.88,,,,,,,,,,,,,
Insj Penile Prosthesos Inflatable Self-Contained,CASE-54401,LOCAL,54401,CPT,,,,,,outpatient,,,88909.98,53345.99,,,,,,,,,,,,,
"HC Unlisted Procedure, Nervous System",CASE-64999,LOCAL,64999,CPT,0360,RC,,,,outpatient,,,62542.15,37525.29,,,,,,,,,,,,,
Egd Intrmural US Needle Aspirate/Biopsy Esophags,CASE-43238,LOCAL,43238,CPT,0360,RC,,,,outpatient,,,14121.23,8472.74,,,,,,,,,,,,,
Exc Breast Les Preop Plmt Rad Marker Open 1 Les|LEFT SIDE,CASE-19125,LOCAL,19125,CPT,,,,,LT,outpatient,,,24306.47,14583.88,,,,,,,,,,,,,
Insj Penile Prosthesos Inflatable Self-Contained,CASE-54401,LOCAL,54401,CPT,0360,RC,,,,outpatient,,,88909.98,53345.99,,,,,,,,,,,,,
PLATE BONE LOCKING SMALL 3.5X272X11X3.4 MM 18 HOLE COMPRESSI,SUP-2837439,CDM,C1713,HCPCS,0278,RC,,,,both,,,7157.63,4652.46,,,,,,,,,,,,,
SUTURE D SPEC VCRL 2 0 D8876,SUP-2257457,CDM,C1713,HCPCS,0278,RC,,,,both,,,350.83,228.04,,,,,,,,,,,,,
GRAFT BNE SUB 7GA 16ML CA PHSPTE SYR DISPNS GUN CANN,SUP-2348207,CDM,C1713,HCPCS,0278,RC,,,,both,,,12419.33,8072.56,,,,,,,,,,,,,
DRILL TWST L29MM DIA1.6MM WRK L18MM FOR 2/2.3MM SCR,SUP-2364185,CDM,2720000010,LOCAL,0272,RC,,,,both,,,560.90,364.58,,,,,,,,,,,,,
SCREW CRANIOMAXILLOFACIAL VIT 2.0MM DIA 20MML,SUP-2364643,CDM,C1713,HCPCS,0278,RC,,,,both,,,97.84,63.60,,,,,,,,,,,,,
STENT URET DBL PGTL 0.035 IN 3 CM 6 FRX20 CM 6 FR POLARIS,SUP-2465265,CDM,C2617,HCPCS,0278,RC,,,,both,,,655.07,425.80,,,,,,,,,,,,,
FLUTICASONE PROPIONATE HFA 110 MCG/ACT IN AERO,RX-40698,CDM,6370000000,HCPCS,0637,RC,66993-0079-96,NDC,,both,12,GR,801.00,520.65,,,,,,,,,,,,,
CONE BODY STEM STD OFFSET AA 75 MM 40X35 MM FEM HIP ZMR,SUP-2439864,CDM,C1776,CPT,0278,RC,,,,both,,,11228.64,7298.62,,,,,,,,,,,,,
PLATE BNE W5XL50MM THK1MM 3X9 H BILAT S STL T SHP RIG NEUT 24323] DEPUY SYNTHES USA],SUP-2186152,CDM,C1713,HCPCS,0278,RC,,,,both,,,682.95,443.92,,,,,,,,,,,,,
WIRE FIX SMOOTH 2X400 MM NS,SUP-2863403,CDM,C1713,HCPCS,0278,RC,,,,both,,,217.54,141.40,,,,,,,,,,,,,
GRAFT L SEG RECON TISS FRZN PELV ILIUM WHL R,SUP-2307412,CDM,C1713,HCPCS,0278,RC,,,,both,,,22284.93,14485.20,,,,,,,,,,,,,
CATHETER CARD 6FR 2-5-2MM ABLAT CSL CRV ELECTRD SPC 120CM,SUP-2356837,CDM,C1730,HCPCS,0272,RC,,,,both,,,1146.10,744.96,,,,,,,,,,,,,
Episiotomy/Vag Rpr Oth/Thn Attending,CASE-59300,LOCAL,59300,CPT,,,,,,outpatient,,,20599.47,12359.68,,,,,,,,,,,,,
Total Thyroid Lobectomy Uni W/WO Isthmusectomy|RIGHT SIDE,CASE-60220,LOCAL,60220,CPT,,,,,RT,outpatient,,,37492.57,22495.54,,,,,,,,,,,,,
Mastectomy Partial|LEFT SIDE,CASE-19301,LOCAL,19301,CPT,0360,RC,,,LT,outpatient,,,36337.32,21802.39,,,,,,,,,,,,,
Episiotomy/Vag Rpr Oth/Thn Attending,CASE-59300,LOCAL,59300,CPT,0360,RC,,,,outpatient,,,20599.47,12359.68,,,,,,,,,,,,,
Mastectomy Partial|LEFT SIDE,CASE-19301,LOCAL,19301,CPT,,,,,LT,outpatient,,,36337.32,21802.39,,,,,,,,,,,,,
Total Thyroid Lobectomy Uni W/WO Isthmusectomy|RIGHT SIDE,CASE-60220,LOCAL,60220,CPT,0360,RC,,,RT,outpatient,,,37492.57,22495.54,,,,,,,,,,,,,
RING ANNULPLSTY CARPENTIER MCCARTHY ADAMS IMR ETLOGIX 24 MM,SUP-2214124,CDM,C1889,HCPCS,0278,RC,,,,both,,,6751.00,4388.15,,,,,,,,,,,,,
BASEPLATE TIB REVERSED 30 MM 26 MM KNEE TRABECULAR MTL,SUP-2436975,CDM,C1776,CPT,0278,RC,,,,both,,,7787.04,5061.58,,,,,,,,,,,,,
PLATE SPNL DECADE 10 MM,SUP-2311213,CDM,C1713,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
PLATE BNE RECON 2-2.5X222X2.5 MM 32 HOLE ANGLED-ANGLED LCK,SUP-2477341,CDM,C1713,HCPCS,0278,RC,,,,both,,,7227.59,4697.93,,,,,,,,,,,,,
PLATE BNE L 78 MM SCREW DIA 3.5 MM 4 HD 6 SHFT H TI T SHP NS,SUP-2907621,CDM,C1713,HCPCS,0278,RC,,,,both,,,3709.13,2410.93,,,,,,,,,,,,,
DEFIBRILLATOR IMPL ITREVIA DR-T W 55 X H 65 MM D 11 MM 33 CC,SUP-2138364,CDM,C1721,HCPCS,0275,RC,,,,both,,,41605.00,27043.25,,,,,,,,,,,,,
CATHETER CV SINGLE LUMEN 4 FR SHERLOCK STYL GROSH NXT,SUP-2126717,CDM,C1751,HCPCS,0278,RC,,,,both,,,659.34,428.57,,,,,,,,,,,,,
PUMP PAIN 120MLX2CC HR 6.5CM 500120025,SUP-2367018,CDM,C1713,HCPCS,0278,RC,,,,both,,,2746.12,1784.98,,,,,,,,,,,,,
SCREW BNE L 4 MM DIA2.2 MM PLLA PGA PDLA ST 2 THRD RESRB,SUP-2909493,CDM,C1713,HCPCS,0278,RC,,,,both,,,3302.31,2146.50,,,,,,,,,,,,,
COVER ORTHOT CUST FOR UPR,SUP-2435583,CDM,L1120,HCPCS,0272,RC,,,,both,,,107.67,69.99,,,,,,,,,,,,,
KNEE IMMOB 22IN QUAL + M,SUP-2195532,CDM,L1830,CPT,0274,RC,,,,both,,,60.92,39.60,,,,,,,,,,,,,
TUBE CHST SET 32 FRX41 CM 1 LUMEN 4 SIDEPRT THAL-QUICK,SUP-2760008,CDM,C1729,HCPCS,0272,RC,,,,both,,,522.46,339.60,,,,,,,,,,,,,
BASEPLATE TIB L54MM THICKNESS 8MM UNIV POLYETH KNEE PRI CEM,SUP-2199769,CDM,C1776,CPT,0278,RC,,,,both,,,7531.29,4895.34,,,,,,,,,,,,,
BINDER ABD XL W15IN 62 74IN CIRC UNISX 5 PNL E CNTCT CLSR,SUP-2197130,CDM,L3650,HCPCS,0274,RC,,,,both,,,70.18,45.62,,,,,,,,,,,,,
DEXAMETHASONE SOD PHOSPHATE PF 10 MG/ML IJ SOLN,RX-118012,CDM,J1100,HCPCS,0636,RC,70069-0021-25,NDC,,both,0.5,ML,54.10,35.16,,,,,,,,,,,,,
Mast Modf Rad W/Ax Lymph Nod W/WO Pect/Alis Min|LEFT SIDE,CASE-19307,LOCAL,19307,CPT,0360,RC,,,LT,outpatient,,,58736.45,35241.87,,,,,,,,,,,,,
Laps Surg Rpr Recurrent Inguinal Hernia|RIGHT SIDE,CASE-49651,LOCAL,49651,CPT,0360,RC,,,RT,outpatient,,,56204.80,33722.88,,,,,,,,,,,,,
Laps Surg Rpr Recurrent Inguinal Hernia|RIGHT SIDE,CASE-49651,LOCAL,49651,CPT,,,,,RT,outpatient,,,56204.80,33722.88,,,,,,,,,,,,,
Sigmoidoscopy Flx W/Biopsy Single/Multiple,CASE-45331,LOCAL,45331,CPT,0360,RC,,,,outpatient,,,7444.33,4466.60,,,,,,,,,,,,,
Sigmoidoscopy Flx W/Biopsy Single/Multiple,CASE-45331,LOCAL,45331,CPT,,,,,,outpatient,,,7444.33,4466.60,,,,,,,,,,,,,
Open Tx Clavicular Fracture Internal Fixation,CASE-23515,LOCAL,23515,CPT,,,,,,outpatient,,,73660.15,44196.09,,,,,,,,,,,,,
Open Tx Clavicular Fracture Internal Fixation,CASE-23515,LOCAL,23515,CPT,0360,RC,,,,outpatient,,,73660.15,44196.09,,,,,,,,,,,,,
Mast Modf Rad W/Ax Lymph Nod W/WO Pect/Alis Min|LEFT SIDE,CASE-19307,LOCAL,19307,CPT,,,,,LT,outpatient,,,58736.45,35241.87,,,,,,,,,,,,,
COIL NEUROVASCULAR VFC L 3 CM DIA1-3 MM MICROCATHETER 0.0165,SUP-2305350,CDM,C1889,HCPCS,0278,RC,,,,both,,,5137.83,3339.59,,,,,,,,,,,,,
CATHETER DRNGE 14FR L35CM DIA4.7MM STD LOOP TIP MULTPURP,SUP-2118775,CDM,C1729,HCPCS,0272,RC,,,,both,,,256.16,166.50,,,,,,,,,,,,,
SCREW BONE STD CORT FULL THRD FLX CANN N LCK NSTERILE 5.5MM,SUP-2341063,CDM,C1713,HCPCS,0278,RC,,,,both,,,110.53,71.84,,,,,,,,,,,,,
GUIDEPIN ORTH JT SEEKING PIN RM WIRE KT STRL DISP VIRTUGUIDE,SUP-2908142,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1460.82,949.53,,,,,,,,,,,,,
LEAD PACE SWEET TIP L 52 CM SIL STEROID ENDOCARD RT,SUP-2148648,CDM,C1898,HCPCS,0275,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
CATHETER ATHRCTMY KITTYCAT 2 L 150 CM DIA 5 FR GUIDEWIRE,SUP-2124799,CDM,C1769,HCPCS,0272,RC,,,,both,,,4694.30,3051.29,,,,,,,,,,,,,
Egd Removal Tumor Polyp/Other Lesion Snare Tech,CASE-43251,LOCAL,43251,CPT,,,,,,outpatient,,,13721.82,8233.09,,,,,,,,,,,,,
"Rpr Coltrl Ligm Mtcarphlngl/Iphal Jt|RIGHT HAND, THUMB",CASE-26540,LOCAL,26540,CPT,,,,,F5,outpatient,,,14782.97,8869.78,,,,,,,,,,,,,
Lam Facetec/Foramot Drg Arthrd Lumbar 1 Vrt Sgm,CASE-63052,LOCAL,63052,CPT,,,,,,outpatient,,,107612.65,64567.59,,,,,,,,,,,,,
"Arthrodesis Interphalangeal Jt W/WO Int Fixj|LEFT HAND, FIFTH DIGIT",CASE-26860,LOCAL,26860,CPT,0360,RC,,,F4,outpatient,,,34139.12,20483.47,,,,,,,,,,,,,
Lam Facetec/Foramot Drg Arthrd Lumbar 1 Vrt Sgm,CASE-63052,LOCAL,63052,CPT,0360,RC,,,,outpatient,,,107612.65,64567.59,,,,,,,,,,,,,
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|LEFT HAND, THUMB",CASE-26160,LOCAL,26160,CPT,0360,RC,,,FA,outpatient,,,11175.20,6705.12,,,,,,,,,,,,,
HC Biopsy/Exc Lymph Node Needle|RIGHT SIDE,CASE-38505,LOCAL,38505,CPT,0361,RC,,,RT,outpatient,,,9947.70,5968.62,,,,,,,,,,,,,
Egd Removal Tumor Polyp/Other Lesion Snare Tech,CASE-43251,LOCAL,43251,CPT,0360,RC,,,,outpatient,,,13721.82,8233.09,,,,,,,,,,,,,
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|LEFT HAND, THUMB",CASE-26160,LOCAL,26160,CPT,,,,,FA,outpatient,,,11175.20,6705.12,,,,,,,,,,,,,
"Rpr Coltrl Ligm Mtcarphlngl/Iphal Jt|RIGHT HAND, THUMB",CASE-26540,LOCAL,26540,CPT,0360,RC,,,F5,outpatient,,,14782.97,8869.78,,,,,,,,,,,,,
"Arthrodesis Interphalangeal Jt W/WO Int Fixj|LEFT HAND, FIFTH DIGIT",CASE-26860,LOCAL,26860,CPT,,,,,F4,outpatient,,,34139.12,20483.47,,,,,,,,,,,,,
LOOP ELECSURG DIA0.3MM BLDR PROST YEL ORNG BPLR W/ 24FR,SUP-2261167,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1298.14,843.79,,,,,,,,,,,,,
PROGRAMMER PT EXT HANDHELD FOR RESTORE NEUROSTIMULATOR,SUP-2278229,CDM,C1787,HCPCS,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
KIT VENTRICULAR DRAINAGE W/ INS8301 SYS INS4500 CATH SET,SUP-2883677,CDM,C1729,HCPCS,0272,RC,,,,both,,,905.98,588.89,,,,,,,,,,,,,
SCREW INTRF BIOSURE REGENESORB 6MMX25MM RT,SUP-2341911,CDM,C1713,HCPCS,0278,RC,,,,both,,,1072.06,696.84,,,,,,,,,,,,,
SHEATH INTRO FLX L 40 CM OD 6 FR GUIDEWIRE 0.035 IN AQ SM,SUP-2168573,CDM,C1894,HCPCS,0272,RC,,,,both,,,599.74,389.83,,,,,,,,,,,,,
DEFIBRILLATOR IMPL ILIVIA NEO 7 DR-T PROMRI TI POLYUR SIL 2,SUP-2739241,CDM,C1721,HCPCS,0275,RC,,,,both,,,58278.40,37880.96,,,,,,,,,,,,,
COIL NEUROVASCULAR ORBIT GALAXY L 4 CM DIA 4 MM OD 0.012 IN,SUP-2427693,CDM,C1713,HCPCS,0278,RC,,,,both,,,6542.13,4252.38,,,,,,,,,,,,,
BIT DRL DIA4.5MM CANN FOR INTOSS FIX IOFIX,SUP-2223750,CDM,2720000010,LOCAL,0272,RC,,,,both,,,467.86,304.11,,,,,,,,,,,,,
"RABIES VACCINE, PCEC IM SUSR",RX-22120,CDM,90675,HCPCS,0636,RC,50632-0010-01,NDC,,both,1,UN,1955.80,1271.27,,,,,,,,,,,,,
DEFIBRILLATOR IMPL INOGEN MINI 28.5 CC TI 2 CHMBR DF1 CONN,SUP-2140378,CDM,C1721,HCPCS,0275,RC,,,,both,,,57462.00,37350.30,,,,,,,,,,,,,
COMPONENT EXT FIX UPPER PART MULT DIR FOR RED II,SUP-2460125,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7156.47,4651.71,,,,,,,,,,,,,
END CAP SCREWS,SUP-2830111,CDM,C1889,HCPCS,0278,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
SUPPORT ORTHOT KNEE LOWER EXTREMITY CUST OFFSET,SUP-2435666,CDM,L2390,HCPCS,0274,RC,,,,both,,,289.79,188.36,,,,,,,,,,,,,
GRAFT BNE SUB 10CC DEMIN CELLULAR MTRX VIVIGEN,SUP-2264614,CDM,C1713,HCPCS,0278,RC,,,,both,,,10513.19,6833.57,,,,,,,,,,,,,
GRAFT SFT TISS X THCK 20X20 CM RECON TISS MTRX STRATTICE,SUP-2484629,CDM,Q4130,HCPCS,0636,RC,,,,both,,,39604.82,25743.13,,,,,,,,,,,,,
SHELL ACET SZ 58D TI G SER MH STRL LOGICAL,SUP-2929682,CDM,C1776,CPT,0278,RC,,,,both,,,6906.12,4488.98,,,,,,,,,,,,,
HC Inj Tendon Sheath/Ligament|PBB CHARGE|SEPARATE STRUCTURE,CASE-20550,LOCAL,20550,CPT,0510,RC,,,PBB|XS,outpatient,,,2285.83,1371.50,,,,,,,,,,,,,
Insj Biomchn Dev Vrt Corpectomy Defect W/Arthrd,CASE-22854,LOCAL,22854,CPT,,,,,,outpatient,,,60430.45,36258.27,,,,,,,,,,,,,
HC Joint Injection/Aspir Large WO US|LEFT SIDE,CASE-20610,LOCAL,20610,CPT,0510,RC,,,LT,outpatient,,,4343.83,2606.30,,,,,,,,,,,,,
Insj Biomchn Dev Vrt Corpectomy Defect W/Arthrd,CASE-22854,LOCAL,22854,CPT,0360,RC,,,,outpatient,,,60430.45,36258.27,,,,,,,,,,,,,
Biopsy Floor Mouth,CASE-41108,LOCAL,41108,CPT,,,,,,outpatient,,,36812.97,22087.78,,,,,,,,,,,,,
Nasal/Sinus Ndsc Tot W/Sphendt W/Sphen Tiss Rmvl|RIGHT SIDE,CASE-31259,LOCAL,31259,CPT,0360,RC,,,RT,outpatient,,,51135.30,30681.18,,,,,,,,,,,,,
Cystourethroscopy W/Dest &/Rmvl Tumor Large,CASE-52240,LOCAL,52240,CPT,0360,RC,,,,outpatient,,,20575.10,12345.06,,,,,,,,,,,,,
Cystourethroscopy W/Dest &/Rmvl Tumor Large,CASE-52240,LOCAL,52240,CPT,,,,,,outpatient,,,20575.10,12345.06,,,,,,,,,,,,,
Biopsy Floor Mouth,CASE-41108,LOCAL,41108,CPT,0360,RC,,,,outpatient,,,36812.97,22087.78,,,,,,,,,,,,,
Nasal/Sinus Ndsc Tot W/Sphendt W/Sphen Tiss Rmvl|RIGHT SIDE,CASE-31259,LOCAL,31259,CPT,,,,,RT,outpatient,,,51135.30,30681.18,,,,,,,,,,,,,
TI MATRIXMANDIBLE 8 HOLE STRUT,SUP-2827976,CDM,C1713,HCPCS,0278,RC,,,,both,,,2116.67,1375.84,,,,,,,,,,,,,
GRAFT BIO TISS W10XL25CM MESHED FET BOV ACELLULAR DERM MTRX,SUP-2243700,CDM,Q4110,HCPCS,0636,RC,,,,both,,,15700.00,10205.00,,,,,,,,,,,,,
PLATE BONE 0DEG 16 H CRANIOMAXILLOFACIAL NONCOMPRESSION STR,SUP-2363621,CDM,C1713,HCPCS,0278,RC,,,,both,,,993.46,645.75,,,,,,,,,,,,,
ROPINIROLE HCL 0.25 MG PO TABS,RX-21688,CDM,6370000000,HCPCS,0637,RC,00904-6373-61,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
NEEDLE ENDOSCP 0 DEG 3 MMX30 CM MIC BITE BIT ULTRAMICRO,SUP-2767021,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1127.64,732.97,,,,,,,,,,,,,
DOXEPIN HCL 10 MG PO CAPS,RX-2608,CDM,6370000000,HCPCS,0637,RC,51079-0436-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
GEMFIBROZIL 600 MG PO TABS,RX-3378,CDM,6370000000,HCPCS,0637,RC,16571-0784-06,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
MEPIVACAINE HCL (PF) 1 % IJ SOLN,RX-106537,CDM,J0670,HCPCS,0636,RC,63323-0260-37,NDC,,both,2,ML,54.10,35.16,,,,,,,,,,,,,
TUBE VENT SHEP GRMMT 1.14 MM 1.6 MM 2.3 MM W/O TAB 525126,SUP-2535155,CDM,L8699,HCPCS,0278,RC,,,,both,,,22.11,14.37,,,,,,,,,,,,,
HC Drain/Inj Joint/Bursa W/US,PX-5102060400,CDM,20604,CPT,0510,RC,,,,outpatient,,,3707.00,2409.55,,,,,,,,,,,,,
SCREW SPINAL POLYAXIAL MODULAR TULIP INVICTUS,SUP-2553710,CDM,C1713,HCPCS,0278,RC,,,,both,,,1532.32,996.01,,,,,,,,,,,,,
SUPPORT ORTHOPEDIC ANK MED,SUP-2330426,CDM,L4350,HCPCS,0272,RC,,,,both,,,59.66,38.78,,,,,,,,,,,,,
SCREW BNE L 12 MM DIA1.5 MM COCR CORTICAL HND ST TIP LCK SQ,SUP-2885044,CDM,C1713,HCPCS,0278,RC,,,,both,,,271.67,176.59,,,,,,,,,,,,,
SCREW SNAP OFF DIAM A 27MM LEN B 13MM NEXFIX,SUP-2400543,CDM,C1713,HCPCS,0278,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
PLATE BONE TIBIAL 246X14X4 MM RIGHT LATERAL TIBIAL HEAD 13 H,SUP-2836988,CDM,C1713,HCPCS,0278,RC,,,,both,,,8726.22,5672.04,,,,,,,,,,,,,
Submucous Rescj Inferior Turbinate Prtl/Compl,CASE-30140,LOCAL,30140,CPT,0360,RC,,,,outpatient,,,35011.15,21006.69,,,,,,,,,,,,,
HC Bx Breast 1st Lesion US Img|RIGHT SIDE,CASE-19083,LOCAL,19083,CPT,0361,RC,,,RT,outpatient,,,10057.37,6034.42,,,,,,,,,,,,,
Laparoscopic Appendectomy|UNUSUAL NON-OVERLAPPING SERVICE,CASE-44970,LOCAL,44970,CPT,0360,RC,,,XU,outpatient,,,79982.37,47989.42,,,,,,,,,,,,,
Submucous Rescj Inferior Turbinate Prtl/Compl,CASE-30140,LOCAL,30140,CPT,,,,,,outpatient,,,35011.15,21006.69,,,,,,,,,,,,,
Laparoscopic Appendectomy|UNUSUAL NON-OVERLAPPING SERVICE,CASE-44970,LOCAL,44970,CPT,,,,,XU,outpatient,,,79982.37,47989.42,,,,,,,,,,,,,
MESH BIOLOGIC OVINE RUMEN PERM OVITEX 6X10 CM,SUP-2383089,CDM,C1781,HCPCS,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
HC MRI-Spine Thoracic WO Contrast,PX-6127214600,CDM,72146,CPT,0612,RC,,,,both,,,5225.00,3396.25,,,,,,,,,,,,,
FIBER LASER OMNIGUIDE,SUP-2225612,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2110.08,1371.55,,,,,,,,,,,,,
INSERT TIB ARTC CRUC RET POST LIP 10MM THCK 65MM MEDL LAT,SUP-2406312,CDM,C1776,CPT,0278,RC,,,,both,,,7570.54,4920.85,,,,,,,,,,,,,
STEM HUM L125MM OD14MM UNIV TI POR SHLDR PRI CEM IMP,SUP-2404709,CDM,C1776,CPT,0278,RC,,,,both,,,14720.32,9568.21,,,,,,,,,,,,,
KIT PORTACATH PERI IMP ACCS SYS,SUP-2351828,CDM,C1894,HCPCS,0272,RC,,,,both,,,1093.98,711.09,,,,,,,,,,,,,
BIT DRL L145MM DIA3.2MM 3 FLUT QUIK CPL FOR EXPERT TIB,SUP-2178873,CDM,2720000010,LOCAL,0272,RC,,,,both,,,496.72,322.87,,,,,,,,,,,,,
CONNECTOR SPNL M TI FOR 635MM ROD TSRH 3D,SUP-2290004,CDM,C1713,HCPCS,0278,RC,,,,both,,,3008.12,1955.28,,,,,,,,,,,,,
KIT REP TI FOR RECON OF ACUTE AC JT SEP AC TIGHTROPE,SUP-2121657,CDM,C1713,HCPCS,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
SHEATH INTRO FAST-CATH L 23 CM DIA 8 FR DIL DIA 5.8 FR,SUP-2357111,CDM,C1894,HCPCS,0272,RC,,,,both,,,78.50,51.02,,,,,,,,,,,,,
SHEATH INTRO PERFRMR L 75 CM OD 10 FR ID 3 MM GUIDEWIRE,SUP-2168382,CDM,C1894,HCPCS,0272,RC,,,,both,,,264.98,172.24,,,,,,,,,,,,,
Cysto/Uretero W/Lithotripsy &Indwell Stent Insrt|LEFT SIDE,CASE-52356,LOCAL,52356,CPT,0360,RC,,,LT,outpatient,,,28634.58,17180.75,,,,,,,,,,,,,
Cmbnd Anterpost Colporraphy W/Cysto,CASE-57260,LOCAL,57260,CPT,,,,,,outpatient,,,37584.83,22550.90,,,,,,,,,,,,,
Cmbnd Anterpost Colporraphy W/Cysto,CASE-57260,LOCAL,57260,CPT,0360,RC,,,,outpatient,,,37584.83,22550.90,,,,,,,,,,,,,
Cysto/Uretero W/Lithotripsy &Indwell Stent Insrt|LEFT SIDE,CASE-52356,LOCAL,52356,CPT,,,,,LT,outpatient,,,28634.58,17180.75,,,,,,,,,,,,,
MICRO PLATE 6 X 4 HOLES RCTNGLR SGMNTS 6MM 15MM SSTM CP TT,SUP-2707409,CDM,C1713,HCPCS,0278,RC,,,,both,,,1019.93,662.95,,,,,,,,,,,,,
CATHETER CV KT 7 FRX20 CM 3L PRESSURE INJ N TUNNELED UNCUF,SUP-2763385,CDM,C1751,HCPCS,0278,RC,,,,both,,,389.36,253.08,,,,,,,,,,,,,
BLADE SAW W7MM CASPR FOR TPS,SUP-2363306,CDM,2720000010,LOCAL,0272,RC,,,,both,,,474.14,308.19,,,,,,,,,,,,,
ILLUMINATOR ELECTROCAUTERY RETRACTED L8IN EXT L11IN DYN,SUP-2247181,CDM,2720000010,LOCAL,0272,RC,,,,both,,,894.90,581.68,,,,,,,,,,,,,
PLATE BNE LCK 159 MM RT DSTL LAT FEM 6 HOLE SS STRL,SUP-2467657,CDM,C1713,HCPCS,0278,RC,,,,both,,,4077.70,2650.50,,,,,,,,,,,,,
GUIDEWIRE ORTH FACETLINX,SUP-2293749,CDM,C1769,HCPCS,0272,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
GUIDEWIRE VASC L260CM DIA0.018IN TIP L3CM STD PERIPH SUP E,SUP-2385100,CDM,C1769,HCPCS,0272,RC,,,,both,,,255.50,166.07,,,,,,,,,,,,,
CATHETER KIT AGBA PICC 1-LUMEN 4.5 FR X 55CM,SUP-2655671,CDM,C1751,HCPCS,0278,RC,,,,both,,,626.74,407.38,,,,,,,,,,,,,
CLIP HEMSTAS W16MMXL230CM MIN WRK CHAN 2.8MM REPLAY,SUP-2418595,CDM,2720000010,LOCAL,0272,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA PLU MAXBARR 3FR S1173108D1,SUP-2632785,CDM,C1751,HCPCS,0278,RC,,,,both,,,768.23,499.35,,,,,,,,,,,,,
PLATE FT 160MM DBL H FOR EXT FIX SYS,SUP-2197252,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3516.80,2285.92,,,,,,,,,,,,,
Exc Cyst/Aberrant Breast Tissue Open 1/> Lesion|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-19120,LOCAL,19120,CPT,0360,RC,,,RT|XU,outpatient,,,78054.75,46832.85,,,,,,,,,,,,,
"Amp F/Th 1/2 Jt/Phalanx W/Neurect W/Dir Clsr|LEFT HAND, SECOND DIGIT",CASE-26951,LOCAL,26951,CPT,,,,,F1,outpatient,,,16026.48,9615.89,,,,,,,,,,,,,
Exc Cyst/Aberrant Breast Tissue Open 1/> Lesion|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-19120,LOCAL,19120,CPT,,,,,RT|XU,outpatient,,,78054.75,46832.85,,,,,,,,,,,,,
"Amp F/Th 1/2 Jt/Phalanx W/Neurect W/Dir Clsr|LEFT HAND, SECOND DIGIT",CASE-26951,LOCAL,26951,CPT,0360,RC,,,F1,outpatient,,,16026.48,9615.89,,,,,,,,,,,,,
Peri-Implant Capsulectomy Breast Complete|RIGHT SIDE,CASE-19371,LOCAL,19371,CPT,,,,,RT,outpatient,,,50309.28,30185.57,,,,,,,,,,,,,
"HC Excis Nail Matrix Perm Rmvl|LEFT FOOT, GREAT TOE|UNUSUAL NON-OVERLAPPING SERVICE",CASE-11750,LOCAL,11750,CPT,0450,RC,,,TA|XU,outpatient,,,27989.30,16793.58,,,,,,,,,,,,,
Peri-Implant Capsulectomy Breast Complete|RIGHT SIDE,CASE-19371,LOCAL,19371,CPT,0360,RC,,,RT,outpatient,,,50309.28,30185.57,,,,,,,,,,,,,
BLADE RETRACTOR YOUNG 1.75X1.5 IN 8.25 IN PROST BIFUR,SUP-2470959,CDM,2720000010,LOCAL,0272,RC,,,,both,,,477.53,310.39,,,,,,,,,,,,,
CATHETER INTVASC OCCL ECLIPSE 2L BALLOON L 9 MM DIA 6 MM TIP,SUP-2895559,CDM,C2628,HCPCS,0272,RC,,,,both,,,5648.86,3671.76,,,,,,,,,,,,,
MESH SURG W20XL30CM THK1MM DUALMESH + BIOMATERIAL EPTFE,SUP-2395343,CDM,C1781,HCPCS,0278,RC,,,,both,,,5444.76,3539.09,,,,,,,,,,,,,
SPLINT WRST THMB XL L8IN R BLK FOAM D RNG CLSR ADJ REUSE,SUP-2336033,CDM,L3809,HCPCS,0274,RC,,,,both,,,20.82,13.53,,,,,,,,,,,,,
KIT INTRO ARW FLX SHTH L 10 CM DIA 8.5 FR GUIDEWIRE 0.035 IN,SUP-2763400,CDM,C1892,HCPCS,0272,RC,,,,both,,,224.82,146.13,,,,,,,,,,,,,
SUPPORT WRST PUL LACE CLOSURE UNIV LT PROCARE QUICK-FIT,SUP-2195780,CDM,L3931,HCPCS,0272,RC,,,,both,,,34.32,22.31,,,,,,,,,,,,,
Prq Skel Fixj Dstl Phlngl Fx Fngr/Thmb Ea,CASE-26756,LOCAL,26756,CPT,0360,RC,,,,outpatient,,,13106.78,7864.07,,,,,,,,,,,,,
Replacement Tissue Expander W/Permanent Implant,CASE-11970,LOCAL,11970,CPT,,,,,,outpatient,,,64242.80,38545.68,,,,,,,,,,,,,
Autograft Spine Surgery Morselized Sep Incision,CASE-20937,LOCAL,20937,CPT,,,,,,outpatient,,,57022.57,34213.54,,,,,,,,,,,,,
Implnt Bio Implnt for Soft Tissue Reinforcement,CASE-15777,LOCAL,15777,CPT,,,,,,outpatient,,,111028.22,66616.93,,,,,,,,,,,,,
Replacement Tissue Expander W/Permanent Implant,CASE-11970,LOCAL,11970,CPT,0360,RC,,,,outpatient,,,64242.80,38545.68,,,,,,,,,,,,,
Esophagogastroduodenoscopy Transoral Diagnostic|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-43235,LOCAL,43235,CPT,0360,RC,,,74,outpatient,,,9157.42,5494.45,,,,,,,,,,,,,
Anoscopy Dx W/HRA &Chem Agnts Enhancement W/Bx|SEPARATE STRUCTURE,CASE-46607,LOCAL,46607,CPT,,,,,XS,outpatient,,,20667.62,12400.57,,,,,,,,,,,,,
Prq Skel Fixj Dstl Phlngl Fx Fngr/Thmb Ea,CASE-26756,LOCAL,26756,CPT,,,,,,outpatient,,,13106.78,7864.07,,,,,,,,,,,,,
Exc Prtd Tum/Prtd Glnd Lat Dsj&Prsrv Facial Nr|RIGHT SIDE,CASE-42415,LOCAL,42415,CPT,0360,RC,,,RT,outpatient,,,30216.58,18129.95,,,,,,,,,,,,,
Exc Prtd Tum/Prtd Glnd Lat Dsj&Prsrv Facial Nr|RIGHT SIDE,CASE-42415,LOCAL,42415,CPT,,,,,RT,outpatient,,,30216.58,18129.95,,,,,,,,,,,,,
Implnt Bio Implnt for Soft Tissue Reinforcement,CASE-15777,LOCAL,15777,CPT,0360,RC,,,,outpatient,,,111028.22,66616.93,,,,,,,,,,,,,
HC Inj Proc Cysto or Void,CASE-51600,LOCAL,51600,CPT,0361,RC,,,,outpatient,,,38218.97,22931.38,,,,,,,,,,,,,
Laps Fulg/Exc Ovary Viscera/Peritoneal Surface|BILATERAL PROCEDURE,CASE-58662,LOCAL,58662,CPT,,,,,50,outpatient,,,55354.52,33212.71,,,,,,,,,,,,,
Esophagogastroduodenoscopy Transoral Diagnostic|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-43235,LOCAL,43235,CPT,,,,,74,outpatient,,,9157.42,5494.45,,,,,,,,,,,,,
Anoscopy Dx W/HRA &Chem Agnts Enhancement W/Bx|SEPARATE STRUCTURE,CASE-46607,LOCAL,46607,CPT,0360,RC,,,XS,outpatient,,,20667.62,12400.57,,,,,,,,,,,,,
Laps Fulg/Exc Ovary Viscera/Peritoneal Surface|BILATERAL PROCEDURE,CASE-58662,LOCAL,58662,CPT,0360,RC,,,50,outpatient,,,55354.52,33212.71,,,,,,,,,,,,,
Autograft Spine Surgery Morselized Sep Incision,CASE-20937,LOCAL,20937,CPT,0360,RC,,,,outpatient,,,57022.57,34213.54,,,,,,,,,,,,,
CATHETER DIL BAL L12MM DIA3.5MM FOR INTRASINAL IRR RELIEVA,SUP-2106337,CDM,C1726,HCPCS,0272,RC,,,,both,,,2263.94,1471.56,,,,,,,,,,,,,
PIN FIX L110MM DIA3MM EX ANCHR DEV ORTHOLOCK,SUP-2364169,CDM,C1713,HCPCS,0278,RC,,,,both,,,29.52,19.19,,,,,,,,,,,,,
DEFIBRILLATOR CRD 2 CHMBR 36 J 4X7.1X1.4 CM 41 CC 80 GM,SUP-2356284,CDM,C1721,HCPCS,0275,RC,,,,both,,,56520.00,36738.00,,,,,,,,,,,,,
ANCHOR SUT DIA5MM W/ VLT BLU ABSRB ORTHOCORD NDL SPIRALOK,SUP-2249449,CDM,C1713,HCPCS,0278,RC,,,,both,,,1243.44,808.24,,,,,,,,,,,,,
K WIRE FIX DIA1.4MM FOR CANN GREAT TOE LPT,SUP-2397197,CDM,C1713,HCPCS,0278,RC,,,,both,,,81.64,53.07,,,,,,,,,,,,,
ANCHOR SUT DIA2.9MM SFT JUGGERKNOT,SUP-2212955,CDM,C1713,HCPCS,0278,RC,,,,both,,,1202.75,781.79,,,,,,,,,,,,,
ANCHOR SUTURE L10.75MM DIAMETER 2.9MM DOUBLE LOADED WITH NO,SUP-2842793,CDM,C1713,HCPCS,0278,RC,,,,both,,,1101.79,716.16,,,,,,,,,,,,,
HC Fetal Eval 1st Tri Sgl Gest,PX-4027680100,CDM,76801,CPT,0402,RC,,,,inpatient,,,1288.00,837.20,,,,,,,,,,,,,
POLARUS 3 CAP SCREW 6MM,SUP-2639518,CDM,C1713,HCPCS,0278,RC,,,,both,,,1208.90,785.78,,,,,,,,,,,,,
GRAFT BIO TISS 8X12CM MESH FET BOV DERM IONIC DERM REP SLV,SUP-2243718,CDM,Q4110,HCPCS,0636,RC,,,,both,,,11555.20,7510.88,,,,,,,,,,,,,
SCREW BONE L55MM D35MM UNVRSL CRTCL PLVC STNLSS STEEL SELF T,SUP-2479301,CDM,C1713,HCPCS,0278,RC,,,,both,,,84.87,55.17,,,,,,,,,,,,,
"Tx Open Tendon Flexor Toe 1 Tendon Spx|RIGHT FOOT, SECOND DIGIT",CASE-28232,LOCAL,28232,CPT,0360,RC,,,T6,outpatient,,,24836.20,14901.72,,,,,,,,,,,,,
Arthrs Knee Debridement/Shaving Artclr Crtlg|RIGHT SIDE,CASE-29877,LOCAL,29877,CPT,,,,,RT,outpatient,,,24167.22,14500.33,,,,,,,,,,,,,
HC Inj Trigger Pt 1-2 Musc Grps|PBB CHARGE|SEPARATE STRUCTURE,CASE-20552,LOCAL,20552,CPT,0510,RC,,,PBB|XS,outpatient,,,2190.50,1314.30,,,,,,,,,,,,,
Rpr Aa Hernia 1st > 10 Cm Reducible,CASE-49595,LOCAL,49595,CPT,0360,RC,,,,outpatient,,,160132.67,96079.60,,,,,,,,,,,,,
HC >= 12 Lead Ekg,CASE-93005,LOCAL,93005,CPT,0730,RC,,,,outpatient,,,2083.03,1249.82,,,,,,,,,,,,,
Arthrs Knee Debridement/Shaving Artclr Crtlg|RIGHT SIDE,CASE-29877,LOCAL,29877,CPT,0360,RC,,,RT,outpatient,,,24167.22,14500.33,,,,,,,,,,,,,
"Tx Open Tendon Flexor Toe 1 Tendon Spx|RIGHT FOOT, SECOND DIGIT",CASE-28232,LOCAL,28232,CPT,,,,,T6,outpatient,,,24836.20,14901.72,,,,,,,,,,,,,
Rpr Aa Hernia 1st > 10 Cm Reducible,CASE-49595,LOCAL,49595,CPT,,,,,,outpatient,,,160132.67,96079.60,,,,,,,,,,,,,
GRAFT DERMAL PLIABLE PRE THN SM 20X17.5 CMX0.7-1.4 MM FLEXHD,SUP-2430130,CDM,Q4128,HCPCS,0636,RC,,,,both,,,33346.80,21675.42,,,,,,,,,,,,,
SCREW BNE LAG 12.7X65 MM HIP COMPR TALON,SUP-2391516,CDM,C1713,HCPCS,0278,RC,,,,both,,,1868.30,1214.39,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9 % IV SOLN,RX-27838,CDM,J7050,HCPCS,0250,RC,00338-0049-02,NDC,,both,250,ML,36.20,23.53,,,,,,,,,,,,,
COMPONENT FEM SM LT KNEE LIBRA,SUP-2442351,CDM,C1776,CPT,0278,RC,,,,both,,,1130.40,734.76,,,,,,,,,,,,,
GUIDEWIRE VASC L190CM DIA0.014INCH COIL L19CM STR TIP,SUP-2123808,CDM,C1769,HCPCS,0272,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
MARKER FIDUCIAL 20G X 20CM X 0.40MM,SUP-2745233,CDM,A4648,CPT,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
SYSTEM INTRO ACUSTK II L 60 CM GUIDEWIRE 0.038 IN TIP 7.5 CM,SUP-2147741,CDM,C1894,HCPCS,0272,RC,,,,both,,,204.10,132.66,,,,,,,,,,,,,
PLATE SPNL 10MM GRFT CONTAINMENT MLX,SUP-2310441,CDM,C1713,HCPCS,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
BUPRENORPHINE HCL 0.3 MG/ML IJ SOLN,RX-9320,CDM,J0592,HCPCS,0636,RC,42023-0179-05,NDC,,both,1,ML,78.40,50.96,,,,,,,,,,,,,
REAMER SURG SZ 22 MM MTP STRL ORTHOLOC 3DI,SUP-2900519,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1152.38,749.05,,,,,,,,,,,,,
DEFIBRILLATOR CRD 2 CHMBR 40 J 4X7.1X1.4 CM 35 CC 75 CC,SUP-2356287,CDM,C1721,HCPCS,0275,RC,,,,both,,,63585.00,41330.25,,,,,,,,,,,,,
PIN FIX SKULL RADLUC STRL DISP,SUP-2150244,CDM,2720000010,LOCAL,0272,RC,,,,both,,,701.26,455.82,,,,,,,,,,,,,
PLATE BNE NAVICULAR GRID,SUP-2864967,CDM,C1713,HCPCS,0278,RC,,,,both,,,6908.00,4490.20,,,,,,,,,,,,,
SCREW BONE L9MM OD2MM T6 CRTX ST TI VLP,SUP-2350907,CDM,C1713,HCPCS,0278,RC,,,,both,,,288.44,187.49,,,,,,,,,,,,,
KWIRE FIX L530MM S STL OLV,SUP-2242952,CDM,C1713,HCPCS,0278,RC,,,,both,,,996.60,647.79,,,,,,,,,,,,,
BUR SURG L9CM HD L351MM DIA3MM TAPR L BOR MIDAS REX LEGEND,SUP-2280240,CDM,2720000010,LOCAL,0272,RC,,,,both,,,351.24,228.31,,,,,,,,,,,,,
Reconstruction Nail Bed W/Graft,CASE-11762,LOCAL,11762,CPT,0360,RC,,,,outpatient,,,33643.98,20186.39,,,,,,,,,,,,,
"Suture Digital Nerve Hand/Foot 1 Nerve|LEFT HAND, THUMB",CASE-64831,LOCAL,64831,CPT,,,,,FA,outpatient,,,33739.18,20243.51,,,,,,,,,,,,,
Reconstruction Nail Bed W/Graft,CASE-11762,LOCAL,11762,CPT,,,,,,outpatient,,,33643.98,20186.39,,,,,,,,,,,,,
"Suture Digital Nerve Hand/Foot 1 Nerve|LEFT HAND, THUMB",CASE-64831,LOCAL,64831,CPT,0360,RC,,,FA,outpatient,,,33739.18,20243.51,,,,,,,,,,,,,
PLATE BONE L342MM 15 H RT PROX FEM LCK FOR 4.5MM SCR,SUP-2351131,CDM,C1713,HCPCS,0278,RC,,,,both,,,14680.76,9542.49,,,,,,,,,,,,,
HEAD FEM EXT 3- MM 10/12 22 MM HIP TAPR OXIN,SUP-2434565,CDM,C1776,CPT,0278,RC,,,,both,,,3654.96,2375.72,,,,,,,,,,,,,
COLLAR CERV MOTN CTRL STOUT W/ REPL PD MIAMI J XTRA,SUP-2270252,CDM,L0174,HCPCS,0274,RC,,,,both,,,120.23,78.15,,,,,,,,,,,,,
PLATE BONE W41XL41MM THK0.6MM MESH ORBIT FLR PDLLA SONICWELD,SUP-2263015,CDM,C1713,HCPCS,0278,RC,,,,both,,,2398.96,1559.32,,,,,,,,,,,,,
SOUND URETH L7IN OD10FR CRV TIP MTL FEM MCCREA,SUP-2126575,CDM,2720000010,LOCAL,0272,RC,,,,both,,,632.99,411.44,,,,,,,,,,,,,
HC So Mog-Igg1 Antibody Cell-Based Imfluor Assay Each,PX-3028636266,CDM,86362,CPT,0302,RC,,,,both,,,780.00,507.00,,,,,,,,,,,,,
PROBE SURG MCCULLOCH 18 MM 9.5 IN FORAMINAL ULTRA,SUP-2470135,CDM,2720000010,LOCAL,0272,RC,,,,both,,,374.23,243.25,,,,,,,,,,,,,
EPOPROSTENOL SODIUM 1.5 MG IV SOLR,RX-15898,CDM,J1325,HCPCS,0636,RC,66215-0402-01,NDC,,both,1,UN,317.80,206.57,,,,,,,,,,,,,
KIT STEREOTAXIC POD DISPOSABLE IASSIST,SUP-2205585,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
CATHETER CV SINGLE LUMEN 8 FRX2 CM PWR INJ POWERHICKMAN,SUP-2126210,CDM,C1751,HCPCS,0278,RC,,,,both,,,1052.37,684.04,,,,,,,,,,,,,
Laparoscopy Surg Rpr Initial Inguinal Hernia|RIGHT SIDE,CASE-49650,LOCAL,49650,CPT,0360,RC,,,RT,outpatient,,,49509.57,29705.74,,,,,,,,,,,,,
Esophageal Motility Study W/Interp&Rpt,CASE-91010,LOCAL,91010,CPT,0750,RC,,,,outpatient,,,1795.08,1077.05,,,,,,,,,,,,,
Laparoscopy Surg Rpr Initial Inguinal Hernia|RIGHT SIDE,CASE-49650,LOCAL,49650,CPT,,,,,RT,outpatient,,,49509.57,29705.74,,,,,,,,,,,,,
Cystourethroscopy,CASE-52000,LOCAL,52000,CPT,0360,RC,,,,outpatient,,,15420.82,9252.49,,,,,,,,,,,,,
Cystourethroscopy,CASE-52000,LOCAL,52000,CPT,,,,,,outpatient,,,15420.82,9252.49,,,,,,,,,,,,,
Esophageal Motility Study W/Interp&Rpt,CASE-91010,LOCAL,91010,CPT,,,,,,outpatient,,,1795.08,1077.05,,,,,,,,,,,,,
TENECTEPLASE 50 MG IV KIT,RX-28530,CDM,J3101,HCPCS,0636,RC,50242-0120-47,NDC,,both,1,UN,24477.00,15910.05,,,,,,,,,,,,,
PLATE BNE MESHED 246X11X1 MM CONTOURED SM GRID STRL,SUP-2477934,CDM,C1713,HCPCS,0278,RC,,,,both,,,5671.19,3686.27,,,,,,,,,,,,,
WASHER ORTH DIA19 MM STAINLESS STELL FOR 6.5-8 MM SCREW NS,SUP-2902235,CDM,C1713,HCPCS,0278,RC,,,,both,,,340.12,221.08,,,,,,,,,,,,,
GRAFT BNE STRP FRZ DRY DEMINERALISED BNE MTRX L 5CMXW 25CM,SUP-2306999,CDM,C1713,HCPCS,0278,RC,,,,both,,,2453.13,1594.53,,,,,,,,,,,,,
KIT BNE SCR 3MM HDLSS W/ RMR,SUP-2175121,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2811.87,1827.72,,,,,,,,,,,,,
PORT MRI PLAS HRD BASE SGL LUMN 96FR PRE ATTCH OPN END SIL,SUP-2126592,CDM,C1788,HCPCS,0278,RC,,,,both,,,631.14,410.24,,,,,,,,,,,,,
IMPLANT BIO TISS W2XL8CM BOV PERICARD CLLGN MTRX MESH SGL,SUP-2130297,CDM,C9354,HCPCS,0278,RC,,,,both,,,1405.46,913.55,,,,,,,,,,,,,
HC Joint Injection/Aspir Large WO US|PBB CHARGE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-20610,LOCAL,20610,CPT,0510,RC,,,PBB|XU,outpatient,,,5564.00,3338.40,,,,,,,,,,,,,
HC Peripheral Block - Femoral Single or Saphenous W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64447,LOCAL,64447,CPT,0360,RC,,,XU,outpatient,,,30741.58,18444.95,,,,,,,,,,,,,
Optx Dstl Radl X-Artic Fx/Epiphysl Sep|RIGHT SIDE,CASE-25607,LOCAL,25607,CPT,,,,,RT,outpatient,,,34272.03,20563.22,,,,,,,,,,,,,
Optx Dstl Radl X-Artic Fx/Epiphysl Sep|RIGHT SIDE,CASE-25607,LOCAL,25607,CPT,0360,RC,,,RT,outpatient,,,34272.03,20563.22,,,,,,,,,,,,,
SCREW BONE M L25MM DIA8MM 60DEG BLU FOR INTOSS,SUP-2223907,CDM,C1713,HCPCS,0278,RC,,,,both,,,5002.02,3251.31,,,,,,,,,,,,,
SHUNT PRUITT CAR OUTLYING@,SUP-2264206,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1943.66,1263.38,,,,,,,,,,,,,
GRAFT HUM TISS W5XL10CM THK1.04-2.28MM ULT THCK REGENERATIVE,SUP-2113075,CDM,Q4116,HCPCS,0636,RC,,,,both,,,5425.92,3526.85,,,,,,,,,,,,,
DEFIBRILLATOR IMPL IPERIA PROMRI DX W 65 X H 55 MM D 11 MM,SUP-2138372,CDM,C1722,HCPCS,0275,RC,,,,both,,,44745.00,29084.25,,,,,,,,,,,,,
GUIDEWIRE ORTHOPEDIC BALL 2 MM,SUP-2431226,CDM,C1769,HCPCS,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
CAP HIP POR TM/CER HDCAP,SUP-2212134,CDM,C1776,CPT,0278,RC,,,,both,,,18840.00,12246.00,,,,,,,,,,,,,
PLATE BNE L 175 MM SCREW DIA 4.5 MM 10 H NAR COMPR LCK NS,SUP-2932851,CDM,C1713,HCPCS,0278,RC,,,,both,,,2150.12,1397.58,,,,,,,,,,,,,
PACEMAKER CARD ENTOVIS PROMRI SR-T SINGLE CHMBR MR,SUP-2138276,CDM,C1786,HCPCS,0275,RC,,,,both,,,11461.00,7449.65,,,,,,,,,,,,,
GRAFT HUM TISS W4XL6CM THN MTRX ANAT BARR FOR ORTH APPL,SUP-2120775,CDM,C1762,CPT,0278,RC,,,,both,,,7123.88,4630.52,,,,,,,,,,,,,
CLARITHROMYCIN 250 MG PO TABS,RX-9616,CDM,6370000000,HCPCS,0637,RC,50268-0178-11,NDC,,both,1,UN,12.90,8.38,,,,,,,,,,,,,
CATHETER ART 7 FRX110 CM FEM ART,SUP-2214679,CDM,2720000010,LOCAL,0272,RC,,,,both,,,470.03,305.52,,,,,,,,,,,,,
Laps Fulg/Exc Ovary Viscera/Peritoneal Surface|LEFT SIDE,CASE-58662,LOCAL,58662,CPT,0360,RC,,,LT,outpatient,,,35169.87,21101.92,,,,,,,,,,,,,
Laps Fulg/Exc Ovary Viscera/Peritoneal Surface|LEFT SIDE,CASE-58662,LOCAL,58662,CPT,,,,,LT,outpatient,,,35169.87,21101.92,,,,,,,,,,,,,
PLATE BONE L61MM 5 H S STL SELF COMPR FOR 3.5MM SCR ECT,SUP-2198564,CDM,C1713,HCPCS,0278,RC,,,,both,,,245.27,159.43,,,,,,,,,,,,,
MICROCATHETER INFUSION PROGREAT L 150 CM DIA2.4 FR COAT L 90,SUP-2385610,CDM,C1887,HCPCS,0272,RC,,,,both,,,1097.43,713.33,,,,,,,,,,,,,
CATHETER ANGIO 4FR 65CM .035IN,SUP-2117140,CDM,C1769,HCPCS,0272,RC,,,,both,,,103.62,67.35,,,,,,,,,,,,,
VALVE AORT 19.2 MM MSTR HP SER FLX CUF,SUP-2356694,CDM,C1889,HCPCS,0278,RC,,,,both,,,17445.84,11339.80,,,,,,,,,,,,,
AUGMENT SL TIB LG CO CHROM FINN,SUP-2406084,CDM,C1776,CPT,0278,RC,,,,both,,,2270.22,1475.64,,,,,,,,,,,,,
PLATE POSTLAT DSTL HUM 3.5MM 3H RT 65MM LCP STRL,SUP-2547554,CDM,C1713,HCPCS,0278,RC,,,,both,,,2532.25,1645.96,,,,,,,,,,,,,
TERBUTALINE SULFATE 2.5 MG PO TABS,RX-11508,CDM,6370000000,HCPCS,0637,RC,62559-0721-01,NDC,,both,1,UN,4.50,2.92,,,,,,,,,,,,,
AXIUM HELIX 9MM X 20CM COIL,SUP-2499308,CDM,C1889,HCPCS,0278,RC,,,,both,,,4835.60,3143.14,,,,,,,,,,,,,
FIBER LASER FLEXIVA PULSE 242,SUP-2718710,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1258.98,818.34,,,,,,,,,,,,,
HC Cyanocobalamin Vit B-12 Unsat Binding Capacity,PX-3018260800,CDM,82608,CPT,0301,RC,,,,both,,,48.00,31.20,,,,,,,,,,,,,
BUR SURG MED 9.5 MM BORING TOOL FOR HD-G1,SUP-2848313,CDM,2720000010,LOCAL,0272,RC,,,,both,,,661.72,430.12,,,,,,,,,,,,,
COLLAR CERV LG BLK,SUP-2414450,CDM,L0120,HCPCS,0272,RC,,,,both,,,34.85,22.65,,,,,,,,,,,,,
ALLOGRAFT BNE 1 CC FD DBM FIBERFUSE,SUP-2736947,CDM,C1713,HCPCS,0278,RC,,,,both,,,910.60,591.89,,,,,,,,,,,,,
NEEDLE KYPHOPLASTY 11GA L7.48IN NIT VERTICAL AUG CRV TIP W/,SUP-2367079,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1779.16,1156.45,,,,,,,,,,,,,
MOLD CEM SPCR DIA65MM UNIV FEM SIL CRUCE SACRIFICING AGC,SUP-2408623,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3717.76,2416.54,,,,,,,,,,,,,
GRAFT VASC HERO L 53 CM OD 7.4 MM ID 6 MM SIL NIT VEN OUTFLO,SUP-2490844,CDM,C1768,CPT,0278,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
INTRODUCER CATH 9FR L23CM W/ GWIRE DIA0.038IN DI-LOCK DIL,SUP-2357081,CDM,C1892,HCPCS,0272,RC,,,,both,,,17.27,11.23,,,,,,,,,,,,,
PLATE BONE L207MM 9 H RT SHFT FOR BUTTRESSING MULTIFRAGMENT,SUP-2152511,CDM,C1713,HCPCS,0278,RC,,,,both,,,4231.15,2750.25,,,,,,,,,,,,,
HANDPIECE PHACO SURG MILL,SUP-2391877,CDM,C1713,HCPCS,0278,RC,,,,both,,,15072.00,9796.80,,,,,,,,,,,,,
STEM POROUS 12.0X115MM STRAIGHT,SUP-2505104,CDM,C1776,CPT,0278,RC,,,,both,,,7460.64,4849.42,,,,,,,,,,,,,
Parathyroidectomy/Exploration Parathyroids|RIGHT SIDE,CASE-60500,LOCAL,60500,CPT,0360,RC,,,RT,outpatient,,,43856.27,26313.76,,,,,,,,,,,,,
Parathyroidectomy/Exploration Parathyroids|RIGHT SIDE,CASE-60500,LOCAL,60500,CPT,,,,,RT,outpatient,,,43856.27,26313.76,,,,,,,,,,,,,
Incision & Removal Foreign Body Subq Tiss Compl,CASE-10121,LOCAL,10121,CPT,0360,RC,,,,outpatient,,,13141.13,7884.68,,,,,,,,,,,,,
Corrj Hallux Valgus W/Sesmdc W/Dist Metar Osteot|RIGHT SIDE,CASE-28296,LOCAL,28296,CPT,,,,,RT,outpatient,,,29328.58,17597.15,,,,,,,,,,,,,
Incision & Removal Foreign Body Subq Tiss Compl,CASE-10121,LOCAL,10121,CPT,,,,,,outpatient,,,13141.13,7884.68,,,,,,,,,,,,,
Corrj Hallux Valgus W/Sesmdc W/Dist Metar Osteot|RIGHT SIDE,CASE-28296,LOCAL,28296,CPT,0360,RC,,,RT,outpatient,,,29328.58,17597.15,,,,,,,,,,,,,
GRAFT BNE BLOCK 11X14X11 MM CORTICAL,SUP-2293858,CDM,C1713,HCPCS,0278,RC,,,,both,,,3611.00,2347.15,,,,,,,,,,,,,
STRUT TELESCOPIC MED 138 201MM BL,SUP-2695647,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5255.10,3415.81,,,,,,,,,,,,,
GUIDEWIRE VASC PRESHAPED 0.035 INX275 CM X SM CRV SAFARI 2,SUP-2140935,CDM,C1769,HCPCS,0272,RC,,,,both,,,1036.20,673.53,,,,,,,,,,,,,
ANCHOR SUTURE 2.8 MM DIAMETER BROACHING Y-KNOT RC,SUP-2828687,CDM,C1713,HCPCS,0278,RC,,,,both,,,929.79,604.36,,,,,,,,,,,,,
HEAD RAD SZ 1 W7.6XL17MM STD STEM TAPR MDLLRY CNL PRSS FIT,SUP-2244257,CDM,C1776,CPT,0278,RC,,,,both,,,9062.86,5890.86,,,,,,,,,,,,,
GRAFT BIO TISS W4XL4CM SLD FET BOV ACELLULAR DERM MTRX,SUP-2243685,CDM,Q4110,HCPCS,0636,RC,,,,both,,,2034.72,1322.57,,,,,,,,,,,,,
GUIDEWIRE ENDO STR REG HYDRPHLC UROLOGY L3CM L260CM OD.025IN,SUP-2385538,CDM,C1769,HCPCS,0272,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
PLATE BNE L207MM 12 H ST R PROX TIB S STL VAR ANG LOK COMPR,SUP-2177921,CDM,C1713,HCPCS,0278,RC,,,,both,,,6607.75,4295.04,,,,,,,,,,,,,
GRAFT PASTE SYNTH CLLGN COPIOS BVF 10CC,SUP-2197453,CDM,C1713,HCPCS,0278,RC,,,,both,,,4465.08,2902.30,,,,,,,,,,,,,
SCREW BONE L10MM D24MM LOK MTRSL SHRTNNG SSTM MSPT,SUP-2588982,CDM,C1713,HCPCS,0278,RC,,,,both,,,373.66,242.88,,,,,,,,,,,,,
SLEEVE DRL MEAS DIA4.3MM SGL END DISP FOR AFFIXUS HIP FRAC,SUP-2412614,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1051.90,683.73,,,,,,,,,,,,,
Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq|COLORECTAL CANCER SCREEN|UNUSUAL NON-OVERLAPPING SERVICE,CASE-45385,LOCAL,45385,CPT,0360,RC,,,PT|XU,outpatient,,,19830.20,11898.12,,,,,,,,,,,,,
Laps Surg Cholecystectomy W/Cholangiography|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-47563,LOCAL,47563,CPT,,,,,74,outpatient,,,55308.37,33185.02,,,,,,,,,,,,,
Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq|COLORECTAL CANCER SCREEN|UNUSUAL NON-OVERLAPPING SERVICE,CASE-45385,LOCAL,45385,CPT,,,,,PT|XU,outpatient,,,19830.20,11898.12,,,,,,,,,,,,,
Laps Surg Cholecystectomy W/Cholangiography|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-47563,LOCAL,47563,CPT,0360,RC,,,74,outpatient,,,55308.37,33185.02,,,,,,,,,,,,,
"Inj Dx/Ther Agnt Paravert Facet Joint, Lumbar/Sac, Add Level",CASE-64495,LOCAL,64495,CPT,,,,,,outpatient,,,3988.28,2392.97,,,,,,,,,,,,,
"Inj Dx/Ther Agnt Paravert Facet Joint, Lumbar/Sac, Add Level",CASE-64495,LOCAL,64495,CPT,0360,RC,,,,outpatient,,,3988.28,2392.97,,,,,,,,,,,,,
Grafting of Autologous Fat by Lipo 50 Cc or Less,CASE-15771,LOCAL,15771,CPT,0360,RC,,,,outpatient,,,65234.35,39140.61,,,,,,,,,,,,,
Grafting of Autologous Fat by Lipo 50 Cc or Less,CASE-15771,LOCAL,15771,CPT,,,,,,outpatient,,,65234.35,39140.61,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED CERM VIVACIT-E,SUP-2212494,CDM,C1776,CPT,0278,RC,,,,both,,,14758.00,9592.70,,,,,,,,,,,,,
SYSTEM FIX 15 FAST ABSRB PERMA FIX,SUP-2125762,CDM,C1713,HCPCS,0278,RC,,,,both,,,3862.20,2510.43,,,,,,,,,,,,,
DEFIBRILLATOR IMPL VITALITY DS DR H 5.9 CM D 1.1 CM DEL,SUP-2149281,CDM,C1721,HCPCS,0275,RC,,,,both,,,58090.00,37758.50,,,,,,,,,,,,,
GRAFT HUM TISS W3XL4CM PLCNTA MEM CRYOPRESERVED CHORION,SUP-2319167,CDM,Q4132,HCPCS,0636,RC,,,,both,,,3815.10,2479.81,,,,,,,,,,,,,
SPLINT ORTH M L13IN 6-17IN GRY ELBW BILAT ZIP OPN NYL LOOP,SUP-2324194,CDM,L3702,HCPCS,0272,RC,,,,both,,,64.40,41.86,,,,,,,,,,,,,
RESERVOIR SHUNT BURR HOLE 6.4X0.8 MM XR DETECTABLE SIDE,SUP-2851487,CDM,C1889,HCPCS,0278,RC,,,,both,,,619.74,402.83,,,,,,,,,,,,,
SUPPORT ORTHOT LOWER EXTREMITY KNEE CTRL FULL KNEECAP,SUP-2435698,CDM,L2795,HCPCS,0272,RC,,,,both,,,232.17,150.91,,,,,,,,,,,,,
PIN EXT FIX HALF 5X200 MM 20 MM BLNT ST THRD HA NS APEX,SUP-2472832,CDM,2720000010,LOCAL,0272,RC,,,,both,,,779.98,506.99,,,,,,,,,,,,,
SCREW BNE L18MM DIA2.5MM CORT WRST TI HEXADRIVE 7 TRILOK,SUP-2268228,CDM,C1713,HCPCS,0278,RC,,,,both,,,543.53,353.29,,,,,,,,,,,,,
SCREW INTFR DIA9.5-11MM POLY LACTIC ACID DELT TAPR CANN BIO,SUP-2121918,CDM,C1713,HCPCS,0278,RC,,,,both,,,609.16,395.95,,,,,,,,,,,,,
MARKER RAD OD10MM COIL FIDUCIAL SUPERLOCK,SUP-2381754,CDM,2720000010,LOCAL,0272,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
DIGOXIN 0.05 MG/ML PO SOLN,RX-43556,CDM,340b,HCPCS,0637,RC,99999-9991-16,NDC,,both,2.5,ML,4.20,2.73,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED BPLR PRSS FT ADD ON,SUP-2212517,CDM,C1776,CPT,0278,RC,,,,both,,,3557.62,2312.45,,,,,,,,,,,,,
SPLINT PREMIER PRO WRST,SUP-2336040,CDM,L3809,HCPCS,0274,RC,,,,both,,,23.90,15.53,,,,,,,,,,,,,
SCREW SPNL L12MM DIA4.6MM ANT CERV BLU TI SELF DRL LOK FOR,SUP-2255538,CDM,C1713,HCPCS,0278,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
REAMER SURG L20MM DISP GLENOJET,SUP-2123642,CDM,2720000010,LOCAL,0272,RC,,,,both,,,998.52,649.04,,,,,,,,,,,,,
SPLINT PREMIER PRO WRST,SUP-2336042,CDM,L3809,HCPCS,0272,RC,,,,both,,,17.93,11.65,,,,,,,,,,,,,
HEAD HUM 18X44 MM SHLDR RESURF TITAN,SUP-2244071,CDM,C1776,CPT,0278,RC,,,,both,,,15725.12,10221.33,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY RESPON L 65 CM 6FR 2-5-2 COURNAND,SUP-2481476,CDM,C1730,HCPCS,0272,RC,,,,both,,,230.41,149.77,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY INQUIRY L 95 CM DIA 5 FR SPC,SUP-2869129,CDM,C1731,HCPCS,0278,RC,,,,both,,,2323.60,1510.34,,,,,,,,,,,,,
BLADE ENDOSCP CRV HIP TEXT HNDL SHRP TIP W/ PAC CAP-FIX DISP,SUP-2849166,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1675.19,1088.87,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY EZ STEER WEBST CS L 115 CM DIA 5,SUP-2458534,CDM,C1730,HCPCS,0272,RC,,,,both,,,792.91,515.39,,,,,,,,,,,,,
MICRO ACC SET 5F SS WIRE SH B BVL,SUP-2116523,CDM,C1894,HCPCS,0272,RC,,,,both,,,86.35,56.13,,,,,,,,,,,,,
PLATE LK COMPRSS BROAD 9HL 173MM,SUP-2702815,CDM,C1713,HCPCS,0278,RC,,,,both,,,1096.49,712.72,,,,,,,,,,,,,
BELL CIRC 3.2 CM REUSE,SUP-2470960,CDM,C1776,CPT,0278,RC,,,,both,,,731.62,475.55,,,,,,,,,,,,,
CATHETER IMAGING DRAGONFLY OPSTAR LENS TO TIP DISTANCE 23 MM,SUP-2574355,CDM,C1753,HCPCS,0278,RC,,,,both,,,2392.68,1555.24,,,,,,,,,,,,,
COIL EMB L11CM LOOP DIA5MM 0.035IN HYDRGEL TECHNOLOGY,SUP-2421309,CDM,C1889,HCPCS,0278,RC,,,,both,,,4003.50,2602.27,,,,,,,,,,,,,
HC Repair Vad,PX-3613657500,CDM,36575,CPT,0361,RC,,,,outpatient,,,706.00,458.90,,,,,,,,,,,,,
CATHETER BRACHYTHERAPY CONTURA,SUP-2126755,CDM,C1725,HCPCS,0272,RC,,,,both,,,8635.00,5612.75,,,,,,,,,,,,,
GUIDEWIRE VASC GLIDEWIRE L 180 CM DIA 0.035 IN TIP L 3 CM,SUP-2141158,CDM,C1769,HCPCS,0272,RC,,,,both,,,156.75,101.89,,,,,,,,,,,,,
DEVICE SPNL STBL 12 MM INTERLAMINAR TECHNOLOGY TI STRL COFLX,SUP-2867272,CDM,C1889,HCPCS,0278,RC,,,,both,,,14915.00,9694.75,,,,,,,,,,,,,
HC Ins Cath Ren Art 2nd+ Unilat,PX-3613625300,CDM,36253,CPT,0361,RC,,,,both,,,16763.00,10895.95,,,,,,,,,,,,,
STENT URET STR 0.035 IN 3 CM 6 FRX22 CM 6 FR STIFF CNTOUR,SUP-2458338,CDM,C2617,HCPCS,0278,RC,,,,both,,,601.59,391.03,,,,,,,,,,,,,
FEEDING TUBE KIT LP 12 FRX1.5 CM BLLN BUTTON SIL MINI 1,SUP-2754570,CDM,2720000010,LOCAL,0272,RC,,,,both,,,890.98,579.14,,,,,,,,,,,,,
GLENOID AUGMENTED LARGE 15R,SUP-2751548,CDM,C1776,CPT,0278,RC,,,,both,,,9655.50,6276.07,,,,,,,,,,,,,
PLATE BNE L 260 MM SCREW DIA 3.5 MM 20 SHFT H SS MTPHSEAL VA,SUP-2908069,CDM,C1713,HCPCS,0278,RC,,,,both,,,5075.75,3299.24,,,,,,,,,,,,,
STEM FEM PRSS FT 2 LAT HIP,SUP-2216923,CDM,C1776,CPT,0278,RC,,,,both,,,12170.64,7910.92,,,,,,,,,,,,,
BIT DRL L85MM OD1.5MM ADD ON,SUP-2402825,CDM,2720000010,LOCAL,0272,RC,,,,both,,,373.66,242.88,,,,,,,,,,,,,
SEALER DIVIDER DISSECTOR ELECTROSURG SHAFT L 10 CM JAW L 12 MM,SUP-2904183,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1585.70,1030.70,,,,,,,,,,,,,
COMPONENT SUBTALAR M UHMWPE ANG STA-PEG,SUP-2397147,CDM,C1776,CPT,0278,RC,,,,both,,,6926.84,4502.45,,,,,,,,,,,,,
GRAFT VASC STR 8 MMX40 CM STD WALL EPTFE CARBOFLO CENTERFLEX,SUP-2761398,CDM,C1768,CPT,0278,RC,,,,both,,,2260.71,1469.46,,,,,,,,,,,,,
SCREW BNE 2.7X12 MM PERIARTICULAR DSTL/PROX TIB OPTILOCK,SUP-2458778,CDM,C1713,HCPCS,0278,RC,,,,both,,,222.94,144.91,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY L 115 CM 6 FR 2-5-2 MM D QPLR,SUP-2535655,CDM,C1730,HCPCS,0272,RC,,,,both,,,166.14,107.99,,,,,,,,,,,,,
CUTTER SPNL OD7MM D12.8CM-11MM PWR BLDE MIDAS CLASS AM,SUP-2290931,CDM,2720000010,LOCAL,0272,RC,,,,both,,,319.93,207.95,,,,,,,,,,,,,
DRAIN SURG 3/16 IN 5 IN 400 CC KIT INF CTRL PVC HEMVAC,SUP-2431702,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3328.40,2163.46,,,,,,,,,,,,,
PLATE BNE L38MM 5 H BILAT TI LO PROF RIG NEUT LOK COMPR MINI,SUP-2420780,CDM,C1713,HCPCS,0278,RC,,,,both,,,759.22,493.49,,,,,,,,,,,,,
NEOMYCIN-POLYMYXIN-HC OP SUSP,RX-19631,CDM,6370000000,HCPCS,0637,RC,61314-0641-75,NDC,,both,7.5,ML,673.60,437.84,,,,,,,,,,,,,
BIT DRL L44.5MM DIA0.7MM STP 6MM L6MM STRL MAXILLOFACIAL S,SUP-2187642,CDM,2720000010,LOCAL,0272,RC,,,,both,,,636.51,413.73,,,,,,,,,,,,,
CATHETER ABLATN F-F 1-7-4 MM 8MM 7 FRX115 CM EZ STEER,SUP-2248499,CDM,C1733,HCPCS,0272,RC,,,,both,,,3413.18,2218.57,,,,,,,,,,,,,
PLATE PA LK NAVICULAR CUNEIFORM RT LNG,SUP-2695657,CDM,C1713,HCPCS,0278,RC,,,,both,,,5451.04,3543.18,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED STEM ADD ON TRAB MEL,SUP-2212525,CDM,C1776,CPT,0278,RC,,,,both,,,1617.10,1051.11,,,,,,,,,,,,,
HC Asp Injection Major Joint|PBB CHARGE|BILATERAL PROCEDURE,PX-4502061000,CDM,20610,CPT,0450,RC,,,PBB|50,outpatient,,,1092.00,709.80,,,,,,,,,,,,,
INSERT TIB SZ 4 THK10MM STD R KNEE POLYETH CRUCE RET PRI,SUP-2304718,CDM,C1776,CPT,0278,RC,,,,both,,,4520.82,2938.53,,,,,,,,,,,,,
STRUT EXT FIX 2XSH STD NS DISP SMRT TSF,SUP-2932803,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4604.21,2992.74,,,,,,,,,,,,,
KIT EL JT SM REG HUM PIN BUSHING REPL COONRAD/MORREY,SUP-2205911,CDM,C1776,CPT,0278,RC,,,,both,,,2306.33,1499.11,,,,,,,,,,,,,
SCREW BNE L70MM DIA5MM THRD L32MM HD DIA6.2MM CANC FEM TI,SUP-2411476,CDM,C1713,HCPCS,0278,RC,,,,both,,,413.98,269.09,,,,,,,,,,,,,
PLATE BNE L52MM 3X3 H S STL T LOK COMPR OBLQ L ANG FOR,SUP-2186025,CDM,C1713,HCPCS,0278,RC,,,,both,,,951.64,618.57,,,,,,,,,,,,,
HC Assay of L7383transferrin,PX-3018446600,CDM,84466,CPT,0301,RC,,,,both,,,350.00,227.50,,,,,,,,,,,,,
HC Rsf Lab Bmh - Special Stain,PX-9900000124,CDM,9900000124,LOCAL,0990,RC,,,,both,,,94.00,61.10,,,,,,,,,,,,,
CATHETER HD LT 15.5 FRX36 CM PRECRV W/ SH TITAN HD,SUP-2269569,CDM,C1881,HCPCS,0278,RC,,,,both,,,580.90,377.58,,,,,,,,,,,,,
PNEUMOTHORAX KIT 8 FRX16 CM W/O HEIMLICH VLV LTX,SUP-2429389,CDM,C1729,HCPCS,0272,RC,,,,both,,,340.78,221.51,,,,,,,,,,,,,
SCREW BONE L14MM DIA3.5MM ST LCK CRTX,SUP-2348360,CDM,C1713,HCPCS,0278,RC,,,,both,,,1105.63,718.66,,,,,,,,,,,,,
PROSTHESIS EAR L4MM PIST DIA0.6MM TI CLASS STAP,SUP-2312798,CDM,C1713,HCPCS,0278,RC,,,,both,,,701.26,455.82,,,,,,,,,,,,,
PLATE BNE L 20 MM SCREW DIA2 MM MED CP TI RT MANDIBULAR HEMI,SUP-2883704,CDM,C1713,HCPCS,0278,RC,,,,both,,,14439.51,9385.68,,,,,,,,,,,,,
STEM ULN L1CM DIA5MM DSTL RAD EXT,SUP-2119916,CDM,C1776,CPT,0278,RC,,,,both,,,7432.38,4831.05,,,,,,,,,,,,,
PORT IMPL INFUSION LP 6 FR ATTCH POLY CATH SUTURE SMRT PRT,SUP-2494792,CDM,C1788,HCPCS,0278,RC,,,,both,,,759.88,493.92,,,,,,,,,,,,,
SCREW BNE L14MM DIA2MM TI QUICKSNAP TQ SER,SUP-2244465,CDM,C1713,HCPCS,0278,RC,,,,both,,,1164.63,757.01,,,,,,,,,,,,,
CATHETER DRAIN 12F 25CM STD LOOP W/ RADIOPAQUE MRKR BND PG,SUP-2659158,CDM,C1729,HCPCS,0272,RC,,,,both,,,235.44,153.04,,,,,,,,,,,,,
MESH PTCH SYNTH ABD N ABSRB OVL POLYPR OBLONG OVL 30CM LEN,SUP-2265970,CDM,C1781,HCPCS,0278,RC,,,,both,,,3887.32,2526.76,,,,,,,,,,,,,
GRAFT BNE 5 CC JR LG DEFCT SUBSTITUTE DBM GRFT ORTHOBLEND,SUP-2293914,CDM,C1713,HCPCS,0278,RC,,,,both,,,2245.73,1459.72,,,,,,,,,,,,,
SPACER SPNL 11 MM ANCHR COALITION,SUP-2433815,CDM,C1713,HCPCS,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
PLATE BNE L119MM 6 H L MED PROX TIB S STL LOK COMPR LO PROF,SUP-2185637,CDM,C1713,HCPCS,0278,RC,,,,both,,,4210.49,2736.82,,,,,,,,,,,,,
FEEDING TUBE KIT LP 14 FRX2.5 CM BLLN BUTTON SIL MINI 1,SUP-2754576,CDM,2720000010,LOCAL,0272,RC,,,,both,,,586.96,381.52,,,,,,,,,,,,,
LIDOCAINE HCL 1% INJ (MIXTURES ONLY),RX-430017,CDM,J2003,HCPCS,0636,RC,63323-0485-27,NDC,,both,5,ML,54.10,35.16,,,,,,,,,,,,,
GRAFT BNE 18X18X6.5 MM EVANS WDG ALLOSYNC,SUP-2570696,CDM,C1713,HCPCS,0278,RC,,,,both,,,4380.30,2847.19,,,,,,,,,,,,,
DEFIBRILLATOR LUMAX740 VR T HI ENERGY SYS W/ TI W/ CELLULAR,SUP-2138415,CDM,C1722,HCPCS,0275,RC,,,,both,,,54950.00,35717.50,,,,,,,,,,,,,
PLATE BONE M MEDL MIDFT OFFSET H ANAT SHP HIND FT ARW MEDLIS,SUP-2321015,CDM,C1713,HCPCS,0278,RC,,,,both,,,5495.00,3571.75,,,,,,,,,,,,,
HEAD HUM RESURF MACROBOND SZ 3 COPELAND EAS,SUP-2403995,CDM,C1776,CPT,0278,RC,,,,both,,,13973.00,9082.45,,,,,,,,,,,,,
INTRODUCER SHTH 5 FRX30 CM 7 CM W/ NIT WIRE REG MICRO-STICK,SUP-2267055,CDM,C1894,HCPCS,0272,RC,,,,both,,,65.94,42.86,,,,,,,,,,,,,
BLADE ARTHSCP SHV HIP CVD FULL RAD EXTREMELY SHRP TIP,SUP-2365415,CDM,2720000010,LOCAL,0272,RC,,,,both,,,816.37,530.64,,,,,,,,,,,,,
GUIDEWIRE VASC HI TORQ COMMND 18 ST L 210 CM DIA 0.018 IN,SUP-2892923,CDM,C1769,HCPCS,0272,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
ALLOGRAFT BNE 43 MM FRZN FEM HD W/ NK MATRIGRAFT,SUP-2741046,CDM,C1762,CPT,0278,RC,,,,both,,,4061.15,2639.75,,,,,,,,,,,,,
PLATE BONE STRAIGHT FOOT 8 HOLE STRATUM,SUP-2469491,CDM,C1713,HCPCS,0278,RC,,,,both,,,3337.69,2169.50,,,,,,,,,,,,,
Z DUP USE 2341990 ELECTRODE ENDOSCP L3.75MM 90DEG XL TURBOVAC 90 ASC133601] SMITH AND NEPHEW ENDOSCOPY],SUP-2341999,CDM,C1713,HCPCS,0278,RC,,,,both,,,1196.34,777.62,,,,,,,,,,,,,
PLATE BNE SM L90MM 2X3 H L MT TI POLYAX LOK COMPR LO PROF,SUP-2398513,CDM,C1713,HCPCS,0278,RC,,,,both,,,5912.62,3843.20,,,,,,,,,,,,,
BLADE SCRDRIVER CRUCFRM HLD SL NONCANNULATED FOR 1.5/2MM,SUP-2187569,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3315.15,2154.85,,,,,,,,,,,,,
CLAMP EXT FIX L1.344XW1.044XH2.27IN 6MM ALUMINIUM ANODIZIED,SUP-2342900,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5177.86,3365.61,,,,,,,,,,,,,
SIZER KIT ACCSRY STRL INSTAFIX LTX DISP,SUP-2857586,CDM,2720000010,LOCAL,0272,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
HC Ot Eval High Complex,PX-4349716700,CDM,97167,CPT,0434,RC,,,,inpatient,,,341.00,221.65,,,,,,,,,,,,,
GRAFT BONE SUB 5ML DEMIN MTRX SYR PUTTY TREL-XPRESS 300,SUP-2244480,CDM,C9359,HCPCS,0278,RC,,,,both,,,4176.20,2714.53,,,,,,,,,,,,,
INTRODUCER HEMSTAS 6FRX23CM SHTH W/ .038IN GWIRE 6FR DIL,SUP-2355416,CDM,C1894,HCPCS,0272,RC,,,,both,,,97.34,63.27,,,,,,,,,,,,,
SPLINT WRST SM L THMB SPICA COT POLY FAB LTHR WRKHRD ORIG,SUP-2326129,CDM,L3908,HCPCS,0274,RC,,,,both,,,74.26,48.27,,,,,,,,,,,,,
PLATE BONE L38MM THK1.25MM 10 H BILAT TI CVD RIG NEUT SAG,SUP-2191225,CDM,C1713,HCPCS,0278,RC,,,,both,,,1342.98,872.94,,,,,,,,,,,,,
PUSHER KNOT SGL H W/ THMB RNG FOR SHLDR AND EL,SUP-2120937,CDM,C1713,HCPCS,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
PLATE CRNL LOW PRFLE LNG HLX4 TTNM CRNFCL DBLE Y SHPD CNTRD,SUP-2677802,CDM,C1713,HCPCS,0278,RC,,,,both,,,678.40,440.96,,,,,,,,,,,,,
CLIP ANEUR L W9XL10MM STD CO CHROM ALLY STR DBL COILED SPR,SUP-2305971,CDM,C1889,HCPCS,0278,RC,,,,both,,,847.80,551.07,,,,,,,,,,,,,
GUIDEWIRE VASC 0.035 INX275 CM X SM CRV LUBRIGREEN SS SAFARI,SUP-2140933,CDM,C1769,HCPCS,0272,RC,,,,both,,,1036.20,673.53,,,,,,,,,,,,,
GRAFT SYN DIA10MM MT CART DURABLE BIOCOMPATIBLE,SUP-2162878,CDM,C1776,CPT,0278,RC,,,,both,,,10990.00,7143.50,,,,,,,,,,,,,
GRAFT BNE SUB 10ML DEMIN BNE MTRX PSTE FRZ DRY DBX,SUP-2306992,CDM,C1713,HCPCS,0278,RC,,,,both,,,3821.85,2484.20,,,,,,,,,,,,,
CATHETER GUID AD 6FR L90CM DIA0.07IN MP1 TIP PTFE RADPQ W/O,SUP-2147673,CDM,C1887,HCPCS,0272,RC,,,,both,,,254.34,165.32,,,,,,,,,,,,,
CLAMP EXT FIX TI ALLY ROD TO ROD,SUP-2188498,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1786.44,1161.19,,,,,,,,,,,,,
PLATE BNE L13MM THK0.3MM 4 H CRANIOMAXILLOFACIAL TI SQ FOR,SUP-2402998,CDM,C1713,HCPCS,0278,RC,,,,both,,,552.64,359.22,,,,,,,,,,,,,
IMPLANT OTO L 59 X W 34 MM THK 19.5 MM SM POLYETHYL LT EAR 1,SUP-2883686,CDM,L8699,HCPCS,0278,RC,,,,both,,,5831.73,3790.62,,,,,,,,,,,,,
NAIL IM L28CM OD11MM FEM TROCH ENTRY VERSANAIL,SUP-2412485,CDM,C1713,HCPCS,0278,RC,,,,both,,,7243.76,4708.44,,,,,,,,,,,,,
GRAFT HUM TISS W3XL3CM COMP AMNIO MEM MTRX SHT AMNIOFIX,SUP-2305707,CDM,V2790,HCPCS,0278,RC,,,,both,,,4600.10,2990.06,,,,,,,,,,,,,
CORD REUS MONO FOR VL ASP BOVI,SUP-2166508,CDM,2720000010,LOCAL,0272,RC,,,,both,,,314.16,204.20,,,,,,,,,,,,,
CATHETER EMB FOGARTY L 40 CM DIA 5.5 FR BALLOON DIA,SUP-2214017,CDM,C1757,HCPCS,0272,RC,,,,both,,,393.54,255.80,,,,,,,,,,,,,
DRILL TWST DIA1.2MM 4MM STP J LATCH END DISP FOR UNIV NEURO,SUP-2364178,CDM,2720000010,LOCAL,0272,RC,,,,both,,,632.36,411.03,,,,,,,,,,,,,
BIT DRL LP STRL JUGGERKNOTLESS DISP,SUP-2608565,CDM,2720000010,LOCAL,0272,RC,,,,both,,,309.48,201.16,,,,,,,,,,,,,
BRACE KNEE ACL PLC MCL ICL SIZED TO FIT UNIV UNISX FASTEN ON,SUP-2150832,CDM,L1810,HCPCS,0272,RC,,,,both,,,1375.57,894.12,,,,,,,,,,,,,
PLATE BNE L 424 MM SCREW DIA 3.5/4.5 MM 21 H SS RT DSTL FEM 72585221N,SUP-2932884,CDM,C1713,HCPCS,0278,RC,,,,both,,,22442.37,14587.54,,,,,,,,,,,,,
SEALANT TISS 4 CC FIBRIN VISTASEAL,SUP-2421675,CDM,2720000010,LOCAL,0272,RC,,,,both,,,734.48,477.41,,,,,,,,,,,,,
FERROUS GLUCONATE 240 (27 FE) MG PO TABS,RX-25938,CDM,6370000000,HCPCS,0637,RC,00904-6403-60,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
HC Forearm 2 Views,PX-3207309000,CDM,73090,CPT,0320,RC,,,,both,,,565.00,367.25,,,,,,,,,,,,,
HC So1 Infectious Agent Antigen,PX-3068789967,CDM,87899,CPT,0306,RC,,,,both,,,49.00,31.85,,,,,,,,,,,,,
CATHETER CV TY 018 4 FRX8 CM DL J TIP POLYETH,SUP-2760009,CDM,C1751,HCPCS,0278,RC,,,,both,,,267.75,174.04,,,,,,,,,,,,,
STEM FEM CEM 16/12X130 MM KNEE MOD W/ M TAPR FOR 6 MM NOSE,SUP-2423132,CDM,C1776,CPT,0278,RC,,,,both,,,4907.82,3190.08,,,,,,,,,,,,,
SCREW BONE L10MM DIA2.4MM HDLSS COMPR SM CANN FLOWERCUBE,SUP-2225508,CDM,C1713,HCPCS,0278,RC,,,,both,,,1077.65,700.47,,,,,,,,,,,,,
PASTE INTRACORDAL INJ 7ML,SUP-2300152,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1303.10,847.01,,,,,,,,,,,,,
NAIL ULNA 2 3.0MM X 120MM STRAIGHT,SUP-2855486,CDM,C1713,HCPCS,0278,RC,,,,both,,,7595.66,4937.18,,,,,,,,,,,,,
PIN FIX PLT HLD REUSE ZEVO,SUP-2278052,CDM,C1713,HCPCS,0278,RC,,,,both,,,374.51,243.43,,,,,,,,,,,,,
PHENYTOIN SODIUM EXTENDED 100 MG PO CAPS,RX-6257,CDM,6370000000,HCPCS,0637,RC,51672-4111-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PLATE CERV PEEK CONVEX OPEL-C 18MM 14MM X 12MM X 7MM 7 DEG,SUP-2847825,CDM,C1713,HCPCS,0278,RC,,,,both,,,6091.60,3959.54,,,,,,,,,,,,,
STENT GRFT VASC AFX BODY L 60 MM DIA22 MM LIMB L 40 MM DIA16,SUP-2217619,CDM,C1768,CPT,0278,RC,,,,both,,,36361.20,23634.78,,,,,,,,,,,,,
GRAFT VASC GORTX L 50 CM DIA 6-8 MM EPTFE TAPR TW N RING,SUP-2396730,CDM,C1768,CPT,0278,RC,,,,both,,,1598.26,1038.87,,,,,,,,,,,,,
SCREW BNE L29MM DIA4.5MM TI MULTDIR ST LOK FULL THRD FOR,SUP-2388661,CDM,C1713,HCPCS,0278,RC,,,,both,,,545.42,354.52,,,,,,,,,,,,,
KIT INTRO L 45 CM DIA 4 FR TIP 7 CM SS WIRE/TIP STD MIC,SUP-2116534,CDM,C1894,HCPCS,0272,RC,,,,both,,,78.50,51.02,,,,,,,,,,,,,
DISSECTOR ENDOSCP BLNT TIP TRCR W OVL BLLN SPCMKR +,SUP-2283390,CDM,C1727,CPT,0278,RC,,,,both,,,1750.24,1137.66,,,,,,,,,,,,,
CAP PROTCT WIRE CLMP,SUP-2898976,CDM,2720000010,LOCAL,0272,RC,,,,both,,,777.15,505.15,,,,,,,,,,,,,
CATHETER HD TWO LUMEN 14 FRX6 IN LG BOR KT STR ARW,SUP-2627029,CDM,C1752,HCPCS,0278,RC,,,,both,,,180.93,117.60,,,,,,,,,,,,,
PIN FIX DIA4MM FOR FEM HD REM SCHNZ,SUP-2304385,CDM,C1713,HCPCS,0278,RC,,,,both,,,433.32,281.66,,,,,,,,,,,,,
DEVICE EMB L25MM OD4.5MM 55DEG SFT DST TIP BRAID 4 FLX,SUP-2296758,CDM,C1884,HCPCS,0278,RC,,,,both,,,46982.25,30538.46,,,,,,,,,,,,,
CONNECTOR SPNL L35.5MM-40MM SM CROSS ROD ADJ TI,SUP-2415637,CDM,C1713,HCPCS,0278,RC,,,,both,,,1147.98,746.19,,,,,,,,,,,,,
CANNULATED DRL 9X185MM,SUP-2417664,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1985.30,1290.44,,,,,,,,,,,,,
DILATOR VES 5FR L20CM 0038FT,SUP-2301453,CDM,C1769,HCPCS,0272,RC,,,,both,,,16.33,10.61,,,,,,,,,,,,,
AUGMENT FEM SZ 3 R KNEE TRITANIUM CONE TRIATHLON,SUP-2373593,CDM,C1776,CPT,0278,RC,,,,both,,,10847.98,7051.19,,,,,,,,,,,,,
LINER ACET SZ B ID22MM FLAT UHMWPE HIGHCROSS MPACT,SUP-2267391,CDM,C1776,CPT,0278,RC,,,,both,,,6034.23,3922.25,,,,,,,,,,,,,
CANNULA BONE GRAFT,SUP-2814449,CDM,2720000010,LOCAL,0272,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
PROBE VITRECTOMY 23 GA STR ENDOILLUMINATOR PK EDGEPLUS,SUP-2109956,CDM,C1713,HCPCS,0278,RC,,,,both,,,2119.37,1377.59,,,,,,,,,,,,,
GUIDEWIRE VASC L 125 CM DIA 0.032 IN TIP L 3 MM SS PTFE J,SUP-2120089,CDM,C1769,HCPCS,0272,RC,,,,both,,,39.41,25.62,,,,,,,,,,,,,
HC Cardioversion,PX-4809296000,CDM,92960,CPT,0480,RC,,,,outpatient,,,1401.00,910.65,,,,,,,,,,,,,
HC So Chromosome Analysis Am Fl,PX-3118826966,CDM,88269,CPT,0311,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
TUBE VENT POPE 1.14 MM 1 MM 2.5X3.5 MM SIL STRL,SUP-2535109,CDM,L8699,HCPCS,0278,RC,,,,both,,,42.64,27.72,,,,,,,,,,,,,
KNIFE SCHUCKNECHT SICKLE,SUP-2668912,CDM,2720000010,LOCAL,0272,RC,,,,both,,,410.21,266.64,,,,,,,,,,,,,
HC Cardioversion,PX-4509296000,CDM,92960,CPT,0450,RC,,,,inpatient,,,1401.00,910.65,,,,,,,,,,,,,
DEVICE SPNL FIX TOP ANTR CERV TI 12MM LEN SPINELINK,SUP-2165649,CDM,C1894,HCPCS,0272,RC,,,,both,,,106.76,69.39,,,,,,,,,,,,,
HEAD FEM DIA36MM NK L+16MM OXIDIZED ZIRCONIUM 12/14 TAPR PRI,SUP-2345373,CDM,C1776,CPT,0278,RC,,,,both,,,6000.54,3900.35,,,,,,,,,,,,,
CATHETER ETER HAD EXCHG STR KT 16FRX50CM GLIDEPATH,SUP-2126481,CDM,C1881,HCPCS,0278,RC,,,,both,,,1341.88,872.22,,,,,,,,,,,,,
CUP ACET CEM NEUT STD 32X60X11 MM HIP PRIMARY HW W/ PEG,SUP-2406740,CDM,C1776,CPT,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
GRAFT VASC PTCH 5X10 CMX1 MM SFT TISS GORTX,SUP-2395294,CDM,C1781,HCPCS,0278,RC,,,,both,,,1039.34,675.57,,,,,,,,,,,,,
SEALENT TISS FIBRIN 10 ML VALUPAK KT TISSEEL,SUP-2129969,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1659.80,1078.87,,,,,,,,,,,,,
SCREW BNE LCK 4.5X15 MM,SUP-2391494,CDM,C1713,HCPCS,0278,RC,,,,both,,,1096.49,712.72,,,,,,,,,,,,,
COMPONENT PAT SM DIA29MM THK7.5MM RESURF BI CRUCE STBL CEM,SUP-2350587,CDM,C1776,CPT,0278,RC,,,,both,,,2840.92,1846.60,,,,,,,,,,,,,
PROBE ELECSURG DYNABLATOR RF DISP,SUP-2745536,CDM,2720000010,LOCAL,0272,RC,,,,both,,,643.70,418.40,,,,,,,,,,,,,
COMPONENT PAT RND PRI STD PRESSFIT POR UHMWPE WITHOUTXRAY,SUP-2199553,CDM,C1776,CPT,0278,RC,,,,both,,,8706.59,5659.28,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED 3 PART,SUP-2212514,CDM,C1776,CPT,0278,RC,,,,both,,,16494.42,10721.37,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED PRSS FT STEM HD EPOCH CERM,SUP-2212731,CDM,C1776,CPT,0278,RC,,,,both,,,15343.61,9973.35,,,,,,,,,,,,,
PLATE BONE MINI THK1MM 2X2 H CRANIOMAXILLOFACIAL ORAL,SUP-2181777,CDM,C1713,HCPCS,0278,RC,,,,both,,,1721.03,1118.67,,,,,,,,,,,,,
GRAFT EVAR L120MM DIA28MM PROX 16MM DST AAA INTUITRAK,SUP-2217574,CDM,C1768,CPT,0278,RC,,,,both,,,32954.30,21420.29,,,,,,,,,,,,,
CONTROLLER CRYOSURGICAL C2 CRYOBLLN,SUP-2422293,CDM,2720000010,LOCAL,0272,RC,,,,both,,,15637.20,10164.18,,,,,,,,,,,,,
KIT SURG PWR MINIMALLY INVASIVE PROC KT FOR HRDWR STRL LF,SUP-2881085,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4593.82,2985.98,,,,,,,,,,,,,
PROSTHESIS RAD 8MM SZ 1 RT MAESTRO FX,SUP-2407359,CDM,C1776,CPT,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
PROSTHESIS VOICE L10MM OD20FR TRACHEOESOPHAGEAL INDWL L FLNG,SUP-2242406,CDM,L8509,HCPCS,0272,RC,,,,both,,,904.32,587.81,,,,,,,,,,,,,
PLATE SPNL 41 MM ANTR LUMBAR 4 HOLE PYRAMID +4,SUP-2631827,CDM,C1713,HCPCS,0278,RC,,,,both,,,12481.50,8112.97,,,,,,,,,,,,,
GRAFT BNE 100X25X4 MM 10 CC GRAN BI-OSTETIC FOAM,SUP-2134722,CDM,C1713,HCPCS,0278,RC,,,,both,,,7743.24,5033.11,,,,,,,,,,,,,
PLATE BONE W9XL61MM THK1.1MM 5 H DSTL ULN FIBULAR S STL 1/3,SUP-2343776,CDM,C1713,HCPCS,0278,RC,,,,both,,,703.58,457.33,,,,,,,,,,,,,
CATHETER ETER URET 12FR L70CM SHFT 7FR WVN CONE TIP REUSE,SUP-2126137,CDM,C1758,HCPCS,0278,RC,,,,both,,,253.77,164.95,,,,,,,,,,,,,
PROSTHESIS VOICE L10MM OD20FR TRACHEOESOPHAGEAL INDWL L FLNG,SUP-2242406,CDM,L8509,HCPCS,0274,RC,,,,both,,,904.32,587.81,,,,,,,,,,,,,
ALLOGRAFT HUM TISS SHT 8X6 CM PLCNTA BASE MEMBRN AMNIOEFFECT,SUP-2872721,CDM,C1762,CPT,0278,RC,,,,both,,,16155.30,10500.94,,,,,,,,,,,,,
PATCH CV ULTRAMAX L 7.6 X W 2.5 CM POLYESTER GEL KNITTED DBL,SUP-2265998,CDM,C1768,CPT,0278,RC,,,,both,,,346.19,225.02,,,,,,,,,,,,,
ROD DISTRACTOR MAXILLOFCL ACTIVATION FLX NS,SUP-2883546,CDM,C1713,HCPCS,0278,RC,,,,both,,,2385.71,1550.71,,,,,,,,,,,,,
BEARING TIB THK20MM 71/75MM KNEE ARCM POST STBL CONSTRN REV,SUP-2407734,CDM,C1776,CPT,0278,RC,,,,both,,,4973.76,3232.94,,,,,,,,,,,,,
SET LD INTRO EVOLUTION RL L 40.6 CM OD 19 FR ID 11 FR CTRL,SUP-2169470,CDM,C1773,HCPCS,0272,RC,,,,both,,,5466.71,3553.36,,,,,,,,,,,,,
GRAFT VASC HEMSHLD PLAT L 50 CM DIA24 MM BRANCH SZ 12/10/8/8,SUP-2682221,CDM,C1768,CPT,0278,RC,,,,both,,,5598.43,3638.98,,,,,,,,,,,,,
BLADE RTRCTR ST MARKS 2 13NW X 7NL WLIP F  UNVRSL RING,SUP-2676583,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1321.66,859.08,,,,,,,,,,,,,
VENETOCLAX 10 MG PO TABS,RX-133765,CDM,J8999,HCPCS,0636,RC,00074-0561-11,NDC,,both,1,UN,58.60,38.09,,,,,,,,,,,,,
GRAFT SYNTHECEL DURA REPR 2.5X2.5CM 1X1 IN S,SUP-2713885,CDM,C1763,HCPCS,0278,RC,,,,both,,,918.45,596.99,,,,,,,,,,,,,
DUODENOSCOPE FLX 120/230 V 50-60 HZ 497X380X140 MM ABOX,SUP-2659122,CDM,C1748,HCPCS,0278,RC,,,,both,,,35701.80,23206.17,,,,,,,,,,,,,
PLATE BNE W6.8XL90.2MM THK1.65MM 12 H TI STR LOK LO PROF,SUP-2411745,CDM,C1713,HCPCS,0278,RC,,,,both,,,1793.57,1165.82,,,,,,,,,,,,,
GRAFT BONE SUB 5ML CA PHOS RESRB FIL,SUP-2256575,CDM,C1763,HCPCS,0278,RC,,,,both,,,2166.60,1408.29,,,,,,,,,,,,,
PLUG FIST ENTEROCUTANEOUS BIODESIGN,SUP-2419222,CDM,C1763,HCPCS,0278,RC,,,,both,,,10676.00,6939.40,,,,,,,,,,,,,
TRAY PICC SUBCL 2/L 5FR 60CML PU RADPQ PEEL AWAY INT 3255115,SUP-2632661,CDM,C1751,HCPCS,0278,RC,,,,both,,,328.44,213.49,,,,,,,,,,,,,
CEFTRIAXONE SODIUM 2 G IV SOLR,RX-27309,CDM,J0696,HCPCS,0636,RC,00409-7336-04,NDC,,both,1,UN,54.10,35.16,,,,,,,,,,,,,
PIN EXT FIX SZ 4 X 120 X 30 MM HALF NS DISP MAV MINI,SUP-2932736,CDM,C1713,HCPCS,0278,RC,,,,both,,,504.44,327.89,,,,,,,,,,,,,
KIT GWIRE L DIA2MM CO CHROM T25 CANN SCRDRVR DEPTH GA,SUP-2225507,CDM,C1769,HCPCS,0272,RC,,,,both,,,499.89,324.93,,,,,,,,,,,,,
PLATE CRAN 120X60X40 MM PT SPEC IMPL PEEK,SUP-2860133,CDM,C1713,HCPCS,0278,RC,,,,both,,,31681.97,20593.28,,,,,,,,,,,,,
IMPLANT HUM TISSSUE 1X4CM THK2.31-3.30MM ALLDERM,SUP-2113415,CDM,Q4116,HCPCS,0636,RC,,,,both,,,995.38,647.00,,,,,,,,,,,,,
HC Pseudo-Aneurysm Compression,PX-4027693600,CDM,76936,CPT,0402,RC,,,,both,,,3211.00,2087.15,,,,,,,,,,,,,
STEM FEM SZ 7 L155MM OD11MM TI HA HIP STR REV NEUT CEM CLLR,SUP-2374170,CDM,C1776,CPT,0278,RC,,,,both,,,17590.28,11433.68,,,,,,,,,,,,,
COMPONENT FEM SZ 9 R KNEE CO CHROM NAR POST STBL CEM,SUP-2206173,CDM,C1776,CPT,0278,RC,,,,both,,,17379.59,11296.73,,,,,,,,,,,,,
BUR SURG L 9 CM DIA 3 MM MTCH SYM TRI DISECT TOOL STRL DISP,SUP-2930042,CDM,2720000010,LOCAL,0272,RC,,,,both,,,646.84,420.45,,,,,,,,,,,,,
ALLOGRAFT DERMAL 10X40X0.8-1.8 MM DERM TISS MTRX PUROS,SUP-2210629,CDM,C1713,HCPCS,0278,RC,,,,both,,,816.40,530.66,,,,,,,,,,,,,
SCREW BONE L10MM DIA2.4MM CORT MAND TI ST NONCANNULATED,SUP-2189414,CDM,C1713,HCPCS,0278,RC,,,,both,,,241.78,157.16,,,,,,,,,,,,,
IMMOBILIZER SHLDR SLNG M,SUP-2276607,CDM,L3660,HCPCS,0272,RC,,,,both,,,10.52,6.84,,,,,,,,,,,,,
CARTRIDGE SUT PERFECT PASS COBRAID BLK MAGNUMWIRE,SUP-2341230,CDM,2720000010,LOCAL,0272,RC,,,,both,,,438.50,285.02,,,,,,,,,,,,,
STAPLER FIX SEPT FLAP CLSR DISP ENTACT,SUP-2341428,CDM,2720000010,LOCAL,0272,RC,,,,both,,,643.57,418.32,,,,,,,,,,,,,
SCREW BNE L18MM DIA2.7MM DST VOLAR RAD MULTDIR FULL THRD SQ,SUP-2411812,CDM,C1713,HCPCS,0278,RC,,,,both,,,466.29,303.09,,,,,,,,,,,,,
GUIDEWIRE ORTH THRD 1.6X220 MM FOR CANN SCREW NS 03333013,SUP-2789099,CDM,C1769,HCPCS,0272,RC,,,,both,,,323.29,210.14,,,,,,,,,,,,,
HC So Brca1&2 Seq & Full Dup/Del,PX-3108116266,CDM,81162,CPT,0310,RC,,,,both,,,2714.00,1764.10,,,,,,,,,,,,,
PIN BNE FIX SHRT STR CADENCE,SUP-2932811,CDM,C1713,HCPCS,0278,RC,,,,both,,,350.05,227.53,,,,,,,,,,,,,
SET PICC 2L 5FR X 55CM W TEG CHG DLX-35552-VPSC,SUP-2887055,CDM,C1751,HCPCS,0278,RC,,,,both,,,2763.20,1796.08,,,,,,,,,,,,,
ALLOGRAFT BNE CHIP 1.7-10 MM 60 CC FD CANC,SUP-2743393,CDM,C1713,HCPCS,0278,RC,,,,both,,,3318.98,2157.34,,,,,,,,,,,,,
SCREW BONE 6.5MM DIA 115MML STNLSS STEEL CNCLLS SOLID DRIVE,SUP-2586755,CDM,C1713,HCPCS,0278,RC,,,,both,,,909.50,591.17,,,,,,,,,,,,,
PACEMAKER CARD STRATOS LT VENTRICULAR 2 CHMBR STRL,SUP-2138183,CDM,C2621,HCPCS,0275,RC,,,,both,,,25434.00,16532.10,,,,,,,,,,,,,
CATHETER EMB 4FR 0.75ML LIQCAP 1.7ML GASCP L40CM DIA9MM 5FR,SUP-2213997,CDM,C1757,HCPCS,0272,RC,,,,both,,,221.50,143.97,,,,,,,,,,,,,
CATHETER CV 2 LUMEN 5 FR INJ PICC CT,SUP-2342114,CDM,C1751,HCPCS,0278,RC,,,,both,,,595.97,387.38,,,,,,,,,,,,,
PLATE BNE HK LNG 2.7X12 MM LT CLAV VA LCK NS VA-LCP,SUP-2758175,CDM,C1713,HCPCS,0278,RC,,,,both,,,3830.55,2489.86,,,,,,,,,,,,,
WIRE FIX L70MM DIA1MM FOR HALLU-LOCK MTP ARTH SYS K,SUP-2242878,CDM,C1713,HCPCS,0278,RC,,,,both,,,116.59,75.78,,,,,,,,,,,,,
HC Bone Survey Complete,PX-3207707500,CDM,77075,CPT,0320,RC,,,,outpatient,,,1477.00,960.05,,,,,,,,,,,,,
CROWN DENT SZ UL1 UP LT CTRL PRI M TRNSPAR SHADE S STL THCK,SUP-2238787,CDM,D6783,CPT,0278,RC,,,,both,,,31.56,20.51,,,,,,,,,,,,,
COMPONENT FEM M L KNEE REV CEM CRUCE RET STEM NONBEADED CO 66320315] STRYKER CORP],SUP-2364830,CDM,C1776,CPT,0278,RC,,,,both,,,5030.03,3269.52,,,,,,,,,,,,,
ALLOGRAFT BNE STRP 20X50X3-6 MM SPNG FD CANC,SUP-2717784,CDM,C1713,HCPCS,0278,RC,,,,both,,,4862.79,3160.81,,,,,,,,,,,,,
OSTEOTOME SURG THK 0.22 IN SPATULA,SUP-2936859,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1202.62,781.70,,,,,,,,,,,,,
SCREW EXTR DIA2.5MM CONIC,SUP-2188322,CDM,C1713,HCPCS,0278,RC,,,,both,,,535.37,347.99,,,,,,,,,,,,,
PLATE 3D PROFYLE REPLANT 4X12MM,SUP-2695488,CDM,C1713,HCPCS,0278,RC,,,,both,,,1156.31,751.60,,,,,,,,,,,,,
GRAFT BNE SUB W11-20X14-27XL14-20MM THK24-26MM IL CREST,SUP-2307146,CDM,C1713,HCPCS,0278,RC,,,,both,,,3042.66,1977.73,,,,,,,,,,,,,
SCREW BNE L16MM OD2.7MM TI TARSALIS FULL THRD LOK TOT FT,SUP-2243272,CDM,C1713,HCPCS,0278,RC,,,,both,,,671.02,436.16,,,,,,,,,,,,,
FILTER VASC 2.25 MMX190 CM FOR EZ SYS FILTERWIRE EZ,SUP-2140772,CDM,C1884,HCPCS,0278,RC,,,,both,,,4615.80,3000.27,,,,,,,,,,,,,
SCREW BNE L13MM OD2MM DRL FREE ORTHOANCHOR SFT CLLR,SUP-2262928,CDM,C1713,HCPCS,0278,RC,,,,both,,,342.57,222.67,,,,,,,,,,,,,
CATHETER THROMCTMY HI FLO ASPIR TBNG DEV 3MAX ACE 68,SUP-2473985,CDM,C1757,HCPCS,0272,RC,,,,both,,,29641.60,19267.04,,,,,,,,,,,,,
KIT FIX PROX INTERPHALANGEAL JT BIOSYMMETRIC,SUP-2408290,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3028.53,1968.54,,,,,,,,,,,,,
APPLIER CLP XL 10 MMX32 CM MANUAL LOAD HEM-O-LOK ENDO10,SUP-2656814,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3256.18,2116.52,,,,,,,,,,,,,
POTASSIUM ALUM POWD,RX-24061,CDM,6370000000,HCPCS,0637,RC,24357-0300-01,NDC,,both,10,GR,375.00,243.75,,,,,,,,,,,,,
SPOON BOB VENT TB,SUP-2312806,CDM,L8699,HCPCS,0278,RC,,,,both,,,31.56,20.51,,,,,,,,,,,,,
"HC OB ER Level 5|SIGNIFICANT, SEPARATELY IDENTIFIABLE EVALUATION AND MANAGEMENT SERVICE BY THE SAME PHYSICIAN ON THE SAME DAY OF THE PROCEDURE OR OTHER SERVICE",PX-4509928501,CDM,99285,CPT,0450,RC,,,25,outpatient,,,3911.00,2542.15,,,,,,,,,,,,,
IMPLANT BIO TISS L CLLGN SCFLD ARTHSCP REGENETEN,SUP-2334694,CDM,C1768,CPT,0278,RC,,,,both,,,6970.80,4531.02,,,,,,,,,,,,,
HYDROXYZINE HCL 50 MG/ML IM SOLN,RX-3770,CDM,J3410,HCPCS,0636,RC,00517-5602-25,NDC,,both,0.5,ML,66.80,43.42,,,,,,,,,,,,,
STEM HUM LNG 8 MM SHLDR REUNION RFX,SUP-2451919,CDM,C1776,CPT,0278,RC,,,,both,,,715.92,465.35,,,,,,,,,,,,,
PLATE BNE L52MM THK13MM 3X7 H NONSTERILE HND S STL Y SHP LOK,SUP-2178036,CDM,C1713,HCPCS,0278,RC,,,,both,,,1668.34,1084.42,,,,,,,,,,,,,
ANCHOR SUT NO 3 SUT ABSRB FIBERWIRE 2.2MM DIA 7MM LEN V TAK,SUP-2122458,CDM,C1713,HCPCS,0278,RC,,,,both,,,910.60,591.89,,,,,,,,,,,,,
CAP END FLSH IMPING 10 MM HUM 1ST SCREW VERSANAIL,SUP-2472246,CDM,C1889,HCPCS,0278,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
SCREW BNE L70MM DIA6MM ST AQUA CORT TI ST CANN LOK FULL,SUP-2191845,CDM,C1713,HCPCS,0278,RC,,,,both,,,474.14,308.19,,,,,,,,,,,,,
SEAL CERV SPRING-LOADED SL EXTENDIBLE CLLR SIL TIP OMNI LOK,SUP-2423148,CDM,2720000010,LOCAL,0272,RC,,,,both,,,371.15,241.25,,,,,,,,,,,,,
K WIRE FIX L150MM DIA2.5MM THRD L15MM S STL TRCR PNT,SUP-2186904,CDM,C1713,HCPCS,0278,RC,,,,both,,,504.66,328.03,,,,,,,,,,,,,
IMPLANT COSMETIC SZ 13 X 38 X 6 MM POLYETHYL BLOCK STRL DISP,SUP-2935315,CDM,C1713,HCPCS,0278,RC,,,,both,,,1359.62,883.75,,,,,,,,,,,,,
SHELL ACET CLUS HOLE 48 MM HIP HA POROUS TRIL,SUP-2210226,CDM,C1776,CPT,0278,RC,,,,both,,,5755.62,3741.15,,,,,,,,,,,,,
SET INT FIX SCREW DIA1.5 MM 6 H TI NEURO STR REG PLATE SD HI 1PK,SUP-2937266,CDM,C1713,HCPCS,0278,RC,,,,both,,,1488.36,967.43,,,,,,,,,,,,,
SHEATH VASC ACCS WATCHMAN L 75 CM DIA14 FR PTFE PEBAX SINGLE,SUP-2141817,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
GRAFT DERMAL ULTRA THCK 4X1 CM ACELLULAR DERM DERMAMATRIX,SUP-2306985,CDM,C1762,CPT,0278,RC,,,,both,,,492.51,320.13,,,,,,,,,,,,,
CATHETER BLLN DIL 6 MMX4 CM URETH URETSCP UROFORCE,SUP-2126691,CDM,C1726,HCPCS,0272,RC,,,,both,,,972.96,632.42,,,,,,,,,,,,,
CATHETER URODYN 481100101] ENDOCARE INC],SUP-2217537,CDM,2720000010,LOCAL,0272,RC,,,,both,,,81.64,53.07,,,,,,,,,,,,,
SCREW BNE L 12 MM DIA 3.5 MM TI NLCK T15 DRV NS LEOS,SUP-2931488,CDM,C1713,HCPCS,0278,RC,,,,both,,,393.76,255.94,,,,,,,,,,,,,
CATHETER CARD ABLATION BLZR II XP L 110 CM DIA 7 FR TIP 8 MM,SUP-2141262,CDM,C1733,HCPCS,0272,RC,,,,both,,,4609.52,2996.19,,,,,,,,,,,,,
RETRIEVER THROMCTMY TREVO XP PROVUE L 25 MM 6 MM NIT PROPACK,SUP-2367809,CDM,C1757,HCPCS,0272,RC,,,,both,,,23095.96,15012.37,,,,,,,,,,,,,
PORT IMPL INFUSION SINGLE LUMEN 9.6 FRX75 CM STD PROF PLAS,SUP-2126166,CDM,C1788,HCPCS,0278,RC,,,,both,,,728.48,473.51,,,,,,,,,,,,,
SCREW INTRF L23MM DIA9MM BIOCRYL CANN ABSRB TAPR,SUP-2256768,CDM,C1713,HCPCS,0278,RC,,,,both,,,690.80,449.02,,,,,,,,,,,,,
TRIAL HD 1 SHLDR RVS COMPHSVE,SUP-2441591,CDM,C1776,CPT,0278,RC,,,,both,,,226.08,146.95,,,,,,,,,,,,,
CONNECTOR SPNL TI AX MECH FOR 5.5MM ROD MOSS MIAMI,SUP-2254451,CDM,C1713,HCPCS,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
HANDPIECE LASER 900 MM MALL FIBERLASE ACUPULSE,SUP-2713713,CDM,2720000010,LOCAL,0272,RC,,,,both,,,879.99,571.99,,,,,,,,,,,,,
PLATE SPNL MULTAXL 58-80 MM TI CD HORZ X10 CROSSLINK,SUP-2289544,CDM,C1713,HCPCS,0278,RC,,,,both,,,1938.95,1260.32,,,,,,,,,,,,,
SYRINGE DELIVERY KIT 4 IN W/ NDL ALIQUOT,SUP-2379528,CDM,C1713,HCPCS,0278,RC,,,,both,,,1055.04,685.78,,,,,,,,,,,,,
BOLT ORTHOPEDIC 90 MM FOR FEM NK SYS TI,SUP-2181055,CDM,C1713,HCPCS,0278,RC,,,,both,,,1212.54,788.15,,,,,,,,,,,,,
DOXYLAMINE-PYRIDOXINE 10-10 MG PO TBEC,RX-120971,CDM,6370000000,HCPCS,0637,RC,69452-0206-20,NDC,,both,1,UN,8.90,5.78,,,,,,,,,,,,,
PIN FIX L80MM DIA4MM BNE,SUP-2368437,CDM,C1713,HCPCS,0278,RC,,,,both,,,326.56,212.26,,,,,,,,,,,,,
SCREW BNE L60MM DIA3.5MM CORT TIB CONIC S STL ST,SUP-2184291,CDM,C1713,HCPCS,0278,RC,,,,both,,,378.87,246.27,,,,,,,,,,,,,
OVITEX PRS PERMANENT RECTANGLE 20X20.5 CM,SUP-2914637,CDM,C1781,HCPCS,0278,RC,,,,both,,,23179.48,15066.66,,,,,,,,,,,,,
DISC INTERVERTEBRAL 6DEG SPNL SUP ENDPLATE PRODISC-L,SUP-2163213,CDM,C1713,HCPCS,0278,RC,,,,both,,,13816.00,8980.40,,,,,,,,,,,,,
PROSTHESIS OSS NAR LG 0.4X1X5 MM CLASSIC STAP TI,SUP-2648920,CDM,L8613,CPT,0278,RC,,,,both,,,727.16,472.65,,,,,,,,,,,,,
WIRE EXT FIX OLV,SUP-2197289,CDM,2720000010,LOCAL,0272,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
PLATE BNE MESH 1.1 MM 84 HOLE LCK TI BABY GORILLA,SUP-2750991,CDM,C1713,HCPCS,0278,RC,,,,both,,,6311.40,4102.41,,,,,,,,,,,,,
BIT DRL DIA25MM HI SPD,SUP-2187153,CDM,2720000010,LOCAL,0272,RC,,,,both,,,748.86,486.76,,,,,,,,,,,,,
SPOOL HUM RT SM CNTR OFFSET FOR TOT ELBW ARTHROPLASTY,SUP-2399818,CDM,C1776,CPT,0278,RC,,,,both,,,14308.98,9300.84,,,,,,,,,,,,,
SCREW BNE SD 2X10 MM IMF,SUP-2859951,CDM,C1713,HCPCS,0278,RC,,,,both,,,775.89,504.33,,,,,,,,,,,,,
PLATE BNE PERIPROSTHETIC 115 MM PROX FEM RT NCB,SUP-2435495,CDM,C1713,HCPCS,0278,RC,,,,both,,,3767.22,2448.69,,,,,,,,,,,,,
CEMENT BONE ROTARY MIX 5 CC REINFORCED STERILE CRANIOS,SUP-2838515,CDM,C1713,HCPCS,0278,RC,,,,both,,,6167.59,4008.93,,,,,,,,,,,,,
COVER BUR H L20MM W/ TAB,SUP-2365243,CDM,C1713,HCPCS,0278,RC,,,,both,,,1290.79,839.01,,,,,,,,,,,,,
CETIRIZINE HCL 1 MG/ML PO SOLN,RX-126710,CDM,340b,HCPCS,0637,RC,16571-0134-48,NDC,,both,2.5,ML,2.70,1.75,,,,,,,,,,,,,
GRAFT DERMAL MESH 3X7 CM FEN WND MTRX MIRODERM,SUP-2431548,CDM,Q4175,HCPCS,0636,RC,,,,both,,,4431.17,2880.26,,,,,,,,,,,,,
PLATE BONE LNG LEFT PROXIMAL HUMERAL SYMMETRY,SUP-2483587,CDM,C1713,HCPCS,0278,RC,,,,both,,,879.20,571.48,,,,,,,,,,,,,
ANCHOR SUT DIA45MM HA PLLA COMP 2 W O NDL 3 LOOP UNIQUE PUL,SUP-2366670,CDM,C1713,HCPCS,0278,RC,,,,both,,,1367.78,889.06,,,,,,,,,,,,,
DEVICE FIX DIA13MM CONT LOOP BTTN ZIPLOOP TECHNOLOGY FOR,SUP-2212825,CDM,C1713,HCPCS,0278,RC,,,,both,,,2245.10,1459.31,,,,,,,,,,,,,
HC Needle Insertion W/O Injection 1 or 2 Muscles,PX-4202056000,CDM,20560,CPT,0420,RC,,,,outpatient,,,42.00,27.30,,,,,,,,,,,,,
KIT MAINT VENT SERVO I,SUP-2227264,CDM,2720000010,LOCAL,0272,RC,,,,both,,,555.15,360.85,,,,,,,,,,,,,
RING HALF 140MM FOR TRUELOK FIX SYS,SUP-2316177,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1486.48,966.21,,,,,,,,,,,,,
NAIL IM 10 MM CAPPED,SUP-2208223,CDM,C1713,HCPCS,0278,RC,,,,both,,,650.98,423.14,,,,,,,,,,,,,
RESIN DENT ADH SELF ETCH 7TH GENERATION LT CURE SGL COMP,SUP-2100155,CDM,2720000010,LOCAL,0272,RC,,,,both,,,519.67,337.79,,,,,,,,,,,,,
CATHETER HD CRV EXTN 11 FRX10 CM CATH NDL DUOFLO,SUP-2627067,CDM,C1752,HCPCS,0278,RC,,,,both,,,273.18,177.57,,,,,,,,,,,,,
PSN REV TM TIB PERIPHERALCONE SZ LRG L,SUP-2508676,CDM,C1776,CPT,0278,RC,,,,both,,,12874.00,8368.10,,,,,,,,,,,,,
SET INTRO PERFRMR L 7 CM OD 3 FR ID 1 MM GUIDEWIRE 0.021 IN,SUP-2169799,CDM,C1894,HCPCS,0272,RC,,,,both,,,122.52,79.64,,,,,,,,,,,,,
BURR SURG 6.5MM DIA HD CARBIDE SM BNE RND FLUTEX10 MICROPOWE,SUP-2605578,CDM,2720000010,LOCAL,0272,RC,,,,both,,,124.56,80.96,,,,,,,,,,,,,
EXTERNAL FIXATION KIT B FLD STRL HOFFMANN 3,SUP-2431372,CDM,2720000010,LOCAL,0272,RC,,,,both,,,20924.96,13601.22,,,,,,,,,,,,,
NAIL IM HUM 7 MMX30 CM NS LTX DISP,SUP-2861165,CDM,C1713,HCPCS,0278,RC,,,,both,,,4812.49,3128.12,,,,,,,,,,,,,
PLATE BNE L12MM STP 8MM 4 H 2 REARFOOT SLOT TI DISPLC CALCNL,SUP-2243233,CDM,C1713,HCPCS,0278,RC,,,,both,,,4226.44,2747.19,,,,,,,,,,,,,
ALLOGRAFT BNE 60 MM PRESERVON FIBULAR SHFT MATRIGRAFT,SUP-2740902,CDM,C1762,CPT,0278,RC,,,,both,,,1717.49,1116.37,,,,,,,,,,,,,
SCREW BONE L4MM DIA1.3MM STD CORT CRANIOMAXILLOFACIAL TI ST,SUP-2189000,CDM,C1713,HCPCS,0278,RC,,,,both,,,218.23,141.85,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED VIVACIT-E POLYETH PERSONA,SUP-2212587,CDM,C1776,CPT,0278,RC,,,,both,,,15150.50,9847.82,,,,,,,,,,,,,
SYSTEM INTGAST BLLN ORBERA,SUP-2119252,CDM,C1889,HCPCS,0278,RC,,,,both,,,6217.20,4041.18,,,,,,,,,,,,,
STEM FEM L150MM DIA12MM HIP TI POR IM BOW CEM ORTH SALV SYS,SUP-2405717,CDM,C1776,CPT,0278,RC,,,,both,,,4493.34,2920.67,,,,,,,,,,,,,
VALVE SHUNT ADJUSTABLE PRSS BUR H IMPL STRATA NSC,SUP-2278346,CDM,C1889,HCPCS,0278,RC,,,,both,,,12977.90,8435.63,,,,,,,,,,,,,
HC So Babesia Mictroti Antibodies Igg & Igm,PX-3028675368,CDM,86753,CPT,0302,RC,,,,both,,,36.00,23.40,,,,,,,,,,,,,
HC Iaadiadoo Not Otherwise Specified,PX-3068789900,CDM,87899,CPT,0306,RC,,,,outpatient,,,689.00,447.85,,,,,,,,,,,,,
COIL VASC AZUR L 34 CM DIA14 MM MICROCATHETER 0.035 IN LOOP,SUP-2385432,CDM,C1889,HCPCS,0278,RC,,,,both,,,4000.23,2600.15,,,,,,,,,,,,,
BASKET EXTR STONE FUS 8 FRX200 CM SHTH 2 CMX4CM BSKT,SUP-2170083,CDM,2720000010,LOCAL,0272,RC,,,,both,,,621.72,404.12,,,,,,,,,,,,,
PACEMAKER CARD 2 CHMBR TEMP EXT STRL,SUP-2138030,CDM,C1785,HCPCS,0275,RC,,,,both,,,13878.80,9021.22,,,,,,,,,,,,,
GRAFT HUM TISS ANT TIBIALIS TEND SM DIAM (ALL FLD DIAM,SUP-2307280,CDM,C1713,HCPCS,0278,RC,,,,both,,,4239.00,2755.35,,,,,,,,,,,,,
WASHER ORTHOPEDIC RND CUP 11 MM SM FRAG LOCKED TI NS VISION,SUP-2457915,CDM,C1713,HCPCS,0278,RC,,,,both,,,504.54,327.95,,,,,,,,,,,,,
PLATE BNE 100DEG 4X6 H L TI OBLQ L SHP FOR 2MM SCR,SUP-2191290,CDM,C1713,HCPCS,0278,RC,,,,both,,,1147.36,745.78,,,,,,,,,,,,,
VALVE AORT 23MM PERICARD BIOPROSTHESIS PERIMT,SUP-2214071,CDM,C1713,HCPCS,0278,RC,,,,both,,,13863.10,9011.01,,,,,,,,,,,,,
CUTTER SHAVER COUGAR END ARTHSCP 4MM DIA STD MENISCU ACL/PCL,SUP-2605865,CDM,2720000010,LOCAL,0272,RC,,,,both,,,169.62,110.25,,,,,,,,,,,,,
STAPLE BNE 15X15 MM FOREFOOT PK NIT DYNAFORCE MOTOCLIP MAX,SUP-2175169,CDM,C1713,HCPCS,0278,RC,,,,both,,,2471.18,1606.27,,,,,,,,,,,,,
HC Debride Skin and Subcu|SEPARATE STRUCTURE,PX-4501104200,CDM,11042,CPT,0450,RC,,,XS,both,,,1247.00,810.55,,,,,,,,,,,,,
PLATE CRAN 140X120X40 MM PT SPEC IMPL PEEK,SUP-2860152,CDM,C1713,HCPCS,0278,RC,,,,both,,,41900.47,27235.31,,,,,,,,,,,,,
PLATE BNE L 102 MM SCREW DIA 4.5 MM 6 H COMPR LCK STRL EVOS,SUP-2932859,CDM,C1713,HCPCS,0278,RC,,,,both,,,2884.09,1874.66,,,,,,,,,,,,,
SET SCREW SPNL CARBON FIBER PEDCL LCK ELEMENT FOR TRNSCONN,SUP-2883025,CDM,C1713,HCPCS,0278,RC,,,,both,,,4082.00,2653.30,,,,,,,,,,,,,
AMINOCAPROIC ACID 250 MG/ML IV SOLN,RX-403,CDM,J0281,HCPCS,0250,RC,00409-4346-16,NDC,,both,20,ML,54.10,35.16,,,,,,,,,,,,,
PLEDGET CV SAUVAGE L 10.2 X W 2.5 CM THK 0.61 MM POLYESTER,SUP-2761350,CDM,C1768,CPT,0278,RC,,,,both,,,197.79,128.56,,,,,,,,,,,,,
HC Remove Foreign Body/Intranasal,PX-4503030000,CDM,30300,CPT,0450,RC,,,,both,,,396.00,257.40,,,,,,,,,,,,,
STEM HUM L150MM OD5MM TI POR R DST CEM FLNG IMPL DISCVR,SUP-2136222,CDM,C1776,CPT,0278,RC,,,,both,,,12550.58,8157.88,,,,,,,,,,,,,
CUFF URETH L4CM INHIBZN OCCL SPHIN FOR AMS 800 SYS,SUP-2138949,CDM,C1815,HCPCS,0278,RC,,,,both,,,23003.64,14952.37,,,,,,,,,,,,,
ALLOGRAFT DERMAL 1X4 CMX1.26-1.75 MM DECELL DERM ORACELL,SUP-2740974,CDM,C1762,CPT,0278,RC,,,,both,,,517.47,336.36,,,,,,,,,,,,,
GRAFT BNE SUB 30CC 17 10MM CORT CANC CHIP MORSELIZED FRZ,SUP-2307051,CDM,C1713,HCPCS,0278,RC,,,,both,,,1382.26,898.47,,,,,,,,,,,,,
SCREW BNE L 26 MM DIA 3.5 MM TI CANN HD NS LEOS,SUP-2932591,CDM,C1713,HCPCS,0278,RC,,,,both,,,764.46,496.90,,,,,,,,,,,,,
SYSTEM DIL BLLN L18MM DIA6MM BALL TIP L2MM MULTISINUS,SUP-2217797,CDM,C1713,HCPCS,0278,RC,,,,both,,,4311.22,2802.29,,,,,,,,,,,,,
SUPPORT ORTHOT ELBW CUST DBL UPR EXTN FLX ASST FABRICATED,SUP-2435758,CDM,L3730,HCPCS,0274,RC,,,,both,,,2335.16,1517.85,,,,,,,,,,,,,
EXTRACTOR STONE 1.7FR L115CM 4W BSKT ATLS WIRE,SUP-2170135,CDM,2720000010,LOCAL,0272,RC,,,,both,,,602.79,391.81,,,,,,,,,,,,,
PROCEDURE KIT ARRY INSRTN ELECTRD TUBE D-ZAP STAR,SUP-2665072,CDM,2720000010,LOCAL,0272,RC,,,,both,,,925.04,601.28,,,,,,,,,,,,,
SLEEVE SMIT ENDOCERV BRACHYTHERAPY F/INTRAUTERINE TUBE 6X40,SUP-2214858,CDM,2720000010,LOCAL,0272,RC,,,,both,,,209.12,135.93,,,,,,,,,,,,,
NAIL CEPHALOMEDULLARY SM L34CM DIA10MM 130DEG LNG TI R CCD,SUP-2208148,CDM,C1713,HCPCS,0278,RC,,,,both,,,6685.75,4345.74,,,,,,,,,,,,,
SUPPORT ORTHOT FT CUST ARCH N REMOVABLE ATTCH TO SHOE,SUP-2435707,CDM,L3070,HCPCS,0274,RC,,,,both,,,90.02,58.51,,,,,,,,,,,,,
SUTURE TAPE,SUP-2907276,CDM,2720000010,LOCAL,0272,RC,,,,both,,,348.54,226.55,,,,,,,,,,,,,
BARRIER ADH W2.5XL3IN 4 SECT USED IN PT UNDERGOING ABD OR,SUP-2227076,CDM,C1765,HCPCS,0278,RC,,,,both,,,1259.67,818.79,,,,,,,,,,,,,
SUTURE PROL SZ 8 0 L24IN NONABSORBABLE BLU L65MM BV130 5 3 8 M8732,SUP-2219635,CDM,C1713,HCPCS,0278,RC,,,,both,,,254.78,165.61,,,,,,,,,,,,,
SCREW BNE RECON 2.3 MM THOR STR TI STRL TALON LEVEL 1 LTX,SUP-2869273,CDM,C1713,HCPCS,0278,RC,,,,both,,,6392.69,4155.25,,,,,,,,,,,,,
KIT DRNGE CATH 6FR SAFE-T-CENTESIS,SUP-2133893,CDM,C1729,HCPCS,0272,RC,,,,both,,,219.80,142.87,,,,,,,,,,,,,
INSERT ACET SZ F OD58X60MM ID32MM HIP ALUMINA CERAMIC,SUP-2375165,CDM,C1776,CPT,0278,RC,,,,both,,,2983.00,1938.95,,,,,,,,,,,,,
GRAFT VASC IMPRA L 35 CM DIA19 MM EPTFE FLEXLG DIAMETER RING,SUP-2761442,CDM,C1768,CPT,0278,RC,,,,both,,,2494.98,1621.74,,,,,,,,,,,,,
PLATE BNE M THK0.7MM 12 H ORBIT RIM PNK TI NEUT,SUP-2181697,CDM,C1713,HCPCS,0278,RC,,,,both,,,1378.15,895.80,,,,,,,,,,,,,
HC So1 Testosterone Free,PX-3018440267,CDM,84402,CPT,0301,RC,,,,outpatient,,,312.00,202.80,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL PEEK SD800.526,SUP-2860207,CDM,C1713,HCPCS,0278,RC,,,,both,,,33231.56,21600.51,,,,,,,,,,,,,
GRAFT BNE SUB SM SZ 07 14MM 1ML B TRICALCIUM PHSPTE SYN,SUP-2194007,CDM,C1713,HCPCS,0278,RC,,,,both,,,346.19,225.02,,,,,,,,,,,,,
STENT PERIPH SMRT RADIANZ L 120 MM DIA 8 MM DEL SYS L 150 CM,SUP-2866205,CDM,C1725,HCPCS,0272,RC,,,,both,,,5046.55,3280.26,,,,,,,,,,,,,
BAR EXT FIX 7 MMX17.8 CM PECTUS NUSS,SUP-2136286,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5623.74,3655.43,,,,,,,,,,,,,
COMPONENT TIB TY REV 5 KNEE OFFSET BKRS,SUP-2434219,CDM,C1776,CPT,0278,RC,,,,both,,,5809.31,3776.05,,,,,,,,,,,,,
"HC So1 Antibody Virus, Nos",PX-3028679067,CDM,86790,CPT,0302,RC,,,,outpatient,,,473.00,307.45,,,,,,,,,,,,,
COLLAR CERV M DENS AD CNTOUR CNTCT CLSR FOAM W/ STOCK SERP,SUP-2210884,CDM,L0120,HCPCS,0272,RC,,,,both,,,44.90,29.18,,,,,,,,,,,,,
RETRACTOR ENDOSCP L 300 MM HRT W 80 MM TROCAR DIA 5 MM LIV,SUP-2905614,CDM,2720000010,LOCAL,0272,RC,,,,both,,,508.15,330.30,,,,,,,,,,,,,
DEVICE VASC CLOSURE ANGIO-SEAL EVOLUTION DIA 6 FR GUIDEWIRE,SUP-2385256,CDM,C1760,HCPCS,0278,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
HC Immunofluorescence per Spec 1st Single Antb Stn,PX-3128834600,CDM,88346,CPT,0312,RC,,,,inpatient,,,443.00,287.95,,,,,,,,,,,,,
PSN REV CCK ART SURF VE 18MM R 11-13 GH,SUP-2508538,CDM,C1776,CPT,0278,RC,,,,both,,,6280.00,4082.00,,,,,,,,,,,,,
GRAFT VASC GELWEAVE L 40 CM DIA28 MM L 15 CM DIA 8 MM AG FLO,SUP-2385037,CDM,C1768,CPT,0278,RC,,,,both,,,3381.09,2197.71,,,,,,,,,,,,,
COMPONENT TIB L79MM CO CHROM POR KNEE FIN HIGHLY POLISHED,SUP-2405415,CDM,C1776,CPT,0278,RC,,,,both,,,7504.60,4877.99,,,,,,,,,,,,,
SPACER SPNL SPIKLS 0 DEG 14X12X17 MM THORLUM TI FORTIFY I-R,SUP-2594900,CDM,C1821,HCPCS,0278,RC,,,,both,,,21980.00,14287.00,,,,,,,,,,,,,
HC I&D Perianal Absc Superficial,PX-4504605000,CDM,46050,CPT,0450,RC,,,,both,,,2029.00,1318.85,,,,,,,,,,,,,
STRAP CLAV SM PD W3XL4IN STD FOAM PD STOCKINET MTL TOOTH,SUP-2276602,CDM,L3650,HCPCS,0272,RC,,,,both,,,16.30,10.59,,,,,,,,,,,,,
Z DISCONTINUED NO SUB IDED BOOT CAST W/ CUF XL BLK,SUP-2277491,CDM,L4386,HCPCS,0272,RC,,,,both,,,267.06,173.59,,,,,,,,,,,,,
HC Thrmbc/Nfs Dialysis Circuit,PX-3613690400,CDM,36904,CPT,0361,RC,,,,both,,,8583.00,5578.95,,,,,,,,,,,,,
CER OPTION 12/14 TPR SLEEVE +7,SUP-2510213,CDM,C1776,CPT,0278,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
BLADE SAW KNEE 13MM CUT EDGE 95MM CUT DEPTH 1.27MM CUT THICK,SUP-2605520,CDM,2720000010,LOCAL,0272,RC,,,,both,,,205.67,133.69,,,,,,,,,,,,,
KIT ENDOSCP HIP DRL DRL GUID OBT DISP FOR 1.8MM Q-FIX,SUP-2342829,CDM,2720000010,LOCAL,0272,RC,,,,both,,,545.01,354.26,,,,,,,,,,,,,
COLLAR CERV PHILLY MED 4.25 IN 13-16 IN REHAB FOAM PROCARE,SUP-2196879,CDM,L0172,HCPCS,0272,RC,,,,both,,,28.39,18.45,,,,,,,,,,,,,
PLATE BONE SM W11XL259MM THK3.3MM 0DEG 20 H BILAT TI STR RIG,SUP-2190801,CDM,C1713,HCPCS,0278,RC,,,,both,,,1682.79,1093.81,,,,,,,,,,,,,
HC Immunofluorescence per Spec 1st Single Antb Stn,PX-3128834600,CDM,88346,CPT,0312,RC,,,,outpatient,,,443.00,287.95,,,,,,,,,,,,,
PIN HALF 3X80 MM,SUP-2197280,CDM,C1713,HCPCS,0278,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
HC Surfactant Admin Thru Tube,PX-4109461000,CDM,94610,CPT,0410,RC,,,,outpatient,,,443.00,287.95,,,,,,,,,,,,,
STENT PANCREATIC GEENEN L 3 CM DIA11.5 FR GUIDEWIRE 0.035 IN,SUP-2737450,CDM,C2617,HCPCS,0278,RC,,,,both,,,241.78,157.16,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED STD CEM HI FLX POLYETH,SUP-2212704,CDM,C1776,CPT,0278,RC,,,,both,,,11834.69,7692.55,,,,,,,,,,,,,
PROXIMAL HUMERAL NAIL 1180150,SUP-2843382,CDM,C1713,HCPCS,0278,RC,,,,both,,,8148.30,5296.39,,,,,,,,,,,,,
SHEATH INTRO L 44 CM DIA12 FR GUIDEWIRE 0.038 IN LNG PTFE X,SUP-2615916,CDM,C1894,HCPCS,0272,RC,,,,both,,,190.57,123.87,,,,,,,,,,,,,
CLAMP SURG TRPL OCPTL LNG PROTEX CT,SUP-2584536,CDM,C1713,HCPCS,0278,RC,,,,both,,,496.12,322.48,,,,,,,,,,,,,
IMPLANT BRST 235CC DIA95CM P49CM SIL GEL SMOOTH RND HI PROF,SUP-2300975,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3485.40,2265.51,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.417,SUP-2859981,CDM,C1713,HCPCS,0278,RC,,,,both,,,36871.45,23966.44,,,,,,,,,,,,,
DEFIBRILLATOR IMPL PUNCTUA W 6.17 X H 7.95 CM D 0.99 CM 32.5,SUP-2149258,CDM,C1882,HCPCS,0275,RC,,,,both,,,52158.54,33903.05,,,,,,,,,,,,,
TROCAR ENDOSCP CONVERTERLESS THRD BLUNTPORT + DISP,SUP-2283194,CDM,2720000010,LOCAL,0272,RC,,,,both,,,997.01,648.06,,,,,,,,,,,,,
TUBING SET PRTBL ARTHRO DISPOSABLE APEX,SUP-2166982,CDM,C1713,HCPCS,0278,RC,,,,both,,,245.86,159.81,,,,,,,,,,,,,
TOTAL KNEE REPLACEMENT KIT PRIMARY E-PLUS,SUP-2217514,CDM,C1776,CPT,0278,RC,,,,both,,,14915.00,9694.75,,,,,,,,,,,,,
COMPONENT FEM SZ 65 POST L KNEE REV INTLOK CEM STBL STEM,SUP-2407548,CDM,C1776,CPT,0278,RC,,,,both,,,15197.60,9878.44,,,,,,,,,,,,,
SPACER ORTH FEM SEG 1 20 MM LAT KNEE TILASTAN ENDO-MODEL-M,SUP-2421834,CDM,C1776,CPT,0278,RC,,,,both,,,2555.96,1661.37,,,,,,,,,,,,,
HC Ot Adl Training 15 Min|OP OCCUPATIONAL THERAPY SERV|SERVICES PROVIDED IN WHOLE OR IN PARTY BY AN OTA FOR MEDICARE PATIENTS,PX-4309753500,CDM,97535,CPT,0430,RC,,,GO|CO,both,,,131.00,85.15,,,,,,,,,,,,,
KIT INTRO GLIDESHEATH SLENDER L 10 CM DIA 5 FR 0.025IN PLAS,SUP-2691361,CDM,C1894,HCPCS,0272,RC,,,,both,,,372.88,242.37,,,,,,,,,,,,,
SHEATH DIL DXL 18.1X16FR ORNG POLYPR LD EXTR TELSCP DISP,SUP-2169009,CDM,C1893,HCPCS,0272,RC,,,,both,,,292.02,189.81,,,,,,,,,,,,,
NICARDIPINE HCL IN NACL 20-0.86 MG/200ML-% IV SOLN,RX-94219,CDM,J2404,HCPCS,0636,RC,43066-0021-10,NDC,,both,200,ML,331.20,215.28,,,,,,,,,,,,,
BLADE OSTEOTOM RAD 8MM,SUP-2136780,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1985.74,1290.73,,,,,,,,,,,,,
IMPLANT BRST NACL SMOOTH RND SIL SHELL ANTR DIAPH VLV STYL,SUP-2113250,CDM,C1789,HCPCS,0278,RC,,,,both,,,1805.50,1173.57,,,,,,,,,,,,,
HC Subsequent Immun Admin,PX-7719047200,CDM,90472,CPT,0771,RC,,,,outpatient,,,65.00,42.25,,,,,,,,,,,,,
BLADE SAW OSCLLTNG 33MMW X71MML 1.2MM THK 1.5MM THK CUT LG B,SUP-2605509,CDM,2720000010,LOCAL,0272,RC,,,,both,,,75.33,48.96,,,,,,,,,,,,,
SUTURE 5 L36IN NONABSORBABLE WHT OS-8 L40MM 1/2 CIR SIL D9212,SUP-2218946,CDM,C1713,HCPCS,0278,RC,,,,both,,,420.48,273.31,,,,,,,,,,,,,
MESH CRAN W100XL100MM TI RECTANG MALL CNTOUR FOR 1.3MM SCR,SUP-2190621,CDM,C1713,HCPCS,0278,RC,,,,both,,,7178.04,4665.73,,,,,,,,,,,,,
SCREW BNE L8MM DIA2MM STD CORT CRANIOMAXILLOFACIAL TI ST 401158] DEPUY SYNTHES USA],SUP-2189368,CDM,C1713,HCPCS,0278,RC,,,,both,,,232.99,151.44,,,,,,,,,,,,,
STENT CAR ENROUTE L 40 MM DIA 9-7 MM WORKING L 57 CM,SUP-2884055,CDM,C1876,HCPCS,0278,RC,,,,both,,,8412.06,5467.84,,,,,,,,,,,,,
CLIP ANEUR W10XL10MM OPN DIA3.5MM CO CHROM ALLOY FEN L TYP,SUP-2306014,CDM,C1889,HCPCS,0278,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
SCREW BONE L14MM DIA3MM PARTIALLY THRD HD M CANN FLOWERCUBE,SUP-2225321,CDM,C1713,HCPCS,0278,RC,,,,both,,,646.21,420.04,,,,,,,,,,,,,
PIN FIX DBL DIAMOND 0.156X9 IN SS NS STEINMANN,SUP-2791596,CDM,C1713,HCPCS,0278,RC,,,,both,,,37.24,24.21,,,,,,,,,,,,,
LEAD PACE CAPSURFIX NOVUS MRI SURESCAN L 110 CM DIA 6 FR SIL,SUP-2281971,CDM,C1898,HCPCS,0275,RC,,,,both,,,1477.06,960.09,,,,,,,,,,,,,
SYSTEM STENT INTRO CATH L320CM OD6X10FR 0.035IN RADPQ BND,SUP-2169523,CDM,C1894,HCPCS,0272,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
UNIVERSAL WIRE FIXATION BOLT 23MM,SUP-2605902,CDM,2720000010,LOCAL,0272,RC,,,,both,,,492.79,320.31,,,,,,,,,,,,,
PLATE BONE L103MM 5 H LT POSTEROLATERAL DSTL HUM LIMIT CNTCT,SUP-2107056,CDM,C1713,HCPCS,0278,RC,,,,both,,,4085.14,2655.34,,,,,,,,,,,,,
SCREW BNE COMPR 2.7 MM SS KREULOCK,SUP-2845739,CDM,C1713,HCPCS,0278,RC,,,,both,,,10613.20,6898.58,,,,,,,,,,,,,
JANNETTA SCRN MESH TRNGLR 2MM 15MM SSTM CP TTNM,SUP-2676689,CDM,C1713,HCPCS,0278,RC,,,,both,,,999.43,649.63,,,,,,,,,,,,,
PARTICLE EMB BNDL S220PRO MIV20500 28MC24150SN EMBOSPHEREPRO,SUP-2798607,CDM,C1889,HCPCS,0278,RC,,,,both,,,2276.50,1479.72,,,,,,,,,,,,,
HC Bx Breast Add Les MR Image,PX-3611908600,CDM,19086,CPT,0361,RC,,,,outpatient,,,5560.00,3614.00,,,,,,,,,,,,,
BLADE SURG SGL PK DISPOSABLE FOR PLNTR FASCIITIS,SUP-2399187,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1629.66,1059.28,,,,,,,,,,,,,
MESH CRAN W100XL100MM THK05MM STR ROW PLT RESRB ORTHOMESH,SUP-2257162,CDM,C1781,HCPCS,0278,RC,,,,both,,,6100.42,3965.27,,,,,,,,,,,,,
PLATE BNE UPPER SYMPHYSIS 2.3 MM FRAC SMRT TI LEVEL 1,SUP-2462430,CDM,C1713,HCPCS,0278,RC,,,,both,,,1614.68,1049.54,,,,,,,,,,,,,
HC Veeg by Tech 2-12 Hours Unmonitored,PX-7409571100,CDM,95711,CPT,0740,RC,,,,both,,,1990.00,1293.50,,,,,,,,,,,,,
BIT DRL L107MM OD1.5MM 20MM STP SHFT END NONRADIOLUCENT FOR,SUP-2366414,CDM,2720000010,LOCAL,0272,RC,,,,both,,,554.90,360.68,,,,,,,,,,,,,
"HC So Folic Acid, RBC",PX-3018274766,CDM,82747,CPT,0301,RC,,,,inpatient,,,108.00,70.20,,,,,,,,,,,,,
CATHETER INFUSION 3X2.4 FRX130 CM 0.021 INX180 CM DIREXION,SUP-2141060,CDM,C1887,HCPCS,0272,RC,,,,both,,,2731.80,1775.67,,,,,,,,,,,,,
RING EXT FIX 140 MM 5/8 CARBON FIBER NS,SUP-2799525,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1672.36,1087.03,,,,,,,,,,,,,
ROD SPNL SCOLIOSIS 5.5X400/80 MM PREBENT TI NS MTRX,SUP-2589417,CDM,C1713,HCPCS,0278,RC,,,,both,,,596.60,387.79,,,,,,,,,,,,,
BIT DRL L110MM DIA27MM 3 FLUT QUIK CPL NONRADIOPAQUE W O,SUP-2187587,CDM,2720000010,LOCAL,0272,RC,,,,both,,,341.88,222.22,,,,,,,,,,,,,
COLLAR CERV PHILLY SM 4.25 IN 10-13 IN REHAB FOAM PROCARE,SUP-2196878,CDM,L0180,HCPCS,0272,RC,,,,both,,,35.67,23.19,,,,,,,,,,,,,
BLADE RTRCTR CHRNLEY LNG 1NW X 6 34NL X 4IND FINTL INCSN J,SUP-2700975,CDM,2720000010,LOCAL,0272,RC,,,,both,,,393.13,255.53,,,,,,,,,,,,,
PLATE BNE 135DEG 8 H S STL FEM BILAT STD TB RIG CLLR DYN,SUP-2197772,CDM,C1713,HCPCS,0278,RC,,,,both,,,1831.88,1190.72,,,,,,,,,,,,,
SHUNT CV L14MM DIA3MM IC SIL TAPR TIP RADPQ CLRVW,SUP-2278146,CDM,C1889,HCPCS,0278,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
KIT CATH PICC G+ARD BL ADV MAX BARRIER SAFETY 6FR 55CM 3LUM,SUP-2855039,CDM,C1751,HCPCS,0278,RC,,,,both,,,850.94,553.11,,,,,,,,,,,,,
COIL EMB COMPLX 0.02 IN 3 MMX6 CM SFT FILLING COIL 400 DISP,SUP-2323390,CDM,C1889,HCPCS,0278,RC,,,,both,,,6964.52,4526.94,,,,,,,,,,,,,
KIT FIX DEV TI FOR ANK SYNDESMOSIS W/ ZIPLOOP TECHNOLOGY,SUP-2212940,CDM,C1776,CPT,0278,RC,,,,both,,,3267.11,2123.62,,,,,,,,,,,,,
SET URET STENT L 20 CM DIA 7 FR TIP L 3 CM STIFF SHFT,SUP-2537669,CDM,C2617,HCPCS,0278,RC,,,,both,,,619.65,402.77,,,,,,,,,,,,,
TEMPLATE SURG 19X6 MM IM CHART FIX SYS STR SZ NIT HAMMERLOCK,SUP-2431398,CDM,C1776,CPT,0278,RC,,,,both,,,2983.00,1938.95,,,,,,,,,,,,,
USTEKINUMAB-AEKN 130 MG/26ML IV SOLN,RX-171139,CDM,Q9998,HCPCS,0636,RC,51759-0708-13,NDC,,both,52,ML,8260.00,5369.00,,,,,,,,,,,,,
STENT NEURO NEVA VS L 22 MM DIA 4 MM CATH L 180 CM VESALIO,SUP-2895057,CDM,C1757,HCPCS,0272,RC,,,,both,,,21195.00,13776.75,,,,,,,,,,,,,
GRAFT ENDOVASC L50MM DIAM 10MM IL VIABAHN,SUP-2396462,CDM,C1874,HCPCS,0278,RC,,,,both,,,8801.42,5720.92,,,,,,,,,,,,,
HEAD FEM DIA36MM +1.5MM OFFSET 12/14 TAPR HIP CERAMIC TI SL,SUP-2251118,CDM,C1776,CPT,0278,RC,,,,both,,,5917.02,3846.06,,,,,,,,,,,,,
OCCLUDER CV WATCHMAN DIA 30 MM SHTH L 75 CM DIA14 FR DEL SYS,SUP-2141823,CDM,C1889,HCPCS,0278,RC,,,,both,,,73790.00,47963.50,,,,,,,,,,,,,
BACITRACIN ZINC 500 UNIT/GM EX OINT,RX-13818,CDM,6370000000,HCPCS,0637,RC,00536-1263-28,NDC,,both,28,GR,11.30,7.34,,,,,,,,,,,,,
PROBE NERVE STIM STIMULATING BALL TIP STRL SAFEOP,SUP-2725219,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
CAGE SPNL L10XW10XH15MM 4 LOBE MESH ANAT FOOTPRINT MOD IMP,SUP-2317726,CDM,C1889,HCPCS,0278,RC,,,,both,,,5790.16,3763.60,,,,,,,,,,,,,
TIAGABINE HCL 4 MG PO TABS,RX-21827,CDM,6370000000,HCPCS,0637,RC,72205-0085-30,NDC,,both,1,UN,28.60,18.59,,,,,,,,,,,,,
PLATE BNE L35MM 6 H BILAT S STL STR LO PROF NEUT,SUP-2186299,CDM,C1713,HCPCS,0278,RC,,,,both,,,1367.50,888.87,,,,,,,,,,,,,
AUGMENT ACET SM 8MM DIA48/50MM GRP 1 TI CEM REV PART HMSPHR,SUP-2222497,CDM,C1776,CPT,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
STENT LACR MONO CRWFRD P,SUP-2224384,CDM,C1783,HCPCS,0278,RC,,,,both,,,240.74,156.48,,,,,,,,,,,,,
IMPLANT ORBIT FLR L 36X37X17MM THK1.2MM LT ORAL,SUP-2365171,CDM,C1713,HCPCS,0278,RC,,,,both,,,7112.10,4622.86,,,,,,,,,,,,,
DRIVER SURG FOR 23MM BIOTENODESIS FT ANK SCR,SUP-2121352,CDM,C1713,HCPCS,0278,RC,,,,both,,,2998.70,1949.15,,,,,,,,,,,,,
TM STEM POR UPLR S,SUP-2212127,CDM,C1776,CPT,0278,RC,,,,both,,,29641.60,19267.04,,,,,,,,,,,,,
KIT MAG AUXILIARY SPNL CLMN DORS ROOT GANG FOR LO LIMB PAIN,SUP-2357687,CDM,2720000010,LOCAL,0272,RC,,,,both,,,459.01,298.36,,,,,,,,,,,,,
GRAFT VASC EXXCEL SFT L 80 CM DIA 6 MM SUPP L 80 CM EPTFE,SUP-2227649,CDM,C1768,CPT,0278,RC,,,,both,,,2637.95,1714.67,,,,,,,,,,,,,
HC Gastroesophag Reflx Test W/Tel Ph Eltrd,PX-7509103500,CDM,91035,CPT,0750,RC,,,,inpatient,,,1657.00,1077.05,,,,,,,,,,,,,
PAD THER X LG KNEE WRP ON PLR CARE,SUP-2150872,CDM,C1713,HCPCS,0278,RC,,,,both,,,458.44,297.99,,,,,,,,,,,,,
PLATE BONE CRANIAL 8 HOLE MATRIX 34X14MM TITANIUM NEURO PLAT,SUP-2825986,CDM,C1713,HCPCS,0278,RC,,,,both,,,362.67,235.74,,,,,,,,,,,,,
GRAFT AAA BIFUR 22X16X120MM,SUP-2217563,CDM,C1874,HCPCS,0278,RC,,,,both,,,33896.30,22032.59,,,,,,,,,,,,,
SCREW BNE ST 2.4X22 MM CRTX T8 STARDRV RECESS SS STRL,SUP-2423821,CDM,C1713,HCPCS,0278,RC,,,,both,,,206.02,133.91,,,,,,,,,,,,,
DOXORUBICIN HCL 2 MG/ML IV SOLN,RX-2616,CDM,J9000,HCPCS,0636,RC,00143-9087-01,NDC,,both,100,ML,403.20,262.08,,,,,,,,,,,,,
CATHETER CV 3L 6 FR STYL NURSE FULL TY POWERPICC SHERLOCK,SUP-2125642,CDM,C1751,HCPCS,0278,RC,,,,both,,,552.64,359.22,,,,,,,,,,,,,
CATHETER DRNGE 12FR L40CM 0.038IN 32 SIDEPORTS BILI RIG,SUP-2168458,CDM,C1729,HCPCS,0272,RC,,,,both,,,218.98,142.34,,,,,,,,,,,,,
GRAFT HUM TISS W5XL5CM AMNIO MEMBRN AMNIOEXCEL,SUP-2194322,CDM,Q4137,HCPCS,0636,RC,,,,both,,,6854.62,4455.50,,,,,,,,,,,,,
HC Adm Tocilizu Covid-19 1st,PX-7710024900,CDM,M0249,CPT,0771,RC,,,,both,,,1182.00,768.30,,,,,,,,,,,,,
DEVICE EXT FIX DISTRCTN 25 MM COMPR RED,SUP-2461623,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2749.07,1786.90,,,,,,,,,,,,,
RING 180MM,SUP-2492232,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4657.25,3027.21,,,,,,,,,,,,,
HC Pt Vasopneumatic Device Therapy,PX-4209701600,CDM,97016,CPT,0420,RC,,,,outpatient,,,206.00,133.90,,,,,,,,,,,,,
SCREW BONE L26MM DIA3.5MM CORT T15 FULL THRD N CANN ST,SUP-2101288,CDM,C1713,HCPCS,0278,RC,,,,both,,,77.87,50.62,,,,,,,,,,,,,
GRAFT BNE SUB 5CC DEMIN PSTE,SUP-2335297,CDM,C1713,HCPCS,0278,RC,,,,both,,,2304.76,1498.09,,,,,,,,,,,,,
HC So Voltage-Gated Calcium Channel Antibody Each,PX-3028659666,CDM,86596,CPT,0302,RC,,,,both,,,72.00,46.80,,,,,,,,,,,,,
PLATE VOLAR UNIV RADIUS STD XLONG,SUP-2695482,CDM,C1713,HCPCS,0278,RC,,,,both,,,3394.97,2206.73,,,,,,,,,,,,,
DISTRACTION INTRNL DIST MNDBLE ZRCH 2 WLLMS RIGHT ANGLE RGHT,SUP-2694396,CDM,C1713,HCPCS,0278,RC,,,,both,,,17316.94,11256.01,,,,,,,,,,,,,
HEADLESS COMPRESSION SCREW SYSTEM2.5/3.0,SUP-2841404,CDM,C1713,HCPCS,0278,RC,,,,both,,,31384.30,20399.79,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED CEM STEM CUP POROUS,SUP-2212087,CDM,C1776,CPT,0278,RC,,,,both,,,6280.00,4082.00,,,,,,,,,,,,,
DRILL HND OD2.4MM PILOT M FRAG SYS DISP FOR 3.5 / 4MM SCR,SUP-2319604,CDM,2720000010,LOCAL,0272,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
VLP 2.7MM PERC CALC PLT LG RIGHT 62MM STER,SUP-2819965,CDM,C1713,HCPCS,0278,RC,,,,both,,,7096.71,4612.86,,,,,,,,,,,,,
PLATE BNE STD MT FT ANK TI STR LO PROF FOR COMPHSVE SYS,SUP-2123062,CDM,C1713,HCPCS,0278,RC,,,,both,,,2810.30,1826.69,,,,,,,,,,,,,
SYSTEM CEMENT MIXING VAC STRL DISP SMARTMIX CEMVAC,SUP-2891677,CDM,2720000010,LOCAL,0272,RC,,,,both,,,503.03,326.97,,,,,,,,,,,,,
MOST HINGED TIBIA INSERTS SIZE 2 9MM,SUP-2509232,CDM,C1776,CPT,0278,RC,,,,both,,,5100.93,3315.60,,,,,,,,,,,,,
HOOK BNE L9IN DIA3 4IN S STL SATIN FINISH HVY MOD SHRP,SUP-2161260,CDM,C1713,HCPCS,0278,RC,,,,both,,,152.64,99.22,,,,,,,,,,,,,
DRILL SURG PILOT 2.4 MM CANN QR NS LTX,SUP-2855941,CDM,2720000010,LOCAL,0272,RC,,,,both,,,238.64,155.12,,,,,,,,,,,,,
SHEATH INTRO VASC RENAL 6FR 45CML ACCEPTS .038IN DIA GWIRE,SUP-2141016,CDM,C1894,HCPCS,0272,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
GUIDE CATH 47 CM FIX CRV SLITTABLE CPS DIR,SUP-2357578,CDM,C1887,HCPCS,0272,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
ANCHOR SUT PRE THRD W NO 2 HI FI SUT ON DISPOSABLE DRV ABSRB,SUP-2166967,CDM,C1713,HCPCS,0278,RC,,,,both,,,864.66,562.03,,,,,,,,,,,,,
PLATE SPNL ANTR CERV 51 MM 3 LEVEL LORDTC VAN GOGH,SUP-2661670,CDM,C1713,HCPCS,0278,RC,,,,both,,,2819.72,1832.82,,,,,,,,,,,,,
PROBE LASER 23GA PRECIS FBR CNTR PLAS HND PC STR DISP RFID,SUP-2109918,CDM,C1713,HCPCS,0278,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
CATHETER EMB NOVASIL SYNTEL L 40 CM DIA 5 FR BALLOON DIA11,SUP-2264198,CDM,C1757,HCPCS,0272,RC,,,,both,,,436.46,283.70,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.520,SUP-2860037,CDM,C1713,HCPCS,0278,RC,,,,both,,,36970.36,24030.73,,,,,,,,,,,,,
HC Total Protein,PX-3018415500,CDM,84155,CPT,0301,RC,,,,inpatient,,,152.00,98.80,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 70 CM DIA 7 MM STR TW REINF,SUP-2525450,CDM,C1768,CPT,0278,RC,,,,both,,,978.42,635.97,,,,,,,,,,,,,
ALLOGRAFT DERMAL 10X20 CMX2.4/0.4 MM RDY TO USE ALLDERM,SUP-2469959,CDM,Q4116,HCPCS,0636,RC,,,,both,,,23377.30,15195.24,,,,,,,,,,,,,
BIT DRL FOR 5MM LNG HALF PIN JET-X,SUP-2342944,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2235.62,1453.15,,,,,,,,,,,,,
STRAW NEOCONNECT 6 IN LG BORE SAMPLING W/ENFIT CONN PUR,SUP-2110451,CDM,V2632,HCPCS,0276,RC,,,,both,,,2.73,1.77,,,,,,,,,,,,,
BIT DRL L10-24MM DIA2.4MM DISP FOR VERTEX MAX RECON SYS,SUP-2286795,CDM,2720000010,LOCAL,0272,RC,,,,both,,,679.81,441.88,,,,,,,,,,,,,
CATHETER VENTRICULAR 14 CM W/ CM MRK STR 1 STYL MEDOS,SUP-2666799,CDM,C1729,HCPCS,0272,RC,,,,both,,,609.69,396.30,,,,,,,,,,,,,
GRAFT HUM TISS L LAT DST FEM OSTEOCHNDRL REFRIGERATED,SUP-2307438,CDM,C1713,HCPCS,0278,RC,,,,both,,,37554.40,24410.36,,,,,,,,,,,,,
CATHETER CARD ABLATION EZ STEER NAV L 115 CM 4 MM D-F CRV,SUP-2248520,CDM,C1732,HCPCS,0272,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
GUIDEWIRE 14INX.062IN DIA NIT HYPRFLX,SUP-2166838,CDM,C1769,HCPCS,0272,RC,,,,both,,,75.64,49.17,,,,,,,,,,,,,
PLATE BNE RECON 2-2.5X2 MM RT MAND 26 HOLE TI LEVEL 1 LF,SUP-2539579,CDM,C1713,HCPCS,0278,RC,,,,both,,,7163.06,4655.99,,,,,,,,,,,,,
SHAVER SURG ULTRA MINI 10 MM UTER TISS REMOVING TRUCLEAR,SUP-2172312,CDM,C1782,HCPCS,0272,RC,,,,both,,,2908.43,1890.48,,,,,,,,,,,,,
CAGE SPNL MESH 28X22X90 MM 6 LOBE,SUP-2602089,CDM,C1889,HCPCS,0278,RC,,,,both,,,20300.10,13195.06,,,,,,,,,,,,,
SPLINT WRST M L10IN L FA LN CIRCUMFERENTIAL STRP SLIP ON,SUP-2276626,CDM,L3809,HCPCS,0274,RC,,,,both,,,21.38,13.90,,,,,,,,,,,,,
DILATOR BAL DEV BILI QNT 10MMX3CMX180CM,SUP-2169435,CDM,C1726,HCPCS,0272,RC,,,,both,,,963.98,626.59,,,,,,,,,,,,,
SCREW CRANIOMAXILLOFACIAL EMER CROSS PIN MID FACE VIT SLD,SUP-2364644,CDM,C1713,HCPCS,0278,RC,,,,both,,,130.03,84.52,,,,,,,,,,,,,
BIT DRL 5 MM DARCO,SUP-2398633,CDM,2720000010,LOCAL,0272,RC,,,,both,,,514.96,334.72,,,,,,,,,,,,,
SHEATH URET PROXIS L 25 CM OD 14 FR ID 12 FR ACCS SHRT DIL,SUP-2655866,CDM,C1894,HCPCS,0272,RC,,,,both,,,101.55,66.01,,,,,,,,,,,,,
SET STPLR 3.5MM HEMORRHOID PROLAPSE TECHNOLOGY EEA DST SER,SUP-2283288,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1464.31,951.80,,,,,,,,,,,,,
KIT EXT FIX STD STRUT ID BND CAP STRL DISP SMRT,SUP-2932946,CDM,2720000010,LOCAL,0272,RC,,,,both,,,857.75,557.54,,,,,,,,,,,,,
GRAFT BNE 1X1MM 30ML CANC CUBE FRZ DRY,SUP-2264690,CDM,C1713,HCPCS,0278,RC,,,,both,,,1311.48,852.46,,,,,,,,,,,,,
SHOE ORTHOT ADDITION CONVERT FIRM SFT COUNT,SUP-2435743,CDM,L3590,HCPCS,0272,RC,,,,both,,,151.25,98.31,,,,,,,,,,,,,
CAGE SPNL 10X12MM ANTR CERV INTBDY FUS BAK/C,SUP-2208743,CDM,C1889,HCPCS,0278,RC,,,,both,,,2590.50,1683.82,,,,,,,,,,,,,
SCREW BNE L 28 MM DIA2 MM TI CANN HDLSS NS LEOS,SUP-2932634,CDM,C1713,HCPCS,0278,RC,,,,both,,,692.43,450.08,,,,,,,,,,,,,
BRACE KNEE BLEDSOE BRAC II,SUP-2341214,CDM,L1810,HCPCS,0272,RC,,,,both,,,364.24,236.76,,,,,,,,,,,,,
SCREW BNE OSTEOPENIA 5X18 MM,SUP-2348610,CDM,C1713,HCPCS,0278,RC,,,,both,,,194.68,126.54,,,,,,,,,,,,,
STIMULATOR NERVE IMPL PULSE GENRTR 16 CHANNEL PRODIGY MRI,SUP-2615540,CDM,C1820,HCPCS,0278,RC,,,,both,,,49592.44,32235.09,,,,,,,,,,,,,
PIN FIX TROCAR PT 2 END 9/64X9 IN 2 PT STYL SMOOTH PLN STRL,SUP-2150472,CDM,C1713,HCPCS,0278,RC,,,,both,,,15.32,9.96,,,,,,,,,,,,,
FRAME EXT FIX 200 MM SALVATION SEFA0200,SUP-2851072,CDM,2720000010,LOCAL,0272,RC,,,,both,,,22783.84,14809.50,,,,,,,,,,,,,
PROCESSOR SND BAHA 3 BP100,SUP-2165006,CDM,L8691,HCPCS,0274,RC,,,,both,,,10990.00,7143.50,,,,,,,,,,,,,
TI CLASSIC 4 HOLE 135 DEG,SUP-2818990,CDM,C1713,HCPCS,0278,RC,,,,both,,,4507.78,2930.06,,,,,,,,,,,,,
STENT BILI L60MM DIA8MM CATH 8.5FR L194CM GWIRE 0.035IN MTL,SUP-2149806,CDM,C1874,HCPCS,0278,RC,,,,both,,,7824.75,5086.09,,,,,,,,,,,,,
BIT DRL L177.5MM OD7MM ID2.4MM CANN FOR ACUFEX ACL PCL,SUP-2340695,CDM,2720000010,LOCAL,0272,RC,,,,both,,,700.22,455.14,,,,,,,,,,,,,
PLATE BNE CUT DELTO PECTORAL SHLDR DELTA-XTEND,SUP-2454176,CDM,C1713,HCPCS,0278,RC,,,,both,,,3419.46,2222.65,,,,,,,,,,,,,
RISPERIDONE 0.5 MG PO TBDP,RX-35686,CDM,6370000000,HCPCS,0637,RC,49884-0311-55,NDC,,both,1,UN,15.80,10.27,,,,,,,,,,,,,
WASHER ORTH FOR 2 MM CANN SCREW NS DISP,SUP-2908291,CDM,C1713,HCPCS,0278,RC,,,,both,,,129.96,84.47,,,,,,,,,,,,,
CATHETER GUID 6FR L50CM ID0.068IN S STL NYL JKT PTFE INNR 100559706] ABBOTT],SUP-2101520,CDM,C1887,HCPCS,0272,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
SHEATH URET SZ 2 14FR DIL 12FR L28CM FORTE ACCS,SUP-2119493,CDM,C1894,HCPCS,0272,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
HC So Creatinine Urine/Other,PX-3018257066,CDM,82570,CPT,0301,RC,,,,both,,,29.00,18.85,,,,,,,,,,,,,
GRAFT HUM TISS 250MG AMNIOFILL,SUP-2305712,CDM,C1762,CPT,0278,RC,,,,both,,,1805.50,1173.57,,,,,,,,,,,,,
HC So Egfr Gene,PX-3108123566,CDM,81235,CPT,0310,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
PIN GUID ORTH OBLQ NTHRD,SUP-2292223,CDM,C1713,HCPCS,0278,RC,,,,both,,,315.44,205.04,,,,,,,,,,,,,
IMPLANT SUBTALAR DIA 9 MM TI CONCL SFT THRD STRL TALAR-FIT,SUP-2913152,CDM,C1776,CPT,0278,RC,,,,both,,,7350.74,4777.98,,,,,,,,,,,,,
NAIL IM L340MM OD11MM LIME TI LT INTERTROCHANTERIC FEM AG,SUP-2205959,CDM,C1713,HCPCS,0278,RC,,,,both,,,12755.97,8291.38,,,,,,,,,,,,,
HC So Chromosome Karyotype Study,PX-3118828066,CDM,88280,CPT,0311,RC,,,,both,,,64.00,41.60,,,,,,,,,,,,,
INTRODUCER PACE LD SAFSHTH II DIA 8.5 FR GUIDEWIRE 0.038 IN,SUP-2909643,CDM,C1894,HCPCS,0272,RC,,,,both,,,226.08,146.95,,,,,,,,,,,,,
GRAFT BNE FRZN STRUT CORT IMPL ALLGRFT L200XW15MM MATRIGRFT,SUP-2264746,CDM,C1713,HCPCS,0278,RC,,,,both,,,1340.18,871.12,,,,,,,,,,,,,
HEAD HUM DIA19MM +2MM NK CO CHROM MOLYBDENUM STD OFFSET PRI,SUP-2351217,CDM,C1776,CPT,0278,RC,,,,both,,,3414.75,2219.59,,,,,,,,,,,,,
HC NM Brain With Flow,PX-3417860600,CDM,78606,CPT,0341,RC,,,,outpatient,,,2873.00,1867.45,,,,,,,,,,,,,
GUIDEWIRE ORTH L16MM DIA32MM S STL W STP,SUP-2177258,CDM,C1769,HCPCS,0272,RC,,,,both,,,173.14,112.54,,,,,,,,,,,,,
SHEET ORBIT W50XL50MM THK0.45MM POLYETH POR SQ SYNPOR,SUP-2182841,CDM,C1781,HCPCS,0278,RC,,,,both,,,1417.71,921.51,,,,,,,,,,,,,
CATHETER DRNGE 30FR 3CM RETEN HD TWO EYE REINF TIP PEZZERS,SUP-2128986,CDM,C1729,HCPCS,0272,RC,,,,both,,,63.18,41.07,,,,,,,,,,,,,
BLADE SAW SAG 16X7 MM 20 MM GRFT HARVESTING W/ STP SS HALL,SUP-2166196,CDM,2720000010,LOCAL,0272,RC,,,,both,,,335.04,217.78,,,,,,,,,,,,,
PLATE SPNL POST 10 MM,SUP-2430747,CDM,C1713,HCPCS,0278,RC,,,,both,,,10365.14,6737.34,,,,,,,,,,,,,
GUIDEWIRE VASC L 260 CM DIA 0.035 IN TAPR L 15 CM FLX TIP 6,SUP-2167732,CDM,C1769,HCPCS,0272,RC,,,,both,,,50.71,32.96,,,,,,,,,,,,,
SEALANT HEMOSTATIC FLOSEAL W/RECOTHROM 5 ML 75X13.25 IN 10CC,SUP-2863036,CDM,2720000010,LOCAL,0272,RC,,,,both,,,817.50,531.37,,,,,,,,,,,,,
STENT VASC L 38 MM DIA 5 MM ULTRA STRL,SUP-2101472,CDM,C1876,HCPCS,0278,RC,,,,both,,,2041.00,1326.65,,,,,,,,,,,,,
BLADE RETRACTOR SHT TEETH 65X15X MM SPNL SELF RET BLK,SUP-2457184,CDM,2720000010,LOCAL,0272,RC,,,,both,,,773.95,503.07,,,,,,,,,,,,,
CUTTER ENDO L35MM DIA12MM WHT TI LIN ARTC DISP,SUP-2218778,CDM,C1713,HCPCS,0278,RC,,,,both,,,2447.82,1591.08,,,,,,,,,,,,,
CAGE SPNL OFFSET 1 PRNG TIP TOP THORLUM PEEK IMP STRL DISP,SUP-2291707,CDM,C1889,HCPCS,0278,RC,,,,both,,,1880.86,1222.56,,,,,,,,,,,,,
ELECTRODE ES URLGY 24FR DIA 12DG CTTNG LOOP HF RSCTN ST DSPS,SUP-2720512,CDM,2720000010,LOCAL,0272,RC,,,,both,,,682.86,443.86,,,,,,,,,,,,,
PLATE BONE L 5 H TI PROX RAD LCK COMPR FOR 2.5MM SCR ALPS,SUP-2411726,CDM,C1713,HCPCS,0278,RC,,,,both,,,2155.30,1400.94,,,,,,,,,,,,,
ALLOGRAFT BNE CRYOPRESERVED LT MEDL FEM CONDYLE,SUP-2867081,CDM,C1762,CPT,0278,RC,,,,both,,,11356.28,7381.58,,,,,,,,,,,,,
PLATE BNE STR 126 MM RIBLOC U +,SUP-2846285,CDM,C1713,HCPCS,0278,RC,,,,both,,,3165.12,2057.33,,,,,,,,,,,,,
GRAFT STRAVIX PL AMNIOTIC MEMBRANE 3CM X 6CM,SUP-2855456,CDM,Q4133,HCPCS,0636,RC,,,,both,,,9993.05,6495.48,,,,,,,,,,,,,
DRILL TWST L115MM DIA1.9MM WRK L35MM CLR STRP,SUP-2365240,CDM,2720000010,LOCAL,0272,RC,,,,both,,,957.39,622.30,,,,,,,,,,,,,
SCREW BNE L 115 MM DIA 3.5 MM SS CORTICAL ST NS EVOS,SUP-2931728,CDM,C1713,HCPCS,0278,RC,,,,both,,,174.33,113.31,,,,,,,,,,,,,
CATHETER BLLN DIL 8 FRX100 CM 16 MMX4 CM LP VIDA,SUP-2551038,CDM,C1725,HCPCS,0272,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
STEM HUM CEM 15X100 MM SHLDR REVERSED COCR HA,SUP-2431492,CDM,C1776,CPT,0278,RC,,,,both,,,6491.95,4219.77,,,,,,,,,,,,,
CATHETER PICC TRIM LEN SGL LUMN FULL TY NRS PWR INJ POLYUR,SUP-2125633,CDM,C1751,HCPCS,0278,RC,,,,both,,,560.96,364.62,,,,,,,,,,,,,
"HC New Pt, Outpt Visit Level 3",PX-7619920300,CDM,99203,CPT,0761,RC,,,,inpatient,,,321.00,208.65,,,,,,,,,,,,,
COIL EMB L6CM DIA2.5MM EXTRA SFT HELIX DETACH AXIUM PRIM,SUP-2295035,CDM,C1889,HCPCS,0278,RC,,,,both,,,4524.74,2941.08,,,,,,,,,,,,,
CANNULA SURG 3.5 MM FOR FIB,SUP-2857727,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1265.42,822.52,,,,,,,,,,,,,
CANNULA ENDOSCOPIC RIGHT MIDDLE FOR MENISCAL REPAIR SYSTEM Z,SUP-2824139,CDM,2720000010,LOCAL,0272,RC,,,,both,,,998.99,649.34,,,,,,,,,,,,,
TUBE FEEDING 8FR 55 IRIS ENFIT,SUP-2878017,CDM,2720000010,LOCAL,0272,RC,,,,both,,,706.94,459.51,,,,,,,,,,,,,
SCREW SPNL CERV TEMP FOR PLATE,SUP-2430804,CDM,C1713,HCPCS,0278,RC,,,,both,,,431.75,280.64,,,,,,,,,,,,,
PIN EXT FIX TRANSFIX 5X35 MM YEL,SUP-2205301,CDM,C1713,HCPCS,0278,RC,,,,both,,,438.82,285.23,,,,,,,,,,,,,
MESH SURG DIA4.6CM POLY PGLA CLLGN FLM RIG ABSRB EXP SEMI,SUP-2283993,CDM,C1781,HCPCS,0278,RC,,,,both,,,1636.16,1063.50,,,,,,,,,,,,,
PIN PREFIXATION VENTURE ANT CERV PLT SYS,SUP-2293244,CDM,2720000010,LOCAL,0272,RC,,,,both,,,403.68,262.39,,,,,,,,,,,,,
GRAFT VASC 30 MMX15 CM 38X30 MM 10 MM AORT CLLGN CARDIOROOT,SUP-2471281,CDM,C1768,CPT,0278,RC,,,,both,,,6586.09,4280.96,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP ANGLED 0.032 INX150 CM TORQUABLE ZBR DISP,SUP-2139360,CDM,C1769,HCPCS,0272,RC,,,,both,,,165.79,107.76,,,,,,,,,,,,,
GUIDE SURG PLN NYL LP DISTRCTN CUSTOMIZABLE UNILAT VSP,SUP-2883941,CDM,2720000010,LOCAL,0272,RC,,,,both,,,15959.05,10373.38,,,,,,,,,,,,,
MESH SURG W6XL8IN RECT FULL REABSORBABLE FOR SFT TISS RECON,SUP-2125870,CDM,C1781,HCPCS,0278,RC,,,,both,,,11916.30,7745.59,,,,,,,,,,,,,
GEM MICROVASCULAR ANAS CPL MAC SYS,SUP-2382615,CDM,C1889,HCPCS,0278,RC,,,,both,,,11024.54,7165.95,,,,,,,,,,,,,
DRESSING WND THERAGENESIS MESHED BILYR MATRIX 8.2X9CM,SUP-2755311,CDM,A2008,HCPCS,0636,RC,,,,both,,,9231.60,6000.54,,,,,,,,,,,,,
SCREW IM L 50 MM DIA 5 MM TI LCK HDLSS STRL TRIGEN MAX,SUP-2931446,CDM,C1713,HCPCS,0278,RC,,,,both,,,915.62,595.15,,,,,,,,,,,,,
EXTRACTOR STONE 3 WIR 2.4 FRX115 CM 1.5 CM TIP NIT NCOMPASS,SUP-2737221,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1051.90,683.73,,,,,,,,,,,,,
COMPONENT ARTC SURF RP 9 KNEE CR ATTUNE,SUP-2454952,CDM,C1776,CPT,0278,RC,,,,both,,,244.92,159.20,,,,,,,,,,,,,
NAIL IM L 380 MM DIA 9 MM TYP II,SUP-2902177,CDM,C1713,HCPCS,0278,RC,,,,both,,,10092.75,6560.29,,,,,,,,,,,,,
MESH SURG W10XL15CM THK1MM EPTFE BIOMATERIAL OVL ANTIMIC,SUP-2395340,CDM,C1781,HCPCS,0278,RC,,,,both,,,1463.24,951.11,,,,,,,,,,,,,
CENTER PC DCOMPR H20-28MM DIA20MM THORLUM TI SIMP FAST EZ TO,SUP-2390808,CDM,C1889,HCPCS,0278,RC,,,,both,,,20410.00,13266.50,,,,,,,,,,,,,
SM FRAG PLT STERILIZER 3.5X73 MM 6 HL,SUP-2818112,CDM,C1713,HCPCS,0278,RC,,,,both,,,1099.53,714.69,,,,,,,,,,,,,
PLATE 7MM DIAM M ATTIC DEFCT HA,SUP-2312564,CDM,C1713,HCPCS,0278,RC,,,,both,,,485.63,315.66,,,,,,,,,,,,,
STEM DSTL MOD 19MM DIA 250MML POR RL HARDENED W/SLOT,SUP-2404201,CDM,C1776,CPT,0278,RC,,,,both,,,10107.66,6569.98,,,,,,,,,,,,,
LINEZOLID 600 MG PO TABS,RX-28224,CDM,6370000000,HCPCS,0637,RC,67877-0419-84,NDC,,both,1,UN,15.80,10.27,,,,,,,,,,,,,
SHEATH INTRO AVNT + DIA11 FR CANN L 11 CM POLYUR PLAS SS STD,SUP-2157384,CDM,C1894,HCPCS,0272,RC,,,,both,,,20.41,13.27,,,,,,,,,,,,,
DENOSUMAB-BBDZ 120 MG/1.7ML SC SOLN,RX-172039,CDM,Q5136,HCPCS,0636,RC,61314-0228-94,NDC,,both,1.7,ML,9464.40,6151.86,,,,,,,,,,,,,
BLADE SCREWDRIVER ANGLED FOR 2 MM SCR SS LEVEL 1 ANGULUS 2,SUP-2470545,CDM,2720000010,LOCAL,0272,RC,,,,both,,,421.07,273.70,,,,,,,,,,,,,
STENT TRANSCAROTID X ACT L 20 MM DIA 7 MM ICA DIA 5.5-6.4 MM,SUP-2925087,CDM,C1876,HCPCS,0278,RC,,,,both,,,6562.60,4265.69,,,,,,,,,,,,,
SYSTEM EXTR 14CM W/ BG SR GELPOINT ADV ACCS PLATFRM,SUP-2119761,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3501.10,2275.71,,,,,,,,,,,,,
CONNECTOR SPNL ROD DIA 3.5 MM POST CERV PARALLEL DBL NS,SUP-2887235,CDM,C1713,HCPCS,0278,RC,,,,both,,,167.90,109.13,,,,,,,,,,,,,
BUR SURG DIA3MM NEURON CUT ELITE,SUP-2367599,CDM,2720000010,LOCAL,0272,RC,,,,both,,,266.90,173.48,,,,,,,,,,,,,
SPHERE EMB LC BEAD PARTIC SZ 70-150UM 2ML SULPHONATE BLK YEL,SUP-2135324,CDM,C1889,HCPCS,0278,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
PLATE BNE 8 H CORT WRST TI SHT BEND SM FRAG SYS FOR,SUP-2191036,CDM,C1713,HCPCS,0278,RC,,,,both,,,2110.08,1371.55,,,,,,,,,,,,,
SIDEKICK  TRANSFIX PIN 4MM TIN 300MM LNG,SUP-2489346,CDM,C1713,HCPCS,0278,RC,,,,both,,,634.28,412.28,,,,,,,,,,,,,
HC Myelogram 2 or More Regions,PX-3616230500,CDM,62305,CPT,0361,RC,,,,outpatient,,,3707.00,2409.55,,,,,,,,,,,,,
OCCLUDER SEPT 6FR WAIST L3MM DIA10MM ATR DISC DIA18X22MM,SUP-2355678,CDM,C1817,HCPCS,0278,RC,,,,both,,,24806.00,16123.90,,,,,,,,,,,,,
PROSTHESIS VOICE 17FR L4MM PROVOX VEGA,SUP-2124378,CDM,L8509,HCPCS,0274,RC,,,,both,,,835.24,542.91,,,,,,,,,,,,,
WAND ARTHSCP L3MM 30DEG FOR H 2000-20 BEND TOOL ARTHWAND,SUP-2341963,CDM,2720000010,LOCAL,0272,RC,,,,both,,,882.34,573.52,,,,,,,,,,,,,
VALVE CSF PROGRAMMABLE MIC W/ RICKHAM RESERVOIR DSTL CATH,SUP-2666481,CDM,C1889,HCPCS,0278,RC,,,,both,,,14668.20,9534.33,,,,,,,,,,,,,
TRAY CATH PICC Q CATH BSC 2FR 30CM 1 LUMAN W/EXCLBR INTRO W/,SUP-2613409,CDM,C1751,HCPCS,0278,RC,,,,both,,,125.91,81.84,,,,,,,,,,,,,
DOBUTAMINE HCL 12.5 MG/ML IV SOLN,RX-9892,CDM,J1250,HCPCS,0636,RC,00409-2344-62,NDC,,both,20,ML,54.10,35.16,,,,,,,,,,,,,
SHEATH INTRO 30FR L18CM W/ SIL PINCH VLV GORE,SUP-2396404,CDM,C1894,HCPCS,0272,RC,,,,both,,,989.10,642.91,,,,,,,,,,,,,
SCREW BNE LCK 5X26 MM LP FOR IM NAIL TI NS RFN-ADVANCED,SUP-2758088,CDM,C1713,HCPCS,0278,RC,,,,both,,,663.83,431.49,,,,,,,,,,,,,
COIL OCCL L30CM DIA325 4MM 002IN POD 4 SYS,SUP-2323697,CDM,C1889,HCPCS,0278,RC,,,,both,,,5306.60,3449.29,,,,,,,,,,,,,
VALVE SHUNT L23.7MM 20CM H2O PRSS TI 2 CONN GRAVITATIONAL,SUP-2108716,CDM,C1889,HCPCS,0278,RC,,,,both,,,4341.65,2822.07,,,,,,,,,,,,,
NUSHIELD 2X4CM 8SQ CM,SUP-2314108,CDM,Q4160,HCPCS,0636,RC,,,,both,,,2565.38,1667.50,,,,,,,,,,,,,
COMPONENT TOE DIA15MM 2.5X3.5MM OFFSET MT CE ARTC TOE2,SUP-2123615,CDM,C1776,CPT,0278,RC,,,,both,,,11630.56,7559.86,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9% INTERMITTENT INFUSION|DISCARDED DRUG NOT ADMINISTE,RX-40840102,CDM,2580000003,HCPCS,0258,RC,00338-0049-04,NDC,JW,both,250,ML,10.70,6.95,,,,,,,,,,,,,
HEAD RAD H16MM OD20MM UNIV CO CHROM ANT DST EL STR MOD,SUP-2404362,CDM,C1776,CPT,0278,RC,,,,both,,,3432.96,2231.42,,,,,,,,,,,,,
Z DISCONTINUED NO SUB IDED BRUSH CYTO GI W/ 3 RNG HNDL 1.8MMX120MM,SUP-2237071,CDM,2720000010,LOCAL,0272,RC,,,,both,,,467.08,303.60,,,,,,,,,,,,,
SCREW BNE L12MM OD2.7MM THRD L6MM TI BRK OFF MONSTER BITE,SUP-2321001,CDM,C1713,HCPCS,0278,RC,,,,both,,,855.02,555.76,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY L 110 CM DIA 5 FR SPC 5 MM YEL,SUP-2248857,CDM,C1730,HCPCS,0272,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
PLATE BNE W15XL136MM THK2MM 6 H BILAT S STL COVERLEAF RIG,SUP-2186008,CDM,C1713,HCPCS,0278,RC,,,,both,,,1719.06,1117.39,,,,,,,,,,,,,
VALVE VENT DRNGE REG ADJ W/ SNAP RESVR PS MED STRATA II,SUP-2284521,CDM,C1889,HCPCS,0278,RC,,,,both,,,13711.22,8912.29,,,,,,,,,,,,,
ANCHOR SUT HIP BIOCRYL RAPIDE PUSH IN W/ ORTHOCORD 2-0 ROT,SUP-2249333,CDM,C1713,HCPCS,0278,RC,,,,both,,,1234.02,802.11,,,,,,,,,,,,,
HC So1 in Situ Hybrid per Specimen,PX-3128836867,CDM,88368,CPT,0312,RC,,,,inpatient,,,125.00,81.25,,,,,,,,,,,,,
MESH HERN PRE SHP 4X1.8 IN SFT W/ KEYHOLE KNIT STRUCT POLYPR,SUP-2125782,CDM,C1781,HCPCS,0278,RC,,,,both,,,167.68,108.99,,,,,,,,,,,,,
COLLAR CERV AD PLAS FOAM EXTRIC ADJ SET TRACH OPN VELC,SUP-2115114,CDM,L0180,HCPCS,0274,RC,,,,both,,,33.35,21.68,,,,,,,,,,,,,
GRAFT DERM PLIABLE FLD HYDRATED THCK ACELLULAR DERM IMPL,SUP-2307559,CDM,Q4128,HCPCS,0636,RC,,,,both,,,6472.95,4207.42,,,,,,,,,,,,,
CATHETER EP XL 2-5-2 MM 6 FRX115 CM LIVEWIRE,SUP-2355234,CDM,C1730,HCPCS,0272,RC,,,,both,,,1778.90,1156.28,,,,,,,,,,,,,
CROWN DENT 1 S STL SEC PRI M UP RT ANTR CUSPID PREFABRICATED,SUP-2238932,CDM,D6783,CPT,0278,RC,,,,both,,,27.04,17.58,,,,,,,,,,,,,
HC US Fetal Anatomic Eval,PX-4027681100,CDM,76811,CPT,0402,RC,,,,both,,,1366.00,887.90,,,,,,,,,,,,,
NAIL TIBIA TI6AL4V ALLOY 10MMX38CM,SUP-2491309,CDM,C1776,CPT,0278,RC,,,,both,,,4864.24,3161.76,,,,,,,,,,,,,
SCREW BNE HD 3.5X48 MM HEX PERSONA (NOT IMPLANTED),SUP-2437521,CDM,C1713,HCPCS,0278,RC,,,,both,,,508.68,330.64,,,,,,,,,,,,,
KIT INTRO GLIDESHEATH SLENDER L 10 CM DIA 6 FR 0.025IN SS,SUP-2385483,CDM,C1894,HCPCS,0272,RC,,,,both,,,207.24,134.71,,,,,,,,,,,,,
KIT BNE SCR L26MM DIA4.5MM GLEN SHLDR ORNG COMPR LOK CAP,SUP-2223389,CDM,C1713,HCPCS,0278,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
KIT DRAINAGE ASPIRA PERITONEAL,SUP-2676359,CDM,C1729,HCPCS,0272,RC,,,,both,,,3611.00,2347.15,,,,,,,,,,,,,
ANCHOR SUT DIA5.5MM PEEK 2 ORTHOCORD SZ 2 L36IN VLT BLU,SUP-2249413,CDM,C1713,HCPCS,0278,RC,,,,both,,,951.42,618.42,,,,,,,,,,,,,
STENT GRFT VASC AFX2 BODY L 110 MM DIA25 MM LIMB L 40 MM,SUP-2217673,CDM,C1874,HCPCS,0278,RC,,,,both,,,43956.86,28571.96,,,,,,,,,,,,,
BIT DRILL REUSABLE 2.7MM BIO-ANCHOR,SUP-2828535,CDM,2720000010,LOCAL,0272,RC,,,,both,,,677.30,440.24,,,,,,,,,,,,,
MESH 55MMX55MM 1.7MM RESRB PLT STRL DELT SYS,SUP-2364986,CDM,C1713,HCPCS,0278,RC,,,,both,,,2237.09,1454.11,,,,,,,,,,,,,
STENT GRFT VASC POWERLINK INTUITRAK L 75 MM DIA25 MM DEL SYS,SUP-2217569,CDM,C1768,CPT,0278,RC,,,,both,,,8148.30,5296.39,,,,,,,,,,,,,
DEXTROSE 5 % AND 0.45 % NACL IV BOLUS|DISCARDED DRUG NOT ADMINISTE,RX-40840056,CDM,J7042,HCPCS,0258,RC,00338-0085-04,NDC,JW,both,250,ML,12.80,8.32,,,,,,,,,,,,,
MESH MIDFACIAL CUSTOMIZED PRIORITY AUG MEDPOR LTX,SUP-2862756,CDM,C1713,HCPCS,0278,RC,,,,both,,,26588.45,17282.49,,,,,,,,,,,,,
SCREW BONE L175MM DIA6.5MM STD CORT S STL ST SELF DRL CANN,SUP-2343258,CDM,C1713,HCPCS,0278,RC,,,,both,,,1745.24,1134.41,,,,,,,,,,,,,
BURR SURG MED SS DIAMOND TEMPOROMANDIBULAR JT NS DISP,SUP-2934559,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1284.26,834.77,,,,,,,,,,,,,
GUIDEWIRE VASC INQWIRE L 210 CM DIA 0.035 IN TIP L 1.5 MM,SUP-2665428,CDM,C1769,HCPCS,0272,RC,,,,both,,,31.65,20.57,,,,,,,,,,,,,
BUR SURG L 10 MM DIA 5 MM DIAMOND STRL DISP ELAN 4 MIS,SUP-2928914,CDM,2720000010,LOCAL,0272,RC,,,,both,,,486.73,316.37,,,,,,,,,,,,,
ADHESIVE SKIN CLOSURE 4X44 CM PREMIERPRO EXOFINFUSION DISP,SUP-2336222,CDM,C1713,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
IMPLANT COCHLEAR REUSE CNTOUR NUCLS 24,SUP-2165053,CDM,L8614,HCPCS,0278,RC,,,,both,,,60916.00,39595.40,,,,,,,,,,,,,
HC So Unlisted Chemistry Procedure,PX-3018499966,CDM,84999,CPT,0301,RC,,,,inpatient,,,78.00,50.70,,,,,,,,,,,,,
BLADE SAW 10 MM HIGH-TORQUE SAG DBL GRFT HARVESTING TRITON,SUP-2628168,CDM,2720000010,LOCAL,0272,RC,,,,both,,,837.60,544.44,,,,,,,,,,,,,
PLATE BONE W24XL85MM 12 H RT DSTL RAD TI LCK COMPR LO PROF,SUP-2136264,CDM,C1713,HCPCS,0278,RC,,,,both,,,3494.82,2271.63,,,,,,,,,,,,,
ALLOGRAFT FEM HD W/O CART FRZ DRY IRRAD ALL SZ,SUP-2165538,CDM,C1713,HCPCS,0278,RC,,,,both,,,3092.90,2010.38,,,,,,,,,,,,,
GUIDEWIRE ORTHOPEDIC 0.9X120 MM PLN TROCAR PT 1 END DISP,SUP-2243907,CDM,C1769,HCPCS,0272,RC,,,,both,,,98.09,63.76,,,,,,,,,,,,,
SCREW BNE CANN 2X48 MM DIGITAL FUSION TI CAPTURE,SUP-2609565,CDM,C1713,HCPCS,0278,RC,,,,both,,,1214.49,789.42,,,,,,,,,,,,,
BEARING TIB FIX 4 RT KNEE PLATE,SUP-2223482,CDM,C1776,CPT,0278,RC,,,,both,,,13188.00,8572.20,,,,,,,,,,,,,
GRAFT BONE SUB W2.5XL10CM TROUGH MTRX GRFTON,SUP-2294007,CDM,C1713,HCPCS,0278,RC,,,,both,,,9812.50,6378.12,,,,,,,,,,,,,
CATHETER CARD ABLATION MARINR MC L 112 CM DIA 7 FR TIP L 4,SUP-2282284,CDM,C1733,HCPCS,0272,RC,,,,both,,,1805.50,1173.57,,,,,,,,,,,,,
COMPONENT FEM 0 LT POR ASYM POST STBL OPTETRAK HI FLX,SUP-2223216,CDM,C1776,CPT,0278,RC,,,,both,,,12377.88,8045.62,,,,,,,,,,,,,
TAP SURG L 130 MM DIA2.2 MM SD HEX FOR 3-4 MM SCREW DELT,SUP-2883159,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2060.37,1339.24,,,,,,,,,,,,,
PROCESSOR HEARING AID SND L CHROMA BGE PONTO PRO PWR,SUP-2319884,CDM,L8691,HCPCS,0274,RC,,,,both,,,14051.50,9133.47,,,,,,,,,,,,,
PLATE BNE W8XL48MM THK3.3MM 6 H ST BILAT PELV S STL,SUP-2186233,CDM,C1713,HCPCS,0278,RC,,,,both,,,1148.61,746.60,,,,,,,,,,,,,
CEFAZOLIN SODIUM 3 G IV SOLR,RX-162907,CDM,J0690,HCPCS,0636,RC,44567-0845-01,NDC,,both,1,UN,54.10,35.16,,,,,,,,,,,,,
VALVE AORT EPIC + SUP SZ 21 MM TISS ANNULUS DIA21 MM STENT,SUP-2893994,CDM,C1889,HCPCS,0278,RC,,,,both,,,15706.28,10209.08,,,,,,,,,,,,,
TRAY TIBIAL SLEEVE SIZE 3 BALANCED KNEE REVISION SYSTEM,SUP-2603527,CDM,C1776,CPT,0278,RC,,,,both,,,8543.94,5553.56,,,,,,,,,,,,,
PLATE CRAN 120X120X40 MM PT SPEC IMPL PEEK,SUP-2860151,CDM,C1713,HCPCS,0278,RC,,,,both,,,39955.24,25970.91,,,,,,,,,,,,,
HC Ot Ultrasound 15 Min|OP PT SERVICES|DOCUMENTATION ON FILE|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS,PX-4309703500,CDM,97035,CPT,0430,RC,,,GP|KX|CQ,outpatient,,,194.00,126.10,,,,,,,,,,,,,
BUR REPROC SHV OD2.9MM MINI PURPLE,SUP-2652896,CDM,2720000010,LOCAL,0272,RC,,,,both,,,103.59,67.33,,,,,,,,,,,,,
PLATE BNE SZ 0 L40MM 5DEG R S SHP FOR HALLU-LOCK MTP ARTH,SUP-2243426,CDM,C1713,HCPCS,0278,RC,,,,both,,,5008.71,3255.66,,,,,,,,,,,,,
KIT SPNL INSTR MILD DEV W/ INITIATOR ACCS AUGER RONGEUR,SUP-2927440,CDM,C1889,HCPCS,0278,RC,,,,both,,,10990.00,7143.50,,,,,,,,,,,,,
AMLODIPINE BESYLATE 10 MG PO TABS,RX-9069,CDM,6370000000,HCPCS,0637,RC,00904-6371-61,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PIN FIX 4 MMX30.5 CM FEMALE SPEC,SUP-2457013,CDM,C1713,HCPCS,0278,RC,,,,both,,,2235.49,1453.07,,,,,,,,,,,,,
PROPRANOLOL HCL 40 MG PO TABS,RX-6658,CDM,6370000000,HCPCS,0637,RC,69238-2079-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
BIOSURGE KIT WITH 5.0CC ALLOSYNC PURE,SUP-2811311,CDM,C1713,HCPCS,0278,RC,,,,both,,,4945.50,3214.57,,,,,,,,,,,,,
CATHETER EMB NOVASIL L 80 CM DIA 7 FR BALLOON DIA14 MM 1.75,SUP-2589469,CDM,C1757,HCPCS,0272,RC,,,,both,,,499.26,324.52,,,,,,,,,,,,,
PLATE BNE L154MM 10 H ST L PROX BILAT TIB S STL NEUT LOK,SUP-2177837,CDM,C1713,HCPCS,0278,RC,,,,both,,,4314.11,2804.17,,,,,,,,,,,,,
GRAFT BNE EVANS WDG 20X25X6 MM BONUS,SUP-2861833,CDM,C1713,HCPCS,0278,RC,,,,both,,,2535.61,1648.15,,,,,,,,,,,,,
DRIVER SURGICAL T 15 PROXIMAL HUMERUS PLATING SYSTEM ALPS,SUP-2466066,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1431.84,930.70,,,,,,,,,,,,,
AUGMENT FEM 2XL THK8MM STD UNIV RT MEDL LT LAT DSTL KNEE CEM,SUP-2407002,CDM,C1776,CPT,0278,RC,,,,both,,,2311.04,1502.18,,,,,,,,,,,,,
DRILL ENDOSCP XL 9 MM,SUP-2849146,CDM,2720000010,LOCAL,0272,RC,,,,both,,,898.04,583.73,,,,,,,,,,,,,
COIL VASC AZUR CX L 7 CM DIA 4 MM MICROCATHETER 0.035 IN,SUP-2385438,CDM,C1889,HCPCS,0278,RC,,,,both,,,4396.00,2857.40,,,,,,,,,,,,,
SCREW BONE CANNULATED 4MM DIA 38MML HIGH TORQUE,SUP-2586597,CDM,C1713,HCPCS,0278,RC,,,,both,,,1169.43,760.13,,,,,,,,,,,,,
HC CT C-Spine W/ Contrast,PX-3527212600,CDM,72126,CPT,0352,RC,,,,outpatient,,,1973.00,1282.45,,,,,,,,,,,,,
PLEDGET CV L 5.1 X W 0.6 CM THK 1.65 MM PTFE FELT BTTRS STRL,SUP-2761357,CDM,C1768,CPT,0278,RC,,,,both,,,76.08,49.45,,,,,,,,,,,,,
PLATE ORTH LNG ATCS STRL DISP 5 PER PK,SUP-2930431,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1071.53,696.49,,,,,,,,,,,,,
PLATE STRNL CLOSURE THK 1.5 MM 10 H TI BX JUNCTION LP NS,SUP-2894524,CDM,C1713,HCPCS,0278,RC,,,,both,,,3014.40,1959.36,,,,,,,,,,,,,
SYSTEM IV INFUSION 4 FRX45 CM 20 CM 20 CC SQUIRT FLUID DEL,SUP-2740491,CDM,2720000010,LOCAL,0272,RC,,,,both,,,457.18,297.17,,,,,,,,,,,,,
BIT DRILL L4MM DIA15MM SUBCHONDRAL,SUP-2589363,CDM,2720000010,LOCAL,0272,RC,,,,both,,,199.23,129.50,,,,,,,,,,,,,
STAPLE INT THK2.5X1.6MM W25XL22-22MM ANK FT NIT SUP E,SUP-2378849,CDM,C1776,CPT,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
DEGARELIX ACETATE 80 MG SC SOLR,RX-96900,CDM,J9155,HCPCS,0636,RC,55566-8303-01,NDC,,both,1,UN,1406.80,914.42,,,,,,,,,,,,,
BUR SURG DIA 3 MM HUB II NEURO CUT STRL REUSE HI-LINE,SUP-2928982,CDM,2720000010,LOCAL,0272,RC,,,,both,,,508.46,330.50,,,,,,,,,,,,,
SHEATH INTRO PINNACLE DESTINATION 90CM 7FR COAT L 15CM MP,SUP-2385203,CDM,C1894,HCPCS,0272,RC,,,,both,,,324.99,211.24,,,,,,,,,,,,,
IMPLANT HUM TISS H10XL10MM FEM WHL FRSH NO ANG,SUP-2257907,CDM,C1762,CPT,0278,RC,,,,both,,,7834.30,5092.29,,,,,,,,,,,,,
PLATE BONE W5MM THK1.2MM 4X9 H S STL T SHP NONCOMPRESSION,SUP-2343837,CDM,C1713,HCPCS,0278,RC,,,,both,,,1790.93,1164.10,,,,,,,,,,,,,
KIT BNE MAR ASPIR L10.16CM 3 H BX CELLECT,SUP-2255619,CDM,2720000010,LOCAL,0272,RC,,,,both,,,492.98,320.44,,,,,,,,,,,,,
HC Fna Without Imaging Guidance,PX-3611002100,CDM,10021,CPT,0361,RC,,,,both,,,1531.00,995.15,,,,,,,,,,,,,
BOLT ORTH FIX WIRE,SUP-2749937,CDM,2720000010,LOCAL,0272,RC,,,,both,,,555.78,361.26,,,,,,,,,,,,,
SET NEPHSTMY 4FR L20CM NDL L15CM 22GA 0.018IN HYDRPHLC,SUP-2168585,CDM,C1894,HCPCS,0272,RC,,,,both,,,266.21,173.04,,,,,,,,,,,,,
SCREW SPNL 27X16MM RESRB FT,SUP-2400588,CDM,C1713,HCPCS,0278,RC,,,,both,,,668.82,434.73,,,,,,,,,,,,,
ESTROGENS CONJUGATED 0.45 MG PO TABS,RX-36198,CDM,6370000000,HCPCS,0637,RC,00046-1101-81,NDC,,both,1,UN,31.90,20.73,,,,,,,,,,,,,
PUTTY W/ CHIP 10.0CC DBM W/ RPM,SUP-2415804,CDM,C9359,HCPCS,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
SUTURE ANCHR HITCH 1 NO 2 MAXBRAID SUTS,SUP-2137202,CDM,C1713,HCPCS,0278,RC,,,,both,,,898.04,583.73,,,,,,,,,,,,,
HC So Hemoglobin Electrophoresis,PX-3018302066,CDM,83020,CPT,0301,RC,,,,both,,,42.00,27.30,,,,,,,,,,,,,
CLAMP ANSTMSS CLEY SRRTD 6 1/2NL 3/4NL X 1/4ND JAW DBLE CRVD,SUP-2473939,CDM,2720000010,LOCAL,0272,RC,,,,both,,,862.31,560.50,,,,,,,,,,,,,
VOLAR DR AIMING BLOCK INTERMEDIATE RIGHT 7 HOLES,SUP-2702832,CDM,C1713,HCPCS,0278,RC,,,,both,,,879.20,571.48,,,,,,,,,,,,,
PLATE BNE DBL ANGLED LG 2 MM RECON MAXILLA PT SPEC,SUP-2860087,CDM,C1713,HCPCS,0278,RC,,,,both,,,28448.71,18491.66,,,,,,,,,,,,,
ELEVATOR SURG L11XW5IN SPNL BLDE COBB,SUP-2244791,CDM,C1713,HCPCS,0278,RC,,,,both,,,305.90,198.83,,,,,,,,,,,,,
SPACER PROX CNTRLZR HIP 13MM SL VERSYS,SUP-2203479,CDM,C1776,CPT,0278,RC,,,,both,,,224.51,145.93,,,,,,,,,,,,,
HC So1 Column Chromotography Quant,PX-3018254267,CDM,82542,CPT,0301,RC,,,,both,,,322.00,209.30,,,,,,,,,,,,,
PLATE BNE LO BEND NEUT 3.5X128 MM RT PROX TIB 8 HOLE LCK TI,SUP-2180958,CDM,C1713,HCPCS,0278,RC,,,,both,,,4654.48,3025.41,,,,,,,,,,,,,
IMPLANT ORBIT RT LAT BICOMPARTMENTAL KNEE W/O PAT RESURF,SUP-2165965,CDM,C1776,CPT,0278,RC,,,,both,,,22608.00,14695.20,,,,,,,,,,,,,
PLATE BNE STR 2.4X170 MM WRST SS STRL LCP,SUP-2422104,CDM,C1713,HCPCS,0278,RC,,,,both,,,11370.82,7391.03,,,,,,,,,,,,,
EXPANDER TISS BRST ULTRA HI PROF SILTEX,SUP-2748663,CDM,C1889,HCPCS,0278,RC,,,,both,,,6201.50,4030.97,,,,,,,,,,,,,
BIT DRILL STP 4.5MM DIA HOWMEDICA TRAUM 5.0IN LGTH CHK END -,SUP-2363950,CDM,2720000010,LOCAL,0272,RC,,,,both,,,370.99,241.14,,,,,,,,,,,,,
KIT ORTH INSTR FT PREP STRL,SUP-2897919,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3155.70,2051.20,,,,,,,,,,,,,
GRAFT BNE SUB W12 20XL45MM ILIUM BICORT STRP FRZ DRY,SUP-2307127,CDM,C1713,HCPCS,0278,RC,,,,both,,,1782.17,1158.41,,,,,,,,,,,,,
PLATE BONE CONTOUR MESH 200X200X0.6 MM RIGID TITANIUM BLUE S,SUP-2837707,CDM,C1713,HCPCS,0278,RC,,,,both,,,26713.24,17363.61,,,,,,,,,,,,,
STEM HUM SZ 4 L100MM CEM CONSTRN NEXEL,SUP-2135760,CDM,C1776,CPT,0278,RC,,,,both,,,17784.96,11560.22,,,,,,,,,,,,,
PLATE BNE MESHED PEDIATRIC 0.6 MM RT NEURO SMRT PTERIONAL,SUP-2481055,CDM,C1713,HCPCS,0278,RC,,,,both,,,9430.55,6129.86,,,,,,,,,,,,,
GUIDEWIRE ORTHOPEDIC L 370 MM DIA 3 MM TROCAR TIP NS LF DISP,SUP-2930398,CDM,2720000010,LOCAL,0272,RC,,,,both,,,741.83,482.19,,,,,,,,,,,,,
HC So Mopath Procedure Level 4,PX-3108140366,CDM,81403,CPT,0310,RC,,,,both,,,463.00,300.95,,,,,,,,,,,,,
CONNECTOR SPNL L16MM ANTR PEDCL THORLUM TI CROSS FOR 5.5MM,SUP-2255188,CDM,C1713,HCPCS,0278,RC,,,,both,,,2747.50,1785.87,,,,,,,,,,,,,
TRAY HUM THK+6MM 35MM OFFSET SHLDR HI REVERSED AEQUALIS,SUP-2399873,CDM,C1776,CPT,0278,RC,,,,both,,,5666.13,3682.98,,,,,,,,,,,,,
FAMOTIDINE (PF) 20 MG/2ML IV SOLN,RX-157659,CDM,J1308,HCPCS,0636,RC,00641-6022-01,NDC,,both,1,ML,54.10,35.16,,,,,,,,,,,,,
EXPANDER TISS MAMM TEXT CNTOUR PROF S,SUP-2300521,CDM,C1789,HCPCS,0278,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
HEAD HUM H23MM DIA52MM STEM L40MM SHLDR HA TI STD STEM,SUP-2388684,CDM,C1776,CPT,0278,RC,,,,both,,,14349.80,9327.37,,,,,,,,,,,,,
ALLOSYNC DBM CHIPS 1-4MM 5.0CC,SUP-2811278,CDM,C1713,HCPCS,0278,RC,,,,both,,,1949.94,1267.46,,,,,,,,,,,,,
PLATE BONE W5.4XL35MM THK1.5MM 6 H FOREFOOT TI STR FOR,SUP-2225447,CDM,C1713,HCPCS,0278,RC,,,,both,,,1906.61,1239.30,,,,,,,,,,,,,
BIT DRL L110MM DIA2.5MM STD RMR ADD ON DISP,SUP-2379291,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
GRAFT VASC L20CM ID6MM RNG L40CM STD WALLED RNGED STR GORTX,SUP-2396002,CDM,C1768,CPT,0278,RC,,,,both,,,1984.48,1289.91,,,,,,,,,,,,,
SUPPORT ORTHOT HND FNGR CUST W/NONTORSION JT FABRICATED,SUP-2435781,CDM,L3921,HCPCS,0274,RC,,,,both,,,827.64,537.97,,,,,,,,,,,,,
GRAFT BNE BLOCK 11X11X7 MM FD CORTICAL,SUP-2277897,CDM,C1713,HCPCS,0278,RC,,,,both,,,3136.86,2038.96,,,,,,,,,,,,,
BLADE SAW W25XL90MM D90MM CUT THK119MM S STL OSC STABLECUT,SUP-2253182,CDM,C1713,HCPCS,0278,RC,,,,both,,,335.35,217.98,,,,,,,,,,,,,
CATHETER ABLATION SHFT L 110 CM DIA 7.5 FR TIP L 4 MM QD,SUP-2890503,CDM,C2630,CPT,0272,RC,,,,both,,,8635.00,5612.75,,,,,,,,,,,,,
HC So Lipid Panel|NOT REASONABLE AND NECESSARY,PX-3018006166,CDM,80061,CPT,0301,RC,,,GZ,outpatient,,,43.00,27.95,,,,,,,,,,,,,
GRAFT HUM TISS L 180 X W 10 MM CALCANEAL BNE BLOCK L 23 X W,SUP-2913170,CDM,C1762,CPT,0278,RC,,,,both,,,10223.84,6645.50,,,,,,,,,,,,,
BLADE RTRCTR BLFR STNDRD 3 5/8NW X 10 3/4NL X 1 3/4ND ABDMNL,SUP-2494033,CDM,2720000010,LOCAL,0272,RC,,,,both,,,495.18,321.87,,,,,,,,,,,,,
GRAFT SURG 7CMX6CM AMNIOFIX,SUP-2305731,CDM,V2790,HCPCS,0274,RC,,,,both,,,7231.42,4700.42,,,,,,,,,,,,,
ADAPTER LD L 17 CM LT VENTRICULAR FOR OSCOR BIS/BIS-17 EXT,SUP-2498643,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1632.80,1061.32,,,,,,,,,,,,,
TRAY PROC SZ 0 130MM 6DEG STD OFFSET ZMLY HIP FEM STEM TAPR,SUP-2205949,CDM,C1776,CPT,0278,RC,,,,both,,,9734.00,6327.10,,,,,,,,,,,,,
INTRODUCER KIT STIFFEN 5 FR SFT TIP SS VSI MIC,SUP-2120528,CDM,C1894,HCPCS,0272,RC,,,,both,,,96.37,62.64,,,,,,,,,,,,,
"HC So Urine,Microalbumin,Quantitativ",PX-3078204366,CDM,82043,CPT,0307,RC,,,,both,,,196.00,127.40,,,,,,,,,,,,,
SODIUM CHLORIDE 3 % IN NEBU,RX-7327,CDM,J3490,HCPCS,0258,RC,00378-6997-89,NDC,,both,15,ML,3.40,2.21,,,,,,,,,,,,,
STENT PERIPH ABS PRO L 80 MM DIA 5 MM CATH L 135 CM DIA 8 FR,SUP-2104808,CDM,C1876,HCPCS,0278,RC,,,,both,,,3077.20,2000.18,,,,,,,,,,,,,
FIBER LASER G-PROBE SLX,SUP-2225632,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
CATHETER DIAG 1.9FR L150CM DIA0.042X0.034IN SPC 15MM GWIRE,SUP-2353147,CDM,C1887,HCPCS,0272,RC,,,,both,,,618.58,402.08,,,,,,,,,,,,,
LINEZOLID 100 MG/5ML PO SUSR,RX-28225,CDM,340b,HCPCS,0637,RC,00054-0319-50,NDC,,both,150,ML,3023.40,1965.21,,,,,,,,,,,,,
WASHER ORTHOPEDIC DIA 19 MM SCREW DIA 6.5/8 MM,SUP-2900796,CDM,C1713,HCPCS,0278,RC,,,,both,,,326.59,212.28,,,,,,,,,,,,,
STAPLER INT AD L55MM DIA5MM STD TISS TI LIN 2 ROW STR,SUP-2174486,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1918.04,1246.73,,,,,,,,,,,,,
PROSTHESIS VOICE 20FR L4MM ESOPH TRACH INDWL W/ L FLNG,SUP-2242385,CDM,L8509,HCPCS,0274,RC,,,,both,,,1055.04,685.78,,,,,,,,,,,,,
PLATE BNE L240MM 15 H ST R DST RAD VOLAR DPHSEAL MTPHSEAL S,SUP-2177220,CDM,C1713,HCPCS,0278,RC,,,,both,,,4781.78,3108.16,,,,,,,,,,,,,
PLATE BONE LOK CMPRSSN 114MML HLX6 TIMAX CRTCL NRRW PRE CNTR,SUP-2494121,CDM,C1713,HCPCS,0278,RC,,,,both,,,4370.72,2840.97,,,,,,,,,,,,,
PLATE BONE L210MM 21 H RT LAT DSTL POST HUM LCK ALPS,SUP-2205425,CDM,C1713,HCPCS,0278,RC,,,,both,,,5371.28,3491.33,,,,,,,,,,,,,
GRAFT BIO TISS MESH 10X10 CM MIROMATRIX MIROMESH,SUP-2115024,CDM,C1781,HCPCS,0278,RC,,,,both,,,9074.60,5898.49,,,,,,,,,,,,,
ORTHOSES THERMOPLASTIC ACROMIOCLAVICULAR SHLDR PREFABRICATED,SUP-2319133,CDM,L3670,HCPCS,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
SUTURE ANCHR TWINFIX TI 5MM W/ TWO NO 2 DURABRAID SUT,SUP-2341072,CDM,C1713,HCPCS,0278,RC,,,,both,,,835.40,543.01,,,,,,,,,,,,,
SCREW BONE SELFTAPPING 1.5X12 MM CORTEX CRANIOMAXILLOFACIAL,SUP-2838125,CDM,C1713,HCPCS,0278,RC,,,,both,,,235.19,152.87,,,,,,,,,,,,,
PLATE BNE L 333 MM SCREW DIA 3.5/4.5 MM 16 H SS DSTL FEM,SUP-2931170,CDM,C1713,HCPCS,0278,RC,,,,both,,,19791.42,12864.42,,,,,,,,,,,,,
ADAPTER SPNL LAT 10 MM OFFSET CENTURION,SUP-2658908,CDM,C1713,HCPCS,0278,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
ENDOPROSTHESIS VASC VIABAHN L 2.5CM 7MM 75CM 8FR HEPARIN,SUP-2396604,CDM,C1876,HCPCS,0278,RC,,,,both,,,9391.74,6104.63,,,,,,,,,,,,,
COIL NEUROVASCULAR GDC-10 L 3 CM DIA2.5 MM MICROCATHETER,SUP-2365659,CDM,C1889,HCPCS,0278,RC,,,,both,,,4619.25,3002.51,,,,,,,,,,,,,
PROSTHESIS OSS OVL TOP UNIV 4X3X6 MM 1.15X0.8 MM HA TORP,SUP-2637865,CDM,L8613,CPT,0278,RC,,,,both,,,1582.34,1028.52,,,,,,,,,,,,,
CROWN FORM DENT STRP U1 PRIMARY ANTR UPPER LT LAT PLAS,SUP-2322245,CDM,D6783,CPT,0278,RC,,,,both,,,31.90,20.73,,,,,,,,,,,,,
SCREW SPNL L15MM DIA4.5MM CANC ANT CERV TI ALLY SELF DRL,SUP-2291140,CDM,C1713,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
GRAFT BNE STRP 50X20X5 MM DBM CANC PUREBONE,SUP-2424611,CDM,C1713,HCPCS,0278,RC,,,,both,,,6934.56,4507.46,,,,,,,,,,,,,
SHEATH RAIN RAD INTRO SHTH W/ HYDRPHLC WIRE 10 CM 506410H,SUP-2639012,CDM,C1894,HCPCS,0272,RC,,,,both,,,147.58,95.93,,,,,,,,,,,,,
PATCH CV HEMACAROTID L 100 X W 25 MM THK 0.41 MM POLYESTER,SUP-2914823,CDM,C1768,CPT,0278,RC,,,,both,,,467.11,303.62,,,,,,,,,,,,,
LEVOCARNITINE 200 MG/ML IV SOLN,RX-20954,CDM,J1955,HCPCS,0636,RC,54482-0147-01,NDC,,both,5,ML,223.60,145.34,,,,,,,,,,,,,
CATHETER DIAG SAFSHTH WORLEY LVI L 66 CM DIA 5.5 FR POLYMER,SUP-2329861,CDM,C1894,HCPCS,0272,RC,,,,both,,,1453.82,944.98,,,,,,,,,,,,,
HC CT Angio Chest W & W/O Cont,PX-3527127500,CDM,71275,CPT,0352,RC,,,,both,,,3343.00,2172.95,,,,,,,,,,,,,
REAMER SURG DIA9MM CANN HD FULL THICKNESS CALIB W/ DEPTH,SUP-2121246,CDM,2720000010,LOCAL,0272,RC,,,,both,,,675.10,438.81,,,,,,,,,,,,,
MESH SURG STD 84X53X0.3 MM TI LEVEL 1 NEURO ULTRAONE,SUP-2477789,CDM,C1713,HCPCS,0278,RC,,,,both,,,3062.57,1990.67,,,,,,,,,,,,,
CATHETER CTRL VEN 8.5FR L20CM QUAD LUMN INDWL RADPQ POLYUR,SUP-2383393,CDM,C1751,HCPCS,0278,RC,,,,both,,,307.72,200.02,,,,,,,,,,,,,
BIT DRL CANN LG 5X215 MM QC FOR 6.5-7.5 MM SCREW PUR GRN NS,SUP-2423427,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1329.10,863.91,,,,,,,,,,,,,
HC Arthrogram Knee Flouro X-Ray,PX-3227358000,CDM,73580,CPT,0322,RC,,,,both,,,666.00,432.90,,,,,,,,,,,,,
CATHETER GUID L 110 CM DIA 7 FR CORONARY JL4 MOD,SUP-2139697,CDM,C1887,HCPCS,0272,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
BIT DRL DIA14MM CANN FLX FOR L QUIK CPL,SUP-2178961,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2601.74,1691.13,,,,,,,,,,,,,
OBTURATOR SHTH L 15 CM DIA 4 FR LL STRL,SUP-2355468,CDM,C1894,HCPCS,0272,RC,,,,both,,,19.63,12.76,,,,,,,,,,,,,
CATHETER DIAG 5MAX DDC TOT L 119 CM L 115 CM DIA 6/5 FR,SUP-2323553,CDM,C1725,HCPCS,0272,RC,,,,both,,,4553.00,2959.45,,,,,,,,,,,,,
JONES BOLT NAIL 4.5MMX47MM STERILE,SUP-2815802,CDM,C1713,HCPCS,0278,RC,,,,both,,,7834.30,5092.29,,,,,,,,,,,,,
SHEATH INTRO FAST-CATH L 60 CM DIA 6.5 FR GUIDEWIRE 0.032 IN,SUP-2357145,CDM,C1893,HCPCS,0272,RC,,,,both,,,204.10,132.66,,,,,,,,,,,,,
CATHETER CV 3L 6 FR BASIC TY PASV VLV POWERPICC SOLO 2,SUP-2126404,CDM,C1751,HCPCS,0278,RC,,,,both,,,686.72,446.37,,,,,,,,,,,,,
IMPLANT COSMETIC SZ 30 X 50 X 0.45 MM POLYETHYL ORBIT FLR,SUP-2935198,CDM,C1713,HCPCS,0278,RC,,,,both,,,1774.10,1153.16,,,,,,,,,,,,,
WASHER ORTH PLATE SYS IMPL INSTRUMENT AXIS,SUP-2610214,CDM,C1713,HCPCS,0278,RC,,,,both,,,379.94,246.96,,,,,,,,,,,,,
DOXORUBICIN HCL 2 MG/ML IV SOLN|DISCARDED DRUG NOT ADMINISTE,RX-2616,CDM,J9000,HCPCS,0636,RC,45963-0733-57,NDC,JW,both,10,ML,57.60,37.44,,,,,,,,,,,,,
HC C-Spine Min 4 Views,PX-3207205000,CDM,72050,CPT,0320,RC,,,,both,,,737.00,479.05,,,,,,,,,,,,,
ROD SPNL POST SMOOTH 5.5MM DIA 150MM LEN,SUP-2289289,CDM,C1713,HCPCS,0278,RC,,,,both,,,417.62,271.45,,,,,,,,,,,,,
"HC So Cult,Pathognic Orgnsms,Screen",PX-3008708166,CDM,87081,CPT,0300,RC,,,,outpatient,,,173.00,112.45,,,,,,,,,,,,,
BLADE RETRACTOR CLOWARD SPREADER 45MML BLUNT,SUP-2672937,CDM,2720000010,LOCAL,0272,RC,,,,both,,,851.16,553.25,,,,,,,,,,,,,
SYSTEM MGMT INCIS CLOSE NEG PRSS CUSTOMIZABLE DRSG,SUP-2262373,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1108.42,720.47,,,,,,,,,,,,,
TROCAR SURG L176MM DIA4MM FOR PROTCT SL,SUP-2188222,CDM,C1713,HCPCS,0278,RC,,,,both,,,756.27,491.58,,,,,,,,,,,,,
PLATE BONE SM L31MM THK1MM CENTRE SPACE 3.4MM 4 H MAND TI,SUP-2191213,CDM,C1713,HCPCS,0278,RC,,,,both,,,2226.57,1447.27,,,,,,,,,,,,,
WIRE EXT FIX L 400 MM DIA2 MM TI SMTH HALF PT NS DISP MONK,SUP-2899223,CDM,C1713,HCPCS,0278,RC,,,,both,,,457.66,297.48,,,,,,,,,,,,,
SCREW BN WSHR CAP 0 MM F/THR STRL,SUP-2639515,CDM,C1713,HCPCS,0278,RC,,,,both,,,1208.90,785.78,,,,,,,,,,,,,
POTASSIUM CHLORIDE IN NACL 40-0.9 MEQ/L-% IV SOLN,RX-102330,CDM,J3480,HCPCS,0636,RC,00990-7116-09,NDC,,both,1000,ML,54.10,35.16,,,,,,,,,,,,,
PLATE BNE L238MM BLDE W58XL38MM 130DEG 14 H NONSTERILE BILAT,SUP-2186589,CDM,C1713,HCPCS,0278,RC,,,,both,,,2786.81,1811.43,,,,,,,,,,,,,
CATHETER PTCA L145CM BLLN L10MM DIA1.5MM DIA1.9X2.6FR,SUP-2158452,CDM,C1725,HCPCS,0272,RC,,,,both,,,516.75,335.89,,,,,,,,,,,,,
GRAFT BNE R OSTEOCHNDRL TROCHLEA FRSH STORED,SUP-2335301,CDM,C1713,HCPCS,0278,RC,,,,both,,,31384.30,20399.79,,,,,,,,,,,,,
SET INT FIX SCREW DIA1.5 MM CRANIOMAXILOFACIAL 3 LNG DOG BNE,SUP-2935313,CDM,C1713,HCPCS,0278,RC,,,,both,,,2015.88,1310.32,,,,,,,,,,,,,
PLATE BONE THK0.6MM 3X8 H BILAT HND T SHP COMPR GRID FOR,SUP-2267898,CDM,C1713,HCPCS,0278,RC,,,,both,,,841.52,546.99,,,,,,,,,,,,,
PLATE EXT FIX 5 H ANK FT FOR TRUELOK FRME ASSEMB HEXAPOD,SUP-2316200,CDM,2720000010,LOCAL,0272,RC,,,,both,,,808.90,525.78,,,,,,,,,,,,,
COMPONENT FEM 1 LT KNEE POROUS MILLER-GALANTE II,SUP-2199486,CDM,C1776,CPT,0278,RC,,,,both,,,22118.16,14376.80,,,,,,,,,,,,,
NAIL IM FEM ANTERGRADE RG LCK CANN TI 12MM 320MM,SUP-2408508,CDM,C1713,HCPCS,0278,RC,,,,both,,,5680.26,3692.17,,,,,,,,,,,,,
MESH SURG L 30 X W 20 CM GLYCOLIDE LACTIDE COPOLYMER,SUP-2931123,CDM,C1781,HCPCS,0278,RC,,,,both,,,18212.00,11837.80,,,,,,,,,,,,,
SET ORTH INSTR SCREW SZ 1.5 MM 2 2 DIAMETER GUIDE WIRE,SUP-2912778,CDM,2720000010,LOCAL,0272,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
COLLAR ASPN AD REG EA,SUP-2196889,CDM,L0172,HCPCS,0272,RC,,,,both,,,73.57,47.82,,,,,,,,,,,,,
VALVE HYDROCEPHALUS 30 WITH SHUNT ASSISTANT PROGAV 2.0  FX41,SUP-2844508,CDM,C1889,HCPCS,0278,RC,,,,both,,,9010.01,5856.51,,,,,,,,,,,,,
SCREW BNE L 18 MM DIA 3.5 MM TI CORTICAL WR ST T15 DRV STRL,SUP-2931922,CDM,C1713,HCPCS,0278,RC,,,,both,,,136.40,88.66,,,,,,,,,,,,,
ALLOGRAFT KIT NAT TISS DENOVO OAC,SUP-2866915,CDM,C1763,HCPCS,0278,RC,,,,both,,,14663.80,9531.47,,,,,,,,,,,,,
IMMUNE GLOBULIN (PRIVIGEN) 10%,RX-4081762,CDM,J1459,HCPCS,0636,RC,44206-0436-05,NDC,,both,50,ML,2830.00,1839.50,,,,,,,,,,,,,
MESH HERN ELLIPSE 9X7 IN W/ ECHO2 POS SYS POLYPR PHASIX ST,SUP-2855264,CDM,C1781,HCPCS,0278,RC,,,,both,,,22513.80,14633.97,,,,,,,,,,,,,
ALLOGRAFT BNE 60 MM PRESERVON FEM SHFT MATRIGRAFT,SUP-2740820,CDM,C1762,CPT,0278,RC,,,,both,,,2381.85,1548.20,,,,,,,,,,,,,
PIN DISTR SPNL DISP CASPR,SUP-2310540,CDM,C1713,HCPCS,0278,RC,,,,both,,,219.80,142.87,,,,,,,,,,,,,
STENT GRFT VASC TAG L 10 CM DIA 31 MM SHTH 22 FR THOR AORT,SUP-2396363,CDM,C1768,CPT,0278,RC,,,,both,,,36110.00,23471.50,,,,,,,,,,,,,
GRAFT NRV L30MM DIA3-4MM PERIPH NAT CONN CBL PROC FOR RECON,SUP-2124852,CDM,C1763,HCPCS,0278,RC,,,,both,,,14035.80,9123.27,,,,,,,,,,,,,
HC Speech/Language Therapy,PX-4409250700,CDM,92507,CPT,0440,RC,,,,both,,,443.00,287.95,,,,,,,,,,,,,
HC So Igh Gene Rearrange Amp Meth,PX-3108126167,CDM,81261,CPT,0310,RC,,,,both,,,445.00,289.25,,,,,,,,,,,,,
BUR SURG TAPR SIDE CUT XCUT,SUP-2628916,CDM,2720000010,LOCAL,0272,RC,,,,both,,,575.12,373.83,,,,,,,,,,,,,
LUSPATERCEPT-AAMT 25 MG SC SOLR,RX-148221,CDM,J0896,HCPCS,0636,RC,59572-0711-01,NDC,,both,1,UN,11845.90,7699.83,,,,,,,,,,,,,
BAR EXT FIX L400MM DIA11MM FOR XTRAFIX SYS,SUP-2199714,CDM,2720000010,LOCAL,0272,RC,,,,both,,,755.52,491.09,,,,,,,,,,,,,
SCREW BNE LOK SELF RET TI L7MM OD2MM MAXDRIVE,SUP-2262887,CDM,C1713,HCPCS,0278,RC,,,,both,,,374.70,243.55,,,,,,,,,,,,,
CLEARSIGHT FINGER CUFF MED,SUP-2696340,CDM,2720000010,LOCAL,0272,RC,,,,both,,,973.40,632.71,,,,,,,,,,,,,
RING EXT FIX MOD 5/8 D 180 MM RX STRL TRUELOK EVO LTX,SUP-2875614,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6264.30,4071.79,,,,,,,,,,,,,
CAGE SPNL XL W18XH12XL60MM 10DEG LUMBER INTBDY FUS PEEK,SUP-2311022,CDM,C1889,HCPCS,0278,RC,,,,both,,,12120.40,7878.26,,,,,,,,,,,,,
PLATE BONE FAN 43.6X1.5 MM WITH FIXATION HOLE SMOOTH REINFOR,SUP-2837809,CDM,C1713,HCPCS,0278,RC,,,,both,,,4763.07,3096.00,,,,,,,,,,,,,
BIT DRL SCALED 1.6X96 MM AO CPL VARIAX,SUP-2435339,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1023.64,665.37,,,,,,,,,,,,,
DEVICE FIX HELCL MULT USE HNDL 5 TUBE TI,SUP-2752180,CDM,C1713,HCPCS,0278,RC,,,,both,,,4879.91,3171.94,,,,,,,,,,,,,
CATHETER HD STR 14 FRX40 CM DL LT BASIC SET SPLIT CATH III,SUP-2269502,CDM,C1881,HCPCS,0278,RC,,,,both,,,894.90,581.68,,,,,,,,,,,,,
ALLOGRAFT BNE PTTY 10 CC DBM,SUP-2632266,CDM,C1713,HCPCS,0278,RC,,,,both,,,2920.20,1898.13,,,,,,,,,,,,,
GUIDEPIN ARTHSCP L15IN DIA2.4MM EYELET DRL TIP DISP FOR,SUP-2341575,CDM,C1769,HCPCS,0272,RC,,,,both,,,400.73,260.47,,,,,,,,,,,,,
GRAFT HUMAN TISSUE THICK 16X20 CM HYDRATED BIOLOGIC TISSUE M,SUP-2838616,CDM,C1763,HCPCS,0278,RC,,,,both,,,29697.18,19303.17,,,,,,,,,,,,,
PLATE BNE L135MM 8 H BILAT S STL BROAD LO PROF RIG DYN,SUP-2185274,CDM,C1713,HCPCS,0278,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
SCREW BNE L90MM DIA12.7MM STD S STL CANC ST CANN LAG,SUP-2410201,CDM,C1713,HCPCS,0278,RC,,,,both,,,921.12,598.73,,,,,,,,,,,,,
HC Pt Manual Therapy Ea 15|DOCUMENTATION ON FILE|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS,PX-4209714000,CDM,97140,CPT,0420,RC,,,KX|CQ,both,,,194.00,126.10,,,,,,,,,,,,,
PROSTHESIS OSS GROTE LG 16X15X20 MM CNL WALL POROUS HA,SUP-2637870,CDM,L8613,CPT,0278,RC,,,,both,,,1430.65,929.92,,,,,,,,,,,,,
ALLOGRAFT BNE SPACER 5 DEG 8X22X12 MM LORDTC PLIF,SUP-2632324,CDM,C1713,HCPCS,0278,RC,,,,both,,,7379.00,4796.35,,,,,,,,,,,,,
NAIL IM L255MM DIA10MM STRL GRN TIB TI NONLOCKING UNREAMED,SUP-2192735,CDM,C1713,HCPCS,0278,RC,,,,both,,,4133.21,2686.59,,,,,,,,,,,,,
MEPOLIZUMAB 100 MG/ML SC SOSY,RX-146588,CDM,J2182,HCPCS,0636,RC,00173-0892-42,NDC,,both,1,ML,11320.60,7358.39,,,,,,,,,,,,,
BLOCK FEM STD THCK UNIV DSTL PRI PRESSFIT TITANIUMXSM 4MM,SUP-2407178,CDM,C1776,CPT,0278,RC,,,,both,,,2860.54,1859.35,,,,,,,,,,,,,
WASHER ORTH SCREW SYS IMPL INSTRUMENT AXIS,SUP-2610215,CDM,C1713,HCPCS,0278,RC,,,,both,,,370.52,240.84,,,,,,,,,,,,,
PLATE BNE STRL LF LAPIPLASTY,SUP-2893047,CDM,C1713,HCPCS,0278,RC,,,,both,,,14601.00,9490.65,,,,,,,,,,,,,
GRAFT HUM TISS BIOINTEGRATIVE 40X30 MM W/ INTRO LAT TAPESTRY,SUP-2867252,CDM,C1763,HCPCS,0278,RC,,,,both,,,4207.60,2734.94,,,,,,,,,,,,,
GRAFT VASC IMPRA L 10 CM DIA 8 MM EPTFE STR TW N RING HEMO,SUP-2761243,CDM,C1768,CPT,0278,RC,,,,both,,,514.21,334.24,,,,,,,,,,,,,
BIT DRL L65MM DIA2.2MM 2IN1 AO DISP FOR HALLU-LOCK MTP ARTH,SUP-2243024,CDM,2720000010,LOCAL,0272,RC,,,,both,,,741.70,482.10,,,,,,,,,,,,,
SUPPORT ORTHOT HEEL CUST LIFT ELEVATION PER INCH,SUP-2435719,CDM,L3334,HCPCS,0274,RC,,,,both,,,107.95,70.17,,,,,,,,,,,,,
PLATE BONE 3 H RT LAT TALUS FOR 2.4MM SCR VLP MINI-MOD SM,SUP-2351103,CDM,C1713,HCPCS,0278,RC,,,,both,,,4918.97,3197.33,,,,,,,,,,,,,
DEVICE SUT W/ 2-0 NONABSORBABLE POLYETH SUT REPL CART,SUP-2163483,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1894.93,1231.70,,,,,,,,,,,,,
HANDPIECE PHACO TORSIONAL OZIL,SUP-2109897,CDM,2720000010,LOCAL,0272,RC,,,,both,,,9420.00,6123.00,,,,,,,,,,,,,
RING EXT FIX DIA220 MM SS 5/8 NS DISP ILIZ,SUP-2932832,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4685.54,3045.60,,,,,,,,,,,,,
SHEATH INTRO PRELUDE PRESTIGE L 13 CM DIA14 FR ADV NDL L 7,SUP-2677193,CDM,C1892,HCPCS,0272,RC,,,,both,,,65.31,42.45,,,,,,,,,,,,,
PLATE BNE L100MM BRL L1.5IN 135DEG PELVIS BILAT S STL STD 4,SUP-2342420,CDM,C1713,HCPCS,0278,RC,,,,both,,,3533.13,2296.53,,,,,,,,,,,,,
SET URET DIL 6-18FR L60CM POLY W/ GWIRE,SUP-2171202,CDM,C2627,HCPCS,0272,RC,,,,both,,,530.28,344.68,,,,,,,,,,,,,
FIBER LASER 295 MH 40 W LNG 0.5X1.04 MMX2 MR FIBERLASE,SUP-2574321,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4123.54,2680.30,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 50 CM DIA 7 MM STR STD WALL HELIX,SUP-2525462,CDM,C1768,CPT,0278,RC,,,,both,,,1968.43,1279.48,,,,,,,,,,,,,
PLUG HERN BIOABSRB TYP 1 CLLGN 3-D SCFLD BIO-A,SUP-2395804,CDM,C1781,HCPCS,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
PLATE FIX ORTHO LCP 4.5MM 2HL 44MM,SUP-2185227,CDM,C1713,HCPCS,0278,RC,,,,both,,,871.70,566.60,,,,,,,,,,,,,
SCREW BNE SET 4 MM CANN 1/3 THRD EXT TAB,SUP-2861013,CDM,C1713,HCPCS,0278,RC,,,,both,,,20181.41,13117.92,,,,,,,,,,,,,
PIN EXT FIX SZ 150 X 45 X 5 MM HALF,SUP-2932900,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1709.51,1111.18,,,,,,,,,,,,,
NERVE STIMULATOR KIT IMPLANTABLE PULSE GENERATOR VERCISE GEV,SUP-2836323,CDM,C1820,HCPCS,0278,RC,,,,both,,,69080.00,44902.00,,,,,,,,,,,,,
ELECTRODE ENDOSCP OD2428FR 0.35 WIRE 12DEG 30DEG MPLR W/,SUP-2797226,CDM,2720000010,LOCAL,0272,RC,,,,both,,,775.42,504.02,,,,,,,,,,,,,
CARD MEAS CREDIT FOR X10 XLNK PLT,SUP-2289439,CDM,C1713,HCPCS,0278,RC,,,,both,,,381.67,248.09,,,,,,,,,,,,,
TUBE MYR VENT SIL ST 114MM DIA PAPARELLA,SUP-2313873,CDM,L8699,HCPCS,0278,RC,,,,both,,,39.12,25.43,,,,,,,,,,,,,
GUIDEPIN ORTHOPAEDIC CALIBRATED 2.4X152 MM THREADED TIP WITH,SUP-2836610,CDM,C1713,HCPCS,0278,RC,,,,both,,,144.38,93.85,,,,,,,,,,,,,
HC Inj Ileal Conduit Ureteropyelo,PX-3615069000,CDM,50690,CPT,0361,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
SPECULUM VAG GRV SM,SUP-2126351,CDM,C1788,HCPCS,0278,RC,,,,both,,,838.38,544.95,,,,,,,,,,,,,
HC Pt Adl Training 15mn|OP OCCUPATIONAL THERAPY SERV,PX-4209753500,CDM,97535,CPT,0420,RC,,,GO,outpatient,,,174.00,113.10,,,,,,,,,,,,,
GRAFT VASC HEMSHLD PLAT 50CM 20MM SZ10MM POLYESTER BOV CLLGN,SUP-2227363,CDM,C1768,CPT,0278,RC,,,,both,,,4902.64,3186.72,,,,,,,,,,,,,
COIL NEUROVASCULAR HELIPAQ 10 CERECYTE L 8 CM DIA 3 MM,SUP-2460312,CDM,C1889,HCPCS,0278,RC,,,,both,,,4711.19,3062.27,,,,,,,,,,,,,
CATHETER ANGIOPLSTY DYNAMIS AV L 75 CM BALLOON L 40 MM DIA16,SUP-2676387,CDM,C1769,HCPCS,0272,RC,,,,both,,,596.60,387.79,,,,,,,,,,,,,
MODULUS XL 10X18X45MM 10 DEG INDIV ST PKG,SUP-2309897,CDM,C1713,HCPCS,0278,RC,,,,both,,,13345.00,8674.25,,,,,,,,,,,,,
BRACE WLK FULL SHELL WLK M M SHOE SZ 7 10 FEM SHOE SZ 8,SUP-2336093,CDM,L4360,HCPCS,0274,RC,,,,both,,,128.61,83.60,,,,,,,,,,,,,
HC CT Orbit/Ear/Fossa W/ Contrast,PX-3517048100,CDM,70481,CPT,0351,RC,,,,outpatient,,,1973.00,1282.45,,,,,,,,,,,,,
PLATE LCP 20 HL 2.7 X 184MM STERILE,SUP-2740108,CDM,C1713,HCPCS,0278,RC,,,,both,,,1500.07,975.05,,,,,,,,,,,,,
ARCH EXT FIX L120MM FOR RNG FIX SYS TRUELOK,SUP-2316154,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2311.13,1502.23,,,,,,,,,,,,,
HC CT Orbit/Ear/Fossa W/ Contrast,PX-3517048100,CDM,70481,CPT,0351,RC,,,,inpatient,,,1973.00,1282.45,,,,,,,,,,,,,
PLATE BNE W13.5XL80MM THK4.2MM 4 H BILAT S STL NAR LOK,SUP-2185231,CDM,C1713,HCPCS,0278,RC,,,,both,,,929.41,604.12,,,,,,,,,,,,,
COLLAR EXTRIC AD L H2XL235IN NAR BRTH M DENS FOAM CNTOUR W,SUP-2194383,CDM,L0120,HCPCS,0272,RC,,,,both,,,20.38,13.25,,,,,,,,,,,,,
SPACER SPNL H14MM ST TRANSITION,SUP-2231431,CDM,C1821,HCPCS,0278,RC,,,,both,,,954.56,620.46,,,,,,,,,,,,,
OLMESARTAN MEDOXOMIL-HCTZ 20-12.5 MG PO TABS,RX-36068,CDM,6370000000,HCPCS,0637,RC,65862-0779-90,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
DEVICE OCCL CLP L40MM LAA EXCLUSION SYS ATRICLP PRO V,SUP-2124475,CDM,C1889,HCPCS,0278,RC,,,,both,,,17270.00,11225.50,,,,,,,,,,,,,
CABLE SPNL NERVE MONITORING LG RETRACTOR SYS CLARITY,SUP-2713115,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2778.90,1806.28,,,,,,,,,,,,,
PLATE BNE 4 H L MINI SM W TAB FOR PINIFORM RIM AND ZYG BTTRS,SUP-2262739,CDM,C1713,HCPCS,0278,RC,,,,both,,,757.12,492.13,,,,,,,,,,,,,
KIT PERICARDCENT L 40 CM DIA 8.3 FR PIGTL 7 SPIRALING,SUP-2482977,CDM,C1729,HCPCS,0272,RC,,,,both,,,373.57,242.82,,,,,,,,,,,,,
HC So Bartonella Henselae,PX-3028661166,CDM,86611,CPT,0302,RC,,,,both,,,62.00,40.30,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 8X3 CM DEHYDR AMNIO MEMBRN ALLOPATCH HD,SUP-2480485,CDM,Q4128,HCPCS,0636,RC,,,,both,,,8520.08,5538.05,,,,,,,,,,,,,
SHUNT SURG REG PERF LEVEL 1.0 DELT,SUP-2628316,CDM,C1729,HCPCS,0272,RC,,,,both,,,1323.82,860.48,,,,,,,,,,,,,
CLAMP EXT FIX L PIN 4 POS MAG RESONANCE CONDITIONAL,SUP-2188502,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1196.69,777.85,,,,,,,,,,,,,
NUSHIELD 4X6CM 24SQ CM,SUP-2314112,CDM,Q4160,HCPCS,0636,RC,,,,both,,,4672.32,3037.01,,,,,,,,,,,,,
GUIDEWIRE VASC 0.018 INX60 CM PLAT TIP INTRO KT SS MAKNV,SUP-2302991,CDM,C1769,HCPCS,0272,RC,,,,both,,,92.32,60.01,,,,,,,,,,,,,
PROSTHESIS OSS PISTON 0.8X3.75 MM NIT FLROPLAS SMRT,SUP-2638193,CDM,L8613,CPT,0278,RC,,,,both,,,950.48,617.81,,,,,,,,,,,,,
SCREW BONE L16MM DIA2.5MM DSTL RAD TI TRILOK EXPR APTUS,SUP-2268239,CDM,C1713,HCPCS,0278,RC,,,,both,,,268.47,174.51,,,,,,,,,,,,,
ALLOGRAFT TISS DEHYDR 2X3 CM AMNIO MEMBRN AMBIO2,SUP-2242545,CDM,V2790,HCPCS,0274,RC,,,,both,,,1868.30,1214.39,,,,,,,,,,,,,
BUR SURG DIAMOND 4 MMX13 CM MTCH HD LILAC STRL LTX,SUP-2859530,CDM,2720000010,LOCAL,0272,RC,,,,both,,,567.05,368.58,,,,,,,,,,,,,
PLATE OLECRANON 65MM 3HL RT,SUP-2705076,CDM,C1713,HCPCS,0278,RC,,,,both,,,3949.81,2567.38,,,,,,,,,,,,,
SHEATH INTRO FAST-CATH DUO L 12 CM DIA10 FR CATH 5 FR,SUP-2357116,CDM,C1894,HCPCS,0272,RC,,,,both,,,18.84,12.25,,,,,,,,,,,,,
GRAFT HUMAN TISSUE PELVIC FLOOR MATRIX 12X9 CM MATRISTEM,SUP-2106487,CDM,C1763,HCPCS,0278,RC,,,,both,,,6782.40,4408.56,,,,,,,,,,,,,
SYSTEM SUT DEL SGL INCIS CRV HNDL TRIG DISPOSABLE FLEXISHAFT,SUP-2165322,CDM,C2631,HCPCS,0278,RC,,,,both,,,1230.88,800.07,,,,,,,,,,,,,
CONNECTOR VENT 15MM DIA 2CM LEN 3 W Y SHP,SUP-2277889,CDM,C1889,HCPCS,0278,RC,,,,both,,,547.80,356.07,,,,,,,,,,,,,
ALLOGRAFT BNE WDG 30X13X15 MM FD IRRADIATED PATELLAR,SUP-2866891,CDM,C1762,CPT,0278,RC,,,,both,,,2034.41,1322.37,,,,,,,,,,,,,
ENDOPROSTHESIS VASC WSTNT RP L52 MM DIA 9 MM CATH TOT L 160,SUP-2148419,CDM,C1876,HCPCS,0278,RC,,,,both,,,3972.10,2581.86,,,,,,,,,,,,,
STRYKER REPLACEMENT BLADE 19X90X0.89MM,SUP-2605752,CDM,2720000010,LOCAL,0272,RC,,,,both,,,179.89,116.93,,,,,,,,,,,,,
CAP END FEM UNIV 10 MM NAIL EXTN TI,SUP-2480497,CDM,C1713,HCPCS,0278,RC,,,,both,,,568.34,369.42,,,,,,,,,,,,,
PIN FIX L50MM DIA2.5MM ELBW CO CHROM AXIS FOR STBL SYS IJS,SUP-2340232,CDM,C1713,HCPCS,0278,RC,,,,both,,,409.77,266.35,,,,,,,,,,,,,
BIT DRL DIA 3.2 MM LNG FOR HALF PIN NS DISP,SUP-2933791,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1440.79,936.51,,,,,,,,,,,,,
SCREW BNE CANN 2X6 MM TS-SERIES TI TI6,SUP-2609937,CDM,C1713,HCPCS,0278,RC,,,,both,,,575.12,373.83,,,,,,,,,,,,,
BIT DRL L70MM DIA19MM BLK S STL TWST J NOTCH W O STP REUSE,SUP-2262756,CDM,2720000010,LOCAL,0272,RC,,,,both,,,430.78,280.01,,,,,,,,,,,,,
ASPIRATION NEEDLE 8G X 23CM OPEN TIP,SUP-2765989,CDM,2720000010,LOCAL,0272,RC,,,,both,,,847.80,551.07,,,,,,,,,,,,,
WIRE FIX 2.5X150 MM PANTA KIRSCHNER,SUP-2422994,CDM,C1713,HCPCS,0278,RC,,,,both,,,331.74,215.63,,,,,,,,,,,,,
PLATE BNE 3 H STD L VOLAR WRST 7 PEG BEAR,SUP-2389746,CDM,C1713,HCPCS,0278,RC,,,,both,,,3124.30,2030.79,,,,,,,,,,,,,
PIN GUID 2.4MM 228MM SMOOTH SHRP TIP S STL,SUP-2166888,CDM,C1713,HCPCS,0278,RC,,,,both,,,79.25,51.51,,,,,,,,,,,,,
SYSTEM DIL BLLN L24MM DIA6MM MULT SNUS LO PROF SKR LIKE TIP,SUP-2106376,CDM,C1726,HCPCS,0272,RC,,,,both,,,6123.00,3979.95,,,,,,,,,,,,,
COMPONENT FEM L125MM DIA9MM HIP CO CHROM ANS,SUP-2406612,CDM,C1776,CPT,0278,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
COIL EMB L24CM DIA9MM MICROCATHETER DIA0.0165IN,SUP-2305187,CDM,C1889,HCPCS,0278,RC,,,,both,,,3579.60,2326.74,,,,,,,,,,,,,
PLATE BNE L W7XL32MM THK1MM 3 H R TI RIG OBLQ,SUP-2191009,CDM,C1713,HCPCS,0278,RC,,,,both,,,231.92,150.75,,,,,,,,,,,,,
IPRATROPIUM BROMIDE 0.02 % IN SOLN,RX-12580,CDM,J7644,HCPCS,0636,RC,00487-9801-01,NDC,,both,2.5,ML,2.70,1.75,,,,,,,,,,,,,
NAIL IM L48CM OD13MM GLD TIB KNEE RG AG LCK CANN TRIGEN,SUP-2347124,CDM,C1713,HCPCS,0278,RC,,,,both,,,5636.93,3664.00,,,,,,,,,,,,,
ALLOGRAFT DERMAL PTCH MED 7X5 CM ACELLULAR HYDRATED DERM,SUP-2321756,CDM,C1713,HCPCS,0278,RC,,,,both,,,5714.80,3714.62,,,,,,,,,,,,,
ANCHOR SUT NO 2 SUT N ABSRB 3MM DIA ETHBND FASTIN,SUP-2256672,CDM,C1713,HCPCS,0278,RC,,,,both,,,965.24,627.41,,,,,,,,,,,,,
STENT BILI WSTNT L 80 MM DIA10 MM CATH L 194 CM DIA 7.5 FR,SUP-2141481,CDM,C1876,HCPCS,0278,RC,,,,both,,,4006.64,2604.32,,,,,,,,,,,,,
TUBE VNTLTN ARMSTRNG R 114MM ID LUMEN 254MM ID 381MM OD F,SUP-2669494,CDM,L8699,HCPCS,0278,RC,,,,both,,,41.64,27.07,,,,,,,,,,,,,
SHEATH INTRO AVNT + DIA 8 FR CANN L 11 CM POLYUR PLAS SS STD,SUP-2424893,CDM,C1894,HCPCS,0272,RC,,,,both,,,31.46,20.45,,,,,,,,,,,,,
BLADE OSTEOTOM L10MM FLAT FLEX W/ BLDE AND DETACH HNDL,SUP-2364281,CDM,2720000010,LOCAL,0272,RC,,,,both,,,364.24,236.76,,,,,,,,,,,,,
FIXATOR ENER KT LENGTHENER 202MML,SUP-2495579,CDM,2720000010,LOCAL,0272,RC,,,,both,,,9176.65,5964.82,,,,,,,,,,,,,
IRON SUCROSE 200 MG IN NS 100 ML IVPB,RX-4081213,CDM,J1756,HCPCS,0636,RC,09999-9907-57,NDC,,both,100,ML,221.60,144.04,,,,,,,,,,,,,
INTRODUCER MICPUNC 4FR L10CM L40CM 0.018IN GWIRE S STL W/,SUP-2170556,CDM,C1894,HCPCS,0272,RC,,,,both,,,86.16,56.00,,,,,,,,,,,,,
GRAFT 1CC ALLGRFT DBM MAXXEUS,SUP-2165612,CDM,C9359,HCPCS,0278,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
BODY FEM SZ 10.5 12/14 TAPR CO CHROM L NP APR,SUP-2210893,CDM,C1776,CPT,0278,RC,,,,both,,,17270.00,11225.50,,,,,,,,,,,,,
GUIDEWIRE SURG L150MM DIA1.25MM L STP S STL THRD FOR DST,SUP-2184109,CDM,C1713,HCPCS,0278,RC,,,,both,,,417.18,271.17,,,,,,,,,,,,,
GRAFT BONE SUB 1-4MM 15CC CANC FN PARTICULATE FRZ DRY,SUP-2165537,CDM,C1713,HCPCS,0278,RC,,,,both,,,816.40,530.66,,,,,,,,,,,,,
SCREW BONE L70MM DIA6.5MM THRD L40MM TI CANN,SUP-2205345,CDM,C1713,HCPCS,0278,RC,,,,both,,,1102.30,716.49,,,,,,,,,,,,,
NAIL IM FEM LT LCK CANN 12MMX36CM GROSSE AND KEMPF,SUP-2362420,CDM,C1713,HCPCS,0278,RC,,,,both,,,1203.25,782.11,,,,,,,,,,,,,
INTRODUCER GUIDEWIRE FOR 0.010-0.018 IN STRL,SUP-2105890,CDM,C1769,HCPCS,0272,RC,,,,both,,,15.70,10.20,,,,,,,,,,,,,
TRAY TIB SZ 1 SLOPED MOD BAL REV SYS,SUP-2315550,CDM,C1776,CPT,0278,RC,,,,both,,,6380.48,4147.31,,,,,,,,,,,,,
STEM FEM L152MM OD17MM FINN L8.5CM HIP SEGMENTED COMP,SUP-2406098,CDM,C1776,CPT,0278,RC,,,,both,,,12914.82,8394.63,,,,,,,,,,,,,
TIP APPL 8 CM STIFFER DISP,SUP-2462296,CDM,2720000010,LOCAL,0272,RC,,,,both,,,732.22,475.94,,,,,,,,,,,,,
CONNECTOR ROD M L6MM DIA5.5MM TI OFFSET LOK SCR TSRH-3D,SUP-2289995,CDM,C1713,HCPCS,0278,RC,,,,both,,,2937.00,1909.05,,,,,,,,,,,,,
CLAMP PLT HLD L6XW.45IN,SUP-2319587,CDM,C1713,HCPCS,0278,RC,,,,both,,,106.76,69.39,,,,,,,,,,,,,
HC Hiv Combo Testing W/Reflx,PX-3028738900,CDM,87389,CPT,0302,RC,,,,both,,,63.00,40.95,,,,,,,,,,,,,
CUP ACET DIA 43 MM SS HIP 2 MOBILITY CEM STRL NOVAE STK,SUP-2913883,CDM,C1776,CPT,0278,RC,,,,both,,,29011.21,18857.29,,,,,,,,,,,,,
PROSTHESIS PENILE 12CM SNAP FIT RT CX,SUP-2139003,CDM,C1813,HCPCS,0278,RC,,,,both,,,24256.50,15766.72,,,,,,,,,,,,,
CATHETER INFUSION UNI-FUSE L 135CM 4FR SLT 5CM 0.035 IN BALL,SUP-2117047,CDM,C1725,HCPCS,0272,RC,,,,both,,,443.09,288.01,,,,,,,,,,,,,
TUBE UTER TRNSVAG 35 MM MCCARTNEY,SUP-2247548,CDM,2720000010,LOCAL,0272,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
REAMER SURG SM GLEN AUGMENTED MGS STRL DISP VIP UNIVERS,SUP-2933959,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
NAIL IM HUM UNIV 7X180 MM STRL VERSANAIL LTX,SUP-2861168,CDM,C1713,HCPCS,0278,RC,,,,both,,,5860.37,3809.24,,,,,,,,,,,,,
SCREW BNE L8MM DIA3MM CORT TI ST NONCANNULATED LOK FULL THRD,SUP-2190331,CDM,C1713,HCPCS,0278,RC,,,,both,,,635.66,413.18,,,,,,,,,,,,,
ROD SPNL CRV 5.5X70 MM TSRH CHROMALOY +,SUP-2627764,CDM,C1713,HCPCS,0278,RC,,,,both,,,832.10,540.86,,,,,,,,,,,,,
GRAFT TISS FRZN ALLGRFT PAT BTB HEMI W/ SHP BONE BLK W/OUT,SUP-2307537,CDM,C1713,HCPCS,0278,RC,,,,both,,,8949.00,5816.85,,,,,,,,,,,,,
SCREW BNE COMPR SHT THRD 3.5X18 MM CANN HDLSS TI NS,SUP-2422324,CDM,C1713,HCPCS,0278,RC,,,,both,,,1191.94,774.76,,,,,,,,,,,,,
PLATE BNE BRIM W 10.5 MM THK 2.5 MM H SPC 12 MM 12 H SCREW,SUP-2902375,CDM,C1713,HCPCS,0278,RC,,,,both,,,5740.55,3731.36,,,,,,,,,,,,,
PLATE BNE 8 HOLE 0.5 MM ADAPTATION 1.3 MM SCR MATRIXMIDFACE,SUP-2776727,CDM,C1713,HCPCS,0278,RC,,,,both,,,7634.72,4962.57,,,,,,,,,,,,,
MESH HERN RECTANGULAR 8X16 CM PREPERITONEAL ENFORM,SUP-2495924,CDM,C1781,HCPCS,0278,RC,,,,both,,,5347.42,3475.82,,,,,,,,,,,,,
GRAFT VASC HEMSHLD PLAT L 50 CM DIA 30 MM BRANCH SZ 10 MM,SUP-2474522,CDM,C1768,CPT,0278,RC,,,,both,,,4226.25,2747.06,,,,,,,,,,,,,
GRAFT BNE BLOCK 12X12X12 MM DBM CANC PUREBONE,SUP-2424599,CDM,C1713,HCPCS,0278,RC,,,,both,,,2504.15,1627.70,,,,,,,,,,,,,
KNIFE SURG Y SHP 5X111 MM STR MENISCOTOME PVC FREE ULTRA LF,SUP-2487778,CDM,2720000010,LOCAL,0272,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
VALVE SHUNT BURR HOLE 12 MM LO PRESSURE PUDENZ,SUP-2852584,CDM,C1889,HCPCS,0278,RC,,,,both,,,2248.84,1461.75,,,,,,,,,,,,,
POTASSIUM CL IN DEXTROSE 5% 20 MEQ/L IV SOLN,RX-102338,CDM,J3480,HCPCS,0636,RC,00264-7625-00,NDC,,both,1000,ML,57.50,37.37,,,,,,,,,,,,,
ADAPTER FEM L+0MM UPLR NEUT NK,SUP-2207892,CDM,C1776,CPT,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
CEMENT BONE FAST SETTING 3 CC DRILLABLE CALCIUM PHOSPHATE BO,SUP-2836349,CDM,C1713,HCPCS,0278,RC,,,,both,,,3532.50,2296.12,,,,,,,,,,,,,
COVER BUR H DIA17MM 6 H TI FOR 1.3MM PLUSDRIVE SCR,SUP-2190678,CDM,C1713,HCPCS,0278,RC,,,,both,,,853.45,554.74,,,,,,,,,,,,,
TRIAL HIP OD54MM ID36MM +4MM 20DEG CROSSLINKED POLYETH LNR,SUP-2345757,CDM,C1776,CPT,0278,RC,,,,both,,,2295.15,1491.85,,,,,,,,,,,,,
PUNCH SURG SKIN COR STRL DISP HEARTMATE II,SUP-2895109,CDM,2720000010,LOCAL,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
KIT INTRO L 11 CM DIA 8 FR PERC NO SIDEPRT CRV HEMOSTATIC,SUP-2120107,CDM,C1751,HCPCS,0278,RC,,,,both,,,53.38,34.70,,,,,,,,,,,,,
COVER BURR H DIA24 MM THK 0.75 MM CRANIOFACIAL CIR,SUP-2883439,CDM,C1713,HCPCS,0278,RC,,,,both,,,2608.37,1695.44,,,,,,,,,,,,,
PLATE BONE LOK 53MML HLX4 STNLSS STEEL STRGHT RCNSTRCTN ST,SUP-2588596,CDM,C1713,HCPCS,0278,RC,,,,both,,,1174.36,763.33,,,,,,,,,,,,,
SUPPORT ORTHOT HIP BILATERAL CUST COMBINATION,SUP-2435602,CDM,L1690,HCPCS,0272,RC,,,,both,,,5474.75,3558.59,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED RESURF H6SN] SMITH AND NEPHEW ORTHOPAEDICS],SUP-2351364,CDM,C1776,CPT,0278,RC,,,,both,,,25905.00,16838.25,,,,,,,,,,,,,
TIP SACROCOLPOPEXY LARGE,SUP-2719538,CDM,2720000010,LOCAL,0272,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
KIT LD L65CM 2X8 MRI COMPATIBLE SURESCAN SPEC,SUP-2284650,CDM,C1778,HCPCS,0278,RC,,,,both,,,19954.70,12970.55,,,,,,,,,,,,,
WRENCH SURG COUNT TORQ FOR BAHA 4 CONN SYS,SUP-2165026,CDM,2720000010,LOCAL,0272,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
WALKER PT M LOWEST PROF W/ CRISS CROSS STRP THREE-D,SUP-2195482,CDM,L4386,HCPCS,0272,RC,,,,both,,,195.03,126.77,,,,,,,,,,,,,
SHEPARD GRMMT VENT TUBE WWRE 1.14MM ID BLUE FLRPLSTC 30 PAC,SUP-2681461,CDM,L8699,HCPCS,0278,RC,,,,both,,,26.60,17.29,,,,,,,,,,,,,
THIAMINE HCL 200 MG/2ML IJ SOLN,RX-163114,CDM,2500000003,HCPCS,0250,RC,72485-0507-01,NDC,,both,2,ML,54.10,35.16,,,,,,,,,,,,,
"HC So1 Immunofix Electphoresis,Othfld",PX-3028633567,CDM,86335,CPT,0302,RC,,,,both,,,182.00,118.30,,,,,,,,,,,,,
PLATE BNE 3D PRNT MINI MIDFACE MAND TI TRUMATCH,SUP-2860363,CDM,C1713,HCPCS,0278,RC,,,,both,,,9655.81,6276.28,,,,,,,,,,,,,
GRAFT BNE SUB SM 1ML CRYOPRESERVED VIABLE CORT CANC BNE,SUP-2264669,CDM,C1713,HCPCS,0278,RC,,,,both,,,1992.02,1294.81,,,,,,,,,,,,,
CATHETER ANGIO L65CM L25CM OD5FR .038IN S STL POLYUR,SUP-2141093,CDM,C1725,HCPCS,0272,RC,,,,both,,,177.88,115.62,,,,,,,,,,,,,
BASKET STONE METALIC 2 IN UTIL,SUP-2501196,CDM,2720000010,LOCAL,0272,RC,,,,both,,,274.91,178.69,,,,,,,,,,,,,
PLATE BNE 40 X 61 MM THK 0.85 MM POLYETHYL EMBEDDED TI MTM,SUP-2883158,CDM,C1713,HCPCS,0278,RC,,,,both,,,3789.10,2462.91,,,,,,,,,,,,,
TACH TUBE BLUE RHINO G2-MULTI SET WITH 8 FLEX,SUP-2718705,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1675.82,1089.28,,,,,,,,,,,,,
STAPLER INT CIR X THCK 33 MM 4/4.5/5 MM TRI-STAPLE BLK EEA,SUP-2858014,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3414.15,2219.20,,,,,,,,,,,,,
NUT SPNL LCK PARL GUIDE SAMBASCREW,SUP-2601144,CDM,C1713,HCPCS,0278,RC,,,,both,,,926.30,602.09,,,,,,,,,,,,,
INSERTER BTTN DISP FOR TENS SLDE TECH DSTL BICEPS REP,SUP-2121664,CDM,2720000010,LOCAL,0272,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
PLATE BNE LCK 10 MM 6 HOLE BAR CRV SAG SPLIT SMARTLOC,SUP-2421796,CDM,C1713,HCPCS,0278,RC,,,,both,,,1458.69,948.15,,,,,,,,,,,,,
HC So Aspergillus Antibody,PX-3028660666,CDM,86606,CPT,0302,RC,,,,both,,,119.00,77.35,,,,,,,,,,,,,
COLLAR CERV L H3.25X23IN M DENS FOAM COT STOCK CVR LO,SUP-2196890,CDM,L0120,HCPCS,0272,RC,,,,both,,,10.96,7.12,,,,,,,,,,,,,
HC So H.Pylori. Serum,PX-3028667766,CDM,86677,CPT,0302,RC,,,,both,,,59.00,38.35,,,,,,,,,,,,,
GUIDEWIRE VASC VICTORY 18 L 300 CM DIA 0.018 IN TIP 2.5 CM,SUP-2140827,CDM,C1769,HCPCS,0272,RC,,,,both,,,433.32,281.66,,,,,,,,,,,,,
PLATE BNE W14XL118MM THK3.8MM 5 H R LAT TIB HD BTTRS S STL,SUP-2185776,CDM,C1713,HCPCS,0278,RC,,,,both,,,2206.45,1434.19,,,,,,,,,,,,,
GUIDEWIRE VASC RDRUN UNIGLIDE L 80 CM DIA 0.038 IN TAPR L 20,SUP-2171135,CDM,C1769,HCPCS,0272,RC,,,,both,,,81.64,53.07,,,,,,,,,,,,,
SUPPORT ORTHOT ANK KNEE CUST MOLD GAUNTLET,SUP-2435623,CDM,L1904,HCPCS,0272,RC,,,,both,,,1277.89,830.63,,,,,,,,,,,,,
BRACE ANK AIR STRRP SM HT 85 IN,SUP-2336085,CDM,L1930,HCPCS,0274,RC,,,,both,,,28.79,18.71,,,,,,,,,,,,,
PLATE SPNL 2 LEVEL 76 MM ANTR LUMBAR TI CITADEL,SUP-2584598,CDM,C1713,HCPCS,0278,RC,,,,both,,,20485.36,13315.48,,,,,,,,,,,,,
NEEDLE MAYO 1/2 CIRCLE SIZE 4 TROCAR POINT 217004,SUP-2844697,CDM,C1713,HCPCS,0278,RC,,,,both,,,19.44,12.64,,,,,,,,,,,,,
CATHETER CTRL VEN OD8FR SGL LUMN SURCUF 2 TISS INGROWTH,SUP-2127895,CDM,C1751,HCPCS,0278,RC,,,,both,,,2237.85,1454.60,,,,,,,,,,,,,
CANNULA SRGCL 48MML PIN TIP WCMPLTE RACK FTRNSBCCL SSTM,SUP-2680125,CDM,2720000010,LOCAL,0272,RC,,,,both,,,388.39,252.45,,,,,,,,,,,,,
BUR SURG DIA9MM S STL ACORN PRECIS ELITE TPS,SUP-2363424,CDM,2720000010,LOCAL,0272,RC,,,,both,,,348.73,226.67,,,,,,,,,,,,,
CATHETER BLLN 1.5MM X 15MM TAKERU RX GWIRE 0.014IN,SUP-2385537,CDM,C1725,HCPCS,0272,RC,,,,both,,,442.74,287.78,,,,,,,,,,,,,
PARACENTESIS TRAY PIG 8 FRX17 CM SLIP FIT CATH ONESTEP,SUP-2472400,CDM,C1729,HCPCS,0272,RC,,,,both,,,204.10,132.66,,,,,,,,,,,,,
PLATE THK1.7MM 2X2 H BX RESRB STRL DELT SYS,SUP-2364982,CDM,C1713,HCPCS,0278,RC,,,,both,,,454.45,295.39,,,,,,,,,,,,,
TRIAL HD 26MM -3MM OFFSET SH FEM CO CHROM TAPR LFIT,SUP-2364469,CDM,C1776,CPT,0278,RC,,,,both,,,263.76,171.44,,,,,,,,,,,,,
INTRODUCER TUBE TY PERC ADV FLX CIAGLIA BLU RHINO,SUP-2759812,CDM,C1769,HCPCS,0272,RC,,,,both,,,1183.78,769.46,,,,,,,,,,,,,
GRAFT HUMAN TSSUE W8XL16CM THK1.04 2.28MM THICK RGNRTVE TSSU,SUP-2466662,CDM,Q4116,HCPCS,0636,RC,,,,both,,,13869.38,9015.10,,,,,,,,,,,,,
PROBE ARTHSCP HK L3.4MM TIP W/ 5MM MRK FOR MENIS REP,SUP-2120783,CDM,C1713,HCPCS,0278,RC,,,,both,,,527.52,342.89,,,,,,,,,,,,,
ALLOGRAFT BNE DSTL HUM FRZN LT,SUP-2717952,CDM,C1762,CPT,0278,RC,,,,both,,,9938.10,6459.76,,,,,,,,,,,,,
Needle Biopsy Craig Vertebral Body 24-2506,SUP-2853278,CDM,2720000010,LOCAL,0272,RC,,,,both,,,494.55,321.46,,,,,,,,,,,,,
PROSTHESIS VOICE 17FR L4MM PRELD IN SMRT INSRTR AND BRSH,SUP-2124396,CDM,L8509,HCPCS,0274,RC,,,,both,,,963.98,626.59,,,,,,,,,,,,,
PLATE BNE THK 0.3 MM SCREW DIA1.5 MM MED TI ORBIT FLR PREFRM,SUP-2883810,CDM,C1713,HCPCS,0278,RC,,,,both,,,2210.56,1436.86,,,,,,,,,,,,,
HC So Vdrl / Rpr,PX-3028659266,CDM,86592,CPT,0302,RC,,,,both,,,72.00,46.80,,,,,,,,,,,,,
PPICC PROVENA SOLO SP 4F DL IR W/NIT70,SUP-2613543,CDM,C1751,HCPCS,0278,RC,,,,both,,,529.78,344.36,,,,,,,,,,,,,
SPACER SPNL 10MM CORT CANC CERV PARA GRFT,SUP-2364354,CDM,C1762,CPT,0278,RC,,,,both,,,3764.86,2447.16,,,,,,,,,,,,,
PACK PHACO 30DEG US FMS MIC SL TAPR ABS KELMAN,SUP-2109893,CDM,C1713,HCPCS,0278,RC,,,,both,,,971.23,631.30,,,,,,,,,,,,,
RESERVOIR AUTOTRANSFUSION 225/120 CC GS FILTERED XTRA,SUP-2326361,CDM,2720000010,LOCAL,0272,RC,,,,both,,,505.92,328.85,,,,,,,,,,,,,
ISRADIPINE 2.5 MG PO CAPS,RX-10362,CDM,6370000000,HCPCS,0637,RC,16252-0539-01,NDC,,both,1,UN,6.50,4.22,,,,,,,,,,,,,
EXTRACTOR STONE 15MMX200CM ABV INFL TO 8.5MM 12MM CLR CONN,SUP-2170078,CDM,2720000010,LOCAL,0272,RC,,,,both,,,524.38,340.85,,,,,,,,,,,,,
PLATE BNE CNDYL 285 MM 13 HOLE BUTTRESS TI NS LC-DCP,SUP-2569065,CDM,C1713,HCPCS,0278,RC,,,,both,,,4866.94,3163.51,,,,,,,,,,,,,
MESH HERN W1.3XL1.55IN M POLYPR INGUINAL NONABSORBABLE,SUP-2125755,CDM,C1781,HCPCS,0278,RC,,,,both,,,397.84,258.60,,,,,,,,,,,,,
SET PRT INFUS STD W/ Y-SITE 19 GAUGEX1 IN LIFEPRT,SUP-2118759,CDM,C1713,HCPCS,0278,RC,,,,both,,,326.56,212.26,,,,,,,,,,,,,
SCREW BNE L42MM DIA4.5MM THRD L12MM S STL PARTIALLY THRDED,SUP-2184434,CDM,C1713,HCPCS,0278,RC,,,,both,,,70.05,45.53,,,,,,,,,,,,,
CATHETER HEMODIALYSI SLXACUTE 14FR DIA LG 20CM STRGHT TAPR T,SUP-2610568,CDM,C1752,HCPCS,0278,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
GUIDEWIRE ORTH DIA14MM FOR MTP FUS SYS MINI MAXLOCK EXTRM,SUP-2400497,CDM,C1769,HCPCS,0272,RC,,,,both,,,31.40,20.41,,,,,,,,,,,,,
PACK PROC ANT VITRCTMY CUT HI SPD 30CPM 5000CPM 20GA,SUP-2129345,CDM,2720000010,LOCAL,0272,RC,,,,both,,,672.59,437.18,,,,,,,,,,,,,
PLATE BNE SZ MINI CALCANEUS,SUP-2243229,CDM,C1713,HCPCS,0278,RC,,,,both,,,6945.40,4514.51,,,,,,,,,,,,,
FORCEP GRASPING STEVENSON 6 INX15.2 CM ALLIGATOR TYP STR JAW,SUP-2423954,CDM,2720000010,LOCAL,0272,RC,,,,both,,,356.61,231.80,,,,,,,,,,,,,
JEJUNOSTOMY SET JEJU 12 FR 0.035 INX200 CM PEG24,SUP-2738116,CDM,C1769,HCPCS,0272,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
PANCRELIPASE (LIP-PROT-AMYL) 20000-63000 UNITS PO CPEP,RX-140364,CDM,6370000000,HCPCS,0637,RC,73562-0112-01,NDC,,both,1,UN,37.20,24.18,,,,,,,,,,,,,
SPACER SPNL 4 DEG 14X20 MM,SUP-2362886,CDM,C1889,HCPCS,0278,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
FIBER LASER 550UM HOLM SMRT ID SYS REUSE FOR ALL LUMENIS LASER,SUP-2141791,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1659.74,1078.83,,,,,,,,,,,,,
DISTRACTION INTRNL ST SIZER 02 424 25 71 02 424 30 7125 30 M,SUP-2707284,CDM,2720000010,LOCAL,0272,RC,,,,both,,,350.80,228.02,,,,,,,,,,,,,
BLADE OPHTH STRL LTX FREE DISP,SUP-2314056,CDM,2720000010,LOCAL,0272,RC,,,,both,,,347.13,225.63,,,,,,,,,,,,,
K WIRE FIX L152MM DIA1.6MM S STL 2 TRCR PNT,SUP-2412978,CDM,C1713,HCPCS,0278,RC,,,,both,,,35.61,23.15,,,,,,,,,,,,,
BOOT WALKING PREFORTED FT GTT,SUP-2265019,CDM,L4387,HCPCS,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
HC Drain Ovary Abscess Perq,PX-3615882200,CDM,58822,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
MATRIX DEMIN BONE 5CC STERIFUSE CRUNCH,SUP-2138659,CDM,C1713,HCPCS,0278,RC,,,,both,,,5259.50,3418.67,,,,,,,,,,,,,
SPACER SPNL W9XH9XL25MM 0DEG PEEK OPTMA LUM TRANSFORAMINAL,SUP-2402806,CDM,C1889,HCPCS,0278,RC,,,,both,,,13502.00,8776.30,,,,,,,,,,,,,
BUPIVACAINE LIPOSOME 1.3 % IJ SUSP|DISCARDED DRUG NOT ADMINISTE,RX-111491,CDM,J0666,HCPCS,0636,RC,65250-0266-09,NDC,JW,both,5,ML,573.20,372.58,,,,,,,,,,,,,
SCREW INTRF L25MM DIA7MM PLLA KNEE CANN BIOABSRB TAPR HD,SUP-2341552,CDM,C1713,HCPCS,0278,RC,,,,both,,,676.54,439.75,,,,,,,,,,,,,
HC Rem Central Venous Cath,PX-3613658900,CDM,36589,CPT,0361,RC,,,,both,,,1901.00,1235.65,,,,,,,,,,,,,
INTRODUCER ORTHOPEDIC ADD FRAC TOOL KYPHON XPANDER 10/3 IBT,SUP-2293644,CDM,C1894,HCPCS,0272,RC,,,,both,,,7171.76,4661.64,,,,,,,,,,,,,
CLAMP EXT FIX QUIK 6MM TO 4MM,SUP-2342954,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3167.63,2058.96,,,,,,,,,,,,,
PIN CLAMP 105MM,SUP-2494702,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2059.56,1338.71,,,,,,,,,,,,,
ALLOGRAFT BNE SPACER 21-26X27-32X21 MM FRZN ANTR LUMINARY-CC,SUP-2737047,CDM,C1713,HCPCS,0278,RC,,,,both,,,16051.99,10433.79,,,,,,,,,,,,,
BLADE SHV DIA4.8MM STR SERR HEMSTAT W/ PK TECHNOLOGY FOR,SUP-2312777,CDM,2720000010,LOCAL,0272,RC,,,,both,,,508.71,330.66,,,,,,,,,,,,,
PLATE BNE VOLAR LT DORS DSTL RADIAL 2 HOLE OPTILOCK,SUP-2522086,CDM,C1713,HCPCS,0278,RC,,,,both,,,1949.94,1267.46,,,,,,,,,,,,,
BIT DRL HUDSON END 28 CM HND COMPLETE DISP,SUP-2481291,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5672.35,3687.03,,,,,,,,,,,,,
HC So Molecular Path Level 2,PX-3108140166,CDM,81401,CPT,0310,RC,,,,both,,,391.00,254.15,,,,,,,,,,,,,
TROCAR ENDOPATH XCEL BLADELESS 5MM 75MM W/ STABILITY SLV,SUP-2855497,CDM,2720000010,LOCAL,0272,RC,,,,both,,,65.00,42.25,,,,,,,,,,,,,
PROSTHESIS PENILE L18CM DIA12MM INFL PS APPRCH W/ INHIBZN 2,SUP-2138973,CDM,C1813,HCPCS,0278,RC,,,,both,,,26620.92,17303.60,,,,,,,,,,,,,
CISPLATIN 100 MG/100ML IV SOLN,RX-88377,CDM,J9060,HCPCS,0636,RC,25021-0253-51,NDC,,both,100,ML,115.20,74.88,,,,,,,,,,,,,
STAPLE BNE 20 MM ANTR BUTTRESS NS BOWTI,SUP-2590315,CDM,C1713,HCPCS,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
PLATE BONE MINI MP PRE BENT CHIN WITH 6MM ADVANCEMENT,SUP-2862614,CDM,C1713,HCPCS,0278,RC,,,,both,,,686.69,446.35,,,,,,,,,,,,,
LOADING SYS AORT VLV SM STRL LF DISP NAVITOR FLEXNAV,SUP-2892359,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
FORCEPS LUM L5.5IN BITE 2MM MIC SGL TOOTH CUP WLLMS,SUP-2257133,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2436.64,1583.82,,,,,,,,,,,,,
LEUPROLIDE ACETATE 7.5 MG SC KIT,RX-32893,CDM,J9217,HCPCS,0636,RC,62935-0756-80,NDC,,both,1,UN,443.60,288.34,,,,,,,,,,,,,
BIT DRL L180MM DIA4.5MM ST TI JCBS CHK NONRADIOPAQUE W/O,SUP-2187292,CDM,2720000010,LOCAL,0272,RC,,,,both,,,415.86,270.31,,,,,,,,,,,,,
PLATE BNE L 147 X W 12 MM THK 3 MM SCREW DIA 3.5 MM 9 H SS 72467109N,SUP-2932861,CDM,C1713,HCPCS,0278,RC,,,,both,,,5774.15,3753.20,,,,,,,,,,,,,
STENT PERIPH L40MM DIA10MM CATH L120CM GWIRE 0.035IN SHTH,SUP-2416730,CDM,C1876,HCPCS,0278,RC,,,,both,,,10990.00,7143.50,,,,,,,,,,,,,
GRAFT BNE SUB 15CC SZ 17 10MM CANC CHIP FRZN MORSELIZED,SUP-2307398,CDM,C1713,HCPCS,0278,RC,,,,both,,,950.48,617.81,,,,,,,,,,,,,
SUBSTITUTE BNE GRFT GRAN MIC CA PHSPTE RESRB ST 15CC VITOSS,SUP-2368165,CDM,C1713,HCPCS,0278,RC,,,,both,,,3226.04,2096.93,,,,,,,,,,,,,
HC Ewhfo W/Joint(S) Cf (Non-Pmm),PX-2740376601,CDM,L3766,HCPCS,0274,RC,,,,both,,,4512.00,2932.80,,,,,,,,,,,,,
NUT TDWRIRE RS,SUP-2653989,CDM,C1713,HCPCS,0278,RC,,,,both,,,339.59,220.73,,,,,,,,,,,,,
GRAFT BNE GRAN 0.5 CC VI RESRB CERM MASTERGRAFT,SUP-2743368,CDM,C1713,HCPCS,0278,RC,,,,both,,,279.46,181.65,,,,,,,,,,,,,
WASHER BNE NAIL NAT NAIL,SUP-2499673,CDM,C1713,HCPCS,0278,RC,,,,both,,,227.71,148.01,,,,,,,,,,,,,
SCREW CPL LNG FOR DH DC SYS,SUP-2187945,CDM,C1713,HCPCS,0278,RC,,,,both,,,301.91,196.24,,,,,,,,,,,,,
LEVOTHYROXINE SODIUM 100 MCG IV SOLR,RX-110987,CDM,J0651,HCPCS,0636,RC,63323-0649-07,NDC,,both,1,UN,692.10,449.86,,,,,,,,,,,,,
GRAFT HUM TISS SEMITENDINOSUS TEND NONIRRADIATED FRZN,SUP-2335549,CDM,C1762,CPT,0278,RC,,,,both,,,6264.30,4071.79,,,,,,,,,,,,,
BLADE SCREWDRIVER 2MM DIA 35MML CROSS DRIVE,SUP-2495995,CDM,2720000010,LOCAL,0272,RC,,,,both,,,668.19,434.32,,,,,,,,,,,,,
NIACIN 500 MG PO TABS,RX-5542,CDM,6370000000,HCPCS,0637,RC,00904-2272-60,NDC,,both,1,UN,0.30,0.19,,,,,,,,,,,,,
PLATE BNE L 168 MM SCREW DIA 4.5 MM 10 H COMPR LCK NS EVOS,SUP-2932840,CDM,C1713,HCPCS,0278,RC,,,,both,,,3099.97,2014.98,,,,,,,,,,,,,
SCREW BONE EMERGENCY 2.7X16 MM MANDIBULAR SELFTAPPING 20/PK,SUP-2842307,CDM,C1713,HCPCS,0278,RC,,,,both,,,348.92,226.80,,,,,,,,,,,,,
SPACER CERV PAR6 FRZN VERTIGRAFT,SUP-2264933,CDM,C1713,HCPCS,0278,RC,,,,both,,,2911.35,1892.38,,,,,,,,,,,,,
EPOETIN ALFA-EPBX 40000 UNIT/ML IJ SOLN,RX-142365,CDM,Q5106,HCPCS,0636,RC,00069-1309-04,NDC,,both,1,ML,1301.60,846.04,,,,,,,,,,,,,
STENT PERIPH L140MM DIA10MM CATH L120CM GWIRE 0.035IN SHTH,SUP-2416735,CDM,C1876,HCPCS,0278,RC,,,,both,,,11618.00,7551.70,,,,,,,,,,,,,
COMPONENT FEM PS CEM SYMMETRICAL SZ 2,SUP-2222820,CDM,C1776,CPT,0278,RC,,,,both,,,9796.80,6367.92,,,,,,,,,,,,,
CATHETER DRAINAGE AMPLATZ 0.038 IN 12 FRX50 CM 6 SP UTHANE,SUP-2168698,CDM,C1729,HCPCS,0272,RC,,,,both,,,198.23,128.85,,,,,,,,,,,,,
CATHETER ANGIO PERFORMA L 125 CM 5 FR CRV 4 CM ULT4 1 SIDE H,SUP-2665522,CDM,C1887,HCPCS,0272,RC,,,,both,,,74.29,48.29,,,,,,,,,,,,,
DEXTROSE 10 % IV SOLN NEONATE,RX-40840075,CDM,2580000003,HCPCS,0258,RC,00338-0023-02,NDC,,both,250,ML,53.20,34.58,,,,,,,,,,,,,
HEMOSTASIS VALVE KIT ADVANTAGE+ WATCHDOG,SUP-2798393,CDM,2720000010,LOCAL,0272,RC,,,,both,,,601.62,391.05,,,,,,,,,,,,,
SLEEVE IM 120DEG LT BLU TI FOR SPRL BLDE FEM NAIL,SUP-2192714,CDM,C1713,HCPCS,0278,RC,,,,both,,,1339.52,870.69,,,,,,,,,,,,,
NAIL LOCKING PROXIMAL 150MML LEFT STERILE POLARUS 3,SUP-2639494,CDM,C1713,HCPCS,0278,RC,,,,both,,,7127.80,4633.07,,,,,,,,,,,,,
KIT BONE CEM PRECIS W/ MX AND DEL SYS W/OUT NDL PCD,SUP-2367029,CDM,C1713,HCPCS,0278,RC,,,,both,,,1325.36,861.48,,,,,,,,,,,,,
SCREW BNE CRTX 4.5X36 MM ST,SUP-2569781,CDM,C1713,HCPCS,0278,RC,,,,both,,,36.27,23.58,,,,,,,,,,,,,
BUR SURGICAL L90MM DIAMETER 3MM 120 GRIT DEEP ACCESS DIAMETE,SUP-2843183,CDM,2720000010,LOCAL,0272,RC,,,,both,,,885.70,575.70,,,,,,,,,,,,,
SET SCR SPNL AILEVON 5 MM,SUP-2264535,CDM,C1713,HCPCS,0278,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
CATHETER LD DEL OD9FR ID7FR L51CM STR OUTER GUID PEELABLE,SUP-2356187,CDM,C1887,HCPCS,0272,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
KIT NEPHSTMY CATH DIA7FR LINGEMAN 0.035IN SUP STIFF J DIL,SUP-2140115,CDM,C1726,HCPCS,0272,RC,,,,both,,,2062.98,1340.94,,,,,,,,,,,,,
DEXTROSE 10 % IV SOLN NEONATE,RX-40840075,CDM,2580000003,HCPCS,0250,RC,00338-0023-02,NDC,,both,250,ML,53.20,34.58,,,,,,,,,,,,,
EZ BOOTX-L,SUP-2326321,CDM,L4396,HCPCS,0274,RC,,,,both,,,201.53,130.99,,,,,,,,,,,,,
COMPONENT PATELLAR 32 MM KNEE RESURF OVL GEN II,SUP-2450676,CDM,C1776,CPT,0278,RC,,,,both,,,2876.24,1869.56,,,,,,,,,,,,,
JOINT TOE STR 0 DEG MED 3.2X21 MM HAMRTOE KT OSSIOFIBER,SUP-2641859,CDM,C1776,CPT,0278,RC,,,,both,,,4082.00,2653.30,,,,,,,,,,,,,
PLATE BONE L149MM 10 H NONSTERILE LT LAT PROX TIB LCK FOR,SUP-2348471,CDM,C1713,HCPCS,0278,RC,,,,both,,,11772.02,7651.81,,,,,,,,,,,,,
CATHETERIZATION KIT 4 FRX8 CM CV BLU FLEXTIP,SUP-2120587,CDM,C1751,HCPCS,0278,RC,,,,both,,,103.62,67.35,,,,,,,,,,,,,
BURR DIAMOND BALL COURSE XLONG 5.5MM,SUP-2843323,CDM,2720000010,LOCAL,0272,RC,,,,both,,,485.07,315.30,,,,,,,,,,,,,
HC So1 Hcv Ultraquant,PX-3068752267,CDM,87522,CPT,0306,RC,,,,both,,,565.00,367.25,,,,,,,,,,,,,
CANNULA SURG CEPHALOMEDULLARY DBL BRL,SUP-2487689,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3849.64,2502.27,,,,,,,,,,,,,
DEXTROSE 10 % IV SOLN NEONATE,RX-40840075,CDM,2580000003,HCPCS,0258,RC,00338-0023-03,NDC,,both,500,ML,51.00,33.15,,,,,,,,,,,,,
GUIDEWIRE 062INX9IN FLX NIT TRCR,SUP-2166837,CDM,C1769,HCPCS,0272,RC,,,,both,,,72.06,46.84,,,,,,,,,,,,,
HC Ot Vasopneumatic Device Therapy|OP PT SERVICES|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS,PX-4309701600,CDM,97016,CPT,0430,RC,,,GP|CQ,both,,,206.00,133.90,,,,,,,,,,,,,
HEAD FEM SZ +3.5 NK L32MM CERAMIC ON MTL,SUP-2359354,CDM,C1776,CPT,0278,RC,,,,both,,,4433.68,2881.89,,,,,,,,,,,,,
STEM FEM 0 HIP NP APOLLO,SUP-2210878,CDM,C1776,CPT,0278,RC,,,,both,,,4473.87,2908.02,,,,,,,,,,,,,
SET INTRO PEELWY ECHOTIP L 9 CM DIA 4.5 FR GUIDEWIRE L 65 CM,SUP-2168660,CDM,C1894,HCPCS,0272,RC,,,,both,,,202.22,131.44,,,,,,,,,,,,,
GUIDEWIRE VASC EMERALD L 180 CM DIA 0.035 IN SS PTFE J STD,SUP-2157299,CDM,C1769,HCPCS,0272,RC,,,,both,,,128.11,83.27,,,,,,,,,,,,,
PLATE SPNL 2 LEVEL 28 MM CERV PROVIDENCE,SUP-2229844,CDM,C1713,HCPCS,0278,RC,,,,both,,,9752.84,6339.35,,,,,,,,,,,,,
CATHETER HD STR 11.5 FRX12 CM DL TAPR TIP BASIC SET DUOFLO,SUP-2627382,CDM,C1752,HCPCS,0278,RC,,,,both,,,135.02,87.76,,,,,,,,,,,,,
SCREW DISTRACTOR L14MM MAXCESS-C,SUP-2311382,CDM,2720000010,LOCAL,0272,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
PENTAFLUOROPROP-TETRAFLUOROETH EX AERO,RX-39802,CDM,6370000000,HCPCS,0637,RC,00386-0008-01,NDC,,both,30,ML,46.40,30.16,,,,,,,,,,,,,
SCREW BNE PEDCL 6X50 MM MOSS MIAMI,SUP-2256220,CDM,C1713,HCPCS,0278,RC,,,,both,,,3405.33,2213.46,,,,,,,,,,,,,
MICROCATHETER ETER VASC PROXIMAL DISTAL 3X24FR L130CM LUMN,SUP-2141063,CDM,C1887,HCPCS,0272,RC,,,,both,,,2417.80,1571.57,,,,,,,,,,,,,
ALLOGRAFT BNE PTTY 5 CC W/ CHIP RPM DBM PUROS,SUP-2415791,CDM,C1889,HCPCS,0278,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
GRAFT VASC GELWEAVE L 15 CM DIA12 MM L 15/30/30CM TRIFURCATE,SUP-2894647,CDM,C1768,CPT,0278,RC,,,,both,,,13065.54,8492.60,,,,,,,,,,,,,
PLATE 8MM DISPLC DWYER,SUP-2243235,CDM,C1713,HCPCS,0278,RC,,,,both,,,5631.72,3660.62,,,,,,,,,,,,,
PLATE 3.5 MM TI LCP POSTEROMEDIAL PROX TIBIA 6 H/131 MM-STER,SUP-2546839,CDM,C1713,HCPCS,0278,RC,,,,both,,,3765.05,2447.28,,,,,,,,,,,,,
BASEPLATE TIB SZ 1 +4MM POR LT MOD THCK STEM PRESSFIT REV,SUP-2209091,CDM,C1776,CPT,0278,RC,,,,both,,,9545.60,6204.64,,,,,,,,,,,,,
CATHETER ANGIOPLSTY PFLX + L 80 CM BALLOON L 40 MM DIA 4 MM,SUP-2153810,CDM,C1725,HCPCS,0272,RC,,,,both,,,317.14,206.14,,,,,,,,,,,,,
GUIDE NAVIGATION SYS EXT WORKING CHANNEL ONLY,SUP-2381724,CDM,C1713,HCPCS,0278,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
DRESSING WOUND SURGICAL MATRIX 5X5 CM PLASTIC MATRISTEM,SUP-2106490,CDM,Q4166,HCPCS,0636,RC,,,,both,,,1738.49,1130.02,,,,,,,,,,,,,
RING EXT FIX COMP C HALF 200MM ID FOR ILIZ FIX,SUP-2340705,CDM,2720000010,LOCAL,0272,RC,,,,both,,,9609.50,6246.17,,,,,,,,,,,,,
CAP HEALING 20MM PLUG DISP BAHA,SUP-2164955,CDM,L8614,HCPCS,0278,RC,,,,both,,,94.20,61.23,,,,,,,,,,,,,
TROCAR SURG SPL DISP,SUP-2243814,CDM,C1894,HCPCS,0272,RC,,,,both,,,806.48,524.21,,,,,,,,,,,,,
METRONIDAZOLE 250 MG PO TABS,RX-5015,CDM,6370000000,HCPCS,0637,RC,60687-0526-11,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
BURR SURG 1.5MM DIA HD 26MML HD CARBIDE TAPR CTTNG MICROPOWE,SUP-2605535,CDM,2720000010,LOCAL,0272,RC,,,,both,,,63.37,41.19,,,,,,,,,,,,,
PACEMAKER CARD PACE 203H 2 CHMBR EXT TEMP NS,SUP-2616259,CDM,2720000010,LOCAL,0272,RC,,,,both,,,14742.30,9582.49,,,,,,,,,,,,,
SET FIX DSTL RAD VOLAR DSTL RAD D-RAD,SUP-2347937,CDM,C1713,HCPCS,0278,RC,,,,both,,,5192.78,3375.31,,,,,,,,,,,,,
OMALIZUMAB 150 MG/ML SC SOSY,RX-144255,CDM,J2357,HCPCS,0636,RC,50242-0215-01,NDC,,both,1,ML,4344.70,2824.05,,,,,,,,,,,,,
GRAFT HUM TISS W40XL40MM THK1MM ACELLULAR DERM RM TEMP,SUP-2264665,CDM,C1762,CPT,0278,RC,,,,both,,,5170.51,3360.83,,,,,,,,,,,,,
PLATE 3.5MM TI LCP POSTLAT DISTAL HUMERUS LAT SUPPORT 5H RT,SUP-2549686,CDM,C1713,HCPCS,0278,RC,,,,both,,,3701.40,2405.91,,,,,,,,,,,,,
BUR ENDOSCP AUGER MED 5.5X120 MM GRY LIGHT PUR UNIDRIVE,SUP-2585891,CDM,2720000010,LOCAL,0272,RC,,,,both,,,257.86,167.61,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED FEM TIB PATELLAR FLX SURF POROUS,SUP-2212269,CDM,C1776,CPT,0278,RC,,,,both,,,15567.40,10118.81,,,,,,,,,,,,,
BUR SURG L10CM HD L113MM DIA6MM CYL BRL SM BOR MIDAS REX,SUP-2277619,CDM,2720000010,LOCAL,0272,RC,,,,both,,,368.70,239.65,,,,,,,,,,,,,
SCREW BNE ST 4.5X85 MM CORTICAL LG HEX SOCKET SS NS LCP DCP,SUP-2184409,CDM,C1713,HCPCS,0278,RC,,,,both,,,211.64,137.57,,,,,,,,,,,,,
CATHETER ABLAT 8FR L115CM TIP ELECTRD L4MM F-J CRV 1-4-1,SUP-2355751,CDM,C2630,CPT,0272,RC,,,,both,,,7588.12,4932.28,,,,,,,,,,,,,
CATHETER DRNGE 10FR L25CM TIGHT LOOP TIP GLYCE MULTPURP TRCR,SUP-2118773,CDM,C1729,HCPCS,0272,RC,,,,both,,,188.40,122.46,,,,,,,,,,,,,
STEM FEM CMNTLS STD 14 HIP MONOBLOC REV STD OFFSET RECLAIM,SUP-2874188,CDM,C1776,CPT,0278,RC,,,,both,,,27152.21,17648.94,,,,,,,,,,,,,
CATHETER ABLATN XL 2-5-2 MM 4 MM 1304-7-25-XL-TH THER,SUP-2491481,CDM,C1733,HCPCS,0272,RC,,,,both,,,2075.54,1349.10,,,,,,,,,,,,,
KYPHOPLASTY PACK 10 GA 4 ML STR W/ BFD OSSEOFLEX SB OCP0014,SUP-2516664,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5353.70,3479.90,,,,,,,,,,,,,
CATHETER DLYS CHRONIC VAXCEL + 45552] NAVILYST MEDICAL],SUP-2308252,CDM,C1750,HCPCS,0278,RC,,,,both,,,1202.62,781.70,,,,,,,,,,,,,
COLESTIPOL HCL 5 G PO PACK,RX-12218,CDM,6370000000,HCPCS,0637,RC,59762-0260-01,NDC,,both,1,UN,14.20,9.23,,,,,,,,,,,,,
CEMENT BNE TOBRA SIMPLEX P,SUP-2365916,CDM,C1713,HCPCS,0278,RC,,,,both,,,1243.44,808.24,,,,,,,,,,,,,
GUIDE SURG SPCR BUR NTHRD,SUP-2292260,CDM,C1713,HCPCS,0278,RC,,,,both,,,175.12,113.83,,,,,,,,,,,,,
BIT DRL L80MM OD2.2MM NONSTERILE REUSE,SUP-2242907,CDM,2720000010,LOCAL,0272,RC,,,,both,,,708.01,460.21,,,,,,,,,,,,,
ANCHOR SUTURE SFT 2.9 MM NDL SHT PNCH JUGGERKNOT,SUP-2608805,CDM,C1713,HCPCS,0278,RC,,,,both,,,1621.24,1053.81,,,,,,,,,,,,,
CATHETER INTVASC OCCL ECLIPSE 2L BALLOON L 7 MM DIA 6 MM TIP,SUP-2717628,CDM,C2628,HCPCS,0272,RC,,,,both,,,6590.86,4284.06,,,,,,,,,,,,,
BUTTON GASTROSTMY 18 FRX1.7 CM LP FEED DEV MINIONE,SUP-2424399,CDM,C1713,HCPCS,0278,RC,,,,both,,,331.27,215.33,,,,,,,,,,,,,
KIT TRACH AD TB L60MM OD73MM ID5MM SIL W OBT SIDEPRT,SUP-2352052,CDM,2720000010,LOCAL,0272,RC,,,,both,,,313.31,203.65,,,,,,,,,,,,,
EXTENSION STEM L100MM OD13MM FEM HIP CEMENTLESS CNL FILL,SUP-2304761,CDM,C1776,CPT,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
BIT DRL L300MM DIA7.3MM QUIK CPL W/O STP REUSE FOR,SUP-2187291,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1120.29,728.19,,,,,,,,,,,,,
SCREW BNE SET 4.5 MM CANN 1/3 THRD EXT TAB,SUP-2861014,CDM,C1713,HCPCS,0278,RC,,,,both,,,24838.66,16145.13,,,,,,,,,,,,,
CLAMP EXT FIX 90DEG PIN ADJ LOK HNG FOR ACUTE TRAUM ILIZ,SUP-2340787,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2013.27,1308.63,,,,,,,,,,,,,
TIBIAL FIXATION KIT 14MM BUTTON,SUP-2811994,CDM,C1713,HCPCS,0278,RC,,,,both,,,1281.12,832.73,,,,,,,,,,,,,
CATHETER CARD ABLATION COBRA FUSION 150 L 150 MM POLYUR,SUP-2124417,CDM,2720000010,LOCAL,0272,RC,,,,both,,,21509.00,13980.85,,,,,,,,,,,,,
GUIDEWIRE ENDO L600CM DIA0.035IN HYDRPHLC COAT L5CM TIP L5CM,SUP-2170824,CDM,C1769,HCPCS,0272,RC,,,,both,,,841.52,546.99,,,,,,,,,,,,,
TAPE SUTURE UHMWPE SMTH LP N ABSRB STRL DISP XBRAID TT,SUP-2906851,CDM,2720000010,LOCAL,0272,RC,,,,both,,,847.80,551.07,,,,,,,,,,,,,
VALACYCLOVIR HCL 500 MG PO TABS,RX-13133,CDM,6370000000,HCPCS,0637,RC,50268-0788-11,NDC,,both,1,UN,7.90,5.13,,,,,,,,,,,,,
PLATE BONE L72MM 5 H LT POST DSTL TIB LCK FOR 3.5MM SCR,SUP-2349804,CDM,C1713,HCPCS,0278,RC,,,,both,,,6304.81,4098.13,,,,,,,,,,,,,
CATHETER ANGIO LANGSTON 145 DEG L 110 CM WORKING L 102 CM OD,SUP-2383140,CDM,C1887,HCPCS,0272,RC,,,,both,,,492.98,320.44,,,,,,,,,,,,,
PLATE LOCKING WEB 1.3MM 14 HOLES STERILE,SUP-2546069,CDM,C1713,HCPCS,0278,RC,,,,both,,,1417.77,921.55,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.527,SUP-2860044,CDM,C1713,HCPCS,0278,RC,,,,both,,,40577.28,26375.23,,,,,,,,,,,,,
RING EXT FIX CIR 5/8 160 MM SIDEKCK,SUP-2472870,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1557.44,1012.34,,,,,,,,,,,,,
RESOLVE BLRY LOK DRNGE CATH 10 FR 14CM 5CM PGTL DST 17 DRNGE,SUP-2677280,CDM,C1729,HCPCS,0272,RC,,,,both,,,241.78,157.16,,,,,,,,,,,,,
SHELL ACET OD56MM UNIV HA POR PLSM SPRY HIP REV PRESSFIT,SUP-2408350,CDM,C1776,CPT,0278,RC,,,,both,,,14139.42,9190.62,,,,,,,,,,,,,
SHEATH INTRO 10FR L63CM DIL 10FR L67CM GWIRE L180CM 0032IN,SUP-2357208,CDM,C1892,HCPCS,0272,RC,,,,both,,,967.12,628.63,,,,,,,,,,,,,
HOOK SPNL BILAT PEDCL S STL OPN NEUT FOR 4MM ROD MOSS MIAMI,SUP-2254423,CDM,C1713,HCPCS,0278,RC,,,,both,,,1155.52,751.09,,,,,,,,,,,,,
COMPONENT FEM SZ 1 UNI OPTETRAK,SUP-2223228,CDM,C1776,CPT,0278,RC,,,,both,,,7121.52,4628.99,,,,,,,,,,,,,
ELECTRODE UROLOGY CUT LOOP 1 STEM STRL DISP 7MM 24FR,SUP-2261163,CDM,2720000010,LOCAL,0272,RC,,,,both,,,431.75,280.64,,,,,,,,,,,,,
PLATE BONE 130DEG 3 H PROX FEM LCK FOR 3.5MM SCR PEDILOC,SUP-2318556,CDM,C1713,HCPCS,0278,RC,,,,both,,,7471.00,4856.15,,,,,,,,,,,,,
SUPPORT ORTHOT FT CUST INSRT MOLD TO PT MODEL PLASTAZOTE EQL,SUP-2435702,CDM,L3002,HCPCS,0272,RC,,,,both,,,457.25,297.21,,,,,,,,,,,,,
STENT PERIPH ENDOPROS 6MMDIA 100MML 8FR CATH 110CM TOT LEN,SUP-2396478,CDM,C1874,HCPCS,0278,RC,,,,both,,,7017.90,4561.63,,,,,,,,,,,,,
ENDOPROSTHESIS VASC VIABAHN L 5CM 7MM 120CM 7FR RADIOPAQUE,SUP-2396652,CDM,C1874,HCPCS,0278,RC,,,,both,,,9869.02,6414.86,,,,,,,,,,,,,
SCAFFOLD WOUND 8X8 PRIMATRIX,SUP-2653423,CDM,Q4110,HCPCS,0636,RC,,,,both,,,7149.78,4647.36,,,,,,,,,,,,,
ROD ORTH THRD 50 MM PILLAR,SUP-2749916,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1460.10,949.06,,,,,,,,,,,,,
HC So2 Ptt|NOT REASONABLE AND NECESSARY,PX-3058573068,CDM,85730,CPT,0305,RC,,,GZ,both,,,9.00,5.85,,,,,,,,,,,,,
SET SZ SM M L BLU GRY GRN UHMWPE ANG STA-PEG,SUP-2397145,CDM,C1713,HCPCS,0278,RC,,,,both,,,3287.58,2136.93,,,,,,,,,,,,,
PLATE BNE L RT 4 HOLE,SUP-2864957,CDM,C1713,HCPCS,0278,RC,,,,both,,,3887.32,2526.76,,,,,,,,,,,,,
SHEATH INTRO PINNACLE R/O II L 25 CM DIA 9 FR DIL PROTRUDING,SUP-2385199,CDM,C1894,HCPCS,0272,RC,,,,both,,,232.36,151.03,,,,,,,,,,,,,
ALLOGRAFT BNE FEM FRZN TISS WHL W/O HD,SUP-2165578,CDM,C1889,HCPCS,0278,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
DEVICE RESECTING SMOL 2.9 MM AVETA DISP,SUP-2739121,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
CATHETER HAD AD 12FR L16CM ADMIN FULL KT 3 LUMN POLYUR CRV,SUP-2283984,CDM,C1751,HCPCS,0278,RC,,,,both,,,293.84,191.00,,,,,,,,,,,,,
DEVICE FIX RND DBL 2 HOLE W/ POST SST STRL ENDOBUTTON LTX,SUP-2877810,CDM,C1713,HCPCS,0278,RC,,,,both,,,964.36,626.83,,,,,,,,,,,,,
LEAD ELECTRODE CLIP ALLIGATOR,SUP-2719740,CDM,2720000010,LOCAL,0272,RC,,,,both,,,178.04,115.73,,,,,,,,,,,,,
SCREW BNE CANN 6.5X50 MM COMPR HDLSS,SUP-2609998,CDM,C1713,HCPCS,0278,RC,,,,both,,,1573.14,1022.54,,,,,,,,,,,,,
CASE STRL ORTHOGNATHIC BNDL VSP,SUP-2366021,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4096.29,2662.59,,,,,,,,,,,,,
BIT DRL L356MM DIA5MM CALIB L126MM 3 FLUT QUIK CPL,SUP-2178833,CDM,2720000010,LOCAL,0272,RC,,,,both,,,918.48,597.01,,,,,,,,,,,,,
SET CATH HEMODIALYSI ACTE 12FR DIA 16CM 2LM INDWL BLU FLEXTI,SUP-2613327,CDM,C1752,HCPCS,0278,RC,,,,both,,,174.08,113.15,,,,,,,,,,,,,
PLEDGET CV SAUVAGE L 15.2 X W 15.2 CM THK 0.61 MM POLYESTER,SUP-2761342,CDM,C1768,CPT,0278,RC,,,,both,,,456.40,296.66,,,,,,,,,,,,,
GRAFT BNE SUB W3-6XL60MM CORT STRUTS FRZ DRY STRUCTURAL,SUP-2307179,CDM,C1713,HCPCS,0278,RC,,,,both,,,2564.53,1666.94,,,,,,,,,,,,,
PLATE BNE MINI CRV BAR NS,SUP-2883294,CDM,C1713,HCPCS,0278,RC,,,,both,,,1725.34,1121.47,,,,,,,,,,,,,
ALLOGRAFT BNE FRZN RT DSTL TIB,SUP-2740914,CDM,C1762,CPT,0278,RC,,,,both,,,14029.05,9118.88,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE 1 CC DBM FLOWABLE FIBER AMBIENT STOR,SUP-2933207,CDM,C1762,CPT,0278,RC,,,,both,,,386.22,251.04,,,,,,,,,,,,,
WAND ARTHSCP DIA3.75MM TIP DIA5.25MM 90DEG W/ INTEGR FNGR,SUP-2342010,CDM,2720000010,LOCAL,0272,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
CAP END TIB NAIL S STL,SUP-2402618,CDM,C1769,HCPCS,0272,RC,,,,both,,,1188.68,772.64,,,,,,,,,,,,,
PLATE BNE BROAD 4.5X269 MM 15 HOLE SS LCP,SUP-2569368,CDM,C1713,HCPCS,0278,RC,,,,both,,,811.69,527.60,,,,,,,,,,,,,
DRILL SURGICAL 1.5MM SOLID SPIDER,SUP-2586707,CDM,2720000010,LOCAL,0272,RC,,,,both,,,634.63,412.51,,,,,,,,,,,,,
ELECTRODE ELECSURG ROBOTIC CAUT HK TIP DA VINCI S/SI,SUP-2246576,CDM,C1713,HCPCS,0278,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
SUPPORT ORTHOT THOR LUMBAR SACR CUST SAGITTAL-CORONAL SHELL,SUP-2435548,CDM,L0490,HCPCS,0272,RC,,,,both,,,800.86,520.56,,,,,,,,,,,,,
GRAFT BNE SUB 25X100X4MM 10ML STRP,SUP-2361879,CDM,C1713,HCPCS,0278,RC,,,,both,,,9437.71,6134.51,,,,,,,,,,,,,
PLATE BNE L45MM 6X2 H R VOLAR DST RAD S STL VAR ANG LOK,SUP-2184116,CDM,C1713,HCPCS,0278,RC,,,,both,,,2103.05,1366.98,,,,,,,,,,,,,
HC Spcl Stn 2 I&R Excpt Microorg/Enzyme/Imcyt,PX-3128831300,CDM,88313,CPT,0312,RC,,,,both,,,249.00,161.85,,,,,,,,,,,,,
DRUM BUR OD8MM MIC FLUT CORNERSTONE,SUP-2363372,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1224.91,796.19,,,,,,,,,,,,,
STENT URET 0.038 IN 6 FRX22 CM 6 FR DBL PGTL 2 FLX PERCFLX +,SUP-2465260,CDM,C2617,HCPCS,0278,RC,,,,both,,,548.12,356.28,,,,,,,,,,,,,
TUBE VENT ARMSTR BVLD PLN END 1.14MM IMMUNDIFF 7.6MML FLROPL,SUP-2637683,CDM,L8699,HCPCS,0278,RC,,,,both,,,430.34,279.72,,,,,,,,,,,,,
GUIDEWIRE ORTH MULT HOLE 3.2X14 MM NS,SUP-2799309,CDM,C1769,HCPCS,0272,RC,,,,both,,,3222.30,2094.49,,,,,,,,,,,,,
PLATE BNE SCREW DIA2.7 MM PATELLAR SPLIT STRL EVOS,SUP-2933102,CDM,C1713,HCPCS,0278,RC,,,,both,,,8553.36,5559.68,,,,,,,,,,,,,
CLAMP EXT FIX CONV STRL DISP SMRT TSF,SUP-2933217,CDM,2720000010,LOCAL,0272,RC,,,,both,,,979.49,636.67,,,,,,,,,,,,,
GRAFT HUM TISS INJ FLUID 0.5 CC AMNIO PLCNTA MEMBRN PRO3-F,SUP-2742031,CDM,C1762,CPT,0278,RC,,,,both,,,4144.80,2694.12,,,,,,,,,,,,,
PACEMAKER CARD SERENA QUAD CRT-P MRI SURESCAN W 46.5 X H 59,SUP-2282511,CDM,C2621,HCPCS,0275,RC,,,,both,,,18880.91,12272.59,,,,,,,,,,,,,
STEM HUM PRI REV CEM IMPL SHLDR 1 PC 15.0MM DIA 8MM HD HT,SUP-2342767,CDM,C1776,CPT,0278,RC,,,,both,,,8898.76,5784.19,,,,,,,,,,,,,
BOLT SPNL L55MM DIA5.5MM ANT LAT LUM PLT SYS XLP,SUP-2311339,CDM,C1713,HCPCS,0278,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
CANNULA SUCTION 4 MMX30 CM 9 MM BENT FLARED MERCED TIP PAL,SUP-2760861,CDM,2720000010,LOCAL,0272,RC,,,,both,,,912.17,592.91,,,,,,,,,,,,,
SCREW CRANIOMAXILLOFACIAL VIT 1.3MM DIA 4MML,SUP-2364630,CDM,C1713,HCPCS,0278,RC,,,,both,,,158.88,103.27,,,,,,,,,,,,,
GUIDEWIRE VASC TAPR STD XL 0.014 INX300 CM 42 CM NEUROSCOUT,SUP-2492092,CDM,C1769,HCPCS,0272,RC,,,,both,,,2850.15,1852.60,,,,,,,,,,,,,
METOCLOPRAMIDE HCL 10 MG/10ML PO SOLN,RX-77710,CDM,6370000000,HCPCS,0637,RC,00121-1576-10,NDC,,both,5,ML,9.20,5.98,,,,,,,,,,,,,
BUR SURG DIAMOND X COARSE 4 MMX10 CM BALL SM BOR LEGEND,SUP-2627620,CDM,2720000010,LOCAL,0272,RC,,,,both,,,360.94,234.61,,,,,,,,,,,,,
BIT COUNTERSINK 2MM L17MM AO,SUP-2705064,CDM,2720000010,LOCAL,0272,RC,,,,both,,,642.92,417.90,,,,,,,,,,,,,
BIT DRILL SURG L 1/4 IN DIA 3.2 MM CANN,SUP-2896680,CDM,2720000010,LOCAL,0272,RC,,,,both,,,781.86,508.21,,,,,,,,,,,,,
STRAP ELBW TENNIS 8 IN BANDIT,SUP-2325152,CDM,L3702,HCPCS,0272,RC,,,,both,,,68.92,44.80,,,,,,,,,,,,,
ASPIRIN 81 MG PO TBEC,RX-688,CDM,6370000000,HCPCS,0637,RC,49483-0481-12,NDC,,both,1,UN,0.20,0.13,,,,,,,,,,,,,
SPLINT ORTHOPEDIC COLLES LG WRST MONTREAL,SUP-2330387,CDM,L3808,HCPCS,0274,RC,,,,both,,,15.70,10.20,,,,,,,,,,,,,
PLATE BNE L169MM 8 H R OLECRANON S STL LO PROF VAR ANG LOK,SUP-2177190,CDM,C1713,HCPCS,0278,RC,,,,both,,,3398.89,2209.28,,,,,,,,,,,,,
ROD MIS NEWPORT 80MM,SUP-2245616,CDM,2720000010,LOCAL,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
STEM FEM L150MM DIA15MM PROX KNEE TI PPS PUREFIX BOW,SUP-2376546,CDM,C1776,CPT,0278,RC,,,,both,,,11547.04,7505.58,,,,,,,,,,,,,
SCREW BNE ST 2X5 MM CRTX FT W/ FLUT TIP TI NS,SUP-2189365,CDM,C1713,HCPCS,0278,RC,,,,both,,,232.99,151.44,,,,,,,,,,,,,
SCREW BNE CANN 7.3X70 MM FT TI STRL TRAUM FIX LTX,SUP-2861357,CDM,C1713,HCPCS,0278,RC,,,,both,,,737.40,479.31,,,,,,,,,,,,,
INSERT TIB CR 1 STD 10 MM HI FLX POLYETH PROVEN GEN-FLEX,SUP-2390381,CDM,C1776,CPT,0278,RC,,,,both,,,5871.80,3816.67,,,,,,,,,,,,,
PLATE BNE TIB NEUT 2.7/3.5X172 MM RT DSTL 10 HOLE VA LCK LP,SUP-2177679,CDM,C1713,HCPCS,0278,RC,,,,both,,,5760.14,3744.09,,,,,,,,,,,,,
PLATE BNE L117MM THK3.7MM 9 H BILAT S STL STR LO PROF RIG,SUP-2184029,CDM,C1713,HCPCS,0278,RC,,,,both,,,2249.53,1462.19,,,,,,,,,,,,,
HC Inj Anes/Steroid L/S Facet Sg,PX-3616449300,CDM,64493,CPT,0361,RC,,,,both,,,4864.00,3161.60,,,,,,,,,,,,,
BEAM FIX L80MM DIA7.5MM ARTH FOR CHARCOT DEFORMITY AXIS,SUP-2223954,CDM,C1776,CPT,0278,RC,,,,both,,,4239.00,2755.35,,,,,,,,,,,,,
SET INTRO MICROPUNCTURE SILHOUETTE 10CM SS PLAT MALLINCKRODT,SUP-2170538,CDM,C1894,HCPCS,0272,RC,,,,both,,,88.33,57.41,,,,,,,,,,,,,
GRAFT HUM TISS W50XL90MM THK15MM ACELLULAR DERM RM TEMP,SUP-2264601,CDM,C1713,HCPCS,0278,RC,,,,both,,,9077.46,5900.35,,,,,,,,,,,,,
AUGMENT FEM SZ 2.5 THK8MM STD POST TI CEM PFC SIG,SUP-2253619,CDM,C1776,CPT,0278,RC,,,,both,,,2334.90,1517.68,,,,,,,,,,,,,
CATHETER INFUSION UNI-FUSE L 45 CM 5FR SLT 10CM 0.035IN BALL,SUP-2117038,CDM,C1887,HCPCS,0272,RC,,,,both,,,1042.48,677.61,,,,,,,,,,,,,
PLATE BNE W6.3XL49MM THK1.6MM 3X4 H R DST RAD VOLAR S STL T,SUP-2186100,CDM,C1713,HCPCS,0278,RC,,,,both,,,1764.11,1146.67,,,,,,,,,,,,,
BASKET SPEC RETRV POLYP 2X4 CM 7 FRX240 CM NS MEM BSKT,SUP-2737565,CDM,2720000010,LOCAL,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
HC Bedside Swallowing Eval|OP SPEECH LANGUAGE SERVICE|DOCUMENTATION ON FILE,PX-4449261000,CDM,92610,CPT,0444,RC,,,GN|KX,both,,,355.00,230.75,,,,,,,,,,,,,
HEAD BPLR OD44MM ID28MM S STL UHMWPE,SUP-2267729,CDM,C1776,CPT,0278,RC,,,,both,,,2279.64,1481.77,,,,,,,,,,,,,
GRAFT HUM TISS W2.5XL2.5CM THK1MM CRYOPRESERVED AMNIO MEM,SUP-2116279,CDM,Q4148,HCPCS,0636,RC,,,,both,,,2945.32,1914.46,,,,,,,,,,,,,
ANCHOR SUT DIA5.5MM BIOCRYLRAPIDE NDL FOR ROT CUF REP HEALIX,SUP-2256659,CDM,C1713,HCPCS,0278,RC,,,,both,,,1516.62,985.80,,,,,,,,,,,,,
SPLINT WR AD L GREATER THAN W4IN RT MCP DLX KAY-SPLNT III,SUP-2324562,CDM,L3906,HCPCS,0272,RC,,,,both,,,82.80,53.82,,,,,,,,,,,,,
WEDGE EVANS 3D PRNT TI L 19X8MM,SUP-2320324,CDM,C1713,HCPCS,0278,RC,,,,both,,,6868.75,4464.69,,,,,,,,,,,,,
PLATE BNE L125MM THK38MM 6 H R MED DST TIB S STL NEUT,SUP-2185216,CDM,C1713,HCPCS,0278,RC,,,,both,,,3236.71,2103.86,,,,,,,,,,,,,
CONFORMER EYE M AD W20XL23MM BILAT OCU METHYLMETHACRYLATE M,SUP-2391940,CDM,L8610,HCPCS,0278,RC,,,,both,,,37.37,24.29,,,,,,,,,,,,,
BONE GRAFT KIT COR DECOMPRESSION 15 CC INJ PRO-DENSE,SUP-2759602,CDM,C1713,HCPCS,0278,RC,,,,both,,,14090.15,9158.60,,,,,,,,,,,,,
BUR SURG DIAMOND COARSE 3 MMX10 CM MTCH HD SM BOR LEGEND,SUP-2665010,CDM,2720000010,LOCAL,0272,RC,,,,both,,,322.13,209.38,,,,,,,,,,,,,
IMMOBILIZER ORTHOPEDIC 3 PNL UNIV 14-29 IN DURABLE TIETEX,SUP-2428152,CDM,L1830,CPT,0272,RC,,,,both,,,31.62,20.55,,,,,,,,,,,,,
GRAFT BONE SUB W19XH19MM D3MM CORT STRUT FEM FRZN,SUP-2294176,CDM,C1713,HCPCS,0278,RC,,,,both,,,4308.08,2800.25,,,,,,,,,,,,,
SUPPORT ORTHOT HEEL CUST SACH CUSH TYP,SUP-2435731,CDM,L3450,HCPCS,0272,RC,,,,both,,,298.77,194.20,,,,,,,,,,,,,
GRAFT VASC FLIXENE L 80 CM DIA 6 MM EPTFE GRAD REINF 3 LAYR,SUP-2478316,CDM,C1768,CPT,0278,RC,,,,both,,,3761.53,2444.99,,,,,,,,,,,,,
HC Temporary External Pacing,PX-4809295300,CDM,92953,CPT,0480,RC,,,,both,,,1976.00,1284.40,,,,,,,,,,,,,
CATHETER DLYS L61CM INSRT L44CM RADPQ DISP PRECIS,SUP-2174247,CDM,C1750,HCPCS,0278,RC,,,,both,,,847.80,551.07,,,,,,,,,,,,,
CATHETER GUID 3DRC 0.070 INX6 FRX100 CM VISTA BRT TIP,SUP-2422843,CDM,C1887,HCPCS,0272,RC,,,,both,,,474.20,308.23,,,,,,,,,,,,,
OSELTAMIVIR PHOSPHATE 30 MG PO CAPS,RX-88704,CDM,6370000000,HCPCS,0637,RC,68180-0675-11,NDC,,both,1,UN,11.70,7.60,,,,,,,,,,,,,
CATHETER EP 3 MM 2 MM TIP 4 FRX120 CM,SUP-2356900,CDM,C1730,HCPCS,0272,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
COMPONENT ULN L84MM 2.5MM OFFSET BOND COAT LT ELBW BEAR,SUP-2215465,CDM,C1776,CPT,0278,RC,,,,both,,,13169.16,8559.95,,,,,,,,,,,,,
SHUNT CAR 12FR TAPR TO 9FR L15.5CM BYPS SFT SMOOTH POLISHED,SUP-2127016,CDM,2720000010,LOCAL,0272,RC,,,,both,,,263.89,171.53,,,,,,,,,,,,,
CAGE SPNL 13 MM POST LUMBAR IF PEEK,SUP-2194085,CDM,C1889,HCPCS,0278,RC,,,,both,,,18130.36,11784.73,,,,,,,,,,,,,
PASSER SUT W/ HK FLEX REUSE EXPRESSEW III,SUP-2256621,CDM,C1713,HCPCS,0278,RC,,,,both,,,22595.44,14687.04,,,,,,,,,,,,,
GRAFT BNE SUB 5CC SZ 1 5MM MILLED CANC CHIP FRZ DRY FOR,SUP-2307068,CDM,C1713,HCPCS,0278,RC,,,,both,,,603.19,392.07,,,,,,,,,,,,,
BLADE RTRCTR CSPR MED LNGTH SHRT TEETH 55MM X 23MM LTRL BALL,SUP-2668415,CDM,2720000010,LOCAL,0272,RC,,,,both,,,415.52,270.09,,,,,,,,,,,,,
OXCARBAZEPINE 300 MG PO TABS,RX-21061,CDM,6370000000,HCPCS,0637,RC,51991-0054-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
HC So Hep C Rna Qual by Pcr,PX-3068752166,CDM,87521,CPT,0306,RC,,,,both,,,386.00,250.90,,,,,,,,,,,,,
PLATE BURR H L 36.2 MM DIA 30 MM SCREW DIA1.5 MM TI NS DISP,SUP-2936444,CDM,C1713,HCPCS,0278,RC,,,,both,,,1259.14,818.44,,,,,,,,,,,,,
SET ENDOSCP DISP FOR 8MM OSTEOCHNDRL HYALINE CART CYL HARV,SUP-2121640,CDM,C1713,HCPCS,0278,RC,,,,both,,,1632.80,1061.32,,,,,,,,,,,,,
RAIL EXT FIX TRANSITION 5.5X495 MM 4D TI,SUP-2517544,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6929.51,4504.18,,,,,,,,,,,,,
KIT DRNGE VENT EDM WIT 120ML GRAD CHMBR,SUP-2278380,CDM,C1729,HCPCS,0272,RC,,,,both,,,930.95,605.12,,,,,,,,,,,,,
PIN EXT FIX CYL SET CONN ELEMENT K-WIRE STRL TRUELOK EVO LTX,SUP-2875606,CDM,C1713,HCPCS,0278,RC,,,,both,,,10895.80,7082.27,,,,,,,,,,,,,
SCREW SPNL SHANK 7.5X35 MM CANN PPS,SUP-2561556,CDM,C1713,HCPCS,0278,RC,,,,both,,,8087.07,5256.60,,,,,,,,,,,,,
CATHETER DRNGE 14FR L25CM 0.038IN 9 H POLYUR HYDRPHLC ORNG,SUP-2303341,CDM,C1729,HCPCS,0272,RC,,,,both,,,189.81,123.38,,,,,,,,,,,,,
HC So Vitamin B-1,PX-3018442566,CDM,84425,CPT,0301,RC,,,,both,,,89.00,57.85,,,,,,,,,,,,,
GRAFT BNE PTTY 1 CC VI DBM DYNAGRAFT II,SUP-2641741,CDM,C1713,HCPCS,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
STENT COR 26MM 4MM RADPQ MRK RX MICROTRAC DEL,SUP-2296996,CDM,C1874,HCPCS,0278,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
SCREW BNE L40MM DIA7MM THRD L16MM CANC S STL ST SELF DRL,SUP-2397732,CDM,C1713,HCPCS,0278,RC,,,,both,,,1120.98,728.64,,,,,,,,,,,,,
STYLET PACE L49CM BALL TIP OD0.014 GRY ATR VENT FOR LD,SUP-2282063,CDM,C1894,HCPCS,0272,RC,,,,both,,,110.75,71.99,,,,,,,,,,,,,
TUNNELER SURG TRANSOSSEOUS FOR RC REP STRL DISP,SUP-2908689,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1978.20,1285.83,,,,,,,,,,,,,
PLATE BNE THK15MM 4X4 H MAND ANG LOK,SUP-2262970,CDM,C1713,HCPCS,0278,RC,,,,both,,,2614.08,1699.15,,,,,,,,,,,,,
COMPONENT TOT SHLDR CAPPED PART,SUP-2365902,CDM,C1876,HCPCS,0278,RC,,,,both,,,11397.57,7408.42,,,,,,,,,,,,,
DEVICE BIOPSY KYPHOPLASTY,SUP-2823540,CDM,2720000010,LOCAL,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
SPACER SPNL SPIKLS 0 DEG 14X14X25-29 MM 14 MM TI FORTIFY I-R,SUP-2594895,CDM,C1821,HCPCS,0278,RC,,,,both,,,21980.00,14287.00,,,,,,,,,,,,,
GRAFT HUM TISS PARTICULATE 50 MG CONNECTIVE TISS INTERFYL,SUP-2845978,CDM,Q4171,HCPCS,0636,RC,,,,both,,,2373.84,1543.00,,,,,,,,,,,,,
LEVEL NEURO ST PLATE ULTRNE LDDR NEURO SCRW4 X 2 HOLES 30 MM,SUP-2707442,CDM,C1713,HCPCS,0278,RC,,,,both,,,1147.61,745.95,,,,,,,,,,,,,
HC Perq Art M-Thrombect &/Nfs,PX-3616164500,CDM,61645,CPT,0361,RC,,,,both,,,8583.00,5578.95,,,,,,,,,,,,,
GRAFT BNE SUB 10CC 25X50X8MM STRP BIMODAL VITOSS,SUP-2361880,CDM,C9362,HCPCS,0278,RC,,,,both,,,9437.71,6134.51,,,,,,,,,,,,,
NUT EXT FIX DIA6MM THK6MM 10MM HEX HD ITALIAN,SUP-2342991,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4873.28,3167.63,,,,,,,,,,,,,
SLEEVE FIX L 30 MM DIA2.1 MM TYP 40 BND L 2 MM DIA 0.75 MM,SUP-2914798,CDM,C1784,HCPCS,0278,RC,,,,both,,,33.82,21.98,,,,,,,,,,,,,
HC Pt Manual Therapy Ea 15,PX-4209714000,CDM,97140,CPT,0420,RC,,,,both,,,194.00,126.10,,,,,,,,,,,,,
VALVE PRESSURE PROGRAMMABLE 120 CM CYL W/ SUTURE TABS HAKIM,SUP-2666801,CDM,C1889,HCPCS,0278,RC,,,,both,,,11315.78,7355.26,,,,,,,,,,,,,
PLATE BNE L 238 MM SCREW DIA 3.5 MM 20 SHFT H SS RECON VA,SUP-2907566,CDM,C1713,HCPCS,0278,RC,,,,both,,,4080.05,2652.03,,,,,,,,,,,,,
SET SCR SPNL S STL MULTIAXIAL REDUC FOR 5.5MM ROD CDH LEG,SUP-2288173,CDM,C1713,HCPCS,0278,RC,,,,both,,,178.98,116.34,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP FUSION LOOPTIP L 260 CM DIA 0.035 IN LOOP,SUP-2170835,CDM,C1769,HCPCS,0272,RC,,,,both,,,527.52,342.89,,,,,,,,,,,,,
SHEATH INTRO FAST-CATH L 73 CM DIA 8.5 FR GUIDEWIRE 0.032 IN,SUP-2357112,CDM,C1893,HCPCS,0272,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
SCREW BONE LOCKING 2X6 MM MANDIBULAR SELFTAPPING 20/PK TITAN,SUP-2842325,CDM,C1713,HCPCS,0278,RC,,,,both,,,419.25,272.51,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY SUPREME 120CM 6FR 5MM FIX TORQUE,SUP-2526073,CDM,C1730,HCPCS,0272,RC,,,,both,,,112.26,72.97,,,,,,,,,,,,,
SPLINT HND M PALM W3-3.5IN RT DORS CRPL TUNN HEAT MOLD,SUP-2332646,CDM,L3808,HCPCS,0272,RC,,,,both,,,69.08,44.90,,,,,,,,,,,,,
FORCEPS BPLR L33CM DIA5MM 360DEG TAPR JAW CVD FN ROUNDED TIP,SUP-2312661,CDM,2720000010,LOCAL,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
CATHETER PICC DBL LUMN BASIC KT INTVENT RAD PWR INJ POLYUR,SUP-2125546,CDM,C1751,HCPCS,0278,RC,,,,both,,,257.48,167.36,,,,,,,,,,,,,
TROCAR ENDOSCP L102MM DIA10MM STD CANN BLNT TIP W/ FIX BLLN,SUP-2283312,CDM,2720000010,LOCAL,0272,RC,,,,both,,,635.00,412.75,,,,,,,,,,,,,
PLATE BNE L CORONOID H FOR K WIRE OFFSET LOK SCR,SUP-2107074,CDM,C1713,HCPCS,0278,RC,,,,both,,,4593.82,2985.98,,,,,,,,,,,,,
CATHETER PICC ARROW TAPERFREE 6FR 55CM 3-LUMEN,SUP-2887056,CDM,C1751,HCPCS,0278,RC,,,,both,,,780.82,507.53,,,,,,,,,,,,,
TROCAR SURG DIA28MM FOR MULT WIRE GUID,SUP-2187474,CDM,2720000010,LOCAL,0272,RC,,,,both,,,346.40,225.16,,,,,,,,,,,,,
BIT DRL CANN 40-65 MM QR NS ACUTRK 6/7 LF DISP,SUP-2518490,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1061.32,689.86,,,,,,,,,,,,,
T-PLT OBLQ 53MM STER HEAD 3HL SHAFT 3HL,SUP-2818495,CDM,C1713,HCPCS,0278,RC,,,,both,,,1717.83,1116.59,,,,,,,,,,,,,
TACROLIMUS 0.5 MG PO CAPS,RX-24914,CDM,J7507,HCPCS,0636,RC,00904-6623-61,NDC,,both,1,UN,4.80,3.12,,,,,,,,,,,,,
KIT MINI ACCS STIFF DIL W 5FR 10CM COAX INTRO SHTH 40CM,SUP-2303436,CDM,C1893,HCPCS,0272,RC,,,,both,,,106.76,69.39,,,,,,,,,,,,,
PLATE BNE 3D PRNT SM MIDFACE MAND FOR ORBIT THN TI TRUMATCH,SUP-2860376,CDM,C1713,HCPCS,0278,RC,,,,both,,,23355.95,15181.37,,,,,,,,,,,,,
NAIL GAM 3 TI RT 120DEG 11X300MM ST,SUP-2701255,CDM,C1713,HCPCS,0278,RC,,,,both,,,7592.52,4935.14,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED BIRMINGHAM,SUP-2351333,CDM,C1776,CPT,0278,RC,,,,both,,,29139.20,18940.48,,,,,,,,,,,,,
PLATE BNE BROAD 4.5X287 MM 16 HOLE SS LCP,SUP-2569369,CDM,C1713,HCPCS,0278,RC,,,,both,,,844.50,548.92,,,,,,,,,,,,,
CATHETER CNTRL VENOU LUMENX1 2.7FR DIA 71CML SIL 0.15ML PRIM,SUP-2613065,CDM,C1751,HCPCS,0278,RC,,,,both,,,924.73,601.07,,,,,,,,,,,,,
IMPLANT HUM TISS 1ML DBM PTTY ALLGRFT BIOSET PSTE SYR OPN,SUP-2335610,CDM,C9359,HCPCS,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
AUGMENT TIB SZ 5/6 THK10MM L MED R LAT KNEE CO CHROM,SUP-2420912,CDM,C1776,CPT,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
COIL EMB L5CM DIA0.02IN LOOP DIA3MM CRV EXTRA SFT FILL,SUP-2323445,CDM,C1889,HCPCS,0278,RC,,,,both,,,6170.10,4010.56,,,,,,,,,,,,,
PLATE BNE SM L MID FT TI POLYAX LO PROF FUS RECON SALVATION,SUP-2401168,CDM,C1713,HCPCS,0278,RC,,,,both,,,8434.04,5482.13,,,,,,,,,,,,,
HC Inj's Anes/Steroid Pudental Nerve,PX-3616443000,CDM,64430,CPT,0361,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
CANNULA PERF ARTRL 14N ACCPTNCE 12FR DIA 9INL CRMDA BCTVE C,SUP-2726388,CDM,2720000010,LOCAL,0272,RC,,,,both,,,468.24,304.36,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP L60CM OD0035IN TIP L7CM NIT HYDRPHLC SLIP,SUP-2168946,CDM,C1769,HCPCS,0272,RC,,,,both,,,200.87,130.57,,,,,,,,,,,,,
VOLAR PLATE 4 HOLES LEFT 28MM,SUP-2830159,CDM,C1713,HCPCS,0278,RC,,,,both,,,2336.16,1518.50,,,,,,,,,,,,,
CATHETER VENTRICULAR RT ANGLED 8 CM HYDROCEPHALUS THER BA,SUP-2665095,CDM,C1729,HCPCS,0272,RC,,,,both,,,385.75,250.74,,,,,,,,,,,,,
SCREW BNE PART THRD 4X40 MM CANC TI,SUP-2374495,CDM,C1713,HCPCS,0278,RC,,,,both,,,83.21,54.09,,,,,,,,,,,,,
SUPPORT ORTHOT LUMBAR SACR CUST SAGITTAL-CORONAL INTFACE,SUP-2435560,CDM,L0651,HCPCS,0274,RC,,,,both,,,3667.77,2384.05,,,,,,,,,,,,,
PROSTHESIS STD SLD CO CHROM ALLOY CEM 1 PC HIP 38MM 127MM,SUP-2205792,CDM,C1776,CPT,0278,RC,,,,both,,,3163.55,2056.31,,,,,,,,,,,,,
PLATE BNE RHOMBOID 20X13X1 MM CNDYL FRAC 3D LCK TI NS,SUP-2457043,CDM,C1713,HCPCS,0278,RC,,,,both,,,821.68,534.09,,,,,,,,,,,,,
ELECTRODE ENDO 24X26FR DIA3MM YEL COAG BALL SHP FOR 24/28FR,SUP-2261192,CDM,2720000010,LOCAL,0272,RC,,,,both,,,431.81,280.68,,,,,,,,,,,,,
SCREW BNE ST 1.5X14 MM LCK W/ T4 STARDRV RECESS,SUP-2569504,CDM,C1713,HCPCS,0278,RC,,,,both,,,67.35,43.78,,,,,,,,,,,,,
ALLOGRAFT BNE BLOCK 6.25X2X0.4 CM 5 CC CRBNT APATITE VENADO,SUP-2718020,CDM,C1713,HCPCS,0278,RC,,,,both,,,2107.82,1370.08,,,,,,,,,,,,,
KIT SUT ENDO 2 DEV 12 FASTENERS COR-KNOT MIS COMB,SUP-2265304,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2810.30,1826.69,,,,,,,,,,,,,
KIT ELECTROPHYSIOLOGY ENSITE X EP SURF ELECTRD X PTCH NS,SUP-2873707,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3843.36,2498.18,,,,,,,,,,,,,
GRAFT BONE PUTTY DEMINERLIZED BONE MTRX 2.5CC DYNAGRFT II,SUP-2242677,CDM,C1713,HCPCS,0278,RC,,,,both,,,1030.92,670.10,,,,,,,,,,,,,
PLATE BNE L90MM BRL L25MM 150DEG 4 H NONSTERILE BILAT PELV,SUP-2186833,CDM,C1713,HCPCS,0278,RC,,,,both,,,1454.35,945.33,,,,,,,,,,,,,
GRAFT SFT TISS W9XL20CM NAT BARR OPTIMIZE SURG PERF,SUP-2305728,CDM,V2790,HCPCS,0274,RC,,,,both,,,29644.74,19269.08,,,,,,,,,,,,,
BIT DRL CANN SHT 12 MM STRL,SUP-2789599,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2310.47,1501.81,,,,,,,,,,,,,
SUCTION BLADE DBL SRRTD EDGE ANGLD 40DGRS RECT WNDW4MMX12CM5,SUP-2574172,CDM,2720000010,LOCAL,0272,RC,,,,both,,,564.07,366.65,,,,,,,,,,,,,
GRAFT BONE SUBSTITUTEXSM 2CC BIOACTIVE GLS PUTTY FIBERGRFT,SUP-2417166,CDM,C1713,HCPCS,0278,RC,,,,both,,,2710.61,1761.90,,,,,,,,,,,,,
BIT DRL L110MM DIA1.6MM STP 26MM PERC FOR IQ SER,SUP-2136987,CDM,2720000010,LOCAL,0272,RC,,,,both,,,788.14,512.29,,,,,,,,,,,,,
GRAFT BONE SUB 1CM MESH CARTIFORM,SUP-2319181,CDM,C1713,HCPCS,0278,RC,,,,both,,,10990.00,7143.50,,,,,,,,,,,,,
HC Additional Panel Charge,PX-3028687000,CDM,86870,CPT,0302,RC,,,,both,,,1200.00,780.00,,,,,,,,,,,,,
HEAD HUM H15MM OD44MM CO CHROM SHLDR EXT ARTC SURF OFFSET,SUP-2404688,CDM,C1776,CPT,0278,RC,,,,both,,,5347.42,3475.82,,,,,,,,,,,,,
LIGATOR ENDOSCP XSM DIA8.6-9.5MM TRIG CRD L122CM MIN ACC,SUP-2169548,CDM,2720000010,LOCAL,0272,RC,,,,both,,,737.90,479.63,,,,,,,,,,,,,
BUR SURG OD4.7MM 7.9MMXLONG CUT DR FLUT,SUP-2363405,CDM,2720000010,LOCAL,0272,RC,,,,both,,,430.59,279.88,,,,,,,,,,,,,
SURFACE ARTC SZ 5-6/CD H28MM AP46MM ML74MM UNIV CNDYL TIV,SUP-2201828,CDM,C1776,CPT,0278,RC,,,,both,,,6143.41,3993.22,,,,,,,,,,,,,
HMRS BEARING - 18 x 24,SUP-2512639,CDM,C1776,CPT,0278,RC,,,,both,,,698.02,453.71,,,,,,,,,,,,,
ROD SPNL POST R CRV SMOOTH TI ALLY PREBENT 5.5MM DIA 55MM,SUP-2415857,CDM,C1713,HCPCS,0278,RC,,,,both,,,879.20,571.48,,,,,,,,,,,,,
INTRODUCER VASC AD 6FR L25CM W/ DIA0.038IN GWIRE PINN,SUP-2141022,CDM,C1894,HCPCS,0272,RC,,,,both,,,1084.40,704.86,,,,,,,,,,,,,
CUBE 3 HOLE SALVATION,SUP-2401121,CDM,2720000010,LOCAL,0272,RC,,,,both,,,712.78,463.31,,,,,,,,,,,,,
SLEEVE RMR +1 JOURNEY,SUP-2347044,CDM,C1713,HCPCS,0278,RC,,,,both,,,458.44,297.99,,,,,,,,,,,,,
PIN FIX TRCR PT 1 END 0.141X9 IN RND END SS NS STEINMANN,SUP-2791374,CDM,C1713,HCPCS,0278,RC,,,,both,,,33.10,21.51,,,,,,,,,,,,,
TRAY CTRL VEN OD6FR 3 LUMN CATH NRS PWR INJ REV TAPR DSGN,SUP-2125556,CDM,C1751,HCPCS,0278,RC,,,,both,,,709.01,460.86,,,,,,,,,,,,,
TUBE JEJUNOSTOMY FEED 20 FR 7-10 CC SECUR-LOK EXT ENFIT MIC,SUP-2764437,CDM,2720000010,LOCAL,0272,RC,,,,both,,,428.55,278.56,,,,,,,,,,,,,
GRAFT VASC IMPRA L 45 CM DIA 6-4 MM EPTFE SHRT TAPR STD WALL,SUP-2761289,CDM,C1768,CPT,0278,RC,,,,both,,,1743.45,1133.24,,,,,,,,,,,,,
BODY EXT FIX XLN PENNIG MINIFIXATOR,SUP-2316457,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2183.43,1419.23,,,,,,,,,,,,,
INCLISIRAN SODIUM 284 MG/1.5ML SC SOSY,RX-156930,CDM,J1306,HCPCS,0636,RC,00078-1000-60,NDC,,both,1.5,ML,10583.90,6879.53,,,,,,,,,,,,,
ANCHOR SUT DIA45MM BIOCRYL RAPIDE ABSRB 3 DYNACORD SZ 2,SUP-2256646,CDM,C1713,HCPCS,0278,RC,,,,both,,,2552.82,1659.33,,,,,,,,,,,,,
CATH BLLN SCORING 6X40MM X 90CM OTW PTA ANGIOSCULPT,SUP-2353203,CDM,C1725,HCPCS,0272,RC,,,,both,,,3218.50,2092.02,,,,,,,,,,,,,
SPHERE GLEN DIA36MM TI REV SCR LOK DELT CTA,SUP-2254051,CDM,C1776,CPT,0278,RC,,,,both,,,3786.84,2461.45,,,,,,,,,,,,,
SCREW BNE L85MM DIA14MM THRD L22MM NONSTERILE CANC S STL ST,SUP-2186517,CDM,C1713,HCPCS,0278,RC,,,,both,,,1058.18,687.82,,,,,,,,,,,,,
SHEATH INTRO PINNACLE R/O II L 6 CM DIA 6 FR 2.5 CM 0.038 IN,SUP-2385187,CDM,C1894,HCPCS,0272,RC,,,,both,,,93.42,60.72,,,,,,,,,,,,,
PLATE BNE L104MM BLDE L90MM 130DEG 6 H ST PROX FEM BILAT S,SUP-2185524,CDM,C1713,HCPCS,0278,RC,,,,both,,,2755.70,1791.20,,,,,,,,,,,,,
BLADE OSTEOTOM L12MM CVD FLEX W/ BLDE AND DETACH HNDL,SUP-2364282,CDM,2720000010,LOCAL,0272,RC,,,,both,,,355.13,230.83,,,,,,,,,,,,,
STAPLE BONE FIX L8XW9MM IMP SUPERELASTIC NIT STAPIX,SUP-2365917,CDM,C1713,HCPCS,0278,RC,,,,both,,,5008.30,3255.39,,,,,,,,,,,,,
AMANTADINE HCL 100 MG PO CAPS,RX-364,CDM,6370000000,HCPCS,0637,RC,62332-0246-31,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
HC So Tissue Culture Skin/Biopsy,PX-3118823366,CDM,88233,CPT,0311,RC,,,,both,,,512.00,332.80,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.524,SUP-2860041,CDM,C1713,HCPCS,0278,RC,,,,both,,,42340.07,27521.05,,,,,,,,,,,,,
KNEE K1 TOT HEMI STD CEM IMPL CAPPED K1 SN,SUP-2431877,CDM,C1776,CPT,0278,RC,,,,both,,,10362.00,6735.30,,,,,,,,,,,,,
DANTROLENE SODIUM 20 MG IV SOLR,RX-9716,CDM,2500000003,HCPCS,0250,RC,42023-0123-06,NDC,,both,1,UN,509.70,331.30,,,,,,,,,,,,,
MESH HERN W10.5XL15.9CM VENTRAL POLYPR EPTFE OVL,SUP-2125814,CDM,C1781,HCPCS,0278,RC,,,,both,,,1032.43,671.08,,,,,,,,,,,,,
APPLIER CLP M L8CM 1.1MM CLP CLSR SYS ANASTOCLP GC,SUP-2264244,CDM,C1713,HCPCS,0278,RC,,,,both,,,1315.66,855.18,,,,,,,,,,,,,
MESH CRAN L 120 X W 120 MM THK 0.3 MM SCREW DIA1.5/1.7 MM LG,SUP-2883680,CDM,C1713,HCPCS,0278,RC,,,,both,,,7508.59,4880.58,,,,,,,,,,,,,
COUNTERSINK SURG DRL CANN 2/2.4 MM SCREW,SUP-2319445,CDM,C1713,HCPCS,0278,RC,,,,both,,,1171.22,761.29,,,,,,,,,,,,,
HC Joint Injection/Aspir Small WO US,PX-5102060000,CDM,20600,CPT,0510,RC,,,,inpatient,,,358.00,232.70,,,,,,,,,,,,,
HEAD RADIAL BPLR 18 MM ELBW KATALYST,SUP-2851910,CDM,C1776,CPT,0278,RC,,,,both,,,10528.99,6843.84,,,,,,,,,,,,,
GUIDE NERVE REP MTRX 4 MMX2 CM STRL NEURAGEN 3D LF,SUP-2877629,CDM,C9352,HCPCS,0278,RC,,,,both,,,7680.53,4992.34,,,,,,,,,,,,,
SPONGE DENT ABSORBABLE 12 2X6 CMX7 MM STRL GELFOAM,SUP-2322375,CDM,2720000010,LOCAL,0272,RC,,,,both,,,495.96,322.37,,,,,,,,,,,,,
PLATE BONE L28MM 10MM STP MIDFOOT HINDFOOT TI FOR 3.5/4MM,SUP-2319680,CDM,C1713,HCPCS,0278,RC,,,,both,,,6091.60,3959.54,,,,,,,,,,,,,
BIT DRL CANN 2.7X145 MM QC STRL,SUP-2563800,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1480.95,962.62,,,,,,,,,,,,,
CLAMP EXT FIX SM DIA4MM FOR BAR CONN,SUP-2188704,CDM,2720000010,LOCAL,0272,RC,,,,both,,,876.12,569.48,,,,,,,,,,,,,
ANCHOR SUT NO 2 SUT PRELD W 2 STRND BRAID POLY 5MM DIA 14MM,SUP-2366664,CDM,C1713,HCPCS,0278,RC,,,,both,,,477.41,310.32,,,,,,,,,,,,,
CATHETER IR PICC 2 LUMN KT 145CM L GWIRE W/ PASV VLV 5FR,SUP-2118956,CDM,C1751,HCPCS,0278,RC,,,,both,,,530.66,344.93,,,,,,,,,,,,,
ARMSTRONG R VENT TUBE WTAB,SUP-2695102,CDM,L8699,HCPCS,0278,RC,,,,both,,,1226.48,797.21,,,,,,,,,,,,,
NEEDLE EPIDURAL TUOHY 20GX4.5IN,SUP-2529755,CDM,C1776,CPT,0278,RC,,,,both,,,18.84,12.25,,,,,,,,,,,,,
PROSTHESIS PENILE 65ML INHIBZN ERECTILE RESTR INFL RESVR MS,SUP-2138961,CDM,C1813,HCPCS,0278,RC,,,,both,,,9960.08,6474.05,,,,,,,,,,,,,
"HC Assess of Aphasia,per Hour",PX-4449610500,CDM,96105,CPT,0444,RC,,,,both,,,554.00,360.10,,,,,,,,,,,,,
SCREW EXT FIX L250MM DIA5MM THRD L80MM S STL HA SELF DRL MR,SUP-2177034,CDM,2720000010,LOCAL,0272,RC,,,,both,,,861.33,559.86,,,,,,,,,,,,,
SCREW BNE LCK 4.5X66 MM T25 PERI-LOC,SUP-2349968,CDM,C1713,HCPCS,0278,RC,,,,both,,,487.01,316.56,,,,,,,,,,,,,
IMMUNE GLOBULIN (FLEBOGAMMA) 10%,RX-4081761,CDM,J1459,HCPCS,0636,RC,44206-0436-05,NDC,,both,50,ML,2830.00,1839.50,,,,,,,,,,,,,
PROBE RF L150MM ACT TIPL4MM OD17GA DISP COOLIEF ADV,SUP-2719765,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1193.20,775.58,,,,,,,,,,,,,
HC So Proinsulin Level,PX-3018420666,CDM,84206,CPT,0301,RC,,,,both,,,123.00,79.95,,,,,,,,,,,,,
HEAD RAD DIA24MM R EL CO CHROM ANAT,SUP-2107858,CDM,C1776,CPT,0278,RC,,,,both,,,9259.86,6018.91,,,,,,,,,,,,,
PLATE 4.5MM TI LCP TM STRAIGHT RECON 11 HOLES 208MM,SUP-2549511,CDM,C1713,HCPCS,0278,RC,,,,both,,,1946.17,1265.01,,,,,,,,,,,,,
HC Joint Injection/Aspir Small WO US,PX-5102060000,CDM,20600,CPT,0510,RC,,,,outpatient,,,358.00,232.70,,,,,,,,,,,,,
CATHETER HEMODIALYSI NIAG ACUTE 13.5FR DIA 24CML INSER 400ML,SUP-2613254,CDM,C1752,HCPCS,0278,RC,,,,both,,,335.98,218.39,,,,,,,,,,,,,
DUALKNIFEJ LOWER LENGTH 1 UNITBX,SUP-2677729,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4078.86,2651.26,,,,,,,,,,,,,
BATTERY SET 14 V LVAD LITHIUM HEARTMATE,SUP-2356043,CDM,C1713,HCPCS,0278,RC,,,,both,,,2119.50,1377.67,,,,,,,,,,,,,
HC So Hiv2 Probe,PX-3068753868,CDM,87538,CPT,0306,RC,,,,both,,,118.00,76.70,,,,,,,,,,,,,
GRAFT VASC L40CM DIA26MM STR STD WALL N RING WVN VASCUTEK,SUP-2385009,CDM,C1768,CPT,0278,RC,,,,both,,,4093.27,2660.63,,,,,,,,,,,,,
ILLUMINATOR RETRACTOR CANYON TL DISP,SUP-2869070,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY VIK L 115 CM DIA 5 FR COURNAND,SUP-2460154,CDM,C1730,HCPCS,0272,RC,,,,both,,,132.67,86.24,,,,,,,,,,,,,
BLADE SCRWDRVR 2MM2.3MM DIA 16MML RIGHT ANGLD CROSS DRIVE,SUP-2707277,CDM,2720000010,LOCAL,0272,RC,,,,both,,,598.64,389.12,,,,,,,,,,,,,
GRAFT HUM TISS 2ML 160MG AMNIO MEM PARTICULATE INJ AMNIOFIX,SUP-2305721,CDM,V2790,HCPCS,0274,RC,,,,both,,,6265.87,4072.82,,,,,,,,,,,,,
CATHETER DRNGE 6FR UNIV NIT LOK PGTL NAVARRE,SUP-2128421,CDM,C1729,HCPCS,0272,RC,,,,both,,,235.41,153.02,,,,,,,,,,,,,
PLATE BONE L100MM 2X20 H BILAT CRANIOMAXILLOFACIAL TI LO,SUP-2191332,CDM,C1713,HCPCS,0278,RC,,,,both,,,2213.39,1438.70,,,,,,,,,,,,,
GRAFT HUM TISS 6X4 CM MEMBRN REGENERATIVE AMNIO STRATOGEN,SUP-2164202,CDM,Q4139,HCPCS,0636,RC,,,,both,,,7536.00,4898.40,,,,,,,,,,,,,
COMPONENT GLEN NO 9 THK4MM SHLDR UHMWPE REG CONSTRN CEM W/ 2,SUP-2372872,CDM,C1776,CPT,0278,RC,,,,both,,,4451.89,2893.73,,,,,,,,,,,,,
HC Needle Insertion W/O Injection 3 or More Muscles,PX-4202056100,CDM,20561,CPT,0940,RC,,,,outpatient,,,42.00,27.30,,,,,,,,,,,,,
BIT DRL L 115 MM WORKING L 35 MM DIA1.6 MM STRYKR END,SUP-2883257,CDM,2720000010,LOCAL,0272,RC,,,,both,,,776.27,504.58,,,,,,,,,,,,,
PLATE BNE W10.2XL143MM THK2.7MM 11 H BILAT S STL STR LO,SUP-2186198,CDM,C1713,HCPCS,0278,RC,,,,both,,,1559.89,1013.93,,,,,,,,,,,,,
BLADE SURG DISP FOR PLNTR FASCTMY KOBYGUARD,SUP-2319777,CDM,C1713,HCPCS,0278,RC,,,,both,,,935.72,608.22,,,,,,,,,,,,,
SCREW BNE L20MM DIA45MM SHT THRD L7MM ST S STL SELF DRL CANN,SUP-2178576,CDM,C1713,HCPCS,0278,RC,,,,both,,,984.83,640.14,,,,,,,,,,,,,
PLATE L DSTL RAD DRSL 2.4MM -90D 2H HD 5H SHFT TI STRL,SUP-2546749,CDM,C1713,HCPCS,0278,RC,,,,both,,,2421.76,1574.14,,,,,,,,,,,,,
PLATE BNE W6.3XL48MM THK1.6MM 5 H R DST RAD VOLAR S STL STR,SUP-2186101,CDM,C1713,HCPCS,0278,RC,,,,both,,,1605.76,1043.74,,,,,,,,,,,,,
BUR SURG RND XLN 1 MM 77 MM ENT FLUT CARBIDE,SUP-2628880,CDM,2720000010,LOCAL,0272,RC,,,,both,,,587.97,382.18,,,,,,,,,,,,,
TITANIUM 3D MESH 200MM X 200MM 6MM 15MM SSTM CP TTNM,SUP-2676603,CDM,C1713,HCPCS,0278,RC,,,,both,,,19720.99,12818.64,,,,,,,,,,,,,
SCREW SPNL MULTAXL 5.5X40 MM ESSENCE KT,SUP-2631911,CDM,C1713,HCPCS,0278,RC,,,,both,,,8102.77,5266.80,,,,,,,,,,,,,
STENT GRFT VASC AFX COCR STRATA LT IL EXT AAA STRL,SUP-2217711,CDM,C1768,CPT,0278,RC,,,,both,,,10613.20,6898.58,,,,,,,,,,,,,
PIN DRL POS 2 MM,SUP-2223973,CDM,2720000010,LOCAL,0272,RC,,,,both,,,279.46,181.65,,,,,,,,,,,,,
COLLAR CERV X TALL AD 2 PC ATLS,SUP-2319264,CDM,L0172,HCPCS,0272,RC,,,,both,,,56.11,36.47,,,,,,,,,,,,,
SUPPORT ORTHOT SACROILIAC PELV CUST FLX STRP FABRICATED,SUP-2435552,CDM,L0622,HCPCS,0274,RC,,,,both,,,756.71,491.86,,,,,,,,,,,,,
GRAFT HUMAN TISSUE BIOLOGICAL TISSUE MATRIX THICK 25X20 CM NON CROSSLINKED SCAFFOLD NATURALLY OCCURRING PORCINE STERILE GENTRIX DISPOSABLE,SUP-2106502,CDM,Q4166,HCPCS,0636,RC,,,,both,,,40553.10,26359.51,,,,,,,,,,,,,
PLATE BONE 16 H PROX ANTR LAT BOW FOR 3.5MM SCR PERI-LOC,SUP-2349063,CDM,C1713,HCPCS,0278,RC,,,,both,,,1081.64,703.07,,,,,,,,,,,,,
PLATE BONE 4 H RT MINI PREBENT FOR ANG FX,SUP-2365248,CDM,C1713,HCPCS,0278,RC,,,,both,,,1007.94,655.16,,,,,,,,,,,,,
PLATE BNE 6 H ST BILAT MIDFOOT TALUS S STL MAL LO PROF LOK,SUP-2177141,CDM,C1713,HCPCS,0278,RC,,,,both,,,2478.94,1611.31,,,,,,,,,,,,,
NAIL ANKLE ARTHRODESIS RT T2 10X620MM,SUP-2701150,CDM,C1713,HCPCS,0278,RC,,,,both,,,24812.28,16127.98,,,,,,,,,,,,,
SPACER SPNL W20XH10XL55MM 12DEG LORD OBLQ LAT LUM INTBDY,SUP-2284878,CDM,C1821,HCPCS,0278,RC,,,,both,,,16365.68,10637.69,,,,,,,,,,,,,
ALLODERM SELECT 3X7 MEDIUM 1.2-2.0,SUP-2822072,CDM,Q4116,HCPCS,0636,RC,,,,both,,,3001.84,1951.20,,,,,,,,,,,,,
GRAFT VASC L20CM ID12MM STR RING STD WALL STR IMP GORTX,SUP-2396026,CDM,C1768,CPT,0278,RC,,,,both,,,2100.66,1365.43,,,,,,,,,,,,,
SHELL BPLR DIA44MM UNIV ACET CONVENE,SUP-2342602,CDM,C1776,CPT,0278,RC,,,,both,,,3039.52,1975.69,,,,,,,,,,,,,
SCREW BNE L70MM DIA3.5MM STD CORT DST TIB TI ST LOK FULL,SUP-2413588,CDM,C1713,HCPCS,0278,RC,,,,both,,,421.20,273.78,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP ANG TIP TORQUABLE HYDRPHLC RADPQ NIT DISP,SUP-2139362,CDM,C1769,HCPCS,0272,RC,,,,both,,,190.03,123.52,,,,,,,,,,,,,
GUIDEWIRE VASC DURAFLO ANGIO,SUP-2130898,CDM,C1769,HCPCS,0272,RC,,,,both,,,75.36,48.98,,,,,,,,,,,,,
BONE SCREW 6.5X30 SELF-TAP,SUP-2503712,CDM,C1713,HCPCS,0278,RC,,,,both,,,109.90,71.43,,,,,,,,,,,,,
TAPE MEAS IMPL 550MM W/ GUID STENT VASC,SUP-2264172,CDM,C1876,HCPCS,0278,RC,,,,both,,,281.03,182.67,,,,,,,,,,,,,
PLATE BNE W15XL104MM THK2MM 4 H BILAT S STL COVERLEAF RIG,SUP-2186006,CDM,C1713,HCPCS,0278,RC,,,,both,,,445.88,289.82,,,,,,,,,,,,,
PLATE BONE TUBULAR 37 MM 3 HOLE 1/3 WITH COLLAR STERILE TC10,SUP-2836661,CDM,C1713,HCPCS,0278,RC,,,,both,,,438.60,285.09,,,,,,,,,,,,,
SYSTEM BILI STENT DEL OASIS 1 ACT GUIDE CATH L 318 CM DIA 5,SUP-2169522,CDM,C1894,HCPCS,0272,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
COLLAR CERV X TALL AD 2 PC ATLS,SUP-2319264,CDM,L0172,HCPCS,0274,RC,,,,both,,,56.11,36.47,,,,,,,,,,,,,
PACEMAKER CARD AVEIR AR L 32 MM DIA 6.5 MM TI ATR SINGLE,SUP-2905602,CDM,C1605,HCPCS,0275,RC,,,,both,,,47100.00,30615.00,,,,,,,,,,,,,
PILLOW FETAL BLLN CEPHALIC ELEVATION FOR C-SECT,SUP-2662072,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2571.13,1671.23,,,,,,,,,,,,,
GRAFT SKIN L 20 X W 16 CM THK 1-2 MM XL ACELLULAR DERMAL,SUP-2905637,CDM,C1762,CPT,0278,RC,,,,both,,,31274.40,20328.36,,,,,,,,,,,,,
PLATE BNE L W13.5XL214MM THK4.2MM 12 H BILAT TI STR RIG,SUP-2190823,CDM,C1713,HCPCS,0278,RC,,,,both,,,813.70,528.90,,,,,,,,,,,,,
PLATE MESH 2.4/2.7MM 5X12H TI VA LCK STRL,SUP-2546966,CDM,C1713,HCPCS,0278,RC,,,,both,,,6173.84,4013.00,,,,,,,,,,,,,
KNIFE ANNULOTOMY RETRCT,SUP-2329745,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1607.68,1044.99,,,,,,,,,,,,,
DRILL SURG DIA2MM SH AO QUIK CPL VLP MINI-MOD,SUP-2344067,CDM,2720000010,LOCAL,0272,RC,,,,both,,,624.39,405.85,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED K2 HYBRID POROUS CAPZIMMERK2] ZIMMER BIOMET INC],SUP-2212501,CDM,C1776,CPT,0278,RC,,,,both,,,10048.00,6531.20,,,,,,,,,,,,,
SHUNT CAR 9 FRX15 CM INLYING BLU YEL PRUITT F3,SUP-2761874,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3293.86,2141.01,,,,,,,,,,,,,
BIT DRL DIA2.4MM,SUP-2280970,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1387.10,901.61,,,,,,,,,,,,,
ZIDOVUDINE 100 MG PO CAPS,RX-11692,CDM,6370000000,HCPCS,0637,RC,65862-0107-01,NDC,,both,1,UN,6.90,4.48,,,,,,,,,,,,,
SLEEVE UPLR DIA14-16MM +4MM OFFSET FEM 14/16 TAPR,SUP-2342620,CDM,C1776,CPT,0278,RC,,,,both,,,435.20,282.88,,,,,,,,,,,,,
GRAFT BNE SUB 15CC SZ 1-5MM MILLED CANC CHIP FRZ DRY,SUP-2307069,CDM,C1713,HCPCS,0278,RC,,,,both,,,979.68,636.79,,,,,,,,,,,,,
BUSHING TIB FINN,SUP-2406066,CDM,C1776,CPT,0278,RC,,,,both,,,720.63,468.41,,,,,,,,,,,,,
KIT BUSHING REG UNIV HUM DST PRSS FIT TI SOLAR,SUP-2372333,CDM,C1776,CPT,0278,RC,,,,both,,,3584.37,2329.84,,,,,,,,,,,,,
CANNULA LNG,SUP-2488483,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1097.24,713.21,,,,,,,,,,,,,
PLATE BNE 2 T-SHAPE1.5MM 2-HOLE,SUP-2247343,CDM,C1713,HCPCS,0278,RC,,,,both,,,1315.66,855.18,,,,,,,,,,,,,
PLATE 3.5MM TI LCP OLECRANON 10 HOLES RIGHT 190MM-STERILE,SUP-2549530,CDM,C1713,HCPCS,0278,RC,,,,both,,,3942.62,2562.70,,,,,,,,,,,,,
GRAFT BNE SUB W13XH35XL25MM 13DEG B TRICALCIUM PHSPTE GRAN,SUP-2194026,CDM,C1713,HCPCS,0278,RC,,,,both,,,2367.94,1539.16,,,,,,,,,,,,,
LOOP CUT 21FR BPLR,SUP-2261118,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1197.19,778.17,,,,,,,,,,,,,
KIT SPNL CEM 5CC FULL DOSE PMMA RADPQ HI VISC W O SYR AND,SUP-2255656,CDM,C1713,HCPCS,0278,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
DISTAL VOLAR PLATE STANDARD LEFT,SUP-2678016,CDM,C1713,HCPCS,0278,RC,,,,both,,,3147.07,2045.60,,,,,,,,,,,,,
STEM FEM SZ 10.5 RT HIP OVRSZ DSTL TEXT APR,SUP-2210921,CDM,C1776,CPT,0278,RC,,,,both,,,16266.77,10573.40,,,,,,,,,,,,,
SCREW BONE L20MM DIA4MM NONSTERILE BLU CORT TI ST,SUP-2192241,CDM,C1713,HCPCS,0278,RC,,,,both,,,590.07,383.55,,,,,,,,,,,,,
ELECTRODE ARTHSCP RAD FREQ SUCT HK 2.5MM ARTHCARE,SUP-2342027,CDM,2720000010,LOCAL,0272,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
METHYLPREDNISOLONE SODIUM SUCC 2000 MG IJ SOLR,RX-10579,CDM,J2919,HCPCS,0636,RC,00009-0850-01,NDC,,both,1,UN,626.00,406.90,,,,,,,,,,,,,
FOOTPLATE EXT FIX 140 MM,SUP-2197248,CDM,C1713,HCPCS,0278,RC,,,,both,,,4239.00,2755.35,,,,,,,,,,,,,
BONE CEMENT KIT 900 DEG LNG 11 GA PCD PRECIS SYS SPINEPLEX,SUP-2367021,CDM,C1713,HCPCS,0278,RC,,,,both,,,1888.05,1227.23,,,,,,,,,,,,,
ALLOGRAFT BNE CHIP 1-4 MM 30 CC PRESERVON CANC READIGRAFT,SUP-2740811,CDM,C1713,HCPCS,0278,RC,,,,both,,,1210.97,787.13,,,,,,,,,,,,,
GRAFT BNE W5XL120MM FIB FRZN SHFT,SUP-2307381,CDM,C1713,HCPCS,0278,RC,,,,both,,,2622.87,1704.87,,,,,,,,,,,,,
GRAFT VASC L40CM DIA8MM RAD L40CM EPTFE HEP THN WALLED,SUP-2395860,CDM,C1768,CPT,0278,RC,,,,both,,,4804.20,3122.73,,,,,,,,,,,,,
PLATE BNE L 209 MM SCREW DIA 4.5 MM 11 H RT PROX LAT TIB NS,SUP-2933534,CDM,C1713,HCPCS,0278,RC,,,,both,,,10215.21,6639.89,,,,,,,,,,,,,
SURGICAL PROCEDURE PACK VITRECTOMY 23 GA BVL,SUP-2110980,CDM,C1713,HCPCS,0278,RC,,,,both,,,1914.74,1244.58,,,,,,,,,,,,,
SCREW HUMERAL LOCKING EQUINOXE TAPERED SIZE 25 ORN,SUP-2855531,CDM,C1713,HCPCS,0278,RC,,,,both,,,1091.94,709.76,,,,,,,,,,,,,
CATHETER HD SHT TERM 13 FRX24 CM STR SPLIT TIP DUO-SPLIT,SUP-2269521,CDM,C1752,HCPCS,0278,RC,,,,both,,,225.39,146.50,,,,,,,,,,,,,
SCREW BNE SET 3.5 MM CANN PART THRD EXT TAB,SUP-2861012,CDM,C1713,HCPCS,0278,RC,,,,both,,,20103.79,13067.46,,,,,,,,,,,,,
HANDPIECE VITRECTOMY 23 GA 225 TD ESA VITESSE,SUP-2537896,CDM,2720000010,LOCAL,0272,RC,,,,both,,,998.52,649.04,,,,,,,,,,,,,
WIRE FIX L102MM DIA1.1MM S STL SMOOTH DBL BAYNT TIP K,SUP-2207938,CDM,C1713,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
SPECULUM NSL COTTLE 140X80 MM,SUP-2473851,CDM,2720000010,LOCAL,0272,RC,,,,both,,,523.25,340.11,,,,,,,,,,,,,
HC So Creatinine,PX-3018256566,CDM,82565,CPT,0301,RC,,,,both,,,159.00,103.35,,,,,,,,,,,,,
LENS INTOCU +40.0 DIOPT L13MM DIA6MM 0DEG HAPTIC ANG A,SUP-2111100,CDM,V2632,HCPCS,0276,RC,,,,both,,,395.51,257.08,,,,,,,,,,,,,
CATHETER PICC ARROWG+ARD BLUE ADVANCE TAPERFREE 5.5FR 55CM 2-LUMEN,SUP-2887068,CDM,C1751,HCPCS,0278,RC,,,,both,,,673.00,437.45,,,,,,,,,,,,,
STEM HUM CEM LNG 9X157 MM SHLDR AEQUALIS,SUP-2715561,CDM,C1776,CPT,0278,RC,,,,both,,,14070.34,9145.72,,,,,,,,,,,,,
PLATE BNE W10XL49MM THK1.2MM 4X3 H S STL T OBLQ BILAT,SUP-2372069,CDM,C1713,HCPCS,0278,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
DOT PG PRO 18 GAUGE 8CM RT BP,SUP-2613505,CDM,C1751,HCPCS,0278,RC,,,,both,,,383.08,249.00,,,,,,,,,,,,,
SCREW BNE SIG NOTCH 26 MM NS,SUP-2463261,CDM,C1713,HCPCS,0278,RC,,,,both,,,535.06,347.79,,,,,,,,,,,,,
ATTACHMENT ROD FOR M MULTIPIN CLMP,SUP-2188525,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1077.43,700.33,,,,,,,,,,,,,
RETRACTOR SURG 1525X625X2IN WILLAUER DEAVER,SUP-2244676,CDM,C1713,HCPCS,0278,RC,,,,both,,,574.18,373.22,,,,,,,,,,,,,
SHEATH INTRO FLX RAABE L 55 CM OD 5 FR GUIDEWIRE 0.038 IN,SUP-2168809,CDM,C1894,HCPCS,0272,RC,,,,both,,,121.83,79.19,,,,,,,,,,,,,
PATCH CV GORTX NOM L 15 X W 10 CM THK 0.6 MM EPTFE CNFRM,SUP-2395303,CDM,C1768,CPT,0278,RC,,,,both,,,4628.36,3008.43,,,,,,,,,,,,,
ELECTRODE RF DIA4MM 90DEG SUCT W/ INTEGR HNDPC VAPR S90,SUP-2249477,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1343.92,873.55,,,,,,,,,,,,,
DEFIBRILLATOR IMPL LUMAX 500 HF-T 59 X 66MM 12MM 30J BPLR,SUP-2138128,CDM,C1721,HCPCS,0275,RC,,,,both,,,58875.00,38268.75,,,,,,,,,,,,,
RING EXT FIX FT EZ FRAME,SUP-2486112,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5633.16,3661.55,,,,,,,,,,,,,
PLEDGET CV SZ 6 MM THK 2.87 MM PTFE FELT RND SHP THCK STRL,SUP-2761356,CDM,C1768,CPT,0278,RC,,,,both,,,3.45,2.24,,,,,,,,,,,,,
CATHETER HAD 11.5FR L24CM STR SIL DBL LUMN HEM CATH ST,SUP-2267081,CDM,C1751,HCPCS,0278,RC,,,,both,,,173.96,113.07,,,,,,,,,,,,,
SET PICC CATHETER TAPR TRIM PERIPH W TRIM,SUP-2384056,CDM,C1751,HCPCS,0278,RC,,,,both,,,269.04,174.88,,,,,,,,,,,,,
PLATE BNE MESHED PEDIATRIC 0.6 MM RT NEURO SMRT TI LEVEL,SUP-2459854,CDM,C1713,HCPCS,0278,RC,,,,both,,,16354.12,10630.18,,,,,,,,,,,,,
HANDPIECE (package is the only valid order uom) ABLAT DISP FOR ENDOMET SYS,SUP-2305833,CDM,C1886,HCPCS,0278,RC,,,,both,,,3124.30,2030.79,,,,,,,,,,,,,
CATHETER GUID .098IN CBL MOD BURKE VASC COR W/O HYDRPHLC,SUP-2158070,CDM,C1887,HCPCS,0272,RC,,,,both,,,273.18,177.57,,,,,,,,,,,,,
BIT REPROC DRL CANN QUICK CPL 3.2X170MM,SUP-2653188,CDM,2720000010,LOCAL,0272,RC,,,,both,,,679.87,441.92,,,,,,,,,,,,,
COMPONENT ULNA L75MM DIA3MM LEFT WITH BEARING E+ DISCOVERY,SUP-2879097,CDM,C1776,CPT,0278,RC,,,,both,,,16525.82,10741.78,,,,,,,,,,,,,
TROCAR ARTHSCP W/ PYR TIP 3.7MM,SUP-2332821,CDM,2720000010,LOCAL,0272,RC,,,,both,,,334.41,217.37,,,,,,,,,,,,,
IMPLANT CAPPED HIP H2 TOT ADV REV MH,SUP-2916302,CDM,C1776,CPT,0278,RC,,,,both,,,19841.35,12896.88,,,,,,,,,,,,,
BLADE IM L70MM DIA12.5MM ST TI CANN FR CUT EDGE SPRL FOR RG,SUP-2180042,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1719.15,1117.45,,,,,,,,,,,,,
CATHETER HD 11.5 FRX24 CM FULL TY KINK RESISTANCE,SUP-2267021,CDM,C1750,HCPCS,0278,RC,,,,both,,,389.36,253.08,,,,,,,,,,,,,
SHEATH INTRO AVNT + DIA 5 FR CANN L 5.5 CM POLYUR PLAS SS,SUP-2156061,CDM,C1894,HCPCS,0272,RC,,,,both,,,23.71,15.41,,,,,,,,,,,,,
HC Perq Dev Breast Add US Image,PX-3611928600,CDM,19286,CPT,0361,RC,,,,inpatient,,,1593.00,1035.45,,,,,,,,,,,,,
PACEMAKER CARD ADVISA DR MRI SURESCAN W 51 X H 45 MM D 8 MM,SUP-2282300,CDM,C1785,HCPCS,0275,RC,,,,both,,,11123.51,7230.28,,,,,,,,,,,,,
ALLOGRAFT BNE STRP 5X2.5 CM FIBER KORE,SUP-2736958,CDM,C1713,HCPCS,0278,RC,,,,both,,,5628.45,3658.49,,,,,,,,,,,,,
GRAFT BNE L60MM TIB SHFT FRZ DRY MATRIGRFT,SUP-2264860,CDM,C1713,HCPCS,0278,RC,,,,both,,,1860.98,1209.64,,,,,,,,,,,,,
ROD SPNL L120MM DIA3.5MM RT POST OCCIPITAL CERV THOR TI,SUP-2256391,CDM,C1713,HCPCS,0278,RC,,,,both,,,3631.41,2360.42,,,,,,,,,,,,,
GUIDEWIRE VASC GLIDEWIRE L 150 CM DIA 0.038 IN NIT HYDRPHLC,SUP-2141157,CDM,C1769,HCPCS,0272,RC,,,,both,,,150.78,98.01,,,,,,,,,,,,,
GRAFT HUM TISS 1CC PLCNTA MTRX FLOWABLE IMMUNOSUPPRESSIVE W/,SUP-2340456,CDM,C1762,CPT,0278,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
STEM FEM PRSS FIT R POR W/ SLOT TI BAL 19.0MM DIA 180MML,SUP-2406869,CDM,C1776,CPT,0278,RC,,,,both,,,28197.20,18328.18,,,,,,,,,,,,,
CONNECTOR SPNL L55MM THORLUM TI SIDELOAD FOR 5.5MM ROD CDH,SUP-2289154,CDM,C1713,HCPCS,0278,RC,,,,both,,,3169.74,2060.33,,,,,,,,,,,,,
DRILL SURG LUG SM HI PERF SIG,SUP-2456283,CDM,2720000010,LOCAL,0272,RC,,,,both,,,640.56,416.36,,,,,,,,,,,,,
GUIDE COR SNUS 9FR SHTH L40CM 3MM 0.035IN R SIDE DSGN W/,SUP-2303507,CDM,C1892,HCPCS,0272,RC,,,,both,,,1273.58,827.83,,,,,,,,,,,,,
BUR SURG DIA06MM BLU WHT DMND NONFLUTED RND SKEETER,SUP-2278155,CDM,2720000010,LOCAL,0272,RC,,,,both,,,686.94,446.51,,,,,,,,,,,,,
GUIDEWIRE ORTH DIA1.6 MM PARALLEL MIS,SUP-2897200,CDM,C1769,HCPCS,0272,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
BALLOON STONE REM DIA8.5/12/15MM CATH 7-5FR L200CM GWIRE,SUP-2169613,CDM,2720000010,LOCAL,0272,RC,,,,both,,,449.02,291.86,,,,,,,,,,,,,
GUIDEWIRE FUS 5CM AQUA COAT TIP 0.035 INCHX205 CM,SUP-2170086,CDM,C1769,HCPCS,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
PLATE BURR H L 44.55 MM DIA 38 MM SCREW DIA1.5 MM TI NS DISP,SUP-2936681,CDM,C1713,HCPCS,0278,RC,,,,both,,,1428.70,928.65,,,,,,,,,,,,,
PLATE BNE LCK 3.5 MM 5 HOLE CNTOUR 2 COMPR FOR SCR TI STRL,SUP-2499614,CDM,C1713,HCPCS,0278,RC,,,,both,,,1416.58,920.78,,,,,,,,,,,,,
PLATE BNE L40MM 4 H NONSTERILE BILAT TARSOMETATARSAL S STL,SUP-2184841,CDM,C1713,HCPCS,0278,RC,,,,both,,,2628.65,1708.62,,,,,,,,,,,,,
IMPLANT HUM TISS L 11 X W 10 CM PLCNTA MEMBRN MULTILAYERED,SUP-2927338,CDM,Q4109,HCPCS,0636,RC,,,,both,,,301440.00,195936.00,,,,,,,,,,,,,
VTCBK 8/35 TEMP TIP,SUP-2141078,CDM,C1729,HCPCS,0272,RC,,,,both,,,499.26,324.52,,,,,,,,,,,,,
MESH SURG W10XL15CM POLY ANAT FOR L INGUINAL HERN PARIETEX,SUP-2174783,CDM,C1781,HCPCS,0278,RC,,,,both,,,370.30,240.69,,,,,,,,,,,,,
PLATE BNE THK0.6MM 24 H STD CRANIOMAXILLOFACIAL G TI STR,SUP-2366267,CDM,C1713,HCPCS,0278,RC,,,,both,,,1449.64,942.27,,,,,,,,,,,,,
ROD EXT FIX L400MM DIA11MM C FBR MR CONDITIONAL 39487R] DEPUY SYNTHES USA],SUP-2188667,CDM,2720000010,LOCAL,0272,RC,,,,both,,,831.69,540.60,,,,,,,,,,,,,
EXPANDER TISS W14XH15CM 600CC PROJCT L5.5CM RND FULL HT NACL,SUP-2113321,CDM,C1789,HCPCS,0278,RC,,,,both,,,3689.50,2398.17,,,,,,,,,,,,,
CATHETER EP CRD 2 2-2 MM 4 FRX120 CM SUPREME,SUP-2356937,CDM,C1730,HCPCS,0272,RC,,,,both,,,722.20,469.43,,,,,,,,,,,,,
GRAFT BNE SUB 20CC OSTEOINDUCTIVE DBM OSTEOGENIC AUTOLGS,SUP-2399144,CDM,C1713,HCPCS,0278,RC,,,,both,,,8940.43,5811.28,,,,,,,,,,,,,
BUR SURG OD5.0MM LNG CUT ACORN N FLUT FOR TPS MIDAS REX,SUP-2363479,CDM,2720000010,LOCAL,0272,RC,,,,both,,,318.27,206.88,,,,,,,,,,,,,
HC So Pretreatment for RBC Ab ID,PX-3028697766,CDM,86977,CPT,0302,RC,,,,both,,,239.00,155.35,,,,,,,,,,,,,
SHUNT SURG CORONARY 1.5X12 MM ATRAUM VES TAPR TIP SOF-FLO,SUP-2261620,CDM,L8612,HCPCS,0278,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
SLING URETH SINGLE INCISION SYS BLU SOLYX,SUP-2424699,CDM,C1771,HCPCS,0278,RC,,,,both,,,6233.21,4051.59,,,,,,,,,,,,,
HC NM Renal Vascular Flow,PX-3417870900,CDM,78709,CPT,0341,RC,,,,both,,,3850.00,2502.50,,,,,,,,,,,,,
CURETTE SRGCL 8 1/2NL CRVCL CRTCL BONE ANGLD FRWRD F/MCRDSCC,SUP-2499391,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1233.17,801.56,,,,,,,,,,,,,
DISC SCR ST PRE LD UNIV 1.5X4MM NEURO 2,SUP-2362176,CDM,C1713,HCPCS,0278,RC,,,,both,,,461.83,300.19,,,,,,,,,,,,,
HC Layer Clos Face 5.1-7.5 Cm,PX-4501205300,CDM,12053,CPT,0450,RC,,,,both,,,1445.00,939.25,,,,,,,,,,,,,
DEVICE NEUROSTIMULATOR W2.9XL3.1IN THK0.8IN 71GM,SUP-2284639,CDM,2720000010,LOCAL,0272,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
SYSTEM SINUPLASTY BAL L16MM DIA6MM SPINPLUS NAV RELIEVA,SUP-2106370,CDM,C1726,HCPCS,0272,RC,,,,both,,,6829.50,4439.17,,,,,,,,,,,,,
PLATE BNE L69MM THK2MM R CALCNL S STL LOK COMPR FOR 3.5MM,SUP-2185988,CDM,C1713,HCPCS,0278,RC,,,,both,,,1975.75,1284.24,,,,,,,,,,,,,
BIT DRL LANX 12MM,SUP-2207867,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1158.66,753.13,,,,,,,,,,,,,
RING EXT FIX 160MM HALF,SUP-2197251,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2088.10,1357.26,,,,,,,,,,,,,
HC MRI-Upper Ext Jnt WO Cont,PX-6107322100,CDM,73221,CPT,0610,RC,,,,both,,,3764.00,2446.60,,,,,,,,,,,,,
IMPLANT OPHTH 2.75X7.5X80MM SIL RETIN STYL 511 SPNG HALF,SUP-2213501,CDM,C1784,HCPCS,0278,RC,,,,both,,,202.22,131.44,,,,,,,,,,,,,
CATHETER EP CSL 2-8-2 MM 4 FRX65 CM SUPREME,SUP-2356906,CDM,C1730,HCPCS,0272,RC,,,,both,,,929.44,604.14,,,,,,,,,,,,,
CATHETER PARACENT 5FR L10CM 4 H TAPR TIP CLR HUB W/ 19GA,SUP-2303174,CDM,C1729,HCPCS,0272,RC,,,,both,,,54.17,35.21,,,,,,,,,,,,,
PLATE SPNL 1 LEVEL 85X54X0.2 MM NEURO TI,SUP-2262593,CDM,C1713,HCPCS,0278,RC,,,,both,,,1649.94,1072.46,,,,,,,,,,,,,
STENT URET UROGUIDE L 24 CM DIA 7 FR SIL NYL TETH HYDRPHLC,SUP-2495689,CDM,C2617,HCPCS,0278,RC,,,,both,,,378.31,245.90,,,,,,,,,,,,,
BIT DRL TWST 1.9X50 MM W/ NOTCH DISP,SUP-2460310,CDM,2720000010,LOCAL,0272,RC,,,,both,,,330.42,214.77,,,,,,,,,,,,,
SUPPORT ORTHOT ANK KNEE CUST CLASP ATTCH SHOE BAR SINGLE,SUP-2435626,CDM,L1910,HCPCS,0274,RC,,,,both,,,793.98,516.09,,,,,,,,,,,,,
PLATE BONE L144MM 4 H LT PROX FEM LCK FOR 4.5MM SCR PERI-LOC,SUP-2351168,CDM,C1713,HCPCS,0278,RC,,,,both,,,11452.21,7443.94,,,,,,,,,,,,,
STEM EXTN LIMB SALV LO BODY ELEOS CEM 10MMX100MM,SUP-2314048,CDM,C1776,CPT,0278,RC,,,,both,,,5680.26,3692.17,,,,,,,,,,,,,
PLATE BNE L 186 MM SCREW DIA 3.5/4.5 MM 6 H RT TROCHANTERIC 72586206,SUP-2933283,CDM,C1713,HCPCS,0278,RC,,,,both,,,20896.70,13582.85,,,,,,,,,,,,,
PROSTHESIS TESTICULAR L L4.5CM DIA2.9CM SIL ELASTMR SHELL,SUP-2165304,CDM,C1889,HCPCS,0278,RC,,,,both,,,7542.28,4902.48,,,,,,,,,,,,,
ARTHROSCOPIC FIXATION KIT DELDEV CANN KNOT PUSH FAST-FIX 360,SUP-2341905,CDM,C1713,HCPCS,0278,RC,,,,both,,,1862.02,1210.31,,,,,,,,,,,,,
SHAFT FIB TRAD ALLGRFT 80X14 - 18 MM FRZ DRY,SUP-2294104,CDM,C1713,HCPCS,0278,RC,,,,both,,,1836.90,1193.98,,,,,,,,,,,,,
SCREW BNE L24MM DIA4.5MM S STL CANN FULL THRD LO PROF,SUP-2318702,CDM,C1713,HCPCS,0278,RC,,,,both,,,992.99,645.44,,,,,,,,,,,,,
PLATE BONE W16XL221MM THK5MM 11 H LT CNDYL FEM S STL BTTRS,SUP-2185794,CDM,C1713,HCPCS,0278,RC,,,,both,,,2696.29,1752.59,,,,,,,,,,,,,
GRAFT BIO TISS W20XL30CM THK18 4MM ACELLULAR DERM MTRX ULT,SUP-2307489,CDM,Q4128,HCPCS,0636,RC,,,,both,,,54474.35,35408.33,,,,,,,,,,,,,
INTRODUCER HEMSTAS 4FRX5CM SHTH W/ .035IN GWIRE ULTIMUM EV,SUP-2355596,CDM,C1894,HCPCS,0272,RC,,,,both,,,38.47,25.01,,,,,,,,,,,,,
SCREW BNE SCHNZ 5X150 MM SD HA TI STRL,SUP-2424237,CDM,C1713,HCPCS,0278,RC,,,,both,,,963.45,626.24,,,,,,,,,,,,,
CATHETER VENTRICULAR ANTIMICROBIAL VENTRICULAR CATH,SUP-2666788,CDM,C1729,HCPCS,0272,RC,,,,both,,,18930.46,12304.80,,,,,,,,,,,,,
PROSTHESIS PENILE L4CM DIA12MM CYL POSITIONABLE MALL DURA II,SUP-2140242,CDM,C1813,HCPCS,0278,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
PLATE BNE L349MM 14 H NONSTERILE PROX FEM S STL HK LO PROF,SUP-2186064,CDM,C1713,HCPCS,0278,RC,,,,both,,,5052.61,3284.20,,,,,,,,,,,,,
CATHETER KT MST PICC W/ PASV VLV TECHNOLOGY W/ 145CM WIRE 3,SUP-2118915,CDM,C1751,HCPCS,0278,RC,,,,both,,,938.86,610.26,,,,,,,,,,,,,
PLATE BNE L199MM THK3.8MM 12 H BILAT S STL NAR DYN COMPR,SUP-2185213,CDM,C1713,HCPCS,0278,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
HEAD FEM DIA32MM NK L+0MM 12/14 TAPR HIP OXINIUM PRI REV,SUP-2345362,CDM,C1776,CPT,0278,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
COLLAR CERV M DENS AD VELC CLSR FOAM W/ STOCK 3.5IN 23.5IN M,SUP-2198742,CDM,L0120,HCPCS,0274,RC,,,,both,,,16.58,10.78,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA FT PLU MAXBARR S1295108FD4,SUP-2632817,CDM,C1751,HCPCS,0278,RC,,,,both,,,1010.58,656.88,,,,,,,,,,,,,
PASSER SUTURE LOOP W/ BRAIDED NIT GRAPPLER DISP P419600030,SUP-2749800,CDM,2720000010,LOCAL,0272,RC,,,,both,,,744.18,483.72,,,,,,,,,,,,,
ALLOGRAFT BNE CERV 7.75X9.22 MM LORDTC VERTIGRAFT VG2,SUP-2264654,CDM,C1889,HCPCS,0278,RC,,,,both,,,3444.58,2238.98,,,,,,,,,,,,,
BUR SURG L48MM DIA07MM 150 200 GRIT DMND RND FOR OTO,SUP-2166380,CDM,2720000010,LOCAL,0272,RC,,,,both,,,316.07,205.45,,,,,,,,,,,,,
LOTEPREDNOL ETABONATE 0.5 % OP GEL,RX-119531,CDM,6370000000,HCPCS,0637,RC,24208-0503-07,NDC,,both,5,GR,1165.90,757.83,,,,,,,,,,,,,
BRACE ANK FT M AD WOM SHOE 7-9 STRP 2IN LT UNISX,SUP-2324848,CDM,L4350,HCPCS,0274,RC,,,,both,,,98.22,63.84,,,,,,,,,,,,,
FINASTERIDE 5 MG PO TABS,RX-10037,CDM,6370000000,HCPCS,0637,RC,65862-0149-90,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
BIT DRILL HIP FIBERTAK 1.6MM,SUP-2841347,CDM,2720000010,LOCAL,0272,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
BLADE SAW 85X10X1.27MM OSCIL HALL SS,SUP-2586312,CDM,2720000010,LOCAL,0272,RC,,,,both,,,65.97,42.88,,,,,,,,,,,,,
SHEATH URET ACC FORTE 10 FR DIL 12 FRX45CM SHTH SZ 1 HD,SUP-2119497,CDM,C1894,HCPCS,0272,RC,,,,both,,,277.04,180.08,,,,,,,,,,,,,
ALLOGRAFT BNE 8-15X100 MM FIBULAR SHFT STRL BIO LF DISP,SUP-2632316,CDM,C1762,CPT,0278,RC,,,,both,,,3303.28,2147.13,,,,,,,,,,,,,
ENDOPROSTHESIS VASC VIABAHN L 2.5CM 10MM 120CM 0.035 IN,SUP-2719582,CDM,C1768,HCPCS,0278,RC,,,,both,,,7614.50,4949.42,,,,,,,,,,,,,
PIN EXT FIX L180MM DIA3MM THRD L35MM TI NITRIDE FOR SIDEKCK,SUP-2400688,CDM,2720000010,LOCAL,0272,RC,,,,both,,,357.96,232.67,,,,,,,,,,,,,
GRAFT BNE 5 CC INJ HA CALCIUM PHOSPHATE HYDROSET DISP,SUP-2374938,CDM,C1713,HCPCS,0278,RC,,,,both,,,4411.70,2867.60,,,,,,,,,,,,,
ANCHOR SUT OD4.75MM BLU BIOCOMP FIBERTAPE LOOP MULTFI,SUP-2121694,CDM,C1713,HCPCS,0278,RC,,,,both,,,2009.60,1306.24,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9 % IR SOLN,RX-11403,CDM,2500000003,HCPCS,0250,RC,00264-2201-00,NDC,,both,500,ML,17.00,11.05,,,,,,,,,,,,,
RING EXT FIX FULL 210 MM ALUM HOFFMANN,SUP-2465578,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4031.76,2620.64,,,,,,,,,,,,,
INTRODUCER SHTH SPLITTABLE 5 FRX13 CM N VLV PRELUDE PRESTIGE,SUP-2798469,CDM,C1892,HCPCS,0272,RC,,,,both,,,46.16,30.00,,,,,,,,,,,,,
NAIL IM L34CM OD10MM 130DEG S STL HIP LT LCK CANN,SUP-2343922,CDM,C1713,HCPCS,0278,RC,,,,both,,,5064.82,3292.13,,,,,,,,,,,,,
MESH HERN DIA12CM CIR BIOMATERIAL PTFE KNIT DURABLE SGL STG,SUP-2395755,CDM,C1781,HCPCS,0278,RC,,,,both,,,1849.46,1202.15,,,,,,,,,,,,,
PROBE SUCT 50-S XL L180MM DIA3.5MM MAX CUT LEV 11,SUP-2366564,CDM,2720000010,LOCAL,0272,RC,,,,both,,,429.30,279.04,,,,,,,,,,,,,
WEDGE FT 0 DEG 4 MM LAPIDUS,SUP-2908986,CDM,C1713,HCPCS,0278,RC,,,,both,,,5557.80,3612.57,,,,,,,,,,,,,
BIT REPROC DRL CANN 4.9MM W/LG AO 6.5/8MM,SUP-2653175,CDM,2720000010,LOCAL,0272,RC,,,,both,,,589.19,382.97,,,,,,,,,,,,,
PROSTHESIS OSS 3-7 MM 2.2X3 MM 0.8 MM MORETZ DELT HA TI SIL,SUP-2461911,CDM,L8613,CPT,0278,RC,,,,both,,,1217.72,791.52,,,,,,,,,,,,,
CANNULA PERF 15FR L17CM FEM ART W/ 10FR INTRO TANDEMHEART,SUP-2152640,CDM,C1889,HCPCS,0278,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
FIXATION KIT SFT TISS STD STRL TENOTAC,SUP-2749804,CDM,C1713,HCPCS,0278,RC,,,,both,,,2778.90,1806.28,,,,,,,,,,,,,
MATRIX BIO SZ 250 SQCM ACELLULAR FISH SKIN DERMAL STRL 10/BX,SUP-2909435,CDM,Q4158,HCPCS,0636,RC,,,,both,,,19625.00,12756.25,,,,,,,,,,,,,
FLUCONAZOLE (DIFLUCAN) 2 MG/ML (PED-NEO) >/= 50 MLS,RX-4090490,CDM,2500000003,HCPCS,0250,RC,25021-0184-87,NDC,,both,100,ML,54.10,35.16,,,,,,,,,,,,,
SCREW BNE PART THRD 5X110 MM PANTA,SUP-2609755,CDM,C1713,HCPCS,0278,RC,,,,both,,,1877.78,1220.56,,,,,,,,,,,,,
PLATE BONE 6 H INFERIOR DSTL CLAV LCK PERI-LOC,SUP-2349100,CDM,C1713,HCPCS,0278,RC,,,,both,,,1700.15,1105.10,,,,,,,,,,,,,
TWIST DRILL 22MM DIA X 105 M CYLINDRICAL SINGLE USE,SUP-2669018,CDM,2720000010,LOCAL,0272,RC,,,,both,,,390.74,253.98,,,,,,,,,,,,,
HC Radiation Treatment Delivery Level 1,PX-3337740200,CDM,77402,CPT,0333,RC,,,,outpatient,,,614.00,399.10,,,,,,,,,,,,,
HC Ot Iontophoresis per 15 Min|OP PT SERVICES|DOCUMENTATION ON FILE|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS,PX-4309703300,CDM,97033,CPT,0430,RC,,,GP|KX|CQ,outpatient,,,221.00,143.65,,,,,,,,,,,,,
LINER ACET SZ E OD50-52MM ID32MM 0DEGXLPE CONSTRN PRI REFLCT,SUP-2348069,CDM,C1776,CPT,0278,RC,,,,both,,,3622.78,2354.81,,,,,,,,,,,,,
GUIDEWIRE VASC VIPERWIRE ADV L 475 CM DIA 0.018 IN SS SIL,SUP-2418055,CDM,C1769,HCPCS,0272,RC,,,,both,,,596.60,387.79,,,,,,,,,,,,,
BLADE ENDOSCP SHAVER 360 DEG L 13 CM DIA 3 MM 5000 RPM STR,SUP-2901903,CDM,2720000010,LOCAL,0272,RC,,,,both,,,803.84,522.50,,,,,,,,,,,,,
GRAFT HUM TISS W40XL70MM THK1.5MM DECELLULARIZED DERM RM,SUP-2264662,CDM,Q4125,HCPCS,0636,RC,,,,both,,,8147.36,5295.78,,,,,,,,,,,,,
CATH CSF EXTERNAL DRAIN SYS NATUS EDS3 W/O CATH,SUP-2843356,CDM,2720000010,LOCAL,0272,RC,,,,both,,,599.90,389.93,,,,,,,,,,,,,
K WIRE FIX L150MM DIA1.6MM S STL TRCR TIP APTUS,SUP-2267989,CDM,C1713,HCPCS,0278,RC,,,,both,,,121.20,78.78,,,,,,,,,,,,,
MESH HERN W12XL14IN MFIL RESRB RECT W/ HYDRGEL BARR SCFLD,SUP-2125885,CDM,C1781,HCPCS,0278,RC,,,,both,,,49455.00,32145.75,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 1 CC CELLENTRA ADV,SUP-2866897,CDM,C1713,HCPCS,0278,RC,,,,both,,,1503.43,977.23,,,,,,,,,,,,,
CATHETER PA L 110 CM DIA 7 FR INTRO DIA 7 FR BALLOON DIA11 1.25CC,SUP-2894137,CDM,2720000010,LOCAL,0272,RC,,,,both,,,182.12,118.38,,,,,,,,,,,,,
BIT DRILL EXTRACTION SZ 4 MM SCREW DIA 7-7.5 MM STRL DISP,SUP-2913563,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2611.22,1697.29,,,,,,,,,,,,,
HC Retrograde,PX-3207442000,CDM,74420,CPT,0320,RC,,,,both,,,1188.00,772.20,,,,,,,,,,,,,
PLATE BONE W8XL36MM 2 H TI DYN COMPR FOR 2.7MM SCR,SUP-2191068,CDM,C1713,HCPCS,0278,RC,,,,both,,,1070.87,696.07,,,,,,,,,,,,,
LINER ACET CONSTRN C 32 MM PROV FRDM G7,SUP-2440185,CDM,C1776,CPT,0278,RC,,,,both,,,226.08,146.95,,,,,,,,,,,,,
CATHETER KIT PICC ANTIMICROBIAL/ANTITHROMBOGENIC,SUP-2655669,CDM,C1751,HCPCS,0278,RC,,,,both,,,626.74,407.38,,,,,,,,,,,,,
LISFRANC HEX DRIVER 2.5MM,SUP-2473956,CDM,2720000010,LOCAL,0272,RC,,,,both,,,725.34,471.47,,,,,,,,,,,,,
PIN EXT FIX L15MM DIA3MM S STL HALF UNILAT JET-X,SUP-2342883,CDM,C1713,HCPCS,0278,RC,,,,both,,,776.68,504.84,,,,,,,,,,,,,
SPLINT REST HND ADL R S DRBLUE BROAD,SUP-2165487,CDM,L3807,HCPCS,0272,RC,,,,both,,,123.25,80.11,,,,,,,,,,,,,
GUIDE SURG U SHP,SUP-2212872,CDM,C1713,HCPCS,0278,RC,,,,both,,,3058.36,1987.93,,,,,,,,,,,,,
FIXATOR SURG L200MM DSTL RAD S STL W/ SELF DRL SCHNZ C FBR,SUP-2188754,CDM,C1713,HCPCS,0278,RC,,,,both,,,1130.40,734.76,,,,,,,,,,,,,
VENLAFAXINE HCL 75 MG PO TABS,RX-12206,CDM,6370000000,HCPCS,0637,RC,68084-0856-11,NDC,,both,1,UN,4.30,2.79,,,,,,,,,,,,,
LENS INTOCU 6.5MM DIAM 13.25MM LEN 3DEG 5.2MM DEPTH + 10,SUP-2129469,CDM,V2632,HCPCS,0276,RC,,,,both,,,364.24,236.76,,,,,,,,,,,,,
DILATOR ENDOSCP 6 FRX180 CM 4X20 MM BILI CATH MAXPASS DISP,SUP-2312951,CDM,C1725,HCPCS,0272,RC,,,,both,,,692.24,449.96,,,,,,,,,,,,,
GENTAMICIN SULFATE 2 MG/ML IVPB (PED-NEO) >/= 50 ML,RX-4090290,CDM,J1580,HCPCS,0636,RC,00338-0511-41,NDC,,both,50,ML,54.10,35.16,,,,,,,,,,,,,
PLATE BONE LOCKING HOLEX16 RIGHT LATERAL PROXIMAL HUMERAL,SUP-2588189,CDM,C1713,HCPCS,0278,RC,,,,both,,,4636.56,3013.76,,,,,,,,,,,,,
LITHOTRIPTER SURG FIBER SUREFLEX REUSE RLLF910] LASER VENTURES],SUP-2263899,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3611.00,2347.15,,,,,,,,,,,,,
PIN FIX TRCR PT 1 END 0.125X9 IN THRD RND END NS STEINMANN,SUP-2791296,CDM,C1713,HCPCS,0278,RC,,,,both,,,89.58,58.23,,,,,,,,,,,,,
MESH HERN SQ 18X18 IN FULL RESRB FOR SFT TISS PHASIX,SUP-2855258,CDM,C1781,HCPCS,0278,RC,,,,both,,,82896.00,53882.40,,,,,,,,,,,,,
SPACER KNEE 3-10 4 MM DSTL SYS REV GUIDE ATTUNE,SUP-2454496,CDM,C1776,CPT,0278,RC,,,,both,,,1513.48,983.76,,,,,,,,,,,,,
BRACE ORTH SHELL ADJ 2XS AD 9-10 IN BILATERAL REUSE,SUP-2319320,CDM,L4350,HCPCS,0274,RC,,,,both,,,39.97,25.98,,,,,,,,,,,,,
SPLINT FT AD SM SZ 3-6 UNISX RT PREFABRICATED POST LEAF,SUP-2325043,CDM,L4398,HCPCS,0274,RC,,,,both,,,79.44,51.64,,,,,,,,,,,,,
GRAFT BNE INJ 12 CC INDUCTIVE PRO-STIM,SUP-2759445,CDM,C1713,HCPCS,0278,RC,,,,both,,,14682.64,9543.72,,,,,,,,,,,,,
SCREW BNE L16MM DIA3.5MM CORT CLAV TI LOK,SUP-2107527,CDM,C1713,HCPCS,0278,RC,,,,both,,,364.24,236.76,,,,,,,,,,,,,
ADMINISTRATION SET PMP PCA IV,SUP-2424817,CDM,C1713,HCPCS,0278,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
NAIL IM ELASTIC 2X440 MM TI GRN NS,SUP-2192725,CDM,C1713,HCPCS,0278,RC,,,,both,,,765.12,497.33,,,,,,,,,,,,,
STENT GRFT VASC AFX2 BODY L 100 MM DIA25 MM LIMB 40 MM 16 MM,SUP-2217669,CDM,C1768,CPT,0278,RC,,,,both,,,37441.36,24336.88,,,,,,,,,,,,,
EXPANDER BRST W14.6XH15.3CM P7.6CM 750CC SIL NACL SHELL RND,SUP-2300642,CDM,C1789,HCPCS,0278,RC,,,,both,,,4772.80,3102.32,,,,,,,,,,,,,
PLATE BNE LCK 3.5X78 MM LT MEDL PLNTR CLMN FUSION VA SS,SUP-2178433,CDM,C1713,HCPCS,0278,RC,,,,both,,,5578.49,3626.02,,,,,,,,,,,,,
CATHETER SPEC RETRV BELOW 15-18 MM EXTRACTOR PRO RX-S,SUP-2486268,CDM,2720000010,LOCAL,0272,RC,,,,both,,,468.96,304.82,,,,,,,,,,,,,
TPS RECIP PRECIS THN SAW BLDE 40.5X.38MM,SUP-2367391,CDM,C1713,HCPCS,0278,RC,,,,both,,,398.87,259.27,,,,,,,,,,,,,
SPLINT FT AD SM SZ 3-6 UNISX RT PREFABRICATED POST LEAF,SUP-2325043,CDM,L4398,HCPCS,0272,RC,,,,both,,,79.44,51.64,,,,,,,,,,,,,
PLATE SPNL 3 LEVEL 45 MM CERV,SUP-2415476,CDM,C1713,HCPCS,0278,RC,,,,both,,,6499.80,4224.87,,,,,,,,,,,,,
PLATE CRAN 60X60X40 MM PT SPEC IMPL PEEK,SUP-2860130,CDM,C1713,HCPCS,0278,RC,,,,both,,,27650.84,17973.05,,,,,,,,,,,,,
PHENOBARBITAL SODIUM 65 MG/ML IJ SOLN,RX-6224,CDM,J2560,HCPCS,0636,RC,42494-0415-25,NDC,,both,1,ML,120.50,78.32,,,,,,,,,,,,,
BRACE ORTH SHELL ADJ 2XS AD 9-10 IN BILATERAL REUSE,SUP-2319320,CDM,L4350,HCPCS,0272,RC,,,,both,,,39.97,25.98,,,,,,,,,,,,,
PLATE BNE TI LT NAVICULOCUNEIFORM FUSION NS UNITE,SUP-2897212,CDM,C1713,HCPCS,0278,RC,,,,both,,,4895.26,3181.92,,,,,,,,,,,,,
GRAFT STENT IL LIMB EXTN 4X14X100 MM 13 FR OVATION IX AAA,SUP-2427395,CDM,C1874,HCPCS,0278,RC,,,,both,,,13275.92,8629.35,,,,,,,,,,,,,
PLATE BONE L59MM 10 H SUBCONDYLAR FT TI FX FUS FOR 2.7MM SCR,SUP-2319674,CDM,C1713,HCPCS,0278,RC,,,,both,,,5934.60,3857.49,,,,,,,,,,,,,
COMPONENT TIB W22XH11MM OD45MM UHMWPE KNEE SLED W/O MTL PD,SUP-2397007,CDM,C1776,CPT,0278,RC,,,,both,,,6813.80,4428.97,,,,,,,,,,,,,
TELMISARTAN 40 MG PO TABS,RX-24335,CDM,6370000000,HCPCS,0637,RC,00597-0040-37,NDC,,both,1,UN,21.10,13.71,,,,,,,,,,,,,
HC So Everolimus Level,PX-3018016966,CDM,80169,CPT,0301,RC,,,,both,,,231.00,150.15,,,,,,,,,,,,,
ALLOGRAFT BNE 250-1000 MH 0.5 CC FD CORTICAL PWD ORAGRAFT,SUP-2741028,CDM,C1713,HCPCS,0278,RC,,,,both,,,155.90,101.33,,,,,,,,,,,,,
KIT RAILWAY ACCESS 7FR VBT SHEATHLESS,SUP-2424883,CDM,C1894,HCPCS,0272,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
PSN TIB HALF BLOCK SZ GH RL 5MM,SUP-2508726,CDM,C1776,CPT,0278,RC,,,,both,,,2763.20,1796.08,,,,,,,,,,,,,
GUIDE STAPLE WIRE/DRILL 2.6MM,SUP-2652942,CDM,2720000010,LOCAL,0272,RC,,,,both,,,879.20,571.48,,,,,,,,,,,,,
HEAD RAD H10MM DIA22MM ANT DST EL CO CHROM STR MOD BILAT,SUP-2404365,CDM,C1776,CPT,0278,RC,,,,both,,,6207.78,4035.06,,,,,,,,,,,,,
PROBE ELECSURG L ANGLED HK 5 MMX42 CM PREATTACH TBNG EPIX,SUP-2422366,CDM,2720000010,LOCAL,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
SUPPORT ANK L PUL ON WHT PROCARE,SUP-2196786,CDM,L1906,HCPCS,0272,RC,,,,both,,,6.28,4.08,,,,,,,,,,,,,
ELEVATOR SURG L95IN 13X22MM BLDE SPNL CRV HEX HNDL COBB,SUP-2160975,CDM,C1713,HCPCS,0278,RC,,,,both,,,369.52,240.19,,,,,,,,,,,,,
PLATE BNE L36MM 6 H BILAT TI STR RIG NONCOMPRESSION FOR,SUP-2191469,CDM,C1713,HCPCS,0278,RC,,,,both,,,1213.55,788.81,,,,,,,,,,,,,
CATHETER ART LN L8CM OD20GA .018IN GWIRE POLYETH SET SGL,SUP-2167834,CDM,C1751,HCPCS,0278,RC,,,,both,,,164.54,106.95,,,,,,,,,,,,,
CHEST TUBE PLEURAFLOW 32FR RT ANGLE ACT SYS WITH FLOWGLIDE,SUP-2655659,CDM,C1729,HCPCS,0272,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
BIT DRL FOR LAG SCR META-TAN TRIGEN,SUP-2347057,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2503.65,1627.37,,,,,,,,,,,,,
CATHETER DEL CARR L 152 CM LG COMP HYDRPHLC 1 LUMEN VAR PK10,SUP-2933998,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5636.30,3663.59,,,,,,,,,,,,,
SCREW 75 L100 THREAD LENGTH 16 CANNULATED,SUP-2586591,CDM,C1713,HCPCS,0278,RC,,,,both,,,1484.91,965.19,,,,,,,,,,,,,
NAIL IM HUM 8 MMX16 CM NS LTX DISP,SUP-2861166,CDM,C1713,HCPCS,0278,RC,,,,both,,,4133.31,2686.65,,,,,,,,,,,,,
SYSTEM FLD MGMT PRSS MON AND RESECT SYMPHION REUSE,SUP-2865688,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1252.86,814.36,,,,,,,,,,,,,
CATHETER HD DL 14.5X28 CM 45 CM SYMMETRICAL TIP PALINDROME,SUP-2283926,CDM,C1750,HCPCS,0278,RC,,,,both,,,1297.13,843.13,,,,,,,,,,,,,
SCREW BNE LCK 4.5X36 MM SILVERBACK PLATE,SUP-2434354,CDM,C1713,HCPCS,0278,RC,,,,both,,,802.27,521.48,,,,,,,,,,,,,
STAPLE CARTRIDGE LINE-REINFORCEMENT STRP VERIT,SUP-2130371,CDM,C1713,HCPCS,0278,RC,,,,both,,,521.99,339.29,,,,,,,,,,,,,
ALLOGRAFT DRML THICK 20X8 CM READY USE TSSUE MTRX ALLDRM,SUP-2496506,CDM,Q4116,HCPCS,0636,RC,,,,both,,,17335.94,11268.36,,,,,,,,,,,,,
MESH CRANIOMAXILLOFACIAL L W120XL120MM THK0.3MM MALL,SUP-2419461,CDM,C1713,HCPCS,0278,RC,,,,both,,,7374.79,4793.61,,,,,,,,,,,,,
TEMPLATE SKIN GRFT L 2 X W 2 IN OUTER SIL FLM INNR CROSS,SUP-2909177,CDM,Q4105,HCPCS,0636,RC,,,,both,,,8846.42,5750.17,,,,,,,,,,,,,
INSERT SYS 12 10DEG DURATN P4 28MM,SUP-2376146,CDM,C1776,CPT,0278,RC,,,,both,,,1440.32,936.21,,,,,,,,,,,,,
SET PRSS MON QUIK INT COMPARTMENTAL SYS,SUP-2366839,CDM,2720000010,LOCAL,0272,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
GUIDEWIRE ORTH DIA0.034IN W/ TRCR TIP THRD LSR MRK DISP FOR,SUP-2122475,CDM,C1769,HCPCS,0272,RC,,,,both,,,81.64,53.07,,,,,,,,,,,,,
SCREW SPNL STBL SYS CDH SPIRE,SUP-2292650,CDM,C1713,HCPCS,0278,RC,,,,both,,,10519.00,6837.35,,,,,,,,,,,,,
LOCK SMOOTH PEG 2.2X16MM STER,SUP-2587123,CDM,C1713,HCPCS,0278,RC,,,,both,,,293.59,190.83,,,,,,,,,,,,,
PLATE BNE L 83 MM SCREW DIA 3.5 MM 7 SHFT H SS 1/3 TUBLR VA ST,SUP-2913393,CDM,C1713,HCPCS,0278,RC,,,,both,,,1834.80,1192.62,,,,,,,,,,,,,
WASHER EXT FIX CPL HOFFMANN 49221007,SUP-2517241,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1582.56,1028.66,,,,,,,,,,,,,
VALVE VENT ULT SM L20MM DIA11MM THK4MM POLYPR SIL ELASTMR LO,SUP-2278340,CDM,C1889,HCPCS,0278,RC,,,,both,,,2064.61,1342.00,,,,,,,,,,,,,
SPACER SPNL LG 12 DEG 16 MM PEEK PERIMETER,SUP-2629068,CDM,C1889,HCPCS,0278,RC,,,,both,,,7457.50,4847.37,,,,,,,,,,,,,
GRAFT BNE PTTY 2.5 CC INJ DBM BEAST,SUP-2742042,CDM,C1713,HCPCS,0278,RC,,,,both,,,1683.83,1094.49,,,,,,,,,,,,,
PLATE BNE L77MM 3 H R POSTEROLATERAL DST FIBULAR S STL LOK,SUP-2177379,CDM,C1713,HCPCS,0278,RC,,,,both,,,1679.77,1091.85,,,,,,,,,,,,,
KIT CRICOTHYROIDOTOMY AD TB ID6MM EMGCY AIRWY ACCS VERES NDL,SUP-2351754,CDM,2720000010,LOCAL,0272,RC,,,,both,,,621.59,404.03,,,,,,,,,,,,,
SEED BRACHYTHERAPY CESIUM STRND LD IN NDL,SUP-2247309,CDM,C2642,HCPCS,0278,RC,,,,both,,,244.92,159.20,,,,,,,,,,,,,
CATHETER DRAINAGE TIGHT LOOP TIP 8 FRX25 CM EXODUS ARRY,SUP-2118771,CDM,C1729,HCPCS,0272,RC,,,,both,,,188.40,122.46,,,,,,,,,,,,,
CATHETER ANGIO L135CM OD5FR 5CM INFUS PERIPH PAT PULSE SPRY,SUP-2118497,CDM,C1757,HCPCS,0272,RC,,,,both,,,832.10,540.86,,,,,,,,,,,,,
SPHERE GLEN SM 40 MM SHLDR GLENOSPHERE RVS EXP EQUINOXE,SUP-2451437,CDM,C1776,CPT,0278,RC,,,,both,,,3611.00,2347.15,,,,,,,,,,,,,
PLATE BONE SYS UTIL STR 5 H IMP L33MM,SUP-2365886,CDM,C1713,HCPCS,0278,RC,,,,both,,,4929.80,3204.37,,,,,,,,,,,,,
VITRECTOMY PACK 23 GA PRB CASSETTE DRN BG ACCURUS TOT +,SUP-2424302,CDM,C1713,HCPCS,0278,RC,,,,both,,,1221.46,793.95,,,,,,,,,,,,,
RESERVOIR VENT L S STL BASE FOR 9.5MM BUR H HOLTER RICKHAM,SUP-2243789,CDM,C1729,HCPCS,0272,RC,,,,both,,,1007.94,655.16,,,,,,,,,,,,,
PLATE BNE L202MM 12 H ST R ANTEROMEDIAL DST TIB S STL VAR,SUP-2177683,CDM,C1713,HCPCS,0278,RC,,,,both,,,6538.77,4250.20,,,,,,,,,,,,,
KNEE IMMOB 20 IN SM,SUP-2195246,CDM,L1830,CPT,0272,RC,,,,both,,,36.71,23.86,,,,,,,,,,,,,
ROD ORTH RT PELV TI NS,SUP-2718778,CDM,C1713,HCPCS,0278,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
PLATE BNE L52MM THK3.7MM 4 H BILAT S STL STR LO PROF RIG,SUP-2177144,CDM,C1713,HCPCS,0278,RC,,,,both,,,1848.49,1201.52,,,,,,,,,,,,,
SCREW BONE CANN SYS 2.0MMX8MM SM QFX,SUP-2343082,CDM,C1713,HCPCS,0278,RC,,,,both,,,1324.92,861.20,,,,,,,,,,,,,
HC Bx Breast 1st Lesion Strtctc,PX-3611908100,CDM,19081,CPT,0361,RC,,,,inpatient,,,6190.00,4023.50,,,,,,,,,,,,,
PLATE BNE 2 HK 3.5/4X116 MM 7 HOLE SS,SUP-2569191,CDM,C1713,HCPCS,0278,RC,,,,both,,,493.92,321.05,,,,,,,,,,,,,
HC Nasal Bones Min 3 Views,PX-3207016000,CDM,70160,CPT,0320,RC,,,,inpatient,,,693.00,450.45,,,,,,,,,,,,,
SHUNT CSF PEDIATRIC 0-20CM H2O ADJUSTABLE 25CM H2O GRAVITATI,SUP-2821855,CDM,C1889,HCPCS,0278,RC,,,,both,,,9161.52,5954.99,,,,,,,,,,,,,
S-ROM*SCREWTROCHANTER52MM,SUP-2515617,CDM,C1713,HCPCS,0278,RC,,,,both,,,398.78,259.21,,,,,,,,,,,,,
COMPLETION REV FEM DISTL BLOCK,SUP-2513639,CDM,C1776,CPT,0278,RC,,,,both,,,6911.14,4492.24,,,,,,,,,,,,,
ANCHOR SUT OD6.5MM PLLA ABSRB TWO SZ 2 ULTRABRAID NDL STR,SUP-2341675,CDM,C1713,HCPCS,0278,RC,,,,both,,,1004.80,653.12,,,,,,,,,,,,,
COMPONENT FEM SZ 6 R KNEE CO CHROM NP CRUCE RET PRI,SUP-2345818,CDM,C1776,CPT,0278,RC,,,,both,,,9184.50,5969.92,,,,,,,,,,,,,
CAGE SPNL SM W8XH10MM 5DEG ANT THORLUM C FBR REINF POLYMER,SUP-2255159,CDM,C1889,HCPCS,0278,RC,,,,both,,,14294.85,9291.65,,,,,,,,,,,,,
HC Application of Paste Boot,PX-4502958000,CDM,29580,CPT,0450,RC,,,,both,,,357.00,232.05,,,,,,,,,,,,,
BRACE ORTH L ANK FT GTT PRSS RELF CNTRCT 1 SZ FIT MOST AD,SUP-2194768,CDM,L4396,HCPCS,0274,RC,,,,both,,,117.84,76.60,,,,,,,,,,,,,
MOLD CEM SPCR DIA75MM UNIV TIB SIL CRUCE SACRIFICING AGC,SUP-2408628,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1833.76,1191.94,,,,,,,,,,,,,
PLATE BNE L 167 MM SCREW DIA 3.5 MM13 H RT PROX LAT TIB STRL,SUP-2931305,CDM,C1713,HCPCS,0278,RC,,,,both,,,7056.05,4586.43,,,,,,,,,,,,,
LOW PROF LORDTC EXP IMPL 22X9X7X15 DEG 8 WAFERS W/ TI COAT,SUP-2354696,CDM,C1713,HCPCS,0278,RC,,,,both,,,17332.80,11266.32,,,,,,,,,,,,,
CATHETER DIAG 6FRX65MMX100CM 5MM 2-5-2MM ELECTRD SPC EP,SUP-2141296,CDM,C1730,HCPCS,0272,RC,,,,both,,,1522.90,989.88,,,,,,,,,,,,,
SET INTRO FLX L 38.5 CM OD 9 FR GUIDEWIRE 0.035 IN CKFLO VLV,SUP-2168825,CDM,C1894,HCPCS,0272,RC,,,,both,,,284.30,184.79,,,,,,,,,,,,,
RING EXT FIX DIA220 MM FT SPEEDWIRE,SUP-2898489,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4144.80,2694.12,,,,,,,,,,,,,
CROWN DENT 3 S STL SEC PRI M UP LT ANTR CUSPID PREFABRICATED,SUP-2238920,CDM,D6783,CPT,0278,RC,,,,both,,,22.33,14.51,,,,,,,,,,,,,
CONNECTOR SPNL L15MM OD5.5MM S STL THORLUM OFFSET REVERE,SUP-2230983,CDM,C1713,HCPCS,0278,RC,,,,both,,,920.02,598.01,,,,,,,,,,,,,
IMMOBILIZER KNEE L19IN ELAS STRP AND T BAR CUTAWAY,SUP-2194898,CDM,L1830,CPT,0272,RC,,,,both,,,53.63,34.86,,,,,,,,,,,,,
BIT DRL 2.9X150 MM STRL VERSANAIL,SUP-2606673,CDM,2720000010,LOCAL,0272,RC,,,,both,,,962.41,625.57,,,,,,,,,,,,,
CATHETER THROMCTMY CLOTTRIEVER BOLD L 80 CM DIA 3.9 MM,SUP-2751577,CDM,C1757,HCPCS,0272,RC,,,,both,,,17270.00,11225.50,,,,,,,,,,,,,
COMPONENT GLEN MOD HYBRID POST FOR COMPHSVE SHLDR SYS,SUP-2409121,CDM,C1776,CPT,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
HC So1 T-3 Uptake,PX-3018447967,CDM,84479,CPT,0301,RC,,,,both,,,26.00,16.90,,,,,,,,,,,,,
CANC SC 95MM FULLY TH 4.0,SUP-2819088,CDM,C1713,HCPCS,0278,RC,,,,both,,,273.97,178.08,,,,,,,,,,,,,
GUIDEWIRE FIX COR PTFE COAT 15MM J TI .035INX145CMP,SUP-2308258,CDM,C1769,HCPCS,0272,RC,,,,both,,,383.08,249.00,,,,,,,,,,,,,
GRAFT BNE DRILLABLE 10 CC VOID FILL STRL LTX,SUP-2865884,CDM,C1713,HCPCS,0278,RC,,,,both,,,10275.37,6678.99,,,,,,,,,,,,,
PLATE BNE L W10.1XL168MM THK3.5MM 12 H BILAT S STL STR LOK,SUP-2186220,CDM,C1713,HCPCS,0278,RC,,,,both,,,1682.73,1093.77,,,,,,,,,,,,,
CATHETER INFUSION SWAN NK 014 2.8/2.1 FRX130 CM FIX MAESTRO,SUP-2466817,CDM,C1887,HCPCS,0272,RC,,,,both,,,1711.30,1112.34,,,,,,,,,,,,,
PROBE ENDOSCP L135MM TIP DIA35MM DIR SERFAS ENERGY PROVIDE,SUP-2366832,CDM,C1713,HCPCS,0278,RC,,,,both,,,418.91,272.29,,,,,,,,,,,,,
IMPLANT SYNTH 82 X 105 MM THK 20 MM LG POLYETHYL LT TEMPORAL,SUP-2883601,CDM,C1713,HCPCS,0278,RC,,,,both,,,5317.09,3456.11,,,,,,,,,,,,,
PIPERACILLIN SOD-TAZOBACTAM SO 2.25 (2-0.25) G IV SOLR,RX-18304,CDM,J2543,HCPCS,0636,RC,00781-3110-90,NDC,,both,1,UN,54.10,35.16,,,,,,,,,,,,,
HC So Cyclosporine,PX-3018015866,CDM,80158,CPT,0301,RC,,,,inpatient,,,326.00,211.90,,,,,,,,,,,,,
"HC So Folic Acid, RBC",PX-3018274766,CDM,82747,CPT,0301,RC,,,,outpatient,,,108.00,70.20,,,,,,,,,,,,,
SCREW BNE L 16 MM DIA2.7 MM LCK VA NS LEOS,SUP-2931343,CDM,C1713,HCPCS,0278,RC,,,,both,,,464.41,301.87,,,,,,,,,,,,,
CRX IMPLANT 4.0X110MM,SUP-2841607,CDM,C1713,HCPCS,0278,RC,,,,both,,,11272.60,7327.19,,,,,,,,,,,,,
CATHETER ANGIOPLSTY ANGIOSCULPT L 137 CM 20 MM 3 MM,SUP-2353192,CDM,C1725,HCPCS,0272,RC,,,,both,,,2747.50,1785.87,,,,,,,,,,,,,
VALVE SHUNT L24MM 9-24CM H2O PRESSURE TITANIUM 2 CONNECTION,SUP-2821791,CDM,C1889,HCPCS,0278,RC,,,,both,,,5263.17,3421.06,,,,,,,,,,,,,
SLEEVE SURG OD4MM ID25MM THRD DRL SGL END FOR AO ASIF M EXT,SUP-2188759,CDM,C1713,HCPCS,0278,RC,,,,both,,,664.52,431.94,,,,,,,,,,,,,
CATHETER ANGIOPLSTY SAPPHIRE II PRO 1.25MM X 8MM,SUP-2858145,CDM,C1725,HCPCS,0272,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
SCREW INTFR 8MMX25MM GENESYS MATRYX,SUP-2166540,CDM,C1713,HCPCS,0278,RC,,,,both,,,1128.83,733.74,,,,,,,,,,,,,
KIT LD L60CM 1X8 COMP TRL SCRN FOR SACR NRV STIM VECTRIS,SUP-2284653,CDM,C1897,HCPCS,0278,RC,,,,both,,,2088.10,1357.26,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 50 CM DIA 8MM STR STD WALL SLDE GDE,SUP-2525463,CDM,C1768,CPT,0278,RC,,,,both,,,1968.43,1279.48,,,,,,,,,,,,,
HC So Hemosiderin Urine,PX-3018307066,CDM,83070,CPT,0301,RC,,,,both,,,71.00,46.15,,,,,,,,,,,,,
RIB PLATE 10MMX61MM,SUP-2841909,CDM,C1713,HCPCS,0278,RC,,,,both,,,3739.74,2430.83,,,,,,,,,,,,,
PLATE BONE L148MM 10 H LT ANTEROLATERAL MEDL DSTL TIB LCK,SUP-2348479,CDM,C1713,HCPCS,0278,RC,,,,both,,,17147.85,11146.10,,,,,,,,,,,,,
PLATE BNE L MINI 2X23 MM OBLQ ANGLED SS,SUP-2460213,CDM,C1713,HCPCS,0278,RC,,,,both,,,257.17,167.16,,,,,,,,,,,,,
SCREW SPNL MULTAXL 6.5X35 MM 6.35 MM PEDCL FOR ROD RED LEG,SUP-2288997,CDM,C1713,HCPCS,0278,RC,,,,both,,,2088.10,1357.26,,,,,,,,,,,,,
OXYCODONE HCL 15 MG PO TABS,RX-28899,CDM,6370000000,HCPCS,0637,RC,00406-8515-23,NDC,,both,1,UN,4.90,3.18,,,,,,,,,,,,,
SHELL ACET 3 HOLE 52 MM HIP LOGICAL G-SERIES,SUP-2322427,CDM,C1776,CPT,0278,RC,,,,both,,,3579.60,2326.74,,,,,,,,,,,,,
RIB PLATE DRILL 10MMX2.7MM,SUP-2841929,CDM,2720000010,LOCAL,0272,RC,,,,both,,,756.74,491.88,,,,,,,,,,,,,
DOXORUBICIN HCL 2 MG/ML IV SOLN,RX-2616,CDM,J9000,HCPCS,0636,RC,45963-0733-57,NDC,,both,10,ML,57.60,37.44,,,,,,,,,,,,,
GRAFT HUM TISS 1ML SYR PASTE IMPL BONE DBM FRZN DEMIN,SUP-2293735,CDM,C1713,HCPCS,0278,RC,,,,both,,,504.44,327.89,,,,,,,,,,,,,
PLATE BNE L92MM 4 H R LAT DST FIBULAR S STL VAR ANG LOK,SUP-2177714,CDM,C1713,HCPCS,0278,RC,,,,both,,,2302.37,1496.54,,,,,,,,,,,,,
LEAD NERVE STIM 41 MM MRI INTERSTIM SURESCAN,SUP-2641995,CDM,C1778,HCPCS,0278,RC,,,,both,,,11429.60,7429.24,,,,,,,,,,,,,
ALLOGRAFT GRAFTLINK: D=7.5 L=68 MM,SUP-2815811,CDM,C1762,CPT,0278,RC,,,,both,,,6963.26,4526.12,,,,,,,,,,,,,
HC Hysterosalpingogram,PX-3207474000,CDM,74740,CPT,0320,RC,,,,outpatient,,,686.00,445.90,,,,,,,,,,,,,
HC Pt Vasopneumatic Device Therapy,PX-4209701600,CDM,97016,CPT,0420,RC,,,,inpatient,,,206.00,133.90,,,,,,,,,,,,,
GUIDEWIRE VASC STR 5 CM 0.014 INX80 CM FLX ILLUMAX NIT-VU,SUP-2117336,CDM,C1769,HCPCS,0272,RC,,,,both,,,176.56,114.76,,,,,,,,,,,,,
PLATE BONE L180MM 6 H LT PROX FEM LCK FOR 4.5MM SCR PERI-LOC,SUP-2351169,CDM,C1713,HCPCS,0278,RC,,,,both,,,11665.41,7582.52,,,,,,,,,,,,,
SCREW BONE L130MM OD8MM STD S STL CORT ST SELF DRL CANN,SUP-2343422,CDM,C1713,HCPCS,0278,RC,,,,both,,,1760.47,1144.31,,,,,,,,,,,,,
TRIAL ANKLE JOINT 7MM SUBTALAR COMPONENT TWISTED,SUP-2878144,CDM,C1776,CPT,0278,RC,,,,both,,,5338.00,3469.70,,,,,,,,,,,,,
PIN DISTRACTOR 16 MM TI STRL 0460002902S,SUP-2591709,CDM,C1713,HCPCS,0278,RC,,,,both,,,219.80,142.87,,,,,,,,,,,,,
HEAD RAD DIA22MM RT ELBW CO CHROM ANAT,SUP-2107856,CDM,C1776,CPT,0278,RC,,,,both,,,8437.18,5484.17,,,,,,,,,,,,,
SCREW BNE L18MM DIA4.5MM COMPR FOR GLEN BASEPLT,SUP-2388920,CDM,C1713,HCPCS,0278,RC,,,,both,,,265.64,172.67,,,,,,,,,,,,,
PLATE SPNL L45MM 6 H LEV 2 ANT BILAT CERV TI LOK LO PROF,SUP-2254588,CDM,C1713,HCPCS,0278,RC,,,,both,,,4473.81,2907.98,,,,,,,,,,,,,
KIT SURG PWR HI SPD HNDPC SAG SAW STRL LF DISP FJ-2000,SUP-2881118,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3868.48,2514.51,,,,,,,,,,,,,
LOCATOR PINPT BONE PELV,SUP-2141756,CDM,C1713,HCPCS,0278,RC,,,,both,,,211.95,137.77,,,,,,,,,,,,,
ELECTRODE ENDO 500ML NRML NACL COBLATION PROCISE EZ VW,SUP-2342049,CDM,C1713,HCPCS,0278,RC,,,,both,,,822.68,534.74,,,,,,,,,,,,,
INSERT TIB SM DIA5MM KNEE S STL FRAG AXSOS,SUP-2371465,CDM,C1713,HCPCS,0278,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
TUBE VENT BVL 1.14 MM ARMSTR V GRMMT PC COAT 70140396,SUP-2638108,CDM,2720000010,LOCAL,0272,RC,,,,both,,,42.86,27.86,,,,,,,,,,,,,
INSERT TIB SZ 7 8 THK15MM STD L KNEE POLYETH PRI NEUT,SUP-2350485,CDM,C1776,CPT,0278,RC,,,,both,,,5353.70,3479.90,,,,,,,,,,,,,
GUIDEWIRE ORTH FLX TIP 2.5X620 MM CALIB,SUP-2563948,CDM,C1769,HCPCS,0272,RC,,,,both,,,267.78,174.06,,,,,,,,,,,,,
PAPILLOTOME ENDO CATH L200CM OD5FR 0.035IN CUT WIRE L7MM,SUP-2169183,CDM,C1713,HCPCS,0278,RC,,,,both,,,637.42,414.32,,,,,,,,,,,,,
GRAFT VASC GORTX L 70 CM DIA 8 MM EPTFE STR TW N RING STRL,SUP-2396714,CDM,C1768,CPT,0278,RC,,,,both,,,2179.16,1416.45,,,,,,,,,,,,,
TIP CONICAL SYSTEM GRFT DEL NSTAFILL,SUP-2865330,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1347.06,875.59,,,,,,,,,,,,,
STAPLE SPNL WASHER FOR ANTR STPL SYS ARI,SUP-2538505,CDM,C1713,HCPCS,0278,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
BIT DRL CINCHLOCK FLX DISP,SUP-2663980,CDM,2720000010,LOCAL,0272,RC,,,,both,,,800.98,520.64,,,,,,,,,,,,,
CATHETER PTCA L135CM BLLN L20MM DIA6MM SHTH 6FR 0.018IN,SUP-2148517,CDM,C1725,HCPCS,0272,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
BIT DRL L85MM DIA2MM JCBS CHK REUSE,SUP-2410945,CDM,2720000010,LOCAL,0272,RC,,,,both,,,496.78,322.91,,,,,,,,,,,,,
SIZER PARTIAL ALTO DORNHOFFER,SUP-2232511,CDM,L8613,CPT,0278,RC,,,,both,,,1302.97,846.93,,,,,,,,,,,,,
HC So1 Jak2 Gene Analysis,PX-3108127067,CDM,81270,CPT,0310,RC,,,,both,,,201.00,130.65,,,,,,,,,,,,,
LEADWIRE SPNL W/ CLP,SUP-2415718,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
SCREW BONE L40MM DIA5.7MM CANC S STL SELF DRL ST CANN LCK,SUP-2348911,CDM,C1713,HCPCS,0278,RC,,,,both,,,2311.76,1502.64,,,,,,,,,,,,,
CATHETER INTVASC ULTRASOUND C7 DRAGONFLY L 135 CM DIA2.7 FR,SUP-2356657,CDM,C1753,HCPCS,0278,RC,,,,both,,,2747.50,1785.87,,,,,,,,,,,,,
STENT PERIPH L22MM DIA4.5MM CATH L220CM NO TIP INTCRAN,SUP-2249133,CDM,C1874,HCPCS,0278,RC,,,,both,,,21804.16,14172.70,,,,,,,,,,,,,
SUPPORT ORTHOT MTCRPL HND ADJ FIT PREFABRICATED,SUP-2435778,CDM,L3917,HCPCS,0274,RC,,,,both,,,272.08,176.85,,,,,,,,,,,,,
PLATE BNE 3 HOLE SINGLE LISFRANC STRATUM,SUP-2475552,CDM,C1713,HCPCS,0278,RC,,,,both,,,4631.50,3010.47,,,,,,,,,,,,,
PLATE BONE SM W11XL56MM THK1.2MM 4X4 H RT DSTL S STL T SHP,SUP-2343783,CDM,C1713,HCPCS,0278,RC,,,,both,,,1072.12,696.88,,,,,,,,,,,,,
GRAFT TISSUE WHOLE FEMORAL CONDYLE LEFT,SUP-2880218,CDM,C1762,CPT,0278,RC,,,,both,,,67039.00,43575.35,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL PEEK SD800.519,SUP-2860200,CDM,C1713,HCPCS,0278,RC,,,,both,,,31075.32,20198.96,,,,,,,,,,,,,
BAR EXTERNAL FIXATION L500MM DIA11MM XTRAFIX SYSTEM,SUP-2478417,CDM,2720000010,LOCAL,0272,RC,,,,both,,,817.62,531.45,,,,,,,,,,,,,
SPHERE EMB ONCOZENE DIA100 UM 2 ML HYDRGEL POLYZENE MIC WHT,SUP-2139574,CDM,C1889,HCPCS,0278,RC,,,,both,,,9843.90,6398.53,,,,,,,,,,,,,
LENS IOL BCNVX 22+ DIOPT 12.5 MM PMMA PLEXIGLAS,SUP-2129725,CDM,C1780,HCPCS,0276,RC,,,,both,,,266.90,173.48,,,,,,,,,,,,,
ANCHOR STRE 2.9MM DIA JGGRLC SOFT TSSUE NON BBSRBLE,SUP-2589046,CDM,C1713,HCPCS,0278,RC,,,,both,,,1783.02,1158.96,,,,,,,,,,,,,
ALLOGRAFT BNE LORDTC 6 DEG 30X16 MM FD FEE CORTICAL CRESCENT,SUP-2743434,CDM,C1713,HCPCS,0278,RC,,,,both,,,17295.12,11241.83,,,,,,,,,,,,,
BUR SURG DIA95MM CONIC W QUIK CPL,SUP-2188267,CDM,C1713,HCPCS,0278,RC,,,,both,,,947.18,615.67,,,,,,,,,,,,,
PLATE 1ST MTCRPL 1.5MM LAT RT STRL VAL,SUP-2546083,CDM,C1713,HCPCS,0278,RC,,,,both,,,2023.20,1315.08,,,,,,,,,,,,,
PLATE FIXATION BOX STERNAL 4 HOLES,SUP-2719527,CDM,C1713,HCPCS,0278,RC,,,,both,,,1004.80,653.12,,,,,,,,,,,,,
IMPLANT BRST W11.5-11.1XH9.5-9.4CM P5.1-6.3CM 275-330CC,SUP-2300536,CDM,C1789,HCPCS,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
PLATE BNE FEM 3.5X182 MM RT DSTL PROX 5 HOLE NS VA-LCP,SUP-2757674,CDM,C1713,HCPCS,0278,RC,,,,both,,,4029.94,2619.46,,,,,,,,,,,,,
GUIDEWIRE ORTH FLUT 2.8X300 MM,SUP-2657803,CDM,C1769,HCPCS,0272,RC,,,,both,,,78.50,51.02,,,,,,,,,,,,,
SUPPORT ORTHOT LOWER EXTREMITY PARASPINAL UPR CUST THOR CTRL,SUP-2435692,CDM,L2670,HCPCS,0274,RC,,,,both,,,451.56,293.51,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL PEEK SD800.548,SUP-2860229,CDM,C1713,HCPCS,0278,RC,,,,both,,,54818.12,35631.78,,,,,,,,,,,,,
SCREW BNE L 105 MM DIA 3.5 MM TI LCK T15 STARDRV STRL V,SUP-2905835,CDM,C1713,HCPCS,0278,RC,,,,both,,,1294.06,841.14,,,,,,,,,,,,,
BONE CEMENT SURG 3 CC HA CRAN SELF SET PREFIL DBL BRL SYR,SUP-2883510,CDM,C1713,HCPCS,0278,RC,,,,both,,,4165.71,2707.71,,,,,,,,,,,,,
KNEE WEDGE UPCHARGE AUGMENT ZIMMER,SUP-2501337,CDM,C1776,CPT,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
GUIDEWIRE ENDOVASC L260CM DIA0.025IN TIP L3CM STD REG PERIPH,SUP-2385564,CDM,C1769,HCPCS,0272,RC,,,,both,,,207.77,135.05,,,,,,,,,,,,,
NEEDLE ENDOSCP SPNL 0 DEG 18 MMX25 CM NEURO W/O BITE,SUP-2768605,CDM,2720000010,LOCAL,0272,RC,,,,both,,,491.60,319.54,,,,,,,,,,,,,
CONNECTOR VLV SELF ADJUSTING CSF PRESSURE SIL ANTISIPHON,SUP-2243846,CDM,C1729,HCPCS,0272,RC,,,,both,,,9115.48,5925.06,,,,,,,,,,,,,
LIFT HEEL SM W2IN BRN FAB WDG 3 LAYR ORTHOT FT W/O CLSR,SUP-2325935,CDM,L3334,HCPCS,0272,RC,,,,both,,,18.34,11.92,,,,,,,,,,,,,
IMPLANT TOT KNEE FLX TIB PAT GENDER,SUP-2212268,CDM,C1776,CPT,0278,RC,,,,both,,,15112.82,9823.33,,,,,,,,,,,,,
ANCHOR SUTURE 2 NDL THRD TWINFIX,SUP-2848585,CDM,C1713,HCPCS,0278,RC,,,,both,,,1155.11,750.82,,,,,,,,,,,,,
PACK NEUROSURGICAL SHTH L 75 X W 13.5 MM MYRIAD HNDPC L 13,SUP-2930203,CDM,2720000010,LOCAL,0272,RC,,,,both,,,22436.93,14584.00,,,,,,,,,,,,,
GUIDEWIRE VASC CHIKAI BLK 14 L 200 CM DIA 0.014 IN,SUP-2123824,CDM,C1769,HCPCS,0272,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
GRAFT HUM TISS W9XH6XL6MM PARA SPNL ALLGRFT FRZ DRY,SUP-2306947,CDM,C1713,HCPCS,0278,RC,,,,both,,,2747.50,1785.87,,,,,,,,,,,,,
LOSARTAN POTASSIUM 50 MG PO TABS,RX-14824,CDM,6370000000,HCPCS,0637,RC,65862-0202-90,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PROBE ENDOSCP ARTHSCP CRV LIGMNT CHSL,SUP-2314079,CDM,C1713,HCPCS,0278,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
FIXATOR WRST DYN PENNIG II,SUP-2316046,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4760.81,3094.53,,,,,,,,,,,,,
SCREW DISTRCTN 14MM TI STRL ULTRA LF,SUP-2475863,CDM,C1713,HCPCS,0278,RC,,,,both,,,122.87,79.87,,,,,,,,,,,,,
FIXATION PIN,SUP-2397042,CDM,C1713,HCPCS,0278,RC,,,,both,,,197.82,128.58,,,,,,,,,,,,,
CUP ACET OD40MM ID22MM ALL POLYPR XLPE CEM REFLCT,SUP-2345690,CDM,C1776,CPT,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
IMPLANT OTO L4MM PIST DIA06MM NIT FLROPLAS SMRT,SUP-2313866,CDM,L8613,CPT,0278,RC,,,,both,,,861.18,559.77,,,,,,,,,,,,,
GRAFT TISS 2CMX10CM CORMATRIX ECM VASC CAR REP,SUP-2172042,CDM,C1768,CPT,0278,RC,,,,both,,,1497.78,973.56,,,,,,,,,,,,,
HC So Human Epididymis Prot 4 (He4),PX-3028630566,CDM,86305,CPT,0302,RC,,,,both,,,477.00,310.05,,,,,,,,,,,,,
PLATE CRANIOFACIAL W1.5MM 7X7 H TI MESH NONCOMPRESSION SH,SUP-2365887,CDM,C1713,HCPCS,0278,RC,,,,both,,,3644.66,2369.03,,,,,,,,,,,,,
PLATE BONE W15XL15MM 4 H TI CRAN BX SHP RIG FOR 2MM SCR,SUP-2191323,CDM,C1713,HCPCS,0278,RC,,,,both,,,712.78,463.31,,,,,,,,,,,,,
RELOAD STPL L45MM EXTRA THCK TISS BLK ARTC INTELLIGENCE FOR,SUP-2283354,CDM,2720000010,LOCAL,0272,RC,,,,both,,,814.39,529.35,,,,,,,,,,,,,
SHUNT PERI W O RESVR PROGRAMMABLE 7FR 120CM M SM,SUP-2278388,CDM,C1889,HCPCS,0278,RC,,,,both,,,12476.13,8109.48,,,,,,,,,,,,,
PLATE BNE THK1.5MM 6 H CRANIOMAXILLOFACIAL ORAL SIL TI STR,SUP-2181769,CDM,C1713,HCPCS,0278,RC,,,,both,,,2661.78,1730.16,,,,,,,,,,,,,
KIT POS CUSH FOAM HEAL PROTCT THGH STRP AND SEAT CVR,SUP-2306276,CDM,C1713,HCPCS,0278,RC,,,,both,,,568.34,369.42,,,,,,,,,,,,,
HC So Myoglobin,PX-3018387466,CDM,83874,CPT,0301,RC,,,,outpatient,,,320.00,208.00,,,,,,,,,,,,,
COMPONENT PATELLAR 3 PEG 26 MM DOMED ROUNDED EXP VIT E,SUP-2390477,CDM,C1776,CPT,0278,RC,,,,both,,,1695.60,1102.14,,,,,,,,,,,,,
KIT RETRIEVAL SINGLE LOOP SNARE,SUP-2715944,CDM,C1773,HCPCS,0272,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
PLATE CRAN 120X100X40 MM PT SPEC IMPL PEEK,SUP-2860146,CDM,C1713,HCPCS,0278,RC,,,,both,,,36717.59,23866.43,,,,,,,,,,,,,
GRAFT VASC L80CM DIA8MM PTFE CBAS HEP SURF THN WALLED REM,SUP-2395824,CDM,C1768,CPT,0278,RC,,,,both,,,8983.54,5839.30,,,,,,,,,,,,,
PLATE BONE L26MM 10 H TI NAR HYBRID COMPR FOR 4.5MM SCR ALPS,SUP-2413747,CDM,C1713,HCPCS,0278,RC,,,,both,,,930.79,605.01,,,,,,,,,,,,,
HC Assay of Blood/Uric Acid,PX-3018455000,CDM,84550,CPT,0301,RC,,,,both,,,140.00,91.00,,,,,,,,,,,,,
CUP ACET OD60MM ID52MM THK4MM FULL POR HIP REDAPT,SUP-2345479,CDM,C1776,CPT,0278,RC,,,,both,,,5777.60,3755.44,,,,,,,,,,,,,
HC Myelogram 2 or More Regions,PX-3616230500,CDM,62305,CPT,0361,RC,,,,inpatient,,,3707.00,2409.55,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH FLX L 30 MM DIA16 MM SS POLYPRO,SUP-2170449,CDM,C1713,HCPCS,0278,RC,,,,both,,,5752.48,3739.11,,,,,,,,,,,,,
FONDAPARINUX SODIUM 2.5 MG/0.5ML SC SOLN,RX-32215,CDM,J1652,HCPCS,0636,RC,67457-0582-10,NDC,,both,0.5,ML,143.00,92.95,,,,,,,,,,,,,
SET INTRO PEELWY ECHOTIP L 9 CM DIA 5.5 FR GUIDEWIRE L 65 CM,SUP-2168658,CDM,C1894,HCPCS,0272,RC,,,,both,,,141.87,92.22,,,,,,,,,,,,,
BIT DRILL DIA4MM WITH STOP WRIST FREEDOM ARTHROPLASTY SYSTEM,SUP-2586702,CDM,2720000010,LOCAL,0272,RC,,,,both,,,859.92,558.95,,,,,,,,,,,,,
SCREW INTFR L23MM DIA10MM BIOCRYL RAPIDE ABSRB MILAGRO,SUP-2249524,CDM,C1713,HCPCS,0278,RC,,,,both,,,1136.68,738.84,,,,,,,,,,,,,
LITHIUM CARBONATE ER 300 MG PO TBCR,RX-10454,CDM,6370000000,HCPCS,0637,RC,68084-0640-11,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
SCREW BONE L4MM DIA1.2MM SELF DRL LO PROF HD HT AXS 5PK,SUP-2363852,CDM,C1713,HCPCS,0278,RC,,,,both,,,346.62,225.30,,,,,,,,,,,,,
CATHETER CV BEDSIDE SET 018 4 FRX60 CM DL NIT TURBO-JECT,SUP-2759823,CDM,C1751,HCPCS,0278,RC,,,,both,,,371.40,241.41,,,,,,,,,,,,,
"HC Pt Therapeutic Exercise,Ea 15 Min|OP OCCUPATIONAL THERAPY SERV|DOCUMENTATION ON FILE|SERVICES PROVIDED IN WHOLE OR IN PARTY BY AN OTA FOR MEDICARE PATIENTS",PX-4209711000,CDM,97110,CPT,0420,RC,,,GO|KX|CO,both,,,195.00,126.75,,,,,,,,,,,,,
SCREW BNE 30MM CTRL MOD,SUP-2123399,CDM,C1713,HCPCS,0278,RC,,,,both,,,832.10,540.86,,,,,,,,,,,,,
PLATE BONE LOCKING HOLEX3 T SHAPED LEFT DORSAL DISTAL,SUP-2721719,CDM,C1713,HCPCS,0278,RC,,,,both,,,2813.75,1828.94,,,,,,,,,,,,,
SHEATH IVC FILTER REMOVAL LASER 16F CAVACLEAR,SUP-2850092,CDM,C1603,HCPCS,0272,RC,,,,both,,,15684.30,10194.79,,,,,,,,,,,,,
IMPL BUTTON DX STAINLESS STEEL,SUP-2718030,CDM,C1713,HCPCS,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
MICROSPHERE EMB EMBOSPHERE DIA 500-700 UM 2 CC 20 CC SYR GRA,SUP-2660775,CDM,C1889,HCPCS,0278,RC,,,,both,,,172.70,112.25,,,,,,,,,,,,,
SET INTRO PEELWY ECHOTIP L 9 CM DIA 4 FR GUIDEWIRE L 65 CM,SUP-2168657,CDM,C1892,HCPCS,0272,RC,,,,both,,,146.83,95.44,,,,,,,,,,,,,
ALLOGRAFT BNE DURA MATER LG ETO,SUP-2867003,CDM,C1763,HCPCS,0278,RC,,,,both,,,5602.07,3641.35,,,,,,,,,,,,,
GRAFT BNE 5 CC DEMINERALIZED CORTICAL SUBSTITUTE FIBERS FD,SUP-2931240,CDM,C1762,CPT,0278,RC,,,,both,,,3428.66,2228.63,,,,,,,,,,,,,
GRAFT BNE L150-200XW6MM THICKNESS 3-15MM CORT TIB FRZN,SUP-2307371,CDM,C1713,HCPCS,0278,RC,,,,both,,,4370.57,2840.87,,,,,,,,,,,,,
PLATE BNE L 56 MM SCREW DIA2.4 MM 6 H SS HK NS V,SUP-2905706,CDM,C1713,HCPCS,0278,RC,,,,both,,,2992.04,1944.83,,,,,,,,,,,,,
ANCHOR SUT 30MM LOOP VERSITOMIC G LOK,SUP-2366527,CDM,C1713,HCPCS,0278,RC,,,,both,,,1694.19,1101.22,,,,,,,,,,,,,
NAIL IM FEM 8X300 MM RT GREATER TROCHANTERIC STRL T2 ALPHA,SUP-2457008,CDM,C1713,HCPCS,0278,RC,,,,both,,,10070.42,6545.77,,,,,,,,,,,,,
STAPLE POD CLOVER 4 LEG 8 MMX10 MMX12.5 MM,SUP-2137802,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6123.00,3979.95,,,,,,,,,,,,,
GRAFT VASC PERIPH BYPS STR THN WALL N RING EPTFE 7MM DIA,SUP-2127826,CDM,C1768,CPT,0278,RC,,,,both,,,2272.86,1477.36,,,,,,,,,,,,,
SCLERA FRESH,SUP-2855185,CDM,C1762,CPT,0278,RC,,,,both,,,1350.20,877.63,,,,,,,,,,,,,
BRACE KNEE HNG WRP SM,SUP-2276702,CDM,L1820,HCPCS,0272,RC,,,,both,,,56.05,36.43,,,,,,,,,,,,,
PLATE BNE 28 PLTTM 4-HOLE STR LOK 1.5MM,SUP-2321440,CDM,C1713,HCPCS,0278,RC,,,,both,,,4788.50,3112.52,,,,,,,,,,,,,
FLAT WASHER 8.0MM STERILE,SUP-2586885,CDM,C1713,HCPCS,0278,RC,,,,both,,,140.58,91.38,,,,,,,,,,,,,
BIT DRILL 2PK 3.2MM,SUP-2890890,CDM,C1776,CPT,0278,RC,,,,both,,,292.02,189.81,,,,,,,,,,,,,
BURR ACORN FLUTED 9.2MM SHD9ACG1,SUP-2843322,CDM,2720000010,LOCAL,0272,RC,,,,both,,,461.71,300.11,,,,,,,,,,,,,
ELECTRODE CORTICAL 1 X 10 KT STRL DISP EVO,SUP-2934927,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2973.58,1932.83,,,,,,,,,,,,,
ANCHOR VERSALOOP 2.5MM DL TAPE,SUP-2756503,CDM,C1713,HCPCS,0278,RC,,,,both,,,1840.04,1196.03,,,,,,,,,,,,,
BELATACEPT 250 MG IV SOLR,RX-109186,CDM,J0485,HCPCS,0636,RC,00003-0371-13,NDC,,both,1,UN,2861.20,1859.78,,,,,,,,,,,,,
PROBE SET W/DRAPE,SUP-2880916,CDM,2720000010,LOCAL,0272,RC,,,,both,,,887.05,576.58,,,,,,,,,,,,,
PLATE TIB MED DIST TI AXSOS 3 6HL 123MM,SUP-2704972,CDM,C1713,HCPCS,0278,RC,,,,both,,,6666.53,4333.24,,,,,,,,,,,,,
ALLOGRAFT BNE 15 CC DBM BONUS TRIAD,SUP-2607052,CDM,C1889,HCPCS,0278,RC,,,,both,,,15307.50,9949.87,,,,,,,,,,,,,
IMPLANT BIO TISS W2XL4CM PORCINE DERM MTRX RECON THINNER,SUP-2388570,CDM,C1713,HCPCS,0278,RC,,,,both,,,3800.97,2470.63,,,,,,,,,,,,,
CAGE SPNL H46-80MM OD22MM 8DEG TI THORLUM INTBDY FUS LORDTC,SUP-2390799,CDM,C1889,HCPCS,0278,RC,,,,both,,,16956.00,11021.40,,,,,,,,,,,,,
BAR RETRACTOR JANETTA SINGLE RND LUMBARTRAK RUGGLES-REDMOND,SUP-2472807,CDM,2720000010,LOCAL,0272,RC,,,,both,,,717.46,466.35,,,,,,,,,,,,,
PLATE BNE L301MM 20 H ST R MED PROX TIB S STL LOK COMPR LO,SUP-2185663,CDM,C1713,HCPCS,0278,RC,,,,both,,,5045.23,3279.40,,,,,,,,,,,,,
"HC So Oligoclonal Bands,CSF",PX-3018391666,CDM,83916,CPT,0301,RC,,,,inpatient,,,59.00,38.35,,,,,,,,,,,,,
CATHETER HEMO DYLS OR HD L20CM 13.5FR AD ADMIN ACUTE COMP,SUP-2126509,CDM,C1752,HCPCS,0278,RC,,,,both,,,297.04,193.08,,,,,,,,,,,,,
SCREW BNE L65MM DIA4.5MM THRD L30MM HD DIA8MM MALL S STL,SUP-2184557,CDM,C1713,HCPCS,0278,RC,,,,both,,,69.87,45.42,,,,,,,,,,,,,
HC Peripheral Block - Ilioinguinal/Iliohypogastric,PX-3606442500,CDM,64425,CPT,0360,RC,,,,both,,,2230.00,1449.50,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY NYL FIX SPEC DECAPOLAR DX STRL,SUP-2727180,CDM,C1730,HCPCS,0272,RC,,,,both,,,1237.16,804.15,,,,,,,,,,,,,
GRAFT FIB SHFT FRZ DRY ALLGRFT 50 75MM,SUP-2335589,CDM,C1713,HCPCS,0278,RC,,,,both,,,1801.58,1171.03,,,,,,,,,,,,,
ENOXAPARIN SODIUM 150 MG/ML IJ SOSY,RX-157666,CDM,J1650,HCPCS,0636,RC,63323-0589-21,NDC,,both,1,ML,80.30,52.19,,,,,,,,,,,,,
GUIDEWIRE VASC L 60 CM DIA 0.032 IN CRV RAD 2.5 MM HVY DBL,SUP-2760034,CDM,C1769,HCPCS,0272,RC,,,,both,,,83.93,54.55,,,,,,,,,,,,,
PASSER SUT NIT PLAS SGL DISP BIPASS,SUP-2212805,CDM,C1713,HCPCS,0278,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
INTRODUCER ORTH SHT 10 GA W/ BVL TIP STYL STABILIT,SUP-2491096,CDM,2720000010,LOCAL,0272,RC,,,,both,,,651.80,423.67,,,,,,,,,,,,,
KIT WRIST MEDIUM FOR SPIDER 2,SUP-2753244,CDM,2720000010,LOCAL,0272,RC,,,,both,,,227.52,147.89,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9% INTERMITTENT INFUSION|DISCARDED DRUG NOT ADMINISTE,RX-40840102,CDM,J7050,HCPCS,0258,RC,00264-7800-20,NDC,JW,both,250,ML,23.40,15.21,,,,,,,,,,,,,
BLADE 50X14MM MIC VLT BLNT ALUM,SUP-2161649,CDM,2720000010,LOCAL,0272,RC,,,,both,,,708.86,460.76,,,,,,,,,,,,,
HC MRI-Pelvis W Contrast,PX-6147219600,CDM,72196,CPT,0614,RC,,,,outpatient,,,4626.00,3006.90,,,,,,,,,,,,,
STYLET 50MM SGL STP,SUP-2114059,CDM,2720000010,LOCAL,0272,RC,,,,both,,,690.80,449.02,,,,,,,,,,,,,
STENT PERIPH LIFESTENT L 150 MM DIA 7 MM CATH L 80 CM DIA 6,SUP-2128195,CDM,C1876,HCPCS,0278,RC,,,,both,,,10032.30,6520.99,,,,,,,,,,,,,
GUIDEWIRE ORTH L20IN TRCR TIP POLARUS,SUP-2106881,CDM,C1769,HCPCS,0272,RC,,,,both,,,332.84,216.35,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9% INTERMITTENT INFUSION|DISCARDED DRUG NOT ADMINISTE,RX-40840102,CDM,2580000003,HCPCS,0258,RC,00264-7800-10,NDC,JW,both,250,ML,14.90,9.68,,,,,,,,,,,,,
ANCHOR SFT TISS REV CRV FOR MENIS REP SYS ULT FAST-FIX,SUP-2341775,CDM,C1713,HCPCS,0278,RC,,,,both,,,945.14,614.34,,,,,,,,,,,,,
BLADE SHAVER RESECT 4.5X130 MM CRV CONCV DISP,SUP-2661226,CDM,2720000010,LOCAL,0272,RC,,,,both,,,388.07,252.25,,,,,,,,,,,,,
SET LD EXTRACTION EVOLUTION SHORTIE RL L 13.6 CM OD 17 FR ID,SUP-2169472,CDM,C1773,HCPCS,0272,RC,,,,both,,,4395.97,2857.38,,,,,,,,,,,,,
SCREW 28MM SCAPHOLUNATE INTERCARPAL RT PK,SUP-2106902,CDM,C1713,HCPCS,0278,RC,,,,both,,,3896.74,2532.88,,,,,,,,,,,,,
STEM FEM PRSS FT 1 HIP PRIMARY CEM UPLR/BPLR LNR POLYETH,SUP-2267795,CDM,C1776,CPT,0278,RC,,,,both,,,17584.00,11429.60,,,,,,,,,,,,,
COIL VASC NIT-OCCLUD L 3.5 MM DIA DSTL/PROX 6/5 MM,SUP-2659225,CDM,C1889,HCPCS,0278,RC,,,,both,,,8425.53,5476.59,,,,,,,,,,,,,
BUR SURG DIA1.5 MM HUB XLI TWST DRL ACTIV C STRL DISP,SUP-2929146,CDM,2720000010,LOCAL,0272,RC,,,,both,,,419.72,272.82,,,,,,,,,,,,,
PACK NEUROSURGICAL SHTH L 60 X W 13.5 MM MYRIAD HNDPC L 13 NN-3004,SUP-2930300,CDM,2720000010,LOCAL,0272,RC,,,,both,,,22369.83,14540.39,,,,,,,,,,,,,
NAIL IM L215MM DIA10.7MM STROKE 50MM 10DEG FEM RG FOR LIMB,SUP-2418824,CDM,C1713,HCPCS,0278,RC,,,,both,,,72734.96,47277.72,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 5 CC CELLENTRA ADV,SUP-2866898,CDM,C1713,HCPCS,0278,RC,,,,both,,,6634.19,4312.22,,,,,,,,,,,,,
SCREW SPNL MONOAX 4.5X25 MM PEDCL,SUP-2175428,CDM,C1713,HCPCS,0278,RC,,,,both,,,3014.40,1959.36,,,,,,,,,,,,,
HC Plmt Biliary Drainage Cath External,PX-3614753300,CDM,47533,CPT,0361,RC,,,,outpatient,,,6875.00,4468.75,,,,,,,,,,,,,
SODIUM CHLORIDE 4 MEQ/ML IV SOLN,RX-7322,CDM,J7131,HCPCS,0258,RC,00409-1141-12,NDC,,both,100,ML,88.60,57.59,,,,,,,,,,,,,
PUNCH ENDOSCP DISP FOR SWIVELOCK CRKSCR FULL THRD,SUP-2121561,CDM,C1713,HCPCS,0278,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
COUNTERSINK SURG FOR 7MM CANN SCR,SUP-2187345,CDM,C1713,HCPCS,0278,RC,,,,both,,,1285.74,835.73,,,,,,,,,,,,,
PLATE BNE W16XL221MM THK5MM 11 H R CNDYL FEM S STL BTTRS,SUP-2185797,CDM,C1713,HCPCS,0278,RC,,,,both,,,2506.57,1629.27,,,,,,,,,,,,,
PIN TEMP FIX AVTR,SUP-2532810,CDM,2720000010,LOCAL,0272,RC,,,,both,,,219.80,142.87,,,,,,,,,,,,,
DISTRACTION PIN 2.0MM X 42MM 7MM CTTNG SHAFT 2/PKG T 6L 4V S,SUP-2499460,CDM,C1713,HCPCS,0278,RC,,,,both,,,449.77,292.35,,,,,,,,,,,,,
PLATE BNE W8XL64MM THK2.5MM 8 H BILAT CALCNL S STL RIG NEUT,SUP-2186284,CDM,C1713,HCPCS,0278,RC,,,,both,,,988.63,642.61,,,,,,,,,,,,,
SCREW BONE L9MM DIA1.7MM STD CORT CRANIOMAXILLOFACIAL TI ST,SUP-2189203,CDM,C1713,HCPCS,0278,RC,,,,both,,,297.17,193.16,,,,,,,,,,,,,
TAP SURG DIA4.5MM CANN QUIK CONN W/O HNDL REUSE,SUP-2123147,CDM,2720000010,LOCAL,0272,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
GUIDEWIRE VASC L 145 CM DIA 0.038 IN TAPR L 9 CM HEPARIN,SUP-2167585,CDM,C1769,HCPCS,0272,RC,,,,both,,,40.82,26.53,,,,,,,,,,,,,
PIN FIX MOTOBAND,SUP-2175001,CDM,C1713,HCPCS,0278,RC,,,,both,,,409.83,266.39,,,,,,,,,,,,,
SYSTEM GYN ANTR BIOLOGIC W/ INTEXEN FOR TRANSOBTURATOR,SUP-2140308,CDM,C1771,HCPCS,0278,RC,,,,both,,,6547.69,4256.00,,,,,,,,,,,,,
NAIL IM LNG 13X340 MM RT TI,SUP-2362241,CDM,C1713,HCPCS,0278,RC,,,,both,,,9831.97,6390.78,,,,,,,,,,,,,
ANCHOR SUT DIA5.5MM KINSA RC,SUP-2341077,CDM,C1713,HCPCS,0278,RC,,,,both,,,1353.34,879.67,,,,,,,,,,,,,
BASEPLATE TIB RESURF LT REV STEM CEM SZ 2 FOUNDATION,SUP-2215744,CDM,C1776,CPT,0278,RC,,,,both,,,7033.60,4571.84,,,,,,,,,,,,,
"HC Glucose, Fasting",PX-3018294700,CDM,82947,CPT,0301,RC,,,,both,,,125.00,81.25,,,,,,,,,,,,,
CANNULA ENDOSCOPIC OD6.7MM SLOTTED,SUP-2842811,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1689.41,1098.12,,,,,,,,,,,,,
ROD EXT FIX 85 MM 1 LEVEL HALF MAND BENT TI,SUP-2423209,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1610.57,1046.87,,,,,,,,,,,,,
KIT BNE FIX L16MM OD15MM FRAC NAIL SMRT,SUP-2166909,CDM,C1713,HCPCS,0278,RC,,,,both,,,582.97,378.93,,,,,,,,,,,,,
PLATE EXT FIX SHT 180 MM FT RNG CARBON FIBER NS,SUP-2799576,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2302.84,1496.85,,,,,,,,,,,,,
CATHETER ADM050300130L ADM US 05L300 UL1300,SUP-2715866,CDM,C1725,HCPCS,0272,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
GUIDE PIN 3.2MM,SUP-2496814,CDM,2720000010,LOCAL,0272,RC,,,,both,,,372.59,242.18,,,,,,,,,,,,,
GUIDEWIRE 3.2MM GUIDE WIRE 475MM STERILE,SUP-2547184,CDM,C1769,HCPCS,0272,RC,,,,both,,,455.24,295.91,,,,,,,,,,,,,
BLADE SURG TREPHINE 10.8 MM,SUP-2363353,CDM,2720000010,LOCAL,0272,RC,,,,both,,,294.19,191.22,,,,,,,,,,,,,
LEAD PACE AD 8.6FR L55CM ATR VENT SIL POLYUR DF4 CONN INSUL,SUP-2282249,CDM,C1777,HCPCS,0275,RC,,,,both,,,8164.00,5306.60,,,,,,,,,,,,,
PIN FIX 240905000] JNJ HEALTHCARE],SUP-2256789,CDM,C1713,HCPCS,0278,RC,,,,both,,,501.30,325.84,,,,,,,,,,,,,
WASHER ORTHOPEDIC LOCKING SURFX ALPHA BONE,SUP-2586519,CDM,C1713,HCPCS,0278,RC,,,,both,,,534.46,347.40,,,,,,,,,,,,,
BLADE SAW W18.5XL32MM THK0.51MM CRESC OSC,SUP-2367519,CDM,2720000010,LOCAL,0272,RC,,,,both,,,341.98,222.29,,,,,,,,,,,,,
CATHETER VENTRICULAR SM 12X21 MMX23 CM STD RT ANGLE OPUS PS,SUP-2284504,CDM,C1713,HCPCS,0278,RC,,,,both,,,446.19,290.02,,,,,,,,,,,,,
BIT DRILL OD95MM FLEXIBLE CLANCY,SUP-2847031,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3368.22,2189.34,,,,,,,,,,,,,
PEG FEM AUG THK5MM KNEE VANGUARD,SUP-2407852,CDM,C1776,CPT,0278,RC,,,,both,,,489.84,318.40,,,,,,,,,,,,,
PLATE BNE L L110MM VIT TROCHANTERIC GRP 2 2MM CBL DALL-MILE,SUP-2377574,CDM,C1713,HCPCS,0278,RC,,,,both,,,2721.75,1769.14,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY EP XT L 110 CM DIA 6 FR SPC 10 MM,SUP-2142245,CDM,C1730,HCPCS,0272,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
KIT BNE CEM ANK SHLDR EL APPLICATIONS W/ SM APPL MIX AND,SUP-2120719,CDM,2720000010,LOCAL,0272,RC,,,,both,,,692.37,450.04,,,,,,,,,,,,,
GRAFT TISS FRZ DRY ALLGRFT SHFT RAD TRAD 60MM,SUP-2294110,CDM,C1713,HCPCS,0278,RC,,,,both,,,1174.36,763.33,,,,,,,,,,,,,
PACK NEUROSURGICAL SHTH L 75 X W 11 MM MYRIAD HNDPC L 13 CM,SUP-2930228,CDM,2720000010,LOCAL,0272,RC,,,,both,,,22169.69,14410.30,,,,,,,,,,,,,
PLATE BNE L205MM 6 H ST PROX FEM S STL HK LO PROF LOK COMPR,SUP-2186057,CDM,C1713,HCPCS,0278,RC,,,,both,,,4882.42,3173.57,,,,,,,,,,,,,
DEFIBRILLATOR CRD BPLR ATR VENTRIC 2 CHMBR EPIC DR V233ROPTSYS] ST JUDE MED CARDIAC RHYM MGMT],SUP-2356539,CDM,C1721,HCPCS,0275,RC,,,,both,,,69036.04,44873.43,,,,,,,,,,,,,
CATHETER ETER CTRL VEN L55CM OD4FR POLYUR 1 LUMN,SUP-2384046,CDM,C1751,HCPCS,0278,RC,,,,both,,,151.60,98.54,,,,,,,,,,,,,
STEM HUM L175MM DIA8MM LNG SHLDR REV,SUP-2223309,CDM,C1776,CPT,0278,RC,,,,both,,,11006.33,7154.11,,,,,,,,,,,,,
HC So Homocystine,PX-3018309066,CDM,83090,CPT,0301,RC,,,,both,,,402.00,261.30,,,,,,,,,,,,,
MESH SURG 1.25 IN LIGHT-WEIGHT SELF FORMING PROLITE ULTRA,SUP-2265956,CDM,C1781,HCPCS,0278,RC,,,,both,,,386.35,251.13,,,,,,,,,,,,,
GRAFT HUM TISS W2XL4CM THK07 14MM THN ACELLULAR HYDRATED,SUP-2307553,CDM,Q4128,HCPCS,0636,RC,,,,both,,,574.62,373.50,,,,,,,,,,,,,
SCREW BNE DIA 3.5 MM COMPR HDLSS STRL SPEEDMTP,SUP-2908894,CDM,C1713,HCPCS,0278,RC,,,,both,,,1855.74,1206.23,,,,,,,,,,,,,
GRAFT MTRX DERM HUM TISS ACELLULAR FRZ DRY THN 4CMX12CM,SUP-2306896,CDM,C1762,CPT,0278,RC,,,,both,,,2486.10,1615.96,,,,,,,,,,,,,
OXYGENATOR PERFSN TUBE 3/8 X 3/32 IN AD 0.5-7 L/MIN 600/273,SUP-2908604,CDM,2720000010,LOCAL,0272,RC,,,,both,,,42583.24,27679.11,,,,,,,,,,,,,
RING EXT FIX L200MM FULL SIDEKCK,SUP-2400662,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4493.34,2920.67,,,,,,,,,,,,,
RESERVOIR EXT DRNGE 0.6ML BUR H DIA12MM CSF CONV,SUP-2284529,CDM,C1889,HCPCS,0278,RC,,,,both,,,894.62,581.50,,,,,,,,,,,,,
PLATE BONE L41MM 5 H S STL QTR TBLR ECT,SUP-2198591,CDM,C1713,HCPCS,0278,RC,,,,both,,,144.41,93.87,,,,,,,,,,,,,
SPLINT ORTHOPEDIC THMB ABDUCTED UNIV LTHR,SUP-2336237,CDM,L3931,HCPCS,0272,RC,,,,both,,,14.60,9.49,,,,,,,,,,,,,
CATHETER ANGIOPLSTY SYNERGY L 150 CM DIA 5.3 FR BALLOON L 10,SUP-2141048,CDM,C1725,HCPCS,0272,RC,,,,both,,,593.46,385.75,,,,,,,,,,,,,
HEAD HUM H18MM OD53MM ID46MM SHLDR CO CHROM MOD NECKLESS,SUP-2404499,CDM,C1776,CPT,0278,RC,,,,both,,,4396.00,2857.40,,,,,,,,,,,,,
SUPPORT ORTHOT ELBW CUST RIGID W/O JT PREFABRICATED,SUP-2435761,CDM,L3762,HCPCS,0272,RC,,,,both,,,277.01,180.06,,,,,,,,,,,,,
SCREW BONE L32MM DIA5.5MM THRD L16MM STD CORT S STL ST SELF,SUP-2343635,CDM,C1713,HCPCS,0278,RC,,,,both,,,1857.94,1207.66,,,,,,,,,,,,,
HC So Alpha Fetoprotein,PX-3018210566,CDM,82105,CPT,0301,RC,,,,both,,,58.00,37.70,,,,,,,,,,,,,
HF RES SML LOOP 24FR 1216DEG,SUP-2722416,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1414.41,919.37,,,,,,,,,,,,,
SCREW IM NAIL L 110 MM DIA 3.7/4 MM FIBULAR,SUP-2896866,CDM,C1713,HCPCS,0278,RC,,,,both,,,2037.86,1324.61,,,,,,,,,,,,,
SHUNT SURG SM 120 CM STRATA II INNERVISION,SUP-2628623,CDM,C1729,HCPCS,0272,RC,,,,both,,,16980.18,11037.12,,,,,,,,,,,,,
PLATE BNE UTIL 2 HOLE CROSSCHECK PLATING SYS,SUP-2399370,CDM,C1713,HCPCS,0278,RC,,,,both,,,5140.18,3341.12,,,,,,,,,,,,,
TUBE SUCTION COOLEY 12 IN 6 MM TIP VASC SS,SUP-2500196,CDM,2720000010,LOCAL,0272,RC,,,,both,,,386.97,251.53,,,,,,,,,,,,,
SET URET STENT MARD L 28 CM DIA 8 FR ZIPWIRE 0.035 IN,SUP-2721561,CDM,C2617,HCPCS,0278,RC,,,,both,,,543.22,353.09,,,,,,,,,,,,,
SYSTEM FIX KNOTLESS TENSIONABLE BICEPS IMPL STRL FIBERTAK,SUP-2859829,CDM,C1713,HCPCS,0278,RC,,,,both,,,1805.50,1173.57,,,,,,,,,,,,,
TRIAL INSRT CS 6 10 MM TIB KNEE SLD TRIATHLON,SUP-2422367,CDM,C1776,CPT,0278,RC,,,,both,,,557.35,362.28,,,,,,,,,,,,,
FILTER VASC DENALI SHTH L 55 CM VENA CAVA KT EMB JUG SUBCLAV,SUP-2126819,CDM,C1880,HCPCS,0278,RC,,,,both,,,5259.50,3418.67,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY RESPON L 120CM 6FR 2-2-2MM SZ 2MM,SUP-2538049,CDM,C1730,HCPCS,0272,RC,,,,both,,,254.03,165.12,,,,,,,,,,,,,
BIT DRL DIA3.3MM CANN QUIK CPL FOR SM SCR SYS,SUP-2344066,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2278.26,1480.87,,,,,,,,,,,,,
PLATE THK1.7MM 2X5 H LADDER RESRB STRL DELT SYS,SUP-2364983,CDM,C1713,HCPCS,0278,RC,,,,both,,,814.23,529.25,,,,,,,,,,,,,
BLADE CUT MORCELLATOR 15MM,SUP-2261148,CDM,C1782,HCPCS,0272,RC,,,,both,,,1814.92,1179.70,,,,,,,,,,,,,
PLATE BNE L 49 X W 8 MM THK 3.5 MM SCREW DIA2.7 MM 6 H SS,SUP-2936378,CDM,C1713,HCPCS,0278,RC,,,,both,,,1434.79,932.61,,,,,,,,,,,,,
MESH SURG 1.5X113X77MM THK0.6MM TI FLX STD CRAN PLATING SYS,SUP-2279903,CDM,C1781,HCPCS,0278,RC,,,,both,,,4364.60,2836.99,,,,,,,,,,,,,
CLAMP EXT FIX 45 MM UNILAT MULTIPIN NS DISP MAV,SUP-2931268,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3306.42,2149.17,,,,,,,,,,,,,
PROSTHESIS LARYN L6MM LO AIRFLO RESISTANCE EZ MAINT FOR,SUP-2124337,CDM,L8509,HCPCS,0274,RC,,,,both,,,920.02,598.01,,,,,,,,,,,,,
CATHETER PERIPH 20/22GA MULT LUMN RADPQ RND WALL NDL TWIN,SUP-2383470,CDM,C1751,HCPCS,0278,RC,,,,both,,,25.87,16.82,,,,,,,,,,,,,
GRAFT HUM TISS W14-18XL60MM FIB SHFT STRUCTURAL FRZ DRY,SUP-2307193,CDM,C1713,HCPCS,0278,RC,,,,both,,,1925.39,1251.50,,,,,,,,,,,,,
HC Hepatitis B Core Antibody Hbcab Total,PX-3028670400,CDM,86704,CPT,0302,RC,,,,both,,,32.00,20.80,,,,,,,,,,,,,
SCREW BNE CAPTURE FOREFT SELF DRL ST CANN HDLSS 2 THRD L22MM,SUP-2243903,CDM,C1713,HCPCS,0278,RC,,,,both,,,989.54,643.20,,,,,,,,,,,,,
CATHETER MAP D CRV 1-4-1 MM SPC 8 FRX117 CM CIR ADVISOR VL,SUP-2867439,CDM,C1730,HCPCS,0272,RC,,,,both,,,5843.54,3798.30,,,,,,,,,,,,,
DEFIBRILLATOR IMPL ITREVIA VR-T W 54 X H 65 MM D 11 MM 31 CC,SUP-2138375,CDM,C1722,HCPCS,0275,RC,,,,both,,,33707.90,21910.13,,,,,,,,,,,,,
BRACE ORTHOPEDIC POST OPERATIVE SM MED 28 IN BLK LTX,SUP-2421714,CDM,L1833,HCPCS,0272,RC,,,,both,,,233.74,151.93,,,,,,,,,,,,,
STEM FEM SEG 15 CM DPHSEAL KNEE POROUS OSS,SUP-2449781,CDM,C1776,CPT,0278,RC,,,,both,,,14854.87,9655.67,,,,,,,,,,,,,
CUBE EXT FIX 1 H RANCHO FEMALE,SUP-2898437,CDM,2720000010,LOCAL,0272,RC,,,,both,,,433.32,281.66,,,,,,,,,,,,,
CUP ACET DIA56MM UNIV HIP TI POR PRESSFIT PRI CEMENTLESS MH 124556000] JNJ DEPUY SYNTHES ORTHOPEDICS],SUP-2250722,CDM,C1776,CPT,0278,RC,,,,both,,,4505.90,2928.83,,,,,,,,,,,,,
FILLER BNE VOID LG CELLULAR BNE LYOGRAFT SHLF STBL VIRTUOS,SUP-2927231,CDM,C1713,HCPCS,0278,RC,,,,both,,,11461.00,7449.65,,,,,,,,,,,,,
COMPONENT FEM 00 LT KNEE CSTI POROUS N-K II,SUP-2210458,CDM,C1776,CPT,0278,RC,,,,both,,,12062.31,7840.50,,,,,,,,,,,,,
KIT SURG ACC L VENT ASST DEV HEARTMATE III,SUP-2355986,CDM,C1713,HCPCS,0278,RC,,,,both,,,5228.10,3398.26,,,,,,,,,,,,,
CATHETER ANGIOPLSTY CONQ L 75 CM BALLOON L 40 MM DIA 7 MM,SUP-2128031,CDM,C1725,HCPCS,0272,RC,,,,both,,,832.10,540.86,,,,,,,,,,,,,
PLATE BNE CALCANEAL CUBOID LG TI RIVAL VW,SUP-2645295,CDM,C1713,HCPCS,0278,RC,,,,both,,,4837.17,3144.16,,,,,,,,,,,,,
RING ANNULPLSTY PHY 24MM CARP EDW 4450M24] EDWARDS LIFESCIENCES CORP],SUP-2214165,CDM,C1713,HCPCS,0278,RC,,,,both,,,7206.30,4684.09,,,,,,,,,,,,,
SCREW BNE ST 3.5X20 MM CRTX PELV SS NS,SUP-2183545,CDM,C1713,HCPCS,0278,RC,,,,both,,,90.93,59.10,,,,,,,,,,,,,
PLATE STRAIGHT LOQTEQ 7 HOLE,SUP-2713860,CDM,C1713,HCPCS,0278,RC,,,,both,,,2121.20,1378.78,,,,,,,,,,,,,
KIT INTRO L 10 CM DIA 4FR SS WIRE TUNGSTEN TIP MIC B BVL STD,SUP-2752717,CDM,C1894,HCPCS,0272,RC,,,,both,,,71.31,46.35,,,,,,,,,,,,,
LEAD PACE L58CM S STL UPLR DF-1 CONN,SUP-2282276,CDM,C1896,HCPCS,0275,RC,,,,both,,,6796.78,4417.91,,,,,,,,,,,,,
TUBE VENT BOB 1.02 MM 1 MM 2.7 MM FLROPLAS BLU STRL,SUP-2465880,CDM,L8699,HCPCS,0278,RC,,,,both,,,22.45,14.59,,,,,,,,,,,,,
CAGE SPNL ALIF 10 DEG 31X24X10 MM PRIM NM,SUP-2245130,CDM,C1889,HCPCS,0278,RC,,,,both,,,18902.80,12286.82,,,,,,,,,,,,,
GRAFT BNE 10 CC OSTEOCURRENT,SUP-2644334,CDM,C1713,HCPCS,0278,RC,,,,both,,,13376.40,8694.66,,,,,,,,,,,,,
CATHETER ETER URET L65CM OD5FR OLV TIP,SUP-2384604,CDM,C1758,HCPCS,0278,RC,,,,both,,,26.69,17.35,,,,,,,,,,,,,
PHILADEPHIA CLLR 1-PIECE - RIG EXTRIC TALL,SUP-2194491,CDM,L0172,HCPCS,0274,RC,,,,both,,,25.62,16.65,,,,,,,,,,,,,
PLATE BNE H0.6MM 24 H STD MID FACE G TI STR LEIBINGER UNIV,SUP-2366290,CDM,C1713,HCPCS,0278,RC,,,,both,,,1519.82,987.88,,,,,,,,,,,,,
LONCASTUXIMAB TESIRINE-LPYL 10 MG IV SOLR|DISCARDED DRUG NOT ADMINISTE,RX-154627,CDM,J9359,HCPCS,0636,RC,79952-0110-01,NDC,JW,both,1,UN,81566.60,53018.29,,,,,,,,,,,,,
SYSTEM IMPL W/ MINI SCORPION DX NDL MIC SUTLASSOS FIBERWIRE,SUP-2122322,CDM,C1713,HCPCS,0278,RC,,,,both,,,3438.30,2234.89,,,,,,,,,,,,,
GRAFT BONE CERV SPCR FRZ DRY CANC H 8MM,SUP-2307223,CDM,C1713,HCPCS,0278,RC,,,,both,,,3068.16,1994.30,,,,,,,,,,,,,
CANNULA SET 3.0MM NON-FENESTRATED,SUP-2812608,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4223.30,2745.14,,,,,,,,,,,,,
MESH HERN 3X6IN POLYPR SYN RECT NONABSORBABLE KNIT MFIL,SUP-2126053,CDM,C1781,HCPCS,0278,RC,,,,both,,,84.78,55.11,,,,,,,,,,,,,
DEFIBRILLATOR CARD HI ENERGY SYS W/ TI W/ LANDLINE HM 2,SUP-2138414,CDM,C1722,HCPCS,0275,RC,,,,both,,,58090.00,37758.50,,,,,,,,,,,,,
SCREW BNE 2.7X44 MM,SUP-2183088,CDM,C1713,HCPCS,0278,RC,,,,both,,,161.08,104.70,,,,,,,,,,,,,
OMEPRAZOLE 10 MG PO CPDR,RX-27693,CDM,6370000000,HCPCS,0637,RC,16714-0714-01,NDC,,both,1,UN,1.30,0.84,,,,,,,,,,,,,
LINER ACET OD64MM ID52MM 0DEG CO CHROM HIP R3,SUP-2345314,CDM,C1776,CPT,0278,RC,,,,both,,,10500.95,6825.62,,,,,,,,,,,,,
FIXATION KIT 11X12/10 MM 1.3X1.5 MM SPEEDARC,SUP-2135443,CDM,C1776,CPT,0278,RC,,,,both,,,3077.20,2000.18,,,,,,,,,,,,,
PLATE BONE L54MM THK2.3MM 3 H RT DSTL RAD VOLAR BLK,SUP-2152597,CDM,C1713,HCPCS,0278,RC,,,,both,,,2778.74,1806.18,,,,,,,,,,,,,
KIT VENTRICULAR DRAINAGE COMB W/ 10100 INS5010 HERM LUMBAR,SUP-2883469,CDM,C1729,HCPCS,0272,RC,,,,both,,,1033.22,671.59,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC BSC 5FR 55CM 1 LUMAN RVS TA 3175118,SUP-2632657,CDM,C1751,HCPCS,0278,RC,,,,both,,,409.36,266.08,,,,,,,,,,,,,
KCL IN DEXTROSE-NACL 20-5-0.9 MEQ/L-%-% IV SOLN,RX-102351,CDM,2500000003,HCPCS,0250,RC,00264-7652-00,NDC,,both,1000,ML,54.10,35.16,,,,,,,,,,,,,
DRILL TWST DENT 1.0MM W/ STP,SUP-2419547,CDM,2720000010,LOCAL,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
TOOL PACE ACUITY X4 PSA TO IS4 CONN STRL,SUP-2140129,CDM,2720000010,LOCAL,0272,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
ICATIBANT ACETATE 30 MG/3ML SC SOSY,RX-162814,CDM,6370000000,HCPCS,0637,RC,55150-0351-03,NDC,,both,3,ML,2950.00,1917.50,,,,,,,,,,,,,
LINEZOLID 100 MG/5ML PO SUSR,RX-28225,CDM,340b,HCPCS,0637,RC,09999-3789-05,NDC,,both,30,ML,613.80,398.97,,,,,,,,,,,,,
KIT FIX DIA10 MM TIB TUNN STRL QUADLINK,SUP-2930404,CDM,C1713,HCPCS,0278,RC,,,,both,,,8964.70,5827.05,,,,,,,,,,,,,
VALVE MITRL ON-X TISS ANNULUS 23 MM ORIFICE 21.4 MM SZ 23,SUP-2175261,CDM,C1713,HCPCS,0278,RC,,,,both,,,10990.00,7143.50,,,,,,,,,,,,,
CATHETER KIT BUNDLED 20 CM CV,SUP-2214468,CDM,C1751,HCPCS,0278,RC,,,,both,,,324.99,211.24,,,,,,,,,,,,,
PROSTHESIS VOICE 20FR L4MM ESOPH TRACH INDWL W/ L FLNG,SUP-2242385,CDM,L8509,HCPCS,0272,RC,,,,both,,,1055.04,685.78,,,,,,,,,,,,,
CATHETER VENTRICULAR EXT LG 1.9 MMX35 CM BA STRIPE TEM,SUP-2851444,CDM,C1729,HCPCS,0272,RC,,,,both,,,476.68,309.84,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PLU MAXBARR 4FR 55CM 1 LU 1174108D4,SUP-2632628,CDM,C1751,HCPCS,0278,RC,,,,both,,,823.15,535.05,,,,,,,,,,,,,
HC Gbl Smoke/Tobac Counsel 3-10|PBB CHARGE,PX-9829940601,CDM,99406,CPT,0982,RC,,,PBB,both,,,70.00,45.50,,,,,,,,,,,,,
CANNULA ENDOSCP DIA 7/8 MM SHRT REDUCER 5 MM DIL RADIALLY,SUP-2896314,CDM,2720000010,LOCAL,0272,RC,,,,both,,,430.05,279.53,,,,,,,,,,,,,
CATH BLLN INTRA AORTIV LINEAR 7.5FRX40CC,SUP-2481924,CDM,C1725,HCPCS,0272,RC,,,,both,,,2543.31,1653.15,,,,,,,,,,,,,
PLATE BNE 6 H R CLOVER COMPR LISFRANC GORILLA,SUP-2321539,CDM,C1713,HCPCS,0278,RC,,,,both,,,4651.13,3023.23,,,,,,,,,,,,,
PLATE BONE L64MM 4 H LT PROX POSTEROMEDIAL VAR ANG LCK FOR,SUP-2349800,CDM,C1713,HCPCS,0278,RC,,,,both,,,9167.86,5959.11,,,,,,,,,,,,,
PLATE SPNL MINI 12X23 MM 2.5 MM OFFSET TITAN STRL ANTERALIGN,SUP-2859407,CDM,C1713,HCPCS,0278,RC,,,,both,,,7664.74,4982.08,,,,,,,,,,,,,
CATHETER PTCA L142CM BLLN L9MM DIA2MM MRAIL RAP EXCHG FULL,SUP-2144436,CDM,C1725,HCPCS,0272,RC,,,,both,,,800.70,520.45,,,,,,,,,,,,,
PLATE BNE THK0.5MM 2MM BAR 5 H 100DEG UNIV,SUP-2366242,CDM,C1713,HCPCS,0278,RC,,,,both,,,616.57,400.77,,,,,,,,,,,,,
GRAFT BNE SUB W40XH10XL50MM BOV CANC CANCELLO-PURE,SUP-2399158,CDM,C1713,HCPCS,0278,RC,,,,both,,,5372.54,3492.15,,,,,,,,,,,,,
SPHINCTEROTOME ENDOSCP 3.9 FRX30X5 MM JAGWIRE CANN TRUTOME,SUP-2498332,CDM,C1769,HCPCS,0272,RC,,,,both,,,1238.95,805.32,,,,,,,,,,,,,
STEM FEM CALCAR 13 30 MM HIP STR POROUS ECHELON,SUP-2450577,CDM,C1776,CPT,0278,RC,,,,both,,,10016.60,6510.79,,,,,,,,,,,,,
GRAFT FRZ DRY ALLGRFT 1-24CM2,SUP-2165567,CDM,C1762,CPT,0278,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
KIT DRNGE LUM 700ML L80CM BA IMPREG CONN FIX TAB BLNT TUOHY,SUP-2284548,CDM,C1713,HCPCS,0278,RC,,,,both,,,657.80,427.57,,,,,,,,,,,,,
GRAFT BONE SUB SM 4CC BIOACTIVE GLS PUTTY,SUP-2330555,CDM,C9359,HCPCS,0278,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
CATHETER PI PICC KIT 3-L 6 FR X 55 CM TIPTRACKER,SUP-2655668,CDM,C1751,HCPCS,0278,RC,,,,both,,,733.72,476.92,,,,,,,,,,,,,
PLATE BONE 192MML HLX24 STNLSS STEEL STRGHT RCNSTRCTN F2.7M,SUP-2724376,CDM,C1713,HCPCS,0278,RC,,,,both,,,1914.65,1244.52,,,,,,,,,,,,,
KIT INTRO OSCOR DIA10 FR PEELWY STRL,SUP-2148777,CDM,C1892,HCPCS,0272,RC,,,,both,,,172.70,112.25,,,,,,,,,,,,,
SHEATH URET ACCS 13 15FR L35CM DIL 11FR SMOOTH ATRAUM INSRT,SUP-2126284,CDM,C1894,HCPCS,0272,RC,,,,both,,,403.24,262.11,,,,,,,,,,,,,
COMPONENT TIB KNEE CROSSOVER BEAR MOD ROT HNG REV GMRS,SUP-2376367,CDM,C1776,CPT,0278,RC,,,,both,,,7104.56,4617.96,,,,,,,,,,,,,
PLATE BNE BURR HOLE CVR 1.5X12X0.5 MM LP CONTOURED TI NS,SUP-2460225,CDM,C1713,HCPCS,0278,RC,,,,both,,,797.56,518.41,,,,,,,,,,,,,
GRAFT HUM TISS L 4 X W 4 CM THK 0.2 MM HUM AMNIO MEMBRN,SUP-2909396,CDM,Q4282,HCPCS,0636,RC,,,,both,,,12717.00,8266.05,,,,,,,,,,,,,
PLATE BNE L 90 X W 11 MM THK 2 MM SCREW DIA 3.5 MM 5 H SS RT,SUP-2933313,CDM,C1713,HCPCS,0278,RC,,,,both,,,7452.01,4843.81,,,,,,,,,,,,,
SCREW CEPHALIC 10.5X90MM,SUP-2717573,CDM,C1713,HCPCS,0278,RC,,,,both,,,1626.52,1057.24,,,,,,,,,,,,,
BASKET SPEC RETRV 5 FRX60 CM STONE W/ 3 RNG HNDL  COIL,SUP-2767786,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6384.84,4150.15,,,,,,,,,,,,,
PLATE BNE 5DEG LNG R MT GORILLA,SUP-2321470,CDM,C1713,HCPCS,0278,RC,,,,both,,,4963.08,3226.00,,,,,,,,,,,,,
KIT VASC DIL 4FR L10CM MINI ACCS STIFF COAX S MAK,SUP-2303435,CDM,C1894,HCPCS,0272,RC,,,,both,,,62.80,40.82,,,,,,,,,,,,,
WIRE BNE FIX L 229 MM DIA2.8 MM FLUT TIP NS LEOS KIRSCHNER,SUP-2933710,CDM,C1713,HCPCS,0278,RC,,,,both,,,264.89,172.18,,,,,,,,,,,,,
BUTTON GASTROSTMY CONT FEED TUBE 24 FRX24 IN NON-BLLN NS,SUP-2166552,CDM,C1713,HCPCS,0278,RC,,,,both,,,18.84,12.25,,,,,,,,,,,,,
GRAFT BNE SUB 1.5CC W10XL15MM MINERALIZED CLLGN SCFLD,SUP-2138523,CDM,C1713,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
IMPLANT CRANIOFACIAL L 40 X W 40 MM THK 2.5/0.73 MM LG,SUP-2909502,CDM,C1713,HCPCS,0278,RC,,,,both,,,2204.06,1432.64,,,,,,,,,,,,,
BIT DRL L30MM DIA2.6MM ADD ON FIT SPEEDGUIDE,SUP-2378003,CDM,2720000010,LOCAL,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
BLADE KEL 2INX4IN BKWALT,SUP-2382392,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1266.05,822.93,,,,,,,,,,,,,
MIDAZOLAM HCL 2 MG/ML PO SYRP,RX-24176,CDM,340b,HCPCS,0637,RC,09999-9902-32,NDC,,both,1,ML,2.70,1.75,,,,,,,,,,,,,
LINER ACET SZ C DIA32MM UHMWPE FLAT HIGHCROSS MPACT,SUP-2267403,CDM,C1776,CPT,0278,RC,,,,both,,,4022.84,2614.85,,,,,,,,,,,,,
COMPONENT ARTC SURF 1 9 MM KNEE,SUP-2200487,CDM,C1776,CPT,0278,RC,,,,both,,,1661.37,1079.89,,,,,,,,,,,,,
SCREW ACET 6.5X40 MM CANC HIP LOGICAL,SUP-2322445,CDM,C1713,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
FIBER LASER ENDOBEAM W/ VMC ULTRA RACK,SUP-2798175,CDM,2720000010,LOCAL,0272,RC,,,,both,,,99186.45,64471.19,,,,,,,,,,,,,
ANCHOR SUT DIA5.5MM NONABSORBABLE OUTER SHELL INNR PLUG ROT,SUP-2341789,CDM,C1713,HCPCS,0278,RC,,,,both,,,1174.36,763.33,,,,,,,,,,,,,
SCREW BNE POS 5.5X45 MM STRL LG QWIX,SUP-2242939,CDM,C1713,HCPCS,0278,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
SCREW CONN FOR HELI BLDE TFN,SUP-2188217,CDM,C1713,HCPCS,0278,RC,,,,both,,,2844.49,1848.92,,,,,,,,,,,,,
GUIDEWIRE VASC L 50 CM DIA 0.025 IN CRV RAD 3 MM SS SAFE-T-J,SUP-2760118,CDM,C1769,HCPCS,0272,RC,,,,both,,,62.39,40.55,,,,,,,,,,,,,
IMPLANT HUM TISS L 30 X W 20 MM THK 5 MM ACHILLES TEND RC,SUP-2933845,CDM,C1762,CPT,0278,RC,,,,both,,,6187.81,4022.08,,,,,,,,,,,,,
PLATE BNE 2.7X84 MM 10 HOLE SS DCP,SUP-2569132,CDM,C1713,HCPCS,0278,RC,,,,both,,,331.58,215.53,,,,,,,,,,,,,
LIDOCAINE-EPINEPHRINE (PF) 1 %-1:200000 IJ SOLN,RX-169107,CDM,J2004,HCPCS,0636,RC,63323-0487-07,NDC,,both,10,ML,54.10,35.16,,,,,,,,,,,,,
PLATE BNE LCK 3.5X224 MM RT PROX LAT TIB 16 HOLE STRL,SUP-2462536,CDM,C1713,HCPCS,0278,RC,,,,both,,,4201.89,2731.23,,,,,,,,,,,,,
ALLOGRAFT BNE HUM HD FRZN TISS,SUP-2165581,CDM,C1889,HCPCS,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
PLATE BONE L45.7MM 0/5DEG 5 H NAR RT 1ST MTP FUS FOR 2.7MM,SUP-2417474,CDM,C1713,HCPCS,0278,RC,,,,both,,,8578.48,5576.01,,,,,,,,,,,,,
SHEATH INTRO 6FR L25CM PINN SUP SHTH,SUP-2139615,CDM,C1894,HCPCS,0272,RC,,,,both,,,106.76,69.39,,,,,,,,,,,,,
ALLOGRAFT BNE PTTY DBM REFICIO,SUP-2731795,CDM,C1713,HCPCS,0278,RC,,,,both,,,225.30,146.44,,,,,,,,,,,,,
HC Surgery Level 3 Base,PX-3600000003,CDM,3600000003,LOCAL,0360,RC,,,,both,,,5325.00,3461.25,,,,,,,,,,,,,
BLADE RTRCTR MCCLLCH 27MMW X 30MML SPNL MSCLE WIDE RGGLS RDM,SUP-2458120,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1708.51,1110.53,,,,,,,,,,,,,
FLUPHENAZINE DECANOATE 25 MG/ML IJ SOLN,RX-3215,CDM,J2680,HCPCS,0636,RC,42023-0129-01,NDC,,both,0.5,ML,54.10,35.16,,,,,,,,,,,,,
MESH HERN W10XL10IN SQ SFT POLYPR FOR ABD WALL FASCIAL,SUP-2219919,CDM,C1781,HCPCS,0278,RC,,,,both,,,5203.11,3382.02,,,,,,,,,,,,,
PLATE BONE W14XL162MM THK3.8MM 90DEG 9 H LT TIB S STL L SHP,SUP-2185784,CDM,C1713,HCPCS,0278,RC,,,,both,,,2062.51,1340.63,,,,,,,,,,,,,
COMPONENT PATELLAR D 12 MM ARTC KNEE,SUP-2200794,CDM,C1776,CPT,0278,RC,,,,both,,,4140.09,2691.06,,,,,,,,,,,,,
AWL SURG 25 MM FOR ALIF SYS CHESAPEAKE,SUP-2855056,CDM,2720000010,LOCAL,0272,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
STAPLE BNE RELIABLE 3 18X18X20 MM COMPR STRL EXPRESS XL,SUP-2223982,CDM,C1713,HCPCS,0278,RC,,,,both,,,4314.36,2804.33,,,,,,,,,,,,,
INSTRUMENT 9560180 18MM MTRXND ATCH STRL,SUP-2292890,CDM,C1713,HCPCS,0278,RC,,,,both,,,987.62,641.95,,,,,,,,,,,,,
GRAFT BNE PTTY 2.5 CC VI DBM DYNAGRAFT II,SUP-2641742,CDM,C1713,HCPCS,0278,RC,,,,both,,,606.02,393.91,,,,,,,,,,,,,
PLATE BNE L22MM 8 H R S STL EXT H SHP LO PROF RIG NEUT LOK,SUP-2186294,CDM,C1713,HCPCS,0278,RC,,,,both,,,1275.75,829.24,,,,,,,,,,,,,
CAGE SPNL 0 DEG H 14X8X8 MM COALITION AGX R,SUP-2424050,CDM,C1889,HCPCS,0278,RC,,,,both,,,4396.00,2857.40,,,,,,,,,,,,,
KIT DBS LD CAP STRL DISP SENSIGHT,SUP-2882980,CDM,2720000010,LOCAL,0272,RC,,,,both,,,357.96,232.67,,,,,,,,,,,,,
CIRCUIT BREATHING INF 38 IN HEATED WIRE,SUP-2162516,CDM,2720000010,LOCAL,0272,RC,,,,both,,,426.98,277.54,,,,,,,,,,,,,
PLATE BNE SM W11XL77MM THK3.3MM 0DEG 6 H BILAT TI STR LIMIT,SUP-2190778,CDM,C1713,HCPCS,0278,RC,,,,both,,,550.69,357.95,,,,,,,,,,,,,
RITUXIMAB-ARRX (RIABNI) 10 MG/ML IV SOLN (MIXTURES ONLY),RX-4082266,CDM,Q5123,HCPCS,0636,RC,55513-0326-01,NDC,,both,50,ML,10322.00,6709.30,,,,,,,,,,,,,
PLATE BNE L7MM THK06MM 3X3 H BILAT CHIN ORAL MAXILLOFACIAL,SUP-2262920,CDM,C1713,HCPCS,0278,RC,,,,both,,,649.29,422.04,,,,,,,,,,,,,
COLLAR CERV TRACHEOTOMY HT 225IN CIRC 13 16IN M PHIL,SUP-2319292,CDM,L0172,HCPCS,0274,RC,,,,both,,,39.56,25.71,,,,,,,,,,,,,
REAMER SURG 3 MM STRL,SUP-2175008,CDM,C1713,HCPCS,0278,RC,,,,both,,,777.15,505.15,,,,,,,,,,,,,
BLADE SHV DIA3.5MM BGE FULL RAD BONECUTTER DISP,SUP-2341659,CDM,2720000010,LOCAL,0272,RC,,,,both,,,247.28,160.73,,,,,,,,,,,,,
CAP HEALING DIA30MM FOR STD USE BAHA,SUP-2164979,CDM,L8614,HCPCS,0278,RC,,,,both,,,119.32,77.56,,,,,,,,,,,,,
PLATE BNE L193MM 8 H L DST LAT FEM S STL LOK FOR 4.5MM SCR,SUP-2348210,CDM,C1713,HCPCS,0278,RC,,,,both,,,13706.10,8908.96,,,,,,,,,,,,,
CATHETER CTRL VEN L70CM OD6FR 3 LUMN NIT GWIRE BLU INTRO,SUP-2125562,CDM,C1751,HCPCS,0278,RC,,,,both,,,480.42,312.27,,,,,,,,,,,,,
BLADE SCREWDRIVER 2/2.3X27 MM RT ANGLED CROSS DRV LEVEL 1,SUP-2474845,CDM,2720000010,LOCAL,0272,RC,,,,both,,,574.34,373.32,,,,,,,,,,,,,
ROPIVACAINE ELASTOMERIC INFUSION 0.5%,RX-4082401,CDM,J2795,HCPCS,0636,RC,70069-0064-01,NDC,,both,100,ML,162.80,105.82,,,,,,,,,,,,,
PLATE BNE 7 HOLE SS NS,SUP-2186087,CDM,C1713,HCPCS,0278,RC,,,,both,,,794.42,516.37,,,,,,,,,,,,,
IMPLANT UROLOGICAL MESH ELEV POST INTEXEN LP,SUP-2140248,CDM,C1781,HCPCS,0278,RC,,,,both,,,6249.39,4062.10,,,,,,,,,,,,,
KIT CATH HEMODIALYSI DUOGLIDE ACUTE 13FR DIA 20CML I 5623200,SUP-2632910,CDM,C1752,HCPCS,0278,RC,,,,both,,,375.54,244.10,,,,,,,,,,,,,
PLATE BONE L45MM 6 H TI GAP FOR CRAN CLSR SYS,SUP-2243976,CDM,C1713,HCPCS,0278,RC,,,,both,,,529.22,343.99,,,,,,,,,,,,,
GRAFT VASC GORTX L 40 CM DIA 7 MM EPTFE STR TW N RING STRL,SUP-2396703,CDM,C1768,CPT,0278,RC,,,,both,,,1299.96,844.97,,,,,,,,,,,,,
HC MRI-Abdomen W & WO Contrast,PX-6107418300,CDM,74183,CPT,0610,RC,,,,both,,,4220.00,2743.00,,,,,,,,,,,,,
TRAY BX SZ 2 BLLN L10MM IBT ADD FRAC KYPHON EXPR KYPHON,SUP-2293624,CDM,C1713,HCPCS,0278,RC,,,,both,,,5331.72,3465.62,,,,,,,,,,,,,
BUR SURG 51X65MM NEURO RND CUT FLUT CARB ST MICROFRANCE,SUP-2278096,CDM,2720000010,LOCAL,0272,RC,,,,both,,,549.03,356.87,,,,,,,,,,,,,
COMPONENT ORIG ILIZ EXT FIX CIR FEM ARCHES 90 L SZ,SUP-2342768,CDM,C1776,CPT,0278,RC,,,,both,,,17376.29,11294.59,,,,,,,,,,,,,
GRAFT BNE PTTY 1 CC OSTEOSURGE 300,SUP-2644321,CDM,C1713,HCPCS,0278,RC,,,,both,,,1391.02,904.16,,,,,,,,,,,,,
NEEDLE BX 21 GAX4 CM ALWAYS-ON TIP TRACKED,SUP-2797907,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2670.57,1735.87,,,,,,,,,,,,,
GRAFT VASC HEMGRD L 100 CM DIA 7 MM POLYESTER BOV CLLGN STR,SUP-2227529,CDM,C1768,CPT,0278,RC,,,,both,,,1927.11,1252.62,,,,,,,,,,,,,
KIT REP FOR HALLUX VALGUS MINI TIGHTROPE,SUP-2122784,CDM,C1713,HCPCS,0278,RC,,,,both,,,1648.50,1071.52,,,,,,,,,,,,,
SCREW BNE L3MM DIA1.3MM STD CORT CRANIOMAXILLOFACIAL TI ST,SUP-2189170,CDM,C1713,HCPCS,0278,RC,,,,both,,,322.23,209.45,,,,,,,,,,,,,
SEEKER BAL L17MM DIA7MM FRONTAL SINUS FOR ENT,SUP-2284116,CDM,C1713,HCPCS,0278,RC,,,,both,,,3389.00,2202.85,,,,,,,,,,,,,
NEEDLE NERVE STIM BLNT ACCS KT INTEGRITY MONITOR XPAK NIM,SUP-2792158,CDM,2720000010,LOCAL,0272,RC,,,,both,,,998.71,649.16,,,,,,,,,,,,,
CLAMP XTRAFIX KROD MULTI PIN,SUP-2721918,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4139.78,2690.86,,,,,,,,,,,,,
"HC So Peptide,C",PX-3018468166,CDM,84681,CPT,0301,RC,,,,both,,,1561.00,1014.65,,,,,,,,,,,,,
BRACE WLK FULL SHELL WLK M M SHOE SZ 7 10 FEM SHOE SZ 8,SUP-2336093,CDM,L4360,HCPCS,0272,RC,,,,both,,,128.61,83.60,,,,,,,,,,,,,
KIT REP FOR CLAVICULAR PLT SYS ACU-SINCH,SUP-2106900,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3130.58,2034.88,,,,,,,,,,,,,
RING EXT FIX DIA230 MM HALF NS DISP SMRT TSF,SUP-2933073,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4775.75,3104.24,,,,,,,,,,,,,
BIT DRL L200MM DIA32MM QUIK CPL W O STP NONRADIOLUCENT,SUP-2315985,CDM,2720000010,LOCAL,0272,RC,,,,both,,,450.59,292.88,,,,,,,,,,,,,
GAUGE DEPTH CALCANEAL PLATE MIS NS VARIAX,SUP-2902301,CDM,C1713,HCPCS,0278,RC,,,,both,,,4069.44,2645.14,,,,,,,,,,,,,
BUR SURG L14CM DIA7MM BALL EXTRA COARSE DMND L BOR MIDAS,SUP-2277721,CDM,2720000010,LOCAL,0272,RC,,,,both,,,395.86,257.31,,,,,,,,,,,,,
INTRODUCER SHTH 0.018 IN 4 FRX10 CM 21 GAX7 CM NDL NIT S-MAK,SUP-2472762,CDM,C1894,HCPCS,0272,RC,,,,both,,,97.18,63.17,,,,,,,,,,,,,
PLATE BNE L282MM 15 H S STL LOK COMPR BROAD CRV FOR 4.5/5MM,SUP-2185307,CDM,C1713,HCPCS,0278,RC,,,,both,,,2366.49,1538.22,,,,,,,,,,,,,
STENT PANCREATIC GEENEN L 5 CM DIA10 FR GUIDEWIRE 0.035 IN,SUP-2169326,CDM,C2617,HCPCS,0278,RC,,,,both,,,188.40,122.46,,,,,,,,,,,,,
STEM FEM HIP PRI NEUT POR STR 40MM OFFSET TIV 11.0MM DIA,SUP-2203129,CDM,C1776,CPT,0278,RC,,,,both,,,15237.79,9904.56,,,,,,,,,,,,,
IMPLANT STRNL CLSR PEEK W NDL ZIPFIX,SUP-2182839,CDM,C1713,HCPCS,0278,RC,,,,both,,,459.23,298.50,,,,,,,,,,,,,
PATCH DURAL SUB 2.5X2.5CM ONLAY LYCOPLANT,SUP-2717534,CDM,C1763,HCPCS,0278,RC,,,,both,,,520.77,338.50,,,,,,,,,,,,,
CONNECTOR SCR FOR EXT FIX XCALIBER,SUP-2316284,CDM,C1713,HCPCS,0278,RC,,,,both,,,852.26,553.97,,,,,,,,,,,,,
VALVE DRAINAGE NEONATAL STD MED PRESSURE IN LN CYL ULTRA VS,SUP-2852576,CDM,C1889,HCPCS,0278,RC,,,,both,,,2330.85,1515.05,,,,,,,,,,,,,
PPICC PROVENA SOLO 4F DL 3CG,SUP-2613530,CDM,C1751,HCPCS,0278,RC,,,,both,,,757.96,492.67,,,,,,,,,,,,,
HC So Hepatitis B Surface Ag - Ref|NOT REASONABLE AND NECESSARY,PX-3068734067,CDM,87340,CPT,0306,RC,,,GZ,both,,,21.00,13.65,,,,,,,,,,,,,
ARTHROSCOPIC SET POSTLESS HIP DISTRCTN SYS DISP,SUP-2845688,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
WASHER ORTH COMPR 6.5 MM HD SCR RIVAL,SUP-2645125,CDM,C1713,HCPCS,0278,RC,,,,both,,,349.48,227.16,,,,,,,,,,,,,
PLATE BNE L210MM 15 H ST L ANTLAT DST TIB S STL LO PROF,SUP-2185965,CDM,C1713,HCPCS,0278,RC,,,,both,,,4660.45,3029.29,,,,,,,,,,,,,
GUIDE SURG DRL UNIV FOR EXTREMITIES STRL DISP,SUP-2882999,CDM,2720000010,LOCAL,0272,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
PLATE BNE 5X12 H ST BILAT MIDFOOT S STL LO PROF VAR ANG LOK,SUP-2178381,CDM,C1713,HCPCS,0278,RC,,,,both,,,5659.22,3678.49,,,,,,,,,,,,,
ALLOGRAFT BNE STRP 20X25X6 MM DEMINERALIZED CANC FLEXIGRAFT,SUP-2740835,CDM,C1713,HCPCS,0278,RC,,,,both,,,4299.23,2794.50,,,,,,,,,,,,,
SYSTEM NAIL FIBULA 2 3.0MMX190MM,SUP-2882446,CDM,C1713,HCPCS,0278,RC,,,,both,,,11052.80,7184.32,,,,,,,,,,,,,
HC So Cyclic Amp,PX-3078203066,CDM,82030,CPT,0307,RC,,,,both,,,437.00,284.05,,,,,,,,,,,,,
FENOFIBRATE 160 MG PO TABS,RX-28252,CDM,6370000000,HCPCS,0637,RC,00115-5522-10,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
BIT DRL DIA4.3MM LNG DST GRAD FOR AFFIXUS HIP FRAC NAIL,SUP-2412612,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1003.54,652.30,,,,,,,,,,,,,
PHENOBARBITAL 20 MG/5ML PO ELIX,RX-6212,CDM,340b,HCPCS,0637,RC,09999-9911-31,NDC,,both,7.5,ML,2.70,1.75,,,,,,,,,,,,,
BRACE WALKING ROCKER FT,SUP-2749880,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4700.58,3055.38,,,,,,,,,,,,,
HC So Chromosome Analysis 20-25,PX-3118826466,CDM,88264,CPT,0311,RC,,,,both,,,636.00,413.40,,,,,,,,,,,,,
STEM FEM L220MM OD11MM TI 80% POR PLSM SPRY DSTL CALCAR MOD,SUP-2403920,CDM,C1776,CPT,0278,RC,,,,both,,,6694.48,4351.41,,,,,,,,,,,,,
BUR SURG 3MM SH TAPR ROUTER FOR DURAGUARD,SUP-2363356,CDM,2720000010,LOCAL,0272,RC,,,,both,,,226.08,146.95,,,,,,,,,,,,,
BURR CARBIDE BALL FLUTED 5.0MM S5BC10FG1,SUP-2843316,CDM,2720000010,LOCAL,0272,RC,,,,both,,,712.69,463.25,,,,,,,,,,,,,
ENVELOP TISS XX LG SFT SUPPLE CORMATRIX CANGAROO EMC,SUP-2653873,CDM,C1889,HCPCS,0278,RC,,,,both,,,3925.00,2551.25,,,,,,,,,,,,,
IMPLANT TOE JT HAMR RMR NONSTERILE FEATURING HTR SYS,SUP-2390552,CDM,C1713,HCPCS,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
SPACER SPNL TRAP 20X10 MM HULL STT,SUP-2120680,CDM,C1821,HCPCS,0278,RC,,,,both,,,5482.44,3563.59,,,,,,,,,,,,,
HC Collection Capillary Blood Specimen,PX-3003641600,CDM,36416,CPT,0300,RC,,,,both,,,30.00,19.50,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE 10 CC CER GRAN TYPE-I BOV CLLGN RPM,SUP-2930811,CDM,C1763,HCPCS,0278,RC,,,,both,,,7693.00,5000.45,,,,,,,,,,,,,
GRAFT VASC GELWEAVE L 50 CM DIA 30 MM L 15CM 10 MM ANTE FLO,SUP-2385050,CDM,C1768,CPT,0278,RC,,,,both,,,2772.40,1802.06,,,,,,,,,,,,,
ALLOGRAFT BNE MENIS LAT LT FRZN FOR GLEN REPL HEMI PLATEAU,SUP-2494197,CDM,C1889,HCPCS,0278,RC,,,,both,,,18103.83,11767.49,,,,,,,,,,,,,
GRAFT BONE SUB 15CC FRZ DRY DEMIN CANC CHIP,SUP-2294030,CDM,C1713,HCPCS,0278,RC,,,,both,,,777.15,505.15,,,,,,,,,,,,,
CONTROLLER NEUROSTIMULATOR ACC REVW THER,SUP-2284583,CDM,C1787,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
VASOPRESSIN 20 UNIT/ML IV SOLN,RX-128198,CDM,J2598,HCPCS,0636,RC,00548-9701-00,NDC,,both,0.25,ML,54.10,35.16,,,,,,,,,,,,,
HC Fluro Esophagram,PX-3207422000,CDM,74220,CPT,0320,RC,,,,both,,,937.00,609.05,,,,,,,,,,,,,
CEMENT BONE 20GM RADPQ FOR KYPHOPLASTY STRL CONCORD HP,SUP-2231423,CDM,C1713,HCPCS,0278,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
CONNECTOR SPNL PARL VAR SIDE LD NORTHSTAR,SUP-2710723,CDM,C1713,HCPCS,0278,RC,,,,both,,,3061.50,1989.97,,,,,,,,,,,,,
DEFIBRILLATOR CARD SGL CHMBR ATLS VR,SUP-2357750,CDM,C1722,HCPCS,0275,RC,,,,both,,,50554.00,32860.10,,,,,,,,,,,,,
PLATE BONE RECONSTRUCTION SMALL 2.5 MM LEFT PREFORMED TITANI,SUP-2837778,CDM,C1713,HCPCS,0278,RC,,,,both,,,10236.09,6653.46,,,,,,,,,,,,,
GRAFT 6X6CM LT PERICARD,SUP-2400553,CDM,C1713,HCPCS,0278,RC,,,,both,,,8635.00,5612.75,,,,,,,,,,,,,
BACITRACIN 500 UNIT/GM OP OINT,RX-852,CDM,6370000000,HCPCS,0637,RC,00574-4022-35,NDC,,both,3.5,GR,486.40,316.16,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY L 115 CM DIA 7 FR D CRV HEXAPOLAR,SUP-2248755,CDM,C1730,HCPCS,0272,RC,,,,both,,,989.10,642.91,,,,,,,,,,,,,
HEAD FEM CERAMIC ON CERAMIC +4 MM NK LEN ALUMINA 32 MM DIA,SUP-2364459,CDM,C1776,CPT,0278,RC,,,,both,,,4041.18,2626.77,,,,,,,,,,,,,
BUR SURG DIA 8 MM HUB III ROSEN STRL REUSE HI-LINE,SUP-2928997,CDM,2720000010,LOCAL,0272,RC,,,,both,,,705.93,458.85,,,,,,,,,,,,,
GRAFT BNE SUB 5ML HA CLLGN INJ FILL RESRB HEALOS FX,SUP-2255629,CDM,C1713,HCPCS,0278,RC,,,,both,,,2911.75,1892.64,,,,,,,,,,,,,
TM STEM/TM CUP/LG HD/XLPE LNR,SUP-2212130,CDM,C1776,CPT,0278,RC,,,,both,,,19094.37,12411.34,,,,,,,,,,,,,
GUIDEWIRE ORTH L304MM OD1.1MM SMOOTH CANN BLNT TIP FLX,SUP-2341320,CDM,C1769,HCPCS,0272,RC,,,,both,,,61.76,40.14,,,,,,,,,,,,,
BUSHING TIB POLY LO FRIC INTFACE OSS,SUP-2405827,CDM,C1776,CPT,0278,RC,,,,both,,,748.89,486.78,,,,,,,,,,,,,
TRIAL SURG DIA1.8MM LNG PROV FOR WIRE,SUP-2351112,CDM,C1713,HCPCS,0278,RC,,,,both,,,529.97,344.48,,,,,,,,,,,,,
EMTRICITABINE-TENOFOVIR DF 200-300 MG PO TABS,RX-39255,CDM,6370000000,HCPCS,0637,RC,61958-0701-01,NDC,,both,1,UN,276.40,179.66,,,,,,,,,,,,,
HC Vaginal Delivery,PX-7200000001,CDM,7200000001,LOCAL,0720,RC,,,,both,,,15853.00,10304.45,,,,,,,,,,,,,
PLATE TIBIAL SIZE 5 BASEPLATE TRABECULAR METAL,SUP-2493918,CDM,C1713,HCPCS,0278,RC,,,,both,,,9831.34,6390.37,,,,,,,,,,,,,
PLATE BONE L77MM THK3.3MM HK D18MM 8 H LT CLAV TI RIG NEUT,SUP-2190921,CDM,C1713,HCPCS,0278,RC,,,,both,,,2461.35,1599.88,,,,,,,,,,,,,
SLEEVE CANN DIA12 MM SHRT RADIALLY EXPANDABLE STRL DISP,SUP-2896315,CDM,2720000010,LOCAL,0272,RC,,,,both,,,317.39,206.30,,,,,,,,,,,,,
WALKER PT M LOWEST PROF W/ CRISS CROSS STRP THREE-D,SUP-2195482,CDM,L4386,HCPCS,0274,RC,,,,both,,,195.03,126.77,,,,,,,,,,,,,
DRILL SURG DIA4.2MM GLD POST/PEG DISP FOR MTP FUS PLATING,SUP-2223992,CDM,2720000010,LOCAL,0272,RC,,,,both,,,489.84,318.40,,,,,,,,,,,,,
NEXGEN PRECOAT STEMMED TIBIAL PLATE SZ 7,SUP-2503045,CDM,C1713,HCPCS,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
STEM FEM L110MM OD11MM 115DEG CO CHROM COMP FULL COAT HIP,SUP-2198926,CDM,C1776,CPT,0278,RC,,,,both,,,17226.04,11196.93,,,,,,,,,,,,,
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,0636,RC,00641-6007-10,NDC,,both,2,ML,54.10,35.16,,,,,,,,,,,,,
MESH PLUG ULTRAPRO 3CM ANCHR 5CM RIM SM,SUP-2220113,CDM,C1781,HCPCS,0278,RC,,,,both,,,697.90,453.63,,,,,,,,,,,,,
KNIFE OPHTH DIAMOND 4.7 INX2-2.4 MM ANGLED TRAP TRU-SIZE,SUP-2465484,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6300.57,4095.37,,,,,,,,,,,,,
CLIP INT USE L 235 CM DIA2.8 MM SS CAPSULE COCR YOKE STYRENE 20/BX,SUP-2905532,CDM,C1889,HCPCS,0278,RC,,,,both,,,1145.16,744.35,,,,,,,,,,,,,
SCREW BONE L4MM OD1.7MM TI CORT CRANIOMAXILLOFACIAL,SUP-2363332,CDM,C1713,HCPCS,0278,RC,,,,both,,,114.58,74.48,,,,,,,,,,,,,
PLATE CRAN L 48 X W 38 MM THK 0.85 MM TI SKULL BASE CRV,SUP-2883682,CDM,C1713,HCPCS,0278,RC,,,,both,,,4785.11,3110.32,,,,,,,,,,,,,
STENT BILI DIA7FR ASMBLY L50CM DIA8.5FR LAPSCP ENDOBILI SET,SUP-2168855,CDM,C2625,HCPCS,0278,RC,,,,both,,,1978.20,1285.83,,,,,,,,,,,,,
PLATE BNE 4 H CRANIOMAXILLOFACIAL TI LO PROF X FOR UNIV,SUP-2366211,CDM,C1713,HCPCS,0278,RC,,,,both,,,752.82,489.33,,,,,,,,,,,,,
CATHETER ANGIOPLSTY POLARCATH L 135 CM BALLOON L 100 MM,SUP-2141226,CDM,C1725,HCPCS,0272,RC,,,,both,,,2885.66,1875.68,,,,,,,,,,,,,
INTRODUCER 4FRX7CM S STEELNITINOL MICPUNC ECHO STIFF,SUP-2267050,CDM,C1894,HCPCS,0272,RC,,,,both,,,56.52,36.74,,,,,,,,,,,,,
DEVICE FIX ARTC RELDABLE W/ 1 HNDL 3 10 TACK STD PURCH RELD,SUP-2283329,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1485.72,965.72,,,,,,,,,,,,,
PLATE BNE L 147 X W 10.5 MM THK 3 MM SCREW DIA2.7/3.5 MM 11 72466611,SUP-2933305,CDM,C1713,HCPCS,0278,RC,,,,both,,,6005.88,3903.82,,,,,,,,,,,,,
NAIL INTRAMEDULLARY 3MM DIA 210MML TITANIUM ULNAR,SUP-2640104,CDM,C1713,HCPCS,0278,RC,,,,both,,,5966.00,3877.90,,,,,,,,,,,,,
GUIDEWIRE ORTH DIA3.2MM THRD TRCR PNT,SUP-2347053,CDM,C1769,HCPCS,0272,RC,,,,both,,,469.05,304.88,,,,,,,,,,,,,
GRAFT BONE SUB 10ML SYR DEMIN MTRX INJ MOLD OPTECURE,SUP-2223575,CDM,C1713,HCPCS,0278,RC,,,,both,,,5086.80,3306.42,,,,,,,,,,,,,
SUBSTITUTE BONE GRFT MINI BEAD FAST SET CA SULF RESRB OD,SUP-2400546,CDM,C1713,HCPCS,0278,RC,,,,both,,,2229.40,1449.11,,,,,,,,,,,,,
SHEATH INTRO FAST-CATH L 12 CM DIA13 FR GUIDEWIRE L 50 CM,SUP-2355542,CDM,C1894,HCPCS,0272,RC,,,,both,,,51.03,33.17,,,,,,,,,,,,,
SHUNT NEUROSURGICAL 10/50CM WATER WITH BURR HOLE RESERVIOR N,SUP-2821795,CDM,C1889,HCPCS,0278,RC,,,,both,,,6900.18,4485.12,,,,,,,,,,,,,
LATANOPROST 0.005 % OP SOLN,RX-18621,CDM,6370000000,HCPCS,0637,RC,61314-0547-01,NDC,,both,2.5,ML,48.20,31.33,,,,,,,,,,,,,
PLATE BNE CONTOURABLE MESH 70X0.6 MM RIGID TI SLV STRL,SUP-2859914,CDM,C1713,HCPCS,0278,RC,,,,both,,,4764.64,3097.02,,,,,,,,,,,,,
PLATE BNE CNDYL 90 DEG PEDIATRIC 5X159 MM 23/15 MM LCP,SUP-2799202,CDM,C1713,HCPCS,0278,RC,,,,both,,,2803.05,1821.98,,,,,,,,,,,,,
MESH SYNTH ABD ABSRB COAT RECT POLYPR O3FA OVL FLAT SH 10CM,SUP-2265954,CDM,C1781,HCPCS,0278,RC,,,,both,,,93.10,60.51,,,,,,,,,,,,,
BIT DRL L170MM DIA3.2MM ST CANN QUIK CPL NONRADIOLUCENT ADJ,SUP-2187333,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1220.24,793.16,,,,,,,,,,,,,
WIRE ORTH TOT FT SYS DISP L100MM OD1.1MM K,SUP-2243135,CDM,C1713,HCPCS,0278,RC,,,,both,,,93.98,61.09,,,,,,,,,,,,,
HC X-Ray Exam Abdomen 2 Views,PX-3207401900,CDM,74019,CPT,0320,RC,,,,both,,,890.00,578.50,,,,,,,,,,,,,
GUIDEWIRE VASC L 30 CM DIA 0.018 IN SS SAFE-T-J STR FIX COR,SUP-2167843,CDM,C1769,HCPCS,0272,RC,,,,both,,,103.31,67.15,,,,,,,,,,,,,
NAIL IM 5X28 MM TIB W/ T25 STARDRV FOR LCK SCREW TI NS,SUP-2179924,CDM,C1713,HCPCS,0278,RC,,,,both,,,749.71,487.31,,,,,,,,,,,,,
CATHETER ABLAT L115 7FR 2-5-2MM SPC TR DEFL A TYP 4 POLE 10,SUP-2248785,CDM,C1730,HCPCS,0272,RC,,,,both,,,2367.56,1538.91,,,,,,,,,,,,,
HC US Guidance for Amniocentsis,PX-4027694600,CDM,76946,CPT,0402,RC,,,,outpatient,,,1605.00,1043.25,,,,,,,,,,,,,
SCREW BNE L12MM DIA2.7MM CORT TI ST FULL THRD SM HEX FOR,SUP-2189693,CDM,C1713,HCPCS,0278,RC,,,,both,,,118.44,76.99,,,,,,,,,,,,,
TROCAR SURG 64 MM FOR 2.0/2.7 MM SYS,SUP-2462645,CDM,2720000010,LOCAL,0272,RC,,,,both,,,350.80,228.02,,,,,,,,,,,,,
CATHETER SUPP NAVIEN L 125 CM OD 0.070 IN ID 0.058 IN FLX,SUP-2281409,CDM,C1887,HCPCS,0272,RC,,,,both,,,5133.90,3337.03,,,,,,,,,,,,,
BRACE ANK AD H95IN UNIV BILAT SEMI RIG SHELL PROTCT,SUP-2196371,CDM,L4350,HCPCS,0274,RC,,,,both,,,53.25,34.61,,,,,,,,,,,,,
GRAFT BNE SUB 9ML VOID FILL RESRB PTTY MASTERGRFT,SUP-2288543,CDM,C9359,HCPCS,0278,RC,,,,both,,,3463.42,2251.22,,,,,,,,,,,,,
CLAMP EXT FIX DIA4MM DST RAD TI ALLY ADJ FOR SCHNZ SCR,SUP-2188538,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2237.72,1454.52,,,,,,,,,,,,,
HC Hepatic Function Panel,PX-3018007600,CDM,80076,CPT,0301,RC,,,,both,,,317.00,206.05,,,,,,,,,,,,,
SPACER SPNL PARL 0 DEG 23X10X8 MM SLD TRABECULAR MTL TM-500,SUP-2414293,CDM,C1889,HCPCS,0278,RC,,,,both,,,10644.60,6918.99,,,,,,,,,,,,,
SCREWDRIVER ASD MAXDRIVE 20 ST,SUP-2262987,CDM,2720000010,LOCAL,0272,RC,,,,both,,,486.07,315.95,,,,,,,,,,,,,
LEAD ICD RT VENT BPLR 21CM SPC A,SUP-2357380,CDM,C1895,HCPCS,0275,RC,,,,both,,,10990.00,7143.50,,,,,,,,,,,,,
COVER BURR HOLE ULTRA LO PROF 15 MM 5 HOLE STR NEUT TAB TI,SUP-2262589,CDM,C1713,HCPCS,0278,RC,,,,both,,,910.63,591.91,,,,,,,,,,,,,
SCREW SPNL TI L15 MM OD4 MM REV PARA COR STALIF C,SUP-2163206,CDM,C1713,HCPCS,0278,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
PLATE BNE STR MINI 6 HOLE COMPR NS LTX,SUP-2855822,CDM,C1713,HCPCS,0278,RC,,,,both,,,295.16,191.85,,,,,,,,,,,,,
BUR REPROC SHV 5.5MMX18CM ABRAD HI VISIBILITY,SUP-2652939,CDM,2720000010,LOCAL,0272,RC,,,,both,,,112.38,73.05,,,,,,,,,,,,,
PACER S ZEPHYR SR 5620,SUP-2356213,CDM,C1786,HCPCS,0275,RC,,,,both,,,18080.12,11752.08,,,,,,,,,,,,,
KIT INTRO VSI L 5.5 CM DIA 5 FR GUIDEWIRE L 40 CM DIA 0.018,SUP-2120552,CDM,C1894,HCPCS,0272,RC,,,,both,,,178.98,116.34,,,,,,,,,,,,,
ENDOPROSTHESIS VASC VIABAHN L 5CM 11MM 120CM HEPARIN,SUP-2396581,CDM,C1874,HCPCS,0278,RC,,,,both,,,11008.84,7155.75,,,,,,,,,,,,,
OSS AVL TIBIAL LOCK RING,SUP-2506413,CDM,C1776,CPT,0278,RC,,,,both,,,1045.62,679.65,,,,,,,,,,,,,
PATCH CV IVENA L 75 X W 10 MM PTFE ARW SHP,SUP-2763171,CDM,C1768,CPT,0278,RC,,,,both,,,716.61,465.80,,,,,,,,,,,,,
RAIL EXT FIX MINI 2.75 IN SYS RX-FIX,SUP-2517151,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8107.48,5269.86,,,,,,,,,,,,,
COMPONENT TIB CR 0 11 MM RT KNEE PRIMARY STEM CEM NP UCONG,SUP-2209405,CDM,C1776,CPT,0278,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
HC US Guidance for Amniocentsis,PX-4027694600,CDM,76946,CPT,0402,RC,,,,inpatient,,,1605.00,1043.25,,,,,,,,,,,,,
CATHETER THROMCTMY ANGIOJET L 140 CM DIA 5 FR RHEOLYTIC STRL,SUP-2277419,CDM,C1757,HCPCS,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
CAP SPNL DIA5.5MM LOK CREO,SUP-2228664,CDM,C1713,HCPCS,0278,RC,,,,both,,,188.40,122.46,,,,,,,,,,,,,
BRACE ORTH CARBON FIBER FRME LT KNEE PCL S/TH S/CF ADJ OA,SUP-2914992,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1338.27,869.88,,,,,,,,,,,,,
INSTRUMENT SFT TISS REL ENDOSCP CENTERLINE,SUP-2122776,CDM,2720000010,LOCAL,0272,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
HC So1 Hepatitis C Virus Antibody,PX-3028680367,CDM,86803,CPT,0302,RC,,,,both,,,145.00,94.25,,,,,,,,,,,,,
BALLOON ENDOSCP EUS CUF US FOR GFUM20 JFUM20 GFUC140PAL5,SUP-2313288,CDM,C1753,HCPCS,0278,RC,,,,both,,,92.25,59.96,,,,,,,,,,,,,
STAPLER INT CUT LN 51MM STPL 51MM BLU CRV HD B FRM,SUP-2716239,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1581.52,1027.99,,,,,,,,,,,,,
HC J Tube Plcmt,PX-3614944100,CDM,49441,CPT,0361,RC,,,,outpatient,,,8583.00,5578.95,,,,,,,,,,,,,
BIT DRL UNIV MIC FX DISP,SUP-2366674,CDM,2720000010,LOCAL,0272,RC,,,,both,,,932.58,606.18,,,,,,,,,,,,,
ELECTRODE ES L DIA4MM SUCT LO PROF INTEGR HNDL VAPR,SUP-2249476,CDM,2720000010,LOCAL,0272,RC,,,,both,,,935.72,608.22,,,,,,,,,,,,,
SYSTEM STENT GRFT OVATION PRIM L 100 MM DIA PROX/DSTL,SUP-2217738,CDM,C1713,HCPCS,0278,RC,,,,both,,,11775.00,7653.75,,,,,,,,,,,,,
ANCHOR SUTURE L14MM DIAMETER 5MM PRELOADED ON DRIVER WITH NO,SUP-2825017,CDM,C1713,HCPCS,0278,RC,,,,both,,,702.54,456.65,,,,,,,,,,,,,
MASK LARYN CHLD 30 50KG SZ 3 20ML CLASS,SUP-2384073,CDM,C1713,HCPCS,0278,RC,,,,both,,,1036.20,673.53,,,,,,,,,,,,,
CATHETER CV KT 9 FRX11.5 CM DSTL DL FOR 7.5-8 FR MAC,SUP-2763355,CDM,C1751,HCPCS,0278,RC,,,,both,,,568.97,369.83,,,,,,,,,,,,,
TUBE VNTLTN RUBE 114MM ID LUMEN 1MM DIA INNER FLNGE DSTNCE,SUP-2669492,CDM,L8699,HCPCS,0278,RC,,,,both,,,44.09,28.66,,,,,,,,,,,,,
PLATE BNE L45MM THK3MM 3 H BILAT S STL STR LIMIT CNTCT DYN,SUP-2185328,CDM,C1713,HCPCS,0278,RC,,,,both,,,1319.05,857.38,,,,,,,,,,,,,
SCREW BONE L10MM OD2.6MM TI REDUC FOR TOT COMPR PLT,SUP-2396927,CDM,C1713,HCPCS,0278,RC,,,,both,,,364.24,236.76,,,,,,,,,,,,,
GRAFT 2CMX7CM ACELLULAR DURADERM,SUP-2126452,CDM,C1762,CPT,0278,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
HC Iadna Trichomonas Vaginalis Amplified Probe Tech,PX-3068766100,CDM,87661,CPT,0306,RC,,,,both,,,120.00,78.00,,,,,,,,,,,,,
PLATE BNE ANTI-GLADE MEDL 4 HOLE,SUP-2518427,CDM,C1713,HCPCS,0278,RC,,,,both,,,3548.20,2306.33,,,,,,,,,,,,,
SCREW BONE L5MM DIA2.7MM TI ST FULL THRD EMER MATRIXMANDIBLE,SUP-2181734,CDM,C1713,HCPCS,0278,RC,,,,both,,,397.84,258.60,,,,,,,,,,,,,
BIT DRVR T10 STARDRV W/ AO END DISP,SUP-2242461,CDM,2720000010,LOCAL,0272,RC,,,,both,,,497.12,323.13,,,,,,,,,,,,,
BLOCK TIB SZ 9 THK10MM UNIV CO CHROM KNEE HALF PRI CEM TOT,SUP-2378522,CDM,C1776,CPT,0278,RC,,,,both,,,2548.42,1656.47,,,,,,,,,,,,,
PLATE BONE DOUBLE ANGLE SMALL 1.5 MM PRECONTOURED RECONSTRUC,SUP-2842353,CDM,C1713,HCPCS,0278,RC,,,,both,,,7844.66,5099.03,,,,,,,,,,,,,
GRAFT HUM TISS PTCH MED 2X3 CM AMNION RESTORIGIN,SUP-2321880,CDM,Q4191,HCPCS,0636,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
CATHETER PACE 5FR L110CM 6FR INTRO D10CM 1MM SPACE POLYUR,SUP-2355209,CDM,C1894,HCPCS,0272,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
THREAD LOCK MNDBLR RCNSTRCTN PLATE ANGLD RGHT 13 HOLE CP TTN,SUP-2681352,CDM,C1713,HCPCS,0278,RC,,,,both,,,3621.05,2353.68,,,,,,,,,,,,,
CATHETER URET OPN END 040 5 FRX70 CM SOFFLX,SUP-2835723,CDM,C1758,HCPCS,0278,RC,,,,both,,,32.94,21.41,,,,,,,,,,,,,
BIT DRL DIA2.8MM FOR 3.5MM SCR SALVATION 2 MIDFOOT NAIL SYS,SUP-2417601,CDM,2720000010,LOCAL,0272,RC,,,,both,,,806.98,524.54,,,,,,,,,,,,,
GUIDE WIRE 1 MMX95 MM STRL,SUP-2814251,CDM,C1769,HCPCS,0272,RC,,,,both,,,62.80,40.82,,,,,,,,,,,,,
HEPARIN (PORK) 100 UNIT/ML IV SOLN - (MIXTURES ONLY),RX-430068,CDM,J1642,HCPCS,0636,RC,64253-0333-35,NDC,,both,1,ML,54.10,35.16,,,,,,,,,,,,,
CONNECTOR SPNL 55 55MM OPN SIDE CDH DOMINO,SUP-2279961,CDM,C1713,HCPCS,0278,RC,,,,both,,,2439.78,1585.86,,,,,,,,,,,,,
NEEDLE ASPRIRATION 25GA EXPECT PULMONARY,SUP-2855142,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3078.77,2001.20,,,,,,,,,,,,,
PLATE BONE SZ 1.5MM REG 6 H SLV DBL Y SHP TRAUMAONE LORENZ,SUP-2402884,CDM,C1713,HCPCS,0278,RC,,,,both,,,452.16,293.90,,,,,,,,,,,,,
SEED BRACHYTHERAPY LOAD 8.01-9.0 MCI STRL ADVANTAGE 2029ILS1] ISOAID LLC],SUP-2247281,CDM,C2642,HCPCS,0278,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
LEAD NEUROSTIMULATOR 16 CNTCT L50CM TRL INFINION,SUP-2138788,CDM,C1778,HCPCS,0278,RC,,,,both,,,10048.00,6531.20,,,,,,,,,,,,,
PLATE 3.5MM TI LCP PROXIMAL TIBIA LOW BEND 10H 154MM LT STER,SUP-2546871,CDM,C1713,HCPCS,0278,RC,,,,both,,,4744.79,3084.11,,,,,,,,,,,,,
HC Pet/CT Limited Area,PX-4047881400,CDM,78814,CPT,0404,RC,,,,both,,,5429.00,3528.85,,,,,,,,,,,,,
VALVE MITRL STENT 23 MM BIOCOR,SUP-2357531,CDM,C1889,HCPCS,0278,RC,,,,both,,,22294.00,14491.10,,,,,,,,,,,,,
ENDOPROSTHESIS TRACHBRONCH VIABAHN L 10 CM DIA10 MM NIT,SUP-2396463,CDM,C1874,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
CROWN DENT LL7 SEC PRI M INDIV SPACE MAINTAINER,SUP-2176706,CDM,D6783,CPT,0278,RC,,,,both,,,21.51,13.98,,,,,,,,,,,,,
IONOMER GLASS VITREBOND POWDER 9GM,SUP-2714084,CDM,2720000010,LOCAL,0272,RC,,,,both,,,662.51,430.63,,,,,,,,,,,,,
BLADE ARTHSCP SHV L11CM DIA4MM 12DEG AGG IRR ANG FOR SM JT,SUP-2363537,CDM,2720000010,LOCAL,0272,RC,,,,both,,,426.16,277.00,,,,,,,,,,,,,
PLATE BNE STRNL 2.3X1.8 MM THOR 2X2 HOLE LCK LADDER LEVEL 1,SUP-2869223,CDM,C1713,HCPCS,0278,RC,,,,both,,,1019.62,662.75,,,,,,,,,,,,,
DISC SURG ALUM SHIM,SUP-2417198,CDM,2720000010,LOCAL,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
VALVE AORT HANCOCK II ULTRA SZ 23 MM PORCINE STENT ACETAL,SUP-2650235,CDM,C1889,HCPCS,0278,RC,,,,both,,,9420.00,6123.00,,,,,,,,,,,,,
NUT 14MM STERILE,SUP-2761698,CDM,C1713,HCPCS,0278,RC,,,,both,,,778.78,506.21,,,,,,,,,,,,,
CATHETER CTRL VEN L55CM L70CM OD6FR .018IN POLYUR 3 LUMN,SUP-2125557,CDM,C1751,HCPCS,0278,RC,,,,both,,,585.61,380.65,,,,,,,,,,,,,
PLATE BNE CRANIOMAXILLOFACIAL THK06MM 7 H Y SHP PROF MIDFACE,SUP-2262679,CDM,C1713,HCPCS,0278,RC,,,,both,,,815.93,530.35,,,,,,,,,,,,,
HC Emergent/Unsched Dialysis,PX-8290025700,CDM,G0257,CPT,0829,RC,,,,both,,,810.00,526.50,,,,,,,,,,,,,
STAPLER INT TRNSOR CIR ANVIL W/ ADVANCING 21MM PROX GUID,SUP-2283247,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1078.90,701.28,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 4.6 MMX72 CM CRYOVEIN,SUP-2264649,CDM,C1762,CPT,0278,RC,,,,both,,,21022.30,13664.49,,,,,,,,,,,,,
ANCHOR SFT TISS L10MM IMPL MENIS ARW,SUP-2137751,CDM,C1713,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
COIL NEUROVASCULAR MICROPLEX L 30 CM LOOP DIA14 MM,SUP-2305217,CDM,C1889,HCPCS,0278,RC,,,,both,,,2323.60,1510.34,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 70 CM DIA 6 MM 20 CM STR STD WALL,SUP-2396265,CDM,C1768,CPT,0278,RC,,,,both,,,3428.88,2228.77,,,,,,,,,,,,,
PLATE BNE L139MM 6 H TI TIM R DST FIBULAR LOK COMPR ANAT,SUP-2413694,CDM,C1713,HCPCS,0278,RC,,,,both,,,2484.84,1615.15,,,,,,,,,,,,,
TAP SURG 4MM,SUP-2320976,CDM,2720000010,LOCAL,0272,RC,,,,both,,,588.75,382.69,,,,,,,,,,,,,
DRILL SURG STP 4X200 MM CANN,SUP-2749974,CDM,2720000010,LOCAL,0272,RC,,,,both,,,414.48,269.41,,,,,,,,,,,,,
SYSTEM DRL GUID ACL PCL COMPONENTS GRAD DRL TIP PASS PIN,SUP-2341114,CDM,2720000010,LOCAL,0272,RC,,,,both,,,365.97,237.88,,,,,,,,,,,,,
PLATE BNE M 5DEG R MT PRI NONBIOABSORBABLE INT FIX SYS,SUP-2321469,CDM,C1713,HCPCS,0278,RC,,,,both,,,4725.70,3071.70,,,,,,,,,,,,,
SYSTEM THROMCTMY CLEANER15 L 135 CM DIA 7 FR SINUSOIDAL WIRE,SUP-2120128,CDM,C1757,HCPCS,0272,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
SIZER SURG GEL 6.7 CM PROJCT 14.5 CM 725 CC RND MEMORYGEL,SUP-2758680,CDM,2720000010,LOCAL,0272,RC,,,,both,,,753.60,489.84,,,,,,,,,,,,,
LOOP ENDOSCP ELECTROCAUTERY L 120 X W 85 MM UPLR SPARE NS,SUP-2884646,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1004.42,652.87,,,,,,,,,,,,,
BODY HUM TI POR PROX EL STD MOSAIC,SUP-2403496,CDM,C1776,CPT,0278,RC,,,,both,,,11253.76,7314.94,,,,,,,,,,,,,
PLATE BNE L177MM 11 H NONSTERILE R LAT DST FIBULAR S STL,SUP-2184165,CDM,C1713,HCPCS,0278,RC,,,,both,,,1835.17,1192.86,,,,,,,,,,,,,
CATHETER HD STR EXTN 12.5 FRX32 CM LT DL STP TIP SIL HEMCATH,SUP-2627318,CDM,C1750,HCPCS,0278,RC,,,,both,,,128.74,83.68,,,,,,,,,,,,,
TROCAR 25GA 2ND CONSTELLATION,SUP-2109940,CDM,2720000010,LOCAL,0272,RC,,,,both,,,438.06,284.74,,,,,,,,,,,,,
CATH BLLN SCORING 7X40MM X 137CM OTW PTA ANGIOSCULPT XL,SUP-2353075,CDM,C1725,HCPCS,0272,RC,,,,both,,,4380.30,2847.19,,,,,,,,,,,,,
CATHETER ANGIO LANGSTON L 102 CM WORKING L 95 CM DIA 6 FR,SUP-2120498,CDM,C1751,HCPCS,0278,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
HC Dna/Rna Amplified Probe,PX-3008715000,CDM,87150,CPT,0300,RC,,,,both,,,177.00,115.05,,,,,,,,,,,,,
ALLOGRAFT HUM TISS AMNIO MEMBRN 4X4 CM DRY ALLOWRAP DRY,SUP-2717792,CDM,Q4150,HCPCS,0636,RC,,,,both,,,12265.63,7972.66,,,,,,,,,,,,,
PLATE PL DSTL HUM 2.7/3.5MM 13H LT 205MM STRL TI VA LCP,SUP-2546793,CDM,C1713,HCPCS,0278,RC,,,,both,,,4310.44,2801.79,,,,,,,,,,,,,
REAMER 17X8MM TREPH CHG,SUP-2207343,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2802.45,1821.59,,,,,,,,,,,,,
PLATE BONE TIBIAL RIGHT PROXIMAL LATERAL 4 HOLE LOCKING,SUP-2836983,CDM,C1713,HCPCS,0278,RC,,,,both,,,8162.74,5305.78,,,,,,,,,,,,,
PROBE NSL STR,SUP-2713678,CDM,2720000010,LOCAL,0272,RC,,,,both,,,715.92,465.35,,,,,,,,,,,,,
GUIDEWIRE VASC PRELUDE L 80 CM DIA 0.038 IN TIP L 3 MM SS,SUP-2303471,CDM,C1769,HCPCS,0272,RC,,,,both,,,25.97,16.88,,,,,,,,,,,,,
CATHETER IVL L 150 CM DIA1.5 MM SHTH 5 FR GUIDEWIRE 0.014 IN,SUP-2910584,CDM,C1725,HCPCS,0272,RC,,,,both,,,14758.00,9592.70,,,,,,,,,,,,,
GUIDEWIRE URO L145CM DIA0.035IN TIP 5CM ULT STIFF FLEX S STL,SUP-2417169,CDM,C1769,HCPCS,0272,RC,,,,both,,,113.29,73.64,,,,,,,,,,,,,
CATH ABLATION TACTIFLEX SE BID CURVE D-F,SUP-2874130,CDM,C2630,CPT,0272,RC,,,,both,,,12089.00,7857.85,,,,,,,,,,,,,
POST EX FX MAXFRAME MULTIPAR PIN MNT 2HIGH,SUP-2737903,CDM,2720000010,LOCAL,0272,RC,,,,both,,,538.82,350.23,,,,,,,,,,,,,
NAIL ELASTIC 1.5MM SS 300MM,SUP-2547599,CDM,C1713,HCPCS,0278,RC,,,,both,,,737.02,479.06,,,,,,,,,,,,,
PLATE BNE L133MM 7 H L PROX HUM LO ALPS,SUP-2411634,CDM,C1713,HCPCS,0278,RC,,,,both,,,6939.40,4510.61,,,,,,,,,,,,,
GUIDEWIRE UROLOGY STR 0.038 INX150 CM STANDARD-BODY HIWIRE,SUP-2835972,CDM,C1769,HCPCS,0272,RC,,,,both,,,103.97,67.58,,,,,,,,,,,,,
MODEL ANAT FULL SKULL PED UPTO 5YR 3D CT BASE OSTEOVIEW,SUP-2883400,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4763.69,3096.40,,,,,,,,,,,,,
IMPLANT JOINT PYROSPHERE PCS SZ 30,SUP-2852828,CDM,C1776,CPT,0278,RC,,,,both,,,10974.30,7133.29,,,,,,,,,,,,,
PROBE ABLAT 17GA L20CM CBL L1.4M STD PERC ACT ZONE DISPLAY 3,SUP-2219810,CDM,C1886,HCPCS,0278,RC,,,,both,,,12484.64,8115.02,,,,,,,,,,,,,
SCREW BONE L24MM DIA3.5MM S STL LCK WSHR SURFIX,SUP-2243355,CDM,C1713,HCPCS,0278,RC,,,,both,,,847.80,551.07,,,,,,,,,,,,,
PLATE EXT FIX BRAC LOK NUT FOR SIDEKCK STLTH FIX REARFOOT,SUP-2400644,CDM,C1713,HCPCS,0278,RC,,,,both,,,113.04,73.48,,,,,,,,,,,,,
PLATE BNE SZ 2.8 MM MIDFACE PMI NS DISP ACCUPLATE,SUP-2935861,CDM,C1713,HCPCS,0278,RC,,,,both,,,56585.94,36780.86,,,,,,,,,,,,,
CLAMP TI 16MM CRANOFIX,SUP-2108407,CDM,2720000010,LOCAL,0272,RC,,,,both,,,360.57,234.37,,,,,,,,,,,,,
DEFIBRILLATOR CRD SINGLE CHMBR 40 J 4X7.1X1.4 CM 35 CC 75 GM,SUP-2356261,CDM,C1722,HCPCS,0275,RC,,,,both,,,56834.00,36942.10,,,,,,,,,,,,,
HC Custom Wrist/Hand Static,PX-2740390601,CDM,L3906,HCPCS,0272,RC,,,,inpatient,,,1403.00,911.95,,,,,,,,,,,,,
MESH HERN W10XL15CM OVL BIOMATERIAL PTFE KNIT DURABLE SGL,SUP-2395758,CDM,C1781,HCPCS,0278,RC,,,,both,,,2345.58,1524.63,,,,,,,,,,,,,
HC Custom Wrist/Hand Static,PX-2740390601,CDM,L3906,HCPCS,0272,RC,,,,outpatient,,,1403.00,911.95,,,,,,,,,,,,,
HC Ot Therapeutic Activities 15 Min|OP OCCUPATIONAL THERAPY SERV|SERVICES PROVIDED IN WHOLE OR IN PARTY BY AN OTA FOR MEDICARE PATIENTS,PX-4309753000,CDM,97530,CPT,0430,RC,,,GO|CO,both,,,144.00,93.60,,,,,,,,,,,,,
EXTENDER BONE GRFT 15ML CUBE CANC,SUP-2165575,CDM,C1762,CPT,0278,RC,,,,both,,,816.40,530.66,,,,,,,,,,,,,
GRAFT VASC GELSFT L 45 CM DIA14 MM BRANCH DIA 7 MM POLYESTER,SUP-2384926,CDM,C1768,CPT,0278,RC,,,,both,,,3532.50,2296.12,,,,,,,,,,,,,
FORCEPS BX L115CM DIA1.1MM ELONG TEETH RNG HNDL DISP,SUP-2139315,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1098.40,713.96,,,,,,,,,,,,,
COIL VASC EMBOLD L 50 CM DIA10 MM CATH LUMEN DIA 0.021 IN,SUP-2753954,CDM,C1889,HCPCS,0278,RC,,,,both,,,4411.70,2867.60,,,,,,,,,,,,,
PLATE BNE L83MM 5 H L DST LAT FIBULAR VAR ANG LOK FOR 3.5MM,SUP-2349828,CDM,C1713,HCPCS,0278,RC,,,,both,,,5863.17,3811.06,,,,,,,,,,,,,
IMPLANT PENILE 21CM CYL INFL MINOCYCLINE RIFAMPIN INHIBIZONE,SUP-2140277,CDM,C1815,HCPCS,0278,RC,,,,both,,,9215.90,5990.33,,,,,,,,,,,,,
PLATE BNE X 2.3X1.5 MM 15 MM THOR RIB 14 HOLE LCK LEVEL 1,SUP-2869167,CDM,C1713,HCPCS,0278,RC,,,,both,,,3641.77,2367.15,,,,,,,,,,,,,
BLADE SURG ULTRA AGGRESSIVE XL 4.2 MM + STRL FMS VUE DISP,SUP-2624800,CDM,2720000010,LOCAL,0272,RC,,,,both,,,336.61,218.80,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 40 CM DIA 5 MM STR HELIX SLDE GDS,SUP-2525460,CDM,C1768,CPT,0278,RC,,,,both,,,1687.88,1097.12,,,,,,,,,,,,,
TRAY CATH PICC Q CATH BSC 2FR 30CM 1 LUMAN W/EXCLBR INTRO FL,SUP-2613411,CDM,C1751,HCPCS,0278,RC,,,,both,,,154.80,100.62,,,,,,,,,,,,,
PEMETREXED DISODIUM 500 MG IV SOLR,RX-37894,CDM,J9305,HCPCS,0636,RC,70069-0835-01,NDC,,both,1,UN,316.40,205.66,,,,,,,,,,,,,
CLIP ANEUR L8.6MM 7MM OPN 180GM CLS FORC STD PHYNOX CVD PERM,SUP-2108372,CDM,C1889,HCPCS,0278,RC,,,,both,,,1273.05,827.48,,,,,,,,,,,,,
PACEMAKER CARD EVIA SR-T D 65 MM TI SINGLE CHMBR PREM VVIR,SUP-2138286,CDM,C1786,HCPCS,0275,RC,,,,both,,,11366.80,7388.42,,,,,,,,,,,,,
TROCAR NEUROENDOSCOPY 3.2MMX150MM MINOP WITH 1 WORKING CHANN,SUP-2826330,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6227.12,4047.63,,,,,,,,,,,,,
SCREW BNE LCK 3.5X10 MM NORMED,SUP-2321725,CDM,C1713,HCPCS,0278,RC,,,,both,,,476.97,310.03,,,,,,,,,,,,,
GRAFT DERMAL MESH 5X5 CM FEN + WND MTRX MIRODERM,SUP-2431541,CDM,Q4175,HCPCS,0636,RC,,,,both,,,5887.50,3826.87,,,,,,,,,,,,,
GRAFT BONE SUB 10CC MTRX DEMIN PASTE INTERGRO +,SUP-2414015,CDM,C1713,HCPCS,0278,RC,,,,both,,,5510.70,3581.95,,,,,,,,,,,,,
KIT ARTHRO HIP W/ BAN BLDE DISP,SUP-2121998,CDM,C1769,HCPCS,0272,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
PLATE BNE STR 1.5X18X0.8 MM MIDFACE 4 HOLE W/ TAB TI STRL,SUP-2518104,CDM,C1713,HCPCS,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
VALVE AORT INSPIRIS RESILIA TISS ANNULUS 19 MM SEW RNG DIA25,SUP-2213990,CDM,C1889,HCPCS,0278,RC,,,,both,,,24963.00,16225.95,,,,,,,,,,,,,
BUR SURG L8CM HD L15.9MM DIA2.3MM SM BOR TAPR FOOTED LEGEND,SUP-2284683,CDM,2720000010,LOCAL,0272,RC,,,,both,,,279.43,181.63,,,,,,,,,,,,,
DEVICE FIXTN PROCINCH ADJ LOOP,SUP-2361152,CDM,C1713,HCPCS,0278,RC,,,,both,,,1764.11,1146.67,,,,,,,,,,,,,
CYCLOPHOSPHAMIDE 2 G IJ SOLR,RX-38280,CDM,J9076,HCPCS,0636,RC,10019-0957-01,NDC,,both,1,UN,1685.70,1095.70,,,,,,,,,,,,,
PROBE LASER OD20GA 45DEG RETIN STD TAPR TIP ANG ENDOPRB,SUP-2247211,CDM,2720000010,LOCAL,0272,RC,,,,both,,,460.54,299.35,,,,,,,,,,,,,
INSTRUMENT KIT PLN PT SPEC MAND RECON W/O MODEL,SUP-2860260,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8257.89,5367.63,,,,,,,,,,,,,
PLATE BNE STRNL 2.3X1.8 MM THOR 11 HOLE LCK JLT NS LEVEL 1,SUP-2869245,CDM,C1713,HCPCS,0278,RC,,,,both,,,914.05,594.13,,,,,,,,,,,,,
RING FIX HALF,SUP-2197268,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3320.55,2158.36,,,,,,,,,,,,,
DEVICE REATTACHMENT W23XL232MM GTR TROCH TIV 4 H EXT W/ 4,SUP-2410265,CDM,C1713,HCPCS,0278,RC,,,,both,,,9831.97,6390.78,,,,,,,,,,,,,
RETRACTOR SURG ORTH PROTECTOR MED LG 17 CM 5-13 CM FLX STRL,SUP-2864522,CDM,2720000010,LOCAL,0272,RC,,,,both,,,690.80,449.02,,,,,,,,,,,,,
SUPPORT ORTHOT ELBW CUST ADJ FIT STRP W/OUT JT FABRICATED,SUP-2435756,CDM,L3702,HCPCS,0272,RC,,,,both,,,744.02,483.61,,,,,,,,,,,,,
PIN BIORESORBABLE 26MM,SUP-2704181,CDM,C1713,HCPCS,0278,RC,,,,both,,,2466.16,1603.00,,,,,,,,,,,,,
HC So Igh Gene Rearrange Am,PX-3108126166,CDM,81261,CPT,0310,RC,,,,both,,,662.00,430.30,,,,,,,,,,,,,
"HC Prostate Biopsy, Any Mthd",PX-3140041600,CDM,G0416,CPT,0314,RC,,,,both,,,2821.00,1833.65,,,,,,,,,,,,,
RING EXT FIX 160 MM 5/8 CARBON FIBER NS,SUP-2799526,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1750.83,1138.04,,,,,,,,,,,,,
HC Pooling Blood Platelets,PX-3008696500,CDM,86965,CPT,0300,RC,,,,both,,,361.00,234.65,,,,,,,,,,,,,
CATHETER CV JACC 4.5 FRX35 CM SINGLE LUMEN PRESSURE INJ ADV,SUP-2763380,CDM,C1751,HCPCS,0278,RC,,,,both,,,642.66,417.73,,,,,,,,,,,,,
ANTEGRADE FEM NAIL RIGHT 14MMX30CM,SUP-2811055,CDM,C1713,HCPCS,0278,RC,,,,both,,,7206.30,4684.09,,,,,,,,,,,,,
HEAD HUM 15X44 MM SHLDR RESURF TITAN,SUP-2244070,CDM,C1776,CPT,0278,RC,,,,both,,,15119.10,9827.41,,,,,,,,,,,,,
NAIL EBA ONE LONG 130 DEG RIGHT,SUP-2714105,CDM,C1713,HCPCS,0278,RC,,,,both,,,5338.00,3469.70,,,,,,,,,,,,,
STENT PERIPH L 18 MM DIA2.5 MM POST DIL DIA 3 MM SHTH 5 FR,SUP-2892902,CDM,C1874,HCPCS,0278,RC,,,,both,,,8792.00,5714.80,,,,,,,,,,,,,
ALLOGRAFT HUM TISS PERICARD 12X2 CM M THN PROC TUTOPLAST,SUP-2847986,CDM,C1762,CPT,0278,RC,,,,both,,,6085.32,3955.46,,,,,,,,,,,,,
ENDCAP SPNL LOK FOR SCR REVERE,SUP-2229228,CDM,C1713,HCPCS,0278,RC,,,,both,,,188.40,122.46,,,,,,,,,,,,,
SCREW BNE OD45MM S STL HINDFOOT LOK REPL SURFIX,SUP-2243057,CDM,C1713,HCPCS,0278,RC,,,,both,,,524.73,341.07,,,,,,,,,,,,,
TUBE VENT ID76MM 1MM 030IN INNR FLNG TI MIC BOB,SUP-2313691,CDM,L8699,HCPCS,0278,RC,,,,both,,,87.45,56.84,,,,,,,,,,,,,
PLATE BNE L249MM 16 H ST R MED PROX TIB S STL LOK COMPR LO,SUP-2185655,CDM,C1713,HCPCS,0278,RC,,,,both,,,4715.21,3064.89,,,,,,,,,,,,,
LEVOFLOXACIN 250 MG PO TABS,RX-18918,CDM,6370000000,HCPCS,0637,RC,00904-6351-61,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
CATHETER INTVASC OCCL CODA L 120 CM DIA10 FR BALLOON DIA 40,SUP-2750349,CDM,C2628,HCPCS,0272,RC,,,,both,,,1391.02,904.16,,,,,,,,,,,,,
ANCHOR SUTURE NO2 LNG HIP SOFT SINGLE LOADED JUGGERKNOT,SUP-2589014,CDM,C1713,HCPCS,0278,RC,,,,both,,,1160.54,754.35,,,,,,,,,,,,,
GRAFT BNE PASTE 1 CC GRFT,SUP-2307041,CDM,C1713,HCPCS,0278,RC,,,,both,,,540.08,351.05,,,,,,,,,,,,,
SUPPORT ORTHOT METATRSL CUST BAR WDG ROCKER,SUP-2435726,CDM,L3400,HCPCS,0274,RC,,,,both,,,115.24,74.91,,,,,,,,,,,,,
COLLAR CERV M AD W3.5XL23.5IN M DENS CNTOUR CNTCT CLSR FOAM,SUP-2197375,CDM,L0120,HCPCS,0274,RC,,,,both,,,17.46,11.35,,,,,,,,,,,,,
PLATE BNE RECON 3.5X106 MM 9 HOLE SS,SUP-2569084,CDM,C1713,HCPCS,0278,RC,,,,both,,,392.03,254.82,,,,,,,,,,,,,
"HC Spinal Puncture, Lumbar, Diagnostic",PX-3616227000,CDM,62270,CPT,0361,RC,,,,inpatient,,,2232.00,1450.80,,,,,,,,,,,,,
GUIDEWIRE ORTH L 150 MM DIA 0.9 MM DBL TROCAR NS ACUTRK 3,SUP-2912794,CDM,C1769,HCPCS,0272,RC,,,,both,,,91.06,59.19,,,,,,,,,,,,,
CATHETER DRNGE 10FR L35CM GWIRE 0.038IN FLEXIMA BILI SFT 5,SUP-2147860,CDM,C1729,HCPCS,0272,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
MATRIX DERM ACELLULAR HYDRATED DERMAMTRX 0.4-0,SUP-2306894,CDM,C1762,CPT,0278,RC,,,,both,,,2140.29,1391.19,,,,,,,,,,,,,
SHEATH INTRO FLX ANSEL 55CM 6 FR 0.018/0.038 IN AQ RENAL,SUP-2169822,CDM,C1894,HCPCS,0272,RC,,,,both,,,165.29,107.44,,,,,,,,,,,,,
PENICILLIN V POTASSIUM 250 MG PO TABS,RX-6092,CDM,6370000000,HCPCS,0637,RC,16714-0234-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
RHINOLARYNGOSCOPE SLIM 4 ASCOPE SGL USE FLEX,SUP-2865123,CDM,2720000010,LOCAL,0272,RC,,,,both,,,753.60,489.84,,,,,,,,,,,,,
SAW BLDE W13XL70MM D70MM CUT THK1.27MM UNIV S STL OSC,SUP-2253190,CDM,2720000010,LOCAL,0272,RC,,,,both,,,402.08,261.35,,,,,,,,,,,,,
KIT SONIC ANCHOR FORCE FIB 2.5X10MM 0,SUP-2474715,CDM,C1776,CPT,0278,RC,,,,both,,,1016.36,660.63,,,,,,,,,,,,,
BLADE SCREWDRIVER 1.5 MM FOR ANGULUS X DRV LEVEL 1,SUP-2461306,CDM,2720000010,LOCAL,0272,RC,,,,both,,,467.99,304.19,,,,,,,,,,,,,
ANCHOR SUT L36IN SZ 2 ETHBND GRN POLY BRAID DBL ARMED EXCEL,SUP-2256635,CDM,C1713,HCPCS,0278,RC,,,,both,,,841.52,546.99,,,,,,,,,,,,,
SCW MMF DF HEX ETCHD2X19MM TEMP USE,SUP-2681349,CDM,C1713,HCPCS,0278,RC,,,,both,,,595.63,387.16,,,,,,,,,,,,,
SCREW BNE L34MM DIA4MM THRD L14MM STD CANC S STL ST CANN,SUP-2342500,CDM,C1713,HCPCS,0278,RC,,,,both,,,1373.66,892.88,,,,,,,,,,,,,
GRAFT BNE SUB 18X18MM PARA WDG SUBTALAR DISTR ARTH UNIV,SUP-2321684,CDM,C1713,HCPCS,0278,RC,,,,both,,,7449.65,4842.27,,,,,,,,,,,,,
PLATE EXT FIX RETENTION 1.8 MM LEIPZIG COMPLETE FOR RED II,SUP-2491541,CDM,C1713,HCPCS,0278,RC,,,,both,,,2470.58,1605.88,,,,,,,,,,,,,
PROSTHESIS OSS CENTERED 0.2X1.45X1.5 MM PART TI PRECIS,SUP-2458236,CDM,L8613,CPT,0278,RC,,,,both,,,1115.52,725.09,,,,,,,,,,,,,
HC Echo Exam of Fetal Heart,PX-4027682500,CDM,76825,CPT,0402,RC,,,,outpatient,,,1453.00,944.45,,,,,,,,,,,,,
ROD SPNL 50X9X12MM 3D AX LIF,SUP-2389066,CDM,C1713,HCPCS,0278,RC,,,,both,,,25104.30,16317.79,,,,,,,,,,,,,
COMPONENT PAT OD26MM THICKNESS 10MM STD TI POLYETH POR PRI,SUP-2370401,CDM,C1776,CPT,0278,RC,,,,both,,,2468.04,1604.23,,,,,,,,,,,,,
COLLAR CERV XL H3XL20IN AD CLS TRACH HK AND LOOP CLSR CNTOUR,SUP-2194433,CDM,L0120,HCPCS,0274,RC,,,,both,,,17.87,11.62,,,,,,,,,,,,,
HC Motion Fluor Eval Swlng Funcj C/V Rec,PX-4449261100,CDM,92611,CPT,0444,RC,,,,both,,,510.00,331.50,,,,,,,,,,,,,
GRAFT HUM TISS DIA12 MM AMNION PLCNTA MEMBRN 2 LAYR PROTCT,SUP-2913160,CDM,C1762,CPT,0278,RC,,,,both,,,2603.06,1691.99,,,,,,,,,,,,,
INSERTER SURG CRV FLX RVS STRL FAST-FIX LTX,SUP-2880224,CDM,C1713,HCPCS,0278,RC,,,,both,,,1711.14,1112.24,,,,,,,,,,,,,
DRILL SURG HD 30 MM HIP GRIPTION TF PINNACLE,SUP-2453608,CDM,2720000010,LOCAL,0272,RC,,,,both,,,354.82,230.63,,,,,,,,,,,,,
SHEATH SPLIT 11F,SUP-2424640,CDM,C1894,HCPCS,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
PLATE BONE SZ 2 LT TIB FIX BEAR CEM,SUP-2223477,CDM,C1713,HCPCS,0278,RC,,,,both,,,13188.00,8572.20,,,,,,,,,,,,,
SCREW BNE SD 2X4 MM CRTX T8 STARDRV RECESS TI NS LF,SUP-2189352,CDM,C1713,HCPCS,0278,RC,,,,both,,,160.14,104.09,,,,,,,,,,,,,
RING EXT FIX DIA130 MM ACCSRY SINGLE ROW 2/3 NS DISP TSF,SUP-2933055,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5345.76,3474.74,,,,,,,,,,,,,
WALKER M SHT LEG NONSKID,SUP-2276711,CDM,L4387,HCPCS,0274,RC,,,,both,,,83.68,54.39,,,,,,,,,,,,,
SYSTEM EMBOLIC PROTCT WIRION L 144 CM RETRV L 145 CM OD 6 FR,SUP-2755161,CDM,C1884,HCPCS,0278,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
STENT TRACHBRONCH L80MM DIA6MM DEL SYS L117CM DIA8FR,SUP-2128282,CDM,C1874,HCPCS,0278,RC,,,,both,,,6892.30,4479.99,,,,,,,,,,,,,
K WIRE FIX L280MM DIA2MM S STL THRD TRCR TIP FOR LISS,SUP-2186895,CDM,C1713,HCPCS,0278,RC,,,,both,,,113.98,74.09,,,,,,,,,,,,,
HC Tcp02/Abi 1-2 Levels,PX-9209392200,CDM,93922,CPT,0920,RC,,,,both,,,810.00,526.50,,,,,,,,,,,,,
SET INTRO SUP ARW FLX SHTH L 80 CM DIA 9 FR HYDRPHLC,SUP-2383420,CDM,C1894,HCPCS,0272,RC,,,,both,,,1268.56,824.56,,,,,,,,,,,,,
CATHETER CV SET 12 FRX20 CM 18 GAX6.35 CM 3L LG BOR INTRO,SUP-2763394,CDM,C1751,HCPCS,0278,RC,,,,both,,,256.22,166.54,,,,,,,,,,,,,
CANC SCREW STERILIZER 6.5X45 MM 32MM THREAD,SUP-2818179,CDM,C1713,HCPCS,0278,RC,,,,both,,,344.18,223.72,,,,,,,,,,,,,
PIN RETRCT L10MM DOCKING FOR MARS 3V MINIMAL ACC SYS,SUP-2232226,CDM,C1713,HCPCS,0278,RC,,,,both,,,1303.10,847.01,,,,,,,,,,,,,
SCREW EXT FIX L 175 MM THRD L 40 MM DIA 6 MM TI BLNT PT STRL,SUP-2913618,CDM,C1713,HCPCS,0278,RC,,,,both,,,888.56,577.56,,,,,,,,,,,,,
PLATE BONE 5 HOLE TITANIUM GRIDLOCK VLC PLATING SYSTEM FOR 2.4/3/4MM SCREW CUSTOM,SUP-2878771,CDM,C1713,HCPCS,0278,RC,,,,both,,,4270.40,2775.76,,,,,,,,,,,,,
IMPLANT VG POR FEM RGX TIB/E1/PAT,SUP-2212443,CDM,C1776,CPT,0278,RC,,,,both,,,16171.00,10511.15,,,,,,,,,,,,,
BUR SURG DIAMOND 15 DEG 3 MMX12.5 CM MTCH HD DSTL BEND IBUR,SUP-2859508,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1083.30,704.14,,,,,,,,,,,,,
INSERT TIB H12MM S STL UHMWPE KNEE REV MOB SLDE COR STAR PGT,SUP-2365352,CDM,C1776,CPT,0278,RC,,,,both,,,6468.40,4204.46,,,,,,,,,,,,,
CATHETER CARD ABLATION NAVISTAR RMT L 125 CM DIA 8 FR SHTH,SUP-2248931,CDM,C1732,HCPCS,0278,RC,,,,both,,,6575.16,4273.85,,,,,,,,,,,,,
GRAFT SFT TISS W/O DWL CART,SUP-2307007,CDM,C1713,HCPCS,0278,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
MESH HERN FLAT SHT 10X14 IN RECT OVL KNITTED PROLITE ULTRA,SUP-2227249,CDM,C1781,HCPCS,0278,RC,,,,both,,,317.08,206.10,,,,,,,,,,,,,
ANCHOR SUT DIA5.5MM PROX PEEK EYELET KNOTLESS REELX STT,SUP-2366712,CDM,C1713,HCPCS,0278,RC,,,,both,,,1515.08,984.80,,,,,,,,,,,,,
NAIL IM L340MM OD11MM 125DEG LNG TIM LT HIP AG CANN LCK,SUP-2211477,CDM,C1713,HCPCS,0278,RC,,,,both,,,9872.16,6416.90,,,,,,,,,,,,,
CONDYLAR PLATE GUIDE,SUP-2548638,CDM,C1713,HCPCS,0278,RC,,,,both,,,574.21,373.24,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH FLX L 50 MM DIA 36 MM SHTH 20 FR RVD,SUP-2170456,CDM,C1874,HCPCS,0278,RC,,,,both,,,6101.02,3965.66,,,,,,,,,,,,,
SCREW BNE EMGCY MIC 1.8X7 MM TI CENTRE-DRIVE,SUP-2459925,CDM,C1713,HCPCS,0278,RC,,,,both,,,170.75,110.99,,,,,,,,,,,,,
INTRODUCER SHTH L12CM OD5FR ODSEC.038IN GUID WIRE STD FEM,SUP-2355793,CDM,C1894,HCPCS,0272,RC,,,,both,,,34.54,22.45,,,,,,,,,,,,,
ADAPTER EXT FIX QUIK CPL FOR 4MM SELDRILL SCHNZ SCR,SUP-2188582,CDM,2720000010,LOCAL,0272,RC,,,,both,,,950.13,617.58,,,,,,,,,,,,,
DEVICE FIX 20MM LOOP DYNEEMA PURITY BRAID CONT FOR ACL PCL,SUP-2366526,CDM,C1713,HCPCS,0278,RC,,,,both,,,1413.22,918.59,,,,,,,,,,,,,
COLLAR CERV PED SM EXTRIC 1 PC TRACH OPN W CHIN REST MINI,SUP-2115115,CDM,L0140,HCPCS,0272,RC,,,,both,,,35.36,22.98,,,,,,,,,,,,,
WIRE BNE FIX L 255 MM DIA 2 MM TROCAR TIP EVOS KIRSCHNER,SUP-2931394,CDM,C1713,HCPCS,0278,RC,,,,both,,,766.79,498.41,,,,,,,,,,,,,
TONGUE SUSPENSION KIT BNE ANCHR KNOTLESS ENCORE,SUP-2339950,CDM,C1713,HCPCS,0278,RC,,,,both,,,8478.00,5510.70,,,,,,,,,,,,,
HEAD BPLR OD53MM ID28MM FEM HIP SELF CNTR,SUP-2249843,CDM,C1776,CPT,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
DIST HUM LAT LT 11H 103MM STE,SUP-2493154,CDM,C1713,HCPCS,0278,RC,,,,both,,,2951.60,1918.54,,,,,,,,,,,,,
STYLET NAVIGATION 2 COIL PRB SGL STEREOTACTIC SURG SYS DISP,SUP-2284347,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1703.45,1107.24,,,,,,,,,,,,,
SCREW BONE L95MM DIA7.3MM CORT S STL ST CANN LCK PARTIALLY,SUP-2185013,CDM,C1713,HCPCS,0278,RC,,,,both,,,818.22,531.84,,,,,,,,,,,,,
ALLOGRAFT BNE STRP FD IRRADIATED IL CREST,SUP-2867216,CDM,C1762,CPT,0278,RC,,,,both,,,8671.58,5636.53,,,,,,,,,,,,,
GUIDE WIRE P4440-WG00,SUP-2752264,CDM,C1769,HCPCS,0272,RC,,,,both,,,1545.67,1004.69,,,,,,,,,,,,,
RING EXT FIX FULL 200 MM TI NS,SUP-2863407,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3446.84,2240.45,,,,,,,,,,,,,
GUIDEWIRE VASC THRUWAY L 190 CM DIA 0.014 IN SS SIL STR SHRT,SUP-2142711,CDM,C1769,HCPCS,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
TIP SUCT L45CM OD5MM SPAT TIP REPOSABLE STRYKEPROBE,SUP-2361204,CDM,2720000010,LOCAL,0272,RC,,,,both,,,890.44,578.79,,,,,,,,,,,,,
STEM FEM LAT 8-10 PROX HIP REDUC PROF BIMTRC X SER INTEGR,SUP-2450452,CDM,C1776,CPT,0278,RC,,,,both,,,805.41,523.52,,,,,,,,,,,,,
BLADE RETRACTOR UNIVERSAL RING 3INW X 6IND MALLEABLE,SUP-2676581,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1001.09,650.71,,,,,,,,,,,,,
TUBE OPHTH IMPL 350 MM DIAM 32 MM TUBE LEN STRL SIL,SUP-2326685,CDM,C1783,HCPCS,0278,RC,,,,both,,,2518.28,1636.88,,,,,,,,,,,,,
HEAD HUM ECC 26X48 MM 5 MM SHLDR COFEILD 2,SUP-2346846,CDM,C1776,CPT,0278,RC,,,,both,,,17270.00,11225.50,,,,,,,,,,,,,
SLING ORTH FNGR 3 IN DYN REINF EYELET SUP-R-SOFT LF,SUP-2477659,CDM,L3933,HCPCS,0274,RC,,,,both,,,2.70,1.75,,,,,,,,,,,,,
DRILL TWST FOR BOS HEX ATTCH 23MMXL 19X70MM,SUP-2262986,CDM,2720000010,LOCAL,0272,RC,,,,both,,,462.58,300.68,,,,,,,,,,,,,
BLADE CARROLL GIRARD 38 708 02 07,SUP-2668410,CDM,2720000010,LOCAL,0272,RC,,,,both,,,860.55,559.36,,,,,,,,,,,,,
RING TRNSJUG INTRAHEPATIC LIV ACCS AND BX SET,SUP-2169805,CDM,C1894,HCPCS,0272,RC,,,,both,,,1679.87,1091.92,,,,,,,,,,,,,
GRAFT VASC EXXCEL SFT L 50 CM DIA 8 MM EPTFE STR TW USFT,SUP-2266006,CDM,C1768,CPT,0278,RC,,,,both,,,1102.14,716.39,,,,,,,,,,,,,
SCREW BNE L55MM DIA6MM ST AQUA CORT TI ST CANN LOK FULL,SUP-2191839,CDM,C1713,HCPCS,0278,RC,,,,both,,,960.84,624.55,,,,,,,,,,,,,
GRAFT VASC W/ RADPQ MRK SIDE BRANCH LEN THOR ARCH 14MM BOR,SUP-2385005,CDM,C1768,CPT,0278,RC,,,,both,,,6217.20,4041.18,,,,,,,,,,,,,
GRAFT VASC IMPRA L 20 CM DIA 6 MM EPTFE FLEXS BEAD RING HEMO,SUP-2761432,CDM,C1768,CPT,0278,RC,,,,both,,,1293.15,840.55,,,,,,,,,,,,,
PACEMAKER CARD PHILOS DR 2 CHMBR,SUP-2137964,CDM,C1785,HCPCS,0275,RC,,,,both,,,12456.38,8096.65,,,,,,,,,,,,,
PLATE BNE L 243 X W 11.5 MM THK 3.6 MM SCREW DIA 3.5 MM 20 HL,SUP-2937096,CDM,C1713,HCPCS,0278,RC,,,,both,,,7669.14,4984.94,,,,,,,,,,,,,
CANNULA ARTHSCP INFLO N SCP INTEL 3MM,SUP-2341417,CDM,C1713,HCPCS,0278,RC,,,,both,,,1018.77,662.20,,,,,,,,,,,,,
NOREPINEPHRINE-SODIUM CHLORIDE 4-0.9 MG/250ML-% IV SOLN,RX-135216,CDM,2500000003,HCPCS,0250,RC,69374-0319-25,NDC,,both,250,ML,83.40,54.21,,,,,,,,,,,,,
BLADE SAW L 16 MM D 11 MM THK MATERIAL 0.5 MM CUT 0.7 MM GC279R,SUP-2928827,CDM,2720000010,LOCAL,0272,RC,,,,both,,,554.40,360.36,,,,,,,,,,,,,
WAND ABLAT LOPRO 90DEG ICW W/O SUCT 3.6MM,SUP-2341975,CDM,2720000010,LOCAL,0272,RC,,,,both,,,693.94,451.06,,,,,,,,,,,,,
COMPONENT ULN L53MM 2.5MM OFFSET BOND COAT RT ELBW BEAR,SUP-2215464,CDM,C1776,CPT,0278,RC,,,,both,,,13172.30,8561.99,,,,,,,,,,,,,
CLIP INT USE DIA16.5 MM THRD L 165CM ENDOSCP DIA 8.5-11MM BLUNT,SUP-2881845,CDM,V2787,HCPCS,0276,RC,,,,both,,,1535.46,998.05,,,,,,,,,,,,,
SCREW SPNL FT 3.5X34 MM BLACKBIRD,SUP-2570091,CDM,C1713,HCPCS,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
CUP VAC EXTR DIA60MM STD BELL W 4IN TBNG FLTR PEARL EDGE,SUP-2171488,CDM,C1713,HCPCS,0278,RC,,,,both,,,83.05,53.98,,,,,,,,,,,,,
K WIRE FIX L6IN DIA0.035IN DBL END SMOOTH TRCR PNT 6PK,SUP-2412236,CDM,C1713,HCPCS,0278,RC,,,,both,,,216.25,140.56,,,,,,,,,,,,,
LINER ACET OD38MM ID24MM +5MM HIP E1 MAX ROM RINGLOC,SUP-2408955,CDM,C1776,CPT,0278,RC,,,,both,,,5402.53,3511.64,,,,,,,,,,,,,
GUIDEWIRE VASC INQWIRE L 145 CM DIA 0.035 IN TAPR L 7 CM TIP,SUP-2301899,CDM,C1769,HCPCS,0272,RC,,,,both,,,36.74,23.88,,,,,,,,,,,,,
SHEATH INTRO PERFRMR L 6 CM OD 6 FR ID 2 MM 0.035IN,SUP-2168595,CDM,C1894,HCPCS,0272,RC,,,,both,,,67.92,44.15,,,,,,,,,,,,,
RESERVOIR KIT 24 MM W/ 1 BA VENTRICULAR CATH STR ACCU-FLO,SUP-2666534,CDM,C1729,HCPCS,0272,RC,,,,both,,,1796.14,1167.49,,,,,,,,,,,,,
GUIDEWIRE SURG 3X980 MM W/O OLV,SUP-2315997,CDM,C1769,HCPCS,0272,RC,,,,both,,,320.03,208.02,,,,,,,,,,,,,
HC Repair Nail Bed,PX-4501176000,CDM,11760,CPT,0450,RC,,,,both,,,1842.00,1197.30,,,,,,,,,,,,,
PLATE BNE L132MM 12 H ST POST DST TIB S STL T LOK COMPR FOR,SUP-2177439,CDM,C1713,HCPCS,0278,RC,,,,both,,,4709.25,3061.01,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA 3FR 55CM 1 LUMAN R S9173108,SUP-2632871,CDM,C1751,HCPCS,0278,RC,,,,both,,,567.68,368.99,,,,,,,,,,,,,
GRAFT HUM TISS 5CM OR SMER COSTAL CART STRUCTURAL NACL,SUP-2165590,CDM,C1713,HCPCS,0278,RC,,,,both,,,1318.80,857.22,,,,,,,,,,,,,
PATCH BIO TISS W12XL25CM BOV PERICARD,SUP-2130369,CDM,C1768,CPT,0278,RC,,,,both,,,3073.62,1997.85,,,,,,,,,,,,,
PATCH CV IMPRA L 60 X W 30 MM THK 0.4 MM EPTFE OVL SHP TW,SUP-2761261,CDM,C1768,CPT,0278,RC,,,,both,,,821.52,533.99,,,,,,,,,,,,,
ALLOGRAFT HUMAN TISS MAXXEUS TIBIALIS ANTERIOR FZ,SUP-2875990,CDM,C1762,CPT,0278,RC,,,,both,,,4614.70,2999.55,,,,,,,,,,,,,
SROM*STXXL36+8LNK20X15X325R,SUP-2540398,CDM,C1776,CPT,0278,RC,,,,both,,,17097.93,11113.65,,,,,,,,,,,,,
PLATE BNE TIB RT DSTL MEDL 8 HOLE TS,SUP-2362736,CDM,C1713,HCPCS,0278,RC,,,,both,,,3534.86,2297.66,,,,,,,,,,,,,
HC Facial Bones Min 3 Views,PX-3207015000,CDM,70150,CPT,0320,RC,,,,outpatient,,,552.00,358.80,,,,,,,,,,,,,
PLATE BNE L46MM 7 H DST ULN S STL LOK COMPR FOR 2MM SCR,SUP-2186125,CDM,C1713,HCPCS,0278,RC,,,,both,,,2122.29,1379.49,,,,,,,,,,,,,
HC Replace Cv Cath Only,PX-3613657800,CDM,36578,CPT,0361,RC,,,,outpatient,,,3707.00,2409.55,,,,,,,,,,,,,
TUBE VENT DIA1.14MM INNR FLNG DIA2.6MM INTERFLNG DISTANCE,SUP-2284022,CDM,L8699,HCPCS,0278,RC,,,,both,,,164.13,106.68,,,,,,,,,,,,,
SHEATH INTRO PRELUDE SNAP L 13CM DIA10 FR NO SIDEPRT FUCHSIA,SUP-2743278,CDM,C1769,HCPCS,0272,RC,,,,both,,,102.21,66.44,,,,,,,,,,,,,
WAND ABLAT L157MM DIA1.07MM 17GA NDL L6IN CRWFRD PLSM ABLAT,SUP-2342057,CDM,C1713,HCPCS,0278,RC,,,,both,,,4396.00,2857.40,,,,,,,,,,,,,
BLADE SURG BLNT 25 MM TUBESET NEXUS BONESCALPEL,SUP-2745899,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1723.23,1120.10,,,,,,,,,,,,,
PATCH PERICARD W5XL10CM THK0.2-0.4MM BOV PERICARD FLEX SFT,SUP-2357533,CDM,C1768,CPT,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
HEAD HUM 3+ MM 40 MM GLEN SHLDR TI COMPHSVE VERSA-DIAL,SUP-2441519,CDM,C1776,CPT,0278,RC,,,,both,,,6217.20,4041.18,,,,,,,,,,,,,
EXTRACTOR STONE HELCL 3.2 FRX115 CM 3 WIR NIT NCIRCLE,SUP-2835766,CDM,2720000010,LOCAL,0272,RC,,,,both,,,686.72,446.37,,,,,,,,,,,,,
SHEATH URO 30FR L17CM CLR NEPHSTMY RADPQ MRK G PRB,SUP-2139237,CDM,C1894,HCPCS,0272,RC,,,,both,,,202.12,131.38,,,,,,,,,,,,,
SCREW BNE L40MM DIA3MM THRD L18MM G CORT TI ALLY ST SELF,SUP-2189784,CDM,C1713,HCPCS,0278,RC,,,,both,,,547.36,355.78,,,,,,,,,,,,,
CATHETER IRRIGATION 4 FRX80 CM OCCL,SUP-2264265,CDM,C2628,HCPCS,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
SET URET STENT AMPLTZ L 20 CM DIA10.2 FR GUIDEWIRE 0.038 IN,SUP-2168644,CDM,C2625,HCPCS,0278,RC,,,,both,,,420.76,273.49,,,,,,,,,,,,,
BOOT CASTXL AD 13.5IN 5.5IN CUSH ROCK OPN TOE AND OPN HEEL,SUP-2205564,CDM,L4387,HCPCS,0274,RC,,,,both,,,29.67,19.29,,,,,,,,,,,,,
HC So1 Phenotype Infect Agent Drug,PX-3068790067,CDM,87900,CPT,0306,RC,,,,both,,,862.00,560.30,,,,,,,,,,,,,
CANNULA DELIVERY INJECTABLE BONE SUBSTITUTE 11 GA ANIKA,SUP-2850036,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
CLAMP EXT FIX XSM DIA3MM C FBR 1 H PIN TO ROD,SUP-2188694,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1907.68,1239.99,,,,,,,,,,,,,
LINER HUM CUPXLPE TM,SUP-2212339,CDM,C1776,CPT,0278,RC,,,,both,,,6123.00,3979.95,,,,,,,,,,,,,
PATCH DURAL 4X5CM NEURO PATCH,SUP-2826139,CDM,C1763,HCPCS,0278,RC,,,,both,,,641.25,416.81,,,,,,,,,,,,,
ELECTRODE ES LAP MNPLR 5MM DIA 45CML J HOOK TIP CGLTNG PRTLL,SUP-2668367,CDM,2720000010,LOCAL,0272,RC,,,,both,,,754.89,490.68,,,,,,,,,,,,,
HEAD FEM OD26MM NK -6MM OFFSET TYP 2 CO CHROM TAPR,SUP-2406792,CDM,C1776,CPT,0278,RC,,,,both,,,5055.40,3286.01,,,,,,,,,,,,,
ANCHOR SUTURE SLIDING 4.5 MM DBL SIDE ROW X2 WHT COMPOSITCP,SUP-2745438,CDM,C1776,CPT,0278,RC,,,,both,,,1264.16,821.70,,,,,,,,,,,,,
GRAFT HUMAN TISSUE 3X6CM THICK AMNIOTIC UMBILICAL CORD PRO3C,SUP-2741749,CDM,C1762,CPT,0278,RC,,,,both,,,7944.20,5163.73,,,,,,,,,,,,,
PLATE BNE MESH PANEL SM 2X30X23X1 MM SPECIALITY GRID TI NS,SUP-2486415,CDM,C1713,HCPCS,0278,RC,,,,both,,,948.09,616.26,,,,,,,,,,,,,
CATHETER HD STR 16 FRX42 CM STD KT AIRGUARD HEMOSPLIT XK,SUP-2127837,CDM,C1750,HCPCS,0278,RC,,,,both,,,1486.95,966.52,,,,,,,,,,,,,
PLATE BONE W15XL168MM THK2MM 8 H BILAT TI THN BLDE RIG,SUP-2190986,CDM,C1713,HCPCS,0278,RC,,,,both,,,1674.59,1088.48,,,,,,,,,,,,,
HC M/Phmtrc Alys Tumor Imhchem Ea Antibody Manual,PX-3128836000,CDM,88360,CPT,0312,RC,,,,both,,,371.00,241.15,,,,,,,,,,,,,
GRAFT BNE SUB M W20XH7XL30MM COMPRESSIBLE SPNG STRP PROVIDE,SUP-2138508,CDM,C1713,HCPCS,0278,RC,,,,both,,,6437.00,4184.05,,,,,,,,,,,,,
BLADE TRIANG DISPOSABLE ST,SUP-2361844,CDM,2720000010,LOCAL,0272,RC,,,,both,,,711.12,462.23,,,,,,,,,,,,,
SEEKER BAL L7MM DIA6MM MAX SINUS FOR ENT ELECTROMAGNETIC,SUP-2284113,CDM,C1713,HCPCS,0278,RC,,,,both,,,1647.24,1070.71,,,,,,,,,,,,,
PLATE OMEGA3 STABILIZING 135 DEG 4 HOLE,SUP-2704777,CDM,C1713,HCPCS,0278,RC,,,,both,,,3122.73,2029.77,,,,,,,,,,,,,
BIT DRL TWST 0.8 MM 4 MMX8 CM SM BOR MIDAS REX LEGEND,SUP-2631336,CDM,2720000010,LOCAL,0272,RC,,,,both,,,403.62,262.35,,,,,,,,,,,,,
SPLINT WRST FA R INSTABILITY INJ W STAY COCK UP FIRM SUPP,SUP-2276618,CDM,L3809,HCPCS,0272,RC,,,,both,,,16.14,10.49,,,,,,,,,,,,,
SUPPORT ORTHOT LUMBAR SACR CUST SAGITTAL-CORONAL INTFACE,SUP-2435560,CDM,L0651,HCPCS,0272,RC,,,,both,,,3667.77,2384.05,,,,,,,,,,,,,
SCREW BONE L26MM DIA2.5MM CORT WR TI HEXADRIVE 7 TRILOK,SUP-2268232,CDM,C1713,HCPCS,0278,RC,,,,both,,,437.75,284.54,,,,,,,,,,,,,
PLATE BNE THK1.5MM 4X4 H MAND TI NONCOMPRESSION FRAC ANG,SUP-2263009,CDM,C1713,HCPCS,0278,RC,,,,both,,,713.41,463.72,,,,,,,,,,,,,
STEM HUM REVERSED LNG 9X210 MM SHLDR FRAC AEQUALIS REVERSED,SUP-2715637,CDM,C1776,CPT,0278,RC,,,,both,,,18243.40,11858.21,,,,,,,,,,,,,
SPLINT ORTHOPEDIC SUPP XS RT WRST,SUP-2196555,CDM,L3931,HCPCS,0274,RC,,,,both,,,15.26,9.92,,,,,,,,,,,,,
BIT DRL L 155/60 MM DIA2.5 MM CALIB AO QC NS REUSE V,SUP-2907606,CDM,2720000010,LOCAL,0272,RC,,,,both,,,809.43,526.13,,,,,,,,,,,,,
CATHETER URET 3 FRX65 CM WHSTL TIP LUER FIT ADPT,SUP-2384602,CDM,C1758,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
MESH CRAN L 57.2 X W 21.2 MM THK 0.3 MM SCREW DIA1.5 MM SM,SUP-2936727,CDM,C1713,HCPCS,0278,RC,,,,both,,,2201.14,1430.74,,,,,,,,,,,,,
GRAFT BIO TISS OMEGA3 MARIGEN MICRO 19SQCM,SUP-2909379,CDM,Q4158,HCPCS,0636,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
GUIDEWIRE URLGCL 0035N DIA 150CML PTFE CTD J WIRE MVBLE COR,SUP-2724971,CDM,C1769,HCPCS,0272,RC,,,,both,,,60.54,39.35,,,,,,,,,,,,,
WEDGE TIB SZ 1-2 THK5MM RT MEDL LT LAT KNEE HNG REV HEMI STP,SUP-2346700,CDM,C1776,CPT,0278,RC,,,,both,,,5080.52,3302.34,,,,,,,,,,,,,
KIT INTRO MINI STK II L 7 CM DIA 6 FR GUIDEWIRE L 60 CM DIA,SUP-2117129,CDM,C1892,HCPCS,0272,RC,,,,both,,,74.95,48.72,,,,,,,,,,,,,
NEEDLE TRANSSEPTAL AD 18GA L89CM S STL BRK CRV STYL BVL ANG,SUP-2357226,CDM,2720000010,LOCAL,0272,RC,,,,both,,,697.08,453.10,,,,,,,,,,,,,
IMPLANT STAP L4MM STD PIST DIA0.6MM L WELL DIA1MM CLASS TI,SUP-2312797,CDM,2780000010,LOCAL,0278,RC,,,,both,,,556.13,361.48,,,,,,,,,,,,,
CATHETER ATHRCTMY 1.8MM L130CM DIA0.014IN NONDEFLECTING,SUP-2327238,CDM,C1724,HCPCS,0278,RC,,,,both,,,10974.30,7133.29,,,,,,,,,,,,,
PLATE BONE W16XL253MM THK5MM 13 H RT CNDYL FEM S STL BTTRS,SUP-2185798,CDM,C1713,HCPCS,0278,RC,,,,both,,,2813.69,1828.90,,,,,,,,,,,,,
GRAFT BNE 85X11 MM DBM BLLST,SUP-2641772,CDM,C1713,HCPCS,0278,RC,,,,both,,,9608.40,6245.46,,,,,,,,,,,,,
PLATE 3.5MM TI LCP TM PROX HUMERUS LONG 5H SHAFT 142MM STER,SUP-2549715,CDM,C1713,HCPCS,0278,RC,,,,both,,,5255.36,3415.98,,,,,,,,,,,,,
WIRE ILLUMINATION SINUS RELIEVA LUMA,SUP-2106380,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1190.06,773.54,,,,,,,,,,,,,
PIN FIX L9IN OD1/8IN S STL TYP D STNMN,SUP-2342716,CDM,C1713,HCPCS,0278,RC,,,,both,,,210.16,136.60,,,,,,,,,,,,,
POST EXT FIX SLT SM/LG,SUP-2162668,CDM,2720000010,LOCAL,0272,RC,,,,both,,,580.27,377.18,,,,,,,,,,,,,
STENT BILI 7FR L7CM PLAS DUODENAL BEND RAP EXCHG PRELD,SUP-2149478,CDM,C2625,HCPCS,0278,RC,,,,both,,,422.33,274.51,,,,,,,,,,,,,
HC Office/OP Consltj New/Est Pt Low Mdm 30 Minutes|RESIDENT/TEACHING PHYS SERV,PX-5109924300,CDM,99243,CPT,0510,RC,,,GC,both,,,185.00,120.25,,,,,,,,,,,,,
ENDOPROSTHESIS VASC VIABAHN L 7.5CM 5MM 120CM 7FR HEPARIN,SUP-2396592,CDM,C1876,HCPCS,0278,RC,,,,both,,,10654.02,6925.11,,,,,,,,,,,,,
HEAD FEM DIA42MM CO CHROM POR CEM RESURF BIRMINGHAM,SUP-2350855,CDM,C1776,CPT,0278,RC,,,,both,,,11490.83,7469.04,,,,,,,,,,,,,
PLATE BNE L 58.85 MM THK 2.59 MM TI SUBMENTAL MANDIBULAR NS,SUP-2936185,CDM,C1713,HCPCS,0278,RC,,,,both,,,4565.56,2967.61,,,,,,,,,,,,,
BLOCK SURG CARVING IMPL TESTICULAR SIL ELASTMR OVL SHP 2 VOL,SUP-2340090,CDM,C1889,HCPCS,0278,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
STAPLE INT M SZ 30MM RELD VASC FOR SIGNIA STPL SYS TRI STPL,SUP-2283352,CDM,C1713,HCPCS,0278,RC,,,,both,,,571.64,371.57,,,,,,,,,,,,,
CATH BLLN INTRA AORTIC MEGA 8FRX50CC,SUP-2468489,CDM,C1725,HCPCS,0272,RC,,,,both,,,2857.87,1857.62,,,,,,,,,,,,,
VPAP III BI-LEVEL DEV,SUP-2331929,CDM,C1713,HCPCS,0278,RC,,,,both,,,3296.97,2143.03,,,,,,,,,,,,,
ALLOGRAFT BNE 11X11X8 MM CORTICAL CANC CORNERSTONE L-ASR,SUP-2293883,CDM,C1713,HCPCS,0278,RC,,,,both,,,3312.70,2153.25,,,,,,,,,,,,,
SPLINT PREMIER PRO WRST,SUP-2336042,CDM,L3809,HCPCS,0274,RC,,,,both,,,17.93,11.65,,,,,,,,,,,,,
STEM FEM L255MM OD12MM SZ 8 TI HA L HIP REV CEM BOW REDUC,SUP-2379112,CDM,C1776,CPT,0278,RC,,,,both,,,17408.16,11315.30,,,,,,,,,,,,,
GRAFT VASC TAPR 8-5 MMX70 CM TW N RING EPTFE CARBOFLO,SUP-2761340,CDM,C1768,CPT,0278,RC,,,,both,,,3602.52,2341.64,,,,,,,,,,,,,
GRAFT SFT TISS W9XL20CM NAT BARR OPTIMIZE SURG PERF,SUP-2305728,CDM,V2790,HCPCS,0278,RC,,,,both,,,29644.74,19269.08,,,,,,,,,,,,,
CATHETER BLLN DIL 15 FRX10 CM URET URETEROSCOPY EZDILATE,SUP-2457665,CDM,C1726,HCPCS,0272,RC,,,,both,,,606.02,393.91,,,,,,,,,,,,,
KIT PICC MAX BARR ANTIMICR/ANITTHROM PRELOAD 4.5FR X 55CM 1L,SUP-2864581,CDM,C1751,HCPCS,0278,RC,,,,both,,,823.72,535.42,,,,,,,,,,,,,
COMPRESSOR SURG SPNL 14-59 MM SILVERTON,SUP-2211160,CDM,2780000010,LOCAL,0278,RC,,,,both,,,3916.84,2545.95,,,,,,,,,,,,,
CATHETER NEPHROSTOMY CANN 12 FRX19.5 CM COPE LOOP,SUP-2835682,CDM,C1729,HCPCS,0272,RC,,,,both,,,265.80,172.77,,,,,,,,,,,,,
FOOTSWITCH ELECSURG BPLR GENRTR CUT/COAG 2 NS LTX,SUP-2859251,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4545.68,2954.69,,,,,,,,,,,,,
BIT DRL DIA4MM GLEN CNTR H QUIK CONN MOD,SUP-2408541,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1814.92,1179.70,,,,,,,,,,,,,
IMPLANT PENILE CYL PROS FOR AMS MALL W/ TIP EXT 600M 16CM,SUP-2140257,CDM,C1813,HCPCS,0278,RC,,,,both,,,5322.30,3459.49,,,,,,,,,,,,,
VALVE VOICE 4.5MM TRACH LT PROVOX ACTIVLV,SUP-2124317,CDM,L8509,HCPCS,0272,RC,,,,both,,,6531.20,4245.28,,,,,,,,,,,,,
OXYBUTYNIN CHLORIDE ER 5 MG PO TB24,RX-24470,CDM,6370000000,HCPCS,0637,RC,64980-0209-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
NEEDLE BX 22GA SHTH 4.1FR ADJ EXTN 0-5CM ENDOBRONCH HD US,SUP-2170150,CDM,2720000010,LOCAL,0272,RC,,,,both,,,574.62,373.50,,,,,,,,,,,,,
PLATE BONE L213MM 11 H S STL BROAD NONLOCKING COMPR CNTOUR,SUP-2348974,CDM,C1713,HCPCS,0278,RC,,,,both,,,2610.25,1696.66,,,,,,,,,,,,,
DEFIBRILLATOR CARD 2 CHMBR CARDIOVERTER W/ 1 ACT FIX LD NOT,SUP-2236356,CDM,C1721,HCPCS,0275,RC,,,,both,,,91750.80,59638.02,,,,,,,,,,,,,
HC So Phosphatase Isoenzymes,PX-3018408066,CDM,84080,CPT,0301,RC,,,,both,,,186.00,120.90,,,,,,,,,,,,,
SET CATH JEJUSTMY STRL BARONE,SUP-2168836,CDM,C1769,HCPCS,0272,RC,,,,both,,,478.57,311.07,,,,,,,,,,,,,
TRAY TIB SZ 3 COCR ALLOY TI PLASMA SPRY ANK CEM USE STRL,SUP-2932843,CDM,C1776,CPT,0278,RC,,,,both,,,21925.05,14251.28,,,,,,,,,,,,,
FOSINOPRIL SODIUM 10 MG PO TABS,RX-10094,CDM,6370000000,HCPCS,0637,RC,43547-0386-09,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
GUIDEWIRE ORTH TROCAR PT 1 END 1.6X220 MM NS,SUP-2789084,CDM,C1769,HCPCS,0272,RC,,,,both,,,1036.83,673.94,,,,,,,,,,,,,
DONANEMAB-AZBT 350 MG/20ML IV SOLN,RX-168527,CDM,J0175,HCPCS,0636,RC,00002-9401-01,NDC,,both,40,ML,4155.80,2701.27,,,,,,,,,,,,,
BRACE CERV HRD CUST,SUP-2388135,CDM,L0174,HCPCS,0274,RC,,,,both,,,1074.63,698.51,,,,,,,,,,,,,
GUIDEWIRE VASC L50CM DIA0038IN TIP L3MM S STL DBL END,SUP-2303470,CDM,C1769,HCPCS,0272,RC,,,,both,,,22.70,14.75,,,,,,,,,,,,,
CUP ACET CEM 32 MM HIP HW W/ PLATE,SUP-2447857,CDM,C1776,CPT,0278,RC,,,,both,,,1017.36,661.28,,,,,,,,,,,,,
STENT CAR PRECIS PRO L 30 MM DIA 9 MM CATH L 135 CM DIA 8 FR,SUP-2159045,CDM,C1876,HCPCS,0278,RC,,,,both,,,6650.52,4322.84,,,,,,,,,,,,,
COMPONENT FEM CR 3 UNISX LT KNEE PRIMARY STEMLESS CEM WFL,SUP-2378037,CDM,C1776,CPT,0278,RC,,,,both,,,9124.21,5930.74,,,,,,,,,,,,,
BOLT SPNL L40MM OD9MM TI CANC ANT THORLUM PEDCL ST FIX ANG,SUP-2292742,CDM,C1713,HCPCS,0278,RC,,,,both,,,5856.10,3806.46,,,,,,,,,,,,,
SCREW SPNL MONOAX 4.5X25 MM TRPL LD,SUP-2175459,CDM,C1713,HCPCS,0278,RC,,,,both,,,3601.58,2341.03,,,,,,,,,,,,,
TERAZOSIN HCL 5 MG PO CAPS,RX-14553,CDM,6370000000,HCPCS,0637,RC,59746-0385-06,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
CATHETER ART L110CM OD7.5FR HPRN VIP LUMN THRMDIL BAL INFL,SUP-2214324,CDM,C1751,HCPCS,0278,RC,,,,both,,,538.89,350.28,,,,,,,,,,,,,
PLATE BNE ORBIT FLR SM 3D,SUP-2363658,CDM,C1713,HCPCS,0278,RC,,,,both,,,4281.36,2782.88,,,,,,,,,,,,,
GRAFT HUM TISS L12SQCM DEHYDR AMNION CHORION MEM MESH,SUP-2305753,CDM,Q4186,HCPCS,0636,RC,,,,both,,,8145.16,5294.35,,,,,,,,,,,,,
BLADE RETRACTOR 7 IN SELF RET MALL BOOKWALTER,SUP-2382588,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2439.97,1585.98,,,,,,,,,,,,,
DIPHENOXYLATE-ATROPINE 2.5-0.025 MG/5ML PO LIQD,RX-2515,CDM,340b,HCPCS,0637,RC,00054-3194-46,NDC,,both,5,ML,26.30,17.09,,,,,,,,,,,,,
PLATE BNE W175XL404MM THK52MM 22 H BILAT S STL BROAD LOK,SUP-2185324,CDM,C1713,HCPCS,0278,RC,,,,both,,,3813.91,2479.04,,,,,,,,,,,,,
ROD SPNL L30MM PRECRV TI ALLOY,SUP-2415625,CDM,C1713,HCPCS,0278,RC,,,,both,,,960.84,624.55,,,,,,,,,,,,,
SHEATH INTRO STEADYSHEATH EVOLUTION L 36.5 CM OD 17.2 FR ID,SUP-2638739,CDM,C1893,HCPCS,0272,RC,,,,both,,,866.83,563.44,,,,,,,,,,,,,
PLATE BNE L78MM THK3.4MM 6 H BILAT PUBIC S STL 2 DCP H LO,SUP-2184022,CDM,C1713,HCPCS,0278,RC,,,,both,,,2723.17,1770.06,,,,,,,,,,,,,
REAMER SURG 3 COMPLT DHS,SUP-2417309,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4149.82,2697.38,,,,,,,,,,,,,
STEM EXTN TIB 11MM DIA 152MM LEN FINN - 11MM DIAM 152MM LEN,SUP-2406057,CDM,C1776,CPT,0278,RC,,,,both,,,4288.46,2787.50,,,,,,,,,,,,,
IMPLANT BRST 560CC DIA13.4-13.1CM P5.7-7.3CM COHESIVE I SIL,SUP-2300321,CDM,C1789,HCPCS,0278,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
KIT TKR HYBRID CEM FEM TRABECULAR MTL TIB VIT E SURF AND PAT,SUP-2212221,CDM,C1776,CPT,0278,RC,,,,both,,,17270.00,11225.50,,,,,,,,,,,,,
COMPONENT FEM STD LT KNEE NONBEADED NP MOD CRUC RET CEM REV,SUP-2250935,CDM,C1776,CPT,0278,RC,,,,both,,,12132.96,7886.42,,,,,,,,,,,,,
ALLOGRAFT HUM TISS UNMESHED 6X12 CMX1.25-2 MM DECELL DERM,SUP-2264720,CDM,Q4122,HCPCS,0636,RC,,,,both,,,6742.05,4382.33,,,,,,,,,,,,,
LINER ACET OD74MM ID28MM HIP MARATHON NEUT SNAP IN REV PINN,SUP-2250352,CDM,C1776,CPT,0278,RC,,,,both,,,3786.84,2461.45,,,,,,,,,,,,,
PLATE BNE W33XL251MM 18 H R DST MED TIB S STL LOK COMPR NEUT,SUP-2185121,CDM,C1713,HCPCS,0278,RC,,,,both,,,5974.64,3883.52,,,,,,,,,,,,,
GUIDEWIRE VASC KATZN L 180 CM TIP L 9 CM DIA 0.035 IN SS,SUP-2148179,CDM,C1769,HCPCS,0272,RC,,,,both,,,564.79,367.11,,,,,,,,,,,,,
PLATE BNE FRACTR ANGLED W/ TMPLT NS,SUP-2883244,CDM,C1713,HCPCS,0278,RC,,,,both,,,3833.97,2492.08,,,,,,,,,,,,,
SCREW BNE 1.5 MM TI NS,SUP-2189273,CDM,C1713,HCPCS,0278,RC,,,,both,,,161.43,104.93,,,,,,,,,,,,,
FIBERTAG TIGHTROPE WITH FLIPCUTTER III,SUP-2811464,CDM,C1713,HCPCS,0278,RC,,,,both,,,3187.10,2071.61,,,,,,,,,,,,,
BUR SURG OVL LNG 4 MMX10 CM MIDAS REX LEGEND,SUP-2627642,CDM,2720000010,LOCAL,0272,RC,,,,both,,,355.10,230.81,,,,,,,,,,,,,
BLADE SHV AD L13CM DIA4.5MM TNSLCTMY ADENOIDECTOMY 45DEG,SUP-2284162,CDM,2720000010,LOCAL,0272,RC,,,,both,,,627.00,407.55,,,,,,,,,,,,,
PLATE ANCHR ORTHODONTIC 17 MM 1 MM W/ FLAT 5 MM AREA CP TI,SUP-2490538,CDM,C1713,HCPCS,0278,RC,,,,both,,,565.23,367.40,,,,,,,,,,,,,
HC Facial Bones Less Than 3 Views,PX-3207014000,CDM,70140,CPT,0320,RC,,,,outpatient,,,446.00,289.90,,,,,,,,,,,,,
PLATE BNE LCK 5.5X128 MM LT PROX LAT TIB 6 HOLE SS STRL,SUP-2469856,CDM,C1713,HCPCS,0278,RC,,,,both,,,3870.71,2515.96,,,,,,,,,,,,,
RETRACTOR SURG WND ALEXIS LAPAROSCOPIC SM,SUP-2855490,CDM,2720000010,LOCAL,0272,RC,,,,both,,,737.90,479.63,,,,,,,,,,,,,
PLATE BONE L74MM 9 H TI RT LAT DSTL POST HUM LO PROF RIG,SUP-2411719,CDM,C1713,HCPCS,0278,RC,,,,both,,,3661.24,2379.81,,,,,,,,,,,,,
CATHETER CV KT 7 FRX20 CM 3L PRESSURE INJ ARROWG+ARD BLU +,SUP-2763331,CDM,C1751,HCPCS,0278,RC,,,,both,,,339.75,220.84,,,,,,,,,,,,,
PLATE BNE CLAV CS3 2.7 MM RT LAT VA LCK COMPR TI NS VA-LCP,SUP-2758164,CDM,C1713,HCPCS,0278,RC,,,,both,,,3628.08,2358.25,,,,,,,,,,,,,
PEG BONE FIX L9MM DIA2.5MM DSTL VOLAR RAD CANC NONLOCKING,SUP-2414170,CDM,C1713,HCPCS,0278,RC,,,,both,,,286.37,186.14,,,,,,,,,,,,,
KWIRE FIX L229MM DIA0.9MM STYL 6 S STL DBL DMND PNT 6PK,SUP-2412583,CDM,C1713,HCPCS,0278,RC,,,,both,,,132.48,86.11,,,,,,,,,,,,,
MESH SURG W75XL15CM WHT MACROPOROUS,SUP-2752154,CDM,C1781,HCPCS,0278,RC,,,,both,,,196.34,127.62,,,,,,,,,,,,,
COMPONENT PAT SZ S39 OD39MM THK11MM TRITANIUM MTL BK KNEE,SUP-2373674,CDM,C1776,CPT,0278,RC,,,,both,,,3472.21,2256.94,,,,,,,,,,,,,
PIN AX DSTL LIMB SALV LO BODY ELEOS 1 SZ,SUP-2314043,CDM,C1776,CPT,0278,RC,,,,both,,,9115.42,5925.02,,,,,,,,,,,,,
DEVICE OCCL CLP L50MM PLUNG GRP FLX SHFT FOR GILLINOV,SUP-2540327,CDM,C1889,HCPCS,0278,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
PLATE BONE L92MM 5 H STRL RT ANK FUS ANTR PRI COMPR SLOT FOR,SUP-2349833,CDM,C1713,HCPCS,0278,RC,,,,both,,,6898.74,4484.18,,,,,,,,,,,,,
COMPONENT FEM SZ 1 CO CHROM NP LT KNEE CRUC RET PRI STEMLESS,SUP-2345805,CDM,C1776,CPT,0278,RC,,,,both,,,9388.60,6102.59,,,,,,,,,,,,,
IMPLANT SYNTH L 124 X W 170 MM THK 6 MM POLYETHYL LT CRAN,SUP-2883412,CDM,C1713,HCPCS,0278,RC,,,,both,,,15308.13,9950.28,,,,,,,,,,,,,
CATHETER DRAINAGE 25 MMX6CM UNITZ SNAP ASMBLY RESERVOIR BASE,SUP-2278322,CDM,C1729,HCPCS,0272,RC,,,,both,,,485.54,315.60,,,,,,,,,,,,,
PATCH HERN MIDLN W6.1XL10.1IN UNCOATED MFIL PROPYLENE ABSRB,SUP-2125899,CDM,C1781,HCPCS,0278,RC,,,,both,,,4916.30,3195.59,,,,,,,,,,,,,
GRAFT VASC HEMSHLD L 60 CM DIA 6 MM POLYESTER BOV CLLGN STR,SUP-2266061,CDM,C1768,CPT,0278,RC,,,,both,,,1842.36,1197.53,,,,,,,,,,,,,
LENS INTOCU 20.0 DIOPT 118.7 A CONSTANT L13MM DIA6MM 0DEG,SUP-2110224,CDM,V2632,HCPCS,0276,RC,,,,both,,,499.26,324.52,,,,,,,,,,,,,
SCREW BNE L10MM DIA2MM HD DIA3.5MM CORT S STL NONCANNULATED,SUP-2183177,CDM,C1713,HCPCS,0278,RC,,,,both,,,106.73,69.37,,,,,,,,,,,,,
PLATE BNE 8 H MIC TI NONSTERILE 1.5MM SCR .6MM,SUP-2262682,CDM,C1713,HCPCS,0278,RC,,,,both,,,189.50,123.17,,,,,,,,,,,,,
IMPL BREAST GEL BOOST SMTH HI PROF 370CC,SUP-2738050,CDM,C1789,HCPCS,0278,RC,,,,both,,,3925.00,2551.25,,,,,,,,,,,,,
GUIDEWIRE ORTHOPEDIC SCREW 2 MMX12 IN BLNT TIP STRL CANNFLX,SUP-2879297,CDM,C1769,HCPCS,0272,RC,,,,both,,,158.26,102.87,,,,,,,,,,,,,
PLATE BNE L159MM 6 H ST R CNDYL S STL CRV LOK COMPR VAR ANG,SUP-2177846,CDM,C1713,HCPCS,0278,RC,,,,both,,,5918.21,3846.84,,,,,,,,,,,,,
SYSTEM EXT DRNGE AND MON BLUECORE W VENT CATHETER DUET,SUP-2284566,CDM,C1713,HCPCS,0278,RC,,,,both,,,1120.67,728.44,,,,,,,,,,,,,
KIT CATH HEMODIALYSI DECATHLON DF CHRONIC STD 16FR DIA 36CM,SUP-2613311,CDM,C1750,HCPCS,0278,RC,,,,both,,,1134.17,737.21,,,,,,,,,,,,,
BUNDLE CATH ACCESSORY FOR PRESEP CATH,SUP-2270771,CDM,2720000010,LOCAL,0272,RC,,,,both,,,254.69,165.55,,,,,,,,,,,,,
CROWN DENT 3L ANTR LOWER CUSPID PRIMARY REFILL SS UNITEK,SUP-2322234,CDM,D6783,CPT,0278,RC,,,,both,,,18.68,12.14,,,,,,,,,,,,,
FOOTPLATE BONE MEDIUM 20 MM 12 MM POSTERIOR MAXILLARY OFFSET,SUP-2837829,CDM,C1713,HCPCS,0278,RC,,,,both,,,4147.63,2695.96,,,,,,,,,,,,,
PIN EXT FIX HALF 6X120 MM 30 MM THRD SS RINGFIX,SUP-2459716,CDM,2720000010,LOCAL,0272,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
ZOLEDRONIC ACID 4 MG/100ML IV SOLN,RX-111077,CDM,J3489,HCPCS,0636,RC,25021-0826-82,NDC,,both,100,ML,96.80,62.92,,,,,,,,,,,,,
NCB SPACER 3,SUP-2722205,CDM,C1713,HCPCS,0278,RC,,,,both,,,445.03,289.27,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE 5 CC DEMINERALIZED CORT CANC BNE FIBER,SUP-2905181,CDM,C1713,HCPCS,0278,RC,,,,both,,,2081.82,1353.18,,,,,,,,,,,,,
SHELL ACET MH 25 62 MM HIP REGENEREX RINGLOK,SUP-2365888,CDM,C1776,CPT,0278,RC,,,,both,,,7919.08,5147.40,,,,,,,,,,,,,
STAPLER INT L340MM VASC THN TISS ARTC LIN CUT W/ WHT RELD,SUP-2257357,CDM,2720000010,LOCAL,0272,RC,,,,both,,,676.64,439.82,,,,,,,,,,,,,
ALLOGRAFT HUM TISS AMNIO FLUID LG 1 CC RESTORIGIN RT,SUP-2321884,CDM,C1713,HCPCS,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 50 CM DIA 5 MM EPTFE STR STD WALL,SUP-2396180,CDM,C1768,CPT,0278,RC,,,,both,,,1821.20,1183.78,,,,,,,,,,,,,
ROD SPNL L20MM 2 BALL SPHERX DBR,SUP-2311186,CDM,C1713,HCPCS,0278,RC,,,,both,,,3061.50,1989.97,,,,,,,,,,,,,
SPLINT WRST SM L THMB SPICA COT POLY FAB LTHR WRKHRD ORIG,SUP-2326129,CDM,L3908,HCPCS,0272,RC,,,,both,,,74.26,48.27,,,,,,,,,,,,,
CATHETER US 5FR L150CM 0.056IN PLAT GLYDX HYDRPHLC INTVASC,SUP-2327229,CDM,C1753,HCPCS,0278,RC,,,,both,,,2504.15,1627.70,,,,,,,,,,,,,
CATHETER VLV DEL BRONCH DIA 4-7 MM J CONFIGURATION STRL DISP,SUP-2930258,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1868.30,1214.39,,,,,,,,,,,,,
IMPLANT SYNTH L 88 X W 86 MM THK 15 MM MED POLYETHYL,SUP-2883438,CDM,C1713,HCPCS,0278,RC,,,,both,,,5009.24,3256.01,,,,,,,,,,,,,
GALANTAMINE HYDROBROMIDE 4 MG PO TABS,RX-29806,CDM,6370000000,HCPCS,0637,RC,68084-0729-11,NDC,,both,1,UN,15.80,10.27,,,,,,,,,,,,,
SCREW BNE SD 1.5X5 MM NS UNIV NEURO III LTX,SUP-2862784,CDM,C1713,HCPCS,0278,RC,,,,both,,,257.48,167.36,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 70 CM DIA 7 MM STR TW HELIX,SUP-2695229,CDM,C1768,CPT,0278,RC,,,,both,,,1790.46,1163.80,,,,,,,,,,,,,
SCREW BONE L90MM DIA6.4MM BLU TI ALLOY ANTIROTATION T25,SUP-2181060,CDM,C1713,HCPCS,0278,RC,,,,both,,,748.42,486.47,,,,,,,,,,,,,
GRAFT HUMAN TISSUE 15CC ALLO ADIPOSE MATRIX AP0001,SUP-2676578,CDM,C1762,CPT,0278,RC,,,,both,,,1534.83,997.64,,,,,,,,,,,,,
HALF RING 140 MM INT DIAM,SUP-2818047,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7020.57,4563.37,,,,,,,,,,,,,
ADO-TRASTUZUMAB EMTANSINE 160 MG IV SOLR,RX-120529,CDM,J9354,HCPCS,0636,RC,50242-0087-01,NDC,,both,1,UN,18384.20,11949.73,,,,,,,,,,,,,
FOIL DENT 50X20X0.1 MM MEMBRN N PERF RESORB X LF,SUP-2470848,CDM,C1713,HCPCS,0278,RC,,,,both,,,1419.12,922.43,,,,,,,,,,,,,
GRAFT HUMAN TSSUE FIRM 20X16 CM RCNSTRCTVE TSSUE MTRX STRTTC,SUP-2483526,CDM,Q4130,HCPCS,0636,RC,,,,both,,,31685.74,20595.73,,,,,,,,,,,,,
CHOLANGIOGRAM KIT RX AUTOTOME UTOM XL SPHINTOM JAGWIRE 7538,SUP-2525332,CDM,C1769,HCPCS,0272,RC,,,,both,,,675.95,439.37,,,,,,,,,,,,,
BIT DRL L 255 MM DIA 4.5 MM LNG COUNTERBORE NS DISP,SUP-2902200,CDM,2720000010,LOCAL,0272,RC,,,,both,,,760.10,494.06,,,,,,,,,,,,,
HC So1 Assay of Manganese,PX-3018378567,CDM,83785,CPT,0301,RC,,,,both,,,306.00,198.90,,,,,,,,,,,,,
NAIL IM SUPCNDYL 10 MMX15 CM NS AIM LTX DISP,SUP-2861167,CDM,C1713,HCPCS,0278,RC,,,,both,,,4560.22,2964.14,,,,,,,,,,,,,
STENT URTRL 6FR DIA 30CML SLCNE TCFLX OPEN END WPSH CATH UR,SUP-2724147,CDM,C2617,HCPCS,0278,RC,,,,both,,,378.31,245.90,,,,,,,,,,,,,
ALLOGRAFT BNE REFRIGERATED RT LAT FEM HEMICONDYLE,SUP-2740863,CDM,C1713,HCPCS,0278,RC,,,,both,,,35358.76,22983.19,,,,,,,,,,,,,
SCREW BNE L25MM DIA4.5MM TIB KNEE GRY TI FULL THRD HEX DRV,SUP-2347227,CDM,C1713,HCPCS,0278,RC,,,,both,,,1422.39,924.55,,,,,,,,,,,,,
PLATE 3.5MM TI LCP POSTEROLATERAL DISTAL HUMERUS 5H RIGHT,SUP-2549678,CDM,C1713,HCPCS,0278,RC,,,,both,,,3284.06,2134.64,,,,,,,,,,,,,
TRASTUZUMAB-QYYP 150 MG IV SOLR|DISCARDED DRUG NOT ADMINISTE,RX-153554,CDM,Q5116,HCPCS,0636,RC,00069-0308-01,NDC,JW,both,1,UN,3512.40,2283.06,,,,,,,,,,,,,
PLATE BNE L184MM 13 H NONSTERILE R ANTLAT DST TIB S STL LO,SUP-2185958,CDM,C1713,HCPCS,0278,RC,,,,both,,,4180.91,2717.59,,,,,,,,,,,,,
HC Drug Screen Quantitative Lidocaine,PX-3018017600,CDM,80176,CPT,0301,RC,,,,both,,,387.00,251.55,,,,,,,,,,,,,
IBUPROFEN 400 MG PO TABS,RX-3843,CDM,6370000000,HCPCS,0637,RC,00904-5853-61,NDC,,both,1,UN,0.60,0.39,,,,,,,,,,,,,
TI LOW PROFILE NEURO ORBITAL,SUP-2823241,CDM,C1713,HCPCS,0278,RC,,,,both,,,1362.76,885.79,,,,,,,,,,,,,
HC Sclerotherapy Single Vein,PX-3613647000,CDM,36470,CPT,0361,RC,,,,both,,,10314.00,6704.10,,,,,,,,,,,,,
PROVEN REV TIB INSRT SZ 3 14 MM,SUP-2359249,CDM,C1776,CPT,0278,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
PSN REV 3MM OFFSET STEM EXT 24X135MM,SUP-2508810,CDM,C1776,CPT,0278,RC,,,,both,,,6531.20,4245.28,,,,,,,,,,,,,
SHELL ACET K 70 MM HIP POROUS REFLECTION,SUP-2435184,CDM,C1776,CPT,0278,RC,,,,both,,,5915.76,3845.24,,,,,,,,,,,,,
PLATE BONE STD RT ANTR PROC POST TUBEROSITY PERC CALCNL FX,SUP-2123138,CDM,C1713,HCPCS,0278,RC,,,,both,,,3438.30,2234.89,,,,,,,,,,,,,
CATHETER PICC AD 5FR 18GA L55CM 2 LUMN NRS PWR INJ N COAT,SUP-2125640,CDM,C1751,HCPCS,0278,RC,,,,both,,,635.79,413.26,,,,,,,,,,,,,
RASP SURG JT PREP STRL DISP OMNI,SUP-2898484,CDM,2720000010,LOCAL,0272,RC,,,,both,,,734.76,477.59,,,,,,,,,,,,,
COIL NEUROVASCULAR WEB SL W 10-11 X H 5 MM DIA10 MM,SUP-2418962,CDM,C1889,HCPCS,0278,RC,,,,both,,,46943.00,30512.95,,,,,,,,,,,,,
ALLOGRAFT BNE PLUG 16 MM,SUP-2741812,CDM,C1762,CPT,0278,RC,,,,both,,,13996.24,9097.56,,,,,,,,,,,,,
LINER ACET NEUT H 28 MM PROV G7,SUP-2440200,CDM,C1776,CPT,0278,RC,,,,both,,,240.21,156.14,,,,,,,,,,,,,
DEVICE SEALER TISSUE REPROC LIGASURE 44CM MARYLAND,SUP-2717600,CDM,2720000010,LOCAL,0272,RC,,,,both,,,877.06,570.09,,,,,,,,,,,,,
DEFIBRILLATOR CARD C HD W/ RIATA ATLS + CR,SUP-2356522,CDM,C1722,HCPCS,0275,RC,,,,both,,,64881.82,42173.18,,,,,,,,,,,,,
TRAY CTRL VEN L70CM OD5FR 2 LUMN CATH BASIC MICROINTRODUCER,SUP-2125538,CDM,C1751,HCPCS,0278,RC,,,,both,,,241.78,157.16,,,,,,,,,,,,,
GRAFT HUM TISS NEO L7.5IN FORESKIN PROC APLIGRAF,SUP-2314094,CDM,Q4101,HCPCS,0636,RC,,,,both,,,14051.50,9133.47,,,,,,,,,,,,,
CATHETER GUID NEURON L 115 CM DSTL FLX ZONE 12 CM,SUP-2323601,CDM,C1887,HCPCS,0272,RC,,,,both,,,2056.70,1336.85,,,,,,,,,,,,,
TRAY CATH PICC Q CATH PLU INTERMED 5FR 65CM 2 LUMAN W/ACCSSR,SUP-2613416,CDM,C1751,HCPCS,0278,RC,,,,both,,,300.81,195.53,,,,,,,,,,,,,
GUIDE SURG DIA3.5MM LCK DRL FOR CONG ELBW CLAV SCAPULAR,SUP-2107726,CDM,2720000010,LOCAL,0272,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
PLATE BNE W195XL42MM NAR 6X2 H ST R DST VOLAR RAD TI VAR ANG,SUP-2180831,CDM,C1713,HCPCS,0278,RC,,,,both,,,2523.65,1640.37,,,,,,,,,,,,,
REAMER SURG DIA18MM METATRSL FOR COMPHSVE FT SYS,SUP-2123055,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
DEVICE CLSR 6FR VASC SUT FOR FEM ART PERCLOSE AT,SUP-2105662,CDM,C1760,HCPCS,0278,RC,,,,both,,,6060.20,3939.13,,,,,,,,,,,,,
ALLOGRAFT BNE 10 CC FIBER STAGRAFT,SUP-2661731,CDM,C1713,HCPCS,0278,RC,,,,both,,,6782.40,4408.56,,,,,,,,,,,,,
PLATE BONE STD 3 H LT ANK FT COMPR FOR LAPIDUS PROC PRECIS,SUP-2321489,CDM,C1713,HCPCS,0278,RC,,,,both,,,5385.10,3500.31,,,,,,,,,,,,,
SCISSORS SURG L4.5IN BLK IRIS OPHTH SUP CUT RAZ EDGE,SUP-2162148,CDM,2720000010,LOCAL,0272,RC,,,,both,,,478.13,310.78,,,,,,,,,,,,,
GRAFT DURA W3XL3IN PURIFIED CLLGN MTRX REGEN DURAGN SECUR,SUP-2244020,CDM,C1713,HCPCS,0278,RC,,,,both,,,2651.64,1723.57,,,,,,,,,,,,,
IMMOBILIZER SHLDR SLNG M,SUP-2276607,CDM,L3660,HCPCS,0274,RC,,,,both,,,10.52,6.84,,,,,,,,,,,,,
CATHETERIZATION KIT ART 021 22 GAX5 CM 25 GA 3 CC SAFGLDE LF,SUP-2865595,CDM,C1751,HCPCS,0278,RC,,,,both,,,135.65,88.17,,,,,,,,,,,,,
ROD EXT FIX XSM L45MM DIA3MM C FBR COMP STR NONRADIOPAQUE,SUP-2188689,CDM,C1713,HCPCS,0278,RC,,,,both,,,118.41,76.97,,,,,,,,,,,,,
CATH 5F 4POLE 5 5 5 SPAE F CURVE,SUP-2471478,CDM,C1730,HCPCS,0272,RC,,,,both,,,530.66,344.93,,,,,,,,,,,,,
CATHETER KIT 7 FRX55 CM 30 FRX12 CM NEPHROSTOMY LP NEPHROMAX,SUP-2141676,CDM,C1726,HCPCS,0272,RC,,,,both,,,1046.03,679.92,,,,,,,,,,,,,
OBTURATOR SURG FOR 1.4 MM SURELOCK REUSE,SUP-2664017,CDM,2720000010,LOCAL,0272,RC,,,,both,,,935.47,608.06,,,,,,,,,,,,,
CATHETER BLLN DIL 26X48 MMX60 CM ANORECT BAROSTAT,SUP-2306877,CDM,C1726,HCPCS,0272,RC,,,,both,,,120.89,78.58,,,,,,,,,,,,,
CATHETER ATHRCTMY L130CM OD7FR TIP OD0.066IN ECCENTRICTRIC,SUP-2353048,CDM,C1724,HCPCS,0278,RC,,,,both,,,9404.30,6112.79,,,,,,,,,,,,,
STENT GRFT VASC AFX L 75 MM DIA PROX/DSTL 25 MM COCR,SUP-2217590,CDM,C1874,HCPCS,0278,RC,,,,both,,,10785.90,7010.83,,,,,,,,,,,,,
SCREW SPNL L30MM DIA6MM CANC SACR TI POLYAX NONCANNULATED,SUP-2254428,CDM,C1713,HCPCS,0278,RC,,,,both,,,2935.90,1908.33,,,,,,,,,,,,,
GRAFT VASC GELWEAVE L 40 CM DIA 30 MM POLYESTER GEL,SUP-2385038,CDM,C1768,CPT,0278,RC,,,,both,,,1497.34,973.27,,,,,,,,,,,,,
LGN PRESSFIT STEM 18X220 STRT GRT BLST,SUP-2822668,CDM,C1776,CPT,0278,RC,,,,both,,,6506.08,4228.95,,,,,,,,,,,,,
PLATE BONE MINI L38MM CVD,SUP-2364914,CDM,C1713,HCPCS,0278,RC,,,,both,,,248.06,161.24,,,,,,,,,,,,,
CLAMP SURG L11MM CRAN TI CRANIOFIX 2,SUP-2108413,CDM,C1713,HCPCS,0278,RC,,,,both,,,405.06,263.29,,,,,,,,,,,,,
STENT CORONARY VERIFLEX MR L 20 MM DIA 3.5 MM SS RX,SUP-2142464,CDM,C1876,HCPCS,0278,RC,,,,both,,,2810.30,1826.69,,,,,,,,,,,,,
GUIDEWIRE ORTH L800MM DIA3MM BALL TIP,SUP-2316305,CDM,C1769,HCPCS,0272,RC,,,,both,,,604.04,392.63,,,,,,,,,,,,,
GRAFT BNE FRZN L SCAPULA IMPL ALLGRFT,SUP-2307322,CDM,C1713,HCPCS,0278,RC,,,,both,,,11081.34,7202.87,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9 % IV SOLN (MINI-BAG),RX-40850049,CDM,2580000003,HCPCS,0250,RC,00338-0553-18,NDC,,both,100,ML,62.10,40.36,,,,,,,,,,,,,
ALLOGRAFT BNE SPACER 7 28X26X14 MM CC-ALIF CANC ALLOQUENT,SUP-2736943,CDM,C1713,HCPCS,0278,RC,,,,both,,,14130.00,9184.50,,,,,,,,,,,,,
KNIFE ROSEN 20MM DIAMETER,SUP-2681599,CDM,2720000010,LOCAL,0272,RC,,,,both,,,387.92,252.15,,,,,,,,,,,,,
MESH HERN SQ 19.5X19.5 IN FULL RESRB FOR SFT TISS PHASIX,SUP-2855259,CDM,C1781,HCPCS,0278,RC,,,,both,,,102207.00,66434.55,,,,,,,,,,,,,
SCREW BNE L4MM DIA1.5MM CORT MAXILLOMANDIBULAR GRN TI SELF,SUP-2403072,CDM,C1713,HCPCS,0278,RC,,,,both,,,147.58,95.93,,,,,,,,,,,,,
PLATE 3.5MM CURVED BROAD LCP 28H TI STRL,SUP-2546941,CDM,C1713,HCPCS,0278,RC,,,,both,,,3503.08,2277.00,,,,,,,,,,,,,
JIG SURG KNEE PS REPL STRL IDENTITY IMPRNT,SUP-2904759,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2425.65,1576.67,,,,,,,,,,,,,
COIL NEUROVASCULAR PENUMBRA COIL 400 L 10 CM DIA 5 MM STD,SUP-2323358,CDM,C1889,HCPCS,0278,RC,,,,both,,,6499.80,4224.87,,,,,,,,,,,,,
HC Perq Dev Breast Add US Image,PX-3611928600,CDM,19286,CPT,0361,RC,,,,outpatient,,,1593.00,1035.45,,,,,,,,,,,,,
SIZER SURG W9XH85CM 140ML P38CM SIL GEL BRST 322 STYL HI,SUP-2300777,CDM,2720000010,LOCAL,0272,RC,,,,both,,,816.40,530.66,,,,,,,,,,,,,
RING EXT FIX DIA120 MM HALF MONK RING,SUP-2899039,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2927.27,1902.73,,,,,,,,,,,,,
HANDLE SCREWDRIVER TORQUE LIMITING 2 NM STRL DISP,SUP-2435492,CDM,2720000010,LOCAL,0272,RC,,,,both,,,910.60,591.89,,,,,,,,,,,,,
RING EXT FIX ID205MM TI C FBR HYBRID 3 4 FOR DST TIB FRME,SUP-2188606,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1607.27,1044.73,,,,,,,,,,,,,
HC Biopsy Soft Tissue Neck/T,PX-3612155000,CDM,21550,CPT,0361,RC,,,,both,,,5012.00,3257.80,,,,,,,,,,,,,
PLATE BNE W12XL230MM THK2.5MM LNG 10 H NONSTERILE BILAT,SUP-2190993,CDM,C1713,HCPCS,0278,RC,,,,both,,,5397.44,3508.34,,,,,,,,,,,,,
DILATOR VASC DIA0.145IN ROT SHTH DISP TIGHTRAIL SUB-C,SUP-2353167,CDM,C1894,HCPCS,0272,RC,,,,both,,,6091.60,3959.54,,,,,,,,,,,,,
CONNECTOR SPNL FOR 55 6MM ROD TETHERING SYS TRANSLACE,SUP-2417656,CDM,C1713,HCPCS,0278,RC,,,,both,,,3877.90,2520.63,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP IGUANA REG 20 MM 450 CM BILI,SUP-2125960,CDM,C1769,HCPCS,0272,RC,,,,both,,,279.46,181.65,,,,,,,,,,,,,
COIL NEUROVASCULAR MICRUSPHERE 10 L 25 CM DIA 9 MM PRIMARY,SUP-2457861,CDM,C1889,HCPCS,0278,RC,,,,both,,,5388.18,3502.32,,,,,,,,,,,,,
MESH HERNIAXL W10XH14IN INT ABD OMEGA 3 FATTY ACID POLYPR,SUP-2265991,CDM,C1781,HCPCS,0278,RC,,,,both,,,4741.40,3081.91,,,,,,,,,,,,,
CATHETER PERIPHERAL ENTENDED DWELL ENDURNC SYSTEM 22GAX8,SUP-2744558,CDM,C1751,HCPCS,0278,RC,,,,both,,,169.25,110.01,,,,,,,,,,,,,
PROSTHESIS OSSCLR TOTAL 2MM2.5MM DIA HEAD 0.8MM2.3MM DST E,SUP-2681465,CDM,L8613,CPT,0278,RC,,,,both,,,1524.82,991.13,,,,,,,,,,,,,
HC Iaad Ia Rotavirus,PX-3068742500,CDM,87425,CPT,0306,RC,,,,outpatient,,,186.00,120.90,,,,,,,,,,,,,
DRILL TWST 1.6MM DIA 4.5INL 2.0/2.3MM SCR DENT SHFT END,SUP-2366421,CDM,2720000010,LOCAL,0272,RC,,,,both,,,511.04,332.18,,,,,,,,,,,,,
CLIP HEMOSTATIC REPOSITIONABLE 235 CMX16 MM SHTH DURACLIP,SUP-2428104,CDM,C1713,HCPCS,0278,RC,,,,both,,,1296.22,842.54,,,,,,,,,,,,,
LAWSON RETROGRADE NEPHROSTOMY WIRE PUNCTURE SET,SUP-2826624,CDM,2720000010,LOCAL,0272,RC,,,,both,,,808.24,525.36,,,,,,,,,,,,,
CLAMP CRAN L 16 MM NEURO BURR H STRL DISP LORENZ RAPIDFLAP,SUP-2935197,CDM,C1713,HCPCS,0278,RC,,,,both,,,901.18,585.77,,,,,,,,,,,,,
HC Pt Therapeutic Activities 15 Min|OP OCCUPATIONAL THERAPY SERV|SERVICES PROVIDED IN WHOLE OR IN PARTY BY AN OTA FOR MEDICARE PATIENTS|UNUSUAL NON-OVERLAPPING SERVICE,PX-4209753000,CDM,97530,CPT,0420,RC,,,GO|CO|XU,both,,,144.00,93.60,,,,,,,,,,,,,
SCREW BNE FEM NAIL HOLDING S2,SUP-2492719,CDM,C1713,HCPCS,0278,RC,,,,both,,,703.36,457.18,,,,,,,,,,,,,
RASP SURG M L18.3MM DIA3.2MM HELICOIDAL,SUP-2367457,CDM,2720000010,LOCAL,0272,RC,,,,both,,,350.33,227.71,,,,,,,,,,,,,
SCREW VA LCK OPTILINK SLF TP 5.0X42MM,SUP-2720103,CDM,C1713,HCPCS,0278,RC,,,,both,,,548.21,356.34,,,,,,,,,,,,,
STAPLE BNE FIX L9MM S STL INTERAXIS QUIK CHARLOTTE,SUP-2397591,CDM,C1713,HCPCS,0278,RC,,,,both,,,464.72,302.07,,,,,,,,,,,,,
KIT INTRO MICROEZ L 35 CM CATH 5 FR NDL L 10 CM SS GUIDEWIRE,SUP-2125476,CDM,C1751,HCPCS,0278,RC,,,,both,,,163.28,106.13,,,,,,,,,,,,,
SHUNT NEUROSURGICAL 5/30CM WATER WITHOUT RESERVOIR NON PROGR,SUP-2825655,CDM,C1889,HCPCS,0278,RC,,,,both,,,6113.52,3973.79,,,,,,,,,,,,,
CLAMP EXT FIX PEDIATRIC SHEFFIELD,SUP-2645884,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2194.48,1426.41,,,,,,,,,,,,,
PLATE BONE THK1MM 12 H CRANIOMAXILLOFACIAL ORAL SLV TI ADPT,SUP-2181764,CDM,C1713,HCPCS,0278,RC,,,,both,,,2459.56,1598.71,,,,,,,,,,,,,
STENT BILI WALLFLEX L 60 MM DIA10 MM CATH L 75 CM SHTH 9 FR,SUP-2149822,CDM,C1874,HCPCS,0278,RC,,,,both,,,11376.22,7394.54,,,,,,,,,,,,,
DEVICE LAPSCP M DIA4-7CM HND ASST LAP-DISC,SUP-2257667,CDM,C1788,HCPCS,0278,RC,,,,both,,,4920.66,3198.43,,,,,,,,,,,,,
GRAFT HUM TISS DIA18MM AMNIO MEMBRN DISK AMNIOEXCEL,SUP-2194317,CDM,Q4137,HCPCS,0636,RC,,,,both,,,1846.32,1200.11,,,,,,,,,,,,,
GRAFT HUM TISS DIA20 70MM FRZN ALLGRFT FEM HD W TROCH L,SUP-2307307,CDM,C1713,HCPCS,0278,RC,,,,both,,,9657.64,6277.47,,,,,,,,,,,,,
BLADE SAW S STL RESECT FOR PART KNEE STRYKR SYS 3 OXFORD,SUP-2408668,CDM,2720000010,LOCAL,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
ALLOGRAFT HUM TISS FRZN ASEP LT LAT MENIS W/ BNE,SUP-2867142,CDM,C1762,CPT,0278,RC,,,,both,,,16830.09,10939.56,,,,,,,,,,,,,
PLATE BNE LNG L EXTN ACU-LOC 2 VDR,SUP-2107046,CDM,C1713,HCPCS,0278,RC,,,,both,,,3557.62,2312.45,,,,,,,,,,,,,
PROSTHESIS OTO L5MM SHFT OD0.4MM S STL MID EAR STAP OFFSET,SUP-2284063,CDM,L8613,CPT,0278,RC,,,,both,,,668.32,434.41,,,,,,,,,,,,,
INTRODUCER SHTH 8FR L81CM DIL 8FR L85CM 0032IN SL4 CRV,SUP-2357244,CDM,C1893,HCPCS,0272,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
GRAFT BNE 3X3 TISSUEMEND PTCH,SUP-2366723,CDM,C1781,HCPCS,0278,RC,,,,both,,,13649.58,8872.23,,,,,,,,,,,,,
GRAFT BONE SUBSTITUTE FIBERGRAFT 11CC,SUP-2741935,CDM,C1713,HCPCS,0278,RC,,,,both,,,16321.72,10609.12,,,,,,,,,,,,,
PUMP HEART IMPELLA 5.5 W/SMART ASSIST S2,SUP-2853216,CDM,C1889,HCPCS,0278,RC,,,,both,,,141300.00,91845.00,,,,,,,,,,,,,
BIT DRL L L385MM DIA15.5MM W/O STP FLX QUIK CPL,SUP-2188303,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1237.13,804.13,,,,,,,,,,,,,
GRAFT BONE SUB 10CC CA PHOS PUTTY FOR NORIAN CRS FAST SET,SUP-2193977,CDM,C1713,HCPCS,0278,RC,,,,both,,,6314.54,4104.45,,,,,,,,,,,,,
BLADE SURG SHT 60 MM,SUP-2363413,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
OCUVITE-LUTEIN PO TABS,RX-138480,CDM,6370000000,HCPCS,0637,RC,00536-5090-08,NDC,,both,1,UN,0.60,0.39,,,,,,,,,,,,,
CATHETER THROMCTMY ANGIOJET DISTAFLEX L 145 CM DIA 4/3 FR,SUP-2664299,CDM,C1757,HCPCS,0272,RC,,,,both,,,6813.80,4428.97,,,,,,,,,,,,,
GRAFT VASC STR 8 MMX70 CM RADIALLY SUPP POLYESTER INTEGARD,SUP-2227576,CDM,C1768,CPT,0278,RC,,,,both,,,2976.09,1934.46,,,,,,,,,,,,,
BLADE FLAT 10MM 11CM STER DISP,SUP-2801000,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2700.40,1755.26,,,,,,,,,,,,,
KIT CATHETER STD 270ML X2ML PER HR ON Q PAINBUSTER,SUP-2236818,CDM,C1713,HCPCS,0278,RC,,,,both,,,248.06,161.24,,,,,,,,,,,,,
DOXYCYCLINE MONOHYDRATE 25 MG/5ML PO SUSR,RX-9902,CDM,340b,HCPCS,0637,RC,68180-0657-01,NDC,,both,20,ML,27.40,17.81,,,,,,,,,,,,,
PLATE BNE FEM 3.5/4.5X320 MM RT PROX 10 HOLE STRL VALCP,SUP-2789579,CDM,C1713,HCPCS,0278,RC,,,,both,,,8634.15,5612.20,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 80 CM DIA 6 MM EPTFE STR TW REINF 2,SUP-2525468,CDM,C1768,CPT,0278,RC,,,,both,,,2399.09,1559.41,,,,,,,,,,,,,
GUIDEPIN ORTH L230MM OD2.4MM DISTRACTOR COMPR THRD TIP,SUP-2319584,CDM,2720000010,LOCAL,0272,RC,,,,both,,,153.86,100.01,,,,,,,,,,,,,
TROCAR SURG HURWITZ 22 FRX8 IN NS,SUP-2458848,CDM,2720000010,LOCAL,0272,RC,,,,both,,,389.61,253.25,,,,,,,,,,,,,
KIT CATH HEMODIALYSI EQUISTREAM CHRONIC STD 14.5FR DIA 36CM,SUP-2613302,CDM,C1750,HCPCS,0278,RC,,,,both,,,1658.39,1077.95,,,,,,,,,,,,,
GUIDEWIRE ANGIO CATH RETRV TIP 6MM QUIK CRSS CAPTURE,SUP-2353171,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
PLATE BNE L74MM 3X5 H OBLQ T SHP FOR 3.5MM SCR,SUP-2411364,CDM,C1713,HCPCS,0278,RC,,,,both,,,579.58,376.73,,,,,,,,,,,,,
K WIRE FIX DIA1.6MM U SHP MED MALL PIN PLT,SUP-2389603,CDM,C1713,HCPCS,0278,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
ALLOGRAFT BNE CRUSH 30 CC FD ASEP CANC,SUP-2867132,CDM,C1762,CPT,0278,RC,,,,both,,,1610.82,1047.03,,,,,,,,,,,,,
SCREW BNE AD PED L7MM DIA2MM CORT TI SELF DRL SELF RET,SUP-2262825,CDM,C1713,HCPCS,0278,RC,,,,both,,,114.30,74.29,,,,,,,,,,,,,
FIXATOR 5/8 RNG 120MM FRDM CIR,SUP-2400631,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1522.90,989.88,,,,,,,,,,,,,
STYLET LD POS L46CM DEFL LOC +,SUP-2356065,CDM,2720000010,LOCAL,0272,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
GRAFT BNE SUB 2CC CA PHSPTE VIT E ACETT HEMSTAT COHESIVE,SUP-2431805,CDM,C9359,HCPCS,0278,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
IMPLANT TOE JT HEMI CANN VILEX MINI,SUP-2392822,CDM,C1776,CPT,0278,RC,,,,both,,,6437.00,4184.05,,,,,,,,,,,,,
GRAFT VASC 6 MMX40 CMX0.35 MM STR ULTRA THN WALL HEMGRD,SUP-2471676,CDM,C1768,CPT,0278,RC,,,,both,,,1612.17,1047.91,,,,,,,,,,,,,
SHEATH INTRO PERFRMR L 40 CM OD 5 FR ID 1.7 MM GUIDEWIRE,SUP-2168402,CDM,C1894,HCPCS,0272,RC,,,,both,,,272.24,176.96,,,,,,,,,,,,,
PLATE BNE BX 1.3 MM TI NS,SUP-2190699,CDM,C1713,HCPCS,0278,RC,,,,both,,,599.74,389.83,,,,,,,,,,,,,
SCREW BNE L28MM DIA4.5MM THRD L12MM S STL PARTIALLY THRDED,SUP-2184427,CDM,C1713,HCPCS,0278,RC,,,,both,,,62.61,40.70,,,,,,,,,,,,,
CATHETER DIGITAL DISCOVER SPYGLASS,SUP-2713871,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8894.05,5781.13,,,,,,,,,,,,,
EXTENSION STEM GTT DN PLUG FOR TIB PLT NXGN MIS,SUP-2208589,CDM,C1713,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
SYSTEM GYN ANTR PELV FLR MESH PELV RECON GYNECARE PROSIMA,SUP-2219811,CDM,C1781,HCPCS,0278,RC,,,,both,,,5463.60,3551.34,,,,,,,,,,,,,
PIN EXTERNAL FIXATION W55XH6XL200MM GREEN HALF XTRAFIX,SUP-2499237,CDM,2720000010,LOCAL,0272,RC,,,,both,,,445.03,289.27,,,,,,,,,,,,,
TOOL EMBDNG FOR TEMPORARILY EMBED EXT PORTION OF PERI DLYS,SUP-2303481,CDM,2720000010,LOCAL,0272,RC,,,,both,,,417.62,271.45,,,,,,,,,,,,,
PROBE BX 10GX140MM VACORA,SUP-2127050,CDM,2720000010,LOCAL,0272,RC,,,,both,,,593.93,386.05,,,,,,,,,,,,,
CROWN DENT 2 S STL 1ST PRI M LO RT ANTR CUSPID PREFABRICATED,SUP-2238896,CDM,D6783,CPT,0278,RC,,,,both,,,18.90,12.28,,,,,,,,,,,,,
DONEPEZIL HCL 5 MG PO TABS,RX-18786,CDM,6370000000,HCPCS,0637,RC,60687-0292-11,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
ALLOGRAFT BNE SPACER 0 DEG 8X26X8 MM LORDTC ALLOCRAFT TL,SUP-2632296,CDM,C1713,HCPCS,0278,RC,,,,both,,,11420.18,7423.12,,,,,,,,,,,,,
PLATE BNE DBL ANGLED SM 2 MM RECON PT SPEC,SUP-2860080,CDM,C1713,HCPCS,0278,RC,,,,both,,,25848.48,16801.51,,,,,,,,,,,,,
INSERT TIB WEDGED 80 MM KNEE REMEDY,SUP-2718143,CDM,C1776,CPT,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
PAD ORTHOT ANTR CUST ASIS,SUP-2435588,CDM,L1250,HCPCS,0272,RC,,,,both,,,223.91,145.54,,,,,,,,,,,,,
PLATE BONE L67MM 5 H RT ANG T SHP PERI-LOC SM FRAG SYS,SUP-2348449,CDM,C1713,HCPCS,0278,RC,,,,both,,,1297.51,843.38,,,,,,,,,,,,,
TRAY INTRO L 11 CM 8 FR TUOHY BORST STR J DIL NDL SIDEPRT,SUP-2120109,CDM,C1894,HCPCS,0272,RC,,,,both,,,107.58,69.93,,,,,,,,,,,,,
PIN FIX TRCR PT 1 END 0.093X9 IN 3 SHANK END SS NS STEINMANN,SUP-2791272,CDM,C1713,HCPCS,0278,RC,,,,both,,,15.13,9.83,,,,,,,,,,,,,
DEFIBRILLATOR CARD 76GM 35CC W40XH73MM THK14MM PARYLENE,SUP-2356268,CDM,C1722,HCPCS,0275,RC,,,,both,,,35168.00,22859.20,,,,,,,,,,,,,
COMPONENT FEM ALL POLY NP TIB GEN II,SUP-2347964,CDM,C1776,CPT,0278,RC,,,,both,,,8949.00,5816.85,,,,,,,,,,,,,
SHELL ACET DIA40MM F/M TI ALLOY POR SPIK W/O H PRI REV UNIV,SUP-2202330,CDM,C1776,CPT,0278,RC,,,,both,,,4612.66,2998.23,,,,,,,,,,,,,
BOOT WALKING PNEUMATIC,SUP-2382018,CDM,L4360,HCPCS,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
STENT BILI PALMAZ GEN L 13 MM DIA 5 MM CATH L 80 CM DIA 8 FR,SUP-2159094,CDM,C1877,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
GRAFT VASC GORTX L 40 CM DIA20 MM EPTFE STRL,SUP-2396442,CDM,C1768,CPT,0278,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
CATHETERIZATION KIT DL 5 FR MAX BARR BIOFLO,SUP-2118856,CDM,C1751,HCPCS,0278,RC,,,,both,,,684.83,445.14,,,,,,,,,,,,,
SET LD EXTRACTION EVOLUTION SHORTIE RL L 13.6 CM OD 19 FR ID,SUP-2169473,CDM,C1773,HCPCS,0272,RC,,,,both,,,4395.97,2857.38,,,,,,,,,,,,,
CATHETER MAP 2 MM 8 FRX120 CM 31 MM 64 ELECTRD CONSTELLATION,SUP-2424694,CDM,C1732,HCPCS,0278,RC,,,,both,,,11486.12,7465.98,,,,,,,,,,,,,
CAGE SPNL MESH 28X22X70 MM 6 LOBE,SUP-2602088,CDM,C1889,HCPCS,0278,RC,,,,both,,,19292.16,12539.90,,,,,,,,,,,,,
CATHETER PERI STR OPN END RADPQ 120CM LNG,SUP-2108712,CDM,C1729,HCPCS,0272,RC,,,,both,,,490.75,318.99,,,,,,,,,,,,,
NUT EXT FIX DIA10MM ANK DC COUNT SQ RINGFIX,SUP-2378778,CDM,2720000010,LOCAL,0272,RC,,,,both,,,354.19,230.22,,,,,,,,,,,,,
PLATE BNE 3X8 H S STL T SHP LOK COMPR LO PROF FOR 15MM MOD,SUP-2177464,CDM,C1713,HCPCS,0278,RC,,,,both,,,1164.75,757.09,,,,,,,,,,,,,
DISTRACTOR SURG COMPRESSOR,SUP-2279590,CDM,C1713,HCPCS,0278,RC,,,,both,,,5103.13,3317.03,,,,,,,,,,,,,
PLATE BNE SM NON-BIOASORB STRL X-PLATE STRATUM,SUP-2656716,CDM,C1713,HCPCS,0278,RC,,,,both,,,2969.00,1929.85,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH FLX L 82 MM PROX/DSTL 36/12 MM,SUP-2171048,CDM,C1768,CPT,0278,RC,,,,both,,,7743.24,5033.11,,,,,,,,,,,,,
BIT DRL DIA4.8MM SHT SHANK FOR HA HALF PIN,SUP-2342999,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2293.49,1490.77,,,,,,,,,,,,,
ALLOGRAFT BNE GRAN 8 CC CHIP DRY MIX DBM CORTICAL CANC G2,SUP-2538800,CDM,C1889,HCPCS,0278,RC,,,,both,,,3611.00,2347.15,,,,,,,,,,,,,
BUR SURG BALL 6 MM FLUT FOR MIA16-G1/MIA16,SUP-2848321,CDM,2720000010,LOCAL,0272,RC,,,,both,,,469.56,305.21,,,,,,,,,,,,,
SHUNT SURG CORONARY 2X12 MM ATRAUM VES TAPR TIP SOF-FLO,SUP-2261622,CDM,L8612,HCPCS,0278,RC,,,,both,,,230.79,150.01,,,,,,,,,,,,,
SEALER/DIVIDER LAP SHFT L44CM DIA5MM STR BLNT TIP JAW HND,SUP-2283562,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1474.70,958.55,,,,,,,,,,,,,
PLATE BNE BURR HOLE CVR 22X3X1.5 MM LP CONTOURED TI SLV NS,SUP-2461351,CDM,C1713,HCPCS,0278,RC,,,,both,,,722.17,469.41,,,,,,,,,,,,,
GRAFT BNE BLOCK SM TRICORT,SUP-2759546,CDM,C1713,HCPCS,0278,RC,,,,both,,,5662.21,3680.44,,,,,,,,,,,,,
STENT ENDOPROS L25CM DIA8MM CATH 8FR L120CM 0.035IN VES,SUP-2396624,CDM,C1874,HCPCS,0278,RC,,,,both,,,19753.74,12839.93,,,,,,,,,,,,,
SCREW BNE RESRB,SUP-2608838,CDM,C1713,HCPCS,0278,RC,,,,both,,,1758.40,1142.96,,,,,,,,,,,,,
PLATE BNE 90 DEG 1X4 MM,SUP-2517345,CDM,C1713,HCPCS,0278,RC,,,,both,,,398.00,258.70,,,,,,,,,,,,,
RESERVOIR EXT DRNGE 01ML DIA12MM BA IMPREG CONV INTEGR R ANG,SUP-2278364,CDM,C1889,HCPCS,0278,RC,,,,both,,,1006.68,654.34,,,,,,,,,,,,,
PLATE BONE L98MM 7 H LT PROX POSTEROMEDIAL VAR ANG LCK FOR,SUP-2349801,CDM,C1713,HCPCS,0278,RC,,,,both,,,9533.35,6196.68,,,,,,,,,,,,,
FORCEP ENDOSCP RAT TOOTH 7.3X1621 MM 2.8 MM GRASPING CHANNEL,SUP-2865649,CDM,2720000010,LOCAL,0272,RC,,,,both,,,513.20,333.58,,,,,,,,,,,,,
STRIP ILIUM BICORTICAL TRAD ALLGRFT 22X45 MM FRZ DRY,SUP-2294075,CDM,C1713,HCPCS,0278,RC,,,,both,,,1764.68,1147.04,,,,,,,,,,,,,
CATHETER DLYS L62CM PERI 2 FELT CUF RADPQ STRP ARGY CURL,SUP-2283899,CDM,C1750,HCPCS,0278,RC,,,,both,,,262.98,170.94,,,,,,,,,,,,,
SCREW BNE L36MM DIA3.5MM CORT DST TIB TI ST NONCANNULATED,SUP-2411695,CDM,C1713,HCPCS,0278,RC,,,,both,,,234.87,152.67,,,,,,,,,,,,,
GRAFT TISS FRZN ALLGRFT PELVIS ACETABULUM STRUCTURAL R,SUP-2307424,CDM,C1713,HCPCS,0278,RC,,,,both,,,8304.45,5397.89,,,,,,,,,,,,,
CATHETER URET 3FR L70CM RT PVC WHSTL TIP USED FOR DRNGE RG,SUP-2168869,CDM,C1758,HCPCS,0278,RC,,,,both,,,37.52,24.39,,,,,,,,,,,,,
SCREW EXT FIX L200MM DIA6.2MM THRD L55MM S STL 2 COR SCHNZ,SUP-2187005,CDM,C1713,HCPCS,0278,RC,,,,both,,,1375.32,893.96,,,,,,,,,,,,,
TRAY CATH HEMODIALYSI PWR TRIALYSI ACUTE 13FR DIA 24CML INSE,SUP-2613250,CDM,C1752,HCPCS,0278,RC,,,,both,,,1041.41,676.92,,,,,,,,,,,,,
BIT SOLAR TOT SHLDR UP EXTRM DRL SM HND,SUP-2374049,CDM,2720000010,LOCAL,0272,RC,,,,both,,,523.75,340.44,,,,,,,,,,,,,
HC Radiation Treatment Delivery Level 1,PX-3337740200,CDM,77402,CPT,0333,RC,,,,inpatient,,,614.00,399.10,,,,,,,,,,,,,
IMPLANT KNEE LT TRICOMPARTMENTAL FEM TIB INSRT W/ O PAT,SUP-2165976,CDM,C1776,CPT,0278,RC,,,,both,,,16328.00,10613.20,,,,,,,,,,,,,
RING EXT FIX 160 MM SALVATION,SUP-2461405,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3937.56,2559.41,,,,,,,,,,,,,
SCREW BONE L85MM OD3.5MM STD TI CORT DSTL TIB ST LCK FULL,SUP-2413591,CDM,C1713,HCPCS,0278,RC,,,,both,,,441.80,287.17,,,,,,,,,,,,,
SCREW BNE HD 4X26 MM,SUP-2365613,CDM,C1713,HCPCS,0278,RC,,,,both,,,79.13,51.43,,,,,,,,,,,,,
PIN FIXATION THREADED 3X355 MM,SUP-2472906,CDM,2720000010,LOCAL,0272,RC,,,,both,,,331.21,215.29,,,,,,,,,,,,,
NAIL IM L160MM DIA8MM L PROX HUM BLU TI STR RND CANN LOK,SUP-2180168,CDM,C1713,HCPCS,0278,RC,,,,both,,,5832.24,3790.96,,,,,,,,,,,,,
COIL NEUROVASCULAR PENUMBRA COIL 400 L 12 CM PRIMARY DIA,SUP-2323356,CDM,C1889,HCPCS,0278,RC,,,,both,,,6559.46,4263.65,,,,,,,,,,,,,
PLATE BONE LOK DUAL CMPRSSN 187MML HLX16 STNLSS STEEL CNTRD,SUP-2588591,CDM,C1713,HCPCS,0278,RC,,,,both,,,1252.29,813.99,,,,,,,,,,,,,
PLATE BONE L106MM THK3.4MM 7 H BILAT NONLOCKING COMPR FOR,SUP-2348950,CDM,C1713,HCPCS,0278,RC,,,,both,,,1489.40,968.11,,,,,,,,,,,,,
SUPPORT ANK L PUL ON WHT PROCARE,SUP-2196786,CDM,L1906,HCPCS,0274,RC,,,,both,,,6.28,4.08,,,,,,,,,,,,,
CAGE SPNL T2 XVBR CENTERPIECE TI COCR NIT 4 DEG L22 MM,SUP-2292819,CDM,C1889,HCPCS,0278,RC,,,,both,,,832.10,540.86,,,,,,,,,,,,,
SET INTRO MICROPUNCTURE CATH L 10 CM 5 FR L 4 CM SS PED,SUP-2170540,CDM,C1894,HCPCS,0272,RC,,,,both,,,86.98,56.54,,,,,,,,,,,,,
HEAD HUM 40-14 MM SHLDR ANAT SHLDR,SUP-2440625,CDM,C1776,CPT,0278,RC,,,,both,,,3504.24,2277.76,,,,,,,,,,,,,
HC Calcium Urine Quantitative Timed Specimen,PX-3018234000,CDM,82340,CPT,0301,RC,,,,both,,,96.00,62.40,,,,,,,,,,,,,
GRAFT BIO W2.5XL2.5CM FOR OTO REP BIODESIGN,SUP-2170501,CDM,C1763,HCPCS,0278,RC,,,,both,,,926.30,602.09,,,,,,,,,,,,,
HC Ffp,PX-3900901700,CDM,P9017,CPT,0390,RC,,,,both,,,548.00,356.20,,,,,,,,,,,,,
HEAD HUM DIA48MM THK18MM SHLDR CO CHROM REPL PROS AEQUALIS,SUP-2388629,CDM,C1776,CPT,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
STENT MOD 25MM 2.50 NIR ON RANG,SUP-2140506,CDM,C1876,HCPCS,0278,RC,,,,both,,,4160.50,2704.32,,,,,,,,,,,,,
GENERATOR PACEMKR STRATOS TI POLYUR SIL 3 CHMBR ADV DDDRV,SUP-2137971,CDM,C2621,HCPCS,0275,RC,,,,both,,,23274.15,15128.20,,,,,,,,,,,,,
COMPONENT INNR 24/10 MM SFC,SUP-2389696,CDM,C1776,CPT,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 45 CM DIA 6 MM STR TW CTR HELIX,SUP-2525456,CDM,C1768,CPT,0278,RC,,,,both,,,1279.36,831.58,,,,,,,,,,,,,
BIT DRL QC 2.7X125 MM CALIB NS,SUP-2757823,CDM,2720000010,LOCAL,0272,RC,,,,both,,,308.91,200.79,,,,,,,,,,,,,
HC Mod Sed Other Phys/Qhp Ea Addl 15 Min,PX-3729915700,CDM,99157,CPT,0372,RC,,,,both,,,154.00,100.10,,,,,,,,,,,,,
GRAFT VASC IMPRA L 40 CM ID 7-4 MM EPTFE SHRT TAPR STD WALL,SUP-2126425,CDM,C1768,CPT,0278,RC,,,,both,,,4195.98,2727.39,,,,,,,,,,,,,
CANNULA ARTHSCP 6.5MM OUTER SPD LCK W/ 2 ROT STPCOCK,SUP-2361389,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1724.55,1120.96,,,,,,,,,,,,,
RETRACTOR EXTENDED WEAR PANNICULUS XL,SUP-2880688,CDM,2720000010,LOCAL,0272,RC,,,,both,,,452.16,293.90,,,,,,,,,,,,,
SCREW BONE L8MM DIA24MM CORTICAL HEADED NON LOCKING MSP,SUP-2465084,CDM,C1713,HCPCS,0278,RC,,,,both,,,286.31,186.10,,,,,,,,,,,,,
COIL NEUROVASCULAR CASHMERE 14 L 20 CM LOOP DIA 8 MM PRIMARY,SUP-2249274,CDM,C1889,HCPCS,0278,RC,,,,both,,,4096.60,2662.79,,,,,,,,,,,,,
CATHETER ETER IRRIG 6FR L80CM FOR VASC CLOT MGMT,SUP-2119769,CDM,C1757,HCPCS,0272,RC,,,,both,,,81.48,52.96,,,,,,,,,,,,,
KIT INTRO L 15 CM DIA 4 FR GUIDEWIRE L 60 CM NDL L 12 CM,SUP-2226026,CDM,C1894,HCPCS,0272,RC,,,,both,,,197.82,128.58,,,,,,,,,,,,,
SUPPORT ORTHOT SACROILIAC PELV CUST W/PANEL STRP PENDULOUS,SUP-2435553,CDM,L0623,HCPCS,0272,RC,,,,both,,,501.05,325.68,,,,,,,,,,,,,
SCREW BNE L40MM DIA7MM THRD L16MM S STL CANN,SUP-2183808,CDM,C1713,HCPCS,0278,RC,,,,both,,,802.74,521.78,,,,,,,,,,,,,
OBTURATOR 8FR 33CM LEN F/9.5-14FR INTRO SNAP LCK - 8FR 33CM,SUP-2355509,CDM,C1894,HCPCS,0272,RC,,,,both,,,18.84,12.25,,,,,,,,,,,,,
CATHETER GUID FLOWGATE 2 L 85 CM OD 8 FR ID 0.084 IN BALLOON,SUP-2884389,CDM,C1887,HCPCS,0272,RC,,,,both,,,4082.00,2653.30,,,,,,,,,,,,,
PLATE STRNL CLOSURE 13 MM TI JL WIDE GAP NS STERNALOCK BLU,SUP-2894491,CDM,C1713,HCPCS,0278,RC,,,,both,,,1877.72,1220.52,,,,,,,,,,,,,
STEM HUM L 150 MM DIA 7 MM CLLR DIA 34 MM SZ 2 XLN PLASMA,SUP-2912558,CDM,C1776,CPT,0278,RC,,,,both,,,23588.62,15332.60,,,,,,,,,,,,,
CATHETER GUID BATES 2 0.091 INX8 FRX55 CM W/ 2 SH PTFE MACH1,SUP-2147723,CDM,C1887,HCPCS,0272,RC,,,,both,,,295.44,192.04,,,,,,,,,,,,,
DISSECTOR ELECTROCAUTERY L 165 CM JAW L6 MM CHANNEL DIA2.8,SUP-2881909,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1252.86,814.36,,,,,,,,,,,,,
BUR SURG DIA2.35 MM HUB II TUNGSTEN CARBIDE SIDE RASP STRL,SUP-2928903,CDM,2720000010,LOCAL,0272,RC,,,,both,,,335.79,218.26,,,,,,,,,,,,,
PLATE BONE L34MM 8 H ORBIT RIM CRANIOMAXILLOFACIAL TI FOR,SUP-2191137,CDM,C1713,HCPCS,0278,RC,,,,both,,,1226.48,797.21,,,,,,,,,,,,,
PIN EXT FIX SZ 3 X 120 X 30 MM HALF NS DISP MAV MINI,SUP-2933300,CDM,2720000010,LOCAL,0272,RC,,,,both,,,519.83,337.89,,,,,,,,,,,,,
STENT TRACHBRONCH 8MMX80MMX117CM FLUENCY +,SUP-2129092,CDM,C1874,HCPCS,0278,RC,,,,both,,,7206.30,4684.09,,,,,,,,,,,,,
BLANK RST PAN POS SP 1 8 INFIN M,SUP-2163841,CDM,L3807,HCPCS,0272,RC,,,,both,,,39.00,25.35,,,,,,,,,,,,,
PLATE BNE THK 1 MM SCREW DIA2.2 MM 49 H PLL POLYGLYCOLIDE,SUP-2883339,CDM,C1713,HCPCS,0278,RC,,,,both,,,8476.21,5509.54,,,,,,,,,,,,,
CATHETER GUID 16FR L62CM DEFLECTED TIP REACH 22MM NK,SUP-2298365,CDM,C1894,HCPCS,0272,RC,,,,both,,,5529.54,3594.20,,,,,,,,,,,,,
COMPONENT NEG PRSS WND THER STRP M NO PRSS RANG SNAP,SUP-2261608,CDM,C1776,CPT,0278,RC,,,,both,,,76.93,50.00,,,,,,,,,,,,,
SYSTEM INT FIX GFS BTB LINK,SUP-2762120,CDM,C1713,HCPCS,0278,RC,,,,both,,,879.20,571.48,,,,,,,,,,,,,
DVR LOCK EXTRA EXTRA LNG R ST,SUP-2587119,CDM,C1713,HCPCS,0278,RC,,,,both,,,4075.72,2649.22,,,,,,,,,,,,,
ARTHROTOME SURG 13 MM ANK AQ/AC,SUP-2897730,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1221.46,793.95,,,,,,,,,,,,,
RING EXT FIX 2/3 150 MM CARBON DFS DYNAFIX,SUP-2466706,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1120.98,728.64,,,,,,,,,,,,,
VERAPAMIL HCL ER 240 MG PO TBCR,RX-13073,CDM,6370000000,HCPCS,0637,RC,68462-0260-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PLATE BNE L107MM THK1.5MM 3X8 H L S STL OBLQ T SHP LOK,SUP-2186030,CDM,C1713,HCPCS,0278,RC,,,,both,,,1225.42,796.52,,,,,,,,,,,,,
STENT CORONARY VERIFLEX MR L 24 MM DIA 4.5 MM SS RX,SUP-2144507,CDM,C1876,HCPCS,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE LG 11 CC CORTICOCANCELLOUS VIABLE,SUP-2932993,CDM,C1762,CPT,0278,RC,,,,both,,,43960.00,28574.00,,,,,,,,,,,,,
PLATE BNE L 180 X W 10.5 MM THK 3 MM SCREW DIA2.7/3.5 MM 14,SUP-2936290,CDM,C1713,HCPCS,0278,RC,,,,both,,,6093.48,3960.76,,,,,,,,,,,,,
SCREW BNE L36MM DIA4MM CORT TI ST LAG CANN FULL THRD UCSS,SUP-2290879,CDM,C1713,HCPCS,0278,RC,,,,both,,,1789.80,1163.37,,,,,,,,,,,,,
PLATE BNE L73MM 6 H S STL 1/3 TBLR LIMIT CNTCT DYN COMPR W/,SUP-2185929,CDM,C1713,HCPCS,0278,RC,,,,both,,,472.10,306.86,,,,,,,,,,,,,
"HC So1 Detect Agent Nos, Dna, Amp",PX-3068779867,CDM,87798,CPT,0306,RC,,,,both,,,609.00,395.85,,,,,,,,,,,,,
RELOAD STPL L45MM M THCK REINF FOR SIGNIA STPLR TRI-STPL,SUP-2174748,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2468.57,1604.57,,,,,,,,,,,,,
RING SEGMENT CARBON FIBER 210MM,SUP-2457135,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4300.54,2795.35,,,,,,,,,,,,,
STERILE WATER FOR IRRIGATION IR SOLN,RX-7485,CDM,2500000003,HCPCS,0250,RC,00338-0004-04,NDC,,both,500,ML,54.10,35.16,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.517,SUP-2860034,CDM,C1713,HCPCS,0278,RC,,,,both,,,40331.10,26215.21,,,,,,,,,,,,,
GRAFT HUM TISS W2XL12CM WHL MEM AMNIO SHT NO ANG AMINOFIX,SUP-2305723,CDM,C1762,CPT,0278,RC,,,,both,,,3965.19,2577.37,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL PEEK SD800.516,SUP-2860198,CDM,C1713,HCPCS,0278,RC,,,,both,,,30218.10,19641.76,,,,,,,,,,,,,
CATHETER KIT AGBA PI PICC 2L 5.5 FR X 55CM,SUP-2655672,CDM,C1751,HCPCS,0278,RC,,,,both,,,614.44,399.39,,,,,,,,,,,,,
SYSTEM DISTR PRPLE FRGD EXTRNL DISTR RED II 51 580 00 04,SUP-2679227,CDM,C1713,HCPCS,0278,RC,,,,both,,,24260.08,15769.05,,,,,,,,,,,,,
COUNTERSINK SURG DRL 3-4 MM,SUP-2390553,CDM,2720000010,LOCAL,0272,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
HC Gbl Advance Care Planning First 30 Mins,PX-9829949701,CDM,99497,CPT,0982,RC,,,,both,,,541.00,351.65,,,,,,,,,,,,,
LIDO-RACEPINEPHRINE-TETRACAINE 4-0.05-0.5 % EX GEL,RX-165078,CDM,6370000000,HCPCS,0637,RC,70092-1611-44,NDC,,both,3,ML,65.20,42.38,,,,,,,,,,,,,
SET PNEUMOTHOR EMER,SUP-2419755,CDM,C1729,HCPCS,0272,RC,,,,both,,,395.20,256.88,,,,,,,,,,,,,
LEAD DEFIB PLEXA PROMRI S DX L 65 CM TIP DISTANCE 15 CM DF4,SUP-2418479,CDM,C1895,HCPCS,0275,RC,,,,both,,,10048.00,6531.20,,,,,,,,,,,,,
SHUNT ASCITES SGL VA DENV,SUP-2133690,CDM,C1713,HCPCS,0278,RC,,,,both,,,597.54,388.40,,,,,,,,,,,,,
COIL NEUROVASCULAR HYPERSOFT 3D L 2 CM LOOP DIA2 MM,SUP-2305365,CDM,C1889,HCPCS,0278,RC,,,,both,,,5388.24,3502.36,,,,,,,,,,,,,
GRAFT HUM TISS W12XL20CM THK18 4MM ACELLULAR DERM MTRX,SUP-2307486,CDM,Q4128,HCPCS,0636,RC,,,,both,,,22838.57,14845.07,,,,,,,,,,,,,
TIP HNDPC SONICFUSION,SUP-2489378,CDM,2720000010,LOCAL,0272,RC,,,,both,,,483.56,314.31,,,,,,,,,,,,,
SCREW SPNL L26MM DIA4MM CANC TI PARTIALLY THRD MULTIAXIAL,SUP-2286887,CDM,C1713,HCPCS,0278,RC,,,,both,,,4160.50,2704.32,,,,,,,,,,,,,
GRAFT BNE SUB 15CC PARTIC 4-9.5MM CANC FRZ DRY CHIP CHIPS15CC] US TISSUE AND CELL],SUP-2391733,CDM,C1713,HCPCS,0278,RC,,,,both,,,1260.71,819.46,,,,,,,,,,,,,
SCREW BNE HIP S STL LO PROF CBL ACCORD,SUP-2345211,CDM,C1713,HCPCS,0278,RC,,,,both,,,373.03,242.47,,,,,,,,,,,,,
GUIDEWIRE VASC APPRCH HYDR ST L 190 CM DIA 0.014 IN TAPR L,SUP-2171007,CDM,C1769,HCPCS,0272,RC,,,,both,,,429.71,279.31,,,,,,,,,,,,,
NEEDLE BX FRNSN DISP 20GAX9CM,SUP-2269635,CDM,2720000010,LOCAL,0272,RC,,,,both,,,781.86,508.21,,,,,,,,,,,,,
TITANIUM FIXATION SCREW 45MM RED DEVICE,SUP-2679222,CDM,C1713,HCPCS,0278,RC,,,,both,,,517.72,336.52,,,,,,,,,,,,,
STRAP CLAV M BCKL CLSR FOAM CONSTR COT STOCK 3 W POST VECT,SUP-2194671,CDM,L3670,HCPCS,0272,RC,,,,both,,,14.73,9.57,,,,,,,,,,,,,
PLATE CRAN THK 0.75 MM SCREW DIA1.7 MM 2 H CRAN COUNTRSNK,SUP-2909570,CDM,C1713,HCPCS,0278,RC,,,,both,,,896.53,582.74,,,,,,,,,,,,,
FIBER LASER FLAT TIP 200 MH ASMBLY HOLM MF200BH] GALLAGHER MEDICAL PRODUCTS LLC],SUP-2225998,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1460.10,949.06,,,,,,,,,,,,,
ANCHOR SUT L14MM DIA4.5MM BIOCOMP FULL THRD W/ DRL BIT GUID,SUP-2122831,CDM,C1713,HCPCS,0278,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
BOLT ARCOS LATERAL TROCH 36MM,SUP-2506132,CDM,C1776,CPT,0278,RC,,,,both,,,1840.98,1196.64,,,,,,,,,,,,,
DORZOLAMIDE HCL-TIMOLOL MAL 2-0.5 % OP SOLN,RX-22982,CDM,6370000000,HCPCS,0637,RC,24208-0486-10,NDC,,both,10,ML,225.00,146.25,,,,,,,,,,,,,
CATHETER HD 2 L LUMEN 13.5 FRX36 CM 19 CM CHRONIC SURCUF KT,SUP-2127705,CDM,C1750,HCPCS,0278,RC,,,,both,,,837.44,544.34,,,,,,,,,,,,,
STAPLER INT LN 55 MM 6 FIRING ENDO GIA II,SUP-2129891,CDM,2720000010,LOCAL,0272,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
HC Special Plan Calculation,PX-3337732100,CDM,77321,CPT,0333,RC,,,,inpatient,,,3253.00,2114.45,,,,,,,,,,,,,
DRILL SURG 11 GA HND OPTABLATE,SUP-2864575,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1282.16,833.40,,,,,,,,,,,,,
COLLAR CERV PHILLY SM 4.25 IN 10-13 IN REHAB FOAM PROCARE,SUP-2196878,CDM,L0180,HCPCS,0274,RC,,,,both,,,35.67,23.19,,,,,,,,,,,,,
CODEINE SULFATE 30 MG PO TABS,RX-1802,CDM,6370000000,HCPCS,0637,RC,00054-0244-24,NDC,,both,1,UN,3.90,2.53,,,,,,,,,,,,,
PATELLA SUTPLT II STAR POLE FRACTURE M STRL,SUP-2811472,CDM,C1713,HCPCS,0278,RC,,,,both,,,9404.30,6112.79,,,,,,,,,,,,,
SYSTEM DRAINAGE NON-PRESSURE TBNG BLU STRP,SUP-2666732,CDM,2720000010,LOCAL,0272,RC,,,,both,,,510.31,331.70,,,,,,,,,,,,,
STRAP CLAV M BCKL CLSR FOAM CONSTR COT STOCK 3 W POST VECT,SUP-2194671,CDM,L3670,HCPCS,0274,RC,,,,both,,,14.73,9.57,,,,,,,,,,,,,
HC Perq Plmt Bile Duct Stent W/O Bili Cath,PX-3614753900,CDM,47539,CPT,0361,RC,,,,both,,,8583.00,5578.95,,,,,,,,,,,,,
PLATE BNE CRV MIC 1.5X0.6 MM NEURO 5X2 HOLE LADDER SQ SEG,SUP-2487369,CDM,C1713,HCPCS,0278,RC,,,,both,,,910.13,591.58,,,,,,,,,,,,,
AWL SURG DIA 8 MM CANN STR,SUP-2934410,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1434.98,932.74,,,,,,,,,,,,,
BUR SURG ACORN CUT NONFLUTED CARB L L640MM OD50MM,SUP-2278138,CDM,2720000010,LOCAL,0272,RC,,,,both,,,551.64,358.57,,,,,,,,,,,,,
HC Special Plan Calculation,PX-3337732100,CDM,77321,CPT,0333,RC,,,,outpatient,,,3253.00,2114.45,,,,,,,,,,,,,
HC Cytp Fine Ndl Aspirate Immt Cytohist Std Dx 1st,PX-3118817200,CDM,88172,CPT,0311,RC,,,,both,,,257.00,167.05,,,,,,,,,,,,,
BLADE SHAVER CRV 40 DEG 4 MM SERRATED CONVX WINDOW DIEGO,SUP-2638086,CDM,2720000010,LOCAL,0272,RC,,,,both,,,423.77,275.45,,,,,,,,,,,,,
HC Adm Tocilizu Covid-19 1st,PX-7710024900,CDM,M0249,CPT,0250,RC,,,,both,,,1182.00,768.30,,,,,,,,,,,,,
CATHETER THROMCTMY AXS VECTA 46 L 125 CM PROX/DSTL OD,SUP-2878077,CDM,C1757,HCPCS,0272,RC,,,,both,,,4882.07,3173.35,,,,,,,,,,,,,
STENT NEPHURET L 26 CM DIA10 FR PERCFLX INTERNAL/EXTERNAL,SUP-2147756,CDM,C2617,HCPCS,0278,RC,,,,both,,,320.28,208.18,,,,,,,,,,,,,
BRUSH CLN 1.25 MM,SUP-2492060,CDM,2720000010,LOCAL,0272,RC,,,,both,,,765.88,497.82,,,,,,,,,,,,,
MICROCATHETER GUID TREVO TRAK 21 L 162 CM PROX/DSTL OD,SUP-2551054,CDM,C1887,HCPCS,0272,RC,,,,both,,,2195.49,1427.07,,,,,,,,,,,,,
PLATE LOCK NARROW 10 HOLES,SUP-2757493,CDM,C1713,HCPCS,0278,RC,,,,both,,,4340.74,2821.48,,,,,,,,,,,,,
GRAFT BNE MAR SM CONC,SUP-2163085,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5338.00,3469.70,,,,,,,,,,,,,
BLADE SAW SAG 19MMW X41MML 0.4MM/0.69MM THK CUT ANTR CRUC LI,SUP-2605388,CDM,2720000010,LOCAL,0272,RC,,,,both,,,194.96,126.72,,,,,,,,,,,,,
PLATE BONE L20MM 90DEG 2X3 H RT CRANIOMAXILLOFACIAL TI L SHP,SUP-2191285,CDM,C1713,HCPCS,0278,RC,,,,both,,,731.62,475.55,,,,,,,,,,,,,
WALKER POSTOP SM AD F ANK BILAT FIX UNISX TRAUM MAXTRAX,SUP-2197140,CDM,L4350,HCPCS,0274,RC,,,,both,,,83.15,54.05,,,,,,,,,,,,,
KIT CATH DLYS 2LUMEN STR SHORT-TERM 12FRENCH 24CENTIMETER,SUP-2126491,CDM,C1752,HCPCS,0278,RC,,,,both,,,386.22,251.04,,,,,,,,,,,,,
GUIDEWIRE VASC L 145 CM DIA 0.035 IN TAPR L 4.5 CM FLX TIP L,SUP-2167752,CDM,C1769,HCPCS,0272,RC,,,,both,,,31.46,20.45,,,,,,,,,,,,,
GUIDEWIRE VASC STR 11 CM 0.035 INX260 CM 4 CM LUNDERQUIST(ORDER BY 5EA),SUP-2170064,CDM,C1769,HCPCS,0272,RC,,,,both,,,363.61,236.35,,,,,,,,,,,,,
SPLINT WRST L R THMB SPICA COT POLY FAB LTHR WRKHRD ORIG BGE,SUP-2326139,CDM,L3908,HCPCS,0274,RC,,,,both,,,63.71,41.41,,,,,,,,,,,,,
PEMBROLIZUMAB-BERAHYALUR-PMPH 790-9600 MG -UNT/4.8ML SC SOLN,RX-173862,CDM,J9999,HCPCS,0636,RC,00006-5083-01,NDC,,both,4.8,ML,69300.70,45045.45,,,,,,,,,,,,,
BOLOGNA SMPHSS DSTRCTR INCLDNG ACTVTNG WIRE 15MM DISTR T 6L,SUP-2669807,CDM,C1713,HCPCS,0278,RC,,,,both,,,9201.55,5981.01,,,,,,,,,,,,,
MESH HERN L25XW20CM RECT COMP REP VENTRAL PROC ELP SYN,SUP-2174719,CDM,C1781,HCPCS,0278,RC,,,,both,,,5084.23,3304.75,,,,,,,,,,,,,
CATHETER DRAINAGE 2 EYE 16 FR PROPORTIONATE HD PEZ,SUP-2126192,CDM,C2627,HCPCS,0272,RC,,,,both,,,53.98,35.09,,,,,,,,,,,,,
HC So Protein Electrophoresis Fluid,PX-3018416666,CDM,84166,CPT,0301,RC,,,,both,,,445.00,289.25,,,,,,,,,,,,,
DISTRACTION INTRNL DIST CLEFT MICRO ZRCH 2 LIOU TRANS LEFT 1,SUP-2491407,CDM,C1713,HCPCS,0278,RC,,,,both,,,11174.48,7263.41,,,,,,,,,,,,,
KIT INSTR AUTOCUFF COMPRISING OM-8000 OM-9010 OM-9015,SUP-2342102,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8933.30,5806.64,,,,,,,,,,,,,
"HC Ultrasound, Fetal Biophys",PX-4027681800,CDM,76818,CPT,0402,RC,,,,inpatient,,,1022.00,664.30,,,,,,,,,,,,,
SLING URETH PRECIS MINIARC 900261,SUP-2140381,CDM,C1771,HCPCS,0278,RC,,,,both,,,4044.32,2628.81,,,,,,,,,,,,,
SPLINT WRST L R THMB SPICA COT POLY FAB LTHR WRKHRD ORIG BGE,SUP-2326139,CDM,L3908,HCPCS,0272,RC,,,,both,,,63.71,41.41,,,,,,,,,,,,,
STAPLER INT L34CM 60MM LNG ENDOSCP ARTC PWR + ECHELON FLX,SUP-2219817,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1134.54,737.45,,,,,,,,,,,,,
GRAFT EVAR ID8-10MM LN L7CM UNLN L2CM SHTH 10FR BLLN,SUP-2395935,CDM,C1874,HCPCS,0278,RC,,,,both,,,16642.00,10817.30,,,,,,,,,,,,,
GRAFT BNE L100MM FIBULAR SHFT FRZN MATRIGRFT,SUP-2264754,CDM,C1713,HCPCS,0278,RC,,,,both,,,2035.35,1322.98,,,,,,,,,,,,,
PLATE BNE NAR 4.5X55 MM 3 HOLE SS DCP,SUP-2569161,CDM,C1713,HCPCS,0278,RC,,,,both,,,198.61,129.10,,,,,,,,,,,,,
HEAD REAMER DIA 9.5 MM FLX,SUP-2898466,CDM,2720000010,LOCAL,0272,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
CAGE SPNL MESH 17X13X13 MM 6 LOBE,SUP-2602079,CDM,C1889,HCPCS,0278,RC,,,,both,,,9228.46,5998.50,,,,,,,,,,,,,
SPLINT WRIST EXTRA SMALL 8 IN THUMB LEFT,SUP-2428142,CDM,L3908,HCPCS,0274,RC,,,,both,,,96.30,62.59,,,,,,,,,,,,,
BIT DRL QC MINI 0.76X44.5 MM 8 MM SS STRL,SUP-2187633,CDM,2720000010,LOCAL,0272,RC,,,,both,,,581.62,378.05,,,,,,,,,,,,,
PLATE BNE L94MM THK3.1MM 8 H BILAT S STL LOK COMPR RECON,SUP-2348691,CDM,C1713,HCPCS,0278,RC,,,,both,,,5162.63,3355.71,,,,,,,,,,,,,
SCREW BNE L64MM DIA4.5MM HD DIA6.5MM CANC S STL ST SELF DRL,SUP-2184472,CDM,C1713,HCPCS,0278,RC,,,,both,,,490.75,318.99,,,,,,,,,,,,,
HC CT Cryo Ablation Renal,PX-3615059300,CDM,50593,CPT,0361,RC,,,,both,,,10438.00,6784.70,,,,,,,,,,,,,
PROCESSOR MAIN MOD BLK NUCLS FRDM,SUP-2164926,CDM,L8614,HCPCS,0278,RC,,,,both,,,16131.75,10485.64,,,,,,,,,,,,,
ANCHOR SUT W/ ETHBND SZ 4-0 P-3 NDL TAPERCUT MIC QUICKANCHR,SUP-2249378,CDM,C1713,HCPCS,0278,RC,,,,both,,,2609.34,1696.07,,,,,,,,,,,,,
CENTRALIZER STEM DIA9MM DST,SUP-2314440,CDM,C1776,CPT,0278,RC,,,,both,,,213.52,138.79,,,,,,,,,,,,,
CATHETER DRAINAGE SHUNT 13X25 MMX90 CM MED PRESSURE PUDENZ,SUP-2244297,CDM,C1729,HCPCS,0272,RC,,,,both,,,509.53,331.19,,,,,,,,,,,,,
PLATE BNE 10 H S STL LOK STR FOR ANK FRAC MGMT,SUP-2123030,CDM,C1713,HCPCS,0278,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
DEVICE ENDOSKELETAL SYS PROSTHETIC BK ULT TI CARBON FIBER,SUP-2388221,CDM,L5940,HCPCS,0272,RC,,,,both,,,1318.45,856.99,,,,,,,,,,,,,
BAR EXT FIX 11X300 MM CARBON XTRAFIX,SUP-2480498,CDM,2720000010,LOCAL,0272,RC,,,,both,,,672.71,437.26,,,,,,,,,,,,,
HYALURONIDASE HUMAN 15 UNITS/ML IJ SYRINGE,RX-4081893,CDM,J3473,HCPCS,0636,RC,09999-9915-14,NDC,,both,0.2,ML,54.40,35.36,,,,,,,,,,,,,
PLATE BNE L92MM 7 H RECON FOR 35MM SCR UNIV LOK SYS,SUP-2411373,CDM,C1713,HCPCS,0278,RC,,,,both,,,1448.92,941.80,,,,,,,,,,,,,
COLLAR CERV CHILD SZ PD1 1 18MON 21 33IN FOR 075IN NK UP EXT,SUP-2123899,CDM,L0190,HCPCS,0274,RC,,,,both,,,89.46,58.15,,,,,,,,,,,,,
CATHETER IRRIGATION L 80 CM DIA 4 FR DSTL,SUP-2264230,CDM,C1757,HCPCS,0272,RC,,,,both,,,244.92,159.20,,,,,,,,,,,,,
COMPONENT GLEN FIX M DIA40MM BACKSIDE RAD CORTILOC PEGGED,SUP-2388693,CDM,C1776,CPT,0278,RC,,,,both,,,7107.39,4619.80,,,,,,,,,,,,,
BIT DRL RG NAILING SYS KT REQ FOR SH NAIL 4MM LEN 310MM,SUP-2315972,CDM,2720000010,LOCAL,0272,RC,,,,both,,,387.79,252.06,,,,,,,,,,,,,
PLATE SPNL L66MM LEV 3 ANTR BILAT CERV TI LCK LO PROF,SUP-2254595,CDM,C1713,HCPCS,0278,RC,,,,both,,,3984.66,2590.03,,,,,,,,,,,,,
STEM FEM LG 13.5 MM LT HIP W/ BODY POROUS APR II,SUP-2449425,CDM,C1776,CPT,0278,RC,,,,both,,,10470.33,6805.71,,,,,,,,,,,,,
LIOU CLEFT TRNSPRT DSTRCTR RGHT 15MM 06MM PLTS T 6L 4V,SUP-2669829,CDM,C1713,HCPCS,0278,RC,,,,both,,,10839.50,7045.67,,,,,,,,,,,,,
COMPONENT FEM KNEE CRUC RET MIC LT UNISX REV CEM STEM PC,SUP-2201426,CDM,C1776,CPT,0278,RC,,,,both,,,18532.28,12045.98,,,,,,,,,,,,,
TIP ASPIR KNIFE 0.83X12.5 MM 11 CM FOR BNE CUT SONOPET IQ,SUP-2791053,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2980.49,1937.32,,,,,,,,,,,,,
GUIDEWIRE ORTH L230MM DIA3MM THRD FOR TOMOFIX OSTEOTMY SYS,SUP-2177212,CDM,C1769,HCPCS,0272,RC,,,,both,,,515.02,334.76,,,,,,,,,,,,,
DVR LOCK STANDARD R ST,SUP-2587115,CDM,C1713,HCPCS,0278,RC,,,,both,,,2348.72,1526.67,,,,,,,,,,,,,
PLATE BNE MESHED 3.5X75X2 MM 14X14 HOLE RESRB,SUP-2484972,CDM,C1713,HCPCS,0278,RC,,,,both,,,3193.38,2075.70,,,,,,,,,,,,,
CATHETER CARD ABLATION EZ STEER NAV L 115 CM 4 MM D-F CRV,SUP-2248520,CDM,C1732,HCPCS,0278,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
SET STENT URTRL 8FR DIA 30CML PRCFLX PLS DBLE PGTL W0.038N,SUP-2725693,CDM,C2617,HCPCS,0278,RC,,,,both,,,472.13,306.88,,,,,,,,,,,,,
KIT PEDCL ACCS SPNL IMPL,SUP-2232070,CDM,C1713,HCPCS,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
PASSER SUTURE SPECTRUM AUTOPASS,SUP-2828669,CDM,2720000010,LOCAL,0272,RC,,,,both,,,28683.90,18644.53,,,,,,,,,,,,,
VALVE AORT CARP EDW PERIMT MAGNA EASE MT OD 21 MM ID 20 MM,SUP-2214117,CDM,C1889,HCPCS,0278,RC,,,,both,,,20253.00,13164.45,,,,,,,,,,,,,
CABLE SURG DIA1.7MM S STL HA CERCLAGE W/ CRMP 29880101S] DEPUY SYNTHES USA],SUP-2187030,CDM,C1713,HCPCS,0278,RC,,,,both,,,1334.94,867.71,,,,,,,,,,,,,
SET SCR SPNL TI POST THORACOLUMBOSACRAL MULTIAXIAL LO PROF,SUP-2289494,CDM,C1713,HCPCS,0278,RC,,,,both,,,109.90,71.43,,,,,,,,,,,,,
STAPLER INT USE DIA21 MM STPL H 3/3.5/4 MM MEDIUM/THICK CIR,SUP-2896339,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2995.69,1947.20,,,,,,,,,,,,,
GUARD SEAM STPL LN REINF ENDOPATH FOR THORACOSCOPIC AND ENDO,SUP-2396262,CDM,2720000010,LOCAL,0272,RC,,,,both,,,753.60,489.84,,,,,,,,,,,,,
PLATE BONE LOK 51MML HLX5 STNLSS STEEL NON ST RIGHT STLD RDL,SUP-2721443,CDM,C1713,HCPCS,0278,RC,,,,both,,,2289.81,1488.38,,,,,,,,,,,,,
HC Anl Sp Inf Pmp W/Mdreprg&Fil,PX-5106237000,CDM,62370,CPT,0510,RC,,,,both,,,961.00,624.65,,,,,,,,,,,,,
SHELL ACET PRESSFIT PRI 48 MM OD UNIV CLUS H TRABECULAR MTL,SUP-2202627,CDM,C1776,CPT,0278,RC,,,,both,,,6449.56,4192.21,,,,,,,,,,,,,
WRIST SPANNING PLATE 16 HOLE,SUP-2493413,CDM,C1713,HCPCS,0278,RC,,,,both,,,1777.24,1155.21,,,,,,,,,,,,,
PIN FIX BUTTRESS 1.8X18 MM LCK NS HPS LTX,SUP-2856894,CDM,C1713,HCPCS,0278,RC,,,,both,,,295.16,191.85,,,,,,,,,,,,,
COMPONENT FEM UNI XS KNEE GEN,SUP-2344261,CDM,C1776,CPT,0278,RC,,,,both,,,9041.63,5877.06,,,,,,,,,,,,,
OCCLUDER CV TIGERPAW SYS II LAA,SUP-2227753,CDM,C1713,HCPCS,0278,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
PLATE BNE 10 H ST BILAT S STL NAR CRV LOK COMPR FOR 35MM SCR,SUP-2178042,CDM,C1713,HCPCS,0278,RC,,,,both,,,1438.53,935.04,,,,,,,,,,,,,
SPACER SPNL W14XH7XL18MM 5DEG PEEK OPTMA ANTR CERV LORDTC LO,SUP-2211889,CDM,C1821,HCPCS,0278,RC,,,,both,,,2590.50,1683.82,,,,,,,,,,,,,
GRAFT BNE SUB W25XH4XL50MM 5ML B TRICALCIUM PHSPTE FOAM,SUP-2368175,CDM,C1713,HCPCS,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
CLAMP EXT FIX SM TI ALLOY COMB MR CONDITIONAL CLP ON SELF,SUP-2188536,CDM,2720000010,LOCAL,0272,RC,,,,both,,,731.62,475.55,,,,,,,,,,,,,
BLADE SAW CUT D20MM THK9MM SAG COR CASPR,SUP-2363667,CDM,2720000010,LOCAL,0272,RC,,,,both,,,559.45,363.64,,,,,,,,,,,,,
GUIDEWIRE ORTH 2.0 MMX14 IN NIT,SUP-2664004,CDM,C1769,HCPCS,0272,RC,,,,both,,,203.97,132.58,,,,,,,,,,,,,
PASSER SUT NIT WIRE FOR ACL CONSTR PROC RETROPASS,SUP-2120921,CDM,2720000010,LOCAL,0272,RC,,,,both,,,389.36,253.08,,,,,,,,,,,,,
HC MRI-Chest WO Contrast,PX-6107155000,CDM,71550,CPT,0610,RC,,,,inpatient,,,4190.00,2723.50,,,,,,,,,,,,,
TRAY EPIDURAL CATH DIA20 GA NDL DIA18 GA CE18TKSTN CONT SFT,SUP-2936784,CDM,2720000010,LOCAL,0272,RC,,,,both,,,83.37,54.19,,,,,,,,,,,,,
ENDOPROSTHESIS VASC VIABAHN L 15CM 5MM 120CM 7FR HEPARIN,SUP-2719622,CDM,C1768,HCPCS,0278,RC,,,,both,,,11818.96,7682.32,,,,,,,,,,,,,
CATHETER ETER UNIT VENT INTODUCING ROD ACCURACY 15CM,SUP-2243868,CDM,2720000010,LOCAL,0272,RC,,,,both,,,10100.94,6565.61,,,,,,,,,,,,,
PLATE BNE 3.5X25 MM 2 HOLE SS DCP,SUP-2569134,CDM,C1713,HCPCS,0278,RC,,,,both,,,176.15,114.50,,,,,,,,,,,,,
CURETTE SURG COBB 3-0 11 IN 3.5X2 MM BNE STR SLD KNURLED,SUP-2473124,CDM,2720000010,LOCAL,0272,RC,,,,both,,,666.47,433.21,,,,,,,,,,,,,
GRAFT TISS FRZ DRY ALLGRFT STRUT CORT CANC STRUCTURAL 40MM,SUP-2307182,CDM,C1713,HCPCS,0278,RC,,,,both,,,965.33,627.46,,,,,,,,,,,,,
DEFIBRILLATOR IMPL EVERA XT DR 36.5 CC 68 GM TI POLYUR SIL,SUP-2282395,CDM,C1721,HCPCS,0275,RC,,,,both,,,36313.47,23603.76,,,,,,,,,,,,,
PIN BNE FIX THRD L 50 MM DIA2.5 MM SHLDR SHRT SHANK NS APEX,SUP-2909058,CDM,C1713,HCPCS,0278,RC,,,,both,,,85.72,55.72,,,,,,,,,,,,,
PLATE BNE L196MM 7 H NONSTERILE R DST FEM TI LOK COMPR FOR,SUP-2190723,CDM,C1713,HCPCS,0278,RC,,,,both,,,4833.59,3141.83,,,,,,,,,,,,,
JOINT FNGR MP 50 SIL STRL,SUP-2464926,CDM,C1776,CPT,0278,RC,,,,both,,,3372.36,2192.03,,,,,,,,,,,,,
GRAFT BNE PTTY 3.75 GM BIOACTIVE OSTEOFUSE,SUP-2225963,CDM,C9359,HCPCS,0278,RC,,,,both,,,3815.10,2479.81,,,,,,,,,,,,,
"HC So Systemic Lupus a, Dna Ab|UNUSUAL NON-OVERLAPPING SERVICE",PX-3028622567,CDM,86225,CPT,0302,RC,,,XU,both,,,28.00,18.20,,,,,,,,,,,,,
CANNULA ENDO DIA5.5MM OP DYONICS,SUP-2340736,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1677.86,1090.61,,,,,,,,,,,,,
IMPLANT HUM TISS L 30 X W 20 MM THK 4 MM ACHILLES TEND RC,SUP-2932778,CDM,C1762,CPT,0278,RC,,,,both,,,4714.52,3064.44,,,,,,,,,,,,,
COMPONENT TOE JT W5XL15MM L PROX DST X TYP HAMMERLOCK 2,SUP-2194198,CDM,C1776,CPT,0278,RC,,,,both,,,2398.39,1558.95,,,,,,,,,,,,,
INSERT TIB SM L64MM THK8MM AP40MM RT MEDL LAT ARTC CRUC RET,SUP-2344078,CDM,C1776,CPT,0278,RC,,,,both,,,3347.24,2175.71,,,,,,,,,,,,,
BIT DRL CANN 10 MM KNEE SINGLE FLUT MTO,SUP-2849085,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2238.82,1455.23,,,,,,,,,,,,,
WASHER CUP L FRAG PLATING SYS ALPS 3PK,SUP-2412017,CDM,C1713,HCPCS,0278,RC,,,,both,,,402.64,261.72,,,,,,,,,,,,,
PROSTHESIS OSS CLASSIC STAP 5X0.9 MM 0.6 MM TI,SUP-2638176,CDM,L8613,CPT,0278,RC,,,,both,,,822.99,534.94,,,,,,,,,,,,,
PROTECTOR TEND W4XL5IN SHT BOV CLLGN GLYCOSAMINOGLYCAN POR,SUP-2244460,CDM,C1776,CPT,0278,RC,,,,both,,,8827.92,5738.15,,,,,,,,,,,,,
PLATE BNE L 177 MM SCREW DIA2.4 MM 20 SHFT H SS ADPT COMB VA,SUP-2908445,CDM,C1713,HCPCS,0278,RC,,,,both,,,4272.91,2777.39,,,,,,,,,,,,,
STIMULATOR BONE GROWTH SGL COIL SZ 2,SUP-2196351,CDM,E0749,HCPCS,0278,RC,,,,both,,,7959.90,5173.93,,,,,,,,,,,,,
BASEPLATE TIB STD UNIV PRI STEM CEM NP PC 46 A/PX67MM M/L,SUP-2200381,CDM,C1776,CPT,0278,RC,,,,both,,,9834.48,6392.41,,,,,,,,,,,,,
HC Repair Wound/Lesion +,PX-4501315300,CDM,13153,CPT,0450,RC,,,,both,,,792.00,514.80,,,,,,,,,,,,,
ENDPLATE SPNL DISK 9DEG M UNIV INTERVERTEBRAL THORACO LUM,SUP-2205504,CDM,C1713,HCPCS,0278,RC,,,,both,,,5259.50,3418.67,,,,,,,,,,,,,
EXTERNAL FIXATION SET COMPLETE Z FRAME GALAXY FIX GEM LTX,SUP-2875647,CDM,C1713,HCPCS,0278,RC,,,,both,,,26128.51,16983.53,,,,,,,,,,,,,
COMPONENT FEM L21MM KNEE HNG BOLT W/ SL LEGION,SUP-2346263,CDM,C1776,CPT,0278,RC,,,,both,,,3303.28,2147.13,,,,,,,,,,,,,
CALCIUM CITRATE 950 (200 CA) MG PO TABS,RX-1308,CDM,6370000000,HCPCS,0637,RC,80681-0140-00,NDC,,both,1,UN,0.40,0.26,,,,,,,,,,,,,
COLLAR CERV SERP SM XLN 23 X 3.5 IN CONTOURED,SUP-2276599,CDM,L0120,HCPCS,0274,RC,,,,both,,,7.76,5.04,,,,,,,,,,,,,
SYSTEM NAVIGATION PALM SZ PRECIS ALIGN TECHNOLOGY DISP FOR,SUP-2314152,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2637.60,1714.44,,,,,,,,,,,,,
GRAFT VASC IMPRA L 70 CM DIA 8 MM EPTFE FLX STD WALL SM BEAD,SUP-2761486,CDM,C1768,CPT,0278,RC,,,,both,,,3218.50,2092.02,,,,,,,,,,,,,
CATHETER DRNGE 8.5FR L25CM GWIRE 0.038IN SGL LUMN HYDRPHLC,SUP-2168475,CDM,C1729,HCPCS,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
HOOK SPNL PEDCL SM 5.5 MM 259000210] CTL AMEDICA US SPINE],SUP-2175458,CDM,C1713,HCPCS,0278,RC,,,,both,,,2816.58,1830.78,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 50 CM DIA 4-7 MM LNG TAPR REINF,SUP-2525448,CDM,C1768,CPT,0278,RC,,,,both,,,704.27,457.78,,,,,,,,,,,,,
OCCLUDER CV AMPLATZER PI MUSCULAR VSD WAIST L 10 MM DIA24 MM,SUP-2737597,CDM,C1817,HCPCS,0278,RC,,,,both,,,20535.60,13348.14,,,,,,,,,,,,,
BURR SURG 1.5MM DIA HD LNG MIC 5.1MML HD CARBIDE SM BNE STRG,SUP-2605563,CDM,2720000010,LOCAL,0272,RC,,,,both,,,68.39,44.45,,,,,,,,,,,,,
SCREW BONE L26MM DIA3MM HDLSS COMPR M CANN FLOWERCUBE,SUP-2225511,CDM,C1713,HCPCS,0278,RC,,,,both,,,1127.89,733.13,,,,,,,,,,,,,
KIT IMPLANT XPRESS CITRELOCK 5MM X 15MM,SUP-2787791,CDM,C1713,HCPCS,0278,RC,,,,both,,,5934.60,3857.49,,,,,,,,,,,,,
GUIDEWIRE SURG L410MM DIA1.6MM S STL FULL THRD SGL END,SUP-2186891,CDM,C1769,HCPCS,0272,RC,,,,both,,,150.97,98.13,,,,,,,,,,,,,
HC So1 Assay of Psa Total,PX-3018415367,CDM,84153,CPT,0301,RC,,,,both,,,57.00,37.05,,,,,,,,,,,,,
STEM FEM CEM 9 HIP EXT ALPINE,SUP-2315834,CDM,C1776,CPT,0278,RC,,,,both,,,6079.04,3951.38,,,,,,,,,,,,,
BRACE KNEE HNG WRP SM,SUP-2276702,CDM,L1820,HCPCS,0274,RC,,,,both,,,56.05,36.43,,,,,,,,,,,,,
GRAFT HUM TISS L220MM DIA3-6MM GRACILIS TEND FRZN,SUP-2335548,CDM,C1713,HCPCS,0278,RC,,,,both,,,3925.00,2551.25,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED PRSS FT ZHCPRESSFIT] ZIMMER BIOMET INC],SUP-2212729,CDM,C1776,CPT,0278,RC,,,,both,,,12674.61,8238.50,,,,,,,,,,,,,
GUIDEWIRE SPNL N THRD 500 MM NIT CORAL,SUP-2707968,CDM,C1769,HCPCS,0272,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
SCREW BONE L19MM OD2.0MM CRANIO MAXILLOFACIAL HD TI MINI,SUP-2262659,CDM,C1713,HCPCS,0278,RC,,,,both,,,98.75,64.19,,,,,,,,,,,,,
COMPONENT TALAR CEM 0 RT ANK COCR SALTO TALARIS,SUP-2244123,CDM,C1776,CPT,0278,RC,,,,both,,,21125.92,13731.85,,,,,,,,,,,,,
SET URET STENT L 26 CM DIA 4.8 FR GUIDEWIRE 0.035 IN CATH,SUP-2141659,CDM,C2617,HCPCS,0278,RC,,,,both,,,579.33,376.56,,,,,,,,,,,,,
MESH SURG 0.5 MM ORBIT FLR FOR 1.5 MM SCREW TI GLD,SUP-2478744,CDM,C1713,HCPCS,0278,RC,,,,both,,,1917.60,1246.44,,,,,,,,,,,,,
CATHETER PICC L 55 CM DIA 5.5 FR 2 LUMEN PRESSURE INJ VPS,SUP-2886215,CDM,C1751,HCPCS,0278,RC,,,,both,,,1046.66,680.33,,,,,,,,,,,,,
PLATE BNE HUM 3.5X163 MM RT PERIARTICULAR PROX 6 HOLE LCK LP,SUP-2177807,CDM,C1713,HCPCS,0278,RC,,,,both,,,5573.56,3622.81,,,,,,,,,,,,,
SCREW SPNL ST 4X13 MM MINIP DIVERGENCE,SUP-2632043,CDM,C1713,HCPCS,0278,RC,,,,both,,,414.48,269.41,,,,,,,,,,,,,
BONE GRAFT KIT DOWEL 18 MM REVISION,SUP-2836348,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
DILATOR ENDOSCP L90CM CATH 14FR BLLN L10CM DIA30MM 0.038IN,SUP-2149642,CDM,C1726,HCPCS,0272,RC,,,,both,,,1989.03,1292.87,,,,,,,,,,,,,
CATHETER CV SET 032 7 FRX15 CM 13 GA 3L CUTLM701JABRMHCRD,SUP-2759885,CDM,C1751,HCPCS,0278,RC,,,,both,,,245.71,159.71,,,,,,,,,,,,,
BIT DRL DIA3.2MM CALIB DISP FOR 4.5MM LCK PROX FEM SCR,SUP-2318883,CDM,2720000010,LOCAL,0272,RC,,,,both,,,829.96,539.47,,,,,,,,,,,,,
PLATE BNE L114MM 5 H STD PROX HUM S STL LOK COMPR FOR 3.5MM,SUP-2186013,CDM,C1713,HCPCS,0278,RC,,,,both,,,4336.34,2818.62,,,,,,,,,,,,,
ACT ARM RIGID RMTE DTCH CNCLD TIP 33 MM T 6L 4V,SUP-2680297,CDM,C1713,HCPCS,0278,RC,,,,both,,,3257.06,2117.09,,,,,,,,,,,,,
BLADE DISP LARYNSCP FBR OPT 195MMX14MM SZ 3 M AD MILLER GRN,SUP-2393649,CDM,2720000010,LOCAL,0272,RC,,,,both,,,317.14,206.14,,,,,,,,,,,,,
GUIDEWIRE VASC CRV 4 CM 0.035 INX300 CM 11 CM LUNDERQUIST,SUP-2422124,CDM,C1769,HCPCS,0272,RC,,,,both,,,370.52,240.84,,,,,,,,,,,,,
HEPARIN SODIUM (PORCINE) 10000 UNIT/ML IJ SOLN,RX-10177,CDM,J1644,HCPCS,0636,RC,00409-2721-30,NDC,,both,0.5,ML,54.10,35.16,,,,,,,,,,,,,
GRAFT VASC IMPRA L 10 CM DIA 8 MM EPTFE STR STD WALL N RING,SUP-2126228,CDM,C1768,CPT,0278,RC,,,,both,,,447.48,290.86,,,,,,,,,,,,,
COLLAR CERV SERP SM XLN 23 X 3.5 IN CONTOURED,SUP-2276599,CDM,L0120,HCPCS,0272,RC,,,,both,,,7.76,5.04,,,,,,,,,,,,,
PIN EXT FIX L20MM DIA4MM TI HALF HEX FIX CIR RANCHO ILIZ,SUP-2342554,CDM,C1713,HCPCS,0278,RC,,,,both,,,1663.01,1080.96,,,,,,,,,,,,,
BAND ARM AD UNIV GEL ELAS STRP BILAT,SUP-2324557,CDM,L3702,HCPCS,0274,RC,,,,both,,,48.17,31.31,,,,,,,,,,,,,
BIT DRL TWST 1.1X50 MM 17 MM W/ STP J NOTCH STRL LEVEL 1,SUP-2468061,CDM,2720000010,LOCAL,0272,RC,,,,both,,,453.89,295.03,,,,,,,,,,,,,
IMPL KIT PROCDR 36.5MM MSP RT ST,SUP-2475302,CDM,C1713,HCPCS,0278,RC,,,,both,,,3164.59,2056.98,,,,,,,,,,,,,
VIASORB STRP 20X50X5MM,SUP-2419482,CDM,C1713,HCPCS,0278,RC,,,,both,,,3469.70,2255.30,,,,,,,,,,,,,
IMPLANT FINGER JOINT SM METACARPOPHALANGEAL FOR ARTHROPLASTY SYSTEM SR MCP,SUP-2879154,CDM,C1776,CPT,0278,RC,,,,both,,,12010.50,7806.82,,,,,,,,,,,,,
SETSCREW SPNL DIA6.35MM TI NONBREAK OFF CDH LEG,SUP-2288548,CDM,C1713,HCPCS,0278,RC,,,,both,,,489.84,318.40,,,,,,,,,,,,,
SCREW BONE L30MM DIA4MM STD FT ANK TI SELF DRL ST CANN FULL,SUP-2122496,CDM,C1713,HCPCS,0278,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
SCREW BNE ST 1.3X17 MM CRTX SS NS,SUP-2177965,CDM,C1713,HCPCS,0278,RC,,,,both,,,158.44,102.99,,,,,,,,,,,,,
ARH SLIDE-LOC NECK +3MM,SUP-2830410,CDM,C1776,CPT,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
GUIDEWIRE VASC GLIDEWIRE ADVANTAGE L 180 CM DIA 0.018 IN TIP,SUP-2385541,CDM,C1769,HCPCS,0272,RC,,,,both,,,892.39,580.05,,,,,,,,,,,,,
SUPPORT ORTHOT LOWER EXTREMITY PELV CTRL SLNG,SUP-2435681,CDM,L2580,HCPCS,0274,RC,,,,both,,,1228.62,798.60,,,,,,,,,,,,,
HC Group Exercise (P),PX-4100023900,CDM,G0239,CPT,0410,RC,,,,both,,,125.00,81.25,,,,,,,,,,,,,
SCREW INTRF L25MM DIA6MM PEEK OPTMA CANN N ABSRB ACL PCL,SUP-2341816,CDM,C1713,HCPCS,0278,RC,,,,both,,,830.84,540.05,,,,,,,,,,,,,
STEM HUM L173MM DIA9MM SHLDR TI SHLDR FX SYS UNIVERSE,SUP-2123245,CDM,C1776,CPT,0278,RC,,,,both,,,8556.50,5561.72,,,,,,,,,,,,,
BIT DRL 1.6X90 MM CONTOURS VPS,SUP-2646712,CDM,2720000010,LOCAL,0272,RC,,,,both,,,199.86,129.91,,,,,,,,,,,,,
STEM XL POROUS 16.5X170MM BOWED,SUP-2504978,CDM,C1776,CPT,0278,RC,,,,both,,,8214.24,5339.26,,,,,,,,,,,,,
GRAFT BNE W10 30XL50 130MM THK1 20MM RIB FRZ DRY SEG,SUP-2307186,CDM,C1713,HCPCS,0278,RC,,,,both,,,1585.92,1030.85,,,,,,,,,,,,,
BUTTON SEPTAL 2 PC DEV 3X25X0.64 MM PLASTI PORE,SUP-2637860,CDM,C1889,HCPCS,0278,RC,,,,both,,,723.17,470.06,,,,,,,,,,,,,
SHUNT SURG SM 16 GA SNAP ASMBLY BLNT NDL VLV BA STRATA NSC,SUP-2628578,CDM,C1729,HCPCS,0272,RC,,,,both,,,13667.29,8883.74,,,,,,,,,,,,,
PLATE BONE L60MM 3 H S STL NAR SELF COMPR,SUP-2198595,CDM,C1713,HCPCS,0278,RC,,,,both,,,252.14,163.89,,,,,,,,,,,,,
STENT CORONARY MAGIC WSTNT STRL,SUP-2140982,CDM,C1876,HCPCS,0278,RC,,,,both,,,6358.50,4133.02,,,,,,,,,,,,,
MESH HERN W20XL30CM THK1MM PTCH RECT 2 SIDE FOR VENTRAL,SUP-2125802,CDM,C1781,HCPCS,0278,RC,,,,both,,,6018.44,3911.99,,,,,,,,,,,,,
GRAFT BNE PTTY 10 CC DBM B201010P] FRONTIER MEDICAL PRODUCTS INC],SUP-2225960,CDM,C9359,HCPCS,0278,RC,,,,both,,,5962.86,3875.86,,,,,,,,,,,,,
GRAFT BNE H12MM IL CREST WDG PRESERVON MATRIGRFT,SUP-2264840,CDM,C1713,HCPCS,0278,RC,,,,both,,,2061.98,1340.29,,,,,,,,,,,,,
VALVE AORT CARBOMEDICS DIA20.5 MM TAD 20.5 MM OH 7.7 MM SZ,SUP-2265217,CDM,C1889,HCPCS,0278,RC,,,,both,,,14990.36,9743.73,,,,,,,,,,,,,
GRAFT BNE SM DIA20-43MM FEM FRZ DRY,SUP-2307305,CDM,C1713,HCPCS,0278,RC,,,,both,,,3914.42,2544.37,,,,,,,,,,,,,
SMALL PLATE 20X242MM 3.5MM,SUP-2818810,CDM,C1713,HCPCS,0278,RC,,,,both,,,4279.35,2781.58,,,,,,,,,,,,,
CATHETER KIT 2 LUMEN 5 FR POWERPICC SOLO,SUP-2126781,CDM,C1751,HCPCS,0278,RC,,,,both,,,350.11,227.57,,,,,,,,,,,,,
PROLAYERXENOGRAFT 2 CMX5 CM,SUP-2418460,CDM,C1763,HCPCS,0278,RC,,,,both,,,5181.00,3367.65,,,,,,,,,,,,,
PLATE BNE LCK 2.7 MM 16 HOLE CNTOUR 2 COMPR FOR SCR TI STRL,SUP-2472662,CDM,C1713,HCPCS,0278,RC,,,,both,,,1190.19,773.62,,,,,,,,,,,,,
PLATE SPNL L43MM 6 H LEV 2 ANTR BILAT CERV TI LCK LO PROF,SUP-2254587,CDM,C1713,HCPCS,0278,RC,,,,both,,,3406.90,2214.48,,,,,,,,,,,,,
HC So1 in Situ Hybrid per Specimen,PX-3128836867,CDM,88368,CPT,0312,RC,,,,outpatient,,,125.00,81.25,,,,,,,,,,,,,
MICRO PLATE TRIANGULAR 6MM 15MM SYSTEM CP TITANIUM,SUP-2707394,CDM,C1713,HCPCS,0278,RC,,,,both,,,427.13,277.63,,,,,,,,,,,,,
PACEMAKER CARD W52XH44MM THK6MM PERM 2 CHMBR STD,SUP-2357346,CDM,C1785,HCPCS,0275,RC,,,,both,,,9734.00,6327.10,,,,,,,,,,,,,
ELECTRODE LOOP DIA24-26FR YEL CUT BPLR DSTL TIP,SUP-2261166,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1607.18,1044.67,,,,,,,,,,,,,
SET SCR SPNL L40MM DIA6.4MM PEDCL TI ALLOY FUS FOR DYN STBL,SUP-2414266,CDM,C1713,HCPCS,0278,RC,,,,both,,,8778.97,5706.33,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY LASSO L 115 CM 7 FR 6 MM DACRON D,SUP-2538040,CDM,C1730,HCPCS,0272,RC,,,,both,,,1225.54,796.60,,,,,,,,,,,,,
GRAFT BIO TISS W7.9XL9.8IN PORCINE DERM RIFAMPIN,SUP-2125843,CDM,C1781,HCPCS,0278,RC,,,,both,,,38210.66,24836.93,,,,,,,,,,,,,
DURVALUMAB 50 MG/ML (MIXTURES ONLY),RX-1150447,CDM,J9173,HCPCS,0636,RC,00310-4500-12,NDC,,both,2.4,ML,2968.50,1929.52,,,,,,,,,,,,,
HC 25 Hydroxy Includes Fractions if Performed,PX-3018230600,CDM,82306,CPT,0301,RC,,,,both,,,233.00,151.45,,,,,,,,,,,,,
GUIDE SURG LAPIDUS KT CUT NS DISP LAPIPLASTY,SUP-2893062,CDM,2720000010,LOCAL,0272,RC,,,,both,,,9718.30,6316.89,,,,,,,,,,,,,
PLATE BNE L139MM 2 H ST PROX FEM S STL HK LO PROF LOK COMPR,SUP-2420803,CDM,C1713,HCPCS,0278,RC,,,,both,,,4740.33,3081.21,,,,,,,,,,,,,
WIRE BNE FIX L 110 MM DIA2.4 MM FLUT NS BABY GORILLA/GORILLA,SUP-2899025,CDM,2720000010,LOCAL,0272,RC,,,,both,,,293.59,190.83,,,,,,,,,,,,,
"HC So Molecular Pathology, Unlisted",PX-3108147966,CDM,81479,CPT,0310,RC,,,,both,,,3280.00,2132.00,,,,,,,,,,,,,
CATHETER SET 3 FRX55 CM PRO-PICC,SUP-2269766,CDM,C1751,HCPCS,0278,RC,,,,both,,,292.02,189.81,,,,,,,,,,,,,
SET INT FIX SCREW DIA1.5 MM 6 H TI NEURO CRV PLATE 12 PK,SUP-2935575,CDM,C1713,HCPCS,0278,RC,,,,both,,,23367.88,15189.12,,,,,,,,,,,,,
GUIDEWIRE VASC L180CM DIA0.018IN TIP L5CM L1MM RADPQ 1MM,SUP-2385553,CDM,C1769,HCPCS,0272,RC,,,,both,,,86.66,56.33,,,,,,,,,,,,,
FIBER LASER 200UM TFL EXCALIBUR TRUE THULIUM DISPOSABLE,SUP-2885345,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1067.60,693.94,,,,,,,,,,,,,
GRAFT HUM TISS L 2 X W 1 CM SM AMNIO MEMBRN RESRB AIR DRY,SUP-2913453,CDM,Q4173,HCPCS,0636,RC,,,,both,,,3504.24,2277.76,,,,,,,,,,,,,
SOTALOL HCL 80 MG PO TABS,RX-11421,CDM,6370000000,HCPCS,0637,RC,00904-7143-61,NDC,,both,1,UN,5.10,3.31,,,,,,,,,,,,,
STAPLER ROBOT SURG SEAMGRD INTUITIVE SUREFORM 60 ENDOSCP BLK,SUP-2762591,CDM,C1768,CPT,0278,RC,,,,both,,,656.26,426.57,,,,,,,,,,,,,
BASEPLATE TIB STD UNIV PRI STEM PRESSFIT POR PUR SZ A 58MM,SUP-2199510,CDM,C1776,CPT,0278,RC,,,,both,,,14524.38,9440.85,,,,,,,,,,,,,
ANG BLADE PL 130 4H 50/60,SUP-2818825,CDM,C1713,HCPCS,0278,RC,,,,both,,,4812.36,3128.03,,,,,,,,,,,,,
PLATE BONE LNG STRL TARSAL METATRSL FUS FOR 2.7MM SCR VLP,SUP-2349943,CDM,C1713,HCPCS,0278,RC,,,,both,,,6045.91,3929.84,,,,,,,,,,,,,
CATHETER SZ PTS L 80 CM BALLOON L 3 CM DIA25 MM INTRO 8 FR,SUP-2659780,CDM,C1725,HCPCS,0272,RC,,,,both,,,926.05,601.93,,,,,,,,,,,,,
SPLINT CLAV HVY PD 24 - 30IN SZ SM,SUP-2196988,CDM,L3650,HCPCS,0274,RC,,,,both,,,17.24,11.21,,,,,,,,,,,,,
DRILL SURG CANN SHT LG 4.8 MM AO QR NS LTX,SUP-2856035,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2351.86,1528.71,,,,,,,,,,,,,
TRIAL SPNL 0DEG IL REUSE,SUP-2287101,CDM,C1713,HCPCS,0278,RC,,,,both,,,554.56,360.46,,,,,,,,,,,,,
TROCAR ENDOSCP SHFT L100MM DIA5MM DIL TIP ENDOPATH XCEL,SUP-2218918,CDM,2720000010,LOCAL,0272,RC,,,,both,,,72.22,46.94,,,,,,,,,,,,,
CLIP BNE FIX HIP SCR AMBI,SUP-2342406,CDM,C1713,HCPCS,0278,RC,,,,both,,,816.27,530.58,,,,,,,,,,,,,
PLATE BNE LNG THK1MM 4 H TI FOR 2MM MINI MOD,SUP-2262768,CDM,C1713,HCPCS,0278,RC,,,,both,,,116.18,75.52,,,,,,,,,,,,,
TAP SURG L5.5MM FT ANK CANN FOR JONE FIX SYS SCR CHARLOTTE,SUP-2398099,CDM,C1713,HCPCS,0278,RC,,,,both,,,351.68,228.59,,,,,,,,,,,,,
NAIL IM L350MM OD15MM SUBTROCHANTERIC ROD RT ZCKL II,SUP-2364777,CDM,C1713,HCPCS,0278,RC,,,,both,,,4704.98,3058.24,,,,,,,,,,,,,
CATHETER EP 6FR L110CM 2-4-2MM SPC POLYUR FIX SM CRV 24 PLAT,SUP-2142306,CDM,C1731,HCPCS,0278,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
LEVOTHYROXINE SODIUM 75 MCG PO TABS,RX-4422,CDM,6370000000,HCPCS,0637,RC,51079-0441-20,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
DRESSING BIO L 2 X W 2IN CLLGN CHONDROITIN-6-SULFATE MESHED,SUP-2909180,CDM,Q4105,HCPCS,0636,RC,,,,both,,,9959.42,6473.62,,,,,,,,,,,,,
DEVICE GLAUCOMA DRNGE 1/4IN CLR CORNEA W/ SCLER,SUP-2247189,CDM,V2785,HCPCS,0278,RC,,,,both,,,957.70,622.50,,,,,,,,,,,,,
SHEATH INTRO CHANNEL L 67 CM DIA 9 FR OD 12.6 FR ID 9.8 FR,SUP-2424650,CDM,C1766,CPT,0272,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
MORPHINE SULFATE ER 30 MG PO TBCR,RX-120941,CDM,6370000000,HCPCS,0637,RC,00406-8330-62,NDC,,both,1,UN,7.90,5.13,,,,,,,,,,,,,
FLEXI-TIP DUAL-LUMEN URETERAL ACCESS CATHETER,SUP-2826630,CDM,C1758,HCPCS,0278,RC,,,,both,,,115.74,75.23,,,,,,,,,,,,,
HEAD HUM DIA40MM SHT FOR TOT SHLDR ARTHROPLASTY GLOB,SUP-2250013,CDM,C1776,CPT,0278,RC,,,,both,,,4574.35,2973.33,,,,,,,,,,,,,
DAKINS (1/2 STRENGTH) 0.25 % EX SOLN,RX-15950,CDM,340b,HCPCS,0637,RC,00436-0936-16,NDC,,both,473,ML,51.10,33.21,,,,,,,,,,,,,
DURVALUMAB 50 MG/ML (MIXTURES ONLY),RX-1150447,CDM,J9173,HCPCS,0636,RC,00310-4611-50,NDC,,both,10,ML,12368.70,8039.65,,,,,,,,,,,,,
SCREW BNE L24MM INTERPHALANGEAL TI ST CANN FULL THRD HDLSS,SUP-2107364,CDM,C1713,HCPCS,0278,RC,,,,both,,,2782.04,1808.33,,,,,,,,,,,,,
TRAY CATH MIDLN POWERMIDLINE 4FR 20CM 2 LUMAN RVS T P4254108,SUP-2632779,CDM,C1751,HCPCS,0278,RC,,,,both,,,495.84,322.30,,,,,,,,,,,,,
STEM HIP SZ 2 FX,SUP-2364954,CDM,C1776,CPT,0278,RC,,,,both,,,1556.62,1011.80,,,,,,,,,,,,,
GUIDE TARGET INVISION REPORT PROPHECY PS,SUP-2481858,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2568.52,1669.54,,,,,,,,,,,,,
CATHETER BLLN OCCL L150CM OD2.95X2.6FR ID0.025IN STR MIC,SUP-2323649,CDM,C1887,HCPCS,0272,RC,,,,both,,,2775.76,1804.24,,,,,,,,,,,,,
NEEDLE NRV STIM BVL TIP INSUL PEDCL ACCS SYS FOR EMG MON,SUP-2310407,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
GRAFT BNE SUB 15ML 1.7-10MM CANC CHIP MORSELIZED FRZ DRY,SUP-2307077,CDM,C1713,HCPCS,0278,RC,,,,both,,,604.45,392.89,,,,,,,,,,,,,
CANNULA ENDOSCP OBLQ THRD 6 MMX10.5 CM W/ INSUFFLATION MTL,SUP-2767615,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1109.27,721.03,,,,,,,,,,,,,
PIN FIX L229MM DIA3.6MM S STL STYL 6 STNMN,SUP-2409664,CDM,C1713,HCPCS,0278,RC,,,,both,,,31.05,20.18,,,,,,,,,,,,,
PLATE BNE STR 140 DEG PEDIATRIC 3.5X70X19 MM HIP 3 HOLE SS,SUP-2546026,CDM,C1713,HCPCS,0278,RC,,,,both,,,2601.80,1691.17,,,,,,,,,,,,,
CABLE ORTH L610MM DIA1.8M GREATER TROCHANTERIC S STL SMOOTH,SUP-2410271,CDM,C1713,HCPCS,0278,RC,,,,both,,,786.57,511.27,,,,,,,,,,,,,
PLATE BONE W12XL151MM THK1MM 9 H BILAT TI SEMI TBLR LO PROF,SUP-2190707,CDM,C1713,HCPCS,0278,RC,,,,both,,,349.67,227.29,,,,,,,,,,,,,
CLAMP CATH MTL DISP,SUP-2126566,CDM,C1751,HCPCS,0278,RC,,,,both,,,34.54,22.45,,,,,,,,,,,,,
GUIDEWIRE VASC L 145 CM DIA 0.035 IN HEPARIN J FIX CRV,SUP-2147060,CDM,C1769,HCPCS,0272,RC,,,,both,,,34.70,22.55,,,,,,,,,,,,,
PUMP 270ML X 5ML/HR ANTIMIC,SUP-2420885,CDM,C2626,HCPCS,0278,RC,,,,both,,,339.12,220.43,,,,,,,,,,,,,
IMMOBILIZER ORTH CUTAWAY UNIV 24 IN 12-24 IN PERF FOAM,SUP-2194891,CDM,L1830,CPT,0272,RC,,,,both,,,94.20,61.23,,,,,,,,,,,,,
BIT DRL L160MM DIA2.7MM CANN QUIK CPL ADJ STP REUSE FOR,SUP-2187336,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1021.47,663.96,,,,,,,,,,,,,
STEM FNGR JT SZ 60 MP SIL NONCOATED PRESSFIT CEMENTLESS,SUP-2250689,CDM,L8630,HCPCS,0278,RC,,,,both,,,3541.42,2301.92,,,,,,,,,,,,,
WIRE FIXATION 32 GAX500 MM NEEDLE TITANIUM STERILE,SUP-2838463,CDM,C1713,HCPCS,0278,RC,,,,both,,,465.98,302.89,,,,,,,,,,,,,
CATHETER GUID CELLO TOT L 100 CM EFFECTIVE L 92 CM OD 0.118,SUP-2277833,CDM,C1887,HCPCS,0272,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
COMPONENT FEM REV RT BEAD VITALLIUMXL DURAC,SUP-2364837,CDM,C1776,CPT,0278,RC,,,,both,,,7857.85,5107.60,,,,,,,,,,,,,
PROBE CARD ABLATION CRYOICE L 10 CM ALUM SMTH MALL,SUP-2124441,CDM,C9808,HCPCS,0272,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 10 CM DIA 6 MM EPTFE STR TW REINF 2,SUP-2500679,CDM,C1768,CPT,0278,RC,,,,both,,,580.37,377.24,,,,,,,,,,,,,
HC So1 Nuclear Antigen Antibody,PX-3028623567,CDM,86235,CPT,0302,RC,,,,both,,,161.00,104.65,,,,,,,,,,,,,
NAIL INTRMDLLRY L380MM OD13MM 125DG LNG TIMAX RIGHT HIP ANTG,SUP-2475386,CDM,C1776,CPT,0278,RC,,,,both,,,6992.78,4545.31,,,,,,,,,,,,,
GUIDEWIRE VASC STR 0.035 INX180 CM SHT STEER PTFE COAT JINDO,SUP-2157315,CDM,C1769,HCPCS,0272,RC,,,,both,,,464.72,302.07,,,,,,,,,,,,,
"HC So1 Dna Quantification, Each",PX-3068779967,CDM,87799,CPT,0306,RC,,,,both,,,503.00,326.95,,,,,,,,,,,,,
SHEATH INTRO L45CM DIA4FR 10ML ECHOGENIC NDL DIA19-21GA W/,SUP-2385250,CDM,C1769,HCPCS,0272,RC,,,,both,,,116.18,75.52,,,,,,,,,,,,,
CATHETER HD STR 9 FRX15 CM CATH INTRO NDL DUOFLO,SUP-2627101,CDM,C1752,HCPCS,0278,RC,,,,both,,,269.57,175.22,,,,,,,,,,,,,
CAPSULE ENDOSCP L26.2MM DIA11.4MM BIOCOMPATIBLE PLAS SB 3,SUP-2173699,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1635.63,1063.16,,,,,,,,,,,,,
GEL EMB TORPEDO L 10 MM HYDRATED 5 MM CATH ID 0.040 IN 3 CC,SUP-2516671,CDM,2720000010,LOCAL,0272,RC,,,,both,,,204.10,132.66,,,,,,,,,,,,,
GRAFT TISS FRZ DRY ALLGRFT CANC OR CORT DWL 16MMX16MM,SUP-2307027,CDM,C1762,CPT,0278,RC,,,,both,,,1777.24,1155.21,,,,,,,,,,,,,
LEAD NERVE STIM KT STRL ENTERRA LTX,SUP-2866566,CDM,C1778,HCPCS,0278,RC,,,,both,,,8242.50,5357.62,,,,,,,,,,,,,
PIN BUTTRESS TI LCP 1.8X20MM,SUP-2548967,CDM,C1713,HCPCS,0278,RC,,,,both,,,347.79,226.06,,,,,,,,,,,,,
GRAFT HUM TISS W4XL8CM THK0.1-.2MM AMNIO MEM 2 LAYR,SUP-2421276,CDM,Q4150,HCPCS,0636,RC,,,,both,,,12541.16,8151.75,,,,,,,,,,,,,
NITROGLYCERIN 0.3 MG/HR TD PT24,RX-27473,CDM,6370000000,HCPCS,0637,RC,50742-0515-01,NDC,,both,1,UN,238.50,155.02,,,,,,,,,,,,,
GUIDEWIRE SURG PARL 1.1 MM 3-3.5 MM FOR BITE COMPR SCR RIVAL,SUP-2644831,CDM,C1769,HCPCS,0272,RC,,,,both,,,214.56,139.46,,,,,,,,,,,,,
HC Flow Cytometry Cell Surf Marker Techl Only Ea,PX-3118818500,CDM,88185,CPT,0311,RC,,,,both,,,72.00,46.80,,,,,,,,,,,,,
HC Intrvasc US Noncoronary 1st,PX-4023725200,CDM,37252,CPT,0402,RC,,,,both,,,1485.00,965.25,,,,,,,,,,,,,
"HC Est Pt, E/M Level 2",PX-5109921200,CDM,99212,CPT,0510,RC,,,,both,,,202.00,131.30,,,,,,,,,,,,,
ALLOGRAFT BNE XS 1 CC DBM FIBER OSTEOSTRAND,SUP-2731812,CDM,C1713,HCPCS,0278,RC,,,,both,,,2684.70,1745.05,,,,,,,,,,,,,
CATHETER NEPHSTMY 24FR L12CM SHTH L17CM PTFE HI PRSS LO PROF,SUP-2139712,CDM,C1729,HCPCS,0272,RC,,,,both,,,772.44,502.09,,,,,,,,,,,,,
SCREW BNE ANK 4X60 MM FOR COMPR FCPS TIBIAXYS,SUP-2609024,CDM,C1713,HCPCS,0278,RC,,,,both,,,436.30,283.59,,,,,,,,,,,,,
PLATE BNE L39MM THK1.5MM 6 H MAND BILAT TI RIG ORAL,SUP-2262988,CDM,C1713,HCPCS,0278,RC,,,,both,,,1034.63,672.51,,,,,,,,,,,,,
COMPONENT PATELLAR 3 PEG XS KNEE ONSET UKNEE,SUP-2391488,CDM,C1776,CPT,0278,RC,,,,both,,,1648.50,1071.52,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA FT PLU MAXBARR S1295108FD2,SUP-2632815,CDM,C1751,HCPCS,0278,RC,,,,both,,,1003.80,652.47,,,,,,,,,,,,,
RIVAROXABAN 20 MG PO TABS,RX-111545,CDM,6370000000,HCPCS,0637,RC,50458-0579-01,NDC,,both,1,UN,89.80,58.37,,,,,,,,,,,,,
BLOCK I/B II CCK TIB 54X10MM,SUP-2205965,CDM,C1776,CPT,0278,RC,,,,both,,,5875.57,3819.12,,,,,,,,,,,,,
RELOAD STPL L100MM REG TISS GRN TI LOR PROX LIN CUT DST SER,SUP-2283276,CDM,2720000010,LOCAL,0272,RC,,,,both,,,321.69,209.10,,,,,,,,,,,,,
CATHETER VASC DIAG SIM 1 PERIPH W/ HYDRPHLC COAT AD RADPQ,SUP-2141099,CDM,C1887,HCPCS,0272,RC,,,,both,,,160.14,104.09,,,,,,,,,,,,,
SET SUT DISP FOR MEND II MENIS REP SYS,SUP-2341601,CDM,2720000010,LOCAL,0272,RC,,,,both,,,511.79,332.66,,,,,,,,,,,,,
PHILADEPHIA CLLR 1-PIECE - RIG EXTRIC TALL,SUP-2194491,CDM,L0172,HCPCS,0272,RC,,,,both,,,25.62,16.65,,,,,,,,,,,,,
GUIDEWIRE VASC L 100 CM DIA 0.035 IN CRV RAD 10 MM SS REUT,SUP-2167578,CDM,C1769,HCPCS,0272,RC,,,,both,,,183.38,119.20,,,,,,,,,,,,,
SPACER SPNL 18 DEG 60X27X14 MM OLIF PIVOX OLIF25,SUP-2627900,CDM,C1889,HCPCS,0278,RC,,,,both,,,17599.70,11439.80,,,,,,,,,,,,,
HC Cns Dna/Rna Amp Probe Multiple Subtypes 12-25,PX-3068748300,CDM,87483,CPT,0306,RC,,,,inpatient,,,907.00,589.55,,,,,,,,,,,,,
PROSTHESIS OSS 4 MM GTR STAPE,SUP-2232476,CDM,L8613,CPT,0278,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
ARNAUD MRCHC CRNL MNBLC DIST BODY ONL20MM3MM PRNGS,SUP-2669825,CDM,C1713,HCPCS,0278,RC,,,,both,,,8447.95,5491.17,,,,,,,,,,,,,
PLATE BNE DELT 117 MM RT DSTL DORS RADIAL 8 HOLE LCK SS NS,SUP-2476105,CDM,C1713,HCPCS,0278,RC,,,,both,,,2649.47,1722.16,,,,,,,,,,,,,
BIT DRL L190MM DIA11MM 2.7MM CANN QUIK CPL,SUP-2188296,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1688.63,1097.61,,,,,,,,,,,,,
CATHETER THROMCTMY 8FR L80CM DIA13MM 2.25ML LIQ 4.5ML GAS,SUP-2214114,CDM,C1757,HCPCS,0272,RC,,,,both,,,266.49,173.22,,,,,,,,,,,,,
MESH SURG L 4 X W 2 CM D 1 MM PORCINE DERMAL CLLGN ABD HERN,SUP-2901706,CDM,C9364,HCPCS,0278,RC,,,,both,,,655.10,425.81,,,,,,,,,,,,,
GRAFT HUM TISS 10MM ACHILLES TEND PRESHAPED FRZN,SUP-2335544,CDM,C1713,HCPCS,0278,RC,,,,both,,,10048.00,6531.20,,,,,,,,,,,,,
PLATE SPNL 4 LEV VIS WIND QUIK LCK BUSHING ANTR CERV,SUP-2207840,CDM,C1713,HCPCS,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
FLORBETAPIR F 18 500-1900 MBQ/ML IV SOLN,RX-115898,CDM,A9586,HCPCS,0343,RC,00002-1200-01,NDC,,both,1,UN,8998.00,5848.70,,,,,,,,,,,,,
INSERT TALAR SZ 4 THK9MM L R ANK POLYETH SADL PROPHECY,SUP-2397102,CDM,C1776,CPT,0278,RC,,,,both,,,3428.88,2228.77,,,,,,,,,,,,,
SODIUM CHLORIDE 3 % IN NEBU,RX-7327,CDM,J3490,HCPCS,0250,RC,00378-6997-89,NDC,,both,15,ML,3.40,2.21,,,,,,,,,,,,,
GRAFT BNE PTTY 1-2 MM 7.5 CC SYNTH KT APPL ACTIFUSE MIS,SUP-2130294,CDM,C1713,HCPCS,0278,RC,,,,both,,,7805.91,5073.84,,,,,,,,,,,,,
PLATE BONE L119MM 20 H BILAT MAND ORAL MAXILLOFACIAL TI LO,SUP-2191331,CDM,C1713,HCPCS,0278,RC,,,,both,,,2529.90,1644.43,,,,,,,,,,,,,
CATHETER GUID L55CM OD6FR ID.070IN J INTRO,SUP-2158224,CDM,C1887,HCPCS,0272,RC,,,,both,,,244.92,159.20,,,,,,,,,,,,,
CATHETER KIT 3L 5 FR PWR 3CG PLCMNT,SUP-2126773,CDM,C1751,HCPCS,0278,RC,,,,both,,,879.20,571.48,,,,,,,,,,,,,
SYSTEM SPNL FIX 16 MM TI STRL COFIX LTX,SUP-2867269,CDM,C1889,HCPCS,0278,RC,,,,both,,,14915.00,9694.75,,,,,,,,,,,,,
BIT DRILL JLATCH 1.5X88 MM 24 MM,SUP-2841960,CDM,2720000010,LOCAL,0272,RC,,,,both,,,492.35,320.03,,,,,,,,,,,,,
CROWN DENT PED SZ UL3 LT UP CTRL PRI M TRNSPAR PLAS GLS,SUP-2100383,CDM,D6783,CPT,0278,RC,,,,both,,,23.86,15.51,,,,,,,,,,,,,
SODIUM CHLORIDE 3 % IN NEBU,RX-7327,CDM,J3490,HCPCS,0258,RC,50190-0142-63,NDC,,both,4,ML,2.90,1.88,,,,,,,,,,,,,
PROBE NERVE STIM CONCENTRIC 100 MM,SUP-2631487,CDM,2720000010,LOCAL,0272,RC,,,,both,,,656.26,426.57,,,,,,,,,,,,,
TROCAR ENDOSCP DIA10 MM SZ 5/ 7/8 MM BLNT TIP SHRT BLT IN,SUP-2896288,CDM,2720000010,LOCAL,0272,RC,,,,both,,,632.18,410.92,,,,,,,,,,,,,
GRAFT BONE 3-6MM 15ML CANC CHIP FRZ DRY,SUP-2294035,CDM,C1713,HCPCS,0278,RC,,,,both,,,806.98,524.54,,,,,,,,,,,,,
LEVOFLOXACIN IN D5W 750 MG/150ML IV SOLN,RX-104435,CDM,J1956,HCPCS,0636,RC,25021-0132-83,NDC,,both,150,ML,63.00,40.95,,,,,,,,,,,,,
PUNCH AORT 4.8MM 203MM LNG TIP DISP,SUP-2330985,CDM,2720000010,LOCAL,0272,RC,,,,both,,,84.03,54.62,,,,,,,,,,,,,
CLAMP CRAN L 20 MM LG NEURO BURR H STRL DISP LORENZ,SUP-2935434,CDM,C1713,HCPCS,0278,RC,,,,both,,,1011.08,657.20,,,,,,,,,,,,,
IMPLANT SYSTEM BIO-TRANSFIX,SUP-2811664,CDM,C1713,HCPCS,0278,RC,,,,both,,,1384.74,900.08,,,,,,,,,,,,,
PLATE BONE L25MM BLDE L15MM THK0.9MM 3X3 H LT MAX TI L SHP,SUP-2191200,CDM,C1713,HCPCS,0278,RC,,,,both,,,837.44,544.34,,,,,,,,,,,,,
PIN DRL HDLSS 3.2X75 MM HEX END TRCR PT,SUP-2760758,CDM,2720000010,LOCAL,0272,RC,,,,both,,,370.90,241.08,,,,,,,,,,,,,
PANTOPRAZOLE 4 MG/ML IJ SOLN (PED-NEO),RX-4090157,CDM,J2470,HCPCS,0636,RC,09999-9918-48,NDC,,both,10,ME,54.10,35.16,,,,,,,,,,,,,
ANCHOR SUTURE 5MM WITH 2 NO 2 SUTURES HI-FI DISPOSABLE DRIVE,SUP-2828533,CDM,C1713,HCPCS,0278,RC,,,,both,,,720.85,468.55,,,,,,,,,,,,,
STIMULATOR NRV SPNL IMP PULSE PRECIS IPG AND CHARGING KT,SUP-2138773,CDM,C1767,HCPCS,0278,RC,,,,both,,,61261.40,39819.91,,,,,,,,,,,,,
BUR SURG L 13 MM DIA 3 MM NEURO CUT STRL DISP ELAN 4 MIS,SUP-2929030,CDM,2720000010,LOCAL,0272,RC,,,,both,,,469.12,304.93,,,,,,,,,,,,,
TIRE SCLER OD7MM ID3.5MM SIL CONVX SYMMETRICAL STYL,SUP-2213482,CDM,L8610,HCPCS,0278,RC,,,,both,,,59.66,38.78,,,,,,,,,,,,,
NEEDLE BRST LOC 20 GAX12.5 CM MAMMO,SUP-2120047,CDM,C1819,HCPCS,0278,RC,,,,both,,,100.48,65.31,,,,,,,,,,,,,
HC Ot Vasopneumatic Device Therapy|OP OCCUPATIONAL THERAPY SERV|DOCUMENTATION ON FILE|SERVICES PROVIDED IN WHOLE OR IN PARTY BY AN OTA FOR MEDICARE PATIENTS,PX-4309701600,CDM,97016,CPT,0430,RC,,,GO|KX|CO,both,,,206.00,133.90,,,,,,,,,,,,,
ANCHOR SUTURE DIAMETER 1.3MM WITH 1.3MM WHITE/BLACK HI-FI RI,SUP-2825062,CDM,C1713,HCPCS,0278,RC,,,,both,,,1541.74,1002.13,,,,,,,,,,,,,
PIN EXT FIX 3MMDIA 16MM THRD L120MM COVE PT,SUP-2342851,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1148.27,746.38,,,,,,,,,,,,,
HC 6-Minute Walk Test/Pulm Stress Test,PX-4609461800,CDM,94618,CPT,0460,RC,,,,both,,,387.00,251.55,,,,,,,,,,,,,
PROBE BX BRST L105MM DIA14GA SYS FINESSE ULT,SUP-2126879,CDM,2720000010,LOCAL,0272,RC,,,,both,,,744.18,483.72,,,,,,,,,,,,,
HOOK SPNL LT ANGLED 5.5X6.5 MM MALIBU,SUP-2244637,CDM,C1713,HCPCS,0278,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
CATHETER EMB L 40 CM DIA 6 FR 1 LUMEN HIGHLY RUPTURE RESIST,SUP-2264181,CDM,C1757,HCPCS,0272,RC,,,,both,,,87.92,57.15,,,,,,,,,,,,,
SCREW 2.0MMX28MM HEADED DART-FIRE,SUP-2857925,CDM,C1713,HCPCS,0278,RC,,,,both,,,1186.92,771.50,,,,,,,,,,,,,
CATHETER ANGIOPLSTY ADV MIC 14 L 50 CM BALLOON L 4 CM DIA1.5,SUP-2169584,CDM,C1725,HCPCS,0272,RC,,,,both,,,1271.32,826.36,,,,,,,,,,,,,
GRAFT BNE L20XW14 18MM FIB SHFT FRZ DRY IMPL,SUP-2307188,CDM,C1713,HCPCS,0278,RC,,,,both,,,1662.82,1080.83,,,,,,,,,,,,,
PLATE BNE L286MM 14 H NONSTERILE R MED PROX TIB S STL LOK,SUP-2185686,CDM,C1713,HCPCS,0278,RC,,,,both,,,4515.38,2935.00,,,,,,,,,,,,,
HC Car-T Therapy Hrvg Bld Drv T Lmphcyt PR Day,PX-8713822500,CDM,38225,CPT,0871,RC,,,,both,,,2291.00,1489.15,,,,,,,,,,,,,
MESH CRAN L 77.52 X W 38.1 MM THK 0.61 MM SZ 80 MM XW TI,SUP-2936194,CDM,C1713,HCPCS,0278,RC,,,,both,,,8145.16,5294.35,,,,,,,,,,,,,
PLATE BONE L48MM THK0.6MM LNG 2X2 H LT CRANIOMAXILLOFACIAL,SUP-2191294,CDM,C1713,HCPCS,0278,RC,,,,both,,,789.08,512.90,,,,,,,,,,,,,
PLATE SPNL SM 2 H FOR OBLQ LAT LUM INTBDY FUS OLIF25 PIVOX,SUP-2284942,CDM,C1713,HCPCS,0278,RC,,,,both,,,14130.00,9184.50,,,,,,,,,,,,,
BRACE ANK XL FOR 14 15IN BLK W O STAY GAMEDAY,SUP-2319318,CDM,L4350,HCPCS,0272,RC,,,,both,,,40.00,26.00,,,,,,,,,,,,,
NEEDLE PLACEMENT 18 GA X 25 CM WITH POLYMARK MARKER,SUP-2665288,CDM,A4648,CPT,0278,RC,,,,both,,,351.68,228.59,,,,,,,,,,,,,
DISTAL POSTERIOR MEDIAL HUMERUS TRIAL 10 HOLELEFT,SUP-2704782,CDM,C1713,HCPCS,0278,RC,,,,both,,,877.44,570.34,,,,,,,,,,,,,
NUT SPNL TI ALLOY THORLUM BRKWY NS PASS LP,SUP-2926459,CDM,C1713,HCPCS,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
RESERVOIR CSF 20MM TI LO PROF MCLANAHAN,SUP-2108714,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1883.25,1224.11,,,,,,,,,,,,,
BIT DRL DIA13MM TRIFLAT FOR ATLNTS ANT CERV PLT SYS,SUP-2291124,CDM,2720000010,LOCAL,0272,RC,,,,both,,,513.23,333.60,,,,,,,,,,,,,
TUBE VENT L7MM ID1.14MM WHT FLROPLAS PLN STR SHANK,SUP-2277598,CDM,L8699,HCPCS,0278,RC,,,,both,,,49.24,32.01,,,,,,,,,,,,,
PLATE CRAN 160X60X40 MM PT SPEC IMPL PEEK,SUP-2860135,CDM,C1713,HCPCS,0278,RC,,,,both,,,30123.59,19580.33,,,,,,,,,,,,,
CATHETER INFUS 4FR L135CM TIP L10CM 0.035IN VLV SGL LUMN,SUP-2172513,CDM,C1751,HCPCS,0278,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
PLATE BONE NARROW 4.5X412 MM 22 HOLE,SUP-2837413,CDM,C1713,HCPCS,0278,RC,,,,both,,,4492.56,2920.16,,,,,,,,,,,,,
AGENT HEMOSTATIC POLYSACCHARIDE 230 CM 2.8 MM 5 GM ENDOCLOT,SUP-2865643,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
CATHETER IVUS REFINITY WORKING L 135 MM TIP TO TRANSDUCER L,SUP-2430604,CDM,C1753,HCPCS,0278,RC,,,,both,,,2072.40,1347.06,,,,,,,,,,,,,
DRAINAGE KIT SUBDURAL EVACUATING PRT SYS W/ LIDO,SUP-2665012,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4912.69,3193.25,,,,,,,,,,,,,
NEEDLE BX MED PLUNG CANULATED STRL CORB LF,SUP-2479377,CDM,2720000010,LOCAL,0272,RC,,,,both,,,610.64,396.92,,,,,,,,,,,,,
CATHETER HD SHT TERM 14 FRX15 CM MAX BARR TY 400XL STR TAPR,SUP-2550544,CDM,C1752,HCPCS,0278,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
HC Hepatitis Antibody Haab Igm Antibody,PX-3028670900,CDM,86709,CPT,0302,RC,,,,both,,,574.00,373.10,,,,,,,,,,,,,
POST EXT FIX NS DISP ILIZ,SUP-2933359,CDM,2720000010,LOCAL,0272,RC,,,,both,,,929.47,604.16,,,,,,,,,,,,,
SCREW BNE 3.5X45 MM SS NS,SUP-2183715,CDM,C1713,HCPCS,0278,RC,,,,both,,,69.65,45.27,,,,,,,,,,,,,
SUPPORT ORTHOT KNEE SINGLE UPR PREFABRICATED OFF THE SHLF,SUP-2435618,CDM,L1851,HCPCS,0272,RC,,,,both,,,2540.29,1651.19,,,,,,,,,,,,,
CATHETER CONT CARD OUTPT 7.5F,SUP-2214038,CDM,C1751,HCPCS,0278,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
PLATE BONE STRL CLMN FUS FOR 3.5MM SCR VLP,SUP-2349957,CDM,C1713,HCPCS,0278,RC,,,,both,,,8452.10,5493.86,,,,,,,,,,,,,
RING EXT FIX HALF 110 MM CARBON FIBER RINGFIX,SUP-2365274,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2913.92,1894.05,,,,,,,,,,,,,
PLATE BNE L27MM THK1.3MM 4 H HND TI STR TRILOK COMPR FOR,SUP-2267934,CDM,C1713,HCPCS,0278,RC,,,,both,,,1657.92,1077.65,,,,,,,,,,,,,
STUD FIX L17MM DIA8.5MM PATELLOFEMORAL JT UHMWPE TAPR POST,SUP-2123654,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1937.38,1259.30,,,,,,,,,,,,,
GUIDEWIRE VASC L 40 CM DIA 0.038 IN SS PTFE PERIPH AMPLTZ X,SUP-2760087,CDM,C1769,HCPCS,0272,RC,,,,both,,,163.22,106.09,,,,,,,,,,,,,
LEAD DEFIB ST SIL ENDOCARD 7FR ST. JUDE MED RIATA,SUP-2357365,CDM,C1895,HCPCS,0275,RC,,,,both,,,15700.00,10205.00,,,,,,,,,,,,,
PATCH CV GELSEAL L 120 X W 40 CM THK 0.53 MM POLYESTER GEL,SUP-2385077,CDM,C1768,CPT,0278,RC,,,,both,,,486.79,316.41,,,,,,,,,,,,,
SCREW BNE L10MM DIA2.7MM HND TI NONLOCKING CRUCFRM,SUP-2107498,CDM,C1713,HCPCS,0278,RC,,,,both,,,128.74,83.68,,,,,,,,,,,,,
HC Hfo W/1 or More Customfit,PX-2740392101,CDM,L3921,HCPCS,0274,RC,,,,both,,,1068.00,694.20,,,,,,,,,,,,,
SPACER SPNL H8MM SM PEEK THORLUM INTBDY FUS FLAT ADD ON STK,SUP-2291491,CDM,C1713,HCPCS,0278,RC,,,,both,,,13056.12,8486.48,,,,,,,,,,,,,
SET SHTH DESTINO REACH L 71 CM DIA12 FR CRV BEND L 22 MM DIL,SUP-2616166,CDM,C1766,CPT,0272,RC,,,,both,,,2433.50,1581.77,,,,,,,,,,,,,
CLIP ANEURYSM SUGITA TEMPORARY 15MM STRAIGHT 07-939-15,SUP-2848786,CDM,C1889,HCPCS,0278,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
ELECTRODE UROLOGY 3MM 24FR RL BALL STRL DISP,SUP-2361447,CDM,2720000010,LOCAL,0272,RC,,,,both,,,320.81,208.53,,,,,,,,,,,,,
SUPPORT ORTHOT HEEL CUST LIFT ELEVATION PER INCH,SUP-2435719,CDM,L3334,HCPCS,0272,RC,,,,both,,,107.95,70.17,,,,,,,,,,,,,
SCREW BONE PROX LCK S STL CONQ FN 7.5MMX100MM,SUP-2341202,CDM,C1713,HCPCS,0278,RC,,,,both,,,2040.69,1326.45,,,,,,,,,,,,,
BIT DRL L380MM DIA5MM TWST,SUP-2187861,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1522.87,989.87,,,,,,,,,,,,,
ALLOGRAFT BNE 10 CC FD DBM GRFT,SUP-2787762,CDM,C1713,HCPCS,0278,RC,,,,both,,,4277.75,2780.54,,,,,,,,,,,,,
PLATE 3.5MM TI LCP PERIARTIC PROX HUM 8H 199MM LT STRL,SUP-2546848,CDM,C1713,HCPCS,0278,RC,,,,both,,,6312.09,4102.86,,,,,,,,,,,,,
CANNULA PERF AD 23FR L50CM FEM VEN W/ INTRO 0.5IN NVENT,SUP-2282858,CDM,2720000010,LOCAL,0272,RC,,,,both,,,787.92,512.15,,,,,,,,,,,,,
SHUNT VALVE M BLUE  ZERO GRAVITATIONAL,SUP-2665172,CDM,C1889,HCPCS,0278,RC,,,,both,,,13354.01,8680.11,,,,,,,,,,,,,
SET INT FIX SCREW DIA1.5 MM CRANIOMAXILOFACIAL LNG DOG BNE 15-730,SUP-2936399,CDM,C1713,HCPCS,0278,RC,,,,both,,,744.18,483.72,,,,,,,,,,,,,
OXYGENATOR PERF CARDOTMY RESERVOIR CORTIVA COAT AFFIN PIXIE,SUP-2477430,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
SET INT FIX SCREW DIA1.5 MM 4 H XLN TI NEURO STR PLT SD HI 12PK,SUP-2937265,CDM,C1713,HCPCS,0278,RC,,,,both,,,15759.66,10243.78,,,,,,,,,,,,,
CLIP EXT FIX ROTATIONAL CTRL,SUP-2459899,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5553.03,3609.47,,,,,,,,,,,,,
ROD SPNL CRV 75 MM,SUP-2211122,CDM,C1713,HCPCS,0278,RC,,,,both,,,1238.16,804.80,,,,,,,,,,,,,
CATHETER DRAINAGE SINGLE LUMEN 0.035 IN 6 FRX25 CM UTHANE,SUP-2168611,CDM,C1729,HCPCS,0272,RC,,,,both,,,186.58,121.28,,,,,,,,,,,,,
CATHETER ANGIO L48CM OD8FR GUID COR SINUS RAPIDO CUT AWAY,SUP-2148983,CDM,C1887,HCPCS,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
BIT DRL TWST 1.5X15 MM ANGLED SCREWDRIVER STRL ANGULUS 2,SUP-2482155,CDM,2720000010,LOCAL,0272,RC,,,,both,,,562.37,365.54,,,,,,,,,,,,,
SYSTEM IMPL 38X28X12 DEG 11MM LUM INTEGR FUS PLSM COAT STRL,SUP-2419775,CDM,C1889,HCPCS,0278,RC,,,,both,,,12560.00,8164.00,,,,,,,,,,,,,
SCREW SET FOR GUID BLOCK,SUP-2653726,CDM,C1713,HCPCS,0278,RC,,,,both,,,1026.78,667.41,,,,,,,,,,,,,
DVR LOCK MED R ST,SUP-2587116,CDM,C1713,HCPCS,0278,RC,,,,both,,,2849.55,1852.21,,,,,,,,,,,,,
GUIDEWIRE SURG DIA3MM BEAD TIP FOR VALOR HINDFOOT FUS SYS,SUP-2397546,CDM,C1769,HCPCS,0272,RC,,,,both,,,521.24,338.81,,,,,,,,,,,,,
ADAPTER O2 BAFFLED TEE 18X22 MM ARM FOR SM NEB PLAS AIRLFE,SUP-2724360,CDM,C1713,HCPCS,0278,RC,,,,both,,,2.07,1.35,,,,,,,,,,,,,
CAGE SPNL LORDTC 15 DEG 30X24X13 MM ALIF ALEUTIAN,SUP-2536830,CDM,C1889,HCPCS,0278,RC,,,,both,,,9843.90,6398.53,,,,,,,,,,,,,
COLLAR EXTRIC AD L H2XL235IN NAR BRTH M DENS FOAM CNTOUR W,SUP-2194383,CDM,L0120,HCPCS,0274,RC,,,,both,,,20.38,13.25,,,,,,,,,,,,,
SUPPORT ORTHOT FT LOWER EXTREMITY INSERT/PLATE PREPREG COMP,SUP-2435704,CDM,L3031,HCPCS,0272,RC,,,,both,,,346.72,225.37,,,,,,,,,,,,,
PLATE BNE W35XL35MM THK05MM ST R ORBIT FLR CP TI GRID SMRT,SUP-2262596,CDM,C1713,HCPCS,0278,RC,,,,both,,,4197.33,2728.26,,,,,,,,,,,,,
SCREW BNE L3MM DIA1.9MM CORT CRANIOMAXILLOFACIAL PUR S STL 5PK,SUP-2366109,CDM,C1713,HCPCS,0278,RC,,,,both,,,190.50,123.82,,,,,,,,,,,,,
DEVICE GRFT FIX 4.75X19.1 MM ANCHR IMPL BIOCOMP SWIVELOCK,SUP-2423812,CDM,C1713,HCPCS,0278,RC,,,,both,,,2276.50,1479.72,,,,,,,,,,,,,
SPACER SPNL 16X13X6MM 7 DEG CERV LORDOTICTITANIUM IRIX-C,SUP-2401535,CDM,C1889,HCPCS,0278,RC,,,,both,,,6908.00,4490.20,,,,,,,,,,,,,
MICROCATHETER GUID 2.8-3.1FR L150CM ID0.027IN SEG DST L6CM,SUP-2280963,CDM,C1887,HCPCS,0272,RC,,,,both,,,3218.50,2092.02,,,,,,,,,,,,,
CONNECTOR SPNL TI MULTIAXIAL FOR 3.2-5.5MM ROD VERTEX MAX,SUP-2286714,CDM,C1713,HCPCS,0278,RC,,,,both,,,1889.97,1228.48,,,,,,,,,,,,,
COIL EMB SUPER SFT 010 1 MMX1 CM DETACHABLE COMPLX OPTMA,SUP-2753875,CDM,C1889,HCPCS,0278,RC,,,,both,,,4788.50,3112.52,,,,,,,,,,,,,
HC Needle Biopsy Muscle,PX-3612020600,CDM,20206,CPT,0361,RC,,,,inpatient,,,3707.00,2409.55,,,,,,,,,,,,,
SCREW STRNL CLOSURE L 14 MM DIA2.7 MM TI STRL STERNALOCK XP,SUP-2895211,CDM,C1713,HCPCS,0278,RC,,,,both,,,310.08,201.55,,,,,,,,,,,,,
COLLAR CERV TRACHEOTOMY HT 225IN CIRC 13 16IN M PHIL,SUP-2319292,CDM,L0172,HCPCS,0272,RC,,,,both,,,39.56,25.71,,,,,,,,,,,,,
CATHETER EP CRD 2 MM SPC 6 FRX110 CM INQUIRY,SUP-2357413,CDM,C1730,HCPCS,0272,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
SUPPORT ORTHOT LUMBAR SACR CUST SAG CTRL PANEL STRP STAY,SUP-2435557,CDM,L0643,HCPCS,0272,RC,,,,both,,,458.57,298.07,,,,,,,,,,,,,
PLATE BNE 20 H NONSTERILE STRNL TI STR LO PROF NEUT LOK,SUP-2192433,CDM,C1713,HCPCS,0278,RC,,,,both,,,6809.40,4426.11,,,,,,,,,,,,,
PLATE BNE RECON 3.5 MM CRV 6 HOLE SS NS,SUP-2905600,CDM,C1713,HCPCS,0278,RC,,,,both,,,2129.33,1384.06,,,,,,,,,,,,,
ALCLOMETASONE DIPROPIONATE 0.05 % EX CREA,RX-8985,CDM,6370000000,HCPCS,0637,RC,51672-1306-01,NDC,,both,15,GR,173.10,112.51,,,,,,,,,,,,,
ELECTRODE NDL L15CM DIA4CM PATENTED LEVEEN UMBRELLA SHP,SUP-2149342,CDM,C1713,HCPCS,0278,RC,,,,both,,,6845.20,4449.38,,,,,,,,,,,,,
PLATE BNE 19 H 2.5MM DORS WRST FUS LNG BEND TRILOK,SUP-2267978,CDM,C1713,HCPCS,0278,RC,,,,both,,,6857.76,4457.54,,,,,,,,,,,,,
BASEPLATE TIB ROT TOT ANK INVISION,SUP-2850836,CDM,C1776,CPT,0278,RC,,,,both,,,5410.22,3516.64,,,,,,,,,,,,,
CALCIUM GLUCONATE 10 % IV SOLN,RX-1312,CDM,J0612,HCPCS,0636,RC,63323-0360-19,NDC,,both,5,ML,54.10,35.16,,,,,,,,,,,,,
CATHETER THROMBS RETRV ERIC L 30 MM DIA 4 MM DSTL TIP L 5 MM,SUP-2898697,CDM,C1757,HCPCS,0272,RC,,,,both,,,20017.50,13011.37,,,,,,,,,,,,,
CONNECTOR SHUNT DIAMETER 1.9MM T SHAPE TITANIUM HYDROCEPHALU,SUP-2825580,CDM,C1889,HCPCS,0278,RC,,,,both,,,872.86,567.36,,,,,,,,,,,,,
TUBE ESOPH AD 20FR L8.25X1.5IN SPEC DISP FOR GI TRACT,SUP-2126706,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1601.40,1040.91,,,,,,,,,,,,,
OSTEOTOME ACET 40MM,SUP-2364385,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1975.69,1284.20,,,,,,,,,,,,,
WASHER ORTH S STL FOR 4MM SCR ASNS III,SUP-2371649,CDM,C1713,HCPCS,0278,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
LENS INTOCU +24.0D L13MM OD6MM 0DEG A CONSTANT 119.1 CYL,SUP-2112172,CDM,V2788,HCPCS,0276,RC,,,,both,,,895.00,581.75,,,,,,,,,,,,,
STABILIZER ORTH CHST CIRC 48-52 IN 3XL SZ 7 POLYESTER LYCRA,SUP-2915153,CDM,2720000010,LOCAL,0272,RC,,,,both,,,365.37,237.49,,,,,,,,,,,,,
HC Allergen Spec Ige Recombinant/Purified Compnt Ea,PX-3058600800,CDM,86008,CPT,0305,RC,,,,both,,,98.00,63.70,,,,,,,,,,,,,
PEG BNE FIX L26MM DIA2.5MM DST VOLAR RAD PARTIALLY THRD FOR,SUP-2414247,CDM,C1713,HCPCS,0278,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
PROBE LARYNGEAL STR W/ SMK EVAC,SUP-2713695,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1012.40,658.06,,,,,,,,,,,,,
CATHETER DRNGE 10FR L30CM UNIV NIT LOK PGTL NAVARRE,SUP-2128418,CDM,C1729,HCPCS,0272,RC,,,,both,,,259.52,168.69,,,,,,,,,,,,,
BIT DRL L300MM DIA10MM CANN TAPR L QUIK CPL FOR DH DC TFN,SUP-2178963,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1400.47,910.31,,,,,,,,,,,,,
COMPONENT HIP POR FEM W/ COCR HD AND XLPE LNR CEMENTLESS,SUP-2347945,CDM,C1776,CPT,0278,RC,,,,both,,,12560.00,8164.00,,,,,,,,,,,,,
CAGE SPNL W8XH24XL34MM 8DEG KT MLX,SUP-2310438,CDM,C1889,HCPCS,0278,RC,,,,both,,,16485.00,10715.25,,,,,,,,,,,,,
HC Antibody Screen,PX-3028685000,CDM,86850,CPT,0302,RC,,,,both,,,160.00,104.00,,,,,,,,,,,,,
DERMATOME BLDE 6IN STRL 10/BOX,SUP-2243525,CDM,2720000010,LOCAL,0272,RC,,,,both,,,301.44,195.94,,,,,,,,,,,,,
INTRODUCER TUBE SET PERC FLX CIAGLIA BLU RHINO,SUP-2759811,CDM,C1769,HCPCS,0272,RC,,,,both,,,982.82,638.83,,,,,,,,,,,,,
ALLOGRAFT DERMAL THN 16X8 CM RDY TO USE TISS MTRX ALLDERM,SUP-2113004,CDM,Q4116,HCPCS,0636,RC,,,,both,,,14962.10,9725.36,,,,,,,,,,,,,
STENT BILI FLEXIMA L 15 CM DIA 7 FR GUIDEWIRE 0.035 IN PLAS,SUP-2149546,CDM,C2625,HCPCS,0278,RC,,,,both,,,292.77,190.30,,,,,,,,,,,,,
BOLT ORTHOPEDIC 85 MM FOR FEM NK SYS TI,SUP-2181053,CDM,C1713,HCPCS,0278,RC,,,,both,,,1616.47,1050.71,,,,,,,,,,,,,
ICP KIT AD PLAS DISP,SUP-2666389,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1110.37,721.74,,,,,,,,,,,,,
CATHETER CTRL VEN 7FR 30CM LEN 3 LUMN N TUNNELED BASIC SET,SUP-2383434,CDM,C1751,HCPCS,0278,RC,,,,both,,,63.80,41.47,,,,,,,,,,,,,
PLATE BNE 3X7 H BILAT TI Y SHP LO PROF RIG NEUT LOK COMPR,SUP-2191256,CDM,C1713,HCPCS,0278,RC,,,,both,,,1280.18,832.12,,,,,,,,,,,,,
PACEMAKER CARD DISCOVERY SR TI SINGLE CHMBR 5/6 MM CONN UPLR,SUP-2148594,CDM,C1785,HCPCS,0275,RC,,,,both,,,12170.64,7910.92,,,,,,,,,,,,,
KEY ORTH VERSE CORRECTION EXPEDIUM,SUP-2719352,CDM,C1713,HCPCS,0278,RC,,,,both,,,580.90,377.58,,,,,,,,,,,,,
HC Iaad Ia Not Otherwise Specified Each Organism,PX-3068744900,CDM,87449,CPT,0306,RC,,,,both,,,66.00,42.90,,,,,,,,,,,,,
PLATE OLECRANON 2.7/3.5MM 2H LT 73MM TI VA LCP STRL,SUP-2546629,CDM,C1713,HCPCS,0278,RC,,,,both,,,3457.74,2247.53,,,,,,,,,,,,,
BAR SPNL STD 6.35 MM IL TI EXPEDIUM,SUP-2693674,CDM,C1713,HCPCS,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
PIN FIX TRCR PT 1 END 0.078X9 IN RND END SS NS STEINMANN,SUP-2791820,CDM,C1713,HCPCS,0278,RC,,,,both,,,9.99,6.49,,,,,,,,,,,,,
GRAFT BONE PROX FIB TRAD FRZN,SUP-2294141,CDM,C1713,HCPCS,0278,RC,,,,both,,,5325.44,3461.54,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA MAXBARR 4FR 55CM S9274108D,SUP-2632875,CDM,C1751,HCPCS,0278,RC,,,,both,,,639.96,415.97,,,,,,,,,,,,,
LOW PRFLE NEURO PLATE 5X2 HOLES CRVD W2 HOLE TABS CP TTNM,SUP-2681098,CDM,C1713,HCPCS,0278,RC,,,,both,,,1326.08,861.95,,,,,,,,,,,,,
NAIL IM CANN 12X390 MM TIB TI LIGHT GRN NS EXPERT,SUP-2179864,CDM,C1713,HCPCS,0278,RC,,,,both,,,4446.24,2890.06,,,,,,,,,,,,,
ACCOLADE CEM HIP STEMNO 7,SUP-2364226,CDM,C1776,HCPCS,0278,RC,,,,both,,,7099.54,4614.70,,,,,,,,,,,,,
CATHETER GUIDE OUTER SLITTABLE CPS DIRECT SL,SUP-2665286,CDM,C1887,HCPCS,0272,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
METOPROLOL SUCCINATE ER 25 MG PO TB24,RX-29858,CDM,6370000000,HCPCS,0637,RC,00904-6322-61,NDC,,both,1,UN,4.00,2.60,,,,,,,,,,,,,
GRIP CBL SM L115MM TROCHANTERIC HIP 3 CBL ACCORD,SUP-2345201,CDM,C1776,CPT,0278,RC,,,,both,,,5444.76,3539.09,,,,,,,,,,,,,
IMPLANT GYN W8XL12CM DERM TUTOPLAST PROC ALLGRFT TISS FOR,SUP-2165391,CDM,C1762,CPT,0278,RC,,,,both,,,9115.42,5925.02,,,,,,,,,,,,,
SIZER BRST 600CC P57CM DIA138CM SIL STYL MSZ20 HI PROF,SUP-2113527,CDM,2720000010,LOCAL,0272,RC,,,,both,,,753.60,489.84,,,,,,,,,,,,,
BLADE TNG DNGMN SIZE 2 MED 29MMW X 136MML X 65MMD JARIT,SUP-2702781,CDM,2720000010,LOCAL,0272,RC,,,,both,,,583.35,379.18,,,,,,,,,,,,,
DEVICE ARTOTMY CLOSURE PERCLOSE PROGLIDE DIA 6 FR ART DIA,SUP-2105663,CDM,C1760,HCPCS,0278,RC,,,,both,,,753.60,489.84,,,,,,,,,,,,,
PLATE BNE L51MM 6 H BILAT S STL STR MINI FRAG ST LO PROF,SUP-2186376,CDM,C1713,HCPCS,0278,RC,,,,both,,,1511.06,982.19,,,,,,,,,,,,,
IMPLANT UROLOGICAL BULK AGNT 3 CC INJ DURASPHERE EXP,SUP-2165454,CDM,L8606,HCPCS,0278,RC,,,,both,,,2100.66,1365.43,,,,,,,,,,,,,
BIT DRL CANN 8 MM KNEE SINGLE FLUT MTO,SUP-2849082,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2301.62,1496.05,,,,,,,,,,,,,
PLATE STRNL CLOSURE THK 1.5 MM 10 H TI V JUNCTION LP NS,SUP-2894552,CDM,C1713,HCPCS,0278,RC,,,,both,,,2939.04,1910.38,,,,,,,,,,,,,
STENT BILI AD 10FR L80MM MIN WRK CHN 37MM POLYETH DUODENAL,SUP-2313493,CDM,C1877,HCPCS,0278,RC,,,,both,,,677.93,440.65,,,,,,,,,,,,,
HC Lyr Clos Sc Tk Ext <2.5 Cm,PX-4501203100,CDM,12031,CPT,0450,RC,,,,inpatient,,,810.00,526.50,,,,,,,,,,,,,
COMPONENT FEM SLED PROSTHESES LINK ENDO-MODEL IMP L46XW17MM,SUP-2397005,CDM,C1776,CPT,0278,RC,,,,both,,,10770.20,7000.63,,,,,,,,,,,,,
"HC Sodium,Urine Spot",PX-3018430000,CDM,84300,CPT,0301,RC,,,,both,,,142.00,92.30,,,,,,,,,,,,,
STAPLE BNE FIX L15MM LEG W1.8XL15MM RMR 3.2MM BRDG H1.7MM,SUP-2175180,CDM,C1713,HCPCS,0278,RC,,,,both,,,4867.00,3163.55,,,,,,,,,,,,,
EXTENSION NEUROSTIMULATOR L40CM OD38MM ID15MM 43MM SPC SGL,SUP-2278215,CDM,C1883,HCPCS,0278,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
MESALAMINE ER 250 MG PO CPCR,RX-10533,CDM,6370000000,HCPCS,0637,RC,54092-0189-81,NDC,,both,1,UN,13.70,8.90,,,,,,,,,,,,,
CATHETER ART 0.025 IN 7.5 FRX110 CM STD 5 LUMEN HEPCOAT LTX,SUP-2662678,CDM,C1751,HCPCS,0278,RC,,,,both,,,244.92,159.20,,,,,,,,,,,,,
CATHETER CV PRESSURE MONITORING TY 018 PEDIATRIC 3 FRX5 CM,SUP-2760024,CDM,C1751,HCPCS,0278,RC,,,,both,,,215.78,140.26,,,,,,,,,,,,,
INSERT ANK THK 11 MM SZ 1 UHMWPE RT FIX MOD REV STRL SALTO,SUP-2931148,CDM,C1776,CPT,0278,RC,,,,both,,,5626.88,3657.47,,,,,,,,,,,,,
ROD SPNL PRECRV 100 MM TI,SUP-2415238,CDM,C1713,HCPCS,0278,RC,,,,both,,,2132.06,1385.84,,,,,,,,,,,,,
GUIDEWIRE ORTH L220MM DIA1.6MM S STL SMOOTH DRL TIP FOR,SUP-2410860,CDM,C1769,HCPCS,0272,RC,,,,both,,,153.17,99.56,,,,,,,,,,,,,
CATHETER ATHRCTMY DIA2.3MM 0.018IN OVR THE WIRE LSR MNL,SUP-2353098,CDM,C1885,CPT,0278,RC,,,,both,,,11035.53,7173.09,,,,,,,,,,,,,
CROSSLINK SPNL M L28-38MM TI FIX LO PROF CDH,SUP-2286945,CDM,C1713,HCPCS,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
STENT URET DBL PGTL FLX TIP SFT 035IN PTFE STIFF SUT POS,SUP-2139134,CDM,C2617,HCPCS,0278,RC,,,,both,,,415.08,269.80,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL PEEK SD800.509,SUP-2860191,CDM,C1713,HCPCS,0278,RC,,,,both,,,27013.42,17558.72,,,,,,,,,,,,,
ROD EXT FIX L150MM DIA11MM C CONN FOR HOFFMANN III MRI SYS,SUP-2372226,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1083.61,704.35,,,,,,,,,,,,,
GUIDE SURG PLN TI LP DISTRCTN CUSTOMIZABLE VSP,SUP-2883940,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8949.00,5816.85,,,,,,,,,,,,,
PLATE BNE L 213 MM SCREW DIA 3.5/4.5 MM H 8 UTIL NS EVOS,SUP-2931151,CDM,C1713,HCPCS,0278,RC,,,,both,,,16389.23,10653.00,,,,,,,,,,,,,
IMPL CAPPED KNEE GS FX CM FMTB STSUR NO PAT,SUP-2212252,CDM,C1776,CPT,0278,RC,,,,both,,,14541.81,9452.18,,,,,,,,,,,,,
CATHETER CRICO 5MMX9CM SET EMER INTRO NDL CVD DIL CUF AIRWY,SUP-2169801,CDM,C1713,HCPCS,0278,RC,,,,both,,,1165.88,757.82,,,,,,,,,,,,,
PLATE SPINE OCCIPITAL M LINEUM OCT,SUP-2205462,CDM,C1713,HCPCS,0278,RC,,,,both,,,5809.00,3775.85,,,,,,,,,,,,,
SCREW CORT BONE SELF TAP 4.5X32MM,SUP-2342655,CDM,C1713,HCPCS,0278,RC,,,,both,,,27.60,17.94,,,,,,,,,,,,,
BRACE HND SHT THMB LG LT SPICA,SUP-2196530,CDM,L3984,HCPCS,0274,RC,,,,both,,,105.50,68.57,,,,,,,,,,,,,
CROWN DENT 7 LO LT 1ST PRI M S STL GLD PREFABRICATED REPL,SUP-2322216,CDM,D6783,CPT,0278,RC,,,,both,,,31.27,20.33,,,,,,,,,,,,,
GUIDEWIRE TGS XPRESS FOR LOPROFILE ENT NAVIGATION SYS STRL,SUP-2659958,CDM,C1769,HCPCS,0272,RC,,,,both,,,786.63,511.31,,,,,,,,,,,,,
DEFIBRILLATOR IMPL VITALITY AVT TI 2 CHMBR 2 LD REMOT,SUP-2140362,CDM,C1721,HCPCS,0275,RC,,,,both,,,90651.80,58923.67,,,,,,,,,,,,,
GRAFT BNE L40MM FIBULAR SHFT SEG FRZ DRY MATRIGRFT,SUP-2264768,CDM,C1713,HCPCS,0278,RC,,,,both,,,1555.18,1010.87,,,,,,,,,,,,,
HC Mech Rem Intracath,PX-3613659600,CDM,36596,CPT,0361,RC,,,,both,,,8583.00,5578.95,,,,,,,,,,,,,
SHEATH INTFR SCR SM TIB TCP/PLA BIOABSRB BIO-INTRAFIX,SUP-2249563,CDM,C1776,CPT,0278,RC,,,,both,,,2307.90,1500.13,,,,,,,,,,,,,
GRAFT DURAMATRIX CLLGN DURA SUB MEM 1 IN X 1 IN ST FR TYOE 1,SUP-2165119,CDM,C1763,HCPCS,0278,RC,,,,both,,,700.22,455.14,,,,,,,,,,,,,
ENDOSCOPIC PACK RAP PAC LF,SUP-2848564,CDM,2720000010,LOCAL,0272,RC,,,,both,,,880.30,572.19,,,,,,,,,,,,,
PROBE BX 10 GAX118 MM VACORA,SUP-2128771,CDM,C1713,HCPCS,0278,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
PROSTHESIS OSS SHEA 0.8X10.9 MM 1.15 MM SPNR STRUT TRIM BLK,SUP-2637890,CDM,L8613,CPT,0278,RC,,,,both,,,1173.79,762.96,,,,,,,,,,,,,
NAIL IM FEM 9X420 MM RETROGRADE STRL DISP,SUP-2461444,CDM,C1713,HCPCS,0278,RC,,,,both,,,5818.42,3781.97,,,,,,,,,,,,,
SHELL ACET DIA42MM NO H TI ALLY PLSM SPR ESCALADE,SUP-2315199,CDM,C1776,CPT,0278,RC,,,,both,,,3755.44,2441.04,,,,,,,,,,,,,
SEXUAL ASSAULT KIT EVIDENCE COLLCTN,SUP-2390655,CDM,2720000011,LOCAL,0272,RC,,,,both,,,59.50,38.67,,,,,,,,,,,,,
GRAFT VASC INTERGARD BODY/BRANCH L 100/55 CM RNG L 60/30 CM,SUP-2462110,CDM,C1768,CPT,0278,RC,,,,both,,,2494.64,1621.52,,,,,,,,,,,,,
BUR SURG L 130 MM DIA 4 MM MH COARSE DIAMOND TUBE FOR SLIM,SUP-2937176,CDM,2720000010,LOCAL,0272,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
BOOT TRAC M L20IN FOR 15.5IN CALF CONVOLUTED FOAM LNR STAY,SUP-2196869,CDM,L4387,HCPCS,0272,RC,,,,both,,,36.33,23.61,,,,,,,,,,,,,
ALLOGRAFT BNE GRND 30 CC FRZN IRRADIATED CANC,SUP-2867071,CDM,C1762,CPT,0278,RC,,,,both,,,1583.97,1029.58,,,,,,,,,,,,,
BIT DRILL L200MM D7MM CNNLTD REAM SBTLR TBTLR ARTCLR SRFCS 3,SUP-2465713,CDM,2720000010,LOCAL,0272,RC,,,,both,,,652.30,423.99,,,,,,,,,,,,,
GUIDEWIRE VASC SAFE-T-J L 15 CM DIA 0.018 IN SS STR FIX COR,SUP-2759998,CDM,C1769,HCPCS,0272,RC,,,,both,,,73.70,47.90,,,,,,,,,,,,,
SLEEVE KNEE SM L13IN FOR 155 18IN NEOPRENE OPN PAT EXTRA LEN,SUP-2196828,CDM,L1820,HCPCS,0274,RC,,,,both,,,22.70,14.75,,,,,,,,,,,,,
PIN BNE FIX TEMP L110MM DIA4MM MAKO,SUP-2368494,CDM,C1713,HCPCS,0278,RC,,,,both,,,436.96,284.02,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.505,SUP-2860022,CDM,C1713,HCPCS,0278,RC,,,,both,,,34831.71,22640.61,,,,,,,,,,,,,
SCREW BNE L36MM DIA4.5MM CORT TI ST NONCANNULATED,SUP-2190465,CDM,C1713,HCPCS,0278,RC,,,,both,,,71.03,46.17,,,,,,,,,,,,,
PLATE BNE L55MM THK1.3MM 8 H MTCRPL TI STR COMPR FOR,SUP-2267915,CDM,C1713,HCPCS,0278,RC,,,,both,,,962.10,625.36,,,,,,,,,,,,,
PROGRAMMER NERVE STIM FOR PERCEPT PC DBS,SUP-2516498,CDM,C1787,HCPCS,0278,RC,,,,both,,,5338.00,3469.70,,,,,,,,,,,,,
BIT DRL L195MM DIA3.5MM TI QUIK CPL FOR NCB SYS,SUP-2204938,CDM,2720000010,LOCAL,0272,RC,,,,both,,,445.03,289.27,,,,,,,,,,,,,
NERVE STIM PERIPH 2 LD NS DISP SPRNT EXTENSA,SUP-2884033,CDM,C1778,HCPCS,0278,RC,,,,both,,,43960.00,28574.00,,,,,,,,,,,,,
CPT REVISION CENTRALIZER,SUP-2507460,CDM,C1776,CPT,0278,RC,,,,both,,,175.84,114.30,,,,,,,,,,,,,
ACETAMINOPHEN 500 MG PO TABS,RX-102,CDM,6370000000,HCPCS,0637,RC,00904-6730-61,NDC,,both,1,UN,0.40,0.26,,,,,,,,,,,,,
GRAFT VASC FUSION BIOLINE L 80 CM DIA 8 MM EXTERNALLY SUPP,SUP-2266011,CDM,C1768,CPT,0278,RC,,,,both,,,7253.40,4714.71,,,,,,,,,,,,,
NEEDLE BX DIA11GA DISP TELLURIDE JAMSH,SUP-2137005,CDM,2720000010,LOCAL,0272,RC,,,,both,,,486.70,316.35,,,,,,,,,,,,,
CATHETER CARD ABLATION FREEZOR L 108 CM 7 FR L 4 MM MED BLU,SUP-2175198,CDM,C1733,HCPCS,0272,RC,,,,both,,,4867.00,3163.55,,,,,,,,,,,,,
BOOT WLK N PNEUMAT,SUP-2319135,CDM,L4386,HCPCS,0272,RC,,,,both,,,737.90,479.63,,,,,,,,,,,,,
HC Custom Elbow Static,PX-2740370201,CDM,L3702,HCPCS,0274,RC,,,,both,,,960.00,624.00,,,,,,,,,,,,,
SHEATH INTRO VASCU-SHEATH II L 14 CM DIA11 FR PTFE VLV,SUP-2905226,CDM,C1892,HCPCS,0272,RC,,,,both,,,54.17,35.21,,,,,,,,,,,,,
SCREW BNE LAG 110 MM CANC SLD,SUP-2607101,CDM,C1713,HCPCS,0278,RC,,,,both,,,140.70,91.45,,,,,,,,,,,,,
SCREW BNE L20MM DIA3MM CORT S STL ST LOK FULL THRD T8 DRV LO,SUP-2371474,CDM,C1713,HCPCS,0278,RC,,,,both,,,239.27,155.53,,,,,,,,,,,,,
REGULATOR ENDO AERO VENT,SUP-2402576,CDM,C1713,HCPCS,0278,RC,,,,both,,,1805.50,1173.57,,,,,,,,,,,,,
BRACE ANK AD H95IN UNIV BILAT SEMI RIG SHELL PROTCT,SUP-2196371,CDM,L4350,HCPCS,0272,RC,,,,both,,,53.25,34.61,,,,,,,,,,,,,
ADO-TRASTUZUMAB EMTANSINE 100 MG IV SOLR,RX-120528,CDM,J9354,HCPCS,0636,RC,50242-0088-01,NDC,,both,1,UN,11490.20,7468.63,,,,,,,,,,,,,
ADAPTER HUM L6MM SHLDR RSP,SUP-2217361,CDM,C1776,CPT,0278,RC,,,,both,,,2381.85,1548.20,,,,,,,,,,,,,
HC So2 Ptt|REPEAT CLINICAL DIAGNOSTIC LABORATORY TEST|NOT REASONABLE AND NECESSARY,PX-3058573068,CDM,85730,CPT,0305,RC,,,91|GZ,both,,,9.00,5.85,,,,,,,,,,,,,
PIN FIX IMPL OD198MM,SUP-2290644,CDM,C1713,HCPCS,0278,RC,,,,both,,,399.47,259.66,,,,,,,,,,,,,
STENT GRFT VASC CP STENT L 3.4 CM 14 FR 3.5CM 18MM 2.5CM 9MM,SUP-2125284,CDM,C1874,HCPCS,0278,RC,,,,both,,,21038.00,13674.70,,,,,,,,,,,,,
KNIFE SHAVER 15 MMX9.5 CM BLADE FOR MORCELLATOR ROTOCUT MTP,SUP-2261063,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1814.92,1179.70,,,,,,,,,,,,,
BIT DRILL QUICK COUPLING 2X100/125 MM STERILE TC100 DISPOSAB,SUP-2837027,CDM,2720000010,LOCAL,0272,RC,,,,both,,,865.01,562.26,,,,,,,,,,,,,
SUPPORT ORTHOT ANK KNEE CUST SINGLE SLD STIRRUP W/O JT,SUP-2435633,CDM,L2010,HCPCS,0272,RC,,,,both,,,2470.33,1605.71,,,,,,,,,,,,,
STENT PANCREATIC JOHLIN L 8 CM DIA10 FR GUIDEWIRE 0.035 IN,SUP-2737534,CDM,C2625,HCPCS,0278,RC,,,,both,,,401.92,261.25,,,,,,,,,,,,,
BURR SURG 2MMX25MM TAPR ROUTER FOR TPS MIDAS REX UPWR,SUP-2367455,CDM,2720000010,LOCAL,0272,RC,,,,both,,,241.53,156.99,,,,,,,,,,,,,
POSTLAT DIST HUM LCK PL RIGHT SMPL,SUP-2820939,CDM,C1713,HCPCS,0278,RC,,,,both,,,1824.43,1185.88,,,,,,,,,,,,,
IMPLANT CRAN L CUST PEEK,SUP-2365129,CDM,C1713,HCPCS,0278,RC,,,,both,,,51707.70,33610.00,,,,,,,,,,,,,
GRAFT HUM TISS CHORION FREE THN 4X4 CM AMNIO ACTISHIELD CF,SUP-2759452,CDM,C1762,CPT,0278,RC,,,,both,,,6292.56,4090.16,,,,,,,,,,,,,
CATHETER THERMOABLATION CLOSUREPLUS L 60 CM DIA 6 FR,SUP-2393081,CDM,C1888,HCPCS,0272,RC,,,,both,,,2339.30,1520.54,,,,,,,,,,,,,
FLUVOXAMINE MALEATE 25 MG PO TABS,RX-20634,CDM,6370000000,HCPCS,0637,RC,60505-0164-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
FIBER LASER 365 MH OPTIMUM PERF HOLM SLM LN SIS EZ DISP,SUP-2462831,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1030.52,669.84,,,,,,,,,,,,,
HINGE EXT FIX UNIV ANK FT TRUELOK FRAME ASMBLY HEXAPOD SYS,SUP-2316166,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1202.84,781.85,,,,,,,,,,,,,
SCREW BNE SM L45MM DIA3.5MM HD DIA6MM CORT TI NONCANNULATED,SUP-2189878,CDM,C1713,HCPCS,0278,RC,,,,both,,,61.04,39.68,,,,,,,,,,,,,
BASEPLATE TIB UNI LT MEDL RT LAT PRI PEG CEM 38MM A/PXSM GEN,SUP-2349782,CDM,C1776,CPT,0278,RC,,,,both,,,3979.95,2586.97,,,,,,,,,,,,,
KIT SHLDR PROS STEMLESS INHANCE,SUP-2884233,CDM,C1776,CPT,0278,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
DRILL SURG CANN 2.7 MM PILOT QR NS LTX,SUP-2857935,CDM,2720000010,LOCAL,0272,RC,,,,both,,,587.18,381.67,,,,,,,,,,,,,
SCREW BNE 2.1X7 MM PDLLA STRL RESORB RX 520212704,SUP-2478188,CDM,C1713,HCPCS,0278,RC,,,,both,,,200.58,130.38,,,,,,,,,,,,,
PLATE BNE BROAD 4.5X286 MM 16 HOLE TI NS LC-DCP,SUP-2568783,CDM,C1713,HCPCS,0278,RC,,,,both,,,3078.64,2001.12,,,,,,,,,,,,,
SCREW BONE L38MM OD3.5MM COARSE THRD CRUCFRM WDRUFF HD,SUP-2362299,CDM,C1713,HCPCS,0278,RC,,,,both,,,21.16,13.75,,,,,,,,,,,,,
PLATE BNE ANGLED 2.5 MM LT 7X23 HOLE RECON PT SPEC,SUP-2860091,CDM,C1713,HCPCS,0278,RC,,,,both,,,24448.35,15891.43,,,,,,,,,,,,,
JIG SURG RT KNEE AREF PT SPEC DISP PERSONA,SUP-2205587,CDM,C1776,CPT,0278,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
PLATE BNE L 306 MM SCREW DIA 4.5 MM 15 H RT DSTL FEM STRL,SUP-2931181,CDM,C1713,HCPCS,0278,RC,,,,both,,,12348.05,8026.23,,,,,,,,,,,,,
PIN FIX L14MM DIA2.7MM PROV FOR VAR ANG PLATING SYS,SUP-2343967,CDM,C1713,HCPCS,0278,RC,,,,both,,,1227.46,797.85,,,,,,,,,,,,,
GRAFT HUM TISS 1CC CART EXTRACELLULAR MTRX INJ BIOCART,SUP-2120736,CDM,C1713,HCPCS,0278,RC,,,,both,,,2769.48,1800.16,,,,,,,,,,,,,
WIRE FIX L150MM DIA0.9MM SMOOTH SGL END TRCR TIP K,SUP-2321614,CDM,C1713,HCPCS,0278,RC,,,,both,,,87.92,57.15,,,,,,,,,,,,,
CATHETER BLLN DIL L75CM DIA5.3FR L20MM DIA4MM .035IN WIRE,SUP-2147605,CDM,C1725,HCPCS,0272,RC,,,,both,,,670.83,436.04,,,,,,,,,,,,,
FILGRASTIM-AYOW 300 MCG/0.5ML SC SOSY,RX-157755,CDM,Q5125,HCPCS,0636,RC,70121-1568-01,NDC,,both,0.5,ML,469.10,304.91,,,,,,,,,,,,,
SCREW SPNL POST LNG 5.5X40 MM TSRH-3D MPA,SUP-2631234,CDM,C1713,HCPCS,0278,RC,,,,both,,,1491.50,969.47,,,,,,,,,,,,,
SONICPIN RX 16 X 5MM 2/CTG STERILE,SUP-2679385,CDM,C1713,HCPCS,0278,RC,,,,both,,,256.79,166.91,,,,,,,,,,,,,
CATHETER CV KT 7 FRX16 CM DL PRESSURE INJ INTRO INJ NDL,SUP-2763324,CDM,C1751,HCPCS,0278,RC,,,,both,,,328.44,213.49,,,,,,,,,,,,,
IMPLANT FACE W20XH2.5XL20MM THK0.45MM POLYETH SH FLR EASILY,SUP-2365179,CDM,C1713,HCPCS,0278,RC,,,,both,,,1974.75,1283.59,,,,,,,,,,,,,
CAFFEINE CITRATE 20 MG/ML PO SOLN,RX-77411,CDM,6370000000,HCPCS,0637,RC,51754-0501-03,NDC,,both,3,ML,54.00,35.10,,,,,,,,,,,,,
CATHETER VENT SM BA IMPREG R ANG CLP S STL STYL,SUP-2284502,CDM,C1729,HCPCS,0272,RC,,,,both,,,342.35,222.53,,,,,,,,,,,,,
CURETTE SURG HOUSE-SHEEHY 6-5/8 INX2.5 MM KNIFE MALL SHFT SM,SUP-2500197,CDM,2720000010,LOCAL,0272,RC,,,,both,,,217.10,141.11,,,,,,,,,,,,,
PLATE BNE L 220.6 X W 8.3 MM THK 2.6 MM SCREW DIA2/2.3 MM SM,SUP-2937004,CDM,C1713,HCPCS,0278,RC,,,,both,,,7696.14,5002.49,,,,,,,,,,,,,
PLATE BNE FIBULAR 12 HOLE COMP STRL LTX,SUP-2861668,CDM,C1713,HCPCS,0278,RC,,,,both,,,1494.20,971.23,,,,,,,,,,,,,
BRACE ORTHOPEDIC TLSO LUMBAR 4 MOD SACR SCRAP PRE,SUP-2265011,CDM,L0464,HCPCS,0272,RC,,,,both,,,5736.78,3728.91,,,,,,,,,,,,,
ENDCAP SPINE EXTND 25X30MM 0 DEG,SUP-2662877,CDM,C1889,HCPCS,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
HEAD HUM DIA44MM SHT SHLDR FOR HEMIARTHROPLASTY EQUINOXE,SUP-2223316,CDM,C1776,CPT,0278,RC,,,,both,,,4266.63,2773.31,,,,,,,,,,,,,
BRONCHOSCOPE RIGID INTUB 4 LG 5.8/2.8 MM 23.6 IN ASCOPE DISP,SUP-2389099,CDM,2720000010,LOCAL,0272,RC,,,,both,,,938.86,610.26,,,,,,,,,,,,,
BUNDLE CASE MICROTIA VSP,SUP-2862837,CDM,2720000010,LOCAL,0272,RC,,,,both,,,10154.76,6600.59,,,,,,,,,,,,,
PLATE LOQTEQ DISTAL LATERAL HUMERUS 3H LT,SUP-2753224,CDM,C1713,HCPCS,0278,RC,,,,both,,,4561.85,2965.20,,,,,,,,,,,,,
PLATE BNE 4 H LT DSTL MEDL TIB NS,SUP-2896828,CDM,C1713,HCPCS,0278,RC,,,,both,,,5334.86,3467.66,,,,,,,,,,,,,
MESH HERN W8XL8CM POLY ABSRB CLLGN FLM COMP HRT SHP FOR,SUP-2752146,CDM,C1781,HCPCS,0278,RC,,,,both,,,2063.64,1341.37,,,,,,,,,,,,,
TROCAR SURG 2.5 MM,SUP-2483025,CDM,2720000010,LOCAL,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
PLATE ATTACHMENT 3.5MM TI LCKNG PL F4.5MM LCP 8H-STER,SUP-2546835,CDM,C1713,HCPCS,0278,RC,,,,both,,,1925.42,1251.52,,,,,,,,,,,,,
STEM FEM CLLRD HI OFFSET FORGED CO CHROM PRSS FIT P SER SZ,SUP-2221761,CDM,C1776,CPT,0278,RC,,,,both,,,15448.80,10041.72,,,,,,,,,,,,,
SYSTEM DEL 8 FR AMPLATZER PFO,SUP-2357465,CDM,C1887,HCPCS,0272,RC,,,,both,,,2427.22,1577.69,,,,,,,,,,,,,
DRILL TWST L 50 MM DIA1.8 MM SCREW DIA 3/4 MM HEX NS DISP,SUP-2909525,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1246.14,809.99,,,,,,,,,,,,,
PACEMAKER CARD PHILOS DR-B 2 CHMBR 6 CONN UPLR DDDR,SUP-2137961,CDM,C1785,HCPCS,0275,RC,,,,both,,,9630.38,6259.75,,,,,,,,,,,,,
PROBE BRST BX STEREOTACTIC W/ TBNG SET TISS MGMT SYS L9CM,SUP-2420811,CDM,2720000010,LOCAL,0272,RC,,,,both,,,989.73,643.32,,,,,,,,,,,,,
MESH HERN W5.5XL4.3IN OMEGA 3 FATTY ACID COAT POLYPR,SUP-2265982,CDM,C1781,HCPCS,0278,RC,,,,both,,,1036.20,673.53,,,,,,,,,,,,,
BENZOCAINE-MENTHOL 6-10 MG MT LOZG,RX-41085,CDM,6370000000,HCPCS,0637,RC,78112-0011-06,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
ANCHOR SUTURE 5.5MM WITH 2 NO 2 SUTURES WITHOUT NEEDLE CROSS,SUP-2824426,CDM,C1713,HCPCS,0278,RC,,,,both,,,1723.86,1120.51,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY L 115 CM DIA 7 FR SPC 2-8-2 MM,SUP-2877986,CDM,C1730,HCPCS,0272,RC,,,,both,,,639.78,415.86,,,,,,,,,,,,,
MESH HERN RECT 18X12 IN FULL RESRB FOR SFT TISS PHASIX,SUP-2855256,CDM,C1781,HCPCS,0278,RC,,,,both,,,56206.00,36533.90,,,,,,,,,,,,,
GUIDEWIRE UROLOGICAL STR TIP 035X4500 HYDRPHLC ZBR,SUP-2791202,CDM,C1769,HCPCS,0272,RC,,,,both,,,452.16,293.90,,,,,,,,,,,,,
VALVE VENT DRNGE RT ANG PROGRAMMABLE W/ INTEGR PLAS CONN,SUP-2243809,CDM,C1729,HCPCS,0272,RC,,,,both,,,14668.20,9534.33,,,,,,,,,,,,,
GRAFT VASC HEMGRD L 20 CM DIA12 MM POLYESTER BOV CLLGN STR,SUP-2227541,CDM,C1768,CPT,0278,RC,,,,both,,,1401.29,910.84,,,,,,,,,,,,,
HYDROCORTISONE SOD SUC (PF) 100 MG IJ SOLR (ACT-0-VIAL),RX-159344,CDM,J1720,HCPCS,0636,RC,00009-0011-03,NDC,,both,1,UN,138.50,90.02,,,,,,,,,,,,,
LITHOTRIPTER SURG BSKT 30MM CHAN 4.2MM 1 BODY DISP,SUP-2312974,CDM,2720000010,LOCAL,0272,RC,,,,both,,,980.15,637.10,,,,,,,,,,,,,
RING EXT FIX L160MM HALF FOR SIDEKCK FREE CIR FIX,SUP-2400649,CDM,C1713,HCPCS,0278,RC,,,,both,,,1337.64,869.47,,,,,,,,,,,,,
GRAFT VASC FLIXENE L 45 CM DIA 6 MM EPTFE TRMPT GRAD WALL,SUP-2475717,CDM,C1768,CPT,0278,RC,,,,both,,,3899.25,2534.51,,,,,,,,,,,,,
BOOT ORTHOSIS FOR 7-9IN ANK FOAM STATIC FOR POS AND PRSS,SUP-2194762,CDM,L4396,HCPCS,0274,RC,,,,both,,,149.37,97.09,,,,,,,,,,,,,
PLATE BNE L65MM 3 H NONSTERILE R POSTEROLAT DST HUM S STL,SUP-2185899,CDM,C1713,HCPCS,0278,RC,,,,both,,,2641.74,1717.13,,,,,,,,,,,,,
CLARITHROMYCIN 500 MG PO TABS,RX-9617,CDM,6370000000,HCPCS,0637,RC,00527-1932-06,NDC,,both,1,UN,4.30,2.79,,,,,,,,,,,,,
PLATE BNE ORBIT FLR 25X0.6 MM TRIANG PLLA-PGA STRL RESORB XG,SUP-2472559,CDM,C1713,HCPCS,0278,RC,,,,both,,,2537.43,1649.33,,,,,,,,,,,,,
COMPONENT TALAR DOMED 5 LT RT TOT ANK INBONE,SUP-2850352,CDM,C1776,CPT,0278,RC,,,,both,,,8503.12,5527.03,,,,,,,,,,,,,
HC Nose to Rectum Child,PX-3207601000,CDM,76010,CPT,0320,RC,,,,inpatient,,,96.00,62.40,,,,,,,,,,,,,
ROUND WASHER 12.7MM O.D TI,SUP-2820845,CDM,C1713,HCPCS,0278,RC,,,,both,,,266.52,173.24,,,,,,,,,,,,,
"HC Culture,Anaerobic",PX-3008707500,CDM,87075,CPT,0300,RC,,,,both,,,245.00,159.25,,,,,,,,,,,,,
CATHETER ANGIOPLSTY STERLING L 150 CM BALLOON L 220 MM DIA 5,SUP-2140769,CDM,C1725,HCPCS,0272,RC,,,,both,,,1042.48,677.61,,,,,,,,,,,,,
PLATE BNE PROF THK 1 MM 8 H SCREW DIA2 MM TI MIDFACE ANGLED,SUP-2883741,CDM,C1713,HCPCS,0278,RC,,,,both,,,1102.14,716.39,,,,,,,,,,,,,
CENTRALIZER DSTL 12MM F/INSIDE STEM F/SMITH,SUP-2344466,CDM,C1776,CPT,0278,RC,,,,both,,,13935.32,9057.96,,,,,,,,,,,,,
SET PERFSN DIA18/20 20/22 22.24 FR GUIDEWIRE L 100 CM DIA,SUP-2908836,CDM,C1769,HCPCS,0272,RC,,,,both,,,289.95,188.47,,,,,,,,,,,,,
SURFACE ARTC SZ EF 7-10 H12MM AP50MM ML82MM UHMWPE BLU STRP,SUP-2208724,CDM,C1776,CPT,0278,RC,,,,both,,,7561.12,4914.73,,,,,,,,,,,,,
PLATE BNE L41MM THK13MM 2X6 H NONSTERILE HND TI ROT CORR LOK,SUP-2181044,CDM,C1713,HCPCS,0278,RC,,,,both,,,2482.33,1613.51,,,,,,,,,,,,,
COIL EMB L30CM OD12MM 0.018IN 2D HELCL STRTCH DETACH GDC-18,SUP-2365711,CDM,C1889,HCPCS,0278,RC,,,,both,,,1829.99,1189.49,,,,,,,,,,,,,
SLEEVE TIB H40MM AP27MM ML45MM MTPHSEAL TI PORCOAT POR REV,SUP-2250949,CDM,C1776,CPT,0278,RC,,,,both,,,6886.65,4476.32,,,,,,,,,,,,,
SCREW BONE L36MM DIA4MM TI NONLOCKING T15 DBL LD FOR,SUP-2319753,CDM,C1713,HCPCS,0278,RC,,,,both,,,1246.58,810.28,,,,,,,,,,,,,
PLATE BONE L82MM 6 H LT PROX MEDL PERIARTC TIB S STL,SUP-2205631,CDM,C1713,HCPCS,0278,RC,,,,both,,,2004.42,1302.87,,,,,,,,,,,,,
PLATE BNE W24.4XL56.6MM STD L DST DORS VOLAR RAD T ANAT DBL,SUP-2414018,CDM,C1713,HCPCS,0278,RC,,,,both,,,2193.29,1425.64,,,,,,,,,,,,,
PIN FIX L9IN OD1/8IN S STL STYL 4 SMOOTH PLN SHANK TRCR,SUP-2398010,CDM,C1713,HCPCS,0278,RC,,,,both,,,336.77,218.90,,,,,,,,,,,,,
SLEEVE TROCAR L110MM DIAMETER 10MM SMOOTH DISPOSABLE WITH TA,SUP-2804215,CDM,2720000010,LOCAL,0272,RC,,,,both,,,648.85,421.75,,,,,,,,,,,,,
SCREW BNE L32MM DIA4.5MM CORT PROX FEM ANK S STL ST FULL,SUP-2350201,CDM,C1713,HCPCS,0278,RC,,,,both,,,215.34,139.97,,,,,,,,,,,,,
VALVE SHUNT SM EXTRACTED STRATA NSC,SUP-2628625,CDM,C1889,HCPCS,0278,RC,,,,both,,,11581.54,7528.00,,,,,,,,,,,,,
DRILL SURG BASEPLT 7.5 MM CRTX TRABECULAR MTL RVS +,SUP-2436861,CDM,2720000010,LOCAL,0272,RC,,,,both,,,777.15,505.15,,,,,,,,,,,,,
PLEDGET CV SAUVAGE L 10.2 X W 10.2 CM THK 0.61 MM POLYESTER,SUP-2761341,CDM,C1768,CPT,0278,RC,,,,both,,,319.50,207.67,,,,,,,,,,,,,
PLATE BNE L195MM THK34MM 15 H BILAT S STL STR LIMIT CNTCT,SUP-2185152,CDM,C1713,HCPCS,0278,RC,,,,both,,,1857.37,1207.29,,,,,,,,,,,,,
Access Instruments,SUP-2757214,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5903.20,3837.08,,,,,,,,,,,,,
MESH CRAN L 55 X W 38 MM THK 0.6 MM SCREW DIA1.5 MM LG TI,SUP-2936919,CDM,C1713,HCPCS,0278,RC,,,,both,,,6594.00,4286.10,,,,,,,,,,,,,
OPIUM 10 MG/ML (1%) PO TINC,RX-99771,CDM,6370000000,HCPCS,0637,RC,42799-0217-01,NDC,,both,0.6,ML,14.20,9.23,,,,,,,,,,,,,
GRAFT HUM TISS W5XL10CM SFT REGEN MTRX REP REPLFRM,SUP-2139392,CDM,C1762,CPT,0278,RC,,,,both,,,5162.95,3355.92,,,,,,,,,,,,,
HC So1 Mgmt Methylation Analysis,PX-3108128767,CDM,81287,CPT,0310,RC,,,,both,,,979.00,636.35,,,,,,,,,,,,,
STEM ULN HD 5.5 SM PART MOD REPL 1ST CHOICE,SUP-2610437,CDM,C1776,CPT,0278,RC,,,,both,,,11663.94,7581.56,,,,,,,,,,,,,
SHUNT NEUROSURGICAL L10CM OD4X5MM CAR STR INT FULL SPR,SUP-2308222,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1718.46,1117.00,,,,,,,,,,,,,
STENT NEURO FRED L 31/23 MM WORKING L 26/17 MM DIA 4 MM SYS,SUP-2739136,CDM,C1876,HCPCS,0278,RC,,,,both,,,39901.55,25936.01,,,,,,,,,,,,,
LABETALOL HCL 5 MG/ML SYRINGE,RX-4081061,CDM,J1920,HCPCS,0636,RC,,,,both,2,ML,54.10,35.16,,,,,,,,,,,,,
PLATE BONE 3X16 HOLE LEFT RECONSTRUCTION WITH CONDYLAR HEAD,SUP-2838420,CDM,C1713,HCPCS,0278,RC,,,,both,,,16779.53,10906.69,,,,,,,,,,,,,
PLATE BNE L 267 MM SCREW DIA 4.5 MM 16 H COMPR LCK NS EVOS,SUP-2933212,CDM,C1713,HCPCS,0278,RC,,,,both,,,3410.83,2217.04,,,,,,,,,,,,,
KIT LD L70CM 4X8 32 SURG COVEREDGE,SUP-2141956,CDM,C1778,HCPCS,0278,RC,,,,both,,,13816.00,8980.40,,,,,,,,,,,,,
CUP ACET OD49MM ID32MM 0DEG LONGEVITY HXLPE SNAP IN SPCR,SUP-2203800,CDM,C1776,CPT,0278,RC,,,,both,,,8551.79,5558.66,,,,,,,,,,,,,
ACL INTERNALBRACE LIGAMENT AUGMEN BUTTON,SUP-2811993,CDM,C1713,HCPCS,0278,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
PACEMAKER CARD 10.4ML W50XH46MM THK6MM IS-1 CONN,SUP-2356460,CDM,C1785,HCPCS,0275,RC,,,,both,,,10676.00,6939.40,,,,,,,,,,,,,
N S BIPOLAR BAYONET 20MM,SUP-2703460,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1921.77,1249.15,,,,,,,,,,,,,
ROD SPNL L35 MM STR CRD STRL TRANSITION,SUP-2230037,CDM,C1713,HCPCS,0278,RC,,,,both,,,1676.76,1089.89,,,,,,,,,,,,,
STENT URET 8.5FR L90CM SGL J SILITEK,SUP-2313762,CDM,C2617,HCPCS,0278,RC,,,,both,,,1004.80,653.12,,,,,,,,,,,,,
PACEMAKER CARD INTUA W 1.75 X H 2.4 IN THK 0.76 CM 34 GM TI,SUP-2149294,CDM,C2621,HCPCS,0275,RC,,,,both,,,18840.00,12246.00,,,,,,,,,,,,,
GRAFT DERM L20CMXW16CM THCKNESS 8 17MM ACELLULAR HYDRATED,SUP-2307477,CDM,Q4128,HCPCS,0636,RC,,,,both,,,25820.22,16783.14,,,,,,,,,,,,,
GRAFT HUM TISS DERMACELL POROUS 2X3CM 6SQCM,SUP-2909262,CDM,Q4122,HCPCS,0636,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
KIT KYPHOPLASTY BALLOON L 25 MM UNIPEDICULAR STRL DISP,SUP-2930330,CDM,2720000010,LOCAL,0272,RC,,,,both,,,10362.00,6735.30,,,,,,,,,,,,,
STEM FEM PRSS FT 14X150 MM KNEE TRIATHLON,SUP-2373844,CDM,C1776,CPT,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
BROACH SURG F 60 MM PROX HI OFFSET PPS COAT ARCOS,SUP-2441644,CDM,C1776,CPT,0278,RC,,,,both,,,14330.96,9315.12,,,,,,,,,,,,,
TM FEM METAPHYSEAL CONE 35 MEDIUM RIGHT,SUP-2502267,CDM,C1776,CPT,0278,RC,,,,both,,,12882.79,8373.81,,,,,,,,,,,,,
ALLOGRAFT BNE PARTICULATE 250-1000 MUM 2 CC CORTICAL PUROS,SUP-2335278,CDM,C1889,HCPCS,0278,RC,,,,both,,,775.58,504.13,,,,,,,,,,,,,
MISOPROSTOL 25 MCG PRE-SPLIT TABLET,RX-40850018,CDM,6370000000,HCPCS,0637,RC,09999-9900-08,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PROBE THERMOMETER ORL ADLT 4FT CRD F/ COVIDIEN FILAC 3000 LT,SUP-2613010,CDM,C1751,HCPCS,0278,RC,,,,both,,,113.13,73.53,,,,,,,,,,,,,
SLEEVE FEM -3.5MM SH NK TI HIP DYNASTY,SUP-2304513,CDM,C1776,CPT,0278,RC,,,,both,,,2418.59,1572.08,,,,,,,,,,,,,
FILLER DERMAL JUVEDERM ULTRA XC 1ML,SUP-2900488,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1095.86,712.31,,,,,,,,,,,,,
STEM FEM L230MM DIA26X21MM 40MM LAT OFFSET L36MM +21MM ANG,SUP-2253211,CDM,C1776,CPT,0278,RC,,,,both,,,14079.13,9151.43,,,,,,,,,,,,,
GUIDEWIRE ORTHOPEDIC 0.094X87 MM TROCAR PT 1 END,SUP-2106430,CDM,C1769,HCPCS,0272,RC,,,,both,,,40.82,26.53,,,,,,,,,,,,,
HC So Ggtp,PX-3018297766,CDM,82977,CPT,0301,RC,,,,both,,,40.00,26.00,,,,,,,,,,,,,
CANNULA PERF AD 17FR L762IN 3 8 CONN FEM ART NVENT PERC,SUP-2282872,CDM,2720000010,LOCAL,0272,RC,,,,both,,,723.77,470.45,,,,,,,,,,,,,
IMPLANT FACE 45 X 41 X 4 MM POLYETHYL GENIOMANDIBULAR,SUP-2883172,CDM,C1713,HCPCS,0278,RC,,,,both,,,1342.92,872.90,,,,,,,,,,,,,
BIT DRILL 10.2MM CANN LEN 251MM,SUP-2417043,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1849.96,1202.47,,,,,,,,,,,,,
SPACER SPNL 45X12X10 MM INTBDY FUSION DEV CRESCENT,SUP-2281753,CDM,C1713,HCPCS,0278,RC,,,,both,,,9106.00,5918.90,,,,,,,,,,,,,
TIOTROPIUM BROMIDE-OLODATEROL 2.5-2.5 MCG/ACT IN AERS,RX-130239,CDM,6370000000,HCPCS,0637,RC,00597-0155-70,NDC,,both,4,GR,337.50,219.37,,,,,,,,,,,,,
CAP ORTH H15MM TIB NAIL,SUP-2208071,CDM,C1776,CPT,0278,RC,,,,both,,,620.97,403.63,,,,,,,,,,,,,
GUIDEWIRE VASC STR 3 CM 0.014 INX180 CM 20 CM SS PROWATER,SUP-2123767,CDM,C1769,HCPCS,0272,RC,,,,both,,,248.06,161.24,,,,,,,,,,,,,
DRILL SURG TIB ATTUNE,SUP-2454814,CDM,2720000010,LOCAL,0272,RC,,,,both,,,492.98,320.44,,,,,,,,,,,,,
PLATE SPNL RT STD POST S STL COLORADO 2 SACR AND SACROILIAC,SUP-2290566,CDM,C1713,HCPCS,0278,RC,,,,both,,,9134.26,5937.27,,,,,,,,,,,,,
KIT CATH 5.5FR L13CM MULTILUMEN INDWL SPR WIRE GUID INTRO,SUP-2383300,CDM,C1751,HCPCS,0278,RC,,,,both,,,173.96,113.07,,,,,,,,,,,,,
HC So Leukocyte Alka Phosphat Stain,PX-3058554066,CDM,85540,CPT,0305,RC,,,,both,,,463.00,300.95,,,,,,,,,,,,,
SYSTEM BNE GRFT L MIX N-FORCE,SUP-2421383,CDM,2720000010,LOCAL,0272,RC,,,,both,,,753.60,489.84,,,,,,,,,,,,,
BRACE ORTH 2 MOD BK PRE CUST TLSO,SUP-2388139,CDM,L0460,HCPCS,0274,RC,,,,both,,,2585.10,1680.31,,,,,,,,,,,,,
PLATE BNE L37MM 6 H TI LAT MED REARFOOT LOK COMPR RECON RPS,SUP-2399637,CDM,C1713,HCPCS,0278,RC,,,,both,,,2584.22,1679.74,,,,,,,,,,,,,
BEARING TIB PS 11X87/91 MM ASCNT,SUP-2449795,CDM,C1776,CPT,0278,RC,,,,both,,,3254.14,2115.19,,,,,,,,,,,,,
CATHETER ETER EDI 6FR L50CM PHT FREE,SUP-2227268,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3730.32,2424.71,,,,,,,,,,,,,
COUNTERSINK SURG FOR 2/2.4MM SCR,SUP-2187360,CDM,2720000010,LOCAL,0272,RC,,,,both,,,552.01,358.81,,,,,,,,,,,,,
SUTURE SYNETURE CHROMIC GUT SZ 2 0 L30IN ABSRB UD V 20 L26MM GG123,SUP-2174673,CDM,C1713,HCPCS,0278,RC,,,,both,,,442.74,287.78,,,,,,,,,,,,,
SUTUREFIX CRVD AHR X-LARGE 1 #2 UB STRAIGHT BL,SUP-2823708,CDM,C1713,HCPCS,0278,RC,,,,both,,,1308.09,850.26,,,,,,,,,,,,,
POST EXT FIX L 3 H S STL FEM ILIZ,SUP-2342289,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1050.80,683.02,,,,,,,,,,,,,
PLATE BNE STR 1.3X48X0.75 MM 12 HOLE LCK SS NS,SUP-2177982,CDM,C1713,HCPCS,0278,RC,,,,both,,,1301.69,846.10,,,,,,,,,,,,,
CUTTER SUT STD TENS PROCINCH,SUP-2361153,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2665.86,1732.81,,,,,,,,,,,,,
ALLOGRAFT PERICARD RESRB MEMBRN NAT BARR 2.0CMX3.0CM MAXXEUS,SUP-2418450,CDM,C1762,CPT,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
GRAFT BIO TISS W10XL15CM THK1MM PORCINE DERM CLLGN HERN ABD,SUP-2174696,CDM,C9364,HCPCS,0278,RC,,,,both,,,10317.60,6706.44,,,,,,,,,,,,,
STABILIZATION KIT LG WRST,SUP-2384731,CDM,C1713,HCPCS,0278,RC,,,,both,,,227.52,147.89,,,,,,,,,,,,,
IMPLANT HUM TISS TEND L 180 X W 10 MM BNE L 25-30 X W 14 X H,SUP-2913408,CDM,C1762,CPT,0278,RC,,,,both,,,8182.84,5318.85,,,,,,,,,,,,,
CATHETER ABLATN F-J 4 MM 1-4-1 MM 8 FRX115 CM FLEXABILITY,SUP-2357520,CDM,C2630,CPT,0272,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
PERIOTOME SET INCLUDES BLADES 1 2 3 HANDLE,SUP-2497938,CDM,2720000010,LOCAL,0272,RC,,,,both,,,760.23,494.15,,,,,,,,,,,,,
COVER ULTRSNC HNDPC HRD TISS FOR BONESCALPEL SYS STRL DISP,SUP-2887850,CDM,2720000010,LOCAL,0272,RC,,,,both,,,527.52,342.89,,,,,,,,,,,,,
PLATE BONE L41MM THK1.25MM 6 H BILAT MAXILLOFACIAL MAND ORAL,SUP-2191336,CDM,C1713,HCPCS,0278,RC,,,,both,,,2002.38,1301.55,,,,,,,,,,,,,
DISTRACTOR SURG L L480MM DIA14MM THRD SPINDLE,SUP-2188633,CDM,C1713,HCPCS,0278,RC,,,,both,,,1737.49,1129.37,,,,,,,,,,,,,
PLATE BNE W13.5XL88MM THK4.2MM 5 H BILAT S STL NAR LIMIT,SUP-2185232,CDM,C1713,HCPCS,0278,RC,,,,both,,,1023.17,665.06,,,,,,,,,,,,,
SUPPORT ORTH CLOSED POPLITEAL 15.5-18 IN SM KNEE DLX,SUP-2336342,CDM,L1810,HCPCS,0274,RC,,,,both,,,51.15,33.25,,,,,,,,,,,,,
BIT DRL 3.5 MM UPEX,SUP-2330464,CDM,2720000010,LOCAL,0272,RC,,,,both,,,318.02,206.71,,,,,,,,,,,,,
STOPPER EXT FIX WIRE PIN STRL DISP SMRT TSF,SUP-2932927,CDM,2720000010,LOCAL,0272,RC,,,,both,,,88.14,57.29,,,,,,,,,,,,,
PLATE 3.5MM TI LCP POSTLAT DISTAL HUMERUS LAT SUPPORT 7H RT,SUP-2549688,CDM,C1713,HCPCS,0278,RC,,,,both,,,4010.72,2606.97,,,,,,,,,,,,,
PROBE ABLATN MICROWAVE 14 GAX150 MM AMICA,SUP-2303520,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8462.30,5500.49,,,,,,,,,,,,,
BEAM FIX 5.5X100 MM,SUP-2421803,CDM,C1713,HCPCS,0278,RC,,,,both,,,4050.60,2632.89,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.431,SUP-2859995,CDM,C1713,HCPCS,0278,RC,,,,both,,,42012.57,27308.17,,,,,,,,,,,,,
SPHINCTEROTOME ENDOSCP L25MM OD6-5FR 0.035IN BRAID TRCE,SUP-2169216,CDM,2720000010,LOCAL,0272,RC,,,,both,,,587.18,381.67,,,,,,,,,,,,,
CATHETER ANGIOPLSTY POLARCATH L 80 CM BALLOON L 80 MM DIA 5,SUP-2141861,CDM,C1725,HCPCS,0272,RC,,,,both,,,2320.46,1508.30,,,,,,,,,,,,,
ELECTRODE ES 14GA L25CM 90DEG SEMIFLEX ANG BEND TIP KATECHO,SUP-2118719,CDM,C1819,HCPCS,0278,RC,,,,both,,,6892.30,4479.99,,,,,,,,,,,,,
GRAFT BIO TISS OMEGA3 MARIGEN MICRO 4SQCM,SUP-2866741,CDM,Q4158,HCPCS,0636,RC,,,,both,,,1667.34,1083.77,,,,,,,,,,,,,
FIBER LASER FLAT TIP 600 MH ASMBLY HOLM,SUP-2226000,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
GRAFT EVAR L140MM DIAM 23MM AORT AND 12MM IL ABD AORT IL,SUP-2395970,CDM,C1768,CPT,0278,RC,,,,both,,,25638.10,16664.76,,,,,,,,,,,,,
WEDGE ANK W18MM D18MM THK8MM EVANS TECH TI PORUS BIOSYNC,SUP-2122989,CDM,C1776,CPT,0278,RC,,,,both,,,6280.00,4082.00,,,,,,,,,,,,,
SPACER KNEE 22 MM VANGUARD,SUP-2446703,CDM,C1776,CPT,0278,RC,,,,both,,,763.02,495.96,,,,,,,,,,,,,
PLATE 4 H 2.3 TRAUM MOD TI 1.5MM MED,SUP-2262994,CDM,C1713,HCPCS,0278,RC,,,,both,,,801.39,520.90,,,,,,,,,,,,,
IMPLANT HUM TISS LT PAT BNE,SUP-2884887,CDM,C1762,CPT,0278,RC,,,,both,,,38465.00,25002.25,,,,,,,,,,,,,
CATHETER GUID MERCI L 95 CM OD 8 FR ID 0.078 IN SS POLYUR,SUP-2367772,CDM,C1887,HCPCS,0272,RC,,,,both,,,3741.00,2431.65,,,,,,,,,,,,,
DEFIBRILLATOR IMPL IFORIA 7 DR-T W 55 X H 65 MM D 11 MM 40 J,SUP-2138359,CDM,C1721,HCPCS,0275,RC,,,,both,,,51810.00,33676.50,,,,,,,,,,,,,
GRAFT HUM TISS W4XL8CM THK0.4-.8MM ACELLULAR DERM MTRX MESH,SUP-2402504,CDM,Q4126,HCPCS,0636,RC,,,,both,,,6280.00,4082.00,,,,,,,,,,,,,
GRIP CBL L85MM STD TROCHANTERIC HIP 3 CBL ACCORD,SUP-2345206,CDM,C1776,CPT,0278,RC,,,,both,,,4628.36,3008.43,,,,,,,,,,,,,
PLATE BNE L169MM 4 H ST PROX FEM S STL HK LO PROF LOK COMPR,SUP-2186055,CDM,C1713,HCPCS,0278,RC,,,,both,,,4803.98,3122.59,,,,,,,,,,,,,
PLATE BNE L 60 MM TI INTRATHORACIC PREBENT NS RIBFIX TITAN,SUP-2905468,CDM,C1713,HCPCS,0278,RC,,,,both,,,11555.20,7510.88,,,,,,,,,,,,,
ALLOGRACT HUM TISS AMNIOBAND MEMBRANE 2X2CM,SUP-2905501,CDM,Q4151,HCPCS,0636,RC,,,,both,,,2576.31,1674.60,,,,,,,,,,,,,
HC Iadna Respiratry Probe & Rev Trnscr 12-25 Target,PX-3068763300,CDM,87633,CPT,0306,RC,,,,both,,,683.00,443.95,,,,,,,,,,,,,
NEEDLE BX 19GA SHTH 5.2FR ENDO US DISP FOR SFT TISS Q COR,SUP-2169552,CDM,C1713,HCPCS,0278,RC,,,,both,,,976.54,634.75,,,,,,,,,,,,,
BIT DRILL W  STOP 2.2MM,SUP-2706715,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1329.79,864.36,,,,,,,,,,,,,
PLATE BONE SM TITANIUM GRIDLOCK VLC PLATING SYSTEM FOR 2.4/3/4MM SCREW,SUP-2878140,CDM,C1713,HCPCS,0278,RC,,,,both,,,3516.80,2285.92,,,,,,,,,,,,,
BOLT ORTH L 36 MM DIA 3.5 MM TI ANTI-DRIFT FT STRL MOTOBAND,SUP-2893272,CDM,C1713,HCPCS,0278,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
PLATE BONE 5 H 2.4MM SCR STRNL TI STRNLOCK,SUP-2136980,CDM,C1713,HCPCS,0278,RC,,,,both,,,1303.10,847.01,,,,,,,,,,,,,
PLATE BNE W11.7XL45.3MM 8 H WRST TI L ANG LOK COMPR HI,SUP-2411671,CDM,C1713,HCPCS,0278,RC,,,,both,,,2276.66,1479.83,,,,,,,,,,,,,
CATHETER DRAINAGE DUROMETER LOOP REG 10 FRX25 CM FLEXIMA,SUP-2147823,CDM,C1729,HCPCS,0272,RC,,,,both,,,248.06,161.24,,,,,,,,,,,,,
SCREW BNE UNICORTICAL 5X10 MM FEM POLYAX TI NS NCB,SUP-2459660,CDM,C1713,HCPCS,0278,RC,,,,both,,,445.03,289.27,,,,,,,,,,,,,
LUTETIUM LU 177 VIPIVOTIDE TET 1000 MBQ/ML IV SOLN|DISCARDED DRUG NOT ADMINISTE,RX-157859,CDM,A9607,HCPCS,0344,RC,69488-0010-61,NDC,JW,both,1,UN,205729.50,133724.17,,,,,,,,,,,,,
STENT GRFT VASC POWERLINK XL INTUITRAK L 80 MM DIA 34 MM,SUP-2217584,CDM,C1768,CPT,0278,RC,,,,both,,,10974.30,7133.29,,,,,,,,,,,,,
BOLT SPNL L25MM DIA5.5MM ANTR THORLUM LAT PLT SYSTEMXLP +,SUP-2311333,CDM,C1713,HCPCS,0278,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
AUGMENT ACET DIA 66 MM THK 15 MM,SUP-2888597,CDM,C1776,CPT,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
HC Portal Film,PX-3337741700,CDM,77417,CPT,0333,RC,,,,both,,,756.00,491.40,,,,,,,,,,,,,
GRAFT VASC FLIXENE L 80 CM DIA 7 MM EPTFE TRMPT GRAD WALL,SUP-2695238,CDM,C1768,CPT,0278,RC,,,,both,,,5279.50,3431.67,,,,,,,,,,,,,
SET SCR SPNL L45MM DIA6MM PEDCL TI ALLOY FUS FOR DYN STBL,SUP-2414264,CDM,C1713,HCPCS,0278,RC,,,,both,,,7759.73,5043.82,,,,,,,,,,,,,
HC Echo Exam of Fetal Heart,PX-4027682500,CDM,76825,CPT,0402,RC,,,,inpatient,,,1453.00,944.45,,,,,,,,,,,,,
COLLAR SPNL TI FOR VAR AXIS SCR,SUP-2193306,CDM,C1713,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
SIZER SURG W13XH12.2CM 95ML P6.5CM SIL GEL BRST 323 STYL HI,SUP-2300816,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
THUMBWHEEL EXT FIX UPPER LT DISP 49221002,SUP-2517240,CDM,2720000010,LOCAL,0272,RC,,,,both,,,248.06,161.24,,,,,,,,,,,,,
ALLOPURINOL 300 MG PO TABS,RX-311,CDM,6370000000,HCPCS,0637,RC,00904-6572-61,NDC,,both,1,UN,3.10,2.01,,,,,,,,,,,,,
"HC So Platelet,Automated",PX-3058504966,CDM,85049,CPT,0305,RC,,,,both,,,15.00,9.75,,,,,,,,,,,,,
CANNULATED DRILL 4.0MM,SUP-2841288,CDM,2720000010,LOCAL,0272,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
HC So Adalimumab Level,PX-3018014566,CDM,80145,CPT,0301,RC,,,,both,,,197.00,128.05,,,,,,,,,,,,,
INFLUENZA VAC TISS-CULT SUBUNT 0.5 ML IM SUSY,RX-119195,CDM,90661,HCPCS,0636,RC,70461-0655-04,NDC,,both,.5,ML,206.90,134.48,,,,,,,,,,,,,
STEM FEM FLNG LT PROX KNEE W/ LIG WSH OSS,SUP-2449905,CDM,C1776,CPT,0278,RC,,,,both,,,15613.65,10148.87,,,,,,,,,,,,,
GRAFT BNE SUB 5CC VI DIA48MM CA SULF PELLET RESRB PRELD,SUP-2399033,CDM,C1713,HCPCS,0278,RC,,,,both,,,1481.23,962.80,,,,,,,,,,,,,
HC So Inhibin-A,PX-3028633666,CDM,86336,CPT,0302,RC,,,,inpatient,,,182.00,118.30,,,,,,,,,,,,,
GRAFT 15CMX15CM SURGIMEND PRS,SUP-2243673,CDM,C9360,HCPCS,0278,RC,,,,both,,,14836.50,9643.72,,,,,,,,,,,,,
CEMENT BONE 40GM W/ GENTMYCN PCH HI VISC CO,SUP-2196557,CDM,C1713,HCPCS,0278,RC,,,,both,,,1602.34,1041.52,,,,,,,,,,,,,
AWL SURG UNIV SPNL REUSE ATLNTS,SUP-2279317,CDM,2720000010,LOCAL,0272,RC,,,,both,,,296.35,192.63,,,,,,,,,,,,,
PLATE TI VA-LCKNG CALCANEAL W/TABS LG 2.7MM 70MM LEFT-STER,SUP-2547008,CDM,C1713,HCPCS,0278,RC,,,,both,,,3873.16,2517.55,,,,,,,,,,,,,
PLATE SPNL L27.5MM ANT CERV BILAT TI VAR ANG LO PROF ZEPHIR,SUP-2291218,CDM,C1713,HCPCS,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
JOINT WRST 3 STD CRPL UHMWPE FRDM,SUP-2852881,CDM,C1776,CPT,0278,RC,,,,both,,,4387.46,2851.85,,,,,,,,,,,,,
CATHETER CV PRESSURE MONITORING SET 015 2.5 FRX5 CM,SUP-2760060,CDM,C1751,HCPCS,0278,RC,,,,both,,,129.93,84.45,,,,,,,,,,,,,
HC Orbits Min 4 Views,PX-3207020000,CDM,70200,CPT,0320,RC,,,,both,,,1219.00,792.35,,,,,,,,,,,,,
GRAFT HUM TISS ACHILLES TEND ACHILLES] US TISSUE AND CELL],SUP-2391732,CDM,C1713,HCPCS,0278,RC,,,,both,,,4628.36,3008.43,,,,,,,,,,,,,
SHEATH INTRO L 25 CM DIA22 FR DIL L 41 CM GUIDEWIRE 0.035 IN,SUP-2168793,CDM,C1894,HCPCS,0272,RC,,,,both,,,1127.26,732.72,,,,,,,,,,,,,
GRAFT HUM TISS L 2 X W 3 CM PLCNTA MEMBRN ALLGRFT CROSS,SUP-2909400,CDM,Q4109,HCPCS,0636,RC,,,,both,,,16328.00,10613.20,,,,,,,,,,,,,
HEAD HUM 39X14 MM SHLDR AEQUALIS DWD802,SUP-2715627,CDM,C1776,CPT,0278,RC,,,,both,,,14349.80,9327.37,,,,,,,,,,,,,
DIGOXIN IMMUNE FAB 40 MG IV SOLR,RX-31432,CDM,J1162,HCPCS,0636,RC,50633-0120-11,NDC,,both,1,UN,14673.30,9537.64,,,,,,,,,,,,,
CATHETER OCCL 12FR L100CM VES DIA10-50MM TAPR FLX TIP STR,SUP-2395996,CDM,C2628,HCPCS,0272,RC,,,,both,,,1502.18,976.42,,,,,,,,,,,,,
KIT INTRO L 10 CM DIA 5 FR NIT SHFT SS TIP STIFF DIL MIC,SUP-2615876,CDM,C1894,HCPCS,0272,RC,,,,both,,,103.49,67.27,,,,,,,,,,,,,
DRILL TWST L115MM OD19MM MORRISON ST,SUP-2436521,CDM,2720000010,LOCAL,0272,RC,,,,both,,,597.60,388.44,,,,,,,,,,,,,
HC So Inhibin-A,PX-3028633666,CDM,86336,CPT,0302,RC,,,,outpatient,,,182.00,118.30,,,,,,,,,,,,,
STEM RAD L26MM DIA7MM TAN STR FOR PRI AND REV JT REPL,SUP-2181496,CDM,C1776,CPT,0278,RC,,,,both,,,8920.74,5798.48,,,,,,,,,,,,,
PROBE SURGICAL MCCULLOCH 9 12INL 8MML TIP ANGLED BALL TIP,SUP-2676450,CDM,2720000010,LOCAL,0272,RC,,,,both,,,359.88,233.92,,,,,,,,,,,,,
REAMER SURG OD51MM S STL ACET SPHR CUTTINGEDGE,SUP-2361874,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1051.27,683.33,,,,,,,,,,,,,
PIN FIX DIA2.7MM BIOCRYL FEM TIB BNE TEND BNE CRSS RIGIDFIX,SUP-2249334,CDM,C1713,HCPCS,0278,RC,,,,both,,,2574.80,1673.62,,,,,,,,,,,,,
SLING ORTH FNGR 3 IN DYN REINF EYELET SUP-R-SOFT LF,SUP-2477659,CDM,L3933,HCPCS,0272,RC,,,,both,,,2.70,1.75,,,,,,,,,,,,,
CATHETER EP 14.51 7 FRX110 1525 MM INQUIRY,SUP-2468757,CDM,C1731,HCPCS,0278,RC,,,,both,,,4509.04,2930.88,,,,,,,,,,,,,
ALLOGRAFT BNE WHL ULNA FRZN LT,SUP-2717950,CDM,C1762,CPT,0278,RC,,,,both,,,16485.00,10715.25,,,,,,,,,,,,,
INSERT TIB ARTC POST STBL HI POST 10MM THCK 71-75MM MEDL LAT,SUP-2409156,CDM,C1776,CPT,0278,RC,,,,both,,,452.16,293.90,,,,,,,,,,,,,
CEFPODOXIME PROXETIL 100 MG PO TABS,RX-9468,CDM,6370000000,HCPCS,0637,RC,65862-0095-20,NDC,,both,1,UN,9.50,6.17,,,,,,,,,,,,,
HC I&D Deep Abscess Upper Leg,PX-4502730100,CDM,27301,CPT,0450,RC,,,,both,,,2779.00,1806.35,,,,,,,,,,,,,
CATHETER EP 7FR L95CM 2-10-2MM SPC SM CRV SPR COR SHFT W/,SUP-2141252,CDM,C1731,HCPCS,0278,RC,,,,both,,,3086.62,2006.30,,,,,,,,,,,,,
CONNECTOR SPNL SLT ROD BOLT SPNL SYS TI 6.35MMXSM CD HORZ,SUP-2293324,CDM,C1713,HCPCS,0278,RC,,,,both,,,2700.40,1755.26,,,,,,,,,,,,,
GRAFT BNE SUB M SZ 14 28MM 20ML B TRICALCIUM PHSPTE SYN,SUP-2194012,CDM,C1713,HCPCS,0278,RC,,,,both,,,2653.58,1724.83,,,,,,,,,,,,,
SCREW BNE L8MM DIA2.4MM CORT S STL ST T8 STARDRV RECESS,SUP-2183262,CDM,C1713,HCPCS,0278,RC,,,,both,,,150.97,98.13,,,,,,,,,,,,,
WASHER 1.3X20MM RND SFT TISS FIX SPIK POST HT LO PROF TI ST,SUP-2166924,CDM,C1713,HCPCS,0278,RC,,,,both,,,612.49,398.12,,,,,,,,,,,,,
COMPONENT PART KNEE CEM FEM TIB KNEE UNI,SUP-2379206,CDM,C1776,CPT,0278,RC,,,,both,,,12089.00,7857.85,,,,,,,,,,,,,
SYSTEM PAIN PMP 2.5 IN 270 CC QN-Q PAIN BUST SILVERSOAKER,SUP-2236826,CDM,C2626,HCPCS,0278,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
PLATE BONE L96MM 8 HOLE RIGHT DST PRRTCLR RDL VOLAR STNLSS S,SUP-2457982,CDM,C1713,HCPCS,0278,RC,,,,both,,,2587.36,1681.78,,,,,,,,,,,,,
HOOK RETRCT RHOTON 2 MM SEMI SHRP STYL 9 NS RUGGLES-REDMOND,SUP-2473847,CDM,2720000010,LOCAL,0272,RC,,,,both,,,219.42,142.62,,,,,,,,,,,,,
GRAFT HUM TISS W20-24XL60MM THK5-30MM ILIUM TRICORT STRP,SUP-2307167,CDM,C1713,HCPCS,0278,RC,,,,both,,,6653.66,4324.88,,,,,,,,,,,,,
GRAFT DERMACELL DERMAL MATRIX 20CM X 20MM THICK,SUP-2854468,CDM,Q4122,HCPCS,0636,RC,,,,both,,,34540.00,22451.00,,,,,,,,,,,,,
PLATE BNE THK0.5MM 5MM BAR 5 H 100DEG UNIV,SUP-2366244,CDM,C1713,HCPCS,0278,RC,,,,both,,,637.95,414.67,,,,,,,,,,,,,
PLEDGET CV DEBAKEY L 10 X W 10 CM THK 0.25 MM POLYESTER,SUP-2126027,CDM,C1768,CPT,0278,RC,,,,both,,,326.40,212.16,,,,,,,,,,,,,
SCREW SPNL COMPR 6X50 MM HA STRL ZYFUSE,SUP-2593511,CDM,C1713,HCPCS,0278,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
GUIDEWIRE VASC L 220 CM DIA 0.035 IN TAPR L 4.5 CM FLPY TIP,SUP-2167796,CDM,C1769,HCPCS,0272,RC,,,,both,,,39.28,25.53,,,,,,,,,,,,,
PROBE SURG FLAT 3.5X20 MM NSL INSUL,SUP-2853207,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1455.08,945.80,,,,,,,,,,,,,
MAGNESIUM SULFATE IN D5W 1-5 GM/100ML-% IV SOLN,RX-137341,CDM,J3475,HCPCS,0636,RC,44567-0410-24,NDC,,both,100,ML,54.10,35.16,,,,,,,,,,,,,
SAFEWIRE 2 = 1.10X559MM,SUP-2867356,CDM,C1769,HCPCS,0272,RC,,,,both,,,969.48,630.16,,,,,,,,,,,,,
NEEDLE ENDOSCP STR 18 CM SHRT CRV F/660530 HNDL,SUP-2773876,CDM,2720000010,LOCAL,0272,RC,,,,both,,,374.63,243.51,,,,,,,,,,,,,
BUR SURG L42MM LNG ABRAD FIT,SUP-2364284,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1042.79,677.81,,,,,,,,,,,,,
GRAFT TISS FEM CRSS SECT FRZ DRY ALLGRFT 28MM,SUP-2307160,CDM,C1713,HCPCS,0278,RC,,,,both,,,2731.61,1775.55,,,,,,,,,,,,,
NAIL IM L 90 CM DIA13 MM TI RT FEM AG KNEE FUSION STRL,SUP-2933174,CDM,C1713,HCPCS,0278,RC,,,,both,,,8711.15,5662.25,,,,,,,,,,,,,
AUGMENT TIB SZ 4 THK5MM RT MEDL LT LAT KNEE CO CHROM TOT,SUP-2363802,CDM,C1776,CPT,0278,RC,,,,both,,,3895.92,2532.35,,,,,,,,,,,,,
BIT DRL DIA4MM FOR FOOTPRINT ANCHR SL SYS,SUP-2341887,CDM,2720000010,LOCAL,0272,RC,,,,both,,,520.93,338.60,,,,,,,,,,,,,
SET INTRO MICROPUNCTURE ECHOTIP NDL L 2.5 CM DIA21 GA,SUP-2633260,CDM,C1894,HCPCS,0272,RC,,,,both,,,216.72,140.87,,,,,,,,,,,,,
CROWN DENT PED SZ 1 SEC PRI M LO R ANTR CUSPID PREFABRICATED,SUP-2238797,CDM,D6783,CPT,0278,RC,,,,both,,,19.97,12.98,,,,,,,,,,,,,
KIT ENDOPYELOTOMY STARTER SYSTEM TAMPONADE BLLN CATHETER URETERAL ACCESS 7 10 SHEATHS ACUCISE,SUP-2119498,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7470.37,4855.74,,,,,,,,,,,,,
PACKING NSL CHITOSAN ENT SINUS GEL POSTOP STRL DISP CHITOGEL,SUP-2902121,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1149.24,747.01,,,,,,,,,,,,,
SCREW BNE CANC STD 6.5X30 MM HIP ST PART THRD CANN NLCK TORX,SUP-2370032,CDM,C1713,HCPCS,0278,RC,,,,both,,,109.90,71.43,,,,,,,,,,,,,
COMPONENT PAT RND PRI STD CEM N POR UHMWPE WITHOUTXRAY WIRE,SUP-2199556,CDM,C1776,CPT,0278,RC,,,,both,,,4245.28,2759.43,,,,,,,,,,,,,
ANCHOR SUTURE L8.5MM DIAMETER 2.7MM PRETHREADED WITH SIZE 2,SUP-2824805,CDM,C1713,HCPCS,0278,RC,,,,both,,,487.70,317.00,,,,,,,,,,,,,
CATHETER PERITONEAL DLYS SET 035X30 CM PEDIATRIC 8.5 FRX8 CM,SUP-2760088,CDM,C1752,HCPCS,0278,RC,,,,both,,,435.30,282.94,,,,,,,,,,,,,
SHELL ACET THRD 37 MM ALTERNATE BEAR,SUP-2442607,CDM,C1776,CPT,0278,RC,,,,both,,,819.54,532.70,,,,,,,,,,,,,
PLATE BNE L 37 MM SCREW DIA1.6 MM TI LT CNDYL 2 COMPR LCK LP,SUP-2912894,CDM,C1713,HCPCS,0278,RC,,,,both,,,1321.94,859.26,,,,,,,,,,,,,
BURR BALL FLUTED 4.0MM ANSPACH S4BG1,SUP-2843314,CDM,2720000010,LOCAL,0272,RC,,,,both,,,413.16,268.55,,,,,,,,,,,,,
GUIDEWIRE VASC HIWIRE L 220 CM 0.035 IN TAPR L 22 CM ANGLED,SUP-2170345,CDM,C1769,HCPCS,0272,RC,,,,both,,,89.65,58.27,,,,,,,,,,,,,
PLATE 4.5MM TI LCP PROXIMAL TIBIA 14 HOLES 262MM LEFT,SUP-2549650,CDM,C1713,HCPCS,0278,RC,,,,both,,,3504.59,2277.98,,,,,,,,,,,,,
BLUE FLPL ARMSTRONG R 114MM ID 60,SUP-2695108,CDM,L8699,HCPCS,0278,RC,,,,both,,,38.56,25.06,,,,,,,,,,,,,
SCREW BNE CANN 7X50 MM,SUP-2420820,CDM,C1713,HCPCS,0278,RC,,,,both,,,2009.60,1306.24,,,,,,,,,,,,,
KYPHOPLASTY KIT BVL 13 GA OSTEO INTRO KYPHON V VPT13B,SUP-2632238,CDM,2720000010,LOCAL,0272,RC,,,,both,,,596.60,387.79,,,,,,,,,,,,,
CAGE CERV B TI ALLOY DISP DTRAX,SUP-2330582,CDM,C1889,HCPCS,0278,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
BLADE OSTEO FLAT TIP 11X50 MM PNEUMATIC VERSADRIVER,SUP-2877744,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1730.93,1125.10,,,,,,,,,,,,,
BASEPLATE TIB L67XW42MM UNIV DURAC KNEE CRUCFRM BEAD IMPL,SUP-2377159,CDM,C1776,CPT,0278,RC,,,,both,,,8911.32,5792.36,,,,,,,,,,,,,
CATHETER ETER ANGIO 5FR GUID EMB COIL MP2 CHAPERON,SUP-2305419,CDM,C1887,HCPCS,0272,RC,,,,both,,,1004.80,653.12,,,,,,,,,,,,,
CATHETER CV CHRONIC 14 FRX19 CM 15 MM,SUP-2308263,CDM,C1751,HCPCS,0278,RC,,,,both,,,1175.96,764.37,,,,,,,,,,,,,
GUIDEWIRE VASC COMET L 185 CM DIA 0.014 IN COCR PLAT TIP,SUP-2146961,CDM,C1769,HCPCS,0272,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
PLATE BNE MESHED 52X52X0.8 MM SM GRID PLLA-PGA STRL,SUP-2458090,CDM,C1713,HCPCS,0278,RC,,,,both,,,3136.08,2038.45,,,,,,,,,,,,,
SYSTEM IMPL SZ 4 MM SUTURE SZ 2-0 FLX PIN STRL DISP,SUP-2882327,CDM,C1713,HCPCS,0278,RC,,,,both,,,2653.30,1724.64,,,,,,,,,,,,,
GRAFT HUM TISS 50MG AMNIO MEM UMB CRD PARTICULATE MTRX FOR,SUP-2116294,CDM,Q4155,HCPCS,0636,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
HC Mech-Mv-Vc-Tv-Rr-Neg If,PX-4609479900,CDM,94799,CPT,0460,RC,,,,inpatient,,,491.00,319.15,,,,,,,,,,,,,
GRAFT VASC GORTX L 70 CM DIA 6 MM RNG L 50 CM EPTFE STR TW,SUP-2396158,CDM,C1768,CPT,0278,RC,,,,both,,,1840.04,1196.03,,,,,,,,,,,,,
IMMOBILIZER ORTH 2 AXIS SHT 17 IN 36 IN KNEERANGER II,SUP-2197133,CDM,L3702,HCPCS,0274,RC,,,,both,,,105.28,68.43,,,,,,,,,,,,,
PIN EXT FIX THRD L45MM DIA5MM SHANK L110MM DIA5MM S STL,SUP-2342932,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1093.44,710.74,,,,,,,,,,,,,
GRAFT BNE SUB 3CC CA PHSPTE HA PTTY INJ HYDROSET,SUP-2371661,CDM,C1713,HCPCS,0278,RC,,,,both,,,3331.85,2165.70,,,,,,,,,,,,,
CATHETER EXTR BAL DASH BILI INFL TO 8.5MM 12MM AND,SUP-2169555,CDM,2720000010,LOCAL,0272,RC,,,,both,,,383.08,249.00,,,,,,,,,,,,,
KIT INSRTN SMRT PICC 5 FR SGL LUMN STD TAPR 65 CM CATH STYL,SUP-2118466,CDM,C1751,HCPCS,0278,RC,,,,both,,,477.28,310.23,,,,,,,,,,,,,
CATHETER GUID JUMBO 6 FRX80 CM CATLYST CONCIERGE,SUP-2798609,CDM,C1887,HCPCS,0272,RC,,,,both,,,1211.66,787.58,,,,,,,,,,,,,
PRAZOSIN HCL 1 MG PO CAPS,RX-6468,CDM,6370000000,HCPCS,0637,RC,00378-1101-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
SCREW BONE L10MM OD3.5MM STD CORT ST LO PROF,SUP-2343754,CDM,C1713,HCPCS,0278,RC,,,,both,,,37.77,24.55,,,,,,,,,,,,,
CLAMP EXT FIX TRANSITION LG MED,SUP-2645925,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1546.95,1005.52,,,,,,,,,,,,,
SLING UROLOGICAL MALE ADVANCE XP,SUP-2138909,CDM,C1771,HCPCS,0278,RC,,,,both,,,27991.53,18194.49,,,,,,,,,,,,,
SPLINT WRST FA R INSTABILITY INJ W STAY COCK UP FIRM SUPP,SUP-2276618,CDM,L3809,HCPCS,0274,RC,,,,both,,,16.14,10.49,,,,,,,,,,,,,
MESH HERN RND 12X12 CMX1MM BIOMATERIAL TRIM DUALMESH LF DISP,SUP-2474291,CDM,C1781,HCPCS,0278,RC,,,,both,,,1183.78,769.46,,,,,,,,,,,,,
GRAFT SFT TISS FLOWABLE 0.3 CC 50 MG TISS MTRX INTERFYL,SUP-2651382,CDM,Q4171,HCPCS,0636,RC,,,,both,,,2983.00,1938.95,,,,,,,,,,,,,
BASKET STONE REM 3 4 90 SEGR DRETLER,SUP-2141706,CDM,2720000010,LOCAL,0272,RC,,,,both,,,778.72,506.17,,,,,,,,,,,,,
FUROSEMIDE 80 MG PO TABS,RX-3296,CDM,6370000000,HCPCS,0637,RC,43547-0403-10,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
DRAINAGE SET CATH 2.7X1.4 MM 20-35 CM 8 FR TBNG CLMP STRL,SUP-2666665,CDM,C1729,HCPCS,0272,RC,,,,both,,,490.00,318.50,,,,,,,,,,,,,
ANCHOR SUTURE BIOCOMP W/ 3 STRANDS W/ 3 STRANDS STRL,SUP-2907515,CDM,C1713,HCPCS,0278,RC,,,,both,,,1299.96,844.97,,,,,,,,,,,,,
SCREW BNE L14MM DIA35MM LOK ST T20 FOR SM FRAG PLATING SYS,SUP-2350129,CDM,C1713,HCPCS,0278,RC,,,,both,,,1120.85,728.55,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 50 CM DIA 6MM STR TW HELIX SLDE GDS,SUP-2681203,CDM,C1768,CPT,0278,RC,,,,both,,,2180.23,1417.15,,,,,,,,,,,,,
CATHETER INFUSION UNI-FUSE L 90 CM DIA 4 FR SLT PAT L 10 CM,SUP-2117045,CDM,C1751,HCPCS,0278,RC,,,,both,,,356.70,231.85,,,,,,,,,,,,,
GUIDEWIRE URO L150CM DIA0.035IN PTFE NIT HYDRPHLC STR TIP,SUP-2139367,CDM,C1769,HCPCS,0272,RC,,,,both,,,140.45,91.29,,,,,,,,,,,,,
CATHETER HD STR AD 15.5 FRX24 CM LT DL VASCPAK KT DURAMAX LF,SUP-2493675,CDM,C1750,HCPCS,0278,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
WASHER ORTH 7 MM F/4 MM SCREW NS,SUP-2458557,CDM,C1713,HCPCS,0278,RC,,,,both,,,115.74,75.23,,,,,,,,,,,,,
TUBE VENT SHEP GRMMT 1.14 MM 1.6 MM 2.3 MM W/ WIRE 525121W,SUP-2471319,CDM,L8699,HCPCS,0278,RC,,,,both,,,26.53,17.24,,,,,,,,,,,,,
PLATE STRNL CLOSURE THK 1.5 MM 6 H TI STR LP NS STERNALOCK,SUP-2894506,CDM,C1713,HCPCS,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
PUMP PERFSN CENTRIFUGE CONN 1/4 IN FLO RATE 1.5 L/MIN,SUP-2894490,CDM,2720000010,LOCAL,0272,RC,,,,both,,,31400.00,20410.00,,,,,,,,,,,,,
PLATE BNE L112MM 6 H R DST LAT FIBULAR S STL LOK COMPR,SUP-2184159,CDM,C1713,HCPCS,0278,RC,,,,both,,,1698.99,1104.34,,,,,,,,,,,,,
PLATE EXT FIX L180MM LNG ALUM FT RNG FOR ILIZ TAY SPAT FRME,SUP-2342981,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8969.88,5830.42,,,,,,,,,,,,,
GRAFT VASC DISTAFLO L 80 CM DIA 7 MM EPTFE CARBON PERIPH,SUP-2128082,CDM,C1768,CPT,0278,RC,,,,both,,,16413.31,10668.65,,,,,,,,,,,,,
AUGMENT FEM SZ E THK5MM STD UNIV DST KNEE TRABECULAR MTL,SUP-2200238,CDM,C1776,CPT,0278,RC,,,,both,,,4961.20,3224.78,,,,,,,,,,,,,
ROD SPNL 11X300 MM,SUP-2205341,CDM,C1713,HCPCS,0278,RC,,,,both,,,663.33,431.16,,,,,,,,,,,,,
PLATE BNE THK0.5MM 8MM BAR 6 H 100DEG UNIV,SUP-2366246,CDM,C1713,HCPCS,0278,RC,,,,both,,,656.26,426.57,,,,,,,,,,,,,
NEEDLE BRACHYTHERAPY L12CM OD18GA PRELD STRL,SUP-2247286,CDM,C2638,HCPCS,0278,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
BUPROPION HCL 100 MG PO TABS,RX-9321,CDM,6370000000,HCPCS,0637,RC,00904-6636-61,NDC,,both,1,UN,7.40,4.81,,,,,,,,,,,,,
ENDOPROSTHESIS VASC VIABAHN L 7.5CM 9MM 120CM HEPARIN,SUP-2719620,CDM,C1768,HCPCS,0278,RC,,,,both,,,10368.28,6739.38,,,,,,,,,,,,,
LP PLATE L SHAPE RGHT RGLR 110 BLMQST 0.6MM T 6L 4V,SUP-2500165,CDM,C1713,HCPCS,0278,RC,,,,both,,,528.65,343.62,,,,,,,,,,,,,
GRAFT BNE PTTY 1 CC DBM,SUP-2391506,CDM,C9359,HCPCS,0278,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
FIBER SURG LASER DIA272UM OPT DISPOSABLE COMPATIBLE,SUP-2313072,CDM,C1713,HCPCS,0278,RC,,,,both,,,1386.91,901.49,,,,,,,,,,,,,
REAMER SURG COMB ASSEMB OMEGA,SUP-2365041,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3952.00,2568.80,,,,,,,,,,,,,
HOOK RETRCT 25 MM 7.75 IN NERVE ANGLED BALL TIP TI NS REUSE,SUP-2457483,CDM,2720000010,LOCAL,0272,RC,,,,both,,,266.59,173.28,,,,,,,,,,,,,
SUPPORT ORTHOT LOWER EXTREMITY KNEE CTRL FULL KNEECAP,SUP-2435698,CDM,L2795,HCPCS,0274,RC,,,,both,,,232.17,150.91,,,,,,,,,,,,,
STENT GRFT VASC AFX2 VELA L 80 MM UNCOVERED L 20 MM DIA 34mm,SUP-2217612,CDM,C1874,HCPCS,0278,RC,,,,both,,,13690.40,8898.76,,,,,,,,,,,,,
CATHETER GUID SHEATHLESS EAUCATH L 100 CM 7.5 FR JL3.5 ST,SUP-2722071,CDM,C1769,HCPCS,0272,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
CISPLATIN 50 MG/50ML IV SOLN,RX-88376,CDM,J9060,HCPCS,0636,RC,00703-5747-11,NDC,,both,50,ML,58.10,37.76,,,,,,,,,,,,,
GUIDEWIRE ENDO L150CM DIA0.025IN TIP L3CM NIT COR HYDRPHLC,SUP-2171363,CDM,C1769,HCPCS,0272,RC,,,,both,,,122.08,79.35,,,,,,,,,,,,,
PLATE SET DIA-META DSTL RAD VOLAR LCP,SUP-2177064,CDM,C1713,HCPCS,0278,RC,,,,both,,,41824.17,27185.71,,,,,,,,,,,,,
BIT DRILL 5MM CANNULATED DISPOSABLE FOR DYNANAIL MINI AND HYBRID,SUP-2878234,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2951.60,1918.54,,,,,,,,,,,,,
PLATE SPINE FIX 56MM 4 LEV AMBASSADOR,SUP-2163989,CDM,C1713,HCPCS,0278,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
BLADE SAW SAG 90X18 MMX1.37 IN,SUP-2364333,CDM,2720000010,LOCAL,0272,RC,,,,both,,,193.46,125.75,,,,,,,,,,,,,
GRAFT BONE SUB W14XH7XL20MM DBM STRP OSTEOSPONGE,SUP-2125422,CDM,C1713,HCPCS,0278,RC,,,,both,,,769.30,500.04,,,,,,,,,,,,,
HANDPIECE ABLATION L 6.1 CM BPLR LT CRV STRL,SUP-2124458,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7322.48,4759.61,,,,,,,,,,,,,
INSERT GLEN PRSS FIT BASEPLT SHLDR SYS AEQUALIS,SUP-2388655,CDM,C1713,HCPCS,0278,RC,,,,both,,,3736.60,2428.79,,,,,,,,,,,,,
STENT URET RESONANCE L 20 CM CATH L 71.5 CM DIA 6 FR SHTH L,SUP-2171368,CDM,C2625,HCPCS,0278,RC,,,,both,,,3830.17,2489.61,,,,,,,,,,,,,
WIRE FIX SUBLAMINAR 1.2 MM ESS MALIBU,SUP-2707689,CDM,C1713,HCPCS,0278,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
SCREW BONE L70MM OD4.5MM STD CORT ST LCK,SUP-2343757,CDM,C1713,HCPCS,0278,RC,,,,both,,,302.95,196.92,,,,,,,,,,,,,
CANNULA INFLTR 12GA L23CM HUNSTAD,SUP-2300769,CDM,C1713,HCPCS,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
DRIVER SURG HEX 3.5 MM N CANN N STRL,SUP-2232024,CDM,C1713,HCPCS,0278,RC,,,,both,,,2527.70,1643.00,,,,,,,,,,,,,
COMPONENT TIB CR SM UNIV 11 MM DSTL STEM NP MONOBLOCK CEM,SUP-2376396,CDM,C1776,CPT,0278,RC,,,,both,,,3935.68,2558.19,,,,,,,,,,,,,
SCREW BNE CANN LNG THRD 6.5X45 MM 32 MM HDLSS COMPR TI PUR,SUP-2564298,CDM,C1713,HCPCS,0278,RC,,,,both,,,2209.18,1435.97,,,,,,,,,,,,,
CANNULA OPHTH COURT X BINKHORST,SUP-2113485,CDM,C1713,HCPCS,0278,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
LOCK DISTAL FIBULA PLT SS LT 14H STRL,SUP-2814836,CDM,C1713,HCPCS,0278,RC,,,,both,,,4396.00,2857.40,,,,,,,,,,,,,
SYSTEM GRFT DEL MOD MAS,SUP-2904122,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2983.00,1938.95,,,,,,,,,,,,,
PLATE BONE LOK CMPRSSN HLX15 TIMAX CRTCL WIDE PRE CNTRD ANTM,SUP-2588752,CDM,C1713,HCPCS,0278,RC,,,,both,,,4030.28,2619.68,,,,,,,,,,,,,
CATHETER URET OPN END 038 5 FRX10 CM MOD FLEXI-TIP,SUP-2835746,CDM,C1758,HCPCS,0278,RC,,,,both,,,38.59,25.08,,,,,,,,,,,,,
TAP SURG DIA65MM CANN QUIK CONN,SUP-2409939,CDM,C1713,HCPCS,0278,RC,,,,both,,,1366.15,888.00,,,,,,,,,,,,,
CATHETER ANGIO 5FR L100CM 0.038IN S STL HYDRPHLC ANG TAPR,SUP-2139769,CDM,C1725,HCPCS,0272,RC,,,,both,,,204.10,132.66,,,,,,,,,,,,,
HC NM Rx IV Admin,PX-3427910100,CDM,79101,CPT,0342,RC,,,,inpatient,,,1865.00,1212.25,,,,,,,,,,,,,
RESORB X TAP FRICTION STOP 100MM LGTH 21MM 15MM,SUP-2679316,CDM,2720000010,LOCAL,0272,RC,,,,both,,,568.25,369.36,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY INQUIRY 45 DEG L 110 CM DIA 7 FR,SUP-2474742,CDM,C1730,HCPCS,0272,RC,,,,both,,,1697.83,1103.59,,,,,,,,,,,,,
SYSTEM DRAINAGE MONITORR SP0017,SUP-2666838,CDM,C1729,HCPCS,0272,RC,,,,both,,,587.43,381.83,,,,,,,,,,,,,
TUBE FEED 18FR L30CM TRANSGASTRIC JEJU UNIV CONN,SUP-2124611,CDM,2720000010,LOCAL,0272,RC,,,,both,,,737.62,479.45,,,,,,,,,,,,,
GUIDEWIRE VASC THRUWAY L 130 CM DIA 0.014 IN SS SIL STR SHRT,SUP-2148327,CDM,C1769,HCPCS,0272,RC,,,,both,,,322.95,209.92,,,,,,,,,,,,,
BIT DRL L DIA5MM TI CANN QUIK CPL STD RECON SCR REUSE,SUP-2178896,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1302.38,846.55,,,,,,,,,,,,,
LEAD PACE BPLR 7 FRX92 CM LT VENTRIC OPTIM IS-1 QUICKFLEX,SUP-2356060,CDM,C1900,HCPCS,0275,RC,,,,both,,,4631.50,3010.47,,,,,,,,,,,,,
KIT PLT RATIO DISPNS KT 2IN CANN TIP SPRY TIP DISP MAGELLAN,SUP-2120693,CDM,2720000010,LOCAL,0272,RC,,,,both,,,690.80,449.02,,,,,,,,,,,,,
DRAINAGE SET 20 CMX35 CM NEEDLE-FREE EDS EXT SET STRL LF,SUP-2666659,CDM,C1729,HCPCS,0272,RC,,,,both,,,806.04,523.93,,,,,,,,,,,,,
ROD EXT FIX 9 MM SUBFIX,SUP-2366066,CDM,C1776,CPT,0278,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
COMPONENT FEM G A/P60MM M/L26MM ZMLY R LAT L MED KNEE PRI,SUP-2342167,CDM,C1776,CPT,0278,RC,,,,both,,,7333.47,4766.76,,,,,,,,,,,,,
HEAD HUM H19MM OD56MM SHLDR OFFSET BIGLIANI FLATOW,SUP-2199051,CDM,C1776,CPT,0278,RC,,,,both,,,4408.56,2865.56,,,,,,,,,,,,,
PLATE BNE BROAD 5.5X252 MM 14 HOLE SS LCP,SUP-2569375,CDM,C1713,HCPCS,0278,RC,,,,both,,,911.86,592.71,,,,,,,,,,,,,
NEUROPATH GUID CATH TIP SHP MOD CEREB WRK LEN 90CM INNR,SUP-2257606,CDM,C1887,HCPCS,0272,RC,,,,both,,,916.88,595.97,,,,,,,,,,,,,
FILTER GRFT 100ML GRAD FOR RMR IRRIG ASPIR,SUP-2188149,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2237.72,1454.52,,,,,,,,,,,,,
GUIDEWIRE VASC NIT HYDRPHLC STR HYBRID TORQ TRNSMIT,SUP-2305456,CDM,C1769,HCPCS,0272,RC,,,,both,,,1271.70,826.60,,,,,,,,,,,,,
KIT REVISION GRAFT BONE DOWEL 11 MM,SUP-2836343,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1384.74,900.08,,,,,,,,,,,,,
TUBE CONN OUTER END TELLURIDE FOR MIS SPNL FIX SYS,SUP-2211189,CDM,2780000010,LOCAL,0278,RC,,,,both,,,2415.29,1569.94,,,,,,,,,,,,,
PLATE BNE 12 H ST BILAT S STL NAR CRV LOK COMPR FOR 45MM SCR,SUP-2178058,CDM,C1713,HCPCS,0278,RC,,,,both,,,2674.31,1738.30,,,,,,,,,,,,,
HC Rt Bronchoscopy Theraputic Aspiration Subsequent,PX-3613164600,CDM,31646,CPT,0361,RC,,,,both,,,1323.00,859.95,,,,,,,,,,,,,
CATHETER EP L110CM OD8FR L10MM 2.5MM SPC QPLR STR TIP BLZR,SUP-2141270,CDM,C1733,HCPCS,0272,RC,,,,both,,,4794.78,3116.61,,,,,,,,,,,,,
CAP END 5MM EXTN SLD TI FOR HUM NAIL,SUP-2192530,CDM,C1713,HCPCS,0278,RC,,,,both,,,716.71,465.86,,,,,,,,,,,,,
DEFIBRILLATOR IMPL CLARIA MRI W 51 X H 74 MM D 13 MM,SUP-2282412,CDM,C1882,HCPCS,0275,RC,,,,both,,,52076.90,33849.98,,,,,,,,,,,,,
GRAFT HUM TISS W0.5XL3CM NOM THK1.4MM HUM DERM REGEN TISS,SUP-2399058,CDM,Q4107,HCPCS,0636,RC,,,,both,,,3152.56,2049.16,,,,,,,,,,,,,
PIN EXT FIX L180MM DIA5MM REDUC ADD ON FIT,SUP-2362536,CDM,C1713,HCPCS,0278,RC,,,,both,,,738.53,480.04,,,,,,,,,,,,,
CLAMP EXT FIX L TI ALLY COMB CLP ON SELF HLD,SUP-2188494,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1730.45,1124.79,,,,,,,,,,,,,
PLATE BONE L93MM 5 HOLE STERILE PROXIMAL HUMERAL NCB,SUP-2463527,CDM,C1713,HCPCS,0278,RC,,,,both,,,3932.79,2556.31,,,,,,,,,,,,,
SODIUM CHLORIDE 0.45 % IV BOLUS,RX-40840053,CDM,J3490,HCPCS,0250,RC,00264-7802-00,NDC,,both,250,ML,8.50,5.52,,,,,,,,,,,,,
PLATE BNE W24XL51MM 12 H L DST RAD TI LOK COMPR LO PROF NAR,SUP-2411822,CDM,C1713,HCPCS,0278,RC,,,,both,,,3488.54,2267.55,,,,,,,,,,,,,
HC Facial Bones Less Than 3 Views,PX-3207014000,CDM,70140,CPT,0320,RC,,,,inpatient,,,446.00,289.90,,,,,,,,,,,,,
PIN EXT FIX THRD 2.7X9 MM 80 MM LEVEL 1 TI,SUP-2423210,CDM,C1713,HCPCS,0278,RC,,,,both,,,662.45,430.59,,,,,,,,,,,,,
DEXTROSE IN LACTATED RINGERS 5 % IV SOLN,RX-9788,CDM,J7121,HCPCS,0258,RC,00338-0125-03,NDC,,both,500,ML,51.00,33.15,,,,,,,,,,,,,
LIDOCAINE HCL 1% INJ (MIXTURES ONLY),RX-430017,CDM,J2003,HCPCS,0636,RC,63323-0492-37,NDC,,both,5,ML,54.10,35.16,,,,,,,,,,,,,
LIDOCAINE HCL 1% INJ (MIXTURES ONLY),RX-430017,CDM,J2003,HCPCS,0636,RC,63323-0201-02,NDC,,both,5,ML,54.10,35.16,,,,,,,,,,,,,
IMPL TOE JT 0 DEG SM CANN STR STRL PHALINX,SUP-2883987,CDM,C1776,CPT,0278,RC,,,,both,,,5099.36,3314.58,,,,,,,,,,,,,
PLATE SYNDESMOTIC 2 H 1/3 TUBLR STRL GORILLA,SUP-2898997,CDM,C1713,HCPCS,0278,RC,,,,both,,,2504.15,1627.70,,,,,,,,,,,,,
SEALANT HEMSTAT 2ML HUM FBRNGN THROM PREFIL SYR EVICEL 10,SUP-2256933,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6150.44,3997.79,,,,,,,,,,,,,
HEAD RADIAL H 0.712 IN DIA 0.945 IN SZ 24L COCR ALLOY ELBW,SUP-2932780,CDM,C1776,CPT,0278,RC,,,,both,,,10699.36,6954.58,,,,,,,,,,,,,
RING SALVATION 200MM,SUP-2487987,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4188.76,2722.69,,,,,,,,,,,,,
SHEATH INTRO FLX RAABE L 95 CM OD 9 FR GUIDEWIRE 0.038 IN,SUP-2170372,CDM,C1894,HCPCS,0272,RC,,,,both,,,122.59,79.68,,,,,,,,,,,,,
MICRO PLATE H SHAPE REGULAR CP TITANIUM,SUP-2676890,CDM,C1713,HCPCS,0278,RC,,,,both,,,994.09,646.16,,,,,,,,,,,,,
GRAFT HUM TISS 2ML 160MG AMNIO MEM PARTICULATE INJ AMNIOFIX,SUP-2305721,CDM,V2790,HCPCS,0278,RC,,,,both,,,6265.87,4072.82,,,,,,,,,,,,,
GRAFT HUM TISS LT MEDL FEM KNEE OSTEOCHNDRL FRSH ASEP HEMI,SUP-2113920,CDM,C1713,HCPCS,0278,RC,,,,both,,,35953.00,23369.45,,,,,,,,,,,,,
IMMUNE GLOBULIN (FLEBOGAMMA) 10%,RX-4081761,CDM,J1459,HCPCS,0636,RC,44206-0437-10,NDC,,both,100,ML,5659.90,3678.93,,,,,,,,,,,,,
PATCH CV HEMGRD L 75 X W 14 MM THK 0.65 MM POLYESTER BOV,SUP-2535421,CDM,C1768,CPT,0278,RC,,,,both,,,381.04,247.68,,,,,,,,,,,,,
SCREW BNE 1.5X6 MM 3.5 MM HEX DRILL-FREE ENDOBROW 10281591,SUP-2466052,CDM,C1713,HCPCS,0278,RC,,,,both,,,318.74,207.18,,,,,,,,,,,,,
GRAFT VASC SYNTH KNT DBL VELR 20MMX30CM,SUP-2496622,CDM,C1768,CPT,0278,RC,,,,both,,,1654.15,1075.20,,,,,,,,,,,,,
NEEDLE ASPIR 11 GAX11 CM STRL MAR CELLUTION,SUP-2743330,CDM,2720000010,LOCAL,0272,RC,,,,both,,,753.60,489.84,,,,,,,,,,,,,
HC Platelets Pheresis Ea Unit,PX-3900903400,CDM,P9034,CPT,0390,RC,,,,both,,,2399.00,1559.35,,,,,,,,,,,,,
GUIDEWIRE ORTH L12IN OD2.4MM LNG KNEE DRL TIP NO EYELET,SUP-2341540,CDM,C1769,HCPCS,0272,RC,,,,both,,,200.96,130.62,,,,,,,,,,,,,
SODIUM CHLORIDE 0.45 % IV BOLUS,RX-40840053,CDM,J3490,HCPCS,0258,RC,00264-7802-00,NDC,,both,250,ML,8.50,5.52,,,,,,,,,,,,,
PLATE BONE 6X24X6 H BILAT TI DBL ANG RIG NONCOMPRESSION,SUP-2191424,CDM,C1713,HCPCS,0278,RC,,,,both,,,14054.64,9135.52,,,,,,,,,,,,,
PIN BNE FIX L 1 1/4 IN DIA 0.062 IN SMILLIE,SUP-2933912,CDM,C1713,HCPCS,0278,RC,,,,both,,,121.55,79.01,,,,,,,,,,,,,
HC Repair of Wound or Lesion,PX-4501315200,CDM,13152,CPT,0450,RC,,,,both,,,1842.00,1197.30,,,,,,,,,,,,,
NEEDLE BONE CEMENT DELIVERY 10 GAX10 CM STERILE,SUP-2838509,CDM,2720000010,LOCAL,0272,RC,,,,both,,,378.06,245.74,,,,,,,,,,,,,
CEMENT DENT CAPSULE RESIN REINF SELF CURE YEL GC FUJI +,SUP-2238653,CDM,2720000010,LOCAL,0272,RC,,,,both,,,501.11,325.72,,,,,,,,,,,,,
SUPPORT ORTHOT LUMBAR SACR CUST SAG CTRL STRP STAY PENDULOUS,SUP-2435558,CDM,L0649,HCPCS,0274,RC,,,,both,,,811.85,527.70,,,,,,,,,,,,,
SHEATH INTRO FAST-CATH 48 DEG L 110 CM DIA 7 FR GUIDEWIRE,SUP-2355529,CDM,C1894,HCPCS,0272,RC,,,,both,,,169.56,110.21,,,,,,,,,,,,,
SET SHTH DESTINO TWST L 65 CM DIA 8.5 FR CRV BEND 17 MM DIL,SUP-2616236,CDM,C1766,CPT,0272,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
PERI-LOC 4.5MM T25 TI LCK SCREW 46MM S-T,SUP-2819240,CDM,C1713,HCPCS,0278,RC,,,,both,,,1209.18,785.97,,,,,,,,,,,,,
KIT EXT FIX MULTAXL CORRECTION SYS HEXAPOD FULL AUTO NS DISP,SUP-2905656,CDM,C1713,HCPCS,0278,RC,,,,both,,,23635.22,15362.89,,,,,,,,,,,,,
OXYGENATOR PERFSN 215 ML SOFTLINE COAT AD DIFFUS MEMBRN,SUP-2908624,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3919.57,2547.72,,,,,,,,,,,,,
CATHETER ANGIOPLSTY ARMDA 35 L 80 CM BALLOON L 20 MM DIA 9,SUP-2106109,CDM,C1725,HCPCS,0272,RC,,,,both,,,348.54,226.55,,,,,,,,,,,,,
TAP BONE SPNL CERV PEDCL SCR W/ SL 3.0MM DIA,SUP-2108504,CDM,C1713,HCPCS,0278,RC,,,,both,,,3190.24,2073.66,,,,,,,,,,,,,
SCREW BNE NLCK 4.5X34 MM DBL STRT THRD SS JPS,SUP-2645473,CDM,C1713,HCPCS,0278,RC,,,,both,,,1126.63,732.31,,,,,,,,,,,,,
PIN EXT FIX FT 7X135 MM BEAM SALVATION,SUP-2850841,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4892.12,3179.88,,,,,,,,,,,,,
PLATE BNE L73MM 6 H BILAT S STL COMPR FOR 3.5MM SCR,SUP-2411338,CDM,C1713,HCPCS,0278,RC,,,,both,,,382.95,248.92,,,,,,,,,,,,,
KIT PANCREAS STNT 5FR L7CM PLAS STR NO LD BARB TRAILING,SUP-2141477,CDM,C2625,HCPCS,0278,RC,,,,both,,,547.05,355.58,,,,,,,,,,,,,
GRAFT BNE STRP 10X10X3 MM DBM ALLOSYNC,SUP-2845375,CDM,C1713,HCPCS,0278,RC,,,,both,,,1497.78,973.56,,,,,,,,,,,,,
CATHETER THORACENTESIS 2 EYELET 8 FR PVC TAPR TIP DRAINAGE,SUP-2227441,CDM,C1729,HCPCS,0272,RC,,,,both,,,30.21,19.64,,,,,,,,,,,,,
LORATADINE-PSEUDOEPHEDRINE ER 5-120 MG PO TB12,RX-27520,CDM,6370000000,HCPCS,0637,RC,41100-0802-08,NDC,,both,1,UN,5.50,3.57,,,,,,,,,,,,,
MEXILETINE HCL 150 MG PO CAPS,RX-10595,CDM,6370000000,HCPCS,0637,RC,00093-8739-01,NDC,,both,1,UN,5.90,3.83,,,,,,,,,,,,,
PLATE BNE L57MM THK3.4MM 4 H BILAT PUBIC S STL 2 DCP H LO,SUP-2184021,CDM,C1713,HCPCS,0278,RC,,,,both,,,2484.87,1615.17,,,,,,,,,,,,,
SCREW BNE L20MM DIA27MM NONLOCKING,SUP-2315951,CDM,C1713,HCPCS,0278,RC,,,,both,,,483.72,314.42,,,,,,,,,,,,,
PLATE BONE W17.5XL160MM THK5.2MM 9 H BILAT S STL BROAD LIMIT,SUP-2185291,CDM,C1713,HCPCS,0278,RC,,,,both,,,1296.41,842.67,,,,,,,,,,,,,
PLATE BNE L107MM 7 H L DST LAT FIBULAR VAR ANG LOK FOR,SUP-2349829,CDM,C1713,HCPCS,0278,RC,,,,both,,,6167.75,4009.04,,,,,,,,,,,,,
SYSTEM TRAC L ADJ OPN BK HALO RNG COMPLT C GRAPHITE TI SKULL,SUP-2328131,CDM,L0810,HCPCS,0274,RC,,,,both,,,7837.44,5094.34,,,,,,,,,,,,,
BIT DRL L195MM DIA4MM QUIK CPL 3 FLUT W/O STP REUSE FOR TIB,SUP-2187605,CDM,2720000010,LOCAL,0272,RC,,,,both,,,464.59,301.98,,,,,,,,,,,,,
SCREW BNE CANC 6.5X20 MM FT TI STRL,SUP-2569922,CDM,C1713,HCPCS,0278,RC,,,,both,,,50.08,32.55,,,,,,,,,,,,,
BUR SURG OD7.9MM 9.1MMXLONG CUT DR FLUT,SUP-2363409,CDM,2720000010,LOCAL,0272,RC,,,,both,,,393.60,255.84,,,,,,,,,,,,,
SPLITTER T BLNT NOSE CEM FOR GRY SYS STRL,SUP-2375022,CDM,C1713,HCPCS,0278,RC,,,,both,,,1297.13,843.13,,,,,,,,,,,,,
SYSTEM TRAC L ADJ OPN BK HALO RNG COMPLT C GRAPHITE TI SKULL,SUP-2328131,CDM,L0810,HCPCS,0272,RC,,,,both,,,7837.44,5094.34,,,,,,,,,,,,,
DEFIBRILLATOR IMPL RIVACOR 7 VR-T PROMRI W 60 X H 61.5 MM D,SUP-2739236,CDM,C1898,HCPCS,0275,RC,,,,both,,,55590.56,36133.86,,,,,,,,,,,,,
PLATE BNE W5XL50MM THK1MM 4X9 H BILAT S STL T SHP RIG NEUT,SUP-2186155,CDM,C1713,HCPCS,0278,RC,,,,both,,,1300.65,845.42,,,,,,,,,,,,,
PLATE BNE L68MM 8 H BILAT S STL LOK COMPR LO PROF FOR 2.4MM,SUP-2186347,CDM,C1713,HCPCS,0278,RC,,,,both,,,1050.77,683.00,,,,,,,,,,,,,
GRAFT HUM TISS 8 MM CERV RNG CORTICAL STRL LF DISP,SUP-2632288,CDM,C1713,HCPCS,0278,RC,,,,both,,,3903.74,2537.43,,,,,,,,,,,,,
GRAFT BONE CORT STRUT ALLGRFT FRZ DRY,SUP-2165592,CDM,C1713,HCPCS,0278,RC,,,,both,,,1482.08,963.35,,,,,,,,,,,,,
PLATE CRAN 100X40X20 MM PT SPEC IMPL PEEK,SUP-2860177,CDM,C1713,HCPCS,0278,RC,,,,both,,,24995.66,16247.18,,,,,,,,,,,,,
PLATE BNE L95MM 2 H TIB TI LOK FOR 4MM SCR AXSOS 3,SUP-2375505,CDM,C1776,CPT,0278,RC,,,,both,,,4082.00,2653.30,,,,,,,,,,,,,
PLATE BNE W12XL160MM THK3.7MM LNG 6 H ST PROX HUM S STL LOK,SUP-2186018,CDM,C1713,HCPCS,0278,RC,,,,both,,,4692.98,3050.44,,,,,,,,,,,,,
SET INTRO PEELWY L 15.5 CM DIA11 FR DIL L 20 CM GUIDEWIRE,SUP-2168018,CDM,C1892,HCPCS,0272,RC,,,,both,,,153.86,100.01,,,,,,,,,,,,,
COMPONENT FEM SZ 2.5 AP59MM ML63MM R KNEE CO CHROM CRUCE,SUP-2253501,CDM,C1776,CPT,0278,RC,,,,both,,,13750.69,8937.95,,,,,,,,,,,,,
COMPONENT FNGR JT SZ 30 PROX MP PYROCARBON SIL SPCR,SUP-2244238,CDM,C1776,CPT,0278,RC,,,,both,,,7319.34,4757.57,,,,,,,,,,,,,
STAPLE SPNL OVL VERT HOLEX1 W/ ROD TI XIA II,SUP-2379332,CDM,C1713,HCPCS,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
CATHETER EP VAR LOOP 5 MM SPC 7 FRX105 CM,SUP-2142370,CDM,C1731,HCPCS,0278,RC,,,,both,,,5036.56,3273.76,,,,,,,,,,,,,
INTRODUCER SHTH L62CM DIA55FR HOCK STK TELSCP WORLEY ADV LVI,SUP-2303513,CDM,C1892,HCPCS,0272,RC,,,,both,,,1205.54,783.60,,,,,,,,,,,,,
HC Group Caregiver Training Strategies & Technique,PX-4409755200,CDM,97552,CPT,0440,RC,,,,both,,,56.00,36.40,,,,,,,,,,,,,
CUBE EXT FIX 3 HOLE RANCHO,SUP-2749948,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1083.30,704.14,,,,,,,,,,,,,
CATHETER ANGIOPLSTY AVTR L 135 CM BALLON L 15 MM DIA 4 MM,SUP-2156426,CDM,C1725,HCPCS,0272,RC,,,,both,,,684.52,444.94,,,,,,,,,,,,,
EXTENSION STEM L65MM OD10MM FEM HIP REV CEM ADV CCK,SUP-2304746,CDM,C1776,CPT,0278,RC,,,,both,,,2599.92,1689.95,,,,,,,,,,,,,
LOOP SURG BILLEAU FIG 1 16.5 CM EAR SS,SUP-2501190,CDM,2720000010,LOCAL,0272,RC,,,,both,,,171.66,111.58,,,,,,,,,,,,,
PIN FIX DIAMOND PT 2 END 5/32X9 IN 4 PT STYL SMOOTH PLN STRL,SUP-2150494,CDM,C1713,HCPCS,0278,RC,,,,both,,,19.03,12.37,,,,,,,,,,,,,
CATHETER HD STR AD 12.5 FRX20 CM 3L SHT TERM MAHRK ELITE,SUP-2283973,CDM,C1752,HCPCS,0278,RC,,,,both,,,462.55,300.66,,,,,,,,,,,,,
KIT PELV FLR REP POST PINN,SUP-2141764,CDM,C1771,HCPCS,0278,RC,,,,both,,,5281.48,3432.96,,,,,,,,,,,,,
ALLOGRAFT BNE PLATE LG FRZN IRRADIATED FEM,SUP-2867178,CDM,C1762,CPT,0278,RC,,,,both,,,2443.08,1588.00,,,,,,,,,,,,,
PLATE BONE W5.4XL26MM THK1.5MM 4 H FOREFOOT TI STR FOR,SUP-2225449,CDM,C1713,HCPCS,0278,RC,,,,both,,,2832.12,1840.88,,,,,,,,,,,,,
INSERT HUM H10MM OD36MM STD ARW,SUP-2224535,CDM,C1776,CPT,0278,RC,,,,both,,,5966.00,3877.90,,,,,,,,,,,,,
PLATE BNE TBLR 2.7X41 MM 5 HOLE 1/4 TI,SUP-2536106,CDM,C1713,HCPCS,0278,RC,,,,both,,,371.46,241.45,,,,,,,,,,,,,
GUIDEWIRE ENDO L210CM MRK SPR TIP SAFEGUIDE,SUP-2277388,CDM,C1769,HCPCS,0272,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
AWL SURG SPNL FIX ANG REUSE ATLNTS,SUP-2279319,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1553.61,1009.85,,,,,,,,,,,,,
SHEATH INTRO FAST-CATH L 12 CM DIA14 FR GUIDEWIRE 0.038 IN,SUP-2355543,CDM,C1893,HCPCS,0272,RC,,,,both,,,62.80,40.82,,,,,,,,,,,,,
SCISSOR SURG FOMON 5.25 IN DORS SUPER CUT ANGLED BLNT/BLNT,SUP-2872585,CDM,C1889,HCPCS,0278,RC,,,,both,,,235.41,153.02,,,,,,,,,,,,,
GUIDE PIN FIX 3.2X980MM SMOOTH DRL TIP FLEX W/ LEN MRK S STL,SUP-2197435,CDM,2720000010,LOCAL,0272,RC,,,,both,,,673.22,437.59,,,,,,,,,,,,,
STAPLE INT L20XW20MM S STL COMPR INTERAXIS NONSTERILE IMPL,SUP-2243126,CDM,C1713,HCPCS,0278,RC,,,,both,,,2983.57,1939.32,,,,,,,,,,,,,
KIT INTRO ARW SHTH L 10 CM DIA 8.5 FR GUIDEWIRE 0.035 IN,SUP-2383284,CDM,C1894,HCPCS,0272,RC,,,,both,,,160.77,104.50,,,,,,,,,,,,,
FIBER LASER 270 MH REUSE,SUP-2498675,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2749.42,1787.12,,,,,,,,,,,,,
GRAFT HUM TISS SZ C W3.5XL3.5CM FRZN ALLGRFT OCU AMNIO MEM,SUP-2135259,CDM,V2790,HCPCS,0278,RC,,,,both,,,2810.30,1826.69,,,,,,,,,,,,,
COIL EMB 10 L8CM OD3MM HELCL STRTCH RESIST FNSH HYDRGEL,SUP-2305156,CDM,C1889,HCPCS,0278,RC,,,,both,,,4882.70,3173.75,,,,,,,,,,,,,
STENT URET L 30 CM DIA 8.5 FR PTFE GUIDEWIRE L 100 CM DIA,SUP-2312689,CDM,C2617,HCPCS,0278,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
KIT INTCRAN PRSS MON AD DISP,SUP-2243739,CDM,C1713,HCPCS,0278,RC,,,,both,,,1617.10,1051.11,,,,,,,,,,,,,
PIN EXT FIX L180MM DIA3MM THRD L35MM HALF FOR SIDEKCK STLTH,SUP-2400687,CDM,C1713,HCPCS,0278,RC,,,,both,,,222.94,144.91,,,,,,,,,,,,,
HC Ot Therapeutic Activities 15 Min|OP PT SERVICES|DOCUMENTATION ON FILE|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS,PX-4309753000,CDM,97530,CPT,0430,RC,,,GP|KX|CQ,both,,,144.00,93.60,,,,,,,,,,,,,
FLUORESCEIN SODIUM 1 MG OP STRP,RX-27663,CDM,6370000000,HCPCS,0637,RC,17238-0900-30,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PLATE BNE STR 6 MM LT HK BRIDGE TI NS LEVEL 1 ORTHOANCHOR LF,SUP-2481307,CDM,C1713,HCPCS,0278,RC,,,,both,,,911.64,592.57,,,,,,,,,,,,,
STIMULATOR NERVE 5.02X6.68 CM,SUP-2637208,CDM,C1767,HCPCS,0278,RC,,,,both,,,57335.18,37267.87,,,,,,,,,,,,,
COMPONENT FMRL MED LEFT RTTNG PLTFRMFLXN GSB LATEX FREE ST,SUP-2720777,CDM,C1776,CPT,0278,RC,,,,both,,,725.34,471.47,,,,,,,,,,,,,
HC Veno Renal Bilat Sel S&I,PX-3207583300,CDM,75833,CPT,0320,RC,,,,both,,,3165.00,2057.25,,,,,,,,,,,,,
ENVELOP TISS SM 5.4X5 CM SFT SUPPLE CORMATRIX CANGAROO EMC,SUP-2653868,CDM,C1889,HCPCS,0278,RC,,,,both,,,3092.90,2010.38,,,,,,,,,,,,,
SYSTEM CARD ICD SYS 2 CHMBR W/ RIATA ST OPTIM SYS FOR V-24,SUP-2356553,CDM,C1721,HCPCS,0275,RC,,,,both,,,67268.22,43724.34,,,,,,,,,,,,,
SCREW BONE L10MM PAN FIX LUHR,SUP-2364709,CDM,C1713,HCPCS,0278,RC,,,,both,,,21.26,13.82,,,,,,,,,,,,,
ALLOGRAFT BNE 250-1000 MH 2.5 CC FD CORTICAL PWD ORAGRAFT,SUP-2741027,CDM,C1713,HCPCS,0278,RC,,,,both,,,343.48,223.26,,,,,,,,,,,,,
HC Temp Pacer Insertion,PX-3613321000,CDM,33210,CPT,0361,RC,,,,both,,,1599.00,1039.35,,,,,,,,,,,,,
SODIUM ZIRCONIUM CYCLOSILICATE 10 G PO PACK,RX-143096,CDM,6370000000,HCPCS,0637,RC,00310-1110-39,NDC,,both,1,UN,129.30,84.04,,,,,,,,,,,,,
PORT INFUS 6FR POLYUR ATTACH CHRONOFLEX CATH TI SIL FIL SUT,SUP-2127782,CDM,C1788,HCPCS,0278,RC,,,,both,,,1224.60,795.99,,,,,,,,,,,,,
CLIP ANEUR T BAR 45 DEG 5 MM PERM TI STRL YASRG,SUP-2108698,CDM,C1889,HCPCS,0278,RC,,,,both,,,4515.32,2934.96,,,,,,,,,,,,,
DISC ARTIFICIAL SZ 2 0DEG UNIV INTERVERTEBRAL LUM MTL ON,SUP-2255726,CDM,C1889,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
DEVICE SUT TRNSVAG CAPT CAPIO CL,SUP-2139399,CDM,C2631,HCPCS,0278,RC,,,,both,,,3592.16,2334.90,,,,,,,,,,,,,
CATHETER ATHRCTMY 5FR L135CM DMND TIP BUR DIA1.25MM PROTCT,SUP-2141003,CDM,C1724,HCPCS,0278,RC,,,,both,,,10974.30,7133.29,,,,,,,,,,,,,
VALVE AORT KONECT RESILIA TISS ANNULUS 19 MM SEW RNG DIA 31,SUP-2624859,CDM,C1889,HCPCS,0278,RC,,,,both,,,50240.00,32656.00,,,,,,,,,,,,,
CATHETER THROMCTMY SOLITAIRE X TOT L 47 MM L 40 MM DIA 6 MM,SUP-2418751,CDM,C1757,HCPCS,0272,RC,,,,both,,,21125.92,13731.85,,,,,,,,,,,,,
CATHETER CTRL VEN PED 6.6FR 0.3ML L71CM SGL LUMN SURECUF,SUP-2126153,CDM,C1751,HCPCS,0278,RC,,,,both,,,491.10,319.21,,,,,,,,,,,,,
STAPLER PWR JAW L 23 CM STPL H 1.2-2.2 MM GASTRC 6 ROW N,SUP-2901853,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8007.00,5204.55,,,,,,,,,,,,,
HEAD HUM 48X18 MM SHAPER GLOB CAP QC,SUP-2453844,CDM,C1776,CPT,0278,RC,,,,both,,,3111.74,2022.63,,,,,,,,,,,,,
PEG KIT FEED 20 FR TUBE CONCL PUL N ENFIT CORFLO,SUP-2764900,CDM,2720000010,LOCAL,0272,RC,,,,both,,,336.36,218.63,,,,,,,,,,,,,
PLATE BNE LT CORONOID ASSEMBLED PROTEAN,SUP-2340324,CDM,C1713,HCPCS,0278,RC,,,,both,,,3752.30,2438.99,,,,,,,,,,,,,
KNIFE SURG ROYCE 3-3/8 INX8 MM EAR ANGLED DN CUT MICROFRANCE,SUP-2473762,CDM,2720000010,LOCAL,0272,RC,,,,both,,,398.81,259.23,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9 % IV SOLN (MINI-BAG),RX-40850049,CDM,2580000003,HCPCS,0258,RC,00338-9151-30,NDC,,both,50,ML,61.20,39.78,,,,,,,,,,,,,
GRAFT VASC VECTRA L 50 CM DIA 5 MM POLYUR STR STD WALL N,SUP-2127040,CDM,C1768,CPT,0278,RC,,,,both,,,3207.13,2084.63,,,,,,,,,,,,,
TRAY PARACENTESIS/THORACENTESIS 18GA VLV DRNGE,SUP-2133917,CDM,C1729,HCPCS,0272,RC,,,,both,,,178.98,116.34,,,,,,,,,,,,,
COIL EMB L20CM OD7MM ODSEC0135IN 1847MM PGLA INTCRAN,SUP-2173114,CDM,C1889,HCPCS,0278,RC,,,,both,,,4967.48,3228.86,,,,,,,,,,,,,
PLATE BNE BROAD 3.5X120 MM 9 HOLE SS LC-DCP,SUP-2569243,CDM,C1713,HCPCS,0278,RC,,,,both,,,322.95,209.92,,,,,,,,,,,,,
GRAFT BNE FEN 15X50 MM DEMINERALIZED CORTICAL FENFLEX,SUP-2742005,CDM,C1713,HCPCS,0278,RC,,,,both,,,1338.43,869.98,,,,,,,,,,,,,
TRAY CATH 6FR 2 LUMN NRS PWR INJ REV TAPR DSGN MAXIMAL BARR,SUP-2125643,CDM,C1751,HCPCS,0278,RC,,,,both,,,814.83,529.64,,,,,,,,,,,,,
NUT EXT FIX W/ WASHER STRL TRUELOK EVO LTX,SUP-2875624,CDM,2720000010,LOCAL,0272,RC,,,,both,,,117.37,76.29,,,,,,,,,,,,,
SCREW BONE L16MM OD2.7MM TI CORT SM HD T8 ST LOQTEQ,SUP-2101282,CDM,C1713,HCPCS,0278,RC,,,,both,,,359.22,233.49,,,,,,,,,,,,,
HC MRI Lower Ext W/ Cont|RIGHT SIDE,PX-6107371900,CDM,73719,CPT,0610,RC,,,RT,both,,,5019.00,3262.35,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9 % IV SOLN (MINI-BAG),RX-40850049,CDM,2580000003,HCPCS,0258,RC,00338-0553-18,NDC,,both,100,ML,62.10,40.36,,,,,,,,,,,,,
ANCHOR SUT MINI SZ 2-0 BRAID COMP SUT W/ V5 L18IN DBL ARMED,SUP-2249349,CDM,C1713,HCPCS,0278,RC,,,,both,,,3061.50,1989.97,,,,,,,,,,,,,
CLAMP SPNL MONOBLOC TENOR SPNL SYS,SUP-2289280,CDM,C1713,HCPCS,0278,RC,,,,both,,,1230.88,800.07,,,,,,,,,,,,,
PLATE BNE L 133 X W 10.5 MM THK 3 MM SCREW DIA2.7/3.5 MM 9 H 72467409N,SUP-2932954,CDM,C1713,HCPCS,0278,RC,,,,both,,,3251.16,2113.25,,,,,,,,,,,,,
CATHETER ANGIOPLSTY 135 CM 5.5X60 MM STERLING MRAIL,SUP-2140039,CDM,C1725,HCPCS,0272,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
BIT REPROC DRL CANN LG 5X300MM,SUP-2526041,CDM,2720000010,LOCAL,0272,RC,,,,both,,,347.00,225.55,,,,,,,,,,,,,
KIT CEM MIXING/DELIVERY W/ 10CC HALF DOSE,SUP-2367020,CDM,C1713,HCPCS,0278,RC,,,,both,,,1888.05,1227.23,,,,,,,,,,,,,
WEDGE ACF ILIUM CREST TRADITION ALLGRFT 13 - 15 MM FRZ DRY,SUP-2294065,CDM,C1713,HCPCS,0278,RC,,,,both,,,2995.56,1947.11,,,,,,,,,,,,,
RING EXT FIX L 220 MM ARCH MONK RING,SUP-2899026,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2409.17,1565.96,,,,,,,,,,,,,
BIT DRILL SURG 1.8X110MM W/ 26MM STP IQ SER,SUP-2136988,CDM,2720000010,LOCAL,0272,RC,,,,both,,,606.02,393.91,,,,,,,,,,,,,
COIL EMB L30CM DIA10MM 360DEG SHP STD DETACH GDC 18,SUP-2365684,CDM,C1889,HCPCS,0278,RC,,,,both,,,6457.72,4197.52,,,,,,,,,,,,,
KIT ACCS PRT I 0-10CC W/ 20IN TBNG S STL CONN BND PRIMING,SUP-2119244,CDM,C1889,HCPCS,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
HC Urinls Dip Stick/Tablet Reagnt Non-Auto Micrscpy,PX-3078100000,CDM,81000,CPT,0307,RC,,,,both,,,13.00,8.45,,,,,,,,,,,,,
KIT EXT FIX ANK CALCNL W/ T WRNCH DRL GUID FIX DISTR UNIT,SUP-2316325,CDM,2720000010,LOCAL,0272,RC,,,,both,,,15896.82,10332.93,,,,,,,,,,,,,
HEAD HUM DIA22MM NK L+0MM SHLDR CO CHROM ALLOY UHMWPE BPLR,SUP-2372522,CDM,C1776,CPT,0278,RC,,,,both,,,2262.68,1470.74,,,,,,,,,,,,,
RING EXT FIX HALF 160 MM CARBON FIBER NS,SUP-2863410,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1589.50,1033.17,,,,,,,,,,,,,
NAIL IM L320MM DIA11.5MM FEM TIB KNEE G TI CANN LOK AG RG,SUP-2347100,CDM,C1713,HCPCS,0278,RC,,,,both,,,4578.75,2976.19,,,,,,,,,,,,,
K ORBITAL PLATE 2MM CP TITANIUM,SUP-2707257,CDM,C1713,HCPCS,0278,RC,,,,both,,,1781.32,1157.86,,,,,,,,,,,,,
STENT BILI L11MM BLLN L15MM DIA5MM CATH L80CM 14/12ATM,SUP-2158996,CDM,C1876,HCPCS,0278,RC,,,,both,,,3975.24,2583.91,,,,,,,,,,,,,
SHEATH INTRO FLX ANSEL L 45 CM OD 8 FR GUIDEWIRE 0.018/0.038,SUP-2170662,CDM,C1894,HCPCS,0272,RC,,,,both,,,155.93,101.35,,,,,,,,,,,,,
PLATE BNE 5 H STD R VOLAR DST RAD TI,SUP-2122808,CDM,C1713,HCPCS,0278,RC,,,,both,,,2496.30,1622.59,,,,,,,,,,,,,
SUPPORT ORTHOT PIP FNGR DSTL INTERPHALANGEAL SPRING W/JT,SUP-2435784,CDM,L3925,HCPCS,0274,RC,,,,both,,,169.25,110.01,,,,,,,,,,,,,
PLATE SPNL W16XL54MM STD DBL HALF H XLNK POST LUM S STL FIX,SUP-2255570,CDM,C1713,HCPCS,0278,RC,,,,both,,,4165.21,2707.39,,,,,,,,,,,,,
RETRACTOR CEM 24MM FOR SHLDR SYS AEQUALIS REVERSED II,SUP-2388809,CDM,C1776,CPT,0278,RC,,,,both,,,587.18,381.67,,,,,,,,,,,,,
PLATE BONE L25MM 4 H MAND ORAL MAXILLOFACIAL TI STR TENS BND,SUP-2191344,CDM,C1713,HCPCS,0278,RC,,,,both,,,1622.12,1054.38,,,,,,,,,,,,,
ENDCAP ORTH 15 MM STRL VERSANAIL,SUP-2483523,CDM,C1889,HCPCS,0278,RC,,,,both,,,568.34,369.42,,,,,,,,,,,,,
PLATE BNE FLAT T PLT SPEC 3X3 H,SUP-2401264,CDM,C1713,HCPCS,0278,RC,,,,both,,,2788.32,1812.41,,,,,,,,,,,,,
AUGMENT FEM M THK8MM STD UNIV RT MEDL LT LAT DSTL KNEE CEM,SUP-2406999,CDM,C1776,CPT,0278,RC,,,,both,,,2603.06,1691.99,,,,,,,,,,,,,
GRAFT BIO TISS W8XL8CM FET BOV SIL FEN ANTIMIC PRIMATRIX AG,SUP-2243713,CDM,Q4110,HCPCS,0636,RC,,,,both,,,7149.78,4647.36,,,,,,,,,,,,,
HC So Hepatitis B Surface Ag|NOT REASONABLE AND NECESSARY,PX-3068734066,CDM,87340,CPT,0306,RC,,,GZ,outpatient,,,57.00,37.05,,,,,,,,,,,,,
ORTHOTIC FT BOOT SM UNISX UNIV AD TAN,SUP-2332644,CDM,L4396,HCPCS,0274,RC,,,,both,,,263.76,171.44,,,,,,,,,,,,,
COMPONENT FEM 38MM OFFSET PROX ZMLY SEG BASIC,SUP-2200518,CDM,C1776,CPT,0278,RC,,,,both,,,12717.00,8266.05,,,,,,,,,,,,,
LEVEL CMF PLATE MDFCE LDDR WTAB 1.5 MM SCRW2 X 2 HOLES 12 M,SUP-2677538,CDM,C1713,HCPCS,0278,RC,,,,both,,,808.24,525.36,,,,,,,,,,,,,
CONNECTOR BRONCHSCP TWO PRONGED FR OER PRO TO BF 30 40 240,SUP-2313262,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1146.95,745.52,,,,,,,,,,,,,
NAIL IM L150MM DIA7.5MM NONSTERILE HUM TI CANN LCK PROX,SUP-2192536,CDM,C1713,HCPCS,0278,RC,,,,both,,,5463.60,3551.34,,,,,,,,,,,,,
CATHETER INFUSION UNI-FUSE L 90 CM DIA 4 FR SLT PAT L 40 CM,SUP-2117144,CDM,C1751,HCPCS,0278,RC,,,,both,,,659.40,428.61,,,,,,,,,,,,,
PROBE ARTHSCP SUCT ASD 3.5MM DIA 90DEG,SUP-2362165,CDM,2720000010,LOCAL,0272,RC,,,,both,,,548.84,356.75,,,,,,,,,,,,,
SCREW BNE COMPR 2X22 MM LP HD BITE,SUP-2644978,CDM,C1713,HCPCS,0278,RC,,,,both,,,806.20,524.03,,,,,,,,,,,,,
COMPONENT HUM L6IN REG ELBW TIV PLSM INTERCHANGEABLE CEM,SUP-2205916,CDM,C1776,CPT,0278,RC,,,,both,,,11643.12,7568.03,,,,,,,,,,,,,
COMPONENT FEM SZ 4 R ANT KNEE CRUCE RET CEM REFERENCING,SUP-2372973,CDM,C1776,CPT,0278,RC,,,,both,,,4082.00,2653.30,,,,,,,,,,,,,
GRAFT VASC STR 10 MMX100 CM AORT ARCH 1 LAYR SFT HEMSHLD GLD,SUP-2457107,CDM,C1768,CPT,0278,RC,,,,both,,,1928.15,1253.30,,,,,,,,,,,,,
PLATE BNE SHT BRL 130 DEG 3 HOLE,SUP-2861269,CDM,C1713,HCPCS,0278,RC,,,,both,,,1688.25,1097.36,,,,,,,,,,,,,
CAGE SPCR CORPECTOMY SM 12X143.5 29 TO 36MM S XPAND,SUP-2229141,CDM,C1889,HCPCS,0278,RC,,,,both,,,15700.00,10205.00,,,,,,,,,,,,,
TEMPLATE SZ TRIANG MESH 30 MM ORBIT FLR ALUM RESORB-X LF,SUP-2466263,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1030.17,669.61,,,,,,,,,,,,,
BUR SURG L4MM OD5.1MM DMND NEURO DRL W/O STP N RADLUC FOR,SUP-2364016,CDM,2720000010,LOCAL,0272,RC,,,,both,,,415.17,269.86,,,,,,,,,,,,,
INSERT TIB L59MM THK8MM MEDL LAT KNEE ARTC CRUC RET MOLD,SUP-2406271,CDM,C1776,CPT,0278,RC,,,,both,,,1934.24,1257.26,,,,,,,,,,,,,
RING ANNULPLSTY CARPENTIER MCCARTHY ADAMS IMR ETLOGIX DIA28,SUP-2214131,CDM,C1713,HCPCS,0278,RC,,,,both,,,6908.00,4490.20,,,,,,,,,,,,,
SHUNT SURG ADJ L 17 MM GRAVITATIONAL L 12 MM CATH DSTL L 900 FX549T,SUP-2932716,CDM,C1729,HCPCS,0272,RC,,,,both,,,16003.92,10402.55,,,,,,,,,,,,,
GRAFT VASC ARTEGRAFT L 45 CM DIA 7 MM CLLGN BOV CAR ART,SUP-2120673,CDM,C1768,CPT,0278,RC,,,,both,,,4553.00,2959.45,,,,,,,,,,,,,
CATHETER THROMCTMY INDIGO SEP 8 L 150 CM DSTL DIA 0.072 IN,SUP-2765592,CDM,C1757,HCPCS,0272,RC,,,,both,,,5824.70,3786.05,,,,,,,,,,,,,
HC Radiation Treatment Delivery Level 2,PX-3337740700,CDM,77407,CPT,0333,RC,,,,outpatient,,,2411.00,1567.15,,,,,,,,,,,,,
TIMOLOL MALEATE 10 MG PO TABS,RX-7967,CDM,6370000000,HCPCS,0637,RC,00378-0221-01,NDC,,both,1,UN,6.50,4.22,,,,,,,,,,,,,
TUBE VENT 1.02 MM 1 MM 2.44/2.16 MM PAPARELLA W/ TAB 510041C,SUP-2460071,CDM,L8699,HCPCS,0278,RC,,,,both,,,40.41,26.27,,,,,,,,,,,,,
PIN FIX 2X30MM COMPR,SUP-2414145,CDM,C1713,HCPCS,0278,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
HYDROXYZINE HCL 50 MG/ML IM SOLN,RX-3770,CDM,J3410,HCPCS,0636,RC,00517-5601-25,NDC,,both,0.5,ML,97.00,63.05,,,,,,,,,,,,,
STENT CORONARY MULTLNK PENTA L 15 MM DIA 3.5 MM GUIDEWIRE,SUP-2101576,CDM,C1876,HCPCS,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
CATHETER THROMCTMY FOGARTY L 50 CM DIA 6 FR SPRL DIA,SUP-2214037,CDM,C1757,HCPCS,0272,RC,,,,both,,,1496.37,972.64,,,,,,,,,,,,,
IMPLANT OTOLARYN 0.8MM DIAM 4MM LEN CUP PLAT FLROPLAS STAP,SUP-2312553,CDM,2780000010,LOCAL,0278,RC,,,,both,,,323.26,210.12,,,,,,,,,,,,,
SCREW BONE L3MM DIA1.3MM GLD CORT CRANIOMAXILLOFACIAL TI ST,SUP-2189048,CDM,C1713,HCPCS,0278,RC,,,,both,,,324.86,211.16,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL PEEK SD800.520,SUP-2860201,CDM,C1713,HCPCS,0278,RC,,,,both,,,32508.42,21130.47,,,,,,,,,,,,,
MARKER BRST BX 17GA L10CM BIODUR 108 INDEPENDENTLY THRU A 864017D] BARD PERIPHERAL VASCULAR],SUP-2127914,CDM,A4648,CPT,0278,RC,,,,both,,,160.14,104.09,,,,,,,,,,,,,
PIN FIX TEMP DIA3.2MM THRD ACCS FOR COMPHSVE TOT SHLDR SYS STNMN,SUP-2411555,CDM,C1713,HCPCS,0278,RC,,,,both,,,324.99,211.24,,,,,,,,,,,,,
PLATE BNE W3.8XL100MM THK0.8MM 20 H BILAT TI STR,SUP-2191138,CDM,C1713,HCPCS,0278,RC,,,,both,,,1195.37,776.99,,,,,,,,,,,,,
LOSARTAN POTASSIUM 25 MG PO TABS,RX-14823,CDM,6370000000,HCPCS,0637,RC,68084-0346-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PLUG VASC AMPLATZER II L 7 MM DIA10 MM DEL SYS L 135 CM CATH,SUP-2116307,CDM,C1889,HCPCS,0278,RC,,,,both,,,2876.24,1869.56,,,,,,,,,,,,,
LENS IOL BCNVX 26.5+ DIOPT 5X11.5 MM CRYSTALENS AT50AO2650] VALEANT BAUSCH AND LOMB SURGICAL],SUP-2392058,CDM,V2788,HCPCS,0276,RC,,,,both,,,950.00,617.50,,,,,,,,,,,,,
BIT DRL TWST 1.9X5 MM ANGLED SCREWDRIVER ANGULUS 2,SUP-2464465,CDM,2720000010,LOCAL,0272,RC,,,,both,,,488.90,317.78,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP L150CM DIA0.038IN TIP L3CM URO FLX ANG,SUP-2139364,CDM,C1769,HCPCS,0272,RC,,,,both,,,190.03,123.52,,,,,,,,,,,,,
CATHETER INTVASC OCCL L 80 CM DIA2 FR BALLOON L 7 CM DIA 7,SUP-2141027,CDM,C2628,HCPCS,0272,RC,,,,both,,,533.80,346.97,,,,,,,,,,,,,
HC Feeding Tube Placement,PX-3207434000,CDM,74340,CPT,0320,RC,,,,both,,,1184.00,769.60,,,,,,,,,,,,,
PIN FIX 1.5MM BIODEGRADABLE KT INION FREEDOMPIN,SUP-2417694,CDM,C1713,HCPCS,0278,RC,,,,both,,,2000.18,1300.12,,,,,,,,,,,,,
AMLODIPINE BESY-BENAZEPRIL HCL 10-20 MG PO CAPS,RX-33111,CDM,6370000000,HCPCS,0637,RC,55111-0341-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
MIS LOCK CALC PLT SM LT,SUP-2492116,CDM,C1713,HCPCS,0278,RC,,,,both,,,2345.27,1524.43,,,,,,,,,,,,,
TUBE TRACH AD L110MM OD9.2MM ID6MM SIL UNCUF EXTRA LEN FIX,SUP-2351991,CDM,2720000010,LOCAL,0272,RC,,,,both,,,340.72,221.47,,,,,,,,,,,,,
CLAMP EXT FIX 6MM BAR TO 4MM PIN FRDM JET-X,SUP-2342897,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4142.29,2692.49,,,,,,,,,,,,,
SEAT REDUC 6.35MM SM EZ STRT VLS,SUP-2415644,CDM,C1713,HCPCS,0278,RC,,,,both,,,1578.13,1025.78,,,,,,,,,,,,,
MESH HERN OPTIMIZED COMP 9 CM RND SKIRTED POLYESTER PARIETEX,SUP-2752192,CDM,C1781,HCPCS,0278,RC,,,,both,,,1762.29,1145.49,,,,,,,,,,,,,
COLLAR CERV M DENS AD VELC CLSR FOAM W/ STOCK 3.5IN 23.5IN M,SUP-2198742,CDM,L0120,HCPCS,0272,RC,,,,both,,,16.58,10.78,,,,,,,,,,,,,
STEM FEM PRSS FIT STD OFFSET FORGED TI ALLOY SZ 0 ACUMATCH,SUP-2221751,CDM,C1776,CPT,0278,RC,,,,both,,,5149.60,3347.24,,,,,,,,,,,,,
CUFF BLD PRESSURE CIRC 17-45 CM URETHANE NYL MRI,SUP-2893209,CDM,C1713,HCPCS,0278,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
ELECTRODE ELECSURG 3FR L110CM COAG BUGBY TIP FLEXXC,SUP-2261087,CDM,2720000010,LOCAL,0272,RC,,,,both,,,341.73,222.12,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED PATELLAR UPCHARGE TRAB MEL,SUP-2212693,CDM,C1776,CPT,0278,RC,,,,both,,,1949.94,1267.46,,,,,,,,,,,,,
WASHER SPNL FIX SM TI,SUP-2714456,CDM,C1713,HCPCS,0278,RC,,,,both,,,2590.50,1683.82,,,,,,,,,,,,,
CATHETER CV SET 018 6 FRX60 CM TURBO-JECT UPICTS60CTABRM1110,SUP-2759762,CDM,C1751,HCPCS,0278,RC,,,,both,,,386.06,250.94,,,,,,,,,,,,,
BIT DRL L150MM DIA3.2MM CANN DISP,SUP-2389442,CDM,2720000010,LOCAL,0272,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
KIT INTRO PTFE MIC ACCS TEARWY,SUP-2117205,CDM,C1894,HCPCS,0272,RC,,,,both,,,119.63,77.76,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC 5FR 55CM 1 LUMAN RVS TAPR PWR INJ W,SUP-2613366,CDM,C1751,HCPCS,0278,RC,,,,both,,,587.75,382.04,,,,,,,,,,,,,
RETRACTOR ENDOSCOPIC HAND FREE INTRACORPOREAL TRIO,SUP-2880420,CDM,2720000010,LOCAL,0272,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
SCREW BONE L54MM DIA4MM STRL BLU CORT TI ST NONCANNULATED,SUP-2192277,CDM,C1713,HCPCS,0278,RC,,,,both,,,740.32,481.21,,,,,,,,,,,,,
GRAFT BNE SUB 5CC CA PHSPTE HI COMPRESSIVE STRENGTH RADPQ,SUP-2106908,CDM,C1713,HCPCS,0278,RC,,,,both,,,4681.74,3043.13,,,,,,,,,,,,,
DEVICE FIX GRFT MINI 12X3.9 MM 15 MM BUTTON GFS,SUP-2762035,CDM,C1713,HCPCS,0278,RC,,,,both,,,876.06,569.44,,,,,,,,,,,,,
PLATE BNE DBL ANGLED MED 2.5 MM RECON PT SPEC TI,SUP-2860102,CDM,C1713,HCPCS,0278,RC,,,,both,,,23307.59,15149.93,,,,,,,,,,,,,
KIT FIBERLOCK SUSPENSION IMPLANT,SUP-2740179,CDM,C1713,HCPCS,0278,RC,,,,both,,,5008.30,3255.39,,,,,,,,,,,,,
RETRACTOR SPINE L4CM OD22MM L D157IN STR MED LAT STR TBLR,SUP-2292996,CDM,C1713,HCPCS,0278,RC,,,,both,,,1382.64,898.72,,,,,,,,,,,,,
STIMULATOR BNE DST TIB FIB TARSAL METATARSAL CASTED APPL,SUP-2316038,CDM,E0749,HCPCS,0278,RC,,,,both,,,7842.15,5097.40,,,,,,,,,,,,,
CATHETER EP 7FR L115CM 2-5-2MM SPC M CURL QPLR BIDIR STEER,SUP-2357028,CDM,C1733,HCPCS,0272,RC,,,,both,,,2515.14,1634.84,,,,,,,,,,,,,
COUNTERSINK SURG DIA3 4MM CANN QUIK REL,SUP-2319461,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1394.16,906.20,,,,,,,,,,,,,
PROSTHESIS OSS PISTON 0.6X4.25 MM SS MCGEE,SUP-2312492,CDM,L8613,CPT,0278,RC,,,,both,,,283.29,184.14,,,,,,,,,,,,,
CEMENT BNE 40GM 2.5% GENT BWL SPAT HND MIX LOW/MEDIUM VISC,SUP-2221996,CDM,C1713,HCPCS,0278,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
PLATE BNE ROT CORRECTION 1.5/2X32 MM 2X5 HOLE SS STRL,SUP-2568764,CDM,C1713,HCPCS,0278,RC,,,,both,,,2457.43,1597.33,,,,,,,,,,,,,
PEN ISOLATOR ELECTRD L7MM BPLR TRANSPOLAR UNIDIR LESION MAXI] ATRICURE INC],SUP-2124461,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8007.00,5204.55,,,,,,,,,,,,,
BRACE ANK FT M AD WOM SHOE 7-9 STRP 2IN LT UNISX,SUP-2324848,CDM,L4350,HCPCS,0272,RC,,,,both,,,98.22,63.84,,,,,,,,,,,,,
SCREW SPNL L5MM DIA2.6MM LAM LEVERAGE LFS,SUP-2311374,CDM,C1713,HCPCS,0278,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
BASKET STONE RETRV L90CM DIA11MM SHTH DIA1MM 4 WIR HELI O,SUP-2139247,CDM,2720000010,LOCAL,0272,RC,,,,both,,,634.00,412.10,,,,,,,,,,,,,
PLATE BNE THK06MM 6 H CRAN TI MESH MIC RECT FOR 15MM SCR,SUP-2262708,CDM,C1713,HCPCS,0278,RC,,,,both,,,644.89,419.18,,,,,,,,,,,,,
SUPPORT ORTHOT ANK KNEE CUST CLASP ATTCH SHOE BAR SINGLE,SUP-2435626,CDM,L1910,HCPCS,0272,RC,,,,both,,,793.98,516.09,,,,,,,,,,,,,
DILATOR ENDO CATH 7FR BAL L8CM DIA10MM ESOPH QNT TTC,SUP-2169338,CDM,C1726,HCPCS,0272,RC,,,,both,,,323.42,210.22,,,,,,,,,,,,,
PROSTHESIS VOICE LO PRSS BLOM-SINGER 16 FRX28 MM,SUP-2242315,CDM,L8507,HCPCS,0274,RC,,,,both,,,395.64,257.17,,,,,,,,,,,,,
NUT SPINE DEV BRK OFF,SUP-2290608,CDM,C1713,HCPCS,0278,RC,,,,both,,,5363.12,3486.03,,,,,,,,,,,,,
IMMOBILIZER ORTH 2 AXIS LNG 26 IN 36 IN KNEERANGER II,SUP-2197134,CDM,L3702,HCPCS,0274,RC,,,,both,,,122.62,79.70,,,,,,,,,,,,,
SPACER SPNL LG 12 DEG 14 MM PEEK PERIMETER,SUP-2629067,CDM,C1889,HCPCS,0278,RC,,,,both,,,7457.50,4847.37,,,,,,,,,,,,,
NEEDLE CUT REV B SER SZ 4 0 WIRE 043MM LEN 1307M,SUP-2109785,CDM,C1713,HCPCS,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
SHEATH ORTHOPEDIC PASS TEND HUNTER,SUP-2422192,CDM,C1763,HCPCS,0278,RC,,,,both,,,5190.42,3373.77,,,,,,,,,,,,,
PROTECTOR TEND W2XL2IN SHT BOV CLLGN GLYCOSAMINOGLYCAN POR,SUP-2244459,CDM,C1776,CPT,0278,RC,,,,both,,,9873.01,6417.46,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE 1 CC CORTICOCANCELLOUS ALLGRFT FRZN,SUP-2933209,CDM,C1762,CPT,0278,RC,,,,both,,,1423.33,925.16,,,,,,,,,,,,,
GAMMATILE THERAPY DEVICE 3 PACK,SUP-2855637,CDM,C2642,HCPCS,0278,RC,,,,both,,,24073.34,15647.67,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE 5 CC DBM CORTICAL FIBER XCITE -RSFH,SUP-2881406,CDM,C1713,HCPCS,0278,RC,,,,both,,,4898.40,3183.96,,,,,,,,,,,,,
PACKING NSL W2.4XL4CM THK0.3CMXEROGEL 8 PER BX,SUP-2217804,CDM,C1713,HCPCS,0278,RC,,,,both,,,510.25,331.66,,,,,,,,,,,,,
HEAD METATARSOPHALANGEAL CANN MINI 11X13X3 MM TOE RND COCR,SUP-2392821,CDM,C1776,CPT,0278,RC,,,,both,,,7507.74,4880.03,,,,,,,,,,,,,
PACEMAKER CARD 23GM 12.81CC W52XH52MM THK6MM SGL CHMBR IS-1,SUP-2356452,CDM,C1786,HCPCS,0275,RC,,,,both,,,7693.00,5000.45,,,,,,,,,,,,,
SCREW BNE FT 4X26 MM CANC TI NS LCP,SUP-2189936,CDM,C1713,HCPCS,0278,RC,,,,both,,,62.14,40.39,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 2X1 CM CRYOPRESERVED UMB CRD NEOX CRD 1K,SUP-2648683,CDM,Q4148,HCPCS,0636,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
HC Iaadiadoo Not Otherwise Specified,PX-3068789900,CDM,87899,CPT,0306,RC,,,,inpatient,,,689.00,447.85,,,,,,,,,,,,,
ALLOGRAFT BNE 150-25 MM FD FEM SHFT,SUP-2866859,CDM,C1762,CPT,0278,RC,,,,both,,,3516.96,2286.02,,,,,,,,,,,,,
FOOTPLATE EXT FIX LNG 120 MM ALUM MAXFRAME,SUP-2423877,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4685.57,3045.62,,,,,,,,,,,,,
ALLOGRAFT BNE BLOCK 30X30X12 MM 10.8 CC PRO OSTEON 500R,SUP-2684315,CDM,C1713,HCPCS,0278,RC,,,,both,,,5881.22,3822.79,,,,,,,,,,,,,
PLATE CRAN 180X80X40 MM PT SPEC IMPL PEEK,SUP-2860143,CDM,C1713,HCPCS,0278,RC,,,,both,,,35561.44,23114.94,,,,,,,,,,,,,
LENS INTOCU +16.5 DIOPT A CONSTANT 118.8 L13MM DIA6MM 0DEG,SUP-2247750,CDM,V2632,HCPCS,0276,RC,,,,both,,,430.18,279.62,,,,,,,,,,,,,
CATHETER CHOLANGIOGRAM LAP 16 GAX76 CM,SUP-2330477,CDM,C1713,HCPCS,0278,RC,,,,both,,,70.65,45.92,,,,,,,,,,,,,
HEAD FEM OD28MM -3.5MM OFFSET CERAMIC ON CERAMIC ALUMINA PRI,SUP-2216740,CDM,C1776,CPT,0278,RC,,,,both,,,1783.52,1159.29,,,,,,,,,,,,,
PROBE LAP 10 MM W/ HANDSWITCH,SUP-2225601,CDM,2720000010,LOCAL,0272,RC,,,,both,,,824.25,535.76,,,,,,,,,,,,,
DEVICE DEL H2O VPR THER W/CABLE SYR SPIKE ADAPTOR VI REZUM,SUP-2432115,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4033.02,2621.46,,,,,,,,,,,,,
GRAFT HUM TISS BNE BLOCK 65-95 MM 20X10-12 MM FLEXIGRAFT,SUP-2740877,CDM,C1762,CPT,0278,RC,,,,both,,,6165.39,4007.50,,,,,,,,,,,,,
PLATE BNE CRV 4.5X301 MM RT CNDYL 14 HOLE VA LCK STRL VALCP,SUP-2789867,CDM,C1713,HCPCS,0278,RC,,,,both,,,6950.83,4518.04,,,,,,,,,,,,,
CATHETER DRAINAGE MCL COPE 0.038 IN 14 FRX60 CM MP UTHANE,SUP-2168391,CDM,C1729,HCPCS,0272,RC,,,,both,,,379.66,246.78,,,,,,,,,,,,,
PLATE BNE L 80 MM SCREW DIA2.7/3.5MM 3 H SS RT MEDL DSTL HUM,SUP-2931372,CDM,C1713,HCPCS,0278,RC,,,,both,,,4458.17,2897.81,,,,,,,,,,,,,
PATCH DURA W10XL12CM ELASTOMERIC INNR LAYR PRECL MVP,SUP-2395357,CDM,C1763,HCPCS,0278,RC,,,,both,,,4493.34,2920.67,,,,,,,,,,,,,
GRAFT DURA PTCH MED 8X10 CM DURAMATER,SUP-2321733,CDM,C1713,HCPCS,0278,RC,,,,both,,,6311.40,4102.41,,,,,,,,,,,,,
HYALURONIDASE HUMAN 150 UNIT/ML IJ SOLN,RX-76338,CDM,J3473,HCPCS,0636,RC,18657-0117-04,NDC,,both,0.02,ML,54.10,35.16,,,,,,,,,,,,,
CATHETER HD STR EXTN 12.5 FRX30 CM TRPL LUMEN MAHRK ELITE,SUP-2626948,CDM,C1752,HCPCS,0278,RC,,,,both,,,208.90,135.78,,,,,,,,,,,,,
GRAFT BONE L14XW11XH7MM 7DEG CERV SPCR INTBDY LORDTC STRL,SUP-2415683,CDM,C1713,HCPCS,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
LEAD DEFIB 5.6FR L65CM PERM TRNSVEN BPLR ACT FIX STEROID,SUP-2356668,CDM,C1777,HCPCS,0275,RC,,,,both,,,13345.00,8674.25,,,,,,,,,,,,,
PLATE BNE L69.3MM 10 H ST BILAT VAR LOK NONCOMPRESSION,SUP-2349959,CDM,C1713,HCPCS,0278,RC,,,,both,,,6913.97,4494.08,,,,,,,,,,,,,
HC So Fungus ID Mold,PX-3008710766,CDM,87107,CPT,0300,RC,,,,both,,,85.00,55.25,,,,,,,,,,,,,
CATHETER MAP 2 MM 8 FRX120 CM 31 MM 64 ELECTRD CONSTELLATION,SUP-2424694,CDM,C1732,HCPCS,0272,RC,,,,both,,,11486.12,7465.98,,,,,,,,,,,,,
BRACE WALKING 14-17 IN XL CUSH LP NYL PROCARE MAXTRAX,SUP-2197143,CDM,L4360,HCPCS,0274,RC,,,,both,,,83.15,54.05,,,,,,,,,,,,,
INTRODUCER VASC 4FR L6CM DIL L2.5CM RADPQ W/O CRV HEMSTAT,SUP-2385179,CDM,C1894,HCPCS,0272,RC,,,,both,,,67.51,43.88,,,,,,,,,,,,,
GRAFT VASC BOR SZ 28MM MAX SKRT L28MM DIA36MM BODY 15CM,SUP-2384986,CDM,C1768,CPT,0278,RC,,,,both,,,6157.54,4002.40,,,,,,,,,,,,,
ROD 11MM 600MM C FBR,SUP-2188675,CDM,2720000010,LOCAL,0272,RC,,,,both,,,593.46,385.75,,,,,,,,,,,,,
HC Molecular Pathology,PX-3108138166,CDM,81381,CPT,0310,RC,,,,both,,,437.00,284.05,,,,,,,,,,,,,
CMHP GENTAMICIN IRRIGATION,RX-40851013,CDM,2500000003,HCPCS,0250,RC,09999-9902-29,NDC,,both,1000,ML,60.00,39.00,,,,,,,,,,,,,
HC Inj Sinus Tract Therapeutic,PX-3612050000,CDM,20500,CPT,0361,RC,,,,both,,,1586.00,1030.90,,,,,,,,,,,,,
PLATE BNE OSTEOTMY 130 DEG AD 4.5X100 MM TI NS DCP,SUP-2569054,CDM,C1713,HCPCS,0278,RC,,,,both,,,1690.76,1098.99,,,,,,,,,,,,,
FLUCONAZOLE 100 MG PO TABS,RX-10044,CDM,6370000000,HCPCS,0637,RC,68462-0102-30,NDC,,both,1,UN,4.50,2.92,,,,,,,,,,,,,
HALF PIN EXT FIX L20MM DIA3MM DSTL RAD FOR JET-X MINI EXT,SUP-2342887,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1251.82,813.68,,,,,,,,,,,,,
CANNULA SUCTION L8 7/8IN WORKING L65MM DIAMETER 3.5MM FOR NE,SUP-2804634,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1031.96,670.77,,,,,,,,,,,,,
IMPLANT MESH DYNAMIC  1.7  200X200X8,SUP-2761706,CDM,C1713,HCPCS,0278,RC,,,,both,,,24907.33,16189.76,,,,,,,,,,,,,
GUIDEWIRE ORTH SHT 115 MM 47 IN MARKER NIT CORAL,SUP-2707642,CDM,C1769,HCPCS,0272,RC,,,,both,,,188.40,122.46,,,,,,,,,,,,,
PLATE BONE L102MM 8 H STRL S STL COMPR FOR 3.5MM SCR EVOS,SUP-2349638,CDM,C1713,HCPCS,0278,RC,,,,both,,,1163.50,756.27,,,,,,,,,,,,,
PATCH EVER CORNEAT,SUP-2890361,CDM,C1781,HCPCS,0278,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
PLATE BNE THK0.6MM 6X2 H BILAT HND TRAPEZOIDAL,SUP-2267897,CDM,C1713,HCPCS,0278,RC,,,,both,,,926.93,602.50,,,,,,,,,,,,,
GRAFT BNE SUB 15CC 17 10MM CANC CHIP READIGRFT,SUP-2264673,CDM,C1713,HCPCS,0278,RC,,,,both,,,691.96,449.77,,,,,,,,,,,,,
HC Slctv Cath Carotid/Innom Art Angio Xtrcranl Art,PX-3613622200,CDM,36222,CPT,0361,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
PLATE BNE RND 1.5X100X0.4 MM MESH MALL CONTOURABLE TI NS LF,SUP-2191125,CDM,C1713,HCPCS,0278,RC,,,,both,,,6524.29,4240.79,,,,,,,,,,,,,
SHELL ACET OD70MM ID28MM UNIV PPS HIP RECON QUAD SPRNG,SUP-2403694,CDM,C1776,CPT,0278,RC,,,,both,,,4860.72,3159.47,,,,,,,,,,,,,
GRAFT BNE SUB W25XL50MM THK3MM CHRONOS SYN TISS STRP,SUP-2182831,CDM,C1713,HCPCS,0278,RC,,,,both,,,2190.15,1423.60,,,,,,,,,,,,,
PLATE BONE H2.8MM 17 H MAND TI STR SEC RECON LEIBINGER,SUP-2363749,CDM,C1713,HCPCS,0278,RC,,,,both,,,3283.91,2134.54,,,,,,,,,,,,,
Z DISCONTINUED NO SUB IDED BOOT CAST W/ CUF XL BLK,SUP-2277491,CDM,L4386,HCPCS,0274,RC,,,,both,,,267.06,173.59,,,,,,,,,,,,,
PLATE BNE RECON UNIV 2.7 MM 6 HOLE 2 COMPR LCK FOR SCR TI NS,SUP-2462930,CDM,C1713,HCPCS,0278,RC,,,,both,,,1045.31,679.45,,,,,,,,,,,,,
BASEPLATE TIB CRUC RET STD UNIV PRI PEG PRESSFIT POR SZ 1,SUP-2201351,CDM,C1776,CPT,0278,RC,,,,both,,,8760.60,5694.39,,,,,,,,,,,,,
PIN FIX L9IN DIA32MM ST S STL 2 SIDE DBL DMND BOTH END PNT,SUP-2150543,CDM,C1713,HCPCS,0278,RC,,,,both,,,25.62,16.65,,,,,,,,,,,,,
COLLAR CERV FOAM PADDING PEDIATRIC CH TODDLER 2 IN PROCARE,SUP-2195749,CDM,L0180,HCPCS,0274,RC,,,,both,,,81.01,52.66,,,,,,,,,,,,,
IMPLANT HUM TISS L 2 X W 2 CM PLCNTA MTRX MEMBRN DEHYDR ASEP,SUP-2905494,CDM,Q4184,HCPCS,0636,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
GUIDEWIRE VASC L 110 CM DIA 0.018 IN TIP CRV RAD 10 MM SS,SUP-2169668,CDM,C1769,HCPCS,0272,RC,,,,both,,,192.64,125.22,,,,,,,,,,,,,
PL LCKNG RCN ANG ANG36H T28MM,SUP-2694247,CDM,C1713,HCPCS,0278,RC,,,,both,,,9665.89,6282.83,,,,,,,,,,,,,
CABLE SPNL STRL LIGAPASS 2.0,SUP-2926032,CDM,C1713,HCPCS,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
HC Sputum Obtaining Spec Aerosol Induced Tx Spx,PX-4108922000,CDM,89220,CPT,0300,RC,,,,outpatient,,,39.00,25.35,,,,,,,,,,,,,
PLATE BNE L 145 X W 8 MM THK 3.5 MM SCREW DIA2.7 MM 18 H SS 72440318N,SUP-2933070,CDM,C1713,HCPCS,0278,RC,,,,both,,,2142.45,1392.59,,,,,,,,,,,,,
BLOCK GUID 6 H FOR 2.4MM VAR ANG 2 CLMN L DST RAD PLT LCP,SUP-2187380,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1322.41,859.57,,,,,,,,,,,,,
PLATE BNE L 195 MM SHFT THK 3 MM HD 2 MM SCREW DIA2.7/3.5 MM,SUP-2931147,CDM,C1713,HCPCS,0278,RC,,,,both,,,6132.42,3986.07,,,,,,,,,,,,,
PROSTHESIS PENILE 18 CM PMP ULTREX,SUP-2140262,CDM,C1813,HCPCS,0278,RC,,,,both,,,11068.50,7194.52,,,,,,,,,,,,,
PREGABALIN 75 MG PO CAPS,RX-42164,CDM,6370000000,HCPCS,0637,RC,62332-0121-90,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
HEAD HUM H21MM DIA52MM SFT TISS BALANCING SIMPLICITI,SUP-2388563,CDM,C1776,CPT,0278,RC,,,,both,,,11468.85,7454.75,,,,,,,,,,,,,
BRACE ANK AIR STRRP PED HT 6 IN,SUP-2336084,CDM,L4350,HCPCS,0274,RC,,,,both,,,31.81,20.68,,,,,,,,,,,,,
SPHERE GLEN DIA40MM CO CHROM GLENOSPHR,SUP-2265042,CDM,C1776,CPT,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
SCREW BNE L 42 MM DIA 5.5 MM SHRT TI CANN HDLSS NS LEOS,SUP-2931461,CDM,C1713,HCPCS,0278,RC,,,,both,,,1202.46,781.60,,,,,,,,,,,,,
PLATE BONE LOK NON CMPRSSN HLX12 1MM THK TTNM LATEX FREE MND,SUP-2680146,CDM,C1713,HCPCS,0278,RC,,,,both,,,1592.45,1035.09,,,,,,,,,,,,,
BUR SURG DMND RND N FLUT COARSE 2.0MM ELITE TPS,SUP-2364025,CDM,2720000010,LOCAL,0272,RC,,,,both,,,217.60,141.44,,,,,,,,,,,,,
CATHETER CV DL 0.018 IN 5 FRX60 CM 150 CM OTW TURBO FLO,SUP-2170005,CDM,C1751,HCPCS,0278,RC,,,,both,,,312.96,203.42,,,,,,,,,,,,,
KIT CATH HEMODIALYSI SPLIT CATH III CHRONIC 14FR DIA 40CM 35,SUP-2610494,CDM,C1750,HCPCS,0278,RC,,,,both,,,998.52,649.04,,,,,,,,,,,,,
COIL EMB 10 L2CM OD2MM HELCL STRTCH RESIST HYDRGEL V-TRAK,SUP-2305135,CDM,C1889,HCPCS,0278,RC,,,,both,,,3689.50,2398.17,,,,,,,,,,,,,
SCREW BNE NLCK 2.7X22 MM,SUP-2363510,CDM,C1713,HCPCS,0278,RC,,,,both,,,200.83,130.54,,,,,,,,,,,,,
KIT ART CATH 0.021INCH 40CENTIMETER GWIRE 21GAUGE 2INCH NDL,SUP-2120112,CDM,C1751,HCPCS,0278,RC,,,,both,,,266.90,173.48,,,,,,,,,,,,,
FORCEPS SURG 33X3CM CUT W/ CRD 9 PIN PLASMACISION 920005PK] OLYMPUS SURGICAL TECH - GYRUS],SUP-2313943,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2275.24,1478.91,,,,,,,,,,,,,
GRAFT VASC RESTOREFLOW SZ 25 MM PA COMPETENT VLV STRL,SUP-2884041,CDM,C1768,CPT,0278,RC,,,,both,,,60441.86,39287.21,,,,,,,,,,,,,
DEVICE STONE RMVL 115MM DIA BLLN 55FR OD TIP 30MM CUT WIRE,SUP-2675768,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1093.44,710.74,,,,,,,,,,,,,
STENT ENDOPROS L10CM DIA7MM CATH 8FR L120CM BLLN DIA7MM,SUP-2396558,CDM,C1874,HCPCS,0278,RC,,,,both,,,11209.80,7286.37,,,,,,,,,,,,,
NAIL INTRMDLLRY L180MM D10MM ANKLE TTNM CORE LOCK TCHNLGY DU,SUP-2460343,CDM,C1713,HCPCS,0278,RC,,,,both,,,8107.92,5270.15,,,,,,,,,,,,,
CANNULA SUCTION HAGAN 23 GAX20 MM SS,SUP-2471430,CDM,2720000010,LOCAL,0272,RC,,,,both,,,393.91,256.04,,,,,,,,,,,,,
MORCELLATOR LAP CRDLSS DISP FOR CUT THRU FIBROTIC UTERI,SUP-2265062,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2466.47,1603.21,,,,,,,,,,,,,
GRAFT DERMAL FEN 25X10 CM CLLGN TISS MTRX,SUP-2243689,CDM,Q4110,HCPCS,0636,RC,,,,both,,,21980.00,14287.00,,,,,,,,,,,,,
ORTHOSIS ANK FT SM SZ M 6-7.5 WOM 7.5-9 RT CLOSE HEEL DLX,SUP-2195190,CDM,L1930,HCPCS,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC MAXBARR 5FR 55CM 1 LUMAN R 3175108D,SUP-2632656,CDM,C1751,HCPCS,0278,RC,,,,both,,,513.45,333.74,,,,,,,,,,,,,
INSERT TIB BUMPER 3 DEG,SUP-2452026,CDM,C1776,CPT,0278,RC,,,,both,,,2167.54,1408.90,,,,,,,,,,,,,
IMPLANT ANTIREFLX 15 BEAD GASTROESOPHAGEAL TI MAG LINX,SUP-2388509,CDM,C1889,HCPCS,0278,RC,,,,both,,,18840.00,12246.00,,,,,,,,,,,,,
STEM FEM REV 0+ MM SHT 19 MM HIP POLISHED EMPERION,SUP-2434542,CDM,C1776,CPT,0278,RC,,,,both,,,13238.24,8604.86,,,,,,,,,,,,,
CATH IVUS VISIONS PV .018 OTW,SUP-2849671,CDM,C1753,HCPCS,0278,RC,,,,both,,,2417.80,1571.57,,,,,,,,,,,,,
GRAFT TISS SZ 2X3CM SINONASAL REP MR SAFE BIODESIGN,SUP-2170296,CDM,C1763,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
KIT TROCHLEOPLASTY W/ 2.9MM BUR SL,SUP-2419177,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
GRAFT BNE WDG 5 MM COTTON TITAN 3-D,SUP-2421813,CDM,C1713,HCPCS,0278,RC,,,,both,,,6539.05,4250.38,,,,,,,,,,,,,
BIT DRL FLUT 0.6X148 MM 15 MM HOUGH STAPEDIAL SS MICROFRANCE,SUP-2475155,CDM,2720000010,LOCAL,0272,RC,,,,both,,,420.85,273.55,,,,,,,,,,,,,
COMPONENT SHLDR LAT AUG BASEPLT AEQUALIS REVERSED FX ASCEND,SUP-2419085,CDM,C1776,CPT,0278,RC,,,,both,,,24492.00,15919.80,,,,,,,,,,,,,
PLATE BONE L48MM 5 H TI MIDFOOT STR W/ SLOT FOR,SUP-2225436,CDM,C1713,HCPCS,0278,RC,,,,both,,,4092.05,2659.83,,,,,,,,,,,,,
PLATE STRNL CLOSURE THK 1.5 MM 10 H TI MANUBRIUM LP NS,SUP-2894547,CDM,C1713,HCPCS,0278,RC,,,,both,,,3843.36,2498.18,,,,,,,,,,,,,
PROSTHESIS MXLFCL ADD RECON VSP,SUP-2862822,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5185.52,3370.59,,,,,,,,,,,,,
COIL EMB L2CM DIA3-2MM CATH DIA0.018IN FOR AV MALFORMATION,SUP-2168310,CDM,C1889,HCPCS,0278,RC,,,,both,,,366.88,238.47,,,,,,,,,,,,,
GRAFT BNE SUB 30ML 01 2MM CORT CANC GRAN MORSELIZED FRZ DRY,SUP-2307061,CDM,C1713,HCPCS,0278,RC,,,,both,,,1379.72,896.82,,,,,,,,,,,,,
BOLT TISS ATTACH SH TI STRL MOST OPTIONS,SUP-2208299,CDM,C1713,HCPCS,0278,RC,,,,both,,,765.85,497.80,,,,,,,,,,,,,
BIT DRL CANN LG 5X215 MM QC STRL,SUP-2563804,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1462.99,950.94,,,,,,,,,,,,,
INTRODUCER SHTH 5FR L11CM GWIRE 0038IN GRY HUB POLYPR,SUP-2303255,CDM,C1894,HCPCS,0272,RC,,,,both,,,27.66,17.98,,,,,,,,,,,,,
SET SHTH DESTINO TWST L 71 CM DIA13.8 FR CRV BEND 39 MM DIL,SUP-2616241,CDM,C1766,CPT,0272,RC,,,,both,,,3124.30,2030.79,,,,,,,,,,,,,
SET DIL RENAL GRAD AMPLATZ,SUP-2139229,CDM,C1894,HCPCS,0272,RC,,,,both,,,780.48,507.31,,,,,,,,,,,,,
ASSEMBLY SWIVEL CONNECTOR ION IF1000,SUP-2844581,CDM,2720000010,LOCAL,0272,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
GRAFT VASC IMPRA L 60 CM DIA 6 MM EPTFE STR STD WALL N RING,SUP-2761312,CDM,C1768,CPT,0278,RC,,,,both,,,2218.10,1441.76,,,,,,,,,,,,,
COIL VASC AZUR CX L 24 CM DIA 8 MM MICROCATHETER 0.018 IN,SUP-2385450,CDM,C1889,HCPCS,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
BLANK RST PAN POS SP 1 8 INFIN M,SUP-2163841,CDM,L3807,HCPCS,0274,RC,,,,both,,,39.00,25.35,,,,,,,,,,,,,
ENDOSCOPIC PACK 1.5 MM RAP PAC LTX,SUP-2848583,CDM,2720000010,LOCAL,0272,RC,,,,both,,,840.74,546.48,,,,,,,,,,,,,
ANCHOR SUT L38IN OD5MM SZ 2 PLLA DBL ARMED ABSRB ULTRABRAID,SUP-2341745,CDM,C1713,HCPCS,0278,RC,,,,both,,,1203.41,782.22,,,,,,,,,,,,,
GUIDEWIRE ORTH TRCR PT 1 END 0.8X100 MM STRL,SUP-2789088,CDM,C1769,HCPCS,0272,RC,,,,both,,,966.62,628.30,,,,,,,,,,,,,
GUIDEWIRE ORTHOPEDIC 240 MM NEWPORT MIS,SUP-2245925,CDM,C1769,HCPCS,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
SYSTEM THERMOABLATION COBRA FUSION MAG RETRV W/ CAP TBNG,SUP-2124419,CDM,C1713,HCPCS,0278,RC,,,,both,,,10676.00,6939.40,,,,,,,,,,,,,
SET INT FIX 2 H MED TI NEURO PLATE ST SCREW STRL DISP LORENZ,SUP-2936148,CDM,C1713,HCPCS,0278,RC,,,,both,,,1284.26,834.77,,,,,,,,,,,,,
PLATE 3.5MM TI LCP PERIARTIC PROX HUM 6H 163MM RT STRL,SUP-2546845,CDM,C1713,HCPCS,0278,RC,,,,both,,,6079.73,3951.82,,,,,,,,,,,,,
ENVELOPE CV DEVICEXL W6.9XL9.5CM PORCINE DERIVED,SUP-2172041,CDM,C1889,HCPCS,0278,RC,,,,both,,,3030.10,1969.56,,,,,,,,,,,,,
INTRODUCER SHTH 12FR L30CM 0.038IN HEMSTAS VLV L LUMN GWIRE,SUP-2355435,CDM,C1894,HCPCS,0272,RC,,,,both,,,270.83,176.04,,,,,,,,,,,,,
LOOP OSS HOUSE TYP 0.13X4.25 MM WIRE TANTALUM,SUP-2637831,CDM,L8613,CPT,0278,RC,,,,both,,,250.54,162.85,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY DIA 6 FR STEER DYN STRL,SUP-2126348,CDM,C1733,HCPCS,0272,RC,,,,both,,,1714.44,1114.39,,,,,,,,,,,,,
PUNCH UP BIG BITE 34MM 15DEG,SUP-2361349,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3223.30,2095.14,,,,,,,,,,,,,
RING EXT FIX HALF 150 MM CARBON FIBER RINGFIX,SUP-2365278,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3246.76,2110.39,,,,,,,,,,,,,
IMMOBILIZER KNEE L19IN ELAS STRP AND T BAR CUTAWAY,SUP-2194898,CDM,L1830,CPT,0274,RC,,,,both,,,53.63,34.86,,,,,,,,,,,,,
GRAFT EVAR L140MM DIAM 23MM AORT AND 14.5MM IL ABD AORT IL,SUP-2395974,CDM,C1768,CPT,0278,RC,,,,both,,,26281.80,17083.17,,,,,,,,,,,,,
COUNTERSINK SURG DRL DIA4MM CANN FOR FIXOS SYS,SUP-2378069,CDM,2720000010,LOCAL,0272,RC,,,,both,,,675.10,438.81,,,,,,,,,,,,,
GRAFT BNE STRP 6 CC ISOTIS PURE,SUP-2644342,CDM,C1713,HCPCS,0278,RC,,,,both,,,3366.08,2187.95,,,,,,,,,,,,,
PLATE SPNL 4 LEVEL 61 MM ANTR CERV C-TEK,SUP-2414503,CDM,C1713,HCPCS,0278,RC,,,,both,,,6245.46,4059.55,,,,,,,,,,,,,
KIT IMPL L CUST CRAN CMF,SUP-2363697,CDM,C1713,HCPCS,0278,RC,,,,both,,,40119.78,26077.86,,,,,,,,,,,,,
DRILL TWST L 54 MM DIA1 MM STP 12 MM CHK NS DISP LEIBINGER,SUP-2883217,CDM,2720000010,LOCAL,0272,RC,,,,both,,,384.90,250.18,,,,,,,,,,,,,
GRAFT HUM TISS W16XL20CM THK.9-1.99MM ACELLULAR DERM MTRX,SUP-2402516,CDM,Q4126,HCPCS,0636,RC,,,,both,,,50240.00,32656.00,,,,,,,,,,,,,
MINI CMPRSSN PLATE STRGHT 8 HOLE 20MM CP TTNM,SUP-2681042,CDM,C1713,HCPCS,0278,RC,,,,both,,,867.68,563.99,,,,,,,,,,,,,
MESH SURG 60X53X0.3 MM TI LEVEL 1 NEURO,SUP-2497077,CDM,C1713,HCPCS,0278,RC,,,,both,,,945.96,614.87,,,,,,,,,,,,,
SUTURE ULTRATAPE SZ 2 NONABSORBABLE BLU COBRAID 72203897,SUP-2341899,CDM,C1713,HCPCS,0278,RC,,,,both,,,194.68,126.54,,,,,,,,,,,,,
HC Nasal Bones Min 3 Views,PX-3207016000,CDM,70160,CPT,0320,RC,,,,outpatient,,,693.00,450.45,,,,,,,,,,,,,
HC So Antb Severe Aqt Respir Synd Sars-Cov-D Covid-19,PX-3028676966,CDM,86769,CPT,0302,RC,,,,both,,,74.00,48.10,,,,,,,,,,,,,
CATH ENROUTE ENFLATE TRANSCAROT RX BLLN DILATATION 4X25,SUP-2854415,CDM,C1725,HCPCS,0272,RC,,,,both,,,1064.46,691.90,,,,,,,,,,,,,
PLATE BNE ANGLED 2.8 MM LT 7X23 HOLE RECON TI PT SPEC,SUP-2860110,CDM,C1713,HCPCS,0278,RC,,,,both,,,23366.94,15188.51,,,,,,,,,,,,,
CATHETER PICC AD 4FR L55CM SGL LUMN NRS PWR INJ N COAT CT,SUP-2125634,CDM,C1751,HCPCS,0278,RC,,,,both,,,624.55,405.96,,,,,,,,,,,,,
PIN FIX L16MM STD CERV NEURO CONSTRUCT SECUR PLT,SUP-2255661,CDM,2720000010,LOCAL,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
PLATE BNE CALCANEAL SM,SUP-2316474,CDM,C1713,HCPCS,0278,RC,,,,both,,,3734.40,2427.36,,,,,,,,,,,,,
CROWN DENT SZ 41 POLYCARB 1ST BICUSPID,SUP-2238429,CDM,D6783,CPT,0278,RC,,,,both,,,2.20,1.43,,,,,,,,,,,,,
TI NARROW 3 HOLE PLATE 39MM,SUP-2704598,CDM,C1713,HCPCS,0278,RC,,,,both,,,243.98,158.59,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 50 CM DIA12 X 6 MM EPTFE BIFURCATE,SUP-2396245,CDM,C1768,CPT,0278,RC,,,,both,,,3749.16,2436.95,,,,,,,,,,,,,
ELECTRODE ES 14GA L25CM SEMI FLX FOR TISS ABLAT STARBURST,SUP-2118720,CDM,C1894,HCPCS,0272,RC,,,,both,,,7897.10,5133.11,,,,,,,,,,,,,
ALLOGRAFT BNE WDG 17-19 MM FD ILIUM TRICORT,SUP-2717915,CDM,C1713,HCPCS,0278,RC,,,,both,,,5275.99,3429.39,,,,,,,,,,,,,
CATHETER HD STR 16 FRX28 CM 23 CM SPLIT TIP LT EQUISTREAM XK,SUP-2126537,CDM,C1750,HCPCS,0278,RC,,,,both,,,1483.65,964.37,,,,,,,,,,,,,
ANCHOR SUT SZ 4.5MM WHT BLU BIOCRYL RAPIDE UHMWPE BRAID FLAT,SUP-2256667,CDM,C1713,HCPCS,0278,RC,,,,both,,,1745.84,1134.80,,,,,,,,,,,,,
NUT ORTH LCK FOR 9-12 MM UNIV FEM NAIL,SUP-2548734,CDM,C1713,HCPCS,0278,RC,,,,both,,,390.71,253.96,,,,,,,,,,,,,
PLATE BONE SM L26MM 2 H STD BILAT COMPR CNTOUR + FOR 3.5MM,SUP-2348989,CDM,C1713,HCPCS,0278,RC,,,,both,,,1120.85,728.55,,,,,,,,,,,,,
LAPIDUS DOME WASHER ORTHOLOC 2 LAPIFUSE,SUP-2830188,CDM,C1713,HCPCS,0278,RC,,,,both,,,285.74,185.73,,,,,,,,,,,,,
"HC So Blood Typing, Rh(D)",PX-3008690166,CDM,86901,CPT,0302,RC,,,,both,,,161.00,104.65,,,,,,,,,,,,,
PLATE BNE L60MM 15 H CALCNL FOR 35MM SCR,SUP-2199385,CDM,C1713,HCPCS,0278,RC,,,,both,,,1262.66,820.73,,,,,,,,,,,,,
BIT DRL L190MM DIA10MM CANN W/O STP QUIK CPL REUSE,SUP-2188295,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1607.27,1044.73,,,,,,,,,,,,,
KIT INTRO L 14 CM DIA14 FR GUIDEWIRE L 50 CM DIA 0.038 IN,SUP-2125279,CDM,C1892,HCPCS,0272,RC,,,,both,,,108.30,70.39,,,,,,,,,,,,,
IMPLANT FNGR JT 3X30MM 10DEG PROX INTERPHALANGEAL DART PEEK,SUP-2121835,CDM,C1713,HCPCS,0278,RC,,,,both,,,1868.30,1214.39,,,,,,,,,,,,,
SET INT FIX SCREW DIA1.5 MM TI NEURO 1 DBL Y SHP XLN PLATE 1,SUP-2936729,CDM,C1713,HCPCS,0278,RC,,,,both,,,2527.70,1643.00,,,,,,,,,,,,,
CABLE BNE FIX DIA1.5MM POLYMER FLX TENSILE STRENGTH W/ TI,SUP-2262260,CDM,C1713,HCPCS,0278,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
HYALURONIDASE HUMAN 15 UNITS/ML IJ SYRINGE,RX-4081893,CDM,J3473,HCPCS,0636,RC,09999-9915-13,NDC,,both,0.2,ML,54.40,35.36,,,,,,,,,,,,,
GRAFT BNE SCAFFOLD 20X20X4 MM MOLD DBM FUSIONFLEX 86082040,SUP-2859710,CDM,C1713,HCPCS,0278,RC,,,,both,,,7300.50,4745.32,,,,,,,,,,,,,
BUTTON CBL 3.5MM HIP S STL HEX USE W/ 1.3MM/1.8MM CBL,SUP-2410259,CDM,C1776,CPT,0278,RC,,,,both,,,248.41,161.47,,,,,,,,,,,,,
FLUTICASONE PROPIONATE HFA 44 MCG/ACT IN AERO,RX-40697,CDM,6370000000,HCPCS,0637,RC,66993-0078-96,NDC,,both,10.6,GR,598.30,388.89,,,,,,,,,,,,,
GRAFT VASC L80CM ID8MM EPTFE HEP THN WALLED NONRINGED STR,SUP-2395821,CDM,C1768,CPT,0278,RC,,,,both,,,7451.22,4843.29,,,,,,,,,,,,,
BUR SURG DR LNG 3.5X19.8 MM FLUT FOR HD/HD-G1,SUP-2848174,CDM,2720000010,LOCAL,0272,RC,,,,both,,,516.66,335.83,,,,,,,,,,,,,
PLATE BONE CURVED 3.5X190 MM 16 HOLE RECONSTRUCTION FOR SCRE,SUP-2836673,CDM,C1713,HCPCS,0278,RC,,,,both,,,4523.01,2939.96,,,,,,,,,,,,,
SCREW BONE L14MM OD2.5MM CANN HD,SUP-2399804,CDM,C1713,HCPCS,0278,RC,,,,both,,,750.46,487.80,,,,,,,,,,,,,
ANCHOR SUTURE 4.5MM WITH WITH 3 HI FI NUMBER 2 SUTURES GENES,SUP-2824353,CDM,C1713,HCPCS,0278,RC,,,,both,,,1836.90,1193.98,,,,,,,,,,,,,
BRACE WR M L8IN LT FOAM LOOP LCK CLSR W/ THMB SPICA R-SOFT,SUP-2324348,CDM,L3931,HCPCS,0272,RC,,,,both,,,72.13,46.88,,,,,,,,,,,,,
SCREW INTRF L20MM DIA8MM ANTR KNEE PLLA HA CANN FOR CRUC,SUP-2341101,CDM,C1713,HCPCS,0278,RC,,,,both,,,1055.35,685.98,,,,,,,,,,,,,
COMPONENT TOT SHLDR CTA,SUP-2249611,CDM,C1776,CPT,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
PLATE BNE PROF THK 0.6 MM 2 X 2 H SCREW DIA2 MM LNG TI LT,SUP-2883753,CDM,C1713,HCPCS,0278,RC,,,,both,,,420.76,273.49,,,,,,,,,,,,,
BIT DRILL 6.4MM DIA 203MML STRGHT SHANK FLTD JACOB CHUCK END 6PK,SUP-2501028,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1138.44,739.99,,,,,,,,,,,,,
SUPPORT TENNIS ELBW GEL AIR FRARM CIRC 8-14IN REG,SUP-2324441,CDM,L3702,HCPCS,0274,RC,,,,both,,,31.97,20.78,,,,,,,,,,,,,
PLATE LOQTEQ VA VOLAR DISTAL RADIUS 2.5 BORAD 4 HL RT,SUP-2713862,CDM,C1713,HCPCS,0278,RC,,,,both,,,5290.27,3438.68,,,,,,,,,,,,,
HC Myocrd Strain Img Speckle Trck Assmt Myocrd Mech (Addon),PX-4839335600,CDM,93356,CPT,0483,RC,,,,both,,,818.00,531.70,,,,,,,,,,,,,
CATHETER ETER EP QPLR LIVEWIRE L115CM OD5FR L2MM,SUP-2356881,CDM,C1730,HCPCS,0272,RC,,,,both,,,1460.10,949.06,,,,,,,,,,,,,
PLIER SURG FOR 2 MM ADPT PLATE LEVEL 1 015101207,SUP-2473376,CDM,2720000010,LOCAL,0272,RC,,,,both,,,980.81,637.53,,,,,,,,,,,,,
CATHETER DRAINAGE EXT 35 CM CSF VENTRICULAR,SUP-2257147,CDM,C1729,HCPCS,0272,RC,,,,both,,,486.70,316.35,,,,,,,,,,,,,
SCREW BNE ST 3.5X24 MM W/ T15 STARDRV RECESS LCK FT TI NS,SUP-2190210,CDM,C1713,HCPCS,0278,RC,,,,both,,,375.89,244.33,,,,,,,,,,,,,
GRAFT ENDOVASC L108MM PROX L37MM DIA32MM DSTL L71MM DIA12MM,SUP-2171097,CDM,C1874,HCPCS,0278,RC,,,,both,,,21066.26,13693.07,,,,,,,,,,,,,
ALLOGRAFT BNE WDG 20X16 MM FD PAT,SUP-2717924,CDM,C1762,CPT,0278,RC,,,,both,,,5714.80,3714.62,,,,,,,,,,,,,
ANCHOR SUTURE PRE LD 2 2.9 MM W/ FORC FIBER QUATTRO GL2,SUP-2608893,CDM,C1713,HCPCS,0278,RC,,,,both,,,1209.78,786.36,,,,,,,,,,,,,
CATHETER MNOMTR 5-3.5FR TIP L5MM SH 0.018IN LEHMAN SPHIN OF,SUP-2169517,CDM,2720000010,LOCAL,0272,RC,,,,both,,,621.72,404.12,,,,,,,,,,,,,
SHELL ACET OD60MM UNIV TI HIP RNG SCR H RECON RESTR GAP,SUP-2370312,CDM,C1776,CPT,0278,RC,,,,both,,,5908.22,3840.34,,,,,,,,,,,,,
GRAFT VASC VENAFLO II L 40 CM DIA 6 MM EPTFE CARBON STR STD,SUP-2127045,CDM,C1768,CPT,0278,RC,,,,both,,,2163.46,1406.25,,,,,,,,,,,,,
BLADE RTRCTR MCCLLCH 27MMW X 60MML SPNL MSCLE WIDE RGGLS RDM,SUP-2668028,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1624.60,1055.99,,,,,,,,,,,,,
PLATE BNE L276MM 11 H NONSTERILE R DST FEM S STL LOK COMPR,SUP-2184899,CDM,C1713,HCPCS,0278,RC,,,,both,,,4574.57,2973.47,,,,,,,,,,,,,
GRAFT TISS FRZN ALLGRFT HUM DST STRUCTURAL L,SUP-2307325,CDM,C1713,HCPCS,0278,RC,,,,both,,,5338.38,3469.95,,,,,,,,,,,,,
SLEEVE COMPR 9 10IN UNIV AMBI CRPL GEL HYPOALRG REUSE,SUP-2340101,CDM,L3912,HCPCS,0272,RC,,,,both,,,53.16,34.55,,,,,,,,,,,,,
VALVE AORT ORIFICE DIA18.6MM TISS ANNULUS DIA21MM 85DEG,SUP-2355090,CDM,C1889,HCPCS,0278,RC,,,,both,,,13062.40,8490.56,,,,,,,,,,,,,
COVER CRAN L 41 X W 39 MM THK 0.3 MM SCREW DIA1.5 MM SM TI,SUP-2935870,CDM,C1713,HCPCS,0278,RC,,,,both,,,2364.42,1536.87,,,,,,,,,,,,,
URSODIOL 50 MG/ML PO SUSP,RX-4081111,CDM,6370000000,HCPCS,0637,RC,09999-9904-34,NDC,,both,6,ML,72.70,47.25,,,,,,,,,,,,,
PLATE BNE NAVICULAR LG 1.1 MM LT 9 HOLE TI BABY GORILLA,SUP-2750974,CDM,C1713,HCPCS,0278,RC,,,,both,,,3570.18,2320.62,,,,,,,,,,,,,
SLEEVE HUM DIA7MM PMMA COMPHSVE,SUP-2404529,CDM,C1776,CPT,0278,RC,,,,both,,,854.08,555.15,,,,,,,,,,,,,
SPLINT ORTH PLASTALUME 4.25X4.25 IN FNGR W/ BLB RADLUC,SUP-2276773,CDM,L3933,HCPCS,0272,RC,,,,both,,,4.33,2.81,,,,,,,,,,,,,
GRAFT BNE SUB 10CC CA PHSPTE FAST SET INJ DRILLABLE VOID,SUP-2182830,CDM,C1713,HCPCS,0278,RC,,,,both,,,7263.70,4721.40,,,,,,,,,,,,,
PLEDGET CV EDW L 15.2 X W 15.2 CM THK 0.91 MM PTFE FABRIC,SUP-2761344,CDM,C1768,CPT,0278,RC,,,,both,,,949.32,617.06,,,,,,,,,,,,,
BIT DRL L270MM DIA3.2MM PICCOLO COMP DSTL FEM PLT SYS,SUP-2152507,CDM,2720000010,LOCAL,0272,RC,,,,both,,,672.59,437.18,,,,,,,,,,,,,
DEFIBRILLATOR LUMAX500 VR T SYS W/ LANDLINE HM,SUP-2138274,CDM,C1722,HCPCS,0275,RC,,,,both,,,49455.00,32145.75,,,,,,,,,,,,,
GRAFT HUM TISS L150MM DIA10MM FEM SHFT FRZN,SUP-2307348,CDM,C1762,CPT,0278,RC,,,,both,,,4627.83,3008.09,,,,,,,,,,,,,
SUPPORT ORTHOT MTCRPL HND ADJ FIT PREFABRICATED,SUP-2435778,CDM,L3917,HCPCS,0272,RC,,,,both,,,272.08,176.85,,,,,,,,,,,,,
ELECTRODE ELECSURG LOOP STD 2.5 MM BPLR CUT PLASMAKINETIC,SUP-2747328,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1520.95,988.62,,,,,,,,,,,,,
PIN FIX L229MM OD2MM S STL SGL TRCR PNT N THRD STNMN,SUP-2303793,CDM,C1713,HCPCS,0278,RC,,,,both,,,14.82,9.63,,,,,,,,,,,,,
ALLOGRAFT BNE SHFT FD HUM,SUP-2321815,CDM,C1713,HCPCS,0278,RC,,,,both,,,2279.64,1481.77,,,,,,,,,,,,,
HC Oscill Chest Wall Mechani,PX-4109466900,CDM,94669,CPT,0410,RC,,,,both,,,496.00,322.40,,,,,,,,,,,,,
GRAFT BNE BNE BRIDGE RT MENIS LAT FRZN BIOCLEANSE,SUP-2335263,CDM,C1713,HCPCS,0278,RC,,,,both,,,16956.00,11021.40,,,,,,,,,,,,,
TWISTER WIRE LUQ,SUP-2410238,CDM,C1713,HCPCS,0278,RC,,,,both,,,993.56,645.81,,,,,,,,,,,,,
GRAFT HUM TISS 3X8CM AMNION CYGNUS MAX,SUP-2393051,CDM,Q4170,HCPCS,0636,RC,,,,both,,,7536.00,4898.40,,,,,,,,,,,,,
HC Inj Aa&/Strd Nerves Nrvtg Si Joint W/Img,PX-3616445100,CDM,64451,CPT,0361,RC,,,,outpatient,,,3707.00,2409.55,,,,,,,,,,,,,
GUIDEWIRE K PARTIAL-THRD 2.2MM DIA 4.73INL 30MM THRD LEN NS,SUP-2316518,CDM,C1769,HCPCS,0272,RC,,,,both,,,90.12,58.58,,,,,,,,,,,,,
DRIVER SURG BALL TIP LOK SPNL ATLNTS NONSTERILE REUSE,SUP-2279321,CDM,2720000010,LOCAL,0272,RC,,,,both,,,466.98,303.54,,,,,,,,,,,,,
GRAFT HUM TISS L 4 X W 4 CM PLCNTA MEMBRN ALLGRFT CROSS,SUP-2909414,CDM,Q4109,HCPCS,0636,RC,,,,both,,,43551.80,28308.67,,,,,,,,,,,,,
MODEL ANAT FULL SKULL PED UPTO 5YR 3D CT BASE SEL CLR VITAL,SUP-2883637,CDM,2720000010,LOCAL,0272,RC,,,,both,,,15657.74,10177.53,,,,,,,,,,,,,
SYSTEM FIX BNE TEND BNE W/ 10MM FLIPCUTTER II TIGHTROPE,SUP-2121385,CDM,C1713,HCPCS,0278,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
KIT DBS DEPTH STOP CRAN TUNN STRL DISP SENSIGHT,SUP-2883058,CDM,2720000010,LOCAL,0272,RC,,,,both,,,894.90,581.68,,,,,,,,,,,,,
LINER ACET SZ 26 DIA38MM 10DEG RINGLOC ARCOMXL,SUP-2409519,CDM,C1776,CPT,0278,RC,,,,both,,,3857.49,2507.37,,,,,,,,,,,,,
METHOCARBAMOL 750 MG PO TABS,RX-4972,CDM,6370000000,HCPCS,0637,RC,70010-0770-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
HC CT Soft Tissue Neck W/O Contrast,PX-3517049000,CDM,70490,CPT,0351,RC,,,,both,,,2388.00,1552.20,,,,,,,,,,,,,
PROBE ABLAT 17GA L15CM MICWV NEUWAVE LK,SUP-2219546,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6217.20,4041.18,,,,,,,,,,,,,
HC Biopsy of Liver; Perc Needle,PX-3614700100,CDM,47001,CPT,0361,RC,,,,outpatient,,,3707.00,2409.55,,,,,,,,,,,,,
PACEMAKER CARD INSIGNIA I ENTRA W 4.4 X H 5.2 CM THK 0.65 CM,SUP-2148600,CDM,C1786,HCPCS,0275,RC,,,,both,,,15046.88,9780.47,,,,,,,,,,,,,
CAGE SPNL W10XH10XL28MM 5DEG ANTR THORLUM C FBR REINF,SUP-2254814,CDM,C1889,HCPCS,0278,RC,,,,both,,,17034.50,11072.42,,,,,,,,,,,,,
BRACE ORTH CLOSURE XL AD BK SHLDR BLK QUIKDRAW PRO,SUP-2123913,CDM,L0628,HCPCS,0274,RC,,,,both,,,321.98,209.29,,,,,,,,,,,,,
BLADE SAW 90X25X1.37MM OSC RIB FOR OXFORD PART KNEE STRYKR,SUP-2136844,CDM,2720000010,LOCAL,0272,RC,,,,both,,,555.78,361.26,,,,,,,,,,,,,
GRAFT ALLGRFT STRUT CORT CANC 60MM LX8MM W 6 EA FRZ DRY,SUP-2307181,CDM,C1713,HCPCS,0278,RC,,,,both,,,2872.16,1866.90,,,,,,,,,,,,,
SCREW BNE L 54 MM DIA 5.5 MM LNG TI CANN HDLSS NS LEOS,SUP-2931481,CDM,C1713,HCPCS,0278,RC,,,,both,,,1018.90,662.28,,,,,,,,,,,,,
HC Cessj Therapy Cath Removal,PX-3613721400,CDM,37214,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
CATHETER CTRL VEN SET DBL LUMN W/ + 7FR 20CM LEN ARROWGUARD,SUP-2383446,CDM,C1751,HCPCS,0278,RC,,,,both,,,174.33,113.31,,,,,,,,,,,,,
SCREW BNE L14MM DIA4MM PERIARTC S STL ST LOK FULL THRD FOR,SUP-2184945,CDM,C1713,HCPCS,0278,RC,,,,both,,,599.11,389.42,,,,,,,,,,,,,
SYSTEM CATH INTRO L60CM 0.018IN N VASC DISP FOR PERC DRNGE,SUP-2167940,CDM,C1769,HCPCS,0272,RC,,,,both,,,230.88,150.07,,,,,,,,,,,,,
REAMER SURG DIA2.7MM CANN FOR 4MM SCR,SUP-2342388,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3152.40,2049.06,,,,,,,,,,,,,
PLATE BNE LCK UNIV 3.5 MM 6 HOLE CONTOURED 2 COMPR RECON,SUP-2486637,CDM,C1713,HCPCS,0278,RC,,,,both,,,1324.73,861.07,,,,,,,,,,,,,
BASKET RETRV L1950MM DIA22MM MIN WRK CHN 28MM SFT WIRE BULL,SUP-2313137,CDM,C1713,HCPCS,0278,RC,,,,both,,,378.56,246.06,,,,,,,,,,,,,
TROCAR ENDOSCP L100MM DIA10MM STRUCTURAL BLLN FOR LAP,SUP-2283314,CDM,2720000010,LOCAL,0272,RC,,,,both,,,487.14,316.64,,,,,,,,,,,,,
GRAFT VASC GELSFT L 60 CM DIA10 MM POLYESTER GEL ABD PERIPH,SUP-2384967,CDM,C1768,CPT,0278,RC,,,,both,,,1383.11,899.02,,,,,,,,,,,,,
CATHETER ABLATN RF SYS OPN IRRIG INTELLANAV MIFI,SUP-2424674,CDM,C1732,HCPCS,0278,RC,,,,both,,,8635.00,5612.75,,,,,,,,,,,,,
CATHETER ANGIOPLSTY L 140 CM BALLOON L 15 MM DIA2 MM NC24,SUP-2928715,CDM,C1713,HCPCS,0278,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
CATHETER ABLATN RF SYS OPN IRRIG INTELLANAV MIFI,SUP-2424674,CDM,C1732,HCPCS,0272,RC,,,,both,,,8635.00,5612.75,,,,,,,,,,,,,
TRIAL PLATE MTCRPL NK 1.3 MM RT,SUP-2525723,CDM,C1713,HCPCS,0278,RC,,,,both,,,2103.80,1367.47,,,,,,,,,,,,,
PLATE SPNL CERV 40 MM ANTR INVIZIA,SUP-2414405,CDM,C1713,HCPCS,0278,RC,,,,both,,,5166.40,3358.16,,,,,,,,,,,,,
JIGS CR RIGHT INDENTITY ITOTAL,SUP-2719730,CDM,2720000010,LOCAL,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
KIT BNE CEM 8CC CA PHSPTE MACROPOROUS INJ 2 CHAMBERED SYR,SUP-2120762,CDM,C1713,HCPCS,0278,RC,,,,both,,,5637.87,3664.62,,,,,,,,,,,,,
COMPONENT PATELLAR 8X29 MM KNEE POROUS MILLER-GALANTE II,SUP-2199561,CDM,C1776,CPT,0278,RC,,,,both,,,5204.86,3383.16,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP WRK L4500MM COAT L70MM DIA0025IN FLUORINE,SUP-2313170,CDM,C1769,HCPCS,0272,RC,,,,both,,,537.03,349.07,,,,,,,,,,,,,
REFL ACET FIXATION PEG 25MM,SUP-2827843,CDM,C1776,CPT,0278,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
Needle Biopsy Craig Vertebral Body 24-2507,SUP-2853279,CDM,2720000010,LOCAL,0272,RC,,,,both,,,471.94,306.76,,,,,,,,,,,,,
SACUBITRIL-VALSARTAN 24-26 MG PO TABS,RX-130694,CDM,6370000000,HCPCS,0637,RC,43598-0643-60,NDC,,both,1,UN,23.90,15.53,,,,,,,,,,,,,
PLATE BNE L74MM 3X5 H S STL T LOK COMPR OBLQ R ANG FOR,SUP-2185827,CDM,C1713,HCPCS,0278,RC,,,,both,,,1037.46,674.35,,,,,,,,,,,,,
TROCAR ENDOSCP L 100 MM DIA11 MM STD LAPSCP BLADED SMTH CANN,SUP-2896203,CDM,2720000010,LOCAL,0272,RC,,,,both,,,452.38,294.05,,,,,,,,,,,,,
KIT BNE PLATE SCREW DIA2.8 MM TI MANDIBULAR SECONDARY RECON,SUP-2883322,CDM,C1713,HCPCS,0278,RC,,,,both,,,33205.50,21583.57,,,,,,,,,,,,,
BOLT ORTH FUSION 6.5X160 MM MIDFOOT TI NS,SUP-2799620,CDM,C1713,HCPCS,0278,RC,,,,both,,,1681.25,1092.81,,,,,,,,,,,,,
ELECTRODE ELECSURG BUTTON 10 FR HI FREQ FLX ENDOSCP UROLOGY,SUP-2475780,CDM,2720000010,LOCAL,0272,RC,,,,both,,,635.85,413.30,,,,,,,,,,,,,
SPACER SPNL 7 DEG 12X14X6 MM HEDRON C,SUP-2433817,CDM,C1889,HCPCS,0278,RC,,,,both,,,5934.60,3857.49,,,,,,,,,,,,,
GUIDEWIRE URO L150CM DIA .035IN STIFF NIT HYDRPHL STR TIP,SUP-2743520,CDM,C1769,HCPCS,0272,RC,,,,both,,,184.51,119.93,,,,,,,,,,,,,
LEAD PACE CAPSUR EPI L 35 CM SIL INSUL STEROID EPICARD,SUP-2278399,CDM,C1898,HCPCS,0275,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
GRAFT BONE SUB SM 20CC CA SULF RAP CURE KT SYNTHECURE,SUP-2124553,CDM,C1713,HCPCS,0278,RC,,,,both,,,6264.30,4071.79,,,,,,,,,,,,,
KIT FIX SCR L30MM DIA2.7MM W/ PIN DRL BIT DISP TRIM-IT,SUP-2121847,CDM,C1713,HCPCS,0278,RC,,,,both,,,643.70,418.40,,,,,,,,,,,,,
HEAD FEM 9X30X140 MM NK BIMTRC,SUP-2791016,CDM,C1776,CPT,0278,RC,,,,both,,,8942.72,5812.77,,,,,,,,,,,,,
SCREW BNE L82MM OD7MM THRD L21MM PUR HINDFOOT ANK CANN M,SUP-2320776,CDM,C1713,HCPCS,0278,RC,,,,both,,,1373.75,892.94,,,,,,,,,,,,,
PLATE BNE LCK 1.5X33X1 MM HND 14 HOLE WEB VA TI NS,SUP-2181013,CDM,C1713,HCPCS,0278,RC,,,,both,,,1342.07,872.35,,,,,,,,,,,,,
HC Chng Perc Tube/Cath With Cont,PX-3207598400,CDM,75984,CPT,0320,RC,,,,both,,,1633.00,1061.45,,,,,,,,,,,,,
BUR ENDOSCP SHAVER L 10 CM DIA2.9 MM SPD 5000 RPM RND STR,SUP-2901992,CDM,2720000010,LOCAL,0272,RC,,,,both,,,686.78,446.41,,,,,,,,,,,,,
PLATE BONE CMPRSSN 204MML HLX11 STNLSS STEEL 95DG ANGLD TUBE,SUP-2726374,CDM,C1713,HCPCS,0278,RC,,,,both,,,2076.36,1349.63,,,,,,,,,,,,,
OCCLUDER SEPT WAIST L3MM DIA5MM SHTH 6FR 45DEG CRV NIT,SUP-2355673,CDM,C1817,HCPCS,0278,RC,,,,both,,,21628.07,14058.25,,,,,,,,,,,,,
GRAFT HUM TISS W40 X L70MM THK2.5-3.5MM ACELLULAR DERM MTRX,SUP-2264664,CDM,Q4122,HCPCS,0636,RC,,,,both,,,12516.04,8135.43,,,,,,,,,,,,,
HC So Chromogenic Ish,PX-3128837766,CDM,88377,CPT,0312,RC,,,,outpatient,,,456.00,296.40,,,,,,,,,,,,,
SCREW BNE 65MM X 30MM SURFIT S STL HINDFOOT IMPLANTS,SUP-2243416,CDM,C1713,HCPCS,0278,RC,,,,both,,,1244.41,808.87,,,,,,,,,,,,,
CONNECTOR SHUNT STR LUMPERITON FOR HYDROCEPHALUS SPETZLER,SUP-2852698,CDM,C1889,HCPCS,0278,RC,,,,both,,,298.36,193.93,,,,,,,,,,,,,
INTRODUCER ORTHOPEDIC 3 ASST DIR KYPHON,SUP-2432064,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1193.20,775.58,,,,,,,,,,,,,
HOOK SPNL 5.5MM LAM ROD DIAM NEUT BILAT OPN 9MM THRT 5MM,SUP-2415305,CDM,C1713,HCPCS,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
SCREW BNE STD 2X6 MM SELF RET TI NS MAXDRIVE LEVEL 1,SUP-2457683,CDM,C1713,HCPCS,0278,RC,,,,both,,,162.24,105.46,,,,,,,,,,,,,
KIT RELF CRPL TUNN SURG,SUP-2166902,CDM,C1713,HCPCS,0278,RC,,,,both,,,461.14,299.74,,,,,,,,,,,,,
REAMER SURG OD47MM S STL ACET SPHR CUTTINGEDGE,SUP-2361871,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1372.18,891.92,,,,,,,,,,,,,
GUIDEWIRE VASC SYNCHRO 2 215CM 0.014IN SEG 35CM PRESHAPED,SUP-2716231,CDM,C1769,HCPCS,0272,RC,,,,both,,,1819.94,1182.96,,,,,,,,,,,,,
SHEATH INTRO L 45 CM DIA 9 FR STRL,SUP-2383418,CDM,C1894,HCPCS,0272,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
GUIDEWIRE VASC HI TORQ POWERTURN L 300 CM DIA 0.014 IN,SUP-2105428,CDM,C1769,HCPCS,0272,RC,,,,both,,,43.96,28.57,,,,,,,,,,,,,
PLATE BONE CRANIOMAXILLOFACIAL 6 HOLE DOUBLE Y-PLATE 17MM TI,SUP-2826364,CDM,C1713,HCPCS,0278,RC,,,,both,,,193.24,125.61,,,,,,,,,,,,,
SUPPORT ORTHOT THGH LOWER EXTREMITY WT BEAR CUST FIT,SUP-2435674,CDM,L2520,HCPCS,0274,RC,,,,both,,,1521.74,989.13,,,,,,,,,,,,,
BRACE BI CRUC DESIGNED TO RESTORE NAT KNEE MOTN ALLOW BOTH,SUP-2347989,CDM,C1776,CPT,0278,RC,,,,both,,,19081.78,12403.16,,,,,,,,,,,,,
LACTULOSE 10 GM/15ML PO SOLN,RX-38245,CDM,340b,HCPCS,0637,RC,00121-1154-30,NDC,,both,15,ML,4.50,2.92,,,,,,,,,,,,,
STENT VASC 3.5-4.5X8 MM ANEUR NK T SHP RECON DEV PULSERIDER,SUP-2248964,CDM,C1876,HCPCS,0278,RC,,,,both,,,39250.00,25512.50,,,,,,,,,,,,,
WIRE FIX L70MM OD8MM HDLSS SMOOTH TI K TH SERIES,SUP-2244121,CDM,C1713,HCPCS,0278,RC,,,,both,,,50.59,32.88,,,,,,,,,,,,,
MESH HERN 7.6CM POLY 4 HYDROXYBUTYRATE RND FULL RESRB SYN,SUP-2125868,CDM,C1781,HCPCS,0278,RC,,,,both,,,3108.60,2020.59,,,,,,,,,,,,,
NEEDLE VENTRICULAR POPPEN 12 GAX3-3/8 IN 2 HOLE LUER LCK HUB,SUP-2666375,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1301.31,845.85,,,,,,,,,,,,,
HC Plmt Biliary Drainage Cath External,PX-3614753300,CDM,47533,CPT,0361,RC,,,,inpatient,,,6875.00,4468.75,,,,,,,,,,,,,
SYSTEM KNEE FEM W/ PC TIB OPT NXGN LCCK,SUP-2212337,CDM,C1776,CPT,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
PLATE BNE L199MM 12 H BILAT S STL BROAD LO PROF RIG DYN,SUP-2185278,CDM,C1713,HCPCS,0278,RC,,,,both,,,1841.42,1196.92,,,,,,,,,,,,,
DRESSING WOUND SURGICAL MATRIX 7X10 CM PLASTIC MATRISTEM,SUP-2106492,CDM,Q4166,HCPCS,0636,RC,,,,both,,,4403.85,2862.50,,,,,,,,,,,,,
KIT ADPT BLU M8 LD NEVRO,SUP-2308594,CDM,C1822,CPT,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
HC So Unlisted Chemistry Procedure,PX-3018499966,CDM,84999,CPT,0301,RC,,,,outpatient,,,78.00,50.70,,,,,,,,,,,,,
FIXATOR ORTH WRST LO PROF W 4 3MM SELF DRL SCHNZ SCR 220MM C,SUP-2179123,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3779.84,2456.90,,,,,,,,,,,,,
DEXTROSE 5 % IV SOLN INTERMITTENT INFUSION|DISCARDED DRUG NOT ADMINISTE,RX-40840103,CDM,2580000003,HCPCS,0258,RC,00264-7510-20,NDC,JW,both,250,ML,31.90,20.73,,,,,,,,,,,,,
GENESIS II OXINIUM FEM W/ CEM TIB,SUP-2347973,CDM,C1776,CPT,0278,RC,,,,both,,,16171.00,10511.15,,,,,,,,,,,,,
HC Repair Wounds 20.1cm to 30cm,PX-4501203600,CDM,12036,CPT,0450,RC,,,,both,,,1842.00,1197.30,,,,,,,,,,,,,
PYRIDOSTIGMINE BROMIDE 60 MG PO TABS,RX-11239,CDM,6370000000,HCPCS,0637,RC,00904-6622-61,NDC,,both,1,UN,6.10,3.96,,,,,,,,,,,,,
PLATE BNE L249MM 16 H NONSTERILE R MED PROX TIB S STL LOK,SUP-2185654,CDM,C1713,HCPCS,0278,RC,,,,both,,,4286.01,2785.91,,,,,,,,,,,,,
PLATE BNE X 8 HOLE RIGID THORECON,SUP-2720002,CDM,C1713,HCPCS,0278,RC,,,,both,,,1095.86,712.31,,,,,,,,,,,,,
BRACE ORTHOPEDIC PRO XL 24-27 IN RT KNEE TRK ORTHOSIS PTO,SUP-2150972,CDM,L1810,HCPCS,0274,RC,,,,both,,,158.82,103.23,,,,,,,,,,,,,
PATCH CV IMPRA L 75 X W 50 MM THK 0.6 MM EPTFE RECTANGULAR,SUP-2761295,CDM,C1768,CPT,0278,RC,,,,both,,,909.75,591.34,,,,,,,,,,,,,
TIP ASPIR 1.57X19.27 CM EXCEL EXT STRL MICROTIP + DISP,SUP-2427659,CDM,C1713,HCPCS,0278,RC,,,,both,,,3359.80,2183.87,,,,,,,,,,,,,
STEM FEM KNEE HIP EXTN DST N MOD CONSTRN W/ LOK SCR IMPACT,SUP-2222918,CDM,C1776,CPT,0278,RC,,,,both,,,2420.00,1573.00,,,,,,,,,,,,,
ROMIPLOSTIM 125 MCG SC SOLR,RX-148026,CDM,J2802,HCPCS,0636,RC,55513-0223-01,NDC,,both,1,UN,4060.80,2639.52,,,,,,,,,,,,,
PLATE BNE STD Y SHP 3X2 H TI FOR 1MM SCR 2MM MINI MOD,SUP-2262770,CDM,C1713,HCPCS,0278,RC,,,,both,,,476.93,310.00,,,,,,,,,,,,,
ALLOGRAFT HUM TISS AMNIO MEMBRN 2X2 CM DRY ALLOWRAP DRY,SUP-2717790,CDM,Q4150,HCPCS,0636,RC,,,,both,,,3852.59,2504.18,,,,,,,,,,,,,
TUBE TYMPANOSTOMY DIA1.14 MM INNR FLANGE DIA2.6 MM FLROPLAS,SUP-2901998,CDM,L8699,HCPCS,0278,RC,,,,both,,,63.43,41.23,,,,,,,,,,,,,
PLATE BNE RECON 2-2.5X2.8 MM 32 HOLE ANGLED-ANGLED LCK NS,SUP-2483887,CDM,C1713,HCPCS,0278,RC,,,,both,,,8377.90,5445.63,,,,,,,,,,,,,
GRAFT VASC HEMSHLD GLD L 15 CM 6 MM POLYESTER BOV CLLGN STR,SUP-2266031,CDM,C1768,CPT,0278,RC,,,,both,,,1212.32,788.01,,,,,,,,,,,,,
PACEMAKER CARD CYLOS VR TI POLYUR SIL SINGLE CHMBR IS1 CONN,SUP-2138078,CDM,C1786,HCPCS,0275,RC,,,,both,,,14186.52,9221.24,,,,,,,,,,,,,
LEAD EXTENSION BLUE ARIA 72IN,SUP-2867350,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1193.20,775.58,,,,,,,,,,,,,
GRAFT VASC IMPRA L 80 CM DIA 5 MM EPTFE FLX STD WALL SM BEAD,SUP-2761500,CDM,C1768,CPT,0278,RC,,,,both,,,3368.22,2189.34,,,,,,,,,,,,,
PLATE BNE SM W10XL67MM THK15MM 90DEG 3X5 H TI T SHP R ANG,SUP-2190932,CDM,C1713,HCPCS,0278,RC,,,,both,,,1058.18,687.82,,,,,,,,,,,,,
SUPPORT ORTHOT LOWER EXTREMITY CUST N CORROSIVE FINISH,SUP-2435696,CDM,L2780,HCPCS,0274,RC,,,,both,,,179.17,116.46,,,,,,,,,,,,,
EVOS VOL PLATE 10H RIGHT STD TI 141MM NS,SUP-2818924,CDM,C1713,HCPCS,0278,RC,,,,both,,,9259.23,6018.50,,,,,,,,,,,,,
PLATE BNE 2 H PELV ACET POST RIM BROAD STRL PRO,SUP-2902429,CDM,C1713,HCPCS,0278,RC,,,,both,,,2687.21,1746.69,,,,,,,,,,,,,
MESH HERN RECTANGULAR 3 11X6 CM MONOFILAMENT VERSATEX,SUP-2752213,CDM,C1781,HCPCS,0278,RC,,,,both,,,269.98,175.49,,,,,,,,,,,,,
CLIP ANEUR CRAN RT ANGLE W/ TABS,SUP-2666515,CDM,C1889,HCPCS,0278,RC,,,,both,,,177.16,115.15,,,,,,,,,,,,,
LOPERAMIDE HCL 2 MG PO CAPS,RX-4560,CDM,6370000000,HCPCS,0637,RC,50268-0482-11,NDC,,both,1,UN,7.20,4.68,,,,,,,,,,,,,
CATHETER PERF L154CM OD4.1 3.4FR ID.032IN PROX WRK POS CONT,SUP-2323622,CDM,C1757,HCPCS,0272,RC,,,,both,,,3736.60,2428.79,,,,,,,,,,,,,
INQUIRY H CURVE STEER DUO DEC 1120 7 5 HL,SUP-2698839,CDM,C1731,HCPCS,0278,RC,,,,both,,,3969.59,2580.23,,,,,,,,,,,,,
CATHETER ABLATN LG CURL 2-5-2 MM SPC 7 FRX110 CM SAPHIRE BLU,SUP-2357498,CDM,C2630,CPT,0272,RC,,,,both,,,4788.50,3112.52,,,,,,,,,,,,,
COMPONENT FEM AUG 100 MM KNEE LIGMNT,SUP-2448358,CDM,C1776,CPT,0278,RC,,,,both,,,2981.43,1937.93,,,,,,,,,,,,,
HEAD FEM MOD 4- MM SHT 54 MM HIP BIRMINGHAM HIPTM RESURF,SUP-2435180,CDM,C1776,CPT,0278,RC,,,,both,,,11511.24,7482.31,,,,,,,,,,,,,
ROD SPNL L 100 MM DIA 6 MM RAD 450 BLACKARMOR CARBON PEEK,SUP-2917065,CDM,C1713,HCPCS,0278,RC,,,,both,,,5495.00,3571.75,,,,,,,,,,,,,
CATHETER HD STR 16 FRX24 CM LT SET W/ 2 STYL SPLIT CATH III,SUP-2627106,CDM,C1750,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
PLATE BNE L142MM 6 H TI L MED DST TIB LOK COMPR FOR 3.5MM,SUP-2413705,CDM,C1713,HCPCS,0278,RC,,,,both,,,4370.72,2840.97,,,,,,,,,,,,,
IMPLANT ORTH L60MM DIA7MM IFUSE,SUP-2337787,CDM,C1713,HCPCS,0278,RC,,,,both,,,9420.00,6123.00,,,,,,,,,,,,,
CATHETER INFUSION 0.021 INX2.8/2.3 FRX150 CM RAPID TRANSIT,SUP-2257075,CDM,C1751,HCPCS,0278,RC,,,,both,,,3206.41,2084.17,,,,,,,,,,,,,
LOCK LAT HOOK PLATE TI 5H,SUP-2815774,CDM,C1713,HCPCS,0278,RC,,,,both,,,3014.40,1959.36,,,,,,,,,,,,,
GRAFT VASC FLIXENE L 45 CM 5-8 MM EPTFE GRAD TAPR REINF SLDE,SUP-2525475,CDM,C1768,CPT,0278,RC,,,,both,,,2975.75,1934.24,,,,,,,,,,,,,
HC Njx Aa&/Strd Ntrcost Nrv Ea,PX-3616442100,CDM,64421,CPT,0361,RC,,,,both,,,2895.00,1881.75,,,,,,,,,,,,,
STENT ESOPH POLYFLEX L 120 CM BODY ID 18 MM FLARE ID 23 MM,SUP-2149392,CDM,C1874,HCPCS,0278,RC,,,,both,,,6170.51,4010.83,,,,,,,,,,,,,
GUIDEWIRE SURG L355MM DIA2.4MM S STL SMOOTH BALL TIP,SUP-2256598,CDM,C1769,HCPCS,0272,RC,,,,both,,,269.41,175.12,,,,,,,,,,,,,
RING EXT FIX ID180MM ALUM HALF FOR TAY SPAT FRME ILIZ,SUP-2342970,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7584.04,4929.63,,,,,,,,,,,,,
BIT DRL DIA2.9MM SH FOR PEDINAIL PED FEM NAIL SYS,SUP-2318887,CDM,2720000010,LOCAL,0272,RC,,,,both,,,507.11,329.62,,,,,,,,,,,,,
INSERT MOBILITY DUAL BH 48/28MM,SUP-2511107,CDM,C1776,CPT,0278,RC,,,,both,,,2763.20,1796.08,,,,,,,,,,,,,
GRAFT BNE PTTY 2.5 CC DBM TENSIX,SUP-2759605,CDM,C1713,HCPCS,0278,RC,,,,both,,,2868.67,1864.64,,,,,,,,,,,,,
PLATE BNE RECON 3.5X238 MM 20 HOLE SS,SUP-2569093,CDM,C1713,HCPCS,0278,RC,,,,both,,,613.09,398.51,,,,,,,,,,,,,
CANNULA ART LNG 17 FR BIOLINE COATED HLS,SUP-2663453,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1067.73,694.02,,,,,,,,,,,,,
KIT GASTROSTMY TB 24FR BLLN 5ML STOMA L3CM SIL SECURLOK INT,SUP-2236551,CDM,2720000010,LOCAL,0272,RC,,,,both,,,302.01,196.31,,,,,,,,,,,,,
CATHETER PRESSURE WEDGE BLLN 6FRX110CM,SUP-2383244,CDM,C1725,HCPCS,0272,RC,,,,both,,,213.52,138.79,,,,,,,,,,,,,
ANCHOR SUT DIA1.8MM FOR ACET LABRAL REP Q-FIX,SUP-2342828,CDM,C1713,HCPCS,0278,RC,,,,both,,,1033.06,671.49,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA PLU MAXBARR 3FR S1173108D5,SUP-2632789,CDM,C1751,HCPCS,0278,RC,,,,both,,,1066.53,693.24,,,,,,,,,,,,,
COVER ACET LNR TAPR H REFLCT,SUP-2351122,CDM,C1776,CPT,0278,RC,,,,both,,,128.58,83.58,,,,,,,,,,,,,
PROSTHESIS VOICE 20FR 10MM LESS STRAINED SPEAK VLV PROVOX,SUP-2124387,CDM,L8509,HCPCS,0274,RC,,,,both,,,912.70,593.25,,,,,,,,,,,,,
KIT STPL BNE FIX BRDG 18MM LEG 18MM SPEEDTITAN BME,SUP-2194269,CDM,C1713,HCPCS,0278,RC,,,,both,,,3215.64,2090.17,,,,,,,,,,,,,
CAGE SPNL L12XW12XH11MM 4 LOBE MESH L ANAT FOOTPRINT MOD,SUP-2317731,CDM,C1889,HCPCS,0278,RC,,,,both,,,5658.28,3677.88,,,,,,,,,,,,,
HC Gbl Self-Mgmt Educ & Train 1 Pt,PX-9829896001,CDM,98960,CPT,0982,RC,,,,both,,,195.00,126.75,,,,,,,,,,,,,
GRAFT BNE CHIP 30 CC FRZN TISS,SUP-2109584,CDM,C1762,CPT,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
CUP ACET DIA52MM 10 H HIP TI GRIPTION MULT H II VIP TAPR,SUP-2250193,CDM,C1776,CPT,0278,RC,,,,both,,,4841.88,3147.22,,,,,,,,,,,,,
NAIL IM L345MM DIA10MM TIB GRN TI CANN LOK BEND,SUP-2192803,CDM,C1713,HCPCS,0278,RC,,,,both,,,2687.84,1747.10,,,,,,,,,,,,,
INTRODUCER NAVIGATION TIP PASS CATHETER,SUP-2280195,CDM,C1894,HCPCS,0272,RC,,,,both,,,1469.05,954.88,,,,,,,,,,,,,
SCREW BONE L85MM DIA6.5MM THRD L16MM STD CANC S STL LAG HEX,SUP-2344184,CDM,C1713,HCPCS,0278,RC,,,,both,,,447.73,291.02,,,,,,,,,,,,,
SPLINT DORSAL AFO SPLNT S RT W STRP,SUP-2163834,CDM,L4396,HCPCS,0274,RC,,,,both,,,99.04,64.38,,,,,,,,,,,,,
DEFIBRILLATOR IMPL CROME VR MRI SURESCAN W 51 X H 66 MM D 13,SUP-2665354,CDM,C1722,HCPCS,0275,RC,,,,both,,,31079.72,20201.82,,,,,,,,,,,,,
NEEDLE OPHTH ILIFF-WRIGHT FASC 127 MM CRV SHFT RNG HNDL SS,SUP-2470743,CDM,2720000010,LOCAL,0272,RC,,,,both,,,457.18,297.17,,,,,,,,,,,,,
TERAZOSIN HCL 1 MG PO CAPS,RX-14550,CDM,6370000000,HCPCS,0637,RC,59746-0383-06,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
HAT-TRICK PIP FUS 4.2MM PROX10DEG4MM+MID,SUP-2819243,CDM,C1713,HCPCS,0278,RC,,,,both,,,4995.11,3246.82,,,,,,,,,,,,,
TUBE CHST SET 20 FRX41 CM 1 LUMEN 4 SIDEPRT THAL-QUICK,SUP-2760080,CDM,C1729,HCPCS,0272,RC,,,,both,,,572.42,372.07,,,,,,,,,,,,,
PLATE BNE CRV MIC 1.5 MM ORBIT CRANIOMAXILLOFACIAL 8 HOLE TI,SUP-2478119,CDM,C1713,HCPCS,0278,RC,,,,both,,,580.37,377.24,,,,,,,,,,,,,
SET ENDOSCP FIX ACL FOR BNE TEND RECON DISP VERSITOMIC,SUP-2366524,CDM,2720000010,LOCAL,0272,RC,,,,both,,,975.85,634.30,,,,,,,,,,,,,
SCREW 9X30MM INTERFERENCE CANNULATED SOFT SILK,SUP-2880371,CDM,C1713,HCPCS,0278,RC,,,,both,,,527.52,342.89,,,,,,,,,,,,,
PLATE DST BONE FBLA SHAFT HLX5 HEAD HLX4 TTNM ACMD,SUP-2640041,CDM,C1713,HCPCS,0278,RC,,,,both,,,4383.44,2849.24,,,,,,,,,,,,,
PLATE 3.5MM TI LCP POSTEROLATERAL DISTAL HUMERUS 7H RIGHT,SUP-2549680,CDM,C1713,HCPCS,0278,RC,,,,both,,,3612.60,2348.19,,,,,,,,,,,,,
FLECAINIDE ACETATE 50 MG PO TABS,RX-10043,CDM,6370000000,HCPCS,0637,RC,00054-0010-20,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PLATE BNE L THK1MM MINI 4 H TI STR LEV 1 PNK FOR 2MM SCR,SUP-2262738,CDM,C1713,HCPCS,0278,RC,,,,both,,,1069.36,695.08,,,,,,,,,,,,,
STENT BILI L12MM CATH L80CM BLLN L15MM DIA6MM 0.018IN 316L,SUP-2159076,CDM,C1876,HCPCS,0278,RC,,,,both,,,2370.70,1540.95,,,,,,,,,,,,,
CATHETER INFUS 5FR 65CM SHFT 7CM INFUS LEN,SUP-2168147,CDM,C1751,HCPCS,0278,RC,,,,both,,,277.54,180.40,,,,,,,,,,,,,
PLATE BNE L53MM THK1.5MM 3X3 H BILAT S STL T SHP OBLQ ANG,SUP-2185882,CDM,C1713,HCPCS,0278,RC,,,,both,,,317.14,206.14,,,,,,,,,,,,,
SYSTEM NEUROSTIMULATOR CHRG AND CHARGING ANT OLD EON,SUP-2356750,CDM,C1767,HCPCS,0278,RC,,,,both,,,2591.29,1684.34,,,,,,,,,,,,,
TRANSFER SET 6 LD NONVENTED PREASSEMBLED BARCODED PINNACLE,SUP-2774378,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1536.25,998.56,,,,,,,,,,,,,
GUIDEWIRE VASC KATZN L 145 CM TIP L 6 CM DIA 0.035 IN SS,SUP-2148176,CDM,C1769,HCPCS,0272,RC,,,,both,,,541.49,351.97,,,,,,,,,,,,,
PROBE E ENDOSCP SPAT TIP 5MMX45CM DISPOSABLE ST 0250070554,SUP-2361228,CDM,2720000010,LOCAL,0272,RC,,,,both,,,671.58,436.53,,,,,,,,,,,,,
"HC Compatibility Test, Ahg Test",PX-3008692200,CDM,86922,CPT,0300,RC,,,,both,,,354.00,230.10,,,,,,,,,,,,,
IMPLANT TOE JT DIA21MM THK5MM MT LENGTHENING DISC,SUP-2321674,CDM,C1776,CPT,0278,RC,,,,both,,,7693.00,5000.45,,,,,,,,,,,,,
CATHETER KIT 1 LUMEN 4 FR W/ PASV BIOFLO,SUP-2117193,CDM,C1751,HCPCS,0278,RC,,,,both,,,634.59,412.48,,,,,,,,,,,,,
BRACE ORTHOPEDIC POST OPERATIVE SM MED 28 IN BLK LTX,SUP-2421714,CDM,L1833,HCPCS,0274,RC,,,,both,,,233.74,151.93,,,,,,,,,,,,,
ALLOGRAFT BNE CUBE 60 CC FRZN IRRADIATED CANC,SUP-2867099,CDM,C1762,CPT,0278,RC,,,,both,,,2493.79,1620.96,,,,,,,,,,,,,
CATHETER CV SET 018 4 FRX15 CM DL J TIP CUDLM401JLSCABRMHC,SUP-2759853,CDM,C1751,HCPCS,0278,RC,,,,both,,,325.02,211.26,,,,,,,,,,,,,
CATHETER HD SET 15 FRX23 CM DL RETROGRADE ACCS VECTORFLOW,SUP-2762973,CDM,C1750,HCPCS,0278,RC,,,,both,,,675.10,438.81,,,,,,,,,,,,,
TAP SURG CANN FOR 3.5MM SCR REPROC,SUP-2187400,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1934.15,1257.20,,,,,,,,,,,,,
EXTENSION LD DBS L 40 CM W/ MARKER STRL DISP SENSIGHT,SUP-2883109,CDM,C1883,HCPCS,0278,RC,,,,both,,,2994.93,1946.70,,,,,,,,,,,,,
PLATE T PROFYLE SHP 90DEG NAR 23MM,SUP-2695490,CDM,C1713,HCPCS,0278,RC,,,,both,,,1062.26,690.47,,,,,,,,,,,,,
BAR EXT FIX L110MM DIA6MM C FOR JET-X MINI EXT FIX,SUP-2342912,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1062.98,690.94,,,,,,,,,,,,,
GRAFT HUM TISS W4XL8CM THK45UM AMNIO MEMBRN DEHYDR OMNI DIR,SUP-2340455,CDM,C1762,CPT,0278,RC,,,,both,,,11709.06,7610.89,,,,,,,,,,,,,
DRESSING HEMSTAT W3INXL2YD 1 PLY Z FLD QUIKCLOT CONTROL+,SUP-2416086,CDM,2720000010,LOCAL,0272,RC,,,,both,,,462.46,300.60,,,,,,,,,,,,,
CUP ACET DIA62MM DP PROF SOL,SUP-2250746,CDM,C1776,CPT,0278,RC,,,,both,,,10895.80,7082.27,,,,,,,,,,,,,
INTRODUCER PACE LD PEELWY L 14 CM DIA12 FR STRL,SUP-2140192,CDM,C1892,HCPCS,0272,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
VALVE MITRL DIA29MM MECH EXP CUF,SUP-2356719,CDM,C1889,HCPCS,0278,RC,,,,both,,,13822.28,8984.48,,,,,,,,,,,,,
KIT INFUS PMP 270ML 4ML/HR 2ML/SITE SOAK CATH L5IN N NARC,SUP-2236835,CDM,C9804,HCPCS,0272,RC,,,,both,,,558.48,363.01,,,,,,,,,,,,,
HC So Factor IX,PX-3058525066,CDM,85250,CPT,0305,RC,,,,inpatient,,,301.00,195.65,,,,,,,,,,,,,
ALLOGRAFT BNE CHIPS 1-4 MM 60 CC CORTICAL CANC BIO,SUP-2637023,CDM,C1713,HCPCS,0278,RC,,,,both,,,1906.61,1239.30,,,,,,,,,,,,,
SUPPORT THMB STBL SM 2.25-2.75 IN LT PROCARE THUMBGUARD,SUP-2195766,CDM,L3931,HCPCS,0272,RC,,,,both,,,30.77,20.00,,,,,,,,,,,,,
GRAFT SURG 7CMX6CM AMNIOFIX,SUP-2305731,CDM,V2790,HCPCS,0278,RC,,,,both,,,7231.42,4700.42,,,,,,,,,,,,,
PLATE BNE SM W11XL215MM THK34MM 16 H BILAT TI RIG NEUT LOK,SUP-2190796,CDM,C1713,HCPCS,0278,RC,,,,both,,,1999.43,1299.63,,,,,,,,,,,,,
CROWN DENT PED SZ UR3 RT UP CTRL PRI M TRNSPAR PLAS GLS,SUP-2100386,CDM,D6783,CPT,0278,RC,,,,both,,,27.91,18.14,,,,,,,,,,,,,
SCREW BONE L55MM DIA6.5MM THRD L16MM STD CANC S STL LAG HEX,SUP-2344178,CDM,C1713,HCPCS,0278,RC,,,,both,,,417.27,271.23,,,,,,,,,,,,,
GRAFT HUM TISS FEMORAL POPLITEAL ARTERY,SUP-2740181,CDM,C1768,CPT,0278,RC,,,,both,,,24319.30,15807.54,,,,,,,,,,,,,
PLATE BNE W11XL32MM THK13MM 7 H LOK COMPR GRID T SHP TI MAL,SUP-2267939,CDM,C1713,HCPCS,0278,RC,,,,both,,,2623.09,1705.01,,,,,,,,,,,,,
MRS 17X127 FEM STM W/FEM TAPER,SUP-2512647,CDM,C1776,CPT,0278,RC,,,,both,,,6114.05,3974.13,,,,,,,,,,,,,
SET CATH L35CM DIA1.9MM DIFFUSE COMB OF ANTIBIO BACTISEAL,SUP-2243801,CDM,C1713,HCPCS,0278,RC,,,,both,,,2248.08,1461.25,,,,,,,,,,,,,
SCREW BNE CANN 4X12 MM PARTIALLY THRD,SUP-2606134,CDM,C1713,HCPCS,0278,RC,,,,both,,,453.01,294.46,,,,,,,,,,,,,
STENT URET PATERSON-FORRESTER L 65 CM DIA 8.5 FR SUBQ,SUP-2826999,CDM,C2627,HCPCS,0272,RC,,,,both,,,309.07,200.90,,,,,,,,,,,,,
SCREW SPNL L50MM PEEK EXT HEX FOR 6.35MM ROD CDH,SUP-2287301,CDM,C1713,HCPCS,0278,RC,,,,both,,,669.45,435.14,,,,,,,,,,,,,
CATHETER KIT 25 MMX15 CM VENTRICULAR RESERVOIR BUR HOLE,SUP-2278368,CDM,C1729,HCPCS,0272,RC,,,,both,,,693.06,450.49,,,,,,,,,,,,,
KIT INJ CEILING FUSIONARY GRFT DEL SPINESMITH,SUP-2163073,CDM,2720000010,LOCAL,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
CATHETER URET 5FR L70CM TIP 8FR OPN END CONE TIP INJ HUB,SUP-2139292,CDM,C1758,HCPCS,0278,RC,,,,both,,,656.23,426.55,,,,,,,,,,,,,
DICLOFENAC SODIUM 1 % EX GEL,RX-152148,CDM,6370000000,HCPCS,0637,RC,43598-0977-10,NDC,,both,100,GR,54.00,35.10,,,,,,,,,,,,,
HANDPIECE THERMOABLATION RF STRL DISP SONATA,SUP-2882680,CDM,C1886,HCPCS,0278,RC,,,,both,,,10833.00,7041.45,,,,,,,,,,,,,
CATHETER EP D-D 8 MM 7 FRX115 CM 4 CELSIUS DS,SUP-2248495,CDM,C1733,HCPCS,0272,RC,,,,both,,,3413.18,2218.57,,,,,,,,,,,,,
COMPONENT FEM SZ 2 TIV POR LT KNEE PRI PRESSFIT CRUC RET,SUP-2199488,CDM,C1776,CPT,0278,RC,,,,both,,,21532.55,13996.16,,,,,,,,,,,,,
PATCH CV HEMGRD L 75 X W 8 MM THK 0.65 MM POLYESTER BOV UTHN,SUP-2535437,CDM,C1768,CPT,0278,RC,,,,both,,,3229.71,2099.31,,,,,,,,,,,,,
UNIT DRNAGE PLEUR CAV SGL COLL SUCT CTRL REGULATED STR CONN,SUP-2266004,CDM,C1729,HCPCS,0272,RC,,,,both,,,154.14,100.19,,,,,,,,,,,,,
DRIVER SURG 120MM SLD H10,SUP-2167420,CDM,2720000010,LOCAL,0272,RC,,,,both,,,580.90,377.58,,,,,,,,,,,,,
MESH HERN 4.5IN VENTRAL POLYPR EPTFE REP LTWT CIR LO PROF L,SUP-2125813,CDM,C1781,HCPCS,0278,RC,,,,both,,,1628.72,1058.67,,,,,,,,,,,,,
CATHETER ANGIO MARINER L 65 CM 4 FR 0.038 IN BERN NONBRAIDED,SUP-2116850,CDM,2720000010,LOCAL,0272,RC,,,,both,,,176.47,114.71,,,,,,,,,,,,,
ORTHOSES THERMOPLASTIC ACROMIOCLAVICULAR SHLDR PREFABRICATED,SUP-2319133,CDM,L3670,HCPCS,0274,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
CATHETER GUID AMPLATZER TREVISIO L 80 CM DIA 8 FR SHTH OD,SUP-2558646,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2408.38,1565.45,,,,,,,,,,,,,
CATHETER PICC AD 6FR L55CM 3 LUMN NRS PWR INJ POLYUR N COAT,SUP-2125559,CDM,C1751,HCPCS,0278,RC,,,,both,,,819.54,532.70,,,,,,,,,,,,,
COIL NEUROVASCULAR OPTMA L 8 CM DIA 3.5 MM SZ 0.010 IN PLAT,SUP-2753279,CDM,C1778,HCPCS,0278,RC,,,,both,,,5730.50,3724.82,,,,,,,,,,,,,
GRAFT HUM TISS W4XL4CM PTCH DECELLULARISED DERM,SUP-2264622,CDM,Q4122,HCPCS,0636,RC,,,,both,,,3344.10,2173.66,,,,,,,,,,,,,
GUIDEWIRE VASC OD.032IN L260CM L.3CM TIP J TIP VASC IMAG,SUP-2355312,CDM,C1769,HCPCS,0272,RC,,,,both,,,36.11,23.47,,,,,,,,,,,,,
HC So Factor IX,PX-3058525066,CDM,85250,CPT,0305,RC,,,,outpatient,,,301.00,195.65,,,,,,,,,,,,,
KCL IN DEXTROSE-NACL 40-5-0.9 MEQ/L-%-% IV SOLN,RX-102352,CDM,2500000003,HCPCS,0250,RC,00338-0807-04,NDC,,both,1000,ML,57.50,37.37,,,,,,,,,,,,,
STAPLE BNE FIX 8X8MM STR ASSEMB,SUP-2321571,CDM,C1776,CPT,0278,RC,,,,both,,,4824.61,3136.00,,,,,,,,,,,,,
PLATE BNE CONTOURABLE MESH SM 0.4 MM CRESCENT BLU STRL,SUP-2859902,CDM,C1713,HCPCS,0278,RC,,,,both,,,2383.26,1549.12,,,,,,,,,,,,,
ELECTRODE ENDOSCP HF-RESECTION SM LNG 12-30 DEG PLASMALOOP,SUP-2466262,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1627.12,1057.63,,,,,,,,,,,,,
HC Mammo Dgx Unilateral Incl Cad if Perf,PX-4017706500,CDM,77065,CPT,0401,RC,,,,inpatient,,,629.00,408.85,,,,,,,,,,,,,
PROSTHESIS TESTICULAR IMPL 5,SUP-2340094,CDM,C1889,HCPCS,0278,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
BLADE RETRACTOR 6 IN HIP STD T BAR HNDL SELF RET,SUP-2242482,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1145.75,744.74,,,,,,,,,,,,,
HC NM Thyroid Uptake Measurement,PX-3417801200,CDM,78012,CPT,0341,RC,,,,both,,,1380.00,897.00,,,,,,,,,,,,,
BLOCKER EB 7FR L75MM Y SHP BIFUR DST END 1 LUNG VENT EZ,SUP-2384373,CDM,2720000010,LOCAL,0272,RC,,,,both,,,935.09,607.81,,,,,,,,,,,,,
SET INTRO SUP ARW FLX SHTH L 45 CM DIA 7 FR HYDRPHLC,SUP-2383408,CDM,C1894,HCPCS,0272,RC,,,,both,,,237.92,154.65,,,,,,,,,,,,,
NAIL IM L340MM DIA13MM UNIV FEM TI SLV BENT AG NONLOCKING,SUP-2408509,CDM,C1713,HCPCS,0278,RC,,,,both,,,6531.20,4245.28,,,,,,,,,,,,,
WIRE GUID 5MM TEMP NIT ANGIOGUARD XP 5FR INTRO 300CM,SUP-2157305,CDM,C1769,HCPCS,0272,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
ANCHOR SUT 5 MM DIA NO 2 SUT,SUP-2341588,CDM,C1713,HCPCS,0278,RC,,,,both,,,653.62,424.85,,,,,,,,,,,,,
PLATE BNE L202MM 10 H NONSTERILE R DST MED TIB S STL VAR,SUP-2184189,CDM,C1713,HCPCS,0278,RC,,,,both,,,4920.91,3198.59,,,,,,,,,,,,,
STENT BILI FLEXXUS L 6 CM DIA10 MM CATH L 190 CM DIA 7.5 FR,SUP-2166291,CDM,C1876,HCPCS,0278,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
ELECTRODE TRAY PACE 5 FRX110 CM TRNSVEN,SUP-2848490,CDM,2720000010,LOCAL,0272,RC,,,,both,,,701.98,456.29,,,,,,,,,,,,,
ELECTRODE ENDSCPC URLGY 24 28FR DIA LNG 12DG ANGLD CTTNG LOO,SUP-2730007,CDM,2720000010,LOCAL,0272,RC,,,,both,,,556.69,361.85,,,,,,,,,,,,,
IMPLANT TALAR SZ 2 R ANK VANTAGE,SUP-2420825,CDM,C1776,CPT,0278,RC,,,,both,,,13585.52,8830.59,,,,,,,,,,,,,
GUIDEWIRE VASC L 15 CM DIA 0.018 IN SS PTFE SAFE-T-J STR FIX,SUP-2760012,CDM,C1769,HCPCS,0272,RC,,,,both,,,87.79,57.06,,,,,,,,,,,,,
SHEATH INTRO 6FR L90CM DIL L15CM HYDRPHLC COAT MULT PURP,SUP-2385202,CDM,C1894,HCPCS,0272,RC,,,,both,,,400.35,260.23,,,,,,,,,,,,,
PLATE CLAV 2.7MM VA LCP CS1 RT,SUP-2720069,CDM,C1713,HCPCS,0278,RC,,,,both,,,3183.96,2069.57,,,,,,,,,,,,,
GUIDEPIN SURG FEM TIB PT SPEC FIX BLK CUT CUST W/ DRL SET,SUP-2201242,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
BLOCK CUT FOR FEM,SUP-2249579,CDM,C1713,HCPCS,0278,RC,,,,both,,,4239.00,2755.35,,,,,,,,,,,,,
SHEATH INTRO PINNACLE R/O II HI FLO L 4CM 6FR 0.035/0.038 IN,SUP-2385642,CDM,C1894,HCPCS,0272,RC,,,,both,,,84.87,55.17,,,,,,,,,,,,,
STRATTICE EXTRA THICK 16 X 20,SUP-2675762,CDM,Q4130,HCPCS,0636,RC,,,,both,,,31685.74,20595.73,,,,,,,,,,,,,
ROD EXT FIX L 300 MM THRD,SUP-2898412,CDM,2720000010,LOCAL,0272,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
SET INTRO SUP ARW FLX SHTH L 11 CM DIA 7 FR GUIDEWIRE 45 CM,SUP-2383427,CDM,C1894,HCPCS,0272,RC,,,,both,,,65.31,42.45,,,,,,,,,,,,,
GRAFT VASC GELWEAVE L 50 CM DIA26 MM BRANCH L 15 CM ANTE FLO,SUP-2385048,CDM,C1768,CPT,0278,RC,,,,both,,,3284.44,2134.89,,,,,,,,,,,,,
IMMUNE GLOBULIN (PRIVIGEN) 10%,RX-4081762,CDM,J1459,HCPCS,0636,RC,44206-0439-40,NDC,,both,400,ML,22639.50,14715.67,,,,,,,,,,,,,
STAPLER INT CIR XL EXTRA THICK 28 MM 4-5 MM BLK EEA,SUP-2787719,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4992.76,3245.29,,,,,,,,,,,,,
CATHETER IV DL 5 FR DOT KT MBP POWERMIDLINE,SUP-2626738,CDM,C1751,HCPCS,0278,RC,,,,both,,,474.14,308.19,,,,,,,,,,,,,
SPACER KNEE BLOCK CUT 10 MM DSTL FEM SLT SPEC 2,SUP-2456665,CDM,C1776,CPT,0278,RC,,,,both,,,464.72,302.07,,,,,,,,,,,,,
BIT DRILL RECON LAG SCREW,SUP-2701128,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2833.22,1841.59,,,,,,,,,,,,,
COMPONENT ACET TRIFLANGED 24 MM HIP,SUP-2137599,CDM,C1776,CPT,0278,RC,,,,both,,,35168.00,22859.20,,,,,,,,,,,,,
PLATE BNE MESH PANEL STD 1.5X85X53X0.3 MM SM GRID TI NS,SUP-2483303,CDM,C1713,HCPCS,0278,RC,,,,both,,,2816.86,1830.96,,,,,,,,,,,,,
SLIDER NDL DEG 25 R,SUP-2366701,CDM,2720000010,LOCAL,0272,RC,,,,both,,,891.76,579.64,,,,,,,,,,,,,
FORCEPS BONE CUT L10.5IN CVD STILLE LISTON,SUP-2249534,CDM,C1713,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
GRAFT HUM TISS W16XH6XL22MM PRESHAPED FRZ DRY FOR FLATFOOT,SUP-2307233,CDM,C1713,HCPCS,0278,RC,,,,both,,,2922.56,1899.66,,,,,,,,,,,,,
NAIL IM TRIM 4X50 MM 1 IMPL SYS BIO INTEGRATIVE OSSIOFIBER,SUP-2641888,CDM,C1713,HCPCS,0278,RC,,,,both,,,5809.00,3775.85,,,,,,,,,,,,,
PLATE BNE RECON 2.7 MM MAND 17 HOLE LT ANGLED TI LEVEL 1,SUP-2461971,CDM,C1713,HCPCS,0278,RC,,,,both,,,4063.07,2641.00,,,,,,,,,,,,,
BAR EXTN STD NS OSCAR 3 LTX,SUP-2875719,CDM,2720000010,LOCAL,0272,RC,,,,both,,,464.72,302.07,,,,,,,,,,,,,
NEEDLE ENDOSCP 22GA FNF PRELD US DEL SYS BEAC,SUP-2173694,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1358.99,883.34,,,,,,,,,,,,,
SPLINT ANK FT L L POST LEAF LTWT SEMI RIG ROLYAN,SUP-2326012,CDM,L4396,HCPCS,0274,RC,,,,both,,,98.56,64.06,,,,,,,,,,,,,
SCREW SPNL 5.5X40MM PEDCL TURRET TI,SUP-2211270,CDM,C1713,HCPCS,0278,RC,,,,both,,,3689.50,2398.17,,,,,,,,,,,,,
"HC Amniocentesis,Ther Amniotic Fluid Reduct",PX-3615900100,CDM,59001,CPT,0361,RC,,,,both,,,963.00,625.95,,,,,,,,,,,,,
SCREW BNE CRANIO MAXILLOFACIAL ST TI 1.5X5MM 5PK,SUP-2366193,CDM,C1713,HCPCS,0278,RC,,,,both,,,153.08,99.50,,,,,,,,,,,,,
HC Chaplain Assessment,PX-9400900100,CDM,Q9001,CPT,0940,RC,,,,both,,,11.00,7.15,,,,,,,,,,,,,
CEMENT CAP LY 000240 FUJI I,SUP-2238618,CDM,C1713,HCPCS,0278,RC,,,,both,,,1006.78,654.41,,,,,,,,,,,,,
ENDCAP ORTH L5MM DIA3.5MM NONSTERILE TI NAIL SPRL BLDE EXTN,SUP-2192476,CDM,C1713,HCPCS,0278,RC,,,,both,,,589.63,383.26,,,,,,,,,,,,,
EXPANDER TISS 1.5-4.3 CM 7.5X6 CM 35-89 CC TEXT SOFTSPAN,SUP-2458695,CDM,C1889,HCPCS,0278,RC,,,,both,,,2276.50,1479.72,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY L 92CM 6FR 1MM D FIX AUTO-ID BLU,SUP-2248673,CDM,C1733,HCPCS,0272,RC,,,,both,,,898.04,583.73,,,,,,,,,,,,,
STEM FEM HIP REV NEUT CEM POR TAPR 145DEG NK ANG 14.0MM DIA,SUP-2206028,CDM,C1776,CPT,0278,RC,,,,both,,,18654.74,12125.58,,,,,,,,,,,,,
HC OB ER Level 2,PX-4509928201,CDM,99282,CPT,0450,RC,,,,inpatient,,,987.00,641.55,,,,,,,,,,,,,
SET INTRO MICROPUNCTURE SHTH L 7 CM DIA 5 FR GUIDEWIRE L 40,SUP-2167897,CDM,C1894,HCPCS,0272,RC,,,,both,,,107.29,69.74,,,,,,,,,,,,,
PLATE BNE CHAMPY MINI 110 DEG 2 MM RT MAND 4 HOLE TI LEVEL 1,SUP-2460822,CDM,C1713,HCPCS,0278,RC,,,,both,,,898.67,584.14,,,,,,,,,,,,,
HC Hfo W/1 or More Customfit,PX-2740392101,CDM,L3921,HCPCS,0272,RC,,,,both,,,1068.00,694.20,,,,,,,,,,,,,
ROSUVASTATIN CALCIUM 40 MG PO TABS,RX-35136,CDM,6370000000,HCPCS,0637,RC,57237-0171-90,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
HC NM Cisternography,PX-3417863000,CDM,78630,CPT,0341,RC,,,,both,,,3207.00,2084.55,,,,,,,,,,,,,
Z DUP USE 2282180 CATHETER GUID INNER L57MM OD2.4MM 130DEG ATTAIN SEL II,SUP-2719773,CDM,C1887,HCPCS,0272,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
PAPARELLA VT WTAB SI 1.14MM,SUP-2680278,CDM,L8699,HCPCS,0278,RC,,,,both,,,32.15,20.90,,,,,,,,,,,,,
PASSER SUT L15MM DIA10X12MM CONE SHP PILOT GUID DISP CARTER,SUP-2171686,CDM,2720000010,LOCAL,0272,RC,,,,both,,,495.90,322.33,,,,,,,,,,,,,
TUBE ENDOTRACHEAL LNG 7 MM ELECTROMYOGRAPHIC ELECTRD NVM5,SUP-2559662,CDM,2720000010,LOCAL,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
PATCH VASC W6XL75MM CAR POLY STR STD WALL NONTAPERED,SUP-2227499,CDM,C1768,CPT,0278,RC,,,,both,,,314.06,204.14,,,,,,,,,,,,,
SCREW BNE L 10 MM DIA2.5 MM TI CANN HDLSS NS LEOS,SUP-2932585,CDM,C1713,HCPCS,0278,RC,,,,both,,,898.07,583.75,,,,,,,,,,,,,
DRIVER PIN CIR FIX SQ END FRDM SIDEKCK,SUP-2400682,CDM,C1713,HCPCS,0278,RC,,,,both,,,763.02,495.96,,,,,,,,,,,,,
"HC Gbl New Pt, E/M Level 2|UNUSUAL NON-OVERLAPPING SERVICE",PX-9829920200,CDM,99202,CPT,0982,RC,,,XU,both,,,365.00,237.25,,,,,,,,,,,,,
SET DIL LAT THOR NIM STIMULATED DIR,SUP-2292840,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2219.35,1442.58,,,,,,,,,,,,,
DRILL SURG DIA3.7MM PERC,SUP-2410871,CDM,2720000010,LOCAL,0272,RC,,,,both,,,765.88,497.82,,,,,,,,,,,,,
SHEATH INTRO PERFRMR L 40 CM DIA 6 FR PERIPH BLKN STRL,SUP-2168414,CDM,C1894,HCPCS,0272,RC,,,,both,,,307.72,200.02,,,,,,,,,,,,,
HC Drain Finger Abscess,PX-4502601100,CDM,26011,CPT,0450,RC,,,,both,,,1649.00,1071.85,,,,,,,,,,,,,
PLATE BONE LOK 106MML HLX6 STNLSS STEEL ST RIGHT LTRL DST FB,SUP-2588179,CDM,C1713,HCPCS,0278,RC,,,,both,,,1858.91,1208.29,,,,,,,,,,,,,
PIN EXT FIX L150MM DIA5MM THRD L50MM CORT S STL ST SELF DRL,SUP-2372360,CDM,2720000010,LOCAL,0272,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
LACOSAMIDE 10 MG/ML PO SOLN,RX-105342,CDM,340b,HCPCS,0637,RC,00131-5410-72,NDC,,both,5,ML,52.70,34.25,,,,,,,,,,,,,
COUPLER 2MM MIC VASC,SUP-2382620,CDM,C1889,HCPCS,0278,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
PACEMAKER CARD ACCOLADE W 4.45 X H 5.02 CM THK 0.75 CM 13.7,SUP-2149249,CDM,C1785,HCPCS,0275,RC,,,,both,,,24146.60,15695.29,,,,,,,,,,,,,
TUBE VENT 0.78 MM 1 MM 2/1.5 MM SPN BOB TI BLU STRL 500061,SUP-2468664,CDM,L8699,HCPCS,0278,RC,,,,both,,,70.62,45.90,,,,,,,,,,,,,
PASSER SUT L162MM MIN CANN DIA6MM BITE D18MM STD PRELD,SUP-2340735,CDM,2720000010,LOCAL,0272,RC,,,,both,,,675.10,438.81,,,,,,,,,,,,,
GUIDEWIRE SURG DIA2.4MM DISP FOR 4.5MM SCR PEDILOC PEDIFRAG,SUP-2318884,CDM,C1769,HCPCS,0272,RC,,,,both,,,815.14,529.84,,,,,,,,,,,,,
SLEEVE POS DIA13MM UNIV SHLDR CO CHROM PRI CEM FOR COMPHSVE,SUP-2404535,CDM,C1776,CPT,0278,RC,,,,both,,,835.24,542.91,,,,,,,,,,,,,
HEAD HUM STD 44 MM OLYMPIA,SUP-2538188,CDM,C1776,CPT,0278,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
CATHETER BLLN 038 10 FRX100 CM 10-50 MM 3-60 CC BLU Q50,SUP-2458769,CDM,C2628,HCPCS,0272,RC,,,,both,,,1444.40,938.86,,,,,,,,,,,,,
TRAY TIB SZ 2 A/P25MM M/L44MM R LAT L MED KNEE TI NP PRI,SUP-2342840,CDM,C1776,CPT,0278,RC,,,,both,,,5928.32,3853.41,,,,,,,,,,,,,
"HC Gonadotropin, Chorionic (Hcg) Qualitative",PX-3018470300,CDM,84703,CPT,0301,RC,,,,both,,,455.00,295.75,,,,,,,,,,,,,
DRESSING BIO L 7 X W 3 CM SZ 200 UM PORCINE SM INTEST,SUP-2905492,CDM,Q4103,HCPCS,0636,RC,,,,both,,,974.28,633.28,,,,,,,,,,,,,
PLATE BONE LOK 144MML HLX11 STNLSS STEEL STRGHT RCNSTRCTN ST,SUP-2588606,CDM,C1713,HCPCS,0278,RC,,,,both,,,1571.57,1021.52,,,,,,,,,,,,,
PUMP INFUS THK19.5MM DIA87.5MM 20ML TI PROGRAMMABLE,SUP-2284621,CDM,C1772,HCPCS,0278,RC,,,,both,,,29830.00,19389.50,,,,,,,,,,,,,
IMPLANT SIZE 2 STANDARD CARPAL POLY,SUP-2586704,CDM,C1776,CPT,0278,RC,,,,both,,,3876.99,2520.04,,,,,,,,,,,,,
ANCHOR SUTURE 1.4 MM NANOTACK,SUP-2418173,CDM,C1713,HCPCS,0278,RC,,,,both,,,2081.19,1352.77,,,,,,,,,,,,,
KIT INTRO ARW FLX SHTH L 10 CM DIA 9 FR GUIDEWIRE 0.035 IN,SUP-2763401,CDM,C1892,HCPCS,0272,RC,,,,both,,,218.54,142.05,,,,,,,,,,,,,
SPLINT FNGR OVL-8 RNG SZ 4 5PK,SUP-2112610,CDM,L3927,HCPCS,0272,RC,,,,both,,,60.82,39.53,,,,,,,,,,,,,
FENTANYL 50 MCG/ML PCA,RX-40851003,CDM,J3010,HCPCS,0636,RC,09999-9901-20,NDC,,both,30,ML,126.50,82.22,,,,,,,,,,,,,
BUR HIP L19CM DIAMETER 4.2MM PREBENT STRAIGHT STYLES UNIQUE,SUP-2828619,CDM,2720000010,LOCAL,0272,RC,,,,both,,,527.52,342.89,,,,,,,,,,,,,
GRAFT HUM TISS W7.5XL15CM PLCNTA MEM CRYOPRESERVED AMNION,SUP-2319179,CDM,Q4133,HCPCS,0636,RC,,,,both,,,28260.00,18369.00,,,,,,,,,,,,,
PAD THER CRYO L R SHLDR SL AD NONSTERILE W STRP ACCELERATED,SUP-2324440,CDM,L3650,HCPCS,0272,RC,,,,both,,,162.65,105.72,,,,,,,,,,,,,
ALLOGRAFT BNE PASTE 1 CC DEMINERALIZED BNE MTRX + CANC,SUP-2717765,CDM,C1713,HCPCS,0278,RC,,,,both,,,870.53,565.84,,,,,,,,,,,,,
SCREW BONE L4MM DIA1.7MM TI CORT ST EMER LCK HDED THRD HD 5PK,SUP-2363333,CDM,C1713,HCPCS,0278,RC,,,,both,,,191.41,124.42,,,,,,,,,,,,,
PLATE BONE RECONSTRUCTION SMALL 2 MM DOUBLE ANGLE TITANIUM M,SUP-2837756,CDM,C1713,HCPCS,0278,RC,,,,both,,,8416.14,5470.49,,,,,,,,,,,,,
SET INT FIX 5 MM MIS CHMFR SCREW REDUCTION WIRE,SUP-2909099,CDM,2720000010,LOCAL,0272,RC,,,,both,,,509.47,331.16,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 8X4 CMX0.80-1.4 MM N MESHED STRL MEMODERM,SUP-2366754,CDM,Q4126,HCPCS,0636,RC,,,,both,,,7253.40,4714.71,,,,,,,,,,,,,
GRAFT HUM TISS SM W10XL17CM THK07 14MM THN ACELLULAR,SUP-2307603,CDM,Q4128,HCPCS,0636,RC,,,,both,,,18089.04,11757.88,,,,,,,,,,,,,
SHEATH INTRO AVNT + DIA 4 FR CANN L 23 CM POLYUR PLAS SS RED,SUP-2156057,CDM,C1894,HCPCS,0272,RC,,,,both,,,23.71,15.41,,,,,,,,,,,,,
SCREW SPNL 6.5MMDIA 35MM LEN PEDCL POLYAX CANC 5.5MM ROD TOP,SUP-2414589,CDM,C1713,HCPCS,0278,RC,,,,both,,,4496.48,2922.71,,,,,,,,,,,,,
SCREW BONE L3MM DIA1.6MM CORT TI NEURO NONCANNULATED FULL,SUP-2189295,CDM,C1713,HCPCS,0278,RC,,,,both,,,238.51,155.03,,,,,,,,,,,,,
BOLT HINGE LNG,SUP-2492712,CDM,2720000010,LOCAL,0272,RC,,,,both,,,291.11,189.22,,,,,,,,,,,,,
STEM FEM L190MM DIA20MM 135DEG STD OFFSET DST HIP BILAT,SUP-2420931,CDM,C1776,CPT,0278,RC,,,,both,,,9372.27,6091.98,,,,,,,,,,,,,
PROBE ELECSURG BPLR 20 GA ACTIVE ASPIR REFLX HEMOSTATIC ERAS,SUP-2309416,CDM,2720000010,LOCAL,0272,RC,,,,both,,,621.72,404.12,,,,,,,,,,,,,
DRL BIT SURG DIA 4 MM BRAD PT NONSTERILE ADVANTAGERIB,SUP-2908969,CDM,2720000010,LOCAL,0272,RC,,,,both,,,857.22,557.19,,,,,,,,,,,,,
SPLINT WRST AND THMB UNIV,SUP-2336035,CDM,L3809,HCPCS,0274,RC,,,,both,,,37.55,24.41,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 8X200 MM FRZN GAM SEMITENDINOSUS GRACILIS,SUP-2866910,CDM,C1762,CPT,0278,RC,,,,both,,,4176.20,2714.53,,,,,,,,,,,,,
ROD ORTH ALIGN FOR BIOARCH SUBTALAR IMPL SYS,SUP-2401366,CDM,C1713,HCPCS,0278,RC,,,,both,,,62.80,40.82,,,,,,,,,,,,,
COMPONENT FEM CR NAR LT KNEE REV NP LEGION,SUP-2346229,CDM,C1776,CPT,0278,RC,,,,both,,,5966.00,3877.90,,,,,,,,,,,,,
GRAFT BNE 10 CC CELLULAR BNE MTRX V92 FC,SUP-2742073,CDM,C1713,HCPCS,0278,RC,,,,both,,,16579.20,10776.48,,,,,,,,,,,,,
ORTHOPAEDIC KIT PELV STRL HOFFMANN II,SUP-2495342,CDM,2720000010,LOCAL,0272,RC,,,,both,,,16418.18,10671.82,,,,,,,,,,,,,
CATHETER EP F 3-3-3-3-7 MM 6 FRX115 CM 6,SUP-2248461,CDM,C1730,HCPCS,0272,RC,,,,both,,,499.26,324.52,,,,,,,,,,,,,
SHEATH INTRO L 30 CM DIA15 FR GUIDEWIRE 0.038 IN LNG PTFE X,SUP-2615913,CDM,C1894,HCPCS,0272,RC,,,,both,,,148.05,96.23,,,,,,,,,,,,,
LINER ACET OD66-68MM ID28MM +4MM 20DEGXLPE REFLCT,SUP-2344762,CDM,C1776,CPT,0278,RC,,,,both,,,2918.63,1897.11,,,,,,,,,,,,,
BIT DRL TWST 3.2 MMX5 IN SLD NS,SUP-2435476,CDM,2720000010,LOCAL,0272,RC,,,,both,,,341.13,221.73,,,,,,,,,,,,,
CATHETER GUID FUBUKI L 90 CM OD 7 FR ID 2.05 MM STR TIP,SUP-2539649,CDM,C1887,HCPCS,0272,RC,,,,both,,,1095.86,712.31,,,,,,,,,,,,,
SCREW BNE L100MM DIA4.9MM 3.5MM HEX HD NONSTERILE GRN CORT,SUP-2192367,CDM,C1713,HCPCS,0278,RC,,,,both,,,562.09,365.36,,,,,,,,,,,,,
SHEATH INTRO PINNACLE L 10 CM 5FR SS HYDRPHLC CORONARY,SUP-2385664,CDM,C1894,HCPCS,0272,RC,,,,both,,,35.48,23.06,,,,,,,,,,,,,
DEFIBRILLATOR IMPL VENTAK PRIZM VR HE DEL ENERGY 31 J TI,SUP-2148619,CDM,C1722,HCPCS,0275,RC,,,,both,,,72534.00,47147.10,,,,,,,,,,,,,
PLATE BNE W11XL216MM THK33MM 16 H BILAT MTPHSEAL TI LOK,SUP-2190768,CDM,C1713,HCPCS,0278,RC,,,,both,,,3887.89,2527.13,,,,,,,,,,,,,
SYSTEM CHARGING LE EON MINI,SUP-2355972,CDM,C1820,HCPCS,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
PLATE BNE STR 1.5X1 MM 4 MM MXLFCL OPN LOOP BRIDGE STP TI NS,SUP-2485770,CDM,C1713,HCPCS,0278,RC,,,,both,,,1093.98,711.09,,,,,,,,,,,,,
CATHETER PERICARDCENT 6FR L60CM STR KT,SUP-2303221,CDM,C1729,HCPCS,0272,RC,,,,both,,,313.22,203.59,,,,,,,,,,,,,
SPACER SPNL TI IMPL H33 TO 39MM 0DEG M XPAND,SUP-2229150,CDM,C1821,HCPCS,0278,RC,,,,both,,,15700.00,10205.00,,,,,,,,,,,,,
DUODENOSCOPE VID L 1240 MM OD 13.7 MM ID 4.2 MM BIOPLASTIC,SUP-2930278,CDM,C1748,HCPCS,0272,RC,,,,both,,,5636.30,3663.59,,,,,,,,,,,,,
PLATE BONE 4 H MIDFOOT TI UTIL FOR 2.7/3/3.5/4MM SCR,SUP-2225434,CDM,C1713,HCPCS,0278,RC,,,,both,,,5649.17,3671.96,,,,,,,,,,,,,
VLP MINI-MOD 1.5MM OVERDRILL MINI QUIK CONN,SUP-2341193,CDM,2720000010,LOCAL,0272,RC,,,,both,,,688.35,447.43,,,,,,,,,,,,,
ANCHOR SUT NO 2 SUT ABSRB POLY 3.5MM DIA 9.04MM LEN STATAK,SUP-2410530,CDM,C1713,HCPCS,0278,RC,,,,both,,,567.15,368.65,,,,,,,,,,,,,
PLATE BNE L286MM 13 H L DST LAT FEM S STL LOK FOR 4.5MM SCR,SUP-2348212,CDM,C1713,HCPCS,0278,RC,,,,both,,,14589.38,9483.10,,,,,,,,,,,,,
COLLAR EXTRIC AD TALL HI DENS POLYETH PD SET XTW,SUP-2194473,CDM,L0172,HCPCS,0274,RC,,,,both,,,107.61,69.95,,,,,,,,,,,,,
SET LOC INTRO 9GA NDL L14CM APER L20MM FOR ATEC MRI GUID,SUP-2240023,CDM,C1894,HCPCS,0272,RC,,,,both,,,452.79,294.31,,,,,,,,,,,,,
MESH SURGICAL CONTOURABLE 1.5X100X0.8 MM STERILE RAPIDSORB,SUP-2838579,CDM,C1713,HCPCS,0278,RC,,,,both,,,11530.71,7494.96,,,,,,,,,,,,,
PLATE BNE REPLICATOR 0 MM SHT SHLDR OFFSET FIX ANGLE KT TI,SUP-2451382,CDM,C1713,HCPCS,0278,RC,,,,both,,,3494.19,2271.22,,,,,,,,,,,,,
APPLIER CLP 12FR L114CM W/ ENDOANCHOR CASS 10 IMPL FOR,SUP-2280985,CDM,C1713,HCPCS,0278,RC,,,,both,,,19518.24,12686.86,,,,,,,,,,,,,
GRAFT DERMAL PLIABLE THCK 20X6 CMX0.8-1.7 MM FOLDING FLEXHD,SUP-2307554,CDM,Q4128,HCPCS,0636,RC,,,,both,,,10192.44,6625.09,,,,,,,,,,,,,
TEMPLATE PLT 24MM 2 CLMN VOLAR DST RAD VAR ANG LCP,SUP-2417332,CDM,2720000010,LOCAL,0272,RC,,,,both,,,268.60,174.59,,,,,,,,,,,,,
PLATE QUIKFLAP 3X2 SD AXS,SUP-2718051,CDM,C1713,HCPCS,0278,RC,,,,both,,,6550.04,4257.53,,,,,,,,,,,,,
METAPHYSEAL TIBIAL CONE ML48MM,SUP-2511819,CDM,C1776,CPT,0278,RC,,,,both,,,8394.16,5456.20,,,,,,,,,,,,,
RING ACET 70X74 MM LT HIP RECON CNTOUR,SUP-2434770,CDM,C1776,CPT,0278,RC,,,,both,,,9784.24,6359.76,,,,,,,,,,,,,
TOBRAMYCIN-DEXAMETHASONE 0.3-0.1 % OP OINT,RX-11566,CDM,6370000000,HCPCS,0637,RC,00078-0876-01,NDC,,both,3.5,GR,1341.50,871.97,,,,,,,,,,,,,
EPOETIN ALFA 10000 UNIT/ML IJ SOLN,RX-9938,CDM,Q4081,HCPCS,0636,RC,55513-0144-10,NDC,,both,1,ML,489.20,317.98,,,,,,,,,,,,,
GRAFT OPHTH DIA16MM AMNIO MEM OCU PROKERA,SUP-2135266,CDM,V2790,HCPCS,0274,RC,,,,both,,,2979.86,1936.91,,,,,,,,,,,,,
PLATE BONE SM 75MML HLX4 STNLSS STEEL DELTA BTTRSS ST RIGHT,SUP-2721435,CDM,C1713,HCPCS,0278,RC,,,,both,,,2406.24,1564.06,,,,,,,,,,,,,
PIN FIX OD3.2MM LNG KNEE PK CLLRD ADV EVOLUTION,SUP-2304614,CDM,C1713,HCPCS,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
HC Inject Tendon Origin/Insert|LEFT SIDE,PX-3612055100,CDM,20551,CPT,0361,RC,,,LT,outpatient,,,1485.00,965.25,,,,,,,,,,,,,
CROSSLINK SPNL FIX PLATE 4.5X16 MM SS SHILLA,SUP-2630561,CDM,C1713,HCPCS,0278,RC,,,,both,,,5071.10,3296.21,,,,,,,,,,,,,
IMPLANT OP RM MINI-MONSTER 3.0 X 24MM H,SUP-2320884,CDM,C1713,HCPCS,0278,RC,,,,both,,,994.75,646.59,,,,,,,,,,,,,
SCREW INTFR L23MM DIA7MM BIOCRYL RAPIDE ABSRB MILAGRO,SUP-2249499,CDM,C1713,HCPCS,0278,RC,,,,both,,,1224.60,795.99,,,,,,,,,,,,,
LASER SURG FOR SLT GLAUCOMA THER W/ 3 YR WARR SELECTA II,SUP-2713801,CDM,2720000010,LOCAL,0272,RC,,,,both,,,141300.00,91845.00,,,,,,,,,,,,,
SCREW SPNL MULTAXL 4X20 MM OCCIPITOCERVICAL UPPER THOR,SUP-2631997,CDM,C1713,HCPCS,0278,RC,,,,both,,,1789.80,1163.37,,,,,,,,,,,,,
HC Egd Flexible Foreign Body Removal,PX-4504324700,CDM,43247,CPT,0450,RC,,,,both,,,1056.00,686.40,,,,,,,,,,,,,
NEXGEN A/P WEDGED PRCT TIBIAL PLATE SZ 3,SUP-2503116,CDM,C1776,CPT,0278,RC,,,,both,,,5526.40,3592.16,,,,,,,,,,,,,
PLATE LOQTEQ NARROW 7 HOLE,SUP-2749487,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3503.80,2277.47,,,,,,,,,,,,,
CHARGER BTTRY FOR VENT ASST DEV HEARTWARE,SUP-2282565,CDM,Q0495,HCPCS,0274,RC,,,,both,,,19154.00,12450.10,,,,,,,,,,,,,
HC Cholesterol Serum/Whole Blood Total,PX-3018246500,CDM,82465,CPT,0301,RC,,,,both,,,78.00,50.70,,,,,,,,,,,,,
PROBE ENDOSCP,SUP-2530891,CDM,2720000010,LOCAL,0272,RC,,,,both,,,893.27,580.63,,,,,,,,,,,,,
BUR SURG DIA 6 MM HUB III BRL STD STRL DISP HI-LINE XS,SUP-2929291,CDM,2720000010,LOCAL,0272,RC,,,,both,,,365.90,237.83,,,,,,,,,,,,,
PLATE BNE L 102 MM 8 H SCREW DIA 3.5 MM TI ANTR MEDL CLAV,SUP-2905543,CDM,C1713,HCPCS,0278,RC,,,,both,,,5703.65,3707.37,,,,,,,,,,,,,
ACARBOSE 50 MG PO TABS,RX-15895,CDM,6370000000,HCPCS,0637,RC,64380-0759-06,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PACEMAKER CARD PHILOS II SR TI POLYUR SIL SINGLE CHMBR W/ LD,SUP-2138037,CDM,C1786,HCPCS,0275,RC,,,,both,,,13040.42,8476.27,,,,,,,,,,,,,
HANDLE DRVR SLAP HAMMER END,SUP-2484709,CDM,C1713,HCPCS,0278,RC,,,,both,,,1038.62,675.10,,,,,,,,,,,,,
MICRO PLATE 4 X 2 HOLES SQRE SGMNTS .6MM 1.5MM SSTM CP TTNM,SUP-2487654,CDM,C1713,HCPCS,0278,RC,,,,both,,,792.85,515.35,,,,,,,,,,,,,
HEAD HUM H15MM DIA44MM SHLDR CO CHROM PRI BIO MOD STD NK,SUP-2404613,CDM,C1776,CPT,0278,RC,,,,both,,,4688.02,3047.21,,,,,,,,,,,,,
IMPLANT ANK JT SUBTALAR IMPLABLE L15MM OD9MM BIOARCH,SUP-2401348,CDM,C1776,CPT,0278,RC,,,,both,,,2659.58,1728.73,,,,,,,,,,,,,
GRAFT VASC ALBOGRAFT L 30 CM DIA16 MM POLYESTER STR KNITTED,SUP-2264279,CDM,C1768,CPT,0278,RC,,,,both,,,1648.50,1071.52,,,,,,,,,,,,,
SCREW BNE LCK 5X14 MM DBL STRT THRD STRL JPS LTX,SUP-2875355,CDM,C1713,HCPCS,0278,RC,,,,both,,,1439.22,935.49,,,,,,,,,,,,,
VALVE AORT SZ 25 MM ANNULUS DIA21-23 MM AREA 338-415 SQ MM,SUP-2892457,CDM,C1889,HCPCS,0278,RC,,,,both,,,75360.00,48984.00,,,,,,,,,,,,,
HC So Allergen Specific,PX-3058600366,CDM,86003,CPT,0305,RC,,,,inpatient,,,161.00,104.65,,,,,,,,,,,,,
HOLDER IMPL L1.6MM THRD TAK EXTREMILOCK,SUP-2319689,CDM,C1713,HCPCS,0278,RC,,,,both,,,160.14,104.09,,,,,,,,,,,,,
DOME TALUS LT ARTC FT BNE,SUP-2257910,CDM,C1776,CPT,0278,RC,,,,both,,,20410.00,13266.50,,,,,,,,,,,,,
DEFIBRILLATOR IMPL ITREVIA HF-T W 58.5 X H 65 MM D 11 MM 36,SUP-2138440,CDM,C1882,HCPCS,0275,RC,,,,both,,,53380.00,34697.00,,,,,,,,,,,,,
COMPONENT HUM SM L4IN UNIV DST EL TIV PLSM INTERCHANGEABLE,SUP-2205912,CDM,C1776,CPT,0278,RC,,,,both,,,16956.00,11021.40,,,,,,,,,,,,,
SUPPORT ORTHOT HIP BILATERAL CUST COMBINATION,SUP-2435602,CDM,L1690,HCPCS,0274,RC,,,,both,,,5474.75,3558.59,,,,,,,,,,,,,
MTOSCR.INTF NON-CAN 7X20 N/S,SUP-2341306,CDM,C1713,HCPCS,0278,RC,,,,both,,,289.04,187.88,,,,,,,,,,,,,
CONNECTOR SPNL ROD LNG 300 MM CLOSED AX MARINER OUTRIG,SUP-2709820,CDM,C1713,HCPCS,0278,RC,,,,both,,,7065.00,4592.25,,,,,,,,,,,,,
STEM HUM SZ 3 NUCLS ANAT STRL PERFORM,SUP-2894285,CDM,C1776,CPT,0278,RC,,,,both,,,17140.88,11141.57,,,,,,,,,,,,,
RING EXT FIX ID130MM 5/8 COMP C ILIZ,SUP-2342283,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8162.74,5305.78,,,,,,,,,,,,,
DISTRACTION INTRNL ACT ARM RIGID CRDNC35 MM T 6L 4V QT001 EA,SUP-2496570,CDM,C1713,HCPCS,0278,RC,,,,both,,,2477.96,1610.67,,,,,,,,,,,,,
BUR SURG OD7MM DMND ST CRNRSTN MAESTRO,SUP-2363370,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1120.98,728.64,,,,,,,,,,,,,
SLEEVE FEM +0MM 12/14 TI UPLR TAPR PLSM SPRY,SUP-2221656,CDM,C1776,CPT,0278,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
SCREW BNE L18MM DIA3MM CORT S STL ST LOK FULL THRD T8 DRV,SUP-2371473,CDM,C1713,HCPCS,0278,RC,,,,both,,,338.49,220.02,,,,,,,,,,,,,
HALF PIN 6MMX35MM,SUP-2820784,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1921.90,1249.23,,,,,,,,,,,,,
FEMORAL M UNI PHASE 4 CEM OXFORD,SUP-2136450,CDM,C1776,CPT,0278,RC,,,,both,,,12776.66,8304.83,,,,,,,,,,,,,
VALVE CSF PROGRAMMABLE IN-LINE UNITZ DSTL CATH CERTAS +,SUP-2666572,CDM,C1889,HCPCS,0278,RC,,,,both,,,12086.77,7856.40,,,,,,,,,,,,,
PLATE BNE THK0.8MM BAR L2MM 5 H CRANIOMAXILLOFACIAL GRY TI,SUP-2366261,CDM,C1713,HCPCS,0278,RC,,,,both,,,677.55,440.41,,,,,,,,,,,,,
IMPLANT COSMETIC SZ 24 X 13 X 6.5 MM POLYETHYL BUR H CVR DRN,SUP-2935531,CDM,C1713,HCPCS,0278,RC,,,,both,,,872.92,567.40,,,,,,,,,,,,,
STEM FEM SZ 7 L135MM NK L39MM 52MM OFFSET 132DEG HIP FORGED,SUP-2375354,CDM,C1776,CPT,0278,RC,,,,both,,,8653.21,5624.59,,,,,,,,,,,,,
SPACER FEM AUG 5 MM TIB MAG VANGUARD 360,SUP-2444539,CDM,C1776,CPT,0278,RC,,,,both,,,84.78,55.11,,,,,,,,,,,,,
KIT CATH DRNGE PERI FEN DRP SUT DSG ALC PD LN DISP PERITX,SUP-2734747,CDM,C1729,HCPCS,0272,RC,,,,both,,,1859.67,1208.79,,,,,,,,,,,,,
GRAFT BNE FIB WDG RND COR FRZ DRY 6MM MATRIGRFT,SUP-2264771,CDM,C1713,HCPCS,0278,RC,,,,both,,,1519.35,987.58,,,,,,,,,,,,,
RESERVOIR VENTRICULAR LG 18 MM HOLTER,SUP-2666417,CDM,C1889,HCPCS,0278,RC,,,,both,,,1348.47,876.51,,,,,,,,,,,,,
DRILL SURG LUG DSTL FEM W/ HUDSON END SPEC 2,SUP-2456546,CDM,2720000010,LOCAL,0272,RC,,,,both,,,307.72,200.02,,,,,,,,,,,,,
OSTEOTOME ACET 46MM,SUP-2364386,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1089.89,708.43,,,,,,,,,,,,,
CATHETER PICC 6FR L55CM GWIRE 80CM 3 LUMN PERIPH NIT WIRE CT,SUP-2117003,CDM,C1894,HCPCS,0272,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
PLATE BNE DBL ANGLED MED 2 MM RECON PT SPEC TI,SUP-2860085,CDM,C1713,HCPCS,0278,RC,,,,both,,,21665.69,14082.70,,,,,,,,,,,,,
ALLOGRAFT BNE SPACER 8 DEG 20X45X15 MM ANGLED FD ORACLE,SUP-2736777,CDM,C1713,HCPCS,0278,RC,,,,both,,,19424.61,12626.00,,,,,,,,,,,,,
ENDCAP ORTH L16MM DIA6.5MM STD TI FOR T2 IM NAIL,SUP-2368731,CDM,C1776,CPT,0278,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
PLATE BNE LCK 30 MM RT DSTL RADIAL VOLAR LAT 2 HOLE CLMN,SUP-2494167,CDM,C1713,HCPCS,0278,RC,,,,both,,,2152.69,1399.25,,,,,,,,,,,,,
COMPONENT PATELLA PERSONA OSSEOTI 3-PEG 29MM,SUP-2935738,CDM,C1776,CPT,0278,RC,,,,both,,,4507.47,2929.86,,,,,,,,,,,,,
PLATE BNE L 113 MM SCREW DIA 4.5 MM 6 H NAR COMPR NLCK NS,SUP-2933279,CDM,C1713,HCPCS,0278,RC,,,,both,,,1794.98,1166.74,,,,,,,,,,,,,
KNIFE SRGCL 30DG ANGLD RIGHT SCKLE STRGHT SHARP TIP LATEX FR,SUP-2674406,CDM,2720000010,LOCAL,0272,RC,,,,both,,,403.02,261.96,,,,,,,,,,,,,
SPHERE EMBOLIZATION 2ML 100UM MIC MAR INSIDE SYR EMBOZENE,SUP-2855464,CDM,C1889,HCPCS,0278,RC,,,,both,,,800.70,520.45,,,,,,,,,,,,,
HC Lyr Clos Sc Tk Ext <2.5 Cm,PX-4501203100,CDM,12031,CPT,0450,RC,,,,outpatient,,,810.00,526.50,,,,,,,,,,,,,
COMPONENT ARTC 58 MM 54 MM SHLDR HUM OFFSET HEMICAPOVO,SUP-2123587,CDM,C1776,CPT,0278,RC,,,,both,,,11775.00,7653.75,,,,,,,,,,,,,
PLATE BNE L 122 X W 122 MM THK 0.75 MM SCREW DIA1.7 MM PLL,SUP-2883166,CDM,C1713,HCPCS,0278,RC,,,,both,,,20441.09,13286.71,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED PATELLOFEMORAL UNI NXGN N-K II,SUP-2212500,CDM,C1776,CPT,0278,RC,,,,both,,,12560.00,8164.00,,,,,,,,,,,,,
FIBER LASER DIA1000UM HOLM 2 WVLNGTH DEL SYS REUSE SLM LN,SUP-2139443,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2900.67,1885.44,,,,,,,,,,,,,
BAND STRUT ID STD FOR ILIZ TAY SPAT FRME EXT FIX,SUP-2342996,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1614.27,1049.28,,,,,,,,,,,,,
PIN BNE FIX L 150 MM DIA 5 MM SS FOR LG EXT FIX NS STEINMANN,SUP-2908443,CDM,C1713,HCPCS,0278,RC,,,,both,,,261.15,169.75,,,,,,,,,,,,,
CABLE SPNL L100MM LUM SULENE POLYCARB TEREPHTHALATE FOR DYN,SUP-2414262,CDM,C1713,HCPCS,0278,RC,,,,both,,,4396.00,2857.40,,,,,,,,,,,,,
IMPLANT FACE L 76 X W 50 MM THK 1.5 MM POLYETHYL EMBEDDED TI,SUP-2883505,CDM,C1713,HCPCS,0278,RC,,,,both,,,4023.88,2615.52,,,,,,,,,,,,,
FRACTURE KIT 2ND SHT W/ POWERCURVE STABILIT,SUP-2497209,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6908.00,4490.20,,,,,,,,,,,,,
BIT DRL L50MM DIA1MM 6MM STP FOR 1.2MM SCR UP FACE,SUP-2366399,CDM,2720000010,LOCAL,0272,RC,,,,both,,,386.82,251.43,,,,,,,,,,,,,
TRAY CATH MIDLN POWERGLIDE PRO 18GA 8CM WNGD 1 LUMA F218081T,SUP-2632749,CDM,C1751,HCPCS,0278,RC,,,,both,,,326.56,212.26,,,,,,,,,,,,,
STEM EXT FLUT 16X160MM W/ SLOT,SUP-2222923,CDM,C1776,CPT,0278,RC,,,,both,,,3589.02,2332.86,,,,,,,,,,,,,
GRAFT VASC IMPRA L 70 CM DIA 8 MM EPTFE FLX TW SM BEAD RING,SUP-2126884,CDM,C1768,CPT,0278,RC,,,,both,,,3195.39,2077.00,,,,,,,,,,,,,
PLATE STRNL CLOSURE THK 1.5 MM 4 H TI STR CONCV LP NS,SUP-2894446,CDM,C1713,HCPCS,0278,RC,,,,both,,,2015.88,1310.32,,,,,,,,,,,,,
PROBE NERVE STIM ELECTRD L 255 MM BALL DIA2.3 MM WIRE L 1.9,SUP-2895970,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1962.50,1275.62,,,,,,,,,,,,,
PLATE BNE L83MM 4 H L PROX HUM LO ALPS,SUP-2411633,CDM,C1713,HCPCS,0278,RC,,,,both,,,6330.24,4114.66,,,,,,,,,,,,,
SPLINT HND THM ADL NVY TERRY,SUP-2165485,CDM,L3807,HCPCS,0272,RC,,,,both,,,198.10,128.76,,,,,,,,,,,,,
HEAD HUM STD H17MM DIA44M BIO MOD,SUP-2404614,CDM,C1776,CPT,0278,RC,,,,both,,,3702.37,2406.54,,,,,,,,,,,,,
TRASTUZUMAB-DTTB 420 MG IV SOLR,RX-150364,CDM,Q5112,HCPCS,0636,RC,78206-0148-01,NDC,,both,1,UN,10682.10,6943.36,,,,,,,,,,,,,
FOOTRING EXT FIX SHT 120 MM HOFFMANN,SUP-2478527,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6182.03,4018.32,,,,,,,,,,,,,
SUTURE PACK 2 2P NDL ASMBLY UHMWPE BLK STRL EASYWHIP EW0110,SUP-2875932,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
BASKET RETRV 3 FR URETHRA SEGR HMSPHR,SUP-2141705,CDM,2720000010,LOCAL,0272,RC,,,,both,,,530.66,344.93,,,,,,,,,,,,,
LITHOTRIPTER SURG MECH SM 4.2 MMX195 CM BSKT LITHOCRUSH DISP,SUP-2312980,CDM,C1713,HCPCS,0278,RC,,,,both,,,1344.61,874.00,,,,,,,,,,,,,
SHEATH INTRO 8.5FR L71CM 8.5FR DIL GWIRE L180CM DIA0.032IN,SUP-2357285,CDM,C1766,CPT,0272,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
SUPPORT ORTHOT ANK KNEE CUST MOLD GAUNTLET,SUP-2435623,CDM,L1904,HCPCS,0274,RC,,,,both,,,1277.89,830.63,,,,,,,,,,,,,
SET INT FIX LAPIDUS SYS,SUP-2900640,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2967.30,1928.74,,,,,,,,,,,,,
NUT EXT FIX SPD NS,SUP-2863415,CDM,2720000010,LOCAL,0272,RC,,,,both,,,476.56,309.76,,,,,,,,,,,,,
HC So Assay of Hydroxyindolacetic Acid 5-Hiaa,PX-3018349766,CDM,83497,CPT,0301,RC,,,,outpatient,,,324.00,210.60,,,,,,,,,,,,,
SYSTEM POS STBL BUND ACROBAT I,SUP-2227773,CDM,C1713,HCPCS,0278,RC,,,,both,,,5959.15,3873.45,,,,,,,,,,,,,
TAP SURG SPNL SCR BONE DELT SYS 1.7MM,SUP-2365067,CDM,C1713,HCPCS,0278,RC,,,,both,,,513.96,334.07,,,,,,,,,,,,,
WEDGE FEM L SZ 1-2 THK5MM STD UNIV POST KNEE CO CHROM PRI,SUP-2346032,CDM,C1776,CPT,0278,RC,,,,both,,,1965.64,1277.67,,,,,,,,,,,,,
ALLOGRAFT BNE CRYOPRESERVED 15 MM FRSH PROCHONDRIX CR,SUP-2717805,CDM,C1762,CPT,0278,RC,,,,both,,,23917.38,15546.30,,,,,,,,,,,,,
STENT CORONARY VERIFLEX MR L 20 MM DIA2.75 MM SS RX,SUP-2144498,CDM,C1876,HCPCS,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
PERI-LOC VLP 2.7MMX20MM CORTEX SCREW,SUP-2819189,CDM,C1713,HCPCS,0278,RC,,,,both,,,145.29,94.44,,,,,,,,,,,,,
KIT INTRO ARROWG+ARD BLU SHTH L 10 CM DIA 8.5 FR SIDEPRT,SUP-2763366,CDM,C1892,HCPCS,0272,RC,,,,both,,,347.91,226.14,,,,,,,,,,,,,
STAPLE INT 6.5 MM,SUP-2435346,CDM,C1713,HCPCS,0278,RC,,,,both,,,4523.96,2940.57,,,,,,,,,,,,,
GRAFT HUM TISS 100MG WHL MICRONIZED ALLGRFT AMNION CHORION,SUP-2305738,CDM,Q4186,HCPCS,0636,RC,,,,both,,,5747.77,3736.05,,,,,,,,,,,,,
KNIFE SURG PAPARELLA SCKL 6.5 INX5 MM STR MICROFRANCE,SUP-2494088,CDM,2720000010,LOCAL,0272,RC,,,,both,,,429.05,278.88,,,,,,,,,,,,,
GRAFT BIO TISS W31XL31IN SQ XENMATRIX,SUP-2126239,CDM,C1781,HCPCS,0278,RC,,,,both,,,6081.24,3952.81,,,,,,,,,,,,,
PLATE BNE OVL LG 1.5X0.2 MM SCRN MESH JANNETTA TI NS,SUP-2490318,CDM,C1713,HCPCS,0278,RC,,,,both,,,1077.62,700.45,,,,,,,,,,,,,
MATRIX DERM 5X10CM ACELLULAR DERM MTRX N MESHED EXTRA THCK,SUP-2366757,CDM,Q4126,HCPCS,0636,RC,,,,both,,,9463.96,6151.57,,,,,,,,,,,,,
SCREW SCHANZ BLNT PT 5.0X40MM,SUP-2739165,CDM,C1713,HCPCS,0278,RC,,,,both,,,599.17,389.46,,,,,,,,,,,,,
PLATE BNE H1MM BAR L4MM 4 H MAND BLU TI MINI STR LOK,SUP-2366341,CDM,C1713,HCPCS,0278,RC,,,,both,,,320.44,208.29,,,,,,,,,,,,,
PLATE BONE 14 H ANTR LAT PROX FOR 4.5MM SCR,SUP-2349068,CDM,C1713,HCPCS,0278,RC,,,,both,,,1121.64,729.07,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.415,SUP-2859979,CDM,C1713,HCPCS,0278,RC,,,,both,,,35049.31,22782.05,,,,,,,,,,,,,
CUTTER SPNL OD9MM D12.8CM-11MM PWR BURR MIDAS CLASS AM,SUP-2290933,CDM,2720000010,LOCAL,0272,RC,,,,both,,,352.50,229.12,,,,,,,,,,,,,
BIT DRL 3.5MM TWST INSTR GIC94,SUP-2415758,CDM,2720000010,LOCAL,0272,RC,,,,both,,,844.66,549.03,,,,,,,,,,,,,
GRAFT HUM TISS 100MG AMNIO MEM UMB CRD PARTICULATE MTRX FOR,SUP-2116293,CDM,Q4155,HCPCS,0636,RC,,,,both,,,3611.00,2347.15,,,,,,,,,,,,,
SPLINT EL M,SUP-2276616,CDM,L3702,HCPCS,0274,RC,,,,both,,,29.01,18.86,,,,,,,,,,,,,
ROD EXT FIX W50XL110MM DIA4MM UNIV C FBR ANG T BAR,SUP-2188719,CDM,C1713,HCPCS,0278,RC,,,,both,,,1077.43,700.33,,,,,,,,,,,,,
SCREW BNE L 135 MM DIA 3.5 MM SS CORTICAL ST NS EVOS,SUP-2931510,CDM,C1713,HCPCS,0278,RC,,,,both,,,192.14,124.89,,,,,,,,,,,,,
SHEATH INTRO FAST-CATH TRIO L 23 CM DIA10 FR CATH 4/5 FR,SUP-2357122,CDM,C1894,HCPCS,0272,RC,,,,both,,,37.05,24.08,,,,,,,,,,,,,
PLATE BNE BROAD 3.5X198 MM 15 HOLE SS LC-DCP,SUP-2569249,CDM,C1713,HCPCS,0278,RC,,,,both,,,390.30,253.69,,,,,,,,,,,,,
MESH HERN RECT 10X4 IN FULL RESRB FOR SFT TISS PHASIX,SUP-2855251,CDM,C1781,HCPCS,0278,RC,,,,both,,,10880.10,7072.06,,,,,,,,,,,,,
BONE CEMENT SURG 40 GM PWDR 13.3 GM LIQ PMMA LO VISC STRL,SUP-2894045,CDM,C1713,HCPCS,0278,RC,,,,both,,,204.98,133.24,,,,,,,,,,,,,
CEFPODOXIME PROXETIL 100 MG/5ML PO SUSR,RX-9466,CDM,6370000000,HCPCS,0637,RC,16714-0403-01,NDC,,both,5,ML,54.10,35.16,,,,,,,,,,,,,
NEEDLE SPNL POS FOR SPS SYS,SUP-2770145,CDM,2720000010,LOCAL,0272,RC,,,,both,,,689.64,448.27,,,,,,,,,,,,,
CABLE INTCONN L15FT REUSE FOR CIRCA S CATH AND S CATH M TO,SUP-2164519,CDM,C1713,HCPCS,0278,RC,,,,both,,,879.20,571.48,,,,,,,,,,,,,
GRAFT HUM TISS W4XL6CM THK200UM AMNIO MEMBRN DEHYDR CHORION,SUP-2340449,CDM,C1762,CPT,0278,RC,,,,both,,,15031.18,9770.27,,,,,,,,,,,,,
RETRIEVER STONE REM W4XL5.5CM SHTH DIA2.5MM UNIV SPR LIKE,SUP-2360676,CDM,C1713,HCPCS,0278,RC,,,,both,,,299.81,194.88,,,,,,,,,,,,,
GRAFT VASC ARTEGRAFT L 30 CM DIA 6 MM CLLGN BOV CAR ART,SUP-2120667,CDM,C1768,CPT,0278,RC,,,,both,,,7721.26,5018.82,,,,,,,,,,,,,
INTRODUCER CATH CANN L 10 CM MINI WIRE L 43 CM DIA 0.021 IN,SUP-2909813,CDM,C1894,HCPCS,0272,RC,,,,both,,,181.34,117.87,,,,,,,,,,,,,
SCREW BNE SET 3 MM CANN 1/3 THRD EXT TAB,SUP-2861011,CDM,C1713,HCPCS,0278,RC,,,,both,,,13971.74,9081.63,,,,,,,,,,,,,
NAIL IM L180MM DIA11MM 125DEG TROCHANTERIC FEM TI CANN LOK,SUP-2370459,CDM,C1713,HCPCS,0278,RC,,,,both,,,3611.00,2347.15,,,,,,,,,,,,,
SHAFT SCRDRVR SELF RET AO QC T25 STRL DISP FLEX-THREAD,SUP-2900445,CDM,2720000010,LOCAL,0272,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
PLATE BONE 6 H LCK BILAT STR HND DISP FOR 2MM SCR H DIA,SUP-2267922,CDM,C1713,HCPCS,0278,RC,,,,both,,,1711.30,1112.34,,,,,,,,,,,,,
MARKER XRAY BRST BX F/9 GX10CM SUROS SYST,SUP-2120150,CDM,A4648,CPT,0278,RC,,,,both,,,262.19,170.42,,,,,,,,,,,,,
COIL NEUROVASCULAR CASHMERE 14 L 15 CM LOOP DIA 6 MM PRIMARY,SUP-2249270,CDM,C1889,HCPCS,0278,RC,,,,both,,,3929.08,2553.90,,,,,,,,,,,,,
PLATE BNE RECON 3.5X94 MM 8 HOLE SS,SUP-2569083,CDM,C1713,HCPCS,0278,RC,,,,both,,,378.21,245.84,,,,,,,,,,,,,
OXYTOCIN-SODIUM CHLORIDE 30-0.9 UT/500ML-% IV SOLN,RX-137274,CDM,J2590,HCPCS,0636,RC,71285-6044-01,NDC,,both,500,ML,54.10,35.16,,,,,,,,,,,,,
PLATE BNE SM L31MM THK1MM CENTRE SPACE 2.5MM 4 H MAND TI,SUP-2191207,CDM,C1713,HCPCS,0278,RC,,,,both,,,1523.21,990.09,,,,,,,,,,,,,
GRAFT BNE CHIP CRUSH FRZ DRY CANC 4MM 10MM RANG 15CC,SUP-2264674,CDM,C1713,HCPCS,0278,RC,,,,both,,,674.03,438.12,,,,,,,,,,,,,
CATHETER URETH 24 FR 5 CM BLLN W/ INFLATION DRUG OPTILUME,SUP-2863023,CDM,2720000010,LOCAL,0272,RC,,,,both,,,11806.40,7674.16,,,,,,,,,,,,,
INTRODUCER PIN L203CM OD8GA BVL TIP SGL USE,SUP-2354633,CDM,C1894,HCPCS,0272,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
SCREW BNE L14MM DIA3.5MM FIX ANG LOK FULL THRD MAXLOCK,SUP-2400223,CDM,C1713,HCPCS,0278,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
PLATE BNE 156 MM HIP 5 HOLE SS BMP,SUP-2468861,CDM,C1713,HCPCS,0278,RC,,,,both,,,9168.80,5959.72,,,,,,,,,,,,,
SHEATH RETRV L 150 CM GUIDEWIRE 0.054 IN CROSSING PROF 1.4,SUP-2146958,CDM,C1894,HCPCS,0272,RC,,,,both,,,320.28,208.18,,,,,,,,,,,,,
HC So1 Immunoassay,PX-3018351667,CDM,83516,CPT,0301,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
CATHETER NEPHROSTOMY FOL 34 FR SUPRAPUBIC PEZ STRL,SUP-2125605,CDM,C2627,HCPCS,0272,RC,,,,both,,,46.69,30.35,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 10 CM DIA 5 MM STR STD WALL HELIX,SUP-2695232,CDM,C1768,CPT,0278,RC,,,,both,,,905.26,588.42,,,,,,,,,,,,,
ELECTRODE ES 24FR L LOOP 12 16DEG PLSM LOOP HF RESECTION,SUP-2436281,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1600.83,1040.54,,,,,,,,,,,,,
CONNECTOR SPNL DIA5.5X5.5MM TI CLOSED/OPEN AX CDH LEG,SUP-2289158,CDM,C1713,HCPCS,0278,RC,,,,both,,,3331.54,2165.50,,,,,,,,,,,,,
GRAFT BNE 1 4MM 60ML CANC CRUSH CHIP FRZN,SUP-2264738,CDM,C1713,HCPCS,0278,RC,,,,both,,,2616.12,1700.48,,,,,,,,,,,,,
HC MRI-Spine Cervical WO Contrast,PX-6127214100,CDM,72141,CPT,0612,RC,,,,both,,,3143.00,2042.95,,,,,,,,,,,,,
PUNCH BX SCHUMACHER 2 6 MM,SUP-2273872,CDM,2720000010,LOCAL,0272,RC,,,,both,,,450.87,293.07,,,,,,,,,,,,,
MICROSPHERE EMB THERASPHERE DIA15-35 UM GLS HEPATIC ART STRL,SUP-2135330,CDM,C2616,HCPCS,0278,RC,,,,both,,,63836.20,41493.53,,,,,,,,,,,,,
KETOROLAC TROMETHAMINE 10 MG PO TABS,RX-10371,CDM,6370000000,HCPCS,0637,RC,00093-0314-01,NDC,,both,1,UN,4.90,3.18,,,,,,,,,,,,,
DEFIBRILLATOR IMPL EMBLEM MRI W 83.1 X H 69.1 MM D 12.7 MM,SUP-2149157,CDM,C1722,HCPCS,0275,RC,,,,both,,,61148.36,39746.43,,,,,,,,,,,,,
BIT DRL L110MM DIA3.5MM STRL 3 FLUT QUIK CPL NONRADIOPAQUE,SUP-2187602,CDM,2720000010,LOCAL,0272,RC,,,,both,,,461.67,300.09,,,,,,,,,,,,,
GUIDEWIRE INTRMDLLRY NAIL 4MM SHAFT 60CML SMTHBLNT TIPS,SUP-2723337,CDM,C1769,HCPCS,0272,RC,,,,both,,,496.78,322.91,,,,,,,,,,,,,
BUR SURG BALL 2 MM 12 CM TELSCP MIDAS REX LEGEND,SUP-2632194,CDM,2720000010,LOCAL,0272,RC,,,,both,,,341.54,222.00,,,,,,,,,,,,,
HC So Calcitionin,PX-3018230866,CDM,82308,CPT,0301,RC,,,,both,,,603.00,391.95,,,,,,,,,,,,,
CATHETER CARD ABLATION NAVISTAR L 115CM 7FR 4MM D CRV UNIDIR,SUP-2475051,CDM,C1732,HCPCS,0272,RC,,,,both,,,6119.86,3977.91,,,,,,,,,,,,,
STEM FEM L180MM OD10MM 140DEG TI POR PLSM SPRY CALCAR HIP,SUP-2406823,CDM,C1776,CPT,0278,RC,,,,both,,,16227.52,10547.89,,,,,,,,,,,,,
PLATE BNE 6 H ULNA SHORTNG LO PROF FOR OSTEOTMY SYS,SUP-2107841,CDM,C1713,HCPCS,0278,RC,,,,both,,,3052.08,1983.85,,,,,,,,,,,,,
HC Treatment Dehiscence Simple,PX-4501202000,CDM,12020,CPT,0450,RC,,,,both,,,1842.00,1197.30,,,,,,,,,,,,,
SPACER SPNL W28XH10MM 12DEG NAR TI ANTR INTBDY FUS LORDTC,SUP-2414761,CDM,C1821,HCPCS,0278,RC,,,,both,,,21195.00,13776.75,,,,,,,,,,,,,
SPLINT DENT OCCLUSAL IPS CUST,SUP-2263023,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4851.30,3153.34,,,,,,,,,,,,,
CANNULA SUCTION BPLR 5 MMX25 CM COAG TUBE DSTL ANGLED SHTH,SUP-2775798,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3077.77,2000.55,,,,,,,,,,,,,
SUPPORT ORTHOT FNGR W/NONTORSION JT FABRICATED SFT INTFACE,SUP-2435790,CDM,L3935,HCPCS,0274,RC,,,,both,,,569.22,369.99,,,,,,,,,,,,,
HEAD RAD H26MM DIA15.5MM +2MM OFFSET BILAT ELBW CO CHROM,SUP-2183049,CDM,C1776,CPT,0278,RC,,,,both,,,6585.99,4280.89,,,,,,,,,,,,,
PLATE BNE STR REINF BAR 4 H MINI FOR 2MM UNIV FIX SYS,SUP-2366349,CDM,C1713,HCPCS,0278,RC,,,,both,,,1161.14,754.74,,,,,,,,,,,,,
CARRIER ATTCH 13MM FOR SM BNE FIX SYS STAPLIZER,SUP-2167242,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2824.74,1836.08,,,,,,,,,,,,,
TUBE SET DIL DISP,SUP-2750391,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
BLADE SHAVER 2.1MM STRAIGHT,SUP-2659959,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4396.00,2857.40,,,,,,,,,,,,,
GRAFT HUM TISS 15MM DISK ALLGRFT AMNIOEXCEL,SUP-2194315,CDM,Q4137,HCPCS,0636,RC,,,,both,,,923.16,600.05,,,,,,,,,,,,,
ASSEMBLY KYPHOPLASTY BI PEDICULAR 20 MM ADDL LEVEL STRL DISP,SUP-2846422,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
FOLTX 1.13-25-2 MG PO TABS,RX-120423,CDM,6370000000,HCPCS,0637,RC,00525-0966-90,NDC,,both,1,UN,9.30,6.04,,,,,,,,,,,,,
ALLOGRAFT BONE CORTICOCANCELLOUS MINERALIZED 0.5MM -,SUP-2418451,CDM,C1889,HCPCS,0278,RC,,,,both,,,285.74,185.73,,,,,,,,,,,,,
SPLINT THMB M L5IN SH RT 1 STRP THERMOPLASTIC INSRT,SUP-2324196,CDM,L3931,HCPCS,0274,RC,,,,both,,,42.23,27.45,,,,,,,,,,,,,
CURETTE BONE ANG SZ 0,SUP-2292914,CDM,C1713,HCPCS,0278,RC,,,,both,,,2314.18,1504.22,,,,,,,,,,,,,
SCREW TIB STEM LCK MOD VANGUARD 360 AGC,SUP-2406042,CDM,C1713,HCPCS,0278,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
SUBSTITUTE BONE GRFT 10CC DBM W/ RPM GEL AND PASTE CANC,SUP-2415800,CDM,C1713,HCPCS,0278,RC,,,,both,,,3256.18,2116.52,,,,,,,,,,,,,
PLATE STRNL CLOSURE THK 1.5 MM 12 H TI WIDE Y LP NS,SUP-2894527,CDM,C1713,HCPCS,0278,RC,,,,both,,,3673.80,2387.97,,,,,,,,,,,,,
SYSTEM ENDOSCP PLNTR FASCTMY DISPOSABLE EPF,SUP-2422354,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2659.58,1728.73,,,,,,,,,,,,,
GRAFT VASC PERIPH BYPS STR THN WALL N RNGD EPTFE SM BEAD,SUP-2128210,CDM,C1768,CPT,0278,RC,,,,both,,,4004.13,2602.68,,,,,,,,,,,,,
SCREW BNE CRTX 2.4X85 MM ST T8 STARDRV RECESS TI NS,SUP-2758285,CDM,C1713,HCPCS,0278,RC,,,,both,,,199.74,129.83,,,,,,,,,,,,,
REV BICONVEX PAT 32MM,SUP-2827854,CDM,C1776,CPT,0278,RC,,,,both,,,2832.28,1840.98,,,,,,,,,,,,,
PLATE BNE W101XL154MM THK35MM 11 H BILAT TI STR RIG LOK,SUP-2191086,CDM,C1713,HCPCS,0278,RC,,,,both,,,1809.99,1176.49,,,,,,,,,,,,,
HC Ventilator Subsequent Day,PX-4109400300,CDM,94003,CPT,0410,RC,,,,inpatient,,,1569.00,1019.85,,,,,,,,,,,,,
TRIAL BONE PLT 4 H T SHP OBLQ TC-100 SM FRAG SYS,SUP-2343730,CDM,C1713,HCPCS,0278,RC,,,,both,,,2110.74,1371.98,,,,,,,,,,,,,
INFUSION PUMP KIT PAIN 1 IN CTRL CATH PAINBUSTER ON-Q PM032] HALYARD SALES LLC FKA I-FLOW],SUP-2236841,CDM,C1713,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED UPCHARGE MOM,SUP-2212689,CDM,C1776,CPT,0278,RC,,,,both,,,6824.79,4436.11,,,,,,,,,,,,,
GRAFT BIO TISS W15XL10CM THK2MM NONDENATURED BOV CLLGN,SUP-2243681,CDM,C9360,HCPCS,0278,RC,,,,both,,,8478.00,5510.70,,,,,,,,,,,,,
SPACER SPNL SM 18 DEG 32X23X14 MM SOVEREIGN,SUP-2631362,CDM,C1889,HCPCS,0278,RC,,,,both,,,13423.50,8725.27,,,,,,,,,,,,,
PLATE BNE 16 H ST BILAT S STL NAR CRV LOK COMPR FOR 3.5MM,SUP-2178048,CDM,C1713,HCPCS,0278,RC,,,,both,,,2666.93,1733.50,,,,,,,,,,,,,
VALVE AORT CARP EDW PERIMT DIA21 MM BOV PERICARD COCR,SUP-2214054,CDM,C1889,HCPCS,0278,RC,,,,both,,,21226.40,13797.16,,,,,,,,,,,,,
DEVICE FIX 7-8 MM TIB BIOSURE SYNC,SUP-2848624,CDM,C1713,HCPCS,0278,RC,,,,both,,,728.64,473.62,,,,,,,,,,,,,
PROSTHESIS VOICE 2 VLV 20 FRX8 MM NS BLOM-SINGER,SUP-2242333,CDM,L8509,HCPCS,0272,RC,,,,both,,,1284.26,834.77,,,,,,,,,,,,,
PLATE BNE L 38 MM SCREW DIA 4.5 MM ST LCK NS EVOS,SUP-2931229,CDM,C1713,HCPCS,0278,RC,,,,both,,,851.41,553.42,,,,,,,,,,,,,
KIT NEUROSTIMULATOR LO PROF CYL WNG BOOT ANCHR FOR DP BRAIN,SUP-2284434,CDM,2720000010,LOCAL,0272,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
PROSTHESIS OTO OD1.1MM HA INCUS STAP CONN SILVERSTEIN,SUP-2284051,CDM,L8613,CPT,0278,RC,,,,both,,,1253.99,815.09,,,,,,,,,,,,,
PLATE BNE DIA17 MM THK 0.5 MM SCREW DIA1.7 MM MAXILLOFCL,SUP-2909635,CDM,C1713,HCPCS,0278,RC,,,,both,,,2210.18,1436.62,,,,,,,,,,,,,
RING EXT FIX DIA100 MM FULL SINGLE ROW MONK RING,SUP-2898994,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4136.17,2688.51,,,,,,,,,,,,,
AUGMENT FEM SZ 4 THK15MM L DST KNEE CO CHROM PRESSFIT REV,SUP-2373517,CDM,C1776,CPT,0278,RC,,,,both,,,2828.51,1838.53,,,,,,,,,,,,,
HEAD FEM 0+ 36 MM HIP CERM BIOLOX DELT,SUP-2390425,CDM,C1776,CPT,0278,RC,,,,both,,,8116.90,5275.98,,,,,,,,,,,,,
GRAFT BNE PTTY 1-2 MM 20 CC CALCIUM PHOSPHATE ACTIFUSE ABX,SUP-2130292,CDM,C9359,HCPCS,0278,RC,,,,both,,,9341.50,6071.97,,,,,,,,,,,,,
ALLOGRAFT DERMAL 2X12 CMX2.31-3.30 MM TISS MTRX ALLDERM,SUP-2113046,CDM,Q4116,HCPCS,0636,RC,,,,both,,,2587.36,1681.78,,,,,,,,,,,,,
CABLE SPNL TI W/ INTEGR CRMP DBL ATLS,SUP-2289632,CDM,C1713,HCPCS,0278,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
VALVE SHUNT AD 14GA NDL LUM BLU S STL MIN VENT ENLMENT HORZ,SUP-2243840,CDM,C1729,HCPCS,0272,RC,,,,both,,,3051.51,1983.48,,,,,,,,,,,,,
SCREW BONE FIX L26MM DIA2.2MM DSTL VOLAR RAD SMOOTH LCK PEG,SUP-2136242,CDM,C1713,HCPCS,0278,RC,,,,both,,,307.72,200.02,,,,,,,,,,,,,
GRAFT VASC HEMSHLD PLAT L 40 CM DIA10 MM POLYESTER BOV CLLGN,SUP-2682169,CDM,C1768,CPT,0278,RC,,,,both,,,1877.75,1220.54,,,,,,,,,,,,,
LOCKING RCNSTRCTN PLATE ANGLE ANGLE 34 HOLE 30MM THCK27MM,SUP-2680246,CDM,C1713,HCPCS,0278,RC,,,,both,,,7347.47,4775.86,,,,,,,,,,,,,
ANTEROLATERAL PILON FUSION PLATE 15H RT,SUP-2815201,CDM,C1713,HCPCS,0278,RC,,,,both,,,13816.00,8980.40,,,,,,,,,,,,,
NUT ORTH LCK 10 MM HEX QR,SUP-2749958,CDM,2720000010,LOCAL,0272,RC,,,,both,,,649.98,422.49,,,,,,,,,,,,,
KIT UPHOLD SLNG,SUP-2141765,CDM,C1763,HCPCS,0278,RC,,,,both,,,6075.90,3949.33,,,,,,,,,,,,,
PLATE BNE THK0.6MM 2X2 H BILAT HND RECTANG NONCOMPRESSION,SUP-2267884,CDM,C1713,HCPCS,0278,RC,,,,both,,,648.10,421.26,,,,,,,,,,,,,
GRAFT MTRX DERM HUM TISS ACELLULAR FRZ DRY THCK 4CMX12CM,SUP-2306912,CDM,C1762,CPT,0278,RC,,,,both,,,4461.34,2899.87,,,,,,,,,,,,,
LK RECON PLATE 14HL 222MM,SUP-2702819,CDM,C1713,HCPCS,0278,RC,,,,both,,,2834.48,1842.41,,,,,,,,,,,,,
ANKLE ARTHRODESIS NUT,SUP-2701069,CDM,C1713,HCPCS,0278,RC,,,,both,,,701.79,456.16,,,,,,,,,,,,,
VLP 2.5MM TALUS PLT MDL L LT 11X20MM ST,SUP-2820181,CDM,C1713,HCPCS,0278,RC,,,,both,,,5832.71,3791.26,,,,,,,,,,,,,
CATHETER UMB DL PEDIATRIC 5 FRX15 IN VEN PREP TY ARGY,SUP-2174254,CDM,C1751,HCPCS,0278,RC,,,,both,,,203.47,132.26,,,,,,,,,,,,,
CATHETER THROMCTMY ANGIOJET ULTRA SOLENT DISTA L 145 CM DIA,SUP-2142040,CDM,C1757,HCPCS,0272,RC,,,,both,,,6225.84,4046.80,,,,,,,,,,,,,
ES RETROGRADE FEM NAIL CASE 12/13MM,SUP-2811382,CDM,C1713,HCPCS,0278,RC,,,,both,,,8148.30,5296.39,,,,,,,,,,,,,
ROD IM L 140 MM DIA22/13 MM PHOTODYNAMIC BNE STBL PROC PK,SUP-2934112,CDM,C1713,HCPCS,0278,RC,,,,both,,,14626.12,9506.98,,,,,,,,,,,,,
PROSTHESIS PENILE 12CM SNAP FIT REAR TIP INHIBIZONE LGX,SUP-2138981,CDM,C1813,HCPCS,0278,RC,,,,both,,,25154.54,16350.45,,,,,,,,,,,,,
GRAFT BONE CHIP FRZ DRY DEMIN CANC CORT 4MM-10MM RANG 30CC,SUP-2294043,CDM,C1713,HCPCS,0278,RC,,,,both,,,1199.48,779.66,,,,,,,,,,,,,
CARVEDILOL 3.125 MG PO TABS,RX-18551,CDM,6370000000,HCPCS,0637,RC,00904-7305-61,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
SYSTEM EMB 18 FR SZ 15 CM LEN PERIPH HYDRGEL HYDROLYSER,SUP-2385399,CDM,C1889,HCPCS,0278,RC,,,,both,,,4264.12,2771.68,,,,,,,,,,,,,
VALVE SHUNT INLINE PROGRAMMABLE CODMAN CERTAS +,SUP-2243823,CDM,C1729,HCPCS,0272,RC,,,,both,,,12086.77,7856.40,,,,,,,,,,,,,
CATHETER INFUSION PMP 4 ML/HR 2X10 IN 275 CC,SUP-2361463,CDM,C1751,HCPCS,0278,RC,,,,both,,,602.88,391.87,,,,,,,,,,,,,
SHAFT FIB TRAD ALLGRFT 180 MM FRZN,SUP-2294145,CDM,C1713,HCPCS,0278,RC,,,,both,,,3165.12,2057.33,,,,,,,,,,,,,
SCREW SPNL ROD DIA 4.75/5 MM SS REDUCTION UNIAXIAL STRL CD 559200023,SUP-2927813,CDM,C1713,HCPCS,0278,RC,,,,both,,,2.83,1.84,,,,,,,,,,,,,
MATRIX BIO SZ 300-540 SQCM FISH SKIN DERMAL MESHED 21 SINGLE,SUP-2909392,CDM,Q4158,HCPCS,0636,RC,,,,both,,,32499.00,21124.35,,,,,,,,,,,,,
GRAFT BNE 2.5 CC CURRENT,SUP-2644309,CDM,C1713,HCPCS,0278,RC,,,,both,,,3485.40,2265.51,,,,,,,,,,,,,
FORCEPS OPHTH 23GA SERR DISP GRIESHABER REVOLUTION DSP,SUP-2109705,CDM,2720000010,LOCAL,0272,RC,,,,both,,,346.06,224.94,,,,,,,,,,,,,
BRACE ORTH 2 MOD BK PRE CUST TLSO,SUP-2388139,CDM,L0460,HCPCS,0272,RC,,,,both,,,2585.10,1680.31,,,,,,,,,,,,,
K WIRE FIX L150MM DIA1.6MM TRCR PNT 1 END FOR SM FRAG UNIV,SUP-2411305,CDM,C1713,HCPCS,0278,RC,,,,both,,,24.84,16.15,,,,,,,,,,,,,
PROBE PERIODONTAL N 22 T,SUP-2936970,CDM,2720000010,LOCAL,0272,RC,,,,both,,,276.32,179.61,,,,,,,,,,,,,
SCREW BNE TI REDUC EXTN SL 635MM 635MMX7MM CDH LEG,SUP-2287821,CDM,C1713,HCPCS,0278,RC,,,,both,,,756.61,491.80,,,,,,,,,,,,,
PLATE BNE BROAD 4.5X263 MM 16 HOLE SS DCP,SUP-2569181,CDM,C1713,HCPCS,0278,RC,,,,both,,,526.74,342.38,,,,,,,,,,,,,
ISOSORBIDE DINITRATE 20 MG PO TABS,RX-4065,CDM,6370000000,HCPCS,0637,RC,72888-0083-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
GRAFT DERMAL MESH THCK 16X8 CMX0.8-1.7 MM PLIABLE KT FLEXHD,SUP-2307596,CDM,C1781,HCPCS,0278,RC,,,,both,,,20264.30,13171.79,,,,,,,,,,,,,
HANDPIECE ASPIR 0.4 MM 23 GAX113 MM POL ROUGHENED SURF TI,SUP-2462252,CDM,2720000010,LOCAL,0272,RC,,,,both,,,549.03,356.87,,,,,,,,,,,,,
GRAFT BNE SUB 2.5CC B TRICALCIUM PHSPTE VERSATILE ULT POR,SUP-2370372,CDM,C1713,HCPCS,0278,RC,,,,both,,,2977.19,1935.17,,,,,,,,,,,,,
MONITOR DOPP PERC SMARTNEEDLE,SUP-2120518,CDM,C1894,HCPCS,0272,RC,,,,both,,,74.39,48.35,,,,,,,,,,,,,
HC CT Chest W/O Contrast,PX-3527125000,CDM,71250,CPT,0352,RC,,,,both,,,1973.00,1282.45,,,,,,,,,,,,,
GUIDEWIRE ORTHO 1.1X150 MM TROCAR PT 1 END,SUP-2422317,CDM,C1769,HCPCS,0272,RC,,,,both,,,195.94,127.36,,,,,,,,,,,,,
BEVACIZUMAB-ADCD 100 MG/4ML IV SOLN,RX-161516,CDM,Q5129,HCPCS,0636,RC,72606-0011-01,NDC,,both,4,ML,1951.00,1268.15,,,,,,,,,,,,,
GRAFT HUM TISS TEND WHL QUADRICEP ALLGRFT,SUP-2307269,CDM,C1762,CPT,0278,RC,,,,both,,,15176.47,9864.71,,,,,,,,,,,,,
BONE SCR,SUP-2281754,CDM,C1713,HCPCS,0278,RC,,,,both,,,3197.43,2078.33,,,,,,,,,,,,,
ELECTRODE MPLR NIT 50MM,SUP-2366965,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8466.98,5503.54,,,,,,,,,,,,,
SEAT REDUC 6.35MM TI VAR ANG LCK,SUP-2415522,CDM,C1713,HCPCS,0278,RC,,,,both,,,2115.36,1374.98,,,,,,,,,,,,,
PUMP PAIN MGMT 600ML 2-14ML/HR 2 ELASTOMERIC NONNARCOTIC,SUP-2236814,CDM,C9804,HCPCS,0272,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
HC Antinuclear Antibodies Ana,PX-3028603800,CDM,86038,CPT,0302,RC,,,,both,,,232.00,150.80,,,,,,,,,,,,,
SUP MED CLAV LCK PL 10H RIGHT SMP,SUP-2818688,CDM,C1713,HCPCS,0278,RC,,,,both,,,2357.45,1532.34,,,,,,,,,,,,,
ROD RMR L950MM DIA3MM NONSTERILE TI STR BALL TIP FOR IM,SUP-2188115,CDM,2720000010,LOCAL,0272,RC,,,,both,,,369.99,240.49,,,,,,,,,,,,,
PLATE BNE L79MM 3 H ST R DST LAT FIBULAR S STL VAR ANG LOK,SUP-2177711,CDM,C1713,HCPCS,0278,RC,,,,both,,,2418.40,1571.96,,,,,,,,,,,,,
SHUNT SURG VENTRICULAR CATH L 180 MM PRESSURE DIFF 5 CM H2O FX846T,SUP-2928932,CDM,C1889,HCPCS,0278,RC,,,,both,,,16745.37,10884.49,,,,,,,,,,,,,
PLATE BNE L20MM 2 H COMPR LO PROF FIX ANG MAL NONLOCKING,SUP-2397372,CDM,C1713,HCPCS,0278,RC,,,,both,,,2455.48,1596.06,,,,,,,,,,,,,
PIN EXT FIX 2 MM,SUP-2198651,CDM,C1713,HCPCS,0278,RC,,,,both,,,271.30,176.34,,,,,,,,,,,,,
MESH SURG Y SHP 24X4 CM POLYPR RESTORELLE Y,SUP-2425006,CDM,C1781,HCPCS,0278,RC,,,,both,,,3092.90,2010.38,,,,,,,,,,,,,
HANDLE INSTRUMENT RASPATORY 5 MM SLGHT CRV,SUP-2487332,CDM,C1713,HCPCS,0278,RC,,,,both,,,441.17,286.76,,,,,,,,,,,,,
COMPONENT PAT L SZ 3 STD KNEE POLYETH NP RND PEG CEM REV,SUP-2251250,CDM,C1776,CPT,0278,RC,,,,both,,,2995.56,1947.11,,,,,,,,,,,,,
MESH SURG CONTOURED SM 0.3 MM ORBIT FLR SPEC BOWLES TI,SUP-2458003,CDM,C1713,HCPCS,0278,RC,,,,both,,,1177.81,765.58,,,,,,,,,,,,,
BLADE SAW 12MM THK.38MM SAG OSC VERTICAL RAMUS OSTEOTMY STRL,SUP-2319795,CDM,C1713,HCPCS,0278,RC,,,,both,,,596.60,387.79,,,,,,,,,,,,,
GRAFT BONE 16X20MM DWL HUM TISS CANC CORT FRZN TISS MDII,SUP-2293890,CDM,C1713,HCPCS,0278,RC,,,,both,,,11278.88,7331.27,,,,,,,,,,,,,
FIXATOR EXT SHT PELV BODY NS LTX,SUP-2874950,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2154.04,1400.13,,,,,,,,,,,,,
NEEDLE TRANSEPTAL HEARTSPAN 50 DEG 98CM,SUP-2141301,CDM,2720000010,LOCAL,0272,RC,,,,both,,,596.60,387.79,,,,,,,,,,,,,
KIT MICROCATHETER RENEGADE HI FLO L 105 CM DSTL TIP L 10 CM,SUP-2141040,CDM,C1887,HCPCS,0272,RC,,,,both,,,1648.50,1071.52,,,,,,,,,,,,,
HC Harvest Auto Stem Cells,PX-3623820600,CDM,38206,CPT,0362,RC,,,,both,,,5037.00,3274.05,,,,,,,,,,,,,
MESH SURG 25X20 CM BIOMATERIAL INTRAPERITONEAL ENFORM,SUP-2435397,CDM,C1781,HCPCS,0278,RC,,,,both,,,29035.58,18873.13,,,,,,,,,,,,,
SCREW SPNL MULTAXL 5.5X15 MM OCCIPITOCERVICAL UPPER THOR,SUP-2631978,CDM,C1713,HCPCS,0278,RC,,,,both,,,2041.00,1326.65,,,,,,,,,,,,,
CABLE ABLATION CATH EXT FOR AFFERA SPHR 9 STRL,SUP-2911934,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6280.00,4082.00,,,,,,,,,,,,,
SYSTEM ENDOPLEDGE HRTPORT FOR ALTERNATIVE TO CONVENTIONAL,SUP-2214470,CDM,C1730,HCPCS,0278,RC,,,,both,,,6210.92,4037.10,,,,,,,,,,,,,
BIT DRILL L200MM OD4.8MM CANNULATED,SUP-2493566,CDM,2720000010,LOCAL,0272,RC,,,,both,,,653.12,424.53,,,,,,,,,,,,,
BLADE SHAVER CRV 15 DEG 4.8 MM SERRATED HEMOSTATIC CONCV,SUP-2648914,CDM,2720000010,LOCAL,0272,RC,,,,both,,,585.80,380.77,,,,,,,,,,,,,
BUR SURG HD DIA2.1MM HELICOIDAL RASP 5 EXPOSE MARK/STEP,SUP-2367593,CDM,2720000010,LOCAL,0272,RC,,,,both,,,383.96,249.57,,,,,,,,,,,,,
PLATE BNE 8 H L TI H SHP OBLQ ANG STRUT EXT FOR 1.5MM SCR,SUP-2191148,CDM,C1713,HCPCS,0278,RC,,,,both,,,1234.30,802.29,,,,,,,,,,,,,
MIDODRINE HCL 5 MG PO TABS,RX-10610,CDM,6370000000,HCPCS,0637,RC,60687-0398-11,NDC,,both,1,UN,3.40,2.21,,,,,,,,,,,,,
PLATE BNE 3.5X287 MM 22 HOLE SS LCP,SUP-2569332,CDM,C1713,HCPCS,0278,RC,,,,both,,,623.45,405.24,,,,,,,,,,,,,
AUGMENT FEM BLK 10 MM POST THICKNESS HALF UNIV STD + CEM POS,SUP-2436144,CDM,C1776,CPT,0278,RC,,,,both,,,2540.89,1651.58,,,,,,,,,,,,,
FOIL DENTAL 25MMW X 25MML 01MM THK RESORB X LATEX FREE,SUP-2694436,CDM,C1713,HCPCS,0278,RC,,,,both,,,1051.43,683.43,,,,,,,,,,,,,
PLATE BONE W5.1XL30MM THK1MM 6 H RT HND T LO PROF FOR,SUP-2417077,CDM,C1713,HCPCS,0278,RC,,,,both,,,1077.65,700.47,,,,,,,,,,,,,
GUIDEWIRE ENDO L145CM OD0.035IN S STL PTFE COONS-BENTSON,SUP-2168892,CDM,C1769,HCPCS,0272,RC,,,,both,,,93.45,60.74,,,,,,,,,,,,,
PLATE BONE 9 H RT OLECRANON S STL LCK PERI-LOC,SUP-2350887,CDM,C1713,HCPCS,0278,RC,,,,both,,,1840.10,1196.06,,,,,,,,,,,,,
KIT HAD CATH 12.5FR L20CM 3 LUMN CRV EXTN MAHRK ELITE,SUP-2283977,CDM,C1752,HCPCS,0278,RC,,,,both,,,326.53,212.24,,,,,,,,,,,,,
BAG TISS CLSR DIA4CM TRNSPAR SIL SILO SPR LD PROX OPN SFT,SUP-2134678,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1212.04,787.83,,,,,,,,,,,,,
CONNECTOR SPNL THORLUM LO PROF WIDE PARA FOR 5.5/5.5MM ROD,SUP-2229568,CDM,C1713,HCPCS,0278,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
DRILL SURG PERIPH REV PINNACLE,SUP-2454006,CDM,C1713,HCPCS,0278,RC,,,,both,,,1447.54,940.90,,,,,,,,,,,,,
COIL EMB L40CM DIA8MM 0.02IN PERIPH COMPLX STD FRME,SUP-2323669,CDM,C1889,HCPCS,0278,RC,,,,both,,,4019.20,2612.48,,,,,,,,,,,,,
HC Dx Breast Tomo Bil|NOT REASONABLE AND NECESSARY,PX-4017706200,CDM,G0279,HCPCS,0401,RC,,,GZ,both,,,99.00,64.35,,,,,,,,,,,,,
COLLAR CERV PED SM EXTRIC 1 PC TRACH OPN W CHIN REST MINI,SUP-2115115,CDM,L0140,HCPCS,0274,RC,,,,both,,,35.36,22.98,,,,,,,,,,,,,
LEAD DEFIB LINOXSMART S L 65 CM SIL INSUL IRIDIUM OXIDE TIP,SUP-2138267,CDM,C1777,HCPCS,0275,RC,,,,both,,,8792.00,5714.80,,,,,,,,,,,,,
GRAFT BONE 30GM 30CC PARTICULATE SYNTH OSTEOCONDUCTIVE CLLGN,SUP-2288538,CDM,C1713,HCPCS,0278,RC,,,,both,,,3037.20,1974.18,,,,,,,,,,,,,
STEM HUM L130MM DIA12MM UNIV DSTL SHLDR TI PRI REV CEM FOR,SUP-2363646,CDM,C1776,CPT,0278,RC,,,,both,,,9857.09,6407.11,,,,,,,,,,,,,
STENT COR 32MM 2.25MM S STL SELF EXP BAL PACLITAXEL,SUP-2139911,CDM,C1874,HCPCS,0278,RC,,,,both,,,5102.50,3316.62,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 260 MM DIA17 MM DEL SHTH,SUP-2934602,CDM,C1713,HCPCS,0278,RC,,,,both,,,19996.43,12997.68,,,,,,,,,,,,,
INTRODUCER KT 10.7FR,SUP-2327387,CDM,C1894,HCPCS,0272,RC,,,,both,,,354.82,230.63,,,,,,,,,,,,,
PLATE BNE L 121 X W 9 MM THK 1 MM DIA12 MM CLLR H 0.5 MM,SUP-2908035,CDM,C1713,HCPCS,0278,RC,,,,both,,,360.91,234.59,,,,,,,,,,,,,
SCREW BONE L10MM DIA4MM STD CANC ST NONCANNULATED NONLOCKING,SUP-2198249,CDM,C1713,HCPCS,0278,RC,,,,both,,,36.68,23.84,,,,,,,,,,,,,
PLATE BNE RIBBON UNIV 3.5X47 MM FOR RECON SYS NS LTX DISP,SUP-2861125,CDM,C1713,HCPCS,0278,RC,,,,both,,,1300.15,845.10,,,,,,,,,,,,,
GRAFT BONE SUB W19XH7XL26MM DBM STRP OSTEOSPONGE,SUP-2125423,CDM,C1713,HCPCS,0278,RC,,,,both,,,3516.80,2285.92,,,,,,,,,,,,,
FRAC ST/COMP RVS GLN/XLPE,SUP-2212472,CDM,C1776,CPT,0278,RC,,,,both,,,24064.96,15642.22,,,,,,,,,,,,,
PLATE BNE SHT BENT 2.5 MM WRST TRILOK,SUP-2423180,CDM,C1713,HCPCS,0278,RC,,,,both,,,7754.54,5040.45,,,,,,,,,,,,,
GRAFT BNE SPACER 4 DEG 16 MM FOR ALIF,SUP-2632276,CDM,C1713,HCPCS,0278,RC,,,,both,,,8504.63,5528.01,,,,,,,,,,,,,
ALLOGRAFT BNE 2 CC VIABLE BNE MTRX VIBONE,SUP-2731786,CDM,C1762,CPT,0278,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
DEFIBRILLATOR IMPL VIVA XT TI POLYUR SIL RUBBER 3 CHMBR DF4,SUP-2282402,CDM,C1882,HCPCS,0275,RC,,,,both,,,53257.13,34617.13,,,,,,,,,,,,,
METHYLPREDNISOLONE NA SUC (PF) 40 MG IJ SOLR,RX-162819,CDM,J2919,HCPCS,0636,RC,00009-0039-33,NDC,,both,1,UN,54.10,35.16,,,,,,,,,,,,,
PLATE BNE L87MM THK2MM CALCNL TI Y SHP FOR SM FRAG SET,SUP-2190980,CDM,C1713,HCPCS,0278,RC,,,,both,,,1850.84,1203.05,,,,,,,,,,,,,
GRAFT HUM TISS W2XL4CM THK200UM AMNIO MEMBRN DEHYDR CHORION,SUP-2340448,CDM,C1762,CPT,0278,RC,,,,both,,,9869.02,6414.86,,,,,,,,,,,,,
BUR SURG HUB III CRANIOTOME CUT SPRL STRL DISP HI-LINE XS,SUP-2929046,CDM,2720000010,LOCAL,0272,RC,,,,both,,,392.97,255.43,,,,,,,,,,,,,
TOBRAMYCIN-DEXAMETHASONE 0.3-0.1 % OP SUSP,RX-11567,CDM,6370000000,HCPCS,0637,RC,24208-0295-25,NDC,,both,2.5,ML,227.60,147.94,,,,,,,,,,,,,
ENDCAP SPNL 4- DEG 30X16X16 MM TI X-CORE 2,SUP-2559806,CDM,C1713,HCPCS,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
CUP ACET PROFORM POR BEAD ACET CUP NO H 46,SUP-2359082,CDM,C1776,CPT,0278,RC,,,,both,,,2518.28,1636.88,,,,,,,,,,,,,
KIT COMP PK VAR-A-PULSE,SUP-2199698,CDM,C1713,HCPCS,0278,RC,,,,both,,,1114.86,724.66,,,,,,,,,,,,,
BURR HOLE COVER CNTRD 3MM 12MM DIA 15MM SSTM T 6L 4V,SUP-2707249,CDM,C1713,HCPCS,0278,RC,,,,both,,,672.84,437.35,,,,,,,,,,,,,
CEMENT BONE 20GM RADPQ ORTHOSET,SUP-2304363,CDM,C1713,HCPCS,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
HC NM Parathyroid Scan,PX-3417807000,CDM,78070,CPT,0341,RC,,,,both,,,3888.00,2527.20,,,,,,,,,,,,,
PLATE BNE TIBIOTALOCALCANEAL RT ANTR CONTOURED BABY GORILLA,SUP-2751222,CDM,C1713,HCPCS,0278,RC,,,,both,,,6208.57,4035.57,,,,,,,,,,,,,
SCREW 65 L115 FT CANN,SUP-2243585,CDM,C1713,HCPCS,0278,RC,,,,both,,,1334.72,867.57,,,,,,,,,,,,,
CHRONOS(TM) BETA-TCP WEDGE 22 DEG/RECTANGULAR-STERILE,SUP-2550434,CDM,C1713,HCPCS,0278,RC,,,,both,,,2181.48,1417.96,,,,,,,,,,,,,
IMPLANT HUM TISS L 30 CM DIA 5-17 MM SZ 49 CM FEM VEIN,SUP-2933441,CDM,C1762,CPT,0278,RC,,,,both,,,23176.59,15064.78,,,,,,,,,,,,,
WASHER ORTH 4 MM FOR PROV TISS TRABECULAR MTL,SUP-2437273,CDM,C1713,HCPCS,0278,RC,,,,both,,,918.45,596.99,,,,,,,,,,,,,
GRAFT VASC GORTX L 110 CM DIA 5 MM RNG L 80 CM EPTFE STR TW,SUP-2396111,CDM,C1768,CPT,0278,RC,,,,both,,,4907.82,3190.08,,,,,,,,,,,,,
TUBE VENT ID 0.76 MM IFD 1.5 MM TINY TYTAN TI PED STRL,SUP-2881787,CDM,L8699,HCPCS,0278,RC,,,,both,,,120.04,78.03,,,,,,,,,,,,,
SET HEMO DYLS OR HD ADMIN ST60 HI PERM HEMDLYZR EXCORP CIRC,SUP-2885241,CDM,2720000010,LOCAL,0272,RC,,,,both,,,727.35,472.78,,,,,,,,,,,,,
SPLINT ORTHOPEDIC COLLES LG WRST MONTREAL,SUP-2330387,CDM,L3808,HCPCS,0272,RC,,,,both,,,15.70,10.20,,,,,,,,,,,,,
PLATE BNE Y UNIV 0.6 MM 6 HOLE W/ 13MM BAR TI,SUP-2457228,CDM,C1713,HCPCS,0278,RC,,,,both,,,565.99,367.89,,,,,,,,,,,,,
ROD X MEDULLARY PROX TIB UP ATTUNE,SUP-2454754,CDM,C1713,HCPCS,0278,RC,,,,both,,,3642.40,2367.56,,,,,,,,,,,,,
TRAY CATH HEMODIALYSI DUO FLO ACTE 11.5FR DIA 15CM STRGHT TA,SUP-2610535,CDM,C1752,HCPCS,0278,RC,,,,both,,,232.36,151.03,,,,,,,,,,,,,
SCREW SET POST EXPANDABLE AILERON,SUP-2430745,CDM,C1713,HCPCS,0278,RC,,,,both,,,1482.08,963.35,,,,,,,,,,,,,
DISTRACTION INTRNL DIST LFRT 3MNO MESH MDFCE END DRV BODY 1,SUP-2681267,CDM,C1713,HCPCS,0278,RC,,,,both,,,12532.34,8146.02,,,,,,,,,,,,,
ELECTRODE BALL 5FR L36CM FOR BPLR ELECSURG SYS GYNECARE,SUP-2218055,CDM,C1713,HCPCS,0278,RC,,,,both,,,1178.94,766.31,,,,,,,,,,,,,
PLATE BNE BURR HOLE CVR 17X0.3 MM LP C3 FOR NEURO SCR TI NS,SUP-2485895,CDM,C1713,HCPCS,0278,RC,,,,both,,,1702.38,1106.55,,,,,,,,,,,,,
CATHETER IVUS PIONEER + L 120 CM SHTH 6 FR GUIDEWIRE 0.014,SUP-2327245,CDM,C1887,HCPCS,0272,RC,,,,both,,,8164.00,5306.60,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 70 CM DIA 6MM STR REINF SLDE GDS,SUP-2681784,CDM,C1768,CPT,0278,RC,,,,both,,,1948.87,1266.77,,,,,,,,,,,,,
TRAY KYPHOPLASTY SZ 2 BLLN L15MM BNE FILL DEV SYR IBT,SUP-2293625,CDM,C1894,HCPCS,0272,RC,,,,both,,,8031.08,5220.20,,,,,,,,,,,,,
SCREW EXT 4X100 MM HA SPADE PT MR CONDITIONAL SS,SUP-2186950,CDM,C1713,HCPCS,0278,RC,,,,both,,,532.80,346.32,,,,,,,,,,,,,
CARTRIDGE RADIOTHERAPY 1X5 MM PLCMNT FUSIONCOIL MARKER STRL,SUP-2164571,CDM,A4648,CPT,0278,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
PLATE BNE STR 15X0.6 MM NEURO 2 HOLE TI STRL 251521271,SUP-2472256,CDM,C1713,HCPCS,0278,RC,,,,both,,,374.70,243.55,,,,,,,,,,,,,
NEXGEN PRECOAT STEMMED TIBIAL PLATE SZ 3,SUP-2503040,CDM,C1776,CPT,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
CLAMP PIN XTRAFIX 1 BAR 45MM BL,SUP-2463618,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3725.80,2421.77,,,,,,,,,,,,,
PROBE ABLAT 90DEG MPLR W/ SUCT ABLATOR-S,SUP-2341619,CDM,2720000010,LOCAL,0272,RC,,,,both,,,527.52,342.89,,,,,,,,,,,,,
ALLOGRAFT BNE FRZN W/ ROT CUF LT WHL HUM,SUP-2740791,CDM,C1762,CPT,0278,RC,,,,both,,,17811.49,11577.47,,,,,,,,,,,,,
BUR SURG 6MM D14X11MM CUT FOR CRNRSTN,SUP-2290950,CDM,2720000010,LOCAL,0272,RC,,,,both,,,624.20,405.73,,,,,,,,,,,,,
KIT TSR GLEN CAPITATED P-M UPCHARGE PERFORM,SUP-2912708,CDM,C1776,CPT,0278,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
PLATE BNE RADIAL DSTL SET PERI-LOC,SUP-2351351,CDM,C1713,HCPCS,0278,RC,,,,both,,,25193.38,16375.70,,,,,,,,,,,,,
SHUNT CSF SM SNAP ASSEMB W BLNT NDL 16GA VENTCULSTMY RESVR,SUP-2277982,CDM,C1889,HCPCS,0278,RC,,,,both,,,14729.14,9573.94,,,,,,,,,,,,,
HC Exc Face-Mm B9+Marg 0.5 Cm/<,PX-4501144000,CDM,11440,CPT,0450,RC,,,,both,,,2188.00,1422.20,,,,,,,,,,,,,
CATHETER ANGIO GLIDECATH L 65 CM DIA 5 FR DIA1.12 MM SIM2,SUP-2385535,CDM,C1887,HCPCS,0272,RC,,,,both,,,164.85,107.15,,,,,,,,,,,,,
DEVICE COAG GUID 3 CM W/O CANN EPI-SENSE ST,SUP-2866237,CDM,2720000010,LOCAL,0272,RC,,,,both,,,39250.00,25512.50,,,,,,,,,,,,,
INSERT SURG L61MM SIL FILL RUB DBL HYDRAJAW RIDGED REUSE,SUP-2214536,CDM,C1757,HCPCS,0272,RC,,,,both,,,101.61,66.05,,,,,,,,,,,,,
SCREW SPNL L14MM OD45MM GRY TI CORT CERV VAR ANG,SUP-2286775,CDM,C1713,HCPCS,0278,RC,,,,both,,,973.05,632.48,,,,,,,,,,,,,
PLATE BONE STRL BARBELL FOR 2.7MM SCR VLP,SUP-2349944,CDM,C1713,HCPCS,0278,RC,,,,both,,,3380.84,2197.55,,,,,,,,,,,,,
GRAFT BONE 76-98MM FIB SHFT FRZN BIOCLEANSE STRL,SUP-2335275,CDM,C1713,HCPCS,0278,RC,,,,both,,,2417.80,1571.57,,,,,,,,,,,,,
GLYCOPYRROLATE 0.4 MG/2ML IJ SOLN,RX-120967,CDM,J1596,HCPCS,0636,RC,63323-0578-04,NDC,,both,0.5,ML,54.10,35.16,,,,,,,,,,,,,
PLATE BNE L19MM 8 H R HND S STL EXT H SHP LO PROF RIG NEUT,SUP-2184850,CDM,C1713,HCPCS,0278,RC,,,,both,,,1145.50,744.57,,,,,,,,,,,,,
INTRODUCER CATH 26GA L1.9CM PRECIS INTROSYTE-N,SUP-2133170,CDM,C1894,HCPCS,0272,RC,,,,both,,,131.85,85.70,,,,,,,,,,,,,
KNIFE SURG BALLENGER 8.25 IN 4X3 MM SWVL BAYNT SHP,SUP-2853086,CDM,2720000010,LOCAL,0272,RC,,,,both,,,351.62,228.55,,,,,,,,,,,,,
CATHETER EP 6FR L110CM 5MM SPC 2MM BND M CRV QPLR STEER,SUP-2357633,CDM,C1730,HCPCS,0272,RC,,,,both,,,1183.78,769.46,,,,,,,,,,,,,
STAPLE INT BIOABSRB LIN CUT SEAMGRD PROX 75,SUP-2395366,CDM,C1713,HCPCS,0278,RC,,,,both,,,624.86,406.16,,,,,,,,,,,,,
TELISOTUZUMAB VEDOTIN-TLLV 20 MG IV SOLR,RX-172130,CDM,J9326,HCPCS,0636,RC,00074-1044-01,NDC,,both,1,UN,8052.50,5234.12,,,,,,,,,,,,,
ANCHOR SUT RIGIDLOOP 15MM,SUP-2249444,CDM,C1713,HCPCS,0278,RC,,,,both,,,2154.04,1400.13,,,,,,,,,,,,,
ALLOGRAFT BNE SPACER LNG 30X11X9 MM BIO AVS UNILIF,SUP-2637045,CDM,C1713,HCPCS,0278,RC,,,,both,,,6829.50,4439.17,,,,,,,,,,,,,
PLATE BNE L 163 X W 115 MM THK 0.6 MM SCREW DIA1.5 MM TI CMF,SUP-2883885,CDM,C1713,HCPCS,0278,RC,,,,both,,,6254.88,4065.67,,,,,,,,,,,,,
FIBER LASER HOLM 550 M FOR USE W/ SMA-905 RED SMARTSYNC,SUP-2835956,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1185.32,770.46,,,,,,,,,,,,,
SPLINT ORTHOPEDIC SUPP XS RT WRST,SUP-2196555,CDM,L3931,HCPCS,0272,RC,,,,both,,,15.26,9.92,,,,,,,,,,,,,
SLEEVE CENTERING STEM 7 MM HUM BIO MOD,SUP-2431669,CDM,C1776,CPT,0278,RC,,,,both,,,731.62,475.55,,,,,,,,,,,,,
BOOT WLK VENTURE 61 TALL M,SUP-2150951,CDM,L4386,HCPCS,0274,RC,,,,both,,,92.32,60.01,,,,,,,,,,,,,
CARTRIDGE BONE TUNN L22MM L CURVTEK,SUP-2137206,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2097.52,1363.39,,,,,,,,,,,,,
SPLINT CLAV M AD BCKL CLSR PD MCLEOD,SUP-2197364,CDM,L3660,HCPCS,0272,RC,,,,both,,,44.90,29.18,,,,,,,,,,,,,
KIT CTRL VEN 2 LUMN W/ ARWGRD + BLU ACCS DEV INTEGR HEMSTAS,SUP-2383304,CDM,C1751,HCPCS,0278,RC,,,,both,,,435.83,283.29,,,,,,,,,,,,,
SHOE ORTHOT EXISTING SLD STIRRUP TRANSFER,SUP-2435747,CDM,L3620,HCPCS,0272,RC,,,,both,,,216.03,140.42,,,,,,,,,,,,,
FIXATION KIT BNE DART FOR ALLOSYNC PIP DISP,SUP-2423624,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1491.50,969.47,,,,,,,,,,,,,
SHEATH URO 13 15FRX46CM UROPS,SUP-2312761,CDM,C1894,HCPCS,0272,RC,,,,both,,,427.13,277.63,,,,,,,,,,,,,
WIRE FIX L300MM DIA2MM PICCOLO COMP DSTL FEM PLT SYS K,SUP-2152506,CDM,C1713,HCPCS,0278,RC,,,,both,,,209.12,135.93,,,,,,,,,,,,,
PURAPLY 6X9CM 54SQ CM,SUP-2314123,CDM,Q4195,HCPCS,0636,RC,,,,both,,,16108.20,10470.33,,,,,,,,,,,,,
BIT DRL L135MM DIA3MM DISP,SUP-2418852,CDM,2720000010,LOCAL,0272,RC,,,,both,,,608.85,395.75,,,,,,,,,,,,,
CEFOXITIN SODIUM-DEXTROSE 2-2.2 GM-%(50ML) IV SOLR,RX-143623,CDM,J0694,HCPCS,0636,RC,00264-3125-11,NDC,,both,1,UN,192.90,125.38,,,,,,,,,,,,,
PUMP PAIN MGMT 400ML 5ML/HR N NARC ELASTOMERIC INCIS FIX FLO,SUP-2236776,CDM,2720000010,LOCAL,0272,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
EVOS 4.5MM PROX HUM PL 11H L 196MM,SUP-2931182,CDM,C1713,HCPCS,0278,RC,,,,both,,,10431.08,6780.20,,,,,,,,,,,,,
GRAFT HUM TISS 2CC CYMETRA REGEN TISS MTRX SYR ALLDERM,SUP-2113044,CDM,Q4116,HCPCS,0636,RC,,,,both,,,1149.24,747.01,,,,,,,,,,,,,
SCREW INTRF L20MM DIA9MM ANTR KNEE PLLA HA CANN FOR CRUC,SUP-2341105,CDM,C1713,HCPCS,0278,RC,,,,both,,,791.28,514.33,,,,,,,,,,,,,
TIP URETH PROX 7FR DSTL 3.8FR L40CM TIP L6CM MALL FILFRM,SUP-2171188,CDM,C1726,HCPCS,0272,RC,,,,both,,,201.96,131.27,,,,,,,,,,,,,
ALLODERM DERMAL X THICK 16CM X 20CM PERFORATED MATRIX,SUP-2866787,CDM,Q4116,HCPCS,0636,RC,,,,both,,,34222.86,22244.86,,,,,,,,,,,,,
SHEATH INTRO PEELWY L 13 CM DIA 5.5 FR GUIDEWIRE 0.035 IN,SUP-2168062,CDM,C1892,HCPCS,0272,RC,,,,both,,,129.05,83.88,,,,,,,,,,,,,
DEVICE FLTR INT LUMN 50/200UM GLAUCOMA P MOD EX-PRESS,SUP-2109669,CDM,C1783,HCPCS,0278,RC,,,,both,,,3124.30,2030.79,,,,,,,,,,,,,
SCREW BNE L 15 MM DIA 3.5 MM TI CORTICAL WR ST T15 DRV STRL,SUP-2932403,CDM,C1713,HCPCS,0278,RC,,,,both,,,136.06,88.44,,,,,,,,,,,,,
HC Gastric Procedure Unlisted,PX-3614399900,CDM,43999,CPT,0361,RC,,,,inpatient,,,174.00,113.10,,,,,,,,,,,,,
NAIL IM L340MM OD15MM FEM N LCK CANN,SUP-2205961,CDM,C1713,HCPCS,0278,RC,,,,both,,,15743.96,10233.57,,,,,,,,,,,,,
MESH HERN W7.5XL15CM POLYPR SYN FLAT L PORE MFIL,SUP-2125778,CDM,C1781,HCPCS,0278,RC,,,,both,,,126.67,82.34,,,,,,,,,,,,,
PLATE TIBIA DISTAL 3.5MM TI LCP LOW BEND MEDIAL 14H LEFT 239MM,SUP-2549692,CDM,C1713,HCPCS,0278,RC,,,,both,,,3313.64,2153.87,,,,,,,,,,,,,
CATHETER GUID CELLO TOT L 103 CM EFFECTIVE L 95 CM OD 0.102,SUP-2277832,CDM,C1887,HCPCS,0272,RC,,,,both,,,4097.70,2663.50,,,,,,,,,,,,,
BUR SURG FLUT 3 MM 2 MM RND CYL SS CARBIDE TEAL UPWR,SUP-2607630,CDM,2720000010,LOCAL,0272,RC,,,,both,,,375.29,243.94,,,,,,,,,,,,,
GUIDEWIRE VASC L 160 CM DIA 0.063 IN HEPARIN MJ6.5,SUP-2147063,CDM,C1769,HCPCS,0272,RC,,,,both,,,124.41,80.87,,,,,,,,,,,,,
CANNULA SUCTION BRINER 4.5 MMX11 CM BPLR ANGULAR INSUL,SUP-2774762,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2751.86,1788.71,,,,,,,,,,,,,
GRAFT VASC L45CM ID6MM EPTFE STD WALLED FIX RNGD STR IMPL,SUP-2395807,CDM,C1768,CPT,0278,RC,,,,both,,,3921.86,2549.21,,,,,,,,,,,,,
SEALANT FIBRIN VHSD FRZN 2 ML SYR TISSEEL,SUP-2130313,CDM,2720000010,LOCAL,0272,RC,,,,both,,,393.88,256.02,,,,,,,,,,,,,
GRAFT HUM TISS 4X7CM PROC PERICARD TUTOPLAST,SUP-2300763,CDM,C1762,CPT,0278,RC,,,,both,,,7140.36,4641.23,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY RESPON L 120 CM DIA 5 FR SPC 10,SUP-2526064,CDM,C1730,HCPCS,0272,RC,,,,both,,,184.00,119.60,,,,,,,,,,,,,
KIT PERFLUOROCARBON LIQ 7ML 23GA BLNT CANN FLTR 20GA 1 1/2IN,SUP-2110014,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1206.83,784.44,,,,,,,,,,,,,
LISINOPRIL 20 MG PO TABS,RX-4526,CDM,6370000000,HCPCS,0637,RC,68180-0981-03,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
COIL HELCL 10 COIL SZ SFT 2MM LOOP DIA 2CM V TRAK DEL,SUP-2305136,CDM,C1889,HCPCS,0278,RC,,,,both,,,2637.60,1714.44,,,,,,,,,,,,,
BIT DRL CANN LG 17X310 MM FLX QC STRL,SUP-2178894,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2144.90,1394.18,,,,,,,,,,,,,
PLATE BNE THK 1 MM ADV 5 MM SCREW DIA2 MM MINI RT,SUP-2883183,CDM,C1713,HCPCS,0278,RC,,,,both,,,1731.08,1125.20,,,,,,,,,,,,,
SCREW BONE L10MM DIA2.5MM LCK ST T7 PERI-LOC,SUP-2350049,CDM,C1713,HCPCS,0278,RC,,,,both,,,928.97,603.83,,,,,,,,,,,,,
CINCH ENDOSCP CRV TIP FOR MENIS REP,SUP-2121859,CDM,C1776,CPT,0278,RC,,,,both,,,894.90,581.68,,,,,,,,,,,,,
HC Apply Finger Splint,PX-4502913100,CDM,29131,CPT,0450,RC,,,,both,,,191.00,124.15,,,,,,,,,,,,,
SCREW BNE L 105 MM DIA 7 MM LNG TI CANN HDLSS NS LEOS,SUP-2931456,CDM,C1713,HCPCS,0278,RC,,,,both,,,1118.81,727.23,,,,,,,,,,,,,
BUPIVACAINE-MELOXICAM ER 400-12 MG/14ML IJ SOLN,RX-154731,CDM,J0668,HCPCS,0636,RC,47426-0501-02,NDC,,both,14,ML,1825.10,1186.31,,,,,,,,,,,,,
CARMUSTINE 100 MG IV SOLR,RX-28911,CDM,J9050,HCPCS,0636,RC,70710-1525-09,NDC,,both,1,UN,2160.00,1404.00,,,,,,,,,,,,,
PLATE BONE LOK SM TIMAX ANTMCL ALPS LEFT NVCLR FOOT,SUP-2588780,CDM,C1713,HCPCS,0278,RC,,,,both,,,1562.12,1015.38,,,,,,,,,,,,,
PLATE BONE L90MM THK3.5-4.5MM 4 H STRL RT MEDL TI DSTL FEM,SUP-2190912,CDM,C1713,HCPCS,0278,RC,,,,both,,,4408.34,2865.42,,,,,,,,,,,,,
SET INTRO SUP ARW FLX SHTH L 65 CM DIA10 FR HYDRPHLC,SUP-2120623,CDM,C1894,HCPCS,0272,RC,,,,both,,,481.68,313.09,,,,,,,,,,,,,
HC Njx Aa&/Strd Ntrcost Nrv 1,PX-3616442000,CDM,64420,CPT,0361,RC,,,,both,,,2230.00,1449.50,,,,,,,,,,,,,
BASKET SPEC RETRV FB 35 CM W/O HNDL FOR 10386B,SUP-2771788,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1062.42,690.57,,,,,,,,,,,,,
BRACE CERV HRD CUST,SUP-2388135,CDM,L0174,HCPCS,0272,RC,,,,both,,,1074.63,698.51,,,,,,,,,,,,,
GRAFT VASC HEMSHLD PLAT L 47 CM DIA26 MM BRANCH SZ 10/10/8/8,SUP-2459829,CDM,C1768,CPT,0278,RC,,,,both,,,8329.51,5414.18,,,,,,,,,,,,,
SPACER SPNL 12 MM COR 0 DEG H15-19 MM VERT BODY REPL PARA NO,SUP-2229948,CDM,C1821,HCPCS,0278,RC,,,,both,,,21980.00,14287.00,,,,,,,,,,,,,
NAIL IM 3X400 MM TI STRL MJ-FLEX,SUP-2646410,CDM,C1713,HCPCS,0278,RC,,,,both,,,1617.54,1051.40,,,,,,,,,,,,,
HC Methacoline Challenge Test,PX-4609407000,CDM,94070,CPT,0460,RC,,,,both,,,1867.00,1213.55,,,,,,,,,,,,,
BAND SURG DISECT CALIB TUBE GI TRACT REALIZE,SUP-2219870,CDM,C1713,HCPCS,0278,RC,,,,both,,,10261.49,6669.97,,,,,,,,,,,,,
STENT PERIPH PULSAR-18 L 100 MM DIA 4 MM CATH L 135 CM PROX,SUP-2227261,CDM,C1876,HCPCS,0278,RC,,,,both,,,2496.30,1622.59,,,,,,,,,,,,,
LEAD DEFIB 5.6FR 65CM VENT ACT FIX BPLR PERM STEROID ELUT,SUP-2356666,CDM,C1777,HCPCS,0275,RC,,,,both,,,7065.00,4592.25,,,,,,,,,,,,,
PLATE BNE SCREW DIA2.5/3 MM TI ALLOY LAT NK TALAR BUTTERFLY,SUP-2907638,CDM,C1713,HCPCS,0278,RC,,,,both,,,5555.82,3611.28,,,,,,,,,,,,,
GUIDEWIRE VASC CRV 7 CM 0.025 INX145 CM 2.5 CMX3 MM SAFE-T-J,SUP-2167592,CDM,C1769,HCPCS,0272,RC,,,,both,,,38.06,24.74,,,,,,,,,,,,,
PLATE BNE X 14X0.35 MM NEURO 4 HOLE W/ TAB TI STRL LEVEL 1,SUP-2471251,CDM,C1713,HCPCS,0278,RC,,,,both,,,953.59,619.83,,,,,,,,,,,,,
PIN HALF THRD 3X100 MM 20 MM,SUP-2197279,CDM,2720000010,LOCAL,0272,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
BIT DRL J NOTCH 1.19X115 MM TWST,SUP-2423220,CDM,2720000010,LOCAL,0272,RC,,,,both,,,346.66,225.33,,,,,,,,,,,,,
PROBE ARTHROSCOPIC X-LARGE 18CM 90DEG EXTENDED LENGTH WITH S,SUP-2824213,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
ANCHOR SUT L11.7MM DIA2.8MM W/ CANN INSRTR AND SZ 2,SUP-2121024,CDM,C1713,HCPCS,0278,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
RING FIX 180MM HALF CIR FIX FRDM,SUP-2400656,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2056.70,1336.85,,,,,,,,,,,,,
CAP END DIA12MM EXTN 20MM TI CANN LOK HD FOR 9-12MM FEM,SUP-2192366,CDM,C1713,HCPCS,0278,RC,,,,both,,,870.69,565.95,,,,,,,,,,,,,
HC Icu Intermediate R&B,PX-2060000000,CDM,2060000000,LOCAL,0206,RC,,,,inpatient,,,3713.00,2413.45,,,,,,,,,,,,,
REAMER SURG DIA10MM CANN HD FOR BIO-TENODESIS SCR SYS,SUP-2121251,CDM,2720000010,LOCAL,0272,RC,,,,both,,,709.64,461.27,,,,,,,,,,,,,
FIBER LASER EVOLVE SIDE FIRE,SUP-2885289,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2480.60,1612.39,,,,,,,,,,,,,
SCREW BONE 4MM DIA 45MML CNCLLS FLLY THRDD 47464004501,SUP-2721560,CDM,C1713,HCPCS,0278,RC,,,,both,,,174.65,113.52,,,,,,,,,,,,,
ANCHOR SUTURE DIAMETER 4.75MM PEEK THREADED PATTERN KNOTLESS,SUP-2828574,CDM,C1713,HCPCS,0278,RC,,,,both,,,1345.43,874.53,,,,,,,,,,,,,
PLATE BNE L190MM 10 H R OLECRANON S STL LOK COMPR FOR 3.5MM,SUP-2185430,CDM,C1713,HCPCS,0278,RC,,,,both,,,3287.01,2136.56,,,,,,,,,,,,,
BUR SURG OD2.3MM BLU RED SPRL ROUTER CUT SIGN,SUP-2367528,CDM,C1713,HCPCS,0278,RC,,,,both,,,418.59,272.08,,,,,,,,,,,,,
PLATE BONE W16XL253MM THK5MM 13 H LT CNDYL FEM S STL BTTRS,SUP-2185795,CDM,C1713,HCPCS,0278,RC,,,,both,,,2775.51,1804.08,,,,,,,,,,,,,
FILLER DERMAL JUVEDERM VOLUMA XC 1ML,SUP-2900487,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1307.81,850.08,,,,,,,,,,,,,
TRAY KYPHOPLASTY SZ 3 BLLN L15MM IBT 1 STP OSTEO INTRO,SUP-2293661,CDM,C1894,HCPCS,0272,RC,,,,both,,,8164.00,5306.60,,,,,,,,,,,,,
LIDOCAINE IN D5W 4-5 MG/ML-% IV SOLN,RX-14868,CDM,J2002,HCPCS,0636,RC,00338-0409-03,NDC,,both,500,ML,54.10,35.16,,,,,,,,,,,,,
COMPONENT TIB SZ 3 RT MEDL LT LAT FIX BEAR CEM PRESERVATION,SUP-2251283,CDM,C1776,CPT,0278,RC,,,,both,,,4873.28,3167.63,,,,,,,,,,,,,
SCREW BONE L36MM DIA5MM S STL CANC MIDFOOT HINDFOOT VOLAR,SUP-2348620,CDM,C1713,HCPCS,0278,RC,,,,both,,,545.20,354.38,,,,,,,,,,,,,
TI LOW PROFILE NEURO X-PLATE,SUP-2823242,CDM,C1713,HCPCS,0278,RC,,,,both,,,904.32,587.81,,,,,,,,,,,,,
PLATE BONE 8 H STR FOR 2MM SCR VLP MINI-MOD SM BONE SYS,SUP-2351086,CDM,C1713,HCPCS,0278,RC,,,,both,,,3304.69,2148.05,,,,,,,,,,,,,
GUIDEWIRE ENDO DIA1.5MM FOR TISS TAK II INSTR SET,SUP-2121578,CDM,C1769,HCPCS,0272,RC,,,,both,,,109.90,71.43,,,,,,,,,,,,,
HC So1 Acetylcholn Rcptr Blckg Antb,PX-3028604267,CDM,86042,CPT,0302,RC,,,,both,,,76.00,49.40,,,,,,,,,,,,,
HC So Antibody Screen With Enzymes,PX-3008697166,CDM,86971,CPT,0300,RC,,,,both,,,361.00,234.65,,,,,,,,,,,,,
SCREW SPNL L70MM OD7.5MM 10DEG S STL CANC PEDCL IL VAR ANG,SUP-2287016,CDM,C1713,HCPCS,0278,RC,,,,both,,,3039.05,1975.38,,,,,,,,,,,,,
PLATE BNE L148MM 4X6 H NONSTERILE PELV BILAT S STL RIG,SUP-2186751,CDM,C1713,HCPCS,0278,RC,,,,both,,,2219.95,1442.97,,,,,,,,,,,,,
NKII POROUS TIBIAL SPACER SIZE 4 4MM LAT,SUP-2509807,CDM,C1776,CPT,0278,RC,,,,both,,,2675.28,1738.93,,,,,,,,,,,,,
PROCHLORPERAZINE MALEATE 10 MG PO TABS,RX-6582,CDM,Q0164,HCPCS,0637,RC,59746-0115-06,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PIN FIX L9IN ODSEC4.8MM BONE THRD SGL TRCR STNMN,SUP-2304055,CDM,C1713,HCPCS,0278,RC,,,,both,,,22.64,14.72,,,,,,,,,,,,,
PLATE BNE L278MM 12 H ST L CNDYL S STL LOK COMPR CRV FOR,SUP-2177081,CDM,C1713,HCPCS,0278,RC,,,,both,,,4916.46,3195.70,,,,,,,,,,,,,
PLATE BONE THK1.5MM 4 H MINI STR FOR 2/2.3MM SCR,SUP-2365230,CDM,C1713,HCPCS,0278,RC,,,,both,,,1899.54,1234.70,,,,,,,,,,,,,
DEXTROSE IN LACTATED RINGERS 5 % IV SOLN,RX-9788,CDM,J7121,HCPCS,0250,RC,00264-7751-00,NDC,,both,1000,ML,25.50,16.57,,,,,,,,,,,,,
GRAFT HUM TISS W4XL7CM NOM THK1.1MM STD HUM DERM REGEN TISS,SUP-2399134,CDM,Q4107,HCPCS,0636,RC,,,,both,,,6716.46,4365.70,,,,,,,,,,,,,
SCREW CORT NON-LOCKING MULTI-DIRECTIONAL 3.8 MMX20.0 MM S3,SUP-2414098,CDM,C1713,HCPCS,0278,RC,,,,both,,,336.67,218.84,,,,,,,,,,,,,
PLATE BNE LCK NAR 2.4X41 MM 6 HOLE VARIAX,SUP-2435315,CDM,C1713,HCPCS,0278,RC,,,,both,,,3755.75,2441.24,,,,,,,,,,,,,
ANCHOR SUT DIA14MM 1 SFT SGL LD MB JUGGERKNOT,SUP-2137224,CDM,C1713,HCPCS,0278,RC,,,,both,,,1241.56,807.01,,,,,,,,,,,,,
STEM CPT 2 HIP,SUP-2205951,CDM,C1776,CPT,0278,RC,,,,both,,,9734.00,6327.10,,,,,,,,,,,,,
CATHETER ANGIOPLSTY POLARCATH L 80 CM BALLOON L 60 MM DIA 7,SUP-2141871,CDM,C1725,HCPCS,0272,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
SHANK SPNL SCREW L 40 MM DIA 6.5 MM NANO OSTEOGRIP STRL CD,SUP-2926396,CDM,C1713,HCPCS,0278,RC,,,,both,,,2593.64,1685.87,,,,,,,,,,,,,
PLATE BNE L 118 X W 9 MM THK 1.1 MM SCREW DIA 3.5 MM 10 H SS,SUP-2933749,CDM,C1713,HCPCS,0278,RC,,,,both,,,354.47,230.41,,,,,,,,,,,,,
PLATE BNE MESHED 11 XL 0.6 MM RT CONTOURED TI STRL,SUP-2472097,CDM,C1713,HCPCS,0278,RC,,,,both,,,17444.58,11338.98,,,,,,,,,,,,,
COMPONENT TOE SZ 1 METATARSAL DCOMPR IMPL,SUP-2398622,CDM,C1776,CPT,0278,RC,,,,both,,,9420.00,6123.00,,,,,,,,,,,,,
PACEMAKER CARD 27GM 15CC W59XH56MM THK6MM RESYNCH THER,SUP-2356472,CDM,C2621,HCPCS,0275,RC,,,,both,,,20410.00,13266.50,,,,,,,,,,,,,
WRX DISTAL RADIUS NAIL 6X70MM STERILE,SUP-2818038,CDM,C1713,HCPCS,0278,RC,,,,both,,,10990.00,7143.50,,,,,,,,,,,,,
HC Replace J Tube,PX-3614945100,CDM,49451,CPT,0361,RC,,,,inpatient,,,1056.00,686.40,,,,,,,,,,,,,
PLATE SPNL L 10 MM TI ANTR CERV LEVEL 1 NS SONOMA,SUP-2887249,CDM,C1713,HCPCS,0278,RC,,,,both,,,59.63,38.76,,,,,,,,,,,,,
NAIL IM L700MM OD13MM RT FEM KNEE AG FOR FUS TRIGEN,SUP-2349053,CDM,C1713,HCPCS,0278,RC,,,,both,,,10165.12,6607.33,,,,,,,,,,,,,
PLATE BNE FEM 401 MM LT PROX 21 HOLE BRIDGE N CONTACT POLYAX,SUP-2472295,CDM,C1713,HCPCS,0278,RC,,,,both,,,5009.15,3255.95,,,,,,,,,,,,,
BUR SURG L 70 MM DIA2.35 MM HD DIA 6 MM DIAMOND NS REUSE,SUP-2928866,CDM,2720000010,LOCAL,0272,RC,,,,both,,,324.33,210.81,,,,,,,,,,,,,
PLATE BONE L119MM 5 H RT PROX HUM LCK FOR 4.5MM SCR PERI-LOC,SUP-2348275,CDM,C1713,HCPCS,0278,RC,,,,both,,,14970.11,9730.57,,,,,,,,,,,,,
GAUGE OPHTH 20GA BACKFLUSH INSTR DISP,SUP-2213457,CDM,C1713,HCPCS,0278,RC,,,,both,,,358.59,233.08,,,,,,,,,,,,,
NAIL IM L440MM DIA3MM OLECRANON GLD S STL ELAS FLEX,SUP-2186444,CDM,C1713,HCPCS,0278,RC,,,,both,,,1026.91,667.49,,,,,,,,,,,,,
DEFIBRILLATOR CRD 63X51X12 MM 30 CC 69 GM SYS DF4 ENTRANT VR,SUP-2876022,CDM,C1722,HCPCS,0275,RC,,,,both,,,49360.80,32084.52,,,,,,,,,,,,,
KIT TMPLT Y SHP DRL ST,SUP-2194193,CDM,2720000010,LOCAL,0272,RC,,,,both,,,190.97,124.13,,,,,,,,,,,,,
PLATE BONE LT EPIPHYSIS ECT FX FIX,SUP-2198584,CDM,C1713,HCPCS,0278,RC,,,,both,,,62.80,40.82,,,,,,,,,,,,,
BIT DRL CANN 6.5 MM KNEE SINGLE FLUT MTO,SUP-2849079,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2480.60,1612.39,,,,,,,,,,,,,
GRAFT HUM TISS L DST FEM FRZN,SUP-2307309,CDM,C1713,HCPCS,0278,RC,,,,both,,,16760.28,10894.18,,,,,,,,,,,,,
HC Manual Diff Wbc Count B-Coat,PX-3088500900,CDM,86079,CPT,0305,RC,,,,both,,,17.00,11.05,,,,,,,,,,,,,
CATHETER NEPHSTMY 6FR L20CM 0.035IN ALL PURP DRNGE W/ LOK,SUP-2381888,CDM,C1729,HCPCS,0272,RC,,,,both,,,273.18,177.57,,,,,,,,,,,,,
GUIDE SURG PRT CANN SINGLE SITE DISP,SUP-2246702,CDM,C1713,HCPCS,0278,RC,,,,both,,,447.45,290.84,,,,,,,,,,,,,
HC So Tp53 Gene Full Gene Sequence,PX-3108135166,CDM,81351,CPT,0310,RC,,,,both,,,1471.00,956.15,,,,,,,,,,,,,
SUPPORT ORTHOT LUMBAR SACR CUST SAG CTRL STRP STAY PENDULOUS,SUP-2435558,CDM,L0649,HCPCS,0272,RC,,,,both,,,811.85,527.70,,,,,,,,,,,,,
PERI-LOC 3.5MM S-T LOCK SCREW 65MM,SUP-2819491,CDM,C1713,HCPCS,0278,RC,,,,both,,,1117.81,726.58,,,,,,,,,,,,,
WIRE FIX L100MM DIA125MM S STL THRD DBL SHRP TIP FOR MINI,SUP-2186880,CDM,C1713,HCPCS,0278,RC,,,,both,,,1262.41,820.57,,,,,,,,,,,,,
HC Joint Bursa Inj Small Joint,PX-7612060000,CDM,20600,CPT,0761,RC,,,,both,,,358.00,232.70,,,,,,,,,,,,,
PLATE BNE L172MM 8 H NONSTERILE L DST MED TIB S STL VAR ANG,SUP-2177639,CDM,C1713,HCPCS,0278,RC,,,,both,,,4873.81,3167.98,,,,,,,,,,,,,
DEVICE EMBOLIC PROTCT FLTR L4MM GWIRE L320/190CM DIA0.014IN,SUP-2173561,CDM,C1884,HCPCS,0278,RC,,,,both,,,2983.00,1938.95,,,,,,,,,,,,,
CATHETER HD SWAN NK PEDIATRIC 43 CM CURL CATH 2 CUF ARGY,SUP-2626971,CDM,C1750,HCPCS,0278,RC,,,,both,,,321.44,208.94,,,,,,,,,,,,,
PLATE BNE L165MM 14 H BILAT S STL STR RECON NONLOCKING,SUP-2197679,CDM,C1713,HCPCS,0278,RC,,,,both,,,1345.43,874.53,,,,,,,,,,,,,
ANCHOR SUT L19.5MM DIA8MM PEEK FORKED EYELET TENODESIS,SUP-2121438,CDM,C1713,HCPCS,0278,RC,,,,both,,,1271.70,826.60,,,,,,,,,,,,,
AUGMENT TIB SZ 1 110DEG L MED R LAT WDG BAL REV SYS,SUP-2315680,CDM,C1776,CPT,0278,RC,,,,both,,,2926.48,1902.21,,,,,,,,,,,,,
STAPLER INT CARTRIDGE MED THCK 60 MM W/ TRI-STAPLE PUR GIA,SUP-2787694,CDM,2720000010,LOCAL,0272,RC,,,,both,,,798.88,519.27,,,,,,,,,,,,,
GUIDEWIRE ORTH OD1.1MM FOR INTROSSEOUS FIX SYS,SUP-2315894,CDM,C1769,HCPCS,0272,RC,,,,both,,,52.75,34.29,,,,,,,,,,,,,
PLATE BNE L154MM 10 H NONSTERILE R PROX BILAT TIB S STL,SUP-2184308,CDM,C1713,HCPCS,0278,RC,,,,both,,,3920.45,2548.29,,,,,,,,,,,,,
PLATE BNE LAT ANT PLT L ANK FUS TIBIAXYS,SUP-2242997,CDM,C1713,HCPCS,0278,RC,,,,both,,,6001.33,3900.86,,,,,,,,,,,,,
ALLOGRAFT DERMAL 2X4 CMX0.76-1.25 MM DECELL DERM ORACELL,SUP-2741068,CDM,C1713,HCPCS,0278,RC,,,,both,,,569.22,369.99,,,,,,,,,,,,,
SPACER SPNL W12XH12XL14MM 5DEG PEEK OPTMA INTERVERTEBRAL,SUP-2211878,CDM,C1821,HCPCS,0278,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
GRAFT HUMAN TISSUE PELVIC FLOOR MATRIX 5X5 CM MATRISTEM,SUP-2106485,CDM,C1763,HCPCS,0278,RC,,,,both,,,2474.32,1608.31,,,,,,,,,,,,,
SCREW SPNL MULTAXL 6.5X65 MM CANN EXT TAB VOYAGER 4.75,SUP-2629441,CDM,C1713,HCPCS,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
ALLOGRAFT CORT RING 12 DIA X 7 H X 4 MM,SUP-2863665,CDM,C1713,HCPCS,0278,RC,,,,both,,,6110.44,3971.79,,,,,,,,,,,,,
IMMOBILIZER SHOULDERXL FOR 42-48IN CHST ELAS W/O NK STRP M,SUP-2197392,CDM,L3660,HCPCS,0274,RC,,,,both,,,70.02,45.51,,,,,,,,,,,,,
SHEET PROTCT BIORESORBABLE 130MMX200MMX0.02MM CARDIOWRAP,SUP-2175202,CDM,C1768,CPT,0278,RC,,,,both,,,1252.86,814.36,,,,,,,,,,,,,
PIN FIX 7/64X9 IN DBL BAY NS STEINMANN DISP,SUP-2861164,CDM,C1713,HCPCS,0278,RC,,,,both,,,252.27,163.98,,,,,,,,,,,,,
SCREW BNE L10MM DIA5MM CORT S STL ST NONCANNULATED LOK FULL,SUP-2178473,CDM,C1713,HCPCS,0278,RC,,,,both,,,713.35,463.68,,,,,,,,,,,,,
FOMEPIZOLE 1.5 GM/1.5ML IV SOLN,RX-91363,CDM,J1451,HCPCS,0636,RC,70710-1478-01,NDC,,both,1.5,ML,2666.20,1733.03,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE 20 CC DEMINERALIZED CORT CANC BNE FIBER,SUP-2905191,CDM,C1713,HCPCS,0278,RC,,,,both,,,6176.38,4014.65,,,,,,,,,,,,,
BUR SURGICALXL DIA4MM DMND RND,SUP-2361442,CDM,2720000010,LOCAL,0272,RC,,,,both,,,904.98,588.24,,,,,,,,,,,,,
SCREW BONE L24MM PROX INTERPHALANGEAL JT HDLSS OPP THREADS,SUP-2121840,CDM,C1713,HCPCS,0278,RC,,,,both,,,2810.30,1826.69,,,,,,,,,,,,,
SET INT FIX SCREW DIA1.5 MM 4 H LNG TI NEURO STR PLT XDRV 1,SUP-2935316,CDM,C1713,HCPCS,0278,RC,,,,both,,,1428.70,928.65,,,,,,,,,,,,,
PIN IM SZ F L165MM DIA3.2MM S STL FOR ROD RUSH 8030107] ZIMMER BIOMET INC],SUP-2211449,CDM,C1713,HCPCS,0278,RC,,,,both,,,254.43,165.38,,,,,,,,,,,,,
GRAFT EXCLUDER 23 X 12 X 12CM,SUP-2395969,CDM,C1768,CPT,0278,RC,,,,both,,,22915.72,14895.22,,,,,,,,,,,,,
SCREW BNE L 65 MM DIA 4 MM SS CANC FULL THRD T15 STARDRV NS,SUP-2905748,CDM,C1713,HCPCS,0278,RC,,,,both,,,603.35,392.18,,,,,,,,,,,,,
SCREW BNE L14MM DIA2.4MM CORT TI ST NONCANNULATED,SUP-2189567,CDM,C1713,HCPCS,0278,RC,,,,both,,,165.76,107.74,,,,,,,,,,,,,
GUIDEWIRE VASC L190CM DIA0.014IN STR TIP L3CM W/ HYDRCOAT,SUP-2105898,CDM,C1769,HCPCS,0272,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
PLATE BNE LCK 2.7 MM 2 HOLE CNTOUR 2 COMPR FOR SCR TI STRL,SUP-2492819,CDM,C1713,HCPCS,0278,RC,,,,both,,,724.46,470.90,,,,,,,,,,,,,
TUBING SURG DRN 29FR OD0.375IN ID0.250IN SIL SIL-TEC,SUP-2383036,CDM,2720000010,LOCAL,0272,RC,,,,both,,,445.88,289.82,,,,,,,,,,,,,
GLUTAMINE 15 G PO PACK,RX-131348,CDM,6370000000,HCPCS,0637,RC,43900-0283-00,NDC,,both,1,UN,8.60,5.59,,,,,,,,,,,,,
SHEATH INTRO PERFRMR L 40 CM DIA18 FR GUIDEWIRE 0.038 IN,SUP-2168592,CDM,C1894,HCPCS,0272,RC,,,,both,,,295.44,192.04,,,,,,,,,,,,,
CATHETER THRMDIL 6FR 110CM BAL TORQ CTRL,SUP-2383251,CDM,C1751,HCPCS,0278,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
SCREW CORTEX 4.5MM 120MM,SUP-2547355,CDM,C1713,HCPCS,0278,RC,,,,both,,,211.64,137.57,,,,,,,,,,,,,
POST EXT FIX 1 H WIRE MR CONDITIONAL FOR DISTR OSTEOGENESIS,SUP-2179148,CDM,2720000010,LOCAL,0272,RC,,,,both,,,643.79,418.46,,,,,,,,,,,,,
CATHETER DRAINAGE 4 FRX15 CM FLUID ASPIR SM VOL NDL M DRN,SUP-2761902,CDM,C1729,HCPCS,0272,RC,,,,both,,,5.34,3.47,,,,,,,,,,,,,
DEVICE FIXATION LADDER PLATE NARROW 14 HOLES,SUP-2719530,CDM,C1713,HCPCS,0278,RC,,,,both,,,1774.10,1153.16,,,,,,,,,,,,,
PROSTHESIS VOICE L10MM LO AIRFLO RESISTANCE PROVOX2,SUP-2124340,CDM,L8509,HCPCS,0274,RC,,,,both,,,624.86,406.16,,,,,,,,,,,,,
BASKET STONE 19FR L90CM 10MM 3 WIR HELI SURLOK,SUP-2312746,CDM,2720000010,LOCAL,0272,RC,,,,both,,,430.93,280.10,,,,,,,,,,,,,
MESH CRAN W100XL100MM THK0.6MM SLV TI CNTOUR FOR 1.5MM,SUP-2402667,CDM,C1781,HCPCS,0278,RC,,,,both,,,5956.58,3871.78,,,,,,,,,,,,,
CEMENT INTRODUCTORY PK DURELON 3M ESPE,SUP-2238644,CDM,C1713,HCPCS,0278,RC,,,,both,,,295.29,191.94,,,,,,,,,,,,,
HC Office/OP Consltj New/Est Pt Mod Mdm 40 Minutes,PX-5109924400,CDM,99244,CPT,0510,RC,,,,both,,,299.00,194.35,,,,,,,,,,,,,
KIT INTRO L 14 CM DIA 7 FR GUIDEWIRE L 50 CM DIA 0.038 IN SS,SUP-2226018,CDM,C1892,HCPCS,0272,RC,,,,both,,,109.90,71.43,,,,,,,,,,,,,
CONNECTOR SPNL DOMINO 3.5-4.75 MM AX INFIN,SUP-2631931,CDM,C1713,HCPCS,0278,RC,,,,both,,,1267.78,824.06,,,,,,,,,,,,,
PLATE BONE L47MM SH 2X2 H RT OBLQ TI L SHP MALL FOR 2MM SCR,SUP-2191291,CDM,C1713,HCPCS,0278,RC,,,,both,,,643.70,418.40,,,,,,,,,,,,,
SCREW BONE L12MM OD3.5MM STD S STL CORT ST NONCANNULATED,SUP-2348771,CDM,C1713,HCPCS,0278,RC,,,,both,,,46.28,30.08,,,,,,,,,,,,,
PLATE BNE L73MM 10 H BILAT S STL LOK COMPR LO PROF FOR 2MM,SUP-2186310,CDM,C1713,HCPCS,0278,RC,,,,both,,,658.58,428.08,,,,,,,,,,,,,
PLATE BNE 3.5X97 MM 8 HOLE SS DCP,SUP-2569140,CDM,C1713,HCPCS,0278,RC,,,,both,,,274.59,178.48,,,,,,,,,,,,,
ALLOGRAFT BNE BLOCK 12X12X12 MM DBM PUROS,SUP-2684559,CDM,C1713,HCPCS,0278,RC,,,,both,,,5030.28,3269.68,,,,,,,,,,,,,
DRILL TWST DIA4MM ADPT RADLUC TARGETING DEV,SUP-2408641,CDM,2720000010,LOCAL,0272,RC,,,,both,,,584.04,379.63,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9 % IV SOLN (MINI-BAG),RX-40850049,CDM,2580000003,HCPCS,0250,RC,00338-9151-30,NDC,,both,50,ML,61.20,39.78,,,,,,,,,,,,,
SHEATH INTRO L 60 CM DIA 8.5 FR SL25 CRV,SUP-2357185,CDM,C1894,HCPCS,0272,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
HC So Chylmd Trach Dna Amp Probe,PX-3068749166,CDM,87491,CPT,0306,RC,,,,both,,,289.00,187.85,,,,,,,,,,,,,
SCREW BNE SM EZ-OUT,SUP-2475360,CDM,C1713,HCPCS,0278,RC,,,,both,,,1666.27,1083.08,,,,,,,,,,,,,
PLATE BNE L 239 X W 12 MM THK 4 MM SCREW DIA2.7/3.5 MM 20 H 72469120,SUP-2933467,CDM,C1713,HCPCS,0278,RC,,,,both,,,6346.57,4125.27,,,,,,,,,,,,,
HC X-Ray Femur 1 View,PX-3207355100,CDM,73551,CPT,0320,RC,,,,outpatient,,,267.00,173.55,,,,,,,,,,,,,
CANC SCREW STERILIZER 6.5X100 MM 16MM THREAD,SUP-2818178,CDM,C1713,HCPCS,0278,RC,,,,both,,,380.73,247.47,,,,,,,,,,,,,
GUIDEWIRE VASC STREAMER SS POLYMER HYDRPHLC J SHP X STIFF,SUP-2699322,CDM,C1769,HCPCS,0272,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
PLATE BNE L 32.33 X W 5.72 MM THK 1.6 MM 4 H GRD III TI MOD,SUP-2936936,CDM,C1713,HCPCS,0278,RC,,,,both,,,1321.94,859.26,,,,,,,,,,,,,
TAP ST 2.8 MM REUNITE SM SCR FIX SYS,SUP-2212976,CDM,2720000010,LOCAL,0272,RC,,,,both,,,876.06,569.44,,,,,,,,,,,,,
DRILL SURG 1.8 MM TCP,SUP-2521531,CDM,2720000010,LOCAL,0272,RC,,,,both,,,543.22,353.09,,,,,,,,,,,,,
SCREW BONE 5X40MM BICORTICAL CANN TRNSVRS FT ALTA,SUP-2363418,CDM,C1713,HCPCS,0278,RC,,,,both,,,475.08,308.80,,,,,,,,,,,,,
REAMER SURG M 19MM,SUP-2321576,CDM,2720000010,LOCAL,0272,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
PLATE BONE LOK 2MM THK HLX26 CP TTNM ANGLD FRCNSTRCTN RIGHT,SUP-2669749,CDM,C1713,HCPCS,0278,RC,,,,both,,,5286.66,3436.33,,,,,,,,,,,,,
PLATE BNE L 28.2 X W 7 MM THK 0.6 MM SCREW DIA1.5 MM 2 H LNG,SUP-2936535,CDM,C1713,HCPCS,0278,RC,,,,both,,,389.36,253.08,,,,,,,,,,,,,
CONTROL REMOT QUIK GUIDE SIM FOR SENZA,SUP-2308596,CDM,2720000010,LOCAL,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
SYSTEM CORT IMPL STD ADJUSTABLE 1 W SLDE LOK KNOT DSGN 1 HND,SUP-2256783,CDM,C1713,HCPCS,0278,RC,,,,both,,,1840.04,1196.03,,,,,,,,,,,,,
PLATE BNE ORBIT FLR 1.5X40X35X0.4 MM LT SMRT TI NS LEVEL 1,SUP-2480291,CDM,C1713,HCPCS,0278,RC,,,,both,,,4120.21,2678.14,,,,,,,,,,,,,
SHUNT SURG L 28 MM RESERVOIR 20 MM CATH L DSTL 600 MM FV172T,SUP-2929167,CDM,C1889,HCPCS,0278,RC,,,,both,,,8431.28,5480.33,,,,,,,,,,,,,
PLATE BNE RECON 3.5 MM PELV 16 HOLE,SUP-2518367,CDM,C1713,HCPCS,0278,RC,,,,both,,,3846.50,2500.22,,,,,,,,,,,,,
GRAFT HUM TISS DIA11MM OSTEOCHNDRL CHONDROFIX,SUP-2200260,CDM,C1713,HCPCS,0278,RC,,,,both,,,11564.62,7517.00,,,,,,,,,,,,,
PLATE BNE THK0.6MM 1 H BILAT HND COMPR 2 HK APTUS,SUP-2267902,CDM,C1713,HCPCS,0278,RC,,,,both,,,1395.10,906.81,,,,,,,,,,,,,
GRAFT BNE WDG 12X20 MM CORTICAL TANGENT,SUP-2335445,CDM,C1713,HCPCS,0278,RC,,,,both,,,5181.00,3367.65,,,,,,,,,,,,,
PLATE BNE W17.5XL196MM THK5.2MM 11 H TI BROAD LIMIT CNTCT,SUP-2190850,CDM,C1713,HCPCS,0278,RC,,,,both,,,1101.64,716.07,,,,,,,,,,,,,
MESH HERN 15X15CM MACROPOROUS ULTRAPRO ADV,SUP-2257824,CDM,C1781,HCPCS,0278,RC,,,,both,,,361.57,235.02,,,,,,,,,,,,,
PLATE BONE CMPRSSN 87MM ID 1219MM OD TUBE 214MML HLX12 38,SUP-2726709,CDM,C1713,HCPCS,0278,RC,,,,both,,,2192.79,1425.31,,,,,,,,,,,,,
BLADE RTRCTR MCCLLCH 4CMD STNLSS STEEL SPNL MSCLE WIDE ULTRA,SUP-2667616,CDM,2720000010,LOCAL,0272,RC,,,,both,,,355.70,231.20,,,,,,,,,,,,,
COMPONENT HUM STD LNG STEM DST STR L SOLAR,SUP-2372325,CDM,C1776,CPT,0278,RC,,,,both,,,23410.58,15216.88,,,,,,,,,,,,,
STAPLER INT BIOABSRB REINF ECHELON ENDOPATH 60,SUP-2395280,CDM,C1781,HCPCS,0278,RC,,,,both,,,521.49,338.97,,,,,,,,,,,,,
SCREW LCKING HDLSS LP F/IM NAIL XL 25/S 5X44MM,SUP-2761695,CDM,C1713,HCPCS,0278,RC,,,,both,,,778.78,506.21,,,,,,,,,,,,,
TRIAL KNEE SZ 4-6 L60MM TIB STEM EXTN PFC,SUP-2253329,CDM,C1776,CPT,0278,RC,,,,both,,,734.76,477.59,,,,,,,,,,,,,
PLATE STRNL CLOSURE THK 1.5 MM 4 H TI V LP NS STERNALOCK EZ,SUP-2894502,CDM,C1713,HCPCS,0278,RC,,,,both,,,1365.90,887.83,,,,,,,,,,,,,
TUBE VENT PAPARELLA 1.27 MM W/ TAB SIL STRL,SUP-2470798,CDM,L8699,HCPCS,0278,RC,,,,both,,,23.83,15.49,,,,,,,,,,,,,
SCREW BNE L80MM OD5MM STD CORT LOK RECON FOR FEM NAIL,SUP-2342533,CDM,C1713,HCPCS,0278,RC,,,,both,,,271.26,176.32,,,,,,,,,,,,,
OCCLUDER CV CARDIOFORM DIA15 MM CATH L 75 CM DIA10 FR PLAT,SUP-2395772,CDM,C1817,HCPCS,0278,RC,,,,both,,,21970.58,14280.88,,,,,,,,,,,,,
SHEATH INTRO FLX L 45 CM OD 6 FR GUIDEWIRE 0.038 IN SM CKFLO,SUP-2168513,CDM,C1894,HCPCS,0272,RC,,,,both,,,173.61,112.85,,,,,,,,,,,,,
HC Mandible Panorex,PX-3207035500,CDM,70355,CPT,0320,RC,,,,both,,,770.00,500.50,,,,,,,,,,,,,
APEX BLUNT HALF PIN 5MM 180 X 20MM,SUP-2703151,CDM,C1713,HCPCS,0278,RC,,,,both,,,779.98,506.99,,,,,,,,,,,,,
PROMETHAZINE HCL 6.25 MG/5ML PO SOLN,RX-6620,CDM,Q0169,HCPCS,0637,RC,09999-9911-77,NDC,,both,5,ML,2.70,1.75,,,,,,,,,,,,,
TUBE TRACH PED L104MM OD67MM ID45MM SIL CUF STR NK FLNG W,SUP-2352029,CDM,2720000010,LOCAL,0272,RC,,,,both,,,828.39,538.45,,,,,,,,,,,,,
PLATE BNE L140MM 5 H NONSTERILE L LAT PROX TIB TI LOK COMPR,SUP-2190712,CDM,C1713,HCPCS,0278,RC,,,,both,,,4217.90,2741.63,,,,,,,,,,,,,
FULL TIB WDG W/O SCR SZ 1,SUP-2359306,CDM,C1776,CPT,0278,RC,,,,both,,,2983.00,1938.95,,,,,,,,,,,,,
GRAFT HUM TISS L 3 X W 0.7-0.9 CM THK 3 MM LG COSTAL CART,SUP-2895218,CDM,C1762,CPT,0278,RC,,,,both,,,1894.46,1231.40,,,,,,,,,,,,,
SET INTRO MICROPUNCTURE CATH L 10 CM 4 FR L 4 CM NIT PD,SUP-2635417,CDM,C1894,HCPCS,0272,RC,,,,both,,,146.61,95.30,,,,,,,,,,,,,
INSTRUMENT KIT PLN PT SPEC BASIC MAND,SUP-2860254,CDM,2720000010,LOCAL,0272,RC,,,,both,,,9945.95,6464.87,,,,,,,,,,,,,
HC So Cpk (CK),PX-3018255066,CDM,82550,CPT,0301,RC,,,,both,,,26.00,16.90,,,,,,,,,,,,,
PLATE BNE L139MM 16 H L FIBULAR TIM LOK COMPR ANAT FOR,SUP-2413689,CDM,C1713,HCPCS,0278,RC,,,,both,,,3786.84,2461.45,,,,,,,,,,,,,
COMPONENT HNG TIB LIMB SALV LO BODY W/O ROTATIONAL STP,SUP-2314042,CDM,C1776,CPT,0278,RC,,,,both,,,12038.76,7825.19,,,,,,,,,,,,,
COLLAR CERV SM PED W25XL14IN FOAM M DENS BRTH COT STOCK LNR,SUP-2194384,CDM,L0120,HCPCS,0272,RC,,,,both,,,21.98,14.29,,,,,,,,,,,,,
STEM FEM CMNTLS 12/14 135 DEG 24X127.6 MM 36.8 MM TAPR,SUP-2440497,CDM,C1776,CPT,0278,RC,,,,both,,,7309.92,4751.45,,,,,,,,,,,,,
SCREW BNE 35MM X 12MM S STL SURFIT INTEGRA TOT WRST FUS SYS,SUP-2243407,CDM,C1713,HCPCS,0278,RC,,,,both,,,1159.29,753.54,,,,,,,,,,,,,
HANDLE DRVR REDUC SCR CAP,SUP-2232118,CDM,C1713,HCPCS,0278,RC,,,,both,,,1164.94,757.21,,,,,,,,,,,,,
TRAY CATH HEMODIALYSI BREVIA ACUTE 11FR DIA 24CML IN 5565240,SUP-2632903,CDM,C1752,HCPCS,0278,RC,,,,both,,,538.07,349.75,,,,,,,,,,,,,
RING EXT FIX DIA130 MM 2/3 PNK NS DISP SPAT FRME TSF,SUP-2932820,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4582.08,2978.35,,,,,,,,,,,,,
SHEATH INTRO L 14 CM DIA 4 FR GUIDEWIRE 0.028 IN PTFE X TW,SUP-2615923,CDM,C1894,HCPCS,0272,RC,,,,both,,,79.13,51.43,,,,,,,,,,,,,
PUSHER KNOT SUT CUT SLED DISP AIR,SUP-2372186,CDM,2720000010,LOCAL,0272,RC,,,,both,,,839.95,545.97,,,,,,,,,,,,,
PROSTHESIS PENILE L14CM W/ GIRTH EXP PS INHIBZN INFL,SUP-2138995,CDM,C1813,HCPCS,0278,RC,,,,both,,,30026.25,19517.06,,,,,,,,,,,,,
BIT DRL TWST 1.5X13 MM ANGULUS 2,SUP-2465286,CDM,2720000010,LOCAL,0272,RC,,,,both,,,750.59,487.88,,,,,,,,,,,,,
INJECTOR EYEJET TYPE 15 RIGHT PRELOADED,SUP-2859239,CDM,2720000010,LOCAL,0272,RC,,,,both,,,659.40,428.61,,,,,,,,,,,,,
SCREW BONE LAG 10MM DIA 105MML FNAIL,SUP-2723147,CDM,C1713,HCPCS,0278,RC,,,,both,,,1688.25,1097.36,,,,,,,,,,,,,
EPINEPHRINE 1 MG/10ML IJ SOSY,RX-143088,CDM,J0169,HCPCS,0636,RC,00409-4921-34,NDC,,both,10,ML,54.10,35.16,,,,,,,,,,,,,
HEAD HUM DIA50MM THK19MM SHLDR TRL AEQUALIS FX,SUP-2388631,CDM,C1776,CPT,0278,RC,,,,both,,,12157.45,7902.34,,,,,,,,,,,,,
WIRE FIX DBL END TROCAR PT 0.9X150 MM SMOOTH KIRSCHNER,SUP-2321642,CDM,C1713,HCPCS,0278,RC,,,,both,,,859.58,558.73,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 180 MM DIA 9 MM DEL SHTH 13ML,SUP-2936819,CDM,C1713,HCPCS,0278,RC,,,,both,,,16514.45,10734.39,,,,,,,,,,,,,
PLATE BNE L L103MM 4 H POST TIBIOTALOCALCANEAL ANK TI,SUP-2398510,CDM,C1713,HCPCS,0278,RC,,,,both,,,6261.16,4069.75,,,,,,,,,,,,,
GRAFT BNE 100X25X8 MM 20 CC POROUS COLLAGEN MATRIX SIGNAFUSE,SUP-2731802,CDM,C1713,HCPCS,0278,RC,,,,both,,,10621.05,6903.68,,,,,,,,,,,,,
HOOK SPNL PROTEX CT,SUP-2593195,CDM,C1713,HCPCS,0278,RC,,,,both,,,596.60,387.79,,,,,,,,,,,,,
COMPONENT FEM L5CM RT DSTL HIP TOT RESURF FIN IMP,SUP-2406047,CDM,C1776,CPT,0278,RC,,,,both,,,17876.02,11619.41,,,,,,,,,,,,,
PURAPLY AM 2X2CM 4SQ CM,SUP-2314115,CDM,Q4196,HCPCS,0636,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
PLATE BNE CROSS SHP SCR STYL HD FOR 6MM BRIDGE ORTHOANCHOR,SUP-2471447,CDM,C1713,HCPCS,0278,RC,,,,both,,,1306.71,849.36,,,,,,,,,,,,,
HC Aspir/Inj Thyroid Cyst,PX-3616030000,CDM,60300,CPT,0361,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
KIT SURG PWR OPN PROC SAG SAW STRL LF DISP FJ-2000,SUP-2881129,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5560.94,3614.61,,,,,,,,,,,,,
SHEATH URET ACCS DIL 6 12FR OD14FR ID12FR L38CM PTFE LN,SUP-2312758,CDM,C1894,HCPCS,0272,RC,,,,both,,,448.77,291.70,,,,,,,,,,,,,
PLATE BNE L W135XL62MM THK42MM 3 H BILAT TI NAR RIG NEUT,SUP-2190806,CDM,C1713,HCPCS,0278,RC,,,,both,,,741.45,481.94,,,,,,,,,,,,,
PURAPLY 5X5CM 25SQ CM,SUP-2314122,CDM,Q4195,HCPCS,0636,RC,,,,both,,,8635.00,5612.75,,,,,,,,,,,,,
SET INT FIX SCREW DIA1.5 MM 2 H TI NEURO WIDE PLATE XDRV 12,SUP-2935390,CDM,C1713,HCPCS,0278,RC,,,,both,,,10117.08,6576.10,,,,,,,,,,,,,
SPLINT ANK WOM SHOE SZ 7-9 IN MED POLYPRO PLAS RT FT,SUP-2930193,CDM,L1930,HCPCS,0272,RC,,,,both,,,251.70,163.60,,,,,,,,,,,,,
POROUS FINN STEM 89MMX12.5MM,SUP-2510726,CDM,C1776,CPT,0278,RC,,,,both,,,5393.42,3505.72,,,,,,,,,,,,,
BONE CEMENT SURG 40 GM PMMA GENTAMICIN SULPHATE LO VISC,SUP-2898408,CDM,C1713,HCPCS,0278,RC,,,,both,,,580.90,377.58,,,,,,,,,,,,,
DEVICE FAT PROC TISS COLLCTN REVOLVE RV0004] ALLERGAN USA - LIFECELL],SUP-2113064,CDM,C1713,HCPCS,0278,RC,,,,both,,,1475.80,959.27,,,,,,,,,,,,,
BUR SURG DIA 5 MM HUB II TUNGSTEN CARBIDE ROSEN STRL DISP,SUP-2929580,CDM,2720000010,LOCAL,0272,RC,,,,both,,,484.44,314.89,,,,,,,,,,,,,
PLATE BSSO SLIDING COLOGNE30MM STERILE,SUP-2676896,CDM,C1713,HCPCS,0278,RC,,,,both,,,1861.74,1210.13,,,,,,,,,,,,,
SCREW SPNL L50MM DIA6MM CORT PEDCL TI ST FIX ANG CANN FOR,SUP-2254921,CDM,C1713,HCPCS,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
CATHETER IABP 7.5FR 40CC SHTH LAIN DATASCP SYS COMPATIBLE,SUP-2227318,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3188.36,2072.43,,,,,,,,,,,,,
CATHETER INFUSION 2.8 FRX130 CM 16 FR STR DIREXION HIFLO,SUP-2139702,CDM,C1887,HCPCS,0272,RC,,,,both,,,2653.30,1724.64,,,,,,,,,,,,,
OBTURATOR TROCAR TRAINGULAR 5X60 MM BLNT REUSE,SUP-2850119,CDM,2720000010,LOCAL,0272,RC,,,,both,,,328.54,213.55,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA MAXBARR 3FR 55CM S1173108PD,SUP-2632790,CDM,C1751,HCPCS,0278,RC,,,,both,,,906.20,589.03,,,,,,,,,,,,,
BLADE RTRCTR SHRT TEETH 15MMW X 75MML SPNL BLACK FLEXI SPINE,SUP-2669119,CDM,2720000010,LOCAL,0272,RC,,,,both,,,902.94,586.91,,,,,,,,,,,,,
SCREW SWVL L36CM POLYPR SUT,SUP-2140290,CDM,C1713,HCPCS,0278,RC,,,,both,,,1416.93,921.00,,,,,,,,,,,,,
ADAPTER FEM STEM 7DEG TRAIL ASSY PFC SIG SPEC,SUP-2253664,CDM,C1776,CPT,0278,RC,,,,both,,,1745.84,1134.80,,,,,,,,,,,,,
PLATE BNE SPCR 3MM 4 H NONSTERILE MIDFOOT S STL VAR ANG LOK,SUP-2184806,CDM,C1713,HCPCS,0278,RC,,,,both,,,2995.28,1946.93,,,,,,,,,,,,,
CABLE ORTH L889MM DIA1.3MM S STL SMOOTH NDL,SUP-2410274,CDM,C1776,CPT,0278,RC,,,,both,,,941.81,612.18,,,,,,,,,,,,,
SET INTRO PEELWY L 15.5 CM DIA 9 FR DIL L 20 CM GUIDEWIRE,SUP-2168024,CDM,C1892,HCPCS,0272,RC,,,,both,,,128.74,83.68,,,,,,,,,,,,,
GRAFT VASC HEMSHLD GLD L 40 CM 7 MM POLYESTER BOV CLLGN STR,SUP-2266035,CDM,C1768,CPT,0278,RC,,,,both,,,1637.54,1064.40,,,,,,,,,,,,,
CENTRALIZER STEM L120MM DIA13.5MM DSTL FEM HIP CEM MOLD FOR,SUP-2251179,CDM,C1776,CPT,0278,RC,,,,both,,,401.92,261.25,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 20 CM DIA 7 MM EPTFE STR STD WALL,SUP-2396192,CDM,C1768,CPT,0278,RC,,,,both,,,854.08,555.15,,,,,,,,,,,,,
DRILL SURG STEM TIB KNEE ROTATING HINGE BASE NXGN,SUP-2437383,CDM,2720000010,LOCAL,0272,RC,,,,both,,,353.25,229.61,,,,,,,,,,,,,
CANNULA INSUL B,SUP-2417905,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3293.86,2141.01,,,,,,,,,,,,,
SET CATH 4FR 12CM CTRL VEN SGL LUMN N TUNNELED N COAT N PWR,SUP-2167833,CDM,C1751,HCPCS,0278,RC,,,,both,,,162.02,105.31,,,,,,,,,,,,,
ALLOGRAFT BNE PROX TIB W/ TUBEROSITY,SUP-2321914,CDM,C1713,HCPCS,0278,RC,,,,both,,,25120.00,16328.00,,,,,,,,,,,,,
CLIP INT 12MM BLK SGL ABSRB LIG LAPRO,SUP-2172327,CDM,C1889,HCPCS,0278,RC,,,,both,,,276.48,179.71,,,,,,,,,,,,,
K WIRE FIX L228MM DIA1.4MM FOR TOT ANK SYS INBONE II,SUP-2397997,CDM,C1713,HCPCS,0278,RC,,,,both,,,59.66,38.78,,,,,,,,,,,,,
SYSTEM CLP DEL MITRACLIP XTR L 109.5 CM DIA16 FR BALLOON L,SUP-2102260,CDM,C1889,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
"HC So Mtb-Rif Naa, Mycobacterium TB",PX-3068755667,CDM,87556,CPT,0306,RC,,,,both,,,155.00,100.75,,,,,,,,,,,,,
TRIAL PLATE 0.8 MM OFFSET,SUP-2525713,CDM,C1713,HCPCS,0278,RC,,,,both,,,719.06,467.39,,,,,,,,,,,,,
SCREW INTRF L14MM OD8MM SUBTALAR FOR ARTHROEREISIS PROSTOP +,SUP-2121854,CDM,C1713,HCPCS,0278,RC,,,,both,,,4066.30,2643.09,,,,,,,,,,,,,
COMPONENT FEM KNEE PS KT STRL ITOTAL,SUP-2904869,CDM,C1776,CPT,0278,RC,,,,both,,,6044.50,3928.92,,,,,,,,,,,,,
HC Needle Insertion W/O Injection 1 or 2 Muscles,PX-4202056000,CDM,20560,CPT,0940,RC,,,,outpatient,,,42.00,27.30,,,,,,,,,,,,,
HEAD HUM L17.7MM OD46MM 4MM OFFSET SHLDR AEQUALIS ASCEND,SUP-2388547,CDM,C1776,CPT,0278,RC,,,,both,,,5495.00,3571.75,,,,,,,,,,,,,
SHEATH INTRO INPUT TS L 11 CM DIA 5 FR GUIDEWIRE 0.038 IN,SUP-2277545,CDM,C1894,HCPCS,0272,RC,,,,both,,,6280.00,4082.00,,,,,,,,,,,,,
GRAFT HUM TISS L 30-53 X W 10 MM BNE L 25-30 X W 10 X H 10,SUP-2913417,CDM,C1762,CPT,0278,RC,,,,both,,,11395.06,7406.79,,,,,,,,,,,,,
HC Mra Chest W/O Contrast,PX-6107155501,CDM,C8910,CPT,0610,RC,,,,both,,,4146.00,2694.90,,,,,,,,,,,,,
EPOCH POR ST/HA CUP/LGXLPE LINER/LG CER HD,SUP-2212322,CDM,C1776,CPT,0278,RC,,,,both,,,16382.29,10648.49,,,,,,,,,,,,,
SCREW INTRF CANN 12X25 MM 1.5 MM RND HD SFT THRD SOFTSILK,SUP-2878059,CDM,C1713,HCPCS,0278,RC,,,,both,,,1375.32,893.96,,,,,,,,,,,,,
FORCEP ENDOSCP W SHP 14X1650 MM 2 MM GRASPING W/ CHANNEL,SUP-2865650,CDM,2720000010,LOCAL,0272,RC,,,,both,,,624.39,405.85,,,,,,,,,,,,,
KIT PROC W/ 180DEG FIRM TIP EXT WRK CHAN TELE FOR BRONCHSCP,SUP-2381761,CDM,C1887,HCPCS,0272,RC,,,,both,,,3705.20,2408.38,,,,,,,,,,,,,
SYSTEM POS STD BLDE VAC OFF PMP RIG FT DEV XPOSE 3 AXIUS,SUP-2142005,CDM,C1713,HCPCS,0278,RC,,,,both,,,4694.30,3051.29,,,,,,,,,,,,,
COMPONENT FEM SZ 5 BILAT KNEE NP NONBEADED UNI CEM SIG,SUP-2253898,CDM,C1776,CPT,0278,RC,,,,both,,,2904.50,1887.92,,,,,,,,,,,,,
PLATE BNE L57MM THK1MM 12 H ST HND S STL STR LOK VAR ANG FOR,SUP-2255804,CDM,C1713,HCPCS,0278,RC,,,,both,,,1585.95,1030.87,,,,,,,,,,,,,
STENT URET 7FR L20CM NYL COAT DBL PGTL BRAID HYDRPHLC OPN,SUP-2313806,CDM,C2617,HCPCS,0278,RC,,,,both,,,453.54,294.80,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 250 MG AMINIOFILL,SUP-2305713,CDM,C1762,CPT,0278,RC,,,,both,,,1491.50,969.47,,,,,,,,,,,,,
MESH HERN SELF FIXATING 15X10 CM LAP PK BILATERAL ANAT LF,SUP-2752178,CDM,C1781,HCPCS,0278,RC,,,,both,,,1117.87,726.62,,,,,,,,,,,,,
SUPPORT ORTHOT ELBW CUST DBL UPR EXTN FLX ASST FABRICATED,SUP-2435758,CDM,L3730,HCPCS,0272,RC,,,,both,,,2335.16,1517.85,,,,,,,,,,,,,
PLATE BONE NONSTERILE UNIV CRAN ORBIT TI FLR LO PROF,SUP-2190646,CDM,C1713,HCPCS,0278,RC,,,,both,,,3532.50,2296.12,,,,,,,,,,,,,
SCREW SPNL L40MM DIA8MM CANC PEDCL TI VAR ANG NONCANNULATED,SUP-2193324,CDM,C1713,HCPCS,0278,RC,,,,both,,,1661.06,1079.69,,,,,,,,,,,,,
IMPLANT HUM TISS L 8 X W 2 CM DECELL PLCNTA MEMBRN TEND NEVE,SUP-2881924,CDM,C1762,CPT,0278,RC,,,,both,,,8463.87,5501.52,,,,,,,,,,,,,
WASHER ORTH 3.5 MM ANK SYNDESMOSIS REP KT ACU-SINCH,SUP-2857602,CDM,C1713,HCPCS,0278,RC,,,,both,,,618.58,402.08,,,,,,,,,,,,,
SCREW BNE ST 1.2X5 MM EMGCY THRD W/ FLUT TIP TI NS,SUP-2189154,CDM,C1713,HCPCS,0278,RC,,,,both,,,351.68,228.59,,,,,,,,,,,,,
SCREW BONE L35MM COMPR META-TAN,SUP-2340870,CDM,C1713,HCPCS,0278,RC,,,,both,,,1809.21,1175.99,,,,,,,,,,,,,
COMPONENT TALAR SZ 0 COCR ALLOY TI PLASMA SPRY LT ANK DOME,SUP-2933126,CDM,C1776,CPT,0278,RC,,,,both,,,16605.89,10793.83,,,,,,,,,,,,,
CLAMP TBL FOR ACUFEX NONINVASIVE ANK DISTRACTOR SYS,SUP-2340723,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2304.76,1498.09,,,,,,,,,,,,,
BLADE SURG FOR SM CUT T2,SUP-2467160,CDM,2720000010,LOCAL,0272,RC,,,,both,,,546.36,355.13,,,,,,,,,,,,,
ALLOGRAFT TISS 3X6 CM MTRX REGENERATIVE,SUP-2393053,CDM,Q4170,HCPCS,0636,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
PLATE NAVICULAR 2.4/2.7MM LT TI VA LCK STRL,SUP-2546963,CDM,C1713,HCPCS,0278,RC,,,,both,,,4384.41,2849.87,,,,,,,,,,,,,
BIT DRL 12 MM CERV FOR ACP STD DISP,SUP-2430716,CDM,2720000010,LOCAL,0272,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
LENS IOL 1 PC 17.5 DIOPT 6X13.75 MM ANTR CHMBR PMMA,SUP-2129206,CDM,V2630,CPT,0276,RC,,,,both,,,266.90,173.48,,,,,,,,,,,,,
SCREW BONE LOK 2.7MM DIA UNVRSL 14MML STNLSS STEEL CRTCL SEL,SUP-2588494,CDM,C1713,HCPCS,0278,RC,,,,both,,,76.62,49.80,,,,,,,,,,,,,
HC Needle Insertion W/O Injection 1 or 2 Muscles,PX-4202056000,CDM,20560,CPT,0940,RC,,,,inpatient,,,42.00,27.30,,,,,,,,,,,,,
BLOCK TIB AUG SZ 3 THK15MM RT LAT LT MEDL KNEE TRABECULAR,SUP-2200134,CDM,C1776,CPT,0278,RC,,,,both,,,4672.32,3037.01,,,,,,,,,,,,,
SET PERI DLYS CATH,SUP-2130773,CDM,C1755,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
STEM RADIAL STD 4X8 MM ELBW,SUP-2106428,CDM,C1776,CPT,0278,RC,,,,both,,,5608.04,3645.23,,,,,,,,,,,,,
KIT TKR TIB POR CRUC RET FEM TIB HI DEMAND LEGION GEN II,SUP-2348038,CDM,C1776,CPT,0278,RC,,,,both,,,14130.00,9184.50,,,,,,,,,,,,,
CONNECTOR VENT STEPDOWN BA IMPREG,SUP-2284391,CDM,2720000010,LOCAL,0272,RC,,,,both,,,199.20,129.48,,,,,,,,,,,,,
STYLET PACE L75CM OD0.012IN LD PLCMNT ATR LT VENT FIRM CPS,SUP-2356389,CDM,2720000010,LOCAL,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
LOOP ELECSURG TUMOR RESECT 24 FR BLDR FOR ACMI USA ELITE SYS,SUP-2754293,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1730.27,1124.68,,,,,,,,,,,,,
WEDGE COT 16X65 TI BNE,SUP-2244445,CDM,C1713,HCPCS,0278,RC,,,,both,,,8496.21,5522.54,,,,,,,,,,,,,
COMPONENT FEM L75MM L KNEE POR ANAT PRI MAXM,SUP-2251196,CDM,C1713,HCPCS,0278,RC,,,,both,,,1120.98,728.64,,,,,,,,,,,,,
PLATE BNE L47MM 2 H 140DEG S STL HIP COMPR LO PROF STD BRL,SUP-2364136,CDM,C1713,HCPCS,0278,RC,,,,both,,,2329.10,1513.91,,,,,,,,,,,,,
BIT DRL WIRE PASS 1.7X6.7 MM STRL ELITE LTX,SUP-2859477,CDM,2720000010,LOCAL,0272,RC,,,,both,,,369.55,240.21,,,,,,,,,,,,,
PROBE ENDO VW OPT,SUP-2392615,CDM,C1713,HCPCS,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
TRAY CATH HEMODIALYSI 400XL ACTE 14FR DIA 15CM CRV EXTN TAPR,SUP-2610500,CDM,C1752,HCPCS,0278,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
GRAFT HUM TISS AMNION PTCH 10X10 CM AMNIO TISS MEMBRN CYGNUS,SUP-2422823,CDM,Q4170,HCPCS,0636,RC,,,,both,,,14130.00,9184.50,,,,,,,,,,,,,
BLADE SURG ULTRA AGGRESSIVE MINI 2.7 MM + FMS VUE,SUP-2624807,CDM,2720000010,LOCAL,0272,RC,,,,both,,,234.87,152.67,,,,,,,,,,,,,
MESH HERN RECT 16X10 IN FULL RESRB FOR SFT TISS RECON PHASIX,SUP-2855238,CDM,C1781,HCPCS,0278,RC,,,,both,,,42233.00,27451.45,,,,,,,,,,,,,
ROD SPNL POST RT TRNSVRS SMOOTH TI ALLOY OD4MM L40MM OMEGA,SUP-2414726,CDM,C1713,HCPCS,0278,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
HC US Breast Comp,PX-4027664100,CDM,76641,CPT,0402,RC,,,,both,,,1082.00,703.30,,,,,,,,,,,,,
WASHER ORTHOPAEDIC 6 MM STERILE,SUP-2836818,CDM,C1713,HCPCS,0278,RC,,,,both,,,262.25,170.46,,,,,,,,,,,,,
WASHER ORTH RT FEM NK LCK STRL CONQ FN,SUP-2933508,CDM,C1713,HCPCS,0278,RC,,,,both,,,5638.87,3665.27,,,,,,,,,,,,,
COLLAR CERV PHILLY MED 4.25 IN 13-16 IN REHAB FOAM PROCARE,SUP-2196879,CDM,L0172,HCPCS,0274,RC,,,,both,,,28.39,18.45,,,,,,,,,,,,,
GRAFT BNE STRP 5X5 CMX3 MM DBM TI NS DBX 048.150,SUP-2653620,CDM,C1713,HCPCS,0278,RC,,,,both,,,3157.33,2052.26,,,,,,,,,,,,,
NAIL IM L 175 MM DIA13 MM ARTH OSTEOSYN NITINAIL,SUP-2898410,CDM,C1713,HCPCS,0278,RC,,,,both,,,31086.00,20205.90,,,,,,,,,,,,,
PLATE BONE CONDYLAR 2.7 MM LEFT 3 HOLE OBLIQUE STAINLESS STE,SUP-2836694,CDM,C1713,HCPCS,0278,RC,,,,both,,,435.55,283.11,,,,,,,,,,,,,
SCREW STRNL CLOSURE L 10 MM DIA 3 MM TI STRL STERNALOCK XP,SUP-2895213,CDM,C1713,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
ROD EXT FIX L185MM DIA6MM BAR JET-X,SUP-2342915,CDM,2720000010,LOCAL,0272,RC,,,,both,,,825.41,536.52,,,,,,,,,,,,,
AMPICILLIN-SULBACTAM SODIUM 1.5 (1-0.5) G IJ SOLR,RX-9083,CDM,J0295,HCPCS,0636,RC,00641-6116-10,NDC,,both,1,UN,54.10,35.16,,,,,,,,,,,,,
PLATE BONE W100XL100MM 4MM H SPC CRAN TI MESH FOR 1/1.5MM,SUP-2190573,CDM,C1713,HCPCS,0278,RC,,,,both,,,7411.66,4817.58,,,,,,,,,,,,,
PLATE BONE LOK 51MML HLX33 HDSHFT T SHPD RIGHT OBLQUE ST,SUP-2726043,CDM,C1713,HCPCS,0278,RC,,,,both,,,1164.31,756.80,,,,,,,,,,,,,
OSSEOFLEX SB 10 GAUGE4ML STRAIGHT SYSTEM CONVENIENCE PACK,SUP-2702594,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2841.70,1847.10,,,,,,,,,,,,,
SCREW BNE L85MM DIA10.5MM LAG FOR AFFIXUS HIP FRAC NAIL SYS,SUP-2413328,CDM,C1713,HCPCS,0278,RC,,,,both,,,1218.32,791.91,,,,,,,,,,,,,
PLATE BNE WDG 0 MM BOW ARW BASE GORILLA,SUP-2751028,CDM,C1713,HCPCS,0278,RC,,,,both,,,3289.15,2137.95,,,,,,,,,,,,,
STRAP CLAV SM PD W3XL4IN STD FOAM PD STOCKINET MTL TOOTH,SUP-2276602,CDM,L3650,HCPCS,0274,RC,,,,both,,,16.30,10.59,,,,,,,,,,,,,
BIT DRL DIA2.7MM CALIB,SUP-2412632,CDM,2720000010,LOCAL,0272,RC,,,,both,,,291.49,189.47,,,,,,,,,,,,,
SCREW BNE 35MMX65MM CORT N CANN FULL THRD N ST DRL N LOK HEX,SUP-2199293,CDM,C1713,HCPCS,0278,RC,,,,both,,,80.73,52.47,,,,,,,,,,,,,
GRAFT BNE 5 CC OSTEOCURRENT,SUP-2644333,CDM,C1713,HCPCS,0278,RC,,,,both,,,6876.60,4469.79,,,,,,,,,,,,,
SHUNT KIT 1 PC 80 CM LUMPERITON SPETZLER,SUP-2851454,CDM,C1889,HCPCS,0278,RC,,,,both,,,2382.66,1548.73,,,,,,,,,,,,,
PLATE BNE THK0.6MM 4X2 H BILAT HND TRAPEZOIDAL,SUP-2267893,CDM,C1713,HCPCS,0278,RC,,,,both,,,811.38,527.40,,,,,,,,,,,,,
PIN EXT FIX CLMP ARTC TOMAHAWK MINI FIX,SUP-2400712,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1673.62,1087.85,,,,,,,,,,,,,
SEALER TISS L20CM DIA13MM ADV BPLR L CRV JAW OPN APPRCH,SUP-2219738,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4488.82,2917.73,,,,,,,,,,,,,
PLATE BNE L 91 MM SHFT THK 2 MM HD 1.8 MM SCREW DIA 3.5 MM 6,SUP-2931289,CDM,C1713,HCPCS,0278,RC,,,,both,,,4380.77,2847.50,,,,,,,,,,,,,
SCREW BNE L13MM DIA2.4MM HD DIA4.5MM STD CORT S STL ST,SUP-2183245,CDM,C1713,HCPCS,0278,RC,,,,both,,,136.15,88.50,,,,,,,,,,,,,
NAIL IM HIP SCR 10DEG AG 130,SUP-2349037,CDM,C1713,HCPCS,0278,RC,,,,both,,,9237.88,6004.62,,,,,,,,,,,,,
GRAFT BNE SUB 5CC FOAM PK VERSATILE COMPR RESIST VITOSS 21022105] STRYKER ORTHOBIOLOGICS],SUP-2368195,CDM,C1713,HCPCS,0278,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
HC So RBC Serum Pretx ID Dilution,PX-3028697666,CDM,86976,CPT,0302,RC,,,,both,,,133.00,86.45,,,,,,,,,,,,,
PLATE BNE L135MM THK3.8MM 8 H BILAT S STL NAR DYN COMPR FOR,SUP-2185208,CDM,C1713,HCPCS,0278,RC,,,,both,,,227.65,147.97,,,,,,,,,,,,,
ANCHOR SUT HEALIX BRAID 6.5MM W/ ORTHOCORD,SUP-2249425,CDM,C1713,HCPCS,0278,RC,,,,both,,,262.50,170.62,,,,,,,,,,,,,
LEAD DEFIB OPTISURE L 52 CM DIA 8 FR POLYUR SIL ENDOCARD 2,SUP-2356417,CDM,C1895,HCPCS,0275,RC,,,,both,,,10676.00,6939.40,,,,,,,,,,,,,
LINER ACET CONSTRN E 36 MM PROV FRDM G7,SUP-2440187,CDM,C1776,CPT,0278,RC,,,,both,,,254.34,165.32,,,,,,,,,,,,,
BLADE SAW W15MM CUT EDGE THK0.51MM D30MM OSC CRESC TPS,SUP-2367309,CDM,2720000010,LOCAL,0272,RC,,,,both,,,405.06,263.29,,,,,,,,,,,,,
PIN DRVR L35IN BNE QUIK REL SMOOTH,SUP-2197199,CDM,C1713,HCPCS,0278,RC,,,,both,,,291.24,189.31,,,,,,,,,,,,,
NAIL IM L150MM DIA12MM UNIV ANK STR RG NONLOCKING CANN FOR,SUP-2136730,CDM,C1713,HCPCS,0278,RC,,,,both,,,4867.00,3163.55,,,,,,,,,,,,,
TREPHINE SURG OD9MM COR SL DISPOSABLE,SUP-2212798,CDM,C1713,HCPCS,0278,RC,,,,both,,,1563.72,1016.42,,,,,,,,,,,,,
SNARE VASC ENSNARE L 175 CM DIA2-4 MM CATH L 150 CM DIA 3.2,SUP-2302532,CDM,C1773,HCPCS,0272,RC,,,,both,,,1946.80,1265.42,,,,,,,,,,,,,
ABUTMENT SNAP COUPLING 8.5MM,SUP-2858177,CDM,L8690,HCPCS,0278,RC,,,,both,,,5003.31,3252.15,,,,,,,,,,,,,
GRAFT HUM TISS CHORION BASE THCK 8X4 CM AMNIO ACTISHIELD,SUP-2759476,CDM,C1762,CPT,0278,RC,,,,both,,,12023.06,7814.99,,,,,,,,,,,,,
IMPLANT NSL L 37 X W 19 X H 18 MM REG POLYETHYL SHELL W/ SM,SUP-2883631,CDM,C1889,HCPCS,0278,RC,,,,both,,,1715.95,1115.37,,,,,,,,,,,,,
DEVICE REVASCULARIZATION EMBOTRAP III L 196 MM STENT RETRV L,SUP-2716211,CDM,C1757,HCPCS,0272,RC,,,,both,,,21352.00,13878.80,,,,,,,,,,,,,
PLATE BONE FAN 35X1.5 MM POROUS POLYETHYLENE STERILE SYNPOR,SUP-2837801,CDM,C1713,HCPCS,0278,RC,,,,both,,,2325.48,1511.56,,,,,,,,,,,,,
PLATE BNE W175XL368MM THK52MM 20 H BILAT S STL BROAD LOK,SUP-2185321,CDM,C1713,HCPCS,0278,RC,,,,both,,,3479.40,2261.61,,,,,,,,,,,,,
SHEATH INTRO L 14 CM DIA14 FR GUIDEWIRE 0.038 IN PTFE X TW,SUP-2615904,CDM,C1894,HCPCS,0272,RC,,,,both,,,86.76,56.39,,,,,,,,,,,,,
PLATE BNE FIBULAR 2.7X79 MM RT LAT DSTL 3 HOLE STRL VALCP,SUP-2789386,CDM,C1713,HCPCS,0278,RC,,,,both,,,2694.12,1751.18,,,,,,,,,,,,,
CATHETER HD SET 15 FRX50 CM RETROGRADE HUB CANNON II +,SUP-2762986,CDM,C1750,HCPCS,0278,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
ULTRA HGH HP SYSLG HD XLPE LN,SUP-2212068,CDM,C1776,CPT,0278,RC,,,,both,,,15227.87,9898.12,,,,,,,,,,,,,
PIN FXTN L65MM D4MM CABLE L508MM HIP STNLSS STEEL CBLRDY,SUP-2491489,CDM,2720000010,LOCAL,0272,RC,,,,both,,,791.72,514.62,,,,,,,,,,,,,
LEVEL CMF PLATE MDFCE Y SHP WTAB 1.5 MM SCRW7 HOLE T0.4 MM,SUP-2707484,CDM,C1713,HCPCS,0278,RC,,,,both,,,800.70,520.45,,,,,,,,,,,,,
WASHER ORTH FIX OLECRANON NUT SPCR SZ 1.0MM,SUP-2106886,CDM,C1713,HCPCS,0278,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
ANCHOR SUTURE PIN 4 MM SUTURE SZ 2 FIBERLINK STRL DISP,SUP-2882172,CDM,C1713,HCPCS,0278,RC,,,,both,,,2684.70,1745.05,,,,,,,,,,,,,
PLATE BNE SEMI TBLR 55 MM 3 HOLE FOR LG FRAG SYS SS NS,SUP-2461521,CDM,C1713,HCPCS,0278,RC,,,,both,,,165.60,107.64,,,,,,,,,,,,,
SYSTEM DEL EUS 19 GA FLX ENDOSCP W/ BX NDL PRE LD NIT BEAC,SUP-2427166,CDM,C1713,HCPCS,0278,RC,,,,both,,,2056.70,1336.85,,,,,,,,,,,,,
BIT DRL L390MM DIA15MM PERC CANN FLX L QUIK CPL FOR RECON,SUP-2178901,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2438.12,1584.78,,,,,,,,,,,,,
BRENTUXIMAB VEDOTIN 50 MG IV SOLR,RX-110553,CDM,J9042,HCPCS,0636,RC,51144-0050-01,NDC,,both,1,UN,36506.40,23729.16,,,,,,,,,,,,,
STAPLE INT 12MMX10MMX10MM MS MEMOFIX,SUP-2244264,CDM,C1713,HCPCS,0278,RC,,,,both,,,3436.35,2233.63,,,,,,,,,,,,,
STEM FEM L152MM OD11MM FINN L8.5CM HIP SEGMENTED COMP,SUP-2406095,CDM,C1776,CPT,0278,RC,,,,both,,,12914.82,8394.63,,,,,,,,,,,,,
SCREW BONE LOCKING 3.5MM DIA 12MML,SUP-2588211,CDM,C1713,HCPCS,0278,RC,,,,both,,,331.21,215.29,,,,,,,,,,,,,
KIT PLT CONCENTRATOR DISP CAPTION,SUP-2344073,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1745.84,1134.80,,,,,,,,,,,,,
ZIPRASIDONE HCL 80 MG PO CAPS,RX-29781,CDM,6370000000,HCPCS,0637,RC,68084-0106-09,NDC,,both,1,UN,12.50,8.12,,,,,,,,,,,,,
PLATE BNE W8XL160MM THK3.3MM 20 H NONSTERILE BILAT PELV S,SUP-2186247,CDM,C1713,HCPCS,0278,RC,,,,both,,,2659.27,1728.53,,,,,,,,,,,,,
IMPLANT BIO TISS W2XL9CM BOV PERICARD BIOCOMPATIBLE STR,SUP-2264298,CDM,C1781,HCPCS,0278,RC,,,,both,,,1221.46,793.95,,,,,,,,,,,,,
BUTTON FIX UHMWPE ATTCH SYS FOR ACL RECON TIGHTROPE,SUP-2121399,CDM,C1713,HCPCS,0278,RC,,,,both,,,577.76,375.54,,,,,,,,,,,,,
PLATE BONE L174MM 13 H RT MEDL DSTL HUM LCK FOR 2.7/3.5MM,SUP-2348600,CDM,C1713,HCPCS,0278,RC,,,,both,,,13340.60,8671.39,,,,,,,,,,,,,
CAGE SPNL 4 DEG 18X40 MM 16 MM UPPER ENDPLATE FOOTPRINT TI,SUP-2422376,CDM,C1889,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
PLATE BONE L192MM 11 H S STL T SHP BTTRS LO PROF RIG,SUP-2185761,CDM,C1713,HCPCS,0278,RC,,,,both,,,2019.27,1312.53,,,,,,,,,,,,,
Z DUP USE 2111353 LENS INTOCU +27.0 DIOPT L13MM DIA6MM 0DEG HAPTIC ANG A,SUP-2111354,CDM,V2632,HCPCS,0276,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
PLATE BONE LOK HLX15 TIMAX CNTRD ANTMCL ALPS NON ST LEFT MED,SUP-2588760,CDM,C1713,HCPCS,0278,RC,,,,both,,,4030.28,2619.68,,,,,,,,,,,,,
HC ED Clsd Tx IP Disloc WO Anesth,PX-4502677000,CDM,26770,CPT,0450,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
PLATE BONE 1.5MM BAR 16MM UNIV 2 H W/ TAB DOG NEURO III,SUP-2363623,CDM,C1713,HCPCS,0278,RC,,,,both,,,478.44,310.99,,,,,,,,,,,,,
SUTURE DURASTAT DURAL REPAIR,SUP-2601077,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2794.60,1816.49,,,,,,,,,,,,,
SCREW BNE 3 HD W/ DEPTH G SCRDRIVER COUNTSINK INSTR HNDL,SUP-2175122,CDM,C1713,HCPCS,0278,RC,,,,both,,,2811.87,1827.72,,,,,,,,,,,,,
CATHETER OCCL BAL URIN TRACT 26 FRX100 CM,SUP-2141680,CDM,C2628,HCPCS,0272,RC,,,,both,,,433.10,281.51,,,,,,,,,,,,,
ANCHOR SUTURE WITH THREE NO 2 HI FI SUTURES 5.0MM O.D.X18.0M,SUP-2824352,CDM,C1713,HCPCS,0278,RC,,,,both,,,1232.14,800.89,,,,,,,,,,,,,
BIT DRL L180MM DIA4.2MM FOR TIB FEM AND PROX FEM NAILING,SUP-2152589,CDM,2720000010,LOCAL,0272,RC,,,,both,,,354.19,230.22,,,,,,,,,,,,,
LEVEL CMF ST PLATE ORTHG TLTS BSSO STR 4 MM BRG 20 25 MM S,SUP-2682287,CDM,C1713,HCPCS,0278,RC,,,,both,,,1093.22,710.59,,,,,,,,,,,,,
SCREW SPNL L13MM DIA4.5MM CANC ANTR CERV TI SELF DRL VAR ANG,SUP-2254607,CDM,C1713,HCPCS,0278,RC,,,,both,,,835.24,542.91,,,,,,,,,,,,,
SPACER EXT FIX 80 MM RNG SALVATION,SUP-2463567,CDM,2720000010,LOCAL,0272,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
SHELL ACET MOLD PRE TIB HIP,SUP-2388179,CDM,L2340,LOCAL,0272,RC,,,,both,,,1420.22,923.14,,,,,,,,,,,,,
GRAFT VASC HEMGRD L 50 CM DIA20 X 11 MM THK 0.49 MM,SUP-2669753,CDM,C1768,CPT,0278,RC,,,,both,,,2567.70,1669.00,,,,,,,,,,,,,
CAGE SPNL H24-40MM OD16MM 6DEG SM TI ANT THORLUM INTBDY FUS,SUP-2390798,CDM,C1889,HCPCS,0278,RC,,,,both,,,28194.06,18326.14,,,,,,,,,,,,,
KIT SURG PROC UPSYLON Y SHP MESH FLAT SUT SURF MULT DIR,SUP-2140347,CDM,C1781,HCPCS,0278,RC,,,,both,,,5402.94,3511.91,,,,,,,,,,,,,
ACETAMINOPHEN 650 MG RE SUPP,RX-105,CDM,6370000000,HCPCS,0637,RC,45802-0730-30,NDC,,both,1,UN,3.10,2.01,,,,,,,,,,,,,
BRACE SHLDR L FA L15 16IN UNIV AIRMESH BRTH SLNG 15DEG ABD,SUP-2150869,CDM,L3650,HCPCS,0274,RC,,,,both,,,171.16,111.25,,,,,,,,,,,,,
PLATE BNE THK0.6MM BAR L8MM 100DEG 5 H R,SUP-2366300,CDM,C1713,HCPCS,0278,RC,,,,both,,,607.37,394.79,,,,,,,,,,,,,
COMPONENT FEM INTERCALARY 55 MM KNEE SEG LPS,SUP-2452897,CDM,C1776,CPT,0278,RC,,,,both,,,3526.22,2292.04,,,,,,,,,,,,,
HC Fluoro for Central Line Place,PX-3207700100,CDM,77001,CPT,0320,RC,,,,both,,,1072.00,696.80,,,,,,,,,,,,,
GUIDEWIRE VASC REGALIA XS 1.0 L 300 CM DIA 0.014 IN,SUP-2123851,CDM,C1769,HCPCS,0272,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
ENDCAP ORTH L15MM DIA3.5MM ST HUM TI NAIL EXTN HEX RECESS,SUP-2192535,CDM,C1713,HCPCS,0278,RC,,,,both,,,949.88,617.42,,,,,,,,,,,,,
KNEE IMMOB 20 IN SM,SUP-2195246,CDM,L1830,CPT,0274,RC,,,,both,,,36.71,23.86,,,,,,,,,,,,,
PLATE BONE L90MM THK3.5-4.5MM 4 H NONSTERILE LT MEDL TI DSTL,SUP-2190913,CDM,C1713,HCPCS,0278,RC,,,,both,,,4160.53,2704.34,,,,,,,,,,,,,
PLATE BNE L109MM 3 H R PROX PERIARTC HUM S STL LOK COMPR,SUP-2184285,CDM,C1713,HCPCS,0278,RC,,,,both,,,4734.43,3077.38,,,,,,,,,,,,,
HC Bx Breast 1st Lesion Strtctc,PX-3611908100,CDM,19081,CPT,0361,RC,,,,outpatient,,,6190.00,4023.50,,,,,,,,,,,,,
KIT LD DEL ACCSRY IS1 CTRL HEMOSTAS VLV INTRO TORQUE,SUP-2148849,CDM,C1894,HCPCS,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
COMPONENT GLEN FIX DIA48X44MM OFFSET OVOID POST HUM ARTC,SUP-2123577,CDM,C1776,CPT,0278,RC,,,,both,,,20008.08,13005.25,,,,,,,,,,,,,
STENT PERIPH SUPERA L 120 MM DIA 5.5 MM SHFT L 120 CM SHTH 6,SUP-2106236,CDM,C1876,HCPCS,0278,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
PLATE BNE MESHED 82X82X0.3 MM SM GRID PDLLA STRL RESORB X,SUP-2463856,CDM,C1713,HCPCS,0278,RC,,,,both,,,7554.53,4910.44,,,,,,,,,,,,,
COMPONENT FEM KNEE YOKE REINF ORTH SALV SYS,SUP-2405843,CDM,C1776,CPT,0278,RC,,,,both,,,3640.83,2366.54,,,,,,,,,,,,,
HC CT L-Spine W/O Contrast,PX-3527213100,CDM,72131,CPT,0352,RC,,,,both,,,1973.00,1282.45,,,,,,,,,,,,,
DOXORUBICIN HCL 2 MG/ML IV SOLN,RX-2616,CDM,J9000,HCPCS,0636,RC,63323-0883-30,NDC,,both,25,ML,96.00,62.40,,,,,,,,,,,,,
BIT DRL 4.4 MM TIB STRL DISP,SUP-2606667,CDM,2720000010,LOCAL,0272,RC,,,,both,,,582.03,378.32,,,,,,,,,,,,,
SPACER KNEE 3-10 12 MM DSTL SYS REV GUIDE ATTUNE,SUP-2454500,CDM,C1776,CPT,0278,RC,,,,both,,,1717.58,1116.43,,,,,,,,,,,,,
EXTENSION STEM L60MM DST FEM MOD PC GMRS,SUP-2376558,CDM,C1776,CPT,0278,RC,,,,both,,,7254.34,4715.32,,,,,,,,,,,,,
STAPE CLSSC PRO 4X1X4 TIT,SUP-2650123,CDM,L8613,CPT,0278,RC,,,,both,,,629.00,408.85,,,,,,,,,,,,,
PARTICLE EMB DIA 500-710 UM 1 CC PVA FOAM NONRADIOACTIVE FOR,SUP-2168482,CDM,C1889,HCPCS,0278,RC,,,,both,,,244.92,159.20,,,,,,,,,,,,,
HC NM Renal W/Vascular Flow,PX-3417870100,CDM,78701,CPT,0341,RC,,,,both,,,2410.00,1566.50,,,,,,,,,,,,,
ALLOGRAFT BNE WDG 5 DEG 60X25X8 MM PRO OSTEON 500R,SUP-2684331,CDM,C1713,HCPCS,0278,RC,,,,both,,,2647.02,1720.56,,,,,,,,,,,,,
SHEATH INTRO J TIP 035 IN 45 DEG 63 CM 180 CM D0 VERSACROSS,SUP-2641950,CDM,C1893,HCPCS,0272,RC,,,,both,,,3042.66,1977.73,,,,,,,,,,,,,
SHEATH DIL SM L23CM OD0.215IN ID0.168IN PEBAX TEF ROBUST,SUP-2353115,CDM,C1893,HCPCS,0272,RC,,,,both,,,769.30,500.04,,,,,,,,,,,,,
SCREW BNE L12MM DIA2MM CORT CRANIOMAXILLOFACIAL S STL SELF 4/EA,SUP-2366114,CDM,C1713,HCPCS,0278,RC,,,,both,,,392.81,255.33,,,,,,,,,,,,,
STEM HUM L194MM OD10MM UNIV CO CHROM SHLDR REV CEM PRESSFIT,SUP-2402741,CDM,C1776,CPT,0278,RC,,,,both,,,16045.40,10429.51,,,,,,,,,,,,,
PIN FIX L35IN DIA1 8IN S STL HDLSS SQ END,SUP-2150348,CDM,C1713,HCPCS,0278,RC,,,,both,,,186.74,121.38,,,,,,,,,,,,,
SCREW BNE 7 X 20 MM BIOSURE REGENESORB,SUP-2341912,CDM,C1713,HCPCS,0278,RC,,,,both,,,1156.59,751.78,,,,,,,,,,,,,
SHEATH INTRO FLX ANSEL L 45 CM OD 4 FR GUIDEWIRE 0.018/0.035,SUP-2170582,CDM,C1894,HCPCS,0272,RC,,,,both,,,147.01,95.56,,,,,,,,,,,,,
SCREW PEDCL SPNL POST THORACO LUM 5.5MM DIA SAG ADJUSTING W/,SUP-2291260,CDM,C1713,HCPCS,0278,RC,,,,both,,,1984.48,1289.91,,,,,,,,,,,,,
STEM FEM 12/14 TAPR STD NEUT MOD NK CO CHROM,SUP-2345381,CDM,C1776,CPT,0278,RC,,,,both,,,5306.60,3449.29,,,,,,,,,,,,,
GRAFT BNE L40MM OD24MM CORT FRZ DRY PIN IMPL ALLOFIX,SUP-2307227,CDM,C1713,HCPCS,0278,RC,,,,both,,,805.63,523.66,,,,,,,,,,,,,
TRAY CATH MIDLN PROVENA PLU 4FR 20CM 2 LUMAN RVS S4254108BP,SUP-2632866,CDM,C1751,HCPCS,0278,RC,,,,both,,,609.38,396.10,,,,,,,,,,,,,
GUIDE WIRE 32MM X 38,SUP-2724396,CDM,C1769,HCPCS,0272,RC,,,,both,,,257.48,167.36,,,,,,,,,,,,,
BASKET STONE RETRV 3FR L120MM POLYIMIDE PTFE NIT 4 WIR 0,SUP-2138885,CDM,2720000010,LOCAL,0272,RC,,,,both,,,607.02,394.56,,,,,,,,,,,,,
PACLITAXEL PROTEIN-BOUND PART 100 MG IV SUSR,RX-40475,CDM,J9264,HCPCS,0636,RC,68817-0134-50,NDC,,both,1,UN,4550.60,2957.89,,,,,,,,,,,,,
IMPLANT OSS L4.5MM PIST DIA0.5MM STAP PLAT S STL RBBN LOOP,SUP-2313662,CDM,L8613,CPT,0278,RC,,,,both,,,473.86,308.01,,,,,,,,,,,,,
COMPONENT TOE 15MM 2.5X3.5MM OFFSET ARTC DF,SUP-2123614,CDM,C1776,CPT,0278,RC,,,,both,,,7222.00,4694.30,,,,,,,,,,,,,
SPLINT WRIST EXTRA SMALL 8 IN THUMB LEFT,SUP-2428142,CDM,L3908,HCPCS,0272,RC,,,,both,,,96.30,62.59,,,,,,,,,,,,,
GRAFT SKIN AUTOGRFT EPICEL,SUP-2227096,CDM,2780000010,LOCAL,0278,RC,,,,both,,,5495.00,3571.75,,,,,,,,,,,,,
LEVEL NEURO ST MESH STNDRD ULTRNE NEURO SCRW83 X 47 MM T035,SUP-2676760,CDM,C1713,HCPCS,0278,RC,,,,both,,,3368.81,2189.73,,,,,,,,,,,,,
TROCAR CANN FOR SINOSCOPY FEN BEAK LEN OF THE CANN 8.5CM O.D,SUP-2261352,CDM,2720000010,LOCAL,0272,RC,,,,both,,,586.49,381.22,,,,,,,,,,,,,
DEFIBRILLATOR IMPL VIVA QUAD S W 51 X H 74 MM D 13 MM,SUP-2282408,CDM,C1882,HCPCS,0275,RC,,,,both,,,54200.26,35230.17,,,,,,,,,,,,,
BONE MARROW ASPIRATION KIT CLOSED 8 GA CPRP ACD-A STRL LTX,SUP-2859799,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3475.98,2259.39,,,,,,,,,,,,,
LINER ACET 36X62 MM HIP CERM BIOLOX FORTE R3,SUP-2434793,CDM,C1776,CPT,0278,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
DEVICE FIX TI ANK SYNDEMOSIS ZIPLOOP TECHNOLOGY ZIPTIGHT,SUP-2137180,CDM,C1713,HCPCS,0278,RC,,,,both,,,2215.58,1440.13,,,,,,,,,,,,,
STENT COR 18MM 3MM DEL SYS 143CM 0.014IN CO CHROM,SUP-2104412,CDM,C1874,HCPCS,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
CAGE SPNL MESH 15X12X12 MM 6 LOBE,SUP-2602071,CDM,C1889,HCPCS,0278,RC,,,,both,,,7953.62,5169.85,,,,,,,,,,,,,
HEAD FEM COMP ACET RESURF CO CHROM 50MM CONSERVE +,SUP-2397309,CDM,C1776,CPT,0278,RC,,,,both,,,12143.95,7893.57,,,,,,,,,,,,,
KIT IR PWR INJ PICC SGL LUMN PASV VLV W/ 145CM WIRE 5 FRX7,SUP-2117125,CDM,C1751,HCPCS,0278,RC,,,,both,,,339.12,220.43,,,,,,,,,,,,,
KIT BNE GRFT M RHBMP-2 4.2MG INJ 5ML CONTAIN NDL 20GA,SUP-2287849,CDM,C1713,HCPCS,0278,RC,,,,both,,,16642.00,10817.30,,,,,,,,,,,,,
PLATE BNE CNDYL 1.5X37 MM LT 7 HOLE,SUP-2861497,CDM,C1713,HCPCS,0278,RC,,,,both,,,950.85,618.05,,,,,,,,,,,,,
DEFIBRILLATOR IMPL VENTAK PRIZM DR HE DEL ENERGY 41 J TI 2,SUP-2139662,CDM,C1721,HCPCS,0275,RC,,,,both,,,77244.00,50208.60,,,,,,,,,,,,,
ANCHOR SUT 27MM MAINSTAY ZIP,SUP-2362541,CDM,C1713,HCPCS,0278,RC,,,,both,,,107.83,70.09,,,,,,,,,,,,,
MESH SURG CONTOURED LG 0.3 MM ORBIT FLR SPEC BOWLES TI,SUP-2485125,CDM,C1713,HCPCS,0278,RC,,,,both,,,1372.49,892.12,,,,,,,,,,,,,
DEVICE GRFT DEL BIOLOGICS,SUP-2861976,CDM,2720000010,LOCAL,0272,RC,,,,both,,,543.35,353.18,,,,,,,,,,,,,
SHELL ACET A SER,SUP-2221813,CDM,C1776,CPT,0278,RC,,,,both,,,12.56,8.16,,,,,,,,,,,,,
SCREW BNE L36MM DIA35MM LAG CROSSCHECK ORTHOLOC 3DI,SUP-2398216,CDM,C1713,HCPCS,0278,RC,,,,both,,,854.08,555.15,,,,,,,,,,,,,
BLADE SURG OSCILLATING 15 DEG 4 MMX37 CM TRICUT DISP,SUP-2691284,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1816.18,1180.52,,,,,,,,,,,,,
IMMUNE GLOBULIN (HUMAN) 10 G IV SOLR,RX-10258,CDM,J1566,HCPCS,0636,RC,00944-2658-04,NDC,,both,1,UN,6714.80,4364.62,,,,,,,,,,,,,
GRAFT HUM TISS W2XL4CM THK1.5MM REGEN TISS MTRX HI SUT,SUP-2399109,CDM,Q4107,HCPCS,0636,RC,,,,both,,,6531.20,4245.28,,,,,,,,,,,,,
AUGMENT TIB SZ 6 THK10MM STD UNIV TRABECULAR MTL CEM REV,SUP-2200164,CDM,C1776,CPT,0278,RC,,,,both,,,9294.40,6041.36,,,,,,,,,,,,,
NEEDLE BX 19GA 155MM UTW TIP TRACKED,SUP-2392617,CDM,C1713,HCPCS,0278,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
FORCEPS 25+ SHARKSKIN ILM,SUP-2431808,CDM,2720000010,LOCAL,0272,RC,,,,both,,,682.89,443.88,,,,,,,,,,,,,
KIT PRB 17GA L150MM ACT TIP 4MM COOLED RF COOLIEF,SUP-2236750,CDM,C1894,HCPCS,0272,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
CATHETERIZATION KIT 26.75 IN 4 FRX30 CM BLU FLEXTIP,SUP-2120590,CDM,C1751,HCPCS,0278,RC,,,,both,,,95.46,62.05,,,,,,,,,,,,,
SCREW BNE L55MM DIA6.5MM HD DIA8MM CANC S STL FULL THRD L,SUP-2184641,CDM,C1713,HCPCS,0278,RC,,,,both,,,105.10,68.31,,,,,,,,,,,,,
CATHETER PERITONEAL MED PRESSURE GRAD SLT VLV PUDENZ,SUP-2852592,CDM,C1729,HCPCS,0272,RC,,,,both,,,650.55,422.86,,,,,,,,,,,,,
GUIDEWIRE VASC CHIKAI L 200 CM 0.014IN L 5CM STR DURABLE TIP,SUP-2123855,CDM,C1769,HCPCS,0272,RC,,,,both,,,1723.86,1120.51,,,,,,,,,,,,,
BLADE LARYN L27CM DIA4MM 360DEG ROT ANG TIP DBL CVD LO PROF,SUP-2277874,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1838.78,1195.21,,,,,,,,,,,,,
OSTEOTOME SMITH PETERSON CRV 6MM 21CM,SUP-2161288,CDM,C1713,HCPCS,0278,RC,,,,both,,,298.43,193.98,,,,,,,,,,,,,
STENT PANCREAS 7FR L12CM PLAS STR LD BARB TRAILING RADPQ,SUP-2149510,CDM,C2617,HCPCS,0278,RC,,,,both,,,279.99,181.99,,,,,,,,,,,,,
HC So Hep B Core Ab - Ref,PX-3028670468,CDM,86704,CPT,0302,RC,,,,both,,,21.00,13.65,,,,,,,,,,,,,
PUMP PAIN 400X10ML/HR ON Q C BLOC,SUP-2236808,CDM,C9804,HCPCS,0272,RC,,,,both,,,616.88,400.97,,,,,,,,,,,,,
IBUPROFEN 800 MG PO TABS,RX-3845,CDM,6370000000,HCPCS,0637,RC,00904-5855-61,NDC,,both,1,UN,0.70,0.45,,,,,,,,,,,,,
PROBE LASER PRECIS 20 GA FIBER HND PC STR PLAS EYELITE,SUP-2109738,CDM,C1713,HCPCS,0278,RC,,,,both,,,2509.49,1631.17,,,,,,,,,,,,,
BUR SURG SHANNON STYL 3 MM BNE NS,SUP-2751459,CDM,2720000010,LOCAL,0272,RC,,,,both,,,370.52,240.84,,,,,,,,,,,,,
ALLOGRAFT BNE SPACER 15 DEG 38X25X12 MM ALIF NS TRIAD DISP,SUP-2716880,CDM,C1889,HCPCS,0278,RC,,,,both,,,10362.00,6735.30,,,,,,,,,,,,,
STEM RADIAL LG 6.5 ULN WRST MOD COCR 1ST CHOICE,SUP-2852822,CDM,C1776,CPT,0278,RC,,,,both,,,15205.23,9883.40,,,,,,,,,,,,,
PLATE BNE L116MM 6 H BILAT S STL T NONCOMPRESSION LO PROF,SUP-2185755,CDM,C1713,HCPCS,0278,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
PLATE BNE ADV 7 MM LT CRANIOMAXILLOFACIAL LEFORT I,SUP-2883263,CDM,C1713,HCPCS,0278,RC,,,,both,,,1912.35,1243.03,,,,,,,,,,,,,
PLATE BNE L194MM 8 H L DST HUM EXTRA ARTC TI LOK COMPR LO,SUP-2180808,CDM,C1713,HCPCS,0278,RC,,,,both,,,4749.22,3086.99,,,,,,,,,,,,,
SET INT FIX BURR H PLATE DIA18.5 MM SCREW DIA1.5 MM 15-7382-12,SUP-2936402,CDM,C1713,HCPCS,0278,RC,,,,both,,,27588.04,17932.23,,,,,,,,,,,,,
COMPONENT TIB CR ALL POLY 13MM SZ 1,SUP-2222625,CDM,C1776,CPT,0278,RC,,,,both,,,4521.60,2939.04,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED UPCHARGE STRYKERHIPUP] STRYKER CORP],SUP-2365978,CDM,C1776,CPT,0278,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
RING EXT FIX DIA105 MM 2/3 RED NS DISP SMRT TSF,SUP-2933118,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4587.60,2981.94,,,,,,,,,,,,,
CATHETER 7 INDIGO 130CM XTORQ + LIGHTNING ASPIRATION TUBING,SUP-2655648,CDM,C1757,HCPCS,0272,RC,,,,both,,,17238.60,11205.09,,,,,,,,,,,,,
SYSTEM NEUROSTIMULATOR TRL NRV MULTIPROGRAM,SUP-2356139,CDM,C1713,HCPCS,0278,RC,,,,both,,,4380.30,2847.19,,,,,,,,,,,,,
SYSTEM IMPL INCL 2 4.75MM BIOCOMPOSITE SWIVELOCK C ANCHR,SUP-2121717,CDM,C1713,HCPCS,0278,RC,,,,both,,,5463.60,3551.34,,,,,,,,,,,,,
PLATE BNE STR 1.5X28X0.8 MM MIDFACE 6 HOLE W/ TAB TI STRL,SUP-2483854,CDM,C1713,HCPCS,0278,RC,,,,both,,,546.36,355.13,,,,,,,,,,,,,
SCREW BNE L11MM OD2.0MM CRANIO MAXILLOFACIAL TI ALLY MINI,SUP-2262638,CDM,C1713,HCPCS,0278,RC,,,,both,,,106.54,69.25,,,,,,,,,,,,,
BRACE KNEE BLEDSOE BRAC II,SUP-2341214,CDM,L1810,HCPCS,0274,RC,,,,both,,,364.24,236.76,,,,,,,,,,,,,
SYSTEM WND DRAINAGE FOR CLOSED INCISION,SUP-2354966,CDM,C1713,HCPCS,0278,RC,,,,both,,,1416.14,920.49,,,,,,,,,,,,,
HC So Myoglobin,PX-3018387466,CDM,83874,CPT,0301,RC,,,,inpatient,,,320.00,208.00,,,,,,,,,,,,,
HC Pet/CT Whole Body,PX-4047881600,CDM,78816,CPT,0404,RC,,,,outpatient,,,6386.00,4150.90,,,,,,,,,,,,,
CANNULA IRRIGATION STROBEL 5 MMX14.5 CM LAT OUTFLO,SUP-2767090,CDM,2720000010,LOCAL,0272,RC,,,,both,,,452.00,293.80,,,,,,,,,,,,,
PLATE BNE L39MM THK1.2MM 0DEG 6 H BILAT S STL STR RIG LIMIT,SUP-2186169,CDM,C1713,HCPCS,0278,RC,,,,both,,,1132.19,735.92,,,,,,,,,,,,,
"HC New Pt, Outpt Visit Level 3",PX-7619920300,CDM,99203,CPT,0761,RC,,,,outpatient,,,321.00,208.65,,,,,,,,,,,,,
BLADE SHV L11CM DIA29MM SNUS 360DEG ROT STR SHFT TRICUT,SUP-2277856,CDM,2720000010,LOCAL,0272,RC,,,,both,,,778.72,506.17,,,,,,,,,,,,,
HEAD RADIAL 3 FLEXSPAN,SUP-2538174,CDM,C1776,CPT,0278,RC,,,,both,,,10387.12,6751.63,,,,,,,,,,,,,
CATHETER ANGIO VEIN SEL 0.046 IN 5 FRX75 CM SIDE PRT IMPRESS,SUP-2798677,CDM,C1887,HCPCS,0272,RC,,,,both,,,296.73,192.87,,,,,,,,,,,,,
LENS INTOCU +14.0 DIOPT L13.5MM DIA6MM AC D5.2MM 5DEG UV,SUP-2247675,CDM,V2632,HCPCS,0276,RC,,,,both,,,383.08,249.00,,,,,,,,,,,,,
NAIL IM L350MM DIA10.5MM UNIV TIB TI ALLOY CANN LCK,SUP-2412957,CDM,C1713,HCPCS,0278,RC,,,,both,,,5598.62,3639.10,,,,,,,,,,,,,
STENT BILI SENTINOL L 79 MM DIA 6 MM CATH L 135 CM SHTH 6 FR,SUP-2140678,CDM,C1876,HCPCS,0278,RC,,,,both,,,2276.50,1479.72,,,,,,,,,,,,,
GRAFT HUM TISS L 2-2.4 X W 0.7-0.9 CM THK 1.8-2.2 MM 2XS,SUP-2895200,CDM,C1762,CPT,0278,RC,,,,both,,,1187.49,771.87,,,,,,,,,,,,,
SCREW BONE CANN HDLSS 4MMX48MM EXTREMIX,SUP-2319487,CDM,C1713,HCPCS,0278,RC,,,,both,,,1114.70,724.55,,,,,,,,,,,,,
STAPLER INT L30MM DIA3.5MM BLU ROTIC USE W/ TI STPL DISP,SUP-2283030,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2013.12,1308.53,,,,,,,,,,,,,
HC CT Orbit/Ear/Fossa W/O Contrast,PX-3517048000,CDM,70480,CPT,0351,RC,,,,both,,,1973.00,1282.45,,,,,,,,,,,,,
SILVERSTEIN TOTAL SHAFT WFOOTPLATE TACK,SUP-2680306,CDM,L8613,CPT,0278,RC,,,,both,,,876.06,569.44,,,,,,,,,,,,,
HALF PIN EXTRNL FXTN 3MM DIA SHRT 100MML STNLSS STEEL 15MML,SUP-2721920,CDM,2720000010,LOCAL,0272,RC,,,,both,,,403.65,262.37,,,,,,,,,,,,,
SCREW BNE L 70 MM DIA 7.3 MM THRD L 20 MM TI CANN NS,SUP-2912941,CDM,C1713,HCPCS,0278,RC,,,,both,,,1369.04,889.88,,,,,,,,,,,,,
INSERT TIB ONLAY KNEE 30550130S] MAKO],SUP-2265749,CDM,C1776,CPT,0278,RC,,,,both,,,1515.74,985.23,,,,,,,,,,,,,
WASHER SUTURE 2 TITANIUM CURVED NEEDLE FIBERWIRE,SUP-2765948,CDM,2720000010,LOCAL,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
DEFIBRILLATOR IMPL LUMOS DR-T TI EPOXY RESIN SIL 2 CHMBR DF1,SUP-2138085,CDM,C1721,HCPCS,0275,RC,,,,both,,,57590.74,37433.98,,,,,,,,,,,,,
VALVE AORT CARP EDW PERIMT DIA25 MM BOV PERICARD COCR,SUP-2214056,CDM,C1889,HCPCS,0278,RC,,,,both,,,17584.00,11429.60,,,,,,,,,,,,,
PLATE BNE 100DEG 2X3 H R CRANIOMAXILLOFACIAL G TI L SHP,SUP-2191156,CDM,C1713,HCPCS,0278,RC,,,,both,,,1090.21,708.64,,,,,,,,,,,,,
NAIL INTRMDLLRY L180MM D13MM 130DG LNG HIP TIMAX CNNLTD LOK,SUP-2460190,CDM,C1776,CPT,0278,RC,,,,both,,,4939.22,3210.49,,,,,,,,,,,,,
HEAD FEM SZ -6MM CO CHROM SLD MOD M2A 38,SUP-2404335,CDM,C1776,CPT,0278,RC,,,,both,,,4108.53,2670.54,,,,,,,,,,,,,
SYSTEM DISTR UPPER MDFD WSLDR ATTCH FRGD EXTRNL DISTR RED,SUP-2669815,CDM,C1713,HCPCS,0278,RC,,,,both,,,6837.38,4444.30,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED FEM TIB CEM SURF TIV PROLONG,SUP-2212333,CDM,C1776,CPT,0278,RC,,,,both,,,11070.23,7195.65,,,,,,,,,,,,,
DRILL TWST L 1.9 IN DIA 0.8 MM STP 6 MM CHK NS DISP,SUP-2883250,CDM,2720000010,LOCAL,0272,RC,,,,both,,,377.90,245.63,,,,,,,,,,,,,
STABILIZER TISS BEAT HRT OCTPS NUVO,SUP-2284350,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5338.00,3469.70,,,,,,,,,,,,,
SCREW BNE CORTICAL 2X8 MM 4 MM ST TI NS,SUP-2460180,CDM,C1713,HCPCS,0278,RC,,,,both,,,208.81,135.73,,,,,,,,,,,,,
PLATE BNE L69MM 1 H NONSTERILE POST MED PROX TIB S STL LOK,SUP-2177790,CDM,C1713,HCPCS,0278,RC,,,,both,,,3041.34,1976.87,,,,,,,,,,,,,
BIT DRL CANN 4.5X100 MM QC,SUP-2392914,CDM,2720000010,LOCAL,0272,RC,,,,both,,,816.40,530.66,,,,,,,,,,,,,
BOLT FIX L150MM DIA6.5MM NONSTERILE MIDFOOT FUS S STL,SUP-2184105,CDM,C1713,HCPCS,0278,RC,,,,both,,,1521.42,988.92,,,,,,,,,,,,,
MODULE EMG W/ NVM5 HARN 2 NEEDLE/NEUROVISION 2 SLD GEL,SUP-2311747,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2778.90,1806.28,,,,,,,,,,,,,
BAND ARM AD UNIV GEL ELAS STRP BILAT,SUP-2324557,CDM,L3702,HCPCS,0272,RC,,,,both,,,48.17,31.31,,,,,,,,,,,,,
BLADE RETRACTOR BALFOUR 2.5 IN ABD FEN LAT 1 PR FOR 50-4503,SUP-2477142,CDM,2720000010,LOCAL,0272,RC,,,,both,,,331.14,215.24,,,,,,,,,,,,,
HC NM Hepatobiliary Imaging WO Pharm,PX-3417822600,CDM,78226,CPT,0341,RC,,,,both,,,3442.00,2237.30,,,,,,,,,,,,,
ROD DISTR 120MML CRBN WGRVE FRGD EXTRNL DISTR RED III,SUP-2669817,CDM,C1713,HCPCS,0278,RC,,,,both,,,1391.77,904.65,,,,,,,,,,,,,
BUR SURG DIA 4 MM DIAMOND COARSE 2 RNG STRL DISP ELAN 4,SUP-2929478,CDM,2720000010,LOCAL,0272,RC,,,,both,,,398.31,258.90,,,,,,,,,,,,,
PLATE BNE SQ MIC 1X0.6 MM CRANIOMAXILLOFACIAL 3X2 LADDER,SUP-2462804,CDM,C1713,HCPCS,0278,RC,,,,both,,,749.89,487.43,,,,,,,,,,,,,
IMPLANT TOE L2.75MM 10DEG PIP JT TI SPRAYED PEEK CANN,SUP-2321072,CDM,C1776,CPT,0278,RC,,,,both,,,4165.21,2707.39,,,,,,,,,,,,,
BARIUM SULFATE PO CAPS,RX-21381,CDM,2500000003,HCPCS,0250,RC,10858-0081-07,NDC,,both,1,UN,55.00,35.75,,,,,,,,,,,,,
BLADE RTRCTR SM 24MMW X 130MML TTNM SPNL TTHX3 THIN LIGHT BL,SUP-2703607,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1018.02,661.71,,,,,,,,,,,,,
ALLOGRAFT DISC DBM AND CORT CANC BONE CHIP FRZN OPTEFORM 8CC,SUP-2223555,CDM,C1762,CPT,0278,RC,,,,both,,,4239.00,2755.35,,,,,,,,,,,,,
PROSTHESIS VOICE 17FR L4MM PROVOX VEGA,SUP-2124378,CDM,L8509,HCPCS,0272,RC,,,,both,,,835.24,542.91,,,,,,,,,,,,,
STENT NEURO ENTRP 2 L 39 MM 4 FR MICROCATHETER .021 IN RECON,SUP-2518822,CDM,C1874,HCPCS,0278,RC,,,,both,,,28918.83,18797.24,,,,,,,,,,,,,
PLATE BONE MESHED 99X66 MM LEFT PREFORMED TEMPORAL TITANIUM,SUP-2837717,CDM,C1713,HCPCS,0278,RC,,,,both,,,10751.99,6988.79,,,,,,,,,,,,,
ALLOGRAFT BNE RNG 20 CM FD TISS FEM,SUP-2165580,CDM,C1889,HCPCS,0278,RC,,,,both,,,1978.20,1285.83,,,,,,,,,,,,,
PLATE L FUSION VA LCP 2.4/2.7MM STD LT TI STRL,SUP-2546993,CDM,C1713,HCPCS,0278,RC,,,,both,,,3516.61,2285.80,,,,,,,,,,,,,
STAPLE 6MM STEPOFF MEMOSTEP,SUP-2696120,CDM,C1776,CPT,0278,RC,,,,both,,,5327.95,3463.17,,,,,,,,,,,,,
RING EXT FIX HALF 200 MM CIR SIDEKCK,SUP-2458427,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1673.62,1087.85,,,,,,,,,,,,,
GUIDEWIRE UROLOGY STR 0.035 INX150 CM STANDARD-BODY BIWIRE,SUP-2836010,CDM,C1769,HCPCS,0272,RC,,,,both,,,153.95,100.07,,,,,,,,,,,,,
CLOBETASOL PROPIONATE 0.05 % EX CREA,RX-9630,CDM,6370000000,HCPCS,0637,RC,00168-0163-15,NDC,,both,15,GR,72.70,47.25,,,,,,,,,,,,,
HC Allergen Spec Ige Crude Allergen Extract Each,PX-3058600300,CDM,86003,CPT,0305,RC,,,,both,,,44.00,28.60,,,,,,,,,,,,,
CATHETER INFUSION L 40 CM DIA 5 FR SEG L 7 CM GUIDEWIRE,SUP-2168146,CDM,C1751,HCPCS,0278,RC,,,,both,,,277.54,180.40,,,,,,,,,,,,,
HEAD HUM ANAT 1.5 MM 37X13.5 MM SHLDR LOW OFFSET COCR,SUP-2715707,CDM,C1776,CPT,0278,RC,,,,both,,,9928.68,6453.64,,,,,,,,,,,,,
TAP SURG DIA45MM THOR LUM S STL FOR SPNL DEFORMITY CDH LEG,SUP-2290726,CDM,C1713,HCPCS,0278,RC,,,,both,,,1247.15,810.65,,,,,,,,,,,,,
K WIRE FIX L105MM DIA1.1MM CO CHROM,SUP-2136627,CDM,C1713,HCPCS,0278,RC,,,,both,,,57.18,37.17,,,,,,,,,,,,,
IMMOBILIZER SHLDR L W8XL18IN COT ADJUSTABLE  SHLDR STRP W  A,SUP-2431841,CDM,L3670,HCPCS,0274,RC,,,,both,,,53.51,34.78,,,,,,,,,,,,,
LEAD NEUROSTIMULATOR L25CM EXTN NEUROMODULATION,SUP-2138802,CDM,C1883,HCPCS,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
TRAY CATH MIDLN POWERGLIDE PRO 18GA 8CM WNGD 1 LUMA F318088T,SUP-2632764,CDM,C1751,HCPCS,0278,RC,,,,both,,,332.84,216.35,,,,,,,,,,,,,
DEVICE FIX LP MINI 3 MM FOREHEAD ENDOTINE,SUP-2760653,CDM,C1713,HCPCS,0278,RC,,,,both,,,853.92,555.05,,,,,,,,,,,,,
GUIDE SURG PT SPEC BNE GRFT HARVESTING,SUP-2860263,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3182.70,2068.75,,,,,,,,,,,,,
GRAFT BNE 1-4 MM 90 CC CORTICAL CANC,SUP-2766767,CDM,C1713,HCPCS,0278,RC,,,,both,,,3724.67,2421.04,,,,,,,,,,,,,
CATHETER CV 1 LUMEN 5 FRX150 MM 17 GAX70 MM KT CAREFLOW,SUP-2516612,CDM,C1751,HCPCS,0278,RC,,,,both,,,48.98,31.84,,,,,,,,,,,,,
LIDOCAINE HCL (PF) 4 % IJ SOLN,RX-133084,CDM,J2003,HCPCS,0636,RC,00409-4283-11,NDC,,both,2.5,ML,54.10,35.16,,,,,,,,,,,,,
SODIUM CHLORIDE 4 MEQ/ML IV SOLN,RX-7322,CDM,J7131,HCPCS,0250,RC,00409-1141-12,NDC,,both,100,ML,88.60,57.59,,,,,,,,,,,,,
CEMENT BONE 70GM FULL DOSE CA PHOS W/ GENTMYCN HI VISC N,SUP-2221984,CDM,C1713,HCPCS,0278,RC,,,,both,,,1836.90,1193.98,,,,,,,,,,,,,
HC Pacu Recovery - First 15 Min,PX-7100000000,CDM,7100000000,LOCAL,0710,RC,,,,both,,,1362.00,885.30,,,,,,,,,,,,,
QUICKSET KIT 16CC,SUP-2811321,CDM,C1713,HCPCS,0278,RC,,,,both,,,8456.81,5496.93,,,,,,,,,,,,,
HC MRI-Pelvis W Contrast,PX-6147219600,CDM,72196,CPT,0614,RC,,,,inpatient,,,4626.00,3006.90,,,,,,,,,,,,,
BLADE SURG 6 LT MIDLN MAST MIDLF,SUP-2631588,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2132.85,1386.35,,,,,,,,,,,,,
GRAFT BNE SUB 5CC CA SULF HA INJ BIPHASIC OSTEOCONDUCTIVE,SUP-2402598,CDM,C1713,HCPCS,0278,RC,,,,both,,,5711.66,3712.58,,,,,,,,,,,,,
HC Iadna Orthopoxvirus Amp Probe Tech Ea,PX-3008759300,CDM,87593,CPT,0300,RC,,,,both,,,110.00,71.50,,,,,,,,,,,,,
ALLOGRAFT BNE WDG 5.5 CMX12 MM CORTICAL FD 2 PC STRL LF DISP,SUP-2495571,CDM,C1889,HCPCS,0278,RC,,,,both,,,3314.90,2154.68,,,,,,,,,,,,,
NAIL FLEX PRECURVED 1.5X300MM,SUP-2463542,CDM,C1713,HCPCS,0278,RC,,,,both,,,737.90,479.63,,,,,,,,,,,,,
SCREW BNE CANC 3X12 MM NS MTRX SMARTLOCK,SUP-2472468,CDM,C1713,HCPCS,0278,RC,,,,both,,,109.90,71.43,,,,,,,,,,,,,
COLLAR CERV FIRM 4X22IN UNIV,SUP-2276587,CDM,L0120,HCPCS,0272,RC,,,,both,,,7.69,5.00,,,,,,,,,,,,,
PANEL CERV CLLR L BK FOR VISTA,SUP-2123901,CDM,L0190,HCPCS,0274,RC,,,,both,,,103.75,67.44,,,,,,,,,,,,,
PLATE BNE 4 H SHT BSSO FOR 2MM SCR CRANIOMAXILLOFACIAL FRAC,SUP-2319393,CDM,C1713,HCPCS,0278,RC,,,,both,,,522.81,339.83,,,,,,,,,,,,,
HC Renal Venogram Unilateral,PX-3207583100,CDM,75831,CPT,0320,RC,,,,both,,,3165.00,2057.25,,,,,,,,,,,,,
CURVED RECON 3.5MM 6X70MM,SUP-2818480,CDM,C1713,HCPCS,0278,RC,,,,both,,,3487.44,2266.84,,,,,,,,,,,,,
SET SPR SNAP LOK 40CM 360DEG ENDOSCP APPL FLX W DUPLOSPR,SUP-2130381,CDM,C1713,HCPCS,0278,RC,,,,both,,,491.63,319.56,,,,,,,,,,,,,
PROPAFENONE HCL ER 225 MG PO CP12,RX-37643,CDM,6370000000,HCPCS,0637,RC,16714-0825-01,NDC,,both,1,UN,23.90,15.53,,,,,,,,,,,,,
CATHETER ATHRCTMY L110CM OD2.5MM .018IN OVR THE WIRE LSR,SUP-2353101,CDM,C1885,CPT,0278,RC,,,,both,,,8478.00,5510.70,,,,,,,,,,,,,
GUIDEWIRE THREADED 3.2 X 450MM,SUP-2855646,CDM,C1769,HCPCS,0272,RC,,,,both,,,690.80,449.02,,,,,,,,,,,,,
COMPONENT GLEN PEGGED SM SHLDR AEQUALIS,SUP-2715556,CDM,C1776,CPT,0278,RC,,,,both,,,6041.36,3926.88,,,,,,,,,,,,,
INTRODUCER SHTH 4FR L10CM DIL L2.5CM RADPQ MRK KINK RESIST,SUP-2385177,CDM,C1894,HCPCS,0272,RC,,,,both,,,45.53,29.59,,,,,,,,,,,,,
SEGMENTAL ART SURF SZ C 12MM,SUP-2502388,CDM,C1776,CPT,0278,RC,,,,both,,,5185.71,3370.71,,,,,,,,,,,,,
NERVE STIMULATOR KIT IMPLANTABLE PULSE GENERATOR VERCISE PC,SUP-2836322,CDM,C1767,HCPCS,0278,RC,,,,both,,,56206.00,36533.90,,,,,,,,,,,,,
COIL EMB HNDL DETACH SMRT COIL,SUP-2323708,CDM,C1889,HCPCS,0278,RC,,,,both,,,747.32,485.76,,,,,,,,,,,,,
PLATE BNE RADIAL DSTL,SUP-2859842,CDM,C1713,HCPCS,0278,RC,,,,both,,,129085.40,83905.51,,,,,,,,,,,,,
LEVOFLOXACIN 500 MG PO TABS,RX-18919,CDM,6370000000,HCPCS,0637,RC,00904-6352-61,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
GUIDEWIRE VASC L145CM 0035IN S STL STR CRV HEP COAT DBL FLX,SUP-2167576,CDM,C1769,HCPCS,0272,RC,,,,both,,,48.98,31.84,,,,,,,,,,,,,
CANN SCREW THD 4.0X14MM,SUP-2586804,CDM,C1713,HCPCS,0278,RC,,,,both,,,421.76,274.14,,,,,,,,,,,,,
SPLINT THMB SM FOR 6-7IN RT CARPOMETACARPAL JT RESTRICT ELAS,SUP-2324695,CDM,L3931,HCPCS,0274,RC,,,,both,,,57.56,37.41,,,,,,,,,,,,,
PANEL CERV CLLR L BK FOR VISTA,SUP-2123901,CDM,L0190,HCPCS,0272,RC,,,,both,,,103.75,67.44,,,,,,,,,,,,,
ELECTRODE ELECSURG COAG 24/26 FR BPLR PT EXT LEN,SUP-2433932,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1472.09,956.86,,,,,,,,,,,,,
BIT DRILL SURG 4.3X152.5 MM FREE HND NAT NAIL,SUP-2198676,CDM,2720000010,LOCAL,0272,RC,,,,both,,,291.39,189.40,,,,,,,,,,,,,
COMPONENT FEM SZ 1 L NP CRUCE RET BAL SYS,SUP-2314641,CDM,C1776,CPT,0278,RC,,,,both,,,6141.84,3992.20,,,,,,,,,,,,,
SPACER SPNL W10XH7X32MM LUM SACR PEEK INTBDY FUS W TANT MRK,SUP-2289141,CDM,C1821,HCPCS,0278,RC,,,,both,,,12246.00,7959.90,,,,,,,,,,,,,
MESH HERN W20XL30CM OPN TISS SEPARATING PHYSIOMESH,SUP-2219748,CDM,C1781,HCPCS,0278,RC,,,,both,,,5652.63,3674.21,,,,,,,,,,,,,
CLIP ANEURYSM SUNDTKEES 7MM SUPER BAYONET 201676,SUP-2848939,CDM,C1889,HCPCS,0278,RC,,,,both,,,734.76,477.59,,,,,,,,,,,,,
SCREW BNE DRILL-FREE 1.5X13 MM 5 MM TI MAXDRIVE,SUP-2540260,CDM,C1713,HCPCS,0278,RC,,,,both,,,198.07,128.75,,,,,,,,,,,,,
ENDCAP ORTH DIA15MM EXTN 0MM LT BLU FEM TI FOR SPRL BLDE,SUP-2192139,CDM,C1713,HCPCS,0278,RC,,,,both,,,677.49,440.37,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY SPC 10 MM F CRV FIX ORTHOGONAL,SUP-2248947,CDM,C1730,HCPCS,0272,RC,,,,both,,,1714.44,1114.39,,,,,,,,,,,,,
BIT DRL DIA2MM CANN,SUP-2122275,CDM,2720000010,LOCAL,0272,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
GRAFT BONE RADLUC DEMIN CORT STRL 50MMX25MMXL OSTEOWRAP,SUP-2125430,CDM,C1713,HCPCS,0278,RC,,,,both,,,4961.20,3224.78,,,,,,,,,,,,,
CANNULA SUCTION IRRIGATION 10MM 330MM COLOR CODED,SUP-2489332,CDM,C1713,HCPCS,0278,RC,,,,both,,,1751.40,1138.41,,,,,,,,,,,,,
PLATE BNE L125MM THK3MM 8 H BILAT S STL STR LIMIT CNTCT DYN,SUP-2185338,CDM,C1713,HCPCS,0278,RC,,,,both,,,1742.92,1132.90,,,,,,,,,,,,,
PROBE SURG NERVE STIMULATING DISP,SUP-2517402,CDM,2720000010,LOCAL,0272,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
AUTOTRANSFUSION PACK 1 SOURC 120 MU M AUTOLOG ATLS00,SUP-2490022,CDM,2720000010,LOCAL,0272,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
PORT IMPL INFUSION CHST VAXCEL,SUP-2117112,CDM,C1788,HCPCS,0278,RC,,,,both,,,753.60,489.84,,,,,,,,,,,,,
SCREW BNE L35MM DIA4MM SM HEX DIA2.5MM CANC S STL ST,SUP-2411117,CDM,C1713,HCPCS,0278,RC,,,,both,,,62.11,40.37,,,,,,,,,,,,,
PROBE DIL 180 MM MOLD LUCENT L,SUP-2740272,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1566.86,1018.46,,,,,,,,,,,,,
PLATE BONE L31MM 4 H STRL S STL LCK COMPR FOR 2.7MM SCR EVOS,SUP-2349615,CDM,C1713,HCPCS,0278,RC,,,,both,,,1842.71,1197.76,,,,,,,,,,,,,
INSERT TIB ARTC CRUCE RET MOD CNDYL STABILIZING NEUT UNIV,SUP-2376286,CDM,C1776,CPT,0278,RC,,,,both,,,2917.06,1896.09,,,,,,,,,,,,,
TUBING SUCT L520MM ASSEMB DISP FOR RMR IRRIG ASPIR DRV SHFT,SUP-2187573,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2992.11,1944.87,,,,,,,,,,,,,
COIL NEUROVASCULAR OPTMA L 17 CM DIA 5 MM SZ 0.010 IN STD,SUP-2753290,CDM,C1778,HCPCS,0278,RC,,,,both,,,4788.50,3112.52,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE 2.5 CC DEMINERALIZED CORT CANC BNE,SUP-2905180,CDM,C1713,HCPCS,0278,RC,,,,both,,,1169.65,760.27,,,,,,,,,,,,,
CATHETER GUID ENVOY L 95 CM OD 6 FR ID 0.071 IN DSTL L 8 CM,SUP-2249008,CDM,C1887,HCPCS,0272,RC,,,,both,,,2538.69,1650.15,,,,,,,,,,,,,
PLATE BNE 130 DEG SHFT L 104 MM BLADE L 50 MM SCREW DIA 4.5,SUP-2908023,CDM,C1713,HCPCS,0278,RC,,,,both,,,1744.84,1134.15,,,,,,,,,,,,,
PLATE BNE L169MM THK3.3MM 14 H BILAT S STL RIG STR DYN,SUP-2186336,CDM,C1713,HCPCS,0278,RC,,,,both,,,1817.24,1181.21,,,,,,,,,,,,,
PLATE BNE CRV 4.5X370 MM RT CNDYL 18 HOLE VA LCK STRL VALCP,SUP-2789388,CDM,C1713,HCPCS,0278,RC,,,,both,,,7549.53,4907.19,,,,,,,,,,,,,
STAPLE INT BIOABSORBABLE REINF LN SUREFORM 60 GRN SEAMGRD,SUP-2650426,CDM,2720000010,LOCAL,0272,RC,,,,both,,,523.34,340.17,,,,,,,,,,,,,
ENDCAP IM NAIL 2MM FEM AG RG EXTN,SUP-2364649,CDM,C1713,HCPCS,0278,RC,,,,both,,,235.66,153.18,,,,,,,,,,,,,
MESH CRAN W38XL45MM DIA0.6MM TI CNTOUR RIG PNK MATRIXNEURO,SUP-2255853,CDM,C1781,HCPCS,0278,RC,,,,both,,,4457.54,2897.40,,,,,,,,,,,,,
TRIAL TIB STEM TIB PROV SZ 4 NXGN,SUP-2201511,CDM,C1713,HCPCS,0278,RC,,,,both,,,401.92,261.25,,,,,,,,,,,,,
INSERT ACET SZ D OD58-61MM ID32MM 10DEG HIP DUR PCA HOOD,SUP-2376063,CDM,C1776,CPT,0278,RC,,,,both,,,936.19,608.52,,,,,,,,,,,,,
SCREW N LOK 24X35MM,SUP-2400447,CDM,C1713,HCPCS,0278,RC,,,,both,,,84.78,55.11,,,,,,,,,,,,,
GRAFT BNE FEM HD 4.5 CM W/O CART 130456024,SUP-2165599,CDM,C1776,CPT,0278,RC,,,,both,,,3092.90,2010.38,,,,,,,,,,,,,
STAPLER INT LN 60 MM ENDO GIA II PSD6002UN] BAXALTA US INC],SUP-2129892,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1120.98,728.64,,,,,,,,,,,,,
ANCHOR SUT DIA1.4MM TAPE 1 STRND INTELLIBRAID TECHNOLOGY,SUP-2366687,CDM,C1713,HCPCS,0278,RC,,,,both,,,1762.45,1145.59,,,,,,,,,,,,,
PLATE BONE L115MM 7 H STRL RT POSTEROLATERAL DSTL FIBULAR S,SUP-2349769,CDM,C1713,HCPCS,0278,RC,,,,both,,,7249.00,4711.85,,,,,,,,,,,,,
EXTRACTOR STONE TIPLSS 3 FRX115 CM 2 CM MOD BSKT NIT NCIRCLE,SUP-2835765,CDM,2720000010,LOCAL,0272,RC,,,,both,,,663.83,431.49,,,,,,,,,,,,,
BUTTON SUT DIA12MM TI FOR PRI BKUP FIBERWIRE FIX OF ACL PCL,SUP-2122820,CDM,C1713,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
HANDPIECE SUCTION IRRIGATION PULSED TRMPT SURGFLX WAVE XP,SUP-2313619,CDM,C1713,HCPCS,0278,RC,,,,both,,,332.84,216.35,,,,,,,,,,,,,
SHEATH INTRO FLX L 45 CM OD 8 FR GUIDEWIRE 0.038 IN SM CKFLO,SUP-2168470,CDM,C1894,HCPCS,0272,RC,,,,both,,,173.61,112.85,,,,,,,,,,,,,
PLATE BONE STRL LT METATARSOPHALANGEAL REV FOR 2.7MM SCR VLP,SUP-2349940,CDM,C1713,HCPCS,0278,RC,,,,both,,,6380.95,4147.62,,,,,,,,,,,,,
CLIP SURG OCPTL,SUP-2245459,CDM,C1713,HCPCS,0278,RC,,,,both,,,3438.30,2234.89,,,,,,,,,,,,,
BRACE BACKXSM FOR 25-30IN WAIST HK RECV MAT SFT BRTH LNR ABD,SUP-2194511,CDM,L0625,HCPCS,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
TUBE VENT 1.02 MM 0.8 MM 1.47 MM SHEA PARASOL TAB SIL STRL,SUP-2464610,CDM,L8699,HCPCS,0278,RC,,,,both,,,55.11,35.82,,,,,,,,,,,,,
BRACE BACKXSM FOR 25-30IN WAIST HK RECV MAT SFT BRTH LNR ABD,SUP-2194511,CDM,L0625,HCPCS,0274,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
CATHETER US GE COMPATIBILITY SOUNDSTAR ECO 10FR,SUP-2248456,CDM,C1759,HCPCS,0272,RC,,,,both,,,7253.40,4714.71,,,,,,,,,,,,,
PLATE BNE RECON UNIV 2.7 MM 14 HOLE 2 COMPR FOR SCR TI NS,SUP-2464918,CDM,C1713,HCPCS,0278,RC,,,,both,,,1335.10,867.81,,,,,,,,,,,,,
ANCHOR SUT DIA5.5MM PEEK 3 ORTHOCORD SZ 2 L36IN VLT BLU,SUP-2249412,CDM,C1713,HCPCS,0278,RC,,,,both,,,1306.24,849.06,,,,,,,,,,,,,
BIT DRL CONCL 4.5X300 MM FITBONE,SUP-2645849,CDM,2720000010,LOCAL,0272,RC,,,,both,,,850.56,552.86,,,,,,,,,,,,,
ANCHOR SUT 5.5MM PEEK SELF PUNCHING HEALIX ADV SP,SUP-2418578,CDM,C1713,HCPCS,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
SUTURE N ABSRB 2-0 W/CRV TAPR NDL BLK BLU MAXBRAID CM0222N,SUP-2435478,CDM,C1713,HCPCS,0278,RC,,,,both,,,218.54,142.05,,,,,,,,,,,,,
PIN LOCATING DIA2.5MM,SUP-2878313,CDM,2720000010,LOCAL,0272,RC,,,,both,,,596.60,387.79,,,,,,,,,,,,,
BIT DRL HIP ANTIROTATION SCR FOR AFFIXUS SYS,SUP-2412615,CDM,2720000010,LOCAL,0272,RC,,,,both,,,854.08,555.15,,,,,,,,,,,,,
BRACE ORTH UNIV FABRIC MESH SHLDR UNISX AD BCKL CLOSURE HK,SUP-2915222,CDM,2720000010,LOCAL,0272,RC,,,,both,,,343.45,223.24,,,,,,,,,,,,,
GUIDEWIRE ORTH THRD 1.4X150 MM FOR CANN SCREW NS 03333012,SUP-2789101,CDM,C1769,HCPCS,0272,RC,,,,both,,,297.17,193.16,,,,,,,,,,,,,
SHEATH INTRO VASCU-SHEATH L 14 CM DIA17 FR PTFE VLV PEELABLE,SUP-2905036,CDM,C1892,HCPCS,0272,RC,,,,both,,,78.50,51.02,,,,,,,,,,,,,
GUAIFENESIN-DM 100-10 MG/5ML PO SYRP,RX-15816,CDM,6370000000,HCPCS,0637,RC,00536-1313-85,NDC,,both,5,ML,0.50,0.32,,,,,,,,,,,,,
PERC INSRT KT FOR 3.0 MM KNOTLESS ST,SUP-2121613,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1114.70,724.55,,,,,,,,,,,,,
PROSTHESIS INCUS STAP HA 0.76MM DIA 10MM LEN GROTE,SUP-2313673,CDM,L8613,CPT,0278,RC,,,,both,,,944.79,614.11,,,,,,,,,,,,,
SPACER KNEE PART KNEE ALIGN TWR PERSONA,SUP-2448188,CDM,C1776,CPT,0278,RC,,,,both,,,480.42,312.27,,,,,,,,,,,,,
DOCETAXEL 80 MG/4ML IV CONC,RX-104437,CDM,J9171,HCPCS,0636,RC,16729-0267-64,NDC,,both,4,ML,264.40,171.86,,,,,,,,,,,,,
GRAFT VASC GELWEAVE L 40 CM DIA26 MM BRANCH SIDE L 15 CM,SUP-2894614,CDM,C1768,CPT,0278,RC,,,,both,,,9184.50,5969.92,,,,,,,,,,,,,
GUAIFENESIN-DM 100-10 MG/5ML PO SYRP,RX-15816,CDM,6370000000,HCPCS,0637,RC,00121-1276-00,NDC,,both,5,ML,10.00,6.50,,,,,,,,,,,,,
CATHETER GUID L100CM OD6FR MULTPURP TIP W/O HYDRPHLC COAT AD,SUP-2103429,CDM,C1887,HCPCS,0272,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
SCREW BNE ST 2.4X20 MM LCK,SUP-2569656,CDM,C1713,HCPCS,0278,RC,,,,both,,,86.35,56.13,,,,,,,,,,,,,
WAND ABLAT AMBIENT 70 IFS 70DEG 3MM COVAC,SUP-2342014,CDM,2720000010,LOCAL,0272,RC,,,,both,,,890.19,578.62,,,,,,,,,,,,,
HC Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn,PX-3606232100,CDM,62321,CPT,0360,RC,,,,outpatient,,,2230.00,1449.50,,,,,,,,,,,,,
SUPPORT PROSTHETIC JT KNEE ADJ MOTN,SUP-2388174,CDM,L2186,HCPCS,0272,RC,,,,both,,,464.97,302.23,,,,,,,,,,,,,
CLAMP EXT FIX SM DIA4/2.5MM OPN ROD TO ROD CONN,SUP-2188700,CDM,C1713,HCPCS,0278,RC,,,,both,,,939.77,610.85,,,,,,,,,,,,,
BIT DRL L300MM DIA5MM CANN L QUIK CPL FOR 6.5/7.3MM CANN,SUP-2187330,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1225.76,796.74,,,,,,,,,,,,,
STAPLES INT L60MM M THCK REINF INTELLIGENT RELD FOR SIGNIA,SUP-2283376,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2368.35,1539.43,,,,,,,,,,,,,
WIRE OD15MM L250MM X FIX W O OLV,SUP-2315980,CDM,C1713,HCPCS,0278,RC,,,,both,,,144.19,93.72,,,,,,,,,,,,,
BOLT ORTH TI INSRT FOR CANN TIB NAIL,SUP-2188192,CDM,C1713,HCPCS,0278,RC,,,,both,,,800.67,520.44,,,,,,,,,,,,,
ALLOGRAFT DERMAL HUM TISS SM X THCK 2X1 CMX2.3-3.3 MM,SUP-2463948,CDM,Q4116,HCPCS,0636,RC,,,,both,,,552.64,359.22,,,,,,,,,,,,,
IMPLANT HUM TISS SZ 2 X 3 CM THK 2000 UM PLCNTA MEMBRN FRSH,SUP-2913439,CDM,C1762,CPT,0278,RC,,,,both,,,13907.06,9039.59,,,,,,,,,,,,,
ASSEMBLY SURG SAW BLADE SZ 15 MM IM STRL DISP,SUP-2887650,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1964.07,1276.65,,,,,,,,,,,,,
PLATE BNE W13.5XL160MM THK4.2MM 9 H BILAT S STL NAR LIMIT,SUP-2185241,CDM,C1713,HCPCS,0278,RC,,,,both,,,1387.47,901.86,,,,,,,,,,,,,
HC Cbc (Hemogram),PX-3058502700,CDM,85027,CPT,0305,RC,,,,both,,,116.00,75.40,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.516,SUP-2860033,CDM,C1713,HCPCS,0278,RC,,,,both,,,39414.54,25619.45,,,,,,,,,,,,,
SCREW BNE L10MM DIA1.3MM STD CORT S STL ST NONCANNULATED,SUP-2183148,CDM,C1713,HCPCS,0278,RC,,,,both,,,207.21,134.69,,,,,,,,,,,,,
POST FIX 12MM BOLT 2 H ASSEMB TRUELOK RNG,SUP-2316107,CDM,2720000010,LOCAL,0272,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
MESH HERN W15XL19CM THK2MM EPTFE PTCH OVL 2 SIDE FOR,SUP-2125770,CDM,C1781,HCPCS,0278,RC,,,,both,,,5010.18,3256.62,,,,,,,,,,,,,
BIT DRL DIA6MM CARB DISP FOR 5/7.3MM SCR,SUP-2187125,CDM,2720000010,LOCAL,0272,RC,,,,both,,,924.98,601.24,,,,,,,,,,,,,
PIN FIX CRSS CANN KT DISP AXL,SUP-2212892,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1880.86,1222.56,,,,,,,,,,,,,
STABILIZER SURG S STL STR ELONG FOR PECTUS BAR EXCAVATUM,SUP-2135889,CDM,C1713,HCPCS,0278,RC,,,,both,,,2552.82,1659.33,,,,,,,,,,,,,
TRAY CATH HEMODIALYSI DUO FLO ACTE 11.5FR DIA 15C MCDLT116IJ,SUP-2633018,CDM,C1750,HCPCS,0278,RC,,,,both,,,271.92,176.75,,,,,,,,,,,,,
GRAFT VASC L45CM ID4-7MM TAPR ACUSEAL,SUP-2395748,CDM,C1768,CPT,0278,RC,,,,both,,,4719.42,3067.62,,,,,,,,,,,,,
CAGE SPNL W9XH13XL21MM C FBR REINF POLYMER POST LUM INTBDY,SUP-2256177,CDM,C1889,HCPCS,0278,RC,,,,both,,,12321.93,8009.25,,,,,,,,,,,,,
RING EXTERNAL FIXATION DIA160MM ALUMINUM FULL,SUP-2586492,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4336.09,2818.46,,,,,,,,,,,,,
ALLOGRAFT BNE WHL TIB,SUP-2321917,CDM,C1713,HCPCS,0278,RC,,,,both,,,19311.00,12552.15,,,,,,,,,,,,,
BOLT ORTH TROCHANTERIC CALCAR HIP MLRY HD 1 PC POLY PLUG,SUP-2403608,CDM,C1776,CPT,0278,RC,,,,both,,,1582.56,1028.66,,,,,,,,,,,,,
SYSTEM DEFIB VR-T LUMAX 300,SUP-2138116,CDM,C1722,HCPCS,0275,RC,,,,both,,,56303.34,36597.17,,,,,,,,,,,,,
RESORB X BURR HOLE COVER CONTOURED 10MM 17MM DIA,SUP-2681138,CDM,C1713,HCPCS,0278,RC,,,,both,,,1014.97,659.73,,,,,,,,,,,,,
SCREW BONE L11MM D2MM FOOT TTNM SELF TPPNG SELF DRLLNG FRS,SUP-2469771,CDM,C1713,HCPCS,0278,RC,,,,both,,,651.80,423.67,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED UPCHARGE HI FLX,SUP-2212681,CDM,C1776,CPT,0278,RC,,,,both,,,800.70,520.45,,,,,,,,,,,,,
TREPHINE SURG OD12MM CRWN DRL,SUP-2368638,CDM,C1713,HCPCS,0278,RC,,,,both,,,2017.45,1311.34,,,,,,,,,,,,,
GUIDEWIRE VASC L 180 CM DIA 0.025 IN TAPR L 7 CM FLX TIP 2.5,SUP-2167793,CDM,C1769,HCPCS,0272,RC,,,,both,,,34.16,22.20,,,,,,,,,,,,,
SCREW BNE COMPR 7X90 MM MULTI-USE,SUP-2399614,CDM,C1713,HCPCS,0278,RC,,,,both,,,1252.86,814.36,,,,,,,,,,,,,
STENT BILI DYNALINK L 28 MM DIA 5 MM CATH L 120 CM GUIDEWIRE,SUP-2104138,CDM,C1876,HCPCS,0278,RC,,,,both,,,4232.72,2751.27,,,,,,,,,,,,,
COMPONENT FEM L60MM INTLOK RT KNEE REV CEM POST STBL STEM,SUP-2405606,CDM,C1776,CPT,0278,RC,,,,both,,,14827.08,9637.60,,,,,,,,,,,,,
PLATE BNE L W135XL404MM THK42MM 22 H BILAT TI NAR RIG NEUT,SUP-2190839,CDM,C1713,HCPCS,0278,RC,,,,both,,,4115.79,2675.26,,,,,,,,,,,,,
GRAFT STENT TAPR LIMB 16X24X146 MM 16 FR AAA C E ENDURANT II,SUP-2749554,CDM,C1768,CPT,0278,RC,,,,both,,,20096.00,13062.40,,,,,,,,,,,,,
BRACE WRST M L7IN FOR 65 75IN R COT E CNTOUR ALUMINUM STAY,SUP-2197008,CDM,L3931,HCPCS,0274,RC,,,,both,,,11.21,7.29,,,,,,,,,,,,,
SCREW BONE L8MM OD2.7MM S STL CORT ST T10 HEXALOBE PEDIFRAG,SUP-2318667,CDM,C1713,HCPCS,0278,RC,,,,both,,,188.97,122.83,,,,,,,,,,,,,
PLATE BNE L266MM 12 H L CNDYL S STL VAR ANG LOK COMPR CRV,SUP-2177857,CDM,C1713,HCPCS,0278,RC,,,,both,,,5861.03,3809.67,,,,,,,,,,,,,
DRILL SURG LUG FEM HI PERF LCS,SUP-2454042,CDM,2720000010,LOCAL,0272,RC,,,,both,,,653.12,424.53,,,,,,,,,,,,,
BLADE SURG L80MM DIA105MM NONSTERILE TI CANN FEN HELI G,SUP-2180771,CDM,C1713,HCPCS,0278,RC,,,,both,,,1839.63,1195.76,,,,,,,,,,,,,
HC Sacroiliac Joints Less Than 3,PX-3207220000,CDM,72200,CPT,0320,RC,,,,both,,,128.00,83.20,,,,,,,,,,,,,
COMPONENT FEM SZ 1 L POST STBL NP HI FLX TRIMAX,SUP-2314934,CDM,C1776,CPT,0278,RC,,,,both,,,8327.28,5412.73,,,,,,,,,,,,,
BIT DRL 3.8X40 MM DURALOC,SUP-2252735,CDM,2720000010,LOCAL,0272,RC,,,,both,,,343.36,223.18,,,,,,,,,,,,,
HC So Histochemical Identification,PX-3128831966,CDM,88319,CPT,0312,RC,,,,both,,,349.00,226.85,,,,,,,,,,,,,
DRESSING GERM W5XL6IN HELIX COMP LAYR JUMPSTART,SUP-2123477,CDM,2720000010,LOCAL,0272,RC,,,,both,,,114.61,74.50,,,,,,,,,,,,,
HC Bx Breast 1st Lesion US Img,PX-3611908300,CDM,19083,CPT,0361,RC,,,,inpatient,,,7265.00,4722.25,,,,,,,,,,,,,
INSTRUMENT COR BX 18GA L9CM PEN 11MM PNK ACTUATOR DISP MPTY,SUP-2127808,CDM,C1713,HCPCS,0278,RC,,,,both,,,71.91,46.74,,,,,,,,,,,,,
NEEDLE SUT KNEE LO PROF SCORPION,SUP-2120939,CDM,2720000010,LOCAL,0272,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
GRAFT VASC STR STD WALL N RING 6MM DIA 90CM LEN GORTX,SUP-2396012,CDM,C1768,CPT,0278,RC,,,,both,,,4901.54,3186.00,,,,,,,,,,,,,
DILATOR UROLOGICAL SET 6-24 FRX20 CM FASCIAL POLYETH,SUP-2835684,CDM,C2627,HCPCS,0272,RC,,,,both,,,507.08,329.60,,,,,,,,,,,,,
GRAFT HUM TISS W4XL7CM NOM THK1.5MM MAXFORC HUM DERM REGEN,SUP-2399062,CDM,Q4107,HCPCS,0636,RC,,,,both,,,8013.28,5208.63,,,,,,,,,,,,,
STEM RADIAL 9X2 MM DEMO,SUP-2798395,CDM,C1776,CPT,0278,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
NEEDLE SUT PASS FLX DISP RP360,SUP-2366719,CDM,2720000010,LOCAL,0272,RC,,,,both,,,698.52,454.04,,,,,,,,,,,,,
SPHINCTEROTOME ENDOSCP 7/20 MM 6 FRX195 CM PUL TYP,SUP-2475924,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1116.96,726.02,,,,,,,,,,,,,
ROD SPNL 3.5X200 MM OCCIPITOCERVICAL PLATE VERTEX SEL,SUP-2630737,CDM,C1713,HCPCS,0278,RC,,,,both,,,3881.04,2522.68,,,,,,,,,,,,,
"HC Compatibility Test, Immed.Spin",PX-3008692000,CDM,86920,CPT,0300,RC,,,,both,,,270.00,175.50,,,,,,,,,,,,,
FIBER LASER ORTHOPEDIC 15 DEG HOLM INFRATOME,SUP-2225606,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1471.88,956.72,,,,,,,,,,,,,
CATHETER CRYOABLATION C2 CRYOBALLOON L 105 CM 3.7 MM 30 MM,SUP-2422296,CDM,C2618,HCPCS,0272,RC,,,,both,,,6123.00,3979.95,,,,,,,,,,,,,
DOXEPIN HCL 25 MG PO CAPS,RX-2611,CDM,6370000000,HCPCS,0637,RC,51079-0437-20,NDC,,both,1,UN,3.20,2.08,,,,,,,,,,,,,
PLATE BNE STR 15X0.6 MM NEURO 2 HOLE TI STRL LEVEL 1,SUP-2518091,CDM,C1713,HCPCS,0278,RC,,,,both,,,353.16,229.55,,,,,,,,,,,,,
MODEL ANAT MANDIBULAR 3D CT BASE OSTEOVIEW,SUP-2883586,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3661.55,2380.01,,,,,,,,,,,,,
COLLAR ASPN AD REG EA,SUP-2196889,CDM,L0172,HCPCS,0274,RC,,,,both,,,73.57,47.82,,,,,,,,,,,,,
PIN FIX TROCAR PT 1 END 3/16X9 IN 1 PT STYL SMOOTH PLN STRL,SUP-2150448,CDM,C1713,HCPCS,0278,RC,,,,both,,,19.15,12.45,,,,,,,,,,,,,
KIT CATH HEMODIALYSI ZENYSI DL ACUTE 11FR DIA 20CM STRGHT 2L,SUP-2613263,CDM,C1752,HCPCS,0278,RC,,,,both,,,672.75,437.29,,,,,,,,,,,,,
GRAFT SPNL W8XL26MM CORT CAPSTONE,SUP-2293985,CDM,C1713,HCPCS,0278,RC,,,,both,,,13838.61,8995.10,,,,,,,,,,,,,
ALLOGRAFT BNE STRP 20X50X3-6 MM DBM PUROS 61615251,SUP-2684573,CDM,C1713,HCPCS,0278,RC,,,,both,,,8889.34,5778.07,,,,,,,,,,,,,
GUIDEWIRE VASC L300CM DIA0.014IN NIT HYDRPHLC STR TIP,SUP-2148154,CDM,C1769,HCPCS,0272,RC,,,,both,,,505.41,328.52,,,,,,,,,,,,,
RESERVOIR VENTRICULAR W/ PLAS BASE FOR 6MM BUR HOLE HOLTER,SUP-2666804,CDM,C1889,HCPCS,0278,RC,,,,both,,,1095.83,712.29,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 80 MM DIA 8 MM DEL SHTH,SUP-2934160,CDM,C1713,HCPCS,0278,RC,,,,both,,,14631.30,9510.34,,,,,,,,,,,,,
STENT GRFT LPS THOR EXTEN,SUP-2277641,CDM,C1713,HCPCS,0278,RC,,,,both,,,432.06,280.84,,,,,,,,,,,,,
SHELL ACET SZ 22 OD48MM POR REV PRESSFIT MULT H FLNG LCK,SUP-2403715,CDM,C1776,CPT,0278,RC,,,,both,,,5790.16,3763.60,,,,,,,,,,,,,
BRACE GAUNTLET WR LT 1 SZ FITS MOST REG ELAS SUPP FABRIFOAM,SUP-2334826,CDM,L3809,HCPCS,0274,RC,,,,both,,,34.26,22.27,,,,,,,,,,,,,
LOCKING CAP MOD,SUP-2232361,CDM,C1713,HCPCS,0278,RC,,,,both,,,4402.28,2861.48,,,,,,,,,,,,,
BOOT ORTHOT L VASC CLASS ROOKE,SUP-2319144,CDM,L4386,HCPCS,0272,RC,,,,both,,,260.62,169.40,,,,,,,,,,,,,
TUBE VENT 1.27 MM 3 MM BAXTER BVL BOB TAPR FLROPLAS BLU,SUP-2477705,CDM,L8699,HCPCS,0278,RC,,,,both,,,31.53,20.49,,,,,,,,,,,,,
RING EXT FIX DIA130MM FULL FOR TRUELOK RNG FIX SYS,SUP-2316168,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2707.72,1760.02,,,,,,,,,,,,,
INTRODUCER SHTH 9.5FR L14CM GWIRE L50CM DIA0.038IN W/ 3MM J,SUP-2357063,CDM,C1892,HCPCS,0272,RC,,,,both,,,27.63,17.96,,,,,,,,,,,,,
BOOT ORTHOT L VASC CLASS ROOKE,SUP-2319144,CDM,L4386,HCPCS,0274,RC,,,,both,,,260.62,169.40,,,,,,,,,,,,,
IMMUNE GLOBULIN (PRIVIGEN) 10%,RX-4081762,CDM,J1459,HCPCS,0636,RC,44206-0437-10,NDC,,both,100,ML,5659.90,3678.93,,,,,,,,,,,,,
BRACE ANK XL FOR 14 15IN BLK W O STAY GAMEDAY,SUP-2319318,CDM,L4350,HCPCS,0274,RC,,,,both,,,40.00,26.00,,,,,,,,,,,,,
HC So Toxoplasma Igm,PX-3028677866,CDM,86778,CPT,0302,RC,,,,both,,,219.00,142.35,,,,,,,,,,,,,
"HC New Pt, E/M Level 4",PX-5109920400,CDM,99204,CPT,0510,RC,,,,outpatient,,,344.00,223.60,,,,,,,,,,,,,
LEAD NEUROSTIMULATOR L75CM DIA13MM CYL SPNL CRD 8 ELECTRD,SUP-2280218,CDM,C1778,HCPCS,0278,RC,,,,both,,,7529.72,4894.32,,,,,,,,,,,,,
ROCKER SURG 4.75 MM RMAS EXT CD HORZ SOLERA 4.75,SUP-2629398,CDM,C1713,HCPCS,0278,RC,,,,both,,,2052.02,1333.81,,,,,,,,,,,,,
STEM HUM 16X170 MM SHLDR RVS TRABECULAR MTL,SUP-2436915,CDM,C1776,CPT,0278,RC,,,,both,,,13720.23,8918.15,,,,,,,,,,,,,
PLATE BNE L124MM THK3.4MM 9 H BILAT S STL STR LOK COMPR FOR,SUP-2185139,CDM,C1713,HCPCS,0278,RC,,,,both,,,953.08,619.50,,,,,,,,,,,,,
SCREW INTFR L25MM DIA7MM CANN 1MM KNEE N ABSRB TI TAPR HD,SUP-2341312,CDM,C1713,HCPCS,0278,RC,,,,both,,,540.71,351.46,,,,,,,,,,,,,
TUBE VENT ID102MM SIL BLU PAPARELLA TYP W TAB FOR MYR,SUP-2313877,CDM,L8699,HCPCS,0278,RC,,,,both,,,39.75,25.84,,,,,,,,,,,,,
INQUIRY H CURVE STEER DEC 110 6 291 HL,SUP-2698825,CDM,C1731,HCPCS,0278,RC,,,,both,,,2772.62,1802.20,,,,,,,,,,,,,
COMPONENT TALAR SZ 3 BILAT ANK POLY SULCUS DOME POR CEM,SUP-2397153,CDM,C1776,CPT,0278,RC,,,,both,,,9583.28,6229.13,,,,,,,,,,,,,
KIT INTRO VSI L 10 CM DIA 4 FR 7 CM 21 GA NIT MANDREL SS TIP,SUP-2606002,CDM,C1894,HCPCS,0272,RC,,,,both,,,56.36,36.63,,,,,,,,,,,,,
BEARING TIB 9 XL KNEE OXFORD,SUP-2136411,CDM,C1776,CPT,0278,RC,,,,both,,,3510.52,2281.84,,,,,,,,,,,,,
PLATE BNE L19MM 8 H L TI EXT H SHP NONCOMPRESSION FOR 1.3MM,SUP-2190691,CDM,C1713,HCPCS,0278,RC,,,,both,,,1241.68,807.09,,,,,,,,,,,,,
GUIDEWIRE ORTH L150MM DIA0.062IN W/ TRCR TIP DISP FOR ANK,SUP-2122969,CDM,C1713,HCPCS,0278,RC,,,,both,,,47.10,30.61,,,,,,,,,,,,,
DRILL TWST L 50 MM DIA1.15 MM STP 6 MM DENT SHFT STRL DISP,SUP-2883227,CDM,2720000010,LOCAL,0272,RC,,,,both,,,522.21,339.44,,,,,,,,,,,,,
CEMENT BONE 20ML W/ GENTMYCN M VISC CO,SUP-2196558,CDM,C1713,HCPCS,0278,RC,,,,both,,,1494.95,971.72,,,,,,,,,,,,,
LACOSAMIDE 10 MG/ML PO SOLN,RX-105342,CDM,340b,HCPCS,0637,RC,99999-9917-57,NDC,,both,5,ML,38.20,24.83,,,,,,,,,,,,,
PLATE EXT FIX L30MM ANK FT FOR TRUELOK FRME ASSEMB HEXAPOD,SUP-2316155,CDM,2720000010,LOCAL,0272,RC,,,,both,,,351.93,228.75,,,,,,,,,,,,,
BIT DRL DIA2MM CANN FOR CSS SYS,SUP-2396783,CDM,2720000010,LOCAL,0272,RC,,,,both,,,668.82,434.73,,,,,,,,,,,,,
CATHETER AIRWY EXCHANGE SET 038X160 CM 14 FRX70 CM ARNDT,SUP-2760019,CDM,2720000010,LOCAL,0272,RC,,,,both,,,392.72,255.27,,,,,,,,,,,,,
ALLOGRAFT BNE BLOCK 14X14X14 MM SPNG FD CANC,SUP-2717781,CDM,C1713,HCPCS,0278,RC,,,,both,,,2282.21,1483.44,,,,,,,,,,,,,
STENT TRACHBRONCH WGRFT L 50 MM DIA 7 MM CATH TOT L 116 CM,SUP-2141192,CDM,C1874,HCPCS,0278,RC,,,,both,,,6446.42,4190.17,,,,,,,,,,,,,
SCREW BNE 14 MM TIP 2-3/4 IN DISTRCTN RUGGLES REDMOND STRL,SUP-2481257,CDM,C1713,HCPCS,0278,RC,,,,both,,,226.71,147.36,,,,,,,,,,,,,
"HC So Chloride, Urine Spot",PX-3018243666,CDM,82436,CPT,0301,RC,,,,both,,,26.00,16.90,,,,,,,,,,,,,
STENT PERIPH L2.5CM DIA5MM CATH 6FR L120CM BAL DIA5MM,SUP-2396626,CDM,C1874,HCPCS,0278,RC,,,,both,,,9482.80,6163.82,,,,,,,,,,,,,
ANCHOR SUTURE DIA 3.9 MM BIOCOMP FLAG MIS CC STRL FIBERTAK,SUP-2910465,CDM,C1713,HCPCS,0278,RC,,,,both,,,10533.92,6847.05,,,,,,,,,,,,,
K WIRE FIX L150MM DIA1.6MM TRCR PNT FOR PERI-LOC VAR ANG,SUP-2343917,CDM,C1713,HCPCS,0278,RC,,,,both,,,292.40,190.06,,,,,,,,,,,,,
SCREW BNE L 3 MM DIA1.7 MM PLA GLYCOLIDE CRANIOMAXILLOFACIAL 10PK,SUP-2884149,CDM,C1713,HCPCS,0278,RC,,,,both,,,2496.05,1622.43,,,,,,,,,,,,,
GUIDEROD ORTH L950MM DIA3MM S STL SMOOTH TIP,SUP-2188171,CDM,C1713,HCPCS,0278,RC,,,,both,,,547.62,355.95,,,,,,,,,,,,,
GUIDEWIRE URO L145CM OD0.038IN TIP L7CM SLIP COAT NIT PLAT,SUP-2171305,CDM,C1769,HCPCS,0272,RC,,,,both,,,147.71,96.01,,,,,,,,,,,,,
SPACER SPNL W9XH9XL30MM 0DEG PEEK OPTMA LUM TRANSFORAMINAL,SUP-2211933,CDM,C1821,HCPCS,0278,RC,,,,both,,,13502.00,8776.30,,,,,,,,,,,,,
PLATE BNE MESHED 0.6X90X90 MM UN3 GLD,SUP-2363581,CDM,C1713,HCPCS,0278,RC,,,,both,,,4970.62,3230.90,,,,,,,,,,,,,
KIT INTRO VSI L 15 CM DIA 4 FR NIT TUNGSTEN TIP SIL REG,SUP-2763488,CDM,C1892,HCPCS,0272,RC,,,,both,,,122.46,79.60,,,,,,,,,,,,,
COLLAR CERV SUPP X TALL AD COMFORT,SUP-2269629,CDM,L0180,HCPCS,0272,RC,,,,both,,,141.30,91.84,,,,,,,,,,,,,
BAR EXT FIX 11X150 MM CARBON,SUP-2749994,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1478.94,961.31,,,,,,,,,,,,,
SURGICAL PROCEDURE PACK VITRECTOMY 23 GA CPM ULTRAVIT,SUP-2431932,CDM,2720000010,LOCAL,0272,RC,,,,both,,,913.49,593.77,,,,,,,,,,,,,
SCREW BNE L18MM DIA2.4MM TI ST LOK FULL THRD STARDRV RECESS,SUP-2190276,CDM,C1713,HCPCS,0278,RC,,,,both,,,347.79,226.06,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 40 CM DIA 8 MM EPTFE STR TW REINF 2,SUP-2681200,CDM,C1768,CPT,0278,RC,,,,both,,,1449.86,942.41,,,,,,,,,,,,,
RING EXT FIX DIA160 MM 1/6 CLOSURE NS DISP MONK RING,SUP-2881131,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1718.37,1116.94,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 15 CM DIA 4 MM EPTFE STR TW N RING,SUP-2396329,CDM,C1768,CPT,0278,RC,,,,both,,,1463.24,951.11,,,,,,,,,,,,,
GRAFT BNE STRP 2X6.25X0.8 CM 20 CC CONDUCT,SUP-2599268,CDM,C1713,HCPCS,0278,RC,,,,both,,,8829.68,5739.29,,,,,,,,,,,,,
"HC Platelets,Leuko Red,Cmv-Neg Ea",PX-3900905500,CDM,P9055,CPT,0390,RC,,,,both,,,2239.00,1455.35,,,,,,,,,,,,,
PAD THER CRYO L R SHLDR SL AD NONSTERILE W STRP ACCELERATED,SUP-2324440,CDM,L3650,HCPCS,0274,RC,,,,both,,,162.65,105.72,,,,,,,,,,,,,
SCREW BNE L 80 MM DIA2.4 MM TI ST LCK T7 DRV NS VLP,SUP-2931896,CDM,C1713,HCPCS,0278,RC,,,,both,,,394.76,256.59,,,,,,,,,,,,,
HYBRID HIP SYS,SUP-2212074,CDM,C1776,CPT,0278,RC,,,,both,,,12474.69,8108.55,,,,,,,,,,,,,
PIN FIX L38MM DIA13MM PROV,SUP-2343745,CDM,C1713,HCPCS,0278,RC,,,,both,,,752.31,489.00,,,,,,,,,,,,,
SPACER ORTH L30MM SALVATION,SUP-2401148,CDM,C1713,HCPCS,0278,RC,,,,both,,,222.94,144.91,,,,,,,,,,,,,
EVOS 2.5MM SNAP IN DRL GUID,SUP-2344051,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1168.08,759.25,,,,,,,,,,,,,
STEM FEM L120MM HD NK L34MM HD OFFSET 37MM DIA10MM HIP TI,SUP-2390359,CDM,C1776,CPT,0278,RC,,,,both,,,5002.02,3251.31,,,,,,,,,,,,,
CATHETER NEPHSTMY L27CM DIA12FR LOK LOOP W/ FADER TIP,SUP-2139314,CDM,C1729,HCPCS,0272,RC,,,,both,,,308.85,200.75,,,,,,,,,,,,,
PLATE BONE L26MM 5X3 H S STL RAD HD ELBW POLYAX LCK LO PROF,SUP-2397934,CDM,C1713,HCPCS,0278,RC,,,,both,,,4810.48,3126.81,,,,,,,,,,,,,
STENT PANCREATIC ZMMN L 60 MM 7 FR 3.2 MM S-SHAPED SFT ERCP,SUP-2474978,CDM,C1877,HCPCS,0278,RC,,,,both,,,172.70,112.25,,,,,,,,,,,,,
GRAFT BNE SUB 5ML ALLGRFT PTTY OSTEOAMP,SUP-2420672,CDM,C9362,HCPCS,0278,RC,,,,both,,,3198.09,2078.76,,,,,,,,,,,,,
IMPLANT BIO TISS W8XL16CM BOV PERICARD CLLGN MTRX MESH SGL,SUP-2130301,CDM,C9354,HCPCS,0278,RC,,,,both,,,11243.62,7308.35,,,,,,,,,,,,,
CATHETER INFUSION PMP 4ML/HR 2X5 IN 550 CC,SUP-2361469,CDM,C1751,HCPCS,0278,RC,,,,both,,,675.10,438.81,,,,,,,,,,,,,
SHEARS ENDOSCP L14CM DIA5MM CRV VES SCIS HNDL RELIABLE,SUP-2218770,CDM,C1713,HCPCS,0278,RC,,,,both,,,1100.92,715.60,,,,,,,,,,,,,
SPACER HUM +9MM OFFSET SHLDR POLYETH FOR DELT XTEND REV SYS,SUP-2251001,CDM,C1776,CPT,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
CANNULA PROTEKDUO 31FR,SUP-2862987,CDM,C1889,HCPCS,0278,RC,,,,both,,,40820.00,26533.00,,,,,,,,,,,,,
TRAY CATH 12FR L20CM STR EXTN 2 LUMN DISP MAHRK ELITE,SUP-2417750,CDM,C1752,HCPCS,0278,RC,,,,both,,,358.12,232.78,,,,,,,,,,,,,
CATHETER GUID SIM2 AD 6 FRX90 CM ENVOY,SUP-2154327,CDM,C1887,HCPCS,0272,RC,,,,both,,,1710.08,1111.55,,,,,,,,,,,,,
TRAY KYPHOPLASTY SZ 2 L15MM IBT KYPHON EXPR OSTEO INTRO SYS,SUP-2293638,CDM,C1894,HCPCS,0272,RC,,,,both,,,8949.00,5816.85,,,,,,,,,,,,,
KIT CATHETER 14GA L8IN POLYUR RADPQ SIDE H INTEGR SUT WNG,SUP-2383273,CDM,C1751,HCPCS,0278,RC,,,,both,,,58.40,37.96,,,,,,,,,,,,,
DILATOR ENDO BAL L8CM DIA30MM CATH L75CM DIA16FR 0.038IN,SUP-2169511,CDM,C1726,HCPCS,0272,RC,,,,both,,,1036.20,673.53,,,,,,,,,,,,,
SCREW BNE 7.5X30 MM VOYAGER SOLERA MAS,SUP-2432047,CDM,C1713,HCPCS,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
BIT DRL DIA4.9MM SH CALIB FOR NAT NAIL SYS,SUP-2205652,CDM,2720000010,LOCAL,0272,RC,,,,both,,,391.87,254.72,,,,,,,,,,,,,
KIT THROMCTMY 5MAX L 132 CM PROX/DSTL OD 6/5.75 FR ID,SUP-2323548,CDM,C1887,HCPCS,0272,RC,,,,both,,,8635.00,5612.75,,,,,,,,,,,,,
GRAFT BNE SUB 5ML CANC FRZN MORSELIZED VIABLE CELL TRINITY,SUP-2307244,CDM,C1713,HCPCS,0278,RC,,,,both,,,7985.02,5190.26,,,,,,,,,,,,,
CATHETER KIT HYSTEROSALPINGOGRAM 5 FR,SUP-2360916,CDM,C1894,HCPCS,0272,RC,,,,both,,,71.28,46.33,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED HYBRID HD CERM,SUP-2212725,CDM,C1776,CPT,0278,RC,,,,both,,,13046.17,8480.01,,,,,,,,,,,,,
PORT IMPL INFUSION SINGLE LUMEN 8 FR VLV PLAS X-PORT ISP,SUP-2126610,CDM,C1788,HCPCS,0278,RC,,,,both,,,1186.92,771.50,,,,,,,,,,,,,
LEVEL CMF ST PLATE MDFCE STR WTAB 1.5 MM SCRW6 HOLE T0.6 MM,SUP-2681872,CDM,C1713,HCPCS,0278,RC,,,,both,,,548.24,356.36,,,,,,,,,,,,,
PLATE BNE FUSION 2 MM NS LTX,SUP-2856946,CDM,C1713,HCPCS,0278,RC,,,,both,,,2380.12,1547.08,,,,,,,,,,,,,
STENT PERIPH SMRT RADIANZ L 80 MM DIA 9 MM DEL SYS L 150 CM,SUP-2866208,CDM,C1725,HCPCS,0272,RC,,,,both,,,3949.49,2567.17,,,,,,,,,,,,,
CATHETER ETER EP DIAG MAP L CRV QPLR 2 5 2MM SPC 5MM TIP BI DIR,SUP-2356987,CDM,C1733,HCPCS,0272,RC,,,,both,,,2188.58,1422.58,,,,,,,,,,,,,
IMPLANT TOE HEMIPROSTHESIS CANN NO 3 19 X 17MM COCR,SUP-2392720,CDM,L8630,HCPCS,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
GRAFT HUM TISS L 1 X W 1 CM AMNION PLCNTA MEMBRN 2 LAYR,SUP-2913216,CDM,C1762,CPT,0278,RC,,,,both,,,2895.08,1881.80,,,,,,,,,,,,,
PLATE BONE L49MM THK1.6MM 6 H WR TI TRILOK SM FRAG FOR 2.5MM,SUP-2267969,CDM,C1713,HCPCS,0278,RC,,,,both,,,2534.33,1647.31,,,,,,,,,,,,,
SCREW BNE SEMICONSTRAINED 4.5X20 MM WRST LCK CAP STRL FRDM,SUP-2852842,CDM,C1713,HCPCS,0278,RC,,,,both,,,1451.62,943.55,,,,,,,,,,,,,
BRACE ORTH CARBON FIBER FRME LT KNEE COMBINED INSTABILITY,SUP-2915075,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1145.85,744.80,,,,,,,,,,,,,
END CAP NEWTON HUMERAL NAIL 2MM,SUP-2828881,CDM,C1889,HCPCS,0278,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
OXINIUM UNI FEM IMPL SM,SUP-2344262,CDM,C1776,CPT,0278,RC,,,,both,,,8684.46,5644.90,,,,,,,,,,,,,
PORT HND ACC DIA8.5MM GUID CANN INSRTN DA VINCI,SUP-2246701,CDM,2720000010,LOCAL,0272,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
CATHETER INTVASC OCCL PRUITT DIA 4 FR SS DL STOPCOCK LL FIT,SUP-2264229,CDM,C1757,HCPCS,0272,RC,,,,both,,,219.80,142.87,,,,,,,,,,,,,
DEVICE BNE BX 13GA BVL STYL 11GA TRCR 11GA KT FOR VERTPLSTY,SUP-2281725,CDM,2720000010,LOCAL,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
BIOTENE DRY MOUTH MT LIQD,RX-97548,CDM,A9154,HCPCS,0636,RC,09999-9917-32,NDC,,both,15,ML,2.70,1.75,,,,,,,,,,,,,
SENSOR OXMTR O2 FOR AESTIVA EXCEL SE 7100 7900,SUP-2226989,CDM,2720000010,LOCAL,0272,RC,,,,both,,,485.10,315.31,,,,,,,,,,,,,
CAGE 9X15MM ADJ RVS STEM AEQUALIS,SUP-2419739,CDM,C1889,HCPCS,0278,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
HC Rmvl FB Corneal W Slit Lamp,PX-4506522200,CDM,65222,CPT,0450,RC,,,,both,,,214.00,139.10,,,,,,,,,,,,,
SCREW INTRF L30MM DIA9MM PEEK FOR INTRAFIX ADV TIB FAST SYS,SUP-2256832,CDM,C1713,HCPCS,0278,RC,,,,both,,,935.72,608.22,,,,,,,,,,,,,
MICRO ACC SET 4F PLAT TIP,SUP-2116524,CDM,C1894,HCPCS,0272,RC,,,,both,,,103.62,67.35,,,,,,,,,,,,,
INSERT BPLR OD41-44MM ID28MM DURAMER POLY ACET HIP SLR,SUP-2304367,CDM,C1776,CPT,0278,RC,,,,both,,,3367.65,2188.97,,,,,,,,,,,,,
SCREW SET FOR PLATE HOLDER,SUP-2653725,CDM,C1713,HCPCS,0278,RC,,,,both,,,799.16,519.45,,,,,,,,,,,,,
URODYNAMICS LOOP CATHETER,SUP-2826944,CDM,C1726,HCPCS,0272,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
BLADE SAW L 79 MM WORKING L 17 MM D 4 MM THK MATERIAL 0.4 MM,SUP-2928861,CDM,2720000010,LOCAL,0272,RC,,,,both,,,599.05,389.38,,,,,,,,,,,,,
ALLOGRAFT BNE TISS,SUP-2431592,CDM,C1889,HCPCS,0278,RC,,,,both,,,9843.90,6398.53,,,,,,,,,,,,,
GRAFT HUM TISS W14XL36MM REV CORES FRZ DRY LIG RECON,SUP-2307074,CDM,C1713,HCPCS,0278,RC,,,,both,,,3230.75,2099.99,,,,,,,,,,,,,
SHEATH INTRO PRELUDE L 7 CM DIA 6 FR GUIDEWIRE L 40 CM DIA,SUP-2303288,CDM,C1894,HCPCS,0272,RC,,,,both,,,90.84,59.05,,,,,,,,,,,,,
CATHETER HD EXTN 14 FRX20 CM ACUTE STAGGERED FULL TY 400XL,SUP-2269513,CDM,C1752,HCPCS,0278,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
GUIDEWIRE URO L150CM DIA0.025IN TIP L3CM NIT HYDRPHLC STIFF,SUP-2417975,CDM,C1769,HCPCS,0272,RC,,,,both,,,195.94,127.36,,,,,,,,,,,,,
SCREW BNE L110MM DIA1035MM PROX FEM G TI CANN PARTIALLY THRD,SUP-2180726,CDM,C1713,HCPCS,0278,RC,,,,both,,,1922.65,1249.72,,,,,,,,,,,,,
PLATE BNE NAR 4.5X214 MM 12 HOLE SS LC-DCP,SUP-2569264,CDM,C1713,HCPCS,0278,RC,,,,both,,,357.49,232.37,,,,,,,,,,,,,
BLADE RETRACTOR CLOWARD 6.75X7 MM CERV ULTRA,SUP-2483556,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1859.73,1208.82,,,,,,,,,,,,,
PRIMIDONE 50 MG PO TABS,RX-11129,CDM,6370000000,HCPCS,0637,RC,53746-0544-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
MIXOR VAC SYS.W/SYRINGE,SUP-2822522,CDM,2720000010,LOCAL,0272,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
IOBP HIP OPEN TIP PROCEDURE KIT,SUP-2811227,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2543.40,1653.21,,,,,,,,,,,,,
PLATE BNE L292MM 16 H ST R MED DST TIB S STL VAR ANG LOK,SUP-2177653,CDM,C1713,HCPCS,0278,RC,,,,both,,,7223.29,4695.14,,,,,,,,,,,,,
PORT INFUS OD9.5FR VEN 2 LUMN VLV ATTCH CATH INTMED KT OPN,SUP-2127754,CDM,C1788,HCPCS,0278,RC,,,,both,,,1475.80,959.27,,,,,,,,,,,,,
SYSTEM IMPL 7MM DBL LD W/ SH FLIPCUTTER II TIGHTROPE RT,SUP-2120927,CDM,C1713,HCPCS,0278,RC,,,,both,,,2182.30,1418.49,,,,,,,,,,,,,
KIT CHOLGM PROC L13CM OD10FR SAFE SHTH W/ SIDE PRT AND,SUP-2148972,CDM,C1894,HCPCS,0272,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
GUIDEWIRE BENT TYP STR 0038INX150CM ZIPWIRE,SUP-2139342,CDM,C1769,HCPCS,0272,RC,,,,both,,,143.22,93.09,,,,,,,,,,,,,
CATHETER HD STR EXTN 15.5 FRX15 CM 3L SHT TERM TY T-3,SUP-2266994,CDM,C1752,HCPCS,0278,RC,,,,both,,,637.42,414.32,,,,,,,,,,,,,
PROTECTOR NERVE L 2 X W 1 CM PORCINE SODIUM HYALURONATE,SUP-2890372,CDM,C1763,HCPCS,0278,RC,,,,both,,,8066.66,5243.33,,,,,,,,,,,,,
VALVE PRESSURE PROGRAMMABLE 100 MM H2O MED HI BACTISEAL,SUP-2666829,CDM,C1889,HCPCS,0278,RC,,,,both,,,4513.00,2933.45,,,,,,,,,,,,,
BLADE SAW OSCLLTNG 19MMW X95MML 1.37MM/1.37MM THK CUT BRAZOL,SUP-2605499,CDM,2720000010,LOCAL,0272,RC,,,,both,,,212.26,137.97,,,,,,,,,,,,,
SYSTEM PACEMKR MICRA AV L 105 CM DIA23 FR DSTL SHFT L 5.8 CM,SUP-2516497,CDM,C1786,HCPCS,0275,RC,,,,both,,,76302.00,49596.30,,,,,,,,,,,,,
NEOSTIGMINE-GLYCOPYRROLATE 3-0.6 MG/3ML IV SOSY,RX-163605,CDM,J2711,HCPCS,0636,RC,42023-0269-05,NDC,,both,3,ML,122.20,79.43,,,,,,,,,,,,,
SHELL ACET OD44MM SPIK TIV ALLY POR TOT HIP PRI PRESSFIT,SUP-2202339,CDM,C1776,CPT,0278,RC,,,,both,,,8038.40,5224.96,,,,,,,,,,,,,
HC So Fta-Abs,PX-3028678066,CDM,86780,CPT,0302,RC,,,,both,,,116.00,75.40,,,,,,,,,,,,,
PHENYLEPHRINE HCL 10 MG/ML SOLN (MIXTURES ONLY),RX-430013,CDM,J2371,HCPCS,0636,RC,00641-6142-25,NDC,,both,0.01,ML,54.10,35.16,,,,,,,,,,,,,
PLATE BNE BAR 4 MM 4 H MINI LT MIDFACE L SHP MALL,SUP-2883295,CDM,C1713,HCPCS,0278,RC,,,,both,,,1638.14,1064.79,,,,,,,,,,,,,
AMOXICILLIN 250 MG/5ML PO SUSR,RX-454,CDM,340b,HCPCS,0637,RC,09999-9903-75,NDC,,both,5,ML,2.70,1.75,,,,,,,,,,,,,
DEVICE SPEC RETRV L175CM OD.4MM ODSEC3MMX3IN 3MM ARD INTCRAN,SUP-2280934,CDM,C1773,HCPCS,0272,RC,,,,both,,,9655.50,6276.07,,,,,,,,,,,,,
PUMP ANALGESIC ELASTOMERIC PIB PCA V1.5 SPIKE FILTER,SUP-2892585,CDM,C9806,HCPCS,0272,RC,,,,both,,,182.12,118.38,,,,,,,,,,,,,
SPACER INTBDY 24X13MM 0 DEG AP LUM CYL NONSCREW TI BAK,SUP-2205735,CDM,C1889,HCPCS,0278,RC,,,,both,,,8164.00,5306.60,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 80 CM DIA 5 MM RNG L 60 CM EPTFE,SUP-2396286,CDM,C1768,CPT,0278,RC,,,,both,,,4100.84,2665.55,,,,,,,,,,,,,
KIT CATH PICC CATH 5FR L50CM GWIRE L17.75IN 0.018IN POLYUR,SUP-2383379,CDM,C1751,HCPCS,0278,RC,,,,both,,,554.52,360.44,,,,,,,,,,,,,
KIT NEUROSTIMULATOR ANCHRING SYS W/ BUMPY ANCHR INJEX,SUP-2284645,CDM,C1713,HCPCS,0278,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
BIT DRL L195MM DIA6MM ST QUIK CPL NONRADIOPAQUE W/O STP,SUP-2187324,CDM,2720000010,LOCAL,0272,RC,,,,both,,,634.91,412.69,,,,,,,,,,,,,
KIT ACC TRANSRADIAL POLYMER COAT WIRE RADIALSOURCE RED,SUP-2157411,CDM,C1894,HCPCS,0272,RC,,,,both,,,101.27,65.83,,,,,,,,,,,,,
SELENIUM 200 MCG PO TABS,RX-7139,CDM,6370000000,HCPCS,0637,RC,40093-0101-96,NDC,,both,1,UN,0.50,0.32,,,,,,,,,,,,,
BLADE SCREWDRIVER 15MM/2MM/23MM DIA TORX,SUP-2694403,CDM,2720000010,LOCAL,0272,RC,,,,both,,,386.60,251.29,,,,,,,,,,,,,
PLATE BNE STR MIC 1X0.6 MM 24 HOLE ADPT TI NS LEVEL 1,SUP-2472552,CDM,C1713,HCPCS,0278,RC,,,,both,,,887.77,577.05,,,,,,,,,,,,,
CANNULA ENDOSCP DIA5.8MM HI FLO SPD LOK W/ 2 ROT STPCOCK,SUP-2366614,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2044.49,1328.92,,,,,,,,,,,,,
BUR SURG L15CM DIA17MM MTCH HD FLUT SM BOR MIDAS REX,SUP-2284384,CDM,C1713,HCPCS,0278,RC,,,,both,,,335.70,218.20,,,,,,,,,,,,,
BAG TISS CLSR DIA6CM TRNSPAR SIL SILO TAPR SPR LD PROX OPN,SUP-2134676,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1441.26,936.82,,,,,,,,,,,,,
GUIDEWIRE VASC DRIVEWIRE 24 L 204 CM RADIOPAQUE L 40 CM COAT,SUP-2930281,CDM,C1769,HCPCS,0272,RC,,,,both,,,5636.30,3663.59,,,,,,,,,,,,,
COUNTERSINK SND PROC 3MM W BKUP FOR PONTO SYS,SUP-2319894,CDM,C1713,HCPCS,0278,RC,,,,both,,,769.30,500.04,,,,,,,,,,,,,
Z DUPLICATE USE 2431329 STENT NEURO NEUROFORM ATLS L 15 MM DIA 3 MM DEL WIRE L 185,SUP-2417547,CDM,C1874,HCPCS,0278,RC,,,,both,,,25748.00,16736.20,,,,,,,,,,,,,
KIT CATH 7FR L20CM CTRL VEN POLYUR 3 LUMN BLU FLEXTIP ARWGRD,SUP-2120598,CDM,C1751,HCPCS,0278,RC,,,,both,,,227.34,147.77,,,,,,,,,,,,,
GRAFT VASC IMPRA L 70 CM DIA10 MM EPTFE STR TW N RING HEMO,SUP-2126598,CDM,C1768,CPT,0278,RC,,,,both,,,1641.37,1066.89,,,,,,,,,,,,,
CLAMP EXT FIX CLP ON SELF HLD MAG RESONANCE CONDITIONAL,SUP-2188500,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1433.28,931.63,,,,,,,,,,,,,
BIT DRL CPL END 6X195 MM,SUP-2795979,CDM,2720000010,LOCAL,0272,RC,,,,both,,,315.38,205.00,,,,,,,,,,,,,
COVER BUR H DIA7MM UNIV CRANIOMAXILLOFACIAL TI MALL LO PROF,SUP-2366287,CDM,C1713,HCPCS,0278,RC,,,,both,,,780.98,507.64,,,,,,,,,,,,,
HC Ther Ivntj Cog Funcj Cntct 1st 15 Mins|OP SPEECH LANGUAGE SERVICE|DOCUMENTATION ON FILE,PX-4409712900,CDM,97129,CPT,0440,RC,,,GN|KX,outpatient,,,186.00,120.90,,,,,,,,,,,,,
APPLICATOR THERMOABLATION L14CM 140W SLD STATE GENRTR INTEGR,SUP-2118730,CDM,2720000010,LOCAL,0272,RC,,,,both,,,11423.32,7425.16,,,,,,,,,,,,,
PLATE BNE L199MM 8 H NONSTERILE R PERIARTC PROX HUM S STL,SUP-2177810,CDM,C1713,HCPCS,0278,RC,,,,both,,,5259.81,3418.88,,,,,,,,,,,,,
CANNULA ASPIR L15CM OD3MM 1 PC REUSE ACCEL III,SUP-2152202,CDM,2720000010,LOCAL,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
PIN EXT FIX L9IN DIA5/64IN S STL DMND PNT W/ SMOOTH SHFT,SUP-2342707,CDM,C1713,HCPCS,0278,RC,,,,both,,,182.75,118.79,,,,,,,,,,,,,
CATHETER EP D 2 MM 1 MM 6 FRX92 CM BLU,SUP-2248655,CDM,C1730,HCPCS,0272,RC,,,,both,,,1331.36,865.38,,,,,,,,,,,,,
HC Asp Injection Major Joint|BILATERAL PROCEDURE|PBB CHARGE,PX-4502061000,CDM,20610,CPT,0450,RC,,,50|PBB,outpatient,,,1092.00,709.80,,,,,,,,,,,,,
WEDGE TIB SZ 1-2 THK10MM KNEE FULL STP HNG REV LEGION,SUP-2346599,CDM,C1776,CPT,0278,RC,,,,both,,,5695.96,3702.37,,,,,,,,,,,,,
SLEEVE FEM SM SZ 18-19 TI STIKTITE HA HIP REV MOD REDAPT,SUP-2421235,CDM,C1776,CPT,0278,RC,,,,both,,,5262.64,3420.72,,,,,,,,,,,,,
PLATE BNE L 226 MM SCREW DIA 4.5 MM 9 H PROX FEM STRL EVOS,SUP-2931141,CDM,C1713,HCPCS,0278,RC,,,,both,,,10068.41,6544.47,,,,,,,,,,,,,
PLATE BNE 100DEG 3X4 H L TI OBLQ L SHP FOR 2MM SCR,SUP-2191282,CDM,C1713,HCPCS,0278,RC,,,,both,,,1057.24,687.21,,,,,,,,,,,,,
PLATE 95 DEG CONDYLAR 9 HOLES 40MM 156MM STERILE,SUP-2547717,CDM,C1713,HCPCS,0278,RC,,,,both,,,3914.01,2544.11,,,,,,,,,,,,,
COLLAR CERV M H3.25IN FOR 13-16IN PLASTAZOTE FOAM 2 PC L,SUP-2336004,CDM,L0140,HCPCS,0272,RC,,,,both,,,30.14,19.59,,,,,,,,,,,,,
DRILL GUIDE HANDLE 23MM LAG SCREW TECHNIQUE,SUP-2696051,CDM,C1713,HCPCS,0278,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
KIT ORTH STBL IMPL ON INSRTR SLD DRL ANGLED GUIDE STRL DISP,SUP-2899045,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4317.50,2806.37,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY STEEROCATH DX L 110 CM DIA 7 FR,SUP-2141248,CDM,C1730,HCPCS,0272,RC,,,,both,,,2194.86,1426.66,,,,,,,,,,,,,
CATHETER EP ABLAT B CRV QPLR 2-5-2MM SPC 4MM TIP UNI DIR,SUP-2248688,CDM,C1733,HCPCS,0272,RC,,,,both,,,2241.96,1457.27,,,,,,,,,,,,,
SPIRATION DEPLOYMENT CATHETER,SUP-2679936,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3375.50,2194.07,,,,,,,,,,,,,
CATHETER HAD L20CM OD14FR ACUTE VES INSRT KINK RESIST REM,SUP-2118063,CDM,C1752,HCPCS,0278,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
COLLAR CERV L H3.25X23IN M DENS FOAM COT STOCK CVR LO,SUP-2196890,CDM,L0120,HCPCS,0274,RC,,,,both,,,10.96,7.12,,,,,,,,,,,,,
ELECTRODE ES 24X26FR YEL COAG PT FOR 24/28FR RESECTSCP,SUP-2261190,CDM,2720000010,LOCAL,0272,RC,,,,both,,,370.11,240.57,,,,,,,,,,,,,
PLATE BNE L42MM THK1.3MM 6 H MTCRPL TI STR COMPR FOR,SUP-2267914,CDM,C1713,HCPCS,0278,RC,,,,both,,,854.08,555.15,,,,,,,,,,,,,
K-WIRE .045X12 PT DM,SUP-2818088,CDM,C1713,HCPCS,0278,RC,,,,both,,,109.65,71.27,,,,,,,,,,,,,
PROBE SURG SCR PEDCL STRL PHANTOM XL DISP,SUP-2851753,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3956.40,2571.66,,,,,,,,,,,,,
PENICILLIN G BENZATHINE & PROC 1200000 UNIT/2ML IM SUSP,RX-104360,CDM,J0558,HCPCS,0636,RC,60793-0600-10,NDC,,both,2,ML,717.20,466.18,,,,,,,,,,,,,
CATHETER DRAINAGE INTRO MINI 11 FRX10.5 CM RET BIO-MEDICUS,SUP-2745325,CDM,C1729,HCPCS,0272,RC,,,,both,,,1212.35,788.03,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE L 10 MM DIA 7.5 MM SZ 2 CART ARAGONITE,SUP-2913173,CDM,C1763,HCPCS,0278,RC,,,,both,,,23864.00,15511.60,,,,,,,,,,,,,
PLATE BNE BROAD 5.5X180 MM 18 HOLE SS LCP,SUP-2569371,CDM,C1713,HCPCS,0278,RC,,,,both,,,740.88,481.57,,,,,,,,,,,,,
COMPONENT PATELLAR 3 PEG STD 26X7 MM KNEE DOMED ROUNDED X3,SUP-2390315,CDM,C1776,CPT,0278,RC,,,,both,,,3862.20,2510.43,,,,,,,,,,,,,
POST TOE JT L16MM DIA8MM HEMICAP TI ARTC COMP TAPR,SUP-2123593,CDM,C1776,CPT,0278,RC,,,,both,,,1328.22,863.34,,,,,,,,,,,,,
PLATE DISTL TIB ANTERIOR 3HOLE,SUP-2718080,CDM,C1713,HCPCS,0278,RC,,,,both,,,2904.50,1887.92,,,,,,,,,,,,,
DRILL SURG CANN 18 MM ENTRY,SUP-2766137,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
SLEEVE KNEE SM L13IN FOR 155 18IN NEOPRENE OPN PAT EXTRA LEN,SUP-2196828,CDM,L1820,HCPCS,0272,RC,,,,both,,,22.70,14.75,,,,,,,,,,,,,
PLATE BONE W8XL80MM THK3.3MM 10 H STRL BILAT PELV S STL,SUP-2186238,CDM,C1713,HCPCS,0278,RC,,,,both,,,1256.63,816.81,,,,,,,,,,,,,
WASHER ORTH SM HUM STRL AFFIXUS NAT NAIL,SUP-2606870,CDM,C1713,HCPCS,0278,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
IMPLANT TOE JT L15MM OD6.6MM 60DEG GRN IOFIXX-POST,SUP-2223896,CDM,C1713,HCPCS,0278,RC,,,,both,,,3925.00,2551.25,,,,,,,,,,,,,
GRAFT HUM TISS W40XL70MM THK176 225MM ACELLULAR DERM MTRX,SUP-2418429,CDM,Q4125,HCPCS,0636,RC,,,,both,,,9168.96,5959.82,,,,,,,,,,,,,
CONNECTOR EXT FIX L35MM ANG PIN FOR TAY SPAT FRME SYS,SUP-2342989,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2390.95,1554.12,,,,,,,,,,,,,
WIRE FIX 1.6 MM ASNS KIRSCHNER,SUP-2362518,CDM,C1713,HCPCS,0278,RC,,,,both,,,28.26,18.37,,,,,,,,,,,,,
PLATE BONE CMPRSSN 204MML HLX11 STNLSS STEEL 90DG ANGLD TUBE,SUP-2720626,CDM,C1713,HCPCS,0278,RC,,,,both,,,1718.02,1116.71,,,,,,,,,,,,,
COMPONENT ULN SM L3IN R EL TIV PLSM INTERCHANGEABLE CEM,SUP-2205936,CDM,C1776,CPT,0278,RC,,,,both,,,14219.27,9242.53,,,,,,,,,,,,,
CATHETER NEPHSTMY L15CM BAL DIA10MM PTFE BURST RATE SHTH BAL,SUP-2169833,CDM,C1726,HCPCS,0272,RC,,,,both,,,860.52,559.34,,,,,,,,,,,,,
GUIDEWIRE VASC L 50 CM DIA 0.021 IN TAPR L 7 CM FLPY TIP L,SUP-2167590,CDM,C1769,HCPCS,0272,RC,,,,both,,,34.10,22.16,,,,,,,,,,,,,
CATHETER ABLATN THERMASTAR BLU,SUP-2248465,CDM,C1733,HCPCS,0272,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
PLATE BNE L 23 MM SCREW DIA 3.5 MM 2 SHFT H TI 1/3 TUBLR NS,SUP-2907645,CDM,C1713,HCPCS,0278,RC,,,,both,,,1668.28,1084.38,,,,,,,,,,,,,
NAIL IM L72MM DIA1.8MM ANK FT THRD SPHR WIRE FOR LAPIDUS,SUP-2321641,CDM,C1713,HCPCS,0278,RC,,,,both,,,384.65,250.02,,,,,,,,,,,,,
GUIDEWIRE VASC J 3 MM AD 0.021 INX260 CM PTFE COAT SAFE-T-J,SUP-2167589,CDM,C1769,HCPCS,0272,RC,,,,both,,,51.21,33.29,,,,,,,,,,,,,
BUR SURG X COARSE DIAMOND 7 MM 14 CM BALL LG BOR MIDAS REX 8,SUP-2664575,CDM,2720000010,LOCAL,0272,RC,,,,both,,,458.94,298.31,,,,,,,,,,,,,
DEVICE TISS FIX FIBERTAPE SUTURE FOR INTERNALBRACE TECH STRL,SUP-2882174,CDM,C1713,HCPCS,0278,RC,,,,both,,,2276.50,1479.72,,,,,,,,,,,,,
CAGE SPNL L12XW12XH30MM 4 LOBE LORDTC END CAP IMP NGAGE,SUP-2317734,CDM,C1889,HCPCS,0278,RC,,,,both,,,12377.88,8045.62,,,,,,,,,,,,,
GRAFT ENDOVASC L3.3CM DIA26MM AORT EXT ENDOPROS EXCLUDER,SUP-2395939,CDM,C1768,CPT,0278,RC,,,,both,,,8509.40,5531.11,,,,,,,,,,,,,
LACOSAMIDE 100 MG PO TABS,RX-96883,CDM,6370000000,HCPCS,0637,RC,00904-7245-68,NDC,,both,1,UN,9.30,6.04,,,,,,,,,,,,,
LOCKNUT ORTH CORTICAL 4.5 MM STRL LTX,SUP-2861519,CDM,C1713,HCPCS,0278,RC,,,,both,,,523.94,340.56,,,,,,,,,,,,,
LENS IOL ASPHERIC 17+ DIOPT ANTR CHMBR MONO FOC 1 PC,SUP-2112424,CDM,V2632,HCPCS,0276,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
PLATE BNE RECON MED 2-2.3X2.8 MM LT PRESHAPED SMRT TI NS,SUP-2487421,CDM,C1713,HCPCS,0278,RC,,,,both,,,9908.84,6440.75,,,,,,,,,,,,,
SET SCR SPNL OD6.35MM STD TI POST THORACOLUMBOSACRAL CANN,SUP-2290653,CDM,C1713,HCPCS,0278,RC,,,,both,,,644.96,419.22,,,,,,,,,,,,,
HC Intra Art Admin Radpharm,PX-3407944500,CDM,79445,CPT,0340,RC,,,,both,,,3319.00,2157.35,,,,,,,,,,,,,
DRILL SURG BUSHING 1.8 MM NC,SUP-2487599,CDM,2720000010,LOCAL,0272,RC,,,,both,,,457.18,297.17,,,,,,,,,,,,,
GRAFT EVAR L100MM DIA46X46MM CATH 25FR THOR CLS WEB STR DST,SUP-2281720,CDM,C1768,CPT,0278,RC,,,,both,,,51009.30,33156.04,,,,,,,,,,,,,
SHEAR HARMONIC VES SEAL 360 DEG SHFT L 45 MM DIA 5 MM JAW L,SUP-2889527,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1514.23,984.25,,,,,,,,,,,,,
EXTRACTOR SURG L4.5-5.5 MMXTRACT ALL DISP FOR 4.5-5.5 MM,SUP-2337713,CDM,C1713,HCPCS,0278,RC,,,,both,,,722.20,469.43,,,,,,,,,,,,,
GRAFT BIO W5XL5CM FOR OTO REP BIODESIGN,SUP-2170502,CDM,C1763,HCPCS,0278,RC,,,,both,,,1475.80,959.27,,,,,,,,,,,,,
STEM FEM CEM STD OFFSET FORGED TI ALLOY SZ 1 ACUMATCH L SER,SUP-2221718,CDM,C1776,CPT,0278,RC,,,,both,,,4647.20,3020.68,,,,,,,,,,,,,
KIT KYPHOPLASTY VUE CEMENT MIXER COMBO,SUP-2798686,CDM,C1713,HCPCS,0278,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
PLATE BNE MESH PANEL STD 1.5X160X135X0.6 MM NEURO 750 HOLE,SUP-2474776,CDM,C1713,HCPCS,0278,RC,,,,both,,,9531.09,6195.21,,,,,,,,,,,,,
PROSTHESIS OSS MANGHAM PISTON 0.6X5 MM FLROPLAS PLAT,SUP-2638201,CDM,L8613,CPT,0278,RC,,,,both,,,510.63,331.91,,,,,,,,,,,,,
CATHETER CV SET 035 9 FRX20 CM 3L POLYURETHANE,SUP-2759979,CDM,C1751,HCPCS,0278,RC,,,,both,,,304.64,198.02,,,,,,,,,,,,,
WIRE FIX 0.8 IN KIRSCHNER,SUP-2433961,CDM,C1713,HCPCS,0278,RC,,,,both,,,145.38,94.50,,,,,,,,,,,,,
SHEATH INTRO PERFRMR L 45 CM DIA14 FR GUIDEWIRE 0.038 IN,SUP-2169787,CDM,C1894,HCPCS,0272,RC,,,,both,,,305.77,198.75,,,,,,,,,,,,,
ANCHOR SUT DIA4.5MM SL FOOTPRINT ULT PK,SUP-2341886,CDM,C1713,HCPCS,0278,RC,,,,both,,,910.60,591.89,,,,,,,,,,,,,
TI NARROW 6 HOLE PLATE 78MM,SUP-2703168,CDM,C1713,HCPCS,0278,RC,,,,both,,,320.91,208.59,,,,,,,,,,,,,
HEAD ULN MOD 17.5 MM ELBW,SUP-2610430,CDM,C1776,CPT,0278,RC,,,,both,,,5045.07,3279.30,,,,,,,,,,,,,
HANDPIECE IRRIG STD W/ A ROT SPR 270DEG ARTC HYDRODEBRIDER,SUP-2284172,CDM,2720000010,LOCAL,0272,RC,,,,both,,,977.64,635.47,,,,,,,,,,,,,
TUBE EXT FIX L300MM OD25MM RED C FOR UNILAT MONOTB TRIAX SYS,SUP-2372616,CDM,C1713,HCPCS,0278,RC,,,,both,,,546.86,355.46,,,,,,,,,,,,,
PLATE BNE L 2-2.5X34X1 MM 18 MM LT 2X2 HOLE TLTS BSSO TI,SUP-2467215,CDM,C1713,HCPCS,0278,RC,,,,both,,,1105.88,718.82,,,,,,,,,,,,,
NAIL FIX L22MM OD2MM LACTOSORB COPOLYMER ABSRB SGL USE FOR,SUP-2212970,CDM,C1713,HCPCS,0278,RC,,,,both,,,697.08,453.10,,,,,,,,,,,,,
CATHETER HD 20 CM KT CHRONIC PRE CRV BASIC SHTH EVENMORE,SUP-2116552,CDM,C1750,HCPCS,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
ANCHOR BONE SP FBRTAK RC FBRTPE BLK/BLU,SUP-2757497,CDM,C1713,HCPCS,0278,RC,,,,both,,,1475.80,959.27,,,,,,,,,,,,,
BIT DRL L16MM OD4MM TI W/O STP NONRADIOLUCENT FOR 4MM SCR,SUP-2415600,CDM,2720000010,LOCAL,0272,RC,,,,both,,,533.80,346.97,,,,,,,,,,,,,
GUIDEWIRE VASC STR 3 CM 0.035 INX150 CM STD STIFF GLIDEWIRE,SUP-2385566,CDM,C1769,HCPCS,0272,RC,,,,both,,,104.91,68.19,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE 5.0 CC DBM PTTY FIBER XCITE,SUP-2881445,CDM,C1713,HCPCS,0278,RC,,,,both,,,5074.24,3298.26,,,,,,,,,,,,,
CONE WAGNER 135 DEG 15MM,SUP-2505549,CDM,C1776,CPT,0278,RC,,,,both,,,7309.92,4751.45,,,,,,,,,,,,,
TRAY 4FX20CM FULL NRS CT MIDLN,SUP-2267040,CDM,C1751,HCPCS,0278,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
HC So Growth Hormone,PX-3018300366,CDM,83003,CPT,0301,RC,,,,both,,,688.00,447.20,,,,,,,,,,,,,
INSERT FEM STD NK HIP CO CHROM TAPR ENDO II,SUP-2405245,CDM,C1776,CPT,0278,RC,,,,both,,,357.96,232.67,,,,,,,,,,,,,
IMPLANT SUBTALAR W9XH17MM DISCO,SUP-2878333,CDM,C1776,CPT,0278,RC,,,,both,,,5385.10,3500.31,,,,,,,,,,,,,
HYDROCODONE-ACETAMINOPHEN 7.5-325 MG PO TABS,RX-34544,CDM,6370000000,HCPCS,0637,RC,00406-0124-23,NDC,,both,1,UN,3.10,2.01,,,,,,,,,,,,,
JOINT FNGR MP 10 SIL PREFLEX STRL,SUP-2536094,CDM,C1776,CPT,0278,RC,,,,both,,,3925.00,2551.25,,,,,,,,,,,,,
GUIDEWIRE ORTHOPEDIC 3.2 MM 351399] DEPUY SYNTHES USA],SUP-2188082,CDM,C1769,HCPCS,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
MESH HERN OPTIMIZED COMP 15 CM RND POLYESTER PARIETEX,SUP-2752190,CDM,C1781,HCPCS,0278,RC,,,,both,,,3029.88,1969.42,,,,,,,,,,,,,
GUIDE RESECT HUM NK SOLAR,SUP-2374005,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1104.02,717.61,,,,,,,,,,,,,
SCREW BONE L14MM DIA4MM CORT TI ST NONCANNULATED LCK FULL,SUP-2181106,CDM,C1713,HCPCS,0278,RC,,,,both,,,472.60,307.19,,,,,,,,,,,,,
SPLINT THMB AD SM FOR 4.75-6.25IN RT WR REG TRIOXON LINING,SUP-2324737,CDM,L3931,HCPCS,0272,RC,,,,both,,,59.72,38.82,,,,,,,,,,,,,
PLATE BNE L 54 MM 4 H ANODIZATION TYP II RT VOLAR DSTL,SUP-2902220,CDM,C1713,HCPCS,0278,RC,,,,both,,,4851.83,3153.69,,,,,,,,,,,,,
ANCHOR SUT DIA1.45MM 2 SHT RIG DRL BIT JUGGERKNOT,SUP-2212785,CDM,C1713,HCPCS,0278,RC,,,,both,,,1111.72,722.62,,,,,,,,,,,,,
KIT TUBING RAPIDPORT EZ,SUP-2119236,CDM,C1713,HCPCS,0278,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
KASSAM SCREEN MESH PANEL 2MM CP TITANIUM,SUP-2680902,CDM,C1713,HCPCS,0278,RC,,,,both,,,798.44,518.99,,,,,,,,,,,,,
BUTTON GASTMY L 2.3 CM DIA14 FR SIL ENFIT LP GLO GRN,SUP-2915190,CDM,C1889,HCPCS,0278,RC,,,,both,,,425.03,276.27,,,,,,,,,,,,,
CATHETER CNTSS 5FR DIA 19GA INTRDCR NDLE 10CML TPRD TIP LOW,SUP-2484882,CDM,C1729,HCPCS,0272,RC,,,,both,,,54.17,35.21,,,,,,,,,,,,,
PLATE BNE 1MM LAPIDUS STP,SUP-2243209,CDM,C1713,HCPCS,0278,RC,,,,both,,,4641.67,3017.09,,,,,,,,,,,,,
BRACE KNEE UNIV RIGID CUSTOMIZABLE ROM HINGE TRIM DONJOY,SUP-2914882,CDM,2720000010,LOCAL,0272,RC,,,,both,,,335.60,218.14,,,,,,,,,,,,,
PLATE BNE THK0.5MM 10 H CRANIOMAXILLOFACIAL BLU TI ORBIT,SUP-2366237,CDM,C1713,HCPCS,0278,RC,,,,both,,,695.82,452.28,,,,,,,,,,,,,
IMPLANT HUM TISS L 4 X W 4 CM DECELL PLCNTA MEMBRN TEND NEVE,SUP-2881925,CDM,C1762,CPT,0278,RC,,,,both,,,8336.70,5418.85,,,,,,,,,,,,,
CAGE SPNL W13XH11XL21MM 10DEG C FBR REINF POLYMER POST LUM,SUP-2256323,CDM,C1889,HCPCS,0278,RC,,,,both,,,10500.16,6825.10,,,,,,,,,,,,,
SYSTEM FIX DIA7-7.5MM FEM HRD SCR SHTH INTRAFIX,SUP-2256823,CDM,C1713,HCPCS,0278,RC,,,,both,,,2059.84,1338.90,,,,,,,,,,,,,
GRAFT ALLGRFT BLK CANC DEMIN FRZ DRY IMPL 20MMX20MMX30MM,SUP-2264683,CDM,C1713,HCPCS,0278,RC,,,,both,,,1386.91,901.49,,,,,,,,,,,,,
STENT URET MULT LEN 6FR 22-28CM GWIRE PTFE FLX .035,SUP-2313749,CDM,C2617,HCPCS,0278,RC,,,,both,,,271.67,176.59,,,,,,,,,,,,,
FILTER BACT INT 0.2 MIC,SUP-2255904,CDM,2720000010,LOCAL,0272,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
BUR SURG NEURO 31 MM CUT TUNGSTEN CARBIDE HI-LINE XS DISP,SUP-2108778,CDM,C1713,HCPCS,0278,RC,,,,both,,,507.02,329.56,,,,,,,,,,,,,
BEVACIZUMAB-ADCD 25 MG/ML IV SOLN (MIXTURES ONLY),RX-4082833,CDM,Q5129,HCPCS,0636,RC,72606-0011-01,NDC,,both,4,ML,1951.00,1268.15,,,,,,,,,,,,,
DEVICE BRST BX NDL L9CM DIA12GA 20MM ATEC,SUP-2239995,CDM,2720000010,LOCAL,0272,RC,,,,both,,,791.91,514.74,,,,,,,,,,,,,
PLATE BNE SM W11XL98MM THK3.4MM 7 H BILAT TI RIG NEUT LOK,SUP-2420739,CDM,C1713,HCPCS,0278,RC,,,,both,,,957.54,622.40,,,,,,,,,,,,,
SLEEVE FEM M HIP MECTACER BIOLOX OPT SYS,SUP-2267358,CDM,C1776,CPT,0278,RC,,,,both,,,615.44,400.04,,,,,,,,,,,,,
ANCHOR SUT L14.7MM DIA6.5MM W/ TWO SZ 2 FIBERWIRE CRKSCR FT,SUP-2121554,CDM,C1713,HCPCS,0278,RC,,,,both,,,926.30,602.09,,,,,,,,,,,,,
LEFT LAT TTC FUS PLT,SUP-2315871,CDM,C1713,HCPCS,0278,RC,,,,both,,,9517.34,6186.27,,,,,,,,,,,,,
CATHETER GUID VISTA BRT TIP L 100 CM 7 FR 0.078 IN NYL SIM2,SUP-2155869,CDM,C1887,HCPCS,0272,RC,,,,both,,,563.79,366.46,,,,,,,,,,,,,
PLATE BNE L93MM 4 H NONSTERILE L MED PROX TIB S STL LOK,SUP-2185632,CDM,C1713,HCPCS,0278,RC,,,,both,,,3776.89,2454.98,,,,,,,,,,,,,
BIT DRL L195MM DIA4MM ST 3 FLUT QUIK CPL NONRADIOPAQUE W/O,SUP-2187608,CDM,2720000010,LOCAL,0272,RC,,,,both,,,617.23,401.20,,,,,,,,,,,,,
SIZER MAMM DIA13.6-13.2CM P5.1-5.9CM 500-600CC SIL NACL,SUP-2300287,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
HC So Hemoglobin Fetal,PX-3058546066,CDM,85460,CPT,0305,RC,,,,outpatient,,,479.00,311.35,,,,,,,,,,,,,
SHEATH INTRO PRELUDE L 23 CM DIA 5 FR 0.018 IN 4 CM 21GA NIT,SUP-2740723,CDM,C1894,HCPCS,0272,RC,,,,both,,,148.37,96.44,,,,,,,,,,,,,
CONFORMER OPHTH AD SM W/ H BILAT METHYLMETHACRYLATE POSTOP,SUP-2129498,CDM,L8610,HCPCS,0278,RC,,,,both,,,46.16,30.00,,,,,,,,,,,,,
APPLIER CLP L4.375IN STD STR FOR PHYNOX YASRG,SUP-2108330,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4831.36,3140.38,,,,,,,,,,,,,
SCREW BONE 9MM THRD 45MM ANK ARTH LCK RETRONAIL,SUP-2316238,CDM,C1713,HCPCS,0278,RC,,,,both,,,372.88,242.37,,,,,,,,,,,,,
CATHETER GUID L132CM STR X SUPP MIC ELITECROSS,SUP-2155670,CDM,C1887,HCPCS,0272,RC,,,,both,,,847.80,551.07,,,,,,,,,,,,,
CATHETER ETER CVC DBL LUMN KT BASIC L 9FRX90CM,SUP-2268422,CDM,C1751,HCPCS,0278,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
SET URET STENT MARD L 28 CM DIA 8 FR ZIPWIRE 0.038 IN,SUP-2457680,CDM,C2617,HCPCS,0278,RC,,,,both,,,566.02,367.91,,,,,,,,,,,,,
ROD SPNL 2 5.5-6.35X450 MM TI NS MONARCH,SUP-2583132,CDM,C1713,HCPCS,0278,RC,,,,both,,,1340.78,871.51,,,,,,,,,,,,,
CATHETER HD LG LUMEN 16 FRX32 CM LT STR HEMOSTAR XK,SUP-2127869,CDM,C1750,HCPCS,0278,RC,,,,both,,,1575.65,1024.17,,,,,,,,,,,,,
GRAFT HUM TISS PTCH 9X2 CM ROUNDED BOV PERICARD PHOTOFIX LTX,SUP-2859716,CDM,C1768,CPT,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
BLADE SAW L 65 X W 7.5 MM D 4 MM THK MATERIAL 0.3 MM CUT 0.4,SUP-2929048,CDM,2720000010,LOCAL,0272,RC,,,,both,,,599.27,389.53,,,,,,,,,,,,,
TOLTERODINE TARTRATE 2 MG PO TABS,RX-22783,CDM,6370000000,HCPCS,0637,RC,33342-0098-09,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
GUIDEWIRE VASC VSI TRU-TORQUE L 180 CM DIA 0.035 IN PTFE MOD,SUP-2763463,CDM,C1769,HCPCS,0272,RC,,,,both,,,200.96,130.62,,,,,,,,,,,,,
PLATE BNE L 93 X W 10 MM THK 2 MM SCREW DIA2.7/3.5 MM 5 H SS 72465405N,SUP-2933247,CDM,C1713,HCPCS,0278,RC,,,,both,,,4157.83,2702.59,,,,,,,,,,,,,
TOE JOINT KIT CANN 10 DEG 3.5 MM STRL HAMMERTUBE,SUP-2749751,CDM,C1776,CPT,0278,RC,,,,both,,,4700.58,3055.38,,,,,,,,,,,,,
PATCH CV HEMACAROTID L 75XW 8MM THK0.41MM POLYESTER BOV PK10,SUP-2227505,CDM,C1781,HCPCS,0278,RC,,,,both,,,348.19,226.32,,,,,,,,,,,,,
BIT DRL L248MM DIA2.8MM QUIK CPL W/O STP CALIB,SUP-2187458,CDM,2720000010,LOCAL,0272,RC,,,,both,,,467.67,303.99,,,,,,,,,,,,,
PACEMAKER CARD INTICA PROMRI DX TI HSNG EPOXY RESIN HEADER,SUP-2138470,CDM,C1722,HCPCS,0275,RC,,,,both,,,66725.00,43371.25,,,,,,,,,,,,,
SCREW INTRF L12MM OD3.5MM HDLSS BLNT THRD TENODESIS,SUP-2321045,CDM,C1713,HCPCS,0278,RC,,,,both,,,1208.90,785.78,,,,,,,,,,,,,
LINER ACET HOOD 36X52-54 MM HIP XLPE LOGICAL,SUP-2322495,CDM,C1776,CPT,0278,RC,,,,both,,,2141.48,1391.96,,,,,,,,,,,,,
GRAFT STENT 18X33 MM ABD AORT TALENT XCELERANT,SUP-2429839,CDM,C1768,CPT,0278,RC,,,,both,,,8085.50,5255.57,,,,,,,,,,,,,
STIMULATOR NERVE PERIPH SUNSTIM LF,SUP-2381625,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1118.63,727.11,,,,,,,,,,,,,
CLIP ENDOSCOPIC L162CM TIP DIA9.5-11MM BIOCOMPATIBLE FOR SCOOP PADLOCK CLIP,SUP-2119263,CDM,C1760,HCPCS,0278,RC,,,,both,,,1378.15,895.80,,,,,,,,,,,,,
GRAFT VASC IMPRA L 15 CM DIA 4-7 MM EPTFE STP STD WALL N,SUP-2761528,CDM,C1768,CPT,0278,RC,,,,both,,,830.66,539.93,,,,,,,,,,,,,
SYSTEM PROLAPSE REP APOGEE W/ INTEPRO,SUP-2140311,CDM,C1781,HCPCS,0278,RC,,,,both,,,3564.69,2317.05,,,,,,,,,,,,,
STENT BILI PRECIS L 20 MM DIA 8 MM CATH L 135 CM DIA 8 FR,SUP-2158958,CDM,C1876,HCPCS,0278,RC,,,,both,,,7046.16,4580.00,,,,,,,,,,,,,
VALVE HYDROCEPHALUS PED W/ BUR H RESVR PROGAV 2.0,SUP-2108750,CDM,C1729,HCPCS,0272,RC,,,,both,,,8903.16,5787.05,,,,,,,,,,,,,
SCREW BNE L38MM DIA3.5MM STD CORT TI ST LOK LO PROF FOR,SUP-2376995,CDM,C1713,HCPCS,0278,RC,,,,both,,,117.75,76.54,,,,,,,,,,,,,
CATHETER DRAINAGE TY 7.5 FR LCK INTRO SYS MARKER BND MAK-NV,SUP-2459609,CDM,C1729,HCPCS,0272,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
HC US Extrem Limited Nonvasc,PX-4027688200,CDM,76882,CPT,0402,RC,,,,both,,,1227.00,797.55,,,,,,,,,,,,,
EXPANDER BRST TISS 225CC W10XH10CM P52CM SIL SMOOTH HI PROF,SUP-2301015,CDM,C1789,HCPCS,0278,RC,,,,both,,,5730.50,3724.82,,,,,,,,,,,,,
STAPLER INST DISP PED 20CM X 5MM JUSTRIGHT,SUP-2427770,CDM,C1713,HCPCS,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
PLATE BNE LCK 46 MM RADIAL 5 HOLE STD CURVATURE HD TI NS,SUP-2518184,CDM,C1713,HCPCS,0278,RC,,,,both,,,3730.32,2424.71,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY LIVEWIRE L 95 CM DIA 7 MM SPC,SUP-2496082,CDM,C1730,HCPCS,0272,RC,,,,both,,,963.10,626.01,,,,,,,,,,,,,
SCREW BNE LAG PARTIALLY THRDED TI 30MM THRD 11MM CANN 16MM,SUP-2392892,CDM,C1713,HCPCS,0278,RC,,,,both,,,469.43,305.13,,,,,,,,,,,,,
KIT ARTHSCP INSTR W/ MTL SPEAR AND DRL DISP FOR 3.5MM,SUP-2121533,CDM,C1713,HCPCS,0278,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
PLATE 3.5MM TI CURVED NARROW LCP 14 HOLE-STERILE,SUP-2546920,CDM,C1713,HCPCS,0278,RC,,,,both,,,2693.52,1750.79,,,,,,,,,,,,,
K WIRE FIX DIA1.8MM SHT SMOOTH OLV TIP,SUP-2321639,CDM,C1769,HCPCS,0272,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
NEEDLE VENTRICULAR SCOVILLE 14 GAX3-3/8 IN TWO HOLE,SUP-2666373,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1167.55,758.91,,,,,,,,,,,,,
SHEATH INTRO L 5.5 CM DIA 5 FR STRL,SUP-2153790,CDM,C1894,HCPCS,0272,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
CHOLANGIOGRAM KIT RX AUTOTOME UTOM XL SPHINTOM JAGWIRE 7533,SUP-2525329,CDM,C1769,HCPCS,0272,RC,,,,both,,,705.43,458.53,,,,,,,,,,,,,
PROCESSOR HEARING AID BLK CP910 NUCLS 6,SUP-2165047,CDM,L8690,HCPCS,0278,RC,,,,both,,,25104.30,16317.79,,,,,,,,,,,,,
HC Clsd Tx Shdr Disl W Neck Fx,PX-4502367500,CDM,23675,CPT,0450,RC,,,,both,,,1633.00,1061.45,,,,,,,,,,,,,
SYSTEM SPNL SEAL 3ML EXACT DURASEAL,SUP-2243115,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2459.06,1598.39,,,,,,,,,,,,,
BUTTON GAST 12FR STOMA L1.2CM APPLE SHP BAL DURABLE EXT,SUP-2119862,CDM,2720000010,LOCAL,0272,RC,,,,both,,,386.22,251.04,,,,,,,,,,,,,
SET FILTER DEL VENATECH LP L 96 CM DIA 9 FR GUIDEWIRE 0.038,SUP-2492090,CDM,C1894,HCPCS,0272,RC,,,,both,,,794.39,516.35,,,,,,,,,,,,,
GUIDEWIRE VASC HI TORQ STEELCORE L 300 CM DIA 0.018 IN TIP L,SUP-2103534,CDM,C1769,HCPCS,0272,RC,,,,both,,,295.16,191.85,,,,,,,,,,,,,
SODIUM CHLORIDE 0.45 % IV BOLUS|DISCARDED DRUG NOT ADMINISTE,RX-40840053,CDM,2580000003,HCPCS,0258,RC,00264-7802-00,NDC,JW,both,250,ML,8.50,5.52,,,,,,,,,,,,,
CENTRALIZER STEM 15 MM POST HIP SPECTRN EF COBRA,SUP-2434606,CDM,C1776,CPT,0278,RC,,,,both,,,200.96,130.62,,,,,,,,,,,,,
TITANIUM SCRN MESH PANEL 100MM X 100MM 2MM 1MM SSTM CP TTN,SUP-2681105,CDM,C1713,HCPCS,0278,RC,,,,both,,,3048.34,1981.42,,,,,,,,,,,,,
SAW SURG JOS 190 BAYNT SHP STR,SUP-2649607,CDM,2720000010,LOCAL,0272,RC,,,,both,,,447.45,290.84,,,,,,,,,,,,,
PRESSURE MONITORING KIT TRANSDUCER 72 IN POLE MT RESERVOIR,SUP-2473695,CDM,2720000010,LOCAL,0272,RC,,,,both,,,78.50,51.02,,,,,,,,,,,,,
SCREW BNE L30MM DIA6MM CORT ST NONCANNULATED NONLOCKING,SUP-2377552,CDM,C1713,HCPCS,0278,RC,,,,both,,,865.86,562.81,,,,,,,,,,,,,
PLATE BNE STR 2-2.5X43X1.5 MM 6 HOLE FRAC TI STRL LEVEL 1,SUP-2539576,CDM,C1713,HCPCS,0278,RC,,,,both,,,1738.30,1129.89,,,,,,,,,,,,,
ROD STBL SIL REUSE LMA FASTRACH,SUP-2383608,CDM,C1713,HCPCS,0278,RC,,,,both,,,63.55,41.31,,,,,,,,,,,,,
BLADE ARTHSCP OD4.5MM AGG + CUT ANG FRMLA,SUP-2361325,CDM,2720000010,LOCAL,0272,RC,,,,both,,,153.86,100.01,,,,,,,,,,,,,
NAIL R 11MMX360MM LNG GAM,SUP-2370050,CDM,C1713,HCPCS,0278,RC,,,,both,,,6918.05,4496.73,,,,,,,,,,,,,
IMPLANT ORBIT DIA20 MM HDPE QUADRO PRT TUNN SPHR ENUC INTRO,SUP-2882658,CDM,C1713,HCPCS,0278,RC,,,,both,,,1962.50,1275.62,,,,,,,,,,,,,
PROSTHESIS OSS EAR LG 2.5 MM APPLBM,SUP-2313845,CDM,L8613,CPT,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
PLUG IM SZ 3 13.5MM BONE AP STUHMER WEBER,SUP-2205843,CDM,C1713,HCPCS,0278,RC,,,,both,,,406.32,264.11,,,,,,,,,,,,,
KIT INSRT 7FR L1900MM COMPATIBLE W STNT SZ 1 ACT BILI STNT,SUP-2421735,CDM,C1769,HCPCS,0272,RC,,,,both,,,262.50,170.62,,,,,,,,,,,,,
MAGNESIUM SULFATE 40 MG/ML SYRINGE (PED-NEO) <50 ML RTU,RX-4090403,CDM,J3475,HCPCS,0636,RC,63323-0106-05,NDC,,both,50,ML,73.90,48.03,,,,,,,,,,,,,
MARKER BX SITE FOR CELERO-12 DEV,SUP-2240010,CDM,A4648,CPT,0278,RC,,,,both,,,205.98,133.89,,,,,,,,,,,,,
METFORMIN HCL 500 MG PO TABS,RX-10544,CDM,6370000000,HCPCS,0637,RC,70010-0063-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
TUBE VENTILATION 1.02MM ID 2.4MM SHEPARD GROMMET,SUP-2902750,CDM,L8699,HCPCS,0278,RC,,,,both,,,40.35,26.23,,,,,,,,,,,,,
CATHETER KIT 3L 7 FRX16 CM CV MULT LUMEN SPRING WIRE LL,SUP-2435362,CDM,C1751,HCPCS,0278,RC,,,,both,,,175.84,114.30,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP J 0.035 INX150 CM FIX COR RADIOPAQUE,SUP-2141739,CDM,C1769,HCPCS,0272,RC,,,,both,,,42.67,27.74,,,,,,,,,,,,,
PLATE BNE W12XL39MM THK1MM 2 H BILAT S STL SEMI TBLR LO,SUP-2184863,CDM,C1713,HCPCS,0278,RC,,,,both,,,190.94,124.11,,,,,,,,,,,,,
SCREW BNE L4MM DIA17MM CORT CRANIOFACIAL STD NONLOCKING LO 4/EA,SUP-2364992,CDM,C1713,HCPCS,0278,RC,,,,both,,,1353.47,879.76,,,,,,,,,,,,,
BLADE RETRCT W2.5XL3IN RT LT SACR CUTOUT SELF RET UNIV,SUP-2382322,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1317.45,856.34,,,,,,,,,,,,,
LCKNG EMERGENCY SCR MD31X11MM5/PKG,SUP-2668810,CDM,C1713,HCPCS,0278,RC,,,,both,,,488.27,317.38,,,,,,,,,,,,,
GRAFT BNE SUB 30CC 15% HYDROXYAPATITE/85% B-TCP GRAN POR,SUP-2288534,CDM,C1713,HCPCS,0278,RC,,,,both,,,2336.16,1518.50,,,,,,,,,,,,,
COMPONENT FEM SZ 5 R REV POST STBL GMK,SUP-2267612,CDM,C1776,CPT,0278,RC,,,,both,,,22765.00,14797.25,,,,,,,,,,,,,
SET ACC NDL OD21GA GWIRE OD0.038IN NEFF TRCR TIP NIT RADPQ,SUP-2170307,CDM,C1894,HCPCS,0272,RC,,,,both,,,301.47,195.96,,,,,,,,,,,,,
LINER ACET OD40MM ID24MM +3MM OFFSET HIP E1 HI WALL RINGLOC,SUP-2408926,CDM,C1776,CPT,0278,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
STENT URET STR 0.035 IN 3 CM 6 FRX22-30 CM 6 FR STRTCH VL,SUP-2491343,CDM,C2617,HCPCS,0278,RC,,,,both,,,507.99,330.19,,,,,,,,,,,,,
"HC So Epstein-Barr Virus, Ea",PX-3028666366,CDM,86663,CPT,0302,RC,,,,both,,,118.00,76.70,,,,,,,,,,,,,
GUIDEWIRE VASC L180CM DIA0.014IN COR STR SHP TIP HYPERCOAT,SUP-2385315,CDM,C1769,HCPCS,0272,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
PLATE BNE L63MM 8 H TI RIG DYN LOK COMPR FOR 2.4MM SCR MOD,SUP-2191478,CDM,C1713,HCPCS,0278,RC,,,,both,,,1996.47,1297.71,,,,,,,,,,,,,
HC Lrbc-Red Cross,PX-3900901600,CDM,P9016,CPT,0390,RC,,,,both,,,966.00,627.90,,,,,,,,,,,,,
PLATE BNE L15MM XSM 2 H S STL FT ANK BILAT POLYAX COMPR LO,SUP-2397455,CDM,C1713,HCPCS,0278,RC,,,,both,,,2486.88,1616.47,,,,,,,,,,,,,
PLATE BNE PRI L SZ 2,SUP-2388825,CDM,C1713,HCPCS,0278,RC,,,,both,,,3105.46,2018.55,,,,,,,,,,,,,
LINER ACET SZ E OD54X56MM ID32MM THK7.9MM 10DEG HIP X3,SUP-2375151,CDM,C1776,CPT,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
STEM FEM SZ 11 HIP TI PLSM SPR EXT OVATION,SUP-2314423,CDM,C1776,CPT,0278,RC,,,,both,,,9696.32,6302.61,,,,,,,,,,,,,
GUIDEWIRE INTRMDLLRY NAIL 32MM SHAFT 60CML 5MM TIP BLLT TIP,SUP-2723228,CDM,C1769,HCPCS,0272,RC,,,,both,,,683.08,444.00,,,,,,,,,,,,,
PLATE EXT FIX RETENTION TLTS T LNG LCK FOR 2.0-2.3 MM RED II,SUP-2481643,CDM,C1713,HCPCS,0278,RC,,,,both,,,4102.41,2666.57,,,,,,,,,,,,,
DISTRACTION INTRNL TUBE ADJ MDFCE BTTRSS 1.5 MM MXDRVE SET S,SUP-2489570,CDM,C1713,HCPCS,0278,RC,,,,both,,,6495.12,4221.83,,,,,,,,,,,,,
PLATE BONE MESHED 1.3 MM MANDIBLE C TYPE FOR CRANIOMAXILLOFA,SUP-2837650,CDM,C1713,HCPCS,0278,RC,,,,both,,,3286.01,2135.91,,,,,,,,,,,,,
"HC Spinal Puncture, Lumbar, Diagnostic",PX-3616227000,CDM,62270,CPT,0361,RC,,,,outpatient,,,2232.00,1450.80,,,,,,,,,,,,,
MATRIX BIO L 2.4 X W 1.6 IN SZ 24 SQCM PORCINE TEND DERIVED,SUP-2909330,CDM,A2008,HCPCS,0636,RC,,,,both,,,5615.89,3650.33,,,,,,,,,,,,,
CATHETER VASC ANGIO DIAG STR FLSH PERIPH W/O HYDRPHLC COAT,SUP-2117056,CDM,C1887,HCPCS,0272,RC,,,,both,,,459.07,298.40,,,,,,,,,,,,,
PACK SURGICAL PROC CUSTOM TISSUE PERFUSION SYSTEM SPY ELITE,SUP-2850065,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2028.47,1318.51,,,,,,,,,,,,,
SYSTEM SINUS IRRIGATION 360 DEG ROTATING FAN SPRY WSH DEL,SUP-2902093,CDM,2720000010,LOCAL,0272,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
COUNTERSINK SURG OD5.5MM HD SGL USE MONSTER,SUP-2320966,CDM,C1713,HCPCS,0278,RC,,,,both,,,571.48,371.46,,,,,,,,,,,,,
SCREW BNE NLCK 2.7X9 MM NS DVR,SUP-2459031,CDM,C1713,HCPCS,0278,RC,,,,both,,,207.24,134.71,,,,,,,,,,,,,
HC Myelogram Lumbar,PX-3616230400,CDM,62304,CPT,0361,RC,,,,inpatient,,,3892.00,2529.80,,,,,,,,,,,,,
SET ORTH INSTR STRL DISP ULTRABRIDGE,SUP-2883091,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6280.00,4082.00,,,,,,,,,,,,,
RELOAD STPL 4.8MM L60MM 0DEG UNIV TISS GRN TI NONCUTTING,SUP-2283419,CDM,2720000010,LOCAL,0272,RC,,,,both,,,585.01,380.26,,,,,,,,,,,,,
CATHETER EMB L 110 CM DIA16 FR GUIDEWIRE 0.035 IN CRV 1 TIME,SUP-2891721,CDM,C1757,HCPCS,0272,RC,,,,both,,,25120.00,16328.00,,,,,,,,,,,,,
SLEEVE FEM ADPT 11/13 TAPR +0MM OFFSET HD ASR,SUP-2254024,CDM,C1776,CPT,0278,RC,,,,both,,,1105.28,718.43,,,,,,,,,,,,,
BIT DRL EL FIX KT 180MMX48MM STP UNIT 48MM ALLEN WRNCH,SUP-2315966,CDM,2720000010,LOCAL,0272,RC,,,,both,,,393.94,256.06,,,,,,,,,,,,,
PLATE BONE L177MM THK6MM 7 H LT FEM CNDYL TI BTTRS RIG CLLR,SUP-2190901,CDM,C1713,HCPCS,0278,RC,,,,both,,,2957.57,1922.42,,,,,,,,,,,,,
CATHETER ABSC APD LOOP ALL PURP PERCFLX 20FRX25CM,SUP-2139709,CDM,C1729,HCPCS,0272,RC,,,,both,,,201.49,130.97,,,,,,,,,,,,,
DEFIBRILLATOR IMPL LIVIAN HE TI CRT BATTERY PWR HI ENERGY,SUP-2149236,CDM,C1882,HCPCS,0275,RC,,,,both,,,58090.00,37758.50,,,,,,,,,,,,,
CATHETER INTVASC OCCL L 65 CM DIA 7 FR BALLOON DIA11.5 MM,SUP-2142113,CDM,C1725,HCPCS,0272,RC,,,,both,,,675.10,438.81,,,,,,,,,,,,,
GRAFT BNE FIBULAR STRUT 110MM LX65MM,SUP-2307388,CDM,C1713,HCPCS,0278,RC,,,,both,,,3193.07,2075.50,,,,,,,,,,,,,
BLEOMYCIN SULFATE 30 UNITS IJ SOLR,RX-17012,CDM,J9040,HCPCS,0636,RC,71288-0107-20,NDC,,both,1,UN,192.10,124.86,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL PEEK SD800.549,SUP-2860230,CDM,C1713,HCPCS,0278,RC,,,,both,,,51995.89,33797.33,,,,,,,,,,,,,
GRAFT BIO TISS W10XL25CM FET BOV DERM MESHED PRIMATRIX AG,SUP-2243715,CDM,Q4110,HCPCS,0636,RC,,,,both,,,18055.00,11735.75,,,,,,,,,,,,,
HC So Mopath Procedure Level 5,PX-3108140466,CDM,81404,CPT,0310,RC,,,,both,,,659.00,428.35,,,,,,,,,,,,,
PROCEDURE KIT PERFLUOROCARBON PERFLUORON,SUP-2109683,CDM,2780000010,LOCAL,0278,RC,,,,both,,,1467.95,954.17,,,,,,,,,,,,,
SCREW BNE L 14 MM DIA2.7 MM MANDIBULAR ST EMER NS AXS,SUP-2909503,CDM,C1713,HCPCS,0278,RC,,,,both,,,584.86,380.16,,,,,,,,,,,,,
FIBER LASER SURGICAL 550 MH MASTERPULSE,SUP-2417215,CDM,2720000010,LOCAL,0272,RC,,,,both,,,857.22,557.19,,,,,,,,,,,,,
SPHERE EMB RESIN SIR-SPHERES Y-90,SUP-2340133,CDM,C1889,HCPCS,0278,RC,,,,both,,,51810.00,33676.50,,,,,,,,,,,,,
COUNTERSINK SURG 2MM HD MONSTER,SUP-2320960,CDM,2720000010,LOCAL,0272,RC,,,,both,,,459.23,298.50,,,,,,,,,,,,,
HC Insertion Uterine Tandem&/Vaginal Ovoids,PX-3425715500,CDM,57155,CPT,0342,RC,,,,both,,,2249.00,1461.85,,,,,,,,,,,,,
HC Signal Average Ekg,PX-7309327800,CDM,93278,CPT,0730,RC,,,,both,,,502.00,326.30,,,,,,,,,,,,,
PLATE BNE L 22 MM 4 H SCREW DIA2 MM PROF MINI FRAG NS VARIAX,SUP-2902422,CDM,C1713,HCPCS,0278,RC,,,,both,,,2229.71,1449.31,,,,,,,,,,,,,
CALIPER SURG FEM,SUP-2437564,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2416.23,1570.55,,,,,,,,,,,,,
SEED BRACHYTHERAPY LOAD 3.01-4.0 MCI STRL ADVANTAGE 2029DLS2] ISOAID LLC],SUP-2247267,CDM,C2642,HCPCS,0278,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
MANIPULATOR SURG IOL STR W/ GRD LESTER,SUP-2261483,CDM,2720000010,LOCAL,0272,RC,,,,both,,,664.17,431.71,,,,,,,,,,,,,
APIXABAN 2.5 MG PO TABS,RX-120067,CDM,6370000000,HCPCS,0637,RC,00003-0893-31,NDC,,both,1,UN,45.50,29.57,,,,,,,,,,,,,
GRAFT FIBULA SEGMENT ALLOGRAFT FROZEN,SUP-2863661,CDM,C1762,CPT,0278,RC,,,,both,,,6236.04,4053.43,,,,,,,,,,,,,
COLLAR CERV XL H3XL20IN AD CLS TRACH HK AND LOOP CLSR CNTOUR,SUP-2194433,CDM,L0120,HCPCS,0272,RC,,,,both,,,17.87,11.62,,,,,,,,,,,,,
PLATE BNE 4 H R DST FIB ANK S STL LOK FOR FRAC MGMT SYS,SUP-2123022,CDM,C1713,HCPCS,0278,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
SCREW BNE L20MM DIA2MM CORT HND EL FT TI TRILOK APTUS,SUP-2268162,CDM,C1713,HCPCS,0278,RC,,,,both,,,388.23,252.35,,,,,,,,,,,,,
PLATE BONE LOK HLX34 HDSHFT T SHPD OBLQUE 47494603405,SUP-2722672,CDM,C1713,HCPCS,0278,RC,,,,both,,,1144.91,744.19,,,,,,,,,,,,,
SCREW CONN 4MM W COCHLEAR PREMOUNTED PONTO,SUP-2319890,CDM,C1713,HCPCS,0278,RC,,,,both,,,5228.10,3398.26,,,,,,,,,,,,,
KIT CAST SZ 3 IN TOT CONTACT SYS W/O BOOT SAW TCC-EZ,SUP-2909201,CDM,2720000010,LOCAL,0272,RC,,,,both,,,336.61,218.80,,,,,,,,,,,,,
FAT EMULSION PLANT BASED (SOY) 20 % IV EMUL,RX-155550,CDM,2500000003,HCPCS,0250,RC,65219-0539-01,NDC,,both,100,ML,54.10,35.16,,,,,,,,,,,,,
PLATE BNE L90MM 20 H TI ADPT FOR 1.5MM SCR,SUP-2191135,CDM,C1713,HCPCS,0278,RC,,,,both,,,1516.62,985.80,,,,,,,,,,,,,
SUPPORT ORTHOT THGH LOWER EXTREMITY NAR M-L BRIM CUST FIT,SUP-2435676,CDM,L2526,HCPCS,0272,RC,,,,both,,,1813.22,1178.59,,,,,,,,,,,,,
CAPSULE ENDO L26MM DIA11MM 145DEG EC TYP 1 ANT LD CVR ACT,SUP-2313257,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7159.20,4653.48,,,,,,,,,,,,,
GRAFT BONE SUB L DEFCT 15ML ORTHOBLEND JR DEMIN BONE MTRX,SUP-2293915,CDM,C1713,HCPCS,0278,RC,,,,both,,,3800.66,2470.43,,,,,,,,,,,,,
CANNULA ENDOSCP STD 2 MMX95 CM STYL BVL TIP HRD RETROGRADE,SUP-2539546,CDM,2720000010,LOCAL,0272,RC,,,,both,,,240.15,156.10,,,,,,,,,,,,,
IMPLANT WR JT STD POLY MAESTRO,SUP-2407380,CDM,C1776,CPT,0278,RC,,,,both,,,3375.50,2194.07,,,,,,,,,,,,,
HC Drug Screen Quantitative Tobramycin,PX-3018020000,CDM,80200,CPT,0301,RC,,,,both,,,322.00,209.30,,,,,,,,,,,,,
CUFF TRNQT 30IN SURG SGL BLDR SGL PRT PNEUMAT ELECTR AD,SUP-2208890,CDM,C1713,HCPCS,0278,RC,,,,both,,,576.13,374.48,,,,,,,,,,,,,
CATHETER THROMCTMY PRODIGY L 160 CM OD 0.067 IN ID 0.055 IN,SUP-2864587,CDM,C1757,HCPCS,0272,RC,,,,both,,,10048.00,6531.20,,,,,,,,,,,,,
KIT PAIN PMP 400ML 4ML PER HR L25IN W ANTIMIC SIL CATHETER,SUP-2236830,CDM,C1713,HCPCS,0278,RC,,,,both,,,109.90,71.43,,,,,,,,,,,,,
PLATE BONE TUBULAR NARROW 4.5 MM 5 HOLE PROVISIONAL FIXATION,SUP-2836971,CDM,C1713,HCPCS,0278,RC,,,,both,,,1443.71,938.41,,,,,,,,,,,,,
KIT INSRTN INTRO L 6 IN CATH DIA 8 FR 50 CC PACKAGED STRL,SUP-2908670,CDM,C1894,HCPCS,0272,RC,,,,both,,,379.31,246.55,,,,,,,,,,,,,
CATHETER HD PRECRV 15.5 FRX24 CM LT DL BASIC SET TITAN HD,SUP-2627351,CDM,C1750,HCPCS,0278,RC,,,,both,,,81.64,53.07,,,,,,,,,,,,,
CENTRALIZER MS 30 DIST CAP SZ 10 STEM 12MM DIA,SUP-2204698,CDM,C1776,CPT,0278,RC,,,,both,,,311.49,202.47,,,,,,,,,,,,,
ENDCAP ORTH EXTN 0MM FEM G TI CANN T40 STARDRV RECESS FOR,SUP-2180032,CDM,C1713,HCPCS,0278,RC,,,,both,,,563.66,366.38,,,,,,,,,,,,,
COIL EMB L8CM OD0.020IN LOOP OD4MM NIT STRTCH RESIST FILL,SUP-2323394,CDM,C1889,HCPCS,0278,RC,,,,both,,,7021.04,4563.68,,,,,,,,,,,,,
GRAFT VASC PERIPH BYPS STR THN WALL N RING SM BEAD 7MM,SUP-2126883,CDM,C1768,CPT,0278,RC,,,,both,,,3775.94,2454.36,,,,,,,,,,,,,
SYSTEM CTRL 3772CONTRLSYS,SUP-2615542,CDM,C1767,HCPCS,0278,RC,,,,both,,,40820.00,26533.00,,,,,,,,,,,,,
SET DIL ESOPH 5/7/9/11/12.8/14/15MM STD -,SUP-2126408,CDM,C1726,HCPCS,0272,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
CABLE ABLATION PMP SMARTABLATE COOLFLOW NS,SUP-2737878,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
SUPPORT ORTHOT WRST HND FNGR CUST EXT PWR ELECTR FABRICATED,SUP-2435771,CDM,L3904,HCPCS,0274,RC,,,,both,,,8696.98,5653.04,,,,,,,,,,,,,
HC Stress Echo W Contrast,PX-4839335000,CDM,C8928,HCPCS,0483,RC,,,,both,,,1944.00,1263.60,,,,,,,,,,,,,
FIBER LASER 200 MH FLX CUST GUID CONN HOLM ACCUTRAC DISP,SUP-2139426,CDM,C1713,HCPCS,0278,RC,,,,both,,,1388.88,902.77,,,,,,,,,,,,,
LOCK DIST TIB MED LT 15H STE,SUP-2588833,CDM,C1713,HCPCS,0278,RC,,,,both,,,3999.04,2599.38,,,,,,,,,,,,,
STEM FEM MAG 11-14 STD HIP EXACT INTEGR,SUP-2450407,CDM,C1776,CPT,0278,RC,,,,both,,,1116.27,725.58,,,,,,,,,,,,,
CATHETER HD STR 11.5 FRX15 CM SHT TERM DL TAPR SOFT-LINE,SUP-2627327,CDM,C1752,HCPCS,0278,RC,,,,both,,,128.74,83.68,,,,,,,,,,,,,
IMPLANT ANK JT TALAR COMP RT CO CHROM SALTO TALARIS SZ 1,SUP-2244124,CDM,C1776,CPT,0278,RC,,,,both,,,9787.38,6361.80,,,,,,,,,,,,,
SCREW BONE L14MM DIA2.4MM TI CANN LAG HDLSS DISP FOR HND,SUP-2319466,CDM,C1713,HCPCS,0278,RC,,,,both,,,1114.70,724.55,,,,,,,,,,,,,
SUPPORT ORTHOT WRST HND FNGR CUST EXT PWR ELECTR FABRICATED,SUP-2435771,CDM,L3904,HCPCS,0272,RC,,,,both,,,8696.98,5653.04,,,,,,,,,,,,,
BIT DRL OD15MM LT GRN W AO,SUP-2244014,CDM,2720000010,LOCAL,0272,RC,,,,both,,,565.61,367.65,,,,,,,,,,,,,
IMMOBILIZER ORTHOPEDIC 3 PNL UNIV 14-29 IN DURABLE TIETEX,SUP-2428152,CDM,L1830,CPT,0274,RC,,,,both,,,31.62,20.55,,,,,,,,,,,,,
CATHETER HD 2 LUMEN 14 FRX24 CM,SUP-2159456,CDM,C1750,HCPCS,0278,RC,,,,both,,,1350.20,877.63,,,,,,,,,,,,,
GUIDEWIRE VASC TORQ-FLEX L 150 CM DIA 0.018 IN FLX TIP L 8,SUP-2170117,CDM,C1769,HCPCS,0272,RC,,,,both,,,138.85,90.25,,,,,,,,,,,,,
CATHETER CTRL VEN L20CM OD5FR .032IN GWIRE KT SGL LUMN N AK04212] ARROW INTERNATIONAL],SUP-2120573,CDM,C1751,HCPCS,0278,RC,,,,both,,,49.61,32.25,,,,,,,,,,,,,
PLATE BONE THK1MM 2X4 H LT HND L SHP LCK TRILOK FOR 2MM SCR,SUP-2267926,CDM,C1713,HCPCS,0278,RC,,,,both,,,1110.30,721.69,,,,,,,,,,,,,
NEEDLE HOLDER 3744016 HALSEY SMOOTH,SUP-2473758,CDM,2720000010,LOCAL,0272,RC,,,,both,,,442.61,287.70,,,,,,,,,,,,,
BLADE ARTHSCP 4MM CVD W/O HNDL CAPSULECUT,SUP-2121996,CDM,C1713,HCPCS,0278,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
SPLINT WR AD L GREATER THAN W4IN RT MCP DLX KAY-SPLNT III,SUP-2324562,CDM,L3906,HCPCS,0274,RC,,,,both,,,82.80,53.82,,,,,,,,,,,,,
PACK ROOT REP MENIS W/ ULTRABRAID DISP,SUP-2416995,CDM,C1713,HCPCS,0278,RC,,,,both,,,2499.44,1624.64,,,,,,,,,,,,,
PLATE BONE THK0.6MM 4 H GRN ORBIT TI CVD HX FOR 1.5MM SCR,SUP-2135903,CDM,C1713,HCPCS,0278,RC,,,,both,,,609.16,395.95,,,,,,,,,,,,,
PLATE BNE 2.7X68 MM 8 HOLE SS DCP,SUP-2569130,CDM,C1713,HCPCS,0278,RC,,,,both,,,298.77,194.20,,,,,,,,,,,,,
HEAD SURG 95 RMR IM FEM MOD S STL BIXCUT,SUP-2368229,CDM,C1713,HCPCS,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
PROSTHESIS OTO L5MM OD0.6MM LOOP 0.8MM STAP PIST L LOOP,SUP-2284055,CDM,L8613,CPT,0278,RC,,,,both,,,258.36,167.93,,,,,,,,,,,,,
MESH DERM MTRX PORCINE 2X7CM INTEXEN LP,SUP-2140303,CDM,C1763,HCPCS,0278,RC,,,,both,,,1327.44,862.84,,,,,,,,,,,,,
SET SCR SPNL CLOSE VLS TI,SUP-2415638,CDM,C1713,HCPCS,0278,RC,,,,both,,,572.36,372.03,,,,,,,,,,,,,
PLATE BNE DBL ANGLED LG 2.5 MM RECON PT SPEC TI,SUP-2860105,CDM,C1713,HCPCS,0278,RC,,,,both,,,24600.02,15990.01,,,,,,,,,,,,,
RELOAD STPL 40MM H1.5-3.5MM WIRE 0.2MM REG TISS BLU CRV,SUP-2716237,CDM,2720000010,LOCAL,0272,RC,,,,both,,,890.13,578.58,,,,,,,,,,,,,
STE TALAR NECK PLATE ASSY SM,SUP-2588800,CDM,C1713,HCPCS,0278,RC,,,,both,,,2843.05,1847.98,,,,,,,,,,,,,
KNIFE SURG SCHKNT ROLLER 90 DEG 7.5 IN 3 MM HORIZONTAL LF,SUP-2460558,CDM,2720000010,LOCAL,0272,RC,,,,both,,,374.70,243.55,,,,,,,,,,,,,
SET SCR SPNL DEV FOR CLOSE CLMP CD HORZ LEG,SUP-2289305,CDM,C1713,HCPCS,0278,RC,,,,both,,,119.32,77.56,,,,,,,,,,,,,
SHELL ACET OD62MM R HIP MTL POR CEMENTLESS HMSPHR ANAT,SUP-2363245,CDM,C1776,CPT,0278,RC,,,,both,,,8829.68,5739.29,,,,,,,,,,,,,
HC Cltx Med Ankle Fx W/Mnpj,PX-4502776200,CDM,27762,CPT,0450,RC,,,,both,,,1633.00,1061.45,,,,,,,,,,,,,
SHEET ORBIT W38XL50MM THK1.5MM BIOMATERIAL RECON AUG MEDPOR,SUP-2366443,CDM,C1713,HCPCS,0278,RC,,,,both,,,769.30,500.04,,,,,,,,,,,,,
GRAFT HUM TISS L 1 X W 1 CM XS AMNIO MEMBRN RESRB AIR DRY,SUP-2913446,CDM,Q4173,HCPCS,0636,RC,,,,both,,,3215.36,2089.98,,,,,,,,,,,,,
CONNECTOR SHUNT DIAMETER 1.9MM TITANIUM STRAIGHT FOR HYDROCE,SUP-2825578,CDM,C1889,HCPCS,0278,RC,,,,both,,,243.10,158.01,,,,,,,,,,,,,
SAW SURG IM LCK NUT,SUP-2448362,CDM,2720000010,LOCAL,0272,RC,,,,both,,,367.38,238.80,,,,,,,,,,,,,
ALLOGRAFT BNE CHIP 4-10 MM 30 CC FD 30/70 MIX CORTICAL CANC,SUP-2792168,CDM,C1713,HCPCS,0278,RC,,,,both,,,1494.95,971.72,,,,,,,,,,,,,
SEALANT HEMSTAT TISS 1ML FIBRIN EVICEL,SUP-2218324,CDM,C1713,HCPCS,0278,RC,,,,both,,,544.57,353.97,,,,,,,,,,,,,
CATHETER EP 5FR L115CM 2-2-2 SPC 2MM TIP 1MM BND OCTAPOLAR,SUP-2356877,CDM,C1730,HCPCS,0272,RC,,,,both,,,1909.12,1240.93,,,,,,,,,,,,,
GRAFT EVAR L49MM DIA28X28MM EXTN FREE FLO CLS WEB FOR ABD,SUP-2295232,CDM,C1768,CPT,0278,RC,,,,both,,,13423.50,8725.27,,,,,,,,,,,,,
REAMER SURG 10MM CONCAVE MTP FOR SM JT RMR MOD HND SYS,SUP-2107731,CDM,C1713,HCPCS,0278,RC,,,,both,,,2072.40,1347.06,,,,,,,,,,,,,
FIBER LASER CO2 2 MM ENDURE,SUP-2713745,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
MASK CPAP MED NSL HEADGEAR CONN DREAMWISP,SUP-2423093,CDM,2720000010,LOCAL,0272,RC,,,,both,,,463.97,301.58,,,,,,,,,,,,,
HC So Allergen Spec Ige Recombinant/Purified Compnt Ea,PX-3028600866,CDM,86008,CPT,0302,RC,,,,both,,,61.00,39.65,,,,,,,,,,,,,
ALLOGRAFT AXIS 6CM X 8CM TUTOPLAST PROCESSED DERMIS,SUP-2165390,CDM,C1762,CPT,0278,RC,,,,both,,,6985.87,4540.82,,,,,,,,,,,,,
COLLAR CERVICALXSM H2.75XL22.5IN EXTRIC EMS 1 PC PLAS FOAM,SUP-2197905,CDM,L0120,HCPCS,0272,RC,,,,both,,,89.80,58.37,,,,,,,,,,,,,
KIT INTRO ARROWG+ARD BLU SHTH L 10CM DIA 8.5FR ANTIMICROBIAL,SUP-2763367,CDM,C1892,HCPCS,0272,RC,,,,both,,,413.85,269.00,,,,,,,,,,,,,
STRAP SPLNT 2INX18IN WHT NYL D RNG HK AND LOOP ROLYAN,SUP-2324781,CDM,L3908,HCPCS,0274,RC,,,,both,,,9.73,6.32,,,,,,,,,,,,,
EXTRACTION KIT BNE MAR 3.5S AUTOCELL CELLXTRACT,SUP-2420671,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2621.62,1704.05,,,,,,,,,,,,,
CANNULA SURG LNG MULTI-TIP ROTATABLE FIXATED LEVEL 1,SUP-2458830,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1883.84,1224.50,,,,,,,,,,,,,
ALLOGRAFT BNE SPACER 12 DEG 55X18X11 MM LAT ELEMAX,SUP-2739106,CDM,C1713,HCPCS,0278,RC,,,,both,,,17270.00,11225.50,,,,,,,,,,,,,
CATHETER ETER DIL 75FR L180CM BLLN L3CM DIA8 9 10MM 0035IN,SUP-2141555,CDM,C1726,HCPCS,0272,RC,,,,both,,,873.23,567.60,,,,,,,,,,,,,
GRAFT BONE SUB 5ML PUTTY W/ RPM INJ CANC RESRB PUROS,SUP-2415794,CDM,C1713,HCPCS,0278,RC,,,,both,,,3717.76,2416.54,,,,,,,,,,,,,
GRAFT HUM TISS L2.5XW2.5CM THK1MM WND MTRX CRYOPRESERVED,SUP-2135265,CDM,Q4148,HCPCS,0636,RC,,,,both,,,4443.10,2888.01,,,,,,,,,,,,,
SHEATH INTRO PERFRMR L 6 CM OD 5.5 FR ID 1.8 MM 0.035IN,SUP-2633272,CDM,C1894,HCPCS,0272,RC,,,,both,,,82.24,53.46,,,,,,,,,,,,,
SLING GYN L 45 X W 1.1 CM POLYPRO MONOFILAMENT DIL,SUP-2929642,CDM,C1771,HCPCS,0278,RC,,,,both,,,3281.30,2132.84,,,,,,,,,,,,,
HC So Immunofixation Serum,PX-3028633466,CDM,86334,CPT,0302,RC,,,,both,,,71.00,46.15,,,,,,,,,,,,,
PLATE BONE 5 HOLE 2X27 MM TITANIUM NON STERILE DCP,SUP-2838375,CDM,C1713,HCPCS,0278,RC,,,,both,,,1241.87,807.22,,,,,,,,,,,,,
AMOXICILLIN 500 MG PO CAPS,RX-451,CDM,6370000000,HCPCS,0637,RC,16714-0299-03,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
DRESSING WND NEG PRESSURE HYDROPHOBIC HND SHP SENSATRAC DISP,SUP-2262347,CDM,2720000010,LOCAL,0272,RC,,,,both,,,355.79,231.26,,,,,,,,,,,,,
PLATE BNE STR 4 H IMPL MAXLOCK EXTRM ORTHOLINK,SUP-2400403,CDM,C1713,HCPCS,0278,RC,,,,both,,,3149.42,2047.12,,,,,,,,,,,,,
PLATE ORTH DELT STRIKE NS T2 ALPHA,SUP-2900558,CDM,C1713,HCPCS,0278,RC,,,,both,,,1818.44,1181.99,,,,,,,,,,,,,
CHOLANGIOGRAM KIT RX AUTOTOME UTOM XL SPHINTOM JAGWIRE 7104,SUP-2493071,CDM,C1769,HCPCS,0272,RC,,,,both,,,876.06,569.44,,,,,,,,,,,,,
NEEDLE ASPIR INJ 18 GAX45 CM NS ENDOLAP LTX REUSE,SUP-2868579,CDM,2720000010,LOCAL,0272,RC,,,,both,,,715.54,465.10,,,,,,,,,,,,,
BLADE RESECTION L8CM DIAMETER 2.9MM 35DEG SMALL JOINT STEALT,SUP-2824674,CDM,2720000010,LOCAL,0272,RC,,,,both,,,745.75,484.74,,,,,,,,,,,,,
PLATE BNE L180MM ALUMINUM BRDG FOR 5 8 RNG MAXFRAME,SUP-2255813,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4358.51,2833.03,,,,,,,,,,,,,
EXPANDER BRST TISS 850CC W14XH14CM P8.9CM SIL SMOOTH ULT HI,SUP-2301023,CDM,C1789,HCPCS,0278,RC,,,,both,,,6672.50,4337.12,,,,,,,,,,,,,
ANCHOR SUT KNOTILUS 35MM,SUP-2366685,CDM,C1713,HCPCS,0278,RC,,,,both,,,1008.57,655.57,,,,,,,,,,,,,
KIT INTRO L 14 CM DIA12 FR GUIDEWIRE L 50 CM DIA 0.038 IN,SUP-2615895,CDM,C1894,HCPCS,0272,RC,,,,both,,,108.30,70.39,,,,,,,,,,,,,
SPLINT CLAV M AD BCKL CLSR PD MCLEOD,SUP-2197364,CDM,L3660,HCPCS,0274,RC,,,,both,,,44.90,29.18,,,,,,,,,,,,,
MORPHINE SULFATE (PF) 1 MG/ML IV SOLN,RX-78084,CDM,J2274,HCPCS,0636,RC,00548-1911-00,NDC,,both,30,ML,54.10,35.16,,,,,,,,,,,,,
BLOCK TIB AUG L71MM THK16MM L MED R LAT KNEE TI ALLY CEM,SUP-2405505,CDM,C1776,CPT,0278,RC,,,,both,,,3403.76,2212.44,,,,,,,,,,,,,
SET CATH HAD 10FR L52CM CUF AT 27 AND 30CM POLYUR TWO,SUP-2266953,CDM,C1881,HCPCS,0278,RC,,,,both,,,921.90,599.23,,,,,,,,,,,,,
CATHETER SUPP L 135 CM DIA 0.0375 IN GUIDEWIRE 0.018 IN SS,SUP-2892948,CDM,C1725,HCPCS,0272,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
CATHETER GUID TWIN-PASS L 135 CM DIA 3.5 FR GUIDEWIRE 0.014,SUP-2435361,CDM,C1887,HCPCS,0272,RC,,,,both,,,1365.90,887.83,,,,,,,,,,,,,
CATHETER ETER HAD 145FR L32CM INSRT L27CM POLYUR BIOBLOC SIL,SUP-2127840,CDM,C1750,HCPCS,0278,RC,,,,both,,,1632.80,1061.32,,,,,,,,,,,,,
MATRIX BONE 5ML GRFT SUB DEMIN PASTE INTERGRO +,SUP-2414014,CDM,C1713,HCPCS,0278,RC,,,,both,,,3579.60,2326.74,,,,,,,,,,,,,
SUPPORT ORTHOT LUMBAR SACR CUST FULL CORSET,SUP-2435565,CDM,L0976,HCPCS,0274,RC,,,,both,,,423.30,275.14,,,,,,,,,,,,,
CAGE SPNL L22XW8XH9MM 5DEG PEEK OPTMA POST LUM INTBDY FUS L,SUP-2353261,CDM,C1889,HCPCS,0278,RC,,,,both,,,5589.20,3632.98,,,,,,,,,,,,,
PLATE BNE L 147 X W 10.5 MM THK 3 MM SCREW DIA2.7/3.5 MM 10 72466410,SUP-2932978,CDM,C1713,HCPCS,0278,RC,,,,both,,,5665.19,3682.37,,,,,,,,,,,,,
LEAD NEUROSTIMULATOR L43CM ID2MM 180-250OHM LT VAGUS NRV,SUP-2175910,CDM,C1778,HCPCS,0278,RC,,,,both,,,26878.40,17470.96,,,,,,,,,,,,,
CATHETER GUID RAPIDO CUT-AWAY WORKING L 47 CM OD 2.7 MM ID,SUP-2149001,CDM,C1887,HCPCS,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
BIT DRIL SURG DIA35MM FOR DIA5MM SCR FOR LT LIF XIA 45 CT,SUP-2381178,CDM,2720000010,LOCAL,0272,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
SUPPORT ORTHOT LUMBAR SACR CUST FULL CORSET,SUP-2435565,CDM,L0976,HCPCS,0272,RC,,,,both,,,423.30,275.14,,,,,,,,,,,,,
LENS INTRAOCULAR 24.0 DIOPT POST CHMBR BCNVX 1 PC ULTRA,SUP-2885208,CDM,V2632,HCPCS,0276,RC,,,,both,,,348.54,226.55,,,,,,,,,,,,,
GRAFT BNE SUB 10CC DBM PRO-DENSE INJ INDUCTIVE PRO-STIM,SUP-2399131,CDM,C1713,HCPCS,0278,RC,,,,both,,,8854.80,5755.62,,,,,,,,,,,,,
INSERT FEM NK +6MM HIP CO CHROM MOLYBDENUM ALLY TAPR 1 ENDO,SUP-2405243,CDM,C1776,CPT,0278,RC,,,,both,,,357.96,232.67,,,,,,,,,,,,,
MESH SURG DIA1.7 IN SM POLY-4-HYDROXYBUTYRATE POLYGLY ACD,SUP-2937423,CDM,C1781,HCPCS,0278,RC,,,,both,,,1962.50,1275.62,,,,,,,,,,,,,
ROD IM DSTL CUT GUIDE MICROPLASTY ELITE,SUP-2446195,CDM,C1713,HCPCS,0278,RC,,,,both,,,960.84,624.55,,,,,,,,,,,,,
MONTELUKAST SODIUM 10 MG PO TABS,RX-22509,CDM,6370000000,HCPCS,0637,RC,50268-0556-11,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PLATE CRANIOFACIAL CVD UP TI 2.3MM 4 H 35MML,SUP-2263006,CDM,C1713,HCPCS,0278,RC,,,,both,,,574.62,373.50,,,,,,,,,,,,,
PL LCKNG RCN ANG ANG34H T28MM,SUP-2680211,CDM,C1713,HCPCS,0278,RC,,,,both,,,8977.98,5835.69,,,,,,,,,,,,,
ALLOGRAFT BNE CHIP 1.7-10 MM 60 CC FD CANC READIGRAFT,SUP-2741072,CDM,C1713,HCPCS,0278,RC,,,,both,,,2186.57,1421.27,,,,,,,,,,,,,
PLATE BNE 6 H S STL TARSOMETATARSAL LOK RECON BRDG FOR,SUP-2397629,CDM,C1713,HCPCS,0278,RC,,,,both,,,2756.92,1792.00,,,,,,,,,,,,,
KIT ACC 10GA 3ML SYR DMND TIP END OPN RADPQ W/O CEM SYNFLATE,SUP-2255819,CDM,2720000010,LOCAL,0272,RC,,,,both,,,737.90,479.63,,,,,,,,,,,,,
PLATE BONE L190MM NAR 9 H DPHSEAL PICCOLO COMP PLT SYS,SUP-2152550,CDM,C1713,HCPCS,0278,RC,,,,both,,,2619.64,1702.77,,,,,,,,,,,,,
SEED BRACHYTHERAPY STRND PROST C4 MRK,SUP-2247305,CDM,C2642,HCPCS,0278,RC,,,,both,,,373.66,242.88,,,,,,,,,,,,,
LINER KERAMOS REPL POLY 28MMX48/50 MM,SUP-2217228,CDM,C1776,CPT,0278,RC,,,,both,,,3818.24,2481.86,,,,,,,,,,,,,
PICC KIT: 4 FRX19-5/8IN 50 CM,SUP-2383962,CDM,C1751,HCPCS,0278,RC,,,,both,,,440.67,286.44,,,,,,,,,,,,,
PLATE BONE 5X20 HOLE RIGHT RECONSTRUCTION WITH CONDYLAR HEAD,SUP-2838423,CDM,C1713,HCPCS,0278,RC,,,,both,,,18634.64,12112.52,,,,,,,,,,,,,
TUBE VENT ID1.32MM BLU SIL T MOD FOR MYR RICHARDS 6PK,SUP-2313723,CDM,L8699,HCPCS,0278,RC,,,,both,,,78.09,50.76,,,,,,,,,,,,,
HEAD FEM OD32MM +0MM OFFSET HIP 12/14 TAPR RESTORIS Z,SUP-2370462,CDM,C1776,CPT,0278,RC,,,,both,,,1005.11,653.32,,,,,,,,,,,,,
NAIL IM CANN 130 DEG 12X340 MM RT DSTL TI STRL TFN- ADV,SUP-2180616,CDM,C1713,HCPCS,0278,RC,,,,both,,,8292.65,5390.22,,,,,,,,,,,,,
SPLINT PREMIER PRO WRST,SUP-2336039,CDM,L3809,HCPCS,0272,RC,,,,both,,,18.46,12.00,,,,,,,,,,,,,
SET INT FIX SCREW DIA1.5 MM 6 H TI NEURO CRV PLATE 1 PK STRL,SUP-2935385,CDM,C1713,HCPCS,0278,RC,,,,both,,,1949.94,1267.46,,,,,,,,,,,,,
PROSTHESIS PENILE L12CM MALL CYL AMS 650,SUP-2140266,CDM,C1813,HCPCS,0278,RC,,,,both,,,10048.00,6531.20,,,,,,,,,,,,,
VALVE VOICE 4.5MM TRACH LT PROVOX ACTIVLV,SUP-2124317,CDM,L8509,HCPCS,0274,RC,,,,both,,,6531.20,4245.28,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE 10 CC DBM CRUNCH,SUP-2913355,CDM,C1713,HCPCS,0278,RC,,,,both,,,7714.98,5014.74,,,,,,,,,,,,,
GRAFT BONE 10 CC,SUP-2424593,CDM,C1713,HCPCS,0278,RC,,,,both,,,7512.45,4883.09,,,,,,,,,,,,,
KIT INTRO GLIDESHEATH L 16 CM DIA 4 FR GUIDEWIRE 0.021 IN,SUP-2385166,CDM,C1894,HCPCS,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
CATHETER SUPP QUICK-CROSS L 90 CM 4FR 0.044/0.03 IN 0.018 IN,SUP-2823683,CDM,C1887,HCPCS,0272,RC,,,,both,,,501.52,325.99,,,,,,,,,,,,,
PLATE BNE STR 3.5X261 MM 22 HOLE RECON FOR SCR SS NS,SUP-2479543,CDM,C1713,HCPCS,0278,RC,,,,both,,,1883.62,1224.35,,,,,,,,,,,,,
HC Biliary Duct Dilat W/Out Stent,PX-3614755500,CDM,47555,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
PLATE BONE ANGLED THICK 2.5 MM MANDIBLE PATIENT SPECIFIC ANG,SUP-2838601,CDM,C1713,HCPCS,0278,RC,,,,both,,,26237.53,17054.39,,,,,,,,,,,,,
KIT CHOLGM PROC L53CM OD8FR CUT AWAY GUID LD COR SNUS,SUP-2148990,CDM,C1887,HCPCS,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
SLEEVE FEM SM SZ 26-27 TI STIKTITE HA HIP REV MOD REDAPT,SUP-2345443,CDM,C1776,CPT,0278,RC,,,,both,,,5369.40,3490.11,,,,,,,,,,,,,
GRAFT VSCLR L3XW1N THCKNSS 76MM TPRD END KNTTD DBLE VLR ST I,SUP-2473388,CDM,C1768,CPT,0278,RC,,,,both,,,445.60,289.64,,,,,,,,,,,,,
GUIDEWIRE ORTH 1.5X150 MM AOS,SUP-2766032,CDM,C1769,HCPCS,0272,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
GRAFT BIO TISS MARIGEN EXPANSE 7X8CM MESHED,SUP-2909357,CDM,Q4158,HCPCS,0636,RC,,,,both,,,8352.40,5429.06,,,,,,,,,,,,,
LEAD PACE 8.6FR L62CM DUAL COIL PERM ACT FIX DF4 CONN SPRNT,SUP-2282266,CDM,C1895,HCPCS,0275,RC,,,,both,,,8769.83,5700.39,,,,,,,,,,,,,
KIT ABLAT PRB 17GA L7MM 2 OSTEOCOOL RF,SUP-2293685,CDM,C1886,HCPCS,0278,RC,,,,both,,,12874.00,8368.10,,,,,,,,,,,,,
COIL EMB L8CM DIA2MM SFT HELI DETACH GDC 18,SUP-2365701,CDM,C1889,HCPCS,0278,RC,,,,both,,,3057.42,1987.32,,,,,,,,,,,,,
SCREW BNE L14MM DIA3MM HDLSS FOR FRAC REP AND FIX OSTEOTMY,SUP-2175071,CDM,C1713,HCPCS,0278,RC,,,,both,,,1342.35,872.53,,,,,,,,,,,,,
MOST OPTIONS POLY REPLACEMENT KIT 4MM,SUP-2509225,CDM,C1776,CPT,0278,RC,,,,both,,,3433.59,2231.83,,,,,,,,,,,,,
CONFORM FLEX Q-PACK 6 MM CUBE,SUP-2547185,CDM,C1713,HCPCS,0278,RC,,,,both,,,408.99,265.84,,,,,,,,,,,,,
"HC Cult,Pathognic Orgnsms,Screen",PX-3008708100,CDM,87081,CPT,0300,RC,,,,both,,,125.00,81.25,,,,,,,,,,,,,
LEAD NEUROSTIMULATOR L50CM PRECIS SPECTR INFINION 16 LD SPNL,SUP-2138787,CDM,C1778,HCPCS,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
BEARING HUM CROSSLINKED 45 MM SHLDR POLYETH VIVACIT-E,SUP-2431692,CDM,C1776,CPT,0278,RC,,,,both,,,7222.00,4694.30,,,,,,,,,,,,,
BIT DRILL ARTHRO DIA15MM BLK FLX DISPOSABLE FOR SFT ANCHR SYS,SUP-2137227,CDM,2720000010,LOCAL,0272,RC,,,,both,,,327.06,212.59,,,,,,,,,,,,,
SET URET STENT MARD L 28 CM DIA 7 FR ZIPWIRE 0.038 IN,SUP-2721280,CDM,C2617,HCPCS,0278,RC,,,,both,,,520.08,338.05,,,,,,,,,,,,,
TWIST DRILL 15MM DIA X 80MM H SHANK BOD/BOS SNGLE USE,SUP-2676843,CDM,2720000010,LOCAL,0272,RC,,,,both,,,528.65,343.62,,,,,,,,,,,,,
BIT DRL CALIB 2.7X160 MM DISP,SUP-2606595,CDM,2720000010,LOCAL,0272,RC,,,,both,,,320.97,208.63,,,,,,,,,,,,,
GRAFT HUMAN TISSUE BIOLOGICAL TISSUE MATRIX THICK 30X20 CM NON CROSSLINKED SCAFFOLD NATURALLY OCCURRING PORCINE STERILE GENTRIX DISPOSABLE,SUP-2106503,CDM,Q4166,HCPCS,0636,RC,,,,both,,,51009.30,33156.04,,,,,,,,,,,,,
ALLOGRAFT BNE GRND 90 CC FD IRRADIATED CORTICAL CANC,SUP-2867129,CDM,C1762,CPT,0278,RC,,,,both,,,4003.50,2602.27,,,,,,,,,,,,,
PLATE BNE L 170 X W 11.4 MM THK 3.4 MM SCREW DIA 3.5 MM 13 H,SUP-2936308,CDM,C1713,HCPCS,0278,RC,,,,both,,,5879.34,3821.57,,,,,,,,,,,,,
INSTRUMENT BACKFLUSH 25GA W/ BRSH NDL ACT ASPIR DISP,SUP-2213461,CDM,2720000010,LOCAL,0272,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
CATHETER ATHRCTMY OCELOT L 110 CM DIA 6 FR GUIDEWIRE 0.014,SUP-2124793,CDM,C1753,HCPCS,0278,RC,,,,both,,,7834.30,5092.29,,,,,,,,,,,,,
SCREW BNE ST 1.7X7 MM NS AXS LTX,SUP-2862786,CDM,C1713,HCPCS,0278,RC,,,,both,,,278.86,181.26,,,,,,,,,,,,,
HC Ot Eval High Complex,PX-4349716700,CDM,97167,CPT,0434,RC,,,,outpatient,,,341.00,221.65,,,,,,,,,,,,,
VALVE MITRL CARP EDW PERIMT MAGNA DIA25 MM SEW RNG DIA 36 MM,SUP-2214302,CDM,C1713,HCPCS,0278,RC,,,,both,,,22881.18,14872.77,,,,,,,,,,,,,
TI SCREW FOR CONDYLAR HEAD,SUP-2823269,CDM,C1889,HCPCS,0278,RC,,,,both,,,514.33,334.31,,,,,,,,,,,,,
PIN COMPR NEXFIX 3.5X30MM NS,SUP-2420188,CDM,C1713,HCPCS,0278,RC,,,,both,,,618.58,402.08,,,,,,,,,,,,,
SYSTEM CLOSURE VASC KNOT TYNG SNR XCLOSER,SUP-2241112,CDM,C1760,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
CLAMP REPROC EXT FIX PIN 5 HOLE,SUP-2516724,CDM,2720000010,LOCAL,0272,RC,,,,both,,,571.10,371.21,,,,,,,,,,,,,
BUR SURG DIA4MM RND W/ RIM GLDE TECHNOLOGY PRECIS,SUP-2367541,CDM,2720000010,LOCAL,0272,RC,,,,both,,,680.03,442.02,,,,,,,,,,,,,
HOOK/TRIANGLE BLDE KT -  ORDER BY 6 EACH,SUP-2370410,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1433.10,931.51,,,,,,,,,,,,,
PACEMAKER CARD 2 CHMBR RATE RESPON IMP IDENTITY ADX DR,SUP-2356211,CDM,C1785,HCPCS,0275,RC,,,,both,,,16321.72,10609.12,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 100 CM DIA 8 MM RNG L 70 CM EPTFE,SUP-2396306,CDM,C1768,CPT,0278,RC,,,,both,,,5721.08,3718.70,,,,,,,,,,,,,
REAMER SURG 10MM FLEX LO PROF,SUP-2121255,CDM,2720000010,LOCAL,0272,RC,,,,both,,,894.90,581.68,,,,,,,,,,,,,
LIDOCAINE HCL 1% INJ (MIXTURES ONLY),RX-430017,CDM,J2003,HCPCS,0636,RC,63323-0201-10,NDC,,both,5,ML,54.10,35.16,,,,,,,,,,,,,
CATHETER CV SINGLE LUMEN 4 FRX45 CM MAXIMAL BARR POWERPICC,SUP-2126367,CDM,C1751,HCPCS,0278,RC,,,,both,,,607.87,395.12,,,,,,,,,,,,,
COIL EMB L45CM PRI DIA0.020IN 2ND DIA11MM NIT COMPLX STD,SUP-2323374,CDM,C1889,HCPCS,0278,RC,,,,both,,,7294.22,4741.24,,,,,,,,,,,,,
TROCAR ENDOPATH BLADELESS 10/12MM 100MM W/ STABILITY SLV,SUP-2855496,CDM,2720000010,LOCAL,0272,RC,,,,both,,,520.05,338.03,,,,,,,,,,,,,
GUIDEWIRE ORTH CRV 8.75 IN,SUP-2459873,CDM,C1769,HCPCS,0272,RC,,,,both,,,570.79,371.01,,,,,,,,,,,,,
HC So Abl1 Gene,PX-3108117066,CDM,81170,CPT,0310,RC,,,,both,,,641.00,416.65,,,,,,,,,,,,,
CRANIAL ACCESS KIT W/ NO DRUG 2 DRL BIT RAZOR,SUP-2852689,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1333.59,866.83,,,,,,,,,,,,,
SCREW BNE L 46 MM DIA 3.5 MM TI CANN HD NS LEOS,SUP-2932609,CDM,C1713,HCPCS,0278,RC,,,,both,,,902.72,586.77,,,,,,,,,,,,,
LASER ENDOSCP 20 W HOLM,SUP-2540076,CDM,2720000010,LOCAL,0272,RC,,,,both,,,142741.26,92781.82,,,,,,,,,,,,,
PLATE BONE 2.4MM SUBCONDYLAR TI TIA HND PLATING,SUP-2319671,CDM,C1713,HCPCS,0278,RC,,,,both,,,2113.22,1373.59,,,,,,,,,,,,,
CATHETER DRNGE 20FR L25CM GWIRE 0.038IN NDL 18GA 6 SIDEPRT,SUP-2168307,CDM,C1729,HCPCS,0272,RC,,,,both,,,278.89,181.28,,,,,,,,,,,,,
PLATE BNE W13XL13MM 4 H CRANIOMAXILLOFACIAL TI BX SHP FOR,SUP-2190682,CDM,C1713,HCPCS,0278,RC,,,,both,,,636.79,413.91,,,,,,,,,,,,,
ALLOGRAFT BNE FIBULAR 6 MMX0.2 CM FD CROSS SECT,SUP-2717740,CDM,C1762,CPT,0278,RC,,,,both,,,1758.40,1142.96,,,,,,,,,,,,,
STENT URET STR 0.035 IN 3 CM 5 FRX12 CM 6 FR POLARIS ULTRA,SUP-2522248,CDM,C2617,HCPCS,0278,RC,,,,both,,,470.59,305.88,,,,,,,,,,,,,
CONNECTOR ROD CLS OPN AX TI IMPL OD55X45MM CDH LEG,SUP-2279783,CDM,C1713,HCPCS,0278,RC,,,,both,,,3583.18,2329.07,,,,,,,,,,,,,
HC Needle Insertion W/O Injection 3 or More Muscles,PX-4202056100,CDM,20561,CPT,0420,RC,,,,outpatient,,,42.00,27.30,,,,,,,,,,,,,
PLATE BNE L292MM 16 H NONSTERILE R MED DST TIB S STL VAR ANG,SUP-2177652,CDM,C1713,HCPCS,0278,RC,,,,both,,,6565.68,4267.69,,,,,,,,,,,,,
WEDGE FEM L20MM HTO,SUP-2307175,CDM,C1713,HCPCS,0278,RC,,,,both,,,2600.55,1690.36,,,,,,,,,,,,,
COLLAR CERV L13-16IN H3.25IN M TRACH OPN W/ CHIN SUPP ADJ,SUP-2197923,CDM,L0120,HCPCS,0272,RC,,,,both,,,266.90,173.48,,,,,,,,,,,,,
SHUNT SURG W/ ANCHR CLP UNI-SHUNT,SUP-2666570,CDM,C1889,HCPCS,0278,RC,,,,both,,,354.29,230.29,,,,,,,,,,,,,
HC Needle Insertion W/O Injection 3 or More Muscles,PX-4202056100,CDM,20561,CPT,0940,RC,,,,inpatient,,,42.00,27.30,,,,,,,,,,,,,
IMPLANT SHLDR TI NIOBIUM NITRIDE RVS GRS BASEPLT,SUP-2888598,CDM,C1776,CPT,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
SCREW BONE L11MM DIA2MM LCK CROSSDRIVE TI THREADLOCK TS,SUP-2262834,CDM,C1713,HCPCS,0278,RC,,,,both,,,360.28,234.18,,,,,,,,,,,,,
HC So Pregnenolone,PX-3018414066,CDM,84140,CPT,0301,RC,,,,inpatient,,,55.00,35.75,,,,,,,,,,,,,
SHELL ACET OD42MM ID32MM HIP ALL POLY PROSTALAC,SUP-2251996,CDM,C1776,CPT,0278,RC,,,,both,,,1799.85,1169.90,,,,,,,,,,,,,
EXTRACTOR SURG SZ 3.5 MM SCREW DIA 3.5-8 MM STRL DISP,SUP-2913544,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2199.10,1429.41,,,,,,,,,,,,,
INTRODUCER SHTH 0.078 IN AD 7 FRX55 CM AMPLATZ1 VISTABRT TIP,SUP-2156087,CDM,C1887,HCPCS,0272,RC,,,,both,,,357.96,232.67,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 260 MM DIA15 MM DEL SHTH 46ML,SUP-2937084,CDM,C1713,HCPCS,0278,RC,,,,both,,,15448.80,10041.72,,,,,,,,,,,,,
CATHETER ABLATN B 2-5-2 MM 3.5 MM 7 FRX115 CM THERMOCOOL LF,SUP-2248838,CDM,C2630,CPT,0272,RC,,,,both,,,3793.12,2465.53,,,,,,,,,,,,,
HC NM Bone Marrow Imaging-Ltd,PX-3417810200,CDM,78102,CPT,0341,RC,,,,both,,,1348.00,876.20,,,,,,,,,,,,,
STAPLER ENDOSCP 75MM STPL OPN H42MM CLS H18MM REG TISS LIN,SUP-2693599,CDM,2720000010,LOCAL,0272,RC,,,,both,,,512.61,333.20,,,,,,,,,,,,,
SCREW BNE LAG 12.7X95 MM HIP COMPR TALON,SUP-2391519,CDM,C1713,HCPCS,0278,RC,,,,both,,,1946.80,1265.42,,,,,,,,,,,,,
PLATE BONE THK1MM 4 H MAND SLV TI STR FOR 2/2.3MM SCR SYS,SUP-2136770,CDM,C1713,HCPCS,0278,RC,,,,both,,,1453.82,944.98,,,,,,,,,,,,,
HC Extremity Arteriogram Bilateral,PX-3237571600,CDM,75716,CPT,0323,RC,,,,both,,,6098.00,3963.70,,,,,,,,,,,,,
COMPONENT FEM B CO CHROM LT KNEE PRI CEM CRUC RET STEMLESS,SUP-2200959,CDM,C1776,CPT,0278,RC,,,,both,,,12184.77,7920.10,,,,,,,,,,,,,
PLATE BNE T 139 MM RT DSTL RADIAL DORS PERIARTICULAR 12 HOLE,SUP-2525045,CDM,C1713,HCPCS,0278,RC,,,,both,,,2897.84,1883.60,,,,,,,,,,,,,
GUIDEWIRE VASC KATZN L 180 CM DIA 0.035 IN SS COR STRL,SUP-2148183,CDM,C1713,HCPCS,0278,RC,,,,both,,,66.44,43.19,,,,,,,,,,,,,
CATHETER HD 3L 11.5 FRX20 CM ADMIN FULL KT PRECRV TRIFLO,SUP-2269543,CDM,C1752,HCPCS,0278,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
APPLIER CLP L9.75IN STD BLU TI STR BAYNT FOR ANEUR CLP REUSE,SUP-2108608,CDM,C1889,HCPCS,0278,RC,,,,both,,,5071.60,3296.54,,,,,,,,,,,,,
HC Cardioversion,PX-4509296000,CDM,92960,CPT,0450,RC,,,,outpatient,,,1401.00,910.65,,,,,,,,,,,,,
GRAFT HUM TISS SZ C W3.5XL3.5CM FRZN ALLGRFT OCU AMNIO MEM,SUP-2135259,CDM,V2790,HCPCS,0274,RC,,,,both,,,2810.30,1826.69,,,,,,,,,,,,,
SCREW BONE SPNL POLYAX REVERE 4X25 MM,SUP-2228088,CDM,C1713,HCPCS,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
PLATE BNE L 59 MM 4 H LT DSTL VOLAR RADIAL STD EXT STRL,SUP-2902195,CDM,C1713,HCPCS,0278,RC,,,,both,,,5415.02,3519.76,,,,,,,,,,,,,
GRAFT VASC FUSION BIOLINE L 40 CM DIA10 MM EXTERNALLY SUPP,SUP-2475869,CDM,C1768,CPT,0278,RC,,,,both,,,5830.79,3790.01,,,,,,,,,,,,,
TUBE VENT 1.02 MM GRMMT W/ TAB SIL,SUP-2535078,CDM,L8699,HCPCS,0278,RC,,,,both,,,29.83,19.39,,,,,,,,,,,,,
IMMOBILIZER SHOULDERXL FOR 42-48IN CHST ELAS W/O NK STRP M,SUP-2197392,CDM,L3660,HCPCS,0272,RC,,,,both,,,70.02,45.51,,,,,,,,,,,,,
CATHETER LD DEL ACUITY PRO 130 DEG L 54 CM DIA 9 FR SS PTFE,SUP-2149032,CDM,C1887,HCPCS,0272,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
PLATE BNE L1665MM THK25MM 14 H ACET S STL FLX ANNEALED,SUP-2362710,CDM,C1713,HCPCS,0278,RC,,,,both,,,3048.63,1981.61,,,,,,,,,,,,,
CATHETER ANGIO MARINER L 65 CM 5 FR 0.035 IN C1 BRAIDED,SUP-2116822,CDM,C1887,HCPCS,0272,RC,,,,both,,,108.64,70.62,,,,,,,,,,,,,
HC So Kit Gene Analysis D816 Variant,PX-3108127366,CDM,81273,CPT,0310,RC,,,,both,,,418.00,271.70,,,,,,,,,,,,,
WIRE SURG 400X2 MM REDUCTION MR SAFE,SUP-2187485,CDM,C1713,HCPCS,0278,RC,,,,both,,,658.21,427.84,,,,,,,,,,,,,
WIRE EXT FIX HALF 1.8X400 MM REDUCTION,SUP-2749890,CDM,C1713,HCPCS,0278,RC,,,,both,,,555.78,361.26,,,,,,,,,,,,,
NUT SPNL TI POLYAX MINI OUTER SUMMIT FIX SYS,SUP-2254419,CDM,C1713,HCPCS,0278,RC,,,,both,,,276.32,179.61,,,,,,,,,,,,,
NEEDLE BONE CEMENT DELIVERY 8 GAX10 CM STERILE,SUP-2838508,CDM,2720000010,LOCAL,0272,RC,,,,both,,,433.01,281.46,,,,,,,,,,,,,
CATHETER GRFT POS DIA18 FR RVD 26-42 MM POLYUR TRILOBE,SUP-2395624,CDM,C1725,HCPCS,0272,RC,,,,both,,,2050.42,1332.77,,,,,,,,,,,,,
SCREW SPNL L10MM DIA3.5MM 15DEG MINI CANC POST OCCIPITAL,SUP-2254400,CDM,C1713,HCPCS,0278,RC,,,,both,,,3045.80,1979.77,,,,,,,,,,,,,
HC Rmvl FB Conjunctiv Embedded,PX-4506521000,CDM,65210,CPT,0450,RC,,,,both,,,954.00,620.10,,,,,,,,,,,,,
ARCH EXT FIX 200-220 MM PLNTR,SUP-2898493,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1296.82,842.93,,,,,,,,,,,,,
PLATE BONE 3MM MAXILLOFACIAL LT,SUP-2372897,CDM,C1713,HCPCS,0278,RC,,,,both,,,929.44,604.14,,,,,,,,,,,,,
GRAFT SYS DEL AGF SYR,SUP-2415892,CDM,2720000010,LOCAL,0272,RC,,,,both,,,471.31,306.35,,,,,,,,,,,,,
BASKET STONE REM 1.5FR L120CM SHTH DIA12MM NIT POLYIMIDE,SUP-2336364,CDM,2720000010,LOCAL,0272,RC,,,,both,,,771.50,501.47,,,,,,,,,,,,,
HC Group Caregiver Training Strategies & Technique,PX-4309755200,CDM,97552,CPT,0430,RC,,,,both,,,56.00,36.40,,,,,,,,,,,,,
SHUNT VLV PROGAV 2.0 W/SPRNG RSVR,SUP-2737584,CDM,C1889,HCPCS,0278,RC,,,,both,,,13766.26,8948.07,,,,,,,,,,,,,
BIT DRL 1.7 MM FOR SM SCR FIX SYS LACTOSORB REUNITE,SUP-2608841,CDM,2720000010,LOCAL,0272,RC,,,,both,,,502.90,326.88,,,,,,,,,,,,,
BIT DRL TWST 1.5X70 MM 7 MM W/ STP HEX ATTCH BOS LEVEL 1,SUP-2463038,CDM,2720000010,LOCAL,0272,RC,,,,both,,,462.58,300.68,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 80 CM DIA 4-7 MM EPTFE XLN TAPR TW,SUP-2525473,CDM,C1768,CPT,0278,RC,,,,both,,,2669.44,1735.14,,,,,,,,,,,,,
RING EXT FIX HALF 90 MM CARBON FIBER RINGFIX,SUP-2365282,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2747.50,1785.87,,,,,,,,,,,,,
BIT DRL QC LG 12.8 MM CANN STRL,SUP-2789167,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2107.88,1370.12,,,,,,,,,,,,,
CEMENT FLX FEM /ST TIB / FLX ART SURF /STD PAT,SUP-2212158,CDM,C1776,CPT,0278,RC,,,,both,,,12071.35,7846.38,,,,,,,,,,,,,
AUTOINJECTOR ENDOGRFT O-PRIME,SUP-2390656,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1566.86,1018.46,,,,,,,,,,,,,
CANNULA ENDOSCP 10 MM FOR STEINER MORCELLATOR HNDL,SUP-2360968,CDM,C1713,HCPCS,0278,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
GRAFT BNE 1 4MM 40ML CANC CHIP DEMIN,SUP-2264715,CDM,C1713,HCPCS,0278,RC,,,,both,,,1930.66,1254.93,,,,,,,,,,,,,
AUGMENT TIB SZ 4 LT KNEE UNIV SGL USE LEGION,SUP-2349124,CDM,C1776,CPT,0278,RC,,,,both,,,5344.28,3473.78,,,,,,,,,,,,,
LEVOTHYROXINE SODIUM 25 MCG PO TABS,RX-4420,CDM,6370000000,HCPCS,0637,RC,68180-0965-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
CUBE EXT FIX OD5MM 4 H SALVATION,SUP-2401122,CDM,2720000010,LOCAL,0272,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
BONESYNC STRIP 10CC,SUP-2811324,CDM,C1713,HCPCS,0278,RC,,,,both,,,3249.90,2112.43,,,,,,,,,,,,,
CONNECTOR SHLDR IMPL,SUP-2204887,CDM,C1776,CPT,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
GRAFT HUM TISS W3XL7CM THK0.2-0.4MM ULTRATHIN FLEXHD,SUP-2307506,CDM,Q4128,HCPCS,0636,RC,,,,both,,,1603.25,1042.11,,,,,,,,,,,,,
WASHER ORTH DIA13.5MM SPIK PEEK FOR 3.5/4MM SCR,SUP-2184672,CDM,C1713,HCPCS,0278,RC,,,,both,,,254.34,165.32,,,,,,,,,,,,,
SPACER FEM SM MOD HIP STEM PMMA GENTMYCN BASE,SUP-2319838,CDM,C1776,CPT,0278,RC,,,,both,,,8635.00,5612.75,,,,,,,,,,,,,
GUIDEWIRE VASC L400CM DIA0.035IN NIT INTMED STR TIP FLX,SUP-2173022,CDM,C1769,HCPCS,0272,RC,,,,both,,,816.40,530.66,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED KNEECAP] ZIMMER BIOMET INC],SUP-2212604,CDM,C1776,CPT,0278,RC,,,,both,,,13188.00,8572.20,,,,,,,,,,,,,
UPCHARGE HIP MODULAR DUAL MOBILITY LINER STRYKER,SUP-2501356,CDM,C1776,CPT,0278,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 70 CM DIA 7MM STR TW HELIX SLDE GDS,SUP-2227379,CDM,C1768,CPT,0278,RC,,,,both,,,2758.36,1792.93,,,,,,,,,,,,,
CANNULA BNE CEMENT END-DELIVERY 11 GA 200 MM DRL ACCUPORT,SUP-2866861,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1640.65,1066.42,,,,,,,,,,,,,
TRAY CATH PICC CUST SUBCLAV POWERPICC SOLO 2 LTXFRDM,SUP-2613404,CDM,C1751,HCPCS,0278,RC,,,,both,,,572.61,372.20,,,,,,,,,,,,,
NAIL IM MTCRPL TI 7.6MM PROX DIAM 4.6MM DST DIAM 60MM LEN,SUP-2340239,CDM,C1713,HCPCS,0278,RC,,,,both,,,2402.10,1561.36,,,,,,,,,,,,,
SET NEPHROSTOMY MCOT DSTL L 20 CM PROX L 30 CM DIA24/7 FR,SUP-2168889,CDM,C1729,HCPCS,0272,RC,,,,both,,,266.77,173.40,,,,,,,,,,,,,
GRAFT HUM TISS PATELLAR TEND BNE 11 MM FRZN PRE-SHAPED,SUP-2430949,CDM,C1762,CPT,0278,RC,,,,both,,,9106.00,5918.90,,,,,,,,,,,,,
"HC So Systemic Lupus a, Dna Ab|ADJ",PX-3028622567,CDM,86225,CPT,0302,RC,,,ADJ,both,,,28.00,18.20,,,,,,,,,,,,,
TRIAL SPACER STR 10X23X11 MM,SUP-2690483,CDM,C1889,HCPCS,0278,RC,,,,both,,,530.66,344.93,,,,,,,,,,,,,
SHEATH INTRO DRYSEAL FLX L 33 CM DIA14 FR BODY DIA 5.3 MM,SUP-2395728,CDM,C1894,HCPCS,0272,RC,,,,both,,,1224.60,795.99,,,,,,,,,,,,,
MESH HERN DIA4.5IN OMEGA 3 FATTY ACID POLYPR RND,SUP-2265995,CDM,C1781,HCPCS,0278,RC,,,,both,,,1701.88,1106.22,,,,,,,,,,,,,
HC X-Ray Femur 1 View,PX-3207355100,CDM,73551,CPT,0320,RC,,,,inpatient,,,267.00,173.55,,,,,,,,,,,,,
ACET RECONSTRUCTION ROOF RING 64MM OD X60MM ID,SUP-2504603,CDM,C1776,CPT,0278,RC,,,,both,,,3994.08,2596.15,,,,,,,,,,,,,
GRAFT MTRX DERM PTCH SFT TISS REP 5CMX4CM,SUP-2335293,CDM,Q4128,HCPCS,0636,RC,,,,both,,,7686.72,4996.37,,,,,,,,,,,,,
ROD IM FLUT 8 MM N-K II,SUP-2449178,CDM,C1713,HCPCS,0278,RC,,,,both,,,1031.49,670.47,,,,,,,,,,,,,
SCREW BNE L75MM DIA5MM CNDYL S STL ST VAR ANG LOK T25,SUP-2178719,CDM,C1713,HCPCS,0278,RC,,,,both,,,555.00,360.75,,,,,,,,,,,,,
PLATE BONE ADAPTION 1.5X33X5 MM 8 HOLE RAPID RESORBABLE SCAL,SUP-2838547,CDM,C1713,HCPCS,0278,RC,,,,both,,,791.28,514.33,,,,,,,,,,,,,
SHUNT NEUROSURGICAL L110CM STD LO PRSS 2PC VLV,SUP-2243849,CDM,C1889,HCPCS,0278,RC,,,,both,,,9115.48,5925.06,,,,,,,,,,,,,
MESH SURG 20CM W/ POS SYS ECHO 2 VENTRALIGHT ST,SUP-2126546,CDM,C1781,HCPCS,0278,RC,,,,both,,,4239.00,2755.35,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.441,SUP-2860005,CDM,C1713,HCPCS,0278,RC,,,,both,,,48749.44,31687.14,,,,,,,,,,,,,
GUIDEWIRE VASC LUNDERQUIST-RING L 145 CM DIA 0.035 IN SS,SUP-2169712,CDM,C1769,HCPCS,0272,RC,,,,both,,,89.87,58.42,,,,,,,,,,,,,
BRACE WRST LEN 6 1 4IN CIRC UP TO 5 3 4IN XSM L REG D RNG W,SUP-2326020,CDM,L3908,HCPCS,0274,RC,,,,both,,,79.54,51.70,,,,,,,,,,,,,
GRAFT BNE STD W55 60XL55 60MM PERICARD TISS BIO SCFLD FRZ,SUP-2307106,CDM,C1713,HCPCS,0278,RC,,,,both,,,1492.98,970.44,,,,,,,,,,,,,
KIT CATH HEMODIALYSI EQUISTREAM XK CHRONIC STD 16FR DIA 36CM,SUP-2613306,CDM,C1750,HCPCS,0278,RC,,,,both,,,1453.82,944.98,,,,,,,,,,,,,
COMPONENT FEM L7CM R PROX HIP TI MOD FINN STYL OSS,SUP-2405808,CDM,C1776,CPT,0278,RC,,,,both,,,18369.00,11939.85,,,,,,,,,,,,,
ANCHOR SUT DIA65MM TRCR TIP DBL HELIX THRD PEEK ZIP,SUP-2366669,CDM,C1713,HCPCS,0278,RC,,,,both,,,610.42,396.77,,,,,,,,,,,,,
PLATE BNE THK0.6MM 7 H CRANIOMAXILLOFACIAL G DBL Y UNIV 2,SUP-2366252,CDM,C1713,HCPCS,0278,RC,,,,both,,,637.86,414.61,,,,,,,,,,,,,
PLATE BNE L82MM 4 H ST R ANTEROMEDIAL DST TIB S STL VAR ANG,SUP-2177667,CDM,C1713,HCPCS,0278,RC,,,,both,,,5583.52,3629.29,,,,,,,,,,,,,
BIT DRL TWST 1.5X15 MM ANGLED SCREWDRIVER ANGULUS 2,SUP-2458010,CDM,2720000010,LOCAL,0272,RC,,,,both,,,488.90,317.78,,,,,,,,,,,,,
TROCAR ENDOSCP L 100 MM DIA11 MM STD OPT BLDELSS FIX CANN,SUP-2896437,CDM,2720000010,LOCAL,0272,RC,,,,both,,,483.84,314.50,,,,,,,,,,,,,
CATHETER TRAY DL 6 FR PERIPH,SUP-2116965,CDM,C1751,HCPCS,0278,RC,,,,both,,,477.28,310.23,,,,,,,,,,,,,
TOOL SURG DIA9.5MM KNEE CRUCIAL GORE SMOOTH,SUP-2341335,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1137.62,739.45,,,,,,,,,,,,,
KYPHOPLASTY KIT BLLN 11 GAX20 MM,SUP-2864564,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8329.70,5414.30,,,,,,,,,,,,,
BIT DRL CANN 5 MM,SUP-2518592,CDM,2720000010,LOCAL,0272,RC,,,,both,,,885.48,575.56,,,,,,,,,,,,,
DM-GUAIFENESIN ER 30-600 MG PO TB12,RX-27543,CDM,6370000000,HCPCS,0637,RC,63824-0056-34,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
CROWN DENT UR4 1ST PRI M INDIV SPACE MAINTAINER,SUP-2176668,CDM,D6783,CPT,0278,RC,,,,both,,,24.18,15.72,,,,,,,,,,,,,
FISH OIL 1000 MG PO CAPS,RX-3113,CDM,6370000000,HCPCS,0637,RC,77333-0308-10,NDC,,both,1,UN,1.50,0.97,,,,,,,,,,,,,
SUPPORT ORTHOT PIP FNGR DSTL INTERPHALANGEAL SPRING W/JT,SUP-2435784,CDM,L3925,HCPCS,0272,RC,,,,both,,,169.25,110.01,,,,,,,,,,,,,
SHEATH INTRO SOLOPATH WORKING L 25 CM EXPANDABLE L 20CM 16FR,SUP-2385695,CDM,C1894,HCPCS,0272,RC,,,,both,,,1852.60,1204.19,,,,,,,,,,,,,
PLATE BNE 34 MM TI,SUP-2208316,CDM,C1713,HCPCS,0278,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
EXTENSION STEM FEM 4 MM KNEE OFFSET OPTETRAK LOGIC,SUP-2432777,CDM,C1776,CPT,0278,RC,,,,both,,,897.88,583.62,,,,,,,,,,,,,
DISTRACTOR EXT FIX 30 MM 1.5-1.8 MM 5 MM 31 HOLE END DRIVEN,SUP-2480421,CDM,C1713,HCPCS,0278,RC,,,,both,,,19177.77,12465.55,,,,,,,,,,,,,
HC Bone Survey Complete,PX-3207707500,CDM,77075,CPT,0320,RC,,,,inpatient,,,1477.00,960.05,,,,,,,,,,,,,
GRAFT HUM TISS 2X4CM DEHYDR AMNIO MEMBRN FLOWERPATCH,SUP-2225381,CDM,Q4178,HCPCS,0636,RC,,,,both,,,4082.00,2653.30,,,,,,,,,,,,,
MICONAZOLE NITRATE 2 % VA CREA,RX-5040,CDM,6370000000,HCPCS,0637,RC,51672-2035-06,NDC,,both,45,GR,36.30,23.59,,,,,,,,,,,,,
COMPONENT TIB PS 5 UNIV 10 MM NP PRIMARY CEM STEM MONOBLOCK,SUP-2378473,CDM,C1776,CPT,0278,RC,,,,both,,,2939.04,1910.38,,,,,,,,,,,,,
SET URET STENT SOFFLX L 22 CM DIA10 FR INSRTR L 40 CM DIA10,SUP-2171246,CDM,C2617,HCPCS,0278,RC,,,,both,,,400.66,260.43,,,,,,,,,,,,,
GRAFT DERM HYDRATED ULT THCK ACELLULAR DERM IMPL ALLGRFT 472510] MUSCULOSKELETAL TRANSPLANT FOUNDATION],SUP-2307496,CDM,Q4128,HCPCS,0636,RC,,,,both,,,4276.68,2779.84,,,,,,,,,,,,,
ROD RELINE O COCR 5.5X500MM TL,SUP-2880393,CDM,C1713,HCPCS,0278,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
GRAFT HUM TISS L 6 X W 6 CM AMNION-CHORION-AMNION LAYR,SUP-2909302,CDM,Q4140,HCPCS,0636,RC,,,,both,,,18207.95,11835.17,,,,,,,,,,,,,
STENT URET UROGUIDE L 30 CM DIA 8.5 FR SIL NYL TETH HYDRPHLC,SUP-2476987,CDM,C2617,HCPCS,0278,RC,,,,both,,,429.90,279.43,,,,,,,,,,,,,
CATHETER GUID MERCI L 180 CM HELIX L 5 MM LOOP DIA2 MM SS,SUP-2365837,CDM,C1887,HCPCS,0272,RC,,,,both,,,10660.30,6929.19,,,,,,,,,,,,,
LINER ACET OD68MM ID28MM HIP MARATHON NEUT SNAP IN REV PINN,SUP-2250349,CDM,C1776,CPT,0278,RC,,,,both,,,4320.64,2808.42,,,,,,,,,,,,,
CATHETER PERITONEAL DSTL OPN ACCU-FLO,SUP-2666407,CDM,C1729,HCPCS,0272,RC,,,,both,,,700.35,455.23,,,,,,,,,,,,,
GUIDEWIRE VASC L 145 CM DIA 0.035 IN HEPARIN J FLX,SUP-2147058,CDM,C1769,HCPCS,0272,RC,,,,both,,,49.36,32.08,,,,,,,,,,,,,
COIL DETACH 2MM DIA 2CM RESTRAINED NEXUS HELIX SUPERSOFT,SUP-2173644,CDM,C1889,HCPCS,0278,RC,,,,both,,,3617.28,2351.23,,,,,,,,,,,,,
SCREW BONE SELFTAPPING 2X14 MM MANDIBULAR 20/PK TITANIUM NON,SUP-2842280,CDM,C1713,HCPCS,0278,RC,,,,both,,,224.20,145.73,,,,,,,,,,,,,
GUIDEWIRE ORTH TRCR PT 1 END 1.6X220 MM STRL,SUP-2789091,CDM,C1769,HCPCS,0272,RC,,,,both,,,1356.86,881.96,,,,,,,,,,,,,
COMPONENT KNEE 7L PATELLAR FEM RESTORIS MCK,SUP-2265747,CDM,C1776,CPT,0278,RC,,,,both,,,8849.09,5751.91,,,,,,,,,,,,,
BUTTON FIX DIA15MM NONABSORBABLE FOR SFT TISS ENDOBTTN,SUP-2341013,CDM,C1713,HCPCS,0278,RC,,,,both,,,953.02,619.46,,,,,,,,,,,,,
PLATE BNE PROF THK 1 MM 2 X 2 H SCREW DIA2 MM TI MIDFACE,SUP-2883814,CDM,C1713,HCPCS,0278,RC,,,,both,,,722.20,469.43,,,,,,,,,,,,,
CATHETER CV RAD SET 018 3 FRX40 CM 1 LUMEN OTW SS TURBO-JECT,SUP-2759782,CDM,C1751,HCPCS,0278,RC,,,,both,,,375.29,243.94,,,,,,,,,,,,,
CATHETER SUPP SIDEKCK L 110 CM SS ANGLED TAPR TIP BRAIDED,SUP-2127015,CDM,C1887,HCPCS,0272,RC,,,,both,,,879.20,571.48,,,,,,,,,,,,,
BLADE SURG CUT EDGE 13.5MM D25.5MM THK0.51MM SAW CRESC S STL,SUP-2361978,CDM,2720000010,LOCAL,0272,RC,,,,both,,,332.09,215.86,,,,,,,,,,,,,
GUIDEWIRE VASC L150CM DIA0035IN TIP L23CM PTFE HEP BENT STR,SUP-2302738,CDM,C1769,HCPCS,0272,RC,,,,both,,,34.38,22.35,,,,,,,,,,,,,
COMPONENT SHLDR RESURF HUM,SUP-2217516,CDM,C1776,CPT,0278,RC,,,,both,,,10205.00,6633.25,,,,,,,,,,,,,
SET INTRO SUP ARW FLX SHTH L 24 CM DIA 6 FR HYDRPHLC,SUP-2383403,CDM,C1894,HCPCS,0272,RC,,,,both,,,200.96,130.62,,,,,,,,,,,,,
PLATE BNE L12MM THK2MM TI TARSAL ISOLATED FUS AFP DARCO MRS,SUP-2399640,CDM,C1713,HCPCS,0278,RC,,,,both,,,2621.90,1704.23,,,,,,,,,,,,,
PLATE T PROFYLE HAND WD 8 HL 23MM,SUP-2703009,CDM,C1713,HCPCS,0278,RC,,,,both,,,982.19,638.42,,,,,,,,,,,,,
GRAFT HUMAN TISSUE AMNIOBAND MEMBRANE 5CMX6CM,SUP-2858220,CDM,Q4151,HCPCS,0636,RC,,,,both,,,14463.28,9401.13,,,,,,,,,,,,,
STENT CORONARY ION MR L 8 MM DIA2.5 MM CATH L 144 CM DIA,SUP-2144863,CDM,C1874,HCPCS,0278,RC,,,,both,,,4396.00,2857.40,,,,,,,,,,,,,
FILIFORM URETH 6FR L18IN PLAS WVN DIL STR TIP REUSE,SUP-2128951,CDM,C1726,HCPCS,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
HC Babygram/Osseous Survey,PX-3207707600,CDM,77076,CPT,0320,RC,,,,both,,,473.00,307.45,,,,,,,,,,,,,
BURR CRANIAL DGR-I 11MM/7MM ACRA CUT,SUP-2842436,CDM,2720000010,LOCAL,0272,RC,,,,both,,,876.06,569.44,,,,,,,,,,,,,
KIT BNE CEMENT HIP MIXING SYS BRKWY FEM NOZ ADV FEM,SUP-2884227,CDM,2720000010,LOCAL,0272,RC,,,,both,,,400.95,260.62,,,,,,,,,,,,,
GUIDEWIRE UROLOGICAL STR TIP 035X2600 HYDRPHLC ZBR,SUP-2791284,CDM,C1769,HCPCS,0272,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
ROD SPNL TAPR OCCIPITOCERVICAL UPPER THOR FOR 5.5/6 MM SCREW,SUP-2631959,CDM,C1713,HCPCS,0278,RC,,,,both,,,3048.94,1981.81,,,,,,,,,,,,,
ECLIPSE TRUNION 47MM SLOTTED TPS CAP,SUP-2815496,CDM,C1776,CPT,0278,RC,,,,both,,,10205.00,6633.25,,,,,,,,,,,,,
PLATE BNE NAR 4.5X124 MM 7 HOLE SS LC-DCP,SUP-2569259,CDM,C1713,HCPCS,0278,RC,,,,both,,,269.41,175.12,,,,,,,,,,,,,
PLUG HERN XL W1.6XL2IN INGUINAL POLYPR REP PRESHAPED ONLAY,SUP-2125757,CDM,C1781,HCPCS,0278,RC,,,,both,,,721.57,469.02,,,,,,,,,,,,,
CATHETER CV SET 018 4 FRX15 CM DL J TIP POLYETH CUDLM401JLSC,SUP-2760054,CDM,C1751,HCPCS,0278,RC,,,,both,,,234.46,152.40,,,,,,,,,,,,,
SECUREMENT KIT FOR BLD PMP,SUP-2152644,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4694.30,3051.29,,,,,,,,,,,,,
BIT DRL L248MM DIA33MM FOR QUIK CPL,SUP-2188457,CDM,2720000010,LOCAL,0272,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
BIT DRL CANN 70-85 MM DENS QR NS ACUTRK 6/7 LF DISP,SUP-2518488,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1051.90,683.73,,,,,,,,,,,,,
PLATE BONE RECONSTRUCTION 2.8 MM 12 HOLE TITANIUM MATRIXMAND,SUP-2837765,CDM,C1713,HCPCS,0278,RC,,,,both,,,4415.78,2870.26,,,,,,,,,,,,,
RESORB XG ST MESH SPCLTY SUN PTTRN PRTL FOIL 101 X 101 MM T0,SUP-2694981,CDM,C1713,HCPCS,0278,RC,,,,both,,,14870.29,9665.69,,,,,,,,,,,,,
ALLOGRAFT BNE CROSS SECT 8 MM PRESERVON CALCANEUS MATRIGRAFT,SUP-2740959,CDM,C1713,HCPCS,0278,RC,,,,both,,,1784.24,1159.76,,,,,,,,,,,,,
ALLOSYNC DBM CORTICAL FIBERS 10CC,SUP-2816366,CDM,C1713,HCPCS,0278,RC,,,,both,,,3362.94,2185.91,,,,,,,,,,,,,
SCREW BONE L7MM DIA2MM TEAL CRANIOMAXILLOFACIAL TI ST FULL,SUP-2188979,CDM,C1713,HCPCS,0278,RC,,,,both,,,1012.65,658.22,,,,,,,,,,,,,
GUIDEWIRE VASC L 100 CM DIA 0.038 IN TIP L 3 MM NDL 18 GA 5,SUP-2214398,CDM,C1769,HCPCS,0272,RC,,,,both,,,96.77,62.90,,,,,,,,,,,,,
GRAFT VASC FLIXENE L 30 CM DIA 6 MM EPTFE STD WALL REINF 3,SUP-2481904,CDM,C1768,CPT,0278,RC,,,,both,,,6923.70,4500.40,,,,,,,,,,,,,
GRAFT BNE SUB 30ML 4-9.5MM CHIP CANC FRZ DRY ALLGRFT CHIPS30CC] US TISSUE AND CELL],SUP-2391734,CDM,C1713,HCPCS,0278,RC,,,,both,,,2037.86,1324.61,,,,,,,,,,,,,
HC So2 Encephalitis St.Louis,PX-3028665368,CDM,86653,CPT,0302,RC,,,,both,,,44.00,28.60,,,,,,,,,,,,,
HC So F5 Factor V Leiden Mutation,PX-3108124166,CDM,81241,CPT,0310,RC,,,,both,,,211.00,137.15,,,,,,,,,,,,,
GRAFT BONE VOID FIL 20CC NANOSS,SUP-2335283,CDM,C1713,HCPCS,0278,RC,,,,both,,,11435.88,7433.32,,,,,,,,,,,,,
ANCHOR SUTURE DIAMETER 4.75MM PEEK LATERAL ROW DUAL THREADED,SUP-2825108,CDM,C1713,HCPCS,0278,RC,,,,both,,,2060.15,1339.10,,,,,,,,,,,,,
CROWN DENT M PRI 3M DLR2 LO RT S STL,SUP-2322179,CDM,D6783,CPT,0278,RC,,,,both,,,19.28,12.53,,,,,,,,,,,,,
FLUCONAZOLE (DIFLUCAN) 2 MG/ML (PED-NEO) >/= 50 MLS,RX-4090490,CDM,J1450,HCPCS,0250,RC,25021-0184-82,NDC,,both,100,ML,54.10,35.16,,,,,,,,,,,,,
GRAFT BNE L7CMXW3CM REGEN MTRX 3 REPLFRM,SUP-2139389,CDM,C1762,CPT,0278,RC,,,,both,,,2698.89,1754.28,,,,,,,,,,,,,
GRAFT CHIP CANC OSTEOCEL 10CC,SUP-2310450,CDM,C1713,HCPCS,0278,RC,,,,both,,,10519.00,6837.35,,,,,,,,,,,,,
COMPONENT FEM SZ 4 NP RT KNEE PRI CRUC RET CEM STEMLESS,SUP-2349033,CDM,C1776,CPT,0278,RC,,,,both,,,10644.60,6918.99,,,,,,,,,,,,,
ASSEMBLY KYPHOPLASTY BI PEDICULAR 15 MM W/ OUT CEMENT STRL,SUP-2846419,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5495.00,3571.75,,,,,,,,,,,,,
SCREW BNE L70MM DIA5MM CORT CONIC S STL ST CANN LOK,SUP-2184927,CDM,C1713,HCPCS,0278,RC,,,,both,,,386.22,251.04,,,,,,,,,,,,,
GRAFT BNE CHIP CRUSH FRZN CANC 4MM 10MM RANG 30CC READIGRFT,SUP-2264737,CDM,C1713,HCPCS,0278,RC,,,,both,,,1270.38,825.75,,,,,,,,,,,,,
SYS HEMORRHAGE CNTRL INTRAUT VACM IND JADA MUST ORDER IN INCREMENTS OF 3 EACH,SUP-2854226,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4066.30,2643.09,,,,,,,,,,,,,
LOOP CUT SM 24X26FR YEL ANG FOR 24 28FR RESECTSCP SHTH THMS,SUP-2261186,CDM,2720000010,LOCAL,0272,RC,,,,both,,,425.63,276.66,,,,,,,,,,,,,
INTRODUCER SHTH 0.035 IN 7 FRX4 CM ORNG HUB SHT GRFT PRELUDE,SUP-2303315,CDM,C1894,HCPCS,0272,RC,,,,both,,,75.36,48.98,,,,,,,,,,,,,
CANISTER SUCT 1200ML W/ INTERMED TBNG RIPTIDE,SUP-2281163,CDM,2720000010,LOCAL,0272,RC,,,,both,,,879.20,571.48,,,,,,,,,,,,,
REAMER SURG OD9MM IM MOD HD FORWARD/SIDE CUT DBL WND SHFT,SUP-2368228,CDM,2720000010,LOCAL,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
PIN FIX L60MM DIA15MM POLYLACTIC ACID NONLOAD BEAR IMMOB,SUP-2166474,CDM,C1713,HCPCS,0278,RC,,,,both,,,449.71,292.31,,,,,,,,,,,,,
SCREW BONE L55MM DIA4MM PARTIALLY THRD HD M CANN FLOWERCUBE,SUP-2225340,CDM,C1713,HCPCS,0278,RC,,,,both,,,672.59,437.18,,,,,,,,,,,,,
PLATE BONE W14XL101MM THK3.8MM 90DEG 5 H LT TIB S STL L SHP,SUP-2185780,CDM,C1713,HCPCS,0278,RC,,,,both,,,1723.77,1120.45,,,,,,,,,,,,,
CATHETER ANGIOPLSTY L90CM BAL L15MM OD5MM DIL RX MRAIL,SUP-2140566,CDM,C1725,HCPCS,0272,RC,,,,both,,,1168.68,759.64,,,,,,,,,,,,,
PLATE BNE L93MM THK3MM 6 H BILAT S STL STR LIMIT CNTCT DYN,SUP-2185334,CDM,C1713,HCPCS,0278,RC,,,,both,,,1587.74,1032.03,,,,,,,,,,,,,
GRAFT VASC GELSFT L 30 CM DIA16 MM POLYESTER GEL ABD PERIPH,SUP-2384959,CDM,C1768,CPT,0278,RC,,,,both,,,1326.30,862.09,,,,,,,,,,,,,
HEAD FEM FRSH FRZN,SUP-2113953,CDM,C1713,HCPCS,0278,RC,,,,both,,,5777.60,3755.44,,,,,,,,,,,,,
NECK FEM +0MM 12/14 HI OFFSET LPB FORGED SEG HIP TI ACUMATCH,SUP-2222200,CDM,C1776,CPT,0278,RC,,,,both,,,5421.37,3523.89,,,,,,,,,,,,,
HC Mra Lower Extremities W/Contr,PX-6107372500,CDM,C8912,CPT,0610,RC,,,,both,,,4365.00,2837.25,,,,,,,,,,,,,
APPLIER CLP L33CM SHFT DIA11MM 8 SUT ABSRB RELD REUSE LAPRA,SUP-2219515,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2732.74,1776.28,,,,,,,,,,,,,
IMMOBILIZER ORTH 2 AXIS LNG 26 IN 36 IN KNEERANGER II,SUP-2197134,CDM,L3702,HCPCS,0272,RC,,,,both,,,122.62,79.70,,,,,,,,,,,,,
NEBULIZER IN-LINE REPLACEMENT AERONEB SOLO,SUP-2720067,CDM,2720000010,LOCAL,0272,RC,,,,both,,,450.09,292.56,,,,,,,,,,,,,
PLATE BNE L156MM 5 H NONSTERILE R DST FEM TI LOK COMPR FOR,SUP-2190721,CDM,C1713,HCPCS,0278,RC,,,,both,,,4737.38,3079.30,,,,,,,,,,,,,
SCREW BONE L32MM DIA4MM CANN SH THRD HDLSS MINI-MONSTER,SUP-2320926,CDM,C1713,HCPCS,0278,RC,,,,both,,,906.68,589.34,,,,,,,,,,,,,
TWISTER WIRE CORWIN 6 IN SERRATED JAW PADGETT,SUP-2473332,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1293.05,840.48,,,,,,,,,,,,,
HC CT C-Spine W/WO Contrast,PX-3527212700,CDM,72127,CPT,0352,RC,,,,both,,,2630.00,1709.50,,,,,,,,,,,,,
BIT DRL CANN 3X215 MM QC STRL,SUP-2563802,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1453.19,944.57,,,,,,,,,,,,,
SYSTEM RETRV TISS ANCHR,SUP-2432214,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1257.10,817.11,,,,,,,,,,,,,
INSERT TIB SZ 3 H14MM POLYETH PRI NEUT UNI NET SHP MOLD HI,SUP-2208541,CDM,C1776,CPT,0278,RC,,,,both,,,2428.79,1578.71,,,,,,,,,,,,,
PLATE BNE W10XL87MM THK1.5MM 90DEG 3X7 H BILAT S STL T SHP,SUP-2185876,CDM,C1713,HCPCS,0278,RC,,,,both,,,1403.01,911.96,,,,,,,,,,,,,
CATHETER HEMODIALYSI NIAG ACUTE 13.5FR DIA 20CML INSER 400ML,SUP-2613253,CDM,C1752,HCPCS,0278,RC,,,,both,,,335.98,218.39,,,,,,,,,,,,,
IMPLANT MASTOID SM 45X36X1 MM POLYETH POROUS,SUP-2366485,CDM,C1713,HCPCS,0278,RC,,,,both,,,2399.12,1559.43,,,,,,,,,,,,,
DEFIBRILLATOR IMPL CARD AIRBAG W 67 X H 55 MM D 13 MM 30 J,SUP-2138012,CDM,C1721,HCPCS,0275,RC,,,,both,,,56303.34,36597.17,,,,,,,,,,,,,
CATHETER INTVASC 9.3FR L22CM RADPQ POLYUR FLX HEAT EXCHG,SUP-2416148,CDM,C1751,HCPCS,0278,RC,,,,both,,,1880.61,1222.40,,,,,,,,,,,,,
ALLOGRAFT BNE PLUG 10 MM,SUP-2741811,CDM,C1762,CPT,0278,RC,,,,both,,,7606.65,4944.32,,,,,,,,,,,,,
TAG HUGS WI-FI,SUP-2873712,CDM,2720000010,LOCAL,0272,RC,,,,both,,,683.08,444.00,,,,,,,,,,,,,
EXTENSION STEM L150MM DIA12MM KNEE FLUT BAL REV SYS,SUP-2315652,CDM,C1776,CPT,0278,RC,,,,both,,,2687.84,1747.10,,,,,,,,,,,,,
COLLAR CERV FOAM PADDING PEDIATRIC CH TODDLER 2 IN PROCARE,SUP-2195749,CDM,L0180,HCPCS,0272,RC,,,,both,,,81.01,52.66,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY INQUIRY DIA 5 FR SPC 5 MM BND 1,SUP-2102297,CDM,C1730,HCPCS,0272,RC,,,,both,,,476.97,310.03,,,,,,,,,,,,,
COMPONENT FEM KNEE SZ 2 RT HINGE REV STRL TRIATHLON,SUP-2889762,CDM,C1776,CPT,0278,RC,,,,both,,,25951.32,16868.36,,,,,,,,,,,,,
PLATE BNE W13.5XL214MM THK4.2MM 12 H BILAT S STL NAR LIMIT,SUP-2185248,CDM,C1713,HCPCS,0278,RC,,,,both,,,1743.23,1133.10,,,,,,,,,,,,,
HC Surfactant Admin Thru Tube,PX-4109461000,CDM,94610,CPT,0410,RC,,,,inpatient,,,443.00,287.95,,,,,,,,,,,,,
G7 DUAL MOBILITY LINER 44MM F,SUP-2505827,CDM,C1776,CPT,0278,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
DUAL-LUMEN URETERAL CATHETER,SUP-2827461,CDM,C1758,HCPCS,0278,RC,,,,both,,,106.82,69.43,,,,,,,,,,,,,
SCREW BNE LAG COMPR ROD,SUP-2644793,CDM,C1713,HCPCS,0278,RC,,,,both,,,1362.70,885.75,,,,,,,,,,,,,
SCREW TRAC STNMN PIN HLDR THMB FOR REPL,SUP-2197326,CDM,C1713,HCPCS,0278,RC,,,,both,,,20.38,13.25,,,,,,,,,,,,,
DRILL SURG BUCKINGHAM HND MED 5.9INL FTPLT RND HNDL STRGHT S,SUP-2637580,CDM,2720000010,LOCAL,0272,RC,,,,both,,,320.41,208.27,,,,,,,,,,,,,
"HC So Immunoglobulin,Ige",PX-3018278566,CDM,82785,CPT,0301,RC,,,,both,,,143.00,92.95,,,,,,,,,,,,,
KIT INTRO ELITE HV SHTH L 7 CM DIA 4 FR GUIDEWIRE L 45 CM,SUP-2125280,CDM,C1894,HCPCS,0272,RC,,,,both,,,63.96,41.57,,,,,,,,,,,,,
HC So1 Testosterone Free,PX-3018440267,CDM,84402,CPT,0301,RC,,,,inpatient,,,312.00,202.80,,,,,,,,,,,,,
STENT TRACHBRONCH WGRFT L 50 MM DIA 9 MM CATH TOT L 116 CM,SUP-2141195,CDM,C1874,HCPCS,0278,RC,,,,both,,,6446.42,4190.17,,,,,,,,,,,,,
SCREW BNE L90MM DIA4.5MM PROX FEM ANK S STL ST LOK FULL,SUP-2350267,CDM,C1713,HCPCS,0278,RC,,,,both,,,1367.56,888.91,,,,,,,,,,,,,
PROSTHESIS PENILE 16CMX9.5MM 700 CXR,SUP-2140301,CDM,C1813,HCPCS,0278,RC,,,,both,,,8525.10,5541.31,,,,,,,,,,,,,
SAPHENOUS VEIN 46CM,SUP-2931384,CDM,C1762,CPT,0278,RC,,,,both,,,25771.11,16751.22,,,,,,,,,,,,,
PLATE BONE L163MM 12 H NONSTERILE LT PROX TIB S STL LO PROF,SUP-2185818,CDM,C1713,HCPCS,0278,RC,,,,both,,,3856.55,2506.76,,,,,,,,,,,,,
NEEDLE REPROC TRANSSEPTAL AD 18G 71CM 30DEG BVL BRK-1 XS CV S,SUP-2877988,CDM,2720000010,LOCAL,0272,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
TUBING ANGIO L72IN OD0.142IN ID0.071IN 1200PSI POLYUR DST,SUP-2302661,CDM,C1713,HCPCS,0278,RC,,,,both,,,20.25,13.16,,,,,,,,,,,,,
LENS INTOCU 21.5 DIOPT 118.7 A CONSTANT L13MM DIA6MM 0DEG,SUP-2110230,CDM,V2632,HCPCS,0276,RC,,,,both,,,436.46,283.70,,,,,,,,,,,,,
BLADE RETRACTOR HOHMN 18 CMX29 MM OLIF,SUP-2627605,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2436.36,1583.63,,,,,,,,,,,,,
SCREW BONE CORT 1.3 MM DIAM 10 MM LEN N CANN FULL THRD TI ST,SUP-2189057,CDM,C1713,HCPCS,0278,RC,,,,both,,,277.89,180.63,,,,,,,,,,,,,
ROD SPNL L 40 MM DIA 5.5 MM TI PRECONTOURED,SUP-2930577,CDM,C1889,HCPCS,0278,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
SET BX NDL 16GA L15CM INTRO L22CM VERT BNE DMND TIP REM HUB,SUP-2168190,CDM,C1713,HCPCS,0278,RC,,,,both,,,496.53,322.74,,,,,,,,,,,,,
PLATE BNE PROF THK 1 MM 2 X 8 H SCREW DIA2 MM TI MIDFACE,SUP-2883767,CDM,C1713,HCPCS,0278,RC,,,,both,,,1447.54,940.90,,,,,,,,,,,,,
IMPLANT ANK JT FIX INSRT RT UHMWPE SALTO TALARIS SZ 0 9MM,SUP-2244132,CDM,C1776,CPT,0278,RC,,,,both,,,3331.54,2165.50,,,,,,,,,,,,,
ENDO FUSE  FUSION BEAM 40X15MM,SUP-2466286,CDM,C1713,HCPCS,0278,RC,,,,both,,,7645.90,4969.83,,,,,,,,,,,,,
INTRODUCER SHTH 6FR L11CM W/OUT GWIRE GRN HUB W/ HEMSTAS,SUP-2303277,CDM,C1894,HCPCS,0272,RC,,,,both,,,28.42,18.47,,,,,,,,,,,,,
BIT DRL L30MM DIA3.2MM S STL FLX W/O STP NONRADIOLUCENT,SUP-2202677,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1444.40,938.86,,,,,,,,,,,,,
BRACE ANK AIR STRRP PED HT 6 IN,SUP-2336084,CDM,L4350,HCPCS,0272,RC,,,,both,,,31.81,20.68,,,,,,,,,,,,,
GRAFT BONE SUB 10ML CA PHOS FIL VOID CEM NORIAN CRS,SUP-2193981,CDM,C1713,HCPCS,0278,RC,,,,both,,,10179.88,6616.92,,,,,,,,,,,,,
HC So Mgmt Methylation Analysis,PX-3108128766,CDM,81287,CPT,0310,RC,,,,both,,,418.00,271.70,,,,,,,,,,,,,
DEVICE ULTRASOUND IMAGING SYS FLUID DOCK FOR ULTRA ICE CATH,SUP-2141336,CDM,2720000010,LOCAL,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
PLATE BONE MINI L27MM CVD,SUP-2364913,CDM,C1713,HCPCS,0278,RC,,,,both,,,311.55,202.51,,,,,,,,,,,,,
INTRODUCER SHTH 9FR BRT TIP REPROC,SUP-2156053,CDM,C1894,HCPCS,0272,RC,,,,both,,,94.20,61.23,,,,,,,,,,,,,
CEMENT BONE 40GM LO VISC PALACOS LV,SUP-2239058,CDM,C1713,HCPCS,0278,RC,,,,both,,,208.81,135.73,,,,,,,,,,,,,
SPLINT ANK STRRP AIR AND FOAM TRAINER,SUP-2276707,CDM,L4350,HCPCS,0274,RC,,,,both,,,40.47,26.31,,,,,,,,,,,,,
SET URET STENT L 20 CM DIA 6 FR GUIDEWIRE 0.038 IN BLK SIL,SUP-2168909,CDM,C2617,HCPCS,0278,RC,,,,both,,,434.07,282.15,,,,,,,,,,,,,
DEVICE SUT KNOTLESS INSRTR HNDL MAG WIRE SUT CART FOR LABRAL,SUP-2342083,CDM,C1713,HCPCS,0278,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
BIT DRL 4X152 MM PRECICE,SUP-2312225,CDM,2720000010,LOCAL,0272,RC,,,,both,,,810.12,526.58,,,,,,,,,,,,,
CAGE ACET OD60MM L HIP TI PPS MOD REV PRESSFIT MAX-TI,SUP-2405124,CDM,C1776,CPT,0278,RC,,,,both,,,13326.16,8662.00,,,,,,,,,,,,,
COMPONENT FEM STBL 13 RT KNEE,SUP-2365176,CDM,C1776,CPT,0278,RC,,,,both,,,6136.56,3988.76,,,,,,,,,,,,,
BLOCK FEM AUG REV UNIV 55X10 MM POST KNEE POLYETH,SUP-2408077,CDM,C1776,CPT,0278,RC,,,,both,,,2549.68,1657.29,,,,,,,,,,,,,
ALLOGRAFT HUM TISS ALLOPATCH PLIABLE MESHED 2X2CM,SUP-2905482,CDM,Q4128,HCPCS,0636,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
FORCEP ELECSURG BAYNT 1.5 MM 24 CM PRECIS BPLR SILVERGLIDE,SUP-2859761,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2888.20,1877.33,,,,,,,,,,,,,
CHOLANGIOGRAM KIT RX AUTOTOME UTOM XL SPHINTOM JAGWIRE 7500,SUP-2491615,CDM,C1769,HCPCS,0272,RC,,,,both,,,957.70,622.50,,,,,,,,,,,,,
TUBE ET OD8.8MM ID6MM 2 CHN REINF DISP FOR EMG NIM,SUP-2284326,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1228.24,798.36,,,,,,,,,,,,,
ASSEMBLY FRME 180MM FOR EXT FIX SYS SALVATION 2,SUP-2401161,CDM,2720000010,LOCAL,0272,RC,,,,both,,,26410.54,17166.85,,,,,,,,,,,,,
SODIUM THIOSULFATE 250 MG/ML IV SOLN,RX-156090,CDM,J0209,HCPCS,0636,RC,60267-0705-50,NDC,,both,1,ML,54.10,35.16,,,,,,,,,,,,,
SCREW GLEN FIX 25MM SHLDR CTRL MOD UNIVERS REVERS,SUP-2123398,CDM,C1713,HCPCS,0278,RC,,,,both,,,832.10,540.86,,,,,,,,,,,,,
BIT DRL DIA2 MM SUBCHONDRAL NS DISP LEOS,SUP-2933830,CDM,2720000010,LOCAL,0272,RC,,,,both,,,333.47,216.76,,,,,,,,,,,,,
PLATE BNE L183MM 11 H NONSTERILE R DST LAT FIBULAR S STL,SUP-2177733,CDM,C1713,HCPCS,0278,RC,,,,both,,,2914.55,1894.46,,,,,,,,,,,,,
GRAFT VASC STENT L 60 MM DIA 8 MM CATH L 117 CM GUIDEWIRE,SUP-2889371,CDM,C1874,HCPCS,0278,RC,,,,both,,,5809.00,3775.85,,,,,,,,,,,,,
BASEPLATE TIB N MOD SHT 63 MM KNEE POROUS OSS,SUP-2449771,CDM,C1776,CPT,0278,RC,,,,both,,,9163.31,5956.15,,,,,,,,,,,,,
LIDOCAINE VISCOUS HCL 2 % MT SOLN,RX-27898,CDM,340b,HCPCS,0637,RC,09999-9904-37,NDC,,both,5,ML,54.10,35.16,,,,,,,,,,,,,
KIT SUT SZ 2 L38IN FIBERWIRE W/ TAPR NDL STR NIT LOOP MIC,SUP-2122141,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
PLATE BNE L 35.2 X W 18.29 MM THK 1 MM TI LT SUBCONDYLAR NS,SUP-2936431,CDM,C1713,HCPCS,0278,RC,,,,both,,,1984.48,1289.91,,,,,,,,,,,,,
TIP ASPIR 2.5X3.15 MM 20 CM FOR BNE CUT APEX 360 SONOPET IQ,SUP-2791054,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3656.37,2376.64,,,,,,,,,,,,,
MENISCUS WITH HEMI PLATEAU LATERAL RIGHT FROZEN,SUP-2727842,CDM,C1762,CPT,0278,RC,,,,both,,,18103.83,11767.49,,,,,,,,,,,,,
PLATE BNE L46MM 5 H NONSTERILE DST DORS RAD S STL CLMN LOK,SUP-2177512,CDM,C1713,HCPCS,0278,RC,,,,both,,,1881.93,1223.25,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH L 121 MM LEG L 62 MM IPSILATERAL DIA16,SUP-2751286,CDM,C1874,HCPCS,0278,RC,,,,both,,,12132.96,7886.42,,,,,,,,,,,,,
KIT CATH HEMODIALYSI HEMOSTAR XK CHRONIC STD 16FR DI 5883350,SUP-2632968,CDM,C1750,HCPCS,0278,RC,,,,both,,,1430.90,930.08,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.507,SUP-2860024,CDM,C1713,HCPCS,0278,RC,,,,both,,,36220.84,23543.55,,,,,,,,,,,,,
MESH SURG W20XL30CM THK1MM EPTFE CORDUROY SURF CNFRM TEXT,SUP-2395335,CDM,C1781,HCPCS,0278,RC,,,,both,,,4788.50,3112.52,,,,,,,,,,,,,
SCREW BNE STD MINI TI NONSTERILE 23MMX13MM MAXDRIVE,SUP-2262860,CDM,C1713,HCPCS,0278,RC,,,,both,,,204.85,133.15,,,,,,,,,,,,,
CROWN DENT 6 UP LT PRI CTRL INCIS PED PREFABRICATED UNITEK,SUP-2100350,CDM,D6783,CPT,0278,RC,,,,both,,,19.59,12.73,,,,,,,,,,,,,
STAPLER INT AD L25MM DIA5MM STD GI WHT RED BLK TI CIR CUT 2,SUP-2283242,CDM,2720000010,LOCAL,0272,RC,,,,both,,,851.88,553.72,,,,,,,,,,,,,
ANCHOR SUTURE FULL THRD DIL 4.75 MM REGENESORB REUSE,SUP-2848635,CDM,C1713,HCPCS,0278,RC,,,,both,,,1580.61,1027.40,,,,,,,,,,,,,
PLATE SPNL 16MM POST WIDE BODY,SUP-2415551,CDM,C1713,HCPCS,0278,RC,,,,both,,,10833.00,7041.45,,,,,,,,,,,,,
ENDOPROSTHESIS VASC EXCLUDER L 12 CM DIA AORTIC/ILIAC 23/12,SUP-2738001,CDM,C1768,CPT,0278,RC,,,,both,,,36279.56,23581.71,,,,,,,,,,,,,
INSTRUMENT KIT EXTREMITY,SUP-2175009,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1059.75,688.84,,,,,,,,,,,,,
INSERT TIB TI OFFSET NEUT LOK,SUP-2405433,CDM,C1776,CPT,0278,RC,,,,both,,,526.58,342.28,,,,,,,,,,,,,
PLATE BONE TCP STR 25MM,SUP-2396851,CDM,C1713,HCPCS,0278,RC,,,,both,,,2857.40,1857.31,,,,,,,,,,,,,
MATRIX BIO L 4.7 X W 3.2 IN SZ 98.4 SQCM PORCINE TEND,SUP-2909275,CDM,A2008,HCPCS,0636,RC,,,,both,,,8923.88,5800.52,,,,,,,,,,,,,
CATHETER BAL DIL HYDR+ COAT BAL 4MMX4CM TIP LEN 4CM,SUP-2139718,CDM,C1726,HCPCS,0272,RC,,,,both,,,867.43,563.83,,,,,,,,,,,,,
BUR SURG DIA 3.1 MM ROSEN XSH STRL REUSE HI-LINE,SUP-2929340,CDM,2720000010,LOCAL,0272,RC,,,,both,,,397.24,258.21,,,,,,,,,,,,,
HC Debrid Wound Tis Addl 20 Cm<,PX-7619759800,CDM,97598,CPT,0761,RC,,,,both,,,194.00,126.10,,,,,,,,,,,,,
GENTAMICIN SULFATE 0.1 % EX CREA,RX-3423,CDM,6370000000,HCPCS,0637,RC,45802-0056-35,NDC,,both,15,GR,177.80,115.57,,,,,,,,,,,,,
PLATE SPNL LUMBAR 65 DEG 45 MM TRINICA,SUP-2414401,CDM,C1713,HCPCS,0278,RC,,,,both,,,13408.59,8715.58,,,,,,,,,,,,,
RING FULL 220MM FOR TRUELOK FIX SYS,SUP-2316175,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3976.21,2584.54,,,,,,,,,,,,,
CATHETER THERMOABLATION HABIB ENDOHPB L 180 CM DIA 8 FR BILI,SUP-2141352,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5158.55,3353.06,,,,,,,,,,,,,
DRILL SURG 2 MM OSTEOPOWER,SUP-2856483,CDM,2720000010,LOCAL,0272,RC,,,,both,,,301.44,195.94,,,,,,,,,,,,,
PLATE BONE 189MML HLX16 STNLSS STEEL STRGHT RCNSTRCTN F/3.5M,SUP-2475827,CDM,C1713,HCPCS,0278,RC,,,,both,,,1438.59,935.08,,,,,,,,,,,,,
CATHETER ETER GUID 6FR 0071IN COR STD JUDKINS R 4 SIDE H MID,SUP-2281123,CDM,C1887,HCPCS,0272,RC,,,,both,,,141.30,91.84,,,,,,,,,,,,,
PLATE BONE DSTL RAD VOLAR S STL VAR ANG 2 CLMN FOR 2.4MM SCR,SUP-2177069,CDM,C1713,HCPCS,0278,RC,,,,both,,,60271.67,39176.59,,,,,,,,,,,,,
SCREW INTFR L25MM DIA9MM CANN,SUP-2121185,CDM,C1713,HCPCS,0278,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
HEAD HUM 38X21X38 MM SHLDR TI COMPHSVE VERSA-DIAL,SUP-2450141,CDM,C1776,CPT,0278,RC,,,,both,,,5708.52,3710.54,,,,,,,,,,,,,
EMTRICITABINE 200 MG PO CAPS,RX-36252,CDM,6370000000,HCPCS,0637,RC,69097-0642-02,NDC,,both,1,UN,69.60,45.24,,,,,,,,,,,,,
PLATE CRAN 200X160X40 MM PT SPEC IMPL PEEK,SUP-2860162,CDM,C1713,HCPCS,0278,RC,,,,both,,,58312.94,37903.41,,,,,,,,,,,,,
WIRE FIX TROCAR PT 2 END 0.045X6 IN SS NS KIRSCHNER DISP,SUP-2791232,CDM,C1713,HCPCS,0278,RC,,,,both,,,8.57,5.57,,,,,,,,,,,,,
PLATE BONE LOW PROFILE 30X0.4 MM CONTOURABLE MESH MALLEABLE,SUP-2838372,CDM,C1713,HCPCS,0278,RC,,,,both,,,2592.38,1685.05,,,,,,,,,,,,,
GUIDEWIRE VASC STRT L 125 CM DIA 0.025 IN TIP L 3 CM SS PTFE,SUP-2148302,CDM,C1769,HCPCS,0272,RC,,,,both,,,21.54,14.00,,,,,,,,,,,,,
CATHETER GUID FL3.5 0.070 INX6 FRX100 CM VASC ACCS MACH 1,SUP-2143760,CDM,C1887,HCPCS,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
VALVE MITRL PASCAL REDUC LEAFLET STRESS INCREASE OPN ORIFICE,SUP-2884185,CDM,C1889,HCPCS,0278,RC,,,,both,,,96084.00,62454.60,,,,,,,,,,,,,
SCREW BNE COMPR IDEAL COMPR 65MMX80MM ICOS,SUP-2242757,CDM,C1713,HCPCS,0278,RC,,,,both,,,1567.52,1018.89,,,,,,,,,,,,,
CANNULA ART LNG 19 FR UNCOATED HLS,SUP-2663471,CDM,2720000010,LOCAL,0272,RC,,,,both,,,950.95,618.12,,,,,,,,,,,,,
SET THROMCTMY ASPIREX S L 85 CM DIA 8 FR GUIDEWIRE L 220 CM,SUP-2877647,CDM,C1757,HCPCS,0272,RC,,,,both,,,10990.00,7143.50,,,,,,,,,,,,,
FIBER LASER CONCL TIP 0.6 MM FOR USE W/ KTP/YAG,SUP-2225626,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1171.22,761.29,,,,,,,,,,,,,
GRAFT BNE SUB 10CC BEAD 25CC CA SULPHATE RAP SET W/ INDIV,SUP-2135334,CDM,C1713,HCPCS,0278,RC,,,,both,,,3925.00,2551.25,,,,,,,,,,,,,
BB-TAK SMALL THREADED,SUP-2811964,CDM,C1713,HCPCS,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
HC Bx Breast Add Les MR Image,PX-3611908600,CDM,19086,CPT,0361,RC,,,,inpatient,,,5560.00,3614.00,,,,,,,,,,,,,
APPLIER LIG CLP L13IN 10MM PSTL GRP CONTAIN 15 TI L CLP,SUP-2283168,CDM,2720000010,LOCAL,0272,RC,,,,both,,,903.85,587.50,,,,,,,,,,,,,
ALLOGRAFT BNE INSRT SM 6X5.2X6 MM FD CYL DBM XPANSE,SUP-2787769,CDM,C1713,HCPCS,0278,RC,,,,both,,,1065.09,692.31,,,,,,,,,,,,,
SET PICC L 15CM DIA 4.5FR SHTH L 7CM DIA 4.5FR PR-41541-BAS,SUP-2887215,CDM,C1751,HCPCS,0278,RC,,,,both,,,395.64,257.17,,,,,,,,,,,,,
SPLINT WRST XL L10IN L FA LN CIRCUMFERENTIAL STRP SLIP ON,SUP-2276628,CDM,L3809,HCPCS,0272,RC,,,,both,,,21.48,13.96,,,,,,,,,,,,,
PLATE BNE T 4.5X148 MM 8 HOLE TI NS LCP,SUP-2569056,CDM,C1713,HCPCS,0278,RC,,,,both,,,2560.10,1664.06,,,,,,,,,,,,,
ODH 56MM ACETABULAR LINER,SUP-2830375,CDM,C1776,CPT,0278,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
MARKER BX SITE TI PLA/PGA MINI CORK SHP W/ INTRO DEPLOYMENT,SUP-2240056,CDM,A4648,CPT,0278,RC,,,,both,,,184.35,119.83,,,,,,,,,,,,,
CATHETER HD CRV EXTN 9 FRX7.5 CM CATH NDL DUOFLO,SUP-2627076,CDM,C1752,HCPCS,0278,RC,,,,both,,,182.12,118.38,,,,,,,,,,,,,
PLATE SPNL L20MM ANT CERV LEV 1 SONOMA,SUP-2244669,CDM,C1713,HCPCS,0278,RC,,,,both,,,46.03,29.92,,,,,,,,,,,,,
PLATE BNE MINI THK0.5MM 3X4 H BILAT CRANIOMAXILLOFACIAL SIL,SUP-2181672,CDM,C1713,HCPCS,0278,RC,,,,both,,,1008.88,655.77,,,,,,,,,,,,,
PLATE BNE ROT CORRECTION 2X42 MM VA LCK FRAC SS NS,SUP-2799219,CDM,C1713,HCPCS,0278,RC,,,,both,,,2312.48,1503.11,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE SZ 1-4 MM 30 CC CANC CRUSH,SUP-2913354,CDM,C1713,HCPCS,0278,RC,,,,both,,,3196.52,2077.74,,,,,,,,,,,,,
HC Extrem Low Ankle Arthrogram,PX-3227361500,CDM,73615,CPT,0322,RC,,,,both,,,1013.00,658.45,,,,,,,,,,,,,
HYDROCODONE BIT-HOMATROP MBR 5-1.5 MG/5ML PO SOLN,RX-157651,CDM,340b,HCPCS,0637,RC,00121-1036-05,NDC,,both,5,ML,57.60,37.44,,,,,,,,,,,,,
GUIDE NDL ULTRASOUND 14-18 GA KT SINGLE ANGLE ACCUSITE,SUP-2164710,CDM,C1713,HCPCS,0278,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
HC Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn,PX-3606232300,CDM,62323,CPT,0360,RC,,,,both,,,2230.00,1449.50,,,,,,,,,,,,,
SET SCR IMPL HDLSS COMPR 3.0 MM,SUP-2177075,CDM,C1713,HCPCS,0278,RC,,,,both,,,93264.66,60622.03,,,,,,,,,,,,,
COIL VASC AZUR L 20 CM DIA 8 MM MICROCATHETER 0.018 IN LOOP,SUP-2385434,CDM,C1889,HCPCS,0278,RC,,,,both,,,2426.44,1577.19,,,,,,,,,,,,,
HEAD HUM 58X27 MM SHLDR COCR BIO MOD,SUP-2449916,CDM,C1776,CPT,0278,RC,,,,both,,,2515.14,1634.84,,,,,,,,,,,,,
"HC Ultrasound, Fetal Biophys",PX-4027681800,CDM,76818,CPT,0402,RC,,,,outpatient,,,1022.00,664.30,,,,,,,,,,,,,
KIT INTRO L10CM OD4FR 1 1/4IN GWIRE OD0.025IN NDL OD20GA,SUP-2384830,CDM,C1894,HCPCS,0272,RC,,,,both,,,280.09,182.06,,,,,,,,,,,,,
ENDCAP SPNL LORDTC 15 DEG 14X22X19 MM MONOLITH,SUP-2567566,CDM,C1889,HCPCS,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
JIG SURG TARGETING ACCS 57104] CONVENTUS ORTHOPAEDICS],SUP-2167391,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2041.00,1326.65,,,,,,,,,,,,,
DILATOR BAL ESOPH QNT TTC INFLATED DIAM 20MM 60FR BAL LEN,SUP-2170068,CDM,C1726,HCPCS,0272,RC,,,,both,,,354.82,230.63,,,,,,,,,,,,,
MONITOR CRD IMPL CNFRM,SUP-2356336,CDM,C1764,HCPCS,0278,RC,,,,both,,,8832.82,5741.33,,,,,,,,,,,,,
TOE IMPL INSRTN KT SIZE: 0 TO 7 CONTENTS: SH INSTR SET SZ,SUP-2397010,CDM,C1776,CPT,0278,RC,,,,both,,,2998.70,1949.15,,,,,,,,,,,,,
DILATOR URET 6-10FR L70CM HYDRGEL DIL 1 STP TAPR NOTTINGHAM,SUP-2139729,CDM,2720000010,LOCAL,0272,RC,,,,both,,,378.56,246.06,,,,,,,,,,,,,
CLAMP CRAN TEXT LG 18 MM FLAPFIX FOR EXT FIX TI NS LF,SUP-2431405,CDM,C1713,HCPCS,0278,RC,,,,both,,,1107.79,720.06,,,,,,,,,,,,,
CANNULA SURG W/ STOPCOCK 70 MM 3.2 MM IRRIGATION OBTUTATOR,SUP-2794069,CDM,2720000010,LOCAL,0272,RC,,,,both,,,589.32,383.06,,,,,,,,,,,,,
PROBE OPHTH VITRECTOMY 25 GA 2 BIMANUAL ENDOPROBE,SUP-2225674,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1295.25,841.91,,,,,,,,,,,,,
BOLT EXT FIX RUS WIRE NS DISP MONK RING,SUP-2898988,CDM,2720000010,LOCAL,0272,RC,,,,both,,,509.47,331.16,,,,,,,,,,,,,
MESH HERN 12X115CM RND COMP VENTRAL REABSORBABLE CLLGN,SUP-2174708,CDM,C1781,HCPCS,0278,RC,,,,both,,,2085.27,1355.43,,,,,,,,,,,,,
PIN FIX POLY LIMB LCK SALV FINN,SUP-2406068,CDM,C1713,HCPCS,0278,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
CLAMP EXTRNL FXTN CHRNLEY 47MM DIA F/LWR EXTRMTY ARTHRDSS P,SUP-2720696,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2608.08,1695.25,,,,,,,,,,,,,
HC Rsf Lab Ecmc - Ihc,PX-9900000127,CDM,9900000127,LOCAL,0990,RC,,,,both,,,50.00,32.50,,,,,,,,,,,,,
WAND ABLAT DIA3MM 30DEG INTEGR CBL SABER COBLATION,SUP-2341984,CDM,2720000010,LOCAL,0272,RC,,,,both,,,579.52,376.69,,,,,,,,,,,,,
BRACE ORTHOPEDIC ANK FT PLAS,SUP-2388162,CDM,L1930,HCPCS,0272,RC,,,,both,,,973.40,632.71,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH L 76 MM LEG L 62 MM IPSILATERAL DIA24,SUP-2750369,CDM,C1768,CPT,0278,RC,,,,both,,,12132.96,7886.42,,,,,,,,,,,,,
BLADE OSTEOTOM W20MM LNG S STL HIP REV MNL THN CVD DISP,SUP-2402665,CDM,2720000010,LOCAL,0272,RC,,,,both,,,596.60,387.79,,,,,,,,,,,,,
GRAFT BNE 10CC 1 8MM CANC CRUSH CHIP READIGRFT,SUP-2264812,CDM,C1713,HCPCS,0278,RC,,,,both,,,485.22,315.39,,,,,,,,,,,,,
ALLOGRAFT BNE SPACER LNG 30X11X11 MM BIO AVS UNILIF,SUP-2637046,CDM,C1713,HCPCS,0278,RC,,,,both,,,7379.00,4796.35,,,,,,,,,,,,,
HC Hysterosalpingogram,PX-3207474000,CDM,74740,CPT,0320,RC,,,,inpatient,,,686.00,445.90,,,,,,,,,,,,,
WASHER ORTH DIA13MM STRL TRIGEN MAX,SUP-2933160,CDM,C1713,HCPCS,0278,RC,,,,both,,,659.40,428.61,,,,,,,,,,,,,
ALLOGRAFT SI INTRA ART FUS 11MM,SUP-2880425,CDM,C1713,HCPCS,0278,RC,,,,both,,,26690.00,17348.50,,,,,,,,,,,,,
IMMOBILIZER ORTH T BAR UNIV 19 IN KNEE CANVS BLU REUSE,SUP-2336063,CDM,L1830,CPT,0272,RC,,,,both,,,38.12,24.78,,,,,,,,,,,,,
INSERT TIBIAL PROLONG SIZE 3 0,SUP-2493171,CDM,C1776,CPT,0278,RC,,,,both,,,4281.39,2782.90,,,,,,,,,,,,,
CATHETER HEMO DYLS OR HD 12.5FRX24CM 3 MAHRK ELITE,SUP-2174267,CDM,C1752,HCPCS,0278,RC,,,,both,,,403.36,262.18,,,,,,,,,,,,,
SET INT FIX SCREW DIA1.5 MM TI NEURO Y PLT XDRV 12 PK STRL,SUP-2935624,CDM,C1713,HCPCS,0278,RC,,,,both,,,26887.82,17477.08,,,,,,,,,,,,,
HC Rpr F/E/E/N/L/M >30.0 Cm,PX-4501201800,CDM,12018,CPT,0450,RC,,,,both,,,1445.00,939.25,,,,,,,,,,,,,
SCREW BNE L 4 MM DIA2 MM TI MANDIBULAR UNIV FIX SYS LCK,SUP-2883997,CDM,C1713,HCPCS,0278,RC,,,,both,,,240.74,156.48,,,,,,,,,,,,,
GUIDEWIRE ORTHPDC D32MM STNDRD STNLSS STEEL DRILL TIP SMOOTH,SUP-2481465,CDM,C1769,HCPCS,0272,RC,,,,both,,,161.46,104.95,,,,,,,,,,,,,
BRACE WR M L8IN LT FOAM LOOP LCK CLSR W/ THMB SPICA R-SOFT,SUP-2324348,CDM,L3931,HCPCS,0274,RC,,,,both,,,72.13,46.88,,,,,,,,,,,,,
RAIL EXT FIX SPD FRAME,SUP-2197309,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7065.00,4592.25,,,,,,,,,,,,,
TROCAR ENDOSCP L100MM DIA12MM BLDELSS CANN DIL W/ RADIALLY,SUP-2283344,CDM,2720000010,LOCAL,0272,RC,,,,both,,,482.34,313.52,,,,,,,,,,,,,
PROBE RF CRV 200 MM DURABLE NIT REUSE,SUP-2753294,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3579.60,2326.74,,,,,,,,,,,,,
SUBSTITUTE BNE GRFT 15ML TYP 1 BOV CLLGN B TRICALCIUM,SUP-2316225,CDM,C9359,HCPCS,0278,RC,,,,both,,,9090.30,5908.69,,,,,,,,,,,,,
STEM FEM L250MM OD19MM TI DST HIP REV MOD TAPR FOR EXT,SUP-2404434,CDM,C1776,CPT,0278,RC,,,,both,,,9193.92,5976.05,,,,,,,,,,,,,
MESH MAND CUSTOMIZED PRIORITY AUG MEDPOR,SUP-2862755,CDM,C1713,HCPCS,0278,RC,,,,both,,,26288.74,17087.68,,,,,,,,,,,,,
NUT EXT FIX SQ FOR SIDEKCK FREE CIR FIX,SUP-2400608,CDM,2720000010,LOCAL,0272,RC,,,,both,,,222.94,144.91,,,,,,,,,,,,,
SHEET CMF 38X50X0.85MM POR HI DENS MEDPOR TI,SUP-2328483,CDM,C1713,HCPCS,0278,RC,,,,both,,,3218.53,2092.04,,,,,,,,,,,,,
SCREW BNE L32MM DIA4MM PROX HUM S STL ST NONCANNULATED LOK,SUP-2371531,CDM,C1713,HCPCS,0278,RC,,,,both,,,518.73,337.17,,,,,,,,,,,,,
PLATE BNE L117MM 6 H NONSTERILE L PROX TIB S STL VAR ANG,SUP-2177912,CDM,C1713,HCPCS,0278,RC,,,,both,,,4677.06,3040.09,,,,,,,,,,,,,
GRAFT HUM TISS W 10 MM BNE DWL TIB L 23 MM DIA10-10.5 MM,SUP-2913330,CDM,C1762,CPT,0278,RC,,,,both,,,18623.34,12105.17,,,,,,,,,,,,,
IMPLANT HUM TISS L20-80CM DIA3-6MM SAPH VEIN CRYOPRESERVED,SUP-2175273,CDM,C1762,CPT,0278,RC,,,,both,,,30263.32,19671.16,,,,,,,,,,,,,
GRAFT VASC HEMGRD BODY/BRANCH L 85/55 CM L 35/20 CM 8X6X6MM,SUP-2480579,CDM,C1768,CPT,0278,RC,,,,both,,,5221.19,3393.77,,,,,,,,,,,,,
HC Intro Need/Intracath Translum,PX-3613616000,CDM,36160,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
CAGE SPNL MESH 15X12X8 MM 6 LOBE,SUP-2602067,CDM,C1889,HCPCS,0278,RC,,,,both,,,6305.12,4098.33,,,,,,,,,,,,,
GRAFT BNE CRUSH FRZN CANC 1MM 8MM RANG 80CC READIGRFT,SUP-2264729,CDM,C1713,HCPCS,0278,RC,,,,both,,,2917.72,1896.52,,,,,,,,,,,,,
GUIDEWIRE VASC R350 L 350 CM DIA 0.013 IN RADIOPAQUE TIP L 5,SUP-2120534,CDM,C1769,HCPCS,0272,RC,,,,both,,,530.66,344.93,,,,,,,,,,,,,
KIT SZR SZ 1-4 INSTR,SUP-2242118,CDM,2720000010,LOCAL,0272,RC,,,,both,,,879.20,571.48,,,,,,,,,,,,,
PLATE BNE HK SM 3.5/4.5X354 MM RT FEM PROX 10 STRL VA-LCP,SUP-2750915,CDM,C1713,HCPCS,0278,RC,,,,both,,,9273.49,6027.77,,,,,,,,,,,,,
EXTERNAL FIXATION SET COMPLETE METATRSL GALAXY FIX GEM LTX,SUP-2875650,CDM,C1713,HCPCS,0278,RC,,,,both,,,9553.17,6209.56,,,,,,,,,,,,,
SYSTEM STIM BONE HEALING BTTRY OPERATED AC ADPT,SUP-2135919,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6179.52,4016.69,,,,,,,,,,,,,
CATHETER CV DL 5 FRX55 CM BASIC NURSING KT PWR INJ POWERPICC,SUP-2125541,CDM,C1751,HCPCS,0278,RC,,,,both,,,409.36,266.08,,,,,,,,,,,,,
BUR SURG L14CM DIA5MM BALL DMND L BOR MIDAS REX LEGEND,SUP-2277720,CDM,2720000010,LOCAL,0272,RC,,,,both,,,392.00,254.80,,,,,,,,,,,,,
TRAY HAD CHRNC W18GA INTRDCR NDLE JFLX GDWRE TEAR AWAY SHT,SUP-2729590,CDM,C1894,HCPCS,0272,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
PROBE LARYNGEAL RT HND 90 DEG MIRRORED W/ SMK EVAC,SUP-2713696,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1655.85,1076.30,,,,,,,,,,,,,
HC Cta Heart Ejection Fract,PX-3507557300,CDM,75573,CPT,0480,RC,,,,both,,,3184.00,2069.60,,,,,,,,,,,,,
SPLINT ORTH PLASTALUME 4.25X4.25 IN FNGR W/ BLB RADLUC,SUP-2276773,CDM,L3933,HCPCS,0274,RC,,,,both,,,4.33,2.81,,,,,,,,,,,,,
CATHETER GUID XL L50CM HYDRPHLC EXT HK L HRT DEL SYS ATTAIN,SUP-2282196,CDM,C1887,HCPCS,0272,RC,,,,both,,,533.80,346.97,,,,,,,,,,,,,
GUIDEWIRE VASC VSI L 60 CM DIA 0.018 IN SS MANDREL TIP,SUP-2763450,CDM,C1769,HCPCS,0272,RC,,,,both,,,51.81,33.68,,,,,,,,,,,,,
INSERT TIB THK 12 MM IPOLY XE KNEE CR NO TRL SINGLE FACETED,SUP-2904522,CDM,C1776,CPT,0278,RC,,,,both,,,2763.20,1796.08,,,,,,,,,,,,,
SUPPORT ORTHOT KNEE LOWER EXTREMITY POLYCENTRIC,SUP-2435665,CDM,L2387,HCPCS,0272,RC,,,,both,,,540.46,351.30,,,,,,,,,,,,,
TRAY CATH HEMODIALYSI SFT LN ACTE 11.5FR DIA 15CM STRGHT TAP,SUP-2610546,CDM,C1752,HCPCS,0278,RC,,,,both,,,263.76,171.44,,,,,,,,,,,,,
NAIL IM L180MM DIA11MM 125DEG SHT FOR HIP FRAC AFFIXUS,SUP-2413324,CDM,C1713,HCPCS,0278,RC,,,,both,,,4994.48,3246.41,,,,,,,,,,,,,
HC CT Facial Bones W/O Contrast,PX-3517048600,CDM,70486,CPT,0351,RC,,,,both,,,1973.00,1282.45,,,,,,,,,,,,,
AMBI SUP PL 10SL 204MM 95,SUP-2820661,CDM,C1713,HCPCS,0278,RC,,,,both,,,5360.61,3484.40,,,,,,,,,,,,,
BLADE OSTEOTOM L15MM CVD FLEX W/ BLDE AND DETACH HNDL,SUP-2364283,CDM,2720000010,LOCAL,0272,RC,,,,both,,,444.94,289.21,,,,,,,,,,,,,
CATHETER ATHRCTMY JETSTREAM XC L 135 CM TIP DIA2.1-3 MM,SUP-2148530,CDM,C1724,HCPCS,0278,RC,,,,both,,,20253.00,13164.45,,,,,,,,,,,,,
TIP ASPIR L4.92IN DIA0.05IN ULTRASONIC CRV EXT FLUE DISP,SUP-2243958,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1844.75,1199.09,,,,,,,,,,,,,
STEM HUM SZ 7 L170MM 135DEG TI ALLOY LNG CEM PRESSFIT UNIV,SUP-2204848,CDM,C1776,CPT,0278,RC,,,,both,,,11699.64,7604.77,,,,,,,,,,,,,
PLATE BNE CONN 90 DEG 5 HOLE OFFSET NS,SUP-2800152,CDM,C1713,HCPCS,0278,RC,,,,both,,,375.89,244.33,,,,,,,,,,,,,
SPLINT ORTH D RNG CLOSURE UNIV 10 IN WRST FOREARM RT,SUP-2336334,CDM,L3809,HCPCS,0272,RC,,,,both,,,22.70,14.75,,,,,,,,,,,,,
PLATE BNE L370MM 18 H ST R CNDYL S STL CRV LOK COMPR VAR,SUP-2177867,CDM,C1713,HCPCS,0278,RC,,,,both,,,7468.80,4854.72,,,,,,,,,,,,,
DRAINAGE KIT STD 100 CM W/ ICP CUP CATH 10-20 CM TIP EXAFLOW,SUP-2666662,CDM,2720000010,LOCAL,0272,RC,,,,both,,,475.52,309.09,,,,,,,,,,,,,
CATHETER ANGIOPLSTY 1.9/2.7 FRX139 CM 2X6 MM EMPIRA NC RX,SUP-2158281,CDM,C1725,HCPCS,0272,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
CAGE SPNL 18X28-41 MM TI X-CORE 2,SUP-2561292,CDM,C1889,HCPCS,0278,RC,,,,both,,,13816.00,8980.40,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL PEEK SD800.528,SUP-2860209,CDM,C1713,HCPCS,0278,RC,,,,both,,,36108.74,23470.68,,,,,,,,,,,,,
RESTRICTOR BONE CEM HARDINGE,SUP-2253883,CDM,C1713,HCPCS,0278,RC,,,,both,,,427.04,277.58,,,,,,,,,,,,,
SCREW BONE L26MM DIA4.9MM CORT S STL NONCANNULATED FULL THRD,SUP-2186379,CDM,C1713,HCPCS,0278,RC,,,,both,,,450.75,292.99,,,,,,,,,,,,,
PLATE BONE 6MM OFFSET 90DEG 3 H PROX FEM LCK FOR 3.5MM SCR,SUP-2318548,CDM,C1713,HCPCS,0278,RC,,,,both,,,6828.09,4438.26,,,,,,,,,,,,,
PERFORATOR SURG DRL BNE FEN,SUP-2321585,CDM,2720000010,LOCAL,0272,RC,,,,both,,,648.41,421.47,,,,,,,,,,,,,
ANCHOR SUT NO 2 SUT W/ NDL SUTX2 TI W/ DIL DURABRAID 3.5MM,SUP-2341043,CDM,C1713,HCPCS,0278,RC,,,,both,,,797.56,518.41,,,,,,,,,,,,,
SCREW BNE CANN SHRT THRD 4.5X68 MM 23 MM MIDFOOT HD COMPR SS,SUP-2609326,CDM,C1713,HCPCS,0278,RC,,,,both,,,1184.44,769.89,,,,,,,,,,,,,
ELECTRODE SUBDERM NDL L 18 MM 4 CHANNEL PRASS PR SM HUB STRL,SUP-2901991,CDM,2720000010,LOCAL,0272,RC,,,,both,,,589.85,383.40,,,,,,,,,,,,,
HC Pet/CT Whole Body,PX-4047881600,CDM,78816,CPT,0404,RC,,,,inpatient,,,6386.00,4150.90,,,,,,,,,,,,,
CATHETER VENTRICULAR L25CM DIAMETER 2.5MM SILICONE WITH DEFL,SUP-2825624,CDM,C1729,HCPCS,0272,RC,,,,both,,,1033.91,672.04,,,,,,,,,,,,,
GRAFT HUM TISS FIRM 6X6 CM RECON DERMAL TISS MTRX STRATTICE,SUP-2112973,CDM,Q4130,HCPCS,0636,RC,,,,both,,,3708.34,2410.42,,,,,,,,,,,,,
ART BMC + PROC KT,SUP-2163075,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
TESTOSTERONE CYPIONATE 200 MG/ML IM SOLN|DISCARDED DRUG NOT ADMINISTE,RX-127408,CDM,J1071,HCPCS,0636,RC,00574-0827-01,NDC,JW,both,0.25,ML,54.10,35.16,,,,,,,,,,,,,
CROWN S STL 1ST PERM M LR7 900347,SUP-2238829,CDM,D6783,CPT,0278,RC,,,,both,,,139.26,90.52,,,,,,,,,,,,,
LIFT HEEL SM W2IN BRN FAB WDG 3 LAYR ORTHOT FT W/O CLSR,SUP-2325935,CDM,L3334,HCPCS,0274,RC,,,,both,,,18.34,11.92,,,,,,,,,,,,,
GRAFT HUM TISS H5MM CANC PLUG CORT RNG CERV SPCR FIBULAR WDG,SUP-2293796,CDM,C1713,HCPCS,0278,RC,,,,both,,,3045.80,1979.77,,,,,,,,,,,,,
LINER ACET OD76MM ID26MM THK19.3MM STD HIP POLYETH MOD CUP,SUP-2202075,CDM,C1776,CPT,0278,RC,,,,both,,,2393.94,1556.06,,,,,,,,,,,,,
WIRE ORTH POLYETHYL CERCLAGE FOR GLEN BNE LOSS IMPL STRL,SUP-2882230,CDM,C1713,HCPCS,0278,RC,,,,both,,,2983.00,1938.95,,,,,,,,,,,,,
CEMENT BNE 40GM FULL DOSE PMMA W GENT M VISC RADPQ FAST SET,SUP-2344337,CDM,C1713,HCPCS,0278,RC,,,,both,,,1063.83,691.49,,,,,,,,,,,,,
PIN DISTR L16MM SELF DRL CASPR,SUP-2108437,CDM,C1713,HCPCS,0278,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
PLATE BNE STR 20X0.6 MM NEURO 4 HOLE TI NS LEVEL 1 ULTRAONE,SUP-2489532,CDM,C1713,HCPCS,0278,RC,,,,both,,,449.49,292.17,,,,,,,,,,,,,
ROD SPNL REVOLVE OD5.5 MMXL80 MM,SUP-2230517,CDM,C1713,HCPCS,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
ORTHODONTIC ANCHRGE PLATE 14MM WTH FLAT 5MM AREA T10MM CP T,SUP-2680878,CDM,C1713,HCPCS,0278,RC,,,,both,,,565.23,367.40,,,,,,,,,,,,,
UGW 0038 150CM RER ANG 3CM,SUP-2725839,CDM,C1769,HCPCS,0272,RC,,,,both,,,183.44,119.24,,,,,,,,,,,,,
HC Biopsy of Liver; Perc Needle,PX-3614700100,CDM,47001,CPT,0361,RC,,,,inpatient,,,3707.00,2409.55,,,,,,,,,,,,,
HEAD ULN 17.5 WRST MOD COCR 1ST CHOICE,SUP-2852954,CDM,C1776,CPT,0278,RC,,,,both,,,5750.72,3737.97,,,,,,,,,,,,,
PLATE BONE L99MM 5 H S STL T SHP,SUP-2198573,CDM,C1713,HCPCS,0278,RC,,,,both,,,444.69,289.05,,,,,,,,,,,,,
GRAFT EVAR L155MM DIA28MM 16MM PROX DST AAA INTUITRAK,SUP-2217577,CDM,C1768,CPT,0278,RC,,,,both,,,31243.00,20307.95,,,,,,,,,,,,,
SCREW BNE 2/PK L 10 MM DIA2.6 MM PLA GLYCOLIDE,SUP-2884159,CDM,C1713,HCPCS,0278,RC,,,,both,,,1109.77,721.35,,,,,,,,,,,,,
WASHER ORTH 4 MM CRV SEG HIP SYS TRABECULAR MTL,SUP-2437240,CDM,C1713,HCPCS,0278,RC,,,,both,,,3405.33,2213.46,,,,,,,,,,,,,
SCREW BONE PEG 2.5X40 MM FOOT DRIVER,SUP-2588904,CDM,C1713,HCPCS,0278,RC,,,,both,,,229.03,148.87,,,,,,,,,,,,,
CURETTE SURG 0 9.5 IN CERV LUMBAR BKWRD STR RUGGLES-REDMOND,SUP-2470975,CDM,C1776,CPT,0278,RC,,,,both,,,425.06,276.29,,,,,,,,,,,,,
GUIDEWIRE VASC ARISTOTLE COLOSSUS L 200 CM DIA 0.035 IN,SUP-2884435,CDM,C1769,HCPCS,0272,RC,,,,both,,,4380.30,2847.19,,,,,,,,,,,,,
BIT DRL L445MM DIA07MM STP 6MM L14MM NONSTERILE,SUP-2187621,CDM,2720000010,LOCAL,0272,RC,,,,both,,,386.28,251.08,,,,,,,,,,,,,
ENDCAP ORTH 10 MM TI STRL AGILE NAIL,SUP-2646466,CDM,C1713,HCPCS,0278,RC,,,,both,,,526.58,342.28,,,,,,,,,,,,,
BIT DRL L100MM DIA17MM CANN QUIK CPL FOR 24MM SCR,SUP-2179009,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1293.49,840.77,,,,,,,,,,,,,
ENDCAP SPNL MONOLITH 5991450,SUP-2567554,CDM,C1889,HCPCS,0278,RC,,,,both,,,12560.00,8164.00,,,,,,,,,,,,,
DEVICE EXTR BAL ERCP 3 LUMN INJ DSTL WIRE GUID BILI DISP,SUP-2312950,CDM,C1725,HCPCS,0272,RC,,,,both,,,300.87,195.57,,,,,,,,,,,,,
ANCHOR SUT DIA475MM BIOCOMPOSITE LAT ROW KNOTLESS CROSSFT,SUP-2418756,CDM,C1713,HCPCS,0278,RC,,,,both,,,2088.41,1357.47,,,,,,,,,,,,,
GUIDEWIRE ORTH L150MM DIA2MM UNTHREADED NS FOR FIXOS  ORDER MULLTIPLES OF 10,SUP-2378064,CDM,C1713,HCPCS,0278,RC,,,,both,,,141.30,91.84,,,,,,,,,,,,,
PLATE BNE CERV SM 2.7X68 MM 8 HOLE TI,SUP-2536117,CDM,C1713,HCPCS,0278,RC,,,,both,,,422.02,274.31,,,,,,,,,,,,,
TRIAL ORTH 2.2 MM SZR TRUVIEW,SUP-2400031,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1635.94,1063.36,,,,,,,,,,,,,
CEMENT ST/POR CP/LGXL/LG HD,SUP-2212365,CDM,C1776,CPT,0278,RC,,,,both,,,13545.96,8804.87,,,,,,,,,,,,,
GRAFT BNE INJ 4 CC EXTREMITY PRO-DENSE,SUP-2759540,CDM,C1713,HCPCS,0278,RC,,,,both,,,4583.80,2979.47,,,,,,,,,,,,,
CATHETER GUID L 90 CM DIA 6 FR MPC STRL,SUP-2154150,CDM,C1887,HCPCS,0272,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
INSERT ACET OD54MM ID36MM HIP ULTAMET COBAL CHROME ARTC MOD,SUP-2250300,CDM,C1776,CPT,0278,RC,,,,both,,,6497.92,4223.65,,,,,,,,,,,,,
PLATE BNE L104MM 4 H BILAT TI LOK COMPR RIG BTTRS THN BLDE,SUP-2190982,CDM,C1713,HCPCS,0278,RC,,,,both,,,1260.14,819.09,,,,,,,,,,,,,
SCREW INTFR L23MM DIA10MM WDG SHP CANN ROUNDED THRD CRUCE,SUP-2366626,CDM,C1713,HCPCS,0278,RC,,,,both,,,687.79,447.06,,,,,,,,,,,,,
NEEDLE BX DIA22GA FN ENDOSCP SHARKCORE,SUP-2174334,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1103.40,717.21,,,,,,,,,,,,,
BASEPLATE TIB CEM SM UNIV 15 MM HIP PS NP PRIMARY STEM REV,SUP-2253234,CDM,C1776,CPT,0278,RC,,,,both,,,4384.70,2850.05,,,,,,,,,,,,,
SCREW BNE L10MM DIA2.7MM CORT S STL ST LOK FULL THRD T8,SUP-2183363,CDM,C1713,HCPCS,0278,RC,,,,both,,,318.21,206.84,,,,,,,,,,,,,
LPS PROX TIB REPLC COMP XSM,SUP-2513220,CDM,C1776,CPT,0278,RC,,,,both,,,21378.69,13896.15,,,,,,,,,,,,,
HC So Chromogenic Ish,PX-3128837766,CDM,88377,CPT,0312,RC,,,,inpatient,,,456.00,296.40,,,,,,,,,,,,,
BASEPLATE GLEN SZ 8 MM MOD TAPR KT NEUT STRL ALTIVATE RVS,SUP-2904162,CDM,C1776,CPT,0278,RC,,,,both,,,18794.47,12216.41,,,,,,,,,,,,,
SCREW SPNL STV HELIX,SUP-2311049,CDM,C1713,HCPCS,0278,RC,,,,both,,,1142.96,742.92,,,,,,,,,,,,,
PLATE BNE L262MM 14 H ST L LAT PROX TIB S STL LOK COMPR LO,SUP-2185728,CDM,C1713,HCPCS,0278,RC,,,,both,,,4801.03,3120.67,,,,,,,,,,,,,
LORDOTIC 8MM,SUP-2309709,CDM,C1713,HCPCS,0278,RC,,,,both,,,2983.00,1938.95,,,,,,,,,,,,,
COIL EMB H 2 MM DIA 7 MM STRL WEB17 SL,SUP-2915263,CDM,C1889,HCPCS,0278,RC,,,,both,,,51794.30,33666.29,,,,,,,,,,,,,
CEMENT BNE PMMA LO VISC RADIOPAQUE STRL V-FAST,SUP-2917103,CDM,C1713,HCPCS,0278,RC,,,,both,,,3375.50,2194.07,,,,,,,,,,,,,
SCREW BNE CORTICAL 2X6 MM 4 MM ST SS NS,SUP-2466086,CDM,C1713,HCPCS,0278,RC,,,,both,,,195.62,127.15,,,,,,,,,,,,,
K WIRE FIX L180MM DIA1.6MM W/ TRCR PT,SUP-2418381,CDM,C1713,HCPCS,0278,RC,,,,both,,,27.63,17.96,,,,,,,,,,,,,
HC N Block Paravert Lumbar 2nd,PX-3606449400,CDM,64494,CPT,0360,RC,,,,both,,,3892.00,2529.80,,,,,,,,,,,,,
HANDPIECE ELECSURG AQUABEAM - ORDER MULTIPLES OF 5,SUP-2745940,CDM,C2596,HCPCS,0272,RC,,,,both,,,10205.00,6633.25,,,,,,,,,,,,,
WASHER ORTH 3.5-4 MM FOR 2.7 MM INSTRUMENT NS LTX,SUP-2857168,CDM,C1713,HCPCS,0278,RC,,,,both,,,354.82,230.63,,,,,,,,,,,,,
LEAD PACE L100CM LT COR VEN POLYUR PLAT SIL IRIDIUM OXIDE,SUP-2141485,CDM,2720000010,LOCAL,0272,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
GRAFT BNE W14XH25X6XL24MM BICORT COT WDG FOR OSTEOTMY,SUP-2399104,CDM,C1734,HCPCS,0278,RC,,,,both,,,5275.20,3428.88,,,,,,,,,,,,,
BIT DRL L127MM DIA3.5MM W/OUT STP NONRADIOLUCENT W/ JACOB,SUP-2412257,CDM,2720000010,LOCAL,0272,RC,,,,both,,,188.40,122.46,,,,,,,,,,,,,
HOLDER NDL L23CM 0.035IN QUIK ACCS,SUP-2353173,CDM,2720000010,LOCAL,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
MESH SURG W15XL19CM THK1MM EPTFE CORDUROY SURF CNFRM TEXT,SUP-2395331,CDM,C1781,HCPCS,0278,RC,,,,both,,,3008.12,1955.28,,,,,,,,,,,,,
BIT DRL L145MM DIA3.2MM ST QUIK CPL W/O STP REUSE,SUP-2187256,CDM,2720000010,LOCAL,0272,RC,,,,both,,,358.15,232.80,,,,,,,,,,,,,
SYSTEM BONE CEM MX VAC M LO VISC W/ CLR CART CHAR FLTR SUCT,SUP-2199462,CDM,C1713,HCPCS,0278,RC,,,,both,,,440.39,286.25,,,,,,,,,,,,,
ESG PLASMALOOP LG 30,SUP-2720994,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1593.55,1035.81,,,,,,,,,,,,,
MPF Shell Revision 48/39,SUP-2511138,CDM,C1776,CPT,0278,RC,,,,both,,,4835.60,3143.14,,,,,,,,,,,,,
CATHETER EP L100CM DIA6FR SPC 5MM TIP L5MM STD CRV MAP EP,SUP-2140176,CDM,C1730,HCPCS,0272,RC,,,,both,,,1846.32,1200.11,,,,,,,,,,,,,
LEAD DEFIB 7FR L65CM TIP TO PROX COIL 17CM SIL OPTIM EXT,SUP-2356224,CDM,C1895,HCPCS,0275,RC,,,,both,,,10676.00,6939.40,,,,,,,,,,,,,
PLATE BNE L69MM 1 H ST POST MED PROX TIB S STL LOK COMPR,SUP-2177791,CDM,C1713,HCPCS,0278,RC,,,,both,,,3344.73,2174.07,,,,,,,,,,,,,
ANCHOR SUT 48 MM DIA SGL ARMED REGENESORB ABSRB THRDR,SUP-2341139,CDM,C1713,HCPCS,0278,RC,,,,both,,,417.62,271.45,,,,,,,,,,,,,
SPHINCTEROTOME ENDO DIA5.5FR CATH L200CM WIRE L30MM TIP L5MM,SUP-2139757,CDM,2720000010,LOCAL,0272,RC,,,,both,,,464.72,302.07,,,,,,,,,,,,,
GUIDEWIRE SM VES ANG TIP ZIPWIRE 0.018IN 150CM,SUP-2142692,CDM,C1769,HCPCS,0272,RC,,,,both,,,145.07,94.30,,,,,,,,,,,,,
MESH HERN OPN SKRT 20X15 CM COMP PARIETEX,SUP-2174714,CDM,C1781,HCPCS,0278,RC,,,,both,,,3024.45,1965.89,,,,,,,,,,,,,
CATHETER THOR HTS CTD SIL MEDIA 11MM10CS,SUP-2265911,CDM,C1729,HCPCS,0272,RC,,,,both,,,62.17,40.41,,,,,,,,,,,,,
PLATE BNE L 162 MM SCREW DIA2.7/3.5MM 12 H LT MEDL DSTL TIB,SUP-2931149,CDM,C1713,HCPCS,0278,RC,,,,both,,,7858.64,5108.12,,,,,,,,,,,,,
CLAMP EXT FIX 4 H PIN JET-X,SUP-2342952,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3807.25,2474.71,,,,,,,,,,,,,
SPACER SPNL 15 DEG 30X24X11 MM ALIF INDEPENDENCE MIS,SUP-2594749,CDM,C1821,HCPCS,0278,RC,,,,both,,,19468.00,12654.20,,,,,,,,,,,,,
GRAFT HUM TISS L 80 MM FIB SHFT LYOPH,SUP-2913231,CDM,C1762,CPT,0278,RC,,,,both,,,3529.36,2294.08,,,,,,,,,,,,,
CATHETER ATHRCTMY COR 1.7MM DIA 135CM LEN RAP EXCHG VITESSE,SUP-2353047,CDM,C1885,CPT,0278,RC,,,,both,,,7834.30,5092.29,,,,,,,,,,,,,
STIMULATOR NERVE PT PRGMR 35 CM SPNL 8 CONTACT,SUP-2138824,CDM,C1787,HCPCS,0278,RC,,,,both,,,2241.96,1457.27,,,,,,,,,,,,,
PLATE BNE L 130 MM SCREW DIA 3.5 MM 10 SHFT H SS MTPHSEAL VA,SUP-2907571,CDM,C1713,HCPCS,0278,RC,,,,both,,,3382.72,2198.77,,,,,,,,,,,,,
STENT BILI ZILVER 518 L 40 MM DIA 4 MM DEL SYS L 125 CM SHTH,SUP-2170061,CDM,C1876,HCPCS,0278,RC,,,,both,,,2868.39,1864.45,,,,,,,,,,,,,
PLATE BONE 3D PRNT MIDFACE MAND W/O PLN TI TRUMATCH,SUP-2860375,CDM,C1713,HCPCS,0278,RC,,,,both,,,33719.52,21917.69,,,,,,,,,,,,,
GUIDEWIRE ORTHOPEDIC HANSSON 2.4MM 300MM THREADED STERILE,SUP-2696004,CDM,C1769,HCPCS,0272,RC,,,,both,,,190.76,123.99,,,,,,,,,,,,,
CATHETER GUID MP 1 SIDE H 8FR WISEGUID,SUP-2139637,CDM,C1887,HCPCS,0272,RC,,,,both,,,166.42,108.17,,,,,,,,,,,,,
MESH SURG W8XL10IN UNCOATED MFIL POLYPR ABSRB HYDRGEL LO,SUP-2125910,CDM,C1781,HCPCS,0278,RC,,,,both,,,3623.56,2355.31,,,,,,,,,,,,,
DESIPRAMINE HCL 25 MG PO TABS,RX-2286,CDM,6370000000,HCPCS,0637,RC,45963-0342-02,NDC,,both,1,UN,5.10,3.31,,,,,,,,,,,,,
PLATE BONE LCK L CRV LT 11 H TI PROX TIB PLATING SYS ALPS,SUP-2413717,CDM,C1713,HCPCS,0278,RC,,,,both,,,4123.61,2680.35,,,,,,,,,,,,,
POR ST/ POR CUP/ XLPE LINER/ DELT CER HD,SUP-2212059,CDM,C1776,CPT,0278,RC,,,,both,,,13556.29,8811.59,,,,,,,,,,,,,
GUIDEWIRE VASC L180CM OD0.035IN NIT HYDRPHLC TAPR STD ANG,SUP-2168287,CDM,C1769,HCPCS,0272,RC,,,,both,,,82.36,53.53,,,,,,,,,,,,,
SCREW BNE L 9 MM DIA2.3 MM XDRV NS DISP LORENZ,SUP-2935116,CDM,C1713,HCPCS,0278,RC,,,,both,,,95.46,62.05,,,,,,,,,,,,,
GRAFT VASC GORTX L 50 CM DIA12 MM RNG L 50 CM EPTFE STR STD,SUP-2396028,CDM,C1768,CPT,0278,RC,,,,both,,,4122.82,2679.83,,,,,,,,,,,,,
HC So Chromosome Count Additional,PX-3118828566,CDM,88285,CPT,0311,RC,,,,both,,,38.00,24.70,,,,,,,,,,,,,
COLLAR CERV AD PLAS FOAM EXTRIC ADJ SET TRACH OPN VELC,SUP-2115114,CDM,L0180,HCPCS,0272,RC,,,,both,,,33.35,21.68,,,,,,,,,,,,,
NAIL IM TIB 10.5X290 MM PROX AG TARGETING ARM CLR CODE TI,SUP-2463978,CDM,C1713,HCPCS,0278,RC,,,,both,,,4954.92,3220.70,,,,,,,,,,,,,
APPLICATOR ENDOCLOT,SUP-2857948,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1507.20,979.68,,,,,,,,,,,,,
BRACE ORTHOPEDIC ANK,SUP-2112657,CDM,L1930,HCPCS,0274,RC,,,,both,,,87.92,57.15,,,,,,,,,,,,,
CATHETER ANGIOPLSTY LP 0.018 IN 130 CM 6X100 MM LUTONIX 018,SUP-2126960,CDM,C2623,HCPCS,0278,RC,,,,both,,,5966.00,3877.90,,,,,,,,,,,,,
PLATE BONE SM UNIV 6 H VAR DEG W LO N COMPR BARBELL,SUP-2363610,CDM,C1713,HCPCS,0278,RC,,,,both,,,940.78,611.51,,,,,,,,,,,,,
PLATE BONE 4X4 H BILAT MAND ORAL MAXILLOFACIAL TI ANG LO,SUP-2191436,CDM,C1713,HCPCS,0278,RC,,,,both,,,5141.12,3341.73,,,,,,,,,,,,,
DEVICE LASER DEL 10 DEG ENT ANGLED OTOPROBE,SUP-2225639,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
BIT DRL L 175/90 MM DIA2 MM SCREW DIA2.7 MM CALIB AO QC CLR,SUP-2907958,CDM,2720000010,LOCAL,0272,RC,,,,both,,,852.26,553.97,,,,,,,,,,,,,
LENS IOL 23.0 DIOPT L 13 MM DIA 6 MM HAPTIC 10 DEG,SUP-2881372,CDM,V2787,HCPCS,0276,RC,,,,both,,,1000.00,650.00,,,,,,,,,,,,,
KNIFE SURG BAYNT 193 CM 1 PC ANNULOTOMY SS TRANSCONTINENTAL,SUP-2232207,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1758.40,1142.96,,,,,,,,,,,,,
BUR DIAMOND RND 5MM,SUP-2736215,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1103.62,717.35,,,,,,,,,,,,,
BIT DRL STP UNIT 48 MM DYN AX FIX SYS SET,SUP-2644553,CDM,2720000010,LOCAL,0272,RC,,,,both,,,84.97,55.23,,,,,,,,,,,,,
GRAFT VASC GELWEAVE L 15 CM DIA 8 MM POLYESTER GEL,SUP-2384993,CDM,C1768,CPT,0278,RC,,,,both,,,3877.90,2520.63,,,,,,,,,,,,,
PLATE BNE L 220 X W 10.2 MM THK 2.8 MM SCREW DIA 3.5 MM 20 H,SUP-2936251,CDM,C1713,HCPCS,0278,RC,,,,both,,,2441.19,1586.77,,,,,,,,,,,,,
GRAFT BNE 10 CC DBM FIBER STRND +,SUP-2644299,CDM,C1713,HCPCS,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
INSERT TIB SZ 6 THK10MM LT CNFRM + NEUT PRI PROFIX,SUP-2419451,CDM,C1776,CPT,0278,RC,,,,both,,,4110.26,2671.67,,,,,,,,,,,,,
SEGMENT FEM L26CM INTERCALARY FINN CPS,SUP-2406907,CDM,C1776,CPT,0278,RC,,,,both,,,16968.56,11029.56,,,,,,,,,,,,,
SET CATH RAP INFUS EXCHG W/ 8.5FR SHTH TISS DIL SPR WIRE,SUP-2383492,CDM,C1769,HCPCS,0272,RC,,,,both,,,38.06,24.74,,,,,,,,,,,,,
IMMOBILIZER KNEE CUTAWAY 24 IN,SUP-2336082,CDM,L1830,CPT,0272,RC,,,,both,,,37.21,24.19,,,,,,,,,,,,,
SL POWERMIDLINE CATHETER KIT W/GUARDIVA,SUP-2613517,CDM,C1751,HCPCS,0278,RC,,,,both,,,364.24,236.76,,,,,,,,,,,,,
BLADE SHV L27.5CM DIA4MM 60-500RPM DBL CRV LO PROF ANG,SUP-2284156,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1529.81,994.38,,,,,,,,,,,,,
BIT DRL L7IN DIA0.25IN N RADPQ W/O STP REUSE,SUP-2412568,CDM,2720000010,LOCAL,0272,RC,,,,both,,,907.77,590.05,,,,,,,,,,,,,
IMPLANT CRANIOMAXILLOFACIAL W58XL56MM THICKNESS 15MM POLYETH,SUP-2366486,CDM,C1713,HCPCS,0278,RC,,,,both,,,3625.76,2356.74,,,,,,,,,,,,,
GRAFT HUM TISS 22X12X22MM WDG EVANS FOR ANAT RECON ALLOSYNC,SUP-2120760,CDM,C1713,HCPCS,0278,RC,,,,both,,,4662.90,3030.88,,,,,,,,,,,,,
DRESSING WND MICRONIZED PARTIC 60 MG MATRISTEM MICROMATRIX,SUP-2106471,CDM,Q4118,HCPCS,0636,RC,,,,both,,,423.52,275.29,,,,,,,,,,,,,
COMPONENT GLEN KEELED 3XL SHLDR AEQUALIS ASCEND FLX,SUP-2715528,CDM,C1776,CPT,0278,RC,,,,both,,,6276.86,4079.96,,,,,,,,,,,,,
BLADE SCREWDRIVER 27MM DIA STAINLESS STEEL CROSS DRIVE,SUP-2679090,CDM,2720000010,LOCAL,0272,RC,,,,both,,,439.10,285.41,,,,,,,,,,,,,
PIN EXT FIX HALF 5X35 MM 160 MM SD SHANK,SUP-2749884,CDM,2720000010,LOCAL,0272,RC,,,,both,,,697.08,453.10,,,,,,,,,,,,,
SEALER LAP L44CM MARYLAND JAW OPN NANO COAT MULTIFUNCTIONAL,SUP-2283565,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1622.19,1054.42,,,,,,,,,,,,,
CATHETER PERITONEAL DLYS 35X53 MMX62 CM FLEX-NECK CLASSIC,SUP-2302485,CDM,C1750,HCPCS,0278,RC,,,,both,,,546.36,355.13,,,,,,,,,,,,,
KIT INFUS PMP 100ML 5IN SOAK CATH NONNARCOTIC ELASTOMERIC,SUP-2236779,CDM,C2626,HCPCS,0278,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
BUR SURG DIAMOND 2.2 MMX10 CM MTCH HD SM BOR LEGEND,SUP-2627638,CDM,2720000010,LOCAL,0272,RC,,,,both,,,318.24,206.86,,,,,,,,,,,,,
GRAFT BONE STRP CORT 14MMX50MM INDUX,SUP-2415400,CDM,C1713,HCPCS,0278,RC,,,,both,,,5611.18,3647.27,,,,,,,,,,,,,
CATHETER ANGIOPLSTY OTW 0.035 IN 17 ATM 5 FRX80 CM 6X120 MM,SUP-2865997,CDM,C1725,HCPCS,0272,RC,,,,both,,,494.55,321.46,,,,,,,,,,,,,
GRAFT VASC RESTOREFLOW SZ 10-19 CM FEM VEIN BLD TYP A B AB O,SUP-2884032,CDM,C1768,CPT,0278,RC,,,,both,,,19339.26,12570.52,,,,,,,,,,,,,
SHEARS SEAL L17CM LNG ULTRASONIC CRV TIP HARM FOCS,SUP-2219098,CDM,C1713,HCPCS,0278,RC,,,,both,,,1494.01,971.11,,,,,,,,,,,,,
CEFTRIAXONE SODIUM 500 MG IJ SOLR,RX-9490,CDM,J0696,HCPCS,0636,RC,00409-7338-11,NDC,,both,1,UN,54.10,35.16,,,,,,,,,,,,,
SCREW ACET 6.5X30 MM HIP,SUP-2308990,CDM,C1713,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
SUPPORT ORTHOT THGH LOWER EXTREMITY WT BEAR LACER,SUP-2435678,CDM,L2540,HCPCS,0272,RC,,,,both,,,1284.79,835.11,,,,,,,,,,,,,
PLATE BONE SM TIM LCK INLINE LO PROF CNTOUR SMOOTH FUS ALPS,SUP-2419525,CDM,C1713,HCPCS,0278,RC,,,,both,,,2535.55,1648.11,,,,,,,,,,,,,
ADAPTER LD L 10 CM SIL INSUL BPLR LV1/IS1 CONN QUADRIFILAR,SUP-2616246,CDM,C1883,HCPCS,0278,RC,,,,both,,,1522.90,989.88,,,,,,,,,,,,,
PIN SPNL COMPR 16 MM,SUP-2719357,CDM,C1713,HCPCS,0278,RC,,,,both,,,219.80,142.87,,,,,,,,,,,,,
PLATE BNE STR 7 HOLE,SUP-2864953,CDM,C1713,HCPCS,0278,RC,,,,both,,,3943.84,2563.50,,,,,,,,,,,,,
CATHETERIZATION KIT 3 L 6FRX55CM VPS,SUP-2641814,CDM,C1751,HCPCS,0278,RC,,,,both,,,1066.56,693.26,,,,,,,,,,,,,
PLATE BNE L115MM THK3.5-4.5MM 4X4 H MED TIB TI LOK FOR,SUP-2190906,CDM,C1713,HCPCS,0278,RC,,,,both,,,3480.91,2262.59,,,,,,,,,,,,,
GUIDEWIRE VASC DBL END,SUP-2264476,CDM,C1769,HCPCS,0272,RC,,,,both,,,43.18,28.07,,,,,,,,,,,,,
CATHETER THROMCTMY INDIGO SEP L 175 CM DSTL DIA 0.055 IN,SUP-2323712,CDM,C1757,HCPCS,0272,RC,,,,both,,,3218.50,2092.02,,,,,,,,,,,,,
ROD RMR L950MM DIA2.5MM W/ EXTN BALL TIP,SUP-2188106,CDM,2720000010,LOCAL,0272,RC,,,,both,,,340.41,221.27,,,,,,,,,,,,,
SCREW INTRF L15MM DIA5.5MM DISP DRVR BIO-TENODESIS,SUP-2121341,CDM,C1713,HCPCS,0278,RC,,,,both,,,1114.70,724.55,,,,,,,,,,,,,
KIT ANEUROPLASTIC CEM 30GM 2 MTRX BG 2 VI LIQ STRL DISP,SUP-2256971,CDM,C1713,HCPCS,0278,RC,,,,both,,,450.59,292.88,,,,,,,,,,,,,
CATHETER HD DL 13 FRX24 CM ACUTE STR SPLIT TIP DUO-SPLIT,SUP-2269520,CDM,C1752,HCPCS,0278,RC,,,,both,,,185.26,120.42,,,,,,,,,,,,,
PROSTHESIS OSS 0.8X37 MM MID EAR TI HA BOJRAB ALTO,SUP-2232500,CDM,L8613,CPT,0278,RC,,,,both,,,1234.02,802.11,,,,,,,,,,,,,
GRAFT HUM TISS W20 25XL150MM HUM SHFT FRZN,SUP-2307376,CDM,C1713,HCPCS,0278,RC,,,,both,,,2845.66,1849.68,,,,,,,,,,,,,
GRAFT HUM TISS 60-69CM SAPH VEIN,SUP-2417193,CDM,C1768,CPT,0278,RC,,,,both,,,30925.86,20101.81,,,,,,,,,,,,,
SCREW BNE CANN 6.5X55 MM 22 MM PARTIALLY THRD TI,SUP-2343351,CDM,C1713,HCPCS,0278,RC,,,,both,,,1873.17,1217.56,,,,,,,,,,,,,
COMPONENT TIB AUG UNIV 47X51X10 MM KNEE OSS RS RD122160,SUP-2449999,CDM,C1776,CPT,0278,RC,,,,both,,,692.37,450.04,,,,,,,,,,,,,
BODY HUM 36MM METAPHYSIS CEM AEQUALIS REVERSED II,SUP-2388649,CDM,C1776,CPT,0278,RC,,,,both,,,6361.33,4134.86,,,,,,,,,,,,,
INSERT TIB CNDYL STABILIZING MED 11 MM LIP X3 STRL DURAC LTX,SUP-2869662,CDM,C1776,CPT,0278,RC,,,,both,,,5177.23,3365.20,,,,,,,,,,,,,
DEVICE BLOWER/MISTER AXIUS,SUP-2717309,CDM,C1713,HCPCS,0278,RC,,,,both,,,174.05,113.13,,,,,,,,,,,,,
MESH HERN W10XL15CM POLYPR FLAT L PORE MFIL SFT KNIT LTWT,SUP-2125779,CDM,C1781,HCPCS,0278,RC,,,,both,,,212.89,138.38,,,,,,,,,,,,,
GUIDEWIRE VASC CHIKAI L 300 CM 0.014IN L 5CM STR DURABLE TIP,SUP-2123856,CDM,C1769,HCPCS,0272,RC,,,,both,,,1723.86,1120.51,,,,,,,,,,,,,
HC Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn,PX-3606232100,CDM,62321,CPT,0360,RC,,,,inpatient,,,2230.00,1449.50,,,,,,,,,,,,,
CATHETER THORACENTESIS SET PEDIATRIC 6.3 FRX19 CM 6 SIDEPRT,SUP-2760154,CDM,C1729,HCPCS,0272,RC,,,,both,,,676.29,439.59,,,,,,,,,,,,,
SCREW BNE CRTX 2X30 MM FOR STARDRV SS NS,SUP-2183199,CDM,C1713,HCPCS,0278,RC,,,,both,,,142.93,92.90,,,,,,,,,,,,,
ALLOGRAFT BNE SPACER LNG 30X11X15 MM BIO AVS UNILIF,SUP-2637048,CDM,C1713,HCPCS,0278,RC,,,,both,,,8478.00,5510.70,,,,,,,,,,,,,
PLATE BNE 5DEG SHT L MT REV GORILLA,SUP-2321459,CDM,C1713,HCPCS,0278,RC,,,,both,,,4545.15,2954.35,,,,,,,,,,,,,
SUPPORT ORTHOT ELBW CUST RIGID W/O JT PREFABRICATED,SUP-2435761,CDM,L3762,HCPCS,0274,RC,,,,both,,,277.01,180.06,,,,,,,,,,,,,
CATHETER THROMCTMY LIGHTNING FLSH L 115 CM BER TIP SEP12,SUP-2865165,CDM,C1757,HCPCS,0272,RC,,,,both,,,31368.60,20389.59,,,,,,,,,,,,,
SCREW BONE L16MM OD3.5MM COARSE THRD CRUCFRM WDRUFF HD,SUP-2362292,CDM,C1713,HCPCS,0278,RC,,,,both,,,21.35,13.88,,,,,,,,,,,,,
CANNULA SURG LNG 8 MM SCREW 00249004180,SUP-2463892,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2018.14,1311.79,,,,,,,,,,,,,
CATHETER GUID 70DEG TIP F-70 NSL SINUS RELIEVA FLX,SUP-2106347,CDM,C1887,HCPCS,0272,RC,,,,both,,,1161.80,755.17,,,,,,,,,,,,,
PROSTHESIS LARYN L6MM LO AIRFLO RESISTANCE EZ MAINT FOR,SUP-2124337,CDM,L8509,HCPCS,0272,RC,,,,both,,,920.02,598.01,,,,,,,,,,,,,
SCREW BNE RUL LAG FOR NAILING SYS GAMMA3,SUP-2361613,CDM,C1713,HCPCS,0278,RC,,,,both,,,577.76,375.54,,,,,,,,,,,,,
ROD EXT FIX THRD 150 MM SQ NUT ASMBLY,SUP-2517347,CDM,2720000010,LOCAL,0272,RC,,,,both,,,479.79,311.86,,,,,,,,,,,,,
CATHETER INFUSION PULSE SPRY PRO L 90 CM 5 FR SLT 20CM FLX Y,SUP-2117007,CDM,C1751,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
COMPONENT GLEN KEELED 40 MM SHLDR W/ 46 MM ARTC SURF,SUP-2436693,CDM,C1776,CPT,0278,RC,,,,both,,,4899.72,3184.82,,,,,,,,,,,,,
WIRE FIX KIRSCHNER KWIRE] TORNIER INC],SUP-2388810,CDM,C1713,HCPCS,0278,RC,,,,both,,,34.54,22.45,,,,,,,,,,,,,
BIT DRL DIA48MM HI SPD,SUP-2187155,CDM,2720000010,LOCAL,0272,RC,,,,both,,,799.19,519.47,,,,,,,,,,,,,
COMPONENT FEM 67.5MM R KNEE TINBN NP POST STBL OPN BX,SUP-2407485,CDM,C1776,CPT,0278,RC,,,,both,,,4396.00,2857.40,,,,,,,,,,,,,
STAPLER INT 35 MM LT ATR APPENDAGE 7 PIN TIGERPAW PRO,SUP-2717308,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5024.00,3265.60,,,,,,,,,,,,,
CAGE SPNL L10XW10XH30MM 4 LOBE LORDTC END CAP IMP NGAGE,SUP-2317727,CDM,C1889,HCPCS,0278,RC,,,,both,,,11592.88,7535.37,,,,,,,,,,,,,
BIT DRL 29X140 MM,SUP-2644591,CDM,2720000010,LOCAL,0272,RC,,,,both,,,283.23,184.10,,,,,,,,,,,,,
IMMOBILIZER ORTH CUTAWAY UNIV 24 IN 12-24 IN PERF FOAM,SUP-2194891,CDM,L1830,CPT,0274,RC,,,,both,,,94.20,61.23,,,,,,,,,,,,,
DRESSING BIO COVERAGE AREA170 SQ CM 1000 MG PORCINE SM,SUP-2905498,CDM,Q4102,HCPCS,0636,RC,,,,both,,,6867.18,4463.67,,,,,,,,,,,,,
ROD SPNL 6.35 MM DIA 120 MM LEN POST R SMOOTH LEG,SUP-2289200,CDM,C1713,HCPCS,0278,RC,,,,both,,,1522.90,989.88,,,,,,,,,,,,,
POST EXT FIX 4 H WIRE,SUP-2255810,CDM,2720000010,LOCAL,0272,RC,,,,both,,,723.68,470.39,,,,,,,,,,,,,
FOSFOMYCIN TROMETHAMINE 3 G PO PACK,RX-14825,CDM,6370000000,HCPCS,0637,RC,70700-0268-94,NDC,,both,1,UN,361.50,234.97,,,,,,,,,,,,,
TUBE FIX FOR CORETRAK ARTC FIX,SUP-2399884,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4992.60,3245.19,,,,,,,,,,,,,
HC So1 Encephalitis Eastern Equine,PX-3028665267,CDM,86652,CPT,0302,RC,,,,both,,,44.00,28.60,,,,,,,,,,,,,
DEVICE CLSR L3.3MM L TI ST DISP FOR ANAS VES ANASTOCLIP VCS,SUP-2264239,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
GRAFT BNE FOAM PK 12 CC VERSATILE SCAFFOLD VITOSS BBTRAUMA,SUP-2431359,CDM,C1713,HCPCS,0278,RC,,,,both,,,1519.76,987.84,,,,,,,,,,,,,
SHEATH DIL SZ B INNR 12.1FR/10FR OUTER 15.2FR/13.1FR,SUP-2169011,CDM,C1893,HCPCS,0272,RC,,,,both,,,307.72,200.02,,,,,,,,,,,,,
HC Cns Dna/Rna Amp Probe Multiple Subtypes 12-25,PX-3068748300,CDM,87483,CPT,0306,RC,,,,outpatient,,,907.00,589.55,,,,,,,,,,,,,
BRACE THORACOLUMBOSACRAL M 15DEG LORDOSIS HK RECV MAT BK,SUP-2195550,CDM,L0650,HCPCS,0274,RC,,,,both,,,1039.34,675.57,,,,,,,,,,,,,
PLATE BNE L38MM THK33MM 3 H BILAT S STL STR LIMIT CNTCT DYN,SUP-2185125,CDM,C1713,HCPCS,0278,RC,,,,both,,,784.40,509.86,,,,,,,,,,,,,
GUIDEWIRE VASC INQWIRE L 150 CM 0.025 IN TIP L 3 MM PTFE FIX,SUP-2301917,CDM,C1769,HCPCS,0272,RC,,,,both,,,28.23,18.35,,,,,,,,,,,,,
RAIL EXT FIX SM 100 MM,SUP-2461387,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3158.84,2053.25,,,,,,,,,,,,,
DEVICE LAA EXCLUSION CLP L 50 MM NIT SPRING POLYESTER CVR,SUP-2905441,CDM,C1889,HCPCS,0278,RC,,,,both,,,7065.00,4592.25,,,,,,,,,,,,,
KIT CATH HEMODIALYSI EQUISTREAM XK CHRONIC STD 16FR DIA 24CM,SUP-2613303,CDM,C1750,HCPCS,0278,RC,,,,both,,,1526.51,992.23,,,,,,,,,,,,,
PIN BNE SM NON-THREADED BB-TAK,SUP-2423858,CDM,2720000010,LOCAL,0272,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
SHEATH INTRO PRELUDEEASE 23CM 5FR 80CM NDL 4CM NIT PLAT,SUP-2740551,CDM,C1894,HCPCS,0272,RC,,,,both,,,151.66,98.58,,,,,,,,,,,,,
CATHETER HD SYMMETRICAL 14.5 FRX19 CM PALINDROMIC EMERALD,SUP-2174236,CDM,C1750,HCPCS,0278,RC,,,,both,,,1786.03,1160.92,,,,,,,,,,,,,
STEM HUM L125MM DIA11MM UNIV DST SHLDR TI PRI REV CEM FOR,SUP-2372854,CDM,C1776,CPT,0278,RC,,,,both,,,10252.73,6664.27,,,,,,,,,,,,,
CARISOPRODOL 350 MG PO TABS,RX-1395,CDM,6370000000,HCPCS,0637,RC,50228-0109-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
BLADE SURG PLANNER 28 MM 3-PEG,SUP-2444440,CDM,2720000010,LOCAL,0272,RC,,,,both,,,536.94,349.01,,,,,,,,,,,,,
HEAD FEM MED 4+ MM 12/14 36 MM HIP TAPR CERM BIOLOX FORTE,SUP-2450926,CDM,C1776,CPT,0278,RC,,,,both,,,6455.84,4196.30,,,,,,,,,,,,,
HC Chemo Infusion 1st Hour Chemo,PX-3359641300,CDM,96413,CPT,0335,RC,,,,both,,,881.00,572.65,,,,,,,,,,,,,
HEAD FEM DIA28MM NK L+8MM CO CHROM V40 TAPR PRI LFIT,SUP-2364467,CDM,C1776,CPT,0278,RC,,,,both,,,985.96,640.87,,,,,,,,,,,,,
INSERTER SURG W/ BIOABSORBABLE 2 ANCHR STRL LF,SUP-2867242,CDM,C1713,HCPCS,0278,RC,,,,both,,,3611.00,2347.15,,,,,,,,,,,,,
GRAFT BNE PTTY 5 CC W/ CHIP DBM PUROS,SUP-2335223,CDM,C9359,HCPCS,0278,RC,,,,both,,,3136.86,2038.96,,,,,,,,,,,,,
COIL EMB L30CM DIA13MM 0.018IN 360DEG STD STRTCH RESIST,SUP-2365687,CDM,C1889,HCPCS,0278,RC,,,,both,,,6490.57,4218.87,,,,,,,,,,,,,
PLATE BONE NAR DSTL VOLAR RAD CROSSLOCK RT STRL,SUP-2137032,CDM,C1713,HCPCS,0278,RC,,,,both,,,6267.88,4074.12,,,,,,,,,,,,,
DEVICE SUT M CONN OPUS SMARTSTITCH,SUP-2342087,CDM,2720000010,LOCAL,0272,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
BLADE ENDOSCP L4MM DETACH FOR CAPSLTMY CAPSULECUT,SUP-2121995,CDM,C1713,HCPCS,0278,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
ALLOGRAFT BNE 2.5 CC DBM REFICIO,SUP-2731796,CDM,C1713,HCPCS,0278,RC,,,,both,,,863.91,561.54,,,,,,,,,,,,,
DEXTROSE 250 MG/ML IV SOLN,RX-2361,CDM,2580000003,HCPCS,0250,RC,00409-1775-10,NDC,,both,10,ML,175.10,113.81,,,,,,,,,,,,,
STAPLE INT BIOABSRB REINF FOR ETHICON FLX ENDOPATH 60 PWR +,SUP-2395316,CDM,C1713,HCPCS,0278,RC,,,,both,,,656.26,426.57,,,,,,,,,,,,,
GRAFT VASC GELWEAVE L 50 CM DIA 28 MM L 15CM 8 MM ANTE FLO,SUP-2894825,CDM,C1768,CPT,0278,RC,,,,both,,,6550.04,4257.53,,,,,,,,,,,,,
SUTURE ANCHOR 5.0X14MM WITH TWO NUMBER 2 POLYESTER SUTURES P,SUP-2824808,CDM,C1713,HCPCS,0278,RC,,,,both,,,529.59,344.23,,,,,,,,,,,,,
GRAFT HUM TISS W6XL16CM THK.9-1.99MM ACELLULAR DERM MTRX,SUP-2402512,CDM,Q4126,HCPCS,0636,RC,,,,both,,,14130.00,9184.50,,,,,,,,,,,,,
STENT PERIPH S.M.A.R.T. CTRL L 60 MM DIA 8 MM DEL SYS L 120,SUP-2158601,CDM,C1876,HCPCS,0278,RC,,,,both,,,2731.80,1775.67,,,,,,,,,,,,,
PIN DISTRACTOR L16MM ST CERV S STL W UNIV FIT,SUP-2194310,CDM,C1713,HCPCS,0278,RC,,,,both,,,219.80,142.87,,,,,,,,,,,,,
CATHETER CV DL 8 FRX20 CM FULL KT ARROWG+ARD BLU +,SUP-2383392,CDM,C1751,HCPCS,0278,RC,,,,both,,,384.34,249.82,,,,,,,,,,,,,
INTRODUCER PACE LD FLOWGUARD DIA 8 FR ART VLV PEELABLE STRL,SUP-2281859,CDM,C1894,HCPCS,0272,RC,,,,both,,,187.65,121.97,,,,,,,,,,,,,
CYLINDER DOSE OF SF6,SUP-2865712,CDM,C1814,HCPCS,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
VALVE HYDROCEPHALUS 10 SYS W/ SHUNT ASST SPRUNG RESVR PROGAV,SUP-2108745,CDM,C1729,HCPCS,0272,RC,,,,both,,,10002.97,6501.93,,,,,,,,,,,,,
WIRE FIX TROCAR PT 2 END 0.035X5 IN SS NS KIRSCHNER,SUP-2791811,CDM,C1713,HCPCS,0278,RC,,,,both,,,8.48,5.51,,,,,,,,,,,,,
CARBON FIBER BAR 6MM X 65MM,SUP-2730000,CDM,2720000010,LOCAL,0272,RC,,,,both,,,672.71,437.26,,,,,,,,,,,,,
PLATE BONE L246MM 15 H RT PROX HUM LCK FOR 4.5MM SCR,SUP-2348280,CDM,C1713,HCPCS,0278,RC,,,,both,,,17421.98,11324.29,,,,,,,,,,,,,
BLADE SAW OSCLLTNG 9.5MMW X30MML 0.64MM THK 0.84 THK CUT ANT,SUP-2605516,CDM,2720000010,LOCAL,0272,RC,,,,both,,,201.65,131.07,,,,,,,,,,,,,
SCREW BNE L8MM DIA2MM CORT TI ST NONCANNULATED FULL THRD 0450360801] DEPUY SYNTHES USA],SUP-2181744,CDM,C1713,HCPCS,0278,RC,,,,both,,,474.77,308.60,,,,,,,,,,,,,
IMPLANT BLGCL TSSUE SHEET 107SQCM 8CMW X 15CML PRCNE TSSUE M,SUP-2675731,CDM,Q4130,HCPCS,0636,RC,,,,both,,,8091.78,5259.66,,,,,,,,,,,,,
STAPLE BNE 15X18X18 MM OSSTAPLE,SUP-2194218,CDM,C1713,HCPCS,0278,RC,,,,both,,,2849.55,1852.21,,,,,,,,,,,,,
HC Mammo Dgx Unilateral Incl Cad if Perf,PX-4017706500,CDM,77065,CPT,0401,RC,,,,outpatient,,,629.00,408.85,,,,,,,,,,,,,
HC OB ER Level 2,PX-4509928201,CDM,99282,CPT,0450,RC,,,,outpatient,,,987.00,641.55,,,,,,,,,,,,,
BLADE RETRACTOR KEL 1X1.5 IN BOOKWALTER,SUP-2691294,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1369.04,889.88,,,,,,,,,,,,,
COMPONENT PAT 8MM 30MM 1 DOME 3 PEG GEM,SUP-2262254,CDM,C1776,CPT,0278,RC,,,,both,,,2025.30,1316.44,,,,,,,,,,,,,
SCREW BNE 5.5X80MM CORT PROX SLD FT TIM,SUP-2412197,CDM,C1713,HCPCS,0278,RC,,,,both,,,542.18,352.42,,,,,,,,,,,,,
BLADE BNE MILL MED STRL MILL + LTX DISP,SUP-2859294,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1774.98,1153.74,,,,,,,,,,,,,
PLATE BNE W10XL107MM THK15MM 3X8 H R TI T OBLQ LO PROF NEUT,SUP-2190923,CDM,C1713,HCPCS,0278,RC,,,,both,,,1342.32,872.51,,,,,,,,,,,,,
WASHER ORTH THRD 10 MM 4.5 MM FOR CANN SCR TI NS,SUP-2190558,CDM,C1713,HCPCS,0278,RC,,,,both,,,81.42,52.92,,,,,,,,,,,,,
IMPLANT FEM L29MM DIA11MM INSRT APERFIX AM,SUP-2416335,CDM,C1776,CPT,0278,RC,,,,both,,,3884.18,2524.72,,,,,,,,,,,,,
BUR SURG DIAMOND BULL 70 DEG 3 MMX13.5 CM STRL DISP,SUP-2638397,CDM,2720000010,LOCAL,0272,RC,,,,both,,,678.24,440.86,,,,,,,,,,,,,
SET URET STENT SOFFLX BANDER L 75 CM DIA 7.2 FR 0.038 IN RT,SUP-2168896,CDM,C2617,HCPCS,0278,RC,,,,both,,,217.04,141.08,,,,,,,,,,,,,
DEVICE VASC CLSR 4FR TO 10FR RAD ART EXT MECH PRSS RADSTAT,SUP-2303324,CDM,C1713,HCPCS,0278,RC,,,,both,,,65.94,42.86,,,,,,,,,,,,,
FIBER LSR FLEXIVA PULSE 910,SUP-2717690,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2289.03,1487.87,,,,,,,,,,,,,
KIT INTRO MAC SHTH L 11.5 CM DIA 9 FR POLYUR LIDO CV 3 LUMEN,SUP-2763402,CDM,C1892,HCPCS,0272,RC,,,,both,,,321.54,209.00,,,,,,,,,,,,,
BLADE SHV L11CM DIA4MM 360DEG ROT SERR STR SHFT,SUP-2277869,CDM,2720000010,LOCAL,0272,RC,,,,both,,,743.55,483.31,,,,,,,,,,,,,
GRAFT ENDOVASC L113MM PROX L59MM DSTL L54MM OD28X12MM SHTH,SUP-2171095,CDM,C1874,HCPCS,0278,RC,,,,both,,,21000.32,13650.21,,,,,,,,,,,,,
PLATE BNE 8 H MTCRPL T SHP,SUP-2389598,CDM,C1713,HCPCS,0278,RC,,,,both,,,1475.80,959.27,,,,,,,,,,,,,
INSERT TALAR SZ 3+ THK10MM ANK POLYETH FOR PROPHECY INBONE,SUP-2397172,CDM,C1713,HCPCS,0278,RC,,,,both,,,3865.34,2512.47,,,,,,,,,,,,,
CATHETER CV DL 5 FR TY W/ MICROINTRODUCER POWERPICC SOLO 2,SUP-2126387,CDM,C1751,HCPCS,0278,RC,,,,both,,,472.32,307.01,,,,,,,,,,,,,
SCREW SPNL 5.5X60 MM HA TSRH 3DX OSTEOGRIP,SUP-2631178,CDM,C1713,HCPCS,0278,RC,,,,both,,,2088.10,1357.26,,,,,,,,,,,,,
DEFIBRILLATOR CARD W523XH714CM D099CM SGL CHMBR VR IS 1 DF 1,SUP-2149180,CDM,C1722,HCPCS,0275,RC,,,,both,,,35029.84,22769.40,,,,,,,,,,,,,
BLADE RETRACTOR 16 CM ANTR POST DLIF,SUP-2628718,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1347.06,875.59,,,,,,,,,,,,,
PLATE BNE 76X50X06MM MESH CRANIOFACIAL DBL BARR TI MEDPOR,SUP-2366476,CDM,C1713,HCPCS,0278,RC,,,,both,,,4455.22,2895.89,,,,,,,,,,,,,
CATH DIAG PERI 5FR IMAGER II C1 65CM 5 FR,SUP-2652849,CDM,C1758,HCPCS,0278,RC,,,,both,,,45.84,29.80,,,,,,,,,,,,,
NEEDLE BX L15CM OD14GA ADJUSTABLE COAX TEMNO,SUP-2302403,CDM,C1713,HCPCS,0278,RC,,,,both,,,103.68,67.39,,,,,,,,,,,,,
RITUXIMAB-ARRX (RIABNI) 10 MG/ML IV SOLN (MIXTURES ONLY),RX-4082266,CDM,Q5123,HCPCS,0636,RC,55513-0224-01,NDC,,both,10,ML,2064.40,1341.86,,,,,,,,,,,,,
GUIDEWIRE VASC STR 15 CM 0.038 INX145 CM FIX COR SS BENT,SUP-2167685,CDM,C1769,HCPCS,0272,RC,,,,both,,,44.05,28.63,,,,,,,,,,,,,
HC So Immunoglobulin Light Chains Free Each,PX-3018352166,CDM,83521,CPT,0301,RC,,,,both,,,59.00,38.35,,,,,,,,,,,,,
CATHETER GUID WINGMAN 14 L 135 CM OD 0.035 IN TIP DIA 0.022,SUP-2227763,CDM,C1887,HCPCS,0272,RC,,,,both,,,3124.30,2030.79,,,,,,,,,,,,,
NOREPINEPHRINE BITARTRATE 8 MG/250 ML (32 MCG/ML) IN 0.9 % NACL IV,RX-135994,CDM,2500000003,HCPCS,0250,RC,44567-0641-01,NDC,,both,250,ML,281.80,183.17,,,,,,,,,,,,,
CATHETER DRAINAGE INTRO 19 FRX55 CM RET FLEX XL BIO-MEDICUS,SUP-2745348,CDM,C1729,HCPCS,0272,RC,,,,both,,,1632.02,1060.81,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 50 MM DIA 5 MM DEL SHTH 2ML,SUP-2936807,CDM,C1713,HCPCS,0278,RC,,,,both,,,6897.17,4483.16,,,,,,,,,,,,,
GUIDEWIRE VASC L190CM 5CM INTMED SEGMENTS 4CM RADPQ TIP,SUP-2103572,CDM,C1769,HCPCS,0272,RC,,,,both,,,188.40,122.46,,,,,,,,,,,,,
BLADE RETRACTOR BALFOUR 2.75X4 IN CENTER BLADE,SUP-2460867,CDM,2720000010,LOCAL,0272,RC,,,,both,,,487.11,316.62,,,,,,,,,,,,,
SPLINT ORTH PLASTALUME 3.25X3.25 IN FNGR W/ BLB RADLUC,SUP-2276772,CDM,L3933,HCPCS,0272,RC,,,,both,,,3.89,2.53,,,,,,,,,,,,,
GRAFT HUM TISS PTCH 3X6 CM UMB CRD RESTORIGIN,SUP-2321894,CDM,Q4191,HCPCS,0636,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
COLLAR CERV UNIV AD AIR VENT MIAMI OCCIAN,SUP-2276575,CDM,L0180,HCPCS,0274,RC,,,,both,,,373.44,242.74,,,,,,,,,,,,,
SET INT FIX SCREW DIA1.5 MM 4 H LNG TI NEURO STR PLT 12 PK,SUP-2935689,CDM,C1713,HCPCS,0278,RC,,,,both,,,15159.92,9853.95,,,,,,,,,,,,,
SET INTRO 10FR CATH 8FR L70X30CM FOR RG AG URET ACC,SUP-2168949,CDM,C1894,HCPCS,0272,RC,,,,both,,,307.72,200.02,,,,,,,,,,,,,
CATHETER GUID 8FR 0.090IN COR NYL STD JL4 L LUMN FLX RADPQ,SUP-2296413,CDM,C1887,HCPCS,0272,RC,,,,both,,,141.30,91.84,,,,,,,,,,,,,
HC Rem Impact Cerumen Irrigat Uni,PX-4506920900,CDM,69209,CPT,0450,RC,,,,both,,,109.00,70.85,,,,,,,,,,,,,
SET BLDE SCALP HK TRIANG FOR PLNTR FASCTMY DISP,SUP-2370273,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1393.53,905.79,,,,,,,,,,,,,
GRAFT HUM TISS W20XH17.5XL50MM 1ST WDG TIB OSTEOTMY FRZ DRY,SUP-2113924,CDM,C1713,HCPCS,0278,RC,,,,both,,,4788.50,3112.52,,,,,,,,,,,,,
GRAFT HUM TISS BIDIR 3X2 CM GRID PAT AMNIO MEMBRN BIOVANCE,SUP-2651374,CDM,Q4154,HCPCS,0636,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
HC Assay of Selenium,PX-3018425500,CDM,84255,CPT,0301,RC,,,,both,,,744.00,483.60,,,,,,,,,,,,,
COLLAR CERV UNIV AD AIR VENT MIAMI OCCIAN,SUP-2276575,CDM,L0180,HCPCS,0272,RC,,,,both,,,373.44,242.74,,,,,,,,,,,,,
SUPPORT ORTHOT KNEE SINGLE UPR PREFABRICATED OFF THE SHLF,SUP-2435618,CDM,L1851,HCPCS,0274,RC,,,,both,,,2540.29,1651.19,,,,,,,,,,,,,
SET INT FIX SCREW DIA1.5 MM TI NEURO 2 Y SHP XLN PLATE 1 PK,SUP-2936670,CDM,C1713,HCPCS,0278,RC,,,,both,,,4034.90,2622.68,,,,,,,,,,,,,
ARTHROSCOPE VID L 180 MM PASSPRT CANN L 5 CM DIA 8 MM,SUP-2930477,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1763.90,1146.53,,,,,,,,,,,,,
SPACER SPNL ALLGRFT 9X16X14 MM CERV ANAT CORNERSTONE,SUP-2423141,CDM,C1713,HCPCS,0278,RC,,,,both,,,3108.60,2020.59,,,,,,,,,,,,,
TRAY VEN ACCS DIA9FR 3 LUMN ADV HF DEV,SUP-2272951,CDM,C1751,HCPCS,0278,RC,,,,both,,,304.05,197.63,,,,,,,,,,,,,
PIN FIX SINGLE DIAMOND 0.109X9 IN 3 SHANK END NS STEINMANN,SUP-2791601,CDM,C1713,HCPCS,0278,RC,,,,both,,,22.23,14.45,,,,,,,,,,,,,
CATHETER GRFT POS DIA26-45 MM POLYUR THOR TRILOBE DESIGN,SUP-2395623,CDM,C1725,HCPCS,0272,RC,,,,both,,,1563.72,1016.42,,,,,,,,,,,,,
CATHETER URET CONE TIP 10 FR POLYURETHANE,SUP-2129015,CDM,C1758,HCPCS,0278,RC,,,,both,,,46.88,30.47,,,,,,,,,,,,,
CATHETER ETER GUID L100CM OD65FR COR AL10 SHEATHLESS EAUCATHETER,SUP-2123837,CDM,C1725,HCPCS,0272,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
HC Dx Laryngoscopy Excl Nb,PX-4503152500,CDM,31525,CPT,0450,RC,,,,both,,,1754.00,1140.10,,,,,,,,,,,,,
GRAFT BNE WDG 12 DEG 12 MM LAPIDUS,SUP-2321728,CDM,C1713,HCPCS,0278,RC,,,,both,,,4914.73,3194.57,,,,,,,,,,,,,
CANNULA RF CRV 22 GAX10 CM,SUP-2308568,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
PROSTHESIS OSS VELEGRAKIS 0.8-0.6X4.5 MM PISTON PLAT,SUP-2651567,CDM,L8613,CPT,0278,RC,,,,both,,,584.17,379.71,,,,,,,,,,,,,
"HC Neuromuscular Re-Education, Ot|OP OCCUPATIONAL THERAPY SERV|SERVICES PROVIDED IN WHOLE OR IN PARTY BY AN OTA FOR MEDICARE PATIENTS",PX-4309711200,CDM,97112,CPT,0430,RC,,,GO|CO,both,,,159.00,103.35,,,,,,,,,,,,,
GRAFT BNE DIA10MM PAT LIG PRESHAPED DWL FLEXIGRFT,SUP-2264637,CDM,C1776,CPT,0278,RC,,,,both,,,9122.39,5929.55,,,,,,,,,,,,,
STENT URET 7FR L26CM NYL COAT DBL PGTL BRAID HYDRPHLC OPN,SUP-2312731,CDM,C2617,HCPCS,0278,RC,,,,both,,,176.15,114.50,,,,,,,,,,,,,
CANNULA IRRIGATION L32CM DIAMETER 10MM REUSABLE POOLE SUCTIO,SUP-2843213,CDM,2720000010,LOCAL,0272,RC,,,,both,,,519.80,337.87,,,,,,,,,,,,,
HC So1 Smear Afb,PX-3008720667,CDM,87206,CPT,0300,RC,,,,both,,,879.00,571.35,,,,,,,,,,,,,
GRAFT NRV L15MM DIA1-2MM PERIPH NAT CONN CBL PROC FOR RECON,SUP-2124846,CDM,C1763,HCPCS,0278,RC,,,,both,,,8499.98,5524.99,,,,,,,,,,,,,
PUNCH AORT L8IN DIA4MM S STL THERMOPLASTIC ROT CUT ACT,SUP-2330983,CDM,2720000010,LOCAL,0272,RC,,,,both,,,82.43,53.58,,,,,,,,,,,,,
PLATE BNE L 261 X W 11.4 MM THK 3.4 MM SCREW DIA2.7/3.5 MM 72464021N,SUP-2933312,CDM,C1713,HCPCS,0278,RC,,,,both,,,8861.87,5760.22,,,,,,,,,,,,,
ALLOGRAFT BNE SHFT FIB,SUP-2321802,CDM,C1713,HCPCS,0278,RC,,,,both,,,2439.78,1585.86,,,,,,,,,,,,,
ALLOGRAFT TISS DEHYDR 2X3 CM AMNIO MEMBRN AMBIO2,SUP-2242545,CDM,V2790,HCPCS,0278,RC,,,,both,,,1868.30,1214.39,,,,,,,,,,,,,
PLATE BNE MEDL STD 17 HOLE SYS IMPL INSTRUMENT AXIS,SUP-2610176,CDM,C1713,HCPCS,0278,RC,,,,both,,,7159.20,4653.48,,,,,,,,,,,,,
GRAFT HUM TISS W10-17XL10-17MM THK13-15MM TRICORT IL FRZ,SUP-2307142,CDM,C1762,CPT,0278,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
PROBE ABLAT 17GA L15CM MICWV LN,SUP-2219548,CDM,C1713,HCPCS,0278,RC,,,,both,,,6217.20,4041.18,,,,,,,,,,,,,
PROCHLORPERAZINE MALEATE 5 MG PO TABS,RX-6583,CDM,Q0164,HCPCS,0637,RC,59746-0113-06,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PROSTHESIS OSS EAR 0.6X4 MM,SUP-2312491,CDM,L8613,CPT,0278,RC,,,,both,,,153.86,100.01,,,,,,,,,,,,,
TRIAL SPNL H9MM ANT LAT LUM INTBDY FUS SPCR,SUP-2188389,CDM,C1713,HCPCS,0278,RC,,,,both,,,734.13,477.18,,,,,,,,,,,,,
SYSTEM VENTRICULAR DRAINAGE ANTIREFLX VLV W/ HERM VENT CATH,SUP-2883403,CDM,C1729,HCPCS,0272,RC,,,,both,,,619.90,402.93,,,,,,,,,,,,,
GUIDEWIRE VASC L 260 CM DIA 0.035 IN TAPR L 6 CM FLX TIP L 2,SUP-2167659,CDM,C1769,HCPCS,0272,RC,,,,both,,,36.68,23.84,,,,,,,,,,,,,
GRAFT BNE 10 CC FILL KT STRL OSTEOCRETE,SUP-2418808,CDM,C1713,HCPCS,0278,RC,,,,both,,,9291.26,6039.32,,,,,,,,,,,,,
PINSKULL REUSE AD,SUP-2160710,CDM,2720000010,LOCAL,0272,RC,,,,both,,,243.16,158.05,,,,,,,,,,,,,
SPACER SPNL 35 DEG 14X14 MM THORLUM UPPER ENDPLATE FORTIFYR,SUP-2231200,CDM,C1713,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
CRANIOPLASTIC RESINOUS 75PPM BONE SUB FOR REPAIRING CRAN,SUP-2243573,CDM,C1889,HCPCS,0278,RC,,,,both,,,4167.00,2708.55,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 20 CM DIA 6 MM STR STD WALL REINF,SUP-2681081,CDM,C1768,CPT,0278,RC,,,,both,,,491.91,319.74,,,,,,,,,,,,,
RASP SURG L10.5IN SATIN FINISH DBL END W/ FLAT TAPERING,SUP-2161317,CDM,2720000010,LOCAL,0272,RC,,,,both,,,312.15,202.90,,,,,,,,,,,,,
SPLINT WRST AND THMB UNIV,SUP-2336035,CDM,L3809,HCPCS,0272,RC,,,,both,,,37.55,24.41,,,,,,,,,,,,,
CAGE SPNL 7 MM BENGAL,SUP-2256273,CDM,C1889,HCPCS,0278,RC,,,,both,,,5341.14,3471.74,,,,,,,,,,,,,
SUPPORT ORTHOT FT LOWER EXTREMITY INSERT/PLATE PREPREG COMP,SUP-2435704,CDM,L3031,HCPCS,0274,RC,,,,both,,,346.72,225.37,,,,,,,,,,,,,
SUPPORT ORTHOT ANK KNEE CUST SINGLE UPR W/O KA PLAS,SUP-2435636,CDM,L2034,HCPCS,0274,RC,,,,both,,,5751.38,3738.40,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA IR 5FR 55CM 3 LUMA S3385355,SUP-2632851,CDM,C1751,HCPCS,0278,RC,,,,both,,,462.33,300.51,,,,,,,,,,,,,
DRILL SURG CANN 3/16 IN 3.8X150 MM SQ CONN SS MONSTER,SUP-2751470,CDM,2720000010,LOCAL,0272,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
BASEPLATE TIB UNI LT MEDL PRI PEG CEM JOURNEY SZ 1,SUP-2346435,CDM,C1776,CPT,0278,RC,,,,both,,,4264.12,2771.68,,,,,,,,,,,,,
GRAFT VASC TW 6 MMX100 CM RNG SFT WRP TUNN ATTCH ADVANTA VXT,SUP-2469020,CDM,C1768,CPT,0278,RC,,,,both,,,3441.25,2236.81,,,,,,,,,,,,,
IMPLANT HEARING 4MM TI ABUTMENT FOR FLNG FIX BAHA BA210,SUP-2164964,CDM,L8690,HCPCS,0278,RC,,,,both,,,7429.24,4829.01,,,,,,,,,,,,,
ELECTRODE ES RESECT W/ HF CBL PLSM OVL BTTN,SUP-2313592,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1936.16,1258.50,,,,,,,,,,,,,
RECON PLATE 14X166MM 3.5MM,SUP-2818476,CDM,C1713,HCPCS,0278,RC,,,,both,,,4644.85,3019.15,,,,,,,,,,,,,
TUBE TRACHEOSTOMY FENESTRATED ADULT 8MM 4 UNCUFFED ADAPTER O,SUP-2793418,CDM,2720000010,LOCAL,0272,RC,,,,both,,,419.38,272.60,,,,,,,,,,,,,
AXLE TIB CHROM ALLOY FOR ORTH SALV SYS TOT FINN,SUP-2406070,CDM,C1776,CPT,0278,RC,,,,both,,,1015.95,660.37,,,,,,,,,,,,,
HC Perq Dev Breast 1st Strtctc,PX-3611928300,CDM,19283,CPT,0361,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
ANCHOR NONSUTURE 16MM IMPLANT FIXATION MENISCAL BIOSTINGER,SUP-2824742,CDM,C1713,HCPCS,0278,RC,,,,both,,,331.46,215.45,,,,,,,,,,,,,
SET GUID RESECT FOR 25 TIB 3 L FEM HI PERF SIG TRUMATCH,SUP-2256962,CDM,C1776,CPT,0278,RC,,,,both,,,2041.00,1326.65,,,,,,,,,,,,,
TRAY HEMO DYLS OR HD CATH AD L72CM SLV ION ANTIMIC SL COILED,SUP-2174245,CDM,C1881,HCPCS,0278,RC,,,,both,,,1397.30,908.24,,,,,,,,,,,,,
GRAFT BIO W6XL10CM THK18 25MM PORCINE CLLGN RECT REGEN,SUP-2126237,CDM,C1781,HCPCS,0278,RC,,,,both,,,5778.86,3756.26,,,,,,,,,,,,,
PACK PROCEDURE UNIVERSAL STAPLE DYNACLIP,SUP-2878341,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1774.10,1153.16,,,,,,,,,,,,,
SAW SURG STD HUM DST SOLAR,SUP-2372593,CDM,C1713,HCPCS,0278,RC,,,,both,,,2090.74,1358.98,,,,,,,,,,,,,
KIT INTRO GLIDESHEATH L 10 CM OD 6FR ID 0.087IN 0.035IN,SUP-2384840,CDM,C1894,HCPCS,0272,RC,,,,both,,,144.75,94.09,,,,,,,,,,,,,
GRAFT VASC GORTX L 30 CM DIA10 MM RNG L 30 CM EPTFE STR TW,SUP-2396172,CDM,C1768,CPT,0278,RC,,,,both,,,2157.18,1402.17,,,,,,,,,,,,,
PLATE BONE L113MM 14 H LCK RECON BILAT RIG FOR 2.7MM SCR,SUP-2348299,CDM,C1713,HCPCS,0278,RC,,,,both,,,6502.78,4226.81,,,,,,,,,,,,,
EIUS UNI TIB MED 10MM RM/LL,SUP-2364891,CDM,C1776,CPT,0278,RC,,,,both,,,3857.49,2507.37,,,,,,,,,,,,,
BIT DRL L380MM DIA35MM W O STP CALIB JCBS CHK,SUP-2188816,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1601.31,1040.85,,,,,,,,,,,,,
SCREW BNE 3X28 MM,SUP-2365612,CDM,C1713,HCPCS,0278,RC,,,,both,,,82.64,53.72,,,,,,,,,,,,,
GUIDEWIRE VASC L180CM DIA0.014IN COR STR SHARPEABLE TIP,SUP-2385226,CDM,C1769,HCPCS,0272,RC,,,,both,,,331.27,215.33,,,,,,,,,,,,,
DEVICE FIX OD9-10MM LNG FEM ANCHR SFT TISS FOR ABV 50MM,SUP-2212830,CDM,C1776,CPT,0278,RC,,,,both,,,2240.20,1456.13,,,,,,,,,,,,,
CUTTER SURG OD46MM PAT KNEE DISP FOR RM SYS XCELERATE,SUP-2378569,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1193.99,776.09,,,,,,,,,,,,,
BURR 5.5MMX19CM POLISHING HIP PRESERVATION SYSTEM,SUP-2824500,CDM,2720000010,LOCAL,0272,RC,,,,both,,,697.08,453.10,,,,,,,,,,,,,
FIBER LASER 200 MH N TAPR POLISHED TIP HOLM ACCUMAX 5/BX,SUP-2537761,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1150.31,747.70,,,,,,,,,,,,,
GUIDEWIRE ORTH TROCAR PT 1 END 0.8X100 MM NS,SUP-2789081,CDM,C1769,HCPCS,0272,RC,,,,both,,,759.25,493.51,,,,,,,,,,,,,
GRAFT HUM TISS SM W10XL17CM THK0.7-1.4MM THN PERF FLEXHD,SUP-2307601,CDM,Q4128,HCPCS,0636,RC,,,,both,,,8896.25,5782.56,,,,,,,,,,,,,
SCREW BNE L45MM DIA5MM TI THRD LO PROF,SUP-2316343,CDM,C1713,HCPCS,0278,RC,,,,both,,,688.10,447.26,,,,,,,,,,,,,
HC Clsd Tx Fx Great Toe W Manip,PX-4502849500,CDM,28495,CPT,0450,RC,,,,both,,,2188.00,1422.20,,,,,,,,,,,,,
TIP LAPSCP L30.14CM ID1.98MM 23KHZ FLUE EXT NONSTERILE,SUP-2243955,CDM,C1713,HCPCS,0278,RC,,,,both,,,2785.18,1810.37,,,,,,,,,,,,,
SCREW BNE FIX 87341008] ZIMMER BIOMET INC],SUP-2137137,CDM,C1713,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
COIL NEUROVASCULAR ORBIT GALAXY G2 L 5 CM DIA 3.5 MM PRIMARY,SUP-2457746,CDM,C1889,HCPCS,0278,RC,,,,both,,,6542.13,4252.38,,,,,,,,,,,,,
BIOPSY KIT BNE LESION 11 GAX6 CM 13 GAX10.8 CM TREK,SUP-2754745,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
GUIDEPIN ORTH L 450 MM DIA2.4 MM THRD TIP STRL DISP TRIGEN,SUP-2933356,CDM,C1713,HCPCS,0278,RC,,,,both,,,810.50,526.82,,,,,,,,,,,,,
GUIDEPIN SURG L29MM FEM TIB PREFERRED PT SPEC CR-FLEX DISP,SUP-2201249,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
PANITUMUMAB 100 MG/5ML IV SOLN,RX-104364,CDM,J9303,HCPCS,0636,RC,55513-0954-01,NDC,,both,5,ML,5217.60,3391.44,,,,,,,,,,,,,
CANNULA ENDOSCOPIC RIGHT CURVE CROSSBOW,SUP-2824972,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1044.80,679.12,,,,,,,,,,,,,
CUBE EXT FIX 1 H RANCHO W/ POST FOR ILIZ TAY SPAT FRME SYS,SUP-2342987,CDM,C1713,HCPCS,0278,RC,,,,both,,,1129.99,734.49,,,,,,,,,,,,,
PROSTHESIS VOICE LO PRESSURE 16 FRX10 MM BLOM-SINGER,SUP-2238267,CDM,L8613,CPT,0278,RC,,,,both,,,266.90,173.48,,,,,,,,,,,,,
SCREW BONE L45MM DIA6.5MM 5.5MM ROD VAR ANG TI PEDCL CANN,SUP-2414591,CDM,C1713,HCPCS,0278,RC,,,,both,,,4282.96,2783.92,,,,,,,,,,,,,
CAGE SPINALXL W26XH10XL60MM X W ANTR CERV INTBDY FUS PEEK,SUP-2310684,CDM,C1889,HCPCS,0278,RC,,,,both,,,9420.00,6123.00,,,,,,,,,,,,,
ANCHOR SUT NO 2 SUT TI DURABRAID W/ TWO 38 5MM DIA TWINFIX,SUP-2341650,CDM,C1713,HCPCS,0278,RC,,,,both,,,772.44,502.09,,,,,,,,,,,,,
MONITOR CARD JOT DX L 9.4 X H 49 MM THK 3.1 MM 1.4 ML 3 GM,SUP-2754048,CDM,C1764,HCPCS,0278,RC,,,,both,,,14758.00,9592.70,,,,,,,,,,,,,
BIT DRL L 135 MM DIA2.7 MM SCREW DIA2.7 MM AO QC DBL CLR BND,SUP-2908230,CDM,2720000010,LOCAL,0272,RC,,,,both,,,766.54,498.25,,,,,,,,,,,,,
CATHETER INTVASC ULTRASOUND SOUNDSTAR ECO L 90 CM DIA10 FR,SUP-2912452,CDM,C1759,HCPCS,0272,RC,,,,both,,,3157.43,2052.33,,,,,,,,,,,,,
KIT CATH 7FR L6IN CTRL VEN POLYUR 3 LUMN BLU FLEXTIP W/,SUP-2383291,CDM,C1751,HCPCS,0278,RC,,,,both,,,82.27,53.48,,,,,,,,,,,,,
SCREW BONE L64MM DIA4.5MM THRD L18MM CORT S STL ST SELF DRL,SUP-2184443,CDM,C1713,HCPCS,0278,RC,,,,both,,,62.83,40.84,,,,,,,,,,,,,
ELECTRODE ELECSURG MED 12-30 DEG CUT ANGLED LOOP PLASMALOOP,SUP-2313588,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1593.55,1035.81,,,,,,,,,,,,,
PLATE BNE THK0.6MM MIC 4 H TI L FOR 1.5MM SCR OSTEOSYN LEV,SUP-2262689,CDM,C1713,HCPCS,0278,RC,,,,both,,,260.62,169.40,,,,,,,,,,,,,
LINER ACET OD44MM ID28MM 0DEG HIP ULTAMET REV LOK RNG,SUP-2250321,CDM,C1776,CPT,0278,RC,,,,both,,,5537.08,3599.10,,,,,,,,,,,,,
LEAD NEUROSTIMULATOR L50CM SPNL CRD PERC W/ ENH STYL IMAG,SUP-2141904,CDM,C1778,HCPCS,0278,RC,,,,both,,,5702.24,3706.46,,,,,,,,,,,,,
SUPPORT LO PROF LUM LSO VISTA 631,SUP-2123915,CDM,L0631,HCPCS,0272,RC,,,,both,,,629.41,409.12,,,,,,,,,,,,,
GRAFT IMPL HUM TISS FRZN ALLGRFT FIB CORT STRUT BNE 150MM,SUP-2307372,CDM,C1713,HCPCS,0278,RC,,,,both,,,4717.98,3066.69,,,,,,,,,,,,,
CANNULA SURGICAL L250MM UTERINE SELF RETAINING WITH SPRING C,SUP-2809560,CDM,2720000010,LOCAL,0272,RC,,,,both,,,858.57,558.07,,,,,,,,,,,,,
RING EXT FIX MED 160 MM SET RX STRUT STRL TRUELOK EVO LTX,SUP-2875586,CDM,2720000010,LOCAL,0272,RC,,,,both,,,29376.65,19094.82,,,,,,,,,,,,,
PLATE BNE L260MM 11 H NONSTERILE R PROX LAT TIB S STL LOK,SUP-2184883,CDM,C1713,HCPCS,0278,RC,,,,both,,,4072.89,2647.38,,,,,,,,,,,,,
LEAD NEUROSTIMULATOR L50CM DIA1MM 5MM SPC 4 ELECTRD PERC FLX,SUP-2357677,CDM,C1778,HCPCS,0278,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
DEFIBRILLATOR CRD SINGLE CHMBR 51X63X12 MM 30 CC GALLANT VR,SUP-2707580,CDM,C1722,HCPCS,0275,RC,,,,both,,,40091.52,26059.49,,,,,,,,,,,,,
SCREW BNE L75MM DIA4MM CORT S STL ST NONCANNULATED,SUP-2183709,CDM,C1713,HCPCS,0278,RC,,,,both,,,137.66,89.48,,,,,,,,,,,,,
CAGE SPNL 10 DEG 31X24X10 MM MERID,SUP-2710944,CDM,C1889,HCPCS,0278,RC,,,,both,,,18290.50,11888.82,,,,,,,,,,,,,
BAR EXT FIX L200MM DIA6MM SACR S STL THRD,SUP-2187004,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1851.44,1203.44,,,,,,,,,,,,,
BLADE SAW MIC OSC AND SAG CUT EDGE .347IN THICKNESS .020IN,SUP-2367315,CDM,2720000010,LOCAL,0272,RC,,,,both,,,91.06,59.19,,,,,,,,,,,,,
GRAFT VASC GELWEAVE L 20 CM DIA26 MM SIDE BRANCH L 15 MM DIA,SUP-2384999,CDM,C1768,CPT,0278,RC,,,,both,,,2535.80,1648.27,,,,,,,,,,,,,
SCREW BONE L85MM DIA4MM CANC T20 FULL THRD SM FRAG PLATING,SUP-2350007,CDM,C1713,HCPCS,0278,RC,,,,both,,,508.65,330.62,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP L150CM DIA0025IN TIP L3CM PTFE FLX STR FIX,SUP-2141738,CDM,C1769,HCPCS,0272,RC,,,,both,,,39.60,25.74,,,,,,,,,,,,,
GUIDEWIRE ORTH 2.4MM FLX PIN W/ SUT EYE,SUP-2120934,CDM,C1769,HCPCS,0272,RC,,,,both,,,486.70,316.35,,,,,,,,,,,,,
SHAFT DRVR CANN T10 HEXALOBE,SUP-2122472,CDM,C1713,HCPCS,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
SCREW SPNL L20MM OD2MM NONLOCKING,SUP-2402828,CDM,C1713,HCPCS,0278,RC,,,,both,,,354.82,230.63,,,,,,,,,,,,,
NAIL IM L140MM DIA7MM HUM TI CANN LOK RG BENT T2,SUP-2369206,CDM,C1713,HCPCS,0278,RC,,,,both,,,5102.50,3316.62,,,,,,,,,,,,,
GALILEO TROCH NAIL TRAY 10MMX130 DEGREE,SUP-2816339,CDM,C1713,HCPCS,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
WAND ARTHSCP 90DEG SHFT DIA425MM ABLAT SUCT W INTEGR CBL,SUP-2342007,CDM,2720000010,LOCAL,0272,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
BEARING TIB CR 12X63/67 MM,SUP-2409223,CDM,C1776,CPT,0278,RC,,,,both,,,879.20,571.48,,,,,,,,,,,,,
INSERT HUM CONSTRN 6+ 39X42 MM COMBINATION UNIVERS REVERS,SUP-2845816,CDM,C1776,CPT,0278,RC,,,,both,,,3187.10,2071.61,,,,,,,,,,,,,
PATCH CV PERICARD TISS STRL,SUP-2321867,CDM,C1713,HCPCS,0278,RC,,,,both,,,2150.90,1398.08,,,,,,,,,,,,,
SUPPORT LO PROF LUM LSO VISTA 631,SUP-2123915,CDM,L0631,HCPCS,0274,RC,,,,both,,,629.41,409.12,,,,,,,,,,,,,
ROD EXT FIX 60MM GRAD TELSCP FOR ILIZ FIX SYS,SUP-2340703,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2385.77,1550.75,,,,,,,,,,,,,
DRESSING BIO L 6 X W 9 CM PORCINE CLLGN PHMB CROSS LINKED,SUP-2909399,CDM,C1763,HCPCS,0278,RC,,,,both,,,11190.96,7274.12,,,,,,,,,,,,,
GRAFT HUM TISS L PERF THCK REGENERATIVE TISS MTRX CNTOUR,SUP-2113437,CDM,Q4116,HCPCS,0636,RC,,,,both,,,39906.26,25939.07,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED FRAC ENDO HD,SUP-2212722,CDM,C1776,CPT,0278,RC,,,,both,,,4059.36,2638.58,,,,,,,,,,,,,
IMPLANT ANK JT L16MM OD10MM TI SUBTALAR SFT THRD CANN CONIC,SUP-2851519,CDM,C1776,CPT,0278,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
IMPLANT TOE L13MM DIA2MM S STL CANN COMPR HAMRTOE FIX SYS,SUP-2397840,CDM,C1776,CPT,0278,RC,,,,both,,,2072.40,1347.06,,,,,,,,,,,,,
IMPLANT OP RM MINI-MONSTER 4.0X40MM HDLSS CANN LNG THRD SCR,SUP-2320928,CDM,C1713,HCPCS,0278,RC,,,,both,,,785.79,510.76,,,,,,,,,,,,,
PLATE BNE L 60 MM RT DORS DSTL RADIAL WIDE LNG NS VARIAX 2,SUP-2902285,CDM,C1713,HCPCS,0278,RC,,,,both,,,4838.55,3145.06,,,,,,,,,,,,,
ROD SPNL L240MM DIA3.5MM POST CERVICOTHORACIC TI RECON,SUP-2289081,CDM,C1713,HCPCS,0278,RC,,,,both,,,596.60,387.79,,,,,,,,,,,,,
GRAFT EVAR L9.5CM DIA16MM IL LIMB EXCLUDER,SUP-2395948,CDM,C1768,CPT,0278,RC,,,,both,,,11294.58,7341.48,,,,,,,,,,,,,
PLATE BONE W12XL71MM 4 H SEMI TBLR ECT,SUP-2198536,CDM,C1713,HCPCS,0278,RC,,,,both,,,142.12,92.38,,,,,,,,,,,,,
PLATE BNE EIGHT 16 MM TI STRL GUID GROWTH,SUP-2646457,CDM,C1713,HCPCS,0278,RC,,,,both,,,1766.25,1148.06,,,,,,,,,,,,,
RING EXT FIX OPN 120 MM ALUM HOFFMANN,SUP-2460473,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3762.98,2445.94,,,,,,,,,,,,,
INTRODUCER LD 7 FR,SUP-2356645,CDM,C1894,HCPCS,0272,RC,,,,both,,,138.16,89.80,,,,,,,,,,,,,
JIG DISTAL RADIAL VOLAR LAT COLUMN PLATE RT,SUP-2724613,CDM,C1713,HCPCS,0278,RC,,,,both,,,745.18,484.37,,,,,,,,,,,,,
BIT DRL 1.1X15 MM 8 MM W/ STP FOR 90 DEG SCREWDRIVER NS LTX,SUP-2859719,CDM,2720000010,LOCAL,0272,RC,,,,both,,,958.33,622.91,,,,,,,,,,,,,
DEVICE DCOMPR M COR BONE POST FUS EXP STATIC AILERON,SUP-2264538,CDM,2780000010,LOCAL,0278,RC,,,,both,,,9420.00,6123.00,,,,,,,,,,,,,
GUIDEWIRE VASC SHORTY L 180 CM DIA 0.016 IN TAPR L 6 CM FLPY,SUP-2168622,CDM,C1769,HCPCS,0272,RC,,,,both,,,168.40,109.46,,,,,,,,,,,,,
CATHETER NEPHSTMY 8FR L25CM PERCFLX GLDEX KT PGTL TIP RADPQ,SUP-2147789,CDM,C1729,HCPCS,0272,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
STEM FEM CONE 125 DEG 135 DEG HIP WAGNER,SUP-2448641,CDM,C1776,CPT,0278,RC,,,,both,,,210932.64,137106.22,,,,,,,,,,,,,
COVER BUR H 14MM W TAB,SUP-2365223,CDM,C1713,HCPCS,0278,RC,,,,both,,,1040.25,676.16,,,,,,,,,,,,,
GRAFT BNE CUBE 6X6X6 MM DBM CANC CONFORM FLX Q-PACK,SUP-2307018,CDM,C1713,HCPCS,0278,RC,,,,both,,,579.33,376.56,,,,,,,,,,,,,
HC So Assay of Hydroxyindolacetic Acid 5-Hiaa,PX-3018349766,CDM,83497,CPT,0301,RC,,,,inpatient,,,324.00,210.60,,,,,,,,,,,,,
GRAFT BNE SYR 10 CC DBM ACCELL CONNEXUS,SUP-2641755,CDM,C1713,HCPCS,0278,RC,,,,both,,,4125.96,2681.87,,,,,,,,,,,,,
CATHETER URET WVN OLV TIP 6 FR 70 CM,SUP-2126411,CDM,C1729,HCPCS,0272,RC,,,,both,,,227.56,147.91,,,,,,,,,,,,,
CATHETER VENTRICULAR EXT 1.5X28 MMX35 CM ANGLED ADPT STRIPE,SUP-2631751,CDM,C1729,HCPCS,0272,RC,,,,both,,,599.11,389.42,,,,,,,,,,,,,
AGENT HEMSTAT 10ML MTRX W/ MALL TRIM TIP FLOSEAL,SUP-2129982,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1062.64,690.72,,,,,,,,,,,,,
SCREW BONE L5MM OD2MM SLV TI CRANIOMAXILLOFACIAL MIDFACE ST,SUP-2135918,CDM,C1713,HCPCS,0278,RC,,,,both,,,147.27,95.73,,,,,,,,,,,,,
CATHETER ABLATN LG CURL 2-5-2 4 MM 7 FRX115 CM LIVEWIRE TC,SUP-2460148,CDM,C1733,HCPCS,0272,RC,,,,both,,,2172.88,1412.37,,,,,,,,,,,,,
CATHETER CV DL 5 FR PWR INJ N COAT CT COMPATIBLE POWERPICC,SUP-2126707,CDM,C1751,HCPCS,0278,RC,,,,both,,,549.78,357.36,,,,,,,,,,,,,
HC So Cbc W/O Diff|NOT REASONABLE AND NECESSARY,PX-3058502766,CDM,85027,CPT,0305,RC,,,GZ,both,,,79.00,51.35,,,,,,,,,,,,,
PLATE BNE 11 H NONSTERILE NAVICULAR S STL LO PROF VAR ANG,SUP-2184811,CDM,C1713,HCPCS,0278,RC,,,,both,,,3654.52,2375.44,,,,,,,,,,,,,
CATHETER NEPHROSTOMY 63FR 20CML FLEXIMA PIGTAIL TIP,SUP-2722033,CDM,C1729,HCPCS,0272,RC,,,,both,,,47.48,30.86,,,,,,,,,,,,,
PLATE BNE FIBULAR 3.5X147 MM LT LAT DSTL 11 HOLE EVOS,SUP-2349745,CDM,C1713,HCPCS,0278,RC,,,,both,,,5132.17,3335.91,,,,,,,,,,,,,
FORCEPS BX L50CM OD5.4FR ENDOMYOCARD CVD LO PROF OVL SHP CUP,SUP-2355656,CDM,C1713,HCPCS,0278,RC,,,,both,,,533.80,346.97,,,,,,,,,,,,,
ENDO FUSE  FUSION ROD 7 X 60MM,SUP-2474082,CDM,C1713,HCPCS,0278,RC,,,,both,,,6518.64,4237.12,,,,,,,,,,,,,
MESH HERN 30X30CM MACROPOROUS PARIETENE,SUP-2172437,CDM,C1781,HCPCS,0278,RC,,,,both,,,325.84,211.80,,,,,,,,,,,,,
SUPPORT ORTHOT ANK KNEE CUST SINGLE SLD STIRRUP W/O JT,SUP-2435633,CDM,L2010,HCPCS,0274,RC,,,,both,,,2470.33,1605.71,,,,,,,,,,,,,
KIT TKR KNEE CRUCE RET CEM HI DEMAND INSRT VERILAST LEGION,SUP-2348030,CDM,C1776,CPT,0278,RC,,,,both,,,10676.00,6939.40,,,,,,,,,,,,,
PLATE HOLDER FOR MINIMALLY INVASIVE PLATING,SUP-2548451,CDM,C1713,HCPCS,0278,RC,,,,both,,,3981.11,2587.72,,,,,,,,,,,,,
GRAFT VASC 4-7 MMX40 CM 25 CM DVAG,SUP-2395724,CDM,C1768,CPT,0278,RC,,,,both,,,3545.06,2304.29,,,,,,,,,,,,,
SYSTEM HIP CEM BPLR,SUP-2212083,CDM,C1776,CPT,0278,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
PIN FIX 2X50 MM STRL INION FREEDOMPIN LTX DISP,SUP-2857895,CDM,C1713,HCPCS,0278,RC,,,,both,,,606.02,393.91,,,,,,,,,,,,,
HEAD FEM SZ 2 DIA48MM FEM HIP M SPECIFICATION MTL 12 14 ARTC,SUP-2251167,CDM,C1776,CPT,0278,RC,,,,both,,,5635.04,3662.78,,,,,,,,,,,,,
STYLET PACE L 80 CM DIA 0.016 IN STR STD STEER WHT KNOB/CAP,SUP-2148812,CDM,C1713,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
CATHETER EP LG CRV 2-5-2 MM 6 FRX110 CM QPLR 81404] ST JUDE MEDICAL INC],SUP-2357435,CDM,C1730,HCPCS,0272,RC,,,,both,,,973.40,632.71,,,,,,,,,,,,,
GRAFT OPHTH W1XL4CM EYELID SPCR 12 LAYR TARSYS,SUP-2261522,CDM,C1763,HCPCS,0278,RC,,,,both,,,1178.00,765.70,,,,,,,,,,,,,
HC J Tube Plcmt,PX-3614944100,CDM,49441,CPT,0361,RC,,,,inpatient,,,8583.00,5578.95,,,,,,,,,,,,,
COMPONENT FEM KNEE CRUC RET LT UNISX PRI CEM STEMLESS PC,SUP-2199586,CDM,C1776,CPT,0278,RC,,,,both,,,17365.46,11287.55,,,,,,,,,,,,,
BOOT WALKING PREFORTED FT GTT,SUP-2265019,CDM,L4387,HCPCS,0274,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
WEDGE TIB 28X12 MM TUBEROSITY ADV,SUP-2564492,CDM,C1776,CPT,0278,RC,,,,both,,,191.70,124.60,,,,,,,,,,,,,
BURR SURG 3MM DIA HD XLN 95MML SM BNE RND DIAMOND FLUTEX8 MI,SUP-2605840,CDM,2720000010,LOCAL,0272,RC,,,,both,,,335.04,217.78,,,,,,,,,,,,,
INSERT TIB CD 1-2 ARTC SURF KNEE,SUP-2198760,CDM,C1776,CPT,0278,RC,,,,both,,,3576.46,2324.70,,,,,,,,,,,,,
TAP SURG L30MM DIA4.5MM CANN THRD TELLURIDE FOR MIS SPNL,SUP-2211176,CDM,2720000010,LOCAL,0272,RC,,,,both,,,659.40,428.61,,,,,,,,,,,,,
GRAFT BNE SUB 5CC SZ 17 7MM DEMIN CANC CHIP FRZ DRY FOR,SUP-2307252,CDM,C1713,HCPCS,0278,RC,,,,both,,,720.63,468.41,,,,,,,,,,,,,
EXPEL NEPH 10.3/25,SUP-2652775,CDM,C1729,HCPCS,0272,RC,,,,both,,,295.16,191.85,,,,,,,,,,,,,
STENT GRFT VASC POWERLINK INTUITRAK L 65 MM 20/25 MM FLARED,SUP-2217560,CDM,C1874,HCPCS,0278,RC,,,,both,,,8933.30,5806.64,,,,,,,,,,,,,
BIOCOM SWIVELOCK BICEPS TENO 7X23,SUP-2812251,CDM,C1713,HCPCS,0278,RC,,,,both,,,1365.90,887.83,,,,,,,,,,,,,
SILTUXIMAB 100 MG IV SOLR,RX-125988,CDM,J2860,HCPCS,0636,RC,73090-0420-01,NDC,,both,1,UN,4694.40,3051.36,,,,,,,,,,,,,
BIT DRL PILOT TIP LNG 5 MM IM PROX W/ STP SS NS M/DN,SUP-2467232,CDM,2720000010,LOCAL,0272,RC,,,,both,,,807.26,524.72,,,,,,,,,,,,,
DRILL SURG 4.5/5.5 MM SUTURE ANCHR,SUP-2857744,CDM,2720000010,LOCAL,0272,RC,,,,both,,,248.06,161.24,,,,,,,,,,,,,
MAND ANGLE PLATE TSLCKNG LT X LNG 3 X 3 23MM SSTM T 6L 4V,SUP-2707237,CDM,C1713,HCPCS,0278,RC,,,,both,,,1516.97,986.03,,,,,,,,,,,,,
PUNCH OPHTH DIA9MM DONOR CORNEAL CYL DEL SHRP NONVACUUM,SUP-2261438,CDM,2720000010,LOCAL,0272,RC,,,,both,,,190.91,124.09,,,,,,,,,,,,,
FERRIC DERISOMALTOSE(ONE DOSE) 1000 MG/10ML IV SOLN,RX-151770,CDM,J1437,HCPCS,0636,RC,73594-9310-01,NDC,,both,5,ML,5387.00,3501.55,,,,,,,,,,,,,
BASEPLATE TIB L74XW50MM SZ 2 M DURAC KNEE CRUCFRM NONBEADED,SUP-2377170,CDM,C1776,CPT,0278,RC,,,,both,,,3291.72,2139.62,,,,,,,,,,,,,
PUSHER KNOT 32CM 5MM ULTRA INSTR LATEX FREE PVC FREE DEHP FR,SUP-2679943,CDM,2720000010,LOCAL,0272,RC,,,,both,,,521.18,338.77,,,,,,,,,,,,,
SYSTEM DEL CARDPLG TRILLIUM SURF MYOTHERM XP,SUP-2473482,CDM,2720000010,LOCAL,0272,RC,,,,both,,,341.95,222.27,,,,,,,,,,,,,
CLOSURE TOP2102-2,SUP-2415298,CDM,C1713,HCPCS,0278,RC,,,,both,,,656.26,426.57,,,,,,,,,,,,,
CATHETER DRNGE L170CM OD3FR 0.018IN GRN ENDOSCP PUSH DISP,SUP-2169520,CDM,C1894,HCPCS,0272,RC,,,,both,,,119.32,77.56,,,,,,,,,,,,,
STENT COLON HANAROSTENT LOWAX L 90 MM DIA25 MM DEL SYS L RED,SUP-2418532,CDM,C1876,HCPCS,0278,RC,,,,both,,,9843.90,6398.53,,,,,,,,,,,,,
WAND PULSE LAVAGE 40 DEG 40 DEG NOZ CARBOJET DISP,SUP-2262259,CDM,2720000010,LOCAL,0272,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
CONNECTOR SPNL L40MM-55MM M CROSS POST ADJ TI CLMP,SUP-2415666,CDM,C1713,HCPCS,0278,RC,,,,both,,,1145.13,744.33,,,,,,,,,,,,,
SHUNT SURG SM ASSY 22017BLL,SUP-2628146,CDM,C1729,HCPCS,0272,RC,,,,both,,,3130.74,2034.98,,,,,,,,,,,,,
PLATE BNE FEM 100 DEG 5 MM 14 MM PROX 4 HOLE SS STRL JPS,SUP-2645598,CDM,C1713,HCPCS,0278,RC,,,,both,,,10977.44,7135.34,,,,,,,,,,,,,
SHEATH INTRO PRELUDE PRESTIGE L 13 CM DIA10.5 FR 12 CC SYR,SUP-2458288,CDM,C1892,HCPCS,0272,RC,,,,both,,,45.72,29.72,,,,,,,,,,,,,
GUIDEWIRE UROLOGICAL ZIPWIRE L 150 CM DIA 0.035 IN TAPR TIP,SUP-2488003,CDM,C1769,HCPCS,0272,RC,,,,both,,,126.67,82.34,,,,,,,,,,,,,
SHEATH INTRO FLX ANSEL L 70 CM OD 8 FR ID 2.87 MM GUIDEWIRE,SUP-2633293,CDM,C1894,HCPCS,0272,RC,,,,both,,,299.56,194.71,,,,,,,,,,,,,
PLATE BNE RECON 3.5 MM PELV 11 HOLE INTLOK,SUP-2518368,CDM,C1713,HCPCS,0278,RC,,,,both,,,3727.18,2422.67,,,,,,,,,,,,,
PLATE BONE NEURO RECT,SUP-2402915,CDM,C1713,HCPCS,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
GRAFT HUM TISS W4XL4CM CRYOPRESERVED AMNIO MEM LO PROF FOR,SUP-2116286,CDM,Q4148,HCPCS,0636,RC,,,,both,,,4380.30,2847.19,,,,,,,,,,,,,
GRAFT HUM TISS DIA16 MM AMNION PLCNTA MEMBRN 2 LAYR PROTCT,SUP-2913281,CDM,C1762,CPT,0278,RC,,,,both,,,3482.26,2263.47,,,,,,,,,,,,,
CHLORZOXAZONE 500 MG PO TABS,RX-1664,CDM,6370000000,HCPCS,0637,RC,00591-2520-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
HEAD RAD DIA18MM CO CHROM W/ LOK SCR ALIGN,SUP-2340136,CDM,C1776,CPT,0278,RC,,,,both,,,6751.00,4388.15,,,,,,,,,,,,,
VALVE SHUNT L23.7MM 25CM H2O PRSS TI 2 CONN GRAVITATIONAL,SUP-2108717,CDM,C1729,HCPCS,0272,RC,,,,both,,,4341.65,2822.07,,,,,,,,,,,,,
PLATE PERIARTICULAR PROX HUM 3.5MM 12H 271MM RT SS LCP STRL,SUP-2546056,CDM,C1713,HCPCS,0278,RC,,,,both,,,6193.68,4025.89,,,,,,,,,,,,,
SEALANT FIBRIN 4 CC FRZN PRE FILLED SYR TISSEEL,SUP-2130314,CDM,2720000010,LOCAL,0272,RC,,,,both,,,850.44,552.79,,,,,,,,,,,,,
IMPLANT CRANIALXL PEEK PRIORITY CUSTOMIZED,SUP-2365151,CDM,C1763,HCPCS,0278,RC,,,,both,,,64879.06,42171.39,,,,,,,,,,,,,
INSERT TIB SM THK11MM STD UNIV KNEE DUR MTL PRI NEUT,SUP-2376454,CDM,C1776,CPT,0278,RC,,,,both,,,3617.28,2351.23,,,,,,,,,,,,,
PIN FIX L9IN DIA2.4MM NONSTERILE S STL 3 SIDE SGL TRCR 1,SUP-2150449,CDM,C1713,HCPCS,0278,RC,,,,both,,,51.84,33.70,,,,,,,,,,,,,
IMMOBILIZER KNEE SIZED CANVS 19 IN 2XL,SUP-2336067,CDM,L1830,CPT,0274,RC,,,,both,,,39.66,25.78,,,,,,,,,,,,,
CLAMP SURG PARL CONN 7.5 MM 4.75 TO 5.5-6.5 MM DBL CREO,SUP-2584168,CDM,C1713,HCPCS,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
BLADE SHV DIA4MM ENT MICRODEBRIDER AGG,SUP-2366838,CDM,2720000010,LOCAL,0272,RC,,,,both,,,298.36,193.93,,,,,,,,,,,,,
ENALAPRIL MALEATE 2.5 MG PO TABS,RX-9925,CDM,6370000000,HCPCS,0637,RC,23155-0704-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
HC Custom Wrist/Hand Static,PX-2740390601,CDM,L3906,HCPCS,0274,RC,,,,inpatient,,,1403.00,911.95,,,,,,,,,,,,,
COMPONENT FEM KNEE UNI UNISX PRI CEM STEMLESS N POR N BEAD,SUP-2208918,CDM,C1776,CPT,0278,RC,,,,both,,,7470.06,4855.54,,,,,,,,,,,,,
GRAFT VASC EXXCEL SFT L 60 CM DIA 6 MM SUPP L 60 CM EPTFE,SUP-2227648,CDM,C1768,CPT,0278,RC,,,,both,,,2228.93,1448.80,,,,,,,,,,,,,
GRAFT HUM TISS W4XL6CM AMNIO TISS MEM WRP AMNIOFIX,SUP-2305761,CDM,V2790,HCPCS,0278,RC,,,,both,,,7824.88,5086.17,,,,,,,,,,,,,
PLATE BNE NONBIOABSORBABLE NS,SUP-2635378,CDM,C1713,HCPCS,0278,RC,,,,both,,,3600.32,2340.21,,,,,,,,,,,,,
SPACER SPNL 22-34MM COR DIA12MM FOR MINI SELF EXP VBR SYS,SUP-2310548,CDM,C1821,HCPCS,0278,RC,,,,both,,,11304.00,7347.60,,,,,,,,,,,,,
HC Vasc Embolize Occlude Venous,PX-3613724100,CDM,37241,CPT,0361,RC,,,,both,,,12876.00,8369.40,,,,,,,,,,,,,
SPHINCTEROTOME ENDOSCP 3.9X0.25X20 MM JAGWIRE TRUETOME,SUP-2417749,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1238.95,805.32,,,,,,,,,,,,,
BIT DRL SELF CNTR SL ANGLED TIP FOR 4MM SCR ELLIPSE,SUP-2598932,CDM,2720000010,LOCAL,0272,RC,,,,both,,,580.90,377.58,,,,,,,,,,,,,
CATHETER ANGIOPLASTY OTW 0.018 IN 130CM 5X120MM  018 DCB,SUP-2757488,CDM,C1725,HCPCS,0272,RC,,,,both,,,3673.80,2387.97,,,,,,,,,,,,,
SET NDL 15GA L15MM STBL KT FOR IO VASC ACCS SYS EZ-IO,SUP-2383215,CDM,2720000010,LOCAL,0272,RC,,,,both,,,484.19,314.72,,,,,,,,,,,,,
HC Repair Blood Vessel Direct Hand Finger,PX-4503520700,CDM,35207,CPT,0450,RC,,,,both,,,8262.00,5370.30,,,,,,,,,,,,,
DRILL SURGICAL 4.5MM PROXIMAL CANNULATED,SUP-2878971,CDM,2720000010,LOCAL,0272,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
HC Ewhfo W/Joint(S) Cf (Non-Pmm),PX-2740376601,CDM,L3766,HCPCS,0272,RC,,,,both,,,4512.00,2932.80,,,,,,,,,,,,,
PLATE BNE STR WRST FUSION NS,SUP-2610352,CDM,C1713,HCPCS,0278,RC,,,,both,,,3309.47,2151.16,,,,,,,,,,,,,
CATHETER DRNGE 10FR L25CM SGL LUMN SFT LOOP GLDEX COAT,SUP-2139736,CDM,C1729,HCPCS,0272,RC,,,,both,,,253.49,164.77,,,,,,,,,,,,,
DRIVER SURG DIA1.7MM SQ REUSE,SUP-2136621,CDM,2720000010,LOCAL,0272,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
PLATE BNE L 95 MM SCREW DIA2.4 MM 5 HD 10 SHFT H TI Y SHP,SUP-2908020,CDM,C1713,HCPCS,0278,RC,,,,both,,,3064.58,1991.98,,,,,,,,,,,,,
CALIBRATED DRILL 4.4MM,SUP-2487831,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1183.72,769.42,,,,,,,,,,,,,
RING EXT FIX DIA200MM FULL FOR TRUELOK RNG FIX SYS,SUP-2316174,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3682.06,2393.34,,,,,,,,,,,,,
LINER ACET 28X52 MM HIP LIP PROF OPT POLYETH DURALOC ENDRN,SUP-2433912,CDM,C1776,CPT,0278,RC,,,,both,,,2108.82,1370.73,,,,,,,,,,,,,
TISSUE T00246 ILIUMTRICORTSTRIP22MMX50MM,SUP-2281640,CDM,C1762,CPT,0278,RC,,,,both,,,6886.02,4475.91,,,,,,,,,,,,,
CATHETER URET 3FR L70CM POLYVINYLCHLORIDE CLOSE END RT,SUP-2168867,CDM,C1758,HCPCS,0278,RC,,,,both,,,62.80,40.82,,,,,,,,,,,,,
CUP FEM OD39XID22MM BPLR,SUP-2359148,CDM,C1776,CPT,0278,RC,,,,both,,,2204.28,1432.78,,,,,,,,,,,,,
BACLOFEN 25 MG/5ML PO SUSP,RX-157483,CDM,2500000003,HCPCS,0250,RC,52536-0600-11,NDC,,both,1,ML,22.40,14.56,,,,,,,,,,,,,
SCREW BNE LCK FOR IM NAIL RACK,SUP-2789519,CDM,C1713,HCPCS,0278,RC,,,,both,,,2115.07,1374.80,,,,,,,,,,,,,
GRAFT VASC GELWEAVE L 45 CM DIA18 MM LEG DIA 9 MM POLYESTER,SUP-2384996,CDM,C1768,CPT,0278,RC,,,,both,,,1603.60,1042.34,,,,,,,,,,,,,
SK SLM CP ENC 4X7MM GRFT,SUP-2243077,CDM,C1713,HCPCS,0278,RC,,,,both,,,3545.06,2304.29,,,,,,,,,,,,,
PLATE BNE L 114 MM 5 H SS PROX HUM STR STRL EVOS,SUP-2931130,CDM,C1713,HCPCS,0278,RC,,,,both,,,5462.03,3550.32,,,,,,,,,,,,,
SCREW BNE CANN 6.5X30 MM SD FT SS,SUP-2409889,CDM,C1713,HCPCS,0278,RC,,,,both,,,673.22,437.59,,,,,,,,,,,,,
HC Vasc Embolize Occlude Bleed,PX-3613724400,CDM,37244,CPT,0361,RC,,,,inpatient,,,11772.00,7651.80,,,,,,,,,,,,,
ALLOGRAFT BNE SPACER 7 28X26X14 MM ALIF CORTICAL ALLOQUENT,SUP-2736914,CDM,C1713,HCPCS,0278,RC,,,,both,,,13878.80,9021.22,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.452,SUP-2860016,CDM,C1713,HCPCS,0278,RC,,,,both,,,63333.17,41166.56,,,,,,,,,,,,,
BRACE ORTH 2X UPR KNEE,SUP-2388161,CDM,L1845,HCPCS,0274,RC,,,,both,,,2397.89,1558.63,,,,,,,,,,,,,
HC Vasc Embolize Occlude Bleed,PX-3613724400,CDM,37244,CPT,0361,RC,,,,outpatient,,,11772.00,7651.80,,,,,,,,,,,,,
BUR SURG BALL 4 MM 12 CM PROX BEND MIDAS REX 8 SD/SP,SUP-2664945,CDM,2720000010,LOCAL,0272,RC,,,,both,,,995.25,646.91,,,,,,,,,,,,,
CATHETER INTVASC OCCL L 100 CM DIA 7 FR BALLOON DIA11.5 MM,SUP-2147466,CDM,C2628,HCPCS,0272,RC,,,,both,,,675.10,438.81,,,,,,,,,,,,,
ROD EXT FIX L335MM DIA16MM S STL THRD CANN BLNT TIP,SUP-2187862,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1522.87,989.87,,,,,,,,,,,,,
GRAFT HUM TISS DIA12MM AMNIO MEMBRN DISK AMNIOEXCEL,SUP-2194314,CDM,Q4137,HCPCS,0636,RC,,,,both,,,846.23,550.05,,,,,,,,,,,,,
SCREW BNE L25MM DIA6MM CORT ST NONCANNULATED NONLOCKING FULL,SUP-2377551,CDM,C1713,HCPCS,0278,RC,,,,both,,,608.53,395.54,,,,,,,,,,,,,
BUTTON SUTURE CLOSURE,SUP-2936918,CDM,C1713,HCPCS,0278,RC,,,,both,,,166.42,108.17,,,,,,,,,,,,,
SHELL ACET PRESSFIT PRI 40 MM OD UNIV SPIK NO H CERAMIC,SUP-2210214,CDM,C1776,CPT,0278,RC,,,,both,,,5469.88,3555.42,,,,,,,,,,,,,
HC Rep Cpx Face H Ft 2.6-7.5cm,PX-4501313200,CDM,13132,CPT,0450,RC,,,,both,,,1842.00,1197.30,,,,,,,,,,,,,
KIT INTELLIS SENSOR MRI PERC,SUP-2882877,CDM,2720000010,LOCAL,0272,RC,,,,both,,,81696.52,53102.74,,,,,,,,,,,,,
SCREW BNE 6.5X85 MM RECON T25 STARDRV RECESS TI NS,SUP-2188991,CDM,C1713,HCPCS,0278,RC,,,,both,,,520.83,338.54,,,,,,,,,,,,,
ASSEMBLY SHUNT SNAP NEONATAL 1.5 LT RESERVOIR DOME NDL DELT,SUP-2664458,CDM,C1889,HCPCS,0278,RC,,,,both,,,5038.10,3274.76,,,,,,,,,,,,,
GRAFT VASC DYNAFLO L 80 CM DIA 7 MM EPTFE CARBON PERIPH STR,SUP-2126824,CDM,C1768,CPT,0278,RC,,,,both,,,6369.80,4140.37,,,,,,,,,,,,,
SHELL ACET SZ 48MM GRP 1 UNIV BRN TI CLUS H PRI REV,SUP-2222500,CDM,C1776,CPT,0278,RC,,,,both,,,9420.00,6123.00,,,,,,,,,,,,,
COMPONENT FEM SZ 7 STD LT KNEE CO CHROM CEM CRUC RET COR SET,SUP-2206280,CDM,C1776,CPT,0278,RC,,,,both,,,21543.32,14003.16,,,,,,,,,,,,,
CAP ORTH LCK 4 MM SM STAT T25 STARDRV COCR DAYTONA,SUP-2709418,CDM,C1713,HCPCS,0278,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
CROWN DENT 5 UP RT 1ST PERM M S STL GLD PREFABRICATED REPL,SUP-2238805,CDM,D6783,CPT,0278,RC,,,,both,,,26.91,17.49,,,,,,,,,,,,,
HC Glb Harvest Auto Stem Cells,PX-9823820600,CDM,38206,CPT,0982,RC,,,,both,,,5037.00,3274.05,,,,,,,,,,,,,
TUBE VENT 1.14 MM 0.93 MM 2.8 MM REUT BOB HOLE MYRINGOTOMY,SUP-2478009,CDM,L8699,HCPCS,0278,RC,,,,both,,,43.99,28.59,,,,,,,,,,,,,
SUPPORT ORTHOT FNGR W/NONTORSION JT FABRICATED SFT INTFACE,SUP-2435790,CDM,L3935,HCPCS,0272,RC,,,,both,,,569.22,369.99,,,,,,,,,,,,,
COMPONENT FEM M R KNEE REV CEM CRUCE RET STEM BEAD VIT AND,SUP-2377065,CDM,C1776,CPT,0278,RC,,,,both,,,6191.58,4024.53,,,,,,,,,,,,,
SPACER ORTH HUM 9X20 MM ADJ REVERSED AEQUALIS,SUP-2715380,CDM,C1776,CPT,0278,RC,,,,both,,,7364.87,4787.17,,,,,,,,,,,,,
BIT DRILL 4.8MM DIA 11INL JACOBS CHUCK END DISPOSABLE,SUP-2588690,CDM,2720000010,LOCAL,0272,RC,,,,both,,,552.42,359.07,,,,,,,,,,,,,
CABLE CATHETER ELECTROPHYSIOLOGY 243CM 4-PIN CONNECTOR YELLOW,SUP-2281834,CDM,C1713,HCPCS,0278,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
INQUIRY 1107 5 25170 L1 CATHETER,SUP-2699065,CDM,C1730,HCPCS,0272,RC,,,,both,,,1720.72,1118.47,,,,,,,,,,,,,
SPLINT THMB M L5IN SH RT 1 STRP THERMOPLASTIC INSRT,SUP-2324196,CDM,L3931,HCPCS,0272,RC,,,,both,,,42.23,27.45,,,,,,,,,,,,,
GRAFT BNE WDG 100X10-12 MM FIB PUROS,SUP-2335233,CDM,C1713,HCPCS,0278,RC,,,,both,,,10713.68,6963.89,,,,,,,,,,,,,
TRANSDUCER PRSS CBL L48IN WNG HSNG M SWVL NUT FEM FIX LUER,SUP-2303074,CDM,C1713,HCPCS,0278,RC,,,,both,,,36.24,23.56,,,,,,,,,,,,,
LEAD PACING UFM 1 ORANGE AND 1 WHITE,SUP-2850072,CDM,C1898,HCPCS,0275,RC,,,,both,,,85.57,55.62,,,,,,,,,,,,,
DEXTROSE 10 % IV SOLN NEONATE,RX-40840075,CDM,2580000003,HCPCS,0258,RC,63323-0824-76,NDC,,both,1000,ML,51.00,33.15,,,,,,,,,,,,,
ELECTRODE ES 90DEG SUCT INTEGR HNDPC DISP COOLPULSE 90 VAPR,SUP-2249483,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1004.80,653.12,,,,,,,,,,,,,
PLATE BNE M L150MM THK4MM VIT TROCHANTERIC GRP LO PROF W/ 2,SUP-2377571,CDM,C1713,HCPCS,0278,RC,,,,both,,,3546.94,2305.51,,,,,,,,,,,,,
MEMANTINE HCL 5 MG PO TABS,RX-37170,CDM,6370000000,HCPCS,0637,RC,00904-6505-61,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
GRAFT BNE CHIP FRZ DRY CANC CORT 1MM 8MM RANG 90CC READIGRFT,SUP-2264697,CDM,C1713,HCPCS,0278,RC,,,,both,,,2926.86,1902.46,,,,,,,,,,,,,
SCREW BNE L14MM DIA2MM HND 316L S STL ST VAR ANG LOK T6,SUP-2178026,CDM,C1713,HCPCS,0278,RC,,,,both,,,375.04,243.78,,,,,,,,,,,,,
STAPLER INT 45MM OPN 4X3.5MM B SHP CLSR 1.5MM BLU TI LIN 7,SUP-2283414,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1255.69,816.20,,,,,,,,,,,,,
PATCH DURAL SUB 5X5CM ONLAY LYCOPLANT,SUP-2714085,CDM,C1763,HCPCS,0278,RC,,,,both,,,865.54,562.60,,,,,,,,,,,,,
KIT HAD 145FR CATHETER L55CM INSRT L50CM STR POLYUR CATHETER,SUP-2126477,CDM,C1750,HCPCS,0278,RC,,,,both,,,1374.85,893.65,,,,,,,,,,,,,
WEDGE PAT TRAD ALLGRFT 13 - 15 MM FRZ DRY,SUP-2294119,CDM,C1713,HCPCS,0278,RC,,,,both,,,2895.08,1881.80,,,,,,,,,,,,,
SET INTRO SUP ARW FLX SHTH L 90 CM DIA 6 FR HYDRPHLC,SUP-2383406,CDM,C1894,HCPCS,0272,RC,,,,both,,,163.03,105.97,,,,,,,,,,,,,
BIT DRL TWST 1.4X54 MM 12 MM 5 HOLE JCBS CHK END W/ STP,SUP-2366407,CDM,2720000010,LOCAL,0272,RC,,,,both,,,394.07,256.15,,,,,,,,,,,,,
DISSECTOR SURG MIC 2 MM 7 IN RHOTON RUGGLES-REDMOND,SUP-2473178,CDM,2720000010,LOCAL,0272,RC,,,,both,,,274.56,178.46,,,,,,,,,,,,,
BIT SCRDRVR L24MM DIA2X2.4MM CANN DISP,SUP-2390534,CDM,2720000010,LOCAL,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
STENT BILI C FLX L 15 CM DIA10 FR PLAS DBL PIGTL AD GRA STRL,SUP-2141398,CDM,C2617,HCPCS,0278,RC,,,,both,,,216.66,140.83,,,,,,,,,,,,,
EVOS RADIAL SHAFT PLATE 16H 193MM,SUP-2820203,CDM,C1713,HCPCS,0278,RC,,,,both,,,7035.80,4573.27,,,,,,,,,,,,,
PLATE BNE THK 1.4 MM SCREW DIA2.2 MM 8 H MAXILLOFCL STR,SUP-2909644,CDM,C1713,HCPCS,0278,RC,,,,both,,,690.58,448.88,,,,,,,,,,,,,
PLATE CRAN 140X40X40 MM PT SPEC IMPL PEEK,SUP-2860126,CDM,C1713,HCPCS,0278,RC,,,,both,,,26279.29,17081.54,,,,,,,,,,,,,
RESERVOIR 75ML W/ LCK OUT VLV TI,SUP-2165356,CDM,C1813,HCPCS,0278,RC,,,,both,,,4144.80,2694.12,,,,,,,,,,,,,
SURFACE ARTC SZ 3-4/EF H20MM PROLONG HXLPE UNIV PRI POST,SUP-2402782,CDM,C1776,CPT,0278,RC,,,,both,,,2926.48,1902.21,,,,,,,,,,,,,
KIT INTRO STIFFEN FLUENT L 10 CM DIA 5 FR GUIDEWIRE L 40 CM,SUP-2164808,CDM,C1894,HCPCS,0272,RC,,,,both,,,130.47,84.81,,,,,,,,,,,,,
TRAY HAD FULL SHT TERM 3 LUMN 15.5FRX24CM T-3,SUP-2266987,CDM,C1752,HCPCS,0278,RC,,,,both,,,449.02,291.86,,,,,,,,,,,,,
BUTTON SUT L PEC FOR FIX OF SFT TISS TO BONE,SUP-2121668,CDM,C1713,HCPCS,0278,RC,,,,both,,,1365.90,887.83,,,,,,,,,,,,,
CONNECTOR SPNL L120MM OD5.5MM S STL THORLUM LO PROF CLOSE,SUP-2230998,CDM,C1713,HCPCS,0278,RC,,,,both,,,920.02,598.01,,,,,,,,,,,,,
COMPONENT FEM CEM KNEE FIX BEAR ATTUNE,SUP-2249621,CDM,C1776,CPT,0278,RC,,,,both,,,10990.00,7143.50,,,,,,,,,,,,,
PLATE BNE L SHT 4X0.7 MM 3X3 HOLE REVERSIBLE OBLQ TI NS LF,SUP-2181815,CDM,C1713,HCPCS,0278,RC,,,,both,,,1046.25,680.06,,,,,,,,,,,,,
MESH SURG W62XL82IN POLYPR EXP PTFE SYN ABD NONABSORBABLE,SUP-2125820,CDM,C1781,HCPCS,0278,RC,,,,both,,,2793.66,1815.88,,,,,,,,,,,,,
SCREW BONE L10MM DIA2.7MM CORT GLD TI FOR MINI FRAG SYS,SUP-2189692,CDM,C1713,HCPCS,0278,RC,,,,both,,,99.00,64.35,,,,,,,,,,,,,
HC Stab Phlebectomy >20,PX-3613776600,CDM,37766,CPT,0361,RC,,,,both,,,15457.00,10047.05,,,,,,,,,,,,,
FORCEPS SURG L7 3 4IN TISS HEMSTAT INSUL LOVELACE,SUP-2161919,CDM,2720000010,LOCAL,0272,RC,,,,both,,,509.28,331.03,,,,,,,,,,,,,
MISOPROSTOL 100 MCG PO TABS,RX-10628,CDM,6370000000,HCPCS,0637,RC,59762-5007-01,NDC,,both,1,UN,3.00,1.95,,,,,,,,,,,,,
DEVICE FIX BIOABSORBABLE 3 MM SFT TISS FOREHEAD ULTRATINE,SUP-2760662,CDM,C1713,HCPCS,0278,RC,,,,both,,,863.81,561.48,,,,,,,,,,,,,
STOP DRL 2 MM PENNIG DYN WRST FIX,SUP-2644603,CDM,2720000010,LOCAL,0272,RC,,,,both,,,92.69,60.25,,,,,,,,,,,,,
BUR SURG DIAMOND 3 MM,SUP-2521573,CDM,2720000010,LOCAL,0272,RC,,,,both,,,659.40,428.61,,,,,,,,,,,,,
SCREW BONE SELFTAPPING 4X50 MM CORTICAL HUMERAL TITANIUM NON,SUP-2837140,CDM,C1713,HCPCS,0278,RC,,,,both,,,1099.53,714.69,,,,,,,,,,,,,
HC Drain/Inj Joint/Bursa W/US Large|BILATERAL PROCEDURE,PX-5102061100,CDM,20611,CPT,0510,RC,,,50,outpatient,,,3707.00,2409.55,,,,,,,,,,,,,
CATHETER EP 6FR L110CM 1MM TIP 2-5-2MM SPC L CRV DECAPOLAR,SUP-2357622,CDM,C1730,HCPCS,0272,RC,,,,both,,,1513.48,983.76,,,,,,,,,,,,,
CATHETER IV SINGLE LEMEN 4 FR DOT KT MBP PC POWERMIDLINE,SUP-2626734,CDM,C1751,HCPCS,0278,RC,,,,both,,,480.42,312.27,,,,,,,,,,,,,
CATHETER PERF 154CM 2.8FRX.026IN PROX WRK POS CONT ASPIR,SUP-2323621,CDM,C1757,HCPCS,0272,RC,,,,both,,,4553.00,2959.45,,,,,,,,,,,,,
KIT INTRO VSI L 12 CM DIA 6 FR NIT MANDREL SS TIP SIL,SUP-2763485,CDM,C1892,HCPCS,0272,RC,,,,both,,,116.18,75.52,,,,,,,,,,,,,
SCREW BNE AD PED L11MM DIA2MM STD CRANIOMAXILLOFACIAL TI ST 256721191] KLS MARTIN LP],SUP-2262796,CDM,C1713,HCPCS,0278,RC,,,,both,,,162.24,105.46,,,,,,,,,,,,,
PLATE BONE L166MM THK4.5MM 7 H LT LAT TIB HD BTTRS TI RIG,SUP-2190895,CDM,C1713,HCPCS,0278,RC,,,,both,,,2685.27,1745.43,,,,,,,,,,,,,
KIT GUID INTRO L63CM DIA8.5FR GWIRE 0.032IN TRANSSEPTAL 407358] ST JUDE MEDICAL INC],SUP-2357230,CDM,C1894,HCPCS,0272,RC,,,,both,,,558.92,363.30,,,,,,,,,,,,,
SUTURE NONABSORBABLE SZ 0 L24IN DBL ARMED CL V 20 SC 6 D/A 8886258963,SUP-2174189,CDM,C1713,HCPCS,0278,RC,,,,both,,,103.62,67.35,,,,,,,,,,,,,
PLATE BNE PATELLAR 2.7 MM LAT RIM VA LCK TI STRL,SUP-2789408,CDM,C1713,HCPCS,0278,RC,,,,both,,,7486.39,4866.15,,,,,,,,,,,,,
HC Peripheral Block - Tap Bilateral Injection,PX-3606448800,CDM,64488,CPT,0360,RC,,,,both,,,1238.00,804.70,,,,,,,,,,,,,
PLATE BNE 110 DEG PEDIATRIC 3.5X73 MM 19/12 MM 3 HOLE LCP,SUP-2799195,CDM,C1713,HCPCS,0278,RC,,,,both,,,2364.99,1537.24,,,,,,,,,,,,,
SUPPORT ORTH CLOSED POPLITEAL 15.5-18 IN SM KNEE DLX,SUP-2336342,CDM,L1810,HCPCS,0272,RC,,,,both,,,51.15,33.25,,,,,,,,,,,,,
CATHETER HAD L28CM DIA16FR HYDRPHLC TIP BASIC CHRONIC SGL,SUP-2117395,CDM,C1750,HCPCS,0278,RC,,,,both,,,1083.30,704.14,,,,,,,,,,,,,
THIAMINE HCL 100 MG/ML IJ SOLN,RX-7876,CDM,J3411,HCPCS,0636,RC,63323-0013-01,NDC,,both,0.5,ML,54.10,35.16,,,,,,,,,,,,,
HEAD FEM UPLR 40 MM HIP FOR ADPT,SUP-2207898,CDM,C1776,CPT,0278,RC,,,,both,,,1127.57,732.92,,,,,,,,,,,,,
ANTENNA ABLAT L20CM STD PERC W/ THERMOSPHERE TECHNOLOGY,SUP-2283238,CDM,C1886,HCPCS,0278,RC,,,,both,,,10010.32,6506.71,,,,,,,,,,,,,
CATHETER ULTRASOUND ACUNAV L 90 CM DIA 8 FR FOR GE SYS,SUP-2525937,CDM,C1759,HCPCS,0272,RC,,,,both,,,2582.78,1678.81,,,,,,,,,,,,,
GRAFT BNE SUB 2.5ML SIL SOD CA PHOS OXIDE FOAM PK RECT CONT,SUP-2368190,CDM,C1713,HCPCS,0278,RC,,,,both,,,1224.60,795.99,,,,,,,,,,,,,
COIL NEUROVASCULAR GDC-10 L 6 CM DIA 4 MM 3D HELCL STRL,SUP-2365673,CDM,C1889,HCPCS,0278,RC,,,,both,,,4929.17,3203.96,,,,,,,,,,,,,
PLATE BNE SIDE L 25 X W 25 MM THK 0.5 MM SCREW DIA1.7 MM PLL,SUP-2883325,CDM,C1713,HCPCS,0278,RC,,,,both,,,2820.91,1833.59,,,,,,,,,,,,,
PLATE BNE RECON 2.7X3 MM 34 HOLE ANGLED-ANGLED LCK TI STRL,SUP-2539591,CDM,C1713,HCPCS,0278,RC,,,,both,,,9818.12,6381.78,,,,,,,,,,,,,
NIPPER NAIL 5IN S STL,SUP-2227916,CDM,C1713,HCPCS,0278,RC,,,,both,,,345.05,224.28,,,,,,,,,,,,,
STAPLER INT SHFT L 20 CM DIA 5 MM LEG L 2 MM LN L 25 MM CUT,SUP-2903963,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2276.50,1479.72,,,,,,,,,,,,,
MATRIX WND SM AMNIO FLD CVR NUCEL,SUP-2309716,CDM,C1713,HCPCS,0278,RC,,,,both,,,2076.51,1349.73,,,,,,,,,,,,,
IMPLANT NSL L 30 X H 28 MM THK 7 MM LG POLYETHYL RT,SUP-2883382,CDM,C1889,HCPCS,0278,RC,,,,both,,,1503.18,977.07,,,,,,,,,,,,,
SIDECUTTING BUR LNG TAPERED QTY 5,SUP-2605575,CDM,2720000010,LOCAL,0272,RC,,,,both,,,70.93,46.10,,,,,,,,,,,,,
COLLAR EXTRIC AD SHT TWO PC TRACH OPN VELC CLSR W/ CHIN,SUP-2194467,CDM,L0180,HCPCS,0274,RC,,,,both,,,54.10,35.16,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.403,SUP-2859967,CDM,C1713,HCPCS,0278,RC,,,,both,,,30484.06,19814.64,,,,,,,,,,,,,
GUIDEWIRE VASC L 60 CM DIA 0.032 IN STR TIP STRL,SUP-2214527,CDM,C1769,HCPCS,0272,RC,,,,both,,,25.50,16.57,,,,,,,,,,,,,
RING EXT FIX FULL 240 MM ALUM NS MAXFRAME,SUP-2799530,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3540.07,2301.05,,,,,,,,,,,,,
REAMER SURG DIA6.6MM FOR INTOSS FIX IOFIX PLUSX-POST,SUP-2223758,CDM,2720000010,LOCAL,0272,RC,,,,both,,,932.58,606.18,,,,,,,,,,,,,
NAIL IM RT HINDFOOT FUSION W/ 2M POST BOW STRL TRIGEN,SUP-2931389,CDM,C1713,HCPCS,0278,RC,,,,both,,,8388.98,5452.84,,,,,,,,,,,,,
PLATE BNE L 231 X W 10.7 MM THK 3.4 MM SCREW DIA 3.5 MM 20 H,SUP-2936314,CDM,C1713,HCPCS,0278,RC,,,,both,,,3645.07,2369.30,,,,,,,,,,,,,
TIGERTAPE STERNAL CLOSURE WITH CUTTING NDL,SUP-2814145,CDM,C1713,HCPCS,0278,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
ANVIL F/BROAD PLATES,SUP-2548475,CDM,C1713,HCPCS,0278,RC,,,,both,,,645.27,419.43,,,,,,,,,,,,,
CATHETER ENDO M-110S TIP SINUS GUID RELIEVA,SUP-2106356,CDM,C1887,HCPCS,0272,RC,,,,both,,,981.25,637.81,,,,,,,,,,,,,
SET PMP CYL L22CM 0DEG BIOFLX SIL SCROT PENILE SYS INFL TCH,SUP-2165447,CDM,C1813,HCPCS,0278,RC,,,,both,,,37680.00,24492.00,,,,,,,,,,,,,
POST ORTH MOD TRABECULAR MTL ALLIANCE,SUP-2450139,CDM,C1776,CPT,0278,RC,,,,both,,,1116.27,725.58,,,,,,,,,,,,,
GUIDEPIN ORTH L343MM DIA3.2MM FOR TRIGEN INTERTAN PROX LOK,SUP-2347058,CDM,2720000010,LOCAL,0272,RC,,,,both,,,986.84,641.45,,,,,,,,,,,,,
HEPARIN NA (PORK) LOCK FLSH PF 100 UNIT/ML IV SOLN,RX-162828,CDM,J1642,HCPCS,0636,RC,64253-0333-35,NDC,,both,1,ML,54.10,35.16,,,,,,,,,,,,,
BLADE ENDOSCP SHAVER L 13 CM SPD 15000 RPM ENT SET PWR,SUP-2902116,CDM,2720000010,LOCAL,0272,RC,,,,both,,,679.24,441.51,,,,,,,,,,,,,
GRAFT VASC IMPRA CARBOFLO L 30 CM DIA 8 MM EPTFE CARBON FLX,SUP-2761439,CDM,C1768,CPT,0278,RC,,,,both,,,2233.33,1451.66,,,,,,,,,,,,,
DEVICE THROMCTMY MINDFRAME CAPTURE LP L 20 MM DIA 3 X 15 MM,SUP-2278033,CDM,C1887,HCPCS,0272,RC,,,,both,,,23942.50,15562.62,,,,,,,,,,,,,
MOST FEMORAL SEGMENT 55MM,SUP-2509221,CDM,C1776,CPT,0278,RC,,,,both,,,7276.95,4730.02,,,,,,,,,,,,,
GRAFT HERN 20X30CM DERM PORCINE TISS RECON PERF STRATTICE,SUP-2113040,CDM,Q4130,HCPCS,0636,RC,,,,both,,,59405.66,38613.68,,,,,,,,,,,,,
FIBER LASER FLEXIVA PULSE TRACTIP 242 EACH,SUP-2716207,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1533.36,996.68,,,,,,,,,,,,,
CATHETER IV 4FR POLYUR SGL LUMN PWR INJ DST TRIM MAX BARR,SUP-2125693,CDM,C1751,HCPCS,0278,RC,,,,both,,,470.18,305.62,,,,,,,,,,,,,
RING EXT FIX HALF 180 MM ALUM NS MAXFRAME,SUP-2757974,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3464.27,2251.78,,,,,,,,,,,,,
HC Incision Labial Frenum Frenotomy,PX-3614080600,CDM,40806,CPT,0361,RC,,,,both,,,1991.00,1294.15,,,,,,,,,,,,,
HC Assay of Thyroxine Total,PX-3018443600,CDM,84436,CPT,0301,RC,,,,both,,,149.00,96.85,,,,,,,,,,,,,
ENDCAP ORTH DIA12MM EXTN 0MM GRN FEM TI FOR 9-12MM NAIL,SUP-2192361,CDM,C1713,HCPCS,0278,RC,,,,both,,,622.85,404.85,,,,,,,,,,,,,
BALLOON EUSTACHIAN TUBE L 16 MM DIA 6 MM PLAS AD ATRAUM TIP,SUP-2902104,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3280.20,2132.13,,,,,,,,,,,,,
BELT MOD SM MED 14 V,SUP-2356010,CDM,C1713,HCPCS,0278,RC,,,,both,,,1083.30,704.14,,,,,,,,,,,,,
NUCELXL 2.5 CC OR ML BIOACTIVE AMNIO SUSP,SUP-2314104,CDM,C1713,HCPCS,0278,RC,,,,both,,,10895.80,7082.27,,,,,,,,,,,,,
PLATE BNE THK06MM CHIN INSRT GRIFFIN MOD LINDORF CP TI SYS,SUP-2262500,CDM,C1713,HCPCS,0278,RC,,,,both,,,614.84,399.65,,,,,,,,,,,,,
SCREW BONE SELF TAPPING 2X6 MM TITANIUM MATRIXMANDIBLE,SUP-2837725,CDM,C1713,HCPCS,0278,RC,,,,both,,,254.09,165.16,,,,,,,,,,,,,
HC So Dna Antibody Single Strand,PX-3028622666,CDM,86226,CPT,0302,RC,,,,both,,,48.00,31.20,,,,,,,,,,,,,
COMPONENT FEM SZ 3 RT POST STBL PRI STEMLESS NP UNISX PROFIX,SUP-2347021,CDM,C1776,CPT,0278,RC,,,,both,,,8164.00,5306.60,,,,,,,,,,,,,
HUMERAL NAIL 11/9.5MMX30CM,SUP-2818964,CDM,C1713,HCPCS,0278,RC,,,,both,,,8756.68,5691.84,,,,,,,,,,,,,
"HC Tracheostomy, Emergency Procedure",PX-3603160500,CDM,31605,CPT,0360,RC,,,,both,,,743.00,482.95,,,,,,,,,,,,,
PACK NEUROSURGICAL MYRIAD HNDPC L 13 CM DIA13 GA S3,SUP-2930306,CDM,2720000010,LOCAL,0272,RC,,,,both,,,46266.36,30073.13,,,,,,,,,,,,,
CATHETER KIT MICROCATHETER 180 CM 10 CM TIP 135 CM RENEGADE,SUP-2141042,CDM,C1887,HCPCS,0272,RC,,,,both,,,2060.34,1339.22,,,,,,,,,,,,,
SNARE VASC MIC ELITE L 180 CM DIA 0.014 IN LOOP DIA 7 MM,SUP-2763474,CDM,C1773,HCPCS,0272,RC,,,,both,,,8738.62,5680.10,,,,,,,,,,,,,
RELOAD STPLR REINF 60 MM X THCK W/ TRISTAPLE TECHNOLOGY BLK,SUP-2174668,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1701.88,1106.22,,,,,,,,,,,,,
CATHETER BLLN DIL 16-17-18 MM FIX EZDILATE BD400P1880A,SUP-2865616,CDM,C1726,HCPCS,0272,RC,,,,both,,,14758.00,9592.70,,,,,,,,,,,,,
TRASTUZUMAB-QYYP 420 MG IV SOLR,RX-149179,CDM,Q5116,HCPCS,0636,RC,00069-0305-01,NDC,,both,1,UN,9766.40,6348.16,,,,,,,,,,,,,
KIT CUTTING S17 DISP BIO UNI,SUP-2741103,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2543.40,1653.21,,,,,,,,,,,,,
FORCEPS BPLR L33CM DISECT TWO TIER JAW DSGN W/ SERR SURF,SUP-2313946,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1212.04,787.83,,,,,,,,,,,,,
CATH BLLN ANGIO 2X8MM NC EUPHORIA RX,SUP-2281201,CDM,C1725,HCPCS,0272,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
MESH SURG W5XL15CM SILK BIOABSRB MULTIFILAMENT KNIT,SUP-2113412,CDM,C1713,HCPCS,0278,RC,,,,both,,,10990.00,7143.50,,,,,,,,,,,,,
POLATUZUMAB VEDOTIN-PIIQ 140 MG IV SOLR,RX-146596,CDM,J9309,HCPCS,0636,RC,50242-0105-01,NDC,,both,1,UN,53600.90,34840.58,,,,,,,,,,,,,
FLUTICASONE PROPIONATE 0.005 % EX OINT,RX-10083,CDM,6370000000,HCPCS,0637,RC,45802-0221-35,NDC,,both,15,GR,83.10,54.01,,,,,,,,,,,,,
DANTROLENE SODIUM 25 MG PO CAPS,RX-9718,CDM,6370000000,HCPCS,0637,RC,68084-0300-11,NDC,,both,1,UN,7.40,4.81,,,,,,,,,,,,,
SUPPORT ORTHOT THGH LOWER EXTREMITY NAR M-L BRIM CUST FIT,SUP-2435676,CDM,L2526,HCPCS,0274,RC,,,,both,,,1813.22,1178.59,,,,,,,,,,,,,
PLATE BNE 8 H CORT WRST TI STD BEND SM FRAG SYS FOR,SUP-2191033,CDM,C1713,HCPCS,0278,RC,,,,both,,,3545.94,2304.86,,,,,,,,,,,,,
PIN FIX POLY LACTIC ACID ANTR CRUC LIGMNT SFT TISS CRV KT,SUP-2256610,CDM,C1713,HCPCS,0278,RC,,,,both,,,1519.76,987.84,,,,,,,,,,,,,
RIGHTADIOLUCENT TARIGHTGET ARIGHTM CALC PLATE RIGHT XS,SUP-2811174,CDM,C1713,HCPCS,0278,RC,,,,both,,,6578.30,4275.89,,,,,,,,,,,,,
SPLINT ARM MP LG,SUP-2274800,CDM,L3809,HCPCS,0274,RC,,,,both,,,40.73,26.47,,,,,,,,,,,,,
WASHER ORTH SQ FOR HUM NAILING SYS T2,SUP-2369201,CDM,C1713,HCPCS,0278,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
STENT URET L28CM OD8FR HYDR+ TAPR TIP DBL PGTL THRD POS W/O,SUP-2139650,CDM,C2617,HCPCS,0278,RC,,,,both,,,406.94,264.51,,,,,,,,,,,,,
PLATE BNE W10.2XL260MM THK2.7MM 20 H BILAT S STL STR LO,SUP-2186205,CDM,C1713,HCPCS,0278,RC,,,,both,,,2419.75,1572.84,,,,,,,,,,,,,
STENT BILI SYM L 40 MM DIA 7 FR CATH L 110 CM DIA 6 MM NIT,SUP-2141180,CDM,C1876,HCPCS,0278,RC,,,,both,,,3723.41,2420.22,,,,,,,,,,,,,
KIT PRCTNS NPHRSTMY 10FR CATH PGTL C FLEX GDWRE 038X150CM D,SUP-2727446,CDM,C1729,HCPCS,0272,RC,,,,both,,,350.96,228.12,,,,,,,,,,,,,
FOIL DENTAL 262MMW X 262MML 03MM THK RESORB X LATEX FREE,SUP-2669264,CDM,C1713,HCPCS,0278,RC,,,,both,,,1327.97,863.18,,,,,,,,,,,,,
GRAFT BNE SUB 20CC SYN TISS MTRX EXT BLK MASTERGRFT,SUP-2288546,CDM,C9362,HCPCS,0278,RC,,,,both,,,4939.22,3210.49,,,,,,,,,,,,,
SCREW BNE NLCK 2X5 MM SELF DRILLING CROSS DRV TI NS,SUP-2754967,CDM,C1713,HCPCS,0278,RC,,,,both,,,229.22,148.99,,,,,,,,,,,,,
CUTTER VITRCTMY 20GA HI SPD FOR WHITESTAR SIGN SYS,SUP-2247709,CDM,2720000010,LOCAL,0272,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
SCREW SPNL ROD DIA 4.75/5 MM SS PEDCL REDUCTION UNIAXIAL,SUP-2926861,CDM,C1713,HCPCS,0278,RC,,,,both,,,3155.70,2051.20,,,,,,,,,,,,,
ANCHOR SUT L12.5MM DIA2.9MM SH HIP BIOCOMP PEEK EYELET,SUP-2121756,CDM,C1713,HCPCS,0278,RC,,,,both,,,1318.80,857.22,,,,,,,,,,,,,
NAIL IM L205MM DIA7.5MM 120DEG UNIV HUM TI BENT SLD RG AND,SUP-2192484,CDM,C1713,HCPCS,0278,RC,,,,both,,,5211.40,3387.41,,,,,,,,,,,,,
VALVE CSF PROGRAMMABLE STD MINI W/O ANTECHAMBER IMPL SYS,SUP-2666621,CDM,C1889,HCPCS,0278,RC,,,,both,,,9286.05,6035.93,,,,,,,,,,,,,
SCREW BNE OD35MM L26MM 27MM HD CORT PERIARTC ST ST,SUP-2207948,CDM,C1713,HCPCS,0278,RC,,,,both,,,115.93,75.35,,,,,,,,,,,,,
HC So Hepatitis Be Antigen,PX-3068735066,CDM,87350,CPT,0306,RC,,,,inpatient,,,106.00,68.90,,,,,,,,,,,,,
PIN PROV 27MM TARGETER,SUP-2343984,CDM,C1713,HCPCS,0278,RC,,,,both,,,625.11,406.32,,,,,,,,,,,,,
DILTIAZEM HCL 125 MG/25ML IV SOLN,RX-97167,CDM,J1163,HCPCS,0636,RC,00641-6015-10,NDC,,both,1,ML,54.10,35.16,,,,,,,,,,,,,
NAIL INTRAMEDULLARY MINI 7X140MM FOR MEDIAL COLUMN FUSION,SUP-2878226,CDM,C1713,HCPCS,0278,RC,,,,both,,,23722.70,15419.75,,,,,,,,,,,,,
CATHETER BAL 135CM L 5.3FR 6MM BAL DIA 40MM BAL LEN .035IN,SUP-2141049,CDM,C1725,HCPCS,0272,RC,,,,both,,,569.97,370.48,,,,,,,,,,,,,
ALLOGRAFT BNE TIB DSTL,SUP-2321906,CDM,C1713,HCPCS,0278,RC,,,,both,,,3438.30,2234.89,,,,,,,,,,,,,
CATHETER KT EXTN LEG REP FOR 3 LUMN NEOSTAR,SUP-2332928,CDM,2720000010,LOCAL,0272,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
SHEATH INTRO 7FR L45CM STEER TOURGUIDE,SUP-2298497,CDM,C1894,HCPCS,0272,RC,,,,both,,,1805.50,1173.57,,,,,,,,,,,,,
CLAMP EXT FIX S STL 4 H PIN ILIZ,SUP-2340704,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2665.08,1732.30,,,,,,,,,,,,,
FORCEP ENDOSCP BX 7.5 FRX50 CM 2.4 MM STR FRMBL SS JAWZ LTX,SUP-2876081,CDM,2720000010,LOCAL,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
PLATE T DSTL RAD DRSL 2.4MM 3H HD 3H SHFT TI VA LCP STRL,SUP-2546754,CDM,C1713,HCPCS,0278,RC,,,,both,,,2379.74,1546.83,,,,,,,,,,,,,
NAIL IM L200MM DIA11MM 130DEG R ANK GRN TI CANN LOK FLUT,SUP-2368725,CDM,C1713,HCPCS,0278,RC,,,,both,,,5887.50,3826.87,,,,,,,,,,,,,
SCR QUINONEZ DF15MMX5MM4MM THD WSC,SUP-2676774,CDM,C1713,HCPCS,0278,RC,,,,both,,,549.28,357.03,,,,,,,,,,,,,
NEUROMONITORING KIT,SUP-2124288,CDM,C1713,HCPCS,0278,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
TRACKER NONINVASIVE CRANIALMASK,SUP-2364151,CDM,2720000010,LOCAL,0272,RC,,,,both,,,308.79,200.71,,,,,,,,,,,,,
CYCLOSPORINE 25 MG PO CAPS,RX-9707,CDM,J7515,HCPCS,0636,RC,00078-0240-61,NDC,,both,1,UN,20.90,13.58,,,,,,,,,,,,,
SYSTEM EXTR BG 3400ML RNG DIA14CM CONTAINED W/ GELPOINT MINI,SUP-2119765,CDM,C1713,HCPCS,0278,RC,,,,both,,,3501.10,2275.71,,,,,,,,,,,,,
HEAD FEM DIA32MM NK L+8MM LNG HIP ALUMINA CERAMIC FORTE,SUP-2344711,CDM,C1776,CPT,0278,RC,,,,both,,,4735.12,3077.83,,,,,,,,,,,,,
FELODIPINE ER 5 MG PO TB24,RX-27490,CDM,6370000000,HCPCS,0637,RC,23155-0049-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
IMPLANT BULK AGNT SYR DURASPHERE,SUP-2140370,CDM,L8606,HCPCS,0278,RC,,,,both,,,558.92,363.30,,,,,,,,,,,,,
BONE GRAFTING KIT BILATERAL CELLULAR BNE MTRX VIVIGEN MIS,SUP-2740950,CDM,C1713,HCPCS,0278,RC,,,,both,,,15608.44,10145.49,,,,,,,,,,,,,
GRAFT BNE SUB 5CC 2MM GRAN ALLOGENIC MORPHOGENETIC PROT W,SUP-2138491,CDM,C1713,HCPCS,0278,RC,,,,both,,,3250.69,2112.95,,,,,,,,,,,,,
INSERT TIB XSM 8MM DST FEM ALL POLY ROT HNG KNEE KINEMATIC,SUP-2376391,CDM,C1776,CPT,0278,RC,,,,both,,,3642.71,2367.76,,,,,,,,,,,,,
BUR SURG MTCH HD 3 MM 7.5 CM FLUT FOR TOOL MIDAS REX LEGEND,SUP-2630558,CDM,2720000010,LOCAL,0272,RC,,,,both,,,376.08,244.45,,,,,,,,,,,,,
KIT FIX DRL 2 GWIRE PAC STRL SURTAC,SUP-2341331,CDM,C1713,HCPCS,0278,RC,,,,both,,,288.88,187.77,,,,,,,,,,,,,
KIT PERICARDCENT L 40 CM DIA 8.3 FR STR 7 SPIRALING DRAINAGE,SUP-2880384,CDM,C1729,HCPCS,0272,RC,,,,both,,,401.92,261.25,,,,,,,,,,,,,
SILVER NITRATE-POT NITRATE 75-25 % EX MISC,RX-11359,CDM,6370000000,HCPCS,0637,RC,09999-9909-98,NDC,,both,10,UN,12.70,8.25,,,,,,,,,,,,,
STEM HUM L175MM DIA6MM UNIV SHLDR PRI CEM RSP,SUP-2217363,CDM,C1776,CPT,0278,RC,,,,both,,,11401.06,7410.69,,,,,,,,,,,,,
GRAFT BNE SUB 10CC DEMIN BNE MTRX ORTHOBLEND FOR SM DEFCT,SUP-2294020,CDM,C1713,HCPCS,0278,RC,,,,both,,,5397.66,3508.48,,,,,,,,,,,,,
HC IV Push Initial Drug,PX-2609637400,CDM,96374,CPT,0260,RC,,,,both,,,320.00,208.00,,,,,,,,,,,,,
K ORBITAL PLATE 3MM CP TITANIUM,SUP-2681040,CDM,C1713,HCPCS,0278,RC,,,,both,,,1781.32,1157.86,,,,,,,,,,,,,
STEM FEM 3X6IN TI PROX HIP MOD 1 PC FIN,SUP-2407279,CDM,C1776,CPT,0278,RC,,,,both,,,14871.04,9666.18,,,,,,,,,,,,,
BLADE SURG BRACKET O/R TBL,SUP-2479549,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1732.53,1126.14,,,,,,,,,,,,,
IMPLANT COSMETIC SZ 38 X 63 X 3 MM POLYETHYL BLOCK STRL DISP,SUP-2935415,CDM,C1713,HCPCS,0278,RC,,,,both,,,2599.92,1689.95,,,,,,,,,,,,,
WIRE FIX TROCAR PT 2 END 1X150 MM SS NS KIRSCHNER,SUP-2905611,CDM,C1713,HCPCS,0278,RC,,,,both,,,33.19,21.57,,,,,,,,,,,,,
PATCH BIO TISS W10PATCH BIO TISS W10XL16CM BOV PERICARD,SUP-2130368,CDM,C1768,CPT,0278,RC,,,,both,,,1937.66,1259.48,,,,,,,,,,,,,
SPACER SPNL W20XH7-14XL60MM ELSA,SUP-2228771,CDM,C1821,HCPCS,0278,RC,,,,both,,,29202.00,18981.30,,,,,,,,,,,,,
STRAP SPLNT 2INX18IN WHT NYL D RNG HK AND LOOP ROLYAN,SUP-2324781,CDM,L3908,HCPCS,0272,RC,,,,both,,,9.73,6.32,,,,,,,,,,,,,
PLATE BNE 145DEG 4 H S STL HIP LOK BILAT COMPR RIG SHT BRL,SUP-2370866,CDM,C1713,HCPCS,0278,RC,,,,both,,,1806.76,1174.39,,,,,,,,,,,,,
PIN COMPR NEXFIX 2X10 MM NS,SUP-2400518,CDM,2720000010,LOCAL,0272,RC,,,,both,,,587.18,381.67,,,,,,,,,,,,,
COMPONENT TOT HIP PRIMARY CERM ALTRX,SUP-2249586,CDM,C1776,CPT,0278,RC,,,,both,,,16799.00,10919.35,,,,,,,,,,,,,
HC Replace Cv Cath Only,PX-3613657800,CDM,36578,CPT,0361,RC,,,,inpatient,,,3707.00,2409.55,,,,,,,,,,,,,
RETRIEVER THROMCTMY MERCI L5 L 180 CM DIA2.5 MM DIA 0.014 IN,SUP-2367767,CDM,C1713,HCPCS,0278,RC,,,,both,,,9341.50,6071.97,,,,,,,,,,,,,
CAGE SPNL W10XH18XL55MM 0DEG CLYDESDALE PTC,SUP-2285761,CDM,C1889,HCPCS,0278,RC,,,,both,,,17599.70,11439.80,,,,,,,,,,,,,
PLATE BONE 5 HOLE COMPRESSION VARIABLE ANGLE LOCKING TITANIUM ARSENAL FOOT PLATING SYSTEM FOR 2.2/2.7/3.5MM SCREW,SUP-2878130,CDM,C1713,HCPCS,0278,RC,,,,both,,,4992.60,3245.19,,,,,,,,,,,,,
CATH GUIDE CPS LOCATOR MEDIUM 3D,SUP-2873674,CDM,C1887,HCPCS,0272,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
CATHETER HAD AD OVERALL L72CM L55CM DIA14.5FR CARBOTHANE,SUP-2283953,CDM,C1881,HCPCS,0278,RC,,,,both,,,1331.05,865.18,,,,,,,,,,,,,
HEAD FEM OD32MM +0 NK LEN 12/14 TAPR CO CHROM MTL ON POLY,SUP-2205555,CDM,C1776,CPT,0278,RC,,,,both,,,3229.18,2098.97,,,,,,,,,,,,,
AUGMENT TIB L75MM THK5MM UNIV KNEE REV VANGUARD 360,SUP-2408011,CDM,C1776,CPT,0278,RC,,,,both,,,2373.84,1543.00,,,,,,,,,,,,,
BIT DRL DIA3.2MM DISP FOR 4.5MM LCK PROX FEM SCR PEDILOC,SUP-2318885,CDM,2720000010,LOCAL,0272,RC,,,,both,,,603.95,392.57,,,,,,,,,,,,,
GRAFT BNE SUB 15CC SZ 0212 0850MM DEMIN CORT PWD FRZ DRY,SUP-2307258,CDM,C1713,HCPCS,0278,RC,,,,both,,,1208.52,785.54,,,,,,,,,,,,,
GUIDEWIRE VASC L 260 CM DIA 0.035 IN TIP L 1.5 MM SS PTFE,SUP-2733980,CDM,C1769,HCPCS,0272,RC,,,,both,,,37.24,24.21,,,,,,,,,,,,,
ATROPINE SULFATE 1 MG/ML IV SOLN,RX-153339,CDM,J0462,HCPCS,0636,RC,00517-1001-25,NDC,,both,0.5,ML,54.10,35.16,,,,,,,,,,,,,
BAR EXT FIX SM SZ 2 FOR XTRAFIX SYS,SUP-2199702,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4036.28,2623.58,,,,,,,,,,,,,
STEM MONOBLOCK SZ 2 L30MM NONCEMENTED + PROMOS,SUP-2351248,CDM,C1776,CPT,0278,RC,,,,both,,,6421.30,4173.84,,,,,,,,,,,,,
SLING GYN FEM RETROPUBIC MIDURETHRAL MESH NDL TENS FRE VAG,SUP-2257135,CDM,C1771,HCPCS,0278,RC,,,,both,,,5546.06,3604.94,,,,,,,,,,,,,
GUIDEWIRE URLGCL BNTSN 0.035N DIA 150CML 9CML TIP PTFE CTD S,SUP-2488661,CDM,C1769,HCPCS,0272,RC,,,,both,,,85.06,55.29,,,,,,,,,,,,,
HC Facial Bones Min 3 Views,PX-3207015000,CDM,70150,CPT,0320,RC,,,,inpatient,,,552.00,358.80,,,,,,,,,,,,,
PLATE BNE L95MM 5 H ST R DST RAD VOLAR DPHSEAL MTPHSEAL S,SUP-2177215,CDM,C1713,HCPCS,0278,RC,,,,both,,,4570.14,2970.59,,,,,,,,,,,,,
ANCHOR SUT DIA2MM NO2 SUT TI DURABRAID TWINFIX,SUP-2341075,CDM,C1713,HCPCS,0278,RC,,,,both,,,973.40,632.71,,,,,,,,,,,,,
TIP 90DEG 03MM ULTRAFLOW S P 8000 90DEG 03MM,SUP-2110010,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1720.72,1118.47,,,,,,,,,,,,,
BIT DRL DIA5MM SH FOR EXTRM L CANN SCR INSTR SET,SUP-2349160,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1186.07,770.95,,,,,,,,,,,,,
ALLOGRAFT HUM TISS STRUT 50 MM FRZN WHL PATELLAR TEND QUAD,SUP-2866906,CDM,C1762,CPT,0278,RC,,,,both,,,7382.93,4798.90,,,,,,,,,,,,,
LIDOCAINE 5 % EX OINT,RX-41831,CDM,6370000000,HCPCS,0637,RC,68462-0418-20,NDC,,both,35.44,GR,124.10,80.66,,,,,,,,,,,,,
WASHER ORTH SM 2 MM FOR CABLE STRL,SUP-2563694,CDM,C1713,HCPCS,0278,RC,,,,both,,,122.84,79.85,,,,,,,,,,,,,
SCREW BNE COMPR 4.5X24 MM ANK FUSION CONSTRUCT,SUP-2609766,CDM,C1713,HCPCS,0278,RC,,,,both,,,933.68,606.89,,,,,,,,,,,,,
POST EXT FIX CIR FEMALE 5 HOLE,SUP-2400699,CDM,2720000010,LOCAL,0272,RC,,,,both,,,456.87,296.97,,,,,,,,,,,,,
GRAFT DERMAL N FEN 4X4 CMX0.4-0.8 MM DERMAL MTRX PARADERM,SUP-2742061,CDM,C1763,HCPCS,0278,RC,,,,both,,,4006.64,2604.32,,,,,,,,,,,,,
SPACER SPNL W10XH8-12XL22MM TRANSFORAMINAL LUM INTBDY FUS,SUP-2230679,CDM,C1821,HCPCS,0278,RC,,,,both,,,13188.00,8572.20,,,,,,,,,,,,,
KIT HEMO DYLS OR HD 14.5FR L23CM CATH LNG TERM STD STR,SUP-2126522,CDM,C1750,HCPCS,0278,RC,,,,both,,,1416.14,920.49,,,,,,,,,,,,,
SCREW BNE CANN 7.3X35 MM LCK,SUP-2340731,CDM,C1713,HCPCS,0278,RC,,,,both,,,1807.04,1174.58,,,,,,,,,,,,,
NAIL IM HD LNG VANGUARD 360,SUP-2445060,CDM,C1713,HCPCS,0278,RC,,,,both,,,226.08,146.95,,,,,,,,,,,,,
MAXDRIVE BLADE ANGULUS 20/23MM,SUP-2679093,CDM,2720000010,LOCAL,0272,RC,,,,both,,,467.99,304.19,,,,,,,,,,,,,
SLING ORTH 9X14IN 4X44IN SZ UNIV SM ENV IMMOB SWTH SLDE,SUP-2196952,CDM,L3660,HCPCS,0272,RC,,,,both,,,21.89,14.23,,,,,,,,,,,,,
ROD ORTH OD2.5MM SIL FLEX DBL STEM SPCR KT ORTHOFLEX,SUP-2396952,CDM,C1713,HCPCS,0278,RC,,,,both,,,1491.50,969.47,,,,,,,,,,,,,
STEM FEM ARCOS 14X210MM BRCH BODY STD,SUP-2506144,CDM,C1776,CPT,0278,RC,,,,both,,,16629.44,10809.14,,,,,,,,,,,,,
DEVICE ELECSURG TIPTOOL SONICFUSION 19102020,SUP-2517217,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1740.82,1131.53,,,,,,,,,,,,,
CUFF ORTHOT HIP BILATERAL THGH CUST W/SPRD BAR,SUP-2435600,CDM,L1652,HCPCS,0274,RC,,,,both,,,1009.23,656.00,,,,,,,,,,,,,
TRACTION KIT PINNING,SUP-2165215,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1146.10,744.96,,,,,,,,,,,,,
ENDOPROSTHESIS VASC FLUENCY + L 80 MM DIA10 MM CATH L 80 CM,SUP-2128269,CDM,C1874,HCPCS,0278,RC,,,,both,,,6123.00,3979.95,,,,,,,,,,,,,
SCREW SHRT CANN 10.0MM OD 8.0MM ID,SUP-2491072,CDM,C1713,HCPCS,0278,RC,,,,both,,,2214.80,1439.62,,,,,,,,,,,,,
HC Njx Px Nfrosgrm &/Urtrgrm,PX-3615043000,CDM,50430,CPT,0361,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
PLATE BNE CONTOURABLE MESH 70X0.4 MM NEURO TI BLU STRL,SUP-2859910,CDM,C1713,HCPCS,0278,RC,,,,both,,,5184.77,3370.10,,,,,,,,,,,,,
ARMSTRONG R VENT TUBE 1.14 MM ID FLUOROPLASTIC 50 PACK,SUP-2491362,CDM,L8699,HCPCS,0278,RC,,,,both,,,36.80,23.92,,,,,,,,,,,,,
PPICC PROVENA SOLO 3F SLEEVE,SUP-2613533,CDM,C1751,HCPCS,0278,RC,,,,both,,,535.87,348.32,,,,,,,,,,,,,
MONITOR CARD IMPL 12CC 448X72X4MM REVEAL LINQ,SUP-2281137,CDM,C1764,HCPCS,0278,RC,,,,both,,,13502.00,8776.30,,,,,,,,,,,,,
FELT SURG L15X15CM DIA6X6IN THK1.85MM PTFE POLY SQ LO,SUP-2126650,CDM,C1781,HCPCS,0278,RC,,,,both,,,550.60,357.89,,,,,,,,,,,,,
SCREW BONE L7MM OD2.7MM DSTL TIB S STL ST LCK FULL THRD,SUP-2183360,CDM,C1713,HCPCS,0278,RC,,,,both,,,401.42,260.92,,,,,,,,,,,,,
STENT PERIPH PALMAZ GEN L 25 MM DIA10 MM SHTH 8 FR GUIDE 10,SUP-2159235,CDM,C1877,HCPCS,0278,RC,,,,both,,,2150.90,1398.08,,,,,,,,,,,,,
SCREW BNE LCK 25 MM ASMBLY PRIMALOK FF,SUP-2319819,CDM,C1713,HCPCS,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
BIT DRL L85MM DIA2.7MM JCBS CHK FOR SM FRAG SYS,SUP-2187237,CDM,2720000010,LOCAL,0272,RC,,,,both,,,214.59,139.48,,,,,,,,,,,,,
SPONGE IMPL 75X275X80MM SCLER BCKL OLK DSGN HALF OVL,SUP-2129439,CDM,L8610,HCPCS,0278,RC,,,,both,,,171.98,111.79,,,,,,,,,,,,,
RING SPNL TI LOK FOR VAR AXIS SCR,SUP-2193305,CDM,C1713,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
SYSTEM ENDOSCP US DEL W/ 25GA FNA NDL BEAC,SUP-2172391,CDM,C1713,HCPCS,0278,RC,,,,both,,,1199.48,779.66,,,,,,,,,,,,,
GRAFT VASC STR STD WALL RING 8MM DIA 45CM LEN GORTX,SUP-2396013,CDM,C1768,CPT,0278,RC,,,,both,,,1931.10,1255.21,,,,,,,,,,,,,
PLATE BNE FUSION MINI WRST SS STRL SPIDER,SUP-2610409,CDM,C1713,HCPCS,0278,RC,,,,both,,,5574.57,3623.47,,,,,,,,,,,,,
PLATE BNE STR NEUT 2.4 MM STRNL 30 HOLE LCK LP COMPR TI NS,SUP-2421472,CDM,C1713,HCPCS,0278,RC,,,,both,,,10220.70,6643.45,,,,,,,,,,,,,
GRAFT BONE PROX TIB W/ TUBEROSITY FZ IRR,SUP-2875987,CDM,C1762,CPT,0278,RC,,,,both,,,8859.51,5758.68,,,,,,,,,,,,,
KIT INTRO SHTH L 10 CM DIA 5.5 FR GUIDEWIRE L 65 CM DIA,SUP-2120532,CDM,C1894,HCPCS,0272,RC,,,,both,,,100.48,65.31,,,,,,,,,,,,,
PLATE BNE 2/2.4X41X1.7 MM 5 HOLE SS LC-DCP,SUP-2569204,CDM,C1713,HCPCS,0278,RC,,,,both,,,278.05,180.73,,,,,,,,,,,,,
PLATE BNE TI MIDFACE RECON 6 PLATE CUSTOMIZED FACE ID,SUP-2883693,CDM,C1713,HCPCS,0278,RC,,,,both,,,41921.76,27249.14,,,,,,,,,,,,,
PROX MEDIAL TIB 11 HOLE LEFT,SUP-2497741,CDM,C1713,HCPCS,0278,RC,,,,both,,,1239.67,805.79,,,,,,,,,,,,,
PLATE BNE 3.5X54 MM 4 HOLE SS LC-DCP,SUP-2569226,CDM,C1713,HCPCS,0278,RC,,,,both,,,210.69,136.95,,,,,,,,,,,,,
GRAFT BNE SUB 10CC 2-4MM GROWTH FACT ALLGRFT OSTEOAMP,SUP-2138498,CDM,C1713,HCPCS,0278,RC,,,,both,,,5799.74,3769.83,,,,,,,,,,,,,
HC CT Lower Ext W&W/O Cont|LEFT SIDE,PX-3527370200,CDM,73702,CPT,0352,RC,,,LT,both,,,2769.00,1799.85,,,,,,,,,,,,,
BLOWER FLUID GAS MIX L165CM S STL SHFT MAL AND HNDPC,SUP-2282581,CDM,C1713,HCPCS,0278,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
SYSTEM VLV SHUNT ADJ DIFF PRSS 0-20CM H2O W/ GRAVITATIONAL,SUP-2108723,CDM,C1713,HCPCS,0278,RC,,,,both,,,10393.40,6755.71,,,,,,,,,,,,,
BUTTON NSL SEPT LG 7CM SIL STRL,SUP-2381502,CDM,C1889,HCPCS,0278,RC,,,,both,,,428.61,278.60,,,,,,,,,,,,,
NAIL IM HUM 8/7MMX24CM,SUP-2348161,CDM,C1713,HCPCS,0278,RC,,,,both,,,10294.80,6691.62,,,,,,,,,,,,,
STEM FEM SZ 0 LT SH NK N CLLRD POR NATURAL-HIP,SUP-2210767,CDM,C1776,CPT,0278,RC,,,,both,,,13531.83,8795.69,,,,,,,,,,,,,
STEM FEM DIA12MM LT HIP SM STAT SH REPLICA,SUP-2251973,CDM,C1776,CPT,0278,RC,,,,both,,,16397.08,10658.10,,,,,,,,,,,,,
ENDOPROSTHESIS VASC VIABAHN L 5CM 13MM 120CM 8FR HEPARIN,SUP-2610471,CDM,C1768,CPT,0278,RC,,,,both,,,9391.74,6104.63,,,,,,,,,,,,,
SCREW BONE L6MM THRD DIA2.7MM HD DIA4.3MM COR DIA2MM PITCH,SUP-2349433,CDM,C1713,HCPCS,0278,RC,,,,both,,,679.21,441.49,,,,,,,,,,,,,
STEM HUM L122MM DIA12MM STD CO CHROM POR PRI PRESSFIT CEM,SUP-2404594,CDM,C1776,CPT,0278,RC,,,,both,,,9831.34,6390.37,,,,,,,,,,,,,
PLATE BNE L399MM 19 H L LAT DST FEM S STL LOK FOR 4.5MM SCR,SUP-2348214,CDM,C1713,HCPCS,0278,RC,,,,both,,,15350.83,9978.04,,,,,,,,,,,,,
JOINT TOE CLASSIC GREAT TOE 60 SIL GRAY/WHITE,SUP-2609610,CDM,L8642,HCPCS,0278,RC,,,,both,,,4353.20,2829.58,,,,,,,,,,,,,
SCREW BONE L5MM DIA2X-DRIVE TRAUMAONE,SUP-2415398,CDM,C1713,HCPCS,0278,RC,,,,both,,,659.97,428.98,,,,,,,,,,,,,
CATHETER URET CONE TIP OPN END 5FRX70CM,SUP-2141717,CDM,C1758,HCPCS,0278,RC,,,,both,,,82.36,53.53,,,,,,,,,,,,,
CONNECTOR ROD AND SCR SM FOR POST SCRS TI TSRH-3D 5.5MM DIA,SUP-2289994,CDM,C1713,HCPCS,0278,RC,,,,both,,,1267.78,824.06,,,,,,,,,,,,,
SCREW WR INTEGRA FRDM ARTHROPLASTY LCK CAP ARE USED IN THE,SUP-2243512,CDM,C1713,HCPCS,0278,RC,,,,both,,,1105.06,718.29,,,,,,,,,,,,,
SPACER SPNL W9XH25XL9MM STD TRL POST LUM INTBDY FUS JAGUAR,SUP-2253223,CDM,C1821,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
PLATE FOOT RINGFIX SYS ALUM LNG 160MM,SUP-2467928,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
PLATE BNE L37MM 2X2 H SHT R FOREFOOT/MIDFOOT S STL VAR ANG,SUP-2184834,CDM,C1713,HCPCS,0278,RC,,,,both,,,2857.37,1857.29,,,,,,,,,,,,,
CANNULA ARTHSCP DIA5MM W/ OBT FOR IATROGENIC DAMAGE,SUP-2366734,CDM,2720000010,LOCAL,0272,RC,,,,both,,,957.70,622.50,,,,,,,,,,,,,
HC Prothrombin Time,PX-3058561000,CDM,85610,CPT,0305,RC,,,,both,,,106.00,68.90,,,,,,,,,,,,,
COMPONENT FEM L25MM TI ALLY M FEM TAPR ANTI ROT TAB SLOT,SUP-2252610,CDM,C1776,CPT,0278,RC,,,,both,,,4335.08,2817.80,,,,,,,,,,,,,
KIT INFSN 5FR CATH 135CML LNGTH 20CM CHECK RELF VLV HEMSTAS,SUP-2676954,CDM,C1751,HCPCS,0278,RC,,,,both,,,333.31,216.65,,,,,,,,,,,,,
BUR 23MM TAPERED ROUTER,SUP-2431337,CDM,2720000010,LOCAL,0272,RC,,,,both,,,454.17,295.21,,,,,,,,,,,,,
PLATE BNE THK0.6MM 2X2 H BILAT HND RECTANG NAR,SUP-2267885,CDM,C1713,HCPCS,0278,RC,,,,both,,,1036.20,673.53,,,,,,,,,,,,,
ANCHOR SUT L16.3MM DIA5.5MM TI W/ TWO SZ 2 TIGERTAIL CRKSCR,SUP-2121573,CDM,C1713,HCPCS,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
KNIFE SURG ASTN 3 MM SCKL LF,SUP-2469858,CDM,2720000010,LOCAL,0272,RC,,,,both,,,314.41,204.37,,,,,,,,,,,,,
RING EXT FIX DIA180MM ANK FT FULL TL HEX,SUP-2316202,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4227.70,2748.00,,,,,,,,,,,,,
SCREW BNE FIX 4.3X55 MM QWIX,SUP-2242837,CDM,C1713,HCPCS,0278,RC,,,,both,,,1088.01,707.21,,,,,,,,,,,,,
DIGOXIN 0.05 MG/ML PO SOLN,RX-43556,CDM,340b,HCPCS,0637,RC,00054-0057-46,NDC,,both,2.5,ML,26.30,17.09,,,,,,,,,,,,,
ADAPTER ORTH 5 CM OSS COMPRESS,SUP-2441844,CDM,C1776,CPT,0278,RC,,,,both,,,2303.19,1497.07,,,,,,,,,,,,,
PLATE BNE HYBRID MMF SMARTLOCK 2PK,SUP-2366228,CDM,C1713,HCPCS,0278,RC,,,,both,,,1047.76,681.04,,,,,,,,,,,,,
"HC E/M Crit Care,ER, 1st 30-74min",PX-4509929100,CDM,99291,CPT,0450,RC,,,,inpatient,,,4946.00,3214.90,,,,,,,,,,,,,
PROSTHESIS OSS 4 MM 0.6 MM BARTELS BCKT OFFSET,SUP-2490949,CDM,L8613,CPT,0278,RC,,,,both,,,697.93,453.65,,,,,,,,,,,,,
PLATE BNE MESHED 9 STD 0.6 MM RT CRAN PRECONTR TI NS LF,SUP-2460590,CDM,C1713,HCPCS,0278,RC,,,,both,,,8430.84,5480.05,,,,,,,,,,,,,
BOLT EXT FIX PHOENIX,SUP-2495102,CDM,2720000010,LOCAL,0272,RC,,,,both,,,469.05,304.88,,,,,,,,,,,,,
STAPLE BONE FIX BRDG W15MM LEG L20X9MM WIRE DIA2MM CALCNL S,SUP-2194221,CDM,C1713,HCPCS,0278,RC,,,,both,,,3752.30,2438.99,,,,,,,,,,,,,
DOXYLAMINE SUCCINATE (SLEEP) 25 MG PO TABS,RX-14847,CDM,6370000000,HCPCS,0637,RC,41167-0006-09,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
CATHETER ATHRCTMY ELCA LASER 130CM DIA 0.9MM TIP DIA 0.038IN SHFT,SUP-2353044,CDM,C1885,CPT,0278,RC,,,,both,,,10344.73,6724.07,,,,,,,,,,,,,
BUR SURG DIA 5 MM R FLUT UL FOR STD ATTACH STRL DISP,SUP-2937200,CDM,2720000010,LOCAL,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
FORCEP BX 1 MMX286 CM FOR MAX ACCSRY DEV SPYBITE,SUP-2423800,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1641.53,1066.99,,,,,,,,,,,,,
PIN FIX TROCAR PT 2 END 7/64X9 IN 2 PT STYL SMOOTH PLN STRL,SUP-2150470,CDM,C1713,HCPCS,0278,RC,,,,both,,,12.69,8.25,,,,,,,,,,,,,
CATHETER GUID VL3.5 6 FR,SUP-2139791,CDM,C1887,HCPCS,0272,RC,,,,both,,,150.72,97.97,,,,,,,,,,,,,
PLATE BNE L157MM THK3MM 9 H TI TIM R DST ANTLAT TIB LOK,SUP-2413678,CDM,C1713,HCPCS,0278,RC,,,,both,,,6418.16,4171.80,,,,,,,,,,,,,
PLATE BONE W5XL100MM THK1.2MM 20 H MINI S STL STR,SUP-2343835,CDM,C1713,HCPCS,0278,RC,,,,both,,,1903.63,1237.36,,,,,,,,,,,,,
DEXTROSE IN LACTATED RINGERS 5 % IV SOLN,RX-9788,CDM,J7121,HCPCS,0258,RC,00264-7751-00,NDC,,both,1000,ML,25.50,16.57,,,,,,,,,,,,,
ANCHOR SUT W 1 SZ 2 HIFI SUT DRVR BIO MINI REVO,SUP-2166969,CDM,C1713,HCPCS,0278,RC,,,,both,,,893.49,580.77,,,,,,,,,,,,,
JOINT FNGR CRPL LUNATE 4 TI SWNSN,SUP-2535900,CDM,C1776,CPT,0278,RC,,,,both,,,11159.56,7253.71,,,,,,,,,,,,,
NAIL IM L180MM OD9MM 130DEG SH TIM HIP AG CANN LCK AFFIXUS,SUP-2402794,CDM,C1713,HCPCS,0278,RC,,,,both,,,7075.52,4599.09,,,,,,,,,,,,,
DEXTROSE IN LACTATED RINGERS 5 % IV SOLN,RX-9788,CDM,J7121,HCPCS,0250,RC,00338-0125-03,NDC,,both,500,ML,51.00,33.15,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 4X3 CM CRYOPRESERVED UMB CRD NEOX CRD 1K,SUP-2648687,CDM,Q4148,HCPCS,0636,RC,,,,both,,,4239.00,2755.35,,,,,,,,,,,,,
SCREW BNE L14MM DIA1.5MM TI ST LOK T4 RECESS STARDRV,SUP-2181269,CDM,C1713,HCPCS,0278,RC,,,,both,,,330.01,214.51,,,,,,,,,,,,,
STRIPS ILIUM TRICORT TRAD ALLGRFT 22X45 MM FRZ DRY,SUP-2294071,CDM,C1713,HCPCS,0278,RC,,,,both,,,4509.04,2930.88,,,,,,,,,,,,,
CANNULA OPHTH 25GA TRANSCONJUNCTIVAL CHOW SIL OIL INJ 6 PER,SUP-2129205,CDM,2720000010,LOCAL,0272,RC,,,,both,,,916.88,595.97,,,,,,,,,,,,,
CATHETER CV DL 5 FRX55 CM ENDEXO NURSING KT BIOFLO 75034,SUP-2734874,CDM,C1751,HCPCS,0278,RC,,,,both,,,144.44,93.89,,,,,,,,,,,,,
PLATE BNE W17.5XL336MM THK5.2MM 18 H NONSTERILE BILAT S STL,SUP-2185318,CDM,C1713,HCPCS,0278,RC,,,,both,,,2956.97,1922.03,,,,,,,,,,,,,
HC So Lipid Cascade,PX-3018006168,CDM,80061,CPT,0301,RC,,,,both,,,66.00,42.90,,,,,,,,,,,,,
PLATE 95 DEG CONDYLAR 7 HOLES 40MM 124MM STERILE,SUP-2547715,CDM,C1713,HCPCS,0278,RC,,,,both,,,3653.96,2375.07,,,,,,,,,,,,,
COMPONENT FEM SZ 2 RT POST STBL CEM GMK,SUP-2267591,CDM,C1776,CPT,0278,RC,,,,both,,,3730.32,2424.71,,,,,,,,,,,,,
HC Reconstruct Nail Bed,PX-4501176200,CDM,11762,CPT,0450,RC,,,,both,,,6021.00,3913.65,,,,,,,,,,,,,
TROCAR FOR 6.5MM AND 7.3MM CANNULATED SCREWS-LONG,SUP-2548324,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2376.82,1544.93,,,,,,,,,,,,,
SPACER SPNL 12X12X9MM 5DEG CORT FORTIS AC,SUP-2136725,CDM,C1889,HCPCS,0278,RC,,,,both,,,10048.00,6531.20,,,,,,,,,,,,,
SCREW BONE L85MM DIA6.5MM PROX CANC FEM ANK S STL PARTIALLY,SUP-2350277,CDM,C1713,HCPCS,0278,RC,,,,both,,,438.60,285.09,,,,,,,,,,,,,
PLATE BONE SM W10XL97MM THK3.4MM 8 H UNIV DSTL HUM RAD ULN,SUP-2343770,CDM,C1713,HCPCS,0278,RC,,,,both,,,1361.47,884.96,,,,,,,,,,,,,
BUMPER TIB 3 DEG HINGE REV STRL TRIATHLON,SUP-2889781,CDM,C1776,CPT,0278,RC,,,,both,,,2959.45,1923.64,,,,,,,,,,,,,
LIDOCAINE HCL 1% INJ (MIXTURES ONLY),RX-430017,CDM,J2003,HCPCS,0636,RC,00409-4276-02,NDC,,both,5,ML,54.10,35.16,,,,,,,,,,,,,
DEVICE SUT L32CM OD12MM TRNSVAG STD W/O SUT DISP FOR OPN,SUP-2140345,CDM,C2631,HCPCS,0278,RC,,,,both,,,32.62,21.20,,,,,,,,,,,,,
WASHER ORTH 2.7 MM TI NS FPS LTX,SUP-2856621,CDM,C1713,HCPCS,0278,RC,,,,both,,,191.54,124.50,,,,,,,,,,,,,
COLLAR CERV SEMI RIGID BRAC ADJ,SUP-2265009,CDM,L0140,HCPCS,0274,RC,,,,both,,,178.98,116.34,,,,,,,,,,,,,
GRAFT SPNL BNE 8MMX22MM CORT FRZ DRY IMP CAPSTONE,SUP-2293984,CDM,C1713,HCPCS,0278,RC,,,,both,,,9482.80,6163.82,,,,,,,,,,,,,
PLATE BONE STR 2.0MM 4 H,SUP-2361576,CDM,C1713,HCPCS,0278,RC,,,,both,,,247.02,160.56,,,,,,,,,,,,,
DEVICE HEARING LT CHROMA BGE PONTO,SUP-2319858,CDM,L8690,HCPCS,0278,RC,,,,both,,,9577.00,6225.05,,,,,,,,,,,,,
GRAFT HUM TISS SM 9MM W8.5MM D20MM 5DEG LORDOSIS POST RAMP,SUP-2294225,CDM,C1713,HCPCS,0278,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
MESH HERN W6XL8IN VENTRAL POLYPR EPTFE REP ELP LO PROF MFIL,SUP-2125806,CDM,C1781,HCPCS,0278,RC,,,,both,,,2097.52,1363.39,,,,,,,,,,,,,
INFUSION PUMP KIT PAINBUSTER 6.5 CM 270 CC ON-Q SILVERSOAKER,SUP-2236827,CDM,C1713,HCPCS,0278,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
CATHETER INFUSION STR 150 CM 50 CM 2 MARKER BND PROWLER 10,SUP-2469714,CDM,C1887,HCPCS,0272,RC,,,,both,,,3847.69,2501.00,,,,,,,,,,,,,
BUR 1883070HSE RAD FRNTL FINESSE 3MM 40D,SUP-2277862,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1384.74,900.08,,,,,,,,,,,,,
COLLAR CERV SEMI RIGID BRAC ADJ,SUP-2265009,CDM,L0140,HCPCS,0272,RC,,,,both,,,178.98,116.34,,,,,,,,,,,,,
BLADE RETRCT D4IN FOR CHARNLEY TYP FRME,SUP-2242483,CDM,2720000010,LOCAL,0272,RC,,,,both,,,990.04,643.53,,,,,,,,,,,,,
CATHETER CTRL VEN L145CM OD5FR ID17.5GA 2 LUMN PASV VLV,SUP-2118817,CDM,C1751,HCPCS,0278,RC,,,,both,,,452.16,293.90,,,,,,,,,,,,,
INTRODUCER SHTH DBL CRV 12X14 FR ACCS W/ DIL,SUP-2424701,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4396.00,2857.40,,,,,,,,,,,,,
SCREW BNE 1.5X4 MM DRILL-FREE TI STRL ONEDRIVE 251530471,SUP-2460469,CDM,C1713,HCPCS,0278,RC,,,,both,,,239.68,155.79,,,,,,,,,,,,,
HC Bone Marrow Harvest Autolog,PX-3623823200,CDM,38232,CPT,0362,RC,,,,both,,,14217.00,9241.05,,,,,,,,,,,,,
SCREW BONE L6MM DIA1.5MM BRNZ CORT TI ST NONCANNULATED,SUP-2181613,CDM,C1713,HCPCS,0278,RC,,,,both,,,319.15,207.45,,,,,,,,,,,,,
PIN DISTRACTOR L12MM S STL FOR ANTR CERV INTBDY FUS,SUP-2176864,CDM,C1713,HCPCS,0278,RC,,,,both,,,219.80,142.87,,,,,,,,,,,,,
GRAFT BNE STRP 50 MM 10 CC,SUP-2430786,CDM,C1889,HCPCS,0278,RC,,,,both,,,4961.20,3224.78,,,,,,,,,,,,,
PLATE BNE L109MM 4 H NONSTERILE R MED DST TIB S STL LO BEND,SUP-2184169,CDM,C1713,HCPCS,0278,RC,,,,both,,,3695.50,2402.07,,,,,,,,,,,,,
VALVE CSF STD 15 CM STR CATH MED PRESSURE RADIOPAQUE YEL DP,SUP-2852668,CDM,C1889,HCPCS,0278,RC,,,,both,,,3560.85,2314.55,,,,,,,,,,,,,
PLATE SPNL L23MM 5 H CERV VERT,SUP-2185978,CDM,C1713,HCPCS,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
HC So1 Alcohol Biomarkers,PX-3018032167,CDM,80321,CPT,0301,RC,,,,both,,,149.00,96.85,,,,,,,,,,,,,
POVIDONE-IODINE 10 % EX OINT,RX-6455,CDM,6370000000,HCPCS,0637,RC,00536-1271-80,NDC,,both,28.4,GR,8.20,5.33,,,,,,,,,,,,,
ELECTRODE STARBURST XLI ENH 9 ARRY + ACT TRCR TIP,SUP-2118723,CDM,C1894,HCPCS,0272,RC,,,,both,,,9332.08,6065.85,,,,,,,,,,,,,
PLATE SPNL 16 H THOR PRE CNTOUR RIBFIX BLU,SUP-2137002,CDM,C1713,HCPCS,0278,RC,,,,both,,,5793.30,3765.64,,,,,,,,,,,,,
KIT CATH HEMODIALYSI RELIANCE XK CHRONIC STD 16FR DIA 31CM 3,SUP-2613287,CDM,C1750,HCPCS,0278,RC,,,,both,,,1483.65,964.37,,,,,,,,,,,,,
PIN EXT FIX L 25 MM DIA 3 MM TIN HALF STRL DISP JET-X MAV,SUP-2933684,CDM,2720000010,LOCAL,0272,RC,,,,both,,,610.35,396.73,,,,,,,,,,,,,
SYSTEM FRAC REDUC AGEE WRISTJACK,SUP-2237245,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
PLATE BONE W13.5XL242MM THK4.2MM 13 H BILAT S STL NAR LCK,SUP-2185251,CDM,C1713,HCPCS,0278,RC,,,,both,,,2628.18,1708.32,,,,,,,,,,,,,
GRAFT BNE FRZN HUM HD IMPL ALLGRFT OD43MM MATRIGRFT,SUP-2264764,CDM,C1713,HCPCS,0278,RC,,,,both,,,2950.31,1917.70,,,,,,,,,,,,,
CHLORDIAZEPOXIDE HCL 10 MG PO CAPS,RX-1622,CDM,6370000000,HCPCS,0637,RC,51079-0375-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
SCREW BNE 3.5X90 MM PERI ARTC,SUP-2402643,CDM,C1713,HCPCS,0278,RC,,,,both,,,104.50,67.92,,,,,,,,,,,,,
SLEEVE IM NAIL NAIL DIA 8-11 MM LNG RIGID TIB FIX STRL,SUP-2905668,CDM,2720000010,LOCAL,0272,RC,,,,both,,,723.11,470.02,,,,,,,,,,,,,
BRACE KNEE ACL PLC MCL ICL SIZED TO FIT UNIV UNISX FASTEN ON,SUP-2150832,CDM,L1810,HCPCS,0274,RC,,,,both,,,1375.57,894.12,,,,,,,,,,,,,
STENT URET DBL PGTL 0.035 INX150 CM 3 CM 6 FRX20 CM POLARIS,SUP-2470105,CDM,C1758,HCPCS,0278,RC,,,,both,,,681.82,443.18,,,,,,,,,,,,,
STENT ENDOPROS L15CM DIA6MM CATH 7FR L120CM 0.035IN VES,SUP-2396535,CDM,C1874,HCPCS,0278,RC,,,,both,,,10952.32,7119.01,,,,,,,,,,,,,
COMPONENT FEM 5 CM RT KNEE RESURF OSS,SUP-2441729,CDM,C1776,CPT,0278,RC,,,,both,,,18905.94,12288.86,,,,,,,,,,,,,
KIT PACE ROT LD HELIX STRL,SUP-2282052,CDM,C1713,HCPCS,0278,RC,,,,both,,,43.18,28.07,,,,,,,,,,,,,
ADAPTER UPLR FEM 12 14 TAPR +6MM OFFSET SOLITUDE,SUP-2314490,CDM,C1776,CPT,0278,RC,,,,both,,,238.64,155.12,,,,,,,,,,,,,
SET ORTH PT SPEC INSTR CAPITATED BNE MOD GUID PIN DRL KT,SUP-2212345,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
DEVICE FIX NO LOOP VERSITOMIC G-LOK,SUP-2421258,CDM,C1713,HCPCS,0278,RC,,,,both,,,1088.32,707.41,,,,,,,,,,,,,
SCREW BONE 40MM LENGTH 45MM LOCKING CAP,SUP-2586706,CDM,C1713,HCPCS,0278,RC,,,,both,,,1005.68,653.69,,,,,,,,,,,,,
GRAFT BNE FRZN STRUCTURAL L PROX FIB IMPL ALLGRFT,SUP-2307383,CDM,C1713,HCPCS,0278,RC,,,,both,,,5221.95,3394.27,,,,,,,,,,,,,
SET INTUB CATH 14FR L70CM GWIRE L110CM 0.038IN RG W/ PTFE,SUP-2168590,CDM,2720000010,LOCAL,0272,RC,,,,both,,,480.42,312.27,,,,,,,,,,,,,
CATHETER CV 3L 7 FRX200 MM 16 GAX70 MM W/ EXTN TY 3 CAREFLOW,SUP-2494069,CDM,C1751,HCPCS,0278,RC,,,,both,,,78.37,50.94,,,,,,,,,,,,,
CATHETER INFUSION PMP 5 ML/HR 2.5 IN 275 CC,SUP-2361466,CDM,C1751,HCPCS,0278,RC,,,,both,,,477.28,310.23,,,,,,,,,,,,,
EXPANDER BRST W10.7XH9.3CM P6.2CM 275CC SIL NACL SHELL RND M,SUP-2300631,CDM,C1789,HCPCS,0278,RC,,,,both,,,4160.50,2704.32,,,,,,,,,,,,,
COUNTERSINK DRL DIA2.7MM ADD ON QUIK CONN DISP,SUP-2340803,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1249.72,812.32,,,,,,,,,,,,,
GUIDEWIRE ORTH 3/32X13 IN,SUP-2664007,CDM,C1769,HCPCS,0272,RC,,,,both,,,519.36,337.58,,,,,,,,,,,,,
PLATE BNE L27MM 5 H ZYG TI STR DYN COMPR FOR 2MM CRUCFRM,SUP-2191060,CDM,C1713,HCPCS,0278,RC,,,,both,,,1041.85,677.20,,,,,,,,,,,,,
SHELL ACET UNIV DIA46MM NO H HA PRI PRESSFIT SECUR FIT PSL,SUP-2370224,CDM,C1776,CPT,0278,RC,,,,both,,,4630.87,3010.07,,,,,,,,,,,,,
IMPLANT BIO TISS W4XL4CM THK0.7MM DERM SCAFFOLD FEN,SUP-2243710,CDM,Q4110,HCPCS,0636,RC,,,,both,,,2339.93,1520.95,,,,,,,,,,,,,
PLATE BNE W175XL372MM THK52MM 20 H BILAT S STL BROAD CRV,SUP-2185322,CDM,C1713,HCPCS,0278,RC,,,,both,,,3477.93,2260.65,,,,,,,,,,,,,
COLLAR CERV L13-16IN H3.25IN M TRACH OPN W/ CHIN SUPP ADJ,SUP-2197923,CDM,L0120,HCPCS,0274,RC,,,,both,,,266.90,173.48,,,,,,,,,,,,,
ROD IM L1150MM DIA25MM TI RM BALL TIP,SUP-2188105,CDM,2720000010,LOCAL,0272,RC,,,,both,,,383.33,249.16,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH FLX L 39 MM DIA24 MM SHTH 18 FR SS,SUP-2171054,CDM,C1874,HCPCS,0278,RC,,,,both,,,6258.02,4067.71,,,,,,,,,,,,,
TRAY CATH MIDLN GROSH INTERMED 3FR 25CM 1 LUMAN W/16GA INTRO,SUP-2613422,CDM,C1751,HCPCS,0278,RC,,,,both,,,202.84,131.85,,,,,,,,,,,,,
GRAFT HUM TISS W3XL3CM COMP AMNIO MEM MTRX SHT AMNIOFIX,SUP-2305707,CDM,V2790,HCPCS,0274,RC,,,,both,,,4600.10,2990.06,,,,,,,,,,,,,
GRAFT DURAL 2INW X 2NL ULTRPRE CLLGN ONLAY STRLSS CLSRE ENHN,SUP-2493464,CDM,C1763,HCPCS,0278,RC,,,,both,,,1482.39,963.55,,,,,,,,,,,,,
SYSTEM ORTH REV MOD TIB TAPE 63 LNG OSS,SUP-2441800,CDM,C1776,CPT,0278,RC,,,,both,,,9170.37,5960.74,,,,,,,,,,,,,
HC Needle Insertion W/O Injection 3 or More Muscles,PX-4202056100,CDM,20561,CPT,0420,RC,,,,inpatient,,,42.00,27.30,,,,,,,,,,,,,
CANISTER PMP MAX ARTEMIS,SUP-2461989,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1130.40,734.76,,,,,,,,,,,,,
HC So Pregnenolone,PX-3018414066,CDM,84140,CPT,0301,RC,,,,outpatient,,,55.00,35.75,,,,,,,,,,,,,
PULSE SPRY PRO INFUS CATH 3FX135CMX2CM,SUP-2117034,CDM,C1757,HCPCS,0272,RC,,,,both,,,273.18,177.57,,,,,,,,,,,,,
KIT STRNL CLOSURE SS TWR CABLE PLATE SCREW STRL THORECON,SUP-2894479,CDM,C1713,HCPCS,0278,RC,,,,both,,,4320.95,2808.62,,,,,,,,,,,,,
SOCK PROSTHETIC BLK,SUP-2388224,CDM,L8420,HCPCS,0274,RC,,,,both,,,53.85,35.00,,,,,,,,,,,,,
SCREW BNE L36MM OD4.2MM NONLOCKING LO PROF TUFFNEK,SUP-2321227,CDM,C1713,HCPCS,0278,RC,,,,both,,,553.43,359.73,,,,,,,,,,,,,
DEFIBRILLATOR CRD BPLR 2 CHMBR IS-1 DF-1 CONN EPIC II DR,SUP-2356560,CDM,C1721,HCPCS,0275,RC,,,,both,,,70179.00,45616.35,,,,,,,,,,,,,
PLATE BNE W24XL45MM 8 H ST BILAT MIDFOOT HINDFOOT TI RIG LOK,SUP-2191458,CDM,C1713,HCPCS,0278,RC,,,,both,,,2936.28,1908.58,,,,,,,,,,,,,
GLIDESHEATH SLENDER TP NI KT 0021 GW 5 FR 10CM,SUP-2385454,CDM,C1894,HCPCS,0272,RC,,,,both,,,279.30,181.54,,,,,,,,,,,,,
GRAFT VASC ARTEGRAFT L 50 CM DIA 7 MM CLLGN BOV CAR ART,SUP-2120671,CDM,C1768,CPT,0278,RC,,,,both,,,13122.06,8529.34,,,,,,,,,,,,,
MILRINONE LACTATE IN DEXTROSE 40-5 MG/200ML-% IV SOLN,RX-123635,CDM,J2260,HCPCS,0636,RC,00143-9718-01,NDC,,both,200,ML,184.00,119.60,,,,,,,,,,,,,
HC Fluoro Xray Venogram Ext Unil,PX-3207582000,CDM,75820,CPT,0320,RC,,,,inpatient,,,1017.00,661.05,,,,,,,,,,,,,
KIT VASC SEAL 4 ML HUM SER ALB POLYETHYL GLYCOL APPL SPRY,SUP-2930546,CDM,C1762,CPT,0278,RC,,,,both,,,3658.10,2377.76,,,,,,,,,,,,,
HC Repair Blood Vessel Low Ext,PX-4503522600,CDM,35226,CPT,0450,RC,,,,both,,,730.00,474.50,,,,,,,,,,,,,
SET INTRO PEELWY L 9 CM DIA 5.5 FR GUIDEWIRE 0.018 IN NIT,SUP-2168419,CDM,C1894,HCPCS,0272,RC,,,,both,,,231.10,150.21,,,,,,,,,,,,,
HC So Urine Cult/Colony Count|NOT REASONABLE AND NECESSARY,PX-3008708666,CDM,87086,CPT,0300,RC,,,GZ,both,,,101.00,65.65,,,,,,,,,,,,,
SPACER SPNL W22XH8XL28MM 4DEG PEEK ANT LUM INTBDY FUS LORD,SUP-2380486,CDM,C1713,HCPCS,0278,RC,,,,both,,,7159.20,4653.48,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED STD CEM SCREW PIN POLYETH,SUP-2212715,CDM,C1713,HCPCS,0278,RC,,,,both,,,12131.77,7885.65,,,,,,,,,,,,,
ALLOGRAFT BNE 1 CC FIBER PLIAFX PRIM,SUP-2741021,CDM,C1713,HCPCS,0278,RC,,,,both,,,518.85,337.25,,,,,,,,,,,,,
BLADE OSTEOTOM SM W50MM S STL FULL HMSPHR EXPLANT,SUP-2210646,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1723.86,1120.51,,,,,,,,,,,,,
PLATE BONE 1MM DIA XL HLX6 CP TTNM STRGHT RIGHT SIDED WTAB,SUP-2677937,CDM,C1713,HCPCS,0278,RC,,,,both,,,1132.91,736.39,,,,,,,,,,,,,
SET INTRO L 60 CM DIA 5 FR SS WIRE SHRT B BVL ECHOGENIC TIP,SUP-2116527,CDM,C1894,HCPCS,0272,RC,,,,both,,,86.35,56.13,,,,,,,,,,,,,
HC So T Helper Cell Cd4,PX-3028636166,CDM,86361,CPT,0302,RC,,,,both,,,165.00,107.25,,,,,,,,,,,,,
COLLAR CERV 2.5X22 IN,SUP-2194374,CDM,L0120,HCPCS,0272,RC,,,,both,,,11.34,7.37,,,,,,,,,,,,,
TRAY CATH PICC GROSH NXT BSC 5FR 0.026N 55CM 2 LUMAN 9927505,SUP-2632712,CDM,C1751,HCPCS,0278,RC,,,,both,,,461.58,300.03,,,,,,,,,,,,,
SPACER TIB SM L10MM DURAMER SL GRDIAN,SUP-2304389,CDM,C1776,CPT,0278,RC,,,,both,,,4144.80,2694.12,,,,,,,,,,,,,
STENT BILI L200MM DIA7MM CATH L135CM DIA6FR 0.035IN NIT OVR,SUP-2420405,CDM,C1876,HCPCS,0278,RC,,,,both,,,7693.00,5000.45,,,,,,,,,,,,,
PROSTHESIS VOICE L10MM LO AIRFLO RESISTANCE PROVOX2,SUP-2124340,CDM,L8509,HCPCS,0272,RC,,,,both,,,624.86,406.16,,,,,,,,,,,,,
POST EXT FIX 3 HOLE STRL TRUELOK EVO LTX,SUP-2875629,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1502.58,976.68,,,,,,,,,,,,,
TUBE VENT DIA1.4MM INNR FLNG DIA3.5MM SIL BVL ARMSTR GRMMT,SUP-2284006,CDM,L8699,HCPCS,0278,RC,,,,both,,,74.26,48.27,,,,,,,,,,,,,
NAIL IM L150MM DIA10MM ANK ARTH PRI N LOK UNIFLEX,SUP-2412888,CDM,C1713,HCPCS,0278,RC,,,,both,,,4169.92,2710.45,,,,,,,,,,,,,
SCREW BONE CNNLTD 7.5MM DIA 115MML TTNM ALLOY PRTLLY THRDD S,SUP-2586462,CDM,C1713,HCPCS,0278,RC,,,,both,,,1925.20,1251.38,,,,,,,,,,,,,
GRAFT VASC STR STD WALL N RING EPTFE STP 5-8MM DIA 45CM LEN,SUP-2127038,CDM,C1768,CPT,0278,RC,,,,both,,,1859.07,1208.40,,,,,,,,,,,,,
WRENCH SURG HEX ROD,SUP-2232099,CDM,C1713,HCPCS,0278,RC,,,,both,,,1127.26,732.72,,,,,,,,,,,,,
BIT DRILL STOP 90 DEGREE 2.2 MM 8 MM FOR SCREWDRIVER NON STE,SUP-2837623,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1028.66,668.63,,,,,,,,,,,,,
SHEATH INTRO PRELUDE L 7 CM DIA 5 FR GUIDEWIRE L 40 CM DIA,SUP-2461396,CDM,C1894,HCPCS,0272,RC,,,,both,,,100.92,65.60,,,,,,,,,,,,,
SHEATH INTRO CLASSICSHEATH L 25 CM DIA 7 FR NDL 18 GA ROBUST,SUP-2302505,CDM,C1894,HCPCS,0272,RC,,,,both,,,117.94,76.66,,,,,,,,,,,,,
OSTEOTOME SURG L120MM DIA12MM FLXIBLE OSTEO FLX,SUP-2375013,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1072.00,696.80,,,,,,,,,,,,,
MESH SURG SM THK0.4MM SLV TI MASTOID MALL CNTOUR LO PROF,SUP-2181584,CDM,C1781,HCPCS,0278,RC,,,,both,,,2485.00,1615.25,,,,,,,,,,,,,
PLATE BONE 11 H PRI RECON W TEMPLT,SUP-2365246,CDM,C1713,HCPCS,0278,RC,,,,both,,,7326.25,4762.06,,,,,,,,,,,,,
WIRE FIX OLV 400 MM KIRSCHNER,SUP-2162650,CDM,2720000010,LOCAL,0272,RC,,,,both,,,856.59,556.78,,,,,,,,,,,,,
SHEATH INTRO DIA 8 FR STRL,SUP-2393093,CDM,C1894,HCPCS,0272,RC,,,,both,,,54.17,35.21,,,,,,,,,,,,,
SHEATH INTRO FLX SHUTTLE L 90 CM OD 8 FR GUIDEWIRE 0.038 IN,SUP-2168797,CDM,C1894,HCPCS,0272,RC,,,,both,,,304.58,197.98,,,,,,,,,,,,,
BALLOON 34CC 9.5,SUP-2227309,CDM,C1725,HCPCS,0272,RC,,,,both,,,185.26,120.42,,,,,,,,,,,,,
PIN EXT FIX L180MM DIA4MM THRD L40MM HALF FOR SIDEKCK FREE,SUP-2400696,CDM,2720000010,LOCAL,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
LEAD NEUROSTIMULATOR L43CM ID2MM 180 TO 250OHM SIL VAGUS NRV,SUP-2175911,CDM,C1778,HCPCS,0278,RC,,,,both,,,21439.92,13935.95,,,,,,,,,,,,,
MESH SURG 8 X 15 CM SUTURE SZ 6-0 OVINE PGA REINF TISS MTRX,SUP-2914799,CDM,C1781,HCPCS,0278,RC,,,,both,,,6327.10,4112.61,,,,,,,,,,,,,
FIBER LASER KIT TMR DISPLAY,SUP-2225629,CDM,2720000010,LOCAL,0272,RC,,,,both,,,10990.00,7143.50,,,,,,,,,,,,,
CATHETER EP MAP SUPREME 4FR QPLR 2-2-2MM ELECTRD SPC JSN,SUP-2356958,CDM,C1730,HCPCS,0272,RC,,,,both,,,584.67,380.04,,,,,,,,,,,,,
GRAFT BONE SUB 3CC CA PHOS INJ VOID FIL FOR SUBCHONDROPLASTY,SUP-2136563,CDM,C1713,HCPCS,0278,RC,,,,both,,,6751.00,4388.15,,,,,,,,,,,,,
LONGEVITY 10 DEG ELEVATED FACE CUP 28X55,SUP-2504682,CDM,C1776,CPT,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
GRAFT VSCLR L50CM D34MM BRNCH D10MM THRCC CLLGN BFRCTD WOVEN,SUP-2464342,CDM,C1768,CPT,0278,RC,,,,both,,,4458.80,2898.22,,,,,,,,,,,,,
ANCHOR SUTURE BRAID 2-0 5 MM SCR IN TI WHT BLU BLK V-LOX,SUP-2762304,CDM,C1713,HCPCS,0278,RC,,,,both,,,728.48,473.51,,,,,,,,,,,,,
BLADE RTRCTR 1 12NW X 1 14ND STNLSS STEEL GRRTT JARIT LATE,SUP-2703325,CDM,2720000010,LOCAL,0272,RC,,,,both,,,669.01,434.86,,,,,,,,,,,,,
CATHETER ART PRESSURE MONITORING SET 018 3 FRX5 CM RADIAL,SUP-2760107,CDM,C1751,HCPCS,0278,RC,,,,both,,,144.91,94.19,,,,,,,,,,,,,
HC So Islet Cell Antibody,PX-3028634166,CDM,86341,CPT,0302,RC,,,,outpatient,,,698.00,453.70,,,,,,,,,,,,,
ALLOGRAFT DERMAL UNMESHED 8X16 CMX1.25-2 MM SFT DERMACELL,SUP-2427791,CDM,Q4122,HCPCS,0636,RC,,,,both,,,10650.88,6923.07,,,,,,,,,,,,,
PIN FIX 2X40 MM BIOTRAK 30249] ACUMED LLC],SUP-2106873,CDM,2780000010,LOCAL,0278,RC,,,,both,,,649.98,422.49,,,,,,,,,,,,,
PLATE BNE LNG LT PLNTR SYS IMPL INSTRUMENT AXIS,SUP-2610216,CDM,C1713,HCPCS,0278,RC,,,,both,,,8666.40,5633.16,,,,,,,,,,,,,
BRACE WRST LEN 6 1 4IN CIRC UP TO 5 3 4IN XSM L REG D RNG W,SUP-2326020,CDM,L3908,HCPCS,0272,RC,,,,both,,,79.54,51.70,,,,,,,,,,,,,
TUBE GASTROSTMY 36FR L107CM CLS ROUNDED TIP SM SIDE H,SUP-2138632,CDM,2720000010,LOCAL,0272,RC,,,,both,,,750.46,487.80,,,,,,,,,,,,,
HC So Islet Cell Antibody,PX-3028634166,CDM,86341,CPT,0302,RC,,,,inpatient,,,698.00,453.70,,,,,,,,,,,,,
MESH HERN ANAT MED 13X9 CM RT PRESHAPED MONOFILAMENT DEXTILE,SUP-2752173,CDM,C1781,HCPCS,0278,RC,,,,both,,,766.00,497.90,,,,,,,,,,,,,
FIBER LASER WAVEGUIDE CARBON DIOX,SUP-2352852,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2812.40,1828.06,,,,,,,,,,,,,
PROSTHESIS OSS L 9 MM SHFT DIA1 MM HD DIA 3.25 MM TI HA FLX,SUP-2902032,CDM,L8613,CPT,0278,RC,,,,both,,,1700.15,1105.10,,,,,,,,,,,,,
PLATE BNE SCREW DIA2.7 MM SM PATELLAR MESH STRL EVOS,SUP-2933646,CDM,C1713,HCPCS,0278,RC,,,,both,,,6575.16,4273.85,,,,,,,,,,,,,
ANCHOR SUT FOR SPNL CRD STIM SWIFT-LOCK,SUP-2355908,CDM,C1713,HCPCS,0278,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
RESERVOIR EXT DRNGE L15CM S STL PLAS SIL RUB BASE 9.5MM BUR,SUP-2243786,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1271.57,826.52,,,,,,,,,,,,,
BLADE RTRCTR MCCLLCH 6CMD SPNL MSCLE MULTI TTHD BLACK FNSH U,SUP-2494073,CDM,2720000010,LOCAL,0272,RC,,,,both,,,623.35,405.18,,,,,,,,,,,,,
PROSTHESIS PENILE PARYLENE INFL NONCONNECTED W/ INHIBIZONE,SUP-2140296,CDM,C1813,HCPCS,0278,RC,,,,both,,,8556.50,5561.72,,,,,,,,,,,,,
PLATE BONE L80MM THK2MM 4 H LAT TIB T SHP BTTRS FOR,SUP-2343788,CDM,C1713,HCPCS,0278,RC,,,,both,,,3106.72,2019.37,,,,,,,,,,,,,
PLATE CRAN 180X20X40 MM PT SPEC IMPL PEEK,SUP-2860120,CDM,C1713,HCPCS,0278,RC,,,,both,,,24613.20,15998.58,,,,,,,,,,,,,
CEMENT BNE 40 GM RADIOPAQUE BA SIMPLEX P,SUP-2374943,CDM,C1713,HCPCS,0278,RC,,,,both,,,188.40,122.46,,,,,,,,,,,,,
GRAFT TEND PERONEUS LONGUS ALLGRFT FRZ DRY 22 38CM L 6 12MM,SUP-2307130,CDM,C1762,CPT,0278,RC,,,,both,,,4370.63,2840.91,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL PEEK SD800.515,SUP-2860197,CDM,C1713,HCPCS,0278,RC,,,,both,,,29578.49,19226.02,,,,,,,,,,,,,
HC Creatine Kinase Total,PX-3018255000,CDM,82550,CPT,0301,RC,,,,both,,,160.00,104.00,,,,,,,,,,,,,
CATHETER ETER FULL TY STR RADPQ TIP POLYUR 11 FR 15 CM,SUP-2269566,CDM,C1750,HCPCS,0278,RC,,,,both,,,254.34,165.32,,,,,,,,,,,,,
TAP BONE MMF FOR LAG SCR LEIBINGER UNIV FIX SYS 2.0MM,SUP-2364416,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1224.60,795.99,,,,,,,,,,,,,
GUIDEWIRE ORTH L 150 MM DIA1.4 MM SCREW DIA 3.5/4 MM TROCAR,SUP-2908060,CDM,C1769,HCPCS,0272,RC,,,,both,,,312.56,203.16,,,,,,,,,,,,,
GUIDEWIRE ENDO L480CM OD0.035IN LOOP TIP 2X4MM NIT SPRL MRK,SUP-2170836,CDM,C1769,HCPCS,0272,RC,,,,both,,,527.52,342.89,,,,,,,,,,,,,
CLAMP SURG 4-6X11 MM OPN PIN TO ROD TRANSFX,SUP-2362752,CDM,2720000010,LOCAL,0272,RC,,,,both,,,687.66,446.98,,,,,,,,,,,,,
BUR SURG OVL 4 MMX10 CM SM BOR MIDAS REX LEGEND,SUP-2627641,CDM,2720000010,LOCAL,0272,RC,,,,both,,,333.78,216.96,,,,,,,,,,,,,
PACEMAKER CARD DISCOVERY II DR W 44 X H 52 MM THK 7 MM 28.7,SUP-2148605,CDM,C1785,HCPCS,0275,RC,,,,both,,,16312.30,10602.99,,,,,,,,,,,,,
CATHETER PERITONEAL SHUNT 1.3X2.5 MMX90 CM MED PUDENZ,SUP-2852590,CDM,C1729,HCPCS,0272,RC,,,,both,,,639.34,415.57,,,,,,,,,,,,,
LENS INTOCU 6.0 TO 30.0 DIOPT 118.7 A CONSTANT 0DEG ANG,SUP-2111276,CDM,V2632,HCPCS,0276,RC,,,,both,,,238.64,155.12,,,,,,,,,,,,,
CANNULA VENT ASST 32FR L10MM LT ART AB KT BYPS FOR BLD PMP,SUP-2106273,CDM,2720000010,LOCAL,0272,RC,,,,both,,,141300.00,91845.00,,,,,,,,,,,,,
SPHERE GLEN INFERIOR 2.5+ MM 24X45 MM,SUP-2845825,CDM,C1776,CPT,0278,RC,,,,both,,,7222.00,4694.30,,,,,,,,,,,,,
HC Iaad Ia Rotavirus,PX-3068742500,CDM,87425,CPT,0306,RC,,,,inpatient,,,186.00,120.90,,,,,,,,,,,,,
DEFIBRILLATOR IMPL LUMOS DR-T SZ 6.7 CM TI EPOXY RESIN SIL 2,SUP-2138062,CDM,C1721,HCPCS,0275,RC,,,,both,,,43702.52,28406.64,,,,,,,,,,,,,
CATHETER NEPHROSTOMY BLLN 8 MMX15 CM SET VLY CLR ULTRAXX,SUP-2836029,CDM,C1726,HCPCS,0272,RC,,,,both,,,1281.43,832.93,,,,,,,,,,,,,
ALLOGRAFT BNE STRP 65X10X15-25 MM FD TRICORT IL CREST,SUP-2866879,CDM,C1762,CPT,0278,RC,,,,both,,,2088.10,1357.26,,,,,,,,,,,,,
PLATE BNE L72MM 12 H TI STR NONCOMPRESSION RIG FOR 2.4MM,SUP-2191470,CDM,C1713,HCPCS,0278,RC,,,,both,,,1340.84,871.55,,,,,,,,,,,,,
PACEMAKER CARD ALTURA20 TI 2 CHMBR 2 LD BATTERY PWR STRL,SUP-2149111,CDM,C1785,HCPCS,0275,RC,,,,both,,,13816.00,8980.40,,,,,,,,,,,,,
PLATE BNE L 235.6 X W 8.3 MM THK 2.6 MM SCREW DIA2/2.3 MM,SUP-2936852,CDM,C1713,HCPCS,0278,RC,,,,both,,,8364.96,5437.22,,,,,,,,,,,,,
SPLINT THMB UNIV NEOPRENE PERF W DORS RAD PALMAR STAY PKT,SUP-2196849,CDM,L3923,HCPCS,0272,RC,,,,both,,,30.14,19.59,,,,,,,,,,,,,
BUR SURG L15CM DIA3MM CYL COARSE DMND SM BOR MIDAS REX,SUP-2277787,CDM,2720000010,LOCAL,0272,RC,,,,both,,,698.59,454.08,,,,,,,,,,,,,
TITANIUM MESH TRAY HEMI MANDIBLE RIGHT CP TITANIUM,SUP-2679029,CDM,C1713,HCPCS,0278,RC,,,,both,,,10268.40,6674.46,,,,,,,,,,,,,
PLATE BNE 5 DEG 7 DEG RT VALGUS MOD,SUP-2438048,CDM,C1713,HCPCS,0278,RC,,,,both,,,438.03,284.72,,,,,,,,,,,,,
HOOK SPNL DIA4.5MM CERVICOTHORACIC LAM VERTEX MAX,SUP-2286783,CDM,C1713,HCPCS,0278,RC,,,,both,,,1044.05,678.63,,,,,,,,,,,,,
SCREW BNE ALIGN HIPLOC,SUP-2466135,CDM,C1713,HCPCS,0278,RC,,,,both,,,725.34,471.47,,,,,,,,,,,,,
SCREW SPNL L40MM DIA5.5MM HA VAR ANG INTERCONTINENTAL,SUP-2230588,CDM,C1713,HCPCS,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
SCREW BONE EMERGENCY 2.7X6 MM MANDIBULAR SELFTAPPING 20/PK T,SUP-2842299,CDM,C1713,HCPCS,0278,RC,,,,both,,,395.86,257.31,,,,,,,,,,,,,
PLATE BNE L 157 X W 12 MM THK 3 MM SCREW DIA 4.5 MM DISTANCE,SUP-2908103,CDM,C1713,HCPCS,0278,RC,,,,both,,,2011.45,1307.44,,,,,,,,,,,,,
KIT BONE GRFT SUB KNEE INSTR FOR SUBCHONDROPLASTY ACCUPORT,SUP-2206118,CDM,C1713,HCPCS,0278,RC,,,,both,,,7222.00,4694.30,,,,,,,,,,,,,
PLATE BNE LCK LG RT CALCANEAL FOR MINIMALLY INVASIVE SURG NS,SUP-2525058,CDM,C1713,HCPCS,0278,RC,,,,both,,,2881.33,1872.86,,,,,,,,,,,,,
PLATE BNE 5MM MED OSTEOTMY WDG,SUP-2400259,CDM,C1713,HCPCS,0278,RC,,,,both,,,2420.94,1573.61,,,,,,,,,,,,,
PLATE BNE THK15MM SHT TI FIX CRV LOK,SUP-2262964,CDM,C1713,HCPCS,0278,RC,,,,both,,,1847.14,1200.64,,,,,,,,,,,,,
PLATE BNE L184MM 9 H R MED DST TIB TIM LOK COMPR FOR 3.5MM,SUP-2413703,CDM,C1713,HCPCS,0278,RC,,,,both,,,4422.50,2874.62,,,,,,,,,,,,,
LINER TRL RNWT BRSTN MAX-TI SIZE: 64X32,SUP-2403318,CDM,C1776,CPT,0278,RC,,,,both,,,1871.44,1216.44,,,,,,,,,,,,,
PROBE LITHO 3FR FOR PNEUMAT SWISS LITHOCLAST,SUP-2141769,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2436.64,1583.82,,,,,,,,,,,,,
HC ED Clsd Tx Shdr W Fx WO Anes,PX-4502366500,CDM,23665,CPT,0450,RC,,,,both,,,1633.00,1061.45,,,,,,,,,,,,,
KIT INTRO ELITE HV L 7 CM DIA 3 FR GUIDEWIRE L 40 CM DIA,SUP-2615941,CDM,C1894,HCPCS,0272,RC,,,,both,,,143.62,93.35,,,,,,,,,,,,,
TROCAR ENDOSCP L100MM DIA12MM BLDELSS OBT RADLUC STBL SL,SUP-2218264,CDM,2720000010,LOCAL,0272,RC,,,,both,,,644.92,419.20,,,,,,,,,,,,,
PLATE BONE 6X18 H RT MAND TI ANG RIG NONCOMPRESSION,SUP-2191418,CDM,C1713,HCPCS,0278,RC,,,,both,,,6016.24,3910.56,,,,,,,,,,,,,
LINER HUM DIA52MM SHLDR ARCM BPLR ABS,SUP-2404525,CDM,C1776,CPT,0278,RC,,,,both,,,800.70,520.45,,,,,,,,,,,,,
INSERT WEDGE TRIAL,SUP-2473324,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1053.28,684.63,,,,,,,,,,,,,
BEARING TIB M A5 THK5MM UNIV R LAT L MED CO CHROM ARCM UNI,SUP-2409282,CDM,C1776,CPT,0278,RC,,,,both,,,4239.00,2755.35,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 220 MM DIA22/13 MM DEL,SUP-2934472,CDM,C1713,HCPCS,0278,RC,,,,both,,,21714.26,14114.27,,,,,,,,,,,,,
PERTUZ-TRASTUZ-HYALURON-ZZXF 60-60-2000 MG-MG-U/ML SC SOLN,RX-151268,CDM,J9316,HCPCS,0636,RC,50242-0260-01,NDC,,both,10,ML,26718.70,17367.15,,,,,,,,,,,,,
TIP OSTEOTOM DIA4MM HELIX DISP FOR ULTRASONIC REV SYS UDRV,SUP-2136774,CDM,2720000010,LOCAL,0272,RC,,,,both,,,771.50,501.47,,,,,,,,,,,,,
TRAY CATH PICC GROSH NXT BSC 5FR 0.026N 55CM 2 LUMAN 7957505,SUP-2632688,CDM,C1751,HCPCS,0278,RC,,,,both,,,487.89,317.13,,,,,,,,,,,,,
CANNULA ENDOSCP TERMANIAN ENDOTIP 13 MMX15 CM STOPCOCK,SUP-2768545,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1961.31,1274.85,,,,,,,,,,,,,
GRAFT HUM TISS SEMITENDINOSUS TEND FRZN,SUP-2137250,CDM,C1762,CPT,0278,RC,,,,both,,,4747.68,3085.99,,,,,,,,,,,,,
SIDEPLATE STD BARL 145 DEG 8H STRL LCP DHHS,SUP-2547674,CDM,C1713,HCPCS,0278,RC,,,,both,,,2319.58,1507.73,,,,,,,,,,,,,
Elite H Continuous Compression Implant 20x20x13mm 4 Legs,SUP-2550446,CDM,C1713,HCPCS,0278,RC,,,,both,,,6591.93,4284.75,,,,,,,,,,,,,
CAGE SPNL MESH 15X12X16 MM 6 LOBE,SUP-2602075,CDM,C1889,HCPCS,0278,RC,,,,both,,,9479.66,6161.78,,,,,,,,,,,,,
CATHETER REPERFUSION L200CM WRK L155CM DIA0.022IN PROX CONT,SUP-2323631,CDM,C1757,HCPCS,0272,RC,,,,both,,,6876.60,4469.79,,,,,,,,,,,,,
LINER ACET OD54MM ID22MM POLYETH CONSTRN R3,SUP-2345189,CDM,C1776,CPT,0278,RC,,,,both,,,7391.56,4804.51,,,,,,,,,,,,,
IMPLANT TOE JT STD METATRSL,SUP-2319765,CDM,C1776,CPT,0278,RC,,,,both,,,3538.78,2300.21,,,,,,,,,,,,,
CULTURELLE KIDS PO PACK,RX-116260,CDM,6370000000,HCPCS,0637,RC,49100-0400-08,NDC,,both,1,UN,2.80,1.82,,,,,,,,,,,,,
COIL NEUROVASCULAR CEREPAK HELIFORM XTRASOFT XL L 4 CM DIA2,SUP-2865277,CDM,C1889,HCPCS,0278,RC,,,,both,,,6057.56,3937.41,,,,,,,,,,,,,
PLATE BNE BAR L8MM THK1MM 4 H CRANIOMAXILLOFACIAL TI MINI,SUP-2366314,CDM,C1713,HCPCS,0278,RC,,,,both,,,510.00,331.50,,,,,,,,,,,,,
RETRACTOR KIT FOR INTERCONTINENTAL PLATE SPACER SYS MARS 3V,SUP-2232230,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2920.20,1898.13,,,,,,,,,,,,,
PIN POS 5MM TI CRMP FOR ORTH CBL SYS,SUP-2181298,CDM,C1713,HCPCS,0278,RC,,,,both,,,750.33,487.71,,,,,,,,,,,,,
GUIDEWIRE VASC L300CM DIA0.014IN ANG TIP TAPR L7CM JOURNEY,SUP-2148155,CDM,C1769,HCPCS,0272,RC,,,,both,,,531.92,345.75,,,,,,,,,,,,,
SCREW INTFR L30MM DIA10MM BIOCRYL RAPIDE ABSRB MILAGRO ADV,SUP-2249516,CDM,C1713,HCPCS,0278,RC,,,,both,,,1648.50,1071.52,,,,,,,,,,,,,
BOOT WALKING PNEUMATIC,SUP-2382018,CDM,L4360,HCPCS,0274,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
CEMENT BNE 40GM PCH HI VISC CO,SUP-2196556,CDM,C1713,HCPCS,0278,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
APPLICATOR ABLATN 29 CM FOR MICROWAVE TISS SYS SOLERO,SUP-2752480,CDM,2720000010,LOCAL,0272,RC,,,,both,,,10676.00,6939.40,,,,,,,,,,,,,
REAMER SURG DIA25MM PAT BLDE BIT PFC SIG,SUP-2253897,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
GUIDEWIRE ORTH L150MM DIA1.1MM S STL THRD FOR 3MM CANN SCR,SUP-2186884,CDM,C1769,HCPCS,0272,RC,,,,both,,,73.29,47.64,,,,,,,,,,,,,
MATRIX BIO L 9.4 X W 7.9 IN SZ 480 SQCM PORCINE TEND DERIVED,SUP-2909328,CDM,A2008,HCPCS,0636,RC,,,,both,,,24617.60,16001.44,,,,,,,,,,,,,
DEFIBRILLATOR IMPL INOGEN MINI TI SINGLE CHMBR DF4 CONN 1 LD,SUP-2140375,CDM,C1722,HCPCS,0275,RC,,,,both,,,52752.00,34288.80,,,,,,,,,,,,,
LINER ACET SZ QU OD68MM ID28MM STD DURASUL UNCEMENTED HOOD,SUP-2205267,CDM,C1776,CPT,0278,RC,,,,both,,,6719.60,4367.74,,,,,,,,,,,,,
GRAFT AMNIOTIC MEMBRANE FLOWERAMNIOPATCH 12MM DISC SIZE,SUP-2866791,CDM,Q4178,HCPCS,0636,RC,,,,both,,,3925.00,2551.25,,,,,,,,,,,,,
LENS IOL MN60AC,SUP-2110511,CDM,V2632,HCPCS,0276,RC,,,,both,,,593.46,385.75,,,,,,,,,,,,,
PLATE BNE BROAD 4.5X135 MM 8 HOLE SS DCP,SUP-2569176,CDM,C1713,HCPCS,0278,RC,,,,both,,,388.58,252.58,,,,,,,,,,,,,
BRACE WALKING 14-17 IN XL CUSH LP NYL PROCARE MAXTRAX,SUP-2197143,CDM,L4360,HCPCS,0272,RC,,,,both,,,83.15,54.05,,,,,,,,,,,,,
KNIFE SURG FUKUSHIMA CHEN 7.5 INX1 MM RND RUGGLES-REDMOND,SUP-2476692,CDM,2720000010,LOCAL,0272,RC,,,,both,,,465.60,302.64,,,,,,,,,,,,,
MESH HERN W3XL4.75IN L PLA PRECUT FLAP STYL PARTIALLY ABSRB,SUP-2174790,CDM,C1781,HCPCS,0278,RC,,,,both,,,785.41,510.52,,,,,,,,,,,,,
CATHETER HD PRECRV 11.5 FRX15 CM SHT TERM DL TAPR SOFT-LINE,SUP-2627328,CDM,C1752,HCPCS,0278,RC,,,,both,,,20.41,13.27,,,,,,,,,,,,,
PLATE BNE L275MM 18 H NONSTERILE R MED PROX TIB S STL LOK,SUP-2185658,CDM,C1713,HCPCS,0278,RC,,,,both,,,4439.90,2885.93,,,,,,,,,,,,,
TRAY KYPHOPLASTY SZ 3 BLLN L15MM SYR 30ML 11GA 1ST FRAC,SUP-2293651,CDM,2720000010,LOCAL,0272,RC,,,,both,,,9734.00,6327.10,,,,,,,,,,,,,
BLADE SHV DIA4MM STD STR SERR CLS ELITE COMPATIBLE DIEGO DS,SUP-2313525,CDM,2720000010,LOCAL,0272,RC,,,,both,,,390.87,254.07,,,,,,,,,,,,,
MESH SURG PELV FLR REP FEM INNOVATIVE DSGN RDY TO USE SFT,SUP-2219785,CDM,C1771,HCPCS,0278,RC,,,,both,,,6829.50,4439.17,,,,,,,,,,,,,
GUIDEWIRE VASC L180CM DIA0.032IN TIP L7CM PTFE COAT S STL,SUP-2355271,CDM,C1769,HCPCS,0272,RC,,,,both,,,47.10,30.61,,,,,,,,,,,,,
GRAFT TISS FRZN FEM CORT STRUT 200MML THIRDS 3MM,SUP-2307539,CDM,C1713,HCPCS,0278,RC,,,,both,,,2298.48,1494.01,,,,,,,,,,,,,
ALLOGRAFT BNE TIB 210X3 MM FD STRUT 1/2 SPLIT 31026021,SUP-2717902,CDM,C1762,CPT,0278,RC,,,,both,,,4498.65,2924.12,,,,,,,,,,,,,
SPHERE GLEN SHLDR,SUP-2199131,CDM,C1776,CPT,0278,RC,,,,both,,,4672.32,3037.01,,,,,,,,,,,,,
PLATE BNE RECON 3.5X112 MM 8 HOLE SS LCP,SUP-2569392,CDM,C1713,HCPCS,0278,RC,,,,both,,,428.30,278.39,,,,,,,,,,,,,
LINER ACET CUP NEUT PRI CEM MTL ON POLY ULT HI MOL WT,SUP-2203661,CDM,C1776,CPT,0278,RC,,,,both,,,5044.10,3278.66,,,,,,,,,,,,,
ANCHOR SUT OD3.4MM BIOCRYL RAPIDE DBL ARMED NONABSORBABLE,SUP-2256665,CDM,C1713,HCPCS,0278,RC,,,,both,,,1526.04,991.93,,,,,,,,,,,,,
PLATE BNE PERIPROSTHETIC TROCHANTERIC NCB,SUP-2474541,CDM,C1713,HCPCS,0278,RC,,,,both,,,4595.17,2986.86,,,,,,,,,,,,,
SHEET HEMSTAT W7XL7CM CLLGN MICFIB ABSRB NONWOVEN AVIT,SUP-2125826,CDM,C1713,HCPCS,0278,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
STIMULATOR NERVE 5.55X4.95X1.34 CM,SUP-2637205,CDM,C1767,HCPCS,0278,RC,,,,both,,,34372.67,22342.24,,,,,,,,,,,,,
GUIDEWIRE VASC COMBOWIRE L 300 CM DIA 0.014 IN OFFSET 1.5 CM,SUP-2393126,CDM,C1769,HCPCS,0272,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
MESH SURG DIA20 30CM WHT POLY CLLGN FLM RECT MFIL BIOABSRB,SUP-2283403,CDM,C1781,HCPCS,0278,RC,,,,both,,,7298.46,4744.00,,,,,,,,,,,,,
NERVE STIMULATOR KIT W/ PULSE GENRTR PERC LD,SUP-2563687,CDM,C1883,HCPCS,0278,RC,,,,both,,,285.74,185.73,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC SV BSC 4FR 55CM 2 LUMAN RVS 3274118,SUP-2632664,CDM,C1751,HCPCS,0278,RC,,,,both,,,513.77,333.95,,,,,,,,,,,,,
SCREW BNE L24MM DIA3MM THRD L8MM CANC S STL ST SELF DRL,SUP-2184994,CDM,C1713,HCPCS,0278,RC,,,,both,,,796.08,517.45,,,,,,,,,,,,,
SOLUTION HEMOSTATIC NDL L 4 MM DIA25 GA WORKING L 230 CM 30,SUP-2912525,CDM,C1889,HCPCS,0278,RC,,,,both,,,2041.00,1326.65,,,,,,,,,,,,,
SCREW BNE L 20 MM DIA2.4 MM TI FUSION FOR HND PLATING SYS NS,SUP-2913056,CDM,C1713,HCPCS,0278,RC,,,,both,,,1023.64,665.37,,,,,,,,,,,,,
DRIVER SURG AO CONN FINAL FOR POLYAX LOK SCR DST VOLAR RAD,SUP-2421214,CDM,2720000010,LOCAL,0272,RC,,,,both,,,341.63,222.06,,,,,,,,,,,,,
N S BIPOLAR STRAIGHT ANGLED 03MM,SUP-2703459,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1613.11,1048.52,,,,,,,,,,,,,
SCREW BONE L10MM DIA2.4MM PARTIALLY THRD HD SM CANN,SUP-2225320,CDM,C1713,HCPCS,0278,RC,,,,both,,,619.84,402.90,,,,,,,,,,,,,
STEM HUM L100MM DIA9MM LNG UNIV SHLDR CO CHROM HA CEM PRI,SUP-2388646,CDM,C1776,CPT,0278,RC,,,,both,,,8082.36,5253.53,,,,,,,,,,,,,
SCREW BONE L6MM THRD DIA2.7MM HD DIA4.5MM COR DIA2MM PITCH,SUP-2349291,CDM,C1713,HCPCS,0278,RC,,,,both,,,215.50,140.07,,,,,,,,,,,,,
SD BLADE 2.0MM PHLLPS WSLVE 2.0MMBSNRORCT USR DRVR,SUP-2682214,CDM,2720000010,LOCAL,0272,RC,,,,both,,,892.51,580.13,,,,,,,,,,,,,
PLATE BONE 107MML HLX8 STNLSS STEEL BTTRSS F/3.5MM/4MM CRTCL,SUP-2478773,CDM,C1713,HCPCS,0278,RC,,,,both,,,2318.29,1506.89,,,,,,,,,,,,,
PLATE BNE L137MM THK3.4MM 10 H BILAT S STL STR LOK COMPR,SUP-2185142,CDM,C1713,HCPCS,0278,RC,,,,both,,,981.22,637.79,,,,,,,,,,,,,
PROBE VASC STERILIZABLE 8MHZ,SUP-2381493,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1165.94,757.86,,,,,,,,,,,,,
MICROCATHETER VASC MC18 + STRL,SUP-2367766,CDM,C1757,HCPCS,0272,RC,,,,both,,,1868.30,1214.39,,,,,,,,,,,,,
SUPPORT ORTHOT SACROILIAC PELV CUST W/PANEL STRP PENDULOUS,SUP-2435553,CDM,L0623,HCPCS,0274,RC,,,,both,,,501.05,325.68,,,,,,,,,,,,,
DRILL TWST L 114.94 MM DIA1.8 MM STP 26 MM SS QC NS DISP,SUP-2936562,CDM,2720000010,LOCAL,0272,RC,,,,both,,,882.34,573.52,,,,,,,,,,,,,
SUPPORT ORTHOT FT CUST ARCH N REMOVABLE ATTCH TO SHOE,SUP-2435707,CDM,L3070,HCPCS,0272,RC,,,,both,,,90.02,58.51,,,,,,,,,,,,,
CATHETER CV FULL TY 7 FRX15 CM 3L CUTLMY701JABRMCUSTOM0053,SUP-2759701,CDM,C1751,HCPCS,0278,RC,,,,both,,,556.09,361.46,,,,,,,,,,,,,
PPICC PROV SOLO 5F TL BASIC W/TLS,SUP-2613562,CDM,C1751,HCPCS,0278,RC,,,,both,,,793.54,515.80,,,,,,,,,,,,,
"HC Culture, Chlamydia, Any Source",PX-3008711000,CDM,87110,CPT,0300,RC,,,,both,,,185.00,120.25,,,,,,,,,,,,,
PLATE BNE DBL T MINI REG 2X0.5 MM LP W/ BAR TI LEVEL 1 LF,SUP-2471249,CDM,C1713,HCPCS,0278,RC,,,,both,,,557.38,362.30,,,,,,,,,,,,,
CATHETER CV KT 8 FRX16 CM DL PRESSURE INJ J ARROWG+ARD BLU,SUP-2763338,CDM,C1751,HCPCS,0278,RC,,,,both,,,258.11,167.77,,,,,,,,,,,,,
SUTURE NONABSORBABLE MONOFILAMENT 7-0 BV-1 24 IN PROLENE D8228,SUP-2218935,CDM,C1713,HCPCS,0278,RC,,,,both,,,650.17,422.61,,,,,,,,,,,,,
HC So Tacrolimus,PX-3018019766,CDM,80197,CPT,0301,RC,,,,outpatient,,,118.00,76.70,,,,,,,,,,,,,
HANDPIECE ELECSURG 23KHZ NOSECONE DISP CUSA EXCEL,SUP-2243964,CDM,2720000010,LOCAL,0272,RC,,,,both,,,753.60,489.84,,,,,,,,,,,,,
PLATE BNE L149MM 8 H R DST ANTLAT TIB S STL LOK FOR 35 4MM,SUP-2362745,CDM,C1713,HCPCS,0278,RC,,,,both,,,6134.62,3987.50,,,,,,,,,,,,,
NAIL IM L340MM OD11MM TIB PICCOLO,SUP-2152616,CDM,C1713,HCPCS,0278,RC,,,,both,,,4696.81,3052.93,,,,,,,,,,,,,
HOLDER NDLE 13 1/4NL 7MMW TIP TNGSTN CRBDE STRGHT F/SZE 40 N,SUP-2473723,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2778.08,1805.75,,,,,,,,,,,,,
HC So Tacrolimus,PX-3018019766,CDM,80197,CPT,0301,RC,,,,inpatient,,,118.00,76.70,,,,,,,,,,,,,
GRAFT BNE 8X4MM CALCANEOCUBOID JT WDG,SUP-2321655,CDM,C1776,CPT,0278,RC,,,,both,,,6341.23,4121.80,,,,,,,,,,,,,
CANNULA ARTHSCP L165MM W/ OBT FOR TRNSPRT HIP ACCS SYS SCP,SUP-2366745,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1316.16,855.50,,,,,,,,,,,,,
GRAFT DELIVERY SYSTEM SET 3 CC GRFT DBF CANN ACCELERATE BG,SUP-2766771,CDM,C1713,HCPCS,0278,RC,,,,both,,,2451.12,1593.23,,,,,,,,,,,,,
COIL VASC EMBOLD L 15 CM DIA 5 MM CATH LUMEN DIA 0.021 IN,SUP-2753948,CDM,C1889,HCPCS,0278,RC,,,,both,,,3529.36,2294.08,,,,,,,,,,,,,
TRAY NERVE BLOCK ST200C OPM BPSK STRL LF DISP DESIGN OPTIONS,SUP-2936588,CDM,2720000010,LOCAL,0272,RC,,,,both,,,36.68,23.84,,,,,,,,,,,,,
TRIAL SPNL 16MM IMPL ALLGRFT DANEK,SUP-2292302,CDM,C1713,HCPCS,0278,RC,,,,both,,,1089.99,708.49,,,,,,,,,,,,,
LEAD NEUROSTIMULATOR L70CM SURG FOR SPNL CRD STIM ARTISAN,SUP-2138837,CDM,C1778,HCPCS,0278,RC,,,,both,,,10990.00,7143.50,,,,,,,,,,,,,
SCREW BNE L19MM OD2.7MM LOK FOR PLT TUFFNEK TECHNOLOGY,SUP-2321106,CDM,C1713,HCPCS,0278,RC,,,,both,,,665.68,432.69,,,,,,,,,,,,,
MESH SURG DIA15CM WHT POLY CLLGN FLM RND MFIL BIOABSRB,SUP-2283398,CDM,C1781,HCPCS,0278,RC,,,,both,,,1719.90,1117.93,,,,,,,,,,,,,
TRAY KYPHOPLASTY BLLN 4ML L10MM DIA15.5MM NDL 11GA SYR 20ML,SUP-2367067,CDM,C1726,HCPCS,0272,RC,,,,both,,,3592.16,2334.90,,,,,,,,,,,,,
SCREW SPNL STR RAIL 4.5X500 MM DEFORMITY TI MESA RAIL 4D,SUP-2538575,CDM,C1713,HCPCS,0278,RC,,,,both,,,5770.32,3750.71,,,,,,,,,,,,,
SHEATH INTRO PRELUDEEASE 23CM 7FR 80CM NDL 4CM NIT PLAT,SUP-2740568,CDM,C1894,HCPCS,0272,RC,,,,both,,,187.93,122.15,,,,,,,,,,,,,
NECK FEM 12/14 TAPR 8 DEG 32MM MOD CERASIV,SUP-2216772,CDM,C1776,CPT,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
PLATE BNE MEDL RT PLNTR W/ TALAR WRP AXIS,SUP-2610178,CDM,C1713,HCPCS,0278,RC,,,,both,,,8383.80,5449.47,,,,,,,,,,,,,
SET HAD CATH 12.5FR L24CM STR DIL GWIRE ADH DSG INTRO NDL,SUP-2267004,CDM,C1752,HCPCS,0278,RC,,,,both,,,492.98,320.44,,,,,,,,,,,,,
ANCHOR SUT DIA55MM PEEK OPTMA POLYMER 3 NO2 MAXBRAID W O,SUP-2212837,CDM,C1713,HCPCS,0278,RC,,,,both,,,1315.66,855.18,,,,,,,,,,,,,
HC Subsequent Immun Admin,PX-7719047200,CDM,90472,CPT,0771,RC,,,,inpatient,,,65.00,42.25,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY WEBST CS L 115 CM DIA 7 FR SPC,SUP-2535607,CDM,C1730,HCPCS,0272,RC,,,,both,,,792.91,515.39,,,,,,,,,,,,,
GUIDEWIRE VASC L335CM DIA0.014IN IMAG SPR COIL TIP INTVENT,SUP-2159528,CDM,C1769,HCPCS,0272,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
WASHER ORTHOPEDIC 1.5MM X 15MM DYNANAIL HELIX,SUP-2878685,CDM,C1713,HCPCS,0278,RC,,,,both,,,266.90,173.48,,,,,,,,,,,,,
GUIDEPIN ORTH L248MM DIA3.2MM TIP THRD TRIGEN,SUP-2348122,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1148.27,746.38,,,,,,,,,,,,,
SPLINT ANK STRRP AIR AND FOAM TRAINER,SUP-2276707,CDM,L4350,HCPCS,0272,RC,,,,both,,,40.47,26.31,,,,,,,,,,,,,
WASHER ORTH BOLT SPIK OSS,SUP-2441741,CDM,C1713,HCPCS,0278,RC,,,,both,,,649.98,422.49,,,,,,,,,,,,,
SHEATH GUID DESTINATION W/ 5CM HYDRPHLC COAT TOUHY BORST,SUP-2385272,CDM,C1894,HCPCS,0272,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
HC Pt Therapeutic Activities 15 Min|OP PT SERVICES|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS|UNUSUAL NON-OVERLAPPING SERVICE,PX-4209753000,CDM,97530,CPT,0420,RC,,,GP|CQ|XU,both,,,144.00,93.60,,,,,,,,,,,,,
PLATE BNE L40MM 2X4 H BILAT S STL T SHP LO PROF RIG NEUT,SUP-2186360,CDM,C1713,HCPCS,0278,RC,,,,both,,,1931.38,1255.40,,,,,,,,,,,,,
PLATE BONE M W9XL78MM THK2.5MM 8 H TI STR LO PROF FOR,SUP-2225499,CDM,C1713,HCPCS,0278,RC,,,,both,,,1670.48,1085.81,,,,,,,,,,,,,
SHEPARD GRMMT VENT TUBE 102MM ID BLUE FLRPLSTC 30 PACK,SUP-2669497,CDM,L8699,HCPCS,0278,RC,,,,both,,,21.48,13.96,,,,,,,,,,,,,
PLATE BNE BROAD 4.5X143 MM 8 HOLE SS LCP,SUP-2569361,CDM,C1713,HCPCS,0278,RC,,,,both,,,594.09,386.16,,,,,,,,,,,,,
GRAFT BNE SM TRICORT BLK FOR OSTEOTMY ALLOPURE,SUP-2400549,CDM,C1762,CPT,0278,RC,,,,both,,,5469.88,3555.42,,,,,,,,,,,,,
VECURONIUM BROMIDE 10 MG IV SOLR,RX-11634,CDM,2500000003,HCPCS,0250,RC,67457-0438-00,NDC,,both,1,UN,54.10,35.16,,,,,,,,,,,,,
CATHETER CARD ABLATION EZ STEER THERMOCOOL L 115 CM 8FR STRL,SUP-2257364,CDM,C1733,HCPCS,0272,RC,,,,both,,,9420.00,6123.00,,,,,,,,,,,,,
EXPEL APD 8.3/20,SUP-2652752,CDM,C1729,HCPCS,0272,RC,,,,both,,,276.32,179.61,,,,,,,,,,,,,
DEFIBRILLATOR IMPL VENTAK PRIZM VR DEL ENERGY 27 J TI SINGLE,SUP-2148616,CDM,C1722,HCPCS,0275,RC,,,,both,,,66254.00,43065.10,,,,,,,,,,,,,
GUIDE DRL DIA2.3MM S STL REM SPCR DISP,SUP-2164968,CDM,2720000010,LOCAL,0272,RC,,,,both,,,657.05,427.08,,,,,,,,,,,,,
MESH CRAN L 100 X W 120 MM SCREW DIA2 MM TI PANEL NS DISP,SUP-2936730,CDM,C1713,HCPCS,0278,RC,,,,both,,,3909.30,2541.04,,,,,,,,,,,,,
GUIDEWIRE VASC L180CM DIA0.018IN TIP L3CM NIT HYDRPHLC STD,SUP-2385560,CDM,C1769,HCPCS,0272,RC,,,,both,,,194.68,126.54,,,,,,,,,,,,,
PLATE BNE L111MM 4 H LNG L MED DST HUM S STL VAR ANG LOK,SUP-2177603,CDM,C1713,HCPCS,0278,RC,,,,both,,,3871.46,2516.45,,,,,,,,,,,,,
TAP SURG DIA2 MM MIDFACE CNTR DRV NO HNDL NS DISP LORENZ,SUP-2937013,CDM,2720000010,LOCAL,0272,RC,,,,both,,,646.84,420.45,,,,,,,,,,,,,
TUBE T SILICONE 16FR STRL,SUP-2715876,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1215.37,789.99,,,,,,,,,,,,,
PLATE SPINAL MEDIUM 16X16 MM 4 HOLE LOW PROFILE BOX NEURO TI,SUP-2838358,CDM,C1713,HCPCS,0278,RC,,,,both,,,904.32,587.81,,,,,,,,,,,,,
MESH HERN W15XL15CM POLYGLACTIN 910 WVN KNIT VCRL,SUP-2220333,CDM,C1781,HCPCS,0278,RC,,,,both,,,1539.60,1000.74,,,,,,,,,,,,,
CATHETER ANGIOPLSTY MAV XL MR L 153 CM BALLOON L 15 CM DIA 5,SUP-2140562,CDM,C1725,HCPCS,0272,RC,,,,both,,,737.90,479.63,,,,,,,,,,,,,
TRAY TIB SZ 2 AP42.6MM ML64.6MM THK25MM STEM L61.8MM THCK,SUP-2250930,CDM,C1776,CPT,0278,RC,,,,both,,,17933.17,11656.56,,,,,,,,,,,,,
CATHETER KIT 3 W 0.025 IN 8 FR 40 CC REPL INSRTN LUER,SUP-2877620,CDM,2720000010,LOCAL,0272,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
CONNECTOR SPINE 5.5MM SACR AND SACROILIAC TI COLORADO 2,SUP-2290605,CDM,C1713,HCPCS,0278,RC,,,,both,,,3764.86,2447.16,,,,,,,,,,,,,
PLATE BNE 2.7 MM W/ 5 MM STP NS LTX,SUP-2857025,CDM,C1713,HCPCS,0278,RC,,,,both,,,3378.64,2196.12,,,,,,,,,,,,,
COVER BURR H DIA13 MM THK 0.5 MM PROF THK 0.6 MM SCREW DIA1,SUP-2883821,CDM,C1713,HCPCS,0278,RC,,,,both,,,665.68,432.69,,,,,,,,,,,,,
DRILL F 6MM SCR 1.3X79MM,SUP-2364180,CDM,2720000010,LOCAL,0272,RC,,,,both,,,455.43,296.03,,,,,,,,,,,,,
BONE SPCR ANTR CERV PUROS 0DEG 11X11,SUP-2414404,CDM,C1776,CPT,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
SYSTEM PRSS MON W/ RADPQ SENS FOR PULM ART IN HRT FAILURE CM2000] ST JUDE MEDICAL INC],SUP-2357560,CDM,C2624,HCPCS,0278,RC,,,,both,,,59660.00,38779.00,,,,,,,,,,,,,
REAMER PLUG SPNL LUM TAPR FUS DEV LT CAGE SGL BRL SHFT,SUP-2291601,CDM,C1713,HCPCS,0278,RC,,,,both,,,594.97,386.73,,,,,,,,,,,,,
CATHETER GUID MP1 AD 0.071 INX6 FRX55 CM LG LUMEN LAUNCHER,SUP-2281127,CDM,C1887,HCPCS,0272,RC,,,,both,,,141.30,91.84,,,,,,,,,,,,,
CARBON FIBER ROD,SUP-2823202,CDM,2720000010,LOCAL,0272,RC,,,,both,,,712.15,462.90,,,,,,,,,,,,,
SPLINT WRST XL L10IN L FA LN CIRCUMFERENTIAL STRP SLIP ON,SUP-2276628,CDM,L3809,HCPCS,0274,RC,,,,both,,,21.48,13.96,,,,,,,,,,,,,
ORTHOPEDIC KIT CENTERING SLEEVE 1.4 MM DISP,SUP-2664008,CDM,2720000010,LOCAL,0272,RC,,,,both,,,386.85,251.45,,,,,,,,,,,,,
PLATE FIXATION STERNAL LADDER 10 HOLES,SUP-2849061,CDM,C1713,HCPCS,0278,RC,,,,both,,,2011.74,1307.63,,,,,,,,,,,,,
CATHETER EPI 19GA L14IN G SGL STYL RND ATRAUM TIP RADPQ,SUP-2217832,CDM,C1725,HCPCS,0272,RC,,,,both,,,240.12,156.08,,,,,,,,,,,,,
HC Debrid Wound Tis Addl 20 Cm<,PX-4209759800,CDM,97598,CPT,0420,RC,,,,both,,,194.00,126.10,,,,,,,,,,,,,
TIP ASPIR L4.6IN L OD2.47MM ID1.92MM SFT TISS STR FOR,SUP-2363700,CDM,2720000010,LOCAL,0272,RC,,,,both,,,10738.42,6979.97,,,,,,,,,,,,,
STEM FEM L225MM DIA15X20MM NK L36+21+8MM LNG HIP NEUT STR,SUP-2253195,CDM,C1776,CPT,0278,RC,,,,both,,,15359.62,9983.75,,,,,,,,,,,,,
CROWN DENT 5L ANTR LOWER CUSPID PRIMARY REFILL SS UNITEK,SUP-2322236,CDM,D6783,CPT,0278,RC,,,,both,,,36.83,23.94,,,,,,,,,,,,,
CUTTER ENDOSCP PAT,SUP-2365163,CDM,2720000010,LOCAL,0272,RC,,,,both,,,739.50,480.67,,,,,,,,,,,,,
BLADE SAW L 88 MM L 33 MM THK MATERIAL 0.4 MM CUT 0.6 MM,SUP-2929256,CDM,2720000010,LOCAL,0272,RC,,,,both,,,544.92,354.20,,,,,,,,,,,,,
SCREWDRIVER BLADE 2/2.3 MM CENTRE DRV SS 508102007,SUP-2525662,CDM,2720000010,LOCAL,0272,RC,,,,both,,,393.76,255.94,,,,,,,,,,,,,
SCREW IM NAIL L 75 MM DIA 4.5 MM TI LP STRL TRIGEN,SUP-2933739,CDM,C1713,HCPCS,0278,RC,,,,both,,,767.26,498.72,,,,,,,,,,,,,
TUBE SALIVARY BYPASS RADIOPAQUE MONTGOMERY 191X36X10MM,SUP-2713902,CDM,C1889,HCPCS,0278,RC,,,,both,,,715.92,465.35,,,,,,,,,,,,,
SCREW BNE PED L12MM DIA3.5MM L R CORT PROX FEM TIB S STL,SUP-2318532,CDM,C1713,HCPCS,0278,RC,,,,both,,,774.39,503.35,,,,,,,,,,,,,
GRAFT HUM TISS L 3 X W 3 CM SZ 9 SQCM AMNION-CHORION-AMNION,SUP-2909309,CDM,Q4137,HCPCS,0636,RC,,,,both,,,4503.51,2927.28,,,,,,,,,,,,,
TUBE VENT SHEEHY 1.27 MM 1.5 MM CLLR BUTTON SIL STRL 510133,SUP-2535102,CDM,L8699,HCPCS,0278,RC,,,,both,,,29.58,19.23,,,,,,,,,,,,,
GRAFT VASC L60CM DIA6MM PTFE NONRINGED STD CUF FLX SM BEAD,SUP-2128076,CDM,C1768,CPT,0278,RC,,,,both,,,13482.09,8763.36,,,,,,,,,,,,,
KIT PROC L70CM OD4FR LSR PRE POSITIONED FBR LCK VARI-LASE,SUP-2120514,CDM,C1894,HCPCS,0272,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
CLAMP REPROC COMBO MR SAFE 8 11MM,SUP-2477612,CDM,2720000010,LOCAL,0272,RC,,,,both,,,648.82,421.73,,,,,,,,,,,,,
SCREW BONE L130MM DIA6.5MM THRD L22MM STD CORT TI ST SELF,SUP-2343367,CDM,C1713,HCPCS,0278,RC,,,,both,,,1955.40,1271.01,,,,,,,,,,,,,
PERFUSION PACK CUST OPN HRT,SUP-2352732,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
PROSTHESIS PENILE L18CM DIA12.5MM INFL TWO PC W/ PREFIL,SUP-2138936,CDM,C1813,HCPCS,0278,RC,,,,both,,,61909.50,40241.17,,,,,,,,,,,,,
CERAMIC ON CERAMIC W/ POR FEM,SUP-2348005,CDM,C1776,CPT,0278,RC,,,,both,,,15386.00,10000.90,,,,,,,,,,,,,
LINER ACET 52-54 MM NEUT XL 36 MM HIP UHMWPE TRYON,SUP-2322435,CDM,C1776,CPT,0278,RC,,,,both,,,1186.92,771.50,,,,,,,,,,,,,
IMPLANT FEM L24MM DIA10MM INSRT APERFIX AM,SUP-2402619,CDM,C1776,CPT,0278,RC,,,,both,,,4163.64,2706.37,,,,,,,,,,,,,
SPACER SPNL SPIKLS 14X14 MM 14 MM UPPER ENDPLATE FORTIFY I-R,SUP-2594929,CDM,C1821,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
TIP ASPIR 25GA ADV BACKFLUSH SFT PASS OR ACT DISP,SUP-2109648,CDM,C1713,HCPCS,0278,RC,,,,both,,,287.37,186.79,,,,,,,,,,,,,
ROD SPNL L 190 MM DIA 6 MM CARBON FIBER PEDCL S SHP TYP 1,SUP-2883100,CDM,C1713,HCPCS,0278,RC,,,,both,,,10362.00,6735.30,,,,,,,,,,,,,
CANNULA VEN SHT 23 FR UNCOATED HLS,SUP-2663486,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1256.50,816.72,,,,,,,,,,,,,
BRACE SHLDR L FA L15 16IN UNIV AIRMESH BRTH SLNG 15DEG ABD,SUP-2150869,CDM,L3650,HCPCS,0272,RC,,,,both,,,171.16,111.25,,,,,,,,,,,,,
CATHETER ETER DRNGE 14FR L35CM GWIRE 0038IN BILI FLEXIMA SFT,SUP-2147835,CDM,C1729,HCPCS,0272,RC,,,,both,,,238.64,155.12,,,,,,,,,,,,,
HC Assay of Hemosiderin Qualitative,PX-3018307000,CDM,83070,CPT,0301,RC,,,,both,,,294.00,191.10,,,,,,,,,,,,,
CATHETER GUID L110CM L CURL BIDEFLECTABLE SFT ATRAUM TIP,SUP-2357042,CDM,C1887,HCPCS,0272,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
KIT BNE SCR TORQ DEFINING SHLDR PRI FIX ANG REV EQUINOXE,SUP-2223386,CDM,C1713,HCPCS,0278,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
STEM FEM H35MM 5DEG OFFSET JUNCTION BX TAPR BAL KNEE REV,SUP-2431848,CDM,C1776,CPT,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
IMPLANT COSMETIC SZ 63 X 31 X 17 MM POLYETHYL LT EAR BASE,SUP-2935586,CDM,C1713,HCPCS,0278,RC,,,,both,,,7278.52,4731.04,,,,,,,,,,,,,
SCREW TIB FIX MOD ROD CAP,SUP-2363497,CDM,C1713,HCPCS,0278,RC,,,,both,,,322.16,209.40,,,,,,,,,,,,,
CONNECTOR SET SCR EXTN LOK MULT AX MAS XLNK MAS EXTN VERTEX,SUP-2289102,CDM,C1713,HCPCS,0278,RC,,,,both,,,367.38,238.80,,,,,,,,,,,,,
CONNECTOR SPNL CROSS SZ CRD,SUP-2211133,CDM,C1713,HCPCS,0278,RC,,,,both,,,146.95,95.52,,,,,,,,,,,,,
GUIDEWIRE VASC ARW L 130 CM DIA 0.018 IN PERIPH MARKED,SUP-2887217,CDM,C1729,HCPCS,0272,RC,,,,both,,,132.51,86.13,,,,,,,,,,,,,
PLATE BNE 2.5X1.6 MM LT DORS WRST 11 HOLE RSL FUSION PL,SUP-2423737,CDM,C1713,HCPCS,0278,RC,,,,both,,,4838.11,3144.77,,,,,,,,,,,,,
PIN FIX CLLRD 50 MM KNEE THRD REV BKRS,SUP-2434339,CDM,C1713,HCPCS,0278,RC,,,,both,,,1053.16,684.55,,,,,,,,,,,,,
COMPONENT KNEE PT SPEC INSTRUMENT TRAB MEL GENDER SOL,SUP-2212606,CDM,C1776,CPT,0278,RC,,,,both,,,9247.30,6010.74,,,,,,,,,,,,,
WALKER POSTOP SM AD F ANK BILAT FIX UNISX TRAUM MAXTRAX,SUP-2197140,CDM,L4350,HCPCS,0272,RC,,,,both,,,83.15,54.05,,,,,,,,,,,,,
"HC Gbl New Pt, E/M Level 2",PX-9829920200,CDM,99202,CPT,0982,RC,,,,both,,,365.00,237.25,,,,,,,,,,,,,
STENT COR 23MM 2.25MM 0.014IN HYDRPHLC RX LO,SUP-2103677,CDM,C1876,HCPCS,0278,RC,,,,both,,,2496.30,1622.59,,,,,,,,,,,,,
PROBE ENDOSCP BICOAGULATION 10 FRX3500 MM 3.7 MM FIX PI,SUP-2475166,CDM,2720000010,LOCAL,0272,RC,,,,both,,,822.90,534.88,,,,,,,,,,,,,
SCREW BONE L14MM DIA2MM HND VAR ANG LCK FLOWERCUBE,SUP-2225442,CDM,C1713,HCPCS,0278,RC,,,,both,,,421.07,273.70,,,,,,,,,,,,,
SCREW BNE L72MM DIA5MM CORT GRN TI ST LOK FULL THRD TRCR,SUP-2192346,CDM,C1713,HCPCS,0278,RC,,,,both,,,514.14,334.19,,,,,,,,,,,,,
HC CT Brain W/WO Contrast,PX-3517047000,CDM,70470,CPT,0351,RC,,,,both,,,1973.00,1282.45,,,,,,,,,,,,,
PLATE BNE RECT 1.5 MM MIDFACE 2X4 HOLE TI SLV,SUP-2754966,CDM,C1713,HCPCS,0278,RC,,,,both,,,540.08,351.05,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY SUP CS L 60 CM DIA 5 FR SPC 2-8-2,SUP-2475506,CDM,C1730,HCPCS,0272,RC,,,,both,,,244.32,158.81,,,,,,,,,,,,,
PLATE BNE 2 H L CORONOID EL CONG,SUP-2107778,CDM,C1713,HCPCS,0278,RC,,,,both,,,3435.16,2232.85,,,,,,,,,,,,,
CATHETER HD STR 15.5 FRX32 CM SHT TERM 3L T-3 CT,SUP-2627216,CDM,C1752,HCPCS,0278,RC,,,,both,,,119.32,77.56,,,,,,,,,,,,,
PLATE BONE L89MM 7 H LCK COMPR FOR 3.5MM SCR,SUP-2349158,CDM,C1713,HCPCS,0278,RC,,,,both,,,1195.15,776.85,,,,,,,,,,,,,
GRAFT DERMAL MESH 8X15 CM FEN + WND MTRX MIRODERM,SUP-2431540,CDM,Q4175,HCPCS,0636,RC,,,,both,,,26376.00,17144.40,,,,,,,,,,,,,
CATHETER ANGIO ARW BERMAN L 90 CM DIA 6 FR BALLOON DIA10 MM,SUP-2383246,CDM,C1725,HCPCS,0272,RC,,,,both,,,976.54,634.75,,,,,,,,,,,,,
NAIL IM L235MM DIA12MM NK 130DEG GRN PROX FEM TI,SUP-2192102,CDM,C1713,HCPCS,0278,RC,,,,both,,,3901.23,2535.80,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY RESPON L 120 CM DIA 6 FR SPC 5 MM,SUP-2526065,CDM,C1730,HCPCS,0272,RC,,,,both,,,169.78,110.36,,,,,,,,,,,,,
STEM FEM DSTL MOD W/ SLOT POR RL HARDENED OD15MM L 300MM,SUP-2404203,CDM,C1776,CPT,0278,RC,,,,both,,,10063.70,6541.40,,,,,,,,,,,,,
CATHETER INTVASC OCCL STINGRAY LP 180 DEG L 135 CM DIA 3.2,SUP-2146905,CDM,C1725,HCPCS,0272,RC,,,,both,,,7203.16,4682.05,,,,,,,,,,,,,
SCREW BNE L6MM DIA2.4MM CORT CRANIOMAXILLOFACIAL TI ST,SUP-2189484,CDM,C1713,HCPCS,0278,RC,,,,both,,,350.80,228.02,,,,,,,,,,,,,
COLLAR CERV CHILD SZ PD1 1 18MON 21 33IN FOR 075IN NK UP EXT,SUP-2123899,CDM,L0190,HCPCS,0272,RC,,,,both,,,89.46,58.15,,,,,,,,,,,,,
PLATE BONE 3D PRNT LG MIDFACE MAND TI TRUMATCH SD980.109,SUP-2860373,CDM,C1713,HCPCS,0278,RC,,,,both,,,51499.14,33474.44,,,,,,,,,,,,,
DISTRACTOR SURG X TRACK FOR ORTHOLOC 3DI,SUP-2398324,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4769.66,3100.28,,,,,,,,,,,,,
TUBE TRACH CUF 6 MM SINGLE CANN,SUP-2264507,CDM,2720000010,LOCAL,0272,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
SCREW BNE PART THRD 5X90 MM PANTA,SUP-2423786,CDM,C1713,HCPCS,0278,RC,,,,both,,,965.58,627.63,,,,,,,,,,,,,
CAP T2 RECON NAIL 10MM END,SUP-2700929,CDM,C1889,HCPCS,0278,RC,,,,both,,,675.89,439.33,,,,,,,,,,,,,
IMMOBILIZER ORTH T BAR UNIV 19 IN KNEE CANVS BLU REUSE,SUP-2336063,CDM,L1830,CPT,0274,RC,,,,both,,,38.12,24.78,,,,,,,,,,,,,
MESH HERN 14X14IN POLY 4 HYDROXYBUTYRATE SYN SQ WVN,SUP-2125878,CDM,C1781,HCPCS,0278,RC,,,,both,,,51684.40,33594.86,,,,,,,,,,,,,
HC Chemo-Bladder Instillation,PX-7615172000,CDM,51720,CPT,0761,RC,,,,both,,,2644.00,1718.60,,,,,,,,,,,,,
BRACE ORTH LUMBAR X SM LT EVERGREEN,SUP-2123875,CDM,L0626,HCPCS,0274,RC,,,,both,,,131.88,85.72,,,,,,,,,,,,,
SET UROLOGICAL SHTH 810 SET L 30 CM DIA 8.5 FR DIL L 88 CM,SUP-2835702,CDM,C2617,HCPCS,0278,RC,,,,both,,,138.85,90.25,,,,,,,,,,,,,
HOOK SPNL 5.5-6 MM RT TRNSVRS CD HORZ,SUP-2629469,CDM,C1713,HCPCS,0278,RC,,,,both,,,1193.20,775.58,,,,,,,,,,,,,
RING EXT FIX DIA180MM TI HALF MR CONDITIONAL FOR DISTR,SUP-2179156,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1589.50,1033.17,,,,,,,,,,,,,
SHOE ORTHOT ADDITION CONVERT FIRM SFT COUNT,SUP-2435743,CDM,L3590,HCPCS,0274,RC,,,,both,,,151.25,98.31,,,,,,,,,,,,,
ELECTRODE LOOP BPLR CUT LONGITUDINAL 24/26FR,SUP-2261170,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1493.07,970.50,,,,,,,,,,,,,
PLATE STD BRL OMEGA SS 8 HL 145DEG,SUP-2487853,CDM,C1713,HCPCS,0278,RC,,,,both,,,2774.19,1803.22,,,,,,,,,,,,,
COMPONENT FEM SZ 1 R KNEE OXINIUM POST STBL PRI CEM,SUP-2346169,CDM,C1776,CPT,0278,RC,,,,both,,,12041.90,7827.23,,,,,,,,,,,,,
CATHETER DRAINAGE LCK 038 LG 14 FRX14 CM 5 CM STAYFIX RESOLV,SUP-2464587,CDM,C1729,HCPCS,0272,RC,,,,both,,,241.78,157.16,,,,,,,,,,,,,
BODY ASSEMBLY KIT SELF ALIGNING STD ARTICULATED PROCALLUS,SUP-2645901,CDM,2720000010,LOCAL,0272,RC,,,,both,,,10415.07,6769.80,,,,,,,,,,,,,
CANNULA PERF PED 12FR L19CM TIP L11CM 1/4IN NVENT CONN,SUP-2282881,CDM,2720000010,LOCAL,0272,RC,,,,both,,,649.07,421.90,,,,,,,,,,,,,
GRAFT HUMAN TSSUE GRTR EQUAL 16CML 1/10MM THK QDRCPS TNDN FR,SUP-2573323,CDM,C1762,CPT,0278,RC,,,,both,,,6104.16,3967.70,,,,,,,,,,,,,
CATHETER VENTRICULAR DRAINAGE L 35 CM OD 10 FR ID 1.9 MM,SUP-2883345,CDM,C1729,HCPCS,0272,RC,,,,both,,,2392.08,1554.85,,,,,,,,,,,,,
RIGHT X SM DISTAL RADIAL COMP STERILE,SUP-2696160,CDM,C1776,CPT,0278,RC,,,,both,,,12012.38,7808.05,,,,,,,,,,,,,
BIT DRL DIA4.4MM DARCO HD FOR 6.5MM SCR,SUP-2398639,CDM,2720000010,LOCAL,0272,RC,,,,both,,,452.16,293.90,,,,,,,,,,,,,
IMPLANT TOE 30 283X127X8X76X14X31X10X64X34X44X44MM,SUP-2244195,CDM,C1776,CPT,0278,RC,,,,both,,,4353.20,2829.58,,,,,,,,,,,,,
BIT DRL L 155/60 MM DIA2.8 MM CALIB AO QC NS REUSE V,SUP-2908109,CDM,2720000010,LOCAL,0272,RC,,,,both,,,801.17,520.76,,,,,,,,,,,,,
HC Inj Aa&/Strd Nerves Nrvtg Si Joint W/Img,PX-3616445100,CDM,64451,CPT,0361,RC,,,,inpatient,,,3707.00,2409.55,,,,,,,,,,,,,
BRACE WR CLUTCH DORS STAY VELSTRETCH WRP LT CIRC 6 1/2-8,SUP-2323979,CDM,L3931,HCPCS,0274,RC,,,,both,,,50.84,33.05,,,,,,,,,,,,,
SCREW FEM UNIV STD TI KNEE REV PRESSFIT IMP ASCNT,SUP-2407027,CDM,C1713,HCPCS,0278,RC,,,,both,,,320.28,208.18,,,,,,,,,,,,,
SET IMPL W/ DEPTH GA DRL BIT FOR 3.5MM PROX TIB LCK SCR,SUP-2183065,CDM,C1713,HCPCS,0278,RC,,,,both,,,72395.15,47056.85,,,,,,,,,,,,,
PLATE BNE L 126 MM 16 H SCREW DIA2.4 MM TI ALLOY MINI FRAG,SUP-2902340,CDM,C1713,HCPCS,0278,RC,,,,both,,,3827.47,2487.86,,,,,,,,,,,,,
PLATE BNE L82MM 4 H NONSTERILE L ANTLAT DST TIB S STL VAR,SUP-2177668,CDM,C1713,HCPCS,0278,RC,,,,both,,,5075.62,3299.15,,,,,,,,,,,,,
GRAFT HUM TISS SZ 7 MM BICORTICAL FT WDG PRESHAPED COTTON,SUP-2913257,CDM,C1713,HCPCS,0278,RC,,,,both,,,6575.16,4273.85,,,,,,,,,,,,,
CATHETER PICC ARROWG+ARD BLUE ADVANCE TAPERFREE 6FR 55CM 3-LUM,SUP-2887071,CDM,C1751,HCPCS,0278,RC,,,,both,,,724.30,470.79,,,,,,,,,,,,,
STEM FEM NO3 NP,SUP-2253261,CDM,C1776,CPT,0278,RC,,,,both,,,5538.96,3600.32,,,,,,,,,,,,,
SURGICAL INSTR SET- 8 MM,SUP-2400367,CDM,2720000010,LOCAL,0272,RC,,,,both,,,838.38,544.95,,,,,,,,,,,,,
FILTER VASC ACCUNET SZ 6.5 MM CATH 8 FR SHTH 6 FR GUIDEWIRE,SUP-2104679,CDM,C1876,HCPCS,0278,RC,,,,both,,,4631.50,3010.47,,,,,,,,,,,,,
MODEL ANAT FULL SKULL AD 3D CT BASE OSTEOVIEW,SUP-2883675,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6203.82,4032.48,,,,,,,,,,,,,
CATHETER BLLN OCCL IRRIGATION 6 FRX40 CM 2 CC AORT PRUITT,SUP-2332926,CDM,C2628,HCPCS,0272,RC,,,,both,,,219.80,142.87,,,,,,,,,,,,,
KIT ARTICULATED ANK COMPLT STRL,SUP-2316324,CDM,2720000010,LOCAL,0272,RC,,,,both,,,14422.21,9374.44,,,,,,,,,,,,,
PIVOT FIG 4 MLNA ORBTL MALAR DSTRCTR T 6L 4V SNGLE USE,SUP-2679250,CDM,C1713,HCPCS,0278,RC,,,,both,,,1735.16,1127.85,,,,,,,,,,,,,
PLATE BNE L105MM 4 H PROX MED POST TIB S STL LOK COMPR FOR,SUP-2177795,CDM,C1713,HCPCS,0278,RC,,,,both,,,3418.74,2222.18,,,,,,,,,,,,,
PLUG SCREW HOLE G7,SUP-2440058,CDM,C1713,HCPCS,0278,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
MESH HERN CIR 10X15CM W/ ECHO 2 POS SYS PHASIX ST,SUP-2716209,CDM,C1781,HCPCS,0278,RC,,,,both,,,8603.60,5592.34,,,,,,,,,,,,,
CARTRIDGE BNE CEMENT PARALLAX,SUP-2308556,CDM,C1713,HCPCS,0278,RC,,,,both,,,838.38,544.95,,,,,,,,,,,,,
SAW SURG 1-2 KNEE MOD POST CAPTURE ATTUNE,SUP-2454798,CDM,2720000010,LOCAL,0272,RC,,,,both,,,734.76,477.59,,,,,,,,,,,,,
PLATE BONE CRANIO FACE MAND FULL SEC RECON 6 H TI W/ TEMPLT,SUP-2363755,CDM,C1713,HCPCS,0278,RC,,,,both,,,4380.83,2847.54,,,,,,,,,,,,,
STRM STRAIGHT PLATE 6 HOLE,SUP-2488253,CDM,C1713,HCPCS,0278,RC,,,,both,,,3298.88,2144.27,,,,,,,,,,,,,
PORT VEN ACC UNASSEMBLED SGL LUMN POLYSULFONE TI ULT LCK,SUP-2352177,CDM,C1788,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
CAGE SPNL W17XH88XL22MM ANT CERV THORLUM TI OBLONG,SUP-2193230,CDM,C1889,HCPCS,0278,RC,,,,both,,,18840.00,12246.00,,,,,,,,,,,,,
GUIDEWIRE VASC GLIDEWIRE L 150 CM DIA 0.025 IN NIT HYDRPHLC,SUP-2141138,CDM,C1769,HCPCS,0272,RC,,,,both,,,174.27,113.28,,,,,,,,,,,,,
LOCKING PLATE ANGLE ANGLE 32 HOLE 255MM THICK CP TTNM,SUP-2669745,CDM,C1713,HCPCS,0278,RC,,,,both,,,6369.77,4140.35,,,,,,,,,,,,,
PLATE BONE LOK 34MML HLX3 STNLSS STEEL NON ST RIGHT STLD RDL,SUP-2721442,CDM,C1713,HCPCS,0278,RC,,,,both,,,2037.55,1324.41,,,,,,,,,,,,,
ROD SPNL 5.5X500 MM SS SHILLA,SUP-2630619,CDM,C1713,HCPCS,0278,RC,,,,both,,,2147.76,1396.04,,,,,,,,,,,,,
FELT CV L 4 X W 4 IN PTFE,SUP-2266054,CDM,C1768,CPT,0278,RC,,,,both,,,266.90,173.48,,,,,,,,,,,,,
MESH HERN W16XL12CM LAP MFIL POLY TEREPHTHALATE MFIL,SUP-2174687,CDM,C1781,HCPCS,0278,RC,,,,both,,,1271.86,826.71,,,,,,,,,,,,,
WIRE FIX BLNT 1.4 MMX21 IN W/ RND END SS,SUP-2430607,CDM,C1713,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
GRAFT DERMAL PLIABLE THCK 20X6 CMX0.8-1.7 MM BRST KT FLEXHD,SUP-2307580,CDM,Q4128,HCPCS,0636,RC,,,,both,,,18995.43,12347.03,,,,,,,,,,,,,
ANCHOR SUT MICRORAPTOR KNOTLESS RG,SUP-2418766,CDM,C1713,HCPCS,0278,RC,,,,both,,,2649.85,1722.40,,,,,,,,,,,,,
SCREW BNE FIX L48MM UNICORTICAL THRD N CANN N LOK S STL HD,SUP-2200478,CDM,C1713,HCPCS,0278,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
NAIL INTRAMEDULLARY SUBTALAR 7X75MM HEADLESS DYNANAIL HELIX,SUP-2878162,CDM,C1713,HCPCS,0278,RC,,,,both,,,15700.00,10205.00,,,,,,,,,,,,,
HC Fluid Pressure Muscle,PX-4502095000,CDM,20950,CPT,0450,RC,,,,both,,,2188.00,1422.20,,,,,,,,,,,,,
PACEMAKER CARD CYLOS VR W 39 X H 57 MM D 6 MM 2.8 V 11 CC 27,SUP-2138040,CDM,C1786,HCPCS,0275,RC,,,,both,,,12459.52,8098.69,,,,,,,,,,,,,
CATHETER CTRL VEN 9.5FR NONPOWER INJ 2 LUMN W/ TISS,SUP-2127897,CDM,C1751,HCPCS,0278,RC,,,,both,,,2411.77,1567.65,,,,,,,,,,,,,
HC Ultrasound Procedure Unlisted,PX-4027699900,CDM,76999,CPT,0402,RC,,,,both,,,276.00,179.40,,,,,,,,,,,,,
SUTURE ACHOR PUSHLOCK,SUP-2812464,CDM,C1713,HCPCS,0278,RC,,,,both,,,1146.10,744.96,,,,,,,,,,,,,
BALLOON PRSS REG 61-70CM H2O W/O INHIBZN FOR PENILE PROS,SUP-2138914,CDM,C1815,HCPCS,0278,RC,,,,both,,,10540.98,6851.64,,,,,,,,,,,,,
GUIDEWIRE ORTH PART THRD 2.8X300 MM,SUP-2319443,CDM,C1769,HCPCS,0272,RC,,,,both,,,106.76,69.39,,,,,,,,,,,,,
PHENYLEPHRINE HCL 0.5 % NA SOLN,RX-6244,CDM,2500000003,HCPCS,0250,RC,00225-0805-47,NDC,,both,15,ML,54.10,35.16,,,,,,,,,,,,,
ALLOGRAFT HUM TISS FRZN RT FULL BONE-PATELLAR TENDON-BONE,SUP-2867033,CDM,C1762,CPT,0278,RC,,,,both,,,10643.34,6918.17,,,,,,,,,,,,,
PROBE HEMSTAS 2.3MM BPLR SGL PLUG DISP,SUP-2313017,CDM,C1713,HCPCS,0278,RC,,,,both,,,497.50,323.37,,,,,,,,,,,,,
GUIDEWIRE VASC MEISTER L 180 CM DIA 0.016 IN L 5 CM RND CRV,SUP-2879068,CDM,C1769,HCPCS,0272,RC,,,,both,,,832.10,540.86,,,,,,,,,,,,,
FORCEPS ENDO MIC GRSP AMHED,SUP-2304857,CDM,C1713,HCPCS,0278,RC,,,,both,,,327.09,212.61,,,,,,,,,,,,,
GUIDEWIRE ORTH 2X330 MM FT SINGLE END SPADE PT DRL TIP,SUP-2186890,CDM,C1769,HCPCS,0272,RC,,,,both,,,144.35,93.83,,,,,,,,,,,,,
CRYOABLATION KIT PROST RENAL ICESPHERE,SUP-2225661,CDM,2720000010,LOCAL,0272,RC,,,,both,,,11702.00,7606.30,,,,,,,,,,,,,
COMPONENT PATELLAR FEM KNEE CUST,SUP-2136069,CDM,C1776,CPT,0278,RC,,,,both,,,20096.00,13062.40,,,,,,,,,,,,,
HC MRI-Chest WO Contrast,PX-6107155000,CDM,71550,CPT,0610,RC,,,,outpatient,,,4190.00,2723.50,,,,,,,,,,,,,
GRAFT EVAR L30MM DIA8MM CATH 9FR L80CM 0.035IN EXP PTFE C,SUP-2128219,CDM,C1874,HCPCS,0278,RC,,,,both,,,6578.30,4275.89,,,,,,,,,,,,,
REFILL SYR B1 PK DYRACT FLO,SUP-2238601,CDM,C1713,HCPCS,0278,RC,,,,both,,,134.39,87.35,,,,,,,,,,,,,
PIN GUIDE L 360 MM DIA 3.2 MM DRL TIP TRIGEN MAX,SUP-2932781,CDM,2720000010,LOCAL,0272,RC,,,,both,,,659.40,428.61,,,,,,,,,,,,,
CLAMP SPNL C 4.75 MM TI POLARIS,SUP-2663623,CDM,C1713,HCPCS,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
COMPONENT FEM SZ 8 CO CHROM NP L KNEE CRUCE RET PRI,SUP-2345812,CDM,C1776,CPT,0278,RC,,,,both,,,10249.75,6662.34,,,,,,,,,,,,,
GRAFT DURA W3XH3CM ULTRAPURE CLLGN ADH BARR MTRX DURAGN +,SUP-2244007,CDM,C1763,HCPCS,0278,RC,,,,both,,,2926.92,1902.50,,,,,,,,,,,,,
HC Psychotherapy - Individual,PX-9149083402,CDM,90834,CPT,0914,RC,,,,both,,,487.00,316.55,,,,,,,,,,,,,
PLATFORM ACCS L45CM DIA4CM TRANSANAL 5 10MM OBT 10MM RETRCT,SUP-2119684,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2363.01,1535.96,,,,,,,,,,,,,
BAG WND LAV 1L CLR ETH ACET ACID SOD ACETT BENZALKONIUM CHL,SUP-2204123,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1993.90,1296.03,,,,,,,,,,,,,
PLATE BONE W5.4XL47MM THK1.5MM 8 H FOREFOOT TI STR FOR,SUP-2225448,CDM,C1713,HCPCS,0278,RC,,,,both,,,2032.21,1320.94,,,,,,,,,,,,,
GRAFT BONE SUB 0.5ML DEMIN BONE MTRX PUTTY BONE BIOREADY,SUP-2335609,CDM,C1713,HCPCS,0278,RC,,,,both,,,266.90,173.48,,,,,,,,,,,,,
HIP H3 TOT ADV DUAL MOBILITY IMPL CAPPED H3 OD,SUP-2431851,CDM,C1776,CPT,0278,RC,,,,both,,,15700.00,10205.00,,,,,,,,,,,,,
BLADE ARTHSCP CRV HIP SHRP TIP,SUP-2608319,CDM,2720000010,LOCAL,0272,RC,,,,both,,,882.78,573.81,,,,,,,,,,,,,
KIT CATH HEMODIALYSI HEMOSPLIT CHRONIC MICROINTRODUC 5744420,SUP-2632967,CDM,C1750,HCPCS,0278,RC,,,,both,,,1605.64,1043.67,,,,,,,,,,,,,
PACEMAKER CARD 9.7CUCM W42.9XH40.2MM D7.5MM IS-1 B OR UNI,SUP-2282313,CDM,C1786,HCPCS,0275,RC,,,,both,,,8241.09,5356.71,,,,,,,,,,,,,
GRAFT BNE EVANS WDG LG 19X12 MM STRL TITAN 3-D,SUP-2742084,CDM,C1713,HCPCS,0278,RC,,,,both,,,5396.88,3507.97,,,,,,,,,,,,,
PLATE BNE W6.3XL66MM THK1.6MM 5X5 H R DST EXTRAARTICULAR,SUP-2186090,CDM,C1713,HCPCS,0278,RC,,,,both,,,2430.11,1579.57,,,,,,,,,,,,,
NAIL IM L22CM OD35MM 8DEG SIL S STL TIM PROX HUM TIB END,SUP-2342807,CDM,C1713,HCPCS,0278,RC,,,,both,,,3533.13,2296.53,,,,,,,,,,,,,
HC So1 Protein Electrophoresis Serum,PX-3018416567,CDM,84165,CPT,0301,RC,,,,both,,,40.00,26.00,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED LNR POLYETH H2SN] SMITH AND NEPHEW ORTHOPAEDICS],SUP-2351356,CDM,C1776,CPT,0278,RC,,,,both,,,15700.00,10205.00,,,,,,,,,,,,,
STIMULATOR NERVE CHARGING SYS,SUP-2568741,CDM,C1820,HCPCS,0278,RC,,,,both,,,2684.70,1745.05,,,,,,,,,,,,,
GRAFT VASC IMPRA L 80 CM DIA 8 MM EPTFE FLX TW RING HEMO,SUP-2126889,CDM,C1768,CPT,0278,RC,,,,both,,,2353.37,1529.69,,,,,,,,,,,,,
TAP SURG DIA2 MM CRANIOMAXILLOFACIAL NS DISP LORENZ,SUP-2937000,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1551.16,1008.25,,,,,,,,,,,,,
GUIDEWIRE ORTH 1.6 MMX6 IN FOR HDLSS SCR SYS NS LTX,SUP-2862166,CDM,C1769,HCPCS,0272,RC,,,,both,,,135.84,88.30,,,,,,,,,,,,,
PATCH VASC CAR 8 MM W 75 MM LEN STD WALL N TAPR N RING KNIT,SUP-2395790,CDM,C1768,CPT,0278,RC,,,,both,,,2866.82,1863.43,,,,,,,,,,,,,
GRAFT SYNTH TISS 25 CC CALCIUM SULF CALCIGEN S,SUP-2462784,CDM,C1713,HCPCS,0278,RC,,,,both,,,3334.68,2167.54,,,,,,,,,,,,,
PLATE BNE L 126 MM SCREW DIA 4.5 MM 7 H NAR COMPR LCK STRL,SUP-2932786,CDM,C1713,HCPCS,0278,RC,,,,both,,,1994.69,1296.55,,,,,,,,,,,,,
PLATE BNE VOLAR STD 26 MM RT DSTL RADIAL 7 HOLE OPTILOCK,SUP-2474415,CDM,C1713,HCPCS,0278,RC,,,,both,,,2279.64,1481.77,,,,,,,,,,,,,
INTRODUCER TRANSSEPTAL SWARTZ SL 62CM SP,SUP-2357197,CDM,C1893,HCPCS,0272,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
CATHETER INFUSION PMP 2 ML/HR 2.5 IN 275 CC,SUP-2365199,CDM,C2626,HCPCS,0278,RC,,,,both,,,464.72,302.07,,,,,,,,,,,,,
RESERVOIR SHUNT 14MM SMALL TITANIUM RADIOPAQUE BUR HOLE VENT,SUP-2825622,CDM,C1729,HCPCS,0272,RC,,,,both,,,2231.35,1450.38,,,,,,,,,,,,,
BLADE SAW L 85 MM L 27 MM THK MATERIAL 0.25 MM CUT 0.35 MM,SUP-2928985,CDM,2720000010,LOCAL,0272,RC,,,,both,,,789.49,513.17,,,,,,,,,,,,,
CANNULA ART SHT 15 FR BIOLINE COATED HLS,SUP-2663457,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1067.69,694.00,,,,,,,,,,,,,
BRUSH CLN 1.6 MM,SUP-2467620,CDM,2720000010,LOCAL,0272,RC,,,,both,,,465.72,302.72,,,,,,,,,,,,,
SET PICC 3L 6FR X 55CM W BP,SUP-2887059,CDM,C1751,HCPCS,0278,RC,,,,both,,,978.64,636.12,,,,,,,,,,,,,
PLATE BNE W175XL443MM THK52MM 24 H S STL BROAD CRV LOK,SUP-2185326,CDM,C1713,HCPCS,0278,RC,,,,both,,,4259.35,2768.58,,,,,,,,,,,,,
SPACER SPNL W11XH11XL44MM 4DEG PEEK OPTMA ANT CERV INTBDY,SUP-2286270,CDM,C1713,HCPCS,0278,RC,,,,both,,,1640.65,1066.42,,,,,,,,,,,,,
STENT TRACHBRONCH L60MM DIA6MM DEL SYS L117CM DIA8FR,SUP-2128281,CDM,C1874,HCPCS,0278,RC,,,,both,,,5809.00,3775.85,,,,,,,,,,,,,
POST EXT FIX M 5 HOLE,SUP-2197285,CDM,2720000010,LOCAL,0272,RC,,,,both,,,381.51,247.98,,,,,,,,,,,,,
PLATE BONE L127MM 10 H STRL S STL COMPR FOR 3.5MM SCR EVOS,SUP-2349639,CDM,C1713,HCPCS,0278,RC,,,,both,,,1212.23,787.95,,,,,,,,,,,,,
NAIL IM L 210 MM DIA 5.5 MM TI ULN UNIV LP ATRAUM BLNT TIP,SUP-2900405,CDM,C1713,HCPCS,0278,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
BASKET SPEC RETRV EXTRACTION 0.035 IN 2X4 CM 8 FR DL MEM II,SUP-2737549,CDM,2720000010,LOCAL,0272,RC,,,,both,,,838.38,544.95,,,,,,,,,,,,,
TECHNETIUM TC 99M SESTAMIBI IV KIT,RX-135012,CDM,A9500,HCPCS,0343,RC,45548-0141-30,NDC,,both,1,UN,19.40,12.61,,,,,,,,,,,,,
DEFIBRILLATOR SGL CHMBR CARDIOVERTER ADV 7.30CM HT 4.00CM,SUP-2356262,CDM,C1722,HCPCS,0275,RC,,,,both,,,46315.00,30104.75,,,,,,,,,,,,,
BRACE ORTH ORTHOSIS LUMBAR,SUP-2388145,CDM,L0625,HCPCS,0272,RC,,,,both,,,141.83,92.19,,,,,,,,,,,,,
PLATE BNE W17.5XL247MM THK5.2MM 13 H S STL BROAD CRV LOK,SUP-2185301,CDM,C1713,HCPCS,0278,RC,,,,both,,,2029.04,1318.88,,,,,,,,,,,,,
BRACE ORTH ORTHOSIS LUMBAR,SUP-2388145,CDM,L0625,HCPCS,0274,RC,,,,both,,,141.83,92.19,,,,,,,,,,,,,
MESH HERN 20X15 CMX1 MM HYDRATED PORCINE CLLGN PERMACOL,SUP-2174697,CDM,C1781,HCPCS,0278,RC,,,,both,,,20635.20,13412.88,,,,,,,,,,,,,
SCREW SPNL L40MM DIA5.5MM REDUC MULTIAXIAL FOR 5.5/6MM 2,SUP-2278812,CDM,C1713,HCPCS,0278,RC,,,,both,,,6879.74,4471.83,,,,,,,,,,,,,
BUR SURG DIAMOND WHL 25.4 MM FOR LOWER MED SPD DRL TEAL UPWR,SUP-2607632,CDM,2720000010,LOCAL,0272,RC,,,,both,,,674.16,438.20,,,,,,,,,,,,,
PLATE BONE DUAL CMPRSSN HLX2/5 T SHPD F/2.7MM SCREW UNVRSL L,SUP-2495529,CDM,C1713,HCPCS,0278,RC,,,,both,,,1003.92,652.55,,,,,,,,,,,,,
PLATE BONE STRAIGHT FRAGMENT,SUP-2492073,CDM,C1713,HCPCS,0278,RC,,,,both,,,1312.52,853.14,,,,,,,,,,,,,
TACK SPNL FOR HALLMARK ANTR CERV PLATING SYS,SUP-2317499,CDM,C1713,HCPCS,0278,RC,,,,both,,,204.10,132.66,,,,,,,,,,,,,
GRAFT VASC FLIXENE L 35 CM DIA 4 TO 7 MM EPTFE TAPR REINF,SUP-2483365,CDM,C1768,CPT,0278,RC,,,,both,,,4797.83,3118.59,,,,,,,,,,,,,
FIXATION KIT 11X15/12 MM 1.3X1.5 MM SPEEDARC,SUP-2135444,CDM,C1776,CPT,0278,RC,,,,both,,,4396.00,2857.40,,,,,,,,,,,,,
PLATE BNE MESHED 1.5X120X120X0.6 MM NEURO 3D FOR SCR LEVEL 1,SUP-2464359,CDM,C1713,HCPCS,0278,RC,,,,both,,,7699.66,5004.78,,,,,,,,,,,,,
INSTRUMENT KIT 3.9 MM KNOTLESS CRKSCR INCL SPEAR PNCH DISP,SUP-2421793,CDM,2720000010,LOCAL,0272,RC,,,,both,,,926.30,602.09,,,,,,,,,,,,,
K WIRE FIX L150MM DIA2MM S STL TRCR TIP DISP FOR EVOS MINI,SUP-2343918,CDM,C1713,HCPCS,0278,RC,,,,both,,,191.89,124.73,,,,,,,,,,,,,
SCREW BONE TI LCK THRD CANC TRIFLANGE ACET COMP L15MM,SUP-2137414,CDM,C1713,HCPCS,0278,RC,,,,both,,,759.25,493.51,,,,,,,,,,,,,
PLATE EXT FIX L 85 MM 7 H SHRT CONN OVL SLOT NS DISP ILIZ,SUP-2933631,CDM,2720000010,LOCAL,0272,RC,,,,both,,,654.44,425.39,,,,,,,,,,,,,
PLATE BLADE ANGL 130 DEG 4H /85MM/60MM STRL,SUP-2547506,CDM,C1713,HCPCS,0278,RC,,,,both,,,2563.31,1666.15,,,,,,,,,,,,,
HC Chaplain Counsel Individual,PX-9400900200,CDM,Q9002,CPT,0940,RC,,,,both,,,11.00,7.15,,,,,,,,,,,,,
SCREW BNE L12MM OD2MM THRD L6MM TI BRK OFF MONSTER BITE,SUP-2320991,CDM,C1713,HCPCS,0278,RC,,,,both,,,847.02,550.56,,,,,,,,,,,,,
HC So CKMB,PX-3018255366,CDM,82553,CPT,0301,RC,,,,both,,,41.00,26.65,,,,,,,,,,,,,
MICROCATHETER GUID MAMBA L 135 CM CROSSING PROF 2.4 FR PROX,SUP-2715873,CDM,C1887,HCPCS,0272,RC,,,,both,,,2041.00,1326.65,,,,,,,,,,,,,
CATHETER URET OPN END 038 5 FRX70 CM SOFFLX,SUP-2835722,CDM,C1758,HCPCS,0278,RC,,,,both,,,40.19,26.12,,,,,,,,,,,,,
SEED BRACHYTHERAPY I-125 MICK DISP,SUP-2247284,CDM,C2638,HCPCS,0278,RC,,,,both,,,72.22,46.94,,,,,,,,,,,,,
SUPPORT ORTHOT LOWER EXTREMITY PELV CTRL SLNG,SUP-2435681,CDM,L2580,HCPCS,0272,RC,,,,both,,,1228.62,798.60,,,,,,,,,,,,,
"HC So Oligoclonal Bands,CSF",PX-3018391666,CDM,83916,CPT,0301,RC,,,,outpatient,,,59.00,38.35,,,,,,,,,,,,,
PLATE BONE LOW PRFLE 0.6MM THK HLX3X2 TTNM SQRE F/1.5MM SCRE,SUP-2494474,CDM,C1713,HCPCS,0278,RC,,,,both,,,711.90,462.73,,,,,,,,,,,,,
SCREW BONE L10MM DIA2.4MM CORT CRANIOMAXILLOFACIAL TI ST,SUP-2189493,CDM,C1713,HCPCS,0278,RC,,,,both,,,349.48,227.16,,,,,,,,,,,,,
STEM HUM REV LNG SHLDR ASCEND FLX,SUP-2388598,CDM,C1776,CPT,0278,RC,,,,both,,,27475.00,17858.75,,,,,,,,,,,,,
BRACE ORTHOPEDIC ANK,SUP-2112657,CDM,L1930,HCPCS,0272,RC,,,,both,,,87.92,57.15,,,,,,,,,,,,,
PROSTHESIS VOICE 16FR SZ 14MM LO PRSS BLOM SINGER,SUP-2242311,CDM,L8507,HCPCS,0274,RC,,,,both,,,266.90,173.48,,,,,,,,,,,,,
STEM HUM SZ 9 L130MM 135DEG CO CHROM MOLYBDENUM CEM,SUP-2204819,CDM,C1776,CPT,0278,RC,,,,both,,,15329.42,9964.12,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 50 CM DIA 5 MM STR STD WALL REINF,SUP-2461766,CDM,C1768,CPT,0278,RC,,,,both,,,914.27,594.28,,,,,,,,,,,,,
HOOK SPNL ANGLED MED LAM PROTEX,SUP-2592385,CDM,C1713,HCPCS,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
TUBE VENT MYR PAPARELLA TYP MAT BLU SIL W/ TAB ID1.27MM,SUP-2341375,CDM,L8699,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
CATHETER DRNGE 10.2FR L25CM NDL 18GA 0.038IN 6 SIDEPRT MP,SUP-2168461,CDM,C1729,HCPCS,0272,RC,,,,both,,,214.65,139.52,,,,,,,,,,,,,
LEAD NEUROSTIMULATOR L50CM 2X8 SPNL CRD PERC 16 ACT CNTCT,SUP-2141953,CDM,C1778,HCPCS,0278,RC,,,,both,,,17507.07,11379.60,,,,,,,,,,,,,
CATHETER ENDOBRONCHIAL BLK SET PEDIATRIC 5 FRX65 CM 4.5 MM,SUP-2759866,CDM,2720000010,LOCAL,0272,RC,,,,both,,,712.31,463.00,,,,,,,,,,,,,
INTRODUCER SHTH 0.038 IN 7 FRX12 CM HEMOSTATIC FAST-CATH,SUP-2357126,CDM,C1894,HCPCS,0272,RC,,,,both,,,39.69,25.80,,,,,,,,,,,,,
PLATE BNE SM L27MM 4 H NONSTERILE BILAT FOREFOOT S STL X,SUP-2184802,CDM,C1713,HCPCS,0278,RC,,,,both,,,3069.29,1995.04,,,,,,,,,,,,,
IMPLANT HUM TISS L 21-30 CM OD 4-10 MM FEM ART CRYOPRESERVED,SUP-2931135,CDM,C1762,CPT,0278,RC,,,,both,,,20498.11,13323.77,,,,,,,,,,,,,
CENTRALIZER DSTL HUM 6.5 MM DIA TI MOSAIC,SUP-2403514,CDM,C1776,CPT,0278,RC,,,,both,,,951.42,618.42,,,,,,,,,,,,,
TUBE JEJUNOSTOMY FEED 22 CM 1.2 CM 3-5 CC LP MIC-KEY,SUP-2764459,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1267.56,823.91,,,,,,,,,,,,,
KNIFE 3734038 FISHER TONSIL 15MM CVD,SUP-2706763,CDM,2720000010,LOCAL,0272,RC,,,,both,,,393.72,255.92,,,,,,,,,,,,,
SCREW BONE L10MM DIA2MM MAND SLV NONLOCKINGXDRIVE FOR LORENZ,SUP-2136748,CDM,C1713,HCPCS,0278,RC,,,,both,,,166.42,108.17,,,,,,,,,,,,,
CALIBRATOR BRACHYTHERAPY SEED CESIUM-131,SUP-2247302,CDM,C2643,HCPCS,0278,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
SCREW PEDCL L25XOD5.5MM S STL CANN REVERE,SUP-2230811,CDM,C1713,HCPCS,0278,RC,,,,both,,,5846.68,3800.34,,,,,,,,,,,,,
PLATE CUTTING PLIERS XS S M L,SUP-2695625,CDM,C1713,HCPCS,0278,RC,,,,both,,,4553.00,2959.45,,,,,,,,,,,,,
LENS INTOCU +6.0 DIOPT L13MM DIA6MM 10DEG HAPTIC ANG A,SUP-2110603,CDM,V2632,HCPCS,0276,RC,,,,both,,,2810.30,1826.69,,,,,,,,,,,,,
SPLINT ORTHOPEDIC THMB ABDUCTED UNIV LTHR,SUP-2336237,CDM,L3931,HCPCS,0274,RC,,,,both,,,14.60,9.49,,,,,,,,,,,,,
BUR SURG 64X60MM NEURO RND CUT FLUT CARB ST MICROFRANCE,SUP-2284184,CDM,C1713,HCPCS,0278,RC,,,,both,,,526.45,342.19,,,,,,,,,,,,,
GRAFT DERM HYDRATED THCK ACELLULAR DERM IMPL ALLGRFT L4XW1CM,SUP-2307450,CDM,Q4128,HCPCS,0636,RC,,,,both,,,492.51,320.13,,,,,,,,,,,,,
ROD IM L20CM DIA14MM TOT FEM TI FOR ORTH SALV SYS,SUP-2405849,CDM,C1713,HCPCS,0278,RC,,,,both,,,7672.59,4987.18,,,,,,,,,,,,,
RELOAD STPL L60MM DIA4.8MM UNIV ROTIC ENDO GIA,SUP-2283063,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1063.49,691.27,,,,,,,,,,,,,
HC CT C-Spine W/ Contrast,PX-3527212600,CDM,72126,CPT,0352,RC,,,,inpatient,,,1973.00,1282.45,,,,,,,,,,,,,
PLATE BNE 2X6 H NONSTERILE CNDYL S STL LOK COMPR W/ SHT,SUP-2177485,CDM,C1713,HCPCS,0278,RC,,,,both,,,1516.97,986.03,,,,,,,,,,,,,
SCREW BONE PET L70MM DIA7.7MM THRD,SUP-2315920,CDM,C1713,HCPCS,0278,RC,,,,both,,,1147.67,745.99,,,,,,,,,,,,,
STEM FEM HIP PRSS FIT COCR HA COAT TI STD OFFSET 160MM SZ,SUP-2375302,CDM,C1776,CPT,0278,RC,,,,both,,,14120.58,9178.38,,,,,,,,,,,,,
SHEATH INTRO DRYSEAL FLX L 33 CM DIA26 FR BODY DIA 9.5 MM,SUP-2395738,CDM,C1894,HCPCS,0272,RC,,,,both,,,1654.78,1075.61,,,,,,,,,,,,,
PIN FIX L120MM DIA4MM THRD L30MM CORT S STL HALF SELF DRL,SUP-2372420,CDM,C1713,HCPCS,0278,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
TRAY DRNGE 8FR SAFE-T-CENTESIS,SUP-2133896,CDM,C1729,HCPCS,0272,RC,,,,both,,,260.62,169.40,,,,,,,,,,,,,
IMPACTOR SURG STR FOR GRFT PYRAMETRIX,SUP-2292625,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1382.98,898.94,,,,,,,,,,,,,
GRAFT BNE 5 CC DBM GRFT,SUP-2319846,CDM,C1713,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
PLATE BNE L116MM THK3.7MM 4 H NONSTERILE R DST MED TIB S,SUP-2185525,CDM,C1713,HCPCS,0278,RC,,,,both,,,3742.63,2432.71,,,,,,,,,,,,,
GUIDEWIRE VASC L 45 CM DIA 0.021 IN STRL,SUP-2744704,CDM,C1729,HCPCS,0272,RC,,,,both,,,31.40,20.41,,,,,,,,,,,,,
PLATE BNE PREBENT 1.7X3X0.9 MM LT 11 HOLE FOR SCREW TI NS,SUP-2366351,CDM,C1713,HCPCS,0278,RC,,,,both,,,1071.21,696.29,,,,,,,,,,,,,
MESH HERN RND 15 CM COMP PARIETENE DS,SUP-2430043,CDM,C1781,HCPCS,0278,RC,,,,both,,,3002.34,1951.52,,,,,,,,,,,,,
BRAIN STIMULATOR KIT IMPL PULSE GENRTR P8 VERCISE GENUS,SUP-2845262,CDM,C1820,HCPCS,0278,RC,,,,both,,,27946.00,18164.90,,,,,,,,,,,,,
PROSTHESIS VOICE 20FR 10MM LESS STRAINED SPEAK VLV PROVOX,SUP-2124387,CDM,L8509,HCPCS,0272,RC,,,,both,,,912.70,593.25,,,,,,,,,,,,,
PLATE BNE PROF THK 0.6 MM 16 H SCREW DIA2 MM TI MIDFACE STR,SUP-2883898,CDM,2720000010,LOCAL,0272,RC,,,,both,,,571.48,371.46,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.510,SUP-2860027,CDM,C1713,HCPCS,0278,RC,,,,both,,,35983.46,23389.25,,,,,,,,,,,,,
BIT DRL FOR 11MM LAG SCR TRIGEN INTERTAN SYS,SUP-2347571,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2508.86,1630.76,,,,,,,,,,,,,
BRACE ORTH THOR LUMBAR SACR CUST,SUP-2138674,CDM,L0486,HCPCS,0274,RC,,,,both,,,6236.17,4053.51,,,,,,,,,,,,,
INSERT TIB H6MM MED POLYETH FOR KNEE ARTHROPLASTY,SUP-2165989,CDM,C1776,CPT,0278,RC,,,,both,,,2245.10,1459.31,,,,,,,,,,,,,
SPACER RECTAL STERILE BARRIGEL BIODEGRADEABLE,SUP-2930568,CDM,C1889,HCPCS,0278,RC,,,,both,,,9734.00,6327.10,,,,,,,,,,,,,
STENT BILI L40MM 10MM DIAM AD PRECIS,SUP-2158896,CDM,C1876,HCPCS,0278,RC,,,,both,,,5840.40,3796.26,,,,,,,,,,,,,
PLATE BNE CONN 90 DEG 4 HOLE OFFSET NS,SUP-2800151,CDM,C1713,HCPCS,0278,RC,,,,both,,,349.29,227.04,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 6X3 CM TERMINALLY STRL WND NEOX CRD RT,SUP-2648699,CDM,Q4148,HCPCS,0636,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
SCREW BONE SELFDRILLING 5 MM LOW PROFILE NEURO TITANIUM NON,SUP-2838226,CDM,C1713,HCPCS,0278,RC,,,,both,,,238.04,154.73,,,,,,,,,,,,,
NEEDLE ASPIR 20 GAX1.8X15 MM ALWAYS ON TIP TRACKED DISP,SUP-2392609,CDM,C1713,HCPCS,0278,RC,,,,both,,,1805.50,1173.57,,,,,,,,,,,,,
PROBE LAP WRK L28CM DIA10MM HND CTRL W/ CRD L10FT DISP,SUP-2166158,CDM,2720000010,LOCAL,0272,RC,,,,both,,,476.46,309.70,,,,,,,,,,,,,
SHEATH INTRO 4.5IN/11CM PERC LD SPNL CRD STIM SYS,SUP-2141925,CDM,C1892,HCPCS,0272,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
STEM HUM L133MM DIA8MM 135DEG LNG SHLDR TI ARTHROPLASTY,SUP-2250044,CDM,C1776,CPT,0278,RC,,,,both,,,21634.60,14062.49,,,,,,,,,,,,,
CATHETER CV KT 12 FRX20 CM 3L INTRO NDL SHRP SAFETY LG BOR,SUP-2763326,CDM,C1751,HCPCS,0278,RC,,,,both,,,434.58,282.48,,,,,,,,,,,,,
DRILL ENDOSCP FLX 9 MM CLANCY,SUP-2849119,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3395.91,2207.34,,,,,,,,,,,,,
ZONISAMIDE 100 MG PO CAPS,RX-27780,CDM,6370000000,HCPCS,0637,RC,68462-0130-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PICK MEMBRN ECKARDT 25 G STRL DISP,SUP-2213469,CDM,2720000010,LOCAL,0272,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
SET INTRO LIVERTY L 43.6 CM WORKING L 40 CM OD 4 MM ID 3.4,SUP-2877230,CDM,C1894,HCPCS,0272,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
BUR SURG L3.8MM DIA3MM NEURO DMND SABER SHANK ELITE TPS,SUP-2367600,CDM,2720000010,LOCAL,0272,RC,,,,both,,,332.12,215.88,,,,,,,,,,,,,
PLATE BNE L119MM 7 H SEMI TBLR FOR 4.5MM SCR L FRAG SYS,SUP-2411404,CDM,C1713,HCPCS,0278,RC,,,,both,,,198.73,129.17,,,,,,,,,,,,,
IMPLANT BRST 755CC DIA15.7CM P5.4CM GEL RND EXTRA SMOOTH,SUP-2301014,CDM,C1789,HCPCS,0278,RC,,,,both,,,3485.40,2265.51,,,,,,,,,,,,,
BIT SCRWDRVR T8 AO QUICK CPL,SUP-2489670,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
BUR SURG DIAMOND 4 MM BALL FOR MIA16-G1/MIA16,SUP-2848318,CDM,2720000010,LOCAL,0272,RC,,,,both,,,446.95,290.52,,,,,,,,,,,,,
PLATE BNE VOLAR NAR LT FT BABY,SUP-2137318,CDM,C1713,HCPCS,0278,RC,,,,both,,,3212.22,2087.94,,,,,,,,,,,,,
CLIP ANEUR W3MM DIA5MM GRFT SLIM LN,SUP-2183272,CDM,C1713,HCPCS,0278,RC,,,,both,,,174.49,113.42,,,,,,,,,,,,,
MESH HERN W18XL23CM VENTRAL OVL COMPOSIX E/X,SUP-2125807,CDM,C1781,HCPCS,0278,RC,,,,both,,,2779.84,1806.90,,,,,,,,,,,,,
SUPPORT ORTHOT HND FNGR CUST W/NONTORSION JT FABRICATED,SUP-2435781,CDM,L3921,HCPCS,0272,RC,,,,both,,,827.64,537.97,,,,,,,,,,,,,
SCREW BNE 9X35 MM SAMBASCREW,SUP-2601128,CDM,C1713,HCPCS,0278,RC,,,,both,,,10440.50,6786.32,,,,,,,,,,,,,
AGENT HEMSTAT 3GM PURIFIED PLNT STARCH ABSRB BIOCOMPATIBLE,SUP-2379553,CDM,2720000010,LOCAL,0272,RC,,,,both,,,690.80,449.02,,,,,,,,,,,,,
EVACUATOR SURG GLS BODY M CONN TBNG AND BLB ELLIK,SUP-2312602,CDM,2720000010,LOCAL,0272,RC,,,,both,,,808.55,525.56,,,,,,,,,,,,,
SCREW BONE L10MM DIA2.4MM STD CORT CRANIOMAXILLOFACIAL TI ST,SUP-2189475,CDM,C1713,HCPCS,0278,RC,,,,both,,,949.85,617.40,,,,,,,,,,,,,
SPACER SPNL TRAPEZIUM LG 20X15X15 MM MTCRPL CMC,SUP-2120679,CDM,C1821,HCPCS,0278,RC,,,,both,,,6751.00,4388.15,,,,,,,,,,,,,
ALLOGRAFT BNE 5 CC FD DBM GRFT,SUP-2787761,CDM,C1713,HCPCS,0278,RC,,,,both,,,2803.93,1822.55,,,,,,,,,,,,,
SUPPORT PROSTHETIC JT KNEE ADJ MOTN,SUP-2388174,CDM,L2186,HCPCS,0274,RC,,,,both,,,464.97,302.23,,,,,,,,,,,,,
COMPONENT FEM L32MM DIA15.6MM TAPR POST HEMICAP,SUP-2123645,CDM,C1776,CPT,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
SHAFT TIB TRAD ALLGRFT 200 MM FRZN,SUP-2294184,CDM,C1713,HCPCS,0278,RC,,,,both,,,3150.05,2047.53,,,,,,,,,,,,,
GRAFT BNE DWL FRZ DRY UNICORTICAL L 16 40MM OD 17MM,SUP-2307090,CDM,C1713,HCPCS,0278,RC,,,,both,,,2012.74,1308.28,,,,,,,,,,,,,
DISTRACTION INTRNL ST SIZER 51 567 09 71SZE 1 9 MM 2 HOLE T,SUP-2679215,CDM,2720000010,LOCAL,0272,RC,,,,both,,,475.30,308.94,,,,,,,,,,,,,
PLEDGET CV 3X7X1.5MM TEF FIRM ENV PRE-PUNCHED,SUP-2174633,CDM,C1768,CPT,0278,RC,,,,both,,,86.70,56.35,,,,,,,,,,,,,
BLADE RTRCTR BLFR 3 1/8NW X 2 7/8ND ABDMNL CNTR,SUP-2497563,CDM,2720000010,LOCAL,0272,RC,,,,both,,,489.21,317.99,,,,,,,,,,,,,
SHOULDER INSTRUMENTS-DRILLS,SUP-2212311,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1664.20,1081.73,,,,,,,,,,,,,
PLATE BNE ORBIT FLR 1.5X0.4 MM LT CONTOURED FOR SCREW STRL,SUP-2462516,CDM,C1713,HCPCS,0278,RC,,,,both,,,3304.03,2147.62,,,,,,,,,,,,,
GRAFT BIO TISS W6XL8CM CVR 48SQCM PLIABLE PORCINE REGEN,SUP-2112974,CDM,Q4130,HCPCS,0636,RC,,,,both,,,4615.80,3000.27,,,,,,,,,,,,,
SHELL ACET UNIV DIA40MM NO H HA PRI PRESSFIT SECUR FIT PSL,SUP-2370221,CDM,C1776,CPT,0278,RC,,,,both,,,4696.81,3052.93,,,,,,,,,,,,,
BUR SURG MED,SUP-2585528,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1566.86,1018.46,,,,,,,,,,,,,
PATCH HERN SM DIA1.7IN CIR W/ STRP SEPRA TECHNOLOGY ABSRB,SUP-2125891,CDM,C1781,HCPCS,0278,RC,,,,both,,,1083.30,704.14,,,,,,,,,,,,,
DEVICE REVASCULARIZATION EMBOTRAP III L 22 MM DIA 5 MM NIT 3,SUP-2525506,CDM,C1889,HCPCS,0278,RC,,,,both,,,28501.31,18525.85,,,,,,,,,,,,,
TAP SURG L150MM THRD CANN QUIK CONN W/O HNDL FOR 7MM SCR,SUP-2187433,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2099.59,1364.73,,,,,,,,,,,,,
SCISSOR OPHTH PHACO 60 DEG DEL BLNT 5MM 0.05IN GRIESHABER,SUP-2109708,CDM,2720000010,LOCAL,0272,RC,,,,both,,,662.79,430.81,,,,,,,,,,,,,
PLATE BNE FEM 3.5/4.5X119 MM LT PROX 2 HOLE STRL VALCP,SUP-2789282,CDM,C1713,HCPCS,0278,RC,,,,both,,,5378.22,3495.84,,,,,,,,,,,,,
PLATE BNE W255XL77MM WIDE 7X5 H ST R DST RAD VOLAR S STL VAR,SUP-2177316,CDM,C1713,HCPCS,0278,RC,,,,both,,,2604.82,1693.13,,,,,,,,,,,,,
BRACE WRST M L7IN FOR 65 75IN R COT E CNTOUR ALUMINUM STAY,SUP-2197008,CDM,L3931,HCPCS,0272,RC,,,,both,,,11.21,7.29,,,,,,,,,,,,,
CONNECTOR SPNL SZ 7 L37-45MM STD POST S STL FIX TRNSVRS CONN,SUP-2254369,CDM,C1713,HCPCS,0278,RC,,,,both,,,3912.44,2543.09,,,,,,,,,,,,,
CANNULA SUCTION 4 MMX15 CM NASOPHARYNX CRV UPWARDS MALL,SUP-2776832,CDM,2720000010,LOCAL,0272,RC,,,,both,,,461.61,300.05,,,,,,,,,,,,,
CEMENT BNE 80GM DBL DOSE PMMA W O ANTIBIO M VISC N RADPQ LNG,SUP-2252880,CDM,C1713,HCPCS,0278,RC,,,,both,,,606.65,394.32,,,,,,,,,,,,,
KIT INTRO MAK L 10 CM DIA 4 FR COAX DIL PR STRL,SUP-2303002,CDM,C1894,HCPCS,0272,RC,,,,both,,,54.95,35.72,,,,,,,,,,,,,
BLADE SAW OSC STRL 25.4MM CUT EDGE 85MM CUT DEPTH 1.35MM CUT,SUP-2408659,CDM,2720000010,LOCAL,0272,RC,,,,both,,,332.84,216.35,,,,,,,,,,,,,
ALLOGRAFT DERMAL PTCH THCK 7X5 CM ACELLULAR HYDRATED DERM,SUP-2321763,CDM,C1713,HCPCS,0278,RC,,,,both,,,6751.00,4388.15,,,,,,,,,,,,,
TAP SURG OD9MM SACROILIAC CANN SI-LOK,SUP-2232166,CDM,2720000010,LOCAL,0272,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
AMMONIUM LACTATE 12 % EX LOTN,RX-10380,CDM,6370000000,HCPCS,0637,RC,45802-0419-26,NDC,,both,400,GR,145.80,94.77,,,,,,,,,,,,,
TEMPLATE SURG SM M FOR CRANIOMAXILLOFACIAL ORBIT FLR PLT,SUP-2366220,CDM,C1713,HCPCS,0278,RC,,,,both,,,144.35,93.83,,,,,,,,,,,,,
INTRODUCER PACE LD SAFSHTH WORLEY L 90 CM DIA 9 FR,SUP-2138007,CDM,C1892,HCPCS,0272,RC,,,,both,,,973.40,632.71,,,,,,,,,,,,,
STAPLE BNE 18X14X14 MM EASYCLIP,SUP-2365481,CDM,C1713,HCPCS,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
IMPLANT PHALANX 45MM MID ST NEXTRA,SUP-2137581,CDM,C1713,HCPCS,0278,RC,,,,both,,,1209.78,786.36,,,,,,,,,,,,,
CATHETER GUID CONCIERGE L 100 CM 5 FR 0.07 IN AL1 2 SIDE H,SUP-2665548,CDM,C1887,HCPCS,0272,RC,,,,both,,,179.61,116.75,,,,,,,,,,,,,
SET PERICARDCENT CATH L 40 CM DIA 8.3 FR GUIDEWIRE L 70 CM,SUP-2760056,CDM,C1729,HCPCS,0272,RC,,,,both,,,586.55,381.26,,,,,,,,,,,,,
SCREW BNE L35MM DIA6.5MM CTRL FOR REV SHLDR SYS COMPHSVE,SUP-2404738,CDM,C1713,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
K WIRE FIX L15.2CM DIA2MM S STL SMOOTH DBL SHRP TIP,SUP-2414096,CDM,C1713,HCPCS,0278,RC,,,,both,,,82.64,53.72,,,,,,,,,,,,,
BRACE THORACOLUMBOSACRAL M 15DEG LORDOSIS HK RECV MAT BK,SUP-2195550,CDM,L0650,HCPCS,0272,RC,,,,both,,,1039.34,675.57,,,,,,,,,,,,,
CATHETER EP CSL CRV 2-2-2 MM 6 FRX120 CM,SUP-2356843,CDM,C1730,HCPCS,0272,RC,,,,both,,,1042.48,677.61,,,,,,,,,,,,,
CATHETERIZATION KIT ART 018 20 GAX3.8 CM 25 GA 3 CC LF,SUP-2865591,CDM,C1751,HCPCS,0278,RC,,,,both,,,121.83,79.19,,,,,,,,,,,,,
IMPLANT METATRSL SZ 3.5 METATRSL SLOT SHORTNG NS,SUP-2898941,CDM,C1713,HCPCS,0278,RC,,,,both,,,1874.58,1218.48,,,,,,,,,,,,,
TAP SURG DIA6MM CANN SELF DRL SCR 2 LD VIPER 2,SUP-2256881,CDM,2720000010,LOCAL,0272,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
KNIFE SURG HARRISON 45 DEG 159X1.8 MM ANGLED,SUP-2467933,CDM,2720000010,LOCAL,0272,RC,,,,both,,,410.02,266.51,,,,,,,,,,,,,
OBTURATOR ARTHSCP SPEAR TRCR TIP DISP FOR 3MM SUTURETAK,SUP-2121621,CDM,C1713,HCPCS,0278,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
GRAFT TISS FRZ DRY ALLGRFT BLK ILIUM TRICORT TRAD 15-18MM M,SUP-2294069,CDM,C1713,HCPCS,0278,RC,,,,both,,,2289.06,1487.89,,,,,,,,,,,,,
DEVICE INT FIX 30 MM ACL/PCL ENDOBUTTON CL,SUP-2341548,CDM,C1713,HCPCS,0278,RC,,,,both,,,1094.60,711.49,,,,,,,,,,,,,
SEED BRACHYTHERAPY CESIUM LOOSE,SUP-2247304,CDM,C2643,HCPCS,0278,RC,,,,both,,,194.68,126.54,,,,,,,,,,,,,
DRIVER SURG HDLSS 2 MM HEX FOR 3MM,SUP-2175118,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1059.75,688.84,,,,,,,,,,,,,
KNEE SYS TOT KNEE,SUP-2351378,CDM,C1776,CPT,0278,RC,,,,both,,,13031.00,8470.15,,,,,,,,,,,,,
SCREW BONE L35MM DIA6.5MM TI ST FULL THRD CTRL FOR GLEN,SUP-2388784,CDM,C1713,HCPCS,0278,RC,,,,both,,,1745.84,1134.80,,,,,,,,,,,,,
SUPPORT THMB STBL SM 2.25-2.75 IN LT PROCARE THUMBGUARD,SUP-2195766,CDM,L3931,HCPCS,0274,RC,,,,both,,,30.77,20.00,,,,,,,,,,,,,
HOOK SPNL 6MM ROD DIA 8.9MM BLDE W 5.0MM PEDCL NEUT OPN,SUP-2415554,CDM,C1713,HCPCS,0278,RC,,,,both,,,1664.33,1081.81,,,,,,,,,,,,,
KIT CATHETER BECKER EXT DRNGE MON VENT BA IMPREG,SUP-2284404,CDM,C1713,HCPCS,0278,RC,,,,both,,,940.84,611.55,,,,,,,,,,,,,
MESH SURG W7.6XL15CM RECT PARTIALLY ABSRB FLAT FOR SFT TISS,SUP-2220106,CDM,C1781,HCPCS,0278,RC,,,,both,,,421.73,274.12,,,,,,,,,,,,,
CATHETER CV BEDSIDE SET 018 6 FRX60 CM 3L NIT TURBO-JECT,SUP-2759935,CDM,C1751,HCPCS,0278,RC,,,,both,,,358.78,233.21,,,,,,,,,,,,,
PLATE BNE L37MM 3 H BILAT S STL 1/3 TBLR FOR 3.5MM SCR,SUP-2411330,CDM,C1713,HCPCS,0278,RC,,,,both,,,182.15,118.40,,,,,,,,,,,,,
SHEATH INTRO PRELUDE L 7 CM DIA 4 FR 0.018 IN 4 CM 21 GA NIT,SUP-2677274,CDM,C1894,HCPCS,0272,RC,,,,both,,,90.84,59.05,,,,,,,,,,,,,
COMPONENT TOT SHLDR CAPPED REVERSED S3LIMA] LIMA USA],SUP-2265057,CDM,C1776,CPT,0278,RC,,,,both,,,16328.00,10613.20,,,,,,,,,,,,,
PLATE BLADE ANGL 130 DEG 4H /110MM/60MM,SUP-2547501,CDM,C1713,HCPCS,0278,RC,,,,both,,,2330.95,1515.12,,,,,,,,,,,,,
IMMUNE GLOBULIN (PRIVIGEN) 10%,RX-4081762,CDM,J1459,HCPCS,0636,RC,44206-0438-20,NDC,,both,200,ML,11319.80,7357.87,,,,,,,,,,,,,
PLATE BNE L77MM 3 H R PROX PERIARTC ULNA LOK,SUP-2198451,CDM,C1713,HCPCS,0278,RC,,,,both,,,2214.80,1439.62,,,,,,,,,,,,,
PROBE SURG PEDIATRIC DSTL RAD,SUP-2535371,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1036.20,673.53,,,,,,,,,,,,,
NUT ORTH COMPR OLECRANON IMP STRL OD6MM,SUP-2106884,CDM,C1713,HCPCS,0278,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
STENT PERIPH L50MM OD9MM CATH L75CM OD11FR VIABAHN,SUP-2396459,CDM,C1874,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
GRAFT WDG EVANS ALLGRFT ADDUCTION 30DEG 12MM TX20MM H X 23MM,SUP-2321722,CDM,C1713,HCPCS,0278,RC,,,,both,,,6966.09,4527.96,,,,,,,,,,,,,
COMPONENT TIB CR 0 13 MM RT KNEE PRIMARY STEM CEM NP UCONG,SUP-2209406,CDM,C1776,CPT,0278,RC,,,,both,,,4143.23,2693.10,,,,,,,,,,,,,
PLATE BNE MEDL STD 94 MM R/L 11 HOLE EVOLVE EPS ORTHOLOC,SUP-2535935,CDM,C1713,HCPCS,0278,RC,,,,both,,,3300.14,2145.09,,,,,,,,,,,,,
TIBIAL NAIL INSTRUMENTS,SUP-2811209,CDM,C1713,HCPCS,0278,RC,,,,both,,,104860.30,68159.19,,,,,,,,,,,,,
SYSTEM THROMCTMY POUNCE LP L 150 CM DIA 7 FR GUIDEWIRE 0.018,SUP-2913917,CDM,C1757,HCPCS,0272,RC,,,,both,,,14758.00,9592.70,,,,,,,,,,,,,
KIT INFUS PMP 270ML 2M/HR SOAK CATH L2.5IN N NARC ON-Q,SUP-2236825,CDM,C9804,HCPCS,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
DRILL SURG DIA4.5MM CANN,SUP-2256847,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1381.60,898.04,,,,,,,,,,,,,
PLATE BONE W53XL85MM THK0.6MM MH TI SM GRID PNL FOR 1.5MM,SUP-2402902,CDM,C1713,HCPCS,0278,RC,,,,both,,,3585.88,2330.82,,,,,,,,,,,,,
EXPANDER TISS BRST SMOOTH ULTRA HI PROF,SUP-2748661,CDM,C1889,HCPCS,0278,RC,,,,both,,,5887.50,3826.87,,,,,,,,,,,,,
GRAFT VASC STR STD WALL N RING 6MM DIA 10CM LEN GORTX,SUP-2395721,CDM,C1768,CPT,0278,RC,,,,both,,,3444.58,2238.98,,,,,,,,,,,,,
INTRODUCER SHTH 11CM X 7FR 40CM X 0.018N NTNL/PLTNM GDWRE 21,SUP-2469012,CDM,C1894,HCPCS,0272,RC,,,,both,,,134.55,87.46,,,,,,,,,,,,,
PLATE BNE STR 12X0.6 MM NEURO 2 HOLE TI STRL 251521371,SUP-2459762,CDM,C1713,HCPCS,0278,RC,,,,both,,,328.19,213.32,,,,,,,,,,,,,
CATHETER ANGIOPLSTY APEX MR L 142 CM BALLOON L 8 MM DIA2.5,SUP-2144619,CDM,C1725,HCPCS,0272,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
VALVE MITRL CARP EDW DURAFLEX DIA 31 MM SEW RNG DIA 40 MM,SUP-2214283,CDM,C1889,HCPCS,0278,RC,,,,both,,,12638.50,8215.02,,,,,,,,,,,,,
CATHETER EP CRD 10 MM 5 FRX120 CM QPLR RESPON,SUP-2356784,CDM,C1730,HCPCS,0272,RC,,,,both,,,367.38,238.80,,,,,,,,,,,,,
GRAFT BONE 30ML CORT CANC CHIP FRZ DRY IRRADIATED,SUP-2113893,CDM,C1713,HCPCS,0278,RC,,,,both,,,1648.50,1071.52,,,,,,,,,,,,,
SUPPORT ORTHOT KNEE LIFT LOOP FOR GTT LCK RNG,SUP-2435671,CDM,L2492,HCPCS,0272,RC,,,,both,,,332.06,215.84,,,,,,,,,,,,,
MESH SURG ELLIP 8X6 IN W/ FEN PORCINE COLLAMEND FM,SUP-2126252,CDM,C1781,HCPCS,0278,RC,,,,both,,,10133.57,6586.82,,,,,,,,,,,,,
BUCK CEMENT REST SIZE 35MM,SUP-2822555,CDM,C1713,HCPCS,0278,RC,,,,both,,,141.30,91.84,,,,,,,,,,,,,
SYSTEM RETRV 20 MM NIT 2 SHTH SNR KINK RESIST RADIOPAQUE,SUP-2128488,CDM,C1773,HCPCS,0272,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
PLATE BONE T TYPE 1.5 MM 4 HOLE STAINLESS STEEL STERILE TC10,SUP-2836680,CDM,C1713,HCPCS,0278,RC,,,,both,,,1626.46,1057.20,,,,,,,,,,,,,
PLATE BNE LCK SHT 126 MM RT DSTL MEDL HUM 7 HOLE SS PUR NS,SUP-2492939,CDM,C1713,HCPCS,0278,RC,,,,both,,,2877.15,1870.15,,,,,,,,,,,,,
TROCAR ENDOSCP L 150 MM DIA12 MM LNG LAPSCP BLADED SMTH CANN,SUP-2896379,CDM,2720000010,LOCAL,0272,RC,,,,both,,,420.67,273.44,,,,,,,,,,,,,
BIT DRL L65MM DIA3.5MM S STL W/O STP NONRADIOPAQUE DISP FOR,SUP-2318878,CDM,2720000010,LOCAL,0272,RC,,,,both,,,674.35,438.33,,,,,,,,,,,,,
SUPPORT ORTHOT KNEE LIFT LOOP FOR GTT LCK RNG,SUP-2435671,CDM,L2492,HCPCS,0274,RC,,,,both,,,332.06,215.84,,,,,,,,,,,,,
STEM FEM L140MM OD13MM CO CHROM HIP NEUT REV CEM LNG BODY,SUP-2203471,CDM,C1776,CPT,0278,RC,,,,both,,,15205.45,9883.54,,,,,,,,,,,,,
PLATE BNE H1.5MM 6 H 115DEG MAND G TI LO PROF W/ BAR FULL,SUP-2366368,CDM,C1713,HCPCS,0278,RC,,,,both,,,1983.79,1289.46,,,,,,,,,,,,,
CATHETER CV 4 LUMEN 8.5 FR,SUP-2383334,CDM,C1751,HCPCS,0278,RC,,,,both,,,232.86,151.36,,,,,,,,,,,,,
PROSTHESIS OSS WEHRS INCUS SHT 2.1X0.9X2.5 MM SINGLE NOTCH,SUP-2637872,CDM,L8613,CPT,0278,RC,,,,both,,,1206.48,784.21,,,,,,,,,,,,,
ENDOPROSTHESIS VASC WSTNT RP L 60 MM DIA 6 MM CATH TOT L 100,SUP-2142745,CDM,C1876,HCPCS,0278,RC,,,,both,,,3375.50,2194.07,,,,,,,,,,,,,
CONTROLLER INTELLIS PTM NONTRAIL,SUP-2750022,CDM,C1787,HCPCS,0278,RC,,,,both,,,3011.26,1957.32,,,,,,,,,,,,,
CATHETER IAB 0.025 IN 0.027 INX8 FRX26 IN 6 IN 50 CC SHTH,SUP-2877608,CDM,C1894,HCPCS,0272,RC,,,,both,,,4254.70,2765.55,,,,,,,,,,,,,
PLATE BONE L300MM 130DEG 14 H PELVIS BILAT S STL STD BRL RIG,SUP-2342589,CDM,C1713,HCPCS,0278,RC,,,,both,,,1613.96,1049.07,,,,,,,,,,,,,
PLATE BNE K MINI 2/2.5X1 MM RT 9 HOLE TI NS 253840909,SUP-2500998,CDM,C1713,HCPCS,0278,RC,,,,both,,,2707.75,1760.04,,,,,,,,,,,,,
SHEATH INTRO PINNACLE PRECIS ACCS SYS L 10 CM DIA 4 FR NIT,SUP-2385474,CDM,C1894,HCPCS,0272,RC,,,,both,,,194.24,126.26,,,,,,,,,,,,,
PEGFILGRASTIM-PBBK 6 MG/0.6ML SC SOSY,RX-159681,CDM,Q5130,HCPCS,0636,RC,70121-1627-01,NDC,,both,.6,ML,7375.10,4793.81,,,,,,,,,,,,,
SPLINT ORTH PLASTALUME 3.25X3.25 IN FNGR W/ BLB RADLUC,SUP-2276772,CDM,L3933,HCPCS,0274,RC,,,,both,,,3.89,2.53,,,,,,,,,,,,,
COMPONENT FEM SM L DST KNEE MOD REPL SYS GMRS,SUP-2376510,CDM,C1776,CPT,0278,RC,,,,both,,,17297.95,11243.67,,,,,,,,,,,,,
SOLUTION HEMOSTATIC NDL L 4 MM DIA25 GA WORKING L 230 CM 15,SUP-2912511,CDM,C1889,HCPCS,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
GRAFT ILIAC CREST WEDGE 10 X 15 FD,SUP-2863671,CDM,C1762,CPT,0278,RC,,,,both,,,5761.90,3745.23,,,,,,,,,,,,,
SLING INCONT RETROPUBIC CONTINENCE SYS GYNECARE TVT EXACT,SUP-2220077,CDM,C1771,HCPCS,0278,RC,,,,both,,,6069.62,3945.25,,,,,,,,,,,,,
GRAFT VASC HEMSHLD GLD L 40 CM DIA18 X 9 MM POLYESTER BOV,SUP-2494374,CDM,C1768,CPT,0278,RC,,,,both,,,2364.67,1537.04,,,,,,,,,,,,,
PROFIX NONPOR CR W/ NP CR TIB AND PROFLX INSRT,SUP-2348006,CDM,C1776,CPT,0278,RC,,,,both,,,7536.00,4898.40,,,,,,,,,,,,,
SURGICAL KIT MAND MIDFACE ZYG TRUMATCH,SUP-2860365,CDM,C1713,HCPCS,0278,RC,,,,both,,,28969.64,18830.27,,,,,,,,,,,,,
HC Thromboplastin Time Prtl Substit Plasma Frctj Ea,PX-3058573200,CDM,85732,CPT,0305,RC,,,,both,,,99.00,64.35,,,,,,,,,,,,,
INSERT ACET OD54-56MM ID32MM 10DEG X FRE CO CHROM HIP CUP,SUP-2370106,CDM,C1776,CPT,0278,RC,,,,both,,,1201.33,780.86,,,,,,,,,,,,,
PLATE BNE L55MM 7 H S STL 1/4 TBLR CLLRD FOR 2.7MM SCR,SUP-2411326,CDM,C1713,HCPCS,0278,RC,,,,both,,,269.10,174.91,,,,,,,,,,,,,
DISC SPNL DP MED 6 MM FOR TOT DISC REPL STRL PRODISC C,SUP-2163160,CDM,C1889,HCPCS,0278,RC,,,,both,,,15072.00,9796.80,,,,,,,,,,,,,
MOD ARTHRO 5 DEG LCK COLLAR,SUP-2510743,CDM,C1776,CPT,0278,RC,,,,both,,,8831.25,5740.31,,,,,,,,,,,,,
BIT DRL LNG 4 MM,SUP-2254049,CDM,2720000010,LOCAL,0272,RC,,,,both,,,339.12,220.43,,,,,,,,,,,,,
ALTEPLASE 50 MG IV SOLR|DISCARDED DRUG NOT ADMINISTE,RX-9003,CDM,J2997,HCPCS,0636,RC,50242-0044-13,NDC,JW,both,1,UN,25301.10,16445.71,,,,,,,,,,,,,
BLADE SAW OSCILLATING MIC 25.5X15X0.51 MM CRESC CUT EDGE,SUP-2862469,CDM,2720000010,LOCAL,0272,RC,,,,both,,,350.20,227.63,,,,,,,,,,,,,
KIT LD STYL SFT FEATURING ISOFLEX OPTIM PACE,SUP-2357110,CDM,C1894,HCPCS,0272,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
PLATE BNE W12XL268MM THK37MM LNG 12 H PROX HUM S STL LOK,SUP-2186024,CDM,C1713,HCPCS,0278,RC,,,,both,,,5212.46,3388.10,,,,,,,,,,,,,
PROSTHESIS OSS PISTON 0.8X6 MM 0.6 MM FLROPLAS,SUP-2637727,CDM,L8613,CPT,0278,RC,,,,both,,,280.50,182.32,,,,,,,,,,,,,
PACEMAKER CARD 2 CHMBR TEMP PULSE GENRTR DDDDDD 500DVIVDDD00,SUP-2138031,CDM,C1713,HCPCS,0278,RC,,,,both,,,13878.80,9021.22,,,,,,,,,,,,,
COMPONENT FEM XSM L DST CO CHROM CEM PRI POST STBL STEMLESS,SUP-2252626,CDM,C1776,CPT,0278,RC,,,,both,,,23761.01,15444.66,,,,,,,,,,,,,
GRAFT BNE SM 15 CC PRO OSTEON 200R,SUP-2685765,CDM,C1713,HCPCS,0278,RC,,,,both,,,5058.54,3288.05,,,,,,,,,,,,,
SCREW SPNL ROD DIA 5.5/6 MM SS UNIAXIAL STRL CD HORZ MODULEX 2PK,SUP-2928046,CDM,C1713,HCPCS,0278,RC,,,,both,,,5055.40,3286.01,,,,,,,,,,,,,
PLATE BONE ADJUSTABLE SLIDER 0.7X33 MM SAGITTAL SPLIT TITANI,SUP-2842388,CDM,C1713,HCPCS,0278,RC,,,,both,,,1951.82,1268.68,,,,,,,,,,,,,
HC IV Push Same Drug,PX-2609637600,CDM,96376,CPT,0260,RC,,,,both,,,92.00,59.80,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.419,SUP-2859983,CDM,C1713,HCPCS,0278,RC,,,,both,,,32486.44,21116.19,,,,,,,,,,,,,
BUR SURG 13.5 MM TREPHINE FOR OTO SPINE,SUP-2607578,CDM,2720000010,LOCAL,0272,RC,,,,both,,,499.61,324.75,,,,,,,,,,,,,
SUPPORT ORTHOT ANK KNEE CUST SINGLE UPR W/O KA PLAS,SUP-2435636,CDM,L2034,HCPCS,0272,RC,,,,both,,,5751.38,3738.40,,,,,,,,,,,,,
COMPONENT CARPAL LG ST,SUP-2696159,CDM,C1776,CPT,0278,RC,,,,both,,,11430.86,7430.06,,,,,,,,,,,,,
PROSTHESIS PENILE INFLATABLE 11 MMX16 CM AMS AMBICOR,SUP-2140273,CDM,C1813,HCPCS,0278,RC,,,,both,,,13737.50,8929.37,,,,,,,,,,,,,
CATHETER HEMODIALYSI DUO SPLIT ACTE 13FR DIA 12CM STRGHT 2LU,SUP-2610504,CDM,C1752,HCPCS,0278,RC,,,,both,,,191.54,124.50,,,,,,,,,,,,,
CHLORDIAZEPOXIDE HCL 5 MG PO CAPS,RX-1624,CDM,6370000000,HCPCS,0637,RC,51079-0374-20,NDC,,both,1,UN,2.90,1.88,,,,,,,,,,,,,
BOLT ORTH 25 MM LAT TROCHANTERIC ARCOS,SUP-2441646,CDM,C1776,CPT,0278,RC,,,,both,,,1667.34,1083.77,,,,,,,,,,,,,
BUR SURG DIA35MM DMND RND NONFLUTED SABER SHANK ELITE TPS,SUP-2367571,CDM,C1713,HCPCS,0278,RC,,,,both,,,454.17,295.21,,,,,,,,,,,,,
"HC So Antibody,Hiv 1 & Hiv 2, Assay",PX-3028670366,CDM,86703,CPT,0302,RC,,,,outpatient,,,187.00,121.55,,,,,,,,,,,,,
BIT DRL L44.5MM DIA0.7MM STP 6MM L14MM STRL MAXILLOFACIAL S,SUP-2187622,CDM,2720000010,LOCAL,0272,RC,,,,both,,,433.63,281.86,,,,,,,,,,,,,
WIRE FIX L9IN OD0.062IN TRCR PNT BOTH END,SUP-2303784,CDM,C1713,HCPCS,0278,RC,,,,both,,,12.62,8.20,,,,,,,,,,,,,
CATHETER GUID SELECTSITE L 43 CM OD 8.4 FR ID 5.7 FR INTRO 9,SUP-2419408,CDM,C1887,HCPCS,0272,RC,,,,both,,,1758.40,1142.96,,,,,,,,,,,,,
BUR SURGICAL OD4MM TUNGSTEN CARBIDE ROSEN DISPOSABLE FOR HANDPIECE I HI LINE XS,SUP-2108767,CDM,C1713,HCPCS,0278,RC,,,,both,,,339.40,220.61,,,,,,,,,,,,,
SPACER HUM 9+ MM TI HUMELOCK II,SUP-2741761,CDM,C1776,CPT,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
KIT PAIN PMP 270ML 4ML HR ELASTOMERIC NONNARCOTIC ON Q,SUP-2236815,CDM,C9804,HCPCS,0272,RC,,,,both,,,254.34,165.32,,,,,,,,,,,,,
COLLAR EXTRIC AD TALL HI DENS POLYETH PD SET XTW,SUP-2194473,CDM,L0172,HCPCS,0272,RC,,,,both,,,107.61,69.95,,,,,,,,,,,,,
GUIDE WIRE USE WITH BOUGIES 745710/11/12/13,SUP-2574268,CDM,C1769,HCPCS,0272,RC,,,,both,,,102.55,66.66,,,,,,,,,,,,,
Blade Surgical Laminectomy W1.5in D.75in Taylor 13-1054,SUP-2853252,CDM,2720000010,LOCAL,0272,RC,,,,both,,,390.30,253.69,,,,,,,,,,,,,
PLATE BNE L 331 MM SCREW DIA 3.5/4.5 MM 14 H LT TROCHANTERIC 72586114,SUP-2933041,CDM,C1713,HCPCS,0278,RC,,,,both,,,21552.96,14009.42,,,,,,,,,,,,,
LENS IOL HYDROPHOBIC ACRYL POST CHMBR ASPHERIC UV CCW0T7,SUP-2881009,CDM,V2788,HCPCS,0276,RC,,,,both,,,415.00,269.75,,,,,,,,,,,,,
TRIAL KNEE SYS FEM AND TIB TRLING KT CONTENTS CRUCIAL RET,SUP-2363756,CDM,C1776,CPT,0278,RC,,,,both,,,404.12,262.68,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED MOD PRIMARY APEX,SUP-2400116,CDM,C1776,CPT,0278,RC,,,,both,,,14444.00,9388.60,,,,,,,,,,,,,
SCREW SPNL MULTAXL XS 3X18 MM OCCIPITOCERVICAL UPPER THOR,SUP-2631942,CDM,C1713,HCPCS,0278,RC,,,,both,,,1789.80,1163.37,,,,,,,,,,,,,
BASKET SPCMN RTRVL 22MMW OPNNG 195CML WRKNG BLLT SHPD TIP ST,SUP-2679347,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1177.53,765.39,,,,,,,,,,,,,
CONFORM FLEX Q-PACK 10 MM CUBE,SUP-2547186,CDM,C1713,HCPCS,0278,RC,,,,both,,,1151.72,748.62,,,,,,,,,,,,,
IMPLANT TOE L22MM OD2.5MM LCTSRB CPLMR THRDD RSRBBLE HMMRTOE,SUP-2485551,CDM,C1776,CPT,0278,RC,,,,both,,,803.84,522.50,,,,,,,,,,,,,
SHEATH INTRO COMPANION SHTH L 30 CM OD 3.01 MM ID 7 FR,SUP-2889619,CDM,2720000010,LOCAL,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
PACEMAKER CARD 24GM 11CC H45XL52MM THK6MM TI PARYLENE EPOXY,SUP-2356210,CDM,C1785,HCPCS,0275,RC,,,,both,,,9420.00,6123.00,,,,,,,,,,,,,
KIT CLMP WIRE FIX K,SUP-2316278,CDM,2720000010,LOCAL,0272,RC,,,,both,,,883.16,574.05,,,,,,,,,,,,,
ALLOGRAFT BNE FD EO RT HEMI MAND,SUP-2867073,CDM,C1762,CPT,0278,RC,,,,both,,,6604.36,4292.83,,,,,,,,,,,,,
HEAD 22MM BPLR MOD NK,SUP-2372633,CDM,C1776,CPT,0278,RC,,,,both,,,422.02,274.31,,,,,,,,,,,,,
PLATE BONE 135DEG 8 H SUPCNDYL S STL COMPR FRELOK,SUP-2197729,CDM,C1713,HCPCS,0278,RC,,,,both,,,1721.44,1118.94,,,,,,,,,,,,,
BOLT ORTHOPEDIC 12 MM,SUP-2316057,CDM,C1713,HCPCS,0278,RC,,,,both,,,6.28,4.08,,,,,,,,,,,,,
SPHERE OPHTH DIA20MM EYE PMMA LTWT PERM,SUP-2129496,CDM,L8610,HCPCS,0278,RC,,,,both,,,47.10,30.61,,,,,,,,,,,,,
INTRODUCER ENDOSCP MINOP DIA22-19 FR RND BLNT OBTURATOR SHTH,SUP-2821661,CDM,2720000010,LOCAL,0272,RC,,,,both,,,822.81,534.83,,,,,,,,,,,,,
NAIL IM L380MM DIA13MM ST AQUA L/R DST FEM TI LOK SLD DYN,SUP-2191819,CDM,C1713,HCPCS,0278,RC,,,,both,,,7336.30,4768.59,,,,,,,,,,,,,
PLATE BONE 18 H BILAT MAND TI STR RIG NONCOMPRESSION,SUP-2191408,CDM,C1713,HCPCS,0278,RC,,,,both,,,3918.72,2547.17,,,,,,,,,,,,,
HEAD FEM DIA47MM UPLR CO CHROM MOD 12/14 TAPR LEG,SUP-2207880,CDM,C1776,CPT,0278,RC,,,,both,,,968.38,629.45,,,,,,,,,,,,,
SCREW BONE EMERGENCY 1.2X8 MM CORTEX CRANIOMAXILLOFACIAL WIT,SUP-2838160,CDM,C1713,HCPCS,0278,RC,,,,both,,,367.07,238.60,,,,,,,,,,,,,
GRAFT BNE 30ML CANC CHIP DEMIN VOID DEFCT FILL FRZ DRY,SUP-2307253,CDM,C1713,HCPCS,0278,RC,,,,both,,,2054.22,1335.24,,,,,,,,,,,,,
TAP SURG L125MM DIA3.5MM G SCR AO FIT AXSOS,SUP-2377949,CDM,2720000010,LOCAL,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
SUPPORT ORTHOT LUMBAR SACR CUST SAG CTRL PANEL STRP STAY,SUP-2435557,CDM,L0643,HCPCS,0274,RC,,,,both,,,458.57,298.07,,,,,,,,,,,,,
FLUPHENAZINE HCL 1 MG PO TABS,RX-3218,CDM,6370000000,HCPCS,0637,RC,00527-1788-01,NDC,,both,1,UN,6.80,4.42,,,,,,,,,,,,,
FOOTSWITCH LASER H65W H100W HOLM EMPOWER,SUP-2489928,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2710.95,1762.12,,,,,,,,,,,,,
KIT HEMTLGY CONC SYS CBMA MAR0 MAX QUICKDRAW W/ LIGHTNING,SUP-2247323,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5338.00,3469.70,,,,,,,,,,,,,
STENT EVAR L60MM DIA8MM DST TRNSJUG EPTFE NYL INTRAHEPATIC,SUP-2395922,CDM,C1874,HCPCS,0278,RC,,,,both,,,13856.82,9006.93,,,,,,,,,,,,,
PLATE BNE 2 T-SHAPE1.0MM 4-HOLE,SUP-2247342,CDM,C1713,HCPCS,0278,RC,,,,both,,,1356.48,881.71,,,,,,,,,,,,,
HC I&D Hematoma Seroma Fluid,PX-4501014000,CDM,10140,CPT,0450,RC,,,,both,,,4946.00,3214.90,,,,,,,,,,,,,
STENT BILI PRECIS L 40 MM DIA 9 MM CATH L 135 CM DIA 8 FR,SUP-2158929,CDM,C1876,HCPCS,0278,RC,,,,both,,,5829.10,3788.91,,,,,,,,,,,,,
SEED BRACHYTHERAPY LOOSE NS SEEDSNS] BIOCOMPATIBLES INC],SUP-2135321,CDM,C2639,HCPCS,0278,RC,,,,both,,,47.10,30.61,,,,,,,,,,,,,
PLATE BNE W17.5XL124MM THK5.2MM 7 H TI BROAD LIMIT CNTCT,SUP-2190842,CDM,C1713,HCPCS,0278,RC,,,,both,,,948.03,616.22,,,,,,,,,,,,,
BLADE SAW THK0.51MM CUT EDGE L18MM D30MM CRESC OSC TPS COR,SUP-2367525,CDM,C1713,HCPCS,0278,RC,,,,both,,,326.37,212.14,,,,,,,,,,,,,
ENDOPROSTHESIS VASC VIABAHN L 15CM 10MM 120CM RADIOPAQUE,SUP-2610468,CDM,C1768,CPT,0278,RC,,,,both,,,12261.70,7970.10,,,,,,,,,,,,,
PLATE 4.5MM TI LCP MEDIAL PROXIMAL TIBIA 10H LEFT 214MM,SUP-2549614,CDM,C1713,HCPCS,0278,RC,,,,both,,,3426.15,2227.00,,,,,,,,,,,,,
CATHETER VENTRICULAR 12X21 MMX23 CM STYL RT ANGLE BA IMPREG,SUP-2277970,CDM,C1729,HCPCS,0272,RC,,,,both,,,346.53,225.24,,,,,,,,,,,,,
PACK ORTHOPEDIC STRL DARTFIRE EDGE,SUP-2900821,CDM,2720000010,LOCAL,0272,RC,,,,both,,,405.06,263.29,,,,,,,,,,,,,
TRAY CATH MIDLN POWERGLIDE PRO 20GA 8CM WNG 1 LUMAN F120081T,SUP-2632733,CDM,C1751,HCPCS,0278,RC,,,,both,,,326.56,212.26,,,,,,,,,,,,,
COMPONENT FEM CR 3 UNISX LT KNEE NP PRIMARY STEMLESS CEM,SUP-2377956,CDM,C1776,CPT,0278,RC,,,,both,,,6053.29,3934.64,,,,,,,,,,,,,
TUBE TRACH L112MM OD12X11MM CLR THOR CANN AIRWY SIL 2 PLUG,SUP-2138750,CDM,C1713,HCPCS,0278,RC,,,,both,,,533.80,346.97,,,,,,,,,,,,,
ALLOGRAFT HUM TISS SHT 5X3 CM PLCNTA BASE MEMBRN AMNIOEFFECT,SUP-2872720,CDM,C1762,CPT,0278,RC,,,,both,,,6713.32,4363.66,,,,,,,,,,,,,
PLATE BONE PREFORMED MEDIUM 2.5 MM LEFT MANDIBLE RECONSTRUCT,SUP-2837779,CDM,C1713,HCPCS,0278,RC,,,,both,,,10625.13,6906.33,,,,,,,,,,,,,
ANCHOR SUTURE DIA 4.75 MM TAPE 1.8/1.4 MM BIOCOMP 1 STRND,SUP-2908710,CDM,C1713,HCPCS,0278,RC,,,,both,,,1450.68,942.94,,,,,,,,,,,,,
KIT NEUROSTIMULATOR LD L28CM DIA1.27MM ELECTRD SPC 1.5MM,SUP-2284490,CDM,C1883,HCPCS,0278,RC,,,,both,,,10723.10,6970.01,,,,,,,,,,,,,
PLATE BONE L140MM 135DEG 6 H PELVIS BILAT S STL STD BRL RIG,SUP-2342586,CDM,C1713,HCPCS,0278,RC,,,,both,,,3990.00,2593.50,,,,,,,,,,,,,
GRAFT BNE SUB 5CC 2-4MM GROWTH FACT ALLGRFT OSTEOAMP,SUP-2138497,CDM,C1713,HCPCS,0278,RC,,,,both,,,3469.70,2255.30,,,,,,,,,,,,,
HC So1 Acetylcholn Rcptr Bndng Antb,PX-3028604167,CDM,86041,CPT,0302,RC,,,,both,,,76.00,49.40,,,,,,,,,,,,,
PLATE BNE 2.7X44 MM 7 HOLE MULTIPLE FRAG SS NS,SUP-2568762,CDM,C1713,HCPCS,0278,RC,,,,both,,,580.15,377.10,,,,,,,,,,,,,
KIT VERTPLSTY BX NDL 13GA CRV W BFC TRCR TAMP CDS GUN AND,SUP-2281726,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3265.60,2122.64,,,,,,,,,,,,,
PLATE BNE LCK 2 MM STRNL 6 HOLE XIPHOID,SUP-2262562,CDM,C1713,HCPCS,0278,RC,,,,both,,,1067.60,693.94,,,,,,,,,,,,,
SYSTEM FIX SHFT L36CM DIA5MM FAST L6.7MM POLY LACTIDE ABSRB,SUP-2125761,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2433.50,1581.77,,,,,,,,,,,,,
SHEATH INTRO BAN PEEL L 15 CM DIA11 FR STRL,SUP-2141069,CDM,C1892,HCPCS,0272,RC,,,,both,,,144.13,93.68,,,,,,,,,,,,,
PLATE BNE L115MM 8 H L SUP CLAV S STL LOK COMPR FOR 3.5MM,SUP-2177369,CDM,C1713,HCPCS,0278,RC,,,,both,,,2808.98,1825.84,,,,,,,,,,,,,
BLADE RTRCTR 2INW X 4 12NL ALMNM SPLNCHNC ABDMNL ABH STYLE,SUP-2703360,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1512.48,983.11,,,,,,,,,,,,,
CRYOPROBE 2.1MM (14G) ISOLIS 20CM SPHR,SUP-2885471,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
PUSHER SURG FOR AC JT RECON TOGGLELOC DISP,SUP-2137214,CDM,2720000010,LOCAL,0272,RC,,,,both,,,590.82,384.03,,,,,,,,,,,,,
CATHETER KIT 3L 7 FRX6 IN PRESSURE INJ FLX ARROWG+ARD BLU +,SUP-2383381,CDM,C1751,HCPCS,0278,RC,,,,both,,,339.75,220.84,,,,,,,,,,,,,
COMPONENT FEM M L KNEE REV CEM CRUCE RET STEM NONBEADED CO 66300315] STRYKER ORTHOPEDICS HOWM],SUP-2377047,CDM,C1776,CPT,0278,RC,,,,both,,,10876.96,7070.02,,,,,,,,,,,,,
ALLOGRAFT BNE STRP 10X2.5 CM FIBER KORE,SUP-2736960,CDM,C1713,HCPCS,0278,RC,,,,both,,,10303.13,6697.03,,,,,,,,,,,,,
ASPIRATION TRAY PORTED NDL 11 GAX102 MM ONCONTROL,SUP-2766679,CDM,2720000010,LOCAL,0272,RC,,,,both,,,484.09,314.66,,,,,,,,,,,,,
TUBE OPHTH IMPL 250 MM DIAM 32 MM TUBE LEN STRL SIL,SUP-2326687,CDM,C1783,HCPCS,0278,RC,,,,both,,,1880.86,1222.56,,,,,,,,,,,,,
PIN FIX SMOOTH 1/8 DRL BIT,SUP-2267682,CDM,2720000010,LOCAL,0272,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
PLATE BONE L25MM THK0.9MM 6 H BILAT CRANIOMAXILLOFACIAL TI,SUP-2191329,CDM,C1713,HCPCS,0278,RC,,,,both,,,2266.14,1472.99,,,,,,,,,,,,,
HC OB ER Level 4,PX-4509928401,CDM,99284,CPT,0450,RC,,,,outpatient,,,2334.00,1517.10,,,,,,,,,,,,,
RING EXT FIX DIA170MM HALF FOR RNG FIX SYS TRUELOK,SUP-2316179,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
GRAFT STRUT CORT STRUCTURAL ALLGRFT FRZ DRY 40 80MM LX1MM,SUP-2307180,CDM,C1713,HCPCS,0278,RC,,,,both,,,2938.47,1910.01,,,,,,,,,,,,,
GRAFT BONE LT FEM WHL TRAD FRZN,SUP-2294155,CDM,C1713,HCPCS,0278,RC,,,,both,,,18934.20,12307.23,,,,,,,,,,,,,
JOINT FNGR 30 SM 10.2X20.2X8.9 MM 10.1 MM PYROCARBON NUGRIP,SUP-2852960,CDM,C1776,CPT,0278,RC,,,,both,,,11097.39,7213.30,,,,,,,,,,,,,
BIT DRL DIA7MM ASSEMB BNE GRFT FOR UNIV PLATTER,SUP-2107742,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4851.30,3153.34,,,,,,,,,,,,,
MESH CRAN KASSAM LG 0.3 MM SCRN PANEL NEURO SCREW CP TI,SUP-2494905,CDM,C1713,HCPCS,0278,RC,,,,both,,,829.18,538.97,,,,,,,,,,,,,
RETRACTOR LAP 2XL SHTH L36CM INCIS RANG 17-25CM WND PROTCT,SUP-2119634,CDM,2720000010,LOCAL,0272,RC,,,,both,,,339.12,220.43,,,,,,,,,,,,,
COMPONENT FEM SZ 4 R REV POST STBL GMK,SUP-2267610,CDM,C1776,CPT,0278,RC,,,,both,,,8116.90,5275.98,,,,,,,,,,,,,
ROD SPNL OD5.5MM L500MM TI R POST SMOOTH STR HEX CDH LEG,SUP-2290758,CDM,C1713,HCPCS,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
SHELL ACET CMNTLS 46 MM MULT HOLE STRL EMPHASYS LTX,SUP-2874345,CDM,C1776,CPT,0278,RC,,,,both,,,10708.66,6960.63,,,,,,,,,,,,,
ENDOPROSTHESIS VASC ICAST L 16 MM DIA 6 MM CATH L 120 CM,SUP-2884912,CDM,C1874,HCPCS,0278,RC,,,,both,,,7586.81,4931.43,,,,,,,,,,,,,
NALOXONE HCL 4 MG/10ML IJ SOLN,RX-135455,CDM,J2312,HCPCS,0636,RC,00409-1219-01,NDC,,both,0.25,ML,54.10,35.16,,,,,,,,,,,,,
SET DRNGE L41CM OD24FR ODSEC.038IN J 3 SIDE PRT ENDOSCP,SUP-2168143,CDM,C1729,HCPCS,0272,RC,,,,both,,,303.86,197.51,,,,,,,,,,,,,
PLATE BNE L 46 MM 3 H ANODIZATION TYP II RT VOLAR DSTL,SUP-2902161,CDM,C1713,HCPCS,0278,RC,,,,both,,,4765.20,3097.38,,,,,,,,,,,,,
COUNTERSINK SURG DIA 5.5 MM CANN HDLSS AO QC,SUP-2898154,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1629.66,1059.28,,,,,,,,,,,,,
BLADE RETRACTOR CLOWARD 7.5X20 MM W/ LIP ULTRA,SUP-2496149,CDM,2720000010,LOCAL,0272,RC,,,,both,,,342.86,222.86,,,,,,,,,,,,,
PASSER SUTURE STRL DISP GRAPPLER KIT 5/BX,SUP-2900171,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2590.50,1683.82,,,,,,,,,,,,,
STEM HUM COMP BODY SECT IMPL CO CHROM PRI CEM TOT 8.0MM DIA,SUP-2344293,CDM,C1776,CPT,0278,RC,,,,both,,,7528.15,4893.30,,,,,,,,,,,,,
GRAFT HUM TISS W15 18XL100MM RADIUS ULNA SHFT FRZ DRY,SUP-2307203,CDM,C1713,HCPCS,0278,RC,,,,both,,,2410.70,1566.95,,,,,,,,,,,,,
PLATE BNE L 52 MM SCREW DIA2 MM 7 SHFT H SS STR VA OPTIMIZED NS,SUP-2908861,CDM,C1713,HCPCS,0278,RC,,,,both,,,2428.26,1578.37,,,,,,,,,,,,,
STEM FEM L N CLLRD POR HA NAT HIP SZ 0,SUP-2210783,CDM,C1776,CPT,0278,RC,,,,both,,,26690.00,17348.50,,,,,,,,,,,,,
DEVICE FIX OPN ABSORBABLE 20 ABSORBABLE FAST OPTIFIX,SUP-2855239,CDM,C1713,HCPCS,0278,RC,,,,both,,,1193.20,775.58,,,,,,,,,,,,,
SUPPORT ORTHOT FT CUST INSRT MOLD TO PT MODEL SIL GEL,SUP-2435703,CDM,L3003,HCPCS,0274,RC,,,,both,,,493.26,320.62,,,,,,,,,,,,,
INSERT TIB THK 19 MM SZ 0 POLYETHYL LT ANK FIX XT REV STRL,SUP-2933230,CDM,C1776,CPT,0278,RC,,,,both,,,9519.54,6187.70,,,,,,,,,,,,,
IMPLANT TOE SZ 30 FOREFOOT PRIMUS GREAT W/ GRMMT FUTURA,SUP-2399910,CDM,C1776,CPT,0278,RC,,,,both,,,3570.18,2320.62,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 70 CM DIA 5 MM RNG L 70 CM EPTFE,SUP-2396287,CDM,C1768,CPT,0278,RC,,,,both,,,3783.70,2459.40,,,,,,,,,,,,,
LINER ACET NEUT B 5+ MM 28 MM PROV G7,SUP-2441106,CDM,C1776,CPT,0278,RC,,,,both,,,155.43,101.03,,,,,,,,,,,,,
IMPLANT OPHTH SCLER TISS,SUP-2303760,CDM,C1762,CPT,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
STEM FEM XSM L40MM STD CO CHROMIUM KNEE EXTN CEM BILAT,SUP-2376289,CDM,C1776,CPT,0278,RC,,,,both,,,2400.22,1560.14,,,,,,,,,,,,,
GRAFT BIO TISS W5XL16CM PORCINE REGEN TISS MTRX PLIABLE,SUP-2112972,CDM,Q4130,HCPCS,0636,RC,,,,both,,,7689.86,4998.41,,,,,,,,,,,,,
WASHER 7MM RED,SUP-2474534,CDM,2720000010,LOCAL,0272,RC,,,,both,,,139.82,90.88,,,,,,,,,,,,,
GRAFT VASC STR 6 MMX5 CM HEMO DYLS or HD ACCS EPTFE IMPRA,SUP-2126470,CDM,C1768,CPT,0278,RC,,,,both,,,1670.48,1085.81,,,,,,,,,,,,,
CATHETER SPEC RETRV BELOW 9-12 MM EXTRACTOR PRO RX-S,SUP-2484405,CDM,2720000010,LOCAL,0272,RC,,,,both,,,468.96,304.82,,,,,,,,,,,,,
COMPONENT PAT OD32MM THK8MM SGL PEG POLYETH ONLAY RM SYS ADV,SUP-2304732,CDM,C1776,CPT,0278,RC,,,,both,,,3359.80,2183.87,,,,,,,,,,,,,
HC Sterno-Clavicular Jt Min 3 Views,PX-3207113000,CDM,71130,CPT,0320,RC,,,,both,,,781.00,507.65,,,,,,,,,,,,,
SYSTEM ACCS PLATFORM PRT GELPOINT,SUP-2119760,CDM,C1713,HCPCS,0278,RC,,,,both,,,1651.64,1073.57,,,,,,,,,,,,,
GUIDEWIRE VASC L 150 CM DIA 0.035 IN TIP L 3 MM PTFE AD J,SUP-2117312,CDM,C1769,HCPCS,0272,RC,,,,both,,,37.68,24.49,,,,,,,,,,,,,
BEARING HUM STD 36 MM SHLDR VIVACIT-E PROLONG COMPHSVE,SUP-2418441,CDM,C1776,CPT,0278,RC,,,,both,,,2656.44,1726.69,,,,,,,,,,,,,
CATHETER THROMCTMY STROKE FAST PK PTFE PEBAX COIL SS STRL,SUP-2551070,CDM,C1757,HCPCS,0272,RC,,,,both,,,9624.51,6255.93,,,,,,,,,,,,,
HC So Allergen Specific,PX-3058600366,CDM,86003,CPT,0305,RC,,,,outpatient,,,161.00,104.65,,,,,,,,,,,,,
DEVICE FIX 5MM SHFT ENDO W/ 20 ANCHR STPLR HERN TACK MULTFI,SUP-2257514,CDM,C1713,HCPCS,0278,RC,,,,both,,,931.70,605.60,,,,,,,,,,,,,
ATTACHMENT PWR TOOL L5CM SH FOR HI PERF INSTR SYS ANSPACH,SUP-2176948,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
GRAFT BONE SUB BONE GRFT 5ML GEL TRANZGRFT,SUP-2353938,CDM,C1713,HCPCS,0278,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
GRAFT VASC PTCH 7.5X8 MM POLYESTER DBL VELOUR ULTRAMAX,SUP-2469104,CDM,C1768,CPT,0278,RC,,,,both,,,386.82,251.43,,,,,,,,,,,,,
STEM CEMENTED 18MM X 80MM TITANIUM,SUP-2863708,CDM,C1776,CPT,0278,RC,,,,both,,,4867.00,3163.55,,,,,,,,,,,,,
PLATE BNE RECON MED 2-2.3X169X2.8 MM RT 22 HOLE TI STRL,SUP-2460103,CDM,C1713,HCPCS,0278,RC,,,,both,,,10215.68,6640.19,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP STR STD 0.018 INX400 CM FIX COR SAFE-T-J,SUP-2738258,CDM,C1769,HCPCS,0272,RC,,,,both,,,301.44,195.94,,,,,,,,,,,,,
STIMULATOR BNE XL 8CM MESH CATHODE 40UA DEV SPF,SUP-2414468,CDM,E0749,HCPCS,0278,RC,,,,both,,,17638.95,11465.32,,,,,,,,,,,,,
GRAFT VASC L90X40CM DIA8X8MM AXILLOBIFEMORAL PTFE CBAS HEP,SUP-2395788,CDM,C1768,CPT,0278,RC,,,,both,,,13806.58,8974.28,,,,,,,,,,,,,
ANASTROZOLE 1 MG PO TABS,RX-16205,CDM,6370000000,HCPCS,0637,RC,16729-0035-10,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
CATHETER HD AG 15 FRX19 CM CHRONIC ARROW-CLARK VECTORFLOW,SUP-2627049,CDM,C1750,HCPCS,0278,RC,,,,both,,,989.10,642.91,,,,,,,,,,,,,
CATHETER DRNGE 12FR L25CM BILI ARRY MULTPURP W/ STD PGTL,SUP-2308250,CDM,C1729,HCPCS,0272,RC,,,,both,,,235.44,153.04,,,,,,,,,,,,,
PIN EXT FIX THRD NONSTERILE DISPOSABLE L70MM L11MM OD32MM,SUP-2263013,CDM,C1713,HCPCS,0278,RC,,,,both,,,662.45,430.59,,,,,,,,,,,,,
BLADE SHAVER QUADCUT M4 3X130MM,SUP-2656689,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1168.36,759.43,,,,,,,,,,,,,
SPACER SPNL W11XH6XL11MM 4DEG PEEK ANT CERV INTBDY FUS LORD,SUP-2286323,CDM,C1889,HCPCS,0278,RC,,,,both,,,1640.65,1066.42,,,,,,,,,,,,,
NAIL IM MOD SM LCK CLLR BOLT,SUP-2449909,CDM,C1713,HCPCS,0278,RC,,,,both,,,183.69,119.40,,,,,,,,,,,,,
SHUNT CAR 9FR L31CM CLR REG 2 LUMN TEMP CONDUIT T PRT W/O,SUP-2264203,CDM,C1757,HCPCS,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
PLATE BONE PRECONTOURED 1 MM 6 HOLE TITANIUM MATRIXMANDIBLE,SUP-2842350,CDM,C1713,HCPCS,0278,RC,,,,both,,,1510.03,981.52,,,,,,,,,,,,,
HC Custom Elbow Static,PX-2740370201,CDM,L3702,HCPCS,0272,RC,,,,both,,,960.00,624.00,,,,,,,,,,,,,
ROD SPNL STBL SYS AXIALIF 1L +,SUP-2330899,CDM,C1713,HCPCS,0278,RC,,,,both,,,31384.30,20399.79,,,,,,,,,,,,,
GRAFT VASC IMPRA L 70 CM DIA 4 MM EPTFE STR TW N RING HEMO,SUP-2761318,CDM,C1768,CPT,0278,RC,,,,both,,,2644.07,1718.65,,,,,,,,,,,,,
SEED BRACHYTHERAPY LOOSE NS CS1LCN] ISORAY MEDICAL],SUP-2247303,CDM,C2643,HCPCS,0278,RC,,,,both,,,185.26,120.42,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED STD FRAC,SUP-2365970,CDM,C1776,CPT,0278,RC,,,,both,,,8807.70,5725.00,,,,,,,,,,,,,
BOLT FEM HIP MOD LCK FOUNDATION,SUP-2217196,CDM,C1713,HCPCS,0278,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
IMMOBOLIZER SHLDR SUPP UNIV COT UNISX VELPEAU M,SUP-2211099,CDM,L3660,HCPCS,0272,RC,,,,both,,,7.91,5.14,,,,,,,,,,,,,
IMMOBOLIZER SHLDR SUPP UNIV COT UNISX VELPEAU M,SUP-2211099,CDM,L3660,HCPCS,0274,RC,,,,both,,,7.91,5.14,,,,,,,,,,,,,
CATHETER BRACHYTHERAPY BRST SAVI PREP,SUP-2164406,CDM,C1728,HCPCS,0272,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
HC Dil Ure Strc Fil/Fol Male Init,PX-4505362000,CDM,53620,CPT,0450,RC,,,,both,,,706.00,458.90,,,,,,,,,,,,,
SYSTEM LOADING VALVE EVOLUT 23MM,SUP-2501424,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1224.60,795.99,,,,,,,,,,,,,
BOOT TRAC M L20IN FOR 15.5IN CALF CONVOLUTED FOAM LNR STAY,SUP-2196869,CDM,L4387,HCPCS,0274,RC,,,,both,,,36.33,23.61,,,,,,,,,,,,,
PLATE LCK STRNL 14 H,SUP-2262584,CDM,C1713,HCPCS,0278,RC,,,,both,,,3108.60,2020.59,,,,,,,,,,,,,
BIT DRL QC 2.5X170 MM 80 MM CALIB NS,SUP-2563750,CDM,2720000010,LOCAL,0272,RC,,,,both,,,419.57,272.72,,,,,,,,,,,,,
DEVICE LASER DEL LNG 2.5 MR ENT ANGLED STRL OTOPROBE,SUP-2225620,CDM,2720000010,LOCAL,0272,RC,,,,both,,,791.28,514.33,,,,,,,,,,,,,
MESH BNE 4 H RT ORBIT PREFRM NS DISP,SUP-2934740,CDM,C1713,HCPCS,0278,RC,,,,both,,,8415.20,5469.88,,,,,,,,,,,,,
HC Soft Tissue Neck US,PX-4027653600,CDM,76536,CPT,0402,RC,,,,both,,,1670.00,1085.50,,,,,,,,,,,,,
CAP ORTH FEM NAIL TI STRL ZNN,SUP-2862126,CDM,C1713,HCPCS,0278,RC,,,,both,,,3104.83,2018.14,,,,,,,,,,,,,
BISOPROLOL-HYDROCHLOROTHIAZIDE 5-6.25 MG PO TABS,RX-18290,CDM,6370000000,HCPCS,0637,RC,29300-0188-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PLATE SPNL CERV 4.5X12 MM SEMI-CONSTRN ST PYRENEES,SUP-2732263,CDM,C1713,HCPCS,0278,RC,,,,both,,,266.90,173.48,,,,,,,,,,,,,
PLATE SPNL FIX 75 ANTR LAT THORLUM TI TRAVERSE,SUP-2561610,CDM,C1713,HCPCS,0278,RC,,,,both,,,5259.50,3418.67,,,,,,,,,,,,,
KIT NEUROSTIM PLSE GENRTR ANALGESIC SPNL CRD ELECTRC SYS,SUP-2148512,CDM,C1820,HCPCS,0278,RC,,,,both,,,65048.24,42281.36,,,,,,,,,,,,,
WASHER ORTH DIA2 MM FOR CANULATED SCREW SYS NS,SUP-2913312,CDM,C1713,HCPCS,0278,RC,,,,both,,,279.46,181.65,,,,,,,,,,,,,
HANDPIECE 9GAX10CM 12MM PET DISPOSABLE EVIVA,SUP-2240011,CDM,2720000010,LOCAL,0272,RC,,,,both,,,651.55,423.51,,,,,,,,,,,,,
SPLINT EL M,SUP-2276616,CDM,L3702,HCPCS,0272,RC,,,,both,,,29.01,18.86,,,,,,,,,,,,,
BIT DRL DIA2MM STD QUIK CONN FOR PERIARTC LOK PLT SYS,SUP-2410867,CDM,2720000010,LOCAL,0272,RC,,,,both,,,620.97,403.63,,,,,,,,,,,,,
STAPLE SPNL OD14MM SM THORLUM RSTRL CROSS CONN FOR 2 ROD SYS,SUP-2229601,CDM,C1713,HCPCS,0278,RC,,,,both,,,2185.44,1420.54,,,,,,,,,,,,,
ROD CONIC EXTR M 13 MM UNIV NAIL EXTR DEV,SUP-2361785,CDM,C1713,HCPCS,0278,RC,,,,both,,,1023.64,665.37,,,,,,,,,,,,,
LINER ACET HW +3 28 40 MM HIP ARCM XL POLYETH RINGLOK,SUP-2409549,CDM,C1776,CPT,0278,RC,,,,both,,,2041.00,1326.65,,,,,,,,,,,,,
ADJUSTER SPNL 14MM LUM TAPR FUS DEV L CAGE IMPL,SUP-2291614,CDM,C1713,HCPCS,0278,RC,,,,both,,,991.20,644.28,,,,,,,,,,,,,
ALIGNER SURG PELV LEV,SUP-2378896,CDM,C1713,HCPCS,0278,RC,,,,both,,,529.40,344.11,,,,,,,,,,,,,
TRAY HUM DIA44MM +10MM OFFSET CO CHROM FOR REV SHLDR SYS,SUP-2404734,CDM,C1776,CPT,0278,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
STEM FEM L200MM CEM MOD,SUP-2265076,CDM,C1776,CPT,0278,RC,,,,both,,,9143.68,5943.39,,,,,,,,,,,,,
CATHETER CV SINGLE LUMEN 5 FR BASIC TY POWERPICC SOLO 2,SUP-2126378,CDM,C1751,HCPCS,0278,RC,,,,both,,,359.15,233.45,,,,,,,,,,,,,
PLATE 4.5MM TI LCP TM PROX TIBIA 14H 262MM RIGHT STERILE,SUP-2549649,CDM,C1713,HCPCS,0278,RC,,,,both,,,5237.58,3404.43,,,,,,,,,,,,,
CONFORM FLEX Q-PACK 10MM X 10MM X 4MM,SUP-2547189,CDM,C1713,HCPCS,0278,RC,,,,both,,,563.03,365.97,,,,,,,,,,,,,
WEDGE FEM 7X18 MM DSTL GRW PROS,SUP-2452023,CDM,C1776,CPT,0278,RC,,,,both,,,1428.54,928.55,,,,,,,,,,,,,
RESERVOIR WRM 3L RAP INFUS RI-2 BELMONT,SUP-2134635,CDM,2720000010,LOCAL,0272,RC,,,,both,,,501.87,326.22,,,,,,,,,,,,,
TWIST DRILL MRRSN/KLS MRTN1.9MMX105MM AO ATTCH LEV1 TRCR,SUP-2500242,CDM,2720000010,LOCAL,0272,RC,,,,both,,,821.68,534.09,,,,,,,,,,,,,
IMMOBILIZER KNEE SIZED CANVS 19 IN 2XL,SUP-2336067,CDM,L1830,CPT,0272,RC,,,,both,,,39.66,25.78,,,,,,,,,,,,,
CRYOABLATION PROC KT - VAR (6X CVA2400 6X CRYO-55-F 1X,SUP-2885436,CDM,2720000010,LOCAL,0272,RC,,,,both,,,13031.00,8470.15,,,,,,,,,,,,,
CLIP ANEURYSM BLADE L9MM 45DEG OPENING 5.5MM T BAR PERMANENT,SUP-2825664,CDM,C1889,HCPCS,0278,RC,,,,both,,,5721.80,3719.17,,,,,,,,,,,,,
COLLAR CERV TRACHEOTOMY MED AD 3.25 IN 13-16 IN PHILADELPHIA,SUP-2319294,CDM,L0172,HCPCS,0274,RC,,,,both,,,22.48,14.61,,,,,,,,,,,,,
HC Viral/Hsv Culture,PX-3008725200,CDM,87252,CPT,0300,RC,,,,both,,,288.00,187.20,,,,,,,,,,,,,
HC Surgery Robot Addtl 15min,PX-3600000019,CDM,3600000019,LOCAL,0360,RC,,,,both,,,5209.00,3385.85,,,,,,,,,,,,,
CATHETER URODYN DBL LUMN W/ EXTN DISP 8FR,SUP-2355029,CDM,C1713,HCPCS,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
LENS VITRCTMY FLAT DISP,SUP-2213462,CDM,2720000010,LOCAL,0272,RC,,,,both,,,148.84,96.75,,,,,,,,,,,,,
CONNECTOR SHUNT OD1.9MM STR TI HYDROCEPHALUS 1 PC,SUP-2108706,CDM,C1729,HCPCS,0272,RC,,,,both,,,277.23,180.20,,,,,,,,,,,,,
HC Unlisted Proc Lungs and Pleura,PX-3613299900,CDM,32999,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
CAP HEALING 20MM W/ PLUG BAHA,SUP-2164966,CDM,L8614,HCPCS,0278,RC,,,,both,,,49.64,32.27,,,,,,,,,,,,,
CLAMP FIX S STL ANGULAR FOR HALF PIN,SUP-2242957,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1302.19,846.42,,,,,,,,,,,,,
PEG FIX LCK 2X28 MM OPTILOCK,SUP-2473128,CDM,C1713,HCPCS,0278,RC,,,,both,,,310.86,202.06,,,,,,,,,,,,,
GRAFT BNE SUB W11XH7XL14MM CORT INTBDY FUS FRZ DRY BLK SPCR,SUP-2293779,CDM,C1713,HCPCS,0278,RC,,,,both,,,678.24,440.86,,,,,,,,,,,,,
SCREW BONE LOCKING 2.9X12 MM MANDIBULAR SELFTAPPING 20/PK TI,SUP-2842345,CDM,C1713,HCPCS,0278,RC,,,,both,,,591.26,384.32,,,,,,,,,,,,,
PLATE SPNL 20 MM ALIF51 DIVERGENCE-L,SUP-2422249,CDM,C1713,HCPCS,0278,RC,,,,both,,,14130.00,9184.50,,,,,,,,,,,,,
CATHETER URET 5FR L70CM UNIV PVC OPN END TIP SGL LUMN W/OUT,SUP-2171224,CDM,C1758,HCPCS,0278,RC,,,,both,,,90.15,58.60,,,,,,,,,,,,,
GRAFT HUM TISS L6-11X4-11CM DIA8-15X4-5MM AORTOILIAC ART,SUP-2175268,CDM,C1768,CPT,0278,RC,,,,both,,,77856.30,50606.59,,,,,,,,,,,,,
MARKER SURG R HK DISPOSABLE FOR M8 SPNL SYS CDH,SUP-2293465,CDM,A4648,CPT,0278,RC,,,,both,,,427.17,277.66,,,,,,,,,,,,,
PACEMAKER RATE RESPON SGL CHMBR IS 1 CONN W/ WIRELESS,SUP-2357690,CDM,C1786,HCPCS,0275,RC,,,,both,,,16014.00,10409.10,,,,,,,,,,,,,
PUMP INFUS 2X10IN CATH 4ML/HOUR 550ML,SUP-2361468,CDM,C1751,HCPCS,0278,RC,,,,both,,,675.10,438.81,,,,,,,,,,,,,
CEMENT BONE SCULP,SUP-2408551,CDM,C1713,HCPCS,0278,RC,,,,both,,,94.20,61.23,,,,,,,,,,,,,
SHEATH INTRO PRELUDE L 23 CM DIA 4 FR 80 CM 0.035 IN SS,SUP-2740719,CDM,C1894,HCPCS,0272,RC,,,,both,,,80.13,52.08,,,,,,,,,,,,,
BIT DRL L330MM DIA15MM CANN L QUIK CPL FOR RECON FEM NAIL,SUP-2178900,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1158.16,752.80,,,,,,,,,,,,,
ALLOGRAFT BNE CROSS SECT 12 MM CALCANEUS MATRIGRAFT,SUP-2740772,CDM,C1713,HCPCS,0278,RC,,,,both,,,1912.48,1243.11,,,,,,,,,,,,,
CANNULA ARTRL EC 14FR DIA 38IN ACCPTNCE CRMDA BCTVE HPRN CT,SUP-2725868,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1087.57,706.92,,,,,,,,,,,,,
PLATE BNE L158MM 11 H NONSTERILE R ANTLAT DST TIB S STL LO,SUP-2185954,CDM,C1713,HCPCS,0278,RC,,,,both,,,4133.56,2686.81,,,,,,,,,,,,,
CEMENT DENT 38 GM PWD ZN OXIDE-EUGENOL IRM,SUP-2176748,CDM,C1713,HCPCS,0278,RC,,,,both,,,257.54,167.40,,,,,,,,,,,,,
PACK SAW BLDE 64MM D405MM CUT EDGE 10MM THK12MM FOR PWR,SUP-2365142,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3176.64,2064.82,,,,,,,,,,,,,
INSTRUMENT PACK WIREPIN,SUP-2878031,CDM,2720000010,LOCAL,0272,RC,,,,both,,,995.69,647.20,,,,,,,,,,,,,
HC Custom Wrist/Hand Static,PX-2740390601,CDM,L3906,HCPCS,0274,RC,,,,outpatient,,,1403.00,911.95,,,,,,,,,,,,,
GRAFT VASC GORTX L 80 CM DIA 6 MM RNG L 50 CM EPTFE STR TW,SUP-2396159,CDM,C1768,CPT,0278,RC,,,,both,,,3903.02,2536.96,,,,,,,,,,,,,
HC Nose to Rectum Child,PX-3207601000,CDM,76010,CPT,0320,RC,,,,outpatient,,,96.00,62.40,,,,,,,,,,,,,
PLATE BONE L95MM 12 H BILAT TI LCK COMPR RECON LO PROF RIG,SUP-2191427,CDM,C1713,HCPCS,0278,RC,,,,both,,,3501.41,2275.92,,,,,,,,,,,,,
MOORSE/C-TAPER ADAPTER SLEEVE,SUP-2512482,CDM,C1776,CPT,0278,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
HC Assay of Free Thyroxine,PX-3018443900,CDM,84439,CPT,0301,RC,,,,both,,,348.00,226.20,,,,,,,,,,,,,
BIT DRL L 145/60 MM DIA2 MM AO QC CALIB NS REUSE V,SUP-2905694,CDM,2720000010,LOCAL,0272,RC,,,,both,,,606.65,394.32,,,,,,,,,,,,,
CATHETER CARD ABLATION NAVISTAR L 115CM 7FR 4MM D CRV UNIDIR,SUP-2475051,CDM,C1732,HCPCS,0278,RC,,,,both,,,6119.86,3977.91,,,,,,,,,,,,,
BLADE SHAVER STR 4 MM SMOOTH RND TIP DIEGO,SUP-2638085,CDM,2720000010,LOCAL,0272,RC,,,,both,,,425.72,276.72,,,,,,,,,,,,,
SCREW BONE L44MM DIA4.5MM THRD L13MM CORT TI ST SELF DRL,SUP-2190385,CDM,C1713,HCPCS,0278,RC,,,,both,,,61.45,39.94,,,,,,,,,,,,,
PLATE BONE L22MM 6 H CRANIOMAXILLOFACIAL TI DBL Y SHP FOR,SUP-2190657,CDM,C1713,HCPCS,0278,RC,,,,both,,,1022.07,664.35,,,,,,,,,,,,,
STENT PERIPH EPIC L 50 MM DIA 6 MM CATH L 120 CM NOM DIA,SUP-2145778,CDM,C1876,HCPCS,0278,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
CATHETER ANGIO MOD HK 035 5 FRX100 CM 6 SP PERFORMA,SUP-2301643,CDM,C1713,HCPCS,0278,RC,,,,both,,,379.63,246.76,,,,,,,,,,,,,
TRIAL SPNL L21MM ANTR LUM INSTR,SUP-2291673,CDM,C1713,HCPCS,0278,RC,,,,both,,,2731.80,1775.67,,,,,,,,,,,,,
STIMULATOR NERVE 2 PRT ACCSRY ADPT,SUP-2423993,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
PUTTY BONE HEMSTAT ABSORB MTRX 2.0GRAM,SUP-2106298,CDM,C1713,HCPCS,0278,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
BLADE TNG SM F/10 PDGTT LATEX FREE PVC FREE DEHP FREE MRCRY,SUP-2457515,CDM,2720000010,LOCAL,0272,RC,,,,both,,,815.68,530.19,,,,,,,,,,,,,
HC Ventilator Subsequent Day,PX-4109400300,CDM,94003,CPT,0410,RC,,,,outpatient,,,1569.00,1019.85,,,,,,,,,,,,,
ANCHOR SUT DIA2.9MM NO2 MAXBRAID DBL LD JUGGERKNOT,SUP-2212947,CDM,C1713,HCPCS,0278,RC,,,,both,,,1419.28,922.53,,,,,,,,,,,,,
TOCILIZUMAB-AAZG 20 MG/ML IV SOLN (MIXTURES ONLY),RX-430078,CDM,Q5135,HCPCS,0636,RC,65219-0592-10,NDC,,both,10,ML,2888.70,1877.65,,,,,,,,,,,,,
FASTTHREAD INTERFERENCE SCREW INST SET,SUP-2841330,CDM,C1713,HCPCS,0278,RC,,,,both,,,10974.30,7133.29,,,,,,,,,,,,,
CATHETER CV 3L 6 FRX60 CM SET PRO-LINE MD28036301,SUP-2626374,CDM,C1751,HCPCS,0278,RC,,,,both,,,847.80,551.07,,,,,,,,,,,,,
CODMAN ACCU-FLO STR CONN S STL,SUP-2249013,CDM,C1713,HCPCS,0278,RC,,,,both,,,388.86,252.76,,,,,,,,,,,,,
PLATE BNE LINDORF LEFORT 1 1.5X1 MM LT ORTHOGNATHIC TI,SUP-2461910,CDM,C1713,HCPCS,0278,RC,,,,both,,,1143.49,743.27,,,,,,,,,,,,,
CUTTER ENDO OD6.5MM CANN 2 RETROCUT,SUP-2120861,CDM,C1713,HCPCS,0278,RC,,,,both,,,693.94,451.06,,,,,,,,,,,,,
KIT INTRO GLIDESHEATH L 10 CM DIA 5 FR GUIDEWIRE 0.021 IN,SUP-2385634,CDM,C1894,HCPCS,0272,RC,,,,both,,,335.04,217.78,,,,,,,,,,,,,
STEM HUM CEM STD UNIV 8X115 MM REV W/ ALIGN HOLE TI PLASMA,SUP-2431670,CDM,C1776,CPT,0278,RC,,,,both,,,10358.86,6733.26,,,,,,,,,,,,,
SET EXT FIX L35MM DIA5MM X SH UNILAT HALF PIN TIN JETX,SUP-2342924,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1093.44,710.74,,,,,,,,,,,,,
TOCILIZUMAB-AAZG 20 MG/ML IV SOLN (MIXTURES ONLY),RX-430078,CDM,Q5135,HCPCS,0636,RC,65219-0594-20,NDC,,both,20,ML,5777.30,3755.24,,,,,,,,,,,,,
COMPONENT FEM SZ 2 R KNEE NP PRI CEM STEM ROT HNG MED PVT,SUP-2304628,CDM,C1776,CPT,0278,RC,,,,both,,,16701.66,10856.08,,,,,,,,,,,,,
SHUNT SURG VENTRICULOPERITONEAL UNI-SHUNT NS0104,SUP-2666778,CDM,C1889,HCPCS,0278,RC,,,,both,,,2254.80,1465.62,,,,,,,,,,,,,
KIT PRP BLD PROC 3 CYCL UPTO 180ML PROGRAMMABLE ANGEL,SUP-2120733,CDM,C1713,HCPCS,0278,RC,,,,both,,,833.67,541.89,,,,,,,,,,,,,
SCREW FEAT PART THRD LCK DIAM 3.7MM LEN 35MM ALTA,SUP-2363500,CDM,C1713,HCPCS,0278,RC,,,,both,,,319.18,207.47,,,,,,,,,,,,,
GENTAMICIN IN SALINE 0.8-0.9 MG/ML-% IV SOLN,RX-15906,CDM,J1580,HCPCS,0636,RC,00338-0503-48,NDC,,both,100,ML,54.10,35.16,,,,,,,,,,,,,
CONDYLAR PL 95 9H 40/156,SUP-2818819,CDM,C1713,HCPCS,0278,RC,,,,both,,,5208.32,3385.41,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 70 CM DIA 8MM STR HELIX SLDE GDS,SUP-2489377,CDM,C1768,CPT,0278,RC,,,,both,,,2529.84,1644.40,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA FT PLU MAXBARR S1295108FD5,SUP-2632818,CDM,C1751,HCPCS,0278,RC,,,,both,,,1044.49,678.92,,,,,,,,,,,,,
CONNECTOR SPNL L26-28MM STD TI POST XLNK ADJ TRNSVRS CONN,SUP-2229236,CDM,C1713,HCPCS,0278,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
NEEDLE CRYOABLATION 90DEG ANG GRY HNDL ICEFORCE 2.1 CX,SUP-2225995,CDM,C2618,HCPCS,0272,RC,,,,both,,,6217.20,4041.18,,,,,,,,,,,,,
TIP ULTRSNC ASPIR L 37 CM WORKING L 32.2 CM OD 2.52 MM ID,SUP-2883138,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7055.58,4586.13,,,,,,,,,,,,,
CATHETER ENDOVASC 10.7FRX65CM C CTRL,SUP-2327390,CDM,C1733,HCPCS,0272,RC,,,,both,,,4851.30,3153.34,,,,,,,,,,,,,
PLATE BNE L237MM 14 H ST R PROX TIB S STL VAR ANG LOK COMPR,SUP-2177925,CDM,C1713,HCPCS,0278,RC,,,,both,,,6897.01,4483.06,,,,,,,,,,,,,
SPHERE OPHTH DIA16MM EYE PMMA LTWT PERM,SUP-2129494,CDM,L8610,HCPCS,0278,RC,,,,both,,,53.38,34.70,,,,,,,,,,,,,
PROG VLV RT ANG W SG,SUP-2194059,CDM,C1729,HCPCS,0272,RC,,,,both,,,15737.68,10229.49,,,,,,,,,,,,,
LEVEL NEURO MESH 3D NEURO SCRW75 X 75 MM T08 MM CP TTNM QT0,SUP-2681431,CDM,C1713,HCPCS,0278,RC,,,,both,,,3044.36,1978.83,,,,,,,,,,,,,
IMPLANT BIO L 3 X W 12 CM FISH SKIN DERMAL FEN 11 INTACT,SUP-2909225,CDM,Q4158,HCPCS,0636,RC,,,,both,,,3956.40,2571.66,,,,,,,,,,,,,
CANNULA SUCT 5FR L230MM DIA70MM WRK L165MM MIC TAPR TEARDROP,SUP-2108796,CDM,2720000010,LOCAL,0272,RC,,,,both,,,674.25,438.26,,,,,,,,,,,,,
BIT DRL TWST 4X260 MM 3 FLUT QC SLD REPL SS NS,SUP-2607937,CDM,2720000010,LOCAL,0272,RC,,,,both,,,359.06,233.39,,,,,,,,,,,,,
ROD SPNL L360MM DIA5.5MM POST CERVICOTHORACIC TI THRD RECON,SUP-2286758,CDM,C1713,HCPCS,0278,RC,,,,both,,,1594.02,1036.11,,,,,,,,,,,,,
MITOMYCIN 40 MG IV SOLR (1 MG/ML),RX-1150448,CDM,J9280,HCPCS,0636,RC,16729-0116-38,NDC,,both,1,UN,3640.30,2366.19,,,,,,,,,,,,,
STRUT EXT FIX L 110-135 MM XSH POLYAXL UTIL,SUP-2898483,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4835.60,3143.14,,,,,,,,,,,,,
NOREPINEPHRINE 8 MG/250 ML INFUSION NS,RX-4083027,CDM,2500000003,HCPCS,0250,RC,09999-9920-24,NDC,,both,250,ML,127.70,83.00,,,,,,,,,,,,,
INSTRUMENT KIT LAPIDUS STRATUM,SUP-2423336,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1048.76,681.69,,,,,,,,,,,,,
PLATE BONE DOUBLE ANGLE MEDIUM 1.5 MM PRECONTOURED RECONSTRU,SUP-2842354,CDM,C1713,HCPCS,0278,RC,,,,both,,,8271.07,5376.20,,,,,,,,,,,,,
PLATE EXT FIX LNG 100 MM FT RNG CARBON FIBER NS,SUP-2800196,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2055.66,1336.18,,,,,,,,,,,,,
SCREW BNE L32MM DIA4.5MM PERIARTC CORT S STL ST,SUP-2410621,CDM,C1713,HCPCS,0278,RC,,,,both,,,101.45,65.94,,,,,,,,,,,,,
GRAFT HUM TISS W14XH5XL12MM ANT CERV INTBDY FUS LORD SPCR,SUP-2306955,CDM,C1713,HCPCS,0278,RC,,,,both,,,3378.33,2195.91,,,,,,,,,,,,,
CLAMP EXT FIX L 75 MM MLTI PIN UNILAT NS DISP MAV,SUP-2931159,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3730.32,2424.71,,,,,,,,,,,,,
PLATE BNE IMPL SM R CHARLOTTE MTP FUS SYS S STL,SUP-2397487,CDM,C1713,HCPCS,0278,RC,,,,both,,,3366.08,2187.95,,,,,,,,,,,,,
TIP ASPIR L4.5IN DIA0.08IN STD EXT FLUE CRV DISP CUSA EXCEL,SUP-2172368,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2194.67,1426.54,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 40 CM DIA 6MM STR TW REMOVABLE RNG,SUP-2396290,CDM,C1768,CPT,0278,RC,,,,both,,,2719.24,1767.51,,,,,,,,,,,,,
SUPPORT ORTHOT FT CUST INSRT MOLD TO PT MODEL PLASTAZOTE EQL,SUP-2435702,CDM,L3002,HCPCS,0274,RC,,,,both,,,457.25,297.21,,,,,,,,,,,,,
GUIDEWIRE VASC STR 3.5 CM 0.038 INX145 CM ST INQUIRE AMPLATZ,SUP-2464716,CDM,C1769,HCPCS,0272,RC,,,,both,,,84.78,55.11,,,,,,,,,,,,,
SCREW BONE CRANIO MAXILLOFACIAL CROSS FIT ST TI 2MM DIA 20MM,SUP-2363432,CDM,C1713,HCPCS,0278,RC,,,,both,,,280.25,182.16,,,,,,,,,,,,,
SCREW SPINAL EMERGENCY 3 MM 20/PK TITANIUM NONSTERILE MATRIX,SUP-2842243,CDM,C1713,HCPCS,0278,RC,,,,both,,,258.67,168.14,,,,,,,,,,,,,
RESTRICTOR CEM M DIA24MM UNIV,SUP-2378790,CDM,C1776,CPT,0278,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
CATHETER DRNGE 30FR 2 EYE PROPORTIONATE HD DISP FOR,SUP-2129056,CDM,C2627,HCPCS,0272,RC,,,,both,,,23.17,15.06,,,,,,,,,,,,,
GRAFT BONE SUB OSTEOCONDUCTIVE SCAFFOLD PUTTY,SUP-2244117,CDM,C1713,HCPCS,0278,RC,,,,both,,,2888.80,1877.72,,,,,,,,,,,,,
CATHETER SUPRPUB 14FR L15CM FADER TIP SET W/ LCK PGTL AND,SUP-2140100,CDM,C2627,HCPCS,0272,RC,,,,both,,,266.90,173.48,,,,,,,,,,,,,
SCREW BNE RVS THRD 9X25 MM BIORCI,SUP-2848558,CDM,C1713,HCPCS,0278,RC,,,,both,,,623.73,405.42,,,,,,,,,,,,,
COMPONENT TOE L10MM DIA3.4X3MM TI ST SELF DRL THRD SPADE TWO,SUP-2390525,CDM,C1776,CPT,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
COLLAR CERV M AD W3.5XL23.5IN M DENS CNTOUR CNTCT CLSR FOAM,SUP-2197375,CDM,L0120,HCPCS,0272,RC,,,,both,,,17.46,11.35,,,,,,,,,,,,,
NEOMYCIN-POLYMYXIN-HC 3.5-10000-1 OT SOLN,RX-34814,CDM,6370000000,HCPCS,0637,RC,24208-0631-10,NDC,,both,10,ML,377.60,245.44,,,,,,,,,,,,,
CATHETER CV SECALON-T L 160 MM DIA14 GA OD 2 MM 206 ML/MIN,SUP-2490878,CDM,C1751,HCPCS,0278,RC,,,,both,,,16.80,10.92,,,,,,,,,,,,,
INTRODUCER PACE LD SAFSHTH II WORLEY DIA 9 FR RT SIDE ACCS,SUP-2483625,CDM,C1893,HCPCS,0272,RC,,,,both,,,1130.40,734.76,,,,,,,,,,,,,
ANG BLDE PL 130 6H {} 70/104,SUP-2818826,CDM,C1713,HCPCS,0278,RC,,,,both,,,5116.94,3326.01,,,,,,,,,,,,,
KNIFE ENDOSCP SLIM SHTH 2X1650 MM 2.8 MM 2 KNOB SHP ITKNIFE2,SUP-2491063,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2208.21,1435.34,,,,,,,,,,,,,
SUPPORT ORTHOT METATRSL CUST BAR WDG ROCKER,SUP-2435726,CDM,L3400,HCPCS,0272,RC,,,,both,,,115.24,74.91,,,,,,,,,,,,,
SUBSTITUTE BNE GRFT 1 CC DBM PTTY OSTEOINDUCTIVE STRL,SUP-2883879,CDM,C1713,HCPCS,0278,RC,,,,both,,,640.56,416.36,,,,,,,,,,,,,
GRAFT EVAR L82MM DIA16X28MM PROX DST IL CONTRALATERAL LIMB,SUP-2295268,CDM,C1768,CPT,0278,RC,,,,both,,,15229.00,9898.85,,,,,,,,,,,,,
STEM HUM N SLT 8X175 MM TOT SHLDR REV OLYMPIA,SUP-2535964,CDM,C1776,CPT,0278,RC,,,,both,,,12638.50,8215.02,,,,,,,,,,,,,
SET CATH HEMODIALYSI ARW EDGE CHRONIC 15FR DIA 24CM 19CML TI,SUP-2613329,CDM,C1750,HCPCS,0278,RC,,,,both,,,926.30,602.09,,,,,,,,,,,,,
PLATE BONE W3.8XL100MM THK0.9MM 20 H S STL STR,SUP-2343826,CDM,C1713,HCPCS,0278,RC,,,,both,,,1918.85,1247.25,,,,,,,,,,,,,
CONNECTOR SPNL OFFSET 15 MM PROTEX,SUP-2584142,CDM,C1713,HCPCS,0278,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
ALLOGRAFT BNE 10X10X13 MM BIOEXPAND,SUP-2637001,CDM,C1713,HCPCS,0278,RC,,,,both,,,3651.76,2373.64,,,,,,,,,,,,,
SCREW BNE L10MM DIA3MM NONBIOABSORBABLE HV,SUP-2399784,CDM,C1713,HCPCS,0278,RC,,,,both,,,1309.38,851.10,,,,,,,,,,,,,
PLATE BNE 5 DEG SM TI ALLOY RT MTP NS LEOS,SUP-2932841,CDM,C1713,HCPCS,0278,RC,,,,both,,,3518.37,2286.94,,,,,,,,,,,,,
CASE MODULE F/ HAND 1.5MM,SUP-2547986,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2592.79,1685.31,,,,,,,,,,,,,
PLATE BNE LCK SM RT CALCANEAL MESH STRL ALPS LTX,SUP-2860964,CDM,C1713,HCPCS,0278,RC,,,,both,,,3784.01,2459.61,,,,,,,,,,,,,
KNOT PUSHER/ PORTAL SKID,SUP-2741731,CDM,2720000010,LOCAL,0272,RC,,,,both,,,690.80,449.02,,,,,,,,,,,,,
GRAFT VASC L40CM DIA6MM PTFE CBAS HEP SURF STD WALLED,SUP-2395778,CDM,C1768,CPT,0278,RC,,,,both,,,3322.12,2159.38,,,,,,,,,,,,,
CAGE SPNL W33XH11MM 12DEG ANTR LUM PEEK COMMERCIALLY PURE,SUP-2163225,CDM,C1889,HCPCS,0278,RC,,,,both,,,17270.00,11225.50,,,,,,,,,,,,,
HC Lipid Panel,PX-3018006100,CDM,80061,CPT,0301,RC,,,,both,,,191.00,124.15,,,,,,,,,,,,,
CATHETER CARD ABLATION NAVISTAR RMT L 125 CM DIA 8 FR SHTH,SUP-2248931,CDM,C1732,HCPCS,0272,RC,,,,both,,,6575.16,4273.85,,,,,,,,,,,,,
GUIDEWIRE VASC COPE L 60 CM DIA 0.018 IN TAPR L 7 CM FLPY,SUP-2168063,CDM,C1769,HCPCS,0272,RC,,,,both,,,76.27,49.58,,,,,,,,,,,,,
BIT DRILL SURG DIA 3.5 MM SM AO QC ATTACH EVOS,SUP-2931404,CDM,2720000010,LOCAL,0272,RC,,,,both,,,606.18,394.02,,,,,,,,,,,,,
STEM RADIAL MED 6.5 ULN WRST MOD COCR 1ST CHOICE,SUP-2852862,CDM,C1776,CPT,0278,RC,,,,both,,,14249.45,9262.14,,,,,,,,,,,,,
CONNECTOR SHUNT OD1.9MM TITANIUM STRAIGHT,SUP-2825884,CDM,C1889,HCPCS,0278,RC,,,,both,,,254.75,165.59,,,,,,,,,,,,,
PATCH HERN XL W7.7XL9.7IN UNCOATED MFIL PROPYLENE OVL ABSRB,SUP-2125900,CDM,C1781,HCPCS,0278,RC,,,,both,,,4179.03,2716.37,,,,,,,,,,,,,
GRAFT DERMAL STRUCTURAL ULTRA THCK 16X8 CMX1.8-4 MM HYDRATED,SUP-2307502,CDM,Q4128,HCPCS,0636,RC,,,,both,,,12516.95,8136.02,,,,,,,,,,,,,
PLATE BONE DIA30MM THK1.5MM NONSTERILE CRANIOMAXILLOFACIAL,SUP-2191126,CDM,C1713,HCPCS,0278,RC,,,,both,,,2528.33,1643.41,,,,,,,,,,,,,
PLATE BNE L17MM 3 H S STL STR FOR 2MM SCR MINI FRAG SYS,SUP-2411311,CDM,C1713,HCPCS,0278,RC,,,,both,,,169.75,110.34,,,,,,,,,,,,,
FAT EMULSION PLANT BASED (SOY) 20 % IV EMUL,RX-155550,CDM,2500000003,HCPCS,0250,RC,65219-0531-10,NDC,,both,100,ML,182.30,118.49,,,,,,,,,,,,,
SLEEVE DRL LCK 2.5 MM TCP,SUP-2521528,CDM,2720000010,LOCAL,0272,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
MESH HERN W5XL15CM THK1MM INGUINAL BIOMATERIAL FOR SFT TISS,SUP-2395363,CDM,C1781,HCPCS,0278,RC,,,,both,,,671.96,436.77,,,,,,,,,,,,,
HC Replacement Tracheostomy Tube,PX-4503150200,CDM,31502,CPT,0450,RC,,,,both,,,694.00,451.10,,,,,,,,,,,,,
CUTTER LOOP L 145 CM DIA2.8 MM STRL DISP,SUP-2912523,CDM,2720000010,LOCAL,0272,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
PATCH HEMSTAT W1.5XL1.5IN FOR THE EXT BLEED CTRL,SUP-2238296,CDM,C1768,CPT,0278,RC,,,,both,,,91.81,59.68,,,,,,,,,,,,,
SAW SURG PNEUMATIC FOR REPEAT STERNOTOMY,SUP-2607457,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7366.85,4788.45,,,,,,,,,,,,,
INTRODUCER SHTH J TIP 0.038 IN 10 FRX13 CM 18 GA HYDRPHLC,SUP-2740669,CDM,C1892,HCPCS,0272,RC,,,,both,,,195.94,127.36,,,,,,,,,,,,,
STENT BILI BLLN EXPANDABLE 0.035 IN 7X25 MM 6 FRX80 CM,SUP-2102318,CDM,C1876,HCPCS,0278,RC,,,,both,,,3440.18,2236.12,,,,,,,,,,,,,
INTRODUCER PEEL AWAY 7FR 23CM SGL,SUP-2357087,CDM,C1892,HCPCS,0272,RC,,,,both,,,188.40,122.46,,,,,,,,,,,,,
BIT DRL DIA 3.7 MM CORTICAL FAR AO QC LG SYS STRL DISP EVOS,SUP-2933920,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1417.71,921.51,,,,,,,,,,,,,
ELECTRODE ENDSCPC URLGY 24 28FR DIA ANGLD CTTNG LOOP HIGH FR,SUP-2730096,CDM,2720000010,LOCAL,0272,RC,,,,both,,,391.21,254.29,,,,,,,,,,,,,
HC Chloride Other Source,PX-3018243800,CDM,82438,CPT,0301,RC,,,,both,,,166.00,107.90,,,,,,,,,,,,,
GRAFT VASC W3XL3CM THK04MM CV PTCH GOR TX,SUP-2395307,CDM,C1768,CPT,0278,RC,,,,both,,,351.68,228.59,,,,,,,,,,,,,
SET URET STENT C FLX L 21-32 CM DIA 3.7 FR SS POLYUR,SUP-2826629,CDM,C2617,HCPCS,0278,RC,,,,both,,,360.72,234.47,,,,,,,,,,,,,
MESH BIO TISS W40XL50MM PORCINE CLLGN MTRX BIO-GIDE,SUP-2416357,CDM,C1713,HCPCS,0278,RC,,,,both,,,2006.46,1304.20,,,,,,,,,,,,,
KIT OTOLOGICAL INSTR INCLUDE CANN GUID DRL WNING DRL SFT,SUP-2319921,CDM,C1713,HCPCS,0278,RC,,,,both,,,1588.06,1032.24,,,,,,,,,,,,,
HC Drain Cerebro Spinal Flui,PX-4506227200,CDM,62272,CPT,0450,RC,,,,both,,,1056.00,686.40,,,,,,,,,,,,,
SYSTEM ENDO INSTR ANTEROLATERAL LIGMNT RECON,SUP-2121948,CDM,C1776,CPT,0278,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
COMPONENT FEM DIA18MM CANN FUS NAIL NONLOCKING WICH,SUP-2377548,CDM,C1776,CPT,0278,RC,,,,both,,,11532.44,7496.09,,,,,,,,,,,,,
SCREW BNE 35MM THRD 4 3X80MM EXT FIX HA XCALIBER OSTEOTITE,SUP-2316321,CDM,C1713,HCPCS,0278,RC,,,,both,,,409.39,266.10,,,,,,,,,,,,,
CATHETER CENTESIS 5FR L10CM 4 DRNGE H FIX LUERLOCK NDL STYL,SUP-2303168,CDM,C1729,HCPCS,0272,RC,,,,both,,,49.64,32.27,,,,,,,,,,,,,
PLATE BONE L232MM 12 H S STL NAR NONLOCKING COMPR CNTOUR FOR,SUP-2348968,CDM,C1713,HCPCS,0278,RC,,,,both,,,1909.72,1241.32,,,,,,,,,,,,,
CATHETER ANGIOPLSTY 18MMX6X110CM BAL DIL PTV NUCLEUSX,SUP-2309685,CDM,C1725,HCPCS,0272,RC,,,,both,,,2606.20,1694.03,,,,,,,,,,,,,
SURGICAL PROCEDURE PACK EYE CUST DR BERGER,SUP-2110978,CDM,C1713,HCPCS,0278,RC,,,,both,,,633.09,411.51,,,,,,,,,,,,,
MESH SURG L20XW15CM MACRO POLYFORM POR POLYPR SYN SGL USE N,SUP-2139415,CDM,C1781,HCPCS,0278,RC,,,,both,,,3671.04,2386.18,,,,,,,,,,,,,
PIN FIX OD5MM DISP SCHNZ,SUP-2399235,CDM,C1713,HCPCS,0278,RC,,,,both,,,185.26,120.42,,,,,,,,,,,,,
GUIDEWIRE ORTH 3X980 MM W/ OLV FOR FEM NAILING SYS SS NS LTX,SUP-2874963,CDM,C1769,HCPCS,0272,RC,,,,both,,,508.68,330.64,,,,,,,,,,,,,
PLATE BNE RECON 2.7X3 MM 32 HOLE ANGLED-ANGLED LCK TI NS,SUP-2474984,CDM,C1713,HCPCS,0278,RC,,,,both,,,6864.48,4461.91,,,,,,,,,,,,,
PIN EXT FIX COLL FOR SIDEKCK STLTH REARFOOT FIX,SUP-2400628,CDM,C1713,HCPCS,0278,RC,,,,both,,,558.92,363.30,,,,,,,,,,,,,
PLATE BUR H L 22 MM SCREW DIA1.5 MM MALL NS DISP,SUP-2935005,CDM,C1713,HCPCS,0278,RC,,,,both,,,891.76,579.64,,,,,,,,,,,,,
GRAFT BIO TISS OMEGA3 MARIGEN MICRO 38SQCM,SUP-2909168,CDM,Q4158,HCPCS,0636,RC,,,,both,,,5714.80,3714.62,,,,,,,,,,,,,
SCREW INTRF L 6 MM DIA2.5 MM PEEK TENODESIS W/ HNDL INSRTR,SUP-2882224,CDM,C1713,HCPCS,0278,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
HC So Hepatitis Be Antigen,PX-3068735066,CDM,87350,CPT,0306,RC,,,,outpatient,,,106.00,68.90,,,,,,,,,,,,,
NICOTINE POLACRILEX 2 MG MT LOZG,RX-34769,CDM,6370000000,HCPCS,0637,RC,43598-0486-24,NDC,,both,1,UN,79.90,51.93,,,,,,,,,,,,,
BRACE ORTH STUMP SHRINKER AK,SUP-2388227,CDM,L8460,HCPCS,0274,RC,,,,both,,,239.08,155.40,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 70 CM DIA 8MM STR TW HELIX SLDE GDS,SUP-2525471,CDM,C1768,CPT,0278,RC,,,,both,,,2677.51,1740.38,,,,,,,,,,,,,
BUR SURG DR 5X7.1 MM FLUT STRL ELITE LTX,SUP-2859321,CDM,2720000010,LOCAL,0272,RC,,,,both,,,369.55,240.21,,,,,,,,,,,,,
DACARBAZINE 200 MG IV SOLR,RX-2091,CDM,J9130,HCPCS,0636,RC,63323-0128-20,NDC,,both,1,UN,54.10,35.16,,,,,,,,,,,,,
PLATE BNE L63MM 3X4 H L T SHP OBLQ FOR 3.5MM SCR UNIV LOK,SUP-2411380,CDM,C1713,HCPCS,0278,RC,,,,both,,,1024.61,666.00,,,,,,,,,,,,,
LITHOTRIPTER SURG FIBER SUREFLEX REUSE RLLF200TG] LASER VENTURES],SUP-2263896,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1295.25,841.91,,,,,,,,,,,,,
HEAD HUM H10MM FOR TOT SHLDR ARTHROPLASTY SYS GLOB ADVNTG,SUP-2250011,CDM,C1776,CPT,0278,RC,,,,both,,,4945.50,3214.57,,,,,,,,,,,,,
MOLESKIN 2INX5YD 6RLS/BX,SUP-2525988,CDM,C1776,CPT,0278,RC,,,,both,,,36.58,23.78,,,,,,,,,,,,,
WRENCH SURG STEM PLUG MONOGRAM DURAC,SUP-2364826,CDM,C1776,CPT,0278,RC,,,,both,,,804.15,522.70,,,,,,,,,,,,,
BLADE SAW SAG 9.5MMW X25.5MML 0.6MM/0.6MM THK CUT SM BNE FN,SUP-2605396,CDM,2720000010,LOCAL,0272,RC,,,,both,,,95.90,62.33,,,,,,,,,,,,,
ANCHOR SUT ROT CUF W/ ETHBND QUICKANCHR +,SUP-2249345,CDM,C1713,HCPCS,0278,RC,,,,both,,,2078.68,1351.14,,,,,,,,,,,,,
SYSTEM CARD MONITORING ARRHYTHMIA BIOMONITOR III,SUP-2422776,CDM,C1764,HCPCS,0278,RC,,,,both,,,13502.00,8776.30,,,,,,,,,,,,,
SPACER SPNL W10XH6XL28MM 0DEG PEEK OPTMA THORLUM INTBDY FUS,SUP-2136950,CDM,C1821,HCPCS,0278,RC,,,,both,,,15119.54,9827.70,,,,,,,,,,,,,
SCREWDRIVER SURG DBL END PLUG STRT CDH LEG,SUP-2287701,CDM,C1713,HCPCS,0278,RC,,,,both,,,776.80,504.92,,,,,,,,,,,,,
SYSTEM IMPL W/ BIOCOMPOSITE SUT ANCHR 2X5IN JUMPSTART DSG,SUP-2122833,CDM,C1713,HCPCS,0278,RC,,,,both,,,6264.30,4071.79,,,,,,,,,,,,,
CATHETER PERIPHERALLY INSERTED CTRL VEN SPL NDL 2FRX30CM,SUP-2394008,CDM,C1751,HCPCS,0278,RC,,,,both,,,97.34,63.27,,,,,,,,,,,,,
INSERT ACET MOB BEAR HIP,SUP-2365998,CDM,C1776,CPT,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
LINER ACET OD49MM ID28MM STD DURASUL HIP PRI NEUT SNAP IN,SUP-2207461,CDM,C1776,CPT,0278,RC,,,,both,,,2326.74,1512.38,,,,,,,,,,,,,
GRAFT AORTIC VALVED SZ 21MM L12CM DIA21.5MM,SUP-2282679,CDM,C1889,HCPCS,0278,RC,,,,both,,,10833.00,7041.45,,,,,,,,,,,,,
SHEATH INTRO PRELUDEEASE 11CM 7FR 45 CM 0.021IN HYDRPHLC,SUP-2485357,CDM,C1894,HCPCS,0272,RC,,,,both,,,154.96,100.72,,,,,,,,,,,,,
PLATE BNE DBL Y MIC LNG 1.5 MM TI,SUP-2480965,CDM,C1713,HCPCS,0278,RC,,,,both,,,649.29,422.04,,,,,,,,,,,,,
HC ED Layer Clos Face 12.6-20,PX-4501205500,CDM,12055,CPT,0450,RC,,,,both,,,1904.00,1237.60,,,,,,,,,,,,,
GRAFT HUM TISS 132 SQ CM THK2-2.8MM THCK M PERF CNTOUR ACELLULAR DERM,SUP-2113057,CDM,Q4116,HCPCS,0636,RC,,,,both,,,15891.54,10329.50,,,,,,,,,,,,,
INTRODUCER DIAG SAFECROSS TRANSSEPTAL SM CRV RF PUNC STEER,SUP-2866239,CDM,C1893,HCPCS,0272,RC,,,,both,,,6892.30,4479.99,,,,,,,,,,,,,
GUIDEWIRE VASC INQWIRE L 150 CM DIA 0.018 IN TIP L 3 MM PTFE,SUP-2301920,CDM,C1769,HCPCS,0272,RC,,,,both,,,32.53,21.14,,,,,,,,,,,,,
PLATE BNE MESHED 123X123X0.8 MM SM GRID PDLLA STRL RESORB X,SUP-2480844,CDM,C1713,HCPCS,0278,RC,,,,both,,,8861.24,5759.81,,,,,,,,,,,,,
MESH SURG W20XL25CM SEPRA TECHNOLOGY RECT PHASIX,SUP-2125884,CDM,C1781,HCPCS,0278,RC,,,,both,,,23675.60,15389.14,,,,,,,,,,,,,
PROBE NERVE STIMULATOR BIPOLAR FLEXIBLE TIP INSULATED STERILE SINGLE-USE,SUP-2887763,CDM,2720000010,LOCAL,0272,RC,,,,both,,,541.81,352.18,,,,,,,,,,,,,
MESH SURG L 5 X W 5 CM D 1 MM PORCINE DERMAL CLLGN ABD HERN,SUP-2901798,CDM,C9364,HCPCS,0278,RC,,,,both,,,1719.59,1117.73,,,,,,,,,,,,,
PLATE BNE Y SM 3.5 MM FOR RECON SYS NS LTX,SUP-2861122,CDM,C1713,HCPCS,0278,RC,,,,both,,,717.99,466.69,,,,,,,,,,,,,
WILLIAMS MAND DIST 25MM LFT END DRVN BODY 3DX ELBOW T 6L 4V,SUP-2494932,CDM,2720000010,LOCAL,0272,RC,,,,both,,,16971.89,11031.73,,,,,,,,,,,,,
SET INTRO S-MAK L 15 CM DIA 5 FR GUIDEWIRE L 60 CM DIA 0.018,SUP-2474699,CDM,C1894,HCPCS,0272,RC,,,,both,,,131.88,85.72,,,,,,,,,,,,,
SCREW COMPR REPL LAPIDUS INCORE,SUP-2473658,CDM,C1713,HCPCS,0278,RC,,,,both,,,121.83,79.19,,,,,,,,,,,,,
INSERT TIB L71/75MM THK14MM UNIV STD KNEE PRI POST STBL,SUP-2407084,CDM,C1776,CPT,0278,RC,,,,both,,,4169.92,2710.45,,,,,,,,,,,,,
CATHETER VALVULOPLASTY ZMED II L 100 CM DIA 8 FR 4 CM 20 MM,SUP-2125251,CDM,C1725,HCPCS,0272,RC,,,,both,,,2344.42,1523.87,,,,,,,,,,,,,
RING EXT FIX HALF 160 MM DNE5160] DNE LLC],SUP-2197283,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2684.70,1745.05,,,,,,,,,,,,,
PLATE 4.5MM LCP CONDYLAR 16 HOLES 350MM LEFT STERILE,SUP-2547445,CDM,C1713,HCPCS,0278,RC,,,,both,,,5029.06,3268.89,,,,,,,,,,,,,
KIT PAIN PMP 270ML 2ML/HR CATH L2.5IN ON-Q PAINBUSTER,SUP-2236778,CDM,C2626,HCPCS,0278,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
GUIDEWIRE UROLOGICAL FIX COR 3 CM 0.038 INX145 CM STD,SUP-2835667,CDM,C1769,HCPCS,0272,RC,,,,both,,,52.97,34.43,,,,,,,,,,,,,
"HC Neuromuscular Re-Education, Ot",PX-4309711200,CDM,97112,CPT,0430,RC,,,,both,,,159.00,103.35,,,,,,,,,,,,,
CATHETER CV OXMTR 16 CM 3L SCVO2 MONITORING KT STRL,SUP-2466466,CDM,C1751,HCPCS,0278,RC,,,,both,,,1146.10,744.96,,,,,,,,,,,,,
PLATE BONE STR 12 H M FRAG SYS FPS FOR 3.5/4 MM SCR,SUP-2319608,CDM,C1713,HCPCS,0278,RC,,,,both,,,2967.30,1928.74,,,,,,,,,,,,,
MATRIX BIO SZ 95 SQCM FISH SKIN DERMAL MIC INTACT STRL,SUP-2909247,CDM,Q4158,HCPCS,0636,RC,,,,both,,,10930.34,7104.72,,,,,,,,,,,,,
SCREW BONE L4MM DIA1.5MM BRNZ CORT TI ST NONCANNULATED,SUP-2181608,CDM,C1713,HCPCS,0278,RC,,,,both,,,318.71,207.16,,,,,,,,,,,,,
PLATE BONE L43MM 6 H MAND TI LCK FOR 2MM SCR,SUP-2191229,CDM,C1713,HCPCS,0278,RC,,,,both,,,2567.26,1668.72,,,,,,,,,,,,,
COMPONENT FEM AUG DSTL LG KNEE OSSEO TI OSS,SUP-2441762,CDM,C1776,CPT,0278,RC,,,,both,,,5397.66,3508.48,,,,,,,,,,,,,
CLIP ENDOSCP WRK L2300MM LO GI TRACT PRECIS ROT ADJ OPN,SUP-2313202,CDM,2720000010,LOCAL,0272,RC,,,,both,,,648.98,421.84,,,,,,,,,,,,,
BIT DRL L 245 MM DIA 8 MM FOR DH-DC 3 REAMER NS REUSE,SUP-2908158,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1723.04,1119.98,,,,,,,,,,,,,
SHEATH INTRO STR 5FRX15 CM SMOOTH TAPR SS PTFE GRN COMPASS,SUP-2846722,CDM,C1894,HCPCS,0272,RC,,,,both,,,184.29,119.79,,,,,,,,,,,,,
LEAD PACE L65IN ATR VENT,SUP-2356689,CDM,C1898,HCPCS,0275,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
CUFF ORTHOT HIP BILATERAL THGH CUST W/SPRD BAR,SUP-2435600,CDM,L1652,HCPCS,0272,RC,,,,both,,,1009.23,656.00,,,,,,,,,,,,,
PLATE BNE L168MM 8 H NONSTERILE R MED DST TIB S STL LOK,SUP-2185586,CDM,C1713,HCPCS,0278,RC,,,,both,,,4498.99,2924.34,,,,,,,,,,,,,
PLATE BNE L106MM 4 H L MED PROX TIB S STL LOK COMPR LO PROF,SUP-2185669,CDM,C1713,HCPCS,0278,RC,,,,both,,,4536.11,2948.47,,,,,,,,,,,,,
BLADE SHAVER STR STD 4.8 MM TYP A STRL DISP,SUP-2638421,CDM,2720000010,LOCAL,0272,RC,,,,both,,,452.16,293.90,,,,,,,,,,,,,
BUR SURG OD3.1MM TUNGSTEN CARB DISP ROSEN FOR HNDPC I HI,SUP-2108765,CDM,C1713,HCPCS,0278,RC,,,,both,,,407.35,264.78,,,,,,,,,,,,,
COLLAR CERVICALXSM H2.75XL22.5IN EXTRIC EMS 1 PC PLAS FOAM,SUP-2197905,CDM,L0120,HCPCS,0274,RC,,,,both,,,89.80,58.37,,,,,,,,,,,,,
HC So Immunoassay Quant,PX-3018351966,CDM,83519,CPT,0301,RC,,,,both,,,104.00,67.60,,,,,,,,,,,,,
PLATE BONE L105MM 8 HOLE NNSTRLE CNTRBLE LOK DUAL CMPRSSN 35,SUP-2476536,CDM,C1713,HCPCS,0278,RC,,,,both,,,1438.59,935.08,,,,,,,,,,,,,
POST EXT FIX DIA11MM 90DEG OUTRIG MAG RESONANCE CONDITIONAL,SUP-2188510,CDM,2720000010,LOCAL,0272,RC,,,,both,,,358.90,233.28,,,,,,,,,,,,,
FILLER BNE VOID 3CC CA PHSPTE FBR REINF DRILLABLE FAST SET,SUP-2182826,CDM,C9359,HCPCS,0278,RC,,,,both,,,2252.51,1464.13,,,,,,,,,,,,,
PIN FIX L180MM DIA4MM S STL SGL END SHRP TIP CTRL THRD,SUP-2420759,CDM,C1713,HCPCS,0278,RC,,,,both,,,313.18,203.57,,,,,,,,,,,,,
KIT HIP IMPL CAPPED H3 ADV 2 MOBILITY VE LNR H3VEZIMMERBIOMET,SUP-2894032,CDM,C1776,CPT,0278,RC,,,,both,,,16171.00,10511.15,,,,,,,,,,,,,
MISOPROSTOL 50 MCG PRE-SPLIT TABLET,RX-4082120,CDM,6370000000,HCPCS,0637,RC,99992-1366-50,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
IMPL EXPANDER SMOOTH W/FILL SYSTEM 200CC,SUP-2423832,CDM,C1789,HCPCS,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
PLATE BONE INSERT 0.50.7 MM HALF HEIGHT MATRIXMIDFACE,SUP-2838505,CDM,C1713,HCPCS,0278,RC,,,,both,,,595.66,387.18,,,,,,,,,,,,,
ALLOGRAFT HUM TISS SEMITENDINOSUS TEND FRZN NO-RAD,SUP-2321842,CDM,C1762,CPT,0278,RC,,,,both,,,4867.00,3163.55,,,,,,,,,,,,,
HC MRI Face Neck Eye W Contrast,PX-6107054200,CDM,70542,CPT,0610,RC,,,,both,,,4451.00,2893.15,,,,,,,,,,,,,
STEM HUM DSTL 19X170 MM SHLDR AEQUALIS FLX REVIVE PTC,SUP-2715477,CDM,C1776,CPT,0278,RC,,,,both,,,24335.00,15817.75,,,,,,,,,,,,,
TORQUE COUNT FINAL TIGHT,SUP-2232121,CDM,C1713,HCPCS,0278,RC,,,,both,,,2493.16,1620.55,,,,,,,,,,,,,
CABLE ORTHOT HIP KNEE ANK CUST UNILAT TORSON,SUP-2435644,CDM,L2080,LOCAL,0274,RC,,,,both,,,1056.52,686.74,,,,,,,,,,,,,
GUIDEWIRE VASC KATZN L 180 CM TIP L 6 CM DIA 0.035 IN SS,SUP-2148177,CDM,C1769,HCPCS,0272,RC,,,,both,,,568.72,369.67,,,,,,,,,,,,,
CATHETER ASPIR 4.2FR XTRCT,SUP-2327203,CDM,C1757,HCPCS,0272,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
PLATE BNE DBL Y 0.5 MM 6 HOLE TI BLU NS MATRIXMIDFACE,SUP-2181684,CDM,C1713,HCPCS,0278,RC,,,,both,,,1131.97,735.78,,,,,,,,,,,,,
PLATE BNE CRV 3.5X213 MM RT PROX HUM 15 HOLE EVOS,SUP-2424160,CDM,C1713,HCPCS,0278,RC,,,,both,,,10310.03,6701.52,,,,,,,,,,,,,
GUIDEWIRE VASC L 145 CM DIA 0.035 IN PTFE J TAPR MOVEABLE,SUP-2147067,CDM,C1769,HCPCS,0272,RC,,,,both,,,37.93,24.65,,,,,,,,,,,,,
KIT TRNSPRT CART BX CARTICEL,SUP-2227073,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
SPLINT HND M PALM W3-3.5IN RT DORS CRPL TUNN HEAT MOLD,SUP-2332646,CDM,L3808,HCPCS,0274,RC,,,,both,,,69.08,44.90,,,,,,,,,,,,,
LIDOCAINE HCL 4 % MT SOLN,RX-43717,CDM,6370000000,HCPCS,0637,RC,76329-6300-05,NDC,,both,4,ML,173.70,112.90,,,,,,,,,,,,,
SPINDLE ORTH SM SHT 38 MM 400 LB COMPRESS,SUP-2441838,CDM,C1776,CPT,0278,RC,,,,both,,,9212.76,5988.29,,,,,,,,,,,,,
PIN FIX FEM KNEE REF TS3 ROSA REUSE,SUP-2656955,CDM,C1713,HCPCS,0278,RC,,,,both,,,3460.28,2249.18,,,,,,,,,,,,,
MESH SURG SHT 19X15 CMX2 MM AORT GRFT VASC OVL DUALMESH,SUP-2469741,CDM,C1781,HCPCS,0278,RC,,,,both,,,4823.04,3134.98,,,,,,,,,,,,,
KIT CATH URTHRL DLTR 4MM OD BLLN 12FR DIA INFLTD 3FR DIA SHA,SUP-2727094,CDM,C2617,HCPCS,0278,RC,,,,both,,,926.93,602.50,,,,,,,,,,,,,
CATHETER ANGIOPLSTY SABER L 200 CM BALLOON L 250 MM DIA 3 MM,SUP-2909685,CDM,C1725,HCPCS,0272,RC,,,,both,,,847.33,550.76,,,,,,,,,,,,,
CATHETER ABLATN D 1-4-1 MM 4 MM TIP 8 FRX115 CM FLEXABILITY,SUP-2357515,CDM,C2630,CPT,0272,RC,,,,both,,,7928.50,5153.52,,,,,,,,,,,,,
ENDOPROSTHESIS VASC WSTNT RP L 67 MM DIA 7 MM CATH TOT L 160,SUP-2148406,CDM,C1876,HCPCS,0278,RC,,,,both,,,6063.34,3941.17,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED BICOMPARTMENTAL ONLAY RESTORIS MCK,SUP-2265789,CDM,C1776,CPT,0278,RC,,,,both,,,15747.10,10235.61,,,,,,,,,,,,,
CRIMPER CABLE 11INL STAINLESS STEEL NON STERILE,SUP-2725759,CDM,C1713,HCPCS,0278,RC,,,,both,,,5630.11,3659.57,,,,,,,,,,,,,
CABLE ORTHOT HIP KNEE ANK CUST UNILAT TORSON,SUP-2435644,CDM,L2080,LOCAL,0272,RC,,,,both,,,1056.52,686.74,,,,,,,,,,,,,
TACROLIMUS 1 MG PO CAPS,RX-12933,CDM,J7507,HCPCS,0636,RC,00904-7097-61,NDC,,both,1,UN,6.20,4.03,,,,,,,,,,,,,
CATHETER THERMODILUTION 7.5 FRX110 CM AMC THROMSHLD SWN GZ,SUP-2214319,CDM,C1751,HCPCS,0278,RC,,,,both,,,623.20,405.08,,,,,,,,,,,,,
SYSTEM IV INFUSION 5 FRX45 CM 10 CM 1 CC,SUP-2471137,CDM,C1751,HCPCS,0278,RC,,,,both,,,273.65,177.87,,,,,,,,,,,,,
BLADE SAW OSCLLTNG 19.5MMW X80MML 0.9MM THK 0.9MM THK CUT ME,SUP-2605481,CDM,2720000010,LOCAL,0272,RC,,,,both,,,128.99,83.84,,,,,,,,,,,,,
CATHETER HD LT 15.5 FRX28 CM SET W/ STYL SYMETREX,SUP-2627450,CDM,C1750,HCPCS,0278,RC,,,,both,,,533.80,346.97,,,,,,,,,,,,,
SUTURE NOVAFIL HGS-21 1/2 CIR 37MM TAPERPOINT 5 X 18 IN SZ 8886445463,SUP-2174596,CDM,C1713,HCPCS,0278,RC,,,,both,,,120.07,78.05,,,,,,,,,,,,,
PUSHER KNOT 5 MMX31 CM EXCORP,SUP-2850164,CDM,2720000010,LOCAL,0272,RC,,,,both,,,436.81,283.93,,,,,,,,,,,,,
TROCAR SURG L232MM DIA32MM FOR TI TROCHANTERIC NAIL FIX SYS,SUP-2188220,CDM,C1769,HCPCS,0272,RC,,,,both,,,1001.94,651.26,,,,,,,,,,,,,
ADAPTER EXT FIX MCREYNOLDS,SUP-2495532,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1861.39,1209.90,,,,,,,,,,,,,
LINER ACET OD50MM ID32MM 20DEG ENDRN HIP CEM ENDUR,SUP-2250675,CDM,C1776,CPT,0278,RC,,,,both,,,2888.80,1877.72,,,,,,,,,,,,,
PLATE BONE TUBULAR BROAD 4.5 MM 14 HOLE PROVISIONAL FIXATION,SUP-2836968,CDM,C1713,HCPCS,0278,RC,,,,both,,,2863.05,1860.98,,,,,,,,,,,,,
SENNA 8.8 MG/5ML PO SYRP,RX-28961,CDM,6370000000,HCPCS,0637,RC,09999-9910-45,NDC,,both,5,ML,2.70,1.75,,,,,,,,,,,,,
KIT VENTRICULAR DRAINAGE COMB W/ SP0004 SYS INS4500 CATH,SUP-2883570,CDM,C1729,HCPCS,0272,RC,,,,both,,,724.15,470.70,,,,,,,,,,,,,
ALLOGRAFT BNE CHIP 0.1-4 MM 60 CC FRZN CANC,SUP-2792184,CDM,C1713,HCPCS,0278,RC,,,,both,,,3744.45,2433.89,,,,,,,,,,,,,
CLONAZEPAM 0.5 MG PO TBDP,RX-35627,CDM,6370000000,HCPCS,0637,RC,49884-0308-52,NDC,,both,1,UN,4.20,2.73,,,,,,,,,,,,,
GUIDEWIRE ORTH MULTIPLE 2.8 MM NS,SUP-2789128,CDM,C1769,HCPCS,0272,RC,,,,both,,,4663.28,3031.13,,,,,,,,,,,,,
VALVE CSF PERF LEVEL 2 SM EXTRACTED DELT,SUP-2628542,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4967.54,3228.90,,,,,,,,,,,,,
MESH HERN W13XL25CM SYN MFIL RESRB RECT PHASIX ST,SUP-2126270,CDM,C1781,HCPCS,0278,RC,,,,both,,,16500.70,10725.45,,,,,,,,,,,,,
SET URET STENT MARD L 22 CM DIA 4.8 FR PERCFLX HYDROPLUS SFT,SUP-2141629,CDM,C2617,HCPCS,0278,RC,,,,both,,,428.52,278.54,,,,,,,,,,,,,
CEMENT DENT 60GM CARBOXYLATE LUTING PWD 3 PK DURELON,SUP-2238646,CDM,C1713,HCPCS,0278,RC,,,,both,,,268.44,174.49,,,,,,,,,,,,,
REAMER SURG 4.0MM BONE CANN,SUP-2342389,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2649.85,1722.40,,,,,,,,,,,,,
CANNULA SUCTION EXTRACTION 270 DEG 3 MMX30 CM 8 MM PAL,SUP-2760833,CDM,2720000010,LOCAL,0272,RC,,,,both,,,876.06,569.44,,,,,,,,,,,,,
GUIDEWIRE VASC TRANSEND L 200 CM DIA 0.010 IN TIP L 2 CM,SUP-2367924,CDM,C1769,HCPCS,0272,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
HC Repair Vad,PX-3613657500,CDM,36575,CPT,0361,RC,,,,inpatient,,,706.00,458.90,,,,,,,,,,,,,
SHEATH INTRO PINNACLE DESTINATION 65CM 6FR COAT L 35CM STR,SUP-2385211,CDM,C1894,HCPCS,0272,RC,,,,both,,,295.16,191.85,,,,,,,,,,,,,
HC US OB 1st Tr Fetal Tran Ea Add,PX-4027681400,CDM,76814,CPT,0402,RC,,,,both,,,519.00,337.35,,,,,,,,,,,,,
SLEEVE LD ANCHR,SUP-2282028,CDM,C1713,HCPCS,0278,RC,,,,both,,,70.65,45.92,,,,,,,,,,,,,
SET STENT URTRL 5FR DIA 24CML PRCFLX DBLE PGTL LOW PRFLE LG,SUP-2724754,CDM,C2617,HCPCS,0278,RC,,,,both,,,519.07,337.40,,,,,,,,,,,,,
PLATE BNE L88MM 3 H BILAT S STL CLVRLF FOR 3.5MM SCR,SUP-2411332,CDM,C1713,HCPCS,0278,RC,,,,both,,,734.82,477.63,,,,,,,,,,,,,
PACK NEUROSURGICAL SHTH L 95 X W 13.5 MM MYRIAD HNDPC L 13 NN-3006,SUP-2930301,CDM,2720000010,LOCAL,0272,RC,,,,both,,,22236.19,14453.52,,,,,,,,,,,,,
SPLINT PREMIER PRO WRST,SUP-2336040,CDM,L3809,HCPCS,0272,RC,,,,both,,,23.90,15.53,,,,,,,,,,,,,
WIRE EXT FIX OLV 2X550 MM ANK SPANNING CONSTRUCT,SUP-2457348,CDM,2720000010,LOCAL,0272,RC,,,,both,,,499.26,324.52,,,,,,,,,,,,,
SPLINT ORTH M L13IN 6-17IN GRY ELBW BILAT ZIP OPN NYL LOOP,SUP-2324194,CDM,L3702,HCPCS,0274,RC,,,,both,,,64.40,41.86,,,,,,,,,,,,,
CLIP INT L235CM WRK CHAN DIA2.8MM OPN 11MM LCK MECHANISM MR,SUP-2149432,CDM,C1889,HCPCS,0278,RC,,,,both,,,495.18,321.87,,,,,,,,,,,,,
PLATE BONE ORBITAL LARGE RIGHT PREFORMED TITANIUM GOLD STERI,SUP-2837775,CDM,C1713,HCPCS,0278,RC,,,,both,,,6354.42,4130.37,,,,,,,,,,,,,
COIL VASC AZUR CX L 16 CM DIA 5 MM MICROCATHETER 0.018 IN,SUP-2385234,CDM,C1889,HCPCS,0278,RC,,,,both,,,2827.57,1837.92,,,,,,,,,,,,,
SCREW BONE L22MM D27MM STNLSS STEEL CRTCL PRRTCLR SELF TPPNG,SUP-2498118,CDM,C1713,HCPCS,0278,RC,,,,both,,,258.74,168.18,,,,,,,,,,,,,
PLATE BNE STR MED 1.5X108X0.8 MM MIDFACE 24 HOLE W/ TAB NS,SUP-2483419,CDM,C1713,HCPCS,0278,RC,,,,both,,,1063.05,690.98,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED INCRD MOTN CKNEEBIOINCMOT] ZIMMER BIOMET INC],SUP-2137377,CDM,C1776,CPT,0278,RC,,,,both,,,14801.96,9621.27,,,,,,,,,,,,,
VITAMIN D3 25 MCG (1000 UT) PO TABS,RX-76997,CDM,6370000000,HCPCS,0637,RC,80681-0168-00,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
HC Gastric Procedure Unlisted,PX-3614399900,CDM,43999,CPT,0361,RC,,,,outpatient,,,174.00,113.10,,,,,,,,,,,,,
BURR SURG L72MM OD1MM LNG RND CUT TOOL S STL NONFLUTED,SUP-2284256,CDM,2720000010,LOCAL,0272,RC,,,,both,,,307.72,200.02,,,,,,,,,,,,,
ALLOGRAFT HUM TISS STRUT 35-10 MM FRZN HALF PATELLAR TEND,SUP-2866905,CDM,C1762,CPT,0278,RC,,,,both,,,5939.15,3860.45,,,,,,,,,,,,,
PLATE BNE THK1MM 0DEG 6 H STR BILAT TI CRANIOMAXILLOFACIAL,SUP-2262765,CDM,C1713,HCPCS,0278,RC,,,,both,,,261.15,169.75,,,,,,,,,,,,,
HC NM Rx IV Admin,PX-3427910100,CDM,79101,CPT,0342,RC,,,,outpatient,,,1865.00,1212.25,,,,,,,,,,,,,
PNEUMOCOCCAL 20-VAL CONJ VACC 0.5 ML IM SUSY,RX-155612,CDM,90677,HCPCS,0636,RC,00005-2000-01,NDC,,both,.5,ML,1120.50,728.32,,,,,,,,,,,,,
"HC E/M Crit Care,ER, 1st 30-74min",PX-4509929100,CDM,99291,CPT,0450,RC,,,,outpatient,,,4946.00,3214.90,,,,,,,,,,,,,
SPLINT PREMIER PRO WRST,SUP-2336039,CDM,L3809,HCPCS,0274,RC,,,,both,,,18.46,12.00,,,,,,,,,,,,,
TRIAMCINOLONE ACETONIDE 10 MG/ML IJ SUSP,RX-11584,CDM,J3301,HCPCS,0636,RC,00003-0494-20,NDC,,both,0.25,ML,54.10,35.16,,,,,,,,,,,,,
PLATE BNE L15MM THK0.6MM MIC 4 H CP TI STR FOR 1.5MM SCR,SUP-2262669,CDM,C1713,HCPCS,0278,RC,,,,both,,,131.88,85.72,,,,,,,,,,,,,
BIT DRL DIA2 MM CANN FUSION QR NS DISP HPS,SUP-2912796,CDM,C1713,HCPCS,0278,RC,,,,both,,,609.16,395.95,,,,,,,,,,,,,
PROSTHESIS PENILE L23CM DIA9.5MM HYDRPHLC MALL TAIL CAP TRIM,SUP-2165369,CDM,C2622,HCPCS,0278,RC,,,,both,,,30147.14,19595.64,,,,,,,,,,,,,
SHEARS ENDO L23CM DIA5MM CVD PSTL GRP HND CTRL HARM ACE,SUP-2257346,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1152.79,749.31,,,,,,,,,,,,,
GRAFT HUM TISS L 3 X W 2 CM AMNION PLCNTA MEMBRN 2 LAYR,SUP-2913214,CDM,C1762,CPT,0278,RC,,,,both,,,3752.30,2438.99,,,,,,,,,,,,,
PLATE BNE MESHED 0.6 MM LT MXLFCL NEURO SMRT KASSAM,SUP-2489849,CDM,C1713,HCPCS,0278,RC,,,,both,,,6373.60,4142.84,,,,,,,,,,,,,
INTRODUCER SHTH 8FR L13CM NDL 18GA GWIRE 0.035IN SYR VLV,SUP-2281845,CDM,C1892,HCPCS,0272,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
SCREW BNE L25MM DIA5MM FULL THRD CORT PANTA,SUP-2243611,CDM,C1713,HCPCS,0278,RC,,,,both,,,1145.28,744.43,,,,,,,,,,,,,
BIT DRL 2.5X18 MM FOR ACP SYS VAN GOGH,SUP-2661683,CDM,2720000010,LOCAL,0272,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
ARROW FIXATION L13MM 1.1MM NONSUTURE MENISCAL CONTOUR PRELOA,SUP-2824129,CDM,C1713,HCPCS,0278,RC,,,,both,,,526.01,341.91,,,,,,,,,,,,,
GUIDEWIRE INSRT FOR SYS,SUP-2289239,CDM,C1769,HCPCS,0272,RC,,,,both,,,2233.89,1452.03,,,,,,,,,,,,,
DRESSING NEG PRESSURE INCISION MGMT SYS 90 CM KIT PREVENA +,SUP-2433936,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1204.35,782.83,,,,,,,,,,,,,
REAMER SURG 12MM CONCAVE MTP FOR SM JT RMR MOD HND SYS,SUP-2107732,CDM,C1713,HCPCS,0278,RC,,,,both,,,2072.40,1347.06,,,,,,,,,,,,,
EXTRACTOR STONE 2.5FR L115CM 2.8FR SHTH TIP 4W URIN TRACT,SUP-2170136,CDM,2720000010,LOCAL,0272,RC,,,,both,,,611.92,397.75,,,,,,,,,,,,,
DIPHENOXYLATE-ATROPINE 2.5-0.025 MG/5ML PO LIQD,RX-2515,CDM,340b,HCPCS,0637,RC,09999-9903-32,NDC,,both,5,ML,2.70,1.75,,,,,,,,,,,,,
IMMUNE GLOBULIN (FLEBOGAMMA) 10%,RX-4081761,CDM,J1459,HCPCS,0636,RC,44206-0438-20,NDC,,both,200,ML,11319.80,7357.87,,,,,,,,,,,,,
SCREW CRAN L 4 MM DIA1.5 MM 100 SD DISK NS DISP,SUP-2929038,CDM,C1713,HCPCS,0278,RC,,,,both,,,79.88,51.92,,,,,,,,,,,,,
PIN FIX L40MM DIA2.7MM PROV VAR ANG LCK PERI-LOC VLP,SUP-2343969,CDM,C1713,HCPCS,0278,RC,,,,both,,,1385.84,900.80,,,,,,,,,,,,,
SHEATH INTRO PERFRMR L 75 CM OD 9 FR ID 3 MM HAUSDORF,SUP-2167960,CDM,C1894,HCPCS,0272,RC,,,,both,,,860.36,559.23,,,,,,,,,,,,,
PLATE BNE KEYLESS 95 DEG 255 MM HIP 14 HOLE COMPR TUBE,SUP-2485113,CDM,C1713,HCPCS,0278,RC,,,,both,,,1811.15,1177.25,,,,,,,,,,,,,
SET SCR RET COMPR RET,SUP-2288454,CDM,C1713,HCPCS,0278,RC,,,,both,,,2465.12,1602.33,,,,,,,,,,,,,
CANN SCREW WASHER 7.0MM ODX3.6MM IMMUNODIFFUSION,SUP-2823117,CDM,C1713,HCPCS,0278,RC,,,,both,,,191.54,124.50,,,,,,,,,,,,,
PLATE BNE 24X55MM NONSTERILE R VOLAR RIM CROSSLOCK DVR,SUP-2411818,CDM,C1713,HCPCS,0278,RC,,,,both,,,2847.98,1851.19,,,,,,,,,,,,,
CATHETER CV DL 4 FR FULL TY W/ STYL PER-Q-CATH,SUP-2125637,CDM,C1751,HCPCS,0278,RC,,,,both,,,589.69,383.30,,,,,,,,,,,,,
MESH CRAN W100XL100MM THK0.5MM RAP RESRB FOR 1.5MM SCR FIX,SUP-2194072,CDM,C1781,HCPCS,0278,RC,,,,both,,,9891.00,6429.15,,,,,,,,,,,,,
PLATE BONE THK0.8MM 3 H HND ROT TRILOK FOR 1.5MM SCR APTUS,SUP-2267905,CDM,C1713,HCPCS,0278,RC,,,,both,,,1732.24,1125.96,,,,,,,,,,,,,
ELECTRODE ELECSURG 20 MM LINEAR,SUP-2866312,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8085.50,5255.57,,,,,,,,,,,,,
SCREW TEMP FIX THOR REDUC FOR RIBFIX BLU SYS,SUP-2413089,CDM,C1713,HCPCS,0278,RC,,,,both,,,741.04,481.68,,,,,,,,,,,,,
GRAFT VASC HEMSHLD PLAT L 60 CM 26MM POLYESTER BOV CLLGN STR,SUP-2265930,CDM,C1768,CPT,0278,RC,,,,both,,,1985.48,1290.56,,,,,,,,,,,,,
PLATE BNE L46MM 3 H R RAD S STL RIM RIG LOK COMPR FOR 2.4MM,SUP-2185998,CDM,C1713,HCPCS,0278,RC,,,,both,,,1804.09,1172.66,,,,,,,,,,,,,
BIT DRL CANN SHT 12 MM NS,SUP-2757693,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2100.69,1365.45,,,,,,,,,,,,,
SCREW BONE MINI L6MM DIA2MM LUHR,SUP-2364680,CDM,C1713,HCPCS,0278,RC,,,,both,,,127.17,82.66,,,,,,,,,,,,,
COMPONENT FEM L + RT CNDYL POR TOT MOD ADVTM,SUP-2397051,CDM,C1776,CPT,0278,RC,,,,both,,,16390.80,10654.02,,,,,,,,,,,,,
STEM FEM SZ 7 L155MM OD11MM 5MM OFFSET HA DST HIP STR,SUP-2379085,CDM,C1776,CPT,0278,RC,,,,both,,,15844.44,10298.89,,,,,,,,,,,,,
SET URET STENT L 20 CM DIA 7 FR CATH 6 FR PTFE GUIDEWIRE,SUP-2461939,CDM,C2617,HCPCS,0278,RC,,,,both,,,397.46,258.35,,,,,,,,,,,,,
PROBE PEDCL PEDIGUARD 3.2MM,SUP-2353384,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4392.86,2855.36,,,,,,,,,,,,,
KIT INTRO MST L 2CM DIA2FR GUIDEWIRE L 20CM DIA 0.010IN 24GA,SUP-2905025,CDM,C1892,HCPCS,0272,RC,,,,both,,,131.88,85.72,,,,,,,,,,,,,
MESH CRAN THK 0.6 MM SCREW DIA1.5 MM TI GRD II OCCPTL PREFRM,SUP-2935070,CDM,C1713,HCPCS,0278,RC,,,,both,,,15238.42,9904.97,,,,,,,,,,,,,
HINGE EXT FIX OUTBOARD 100 MM NS TRUELOK LTX,SUP-2875016,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1423.21,925.09,,,,,,,,,,,,,
SET DRNGE 1ML 47-90UM BILI DRY VOL VI PARTIC EMB RNG,SUP-2167939,CDM,C1729,HCPCS,0272,RC,,,,both,,,370.52,240.84,,,,,,,,,,,,,
BIT DRL L58MM OD1.6MM 20MM STP DENT SHFT END NONRADIOLUCENT,SUP-2364187,CDM,2720000010,LOCAL,0272,RC,,,,both,,,455.43,296.03,,,,,,,,,,,,,
INTRODUCER LD PLCMNT 85FR 81CM N PEEL AWAY N COR SNUS ACCS,SUP-2357220,CDM,C1893,HCPCS,0272,RC,,,,both,,,1758.40,1142.96,,,,,,,,,,,,,
BLADE SAW W5.5XL28.5MM THK0.4MM CUT THK0.6MM FN TOOTH STR,SUP-2166582,CDM,C1713,HCPCS,0278,RC,,,,both,,,84.09,54.66,,,,,,,,,,,,,
RELOAD STPL L100MM OPN H3.8MM CLS H1.5MM WIRE DIA0.2MM BLU,SUP-2220023,CDM,2720000010,LOCAL,0272,RC,,,,both,,,347.25,225.71,,,,,,,,,,,,,
IMPLANT FACE L 42 X H 20 MM THK 0.35 MM POLYETHYL LOWER,SUP-2883475,CDM,C1713,HCPCS,0278,RC,,,,both,,,1651.20,1073.28,,,,,,,,,,,,,
SYSTEM FIX STD FEM W/ SHTH 7MM SCR L23MM DIA7-7.5MM INTRAFIX,SUP-2256824,CDM,C1713,HCPCS,0278,RC,,,,both,,,2574.80,1673.62,,,,,,,,,,,,,
HC Replace J Tube,PX-3614945100,CDM,49451,CPT,0361,RC,,,,outpatient,,,1056.00,686.40,,,,,,,,,,,,,
CATHETER GUID 6FR INSIDE DIA0.07IN AL Q4 PTFE LNR RND BRAID,SUP-2144699,CDM,C1887,HCPCS,0272,RC,,,,both,,,150.72,97.97,,,,,,,,,,,,,
SCREW BONE 1.3X8MM CORT N LCK ALPS,SUP-2411750,CDM,C1713,HCPCS,0278,RC,,,,both,,,187.36,121.78,,,,,,,,,,,,,
"HC So Cytomegalovirus, Igg Antibody",PX-3028664466,CDM,86644,CPT,0302,RC,,,,both,,,179.00,116.35,,,,,,,,,,,,,
SCREW BNE ST 1.2X5 MM NS AXS LTX 5PK,SUP-2862772,CDM,C1713,HCPCS,0278,RC,,,,both,,,312.74,203.28,,,,,,,,,,,,,
BALLOON CERV 18FR 80ML RIPENING W/ STYL FOR DIL,SUP-2168996,CDM,C1726,HCPCS,0272,RC,,,,both,,,226.52,147.24,,,,,,,,,,,,,
NAIL IM 12 MMX37.5 CM TIB,SUP-2252428,CDM,C1713,HCPCS,0278,RC,,,,both,,,4541.26,2951.82,,,,,,,,,,,,,
CATHETER BLLN DIL FIX WIRE 5-6-7-8-9 MM 8 CM ELATION 5,SUP-2488614,CDM,2720000010,LOCAL,0272,RC,,,,both,,,690.80,449.02,,,,,,,,,,,,,
FILTER VASC 300CM 5MM NIT ANGIOGUARDXP,SUP-2157304,CDM,C1769,HCPCS,0272,RC,,,,both,,,3532.50,2296.12,,,,,,,,,,,,,
CATHETER ABLATN LG CRV 2-5-2 MM SPC 4 MM TIP 7 FRX110 CM,SUP-2102290,CDM,C1733,HCPCS,0272,RC,,,,both,,,2389.54,1553.20,,,,,,,,,,,,,
PIN CLAMP 3 HOLE,SUP-2853454,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1906.67,1239.34,,,,,,,,,,,,,
KIT VASC SNR ATRIEVE 90 DEG TIP 15 DEG L 120 CM DIA27-45 MM,SUP-2120071,CDM,C1773,HCPCS,0272,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
BODY EXT FIX L62MM SHT 1 STD BAR PENNIG MINIFIXATOR,SUP-2316455,CDM,C1713,HCPCS,0278,RC,,,,both,,,1925.95,1251.87,,,,,,,,,,,,,
GUIDEWIRE VASC L260CM DIA0.035IN STIFF SHFT ANG HYDRPHLC,SUP-2302968,CDM,C1769,HCPCS,0272,RC,,,,both,,,103.49,67.27,,,,,,,,,,,,,
TUBE ENTRL FEED GASTRO-ENTERIC 24 FRX57.9 CM SECUR-LOK MIC,SUP-2764445,CDM,2720000010,LOCAL,0272,RC,,,,both,,,562.34,365.52,,,,,,,,,,,,,
RECON TS LCK DBL ANG36 H,SUP-2669751,CDM,C1713,HCPCS,0278,RC,,,,both,,,8723.30,5670.14,,,,,,,,,,,,,
PLATE BNE THK2.3MM LNG CRV NONCOMPRESSION FRAC,SUP-2263004,CDM,C1713,HCPCS,0278,RC,,,,both,,,903.03,586.97,,,,,,,,,,,,,
KIT VENTRICULAR DRAINAGE W/ INS0001 SYS INS0001 CATH SET,SUP-2883507,CDM,C1729,HCPCS,0272,RC,,,,both,,,963.48,626.26,,,,,,,,,,,,,
STEM FEM SZ 10 STD HIP TI PLSM SPR OVATION,SUP-2314395,CDM,C1776,CPT,0278,RC,,,,both,,,9852.38,6404.05,,,,,,,,,,,,,
CATHETER PTCA L80CM L2CM OD4FR ODSEC5MM .018IN 14ATM PERIPH,SUP-2170756,CDM,C1725,HCPCS,0272,RC,,,,both,,,650.14,422.59,,,,,,,,,,,,,
GRAFT BONE 21CM FRZN 1/2 SPL STRUT TIB SHFT,SUP-2113906,CDM,C1776,CPT,0278,RC,,,,both,,,3595.30,2336.94,,,,,,,,,,,,,
DEXAMETHASONE 4 MG PO TABS,RX-2327,CDM,J8540,HCPCS,0636,RC,00054-8175-25,NDC,,both,1,UN,4.60,2.99,,,,,,,,,,,,,
HC Fluoro Xray Venogram Ext Unil,PX-3207582000,CDM,75820,CPT,0320,RC,,,,outpatient,,,1017.00,661.05,,,,,,,,,,,,,
BUR SURG PRECIS 15 DEG 2.5MMX12.5 CM MTCH HD PROX ORNG IBUR,SUP-2859514,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1125.56,731.61,,,,,,,,,,,,,
LEAD PACE AD 8.6FR L72CM ATR VENT SIL POLYUR INSUL 3PLR,SUP-2282251,CDM,C1777,HCPCS,0275,RC,,,,both,,,9744.24,6333.76,,,,,,,,,,,,,
POR STD BODY STM LT 10.5MM APR II-T,SUP-2210903,CDM,C1776,CPT,0278,RC,,,,both,,,15290.54,9938.85,,,,,,,,,,,,,
CATHETER HEMO DYLS OR HD ADMIN BASIC KT 3 LUMN SIL STR STD,SUP-2267073,CDM,C1751,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
INTRODUCER SHTH 0.018/0.038 IN 5 FRX55 CM TOUHY BORST FLX,SUP-2169827,CDM,C1894,HCPCS,0272,RC,,,,both,,,180.24,117.16,,,,,,,,,,,,,
PLATE BONE L218MM 11 H BILAT S STL COBRA HD LO PROF RIG NEUT,SUP-2185802,CDM,C1713,HCPCS,0278,RC,,,,both,,,2199.10,1429.41,,,,,,,,,,,,,
HC Pt Eval Low Complex,PX-4249716100,CDM,97161,CPT,0424,RC,,,,both,,,174.00,113.10,,,,,,,,,,,,,
FERROUS SULFATE 325 (65 FE) MG PO TABS,RX-3074,CDM,6370000000,HCPCS,0637,RC,00904-7590-60,NDC,,both,1,UN,0.20,0.13,,,,,,,,,,,,,
ANCHOR SUT ETHBND SZ 2 L36IN GRN POLY BRAID CP-2 DBL ARMED,SUP-2249346,CDM,C1713,HCPCS,0278,RC,,,,both,,,2464.90,1602.18,,,,,,,,,,,,,
EXPEL APD 16/30,SUP-2652769,CDM,C1729,HCPCS,0272,RC,,,,both,,,295.16,191.85,,,,,,,,,,,,,
LEAD PACE 8.6FR L55CM SGL COIL PERM ACT FIX DF4 CONN SPRNT,SUP-2282265,CDM,C1895,HCPCS,0275,RC,,,,both,,,8769.83,5700.39,,,,,,,,,,,,,
GUIDE SURG FRONTAL SINUS DEPLOYMENT RELIEVA STRATUS,SUP-2106352,CDM,C1887,HCPCS,0272,RC,,,,both,,,1095.86,712.31,,,,,,,,,,,,,
ENALAPRIL MALEATE 1 MG/ML PO SOLN,RX-136449,CDM,6370000000,HCPCS,0637,RC,69238-1729-07,NDC,,both,1,ML,8.10,5.26,,,,,,,,,,,,,
PLATE BNE Y 1.5X29X1 MM MIDFACE 7 HOLE W/ TAB TI STRL,SUP-2480848,CDM,C1713,HCPCS,0278,RC,,,,both,,,845.92,549.85,,,,,,,,,,,,,
Z DISCONTINUED NO SUB IDED CATHETER CTRL VEN L8CM OD5FR DBL LUMN POLYUR SET,SUP-2167975,CDM,C1751,HCPCS,0278,RC,,,,both,,,227.65,147.97,,,,,,,,,,,,,
GRAFT BNE PTTY 5 CC DBM B201005P] FRONTIER MEDICAL PRODUCTS INC],SUP-2225959,CDM,C9359,HCPCS,0278,RC,,,,both,,,3378.64,2196.12,,,,,,,,,,,,,
POST EXT FIX DIA8MM 90DEG TRAC OUTRIG,SUP-2188520,CDM,2720000010,LOCAL,0272,RC,,,,both,,,273.18,177.57,,,,,,,,,,,,,
TUBE VENT BUTTERFLY 1.27 MM 7.6X5.3 MM EAR TYMPANUM T SHP,SUP-2312834,CDM,L8699,HCPCS,0278,RC,,,,both,,,80.13,52.08,,,,,,,,,,,,,
IMPLANT BIO TISS W18XL22CM REINF BIOSCAFFOLDS PERM OVITEX 1S,SUP-2383096,CDM,C1781,HCPCS,0278,RC,,,,both,,,22381.92,14548.25,,,,,,,,,,,,,
COMPONENT ULN L100MM STD RT ELBW MRS,SUP-2363215,CDM,C1776,CPT,0278,RC,,,,both,,,9231.60,6000.54,,,,,,,,,,,,,
PPICC PROVENA SOLO SP 4F DL MAX TL,SUP-2613559,CDM,C1751,HCPCS,0278,RC,,,,both,,,765.56,497.61,,,,,,,,,,,,,
SCREW BONE L65MM DIA2.4MM CORT ST T7 SELF RET FOR MINI,SUP-2349287,CDM,C1713,HCPCS,0278,RC,,,,both,,,280.21,182.14,,,,,,,,,,,,,
PLATE BNE L29MM THK1.3MM 4 H MTCRPL TI STR COMPR FOR,SUP-2267912,CDM,C1713,HCPCS,0278,RC,,,,both,,,743.55,483.31,,,,,,,,,,,,,
DRESSING WND MTRX 7X3 IN,SUP-2106518,CDM,Q4166,HCPCS,0636,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
CATHETER EP DIAG MAP M CRV QPLR 2-5-2MM SPC 2MM TIP UNI DIR,SUP-2356857,CDM,C1730,HCPCS,0272,RC,,,,both,,,1394.16,906.20,,,,,,,,,,,,,
EXTRACTOR SURG BOLT TRIGEN DISP IM NAIL,SUP-2347055,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1519.85,987.90,,,,,,,,,,,,,
PLATE BONE L121MM 6 H S STL LCK COMPR FOR 4.5MM SCR PERI-LOC,SUP-2348941,CDM,C1713,HCPCS,0278,RC,,,,both,,,3792.02,2464.81,,,,,,,,,,,,,
GUIDEWIRE OD1.4 MM K,SUP-2320977,CDM,C1769,HCPCS,0272,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
HC NM Myocard Infarct Spect Scan,PX-3417846900,CDM,78469,CPT,0341,RC,,,,both,,,2886.00,1875.90,,,,,,,,,,,,,
PLATE BNE 135DEG FEM TRL DHS,SUP-2187955,CDM,C1713,HCPCS,0278,RC,,,,both,,,893.90,581.03,,,,,,,,,,,,,
HC Tmj Open/Closed Mouth Bilateral,PX-3207033000,CDM,70330,CPT,0320,RC,,,,both,,,902.00,586.30,,,,,,,,,,,,,
HC Cardioversion,PX-4809296000,CDM,92960,CPT,0480,RC,,,,inpatient,,,1401.00,910.65,,,,,,,,,,,,,
COLLAR CERV 2.5X22 IN,SUP-2194374,CDM,L0120,HCPCS,0274,RC,,,,both,,,11.34,7.37,,,,,,,,,,,,,
KIT SGL USE W/ PRE FIL LIDO SYR 24FR SAFT PEG PUL ENDOVIVE,SUP-2141589,CDM,2720000010,LOCAL,0272,RC,,,,both,,,596.60,387.79,,,,,,,,,,,,,
CATHETER ANGIO DIA 4 FR COBRA STRL,SUP-2383189,CDM,C1894,HCPCS,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
PLATE SPNL L55MM BILAT SACR ANTR CONN,SUP-2290523,CDM,C1713,HCPCS,0278,RC,,,,both,,,3356.66,2181.83,,,,,,,,,,,,,
HC Group Caregiver Training Strategies & Technique,PX-4209755200,CDM,97552,CPT,0420,RC,,,,both,,,56.00,36.40,,,,,,,,,,,,,
TUBE TRACH PED L93MM OD6MM ID4MM SIL CUF STR NK FLNG W OBT,SUP-2352028,CDM,2720000010,LOCAL,0272,RC,,,,both,,,828.39,538.45,,,,,,,,,,,,,
BOLT FUSION MIDFOOT 6.5X125MM TI STRL,SUP-2546679,CDM,C1713,HCPCS,0278,RC,,,,both,,,1833.67,1191.89,,,,,,,,,,,,,
CLAMP EXT FIX SYMTRC 5 MM HEX CLMP NUT TI STRL X FIX,SUP-2423208,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1455.61,946.15,,,,,,,,,,,,,
PLATE BONE L155MM 6 H RT DSTL LAT FEM S STL LCK FOR 4.5MM,SUP-2348215,CDM,C1713,HCPCS,0278,RC,,,,both,,,12944.65,8414.02,,,,,,,,,,,,,
WRAP KNEE INSRT ICE W/2 DURA SFT,SUP-2197214,CDM,L1820,HCPCS,0272,RC,,,,both,,,98.63,64.11,,,,,,,,,,,,,
POST EXT FIX 3 H S STL M SUPP FOR ILIZ TAY SPAT FRME SYS,SUP-2342287,CDM,2720000010,LOCAL,0272,RC,,,,both,,,922.88,599.87,,,,,,,,,,,,,
CATHETER SUPP QUICK-CROSS SEL L 150 CM DIA 5 FR 0.035 IN,SUP-2823588,CDM,C1887,HCPCS,0272,RC,,,,both,,,624.86,406.16,,,,,,,,,,,,,
STENT CORONARY MULTLNK ULTRA L 18 MM DIA 5 MM GUIDE CATH,SUP-2103568,CDM,C1876,HCPCS,0278,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
IMPLANT FNGR JT SM L13.5MM SCR OD2.8MM BARB L5.5MM OD4MM,SUP-2223969,CDM,C1713,HCPCS,0278,RC,,,,both,,,5231.24,3400.31,,,,,,,,,,,,,
COMPONENT GLEN PEGGED 7 4 MM SHLDR KEELED FIX UHMWPE STRL,SUP-2372875,CDM,C1776,CPT,0278,RC,,,,both,,,7576.51,4924.73,,,,,,,,,,,,,
TOOL VLV BYPS FOR SLITTABLE OUTER GUID CATH CPS DIR SL II,SUP-2356362,CDM,C1893,HCPCS,0272,RC,,,,both,,,47.10,30.61,,,,,,,,,,,,,
CLAMP EXT FIX ADJ MR CONDITIONAL FOR SCHNZ SCR,SUP-2188597,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1069.80,695.37,,,,,,,,,,,,,
PLATE BNE L36MM 4 H MAXILLOFACIAL ORAL TI STR LIMIT CNTCT,SUP-2191396,CDM,C1713,HCPCS,0278,RC,,,,both,,,2349.66,1527.28,,,,,,,,,,,,,
GRAFT VASC GELWEAVE L 15 CM DIA10 MM POLYESTER GEL,SUP-2384994,CDM,C1768,CPT,0278,RC,,,,both,,,3877.90,2520.63,,,,,,,,,,,,,
PLATE BNE LCK 349 MM LT DSTL LAT FEM 18 HOLE SS STRL,SUP-2466893,CDM,C1713,HCPCS,0278,RC,,,,both,,,4740.05,3081.03,,,,,,,,,,,,,
COUNTERSINK SURG HDLSS 3X3 MM,SUP-2175119,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1059.75,688.84,,,,,,,,,,,,,
WRAP KNEE INSRT ICE W/2 DURA SFT,SUP-2197214,CDM,L1820,HCPCS,0274,RC,,,,both,,,98.63,64.11,,,,,,,,,,,,,
GRAFT EVAR L100MM DIA42X42MM CATH 25FR THOR CLS WEB STR DST,SUP-2281716,CDM,C1768,CPT,0278,RC,,,,both,,,58859.30,38258.54,,,,,,,,,,,,,
GRAFT BNE SUB 4CC DBM OSTEOINDUCTIVE OSTEOGENIC AUTOLGS BNE,SUP-2399143,CDM,C1713,HCPCS,0278,RC,,,,both,,,4914.32,3194.31,,,,,,,,,,,,,
SCREW BNE COMPR 3.5 MM SS KREULOCK,SUP-2845740,CDM,C1713,HCPCS,0278,RC,,,,both,,,8399.50,5459.67,,,,,,,,,,,,,
INTRODUCER HEMSTAS 20FR L30CM 0.035IN VLV SIDEPRT 2 TAPR DIL,SUP-2355621,CDM,C1894,HCPCS,0272,RC,,,,both,,,162.50,105.62,,,,,,,,,,,,,
CATHETER IABP 8FR 50CC FBROPT CONN W INSRT KT TWO STATLOK,SUP-2582811,CDM,C1889,HCPCS,0278,RC,,,,both,,,3188.36,2072.43,,,,,,,,,,,,,
PACK SAW BLDE 56MM D367MM CUT EDGE 10MM THK12MM FOR PWR,SUP-2365138,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
LEAD PACE AD 8.6FR L62CM ATR VENT SIL POLYUR DF4 CONN INSUL,SUP-2282250,CDM,C1777,HCPCS,0275,RC,,,,both,,,8164.00,5306.60,,,,,,,,,,,,,
PIN FIX L200MM OD4.8MM S STL BLNT TIP RND BVL PT SMOOTH,SUP-2342644,CDM,C1713,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
CUFF URETH L4.5CM PENILE INHIBZN OCCL SPHIN FOR URIN CTRL,SUP-2138950,CDM,C1815,HCPCS,0278,RC,,,,both,,,23003.64,14952.37,,,,,,,,,,,,,
PLATE BNE SM LT FIBULAR LAT,SUP-2896599,CDM,C1713,HCPCS,0278,RC,,,,both,,,2508.86,1630.76,,,,,,,,,,,,,
PLATE BONE W10XL118MM THK2.8MM 10 H S STL STR NONCOMPRESSION,SUP-2343766,CDM,C1713,HCPCS,0278,RC,,,,both,,,3883.40,2524.21,,,,,,,,,,,,,
GRAFT BNE 4 10MM 5CC CANC CHIP FRZN,SUP-2335542,CDM,C1762,CPT,0278,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
STEM RAD L12MM WR MAESTRO,SUP-2407335,CDM,C1776,CPT,0278,RC,,,,both,,,19615.58,12750.13,,,,,,,,,,,,,
COMPONENT FIX DIA13.6MM DF-P TOEMOTION,SUP-2123622,CDM,C1776,CPT,0278,RC,,,,both,,,3240.48,2106.31,,,,,,,,,,,,,
ALLOGRAFT ACHILLES TEND W/ CALCANEUS FRZN LEN 19.5-38CM,SUP-2419467,CDM,C1762,CPT,0278,RC,,,,both,,,6226.24,4047.06,,,,,,,,,,,,,
PLATE BNE L121MM 10 H BILAT S STL CNTOUR 2 COMPR FOR 3.5MM,SUP-2411350,CDM,C1713,HCPCS,0278,RC,,,,both,,,413.98,269.09,,,,,,,,,,,,,
GRAFT BONE RADLUC DEMIN CORT STRL 30MMX30MM L OSTEOWRAP,SUP-2125429,CDM,C1713,HCPCS,0278,RC,,,,both,,,3736.60,2428.79,,,,,,,,,,,,,
CATHETER EMB FOGARTY L 80 CM DIA 4 FR DIA 9 MM FLAT PK RED,SUP-2214589,CDM,C1757,HCPCS,0272,RC,,,,both,,,160.45,104.29,,,,,,,,,,,,,
COIL VASC I-ED COIL PRIMARY L 20 CM DIA 0.010 IN SECONDARY,SUP-2865283,CDM,C1889,HCPCS,0278,RC,,,,both,,,6091.60,3959.54,,,,,,,,,,,,,
WASHER ORTH DIA 7 MM FOR CANN SCREW SYS NS LEOS,SUP-2933760,CDM,C1713,HCPCS,0278,RC,,,,both,,,342.73,222.77,,,,,,,,,,,,,
PLATE BNE L83MM 5 H ST R DST LAT FIBULAR VAR ANG LOK FOR,SUP-2349839,CDM,C1713,HCPCS,0278,RC,,,,both,,,5817.48,3781.36,,,,,,,,,,,,,
GUIDEWIRE URO L260CM DIA0.018IN STR TIP STD DISP NAVIPRO,SUP-2141536,CDM,C1769,HCPCS,0272,RC,,,,both,,,305.58,198.63,,,,,,,,,,,,,
TECHNETIUM 99M DTPA,RX-40840098,CDM,A9539,HCPCS,0343,RC,09999-9918-72,NDC,,both,1,UN,75.00,48.75,,,,,,,,,,,,,
MESH SYNTH INGUINAL N ABSRB TITANIZED POLYPR LT 30CM LEN,SUP-2402532,CDM,C1781,HCPCS,0278,RC,,,,both,,,3532.50,2296.12,,,,,,,,,,,,,
COMPONENT PAT DIA37MM KNEE SEMICONSTRAINED REGENEREX,SUP-2405418,CDM,C1776,CPT,0278,RC,,,,both,,,7504.60,4877.99,,,,,,,,,,,,,
PLATE BONE L130MM THK4.5MM 5 H LT LAT TIB HD BTTRS TI RIG,SUP-2190894,CDM,C1713,HCPCS,0278,RC,,,,both,,,2506.88,1629.47,,,,,,,,,,,,,
STAPLER INT CARTRIDGE EXTRA THICK 60 MM TRI-STAPLE BLK GIA,SUP-2787696,CDM,2720000010,LOCAL,0272,RC,,,,both,,,812.19,527.92,,,,,,,,,,,,,
KIT STRT TBNG L 7 FT AD HNDHLD SM VOL ERGO VLV MOUTHPIECE T,SUP-2881892,CDM,2720000010,LOCAL,0272,RC,,,,both,,,200.77,130.50,,,,,,,,,,,,,
STEM RAD DIA9.5MM UNIV CO CHROM STR PRSS FIT DISP EVOLVE,SUP-2397992,CDM,C1776,CPT,0278,RC,,,,both,,,5212.40,3388.06,,,,,,,,,,,,,
BASEPLATE TIB 26 DEG D+ RL/LM KNEE WDG MILLER-GALANTE II,SUP-2199627,CDM,C1776,CPT,0278,RC,,,,both,,,15659.81,10178.88,,,,,,,,,,,,,
PROSTHESIS OSS VENT TUBE 1.02X0.040X1 MM ROCK EAR FLROPLAS,SUP-2312783,CDM,L8699,HCPCS,0278,RC,,,,both,,,56.52,36.74,,,,,,,,,,,,,
RING EXT FIX HALF 130 MM CARBON FIBER RINGFIX,SUP-2365276,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3080.34,2002.22,,,,,,,,,,,,,
KIT IMPL SYS PROX TENODESIS W/ BICEPSBUTTON INSRT FIBERLOOP,SUP-2121681,CDM,C1776,CPT,0278,RC,,,,both,,,2119.50,1377.67,,,,,,,,,,,,,
NEEDLE VENTRICULAR TOUHY 14 GAX3.5 IN NS,SUP-2666370,CDM,2720000010,LOCAL,0272,RC,,,,both,,,933.77,606.95,,,,,,,,,,,,,
KIT OTOLOGICAL INSTR BKUP INCLUDE CANN WNING DRL DISP FOR,SUP-2319922,CDM,C1713,HCPCS,0278,RC,,,,both,,,787.36,511.78,,,,,,,,,,,,,
GRAFT VASC LIFESPAN L 80 CM DIA 8 MM EPTFE STR TW STRL,SUP-2264308,CDM,C1768,CPT,0278,RC,,,,both,,,2113.28,1373.63,,,,,,,,,,,,,
SPLINT THMB UNIV NEOPRENE PERF W DORS RAD PALMAR STAY PKT,SUP-2196849,CDM,L3923,HCPCS,0274,RC,,,,both,,,30.14,19.59,,,,,,,,,,,,,
SET GUID SYS OSTEOTMY ACCU CUT 2 STG PASA DMAA,SUP-2137807,CDM,C1713,HCPCS,0278,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
SYSTEM SUC IRR SINONASAL 2 ACT SINGLE HND DESIGN RESHAPEABLE,SUP-2900106,CDM,2720000010,LOCAL,0272,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
IMPLANT NSL SHT LG 40X9X1.1 MM POLYETH MEDPOR LF,SUP-2431316,CDM,C1889,HCPCS,0278,RC,,,,both,,,649.32,422.06,,,,,,,,,,,,,
SCREW BNE L16MM OD2.3MM TI CORT ST FULL THRD STD NONLOCKING,SUP-2372648,CDM,C1713,HCPCS,0278,RC,,,,both,,,547.15,355.65,,,,,,,,,,,,,
GRAFT BIO L8CM W8CM THK1MM MESH BOV MTRX WND TISS N PERF,SUP-2364670,CDM,C9359,HCPCS,0278,RC,,,,both,,,7174.90,4663.68,,,,,,,,,,,,,
SCREW BNE PART THRD SM 4.3X65 MM STRL PROPELLER HD LTX,SUP-2861172,CDM,C1713,HCPCS,0278,RC,,,,both,,,873.23,567.60,,,,,,,,,,,,,
TUBE VNTLTN RUBE 1.27MM ID LUMEN 1MM DIA INNER FLNGE DSTNCE,SUP-2492679,CDM,L8699,HCPCS,0278,RC,,,,both,,,50.74,32.98,,,,,,,,,,,,,
HC So Microsomal Ab Ea,PX-3058637668,CDM,86376,CPT,0305,RC,,,,both,,,32.00,20.80,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 80 CM DIA 6MM STR TW REMOVABLE RNG,SUP-2396298,CDM,C1768,CPT,0278,RC,,,,both,,,4904.68,3188.04,,,,,,,,,,,,,
WIRE PACE MYO/WIRE L 61 CM SZ 2-0 NDL L 89 MM SS TEMP WHT,SUP-2116191,CDM,C1786,HCPCS,0275,RC,,,,both,,,32.59,21.18,,,,,,,,,,,,,
CUTTER ENDOSCP L 220 CM DIA2.6 MM CHANNEL DIA2.8 MM BPLR,SUP-2881890,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1535.46,998.05,,,,,,,,,,,,,
HC Creatinine Clearance,PX-3018257500,CDM,82575,CPT,0301,RC,,,,inpatient,,,265.00,172.25,,,,,,,,,,,,,
CATHETER HD MAXIMAL BARR TY 035 12 FRX20 CM DRY TURBO-FLO HD,SUP-2759847,CDM,C1752,HCPCS,0278,RC,,,,both,,,475.62,309.15,,,,,,,,,,,,,
BLADE ARTHSCP SHV L180MM DIA4MM LNG ANG HIP CUT TOMCAT FRMLA,SUP-2362529,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1165.07,757.30,,,,,,,,,,,,,
SLING GYN L33CM CONTINENCE PP SUT SLNG TRANSURETHRAL M,SUP-2140328,CDM,C1713,HCPCS,0278,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
HC Creatinine Clearance,PX-3018257500,CDM,82575,CPT,0301,RC,,,,outpatient,,,265.00,172.25,,,,,,,,,,,,,
DEFIBRILLATOR IMPL VISIA AF MRI VR SURESCAN W 51 X H 66 MM D,SUP-2282424,CDM,C1722,HCPCS,0275,RC,,,,both,,,36743.59,23883.33,,,,,,,,,,,,,
SEALER TISS L14CM ADV BPLR STR RND TIP OPN APPRCH ENSEAL,SUP-2257688,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5743.00,3732.95,,,,,,,,,,,,,
SCREW BNE L9MM DIA13MM G CORT TI ALLY ST SELF RET W T4,SUP-2180964,CDM,C1713,HCPCS,0278,RC,,,,both,,,137.91,89.64,,,,,,,,,,,,,
COLLAR CERV SM PED W25XL14IN FOAM M DENS BRTH COT STOCK LNR,SUP-2194384,CDM,L0120,HCPCS,0274,RC,,,,both,,,21.98,14.29,,,,,,,,,,,,,
RING EXT FIX FULL 140 MM TI NS,SUP-2800050,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2541.11,1651.72,,,,,,,,,,,,,
ALLOGRAFT HUM TISS STRUT 35X15 MM FRZN WHL PATELLAR TEND,SUP-2866893,CDM,C1762,CPT,0278,RC,,,,both,,,9312.93,6053.40,,,,,,,,,,,,,
PIN 45MM FLAT HD FIX,SUP-2400113,CDM,C1713,HCPCS,0278,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
BUR SURG FN DIAMOND LNG 1 MM 10 CM BALL MIDAS REX 8 LEGEND,SUP-2664471,CDM,2720000010,LOCAL,0272,RC,,,,both,,,490.59,318.88,,,,,,,,,,,,,
HC Gases Blood Ph Direct Meas Xcpt Pulse Oximitry,PX-3018280500,CDM,82805,CPT,0301,RC,,,,both,,,323.00,209.95,,,,,,,,,,,,,
GRAFT BONE POSTEROLATERAL 2.5CMX10CM MAGNIFUSE,SUP-2293966,CDM,C1713,HCPCS,0278,RC,,,,both,,,14230.48,9249.81,,,,,,,,,,,,,
GRAFT DERMAL MESH 7X10 CM FEN + WND MTRX MIRODERM,SUP-2431542,CDM,Q4175,HCPCS,0636,RC,,,,both,,,15386.00,10000.90,,,,,,,,,,,,,
PLATE BNE L131MM 9 H ST R DST LAT FIBULAR VAR ANG LOK FOR,SUP-2349841,CDM,C1713,HCPCS,0278,RC,,,,both,,,6487.55,4216.91,,,,,,,,,,,,,
BLADE RTRCTR MCCLLCH 5CMD STNLSS STEEL SPNL MSCLE WIDE ULTRA,SUP-2491576,CDM,2720000010,LOCAL,0272,RC,,,,both,,,360.35,234.23,,,,,,,,,,,,,
PLATE BNE SM L131MM 2X2X2 H L MT TI POLYAX LOK COMPR LO,SUP-2398504,CDM,C1713,HCPCS,0278,RC,,,,both,,,5890.64,3828.92,,,,,,,,,,,,,
NEEDLE TRANSSEPTAL 50 DEG 18 GAX89 CM STD CRV LCK STYL TSX,SUP-2424684,CDM,C1713,HCPCS,0278,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
PLATE BNE 5 DEG 18 MM RT DYNAFORCE MOTOBAND CP,SUP-2431506,CDM,C1713,HCPCS,0278,RC,,,,both,,,7022.61,4564.70,,,,,,,,,,,,,
HC Remove Retrievable Filter,PX-3613719300,CDM,37193,CPT,0361,RC,,,,both,,,8583.00,5578.95,,,,,,,,,,,,,
KIT VLV SZR SZ 19/21/23/25/27/29 MM AORT COMMON L/R N,SUP-2895323,CDM,2720000010,LOCAL,0272,RC,,,,both,,,9363.48,6086.26,,,,,,,,,,,,,
SAPHENOUS VEIN 39CM,SUP-2931207,CDM,C1762,CPT,0278,RC,,,,both,,,23255.06,15115.79,,,,,,,,,,,,,
BIT DRL 2 .7X215MM STRL DISP,SUP-2152617,CDM,2720000010,LOCAL,0272,RC,,,,both,,,448.39,291.45,,,,,,,,,,,,,
PROSTHESIS TOT OSS OFFSET HD PLASTIPORE 4MM DIA .8MM SHFT,SUP-2312531,CDM,L8613,CPT,0278,RC,,,,both,,,655.07,425.80,,,,,,,,,,,,,
STENT BILI COT-LNG L 17 CM DIA11.5 FR GUIDEWIRE 0.035 IN PUR,SUP-2169361,CDM,C2617,HCPCS,0278,RC,,,,both,,,182.12,118.38,,,,,,,,,,,,,
GUIDEWIRE VASC 300 CM STINGRAY,SUP-2466233,CDM,C1769,HCPCS,0272,RC,,,,both,,,1541.74,1002.13,,,,,,,,,,,,,
GUIDEWIRE VASC L50CM OD0035IN S STL PTFE HEP FIX COR AD,SUP-2167662,CDM,C1769,HCPCS,0272,RC,,,,both,,,30.77,20.00,,,,,,,,,,,,,
ANCHOR SUT SZ 2 DIA3.5MM BNE ABSRB DBL ARMED CP-2 NDL,SUP-2249330,CDM,C1713,HCPCS,0278,RC,,,,both,,,1331.36,865.38,,,,,,,,,,,,,
PLATE BNE 130DEG 4 H S STL HIP LOK BILAT COMPR RIG SHT BRL,SUP-2370860,CDM,C1713,HCPCS,0278,RC,,,,both,,,1874.89,1218.68,,,,,,,,,,,,,
SCREW SPNL L 85 MM DIA10.5 MM TI PEDCL THORLUM POLYAXL CANN,SUP-2885872,CDM,C1713,HCPCS,0278,RC,,,,both,,,1529.18,993.97,,,,,,,,,,,,,
GUIDEWIRE UROLOGICAL ANGLED 3 CM 0.038 INX150 CM NIT SENSOR,SUP-2139366,CDM,C1769,HCPCS,0272,RC,,,,both,,,147.05,95.58,,,,,,,,,,,,,
PLATE BONE L56MM LNG NONSTERILE LT ANTEROLATERAL CALCNL S,SUP-2178430,CDM,C1713,HCPCS,0278,RC,,,,both,,,2907.83,1890.09,,,,,,,,,,,,,
BUR SURG L 54.5 MM HD L 4 MM DIA 4 MM 24 FLUT RND POL STRL,SUP-2898832,CDM,2720000010,LOCAL,0272,RC,,,,both,,,150.12,97.58,,,,,,,,,,,,,
ALLOGRAFT BNE SPACER 10/11X30X12 MM FRZN T-PLIF LUMINARY,SUP-2736969,CDM,C1713,HCPCS,0278,RC,,,,both,,,14737.09,9579.11,,,,,,,,,,,,,
HC X-Ray Xm Esophagus Double Cntrst,PX-3207422100,CDM,74221,CPT,0320,RC,,,,both,,,1077.00,700.05,,,,,,,,,,,,,
DRILL SURG HND XCALIBER,SUP-2645908,CDM,2720000010,LOCAL,0272,RC,,,,both,,,993.87,646.02,,,,,,,,,,,,,
COMPONENT FEM CR CEM SYMMETRICAL SZ 0,SUP-2222521,CDM,C1776,CPT,0278,RC,,,,both,,,9219.04,5992.38,,,,,,,,,,,,,
PLATE BNE MESHED 106X31X1 MM SM GRID PLLA-PGA STRL RESORB XG,SUP-2476058,CDM,C1713,HCPCS,0278,RC,,,,both,,,5497.26,3573.22,,,,,,,,,,,,,
CEFTAROLINE FOSAMIL 600 MG IV SOLR,RX-106958,CDM,J0712,HCPCS,0636,RC,00456-0600-01,NDC,,both,1,UN,1342.80,872.82,,,,,,,,,,,,,
CATHETER IV 18 GAX10 CM FULL TY W/O GUARDIVA POWERGLIDE ST,SUP-2424483,CDM,C1751,HCPCS,0278,RC,,,,both,,,398.78,259.21,,,,,,,,,,,,,
NEEDLE BIOPSY 4 12INL GEARBOX CORB LATEX FREE STERILE,SUP-2720333,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7317.08,4756.10,,,,,,,,,,,,,
ANCHOR SUT DIA5.5MM BIOCRYL RAPIDE ABSRB 3 PERMACORD SZ 2,SUP-2256703,CDM,C1713,HCPCS,0278,RC,,,,both,,,1629.66,1059.28,,,,,,,,,,,,,
CATHETER IRRIGATION 4 FRX65 CM CLINICATH,SUP-2352473,CDM,C1751,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
PLATE BNE 6 H CRANIOMAXILLOFACIAL TI H SHP FOR 1MM SCR,SUP-2190616,CDM,C1713,HCPCS,0278,RC,,,,both,,,951.73,618.62,,,,,,,,,,,,,
CATHETER ENDOSCP 180 DEG SPIN ACCS INS5925,SUP-2797902,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3391.20,2204.28,,,,,,,,,,,,,
GUIDEWIRE ORTHOPEDIC THRD PEDICULAR FIX SYS THRESHOLD,SUP-2354644,CDM,C1769,HCPCS,0272,RC,,,,both,,,204.10,132.66,,,,,,,,,,,,,
CATHETER HD LT 15.5 FRX19 CM STR STD KT SYMETREX,SUP-2269555,CDM,C1881,HCPCS,0278,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
PLATE BONE W9XL43MM AUG 11MM CO CHROM RIG FOR MAESTRO TOT WR,SUP-2407333,CDM,C1776,CPT,0278,RC,,,,both,,,19615.58,12750.13,,,,,,,,,,,,,
DEVICE PESSARY DIA1.75IN SIL FLEX GELLHORN SH STEM FOR 3RD,SUP-2171824,CDM,A4562,HCPCS,0274,RC,,,,both,,,179.07,116.40,,,,,,,,,,,,,
HC Venous Sampling Through Cath,PX-3207589300,CDM,75893,CPT,0320,RC,,,,both,,,7130.00,4634.50,,,,,,,,,,,,,
CATHETER INTVASC OCCL ASCNT L 150 CM 2.9 FR 0.0170 IN 7 MM,SUP-2458036,CDM,C2628,HCPCS,0272,RC,,,,both,,,6208.72,4035.67,,,,,,,,,,,,,
GRAFT VASC GELWEAVE L 60 CM DIA 6 MM POLYESTER GEL,SUP-2385051,CDM,C1768,CPT,0278,RC,,,,both,,,1193.04,775.48,,,,,,,,,,,,,
GLOFITAMAB-GXBM 10 MG/10ML IV SOLN,RX-163982,CDM,J9286,HCPCS,0636,RC,50242-0127-01,NDC,,both,10,ML,31223.10,20295.01,,,,,,,,,,,,,
SPLINT ANK WOM SHOE SZ 7-9 IN MED POLYPRO PLAS RT FT,SUP-2930193,CDM,L1930,HCPCS,0274,RC,,,,both,,,251.70,163.60,,,,,,,,,,,,,
RHS SHORT RADIAMETERL STEM DIAMETER 8MM NECK 16MM,SUP-2822290,CDM,C1776,CPT,0278,RC,,,,both,,,8939.58,5810.73,,,,,,,,,,,,,
STENT URET DBL PGTL 7 FRX24 CM UNCOATED CLASSIC OPN END NYL,SUP-2312735,CDM,C2617,HCPCS,0278,RC,,,,both,,,166.70,108.35,,,,,,,,,,,,,
PLATE BNE W12XL142MM THK3.7MM LNG 5 H ST PROX HUM S STL LOK,SUP-2186016,CDM,C1713,HCPCS,0278,RC,,,,both,,,4518.33,2936.91,,,,,,,,,,,,,
KIT INSTR GUID FLX DRL BIT OBT FOR 2.9MM SFT SUT ANCHR,SUP-2212956,CDM,C1713,HCPCS,0278,RC,,,,both,,,1205.76,783.74,,,,,,,,,,,,,
HC So Dpyd Gene Common Variants,PX-3108123266,CDM,81232,CPT,0310,RC,,,,both,,,443.00,287.95,,,,,,,,,,,,,
SPHERE EMB PREFIL SYR ACRYL GEL 900-1200 MIC 1ML 20ML SYR N,SUP-2303390,CDM,C1889,HCPCS,0278,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
PAD ORTHOT ANTR CUST ASIS,SUP-2435588,CDM,L1250,HCPCS,0274,RC,,,,both,,,223.91,145.54,,,,,,,,,,,,,
COMPONENT CRPL XS WRST POLYETH UNIV 2,SUP-2610318,CDM,C1776,CPT,0278,RC,,,,both,,,11733.02,7626.46,,,,,,,,,,,,,
GRAFT BNE SUB 80CC 1 4MM CANC CRUSH CHIP READIGRFT,SUP-2264827,CDM,C1713,HCPCS,0278,RC,,,,both,,,2988.56,1942.56,,,,,,,,,,,,,
CATHETER URET OD6FR 2MM OPN END AXXCESS,SUP-2139306,CDM,C1758,HCPCS,0278,RC,,,,both,,,31.68,20.59,,,,,,,,,,,,,
PLATE SPNL ANTR CERV 30 MM 2 LEVEL LORDTC VAN GOGH,SUP-2661655,CDM,C1713,HCPCS,0278,RC,,,,both,,,2521.42,1638.92,,,,,,,,,,,,,
PLATE BNE STR 2.5 MM LCK STRL,SUP-2525142,CDM,C1713,HCPCS,0278,RC,,,,both,,,1880.86,1222.56,,,,,,,,,,,,,
HC Blood Culture Multiplex Pcr 2|NOT REASONABLE AND NECESSARY,PX-3008715400,CDM,87154,CPT,0300,RC,,,GZ,outpatient,,,524.00,340.60,,,,,,,,,,,,,
HC Needle Insertion W/O Injection 1 or 2 Muscles,PX-4202056000,CDM,20560,CPT,0420,RC,,,,inpatient,,,42.00,27.30,,,,,,,,,,,,,
ELECTRODE ELECSURG 24FR LOOP WNG VAPORTRODE,SUP-2332858,CDM,C1713,HCPCS,0278,RC,,,,both,,,395.64,257.17,,,,,,,,,,,,,
BLADE SURG 70 MM POST MARS 3V,SUP-2599079,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1212.04,787.83,,,,,,,,,,,,,
SET URET STENT C FLX L 8 CM CATH L 70 CM DIA 3.7 FR,SUP-2171247,CDM,C2617,HCPCS,0278,RC,,,,both,,,632.71,411.26,,,,,,,,,,,,,
PLATE BNE W10XL77MM THK3.3MM HK D18MM 8 H L CLAV S STL LOK,SUP-2185837,CDM,C1713,HCPCS,0278,RC,,,,both,,,2266.83,1473.44,,,,,,,,,,,,,
SPACER SPNL INTBDY ANTR LUM LTX FRE,SUP-2101158,CDM,C1821,HCPCS,0278,RC,,,,both,,,19468.00,12654.20,,,,,,,,,,,,,
SCREW BNE L55MM DIA6MM CORT TI ST CANN LOK FULL THRD HEX HD,SUP-2191838,CDM,C1713,HCPCS,0278,RC,,,,both,,,708.35,460.43,,,,,,,,,,,,,
SPLINT REST HND ADL R S DRBLUE BROAD,SUP-2165487,CDM,L3807,HCPCS,0274,RC,,,,both,,,123.25,80.11,,,,,,,,,,,,,
PLATE BNE L LNG LT 6 HOLE W/ INTERMED SPACE STRL RESORB X,SUP-2478805,CDM,C1713,HCPCS,0278,RC,,,,both,,,680.69,442.45,,,,,,,,,,,,,
MATRIX BIO L 6 X W 14 CM SZ 84 SQCM FISH SKIN SIL DERMAL FEN,SUP-2909237,CDM,Q4158,HCPCS,0636,RC,,,,both,,,9784.24,6359.76,,,,,,,,,,,,,
PLATE BNE W5XL27MM THK1MM 5 H BILAT TI STR RIG NEUT DYN,SUP-2191042,CDM,C1713,HCPCS,0278,RC,,,,both,,,733.10,476.51,,,,,,,,,,,,,
GRAFT SKIN WXL65CM HUM AMNION CHORION MEM MULTILAYER DEHYDR,SUP-2305756,CDM,Q4186,HCPCS,0636,RC,,,,both,,,19549.64,12707.27,,,,,,,,,,,,,
SHUNT SURG ADJ L 17 MM GRAVITATIONAL L 12 MM PRESSURE ADJ FX662T,SUP-2928843,CDM,C1889,HCPCS,0278,RC,,,,both,,,15369.04,9989.88,,,,,,,,,,,,,
KIT NEUROSTIMULATOR L 45 CM DIA1.35 MM PERIPH PERM 8 CONTACT 1 CHAN,SUP-2925125,CDM,C1816,LOCAL,0278,RC,,,,both,,,59660.00,38779.00,,,,,,,,,,,,,
CATHETER ANGIOPLSTY SAVVY L 120 CM BALLOON L 40 MM DIA 3 MM,SUP-2156574,CDM,C1725,HCPCS,0272,RC,,,,both,,,1073.88,698.02,,,,,,,,,,,,,
SET INTRO MICROPUNCTURE CATH L 10 CM 5 FR L 7 CM SS PLAT,SUP-2170535,CDM,C1894,HCPCS,0272,RC,,,,both,,,77.50,50.37,,,,,,,,,,,,,
HC Pt Gait Training Ea 15 Min,PX-4209711600,CDM,97116,CPT,0420,RC,,,,both,,,164.00,106.60,,,,,,,,,,,,,
GRAFT HUM TISS SM PERF M REGENERATIVE TISS MTRX CNTOUR,SUP-2113443,CDM,Q4116,HCPCS,0636,RC,,,,both,,,18742.66,12182.73,,,,,,,,,,,,,
PLATE BONE L204MM 12 H S STL BROAD SELF COMPR,SUP-2198610,CDM,C1713,HCPCS,0278,RC,,,,both,,,481.36,312.88,,,,,,,,,,,,,
APPLIER CLIP HEM-O-LOK ML ENDO 5,SUP-2747678,CDM,C1889,HCPCS,0278,RC,,,,both,,,3256.18,2116.52,,,,,,,,,,,,,
BIT DRL L130MM DIA3.2MM ST TI JCBS CHK NONRADIOPAQUE W/O,SUP-2187258,CDM,2720000010,LOCAL,0272,RC,,,,both,,,355.20,230.88,,,,,,,,,,,,,
BENAZEPRIL HCL 5 MG PO TABS,RX-9223,CDM,6370000000,HCPCS,0637,RC,43547-0335-10,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
HC Iadna S Aureus Amplified Probe Tq,PX-3068764000,CDM,87640,CPT,0306,RC,,,,both,,,105.00,68.25,,,,,,,,,,,,,
IMPLANT PAT DIA32MM THK10MM X3 ASYM TRIATHLON,SUP-2373615,CDM,C1776,CPT,0278,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
INTRODUCER CARD LD PLCMNT STR 50CM LEN 9FR HEMSTAT VLV COR,SUP-2282360,CDM,C1892,HCPCS,0272,RC,,,,both,,,899.80,584.87,,,,,,,,,,,,,
GRAFT SKIN 5X5 CM ANTIMICROBIAL PURAPLY,SUP-2314118,CDM,Q4195,HCPCS,0636,RC,,,,both,,,8164.00,5306.60,,,,,,,,,,,,,
CABLE SPNL FLANGE W/ CRMP SS SONGER,SUP-2713123,CDM,C1713,HCPCS,0278,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
HC Sel Cath Abd/Pelvc/Le Init 2nd,PX-3613624600,CDM,36246,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
COUNTERSINK DRL DIA6MM SLD FOR ANK FRAC SYS ORTHOLOC 3DI,SUP-2398335,CDM,2720000010,LOCAL,0272,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
COLLAR CERV M DENS AD CNTOUR CNTCT CLSR FOAM W/ STOCK SERP,SUP-2210884,CDM,L0120,HCPCS,0274,RC,,,,both,,,44.90,29.18,,,,,,,,,,,,,
GUIDEWIRE VASC GLIDEWIRE L 260 CM DIA 0.035 IN TIP L 5 CM,SUP-2385592,CDM,C1769,HCPCS,0272,RC,,,,both,,,176.78,114.91,,,,,,,,,,,,,
FLUOCINOLONE ACETONIDE 0.01 % EX SOLN,RX-3186,CDM,6370000000,HCPCS,0637,RC,00168-0059-60,NDC,,both,60,ML,150.40,97.76,,,,,,,,,,,,,
SCREW INTRF L30MM DIA6-8MM TIB PEEK TAPR INTRAFIX,SUP-2256820,CDM,C1713,HCPCS,0278,RC,,,,both,,,850.94,553.11,,,,,,,,,,,,,
SCREW BNE L95MM DIA6.5MM THRD L20MM S STL CORT CANN LAG,SUP-2342481,CDM,C1713,HCPCS,0278,RC,,,,both,,,1842.71,1197.76,,,,,,,,,,,,,
MESH SURG 9CM OMEGA 3 FATTY ACID POLYPR SEE THRU CLARITY,SUP-2265959,CDM,C1781,HCPCS,0278,RC,,,,both,,,888.40,577.46,,,,,,,,,,,,,
CATHETER DIL L40MM DIA10MM HI PRSS NONCOMPLIANT INTEGR STYL,SUP-2106330,CDM,C1726,HCPCS,0272,RC,,,,both,,,3428.88,2228.77,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.519,SUP-2860036,CDM,C1713,HCPCS,0278,RC,,,,both,,,35943.89,23363.53,,,,,,,,,,,,,
PUMP PAIN PROGRAMMABLE FOR PRE MRI PROC FLOWONIX PROMETRA II,SUP-2225540,CDM,E0783,HCPCS,0278,RC,,,,both,,,31714.00,20614.10,,,,,,,,,,,,,
PLATE BNE L 45 MM SCREW DIA2 MM 3 HD 6 SHFT H TI T SHP MINI,SUP-2907575,CDM,C1713,HCPCS,0278,RC,,,,both,,,2830.46,1839.80,,,,,,,,,,,,,
IMPLANT BIO TISS W19XL35CM REGEN PORCINE CLLGN RECT,SUP-2125849,CDM,C1781,HCPCS,0278,RC,,,,both,,,44745.00,29084.25,,,,,,,,,,,,,
PROBE LITHOTROPIC ELECTRD 9 FR,SUP-2332789,CDM,2720000010,LOCAL,0272,RC,,,,both,,,595.34,386.97,,,,,,,,,,,,,
GRAFT HUM TISS CHORION FREE THN 8X4 CM AMNIO ACTISHIELD CF,SUP-2759543,CDM,C1762,CPT,0278,RC,,,,both,,,10085.68,6555.69,,,,,,,,,,,,,
STYLET LD STR EXT TAPR BALL TIP PUR KNOB 55CM OD.016IN,SUP-2282080,CDM,C1887,HCPCS,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
PLATE BNE L105MM 5 H ST L DST LAT FIBULAR S STL VAR ANG LOK,SUP-2177720,CDM,C1713,HCPCS,0278,RC,,,,both,,,2653.87,1725.02,,,,,,,,,,,,,
SHEATH GUID R2P DESTINATION SLENDER L 154CM L149CM 6FR 2.5MM,SUP-2540721,CDM,C1894,HCPCS,0272,RC,,,,both,,,1003.23,652.10,,,,,,,,,,,,,
"HC So1 Antibody Virus, Nos",PX-3028679067,CDM,86790,CPT,0302,RC,,,,inpatient,,,473.00,307.45,,,,,,,,,,,,,
INTRODUCER HEMSTAS 7FRX85CM SHTH 7CM J CRV .038IN GWIRE FAST,SUP-2355585,CDM,C1894,HCPCS,0272,RC,,,,both,,,167.21,108.69,,,,,,,,,,,,,
PLATE BNE L H1MM REG MINI 4 H R CRANIOMAXILLOFACIAL FOR 2MM,SUP-2366317,CDM,C1713,HCPCS,0278,RC,,,,both,,,605.20,393.38,,,,,,,,,,,,,
CLAMP SPNL FOR 5.5/6.5MM ROD TO ROD REVERE ADDITION,SUP-2230106,CDM,C1713,HCPCS,0278,RC,,,,both,,,1036.20,673.53,,,,,,,,,,,,,
ANCHOR SUT PEEK KNOTLESS RADLUC OPUS SPEEDLOCK,SUP-2342086,CDM,C1713,HCPCS,0278,RC,,,,both,,,1651.01,1073.16,,,,,,,,,,,,,
ROD EXT FIX L850MM DIA11MM 180DEG UNIV C FBR SEMI CIR CRV,SUP-2188641,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2019.62,1312.75,,,,,,,,,,,,,
SHIM SPNL INTDISC NAR LIF-PTP,SUP-2736562,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
CROWN DENT LR1 1ST PRI M INDIV SPACE MAINTAINER,SUP-2176679,CDM,D6783,CPT,0278,RC,,,,both,,,22.61,14.70,,,,,,,,,,,,,
CATHETER CV STD SET 035 7.5 FRX15 CM DL J TIP POLYETH,SUP-2760165,CDM,C1751,HCPCS,0278,RC,,,,both,,,261.44,169.94,,,,,,,,,,,,,
SPACER UROLOGICAL PEG HYDROGEL PERIRECTAL TEMPORARY RADIOTHERAPY SPACEOAR VUE,SUP-2902926,CDM,C1889,HCPCS,0278,RC,,,,both,,,9420.00,6123.00,,,,,,,,,,,,,
STENT ES L12CM DIA18MM PROX FLARE DIA23MM CVR L9CM DST REL,SUP-2149380,CDM,C1874,HCPCS,0278,RC,,,,both,,,5352.60,3479.19,,,,,,,,,,,,,
LENS INTOCU +0.0-30.0 DIOPT DIA6MM BCNVX ASPHERIC 10DEG A,SUP-2129258,CDM,V2632,HCPCS,0276,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
PLATE BNE ANTR TIBIAXYS,SUP-2609014,CDM,C1713,HCPCS,0278,RC,,,,both,,,6001.14,3900.74,,,,,,,,,,,,,
GRAFT BNE 20MM LEN 8 15MM W IMPL HUM TISS FIB SHFT BNE FRZN,SUP-2264879,CDM,C1713,HCPCS,0278,RC,,,,both,,,3236.46,2103.70,,,,,,,,,,,,,
GUIDEWIRE FIX COR DSGN N STRL W/ J TIP 0.035 INX150CM STD,SUP-2355594,CDM,C1769,HCPCS,0272,RC,,,,both,,,4.40,2.86,,,,,,,,,,,,,
DEFIBRILLATOR IMPL EPIC + DR 30 J TI 2 CHMBR STD LD BPLR,SUP-2357753,CDM,C1721,HCPCS,0275,RC,,,,both,,,50240.00,32656.00,,,,,,,,,,,,,
SCREW BNE TWST OFF 2X10 MM CORTICAL NS,SUP-2435436,CDM,C1713,HCPCS,0278,RC,,,,both,,,819.38,532.60,,,,,,,,,,,,,
GRAFT BNE 0.8 CC PREFILLED PRO OSTEON 200R 2RGS05,SUP-2685766,CDM,C1713,HCPCS,0278,RC,,,,both,,,2263.94,1471.56,,,,,,,,,,,,,
STENT BILI L24MM BLLN L25MM DIA7MM CATH 6FR L80CM 0.018IN,SUP-2159030,CDM,C1876,HCPCS,0278,RC,,,,both,,,3975.24,2583.91,,,,,,,,,,,,,
SEED BRACHYTHERAPY LOAD 7.01-8.0 MCI STRL ADVANTAGE 2029HLS1] ISOAID LLC],SUP-2247278,CDM,C2642,HCPCS,0278,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
PLATE PELVIC CVD 8 HOLE R88,SUP-2464792,CDM,C1713,HCPCS,0278,RC,,,,both,,,1271.70,826.60,,,,,,,,,,,,,
CATHETER CV FULL TY 7 FRX20 CM 3L CUTLMY701JABRMCUSTOM0043,SUP-2759848,CDM,C1751,HCPCS,0278,RC,,,,both,,,444.84,289.15,,,,,,,,,,,,,
PLATE BNE MEDL CLMN SM 2.7/3.5 MM MIDFOOT 6 HOLE COMPR TI,SUP-2398189,CDM,C1713,HCPCS,0278,RC,,,,both,,,4370.88,2841.07,,,,,,,,,,,,,
CATHETER THROMCTMY ANGIOJET XMI RX RHEOLYTIC STRL,SUP-2277421,CDM,C1757,HCPCS,0272,RC,,,,both,,,4380.30,2847.19,,,,,,,,,,,,,
IMPLANT TOE JT L21.5MM PROF HD DIA2.4MM METATARSOPHALANGEAL,SUP-2123309,CDM,C1776,CPT,0278,RC,,,,both,,,2182.30,1418.49,,,,,,,,,,,,,
PACK NEUROSURGICAL SHTH L 60 X W 13.5 MM MYRIAD HNDPC L 13 NN-2004,SUP-2930267,CDM,2720000010,LOCAL,0272,RC,,,,both,,,17898.00,11633.70,,,,,,,,,,,,,
NEEDLE BRST LOC BLNT 20 GAX7.5 CM STRL HAWKINS II LTX,SUP-2876178,CDM,C1819,HCPCS,0278,RC,,,,both,,,171.76,111.64,,,,,,,,,,,,,
KIT PHLEBECTOMY BLDE L4.5MM W/ TBNG TRANSILLUMINATED PWR,SUP-2264270,CDM,C1713,HCPCS,0278,RC,,,,both,,,626.96,407.52,,,,,,,,,,,,,
PLATE BNE X 1.5X1 MM 12 MM C-TUBE BRIDGE TI NS LEVEL 1,SUP-2464188,CDM,C1713,HCPCS,0278,RC,,,,both,,,625.99,406.89,,,,,,,,,,,,,
SPACER SPNL 3 MM OFFSET,SUP-2569441,CDM,C1821,HCPCS,0278,RC,,,,both,,,77.72,50.52,,,,,,,,,,,,,
"HC So Morph Analysis,Tumor,Ea Ab",PX-3128836066,CDM,88360,CPT,0312,RC,,,,both,,,431.00,280.15,,,,,,,,,,,,,
PLATE BNE L254MM THK4MM 9 H 10 GRV STD S STL BILAT COMPR,SUP-2371522,CDM,C1713,HCPCS,0278,RC,,,,both,,,1240.93,806.60,,,,,,,,,,,,,
PLATE BONE RECONSTRUCTION MEDIUM 2.5 MM DOUBLE ANGLE TITANIU,SUP-2837761,CDM,C1713,HCPCS,0278,RC,,,,both,,,9563.50,6216.27,,,,,,,,,,,,,
GABAPENTIN 400 MG PO CAPS,RX-18307,CDM,6370000000,HCPCS,0637,RC,60687-0602-11,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PIN EXT FIX L 30 MM DIA 6 MM HA HALF STRL DISP,SUP-2932756,CDM,2720000010,LOCAL,0272,RC,,,,both,,,651.52,423.49,,,,,,,,,,,,,
ORTHOSIS ANK FT SM SZ M 6-7.5 WOM 7.5-9 RT CLOSE HEEL DLX,SUP-2195190,CDM,L1930,HCPCS,0274,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
COMPONENT CRPL SM 1+ MM WRST POLYETH UNIV 2 262301,SUP-2610327,CDM,C1776,CPT,0278,RC,,,,both,,,3528.79,2293.71,,,,,,,,,,,,,
IMPL TOE JT 0 DEG XS CANN STR STRL PHALINX,SUP-2900773,CDM,C1713,HCPCS,0278,RC,,,,both,,,5099.36,3314.58,,,,,,,,,,,,,
PIN BNE FIX DIA 5 MM REDUCTION CANC THRD NS VARIAX,SUP-2900539,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1627.78,1058.06,,,,,,,,,,,,,
COIL NEUROVASCULAR TARGET 360 DEG L 6 CM DIA 3 MM STD,SUP-2367994,CDM,C1889,HCPCS,0278,RC,,,,both,,,5888.44,3827.49,,,,,,,,,,,,,
HC US Guidance for Needle Place - Anes Block,PX-4027694201,CDM,76942,CPT,0402,RC,,,,both,,,978.00,635.70,,,,,,,,,,,,,
TUBE ET 5MM ORAL LSR RESIST 2 CUF MURPHY EYE NONFLAMMABLE S,SUP-2283782,CDM,2720000010,LOCAL,0272,RC,,,,both,,,129.62,84.25,,,,,,,,,,,,,
NUT SPNL W11MM TI 12 PNT,SUP-2193680,CDM,C1713,HCPCS,0278,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
DISSECTOR ULTRASONIC L26CM CRDLSS W/ TORQ WRNCH SONICISION,SUP-2283579,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
SCREW KNEE ARTHROPLASTY TI STRL 22MML GEN UNI,SUP-2349781,CDM,C1713,HCPCS,0278,RC,,,,both,,,773.54,502.80,,,,,,,,,,,,,
NAIL IM L440MM DIA2MM 85DEG ST GRN FEM TI CANN NONLOCKING,SUP-2192726,CDM,C1713,HCPCS,0278,RC,,,,both,,,836.18,543.52,,,,,,,,,,,,,
SET INTRO S-MAK L 10 CM DIA 5 FR L 40 CM SS COR PLAT TIP,SUP-2303439,CDM,C1893,HCPCS,0272,RC,,,,both,,,116.18,75.52,,,,,,,,,,,,,
ARCOS 9.5X175MM BRCH BODY STD,SUP-2506134,CDM,C1776,CPT,0278,RC,,,,both,,,12107.84,7870.10,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC SOLO2 FT 5FR 55CM 2 LUMAN 1295108F,SUP-2632637,CDM,C1751,HCPCS,0278,RC,,,,both,,,665.59,432.63,,,,,,,,,,,,,
COMPONENT TIBIAL LG W33XL40MM SINGLE COATED US VERSION STAR,SUP-2878521,CDM,C1776,CPT,0278,RC,,,,both,,,18197.24,11828.21,,,,,,,,,,,,,
APPLICATOR HEMOSTATIC CLLGN 2 CMX16.5 CM PRE LD ENDOAVITENE,SUP-2846978,CDM,C1763,HCPCS,0278,RC,,,,both,,,411.97,267.78,,,,,,,,,,,,,
PIN FIX DIA11MM GUID CERCLAGE POS,SUP-2193589,CDM,C1713,HCPCS,0278,RC,,,,both,,,444.88,289.17,,,,,,,,,,,,,
SYSTEM TROCAR SHT SYR PRT BLNT TIP,SUP-2241159,CDM,2720000010,LOCAL,0272,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
BLADE REPROC LARYNSCP GLIDESCOPE SPECTRM DVM SZ 3,SUP-2653266,CDM,2720000010,LOCAL,0272,RC,,,,both,,,89.18,57.97,,,,,,,,,,,,,
SCREW BONE 4MM DIA 60MML TTNM CRTCL HXGNL HEAD PRTLLY THRDD,SUP-2588280,CDM,C1713,HCPCS,0278,RC,,,,both,,,579.58,376.73,,,,,,,,,,,,,
ELECTRODE ELECSURG CUT LOOP LNG 24 FR,SUP-2332863,CDM,C1713,HCPCS,0278,RC,,,,both,,,396.17,257.51,,,,,,,,,,,,,
HC Gastroesophag Reflx Test W/Tel Ph Eltrd,PX-7509103500,CDM,91035,CPT,0750,RC,,,,outpatient,,,1657.00,1077.05,,,,,,,,,,,,,
DEFIBRILLATOR CARD 36ML DF4 IS4 IS1 SENSE PACE CONN RF,SUP-2356319,CDM,C1882,HCPCS,0275,RC,,,,both,,,56520.00,36738.00,,,,,,,,,,,,,
TUNNELER SURG FLUID SHTH 16 GAX8 IN REMOVABLE WNG STRL ON Q,SUP-2424457,CDM,C1713,HCPCS,0278,RC,,,,both,,,172.70,112.25,,,,,,,,,,,,,
DRILL TWST DIA2MM DSTL RAD COLE,SUP-2342947,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2235.62,1453.15,,,,,,,,,,,,,
MATRIX BIO L 10 X W 18 CM SZ 180 SQCM FISH SKIN SIL DERMAL SINGLE,SUP-2909459,CDM,Q4158,HCPCS,0636,RC,,,,both,,,28930.17,18804.61,,,,,,,,,,,,,
IMPLANT SPNL L50MM OD4MM POR TI PLSM SPRAYED SACROILIAC JT,SUP-2337737,CDM,C1713,HCPCS,0278,RC,,,,both,,,10990.00,7143.50,,,,,,,,,,,,,
KIT TKR THK4MM KNEE POLY BUSHING REPL MOST OPTIONS,SUP-2208390,CDM,C1776,CPT,0278,RC,,,,both,,,14525.64,9441.67,,,,,,,,,,,,,
CATHETER ENDO S-30 TIP SINUS GUID RELIEVA FLX,SUP-2106346,CDM,C1729,HCPCS,0272,RC,,,,both,,,232.36,151.03,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED HI DEMAND 2 POROUS STRYKERH2POR] STRYKER CORP],SUP-2365974,CDM,C1776,CPT,0278,RC,,,,both,,,16328.00,10613.20,,,,,,,,,,,,,
PLATE STRNL CLOSURE 4 H TI BX CONVX NS STERNALOCK EZ,SUP-2894456,CDM,C1713,HCPCS,0278,RC,,,,both,,,1827.48,1187.86,,,,,,,,,,,,,
COMPONENT FEM L CO CHROM KNEE NP PRI STEMLESS UNI NONBEADED,SUP-2409238,CDM,C1776,CPT,0278,RC,,,,both,,,3925.00,2551.25,,,,,,,,,,,,,
PLATE SPNL 1 CENTER SCREW 6X15 MM LAT INTBDY FUSION AMP,SUP-2736574,CDM,C1713,HCPCS,0278,RC,,,,both,,,9420.00,6123.00,,,,,,,,,,,,,
INSERT ACET SZ E OD50 52MM ID26MM 0DEG UHMWPE CONSTRN REFLCT,SUP-2344624,CDM,C1776,CPT,0278,RC,,,,both,,,7510.88,4882.07,,,,,,,,,,,,,
SHELL ACET MOLD PRE TIB HIP,SUP-2388179,CDM,L2340,LOCAL,0274,RC,,,,both,,,1420.22,923.14,,,,,,,,,,,,,
BLADE RTRCTR 4MM DIA HEAD MED CRVCL PEAR F/MDS REX ZMMR ULTR,SUP-2461602,CDM,2720000010,LOCAL,0272,RC,,,,both,,,423.87,275.52,,,,,,,,,,,,,
WAND ELECSURG INTEGR CABLE COVAC 70,SUP-2848690,CDM,2720000010,LOCAL,0272,RC,,,,both,,,580.90,377.58,,,,,,,,,,,,,
PLATE BNE IM LT FEM KNEE REV LCS COMPLETE,SUP-2453531,CDM,C1713,HCPCS,0278,RC,,,,both,,,2389.54,1553.20,,,,,,,,,,,,,
STENT VASC L40MM DIA6MM CATH L80CM SHTH 8FR FLR HELI DSGN,SUP-2418862,CDM,C1874,HCPCS,0278,RC,,,,both,,,8148.30,5296.39,,,,,,,,,,,,,
SCREW BNE L18MM DIA2.7MM NONSTERILE CORT S STL ST,SUP-2183157,CDM,C1713,HCPCS,0278,RC,,,,both,,,395.51,257.08,,,,,,,,,,,,,
DRILL TWST SHFT END DISP UNIV CMF 1.15MM TIP DIA 1.5MM SCR,SUP-2364177,CDM,2720000010,LOCAL,0272,RC,,,,both,,,373.66,242.88,,,,,,,,,,,,,
SCREW BNE L165MM DIA7.3MM HD DIA8.2MM NONSTERILE CANC S STL,SUP-2183991,CDM,C1713,HCPCS,0278,RC,,,,both,,,635.10,412.81,,,,,,,,,,,,,
HC So Cyclosporine,PX-3018015866,CDM,80158,CPT,0301,RC,,,,outpatient,,,326.00,211.90,,,,,,,,,,,,,
HC Ther Ivntj Cog Funcj Cntct 1st 15 Mins|OP OCCUPATIONAL THERAPY SERV,PX-4409712900,CDM,97129,CPT,0440,RC,,,GO,outpatient,,,186.00,120.90,,,,,,,,,,,,,
CANNULATED CHISEL FOR ADULT ANGLED BLADE PLATES 320MM,SUP-2548621,CDM,C1713,HCPCS,0278,RC,,,,both,,,2663.94,1731.56,,,,,,,,,,,,,
CABLE CATH ABLATN 5 FT EKG CONN STRL LF,SUP-2867398,CDM,2720000010,LOCAL,0272,RC,,,,both,,,483.56,314.31,,,,,,,,,,,,,
SCREW BNE L12MM DIA3.5MM S STL CORT ST NONCANNULATED,SUP-2348770,CDM,C1713,HCPCS,0278,RC,,,,both,,,153.20,99.58,,,,,,,,,,,,,
PLATE BURR H L 17.52 MM DIA13 MM SCREW DIA1.5 MM TI CRAN NS,SUP-2936867,CDM,C1713,HCPCS,0278,RC,,,,both,,,772.44,502.09,,,,,,,,,,,,,
SCREW HD THRD 5MMX85MM CENTRONAIL,SUP-2316513,CDM,C1713,HCPCS,0278,RC,,,,both,,,853.55,554.81,,,,,,,,,,,,,
CROWN DENT SZ UL3 UP LT 1ST PERM M S STL THCK OCCLUSAL SURF,SUP-2238936,CDM,D6783,CPT,0278,RC,,,,both,,,111.56,72.51,,,,,,,,,,,,,
PROBE SNR L230CM DIA2.5MM OVL SPRL BRAID FIRM LOOP BEAMER AR,SUP-2166260,CDM,2720000010,LOCAL,0272,RC,,,,both,,,737.90,479.63,,,,,,,,,,,,,
BOLT EXT FIX EYE NS,SUP-2863451,CDM,2720000010,LOCAL,0272,RC,,,,both,,,325.59,211.63,,,,,,,,,,,,,
SHEATH TRANSSEPTAL L 72 CM DIA 8.5 FR CRV L 22 MM DIL L 95 MED,SUP-2913481,CDM,C1766,HCPCS,0272,RC,,,,both,,,5385.10,3500.31,,,,,,,,,,,,,
SET SCR SPNL L L10MM DIA1.5MM LUM TI OPTMA,SUP-2212645,CDM,C1713,HCPCS,0278,RC,,,,both,,,963.98,626.59,,,,,,,,,,,,,
COMPONENT FEM SZ 3 L KNEE CO CHROM CRUCE RET NP PRI CEM,SUP-2346615,CDM,C1776,CPT,0278,RC,,,,both,,,4396.00,2857.40,,,,,,,,,,,,,
ANCHOR SUT 2 ORTHOCORD BRAID GRSP SET BIOKNOTLESS,SUP-2249362,CDM,C1713,HCPCS,0278,RC,,,,both,,,1372.18,891.92,,,,,,,,,,,,,
STEM POROUS 16.5X220MM BOWED,SUP-2505117,CDM,C1776,CPT,0278,RC,,,,both,,,10248.96,6661.82,,,,,,,,,,,,,
GRAFT BNE H18XL25MM FRZ DRY CALCNL WDG MATRIGRFT,SUP-2264846,CDM,C1713,HCPCS,0278,RC,,,,both,,,1533.70,996.90,,,,,,,,,,,,,
TRAY PICC SUBCL 1/L 5FR 60CML PU RADPQ PEEL AWAY INT 3155115,SUP-2632644,CDM,C1751,HCPCS,0278,RC,,,,both,,,294.22,191.24,,,,,,,,,,,,,
KNIFE SURG SCHKNT 150 DEG 165X7 MM SCKL ANGLED SHFT,SUP-2469747,CDM,2720000010,LOCAL,0272,RC,,,,both,,,396.46,257.70,,,,,,,,,,,,,
VALVE AORT H14MM CUF DIA25MM TISS ANNULUS DIA19MM EPIC SUP,SUP-2355841,CDM,C1889,HCPCS,0278,RC,,,,both,,,13816.00,8980.40,,,,,,,,,,,,,
SPHERE GLEN LNG L15MM POST FIX PRESSFIT AEQUALIS PERFORM,SUP-2388774,CDM,C1776,CPT,0278,RC,,,,both,,,1745.84,1134.80,,,,,,,,,,,,,
GRAFT BNE 50X25X8 MM 10 CC POROUS COLLAGEN MATRIX SIGNAFUSE,SUP-2731801,CDM,C1713,HCPCS,0278,RC,,,,both,,,5310.53,3451.84,,,,,,,,,,,,,
PLATE BNE SM W11XL33MM THK34MM 2 H BILAT TI RIG NEUT LOK,SUP-2190771,CDM,C1713,HCPCS,0278,RC,,,,both,,,775.52,504.09,,,,,,,,,,,,,
SET BILI DRNGE 14FR L35CM GWIRE 0.038IN 5 H PGTL POLYETH,SUP-2141065,CDM,C1729,HCPCS,0272,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
BIT DRL 4.5 MM PROX QC STRL,SUP-2875384,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1034.00,672.10,,,,,,,,,,,,,
SYSTEM IMPLANT WITH 5.5MM CROSSFT KNOTLESS CUFFLINK,SUP-2824388,CDM,C1713,HCPCS,0278,RC,,,,both,,,9034.72,5872.57,,,,,,,,,,,,,
POST EXT FIX L DIA8MM S STL STR HOFFMANN II,SUP-2372203,CDM,2720000010,LOCAL,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
SUPPORT TENNIS ELBW GEL AIR FRARM CIRC 8-14IN REG,SUP-2324441,CDM,L3702,HCPCS,0272,RC,,,,both,,,31.97,20.78,,,,,,,,,,,,,
COMPONENT ARTC SURF FIX BEAR 9 KNEE CR ATTUNE,SUP-2454950,CDM,C1776,CPT,0278,RC,,,,both,,,916.88,595.97,,,,,,,,,,,,,
RUSSELL-TAYLOR FEMORAL NAIL 15MMX42CM,SUP-2818215,CDM,C1713,HCPCS,0278,RC,,,,both,,,8254.12,5365.18,,,,,,,,,,,,,
SCREW BNE L44MM DIA4.5MM CORT TI N ST N SELF DRL,SUP-2190357,CDM,C1713,HCPCS,0278,RC,,,,both,,,53.32,34.66,,,,,,,,,,,,,
SUPPORT ORTHOT BK PREPARATORY NO CVR SACH FT PREFABRICATED,SUP-2694035,CDM,L5535,HCPCS,0272,RC,,,,both,,,5487.28,3566.73,,,,,,,,,,,,,
SCREW BNE THRD 6.5X25 MM 16 MM SS,SUP-2198290,CDM,C1713,HCPCS,0278,RC,,,,both,,,40.82,26.53,,,,,,,,,,,,,
NUT ORTH 47 MM OLECRANON SLED,SUP-2389621,CDM,C1713,HCPCS,0278,RC,,,,both,,,2496.30,1622.59,,,,,,,,,,,,,
KIT SYR 1ML 2ML TRAUM TRAUMCEM V+,SUP-2179485,CDM,2720000010,LOCAL,0272,RC,,,,both,,,378.90,246.28,,,,,,,,,,,,,
PLATE BNE STR 63X0.6 MM NEURO 16 HOLE TI NS LEVEL 1 ULTRAONE,SUP-2481557,CDM,C1713,HCPCS,0278,RC,,,,both,,,827.14,537.64,,,,,,,,,,,,,
CATHETER HEMODIALYSI NIAG SLIM CATH ACTE 12FR DIA 20 5551200,SUP-2632899,CDM,C1752,HCPCS,0278,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
PEG BNE FIX L18MM DIA2.5MM DST VOLAR RAD PARTIALLY THRD FOR,SUP-2414243,CDM,C1713,HCPCS,0278,RC,,,,both,,,339.12,220.43,,,,,,,,,,,,,
HC So1 Collagen Cross-Link N-Telopep,PX-3018252367,CDM,82523,CPT,0301,RC,,,,both,,,215.00,139.75,,,,,,,,,,,,,
BRACE ORTH LUMBAR X SM LT EVERGREEN,SUP-2123875,CDM,L0626,HCPCS,0272,RC,,,,both,,,131.88,85.72,,,,,,,,,,,,,
BIT DRL DIA4MM SH ADD ON FIT FOR TRIGEN SURESHOT DSTL,SUP-2347935,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1212.23,787.95,,,,,,,,,,,,,
TRAY NAIL ATTCH ROD INSRT INSTR LO CENTRONAIL,SUP-2316000,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1257.16,817.15,,,,,,,,,,,,,
COMPONENT PAT DIA26MM THK7.5MM POLYETH CEM CONVENTIONAL,SUP-2207281,CDM,C1776,CPT,0278,RC,,,,both,,,3202.49,2081.62,,,,,,,,,,,,,
SCREW BONE L36MM OD4.5MM TI CORT T25 ST,SUP-2101302,CDM,C1713,HCPCS,0278,RC,,,,both,,,82.90,53.88,,,,,,,,,,,,,
BLADE ENDOSCP SHAVER 60 DEG L 11 CM DIA 4 MM 5000 RPM ENT,SUP-2901910,CDM,2720000010,LOCAL,0272,RC,,,,both,,,745.06,484.29,,,,,,,,,,,,,
CATHETER DRNGE 14FR BILI LUERLOCK ADPT,SUP-2134679,CDM,C1876,HCPCS,0278,RC,,,,both,,,486.70,316.35,,,,,,,,,,,,,
SCREW BONE L65MM OD2.7MM THRD L15MM S STL CORT ST PERIARTC,SUP-2349971,CDM,C1713,HCPCS,0278,RC,,,,both,,,368.54,239.55,,,,,,,,,,,,,
DEVICE ENDOSKELETAL SYS PROSTHETIC BK ULT TI CARBON FIBER,SUP-2388221,CDM,L5940,HCPCS,0274,RC,,,,both,,,1318.45,856.99,,,,,,,,,,,,,
SCREW INTRF 7MM 25MM 1.5MM DIA GWIRE FIX KNEE CANN N ABSRB,SUP-2341645,CDM,C1713,HCPCS,0278,RC,,,,both,,,613.24,398.61,,,,,,,,,,,,,
LINER BPLR OD38-42MM ID26MM UNIV FEM ACET,SUP-2344597,CDM,C1776,CPT,0278,RC,,,,both,,,412.75,268.29,,,,,,,,,,,,,
SYSTEM SUPP FOR ANTR BIOSYN AVAULTA SOLO,SUP-2126905,CDM,C1771,HCPCS,0278,RC,,,,both,,,2734.88,1777.67,,,,,,,,,,,,,
NEEDLE INSUF 12CM LEN 2MM DIAM ENDOSCP ABD PNEUMOPERI,SUP-2261123,CDM,2720000010,LOCAL,0272,RC,,,,both,,,730.33,474.71,,,,,,,,,,,,,
GRAFT VASC VENAFLO II L 45 CM DIA 4-7 MM EPTFE CARBON,SUP-2761418,CDM,C1768,CPT,0278,RC,,,,both,,,3258.69,2118.15,,,,,,,,,,,,,
INTRODUCER TRANSSEPTAL GUID 8FR L63CM DIL 8FR L67CM GWIRE,SUP-2357162,CDM,C1893,HCPCS,0272,RC,,,,both,,,486.70,316.35,,,,,,,,,,,,,
INSERT TIB SZ 4-5 FEM 3-4 TIB THK9MM CONSTRN LEGION,SUP-2349162,CDM,C1776,CPT,0278,RC,,,,both,,,6625.40,4306.51,,,,,,,,,,,,,
PLATE BNE L 92 X W 12 MM THK 3 MM SCREW DIA 3.5 MM 4 H SS RT 72467204,SUP-2933662,CDM,C1713,HCPCS,0278,RC,,,,both,,,5450.88,3543.07,,,,,,,,,,,,,
CORMET HD SIZE: 6/48MM,SUP-2363937,CDM,C1776,CPT,0278,RC,,,,both,,,16623.16,10805.05,,,,,,,,,,,,,
ROD SPNL L480MM DIA5.5MM TI STR HEX END EXPEDIUM,SUP-2254713,CDM,C1713,HCPCS,0278,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
SUPPORT ORTHOT BK PREPARATORY NO CVR SACH FT PREFABRICATED,SUP-2694035,CDM,L5535,HCPCS,0274,RC,,,,both,,,5487.28,3566.73,,,,,,,,,,,,,
HEAD HUM CAST 46X18 MM 53 MM SHLDR VERSA-DIAL,SUP-2441686,CDM,C1776,CPT,0278,RC,,,,both,,,4394.43,2856.38,,,,,,,,,,,,,
PLATE BNE L 76.8 X W 33 MM CLP L 15 MM TRIJOINT VERO NS,SUP-2913511,CDM,C1713,HCPCS,0278,RC,,,,both,,,7439.70,4835.80,,,,,,,,,,,,,
SCREW BNE CANN 3X29 MM SD HALF THRD SS,SUP-2409879,CDM,C1713,HCPCS,0278,RC,,,,both,,,512.45,333.09,,,,,,,,,,,,,
GRAFT HUM TISS W4XL3CM THK1MM UMB CRD AMNIO MEM CLARIX 1K,SUP-2116280,CDM,Q4148,HCPCS,0636,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
BLADE IM 125 MM HELIX SS STRL LCP DHHS,SUP-2547636,CDM,C1713,HCPCS,0278,RC,,,,both,,,1139.85,740.90,,,,,,,,,,,,,
GRAFT BNE 5 CC BIOACTIVE FOAM PK VITOSS,SUP-2368191,CDM,C1713,HCPCS,0278,RC,,,,both,,,2292.20,1489.93,,,,,,,,,,,,,
HC Anl Sp Inf Pmp W/Mdreprg&Fil,PX-3606237000,CDM,62370,CPT,0360,RC,,,,both,,,961.00,624.65,,,,,,,,,,,,,
CUP ACET OD46MM ID40MM DUROM,SUP-2204668,CDM,C1776,CPT,0278,RC,,,,both,,,12811.20,8327.28,,,,,,,,,,,,,
SLEEVE COMPR 9 10IN UNIV AMBI CRPL GEL HYPOALRG REUSE,SUP-2340101,CDM,L3912,HCPCS,0274,RC,,,,both,,,53.16,34.55,,,,,,,,,,,,,
ROPINIROLE HCL 1 MG PO TABS,RX-21689,CDM,6370000000,HCPCS,0637,RC,00904-6374-61,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
STENT DIVERTER FLOW FREDX 27 4.5MM X 39 / 45,SUP-2855028,CDM,C1876,HCPCS,0278,RC,,,,both,,,41903.30,27237.14,,,,,,,,,,,,,
ALLOGRAFT DERMAL UNMESHED 4X16 CMX2-3.3 MM MTRX PROLAYER,SUP-2717809,CDM,C1763,HCPCS,0278,RC,,,,both,,,16602.12,10791.38,,,,,,,,,,,,,
END CAP ORTH L 10 MM DIA15.5 MM HIP IM NAIL STRL GAMMA4,SUP-2900537,CDM,C1889,HCPCS,0278,RC,,,,both,,,1640.65,1066.42,,,,,,,,,,,,,
SET THROMCTMY ANGIOJET AVX L 50 CM DIA 6 FR SHTH 6 FR,SUP-2867275,CDM,C1757,HCPCS,0272,RC,,,,both,,,2904.50,1887.92,,,,,,,,,,,,,
BASEPLATE TIB SZ 4 THK9-19MM LT TI ALLOY POR RESURF STEM,SUP-2215745,CDM,C1776,CPT,0278,RC,,,,both,,,5934.60,3857.49,,,,,,,,,,,,,
CAGE SPNL EXPANDABLE 0 DEG 27X10-15X11 MM PLIF EZSPAND,SUP-2572219,CDM,C1889,HCPCS,0278,RC,,,,both,,,13188.00,8572.20,,,,,,,,,,,,,
CATHETER DRNGE 8FR L15CM UNIV NIT LCK PGTL NAVARRE,SUP-2128422,CDM,C1729,HCPCS,0272,RC,,,,both,,,247.18,160.67,,,,,,,,,,,,,
BRACE WR CLUTCH DORS STAY VELSTRETCH WRP LT CIRC 6 1/2-8,SUP-2323979,CDM,L3931,HCPCS,0272,RC,,,,both,,,50.84,33.05,,,,,,,,,,,,,
SPLINT ORTH D RNG CLOSURE UNIV 10 IN WRST FOREARM RT,SUP-2336334,CDM,L3809,HCPCS,0274,RC,,,,both,,,22.70,14.75,,,,,,,,,,,,,
HC Total Protein,PX-3018415500,CDM,84155,CPT,0301,RC,,,,outpatient,,,152.00,98.80,,,,,,,,,,,,,
INSULIN ASPART PROT & ASPART (70-30) 100 UNIT/ML SC SUSP,RX-33666,CDM,J1815,HCPCS,0637,RC,00169-3685-12,NDC,,both,10,ML,57.90,37.63,,,,,,,,,,,,,
SUPPORT ORTHOT KNEE LOWER EXTREMITY POLYCENTRIC,SUP-2435665,CDM,L2387,HCPCS,0274,RC,,,,both,,,540.46,351.30,,,,,,,,,,,,,
SCREW BNE L75MM DIA6.5MM THRD L32MM CANC BIODUR ALLY ST,SUP-2410054,CDM,C1713,HCPCS,0278,RC,,,,both,,,673.22,437.59,,,,,,,,,,,,,
ENDCAP SPNL 0 DEG 60X22X18 MM TI X-CORE 2,SUP-2560393,CDM,C1889,HCPCS,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
CROSSLINK SPNL FIX PLATE 4.5X22 MM SS SHILLA,SUP-2630563,CDM,C1713,HCPCS,0278,RC,,,,both,,,5071.10,3296.21,,,,,,,,,,,,,
PLATE PHLANG BASE 1.5MM 2H HD 6H SHFT STRL VAL,SUP-2546073,CDM,C1713,HCPCS,0278,RC,,,,both,,,1723.86,1120.51,,,,,,,,,,,,,
KIT WRIST SMALL FOR SPIDER 2,SUP-2753243,CDM,2720000010,LOCAL,0272,RC,,,,both,,,185.26,120.42,,,,,,,,,,,,,
SCREW BNE L115MM DIA12.7MM CANC S STL LAG OCTAGONAL RECESS,SUP-2186489,CDM,C1713,HCPCS,0278,RC,,,,both,,,1072.97,697.43,,,,,,,,,,,,,
TRAY THORCENT CATH 6FR PGTL DRNGE SYS SAFE T CENTESIS,SUP-2133894,CDM,C1729,HCPCS,0272,RC,,,,both,,,266.90,173.48,,,,,,,,,,,,,
PUSHER KNOT SUT CUT DISP FOR 2-0 FIBERWIRE,SUP-2121863,CDM,2720000010,LOCAL,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
SET INTRO OUTER CATH 4FR L10CM NDL 21GA L7CM 0.018IN PLAT,SUP-2170545,CDM,C1894,HCPCS,0272,RC,,,,both,,,86.98,56.54,,,,,,,,,,,,,
SUPPORT ORTHOT LOWER EXTREMITY PARASPINAL UPR CUST THOR CTRL,SUP-2435692,CDM,L2670,HCPCS,0272,RC,,,,both,,,451.56,293.51,,,,,,,,,,,,,
DRILL SURG DOME 35 MM REV PINNACLE,SUP-2453991,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1729.51,1124.18,,,,,,,,,,,,,
SPLINT WRST M L10IN L FA LN CIRCUMFERENTIAL STRP SLIP ON,SUP-2276626,CDM,L3809,HCPCS,0272,RC,,,,both,,,21.38,13.90,,,,,,,,,,,,,
INSERT TIB SZ 2 THK175MM CRUCE SUB STBL MOD PFC,SUP-2254012,CDM,C1776,CPT,0278,RC,,,,both,,,4261.61,2770.05,,,,,,,,,,,,,
CATHETER ANGIOPLSTY IMPACT L 75 CM SHFT 9 FR BALLOON L 4 CM,SUP-2124919,CDM,C1725,HCPCS,0272,RC,,,,both,,,926.30,602.09,,,,,,,,,,,,,
CATHETER GUID AMPLATZER TREVISIO L 80 CM DIA12 FR SHTH OD,SUP-2574332,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2069.26,1345.02,,,,,,,,,,,,,
PUMP BLD CNTRFUG BAL BIOSURFACE AFFIN CP,SUP-2467203,CDM,2720000010,LOCAL,0272,RC,,,,both,,,584.98,380.24,,,,,,,,,,,,,
MESH CRAN W41XL42MM D0.5MM THK1MM L ORBIT TIIUM BARR SURF,SUP-2366482,CDM,C1713,HCPCS,0278,RC,,,,both,,,3978.38,2585.95,,,,,,,,,,,,,
COVER BUR H DIA7MM CRANIOMAXILLOFACIAL PLT LO PROF W/ TAB,SUP-2366204,CDM,C1713,HCPCS,0278,RC,,,,both,,,507.30,329.74,,,,,,,,,,,,,
STENT TRACHBRONCH COOK-Z GIANTURCO-ROSCH L 5 CM DIA25 MM,SUP-2693658,CDM,C1877,HCPCS,0278,RC,,,,both,,,2888.80,1877.72,,,,,,,,,,,,,
REAMER SURG DIA 8.5 MM STP NS DISP,SUP-2930409,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1475.80,959.27,,,,,,,,,,,,,
FOMEPIZOLE 1 GM/ML IV SOLN,RX-22185,CDM,J1451,HCPCS,0636,RC,70710-1478-01,NDC,,both,1.5,ML,2666.20,1733.03,,,,,,,,,,,,,
ISOSORBIDE DINITRATE 10 MG PO TABS,RX-4064,CDM,6370000000,HCPCS,0637,RC,50268-0448-11,NDC,,both,1,UN,3.70,2.40,,,,,,,,,,,,,
TUBE VENT ID1.14MM BLU SIL DONALDSON,SUP-2312635,CDM,L8699,HCPCS,0278,RC,,,,both,,,27.95,18.17,,,,,,,,,,,,,
CAGE SPNL HYPERLORDOTIC STD 16 MM ENDOSKELETON TAS NANOLOCK,SUP-2730360,CDM,C1889,HCPCS,0278,RC,,,,both,,,21666.00,14082.90,,,,,,,,,,,,,
DEFIBRILLATOR CRD 2 CHMBR CONTAK RENEWAL TR H121 BSC CRM,SUP-2149219,CDM,C1721,HCPCS,0275,RC,,,,both,,,21980.00,14287.00,,,,,,,,,,,,,
CATHETER HD STR AD 15.5 FRX40 CM LT DL VASCPAK KT DURAFLO 2,SUP-2472810,CDM,C1750,HCPCS,0278,RC,,,,both,,,690.80,449.02,,,,,,,,,,,,,
PLATE BONE NARROW 4.5X55 MM 3 HOLE FOR SCREW STERILE TC100,SUP-2836675,CDM,C1713,HCPCS,0278,RC,,,,both,,,1075.17,698.86,,,,,,,,,,,,,
COMPONENT HIP RESURF H6,SUP-2123624,CDM,C1776,CPT,0278,RC,,,,both,,,21509.00,13980.85,,,,,,,,,,,,,
GUIDEWIRE VASC 145CM 0.018 IN TAPR 7 CM FLPY TIP 2 CM,SUP-2167642,CDM,C1769,HCPCS,0272,RC,,,,both,,,43.77,28.45,,,,,,,,,,,,,
CATHETER KIT 6 FRX70X370 CM FIBEROPTIC EMITTING IRIS,SUP-2366515,CDM,C1758,HCPCS,0278,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
GRAFT BNE SPHR 23 MM PRO OSTEON 200,SUP-2861988,CDM,C1713,HCPCS,0278,RC,,,,both,,,475.43,309.03,,,,,,,,,,,,,
ROD IM L 120 MM DIA22 MM PHOTODYNAMIC BNE STBL PROC PK STRL,SUP-2934113,CDM,C1713,HCPCS,0278,RC,,,,both,,,13740.64,8931.42,,,,,,,,,,,,,
SCREW SPNL L 90 MM DIA11.5 MM PEDCL SLD NS MARINER,SUP-2884749,CDM,C1889,HCPCS,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
DRILL SURG KT STRL MINIBUNION,SUP-2432224,CDM,2720000010,LOCAL,0272,RC,,,,both,,,775.58,504.13,,,,,,,,,,,,,
PLATE BONE DUAL CMPRSSN HLX15 RCNSTRCTN F3.5MM LOK SCREW ST,SUP-2724422,CDM,C1713,HCPCS,0278,RC,,,,both,,,2056.95,1337.02,,,,,,,,,,,,,
CATHETERIZATION KIT 0.018 IN 4 FRX2 IN CV ARROWG+ARD,SUP-2383309,CDM,C1751,HCPCS,0278,RC,,,,both,,,247.43,160.83,,,,,,,,,,,,,
TRAY CATH HEMODIALYSI PWR TRIALYSI SLIM CATH ACTE 1 5865150G,SUP-2632938,CDM,C1752,HCPCS,0278,RC,,,,both,,,1044.65,679.02,,,,,,,,,,,,,
GRAFT BONE SUB W1.5XL1.5CM DEMIN MTRX FLX GRFTON,SUP-2281662,CDM,C1713,HCPCS,0278,RC,,,,both,,,828.96,538.82,,,,,,,,,,,,,
PLATE 22MM ANT CERV,SUP-2244670,CDM,C1713,HCPCS,0278,RC,,,,both,,,90.93,59.10,,,,,,,,,,,,,
HC NM Brain With Flow,PX-3417860600,CDM,78606,CPT,0341,RC,,,,inpatient,,,2873.00,1867.45,,,,,,,,,,,,,
SCREW BNE L42MM DIA4MM THRD L14MM STD CANC S STL ST CANN,SUP-2342504,CDM,C1713,HCPCS,0278,RC,,,,both,,,13.72,8.92,,,,,,,,,,,,,
BRACE ORTH CLOSURE XL AD BK SHLDR BLK QUIKDRAW PRO,SUP-2123913,CDM,L0628,HCPCS,0272,RC,,,,both,,,321.98,209.29,,,,,,,,,,,,,
SET GASTSTMY M DIL 16X18FR SHTH 18X20FR DISP STRT INIT,SUP-2170216,CDM,C1769,HCPCS,0272,RC,,,,both,,,331.24,215.31,,,,,,,,,,,,,
SPACER SPNL 30X12X8-12 MM CALIB,SUP-2231981,CDM,C1713,HCPCS,0278,RC,,,,both,,,14130.00,9184.50,,,,,,,,,,,,,
BUR DENT L70MM DIA5MM 80000RPM VOLLKARBID DISP PM2 BOHRER,SUP-2134830,CDM,2720000010,LOCAL,0272,RC,,,,both,,,675.10,438.81,,,,,,,,,,,,,
SHEATH GUID 5FR L45CM HOCK STK HYDRPHLC XCUT W/ DIL PINN,SUP-2384891,CDM,C1894,HCPCS,0272,RC,,,,both,,,268.47,174.51,,,,,,,,,,,,,
PLATE BNE W31.5XL62.7MM R 2 TIER STD FAST GUID TECHNOLOGY,SUP-2414027,CDM,C1713,HCPCS,0278,RC,,,,both,,,2295.34,1491.97,,,,,,,,,,,,,
CONNECTOR CATH STEPDOWN 0.8X1.5-1.8 MM RADIOPAQUE POLYPR,SUP-2851301,CDM,C1729,HCPCS,0272,RC,,,,both,,,2866.85,1863.45,,,,,,,,,,,,,
BUR SURG OD3MM LNG DMND RND N FLUT FOR TPS MIDAS REX UPWR,SUP-2367482,CDM,C1713,HCPCS,0278,RC,,,,both,,,344.49,223.92,,,,,,,,,,,,,
PIN EXT FIX L 230 MM DIA 3.2 MM OAL AO CONN SMTH DRL TIP NS,SUP-2899114,CDM,C1713,HCPCS,0278,RC,,,,both,,,509.47,331.16,,,,,,,,,,,,,
CATHETER DRAINAGE VLV 4 FRX7 CM 51 IN KT SPIN-LOCK ACCEL,SUP-2659255,CDM,C1729,HCPCS,0272,RC,,,,both,,,129.15,83.95,,,,,,,,,,,,,
GRAFT TISS FRZN ALLGRFT TIB WHL STRUCTURAL L,SUP-2307315,CDM,C1713,HCPCS,0278,RC,,,,both,,,21804.66,14173.03,,,,,,,,,,,,,
SCREW BNE L100MM DIA3MM THRD L30MM CORT SELF DRL,SUP-2316454,CDM,C1713,HCPCS,0278,RC,,,,both,,,288.88,187.77,,,,,,,,,,,,,
STENT BILI M L13MM BLLN L17MM DIA6MM CATH L135CM 12ATM,SUP-2159119,CDM,C1876,HCPCS,0278,RC,,,,both,,,2606.20,1694.03,,,,,,,,,,,,,
PLATE BNE HUM 154 MM RT DSTL DORSOLATERAL 7 HOLE LOQTEQ,SUP-2691244,CDM,C1713,HCPCS,0278,RC,,,,both,,,3981.52,2587.99,,,,,,,,,,,,,
CATHETER VAXCEL TUNNELED VENUS 6FR,SUP-2141137,CDM,C1751,HCPCS,0278,RC,,,,both,,,796.71,517.86,,,,,,,,,,,,,
COMPONENT ARTC 3X3MM OFFSET PATELLOFEMORAL HEMICAP,SUP-2123663,CDM,C1776,CPT,0278,RC,,,,both,,,18648.46,12121.50,,,,,,,,,,,,,
GRAFT BIO TISS OASIS ULTRA 3LAYER MATRIX 3X3.5CM FEN,SUP-2341247,CDM,Q4124,HCPCS,0636,RC,,,,both,,,706.37,459.14,,,,,,,,,,,,,
RELOAD INT DIA3.5MM BLU 6 ROW ENDOWRIST DA VINCI SI,SUP-2246599,CDM,2720000010,LOCAL,0272,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
HEAD FEM BPLR 28X53 MM HIP,SUP-2322482,CDM,C1776,CPT,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
CAGE SPNL LORDTC 7 DEG 16X13X7 MM CERV TI PEEK IRIX-C,SUP-2366041,CDM,C1889,HCPCS,0278,RC,,,,both,,,6908.00,4490.20,,,,,,,,,,,,,
HC 2-D Tte Lmt W/Contrast,PX-4839330801,CDM,C8924,HCPCS,0483,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
HEMOCONCENTRATOR PERF MEDIVATORS HEMOCOR HPH 1400,SUP-2489325,CDM,2720000010,LOCAL,0272,RC,,,,both,,,226.39,147.15,,,,,,,,,,,,,
CABLE SPNL DIA1.1MM ST TI DBL LOOP W/ TWO CRMP SONGER,SUP-2255761,CDM,C1713,HCPCS,0278,RC,,,,both,,,1264.04,821.63,,,,,,,,,,,,,
GRAFT BNE W20XL100MM THK3-12MM CORT FEM STRUT FRZ DRY,SUP-2307184,CDM,C1713,HCPCS,0278,RC,,,,both,,,973.31,632.65,,,,,,,,,,,,,
IMMOBILIZER SHLDR L W8XL18IN COT ADJUSTABLE  SHLDR STRP W  A,SUP-2431841,CDM,L3670,HCPCS,0272,RC,,,,both,,,53.51,34.78,,,,,,,,,,,,,
IMPLANT OSS L4.5MM PIST DIA0.4MM WELL DIA1MM STAP S STL BCKT,SUP-2312586,CDM,L8613,CPT,0278,RC,,,,both,,,323.42,210.22,,,,,,,,,,,,,
SYSTEM ASPIR BNE MAR 11 GAX11 CM W/ PREP MAXX CELL,SUP-2740205,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5495.00,3571.75,,,,,,,,,,,,,
CROWN DENT 4 S STL PRI ANTR UP CUSPID PREFABRICATED,SUP-2100371,CDM,D6783,CPT,0278,RC,,,,both,,,17.58,11.43,,,,,,,,,,,,,
SYSTEM STENT GRFT OVATION IX L 80 MM DIA 34 MM DEL CATH 15,SUP-2217722,CDM,C1768,CPT,0278,RC,,,,both,,,39246.86,25510.46,,,,,,,,,,,,,
ADAPTER LD BRADY 6 MM UPLR IS-1 CONN,SUP-2473470,CDM,2720000010,LOCAL,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
SUPPORT ORTHOT THGH LOWER EXTREMITY WT BEAR CUST FIT,SUP-2435674,CDM,L2520,HCPCS,0272,RC,,,,both,,,1521.74,989.13,,,,,,,,,,,,,
DRILL 35MM,SUP-2841578,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1152.38,749.05,,,,,,,,,,,,,
PIN BNE FIX LAT TEMP,SUP-2884722,CDM,C1713,HCPCS,0278,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
LINER ACET ANTEVERTED 4+ MM 20 DEG 28X46 MM HIP XLPE R3,SUP-2434669,CDM,C1776,CPT,0278,RC,,,,both,,,4477.64,2910.47,,,,,,,,,,,,,
PLATE SPNL OCCIPITOCERVICAL UP THOR ADJ INFIN,SUP-2421093,CDM,C1713,HCPCS,0278,RC,,,,both,,,4474.50,2908.42,,,,,,,,,,,,,
OSTEOTOME SURG BLADE 15 MM FLX FLAT SAW SS,SUP-2364278,CDM,2720000010,LOCAL,0272,RC,,,,both,,,232.36,151.03,,,,,,,,,,,,,
NECK FEM L38MM 8DEG GRN MOD HIP REJUVENATE,SUP-2365870,CDM,C1776,CPT,0278,RC,,,,both,,,2642.31,1717.50,,,,,,,,,,,,,
SCREW BNE L12MM OD3.5MM LOK TUFFNEK TECHNOLOGY FOR PLT,SUP-2321120,CDM,C1713,HCPCS,0278,RC,,,,both,,,681.38,442.90,,,,,,,,,,,,,
HC Treat Metatarsal Fx,PX-4502847500,CDM,28475,CPT,0450,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
ALLOGRAFT DERMAL MESHED 8X16 CMX0.4-1.0 MM 1:1 PROLAYER EDM,SUP-2717795,CDM,C1763,HCPCS,0278,RC,,,,both,,,23894.68,15531.54,,,,,,,,,,,,,
DISPOSABLES KIT FOR DX KNOTLESS FIBERTAK,SUP-2815355,CDM,2720000010,LOCAL,0272,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
KIT FASTENER IMPL SEROSAFUSE,SUP-2660819,CDM,C1889,HCPCS,0278,RC,,,,both,,,21964.30,14276.79,,,,,,,,,,,,,
SCREW SPNL 4.5X12 MM MOUNTAINEER,SUP-2256378,CDM,C1713,HCPCS,0278,RC,,,,both,,,1229.31,799.05,,,,,,,,,,,,,
ROD REPROC EXT FIX HYBRID 8X240 MM CARBON FIBER,SUP-2188745,CDM,2720000010,LOCAL,0272,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA PLU MAXBARR 5FR S1395108D5,SUP-2632830,CDM,C1751,HCPCS,0278,RC,,,,both,,,1207.27,784.73,,,,,,,,,,,,,
MICROCATHETER DIAG RENEGADE HI FLO L 80 CM OD,SUP-2653472,CDM,C1887,HCPCS,0272,RC,,,,both,,,973.40,632.71,,,,,,,,,,,,,
DEFIBRILLATOR IMPL AURORA EV-ICD MRI SURESCAN W 51 X H 64 MM,SUP-2891565,CDM,C1722,HCPCS,0275,RC,,,,both,,,62800.00,40820.00,,,,,,,,,,,,,
ALLOGRAFT BNE CORTICAL STRUT FD,SUP-2391735,CDM,C1889,HCPCS,0278,RC,,,,both,,,1808.64,1175.62,,,,,,,,,,,,,
RESTRICTOR CEM SM DIA10MM UNIV FEM CNL UHMWPE SUMMIT BASIC,SUP-2253094,CDM,C1713,HCPCS,0278,RC,,,,both,,,115.52,75.09,,,,,,,,,,,,,
STENT COLON EVOLUTION L 8 CM BODY DIA25 MM FLANGE DIA 30 MM,SUP-2170563,CDM,C1876,HCPCS,0278,RC,,,,both,,,7209.44,4686.14,,,,,,,,,,,,,
DEFIBRILLATOR IMPL EVERA S DELIVERED ENERGY 36 J TI POLYUR,SUP-2282423,CDM,C1722,HCPCS,0275,RC,,,,both,,,36642.45,23817.59,,,,,,,,,,,,,
PLATE BNE CONTOURABLE MESH 200X200X0.6 MM RIGID TI SLV STRL,SUP-2859900,CDM,C1713,HCPCS,0278,RC,,,,both,,,25673.27,16687.63,,,,,,,,,,,,,
SLEEVE SURG ENTRY 7.5 MM,SUP-2460639,CDM,C1713,HCPCS,0278,RC,,,,both,,,898.04,583.73,,,,,,,,,,,,,
FLOSEAL NT 5ML,SUP-2822244,CDM,2720000010,LOCAL,0272,RC,,,,both,,,366.44,238.19,,,,,,,,,,,,,
DRESSING BIO L 7 X W 5 CM SZ 200 UM PORCINE SM INTEST,SUP-2905523,CDM,Q4103,HCPCS,0636,RC,,,,both,,,1353.15,879.55,,,,,,,,,,,,,
PROSTHESIS OSS 0.5X4.50 MM PISTON NIT/FLROPLAS SMRT 360,SUP-2651576,CDM,L8613,CPT,0278,RC,,,,both,,,996.79,647.91,,,,,,,,,,,,,
ENDPLATE SPNL DISK L20MM 20MM FOOTPRINT 8DEG VERT BODY REPL,SUP-2229981,CDM,C1713,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
OCCLUDER CV L12MM BLB DIA2.75MM SIL RUB COR VES RADPQ DISP,SUP-2130330,CDM,C1760,HCPCS,0278,RC,,,,both,,,266.02,172.91,,,,,,,,,,,,,
CATHETER GUID HEARTRAIL III L 100 CM DIA 6 FR IR1.5 2 SIDE H,SUP-2522837,CDM,C1887,HCPCS,0272,RC,,,,both,,,296.73,192.87,,,,,,,,,,,,,
SHEATH INTRO FLX ANSEL 70CM 5FR ID 1.9MM 0.035IN AQ MULTPURP,SUP-2171140,CDM,C1894,HCPCS,0272,RC,,,,both,,,197.98,128.69,,,,,,,,,,,,,
KIT INTRO 5FR L30CM NDL 21GA L15CM GWIRE L70CM MIC MRK,SUP-2120544,CDM,C1894,HCPCS,0272,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
PLATE BNE 2 HOLE ORTHOLINK,SUP-2315902,CDM,C1713,HCPCS,0278,RC,,,,both,,,4069.44,2645.14,,,,,,,,,,,,,
POST EXT FIX 6 HOLE SIDEKCK EZ FRAME,SUP-2850663,CDM,2720000010,LOCAL,0272,RC,,,,both,,,364.24,236.76,,,,,,,,,,,,,
SUPPORT ORTHOT LOWER EXTREMITY CUST N CORROSIVE FINISH,SUP-2435696,CDM,L2780,HCPCS,0272,RC,,,,both,,,179.17,116.46,,,,,,,,,,,,,
HC Repair Lip,PX-4504065200,CDM,40652,CPT,0450,RC,,,,both,,,1337.00,869.05,,,,,,,,,,,,,
COLLAR CERV FIRM 4X22IN UNIV,SUP-2276587,CDM,L0120,HCPCS,0274,RC,,,,both,,,7.69,5.00,,,,,,,,,,,,,
IMPLANT TOE JT DORS MTP ULTRA LP STD RAPID COMPR STRL,SUP-2908878,CDM,C1713,HCPCS,0278,RC,,,,both,,,11671.38,7586.40,,,,,,,,,,,,,
ANCHOR SUTURE DIA 4.75 MM BIOCOMP KNOTLESS SWIVELOCK STRL HD,SUP-2910049,CDM,C1713,HCPCS,0278,RC,,,,both,,,2559.10,1663.41,,,,,,,,,,,,,
SHEATH INTRO PINNACLE L 25 CM 5 FR SS HYDRPHLC PERIPHERAL,SUP-2385665,CDM,C1894,HCPCS,0272,RC,,,,both,,,81.26,52.82,,,,,,,,,,,,,
BLADE SHAVER CUT 4.2X120 MM END STRL UNIDRIVE DISP,SUP-2585879,CDM,2720000010,LOCAL,0272,RC,,,,both,,,133.95,87.07,,,,,,,,,,,,,
KIT TKR IMPL CAPPED K1 IDEN1XE STD CEM,SUP-2905017,CDM,C1776,CPT,0278,RC,,,,both,,,12952.50,8419.12,,,,,,,,,,,,,
VALVE MITRL STENTED PORCINE 29 MM,SUP-2357532,CDM,C1889,HCPCS,0278,RC,,,,both,,,15072.00,9796.80,,,,,,,,,,,,,
DEXTROSE 5 % IV SOLN INTERMITTENT INFUSION|DISCARDED DRUG NOT ADMINISTE,RX-40840103,CDM,2580000003,HCPCS,0258,RC,00264-7510-10,NDC,JW,both,250,ML,17.00,11.05,,,,,,,,,,,,,
GUIDEPIN ORTH 1.1X635 MM STRL DISP,SUP-2520357,CDM,2720000010,LOCAL,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
PLATE BNE L313MM 12 H NONSTERILE PROX FEM S STL HK LO PROF,SUP-2186062,CDM,C1713,HCPCS,0278,RC,,,,both,,,4993.42,3245.72,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA MAXBARR 4FR 55CM S3274108D,SUP-2632841,CDM,C1751,HCPCS,0278,RC,,,,both,,,625.68,406.69,,,,,,,,,,,,,
GRAFT ENDOVASC L15CM DIA8MM PROF 8FR CATH L75CM 0.035IN,SUP-2396458,CDM,C1874,HCPCS,0278,RC,,,,both,,,10974.30,7133.29,,,,,,,,,,,,,
BRACE ORTHOPEDIC PRO XL 24-27 IN RT KNEE TRK ORTHOSIS PTO,SUP-2150972,CDM,L1810,HCPCS,0272,RC,,,,both,,,158.82,103.23,,,,,,,,,,,,,
PLATE BONE RECONSTRUCTION LARGE 2.5 MM DOUBLE ANGLE TITANIUM,SUP-2837762,CDM,C1713,HCPCS,0278,RC,,,,both,,,10095.41,6562.02,,,,,,,,,,,,,
HEAD HUM RESURF 47 MM SHLDR EQUINOXE,SUP-2451410,CDM,C1776,CPT,0278,RC,,,,both,,,9404.93,6113.20,,,,,,,,,,,,,
RESERVOIR DRAINAGE NEONATAL 75X3 CM VENTRICULAR FLAT DOME,SUP-2277913,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1006.68,654.34,,,,,,,,,,,,,
PLATE BNE LAPIDUS RT 5 HOLE OMNI,SUP-2610160,CDM,C1713,HCPCS,0278,RC,,,,both,,,4399.14,2859.44,,,,,,,,,,,,,
GRAFT VASC L50CM DIA16X8MM UNIV POLY KNIT BIFUR STD WALL,SUP-2395628,CDM,C1768,CPT,0278,RC,,,,both,,,1673.62,1087.85,,,,,,,,,,,,,
SCREW SPNL L14MM DIA3.5MM ANODIZED BLU POST PEDCL,SUP-2380761,CDM,C1713,HCPCS,0278,RC,,,,both,,,1617.10,1051.11,,,,,,,,,,,,,
PLEDGET SURG L 75 CM 3/4 X 5/16 X 1/16 IN PTFE SFT DA,SUP-2904099,CDM,C1768,CPT,0278,RC,,,,both,,,37.43,24.33,,,,,,,,,,,,,
SET ENDOSCP W/ 8-9MM CLLRD PIN DISP FOR OSTEOCHNDRL,SUP-2121635,CDM,C1713,HCPCS,0278,RC,,,,both,,,1410.17,916.61,,,,,,,,,,,,,
HEAD FEM UNIV 36 MM HIP BIOLOX DELT,SUP-2364694,CDM,C1776,CPT,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
ENDOPROSTHESIS VASC VIABAHN L 25CM 5MM 120CM 7FR HEPARIN,SUP-2719623,CDM,C1768,HCPCS,0278,RC,,,,both,,,19778.86,12856.26,,,,,,,,,,,,,
DRILL SURG 2.9 MM CERV FOR 4 MM SCREW S4,SUP-2108735,CDM,2720000010,LOCAL,0272,RC,,,,both,,,596.60,387.79,,,,,,,,,,,,,
GRAFT HUM TISS L 2 X W 2 CM SZ 4 SQCM AMNION-CHORION-AMNION,SUP-2909214,CDM,Q4137,HCPCS,0636,RC,,,,both,,,3250.06,2112.54,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.529,SUP-2860046,CDM,C1713,HCPCS,0278,RC,,,,both,,,41388.34,26902.42,,,,,,,,,,,,,
GRAFT BNE SUB 12ML W2XL10MM B TRICALCIUM PHSPTE CLLGN HA,SUP-2289161,CDM,C1713,HCPCS,0278,RC,,,,both,,,4876.42,3169.67,,,,,,,,,,,,,
GUIDEWIRE VASC TEFCOR L 145 CM DIA 0.038 IN TAPR L 15 CM CRV,SUP-2167807,CDM,C1769,HCPCS,0272,RC,,,,both,,,54.07,35.15,,,,,,,,,,,,,
DEVICE GLAUCOMA DRNGE 1/4IN CLR CORNEA W/ SCLER,SUP-2247189,CDM,V2785,HCPCS,0810,RC,,,,both,,,957.70,622.50,,,,,,,,,,,,,
WIRE FIX K TRCR TIP RND END 1X100MM,SUP-2320980,CDM,C1769,HCPCS,0272,RC,,,,both,,,61.23,39.80,,,,,,,,,,,,,
CATHETER ANGIO 6FR L110CM 0.038IN SARAH RAD 4.0 NYL POLYUR,SUP-2385357,CDM,C1887,HCPCS,0272,RC,,,,both,,,109.90,71.43,,,,,,,,,,,,,
Z DISCONTINUED SUGGESTED SUBS IN COMMENTS GUIDEWIRE VASC L260CM OD0.035IN S STL PTFE ULT STIFF 2 STR,SUP-2168995,CDM,C1769,HCPCS,0272,RC,,,,both,,,217.60,141.44,,,,,,,,,,,,,
GRAFT VASC PROPATEN L 5 CM DIA 3 MM EPTFE CBAS HEPARIN TW,SUP-2655620,CDM,C1768,CPT,0278,RC,,,,both,,,2395.82,1557.28,,,,,,,,,,,,,
HC Surgery Ohs Addtl 15min,PX-3600000018,CDM,3600000018,LOCAL,0360,RC,,,,both,,,5570.00,3620.50,,,,,,,,,,,,,
PRAMOXINE HCL (PERIANAL) 1 % EX FOAM,RX-150001,CDM,6370000000,HCPCS,0637,RC,00037-6823-15,NDC,,both,15,GR,433.90,282.03,,,,,,,,,,,,,
GRAFT BIO TISS W6XL6CM FET BOV SIL MESHED ANTIMIC PRIMATRIX,SUP-2243717,CDM,Q4110,HCPCS,0636,RC,,,,both,,,5416.50,3520.72,,,,,,,,,,,,,
GRAFT BONE SUB 1-4MM 60ML ALLGRFT CHIP CANC DEMIN COPIOS,SUP-2205388,CDM,C1734,HCPCS,0278,RC,,,,both,,,2888.80,1877.72,,,,,,,,,,,,,
KNIFE SURG LO BRECK 10.75 IN CART STR EDGE GUARDS CRV,SUP-2459935,CDM,2720000010,LOCAL,0272,RC,,,,both,,,477.28,310.23,,,,,,,,,,,,,
PLATE BNE L46MM 7 H DST ULN TI LOK COMPR FOR 2MM SCR,SUP-2191038,CDM,C1713,HCPCS,0278,RC,,,,both,,,2194.80,1426.62,,,,,,,,,,,,,
WASHER ORTH DIA2.5MM RND THRD LO PROF ALPS,SUP-2411738,CDM,C1713,HCPCS,0278,RC,,,,both,,,87.92,57.15,,,,,,,,,,,,,
CUTTER LOOP DISPOSABLE 230CM,SUP-2665296,CDM,2720000010,LOCAL,0272,RC,,,,both,,,797.56,518.41,,,,,,,,,,,,,
PIN FIX L9IN DIA32MM ST S STL 3 SIDE SGL TRCR 1 END PNT,SUP-2150502,CDM,C1713,HCPCS,0278,RC,,,,both,,,26.31,17.10,,,,,,,,,,,,,
GUIDEWIRE ORTHPDC 2MM DIA 20NL NTNL HMRL F/ROD SSTM PLRS NON,SUP-2640112,CDM,C1769,HCPCS,0272,RC,,,,both,,,276.32,179.61,,,,,,,,,,,,,
MATRIX BIO SZ 8 SQCM FISH SKIN DERMAL INTACT STRL OMEGA3,SUP-2909239,CDM,Q4158,HCPCS,0636,RC,,,,both,,,1598.26,1038.87,,,,,,,,,,,,,
GRAFT HUM TISS W1XL12CM THK04 07MM DERM HUM ACELLULAR,SUP-2307440,CDM,Q4128,HCPCS,0636,RC,,,,both,,,2177.90,1415.63,,,,,,,,,,,,,
GRAFT 1-8MM BONE CANCELLOUS CHIP 40ML,SUP-2655884,CDM,C1713,HCPCS,0278,RC,,,,both,,,1420.22,923.14,,,,,,,,,,,,,
IODINE 2 % EX TINC,RX-3962,CDM,6370000000,HCPCS,0637,RC,00395-1213-91,NDC,,both,30,ML,15.70,10.20,,,,,,,,,,,,,
BIT DRL 2.7 MM SLD W/ QUIK CONN,SUP-2848907,CDM,2720000010,LOCAL,0272,RC,,,,both,,,593.46,385.75,,,,,,,,,,,,,
SPACER 7770832 ELEV STD 32X8MM,SUP-2289144,CDM,C1889,HCPCS,0278,RC,,,,both,,,12246.00,7959.90,,,,,,,,,,,,,
SCREW BNE L30MM DIA6.5MM CANC HIP S STL GRIPTION FULL THRD,SUP-2250204,CDM,C1713,HCPCS,0278,RC,,,,both,,,188.40,122.46,,,,,,,,,,,,,
HC So2 Hepatitis C Virus Antibody,PX-3028680368,CDM,86803,CPT,0302,RC,,,,both,,,413.00,268.45,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE XL 16 CC CORTICOCANCELLOUS VIABLE,SUP-2932818,CDM,C1762,CPT,0278,RC,,,,both,,,62800.00,40820.00,,,,,,,,,,,,,
MESH HERN W4XL8IN RECTANG COMP POLYMER MACROPOROUS NAT,SUP-2219760,CDM,C1781,HCPCS,0278,RC,,,,both,,,1767.76,1149.04,,,,,,,,,,,,,
CATHETER HYDRPHLC COAT XP GLDECATH SIM 1 TIP 5FRX65CM,SUP-2385159,CDM,C1887,HCPCS,0272,RC,,,,both,,,159.20,103.48,,,,,,,,,,,,,
GUIDEWIRE ORTH THRD 1.6X220 MM FOR CANN SCREW NS 0333301304,SUP-2789100,CDM,C1769,HCPCS,0272,RC,,,,both,,,1299.71,844.81,,,,,,,,,,,,,
GUIDEWIRE VASC STR 025X150 STIFF GLIDEWIRE ZIPWIRE,SUP-2140204,CDM,C1769,HCPCS,0272,RC,,,,both,,,154.86,100.66,,,,,,,,,,,,,
PLATE BONE REG L95MM THK1MM 16 H MIDFACE SLV TI STR FOR 2MM,SUP-2402949,CDM,C1713,HCPCS,0278,RC,,,,both,,,1127.26,732.72,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA PLU MAXBARR 5FR S1395108D1,SUP-2632826,CDM,C1751,HCPCS,0278,RC,,,,both,,,911.23,592.30,,,,,,,,,,,,,
EYELET SPNL LP VUEPOINT II,SUP-2563644,CDM,C1713,HCPCS,0278,RC,,,,both,,,1491.50,969.47,,,,,,,,,,,,,
STAPLER INT 12 MM 2.5 MM TI MULTFI ENDO TA LF DISP,SUP-2787746,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2307.12,1499.63,,,,,,,,,,,,,
SUPPORT ORTHOT THGH LOWER EXTREMITY WT BEAR LACER,SUP-2435678,CDM,L2540,HCPCS,0274,RC,,,,both,,,1284.79,835.11,,,,,,,,,,,,,
SPLINT CLAV HVY PD 24 - 30IN SZ SM,SUP-2196988,CDM,L3650,HCPCS,0272,RC,,,,both,,,17.24,11.21,,,,,,,,,,,,,
SCREW BNE L75MM DIA6.5MM THRD L16MM S STL CANN HEX SOCK,SUP-2183840,CDM,C1713,HCPCS,0278,RC,,,,both,,,619.55,402.71,,,,,,,,,,,,,
WASHER ORTH OD10MM ID4.7MM S STL RND TC-100,SUP-2343823,CDM,C1713,HCPCS,0278,RC,,,,both,,,1573.52,1022.79,,,,,,,,,,,,,
PIN EXT FIX DIA 4/5 MM HALF CAP,SUP-2898418,CDM,C1713,HCPCS,0278,RC,,,,both,,,131.88,85.72,,,,,,,,,,,,,
DECITABINE (DACOGEN) SC CHEMO SYRINGE,RX-1150519,CDM,J3376,HCPCS,0636,RC,55111-0556-10,NDC,,both,1,UN,133.60,86.84,,,,,,,,,,,,,
SCREW BNE CORTICAL 1.5X9 MM,SUP-2199235,CDM,C1713,HCPCS,0278,RC,,,,both,,,44.53,28.94,,,,,,,,,,,,,
ALLOGRAFT DERMAL HUM TISS THCK 20X12 CMX2.3-3.3 MM ALLDERM,SUP-2475878,CDM,Q4116,HCPCS,0636,RC,,,,both,,,26002.34,16901.52,,,,,,,,,,,,,
STENT URET TRIA L 20 CM DIA 6 FR POLYUR PERCUSHIELD SFT,SUP-2457256,CDM,C2617,HCPCS,0278,RC,,,,both,,,695.79,452.26,,,,,,,,,,,,,
MESH SYN ABD N ABSRB OVL POLYPR W EXP,SUP-2125819,CDM,C1781,HCPCS,0278,RC,,,,both,,,3386.80,2201.42,,,,,,,,,,,,,
PLATE BONE 8 H STR THOR FIX RIBFIX BLU,SUP-2413096,CDM,C1713,HCPCS,0278,RC,,,,both,,,3114.88,2024.67,,,,,,,,,,,,,
GUIDEWIRE 100CM FLPY SINUS RELIEVA,SUP-2106358,CDM,C1769,HCPCS,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
PEGFILGRASTIM-JMDB 6 MG/0.6ML SC SOSY,RX-142877,CDM,Q5108,HCPCS,0636,RC,67457-0833-06,NDC,,both,0.6,ML,6158.20,4002.83,,,,,,,,,,,,,
PLATE BONE 6X42MM ULN BILAT CROSSLOCK DVR,SUP-2137043,CDM,C1713,HCPCS,0278,RC,,,,both,,,5006.54,3254.25,,,,,,,,,,,,,
GUIDEWIRE VASC ARW L 35 CM DIA 0.025 IN SS PERIPH SPRING STR,SUP-2838739,CDM,C1769,HCPCS,0272,RC,,,,both,,,34.04,22.13,,,,,,,,,,,,,
CATHETER THORACIC X-LARGE 24FR L26IN EXTENDED LENGTH STRAIGH,SUP-2825082,CDM,C1729,HCPCS,0272,RC,,,,both,,,83.74,54.43,,,,,,,,,,,,,
RESERVOIR 65MM,SUP-2140263,CDM,C1813,HCPCS,0278,RC,,,,both,,,2417.80,1571.57,,,,,,,,,,,,,
PLATE BNE T SM 2.7X32 MM 2/3 HOLE SS,SUP-2536129,CDM,C1713,HCPCS,0278,RC,,,,both,,,274.75,178.59,,,,,,,,,,,,,
NEONATAL AND PEDIATRIC PERCUTANEOUS PIGTAIL NEPHROSTOMY CATH,SUP-2822049,CDM,C1729,HCPCS,0272,RC,,,,both,,,512.92,333.40,,,,,,,,,,,,,
PLATE BNE L125MM 7 H NONSTERILE L DST RAD VOLAR DPHSEAL,SUP-2184061,CDM,C1713,HCPCS,0278,RC,,,,both,,,4256.40,2766.66,,,,,,,,,,,,,
SCREW BONE THOR STD 6MMX22MM,SUP-2362800,CDM,C1713,HCPCS,0278,RC,,,,both,,,1764.84,1147.15,,,,,,,,,,,,,
SHEATH INTRO 8FR L10CM 0.35IN TIP PERIPH PINN TIF,SUP-2384797,CDM,C1894,HCPCS,0272,RC,,,,both,,,427.67,277.99,,,,,,,,,,,,,
SCREW CRTX 5.0MM DIA 35MM LGTH FT SELF TAP F/BIOMET - 5.0MM,SUP-2136670,CDM,C1713,HCPCS,0278,RC,,,,both,,,543.22,353.09,,,,,,,,,,,,,
PLATE BNE STR 2.3X30 MM MAND 4 HOLE COMPR FRAC TI LEVEL 1 LF,SUP-2470388,CDM,C1713,HCPCS,0278,RC,,,,both,,,769.99,500.49,,,,,,,,,,,,,
KIT CATH 4.5FR L15CM SHTH L2.75IN NDL 25GA L1.5IN SYR 5ML,SUP-2120614,CDM,C1751,HCPCS,0278,RC,,,,both,,,736.86,478.96,,,,,,,,,,,,,
HYSTEROSCOPE RIGID CORAL AVETA DISP,SUP-2739124,CDM,2720000010,LOCAL,0272,RC,,,,both,,,599.74,389.83,,,,,,,,,,,,,
ARM DISTRACTOR 25MML EXTERNAL MANDIBULAR 3DX 51 601 25 09,SUP-2500751,CDM,C1713,HCPCS,0278,RC,,,,both,,,875.18,568.87,,,,,,,,,,,,,
IMPLANT 17MM M PAT FLNG CO CHROM ALLOY,SUP-2419630,CDM,C1776,CPT,0278,RC,,,,both,,,27324.28,17760.78,,,,,,,,,,,,,
COLLAGEN REP PTCH,SUP-2172379,CDM,C9364,HCPCS,0278,RC,,,,both,,,5495.00,3571.75,,,,,,,,,,,,,
ENDCAP ORTHOPEDIC OFFSET +6MM SUBTALAR FUSION DYNANAIL MINI HYBRID MEDSHAPE,SUP-2878729,CDM,C1889,HCPCS,0278,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
GUIDE NERVE REP MTRX 5 MMX3 CM STRL NEURAGEN 3D LF,SUP-2877632,CDM,C9352,HCPCS,0278,RC,,,,both,,,8631.86,5610.71,,,,,,,,,,,,,
BUNDLE ORTHOGNATHIC MOD W ADV GUID VSP,SUP-2366019,CDM,2720000010,LOCAL,0272,RC,,,,both,,,12664.06,8231.64,,,,,,,,,,,,,
CATHETER DIL L 135 CM DIA 3.3 FR BALLOON L 2 CM DIA 4 MM,SUP-2139578,CDM,C1725,HCPCS,0272,RC,,,,both,,,1064.46,691.90,,,,,,,,,,,,,
SHELL ACET TOT HIP PRI PRESSFIT CLUS H UNIV A SER 52MM OD,SUP-2221792,CDM,C1776,CPT,0278,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
COMPONENT TIB 10.6MM SM TAPR POST UNI UNICAP,SUP-2123718,CDM,C1776,CPT,0278,RC,,,,both,,,1555.43,1011.03,,,,,,,,,,,,,
PLATE BNE L 221 X W 11.5 MM THK 3.6 MM SCREW DIA 3.5 MM 18 H 72463118N,SUP-2932917,CDM,C1713,HCPCS,0278,RC,,,,both,,,7884.54,5124.95,,,,,,,,,,,,,
PUMP PERF IMPELLA 2.5,SUP-2106287,CDM,2720000010,LOCAL,0272,RC,,,,both,,,62800.00,40820.00,,,,,,,,,,,,,
SCREW BNE L 6 MM DIA1.7 MM MANDIBULAR ST CROSS PIN INCREASED,SUP-2884166,CDM,C1713,HCPCS,0278,RC,,,,both,,,321.88,209.22,,,,,,,,,,,,,
CLAMP SURG ROD TO ROD 5.5-6.5 MM REVERE,SUP-2584886,CDM,C1713,HCPCS,0278,RC,,,,both,,,1036.20,673.53,,,,,,,,,,,,,
INSULIN ASPART 100 UNIT/ML IJ SOLN,RX-157658,CDM,J1815,HCPCS,0637,RC,00169-7501-11,NDC,,both,10,ML,57.90,37.63,,,,,,,,,,,,,
SODIUM CHLORIDE 3 % IN NEBU,RX-7327,CDM,J3490,HCPCS,0250,RC,50190-0142-63,NDC,,both,4,ML,2.90,1.88,,,,,,,,,,,,,
HC Canalith Repositioning Proc,PX-4209599200,CDM,95992,CPT,0420,RC,,,,both,,,333.00,216.45,,,,,,,,,,,,,
HEAD HUM OD40MM CO CHROM PROX SHLDR MORSE TAPR MRS,SUP-2376488,CDM,C1776,CPT,0278,RC,,,,both,,,8482.24,5513.46,,,,,,,,,,,,,
SET SHTH DESTINO L 87 CM L 67 CM 8.5FRCRV BEND 17 MM,SUP-2616200,CDM,C1766,CPT,0272,RC,,,,both,,,2088.10,1357.26,,,,,,,,,,,,,
KIT IOBP HIP STRL,SUP-2653377,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
PLATE BONE RT DSTL VOLAR RIM CROSSLOCK TECHNOLOGY EPAK DVR,SUP-2137034,CDM,C1713,HCPCS,0278,RC,,,,both,,,6888.85,4477.75,,,,,,,,,,,,,
ENDOPROSTHESIS VASC VIABAHN L 10 CM DIA11 MM NIT EPTFE LNR,SUP-2396468,CDM,C1874,HCPCS,0278,RC,,,,both,,,8007.00,5204.55,,,,,,,,,,,,,
GRAFT VASC IMPRA L 35 CM DIA19 MM EPTFE STR STD WALL LG,SUP-2761269,CDM,C1768,CPT,0278,RC,,,,both,,,2288.09,1487.26,,,,,,,,,,,,,
KIT NEUROSTIM L8IN 1X8 LO PROF CLS BOOT PLUG FOR INTERSTIM,SUP-2284436,CDM,2720000010,LOCAL,0272,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
PLATE BNE DBL ANGLED SM 2 MM RECON PT SPEC TI,SUP-2860082,CDM,C1713,HCPCS,0278,RC,,,,both,,,20509.54,13331.20,,,,,,,,,,,,,
GRAFT BIO TISS W8XL8CM SLD FET BOV ACELLULAR DERM MTRX,SUP-2243688,CDM,Q4110,HCPCS,0636,RC,,,,both,,,6217.20,4041.18,,,,,,,,,,,,,
IMPL HIP TRIFLANGE SZ24 LT,SUP-2422277,CDM,C1776,CPT,0278,RC,,,,both,,,36110.00,23471.50,,,,,,,,,,,,,
SET INT FIX BURR H PLATE DIA18.5 MM SCREW DIA1.5 MM 15-7379X,SUP-2936398,CDM,C1713,HCPCS,0278,RC,,,,both,,,3400.62,2210.40,,,,,,,,,,,,,
CATHETER DRNGE 6.5FR L30CM TOT ABSCESSION,SUP-2117065,CDM,C1729,HCPCS,0272,RC,,,,both,,,212.80,138.32,,,,,,,,,,,,,
VALVE SHUNT ADJUSTABLE UNIT 0-20CM H2O WITHOUT GRAVITATIONAL,SUP-2821851,CDM,C1889,HCPCS,0278,RC,,,,both,,,8007.03,5204.57,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 50 CM DIA 8 MM STR STD WALL REINF,SUP-2525436,CDM,C1768,CPT,0278,RC,,,,both,,,671.65,436.57,,,,,,,,,,,,,
BASKET EXTR STONE THE WEB II 4 WIR 7 FR X 220 CM SHTH 2 CM,SUP-2169437,CDM,2720000010,LOCAL,0272,RC,,,,both,,,533.80,346.97,,,,,,,,,,,,,
CEMENT BNE 20ML 40GM PCH M VISC CO,SUP-2216771,CDM,C1713,HCPCS,0278,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
PLATE BNE RECON 2.7X241 MM 20 HOLE LCK STR SS STRL,SUP-2469129,CDM,C1713,HCPCS,0278,RC,,,,both,,,2580.89,1677.58,,,,,,,,,,,,,
PLATE BNE 10 H 98DEG SUPCONDYLAR S STL BILAT LOK RIG SHT,SUP-2370901,CDM,C1713,HCPCS,0278,RC,,,,both,,,4052.96,2634.42,,,,,,,,,,,,,
BLADE SHV PLAT 5.5MM DYONICS INCIS +,SUP-2341135,CDM,2720000010,LOCAL,0272,RC,,,,both,,,325.49,211.57,,,,,,,,,,,,,
BIT DRL L19MM DIA1.6MM DENT SHFT END FOR 2/2.3X8MM,SUP-2366426,CDM,2720000010,LOCAL,0272,RC,,,,both,,,359.72,233.82,,,,,,,,,,,,,
BIT DRILL SURG W/ NEEDLE FOR Q-FIX STRL DISP,SUP-2882970,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1259.93,818.95,,,,,,,,,,,,,
TUBE MYR DIAM 4.5MM LEN 1.32MM T SHP SIL,SUP-2312838,CDM,L8699,HCPCS,0278,RC,,,,both,,,46.03,29.92,,,,,,,,,,,,,
PLATE THRD RINGFIX SYS 7 HL 175MM,SUP-2704819,CDM,C1713,HCPCS,0278,RC,,,,both,,,994.75,646.59,,,,,,,,,,,,,
DEXTROSE 250 MG/ML IV SOLN,RX-2361,CDM,2580000003,HCPCS,0258,RC,00409-1775-10,NDC,,both,10,ML,175.10,113.81,,,,,,,,,,,,,
ASSEMBLY ENDOSCP FIX STR AB FOR MENIS REP SYS ULT FAST-FIX,SUP-2341776,CDM,C1713,HCPCS,0278,RC,,,,both,,,1198.76,779.19,,,,,,,,,,,,,
RIB PLATE 14MMX76MM,SUP-2841915,CDM,C1713,HCPCS,0278,RC,,,,both,,,4075.72,2649.22,,,,,,,,,,,,,
STENT LARYNGEAL MONTGOMERY L 11 X W 10 X H 37 MM SM SIL FIRM,SUP-2138741,CDM,C1875,HCPCS,0278,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
SINGLE CDP PM KT ST. ELIZABETH HOSP,SUP-2214644,CDM,2720000010,LOCAL,0272,RC,,,,both,,,46.25,30.06,,,,,,,,,,,,,
HC Neonatal Resusitation,PX-7229946500,CDM,99465,CPT,0722,RC,,,,outpatient,,,113.00,73.45,,,,,,,,,,,,,
SYSTEM INTRO SAFSHTH ULTRA DIA12 FR HEMOSTATIC TEARWY VLV,SUP-2159471,CDM,C1892,HCPCS,0272,RC,,,,both,,,626.30,407.09,,,,,,,,,,,,,
HC Neonatal Resusitation,PX-7229946500,CDM,99465,CPT,0722,RC,,,,inpatient,,,113.00,73.45,,,,,,,,,,,,,
SIDEKICK  HALF PIN5X50 TIN 180MM LNG,SUP-2499229,CDM,C1713,HCPCS,0278,RC,,,,both,,,335.98,218.39,,,,,,,,,,,,,
STEM HUM L205MM OD8MM TI POR SHLDR REV UNCEMENTED IMP,SUP-2404710,CDM,C1776,CPT,0278,RC,,,,both,,,11533.22,7496.59,,,,,,,,,,,,,
SCREW BONE L24MM OD4MM HEADLESS,SUP-2431345,CDM,C1713,HCPCS,0278,RC,,,,both,,,879.20,571.48,,,,,,,,,,,,,
BOLT ORTHOPEDIC 125 MM FEM TI STRL FNS,SUP-2432246,CDM,C1713,HCPCS,0278,RC,,,,both,,,1109.99,721.49,,,,,,,,,,,,,
SCREW BNE DRILL-FREE 1.5X5 MM MIDFACIAL SELF RET NS MAXDRIVE,SUP-2459684,CDM,C1713,HCPCS,0278,RC,,,,both,,,185.01,120.26,,,,,,,,,,,,,
SHEATH GUID R2P DESTINATION SLENDER L124CM 119CM 6FR 0.038IN,SUP-2385124,CDM,C1894,HCPCS,0272,RC,,,,both,,,1004.80,653.12,,,,,,,,,,,,,
BRACE GAUNTLET WR LT 1 SZ FITS MOST REG ELAS SUPP FABRIFOAM,SUP-2334826,CDM,L3809,HCPCS,0272,RC,,,,both,,,34.26,22.27,,,,,,,,,,,,,
IMPLANT COSMETIC SZ 29 X 19 X 6 MM POLYETHYL LT PARANASAL,SUP-2935830,CDM,C1713,HCPCS,0278,RC,,,,both,,,1836.90,1193.98,,,,,,,,,,,,,
ALLOGRAFT BNE LT HEMI ILIUM FRZN,SUP-2717846,CDM,C1762,CPT,0278,RC,,,,both,,,17307.68,11249.99,,,,,,,,,,,,,
BURR SURG DIAMOND 5 MM,SUP-2661405,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
GUIDE WIRE .090X4,SUP-2814017,CDM,C1769,HCPCS,0272,RC,,,,both,,,248.06,161.24,,,,,,,,,,,,,
"HC New Pt, E/M Level 4",PX-5109920400,CDM,99204,CPT,0510,RC,,,,inpatient,,,344.00,223.60,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY INQUIRY L 110 CM 5FR 5MM MED QPLR,SUP-2499986,CDM,C1730,HCPCS,0272,RC,,,,both,,,503.66,327.38,,,,,,,,,,,,,
WASHER ORTH OD7MM ID3.7MM STRL S STL RND TC-100,SUP-2343819,CDM,C1713,HCPCS,0278,RC,,,,both,,,237.57,154.42,,,,,,,,,,,,,
BLADE SHAVER BPLR STD 40 DEG 4 MM SERRATED STRL DISP,SUP-2638395,CDM,2720000010,LOCAL,0272,RC,,,,both,,,536.94,349.01,,,,,,,,,,,,,
SHORT RADIAL OSTEOTOME BLADE,SUP-2514518,CDM,2720000010,LOCAL,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
HC Bx Breast 1st Lesion US Img,PX-3611908300,CDM,19083,CPT,0361,RC,,,,outpatient,,,7265.00,4722.25,,,,,,,,,,,,,
ENDOTRACHEAL TUBE KIT 39 FR LT DL BLT IN VID CAM VIVASIGHT 2,SUP-2752996,CDM,2720000010,LOCAL,0272,RC,,,,both,,,816.40,530.66,,,,,,,,,,,,,
FRAME ORTH L200MM ASSEMB SALVATION,SUP-2401159,CDM,2720000010,LOCAL,0272,RC,,,,both,,,22783.84,14809.50,,,,,,,,,,,,,
CATHETER ANGIOPLSTY ADV 14LP L 110 CM BALLOON L 6 CM DIA2 MM,SUP-2168966,CDM,C1725,HCPCS,0272,RC,,,,both,,,1295.25,841.91,,,,,,,,,,,,,
BUR SURG DIAMOND 0.5 MM FOR STAP NS REUSE,SUP-2638246,CDM,2720000010,LOCAL,0272,RC,,,,both,,,338.62,220.10,,,,,,,,,,,,,
SET SCR IM HIP,SUP-2351366,CDM,C1713,HCPCS,0278,RC,,,,both,,,458.94,298.31,,,,,,,,,,,,,
DOXORUBICIN HCL 2 MG/ML IV SOLN|DISCARDED DRUG NOT ADMINISTE,RX-2616,CDM,J9000,HCPCS,0636,RC,63323-0883-30,NDC,JW,both,25,ML,96.00,62.40,,,,,,,,,,,,,
GRAFT VASC ADVANTA SST L 70 CM DIA 6 MM EPTFE STR TW REINF 3,SUP-2265943,CDM,C1768,CPT,0278,RC,,,,both,,,3764.45,2446.89,,,,,,,,,,,,,
BLADE LARYN L22.5CM DIA4MM NONROTATABLE STR TIP CURED AT,SUP-2284154,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1548.24,1006.36,,,,,,,,,,,,,
HEAD HUMERAL 46MM,SUP-2863709,CDM,C1776,CPT,0278,RC,,,,both,,,3350.38,2177.75,,,,,,,,,,,,,
JIG SURG LT TIB KNEE PREF ROT PT SPEC DISP PERSONA,SUP-2205591,CDM,C1776,CPT,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
HC Ot Therapeutic Activities 15 Min,PX-4309753000,CDM,97530,CPT,0430,RC,,,,both,,,144.00,93.60,,,,,,,,,,,,,
COMPONENT CNTRL BODY EXTRNL FXTR INNER BODY MALE RTTN FDFS,SUP-2720668,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1362.76,885.79,,,,,,,,,,,,,
PACEMAKER CARD ELUNA 8 PROMRI SR-T SINGLE CHMBR CLOSED LOOP,SUP-2138421,CDM,C1786,HCPCS,0275,RC,,,,both,,,11461.00,7449.65,,,,,,,,,,,,,
BUR SURG MTCH HD 3 MM 14 CM SYMMETRI PROX MIDAS REX 8 SD/SP,SUP-2664959,CDM,2720000010,LOCAL,0272,RC,,,,both,,,995.25,646.91,,,,,,,,,,,,,
GRAFT BNE GEL 1 CC DBM MAROFUSE,SUP-2120697,CDM,C1713,HCPCS,0278,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
PROBE ARTHSCP OD3MM BLK ABLAT MPLR RF INTEGR VULCAN DYONICS,SUP-2341028,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1551.16,1008.25,,,,,,,,,,,,,
PIN BNE FIX STR DRL TIP CADENCE,SUP-2933321,CDM,C1713,HCPCS,0278,RC,,,,both,,,372.28,241.98,,,,,,,,,,,,,
DRILL HIP PL HARD BONE 2.9MM,SUP-2812123,CDM,2720000010,LOCAL,0272,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
"HC So Cult,Pathognic Orgnsms,Screen",PX-3008708166,CDM,87081,CPT,0300,RC,,,,inpatient,,,173.00,112.45,,,,,,,,,,,,,
BUR SURG DIA 3.1 MM HUB III DIAMOND NEURO CUT COARSE STRL,SUP-2929450,CDM,2720000010,LOCAL,0272,RC,,,,both,,,524.69,341.05,,,,,,,,,,,,,
KIT BPH W/ 90FR X 30MM DCB 90FR X 30MM BASIC BALL INFL DEV,SUP-2915375,CDM,C1889,HCPCS,0278,RC,,,,both,,,18526.00,12041.90,,,,,,,,,,,,,
EPICORD EXPANDABLE 2x3cm 6SQ CM,SUP-2660776,CDM,Q4187,HCPCS,0636,RC,,,,both,,,4753.96,3090.07,,,,,,,,,,,,,
PLATE BNE W10XL75MM THK1.5MM 90DEG 4X6 H BILAT S STL T SHP,SUP-2185873,CDM,C1713,HCPCS,0278,RC,,,,both,,,1121.83,729.19,,,,,,,,,,,,,
BIT DRL L270MM DIA4MM CALIB L95MM 3 FLUT QUIK CPL,SUP-2188199,CDM,2720000010,LOCAL,0272,RC,,,,both,,,769.87,500.42,,,,,,,,,,,,,
MESH SURG STRUT THK0.4MM SLV CRANIOFACIAL TI MALL CNTOUR LO,SUP-2181552,CDM,C1713,HCPCS,0278,RC,,,,both,,,1940.52,1261.34,,,,,,,,,,,,,
GENTAMICIN SULFATE 2 MG/ML IVPB (PED-NEO) >/= 50 ML|DISCARDED DRUG NOT ADMINISTE,RX-4090290,CDM,J1580,HCPCS,0636,RC,00338-0511-41,NDC,JW,both,50,ML,54.10,35.16,,,,,,,,,,,,,
SCREW BONE L36MM DIA3.5MM STD FT ANK TI LCK,SUP-2321027,CDM,C1713,HCPCS,0278,RC,,,,both,,,486.70,316.35,,,,,,,,,,,,,
MESH SURG W0.2XL2.7CM SPCR POLYETH SGL USE OPTIMESH,SUP-2354629,CDM,C1781,HCPCS,0278,RC,,,,both,,,10990.00,7143.50,,,,,,,,,,,,,
STEM FEM L250MM OD19MM LT HIP REV CO CHROM 3DEG BIPLANAR,SUP-2405149,CDM,C1713,HCPCS,0278,RC,,,,both,,,14820.80,9633.52,,,,,,,,,,,,,
CLAMP SURG STD LEN JAW STRL ISOLATOR SYNERGY ENCOMPASS DISP,SUP-2866238,CDM,2720000010,LOCAL,0272,RC,,,,both,,,16956.00,11021.40,,,,,,,,,,,,,
PIN GUID DIA2MM GLEN SYS HEMICAP,SUP-2123637,CDM,2720000010,LOCAL,0272,RC,,,,both,,,351.68,228.59,,,,,,,,,,,,,
SCREW BONE L90MM DIA6.5MM CANC PARTIALLY THRD S STL,SUP-2348932,CDM,C1713,HCPCS,0278,RC,,,,both,,,365.50,237.57,,,,,,,,,,,,,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN,RX-9626,CDM,J0736,HCPCS,0636,RC,00781-3289-09,NDC,,both,50,ML,68.20,44.33,,,,,,,,,,,,,
COMPONENT FEM 1.5 KNEE 3 IN 1 SIG,SUP-2456217,CDM,C1776,CPT,0278,RC,,,,both,,,8308.44,5400.49,,,,,,,,,,,,,
GRAFT VASC HEMGRD BODY/BRANCH L 100/60 CM DIA 8 X 8 MM,SUP-2478763,CDM,C1768,CPT,0278,RC,,,,both,,,2569.96,1670.47,,,,,,,,,,,,,
FIXATOR EXT FIX COMPR DISTRCTN STATIC XCALIBER PVC FREE STRL,SUP-2646338,CDM,2720000010,LOCAL,0272,RC,,,,both,,,965.55,627.61,,,,,,,,,,,,,
PLATE BONE L245MM 9 HOLE NNSTRLE PRPRSTHTC RIGHT PRXML FMRL,SUP-2481444,CDM,C1713,HCPCS,0278,RC,,,,both,,,3891.40,2529.41,,,,,,,,,,,,,
PLATE BNE CRV SHT 2-2.5X2 MM FRAC NC LCK FOR SCR TI LEVEL 1,SUP-2467710,CDM,C1713,HCPCS,0278,RC,,,,both,,,1408.04,915.23,,,,,,,,,,,,,
DRIVER SURG T7 CANN STK FIT HEXALOBE NS DISP,SUP-2912797,CDM,C1713,HCPCS,0278,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
KIT CATH NPHRSTMY LNGMN 7FR DIA 150CML PRCTNS LOW PRFLE HIGH,SUP-2722034,CDM,C1729,HCPCS,0272,RC,,,,both,,,2002.66,1301.73,,,,,,,,,,,,,
COMPONENT GLEN PEXSM BIOMET -X-SM,SUP-2403415,CDM,C1776,CPT,0278,RC,,,,both,,,4816.76,3130.89,,,,,,,,,,,,,
HC Therapeutic Excercise/Imt Ea 15min,PX-4100023700,CDM,G0237,CPT,0410,RC,,,,both,,,96.00,62.40,,,,,,,,,,,,,
CATHETER INFUSION EMB 2.9 FRX100 CM MIC STR EMBOCATH +,SUP-2302530,CDM,C1757,HCPCS,0272,RC,,,,both,,,846.86,550.46,,,,,,,,,,,,,
SCREW BONE L75MM OD4.5MM CORT SLD FULL THRD STRL,SUP-2413175,CDM,C1713,HCPCS,0278,RC,,,,both,,,181.05,117.68,,,,,,,,,,,,,
BLADE SAW OSCLLTNG 19.5MMW X 80MML 0.8MM THK 0.9MM THK CUT M,SUP-2586311,CDM,2720000010,LOCAL,0272,RC,,,,both,,,82.24,53.46,,,,,,,,,,,,,
GUIDEWIRE VASC BLNT 610 MM NIT,SUP-2630451,CDM,C1769,HCPCS,0272,RC,,,,both,,,238.64,155.12,,,,,,,,,,,,,
VALVE CSF REG W/ BIOGLDE STRATA II,SUP-2631433,CDM,C1889,HCPCS,0278,RC,,,,both,,,13634.29,8862.29,,,,,,,,,,,,,
HEAD HUM 44X16 MM SHLDR STEM FREE SIDUS,SUP-2440779,CDM,C1776,CPT,0278,RC,,,,both,,,5369.40,3490.11,,,,,,,,,,,,,
BLADE SAW OSCILLATING 63X49X0.6 MM 0.6 MM FOR LG BNE HALL,SUP-2607472,CDM,2720000010,LOCAL,0272,RC,,,,both,,,76.93,50.00,,,,,,,,,,,,,
SPACER SPNL W10XH7XL27MM 0DEG PEEK PARA LAT THORLUM INTBDY,SUP-2194086,CDM,C1821,HCPCS,0278,RC,,,,both,,,10048.00,6531.20,,,,,,,,,,,,,
SCREW BONE L80MM DIA6.35MM FULL THRD LCK GS KEMPF,SUP-2362425,CDM,C1713,HCPCS,0278,RC,,,,both,,,251.33,163.36,,,,,,,,,,,,,
BALLOON IMPL LIMB SALV L 80 CM DIA18/22 MM SHTH 7 MM 65 ML,SUP-2883004,CDM,C1713,HCPCS,0278,RC,,,,both,,,16271.48,10576.46,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED COCR JOURNEY,SUP-2348007,CDM,C1776,CPT,0278,RC,,,,both,,,22934.56,14907.46,,,,,,,,,,,,,
CEMENT BONE POLYMETHYLMETHACRYLATE,SUP-2351722,CDM,C1713,HCPCS,0278,RC,,,,both,,,769.30,500.04,,,,,,,,,,,,,
PLATE BNE Y MED 1.5X29X0.8 MM MIDFACE 7 HOLE W/ TAB NS,SUP-2494949,CDM,C1713,HCPCS,0278,RC,,,,both,,,815.93,530.35,,,,,,,,,,,,,
JOINT TOE 1ST MTP 8 MM HA COAT ENCOMPASS LTX,SUP-2857525,CDM,C1776,CPT,0278,RC,,,,both,,,4179.34,2716.57,,,,,,,,,,,,,
PLATE BONE THK0.6MM 6 H ORBIT RIM SLV FOR 2MM SCR LORENZ,SUP-2402930,CDM,C1713,HCPCS,0278,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
PLATE EXT FIX 180MM FT ALUM,SUP-2242954,CDM,C1713,HCPCS,0278,RC,,,,both,,,5638.31,3664.90,,,,,,,,,,,,,
IMPLANT FACE 76 X 127 MM THK 0.85 MM POLYETHYL CRANIOFACIAL,SUP-2883399,CDM,C1713,HCPCS,0278,RC,,,,both,,,3629.34,2359.07,,,,,,,,,,,,,
NAIL IM L380MM DIA10MM FEM KNEE GLD TI CANN LCK RG BENT,SUP-2347395,CDM,C1713,HCPCS,0278,RC,,,,both,,,12015.68,7810.19,,,,,,,,,,,,,
PLATE BONE MESHED 151X125 MM LEFT CRANIAL PREFORMED FRONTOTE,SUP-2837719,CDM,C1713,HCPCS,0278,RC,,,,both,,,22851.04,14853.18,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP L150CM DIA0.025IN TIP L3CM NIT HYDRPHLC,SUP-2139343,CDM,C1769,HCPCS,0272,RC,,,,both,,,184.51,119.93,,,,,,,,,,,,,
COMPONENT PAT DIA35MM THK9MM STD KNEE VIVACIT-E CEM PERSONA,SUP-2207292,CDM,C1776,CPT,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
RING ACET SZ F CONSTRAINING SNAP FOR CLUS AND MH SHELL,SUP-2222081,CDM,C1776,CPT,0278,RC,,,,both,,,2336.47,1518.71,,,,,,,,,,,,,
WIRE GUID PRSS PRIMEWIRE SHT J TIP .014INX185CM PRESTIGE,SUP-2327225,CDM,C1769,HCPCS,0272,RC,,,,both,,,2072.40,1347.06,,,,,,,,,,,,,
MESH GYN W4XL24CM POLYPR UNIDIR Y CNTOUR FOR TRANSABDOMINAL,SUP-2165308,CDM,C1781,HCPCS,0278,RC,,,,both,,,2935.90,1908.33,,,,,,,,,,,,,
"HC So Antibody,Hiv 1 & Hiv 2, Assay",PX-3028670366,CDM,86703,CPT,0302,RC,,,,inpatient,,,187.00,121.55,,,,,,,,,,,,,
ALLOGRAFT BNE 5 CC DBM BONUS TRIAD,SUP-2607050,CDM,C1889,HCPCS,0278,RC,,,,both,,,6711.75,4362.64,,,,,,,,,,,,,
GRAFT STENT LIMB AAA ENDOPROSTHESIS,SUP-2395937,CDM,C1768,HCPCS,0278,RC,,,,both,,,8509.40,5531.11,,,,,,,,,,,,,
HC Assay of Sodium Other Source,PX-3018430200,CDM,84302,CPT,0301,RC,,,,both,,,203.00,131.95,,,,,,,,,,,,,
CONTOURED PLATE 12 HOLE LEFT,SUP-2722550,CDM,C1713,HCPCS,0278,RC,,,,both,,,3903.02,2536.96,,,,,,,,,,,,,
COLLAR CERV SUPP X TALL AD COMFORT,SUP-2269629,CDM,L0180,HCPCS,0274,RC,,,,both,,,141.30,91.84,,,,,,,,,,,,,
TUBE VENT 1.27 MM 1.5 MM 2.75 MM SHEEHY CLLR BUTTON SIL STRL,SUP-2458252,CDM,L8699,HCPCS,0278,RC,,,,both,,,29.39,19.10,,,,,,,,,,,,,
HC Fna Bx W/US Gdn 1st Les,PX-3611000500,CDM,10005,CPT,0361,RC,,,,both,,,3993.00,2595.45,,,,,,,,,,,,,
RING ANNULPLSTY CARP EDW PHY 40MM 45.3MM 38.7MM 804SQMM FLX2,SUP-2214164,CDM,C1889,HCPCS,0278,RC,,,,both,,,10990.00,7143.50,,,,,,,,,,,,,
MESH SURG L 30 X W 30 CM POLYPRO POLYLACTIC ACD GRP,SUP-2901781,CDM,C1781,HCPCS,0278,RC,,,,both,,,5408.90,3515.78,,,,,,,,,,,,,
VISE EXT FIX INSUL MINI HM29,SUP-2517251,CDM,2720000010,LOCAL,0272,RC,,,,both,,,600.05,390.03,,,,,,,,,,,,,
GRAFT BONE SUB 5CC PASTE DEMIN MTRX VIAGRAF,SUP-2348208,CDM,C1713,HCPCS,0278,RC,,,,both,,,2078.68,1351.14,,,,,,,,,,,,,
PEDIATRIC SLOT HEAD COMP SCREW,SUP-2818327,CDM,C1713,HCPCS,0278,RC,,,,both,,,581.75,378.14,,,,,,,,,,,,,
SCREW INTRF L25MM DIA7MM ANTR KNEE PLLA HA CANN FOR CRUC,SUP-2341099,CDM,C1713,HCPCS,0278,RC,,,,both,,,1055.35,685.98,,,,,,,,,,,,,
PLATE BONE 13 H DSTL RAD VOLAR LT LNG 2.5 ADAPTIVE II TRILOK,SUP-2267962,CDM,C1713,HCPCS,0278,RC,,,,both,,,4612.66,2998.23,,,,,,,,,,,,,
PLATE BNE L61MM THK3.3MM 5 H BILAT S STL RIG STR DYN COMPR,SUP-2186329,CDM,C1713,HCPCS,0278,RC,,,,both,,,469.46,305.15,,,,,,,,,,,,,
HC Perq Drainage Pleura Insert Cath W/O Imaging,PX-4503255600,CDM,32556,CPT,0450,RC,,,,both,,,5820.00,3783.00,,,,,,,,,,,,,
ATTACHMENT SAG SAW FOR UNIV DRVR,SUP-2362647,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5719.04,3717.38,,,,,,,,,,,,,
SCREW BNE SELF DRL GALLERY LAMINOPLASTY SPINE 2.4 MM X 5.0,SUP-2414966,CDM,C1713,HCPCS,0278,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
HC Fetal Echo 2d W/WO M-Mode F/U or Repeat,PX-4027682600,CDM,76826,CPT,0402,RC,,,,both,,,727.00,472.55,,,,,,,,,,,,,
HC Abdom Paracentesis Dx/Ther W Imaging Guidance,PX-4504908300,CDM,49083,CPT,0450,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
KIT INTRO PEEL AWAY 8.5F,SUP-2357064,CDM,C1894,HCPCS,0272,RC,,,,both,,,25.12,16.33,,,,,,,,,,,,,
DILATOR URO L35CM OD24FR ID8FR AMPLTZ TYP TEF RENAL TAPR,SUP-2139745,CDM,C1894,HCPCS,0272,RC,,,,both,,,66.41,43.17,,,,,,,,,,,,,
PREMASOL 10 % IV SOLN,RX-36160,CDM,2500000003,HCPCS,0250,RC,00338-1130-03,NDC,,both,500,ML,310.50,201.82,,,,,,,,,,,,,
STENT COR 0.018 IN 3 MM 135 CM,SUP-2159051,CDM,C1876,HCPCS,0278,RC,,,,both,,,2370.70,1540.95,,,,,,,,,,,,,
LENS INTOCU 6.0 TO 30.0 DIOPT 118.4 A CONSTANT 0DEG ANG,SUP-2110986,CDM,V2632,HCPCS,0276,RC,,,,both,,,580.90,377.58,,,,,,,,,,,,,
PLATE BNE RNG ATTCH LG 3.5 MM RT PROX GTR TROCH NS VA-LCP,SUP-2757654,CDM,C1713,HCPCS,0278,RC,,,,both,,,4360.02,2834.01,,,,,,,,,,,,,
HC Drain Outer Ear Canal Lesion,PX-4506902000,CDM,69020,CPT,0450,RC,,,,both,,,730.00,474.50,,,,,,,,,,,,,
GRAFT BNE SUB 25CC 1 4MM DEMIN CANC SPNG CHIP FLEXIGRFT,SUP-2264610,CDM,C1713,HCPCS,0278,RC,,,,both,,,940.46,611.30,,,,,,,,,,,,,
CABLE EP BPLR EXTN FOR USE W CPS LUMINARY,SUP-2357044,CDM,C1887,HCPCS,0272,RC,,,,both,,,270.04,175.53,,,,,,,,,,,,,
HOOK SPNL BLDE W5.5MM RT TI SUPRALAMINAR ANG OPN FOR 5.5MM,SUP-2254447,CDM,C1713,HCPCS,0278,RC,,,,both,,,2873.10,1867.51,,,,,,,,,,,,,
PLATE BNE L 98 MM 8 H SS RADIAL SHFT STRL EVOS,SUP-2932808,CDM,C1713,HCPCS,0278,RC,,,,both,,,2404.30,1562.79,,,,,,,,,,,,,
BLADE SURG FASCIAL INVICTUS,SUP-2728785,CDM,2720000010,LOCAL,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
PLATE BNE POST ELBW,SUP-2525761,CDM,C1713,HCPCS,0278,RC,,,,both,,,3460.28,2249.18,,,,,,,,,,,,,
TRAY CATH HEMODIALYSI PWR TRIALYSI ACUTE 13FR DIA 12.5CML IN,SUP-2613248,CDM,C1752,HCPCS,0278,RC,,,,both,,,1041.41,676.92,,,,,,,,,,,,,
HC Needle Biopsy Muscle,PX-3612020600,CDM,20206,CPT,0361,RC,,,,outpatient,,,3707.00,2409.55,,,,,,,,,,,,,
DEFIBRILLATOR CARDIOVERTER SGL CHMBR 40 J BPLR ADV VVED 20,SUP-2138123,CDM,C1722,HCPCS,0275,RC,,,,both,,,48310.31,31401.70,,,,,,,,,,,,,
NEEDLE LIGATURE L7.5IN MALLEABLE TIP AL MEFTY,SUP-2805560,CDM,2720000010,LOCAL,0272,RC,,,,both,,,793.82,515.98,,,,,,,,,,,,,
DRIVER SURG SQ TIP DIA2MM PEG TORQ LIMITING FOR GEMINUS,SUP-2340184,CDM,2720000010,LOCAL,0272,RC,,,,both,,,163.28,106.13,,,,,,,,,,,,,
HC 'hepatitis B Surface Ag - Dono|NOT REASONABLE AND NECESSARY,PX-3028734000,CDM,87340,CPT,0302,RC,,,GZ,both,,,27.00,17.55,,,,,,,,,,,,,
FORCEPS STONE RETRV 2.4FR L120CM PTFE RETRACTING GRSP,SUP-2139263,CDM,2720000010,LOCAL,0272,RC,,,,both,,,538.86,350.26,,,,,,,,,,,,,
IMPLANT COSMETIC SZ 40 X 40 X 2.7 X 0.7 MM LG POLYETHYL,SUP-2935647,CDM,C1713,HCPCS,0278,RC,,,,both,,,2687.84,1747.10,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 10 CM DIA 6 MM EPTFE STR STD WALL,SUP-2681080,CDM,C1768,CPT,0278,RC,,,,both,,,356.30,231.59,,,,,,,,,,,,,
STEM FEM SZ 13.5 L HIP CLLRLSS STD BODY DST TEXT APR,SUP-2210973,CDM,C1776,CPT,0278,RC,,,,both,,,28228.60,18348.59,,,,,,,,,,,,,
SCISSORS OPHTH 25GA CRV DISP GRIESHABER REVOLUTION DSP,SUP-2109698,CDM,2720000010,LOCAL,0272,RC,,,,both,,,617.20,401.18,,,,,,,,,,,,,
CHIARI MLFRMTN PLATE CRSCNT SHAPE LG 06MM THICK CP TTNM,SUP-2676600,CDM,C1713,HCPCS,0278,RC,,,,both,,,4955.39,3221.00,,,,,,,,,,,,,
KIT BNE FIX STPL BRIDGE L 20 X 20 MM MAX NIT ANK FT ULTRA LP,SUP-2896921,CDM,C1713,HCPCS,0278,RC,,,,both,,,4706.86,3059.46,,,,,,,,,,,,,
KIT TMPLT W/ WIRE GWIRE GUIDEPIN FOR MINIRAIL FIX SYS,SUP-2316445,CDM,2720000010,LOCAL,0272,RC,,,,both,,,149.34,97.07,,,,,,,,,,,,,
CALCIUM GLUCONATE 10 % IV SOLN,RX-1312,CDM,J0612,HCPCS,0636,RC,63323-0360-59,NDC,,both,5,ML,54.10,35.16,,,,,,,,,,,,,
KIT INTRO ACCS 5FR L10CM GWIRE 0018IN NDL 21GA L7CM MINI S,SUP-2303010,CDM,C1894,HCPCS,0272,RC,,,,both,,,83.21,54.09,,,,,,,,,,,,,
DEVICE FIX BIOABSORBABLE 3.5 MM W/ DRL BIT INSRTN TOOL,SUP-2760657,CDM,C1713,HCPCS,0278,RC,,,,both,,,867.11,563.62,,,,,,,,,,,,,
GUIDEWIRE VASC GO2WIRE L 155 CM DIA 0.035 IN SS COR PTFE,SUP-2665404,CDM,C1769,HCPCS,0272,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
BIT DRL L41MM DIA3.3MM NONRADIOLUCENT W/O STP,SUP-2414006,CDM,2720000010,LOCAL,0272,RC,,,,both,,,326.56,212.26,,,,,,,,,,,,,
SCREW LCK PERIPRSTHTIC ST 5X18MM STRL,SUP-2547436,CDM,C1713,HCPCS,0278,RC,,,,both,,,723.68,470.39,,,,,,,,,,,,,
BUR SURG RND LG 4 MM,SUP-2521572,CDM,2720000010,LOCAL,0272,RC,,,,both,,,480.42,312.27,,,,,,,,,,,,,
IMPLANT HUM TISS L 7 X W 7 CM DECELL PLCNTA MEMBRN TEND NEVE,SUP-2881941,CDM,C1762,CPT,0278,RC,,,,both,,,18651.60,12123.54,,,,,,,,,,,,,
CHARGER BTTRY FOR VENT ASST DEV HEARTWARE,SUP-2282565,CDM,Q0495,HCPCS,0272,RC,,,,both,,,19154.00,12450.10,,,,,,,,,,,,,
GRAFT BNE SUB 5CC B TRICALCIUM PHSPTE CLLGN HA POR ALLGRFT,SUP-2288531,CDM,C1713,HCPCS,0278,RC,,,,both,,,779.51,506.68,,,,,,,,,,,,,
BONE MARROW ASPIRATION KIT CLOSED TIP 13 GA STRL LTX,SUP-2859801,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1342.35,872.53,,,,,,,,,,,,,
ULS 2.0MM PERC CANNULA,SUP-2495640,CDM,2720000010,LOCAL,0272,RC,,,,both,,,983.20,639.08,,,,,,,,,,,,,
ALLOGRAFT BNE CRUSH 5 CC FD ASEP CANC,SUP-2867153,CDM,C1762,CPT,0278,RC,,,,both,,,402.71,261.76,,,,,,,,,,,,,
GRAFT OPHTH DIA16MM AMNIO MEM OCU PROKERA,SUP-2135266,CDM,V2790,HCPCS,0278,RC,,,,both,,,2979.86,1936.91,,,,,,,,,,,,,
GRAFT BNE SYR 0.5 CC DBM ACCELL CONNEXUS,SUP-2641751,CDM,C1713,HCPCS,0278,RC,,,,both,,,609.95,396.47,,,,,,,,,,,,,
RELOAD STPL OPN H2.5MM CLOSE H1MM VASC THN TISS WHT 6 ROW,SUP-2220064,CDM,C1713,HCPCS,0278,RC,,,,both,,,1235.50,803.07,,,,,,,,,,,,,
SHEATH INTRO FLX ANSEL 55CM 6FR ID 2.2MM 0.035IN AQ MULTPURP,SUP-2171148,CDM,C1894,HCPCS,0272,RC,,,,both,,,177.57,115.42,,,,,,,,,,,,,
GRAFT HUM TISS L 250 MM DIA 5 MM GRACILIS TEND FRZN STRL,SUP-2913201,CDM,C1762,CPT,0278,RC,,,,both,,,5843.54,3798.30,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY LASSO L 115 CM DIA 7 FR SPC 2-6-2,SUP-2476144,CDM,C1730,HCPCS,0272,RC,,,,both,,,1901.24,1235.81,,,,,,,,,,,,,
"HC Pt Therapeutic Exercise,Ea 15 Min|OP OCCUPATIONAL THERAPY SERV|DOCUMENTATION ON FILE|SERVICES PROVIDED IN WHOLE OR IN PARTY BY AN OTA FOR MEDICARE PATIENTS|UNUSUAL NON-OVERLAPPING SERVICE",PX-4209711000,CDM,97110,CPT,0420,RC,,,GO|KX|CO|XU,both,,,195.00,126.75,,,,,,,,,,,,,
CATHETER DIL BAL 20.0MMX4.5CMX100CM Z MED II,SUP-2125228,CDM,C1725,HCPCS,0272,RC,,,,both,,,2344.42,1523.87,,,,,,,,,,,,,
BIT DRL DIA2.5MM,SUP-2175006,CDM,2720000010,LOCAL,0272,RC,,,,both,,,777.15,505.15,,,,,,,,,,,,,
GRAFT BNE GRAN 15 CC,SUP-2861515,CDM,C1713,HCPCS,0278,RC,,,,both,,,2762.01,1795.31,,,,,,,,,,,,,
PERI-LOC 4.5MM S-T LOCK SCREW 36MM,SUP-2819183,CDM,C1713,HCPCS,0278,RC,,,,both,,,1221.37,793.89,,,,,,,,,,,,,
SCREW BNE HEX HD 6.5X40 MM CANC SS NS,SUP-2184600,CDM,C1713,HCPCS,0278,RC,,,,both,,,69.08,44.90,,,,,,,,,,,,,
WASHER T8 T10 SCREWS 24MM/27MM/35MM,SUP-2704874,CDM,C1713,HCPCS,0278,RC,,,,both,,,175.84,114.30,,,,,,,,,,,,,
COIL EMB HELCL 12 MMX80.4 CM DETACHABLE SUPER SFT AXIUM PRIM,SUP-2429577,CDM,C1889,HCPCS,0278,RC,,,,both,,,2983.00,1938.95,,,,,,,,,,,,,
SUPPORT ORTHOT FT CUST INSRT MOLD TO PT MODEL SIL GEL,SUP-2435703,CDM,L3003,HCPCS,0272,RC,,,,both,,,493.26,320.62,,,,,,,,,,,,,
CANNULA OPHTH ANIS VECTIS 16 GA LOOP,SUP-2471397,CDM,2720000010,LOCAL,0272,RC,,,,both,,,398.00,258.70,,,,,,,,,,,,,
SPACER SPNL W11XH4XL11MM PEEK CERV INTBDY FUS TANT MRK,SUP-2279511,CDM,C1821,HCPCS,0278,RC,,,,both,,,1789.80,1163.37,,,,,,,,,,,,,
PLATE BNE LCK 2 MM STRNL 10 HOLE BODY,SUP-2262564,CDM,C1713,HCPCS,0278,RC,,,,both,,,1428.70,928.65,,,,,,,,,,,,,
LINER ACET CONSTRN 32/36 MM JUMBO INSTRUMENT TY CONTINUUM,SUP-2439844,CDM,C1776,CPT,0278,RC,,,,both,,,1455.39,946.00,,,,,,,,,,,,,
SCREW INTRF RND HD 8X25MM COMPOSITCP 30,SUP-2212840,CDM,C1713,HCPCS,0278,RC,,,,both,,,1004.80,653.12,,,,,,,,,,,,,
SLING GYN TENS FRE VAG TAPE W/ SECUR SYS GYNECARE TVT,SUP-2257820,CDM,C1771,HCPCS,0278,RC,,,,both,,,5199.84,3379.90,,,,,,,,,,,,,
ALLOGRAFT DERMAL MESHED THN 12X8 CM MTRX SOMAGEN,SUP-2434143,CDM,C1762,CPT,0278,RC,,,,both,,,17290.79,11239.01,,,,,,,,,,,,,
ENDCAP ROD FIB SONOMA,SUP-2352594,CDM,C1713,HCPCS,0278,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
WIRE GUID TRANSRADIAL HYDRPHLC STIFF STIFFNESS SHT TAPR ANG,SUP-2158677,CDM,C1769,HCPCS,0272,RC,,,,both,,,175.21,113.89,,,,,,,,,,,,,
TRAY HUM OFFSET 0 MM SHLDR RVS ADPT STRL EQUINOXE,SUP-2889628,CDM,C1776,CPT,0278,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
ATTACHMENT REPROC ROD MULTIPIN CLAMP LG,SUP-2500274,CDM,2720000010,LOCAL,0272,RC,,,,both,,,550.66,357.93,,,,,,,,,,,,,
PLATE BONE W14XL240MM THK3.8MM 13 H RT LAT TIB HD BTTRS S,SUP-2185779,CDM,C1713,HCPCS,0278,RC,,,,both,,,4350.25,2827.66,,,,,,,,,,,,,
DISTRACTION PIN 20MM X 62MM 7MM CTTNG SHAFT PKG/2 T 6L 4V S,SUP-2669823,CDM,C1713,HCPCS,0278,RC,,,,both,,,449.77,292.35,,,,,,,,,,,,,
NEEDLE CRYOABLATION ICESPHERE 1.5MM,SUP-2225663,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4356.75,2831.89,,,,,,,,,,,,,
CATHETER ITH L86CM ASCENDA SPNL SEG,SUP-2284626,CDM,C1755,HCPCS,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
HC Repair Liphc Repair Lip Full Thickness Vermilion Only,PX-4504065000,CDM,40650,CPT,0450,RC,,,,both,,,1526.00,991.90,,,,,,,,,,,,,
ALLOGRAFT BNE SPACER 21-26X27-32X17 MM FD ANTR LUMINARY-CC,SUP-2736805,CDM,C1713,HCPCS,0278,RC,,,,both,,,15292.08,9939.85,,,,,,,,,,,,,
PROBE SRGCL FKSHMA GNNTTA 7 1/4NL BNT BLLT TIP RGGLS RDMND,SUP-2494348,CDM,2720000010,LOCAL,0272,RC,,,,both,,,467.55,303.91,,,,,,,,,,,,,
SCREW BNE L18MM OD35MM DST VPS III,SUP-2316491,CDM,C1713,HCPCS,0278,RC,,,,both,,,270.35,175.73,,,,,,,,,,,,,
ALLOGRAFT BNE CRUSH 1-10 MM 10 CC CANC,SUP-2165596,CDM,C1889,HCPCS,0278,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
BIT DRL L20MM DIA5 73MM THRD STP W O STP NONRADIOLUCENT,SUP-2179057,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1496.27,972.58,,,,,,,,,,,,,
COLLAR CERV M H3.25IN FOR 13-16IN PLASTAZOTE FOAM 2 PC L,SUP-2336004,CDM,L0140,HCPCS,0274,RC,,,,both,,,30.14,19.59,,,,,,,,,,,,,
KIT SUBCHONDROPLASTY PROC SIDE TARGETED ACCUPORT,SUP-2414255,CDM,C1713,HCPCS,0278,RC,,,,both,,,10644.60,6918.99,,,,,,,,,,,,,
PLATE BNE CONN 6 HOLE,SUP-2468568,CDM,C1713,HCPCS,0278,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
ALLOGRAFT HUM TISS MED VIABLE AMNION MTRX ESSENCE,SUP-2538798,CDM,C1762,CPT,0278,RC,,,,both,,,6848.34,4451.42,,,,,,,,,,,,,
WIRE FIX SMOOTH 1.6X150 MM KIRSCHNER,SUP-2321715,CDM,C1713,HCPCS,0278,RC,,,,both,,,109.90,71.43,,,,,,,,,,,,,
STEM FEM L160MM DIA15MM 135DEG TIV HIP FBR MTL MIDCOAT,SUP-2203145,CDM,C1776,CPT,0278,RC,,,,both,,,13674.70,8888.55,,,,,,,,,,,,,
GRAFT BIO TISS W10XL25CM PORCINE REGEN TISS MTRX PLIABLE,SUP-2113003,CDM,Q4130,HCPCS,0636,RC,,,,both,,,24036.70,15623.85,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 160 MM DIA 7 MM DEL SHTH 7ML,SUP-2936818,CDM,C1713,HCPCS,0278,RC,,,,both,,,16932.92,11006.40,,,,,,,,,,,,,
DRESSING HEMOSTATIC ABSORBABLE 4X3 IN SL FABRIC STRL,SUP-2266129,CDM,2720000010,LOCAL,0272,RC,,,,both,,,357.96,232.67,,,,,,,,,,,,,
SCREW BONE LG EZ,SUP-2720254,CDM,C1713,HCPCS,0278,RC,,,,both,,,1542.09,1002.36,,,,,,,,,,,,,
CATHETER ANGIOPLSTY L 100 CM DIA 9 FR BALLOON L 20 MM DIA 3,SUP-2140991,CDM,C1725,HCPCS,0272,RC,,,,both,,,1538.60,1000.09,,,,,,,,,,,,,
CATHETER ANGIO SOFT-VU L 100 CM 4 FR 0.038 IN H1 NONBRAIDED,SUP-2116685,CDM,C1887,HCPCS,0272,RC,,,,both,,,41.45,26.94,,,,,,,,,,,,,
CATH BLLN SCORING 4X100MM X 137CM OTW PTA ANGIOSCULPT,SUP-2353230,CDM,C1725,HCPCS,0272,RC,,,,both,,,3972.10,2581.86,,,,,,,,,,,,,
SEALER/DIVIDER LAP SHFT L37CM JAW APER 11.4MM 315DEG ROT,SUP-2283569,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1898.13,1233.78,,,,,,,,,,,,,
BRACE ANK AIR STRRP SM HT 85 IN,SUP-2336085,CDM,L1930,HCPCS,0272,RC,,,,both,,,28.79,18.71,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC BONE STABILIZATION SYSTEM 17 X 260MM,SUP-2881211,CDM,C1713,HCPCS,0278,RC,,,,both,,,15941.78,10362.16,,,,,,,,,,,,,
HC So Cystatin C,PX-3018261066,CDM,82610,CPT,0301,RC,,,,both,,,80.00,52.00,,,,,,,,,,,,,
MULTIVITAMIN CHILDRENS PO CHEW,RX-137626,CDM,6370000000,HCPCS,0637,RC,80681-0049-00,NDC,,both,1,UN,0.30,0.19,,,,,,,,,,,,,
CATHETER EP DIAG MAPPINGXLARGE CRV QPLR 2 -5 -2MM SPC 4MM,SUP-2357661,CDM,C2630,CPT,0272,RC,,,,both,,,3846.50,2500.22,,,,,,,,,,,,,
TRAY MAXIMAL BARR PICC CATH SGL LUMN 5 FR 55 CM LEN N COAT N,SUP-2118885,CDM,C1751,HCPCS,0278,RC,,,,both,,,511.82,332.68,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED UNI CKNEEBIOUNI] ZIMMER BIOMET INC],SUP-2137380,CDM,C1776,CPT,0278,RC,,,,both,,,9423.14,6125.04,,,,,,,,,,,,,
RING 12 RINGFIX SYS ALUM 160MM,SUP-2696084,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3747.28,2435.73,,,,,,,,,,,,,
SHUNT VLV PRECHAMBER PEDIATRIC 15 CM H2O ADJ PROGAV 2.0,SUP-2846932,CDM,C1889,HCPCS,0278,RC,,,,both,,,9218.35,5991.93,,,,,,,,,,,,,
BIT DRILL J LATCH 1.8X88 MM 22 MM WITH STOP TITANIUM NON STE,SUP-2837620,CDM,2720000010,LOCAL,0272,RC,,,,both,,,641.82,417.18,,,,,,,,,,,,,
SET INTRO CATH 5FR L15CM GWIRE L60CM DIA0.018IN NDL 21GA,SUP-2168211,CDM,C1894,HCPCS,0272,RC,,,,both,,,70.37,45.74,,,,,,,,,,,,,
NEGATIVE PRESSURE KIT 20X15 CM DRSG PMP CLP PICO 7,SUP-2429339,CDM,2720000010,LOCAL,0272,RC,,,,both,,,677.02,440.06,,,,,,,,,,,,,
PLATE BNE CONN 1 HOLE,SUP-2422098,CDM,C1713,HCPCS,0278,RC,,,,both,,,1270.32,825.71,,,,,,,,,,,,,
SYSTEM SLNG POLYPRO TRNSVAG MIDURETHRAL MESH ASMBLY,SUP-2930142,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5301.48,3445.96,,,,,,,,,,,,,
HC Treat Toe Fx,PX-4502851000,CDM,28510,CPT,0450,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
PLATE BNE L194MM 8 H L DST EXTRAARTICULAR HUM S STL LOK,SUP-2184049,CDM,C1713,HCPCS,0278,RC,,,,both,,,3958.91,2573.29,,,,,,,,,,,,,
TRAY TIB KNEE CR KT STRL ITOTAL,SUP-2904600,CDM,C1776,CPT,0278,RC,,,,both,,,7339.75,4770.84,,,,,,,,,,,,,
BIT DRL L65MM DIA1.1MM STP L40MM STRL MAXILLOFACIAL S STL J,SUP-2187687,CDM,2720000010,LOCAL,0272,RC,,,,both,,,576.41,374.67,,,,,,,,,,,,,
PLATE 1ST MTCRPL 2MM DORS TI STRL VAL,SUP-2546915,CDM,C1713,HCPCS,0278,RC,,,,both,,,2707.68,1759.99,,,,,,,,,,,,,
RELOAD INT USE SHFT L 24 CM STPL LN L 45 MM OPN LEG H 2.5 MM,SUP-2896192,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2540.23,1651.15,,,,,,,,,,,,,
BLADE SHV 4.5MM DIA ENDO ANG CVD DBL SERR ULT SER DISP CUT,SUP-2341583,CDM,2720000010,LOCAL,0272,RC,,,,both,,,342.35,222.53,,,,,,,,,,,,,
PLATE BONE HOLEX8 STAINLES STEEL RECESSED SPIDER WRIST,SUP-2604355,CDM,C1713,HCPCS,0278,RC,,,,both,,,5956.99,3872.04,,,,,,,,,,,,,
BOOT WLK N PNEUMAT,SUP-2319135,CDM,L4386,HCPCS,0274,RC,,,,both,,,737.90,479.63,,,,,,,,,,,,,
ALLOGRAFT BNE FEM 21 MMX0.4 CM FD CROSS SECT,SUP-2717821,CDM,C1762,CPT,0278,RC,,,,both,,,3611.00,2347.15,,,,,,,,,,,,,
BUTTON FIX OVL LG 15X21 MM 10 MM PEG STRL XTENDOBUTTON LTX,SUP-2877816,CDM,C1713,HCPCS,0278,RC,,,,both,,,741.83,482.19,,,,,,,,,,,,,
PLATE BNE STR 4 HOLE 15411400,SUP-2864950,CDM,C1713,HCPCS,0278,RC,,,,both,,,3491.68,2269.59,,,,,,,,,,,,,
COMPONENT FEM CEM 15 DEG STD UNISX LT PROX KNEE CR STEMLESS,SUP-2376507,CDM,C1776,CPT,0278,RC,,,,both,,,12971.34,8431.37,,,,,,,,,,,,,
SCREW BNE L22MM DIA2.7MM CORT TI ST FULL THRD SM HEX FOR,SUP-2189698,CDM,C1713,HCPCS,0278,RC,,,,both,,,89.49,58.17,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 45 CM DIA 6 MM STR STD WALL HELIX,SUP-2525445,CDM,C1768,CPT,0278,RC,,,,both,,,1129.18,733.97,,,,,,,,,,,,,
GRAFT VASC L80CM ID6MM EPTFE STD WALLED STRTCH TECHNOLOGY,SUP-2395780,CDM,C1768,CPT,0278,RC,,,,both,,,6741.58,4382.03,,,,,,,,,,,,,
DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN,RX-2508,CDM,J1200,HCPCS,0636,RC,72485-0101-05,NDC,,both,0.2,ML,54.10,35.16,,,,,,,,,,,,,
SET ENDO INSTR GAST RECESSION FOR SFT TISS REL SYS,SUP-2122779,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2810.30,1826.69,,,,,,,,,,,,,
TRAY CATH MIDLN POWERGLIDE PRO 18GA 10CM WNGD 1 LU F218108PT,SUP-2632753,CDM,C1751,HCPCS,0278,RC,,,,both,,,397.02,258.06,,,,,,,,,,,,,
PLATE BNE L 57 MM SCREW DIA2.4 MM 8 SHFT H SS COMPACT STR VA ST,SUP-2910648,CDM,C1713,HCPCS,0278,RC,,,,both,,,4604.28,2992.78,,,,,,,,,,,,,
PLATE BONE L234MM 16 HOLE RIGHT LTRL PRXML PRRTCLR HMRL LOK,SUP-2470267,CDM,C1713,HCPCS,0278,RC,,,,both,,,4636.56,3013.76,,,,,,,,,,,,,
STEM RADIAL 9X2 MM ARH PART BLAST DEMO,SUP-2798394,CDM,C1776,CPT,0278,RC,,,,both,,,1375.32,893.96,,,,,,,,,,,,,
KNOT PUSHER,SUP-2811803,CDM,2720000010,LOCAL,0272,RC,,,,both,,,847.80,551.07,,,,,,,,,,,,,
CONNECTOR SHUNT DIAMETER 1.9MM TITANIUM F SHAPED FOR HYDROCE,SUP-2825888,CDM,C1889,HCPCS,0278,RC,,,,both,,,1105.06,718.29,,,,,,,,,,,,,
GRAFT VASC GELWEAVE L 50CM DIA28MM L 15CM 10MM 12/8MM PLEXUS,SUP-2894604,CDM,C1768,CPT,0278,RC,,,,both,,,10660.30,6929.19,,,,,,,,,,,,,
PLATE BONE BAR L8MM 6 H MIC DBL Y,SUP-2365224,CDM,C1713,HCPCS,0278,RC,,,,both,,,1140.07,741.05,,,,,,,,,,,,,
SCREW BNE LCK 2.3X9 MM THOR STRNL DRL FREE LEVEL 1 MAXDRIVE,SUP-2869240,CDM,C1713,HCPCS,0278,RC,,,,both,,,87.26,56.72,,,,,,,,,,,,,
SPLINT THMB AD SM FOR 4.75-6.25IN RT WR REG TRIOXON LINING,SUP-2324737,CDM,L3931,HCPCS,0274,RC,,,,both,,,59.72,38.82,,,,,,,,,,,,,
ANCHOR SUT SZ 3-0 BRAID ORTHOCORD V-4 NDL 1.3X5MM DRL BIT,SUP-2249370,CDM,C1713,HCPCS,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
MEMBRANE PERICARD 16CM X 8CM X 0.1MM THICKNESS GORE PRECL,SUP-2395369,CDM,C1768,CPT,0278,RC,,,,both,,,1971.92,1281.75,,,,,,,,,,,,,
PLATE BNE LCK 3.5 MM 4 HOLE ATTCH VA COMPR STRL VALCP,SUP-2789944,CDM,C1713,HCPCS,0278,RC,,,,both,,,2224.41,1445.87,,,,,,,,,,,,,
CATHETER CV SET 032 REG 8 FRX15 CM 12 GA DL J TIP SPECTRUM,SUP-2759723,CDM,C1751,HCPCS,0278,RC,,,,both,,,238.11,154.77,,,,,,,,,,,,,
SCREW BNE SEMICONSTRAINED 4.5X15 MM WRST LCK CAP STRL FRDM,SUP-2852844,CDM,C1713,HCPCS,0278,RC,,,,both,,,1498.85,974.25,,,,,,,,,,,,,
DRESSING NEG PRSS M W1.8XH8XL11CM FOAM SH RUL LBL NO STING,SUP-2261617,CDM,2720000010,LOCAL,0272,RC,,,,both,,,307.72,200.02,,,,,,,,,,,,,
UB IMA RETRACTOR BLADE,SUP-2674216,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1158.00,752.70,,,,,,,,,,,,,
SCREW SYS DUALTHRD HDLSS COMPR TI THRD 65 MM CANN 20 MM,SUP-2392787,CDM,C1713,HCPCS,0278,RC,,,,both,,,595.03,386.77,,,,,,,,,,,,,
GRAFT VASC STR 6 MMX70 CM RADIALLY SUPP POLYESTER INTEGARD,SUP-2227567,CDM,C1768,CPT,0278,RC,,,,both,,,3069.51,1995.18,,,,,,,,,,,,,
COMPONENT TIB AUG 55X59X20 MM LL/RM KNEE OSS RS RD122164,SUP-2450003,CDM,C1776,CPT,0278,RC,,,,both,,,1384.74,900.08,,,,,,,,,,,,,
COLLAR CERV TRACHEOTOMY MED AD 3.25 IN 13-16 IN PHILADELPHIA,SUP-2319294,CDM,L0172,HCPCS,0272,RC,,,,both,,,22.48,14.61,,,,,,,,,,,,,
MIDAZOLAM HCL 50 MG/10ML IJ SOLN,RX-93523,CDM,J2250,HCPCS,0636,RC,00641-6060-10,NDC,,both,10,ML,54.10,35.16,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.546,SUP-2860063,CDM,C1713,HCPCS,0278,RC,,,,both,,,55690.73,36198.97,,,,,,,,,,,,,
POTASSIUM PHOSPHATES(66 MEQ K) 45 MMOLE/15ML IV SOLN,RX-149327,CDM,2500000003,HCPCS,0250,RC,00409-7295-11,NDC,,both,15,ML,85.10,55.31,,,,,,,,,,,,,
CATHETER ETER HAD 12FR L13CM STR EXTN 2 LUMN MAHRK ELITE,SUP-2613223,CDM,C1752,HCPCS,0278,RC,,,,both,,,125.35,81.48,,,,,,,,,,,,,
GRAFT VASC STP 4-7 MMX50 CM STD WALL N RING EPTFE CARBOFLO,SUP-2761532,CDM,C1768,CPT,0278,RC,,,,both,,,2020.34,1313.22,,,,,,,,,,,,,
CATHETER CV 1 LUMEN 6.6 FRX90 CM 0.7 CC PEEL APART BRVC,SUP-2127878,CDM,C1751,HCPCS,0278,RC,,,,both,,,976.76,634.89,,,,,,,,,,,,,
SCREW BNE CANN 3X32 MM CAPTURE HIGH-TORQUE,SUP-2609498,CDM,C1713,HCPCS,0278,RC,,,,both,,,1079.47,701.66,,,,,,,,,,,,,
PLATE BNE 2.4X72X2 MM 9 HOLE SS LCP,SUP-2569301,CDM,C1713,HCPCS,0278,RC,,,,both,,,417.93,271.65,,,,,,,,,,,,,
SURGICAL INSTRUMENT KIT 4 MM MINIMALLY INVASIVE PONTO CANN,SUP-2430321,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1647.87,1071.12,,,,,,,,,,,,,
BLOCKER SPNL PEDCL LG FOR 8.2 MM SCREW,SUP-2864174,CDM,C1713,HCPCS,0278,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
SHELL ACET TOT HIP PRI PRESSFIT POR UNIV TI 44MM ID 44MM OD,SUP-2204667,CDM,C1776,CPT,0278,RC,,,,both,,,12811.20,8327.28,,,,,,,,,,,,,
KIT PERI DRNGE CATH 15.5FR BG 1000ML VLV CAP SLDE CLMP WIPE,SUP-2126463,CDM,C1729,HCPCS,0272,RC,,,,both,,,3611.00,2347.15,,,,,,,,,,,,,
GRAFT HUM TISS W3MMXL20-25.9CM SEMITENDINOSUS TEND FRZN FOR,SUP-2307286,CDM,C1713,HCPCS,0278,RC,,,,both,,,5495.00,3571.75,,,,,,,,,,,,,
PLATE BONE MINI M RIG BLU SAG 6 H CLVRLF STYL TI ALLOY,SUP-2262505,CDM,C1713,HCPCS,0278,RC,,,,both,,,557.73,362.52,,,,,,,,,,,,,
LEUPROLIDE ACETATE (3 MONTH) 22.5 MG IM KIT,RX-21045,CDM,J9217,HCPCS,0636,RC,00074-3346-03,NDC,,both,1,UN,1970.50,1280.82,,,,,,,,,,,,,
GRAFT BNE CHIP 30 CC FD CORTICAL CANC,SUP-2321738,CDM,C1713,HCPCS,0278,RC,,,,both,,,1303.10,847.01,,,,,,,,,,,,,
GRAFT HUM TISS W4XL6CM AMNIO TISS MEM WRP AMNIOFIX,SUP-2305761,CDM,V2790,HCPCS,0274,RC,,,,both,,,7824.88,5086.17,,,,,,,,,,,,,
BOLT 8 MM,SUP-2696096,CDM,C1713,HCPCS,0278,RC,,,,both,,,32.97,21.43,,,,,,,,,,,,,
DOUBLE BARREL CANNULA SM,SUP-2720854,CDM,2720000010,LOCAL,0272,RC,,,,both,,,22086.76,14356.39,,,,,,,,,,,,,
FORCEP SPEC RETRV GRASPING 5 FRX40 CM 20 MM,SUP-2835653,CDM,2720000010,LOCAL,0272,RC,,,,both,,,572.27,371.98,,,,,,,,,,,,,
SHEATH INTRO ARW FLX L 7 CM DIA 9 FR TIP ID 2.9 MM OBTURATOR,SUP-2383498,CDM,C1894,HCPCS,0272,RC,,,,both,,,31.31,20.35,,,,,,,,,,,,,
TRAY PICC SUBCL 2/L 5FR 55CML PU PWR INJ RADPQ PEEL 3275110,SUP-2632669,CDM,C1751,HCPCS,0278,RC,,,,both,,,413.22,268.59,,,,,,,,,,,,,
SUPPORT ORTHOT CUST LEGG PERTHES PATTEN BTM TYP,SUP-2435606,CDM,L1755,HCPCS,0272,RC,,,,both,,,5069.15,3294.95,,,,,,,,,,,,,
GRAFT BNE SUB 25MM IL CREST WDG TREAT W PRESERVON,SUP-2264841,CDM,C1713,HCPCS,0278,RC,,,,both,,,3326.74,2162.38,,,,,,,,,,,,,
ALLOGRAFT BNE SPACER LNG 30X11X13 MM BIO AVS UNILIF,SUP-2637047,CDM,C1713,HCPCS,0278,RC,,,,both,,,7928.50,5153.52,,,,,,,,,,,,,
TWIST DRILL 2.7MM,SUP-2818384,CDM,2720000010,LOCAL,0272,RC,,,,both,,,551.29,358.34,,,,,,,,,,,,,
PLATE BNE L 287 X W 11.5 MM THK 3.6 MM SCREW DIA 3.5 MM 24 H 72463124,SUP-2933309,CDM,C1713,HCPCS,0278,RC,,,,both,,,8326.81,5412.43,,,,,,,,,,,,,
MESALAMINE ER 500 MG PO CPCR,RX-39575,CDM,6370000000,HCPCS,0637,RC,54092-0191-12,NDC,,both,1,UN,27.40,17.81,,,,,,,,,,,,,
IMPLANT SYNTH 25 X 50 MM THK 3 MM POLYETHYL CRANIOFACIAL,SUP-2883277,CDM,C1713,HCPCS,0278,RC,,,,both,,,2680.30,1742.19,,,,,,,,,,,,,
CROWN DENT PED SZ LL5 LO LT ANTR CUSPID SEC PRI M S STL,SUP-2238793,CDM,D6783,CPT,0278,RC,,,,both,,,19.72,12.82,,,,,,,,,,,,,
BUTTON SUTURE FEM ADJ LOOP 2 LCK MECHANISM LP INFIN DISP,SUP-2846780,CDM,C1713,HCPCS,0278,RC,,,,both,,,3064.64,1992.02,,,,,,,,,,,,,
HC So Hemoglobin Fetal,PX-3058546066,CDM,85460,CPT,0305,RC,,,,inpatient,,,479.00,311.35,,,,,,,,,,,,,
OSTEOTOME SURG SZ 17 CRV LAT NS,SUP-2930312,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
BLADE SHV L11CM 360DEG ENDO AIRWY ANG ROTATE RAD IRR TBNG,SUP-2284135,CDM,2720000010,LOCAL,0272,RC,,,,both,,,786.26,511.07,,,,,,,,,,,,,
PLATE BNE L 62 MM BAR 9 MM 5 H SHRT TI CRANIOMAXILLOFACIAL T,SUP-2883486,CDM,C1713,HCPCS,0278,RC,,,,both,,,478.82,311.23,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY SUPREME L 120 CM DIA 6 FR SPC 2,SUP-2867396,CDM,C1730,HCPCS,0272,RC,,,,both,,,668.82,434.73,,,,,,,,,,,,,
INTRODUCER SHTH L40CM OD0157IN ID0130IN TIP DIA012IN STD CRV,SUP-2356333,CDM,C1892,HCPCS,0272,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
COMPONENT FEM TROCHANTERIC KNEE MOD OSSEO TI OSS,SUP-2441740,CDM,C1776,CPT,0278,RC,,,,both,,,14313.69,9303.90,,,,,,,,,,,,,
SHUNT LUMBO PERI 3.6MM HOFF HOLTER,SUP-2243797,CDM,C1889,HCPCS,0278,RC,,,,both,,,2166.60,1408.29,,,,,,,,,,,,,
HC Endo Level 2 Addl 15 Min,PX-3600007512,CDM,3600007512,LOCAL,0360,RC,,,,both,,,2137.00,1389.05,,,,,,,,,,,,,
GRAFT VASC HEMSHLD PLAT L 50 CM DIA 34 MM BRANCH SZ,SUP-2695457,CDM,C1768,CPT,0278,RC,,,,both,,,5383.78,3499.46,,,,,,,,,,,,,
BIT DRL TWST 1.6X100 MM 45 MM SEGMENTED STP SS SONICWELD RX,SUP-2462055,CDM,2720000010,LOCAL,0272,RC,,,,both,,,431.53,280.49,,,,,,,,,,,,,
PLATE BONE SM W10XL121MM THK3.4MM 10 H UNIV DSTL HUM RAD ULN,SUP-2343772,CDM,C1713,HCPCS,0278,RC,,,,both,,,1425.43,926.53,,,,,,,,,,,,,
KIT INSRT INTAORT CATH 9.5FR 40ML 650MM 90 SER EXT 0.30IN,SUP-2227306,CDM,C1713,HCPCS,0278,RC,,,,both,,,2041.00,1326.65,,,,,,,,,,,,,
PLATE BNE THK 2.6 MM SCREW DIA2/2.3 MM LG GRD II TI,SUP-2936149,CDM,C1713,HCPCS,0278,RC,,,,both,,,5661.42,3679.92,,,,,,,,,,,,,
MESH SRGCL 41MMW X 160MML 1MM THK MXLFCL FOA STRIP RSRB X LA,SUP-2681134,CDM,C1713,HCPCS,0278,RC,,,,both,,,15218.45,9891.99,,,,,,,,,,,,,
TROCAR SURG TRANSBUCCAL 70 MM,SUP-2470658,CDM,2720000010,LOCAL,0272,RC,,,,both,,,699.22,454.49,,,,,,,,,,,,,
SUPPORT ORTHOT CUST LEGG PERTHES PATTEN BTM TYP,SUP-2435606,CDM,L1755,HCPCS,0274,RC,,,,both,,,5069.15,3294.95,,,,,,,,,,,,,
STAPLE BNE FIX L 12 X W 12 MM THK 12 MM NIT GREAT WHT STR,SUP-2881087,CDM,C1713,HCPCS,0278,RC,,,,both,,,3629.84,2359.40,,,,,,,,,,,,,
PATCH CV W10XL15CM THK0.8MM FOR CARD RECON EPTFE GOR TX,SUP-2395310,CDM,C1768,CPT,0278,RC,,,,both,,,4449.38,2892.10,,,,,,,,,,,,,
PACEMAKER CARD VIVA W 59 X H 57 MM D 6 MM 15 CC 26 GM TI,SUP-2282346,CDM,C2621,HCPCS,0275,RC,,,,both,,,20213.72,13138.92,,,,,,,,,,,,,
STAPLE BNE FIX 18X18X18MM NIT SUPERPLASTIC DYNAFORCE,SUP-2175184,CDM,C1713,HCPCS,0278,RC,,,,both,,,5181.00,3367.65,,,,,,,,,,,,,
SNARE ENDOVASC L120CM WRK DIA12-20MM COLLAPSED DIA0.055IN,SUP-2302537,CDM,C1773,HCPCS,0272,RC,,,,both,,,978.02,635.71,,,,,,,,,,,,,
INSERT TIB THICKNESS 8.5MM SM UNIV STD POLYETH PRI NEUT IMP,SUP-2200347,CDM,C1776,CPT,0278,RC,,,,both,,,5960.98,3874.64,,,,,,,,,,,,,
SHUNT CAR 9FR L31CM BLU LUMN POLYUR T-PORT PRUITT F3-S,SUP-2264220,CDM,C1889,HCPCS,0278,RC,,,,both,,,4078.86,2651.26,,,,,,,,,,,,,
COIL NEUROVASCULAR PRESIDIO 18 CERECYTE L 50 CM LOOP DIA15,SUP-2457160,CDM,C1889,HCPCS,0278,RC,,,,both,,,11333.33,7366.66,,,,,,,,,,,,,
HC Inject Tendon Origin/Insert|BILATERAL PROCEDURE,PX-3612055100,CDM,20551,CPT,0361,RC,,,50,outpatient,,,1485.00,965.25,,,,,,,,,,,,,
HEAD FEM L28MM +4 NK MTL ON POLY,SUP-2364466,CDM,C1776,CPT,0278,RC,,,,both,,,1081.51,702.98,,,,,,,,,,,,,
BIT DRL SLD 2.5 MM W/ STP FOR STBL ANK FRAC SYS OMNI DISP,SUP-2865035,CDM,2720000010,LOCAL,0272,RC,,,,both,,,932.58,606.18,,,,,,,,,,,,,
DEXTROSE 10 % IV SOLN NEONATE,RX-40840075,CDM,2580000003,HCPCS,0250,RC,00338-0023-03,NDC,,both,500,ML,51.00,33.15,,,,,,,,,,,,,
PLATE BNE SUP 3.5X94 MM RT ANTR CLAV 5 HOLE W/ LAT EXTN SS,SUP-2184133,CDM,C1713,HCPCS,0278,RC,,,,both,,,2638.79,1715.21,,,,,,,,,,,,,
PIN BONE L89MM DIA4MM NAVIO,SUP-2341231,CDM,C1713,HCPCS,0278,RC,,,,both,,,266.90,173.48,,,,,,,,,,,,,
HINGE EXT FIX LCK UNIV JT,SUP-2749936,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1309.38,851.10,,,,,,,,,,,,,
LINER ACET LAT F 35 DEG 32X54-56 MM HIP XLPE REFLECTION,SUP-2434806,CDM,C1776,CPT,0278,RC,,,,both,,,6926.84,4502.45,,,,,,,,,,,,,
STRUT EXT FIX MED RX W/ DYNA STRL TRUELOK EVO LTX,SUP-2875634,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6892.30,4479.99,,,,,,,,,,,,,
PROSTHESIS VOICE 2 VLV 20 FRX8 MM NS BLOM-SINGER,SUP-2242333,CDM,L8509,HCPCS,0274,RC,,,,both,,,1284.26,834.77,,,,,,,,,,,,,
CATHETER DRAINAGE 0.038 IN 14 FRX60 CM MAC LOC LCK MP,SUP-2638509,CDM,C1729,HCPCS,0272,RC,,,,both,,,415.77,270.25,,,,,,,,,,,,,
WASHER ORTH FOR COUNT TORQUE ARM TRABECULAR MTL,SUP-2437279,CDM,C1713,HCPCS,0278,RC,,,,both,,,536.94,349.01,,,,,,,,,,,,,
JOINT TOE HAMRTOE 10 DEG 3.3 MM KT TOE-LEGIT,SUP-2749829,CDM,C1776,CPT,0278,RC,,,,both,,,4888.98,3177.84,,,,,,,,,,,,,
STEM FEM SEG 8.5 CM RT KNEE REDUC RESECT TAPR COMPRESS,SUP-2441847,CDM,C1776,CPT,0278,RC,,,,both,,,18821.16,12233.75,,,,,,,,,,,,,
TRAY KYPHOPLASTY SZ 3 BLLN L20MM IBT OSTEO INTRO KYPHON,SUP-2281102,CDM,C1894,HCPCS,0272,RC,,,,both,,,11062.22,7190.44,,,,,,,,,,,,,
RING BPLR DIA58MM HIP REPL RNGLOC,SUP-2404325,CDM,C1776,CPT,0278,RC,,,,both,,,172.70,112.25,,,,,,,,,,,,,
SUPPORT ORTHOT ELBW CUST ADJ FIT STRP W/OUT JT FABRICATED,SUP-2435756,CDM,L3702,HCPCS,0274,RC,,,,both,,,744.02,483.61,,,,,,,,,,,,,
TRAY CATH MIDLN POWERGLIDE PRO 18GA 10CM WNGD 1 LU F118108PT,SUP-2632730,CDM,C1751,HCPCS,0278,RC,,,,both,,,397.02,258.06,,,,,,,,,,,,,
DEFIBRILLATOR IMPL PROTEGO S W 5 X L 75 CM D 1.3 CM DIA2.6,SUP-2138290,CDM,C1777,HCPCS,0275,RC,,,,both,,,8792.00,5714.80,,,,,,,,,,,,,
HC Soft Tissue Lat Neck,PX-3207036000,CDM,70360,CPT,0320,RC,,,,both,,,734.00,477.10,,,,,,,,,,,,,
OPIUM 10 MG/ML (1%) PO TINC,RX-99771,CDM,6370000000,HCPCS,0637,RC,09999-9908-42,NDC,,both,0.6,ML,10.30,6.69,,,,,,,,,,,,,
STEM HUM 5X100 MM LT SHLDR DISCOVERY,SUP-2136215,CDM,C1776,CPT,0278,RC,,,,both,,,9282.47,6033.61,,,,,,,,,,,,,
HANDLE CATH SNUS GUID LO PROF RELIEVA SIDEKCK,SUP-2106378,CDM,C1729,HCPCS,0272,RC,,,,both,,,172.70,112.25,,,,,,,,,,,,,
GUIDEWIRE UROLOGY DBL FLX 038 INX145 CM ULTRA STIFF AMPLATZ,SUP-2836143,CDM,C1769,HCPCS,0272,RC,,,,both,,,93.95,61.07,,,,,,,,,,,,,
HC NM Gastric Emptying Study,PX-3417826400,CDM,78264,CPT,0341,RC,,,,both,,,2796.00,1817.40,,,,,,,,,,,,,
GUIDEWIRE VASC L 210 CM DIA 0.035 IN TIP L 1.5 MM PTFE J SHP,SUP-2763622,CDM,C1769,HCPCS,0272,RC,,,,both,,,49.52,32.19,,,,,,,,,,,,,
PACEMAKER CARD W 8.6 X H 20.3 CM D 4.45 CM 680 GM 2 CHMBR,SUP-2278429,CDM,C1785,HCPCS,0275,RC,,,,both,,,17013.84,11059.00,,,,,,,,,,,,,
PROSTHESIS OSS L 3.75 MM SHFT DIA1.1 MM HA INCUS PART,SUP-2901957,CDM,L8613,CPT,0278,RC,,,,both,,,1348.44,876.49,,,,,,,,,,,,,
MEMBRANE CLLGN DURA REP DURAMATRIX SUTURABLE 1IN X 3IN,SUP-2165129,CDM,C1763,HCPCS,0278,RC,,,,both,,,952.30,618.99,,,,,,,,,,,,,
SEED BRACHYTHERAPY LOOSE 4.01-5.0 MCI NS ADVANTAGE,SUP-2247271,CDM,C2643,HCPCS,0278,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
SET INTRO MICROPUNCTURE L 15 CM DIA 4 FR GUIDEWIRE 0.018 IN,SUP-2168210,CDM,C1894,HCPCS,0272,RC,,,,both,,,59.50,38.67,,,,,,,,,,,,,
HEAD FEM DIA 32 MM NK -3 MM COCR HIP 12/14 TAPR STRL FRDM,SUP-2887730,CDM,C1776,CPT,0278,RC,,,,both,,,4125.96,2681.87,,,,,,,,,,,,,
GUIDEWIRE ORTH L4MM OD.035IN PARTIALLY THRD EXTREMIFIX,SUP-2319455,CDM,C1769,HCPCS,0272,RC,,,,both,,,78.50,51.02,,,,,,,,,,,,,
BIT DRL L445MM DIA07MM STP 6MM L8MM ST MAXILLOFACIAL S,SUP-2187644,CDM,2720000010,LOCAL,0272,RC,,,,both,,,581.62,378.05,,,,,,,,,,,,,
SOLID LOCKING LAG SCREW 10.5MMX80MM,SUP-2828885,CDM,C1713,HCPCS,0278,RC,,,,both,,,2496.30,1622.59,,,,,,,,,,,,,
ROD IM L180MM DIA3.6MM FIBULAR,SUP-2106892,CDM,C1713,HCPCS,0278,RC,,,,both,,,5146.46,3345.20,,,,,,,,,,,,,
IMPLANT HUM TISS L 35 X W 25 MM THK 5 MM ACHILLES TEND RC,SUP-2932882,CDM,C1762,CPT,0278,RC,,,,both,,,8928.12,5803.28,,,,,,,,,,,,,
PLATE BNE 15 MM FEM OPENING WDG OSTEOTMY SS,SUP-2431989,CDM,C1713,HCPCS,0278,RC,,,,both,,,2292.20,1489.93,,,,,,,,,,,,,
PANCRELIPASE (LIP-PROT-AMYL) 10440-39150 UNITS PO TABS,RX-117565,CDM,6370000000,HCPCS,0637,RC,73562-0104-10,NDC,,both,1,UN,20.10,13.06,,,,,,,,,,,,,
PLATE BONE W18XL24MM THK1.4MM STRL TRAP FOR 2.4MM SCR EVOS,SUP-2349690,CDM,C1713,HCPCS,0278,RC,,,,both,,,5269.23,3425.00,,,,,,,,,,,,,
CUFF SURG TRNQT 12IN SGL BLDR PRT PNEUMAT ELECTR PED CONIC,SUP-2208887,CDM,C1713,HCPCS,0278,RC,,,,both,,,422.49,274.62,,,,,,,,,,,,,
ZIDOVUDINE 50 MG/5ML PO SYRP,RX-42918,CDM,340b,HCPCS,0637,RC,65862-0048-24,NDC,,both,240,ML,162.00,105.30,,,,,,,,,,,,,
PACEMAKER CARD MERID TI 2 CHMBR IS1 COMPATIBLE CONN UPLR,SUP-2139585,CDM,C1785,HCPCS,0275,RC,,,,both,,,14428.30,9378.39,,,,,,,,,,,,,
SCREW SPNL ROD DIA 5.5/6 MM SS REDUCTION MULTAXL STRL CD 2PK,SUP-2928047,CDM,C1713,HCPCS,0278,RC,,,,both,,,5369.40,3490.11,,,,,,,,,,,,,
PLATE BNE ORTHOGNATHIC 1 NS FACE ID,SUP-2883352,CDM,C1713,HCPCS,0278,RC,,,,both,,,22922.72,14899.77,,,,,,,,,,,,,
BIT DRL BI CORT BIO-POST,SUP-2121144,CDM,2720000010,LOCAL,0272,RC,,,,both,,,643.70,418.40,,,,,,,,,,,,,
CEMENT B1 70GM HI VISC ALL IN 1 SYS RALLY,SUP-2340807,CDM,C1713,HCPCS,0278,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
PLATE BNE L54MM BRL L38MM 135DEG 2 H ST BILAT PELV HIP S STL,SUP-2186803,CDM,C1713,HCPCS,0278,RC,,,,both,,,1908.30,1240.39,,,,,,,,,,,,,
PLATE BNE L213MM 12 H ST R MED DST TIB S STL LOK COMPR LO,SUP-2177452,CDM,C1713,HCPCS,0278,RC,,,,both,,,4240.13,2756.08,,,,,,,,,,,,,
BIT DRL CANN 6 MM KNEE SINGLE FLUT MTO,SUP-2849078,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2402.10,1561.36,,,,,,,,,,,,,
PACK ARTHSCP HIP 3 GWIRE 2 NDL DISP,SUP-2341626,CDM,C1769,HCPCS,0272,RC,,,,both,,,930.79,605.01,,,,,,,,,,,,,
PLATE BNE L66MM 6X4 H R VOLAR DST RAD S STL VAR ANG LOK,SUP-2184118,CDM,C1713,HCPCS,0278,RC,,,,both,,,2279.07,1481.40,,,,,,,,,,,,,
TRAY CATH MIDLN POWERGLIDE PRO BASIC 18GA 10CM WNGD F118107T,SUP-2632728,CDM,C1751,HCPCS,0278,RC,,,,both,,,248.15,161.30,,,,,,,,,,,,,
HC X-Ray Exam Hip Uni 2-3 Views,PX-3207350200,CDM,73502,CPT,0320,RC,,,,both,,,368.00,239.20,,,,,,,,,,,,,
CATHETER BLLN DIL 6FR L180CM L6CM DIA15MM ES HI PERF,SUP-2149862,CDM,C1726,HCPCS,0272,RC,,,,both,,,291.08,189.20,,,,,,,,,,,,,
HC Glb Complex E/M Visit Add On,PX-9820221100,CDM,G2211,CPT,0982,RC,,,,both,,,51.00,33.15,,,,,,,,,,,,,
SCREW BNE ST 2X4 MM MAND MXLFCL MONOCORTICAL TI BLU NS LF,SUP-2189547,CDM,C1713,HCPCS,0278,RC,,,,both,,,292.33,190.01,,,,,,,,,,,,,
SHUNT CV L13CM DIA12FR CAR BYPS STR 1 SIDE H EA END DISP,SUP-2127889,CDM,2720000010,LOCAL,0272,RC,,,,both,,,357.96,232.67,,,,,,,,,,,,,
SCREW BNE L55MM DIA4MM CANC TI NONLOCKING FOR SM FRAG,SUP-2412088,CDM,C1713,HCPCS,0278,RC,,,,both,,,533.80,346.97,,,,,,,,,,,,,
ELECTRODE SUBDERM NDL L 22 MM 8 CHANNEL TWISTED PR GRN WHT,SUP-2901949,CDM,2720000010,LOCAL,0272,RC,,,,both,,,926.14,601.99,,,,,,,,,,,,,
GRAFT BONE SUB L13.5MM OD6.5MM FACET DWL FLX HD THRD,SUP-2306918,CDM,C1713,HCPCS,0278,RC,,,,both,,,6661.82,4330.18,,,,,,,,,,,,,
PLATE BNE RECON 3 MM MAND 32 HOLE ANGLED-ANGLED LCK TI,SUP-2457346,CDM,C1713,HCPCS,0278,RC,,,,both,,,216.60,140.79,,,,,,,,,,,,,
SCREW BNE L18MM DIA2.4MM THRD L6MM CANC S STL SELF DRL ST,SUP-2185009,CDM,C1713,HCPCS,0278,RC,,,,both,,,797.18,518.17,,,,,,,,,,,,,
SCREW BONE L16MM DIA4.5MM CORT LCK FULL THRD FOR PEDINAIL,SUP-2318933,CDM,C1713,HCPCS,0278,RC,,,,both,,,952.24,618.96,,,,,,,,,,,,,
PLATE BONE W8XL68MM THK2MM 0DEG 8 H BILAT TI STR RIG DYN,SUP-2191072,CDM,C1713,HCPCS,0278,RC,,,,both,,,1510.69,981.95,,,,,,,,,,,,,
PLATE 3.5MM TI LCP POSTLAT DISTAL HUMERUS LAT SUPPORT 9H LT,SUP-2549691,CDM,C1713,HCPCS,0278,RC,,,,both,,,4351.13,2828.23,,,,,,,,,,,,,
ANCHOR SUT 35 MM DIA #2 SUT HERCULINE,SUP-2166907,CDM,C1713,HCPCS,0278,RC,,,,both,,,954.75,620.59,,,,,,,,,,,,,
INSERT TIB SZ 1-2 THK25MMXLPE POST STBL HI FLX KNEE OXINIUM,SUP-2346939,CDM,C1776,CPT,0278,RC,,,,both,,,5908.70,3840.65,,,,,,,,,,,,,
STEM TIB L150MM DIA12MM KNEE EXTN STABILIZING PRI FLUT,SUP-2253322,CDM,C1713,HCPCS,0278,RC,,,,both,,,3783.70,2459.40,,,,,,,,,,,,,
PLATE BNE RADIAL 2.4X63 MM RT VOLAR CLMN DSTL 6X5 HOLE LCK,SUP-2177243,CDM,C1713,HCPCS,0278,RC,,,,both,,,2739.40,1780.61,,,,,,,,,,,,,
CAGE SPNL MESH 22X17X70 MM 6 LOBE,SUP-2602084,CDM,C1889,HCPCS,0278,RC,,,,both,,,18607.64,12094.97,,,,,,,,,,,,,
FIBER LASER 2 MM FIBERLASE STC,SUP-2713720,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3281.30,2132.84,,,,,,,,,,,,,
PLATE BNE THK 0.5 MM SCREW DIA1.7 MM 2 X 21 H PLL,SUP-2883202,CDM,C1713,HCPCS,0278,RC,,,,both,,,12848.88,8351.77,,,,,,,,,,,,,
TITANIUM MESH PANEL ROUND CNTRD 73MM DIA 6MM 15MM SSTM CP,SUP-2677366,CDM,C1713,HCPCS,0278,RC,,,,both,,,3495.26,2271.92,,,,,,,,,,,,,
BLADE RTRCTR SCVLLE MRDNG SM MED 1INW X 3IND SRRTD TIP ULTRA,SUP-2487609,CDM,2720000010,LOCAL,0272,RC,,,,both,,,369.70,240.30,,,,,,,,,,,,,
HC Repl Duo/Jeju Tube Under Fluor,PX-4504945100,CDM,49451,CPT,0450,RC,,,,both,,,1056.00,686.40,,,,,,,,,,,,,
ALLOGRAFT TEND TIBIALIS ANT 23ML FRZN,SUP-2421704,CDM,C1762,CPT,0278,RC,,,,both,,,5495.00,3571.75,,,,,,,,,,,,,
VITAMIN B-6 50 MG PO TABS,RX-8667,CDM,6370000000,HCPCS,0637,RC,50268-0858-11,NDC,,both,1,UN,2.10,1.36,,,,,,,,,,,,,
CROWN DENT NOELR6 SEC M PRI LO R S STL,SUP-2322213,CDM,D6783,CPT,0278,RC,,,,both,,,36.05,23.43,,,,,,,,,,,,,
LEAD DEFIB RELIANCE SG L 64 CM SIL EPTFE ENDOCARD RT,SUP-2148558,CDM,C2628,HCPCS,0272,RC,,,,both,,,10676.00,6939.40,,,,,,,,,,,,,
SCREW SPNL MONOAX 5.5X45 MM FOR 4.5 MM ROD SS SHILLA,SUP-2630571,CDM,C1713,HCPCS,0278,RC,,,,both,,,4436.82,2883.93,,,,,,,,,,,,,
NAIL IM L300MM DIA10MM 130DEG NONSTERILE GRN FEM TI CANN,SUP-2192590,CDM,C1713,HCPCS,0278,RC,,,,both,,,4431.42,2880.42,,,,,,,,,,,,,
SPLINT ARM MP LG,SUP-2274800,CDM,L3809,HCPCS,0272,RC,,,,both,,,40.73,26.47,,,,,,,,,,,,,
CATHETER CV SET 025 5 FRX12 CM 16 GA 3L RIFAMPIN SPECTRUM,SUP-2759744,CDM,C1751,HCPCS,0278,RC,,,,both,,,435.17,282.86,,,,,,,,,,,,,
CUTTER SURG L9.5CM DIA12MM DISP FOR LAPSCP,SUP-2261062,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
BIT DRL DIA4MM LNG S STL PILOT QUIK CONN FOR TRIGEN AG IM,SUP-2347046,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1632.55,1061.16,,,,,,,,,,,,,
WALKER M SHT LEG NONSKID,SUP-2276711,CDM,L4387,HCPCS,0272,RC,,,,both,,,83.68,54.39,,,,,,,,,,,,,
HC Tcp02/Abi 1-2 Levels,PX-9209392200,CDM,93922,CPT,0921,RC,,,,both,,,810.00,526.50,,,,,,,,,,,,,
PLATE BNE RECON 3.5 MM 10 HOLE 2 COMPR LCK FOR SCR TI STRL,SUP-2483579,CDM,C1713,HCPCS,0278,RC,,,,both,,,1490.34,968.72,,,,,,,,,,,,,
PLATE BNE SCREW DIA2.6 MM SM TI CRANIOMAXILLOFACIAL DBL,SUP-2936969,CDM,C1713,HCPCS,0278,RC,,,,both,,,9853.32,6404.66,,,,,,,,,,,,,
HC CT-Guided Aspiration,PX-3507598900,CDM,75989,CPT,0350,RC,,,,both,,,7563.00,4915.95,,,,,,,,,,,,,
PLATE BNE MESH PANEL 1X83X50X0.6 MM CRANIOMAXILLOFACIAL,SUP-2468844,CDM,C1713,HCPCS,0278,RC,,,,both,,,2703.57,1757.32,,,,,,,,,,,,,
OBTURATOR SURG CONCL TIP 3.8 MM 2.7 MM,SUP-2849701,CDM,2720000010,LOCAL,0272,RC,,,,both,,,621.44,403.94,,,,,,,,,,,,,
PROSOURCE NO CARB PO LIQD,RX-102212,CDM,6370000000,HCPCS,0637,RC,94688-0114-76,NDC,,both,30,ML,6.10,3.96,,,,,,,,,,,,,
DRILL SURG GRAD BRAD PT,SUP-2196675,CDM,2720000010,LOCAL,0272,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
BUR SURG DIA3MM DMND RND 5 STP NOTCH EXPOSE MRK ELITE 5820012030] STRYKER INSTRUMENT DIV],SUP-2367570,CDM,C1713,HCPCS,0278,RC,,,,both,,,361.23,234.80,,,,,,,,,,,,,
GRAFT HUM TISS BIDIR 2X2 CM GRID PAT AMNIO MEMBRN BIOVANCE,SUP-2651373,CDM,Q4154,HCPCS,0636,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
HC Myelogram Lumbar,PX-3616230400,CDM,62304,CPT,0361,RC,,,,outpatient,,,3892.00,2529.80,,,,,,,,,,,,,
SHEETING SIL 6X8IN THK.020IN SILAS N REINF,SUP-2134687,CDM,C1781,HCPCS,0278,RC,,,,both,,,229.22,148.99,,,,,,,,,,,,,
SUPPORT ORTHOT THOR LUMBAR SACR CUST SAGITTAL-CORONAL SHELL,SUP-2435548,CDM,L0490,HCPCS,0274,RC,,,,both,,,800.86,520.56,,,,,,,,,,,,,
PACK 23 KHZ ST STD TIP,SUP-2243954,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
HEPARIN SODIUM (PORCINE) 5000 UNIT/ML IJ SOLN|DISCARDED DRUG NOT ADMINISTE,RX-10181,CDM,J1644,HCPCS,0636,RC,00409-2723-30,NDC,JW,both,0.5,ML,54.10,35.16,,,,,,,,,,,,,
PLATE BNE L135MM 8 H BROAD CNTOUR 2 COMPR FOR 45MM SCR L,SUP-2411411,CDM,C1713,HCPCS,0278,RC,,,,both,,,631.33,410.36,,,,,,,,,,,,,
GRAFT HUM TISS CORTICAL 4 DEG 10 MM CERV CANC STRL LF DISP,SUP-2463162,CDM,C1713,HCPCS,0278,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
HC Perq Cervicothoracic Inject,PX-3612251000,CDM,22510,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
SCREW BNE 20X25 MM,SUP-2397621,CDM,C1713,HCPCS,0278,RC,,,,both,,,1315.66,855.18,,,,,,,,,,,,,
WAND ARTHSCP 90DEG IFS AMBIENT SUP TURBOVAC,SUP-2342015,CDM,2720000010,LOCAL,0272,RC,,,,both,,,580.90,377.58,,,,,,,,,,,,,
SET INTRO MICROPUNCTURE SILHOUETTE CATH 10 CM 5 FR NIT PD,SUP-2633290,CDM,C1894,HCPCS,0272,RC,,,,both,,,146.61,95.30,,,,,,,,,,,,,
CURETTE SURG XLN 2-0 9.5 IN BNE BKWRD STR RUGGLES-REDMOND,SUP-2537767,CDM,2720000010,LOCAL,0272,RC,,,,both,,,425.06,276.29,,,,,,,,,,,,,
SCREW TEMP FIX SH THOR CONTRA ANG FOR RIBFIX BLU SYS,SUP-2413090,CDM,C1713,HCPCS,0278,RC,,,,both,,,741.04,481.68,,,,,,,,,,,,,
STEM TIB SMOOTH TOP 12 MM R/L TOT ANK COAT INBONE II,SUP-2483477,CDM,C1776,CPT,0278,RC,,,,both,,,1337.64,869.47,,,,,,,,,,,,,
COMPONENT HIP CEM STEMED W/ HD,SUP-2212280,CDM,C1776,CPT,0278,RC,,,,both,,,8249.66,5362.28,,,,,,,,,,,,,
GRAFT VASC VENAFLO II L 45 CM DIA 4-7 MM EPTFE CARBON STP N,SUP-2128790,CDM,L8670,HCPCS,0278,RC,,,,both,,,5984.59,3889.98,,,,,,,,,,,,,
CANNULA ENDOSCOPIC OD6.7MM LOW PROFILE SLOTTED,SUP-2825163,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1837.59,1194.43,,,,,,,,,,,,,
BLADE ARTHROSCOPY CAP-FIX STRAIGHT,SUP-2822789,CDM,2720000010,LOCAL,0272,RC,,,,both,,,577.76,375.54,,,,,,,,,,,,,
IMPLANT GYN L 24 X W 2 CM ALLGRFT FASC LATA PROC UNI DIR,SUP-2896113,CDM,C1762,CPT,0278,RC,,,,both,,,5881.22,3822.79,,,,,,,,,,,,,
STENT PERIPH L100MM DIA13MM CATH L120CM DIA12FR 0.035IN NIT,SUP-2396589,CDM,C1874,HCPCS,0278,RC,,,,both,,,10654.02,6925.11,,,,,,,,,,,,,
PLATE BNE L132MM BLDE W9.2XL30MM 90DEG 10 H BILAT S STL LOK,SUP-2185355,CDM,C1713,HCPCS,0278,RC,,,,both,,,3981.36,2587.88,,,,,,,,,,,,,
NEUROSTIMULATOR AXONICS 4101,SUP-2853157,CDM,C1820,HCPCS,0278,RC,,,,both,,,34715.84,22565.30,,,,,,,,,,,,,
"HC So1 Detect, Agnt Mult, Dna Ampli",PX-3068780167,CDM,87801,CPT,0306,RC,,,,both,,,498.00,323.70,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.451,SUP-2860015,CDM,C1713,HCPCS,0278,RC,,,,both,,,59482.28,38663.48,,,,,,,,,,,,,
SCREW BNE CROSS DRV 1.5X7 MM 4 MM 3X5 MM THRD DRL FREE,SUP-2467923,CDM,C1713,HCPCS,0278,RC,,,,both,,,284.61,185.00,,,,,,,,,,,,,
COMPONENT PAT RECESS ADV 28 MM MTL BK,SUP-2400119,CDM,C1776,CPT,0278,RC,,,,both,,,4961.20,3224.78,,,,,,,,,,,,,
PLATE BNE BROAD 3.5X242 MM 20 HOLE SS DCP,SUP-2569159,CDM,C1713,HCPCS,0278,RC,,,,both,,,462.84,300.85,,,,,,,,,,,,,
HC Treatment Devices Simple,PX-3337733200,CDM,77332,CPT,0333,RC,,,,both,,,1161.00,754.65,,,,,,,,,,,,,
IMPLANT COSMETIC SZ 38 X 63 X 6 MM POLYETHYL BLOCK STRL DISP,SUP-2935525,CDM,C1713,HCPCS,0278,RC,,,,both,,,2804.02,1822.61,,,,,,,,,,,,,
CATHETER INFUSION SPEEDLYSER L 25 CM DIA 5 FR SLT PAT L 20,SUP-2118523,CDM,C1757,HCPCS,0272,RC,,,,both,,,509.37,331.09,,,,,,,,,,,,,
GRAFT BNE W22XH35X8XL20MM BICORT EVANS WDG FOR OSTEOTMY,SUP-2399105,CDM,C1734,HCPCS,0278,RC,,,,both,,,6418.16,4171.80,,,,,,,,,,,,,
GRAFT VASC HEMSHLD PLAT L 30 CM DIA14 MM BRANCH SZ 10/10 MM,SUP-2669853,CDM,C1768,CPT,0278,RC,,,,both,,,4895.54,3182.10,,,,,,,,,,,,,
EVOS TI 3.5MMX10MM CTX SCREW T15 S-T,SUP-2820419,CDM,C1713,HCPCS,0278,RC,,,,both,,,153.95,100.07,,,,,,,,,,,,,
HC Ot Therapeutic Activities 15 Min|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS,PX-4309753000,CDM,97530,CPT,0430,RC,,,CQ,both,,,144.00,93.60,,,,,,,,,,,,,
SYSTEM TEND REP POLYETHYL SS HND WR FRARM SUTURE ANCHR FIBER,SUP-2881062,CDM,C1889,HCPCS,0278,RC,,,,both,,,5181.00,3367.65,,,,,,,,,,,,,
SUPPORT ORTHOT HEEL CUST SACH CUSH TYP,SUP-2435731,CDM,L3450,HCPCS,0274,RC,,,,both,,,298.77,194.20,,,,,,,,,,,,,
ALLOGRAFT BNE TIB SHFT 160X2 MM FRZN 31024269,SUP-2717866,CDM,C1762,CPT,0278,RC,,,,both,,,5140.59,3341.38,,,,,,,,,,,,,
STRAP ELBW TENNIS 8 IN BANDIT,SUP-2325152,CDM,L3702,HCPCS,0274,RC,,,,both,,,68.92,44.80,,,,,,,,,,,,,
CAGE SPNL SHIM 7X33 MM LORDTC TI VERSION C FLAREHAWK 9,SUP-2871237,CDM,C1889,HCPCS,0278,RC,,,,both,,,5495.00,3571.75,,,,,,,,,,,,,
SLING URETH W2XL10CM PORCINE CLLGN SURGISIS BIODESIGN,SUP-2168973,CDM,C1763,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
PANITUMUMAB 400 MG/20ML IV SOLN,RX-104366,CDM,J9303,HCPCS,0636,RC,55513-0956-01,NDC,,both,20,ML,20870.30,13565.69,,,,,,,,,,,,,
LACTASE 3000 UNITS PO TABS,RX-22469,CDM,6370000000,HCPCS,0637,RC,00904-5224-52,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
SCREW BONE SELFTAPPING 1.7X6 MM CRANIOMAXILLOFACIAL EMERGENC,SUP-2837663,CDM,C1713,HCPCS,0278,RC,,,,both,,,604.45,392.89,,,,,,,,,,,,,
STAPLE BONE FIXATION 20X20MM WIRE 2.3X1.6MM NONSTERILE SNIPER,SUP-2878265,CDM,C1713,HCPCS,0278,RC,,,,both,,,5055.40,3286.01,,,,,,,,,,,,,
SCREW BNE 2X8 MM 6 MM DRILL-FREE TI STRL L1 MAXDRIVE,SUP-2540173,CDM,C1713,HCPCS,0278,RC,,,,both,,,478.54,311.05,,,,,,,,,,,,,
BIT DRL CANN 3.5X140 MM STRL,SUP-2607160,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1332.27,865.98,,,,,,,,,,,,,
HC Hepatic Vein W/Hemo Eval,PX-3207588900,CDM,75889,CPT,0320,RC,,,,both,,,5817.00,3781.05,,,,,,,,,,,,,
AMNION DELIVERY DEVICE,SUP-2811352,CDM,2720000010,LOCAL,0272,RC,,,,both,,,678.24,440.86,,,,,,,,,,,,,
PACK SAW BLDE 42MM D302MM CUT EDGE 10MM THK12MM FOR PWR,SUP-2365131,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
CLAMP EXTERNAL FIXATION 45MML BLUE F/PIN XTRAFIX,SUP-2475525,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1645.58,1069.63,,,,,,,,,,,,,
PACEMAKER CARD TRIL SR + SINGLE CHMBR STRL,SUP-2320133,CDM,C1786,HCPCS,0275,RC,,,,both,,,13172.30,8561.99,,,,,,,,,,,,,
WEDGE FEM SZ 1 THK5MM STD UNIV DST KNEE CO CHROM PRI,SUP-2346018,CDM,C1776,CPT,0278,RC,,,,both,,,2237.25,1454.21,,,,,,,,,,,,,
COMPONENT TALAR 5 LT TOT ANK TRABECULAR MTL,SUP-2477211,CDM,C1776,CPT,0278,RC,,,,both,,,13074.11,8498.17,,,,,,,,,,,,,
SURFACE ARTC SZ 5-6 CH THK14MM AP46MM ML74MM KNEE UHMWPE GRN,SUP-2201370,CDM,C1776,CPT,0278,RC,,,,both,,,3683.22,2394.09,,,,,,,,,,,,,
ELECTRODE LAP SPATULA 5 MMX12.5 IN MONOPOLAR W/ VLV OLSEN,SUP-2489544,CDM,2720000010,LOCAL,0272,RC,,,,both,,,916.06,595.44,,,,,,,,,,,,,
SHEATH INTRO PERFRMR L 30 CM OD 5 FR ID 1.7 MM GUIDEWIRE,SUP-2168655,CDM,C1894,HCPCS,0272,RC,,,,both,,,69.80,45.37,,,,,,,,,,,,,
ALPHAVENT SUTURE ANCHR 4.75MM PEEK SUTURE ANCHR,SUP-2906833,CDM,C1713,HCPCS,0278,RC,,,,both,,,1880.86,1222.56,,,,,,,,,,,,,
PERFORATOR SURG L11MM DIA7MM CRAN AUTO CAMMED LUG RELEASING,SUP-2106557,CDM,2720000010,LOCAL,0272,RC,,,,both,,,602.88,391.87,,,,,,,,,,,,,
BOLT ORTH CONCL 10-12 MM FOR FEM NAIL NS,SUP-2564349,CDM,C1713,HCPCS,0278,RC,,,,both,,,3328.49,2163.52,,,,,,,,,,,,,
COMPONENT CARPOMETACARPAL FIX SYS CABLEFIX XPRESS,SUP-2476449,CDM,C1713,HCPCS,0278,RC,,,,both,,,2022.16,1314.40,,,,,,,,,,,,,
DISTAL RAD NAIL 6.5MM / 7.6MMX59MM TI,SUP-2340236,CDM,C1713,HCPCS,0278,RC,,,,both,,,2072.40,1347.06,,,,,,,,,,,,,
DEVICE COMBINATION TISS FIX BIOCOMP 4 SWIVELOCK FIBERTAK,SUP-2882316,CDM,C1713,HCPCS,0278,RC,,,,both,,,8713.50,5663.77,,,,,,,,,,,,,
PIN BNE FIX TEMP L80MM DIA4MM MAKO,SUP-2368491,CDM,C1713,HCPCS,0278,RC,,,,both,,,326.56,212.26,,,,,,,,,,,,,
LORAZEPAM 1 MG/ML PO CONC (NEO),RX-4082689,CDM,6370000000,HCPCS,0637,RC,09999-9918-91,NDC,,both,0.5,ML,2.70,1.75,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED LO DEMAND CEM POLYETH STRYKERKLCEM] STRYKER CORP],SUP-2365985,CDM,C1776,CPT,0278,RC,,,,both,,,8792.00,5714.80,,,,,,,,,,,,,
SLING ORTH 9X14IN 4X44IN SZ UNIV SM ENV IMMOB SWTH SLDE,SUP-2196952,CDM,L3660,HCPCS,0274,RC,,,,both,,,21.89,14.23,,,,,,,,,,,,,
INSERT MGII AC TIB ART SURF CDD+ YEL 17MM,SUP-2199632,CDM,C1776,CPT,0278,RC,,,,both,,,6011.22,3907.29,,,,,,,,,,,,,
CLINDAMYCIN PHOSPHATE IN D5W 300 MG/50ML IV SOLN,RX-9625,CDM,J0737,HCPCS,0636,RC,00338-3410-50,NDC,,both,50,ML,54.10,35.16,,,,,,,,,,,,,
BOOT CASTXL AD 13.5IN 5.5IN CUSH ROCK OPN TOE AND OPN HEEL,SUP-2205564,CDM,L4387,HCPCS,0272,RC,,,,both,,,29.67,19.29,,,,,,,,,,,,,
CERAMIC BALL HD 12/14 28 IN E M,SUP-2267744,CDM,C1776,CPT,0278,RC,,,,both,,,3833.94,2492.06,,,,,,,,,,,,,
BOLT ORTH FUSION 6.5X50 MM MIDFOOT TI NS,SUP-2799613,CDM,C1713,HCPCS,0278,RC,,,,both,,,1622.06,1054.34,,,,,,,,,,,,,
KIT LASER L65CM 0.035IN NEEDLE 21GA 4FR TRE-SHEATH HYDROPHILIC STAINLESS STEEL BRAID INTRODUCER GOLD TIP FIBER ENDOVENOUS PROCEDURE NEVERTOUCH VENACURE,SUP-2116797,CDM,C1888,HCPCS,0272,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
KIT STRNL CLOSURE FIBERTAPE L 36 IN DIA2 MM SUTURE X5 BLU,SUP-2930454,CDM,C1713,HCPCS,0278,RC,,,,both,,,3791.55,2464.51,,,,,,,,,,,,,
PLATE BONE LOK 280MML HLX19 YELLW ST LEFT PSTRLTRL DST HMRL,SUP-2484907,CDM,C1713,HCPCS,0278,RC,,,,both,,,3767.22,2448.69,,,,,,,,,,,,,
CATHETER CHOLANGIOGRAM TRAD 4 FRX7 IN OPN DISP,SUP-2330479,CDM,C1726,HCPCS,0272,RC,,,,both,,,72.47,47.11,,,,,,,,,,,,,
PACEMAKER CARD SINGLE CHMBR EXT BATTERY PWR STRL,SUP-2419366,CDM,2720000010,LOCAL,0272,RC,,,,both,,,12544.30,8153.79,,,,,,,,,,,,,
WEDGE 10MM SUBTUBULAR DISTRACTION ALLOGRAFT ARTHRODESIS,SUP-2741757,CDM,C1762,CPT,0278,RC,,,,both,,,7017.90,4561.63,,,,,,,,,,,,,
BOOT WLK VENTURE 61 TALL M,SUP-2150951,CDM,L4386,HCPCS,0272,RC,,,,both,,,92.32,60.01,,,,,,,,,,,,,
EXTENSION NEUROSTIMULATOR L40CM OD38MM ID15MM SPC 43MM,SUP-2629128,CDM,C1883,HCPCS,0278,RC,,,,both,,,4364.60,2836.99,,,,,,,,,,,,,
ROD EXT FIX L250MM DIA6MM THRD FOR HOFFMANN LRF SYS,SUP-2418164,CDM,2720000010,LOCAL,0272,RC,,,,both,,,259.99,168.99,,,,,,,,,,,,,
SHOE ORTHOT EXISTING SLD STIRRUP TRANSFER,SUP-2435747,CDM,L3620,HCPCS,0274,RC,,,,both,,,216.03,140.42,,,,,,,,,,,,,
COIL VASC EMBOLD L 6 CM DIA2 MM CATH LUMEN DIA 0.021 IN PLAT,SUP-2753942,CDM,C1889,HCPCS,0278,RC,,,,both,,,3209.08,2085.90,,,,,,,,,,,,,
GUIDEWIRE VASC TORQ-FLEX L 40 CM DIA 0.018 IN FLX TIP L 8 CM,SUP-2168207,CDM,C1769,HCPCS,0272,RC,,,,both,,,73.07,47.50,,,,,,,,,,,,,
IMMOBILIZER ORTH 2 AXIS SHT 17 IN 36 IN KNEERANGER II,SUP-2197133,CDM,L3702,HCPCS,0272,RC,,,,both,,,105.28,68.43,,,,,,,,,,,,,
PLATE BNE CUBOID 2.4/2.7 MM LT LCK SS NS,SUP-2799093,CDM,C1713,HCPCS,0278,RC,,,,both,,,2280.64,1482.42,,,,,,,,,,,,,
BIT DRL L50MM DIA1.5MM 2 FLUT W/ 6MM STP FOR J LATCH CPL,SUP-2179212,CDM,2720000010,LOCAL,0272,RC,,,,both,,,597.86,388.61,,,,,,,,,,,,,
PLATE BNE L L70MM ST R CALCNL S STL VAR ANG LOK FOR 27MM SCR,SUP-2178425,CDM,C1713,HCPCS,0278,RC,,,,both,,,3363.57,2186.32,,,,,,,,,,,,,
HC Natriuretic Peptide|NOT REASONABLE AND NECESSARY,PX-3018388000,CDM,83880,CPT,0301,RC,,,GZ,both,,,179.00,116.35,,,,,,,,,,,,,
PROBE BRST BX 11GA STEREOTACTIC BLADED DISP MAMTOM,SUP-2195658,CDM,2720000010,LOCAL,0272,RC,,,,both,,,855.34,555.97,,,,,,,,,,,,,
PLATE BONE 5X8 H BILAT LT MAND ORAL MAXILLOFACIAL TI ANG LO,SUP-2191437,CDM,C1713,HCPCS,0278,RC,,,,both,,,5609.30,3646.04,,,,,,,,,,,,,
SCREW BONE L40MM DIA4MM CORT DSTL LCK FULL THRD FOR 7MM,SUP-2318931,CDM,C1713,HCPCS,0278,RC,,,,both,,,852.20,553.93,,,,,,,,,,,,,
HC Mech-Mv-Vc-Tv-Rr-Neg If,PX-4609479900,CDM,94799,CPT,0460,RC,,,,outpatient,,,491.00,319.15,,,,,,,,,,,,,
SHEATH NEPHROSTOMY L 13 CM DIA22/24 FR,SUP-2937333,CDM,C1894,HCPCS,0272,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
CATHETER ANGIOPLSTY ANGIOSCULPT L 155 CM 40 MM 2 MM,SUP-2353206,CDM,C1725,HCPCS,0272,RC,,,,both,,,3367.65,2188.97,,,,,,,,,,,,,
LOCK DIST TIB MED LT 12H STE,SUP-2588832,CDM,C1713,HCPCS,0278,RC,,,,both,,,3874.07,2518.15,,,,,,,,,,,,,
CONNECTOR SPNL PARL 3.7-4.5 MM FOR ROD PROTEX CT,SUP-2584540,CDM,C1713,HCPCS,0278,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
GRAFT VASC GORTX L 70 CM DIA 4-7 MM EPTFE TAPR STD WALL N,SUP-2396454,CDM,C1768,CPT,0278,RC,,,,both,,,2442.92,1587.90,,,,,,,,,,,,,
PLATE BNE THK0.6MM 6 H MIC SHT TI DBL Y SHP BILAT,SUP-2262706,CDM,C1713,HCPCS,0278,RC,,,,both,,,312.12,202.88,,,,,,,,,,,,,
CLIP ANEUR PERM 8.3 MM SLIGHTLY CRV YASRG,SUP-2108664,CDM,C1889,HCPCS,0278,RC,,,,both,,,958.20,622.83,,,,,,,,,,,,,
CATHETER CV KT 0.025 IN 7 FRX16 CM DL INDWELL NDL FLX TIP,SUP-2763359,CDM,C1751,HCPCS,0278,RC,,,,both,,,378.06,245.74,,,,,,,,,,,,,
CLAMP CRAN DIA13MM TI FLAP TUBE,SUP-2192428,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1462.30,950.49,,,,,,,,,,,,,
ANCHOR SUTURE KNOTLESS PK MICRORAPTOR,SUP-2848661,CDM,C1713,HCPCS,0278,RC,,,,both,,,1186.92,771.50,,,,,,,,,,,,,
ANCHOR SUTURE PLNTR PLATE REP STRL DISP PARATROOPER,SUP-2899139,CDM,C1713,HCPCS,0278,RC,,,,both,,,2176.02,1414.41,,,,,,,,,,,,,
SCREW SPNL L40MM DIA6.25MM CANC ANT PEDCL TI MNRCH,SUP-2254477,CDM,C1713,HCPCS,0278,RC,,,,both,,,1946.23,1265.05,,,,,,,,,,,,,
HEAD RADIAL REPL EXPLORE,SUP-2416960,CDM,C1776,CPT,0278,RC,,,,both,,,15700.00,10205.00,,,,,,,,,,,,,
GUIDEWIRE VASC ARW L 68 CM DIA 0.032 IN SS PERIPH MARKED,SUP-2383971,CDM,C1769,HCPCS,0272,RC,,,,both,,,29.52,19.19,,,,,,,,,,,,,
COIL EMB 2MMX15CM MIC NEUROVASC XSFT MIC NEUROVASC GALAXY,SUP-2249159,CDM,C1889,HCPCS,0278,RC,,,,both,,,4087.90,2657.13,,,,,,,,,,,,,
INTRODUCER VASC 8 FR 98 CM LEN AD,SUP-2355589,CDM,C1894,HCPCS,0272,RC,,,,both,,,82.43,53.58,,,,,,,,,,,,,
GRAFT BNE 20ML CORT CANC DEMIN,SUP-2264716,CDM,C1713,HCPCS,0278,RC,,,,both,,,1055.57,686.12,,,,,,,,,,,,,
GUIDEWIRE VASC BENT L 260 CM DIA 0.035 IN TAPR L 15 CM FLPY,SUP-2168540,CDM,C1769,HCPCS,0272,RC,,,,both,,,55.70,36.20,,,,,,,,,,,,,
GRAFT VASC GELWEAVE L 50 CM DIA 22 MM L 15 CM 10 MM PRECRV,SUP-2894632,CDM,C1889,HCPCS,0278,RC,,,,both,,,10205.00,6633.25,,,,,,,,,,,,,
CATHETER TEMP PACE L 110 CM DIA 4 FR PROX 1 CM POLYUR SS,SUP-2126010,CDM,2720000010,LOCAL,0272,RC,,,,both,,,661.16,429.75,,,,,,,,,,,,,
KIT STEERABLE VERSACROSS WIRE/SHEATH MD,SUP-2525909,CDM,C1766,CPT,0272,RC,,,,both,,,5495.00,3571.75,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA BASIC 3FR 55CM 1 LUMAN RVS,SUP-2613532,CDM,C1751,HCPCS,0278,RC,,,,both,,,506.98,329.54,,,,,,,,,,,,,
IMPLANT PATELLARXLPE CEMENTLESS KNEE PROLONG,SUP-2212169,CDM,C1776,CPT,0278,RC,,,,both,,,11972.82,7782.33,,,,,,,,,,,,,
DEVICE TISS REMOVING 17OZ L25.25IN DIA3MM INTUTER CTRL UNIT,SUP-2239905,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4066.30,2643.09,,,,,,,,,,,,,
FIBER LASER 0.6MM BALL TIP KTP/YAG LP,SUP-2885373,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1124.12,730.68,,,,,,,,,,,,,
BLADE SURG 4MM 30DEG E DISPOSABLE FOR PLNTR FASCIITIS,SUP-2399188,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8000.72,5200.47,,,,,,,,,,,,,
ANCHOR SUT NDL DX FIBERTAK,SUP-2123221,CDM,C1713,HCPCS,0278,RC,,,,both,,,1460.10,949.06,,,,,,,,,,,,,
TROCAR FLEXIPATH FLX THORACIC PAK W/15MM OBT 15MM FLX SLVS,SUP-2855499,CDM,2720000010,LOCAL,0272,RC,,,,both,,,906.77,589.40,,,,,,,,,,,,,
IMPLANT OP RM MINI-MONSTER 4.0 X 32MM HD CANN LNG THRD SCR,SUP-2320546,CDM,C1713,HCPCS,0278,RC,,,,both,,,839.95,545.97,,,,,,,,,,,,,
PLATE BONE W11.7XL45.3MM 8 H WR TI RT ANG LCK COMPR HI,SUP-2411670,CDM,C1713,HCPCS,0278,RC,,,,both,,,1667.34,1083.77,,,,,,,,,,,,,
Surgical Arthroscopy Shoulder Xtnsv Dbrdmt 3+|LEFT SIDE,CASE-29823,LOCAL,29823,CPT,0360,RC,,,LT,outpatient,,,49865.88,29919.53,,,,,,,,,,,,,
Rinsj Rptd Biceps/Triceps Tdn Dstl W/WO Tdn Grf|LEFT SIDE,CASE-24342,LOCAL,24342,CPT,,,,,LT,outpatient,,,36018.77,21611.26,,,,,,,,,,,,,
Rinsj Rptd Biceps/Triceps Tdn Dstl W/WO Tdn Grf|LEFT SIDE,CASE-24342,LOCAL,24342,CPT,0360,RC,,,LT,outpatient,,,36018.77,21611.26,,,,,,,,,,,,,
Surgical Arthroscopy Shoulder Xtnsv Dbrdmt 3+|LEFT SIDE,CASE-29823,LOCAL,29823,CPT,,,,,LT,outpatient,,,49865.88,29919.53,,,,,,,,,,,,,
HC Gastric Procedure Unlisted,CASE-43999,LOCAL,43999,CPT,0361,RC,,,,outpatient,,,1020.60,612.36,,,,,,,,,,,,,
LIDOCAINE HCL 1% INJ (MIXTURES ONLY),RX-430017,CDM,J2003,HCPCS,0636,RC,55150-0159-74,NDC,,both,5,ML,54.10,35.16,,,,,,,,,,,,,
CEMENT DENT 12ML RADPQ PERM GLS IONOMER LUTING KETAC,SUP-2238638,CDM,C1713,HCPCS,0278,RC,,,,both,,,142.84,92.85,,,,,,,,,,,,,
GRAFT BNE SUB 90CC SZ 05 5MM CORT CANC GRAN FRZN MORSELIZED,SUP-2307406,CDM,C1713,HCPCS,0278,RC,,,,both,,,3423.73,2225.42,,,,,,,,,,,,,
GRAFT BNE 1 8MM 60ML CORTICAL CANELLOUS CHIP FRZ DRY,SUP-2264696,CDM,C1713,HCPCS,0278,RC,,,,both,,,1971.83,1281.69,,,,,,,,,,,,,
POST EXT FIX 3 H WIRE MR CONDITIONAL FOR DISTR OSTEOGENESIS,SUP-2176967,CDM,2720000010,LOCAL,0272,RC,,,,both,,,694.10,451.16,,,,,,,,,,,,,
TI LCP VOLR CLMN DSTL RADIUS PL 7H HEAD/4H SHAFT/LT-STERILE,SUP-2546661,CDM,C1713,HCPCS,0278,RC,,,,both,,,3071.77,1996.65,,,,,,,,,,,,,
CATHETER CV FULL SAFETY TY 032 9 FRX20 CM 3L STRL,SUP-2759922,CDM,C1751,HCPCS,0278,RC,,,,both,,,446.07,289.95,,,,,,,,,,,,,
SCREW SPNL ROD DIA 4.75/5 MM SS REDUCTION MULTAXL STRL CD 559200021,SUP-2927812,CDM,C1713,HCPCS,0278,RC,,,,both,,,2.70,1.75,,,,,,,,,,,,,
HC So Cholesterol,PX-3018246566,CDM,82465,CPT,0301,RC,,,,both,,,53.00,34.45,,,,,,,,,,,,,
GRAFT DERMAL MICROPREFORATED 8X20CM X 0.6-1.05MM DERMACELL,SUP-2866527,CDM,Q4122,HCPCS,0636,RC,,,,both,,,14569.60,9470.24,,,,,,,,,,,,,
Surgical Arthroscopy Shoulder W/Rotator Cuff Rpr|LEFT SIDE,CASE-29827,LOCAL,29827,CPT,0360,RC,,,LT,outpatient,,,56339.92,33803.95,,,,,,,,,,,,,
Secondary Closure Surg Wound/Dehsn Extsv/Complic,CASE-13160,LOCAL,13160,CPT,,,,,,outpatient,,,40616.65,24369.99,,,,,,,,,,,,,
HC Icu Intermediate R&B,PX-2060000000,CDM,2060000000,LOCAL,,,,,,outpatient,,,4022.42,2413.45,,,,,,,,,,,,,
Secondary Closure Surg Wound/Dehsn Extsv/Complic,CASE-13160,LOCAL,13160,CPT,0360,RC,,,,outpatient,,,40616.65,24369.99,,,,,,,,,,,,,
Surgical Arthroscopy Shoulder W/Rotator Cuff Rpr|LEFT SIDE,CASE-29827,LOCAL,29827,CPT,,,,,LT,outpatient,,,56339.92,33803.95,,,,,,,,,,,,,
STAPLER INT 30 MM TA PREM REUSE,SUP-2787756,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3190.90,2074.08,,,,,,,,,,,,,
FENTANYL 0.05 MG/ML SOLN (MIXTURES ONLY),RX-430015,CDM,J3010,HCPCS,0636,RC,00409-9094-31,NDC,,both,0.5,ML,54.10,35.16,,,,,,,,,,,,,
SCREW BNE L14MM OD27MM STD TI TARSALIS FULL THRD NONLOCKING,SUP-2243282,CDM,C1713,HCPCS,0278,RC,,,,both,,,471.25,306.31,,,,,,,,,,,,,
COMPONENT FEM MOD SM 8.5 CM LT CNDYL DSTL KNEE REV RECON,SUP-2376389,CDM,C1776,CPT,0278,RC,,,,both,,,18510.30,12031.69,,,,,,,,,,,,,
IFOSFAMIDE 1 GM/20ML IV SOLN,RX-87925,CDM,J9208,HCPCS,0636,RC,00143-9531-01,NDC,,both,20,ML,105.90,68.83,,,,,,,,,,,,,
CONNECTOR SPNL DIA5.5MM SIDE LD CLS CDH SOLERA,SUP-2289159,CDM,C1713,HCPCS,0278,RC,,,,both,,,2775.76,1804.24,,,,,,,,,,,,,
CATHETER CV DL 5 FRX55 CM PWR INJ N COAT SIL GROSH NXT,SUP-2126669,CDM,C1751,HCPCS,0278,RC,,,,both,,,302.01,196.31,,,,,,,,,,,,,
"Excis Intrasp Lesn,Xdural,Lumbar",CASE-63267,LOCAL,63267,CPT,0360,RC,,,,outpatient,,,49835.82,29901.49,,,,,,,,,,,,,
"Repair Extensor Tendon Finger W/O Graft Each|LEFT HAND, THIRD DIGIT",CASE-26418,LOCAL,26418,CPT,0360,RC,,,F2,outpatient,,,12568.70,7541.22,,,,,,,,,,,,,
"Repair Extensor Tendon Finger W/O Graft Each|LEFT HAND, THIRD DIGIT",CASE-26418,LOCAL,26418,CPT,,,,,F2,outpatient,,,12568.70,7541.22,,,,,,,,,,,,,
Ndsc Njx Implt Matrl Urt&/Bldr Nck,CASE-51715,LOCAL,51715,CPT,,,,,,outpatient,,,20176.53,12105.92,,,,,,,,,,,,,
"Excis Intrasp Lesn,Xdural,Lumbar",CASE-63267,LOCAL,63267,CPT,,,,,,outpatient,,,49835.82,29901.49,,,,,,,,,,,,,
Ndsc Njx Implt Matrl Urt&/Bldr Nck,CASE-51715,LOCAL,51715,CPT,0360,RC,,,,outpatient,,,20176.53,12105.92,,,,,,,,,,,,,
ROD REPROC EXT FIX ATTCH FOR MED MULT PIN CLMP NS,SUP-2188526,CDM,C1713,HCPCS,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
STENT PERIPH ZILVER PTX L 140 MM DIA 6 MM CATH L 125 CM SHTH,SUP-2170401,CDM,C1874,HCPCS,0278,RC,,,,both,,,7523.41,4890.22,,,,,,,,,,,,,
PLATE SPINE 2 LEV LORDOSED TRANSITION 24MM,SUP-2230030,CDM,C1713,HCPCS,0278,RC,,,,both,,,5338.00,3469.70,,,,,,,,,,,,,
PIN FIX L42MM DIA3.3MM FEM BIOCRYL CROSS SL ASMBLY INTLOK,SUP-2256592,CDM,C1713,HCPCS,0278,RC,,,,both,,,2703.54,1757.30,,,,,,,,,,,,,
STRATOGEN MEM 2 X 3 CM,SUP-2164198,CDM,Q4139,HCPCS,0636,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
STENT CAR WSTNT UNCONSTRAINED L 24 MM DIA10 MM CATH L 135 CM,SUP-2148434,CDM,C1876,HCPCS,0278,RC,,,,both,,,7834.30,5092.29,,,,,,,,,,,,,
INSERT TIB SM 60MM WDG KNEE SPCR ANTIBIO TREAT REMEDY,SUP-2419484,CDM,C1776,CPT,0278,RC,,,,both,,,4553.00,2959.45,,,,,,,,,,,,,
ROD SPNL TRNS 3.5-5.5X400 MM C-T TI INVICTUS,SUP-2553928,CDM,C1713,HCPCS,0278,RC,,,,both,,,1406.72,914.37,,,,,,,,,,,,,
PLATE BNE W7XL47MM THK1MM 6 H BILAT TI 1/4 TBLR RIG,SUP-2191004,CDM,C1713,HCPCS,0278,RC,,,,both,,,1063.02,690.96,,,,,,,,,,,,,
Colonoscopy W/Biopsy Single/Multiple|UNUSUAL NON-OVERLAPPING SERVICE|COLORECTAL CANCER SCREEN,CASE-45380,LOCAL,45380,CPT,0360,RC,,,XU|PT,outpatient,,,13068.90,7841.34,,,,,,,,,,,,,
Breast Augmentation With Implant|RIGHT SIDE,CASE-19325,LOCAL,19325,CPT,,,,,RT,outpatient,,,95445.73,57267.44,,,,,,,,,,,,,
Prq Impltj Neurostimulator Eltrd Peripheral Nrv|LEFT SIDE,CASE-64555,LOCAL,64555,CPT,0360,RC,,,LT,outpatient,,,25429.30,15257.58,,,,,,,,,,,,,
Prq Impltj Neurostimulator Eltrd Peripheral Nrv|LEFT SIDE,CASE-64555,LOCAL,64555,CPT,,,,,LT,outpatient,,,25429.30,15257.58,,,,,,,,,,,,,
Colorectal Scrn; Hi Risk Ind|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-G0105,LOCAL,G0105,CPT,,,,,74,outpatient,,,7395.27,4437.16,,,,,,,,,,,,,
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 2nd Level|BILATERAL PROCEDURE,CASE-64494,LOCAL,64494,CPT,0360,RC,,,50,outpatient,,,4008.43,2405.06,,,,,,,,,,,,,
Breast Augmentation With Implant|RIGHT SIDE,CASE-19325,LOCAL,19325,CPT,0360,RC,,,RT,outpatient,,,95445.73,57267.44,,,,,,,,,,,,,
Colorectal Scrn; Hi Risk Ind|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-G0105,LOCAL,G0105,CPT,0360,RC,,,74,outpatient,,,7395.27,4437.16,,,,,,,,,,,,,
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 2nd Level|BILATERAL PROCEDURE,CASE-64494,LOCAL,64494,CPT,,,,,50,outpatient,,,4008.43,2405.06,,,,,,,,,,,,,
Tissue Expander Placement Breast Reconstruction|LEFT SIDE,CASE-19357,LOCAL,19357,CPT,,,,,LT,outpatient,,,44035.20,26421.12,,,,,,,,,,,,,
Colonoscopy W/Biopsy Single/Multiple|UNUSUAL NON-OVERLAPPING SERVICE|COLORECTAL CANCER SCREEN,CASE-45380,LOCAL,45380,CPT,,,,,XU|PT,outpatient,,,13068.90,7841.34,,,,,,,,,,,,,
Tissue Expander Placement Breast Reconstruction|LEFT SIDE,CASE-19357,LOCAL,19357,CPT,0360,RC,,,LT,outpatient,,,44035.20,26421.12,,,,,,,,,,,,,
TRAY GRFT PREP SYS STRL,SUP-2256632,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5397.66,3508.48,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP STR 0.035 INX150 CM FIX COR INQWIRE DISP,SUP-2301900,CDM,C1769,HCPCS,0272,RC,,,,both,,,28.73,18.67,,,,,,,,,,,,,
COMPONENT GLEN SOCK REG CONSTRN CEM KEELED TRABECULAR MTL,SUP-2199071,CDM,C1776,CPT,0278,RC,,,,both,,,3617.28,2351.23,,,,,,,,,,,,,
SHEATH INTRO PINNACLE DESTINATION 65CM 6FR COAT L 35CM XCUT,SUP-2385656,CDM,C1894,HCPCS,0272,RC,,,,both,,,368.95,239.82,,,,,,,,,,,,,
TAP 20MM CNTRE DRIVE SCRWS W/DPTH GAUGE MRKNGS WORKS W/01 4,SUP-2707274,CDM,2720000010,LOCAL,0272,RC,,,,both,,,397.34,258.27,,,,,,,,,,,,,
BAR EXT FIX L180MM DIA4MM S STL CONN FOR SM FIX,SUP-2188731,CDM,2720000010,LOCAL,0272,RC,,,,both,,,124.91,81.19,,,,,,,,,,,,,
FOOT RING SHRT DIA 210 MM ALUMINIUM,SUP-2695673,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5325.44,3461.54,,,,,,,,,,,,,
SCREW IM NAIL L 70 MM DIA 5 MM TI CORTICAL HINDFOOT HDLSS NS,SUP-2930399,CDM,C1713,HCPCS,0278,RC,,,,both,,,1961.72,1275.12,,,,,,,,,,,,,
COMPONENT ACET AUG BLADE 50 MM HIP REDAPT,SUP-2434892,CDM,C1776,CPT,0278,RC,,,,both,,,6851.48,4453.46,,,,,,,,,,,,,
INSERT TIB SZ 5 THICKNESS 15MM UHMWPE KNEE PRI NEUT UNIV,SUP-2365101,CDM,C1776,CPT,0278,RC,,,,both,,,1934.33,1257.31,,,,,,,,,,,,,
SCREW BONE L10MM SUBTALAR TI CONCL SFT THRD ARTHROEREISIS,SUP-2319755,CDM,C1713,HCPCS,0278,RC,,,,both,,,7350.74,4777.98,,,,,,,,,,,,,
Breast Reduction|BILATERAL PROCEDURE,CASE-19318,LOCAL,19318,CPT,,,,,50,outpatient,,,68433.57,41060.14,,,,,,,,,,,,,
Rmvl Spinal Nstim Eltrd Prq Array Incl Fluor,CASE-63661,LOCAL,63661,CPT,,,,,,outpatient,,,18667.37,11200.42,,,,,,,,,,,,,
Rmvl Spinal Nstim Eltrd Prq Array Incl Fluor,CASE-63661,LOCAL,63661,CPT,0360,RC,,,,outpatient,,,18667.37,11200.42,,,,,,,,,,,,,
"Amp F/Th 1/2 Jt/Phalanx W/Neurect W/Dir Clsr|RIGHT HAND, SECOND DIGIT",CASE-26951,LOCAL,26951,CPT,0360,RC,,,F6,outpatient,,,24588.38,14753.03,,,,,,,,,,,,,
Wmhc Perc Implant Stim Lead Ea,CASE-63650,LOCAL,63650,CPT,0360,RC,,,,outpatient,,,10613.08,6367.85,,,,,,,,,,,,,
"Amp F/Th 1/2 Jt/Phalanx W/Neurect W/Dir Clsr|RIGHT HAND, SECOND DIGIT",CASE-26951,LOCAL,26951,CPT,,,,,F6,outpatient,,,24588.38,14753.03,,,,,,,,,,,,,
Excision Hydrocele Unilateral|RIGHT SIDE,CASE-55040,LOCAL,55040,CPT,0360,RC,,,RT,outpatient,,,19454.28,11672.57,,,,,,,,,,,,,
"Open Tx Phalangeal Shaft Fracture Prox/Middle Ea|RIGHT HAND, FOURTH DIGIT",CASE-26735,LOCAL,26735,CPT,,,,,F8,outpatient,,,26216.42,15729.85,,,,,,,,,,,,,
Excision Hydrocele Unilateral|RIGHT SIDE,CASE-55040,LOCAL,55040,CPT,,,,,RT,outpatient,,,19454.28,11672.57,,,,,,,,,,,,,
Cysto/Uretero W/Lithotripsy &Indwell Stent Insrt|BILATERAL PROCEDURE,CASE-52356,LOCAL,52356,CPT,,,,,50,outpatient,,,47439.68,28463.81,,,,,,,,,,,,,
"Open Tx Phalangeal Shaft Fracture Prox/Middle Ea|RIGHT HAND, FOURTH DIGIT",CASE-26735,LOCAL,26735,CPT,0360,RC,,,F8,outpatient,,,26216.42,15729.85,,,,,,,,,,,,,
Cysto/Uretero W/Lithotripsy &Indwell Stent Insrt|BILATERAL PROCEDURE,CASE-52356,LOCAL,52356,CPT,0360,RC,,,50,outpatient,,,47439.68,28463.81,,,,,,,,,,,,,
Breast Reduction|BILATERAL PROCEDURE,CASE-19318,LOCAL,19318,CPT,0360,RC,,,50,outpatient,,,68433.57,41060.14,,,,,,,,,,,,,
PRALIDOXIME CHLORIDE 1 G IV SOLR,RX-6462,CDM,J2730,HCPCS,0636,RC,60977-0141-01,NDC,,both,1,UN,498.60,324.09,,,,,,,,,,,,,
HANDPIECE LASER LAP-S FIBERLASE,SUP-2713722,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4898.40,3183.96,,,,,,,,,,,,,
HC Radiation Treatment Delivery Level 2,PX-3337740700,CDM,77407,CPT,0333,RC,,,,inpatient,,,2411.00,1567.15,,,,,,,,,,,,,
PROSTHESIS 3.25MM DIAM 5MM LEN PORP FULL CANN OFFSET W/,SUP-2312808,CDM,L8613,CPT,0278,RC,,,,both,,,1256.60,816.79,,,,,,,,,,,,,
BIT DRILL NON QUICK COUPLING 2.5X95 MM JACOBS CHUCK END GOLD,SUP-2837044,CDM,2720000010,LOCAL,0272,RC,,,,both,,,992.93,645.40,,,,,,,,,,,,,
SCREW BNE FT 3.5X16 MM CORTICAL PER ARTC,SUP-2198461,CDM,C1713,HCPCS,0278,RC,,,,both,,,244.61,159.00,,,,,,,,,,,,,
COMPONENT FEM UNI LM/RL L EIUS,SUP-2364878,CDM,C1776,CPT,0278,RC,,,,both,,,8729.20,5673.98,,,,,,,,,,,,,
IMPLANT SUBTALAR 8MM TI NON-BIOABSORBABLE HORZ,SUP-2137777,CDM,C1776,CPT,0278,RC,,,,both,,,3925.00,2551.25,,,,,,,,,,,,,
GRAFT HUM TISS 100MM FRZN ALLGRFT HUM W O ROT CUF PROX,SUP-2307324,CDM,C1713,HCPCS,0278,RC,,,,both,,,15938.64,10360.12,,,,,,,,,,,,,
ALLOGRAFT BNE SPACER 12X12X8 MM CERV LORDTC FORTIS,SUP-2135931,CDM,C1889,HCPCS,0278,RC,,,,both,,,3626.70,2357.35,,,,,,,,,,,,,
PLATE BNE L 234 MM SCREW DIA 4.5 MM 14 H COMPR LCK STRL EVOS,SUP-2933227,CDM,C1713,HCPCS,0278,RC,,,,both,,,3298.57,2144.07,,,,,,,,,,,,,
KNIFE BROAD 10CM IQ,SUP-2717564,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3387.12,2201.63,,,,,,,,,,,,,
PROSTHESIS OSS PISTON 0.6X4.75 MM MCGEE SS,SUP-2637764,CDM,L8613,CPT,0278,RC,,,,both,,,262.79,170.81,,,,,,,,,,,,,
SCREW BNE L32MM DIA5MM CORT DST ST FULL THRD FOR AFFIXUS,SUP-2413333,CDM,C1713,HCPCS,0278,RC,,,,both,,,803.37,522.19,,,,,,,,,,,,,
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral Ea Addl|RIGHT SIDE,CASE-64484,LOCAL,64484,CPT,,,,,RT,outpatient,,,4034.43,2420.66,,,,,,,,,,,,,
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral Ea Addl|RIGHT SIDE,CASE-64484,LOCAL,64484,CPT,0360,RC,,,RT,outpatient,,,4034.43,2420.66,,,,,,,,,,,,,
Surgical Arthroscopy Shoulder W/Rotator Cuff Rpr|RIGHT SIDE,CASE-29827,LOCAL,29827,CPT,0360,RC,,,RT,outpatient,,,55001.43,33000.86,,,,,,,,,,,,,
Surgical Arthroscopy Shoulder W/Rotator Cuff Rpr|RIGHT SIDE,CASE-29827,LOCAL,29827,CPT,,,,,RT,outpatient,,,55001.43,33000.86,,,,,,,,,,,,,
Laparoscopy Surg W/Bx Single/Multiple|UNUSUAL NON-OVERLAPPING SERVICE,CASE-49321,LOCAL,49321,CPT,0360,RC,,,XU,outpatient,,,46244.15,27746.49,,,,,,,,,,,,,
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 2nd Level,CASE-64494,LOCAL,64494,CPT,,,,,,outpatient,,,3988.28,2392.97,,,,,,,,,,,,,
Excision Inferior Turbinate Partial/Complete|LEFT SIDE,CASE-30130,LOCAL,30130,CPT,0360,RC,,,LT,outpatient,,,31794.17,19076.50,,,,,,,,,,,,,
Colonoscopy Flx Dx W/Collj Spec When Pfrmd|COLORECTAL CANCER SCREEN,CASE-45378,LOCAL,45378,CPT,0360,RC,,,PT,outpatient,,,11066.68,6640.01,,,,,,,,,,,,,
Esophagogastroduodenoscopy Transoral Diagnostic,CASE-43235,LOCAL,43235,CPT,,,,,,outpatient,,,9545.25,5727.15,,,,,,,,,,,,,
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 2nd Level,CASE-64494,LOCAL,64494,CPT,0360,RC,,,,outpatient,,,3988.28,2392.97,,,,,,,,,,,,,
Colonoscopy Flx Dx W/Collj Spec When Pfrmd|COLORECTAL CANCER SCREEN,CASE-45378,LOCAL,45378,CPT,,,,,PT,outpatient,,,11066.68,6640.01,,,,,,,,,,,,,
Laparoscopy Surg W/Bx Single/Multiple|UNUSUAL NON-OVERLAPPING SERVICE,CASE-49321,LOCAL,49321,CPT,,,,,XU,outpatient,,,46244.15,27746.49,,,,,,,,,,,,,
Esophagogastroduodenoscopy Transoral Diagnostic,CASE-43235,LOCAL,43235,CPT,0360,RC,,,,outpatient,,,9545.25,5727.15,,,,,,,,,,,,,
Excision Inferior Turbinate Partial/Complete|LEFT SIDE,CASE-30130,LOCAL,30130,CPT,,,,,LT,outpatient,,,31794.17,19076.50,,,,,,,,,,,,,
DEVICE PESSARY DIA1.75IN SIL FLEX GELLHORN SH STEM FOR 3RD,SUP-2171824,CDM,A4562,HCPCS,0272,RC,,,,both,,,179.07,116.40,,,,,,,,,,,,,
INSERT TIB 9 5 MM KNEE BEAR,SUP-2365105,CDM,C1776,CPT,0278,RC,,,,both,,,2564.94,1667.21,,,,,,,,,,,,,
FILLER BNE VOID 1 CC CORTICAL BNE SODIUM HYALURONATE KOLOSIS,SUP-2927223,CDM,C1713,HCPCS,0278,RC,,,,both,,,442.74,287.78,,,,,,,,,,,,,
SAXAGLIPTIN HCL 5 MG PO TABS,RX-98424,CDM,6370000000,HCPCS,0637,RC,00310-6105-30,NDC,,both,1,UN,76.90,49.98,,,,,,,,,,,,,
TUBE HARV L9MM BNE DWL DISPOSABLE,SUP-2212802,CDM,C1713,HCPCS,0278,RC,,,,both,,,1403.58,912.33,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 25 MG UMB CRD CLARIX FLO,SUP-2648677,CDM,Q4155,HCPCS,0636,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
SCREW BONE L8MM DIA2.4MM CORT MAND VIO TI ST FOR LCK RECON,SUP-2193356,CDM,C1713,HCPCS,0278,RC,,,,both,,,593.46,385.75,,,,,,,,,,,,,
HC Fingers Min 2 Views,PX-3207314000,CDM,73140,CPT,0320,RC,,,,both,,,397.00,258.05,,,,,,,,,,,,,
BERACTANT IN NACL 25-0.9 MG/ML-% INTRATRACHEA SUSP,RX-137604,CDM,2500000003,HCPCS,0250,RC,00074-1040-08,NDC,,both,8,ML,3897.90,2533.63,,,,,,,,,,,,,
BLADE RTRCTR 2INW X 65NL ALMNM MAL NON RDPQUE NON ST,SUP-2703356,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1480.13,962.08,,,,,,,,,,,,,
Exc Cyst/Aberrant Breast Tissue Open 1/> Lesion|RIGHT SIDE,CASE-19120,LOCAL,19120,CPT,,,,,RT,outpatient,,,18929.67,11357.80,,,,,,,,,,,,,
Gastroenterology Procedure,CASE-91299,LOCAL,91299,CPT,0750,RC,,,,outpatient,,,1795.08,1077.05,,,,,,,,,,,,,
Dstr Nrolytc Agnt Parverteb Fct Addl Lmbr/Sacral|RIGHT SIDE,CASE-64636,LOCAL,64636,CPT,0360,RC,,,RT,outpatient,,,11924.68,7154.81,,,,,,,,,,,,,
Laparoscopy Radical Nephrectomy|RIGHT SIDE,CASE-50545,LOCAL,50545,CPT,0360,RC,,,RT,outpatient,,,54271.45,32562.87,,,,,,,,,,,,,
Gastroenterology Procedure,CASE-91299,LOCAL,91299,CPT,,,,,,outpatient,,,1795.08,1077.05,,,,,,,,,,,,,
Unlisted Laparoscopy Px Abd Pertoneum & Omentum,CASE-49329,LOCAL,49329,CPT,0360,RC,,,,outpatient,,,102462.67,61477.60,,,,,,,,,,,,,
Laparoscopy Radical Nephrectomy|RIGHT SIDE,CASE-50545,LOCAL,50545,CPT,,,,,RT,outpatient,,,54271.45,32562.87,,,,,,,,,,,,,
Dstr Nrolytc Agnt Parverteb Fct Addl Lmbr/Sacral|RIGHT SIDE,CASE-64636,LOCAL,64636,CPT,,,,,RT,outpatient,,,11924.68,7154.81,,,,,,,,,,,,,
Exc Cyst/Aberrant Breast Tissue Open 1/> Lesion|RIGHT SIDE,CASE-19120,LOCAL,19120,CPT,0360,RC,,,RT,outpatient,,,18929.67,11357.80,,,,,,,,,,,,,
Esophagogastroduodenoscopy Submucosal Injection,CASE-43236,LOCAL,43236,CPT,,,,,,outpatient,,,11270.13,6762.08,,,,,,,,,,,,,
Esophagogastroduodenoscopy Submucosal Injection,CASE-43236,LOCAL,43236,CPT,0360,RC,,,,outpatient,,,11270.13,6762.08,,,,,,,,,,,,,
Unlisted Laparoscopy Px Abd Pertoneum & Omentum,CASE-49329,LOCAL,49329,CPT,,,,,,outpatient,,,102462.67,61477.60,,,,,,,,,,,,,
PLATE BONE 8 H MIC UN2 STR W/O BAR,SUP-2365225,CDM,C1713,HCPCS,0278,RC,,,,both,,,659.02,428.36,,,,,,,,,,,,,
INSERT SHLDR C DIA39MM THK+6MM 7.5DEG REVERSED AEQUALIS,SUP-2416996,CDM,C1776,CPT,0278,RC,,,,both,,,4661.33,3029.86,,,,,,,,,,,,,
CATH DAIG S2STR 5FR 100CM,SUP-2301645,CDM,C1713,HCPCS,0278,RC,,,,both,,,75.93,49.35,,,,,,,,,,,,,
BIT DRL L228MM DIA2.7MM LNG QUIK CONN DISP FOR PERI-LOC L,SUP-2343997,CDM,2720000010,LOCAL,0272,RC,,,,both,,,965.52,627.59,,,,,,,,,,,,,
CASE GRFT ENDURANT II NIT POLYESTER 2PC STRL,SUP-2873744,CDM,C1768,CPT,0278,RC,,,,both,,,43960.00,28574.00,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED CMNTLS,SUP-2365522,CDM,C1776,CPT,0278,RC,,,,both,,,14138.85,9190.25,,,,,,,,,,,,,
HC Plcmt Tunnel Pleural Drain Cat,PX-3613255000,CDM,32550,CPT,0361,RC,,,,both,,,8583.00,5578.95,,,,,,,,,,,,,
GRAFT VASC GORTX L 50 CM DIA 8 MM EPTFE STR TW N RING STRL,SUP-2396712,CDM,C1768,CPT,0278,RC,,,,both,,,1796.08,1167.45,,,,,,,,,,,,,
GRAFT HUM TISS W2XL4CM THK0.23-0.51MM GRFTABLE REGEN TISS,SUP-2112985,CDM,Q4116,HCPCS,0636,RC,,,,both,,,876.06,569.44,,,,,,,,,,,,,
GRAFT BNE CHIP CRUSH FRZN CANC 4MM 10MM RANG 60CC READIGRFT,SUP-2264739,CDM,C1713,HCPCS,0278,RC,,,,both,,,2124.90,1381.18,,,,,,,,,,,,,
IMPLANT HUM TISS L 10 X W 6 CM AMNION/CHORION MEMBRN DEHYDR,SUP-2905525,CDM,C1762,CPT,0278,RC,,,,both,,,13875.66,9019.18,,,,,,,,,,,,,
TROCHANTERIC NAIL 11MMX20CMX120 DEGREE,SUP-2811014,CDM,C1713,HCPCS,0278,RC,,,,both,,,6892.30,4479.99,,,,,,,,,,,,,
TRAY CATH HEMODIALYSI HEM CATH CHRONIC 12.5FR DIA LNG 28CM P,SUP-2610597,CDM,C1750,HCPCS,0278,RC,,,,both,,,659.40,428.61,,,,,,,,,,,,,
Breast Reduction|RIGHT SIDE,CASE-19318,LOCAL,19318,CPT,0360,RC,,,RT,outpatient,,,47664.90,28598.94,,,,,,,,,,,,,
Dbrdmt W/Rmvl Fm Fx&/Dislc Skin&Subq Tissus,CASE-11010,LOCAL,11010,CPT,0360,RC,,,,outpatient,,,17935.63,10761.38,,,,,,,,,,,,,
HC Plcmt Tunnel Pleural Drain Cat,CASE-32550,LOCAL,32550,CPT,0361,RC,,,,outpatient,,,18584.37,11150.62,,,,,,,,,,,,,
Dbrdmt W/Rmvl Fm Fx&/Dislc Skin&Subq Tissus,CASE-11010,LOCAL,11010,CPT,,,,,,outpatient,,,17935.63,10761.38,,,,,,,,,,,,,
Breast Reduction|RIGHT SIDE,CASE-19318,LOCAL,19318,CPT,,,,,RT,outpatient,,,47664.90,28598.94,,,,,,,,,,,,,
GRAFT BNE SUB 20CC W1XH1XL1CM CANC CUBE ALLGRFT FRZ DRY,SUP-2264688,CDM,C1713,HCPCS,0278,RC,,,,both,,,977.92,635.65,,,,,,,,,,,,,
TI MATRIXMIDFACE SCREW  1.3MM  450394501,SUP-2844115,CDM,C1713,HCPCS,0278,RC,,,,both,,,12721.77,8269.15,,,,,,,,,,,,,
STENT BILI L40MM DIA7MM DEL SYS L80CM SHTH 6FR GWIRE,SUP-2257374,CDM,C1876,HCPCS,0278,RC,,,,both,,,5165.30,3357.44,,,,,,,,,,,,,
GUIDEWIRE VASC MICROPUNCTURE L 60 CM DIA 0.018 IN TAPR L 10,SUP-2171100,CDM,C1769,HCPCS,0272,RC,,,,both,,,49.33,32.06,,,,,,,,,,,,,
CATHETER HD FULL SAFETY TY 035 12 FRX15 CM DL TURBO-FLO HD,SUP-2759836,CDM,C1752,HCPCS,0278,RC,,,,both,,,491.25,319.31,,,,,,,,,,,,,
GRAFT BNE SUB W10XH25XL20MM 18DEG B TRICALCIUM PHSPTE GRAN,SUP-2194023,CDM,C1713,HCPCS,0278,RC,,,,both,,,2071.96,1346.77,,,,,,,,,,,,,
SHELL ACET SZ E OD50MM ID22X26X28X32MM TI ALLOY POR MH,SUP-2344961,CDM,C1776,CPT,0278,RC,,,,both,,,7163.91,4656.54,,,,,,,,,,,,,
MENISCAL CINCH II,SUP-2121860,CDM,C1713,HCPCS,0278,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
LEAD CARD PACE AD L52CM PERM ATR LD PACE BPLR PASS FIX IS 1,SUP-2356673,CDM,C1779,HCPCS,0275,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
BASEPLATE TIB SZ 6 OXIN TI RT KNEE STRL LEGION HK,SUP-2910024,CDM,C1776,CPT,0278,RC,,,,both,,,23738.40,15429.96,,,,,,,,,,,,,
HC Sputum Obtaining Spec Aerosol Induced Tx Spx,PX-4108922000,CDM,89220,CPT,0300,RC,,,,inpatient,,,39.00,25.35,,,,,,,,,,,,,
Insertion Breast Implant Same Day of Mastectomy|RIGHT SIDE,CASE-19340,LOCAL,19340,CPT,0360,RC,,,RT,outpatient,,,104951.48,62970.89,,,,,,,,,,,,,
Insertion Breast Implant Same Day of Mastectomy|RIGHT SIDE,CASE-19340,LOCAL,19340,CPT,,,,,RT,outpatient,,,104951.48,62970.89,,,,,,,,,,,,,
Laps Rpr Paraesphgl Hrna Incl Fundplsty W/O Mesh,CASE-43281,LOCAL,43281,CPT,,,,,,outpatient,,,96901.38,58140.83,,,,,,,,,,,,,
Hysteroscopy Removal Impacted Foreign Body,CASE-58562,LOCAL,58562,CPT,0360,RC,,,,outpatient,,,19459.58,11675.75,,,,,,,,,,,,,
Exc Bartholins Gland/Cyst|LEFT SIDE,CASE-56740,LOCAL,56740,CPT,0360,RC,,,LT,outpatient,,,33215.53,19929.32,,,,,,,,,,,,,
Laps Rpr Paraesphgl Hrna Incl Fundplsty W/O Mesh,CASE-43281,LOCAL,43281,CPT,0360,RC,,,,outpatient,,,96901.38,58140.83,,,,,,,,,,,,,
Exc Bartholins Gland/Cyst|LEFT SIDE,CASE-56740,LOCAL,56740,CPT,,,,,LT,outpatient,,,33215.53,19929.32,,,,,,,,,,,,,
Hysteroscopy Removal Impacted Foreign Body,CASE-58562,LOCAL,58562,CPT,,,,,,outpatient,,,19459.58,11675.75,,,,,,,,,,,,,
"Laminec/Facetect/Foramin,Lumbar|LEFT SIDE",CASE-63047,LOCAL,63047,CPT,0360,RC,,,LT,outpatient,,,38400.10,23040.06,,,,,,,,,,,,,
"Laminec/Facetect/Foramin,Lumbar|LEFT SIDE",CASE-63047,LOCAL,63047,CPT,,,,,LT,outpatient,,,38400.10,23040.06,,,,,,,,,,,,,
STEM FEM CEM HIP PRSS FT UPLR,SUP-2351416,CDM,C1776,CPT,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
PLATE BNE L106MM 9 H BILAT TI RIG LO PROF RIG LOK COMPR,SUP-2191096,CDM,C1713,HCPCS,0278,RC,,,,both,,,1857.97,1207.68,,,,,,,,,,,,,
CATHETER ANGIOPLSTY L 75 CM DIA 5 FR BALLOON L 4 CM DIA 5 MM,SUP-2139601,CDM,C1725,HCPCS,0272,RC,,,,both,,,744.18,483.72,,,,,,,,,,,,,
CATHETER INTVASC 9.3FR L45CM POLYUR APPLAUSE HEAT EXCHG FLX,SUP-2416150,CDM,C1751,HCPCS,0278,RC,,,,both,,,3359.67,2183.79,,,,,,,,,,,,,
SCREW BNE L12MM DIA2.7MM ANK S STL LOK LO PROF FOR FRAC,SUP-2122625,CDM,C1713,HCPCS,0278,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
ANCHOR SUTURE DIAMETER 2.3MM STAINLESS STEEL KNOTLESS PRE LO,SUP-2824591,CDM,C1713,HCPCS,0278,RC,,,,both,,,618.89,402.28,,,,,,,,,,,,,
CLAMP SURG ROD TO ROD WIDE 6.35-6.35 MM SS REVERE,SUP-2585149,CDM,C1713,HCPCS,0278,RC,,,,both,,,935.72,608.22,,,,,,,,,,,,,
INSERT TIB XL THK11MM AP58MM ML82MM UNIV CNDYL KNEE NEUT,SUP-2377420,CDM,C1776,CPT,0278,RC,,,,both,,,2526.76,1642.39,,,,,,,,,,,,,
KIT INSTR W/ 2.4MM STP DRL GUID FOR SM JT DISP SUTURETAK,SUP-2122904,CDM,2720000010,LOCAL,0272,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
STENT NEPHURET L 24 CM DIA 8 FR PERCFLX LCK PIGTL GUIDEWIRE,SUP-2141080,CDM,C2617,HCPCS,0278,RC,,,,both,,,334.10,217.16,,,,,,,,,,,,,
GRAFT HUM TISS INJ FLUID 1 CC AMNIO PLCNTA MEMBRN PRO3-FA,SUP-2742036,CDM,C1762,CPT,0278,RC,,,,both,,,6951.18,4518.27,,,,,,,,,,,,,
PLATE BONE L125MM 135DEG 6 H HIP BILAT S STL STD BRL LEN RIG,SUP-2197817,CDM,C1713,HCPCS,0278,RC,,,,both,,,891.67,579.59,,,,,,,,,,,,,
"HC So Compatibility Test, Immed.Spin",PX-3008692066,CDM,86920,CPT,0300,RC,,,,both,,,359.00,233.35,,,,,,,,,,,,,
GRAFT HUM TISS H10MM DIA7MM OSTEOCHNDRL CHONDROFIX,SUP-2200258,CDM,C1713,HCPCS,0278,RC,,,,both,,,8521.96,5539.27,,,,,,,,,,,,,
SCREW BNE LCK 3X30 MM STRL MOTOBAND CP,SUP-2175145,CDM,C1713,HCPCS,0278,RC,,,,both,,,833.67,541.89,,,,,,,,,,,,,
CATHETER DEL 4MAX L 134 CM WORKING L 130 CM DIA,SUP-2323546,CDM,C1725,HCPCS,0272,RC,,,,both,,,4553.00,2959.45,,,,,,,,,,,,,
"Repair Extensor Tendon Finger W/O Graft Each|LEFT HAND, FOURTH DIGIT",CASE-26418,LOCAL,26418,CPT,0360,RC,,,F3,outpatient,,,31910.03,19146.02,,,,,,,,,,,,,
Mastopexy|BILATERAL PROCEDURE,CASE-19316,LOCAL,19316,CPT,,,,,50,outpatient,,,85355.23,51213.14,,,,,,,,,,,,,
Cysto Bladder W/Ureteral Catheterization,CASE-52005,LOCAL,52005,CPT,,,,,,outpatient,,,20329.33,12197.60,,,,,,,,,,,,,
Mastopexy|BILATERAL PROCEDURE,CASE-19316,LOCAL,19316,CPT,0360,RC,,,50,outpatient,,,85355.23,51213.14,,,,,,,,,,,,,
Largsc Exc Tum&/Strpg Cords/Epigl Mcrscp/Tlscp,CASE-31541,LOCAL,31541,CPT,0360,RC,,,,outpatient,,,21137.88,12682.73,,,,,,,,,,,,,
Cysto Bladder W/Ureteral Catheterization,CASE-52005,LOCAL,52005,CPT,0360,RC,,,,outpatient,,,20329.33,12197.60,,,,,,,,,,,,,
"Tendon Sheath Incision|RIGHT HAND, SECOND DIGIT",CASE-26055,LOCAL,26055,CPT,0360,RC,,,F6,outpatient,,,8656.78,5194.07,,,,,,,,,,,,,
Largsc Exc Tum&/Strpg Cords/Epigl Mcrscp/Tlscp,CASE-31541,LOCAL,31541,CPT,,,,,,outpatient,,,21137.88,12682.73,,,,,,,,,,,,,
Egd Endoscopic Stent Placement W/Wire& Dilation,CASE-43266,LOCAL,43266,CPT,0360,RC,,,,outpatient,,,34682.53,20809.52,,,,,,,,,,,,,
"Repair Extensor Tendon Finger W/O Graft Each|LEFT HAND, FOURTH DIGIT",CASE-26418,LOCAL,26418,CPT,,,,,F3,outpatient,,,31910.03,19146.02,,,,,,,,,,,,,
"Tendon Sheath Incision|RIGHT HAND, THIRD DIGIT|UNUSUAL NON-OVERLAPPING SERVICE",CASE-26055,LOCAL,26055,CPT,,,,,F7|XU,outpatient,,,14065.00,8439.00,,,,,,,,,,,,,
"Tendon Sheath Incision|RIGHT HAND, THIRD DIGIT|UNUSUAL NON-OVERLAPPING SERVICE",CASE-26055,LOCAL,26055,CPT,0360,RC,,,F7|XU,outpatient,,,14065.00,8439.00,,,,,,,,,,,,,
"Tendon Sheath Incision|RIGHT HAND, SECOND DIGIT",CASE-26055,LOCAL,26055,CPT,,,,,F6,outpatient,,,8656.78,5194.07,,,,,,,,,,,,,
Egd Endoscopic Stent Placement W/Wire& Dilation,CASE-43266,LOCAL,43266,CPT,,,,,,outpatient,,,34682.53,20809.52,,,,,,,,,,,,,
HC Joint Injection/Aspir Large WO US|SEPARATE STRUCTURE|LEFT SIDE,CASE-20610,LOCAL,20610,CPT,0510,RC,,,XS|LT,outpatient,,,5654.02,3392.41,,,,,,,,,,,,,
COMPONENT PAT DIA35MM THK8MM TRI PEG POLYETH ONLAY RM SYS,SUP-2304739,CDM,C1776,CPT,0278,RC,,,,both,,,2249.18,1461.97,,,,,,,,,,,,,
GRAFT STENT FLARED 0.035 IN 7X40 MM 9 FRX80 CM VASC FLAIR,SUP-2469671,CDM,C1874,HCPCS,0278,RC,,,,both,,,6892.30,4479.99,,,,,,,,,,,,,
INSERT HUM DIA36MM THK+9MM B 125DEG ANG RETENTIVE REVERSED,SUP-2399871,CDM,C1776,CPT,0278,RC,,,,both,,,6149.69,3997.30,,,,,,,,,,,,,
INBONE  POLY SZ 4 15MM SULCUS,SUP-2493374,CDM,C1776,CPT,0278,RC,,,,both,,,5221.82,3394.18,,,,,,,,,,,,,
GUIDEWIRE ORTHOPEDIC BALL NOSE 8 CM DISP,SUP-2252857,CDM,C1769,HCPCS,0272,RC,,,,both,,,527.52,342.89,,,,,,,,,,,,,
INTRODUCER ENDO 17GA CVD,SUP-2362639,CDM,2720000010,LOCAL,0272,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
HC So Platelet Aggr(Invitro) Ea Agnt,PX-3058557666,CDM,85576,CPT,0305,RC,,,,both,,,111.00,72.15,,,,,,,,,,,,,
ADAPTER FEM 4MM SM TI HIP ENDOPROS STRL IMP METASUL LDH,SUP-2204651,CDM,C1776,CPT,0278,RC,,,,both,,,469.43,305.13,,,,,,,,,,,,,
Xpedicul Decompress Throacic Cord|RIGHT SIDE,CASE-63055,LOCAL,63055,CPT,0360,RC,,,RT,outpatient,,,43438.43,26063.06,,,,,,,,,,,,,
Replacement Tissue Expander W/Permanent Implant|BILATERAL PROCEDURE,CASE-11970,LOCAL,11970,CPT,0360,RC,,,50,outpatient,,,54011.75,32407.05,,,,,,,,,,,,,
HC Gastroesophag Reflx Test W/Tel Ph Eltrd,CASE-91035,LOCAL,91035,CPT,0750,RC,,,,outpatient,,,1795.08,1077.05,,,,,,,,,,,,,
Replacement Tissue Expander W/Permanent Implant|BILATERAL PROCEDURE,CASE-11970,LOCAL,11970,CPT,,,,,50,outpatient,,,54011.75,32407.05,,,,,,,,,,,,,
Carpectomy All Bones Proximal Row|RIGHT SIDE,CASE-25215,LOCAL,25215,CPT,,,,,RT,outpatient,,,29971.03,17982.62,,,,,,,,,,,,,
Xpedicul Decompress Throacic Cord|RIGHT SIDE,CASE-63055,LOCAL,63055,CPT,,,,,RT,outpatient,,,43438.43,26063.06,,,,,,,,,,,,,
Carpectomy All Bones Proximal Row|RIGHT SIDE,CASE-25215,LOCAL,25215,CPT,0360,RC,,,RT,outpatient,,,29971.03,17982.62,,,,,,,,,,,,,
ELECTRODE ELECSURG RF 50 MM SELF GRND NITRODE,SUP-2366981,CDM,C1713,HCPCS,0278,RC,,,,both,,,7503.53,4877.29,,,,,,,,,,,,,
BURR SIDE CUTTING CARBIDE 3.2MM MHD15CG1,SUP-2843306,CDM,2720000010,LOCAL,0272,RC,,,,both,,,588.31,382.40,,,,,,,,,,,,,
BRACE ORTHOPEDIC ANK FT PLAS,SUP-2388162,CDM,L1930,HCPCS,0274,RC,,,,both,,,973.40,632.71,,,,,,,,,,,,,
WASHER ORTHOPEDIC SPIKE NONSTERILE LATEX GRIDLOCK,SUP-2880180,CDM,C1713,HCPCS,0278,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
HC Wedge Excision Skin Nail Fold,PX-4501176500,CDM,11765,CPT,0450,RC,,,,both,,,1216.00,790.40,,,,,,,,,,,,,
PLATE BONE LOW PRFLE HLX3X2 06MM THK TTNM CRVD SQRE SGMNT P,SUP-2676648,CDM,C1713,HCPCS,0278,RC,,,,both,,,792.85,515.35,,,,,,,,,,,,,
PLATE BNE SM W10.1XL149MM THK3.5MM 12 H BILAT S STL CRV RIG,SUP-2186264,CDM,C1713,HCPCS,0278,RC,,,,both,,,2286.83,1486.44,,,,,,,,,,,,,
CANNULA LAP FOR FACE CLOSURE NDL SPARE SUTURE PASS,SUP-2748430,CDM,2720000010,LOCAL,0272,RC,,,,both,,,428.92,278.80,,,,,,,,,,,,,
GRAFT STENT 0.035 IN 7X80 MM 9 FRX80 CM ENDOVASC FLUENCY +,SUP-2464831,CDM,C1874,HCPCS,0278,RC,,,,both,,,6123.00,3979.95,,,,,,,,,,,,,
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|SEPARATE STRUCTURE|LEFT FOOT, SECOND DIGIT",CASE-28270,LOCAL,28270,CPT,,,,,XS|T1,outpatient,,,38410.67,23046.40,,,,,,,,,,,,,
Insj/Rplcmt Perq Eltrd Ra Pn W/Int Nstim 1st Ra,CASE-64596,LOCAL,64596,CPT,,,,,,outpatient,,,24320.83,14592.50,,,,,,,,,,,,,
Neuroplasty &/Transpos Median Nrv Carpal Tunne|RIGHT SIDE|SEPARATE STRUCTURE,CASE-64721,LOCAL,64721,CPT,,,,,RT|XS,outpatient,,,34272.03,20563.22,,,,,,,,,,,,,
Nerve Repair W/Nerve Allograft First Strand|LEFT SIDE,CASE-64912,LOCAL,64912,CPT,0360,RC,,,LT,outpatient,,,43459.03,26075.42,,,,,,,,,,,,,
Nerve Repair W/Nerve Allograft First Strand|LEFT SIDE,CASE-64912,LOCAL,64912,CPT,,,,,LT,outpatient,,,43459.03,26075.42,,,,,,,,,,,,,
Neuroplasty &/Transpos Median Nrv Carpal Tunne|RIGHT SIDE|SEPARATE STRUCTURE,CASE-64721,LOCAL,64721,CPT,0360,RC,,,RT|XS,outpatient,,,34272.03,20563.22,,,,,,,,,,,,,
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|SEPARATE STRUCTURE|LEFT FOOT, SECOND DIGIT",CASE-28270,LOCAL,28270,CPT,0360,RC,,,XS|T1,outpatient,,,38410.67,23046.40,,,,,,,,,,,,,
Insj/Rplcmt Perq Eltrd Ra Pn W/Int Nstim 1st Ra,CASE-64596,LOCAL,64596,CPT,0360,RC,,,,outpatient,,,24320.83,14592.50,,,,,,,,,,,,,
ALLOGRAFT BNE SPNG 25X20X7 MM BLOCK DBM CANC H-GENIN,SUP-2225962,CDM,C1889,HCPCS,0278,RC,,,,both,,,7278.52,4731.04,,,,,,,,,,,,,
SEED BRACHYTHERAPY LOOSE 1.01-2.0 MCI NS ADVANTAGE,SUP-2247262,CDM,C2643,HCPCS,0278,RC,,,,both,,,188.40,122.46,,,,,,,,,,,,,
PROSTHESIS OSS PISTON 0.8X1.12X4.5 MM 1.04 MM LT EAR SHEA,SUP-2637801,CDM,L8613,CPT,0278,RC,,,,both,,,456.34,296.62,,,,,,,,,,,,,
STIMULATOR BNE MINI MESH CATHODE 60UA DEV SPF +,SUP-2414470,CDM,E0749,HCPCS,0278,RC,,,,both,,,20410.00,13266.50,,,,,,,,,,,,,
STIMULATOR BONE ELEC LTWT FOR BONE GROWTH STIM PHYSIO-STIM,SUP-2316215,CDM,E0749,HCPCS,0278,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
PLATE BNE SZ 2 MM MIDFACE PMI NS DISP ACCUPLATE,SUP-2936114,CDM,C1713,HCPCS,0278,RC,,,,both,,,34273.10,22277.51,,,,,,,,,,,,,
SCREW BNE L24MM DIA3.8MM 90DEG S STL CORT PROX HUM CANN LOK,SUP-2414109,CDM,C1713,HCPCS,0278,RC,,,,both,,,396.08,257.45,,,,,,,,,,,,,
ENDOSCOPIC PACK INSTRUMENT 30 DEG 4X138 MM RIGID SCP,SUP-2243452,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3603.84,2342.50,,,,,,,,,,,,,
TUBE SET MICRO-HOOK BONESCALPEL MIS,SUP-2748600,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
PICC KIT CHLOROGUARD 4.5 FR VPS PRECIS ARROWG+ARD BLU +,SUP-2763312,CDM,C1751,HCPCS,0278,RC,,,,both,,,824.78,536.11,,,,,,,,,,,,,
PLATE BNE L81MM 10 H NONSTERILE STR RECON FOR 27MM SCR UNIV,SUP-2199376,CDM,C1713,HCPCS,0278,RC,,,,both,,,1148.80,746.72,,,,,,,,,,,,,
"Amputation Toe Metatarsophalangeal Joint|RIGHT FOOT, SECOND DIGIT",CASE-28820,LOCAL,28820,CPT,,,,,T6,outpatient,,,34933.33,20960.00,,,,,,,,,,,,,
Lamnotmy Incl W/Dcmprsn Nrv Root 1 Intrspc Lumbr|RIGHT SIDE,CASE-63030,LOCAL,63030,CPT,0360,RC,,,RT,outpatient,,,42993.00,25795.80,,,,,,,,,,,,,
Int Hrhc by Ligation Single Hroid W/O Img Gdn,CASE-46945,LOCAL,46945,CPT,,,,,,outpatient,,,12663.30,7597.98,,,,,,,,,,,,,
Dstr Nrolytc Agnt Parverteb Fct Addl Crvcl/Thora|LEFT SIDE,CASE-64634,LOCAL,64634,CPT,0360,RC,,,LT,outpatient,,,11822.95,7093.77,,,,,,,,,,,,,
Hrv Skin for Skin Cell Ssp Agrft 1st 25 Sq Cm/<,CASE-15011,LOCAL,15011,CPT,,,,,,outpatient,,,54254.85,32552.91,,,,,,,,,,,,,
Cysto W/Urtroscopy&/Pyeloscopy Dx,CASE-52351,LOCAL,52351,CPT,,,,,,outpatient,,,16435.38,9861.23,,,,,,,,,,,,,
Surgical Arthroscopy Shoulder Dstl Claviculc|RIGHT SIDE,CASE-29824,LOCAL,29824,CPT,,,,,RT,outpatient,,,38146.35,22887.81,,,,,,,,,,,,,
Cystostomy Cystotomy W/Drainage,CASE-51040,LOCAL,51040,CPT,0360,RC,,,,outpatient,,,15257.60,9154.56,,,,,,,,,,,,,
Surgical Arthroscopy Shoulder Dstl Claviculc|RIGHT SIDE,CASE-29824,LOCAL,29824,CPT,0360,RC,,,RT,outpatient,,,38146.35,22887.81,,,,,,,,,,,,,
Cystostomy Cystotomy W/Drainage,CASE-51040,LOCAL,51040,CPT,,,,,,outpatient,,,15257.60,9154.56,,,,,,,,,,,,,
Lamnotmy Incl W/Dcmprsn Nrv Root 1 Intrspc Lumbr|RIGHT SIDE,CASE-63030,LOCAL,63030,CPT,,,,,RT,outpatient,,,42993.00,25795.80,,,,,,,,,,,,,
"Amputation Toe Metatarsophalangeal Joint|RIGHT FOOT, SECOND DIGIT",CASE-28820,LOCAL,28820,CPT,0360,RC,,,T6,outpatient,,,34933.33,20960.00,,,,,,,,,,,,,
Dstr Nrolytc Agnt Parverteb Fct Addl Crvcl/Thora|LEFT SIDE,CASE-64634,LOCAL,64634,CPT,,,,,LT,outpatient,,,11822.95,7093.77,,,,,,,,,,,,,
Int Hrhc by Ligation Single Hroid W/O Img Gdn,CASE-46945,LOCAL,46945,CPT,0360,RC,,,,outpatient,,,12663.30,7597.98,,,,,,,,,,,,,
Cysto W/Urtroscopy&/Pyeloscopy Dx,CASE-52351,LOCAL,52351,CPT,0360,RC,,,,outpatient,,,16435.38,9861.23,,,,,,,,,,,,,
Ercp Stent Placement Biliary/Pancreatic Duct,CASE-43274,LOCAL,43274,CPT,0360,RC,,,,outpatient,,,28994.82,17396.89,,,,,,,,,,,,,
Ercp Stent Placement Biliary/Pancreatic Duct,CASE-43274,LOCAL,43274,CPT,,,,,,outpatient,,,28994.82,17396.89,,,,,,,,,,,,,
Hrv Skin for Skin Cell Ssp Agrft 1st 25 Sq Cm/<,CASE-15011,LOCAL,15011,CPT,0360,RC,,,,outpatient,,,54254.85,32552.91,,,,,,,,,,,,,
BLADE OSTEO L12MM THN CRV END,SUP-2408597,CDM,2720000010,LOCAL,0272,RC,,,,both,,,276.32,179.61,,,,,,,,,,,,,
HC Rep Cpx Face H Ft 1.1-2.5cm,PX-4501313100,CDM,13131,CPT,0450,RC,,,,both,,,1216.00,790.40,,,,,,,,,,,,,
GUIDEWIRE ORTH L400MM DIA3.2MM FOR TFN,SUP-2188232,CDM,C1769,HCPCS,0272,RC,,,,both,,,283.86,184.51,,,,,,,,,,,,,
GRAFT BNE SUB 5CC SZ 05 3MM DEMIN CORT CANC GRAN FRZ DRY,SUP-2307255,CDM,C1713,HCPCS,0278,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
PLATE BNE L132MM 12 H NONSTERILE POST DST TIB S STL T LOK,SUP-2177438,CDM,C1713,HCPCS,0278,RC,,,,both,,,4280.07,2782.05,,,,,,,,,,,,,
NAIL IM L34CM DIA11.5MM LT LIME META-TAN,SUP-2340898,CDM,C1713,HCPCS,0278,RC,,,,both,,,11391.29,7404.34,,,,,,,,,,,,,
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,0636,RC,70436-0019-82,NDC,,both,1,UN,54.10,35.16,,,,,,,,,,,,,
HC Ot Vasopneumatic Device Therapy|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS,PX-4309701600,CDM,97016,CPT,0430,RC,,,CQ,both,,,206.00,133.90,,,,,,,,,,,,,
PLATE BNE L 140 MM SCREW DIA2.7 MM 20 SHFT H SS ADPT VA SLV,SUP-2907644,CDM,C1713,HCPCS,0278,RC,,,,both,,,4788.88,3112.77,,,,,,,,,,,,,
SHEAR HARMONIC 700 VES SEAL 360 DEG SHFT L 36 MM DIA 5 MM JAW L,SUP-2889526,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1599.96,1039.97,,,,,,,,,,,,,
LINER ACET DUR 15 DEG 28MM ID 58-60MM OD,SUP-2376155,CDM,C1776,CPT,0278,RC,,,,both,,,1701.31,1105.85,,,,,,,,,,,,,
HC Ot Group Therapy,PX-4309715000,CDM,97150,CPT,0430,RC,,,,both,,,135.00,87.75,,,,,,,,,,,,,
ANCHOR SUTURE BIOCOMP 4.75X22 MM DBL LD WHT SWIVELOCK C,SUP-2121693,CDM,C1713,HCPCS,0278,RC,,,,both,,,1309.38,851.10,,,,,,,,,,,,,
HC ED Cltx Rad Ulnr Shft Fx Manip,PX-4502556500,CDM,25565,CPT,0450,RC,,,,both,,,1633.00,1061.45,,,,,,,,,,,,,
CATHETERIZATION SET ROSCH-THURMOND 5.5 FR FALLOPIAN TUBE,SUP-2755162,CDM,C1769,HCPCS,0272,RC,,,,both,,,511.82,332.68,,,,,,,,,,,,,
Excision Olecranon Bursa|LEFT SIDE,CASE-24105,LOCAL,24105,CPT,,,,,LT,outpatient,,,54970.60,32982.36,,,,,,,,,,,,,
Colsc Flexible W/Control Bleeding Any Method,CASE-45382,LOCAL,45382,CPT,,,,,,outpatient,,,19999.47,11999.68,,,,,,,,,,,,,
Hysteroscopy Lysis Intrauterine Adhesions,CASE-58559,LOCAL,58559,CPT,,,,,,outpatient,,,24337.68,14602.61,,,,,,,,,,,,,
Hysteroscopy Lysis Intrauterine Adhesions,CASE-58559,LOCAL,58559,CPT,0360,RC,,,,outpatient,,,24337.68,14602.61,,,,,,,,,,,,,
Colsc Flexible W/Control Bleeding Any Method,CASE-45382,LOCAL,45382,CPT,0360,RC,,,,outpatient,,,19999.47,11999.68,,,,,,,,,,,,,
Excision Olecranon Bursa|LEFT SIDE,CASE-24105,LOCAL,24105,CPT,0360,RC,,,LT,outpatient,,,54970.60,32982.36,,,,,,,,,,,,,
TRAY HEMO DYLS OR HD 15.5FR 19CM IMPL LEN CHRONIC 2 SPL TIP,SUP-2354974,CDM,C1752,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
PIN AXLE STABILIZING 1 PC EL SOLAR L,SUP-2372319,CDM,C1713,HCPCS,0278,RC,,,,both,,,1575.02,1023.76,,,,,,,,,,,,,
DEFIBRILLATOR IMPL CLARIA MRI CRT-D SURESCAN W 51 X H 71 MM,SUP-2282409,CDM,C1882,HCPCS,0275,RC,,,,both,,,58486.21,38016.04,,,,,,,,,,,,,
BLADE SURGICAL MINI EDGE 64 CHISEL SM STERILE,SUP-2582892,CDM,2720000010,LOCAL,0272,RC,,,,both,,,27.88,18.12,,,,,,,,,,,,,
PLATE BNE INTERMED CLMN -90 DEG 2.4X49 MM DSTL RADIAL 2X4,SUP-2180923,CDM,C1713,HCPCS,0278,RC,,,,both,,,2356.19,1531.52,,,,,,,,,,,,,
KIT INTRO L 10 CM NIT WIRE TUNGSTEN TIP MIC B BVL STD,SUP-2752723,CDM,C1894,HCPCS,0272,RC,,,,both,,,78.09,50.76,,,,,,,,,,,,,
COMPONENT TIB W33.5MMXL D45MM ANK CO CHROM TI CEMENTLESS SGL,SUP-2362589,CDM,C1776,CPT,0278,RC,,,,both,,,12486.84,8116.45,,,,,,,,,,,,,
SCREW BNE CRTX 2X4 MM RAPID RESRB W/PLATE STRL 80600410S,SUP-2859939,CDM,C1713,HCPCS,0278,RC,,,,both,,,316.73,205.87,,,,,,,,,,,,,
CLIP ANEURYSM SUNDTKEES 12MM REINFORCING 30 DEG 201746,SUP-2844626,CDM,C1889,HCPCS,0278,RC,,,,both,,,1182.30,768.49,,,,,,,,,,,,,
GRAFT BNE STRP 30X20X5 MM CANC INDUX,SUP-2684160,CDM,C1713,HCPCS,0278,RC,,,,both,,,3818.24,2481.86,,,,,,,,,,,,,
WASHER ORTHOPEDIC DIA 9.5 MM NS LF DISP ADVANTAGERIB,SUP-2908965,CDM,C1713,HCPCS,0278,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
GRAFT SO 6CMX16CM SURGIMEND PRS,SUP-2243677,CDM,C9360,HCPCS,0278,RC,,,,both,,,6330.24,4114.66,,,,,,,,,,,,,
CATHETER EP H CRV 7 FR STEER 3D MAP INQUIRY,SUP-2357426,CDM,C1730,HCPCS,0272,RC,,,,both,,,2019.71,1312.81,,,,,,,,,,,,,
SHEATH INTRO FLX L 30 CM OD 10 FR ID 3.4 MM GUIDEWIRE 0.038,SUP-2168815,CDM,C1894,HCPCS,0272,RC,,,,both,,,176.66,114.83,,,,,,,,,,,,,
Sigmoidoscopy Flx Control Bleeding,CASE-45334,LOCAL,45334,CPT,0360,RC,,,,outpatient,,,10419.67,6251.80,,,,,,,,,,,,,
"Surg Implnt Neuroelect,Epidural",CASE-63655,LOCAL,63655,CPT,0360,RC,,,,outpatient,,,96279.37,57767.62,,,,,,,,,,,,,
Nasal/Sinus Ndsc W/Partial Ethmoidectomy|LEFT SIDE,CASE-31254,LOCAL,31254,CPT,0360,RC,,,LT,outpatient,,,35240.75,21144.45,,,,,,,,,,,,,
"Surg Implnt Neuroelect,Epidural",CASE-63655,LOCAL,63655,CPT,,,,,,outpatient,,,96279.37,57767.62,,,,,,,,,,,,,
Arthrs Knee W/Meniscectomy Med&Lat W/Shaving|LEFT SIDE,CASE-29880,LOCAL,29880,CPT,0360,RC,,,LT,outpatient,,,26775.88,16065.53,,,,,,,,,,,,,
Tonsillectomy Primary/Secondary Age 12/>,CASE-42826,LOCAL,42826,CPT,,,,,,outpatient,,,17902.18,10741.31,,,,,,,,,,,,,
Arthrs Knee W/Meniscectomy Med&Lat W/Shaving|LEFT SIDE,CASE-29880,LOCAL,29880,CPT,,,,,LT,outpatient,,,26775.88,16065.53,,,,,,,,,,,,,
Colonoscopy Flx Dx W/Collj Spec When Pfrmd,CASE-45378,LOCAL,45378,CPT,,,,,,outpatient,,,10619.27,6371.56,,,,,,,,,,,,,
Cysto W/Ureteroscopy W/Lithotripsy|LEFT SIDE,CASE-52353,LOCAL,52353,CPT,0360,RC,,,LT,outpatient,,,24938.23,14962.94,,,,,,,,,,,,,
Colonoscopy Flx Dx W/Collj Spec When Pfrmd,CASE-45378,LOCAL,45378,CPT,0360,RC,,,,outpatient,,,10619.27,6371.56,,,,,,,,,,,,,
Nasal/Sinus Ndsc W/Partial Ethmoidectomy|LEFT SIDE,CASE-31254,LOCAL,31254,CPT,,,,,LT,outpatient,,,35240.75,21144.45,,,,,,,,,,,,,
"Amputation Metatarsal W/Toe Single|RIGHT FOOT, FOURTH DIGIT",CASE-28810,LOCAL,28810,CPT,0360,RC,,,T8,outpatient,,,28867.77,17320.66,,,,,,,,,,,,,
Sigmoidoscopy Flx Control Bleeding,CASE-45334,LOCAL,45334,CPT,,,,,,outpatient,,,10419.67,6251.80,,,,,,,,,,,,,
Tonsillectomy Primary/Secondary Age 12/>,CASE-42826,LOCAL,42826,CPT,0360,RC,,,,outpatient,,,17902.18,10741.31,,,,,,,,,,,,,
Cysto W/Ureteroscopy W/Lithotripsy|LEFT SIDE,CASE-52353,LOCAL,52353,CPT,,,,,LT,outpatient,,,24938.23,14962.94,,,,,,,,,,,,,
"Amputation Metatarsal W/Toe Single|RIGHT FOOT, FOURTH DIGIT",CASE-28810,LOCAL,28810,CPT,,,,,T8,outpatient,,,28867.77,17320.66,,,,,,,,,,,,,
IMPLANT OTO L9MM HD DIA3.25MM SHFT DIA1MM TI HA CAP OFFSET,SUP-2277546,CDM,L8613,CPT,0278,RC,,,,both,,,1607.68,1044.99,,,,,,,,,,,,,
PLATE BNE L36MM THK1MM 12 H NONSTERILE HND S STL RECTANG LOK,SUP-2178014,CDM,C1713,HCPCS,0278,RC,,,,both,,,1587.62,1031.95,,,,,,,,,,,,,
SCREW PEDCL SPNL LCK VAR TI MOD 5.5MMDIA 35MML,SUP-2415523,CDM,C1713,HCPCS,0278,RC,,,,both,,,2199.76,1429.84,,,,,,,,,,,,,
HC Decalcification Procedure,PX-3128831100,CDM,88311,CPT,0312,RC,,,,both,,,105.00,68.25,,,,,,,,,,,,,
SPHINCTEROTOME ENDO 3 LUMN MFIL CUT GWIRE PC CANN OF DUCTAL,SUP-2170667,CDM,2720000010,LOCAL,0272,RC,,,,both,,,555.78,361.26,,,,,,,,,,,,,
PLATE BNE L945MM THK25MM 8 H ACET S STL FLX ANNEALED,SUP-2362707,CDM,C1713,HCPCS,0278,RC,,,,both,,,2762.89,1795.88,,,,,,,,,,,,,
MIS LOCK CALC PLT SM RT,SUP-2586883,CDM,C1713,HCPCS,0278,RC,,,,both,,,2062.01,1340.31,,,,,,,,,,,,,
HC Dialysis Circuit Embolj,PX-3613690900,CDM,36909,CPT,0361,RC,,,,both,,,8583.00,5578.95,,,,,,,,,,,,,
ANCHOR SUT ARTHSCP HNDL INSRTR NO 2 SUT TI 3.5MM DIA TWINFIX,SUP-2341070,CDM,C1713,HCPCS,0278,RC,,,,both,,,763.02,495.96,,,,,,,,,,,,,
SPLINT THMB SM FOR 6-7IN RT CARPOMETACARPAL JT RESTRICT ELAS,SUP-2324695,CDM,L3931,HCPCS,0272,RC,,,,both,,,57.56,37.41,,,,,,,,,,,,,
KIT INTRO GLIDESHEATH SLENDER L 10 CM DIA 6 FR 0.021IN,SUP-2385482,CDM,C1894,HCPCS,0272,RC,,,,both,,,172.70,112.25,,,,,,,,,,,,,
PACEMAKER CARD LUMAX 540 HF-T 40 J SCOUTPRO HOME MONITORING,SUP-2138264,CDM,C1882,HCPCS,0275,RC,,,,both,,,85046.90,55280.48,,,,,,,,,,,,,
"Arthrodesis Great Toe Metatarsophalangeal Joint|RIGHT FOOT, GREAT TOE",CASE-28750,LOCAL,28750,CPT,,,,,T5,outpatient,,,63367.73,38020.64,,,,,,,,,,,,,
"Arthrodesis Great Toe Metatarsophalangeal Joint|RIGHT FOOT, GREAT TOE",CASE-28750,LOCAL,28750,CPT,0360,RC,,,T5,outpatient,,,63367.73,38020.64,,,,,,,,,,,,,
STEM HUM L74MM DIA3B 132.5DEG STD SHLDR PTC AEQUALIS ASCEND,SUP-2388733,CDM,C1776,CPT,0278,RC,,,,both,,,11016.69,7160.85,,,,,,,,,,,,,
FIBER LASER HOLM 550 M FOR USE W/ H-30 RED SMARTSYNC DISP,SUP-2835950,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1317.01,856.06,,,,,,,,,,,,,
BUR SURG L14CM DIA2MM BALL FLUT L BOR MIDAS REX LEGEND,SUP-2277718,CDM,2720000010,LOCAL,0272,RC,,,,both,,,362.89,235.88,,,,,,,,,,,,,
HC Fecal Leukocytes,PX-3008905500,CDM,89055,CPT,0300,RC,,,,both,,,224.00,145.60,,,,,,,,,,,,,
PLATE BONE THK0.5MM 18 H ORBIT GRN TI HX FOR 1.5MM SCR,SUP-2135902,CDM,C1713,HCPCS,0278,RC,,,,both,,,1029.92,669.45,,,,,,,,,,,,,
PLATE BNE W8XL64MM THK3.3MM 8 H NONSTERILE BILAT PELV S STL,SUP-2186234,CDM,C1713,HCPCS,0278,RC,,,,both,,,1568.78,1019.71,,,,,,,,,,,,,
STEM HUM 79MM DST R STR PRSS FIT TI SOLAR,SUP-2372322,CDM,C1776,CPT,0278,RC,,,,both,,,19863.33,12911.16,,,,,,,,,,,,,
BIT DRL L90MM DIA1.8MM MINI FLUT PROX END DISP,SUP-2389424,CDM,2720000010,LOCAL,0272,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
ROD EXT FIX LNG 500 MM NS PREFIX FIX LTX,SUP-2875766,CDM,2720000010,LOCAL,0272,RC,,,,both,,,486.51,316.23,,,,,,,,,,,,,
SHEATH INTRO GLIDESHEATH L 16 CM OD 5 FR ID 0.074 IN TIP DIA,SUP-2385327,CDM,C1894,HCPCS,0272,RC,,,,both,,,133.14,86.54,,,,,,,,,,,,,
IMMOBILIZER KNEE CUTAWAY 24 IN,SUP-2336082,CDM,L1830,CPT,0274,RC,,,,both,,,37.21,24.19,,,,,,,,,,,,,
BLADE RETRACTOR THERAPON MORSE 30X28 MM SET INSTRUMENT ULTRA,SUP-2480817,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1495.21,971.89,,,,,,,,,,,,,
ANCHOR SUTURE SIZE 1 LNG SOFT SINGLE LOADED JUGGERKNOT,SUP-2589015,CDM,C1713,HCPCS,0278,RC,,,,both,,,1046.59,680.28,,,,,,,,,,,,,
LINER ACET SZ B ID22MM STD HIP HGP II CUP ELEV RIM,SUP-2202715,CDM,C1776,CPT,0278,RC,,,,both,,,2461.76,1600.14,,,,,,,,,,,,,
IMPLANT SYNTH 38 X 63 MM THK 9.5 MM POLYETHYL CRANIOFACIAL,SUP-2883272,CDM,C1713,HCPCS,0278,RC,,,,both,,,4025.98,2616.89,,,,,,,,,,,,,
Brnchsc Ebus Guided Sampl 1/2 Node Station/Strux,CASE-31652,LOCAL,31652,CPT,,,,,,outpatient,,,37138.13,22282.88,,,,,,,,,,,,,
Arthroscopy Knee W/Meniscus Rpr Medial/Lateral|RIGHT SIDE,CASE-29882,LOCAL,29882,CPT,0360,RC,,,RT,outpatient,,,49061.08,29436.65,,,,,,,,,,,,,
Mastectomy Simple Complete|RIGHT SIDE,CASE-19303,LOCAL,19303,CPT,0360,RC,,,RT,outpatient,,,51974.92,31184.95,,,,,,,,,,,,,
Brnchsc Ebus Guided Sampl 1/2 Node Station/Strux,CASE-31652,LOCAL,31652,CPT,0360,RC,,,,outpatient,,,37138.13,22282.88,,,,,,,,,,,,,
Mastectomy Simple Complete|RIGHT SIDE,CASE-19303,LOCAL,19303,CPT,,,,,RT,outpatient,,,51974.92,31184.95,,,,,,,,,,,,,
Arthroscopy Knee W/Meniscus Rpr Medial/Lateral|RIGHT SIDE,CASE-29882,LOCAL,29882,CPT,,,,,RT,outpatient,,,49061.08,29436.65,,,,,,,,,,,,,
Excision Tumor Soft Tissue Shoulder Subq 3 Cm/>,CASE-23071,LOCAL,23071,CPT,0360,RC,,,,outpatient,,,96595.47,57957.28,,,,,,,,,,,,,
Excision Tumor Soft Tissue Shoulder Subq 3 Cm/>,CASE-23071,LOCAL,23071,CPT,,,,,,outpatient,,,96595.47,57957.28,,,,,,,,,,,,,
PLATE BONE 3 H STD LT VOLAR TI D-RAD,SUP-2343910,CDM,C1713,HCPCS,0278,RC,,,,both,,,3198.09,2078.76,,,,,,,,,,,,,
POTASSIUM BICARB-CITRIC ACID 20 MEQ PO TBEF,RX-87912,CDM,6370000000,HCPCS,0637,RC,51801-0012-30,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
DILATOR ENDO CATH 7FR BAL L5.5CM DIA8MM COLON QNT TTC,SUP-2169385,CDM,C1726,HCPCS,0272,RC,,,,both,,,442.74,287.78,,,,,,,,,,,,,
HC So Microdissection Manual,PX-3128838166,CDM,88381,CPT,0312,RC,,,,both,,,201.00,130.65,,,,,,,,,,,,,
COIL EMB L30CM OD0.020IN LOOP OD10MM NIT STRTCH RESIST FILL,SUP-2323410,CDM,C1889,HCPCS,0278,RC,,,,both,,,7655.32,4975.96,,,,,,,,,,,,,
SCREW EXT FIX L65MM DIA4X25MM S STL TRCR PNT MR CONDITIONAL,SUP-2186969,CDM,C1713,HCPCS,0278,RC,,,,both,,,401.07,260.70,,,,,,,,,,,,,
PLATE BONE SM L145MM 12 H TI 1/3 TBLR,SUP-2190924,CDM,C1713,HCPCS,0278,RC,,,,both,,,148.37,96.44,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.404,SUP-2859968,CDM,C1713,HCPCS,0278,RC,,,,both,,,30903.88,20087.52,,,,,,,,,,,,,
IPRATROPIUM BROMIDE HFA 17 MCG/ACT IN AERS,RX-41142,CDM,6370000000,HCPCS,0637,RC,00597-0087-17,NDC,,both,12.9,GR,1380.80,897.52,,,,,,,,,,,,,
COVER BURR H DIA10 MM THK 0.5 MM CRANIOFACIAL FOR 1.7 MM,SUP-2883561,CDM,C1713,HCPCS,0278,RC,,,,both,,,1867.04,1213.58,,,,,,,,,,,,,
PROBE LASER ASPIR 20 GA STR PRECIS FIBER CENTERING,SUP-2466332,CDM,2720000010,LOCAL,0272,RC,,,,both,,,542.59,352.68,,,,,,,,,,,,,
BASEPLATE TIB L47MM LNG MEDL LAT KNEE CO CHROM RESURF,SUP-2406481,CDM,C1776,CPT,0278,RC,,,,both,,,8633.43,5611.73,,,,,,,,,,,,,
HC Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn,CASE-62321,LOCAL,62321,CPT,0360,RC,,,,outpatient,,,4402.45,2641.47,,,,,,,,,,,,,
HC Injection Small Joint/Bursa|PBB CHARGE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-20600,LOCAL,20600,CPT,0361,RC,,,PBB|XU,outpatient,,,4773.17,2863.90,,,,,,,,,,,,,
Esophagoscopy Intra/Transmural Needle Aspirat/Bx,CASE-43232,LOCAL,43232,CPT,0360,RC,,,,outpatient,,,14401.28,8640.77,,,,,,,,,,,,,
Anterior Colporraphy Rpr Cystocele W/Cysto,CASE-57240,LOCAL,57240,CPT,0360,RC,,,,outpatient,,,35315.68,21189.41,,,,,,,,,,,,,
Revj/Rmvl Impl Spi Npg/Rcvr Dtch Connj Eltrd Ra,CASE-63688,LOCAL,63688,CPT,0360,RC,,,,outpatient,,,23926.27,14355.76,,,,,,,,,,,,,
Arthrp Interpos Intercarpal/Metacarpal Joints|LEFT SIDE,CASE-25447,LOCAL,25447,CPT,0360,RC,,,LT,outpatient,,,24512.23,14707.34,,,,,,,,,,,,,
Rmvl & Rplcmt Inflatable Penile Prosth Same Sess,CASE-54410,LOCAL,54410,CPT,,,,,,outpatient,,,95076.45,57045.87,,,,,,,,,,,,,
Arthrp Interpos Intercarpal/Metacarpal Joints|LEFT SIDE,CASE-25447,LOCAL,25447,CPT,,,,,LT,outpatient,,,24512.23,14707.34,,,,,,,,,,,,,
Esophagoscopy Intra/Transmural Needle Aspirat/Bx,CASE-43232,LOCAL,43232,CPT,,,,,,outpatient,,,14401.28,8640.77,,,,,,,,,,,,,
"Open Tx Metacarpal Fracture Single Ea Bone|RIGHT HAND, THIRD DIGIT",CASE-26615,LOCAL,26615,CPT,,,,,F7,outpatient,,,26216.42,15729.85,,,,,,,,,,,,,
Revj/Rmvl Impl Spi Npg/Rcvr Dtch Connj Eltrd Ra,CASE-63688,LOCAL,63688,CPT,,,,,,outpatient,,,23926.27,14355.76,,,,,,,,,,,,,
Anterior Colporraphy Rpr Cystocele W/Cysto,CASE-57240,LOCAL,57240,CPT,,,,,,outpatient,,,35315.68,21189.41,,,,,,,,,,,,,
Rmvl & Rplcmt Inflatable Penile Prosth Same Sess,CASE-54410,LOCAL,54410,CPT,0360,RC,,,,outpatient,,,95076.45,57045.87,,,,,,,,,,,,,
"Open Tx Metacarpal Fracture Single Ea Bone|RIGHT HAND, THIRD DIGIT",CASE-26615,LOCAL,26615,CPT,0360,RC,,,F7,outpatient,,,26216.42,15729.85,,,,,,,,,,,,,
LEVOTHYROXINE SODIUM 100 MCG PO TABS,RX-4423,CDM,6370000000,HCPCS,0637,RC,51079-0442-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PLATE BNE L292MM 18 H ST R ANTLAT DST TIB S STL VAR ANG LOK,SUP-2177695,CDM,C1713,HCPCS,0278,RC,,,,both,,,7845.54,5099.60,,,,,,,,,,,,,
SCREW BNE CANC UNIV 4X32 MM LCK ST FT SM FRAG TI,SUP-2458615,CDM,C1713,HCPCS,0278,RC,,,,both,,,78.66,51.13,,,,,,,,,,,,,
CMPLT MICROTIA TEMPLATE SET MOD 59LT PA,SUP-2682131,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4461.81,2900.18,,,,,,,,,,,,,
NAIL IM LENGTHENING 11X225 MM FITBONE 60001468000,SUP-2645845,CDM,C1713,HCPCS,0278,RC,,,,both,,,72220.00,46943.00,,,,,,,,,,,,,
CUP HUM DIA 33 MM OFFSET 2 MM RT STRL UNIVERS REVERS,SUP-2933960,CDM,C1776,CPT,0278,RC,,,,both,,,5604.90,3643.18,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY EXPLORER ST L 100 CM DIA 6 FR TIP,SUP-2141294,CDM,C1730,HCPCS,0272,RC,,,,both,,,671.96,436.77,,,,,,,,,,,,,
PLATE BNE L266MM 12 H ST L CNDYL S STL CRV LOK COMPR VAR,SUP-2177858,CDM,C1713,HCPCS,0278,RC,,,,both,,,6446.29,4190.09,,,,,,,,,,,,,
ISOSORBIDE MONONITRATE 20 MG PO TABS,RX-10357,CDM,6370000000,HCPCS,0637,RC,81665-0103-10,NDC,,both,1,UN,15.80,10.27,,,,,,,,,,,,,
BUR SURG 51X23MM RND CUT NONFLUTED CARB ST MICROFRANCE,SUP-2278143,CDM,2720000010,LOCAL,0272,RC,,,,both,,,585.36,380.48,,,,,,,,,,,,,
STAPLER INT 60 48MM AUTO SGL USE RELD GIA,SUP-2787663,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1250.63,812.91,,,,,,,,,,,,,
NAIL IM L360MM DIA9MM 130DEG LNG RT HIP TIM CANN LCK FOR AG,SUP-2419524,CDM,C1713,HCPCS,0278,RC,,,,both,,,10059.46,6538.65,,,,,,,,,,,,,
Egd Dilation Gastric/Duodenal Stricture,CASE-43245,LOCAL,43245,CPT,,,,,,outpatient,,,12149.90,7289.94,,,,,,,,,,,,,
Egd Band Ligation Esophgeal/Gastric Varices,CASE-43244,LOCAL,43244,CPT,0360,RC,,,,outpatient,,,10195.78,6117.47,,,,,,,,,,,,,
Rhytidectomy Smas Flap,CASE-15829,LOCAL,15829,CPT,,,,,,outpatient,,,113250.58,67950.35,,,,,,,,,,,,,
Egd Dilation Gastric/Duodenal Stricture,CASE-43245,LOCAL,43245,CPT,0360,RC,,,,outpatient,,,12149.90,7289.94,,,,,,,,,,,,,
Injection Aa&/Strd Genicular Nrv Branches W/Img|BILATERAL PROCEDURE,CASE-64454,LOCAL,64454,CPT,,,,,50,outpatient,,,4392.15,2635.29,,,,,,,,,,,,,
Injection Aa&/Strd Genicular Nrv Branches W/Img|BILATERAL PROCEDURE,CASE-64454,LOCAL,64454,CPT,0360,RC,,,50,outpatient,,,4392.15,2635.29,,,,,,,,,,,,,
Egd Band Ligation Esophgeal/Gastric Varices,CASE-43244,LOCAL,43244,CPT,,,,,,outpatient,,,10195.78,6117.47,,,,,,,,,,,,,
Rhytidectomy Smas Flap,CASE-15829,LOCAL,15829,CPT,0360,RC,,,,outpatient,,,113250.58,67950.35,,,,,,,,,,,,,
CATHETER ANGIOPLSTY BALLOON L11.5 MM RX STRL,SUP-2141486,CDM,2720000010,LOCAL,0272,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
STENT BILI PRECIS L 40 MM DIA 5 MM CATH L 135 CM DIA 7 FR,SUP-2158938,CDM,C1876,HCPCS,0278,RC,,,,both,,,6594.00,4286.10,,,,,,,,,,,,,
BENDER SURG LG STRL DISP MOTOBAND CP,SUP-2893314,CDM,2720000010,LOCAL,0272,RC,,,,both,,,775.58,504.13,,,,,,,,,,,,,
MICROCATHETER INFUSION MAGIC L 165 CM DSTL TIP DIA1.8 FR,SUP-2717637,CDM,C1887,HCPCS,0272,RC,,,,both,,,3658.10,2377.76,,,,,,,,,,,,,
DAUNORUBICIN HCL 20 MG/4ML IV SOLN,RX-142398,CDM,J9150,HCPCS,0636,RC,00143-9551-10,NDC,,both,4,ML,386.40,251.16,,,,,,,,,,,,,
PLATE BNE FIBULAR RT LAT ANK 4 HOLE NS,SUP-2518398,CDM,C1713,HCPCS,0278,RC,,,,both,,,5199.84,3379.90,,,,,,,,,,,,,
KIT INTRO SHTH 5 CM GUIDEWIRE L 30 CM DIA 4.5 FR NDL L 1.5,SUP-2734924,CDM,C1894,HCPCS,0272,RC,,,,both,,,11.93,7.75,,,,,,,,,,,,,
PLATE BNE T SM 2X0.7 MM 9 MM CRANIOMAXILLOFACIAL 4 LEFORT,SUP-2479068,CDM,C1713,HCPCS,0278,RC,,,,both,,,634.97,412.73,,,,,,,,,,,,,
GRAFT SFT TISS X THCK 35X15 CM RECON TISS MTRX STRATTICE,SUP-2488678,CDM,Q4130,HCPCS,0636,RC,,,,both,,,51976.42,33784.67,,,,,,,,,,,,,
PATCH DURA REP W6XL8CM BOV PERICARD GTA NONPYROGENIC,SUP-2130352,CDM,C1763,HCPCS,0278,RC,,,,both,,,2200.70,1430.45,,,,,,,,,,,,,
COIL VASC TORNADO EMBOLUS L 14.2 CM DIA10-5 MM CATH DIA,SUP-2168427,CDM,C1889,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
NAIL IM L200MM DIA13MM SHT FEM TIB KNEE G TI CANN LOK RG,SUP-2347111,CDM,C1713,HCPCS,0278,RC,,,,both,,,12716.22,8265.54,,,,,,,,,,,,,
PIN FIX DBL DIAMOND 0.078X9 IN SS NS STEINMANN,SUP-2791274,CDM,C1713,HCPCS,0278,RC,,,,both,,,11.02,7.16,,,,,,,,,,,,,
METHAZOLAMIDE 50 MG PO TABS,RX-4962,CDM,6370000000,HCPCS,0637,RC,00574-0791-01,NDC,,both,1,UN,20.70,13.45,,,,,,,,,,,,,
CROWN DENT 2 1ST PRIMARY M UPPER LT SS,SUP-2100173,CDM,D6783,CPT,0278,RC,,,,both,,,34.79,22.61,,,,,,,,,,,,,
Litholapaxy Smpl/Sm <2.5 Cm,CASE-52317,LOCAL,52317,CPT,0360,RC,,,,outpatient,,,23258.68,13955.21,,,,,,,,,,,,,
Cystourethroscopy With Biopsy,CASE-52204,LOCAL,52204,CPT,,,,,,outpatient,,,14374.97,8624.98,,,,,,,,,,,,,
"Amputation Toe Metatarsophalangeal Joint|LEFT FOOT, SECOND DIGIT",CASE-28820,LOCAL,28820,CPT,,,,,T1,outpatient,,,16022.28,9613.37,,,,,,,,,,,,,
Parathyroidectomy/Exploration Parathyroids|LEFT SIDE,CASE-60500,LOCAL,60500,CPT,0360,RC,,,LT,outpatient,,,39068.25,23440.95,,,,,,,,,,,,,
"Prq Skel Fixj Phlngl Shft Fx Prox/Middle Px/F/T|RIGHT HAND, THUMB",CASE-26727,LOCAL,26727,CPT,,,,,F5,outpatient,,,21422.98,12853.79,,,,,,,,,,,,,
"Amputation Toe Metatarsophalangeal Joint|LEFT FOOT, SECOND DIGIT",CASE-28820,LOCAL,28820,CPT,0360,RC,,,T1,outpatient,,,16022.28,9613.37,,,,,,,,,,,,,
"Prq Skel Fixj Phlngl Shft Fx Prox/Middle Px/F/T|RIGHT HAND, THUMB",CASE-26727,LOCAL,26727,CPT,0360,RC,,,F5,outpatient,,,21422.98,12853.79,,,,,,,,,,,,,
Cystourethroscopy With Biopsy,CASE-52204,LOCAL,52204,CPT,0360,RC,,,,outpatient,,,14374.97,8624.98,,,,,,,,,,,,,
Parathyroidectomy/Exploration Parathyroids|LEFT SIDE,CASE-60500,LOCAL,60500,CPT,,,,,LT,outpatient,,,39068.25,23440.95,,,,,,,,,,,,,
Litholapaxy Smpl/Sm <2.5 Cm,CASE-52317,LOCAL,52317,CPT,,,,,,outpatient,,,23258.68,13955.21,,,,,,,,,,,,,
DEFIBRILLATOR CARD RESYNCHRONIZATION THER DEFIB CRT-D 3,SUP-2138032,CDM,C1721,HCPCS,0275,RC,,,,both,,,57257.90,37217.63,,,,,,,,,,,,,
WIRE EMBOLIC PROTCT L190CM OD0.014IN BAREWIRE DSGN PRELD,SUP-2101962,CDM,2720000010,LOCAL,0272,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
PAD FT SANDAL,SUP-2473252,CDM,2720000010,LOCAL,0272,RC,,,,both,,,530.03,344.52,,,,,,,,,,,,,
PIN FIX L70MM DIA16MM S STL TENS BND LO PROF EYELET DSGN,SUP-2106636,CDM,C1713,HCPCS,0278,RC,,,,both,,,166.42,108.17,,,,,,,,,,,,,
HALF PIN EXTRNL FXTN 3MM DIA SHRT 100MML STNLSS STEEL 25MML,SUP-2720657,CDM,2720000010,LOCAL,0272,RC,,,,both,,,403.65,262.37,,,,,,,,,,,,,
PROBE ES L230CM CHN 3.7MM STR HEMSTAS REUSE HEATPRBS,SUP-2313013,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1572.01,1021.81,,,,,,,,,,,,,
MOST ELLIPTICAL ALL-POLY PATELLA MEDIUM,SUP-2509223,CDM,C1776,CPT,0278,RC,,,,both,,,2881.11,1872.72,,,,,,,,,,,,,
PLATE SPNL 21X27X10 MM VU APOD,SUP-2244701,CDM,C1713,HCPCS,0278,RC,,,,both,,,5495.00,3571.75,,,,,,,,,,,,,
HC So2 Immunoassay,PX-3018351668,CDM,83516,CPT,0301,RC,,,,both,,,564.00,366.60,,,,,,,,,,,,,
LEAD PACE BPLR ACT DEFIB OPTIM INSUL INTEGRATEDDURATA L21MM,SUP-2356241,CDM,C1895,HCPCS,0275,RC,,,,both,,,14130.00,9184.50,,,,,,,,,,,,,
SHUNT SURG L 8.9 MM VENTRICULAR CATH L 180 MM PRESSURE 0 CM,SUP-2931062,CDM,C1729,HCPCS,0272,RC,,,,both,,,2853.98,1855.09,,,,,,,,,,,,,
ROPIVACAINE HCL 5 MG/ML IJ SOLN,RX-18195,CDM,J2795,HCPCS,0636,RC,63323-0286-05,NDC,,both,15,ML,71.30,46.34,,,,,,,,,,,,,
CATHETER SNUS BLLN L16MM DIA6MM HI PERF DIL INT SNUS IRRIG,SUP-2106319,CDM,C1729,HCPCS,0272,RC,,,,both,,,2452.34,1594.02,,,,,,,,,,,,,
GRAFT BIO TISS W8XL12CM FET BOV SIL FEN ANTIMIC PRIMATRIX,SUP-2243712,CDM,Q4110,HCPCS,0636,RC,,,,both,,,10399.68,6759.79,,,,,,,,,,,,,
PLATE BNE W10XL52MM THK15MM 3X3 H R TI T SHP OBLQ LO PROF,SUP-2190917,CDM,C1713,HCPCS,0278,RC,,,,both,,,1044.87,679.17,,,,,,,,,,,,,
ROD IM BAL 3 DEG FEM SIG HP,SUP-2456314,CDM,C1713,HCPCS,0278,RC,,,,both,,,2380.12,1547.08,,,,,,,,,,,,,
BLADE SAW 90X19.5X1.2 MM 1.2 MM FOR LG BNE,SUP-2607462,CDM,2720000010,LOCAL,0272,RC,,,,both,,,145.01,94.26,,,,,,,,,,,,,
Repair Each Addnl Digit Nerve,CASE-64832,LOCAL,64832,CPT,0360,RC,,,,outpatient,,,33739.18,20243.51,,,,,,,,,,,,,
"Tendon Sheath Incision|UNUSUAL NON-OVERLAPPING SERVICE|LEFT HAND, THIRD DIGIT",CASE-26055,LOCAL,26055,CPT,,,,,XU|F2,outpatient,,,10871.55,6522.93,,,,,,,,,,,,,
"Tendon Sheath Incision|UNUSUAL NON-OVERLAPPING SERVICE|LEFT HAND, THIRD DIGIT",CASE-26055,LOCAL,26055,CPT,0360,RC,,,XU|F2,outpatient,,,10871.55,6522.93,,,,,,,,,,,,,
Arthrs Aided Ant Cruciate Ligm Rpr/Agmntj/Rcnstj|SEPARATE STRUCTURE|LEFT SIDE,CASE-29888,LOCAL,29888,CPT,0360,RC,,,XS|LT,outpatient,,,76007.77,45604.66,,,,,,,,,,,,,
Suture Infrapatellar Tendon Primary|BILATERAL PROCEDURE,CASE-27380,LOCAL,27380,CPT,0360,RC,,,50,outpatient,,,50593.62,30356.17,,,,,,,,,,,,,
Repair Each Addnl Digit Nerve,CASE-64832,LOCAL,64832,CPT,,,,,,outpatient,,,33739.18,20243.51,,,,,,,,,,,,,
Arthrs Aided Ant Cruciate Ligm Rpr/Agmntj/Rcnstj|SEPARATE STRUCTURE|LEFT SIDE,CASE-29888,LOCAL,29888,CPT,,,,,XS|LT,outpatient,,,76007.77,45604.66,,,,,,,,,,,,,
Laparoscopy Surg Rpr Initial Inguinal Hernia|BILATERAL PROCEDURE,CASE-49650,LOCAL,49650,CPT,,,,,50,outpatient,,,57191.32,34314.79,,,,,,,,,,,,,
Cysto W/Ureteroscopy W/Lithotripsy,CASE-52353,LOCAL,52353,CPT,0360,RC,,,,outpatient,,,27600.82,16560.49,,,,,,,,,,,,,
Cysto W/Ureteroscopy W/Lithotripsy,CASE-52353,LOCAL,52353,CPT,,,,,,outpatient,,,27600.82,16560.49,,,,,,,,,,,,,
Breast Reduction|LEFT SIDE,CASE-19318,LOCAL,19318,CPT,,,,,LT,outpatient,,,48312.63,28987.58,,,,,,,,,,,,,
Breast Reduction|LEFT SIDE,CASE-19318,LOCAL,19318,CPT,0360,RC,,,LT,outpatient,,,48312.63,28987.58,,,,,,,,,,,,,
Suture Infrapatellar Tendon Primary|BILATERAL PROCEDURE,CASE-27380,LOCAL,27380,CPT,,,,,50,outpatient,,,50593.62,30356.17,,,,,,,,,,,,,
Laparoscopy Surg Rpr Initial Inguinal Hernia|BILATERAL PROCEDURE,CASE-49650,LOCAL,49650,CPT,0360,RC,,,50,outpatient,,,57191.32,34314.79,,,,,,,,,,,,,
IMPL BREAST GEL BOOST SMTH HI PROF 230CC,SUP-2738046,CDM,C1789,HCPCS,0278,RC,,,,both,,,4082.00,2653.30,,,,,,,,,,,,,
GUIDEWIRE VASC LAUREATE L 150 CM DIA 0.038 IN NIT STR,SUP-2462167,CDM,C1769,HCPCS,0272,RC,,,,both,,,93.79,60.96,,,,,,,,,,,,,
PLATE BNE THK 2 MM SCREW DIA2/2.3 MM SM GRD IV TI MANDIBULAR,SUP-2935840,CDM,C1713,HCPCS,0278,RC,,,,both,,,5749.34,3737.07,,,,,,,,,,,,,
SCREW BONE L8MM DIA2.4MM CORT TI ST LCK FULL THRD HD,SUP-2181750,CDM,C1713,HCPCS,0278,RC,,,,both,,,585.11,380.32,,,,,,,,,,,,,
SPLINT FNGR OVL-8 RNG SZ 4 5PK,SUP-2112610,CDM,L3927,HCPCS,0274,RC,,,,both,,,60.82,39.53,,,,,,,,,,,,,
SCREW BNE LCK 2.7X20 MM SS,SUP-2361758,CDM,C1713,HCPCS,0278,RC,,,,both,,,363.93,236.55,,,,,,,,,,,,,
CATHETER EP LG 2 MM 6 FRX110 STEER INQUIRY,SUP-2469550,CDM,C1730,HCPCS,0272,RC,,,,both,,,1419.28,922.53,,,,,,,,,,,,,
GRAFT HUM TISS POST TIBIALIS TEND FRZN,SUP-2165552,CDM,C1762,CPT,0278,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
Arthrs Kne Surg W/Meniscectomy Med/Lat W/Shvg|RIGHT SIDE|SEPARATE STRUCTURE,CASE-29881,LOCAL,29881,CPT,0360,RC,,,RT|XS,outpatient,,,49061.08,29436.65,,,,,,,,,,,,,
"HC Repair Nail Bed|RIGHT HAND, FIFTH DIGIT",CASE-11760,LOCAL,11760,CPT,0450,RC,,,F9,outpatient,,,20298.53,12179.12,,,,,,,,,,,,,
Mastectomy Partial,CASE-19301,LOCAL,19301,CPT,0360,RC,,,,outpatient,,,19053.93,11432.36,,,,,,,,,,,,,
"Corrj Hallux Valgus W/Sesmdc W/Dist Metar Osteot|LEFT FOOT, GREAT TOE",CASE-28296,LOCAL,28296,CPT,0360,RC,,,TA,outpatient,,,38410.67,23046.40,,,,,,,,,,,,,
Bronchoscopy W/Transbronchial Lung Bx 1 Lobe,CASE-31628,LOCAL,31628,CPT,0360,RC,,,,outpatient,,,42014.37,25208.62,,,,,,,,,,,,,
Arthrs Kne Surg W/Meniscectomy Med/Lat W/Shvg|RIGHT SIDE|SEPARATE STRUCTURE,CASE-29881,LOCAL,29881,CPT,,,,,RT|XS,outpatient,,,49061.08,29436.65,,,,,,,,,,,,,
Preparation Skin Cell Ssp Agrft 1st 25 Sq Cm/<,CASE-15013,LOCAL,15013,CPT,0360,RC,,,,outpatient,,,54254.85,32552.91,,,,,,,,,,,,,
Mastectomy Partial,CASE-19301,LOCAL,19301,CPT,,,,,,outpatient,,,19053.93,11432.36,,,,,,,,,,,,,
HC Joint Injection/Aspir Large WO US|PBB CHARGE|LEFT SIDE,CASE-20610,LOCAL,20610,CPT,0510,RC,,,PBB|LT,outpatient,,,1504.75,902.85,,,,,,,,,,,,,
"Corrj Hallux Valgus W/Sesmdc W/Dist Metar Osteot|LEFT FOOT, GREAT TOE",CASE-28296,LOCAL,28296,CPT,,,,,TA,outpatient,,,38410.67,23046.40,,,,,,,,,,,,,
Neuroplasty &/Transposition Ulnar Nerve Elbow|UNUSUAL NON-OVERLAPPING SERVICE|LEFT SIDE,CASE-64718,LOCAL,64718,CPT,0360,RC,,,XU|LT,outpatient,,,17937.10,10762.26,,,,,,,,,,,,,
Neuroplasty &/Transposition Ulnar Nerve Elbow|UNUSUAL NON-OVERLAPPING SERVICE|LEFT SIDE,CASE-64718,LOCAL,64718,CPT,,,,,XU|LT,outpatient,,,17937.10,10762.26,,,,,,,,,,,,,
Preparation Skin Cell Ssp Agrft 1st 25 Sq Cm/<,CASE-15013,LOCAL,15013,CPT,,,,,,outpatient,,,54254.85,32552.91,,,,,,,,,,,,,
Bronchoscopy W/Transbronchial Lung Bx 1 Lobe,CASE-31628,LOCAL,31628,CPT,,,,,,outpatient,,,42014.37,25208.62,,,,,,,,,,,,,
POST EXT FIX 6 H FOR SIDEKCK EZ FRME FIX SYS,SUP-2418809,CDM,2720000010,LOCAL,0272,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
PLATE BONE LOK 117MML HLX7 PRTSL 64 CNTRD NCB ST PRXML HMRL,SUP-2729943,CDM,C1713,HCPCS,0278,RC,,,,both,,,4719.36,3067.58,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 70 CM DIA 5-8 MM EPTFE LNG TAPR TW,SUP-2669695,CDM,C1768,CPT,0278,RC,,,,both,,,2177.28,1415.23,,,,,,,,,,,,,
HC OB ER Level 4,PX-4509928401,CDM,99284,CPT,0450,RC,,,,inpatient,,,2334.00,1517.10,,,,,,,,,,,,,
HC Stool Culture,PX-3008704500,CDM,87045,CPT,0300,RC,,,,both,,,260.00,169.00,,,,,,,,,,,,,
HC Tee Cong Anom,PX-4839331500,CDM,93315,CPT,0483,RC,,,,both,,,2549.00,1656.85,,,,,,,,,,,,,
Sling Operation Stress Incontinence,CASE-57288,LOCAL,57288,CPT,,,,,,outpatient,,,50690.38,30414.23,,,,,,,,,,,,,
Lamnotmy Incl W/Dcmprsn Nrv Root 1 Intrspc Lumbr|LEFT SIDE|SEPARATE STRUCTURE,CASE-63030,LOCAL,63030,CPT,,,,,LT|XS,outpatient,,,49020.00,29412.00,,,,,,,,,,,,,
Sling Operation Stress Incontinence,CASE-57288,LOCAL,57288,CPT,0360,RC,,,,outpatient,,,50690.38,30414.23,,,,,,,,,,,,,
HC Inject Tendon Origin/Insert|LEFT SIDE,CASE-20551,LOCAL,20551,CPT,0361,RC,,,LT,outpatient,,,3549.32,2129.59,,,,,,,,,,,,,
Lamnotmy Incl W/Dcmprsn Nrv Root 1 Intrspc Lumbr|LEFT SIDE|SEPARATE STRUCTURE,CASE-63030,LOCAL,63030,CPT,0360,RC,,,LT|XS,outpatient,,,49020.00,29412.00,,,,,,,,,,,,,
Laps Surg Bilateral Total Pelvic Lmphadectomy,CASE-38571,LOCAL,38571,CPT,0360,RC,,,,outpatient,,,110869.92,66521.95,,,,,,,,,,,,,
Laps Surg Bilateral Total Pelvic Lmphadectomy,CASE-38571,LOCAL,38571,CPT,,,,,,outpatient,,,110869.92,66521.95,,,,,,,,,,,,,
"Suture Digital Nerve Hand/Foot 1 Nerve|LEFT HAND, FOURTH DIGIT",CASE-64831,LOCAL,64831,CPT,,,,,F3,outpatient,,,29931.07,17958.64,,,,,,,,,,,,,
Tonsillectomy & Adenoidectomy Age 12/>,CASE-42821,LOCAL,42821,CPT,0360,RC,,,,outpatient,,,21755.50,13053.30,,,,,,,,,,,,,
Tonsillectomy & Adenoidectomy Age 12/>,CASE-42821,LOCAL,42821,CPT,,,,,,outpatient,,,21755.50,13053.30,,,,,,,,,,,,,
"Suture Digital Nerve Hand/Foot 1 Nerve|LEFT HAND, FOURTH DIGIT",CASE-64831,LOCAL,64831,CPT,0360,RC,,,F3,outpatient,,,29931.07,17958.64,,,,,,,,,,,,,
SCREW BNE LCK 3.5X18 MM NS PERI-LOC,SUP-2348523,CDM,C1713,HCPCS,0278,RC,,,,both,,,433.32,281.66,,,,,,,,,,,,,
BUR SURG 2 FLUT 3 MM CYL UPWR,SUP-2166784,CDM,2720000010,LOCAL,0272,RC,,,,both,,,231.10,150.21,,,,,,,,,,,,,
CAGE SPNL L12XW12XH16MM 4 LOBE MESH ANAT FOOTPRINT MOD IMP,SUP-2317733,CDM,C1889,HCPCS,0278,RC,,,,both,,,7108.96,4620.82,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL PEEK SD800.521,SUP-2860202,CDM,C1713,HCPCS,0278,RC,,,,both,,,33948.11,22066.27,,,,,,,,,,,,,
NUT ORTH DOME SPINE OCCIPITAL-CERVICO-THORACIC VIRAGE,SUP-2685023,CDM,C1713,HCPCS,0278,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
Exc Cyst/Aberrant Breast Tissue Open 1/> Lesion|BILATERAL PROCEDURE,CASE-19120,LOCAL,19120,CPT,,,,,50,outpatient,,,66609.53,39965.72,,,,,,,,,,,,,
Tenodesis Long Tendon Biceps|LEFT SIDE,CASE-23430,LOCAL,23430,CPT,,,,,LT,outpatient,,,51672.72,31003.63,,,,,,,,,,,,,
Perq Nl/Pl Lithotrp Complex >2 Cm Mlt Locations|RIGHT SIDE,CASE-50081,LOCAL,50081,CPT,,,,,RT,outpatient,,,78117.40,46870.44,,,,,,,,,,,,,
Exc Cyst/Aberrant Breast Tissue Open 1/> Lesion|BILATERAL PROCEDURE,CASE-19120,LOCAL,19120,CPT,0360,RC,,,50,outpatient,,,66609.53,39965.72,,,,,,,,,,,,,
Tenodesis Long Tendon Biceps|LEFT SIDE,CASE-23430,LOCAL,23430,CPT,0360,RC,,,LT,outpatient,,,51672.72,31003.63,,,,,,,,,,,,,
Unlisted Procedure Hemic or Lymphatic System,CASE-38999,LOCAL,38999,CPT,0360,RC,,,,outpatient,,,257392.97,154435.78,,,,,,,,,,,,,
Unlisted Procedure Hemic or Lymphatic System,CASE-38999,LOCAL,38999,CPT,,,,,,outpatient,,,257392.97,154435.78,,,,,,,,,,,,,
Perq Nl/Pl Lithotrp Complex >2 Cm Mlt Locations|RIGHT SIDE,CASE-50081,LOCAL,50081,CPT,0360,RC,,,RT,outpatient,,,78117.40,46870.44,,,,,,,,,,,,,
MODEL ANAT MAXILLA 3D CT BASE SEL CLR VITAL STRUCT CLRVW,SUP-2883414,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8697.11,5653.12,,,,,,,,,,,,,
HYSTEROSCOPE RIGID STRL DISP AVETA OPAL,SUP-2914750,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
COMPONENT FEM SZ 4 R KNEE OXINIUM CRUCE RET PRI CEM FOR TOT,SUP-2345848,CDM,C1776,CPT,0278,RC,,,,both,,,5966.00,3877.90,,,,,,,,,,,,,
KIT THROMCTMY ACE68 L 132 CM OD 6 FR ID 0.068 IN HI FLO TBNG,SUP-2323550,CDM,C1757,HCPCS,0272,RC,,,,both,,,8635.00,5612.75,,,,,,,,,,,,,
SPLINT HND THM ADL NVY TERRY,SUP-2165485,CDM,L3807,HCPCS,0274,RC,,,,both,,,198.10,128.76,,,,,,,,,,,,,
BIOPSY PROCEDURE KIT UNIV SHT BLDELSS PRB MARKER MAMTOM,SUP-2195660,CDM,C1713,HCPCS,0278,RC,,,,both,,,1848.20,1201.33,,,,,,,,,,,,,
STIMULATOR NERVE IMPL PULSE GENRTR PRODIGY MRI,SUP-2615541,CDM,C1820,HCPCS,0278,RC,,,,both,,,40898.50,26584.02,,,,,,,,,,,,,
STYLET LD EXTRACTION LIBERATOR BEAC TIP L 140 CM ACTIVE L 70,SUP-2169593,CDM,C1773,HCPCS,0272,RC,,,,both,,,1745.81,1134.78,,,,,,,,,,,,,
HOLDER SURG IMPL PLT TACK,SUP-2107840,CDM,C1713,HCPCS,0278,RC,,,,both,,,97.34,63.27,,,,,,,,,,,,,
MARKER BRST BX L10CM 18GA Q SHP INTRO FREE HND NIT TUMARK,SUP-2427467,CDM,A4648,CPT,0278,RC,,,,both,,,258.89,168.28,,,,,,,,,,,,,
PUNCH ENDOSCP 4MM DIA SUT STR JAW 4MM DIA W O SUT REUSE,SUP-2166509,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6113.83,3973.99,,,,,,,,,,,,,
"Amputation Toe Interphalangeal Joint|RIGHT FOOT, FOURTH DIGIT",CASE-28825,LOCAL,28825,CPT,0360,RC,,,T8,outpatient,,,15713.85,9428.31,,,,,,,,,,,,,
"Partical Excision Bone Phalanx Toe|LEFT FOOT, THIRD DIGIT",CASE-28124,LOCAL,28124,CPT,0360,RC,,,T2,outpatient,,,38410.67,23046.40,,,,,,,,,,,,,
Cysto/Uretero W/Lithotripsy &Indwell Stent Insrt|RIGHT SIDE,CASE-52356,LOCAL,52356,CPT,0360,RC,,,RT,outpatient,,,29373.15,17623.89,,,,,,,,,,,,,
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level|LEFT SIDE,CASE-64483,LOCAL,64483,CPT,,,,,LT,outpatient,,,3979.52,2387.71,,,,,,,,,,,,,
"Partical Excision Bone Phalanx Toe|LEFT FOOT, THIRD DIGIT",CASE-28124,LOCAL,28124,CPT,,,,,T2,outpatient,,,38410.67,23046.40,,,,,,,,,,,,,
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level|LEFT SIDE,CASE-64483,LOCAL,64483,CPT,0360,RC,,,LT,outpatient,,,3979.52,2387.71,,,,,,,,,,,,,
Cysto/Uretero W/Lithotripsy &Indwell Stent Insrt|RIGHT SIDE,CASE-52356,LOCAL,52356,CPT,,,,,RT,outpatient,,,29373.15,17623.89,,,,,,,,,,,,,
"Amputation Toe Interphalangeal Joint|RIGHT FOOT, FOURTH DIGIT",CASE-28825,LOCAL,28825,CPT,,,,,T8,outpatient,,,15713.85,9428.31,,,,,,,,,,,,,
Arthrs Kne Surg W/Meniscectomy Med/Lat W/Shvg|LEFT SIDE|SEPARATE STRUCTURE,CASE-29881,LOCAL,29881,CPT,0360,RC,,,LT|XS,outpatient,,,39947.87,23968.72,,,,,,,,,,,,,
Arthrs Kne Surg W/Meniscectomy Med/Lat W/Shvg|LEFT SIDE|SEPARATE STRUCTURE,CASE-29881,LOCAL,29881,CPT,,,,,LT|XS,outpatient,,,39947.87,23968.72,,,,,,,,,,,,,
MATRIX BIO L 10 X W 7 CM FISH SKIN DERMAL FEN INTACT STRL 10/BX,SUP-2909356,CDM,Q4158,HCPCS,0636,RC,,,,both,,,12089.00,7857.85,,,,,,,,,,,,,
PROSTHESIS VOICE 17FR L4MM PRELD IN SMRT INSRTR AND BRSH,SUP-2124396,CDM,L8509,HCPCS,0272,RC,,,,both,,,963.98,626.59,,,,,,,,,,,,,
POST FIX L35MM OD4.5MM TI KNEE SUT STRL FOR ACL PCL FIX SYS,SUP-2340693,CDM,C1713,HCPCS,0278,RC,,,,both,,,405.06,263.29,,,,,,,,,,,,,
DRESSING WND W4XL10IN 258 SQ CM CROSSLINKED BOV TEND CLLGN,SUP-2243934,CDM,Q4104,HCPCS,0636,RC,,,,both,,,11928.86,7753.76,,,,,,,,,,,,,
GUIDEWIRE URO L145CM DIA0.038IN TIP 5CM DBL FLEX S STL PTFE,SUP-2171450,CDM,C1769,HCPCS,0272,RC,,,,both,,,104.00,67.60,,,,,,,,,,,,,
SYSTEM STENT GRFT OVATION IX L 80 MM DIA29 MM DEL CATH 14 FR,SUP-2217721,CDM,C1768,CPT,0278,RC,,,,both,,,37676.86,24489.96,,,,,,,,,,,,,
PLATE SPNL 2 LEVEL 34 MM ANTR CERV NEO-SL,SUP-2430703,CDM,C1713,HCPCS,0278,RC,,,,both,,,4317.50,2806.37,,,,,,,,,,,,,
STENT URET L24CM DIA7FR TECOFLEX LITHOSTNT,SUP-2312743,CDM,C2617,HCPCS,0278,RC,,,,both,,,290.20,188.63,,,,,,,,,,,,,
ROD SURG ROCK SILVERTON,SUP-2211164,CDM,C1713,HCPCS,0278,RC,,,,both,,,1239.67,805.79,,,,,,,,,,,,,
COMPONENT ARTC SURF CR 7 KNEE FIX BEAR ATTUNE,SUP-2454890,CDM,C1776,CPT,0278,RC,,,,both,,,323.42,210.22,,,,,,,,,,,,,
PIN POS L3.5MM S STL CERCLAGE THRD FOR LOK COMPR PLT,SUP-2187038,CDM,C1713,HCPCS,0278,RC,,,,both,,,498.76,324.19,,,,,,,,,,,,,
BRACE ORTHOPEDIC TLSO LUMBAR 4 MOD SACR SCRAP PRE,SUP-2265011,CDM,L0464,HCPCS,0274,RC,,,,both,,,5736.78,3728.91,,,,,,,,,,,,,
Osteoplasty Radius/Ulna Shortening|LEFT SIDE,CASE-25390,LOCAL,25390,CPT,0360,RC,,,LT,outpatient,,,53217.18,31930.31,,,,,,,,,,,,,
Lam Facetec/Foramot Drg Arthrd Lmbr Ea Addl Sgm,CASE-63053,LOCAL,63053,CPT,,,,,,outpatient,,,107612.65,64567.59,,,,,,,,,,,,,
Optx Dstl Radl I-Artic Fx/Epiphysl Sep 2 Frag|LEFT SIDE,CASE-25608,LOCAL,25608,CPT,,,,,LT,outpatient,,,28594.38,17156.63,,,,,,,,,,,,,
"Open Tx Distal Phalangeal Fracture Each|RIGHT HAND, FIFTH DIGIT",CASE-26765,LOCAL,26765,CPT,,,,,F9,outpatient,,,20298.53,12179.12,,,,,,,,,,,,,
Optx Dstl Radl I-Artic Fx/Epiphysl Sep 2 Frag|LEFT SIDE,CASE-25608,LOCAL,25608,CPT,0360,RC,,,LT,outpatient,,,28594.38,17156.63,,,,,,,,,,,,,
Osteot W/WO Lngth Shrt/Corrj Metar Xcp 1st Ea|RIGHT SIDE,CASE-28308,LOCAL,28308,CPT,0360,RC,,,RT,outpatient,,,15539.43,9323.66,,,,,,,,,,,,,
Lam Facetec/Foramot Drg Arthrd Lmbr Ea Addl Sgm,CASE-63053,LOCAL,63053,CPT,0360,RC,,,,outpatient,,,107612.65,64567.59,,,,,,,,,,,,,
Osteoplasty Radius/Ulna Shortening|LEFT SIDE,CASE-25390,LOCAL,25390,CPT,,,,,LT,outpatient,,,53217.18,31930.31,,,,,,,,,,,,,
HC Rt Bronchoscopy Alveolar Lavage,CASE-31624,LOCAL,31624,CPT,0361,RC,,,,outpatient,,,39358.50,23615.10,,,,,,,,,,,,,
"Open Tx Distal Phalangeal Fracture Each|RIGHT HAND, FIFTH DIGIT",CASE-26765,LOCAL,26765,CPT,0360,RC,,,F9,outpatient,,,20298.53,12179.12,,,,,,,,,,,,,
Osteot W/WO Lngth Shrt/Corrj Metar Xcp 1st Ea|RIGHT SIDE,CASE-28308,LOCAL,28308,CPT,,,,,RT,outpatient,,,15539.43,9323.66,,,,,,,,,,,,,
STIMULATOR NERVE PT CHARGER NS ETERNA LTX,SUP-2858396,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
PLATE BONE SM L53MM 3 H T SHP OBLQ ECT,SUP-2198579,CDM,C1713,HCPCS,0278,RC,,,,both,,,382.80,248.82,,,,,,,,,,,,,
STAPLER INTERNAL 12X4 MM TITANIUM MULTIFIRE ENDO HERNIA,SUP-2752260,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1705.93,1108.85,,,,,,,,,,,,,
TIP ASPIR 03MM 45DEG BEND INTERCHANGABLE HNDPC ULTRAFLOW,SUP-2110007,CDM,C1713,HCPCS,0278,RC,,,,both,,,1083.30,704.14,,,,,,,,,,,,,
INSTRUMENT 28MM PINN AB IN TR 48,SUP-2514004,CDM,C1776,CPT,0278,RC,,,,both,,,1469.52,955.19,,,,,,,,,,,,,
GRAFT VASC HEMSHLD L 50 CM DIA 30 MM BRANCH SZ 10/10/8/8 MM,SUP-2669856,CDM,C1768,CPT,0278,RC,,,,both,,,5382.53,3498.64,,,,,,,,,,,,,
SNARE POLYP 5FR L35CM HYSTEROSCOPIC NIT NCIRCLE,SUP-2168971,CDM,C1713,HCPCS,0278,RC,,,,both,,,408.04,265.23,,,,,,,,,,,,,
PLATE BNE SM W11XL89MM THK15MM 90DEG 4X7 H TI T SHP R ANG,SUP-2190938,CDM,C1713,HCPCS,0278,RC,,,,both,,,1537.66,999.48,,,,,,,,,,,,,
RELOAD STPL OPN H42MM CLS H18MM WIRE DIA02MM REG THCK TISS,SUP-2693603,CDM,2720000010,LOCAL,0272,RC,,,,both,,,255.91,166.34,,,,,,,,,,,,,
PLATE BNE L 16 MM STRL ORTHOLOC 3DI,SUP-2900676,CDM,C1713,HCPCS,0278,RC,,,,both,,,1152.38,749.05,,,,,,,,,,,,,
GUIDE STAPLE WIRE/DRILL 1.5MM,SUP-2652944,CDM,2720000010,LOCAL,0272,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
GRAFT VASC IMPRA CARBOFLO L 10 CM DIA 7 MM EPTFE CARBON STR,SUP-2761241,CDM,C1768,CPT,0278,RC,,,,both,,,596.35,387.63,,,,,,,,,,,,,
CAGE SPNL VERT BONE REPL CENTERPIECE IMP H40 TO 62MM OD20MM,SUP-2390809,CDM,C1889,HCPCS,0278,RC,,,,both,,,51656.14,33576.49,,,,,,,,,,,,,
PLATE 12HL LT,SUP-2470214,CDM,C1713,HCPCS,0278,RC,,,,both,,,3994.90,2596.68,,,,,,,,,,,,,
POSTERIOR PILON FUSION PLATE 9H,SUP-2815016,CDM,C1713,HCPCS,0278,RC,,,,both,,,10990.00,7143.50,,,,,,,,,,,,,
BUR SURG L14CM DIA6MM BALL FLUT L BOR MIDAS REX LEGEND,SUP-2284378,CDM,C1713,HCPCS,0278,RC,,,,both,,,368.70,239.65,,,,,,,,,,,,,
SCREW BNE LCK 2.7X5 MM CRANIOMAXILLOFACIAL MAXDRIVE LEVEL 1,SUP-2461495,CDM,C1713,HCPCS,0278,RC,,,,both,,,447.89,291.13,,,,,,,,,,,,,
VALVE AORT OD23MM HRT TRANSCATHETER ASCENDRA + TRANSAPICAL,SUP-2214358,CDM,C1889,HCPCS,0278,RC,,,,both,,,102050.00,66332.50,,,,,,,,,,,,,
SCREW SPNL RECON 4X20 MM POSTED EXT BLU VERTEX SEL,SUP-2630724,CDM,C1713,HCPCS,0278,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
Hemorrhoidectomy Int & Xtrnl 2/> Column/Gro,CASE-46260,LOCAL,46260,CPT,0360,RC,,,,outpatient,,,14395.98,8637.59,,,,,,,,,,,,,
Hallux Rigidus W/Cheilectomy 1st Mp Jt W/O Implt|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-28289,LOCAL,28289,CPT,,,,,LT|XU,outpatient,,,32745.13,19647.08,,,,,,,,,,,,,
Colonoscopy W/Biopsy Single/Multiple|SEPARATE STRUCTURE,CASE-45380,LOCAL,45380,CPT,0360,RC,,,XS,outpatient,,,16072.23,9643.34,,,,,,,,,,,,,
Excision H/P/P/U Simple/Intermediate Repair,CASE-11470,LOCAL,11470,CPT,0360,RC,,,,outpatient,,,19855.65,11913.39,,,,,,,,,,,,,
Repair Brow Ptosis|BILATERAL PROCEDURE,CASE-67900,LOCAL,67900,CPT,,,,,50,outpatient,,,113250.58,67950.35,,,,,,,,,,,,,
"Tendon Sheath Incision|RIGHT HAND, THUMB",CASE-26055,LOCAL,26055,CPT,0360,RC,,,F5,outpatient,,,10509.72,6305.83,,,,,,,,,,,,,
"Remove Spinal Neurostim Electrode Plate/Paddle, Incl Fluoro",CASE-63662,LOCAL,63662,CPT,0360,RC,,,,outpatient,,,24329.38,14597.63,,,,,,,,,,,,,
"Remove Spinal Neurostim Electrode Plate/Paddle, Incl Fluoro",CASE-63662,LOCAL,63662,CPT,,,,,,outpatient,,,24329.38,14597.63,,,,,,,,,,,,,
Repair Brow Ptosis|BILATERAL PROCEDURE,CASE-67900,LOCAL,67900,CPT,0360,RC,,,50,outpatient,,,113250.58,67950.35,,,,,,,,,,,,,
Colonoscopy Flx Dx W/Collj Spec When Pfrmd|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-45378,LOCAL,45378,CPT,0360,RC,,,74,outpatient,,,10673.43,6404.06,,,,,,,,,,,,,
Colonoscopy Flx Dx W/Collj Spec When Pfrmd|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-45378,LOCAL,45378,CPT,,,,,74,outpatient,,,10673.43,6404.06,,,,,,,,,,,,,
Colonoscopy W/Biopsy Single/Multiple|SEPARATE STRUCTURE,CASE-45380,LOCAL,45380,CPT,,,,,XS,outpatient,,,16072.23,9643.34,,,,,,,,,,,,,
Hemorrhoidectomy Int & Xtrnl 2/> Column/Gro,CASE-46260,LOCAL,46260,CPT,,,,,,outpatient,,,14395.98,8637.59,,,,,,,,,,,,,
HC Inj Aa&/Strd Greater Occipital Nerve|LEFT SIDE,CASE-64405,LOCAL,64405,CPT,0450,RC,,,LT,outpatient,,,3533.83,2120.30,,,,,,,,,,,,,
"Tendon Sheath Incision|RIGHT HAND, THUMB",CASE-26055,LOCAL,26055,CPT,,,,,F5,outpatient,,,10509.72,6305.83,,,,,,,,,,,,,
Excision H/P/P/U Simple/Intermediate Repair,CASE-11470,LOCAL,11470,CPT,,,,,,outpatient,,,19855.65,11913.39,,,,,,,,,,,,,
Hallux Rigidus W/Cheilectomy 1st Mp Jt W/O Implt|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-28289,LOCAL,28289,CPT,0360,RC,,,LT|XU,outpatient,,,32745.13,19647.08,,,,,,,,,,,,,
DEXTROSE 10 % IV SOLN NEONATE,RX-40840075,CDM,2580000003,HCPCS,0250,RC,63323-0824-76,NDC,,both,1000,ML,51.00,33.15,,,,,,,,,,,,,
BLADE SURG SAW STD S STL OSC W/ SERR EDGE DISP,SUP-2367091,CDM,2720000010,LOCAL,0272,RC,,,,both,,,722.20,469.43,,,,,,,,,,,,,
SPACER SPNL 0 DEG SM L14 MMXW12 MMXH19 MM CORPECTOMY PARA,SUP-2417200,CDM,C1889,HCPCS,0278,RC,,,,both,,,9106.00,5918.90,,,,,,,,,,,,,
BASEPLATE TIB 4 CEM LT PRI STEM STD N POR W/ SCR H PROFIX,SUP-2351222,CDM,C1776,CPT,0278,RC,,,,both,,,3414.75,2219.59,,,,,,,,,,,,,
STAPLE INT W9XH7MM WIRE OD1.5X1.5MM HND WRST COMPR,SUP-2194248,CDM,C1713,HCPCS,0278,RC,,,,both,,,2301.49,1495.97,,,,,,,,,,,,,
PROBE LITHO DIA7FR ELEC HYDRLC,SUP-2261214,CDM,2720000010,LOCAL,0272,RC,,,,both,,,902.75,586.79,,,,,,,,,,,,,
CATHETER DRAINAGE SINGLE PIG 8.5 FRX250 CM TUBE NIT FLEXIMA,SUP-2478590,CDM,C1729,HCPCS,0272,RC,,,,both,,,333.12,216.53,,,,,,,,,,,,,
NAIL IM HUM 7X230 MM RT STRL AEQUALIS DISP,SUP-2715506,CDM,C1713,HCPCS,0278,RC,,,,both,,,6430.72,4179.97,,,,,,,,,,,,,
STENT URETH FIRLIT-KLUGE L 31 CM DIA 8 FR SIL BALL/TUBING NO,SUP-2171269,CDM,C2617,HCPCS,0278,RC,,,,both,,,120.20,78.13,,,,,,,,,,,,,
Colonoscopy W/Biopsy Single/Multiple,CASE-45380,LOCAL,45380,CPT,,,,,,outpatient,,,10710.37,6426.22,,,,,,,,,,,,,
Egd US Guided Transmural Injxn/Fiducial Marker,CASE-43253,LOCAL,43253,CPT,0360,RC,,,,outpatient,,,11091.37,6654.82,,,,,,,,,,,,,
Excision Olecranon Bursa|RIGHT SIDE,CASE-24105,LOCAL,24105,CPT,,,,,RT,outpatient,,,19913.72,11948.23,,,,,,,,,,,,,
Excision Interdigital Morton Neuroma Single Each|RIGHT SIDE,CASE-28080,LOCAL,28080,CPT,0360,RC,,,RT,outpatient,,,21746.58,13047.95,,,,,,,,,,,,,
Osteoplasty Radius/Ulna Shortening,CASE-25390,LOCAL,25390,CPT,0360,RC,,,,outpatient,,,34253.13,20551.88,,,,,,,,,,,,,
Colonoscopy W/Biopsy Single/Multiple,CASE-45380,LOCAL,45380,CPT,0360,RC,,,,outpatient,,,10710.37,6426.22,,,,,,,,,,,,,
Rpr Aa Hernia 1st 3-10 Cm Ncrc8/Strangulated,CASE-49594,LOCAL,49594,CPT,0360,RC,,,,outpatient,,,64473.07,38683.84,,,,,,,,,,,,,
Egd US Guided Transmural Injxn/Fiducial Marker,CASE-43253,LOCAL,43253,CPT,,,,,,outpatient,,,11091.37,6654.82,,,,,,,,,,,,,
Excision Interdigital Morton Neuroma Single Each|RIGHT SIDE,CASE-28080,LOCAL,28080,CPT,,,,,RT,outpatient,,,21746.58,13047.95,,,,,,,,,,,,,
Osteoplasty Radius/Ulna Shortening,CASE-25390,LOCAL,25390,CPT,,,,,,outpatient,,,34253.13,20551.88,,,,,,,,,,,,,
Rpr Aa Hernia 1st 3-10 Cm Ncrc8/Strangulated,CASE-49594,LOCAL,49594,CPT,,,,,,outpatient,,,64473.07,38683.84,,,,,,,,,,,,,
HC Inject Tendon Origin/Insert|BILATERAL PROCEDURE,CASE-20551,LOCAL,20551,CPT,0361,RC,,,50,outpatient,,,1608.75,965.25,,,,,,,,,,,,,
Excision Olecranon Bursa|RIGHT SIDE,CASE-24105,LOCAL,24105,CPT,0360,RC,,,RT,outpatient,,,19913.72,11948.23,,,,,,,,,,,,,
COMPONENT FEM SZ 3CM CO CHROM LT DSTL KNEE RESURF FINN,SUP-2406043,CDM,C1776,CPT,0278,RC,,,,both,,,16604.32,10792.81,,,,,,,,,,,,,
LINER POLYXLPE 10DEG 50/52/54X36MM,SUP-2202581,CDM,C1776,CPT,0278,RC,,,,both,,,5388.24,3502.36,,,,,,,,,,,,,
SET THROMCTMY OASIS STRL,SUP-2141172,CDM,C1757,HCPCS,0272,RC,,,,both,,,94.20,61.23,,,,,,,,,,,,,
BIT DRL 3 MMX6 IN FOR HDLSS SCR SYS NS LTX,SUP-2862178,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1086.69,706.35,,,,,,,,,,,,,
TUBE ENTRL FEED GAST-JEJU 14 FRX1.7X15 CM LP G-JET BUTTON,SUP-2754588,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2807.69,1825.00,,,,,,,,,,,,,
CATHETER NEPHSTMY 14FR 4 WNG MCOT DISP G14488] COOK UROLOGY],SUP-2171222,CDM,C1729,HCPCS,0272,RC,,,,both,,,64.02,41.61,,,,,,,,,,,,,
PLATE BONE W9XL145MM THK1.1MM 12 H DSTL ULN FIBULAR S STL,SUP-2343781,CDM,C1713,HCPCS,0278,RC,,,,both,,,609.16,395.95,,,,,,,,,,,,,
PLATE BNE L 42 MM SCREW DIA 3.5/4 MM 30 H H SHP FOR FRAG FT,SUP-2912940,CDM,C1713,HCPCS,0278,RC,,,,both,,,2662.72,1730.77,,,,,,,,,,,,,
SYSTEM CTRL 3664CONTRLSYS,SUP-2615537,CDM,C1767,HCPCS,0278,RC,,,,both,,,66083.28,42954.13,,,,,,,,,,,,,
ALLOGRAFT BNE REFRIGERATED LT LAT PART CONDYLE,SUP-2740800,CDM,C1762,CPT,0278,RC,,,,both,,,23985.30,15590.44,,,,,,,,,,,,,
BENDING PLIERS FOR PLATES COMPLETE WITH TWO ANVILS,SUP-2548473,CDM,C1713,HCPCS,0278,RC,,,,both,,,5327.89,3463.13,,,,,,,,,,,,,
HC Vasc Emb/Occ W/Prs Cath,PX-3610979700,CDM,C9797,CPT,0361,RC,,,,both,,,54207.00,35234.55,,,,,,,,,,,,,
COLLAR EXTRIC AD SHT TWO PC TRACH OPN VELC CLSR W/ CHIN,SUP-2194467,CDM,L0180,HCPCS,0272,RC,,,,both,,,54.10,35.16,,,,,,,,,,,,,
Arthroscopy Knee W/Meniscus Rpr Medial&Lateral|RIGHT SIDE,CASE-29883,LOCAL,29883,CPT,0360,RC,,,RT,outpatient,,,55254.43,33152.66,,,,,,,,,,,,,
Arthroscopy Knee W/Meniscus Rpr Medial&Lateral|RIGHT SIDE,CASE-29883,LOCAL,29883,CPT,,,,,RT,outpatient,,,55254.43,33152.66,,,,,,,,,,,,,
HC Drain/Inj Joint/Bursa W/US Large|BILATERAL PROCEDURE,CASE-20611,LOCAL,20611,CPT,0510,RC,,,50,outpatient,,,4391.62,2634.97,,,,,,,,,,,,,
HC Joint Injection/Aspir Large WO US|PBB CHARGE,CASE-20610,LOCAL,20610,CPT,0510,RC,,,PBB,outpatient,,,1504.75,902.85,,,,,,,,,,,,,
RAVULIZUMAB-CWVZ 1100 MG/11ML IV SOLN,RX-152087,CDM,J1303,HCPCS,0636,RC,25682-0028-01,NDC,,both,11,ML,70655.40,45926.01,,,,,,,,,,,,,
SCREW BNE SD 4X80 MM 20 MM THRD HA SCHNZ SS NS,SUP-2186976,CDM,C1713,HCPCS,0278,RC,,,,both,,,451.41,293.42,,,,,,,,,,,,,
VENLAFAXINE HCL 37.5 MG PO TABS,RX-12207,CDM,6370000000,HCPCS,0637,RC,68084-0844-11,NDC,,both,1,UN,3.90,2.53,,,,,,,,,,,,,
BRACE WR M AD FOR 6.75-7.75IN RT ADJ MALL STAY COCKUP LOOP,SUP-2197947,CDM,L3931,HCPCS,0272,RC,,,,both,,,46.63,30.31,,,,,,,,,,,,,
STEM FEM L250MM OD9MM RT HIP POR NONCOATED TYP 1 TAPR PRI,SUP-2406663,CDM,C1776,CPT,0278,RC,,,,both,,,18664.16,12131.70,,,,,,,,,,,,,
FAT EMULSION PLANT BASED (SOY) 20 % IV EMUL,RX-155550,CDM,2500000003,HCPCS,0250,RC,65219-0533-25,NDC,,both,100,ML,111.60,72.54,,,,,,,,,,,,,
CEMENT BONE INJ TRAUMACEM V+ STERILE,SUP-2547171,CDM,C1713,HCPCS,0278,RC,,,,both,,,1134.04,737.13,,,,,,,,,,,,,
ALLOGRAFT BNE 5 CC DBM,SUP-2430248,CDM,C1713,HCPCS,0278,RC,,,,both,,,6892.30,4479.99,,,,,,,,,,,,,
CATHETER ANGIOPLSTY L 200 CM BALLOON L 150 MM DIA 5 MM SHTH,SUP-2890494,CDM,C1725,HCPCS,0272,RC,,,,both,,,1146.10,744.96,,,,,,,,,,,,,
BRACE WR M AD FOR 6.75-7.75IN RT ADJ MALL STAY COCKUP LOOP,SUP-2197947,CDM,L3931,HCPCS,0274,RC,,,,both,,,46.63,30.31,,,,,,,,,,,,,
STAPLE SURG 10X10X10MM,SUP-2390575,CDM,C1713,HCPCS,0278,RC,,,,both,,,4396.00,2857.40,,,,,,,,,,,,,
CONNECTOR EXT FIX SM QUIK XTRAFIX,SUP-2468261,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2521.42,1638.92,,,,,,,,,,,,,
ORTHO ANCHRGE CROSS SHAPE PLATE SCREW STYLE HEAD 9MM BRDGE C,SUP-2676796,CDM,C1713,HCPCS,0278,RC,,,,both,,,1306.71,849.36,,,,,,,,,,,,,
SYSTEM INT FIX INCL RIG INTFR SCR AND BIOCOMPOSITE,SUP-2121445,CDM,C1776,CPT,0278,RC,,,,both,,,5495.00,3571.75,,,,,,,,,,,,,
Cysto W/Removal of Tumors Small,CASE-52234,LOCAL,52234,CPT,0360,RC,,,,outpatient,,,20080.67,12048.40,,,,,,,,,,,,,
Mast Modf Rad W/Ax Lymph Nod W/WO Pect/Alis Min,CASE-19307,LOCAL,19307,CPT,,,,,,outpatient,,,58736.45,35241.87,,,,,,,,,,,,,
Cysto W/Removal of Tumors Small,CASE-52234,LOCAL,52234,CPT,,,,,,outpatient,,,20080.67,12048.40,,,,,,,,,,,,,
Mast Modf Rad W/Ax Lymph Nod W/WO Pect/Alis Min,CASE-19307,LOCAL,19307,CPT,0360,RC,,,,outpatient,,,58736.45,35241.87,,,,,,,,,,,,,
Open Implantation Nea Sacral Nerve,CASE-64581,LOCAL,64581,CPT,0360,RC,,,,outpatient,,,50967.42,30580.45,,,,,,,,,,,,,
Open Implantation Nea Sacral Nerve,CASE-64581,LOCAL,64581,CPT,,,,,,outpatient,,,50967.42,30580.45,,,,,,,,,,,,,
BIT DRILL CALIBRATED 4.2 EX-LONG,SUP-2718101,CDM,2720000010,LOCAL,0272,RC,,,,both,,,718.43,466.98,,,,,,,,,,,,,
TUBING INSUF STRL DISP PMP INSTR SYS COMB TEM,SUP-2332797,CDM,C1713,HCPCS,0278,RC,,,,both,,,486.70,316.35,,,,,,,,,,,,,
CATHETER CARD ABLATION CELSIUS DIA 7 FR TIP 4 MM SPC 2-5-2,SUP-2257449,CDM,C1733,HCPCS,0272,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
DEVICE SUT SPNL CRD STIM SYS SURG EQUIP FIXATE,SUP-2138772,CDM,C1713,HCPCS,0278,RC,,,,both,,,5620.60,3653.39,,,,,,,,,,,,,
HOOK SPNL L PEDCL TI FOR 5.5MM ROD CDH LEG,SUP-2287857,CDM,C1713,HCPCS,0278,RC,,,,both,,,2863.52,1861.29,,,,,,,,,,,,,
BIT DRL DIA3.5MM QUIK CONN FOR PERI-LOC PERIARTC LOCKED,SUP-2343999,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1245.73,809.72,,,,,,,,,,,,,
SCREW BNE CORTICAL 3.5 MM 5X38 MM DSTL FEM ST LCK TI NS NCB,SUP-2500515,CDM,C1713,HCPCS,0278,RC,,,,both,,,486.45,316.19,,,,,,,,,,,,,
SPACER SPNL ANGLED 7 DEG 11X14X10 MM LORDTC FUSION PEEK TM-S,SUP-2246224,CDM,C1821,HCPCS,0278,RC,,,,both,,,4239.00,2755.35,,,,,,,,,,,,,
PLATE BNE FUSION 0 DEG 2.4/2.7X53 MM RT 1ST MTP REV VA SS,SUP-2184826,CDM,C1713,HCPCS,0278,RC,,,,both,,,4054.81,2635.63,,,,,,,,,,,,,
Laps Supracrv Hysterect 250 Gm/< Rmvl Tube/Ovar,CASE-58542,LOCAL,58542,CPT,,,,,,outpatient,,,64633.68,38780.21,,,,,,,,,,,,,
Egd Transoral Control Bleeding Any Method,CASE-43255,LOCAL,43255,CPT,0360,RC,,,,outpatient,,,10998.17,6598.90,,,,,,,,,,,,,
Sgmdsc Flx Rmvl Tum Polyp/Oth Les Snare Tq|COLORECTAL CANCER SCREEN,CASE-45338,LOCAL,45338,CPT,,,,,PT,outpatient,,,11951.77,7171.06,,,,,,,,,,,,,
Laps Supracrv Hysterect 250 Gm/< Rmvl Tube/Ovar,CASE-58542,LOCAL,58542,CPT,0360,RC,,,,outpatient,,,64633.68,38780.21,,,,,,,,,,,,,
Egd Transoral Control Bleeding Any Method,CASE-43255,LOCAL,43255,CPT,,,,,,outpatient,,,10998.17,6598.90,,,,,,,,,,,,,
Neuroplasty &/Transpos Median Nrv Carpal Tunne|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64721,LOCAL,64721,CPT,,,,,RT|XU,outpatient,,,13874.00,8324.40,,,,,,,,,,,,,
Ercp Remove Calculi/Debris Biliary/Pancreas Duct,CASE-43264,LOCAL,43264,CPT,0360,RC,,,,outpatient,,,28366.08,17019.65,,,,,,,,,,,,,
Neuroplasty &/Transpos Median Nrv Carpal Tunne|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64721,LOCAL,64721,CPT,0360,RC,,,RT|XU,outpatient,,,13874.00,8324.40,,,,,,,,,,,,,
Sgmdsc Flx Rmvl Tum Polyp/Oth Les Snare Tq|COLORECTAL CANCER SCREEN,CASE-45338,LOCAL,45338,CPT,0360,RC,,,PT,outpatient,,,11951.77,7171.06,,,,,,,,,,,,,
Ercp Remove Calculi/Debris Biliary/Pancreas Duct,CASE-43264,LOCAL,43264,CPT,,,,,,outpatient,,,28366.08,17019.65,,,,,,,,,,,,,
SCREW BNE ST 2.4X5 MM CRTX EMGCY W/ STARDRV RECESS TI NS,SUP-2189405,CDM,C1713,HCPCS,0278,RC,,,,both,,,241.34,156.87,,,,,,,,,,,,,
SET LD INTRO EVOLUTION RL L 40.6 CM OD 17 FR ID 9 FR CTRL,SUP-2169469,CDM,C1773,HCPCS,0272,RC,,,,both,,,4835.60,3143.14,,,,,,,,,,,,,
CATHETER EVD L35CM LUMN ID1.5MM DEPTH MRK 3-15CM FOR EXT,SUP-2249015,CDM,C1729,HCPCS,0272,RC,,,,both,,,2098.05,1363.73,,,,,,,,,,,,,
GUIDEWIRE VASC L 260 CM DIA 0.025 IN TAPR L 8 CM FLPY TIP L,SUP-2167979,CDM,C1769,HCPCS,0272,RC,,,,both,,,57.84,37.60,,,,,,,,,,,,,
PLATE BNE L MINI 2X23 MM OBLQ ANGLED TI,SUP-2536099,CDM,C1713,HCPCS,0278,RC,,,,both,,,270.35,175.73,,,,,,,,,,,,,
GRAFT HUMAN TSSUE PLBLE 16X8 CM RCNSTRCTVE TSSUE MTRX STRTTC,SUP-2484083,CDM,Q4130,HCPCS,0636,RC,,,,both,,,12305.66,7998.68,,,,,,,,,,,,,
LOCKING FRACTURE PLATE 6 HOLE 43MM 2.0MM THICK TI 6AL 4V,SUP-2500729,CDM,C1713,HCPCS,0278,RC,,,,both,,,1814.92,1179.70,,,,,,,,,,,,,
PALONOSETRON HCL 0.25 MG/5ML IV SOLN,RX-36591,CDM,J2469,HCPCS,0636,RC,83634-0777-05,NDC,,both,5,ML,54.10,35.16,,,,,,,,,,,,,
WEDGE TIB L 12DEG/XL 11DEG PEEK IBALANCE HTO,SUP-2121060,CDM,C1713,HCPCS,0278,RC,,,,both,,,5966.00,3877.90,,,,,,,,,,,,,
COVER IMPL LCK 6-7 MM CERV NO PROF SHORELINE ACS,SUP-2245866,CDM,C1713,HCPCS,0278,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
SEALANT TISS GLUE 2.5 ML LIQUIC TOP MICROBIAL STRL LF DISP,SUP-2906583,CDM,C1713,HCPCS,0278,RC,,,,both,,,141.30,91.84,,,,,,,,,,,,,
BASKET SPEC RETRV STONE 3.1 FRX90 CM 5 MM LESLIE PARACHUTE,SUP-2141708,CDM,2720000010,LOCAL,0272,RC,,,,both,,,573.46,372.75,,,,,,,,,,,,,
STIMULATOR NERVE IMPL PULSE GENRTR STRL PROCLAIM + 7 LTX,SUP-2858408,CDM,C1767,HCPCS,0278,RC,,,,both,,,68295.00,44391.75,,,,,,,,,,,,,
PATCH HERN W20XL30CM THK1MM EPTFE MICROPOROUS SFT TISS GOR,SUP-2395298,CDM,C1781,HCPCS,0278,RC,,,,both,,,6323.96,4110.57,,,,,,,,,,,,,
HC Peripheral Block - Femoral Single or Saphenous W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE|RIGHT SIDE,CASE-64447,LOCAL,64447,CPT,0360,RC,,,XU|RT,outpatient,,,13183.18,7909.91,,,,,,,,,,,,,
Marsupialization Bartholins Gland Cyst|LEFT SIDE,CASE-56440,LOCAL,56440,CPT,,,,,LT,outpatient,,,19025.07,11415.04,,,,,,,,,,,,,
Nasal/Sinus Ndsc Total With Sphenoidotomy|BILATERAL PROCEDURE,CASE-31257,LOCAL,31257,CPT,,,,,50,outpatient,,,60525.53,36315.32,,,,,,,,,,,,,
Marsupialization Bartholins Gland Cyst|LEFT SIDE,CASE-56440,LOCAL,56440,CPT,0360,RC,,,LT,outpatient,,,19025.07,11415.04,,,,,,,,,,,,,
Nasal/Sinus Ndsc Total With Sphenoidotomy|BILATERAL PROCEDURE,CASE-31257,LOCAL,31257,CPT,0360,RC,,,50,outpatient,,,60525.53,36315.32,,,,,,,,,,,,,
BLADE SAW W9XL31MM THK0.38MM OSC AND SAG MIC 2 CUT,SUP-2367515,CDM,2720000010,LOCAL,0272,RC,,,,both,,,153.45,99.74,,,,,,,,,,,,,
DARBEPOETIN ALFA 40 MCG/0.4ML IJ SOSY,RX-131223,CDM,J0881,HCPCS,0636,RC,55513-0021-01,NDC,,both,0.4,ML,913.40,593.71,,,,,,,,,,,,,
HMRS ROT HINGE FEMORAL BUSHING,SUP-2512642,CDM,C1776,CPT,0278,RC,,,,both,,,1161.49,754.97,,,,,,,,,,,,,
SYSTEM BLLN OCCL L150CM L30MM ODSEC4MM L4 MM TIP 01IN,SUP-2172473,CDM,C2628,HCPCS,0272,RC,,,,both,,,4521.60,2939.04,,,,,,,,,,,,,
BIT DRL L215MM DIA3.2MM CALIB L82MM 3 FLUT QUIK CPL,SUP-2188197,CDM,2720000010,LOCAL,0272,RC,,,,both,,,656.07,426.45,,,,,,,,,,,,,
ENDOPROSTHESIS VASC EXCLUDER L 12 CM AORTIC/ILIAC 23/14.5 MM,SUP-2737604,CDM,C1768,CPT,0278,RC,,,,both,,,36279.56,23581.71,,,,,,,,,,,,,
ASSEMBLY PMP TI AND TI OTR,SUP-2165352,CDM,C1813,HCPCS,0278,RC,,,,both,,,12355.90,8031.33,,,,,,,,,,,,,
SEALER MPLR HK DSGN TRANSCOLLATION DISP ENDOSH2.0,SUP-2281801,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3020.68,1963.44,,,,,,,,,,,,,
DRILL TWST L50MM OD1.5MM W/ STP NONRADIOLUCENT,SUP-2361103,CDM,2720000010,LOCAL,0272,RC,,,,both,,,194.68,126.54,,,,,,,,,,,,,
GUIDEWIRE VASC MINI HYDRPHLC HYBRID SFT TRAXCESS,SUP-2305451,CDM,C1769,HCPCS,0272,RC,,,,both,,,1766.25,1148.06,,,,,,,,,,,,,
ROD SPNL LORDOSED END SPOOL CRD ST TRANSITION,SUP-2230049,CDM,C1713,HCPCS,0278,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
WEDGE BNE LG 10 MM TITAN 3D,SUP-2321682,CDM,C1713,HCPCS,0278,RC,,,,both,,,6868.75,4464.69,,,,,,,,,,,,,
SYSTEM LD DEL RAPIDO ADV STRL,SUP-2149267,CDM,C1887,HCPCS,0272,RC,,,,both,,,2260.80,1469.52,,,,,,,,,,,,,
DRILL SURG CANN 4 MM N-FORC DISP,SUP-2471360,CDM,2720000010,LOCAL,0272,RC,,,,both,,,414.48,269.41,,,,,,,,,,,,,
Inj for Sacroiliac Jt Anesth|LEFT SIDE,CASE-G0260,LOCAL,G0260,CPT,0360,RC,,,LT,outpatient,,,4418.58,2651.15,,,,,,,,,,,,,
Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn,CASE-62323,LOCAL,62323,CPT,,,,,,outpatient,,,3964.35,2378.61,,,,,,,,,,,,,
Musc Myocutaneous/Fasciocutaneous Flap Trunk,CASE-15734,LOCAL,15734,CPT,,,,,,outpatient,,,51620.17,30972.10,,,,,,,,,,,,,
Inj for Sacroiliac Jt Anesth|LEFT SIDE,CASE-G0260,LOCAL,G0260,CPT,,,,,LT,outpatient,,,4418.58,2651.15,,,,,,,,,,,,,
Musc Myocutaneous/Fasciocutaneous Flap Trunk,CASE-15734,LOCAL,15734,CPT,0360,RC,,,,outpatient,,,51620.17,30972.10,,,,,,,,,,,,,
Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn,CASE-62323,LOCAL,62323,CPT,0360,RC,,,,outpatient,,,3964.35,2378.61,,,,,,,,,,,,,
HC So Tissue Thromboplastin Inhib,PX-3058570566,CDM,85705,CPT,0305,RC,,,,both,,,36.00,23.40,,,,,,,,,,,,,
STEM FEM SZ 1 L115MM DIA11MM NK L31MM 34MM OFFSET 132DEG 62650003] STRYKER CORP],SUP-2364473,CDM,C1776,CPT,0278,RC,,,,both,,,8220.52,5343.34,,,,,,,,,,,,,
STRAP ORTH W3XL4IN STD M FOAM COT MTL TOOTH CLAV BCKL CLSR,SUP-2276601,CDM,L3650,HCPCS,0274,RC,,,,both,,,22.26,14.47,,,,,,,,,,,,,
K WIRE FIX L150MM DIA1.6MM FOR EXTREMILOCK ANK PLATING SYS,SUP-2319589,CDM,C1713,HCPCS,0278,RC,,,,both,,,84.78,55.11,,,,,,,,,,,,,
PLATE BNE L163MM 8 H R MED DST HUM S STL VAR ANG FOR,SUP-2177596,CDM,C1713,HCPCS,0278,RC,,,,both,,,4039.64,2625.77,,,,,,,,,,,,,
SYSTEM OCCL DEL AMPLATZER 45 DEG L 60 CM SHTH 8 FR NIT MESH,SUP-2116321,CDM,C1894,HCPCS,0272,RC,,,,both,,,2047.28,1330.73,,,,,,,,,,,,,
LONG CALIBRATED DRILL 49MM,SUP-2720866,CDM,2720000010,LOCAL,0272,RC,,,,both,,,786.57,511.27,,,,,,,,,,,,,
PLATE BNE L79MM 3 H R LAT DST FIBULAR S STL VAR ANG LOK,SUP-2177710,CDM,C1713,HCPCS,0278,RC,,,,both,,,2203.15,1432.05,,,,,,,,,,,,,
GRAFT ENDOPROS L3.3CM DIA26MM ID22-23MM AORT EXT EXCLUDER,SUP-2395891,CDM,C1768,CPT,0278,RC,,,,both,,,9432.56,6131.16,,,,,,,,,,,,,
PIN FIX 700650002] ZIMMER SPINE],SUP-2415675,CDM,C1713,HCPCS,0278,RC,,,,both,,,204.10,132.66,,,,,,,,,,,,,
NAIL IM ELASTIC 1.5X300 MM TI PUR NS,SUP-2192723,CDM,C1713,HCPCS,0278,RC,,,,both,,,720.76,468.49,,,,,,,,,,,,,
HC Treat Dental Ridge Fx,PX-4502144000,CDM,21440,CPT,0450,RC,,,,both,,,9508.00,6180.20,,,,,,,,,,,,,
BASKET RETRV L1900MM DIA22MM MIN WRK CHN 28MM ROT 4 WIR BULL,SUP-2313157,CDM,C1713,HCPCS,0278,RC,,,,both,,,709.95,461.47,,,,,,,,,,,,,
GRAFT HUM TISS L 2 X W 2 CM MED AMNIO MEMBRN RESRB STRL,SUP-2913451,CDM,Q4173,HCPCS,0636,RC,,,,both,,,3658.10,2377.76,,,,,,,,,,,,,
GRAFT HUM TISS BOLSTER TRNS ABD WALL,SUP-2329846,CDM,C1713,HCPCS,0278,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
ANCHOR SUT W TWO NO 2 HI FI SUTS W NDL 17MM LEN 65MM,SUP-2167097,CDM,C1713,HCPCS,0278,RC,,,,both,,,1526.73,992.37,,,,,,,,,,,,,
COMPONENT TOE DIA15MM 1.5X4.5MM OFFSET MT CE ARTC TOE2,SUP-2123613,CDM,C1776,CPT,0278,RC,,,,both,,,9438.84,6135.25,,,,,,,,,,,,,
GRAFT BNE W12XL100MM CORT CANC STRUT FRZ DRY,SUP-2307183,CDM,C1713,HCPCS,0278,RC,,,,both,,,625.90,406.83,,,,,,,,,,,,,
INSERT TIB THICKNESS 10MM UNIV STRP YEL POLYETH PRI NEUT,SUP-2201278,CDM,C1776,CPT,0278,RC,,,,both,,,2541.42,1651.92,,,,,,,,,,,,,
BIT DRL L45MM 15MM FLUT WIRE PASS,SUP-2166389,CDM,2720000010,LOCAL,0272,RC,,,,both,,,107.17,69.66,,,,,,,,,,,,,
PIN FIX FOR SM FRAG SYS STRL A.L.P.S,SUP-2467661,CDM,2720000010,LOCAL,0272,RC,,,,both,,,395.64,257.17,,,,,,,,,,,,,
LEAD DEFIB L90CM ENDOCARD SGL COIL PASS NO CHRG RELIANCE S,SUP-2139493,CDM,C1779,HCPCS,0275,RC,,,,both,,,21116.50,13725.72,,,,,,,,,,,,,
IMPLANT NSL W 3 MM ID 15 X 21 MM NEODYMIUM MAG COAT SIL SEPT,SUP-2887848,CDM,C1889,HCPCS,0278,RC,,,,both,,,1036.20,673.53,,,,,,,,,,,,,
PROBE ABLATOR-S VULCAN 90 DEG HP,SUP-2850057,CDM,2720000010,LOCAL,0272,RC,,,,both,,,590.07,383.55,,,,,,,,,,,,,
BLADE RMR L35MM PAT PILOT H,SUP-2201485,CDM,2720000010,LOCAL,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
SYSTEM SCREW INTERFERENCE FASTTHREAD 6MM 20MM,SUP-2811822,CDM,C1713,HCPCS,0278,RC,,,,both,,,6264.30,4071.79,,,,,,,,,,,,,
HC Stent Place Initial Artery Ang,PX-3603723600,CDM,37236,CPT,0360,RC,,,,both,,,15457.00,10047.05,,,,,,,,,,,,,
TRIAL HD -3MM OFFSET UNIV FEM BPLR UPLR UHT V-40,SUP-2361590,CDM,C1776,CPT,0278,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
SCREW BNE CANN MIC 28 MM ASNS,SUP-2362774,CDM,C1713,HCPCS,0278,RC,,,,both,,,508.68,330.64,,,,,,,,,,,,,
ALLOGRAFT BNE 250-1000 MH 0.5 CC FD CANC PWD ORAGRAFT,SUP-2740969,CDM,C1713,HCPCS,0278,RC,,,,both,,,227.68,147.99,,,,,,,,,,,,,
BLOCK FEM M THK10MM DST KNEE MOD ROT HNG,SUP-2376359,CDM,C1776,CPT,0278,RC,,,,both,,,1688.54,1097.55,,,,,,,,,,,,,
STENT URET 0.038 IN 8 FRX26 CM 6 FR FLX FIRM PERCFLX +,SUP-2464911,CDM,C2617,HCPCS,0278,RC,,,,both,,,526.04,341.93,,,,,,,,,,,,,
LEAD DEFIB EPSILA EV MRI SURESCAN L 63 CM SUBSTERNAL QPLR,SUP-2891572,CDM,C1896,HCPCS,0275,RC,,,,both,,,16924.60,11000.99,,,,,,,,,,,,,
CANNULA ART LNG 17 FR UNCOATED HLS,SUP-2663470,CDM,2720000010,LOCAL,0272,RC,,,,both,,,950.64,617.92,,,,,,,,,,,,,
CATHETER ANGIOPLSTY L90CM BAL L15MM OD6MM DIL RX MRAIL,SUP-2140568,CDM,C1725,HCPCS,0272,RC,,,,both,,,1139.82,740.88,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 30 CM DIA 4-7 MM EPTFE TAPR STD,SUP-2396211,CDM,C1768,CPT,0278,RC,,,,both,,,1456.96,947.02,,,,,,,,,,,,,
CABLE ABLATION CATH FARASTAR PULSED FLD RX GEN 2 CONN,SUP-2927924,CDM,2720000010,LOCAL,0272,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
THROMBIN 5000 UNITS EX SOLR,RX-11548,CDM,2500000003,HCPCS,0250,RC,60793-0215-05,NDC,,both,1,UN,435.80,283.27,,,,,,,,,,,,,
HC Doppler Echo,PX-4839332000,CDM,93320,CPT,0483,RC,,,,inpatient,,,2133.00,1386.45,,,,,,,,,,,,,
BLADE SAW OSC OXFORD STRYKR 6 HUB,SUP-2136846,CDM,2720000010,LOCAL,0272,RC,,,,both,,,109.90,71.43,,,,,,,,,,,,,
SYSTEM PACEMKR CARD ZEPHYRXL DR 2 CHMBR RATE RESPON,SUP-2356219,CDM,C1785,HCPCS,0275,RC,,,,both,,,17332.80,11266.32,,,,,,,,,,,,,
KIT BONE MAR ASPIR L4IN 1 H NDL CELLECT,SUP-2255618,CDM,C1713,HCPCS,0278,RC,,,,both,,,461.58,300.03,,,,,,,,,,,,,
IMPLANT HUM TISS L 12 X W 2 CM PLCNTA MTRX MEMBRN DEHYDR,SUP-2905527,CDM,Q4184,HCPCS,0636,RC,,,,both,,,18840.00,12246.00,,,,,,,,,,,,,
BIT DRL DIA2.5MM DISP FOR 3.5MM LOK PROX FEM SCR PEDILOC,SUP-2318877,CDM,2720000010,LOCAL,0272,RC,,,,both,,,615.06,399.79,,,,,,,,,,,,,
RASP SURG CTTL NSL HANDHELD SGL END STR TAPR FLAT BLDE CNVX,SUP-2367145,CDM,2720000010,LOCAL,0272,RC,,,,both,,,401.92,261.25,,,,,,,,,,,,,
SCREW BNE L115MM DIA10.5MM CANC TIM CANN LAG NONLOCKING,SUP-2413937,CDM,C1713,HCPCS,0278,RC,,,,both,,,1649.44,1072.14,,,,,,,,,,,,,
ALLOGRAFT BNE 1-4 MM 30 CC FD IRRADIATED CORTICAL CANC,SUP-2866826,CDM,C1762,CPT,0278,RC,,,,both,,,987.37,641.79,,,,,,,,,,,,,
STEM FEM 98MM LEN 12/14 TAPR L HIP PRI NEUT PRESSFIT HA,SUP-2210417,CDM,C1776,CPT,0278,RC,,,,both,,,27475.00,17858.75,,,,,,,,,,,,,
AML SM STATURE 12.0MM,SUP-2513034,CDM,C1776,CPT,0278,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
ELECTRODE SUBDERM NDL L 18 MM 2 CHANNEL PRASS PR SM HUB STRL,SUP-2902089,CDM,2720000010,LOCAL,0272,RC,,,,both,,,422.24,274.46,,,,,,,,,,,,,
GUIDEWIRE VASC L190CM DIA0.014IN RADPQ L30CM MICROGLIDE STR,SUP-2105897,CDM,C1769,HCPCS,0272,RC,,,,both,,,219.80,142.87,,,,,,,,,,,,,
CATHETER PTCA BLLN PERIPH OVR THE WIRE N COMPLIANT 10.0MM,SUP-2156685,CDM,C1725,HCPCS,0272,RC,,,,both,,,1329.16,863.95,,,,,,,,,,,,,
INSERT TIB SZ 6 THK8MM UNI KNEE UHMWPE ONLAY MAKO X3,SUP-2368707,CDM,C1776,CPT,0278,RC,,,,both,,,3052.08,1983.85,,,,,,,,,,,,,
PLATE EXT FIX L 35 MM 2 H SHRT CONN OVL SLOT NS DISP ILIZ,SUP-2933252,CDM,2720000010,LOCAL,0272,RC,,,,both,,,494.02,321.11,,,,,,,,,,,,,
SHEATH INTRO CKFLO XL STRL,SUP-2142009,CDM,C1894,HCPCS,0272,RC,,,,both,,,631.14,410.24,,,,,,,,,,,,,
PLATE PL LAT SUPP 2.7/3.5MM 13H LT 205MM TI DHP STRL,SUP-2546781,CDM,C1713,HCPCS,0278,RC,,,,both,,,4443.29,2888.14,,,,,,,,,,,,,
CATHETER US 8FR L90CM GRN TIP OVERLAY FOR GE-VIVID I VIVID,SUP-2248457,CDM,C1759,HCPCS,0272,RC,,,,both,,,7253.40,4714.71,,,,,,,,,,,,,
MESH HERN 20X15 CM COMP PARIETEX,SUP-2174713,CDM,C1781,HCPCS,0278,RC,,,,both,,,2477.49,1610.37,,,,,,,,,,,,,
SHEATH NDL 6FR L150MM FOR FLX CYSTO CYF-4/4A,SUP-2313302,CDM,C1894,HCPCS,0272,RC,,,,both,,,586.40,381.16,,,,,,,,,,,,,
HOOK SPNL SM PEDCL TI OPN FOR 5.5MM ROD EXPEDIUM,SUP-2256241,CDM,C1713,HCPCS,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
COLLAR CERV DEFINITIVE PEDIATRIC 8-11X2 IN 2 PC,SUP-2428148,CDM,L0172,HCPCS,0274,RC,,,,both,,,173.83,112.99,,,,,,,,,,,,,
SALINE 0.65 % NA SOLN,RX-18225,CDM,6370000000,HCPCS,0637,RC,00225-0382-80,NDC,,both,50,ML,9.50,6.17,,,,,,,,,,,,,
GRAFT BNE FEM HD FD,SUP-2684083,CDM,C1762,CPT,0278,RC,,,,both,,,10949.18,7116.97,,,,,,,,,,,,,
POST EXTERNAL FIXATION L STAINLESS STEEL SLOTTED,SUP-2586505,CDM,2720000010,LOCAL,0272,RC,,,,both,,,635.98,413.39,,,,,,,,,,,,,
PLATE BNE 2 H SM TI ALLOY STR LCK NS LEOS,SUP-2933246,CDM,C1713,HCPCS,0278,RC,,,,both,,,3023.82,1965.48,,,,,,,,,,,,,
INTRODUCER SHTH 0.035 IN 5 FRX11 CM VLV GRY HUB PRELUDE,SUP-2303268,CDM,C1894,HCPCS,0272,RC,,,,both,,,30.05,19.53,,,,,,,,,,,,,
INSERT TIB HD CONSTRAINT N-K,SUP-2449035,CDM,C1776,CPT,0278,RC,,,,both,,,1639.08,1065.40,,,,,,,,,,,,,
GRAFT VASC INTERGARD L 70 CM DIA 7 MM RNG L 30 CM,SUP-2227613,CDM,C1768,CPT,0278,RC,,,,both,,,3149.58,2047.23,,,,,,,,,,,,,
SCREW BNE L 36 MM DIA 4.5 MM TI ST SD CANN SHRT THRD COMPR,SUP-2912868,CDM,C1713,HCPCS,0278,RC,,,,both,,,857.22,557.19,,,,,,,,,,,,,
VITAMIN B-12 1000 MCG PO TABS,RX-8654,CDM,6370000000,HCPCS,0637,RC,00904-7403-61,NDC,,both,1,UN,1.60,1.04,,,,,,,,,,,,,
SCREW BNE L 85 MM DIA 6.5 MM SS CANN LCK NS EVOS,SUP-2931450,CDM,C1713,HCPCS,0278,RC,,,,both,,,1490.40,968.76,,,,,,,,,,,,,
ALLOGRAFT BNE STRUT 5 CM SEG FRZN FIB,SUP-2321863,CDM,C1713,HCPCS,0278,RC,,,,both,,,1249.72,812.32,,,,,,,,,,,,,
LAT DIST FIB PLATE LONG 15 HOLE RT,SUP-2829318,CDM,C1713,HCPCS,0278,RC,,,,both,,,5542.10,3602.36,,,,,,,,,,,,,
SCREW SPNL L35MM DIA5.5MM CANC TI MULTAXL ST REDUC EXT ARRY,SUP-2137269,CDM,C1713,HCPCS,0278,RC,,,,both,,,3956.40,2571.66,,,,,,,,,,,,,
SET SCR 5.5MM,SUP-2256299,CDM,C1713,HCPCS,0278,RC,,,,both,,,813.89,529.03,,,,,,,,,,,,,
COMPONENT ULNA DISCOVERY WITH BEARING E+ RIGHT 4.0X155MM,SUP-2879098,CDM,C1776,CPT,0278,RC,,,,both,,,18833.72,12241.92,,,,,,,,,,,,,
DEFIBRILLATOR CARD SGL CHMBR CARDIOVERTER STD BPLR REMOT MON,SUP-2236358,CDM,C1722,HCPCS,0275,RC,,,,both,,,83586.80,54331.42,,,,,,,,,,,,,
BIT DRL L180MM DIA25MM 3 FLUT QUIK CPL FOR NCB,SUP-2199207,CDM,2720000010,LOCAL,0272,RC,,,,both,,,569.22,369.99,,,,,,,,,,,,,
BUR SURG L57MM DIA2MM STD NEURO RND FN DMND CUT NONFLUTED,SUP-2278117,CDM,2720000010,LOCAL,0272,RC,,,,both,,,489.18,317.97,,,,,,,,,,,,,
DRILL SURG PILOT DSTL TROCHANTERIC HI PERF SIG,SUP-2453138,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1604.54,1042.95,,,,,,,,,,,,,
PLATE BONE L205MM 95DEG SUPCNDYL TUBE FRELOK,SUP-2197719,CDM,C1713,HCPCS,0278,RC,,,,both,,,1794.79,1166.61,,,,,,,,,,,,,
CENTRALIZER STEM DIA10MM UNIV DST HIP,SUP-2210692,CDM,C1776,CPT,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
GRAFT BNE 1 CC DEMINERALIZED BNE FIBER PROGRAFT,SUP-2858503,CDM,C1713,HCPCS,0278,RC,,,,both,,,615.13,399.83,,,,,,,,,,,,,
PROBE MICROWAVE ABLATION L 15 CM DIA15-17 GA CABLE L 2.9 M,SUP-2908906,CDM,C1886,HCPCS,0278,RC,,,,both,,,9215.90,5990.33,,,,,,,,,,,,,
SHUNT CSF L87CM DIA4.5FR LP CATH T TB CONN FIX TAB N,SUP-2284531,CDM,C1889,HCPCS,0278,RC,,,,both,,,1850.90,1203.08,,,,,,,,,,,,,
GRAFT BNE SYR 1 CC GRFT 945001] MUSCULOSKELETAL TRANSPLANT FOUNDATION],SUP-2307548,CDM,C1713,HCPCS,0278,RC,,,,both,,,508.68,330.64,,,,,,,,,,,,,
SCREW INTRF L23MM DIA7MM BIO-TENODESIS,SUP-2121350,CDM,C1713,HCPCS,0278,RC,,,,both,,,1161.80,755.17,,,,,,,,,,,,,
LINER ACET NEUT J 36 MM PROV G7,SUP-2440215,CDM,C1776,CPT,0278,RC,,,,both,,,268.47,174.51,,,,,,,,,,,,,
MICROSPHERE EMB CNTOUR SE DIA 500-700 UM 2 ML PVA STRL,SUP-2142756,CDM,C1889,HCPCS,0278,RC,,,,both,,,794.73,516.57,,,,,,,,,,,,,
CATHETER CTRL VEN L8IN OD12FR POLYUR FOR HI VOL INFUS,SUP-2120627,CDM,C1751,HCPCS,0278,RC,,,,both,,,327.19,212.67,,,,,,,,,,,,,
GRAFT HUM TISS M W11XL20CM THK0.7-1.4MM THN ACELLULAR,SUP-2307604,CDM,Q4128,HCPCS,0636,RC,,,,both,,,11417.04,7421.08,,,,,,,,,,,,,
SCREW BONE L65MM DIA5MM PARTIALLY THRD FOR ARTH NAIL SYS,SUP-2417660,CDM,C1713,HCPCS,0278,RC,,,,both,,,1877.78,1220.56,,,,,,,,,,,,,
LINER ACET OD56MM ID32MM +4MM OFFSET 10DEG HIP GVF POLYETH,SUP-2250264,CDM,C1776,CPT,0278,RC,,,,both,,,10927.20,7102.68,,,,,,,,,,,,,
SPLINT HND AD L115IN L DK BLU HEADLINER BROAD CLTH REST,SUP-2165488,CDM,L3807,HCPCS,0272,RC,,,,both,,,211.04,137.18,,,,,,,,,,,,,
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ SOLN,RX-2332,CDM,J1100,HCPCS,0636,RC,00641-6145-25,NDC,,both,.5,ML,54.10,35.16,,,,,,,,,,,,,
IMPLANT HUM TISS ANGIOGRAFT,SUP-2931356,CDM,C1762,CPT,0278,RC,,,,both,,,31888.80,20727.72,,,,,,,,,,,,,
BIT DRL DIA6MM DSTL RAD ULN CANN,SUP-2119913,CDM,2720000010,LOCAL,0272,RC,,,,both,,,478.85,311.25,,,,,,,,,,,,,
BLADE SURG CRV XL 4.2 MM FULL RAD + FMS,SUP-2637149,CDM,2720000010,LOCAL,0272,RC,,,,both,,,317.14,206.14,,,,,,,,,,,,,
GRAFT HUM TISS W2XL4CM THK1.04-2.28MM THCK REGEN TISS MTRX,SUP-2112988,CDM,Q4116,HCPCS,0636,RC,,,,both,,,1733.28,1126.63,,,,,,,,,,,,,
SHIM FIX SCR LNG 28 MM NS PHANTOM XL DISP,SUP-2750542,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1491.50,969.47,,,,,,,,,,,,,
PLATE 3.5MM TI LCP TM PROX HUMERUS LONG 10H SHAFT 232MM STER,SUP-2549718,CDM,C1713,HCPCS,0278,RC,,,,both,,,5888.79,3827.71,,,,,,,,,,,,,
SCREW BNE L50MM DIA45MM COMPR FOR GLEN BASEPLT,SUP-2401415,CDM,C1713,HCPCS,0278,RC,,,,both,,,295.32,191.96,,,,,,,,,,,,,
LEAD DEFIB FIX EXT RET HELIX MIN INTRO 7FR SHOCK,SUP-2356226,CDM,C1895,HCPCS,0275,RC,,,,both,,,17270.00,11225.50,,,,,,,,,,,,,
GRAFT VASC TW 6 MMX40 CM AORT STR REINF SLDE GDS ADVANTA VXT,SUP-2467687,CDM,C1768,CPT,0278,RC,,,,both,,,1402.92,911.90,,,,,,,,,,,,,
EVOS 2.7/3.5MM L-D HUM PL 13H RIGHT 156MM,SUP-2820154,CDM,C1713,HCPCS,0278,RC,,,,both,,,8908.97,5790.83,,,,,,,,,,,,,
COMPONENT FEM KNEE CRUC RET LT UNISX PRI CEM STEM MOD PC,SUP-2200373,CDM,C1776,CPT,0278,RC,,,,both,,,15612.08,10147.85,,,,,,,,,,,,,
DEVICE FIX MENIS LD NONABSORBABLE STR FAST-FIX,SUP-2341567,CDM,C1713,HCPCS,0278,RC,,,,both,,,854.27,555.28,,,,,,,,,,,,,
HEAD FEM SM 12/14 28 MM,SUP-2440579,CDM,C1776,CPT,0278,RC,,,,both,,,141.30,91.84,,,,,,,,,,,,,
PIN PERC 100MM,SUP-2756513,CDM,2720000010,LOCAL,0272,RC,,,,both,,,832.10,540.86,,,,,,,,,,,,,
ENDOPROSTHESIS VASC VIABAHN L 5 MM DIA10 MM CATH L 120 CM,SUP-2639011,CDM,C1768,CPT,0278,RC,,,,both,,,9391.74,6104.63,,,,,,,,,,,,,
STEM HUM UNIV STD L122MM DIA13MM SHLDR CO CHROM PRI CEM,SUP-2404595,CDM,C1776,CPT,0278,RC,,,,both,,,12738.98,8280.34,,,,,,,,,,,,,
ALLOGRAFT DERMAL SHP THN SM 17X10 CMX0.7-1.4 MM FLEXHD,SUP-2458339,CDM,Q4128,HCPCS,0636,RC,,,,both,,,9044.52,5878.94,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 2X2 CM AMNIO MEMBRN MTRX NEOX,SUP-2135261,CDM,Q4148,HCPCS,0636,RC,,,,both,,,3611.00,2347.15,,,,,,,,,,,,,
PRISMASATE B22GK 4/0 DIALYSIS SOLUTION,RX-40840083,CDM,2580000003,HCPCS,0250,RC,09999-9999-45,NDC,,both,5000,ML,103.50,67.27,,,,,,,,,,,,,
SUPPORT ORTHOT WRST ELBW HND CUST ADJ FIT W/NONTORSION JT,SUP-2435763,CDM,L3764,HCPCS,0274,RC,,,,both,,,2017.89,1311.63,,,,,,,,,,,,,
SUPPORT ORTHOT WRST ELBW HND CUST ADJ FIT W/NONTORSION JT,SUP-2435763,CDM,L3764,HCPCS,0272,RC,,,,both,,,2017.89,1311.63,,,,,,,,,,,,,
BUR SURG DIAMOND BALL 6 MMX7 CM SM BOR MIDAS REX LEGEND,SUP-2422342,CDM,2720000010,LOCAL,0272,RC,,,,both,,,374.54,243.45,,,,,,,,,,,,,
QUARTEX LAT CONNECTOR4.0MM ROD,SUP-2229090,CDM,C1713,HCPCS,0278,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
CATHETER COR LSR ATHRCTMY OVR THE WIRE 0.9 MMX130 CM ELCA,SUP-2353041,CDM,C1885,CPT,0278,RC,,,,both,,,9404.30,6112.79,,,,,,,,,,,,,
COMPONENT PATELLAR 29 MM KNEE E-VITALIZE BKS TRIMAX,SUP-2314929,CDM,C1776,CPT,0278,RC,,,,both,,,1708.16,1110.30,,,,,,,,,,,,,
LOCKING DLVRY CNNLA 11 G WTH DMND TPPD STLT SHRT,SUP-2475596,CDM,2720000010,LOCAL,0272,RC,,,,both,,,736.80,478.92,,,,,,,,,,,,,
COMPONENT FEM 54MM R MED L LAT CO CHROM MOLYBDENUM REPICCI,SUP-2403265,CDM,C1776,CPT,0278,RC,,,,both,,,7536.00,4898.40,,,,,,,,,,,,,
LEAD DEFIB INTRO 7FR L60X65X75CM OPTIM SGL COIL TRUE BPLR,SUP-2357377,CDM,C1777,HCPCS,0275,RC,,,,both,,,15700.00,10205.00,,,,,,,,,,,,,
CONE TIP URETERAL CATHETER,SUP-2827459,CDM,C1758,HCPCS,0278,RC,,,,both,,,38.56,25.06,,,,,,,,,,,,,
IMPLANT STAP LOOP PIST FLROPLAS S STL 06MM DIA 525MM LEN,SUP-2313659,CDM,C1769,HCPCS,0272,RC,,,,both,,,300.03,195.02,,,,,,,,,,,,,
HC Replc Centrl Tun Cath W/O Port,PX-3613658100,CDM,36581,CPT,0361,RC,,,,outpatient,,,4893.00,3180.45,,,,,,,,,,,,,
CATHETER GUID ANGLED 0.018 IN 65 CM SUPP 3 MARKER NAVICROSS,SUP-2435365,CDM,C1887,HCPCS,0272,RC,,,,both,,,680.12,442.08,,,,,,,,,,,,,
ENDCAP SPNL 0 DEG 18X18X60 MM TI X-CORE 2,SUP-2560273,CDM,C1889,HCPCS,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
CATHETER THROMCTMY INDIGO L 132 CM PROX/DSTL DIA 6/5,SUP-2323572,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4364.60,2836.99,,,,,,,,,,,,,
METHYLPHENIDATE HCL 20 MG PO TABS,RX-4987,CDM,6370000000,HCPCS,0637,RC,00406-1146-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
STENT BILI L 7 CM DIA 7 FR GUIDEWIRE 0.035 IN PERCFLX,SUP-2149459,CDM,C2617,HCPCS,0278,RC,,,,both,,,155.59,101.13,,,,,,,,,,,,,
FENTANYL 50 MCG/ML PCA (DISCRETE DOSING),RX-4081981,CDM,J7999,HCPCS,0636,RC,71266-9170-05,NDC,,both,30,ML,202.40,131.56,,,,,,,,,,,,,
BLADE IM L110MM DIA12.5MM ST LT BLU CANC TI SPRL NTHREADED,SUP-2191889,CDM,C1713,HCPCS,0278,RC,,,,both,,,2644.32,1718.81,,,,,,,,,,,,,
ELECTRODE EMG DISP 8 CNTCT STRP,SUP-2308207,CDM,C1713,HCPCS,0278,RC,,,,both,,,2073.91,1348.04,,,,,,,,,,,,,
NEXGEN RH KNEE TM 10MM FULL BLK TIB AGMT SZ 2,SUP-2502547,CDM,C1776,CPT,0278,RC,,,,both,,,10456.20,6796.53,,,,,,,,,,,,,
SCREW BNE PERIARTICULAR 3.5X120 MM ST FN THRD HD HEX NS LTX,SUP-2861325,CDM,C1713,HCPCS,0278,RC,,,,both,,,194.05,126.13,,,,,,,,,,,,,
BLADE SHAVER RESECT 4.5X130 MM OVL DISP,SUP-2661222,CDM,2720000010,LOCAL,0272,RC,,,,both,,,493.01,320.46,,,,,,,,,,,,,
STEM FEM HIP CNL PRB WAGNER CONE PROS,SUP-2449519,CDM,C1776,CPT,0278,RC,,,,both,,,593.46,385.75,,,,,,,,,,,,,
STEM HUM HA FRAC 12MM REUNION,SUP-2379014,CDM,C1776,CPT,0278,RC,,,,both,,,15015.48,9760.06,,,,,,,,,,,,,
KIT VAG SUPP SYS REP ARISE,SUP-2141762,CDM,C1771,HCPCS,0278,RC,,,,both,,,5129.19,3333.97,,,,,,,,,,,,,
PROTECTOR NERVE L 4 X W 2 CM PORCINE SODIUM HYALURONATE,SUP-2890380,CDM,C1763,HCPCS,0278,RC,,,,both,,,10299.20,6694.48,,,,,,,,,,,,,
CANNULA ART SHT 19 FR UNCOATED HLS,SUP-2663477,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1010.86,657.06,,,,,,,,,,,,,
SHEATH GUID 8FR L95CM HYDRPHLC COAT L60CM S STL COIL STR CRV,SUP-2384900,CDM,C1887,HCPCS,0272,RC,,,,both,,,424.37,275.84,,,,,,,,,,,,,
STENT BILI VIABIL L 6 CM DIA10 MM CATH L 200 CM DIA 8.5 FR,SUP-2166311,CDM,C1874,HCPCS,0278,RC,,,,both,,,6462.12,4200.38,,,,,,,,,,,,,
SUPPORT ORTH SM NYL LEG LTWT XCELTRAX AIR,SUP-2197147,CDM,L4370,HCPCS,0274,RC,,,,both,,,78.06,50.74,,,,,,,,,,,,,
PACK VITRECTOMY POSTERIOR 25GA BL5225V,SUP-2844715,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1833.76,1191.94,,,,,,,,,,,,,
COMPONENT PART KNEE CAPPED UNI TRIATHLON,SUP-2365443,CDM,C1776,CPT,0278,RC,,,,both,,,14679.50,9541.67,,,,,,,,,,,,,
PLATE BNE W5XL37MM THK1.5MM 7 H BILAT TI STR RIG NEUT DYN,SUP-2191044,CDM,C1713,HCPCS,0278,RC,,,,both,,,968.00,629.20,,,,,,,,,,,,,
BIT DRILL CANN 4.9MM,SUP-2497212,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1573.14,1022.54,,,,,,,,,,,,,
CATHETER EMB NOVASIL L 40 CM DIA2 FR BALLOON DIA 4 MM 0.05,SUP-2424165,CDM,C1757,HCPCS,0272,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
SCREW BNE L44MM DIA3.5MM EL TI LOK MULTDIR FOR ALPS FRAC,SUP-2413775,CDM,C1713,HCPCS,0278,RC,,,,both,,,641.82,417.18,,,,,,,,,,,,,
HC ED Layer Clos Face 7.6-12.5,PX-4501205400,CDM,12054,CPT,0450,RC,,,,both,,,1674.00,1088.10,,,,,,,,,,,,,
CATHETER HD 55 CM GLD DECATHLON,SUP-2165201,CDM,C1750,HCPCS,0278,RC,,,,both,,,1252.86,814.36,,,,,,,,,,,,,
HC So T3 Reverse,PX-3018448266,CDM,84482,CPT,0301,RC,,,,outpatient,,,181.00,117.65,,,,,,,,,,,,,
NAIL INTRAMEDULLARY MEDIUM COMPLETE KNEE SYSTEM STERILE VANG,SUP-2836599,CDM,C1713,HCPCS,0278,RC,,,,both,,,141.30,91.84,,,,,,,,,,,,,
GRAFT HUM TISS W4XL6CM COMP AMNIO MEM MTRX SHT AMNIOFIX,SUP-2305708,CDM,V2790,HCPCS,0278,RC,,,,both,,,7071.28,4596.33,,,,,,,,,,,,,
PLATE BNE STR 1.5X1 MM 12 MM MXLFCL OPN LOOP BRIDGE TI NS,SUP-2478205,CDM,C1713,HCPCS,0278,RC,,,,both,,,723.24,470.11,,,,,,,,,,,,,
SUPPORT WR SM AD FOR 7-8IN RT CRPL TUNN REG FIRM SUPP,SUP-2324888,CDM,L3931,HCPCS,0274,RC,,,,both,,,47.32,30.76,,,,,,,,,,,,,
HC So Bcr/Abl1 Gene Minor Bp,PX-3108120766,CDM,81207,CPT,0310,RC,,,,both,,,189.00,122.85,,,,,,,,,,,,,
HC So Diphtheria Antibody,PX-3028664866,CDM,86648,CPT,0302,RC,,,,inpatient,,,202.00,131.30,,,,,,,,,,,,,
DRIVER POWER 2 DRIVE DISP,SUP-2136973,CDM,2720000010,LOCAL,0272,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
PLATE BNE W8XL20MM THK2MM 0DEG 2 H BILAT TI STR RIG DYN,SUP-2191067,CDM,C1713,HCPCS,0278,RC,,,,both,,,888.49,577.52,,,,,,,,,,,,,
HC Pt Ultrasound Each 15 Min|OP PT SERVICES|DOCUMENTATION ON FILE|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS,PX-4209703500,CDM,97035,CPT,0420,RC,,,GP|KX|CQ,outpatient,,,194.00,126.10,,,,,,,,,,,,,
CARBAMAZEPINE ER 100 MG PO TB12,RX-27634,CDM,6370000000,HCPCS,0637,RC,00078-0510-05,NDC,,both,1,UN,7.50,4.87,,,,,,,,,,,,,
PLATE BONE 4 H CRANIOMAXILLOFACIAL NONCOMPRESSIONXSHAPED,SUP-2363641,CDM,C1713,HCPCS,0278,RC,,,,both,,,907.71,590.01,,,,,,,,,,,,,
STEM FEM L200MM L30MM OD12MM SZ 5 R HIP REV CEM BOW IMPL,SUP-2374699,CDM,C1776,CPT,0278,RC,,,,both,,,12920.47,8398.31,,,,,,,,,,,,,
GRAFT BONE 100X25MM DEMIN BOAT CORT 3DEMIN,SUP-2125438,CDM,C1713,HCPCS,0278,RC,,,,both,,,13737.50,8929.37,,,,,,,,,,,,,
GRAFT BONE LT TALUS WHL TRAD FRZN,SUP-2294187,CDM,C1713,HCPCS,0278,RC,,,,both,,,8264.48,5371.91,,,,,,,,,,,,,
IMPLANT OP RM MINI-MONSTER 4.0X38MM H,SUP-2320927,CDM,C1713,HCPCS,0278,RC,,,,both,,,846.23,550.05,,,,,,,,,,,,,
ALLOGRAFT HUM TISS THN 8X4 CM REGENERATIVE GRAFTJACKET NOW,SUP-2759588,CDM,Q4107,HCPCS,0636,RC,,,,both,,,7158.76,4653.19,,,,,,,,,,,,,
GUIDEWIRE ORTH DIA14MM FOR IO FIX SYS,SUP-2400060,CDM,C1769,HCPCS,0272,RC,,,,both,,,53.38,34.70,,,,,,,,,,,,,
HC ER Level 5,PX-4509928500,CDM,99285,CPT,0450,RC,,,,inpatient,,,3911.00,2542.15,,,,,,,,,,,,,
SCREW INTRF POLYPR INTRAFIX ADV SM 30MM,SUP-2256835,CDM,C1713,HCPCS,0278,RC,,,,both,,,976.54,634.75,,,,,,,,,,,,,
HC Pt Prosthetic Training 15 Min,PX-4209776100,CDM,97761,CPT,0420,RC,,,,both,,,135.00,87.75,,,,,,,,,,,,,
SYSTEM PACEMKR SENSIA SR TI STRL,SUP-2282483,CDM,C1786,HCPCS,0275,RC,,,,both,,,10362.00,6735.30,,,,,,,,,,,,,
STAPLER ENDOSCP SKIN STRP CLSR W/ UNIV BOV PERICARD DEHYDR,SUP-2130377,CDM,2720000010,LOCAL,0272,RC,,,,both,,,585.61,380.65,,,,,,,,,,,,,
HELMET SURG PROTCT HRD PREFABRICATED,SUP-2265008,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
SPLINT DORSAL AFO SPLNT L RT W STRP,SUP-2163838,CDM,L4396,HCPCS,0274,RC,,,,both,,,110.94,72.11,,,,,,,,,,,,,
STEM FEM HNR PR1 160X43MM,SUP-2364448,CDM,C1776,CPT,0278,RC,,,,both,,,6874.12,4468.18,,,,,,,,,,,,,
RIGHT EXTRA ART NARROW PLATE STERILE,SUP-2488801,CDM,C1713,HCPCS,0278,RC,,,,both,,,2348.03,1526.22,,,,,,,,,,,,,
SCREW BONE TI LCK THRD CANC TRIFLANGE ACET COMP L20MM,SUP-2137415,CDM,C1713,HCPCS,0278,RC,,,,both,,,715.92,465.35,,,,,,,,,,,,,
HC Rem Neph Tube,PX-3615038900,CDM,50389,CPT,0361,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
PLATE BNE SM L263MM 22 H BILAT S STL LO PROF RIG LIMIT,SUP-2186219,CDM,C1713,HCPCS,0278,RC,,,,both,,,2708.34,1760.42,,,,,,,,,,,,,
SUPPORT WR SM AD FOR 7-8IN RT CRPL TUNN REG FIRM SUPP,SUP-2324888,CDM,L3931,HCPCS,0272,RC,,,,both,,,47.32,30.76,,,,,,,,,,,,,
COUNTERSINK SURG DIA 6.5/7.5 MM LNG CANN HD STRL DISP,SUP-2905556,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2435.29,1582.94,,,,,,,,,,,,,
CATHETER HD KT 8 FRX24.5 CM 15 CM 1 CC 1 LUMEN STR ARGY,SUP-2754726,CDM,C1750,HCPCS,0278,RC,,,,both,,,121.05,78.68,,,,,,,,,,,,,
PLATE BNE L 97 X W 12 MM THK 3 MM SCREW DIA 3.5 MM 9 H SS LT,SUP-2933198,CDM,C1713,HCPCS,0278,RC,,,,both,,,2842.33,1847.51,,,,,,,,,,,,,
ANCHOR SFT TISS PROX TENODESIS BTTN,SUP-2121682,CDM,C1713,HCPCS,0278,RC,,,,both,,,1365.90,887.83,,,,,,,,,,,,,
GRAFT VASC STR 8 MMX40 CM COAT W/ RNG SUPP FUSION BIOLINE,SUP-2464469,CDM,C1768,CPT,0278,RC,,,,both,,,3023.98,1965.59,,,,,,,,,,,,,
GRAFT BONE SUB SM 7MM 5DEG LORDOSIS RAMP POST SPNL GRFTECH,SUP-2294224,CDM,C1713,HCPCS,0278,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
PLATE BNE L W10.1XL56MM THK3.5MM 4 H BILAT S STL STR RIG,SUP-2186207,CDM,C1713,HCPCS,0278,RC,,,,both,,,1183.97,769.58,,,,,,,,,,,,,
PLATE CRAN L 53 X W 48 MM THK 0.3 MM SCREW DIA1.5 MM LG TI,SUP-2936461,CDM,C1713,HCPCS,0278,RC,,,,both,,,2521.42,1638.92,,,,,,,,,,,,,
ANCHOR SUT SM 1.7MM NO5 POLY SFT SGL LD W/ 1 NO2 BLU COBRAID,SUP-2341894,CDM,C1713,HCPCS,0278,RC,,,,both,,,976.41,634.67,,,,,,,,,,,,,
CATHETER GUID NEURON L 115 CM DSTL FLX ZONE 6 CM,SUP-2323602,CDM,C1887,HCPCS,0272,RC,,,,both,,,2056.70,1336.85,,,,,,,,,,,,,
STEM FEM L225MM DIA14MM +30MM OFFSET NEUT CALCAR HIP REV,SUP-2344483,CDM,C1776,CPT,0278,RC,,,,both,,,11281.39,7332.90,,,,,,,,,,,,,
MICRO BONE PLATE TRNGLR 6MM 10MM SSTM CP TTNM,SUP-2707393,CDM,C1713,HCPCS,0278,RC,,,,both,,,419.47,272.66,,,,,,,,,,,,,
HC Treat Wrist Bone Fx,PX-4502565000,CDM,25650,CPT,0450,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
CATHETER MIDLINE 4.5FR 15CM 1 LUMN PRSS INJ ARROWG+ARD,SUP-2120615,CDM,C1751,HCPCS,0278,RC,,,,both,,,481.36,312.88,,,,,,,,,,,,,
PLUG SYN HERN W4CM D4.5CM POLYPR NONABSORBABLE PRESHAPED,SUP-2227399,CDM,C1781,HCPCS,0278,RC,,,,both,,,398.78,259.21,,,,,,,,,,,,,
MICROSTENT LACR HYDRUS L 8 MM NIT GLAUCOMA NONBIOABSORBABLE,SUP-2714092,CDM,C1783,HCPCS,0278,RC,,,,both,,,5264.15,3421.70,,,,,,,,,,,,,
SIZER BRST 175CC DIA10CM P31CM SIL GEL MOD + PROF RND SMOOTH,SUP-2300840,CDM,2720000010,LOCAL,0272,RC,,,,both,,,816.40,530.66,,,,,,,,,,,,,
PIN EXT FIX L 25 MM DIA 3 MM SS HALF NS DISP JET-X,SUP-2933746,CDM,2720000010,LOCAL,0272,RC,,,,both,,,446.48,290.21,,,,,,,,,,,,,
STENT TRACHBRONCH WGRFT L 70 MM DIA12 MM CATH TOT L 116 CM,SUP-2424707,CDM,C1874,HCPCS,0278,RC,,,,both,,,8069.80,5245.37,,,,,,,,,,,,,
PLATE BNE 10 H ST BILAT S STL NAR CRV LOK COMPR FOR 45MM SCR,SUP-2178056,CDM,C1713,HCPCS,0278,RC,,,,both,,,2317.63,1506.46,,,,,,,,,,,,,
DEFIBRILLATOR CARD 41CC 14MM 36J LD W5CM BPLR DF4 IS1 CONN,SUP-2357760,CDM,C1882,HCPCS,0275,RC,,,,both,,,67510.00,43881.50,,,,,,,,,,,,,
MESH CRAN L 80.26 X W 60.96 MM THK 0.6 MM SCREW DIA1.5 MM TI,SUP-2936698,CDM,C1713,HCPCS,0278,RC,,,,both,,,2706.68,1759.34,,,,,,,,,,,,,
SHEATH DIL L 16FR L43CM OD0.293IN ID0.236IN STR TORQ DEL,SUP-2353111,CDM,C1894,HCPCS,0272,RC,,,,both,,,910.60,591.89,,,,,,,,,,,,,
PLATE BNE L20MM 2 H COMPR GORILLA,SUP-2321426,CDM,C1713,HCPCS,0278,RC,,,,both,,,3756.23,2441.55,,,,,,,,,,,,,
PLATE BNE L100MM 34 H CRANIOMAXILLOFACIAL TI ADPT FOR 1MM,SUP-2190574,CDM,C1713,HCPCS,0278,RC,,,,both,,,2494.73,1621.57,,,,,,,,,,,,,
PROBE LITHO COHERENT DIR DISP,SUP-2129216,CDM,2720000010,LOCAL,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
TRAY CATH MIDLN PROVENA BASIC 4FR 20CM 2 LUMAN RVS TAPR PWR,SUP-2613551,CDM,C1751,HCPCS,0278,RC,,,,both,,,494.80,321.62,,,,,,,,,,,,,
ALLOGRAFT BNE WDG 14-16 MM FD ILIUM TRICORT,SUP-2717914,CDM,C1713,HCPCS,0278,RC,,,,both,,,4593.95,2986.07,,,,,,,,,,,,,
PLATE BONE W14.9XL120MM THK1.2MM 7 H DSTL TIB S STL,SUP-2185736,CDM,C1713,HCPCS,0278,RC,,,,both,,,1013.50,658.77,,,,,,,,,,,,,
GUIDEWIRE VASC L 260 CM 0.035IN L 8CM 3CM HEPARIN AMPLTZ STR,SUP-2169715,CDM,C1769,HCPCS,0272,RC,,,,both,,,89.43,58.13,,,,,,,,,,,,,
CRANIO SCULPT FLOW BONE VOID FILLER5CC QTY001 EA,SUP-2457216,CDM,C1713,HCPCS,0278,RC,,,,both,,,5538.18,3599.82,,,,,,,,,,,,,
SCREW BNE CANN 2X10X25 MM AP CRUC LIGMNT BLNT THRD RCI,SUP-2691285,CDM,C1713,HCPCS,0278,RC,,,,both,,,451.69,293.60,,,,,,,,,,,,,
SCREW BNE LCK 2X6 MM SELF RET TI MAXDRIVE THREADLOCK TS,SUP-2469560,CDM,C1713,HCPCS,0278,RC,,,,both,,,366.50,238.22,,,,,,,,,,,,,
REPLACEMENT PD F VISTA CERV CLLR ADLT,SUP-2196894,CDM,L0120,HCPCS,0274,RC,,,,both,,,52.19,33.92,,,,,,,,,,,,,
PIN EXTERNAL FIXATION HALF 4X20 MM STAINLESS STEEL NON STERI,SUP-2836768,CDM,2720000010,LOCAL,0272,RC,,,,both,,,855.87,556.32,,,,,,,,,,,,,
HC So1 Infectious Agent Ab Quant,PX-3028631767,CDM,86317,CPT,0302,RC,,,,outpatient,,,44.00,28.60,,,,,,,,,,,,,
DRILL TWST L 58 MM DIA1.9 MM WORKING L 9 MM SCREW DIA 6/7 MM,SUP-2883609,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1129.87,734.42,,,,,,,,,,,,,
DEFIBRILLATOR IMPL INOGEN W 5.37 X H 8.18 CM D 0.99 CM 32.5,SUP-2149208,CDM,C1882,HCPCS,0275,RC,,,,both,,,53389.42,34703.12,,,,,,,,,,,,,
PLATE SPNL M L23MM DIA8MM ANTI GIC59 STR VBR PEEK,SUP-2211899,CDM,C1713,HCPCS,0278,RC,,,,both,,,8164.00,5306.60,,,,,,,,,,,,,
SLEEVE TIB L9CM ELLIP TI POR PROX KNEE REDUC SZ OSS MARTI,SUP-2406488,CDM,C1776,CPT,0278,RC,,,,both,,,14139.89,9190.93,,,,,,,,,,,,,
COIL VASC RETRACTA L 7 CM DIA 8 MM CATH 0.035 IN LOOP 2.8,SUP-2638513,CDM,C1889,HCPCS,0278,RC,,,,both,,,1522.90,989.88,,,,,,,,,,,,,
CATHETER CV 3L 6 FRX55 CM ENDEXO NURSING KT 2 NIT BIOFLO,SUP-2734875,CDM,C1751,HCPCS,0278,RC,,,,both,,,148.21,96.34,,,,,,,,,,,,,
PERI-LOC 4.5MM T25 TI LCK SCREW 78MM S-T,SUP-2819241,CDM,C1713,HCPCS,0278,RC,,,,both,,,1227.46,797.85,,,,,,,,,,,,,
SCREW BONE L4MM DIA1.5MM GLD CORT CRANIOMAXILLOFACIAL TI ST,SUP-2188924,CDM,C1713,HCPCS,0278,RC,,,,both,,,236.07,153.45,,,,,,,,,,,,,
DRIVER SURG CANN FRAG LOC 1.5MM,SUP-2107138,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1029.92,669.45,,,,,,,,,,,,,
ANCHOR SUTURE SFT 2.9 MM W/ TAPR NDL IMPL JUGGERKNOTLESS,SUP-2608585,CDM,C1713,HCPCS,0278,RC,,,,both,,,1209.09,785.91,,,,,,,,,,,,,
DRILL SURG MED SPD BURR CONTRA LINVATEC HOSE CONN BSPMICRO,SUP-2745751,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5372.54,3492.15,,,,,,,,,,,,,
BLADE ENDOSCP SHAVER 60 DEG L 11 CM DIA 3.5 MM SPD 5000 RPM HRE,SUP-2902790,CDM,2720000010,LOCAL,0272,RC,,,,both,,,836.50,543.72,,,,,,,,,,,,,
KIT DRL BIT OD1.8MM DEPTH MEAS DRL GUID FOR 2.4MM SCR,SUP-2225431,CDM,2720000010,LOCAL,0272,RC,,,,both,,,511.82,332.68,,,,,,,,,,,,,
ROD SPNL 5.5 MM DIAM 35 MM LEN POST SMOOTH PRE CVD RT,SUP-2415457,CDM,C1713,HCPCS,0278,RC,,,,both,,,1067.60,693.94,,,,,,,,,,,,,
HALF PIN 5MMX70MM,SUP-2820679,CDM,2720000010,LOCAL,0272,RC,,,,both,,,791.91,514.74,,,,,,,,,,,,,
DRILL ENDOSCP FLX 10 MM CLANCY,SUP-2849120,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3497.80,2273.57,,,,,,,,,,,,,
KIT INSTR SZ 3-4 RAP TRANSLATION SYS,SUP-2242119,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1997.04,1298.08,,,,,,,,,,,,,
GUIDE SURG SZ 03-05 CT MOD SET FOR TOT KNEE ARTHROPLASTY,SUP-2136776,CDM,C1776,CPT,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
SHEATH INTRO FAST-CATH L 40 CM DIA 7 FR GUIDEWIRE 0.038 IN,SUP-2355553,CDM,C1894,HCPCS,0272,RC,,,,both,,,54.95,35.72,,,,,,,,,,,,,
STENT OPHTH L EYE TRABECULAR MIC BYPS ISTNT,SUP-2227949,CDM,C1783,HCPCS,0278,RC,,,,both,,,6201.50,4030.97,,,,,,,,,,,,,
CATHETER GUID MERCI L 80 CM OD 8 FR ID 0.078 IN SS POLYUR,SUP-2367774,CDM,C1887,HCPCS,0272,RC,,,,both,,,3741.00,2431.65,,,,,,,,,,,,,
INSERT TIB CS 4 11 MM KNEE TRIATHLON,SUP-2363730,CDM,C1776,CPT,0278,RC,,,,both,,,4966.38,3228.15,,,,,,,,,,,,,
NAIL IM 3X130 MM RT FIBULAR,SUP-2432019,CDM,C1713,HCPCS,0278,RC,,,,both,,,8374.38,5443.35,,,,,,,,,,,,,
SHELL BPLR OD52MM ID36MM ACET 1 PC GLADIATOR,SUP-2304609,CDM,C1776,CPT,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
PLATE BNE LCK 165 MM RT DSTL LAT HUM PERIARTICULAR 11 HOLE,SUP-2459468,CDM,C1713,HCPCS,0278,RC,,,,both,,,3063.45,1991.24,,,,,,,,,,,,,
PLATE BONE SM L44MM THK1MM CENTRE SPACE 2.5MM 6 H MAND TI,SUP-2191206,CDM,C1713,HCPCS,0278,RC,,,,both,,,1659.49,1078.67,,,,,,,,,,,,,
BIT DRL L30MM DIA2MM FOR VARIAX CLAVICULAR LOK PLT SYS,SUP-2378009,CDM,2720000010,LOCAL,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
ENDCAP RG NAIL,SUP-2316248,CDM,C1713,HCPCS,0278,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
HOOK SPNL SM THORLUM LAM STD BLADE TI XIA II,SUP-2361400,CDM,C1713,HCPCS,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
DRILL PACK 2.8 MM RCG 2 SL STRL T FIX DISP,SUP-2849076,CDM,2720000010,LOCAL,0272,RC,,,,both,,,659.40,428.61,,,,,,,,,,,,,
SPHERE GLEN DIA36MM +3MM OFFSET CO CHROM SHLDR REV SYS,SUP-2404720,CDM,C1776,CPT,0278,RC,,,,both,,,5491.86,3569.71,,,,,,,,,,,,,
STENT PERIPH LIFESTREAM L 58 MM DIA 9 MM CATH L 135 CM,SUP-2128350,CDM,C1874,HCPCS,0278,RC,,,,both,,,7567.40,4918.81,,,,,,,,,,,,,
HC So Quantitative Enzyme Immunoassy,PX-3028631666,CDM,86316,CPT,0302,RC,,,,outpatient,,,177.00,115.05,,,,,,,,,,,,,
KIT CATH HEMODIALYSI RETRO CHRONIC STD 16FR DIA 28CM 23CML I,SUP-2613315,CDM,C1750,HCPCS,0278,RC,,,,both,,,1318.80,857.22,,,,,,,,,,,,,
RING SPNL SZ 2 L22MM DIA17MM 0DEG STD TI FOR MESH,SUP-2256181,CDM,2780000010,LOCAL,0278,RC,,,,both,,,621.72,404.12,,,,,,,,,,,,,
SET CATH HEMODIALYSI ARWGRD BLU BEND ACUTE 12FR DIA 16CM 2LM,SUP-2613340,CDM,C1752,HCPCS,0278,RC,,,,both,,,230.04,149.53,,,,,,,,,,,,,
SET CTRL VEN CATH 5FR L25CM STR J TIP 3MM GWIRE DIA0.035IN,SUP-2167826,CDM,C1751,HCPCS,0278,RC,,,,both,,,87.92,57.15,,,,,,,,,,,,,
BIT DRILL CANN TH SER RELF,SUP-2244048,CDM,2720000010,LOCAL,0272,RC,,,,both,,,737.21,479.19,,,,,,,,,,,,,
GRAFT BNE M TRICORT BLK FOR OSTEOTMY ALLOPURE,SUP-2400550,CDM,C1762,CPT,0278,RC,,,,both,,,5683.40,3694.21,,,,,,,,,,,,,
CATHETER GUID DAC L 125 CM OD 3.9 FR ID 0.038 IN DSTL ACCS,SUP-2367799,CDM,C1887,HCPCS,0272,RC,,,,both,,,3611.00,2347.15,,,,,,,,,,,,,
PLATE BNE L 248 MM SCREW DIA 4.5 MM 15 H PROX HUM NS EVOS,SUP-2931249,CDM,C1713,HCPCS,0278,RC,,,,both,,,11173.69,7262.90,,,,,,,,,,,,,
KIT HAD CATHETER L40CM DIA145FR INSRT L35CM POLYUR NONCOATED,SUP-2126534,CDM,C1750,HCPCS,0278,RC,,,,both,,,1615.53,1050.09,,,,,,,,,,,,,
DEVICE TISS FIX BNE BLOCK ADJ STRL,SUP-2896385,CDM,C1713,HCPCS,0278,RC,,,,both,,,1522.90,989.88,,,,,,,,,,,,,
DEVICE TRACTION DGT TRAP HANDSTAND DISP,SUP-2846768,CDM,2720000010,LOCAL,0272,RC,,,,both,,,847.80,551.07,,,,,,,,,,,,,
NEEDLE ASPIR L10CM NTHRD FOR SPNL CRD STIM,SUP-2419161,CDM,2720000010,LOCAL,0272,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
ENDPLATE SPNL SM W19XL20MM 0DEG ANTR THORLUM TI SYNEX-II,SUP-2182821,CDM,C1713,HCPCS,0278,RC,,,,both,,,3329.03,2163.87,,,,,,,,,,,,,
KD TOMES PRELOADED WITH VISIGLIDE GUIDEWIRES,SUP-2675534,CDM,C1769,HCPCS,0272,RC,,,,both,,,1201.93,781.25,,,,,,,,,,,,,
PLATE EXT FIX L140MM FT DBL H FOR SIDEKCK FRDM CIR FIX,SUP-2400642,CDM,C1713,HCPCS,0278,RC,,,,both,,,3121.16,2028.75,,,,,,,,,,,,,
PLATE BNE CRANIOMAXILLOFACIAL THK08MM 4 H STR PROF MIDFACE,SUP-2262684,CDM,C1713,HCPCS,0278,RC,,,,both,,,430.97,280.13,,,,,,,,,,,,,
PLATE BNE W11XL246MM THK37MM 14 H ST R MED DST TIB S STL LOK,SUP-2185599,CDM,C1713,HCPCS,0278,RC,,,,both,,,5206.81,3384.43,,,,,,,,,,,,,
COUNTERSINK SURG DIA5.5MM HDLSS DISP MONSTER,SUP-2320974,CDM,C1713,HCPCS,0278,RC,,,,both,,,824.25,535.76,,,,,,,,,,,,,
IMPLANT ZIM UNI TIB SZ 3 LFT MED/RT LAT,SUP-2340774,CDM,C1776,CPT,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
DEVICE OCCL CLP L35MM 60DEG HD ARTC DEPLOYMENT LAA EXCLUSION,SUP-2124467,CDM,C1713,HCPCS,0278,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
NAIL IM L 200 MM DIA10 MM CARBON FIBER POLYMER ANK ARTH CANN,SUP-2930815,CDM,C1713,HCPCS,0278,RC,,,,both,,,6325.31,4111.45,,,,,,,,,,,,,
TRIAL BONE PLT 7 H RT LAT TIB BTTRS TC-100 L FRAG SYS,SUP-2343736,CDM,C1713,HCPCS,0278,RC,,,,both,,,6015.46,3910.05,,,,,,,,,,,,,
STENT VASC L12MM BAL L15MM OD7MM DEL SYS L80CM 0.018IN M S,SUP-2159086,CDM,C1877,HCPCS,0278,RC,,,,both,,,2370.70,1540.95,,,,,,,,,,,,,
IMPLANT FACE L 93 X W 75 MM RT COMPLETE ORBIT OCULOPLASTIC,SUP-2883656,CDM,C1713,HCPCS,0278,RC,,,,both,,,14633.47,9511.76,,,,,,,,,,,,,
AUGMENT DPHSEAL SM CONE SYMM STRL EMPOWR,SUP-2929664,CDM,C1776,CPT,0278,RC,,,,both,,,19887.50,12926.87,,,,,,,,,,,,,
ENDRING SPNL W17XL22MM STD GRN TI W LOK SCR FOR VERT BODY,SUP-2193255,CDM,C1889,HCPCS,0278,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
IMPLANT HUM TISS L 21 CM DIA 5-17 MM SZ 17 CM FEM VEIN,SUP-2933021,CDM,C1762,CPT,0278,RC,,,,both,,,15347.32,9975.76,,,,,,,,,,,,,
PATCH CV XENOSURE L 8 X W 6 CM BOV PERICARD BIOLOGIC UNIF,SUP-2217971,CDM,C1768,CPT,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
SET INTRO PERFRMR L 23 CM OD 5 FR ID 1.7 MM GUIDEWIRE L 80,SUP-2168552,CDM,C1894,HCPCS,0272,RC,,,,both,,,110.84,72.05,,,,,,,,,,,,,
COMPONENT TOT SHLDR CAPPED HUM REVERSED 2 INSRT LNR TRAB MEL,SUP-2212305,CDM,C1776,CPT,0278,RC,,,,both,,,15307.50,9949.87,,,,,,,,,,,,,
SCREW BNE L70MM OD7MM PUR HINDFOOT ANK CANN FULL THRD HD,SUP-2320749,CDM,C1713,HCPCS,0278,RC,,,,both,,,1340.78,871.51,,,,,,,,,,,,,
VALVE DRNGE W/ INTEGR PLAS CONN 14CM VENT CATH 120CM DSTL,SUP-2194063,CDM,C1729,HCPCS,0272,RC,,,,both,,,13061.77,8490.15,,,,,,,,,,,,,
STENT BILI L30MM 6FR 135CM CATH LEN 10MM DIAM AD,SUP-2158932,CDM,C2625,HCPCS,0278,RC,,,,both,,,6735.30,4377.94,,,,,,,,,,,,,
PLATE 4.5MM TI LCP TM PROX TIBIA 8H 154MM RIGHT STERILE,SUP-2549637,CDM,C1713,HCPCS,0278,RC,,,,both,,,5070.38,3295.75,,,,,,,,,,,,,
SEMI-TUB PLT STERILIZER 87 MM LENGTH 5 HL,SUP-2818126,CDM,C1713,HCPCS,0278,RC,,,,both,,,508.65,330.62,,,,,,,,,,,,,
PIN FIX L 40 MM DIA2.5 MM PROV SM TARGETER SYS STRL EVOS,SUP-2933910,CDM,C1713,HCPCS,0278,RC,,,,both,,,1591.98,1034.79,,,,,,,,,,,,,
JOINT TOE SUBTALAR 14 MM MBA,SUP-2609514,CDM,C1776,CPT,0278,RC,,,,both,,,6941.63,4512.06,,,,,,,,,,,,,
EXPANDER BRST TISS 350CC W10XH10CM P7CM SIL SMOOTH ULT HI,SUP-2421121,CDM,C1789,HCPCS,0278,RC,,,,both,,,5887.50,3826.87,,,,,,,,,,,,,
SCREW SPNL TULIP HD FOR 5.5MM ROD SPHERX PPS,SUP-2311520,CDM,C1713,HCPCS,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
PSEUDOEPHEDRINE HCL 30 MG PO TABS,RX-6714,CDM,6370000000,HCPCS,0637,RC,00904-5053-59,NDC,,both,1,UN,0.20,0.13,,,,,,,,,,,,,
KNIFE SURG L160MM SHTH,SUP-2284813,CDM,C1713,HCPCS,0278,RC,,,,both,,,1192.92,775.40,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE 4-10 MM 10 CC CANC PROX DSTL END LNG,SUP-2913283,CDM,C1713,HCPCS,0278,RC,,,,both,,,2587.36,1681.78,,,,,,,,,,,,,
PLATE BONE LOK 81MML HLX6 STNLSS STEEL 1/3 TBLR W/CLLR NON S,SUP-2474678,CDM,C1713,HCPCS,0278,RC,,,,both,,,496.78,322.91,,,,,,,,,,,,,
LEAD PACE L65CMXOD5.6FR 21CM SPACE SIL POLYUR TRNSVEN TRUE,SUP-2356670,CDM,C1900,HCPCS,0275,RC,,,,both,,,13345.00,8674.25,,,,,,,,,,,,,
SPLINT FNGR L W1XL18IN ALUMINUM MAL,SUP-2276741,CDM,L3933,HCPCS,0272,RC,,,,both,,,2.92,1.90,,,,,,,,,,,,,
SYSTEM TOT KNEE CEM FEM TIB COMP STD TIB INSRT STD PAT,SUP-2212213,CDM,C1776,CPT,0278,RC,,,,both,,,10362.00,6735.30,,,,,,,,,,,,,
KIT INSTR TRANSTIBIAL CRUCE W/O SAW BLDE DISP,SUP-2121486,CDM,2720000010,LOCAL,0272,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
KIT CATH HEMODIALYSI ZENYSI DL ACUTE 11FR DIA 15CM PCED 2LUM,SUP-2613268,CDM,C1752,HCPCS,0278,RC,,,,both,,,715.14,464.84,,,,,,,,,,,,,
DEVICE PESSARY DSH 2 60 MM W/ SUPP,SUP-2273824,CDM,A4562,HCPCS,0272,RC,,,,both,,,94.45,61.39,,,,,,,,,,,,,
SCREW BNE CANN 4X22 MM COMPR FT TI NS,SUP-2788078,CDM,C1713,HCPCS,0278,RC,,,,both,,,858.85,558.25,,,,,,,,,,,,,
DEFIBRILLATOR IMPL PHOTON DR TI POLYUR SIL 2 CHMBR IS1/DF1,SUP-2357751,CDM,C1721,HCPCS,0275,RC,,,,both,,,54086.50,35156.22,,,,,,,,,,,,,
BUR SURG L9CM DIA3MM MTCH HD FLUT L BOR MIDAS REX LEGEND,SUP-2284664,CDM,2720000010,LOCAL,0272,RC,,,,both,,,337.64,219.47,,,,,,,,,,,,,
PLATE BNE L458MM 22 H ST L CNDYL S STL LOK COMPR CRV FOR,SUP-2177087,CDM,C1713,HCPCS,0278,RC,,,,both,,,5193.21,3375.59,,,,,,,,,,,,,
BUR SURG DIA1.4 MM HUB II ROSEN STRL REUSE HI-LINE,SUP-2929495,CDM,2720000010,LOCAL,0272,RC,,,,both,,,339.81,220.88,,,,,,,,,,,,,
ROD EXT FIX THRD 60 MM FOR SM BNE SHFT FIX SS,SUP-2525826,CDM,2720000010,LOCAL,0272,RC,,,,both,,,653.12,424.53,,,,,,,,,,,,,
SPACER SPNL 37X16X8MM 6DEG LORDTC LO PROF PEEK CERV BCNVX,SUP-2354683,CDM,C1821,HCPCS,0278,RC,,,,both,,,22356.80,14531.92,,,,,,,,,,,,,
PLATE BNE CONN 5 HOLE NS,SUP-2799567,CDM,C1713,HCPCS,0278,RC,,,,both,,,337.42,219.32,,,,,,,,,,,,,
DRILL CANN 4.5X90MM A/O SHFT,SUP-2321241,CDM,2720000010,LOCAL,0272,RC,,,,both,,,741.04,481.68,,,,,,,,,,,,,
INSERT TIB L L75MM THK15MM AP46MM L MED LAT ARTC CRUCE RET,SUP-2344101,CDM,C1776,CPT,0278,RC,,,,both,,,3436.73,2233.87,,,,,,,,,,,,,
GUIDEWIRE VASC L 50 CM DIA 0.021 IN CRV RAD 2 MM STR CRV DBL,SUP-2760070,CDM,C1769,HCPCS,0272,RC,,,,both,,,134.67,87.54,,,,,,,,,,,,,
CATHETER GUID VISTA BRT TIP L 90 CM OD 6 FR ID 0.067 IN NYL,SUP-2158731,CDM,C1887,HCPCS,0272,RC,,,,both,,,431.75,280.64,,,,,,,,,,,,,
PANITUMUMAB 20 MG/ML IV SOLN (MIXTURES ONLY),RX-1150401,CDM,J9303,HCPCS,0636,RC,55513-0956-01,NDC,,both,20,ML,20870.30,13565.69,,,,,,,,,,,,,
SCREW BONE TI FEM KNEE REV IMP ASCNT,SUP-2406978,CDM,C1713,HCPCS,0278,RC,,,,both,,,438.03,284.72,,,,,,,,,,,,,
CATHETER HD SYMMETRICAL 14.5 FRX19 CM TAL KT PALINDROMIC,SUP-2174233,CDM,C1881,HCPCS,0278,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
CATHETER HD STR 9 FRX15 CM SHT TERM DL TAPR TIP DUOFLO,SUP-2627401,CDM,C1752,HCPCS,0278,RC,,,,both,,,139.73,90.82,,,,,,,,,,,,,
SET SCR SPNL DIA6.35MM IL TI HEX BRK OFF CDH SOLERA,SUP-2288547,CDM,C1713,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
LIDOCAINE 5 % EX PTCH,RX-28203,CDM,6370000000,HCPCS,0637,RC,00591-3525-30,NDC,,both,1,UN,13.50,8.77,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED UPCHARGE PRIMARY STEM MOD NK,SUP-2212695,CDM,C1776,CPT,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
CATHETER CV 1 LUMEN 3 FR VLV MAX BARR NURSING KT BIOFLO,SUP-2734866,CDM,C1751,HCPCS,0278,RC,,,,both,,,149.46,97.15,,,,,,,,,,,,,
HC Ot Therapeutic Activities 15 Min|DOCUMENTATION ON FILE|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS,PX-4309753000,CDM,97530,CPT,0430,RC,,,KX|CQ,both,,,144.00,93.60,,,,,,,,,,,,,
GUIDEWIRE ENDO L150CM DIA0.038IN TIP L3CM NIT COR HYDRPHLC,SUP-2169840,CDM,C1769,HCPCS,0272,RC,,,,both,,,105.41,68.52,,,,,,,,,,,,,
SCREW BNE L28MM OD4.5MM STD CORT ST N LOK,SUP-2342653,CDM,C1713,HCPCS,0278,RC,,,,both,,,26.28,17.08,,,,,,,,,,,,,
PROGRAMMER NEUROSTIMULATOR PT HND HELD CA WR STRP BTTRY FOR,SUP-2279560,CDM,C1787,HCPCS,0278,RC,,,,both,,,3736.60,2428.79,,,,,,,,,,,,,
GOUGE SPNL RND KNURLED HNDL STR CRV 11IN COBB,SUP-2244790,CDM,C1713,HCPCS,0278,RC,,,,both,,,312.15,202.90,,,,,,,,,,,,,
PLATE BNE CHIN 1.7X4 MM 6 HOLE PRE-BENT ADV GLD NS LTX,SUP-2862767,CDM,C1713,HCPCS,0278,RC,,,,both,,,686.69,446.35,,,,,,,,,,,,,
KIT VAG BALLOON ALATUS HDR BRACHYTHERAPY DEL 2 ATTACH,SUP-2752567,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
BUR SURG STD LNG 100 K 2 MM HI SPD HNDPC STRL UNIDRIVE DISP,SUP-2599315,CDM,2720000010,LOCAL,0272,RC,,,,both,,,657.36,427.28,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 3X3 CM CRYOPRESERVED UMB CRD NEOX CRD 1K,SUP-2648686,CDM,Q4148,HCPCS,0636,RC,,,,both,,,3180.82,2067.53,,,,,,,,,,,,,
GRAFT BNE SUB 5CC CA SULF HI STRENGTH INJ RESRB MIIG X3,SUP-2399046,CDM,C1713,HCPCS,0278,RC,,,,both,,,5451.42,3543.42,,,,,,,,,,,,,
NEEDLE VENTRICULAR CONE 17 GAX3.5 IN 2 HOLE LUER LCK HUB,SUP-2666367,CDM,2720000010,LOCAL,0272,RC,,,,both,,,492.51,320.13,,,,,,,,,,,,,
GUIDEWIRE ORTH L220MM DIA1.6MM S STL FULL THRD TRCR PNT,SUP-2184962,CDM,C1769,HCPCS,0272,RC,,,,both,,,92.16,59.90,,,,,,,,,,,,,
PEG BONE FIX 15MM ACET REFECTION,SUP-2351123,CDM,C1776,CPT,0278,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
CROWN DENT 1 PEDIATRIC CTRL,SUP-2119367,CDM,D6783,CPT,0278,RC,,,,both,,,56.36,36.63,,,,,,,,,,,,,
CATHETER EP DAO-1 2-5-2 5 FRX120 CM SUPREME,SUP-2537995,CDM,C1730,HCPCS,0272,RC,,,,both,,,386.22,251.04,,,,,,,,,,,,,
SCREW SPNL L11MM DIA3.5MM ANT CERV SELF DRL F/ STD ALONE 2PK,SUP-2293581,CDM,C1713,HCPCS,0278,RC,,,,both,,,828.96,538.82,,,,,,,,,,,,,
ENDOPROSTHESIS TRACHBRONCH FLUENCY + L 40 MM DIA 8 MM CATH L,SUP-2128286,CDM,C1874,HCPCS,0278,RC,,,,both,,,6264.30,4071.79,,,,,,,,,,,,,
GUSELKUMAB 200 MG/20ML IV SOLN,RX-169243,CDM,J1628,HCPCS,0636,RC,57894-0650-01,NDC,,both,20,ML,83757.10,54442.11,,,,,,,,,,,,,
GUAIFENESIN-CODEINE 100-10 MG/5ML PO SOLN,RX-79088,CDM,340b,HCPCS,0637,RC,00121-1775-40,NDC,,both,5,ML,15.20,9.88,,,,,,,,,,,,,
GRAFT 1CC DBM GEL ALLOFUSE,SUP-2415844,CDM,C1713,HCPCS,0278,RC,,,,both,,,546.36,355.13,,,,,,,,,,,,,
CATHETER CV FULL SAFETY TY 032 7 FRX15 CM 13 GA 3L SPECTRUM,SUP-2759868,CDM,C1751,HCPCS,0278,RC,,,,both,,,476.62,309.80,,,,,,,,,,,,,
GENERATOR NEUROSTIM SPNL CRD PLSE STIM SYS PRECISION PLUS,SUP-2138775,CDM,C1820,HCPCS,0278,RC,,,,both,,,43960.00,28574.00,,,,,,,,,,,,,
PLATE BNE H1MM 16 H MAND BLU TI MINI STR COND LOK LEIBINGER,SUP-2366344,CDM,C1713,HCPCS,0278,RC,,,,both,,,1251.35,813.38,,,,,,,,,,,,,
PLATE BONE L 6 H GAP LO PROF FOR 1.5MM SCR CRAN FIX SYS UNIV,SUP-2363640,CDM,C1713,HCPCS,0278,RC,,,,both,,,1148.11,746.27,,,,,,,,,,,,,
BUTTON FIX 14MM ACL PCL FOR SFT TISS BNE TEND ENDOBTTN,SUP-2341303,CDM,C1713,HCPCS,0278,RC,,,,both,,,227.12,147.63,,,,,,,,,,,,,
DRILL SURG 2.4X9 MM CALCANEAL INBONE,SUP-2850353,CDM,2720000010,LOCAL,0272,RC,,,,both,,,430.18,279.62,,,,,,,,,,,,,
FREECLIMB 70 132CM REPERFUSION SYSTEMFC70 TENZING 7,SUP-2878099,CDM,C1887,HCPCS,0272,RC,,,,both,,,15386.00,10000.90,,,,,,,,,,,,,
CONNECTOR SPNL TI SIDE BY SIDE ROD TO ROD FOR 5.5MM ROD,SUP-2254576,CDM,C1713,HCPCS,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
PLATE BNE SZ 2 L45MM 10DEG 5 H L C SHP FOR HALLU LOCK MTP,SUP-2243425,CDM,C1713,HCPCS,0278,RC,,,,both,,,4550.61,2957.90,,,,,,,,,,,,,
ADAPTER EARTIP SANIBEL INFANT,SUP-2719738,CDM,2720000010,LOCAL,0272,RC,,,,both,,,116.49,75.72,,,,,,,,,,,,,
STENT NEURO ENTRP 2 L 30MM 4FR MICROCATHETER 0.021IN NO DSTL,SUP-2498179,CDM,C1876,HCPCS,0278,RC,,,,both,,,28918.83,18797.24,,,,,,,,,,,,,
SNARE ENDOSCP WIRE 6 FRX6-10 MMX120 CM VASC RETRV,SUP-2120087,CDM,C1773,HCPCS,0272,RC,,,,both,,,1083.30,704.14,,,,,,,,,,,,,
CATHETER ART STD 0.025 IN 7.5 FRX110 CM 5 LUMEN WDG/SL,SUP-2798496,CDM,C1727,CPT,0278,RC,,,,both,,,155.78,101.26,,,,,,,,,,,,,
COLLAR CERV L H3XL18IN COT M DENS FOAM BRTH ADJ LO-CONTOUR,SUP-2335995,CDM,L0120,HCPCS,0274,RC,,,,both,,,17.68,11.49,,,,,,,,,,,,,
COIL NEUROVASCULAR HYPERSOFT L 1 CM LOOP DIA1.5 MM,SUP-2305389,CDM,C1889,HCPCS,0278,RC,,,,both,,,3893.60,2530.84,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED CEM HI FLX M HXLPE,SUP-2212706,CDM,C1776,CPT,0278,RC,,,,both,,,11991.69,7794.60,,,,,,,,,,,,,
DRAINAGE SET STD INTEGR 1 PC M LL CONN TUBE ADJ CLP EXAFLOW,SUP-2666668,CDM,2720000010,LOCAL,0272,RC,,,,both,,,320.41,208.27,,,,,,,,,,,,,
STENT BILI E-LUMINEXX L 20 MM DIA 5 MM CATH L 135 CM DIA 6,SUP-2128906,CDM,C1876,HCPCS,0278,RC,,,,both,,,2747.50,1785.87,,,,,,,,,,,,,
NAIL IM CANN LNG 210 MM FOR PELV C-CLAMP II SS NS,SUP-2799343,CDM,C1713,HCPCS,0278,RC,,,,both,,,1414.85,919.65,,,,,,,,,,,,,
DEVICE RESECTING SZ 3.9 MM STRL DISP AVETA MAX,SUP-2914489,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
GUIDEWIRE VASC WORKER L 260CM 0.035IN 6.5CM 3.5CM AMPLTZ STR,SUP-2876077,CDM,C1769,HCPCS,0272,RC,,,,both,,,255.91,166.34,,,,,,,,,,,,,
ANCHOR SUT DIA6.5MM 2 ERGO HNDL LSR BND W/O NDL DBL END HA,SUP-2366673,CDM,C1713,HCPCS,0278,RC,,,,both,,,1604.54,1042.95,,,,,,,,,,,,,
STEM FEM STD OFFSET 11-14 W/ TRUNNION MALLORY-HEAD XR SER,SUP-2442622,CDM,C1776,CPT,0278,RC,,,,both,,,791.28,514.33,,,,,,,,,,,,,
CATHETER ETER EP 6FR L115CM 2 2 2MM SPC STABILENE OCTAPOLAR FIX,SUP-2142594,CDM,C1730,HCPCS,0272,RC,,,,both,,,690.80,449.02,,,,,,,,,,,,,
PLATE BNE L157MM 8 H S STL LOK COMPR FOR 4.5MM SCR PERI-LOC,SUP-2348942,CDM,C1713,HCPCS,0278,RC,,,,both,,,4888.51,3177.53,,,,,,,,,,,,,
SCREW HD 6.5MMX35MMX16 DARCO,SUP-2401066,CDM,C1713,HCPCS,0278,RC,,,,both,,,1299.96,844.97,,,,,,,,,,,,,
SCREW BNE HIP 6.5X105 MM RECON THRD STRL TUBE FRNADVANCED,SUP-2789376,CDM,C1713,HCPCS,0278,RC,,,,both,,,620.46,403.30,,,,,,,,,,,,,
PLATE BNE L195MM THK3.7MM 15 H BILAT S STL STR LO PROF RIG,SUP-2177147,CDM,C1713,HCPCS,0278,RC,,,,both,,,2737.95,1779.67,,,,,,,,,,,,,
IMPLANT SLNG SWVL SCR 39CM POLY SUT,SUP-2140291,CDM,C1713,HCPCS,0278,RC,,,,both,,,1416.93,921.00,,,,,,,,,,,,,
PLATE EXT FIX 115MM 10 H SH FOR ILIZ,SUP-2340711,CDM,C1713,HCPCS,0278,RC,,,,both,,,1373.66,892.88,,,,,,,,,,,,,
MESH SURG W7XL10CM SEPRA TECHNOLOGY RECT PHASIX,SUP-2125881,CDM,C1781,HCPCS,0278,RC,,,,both,,,4176.20,2714.53,,,,,,,,,,,,,
HC Arthrogram Wrist S&I,PX-3227311500,CDM,73115,CPT,0322,RC,,,,inpatient,,,601.00,390.65,,,,,,,,,,,,,
STENT TRACHBRONCH L 80 MM DIA20 MM CATH L 95 CM DIA16 FR,SUP-2148910,CDM,C1883,HCPCS,0278,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
CATHETER PICC L55CM OD6FR 3 LUMN N COAT N CT COMPATIBLE PWR,SUP-2118838,CDM,C1751,HCPCS,0278,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
PATCH VASC VASCU-GUARD L 9 X W 2 CM BOV PERICARD FOR CARTOID,SUP-2130384,CDM,C1768,CPT,0278,RC,,,,both,,,1090.43,708.78,,,,,,,,,,,,,
HANDPIECE ASPIR EXTRUSION 1.5 MM 23 GAX6.1 IN SFT TIP CANN,SUP-2493889,CDM,2720000010,LOCAL,0272,RC,,,,both,,,867.43,563.83,,,,,,,,,,,,,
GRAFT BONE SUB 5ML CA PHOS FIL VOID CEM NORIAN CRS,SUP-2193980,CDM,C1713,HCPCS,0278,RC,,,,both,,,5177.86,3365.61,,,,,,,,,,,,,
GUIDEWIRE VASC L300CM DIA0.018IN TIP L8CM STR TIP POLY V-18,SUP-2148249,CDM,C1769,HCPCS,0272,RC,,,,both,,,279.46,181.65,,,,,,,,,,,,,
PLATE BNE COMPR 60 DEG 2.3X35X2.3 MM MAND 6 HOLE TI LEVEL 1,SUP-2490319,CDM,C1713,HCPCS,0278,RC,,,,both,,,1212.45,788.09,,,,,,,,,,,,,
SEGMENTAL ART SURF SZ C 17MM,SUP-2502390,CDM,C1776,CPT,0278,RC,,,,both,,,5736.78,3728.91,,,,,,,,,,,,,
HC MRI Breast W/O Contrast Bilateral,PX-6107704700,CDM,77047,CPT,0610,RC,,,,inpatient,,,5019.00,3262.35,,,,,,,,,,,,,
ENDOPROSTHESIS VASC EXCLUDER L 4.5 CM DIA23 MM SHTH 15 FR,SUP-2737994,CDM,C1768,CPT,0278,RC,,,,both,,,13162.88,8555.87,,,,,,,,,,,,,
CATHETER HD STR 11.5 FRX15 CM SHT TERM DL TAPR SIL HEMCATH,SUP-2627302,CDM,C1752,HCPCS,0278,RC,,,,both,,,34.54,22.45,,,,,,,,,,,,,
NUT BONE 13.8MM SPINE HEX TI LCK,SUP-2415519,CDM,C1713,HCPCS,0278,RC,,,,both,,,677.86,440.61,,,,,,,,,,,,,
ELECTRODE MONOPOLAR L HK 3.5 MMX20 CM FOR HNDL GN230,SUP-2852497,CDM,2720000010,LOCAL,0272,RC,,,,both,,,381.57,248.02,,,,,,,,,,,,,
ALLOGRAFT BNE CERV 4.75X6.22 MM LORDTC VERTIGRAFT VG2,SUP-2264651,CDM,C1889,HCPCS,0278,RC,,,,both,,,3124.30,2030.79,,,,,,,,,,,,,
SUMATRIPTAN SUCCINATE 6 MG/0.5ML SC SOLN,RX-97253,CDM,6370000000,HCPCS,0637,RC,63323-0273-01,NDC,,both,0.5,ML,281.80,183.17,,,,,,,,,,,,,
FILTER VASC EMBOL-X ID 32-35 MM LG POLYESTER MESH DURAFLO,SUP-2214503,CDM,C1884,HCPCS,0278,RC,,,,both,,,1065.87,692.82,,,,,,,,,,,,,
GRAFT BONE 3-6MM 30ML CANC CHIP FRZ DRY,SUP-2294036,CDM,C1713,HCPCS,0278,RC,,,,both,,,1039.34,675.57,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH FLX L 56 MM DIA16 MM SHTH 16 FR SS,SUP-2170645,CDM,C1874,HCPCS,0278,RC,,,,both,,,9686.90,6296.48,,,,,,,,,,,,,
SUPPORT ORTHOT LOWER EXTREMITY CUST FT PLATE STIRRUP ATTCH,SUP-2435655,CDM,L2250,HCPCS,0272,RC,,,,both,,,945.67,614.69,,,,,,,,,,,,,
HC Remove Impacted Cerumen,PX-4506921000,CDM,69210,CPT,0450,RC,,,,both,,,195.00,126.75,,,,,,,,,,,,,
COMPONENT GLEN OD46MM 40MM SURF MTL SHLDR TRABECULAR SIDUS,SUP-2199086,CDM,C1776,CPT,0278,RC,,,,both,,,4634.64,3012.52,,,,,,,,,,,,,
SCREW INTFR L20MM DIA7MM VENT BIOCOMPOSITE,SUP-2121791,CDM,C1713,HCPCS,0278,RC,,,,both,,,926.30,602.09,,,,,,,,,,,,,
SUBSTITUTE BNE GRFT 10ML DBM PTTY ST IMPL DYNAGRFT II,SUP-2242679,CDM,C9359,HCPCS,0278,RC,,,,both,,,2875.74,1869.23,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA MAXBARR 5FR 55CM S3395108D,SUP-2632853,CDM,C1751,HCPCS,0278,RC,,,,both,,,713.50,463.77,,,,,,,,,,,,,
FILLER SCR BONE H DIA4.5MM S STL PERI-LOC,SUP-2351135,CDM,C1713,HCPCS,0278,RC,,,,both,,,1035.57,673.12,,,,,,,,,,,,,
SCREW BNE L 30 MM DIA 6.5 MM SS ST SD CANN FULL THRD RVS CUT,SUP-2900958,CDM,C1713,HCPCS,0278,RC,,,,both,,,1001.50,650.97,,,,,,,,,,,,,
HC Spinal Puncture Lumbar Diagnos,PX-4506227000,CDM,62270,CPT,0450,RC,,,,inpatient,,,2232.00,1450.80,,,,,,,,,,,,,
HC Spinal Puncture Lumbar Diagnos,PX-4506227000,CDM,62270,CPT,0450,RC,,,,outpatient,,,2232.00,1450.80,,,,,,,,,,,,,
SUPPORT ORTHOT KNEE CUST W/ADJACENT JT ROT CNTRL MOLD,SUP-2435613,CDM,L1844,LOCAL,0272,RC,,,,both,,,4311.38,2802.40,,,,,,,,,,,,,
SHUNT PERI REG W SNAP RESVR PROGRAMMABLE VENTCULSTMY CSF,SUP-2277983,CDM,2720000010,LOCAL,0272,RC,,,,both,,,14729.14,9573.94,,,,,,,,,,,,,
HC Arterial Line Insertion,PX-3613662000,CDM,36620,CPT,0361,RC,,,,both,,,789.00,512.85,,,,,,,,,,,,,
HC Coagulation Time Activated,PX-3058534700,CDM,85347,CPT,0305,RC,,,,both,,,143.00,92.95,,,,,,,,,,,,,
PLATE BONE L142MM BLDE W5.8XL38MM 150DEG 8 H STRL BILAT PELV,SUP-2186698,CDM,C1713,HCPCS,0278,RC,,,,both,,,1946.80,1265.42,,,,,,,,,,,,,
CATHETER LD DEL ATTAIN LDS L 45 CM OD 9 FR ID 7.2 FR LT,SUP-2282151,CDM,C1893,HCPCS,0272,RC,,,,both,,,1645.80,1069.77,,,,,,,,,,,,,
PLATE BNE L177MM 10 H NONSTERILE L PROX TIB S STL VAR ANG,SUP-2184331,CDM,C1713,HCPCS,0278,RC,,,,both,,,5383.40,3499.21,,,,,,,,,,,,,
SCREW BNE L14MM DIA2.7MM DST VOLAR RAD NONLOCKING FULL THRD,SUP-2411803,CDM,C1713,HCPCS,0278,RC,,,,both,,,189.97,123.48,,,,,,,,,,,,,
PIN 5MMX180MM HALF ORTH RECON,SUP-2342846,CDM,C1713,HCPCS,0278,RC,,,,both,,,1340.15,871.10,,,,,,,,,,,,,
PLATE BONE STRAIGHT 2 MM 4 HOLE STAINLESS STEEL STERILE TC10,SUP-2836684,CDM,C1713,HCPCS,0278,RC,,,,both,,,450.78,293.01,,,,,,,,,,,,,
COLLAR CERV 2 PC SM AD 10-20X2 IN ADJ EMS MIAMI J PLAS FOAM,SUP-2247597,CDM,L0190,HCPCS,0274,RC,,,,both,,,174.84,113.65,,,,,,,,,,,,,
SYSTEM THERMOABLATION COBRA ADHEREXL SURG ASMBLY STRL,SUP-2124413,CDM,C1713,HCPCS,0278,RC,,,,both,,,16956.00,11021.40,,,,,,,,,,,,,
PLATE BNE L45-55MM TROCHANTERIC HIP MALLORY-HEAD TI POR,SUP-2403612,CDM,C1776,CPT,0278,RC,,,,both,,,1384.74,900.08,,,,,,,,,,,,,
SPLINT HND M ULN DEVIATION RT NEOPRNE WRP ARND W/ THMB H ADJ,SUP-2324909,CDM,L3906,HCPCS,0272,RC,,,,both,,,28.01,18.21,,,,,,,,,,,,,
NEEDLE SUTURE KNOTLESS IMPL SYS MULTFI SWIVELOCK C SCORPION,SUP-2845509,CDM,C1713,HCPCS,0278,RC,,,,both,,,6751.00,4388.15,,,,,,,,,,,,,
COMPONENT PAT RESURF CUST IDUO RT MEDL,SUP-2165959,CDM,C1776,CPT,0278,RC,,,,both,,,21352.00,13878.80,,,,,,,,,,,,,
GUIDEWIRE URO L150CM DIA0.038IN TIP L3CM STR FLX TIP DISP,SUP-2313744,CDM,C1769,HCPCS,0272,RC,,,,both,,,150.69,97.95,,,,,,,,,,,,,
HC Plmt Access Bil Tree Sm Bwl,PX-3614754100,CDM,47541,CPT,0361,RC,,,,inpatient,,,6875.00,4468.75,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL PEEK SD800.527,SUP-2860208,CDM,C1713,HCPCS,0278,RC,,,,both,,,34662.46,22530.60,,,,,,,,,,,,,
PLATE BNE THK 2.6 MM 24 H TI STR NS DISP TRAUMAONE,SUP-2936182,CDM,C1713,HCPCS,0278,RC,,,,both,,,7994.44,5196.39,,,,,,,,,,,,,
TRAY INTRO PERC UNIV STRL,SUP-2876581,CDM,C1894,HCPCS,0272,RC,,,,both,,,213.52,138.79,,,,,,,,,,,,,
MESH CRAN CUSTOMIZED XL KT STRL MEDPOR LTX,SUP-2862741,CDM,C1713,HCPCS,0278,RC,,,,both,,,65097.04,42313.08,,,,,,,,,,,,,
OLECR PLATE RT 21H 194MM,SUP-2588823,CDM,C1713,HCPCS,0278,RC,,,,both,,,3455.26,2245.92,,,,,,,,,,,,,
PLATE BNE L 100 DEG XLN 1.5 MM RT 3X3 HOLE LORENZ,SUP-2402869,CDM,C1713,HCPCS,0278,RC,,,,both,,,496.43,322.68,,,,,,,,,,,,,
KIT GASTROSTMY L25CM OD16FR UTHANE 6 SIDEPRT RADPQ CATHETER,SUP-2167776,CDM,C1729,HCPCS,0272,RC,,,,both,,,259.02,168.36,,,,,,,,,,,,,
GRAFT BONE SUB 2-5MM 30ML MORSELIZED CANC CORT SPIERING,SUP-2307426,CDM,C1713,HCPCS,0278,RC,,,,both,,,3207.35,2084.78,,,,,,,,,,,,,
MARKER SKIN PREP ULTRA FN TIP RESIST INK STRL MINI XL DISP,SUP-2718590,CDM,C1713,HCPCS,0278,RC,,,,both,,,3.01,1.96,,,,,,,,,,,,,
SCREW INTFR L20MM DIA7MM KNEE PLLA HA BIOABSRB FOR ACL PCL,SUP-2341562,CDM,C1713,HCPCS,0278,RC,,,,both,,,762.61,495.70,,,,,,,,,,,,,
BIT DRL DIA5MM CANN QUIK CONN,SUP-2409880,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1547.39,1005.80,,,,,,,,,,,,,
STEM FEM STD OFFSET CERAMIC STR CEMENTLESS IMPL SZ 12,SUP-2390361,CDM,C1776,CPT,0278,RC,,,,both,,,8478.00,5510.70,,,,,,,,,,,,,
ALLOGRAFT BNE CHIP 1-8 MM 10 CC PRESERVON CANC READIGRAFT,SUP-2741066,CDM,C1713,HCPCS,0278,RC,,,,both,,,377.11,245.12,,,,,,,,,,,,,
BODY RAD W15XH7MM 7.5MM LT WR MAESTRO,SUP-2407292,CDM,C1776,CPT,0278,RC,,,,both,,,6116.72,3975.87,,,,,,,,,,,,,
CATHETER ANGIOPLSTY BIB L 110 CM DIA 8 FR BALLOON L 3.5 CM,SUP-2309671,CDM,C1725,HCPCS,0272,RC,,,,both,,,2543.40,1653.21,,,,,,,,,,,,,
GRAFT DURA STRP 3X1 IN DURA REGEN MTRX DURAGN +,SUP-2427678,CDM,C1763,HCPCS,0278,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
CANCL BONE SCW Ti 6.5MMX30MM FULLY THREADED,SUP-2508850,CDM,C1713,HCPCS,0278,RC,,,,both,,,109.90,71.43,,,,,,,,,,,,,
ANCHOR BNE 3 W/ ARTHSCP DEL SYS REGENETEN,SUP-2341376,CDM,C1713,HCPCS,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
COMPONENT ARTC 3X2MM OFFSET PATELLOFEMORAL HEMICAP,SUP-2123661,CDM,C1776,CPT,0278,RC,,,,both,,,14973.72,9732.92,,,,,,,,,,,,,
TRAY CATH HEMODIALYSI SFT LN ACTE 11.5FR DIA 20CM IN T118IJ2,SUP-2633028,CDM,C1752,HCPCS,0278,RC,,,,both,,,254.34,165.32,,,,,,,,,,,,,
PLATE BNE THK2MM 26 H TI L LOK ANG MINI FOR 23MM SCR,SUP-2262973,CDM,C1713,HCPCS,0278,RC,,,,both,,,5034.93,3272.70,,,,,,,,,,,,,
KNEE IMMOB 22IN QUAL + S,SUP-2195531,CDM,L1830,CPT,0274,RC,,,,both,,,46.66,30.33,,,,,,,,,,,,,
HOOK RETRCT GREENBERG STRL DISP BRAINPATH SHEPHARD'S,SUP-2930207,CDM,2720000010,LOCAL,0272,RC,,,,both,,,430.05,279.53,,,,,,,,,,,,,
GUIDEWIRE VASC AQUALINER 260CM 0.038IN TIP 3CM STR STIFF,SUP-2117149,CDM,C1769,HCPCS,0272,RC,,,,both,,,169.56,110.21,,,,,,,,,,,,,
GRAFT BNE LG,SUP-2424567,CDM,C1713,HCPCS,0278,RC,,,,both,,,5834.12,3792.18,,,,,,,,,,,,,
TAPESTERY RC BIOINTEGRATIVE 30X20 MM ANTR LF,SUP-2867245,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3862.20,2510.43,,,,,,,,,,,,,
ELECTRODE ES LAP 5MM DIA 37CML BALL TIP STRGHT HNDLE CGLTNG,SUP-2675721,CDM,2720000010,LOCAL,0272,RC,,,,both,,,681.32,442.86,,,,,,,,,,,,,
SET CATH HEMODIALYSI TRI FLO ACTE BSC 11.5FR DIA 15CM STRGHT,SUP-2610549,CDM,C1752,HCPCS,0278,RC,,,,both,,,185.26,120.42,,,,,,,,,,,,,
GUIDEWIRE VASC L150CM DIA0.035IN L15CM STR TIP PTFE HEP S,SUP-2148295,CDM,C1769,HCPCS,0272,RC,,,,both,,,46.16,30.00,,,,,,,,,,,,,
KIT EXT REAR TIP PENILE PROS SNAPCONE,SUP-2138944,CDM,C1813,HCPCS,0278,RC,,,,both,,,1254.43,815.38,,,,,,,,,,,,,
GRAFT BNE FEM,SUP-2264894,CDM,C1762,CPT,0278,RC,,,,both,,,9592.89,6235.38,,,,,,,,,,,,,
IMPLANT BIO TISS W18 25XL300MM THCK CLLGN DERM MTRX XENMTRX,SUP-2126245,CDM,C1781,HCPCS,0278,RC,,,,both,,,83692.62,54400.20,,,,,,,,,,,,,
ANCHOR SUTURE 2 2.9 MM 1 ULTRABRAID II BLU OSTEORAPTOR,SUP-2849145,CDM,C1713,HCPCS,0278,RC,,,,both,,,970.26,630.67,,,,,,,,,,,,,
KIT EEG ELECTRD L 33.5 MM 10 CONTACT STRL DISP EVO,SUP-2936623,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3209.08,2085.90,,,,,,,,,,,,,
BLADE RETRCT W2XL4CM NAR MUSC REUSE MCCULLOCH,SUP-2161007,CDM,2720000010,LOCAL,0272,RC,,,,both,,,398.21,258.84,,,,,,,,,,,,,
MESH HERN W3XL8IN POLY-4-HYDROXYBUTYRATE SYN RECT WVN,SUP-2125877,CDM,C1781,HCPCS,0278,RC,,,,both,,,9350.92,6078.10,,,,,,,,,,,,,
SCREW BNE L10MM DIA35MM CORT TAN ST T15 STARDRV RECESS SM,SUP-2181064,CDM,C1713,HCPCS,0278,RC,,,,both,,,75.45,49.04,,,,,,,,,,,,,
PLATE BNE SM L58MM 5 H BILAT S STL LO PROF RIG LIMIT CNTCT,SUP-2186224,CDM,C1713,HCPCS,0278,RC,,,,both,,,1158.82,753.23,,,,,,,,,,,,,
PLATE BONE W5XL32MM THK1MM 0DEG 6 H BILAT S STL STR RIG DYN,SUP-2186164,CDM,C1713,HCPCS,0278,RC,,,,both,,,587.34,381.77,,,,,,,,,,,,,
BLADE SAW L 7.3 MM D 30 MM THK MATERIAL 0.6 MM CUT 0.7 MM,SUP-2928829,CDM,2720000010,LOCAL,0272,RC,,,,both,,,385.40,250.51,,,,,,,,,,,,,
SET URET STENT SOFFLX L 70 CM DIA 7.2FR GUIDEWIRE L 145CM LT,SUP-2835687,CDM,C2617,HCPCS,0278,RC,,,,both,,,192.39,125.05,,,,,,,,,,,,,
BLADE SCRDRVR ASSEMB W/ GRSP SL FOR MAND FX,SUP-2364413,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3111.36,2022.38,,,,,,,,,,,,,
AID HEARING SM 31.5 CM NS BAHA LTX,SUP-2858120,CDM,L8690,HCPCS,0278,RC,,,,both,,,151.19,98.27,,,,,,,,,,,,,
KIT BONE GRFT 3CC CANN L120MM NDL 11GA FT ANK FOR,SUP-2208437,CDM,C1776,CPT,0278,RC,,,,both,,,8635.00,5612.75,,,,,,,,,,,,,
CATHETER REPROC 8FRX110CM DIAG ACUNAV,SUP-2255864,CDM,C1759,HCPCS,0272,RC,,,,both,,,9106.00,5918.90,,,,,,,,,,,,,
ENDOPROSTHESIS VASC VIABAHN L 25CM 6MM 120CM 6FR RADIOPAQUE,SUP-2396650,CDM,C1874,HCPCS,0278,RC,,,,both,,,22717.90,14766.63,,,,,,,,,,,,,
BEARING TIB 10X67 MM POST STBL MAXM VI ARCM,SUP-2441597,CDM,C1776,CPT,0278,RC,,,,both,,,2712.96,1763.42,,,,,,,,,,,,,
HC Inj for Si Joint Therapeutic,PX-3610026000,CDM,G0260,CPT,0361,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
HC Aspir &/or Inject of Renal Cys,PX-3615039000,CDM,50390,CPT,0361,RC,,,,inpatient,,,3707.00,2409.55,,,,,,,,,,,,,
NAIL GAM 3 TI RT 125DEG 15X440MM ST,SUP-2701718,CDM,C1713,HCPCS,0278,RC,,,,both,,,8077.65,5250.47,,,,,,,,,,,,,
PLATE BNE L164MM 90DEG 8 H SUPCNDYL BILAT S STL TB STD BRL,SUP-2342590,CDM,C1713,HCPCS,0278,RC,,,,both,,,5177.86,3365.61,,,,,,,,,,,,,
HC Aspir &/or Inject of Renal Cys,PX-3615039000,CDM,50390,CPT,0361,RC,,,,outpatient,,,3707.00,2409.55,,,,,,,,,,,,,
HC So Vip(Vasoact.Intest.Polypept.),PX-3018458666,CDM,84586,CPT,0301,RC,,,,inpatient,,,2406.00,1563.90,,,,,,,,,,,,,
MESH BONE 126MMW X 126MML 06MM THK RSRB XG SM GRID LATEX FR,SUP-2694977,CDM,C1713,HCPCS,0278,RC,,,,both,,,8506.79,5529.41,,,,,,,,,,,,,
COIL NEUROVASCULAR GDC-10 L 6 CM DIA 4 MM SFT 2D HELCL STRL,SUP-2365667,CDM,C1889,HCPCS,0278,RC,,,,both,,,2999.33,1949.56,,,,,,,,,,,,,
PLATE BONE 4 H RT GLEN SCAPULAR LCK,SUP-2107832,CDM,C1713,HCPCS,0278,RC,,,,both,,,3256.18,2116.52,,,,,,,,,,,,,
STRUT EXT FIX LNG STD MAXFRAME,SUP-2432235,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3303.28,2147.13,,,,,,,,,,,,,
GRAFT BIO W38XL50MM THK0.85MM MEDPOR,SUP-2366459,CDM,C1713,HCPCS,0278,RC,,,,both,,,1406.91,914.49,,,,,,,,,,,,,
SYSTEM MIC ACCS GLIDEACCESS 5 FR L 40 CM PLAT NIT ECHOGENIC,SUP-2385210,CDM,C1894,HCPCS,0272,RC,,,,both,,,92.32,60.01,,,,,,,,,,,,,
ROD BENDR FOR 5.5 ROD,SUP-2232126,CDM,C1713,HCPCS,0278,RC,,,,both,,,1441.26,936.82,,,,,,,,,,,,,
CEMENT BNE 5 CC DEMINERALIZED BONE MATRIX STRL TRABEXUS LTX,SUP-2855699,CDM,C1713,HCPCS,0278,RC,,,,both,,,16858.66,10958.13,,,,,,,,,,,,,
COIL DET 3D AXIUM 3MMX8CM,SUP-2471136,CDM,C1889,HCPCS,0278,RC,,,,both,,,4553.00,2959.45,,,,,,,,,,,,,
SCREW BNE L11MM OD2MM THRD L5.5MM TI BRK OFF MONSTER BITE,SUP-2320989,CDM,C1713,HCPCS,0278,RC,,,,both,,,671.80,436.67,,,,,,,,,,,,,
TUBE ENDOTRACHEL PED SZ 4.5 OD8.5MM ID4.5MM CUF HI VOL LO,SUP-2265227,CDM,2720000010,LOCAL,0272,RC,,,,both,,,569.91,370.44,,,,,,,,,,,,,
GRAFT HUM TISS W5XL10CM PROC DERM CLLGN RECTANG ALLOMAX,SUP-2125854,CDM,C1781,HCPCS,0278,RC,,,,both,,,4961.20,3224.78,,,,,,,,,,,,,
GUIDE SURG WASHER HIP SEGMENTED TRABECULAR MTL,SUP-2437274,CDM,C1713,HCPCS,0278,RC,,,,both,,,155.43,101.03,,,,,,,,,,,,,
GRAFT BONE H1.7-10MM 30ML CANC CHIP FRZ DRY,SUP-2294031,CDM,C1713,HCPCS,0278,RC,,,,both,,,989.73,643.32,,,,,,,,,,,,,
CATHETER CHOLANGIOGRAM FANELLI 0.021 IN 5 FRX90 CM SET,SUP-2737156,CDM,C1769,HCPCS,0272,RC,,,,both,,,266.90,173.48,,,,,,,,,,,,,
MESH SYNTH INGUINAL N ABSRB TITANIZED POLYPR LT 15CM LEN,SUP-2402531,CDM,C1781,HCPCS,0278,RC,,,,both,,,354.82,230.63,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 70 MM DIA13/10 MM DEL,SUP-2934223,CDM,C1713,HCPCS,0278,RC,,,,both,,,15468.27,10054.38,,,,,,,,,,,,,
ALLOGRAFT DERMAL 1X1 CMX1.27-3.30 MM TISS MTRX ALLDERM,SUP-2113045,CDM,Q4116,HCPCS,0636,RC,,,,both,,,241.78,157.16,,,,,,,,,,,,,
ALLOGRAFT BNE FEM SHFT 51-150 MMX0.3 CM FRZN,SUP-2717852,CDM,C1762,CPT,0278,RC,,,,both,,,4749.41,3087.12,,,,,,,,,,,,,
SUPPORT ORTHOPEDIC FLX SM AD LT FNGR ORTHOSIS FLX BRAC,SUP-2325138,CDM,L3807,HCPCS,0274,RC,,,,both,,,243.51,158.28,,,,,,,,,,,,,
LCS PW TIB SHIM SM/SM+ 12.5,SUP-2513619,CDM,C1776,CPT,0278,RC,,,,both,,,1111.56,722.51,,,,,,,,,,,,,
IMPLANT CRAN M PEEK PRIORITY CUSTOMIZED,SUP-2365149,CDM,C1713,HCPCS,0278,RC,,,,both,,,46446.28,30190.08,,,,,,,,,,,,,
PLATE BNE 2.4X32X1.7 MM 4 HOLE SS LCP,SUP-2569295,CDM,C1713,HCPCS,0278,RC,,,,both,,,328.13,213.28,,,,,,,,,,,,,
SYSTEM ACCS DISECT BLLN OVL BLNT TIP LP 2 PK KII,SUP-2424365,CDM,C1713,HCPCS,0278,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
GRAFT VASC EXXCEL SFT L 50 CM DIA 6 MM SUPP L 50 CM EPTFE,SUP-2227647,CDM,C1768,CPT,0278,RC,,,,both,,,1768.86,1149.76,,,,,,,,,,,,,
BUR SURG DIA 5 MM HUB II CONE STRL REUSE HI-LINE,SUP-2929248,CDM,2720000010,LOCAL,0272,RC,,,,both,,,457.87,297.62,,,,,,,,,,,,,
PROSTHESIS OSS EAR 0.6X0.9X4 MM,SUP-2312796,CDM,L8613,CPT,0278,RC,,,,both,,,367.38,238.80,,,,,,,,,,,,,
CATHETER NEPHSTMY 7FR L65CM 35FR INFLATED LTX BLLN OCCL,SUP-2139187,CDM,C2628,HCPCS,0272,RC,,,,both,,,485.44,315.54,,,,,,,,,,,,,
MICROPOWER RECIPROCATING SAW,SUP-2605740,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8908.21,5790.34,,,,,,,,,,,,,
SHEATH INTRO FAST-CATH SAFL L 60 CM DIA 8 FR GUIDEWIRE L 145,SUP-2357179,CDM,C1893,HCPCS,0272,RC,,,,both,,,530.66,344.93,,,,,,,,,,,,,
PLATE BNE 3.5X242 MM 20 HOLE SS DCP,SUP-2569147,CDM,C1713,HCPCS,0278,RC,,,,both,,,455.93,296.35,,,,,,,,,,,,,
CATHETER HAD 11.5FR L20CM STR POLYUR 3 LUMN FULL KT TR FL,SUP-2267014,CDM,C1751,HCPCS,0278,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
NAIL 13MMX180MM,SUP-2244340,CDM,C1713,HCPCS,0278,RC,,,,both,,,13703.49,8907.27,,,,,,,,,,,,,
PROXIMAL HUMERAL PLATE 5 HOLE,SUP-2829258,CDM,C1713,HCPCS,0278,RC,,,,both,,,6892.30,4479.99,,,,,,,,,,,,,
SPHERE FINGER JOINT SIZE 10 CMC SYSTEM PYROSPHERE,SUP-2586709,CDM,C1776,CPT,0278,RC,,,,both,,,7700.07,5005.05,,,,,,,,,,,,,
NEEDLE PRE WAXED 0.50MM X 01.0CM 21 GAUGE 15CM,SUP-2716306,CDM,2720000010,LOCAL,0272,RC,,,,both,,,484.66,315.03,,,,,,,,,,,,,
PLATE BONE DUAL CMPRSSN HLX12 TTNM RCNSTRCTN F/3.5MM SCREW U,SUP-2494324,CDM,C1713,HCPCS,0278,RC,,,,both,,,1624.89,1056.18,,,,,,,,,,,,,
HC Leukopoor Plt Pher,PX-3900903500,CDM,P9035,CPT,0390,RC,,,,both,,,2210.00,1436.50,,,,,,,,,,,,,
TUNNELER SURG L 450 MM MED RIGID NO RNG MARKING STRL DISP 10/PK,SUP-2928801,CDM,2720000010,LOCAL,0272,RC,,,,both,,,435.39,283.00,,,,,,,,,,,,,
SCALPEL SRGCL SMLLIE 6 14NL MNSCS CRVD RIGHT ULTRA INSTR LA,SUP-2675393,CDM,2720000010,LOCAL,0272,RC,,,,both,,,227.30,147.74,,,,,,,,,,,,,
PLATE 3.5MM TI LCP PROXIMAL TIBIA 16 HOLES 237MM RIGHT,SUP-2549560,CDM,C1713,HCPCS,0278,RC,,,,both,,,3630.37,2359.74,,,,,,,,,,,,,
SCREW BNE L75MM DIA3.5MM PROX TIB S STL ST FULL THRD T15,SUP-2177901,CDM,C1713,HCPCS,0278,RC,,,,both,,,460.80,299.52,,,,,,,,,,,,,
TALC 4 G PL POWD,RX-141989,CDM,2500000003,HCPCS,0250,RC,62327-0444-44,NDC,,both,1,UN,879.80,571.87,,,,,,,,,,,,,
LEAD PACE COROX L 77 CM DIA1.6 MM POLYUR IRIDIUM OXIDE TIP,SUP-2138025,CDM,C1900,HCPCS,0275,RC,,,,both,,,5960.44,3874.29,,,,,,,,,,,,,
MESH HERN W12XL20CM SYN ABSRB POLY COMP ELP MFIL OVL,SUP-2174765,CDM,C1781,HCPCS,0278,RC,,,,both,,,3345.10,2174.31,,,,,,,,,,,,,
PLATE BNE L11MM THK1MM 4 H NONSTERILE TI BX RECTANG VAR ANG,SUP-2181014,CDM,C1713,HCPCS,0278,RC,,,,both,,,1234.43,802.38,,,,,,,,,,,,,
CROWN DENT 2 1ST PRIMARY M UPPER RT SS,SUP-2100174,CDM,D6783,CPT,0278,RC,,,,both,,,33.54,21.80,,,,,,,,,,,,,
AGENT HEMOSTATIC SURGIFLOW MATRIX KIT W/THROMBIN,SUP-2218263,CDM,2720000010,LOCAL,0272,RC,,,,both,,,583.51,379.28,,,,,,,,,,,,,
BLOCK TIB THK10MM W/ SCR PROVEN,SUP-2359284,CDM,C1776,CPT,0278,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
BUR ENDOSCP SHAVER 40 DEG L 13 CM DIA 3 MM ENT PWR 30K,SUP-2902065,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1449.27,942.03,,,,,,,,,,,,,
BUR SURG DIA2MM RND TAPR EXT NONFLUTED CUT FOR ELITE SABER,SUP-2363980,CDM,2720000010,LOCAL,0272,RC,,,,both,,,420.45,273.29,,,,,,,,,,,,,
CROWN DENT 1 S STL SEC PRI M UP LT ANTR CUSPID PREFABRICATED,SUP-2238912,CDM,D6783,CPT,0278,RC,,,,both,,,21.48,13.96,,,,,,,,,,,,,
BIT DRL SLD 3 MM STRL DISP,SUP-2194151,CDM,2720000010,LOCAL,0272,RC,,,,both,,,351.68,228.59,,,,,,,,,,,,,
LEAD PACE BPLR 59 CM IS-1 CONN W/ INSUL SWEET PICOTIP RX,SUP-2148638,CDM,C1898,HCPCS,0275,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
SUPPORT ORTHOT CUST LEGG PERTHES ORTHOSIS TORONTO TYP,SUP-2435603,CDM,L1700,HCPCS,0272,RC,,,,both,,,4404.76,2863.09,,,,,,,,,,,,,
DEFIBRILLATOR CRD SINGLE CHMBR ATLS + C-HD,SUP-2356524,CDM,C1722,HCPCS,0275,RC,,,,both,,,64134.50,41687.42,,,,,,,,,,,,,
GRAFT BNE 15 CC HI VISC MIIG X3,SUP-2486754,CDM,C1713,HCPCS,0278,RC,,,,both,,,10098.24,6563.86,,,,,,,,,,,,,
SEPARATOR THROMCTMY 4 200 CM FOR CAT RX ASPIR CATH INDIGO,SUP-2323714,CDM,C1757,HCPCS,0272,RC,,,,both,,,2590.50,1683.82,,,,,,,,,,,,,
MESH CRAN W40XL62MM THK1MM TIIUM POLYETH MTRX POR BARR,SUP-2365173,CDM,C1713,HCPCS,0278,RC,,,,both,,,3668.84,2384.75,,,,,,,,,,,,,
IMMOBILIZER ORTHOPEDIC CUST KNEE,SUP-2422975,CDM,L2308,HCPCS,0274,RC,,,,both,,,4166.78,2708.41,,,,,,,,,,,,,
BLADE SURG 9MM S STL ST DISPOSABLE GRFT PARASMILLIE,SUP-2167032,CDM,2720000010,LOCAL,0272,RC,,,,both,,,404.56,262.96,,,,,,,,,,,,,
SHOE ORTHOT MEN CUST OXFORD INTEGR PART OF BRAC,SUP-2435715,CDM,L3225,HCPCS,0274,RC,,,,both,,,208.97,135.83,,,,,,,,,,,,,
JOINT SHOULDER HUMERAL STEM PROXIMAL BODY EQUINOXE XSM +0MM,SUP-2855529,CDM,C1776,CPT,0278,RC,,,,both,,,11378.58,7396.08,,,,,,,,,,,,,
BLADE SCREWDRIVER 2MM2.3MM DIA 94MML CROSS DRIVE RATCHETED,SUP-2682215,CDM,2720000010,LOCAL,0272,RC,,,,both,,,350.80,228.02,,,,,,,,,,,,,
TAP NCB PT 4 MM QUIK CONN,SUP-2204933,CDM,2720000010,LOCAL,0272,RC,,,,both,,,579.58,376.73,,,,,,,,,,,,,
REAMER SPNL 14MM DIA HLLW ADJUSTABLE TAPR,SUP-2292333,CDM,C1713,HCPCS,0278,RC,,,,both,,,1385.24,900.41,,,,,,,,,,,,,
KIT TOOL INSERTABLE ACC REVEAL LINQ,SUP-2281140,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
KIT CLEANING EARTIP ADAPTER SANIBEL,SUP-2719739,CDM,2720000010,LOCAL,0272,RC,,,,both,,,11.93,7.75,,,,,,,,,,,,,
COIL EMB L15CM OD5MM 10 STRTCH RESIST FRAMING FIL FNSH,SUP-2305171,CDM,C1889,HCPCS,0278,RC,,,,both,,,4647.20,3020.68,,,,,,,,,,,,,
HC Sarscov-2 Ag/Flu Ab (Sophia),PX-3008742800,CDM,87428,CPT,0300,RC,,,,both,,,211.00,137.15,,,,,,,,,,,,,
COMPONENT FEM SLT 55 MM M KNEE SEG TAPR ANTIROTATION TAB TI,SUP-2252619,CDM,C1776,CPT,0278,RC,,,,both,,,4720.83,3068.54,,,,,,,,,,,,,
TROCAR ENDOSCP L100MM DIA12MM BLDELSS SMOOTH SL ENDOPATH,SUP-2218784,CDM,2720000010,LOCAL,0272,RC,,,,both,,,670.70,435.95,,,,,,,,,,,,,
PLATE BNE L18MM 10 H CRPL PEEK FUS CUP XPODE,SUP-2389449,CDM,C1713,HCPCS,0278,RC,,,,both,,,2951.60,1918.54,,,,,,,,,,,,,
IMPLANT CONDYLE SCREW DIA2.4 MM LT LCK ADDON RECON SYS NS,SUP-2936480,CDM,C1713,HCPCS,0278,RC,,,,both,,,4414.84,2869.65,,,,,,,,,,,,,
TUBE TYMPANOSTOMY DRN STRL,SUP-2381495,CDM,L8699,HCPCS,0278,RC,,,,both,,,60.29,39.19,,,,,,,,,,,,,
RAIL ORTH 2 TRANSITION 5.5X600 MM 200 MM MESA,SUP-2732254,CDM,C1713,HCPCS,0278,RC,,,,both,,,7338.18,4769.82,,,,,,,,,,,,,
DEFIBRILLATOR IMPL VITALITY DR HE TI 2 CHMBR A IS1 BPLR V,SUP-2149288,CDM,C1721,HCPCS,0275,RC,,,,both,,,67510.00,43881.50,,,,,,,,,,,,,
PACK VENT ASST L SHLDR BG PT PERS SUPP,SUP-2282574,CDM,Q0498,HCPCS,0272,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
PLATE BNE THK0.5MM 6X6 H UNIV CRANIOMAXILLOFACIAL TI 3D MAL,SUP-2366234,CDM,C1713,HCPCS,0278,RC,,,,both,,,2975.56,1934.11,,,,,,,,,,,,,
CATHETER VENTRICULAR SHUNT STANDARD STRAIGHT RIGHT ANGLE 1.2,SUP-2825901,CDM,C1729,HCPCS,0272,RC,,,,both,,,872.86,567.36,,,,,,,,,,,,,
PLATE BONE 6 H STR FOR SM BONES ORTHOLOC 3DI,SUP-2398061,CDM,C1713,HCPCS,0278,RC,,,,both,,,2069.26,1345.02,,,,,,,,,,,,,
"HC Phlebotomy,Tx",PX-9409919500,CDM,99195,CPT,0940,RC,,,,inpatient,,,330.00,214.50,,,,,,,,,,,,,
PACK ORTH INSTR DEPTHING FOR 5 MM CHMFR SCREW K WIRE 1.8 MM,SUP-2902694,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2902.30,1886.49,,,,,,,,,,,,,
HC Ptt,PX-3058573000,CDM,85730,CPT,0305,RC,,,,both,,,120.00,78.00,,,,,,,,,,,,,
BIT DRL CANN 8.5 MM KNEE SINGLE FLUT MTO,SUP-2849083,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2442.92,1587.90,,,,,,,,,,,,,
KIT FIX BNE TO BNE TI RND BTTN W 29X35MM SLD DRL,SUP-2136096,CDM,C1713,HCPCS,0278,RC,,,,both,,,2539.73,1650.82,,,,,,,,,,,,,
OSELTAMIVIR PHOSPHATE 75 MG PO CAPS,RX-26546,CDM,6370000000,HCPCS,0637,RC,72205-0044-11,NDC,,both,1,UN,8.40,5.46,,,,,,,,,,,,,
GRAFT DURA 5X4 IN REGEN MTRX DURAGN,SUP-2624230,CDM,C1763,HCPCS,0278,RC,,,,both,,,5148.41,3346.47,,,,,,,,,,,,,
SCREW BONE L16XOD2.3MM TI CORT CRANIO MAXIOFACIAL ST CROSS,SUP-2363449,CDM,C1713,HCPCS,0278,RC,,,,both,,,225.30,146.44,,,,,,,,,,,,,
DEVICE RETRV DEPLOYMENT LITHOVUE EMPOWER,SUP-2436264,CDM,C2617,HCPCS,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
SUPPORT ORTHOT THGH LOWER EXTREMITY WT BEAR LACER N MOLD,SUP-2435677,CDM,L2530,HCPCS,0272,RC,,,,both,,,678.96,441.32,,,,,,,,,,,,,
CEMENT BNE 40GM HI VISC RADPQ FOR REV SURG,SUP-2403495,CDM,C1713,HCPCS,0278,RC,,,,both,,,188.40,122.46,,,,,,,,,,,,,
AGENT HEMSTAT 4.5ML GEL VITAGEL 21130000] STRYKER SPINE HOWM],SUP-2379548,CDM,C1713,HCPCS,0278,RC,,,,both,,,1571.57,1021.52,,,,,,,,,,,,,
PLATE BNE TIBIOTALAR STD RT LAT BABY GORILLA,SUP-2751228,CDM,C1713,HCPCS,0278,RC,,,,both,,,5172.37,3362.04,,,,,,,,,,,,,
PROBE SURG TARGETING 3.5 MM DEPTH MARKING,SUP-2535358,CDM,2720000010,LOCAL,0272,RC,,,,both,,,791.28,514.33,,,,,,,,,,,,,
CATHETER CV PICC 5.5 FRX50 CM DL PRESSURE ARROWG+ARD BLU ADV,SUP-2846972,CDM,C1751,HCPCS,0278,RC,,,,both,,,310.23,201.65,,,,,,,,,,,,,
PLATE BONE 16 H RT RIB 4 5 ROSE RED TI PRECONTOURED,SUP-2181506,CDM,C1713,HCPCS,0278,RC,,,,both,,,6144.20,3993.73,,,,,,,,,,,,,
BLADE SHAVER 3.5 MMX7 CM TORPEDO,SUP-2424064,CDM,2720000010,LOCAL,0272,RC,,,,both,,,317.14,206.14,,,,,,,,,,,,,
PLATE BNE L MINI 2X19 MM LT 4 HOLE OBLQ ANGLED TI,SUP-2481111,CDM,C1713,HCPCS,0278,RC,,,,both,,,292.33,190.01,,,,,,,,,,,,,
HC Voice Prosthesis Eval,PX-4449259700,CDM,92597,CPT,0444,RC,,,,inpatient,,,478.00,310.70,,,,,,,,,,,,,
ANCHOR SUTURE ABSORBABLE 2 BRAIDED LUPINE LOOP COMP,SUP-2249328,CDM,C1713,HCPCS,0278,RC,,,,both,,,979.68,636.79,,,,,,,,,,,,,
PIN FIX POLYETH BUMPER LCK OSS,SUP-2405860,CDM,C1713,HCPCS,0278,RC,,,,both,,,1045.62,679.65,,,,,,,,,,,,,
BUR SURG CYL LNG 5 MMX10 CM FLUT SM BOR MIDAS REX LEGEND,SUP-2627633,CDM,2720000010,LOCAL,0272,RC,,,,both,,,324.08,210.65,,,,,,,,,,,,,
BRACE KNEE ADULTXL UNIV FOAM POSTOP UNISX WRP ARND HNG T SCP,SUP-2150861,CDM,L1810,HCPCS,0274,RC,,,,both,,,326.56,212.26,,,,,,,,,,,,,
EXTERNAL FIXATION KIT DSTL RADIAL FASTFRAME,SUP-2494462,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
PIN EXT FIX THRD L50MM DIA7MM SHANK L375MM DIA5MM S STL,SUP-2342935,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2122.92,1379.90,,,,,,,,,,,,,
SET JEFFREY 21GA NDL - NIT WIRE,SUP-2168369,CDM,C1769,HCPCS,0272,RC,,,,both,,,284.61,185.00,,,,,,,,,,,,,
GRAFT VSCLR L30CM D10MM THRCC STRGHT DBLE VLR PASS SWNG TUBE,SUP-2466785,CDM,C1768,CPT,0278,RC,,,,both,,,1823.59,1185.33,,,,,,,,,,,,,
GRAFT VASC HEMSHLD GLD L 15 CM DIA14 MM POLYESTER BOV CLLGN,SUP-2265890,CDM,C1768,CPT,0278,RC,,,,both,,,1014.44,659.39,,,,,,,,,,,,,
ABUTMENT HEARING AID 10 DEG ANGLED PONTO,SUP-2430339,CDM,L8690,HCPCS,0278,RC,,,,both,,,6330.24,4114.66,,,,,,,,,,,,,
GRAFT HUM TISS L 10 X W 10 CM SZ 100 SQCM AMNIO,SUP-2909297,CDM,Q4137,HCPCS,0636,RC,,,,both,,,17327.96,11263.17,,,,,,,,,,,,,
HC So Assay Thiopurine S-Methyltransferase,PX-3018443366,CDM,84433,CPT,0301,RC,,,,both,,,194.00,126.10,,,,,,,,,,,,,
GUIDEWIRE VASC L 145 CM DIA 0.038 IN TAPR L 6 CM RAD 3 MM,SUP-2167619,CDM,C1769,HCPCS,0272,RC,,,,both,,,32.34,21.02,,,,,,,,,,,,,
"HC X-Ray, Thoracic Spine/4 V",PX-3207207400,CDM,72074,CPT,0320,RC,,,,outpatient,,,795.00,516.75,,,,,,,,,,,,,
BOOT WALKING PNEUMATIC PREFABRIC,SUP-2388197,CDM,L4360,HCPCS,0274,RC,,,,both,,,759.16,493.45,,,,,,,,,,,,,
CANNULA KIT UNI PEDICULAR 10 GA CEMENT DEL,SUP-2846424,CDM,2720000010,LOCAL,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
MESH HERN RECT 12X6 IN FULL RESRB FOR SFT TISS PHASIX,SUP-2855253,CDM,C1781,HCPCS,0278,RC,,,,both,,,16956.00,11021.40,,,,,,,,,,,,,
CLAMP REPROC MULTI PIN HII MRI 10 HL,SUP-2700102,CDM,2720000010,LOCAL,0272,RC,,,,both,,,899.17,584.46,,,,,,,,,,,,,
STEM HUM W/ ALIGN H STD 9X115 BIO-MOD,SUP-2136162,CDM,C1776,CPT,0278,RC,,,,both,,,9704.96,6308.22,,,,,,,,,,,,,
BOOT WALKING PNEUMATIC PREFABRIC,SUP-2388197,CDM,L4360,HCPCS,0272,RC,,,,both,,,759.16,493.45,,,,,,,,,,,,,
SCREW BNE HDLSS SHT THRD 3.5X14 MM CANN MINI-MONSTER,SUP-2320899,CDM,C1713,HCPCS,0278,RC,,,,both,,,847.02,550.56,,,,,,,,,,,,,
GRAFT VASC GORTX L 10 CM DIA10 MM EPTFE STR TW N RING STRL,SUP-2396717,CDM,C1768,CPT,0278,RC,,,,both,,,414.48,269.41,,,,,,,,,,,,,
NUT SPNL ANT TI FIX VANTAGE,SUP-2292684,CDM,C1713,HCPCS,0278,RC,,,,both,,,109.90,71.43,,,,,,,,,,,,,
SCREW BNE GHST LONGITUDE II,SUP-2630464,CDM,C1713,HCPCS,0278,RC,,,,both,,,344.62,224.00,,,,,,,,,,,,,
PLATE BNE L113MM 6 H R PROX MED PERIARTC TIB S STL,SUP-2410552,CDM,C1713,HCPCS,0278,RC,,,,both,,,2338.99,1520.34,,,,,,,,,,,,,
PIN EXT FIX L80MM OD3MM THRD L15MM TI NITRIDE HALF CORETRAK,SUP-2399883,CDM,2720000010,LOCAL,0272,RC,,,,both,,,222.94,144.91,,,,,,,,,,,,,
GRAFT BONE L5XW2.5CM DEMIN BONE MTRX MAGNIFUSE II,SUP-2279578,CDM,C1713,HCPCS,0278,RC,,,,both,,,10754.50,6990.42,,,,,,,,,,,,,
SET PROC HYDROTHERMABLATOR STRL SGL,SUP-2140173,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2480.60,1612.39,,,,,,,,,,,,,
MATRIX BIO SZ 38 SQCM FISH SKIN DERMAL INTACT STRL OMEGA3,SUP-2909260,CDM,Q4158,HCPCS,0636,RC,,,,both,,,4835.60,3143.14,,,,,,,,,,,,,
TRAY CATH HEMODIALYSI ZENYSI DL ACUTE 11FR DIA 20CM A855200G,SUP-2632942,CDM,C1752,HCPCS,0278,RC,,,,both,,,823.47,535.26,,,,,,,,,,,,,
RING OPEN 180MM,SUP-2480146,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4569.33,2970.06,,,,,,,,,,,,,
IMPLANT EYELID 16X27X0.45MM RT LO SPCR POREX,SUP-2366497,CDM,C1713,HCPCS,0278,RC,,,,both,,,1475.80,959.27,,,,,,,,,,,,,
PLATE BNE 130 DEG PEDIATRIC 3.5X140 MM 19/12 MM 9 HOLE LCP,SUP-2799200,CDM,C1713,HCPCS,0278,RC,,,,both,,,2752.74,1789.28,,,,,,,,,,,,,
RACK INSTR RETRCT WIREFIX,SUP-2399615,CDM,C1776,CPT,0278,RC,,,,both,,,1378.46,896.00,,,,,,,,,,,,,
ROD SPNL L240MM OD4MM 115DEG OCCIPITAL QUARTEX,SUP-2229111,CDM,C1713,HCPCS,0278,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
MICROCATHETER INFUSION SUPERCROSS 90 DEG L 130 CM OD,SUP-2120493,CDM,C1887,HCPCS,0272,RC,,,,both,,,1667.34,1083.77,,,,,,,,,,,,,
GUIDEWIRE VASC INQWIRE L 260 CM 0.035IN TIP 1.5 MM J FIX COR,SUP-2701663,CDM,C1769,HCPCS,0272,RC,,,,both,,,34.63,22.51,,,,,,,,,,,,,
WRAP SHLDR L THERMOSKIN,SUP-2324274,CDM,L3650,HCPCS,0272,RC,,,,both,,,139.01,90.36,,,,,,,,,,,,,
INTRODUCER PACE LD CPS DIR SL II L 47 CM DIA10.06 FR SS,SUP-2357577,CDM,C1893,HCPCS,0272,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
SHEATH INTRO PINNACLE DESTINATION 90CM 7FR COAT 15CM MP XCUT,SUP-2385204,CDM,C1894,HCPCS,0272,RC,,,,both,,,400.35,260.23,,,,,,,,,,,,,
GRAFT BNE 2.5CC VIABLE BNE MTRX COMPRESSIBLE MOLD RDY TO,SUP-2370452,CDM,C1763,HCPCS,0278,RC,,,,both,,,3037.95,1974.67,,,,,,,,,,,,,
PLATE BNE 2 T-SHAPE1.0MM 2-HOLE,SUP-2247340,CDM,C1713,HCPCS,0278,RC,,,,both,,,1202.62,781.70,,,,,,,,,,,,,
ALLOGRAFT BNE CRUSH 60 CC FD ASEP CANC,SUP-2867133,CDM,C1762,CPT,0278,RC,,,,both,,,2120.91,1378.59,,,,,,,,,,,,,
TRIAL BONE PLT 3 H CLVRLF TC-100 SM FRAG SYS,SUP-2343732,CDM,C1713,HCPCS,0278,RC,,,,both,,,2750.36,1787.73,,,,,,,,,,,,,
CATHETER VENTRICULAR TUNNELED CAMINO FLX,SUP-2244471,CDM,C1729,HCPCS,0272,RC,,,,both,,,4738.26,3079.87,,,,,,,,,,,,,
IMPLANT HUM TISS L 6 X W 4 CM AMNIO MEMBRN FLX MULTLYR,SUP-2905513,CDM,C1762,CPT,0278,RC,,,,both,,,5275.20,3428.88,,,,,,,,,,,,,
HC ER Level 4,PX-4509928400,CDM,99284,CPT,0450,RC,,,,inpatient,,,2334.00,1517.10,,,,,,,,,,,,,
BI MENTUM PFR REVISION CUP 47MM,SUP-2540587,CDM,C1776,CPT,0278,RC,,,,both,,,9305.70,6048.70,,,,,,,,,,,,,
MATRIX DERM ACELLULAR DERMAMTRX THCK 0.8-1.7,SUP-2306905,CDM,C1762,CPT,0278,RC,,,,both,,,206.96,134.52,,,,,,,,,,,,,
PLATE BNE LCK 2 MM STRNL 6 HOLE BODY 2402540] KLS MARTIN LP],SUP-2262571,CDM,C1713,HCPCS,0278,RC,,,,both,,,1796.08,1167.45,,,,,,,,,,,,,
COMPONENT SHLDR CAPPED SHT FEM HIP ST COV UPLR CEM JEAD GLD,SUP-2421718,CDM,C1776,CPT,0278,RC,,,,both,,,26847.00,17450.55,,,,,,,,,,,,,
PLATE BNE 6 H ULN SHORTNG,SUP-2107842,CDM,C1713,HCPCS,0278,RC,,,,both,,,10833.00,7041.45,,,,,,,,,,,,,
SCREW BNE L12MM DIA2.4MM MAXILLOMANDIBULAR TI NONLOCKING HI,SUP-2403058,CDM,C1713,HCPCS,0278,RC,,,,both,,,163.28,106.13,,,,,,,,,,,,,
GUIDEWIRE ORTH THRD 0.086 MM LASER LN SS QUICKFIX DISP,SUP-2122468,CDM,C1769,HCPCS,0272,RC,,,,both,,,62.80,40.82,,,,,,,,,,,,,
PLATE BNE FIBULAR 6 HOLE STR HK BABY GORILLA,SUP-2751151,CDM,C1713,HCPCS,0278,RC,,,,both,,,3100.75,2015.49,,,,,,,,,,,,,
PACK HEAT AIR ACT SGL LACTOSORB,SUP-2403061,CDM,C1713,HCPCS,0278,RC,,,,both,,,301.44,195.94,,,,,,,,,,,,,
ALLOGRAFT BNE SPACER 5 DEG 10 MM LORDTC PLIF BULL TIP STRL,SUP-2632318,CDM,C1713,HCPCS,0278,RC,,,,both,,,9383.95,6099.57,,,,,,,,,,,,,
HC Control Nosebleed Posterior,PX-4503090500,CDM,30905,CPT,0450,RC,,,,both,,,214.00,139.10,,,,,,,,,,,,,
SLING SHLDR PCH 13X19IN SWTH 5X54IN UNIV FOAM ADJ STRP,SUP-2195491,CDM,L3660,HCPCS,0274,RC,,,,both,,,30.33,19.71,,,,,,,,,,,,,
ANCHOR SUTURE SYS MIC ABD BNE DRL BIT CANN ACUTRK 2,SUP-2257130,CDM,C1713,HCPCS,0278,RC,,,,both,,,492.98,320.44,,,,,,,,,,,,,
GUIDEWIRE VASC ANGLED 3 CM 035X180 STIFF COR CANALIZER,SUP-2120025,CDM,C1769,HCPCS,0272,RC,,,,both,,,150.72,97.97,,,,,,,,,,,,,
RECON PLATE 6X93MM 4.5MM,SUP-2818428,CDM,C1713,HCPCS,0278,RC,,,,both,,,3274.24,2128.26,,,,,,,,,,,,,
HOOK 3714111 SISSON NERVE 6MM 90DG BLUNT,SUP-2705132,CDM,C1713,HCPCS,0278,RC,,,,both,,,640.72,416.47,,,,,,,,,,,,,
SPLINT ORTHOPEDICXSM FNGR DYN WIRE FOAM PIP EXTN ASST AA,SUP-2324550,CDM,L3933,HCPCS,0274,RC,,,,both,,,63.02,40.96,,,,,,,,,,,,,
JUGGERKNOT SHRT RIGID SZ 1 IMPLANT PK 10,SUP-2589030,CDM,C1713,HCPCS,0278,RC,,,,both,,,912.99,593.44,,,,,,,,,,,,,
SCREW SPNL REDUCTION 5.5X30 MM TRPL LD,SUP-2175728,CDM,C1713,HCPCS,0278,RC,,,,both,,,6053.92,3935.05,,,,,,,,,,,,,
DISSECTOR ARTHSCP LUMITIP 27 CM,SUP-2691376,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5809.00,3775.85,,,,,,,,,,,,,
PLATE BONE W12XL87MM 5 H SEMI TBLR ECT,SUP-2198537,CDM,C1713,HCPCS,0278,RC,,,,both,,,151.29,98.34,,,,,,,,,,,,,
PIN FIX L10MM DIA15MM PLLA SELF REINF FRAC SMRTPIN,SUP-2166471,CDM,2720000010,LOCAL,0272,RC,,,,both,,,449.71,292.31,,,,,,,,,,,,,
DEXAMETHASONE SODIUM PHOSPHATE 0.1 % OP SOLN,RX-2335,CDM,6370000000,HCPCS,0637,RC,24208-0720-02,NDC,,both,5,ML,242.60,157.69,,,,,,,,,,,,,
HC Venography Canal Inferior,PX-3207582500,CDM,75825,CPT,0320,RC,,,,both,,,3006.00,1953.90,,,,,,,,,,,,,
COIL VASC NEST EMBOLUS L 5 CM DIA2 MM CATH DIA 0.018 IN LOOP,SUP-2638545,CDM,C1889,HCPCS,0278,RC,,,,both,,,207.24,134.71,,,,,,,,,,,,,
CANNULA HEMO DYLS ANGIOVAC 180 DEG NIT TIP SELF EXPND,SUP-2421876,CDM,2720000010,LOCAL,0272,RC,,,,both,,,40820.00,26533.00,,,,,,,,,,,,,
GRAFT HUM TISS L 60X60MM PERICARD FRZ DRY READIGRFT,SUP-2264832,CDM,C1713,HCPCS,0278,RC,,,,both,,,1583.85,1029.50,,,,,,,,,,,,,
PLATE BNE LCK 2.7 MM 6 HOLE CNTOUR 2 COMPR FOR SCR TI STRL,SUP-2468222,CDM,C1713,HCPCS,0278,RC,,,,both,,,807.26,524.72,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY LIVEWIRE L 115 CM DIA 7 FR SPC 2,SUP-2356924,CDM,C1730,HCPCS,0272,RC,,,,both,,,1899.70,1234.80,,,,,,,,,,,,,
STENT URET 7 FRX80 CM DIV OPN TIP PERCFLX,SUP-2141654,CDM,C2617,HCPCS,0278,RC,,,,both,,,610.23,396.65,,,,,,,,,,,,,
PROBE SURG FUKUSHIMA-GIANNOTTA 90 DEG 4.9 MM 7.25 IN,SUP-2485728,CDM,2720000010,LOCAL,0272,RC,,,,both,,,345.97,224.88,,,,,,,,,,,,,
IMMOBILIZER KNEE XL L19IN FOR 20 22IN BLU CANVS T BAR STAY,SUP-2336066,CDM,L1830,CPT,0274,RC,,,,both,,,39.25,25.51,,,,,,,,,,,,,
GADOXETATE DISODIUM 0.25 MMOL/ML IV SOLN,RX-93574,CDM,A9581,HCPCS,0636,RC,50419-0320-05,NDC,,both,10,ML,78.10,50.76,,,,,,,,,,,,,
SCREW BNE ST 4.5X42 MM CORTICAL ACCORD,SUP-2344026,CDM,C1713,HCPCS,0278,RC,,,,both,,,8528.24,5543.36,,,,,,,,,,,,,
PLATE BNE L146MM BLDE W4.8XL25MM 95DEG 8 H NONSTERILE HIP S,SUP-2186771,CDM,C1713,HCPCS,0278,RC,,,,both,,,2732.02,1775.81,,,,,,,,,,,,,
SPACER SPINE PARA PEEK 23MM 31MMH 12MMW 8DEG ABBT SPINE,SUP-2416031,CDM,C1713,HCPCS,0278,RC,,,,both,,,16328.00,10613.20,,,,,,,,,,,,,
HC MRI Face Neck Eye W & WO Cont,PX-6107054300,CDM,70543,CPT,0610,RC,,,,inpatient,,,5040.00,3276.00,,,,,,,,,,,,,
TIP US SONOTRODE STD STR FOR SONICWELD RX II,SUP-2486770,CDM,2720000010,LOCAL,0272,RC,,,,both,,,730.24,474.66,,,,,,,,,,,,,
COMPONENT FEM ML 64 MM AP 60 MM SZ D TINBN LT KNEE PS STRL,SUP-2914453,CDM,C1776,CPT,0278,RC,,,,both,,,5196.70,3377.85,,,,,,,,,,,,,
CATHETER ANGIO GLIDECATH L 100 CM DIA 5 FR DIA1.12 MM JB1,SUP-2385531,CDM,C1887,HCPCS,0272,RC,,,,both,,,164.85,107.15,,,,,,,,,,,,,
REAMER SURG 11MM GRY FEM FLEX SHFT FIX COMMND,SUP-2362248,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1329.16,863.95,,,,,,,,,,,,,
LENS INTOCU 17.0 DIOPT L13MM D6MM 0DEG ANG HAPTIC UV AND,SUP-2112144,CDM,V2787,HCPCS,0276,RC,,,,both,,,895.00,581.75,,,,,,,,,,,,,
EXPANDER LD FOR LCK STR STYL INSRTN STRL,SUP-2169001,CDM,C1789,HCPCS,0278,RC,,,,both,,,141.30,91.84,,,,,,,,,,,,,
BLADE SAW SAGITTAL MICRO W/O HOSE HALL STERILE,SUP-2605429,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6678.78,4341.21,,,,,,,,,,,,,
HC ED Clsd Tx Rad Hd Sublux Child,PX-4502464000,CDM,24640,CPT,0450,RC,,,,both,,,243.00,157.95,,,,,,,,,,,,,
JACKET ORTHOT CUST BODY MOLD TO PT,SUP-2435593,CDM,L1300,HCPCS,0274,RC,,,,both,,,4879.40,3171.61,,,,,,,,,,,,,
GUIDEWIRE VASC GLIDEWIRE DIA 0.025 IN NIT HYDRPHLC ANGLED,SUP-2148190,CDM,C1769,HCPCS,0272,RC,,,,both,,,398.78,259.21,,,,,,,,,,,,,
COUNTERSINK BNE SM 6 MM REUSE,SUP-2422355,CDM,2720000010,LOCAL,0272,RC,,,,both,,,989.10,642.91,,,,,,,,,,,,,
ADAPTER LD L 10 CM SIL INSUL UPLR 5 MM RECEPTACLE IS1 CONN,SUP-2616256,CDM,C1883,HCPCS,0278,RC,,,,both,,,637.42,414.32,,,,,,,,,,,,,
NEEDLE BRST LOC L5CM DIA20GA WIRE L15CM BEAD BARD GHIATAS 10/CA,SUP-2127822,CDM,C1819,HCPCS,0278,RC,,,,both,,,64.06,41.64,,,,,,,,,,,,,
ROD EXT FIX THRD 25 MM DNE25TR] DNE LLC],SUP-2197274,CDM,C1713,HCPCS,0278,RC,,,,both,,,113.04,73.48,,,,,,,,,,,,,
PLATE BNE ANGLED BLADE 130 DEG 152 MM 50 MM 9 HOLE SS NS,SUP-2905686,CDM,C1713,HCPCS,0278,RC,,,,both,,,1886.29,1226.09,,,,,,,,,,,,,
PLATE BNE FIBULAR 2.7/3.5X136 MM LT PL 10 HOLE BUTTRESS SS,SUP-2462496,CDM,C1713,HCPCS,0278,RC,,,,both,,,1530.88,995.07,,,,,,,,,,,,,
COMPONENT GLEN SHLDR CAPPED REVERSED,SUP-2417151,CDM,C1776,CPT,0278,RC,,,,both,,,18400.40,11960.26,,,,,,,,,,,,,
SEALER LAP SM L18.8CM OPN JAW HAND/FOOT SWCH FORCETRIAD,SUP-2283557,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1209.25,786.01,,,,,,,,,,,,,
SCREW BONE LOK 4MM DIA UNVRSL 45MML TTNM CNCLLS FLLY THRDD S,SUP-2588579,CDM,C1713,HCPCS,0278,RC,,,,both,,,78.66,51.13,,,,,,,,,,,,,
PLATE 4.5MM TI LCP MEDIAL PROXIMAL TIBIA 6H RT 142MM STER,SUP-2549605,CDM,C1713,HCPCS,0278,RC,,,,both,,,5011.19,3257.27,,,,,,,,,,,,,
T-PLT RIGHT ANGLE 50MM STERIGHT HEAD 3HL SHAFT 3HL,SUP-2818500,CDM,C1713,HCPCS,0278,RC,,,,both,,,956.38,621.65,,,,,,,,,,,,,
PLATE BNE L23MM 4 H NONSTERILE S STL STR LOK COMPR FOR,SUP-2177460,CDM,C1713,HCPCS,0278,RC,,,,both,,,605.30,393.44,,,,,,,,,,,,,
OXYGENATOR PERF PRF FIBER HPRNHDRPHLC CTD 270ML PRIME VLME,SUP-2722904,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1109.33,721.06,,,,,,,,,,,,,
IOBP HIP CLOSED TIP PROCEDURE KIT,SUP-2811226,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1695.60,1102.14,,,,,,,,,,,,,
TILENE PLG ST SM 5CM DI PT 3PK,SUP-2402565,CDM,C1781,HCPCS,0278,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
EXTENSION ORTHOT LAT THOR CUST,SUP-2435585,CDM,L1210,HCPCS,0274,RC,,,,both,,,692.68,450.24,,,,,,,,,,,,,
PLATE BNE ORBIT FLR 1.5X0.3 MM TRANSANTRAL FOR SCREW TI STRL,SUP-2498482,CDM,C1713,HCPCS,0278,RC,,,,both,,,2131.75,1385.64,,,,,,,,,,,,,
BIT DRL 3.8X40 MM QUICKSET,SUP-2453995,CDM,2720000010,LOCAL,0272,RC,,,,both,,,299.56,194.71,,,,,,,,,,,,,
TOLTERODINE TARTRATE ER 2 MG PO CP24,RX-29434,CDM,6370000000,HCPCS,0637,RC,43975-0322-03,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
MICROSPHERE EMB THERASPHERE 12 GBQ YTTRIUM-90 GLS DOSE VI,SUP-2135285,CDM,C2616,HCPCS,0278,RC,,,,both,,,57603.30,37442.14,,,,,,,,,,,,,
ANCHOR SUTURE DIA 3.9 MM BIOCOMP KNOTLESS DX CC STRL DISP,SUP-2882173,CDM,C1713,HCPCS,0278,RC,,,,both,,,9090.30,5908.69,,,,,,,,,,,,,
CUP ACET CEM 28X44 MM HW ALL POLY HIP SYS ARCOMXL,SUP-2450465,CDM,C1776,CPT,0278,RC,,,,both,,,3541.92,2302.25,,,,,,,,,,,,,
SCREW BNE L12MM DIA3.5MM CORT DST TIB TI NONCANNULATED,SUP-2413361,CDM,C1713,HCPCS,0278,RC,,,,both,,,191.54,124.50,,,,,,,,,,,,,
STEM FEM L8IN DIA15MM HIP POR SM STAT STR 12/14 TAPR REV,SUP-2252164,CDM,C1776,CPT,0278,RC,,,,both,,,18993.23,12345.60,,,,,,,,,,,,,
BASEPLATE GLEN DIA29 MM POST 35 MM OFFSET 3 MM SHLDR,SUP-2912691,CDM,C1776,CPT,0278,RC,,,,both,,,10362.00,6735.30,,,,,,,,,,,,,
CATHETER INTVASC ULTRASOUND OPTICROSS HD L 135 MM DIA 3 FR,SUP-2485899,CDM,C1753,HCPCS,0278,RC,,,,both,,,2747.00,1785.55,,,,,,,,,,,,,
RESERVOIR VENTRICULAR DRAINAGE 60CM CATHETER LENGTH 20MM DIA,SUP-2830488,CDM,C1729,HCPCS,0272,RC,,,,both,,,944.01,613.61,,,,,,,,,,,,,
SYSTEM ACUCISE 6 ACCESSORIES,SUP-2119502,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5035.65,3273.17,,,,,,,,,,,,,
SUPPORT KNEE CLS PAT M,SUP-2276695,CDM,L1810,HCPCS,0272,RC,,,,both,,,11.46,7.45,,,,,,,,,,,,,
GRAFT VASC FLX 6 MMX80 CM STD WALL SM BEAD EPTFE CARBOFLO,SUP-2761503,CDM,C1768,CPT,0278,RC,,,,both,,,3705.95,2408.87,,,,,,,,,,,,,
WASHER MULT AX SPNL TI CDH LEG,SUP-2289643,CDM,C1713,HCPCS,0278,RC,,,,both,,,178.98,116.34,,,,,,,,,,,,,
BLADE MONOPOLAR SERRATED 0-40 DEG 4 MM MALL STRL DISP,SUP-2638416,CDM,2720000010,LOCAL,0272,RC,,,,both,,,548.87,356.77,,,,,,,,,,,,,
CATHETER ETER CTRL VEN OD7FR 3 LUMN COMP,SUP-2120646,CDM,C1751,HCPCS,0278,RC,,,,both,,,107.39,69.80,,,,,,,,,,,,,
STEM FEM M L54MM NK L25MM LNG CEMEX GENT HI REL IMPREG,SUP-2223685,CDM,C1776,CPT,0278,RC,,,,both,,,11183.11,7269.02,,,,,,,,,,,,,
TUBE VENT ARMSTR 8 MM 1.14 MM 2.79 MM BVL PLN END FLROPLAS,SUP-2535142,CDM,L8699,HCPCS,0278,RC,,,,both,,,26.75,17.39,,,,,,,,,,,,,
SCREW BONE L5MM DIA1.4MM EMER LO PROF HD HT AXS 5PK,SUP-2363853,CDM,C1713,HCPCS,0278,RC,,,,both,,,323.17,210.06,,,,,,,,,,,,,
KIT BONE MAR ASPIR SYR 60CC PREP TY,SUP-2120787,CDM,C1713,HCPCS,0278,RC,,,,both,,,409.77,266.35,,,,,,,,,,,,,
CATHETER GUID R2P SLENGUIDE L 150 CM COAT L 300 MM OD 7 FR,SUP-2519310,CDM,C1887,HCPCS,0272,RC,,,,both,,,947.50,615.87,,,,,,,,,,,,,
KIT LD COILED BLNK STRL,SUP-2905280,CDM,2720000010,LOCAL,0272,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
COLLAR CERV AD COT LN PD HT ADJ TECHNOLOGY W/ REPL PDS,SUP-2124227,CDM,L0180,HCPCS,0274,RC,,,,both,,,122.59,79.68,,,,,,,,,,,,,
SHEATH INTRO SAFSHTH ULTRA LT L 13 CM DIA10 FR DIL L 18 CM,SUP-2118985,CDM,C1894,HCPCS,0272,RC,,,,both,,,131.25,85.31,,,,,,,,,,,,,
GUIDE SURG SFT TISS DRT FOR DVR PLATING SYS,SUP-2137637,CDM,2720000010,LOCAL,0272,RC,,,,both,,,963.16,626.05,,,,,,,,,,,,,
PROBE KIT ANGLED WRNCH TI COPPER SONICONE OR,SUP-2745916,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2343.23,1523.10,,,,,,,,,,,,,
STAPLE MEMOSTEP 4MM OFFSET,SUP-2479534,CDM,C1713,HCPCS,0278,RC,,,,both,,,5327.95,3463.17,,,,,,,,,,,,,
FIBER LASER HOLMIUM L.UMENLS GI SLIMLINE,SUP-2885414,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1252.86,814.36,,,,,,,,,,,,,
LEVALBUTEROL HCL 1.25 MG/3ML IN NEBU|DISCARDED DRUG NOT ADMINISTE,RX-24916,CDM,J7614,HCPCS,0636,RC,76204-0900-11,NDC,JW,both,3,ML,7.20,4.68,,,,,,,,,,,,,
STEM HUM DSTL 50 MM LT SHLDR W/ BODY COMPHSVE SRS,SUP-2441468,CDM,C1776,CPT,0278,RC,,,,both,,,11021.40,7163.91,,,,,,,,,,,,,
SET SCR LCK SPINE TI ICON DEV,SUP-2317371,CDM,C1713,HCPCS,0278,RC,,,,both,,,709.64,461.27,,,,,,,,,,,,,
SUTURE MAGNUMWIRE L48IN NONABSORBABLE COBRAID BLU OM9043,SUP-2342106,CDM,C1713,HCPCS,0278,RC,,,,both,,,65.85,42.80,,,,,,,,,,,,,
SUPPORT KNEE CLS PAT M,SUP-2276695,CDM,L1810,HCPCS,0274,RC,,,,both,,,11.46,7.45,,,,,,,,,,,,,
PLATE BNE SM L106MM 9 H BILAT S STL LO PROF RIG LIMIT CNTCT,SUP-2186230,CDM,C1713,HCPCS,0278,RC,,,,both,,,1545.10,1004.31,,,,,,,,,,,,,
HC Airway Insertion Emergent,PX-3703150000,CDM,31500,CPT,0370,RC,,,,inpatient,,,403.00,261.95,,,,,,,,,,,,,
WIRE FIX L100MM DIA16MM K,SUP-2243138,CDM,C1713,HCPCS,0278,RC,,,,both,,,483.50,314.27,,,,,,,,,,,,,
PROCEDURE PACK 4.5 MM DRL GUIDE STRL MORPHIX DISP,SUP-2277447,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1397.30,908.24,,,,,,,,,,,,,
CATHETER EP CRD 2 5-5 MM 4 FRX120 CM SUPREME,SUP-2356936,CDM,C1730,HCPCS,0272,RC,,,,both,,,737.90,479.63,,,,,,,,,,,,,
PLATE BNE TBLR SS NS,SUP-2185994,CDM,C1713,HCPCS,0278,RC,,,,both,,,3159.47,2053.66,,,,,,,,,,,,,
Z DUP USE 2111317 LENS INTOCU +18.0 DIOPT L13MM DIA6MM 0DEG HAPTIC ANG A,SUP-2111318,CDM,V2632,HCPCS,0276,RC,,,,both,,,483.56,314.31,,,,,,,,,,,,,
HC ED Lyr Clos Nk Hnd Ft 12.6-20,PX-4501204500,CDM,12045,CPT,0450,RC,,,,both,,,1842.00,1197.30,,,,,,,,,,,,,
CLAMP SPNL L100MM OD5.5MM S STL THORLUM REVERE,SUP-2230986,CDM,C1713,HCPCS,0278,RC,,,,both,,,920.02,598.01,,,,,,,,,,,,,
SLEEVE IM NAIL DIA 8-13 MM PROTCT RIGID LNG STRL DISP,SUP-2905678,CDM,2720000010,LOCAL,0272,RC,,,,both,,,972.99,632.44,,,,,,,,,,,,,
SET INSTR IMPL SCR DIA7.3MM FULL THRD CANN,SUP-2183059,CDM,C1713,HCPCS,0278,RC,,,,both,,,72293.35,46990.68,,,,,,,,,,,,,
REPAIR KIT 3.5 MM KNOTLESS SYS W/ INSRTR ACU-SINCH,SUP-2857596,CDM,C1713,HCPCS,0278,RC,,,,both,,,3114.88,2024.67,,,,,,,,,,,,,
CATHETER INFUSION ENDOVASC DEV 18 FRX106 CM US COR EKOSONIC,SUP-2214799,CDM,C1887,HCPCS,0272,RC,,,,both,,,18887.10,12276.61,,,,,,,,,,,,,
CATHETER INTVASC OCCL L 90 CM DIA10 FR BALLOON L 4 CM,SUP-2395865,CDM,C2628,HCPCS,0272,RC,,,,both,,,1504.06,977.64,,,,,,,,,,,,,
SHUNT CAR 9 FRX30 CM BLLN W/ CHECK VLV SIL VASCUSHUNT II,SUP-2755079,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1455.39,946.00,,,,,,,,,,,,,
GRAFT BNE 2.5X10 CM FLX DBM GRFT,SUP-2293899,CDM,C1713,HCPCS,0278,RC,,,,both,,,3055.22,1985.89,,,,,,,,,,,,,
BUR SURG L30MM DIA1.5MM FLUT 6MM RND FLUTD OSTEON,SUP-2166640,CDM,C1713,HCPCS,0278,RC,,,,both,,,341.38,221.90,,,,,,,,,,,,,
MINI MAXLOCK EXTRM FLAT 3 H T PLT,SUP-2400401,CDM,C1713,HCPCS,0278,RC,,,,both,,,3290.72,2138.97,,,,,,,,,,,,,
GRAFT VASC IMPRA L 40 CM DIA 6-4 MM EPTFE SHRT TAPR STD WALL,SUP-2761270,CDM,C1768,CPT,0278,RC,,,,both,,,1655.22,1075.89,,,,,,,,,,,,,
HC Airway Insertion Emergent,PX-3703150000,CDM,31500,CPT,0370,RC,,,,outpatient,,,403.00,261.95,,,,,,,,,,,,,
COMPONENT FEM L THCK UNI GEN,SUP-2344260,CDM,C1776,CPT,0278,RC,,,,both,,,7512.45,4883.09,,,,,,,,,,,,,
PLATE BNE SPCR 0MM 4 H ST MIDFOOT TI VAR ANG LOK OPN WDG FOR,SUP-2181213,CDM,C1713,HCPCS,0278,RC,,,,both,,,3694.90,2401.68,,,,,,,,,,,,,
CABLE ELECTRD L3M MIC TARGETING ACT SHLD DISPOSABLE,SUP-2284685,CDM,C1713,HCPCS,0278,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
PLATE 3.5MM CURVED BROAD LCP 30H TI STRL,SUP-2546942,CDM,C1713,HCPCS,0278,RC,,,,both,,,3805.02,2473.26,,,,,,,,,,,,,
STENT URTRL 85FR DIA 20CML TCFLX DBLE PGTL ST SNGLE USE,SUP-2721831,CDM,C2617,HCPCS,0278,RC,,,,both,,,190.47,123.81,,,,,,,,,,,,,
PROBE LASER WDG DSGN DESTRUCTIVE RFID PARAMETER MEM ENABLED,SUP-2247222,CDM,2720000010,LOCAL,0272,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
CATHETER THERMODILUTION 4 LUMEN 5 FRX75 CM STD CO SWN GZ,SUP-2214027,CDM,C1725,HCPCS,0272,RC,,,,both,,,517.47,336.36,,,,,,,,,,,,,
COMPONENT PATELLAR G 12 MM ARTC KNEE,SUP-2200802,CDM,C1776,CPT,0278,RC,,,,both,,,9168.80,5959.72,,,,,,,,,,,,,
SCREW BNE L13MM DIA2.4MM S STL CANN COMPR HAMRTOE FIX SYS,SUP-2397841,CDM,C1713,HCPCS,0278,RC,,,,both,,,2524.56,1640.96,,,,,,,,,,,,,
GUIDEWIRE ORTH FLUT TIP 2.8X450 MM STRL,SUP-2789103,CDM,C1769,HCPCS,0272,RC,,,,both,,,644.96,419.22,,,,,,,,,,,,,
SCREW BNE ST 1.5X6 MM NS UNIV NEURO III AXS LTX,SUP-2862782,CDM,C1713,HCPCS,0278,RC,,,,both,,,233.18,151.57,,,,,,,,,,,,,
BLADE RTRCTR MCCLLCH 4CMD SPNL MSCLE MULTI TTHD BLACK FNSH U,SUP-2476158,CDM,2720000010,LOCAL,0272,RC,,,,both,,,618.05,401.73,,,,,,,,,,,,,
SCREW IC NAIL LCK,SUP-2362475,CDM,C1713,HCPCS,0278,RC,,,,both,,,235.66,153.18,,,,,,,,,,,,,
NUT REDUC SPNL VERT BODY THRD POST SCR TSRH 3D,SUP-2289809,CDM,C1713,HCPCS,0278,RC,,,,both,,,1151.75,748.64,,,,,,,,,,,,,
SCREW BNE L12MM DIA24MM CORT TAN T8 STARDRV RECESS TB,SUP-2418617,CDM,C1713,HCPCS,0278,RC,,,,both,,,205.70,133.70,,,,,,,,,,,,,
HC Immunoassay Analyte Qual/Semiquan Multiple Step,PX-3018351600,CDM,83516,CPT,0301,RC,,,,both,,,38.00,24.70,,,,,,,,,,,,,
ELECTRODE ELECSURG KNIFE 30 DEG UROLOGY BPLR STRL DISP,SUP-2494188,CDM,2720000010,LOCAL,0272,RC,,,,both,,,672.40,437.06,,,,,,,,,,,,,
SUPPORT ORTHOT KNEE CUST SUPCNDYL SOCKET MOLD,SUP-2435620,CDM,L1860,HCPCS,0272,RC,,,,both,,,3530.36,2294.73,,,,,,,,,,,,,
GRAFT VASC GELWEAVE L 60 CM DIA28 MM BRANCH SIDE L 10 CM DIA,SUP-2894690,CDM,C1768,CPT,0278,RC,,,,both,,,12456.38,8096.65,,,,,,,,,,,,,
SCREW BNE L65MM OD7.5MM PUR TI LO EXT ST SELF DRL CANN FIX,SUP-2242858,CDM,C1713,HCPCS,0278,RC,,,,both,,,1754.16,1140.20,,,,,,,,,,,,,
ALLOSYNC DBM STRIP 10X20X7MM,SUP-2811277,CDM,C1713,HCPCS,0278,RC,,,,both,,,2614.05,1699.13,,,,,,,,,,,,,
INSERT TIB M THK11MM KNEE DUR CNDYL STBL LIP DURAC,SUP-2377697,CDM,C1776,CPT,0278,RC,,,,both,,,3147.54,2045.90,,,,,,,,,,,,,
GUIDEWIRE EMBOLIC PROTCT EMBOSHIELD DIA 6 FR FILTER DIA 4 MM,SUP-2102270,CDM,C1884,HCPCS,0278,RC,,,,both,,,5322.30,3459.49,,,,,,,,,,,,,
CLAMP EXT FIX SZ 11-5/6 MM COMB NS DISP MAV,SUP-2931171,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3513.66,2283.88,,,,,,,,,,,,,
DILTIAZEM HCL ER COATED BEADS 240 MG PO CP24,RX-29274,CDM,6370000000,HCPCS,0637,RC,60687-0217-01,NDC,,both,1,UN,2.80,1.82,,,,,,,,,,,,,
BUR SURG L750MM DIA4MM LNG BALL FLUT MIDAS REX LEGEND,SUP-2279700,CDM,2720000010,LOCAL,0272,RC,,,,both,,,378.53,246.04,,,,,,,,,,,,,
MESH HERN W10XL15CM OVL ABSRB MACROPOROUS KNIT LO PROF,SUP-2395763,CDM,C1781,HCPCS,0278,RC,,,,both,,,2311.04,1502.18,,,,,,,,,,,,,
ALLOGRAFT BNE DWL 20X25-29 MM PRESERVON CANN CANC FLEXIGRAFT,SUP-2740896,CDM,C1713,HCPCS,0278,RC,,,,both,,,3222.83,2094.84,,,,,,,,,,,,,
PLATE BNE L150MM THK3.4MM 11 H BILAT S STL STR LOK COMPR,SUP-2185144,CDM,C1713,HCPCS,0278,RC,,,,both,,,1024.11,665.67,,,,,,,,,,,,,
PPICC PROVENA SOLO 3F SLEEVE MAX TL,SUP-2613554,CDM,C1751,HCPCS,0278,RC,,,,both,,,681.32,442.86,,,,,,,,,,,,,
KIT HAD ADMIN CATH 13.5FR 50CM LEN BASIC DBL LUMN SIL STR,SUP-2127695,CDM,C1750,HCPCS,0278,RC,,,,both,,,870.41,565.77,,,,,,,,,,,,,
SCREW BNE 2.6X26 MM SELF COMPRESSIVE DYNAFIT,SUP-2610295,CDM,C1713,HCPCS,0278,RC,,,,both,,,1447.54,940.90,,,,,,,,,,,,,
MICROSPHERE EMB CNTOUR DIA 700-900 UM 2 ML PVA,SUP-2140325,CDM,C1889,HCPCS,0278,RC,,,,both,,,781.86,508.21,,,,,,,,,,,,,
SCREW BNE OD65MM S STL HINDFOOT LOK REPL SURFIX,SUP-2243058,CDM,C1713,HCPCS,0278,RC,,,,both,,,554.74,360.58,,,,,,,,,,,,,
STENT PERIPH L40MM DIA7MM CATH L135CM NIT SELF EXP RADPQ,SUP-2104818,CDM,C1876,HCPCS,0278,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
CATHETER EP CRD 2-3-2-5-2(60)2-10-2 SUPREME,SUP-2537999,CDM,C1730,HCPCS,0272,RC,,,,both,,,2433.50,1581.77,,,,,,,,,,,,,
DEVICE INFL BLLN FOR DEFLATION OF CATH ACCLARENT,SUP-2420256,CDM,C1726,HCPCS,0272,RC,,,,both,,,430.18,279.62,,,,,,,,,,,,,
WAND ABLAT XL L195MM DIA375MM ARTHSCP MULTIVAC W INTEGR,SUP-2341215,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1036.14,673.49,,,,,,,,,,,,,
CATHETER ETER BRACHYTHERAPY L5 6CM MULT LUMN BLLN CONTURA,SUP-2239951,CDM,C1728,HCPCS,0272,RC,,,,both,,,8223.66,5345.38,,,,,,,,,,,,,
CHLOROTHIAZIDE 250 MG/5ML PO SUSP,RX-9525,CDM,340b,HCPCS,0637,RC,65649-0311-12,NDC,,both,5,ML,7.20,4.68,,,,,,,,,,,,,
PLATE BNE L W135XL224MM THK42MM 12 H BILAT TI NAR RIG NEUT,SUP-2190824,CDM,C1713,HCPCS,0278,RC,,,,both,,,1864.75,1212.09,,,,,,,,,,,,,
SCREW SPNL POLYAX 4.5X25 MM THORLUM PEDCL TRPL LD PREF 2,SUP-2175464,CDM,C1713,HCPCS,0278,RC,,,,both,,,4775.94,3104.36,,,,,,,,,,,,,
PLATE BNE LAT CLMN FUSION SM RT BABY GORILLA,SUP-2751118,CDM,C1713,HCPCS,0278,RC,,,,both,,,4702.15,3056.40,,,,,,,,,,,,,
SEALANT HEMOSTATIC FAST PREP 10.75X5.75X13.25 IN 10 CC,SUP-2424553,CDM,C1713,HCPCS,0278,RC,,,,both,,,1495.68,972.19,,,,,,,,,,,,,
PLATE BNE TIB LT ANTEROLATERAL 27 HOLE NS LTX,SUP-2857006,CDM,C1713,HCPCS,0278,RC,,,,both,,,9055.76,5886.24,,,,,,,,,,,,,
DRILL SURG TWST 1.8 MM ALL-SUTURE ANCHR STRL Q-FIX MINI LTX,SUP-2880231,CDM,2720000010,LOCAL,0272,RC,,,,both,,,576.98,375.04,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY INQUIRY OPTMA + L 110 CM DIA 7 FR,SUP-2102281,CDM,C1731,HCPCS,0278,RC,,,,both,,,5259.50,3418.67,,,,,,,,,,,,,
PROBE MICROWAVE ABLATION L 35 CM DIA11-13 GA CABLE L 2.9 M,SUP-2908899,CDM,C1886,HCPCS,0278,RC,,,,both,,,10785.90,7010.83,,,,,,,,,,,,,
HC Dress or Debride Burn Large,PX-4501603000,CDM,16030,CPT,0450,RC,,,,both,,,1216.00,790.40,,,,,,,,,,,,,
BUR SURG DIAMOND 1.4 MM 98 MM OTO-FLEX GRY WHT SKEETER,SUP-2629051,CDM,2720000010,LOCAL,0272,RC,,,,both,,,619.27,402.53,,,,,,,,,,,,,
SYSTEM CARD W/ RIATA ST SYS FOR V-196 EPIC CONVERT VR,SUP-2356534,CDM,C1721,HCPCS,0275,RC,,,,both,,,64134.50,41687.42,,,,,,,,,,,,,
FIBER LASER HOLM 940 M FOR USE W/ SMA-905 RED SMARTSYNC,SUP-2835957,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1962.78,1275.81,,,,,,,,,,,,,
VALVE AORT TISS ANNULUS OD17MM VLV ORIFICE ID148MM MECH HRT,SUP-2355067,CDM,C1713,HCPCS,0278,RC,,,,both,,,13062.40,8490.56,,,,,,,,,,,,,
ROD IM FEM NXGN,SUP-2437530,CDM,C1713,HCPCS,0278,RC,,,,both,,,748.89,486.78,,,,,,,,,,,,,
IMPLANT FACE L 108 X W 75 MM RT INFERIOR 2/3 ORBIT,SUP-2883611,CDM,C1713,HCPCS,0278,RC,,,,both,,,12324.63,8011.01,,,,,,,,,,,,,
SPLINT SLD BGE 3/32IN TAILORSPLNT,SUP-2324804,CDM,L4350,HCPCS,0272,RC,,,,both,,,132.79,86.31,,,,,,,,,,,,,
WASHER SPNL LAT OCCIPITOCERVICOTHORACIC TI ALLY MOUNTAINEER,SUP-2255364,CDM,C1713,HCPCS,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
HC Splint App Short Arm Stat,PX-4502912500,CDM,29125,CPT,0450,RC,,,,inpatient,,,700.00,455.00,,,,,,,,,,,,,
FIBRIN KIT SYS,SUP-2130788,CDM,C1713,HCPCS,0278,RC,,,,both,,,257.48,167.36,,,,,,,,,,,,,
AUGMENT TIB THK 5 MM SZ EF TRABECULAR MTL LT MEDL HALF BLOCK,SUP-2887382,CDM,C1776,CPT,0278,RC,,,,both,,,4745.33,3084.46,,,,,,,,,,,,,
SCREW BNE MINI 2X7 MM CROSS DRV CNTRDRV,SUP-2262634,CDM,C1713,HCPCS,0278,RC,,,,both,,,27.48,17.86,,,,,,,,,,,,,
GRAFT BNE INJ 3 CC AUG,SUP-2759545,CDM,C1734,HCPCS,0278,RC,,,,both,,,8449.74,5492.33,,,,,,,,,,,,,
SUBSTITUTE BONE GRFT 16X16X16MM DEMIN CANC CNFRM FLX,SUP-2307020,CDM,C1713,HCPCS,0278,RC,,,,both,,,2252.95,1464.42,,,,,,,,,,,,,
PLATE BNE SM W11XL46MM THK34MM 3 H BILAT TI RIG NEUT LOK,SUP-2190773,CDM,C1713,HCPCS,0278,RC,,,,both,,,805.10,523.31,,,,,,,,,,,,,
SHAFT FIB TRAD ALLGRFT 20X14 - 18 MM FRZ DRY,SUP-2294101,CDM,C1713,HCPCS,0278,RC,,,,both,,,1456.96,947.02,,,,,,,,,,,,,
GUIDEPIN ORTH INTERMETATARSAL/FRONTAL PLANE ANGLE 20/40 DEG,SUP-2907570,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5368.27,3489.38,,,,,,,,,,,,,
KIT METADIAPHYSEAL W/ INSTRMT STERILEXCALIBER,SUP-2316323,CDM,2720000010,LOCAL,0272,RC,,,,both,,,9737.89,6329.63,,,,,,,,,,,,,
PICC AGBA NAVICURVE 2L 5.5FR X 55CM TCG,SUP-2867376,CDM,C1751,HCPCS,0278,RC,,,,both,,,846.76,550.39,,,,,,,,,,,,,
SPACER SPNL W28XH10MM 6DEG NAR TI ANTR INTBDY FUS LORDTC,SUP-2414740,CDM,C1713,HCPCS,0278,RC,,,,both,,,21195.00,13776.75,,,,,,,,,,,,,
SHEATH DELIVERY STEERABLE AMPLATZER 14F,SUP-2858706,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
STENT URET 7FR L26CM POLYMER BLEND PH FREE COAT GRADUAL,SUP-2129073,CDM,C2617,HCPCS,0278,RC,,,,both,,,611.73,397.62,,,,,,,,,,,,,
COUPLING REPROC EXT FIX ROD TO ROD STR4940-1-010,SUP-2516727,CDM,2720000010,LOCAL,0272,RC,,,,both,,,331.11,215.22,,,,,,,,,,,,,
ANCHOR SUTURE SFT 1.4 MM 2 IMPL PK GUIDE DRL BIT JUGGERKNOT,SUP-2608797,CDM,C1713,HCPCS,0278,RC,,,,both,,,2278.89,1481.28,,,,,,,,,,,,,
SCREW BNE HDLSS LNG THRD 3X25 MM COMPR,SUP-2183090,CDM,C1713,HCPCS,0278,RC,,,,both,,,994.69,646.55,,,,,,,,,,,,,
BLADE SHV L11CM DIA4MM 360DEG 5000RPM M4 ROT 12DEG LNG CRV,SUP-2284152,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1220.83,793.54,,,,,,,,,,,,,
BLADE SAW NAR FOR STRYKR SYS 6 PROPHECY INBONE,SUP-2397083,CDM,2720000010,LOCAL,0272,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
LASER SURG ZEISS LINK FOR 130SL,SUP-2713636,CDM,2720000010,LOCAL,0272,RC,,,,both,,,19282.74,12533.78,,,,,,,,,,,,,
CATHETER HEMO DYLS OR HD L15CM ADMIN ACUTE BASIC KT 8.5 FR,SUP-2267026,CDM,C1750,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
ROD SPNL L55MM DIA5.5MM POST THORLUM TI CRV SMOOTH NTHRD,SUP-2229463,CDM,C1713,HCPCS,0278,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
INOTUZUMAB OZOGAMICIN 0.9 MG IV SOLR,RX-139756,CDM,J9229,HCPCS,0636,RC,00008-0100-01,NDC,,both,1,UN,68878.00,44770.70,,,,,,,,,,,,,
BEAM FIX L75MM DIA5.5MM ARTH FOR CHARCOT DEFORMITY AXIS,SUP-2223938,CDM,C1776,CPT,0278,RC,,,,both,,,4050.60,2632.89,,,,,,,,,,,,,
WIRE ORTH SMOOTH SGL SHRP TIP TRCR PLN S STL ST 16MM DIA,SUP-2304030,CDM,C1713,HCPCS,0278,RC,,,,both,,,17.77,11.55,,,,,,,,,,,,,
GRAFT HUM TISS W4XL4CM AMNIO MEMBRN ALLGRFT AMBIO5,SUP-2247197,CDM,V2790,HCPCS,0278,RC,,,,both,,,2496.30,1622.59,,,,,,,,,,,,,
STEM FEM SZ 5 L140MM DIA15MM NK L37MM 47MM OFFSET 132DEG 62651011] STRYKER ORTHOPEDICS HOWM],SUP-2375330,CDM,C1776,CPT,0278,RC,,,,both,,,12654.83,8225.64,,,,,,,,,,,,,
OFFSET ALTO CONCISE PARTIAL,SUP-2680309,CDM,L8613,CPT,0278,RC,,,,both,,,1234.21,802.24,,,,,,,,,,,,,
PLATE BNE T 6 HOLE,SUP-2205647,CDM,C1713,HCPCS,0278,RC,,,,both,,,551.60,358.54,,,,,,,,,,,,,
HINGE EXT FIX UNIV,SUP-2432233,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1318.64,857.12,,,,,,,,,,,,,
PLATE BNE SPCR 0MM 4 H NONSTERILE MIDFOOT TI VAR ANG LOK OPN,SUP-2181212,CDM,C1713,HCPCS,0278,RC,,,,both,,,3387.12,2201.63,,,,,,,,,,,,,
BLADE REPROC SAW SAG FINE FLAT 5.5X18.5X0.4MM,SUP-2652955,CDM,2720000010,LOCAL,0272,RC,,,,both,,,65.81,42.78,,,,,,,,,,,,,
STAPLER INT ARTC RELDABLE W/ 3X8 AND 1X5 DP PURCH TACK RELD,SUP-2283330,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3045.08,1979.30,,,,,,,,,,,,,
SCREW BNE L40MM OD4.5MM FULL THRD IMPL MONSTER,SUP-2320614,CDM,C1713,HCPCS,0278,RC,,,,both,,,780.29,507.19,,,,,,,,,,,,,
KIT BONE BX 11GA L10CM HARP TIP CANN L14CM DIA2.4MM TRCR TIP,SUP-2263903,CDM,C1894,HCPCS,0272,RC,,,,both,,,753.60,489.84,,,,,,,,,,,,,
SAW HND JOS 7.25 IN STR BAYNT,SUP-2487362,CDM,2720000010,LOCAL,0272,RC,,,,both,,,358.68,233.14,,,,,,,,,,,,,
OCCLUDER CV AMPLATZER TALISMAN ATR DISC DIA R/L 25/18 MM,SUP-2716345,CDM,C1817,HCPCS,0278,RC,,,,both,,,29830.00,19389.50,,,,,,,,,,,,,
PLATE BNE COMPR NAR 231 MM 14 HOLE DYN NS DCP LTX,SUP-2861920,CDM,C1713,HCPCS,0278,RC,,,,both,,,582.16,378.40,,,,,,,,,,,,,
PLATE BNE L72MM BRL L25MM 130DEG 3 H ST BILAT PELV HIP S STL,SUP-2186821,CDM,C1713,HCPCS,0278,RC,,,,both,,,1957.98,1272.69,,,,,,,,,,,,,
GRAFT HUM TISS W4XL4CM AMNIO MEMBRN ALLGRFT AMBIO5,SUP-2247197,CDM,V2790,HCPCS,0274,RC,,,,both,,,2496.30,1622.59,,,,,,,,,,,,,
HC Blood Gases Any Combination Ph Pco2 Po2 Co2 Hco3,PX-3018280300,CDM,82803,CPT,0301,RC,,,,inpatient,,,301.00,195.65,,,,,,,,,,,,,
GUIDEWIRE SURG 0.045X14 IN NIT INTRF SCR BIOSCREW HYPRFLX,SUP-2765767,CDM,C1769,HCPCS,0272,RC,,,,both,,,123.87,80.52,,,,,,,,,,,,,
CLIP ANEURYSM BLADE L5MM MAX OPENING 2.3MM MICRO TYPE,SUP-2826322,CDM,C1889,HCPCS,0278,RC,,,,both,,,731.31,475.35,,,,,,,,,,,,,
GUIDEWIRE SURG RET SLT FOR RG INSRTN OF PROVOX INDWL VOICE,SUP-2124335,CDM,C1769,HCPCS,0272,RC,,,,both,,,405.75,263.74,,,,,,,,,,,,,
RESERVOIR SHUNT ONOFF DEV W/O ANTI SIPHON DEV PROX OCCL,SUP-2851446,CDM,C1889,HCPCS,0278,RC,,,,both,,,3165.09,2057.31,,,,,,,,,,,,,
GRAFT FEM HD GRNDR FRZN ALLGRFT 43MM MATRIGRFT,SUP-2264752,CDM,C1713,HCPCS,0278,RC,,,,both,,,2752.02,1788.81,,,,,,,,,,,,,
WEDGE FEM SZ 7 THK20MM DSTL KNEE FOR HNG SYS LEGION,SUP-2346409,CDM,C1776,CPT,0278,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
GUIDEWIRE VASC L 180 CM DIA 0.035 IN TAPR L 6 CM FLX TIP L 2,SUP-2167658,CDM,C1769,HCPCS,0272,RC,,,,both,,,29.74,19.33,,,,,,,,,,,,,
HC Inj Anesth Celiac Plexus,PX-3616453000,CDM,64530,CPT,0361,RC,,,,both,,,2895.00,1881.75,,,,,,,,,,,,,
SCREW BNE RESCUE 12 MM,SUP-2207856,CDM,C1713,HCPCS,0278,RC,,,,both,,,776.21,504.54,,,,,,,,,,,,,
CHUCK DRL QR AGC,SUP-2445376,CDM,2720000010,LOCAL,0272,RC,,,,both,,,763.02,495.96,,,,,,,,,,,,,
BLADE RETRACTOR SPLANCHNIC 6X2 IN ABD RADLUC NS GHOSTRACT,SUP-2464374,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1528.80,993.72,,,,,,,,,,,,,
PLATE BONE L220MM BLDE W11.7XL40MM 90DEG 12 H NONSTERILE,SUP-2190873,CDM,C1713,HCPCS,0278,RC,,,,both,,,4144.52,2693.94,,,,,,,,,,,,,
MESH CRAN L 75.18 X W 30.2 MM THK 0.3 MM SCREW DIA1.5 MM MED,SUP-2936686,CDM,C1713,HCPCS,0278,RC,,,,both,,,3432.02,2230.81,,,,,,,,,,,,,
DRAIN SURG 8FR STEM 12IN XBAR 5IN GRAV W/ DEAVER T TB FOR,SUP-2127143,CDM,C1729,HCPCS,0272,RC,,,,both,,,35.45,23.04,,,,,,,,,,,,,
TRAY BIOPSY BONE T LOK,SUP-2854988,CDM,2720000010,LOCAL,0272,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
SCREW INTRF L30MM DIA6-8MM TIB TAPR NONABSORBABLE FOR SFT,SUP-2256819,CDM,C1713,HCPCS,0278,RC,,,,both,,,700.22,455.14,,,,,,,,,,,,,
SCREW BNE L19MM FEM HIP CAPT COMPR,SUP-2347913,CDM,C1713,HCPCS,0278,RC,,,,both,,,515.40,335.01,,,,,,,,,,,,,
VALVE SHUNT CONTROL RESERVOIR,SUP-2711648,CDM,C1889,HCPCS,0278,RC,,,,both,,,1198.76,779.19,,,,,,,,,,,,,
FIBER LASER DIA550UM HOLM 2 WVLNGTH DEL SYS REUSE SLM LN,SUP-2139042,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1464.15,951.70,,,,,,,,,,,,,
KIT GRAFT BONE SM RHBMP-2 4.2MG INJ 5ML CONTAIN NDL 20GA,SUP-2287848,CDM,C1713,HCPCS,0278,RC,,,,both,,,11947.70,7766.00,,,,,,,,,,,,,
FORCEPS GRSP OPN DIA20MM WRK L2300MM CHN 28MM TRIPOOD REUSE,SUP-2312678,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1270.19,825.62,,,,,,,,,,,,,
FIXATION K WIRE SPI 3X285 MM WCH COATED,SUP-2701033,CDM,2720000010,LOCAL,0272,RC,,,,both,,,312.43,203.08,,,,,,,,,,,,,
HEAD FEM BPLR 62 HIP UHMWP,SUP-2216840,CDM,C1776,CPT,0278,RC,,,,both,,,3102.32,2016.51,,,,,,,,,,,,,
PLATE BNE INFRAPECTINEAL LG RT QUADRILATERAL SURF STRL PRO,SUP-2470893,CDM,C1713,HCPCS,0278,RC,,,,both,,,5181.00,3367.65,,,,,,,,,,,,,
ALTEPLASE (ACTIVASE) 100 MG VIAL IV BOLUS,RX-4081200,CDM,J2997,HCPCS,0636,RC,50242-0085-27,NDC,,both,1,UN,50602.10,32891.36,,,,,,,,,,,,,
TRIAL BONE PLT 5 H T SHP TC-100 SM FRAG SYS,SUP-2343728,CDM,C1713,HCPCS,0278,RC,,,,both,,,1535.08,997.80,,,,,,,,,,,,,
WIRE FIX DIAMOND PT 2 END 0.062X6 IN SS NS KIRSCHNER,SUP-2791248,CDM,C1713,HCPCS,0278,RC,,,,both,,,9.23,6.00,,,,,,,,,,,,,
PLATE SPNL L14MM STD ANTR BILAT CERV TI LCK SLIM PROF LEV 1,SUP-2255523,CDM,C1713,HCPCS,0278,RC,,,,both,,,2800.88,1820.57,,,,,,,,,,,,,
HEAD RMR DIA14.5MM S STL CONIC TIP SHRP CUT EDGE ATTACH W/,SUP-2188155,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2479.28,1611.53,,,,,,,,,,,,,
SCREW BNE EMGCY 1.2X7 MM TI CENTRE-DRIVE LEVEL 1,SUP-2461682,CDM,C1713,HCPCS,0278,RC,,,,both,,,227.68,147.99,,,,,,,,,,,,,
RASP SURG DBL SIDE SAW STRYKR IO FRDM CARTILAGINATOR,SUP-2865105,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2518.28,1636.88,,,,,,,,,,,,,
SLING GYN SYS II SACR COLPOPEXY STRL,SUP-2140287,CDM,C1771,HCPCS,0278,RC,,,,both,,,4788.50,3112.52,,,,,,,,,,,,,
BRACE KNEE HNG WRP X L,SUP-2276703,CDM,L1820,HCPCS,0274,RC,,,,both,,,50.11,32.57,,,,,,,,,,,,,
BEVACIZUMAB 25 MG/ML IV SOLN (MIXTURES ONLY),RX-1150416,CDM,J9035,HCPCS,0636,RC,50242-0061-01,NDC,,both,16,ML,9180.80,5967.52,,,,,,,,,,,,,
RESTRICTOR CEM D16MM DIA10MM FOR BAL KNEE REV SYS,SUP-2314458,CDM,C1713,HCPCS,0278,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
FORCEPS SURG AD L6IN PLT HLD W SWVL FT REUSE FOR MOD HND SYS,SUP-2188843,CDM,C1713,HCPCS,0278,RC,,,,both,,,3298.85,2144.25,,,,,,,,,,,,,
SPLINT ANK FT 3-6 SM ORTHOSIS AD UNISX WMN SHOE R STRP CLSR,SUP-2326061,CDM,L4350,HCPCS,0272,RC,,,,both,,,123.59,80.33,,,,,,,,,,,,,
GRAFT HUM TISS 40MG AMNIO MEM PARTICULATE DEHYDR AMNIOFIX,SUP-2305719,CDM,V2790,HCPCS,0274,RC,,,,both,,,2278.07,1480.75,,,,,,,,,,,,,
CATHETER GUID AXS CATLYST 7 L 132 CM PROX/DSTL OD,SUP-2715845,CDM,C1887,HCPCS,0272,RC,,,,both,,,6629.80,4309.37,,,,,,,,,,,,,
FIXTURE 3MM W/ ABUTMENT,SUP-2164943,CDM,L8614,HCPCS,0278,RC,,,,both,,,6123.00,3979.95,,,,,,,,,,,,,
CATHETER DRNGE MULTPURP,SUP-2117063,CDM,C1729,HCPCS,0272,RC,,,,both,,,121.20,78.78,,,,,,,,,,,,,
APPLIER CLP 12FR L86CM W/ ENDOANCHOR CASS FOR EVAR HELI-FX 10 CLIPS PER APPLIER,SUP-2297452,CDM,2720000010,LOCAL,0272,RC,,,,both,,,14915.00,9694.75,,,,,,,,,,,,,
BUR SURG DIA13MM WIRE PASS DRL COR REUSE ELITE TPS,SUP-2367595,CDM,2720000010,LOCAL,0272,RC,,,,both,,,405.85,263.80,,,,,,,,,,,,,
TIZANIDINE HCL 4 MG PO TABS,RX-14793,CDM,6370000000,HCPCS,0637,RC,68084-0645-01,NDC,,both,1,UN,2.90,1.88,,,,,,,,,,,,,
IONOMER GLASS VITREBOND LIQUID 6.4G,SUP-2714083,CDM,2720000010,LOCAL,0272,RC,,,,both,,,643.67,418.39,,,,,,,,,,,,,
STENT URET 4.8 FRX22-30 CM 6 FR INJ FLEXIMA STRTCH VL DISP,SUP-2468573,CDM,C2617,HCPCS,0278,RC,,,,both,,,413.10,268.51,,,,,,,,,,,,,
CATHETER ANGIOPLSTY CHARGER L 135 CM BALLOON L 200 MM DIA 3,SUP-2140057,CDM,C1725,HCPCS,0272,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
COMPONENT KNEE FEM PT SPEC INSTRUMENT GENDER SOL,SUP-2212607,CDM,C1776,CPT,0278,RC,,,,both,,,8321.00,5408.65,,,,,,,,,,,,,
TUBE VENT L6MM ID1.14MM C FLX T TYP,SUP-2284037,CDM,L8699,HCPCS,0278,RC,,,,both,,,270.64,175.92,,,,,,,,,,,,,
DEVICE TORQ GWIRE DIA0010 0020IN COMPATIBLE YEL H2O TORQ,SUP-2303479,CDM,C1769,HCPCS,0272,RC,,,,both,,,12.56,8.16,,,,,,,,,,,,,
CANNULA CEM DEL FEN OPN DISP VIPER,SUP-2255637,CDM,C1713,HCPCS,0278,RC,,,,both,,,973.40,632.71,,,,,,,,,,,,,
KIT INTRO ACCS 5FR L15CM GWIRE 0018IN NDL 21GA L7CM,SUP-2303438,CDM,C1894,HCPCS,0272,RC,,,,both,,,131.88,85.72,,,,,,,,,,,,,
HC So Estriol,PX-3018267766,CDM,82677,CPT,0301,RC,,,,inpatient,,,185.00,120.25,,,,,,,,,,,,,
WASHER ORTH LCK 2.7 MM BNE THRD LIP SOCKET SS NS SURFIX DISP,SUP-2852096,CDM,C1713,HCPCS,0278,RC,,,,both,,,519.73,337.82,,,,,,,,,,,,,
IMPLANT HUM TISS RT HEMI PA NO LEAFLET REDUC THROMBOSIS,SUP-2932957,CDM,C1762,CPT,0278,RC,,,,both,,,20495.47,13322.06,,,,,,,,,,,,,
HC Fna Bx W/Fluor Gdn Ea Addl,PX-3611000800,CDM,10008,CPT,0361,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
COMPONENT HIP CAPPED UPLR,SUP-2365529,CDM,C1776,CPT,0278,RC,,,,both,,,4527.88,2943.12,,,,,,,,,,,,,
RETRIEVER THROMCTMY TREVO XP PROVUE L 20 MM DIA 3 MM NIT,SUP-2367791,CDM,C1757,HCPCS,0272,RC,,,,both,,,22518.20,14636.83,,,,,,,,,,,,,
CAP SCREW D 3.5 MM DIA 5.93 MM SCREW DIA 4.5 MM WR LCK STRL,SUP-2932965,CDM,C1713,HCPCS,0278,RC,,,,both,,,533.74,346.93,,,,,,,,,,,,,
BIT DRL DIA2 MM NIT 5TH METATRSL JT FEN NS REUSE UNITE,SUP-2897366,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1064.46,691.90,,,,,,,,,,,,,
PLATE BONE 5 H T SHP BTTRS ECT,SUP-2198571,CDM,C1713,HCPCS,0278,RC,,,,both,,,614.31,399.30,,,,,,,,,,,,,
HC So Mthfr Gene Analysis,PX-3108129166,CDM,81291,CPT,0310,RC,,,,outpatient,,,229.00,148.85,,,,,,,,,,,,,
CANNULA VEN SHT 21 FR BIOLINE COATED HLS,SUP-2663466,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1584.10,1029.66,,,,,,,,,,,,,
STAPLER INT USE DIA21 MM STPL H 3/3.5/4 MM XL MEDIUM/THICK,SUP-2896172,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4569.33,2970.06,,,,,,,,,,,,,
SLING GYN POLYPR TRNSVAG MIDURETHRAL MESH DEL DEV FOR,SUP-2139447,CDM,C1771,HCPCS,0278,RC,,,,both,,,5513.53,3583.79,,,,,,,,,,,,,
SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG PO TABS,RX-7557,CDM,6370000000,HCPCS,0637,RC,65862-0419-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
AUGMENT WDG TIB LEGION FIN SZ 7 10MM RT,SUP-2418589,CDM,C1776,CPT,0278,RC,,,,both,,,5658.28,3677.88,,,,,,,,,,,,,
INFINITY ADAPTIS TALDOME SZ2 INFINITY ADAPTIS,SUP-2822348,CDM,C1776,CPT,0278,RC,,,,both,,,16579.20,10776.48,,,,,,,,,,,,,
IMPLANT HUM TISS LT HUM HD OSTEOCHNDRL,SUP-2902057,CDM,C1762,CPT,0278,RC,,,,both,,,24570.50,15970.82,,,,,,,,,,,,,
BLADE REPROC CUTTER FULL RAD FORMULA SM JOINT 2.5MM,SUP-2653129,CDM,2720000010,LOCAL,0272,RC,,,,both,,,104.44,67.89,,,,,,,,,,,,,
AMIVANTAMAB-HYALURONIDASE-LPUJ 2240-28000 MG-UT/14ML SC SOLN,RX-174609,CDM,2500000003,HCPCS,0250,RC,57894-0514-01,NDC,,both,14,ML,49926.90,32452.48,,,,,,,,,,,,,
MIDAZOLAM HCL (PF) 5 MG/ML IJ SOLN,RX-147440,CDM,J2250,HCPCS,0636,RC,00409-2308-01,NDC,,both,0.4,ML,54.10,35.16,,,,,,,,,,,,,
HC Potassium 24hr Urine,PX-3018413300,CDM,84133,CPT,0301,RC,,,,inpatient,,,119.00,77.35,,,,,,,,,,,,,
RING EXT FIX FULL 200 MM CARBON FIBER NS,SUP-2799524,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3809.45,2476.14,,,,,,,,,,,,,
POROUS TIB BASE W SCREWHOLE MED+,SUP-2397059,CDM,C1776,CPT,0278,RC,,,,both,,,9843.90,6398.53,,,,,,,,,,,,,
CEFTAZIDIME-AVIBACTAM 2.5 (2-0.5) G IV SOLR,RX-129586,CDM,J0714,HCPCS,0636,RC,00456-2700-01,NDC,,both,1,UN,2388.40,1552.46,,,,,,,,,,,,,
NEEDLE PHACO 30 DEG 2.75 MM TIP MICROFLOW REUSE,SUP-2487420,CDM,2720000010,LOCAL,0272,RC,,,,both,,,346.19,225.02,,,,,,,,,,,,,
PLATE BNE L46MM 3X8 H TI Y SHP FOR 1.5MM SCR MOD HND SYS,SUP-2191165,CDM,C1713,HCPCS,0278,RC,,,,both,,,1232.83,801.34,,,,,,,,,,,,,
HC So Mthfr Gene Analysis,PX-3108129166,CDM,81291,CPT,0310,RC,,,,inpatient,,,229.00,148.85,,,,,,,,,,,,,
BLADE RETRACTOR ANKENEY,SUP-2382094,CDM,2720000010,LOCAL,0272,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
COVER BURR HOLE CONTOURED 22X0.3 MM LP TI,SUP-2495649,CDM,C1713,HCPCS,0278,RC,,,,both,,,1046.25,680.06,,,,,,,,,,,,,
LEUPROLIDE ACETATE (3 MONTH) 11.25 MG IM KIT,RX-21044,CDM,J1950,HCPCS,0636,RC,00074-3663-03,NDC,,both,1,UN,15561.80,10115.17,,,,,,,,,,,,,
PLATE BONE L83MM 7 H FIB TI STR LCK FOR 2.7/3/3.5/4MM SCR,SUP-2420209,CDM,C1713,HCPCS,0278,RC,,,,both,,,3595.30,2336.94,,,,,,,,,,,,,
GUIDEWIRE ORTH L230MM DIA2.5MM S STL SPADE PNT TIP,SUP-2194146,CDM,C1769,HCPCS,0272,RC,,,,both,,,134.67,87.54,,,,,,,,,,,,,
HC Guide Cathet Fluid Drainage,PX-3611003000,CDM,10030,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
CANDESARTAN CILEXETIL 4 MG PO TABS,RX-23229,CDM,6370000000,HCPCS,0637,RC,33342-0114-07,NDC,,both,1,UN,5.80,3.77,,,,,,,,,,,,,
CATHETER ANGIO L100CM OD6FR 0.038IN TEMPO BERN,SUP-2249319,CDM,C1730,HCPCS,0272,RC,,,,both,,,445.10,289.31,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.448,SUP-2860012,CDM,C1713,HCPCS,0278,RC,,,,both,,,52461.86,34100.21,,,,,,,,,,,,,
SYRINGE GEL INJECTABLE BARRIGEL 3ML,SUP-2875934,CDM,C1889,HCPCS,0278,RC,,,,both,,,4380.30,2847.19,,,,,,,,,,,,,
CATHETER CHST DRNGE 14FR L25CM PERCFLX GLDEX LOOP STR VAN,SUP-2147784,CDM,C1729,HCPCS,0272,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
COMPONENT KNEE,SUP-2366062,CDM,C1776,CPT,0278,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
WIRE BNE FIX L 152 MM DIA1.4 MM NS LEOS KIRSCHNER,SUP-2933468,CDM,C1713,HCPCS,0278,RC,,,,both,,,104.56,67.96,,,,,,,,,,,,,
SYSTEM SURG HEMSTAT PWD 1 GM POLYSACCHARIDE HEMOSPHERES,SUP-2127018,CDM,2720000010,LOCAL,0272,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
SUBSTITUTE BONE GRFT 5X5X.5CM TOT BONE MTRX SQ ACCELL,SUP-2242683,CDM,C1713,HCPCS,0278,RC,,,,both,,,6150.88,3998.07,,,,,,,,,,,,,
CAGE SPNL 12 MM INSRT INTERBRIDGE,SUP-2715280,CDM,C1889,HCPCS,0278,RC,,,,both,,,8949.00,5816.85,,,,,,,,,,,,,
CANNULA SURG JARCHO 12.5 IN UTER SELF-RETAINIG MALL TIP,SUP-2794553,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1206.29,784.09,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 160 MM DIA22/13 MM DEL,SUP-2934522,CDM,C1713,HCPCS,0278,RC,,,,both,,,19565.97,12717.88,,,,,,,,,,,,,
HC Declotting Central Vad,PX-4503659300,CDM,36593,CPT,0450,RC,,,,both,,,1120.00,728.00,,,,,,,,,,,,,
PLATE BNE L260MM BRL L15IN 135DEG PELVIS BILAT S STL STD 12,SUP-2342442,CDM,C1713,HCPCS,0278,RC,,,,both,,,5969.77,3880.35,,,,,,,,,,,,,
SET PANCREATIC STENT GEENEN L 3 CM DIA10 FR PUSH L 170 CM,SUP-2737423,CDM,C2625,HCPCS,0278,RC,,,,both,,,445.88,289.82,,,,,,,,,,,,,
SCREW INTFR BIOSURE REGENESORB 7MM X 25MM,SUP-2341913,CDM,C1713,HCPCS,0278,RC,,,,both,,,1172.88,762.37,,,,,,,,,,,,,
PLATE BNE L214MM 10 H ST R MED PROX TIB S STL LOK COMPR LO,SUP-2185679,CDM,C1713,HCPCS,0278,RC,,,,both,,,4694.46,3051.40,,,,,,,,,,,,,
KIT ACCESS VASCULAR 21030,SUP-2853473,CDM,C1769,HCPCS,0272,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
CHRONOS TM BETA-TCP BLOCK,SUP-2823512,CDM,C1713,HCPCS,0278,RC,,,,both,,,872.61,567.20,,,,,,,,,,,,,
PLATE BNE NAR 3.5X161 MM 9 HOLE SS LCP,SUP-2569353,CDM,C1713,HCPCS,0278,RC,,,,both,,,535.37,347.99,,,,,,,,,,,,,
COIL NEUROVASCULAR DELTAMAXX CERECYTE L 33 CM DIA 7 MM,SUP-2460527,CDM,C1889,HCPCS,0278,RC,,,,both,,,7605.80,4943.77,,,,,,,,,,,,,
INSERT TIB L83MM THK18MM UNIV KNEE PRI ANTR STBL NEUT ASCNT,SUP-2407235,CDM,C1776,CPT,0278,RC,,,,both,,,3114.88,2024.67,,,,,,,,,,,,,
BIT DRL L5IN DIA11/64IN S STL TWST,SUP-2412259,CDM,2720000010,LOCAL,0272,RC,,,,both,,,109.90,71.43,,,,,,,,,,,,,
HC Cardiac Rehab Phase 3 -1 Visit (Bulk Charge for 45 Visits),PX-9900000116,CDM,9900000116,LOCAL,0990,RC,,,,both,,,225.00,146.25,,,,,,,,,,,,,
CATHETER THRMDIL 7.5FRX110CM SIX LUMN REFOX VOL OXMTR W/ AMC,SUP-2214321,CDM,C1751,HCPCS,0278,RC,,,,both,,,624.36,405.83,,,,,,,,,,,,,
CATHETER KIT DL 8 FRX6 IN GUIDE RAULERSON CVC POLYURETHANE,SUP-2383947,CDM,C1750,HCPCS,0278,RC,,,,both,,,1396.73,907.87,,,,,,,,,,,,,
PLATE BNE RNG ATTCH SM 3.5 MM RT PROX GTR TROCH NS VA-LCP,SUP-2757652,CDM,C1713,HCPCS,0278,RC,,,,both,,,4281.55,2783.01,,,,,,,,,,,,,
PLATE BNE L 29.21 X W 25.22 MM THK 0.6 MM ADV 10 MM SCREW LT,SUP-2937356,CDM,C1713,HCPCS,0278,RC,,,,both,,,788.14,512.29,,,,,,,,,,,,,
PERI SCR 40MMX60MM,SUP-2726463,CDM,C1713,HCPCS,0278,RC,,,,both,,,89.02,57.86,,,,,,,,,,,,,
PLATE BNE L 33 MM 4 HOLE SCREW DIA 2.7 MM STAINLESS STL RECO,SUP-2931381,CDM,C1713,HCPCS,0278,RC,,,,both,,,1246.52,810.24,,,,,,,,,,,,,
IMPLANT LOOP ADJ W/O BTTN STRL DISP PROCINCH,SUP-2905820,CDM,C1713,HCPCS,0278,RC,,,,both,,,800.70,520.45,,,,,,,,,,,,,
BIOPSY PROCEDURE KIT UNIV LNG BLDELSS PRB MARKER MAMTOM MUK304] DEVICOR MED PRODUCTS MAMMOTOME],SUP-2195663,CDM,C1713,HCPCS,0278,RC,,,,both,,,1986.68,1291.34,,,,,,,,,,,,,
SYSTEM DEL AORT TRANSCATHETER HRT VLV BIOPROSTHESIS STNT,SUP-2280902,CDM,C1894,HCPCS,0272,RC,,,,both,,,6625.40,4306.51,,,,,,,,,,,,,
MCCULLOCH MULTI TOOTH BLADE 30 CM TITANIUM,SUP-2676425,CDM,2720000010,LOCAL,0272,RC,,,,both,,,354.95,230.72,,,,,,,,,,,,,
DEFIBRILLATOR IMPL CONFIENT W 6.7 X H 8.25 CM D 1.45 CM 41 J,SUP-2149191,CDM,C1882,HCPCS,0275,RC,,,,both,,,44588.00,28982.20,,,,,,,,,,,,,
CATHETER HD STR 14.5 FRX36 CM LT DL STP BASIC SET HEMO-FLOW,SUP-2627204,CDM,C1750,HCPCS,0278,RC,,,,both,,,119.32,77.56,,,,,,,,,,,,,
DEVICE FIX FULL MESH ABSORBABLE W/ ARTICULATING OPTIFIX AT,SUP-2858041,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1083.30,704.14,,,,,,,,,,,,,
KETAMINE HCL 50 MG/5ML IJ SOSY,RX-143112,CDM,2500000003,HCPCS,0250,RC,71266-9080-02,NDC,,both,0.5,ML,54.10,35.16,,,,,,,,,,,,,
PLATE BNE L185MM 12 H NONSTERILE R PROX TIB TI LOK COMPR LO,SUP-2190886,CDM,C1713,HCPCS,0278,RC,,,,both,,,4370.35,2840.73,,,,,,,,,,,,,
PROBE BRST BX 18GA TI W/ RADPQ CLP W/IN HYDRGEL MAMTOM,SUP-2195599,CDM,A4648,CPT,0278,RC,,,,both,,,24.18,15.72,,,,,,,,,,,,,
ROD EXT FIX SM L117MM DIA4MM 90DEG UNIV C FBR CRV CONN,SUP-2188717,CDM,C1713,HCPCS,0278,RC,,,,both,,,547.58,355.93,,,,,,,,,,,,,
SLING GYN W1XL60CM MIDURETHRAL RETROPUBIC SYN POLYPR SUPRIS R,SUP-2165382,CDM,C1771,HCPCS,0278,RC,,,,both,,,2954.74,1920.58,,,,,,,,,,,,,
SCREW BNE L30MM DIA3.5MM SHT THRD HD MINI-MONSTER,SUP-2320504,CDM,C1713,HCPCS,0278,RC,,,,both,,,718.28,466.88,,,,,,,,,,,,,
PLATE BNE MTP L FLAT MINI MAXLOCK EXTRM,SUP-2400411,CDM,C1713,HCPCS,0278,RC,,,,both,,,5702.24,3706.46,,,,,,,,,,,,,
STEM FEM L200MM DIA16MM LNG PROX KNEE TI PPS PUREFIX BOW,SUP-2376538,CDM,C1776,CPT,0278,RC,,,,both,,,11547.04,7505.58,,,,,,,,,,,,,
SCREW HEADED 25X10MM,SUP-2696128,CDM,C1713,HCPCS,0278,RC,,,,both,,,1090.84,709.05,,,,,,,,,,,,,
PLATE BONE L21MM 3X3 H S STL RAD NK ELBW POLYAX LCK LO PROF,SUP-2397935,CDM,C1713,HCPCS,0278,RC,,,,both,,,4615.80,3000.27,,,,,,,,,,,,,
STENT COR CATH 5FR L19MM 2.5MM 0.014IN 8ATM CO CHROM,SUP-2155971,CDM,C1876,HCPCS,0278,RC,,,,both,,,3673.80,2387.97,,,,,,,,,,,,,
INTRODUCER SHTH LAMP 135 0.032 IN 3 MM 8 FRX63 CM 8 FRX67 CM,SUP-2357237,CDM,C1893,HCPCS,0272,RC,,,,both,,,558.92,363.30,,,,,,,,,,,,,
SPHERE GLEN TILTED 10 DEG 39 MM 29 MM SHLDR COCR AEQUALIS,SUP-2715797,CDM,C1776,CPT,0278,RC,,,,both,,,9438.84,6135.25,,,,,,,,,,,,,
IMIPRAMINE HCL 25 MG PO TABS,RX-3861,CDM,6370000000,HCPCS,0637,RC,69315-0134-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PLATE BONE 7 H LT FIBULAR ANAT FOR ANK FX GORILLA,SUP-2321561,CDM,C1713,HCPCS,0278,RC,,,,both,,,7206.30,4684.09,,,,,,,,,,,,,
PLATE BNE L97MM THK1.3MM 100DEG 8 H TI TBLR FOR 3.5MM SCR,SUP-2412038,CDM,C1713,HCPCS,0278,RC,,,,both,,,265.05,172.28,,,,,,,,,,,,,
PLATE BNE L 95 MM SCREW DIA2.4 MM 5 HD 10 SHFT H TI Y SHP NS,SUP-2927235,CDM,C1713,HCPCS,0278,RC,,,,both,,,2785.97,1810.88,,,,,,,,,,,,,
PIN FIX L 60 MM DIA 3.5 MM PROV LG TARGETER SYS STRL EVOS,SUP-2933596,CDM,C1713,HCPCS,0278,RC,,,,both,,,1740.82,1131.53,,,,,,,,,,,,,
TEMPLATE SURG SM ANTR STPL REVERE,SUP-2232149,CDM,C1713,HCPCS,0278,RC,,,,both,,,1466.38,953.15,,,,,,,,,,,,,
CANNULA PERF 22FR 20DEG W/ DIL EC BYPS PROC ANGIOVAC,SUP-2118779,CDM,2720000010,LOCAL,0272,RC,,,,both,,,36110.00,23471.50,,,,,,,,,,,,,
STEM FEM PRSS FIT LAT POR TI 12/14 9MM DIA 137MM TAPRLOK,SUP-2408381,CDM,C1776,CPT,0278,RC,,,,both,,,12748.40,8286.46,,,,,,,,,,,,,
PROBE LASER 25GA STD STR TAPR TIP DISP ENDOPRB,SUP-2247213,CDM,C1713,HCPCS,0278,RC,,,,both,,,528.56,343.56,,,,,,,,,,,,,
CYTARABINE (PF) 20 MG/ML IJ SOLN,RX-96896,CDM,J9100,HCPCS,0636,RC,61703-0305-38,NDC,,both,5,ML,54.10,35.16,,,,,,,,,,,,,
PLEDGET SURGICAL W3/8XL1/16IN THK1.5MM PTFE RECTANGLE,SUP-2425485,CDM,C1768,CPT,0278,RC,,,,both,,,74.45,48.39,,,,,,,,,,,,,
OXYBUTYNIN CHLORIDE 5 MG/5ML PO SOLN,RX-161504,CDM,340b,HCPCS,0637,RC,09999-9902-22,NDC,,both,2.5,ML,3.40,2.21,,,,,,,,,,,,,
BIT DRL L 115/30 MM DIA2 MM SCREW DIA2.7 MM CALIB AO QC STRL,SUP-2907646,CDM,2720000010,LOCAL,0272,RC,,,,both,,,774.80,503.62,,,,,,,,,,,,,
MESH HERN L6XW3IN DISP TRELEX NAT,SUP-2227625,CDM,C1781,HCPCS,0278,RC,,,,both,,,252.39,164.05,,,,,,,,,,,,,
CATHETER HAD AD 14FR L15CM ADMIN BASIC KT DBL LUMN POLYUR,SUP-2266963,CDM,C1752,HCPCS,0278,RC,,,,both,,,185.26,120.42,,,,,,,,,,,,,
PIN FXTN 32MM DIA 70MML 13MM THRD F/EXTRNL FXTN SSTM X FIX,SUP-2681413,CDM,C1713,HCPCS,0278,RC,,,,both,,,662.45,430.59,,,,,,,,,,,,,
CATHETER INTVASC ULTRASOUND VIEWFLEX X ICE L 90 CM DIA 9 FR,SUP-2880927,CDM,C1759,HCPCS,0272,RC,,,,both,,,3612.88,2348.37,,,,,,,,,,,,,
GRAFT NERVE REP L 4 X W 2 CM AMNIO MEMBRN MULTLYRED MTRX,SUP-2914047,CDM,C1762,CPT,0278,RC,,,,both,,,7049.30,4582.04,,,,,,,,,,,,,
PACK VTRCTMY 25GA PSTRR STAND WIDE FIELD ILLMNTR F/VSN ENHNC,SUP-2497590,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1650.38,1072.75,,,,,,,,,,,,,
LEAD PACE SWEET PICOTIP RX L 70 CM SIL ENDOCARD RT,SUP-2148637,CDM,C1898,HCPCS,0275,RC,,,,both,,,2336.16,1518.50,,,,,,,,,,,,,
STENT URET L 24 CM DIA 7 FR PTFE GUIDEWIRE L 100 CM DIA BLK,SUP-2312684,CDM,C2617,HCPCS,0278,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
VALVE VENT LO REG W O RESVR N PROGRAMMABLE 54FR 3CM,SUP-2284395,CDM,C1713,HCPCS,0278,RC,,,,both,,,1926.77,1252.40,,,,,,,,,,,,,
SPLINT ORTHOPEDIC MED LT MTCRPL,SUP-2124892,CDM,L3808,HCPCS,0274,RC,,,,both,,,32.97,21.43,,,,,,,,,,,,,
ROD SPNL REDUCTION TEMP POINTER SEXTANT II,SUP-2630475,CDM,C1713,HCPCS,0278,RC,,,,both,,,1369.51,890.18,,,,,,,,,,,,,
GRAFT HUM TISS W5XL10CM THK.9-1.99MM ACELLULAR DERM MTRX 480900510] ZIMMER BIOMET BIOLOGICS],SUP-2402510,CDM,Q4126,HCPCS,0636,RC,,,,both,,,6751.00,4388.15,,,,,,,,,,,,,
MESH SYNTH ABD BIOMATERIAL N ABSRB EXP,SUP-2395360,CDM,C1781,HCPCS,0278,RC,,,,both,,,188.40,122.46,,,,,,,,,,,,,
SET INTRO MICROPUNCTURE L 13 CM DIL L 20 CM OD 7 FR ID 2.3,SUP-2168785,CDM,C1894,HCPCS,0272,RC,,,,both,,,123.81,80.48,,,,,,,,,,,,,
MESH CRAN L 23.6 X W 13.2 CM THK 0.07 CM SZ 2 MM TI NS DISP,SUP-2935627,CDM,C1713,HCPCS,0278,RC,,,,both,,,1164.94,757.21,,,,,,,,,,,,,
PLATE BNE L60MM THK1.3MM 2X8 H MTCRPL TI T SHP COMPR FOR,SUP-2267917,CDM,C1713,HCPCS,0278,RC,,,,both,,,1042.48,677.61,,,,,,,,,,,,,
PLATE BONE W40XH0.3XL60MM CRANIOFACIAL VIT MESH MALL FOR,SUP-2364704,CDM,C1713,HCPCS,0278,RC,,,,both,,,2301.62,1496.05,,,,,,,,,,,,,
BRACE ANKLEXL AD FOR 11.5-13IN UNIV VLY CNTOUR STL STAY,SUP-2197935,CDM,L4350,HCPCS,0274,RC,,,,both,,,30.21,19.64,,,,,,,,,,,,,
CONNECTOR SPNL 35.5MM-40MM SM CROSS CLMP ADJ TI,SUP-2415636,CDM,C1713,HCPCS,0278,RC,,,,both,,,1147.98,746.19,,,,,,,,,,,,,
PLATE BONE L202MM 16 H STRL LT LAT DSTL FIBULAR S STL FOR,SUP-2349761,CDM,C1713,HCPCS,0278,RC,,,,both,,,6274.35,4078.33,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE 10 CC VIABLE MTRX NEO MTX,SUP-2901719,CDM,C1713,HCPCS,0278,RC,,,,both,,,15112.82,9823.33,,,,,,,,,,,,,
CATHETER PERIPH 5FR L135CM 0.014IN DST TIP 0.028IN RADPQ,SUP-2383147,CDM,C1887,HCPCS,0272,RC,,,,both,,,1915.40,1245.01,,,,,,,,,,,,,
PLATE BNE MESHED 0.6 MM 3X20 HOLE SPECIALITY PLLA-PGA STRL,SUP-2472274,CDM,C1713,HCPCS,0278,RC,,,,both,,,3169.52,2060.19,,,,,,,,,,,,,
RING EXT FIX SLT 1/8 UNIV SALVATION,SUP-2851105,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1463.24,951.11,,,,,,,,,,,,,
STEM FEM L100MM DIA10MM KNEE CO CHROM ALLY PORCOAT STR CEM,SUP-2252656,CDM,C1776,CPT,0278,RC,,,,both,,,10385.55,6750.61,,,,,,,,,,,,,
EVOS 2.7/3.5MM M-D HUMERIGHTUS PL 9H RIGHT 146MM,SUP-2820153,CDM,C1713,HCPCS,0278,RC,,,,both,,,8787.13,5711.63,,,,,,,,,,,,,
SODIUM CHLORIDE 3% IV BOLUS,RX-4082505,CDM,J7131,HCPCS,0258,RC,00264-7805-10,NDC,,both,100,ML,9.40,6.11,,,,,,,,,,,,,
SUBSTITUTE BNE GRFT 10X10X4MM DEMIN CANC FILL MTRX CNFRM,SUP-2894186,CDM,C1713,HCPCS,0278,RC,,,,both,,,798.19,518.82,,,,,,,,,,,,,
GUIDEWIRE ENDO EXCHG TUBE DISP,SUP-2152523,CDM,C1769,HCPCS,0272,RC,,,,both,,,211.01,137.16,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED HYBRID HD SHELL TRAB MEL CERM,SUP-2212726,CDM,C1776,CPT,0278,RC,,,,both,,,13831.17,8990.26,,,,,,,,,,,,,
PIN FIX SHT THRD,SUP-2267681,CDM,C1713,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY PENTARAY L115CM 7FR 2-6-2MM D CRV,SUP-2912313,CDM,C1731,HCPCS,0278,RC,,,,both,,,3559.25,2313.51,,,,,,,,,,,,,
PATCH DURAL SUB 7.5X7.5CM ONLAY LYCOPLANT,SUP-2717536,CDM,C1763,HCPCS,0278,RC,,,,both,,,1731.05,1125.18,,,,,,,,,,,,,
CURETTE SURG MARINO 5-3/8 IN 3 MM TRNSSPHND VERTICAL RNG,SUP-2872847,CDM,C1762,CPT,0278,RC,,,,both,,,914.02,594.11,,,,,,,,,,,,,
GUIDEWIRE ORTHOPEDIC N THRD 1.4X150 MM,SUP-2221706,CDM,C1769,HCPCS,0272,RC,,,,both,,,100.48,65.31,,,,,,,,,,,,,
PLATE BNE L81MM 4 H NONSTERILE R SUP ANT CLAV S STL LOK,SUP-2184131,CDM,C1713,HCPCS,0278,RC,,,,both,,,2594.39,1686.35,,,,,,,,,,,,,
TRAY CTRL VEN CATH 2.5FR L2.5CM 0.015IN GWIRE TIP NDL,SUP-2167881,CDM,C1751,HCPCS,0278,RC,,,,both,,,114.45,74.39,,,,,,,,,,,,,
PLATE CRAN L 14 MM THK 0.4 MM SCREW DIA1.5 MM TI SHUNT LP,SUP-2883402,CDM,C1713,HCPCS,0278,RC,,,,both,,,1118.53,727.04,,,,,,,,,,,,,
PLATE BNE THK0.4MM ORBIT PNK TI MESH MATRIXMIDFACE,SUP-2181660,CDM,C1713,HCPCS,0278,RC,,,,both,,,4941.10,3211.71,,,,,,,,,,,,,
DEFIBRILLATOR CARD 36J RESYNCHRONIZATION THER 2 CHMBR ATLS,SUP-2356596,CDM,C1721,HCPCS,0275,RC,,,,both,,,90275.00,58678.75,,,,,,,,,,,,,
SCREW BONE L60MM DIA5.5MM PARTIALLY THRD HD L CANN,SUP-2225349,CDM,C1713,HCPCS,0278,RC,,,,both,,,791.28,514.33,,,,,,,,,,,,,
PROBE OPHTH VITRECTOMY 20 GA STD TAPR TIP ENDOPROBE,SUP-2225636,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1059.75,688.84,,,,,,,,,,,,,
SCREW BONE SCHANZ 2.5 MM 4X70 MM SELFDRILLING TITANIUM NONST,SUP-2842152,CDM,C1713,HCPCS,0278,RC,,,,both,,,1369.35,890.08,,,,,,,,,,,,,
NAIL INTRMDLLRY L200MM OD9MM UNVRSL HMRL CNNLTD LOK END CAP,SUP-2484515,CDM,C1713,HCPCS,0278,RC,,,,both,,,4644.06,3018.64,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE 4-10 MM 30 CC CANC PROX DSTL END LNG,SUP-2913264,CDM,C1713,HCPCS,0278,RC,,,,both,,,3215.36,2089.98,,,,,,,,,,,,,
SCREW SPNL STD OPN BODY PHOENIX,SUP-2316620,CDM,C1713,HCPCS,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
WIRE EXT FIX DIA1.2 MM SMTH FOR SM BNE FIX STRL DISP TSF,SUP-2933519,CDM,C1713,HCPCS,0278,RC,,,,both,,,359.94,233.96,,,,,,,,,,,,,
SHUNT CV SUNDT L 30 CM DSTL TBNG OD 4 MM ID 2 MM PROX TBNG,SUP-2308225,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2093.53,1360.79,,,,,,,,,,,,,
BRACE WLK XL 13+ M 15+ WOM ANK FOAM PNEUMAT SEMI RIG SHELL,SUP-2196362,CDM,L4361,HCPCS,0274,RC,,,,both,,,138.16,89.80,,,,,,,,,,,,,
KIT REVISION GRAFT BONE DOWEL 13 MM,SUP-2836345,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
HC Platelet Conc. Each Unit,PX-3900901900,CDM,P9019,CPT,0390,RC,,,,both,,,374.00,243.10,,,,,,,,,,,,,
CATHETER EP DIAG MAP D CRV QPLR 5MM SPC 5MM TIP UNI DIR RF,SUP-2356794,CDM,C1730,HCPCS,0272,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
SCISSORS ENDO L33CM L5MM SMOOTH ROTICULATING NONRETRACTABLE,SUP-2312662,CDM,2720000010,LOCAL,0272,RC,,,,both,,,675.10,438.81,,,,,,,,,,,,,
PLATE BNE L 118 SCREW DIA 3.5 MM 10 H SS RECON NS,SUP-2908829,CDM,C1713,HCPCS,0278,RC,,,,both,,,1619.64,1052.77,,,,,,,,,,,,,
RHS RADIAMETERL HEAD DIAMETER 24MM,SUP-2830221,CDM,C1776,CPT,0278,RC,,,,both,,,4813.62,3128.85,,,,,,,,,,,,,
OBTURATOR ENDOSCP SHT,SUP-2496811,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1767.19,1148.67,,,,,,,,,,,,,
ALLOGRAFT BNE 4X8X20 MM BIOEXPAND,SUP-2637000,CDM,C1713,HCPCS,0278,RC,,,,both,,,2869.24,1865.01,,,,,,,,,,,,,
VEST PT CERV HALO,SUP-2322423,CDM,L0112,HCPCS,0272,RC,,,,both,,,19625.00,12756.25,,,,,,,,,,,,,
COMPONENT HUM W10XL8MM SHLDR ASMBLY GLOB,SUP-2250012,CDM,C1776,CPT,0278,RC,,,,both,,,4945.50,3214.57,,,,,,,,,,,,,
BURR ROUTER FLUTED 1.12MM X 6.35MM SHD6RG1,SUP-2843321,CDM,2720000010,LOCAL,0272,RC,,,,both,,,443.71,288.41,,,,,,,,,,,,,
CATHETER PICC ARROWG+ARD BLUE ADVANCE 6FR 55CM 3-LUMEN,SUP-2887070,CDM,C1751,HCPCS,0278,RC,,,,both,,,730.58,474.88,,,,,,,,,,,,,
MESH HERN DIA9CM UMB RND PARIETEX,SUP-2752148,CDM,C1781,HCPCS,0278,RC,,,,both,,,1520.51,988.33,,,,,,,,,,,,,
PLATE BNE L109MM THK3MM 7 H BILAT S STL STR LIMIT CNTCT DYN,SUP-2185336,CDM,C1713,HCPCS,0278,RC,,,,both,,,1659.58,1078.73,,,,,,,,,,,,,
POST EXT FIX 3/5 2 CLMP IMPL,SUP-2136334,CDM,2720000010,LOCAL,0272,RC,,,,both,,,753.60,489.84,,,,,,,,,,,,,
COMPONENT TOT KNEE BICOMPARTMENTAL MEDL LT W/O PAT RESURF,SUP-2165958,CDM,C1776,CPT,0278,RC,,,,both,,,21352.00,13878.80,,,,,,,,,,,,,
GRAFT VASC GORTX L 40 CM DIA 4.5-6.5 MM EPTFE TAPR STD WALL,SUP-2396443,CDM,C1768,CPT,0278,RC,,,,both,,,1325.08,861.30,,,,,,,,,,,,,
FIXATION KIT OFFSET 15X20X20 MM 4 MM SPPEDSHIFT,SUP-2135438,CDM,C1713,HCPCS,0278,RC,,,,both,,,6248.60,4061.59,,,,,,,,,,,,,
BLADE SAW W13XL90MM THK119MM S STL OSC STABLECUT,SUP-2253183,CDM,C1713,HCPCS,0278,RC,,,,both,,,314.63,204.51,,,,,,,,,,,,,
GRAFT HUM TISS W4XL8CM THK0.5-.9MM ACELLULAR DERM MTRX,SUP-2421360,CDM,Q4126,HCPCS,0636,RC,,,,both,,,6160.68,4004.44,,,,,,,,,,,,,
SCREW BNE L16MM OD27MM TI CORT DST FIBULAR ST LOK FULL THRD,SUP-2417469,CDM,C1713,HCPCS,0278,RC,,,,both,,,496.43,322.68,,,,,,,,,,,,,
KIT INTMED MST CATHETER SGL LUMN S STL GWIRE AND LIDO W PASV,SUP-2118830,CDM,C1751,HCPCS,0278,RC,,,,both,,,540.08,351.05,,,,,,,,,,,,,
THEOPHYLLINE ER 400 MG PO TB24,RX-36973,CDM,6370000000,HCPCS,0637,RC,29033-0001-01,NDC,,both,1,UN,5.50,3.57,,,,,,,,,,,,,
ALLOGRAFT BNE STRP 20X50X2 MM FD SPNG CANC READIGRAFT BLX,SUP-2740799,CDM,C1713,HCPCS,0278,RC,,,,both,,,3357.88,2182.62,,,,,,,,,,,,,
LOW PRFLE NEURO PLATE STRGHT 2 HOLE LNG CP TTNM ST,SUP-2677535,CDM,C1713,HCPCS,0278,RC,,,,both,,,208.81,135.73,,,,,,,,,,,,,
MICROCATHETER VASC PROXIMAL/DST 3/2.8FR L150CM LUMN,SUP-2147591,CDM,C1887,HCPCS,0272,RC,,,,both,,,1161.80,755.17,,,,,,,,,,,,,
HC Chloride Urine,PX-3018243600,CDM,82436,CPT,0301,RC,,,,inpatient,,,195.00,126.75,,,,,,,,,,,,,
COMPONENT TIB 1 PC PROX 15MM DIA 95MML FINN,SUP-2406146,CDM,C1776,CPT,0278,RC,,,,both,,,20767.96,13499.17,,,,,,,,,,,,,
KIT CELL HARVESTING AUTOLGS FOR WND HEALING THERM BURN FULL,SUP-2927449,CDM,C1832,CPT,0272,RC,,,,both,,,21587.50,14031.87,,,,,,,,,,,,,
PROSTHESIS OSS PORE DISC 1X54 MM EAR PLAS,SUP-2312558,CDM,L8613,CPT,0278,RC,,,,both,,,152.01,98.81,,,,,,,,,,,,,
GUIDEWIRE VASC VASSALLO GT L 190 CM DIA 0.018 IN TIP LOAD 30,SUP-2909245,CDM,C1769,HCPCS,0272,RC,,,,both,,,115.46,75.05,,,,,,,,,,,,,
HC in Situ Hybridization 1st Probe Stain,PX-3128836500,CDM,88365,CPT,0312,RC,,,,both,,,232.00,150.80,,,,,,,,,,,,,
PLATE SPNL SLAP SPCR CAPSTONE,SUP-2285080,CDM,2720000010,LOCAL,0272,RC,,,,both,,,453.51,294.78,,,,,,,,,,,,,
DRILL SURG VAR 35 MM,SUP-2417120,CDM,2720000010,LOCAL,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
PROSTHESIS OSS DE LA CRUZ PISTON 0.6X5 MM SS FLROPLAS,SUP-2638116,CDM,L8613,CPT,0278,RC,,,,both,,,486.10,315.96,,,,,,,,,,,,,
SCREW BNE ST 2.7X10 MM 2.4 MM LCK HD W/ T8 STARDRV RECESS SS,SUP-2569615,CDM,C1713,HCPCS,0278,RC,,,,both,,,94.99,61.74,,,,,,,,,,,,,
CATHETER EMB NOVASIL SYNTEL L 60 CM DIA2 FR BALLOON DIA 4 MM,SUP-2264193,CDM,C1757,HCPCS,0272,RC,,,,both,,,624.86,406.16,,,,,,,,,,,,,
PLATE BNE SHFT L204MM BLDE L70MM THK4.8MM 95DEG 12 H,SUP-2185464,CDM,C1713,HCPCS,0278,RC,,,,both,,,3227.83,2098.09,,,,,,,,,,,,,
ELECTRODE ENDO COAG BALL END STRL YEL OD24FR 5MM,SUP-2261176,CDM,2720000010,LOCAL,0272,RC,,,,both,,,400.35,260.23,,,,,,,,,,,,,
CROWN DENT 7 S STL 1ST PRI M LO LT ANTR CUSPID PREFABRICATED,SUP-2238892,CDM,D6783,CPT,0278,RC,,,,both,,,20.41,13.27,,,,,,,,,,,,,
BLADE OSTEO SAW HUB STYL S,SUP-2107137,CDM,2720000010,LOCAL,0272,RC,,,,both,,,210.38,136.75,,,,,,,,,,,,,
KIT SEEDNET INDIV ICE ROD NDL,SUP-2225990,CDM,C2618,HCPCS,0272,RC,,,,both,,,4702.15,3056.40,,,,,,,,,,,,,
CATHETER CV SET 018 PEDIATRIC 4 FRX5 CM DL CUDLM401JPED,SUP-2760046,CDM,C1751,HCPCS,0278,RC,,,,both,,,236.25,153.56,,,,,,,,,,,,,
HC Inj for Cholangiogram New Acc,PX-3614753200,CDM,47532,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
GII CONST INSRT W/JRNY LOCK SZ 3-4 15MM,SUP-2822672,CDM,C1776,CPT,0278,RC,,,,both,,,7002.20,4551.43,,,,,,,,,,,,,
COIL EMB L3CM DIA0.02IN LOOP DIA2MM COMPLX EXTRA SFT FILL,SUP-2323426,CDM,C1889,HCPCS,0278,RC,,,,both,,,5849.82,3802.38,,,,,,,,,,,,,
ALLOGRAFT BNE PLUG 9 MM OSTEOCHNDRL,SUP-2866830,CDM,C1762,CPT,0278,RC,,,,both,,,11424.89,7426.18,,,,,,,,,,,,,
DEVICE CLOSURE PDLOK CLP PRO-SELECT L 162 CM OD 19 MM ID 11,SUP-2360695,CDM,C1760,HCPCS,0278,RC,,,,both,,,1497.28,973.23,,,,,,,,,,,,,
GRAFT ALLGRFT PARTICULATE CORT DEMIN FRZ DRY READIGRFT 20CC,SUP-2264721,CDM,C1713,HCPCS,0278,RC,,,,both,,,1322.91,859.89,,,,,,,,,,,,,
SNARE ENDOSCP 15 MMX230 CM POLYP OVL LOOP SD-12U-1 WIRE REPL,SUP-2468176,CDM,2720000010,LOCAL,0272,RC,,,,both,,,508.93,330.80,,,,,,,,,,,,,
GRAFT ENDOVASC L14CM DIA27MM IL LIMB EXCLUDER,SUP-2395963,CDM,C1876,HCPCS,0278,RC,,,,both,,,12874.00,8368.10,,,,,,,,,,,,,
HC Rep Lac Simple Face 20.1-30.0c,PX-4501201700,CDM,12017,CPT,0450,RC,,,,both,,,1445.00,939.25,,,,,,,,,,,,,
SCREW BNE L12MM DIA2.7MM HEX HD DIA2.5MM CANC BIODUR 108C,SUP-2411044,CDM,C1713,HCPCS,0278,RC,,,,both,,,320.85,208.55,,,,,,,,,,,,,
CATHETER THROMCTMY LIGHTNING FLSH HTORQ L 100 CM DIA 6 FR,SUP-2937135,CDM,C1757,HCPCS,0272,RC,,,,both,,,30301.00,19695.65,,,,,,,,,,,,,
SPHERE GLEN LAT SM 36 MM SHLDR GLENOSPHERE RVS EXP EQUINOXE,SUP-2451441,CDM,C1776,CPT,0278,RC,,,,both,,,3611.00,2347.15,,,,,,,,,,,,,
REAMER EXTRACTION SZ 4 MM SCREW DIA 3.4-4 MM STRL DISP,SUP-2913585,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2748.07,1786.25,,,,,,,,,,,,,
PLATE CRAN 160X160X40 MM PT SPEC IMPL PEEK,SUP-2860160,CDM,C1713,HCPCS,0278,RC,,,,both,,,46780.03,30407.02,,,,,,,,,,,,,
ROMIPLOSTIM 500 MCG SC SOLR,RX-93567,CDM,J2802,HCPCS,0636,RC,55513-0222-01,NDC,,both,1,UN,16242.80,10557.82,,,,,,,,,,,,,
LEAD PACE ENDO RA RV IS-1 CONN BPLR SIL INSUL FINELINE II,SUP-2148668,CDM,C1779,HCPCS,0275,RC,,,,both,,,2555.96,1661.37,,,,,,,,,,,,,
MODULE PT POS 2.0 LIF-PTP ATEC,SUP-2739132,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
CATHETER CTRL VEN 3 LUMN N TUNNELED BASIC KT POLYUR ANTIMIC,SUP-2383308,CDM,C1751,HCPCS,0278,RC,,,,both,,,192.61,125.20,,,,,,,,,,,,,
VALVE AORT CARP EDW PERIMT RSR 27 MM BOV PERICARD COCR REDUC,SUP-2214074,CDM,C1889,HCPCS,0278,RC,,,,both,,,20408.43,13265.48,,,,,,,,,,,,,
GRAFT NSL REP N DERM BIODESIGN 4X7 CM,SUP-2170297,CDM,C1763,HCPCS,0278,RC,,,,both,,,1648.50,1071.52,,,,,,,,,,,,,
CLIP SAFETY BONE TRANSPORT,SUP-2468106,CDM,2720000010,LOCAL,0272,RC,,,,both,,,69.08,44.90,,,,,,,,,,,,,
BUR SURGICAL CUSHING,SUP-2792303,CDM,2720000010,LOCAL,0272,RC,,,,both,,,527.27,342.73,,,,,,,,,,,,,
SYSTEM KNEE N POR CO CHROM FEM COMP N POR TIB JOURNEY,SUP-2347990,CDM,C1776,CPT,0278,RC,,,,both,,,25079.18,16301.47,,,,,,,,,,,,,
MESH HERN W6XL6IN POLYPR SQ L PORE MFIL SFT KNIT,SUP-2125780,CDM,C1781,HCPCS,0278,RC,,,,both,,,543.22,353.09,,,,,,,,,,,,,
GRAFT BNE VOID FILL 15 CC MG,SUP-2742077,CDM,C1713,HCPCS,0278,RC,,,,both,,,16202.40,10531.56,,,,,,,,,,,,,
NEXGEN PROV A/P WEDGED TIB PLT SZ 5,SUP-2201706,CDM,C1713,HCPCS,0278,RC,,,,both,,,3925.00,2551.25,,,,,,,,,,,,,
SPINAL KIT 17 MM BUR HOLE COVER TITANIUM STERILE MATRIXNEURO,SUP-2837711,CDM,C1713,HCPCS,0278,RC,,,,both,,,3174.54,2063.45,,,,,,,,,,,,,
IMPLANT OTO L4MM DIA0.84MM DENS HA OFF CNTR,SUP-2312570,CDM,2780000010,LOCAL,0278,RC,,,,both,,,926.49,602.22,,,,,,,,,,,,,
HC I&D Abcess Complic Multiple,PX-4501006100,CDM,10061,CPT,0450,RC,,,,outpatient,,,405.00,263.25,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL PEEK SD800.544,SUP-2860225,CDM,C1713,HCPCS,0278,RC,,,,both,,,46755.86,30391.31,,,,,,,,,,,,,
PLATE BONE DSTL RAD TRL,SUP-2225432,CDM,C1713,HCPCS,0278,RC,,,,both,,,75.36,48.98,,,,,,,,,,,,,
FORCEPS BOWEL MTL HNDL 5MMX43CM,SUP-2261299,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3915.80,2545.27,,,,,,,,,,,,,
PLATE BNE SM W11XL176MM THK34MM 13 H BILAT TI RIG NEUT LOK,SUP-2190790,CDM,C1713,HCPCS,0278,RC,,,,both,,,1371.93,891.75,,,,,,,,,,,,,
LINER ACET OD48MM ID28MM GG METASUL HIP ALPHA UNCEMENTED,SUP-2204556,CDM,C1776,CPT,0278,RC,,,,both,,,5184.14,3369.69,,,,,,,,,,,,,
WIRE FIX L102MM OD1.1MM S STL SMOOTH TRCR PT TWO END SHRP,SUP-2304018,CDM,C1713,HCPCS,0278,RC,,,,both,,,13.56,8.81,,,,,,,,,,,,,
PLATE BNE H1.5MM 6 H MAND G TI LO PROF FRAC W/ BAR FOR,SUP-2366365,CDM,C1713,HCPCS,0278,RC,,,,both,,,1467.95,954.17,,,,,,,,,,,,,
BRA SURG SUPP LG 38-40 IN ZIPPER,SUP-2213721,CDM,L8000,HCPCS,0274,RC,,,,both,,,125.41,81.52,,,,,,,,,,,,,
LEAD DEFIB LUMAX 300 2 COIL,SUP-2138118,CDM,C1721,HCPCS,0275,RC,,,,both,,,63921.01,41548.66,,,,,,,,,,,,,
PLATE EXT FIX DIA180MM ANK FT FOR TRUELOK FRME ASSEMB,SUP-2316195,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1877.81,1220.58,,,,,,,,,,,,,
CATHETER HEMO DYLS OR HD L55CM OD13.5FR INSRTN L38CM SIL STR,SUP-2127696,CDM,C1750,HCPCS,0278,RC,,,,both,,,552.64,359.22,,,,,,,,,,,,,
BIT DRL QC 4 MMX7.68 IN 3 FLUT FOR 4.9 MM LCK BOLT NS,SUP-2905554,CDM,2720000010,LOCAL,0272,RC,,,,both,,,464.34,301.82,,,,,,,,,,,,,
BUR SHV L18CM DIA5.5MM ABRAD HI VISIBILITY SHTH DYONIC,SUP-2341867,CDM,2720000010,LOCAL,0272,RC,,,,both,,,387.13,251.63,,,,,,,,,,,,,
SCREW SPNL MULTAXL 11.5X110 MM CANN CD HORZ,SUP-2628411,CDM,C1713,HCPCS,0278,RC,,,,both,,,3355.88,2181.32,,,,,,,,,,,,,
PLATE BONE L84MM 10 H STRL S STL COMPR FOR 2.7MM SCR EVOS,SUP-2349624,CDM,C1713,HCPCS,0278,RC,,,,both,,,2293.49,1490.77,,,,,,,,,,,,,
PENTAMIDINE ISETHIONATE 300 MG IJ SOLR,RX-27430,CDM,J2516,HCPCS,0636,RC,13925-0515-01,NDC,,both,1,UN,489.70,318.30,,,,,,,,,,,,,
LINDEMANN BURR LG 80MM TOTAL LNGTH 35MM WRKNG LNGTH WNTCH,SUP-2677545,CDM,2720000010,LOCAL,0272,RC,,,,both,,,343.33,223.16,,,,,,,,,,,,,
STEM FEM SZ 15 L170X150MM ML34MM 135DEG TI PLSM SPRAYED HIP,SUP-2400570,CDM,C1776,CPT,0278,RC,,,,both,,,6908.00,4490.20,,,,,,,,,,,,,
PLATE BONE W14.1XL39.3MM THK1.1MM 14 H TI T Y LCK LO PROF,SUP-2411742,CDM,C1713,HCPCS,0278,RC,,,,both,,,1610.82,1047.03,,,,,,,,,,,,,
CLIP SPNL CONN XLNK,SUP-2286716,CDM,C1713,HCPCS,0278,RC,,,,both,,,1655.25,1075.91,,,,,,,,,,,,,
PHENYLEPHRINE HCL 0.25 % NA SOLN,RX-6243,CDM,6370000000,HCPCS,0637,RC,00225-0800-47,NDC,,both,15,ML,54.10,35.16,,,,,,,,,,,,,
HC Remove Tun Cath Vad W/Port,PX-3613659000,CDM,36590,CPT,0361,RC,,,,inpatient,,,3707.00,2409.55,,,,,,,,,,,,,
KIT ANK CARE AD H95IN UNIV BILAT W BRAC WRP CLD PK EXER,SUP-2196372,CDM,L4350,HCPCS,0274,RC,,,,both,,,53.91,35.04,,,,,,,,,,,,,
PLATE 95 DEG CONDYLAR 5 HOLES 40MM 92MM,SUP-2547642,CDM,C1713,HCPCS,0278,RC,,,,both,,,3174.04,2063.13,,,,,,,,,,,,,
BIT DRL DIA4.5MM CANN FOR DOCKING TECH,SUP-2120805,CDM,2720000010,LOCAL,0272,RC,,,,both,,,577.76,375.54,,,,,,,,,,,,,
TAP BONE L12MM DIA8MM BIO-TENODESIS,SUP-2121455,CDM,C1713,HCPCS,0278,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
SCREW LCK CANC 2.7X14MM,SUP-2397247,CDM,C1713,HCPCS,0278,RC,,,,both,,,430.65,279.92,,,,,,,,,,,,,
SCREW INTRF L23MM DIA9MM NONABSORBABLE ADV PEEK MILAGRO,SUP-2256774,CDM,C1713,HCPCS,0278,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
ALLOGRAFT BNE FRZN LT WHL RAD,SUP-2740816,CDM,C1762,CPT,0278,RC,,,,both,,,11702.15,7606.40,,,,,,,,,,,,,
SCREW BONE L50MM OD4.7MM WR FIX ANG LCK IMP MAESTRO,SUP-2407345,CDM,C1713,HCPCS,0278,RC,,,,both,,,492.98,320.44,,,,,,,,,,,,,
BRACE SHLDR L RT UNILAT LYCRA SPANDEX ORTHOSIS MFC II ROLYAN,SUP-2324867,CDM,L3660,HCPCS,0274,RC,,,,both,,,114.74,74.58,,,,,,,,,,,,,
WASHER EX FIX 1MM,SUP-2467313,CDM,2720000010,LOCAL,0272,RC,,,,both,,,139.82,90.88,,,,,,,,,,,,,
RASP SURG CRV MTP SAW CONCV R14 STRYKR CONN,SUP-2883377,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2245.10,1459.31,,,,,,,,,,,,,
ALLOGRAFT BNE 2.7X18 MM PIP STRL TENFUSE,SUP-2423166,CDM,C1889,HCPCS,0278,RC,,,,both,,,4229.58,2749.23,,,,,,,,,,,,,
BOOT CAST OPN TOE 2XS 5.5X3 IN OPN HEEL PROCARE,SUP-2196779,CDM,L4387,HCPCS,0272,RC,,,,both,,,15.42,10.02,,,,,,,,,,,,,
PLATE BNE THK15MM M 6 H TI LOK FOR 27MM SCR 2MM MINI SYS,SUP-2262963,CDM,C1713,HCPCS,0278,RC,,,,both,,,1630.48,1059.81,,,,,,,,,,,,,
GRAFT BNE SUB 15ML 25GM SYN TISS PSTE CA PHSPTE HA RESRB,SUP-2374937,CDM,C1713,HCPCS,0278,RC,,,,both,,,6886.02,4475.91,,,,,,,,,,,,,
COLLAGENASE 250 UNIT/GM EX OINT,RX-9682,CDM,6370000000,HCPCS,0637,RC,50484-0010-30,NDC,,both,30,GR,1428.60,928.59,,,,,,,,,,,,,
CANNULA ENDOSCP 3.5 MMX10 CM W/ LUER LCK CONN GRN YEL,SUP-2767459,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1467.51,953.88,,,,,,,,,,,,,
IMPLANT WRIST JOINT SIZE 20 SM CARPOMETACARPAL NUGRIP,SUP-2586708,CDM,C1776,CPT,0278,RC,,,,both,,,7501.37,4875.89,,,,,,,,,,,,,
VALVE VENT PUR TRACH TBNG SWALLOING LO PROF DISP PASSY MUIR,SUP-2322024,CDM,L8501,HCPCS,0274,RC,,,,both,,,231.10,150.21,,,,,,,,,,,,,
TRAY TIB SZ 2 STD ANK PROPHECY INFIN,SUP-2397274,CDM,C1776,CPT,0278,RC,,,,both,,,13985.56,9090.61,,,,,,,,,,,,,
HC Skin Test Candida,PX-3028648500,CDM,86485,CPT,0302,RC,,,,both,,,86.00,55.90,,,,,,,,,,,,,
SUPPORT ORTHOT LOWER EXTREMITY KNEE CTRL CNDYL PD,SUP-2435699,CDM,L2810,HCPCS,0272,RC,,,,both,,,231.23,150.30,,,,,,,,,,,,,
ANCHOR SUT 1MM MINI W/ 2-0 NDL DRL JUGGERKNOT,SUP-2212960,CDM,C1713,HCPCS,0278,RC,,,,both,,,1455.23,945.90,,,,,,,,,,,,,
HC Mod Sed Same Phys/Qhp 5/>Yrs,PX-3729915200,CDM,99152,CPT,0372,RC,,,,outpatient,,,297.00,193.05,,,,,,,,,,,,,
FILGRASTIM-AAFI 300 MCG/0.5ML IJ SOSY,RX-143507,CDM,Q5110,HCPCS,0636,RC,00069-0291-01,NDC,,both,0.5,ML,1259.30,818.54,,,,,,,,,,,,,
STABILIZER ORTH CHST CIRC 30-34 IN SM SZ 2 POLYESTER LYCRA,SUP-2914907,CDM,2720000010,LOCAL,0272,RC,,,,both,,,427.29,277.74,,,,,,,,,,,,,
PACEMAKER CRD 52X44X6 MM 11 CC 2 CHMBR GENRTR IDENTITY DR,SUP-2357344,CDM,C1785,HCPCS,0275,RC,,,,both,,,13188.00,8572.20,,,,,,,,,,,,,
OXAZEPAM 10 MG PO CAPS,RX-5930,CDM,6370000000,HCPCS,0637,RC,62584-0812-01,NDC,,both,1,UN,10.80,7.02,,,,,,,,,,,,,
TRAY HUM STD FOR COMPHSVE REV SHLDR SYS,SUP-2418442,CDM,C1776,CPT,0278,RC,,,,both,,,5146.46,3345.20,,,,,,,,,,,,,
PLATING,SUP-2900677,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1152.38,749.05,,,,,,,,,,,,,
SUPPORT ORTHOT LOWER EXTREMITY KNEE CTRL CNDYL PD,SUP-2435699,CDM,L2810,HCPCS,0274,RC,,,,both,,,231.23,150.30,,,,,,,,,,,,,
COUNTERSINK DRL FOR 7MM SCR HD MONSTER,SUP-2320967,CDM,C1713,HCPCS,0278,RC,,,,both,,,818.60,532.09,,,,,,,,,,,,,
MODEL 8F MACH 1 AL2 90CM SH HOLES,SUP-2664329,CDM,C1887,HCPCS,0272,RC,,,,both,,,160.14,104.09,,,,,,,,,,,,,
SHELL ACET SZ 50B 3 H LOGICAL G SER,SUP-2322426,CDM,C1776,CPT,0278,RC,,,,both,,,3579.60,2326.74,,,,,,,,,,,,,
CATHETER INFUSION 85 CM ROTATING WIRE EFFICIENT CLARIVEIN IC,SUP-2471532,CDM,C1751,HCPCS,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
RASP SPINE L INTBDY PYRAMETRIX,SUP-2292095,CDM,C1713,HCPCS,0278,RC,,,,both,,,2037.42,1324.32,,,,,,,,,,,,,
PLATE SPNL L14MM ANT CERV LOK BILAT LEV 1 PROVIDENCE,SUP-2229837,CDM,C1713,HCPCS,0278,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
SET INT FIX SCREW DIA1.5 MM 6 H TI NEURO CRV PLATE XDRV 12,SUP-2935601,CDM,C1713,HCPCS,0278,RC,,,,both,,,26322.62,17109.70,,,,,,,,,,,,,
GRAFT HUM TISS NAT MESH 5 MMX65 CM BIOGRAFT TRELEX,SUP-2129886,CDM,C1762,CPT,0278,RC,,,,both,,,310.86,202.06,,,,,,,,,,,,,
TAP SURG FIX FOR SNOWMASS ANTR CERV PLT SYS,SUP-2207792,CDM,2720000010,LOCAL,0272,RC,,,,both,,,983.45,639.24,,,,,,,,,,,,,
BUR SURG L26CM HD L351MM DIA3MM TAPR L BOR MIDAS REX,SUP-2277966,CDM,2720000010,LOCAL,0272,RC,,,,both,,,393.91,256.04,,,,,,,,,,,,,
MESH HERN W11XL6CM TRNSPAR MACROPOROUS MFIL POLYPR INGUINAL,SUP-2752153,CDM,C1781,HCPCS,0278,RC,,,,both,,,109.81,71.38,,,,,,,,,,,,,
CATHETER INFUS 2.1-1.3FR L167CM ID0.0165IN MIC STR 2 MRK,SUP-2305459,CDM,C1887,HCPCS,0272,RC,,,,both,,,3736.60,2428.79,,,,,,,,,,,,,
BASE GLEN L COMPHSVE MOD HYBRID,SUP-2404687,CDM,C1776,CPT,0278,RC,,,,both,,,5617.46,3651.35,,,,,,,,,,,,,
"HC Gbl New Pt, E/M Level 5",PX-9829920500,CDM,99205,CPT,0982,RC,,,,inpatient,,,802.00,521.30,,,,,,,,,,,,,
PIN POS DIA3MM FOR EASYCLIP,SUP-2378781,CDM,C1713,HCPCS,0278,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
"HC Gbl New Pt, E/M Level 5",PX-9829920500,CDM,99205,CPT,0982,RC,,,,outpatient,,,802.00,521.30,,,,,,,,,,,,,
SET INTRO FLX L 13 CM OD 5 FR ID 1.9 MM GUIDEWIRE L 40 CM,SUP-2168781,CDM,C1894,HCPCS,0272,RC,,,,both,,,118.06,76.74,,,,,,,,,,,,,
ENOXAPARIN SODIUM 40 MG/0.4ML IJ SOSY,RX-157661,CDM,J1650,HCPCS,0636,RC,63323-0564-63,NDC,,both,0.4,ML,54.10,35.16,,,,,,,,,,,,,
APPLICATOR SURG 10 CM LOCALIZER 21,SUP-2137814,CDM,A4648,CPT,0278,RC,,,,both,,,887.05,576.58,,,,,,,,,,,,,
HC Pt Neuro Facilitation Ea 15 Min|OP PT SERVICES|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS,PX-4209711200,CDM,97112,CPT,0420,RC,,,GP|CQ,both,,,159.00,103.35,,,,,,,,,,,,,
GUIDEWIRE VASC L 300 CM 0.035IN L 7CM 3CM AMPLTZ STR X STIFF,SUP-2167976,CDM,C1769,HCPCS,0272,RC,,,,both,,,90.31,58.70,,,,,,,,,,,,,
CATHETER THERMOABLATION CLOSUREFAST L 100 CM DIA 6 FR HEAT,SUP-2874944,CDM,C1888,HCPCS,0272,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
PLATE BONE L24MM THK0.8MM ORBIT FLR POLYETH TI REINF SMOOTH,SUP-2182843,CDM,C1713,HCPCS,0278,RC,,,,both,,,1978.20,1285.83,,,,,,,,,,,,,
THREADED GUIDE WIRE 32MM X 230MM,SUP-2705142,CDM,C1769,HCPCS,0272,RC,,,,both,,,503.34,327.17,,,,,,,,,,,,,
ROD EXT FIX L400MM DIA11MM C FBR MR CONDITIONAL 39487] DEPUY SYNTHES USA],SUP-2188665,CDM,2720000010,LOCAL,0272,RC,,,,both,,,699.50,454.67,,,,,,,,,,,,,
SCREW BNE CORTICAL 2.7X10 MM TOT WR SS NS,SUP-2610354,CDM,C1713,HCPCS,0278,RC,,,,both,,,308.88,200.77,,,,,,,,,,,,,
GRAFT BNE L25MM DIA10MM ACL PCL CANC REV DWL FLEXIGRFT,SUP-2264648,CDM,C1713,HCPCS,0278,RC,,,,both,,,3161.45,2054.94,,,,,,,,,,,,,
ALLOGRAFT BNE CLOWARD DWL 11X15 MM CERV FD MATRIGRAFT,SUP-2264806,CDM,C1713,HCPCS,0278,RC,,,,both,,,1591.98,1034.79,,,,,,,,,,,,,
GUIDEWIRE ENDSCPC 0035N OD STNDRD 260CML NTNL BLRY ROUND AN,SUP-2676533,CDM,C1729,HCPCS,0272,RC,,,,both,,,551.38,358.40,,,,,,,,,,,,,
SHEATH INTRO PINNACLE L 25 CM DIA 8 FR GUIDEWIRE 0.038 IN,SUP-2139633,CDM,C1894,HCPCS,0272,RC,,,,both,,,312.43,203.08,,,,,,,,,,,,,
USTEKINUMAB-KFCE 130 MG/26ML IV SOLN,RX-170465,CDM,Q5100,HCPCS,0636,RC,83257-0026-11,NDC,,both,52,ML,2360.00,1534.00,,,,,,,,,,,,,
GRAFT HUM TISS FRZN ALLGRFT CART DST FEM OSTEOCHNDRL MED R,SUP-2307437,CDM,C1762,CPT,0278,RC,,,,both,,,21854.40,14205.36,,,,,,,,,,,,,
SPLINT ORTH PLASTALUME 5.25X5.25 IN FNGR W/ BLB RADLUC,SUP-2276774,CDM,L3933,HCPCS,0274,RC,,,,both,,,5.21,3.39,,,,,,,,,,,,,
TAP SURG DIA2.7MM QUIK REL SCR FOR CONG EL PLATING SYS,SUP-2107791,CDM,C1713,HCPCS,0278,RC,,,,both,,,1993.90,1296.03,,,,,,,,,,,,,
IMPLANT MAXILLOFACIAL W61XL78MM THK18MM SM LT TEMPORAL FOSSA,SUP-2365350,CDM,C1889,HCPCS,0278,RC,,,,both,,,5193.56,3375.81,,,,,,,,,,,,,
PLATE BONE LOK SHFT 210MML HLX10 PRTSL 64 CRVD NON CNTCT BRD,SUP-2471402,CDM,C1713,HCPCS,0278,RC,,,,both,,,1862.90,1210.88,,,,,,,,,,,,,
SCREW CORT 3.5MM DIAX24MM LNG,SUP-2198414,CDM,C1713,HCPCS,0278,RC,,,,both,,,57.31,37.25,,,,,,,,,,,,,
SPLINT ORTH NT ANK FT,SUP-2388199,CDM,L4397,HCPCS,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
BLADE SURG 11 RT MIDLN MAST MIDLF,SUP-2631612,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2132.85,1386.35,,,,,,,,,,,,,
CLIP NSL TB RET AD 16FR YEL REPL AMT BRIDLE,SUP-2119781,CDM,2720000010,LOCAL,0272,RC,,,,both,,,776.21,504.54,,,,,,,,,,,,,
SHEATH INTRO L10CM DIA7FR TIF TIP PINN,SUP-2384800,CDM,C1894,HCPCS,0272,RC,,,,both,,,28.10,18.26,,,,,,,,,,,,,
LIGATOR ENDOSCP L230CM CHN DIA2.8MM DETACH LOOP,SUP-2313204,CDM,2720000010,LOCAL,0272,RC,,,,both,,,300.81,195.53,,,,,,,,,,,,,
HC Drug Assay Valproic Dipropylacetic Acid Total,PX-3018016400,CDM,80164,CPT,0301,RC,,,,both,,,520.00,338.00,,,,,,,,,,,,,
CATHETER INFUSION DIA2.4-3 FR 1 LUMEN STRL,SUP-2365833,CDM,C1887,HCPCS,0272,RC,,,,both,,,1491.50,969.47,,,,,,,,,,,,,
BURR RND SFT TCH OSTEON ELITE 4.0MM,SUP-2367553,CDM,C1713,HCPCS,0278,RC,,,,both,,,451.34,293.37,,,,,,,,,,,,,
DISTRACTION EXTERNAL UPPER RED 2 BLACK QTY001 EA,SUP-2694364,CDM,C1713,HCPCS,0278,RC,,,,both,,,2005.86,1303.81,,,,,,,,,,,,,
SCREW BNE COMPR SHT THRD 5.5X24 MM CANN HDLSS NS LTX,SUP-2856135,CDM,C1713,HCPCS,0278,RC,,,,both,,,2047.28,1330.73,,,,,,,,,,,,,
HC Rep Lac Smp Not Face <2.5cm,PX-4501200100,CDM,12001,CPT,0450,RC,,,,inpatient,,,421.00,273.65,,,,,,,,,,,,,
RING EXT FIX CIR 5/8 140 MM SIDEKCK,SUP-2485922,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1337.64,869.47,,,,,,,,,,,,,
ROD SPNL 11X350 MM,SUP-2205342,CDM,C1713,HCPCS,0278,RC,,,,both,,,704.15,457.70,,,,,,,,,,,,,
BASKET STONE REMV L90CM DIA14MM TIP L5CM DIA3FR S STL FLAT,SUP-2126138,CDM,2720000010,LOCAL,0272,RC,,,,both,,,736.17,478.51,,,,,,,,,,,,,
HC CT Pelvis W/WO Contrast,PX-3527219400,CDM,72194,CPT,0352,RC,,,,outpatient,,,2630.00,1709.50,,,,,,,,,,,,,
STAPLER HERN H48MM DIA12MM ENDO MULTFI,SUP-2752143,CDM,2720000010,LOCAL,0272,RC,,,,both,,,412.25,267.96,,,,,,,,,,,,,
PLATE BNE STRNL 2.3X1.8 MM THOR 6 HOLE LCK BODY NS LEVEL 1,SUP-2869221,CDM,C1713,HCPCS,0278,RC,,,,both,,,1764.87,1147.17,,,,,,,,,,,,,
REAMER SURG CUP SET X-REAM,SUP-2401423,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1400.44,910.29,,,,,,,,,,,,,
SPHINCTEROTOME ENDOSCP 4.5X190 CM APL32C 3LUMEN,SUP-2126017,CDM,2720000010,LOCAL,0272,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
GII PS INSERT SZ 3-4 9MM,SUP-2822743,CDM,C1776,CPT,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
BLADE SHVR ARTHSCP 4MM DIA 120MML STRGHT RCTNGLR WNDW RDS DB,SUP-2574155,CDM,2720000010,LOCAL,0272,RC,,,,both,,,525.42,341.52,,,,,,,,,,,,,
HC Deb Skin Bone at Fx Site,PX-4501101200,CDM,11012,CPT,0450,RC,,,,both,,,8335.00,5417.75,,,,,,,,,,,,,
GUIDE SURG CUT TMPLT VSP,SUP-2530173,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4231.15,2750.25,,,,,,,,,,,,,
KIT SURGICAL PROCEDURE QUADRICEP TEND HARV GUIDE QUADTRAC,SUP-2880214,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
HC Natriuretic Peptide,PX-3018388000,CDM,83880,CPT,0301,RC,,,,both,,,179.00,116.35,,,,,,,,,,,,,
IMPLANT HAMRTOE CORR 45MM FOR PROX PHALANX CORR NEXTRA,SUP-2137582,CDM,C1713,HCPCS,0278,RC,,,,both,,,2025.68,1316.69,,,,,,,,,,,,,
SET NEPHSTMY BAL L15CM DIA10MM SHTH 30FR L17CM NYL RADPQ,SUP-2171358,CDM,C1726,HCPCS,0272,RC,,,,both,,,926.93,602.50,,,,,,,,,,,,,
JOINT TOE 0 DEG 3.1X15 MM PRO-TOE X-FLEX,SUP-2468529,CDM,C1776,CPT,0278,RC,,,,both,,,4270.40,2775.76,,,,,,,,,,,,,
MESH HERN W20XL30CM VENTRAL COMP SMRT DSGN HANDLING REP,SUP-2173623,CDM,C1781,HCPCS,0278,RC,,,,both,,,7969.26,5180.02,,,,,,,,,,,,,
SUPPORT PROSTHETIC JT KNEE TORSION CTRL STRL,SUP-2388181,CDM,L2380,HCPCS,0274,RC,,,,both,,,303.73,197.42,,,,,,,,,,,,,
LINER ACET CUPS HOOD 28MM STD,SUP-2359075,CDM,C1776,CPT,0278,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
PLEDGET CV SAUVAGE L 10.2 X W 5.1 CM THK 0.61 MM POLYESTER,SUP-2761352,CDM,C1768,CPT,0278,RC,,,,both,,,255.60,166.14,,,,,,,,,,,,,
CEMENT BONE ROTARY MIX 10 CC REINFORCED STERILE CRANIOS,SUP-2838516,CDM,C1713,HCPCS,0278,RC,,,,both,,,12121.97,7879.28,,,,,,,,,,,,,
LEAD NEUROSTIMULATOR L60CM 8 CHN PADDLE TRIPOLE EXCLAIM,SUP-2356736,CDM,C1778,HCPCS,0278,RC,,,,both,,,12403.00,8061.95,,,,,,,,,,,,,
INTRODUCER TUBE SET 8.5/9/10 MM MULTI PERC TY W/O PHAR,SUP-2759713,CDM,C1769,HCPCS,0272,RC,,,,both,,,1163.56,756.31,,,,,,,,,,,,,
SUPPORT ORTHOPEDIC ADJ LG AD PEDIATRIC LT HND WRST FNGR SEP,SUP-2264311,CDM,L3807,HCPCS,0272,RC,,,,both,,,171.92,111.75,,,,,,,,,,,,,
SCREW BONE 6.5MMDIA 100MML STD CANC PARTIALLY THRD CANN ST N,SUP-2198304,CDM,C1713,HCPCS,0278,RC,,,,both,,,71.06,46.19,,,,,,,,,,,,,
SCREW SPNL 9X50 MM SAMBASCREW,SUP-2601141,CDM,C1713,HCPCS,0278,RC,,,,both,,,10440.50,6786.32,,,,,,,,,,,,,
LEAD PACE L60CM 8 CHAN FLX EXTN DIR INFIN,SUP-2357359,CDM,C1883,HCPCS,0278,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
CEFEPIME-DEXTROSE 2-5 GM-%(50ML) IV SOLR,RX-143621,CDM,J0703,HCPCS,0636,RC,00264-3195-11,NDC,,both,1,UN,171.70,111.60,,,,,,,,,,,,,
CEFDINIR 250 MG/5ML PO SUSR,RX-39522,CDM,340b,HCPCS,0637,RC,67877-0548-98,NDC,,both,6,ML,4.60,2.99,,,,,,,,,,,,,
STEM ORTH L10MM FNGR JT THMB PRI PLSM COAT CO CHROM PRSS,SUP-2137793,CDM,C1776,CPT,0278,RC,,,,both,,,8949.00,5816.85,,,,,,,,,,,,,
PLATE BNE L42MM THK1.25MM 6 H BILAT MAXILLOFACIAL MAND ORAL,SUP-2191335,CDM,C1713,HCPCS,0278,RC,,,,both,,,1782.58,1158.68,,,,,,,,,,,,,
EVOS VOL PLATE 4H LEFT STD TI 56MM NS,SUP-2818638,CDM,C1713,HCPCS,0278,RC,,,,both,,,5314.92,3454.70,,,,,,,,,,,,,
LEAD NEUROSTIMULATOR L43CM DIA3MM ELECTRD PLAT IRIDIUM SGL,SUP-2175907,CDM,C1778,HCPCS,0278,RC,,,,both,,,14393.76,9355.94,,,,,,,,,,,,,
STEM FEM STD OFFSET A MAG NK W/ TRUNNION ARCOS,SUP-2443216,CDM,C1776,CPT,0278,RC,,,,both,,,1921.68,1249.09,,,,,,,,,,,,,
KNIFE ARTHSCP L254MM HIP BAN,SUP-2121997,CDM,2720000010,LOCAL,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
PLATE BNE W11XL194MM THK37MM 10 H ST R MED DST TIB S STL LOK,SUP-2185591,CDM,C1713,HCPCS,0278,RC,,,,both,,,5089.34,3308.07,,,,,,,,,,,,,
TRAY KYPHOPLASTY SZ 3 BLLN L15MM SYR 30ML 11GA ADD FRAC,SUP-2293649,CDM,C1894,HCPCS,0272,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
BIT DRL 3.2 MM DSTL,SUP-2644749,CDM,2720000010,LOCAL,0272,RC,,,,both,,,934.94,607.71,,,,,,,,,,,,,
KIT IMPL L450MM DIA3.5MM TIM IM AND ENDCAP THE NANCY NAIL,SUP-2253252,CDM,C1713,HCPCS,0278,RC,,,,both,,,681.38,442.90,,,,,,,,,,,,,
SPACER HUM DIA39MM +12MM OFFSET SHLDR TI UNIVERS REVERS,SUP-2123377,CDM,C1776,CPT,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
ULNAR HD 16X1.5MM OFFSET,SUP-2398595,CDM,C1776,CPT,0278,RC,,,,both,,,4077.92,2650.65,,,,,,,,,,,,,
HC So Hepatitis Be Antibody,PX-3028670766,CDM,86707,CPT,0302,RC,,,,inpatient,,,106.00,68.90,,,,,,,,,,,,,
STABILIZER FEMORALXL DURAC RT KNEE MOD MONO IMP,SUP-2364847,CDM,C1776,CPT,0278,RC,,,,both,,,5172.71,3362.26,,,,,,,,,,,,,
GRAFT VASC 4-6MM DIA 45CM LEN STR STRTCH STD WALL N RNGD,SUP-2395842,CDM,C1768,CPT,0278,RC,,,,both,,,2132.06,1385.84,,,,,,,,,,,,,
KIT PERC DILATIONAL TRACH TUBE DIA 7 MM DIL DIA14 FR SYR 5,SUP-2887178,CDM,C1769,HCPCS,0272,RC,,,,both,,,1243.00,807.95,,,,,,,,,,,,,
PLATE BNE L 246 MM SCREW DIA 3.5/4.5 MM H 10 UTIL NS EVOS,SUP-2931239,CDM,C1713,HCPCS,0278,RC,,,,both,,,22430.59,14579.88,,,,,,,,,,,,,
BLADE SCRDRVR W2.4MM STD PRI CLSR SYS STERNALOCK BLU,SUP-2136992,CDM,2720000010,LOCAL,0272,RC,,,,both,,,725.34,471.47,,,,,,,,,,,,,
WASHER ORTH FOR 3 MM CANN SCREW NS,SUP-2788645,CDM,C1713,HCPCS,0278,RC,,,,both,,,489.84,318.40,,,,,,,,,,,,,
PLATFORM GELPOINT V PATH TRANSVAGINAL ACCEES,SUP-2848990,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
ECLIPSE TRUNION 47 MM TPS CTD,SUP-2815661,CDM,C1776,CPT,0278,RC,,,,both,,,3611.00,2347.15,,,,,,,,,,,,,
BASEPLATE TIB SZ 4 LT KNEE TI PRI CEM STEM GEN II,SUP-2346611,CDM,C1776,CPT,0278,RC,,,,both,,,5612.75,3648.29,,,,,,,,,,,,,
FIXATOR EXT LNG MOD S STL W DISTR FOR WRST PENNIG II,SUP-2316047,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5100.68,3315.44,,,,,,,,,,,,,
CUP ACET OD46MM ID22MM ALL POLYETH CEM REFLCT,SUP-2345387,CDM,C1776,CPT,0278,RC,,,,both,,,2132.85,1386.35,,,,,,,,,,,,,
ELECTRODE LOOP CUTTING 12 DEG LARGE,SUP-2866522,CDM,2720000010,LOCAL,0272,RC,,,,both,,,973.40,632.71,,,,,,,,,,,,,
GRAFT BNE PAT LIGMNT 9-10 MM,SUP-2361834,CDM,C1713,HCPCS,0278,RC,,,,both,,,8148.30,5296.39,,,,,,,,,,,,,
STENT GRFT VASC AFX L 88 MM DIA PROX/DSTL 20/13 MM,SUP-2217716,CDM,C1768,CPT,0278,RC,,,,both,,,10346.30,6725.09,,,,,,,,,,,,,
CATHETER HEMO DYLS OR HD 15.5FR L24CM BASIC DBL LUMN W/,SUP-2116516,CDM,C1881,HCPCS,0278,RC,,,,both,,,1381.60,898.04,,,,,,,,,,,,,
PROLONG TIBIAL INSERT SZ 5 2,SUP-2720345,CDM,C1776,CPT,0278,RC,,,,both,,,4281.39,2782.90,,,,,,,,,,,,,
HC Access Thoracic Lymph Duct,PX-3613879400,CDM,38794,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
BIT DRL OD2.9MM OCCIPITAL FOR 4.5MM SCR,SUP-2108737,CDM,2720000010,LOCAL,0272,RC,,,,both,,,758.31,492.90,,,,,,,,,,,,,
HEADBAND EEG MEDIUM ADLT SINGLE PT USE,SUP-2740085,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
CAGE SPNL LORDTC 7 DEG 16X13X8 MM CERV INTBDY TI CASCADIA,SUP-2520140,CDM,C1889,HCPCS,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
ANCHOR SUT PEEK DBL STRND W/ ORTHOCORD GRYPHON,SUP-2249322,CDM,C1713,HCPCS,0278,RC,,,,both,,,1215.18,789.87,,,,,,,,,,,,,
PLATE BNE L 27.8 X W 4.5 MM THK 1.6 MM SCREW DIA2 MM GAP 12,SUP-2936477,CDM,C1713,HCPCS,0278,RC,,,,both,,,1428.70,928.65,,,,,,,,,,,,,
WIRE K LANC 1.6X150 MM,SUP-2267996,CDM,2720000010,LOCAL,0272,RC,,,,both,,,103.62,67.35,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP L230CM DIA0.038IN DEPTH MRK STR FLX DST,SUP-2172401,CDM,C1769,HCPCS,0272,RC,,,,both,,,656.26,426.57,,,,,,,,,,,,,
PLATE BONE 6X21 H RT MAND TI ANG RIG NONCOMPRESSION,SUP-2191420,CDM,C1713,HCPCS,0278,RC,,,,both,,,6572.02,4271.81,,,,,,,,,,,,,
CLIP ENDO L165CM NIT PT PRELD HND WHL MOD 112/6T FOR GASTSCP,SUP-2319930,CDM,C1889,HCPCS,0278,RC,,,,both,,,1739.56,1130.71,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP L150CM DIA0.038IN NIT HYDRPHLC STR TIP,SUP-2139349,CDM,C1769,HCPCS,0272,RC,,,,both,,,184.51,119.93,,,,,,,,,,,,,
PEGFILGRASTIM 6 MG/0.6ML SC SOSY,RX-131197,CDM,J2506,HCPCS,0636,RC,55513-0190-01,NDC,,both,0.6,ML,18933.10,12306.51,,,,,,,,,,,,,
PLATE BNE L63MM THK1.3MM SCR L8MM DIA2MM R MTCRPL TI COMPR,SUP-2267921,CDM,C1713,HCPCS,0278,RC,,,,both,,,954.56,620.46,,,,,,,,,,,,,
KIT INTRO 18FR ANCHR SET W/ 4 SAF-T-PEXY T FAST HEMSTAT FOR,SUP-2124618,CDM,C1894,HCPCS,0272,RC,,,,both,,,758.59,493.08,,,,,,,,,,,,,
COMPONENT FEM CRUC RET N POR LT 68MM MEDL LAT 43MM ANT POST,SUP-2252373,CDM,C1776,CPT,0278,RC,,,,both,,,9492.22,6169.94,,,,,,,,,,,,,
HYDROMORPHONE HCL-NACL 20-0.9 MG/100ML-% IV SOLN,RX-139325,CDM,J1171,HCPCS,0636,RC,09999-5126-10,NDC,,both,100,ML,127.70,83.00,,,,,,,,,,,,,
BIT DRL FOR IM FIBULAR ROD,SUP-2106893,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1186.92,771.50,,,,,,,,,,,,,
PLATE BNE W17.5XL314MM THK5.2MM 14 H NONSTERILE R CNDYL FEM,SUP-2185035,CDM,C1713,HCPCS,0278,RC,,,,both,,,4664.88,3032.17,,,,,,,,,,,,,
DEXTROSE 10 % IV BOLUS,RX-4081995,CDM,2580000003,HCPCS,0250,RC,63323-0824-76,NDC,,both,125,ML,6.40,4.16,,,,,,,,,,,,,
BUR SURG DIAMOND X COARSE 6.5 MMX10 CM CYL SM BOR LEGEND,SUP-2627635,CDM,2720000010,LOCAL,0272,RC,,,,both,,,353.19,229.57,,,,,,,,,,,,,
CATHETER VASC L135CM OD5FR INFUS L5CM 0.038IN LNG VLV CRAGG,SUP-2172527,CDM,C1751,HCPCS,0278,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
COVER BURR HOLE 03MM 22MM DIA CMMRCLLY PURE TTNM C3 LOW PRF,SUP-2669084,CDM,C1713,HCPCS,0278,RC,,,,both,,,1656.00,1076.40,,,,,,,,,,,,,
BIT DRILL 1.5X82 MM 10 MM WITH STOP FOR J LATCH TITANIUM NON,SUP-2837610,CDM,2720000010,LOCAL,0272,RC,,,,both,,,641.82,417.18,,,,,,,,,,,,,
GAUGE DEPTH 2MM K WIRE STNMN PIN,SUP-2212972,CDM,C1776,CPT,0278,RC,,,,both,,,113.04,73.48,,,,,,,,,,,,,
CLAMP PIN XTRAFIX 2 BAR 45MM BL,SUP-2459420,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3932.79,2556.31,,,,,,,,,,,,,
PIN FIX DPLX HD 1/8X2.5 IN,SUP-2361949,CDM,C1713,HCPCS,0278,RC,,,,both,,,39.25,25.51,,,,,,,,,,,,,
SET CATH INTRO 9FR L12CM VEN J STR TIP W/ DIL,SUP-2355253,CDM,C1894,HCPCS,0272,RC,,,,both,,,33.76,21.94,,,,,,,,,,,,,
BIT DRL QC 4.3X245 MM FEM PERIPROSTHETIC NCB,SUP-2466361,CDM,2720000010,LOCAL,0272,RC,,,,both,,,331.21,215.29,,,,,,,,,,,,,
IMPL EYE OCCULAR HYDROXYAPPETITE NO 20MM,SUP-2525521,CDM,C1713,HCPCS,0278,RC,,,,both,,,2496.30,1622.59,,,,,,,,,,,,,
PLATE BNE W16XL124MM BLDE L60MM THK4.8MM 95DEG 7 H,SUP-2185500,CDM,C1713,HCPCS,0278,RC,,,,both,,,2828.23,1838.35,,,,,,,,,,,,,
HC Basic Metabolic Panel Calcium Ionized,PX-3018004700,CDM,80047,CPT,0301,RC,,,,both,,,82.00,53.30,,,,,,,,,,,,,
BAND ORTHODONTIC M SZ 33.5 UP MAX S STL SEAMLESS CHAIRSIDE,SUP-2176619,CDM,D6783,CPT,0278,RC,,,,both,,,17.24,11.21,,,,,,,,,,,,,
PLATE BNE 6 X 2 H CRANIOMAXILLOFACIAL 3D CRV SQ SEG NS,SUP-2883260,CDM,C1713,HCPCS,0278,RC,,,,both,,,1506.82,979.43,,,,,,,,,,,,,
GRAFT BONE PRO DENS CDK,SUP-2399155,CDM,2720000010,LOCAL,0272,RC,,,,both,,,14093.36,9160.68,,,,,,,,,,,,,
COLLAR PREMIER PRO UNIV ADJ CLS CELL FOAM LNR L TRACH OPN,SUP-2336009,CDM,L0140,HCPCS,0272,RC,,,,both,,,14.32,9.31,,,,,,,,,,,,,
INSERT BONE SPNL IMPLANTXPANSE R SM 20 MM LX5 MM WX8 MM H,SUP-2294191,CDM,C1713,HCPCS,0278,RC,,,,both,,,3532.50,2296.12,,,,,,,,,,,,,
HC So Culture Aerobic Identify|UNUSUAL NON-OVERLAPPING SERVICE,PX-3008707766,CDM,87077,CPT,0300,RC,,,XU,both,,,109.00,70.85,,,,,,,,,,,,,
SCREWDRIVER BLADE MED 1.5X58 MM FOR PLATING SYS MAXDRIVE,SUP-2463409,CDM,2720000010,LOCAL,0272,RC,,,,both,,,462.96,300.92,,,,,,,,,,,,,
MESH HERN 28X18 CMX1.5 MM HYDRATED PORCINE CLLGN PERMACOL,SUP-2174702,CDM,C1781,HCPCS,0278,RC,,,,both,,,38133.82,24786.98,,,,,,,,,,,,,
PLATE BNE ANGLED 2.8 MM LT 7X23 HOLE RECON MAXILLA PT SPEC,SUP-2860109,CDM,C1713,HCPCS,0278,RC,,,,both,,,30398.34,19758.92,,,,,,,,,,,,,
AZACITIDINE 100 MG IJ SUSR (MIXTURES ONLY),RX-1150427,CDM,J9025,HCPCS,0636,RC,59572-0102-01,NDC,,both,1,UN,1685.50,1095.57,,,,,,,,,,,,,
DEFIBRILLATOR CRD 2 CHMBR,SUP-2140351,CDM,C1721,HCPCS,0275,RC,,,,both,,,90180.80,58617.52,,,,,,,,,,,,,
LEAD NERVE STIM 3 MM ELECTRD 4 MM SPC 90 CM OCTRODE,SUP-2615508,CDM,C1897,HCPCS,0278,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
FOOTPLATE EXT FIX 180 MM NS TRUELOK LTX,SUP-2875087,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1177.03,765.07,,,,,,,,,,,,,
PACEMAKER SGL CHMBR RATE RESPON IMP TRIL SR +,SUP-2356703,CDM,C1786,HCPCS,0275,RC,,,,both,,,13973.00,9082.45,,,,,,,,,,,,,
ALLOGRAFT HUM TISS HEMI BTB FRZN PRESHAPED COLL-E-STRONG,SUP-2321873,CDM,C1762,CPT,0278,RC,,,,both,,,11602.30,7541.49,,,,,,,,,,,,,
STENT GRFT VASC AFX2 L 55 MM DIA PROX/DSTL 16 MM COCR,SUP-2217704,CDM,C1768,CPT,0278,RC,,,,both,,,10481.32,6812.86,,,,,,,,,,,,,
DRILL SURG SPNL JACOB CHK TWST DISPOSABLE TRIMLINE,SUP-2290999,CDM,C1713,HCPCS,0278,RC,,,,both,,,901.62,586.05,,,,,,,,,,,,,
SHEATH GUID 6FR L45CM GWIRE 0.018-0.038IN POLYUR COBRA TIP,SUP-2169816,CDM,C1894,HCPCS,0272,RC,,,,both,,,137.06,89.09,,,,,,,,,,,,,
ZINC GLUCONATE 50 MG PO TABS,RX-8872,CDM,6370000000,HCPCS,0637,RC,80681-0002-00,NDC,,both,1,UN,0.20,0.13,,,,,,,,,,,,,
PLATE BNE SM TI MIDFACE 3D PRNT NS DISP ACCUPLATE,SUP-2934754,CDM,C1713,HCPCS,0278,RC,,,,both,,,26752.80,17389.32,,,,,,,,,,,,,
LEAD NERVE STIM 4.32 MM INTERSTIM SURESCAN,SUP-2550571,CDM,C1778,HCPCS,0278,RC,,,,both,,,11473.56,7457.81,,,,,,,,,,,,,
SYSTEM SFT TISS FIX STRL LF DISP GRAFTLINK CP 2,SUP-2882176,CDM,C1713,HCPCS,0278,RC,,,,both,,,6138.70,3990.15,,,,,,,,,,,,,
COMPONENT TIB SZ 1 8MM LT MEDL RT LAT POLYETH UNI OPTETRAK,SUP-2223235,CDM,C1776,CPT,0278,RC,,,,both,,,4471.36,2906.38,,,,,,,,,,,,,
HC Plmt Biliary Drainage Cath Internal-External,PX-3614753400,CDM,47534,CPT,0361,RC,,,,outpatient,,,6875.00,4468.75,,,,,,,,,,,,,
PLATE BNE TIB 172 MM RT DSTL MEDL 10X4 HOLE SS NS AXSOS,SUP-2459192,CDM,C1713,HCPCS,0278,RC,,,,both,,,5409.28,3516.03,,,,,,,,,,,,,
INSERT TIB L71MM THK12MM UNIV KNEE PRI ANT STBL NEUT ASCNT,SUP-2407214,CDM,C1776,CPT,0278,RC,,,,both,,,2675.28,1738.93,,,,,,,,,,,,,
HC Blood Draw per Picc/Cl,PX-7613659200,CDM,36592,CPT,0761,RC,,,,both,,,218.00,141.70,,,,,,,,,,,,,
SCREW BNE 3.0MM DIA 14MM BNE CORT SHFT 1/3 THRD CANN ST,SUP-2409808,CDM,C1713,HCPCS,0278,RC,,,,both,,,512.45,333.09,,,,,,,,,,,,,
HC Platelets Hla-M Lr,PX-3900905200,CDM,P9052,CPT,0390,RC,,,,both,,,2460.00,1599.00,,,,,,,,,,,,,
ANCHOR SUT W/ TWO NO 2 SUT COBRAID BLU COBRAID BLK 5.5MM,SUP-2341859,CDM,C1713,HCPCS,0278,RC,,,,both,,,892.67,580.24,,,,,,,,,,,,,
PACEMAKER CARD PHILOS II DR-T W 44 X H 51 MM D 6 MM TI,SUP-2138036,CDM,C1785,HCPCS,0275,RC,,,,both,,,19157.14,12452.14,,,,,,,,,,,,,
PLATE BONE W7XL57MM THK1.5MM 7 H RT CNDYL TI FOR 2.7MM SCR,SUP-2191040,CDM,C1713,HCPCS,0278,RC,,,,both,,,1098.18,713.82,,,,,,,,,,,,,
SCREW BONE 5.5 MMX25MM SLD CORT FT PROX VERSANAIL TIB,SUP-2412186,CDM,C1713,HCPCS,0278,RC,,,,both,,,564.89,367.18,,,,,,,,,,,,,
BIT DRILL SURG DIA2 MM NS DISP LEOS,SUP-2931262,CDM,2720000010,LOCAL,0272,RC,,,,both,,,401.29,260.84,,,,,,,,,,,,,
VLP TI 2.4MMX25MM CTX SCREW T7 S-T,SUP-2821437,CDM,C1713,HCPCS,0278,RC,,,,both,,,271.99,176.79,,,,,,,,,,,,,
PACK ACCESSORY VPS RHYTHM ECG JOHANS ADAPTER,SUP-2855520,CDM,C1751,HCPCS,0278,RC,,,,both,,,91.03,59.17,,,,,,,,,,,,,
SCREW BONE 2.8X23MM BICORTICAL FT OPTMA INION OTPS,SUP-2365493,CDM,C1713,HCPCS,0278,RC,,,,both,,,1161.02,754.66,,,,,,,,,,,,,
K WIRE FIX L150MM DIA2MM THRD L15MM S STL W/ TRCR TIP,SUP-2186906,CDM,C1713,HCPCS,0278,RC,,,,both,,,473.57,307.82,,,,,,,,,,,,,
CATHETER DRNGE 14FR L35CM CHST NONVASCULAR INTERVENTIONS,SUP-2147733,CDM,C1729,HCPCS,0272,RC,,,,both,,,313.75,203.94,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED LNR POLYETH H2STRYKER] STRYKER CORP],SUP-2365527,CDM,C1776,CPT,0278,RC,,,,both,,,15072.00,9796.80,,,,,,,,,,,,,
GUIDEWIRE ARTHSCP L12IN DIA1MM NIT BLNT TIP SMOOTH FLEX W/,SUP-2340697,CDM,C1769,HCPCS,0272,RC,,,,both,,,141.30,91.84,,,,,,,,,,,,,
MICROFREE SAGITTAL SAW,SUP-2605745,CDM,2720000010,LOCAL,0272,RC,,,,both,,,19795.00,12866.75,,,,,,,,,,,,,
PLATE BNE PROF THK 1 MM 8 H SCREW DIA2 MM MED TI MIDFACE STR CMPRSS,SUP-2883775,CDM,C1713,HCPCS,0278,RC,,,,both,,,819.54,532.70,,,,,,,,,,,,,
COIL NEUROVASCULAR TRUFILL L 10 MM DIA 5 MM MICROCATHETER,SUP-2474361,CDM,C1889,HCPCS,0278,RC,,,,both,,,1843.24,1198.11,,,,,,,,,,,,,
RASP SURG CROSSCUT BONE HANDHELD SGL END STR TAPR FLAT BLDE,SUP-2319802,CDM,C1713,HCPCS,0278,RC,,,,both,,,486.70,316.35,,,,,,,,,,,,,
CEFPODOXIME PROXETIL 200 MG PO TABS,RX-9469,CDM,6370000000,HCPCS,0637,RC,65862-0096-20,NDC,,both,1,UN,16.80,10.92,,,,,,,,,,,,,
SPACER SPNL 0 DEG 22X10X9-15 MM SABLE,SUP-2763880,CDM,C1889,HCPCS,0278,RC,,,,both,,,17756.70,11541.85,,,,,,,,,,,,,
IMPLANT STRNL CLSR PEEK CBL W/ NDL ZIPFIX 5 PER PK,SUP-2182840,CDM,C1713,HCPCS,0278,RC,,,,both,,,328.29,213.39,,,,,,,,,,,,,
SHEATH INTRO STEADYSHEATH EVOLUTION L 36.5 CM OD 21.3 FR ID,SUP-2169519,CDM,C1893,HCPCS,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
GRAFT BNE 1 CC,SUP-2644304,CDM,C1713,HCPCS,0278,RC,,,,both,,,1460.10,949.06,,,,,,,,,,,,,
STENT BILI 10FR L7CM 0.035IN ACC CHN 3.7MM PLAS FOR,SUP-2169042,CDM,C2617,HCPCS,0278,RC,,,,both,,,194.68,126.54,,,,,,,,,,,,,
KIT ACCS INTRO L10CM DIA5FR GWIRE L40CM DIA0018IN NDL L7CM,SUP-2303007,CDM,C1894,HCPCS,0272,RC,,,,both,,,94.04,61.13,,,,,,,,,,,,,
SET PICC L 55 CM DIA 5 FR SHTH L 7 CM DIA 5 FR,SUP-2886978,CDM,C1751,HCPCS,0278,RC,,,,both,,,1695.60,1102.14,,,,,,,,,,,,,
COMPONENT CARPOMETACARPAL 40 MED NUGRIP,SUP-2610448,CDM,C1776,CPT,0278,RC,,,,both,,,7501.37,4875.89,,,,,,,,,,,,,
GRAFT HUM TISS L HUM WHL W CUF FRZN,SUP-2307321,CDM,C1713,HCPCS,0278,RC,,,,both,,,28938.24,18809.86,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 45 CM DIA 4-7 MM SHRT TAPR STR,SUP-2669696,CDM,C1768,CPT,0278,RC,,,,both,,,1130.27,734.68,,,,,,,,,,,,,
GUN BNE CEMENT ANGLED TIP L 12 IN 15 ML HI PRESSURE INJ SYS,SUP-2917159,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1632.80,1061.32,,,,,,,,,,,,,
LINER ACET OD46MM ID28MM STD UHMWPE HIP PRI CEM NEUT HOOD,SUP-2207577,CDM,C1776,CPT,0278,RC,,,,both,,,2367.56,1538.91,,,,,,,,,,,,,
DRILL TWIST D3.2MM RDLCNT TRGTNG DVCE TBL NAIL SSTM PHNX,SUP-2488930,CDM,2720000010,LOCAL,0272,RC,,,,both,,,568.34,369.42,,,,,,,,,,,,,
PLATE BNE THK 0.6 MM ADV 6 MM SCREW DIA2 MM 4 H MINI CHIN,SUP-2883181,CDM,C1713,HCPCS,0278,RC,,,,both,,,1283.82,834.48,,,,,,,,,,,,,
STEM HUM 7.9X125MM MOD II +,SUP-2408648,CDM,C1776,CPT,0278,RC,,,,both,,,10497.02,6823.06,,,,,,,,,,,,,
LITHOTRIPTER SURG MECH GUIDEWIRE TYP STRL DISP,SUP-2912507,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1352.05,878.83,,,,,,,,,,,,,
KIT INTRO ONESTIC L 5.75 CM DIA 7FR 7CM 21GA NIT WIRE PD TIP,SUP-2876557,CDM,C1894,HCPCS,0272,RC,,,,both,,,241.78,157.16,,,,,,,,,,,,,
ANCHOR N SUT FIX 1.1 MM SZ 16 MM LEN MENIS BIONX,SUP-2166727,CDM,C1713,HCPCS,0278,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
CATHETER CV 2 LUMEN 8 FR DISP,SUP-2384677,CDM,C1751,HCPCS,0278,RC,,,,both,,,43.96,28.57,,,,,,,,,,,,,
KWIRE DRILL TIP RECON 32X400MM,SUP-2701538,CDM,2720000010,LOCAL,0272,RC,,,,both,,,696.77,452.90,,,,,,,,,,,,,
SLEEVE TIB L30MM PROX KNEE ORTH SALV SYS,SUP-2406463,CDM,C1776,CPT,0278,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
NEEDLE VERTEBROPLASTY 10GA L4.721IN YEL DMND TIP RADPQ,SUP-2179486,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1237.16,804.15,,,,,,,,,,,,,
STEM FEM L90MM OD17MM STR TI POR IM REV CEM NEUT MOD LNG,SUP-2405715,CDM,C1776,CPT,0278,RC,,,,both,,,4125.96,2681.87,,,,,,,,,,,,,
SLEEVE LCK 130 DEG NAIL FEM SPRL BLADE TI NS,SUP-2191882,CDM,C1713,HCPCS,0278,RC,,,,both,,,1185.60,770.64,,,,,,,,,,,,,
SYSTEM INTRO SAFSHTH II WORLEY RIGHT-SIDED W/ TEARWY SIDEPRT,SUP-2329876,CDM,C1894,HCPCS,0272,RC,,,,both,,,294.66,191.53,,,,,,,,,,,,,
WEDGE FEM 2 5X10 MM KNEE LEGION,SUP-2797208,CDM,C1776,CPT,0278,RC,,,,both,,,5920.47,3848.31,,,,,,,,,,,,,
CATHETER STONE REMV 5FR L23CM 0.4ML BILI BLLN PRB ATRAUM,SUP-2214135,CDM,C1726,HCPCS,0272,RC,,,,both,,,529.97,344.48,,,,,,,,,,,,,
ALLOGRAFT BNE FRZN W/ GROWTH PLATE RT FEM DSTL,SUP-2740860,CDM,C1762,CPT,0278,RC,,,,both,,,25453.94,16545.06,,,,,,,,,,,,,
STENT BILI L26MM DIA4.5MM SELF EXP UNMOUNTED FLEXIBILITY,SUP-2172553,CDM,C1877,HCPCS,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
SUPPORT ORTHOT WRST HND FNGR CUST W/NONTORSION JT,SUP-2435788,CDM,L3931,HCPCS,0272,RC,,,,both,,,537.22,349.19,,,,,,,,,,,,,
PLEDGET SURG PTFE RECT FELT 3/16X.025IN 1.65MM THK STRL 10PK,SUP-2913772,CDM,C1781,HCPCS,0278,RC,,,,both,,,399.09,259.41,,,,,,,,,,,,,
EXTENSION STEM REV 175X6X14 MM KNEE PERSONA,SUP-2508839,CDM,C1776,CPT,0278,RC,,,,both,,,8980.40,5837.26,,,,,,,,,,,,,
DEVICE VENTRICULAR ASST SHT 3 IN,SUP-2355997,CDM,L8670,HCPCS,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
ALLOGRAFT CELLENTRA ADV 10CC,SUP-2208254,CDM,C1713,HCPCS,0278,RC,,,,both,,,15888.40,10327.46,,,,,,,,,,,,,
PLATE BNE L 132 MM 20 H SCREW DIA2.4 MM PROF MINI FRAG NS,SUP-2902325,CDM,C1713,HCPCS,0278,RC,,,,both,,,2814.70,1829.55,,,,,,,,,,,,,
GUIDEWIRE UROLOGICAL STR 3 CM 0.038 INX150 CM DUAL-FLEX,SUP-2139370,CDM,C1769,HCPCS,0272,RC,,,,both,,,735.29,477.94,,,,,,,,,,,,,
PLATE BNE L143MM 9 H R DST POSTEROLATERAL HUM S STL LOK,SUP-2185897,CDM,C1713,HCPCS,0278,RC,,,,both,,,3033.93,1972.05,,,,,,,,,,,,,
PLATE BONE SM W11XL181MM THK3.3MM 0DEG 14 H BILAT TI STR RIG,SUP-2190791,CDM,C1713,HCPCS,0278,RC,,,,both,,,1182.87,768.87,,,,,,,,,,,,,
FOUNDATION ALL POLY TIB SZ 2 9 MM LT,SUP-2216303,CDM,C1776,CPT,0278,RC,,,,both,,,3438.30,2234.89,,,,,,,,,,,,,
PLATE BNE 1 H TI ALPHA LOCKED REV MAXLOCK EXTRM LPS,SUP-2400379,CDM,C1713,HCPCS,0278,RC,,,,both,,,3064.64,1992.02,,,,,,,,,,,,,
STENT URET 47FR L26CM DBL PIGTAILS LUBRICIOUS COAT TAPR TIP,SUP-2126633,CDM,C2617,HCPCS,0278,RC,,,,both,,,578.11,375.77,,,,,,,,,,,,,
MESH HERN RECTANGULAR 10X10 CM PREPERITONEAL ENFORM,SUP-2539549,CDM,C1781,HCPCS,0278,RC,,,,both,,,4176.20,2714.53,,,,,,,,,,,,,
"HC So Fecal Fat, Qualitative",PX-3018270566,CDM,82705,CPT,0301,RC,,,,both,,,194.00,126.10,,,,,,,,,,,,,
INSULIN REGULAR HUMAN 100 UNIT/ML IJ SOLN,RX-10289,CDM,J1815,HCPCS,0637,RC,09999-9907-70,NDC,,both,.01,ML,0.10,0.06,,,,,,,,,,,,,
EXPANDER BRST TISS HSC TEXT RND MOD + PROJCT 650CC 148CM X,SUP-2422110,CDM,C1789,HCPCS,0278,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
VALPROIC ACID 250 MG PO CAPS,RX-8429,CDM,6370000000,HCPCS,0637,RC,00591-4012-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
GRAFT HUM TISS W2XL5CM THK04 07MM ACELLULAR HUM DERM,SUP-2307442,CDM,Q4128,HCPCS,0636,RC,,,,both,,,1006.21,654.04,,,,,,,,,,,,,
GRAFT HUM TISS 4X4CM THN REGENERATIVE TISS MTRX GRFTJACKET,SUP-2261537,CDM,Q4107,HCPCS,0636,RC,,,,both,,,4755.47,3091.06,,,,,,,,,,,,,
STANDARD DRL BIT D15X125MM QUIK CONN,SUP-2315949,CDM,2720000010,LOCAL,0272,RC,,,,both,,,627.97,408.18,,,,,,,,,,,,,
COUPLER FIX ANG OFFSET FEM KNEE LEGION,SUP-2346814,CDM,C1776,CPT,0278,RC,,,,both,,,4157.36,2702.28,,,,,,,,,,,,,
FIBER LASER 550 MH OPTIMUM PERF HOLM SLM LN SIS EZ DISP,SUP-2479584,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1353.53,879.79,,,,,,,,,,,,,
BRACE KNEE SM FOR 115 13IN UNIV BUTTERESS NEOPRENE W STBL,SUP-2319243,CDM,L1810,HCPCS,0274,RC,,,,both,,,54.13,35.18,,,,,,,,,,,,,
PLATE BNE LADDER WIDE 12 HOLE,SUP-2136993,CDM,C1713,HCPCS,0278,RC,,,,both,,,2270.22,1475.64,,,,,,,,,,,,,
HC Cardiac Rehab Phase 3 - 10 Visits (Spouse),PX-9900000060,CDM,9900000060,LOCAL,0990,RC,,,,both,,,50.00,32.50,,,,,,,,,,,,,
COMPONENT TALAR SZ 4 POLYETH L R ANK PRI CEM DOME SADL,SUP-2397093,CDM,C1776,CPT,0278,RC,,,,both,,,8503.12,5527.03,,,,,,,,,,,,,
CONTOURED MESH UNIV CENTER06MM PROFILE,SUP-2677393,CDM,C1713,HCPCS,0278,RC,,,,both,,,14468.74,9404.68,,,,,,,,,,,,,
PURAPLY AM 2X4CM 8SQ CM,SUP-2314117,CDM,Q4196,HCPCS,0636,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
HEAD FEM 2XL DIA28MM CO CHROM AMISTEM,SUP-2267302,CDM,C1776,CPT,0278,RC,,,,both,,,1600.93,1040.60,,,,,,,,,,,,,
GRAFT BNE SUB W14XH6MM D12 4DEG PLUG LORD BIO AVS,SUP-2381462,CDM,C1713,HCPCS,0278,RC,,,,both,,,2653.30,1724.64,,,,,,,,,,,,,
PLATE BNE L116MM 6 H ST R POSTEROLATERAL DST FIBULAR S STL,SUP-2176957,CDM,C1713,HCPCS,0278,RC,,,,both,,,2020.15,1313.10,,,,,,,,,,,,,
HC Rsf Lab Ecmc - Special Stain,PX-9900000128,CDM,9900000128,LOCAL,0990,RC,,,,both,,,19.00,12.35,,,,,,,,,,,,,
GRAFT HUM TISS W4XL6CM COMP AMNIO MEM MTRX SHT AMNIOFIX,SUP-2305708,CDM,V2790,HCPCS,0274,RC,,,,both,,,7071.28,4596.33,,,,,,,,,,,,,
KIT CATHETER DRNGE LNG L864CM INTRO NDL 16GA L114CM SPNL,SUP-2280045,CDM,C1755,HCPCS,0278,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
MARKER BRST BX XR 11 GA MAMTOM FLX MINIMALLY INVASIVE TISS,SUP-2195652,CDM,A4648,CPT,0278,RC,,,,both,,,253.77,164.95,,,,,,,,,,,,,
BUTORPHANOL TARTRATE 2 MG/ML IJ SOLN,RX-9334,CDM,J0595,HCPCS,0636,RC,00409-1626-01,NDC,,both,0.25,ML,54.10,35.16,,,,,,,,,,,,,
GRAFT BONE SUB W14XH6XL11MM CANC CERV TISS UNICORTICAL DWL,SUP-2277987,CDM,C1713,HCPCS,0278,RC,,,,both,,,1805.50,1173.57,,,,,,,,,,,,,
SCREW BNE LCK 3.5X12 MM POLYAX MOTOBAND,SUP-2432221,CDM,C1713,HCPCS,0278,RC,,,,both,,,730.05,474.53,,,,,,,,,,,,,
HC CT Colonography Screening,PX-3507426300,CDM,74263,CPT,0350,RC,,,,inpatient,,,2769.00,1799.85,,,,,,,,,,,,,
INSERT TIB X FRE 10 DEG 22 MM SER II OMFIT,SUP-2451565,CDM,C1776,CPT,0278,RC,,,,both,,,1201.33,780.86,,,,,,,,,,,,,
COUNTERSINK DRL DIA7MM BLU,SUP-2400359,CDM,2720000010,LOCAL,0272,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
COMPONENT ARTC SURF PS 10-11 EF 14 MM LT TIB KNEE FIX BEAR,SUP-2206670,CDM,C1776,CPT,0278,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
KIT THROMCTMY STROKE FAST PK CATH AXS VECTA 71 L 132 CM,SUP-2884577,CDM,C1757,HCPCS,0272,RC,,,,both,,,8792.00,5714.80,,,,,,,,,,,,,
HINGE EXT FIX STRL TRUELOK TORNADO LTX,SUP-2875238,CDM,2720000010,LOCAL,0272,RC,,,,both,,,11869.20,7714.98,,,,,,,,,,,,,
MESH HERN W10XL15CM SYNTH ABSRB POLY COMP RECT OPN SKRT,SUP-2173619,CDM,C1781,HCPCS,0278,RC,,,,both,,,2915.11,1894.82,,,,,,,,,,,,,
PEG-3350/ELECTROLYTES 236 G PO SOLR,RX-98270,CDM,6370000000,HCPCS,0637,RC,10572-0100-01,NDC,,both,4000,ML,108.00,70.20,,,,,,,,,,,,,
BROAD PLT STERILIZER 4.5X167 MM 10 HL,SUP-2818117,CDM,C1713,HCPCS,0278,RC,,,,both,,,2071.14,1346.24,,,,,,,,,,,,,
ARM EXT FIX VERTICLE ADJ 20 MM TUBE LEFORT 1 BUTTRESS,SUP-2497331,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6228.63,4048.61,,,,,,,,,,,,,
BIT DRL DIA1.5MM ADD ON QUIK CONN DISP,SUP-2344027,CDM,2720000010,LOCAL,0272,RC,,,,both,,,566.52,368.24,,,,,,,,,,,,,
LINER ACET COMP 28MM ID SZ A STD RIM LCK RNG UHMWPE ARCM,SUP-2404822,CDM,C1776,CPT,0278,RC,,,,both,,,2041.00,1326.65,,,,,,,,,,,,,
POR PRI BIPOLAR/STD HD,SUP-2408788,CDM,C1776,CPT,0278,RC,,,,both,,,6573.06,4272.49,,,,,,,,,,,,,
GRAFT BNE SUB 10ML CANC CORT DBM CHIP RM TEMP FRZ DRY,SUP-2223563,CDM,C1762,CPT,0278,RC,,,,both,,,7520.30,4888.19,,,,,,,,,,,,,
CATHETER DRAINAGE PIG 14 FRX25 CM W/ STAYFIX RESOLV +,SUP-2303343,CDM,C1729,HCPCS,0272,RC,,,,both,,,210.25,136.66,,,,,,,,,,,,,
PLATE BNE L125MM 7 H ST R DST RAD VOLAR DPHSEAL MTPHSEAL S,SUP-2177216,CDM,C1713,HCPCS,0278,RC,,,,both,,,4725.54,3071.60,,,,,,,,,,,,,
STENT BILI SELF EXP OVR THE WIRE 6FR CATH 80CM CATH LEN,SUP-2159276,CDM,C1876,HCPCS,0278,RC,,,,both,,,4050.60,2632.89,,,,,,,,,,,,,
BUPROPION HCL ER (XL) 150 MG PO TB24,RX-36775,CDM,6370000000,HCPCS,0637,RC,50228-0144-30,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
REAMER SURG OD21 MM SPIN GRD CUP CONE FEM,SUP-2320319,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1083.30,704.14,,,,,,,,,,,,,
DARBEPOETIN ALFA 25 MCG/ML IJ SOLN,RX-131219,CDM,J0881,HCPCS,0636,RC,55513-0002-04,NDC,,both,1,ML,570.90,371.08,,,,,,,,,,,,,
SCREW BNE L32MM DIA3.5MM CORT DST TIB TYP II ANODIZED TI ST,SUP-2411693,CDM,C1713,HCPCS,0278,RC,,,,both,,,156.40,101.66,,,,,,,,,,,,,
FIXATOR EXT FIX 16X80 MM 25 MM COMPR DISTRCTN RANG CORETRAK,SUP-2399885,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5677.12,3690.13,,,,,,,,,,,,,
CUBE EXT FIX 3 H S STL RANCHO FOR ILIZ TAY SPAT FRME EXT,SUP-2342334,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1388.88,902.77,,,,,,,,,,,,,
PUMP CNTRFUG W CARMD BIOACTIVE SURF BIO PMP + BPX 80,SUP-2282914,CDM,C1713,HCPCS,0278,RC,,,,both,,,2461.76,1600.14,,,,,,,,,,,,,
PEMETREXED DISODIUM 500 MG/20ML IV SOLN,RX-158742,CDM,J9294,HCPCS,0636,RC,00409-2188-01,NDC,,both,20,ML,1433.80,931.97,,,,,,,,,,,,,
PLATE BNE CRV 2-2.5X34X1 MM LT 4 HOLE ELEV HOLE FRAC TI,SUP-2470230,CDM,C1713,HCPCS,0278,RC,,,,both,,,1819.76,1182.84,,,,,,,,,,,,,
DEVICE ENDOSCP DIA9.5-13MM 7FR SHTH 1.5X2.5CM SNR 6 BNDS,SUP-2170143,CDM,2720000010,LOCAL,0272,RC,,,,both,,,920.02,598.01,,,,,,,,,,,,,
PACK NEUROSURGICAL SHTH L 75 X W 13.5 MM MYRIAD HNDPC L 13 NN-3009,SUP-2930303,CDM,2720000010,LOCAL,0272,RC,,,,both,,,22480.23,14612.15,,,,,,,,,,,,,
SHEATH INTRO FAST-CATH 90 DEG L 60 CM DIA 8 FR DIL L 67 CM,SUP-2357129,CDM,C1893,HCPCS,0272,RC,,,,both,,,332.84,216.35,,,,,,,,,,,,,
WIRE FIX 1.6X150 MM KIRSCHNER HALLU,SUP-2242883,CDM,C1713,HCPCS,0278,RC,,,,both,,,91.06,59.19,,,,,,,,,,,,,
SET IMPL FOR PROX TIB 4.5MM LCK COMPR PLT,SUP-2183064,CDM,C1713,HCPCS,0278,RC,,,,both,,,57597.08,37438.10,,,,,,,,,,,,,
COIL EMB L25MM DIA3.75MM NEUROVASC BRAID DSGN FLXIBLE,SUP-2296731,CDM,C1889,HCPCS,0278,RC,,,,both,,,46982.25,30538.46,,,,,,,,,,,,,
SCREW BNE THRD 4X100 MM SPADE PT SCHNZ SS NS,SUP-2186948,CDM,C1713,HCPCS,0278,RC,,,,both,,,232.36,151.03,,,,,,,,,,,,,
PLATE BONE THK1MM 3X2 H LT HND TRAPEZOIDAL LCK TRILOK FOR,SUP-2267930,CDM,C1713,HCPCS,0278,RC,,,,both,,,1419.28,922.53,,,,,,,,,,,,,
PLATE BNE RECON 3.5 MM 11 HOLE 2 COMPR LCK FOR SCR TI STRL,SUP-2473515,CDM,C1713,HCPCS,0278,RC,,,,both,,,1573.14,1022.54,,,,,,,,,,,,,
TRIAL ANK TALUS PT SPEC,SUP-2899085,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8007.00,5204.55,,,,,,,,,,,,,
HC So N Gonorrhoeae Dna Amp Prob,PX-3068759166,CDM,87591,CPT,0306,RC,,,,both,,,289.00,187.85,,,,,,,,,,,,,
BURR BALL FLUTED 2.0MM EXTENDED ANSPACH S2BG1,SUP-2843309,CDM,2720000010,LOCAL,0272,RC,,,,both,,,364.05,236.63,,,,,,,,,,,,,
GRAFT BNE STRP 5 CC AUGMATRIX,SUP-2495205,CDM,C1768,CPT,0278,RC,,,,both,,,2989.28,1943.03,,,,,,,,,,,,,
BIT DRILL 8MML BIT ANT CRVCL JACOB CHUCK END RGGLS RDMND ST,SUP-2670333,CDM,2720000010,LOCAL,0272,RC,,,,both,,,472.26,306.97,,,,,,,,,,,,,
CATHETER ANGIOPLSTY L 95 CM BALLOON L 20 MM RX COMPLIANT,SUP-2141002,CDM,C1725,HCPCS,0272,RC,,,,both,,,2088.10,1357.26,,,,,,,,,,,,,
CARBOPLATIN 10 MG/ML IV SOLN (MIXTURES ONLY),RX-1150452,CDM,J9045,HCPCS,0636,RC,61703-0339-50,NDC,,both,45,ML,135.90,88.33,,,,,,,,,,,,,
PLATE BNE L W135XL368MM THK42MM 20 H BILAT TI NAR RIG NEUT,SUP-2190837,CDM,C1713,HCPCS,0278,RC,,,,both,,,3772.46,2452.10,,,,,,,,,,,,,
CATHETER ATHRCTMY ROTLNK L 135 MM DIA 0.058 IN BUR DIA2 MM,SUP-2147021,CDM,C1724,HCPCS,0278,RC,,,,both,,,4034.90,2622.68,,,,,,,,,,,,,
PLATE BNE L 58 MM SCREW DIA2.4/2.7 MM 6 HD 3 SHFT H LT DSTL,SUP-2913549,CDM,C1713,HCPCS,0278,RC,,,,both,,,8023.27,5215.13,,,,,,,,,,,,,
GUIDEWIRE VASC GLIDEWIRE 350CM 0.035IN NIT POLYUR STD STR,SUP-2761854,CDM,C1769,HCPCS,0272,RC,,,,both,,,245.86,159.81,,,,,,,,,,,,,
HEAD FEM DIA40MM CO CHROME POR CEM HEMI RESURF BIRMINGHAM,SUP-2350871,CDM,C1776,CPT,0278,RC,,,,both,,,8919.96,5797.97,,,,,,,,,,,,,
CATHETER THROMCTMY AXS VECTA 74 L 132 CM PROX/DSTL OD,SUP-2551068,CDM,C1757,HCPCS,0272,RC,,,,both,,,8521.96,5539.27,,,,,,,,,,,,,
PIN EXT FIX SZ 150 X 50 X 5 MM HALF,SUP-2932987,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1552.79,1009.31,,,,,,,,,,,,,
INTRODUCER SURG KT 0.018 IN 4 FR SFT TIP REG NIT VSI,SUP-2606004,CDM,C1894,HCPCS,0272,RC,,,,both,,,63.74,41.43,,,,,,,,,,,,,
COIL VASC I-ED COIL L 50 CM DIA 0.014 IN SECONDARY 14 MM,SUP-2865316,CDM,C1889,HCPCS,0278,RC,,,,both,,,6782.40,4408.56,,,,,,,,,,,,,
CATHETER THROMCTMY QUICKCLEAR L 85 CM DIA10 FR NOM DIA 0.107,SUP-2823724,CDM,C1757,HCPCS,0272,RC,,,,both,,,8949.00,5816.85,,,,,,,,,,,,,
INTRODUCER VASC 8.5FR LUMN L81CM CURL 168MM SHTH 85FR L61CM,SUP-2357597,CDM,C1766,CPT,0272,RC,,,,both,,,2656.13,1726.48,,,,,,,,,,,,,
PLATE BNE RIM SM LT,SUP-2402824,CDM,C1713,HCPCS,0278,RC,,,,both,,,3243.62,2108.35,,,,,,,,,,,,,
KIT THROMCTMY RED 72 L 132 CM PTFE SS NIT COIL,SUP-2880247,CDM,C1887,HCPCS,0272,RC,,,,both,,,15386.00,10000.90,,,,,,,,,,,,,
SHUNT SURG 90 CM W/ VENTRICULOPERITONEAL CATH,SUP-2628568,CDM,C1729,HCPCS,0272,RC,,,,both,,,3784.64,2460.02,,,,,,,,,,,,,
BLADE SAW L 79 MM L 17 MM D 4 MM THK MATERIAL 0.4 MM CUT 0.6,SUP-2929480,CDM,2720000010,LOCAL,0272,RC,,,,both,,,982.57,638.67,,,,,,,,,,,,,
PROGRAMMER DBS PT NS REUSE PERCEPT,SUP-2883011,CDM,C1787,HCPCS,0278,RC,,,,both,,,5115.44,3325.04,,,,,,,,,,,,,
CATHETER ABLAT 7FR L110CM 2-5-2MM SPC RF L CRV THRMCPL QPLR,SUP-2357655,CDM,C2630,CPT,0272,RC,,,,both,,,3689.50,2398.17,,,,,,,,,,,,,
FLANGE ACET PAR 5 SHT L W/ SCR,SUP-2403445,CDM,C1776,CPT,0278,RC,,,,both,,,2223.12,1445.03,,,,,,,,,,,,,
BLADE SAW SAG 9.5MMW X13.5MML 0.4MM/0.6MM THK CUT SM BNE 70D,SUP-2605378,CDM,2720000010,LOCAL,0272,RC,,,,both,,,81.29,52.84,,,,,,,,,,,,,
HC Tips,PX-3613718200,CDM,37182,CPT,0361,RC,,,,inpatient,,,15457.00,10047.05,,,,,,,,,,,,,
SUTURE MAXON SZ 0 L36IN ABSRB GRN SZ GS-21 L37MM 1/2 CIR 8886626961,SUP-2174617,CDM,C1713,HCPCS,0278,RC,,,,both,,,605.55,393.61,,,,,,,,,,,,,
NECK FEM MOD TI NEUT LNG PROFEMUR,SUP-2400557,CDM,C1776,CPT,0278,RC,,,,both,,,6531.20,4245.28,,,,,,,,,,,,,
LINER ACET CM ST/G7 CP/VE AA DM LN/MTL,SUP-2736177,CDM,C1776,CPT,0278,RC,,,,both,,,16171.00,10511.15,,,,,,,,,,,,,
SPACER SHLDR SUBACROMIAL SM BIODEGRADABLE INSPACE,SUP-2736622,CDM,C1889,HCPCS,0278,RC,,,,both,,,17270.00,11225.50,,,,,,,,,,,,,
IMPLANT TOE JT W10 14MMXH25MM THK5MM BNE COT WDG,SUP-2321661,CDM,C1713,HCPCS,0278,RC,,,,both,,,4519.09,2937.41,,,,,,,,,,,,,
LEAD DBS L 42 CM DIA1.5 MM DIRECTIONAL W/ MARKER STRL DISP,SUP-2882977,CDM,C1778,HCPCS,0278,RC,,,,both,,,12006.58,7804.28,,,,,,,,,,,,,
ADAPTER LD PACEMKR VEN LL TUOHY,SUP-2148885,CDM,C1883,HCPCS,0278,RC,,,,both,,,78.50,51.02,,,,,,,,,,,,,
BLADE SURG SAW SAG 105MM LEN 18MM W 2 CUT,SUP-2362663,CDM,2720000010,LOCAL,0272,RC,,,,both,,,231.07,150.20,,,,,,,,,,,,,
GRAFT BNE SUB W15XL15MM TRICORT ILIUM CREST BLK FRZ DRY,SUP-2293828,CDM,C1713,HCPCS,0278,RC,,,,both,,,3158.84,2053.25,,,,,,,,,,,,,
CATHETER ABLATION L 35 MM DIA12 FR CARD PULSED FLD STRL DISP,SUP-2930291,CDM,C1732,HCPCS,0278,RC,,,,both,,,26533.00,17246.45,,,,,,,,,,,,,
INT HEX SCREW 4.5MMX20MM,SUP-2819500,CDM,C1713,HCPCS,0278,RC,,,,both,,,922.88,599.87,,,,,,,,,,,,,
PLATE BONE L38MM 135DEG 3 H TALON S STL STD BRL SIDE COMPR,SUP-2318970,CDM,C1713,HCPCS,0278,RC,,,,both,,,1217.06,791.09,,,,,,,,,,,,,
HANDPIECE LASER 0.2 MM FOC INCIS ACUPULSE,SUP-2713657,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3579.60,2326.74,,,,,,,,,,,,,
GRAFT HUM TISS 5ML STERIFUSE DEMIN BNE MTRX,SUP-2138658,CDM,C9359,HCPCS,0278,RC,,,,both,,,3752.30,2438.99,,,,,,,,,,,,,
SCREW BNE L34MM DIA3.5MM SHT THRD HD MINI-MONSTER,SUP-2320508,CDM,C1713,HCPCS,0278,RC,,,,both,,,622.51,404.63,,,,,,,,,,,,,
HC Drug Screen Quantitative Theophylline,PX-3018019800,CDM,80198,CPT,0301,RC,,,,both,,,449.00,291.85,,,,,,,,,,,,,
PACK 155F X 19CM SYMETREX SPRT,SUP-2269561,CDM,C1750,HCPCS,0278,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
HEAD HUM H18MM DIA48MM CO CHROM ALLY BPLR STD OFFSET REV,SUP-2193860,CDM,C1776,CPT,0278,RC,,,,both,,,7659.40,4978.61,,,,,,,,,,,,,
CATHETER EP 4FR L120CM SPC 2-5-2MM 1MM BND JSN CRV QPLR,SUP-2356959,CDM,C1730,HCPCS,0272,RC,,,,both,,,606.02,393.91,,,,,,,,,,,,,
ALLOGRAFT BNE 7 DEG 18X10.5X5 MM COALITION,SUP-2418002,CDM,C1734,HCPCS,0278,RC,,,,both,,,4521.60,2939.04,,,,,,,,,,,,,
ALLOGRAFT BNE GEL 5 CC FD PREFILLED OPTIUM,SUP-2264602,CDM,C1889,HCPCS,0278,RC,,,,both,,,2204.28,1432.78,,,,,,,,,,,,,
BIT DRL STRL VERSANAIL,SUP-2606671,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1161.80,755.17,,,,,,,,,,,,,
PIN IM SZ E L152MM DIA3.2MM S STL FOR ROD RUSH,SUP-2211448,CDM,C1713,HCPCS,0278,RC,,,,both,,,320.28,208.18,,,,,,,,,,,,,
CATHETER ABLATN F CRV CONTACT FORC SENSORENABLED TACTICATH,SUP-2574333,CDM,C1725,HCPCS,0272,RC,,,,both,,,9734.00,6327.10,,,,,,,,,,,,,
GUIDEWIRE URLGCL 0.035N DIA 145CML 3CML TIP HDRPHLC CTD ANGL,SUP-2487525,CDM,C1769,HCPCS,0272,RC,,,,both,,,103.43,67.23,,,,,,,,,,,,,
SPACER SPNL 11X11MM H5MM TRABECULAR MTL,SUP-2414452,CDM,C1821,HCPCS,0278,RC,,,,both,,,6594.00,4286.10,,,,,,,,,,,,,
SPLINT FNGR 9CM L 3.5IN 4 PRNG PROTCT ALUMINIUM NONPADDED,SUP-2197320,CDM,L3933,HCPCS,0274,RC,,,,both,,,126.35,82.13,,,,,,,,,,,,,
FELT SURG W4XL4IN THK1.65MM POLY PTFE,SUP-2127684,CDM,C1768,CPT,0278,RC,,,,both,,,771.75,501.64,,,,,,,,,,,,,
HC Lyr Clos Sc Tk Ext 7.6-12cm,PX-4501203400,CDM,12034,CPT,0450,RC,,,,outpatient,,,1445.00,939.25,,,,,,,,,,,,,
ROD FOR GALAXY FIXATION SYSTEM 9MM 100MM,SUP-2633890,CDM,C1713,HCPCS,0278,RC,,,,both,,,551.92,358.75,,,,,,,,,,,,,
COMPONENT ULN XSM L4.5IN L EL TIV PLSM INTERCHANGEABLE CEM,SUP-2205945,CDM,C1776,CPT,0278,RC,,,,both,,,14823.16,9635.05,,,,,,,,,,,,,
GRASPER ARTHSCP PROX FOR HAMRTOE CORR NEXTRA,SUP-2137584,CDM,2720000010,LOCAL,0272,RC,,,,both,,,647.09,420.61,,,,,,,,,,,,,
NAIL IM L320MM DIA8.5MM TIB KNEE GRY TI CANN LOK RG BENT,SUP-2347076,CDM,C1713,HCPCS,0278,RC,,,,both,,,4458.80,2898.22,,,,,,,,,,,,,
COIL EMB L5CM DIA5MM 0.035IN FOR ART AND VEN VES MREYE,SUP-2170375,CDM,C1889,HCPCS,0278,RC,,,,both,,,345.37,224.49,,,,,,,,,,,,,
KIT CATHETER ARTERIAL ARROW SAFETY 18GA 12CM INDWELLING,SUP-2865695,CDM,C1751,HCPCS,0278,RC,,,,both,,,271.92,176.75,,,,,,,,,,,,,
CUP ACET OD44MM CO CHROM HA POR HIP IMPCT ST IMPL DISP FOR,SUP-2350842,CDM,C1776,CPT,0278,RC,,,,both,,,15562.63,10115.71,,,,,,,,,,,,,
BRACE ANK SPRAIN AND TRAUM AND CHRONIC DISORD 1 SZ FIT MOST,SUP-2319275,CDM,L4350,HCPCS,0272,RC,,,,both,,,41.67,27.09,,,,,,,,,,,,,
ANCHOR SUTURE DIA 5.5 MM SZ 2 PEEK 3 STRND FORC FIBER,SUP-2882666,CDM,C1713,HCPCS,0278,RC,,,,both,,,2530.84,1645.05,,,,,,,,,,,,,
PIN FXTN L275MM D5MM THRD L6MM BLACK HALF SIZE EXTRNL FXTN X,SUP-2501112,CDM,2720000010,LOCAL,0272,RC,,,,both,,,548.53,356.54,,,,,,,,,,,,,
SPLINT ORTHOPEDIC SLIP ON SM 8 IN RT WRST PLUSH FOAM LNR NYL,SUP-2276664,CDM,L3908,HCPCS,0272,RC,,,,both,,,16.86,10.96,,,,,,,,,,,,,
STAPLE BNE COMPR 25 MM 20 MM CONT 2 LEG BME ELITE,SUP-2564469,CDM,C1713,HCPCS,0278,RC,,,,both,,,4518.74,2937.18,,,,,,,,,,,,,
SCREW BNE NLCK 3.5X12 MM DBL STRT THRD SS JPS,SUP-2645448,CDM,C1713,HCPCS,0278,RC,,,,both,,,231.10,150.21,,,,,,,,,,,,,
PLATE MEDL CLMN STD TI RT TALONAVICULOCUNEIFORM METATRSL NS,SUP-2897093,CDM,C1713,HCPCS,0278,RC,,,,both,,,5648.86,3671.76,,,,,,,,,,,,,
SLING URO L7CMX4CM INCONT M SCR 6 LONESTAR W/ STAY CYSTO,SUP-2140282,CDM,C1771,HCPCS,0278,RC,,,,both,,,8870.50,5765.82,,,,,,,,,,,,,
GRAFT TISS FRZ DRY ALLGRFT STRP ILIUM TRICORT STRUCTURAL,SUP-2307029,CDM,C1713,HCPCS,0278,RC,,,,both,,,5361.64,3485.07,,,,,,,,,,,,,
SPACER SPNL W26XH9MM PEEK-OPTIMA 1 LEV NONTAPERED ADJ VU,SUP-2385987,CDM,C1889,HCPCS,0278,RC,,,,both,,,10701.12,6955.73,,,,,,,,,,,,,
SPACER SPNL 30X11 MM CRESCENT,SUP-2631449,CDM,C1889,HCPCS,0278,RC,,,,both,,,6656.80,4326.92,,,,,,,,,,,,,
HC Bx Bone Trocar/Needle Superfic,PX-3612022000,CDM,20220,CPT,0361,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
CAGE SPNL 14X23-32MM 2-5 DEG GIZA,SUP-2362882,CDM,C1889,HCPCS,0278,RC,,,,both,,,11304.00,7347.60,,,,,,,,,,,,,
HC Nonvascular Shunt X-Ray,PX-3207580900,CDM,75809,CPT,0320,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
IMPLANT FNGR JT MOD THMB HD CO CHROM 14MM,SUP-2137771,CDM,C1776,CPT,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
COUNTERSINK SURG DIA3MM SCR CANN,SUP-2187347,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1025.93,666.85,,,,,,,,,,,,,
SHEATH INTRO FAST-CATH L 40 CM DIA 8 FR GUIDEWIRE 0.038 IN,SUP-2355554,CDM,C1894,HCPCS,0272,RC,,,,both,,,55.74,36.23,,,,,,,,,,,,,
"HC Apply Finger Splint,Static",PX-7612913000,CDM,29130,CPT,0761,RC,,,,both,,,363.00,235.95,,,,,,,,,,,,,
CURETTE BONE STR SZ 0,SUP-2292912,CDM,C1713,HCPCS,0278,RC,,,,both,,,2314.18,1504.22,,,,,,,,,,,,,
GREAT TOE BIOACTION PHLANG SM NEUT CO,SUP-2303799,CDM,C1776,CPT,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
SYMBOTEX COMP MESH STEX SKRT 8CM(3.1INCH),SUP-2174766,CDM,C1781,HCPCS,0278,RC,,,,both,,,2179.10,1416.41,,,,,,,,,,,,,
BAR THRD 80MM FOR SHEFFIELD STRL TY SYS,SUP-2316264,CDM,2720000010,LOCAL,0272,RC,,,,both,,,345.02,224.26,,,,,,,,,,,,,
SCREW BNE PERC COMPR BUTTERFLY GOTFRIED,SUP-2644773,CDM,C1713,HCPCS,0278,RC,,,,both,,,378.50,246.02,,,,,,,,,,,,,
STOP EXT FIX POS FOR RED II TI,SUP-2460630,CDM,2720000010,LOCAL,0272,RC,,,,both,,,452.16,293.90,,,,,,,,,,,,,
CUP ACET DIA44MM RESTORIS PST,SUP-2369632,CDM,C1776,CPT,0278,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
DRILL SURG OD48MM SPNL FIX VANATGE,SUP-2292757,CDM,C1713,HCPCS,0278,RC,,,,both,,,1185.41,770.52,,,,,,,,,,,,,
APPLIER CLP 13IN M L 20 5MM CLPS ENDOSCP LIG POLYMER SGL,SUP-2384288,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3072.49,1997.12,,,,,,,,,,,,,
VALVE NEUROSURGICAL OD1.4MM CATHETERL90CM 30CM VERTICAL WATE,SUP-2825679,CDM,C1889,HCPCS,0278,RC,,,,both,,,7124.94,4631.21,,,,,,,,,,,,,
TROCAR ENDOSCP BLDELSS UNIV 5X100 MM STBL SL ENDOPATH BASX,SUP-2857939,CDM,2720000010,LOCAL,0272,RC,,,,both,,,356.23,231.55,,,,,,,,,,,,,
CATHETER EMB PYTHON L 80 CM DIA 5 FR INFLATED DIA 5 MM SHTH,SUP-2761878,CDM,C1757,HCPCS,0272,RC,,,,both,,,656.26,426.57,,,,,,,,,,,,,
ALLOGRAFT OSTEOTOMY WDG FD IRR,SUP-2875976,CDM,C1713,HCPCS,0278,RC,,,,both,,,2738.39,1779.95,,,,,,,,,,,,,
SET TBNG EXT FLTR DISP FOR ULTRASONIC ASPIR SONOPET,SUP-2367534,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1010.14,656.59,,,,,,,,,,,,,
HC Chemo IV Push Initial Drug,PX-3319640900,CDM,96409,CPT,0331,RC,,,,outpatient,,,673.00,437.45,,,,,,,,,,,,,
BLADE RTRCTR MCCLLCH 6CMD STNLSS STEEL SPNL MSCLE NRRW BLACK,SUP-2464799,CDM,2720000010,LOCAL,0272,RC,,,,both,,,408.39,265.45,,,,,,,,,,,,,
PLATE BNE 20 H NONSTERILE BILAT S STL NAR CRV LOK COMPR FOR,SUP-2178051,CDM,C1713,HCPCS,0278,RC,,,,both,,,3028.03,1968.22,,,,,,,,,,,,,
DISPOSABLE KIT FOR DX SWIVELOCK 4.75 MM,SUP-2815353,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
STEM HUM PRSS FT SHLDR PART,SUP-2379209,CDM,C1776,CPT,0278,RC,,,,both,,,12246.00,7959.90,,,,,,,,,,,,,
PLATE BNE L391MM 16 H R PROX FEM S STL LOK COMPR FOR,SUP-2186144,CDM,C1713,HCPCS,0278,RC,,,,both,,,5120.68,3328.44,,,,,,,,,,,,,
CATHETER EMB ARW L 80 CM DIA 5 FR 2 LUMEN STRL,SUP-2383506,CDM,C1757,HCPCS,0272,RC,,,,both,,,243.98,158.59,,,,,,,,,,,,,
RESERVOIR CEREBROSPINAL SM LUM PERI TWO MTL CONN SPETZLER,SUP-2244301,CDM,2720000010,LOCAL,0272,RC,,,,both,,,865.07,562.30,,,,,,,,,,,,,
SET THROMCTMY ANGIOJET FETCH 2 L 135 CM DIA 4 FR SHTH 5 FR,SUP-2142037,CDM,C1757,HCPCS,0272,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
ALUMINUM HYDROXIDE GEL 320 MG/5ML PO SUSP,RX-353,CDM,340b,HCPCS,0637,RC,09999-9902-57,NDC,,both,30,ML,1.90,1.23,,,,,,,,,,,,,
IMPLANT BIO TISS W18XL28CM THK1.5MM CLLGN PERMACOL,SUP-2388450,CDM,C9364,HCPCS,0278,RC,,,,both,,,32170.30,20910.69,,,,,,,,,,,,,
TUBE MYRINGOTOMY 1.27 MM CLLR BUTTON FLROPLAS BLU,SUP-2430211,CDM,C1713,HCPCS,0278,RC,,,,both,,,1197.69,778.50,,,,,,,,,,,,,
RETRACTOR RNG MALYUGIN 7 MM IRIS,SUP-2304013,CDM,2720000010,LOCAL,0272,RC,,,,both,,,470.47,305.81,,,,,,,,,,,,,
ALLOGRAFT BNE FIBULAR SHFT 101-159 MMX0.1 CM FRZN,SUP-2717861,CDM,C1762,CPT,0278,RC,,,,both,,,3656.09,2376.46,,,,,,,,,,,,,
SCREW COMPR 6.5X30MM HEADLESS TI THRD LEN 16MM STRL,SUP-2547113,CDM,C1713,HCPCS,0278,RC,,,,both,,,919.33,597.56,,,,,,,,,,,,,
PORT IMPL INFUSION PRECON 5 FR TI VORT,SUP-2240130,CDM,C1788,HCPCS,0278,RC,,,,both,,,953.30,619.64,,,,,,,,,,,,,
KIT INTRO VSI L 10 CM 4 FR NIT TUNGSTEN TIP SIL ANGLED SMTH,SUP-2765617,CDM,C1894,HCPCS,0272,RC,,,,both,,,88.23,57.35,,,,,,,,,,,,,
SPLINT FNGR L L3.25IN ALUM PD LTWT COT,SUP-2196692,CDM,L3809,HCPCS,0272,RC,,,,both,,,2.32,1.51,,,,,,,,,,,,,
GUIDEWIRE VASC 145CM 0.035IN TIP 2CM PTFE HEPARIN STR,SUP-2167657,CDM,C1769,HCPCS,0272,RC,,,,both,,,30.46,19.80,,,,,,,,,,,,,
BIT DRL L195MM DIA4.3MM S STL FOR NCB SYS,SUP-2411439,CDM,2720000010,LOCAL,0272,RC,,,,both,,,320.85,208.55,,,,,,,,,,,,,
COMPONENT KNEE 2 SPECIALITY KNEE2ZI1800] ZIMMER BIOMET INC],SUP-2212598,CDM,C1776,CPT,0278,RC,,,,both,,,15700.00,10205.00,,,,,,,,,,,,,
PLATE BONE EVANS TITANIUM ARSENAL FOOT PLATING SYSTEM FOR 2.2/2.7/3.5MM SCREW,SUP-2878969,CDM,C1713,HCPCS,0278,RC,,,,both,,,5997.40,3898.31,,,,,,,,,,,,,
LIFT HEEL LG ADJLFT,SUP-2394116,CDM,L3334,HCPCS,0274,RC,,,,both,,,40.66,26.43,,,,,,,,,,,,,
DRILL TWST 1.4X18X8MM,SUP-2364181,CDM,2720000010,LOCAL,0272,RC,,,,both,,,620.75,403.49,,,,,,,,,,,,,
CATHETER ANGIOPLSTY METACROSS 135 CM 3.9/5.7 FR 80 MM 5 MM,SUP-2384778,CDM,C1725,HCPCS,0272,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
COOLCUT 90 ABLATOR,SUP-2816012,CDM,2720000010,LOCAL,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
SPACER HUM +9MM W TIGHT SCR,SUP-2399863,CDM,C1776,CPT,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
CLIP ENDOSCP 235 CM 2.8 MM STRL MANTIS LTX 1 PER BX,SUP-2862928,CDM,C1889,HCPCS,0278,RC,,,,both,,,1271.70,826.60,,,,,,,,,,,,,
DEVICE FIX STRND 5 MM ARTICULATING RELD 30 STD ABSORBABLE,SUP-2913727,CDM,C1713,HCPCS,0278,RC,,,,both,,,2959.67,1923.79,,,,,,,,,,,,,
SCREW SPNL SD 4X11 MM MINIP DIVERGENCE,SUP-2632032,CDM,C1713,HCPCS,0278,RC,,,,both,,,414.48,269.41,,,,,,,,,,,,,
GRAFT BNE GEL 5 CC SYR DBM DYNAGRAFT II,SUP-2641739,CDM,C1713,HCPCS,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
SCREW BNE L40MM DIA43MM TI ALLY SELF DRL ST VAR LAG DSGN FOR,SUP-2242833,CDM,C1713,HCPCS,0278,RC,,,,both,,,1409.33,916.06,,,,,,,,,,,,,
INTRODUCER KT MINI ACCS N VASC 6FRX20CM 4FR W DIL AND,SUP-2303018,CDM,C1894,HCPCS,0272,RC,,,,both,,,189.81,123.38,,,,,,,,,,,,,
SCREW BNE L18MM DIA4.2MM NONLOCKING FOR TUFFNEK TECHNOLOGY,SUP-2321218,CDM,C1713,HCPCS,0278,RC,,,,both,,,479.64,311.77,,,,,,,,,,,,,
SPACER SPNL H8MM ASSEMB PRIMALOK SP,SUP-2319811,CDM,C1889,HCPCS,0278,RC,,,,both,,,19154.00,12450.10,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 60 CM DIA 6 MM EPTFE STR TW N RING,SUP-2396342,CDM,C1768,CPT,0278,RC,,,,both,,,2873.10,1867.51,,,,,,,,,,,,,
WIRE FIX TROCAR PT 1 END 2X150 MM TI NS KIRSCHNER,SUP-2905550,CDM,C1713,HCPCS,0278,RC,,,,both,,,32.47,21.11,,,,,,,,,,,,,
PLATE BNE L106MM 7 H ST L ANTLAT DST TIB S STL LO PROF NEUT,SUP-2185949,CDM,C1713,HCPCS,0278,RC,,,,both,,,4460.62,2899.40,,,,,,,,,,,,,
PLATE BNE W10XL50MM THK1.5MM 3X3 H BILAT S STL T SHP R ANG,SUP-2185864,CDM,C1713,HCPCS,0278,RC,,,,both,,,846.54,550.25,,,,,,,,,,,,,
BLADE SHAVER MULT FUNC 5 MM 3 IN 1 DISP,SUP-2745539,CDM,2720000010,LOCAL,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
SHEATH LASER 12FR L50CM DIA4.17MM 15DEG 25-40 REPETITION RATE,SUP-2353103,CDM,C2629,CPT,0272,RC,,,,both,,,9545.60,6204.64,,,,,,,,,,,,,
WIRE FIX L450MM OD1.6MM SHRP TIP FOR TRANSCONTINENTAL SPCR,SUP-2232206,CDM,C1713,HCPCS,0278,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
PEDIALYTE PO PACK,RX-108900,CDM,6370000000,HCPCS,0637,RC,00851-0000-05,NDC,,both,1,UN,22.60,14.69,,,,,,,,,,,,,
KIT ORTH ANK SYNDESMOSIS REP FRAC INCL CONSTRUCT AND DRL,SUP-2349222,CDM,C1713,HCPCS,0278,RC,,,,both,,,3940.70,2561.45,,,,,,,,,,,,,
ANCHOR PK CINCH SIZE: 4.0MM,SUP-2300758,CDM,C2631,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
GRAFT VASC L80CM OD6MM EPTFE STD WALL NONRINGED MINI CUF,SUP-2128085,CDM,C1768,CPT,0278,RC,,,,both,,,8050.87,5233.07,,,,,,,,,,,,,
HINGE EXT FIX FEMALE,SUP-2898468,CDM,2720000010,LOCAL,0272,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
CATHETER KIT 7 FRX16 CM CV 3L HEPARIN N LIDO,SUP-2214564,CDM,C1751,HCPCS,0278,RC,,,,both,,,117.94,76.66,,,,,,,,,,,,,
TROCAR ENDOSCP L 100 MM DIA11 MM STD LAPSCP BLADED FIX CANN,SUP-2896386,CDM,2720000010,LOCAL,0272,RC,,,,both,,,454.14,295.19,,,,,,,,,,,,,
NEEDLE BX 19GA L60CM THROW L2CM SHTH 7FR LIV ACCS QUIK COR,SUP-2168312,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1502.49,976.62,,,,,,,,,,,,,
COIL EMB L4CM OD3MM 360DEG HELI SFT STRTCH RESIST BIG LOOP,SUP-2365739,CDM,C1889,HCPCS,0278,RC,,,,both,,,8172.16,5311.90,,,,,,,,,,,,,
MESH CRAN THK03MM TI ORBIT FLR FOR 15MM SCR MIC SYS,SUP-2262595,CDM,C1713,HCPCS,0278,RC,,,,both,,,1722.92,1119.90,,,,,,,,,,,,,
SCREW CORTEX RESORB 2X6MM F/ORTHOMESH STRL,SUP-2550440,CDM,C1713,HCPCS,0278,RC,,,,both,,,390.71,253.96,,,,,,,,,,,,,
PLATE BNE FEM 3.5/4.5X388 MM RT PROX 12 HOLE NS VA-LCP,SUP-2757668,CDM,C1713,HCPCS,0278,RC,,,,both,,,9249.81,6012.38,,,,,,,,,,,,,
COMPONENT FEM SZ 4 L POST KNEE NP PRI BICRUCIATE CEM STBL,SUP-2350305,CDM,C1776,CPT,0278,RC,,,,both,,,13755.56,8941.11,,,,,,,,,,,,,
TRAY CTRL VEN CATH 3FR L8CM 0.018IN POLYUR SGL LUMN CATH STR,SUP-2167839,CDM,C1751,HCPCS,0278,RC,,,,both,,,208.40,135.46,,,,,,,,,,,,,
PLATE BNE BAR L12MM 2 H CRANIOMAXILLOFACIAL TI RIG FOR UNIV,SUP-2366213,CDM,C1713,HCPCS,0278,RC,,,,both,,,326.34,212.12,,,,,,,,,,,,,
PLATE 3.5MM TI LCP TM PROX TIBIA PLATE 10H 159MM RIGHT-STER,SUP-2549550,CDM,C1713,HCPCS,0278,RC,,,,both,,,3543.05,2302.98,,,,,,,,,,,,,
HC So1 Porphobilinogenurine Quant,PX-3018411067,CDM,84110,CPT,0301,RC,,,,both,,,65.00,42.25,,,,,,,,,,,,,
PLATE BONE SHFT L428MM BLDE L70MM THK4.8MM 95DEG 26 H BILAT,SUP-2185472,CDM,C1713,HCPCS,0278,RC,,,,both,,,4003.88,2602.52,,,,,,,,,,,,,
BOOT WLK LO XS NOAIR EA,SUP-2319305,CDM,L4386,HCPCS,0272,RC,,,,both,,,72.97,47.43,,,,,,,,,,,,,
SPHINCTEROTOME ENDO L30MM OD7FR 0.035IN 3 LUMN MFIL CUT,SUP-2169395,CDM,2720000010,LOCAL,0272,RC,,,,both,,,637.42,414.32,,,,,,,,,,,,,
CATHETER CV SINGLE LUMEN 5 FRX55 CM W/ ECHOGENIC TIP XCELA,SUP-2118960,CDM,C1751,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
KIT CANN 19FR TIP L18CM VENT CONN 3/8IN ART POLYUR PERC,SUP-2282864,CDM,2720000010,LOCAL,0272,RC,,,,both,,,759.97,493.98,,,,,,,,,,,,,
BODY EXT FIX CTRL STD M COMP PVC FREE STRL PROCALLUS,SUP-2645893,CDM,2720000010,LOCAL,0272,RC,,,,both,,,916.63,595.81,,,,,,,,,,,,,
GUIDEWIRE VASC VICTORY 14 L 195 CM DIA 0.014 IN TIP L 2.5 CM,SUP-2140820,CDM,C1769,HCPCS,0272,RC,,,,both,,,467.86,304.11,,,,,,,,,,,,,
BEAM FIX L65MM DIA4.5MM ARTH,SUP-2223926,CDM,C1776,CPT,0278,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
TOTAL KNEE IMPL NXGN PROVIDE THE ABIL TO WLK SIT OR,SUP-2212255,CDM,C1776,CPT,0278,RC,,,,both,,,15543.00,10102.95,,,,,,,,,,,,,
IMPLANT OTO DIA3MM EAR TI STR HEX HD FLNG FIX FOR VISTAFIX,SUP-2164937,CDM,L8614,HCPCS,0278,RC,,,,both,,,2810.30,1826.69,,,,,,,,,,,,,
SCREW BONE L65MM DIA4.7MM STRL S STL PARTIALLY THRD FOR,SUP-2349607,CDM,C1713,HCPCS,0278,RC,,,,both,,,469.05,304.88,,,,,,,,,,,,,
GUIDEWIRE ORTH BALL NOSE 3X900 MM STRL,SUP-2766027,CDM,C1769,HCPCS,0272,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
BIT DRL DIA3MM FOR ANK FUS PLATING SYS ORTHOLOC 3DI,SUP-2398588,CDM,2720000010,LOCAL,0272,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
SHELL ACET AUG LG 13 MM HIP GRP 2 INTEGRIP,SUP-2433606,CDM,C1776,CPT,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
SEED BRACHYTHERAPY LOAD 0.7-1.0 MCI STRL ADVANTAGE 2029ALS2] ISOAID LLC],SUP-2247258,CDM,C2642,HCPCS,0278,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
SCREW SPNL ROD DIA 4.75/5 MM SS PEDCL REDUCTION MULTAXL STRL,SUP-2926487,CDM,C1713,HCPCS,0278,RC,,,,both,,,2998.70,1949.15,,,,,,,,,,,,,
HC So Collagen Cross-Link N-Telopep,PX-3018252366,CDM,82523,CPT,0301,RC,,,,inpatient,,,139.00,90.35,,,,,,,,,,,,,
LINAGLIPTIN 5 MG PO TABS,RX-108630,CDM,6370000000,HCPCS,0637,RC,00597-0140-30,NDC,,both,1,UN,78.80,51.22,,,,,,,,,,,,,
ANCHOR VERSALOOP 1.8MM DL TAPE,SUP-2756501,CDM,C1713,HCPCS,0278,RC,,,,both,,,1752.12,1138.88,,,,,,,,,,,,,
LENS INTOCU +21.5 DIOPT L13.5MM DIA6MM AC D5.2MM 5DEG UV,SUP-2247690,CDM,V2632,HCPCS,0276,RC,,,,both,,,477.28,310.23,,,,,,,,,,,,,
TRAY TIB L59MM KNEE TI ALLOY PRI CRUC RET POST STBL,SUP-2405402,CDM,C1776,CPT,0278,RC,,,,both,,,6044.50,3928.92,,,,,,,,,,,,,
PROXILOCK COCR BEAD STEM 10MM 01-230-10241,SUP-2198963,CDM,C1776,CPT,0278,RC,,,,both,,,15051.90,9783.73,,,,,,,,,,,,,
SCREW SPNL POLYAX 6.5X60 MM CANN 35506560] ZIMMER SPINE],SUP-2415396,CDM,C1713,HCPCS,0278,RC,,,,both,,,5805.08,3773.30,,,,,,,,,,,,,
GLOBAL UNITE REV STEM SZ 6 TR,SUP-2513427,CDM,C1776,CPT,0278,RC,,,,both,,,1391.02,904.16,,,,,,,,,,,,,
IMMOBILIZER KNEE SIZED CANVS 16 IN L,SUP-2336062,CDM,L1830,CPT,0272,RC,,,,both,,,35.76,23.24,,,,,,,,,,,,,
PARTICLE EMB BNDL S220PRO MAESTRO 28MC24150SN EMBOSPHEREPRO,SUP-2798605,CDM,C1889,HCPCS,0278,RC,,,,both,,,1491.50,969.47,,,,,,,,,,,,,
SURFACE ARTC 1-2 AB THK9MM AP40MM ML58MM PUR POLYETH KNEE,SUP-2211970,CDM,C1776,CPT,0278,RC,,,,both,,,3877.90,2520.63,,,,,,,,,,,,,
CATHETER DIAG SZ 7FRX115CM 20 ELECTRD 2-6-2 SPC D CRV MAP HI,SUP-2248709,CDM,C1730,HCPCS,0272,RC,,,,both,,,5639.44,3665.64,,,,,,,,,,,,,
STEM FEM SZ 1 STD OFFSET HIP ENDUR,SUP-2251937,CDM,C1776,CPT,0278,RC,,,,both,,,8531.38,5545.40,,,,,,,,,,,,,
SIDEKICK STLTH REARFOOT FIX HALF PIN 3 MMX180 MM 40 MM THRD,SUP-2400689,CDM,2720000010,LOCAL,0272,RC,,,,both,,,304.58,197.98,,,,,,,,,,,,,
GRAFT VASC 2XL 10.8X8.9CM BIOSCAFFOLD ENV CANGAROO ECM,SUP-2417653,CDM,C1768,CPT,0278,RC,,,,both,,,3925.00,2551.25,,,,,,,,,,,,,
BIT DRL L195MM DIA4.5MM QUIK CPL FOR L EXT FIX,SUP-2187288,CDM,2720000010,LOCAL,0272,RC,,,,both,,,352.21,228.94,,,,,,,,,,,,,
SET INTRO PERFRMR L 7 CM DIL L 13 CM OD 4 FR ID 1.3 MM,SUP-2168342,CDM,C1894,HCPCS,0272,RC,,,,both,,,60.98,39.64,,,,,,,,,,,,,
SUPPORT ORTHOT HEEL CUST THMS W/WDG,SUP-2435734,CDM,L3465,HCPCS,0272,RC,,,,both,,,165.73,107.72,,,,,,,,,,,,,
GRAFT BNE CRUSH 60 CC TISS CANC,SUP-2165615,CDM,C1713,HCPCS,0278,RC,,,,both,,,2072.40,1347.06,,,,,,,,,,,,,
HOUSING DISTRACTOR 8DEG 10MM ALLGRFT INSRT STR,SUP-2292240,CDM,C1713,HCPCS,0278,RC,,,,both,,,1973.46,1282.75,,,,,,,,,,,,,
OVERDRILL SURG 2.8MM SM SCR FIX SYS LACTOSORB REUNITE,SUP-2137301,CDM,2720000010,LOCAL,0272,RC,,,,both,,,759.88,493.92,,,,,,,,,,,,,
PLATE BNE BROAD 3.5X211 MM 16 HOLE SS LC-DCP,SUP-2569250,CDM,C1713,HCPCS,0278,RC,,,,both,,,400.66,260.43,,,,,,,,,,,,,
PLATE STRNL 4 H TI ANGLED NS MATRIXSTERNUM,SUP-2904236,CDM,C1713,HCPCS,0278,RC,,,,both,,,1639.11,1065.42,,,,,,,,,,,,,
PATCH VASC W20XL30CM THK2MM SFT TISS GOR TX,SUP-2395292,CDM,C1768,CPT,0278,RC,,,,both,,,10465.62,6802.65,,,,,,,,,,,,,
COMPONENT FEM CRUC RET POR RT SZ 7 OXINIUM PROFIX,SUP-2347007,CDM,C1776,CPT,0278,RC,,,,both,,,8759.03,5693.37,,,,,,,,,,,,,
DEFIBRILLATOR IMPL DYNAGEN W 5.37 X H 7.36 CM D 0.99 CM 29.5,SUP-2149174,CDM,C1722,HCPCS,0275,RC,,,,both,,,30071.78,19546.66,,,,,,,,,,,,,
RELOAD STPL L45MM OPN H4.1MM CLS H2MM THCK TISS GRN 4 ROW,SUP-2220065,CDM,2720000010,LOCAL,0272,RC,,,,both,,,368.38,239.45,,,,,,,,,,,,,
COLLAR CERV 2 PC SM AD 10-20X2 IN ADJ EMS MIAMI J PLAS FOAM,SUP-2247597,CDM,L0190,HCPCS,0272,RC,,,,both,,,174.84,113.65,,,,,,,,,,,,,
GRAFT HUM TISS SAPH VEIN DONOR,SUP-2175269,CDM,C1768,CPT,0278,RC,,,,both,,,24806.00,16123.90,,,,,,,,,,,,,
SHEATH LD INTRO SAFSHTH ULTRA L 13 CM DIA10.5 FR GUIDEWIRE L,SUP-2159468,CDM,C1892,HCPCS,0272,RC,,,,both,,,143.81,93.48,,,,,,,,,,,,,
TRAY CRANIOFIX 2 CRAN REP,SUP-2370392,CDM,C1713,HCPCS,0278,RC,,,,both,,,1924.82,1251.13,,,,,,,,,,,,,
CAGE SPNL L14XW14XH15MM 4 LOBE MESH ANAT FOOTPRINT MOD IMP,SUP-2317737,CDM,C1889,HCPCS,0278,RC,,,,both,,,7545.42,4904.52,,,,,,,,,,,,,
ADAPTER ORTH HUM SHLDR N REVERSED HEMI-PROSTHESIS AEQUALIS,SUP-2715632,CDM,C1776,CPT,0278,RC,,,,both,,,8277.04,5380.08,,,,,,,,,,,,,
MESH HERN DIA45IN POLY 4 HYDROXYBUTYRATE SYN FULL RESRB,SUP-2126265,CDM,C1781,HCPCS,0278,RC,,,,both,,,5997.40,3898.31,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 10 CM DIA 8 MM STR STD WALL REINF,SUP-2525431,CDM,C1768,CPT,0278,RC,,,,both,,,345.84,224.80,,,,,,,,,,,,,
CLIP INT USE DIA14.6 MM THRD L 165 CM ENDOSCP DIA 8.5-10 MM BLUNT,SUP-2881815,CDM,C1889,HCPCS,0278,RC,,,,both,,,1535.46,998.05,,,,,,,,,,,,,
SHELL STPL PWR FOR SIGNIA HNDL STPL SYS,SUP-2283368,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1359.65,883.77,,,,,,,,,,,,,
TRAY PICC CATH 1.9FR 35CM 22GAX25MM INTRO COMPLT SGL LUMN,SUP-2391833,CDM,C1751,HCPCS,0278,RC,,,,both,,,160.14,104.09,,,,,,,,,,,,,
CYGNUS ANTR CERV 14MM PLTE MTI LVL,SUP-2664161,CDM,C1713,HCPCS,0278,RC,,,,both,,,2166.60,1408.29,,,,,,,,,,,,,
SPLINT ORTH SM SHOE SZ M 4 6 WOM 5 7 NT FT ANK PLNTR,SUP-2195477,CDM,L4396,HCPCS,0274,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
SCREW BNE L6MM DIA2MM CRANIOMAXILLOFACIAL SIL TI LOK CRSS 5PK,SUP-2366127,CDM,C1713,HCPCS,0278,RC,,,,both,,,301.03,195.67,,,,,,,,,,,,,
SCREW BONE SELF TAPPING 2.9X10 MM LOCKING TITANIUM MATRIXRIB,SUP-2837687,CDM,C1713,HCPCS,0278,RC,,,,both,,,754.07,490.15,,,,,,,,,,,,,
CATHETER PICC KT 3 LUMN 6FR FULL LO MORPHEUS SMRT,SUP-2116998,CDM,C1751,HCPCS,0278,RC,,,,both,,,346.03,224.92,,,,,,,,,,,,,
CATHETER GUID L125CM OD5FR GWIRE OD0.056IN LIMA VISTA BRT,SUP-2155876,CDM,C1887,HCPCS,0272,RC,,,,both,,,474.77,308.60,,,,,,,,,,,,,
RESERVOIR CSF VENTRICULAR ON-OFF FLSH ANTISIPH DEV,SUP-2852570,CDM,C1889,HCPCS,0278,RC,,,,both,,,3823.74,2485.43,,,,,,,,,,,,,
PLATE BNE SM 10 H MAXILLOMANDIBULAR TI MATRIXWAVE,SUP-2181782,CDM,C1713,HCPCS,0278,RC,,,,both,,,1077.02,700.06,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL PEEK SD800.517,SUP-2860199,CDM,C1713,HCPCS,0278,RC,,,,both,,,30851.13,20053.23,,,,,,,,,,,,,
HC Plmt Access Bil Tree Sm Bwl,PX-3614754100,CDM,47541,CPT,0361,RC,,,,outpatient,,,6875.00,4468.75,,,,,,,,,,,,,
TRAY PICC MAXIMAL BARR 4FR 2 LUMN CATHETER W BIOPATCH PROTCT,SUP-2125697,CDM,C1751,HCPCS,0278,RC,,,,both,,,1066.53,693.24,,,,,,,,,,,,,
BIT DRL L300MM OD5.5MM W/O STP NONRADIOLUCENT AO QUIK CPL,SUP-2368454,CDM,2720000010,LOCAL,0272,RC,,,,both,,,624.23,405.75,,,,,,,,,,,,,
MASK LARYN AIRWY SZ 2 DEV ONLY INTEGR DRN TUBE REUSE LMA,SUP-2383624,CDM,2720000010,LOCAL,0272,RC,,,,both,,,856.59,556.78,,,,,,,,,,,,,
DRILL CANN 19MM TRUVIEW,SUP-2400036,CDM,2720000010,LOCAL,0272,RC,,,,both,,,587.18,381.67,,,,,,,,,,,,,
OVERTUBE ENDOSCP L50CM ID16.7MM SCP DIA8.6-10MM GAST INSUF,SUP-2360646,CDM,C1713,HCPCS,0278,RC,,,,both,,,708.86,460.76,,,,,,,,,,,,,
CONNECTOR SPNL L CDH DOMINO,SUP-2279960,CDM,C1713,HCPCS,0278,RC,,,,both,,,2176.02,1414.41,,,,,,,,,,,,,
HYBRID HUM CUP EPI36 D42 +9MM,SUP-2513009,CDM,C1776,CPT,0278,RC,,,,both,,,5783.88,3759.52,,,,,,,,,,,,,
CATHETER ABLATN STD 2-5 MM 4.5 MM 7.5 FRX110 CM INTELLATIP,SUP-2424671,CDM,C1732,HCPCS,0278,RC,,,,both,,,6123.00,3979.95,,,,,,,,,,,,,
PIN EXT FIX HALF 3X100 MM 15 MM BLNT BLU XTRAFIX,SUP-2488023,CDM,2720000010,LOCAL,0272,RC,,,,both,,,403.65,262.37,,,,,,,,,,,,,
TOCILIZUMAB 20 MG/ML IV SOLN (MIXTURES ONLY),RX-430062,CDM,J3262,HCPCS,0636,RC,50242-0135-01,NDC,,both,4,ML,1567.00,1018.55,,,,,,,,,,,,,
CATHETER HD DL 14 FRX40 CM STR STP TIP HEMO-FLOW,SUP-2266983,CDM,C1750,HCPCS,0278,RC,,,,both,,,458.44,297.99,,,,,,,,,,,,,
SET URET STENT L 22 CM DIA 4.8 FR PERCFLX + HYDROPLUS 2,SUP-2139089,CDM,C2617,HCPCS,0278,RC,,,,both,,,382.86,248.86,,,,,,,,,,,,,
BURR HOLE KIT W/ SKULL MT SMARTFRAME XG,SUP-2328068,CDM,2720000010,LOCAL,0272,RC,,,,both,,,14519.36,9437.58,,,,,,,,,,,,,
PIN FIX STD ANTR LUM TEMP TRINICA,SUP-2205179,CDM,C1713,HCPCS,0278,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
INSERT NDLHLDR SINGLE ACT 5 MMX13 IN RT 3 PC CRV CARB-BITE,SUP-2472874,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1466.91,953.49,,,,,,,,,,,,,
AUGMENT FEM 2XL THK4MM STD RT POST KNEE TI CEM BLK PRESSFIT,SUP-2406984,CDM,C1776,CPT,0278,RC,,,,both,,,1745.84,1134.80,,,,,,,,,,,,,
COMPONENT TOT SHLDR CAPPED REVERSED W/ POST BASEPLT,SUP-2212512,CDM,C1776,CPT,0278,RC,,,,both,,,26828.16,17438.30,,,,,,,,,,,,,
HC X-Ray Exam Entire Spine 6/> Vw,PX-3207208400,CDM,72084,CPT,0320,RC,,,,inpatient,,,1492.00,969.80,,,,,,,,,,,,,
HC X-Ray Exam Entire Spine 6/> Vw,PX-3207208400,CDM,72084,CPT,0320,RC,,,,outpatient,,,1492.00,969.80,,,,,,,,,,,,,
PLATE CHIN DBL Y ARNETT 6MM,SUP-2262921,CDM,C1713,HCPCS,0278,RC,,,,both,,,851.07,553.20,,,,,,,,,,,,,
BALLOON STONE REM 7FR L15MM CATH L210CM DBL LUMN BILI,SUP-2149636,CDM,C1726,HCPCS,0272,RC,,,,both,,,266.90,173.48,,,,,,,,,,,,,
PLATE BNE FIBULAR RT LAT 11 HOLE GLD,SUP-2865046,CDM,C1713,HCPCS,0278,RC,,,,both,,,4656.62,3026.80,,,,,,,,,,,,,
CHLORPROMAZINE HCL 25 MG PO TABS,RX-1656,CDM,6370000000,HCPCS,0637,RC,00527-2962-37,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
TI MAXILLARY FOOTPLATE,SUP-2823036,CDM,C1713,HCPCS,0278,RC,,,,both,,,1762.80,1145.82,,,,,,,,,,,,,
ALLOGRAFT BNE EVANS WDG 18X18X8 MM,SUP-2864938,CDM,C1713,HCPCS,0278,RC,,,,both,,,5840.40,3796.26,,,,,,,,,,,,,
GUIDEWIRE STRL DISP STD STR TIP NO TORQ VISE,SUP-2166103,CDM,C1769,HCPCS,0272,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
GRAFT BIO TISS W8XL8CM FEN FET BOV ACELLULAR DERM MTRX,SUP-2243696,CDM,Q4110,HCPCS,0636,RC,,,,both,,,6217.20,4041.18,,,,,,,,,,,,,
JOINT TOE CANN SCR 3.5X16 MM COMPR SS HAMRTOE PROTOE XFLEX,SUP-2851265,CDM,C1776,CPT,0278,RC,,,,both,,,2524.56,1640.96,,,,,,,,,,,,,
MESH HERN FLAT SHT 6X3 IN RECT OVL FLX KNITTED PROLITE ULTRA,SUP-2227246,CDM,C1781,HCPCS,0278,RC,,,,both,,,98.72,64.17,,,,,,,,,,,,,
PLATE BNE W13.5XL152MM THK4.2MM 8 H BILAT S STL NAR LOK,SUP-2185240,CDM,C1713,HCPCS,0278,RC,,,,both,,,1289.06,837.89,,,,,,,,,,,,,
BUTTON SUT DIA5 8IN POLY 2 H PEARL,SUP-2431814,CDM,C1713,HCPCS,0278,RC,,,,both,,,4.77,3.10,,,,,,,,,,,,,
CATHETER DRNGE BILI 12FRX40CM 0.038IN GWIRE SKATER LCK PGTL,SUP-2120144,CDM,C1729,HCPCS,0272,RC,,,,both,,,245.30,159.44,,,,,,,,,,,,,
BIT DRL L6MM DIA2.7MM REUSE FOR ILIZ AND TAY SPAT FRME EXT,SUP-2342319,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2180.79,1417.51,,,,,,,,,,,,,
IMPLANT HUM TISS DIA16 MM SM PA CONDUIT NONVALVED REDUC,SUP-2932799,CDM,C1762,CPT,0278,RC,,,,both,,,24891.03,16179.17,,,,,,,,,,,,,
KIT EXT FIX ID BND CAP STRL DISP SMRT FX,SUP-2933429,CDM,2720000010,LOCAL,0272,RC,,,,both,,,779.16,506.45,,,,,,,,,,,,,
BASEPLATE 24MM 10* FULL AUGMENT,SUP-2749342,CDM,C1776,CPT,0278,RC,,,,both,,,4553.00,2959.45,,,,,,,,,,,,,
TI LCP VOLR CLMN DSTL RADIUS PL 6H HEAD/5H SHAFT/RT-STERILE,SUP-2546656,CDM,C1713,HCPCS,0278,RC,,,,both,,,3162.48,2055.61,,,,,,,,,,,,,
RING 5 8 140MM FOR TRUELOK FIX SYS,SUP-2316183,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1801.64,1171.07,,,,,,,,,,,,,
GUIDEWIRE VASC L200CM COIL L10CM DIA0.01IN HYDRPHLC,SUP-2172467,CDM,C1769,HCPCS,0272,RC,,,,both,,,932.58,606.18,,,,,,,,,,,,,
COMPOUND RESTORATIVE 14ML OXIDE-EUGENOL INTERMED POLYMER IRM,SUP-2238598,CDM,C1713,HCPCS,0278,RC,,,,both,,,69.05,44.88,,,,,,,,,,,,,
GLIDEWIRE ENDO L260CM OD0.035IN ANG BILI DEV,SUP-2141515,CDM,C1769,HCPCS,0272,RC,,,,both,,,442.74,287.78,,,,,,,,,,,,,
KIT IMPL FNGR CUST,SUP-2397185,CDM,L8630,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE 10 CC CORTICOCANCELLOUS ALLGRFT FRZN,SUP-2933459,CDM,C1762,CPT,0278,RC,,,,both,,,10513.19,6833.57,,,,,,,,,,,,,
IMPLANT HUM TISS L 1 CM AORT DIA10 MM ABD AORT ALLGRFT,SUP-2933873,CDM,C1762,CPT,0278,RC,,,,both,,,71267.95,46324.17,,,,,,,,,,,,,
ALLOGRAFT BNE CART 2-5.9X1 CM NACL COSTAL,SUP-2717801,CDM,C1762,CPT,0278,RC,,,,both,,,3837.05,2494.08,,,,,,,,,,,,,
GRAFT VASC PERIPH BYPS STR THN WALL N RING 6MM DIA 80CM LEN,SUP-2126680,CDM,C1768,CPT,0278,RC,,,,both,,,3422.60,2224.69,,,,,,,,,,,,,
PIN HALF 45X100X30MM,SUP-2704542,CDM,C1713,HCPCS,0278,RC,,,,both,,,357.96,232.67,,,,,,,,,,,,,
TRAY INTRO DIA 8.5 FR 1 PC STYL STRL,SUP-2876455,CDM,C1894,HCPCS,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
ALLOGRAFT BNE PROX METATRSL SEG FD STRL LF DISP,SUP-2458254,CDM,C1889,HCPCS,0278,RC,,,,both,,,3733.15,2426.55,,,,,,,,,,,,,
STEM FEM HIP L 115 MM DIA15 MM CONCL STR SHOT PEENED TAPR,SUP-2889761,CDM,C1776,CPT,0278,RC,,,,both,,,9185.44,5970.54,,,,,,,,,,,,,
GRAFT HUM TISS L 22 X W 22 X H 10/5 MM IL CREST UNICORTICAL,SUP-2913413,CDM,C1762,CPT,0278,RC,,,,both,,,7887.68,5126.99,,,,,,,,,,,,,
BLADE KEL 2INX3IN BKWALT,SUP-2382391,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1249.25,812.01,,,,,,,,,,,,,
BETAXOLOL HCL 0.25 % OP SUSP,RX-19703,CDM,6370000000,HCPCS,0637,RC,00078-0729-10,NDC,,both,10,ML,1825.40,1186.51,,,,,,,,,,,,,
METATARSAL DCOMPR IMPL SZ 1 163MM W 126MM HT HD,SUP-2400139,CDM,C1776,CPT,0278,RC,,,,both,,,10104.52,6567.94,,,,,,,,,,,,,
SCREW BONE L40MM DIA4.5MM CORT S STL ST NONCANNULATED,SUP-2363884,CDM,C1713,HCPCS,0278,RC,,,,both,,,56.68,36.84,,,,,,,,,,,,,
SLING GYN ANTR PELV MESH RECON TRNSVAG POLYPR PROLIFT,SUP-2219783,CDM,C1781,HCPCS,0278,RC,,,,both,,,5711.66,3712.58,,,,,,,,,,,,,
COMPONENT ARTC SURF TIB 7-10 EF 12 MM KNEE STRP BLU NXGN LPS,SUP-2208738,CDM,C1776,CPT,0278,RC,,,,both,,,2469.92,1605.45,,,,,,,,,,,,,
PLATE BNE L211MM 6 H NONSTERILE L PROX FEM S STL LO PROF,SUP-2186041,CDM,C1713,HCPCS,0278,RC,,,,both,,,3868.64,2514.62,,,,,,,,,,,,,
PLATE BNE L 243 X W 11.5 MM THK 3.6 MM SCREW DIA 3.5 MM 20 H 72463220N,SUP-2932753,CDM,C1713,HCPCS,0278,RC,,,,both,,,7981.88,5188.22,,,,,,,,,,,,,
HEAD FEM MOD 4- MM SHT 42 MM HIP BIRMINGHAM HIPTM RESURF,SUP-2435178,CDM,C1776,CPT,0278,RC,,,,both,,,10437.36,6784.28,,,,,,,,,,,,,
SCREW BONE L14MM DIA4MM CORT MID/FOREFOOT S STL OSTEOPENIA,SUP-2349882,CDM,C1713,HCPCS,0278,RC,,,,both,,,1200.05,780.03,,,,,,,,,,,,,
ALLOGRAFT BNE CHIP 90 CC CANC,SUP-2743352,CDM,C1713,HCPCS,0278,RC,,,,both,,,5077.38,3300.30,,,,,,,,,,,,,
PLATE BNE L 39 MM LT DORS MEDL DSTL RADIAL SHRT NS VARIAX 2,SUP-2902242,CDM,C1713,HCPCS,0278,RC,,,,both,,,3143.80,2043.47,,,,,,,,,,,,,
BAND SPNL 5.5 MM 2 MALL END VERSATIE,SUP-2562505,CDM,C1713,HCPCS,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
SNARE VASC L120CM DIA10MM CATH 4FR L100CM G STD PLT RADPQ,SUP-2303141,CDM,C1773,HCPCS,0272,RC,,,,both,,,828.65,538.62,,,,,,,,,,,,,
REAMER LAPIDUS NAIL CANN 5.5MM,SUP-2321048,CDM,2720000010,LOCAL,0272,RC,,,,both,,,824.25,535.76,,,,,,,,,,,,,
LEAD PACE POLYUR SIL ENDOCARD MYOCARDIAL RT ATRIOVENTRICULAR,SUP-2148639,CDM,C1898,HCPCS,0275,RC,,,,both,,,1384.74,900.08,,,,,,,,,,,,,
HC Inj Trigger Points 1-2 Musc,PX-4502055200,CDM,20552,CPT,0450,RC,,,,both,,,613.00,398.45,,,,,,,,,,,,,
SCREW BNE ST 4X16 MM LCK SALVATION,SUP-2401330,CDM,C1713,HCPCS,0278,RC,,,,both,,,756.74,491.88,,,,,,,,,,,,,
STEM FEM PRSS FIT TI ALLOY HA SIZE9 OSTEONICS SECUR FIT,SUP-2364222,CDM,C1776,CPT,0278,RC,,,,both,,,8950.22,5817.64,,,,,,,,,,,,,
STEM HUM L140MM DIA16MM UNIV DSTL SHLDR TI PRI REV CEM FOR,SUP-2372858,CDM,C1776,CPT,0278,RC,,,,both,,,9534.92,6197.70,,,,,,,,,,,,,
GRAFT BONE PATELLA LEFT OC AMBIENT MOPS,SUP-2570514,CDM,C1762,CPT,0278,RC,,,,both,,,20601.54,13391.00,,,,,,,,,,,,,
GRAFT HUM TISS PTCH 3X4 CM UMB CRD RESTORIGIN,SUP-2321893,CDM,Q4191,HCPCS,0636,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
KYPHOPLASTY TRAY 2 10 MM CEMENT DEL INTRO KYPHON EXPRESS II,SUP-2429555,CDM,C1713,HCPCS,0278,RC,,,,both,,,8031.08,5220.20,,,,,,,,,,,,,
SCREW MULTIDIRECTION 3.8X30MM,SUP-2414103,CDM,C1713,HCPCS,0278,RC,,,,both,,,445.88,289.82,,,,,,,,,,,,,
CATHETER CV MAXIMAL BARR TY 025 5 FRX5 CM 16 GA 3L SPECTRUM,SUP-2759897,CDM,C1751,HCPCS,0278,RC,,,,both,,,569.41,370.12,,,,,,,,,,,,,
GUIDEWIRE ORTH DIA3.2MM THRD TIP FOR FEM NAIL PEDINAIL,SUP-2318959,CDM,C1769,HCPCS,0272,RC,,,,both,,,1016.42,660.67,,,,,,,,,,,,,
WALKER PNEUMAT DLX L,SUP-2276721,CDM,L4361,HCPCS,0272,RC,,,,both,,,101.30,65.84,,,,,,,,,,,,,
TUBE VENT ARMSTR R 1.14 PHOSPHORYLCHOLINE COAT SIL 510286C,SUP-2486581,CDM,L8699,HCPCS,0278,RC,,,,both,,,48.51,31.53,,,,,,,,,,,,,
IRINOTECAN HCL 100 MG/5ML IV SOLN,RX-91054,CDM,J9206,HCPCS,0636,RC,60505-6128-01,NDC,,both,5,ML,54.10,35.16,,,,,,,,,,,,,
PLATE BNE L 88 MM SCREW DIA2.4 MM HD 2 SHFT 10 H SS CNDYL NS,SUP-2905642,CDM,C1713,HCPCS,0278,RC,,,,both,,,2589.81,1683.38,,,,,,,,,,,,,
GRAFT HUM TISS L230MM DIA 7.5MM ANT TIBIALIS TEND FLEXIGRFT,SUP-2264723,CDM,C1762,CPT,0278,RC,,,,both,,,5505.71,3578.71,,,,,,,,,,,,,
BIT DRL DIA2.7MM PERIPH SCR REUSE FOR COMPHSVE REV SHLDR,SUP-2408540,CDM,2720000010,LOCAL,0272,RC,,,,both,,,419.19,272.47,,,,,,,,,,,,,
SHEATH CV KT PERM VLV NO RADPQ BND 0.038IN NO HYDRPHLC COAT 406195] ST JUDE MED CARDIOVASCULAR DIV],SUP-2355443,CDM,C1894,HCPCS,0272,RC,,,,both,,,76.93,50.00,,,,,,,,,,,,,
GUIDEWIRE VASC MORPHEUS L 130 CM DIA 0.018 IN SS PERIPH,SUP-2117373,CDM,C1769,HCPCS,0272,RC,,,,both,,,123.09,80.01,,,,,,,,,,,,,
PROSTHESIS OSS BCKT HNDL 0.4X3.50 MM 1 MM RICHARD FLROPLAS,SUP-2637904,CDM,L8613,CPT,0278,RC,,,,both,,,396.24,257.56,,,,,,,,,,,,,
TAP SURG DIA35MM CORT ST REUSE FOR BNE SCR POLARUS,SUP-2107699,CDM,C1713,HCPCS,0278,RC,,,,both,,,3896.74,2532.88,,,,,,,,,,,,,
GUIDE PIN ORTH 3.2X330 MM AOS,SUP-2766025,CDM,2720000010,LOCAL,0272,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
SPLINT FRARM AD SM/M RT NEOPRNE TERRY LNR BASE CVA/TBI DGT,SUP-2324472,CDM,L3809,HCPCS,0272,RC,,,,both,,,375.98,244.39,,,,,,,,,,,,,
SET VASC ACCS PEELWY L 13 CM INTRO L 20 CM DIA20 FR,SUP-2168025,CDM,C1892,HCPCS,0272,RC,,,,both,,,183.66,119.38,,,,,,,,,,,,,
GRAFT BNE SUB 25CC 2MM GRAN ALLOGENIC MORPHOGENETIC PROT W,SUP-2138495,CDM,C1713,HCPCS,0278,RC,,,,both,,,2075.92,1349.35,,,,,,,,,,,,,
CATHETER GUID VERIPATH L 50 CM OD 8 FR ID 0.088 IN INNR PTFE,SUP-2101518,CDM,C1887,HCPCS,0272,RC,,,,both,,,188.40,122.46,,,,,,,,,,,,,
CATHETER INFUSION ENDOVASC DEV 12 FRX106 CM US COR EKOSONIC,SUP-2214798,CDM,C1887,HCPCS,0272,RC,,,,both,,,18887.10,12276.61,,,,,,,,,,,,,
POST EXT FIX 1 H M CONN FOR SIDEKCK EZ FRME EXT FIX FREE,SUP-2400617,CDM,2720000010,LOCAL,0272,RC,,,,both,,,257.48,167.36,,,,,,,,,,,,,
REPAIR KIT KNOTLESS OPN AC IMPL STRL LTX,SUP-2859828,CDM,C1713,HCPCS,0278,RC,,,,both,,,5479.30,3561.54,,,,,,,,,,,,,
BIT DRILL CANN TAP S CP 5.0MM,SUP-2587567,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1026.18,667.02,,,,,,,,,,,,,
WRIST RADIAL RIGHT MED,SUP-2479890,CDM,C1776,CPT,0278,RC,,,,both,,,11775.00,7653.75,,,,,,,,,,,,,
PLATE BNE L 95 MM SCREW DIA 3.5 MM 8 SHFT H SS 1/3 TUBLR VA,SUP-2907785,CDM,C1713,HCPCS,0278,RC,,,,both,,,1834.76,1192.59,,,,,,,,,,,,,
GUIDEWIRE UROLOGY ANGLED 0.025 INX150 CM STIFF-BODY HIWIRE,SUP-2835975,CDM,C1769,HCPCS,0272,RC,,,,both,,,165.67,107.69,,,,,,,,,,,,,
SCREW BONE L12MM DIA4.5MM STD CORT S STL ST NONCANNULATED,SUP-2371085,CDM,C1713,HCPCS,0278,RC,,,,both,,,76.93,50.00,,,,,,,,,,,,,
MESH CRAN W120XL120MM PROF H0.3MM MIC MID FACE,SUP-2363670,CDM,C1713,HCPCS,0278,RC,,,,both,,,5458.11,3547.77,,,,,,,,,,,,,
GUIDEWIRE VASC VSI L 130 CM DIA 0.018 IN NIT MANDREL,SUP-2383179,CDM,C1769,HCPCS,0272,RC,,,,both,,,135.02,87.76,,,,,,,,,,,,,
POST SURG ANKLEXPOST INTOSS FIX GRN L25MM OD6.6MM 60DEG,SUP-2223898,CDM,C1713,HCPCS,0278,RC,,,,both,,,4160.50,2704.32,,,,,,,,,,,,,
INTRODUCER SHTH BLU HUB W O GWIRE 8FRX23CM PRELUDE,SUP-2303303,CDM,C1894,HCPCS,0272,RC,,,,both,,,36.27,23.58,,,,,,,,,,,,,
PLATEXSTERNAL 2402541,SUP-2262572,CDM,C1713,HCPCS,0278,RC,,,,both,,,2226.26,1447.07,,,,,,,,,,,,,
SCREW BNE 2X15 MM 5 MM THRD BROWLIFT CENTRE DRV DRL FREE,SUP-2457259,CDM,C1713,HCPCS,0278,RC,,,,both,,,267.53,173.89,,,,,,,,,,,,,
HC Iaad Ia Hepatitis B Surface Antigen|NOT REASONABLE AND NECESSARY,PX-3068734000,CDM,87340,CPT,0306,RC,,,GZ,both,,,554.00,360.10,,,,,,,,,,,,,
BRACE ORTHOPEDIC POST OPERATIVE UNIV KNEE WARRIOR RECOVERY,SUP-2336061,CDM,L1810,HCPCS,0272,RC,,,,both,,,210.22,136.64,,,,,,,,,,,,,
SCREW BNE NLCK 4.5X14 MM DBL STRT THRD SS JPS,SUP-2645463,CDM,C1713,HCPCS,0278,RC,,,,both,,,245.55,159.61,,,,,,,,,,,,,
PLATE BONE DUAL CMPRSSN HLX12 TTNM RCNSTRCTN F/3.5MM LOK SCR,SUP-2480536,CDM,C1713,HCPCS,0278,RC,,,,both,,,1624.89,1056.18,,,,,,,,,,,,,
CATHETER PERI DLYS AD 15FR L47CM UNIV DBL CUF LIN STR RADPQ,SUP-2283889,CDM,C1750,HCPCS,0278,RC,,,,both,,,181.49,117.97,,,,,,,,,,,,,
PLATE BNE BURR HOLE CVR 12X0.5 MM SLGHT CONTOURED PDLLA STRL,SUP-2467302,CDM,C1713,HCPCS,0278,RC,,,,both,,,902.53,586.64,,,,,,,,,,,,,
STEM FEM L195MM DIA18MM BOW CONIC TI ALLY HA DST HIP REV,SUP-2375844,CDM,C1776,CPT,0278,RC,,,,both,,,7855.02,5105.76,,,,,,,,,,,,,
ANCHOR SUT L11.7MM DIA2.8MM W/ INSRTR FASTAK LL,SUP-2121023,CDM,C1713,HCPCS,0278,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
BURR SURG 2MM DIA HD LNG MIC 72MML 10MML HD CARBIDE SM BNE B,SUP-2605566,CDM,2720000010,LOCAL,0272,RC,,,,both,,,69.49,45.17,,,,,,,,,,,,,
CONNECTOR FEM L40-50MM LAT TROCHANTERIC CALCAR HIP,SUP-2403673,CDM,C1776,CPT,0278,RC,,,,both,,,1142.96,742.92,,,,,,,,,,,,,
KIT CATH HEMODIALYSI AHDC SAFETY 12FR DIA 25CM 3 LUMAN INDWL,SUP-2613324,CDM,C1751,HCPCS,0278,RC,,,,both,,,447.14,290.64,,,,,,,,,,,,,
GUIDEWIRE VASC L 40 CM 0.018 IN L 5 CM SS MANDREL STR FIX,SUP-2828287,CDM,C1769,HCPCS,0272,RC,,,,both,,,58.25,37.86,,,,,,,,,,,,,
PLATE BNE RADIAL 2.4X59.5 MM LT DSTL 8X4 HOLE VOLAR CLMN TI,SUP-2190181,CDM,C1713,HCPCS,0278,RC,,,,both,,,2816.80,1830.92,,,,,,,,,,,,,
PLATE 4.5MM TI LCP TM STRAIGHT RECON 16 HOLES 303MM,SUP-2549516,CDM,C1713,HCPCS,0278,RC,,,,both,,,1823.30,1185.14,,,,,,,,,,,,,
SET VASC SNR MULTI-SNARE L 125 CM DIA20 MM INTRO L 105 CM,SUP-2125282,CDM,C1773,HCPCS,0272,RC,,,,both,,,829.78,539.36,,,,,,,,,,,,,
CARBON FIBER ROD 5.0MMX250MM,SUP-2810995,CDM,2720000010,LOCAL,0272,RC,,,,both,,,580.90,377.58,,,,,,,,,,,,,
SLEEVE CNTR L8MM PMMA FOR FEM HIP FX,SUP-2406635,CDM,C1776,CPT,0278,RC,,,,both,,,568.34,369.42,,,,,,,,,,,,,
PLATE 4.5MM TI LCP MEDIAL PROXIMAL TIBIA 16H LEFT 322MM,SUP-2549626,CDM,C1713,HCPCS,0278,RC,,,,both,,,3541.57,2302.02,,,,,,,,,,,,,
KIT CTRL VEN CATHETER L20CM OD85FR QUAD LUMN NONCOATED INJ,SUP-2270273,CDM,C1751,HCPCS,0278,RC,,,,both,,,242.88,157.87,,,,,,,,,,,,,
MESH SURG DIA100MM THK0.6MM PNK CRANIOFACIAL TI RIG CNTOUR,SUP-2181605,CDM,C1781,HCPCS,0278,RC,,,,both,,,6609.07,4295.90,,,,,,,,,,,,,
NAIL IM L180MM DIA11.5MM NK ANG 130DEG SHT,SUP-2347582,CDM,C1713,HCPCS,0278,RC,,,,both,,,11041.03,7176.67,,,,,,,,,,,,,
KIT BNE VOID FILL 5ML INJ CALLOS,SUP-2106910,CDM,C1713,HCPCS,0278,RC,,,,both,,,304.58,197.98,,,,,,,,,,,,,
SUPPORT ORTHOT THGH LOWER EXTREMITY WT BEAR LACER N MOLD,SUP-2435677,CDM,L2530,HCPCS,0274,RC,,,,both,,,678.96,441.32,,,,,,,,,,,,,
LIDOCAINE HCL 2 % IJ SOLN,RX-4454,CDM,J2003,HCPCS,0636,RC,00409-4277-17,NDC,,both,5,ML,54.10,35.16,,,,,,,,,,,,,
BODY HUM OFFSET 5 MM POLY TY ADPT STD FOR RVS SHLDR SYS,SUP-2884027,CDM,C1776,CPT,0278,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
PLATE BNE L 130 MM SCREW DIA2.7/3.5 MM 9 H SS LT DSTL MEDL,SUP-2931267,CDM,C1713,HCPCS,0278,RC,,,,both,,,7691.43,4999.43,,,,,,,,,,,,,
GUIDEPIN ORTH L330MM DIA3.2MM TRCR TIP DISP,SUP-2312267,CDM,2720000010,LOCAL,0272,RC,,,,both,,,703.36,457.18,,,,,,,,,,,,,
HC So1 Drg Scrn Class List A,PX-3018030767,CDM,80307,CPT,0301,RC,,,,inpatient,,,147.00,95.55,,,,,,,,,,,,,
PLATE BONE TUBULAR 49 MM 4 HOLE 1/3 WITH COLLAR STERILE TC10,SUP-2836662,CDM,C1713,HCPCS,0278,RC,,,,both,,,514.74,334.58,,,,,,,,,,,,,
PLATE BONE 6MM OFFSET 100DEG 3 H PROX FEM LCK FOR 3.5MM SCR,SUP-2318549,CDM,C1713,HCPCS,0278,RC,,,,both,,,7685.31,4995.45,,,,,,,,,,,,,
AGENT HEMOSTATIC POLYSACCHARIDE 230 CM 2.8 MM 3 GM ENDOCLOT,SUP-2865641,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
HEALICOIL KNOTLESS PK ST,SUP-2823709,CDM,C1713,HCPCS,0278,RC,,,,both,,,1535.90,998.33,,,,,,,,,,,,,
SET INTRO PERFRMR L 7 CM OD 5 FR ID 1.7 MM GUIDEWIRE 0.021,SUP-2168445,CDM,C1894,HCPCS,0272,RC,,,,both,,,125.22,81.39,,,,,,,,,,,,,
STABILIZER SURG TISS W/ CANSTR TBNG EVOLUTION OCTPS,SUP-2283006,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4631.50,3010.47,,,,,,,,,,,,,
NEEDLE BX BONE MAR ASPIR NS,SUP-2415887,CDM,C1713,HCPCS,0278,RC,,,,both,,,730.84,475.05,,,,,,,,,,,,,
CATHETER HAD SET LNG TERM PRECRV W/ SIDE H 15.5FRX24CM TI,SUP-2268416,CDM,C1881,HCPCS,0278,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
BRACE KNEE ADULTXL UNIV FOAM POSTOP UNISX WRP ARND HNG T SCP,SUP-2150861,CDM,L1810,HCPCS,0272,RC,,,,both,,,326.56,212.26,,,,,,,,,,,,,
SPACER FEM M/L THK5MM R MED DST DURAC,SUP-2377201,CDM,C1776,CPT,0278,RC,,,,both,,,39.53,25.69,,,,,,,,,,,,,
DEVICE FIX DIA9-10MM STD FEM FOR 35-50MM TUNN EZLOC,SUP-2212828,CDM,C1713,HCPCS,0278,RC,,,,both,,,2240.20,1456.13,,,,,,,,,,,,,
SET EXTN OD10FR RED ART TESIO,SUP-2269528,CDM,C1881,HCPCS,0278,RC,,,,both,,,40.82,26.53,,,,,,,,,,,,,
BAND LAPAROSCOPY GASTRIC 11 CM ADJUSTABLE STERILE LAP-BAND VG,SUP-2119232,CDM,C1889,HCPCS,0278,RC,,,,both,,,10032.30,6520.99,,,,,,,,,,,,,
CLAMP SURG IN LN EXTN 200 MM 6-6.5 MM RT 6.35 MM ROD,SUP-2584891,CDM,C1713,HCPCS,0278,RC,,,,both,,,8333.56,5416.81,,,,,,,,,,,,,
ALLOGRAFT HUM TISS ANTR TIBIALIS TEND FRZN NO-RAD,SUP-2321830,CDM,C1762,CPT,0278,RC,,,,both,,,5950.30,3867.69,,,,,,,,,,,,,
LENS IOL BCNVX 24.5+ DIOPT 6X13 MM MONO FOC TECNIS,SUP-2102416,CDM,V2632,HCPCS,0276,RC,,,,both,,,307.72,200.02,,,,,,,,,,,,,
KIT INTRO TSX 55 DEG L 60 CM DIA 8.5 FR GUIDEWIRE L 135 CM,SUP-2148497,CDM,C1894,HCPCS,0272,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
ALLOGRAFT BNE CHIP 0.1-2 MM 15 CC PRESERVON CANC READIGRAFT,SUP-2740888,CDM,C1713,HCPCS,0278,RC,,,,both,,,845.38,549.50,,,,,,,,,,,,,
GRAFT BNE SUB 2.5ML PTTY SYR IRRADIATED DEMIN MTRX GRFTON,SUP-2294010,CDM,C1713,HCPCS,0278,RC,,,,both,,,967.12,628.63,,,,,,,,,,,,,
BIT DRL TWST 1.6X50 MM 8 MM W/ STP SONICWELD RX DISP,SUP-2458397,CDM,2720000010,LOCAL,0272,RC,,,,both,,,416.30,270.59,,,,,,,,,,,,,
BUR SURG CYL 8X13.5 MM 14 CM FLUT CORNERSTONE MIDAS REX 8,SUP-2664600,CDM,2720000010,LOCAL,0272,RC,,,,both,,,483.87,314.52,,,,,,,,,,,,,
PLATE BONE W10XL82MM THK2.8MM 7 H S STL STR NONCOMPRESSION,SUP-2343764,CDM,C1713,HCPCS,0278,RC,,,,both,,,3289.46,2138.15,,,,,,,,,,,,,
GUIDEWIRE VASC HYBRID L 200 CM PROX/DSTL DIA,SUP-2895575,CDM,C1769,HCPCS,0272,RC,,,,both,,,1444.40,938.86,,,,,,,,,,,,,
SCREW BNE MIC MINI 2.4X8 MM CRANIOMAXILLOFACIAL FIX,SUP-2364645,CDM,C1713,HCPCS,0278,RC,,,,both,,,130.03,84.52,,,,,,,,,,,,,
STIMULATOR BNE GROWTH OL1000,SUP-2196347,CDM,C1713,HCPCS,0278,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
COUNTERSINK ORTH L37MM DIA2.7MM DENT SHFT END FOR 1.2/1.5MM,SUP-2267832,CDM,2720000010,LOCAL,0272,RC,,,,both,,,952.05,618.83,,,,,,,,,,,,,
STAPLE BONE MIDFOOT COMPR UNI CLP L 2 H 17 MM S STL,SUP-2243481,CDM,C1713,HCPCS,0278,RC,,,,both,,,4003.50,2602.27,,,,,,,,,,,,,
TRAY TIB SZ 1 NP A BAL SYS,SUP-2314673,CDM,C1776,CPT,0278,RC,,,,both,,,3994.08,2596.15,,,,,,,,,,,,,
POROUS FEM /POR TIBIA/ PRLNG SURF/ NO PAT,SUP-2212153,CDM,C1776,CPT,0278,RC,,,,both,,,11595.02,7536.76,,,,,,,,,,,,,
GRAFT HUM TISS W8XL3CM 12SQCM UMB CRD AMNIO MEM,SUP-2116292,CDM,Q4148,HCPCS,0636,RC,,,,both,,,9718.30,6316.89,,,,,,,,,,,,,
STIMULATOR NERVE IMPL PULSE GENRTR STRL PROCLAIM + 5 LTX,SUP-2858407,CDM,C1767,HCPCS,0278,RC,,,,both,,,68295.00,44391.75,,,,,,,,,,,,,
COIL VASC AZUR L 50 CM DIA20 MM MICROCATHETER 0.018 IN LOOP,SUP-2385437,CDM,C1889,HCPCS,0278,RC,,,,both,,,2854.61,1855.50,,,,,,,,,,,,,
CAGE SPNL MED 24 DEG 16 MM DIVERGENCE-L,SUP-2422248,CDM,C1889,HCPCS,0278,RC,,,,both,,,16365.68,10637.69,,,,,,,,,,,,,
STENT VASC L150MM DIA6MM CATH L130CM SHTH 6FR DRUG ELUT,SUP-2853968,CDM,C1874,HCPCS,0278,RC,,,,both,,,14444.00,9388.60,,,,,,,,,,,,,
DRILL SURG CANN 2 MM FUSION MANUAL NS HPS LTX,SUP-2855998,CDM,2720000010,LOCAL,0272,RC,,,,both,,,609.16,395.95,,,,,,,,,,,,,
CLIP ANEUR 8X1.143 MM SLIGHTLY CRV NS SLIM-LINE SUNDT-KEES,SUP-2183225,CDM,C1713,HCPCS,0278,RC,,,,both,,,141.43,91.93,,,,,,,,,,,,,
WRAP SHLDR L THERMOSKIN,SUP-2324274,CDM,L3650,HCPCS,0274,RC,,,,both,,,139.01,90.36,,,,,,,,,,,,,
PLATE BONE L65MM 8 H LCK RECON BILAT RIG FOR 2.7MM SCR,SUP-2348296,CDM,C1713,HCPCS,0278,RC,,,,both,,,5284.46,3434.90,,,,,,,,,,,,,
GRAFT BNE FRZN STRUT CORT IMPL ALLGRFT L45XW10MM MATRIGRFT,SUP-2264745,CDM,C1713,HCPCS,0278,RC,,,,both,,,1251.79,813.66,,,,,,,,,,,,,
STENT BILI PRECIS L 40 MM DIA 5 MM CATH L 135 CM DIA 8 FR,SUP-2158903,CDM,C1876,HCPCS,0278,RC,,,,both,,,5887.50,3826.87,,,,,,,,,,,,,
SCREW BNE L 42 MM DIA 4 MM SHRT TI CANN HDLSS NS LEOS,SUP-2931452,CDM,C1713,HCPCS,0278,RC,,,,both,,,912.01,592.81,,,,,,,,,,,,,
PLATE 6 HOLE P MANDIBLE,SUP-2843359,CDM,C1713,HCPCS,0278,RC,,,,both,,,2239.89,1455.93,,,,,,,,,,,,,
SCREW SPNL REDUCTION 4X12 MM PYRENEES,SUP-2531426,CDM,C1713,HCPCS,0278,RC,,,,both,,,193.90,126.03,,,,,,,,,,,,,
TRAY HUM THK+6MM 0MM OFFSET CEM REVERSED AEQUALIS ASCEND,SUP-2388721,CDM,C1776,CPT,0278,RC,,,,both,,,1667.34,1083.77,,,,,,,,,,,,,
PLATE BNE L ADVANSYS R DORS FT LISFRANC ADVANSYS,SUP-2243043,CDM,C1713,HCPCS,0278,RC,,,,both,,,5112.58,3323.18,,,,,,,,,,,,,
COMPONENT ARTC SURF CD 17 MM KNEE YEL NXGN LEG,SUP-2201853,CDM,C1776,CPT,0278,RC,,,,both,,,5407.39,3514.80,,,,,,,,,,,,,
KIT VENTRICULAR DRAINAGE COMB,SUP-2883563,CDM,C1729,HCPCS,0272,RC,,,,both,,,772.16,501.90,,,,,,,,,,,,,
CHOLANGIOGRAM KIT RX AUTOTOME UTOM XL SPHINTOM JAGWIRE 7526,SUP-2482989,CDM,C1769,HCPCS,0272,RC,,,,both,,,870.00,565.50,,,,,,,,,,,,,
ALLOGRAFT DERMAL 60-90X7 MM FRZN COSTAL CART DERM ORACELL,SUP-2741029,CDM,C1762,CPT,0278,RC,,,,both,,,1879.29,1221.54,,,,,,,,,,,,,
COMPONENT PAT STANDARD+ POLYETH CRUCFRM MOB BEAR REPL NP,SUP-2250806,CDM,C1776,CPT,0278,RC,,,,both,,,1880.23,1222.15,,,,,,,,,,,,,
PROSTHESIS OSS STAP DIA1.17 MM INCUS DIA 0.8 MM MED FLX H/A,SUP-2901942,CDM,L8613,CPT,0278,RC,,,,both,,,1689.95,1098.47,,,,,,,,,,,,,
CONDUIT CV CONTEGRA ID 12 MM BOV JUG VEIN FLX THN VERSATILE,SUP-2429904,CDM,C1713,HCPCS,0278,RC,,,,both,,,15684.30,10194.79,,,,,,,,,,,,,
STENT PERIPH FORMULA 414 L 12 MM DIA 4 MM CATH L 80 CM SHTH,SUP-2639028,CDM,C1876,HCPCS,0278,RC,,,,both,,,3611.00,2347.15,,,,,,,,,,,,,
BUR SURG MTCH HD 3 MM 12 CM SYMMETRI PROX MIDAS REX 8 CLRVW,SUP-2632186,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1129.62,734.25,,,,,,,,,,,,,
CATHETER HD STR EXTN 11.5 FRX20 CM SHT TERM DL HEMCATH,SUP-2627308,CDM,C1752,HCPCS,0278,RC,,,,both,,,12.56,8.16,,,,,,,,,,,,,
CANNULA ORTH L 250 MM DIA 8 GA ACCESS/DELIVERY DRILLABLE,SUP-2893110,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
PLATE BONE L NONSTERILE CRAN TI ARC CNTOUR MESH MALL FOR,SUP-2190627,CDM,C1713,HCPCS,0278,RC,,,,both,,,4301.80,2796.17,,,,,,,,,,,,,
DEVICE ARTOTMY CLOSURE EXOSEAL DIA 6 FR FEM ART 2 UNIQUE,SUP-2158725,CDM,C1760,HCPCS,0278,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
GRAFT VASC HEMSHLD GLD L 40 MM DIA14 X 8 MM POLYESTER BOV,SUP-2266030,CDM,C1768,CPT,0278,RC,,,,both,,,1927.96,1253.17,,,,,,,,,,,,,
PPICC PROVENA SOLO 3F SLEEVE BASIC TL,SUP-2613556,CDM,C1751,HCPCS,0278,RC,,,,both,,,571.07,371.20,,,,,,,,,,,,,
KIT PT PULSE PREC PRGMR,SUP-2141944,CDM,C1787,HCPCS,0278,RC,,,,both,,,2802.45,1821.59,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.534,SUP-2860051,CDM,C1713,HCPCS,0278,RC,,,,both,,,44188.59,28722.58,,,,,,,,,,,,,
GUIDEWIRE URO L150CM DIA0.038IN TIP L3CM NIT HYDRPHLC STIFF,SUP-2169839,CDM,C1769,HCPCS,0272,RC,,,,both,,,165.67,107.69,,,,,,,,,,,,,
RING SPNL SPCR 5MM DIA 0DEG,SUP-2291556,CDM,C1713,HCPCS,0278,RC,,,,both,,,358.09,232.76,,,,,,,,,,,,,
SPACER SPNL 24X15 MM ADAPTIX,SUP-2731000,CDM,C1889,HCPCS,0278,RC,,,,both,,,32798.09,21318.76,,,,,,,,,,,,,
RAIL EXT FIX 4IN MINI RX FIX,SUP-2396841,CDM,C1713,HCPCS,0278,RC,,,,both,,,4066.30,2643.09,,,,,,,,,,,,,
PLATE BNE L 146 X W 11 MM THK 3 MM SCREW DIA2.7/3.5 MM 9 H 72465509N,SUP-2933122,CDM,C1713,HCPCS,0278,RC,,,,both,,,5295.30,3441.94,,,,,,,,,,,,,
PATCH CV HEMSHLD L 3 X W 2 IN THK 0.76 MM POLYESTER BOV,SUP-2485400,CDM,C1768,CPT,0278,RC,,,,both,,,538.10,349.76,,,,,,,,,,,,,
GRAFT VASC GORTX L 70 CM DIA 6 MM OFFSET RNG L 20 CM EPTFE,SUP-2396154,CDM,C1768,CPT,0278,RC,,,,both,,,3199.66,2079.78,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP L260CM DIA0.035IN TIP L4CM NIT HYDRPHLC,SUP-2170149,CDM,C1769,HCPCS,0272,RC,,,,both,,,558.92,363.30,,,,,,,,,,,,,
PLATE BNE L24MM 5 H CRANIOMAXILLOFACIAL TI Y SHP FOR 2MM,SUP-2191308,CDM,C1713,HCPCS,0278,RC,,,,both,,,1015.48,660.06,,,,,,,,,,,,,
RING HALF 130MM FOR TRUELOK FIX SYS,SUP-2316176,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1394.57,906.47,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL PEEK SD800.532,SUP-2860213,CDM,C1713,HCPCS,0278,RC,,,,both,,,38541.93,25052.25,,,,,,,,,,,,,
CATHETER VENTRICULAR 25 CM HYDROCEPHALUS MGMT MRI SAFE,SUP-2852681,CDM,C1729,HCPCS,0272,RC,,,,both,,,393.41,255.72,,,,,,,,,,,,,
GRAFT VASC L200MM DIA6MM UNIV PTFE STR STD WALL NONTAPERED,SUP-2395722,CDM,C1768,CPT,0278,RC,,,,both,,,2562.24,1665.46,,,,,,,,,,,,,
INTRODUCER SHTH 0.018 IN 4 FRX45 CM 21 GAX7 CM MINI STK II,SUP-2118825,CDM,C1769,HCPCS,0272,RC,,,,both,,,87.92,57.15,,,,,,,,,,,,,
CANNULA SPNL SCREW CARBON FIBER PEDCL FOR FEN PEDCL SCREW,SUP-2883066,CDM,C1713,HCPCS,0278,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
SCREW BONE EMERGENCY 18 MM TITANIUM LIGHT BLUE NON STERILE M,SUP-2837724,CDM,C1713,HCPCS,0278,RC,,,,both,,,290.80,189.02,,,,,,,,,,,,,
ATENOLOL 25 MG PO TABS,RX-717,CDM,6370000000,HCPCS,0637,RC,51079-0759-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PLATE BONE L257MM 17 H TI RT PROX LAT TIB FOR 3.5MM SCR,SUP-2418799,CDM,C1713,HCPCS,0278,RC,,,,both,,,4836.86,3143.96,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED CEM STEM ADD ON,SUP-2137373,CDM,C1776,CPT,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
PLATE BNE Y MED 1.5X29X0.8 MM MIDFACE 7 HOLE W/ TAB STRL,SUP-2518106,CDM,C1713,HCPCS,0278,RC,,,,both,,,825.19,536.37,,,,,,,,,,,,,
PROGRAMMER NEUROSTIMULATOR HANDHELD WAND RECHRG EON,SUP-2356763,CDM,C1787,HCPCS,0278,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
PLATE BNE W25.5XL68MM WIDE 7X4 H ST R DST RAD VOLAR S STL,SUP-2420724,CDM,C1713,HCPCS,0278,RC,,,,both,,,2511.09,1632.21,,,,,,,,,,,,,
SYSTEM BUR H CVR CRAN BASE HLDR 2 SCR 1 SCRDRIVER CLP INSRTN,SUP-2357353,CDM,C1713,HCPCS,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
GUIDEWIRE VASC VSI L 80 CM DIA 0.018 IN NIT MANDREL TUNGSTEN,SUP-2763454,CDM,C1769,HCPCS,0272,RC,,,,both,,,147.58,95.93,,,,,,,,,,,,,
CANNULA VITRECTOMY 25 GA 1 STP STRL DISP,SUP-2424170,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1248.46,811.50,,,,,,,,,,,,,
STRIP DENT 2 FOR CRWN FRM REPL UNITEK,SUP-2238917,CDM,D6783,CPT,0278,RC,,,,both,,,25.87,16.82,,,,,,,,,,,,,
PLATE BNE BROAD 3.5X110 MM 9 HOLE SS DCP,SUP-2569151,CDM,C1713,HCPCS,0278,RC,,,,both,,,321.22,208.79,,,,,,,,,,,,,
PLATE BONE W20.4XL56.3MM THK1.1MM TI T LCK LO PROF FOR 1.5MM,SUP-2411740,CDM,C1713,HCPCS,0278,RC,,,,both,,,1277.98,830.69,,,,,,,,,,,,,
MESH SYNTH ABD N ABSRB RECT EXP POLYTETRAFLUROETHYLENE 24CM,SUP-2395832,CDM,C1781,HCPCS,0278,RC,,,,both,,,3742.88,2432.87,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 60 MM DIA 6 MM DEL SHTH 2.7ML,SUP-2937071,CDM,C1713,HCPCS,0278,RC,,,,both,,,6160.68,4004.44,,,,,,,,,,,,,
STEM FEM L75MM DIA14MM UNIV KNEE FLUT PRESSFIT FOR ROT HNG,SUP-2253332,CDM,C1776,CPT,0278,RC,,,,both,,,3686.36,2396.13,,,,,,,,,,,,,
ROD SPNL L40MM OD4.75MM CO CHROM MOLYBDENUM POST,SUP-2284729,CDM,C1713,HCPCS,0278,RC,,,,both,,,894.90,581.68,,,,,,,,,,,,,
PLATE BNE L181MM 10 H NONSTERILE L PROX TIB S STL,SUP-2185703,CDM,C1713,HCPCS,0278,RC,,,,both,,,3772.49,2452.12,,,,,,,,,,,,,
SENNOSIDES 8.6 MG PO TABS,RX-11349,CDM,6370000000,HCPCS,0637,RC,00904-7252-61,NDC,,both,1,UN,0.40,0.26,,,,,,,,,,,,,
FILTER VASC ACCUNET SZ 4.5 MM SHTH 6 FR GUIDEWIRE L 300 MM,SUP-2104681,CDM,C1889,HCPCS,0278,RC,,,,both,,,4631.50,3010.47,,,,,,,,,,,,,
BOOT CAST ASMBLY ROCKER BTM,SUP-2162677,CDM,L4361,HCPCS,0274,RC,,,,both,,,4220.16,2743.10,,,,,,,,,,,,,
ENDCAP ORTH EXTN 0MM TIB GRY TI CANN T40 STARDRV RECESS EXT,SUP-2189029,CDM,C1713,HCPCS,0278,RC,,,,both,,,502.09,326.36,,,,,,,,,,,,,
KIT INTRO SHTH 5 CM GUIDEWIRE L 30 CM DIA 5 FR NDL L 1.5 IN,SUP-2734925,CDM,C1894,HCPCS,0272,RC,,,,both,,,9.42,6.12,,,,,,,,,,,,,
SPHERE EMB ONCOZENE DIA 40 UM 3 ML HYDRGEL POLYZENE MIC WHT,SUP-2139504,CDM,C1889,HCPCS,0278,RC,,,,both,,,15543.00,10102.95,,,,,,,,,,,,,
INSERT TIB CONSTRN CNDYL 18MM SZ 1,SUP-2223084,CDM,C1776,CPT,0278,RC,,,,both,,,4075.09,2648.81,,,,,,,,,,,,,
HC Prothrombin Time|NOT REASONABLE AND NECESSARY,PX-3058561000,CDM,85610,CPT,0305,RC,,,GZ,both,,,106.00,68.90,,,,,,,,,,,,,
PLATE BNE L250MM 12 H ST R MED PROX TIB S STL LOK COMPR LO,SUP-2185683,CDM,C1713,HCPCS,0278,RC,,,,both,,,4914.98,3194.74,,,,,,,,,,,,,
GRAFT VASC RESTOREFLOW SZ 20-29 CM FEM ART BLD TYP A B AB O,SUP-2884011,CDM,C1768,CPT,0278,RC,,,,both,,,22290.86,14489.06,,,,,,,,,,,,,
CETIRIZINE-PSEUDOEPHEDRINE ER 5-120 MG PO TB12,RX-31239,CDM,6370000000,HCPCS,0637,RC,51660-0940-24,NDC,,both,1,UN,3.40,2.21,,,,,,,,,,,,,
HC So Assay of Psa Total,PX-3018415366,CDM,84153,CPT,0301,RC,,,,inpatient,,,338.00,219.70,,,,,,,,,,,,,
NAIL IM ZCKL II SUBTROCHANTERIC 17MMX400MM ROD LT,SUP-2364774,CDM,C1713,HCPCS,0278,RC,,,,both,,,4717.22,3066.19,,,,,,,,,,,,,
ROD SPNL STR END SPOOL CRD STRL TRANSITION,SUP-2230050,CDM,C1713,HCPCS,0278,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
SHELL ACET SZ A DIA42MM RIM 8 H HIP TI W ARC DEPOSIT SURF,SUP-2372525,CDM,C1776,CPT,0278,RC,,,,both,,,5352.44,3479.09,,,,,,,,,,,,,
TRAY CATHETER NEO 19FR L30CM SGL LUMN,SUP-2173950,CDM,C1751,HCPCS,0278,RC,,,,both,,,139.45,90.64,,,,,,,,,,,,,
GRAFT BNE W15XH5XL125MM ANT CERV INTBDY FUS SPCR PARA PROF,SUP-2306971,CDM,C1713,HCPCS,0278,RC,,,,both,,,4414.31,2869.30,,,,,,,,,,,,,
MESH HERN W10XL15CM THK0.5MM SYNTH ABD ABSRB COAT POLYPR,SUP-2265976,CDM,C1781,HCPCS,0278,RC,,,,both,,,386.22,251.04,,,,,,,,,,,,,
BLOCK FEM AUG HINGED XS UNIV 10 MM DSTL PRIMARY PRSS FT,SUP-2376357,CDM,C1776,CPT,0278,RC,,,,both,,,1823.71,1185.41,,,,,,,,,,,,,
TRANEXAMIC ACID 1000 MG/10ML IV SOLN,RX-133085,CDM,J3290,HCPCS,0250,RC,81284-0611-00,NDC,,both,10,ML,54.10,35.16,,,,,,,,,,,,,
SCREW BNE L18MM DIA4.2MM NONLOCKING PLT GORILLA R3CON,SUP-2321383,CDM,C1713,HCPCS,0278,RC,,,,both,,,522.03,339.32,,,,,,,,,,,,,
GRAFT HUM TISS L150MM DIA4-5.5MM SEMITENDINOSUS FRZN ROPE,SUP-2264787,CDM,C1762,CPT,0278,RC,,,,both,,,2568.80,1669.72,,,,,,,,,,,,,
PLATE BNE STR MINI XLN 4 HOLE W/ BREAK-AWAY TAB TI,SUP-2469478,CDM,C1713,HCPCS,0278,RC,,,,both,,,907.90,590.13,,,,,,,,,,,,,
CATHETER ASPIR MILLIPEDE 070 HYDRPHLC 1 LUMEN VAR STIFFNESS,SUP-2929969,CDM,C1757,HCPCS,0272,RC,,,,both,,,7834.30,5092.29,,,,,,,,,,,,,
HC MRI Lower Ext W&W/O Cont,PX-6107372000,CDM,73720,CPT,0610,RC,,,,both,,,4220.00,2743.00,,,,,,,,,,,,,
BONE GRAFT KIT COR DECOMPRESSION 15 CC PRO-STIM,SUP-2759594,CDM,C1713,HCPCS,0278,RC,,,,both,,,18956.18,12321.52,,,,,,,,,,,,,
GUIDEWIRE VASC L150CM DIA0.025IN L3CM STD SM VES NIT,SUP-2385563,CDM,C1769,HCPCS,0272,RC,,,,both,,,148.77,96.70,,,,,,,,,,,,,
FILTER VASC CELECT L 49 MM DIA 30 MM CATH L 79 CM SHTH L 65,SUP-2170217,CDM,C1880,HCPCS,0278,RC,,,,both,,,2919.04,1897.38,,,,,,,,,,,,,
FIBER LASER HOLMIUM DISPOSABLE 11553,SUP-2264315,CDM,2720000010,LOCAL,0272,RC,,,,both,,,411.34,267.37,,,,,,,,,,,,,
PLATE EXT FIX L130MM ALUM U FOR SPAT FRME TAY,SUP-2340796,CDM,C1713,HCPCS,0278,RC,,,,both,,,10081.60,6553.04,,,,,,,,,,,,,
SCREW BNE COMPR 13X14 MM NOTCH TI UNI-CLIP,SUP-2609072,CDM,C1713,HCPCS,0278,RC,,,,both,,,2983.57,1939.32,,,,,,,,,,,,,
GUIDEWIRE VASC L195CM OD0.012IN LD L VENT FIRM CPS DUO,SUP-2356391,CDM,C1769,HCPCS,0272,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
GRAFT EVAR L3.3CM DIA32MM AORT EXT ENDOPROS EXCLUDER,SUP-2395941,CDM,C1768,CPT,0278,RC,,,,both,,,9027.50,5867.87,,,,,,,,,,,,,
GRAFT BNE 10CC BLU N-FORCE,SUP-2421384,CDM,C1713,HCPCS,0278,RC,,,,both,,,13527.12,8792.63,,,,,,,,,,,,,
BUR SURG OD4.0MM CUT DR N FLUT FOR ELITE SABER SHANK,SUP-2363999,CDM,2720000010,LOCAL,0272,RC,,,,both,,,347.28,225.73,,,,,,,,,,,,,
PROCESSOR SND RT SET FOR PRO PWR WHT SLV PONTO,SUP-2319885,CDM,L8691,HCPCS,0274,RC,,,,both,,,13486.30,8766.09,,,,,,,,,,,,,
NEEDLE ENDOSCP BPLR 5 MMX36 CM HNDL 3 RNG,SUP-2767413,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3152.40,2049.06,,,,,,,,,,,,,
NEEDLE BRST LOC 20 GAX57 MM DUALOK,SUP-2108890,CDM,C1819,HCPCS,0278,RC,,,,both,,,62.80,40.82,,,,,,,,,,,,,
PLATE BNE L90MM THK1MM 7 H S STL NONLOCKING 1/3 TBLR FOR,SUP-2372053,CDM,C1713,HCPCS,0278,RC,,,,both,,,172.70,112.25,,,,,,,,,,,,,
ANTERIOR ANKLE FUSION PLATE STANDARD LEFT,SUP-2586672,CDM,C1713,HCPCS,0278,RC,,,,both,,,9118.56,5927.06,,,,,,,,,,,,,
BASE TY TAG LIBRA ST,SUP-2442362,CDM,C1776,CPT,0278,RC,,,,both,,,2501.01,1625.66,,,,,,,,,,,,,
SUPPORT ORTHOT CUST LIFT ELEVATION INSIDE SHOE UP TO 1 HALF,SUP-2435718,CDM,L3332,HCPCS,0272,RC,,,,both,,,208.81,135.73,,,,,,,,,,,,,
DRAINAGE KIT CATH SUBDURAL STL DRL BIT STP EXAFLOW DISP,SUP-2666675,CDM,2720000010,LOCAL,0272,RC,,,,both,,,885.26,575.42,,,,,,,,,,,,,
CLIP ANEUR BLDE L13MM FEN DIA5MM OPN 55MM CLS FORC 180GM,SUP-2108702,CDM,C1889,HCPCS,0278,RC,,,,both,,,6682.71,4343.76,,,,,,,,,,,,,
CROWN FORM DENT STRP U4 PRIMARY ANTR UPPER RT LAT PLAS,SUP-2322251,CDM,D6783,CPT,0278,RC,,,,both,,,37.11,24.12,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC FT IR 5FR 55CM 2 LUMAN RVS 3275335F,SUP-2632670,CDM,C1751,HCPCS,0278,RC,,,,both,,,282.88,183.87,,,,,,,,,,,,,
SPLINT ORTH SUPP MED YTH WRST FOREARM RT ALUM FOAM,SUP-2194488,CDM,L3808,HCPCS,0272,RC,,,,both,,,12.15,7.90,,,,,,,,,,,,,
IMPLANT FACE L 59 X W 29 MM THK 7 MM D 11 MM POLYETHYL RT,SUP-2883141,CDM,C1713,HCPCS,0278,RC,,,,both,,,2004.04,1302.63,,,,,,,,,,,,,
WIRE FIX DIAMOND PT 2 END 0.045X9 IN SS NS KIRSCHNER KI71212,SUP-2791592,CDM,C1713,HCPCS,0278,RC,,,,both,,,8.79,5.71,,,,,,,,,,,,,
SET BNE FIX PIN DIA2.8MM K WIRE DIA1.6MM ECLIPSE UNIVERS II,SUP-2123299,CDM,C1713,HCPCS,0278,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
PLATE BONE L L55MM 7DEG 8 H LT 1ST METATARSOPHALANGEAL TIM,SUP-2137080,CDM,C1713,HCPCS,0278,RC,,,,both,,,3637.85,2364.60,,,,,,,,,,,,,
CANNULA ARTHSCP L5.5MM OP OUTER,SUP-2341437,CDM,C1713,HCPCS,0278,RC,,,,both,,,530.82,345.03,,,,,,,,,,,,,
VITAMIN E 450 MG (1000 UT) PO CAPS,RX-155568,CDM,6370000000,HCPCS,0637,RC,40093-0106-05,NDC,,both,1,UN,1.40,0.91,,,,,,,,,,,,,
PRAVASTATIN SODIUM 10 MG PO TABS,RX-11110,CDM,6370000000,HCPCS,0637,RC,00904-5891-61,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 30 CM DIA 4-7 MM SHRT TAPR SLDE GDS,SUP-2484639,CDM,C1768,CPT,0278,RC,,,,both,,,690.08,448.55,,,,,,,,,,,,,
BIT DRL L165MM DIA4.5MM JCBS CHK L135MM STP CANN,SUP-2187051,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1119.32,727.56,,,,,,,,,,,,,
COIL NEUROVASCULAR MICROPLEX L 4 CM 2 MM 0.0165 IN HELCL,SUP-2305142,CDM,C1889,HCPCS,0278,RC,,,,both,,,2241.96,1457.27,,,,,,,,,,,,,
POST EXT FIX OUTRIG 8 MM 90 DEG,SUP-2188519,CDM,2720000010,LOCAL,0272,RC,,,,both,,,369.99,240.49,,,,,,,,,,,,,
PLATE BNE STR 1.5X0.6 MM 6 MM 4 HOLE C-TUBE BRIDGE TI NS,SUP-2486399,CDM,C1713,HCPCS,0278,RC,,,,both,,,495.34,321.97,,,,,,,,,,,,,
GRAFT BNE SUB 10CC DBX MIX FRZ DRY FOR VOID FILL,SUP-2307003,CDM,C1713,HCPCS,0278,RC,,,,both,,,3359.80,2183.87,,,,,,,,,,,,,
BRINZOLAMIDE 1 % OP SUSP,RX-22953,CDM,6370000000,HCPCS,0637,RC,00781-6014-70,NDC,,both,10,ML,1683.70,1094.40,,,,,,,,,,,,,
IMPLANT FACE 76 X 50MM THK 0.25 MM POLYETHYL MIC THN SHT FOR,SUP-2883161,CDM,C1713,HCPCS,0278,RC,,,,both,,,1919.98,1247.99,,,,,,,,,,,,,
ALLOGRAFT BNE CERV 5.75X7.22 MM LORDTC VERTIGRAFT VG2,SUP-2264652,CDM,C1889,HCPCS,0278,RC,,,,both,,,3799.40,2469.61,,,,,,,,,,,,,
GRAFT BNE DEMIN BNE MTRX BIO DBM BOAT,SUP-2364715,CDM,C1713,HCPCS,0278,RC,,,,both,,,6280.00,4082.00,,,,,,,,,,,,,
DRILL SURG CANN 10.3 MM FOR HIP SCR,SUP-2766130,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
ALLOGRAFT BNE CORTICAL 109X10 MM FD STRUT,SUP-2717906,CDM,C1762,CPT,0278,RC,,,,both,,,3916.87,2545.97,,,,,,,,,,,,,
COUPLER EXT FIX PENNIG II,SUP-2875763,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1707.85,1110.10,,,,,,,,,,,,,
Z DISCONTINUED USE 2884904 STENT TRACHBRONCH L38MM DIA6MM CATH 7FR L80CM S STL PTFE,SUP-2227447,CDM,C1874,HCPCS,0278,RC,,,,both,,,7824.53,5085.94,,,,,,,,,,,,,
ELECTRODE ENDOSCP L3.75MM 90DEG XL TURBOVAC 90 AS133601] SMITH AND NEPHEW ENDOSCOPY],SUP-2341990,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1036.14,673.49,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP L145CM DIA0.035IN TIP L3CM S STL PTFE FLX,SUP-2171225,CDM,C1769,HCPCS,0272,RC,,,,both,,,63.30,41.14,,,,,,,,,,,,,
PLATE BNE L 220 X W 10.2 MM THK 2.8 MM SCREW DIA 3.5 MM 20 H 72440620N,SUP-2932806,CDM,C1713,HCPCS,0278,RC,,,,both,,,3591.85,2334.70,,,,,,,,,,,,,
VALVE AORT DIA29MM ASCEND CONDUIT CARBO-SEAL VALSALVA,SUP-2352651,CDM,C1889,HCPCS,0278,RC,,,,both,,,19154.00,12450.10,,,,,,,,,,,,,
SYRINGE MX 14CC W/ LUER CAP,SUP-2120741,CDM,C1713,HCPCS,0278,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
INTRODUCER CATH OD12FR WHT SUPRA-FOLEY,SUP-2391834,CDM,C2627,HCPCS,0272,RC,,,,both,,,59.66,38.78,,,,,,,,,,,,,
GUIDEWIRE VASC L80CM DIA0.035IN TAPR L6CM FLPY TIP L2.5CM,SUP-2167613,CDM,C1769,HCPCS,0272,RC,,,,both,,,29.96,19.47,,,,,,,,,,,,,
NAIL IM L260MM DIA10MM ST AQUA L/R DST FEM TI LOK CANN DYN,SUP-2191737,CDM,C1713,HCPCS,0278,RC,,,,both,,,5527.06,3592.59,,,,,,,,,,,,,
STEM RAD L30X19MM DIA8MM NK OFFSET 4MM TI ALIGN,SUP-2340147,CDM,C1776,CPT,0278,RC,,,,both,,,6594.00,4286.10,,,,,,,,,,,,,
COMPONENT GLEN FIX 48 HAP CONVX MTL BK BASE ARW,SUP-2224547,CDM,C1776,CPT,0278,RC,,,,both,,,5181.00,3367.65,,,,,,,,,,,,,
STENT NEURO SURPS EVOLVE L 40 MM DIA 4.5 MM COCR PLAT FLO,SUP-2541460,CDM,C1876,HCPCS,0278,RC,,,,both,,,46654.12,30325.18,,,,,,,,,,,,,
PLATE BNE W13.5XL106MM THK4.2MM 6 H BILAT S STL NAR LIMIT,SUP-2185235,CDM,C1713,HCPCS,0278,RC,,,,both,,,1082.95,703.92,,,,,,,,,,,,,
SPACER SPNL W18XH8XL55MM PEEK ANTR CERV INTBDY FUS,SUP-2311622,CDM,C1821,HCPCS,0278,RC,,,,both,,,15072.00,9796.80,,,,,,,,,,,,,
CLAMP 11MM PROV FIX WIRE 6MM,SUP-2351107,CDM,2720000010,LOCAL,0272,RC,,,,both,,,496.47,322.71,,,,,,,,,,,,,
PLATE BNE 8 H CRANIOMAXILLOFACIAL TI Y SHP FOR 2MM SCR,SUP-2191311,CDM,C1713,HCPCS,0278,RC,,,,both,,,1046.25,680.06,,,,,,,,,,,,,
"HC Whole/Red Bld,Leuko Red,Cmv",PX-3900905100,CDM,P9051,CPT,0390,RC,,,,both,,,1072.00,696.80,,,,,,,,,,,,,
SHEARS ENDO L17CM LNG CVD TIP HARM FOCUS,SUP-2219044,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1889.71,1228.31,,,,,,,,,,,,,
GUIDEWIRE VASC INQWIRE L 260 CM DIA 0.035 IN TIP L 3 MM SS,SUP-2499619,CDM,C1729,HCPCS,0272,RC,,,,both,,,141.30,91.84,,,,,,,,,,,,,
CATHETER HD PRECRV 15.5 FRX28 CM LT DL BASIC SET TITAN HD,SUP-2627352,CDM,C1750,HCPCS,0278,RC,,,,both,,,401.92,261.25,,,,,,,,,,,,,
FOOTRING EXT FIX TY SHT,SUP-2461213,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8607.37,5594.79,,,,,,,,,,,,,
PLATE SPNL L28MM STD UNIV ANTR BILAT CERV TI LCK SLIM PROF,SUP-2256432,CDM,C1713,HCPCS,0278,RC,,,,both,,,4041.18,2626.77,,,,,,,,,,,,,
STEM FEM HI OFFSET EF MAG NK W/ TRUNNION ARCOS,SUP-2443223,CDM,C1776,CPT,0278,RC,,,,both,,,1949.94,1267.46,,,,,,,,,,,,,
PLATE BNE L119MM THK3.8MM 7 H BILAT S STL NAR DYN COMPR FOR,SUP-2185207,CDM,C1713,HCPCS,0278,RC,,,,both,,,1361.85,885.20,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.515,SUP-2860032,CDM,C1713,HCPCS,0278,RC,,,,both,,,38511.16,25032.25,,,,,,,,,,,,,
DEVICE PESSARY 3 IN INCONT RNG,SUP-2171747,CDM,A4562,HCPCS,0272,RC,,,,both,,,181.90,118.23,,,,,,,,,,,,,
KIT BNE BX SZ 3 8GA DIA42MM NDL 18GA COMPLT W FILL NOZ,SUP-2280931,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3925.00,2551.25,,,,,,,,,,,,,
ANCHOR SUT L28MM DIA4.5MM SELF PUNCHING BIO-PUSHLOCK SP,SUP-2121508,CDM,C1713,HCPCS,0278,RC,,,,both,,,1161.80,755.17,,,,,,,,,,,,,
SCREW SPNL MULTAXL 5X25 MM 6.35 MM PEDCL FOR ROD RED LEG,SUP-2288980,CDM,C1713,HCPCS,0278,RC,,,,both,,,2088.10,1357.26,,,,,,,,,,,,,
GRAFT HUM TISS L 8 X W 4 CM AMNION-CHORION-AMNION LAYR,SUP-2909253,CDM,Q4140,HCPCS,0636,RC,,,,both,,,21225.43,13796.53,,,,,,,,,,,,,
BIT DRL OD2MM PIN MIC HELCL NAIL BIOTRAK,SUP-2107107,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1146.10,744.96,,,,,,,,,,,,,
LEVEL CMF ST PLATE RECON TLTS ANGLE ANGLE BENT 20 25 MM SC,SUP-2669750,CDM,C1713,HCPCS,0278,RC,,,,both,,,7303.51,4747.28,,,,,,,,,,,,,
CATHETER GUID L 95 CM OD 9 FR ID 0.098 IN CORONARY HNCK HH1,SUP-2158072,CDM,C1887,HCPCS,0272,RC,,,,both,,,273.18,177.57,,,,,,,,,,,,,
COMPONENT TIB AUG 47X51X20 MM LM/RL KNEE OSS RS RD122163,SUP-2450002,CDM,C1776,CPT,0278,RC,,,,both,,,1356.48,881.71,,,,,,,,,,,,,
BLADE RETRACTOR RICHARDSON UNIV PEDIATRIC 1X1.25 IN RNG SYS,SUP-2460488,CDM,2720000010,LOCAL,0272,RC,,,,both,,,923.22,600.09,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL PEEK SD800.546,SUP-2860227,CDM,C1713,HCPCS,0278,RC,,,,both,,,53378.43,34695.98,,,,,,,,,,,,,
SCREW BNE LCK SHT THRD 4X20 MM NS FITBONE TAA LTX,SUP-2875096,CDM,C1713,HCPCS,0278,RC,,,,both,,,707.76,460.04,,,,,,,,,,,,,
GRAFT NRV L50MM DIA1-2MM PERIPH NAT CONN CBL PROC FOR RECON,SUP-2124848,CDM,C1763,HCPCS,0278,RC,,,,both,,,21160.46,13754.30,,,,,,,,,,,,,
SET URET STENT MARD L 26 CM DIA 6 FR GUIDEWIRE 0.038 IN,SUP-2139052,CDM,C2617,HCPCS,0278,RC,,,,both,,,521.37,338.89,,,,,,,,,,,,,
SCREW SPNL L25MM OD4MM 0DEG STD TI CORT CANC ST,SUP-2415605,CDM,C1713,HCPCS,0278,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
BIT DRL L110MM DIA15MM 2 FLUT J LATCH NONRADIOPAQUE W O,SUP-2187192,CDM,2720000010,LOCAL,0272,RC,,,,both,,,441.01,286.66,,,,,,,,,,,,,
SCREW BNE L 12 MM DIA2.7 MM TI HI TORQUE XDRV FOR 2.4 MM SYS,SUP-2934690,CDM,C1713,HCPCS,0278,RC,,,,both,,,340.38,221.25,,,,,,,,,,,,,
PLATE STRNL CLOSURE 4 H TI V CONCV NS STERNALOCK EZ,SUP-2894428,CDM,C1713,HCPCS,0278,RC,,,,both,,,1752.12,1138.88,,,,,,,,,,,,,
OXYCODONE HCL 5 MG/5ML PO SOLN,RX-10813,CDM,6370000000,HCPCS,0637,RC,00904-6828-94,NDC,,both,5,ML,19.80,12.87,,,,,,,,,,,,,
DILTIAZEM HCL ER 90 MG PO CP12,RX-14101,CDM,6370000000,HCPCS,0637,RC,00378-6090-01,NDC,,both,1,UN,13.10,8.51,,,,,,,,,,,,,
COUPLER ANAS DIA2MM 20MHZ POLYETH PRB FLO DOPP VASC ASMBLY,SUP-2382619,CDM,C1889,HCPCS,0278,RC,,,,both,,,3444.58,2238.98,,,,,,,,,,,,,
SUBSTITUTE BONE GRFT 10ML SIGNIFY CRUNCH BIOACTIVE,SUP-2232305,CDM,C1713,HCPCS,0278,RC,,,,both,,,6594.00,4286.10,,,,,,,,,,,,,
CLOPIDOGREL BISULFATE 300 MG PO TABS,RX-89346,CDM,6370000000,HCPCS,0637,RC,55111-0671-31,NDC,,both,1,UN,93.50,60.77,,,,,,,,,,,,,
SCREW CONN 4MM W COCHLEAR W/ ABUTMENT 6MM PREMOUNTED PONTO,SUP-2319887,CDM,C1713,HCPCS,0278,RC,,,,both,,,9074.60,5898.49,,,,,,,,,,,,,
BIT DRL FLX 3.2 MM OCCIPITOCERVICAL NS VERTEX SEL,SUP-2630771,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1456.46,946.70,,,,,,,,,,,,,
CATHETER CARD ABLATION NAVISTAR RMT L 125 CM DIA 7 FR TIP 8,SUP-2248933,CDM,C1732,HCPCS,0278,RC,,,,both,,,7912.80,5143.32,,,,,,,,,,,,,
PLATE BNE 3X8 H NONSTERILE S STL T SHP LOK COMPR W/ SHT,SUP-2184182,CDM,C1713,HCPCS,0278,RC,,,,both,,,1303.85,847.50,,,,,,,,,,,,,
COUNTERSINK DRL S STL QUIK CONN FOR 27MM SCR,SUP-2199213,CDM,C1713,HCPCS,0278,RC,,,,both,,,331.21,215.29,,,,,,,,,,,,,
FORCEP ENDOSCP BX 1050 MM 2 MM HOT OVL FEN W/ CHANNEL BLK,SUP-2865646,CDM,2720000010,LOCAL,0272,RC,,,,both,,,596.60,387.79,,,,,,,,,,,,,
GRAFT HUM TISS W4XL7CM THK02 04MM ACELLULAR DERM MTRX,SUP-2307507,CDM,Q4128,HCPCS,0636,RC,,,,both,,,2143.99,1393.59,,,,,,,,,,,,,
BUR SURG OD6MM FLUT RND SFT TCH,SUP-2367565,CDM,2720000010,LOCAL,0272,RC,,,,both,,,597.86,388.61,,,,,,,,,,,,,
COMPONENT FEM F AP55.5MM ML25MM UNI PC PRI CEM STEMLESS R,SUP-2342165,CDM,C1776,CPT,0278,RC,,,,both,,,6845.20,4449.38,,,,,,,,,,,,,
DRILL SURG LUG 0.25 IN W/ STP VANGUARD XP,SUP-2446450,CDM,2720000010,LOCAL,0272,RC,,,,both,,,763.02,495.96,,,,,,,,,,,,,
MESH SURG PROGRIP 6X6 CM POLY POLYLACTIC ACID MFIL KNIT RECTANG,SUP-2174794,CDM,C1781,HCPCS,0278,RC,,,,both,,,762.27,495.48,,,,,,,,,,,,,
MESH PARIETEX COMP 37 CM X 28 CM,SUP-2752152,CDM,C1781,HCPCS,0278,RC,,,,both,,,8254.24,5365.26,,,,,,,,,,,,,
HEAD HUM ECC 14X36 MM 4 MM SHLDR COFIELD2,SUP-2344317,CDM,C1776,CPT,0278,RC,,,,both,,,3375.50,2194.07,,,,,,,,,,,,,
GENII TIB BSPL SZ5 LT HA COAT,SUP-2822760,CDM,C1776,CPT,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
DRESSING BIO 250 MG PORCINE EXTRACELLULAR MTRX PWDR WND STRL,SUP-2911924,CDM,A2004,HCPCS,0278,RC,,,,both,,,1632.80,1061.32,,,,,,,,,,,,,
CEFTRIAXONE SODIUM 1 G IJ SOLR,RX-9487,CDM,J0696,HCPCS,0636,RC,00409-7332-01,NDC,,both,1,UN,54.10,35.16,,,,,,,,,,,,,
MODULAR UPLR CONSTRUCT,SUP-2212084,CDM,C1776,CPT,0278,RC,,,,both,,,6751.00,4388.15,,,,,,,,,,,,,
PLATE TBL 25MM SCREW TTNM OPEN WEDGE OSTEO BONE LEFT ULTRA,SUP-2675410,CDM,C1713,HCPCS,0278,RC,,,,both,,,85.47,55.56,,,,,,,,,,,,,
BIT DRL 3.5 MM STP KNOTILUS,SUP-2608460,CDM,2720000010,LOCAL,0272,RC,,,,both,,,622.79,404.81,,,,,,,,,,,,,
DEVICE ASPIRATION ALPHAVAC MULTIPURPOSE,SUP-2855524,CDM,C1757,HCPCS,0272,RC,,,,both,,,28260.00,18369.00,,,,,,,,,,,,,
HC Splint App Short Arm Stat,PX-4502912500,CDM,29125,CPT,0450,RC,,,,outpatient,,,700.00,455.00,,,,,,,,,,,,,
FLEXHD PLIABLE SHAPED THICK MED 11CM,SUP-2676607,CDM,Q4128,HCPCS,0636,RC,,,,both,,,11607.32,7544.76,,,,,,,,,,,,,
GRAFT HUM TISS L 22 X W 22 X H 8/5 MM IL CREST UNICORTICAL,SUP-2913406,CDM,C1762,CPT,0278,RC,,,,both,,,7598.80,4939.22,,,,,,,,,,,,,
BIT DRL L100MM DIA2MM AO FOR HALLU-LOCK MTP ARTH SYS,SUP-2243439,CDM,2720000010,LOCAL,0272,RC,,,,both,,,727.16,472.65,,,,,,,,,,,,,
KIT CATH HEMODIALYSI ZENYSI DL ACUTE 11FR DIA 15CM STRGHT 2L,SUP-2613262,CDM,C1752,HCPCS,0278,RC,,,,both,,,672.75,437.29,,,,,,,,,,,,,
GRAFT HUM TISS 10MM DISC CRYOPRESERVED VIABLE OSTEOCHNDRL,SUP-2120737,CDM,C1713,HCPCS,0278,RC,,,,both,,,9891.00,6429.15,,,,,,,,,,,,,
COMPONENT PATELLAR KNEE SCORP,SUP-2378449,CDM,C1776,CPT,0278,RC,,,,both,,,1701.25,1105.81,,,,,,,,,,,,,
CATHETER DIL L 75 CM DIA 5 FR BALLOON L 4 CM DIA 6 MM UT,SUP-2139597,CDM,C1725,HCPCS,0272,RC,,,,both,,,850.94,553.11,,,,,,,,,,,,,
SHEATH DEL AMPLATZER TALISMAN TIP 45 DEG L 80 CM DIA 8 FR OD,SUP-2716356,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2675.28,1738.93,,,,,,,,,,,,,
ANCHOR SPNL LUMBAR 30 MM INDEPENDENCE MIS,SUP-2663501,CDM,C1889,HCPCS,0278,RC,,,,both,,,2041.00,1326.65,,,,,,,,,,,,,
MESH MXLFCL 157X134 MM 0.2 MM STD SCRN BNE 1.0 1.5 MM CP TI,SUP-2468553,CDM,C1713,HCPCS,0278,RC,,,,both,,,14000.51,9100.33,,,,,,,,,,,,,
TROCAR ENDOSCP L 100 MM DIA 5 MM STD OPT 2 FIX CANN DOLPHIN,SUP-2896330,CDM,2720000010,LOCAL,0272,RC,,,,both,,,383.52,249.29,,,,,,,,,,,,,
PROBE SURG HATCHED TUBESET NEXUS SONICONE OR,SUP-2745903,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1530.75,994.99,,,,,,,,,,,,,
RESERVOIR 60ML W/ LOK OUT VLV TI,SUP-2165354,CDM,C1813,HCPCS,0278,RC,,,,both,,,4631.50,3010.47,,,,,,,,,,,,,
MESH CRAN THK 0.6 MM SCREW DIA1.5 MM LG TI GRD II RT PARIETL,SUP-2934682,CDM,C1713,HCPCS,0278,RC,,,,both,,,19392.64,12605.22,,,,,,,,,,,,,
ALLOGRAFT BNE PTTY 1 CC OSTEOINDUCTIVE DBM REFICIO,SUP-2731792,CDM,C1713,HCPCS,0278,RC,,,,both,,,354.82,230.63,,,,,,,,,,,,,
TRIAL KNEE DIA35MM THK10MM ASYM TOT STBL TRIATHLON,SUP-2363807,CDM,C1776,CPT,0278,RC,,,,both,,,400.04,260.03,,,,,,,,,,,,,
INTRODUCER LD L14CM OD9FR 0.038IN STD PLCMNT PEEL AWAY COR,SUP-2357076,CDM,C1892,HCPCS,0272,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
TRAY CATH 5FR DUAL LUMEN NONCOATED VLV COMPATIBLE TRIM LEN,SUP-2125641,CDM,C1751,HCPCS,0278,RC,,,,both,,,732.50,476.12,,,,,,,,,,,,,
BLADE SAW OSCLLTNG 11.5MMW X12MML 0.4MM THK 0.6MM THK CUT IN,SUP-2605373,CDM,2720000010,LOCAL,0272,RC,,,,both,,,339.43,220.63,,,,,,,,,,,,,
CATHETER HD SET 15 FRX55 CM RETROGRADE REPL HUB VECTORFLOW,SUP-2763048,CDM,C1750,HCPCS,0278,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
SCREW BNE ST 6.5X45 MM ACET TRIL,SUP-2202544,CDM,C1713,HCPCS,0278,RC,,,,both,,,387.79,252.06,,,,,,,,,,,,,
GUIDEPIN SURG PAT KNEE,SUP-2351422,CDM,C1713,HCPCS,0278,RC,,,,both,,,2637.60,1714.44,,,,,,,,,,,,,
PLATE BNE SM W11XL25MM THK3.3MM 0DEG 2 H BILAT TI STR RIG,SUP-2190770,CDM,C1713,HCPCS,0278,RC,,,,both,,,463.87,301.52,,,,,,,,,,,,,
JIG SURG LT TIB KNEE AREF ROT PT SPEC DISP PERSONA,SUP-2205588,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
KIT PEG BEND 90 DEG DIA20 FR POLYUR CATH DOBBHOFF TIP SAFETY,SUP-2927549,CDM,2720000010,LOCAL,0272,RC,,,,both,,,388.61,252.60,,,,,,,,,,,,,
CONNECTOR SPNL STD POST TRNSVRS CONN FIX ASMBLY FOR 3MM ROD,SUP-2254417,CDM,C1713,HCPCS,0278,RC,,,,both,,,263.76,171.44,,,,,,,,,,,,,
DRILL SURG SHT 5.5X185 MM COUNTERBORE STRL T2,SUP-2466861,CDM,2720000010,LOCAL,0272,RC,,,,both,,,865.57,562.62,,,,,,,,,,,,,
COMPONENT TIB UNI SM 9 MM LL/RM KNEE ONLAY GEN,SUP-2344216,CDM,C1776,CPT,0278,RC,,,,both,,,5337.22,3469.19,,,,,,,,,,,,,
TRIAMCINOLONE ACETONIDE 0.5 % EX CREA,RX-8114,CDM,6370000000,HCPCS,0637,RC,00168-0002-15,NDC,,both,15,GR,41.70,27.10,,,,,,,,,,,,,
HC Assay of Testosterone Total|NOT REASONABLE AND NECESSARY,PX-3018440300,CDM,84403,CPT,0301,RC,,,GZ,both,,,359.00,233.35,,,,,,,,,,,,,
SHEATH INTRO L 45 CM DIA 6 FR GUIDEWIRE 0.038 IN MULTPURP,SUP-2876096,CDM,C1894,HCPCS,0272,RC,,,,both,,,285.74,185.73,,,,,,,,,,,,,
HC Iadna Sars-Cov-2-19 Amp Probe Tq,PX-3068763500,CDM,87635,CPT,0306,RC,,,,outpatient,,,110.00,71.50,,,,,,,,,,,,,
PIN ORTH SMOOTH SGL SHRP TIP S STL ST 2.0MM DIA 229MM,SUP-2212973,CDM,C1713,HCPCS,0278,RC,,,,both,,,128.74,83.68,,,,,,,,,,,,,
NAIL IM L340MM DIA9MM 130DEG ST GRN FEM TI LOK UNREAMED AG,SUP-2192542,CDM,C1713,HCPCS,0278,RC,,,,both,,,3524.02,2290.61,,,,,,,,,,,,,
PUMP KIT FOR PERISTALTIC PMP US STRL LTX,SUP-2875221,CDM,2720000010,LOCAL,0272,RC,,,,both,,,891.76,579.64,,,,,,,,,,,,,
KIT INTRO ARW SHTH L 10 CM DIA 6 FR GUIDEWIRE L 45 CM DIA,SUP-2383281,CDM,C1894,HCPCS,0272,RC,,,,both,,,107.07,69.60,,,,,,,,,,,,,
SCREW BONE 3.5X9.4MM IMPL POLYAX,SUP-2317565,CDM,C1713,HCPCS,0278,RC,,,,both,,,2983.00,1938.95,,,,,,,,,,,,,
CATHETER CARD ABLATION NAVISTAR L 115 CM 7FR 4MM C CRV SFT,SUP-2248471,CDM,C1732,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
SET PRO HYDR ABLAT,SUP-2141731,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2182.30,1418.49,,,,,,,,,,,,,
SET PANCREATIC STENT GEENEN L 12 CM DIA 8.5 FR PUSH L 170 CM,SUP-2737433,CDM,C2625,HCPCS,0278,RC,,,,both,,,452.16,293.90,,,,,,,,,,,,,
HC Ribs Bilat 3 Vw W/O Chest,PX-3207111000,CDM,71110,CPT,0320,RC,,,,inpatient,,,732.00,475.80,,,,,,,,,,,,,
PLATE BNE L 17.86 X W 9.35 MM THK 0.6 MM SCREW DIA1.5 MM 6 H,SUP-2937031,CDM,C1713,HCPCS,0278,RC,,,,both,,,806.98,524.54,,,,,,,,,,,,,
EYE STREAM OP SOLN,RX-2999,CDM,6370000000,HCPCS,0637,RC,00065-0530-01,NDC,,both,30,ML,89.80,58.37,,,,,,,,,,,,,
BLADE RTRCTR 14MMW X 35MML SPNL BALL SNAP CNTR FMCRO LMBR D,SUP-2667434,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1040.50,676.32,,,,,,,,,,,,,
SCREW CRAN L 4 MM DIA1.5 MM ST PRELD DISC NS UNIV NEURO III,SUP-2883981,CDM,C1713,HCPCS,0278,RC,,,,both,,,18274.64,11878.52,,,,,,,,,,,,,
NAIL IM FEM UNIV LNG 11.5 MMX28 CM RETROGRADE TI NAT NAIL,SUP-2459942,CDM,C1713,HCPCS,0278,RC,,,,both,,,6313.16,4103.55,,,,,,,,,,,,,
BLADE SHAVER 4.2 MMX10.5 CM STR IRRIG XTRASHRP MICROXCISOR,SUP-2607703,CDM,2720000010,LOCAL,0272,RC,,,,both,,,287.94,187.16,,,,,,,,,,,,,
TRAY CATH MIDLN PROVENA MAXBARR 3FR 20CM 1 LUMAN R S4153108D,SUP-2632859,CDM,C1751,HCPCS,0278,RC,,,,both,,,509.40,331.11,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY L 115 CM 6 FR 1MM 2MM F DECAPOLAR,SUP-2248885,CDM,C1730,HCPCS,0272,RC,,,,both,,,791.28,514.33,,,,,,,,,,,,,
GRAFT BIO TISS W6XL6CM MESHED FET BOV ACELLULAR DERM MTRX,SUP-2243705,CDM,Q4110,HCPCS,0636,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
GRAFT VASC VENAFLO II L 10 CM DIA 8 MM EPTFE CARBON STR STD,SUP-2127042,CDM,C1768,CPT,0278,RC,,,,both,,,1559.48,1013.66,,,,,,,,,,,,,
CATHETER ANGIOPLSTY SABER L 200 CM BALLOON L 250 MM DIA2 MM,SUP-2909702,CDM,C1725,HCPCS,0272,RC,,,,both,,,821.80,534.17,,,,,,,,,,,,,
VARENICLINE TARTRATE 1 MG PO TABS,RX-76445,CDM,6370000000,HCPCS,0637,RC,49884-0156-76,NDC,,both,1,UN,4.50,2.92,,,,,,,,,,,,,
KIT ARTHSCP LAT ANK ARTHROBROSTROM REP,SUP-2122948,CDM,C1776,CPT,0278,RC,,,,both,,,4553.00,2959.45,,,,,,,,,,,,,
GRAFT BNE SUB W14-18MMXL8CM FIB SHFT FRZ DRY,SUP-2307195,CDM,C1776,CPT,0278,RC,,,,both,,,2055.35,1335.98,,,,,,,,,,,,,
GELFOAM SZ 100 SPNG,SUP-2326434,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1048.76,681.69,,,,,,,,,,,,,
HC Canalith Repositioning Proc|OP PT SERVICES|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS|ADJ,PX-4209599200,CDM,95992,CPT,0420,RC,,,GP|CQ|ADJ,both,,,333.00,216.45,,,,,,,,,,,,,
STENT PERIPH EVERFLEX L 150 MM DIA 7 MM CATH L 120 CM SHTH 5,SUP-2716352,CDM,C1876,HCPCS,0278,RC,,,,both,,,2041.00,1326.65,,,,,,,,,,,,,
PARTICLE EMB 1ML 900-1200UM MICROSPHERE PVA CNTOUR SE,SUP-2148450,CDM,C1889,HCPCS,0278,RC,,,,both,,,413.22,268.59,,,,,,,,,,,,,
PLATE BNE STD TI LT MALL HK NS UNITE,SUP-2896839,CDM,C1713,HCPCS,0278,RC,,,,both,,,4078.86,2651.26,,,,,,,,,,,,,
HC Imhchem/Imcytchm 1st Single Antb Stain Procedure,PX-3128834200,CDM,88342,CPT,0312,RC,,,,both,,,371.00,241.15,,,,,,,,,,,,,
RETRIEVER ENDOSCP MINI 2.5X4.5 CM BODY ROTH NET,SUP-2736669,CDM,2720000010,LOCAL,0272,RC,,,,both,,,324.99,211.24,,,,,,,,,,,,,
PLATE BONE 6 H TI Y SHP FOR 1.5MM SCR VLP MINI-MOD SM BONE,SUP-2351067,CDM,C1713,HCPCS,0278,RC,,,,both,,,3944.31,2563.80,,,,,,,,,,,,,
GRAFT BNE MAR L CONC,SUP-2163080,CDM,C1713,HCPCS,0278,RC,,,,both,,,5495.00,3571.75,,,,,,,,,,,,,
COMPONENT TOT SHLDR CAPPED 4200] ARTHROSURFACE],SUP-2123521,CDM,C1776,CPT,0278,RC,,,,both,,,13188.00,8572.20,,,,,,,,,,,,,
REMDESIVIR 100 MG IV SOLR,RX-150300,CDM,J0248,HCPCS,0636,RC,61958-2901-02,NDC,,both,1,UN,2600.00,1690.00,,,,,,,,,,,,,
SHUNT VENTRICULOPERTIONEAL 7FR 90CM M ULT SM W SNAP RESVR,SUP-2278383,CDM,C1889,HCPCS,0278,RC,,,,both,,,2901.83,1886.19,,,,,,,,,,,,,
SCREW BONE SELFDRILLING 8 MM MIDFACIAL 20/PK TITANIUM SILVER,SUP-2842262,CDM,C1713,HCPCS,0278,RC,,,,both,,,329.83,214.39,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE 2.5 CC CORTICAL FIBER,SUP-2899186,CDM,C1713,HCPCS,0278,RC,,,,both,,,1942.88,1262.87,,,,,,,,,,,,,
BOLT TIB AUG 5MM KNEE VANGUARD 360,SUP-2408016,CDM,C1776,CPT,0278,RC,,,,both,,,279.46,181.65,,,,,,,,,,,,,
KIT CRICOTHYROTOMY SINGLE USE,SUP-2862618,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2216.84,1440.95,,,,,,,,,,,,,
PLATE BNE W10.1XL94MM 8 H BILAT TI LOK COMPR LO PROF RIG,SUP-2191094,CDM,C1713,HCPCS,0278,RC,,,,both,,,1803.40,1172.21,,,,,,,,,,,,,
COMPONENT HUM L200MM 4MM OFFSET BOND COAT LT SHLDR DISCVR,SUP-2215500,CDM,C1776,CPT,0278,RC,,,,both,,,12186.34,7921.12,,,,,,,,,,,,,
SCREW BNE L16MM DIA3.5MM CORT TI ST NONCANNULATED LOK FULL,SUP-2189884,CDM,C1713,HCPCS,0278,RC,,,,both,,,72.53,47.14,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED STD CEM M HXLPE,SUP-2212711,CDM,C1776,CPT,0278,RC,,,,both,,,11206.69,7284.35,,,,,,,,,,,,,
SYSTEM OCCL DEL L60CM SHTH 6FR 180DEG CRV CBL DIL HEMSTAS,SUP-2355727,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2152.03,1398.82,,,,,,,,,,,,,
CATHETER ANGIO STR 0.035 IN 5 FRX65 CM HI FLO IMAGER II,SUP-2653482,CDM,C1758,HCPCS,0278,RC,,,,both,,,30.71,19.96,,,,,,,,,,,,,
GRAFT BNE CUBE 8X8X8 MM DBM ALLOSYNC,SUP-2845372,CDM,C1713,HCPCS,0278,RC,,,,both,,,1455.39,946.00,,,,,,,,,,,,,
SCREW BNE L16MM DIA2MM STD CORT TI NCANNULATED FULL THRD N,SUP-2189310,CDM,C1713,HCPCS,0278,RC,,,,both,,,96.87,62.97,,,,,,,,,,,,,
SHUNT KIT MED FLO CTRL CNTOUR SM ASMBLY UNITZ MR SAFE,SUP-2631360,CDM,C1729,HCPCS,0272,RC,,,,both,,,2528.14,1643.29,,,,,,,,,,,,,
SHEATH INTRO MEDIKIT SUPERSHEATH RO L 11 CM DIA 6 FR BLU,SUP-2147309,CDM,C1894,HCPCS,0272,RC,,,,both,,,58.72,38.17,,,,,,,,,,,,,
PROBE ARTHROSCOPIC 70DEG MEASUREMENT FOR SUTURE PASSING,SUP-2766022,CDM,2720000010,LOCAL,0272,RC,,,,both,,,496.12,322.48,,,,,,,,,,,,,
CLIP INT LIG LG TI RED,SUP-2757598,CDM,C1889,HCPCS,0278,RC,,,,both,,,70.74,45.98,,,,,,,,,,,,,
CATHETER INTVASC OCCL SCEPTER MINI L 165 CM PROX/DSTL,SUP-2753241,CDM,C2628,HCPCS,0272,RC,,,,both,,,9594.27,6236.28,,,,,,,,,,,,,
DRIVER SURG 2.5MM HEX,SUP-2123644,CDM,2720000010,LOCAL,0272,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
SCREW BNE L40MM DIA5MM CORT TI SELF DRL LOK HEX RECESS,SUP-2190749,CDM,C1713,HCPCS,0278,RC,,,,both,,,580.15,377.10,,,,,,,,,,,,,
MESH HERN L13XW10IN POLYPR EPTFE ABD NONABSORBABLE ELP,SUP-2125803,CDM,C1781,HCPCS,0278,RC,,,,both,,,4385.32,2850.46,,,,,,,,,,,,,
SCREW BNE L32MM OD23MM TI CORT DST RAD NONLOCKING,SUP-2372665,CDM,C1713,HCPCS,0278,RC,,,,both,,,558.29,362.89,,,,,,,,,,,,,
GRFT CHIPS CANC 4-9.5MM 60CC PUROS,SUP-2693923,CDM,C1713,HCPCS,0278,RC,,,,both,,,5300.32,3445.21,,,,,,,,,,,,,
PIN FIX TEMP FOR ANK PLATE,SUP-2766043,CDM,2720000010,LOCAL,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
KIT TUNNELED CTRL VEN CATH SGL LUMN 9.8 FRX85 CM L,SUP-2332924,CDM,C1751,HCPCS,0278,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
BUR SURG BALL LNG 3.5 MM 7.5 CM FLUT MIDAS REX LEGEND,SUP-2630538,CDM,2720000010,LOCAL,0272,RC,,,,both,,,373.63,242.86,,,,,,,,,,,,,
ROD EXT FIX L207MM DIA11MM 45DEG UNIV C FBR SEMI CIR CRV,SUP-2188642,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1559.01,1013.36,,,,,,,,,,,,,
SPECULUM OPHTH DEVGAN LIEBERMAN 86 MM TEMPORAL APPRCH TI NS,SUP-2473741,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1575.65,1024.17,,,,,,,,,,,,,
GRAFT HUM TISS FRZN DBL STRND SEMITENDINOSUS,SUP-2113905,CDM,C1713,HCPCS,0278,RC,,,,both,,,7206.30,4684.09,,,,,,,,,,,,,
SEGMENT FEM SZ 1 H20MM LT MEDL TILASTAN FOR W60MM COMP,SUP-2265081,CDM,C1776,CPT,0278,RC,,,,both,,,2838.56,1845.06,,,,,,,,,,,,,
GRAFT HUM TISS 6MM CERV F6183 4 007,SUP-2364362,CDM,C1713,HCPCS,0278,RC,,,,both,,,4504.33,2927.81,,,,,,,,,,,,,
CATHETER DIAG L150CM OD0.059X0.052IN TIP OD3.2FR 50MM SPC,SUP-2353142,CDM,C1887,HCPCS,0272,RC,,,,both,,,533.80,346.97,,,,,,,,,,,,,
BUTAMBEN-TETRACAINE-BENZOCAINE 2-2-14 % EX AERO,RX-9328,CDM,6370000000,HCPCS,0637,RC,10223-0201-03,NDC,,both,0.2,GR,6.40,4.16,,,,,,,,,,,,,
GRAFT DURA W4XL5IN THK0.6MM CLLGN MEM DURAMATRIX-ONLAY +,SUP-2165127,CDM,C1763,HCPCS,0278,RC,,,,both,,,2872.88,1867.37,,,,,,,,,,,,,
ROD REPROC EXT FIX CARBN FIBR 4X200MM,SUP-2467587,CDM,2720000010,LOCAL,0272,RC,,,,both,,,49.20,31.98,,,,,,,,,,,,,
PLATE BNE NAR 3.5X143 MM 8 HOLE SS LCP,SUP-2569352,CDM,C1713,HCPCS,0278,RC,,,,both,,,509.47,331.16,,,,,,,,,,,,,
GRAFT HUM TISS L 2 X W 2 CM AMNION-CHORION-AMNION LAYR,SUP-2909209,CDM,Q4140,HCPCS,0636,RC,,,,both,,,5806.27,3774.08,,,,,,,,,,,,,
MORPHINE SULFATE ER 100 MG PO TBCR,RX-120981,CDM,6370000000,HCPCS,0637,RC,00904-6560-61,NDC,,both,1,UN,15.80,10.27,,,,,,,,,,,,,
SCREW BNE CANN 2X14 MM FIXOS,SUP-2366009,CDM,C1713,HCPCS,0278,RC,,,,both,,,1390.39,903.75,,,,,,,,,,,,,
METHOTREXATE ECTOPIC PREGNANCY SYRINGE,RX-4081729,CDM,J9260,HCPCS,0636,RC,00143-9519-10,NDC,,both,2,ML,54.10,35.16,,,,,,,,,,,,,
LINER ACET 50-52 0 DEG 38X54 MM FEM HIP,SUP-2202561,CDM,C1776,CPT,0278,RC,,,,both,,,3848.07,2501.25,,,,,,,,,,,,,
KIT NEPHSTMY CATH 30FR L12CM SHTH L17CM PTFE NONCOMPLIANT,SUP-2139180,CDM,C1726,HCPCS,0272,RC,,,,both,,,920.84,598.55,,,,,,,,,,,,,
GUIDEWIRE VASC GLIDEWIRE 180CM 0.025IN TIP L 3 CM ANGLED,SUP-2385606,CDM,C1769,HCPCS,0272,RC,,,,both,,,200.52,130.34,,,,,,,,,,,,,
KIT PROC SM NS DISP PVT GRDIAN,SUP-2906451,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2810.30,1826.69,,,,,,,,,,,,,
TI MATRIXMANDIBLE 20H PLATE,SUP-2827977,CDM,C1713,HCPCS,0278,RC,,,,both,,,4400.40,2860.26,,,,,,,,,,,,,
ROD FIXATION 300MM,SUP-2854266,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2238.32,1454.91,,,,,,,,,,,,,
HYDROCORTISONE SOD SUC (PF) 250 MG IJ SOLR|DISCARDED DRUG NOT ADMINISTE,RX-159345,CDM,J1720,HCPCS,0636,RC,00009-0013-05,NDC,JW,both,1,UN,256.10,166.46,,,,,,,,,,,,,
CANNULA LAP W/O VLV 11 MM,SUP-2776234,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1281.50,832.97,,,,,,,,,,,,,
BIT DRL L300MM DIA5MM CANN QUIK CPL ADJ STP REUSE,SUP-2187325,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1023.70,665.40,,,,,,,,,,,,,
PLATE BONE L76MM 10 H STRL S STL LCK COMPR FOR 2.7MM SCR,SUP-2349618,CDM,C1713,HCPCS,0278,RC,,,,both,,,2406.18,1564.02,,,,,,,,,,,,,
ALLOGRAFT BNE LG 126 MM FD IRRADIATED CORTICAL SHFT,SUP-2866974,CDM,C1762,CPT,0278,RC,,,,both,,,2117.93,1376.65,,,,,,,,,,,,,
GRAFT VASC RESTOREFLOW SZ 40 CM SAPH VEIN BLD TYP A B AB O,SUP-2264305,CDM,C1768,CPT,0278,RC,,,,both,,,27471.86,17856.71,,,,,,,,,,,,,
"HC So Oxalate Urine, 24hr",PX-3018394566,CDM,83945,CPT,0301,RC,,,,both,,,78.00,50.70,,,,,,,,,,,,,
SYSTEM LD DEL L5IN INTRO NDL GWIRE STR CVD KINK RESIST STYL,SUP-2356682,CDM,C1769,HCPCS,0272,RC,,,,both,,,1664.20,1081.73,,,,,,,,,,,,,
SYSTEM VLV 23GA 6MM 3 COUNT ASSY SHIP DISP OTH ACCURUS DISP,SUP-2109964,CDM,2720000010,LOCAL,0272,RC,,,,both,,,486.70,316.35,,,,,,,,,,,,,
ALLOGRAFT DERMAL MESH 12X8 CMX2.31-3.30 MM TISS MTRX ALLDERM,SUP-2113049,CDM,Q4116,HCPCS,0636,RC,,,,both,,,11250.62,7312.90,,,,,,,,,,,,,
PLATE BNE THK0.6MM 4 H STD CRANIOMAXILLOFACIAL G TI STR,SUP-2366288,CDM,C1713,HCPCS,0278,RC,,,,both,,,357.08,232.10,,,,,,,,,,,,,
HC So1 Platelet Aggr(Invitro) Ea Agnt,PX-3058557667,CDM,85576,CPT,0305,RC,,,,both,,,192.00,124.80,,,,,,,,,,,,,
HC Place Cath Vertebral Art,PX-3613622600,CDM,36226,CPT,0361,RC,,,,both,,,5589.00,3632.85,,,,,,,,,,,,,
STEM FEM L217MM OD13MM BOW TRI SLOT PLSM SPRAYED HA DST HIP,SUP-2375884,CDM,C1776,CPT,0278,RC,,,,both,,,8991.70,5844.60,,,,,,,,,,,,,
NALBUPHINE HCL 10 MG/ML IJ SOLN,RX-5339,CDM,J2300,HCPCS,0636,RC,00409-1463-01,NDC,,both,0.5,ML,54.10,35.16,,,,,,,,,,,,,
CLAMP CRAN TEXT 22 MM FLAPFIX FOR EXT FIX TI STRL LF,SUP-2431410,CDM,C1713,HCPCS,0278,RC,,,,both,,,1320.68,858.44,,,,,,,,,,,,,
ANCHOR SUTURE 3.3MM POPLOK KNOTLESS WITH ONE STRAND OF NUMBE,SUP-2825150,CDM,C1713,HCPCS,0278,RC,,,,both,,,1690.89,1099.08,,,,,,,,,,,,,
SEALANT TISS CLOSURE ABSORB SYNTHESIZER KT,SUP-2227098,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
SCREW BONE L6MM DIA2.7MM BRN LCK RIBLOC,SUP-2107911,CDM,C1713,HCPCS,0278,RC,,,,both,,,536.94,349.01,,,,,,,,,,,,,
REAMER SURG 2.5 MM,SUP-2175003,CDM,2720000010,LOCAL,0272,RC,,,,both,,,777.15,505.15,,,,,,,,,,,,,
SCREW BNE L38MM DIA4MM THRD L15MM CANC TI SELF DRL ST,SUP-2189941,CDM,C1713,HCPCS,0278,RC,,,,both,,,52.53,34.14,,,,,,,,,,,,,
HC So Estriol,PX-3018267766,CDM,82677,CPT,0301,RC,,,,outpatient,,,185.00,120.25,,,,,,,,,,,,,
CATHETER DEL CARR L 152 CM MED HYDRPHLC 1 LUMEN COMP VAR PK5,SUP-2912310,CDM,C1887,HCPCS,0272,RC,,,,both,,,5950.30,3867.69,,,,,,,,,,,,,
PLATE BONE TIBIAL 4.5 MM LEFT PROXIMAL LATERAL 8 HOLE LOCKIN,SUP-2836980,CDM,C1713,HCPCS,0278,RC,,,,both,,,8375.95,5444.37,,,,,,,,,,,,,
CATHETER TRAY PICC 5 FR 3 LT MAX BARR,SUP-2126402,CDM,C1751,HCPCS,0278,RC,,,,both,,,713.50,463.77,,,,,,,,,,,,,
RING EXT FIX HALF 210 MM ALUM NS MAXFRAME,SUP-2757975,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3592.16,2334.90,,,,,,,,,,,,,
KIT INTRO VSI L 10 CM 4 FR NIT TUNGSTEN TIP SIL STIFFEN DIL,SUP-2763434,CDM,C1894,HCPCS,0272,RC,,,,both,,,68.77,44.70,,,,,,,,,,,,,
GRAFT VSCLR STRGHT WOVEN DBLE VLR 24MM DX15CM L HMSHLD PLTNM,SUP-2472257,CDM,C1768,CPT,0278,RC,,,,both,,,1330.14,864.59,,,,,,,,,,,,,
COIL VASC AZUR CX L 20 CM DIA 6 MM MICROCATHETER 0.018 IN,SUP-2385235,CDM,C1889,HCPCS,0278,RC,,,,both,,,2824.43,1835.88,,,,,,,,,,,,,
LEAD DEFIB PAMIRA PROMRI S L 60 CM DF4 TRIPOLAR CONN MR,SUP-2887116,CDM,C1898,HCPCS,0275,RC,,,,both,,,8164.00,5306.60,,,,,,,,,,,,,
CATHETER HD FULL SAFETY TY 035 12 FRX25 CM DL TURBO-FLO HD,SUP-2759837,CDM,C1752,HCPCS,0278,RC,,,,both,,,478.72,311.17,,,,,,,,,,,,,
HANDPIECE HYDROSURGERY DIA14MM 15DEG TBNG SET VERSAJET,SUP-2340770,CDM,C1713,HCPCS,0278,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
CATHETER KIT 2 LUMEN 5 FR W/ PASV BIOFLO,SUP-2117194,CDM,C1751,HCPCS,0278,RC,,,,both,,,770.49,500.82,,,,,,,,,,,,,
TAP SURG 5.5MM CANN,SUP-2223984,CDM,2720000010,LOCAL,0272,RC,,,,both,,,894.90,581.68,,,,,,,,,,,,,
HYDRALAZINE 1 MG/ML INJ SOLN (NEO),RX-4090132,CDM,J0360,HCPCS,0636,RC,09999-9906-56,NDC,,both,10,ML,144.30,93.79,,,,,,,,,,,,,
PROTECTOR NRV L20MM DIA3.5MM PORCINE EXTRACELLULAR MTRX WRP,SUP-2124856,CDM,C1763,HCPCS,0278,RC,,,,both,,,7714.98,5014.74,,,,,,,,,,,,,
STENT CORONARY JOSTENT GRAFTMASTER L 12 MM DIA 5 MM GUIDE,SUP-2106196,CDM,C1876,HCPCS,0278,RC,,,,both,,,7520.30,4888.19,,,,,,,,,,,,,
TUBE TRACH PED L42MM OD67MM ID45MM SIL CUF STR NK FLNG FLX,SUP-2352327,CDM,2720000010,LOCAL,0272,RC,,,,both,,,575.69,374.20,,,,,,,,,,,,,
GRAFT NRV L70MM DIA3-4MM PERIPH NAT CONN CBL PROC FOR RECON,SUP-2124853,CDM,C1763,HCPCS,0278,RC,,,,both,,,29443.78,19138.46,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH L 54 MM DIA DSTL 12 MM SHTH 14 FR SS,SUP-2168729,CDM,C1768,CPT,0278,RC,,,,both,,,8992.96,5845.42,,,,,,,,,,,,,
FORCEPS 25GA SERR +,SUP-2109697,CDM,C1713,HCPCS,0278,RC,,,,both,,,473.51,307.78,,,,,,,,,,,,,
CATHETER HD SET 15 FRX23 CM RETROGRADE REPL HUB VECTORFLOW,SUP-2763044,CDM,C1750,HCPCS,0278,RC,,,,both,,,266.90,173.48,,,,,,,,,,,,,
FRACTURE KIT BNE CEMENT SATURATE MIXING SYS STABILIT,SUP-2460164,CDM,C1713,HCPCS,0278,RC,,,,both,,,6908.00,4490.20,,,,,,,,,,,,,
"HC So Dihydroxyvitamin D, 1 25|NOT REASONABLE AND NECESSARY",PX-3018265266,CDM,82652,CPT,0301,RC,,,GZ,both,,,229.00,148.85,,,,,,,,,,,,,
SCREW BNE LCK 3.5X50 MM MULT DIR FOR T16,SUP-2411601,CDM,C1713,HCPCS,0278,RC,,,,both,,,488.84,317.75,,,,,,,,,,,,,
HANDPIECE SURG 3 IN BEND-A-BEAM ABC,SUP-2225594,CDM,2720000010,LOCAL,0272,RC,,,,both,,,694.73,451.57,,,,,,,,,,,,,
PLATE BNE 24 HOLE 0.5 MM ADAPTATION 1.3 MM SCR MATRIXMIDFACE,SUP-2776725,CDM,C1713,HCPCS,0278,RC,,,,both,,,384.08,249.65,,,,,,,,,,,,,
GRAFT VASC EXXCEL SFT L 40 CM DIA 8 MM EPTFE STR STD WALL,SUP-2227643,CDM,C1768,CPT,0278,RC,,,,both,,,1063.99,691.59,,,,,,,,,,,,,
CATHETER URET 6FR L70CM 0.038IN OPN END FLEXITIP FOR DRNGE,SUP-2171249,CDM,C1758,HCPCS,0278,RC,,,,both,,,61.58,40.03,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE 5 CC CORTICAL FIBER,SUP-2898991,CDM,C1713,HCPCS,0278,RC,,,,both,,,3065.43,1992.53,,,,,,,,,,,,,
WIRE FIX L450MM OD15MM ORTH ETCHED OLV HOFFMANN II,SUP-2372242,CDM,C1713,HCPCS,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
NEEDLE NAVIGATION SYS 22GA L15MM DIA1.8MM NIT FLXIBLE SPIN,SUP-2392618,CDM,C1713,HCPCS,0278,RC,,,,both,,,2670.57,1735.87,,,,,,,,,,,,,
SCREW BONE L85MM DIA4.5MM THRD L38MM MALL S STL ST SELF DRL,SUP-2184560,CDM,C1713,HCPCS,0278,RC,,,,both,,,108.33,70.41,,,,,,,,,,,,,
NUT SPNL W55MM TI ACROS FLAT USS,SUP-2193639,CDM,C1713,HCPCS,0278,RC,,,,both,,,222.94,144.91,,,,,,,,,,,,,
SPACER SPNL L20XW11XH11MM 4DEG PEEK POST THORLUM INTBDY FUS,SUP-2380616,CDM,C1821,HCPCS,0278,RC,,,,both,,,5589.20,3632.98,,,,,,,,,,,,,
SYSTEM ICD CRT VR-T W/ HOME MON LUMAX 340,SUP-2138125,CDM,C1722,HCPCS,0275,RC,,,,both,,,53986.93,35091.50,,,,,,,,,,,,,
PORT IMPL INFUSION STR 26X60 MM SS,SUP-2232156,CDM,2720000010,LOCAL,0272,RC,,,,both,,,722.20,469.43,,,,,,,,,,,,,
GRAFT BONE 6MM IMPL HUM TISS SEMITENDINOSUS TEND,SUP-2402807,CDM,C1713,HCPCS,0278,RC,,,,both,,,4019.20,2612.48,,,,,,,,,,,,,
GUIDEROD L900MM DIA2MM SMOOTH STR BLNT TIP,SUP-2343597,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1099.53,714.69,,,,,,,,,,,,,
GRAFT BNE LCL WDG MED 8 MM TI,SUP-2609850,CDM,C1713,HCPCS,0278,RC,,,,both,,,9107.44,5919.84,,,,,,,,,,,,,
SCREW SPNL L12MM DIA4MM 15DEG MINI CANC POST OCCIPITAL CERV,SUP-2254407,CDM,C1713,HCPCS,0278,RC,,,,both,,,3064.64,1992.02,,,,,,,,,,,,,
CEMENT BNE 40GM 1GM 25% GENT 1GM 25% VANCO BASE GV HIP AND,SUP-2319845,CDM,C1713,HCPCS,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
RELOAD STPLR CRV TIP SM LNG 30 MM INTELLIGENT WHT,SUP-2787712,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2556.43,1661.68,,,,,,,,,,,,,
CATHETER HEMODILAYSIS KT DIAL CHRONIC DBL LUMN LNG TERM,SUP-2383442,CDM,C1752,HCPCS,0278,RC,,,,both,,,1186.92,771.50,,,,,,,,,,,,,
HC 3d Echo Img&Pst-Pxessing Tee/Tte Cgen Car Anomal,PX-4839331900,CDM,93319,CPT,0483,RC,,,,outpatient,,,1225.00,796.25,,,,,,,,,,,,,
CAP NAIL H10MM CEPHALOMEDULLARY,SUP-2208069,CDM,C1713,HCPCS,0278,RC,,,,both,,,600.27,390.18,,,,,,,,,,,,,
WAND ABLAT DIA1.4MM TIP 0.9MM 30DEG INTEGR CBL MICROBLATOR,SUP-2341983,CDM,2720000010,LOCAL,0272,RC,,,,both,,,596.91,387.99,,,,,,,,,,,,,
SUPPORT ORTHOT THOR LUMBAR SACR CUST TRIPLANAR CTRL MOD,SUP-2435540,CDM,L0458,HCPCS,0272,RC,,,,both,,,2524.97,1641.23,,,,,,,,,,,,,
DEVICE CARD MONITOR MYLUX MOB FOR LUX-DX II+ INSERTABLE SYS,SUP-2880201,CDM,2720000010,LOCAL,0272,RC,,,,both,,,624.86,406.16,,,,,,,,,,,,,
PLATE BNE DORS VOLAR FRAG Y SHP DVR 131217103] ZIMMER BIOMET TRAUMA],SUP-2411677,CDM,C1713,HCPCS,0278,RC,,,,both,,,1805.00,1173.25,,,,,,,,,,,,,
SCREW BNE SM L6MM DIA17MM CANC CORT HND TI ST NONLOCKING,SUP-2364054,CDM,C1713,HCPCS,0278,RC,,,,both,,,44.27,28.78,,,,,,,,,,,,,
KIT ANAS 14GM 1 TO 4MM ACTUATOR TOOL NDL PROX DEV AORT PNCH,SUP-2282927,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1819.10,1182.41,,,,,,,,,,,,,
BAND COMPR CHST LIFEBAND AUTOPULSE DISP,SUP-2416147,CDM,2720000010,LOCAL,0272,RC,,,,both,,,431.50,280.47,,,,,,,,,,,,,
RETRIEVER STENT 8.5FR L180CM 0.035IN 3.2 CHAN PUR FOR SOEH,SUP-2169123,CDM,2720000010,LOCAL,0272,RC,,,,both,,,405.06,263.29,,,,,,,,,,,,,
KIT GASTSTMY COMPHSVE INIT PLCMNT,SUP-2119857,CDM,2720000010,LOCAL,0272,RC,,,,both,,,577.76,375.54,,,,,,,,,,,,,
BUR REPROC SURG RND LNG HIP FORMULA 8-FLUT 5.5MM,SUP-2653237,CDM,2720000010,LOCAL,0272,RC,,,,both,,,102.21,66.44,,,,,,,,,,,,,
TAP SURG DIA65MM CANC CANN,SUP-2412175,CDM,C1713,HCPCS,0278,RC,,,,both,,,901.18,585.77,,,,,,,,,,,,,
FIBER LASER HOLMIUM 600 OLYMPUS,SUP-2885280,CDM,2720000010,LOCAL,0272,RC,,,,both,,,420.76,273.49,,,,,,,,,,,,,
GRAFT AMNIOTIC MEMBRANE FLOWERAMNIOPATCH 2CM X 4CM,SUP-2866794,CDM,Q4178,HCPCS,0636,RC,,,,both,,,8036.20,5223.53,,,,,,,,,,,,,
ANCHOR SUTURE ABSORBABLE 2-0 4.5 MM BLU BLU STRL,SUP-2848958,CDM,C1713,HCPCS,0278,RC,,,,both,,,886.89,576.48,,,,,,,,,,,,,
PLATE BNE L115MM 8 H L LAT DST PERIARTC FIBULAR S STL,SUP-2410567,CDM,C1713,HCPCS,0278,RC,,,,both,,,1531.72,995.62,,,,,,,,,,,,,
CANNULA X FIX,SUP-2669720,CDM,2720000010,LOCAL,0272,RC,,,,both,,,598.64,389.12,,,,,,,,,,,,,
GRAFT BNE INJ 5 CC INDUCTIVE PRO-STIM,SUP-2759592,CDM,C1713,HCPCS,0278,RC,,,,both,,,7900.24,5135.16,,,,,,,,,,,,,
GRAFT HUM TISS LT LAT HEMITIBIAL PLT FRSH OSTEOCHNDRL,SUP-2113929,CDM,C1713,HCPCS,0278,RC,,,,both,,,21195.00,13776.75,,,,,,,,,,,,,
ALLOGRAFT BNE 10 CC DEMINERALIZED BONE MTRX ALLOCRAFT,SUP-2636997,CDM,C1713,HCPCS,0278,RC,,,,both,,,4504.33,2927.81,,,,,,,,,,,,,
PLATE BONE THK1MM 2X2 H BILAT HND RECTANG LCK TRILOK FOR 2MM,SUP-2267928,CDM,C1713,HCPCS,0278,RC,,,,both,,,1301.22,845.79,,,,,,,,,,,,,
BEARING HUM DIA44MM STD TI FOR REV SHLDR SYS COMPHSVE,SUP-2404729,CDM,C1776,CPT,0278,RC,,,,both,,,5024.00,3265.60,,,,,,,,,,,,,
PISTON OTO KRAUS 0.6X4.7 MM 2.75 MM K-HELIX TI,SUP-2485850,CDM,L8613,CPT,0278,RC,,,,both,,,1480.54,962.35,,,,,,,,,,,,,
STENT BILI L80MM DIA10MM CATH L194CM 8FR 0.035IN MTL,SUP-2149794,CDM,C1876,HCPCS,0278,RC,,,,both,,,4473.06,2907.49,,,,,,,,,,,,,
GUIDEWIRE ORTH TROCAR PT 2 END 0.035X6 IN STRL,SUP-2846262,CDM,C1769,HCPCS,0272,RC,,,,both,,,606.02,393.91,,,,,,,,,,,,,
CONNECTOR SPNL L13MM CROSS 1 STP GTT LCK DSGN FOR STPL SYS,SUP-2229612,CDM,C1713,HCPCS,0278,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
KIT PICC CATH 5FR L55CM POLYUR NRS DBL LUMN INDWL BLU,SUP-2383476,CDM,C1751,HCPCS,0278,RC,,,,both,,,175.31,113.95,,,,,,,,,,,,,
GRAFT BNE SUB 10CC CANC CORT DEMIN CHIP OPTECURE,SUP-2223580,CDM,C1713,HCPCS,0278,RC,,,,both,,,6207.78,4035.06,,,,,,,,,,,,,
PLATE BNE COMPR 2.7X184 MM 20 HOLE LCK TI STRL LCP,SUP-2789990,CDM,C1713,HCPCS,0278,RC,,,,both,,,1649.50,1072.17,,,,,,,,,,,,,
SYSTEM RADAR LOC DEL 7.5 CM NDL MINI REFLCT 16 GA HND SCOUT,SUP-2864536,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1444.40,938.86,,,,,,,,,,,,,
PATCH BIO BOV PERICARD PTCH PERICARD 8CM LEN 6CM W CARDIOFIX,SUP-2352647,CDM,C1768,CPT,0278,RC,,,,both,,,1573.14,1022.54,,,,,,,,,,,,,
DRESSING BIO L 20 X W 7 CM SZ 200 UM PORCINE SM INTEST,SUP-2905516,CDM,Q4103,HCPCS,0636,RC,,,,both,,,5412.58,3518.18,,,,,,,,,,,,,
SLIDER TI,SUP-2415541,CDM,C1713,HCPCS,0278,RC,,,,both,,,946.90,615.48,,,,,,,,,,,,,
BOLT EXT FIX SHLDR FOR ILIZ TAY SPAT FRME EXT FIX,SUP-2342995,CDM,2720000010,LOCAL,0272,RC,,,,both,,,325.90,211.83,,,,,,,,,,,,,
PLATE BNE MEDL SLIM 15 HOLE SYS IMPL INSTRUMENT AXIS,SUP-2610175,CDM,C1713,HCPCS,0278,RC,,,,both,,,6782.40,4408.56,,,,,,,,,,,,,
SLEEVE FEM STD OFFSET HIP TYP 1 TAPR FOR CERAMIC BIOLOX,SUP-2408753,CDM,C1776,CPT,0278,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
PLATE BNE RECON 2.7X3 MM LT MAND 26 HOLE ANGLED LCK TI STRL,SUP-2498438,CDM,C1713,HCPCS,0278,RC,,,,both,,,6575.73,4274.22,,,,,,,,,,,,,
GRAFT BNE H18MM IL CREST WDG PRESERVON MATRIGRFT,SUP-2264843,CDM,C1713,HCPCS,0278,RC,,,,both,,,2595.93,1687.35,,,,,,,,,,,,,
IMPLANT BRST W13.2CM OD2.9CM 275ML FILL VOL PLAS SIL MOD,SUP-2300403,CDM,C1789,HCPCS,0278,RC,,,,both,,,2747.50,1785.87,,,,,,,,,,,,,
BUR SURG DIAMOND COARSE 2 MM 5 CM BALL MIDAS REX 8 CLRVW LP,SUP-2664910,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1052.69,684.25,,,,,,,,,,,,,
PLATE BONE LOK WEDGE MED TIMAX ANTMCL LTRL CLMN LNGTHNNG ALP,SUP-2588781,CDM,C1713,HCPCS,0278,RC,,,,both,,,1890.15,1228.60,,,,,,,,,,,,,
"HC So Transferrin, Carbohydrate Dfct",PX-3018237366,CDM,82373,CPT,0301,RC,,,,outpatient,,,146.00,94.90,,,,,,,,,,,,,
RESURFACING CAGE 30MM,SUP-2512433,CDM,C1776,CPT,0278,RC,,,,both,,,1694.34,1101.32,,,,,,,,,,,,,
BRACE WR CLUTCH DORS STAY VELSTRETCH WRP RT CIRC 6 1/2-8,SUP-2323980,CDM,L3906,HCPCS,0272,RC,,,,both,,,50.84,33.05,,,,,,,,,,,,,
BIT DRL DIA2.4MM CANN W/ AO FIT FOR 4MM SCR,SUP-2136104,CDM,2720000010,LOCAL,0272,RC,,,,both,,,926.30,602.09,,,,,,,,,,,,,
PLATE EXT FIX 3 H THRD CONN MRI CONDITIONAL FOR DISTR,SUP-2255811,CDM,2720000010,LOCAL,0272,RC,,,,both,,,270.86,176.06,,,,,,,,,,,,,
STOP DRL FOR 6/10MM STP CANN DRL BIT,SUP-2188236,CDM,2720000010,LOCAL,0272,RC,,,,both,,,895.40,582.01,,,,,,,,,,,,,
MAGNET IMPL TI CONIC FOR ATTRACT 1 STG SURG BAHA BIM400,SUP-2164992,CDM,L8614,HCPCS,0278,RC,,,,both,,,7222.00,4694.30,,,,,,,,,,,,,
SCREW INTFR L25MM DIA8MM TI RND HD CANN FOR ACL RECON,SUP-2212929,CDM,C1713,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
TUBE TRACH PED L44MM OD73MM ID5MM SIL CUF V NK FLNG W OBT,SUP-2352451,CDM,2720000010,LOCAL,0272,RC,,,,both,,,615.03,399.77,,,,,,,,,,,,,
COMPONENT ACET TRIFLANGED 25 MM LT HIP,SUP-2402835,CDM,C1776,CPT,0278,RC,,,,both,,,37366.00,24287.90,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.528,SUP-2860045,CDM,C1713,HCPCS,0278,RC,,,,both,,,42067.52,27343.89,,,,,,,,,,,,,
BAND SCLER L125MM DIA2.5MM CIR BCKL LABTICIAN,SUP-2263419,CDM,C1784,HCPCS,0278,RC,,,,both,,,50.87,33.07,,,,,,,,,,,,,
PROBE SURG L231CM DIA0.9MM 70DEG FLD OF VW 6000 PIXEL IMAG,SUP-2149605,CDM,2720000010,LOCAL,0272,RC,,,,both,,,11890.43,7728.78,,,,,,,,,,,,,
BRACE WR CLUTCH DORS STAY VELSTRETCH WRP RT CIRC 6 1/2-8,SUP-2323980,CDM,L3906,HCPCS,0274,RC,,,,both,,,50.84,33.05,,,,,,,,,,,,,
KIT VASC CLOSURE VASOSEAL CLLGN MEDIATED EXTRAVASCULAR ORN,SUP-2227428,CDM,C1760,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA MAXBARR 3FR 55CM S9173108PD,SUP-2632873,CDM,C1751,HCPCS,0278,RC,,,,both,,,681.32,442.86,,,,,,,,,,,,,
GUIDE PIN LG 37.5X27.5 MM BIOPATELLA OATS,SUP-2845386,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1017.36,661.28,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP L200CM DIA0035IN BILI HYDRPHLC TIP EXTN HI,SUP-2149675,CDM,C1769,HCPCS,0272,RC,,,,both,,,279.62,181.75,,,,,,,,,,,,,
DRILL TWST L 21 MM DIA1 MM STP 8 MM DENT SHFT NS DISP,SUP-2883162,CDM,2720000010,LOCAL,0272,RC,,,,both,,,413.73,268.92,,,,,,,,,,,,,
SCREW EXT FIX L200MM DIA5MM S STL HA BLNT TRCR PNT MR,SUP-2418493,CDM,C1713,HCPCS,0278,RC,,,,both,,,550.72,357.97,,,,,,,,,,,,,
COMPONENT TOT KNEE BICOMPARTMENTAL LT MEDL W/O PATELLAR,SUP-2165962,CDM,C1776,CPT,0278,RC,,,,both,,,12874.00,8368.10,,,,,,,,,,,,,
GENERATOR NEUROSTIMULATOR SPNL PERC 8 CHAN INT PULSE GENRTR,SUP-2356745,CDM,C1767,HCPCS,0278,RC,,,,both,,,33896.30,22032.59,,,,,,,,,,,,,
GRAFT HUM TISS L 4 X W 4 CM AMNION-CHORION-AMNION LAYR,SUP-2909220,CDM,Q4140,HCPCS,0636,RC,,,,both,,,11370.32,7390.71,,,,,,,,,,,,,
GRFT CRUSH CANC 1-4MM 5CC PUROS,SUP-2693924,CDM,C1713,HCPCS,0278,RC,,,,both,,,1089.58,708.23,,,,,,,,,,,,,
PLATE BNE L 43 MM SCREW DIA2 MM 8 SHFT H SS COMPACT STR VA,SUP-2908106,CDM,C1713,HCPCS,0278,RC,,,,both,,,4338.85,2820.25,,,,,,,,,,,,,
BUTTON SUTURE STRL FIBERTAK,SUP-2882214,CDM,C1713,HCPCS,0278,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
PLATE BNE TI LT TT FUSION PRIMARY PILON NS,SUP-2897778,CDM,C1713,HCPCS,0278,RC,,,,both,,,7218.86,4692.26,,,,,,,,,,,,,
PIN DRL L15IN DIA2.4MM CALIB FOR ARTHSCP ANTR CRUC LIGMNT,SUP-2256828,CDM,2720000010,LOCAL,0272,RC,,,,both,,,891.76,579.64,,,,,,,,,,,,,
DEFIBRILLATOR IMPL LUMAX 300 DR-T 55 X 66MM 12MM 30J DDDRV,SUP-2138073,CDM,C1721,HCPCS,0275,RC,,,,both,,,44544.04,28953.63,,,,,,,,,,,,,
GRAFT VASC IMPRA L 70 CM DIA 7-4 MM EPTFE TAPR FLX TW RING,SUP-2761494,CDM,C1768,CPT,0278,RC,,,,both,,,3572.10,2321.86,,,,,,,,,,,,,
PLATE BNE W175XL134MM THK52MM 7 H BILAT TI RIG NEUT LOK,SUP-2190843,CDM,C1713,HCPCS,0278,RC,,,,both,,,1311.26,852.32,,,,,,,,,,,,,
"HC So Transferrin, Carbohydrate Dfct",PX-3018237366,CDM,82373,CPT,0301,RC,,,,inpatient,,,146.00,94.90,,,,,,,,,,,,,
PLATE BNE L90MM STD 3 H PROX HUM S STL LOK COMPR FOR 3.5MM,SUP-2186012,CDM,C1713,HCPCS,0278,RC,,,,both,,,4204.59,2732.98,,,,,,,,,,,,,
STEM HUM PROX 142 DEG 6/8 SHLDR ANAT W/ BODY GLOB UNITE,SUP-2452214,CDM,C1776,CPT,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
FOOTPLATE EXT FIX DIA150MM FOR RNG FIX SYS TRUELOK,SUP-2316189,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1573.14,1022.54,,,,,,,,,,,,,
SLING SUT PASS AND SPCR VESICA,SUP-2141755,CDM,2720000010,LOCAL,0272,RC,,,,both,,,551.07,358.20,,,,,,,,,,,,,
KIT CATH HEMODIALYSI EQUISTREAM CHRONIC MICROINTRODU 5904230,SUP-2632974,CDM,C1750,HCPCS,0278,RC,,,,both,,,1803.46,1172.25,,,,,,,,,,,,,
SPECULUM VGNL AUVRD 1 1/2NW X 2 3/4NL BLADE 2.5LB CPCTY WGHT,SUP-2473602,CDM,2720000010,LOCAL,0272,RC,,,,both,,,505.82,328.78,,,,,,,,,,,,,
HC Admin Hepatitis B Vaccine,PX-7710001000,CDM,G0010,HCPCS,0771,RC,,,,outpatient,,,116.00,75.40,,,,,,,,,,,,,
COMPONENT FEM XSM L KNEE REV CEM CRUCE RET STEM NONBEADED,SUP-2377030,CDM,C1776,CPT,0278,RC,,,,both,,,7201.37,4680.89,,,,,,,,,,,,,
STENT NEPHURET L 26 CM DIA 8 FR PERCFLX HYDRPHLC 2 PIGTL N,SUP-2147765,CDM,C2617,HCPCS,0278,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
LENS INTOCU 16.5 DIOPT 1.5 DIOPT CYL PWR L13MM DIA6MM 0DEG,SUP-2248249,CDM,V2788,HCPCS,0276,RC,,,,both,,,967.00,628.55,,,,,,,,,,,,,
URETEROSCOPE FLX DIGITAL MODEL D RVS DEFLECTION STRL DISP,SUP-2894008,CDM,C1747,HCPCS,0272,RC,,,,both,,,2483.74,1614.43,,,,,,,,,,,,,
ADAPTER FEM SEG STK DIAPHYSIS ORTH SALV SYS,SUP-2405834,CDM,C1776,CPT,0278,RC,,,,both,,,357.18,232.17,,,,,,,,,,,,,
PLATE SPNL LCK 10 MM ANTR CVR MERID,SUP-2710909,CDM,C1713,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
PIN FIX HALF SELF DRL APEX 5X250 MM W/ 70 MM THRD,SUP-2363230,CDM,C1713,HCPCS,0278,RC,,,,both,,,491.72,319.62,,,,,,,,,,,,,
STENT ES L10CM DIA18MM CATH 18.5FR L120CM MTL PARTIALLY CVR,SUP-2149418,CDM,C1874,HCPCS,0278,RC,,,,both,,,7600.37,4940.24,,,,,,,,,,,,,
GUIDEWIRE BENSTON .035 X 80CM,SUP-2859245,CDM,C1769,HCPCS,0272,RC,,,,both,,,37.68,24.49,,,,,,,,,,,,,
BRACE ANK L H10IN RIG THERMOPLASTIC SHELL ADJ HEEL STRP W/,SUP-2197171,CDM,L4350,HCPCS,0274,RC,,,,both,,,40.41,26.27,,,,,,,,,,,,,
CONTROLLER STIM SYS MY SCS GO THER,SUP-2905201,CDM,C1787,HCPCS,0278,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
CATHETER HEMO DYLS OR HD ADMIN FULL KT DBL LUMN POLYUR STR,SUP-2283927,CDM,C1750,HCPCS,0278,RC,,,,both,,,576.22,374.54,,,,,,,,,,,,,
STAPLER INT H44X15MM DIA55MM 0DEG TI UNIV 6 ROW CART,SUP-2693602,CDM,2720000010,LOCAL,0272,RC,,,,both,,,159.98,103.99,,,,,,,,,,,,,
KIT INTRO DIL DIA20 FR LAPSCP FOR GASTMY FEED TUBE STRL,SUP-2764618,CDM,2720000010,LOCAL,0272,RC,,,,both,,,758.59,493.08,,,,,,,,,,,,,
SLING GYN UNIV POLYPR TRNSVAG MIDURETHRAL MESH ASSEMB HALO,SUP-2139446,CDM,C1771,HCPCS,0278,RC,,,,both,,,5890.55,3828.86,,,,,,,,,,,,,
ROD SPNL STR 5.5X90 MM CD HORZ,SUP-2279595,CDM,C1713,HCPCS,0278,RC,,,,both,,,1108.42,720.47,,,,,,,,,,,,,
HC So2 Drvvt,PX-3058561368,CDM,85613,CPT,0305,RC,,,,both,,,13.00,8.45,,,,,,,,,,,,,
SCREW BNE L8MM DIA2.4MM STD CORT CRANIOMAXILLOFACIAL TI ST,SUP-2189411,CDM,C1713,HCPCS,0278,RC,,,,both,,,241.34,156.87,,,,,,,,,,,,,
CATHETER DRAINAGE PIG 12 FRX25 CM BILI 6 HOLE UTHANE,SUP-2168132,CDM,C1729,HCPCS,0272,RC,,,,both,,,345.75,224.74,,,,,,,,,,,,,
PIN FIX AXIS 2.5X35 MM ELBW COCR IJS,SUP-2434522,CDM,2720000010,LOCAL,0272,RC,,,,both,,,833.67,541.89,,,,,,,,,,,,,
BRACE EL R ROM TELSCP 4 CUF X ACT,SUP-2196500,CDM,L3702,HCPCS,0272,RC,,,,both,,,294.38,191.35,,,,,,,,,,,,,
SNARE VASC SYMPRO ELITE L 150 CM DIA 0.035 IN LOOP DIA10 MM,SUP-2763476,CDM,C1773,HCPCS,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
VALVE 0 WITH PRECHAMBER MININAV,SUP-2825730,CDM,C1889,HCPCS,0278,RC,,,,both,,,2033.18,1321.57,,,,,,,,,,,,,
CLIP ANEUR 8MM STD PERM SIDE CRV EL GILOY SUGITA,SUP-2306040,CDM,C1889,HCPCS,0278,RC,,,,both,,,659.40,428.61,,,,,,,,,,,,,
ALLOFUSE 1CC GEL,SUP-2415364,CDM,C1889,HCPCS,0278,RC,,,,both,,,546.36,355.13,,,,,,,,,,,,,
MORPHINE NEONATAL ORAL SOLUTION 0.4 MG/ML,RX-4081359,CDM,6370000000,HCPCS,0637,RC,09999-9910-42,NDC,,both,1,ML,7.50,4.87,,,,,,,,,,,,,
CATHETER LD DEL CPS DIR SL II L 57.7 AVAILABLE L 54 CM OD 9,SUP-2356369,CDM,C1893,HCPCS,0272,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
CATHETER ATHRCTMY CROSSER L 146 CM DIA1.6 MM GUIDEWIRE 0.014,SUP-2128075,CDM,C1714,HCPCS,0272,RC,,,,both,,,8003.86,5202.51,,,,,,,,,,,,,
FORCEPS ES L20CM DIA15MM SLIM BPLR NONSTICK DISPOSABLE,SUP-2364936,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1287.40,836.81,,,,,,,,,,,,,
Z DISCONTINUED NO SUB IDED CATHETER ANGIO FL3 6 FRX100 CM EXPO,SUP-2142024,CDM,2720000010,LOCAL,0272,RC,,,,both,,,70.34,45.72,,,,,,,,,,,,,
BLADE SCREWDRIVER 1MM DIA CENTRE DRIVE,SUP-2667828,CDM,2720000010,LOCAL,0272,RC,,,,both,,,596.60,387.79,,,,,,,,,,,,,
GRAFT HUM TISS L 6 X W 3 CM AMNION-CHORION-AMNION LAYR,SUP-2909308,CDM,Q4140,HCPCS,0636,RC,,,,both,,,12040.17,7826.11,,,,,,,,,,,,,
SPLINT WRST L INSTABILITY INJ LACE W STAY COCK UP FIRM SUPP,SUP-2197063,CDM,L3908,HCPCS,0274,RC,,,,both,,,27.41,17.82,,,,,,,,,,,,,
PLATE BNE L140MM 5 H NONSTERILE R PROX LAT TIB S STL LOK,SUP-2184877,CDM,C1713,HCPCS,0278,RC,,,,both,,,3834.60,2492.49,,,,,,,,,,,,,
SET CERV PD4 FOR 35 45IN 2 5YRS PED L89 114CM W REPL PD,SUP-2123894,CDM,L0190,HCPCS,0272,RC,,,,both,,,219.08,142.40,,,,,,,,,,,,,
STIMULATOR NERVE DBS SPINE PT CTRL,SUP-2357363,CDM,C1787,HCPCS,0278,RC,,,,both,,,5102.50,3316.62,,,,,,,,,,,,,
SYSTEM LT VISN RFID CHANDELIER CONSTELLATION,SUP-2109950,CDM,2720000010,LOCAL,0272,RC,,,,both,,,424.50,275.92,,,,,,,,,,,,,
INTRODUCER TUBE SET 6 FR PERC ADV CIAGLIA BLU RHINO G2,SUP-2759752,CDM,C1769,HCPCS,0272,RC,,,,both,,,1352.24,878.96,,,,,,,,,,,,,
"HC OB ER Level 5|MULTIPLE OUTPATIENT HOSPITAL E/M ENCOUNTERS ON THE SAME DATE|SIGNIFICANT, SEPARATELY IDENTIFIABLE EVALUATION AND MANAGEMENT SERVICE BY THE SAME PHYSICIAN ON THE SAME DAY OF THE PROCEDURE OR OTHER SERVICE",PX-4509928501,CDM,99285,CPT,0450,RC,,,27|25,outpatient,,,3911.00,2542.15,,,,,,,,,,,,,
SCREW BNE L35MM DIA5MM CANC HUM S STL FOR PROX PLT SYS,SUP-2107652,CDM,C1713,HCPCS,0278,RC,,,,both,,,1212.04,787.83,,,,,,,,,,,,,
VORTIOXETINE HBR 5 MG PO TABS,RX-124079,CDM,6370000000,HCPCS,0637,RC,64764-0720-30,NDC,,both,1,UN,77.20,50.18,,,,,,,,,,,,,
BOX CTRL COIL DETACH ENPOWER,SUP-2467544,CDM,C1889,HCPCS,0278,RC,,,,both,,,5905.15,3838.35,,,,,,,,,,,,,
COIL VASC VORTX-35 L 35 MM UNRESTRAINED L 4.5 MM DIA 5 MM,SUP-2142386,CDM,C1889,HCPCS,0278,RC,,,,both,,,270.04,175.53,,,,,,,,,,,,,
CATHETER VALVULOPLASTY AORT ENDOCLAMP,SUP-2214465,CDM,2720000010,LOCAL,0272,RC,,,,both,,,9021.22,5863.79,,,,,,,,,,,,,
SCISSOR SURG PECK-JOSEPH 5.5 IN 4.9 CM CRV SHRP/SHRP BLADE,SUP-2872580,CDM,C1889,HCPCS,0278,RC,,,,both,,,257.17,167.16,,,,,,,,,,,,,
APPLICATOR DURASEAL 15 CM ST DISP,SUP-2243103,CDM,2720000010,LOCAL,0272,RC,,,,both,,,650.64,422.92,,,,,,,,,,,,,
PLATE BNE LCK MINI NAR BROAD 2 MM MAND 4 HOLE FOR SCREW TI,SUP-2191212,CDM,C1713,HCPCS,0278,RC,,,,both,,,1956.22,1271.54,,,,,,,,,,,,,
ALLOGRAFT BNE FRZN ASEP RT FEM SHFT,SUP-2867030,CDM,C1762,CPT,0278,RC,,,,both,,,5297.81,3443.58,,,,,,,,,,,,,
DEVICE FIX 5MM TI FOR LAP HERN REP PROTACK,SUP-2283142,CDM,2720000010,LOCAL,0272,RC,,,,both,,,986.24,641.06,,,,,,,,,,,,,
COLLAR CERV L H4.25IN FOR 16-19IN PLASTAZOTE FOAM 2 PC L,SUP-2336006,CDM,L0140,HCPCS,0274,RC,,,,both,,,30.87,20.07,,,,,,,,,,,,,
CAP SCR IM NAIL ST GAM NAIL,SUP-2370987,CDM,C1713,HCPCS,0278,RC,,,,both,,,699.28,454.53,,,,,,,,,,,,,
TRAY CATH MIDLN POWERMIDLINE MAXBARR 4FR 20CM 2 LUMAN RVS TA,SUP-2613519,CDM,C1751,HCPCS,0278,RC,,,,both,,,568.53,369.54,,,,,,,,,,,,,
SHELL ACET DIA54MM GRP E BIOFOAM TI MTL FOAM HIP PRESSFIT,SUP-2304548,CDM,C1776,CPT,0278,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
SYSTEM CAPPING SCALP COOLING LARGE,SUP-2866233,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3140.16,2041.10,,,,,,,,,,,,,
SCREW BNE L60MM DIA4.5MM THRD L28MM HD DIA8MM MALL S STL,SUP-2184556,CDM,C1713,HCPCS,0278,RC,,,,both,,,133.51,86.78,,,,,,,,,,,,,
GRAFT VASC GELWEAVE L 20 CM DIA12 MM SIDE BRANCH L 10 CM DIA,SUP-2384998,CDM,C1768,CPT,0278,RC,,,,both,,,5086.80,3306.42,,,,,,,,,,,,,
STIMULATOR NERVE 47X17 MM BLDR BWL RECHRG INTERSTIM,SUP-2550569,CDM,C1820,HCPCS,0278,RC,,,,both,,,35011.00,22757.15,,,,,,,,,,,,,
COVER BUR H SM DIA13MM THK0.5MM 5 H NEURO TI FOR 1.5MM SCR,SUP-2402904,CDM,C1713,HCPCS,0278,RC,,,,both,,,530.66,344.93,,,,,,,,,,,,,
PIN EXT FIX 6 MM GRN,SUP-2205339,CDM,2720000010,LOCAL,0272,RC,,,,both,,,438.82,285.23,,,,,,,,,,,,,
KIT TIP NDL PEDCL ACCS PERC SPNL 2 BVL,SUP-2290655,CDM,C1713,HCPCS,0278,RC,,,,both,,,2560.54,1664.35,,,,,,,,,,,,,
BLADE OSTEO LNG 2015] UNIVERSAL MEDICAL INC],SUP-2391404,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
PLATE BNE W11XL190MM THK4.2MM 12 H MTPHSEAL S STL LOK COMPR,SUP-2185265,CDM,C1713,HCPCS,0278,RC,,,,both,,,3353.61,2179.85,,,,,,,,,,,,,
PORT INFUS CATH 6.6FR TI SGL LUMN PEEL APART PERC INTRO SYS,SUP-2126165,CDM,C1788,HCPCS,0278,RC,,,,both,,,571.48,371.46,,,,,,,,,,,,,
HC Ot Vasopneumatic Device Therapy|DOCUMENTATION ON FILE|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS,PX-4309701600,CDM,97016,CPT,0430,RC,,,KX|CQ,both,,,206.00,133.90,,,,,,,,,,,,,
GRAFT DERMAL MESH 7X10 CM FEN WND MTRX MIRODERM,SUP-2431549,CDM,Q4175,HCPCS,0636,RC,,,,both,,,12924.24,8400.76,,,,,,,,,,,,,
CATHETER HD STR 13 FRX12 CM BASIC SET SHT TERM DUO-SPLIT,SUP-2269517,CDM,C1752,HCPCS,0278,RC,,,,both,,,225.39,146.50,,,,,,,,,,,,,
PLATE BNE W6XL42MM 24 H CRANIOMAXILLOFACIAL TI STRUT FOR,SUP-2190569,CDM,C1713,HCPCS,0278,RC,,,,both,,,2270.53,1475.84,,,,,,,,,,,,,
MESH GORE SYNECOR 40CM X 50CM RECTANGLE,SUP-2763183,CDM,C1781,HCPCS,0278,RC,,,,both,,,48516.14,31535.49,,,,,,,,,,,,,
DEFIBRILLATOR IMPL ILESTO 7 HF-T W 56 X H 65 MM D 11 MM 40 J,SUP-2138297,CDM,C1882,HCPCS,0275,RC,,,,both,,,47885.00,31125.25,,,,,,,,,,,,,
LUMBAR BLD SACRAL WTEETH TITN 30X40MM LEFT,SUP-2676794,CDM,2720000010,LOCAL,0272,RC,,,,both,,,594.15,386.20,,,,,,,,,,,,,
SET INTRO SUP ARW FLX SHTH L 11 CM DIA 5 FR HYDRPHLC,SUP-2383978,CDM,C1894,HCPCS,0272,RC,,,,both,,,273.18,177.57,,,,,,,,,,,,,
GRAFT BIO TISS W2XL3CM 1 LAYR PORCINE MTRX ABD HERN SURGISIS,SUP-2168830,CDM,C1763,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
SCREW BNE CANN 3.5X23 MM COMPR LP TRNSVRS TI LAPIPLASTY,SUP-2422332,CDM,C1713,HCPCS,0278,RC,,,,both,,,1648.50,1071.52,,,,,,,,,,,,,
BIT DRILL SLD STP T2 RECON,SUP-2701848,CDM,2720000010,LOCAL,0272,RC,,,,both,,,869.00,564.85,,,,,,,,,,,,,
DEFIBRILLATOR IMPL EVERA XT VR DELIVERED ENERGY 36 J 35 CC,SUP-2282420,CDM,C1722,HCPCS,0275,RC,,,,both,,,38016.51,24710.73,,,,,,,,,,,,,
HC Rep Lac Smp Face 5.1-7.5 Cm,PX-4501201400,CDM,12014,CPT,0450,RC,,,,both,,,861.00,559.65,,,,,,,,,,,,,
SPACER SPNL 11X14X10MM 7 DEG CERV LORD CALIX,SUP-2402243,CDM,C1821,HCPCS,0278,RC,,,,both,,,5286.03,3435.92,,,,,,,,,,,,,
PLATE BNE L55MM +20DEG 8 H DST DORS RAD S STL L VAR ANG LOK,SUP-2184183,CDM,C1713,HCPCS,0278,RC,,,,both,,,2016.48,1310.71,,,,,,,,,,,,,
HC Cast - Short Arm,PX-4502907500,CDM,29075,CPT,0450,RC,,,,both,,,802.00,521.30,,,,,,,,,,,,,
PLATE BONE LOK 161MML HLX20 STNLSS STEEL STRGHT RCNSTRCTN ST,SUP-2720494,CDM,C1713,HCPCS,0278,RC,,,,both,,,1882.30,1223.49,,,,,,,,,,,,,
SCREW BNE L12MM DIA2MM CRANIOMAXILLOFACIAL S STL SELF DRL,SUP-2183325,CDM,C1713,HCPCS,0278,RC,,,,both,,,441.36,286.88,,,,,,,,,,,,,
CONNECTOR SPNL M LAT TOP ANT FIX TI XLNK,SUP-2415884,CDM,C1713,HCPCS,0278,RC,,,,both,,,1648.50,1071.52,,,,,,,,,,,,,
MESH HERN L14XW10IN POLYPR EPTFE ABD NONABSORBABLE RECTANG,SUP-2125804,CDM,C1781,HCPCS,0278,RC,,,,both,,,4614.54,2999.45,,,,,,,,,,,,,
PLATE BNE W11XL262MM THK42MM 16 H MTPHSEAL S STL LOK COMPR,SUP-2185268,CDM,C1713,HCPCS,0278,RC,,,,both,,,3634.80,2362.62,,,,,,,,,,,,,
PIN EXT FIX CYL SET CONN ELEMENT STRL TRUELOK EVO LTX,SUP-2875603,CDM,C1713,HCPCS,0278,RC,,,,both,,,18487.19,12016.67,,,,,,,,,,,,,
BIT DRL L110MM WRK L20MM DIA1.9MM CLR DEPTH MRK FOR,SUP-2364194,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1373.40,892.71,,,,,,,,,,,,,
DEVICE PESSARY RNG W/ SUPP FLD 3IN,SUP-2171843,CDM,A4562,HCPCS,0274,RC,,,,both,,,172.70,112.25,,,,,,,,,,,,,
KIT HAD ADMIN TY CHRONIC SIDE H INTRO NDL J STR GWIRE SHTH,SUP-2283954,CDM,C1750,HCPCS,0278,RC,,,,both,,,691.46,449.45,,,,,,,,,,,,,
EPOETIN ALFA 40000 UNIT/ML IJ SOLN|DISCARDED DRUG NOT ADMINISTE,RX-24513,CDM,J0885,HCPCS,0636,RC,59676-0340-00,NDC,JW,both,1,ML,3153.60,2049.84,,,,,,,,,,,,,
INSERT TIB L87/91MM THK10MM UNIV STD KNEE PRI POST STBL NEUT,SUP-2407098,CDM,C1776,CPT,0278,RC,,,,both,,,4688.02,3047.21,,,,,,,,,,,,,
HYDROCHLOROTHIAZIDE 12.5 MG PO CAPS,RX-19146,CDM,6370000000,HCPCS,0637,RC,50228-0146-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
LID STRL PROX HUM BASE FOR IMPL TY,SUP-2490627,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1505.19,978.37,,,,,,,,,,,,,
COLLAR CERV PD REG INF BK PANEL REPL,SUP-2124226,CDM,L0174,HCPCS,0272,RC,,,,both,,,56.14,36.49,,,,,,,,,,,,,
SCREW BNE L7MM DIA1.2MM CORT CRANIOMAXILLOFACIAL TI ST,SUP-2189159,CDM,C1713,HCPCS,0278,RC,,,,both,,,353.88,230.02,,,,,,,,,,,,,
KIT PROCEDURE BARIATRIC,SUP-2752113,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5734.27,3727.28,,,,,,,,,,,,,
SCREW BNE LAG 2X24 MM CROSS PIN NS LTX,SUP-2862738,CDM,C1713,HCPCS,0278,RC,,,,both,,,198.98,129.34,,,,,,,,,,,,,
COIL EMB L45CM OD0.020IN LOOP OD16MM NIT STRTCH RESIST FILL,SUP-2323420,CDM,C1889,HCPCS,0278,RC,,,,both,,,8088.64,5257.62,,,,,,,,,,,,,
KIT INSRT W/ 6IN INTRO FOR USE W/ FIDELITY 8FR 34 AND 40CC,SUP-2227323,CDM,C1894,HCPCS,0272,RC,,,,both,,,333.63,216.86,,,,,,,,,,,,,
HC Repair Complex Scalp/Arm/Leg 1.1-2.5 Cm,PX-4501312000,CDM,13120,CPT,0450,RC,,,,inpatient,,,1842.00,1197.30,,,,,,,,,,,,,
CATHETER ANGIO ARW BERMAN L 60 CM DIA 6 FR BALLOON DIA10 MM,SUP-2383951,CDM,C1725,HCPCS,0272,RC,,,,both,,,643.70,418.40,,,,,,,,,,,,,
CLIP INT L235CM OPN 11MM WRK CHN 2.8MM LOK MECHANISM MR,SUP-2436451,CDM,2720000010,LOCAL,0272,RC,,,,both,,,522.46,339.60,,,,,,,,,,,,,
BIT DRL L8IN DIA0.125IN GRY TIP JCBS CHK END DISP,SUP-2373942,CDM,2720000010,LOCAL,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
KIT SPLNT CSTNG TCC EZ 4INW FIBERGLAS 1 PC WOVEN OP TCC24005,SUP-2194348,CDM,L4386,HCPCS,0274,RC,,,,both,,,371.96,241.77,,,,,,,,,,,,,
STENT URET 0.035 IN 6 FRX30 CM 6 FR DBL PGTL PERCFLX POLARIS,SUP-2468915,CDM,C2617,HCPCS,0278,RC,,,,both,,,578.36,375.93,,,,,,,,,,,,,
SHEATH INTRO FAST-CATH L 75 CM DIA11 FR GUIDEWIRE 0.038 IN,SUP-2355525,CDM,C1894,HCPCS,0272,RC,,,,both,,,85.57,55.62,,,,,,,,,,,,,
DRIVER SURG SH EXCEL,SUP-2255609,CDM,C1713,HCPCS,0278,RC,,,,both,,,690.80,449.02,,,,,,,,,,,,,
STEM FEM L135MM DIA14MM TIV TI HIP 12/14 NK TAPR PRI NEUT,SUP-2203497,CDM,C1776,CPT,0278,RC,,,,both,,,17646.80,11470.42,,,,,,,,,,,,,
COVER SPNL LCK WIDE ARCHON,SUP-2751694,CDM,C1713,HCPCS,0278,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
GRAFT NRV L30MM DIA1-2MM PERIPH NAT CONN CBL PROC FOR RECON,SUP-2124847,CDM,C1763,HCPCS,0278,RC,,,,both,,,14035.80,9123.27,,,,,,,,,,,,,
BLADE IM NAIL HELCL 75 MM STR FEN IMPL,SUP-2417919,CDM,C1713,HCPCS,0278,RC,,,,both,,,6550.86,4258.06,,,,,,,,,,,,,
IMPLANT HUM TISS L 35 X W 25 MM THK 4 MM ACHILLES TEND RC,SUP-2932950,CDM,C1762,CPT,0278,RC,,,,both,,,7440.10,4836.06,,,,,,,,,,,,,
VALVE AORT CARP EDW TISS ANNULUS 25MM 31MM 21MM PERICARD,SUP-2214048,CDM,C1889,HCPCS,0278,RC,,,,both,,,17301.40,11245.91,,,,,,,,,,,,,
GUIDE SURG FRAMELESS FOR NEURO NAVIGATION 6000022000] STRYKER CORP],SUP-2364148,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1355.22,880.89,,,,,,,,,,,,,
REAMER SURG DIA10MM TIB CANN COR W/ CLLRD PIN FOR TUNN GRFT,SUP-2120899,CDM,2720000010,LOCAL,0272,RC,,,,both,,,643.70,418.40,,,,,,,,,,,,,
BODY FEM DIA29MM +30MM CALCAR HIP MOD REV SYS RESTR,SUP-2375613,CDM,C1776,CPT,0278,RC,,,,both,,,10227.61,6647.95,,,,,,,,,,,,,
COLLAR CERV FOAM PADDING XTALL ADLT 4.5 IN TRNS ATLS PROCARE,SUP-2195753,CDM,L0180,HCPCS,0274,RC,,,,both,,,74.51,48.43,,,,,,,,,,,,,
PROCESSOR HEARING AID DMND BLK LT EAR DISP PONTO PRO PWR,SUP-2319880,CDM,L8690,HCPCS,0278,RC,,,,both,,,13188.00,8572.20,,,,,,,,,,,,,
SHEATH NEPHSTMY 11 FRX30CM,SUP-2141701,CDM,C1894,HCPCS,0272,RC,,,,both,,,185.39,120.50,,,,,,,,,,,,,
MESH CRAN KASSAM 0.3 MM SLD PANEL W/ HOLE REG CP TI,SUP-2498071,CDM,C1713,HCPCS,0278,RC,,,,both,,,1177.97,765.68,,,,,,,,,,,,,
SCHANZ SCREW {} 6.0MM,SUP-2820929,CDM,C1713,HCPCS,0278,RC,,,,both,,,3365.61,2187.65,,,,,,,,,,,,,
PLATE BNE L 203 MM SCREW DIA 4.5 MM 11 H SS NAR COMPR NLCK,SUP-2933496,CDM,C1713,HCPCS,0278,RC,,,,both,,,2138.72,1390.17,,,,,,,,,,,,,
SCREW BNE L5MM DIA2MM MAND CRANIOMAXILLOFACIAL SIL LOK CRSS 5PK,SUP-2366126,CDM,C1713,HCPCS,0278,RC,,,,both,,,301.06,195.69,,,,,,,,,,,,,
DEVICE RESECT 4X LAP BPLR HABIB,SUP-2118728,CDM,C1713,HCPCS,0278,RC,,,,both,,,9875.30,6418.94,,,,,,,,,,,,,
SCREW BONE L4MM DIA1.7MM CORT CRANIOMAXILLOFACIAL TI EMER W/,SUP-2189198,CDM,C1713,HCPCS,0278,RC,,,,both,,,334.10,217.16,,,,,,,,,,,,,
HGH DMD HP SYS(LG HD,SUP-2212057,CDM,C1776,CPT,0278,RC,,,,both,,,13186.87,8571.47,,,,,,,,,,,,,
PLATE STR 6H SS STRL VAL,SUP-2546091,CDM,C1713,HCPCS,0278,RC,,,,both,,,1690.20,1098.63,,,,,,,,,,,,,
STENT CORONARY MULTLNK TRI L 18 MM DIA 3 MM GUIDE CATH 0.064,SUP-2101459,CDM,C1876,HCPCS,0278,RC,,,,both,,,4926.66,3202.33,,,,,,,,,,,,,
RAIL EXT FIX TRANSITION 5.5X495 MM 4D COBALT CHROM,SUP-2517552,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7338.18,4769.82,,,,,,,,,,,,,
PERPHENAZINE 2 MG PO TABS,RX-6157,CDM,6370000000,HCPCS,0637,RC,00603-5060-21,NDC,,both,1,UN,4.20,2.73,,,,,,,,,,,,,
PACEMAKER CARD TRIL DR + 2 CHMBR NOT MRI COMPATIBLE STD,SUP-2320134,CDM,C1785,HCPCS,0275,RC,,,,both,,,15370.30,9990.69,,,,,,,,,,,,,
ANCHOR SUT CROSSFT BC 55MMX17MM W TWO NUMBER 2 HI FI SUTS,SUP-2167093,CDM,C1713,HCPCS,0278,RC,,,,both,,,1495.33,971.96,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE MATERIAL 5 CC PREFILL STRL ACCUFILL LF,SUP-2866848,CDM,C1713,HCPCS,0278,RC,,,,both,,,11114.66,7224.53,,,,,,,,,,,,,
CATHETER SUPP L150CM 15MM MRK BND SPC GWIRE 0.014IN,SUP-2173450,CDM,C1887,HCPCS,0272,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
CATHETER EP 8FR L105CM LOOP DIA15MM 3-3-3MM SPC D CRV CIR,SUP-2357571,CDM,C1732,HCPCS,0272,RC,,,,both,,,5290.90,3439.08,,,,,,,,,,,,,
RESOLVE BLRY DRNGE CTHTRS LOK 10FR 40CM 038N 17 DRNGE HOLES,SUP-2677279,CDM,C1729,HCPCS,0272,RC,,,,both,,,210.38,136.75,,,,,,,,,,,,,
CATHETER ATR 7FR L46CM OD2.3MM ID1.2MM BA STRP STYL PUDENZ,SUP-2243862,CDM,C1729,HCPCS,0272,RC,,,,both,,,355.54,231.10,,,,,,,,,,,,,
BUTTON FIX L15MM TI CONT LOOP FOR ACL RECON ENDOBTTN CL ULT,SUP-2341701,CDM,C1713,HCPCS,0278,RC,,,,both,,,1066.31,693.10,,,,,,,,,,,,,
PLATE BNE THK 0.75 MM SCREW DIA1.7 MM 1 X 21 H PLL,SUP-2883154,CDM,C1713,HCPCS,0278,RC,,,,both,,,9636.50,6263.72,,,,,,,,,,,,,
ENDCAP ORTH L10MM DIA15MM ST FEM TI NAIL SPRL BLDE EXTN LOK,SUP-2192142,CDM,C1713,HCPCS,0278,RC,,,,both,,,854.39,555.35,,,,,,,,,,,,,
SET INSTR ORTH SPHR IMPL,SUP-2399055,CDM,C1776,CPT,0278,RC,,,,both,,,30074.92,19548.70,,,,,,,,,,,,,
K WIRE FIX L160MM DIA1.1MM FOR VAR DST - ORDER MULT OF 10 EA,SUP-2368331,CDM,C1713,HCPCS,0278,RC,,,,both,,,31.40,20.41,,,,,,,,,,,,,
SPACER ORTHOPEDIC +12MM 39 MM SHLDR RVS,SUP-2123333,CDM,C1776,CPT,0278,RC,,,,both,,,1249.72,812.32,,,,,,,,,,,,,
ANTEROLATERAL PILON FUSION PLATE 7H LT,SUP-2815224,CDM,C1713,HCPCS,0278,RC,,,,both,,,11304.00,7347.60,,,,,,,,,,,,,
ALLOGRAFT BNE 17 MM INSTR PROCHONDRIX DISP,SUP-2718025,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6239.75,4055.84,,,,,,,,,,,,,
GRAFT HUM TISS W4XL8CM THK04 07MM DERM HUM ACELLULAR,SUP-2307043,CDM,Q4128,HCPCS,0636,RC,,,,both,,,4750.82,3088.03,,,,,,,,,,,,,
ANCHOR SUT DIA2.8MM TI W/ NO1 PRELD SUT TWINFIX,SUP-2341586,CDM,C1713,HCPCS,0278,RC,,,,both,,,542.91,352.89,,,,,,,,,,,,,
RING EXT FIX CIR 5/8 180 MM SIDEKCK,SUP-2851274,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1780.38,1157.25,,,,,,,,,,,,,
BIT DRL DIA6.5MM GLIDING H CANN FOR 6.5MM SCR FLOWERCUBE,SUP-2225314,CDM,2720000010,LOCAL,0272,RC,,,,both,,,759.63,493.76,,,,,,,,,,,,,
FLUPHENAZINE HCL 2.5 MG PO TABS,RX-3220,CDM,6370000000,HCPCS,0637,RC,70954-0274-10,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
CLIP SURG L155CM CHN DIA2.8MM OPN W11IN RESOL 360 1/BX,SUP-2141392,CDM,2720000010,LOCAL,0272,RC,,,,both,,,750.46,487.80,,,,,,,,,,,,,
SUPPORT ORTHOT FT METATRSL ARCH ATTCH TO SHOE LONGITUDINAL,SUP-2435709,CDM,L3090,HCPCS,0272,RC,,,,both,,,115.24,74.91,,,,,,,,,,,,,
GUIDEWIRE ORTH L750MM DIA3MM DRV BLNT BALL TIP GAM,SUP-2371036,CDM,C1769,HCPCS,0272,RC,,,,both,,,487.96,317.17,,,,,,,,,,,,,
RING EXT FIX DIA275 MM FULL NS DISP TAY SPAT FRME,SUP-2932783,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7891.32,5129.36,,,,,,,,,,,,,
MAGNESIUM OXIDE -MG SUPPLEMENT 400 (240 MG) MG PO TABS,RX-118293,CDM,6370000000,HCPCS,0637,RC,10006-0700-28,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
STEM FEM SZ 0 L105MM 130DEG CO CHROM POR BILAT SH NK CEM,SUP-2210811,CDM,C1776,CPT,0278,RC,,,,both,,,10030.42,6519.77,,,,,,,,,,,,,
PRESSURIZER BONE CEM L PROX FEM CNL W/O HUB FOR HI VAC INJ,SUP-2361847,CDM,C1713,HCPCS,0278,RC,,,,both,,,60.16,39.10,,,,,,,,,,,,,
TRAY PNEUMOPERICARDIAL DRNGE CATH 8FR L15CM NDL 18GA L7CM,SUP-2171104,CDM,C1729,HCPCS,0272,RC,,,,both,,,608.85,395.75,,,,,,,,,,,,,
CATHETER HAD AD 14FR L20CM ADMIN BASIC KT DBL LUMN POLYUR,SUP-2266969,CDM,C1752,HCPCS,0278,RC,,,,both,,,248.06,161.24,,,,,,,,,,,,,
GRAFT BNE SUB 7.2CC W15XL50MM MINERALIZED CLLGN SCFLD,SUP-2138524,CDM,C9362,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
PLATE BNE L66MM 4 H NAR 2 COMPR FOR 45MM SCR,SUP-2411387,CDM,C1713,HCPCS,0278,RC,,,,both,,,351.90,228.73,,,,,,,,,,,,,
GUIDEWIRE VASC TREASURE 12 L 300 CM DIA 0.018 IN RADIOPAQUE,SUP-2123849,CDM,C1769,HCPCS,0272,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
STEM FEM LT N CLLRD POR HA NAT HIP SZ 2,SUP-2210785,CDM,C1776,CPT,0278,RC,,,,both,,,15368.73,9989.67,,,,,,,,,,,,,
TIGHTROPE II BTB RECON IB,SUP-2811991,CDM,C1713,HCPCS,0278,RC,,,,both,,,2025.30,1316.44,,,,,,,,,,,,,
CATHETER ART DL 0.025 IN 7 FRX110 CM MONITORING,SUP-2798491,CDM,C1727,CPT,0278,RC,,,,both,,,88.36,57.43,,,,,,,,,,,,,
TUBE JEJUNOSTOMY 9 FRX27 IN SIL 319] BARD PERIPHERAL VASCULAR],SUP-2127814,CDM,C1713,HCPCS,0278,RC,,,,both,,,326.56,212.26,,,,,,,,,,,,,
ANCHOR SUT OD4.5MM BIOCOMP W/ 1 STRND O INSITE FT,SUP-2315931,CDM,C1713,HCPCS,0278,RC,,,,both,,,2323.60,1510.34,,,,,,,,,,,,,
T PLATE OBLIQUE SMALL,SUP-2820885,CDM,C1713,HCPCS,0278,RC,,,,both,,,1967.59,1278.93,,,,,,,,,,,,,
PLATE BNE ADV 10 MM SCREW DIA2 MM MINI LT,SUP-2883160,CDM,C1713,HCPCS,0278,RC,,,,both,,,2040.78,1326.51,,,,,,,,,,,,,
PLATE BNE 5 H CRANIO FACE N COMPR L R RIG FOR 2MM SCR H,SUP-2366323,CDM,C1713,HCPCS,0278,RC,,,,both,,,725.81,471.78,,,,,,,,,,,,,
PLATE BNE L292MM 18 H NONSTERILE R ANTLAT DST TIB S STL VAR,SUP-2177694,CDM,C1713,HCPCS,0278,RC,,,,both,,,7134.14,4637.19,,,,,,,,,,,,,
PLATE BONE DOUBLE ANGLE THICK 2 MM MANDIBLE PATIENT SPECIFIC,SUP-2838605,CDM,C1713,HCPCS,0278,RC,,,,both,,,29796.09,19367.46,,,,,,,,,,,,,
BUNDLE CASE SINGLE STG CRAN VSP,SUP-2862824,CDM,2720000010,LOCAL,0272,RC,,,,both,,,32861.58,21360.03,,,,,,,,,,,,,
SHAVER SURG MIC TUBESET HK MIS NEXUS BONESCALPEL,SUP-2745902,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2385.21,1550.39,,,,,,,,,,,,,
PREM ST/G7 CP/E1 AA DM LN/STD,SUP-2212431,CDM,C1776,CPT,0278,RC,,,,both,,,16745.62,10884.65,,,,,,,,,,,,,
CATHETER HD RETROGRADE 23 CM CHRONIC REPL HUB ARW NEXTSTEP,SUP-2627066,CDM,C1750,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
ROD SPNL L95MM DIA6.35MM R ANT TI SMOOTH PRECRV MNRCH,SUP-2254475,CDM,C1713,HCPCS,0278,RC,,,,both,,,1234.40,802.36,,,,,,,,,,,,,
INTRODUCER SHTH L66CM DIA55FR RENAL TELSCP WORLEY ADV LVI,SUP-2303516,CDM,C1892,HCPCS,0272,RC,,,,both,,,1469.52,955.19,,,,,,,,,,,,,
HC So Fungus Culture Skin,PX-3008710166,CDM,87101,CPT,0300,RC,,,,outpatient,,,112.00,72.80,,,,,,,,,,,,,
FIBER LASER L12FT DIA0.6MM SMARTCONNECTOR TECHNOLOGY FOR FLEX,SUP-2138858,CDM,C1713,HCPCS,0278,RC,,,,both,,,967.12,628.63,,,,,,,,,,,,,
BUR SURG L 95 MM DIA2.35 MM HD DIA 4.5 MM DIAMOND NS REUSE,SUP-2929039,CDM,2720000010,LOCAL,0272,RC,,,,both,,,468.43,304.48,,,,,,,,,,,,,
DRILL SURG W/ STP LCK SCREW NS LTX,SUP-2861398,CDM,2720000010,LOCAL,0272,RC,,,,both,,,504.54,327.95,,,,,,,,,,,,,
SPLINT ORTH NT ANK FT,SUP-2388199,CDM,L4397,HCPCS,0274,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
PROXIMAL LAT TIB PLATE LEFT 14 HOLE,SUP-2829403,CDM,C1713,HCPCS,0278,RC,,,,both,,,8148.30,5296.39,,,,,,,,,,,,,
HC Endo Level 3 Base 15 Min,PX-3600007503,CDM,3600007503,LOCAL,0360,RC,,,,both,,,4659.00,3028.35,,,,,,,,,,,,,
GRAFT BNE FRZN PROX FEM HD IMPL ALLGRFT MATRIGRFT,SUP-2264784,CDM,C1713,HCPCS,0278,RC,,,,both,,,13358.85,8683.25,,,,,,,,,,,,,
PLATE BNE 3.5X69 MM POSTEROMEDIAL PROX TIB STRL LCP,SUP-2432242,CDM,C1713,HCPCS,0278,RC,,,,both,,,3648.15,2371.30,,,,,,,,,,,,,
GRAFT BNE H10MM UNICORTICAL CANC SPCR PARA FRZ DRY MATRIGRFT,SUP-2264699,CDM,C1713,HCPCS,0278,RC,,,,both,,,2157.18,1402.17,,,,,,,,,,,,,
PLATE BNE L20MM S STL FT 4 H COMPR FOR 3.5MM SCR CHARLOTTE,SUP-2397368,CDM,C1713,HCPCS,0278,RC,,,,both,,,2615.62,1700.15,,,,,,,,,,,,,
SHEATH INTRO PINNACLE DESTINATION 45CM 6FR COAT 35CM XCUT,SUP-2385455,CDM,C1894,HCPCS,0272,RC,,,,both,,,347.82,226.08,,,,,,,,,,,,,
INSERT TIB SZ 6-7 THK11MM LT KNEE HNG GUID MOTN LEGION,SUP-2346690,CDM,C1776,CPT,0278,RC,,,,both,,,7165.48,4657.56,,,,,,,,,,,,,
PLATE BNE TIB MEDL 2 HOLE NS LTX,SUP-2857070,CDM,C1713,HCPCS,0278,RC,,,,both,,,8066.66,5243.33,,,,,,,,,,,,,
GUIDEWIRE VASC L260CM DIA0.035IN 7.5MM TIP PTFE S STL COR,SUP-2355723,CDM,C1769,HCPCS,0272,RC,,,,both,,,182.87,118.87,,,,,,,,,,,,,
SCREW BNE SCHNZ 3 MM,SUP-2150262,CDM,C1713,HCPCS,0278,RC,,,,both,,,87.92,57.15,,,,,,,,,,,,,
PLATE BNE FIBULAR 7 HOLE COMP LCK STRL ALPS LTX,SUP-2861800,CDM,C1713,HCPCS,0278,RC,,,,both,,,601.56,391.01,,,,,,,,,,,,,
BUR SURG OD4.5MM CUT RND FLUT STRL TIP FOR SHANK ELITE,SUP-2364010,CDM,2720000010,LOCAL,0272,RC,,,,both,,,434.36,282.33,,,,,,,,,,,,,
SHEATH INTRO PRELUDE IDEAL L 11 CM DIA 45 CM 0.021 IN 5 FR,SUP-2740586,CDM,C1892,HCPCS,0272,RC,,,,both,,,174.74,113.58,,,,,,,,,,,,,
ALLOGRAFT BNE MATCHSTICK SM 60X3-6 MM CORTICAL CANC 18A006,SUP-2866840,CDM,C1762,CPT,0278,RC,,,,both,,,1774.89,1153.68,,,,,,,,,,,,,
SPACER SPNL 3 MM SFS,SUP-2601816,CDM,C1713,HCPCS,0278,RC,,,,both,,,204.10,132.66,,,,,,,,,,,,,
GRAFT BNE MORSL MED 6 CC FIBERGRAFT BG,SUP-2736515,CDM,C1713,HCPCS,0278,RC,,,,both,,,4804.20,3122.73,,,,,,,,,,,,,
CABLE SPNL DIA1MM S STL SGL W/ LEADER 1 CINCH AND TIGHTENER,SUP-2257003,CDM,C1713,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
PLATE BNE L 50 MM 10 H SCREW DIA2.7 MM BROAD LCK T8 FOR MINI,SUP-2900597,CDM,C1713,HCPCS,0278,RC,,,,both,,,4634.64,3012.52,,,,,,,,,,,,,
KIT THR HIP LO DEMAND FRAC UPLR PROS,SUP-2212086,CDM,C1776,CPT,0278,RC,,,,both,,,5052.64,3284.22,,,,,,,,,,,,,
PLATE BNE BROAD 3.5X211 MM 16 HOLE SS LCP,SUP-2569342,CDM,C1713,HCPCS,0278,RC,,,,both,,,563.00,365.95,,,,,,,,,,,,,
WIRE EXT FIX L400MM DIA1.8MM SMOOTH MRI SAFE FOR DISTR,SUP-2179128,CDM,C1713,HCPCS,0278,RC,,,,both,,,217.54,141.40,,,,,,,,,,,,,
SCREW BNE L4MM DIA1.3MM CORT CRANIOMAXILLOFACIAL SIL TI,SUP-2189063,CDM,C1713,HCPCS,0278,RC,,,,both,,,333.66,216.88,,,,,,,,,,,,,
SCREW BONE L65MM THRD DIA2.4MM HD DIA3.8MM COR DIA1.6MM,SUP-2349429,CDM,C1713,HCPCS,0278,RC,,,,both,,,743.18,483.07,,,,,,,,,,,,,
PLATE EXT FIX L 75 MM 6 H SHRT CONN OVL SLOT NS DISP ILIZ,SUP-2933393,CDM,2720000010,LOCAL,0272,RC,,,,both,,,634.91,412.69,,,,,,,,,,,,,
KIT INSERTION INTRA-AORTIC CATH 8FR 40ML 0.25IN GUIDEWIRE 6IN INTRO,SUP-2876891,CDM,C1769,HCPCS,0272,RC,,,,both,,,3579.60,2326.74,,,,,,,,,,,,,
FIBER LASER OTO-M OMNIGUIDE,SUP-2225613,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
GUIDEWIRE VASC L 150 CM DIA 0.035 IN TIP L 3 MM PTFE HEPARIN,SUP-2301942,CDM,C1769,HCPCS,0272,RC,,,,both,,,25.91,16.84,,,,,,,,,,,,,
GRAFT BNE SUB 5CC DBX MIX FRZ DRY FOR VOID FILL,SUP-2307002,CDM,C9359,HCPCS,0278,RC,,,,both,,,2620.64,1703.42,,,,,,,,,,,,,
CATHETER GUID 8FR L150CM GUID SEG L25CM PLAT IRIDIUM HELCL,SUP-2140878,CDM,C1887,HCPCS,0272,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
GRAFT BNE 5ML DEMIN BNE MTRX PTY INTERGRO,SUP-2414010,CDM,C9359,HCPCS,0278,RC,,,,both,,,2712.96,1763.42,,,,,,,,,,,,,
BOOT CAST L TOT CNTCT SYS TCC-EZ,SUP-2244448,CDM,L4387,HCPCS,0274,RC,,,,both,,,355.39,231.00,,,,,,,,,,,,,
SCREW BNE L95MM DIA5MM CANN LOK,SUP-2184923,CDM,C1713,HCPCS,0278,RC,,,,both,,,621.09,403.71,,,,,,,,,,,,,
COMPONENT FEM POST STBL L MED LAT 70MM ANT POST 67MM PROVEN,SUP-2390421,CDM,C1776,CPT,0278,RC,,,,both,,,11304.00,7347.60,,,,,,,,,,,,,
CRYOABLATION KIT CLARIFIX DISP,SUP-2419520,CDM,C2618,HCPCS,0272,RC,,,,both,,,6036.02,3923.41,,,,,,,,,,,,,
SET DRNAGE 16FR L18CM 0038IN LOK LOOP SUMP TO DRN,SUP-2168260,CDM,C1729,HCPCS,0272,RC,,,,both,,,495.34,321.97,,,,,,,,,,,,,
SCREW BNE EMGCY 2X7 MM CRUCFRM HD FT ST FLUT TIP TI NS,SUP-2189256,CDM,C1713,HCPCS,0278,RC,,,,both,,,243.10,158.01,,,,,,,,,,,,,
GRAFT BIO TISS W10XL16CM THK18 4MM ACELLULAR DERM MTRX ULT,SUP-2307480,CDM,Q4128,HCPCS,0636,RC,,,,both,,,14253.81,9264.98,,,,,,,,,,,,,
SET URET STENT C FLX L 8-20 CM DIA 3.7 FR GUIDEWIRE 0.038 IN,SUP-2168935,CDM,C2617,HCPCS,0278,RC,,,,both,,,346.66,225.33,,,,,,,,,,,,,
SCREW BONE 2MM DIA 12MML STNLSS STEEL MXDRVE 8MM THRDD FMLT,SUP-2681179,CDM,C1713,HCPCS,0278,RC,,,,both,,,312.40,203.06,,,,,,,,,,,,,
ANCHOR SUT 50MM LOOP VERSITOMIC G LOK,SUP-2366637,CDM,C1713,HCPCS,0278,RC,,,,both,,,1232.04,800.83,,,,,,,,,,,,,
MESH HERN REP W15XL20CM RECT LAP,SUP-2717686,CDM,C1781,HCPCS,0278,RC,,,,both,,,3345.10,2174.31,,,,,,,,,,,,,
SCREW BNE OD1.5MM L4MM CORT TI ST MIC N LOK NSTERILE CRANIO,SUP-2262609,CDM,C1713,HCPCS,0278,RC,,,,both,,,138.16,89.80,,,,,,,,,,,,,
SD BLADE 2.7MM MD,SUP-2678834,CDM,2720000010,LOCAL,0272,RC,,,,both,,,484.44,314.89,,,,,,,,,,,,,
MESH BONE 287MMW X 287MML 03MM THK RSRB X LG GRID LATEX F,SUP-2669263,CDM,C1713,HCPCS,0278,RC,,,,both,,,1291.51,839.48,,,,,,,,,,,,,
GRAFT HUM TISS W10XL19MM MT LENGTHENING DISC,SUP-2321676,CDM,C1776,CPT,0278,RC,,,,both,,,7473.20,4857.58,,,,,,,,,,,,,
TRAY PICC SUBCL 2/L 5FR 45CML SIL RADPQ SHERLOCK MAG 9827505,SUP-2632708,CDM,C1751,HCPCS,0278,RC,,,,both,,,385.40,250.51,,,,,,,,,,,,,
CATHETER THROMCTMY OASIS L 65 CM DIA 6 FR STRL,SUP-2141171,CDM,C1757,HCPCS,0272,RC,,,,both,,,1818.06,1181.74,,,,,,,,,,,,,
CAP END PLUS ANKLE 10MM PHOENIX,SUP-2485267,CDM,C1889,HCPCS,0278,RC,,,,both,,,483.56,314.31,,,,,,,,,,,,,
SPACER SPNL 15-30 DEG 65X20X11-20 MM ELSA,SUP-2732455,CDM,C1889,HCPCS,0278,RC,,,,both,,,29202.00,18981.30,,,,,,,,,,,,,
ALLOGRAFT BNE STRP 20X40 MM PRESERVON STRUCTURAL ORAGRAFT,SUP-2745099,CDM,C1713,HCPCS,0278,RC,,,,both,,,1765.87,1147.82,,,,,,,,,,,,,
COMPONENT TIB STEMMABLE 1 KNEE FLUT STEM MOB PC NEGEN,SUP-2200827,CDM,C1776,CPT,0278,RC,,,,both,,,8886.20,5776.03,,,,,,,,,,,,,
ELECTRODE ES OD24 28FR 12 30DEG BRL MPLR DISPOSABLE,SUP-2312911,CDM,C1713,HCPCS,0278,RC,,,,both,,,455.05,295.78,,,,,,,,,,,,,
PACEMAKER CARD PACE 101H SZ 45 X 60 X 115 X 20 MM 6.5 OZ,SUP-2616258,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5730.50,3724.82,,,,,,,,,,,,,
PLATE BNE THK1MM 6X2 H BLU MAND TI 3D CRV FOR LEIBINGER,SUP-2366348,CDM,C1713,HCPCS,0278,RC,,,,both,,,1251.29,813.34,,,,,,,,,,,,,
PLATE BNE L77MM THK3.3MM 6 H BILAT S STL STR LIMIT CNTCT,SUP-2185131,CDM,C1713,HCPCS,0278,RC,,,,both,,,898.32,583.91,,,,,,,,,,,,,
PLATE BNE THK 0.8 MM SCREW DIA1.7 MM 4 H LG TI GRA,SUP-2883633,CDM,C1713,HCPCS,0278,RC,,,,both,,,863.22,561.09,,,,,,,,,,,,,
PLATE 4 H 2.3 TRAUM MOD TI 1.5MM LNG,SUP-2262997,CDM,C1713,HCPCS,0278,RC,,,,both,,,802.02,521.31,,,,,,,,,,,,,
GUIDEWIRE VASC ARW L 45 CM DIA 0.025 IN SS PERIPH SFT,SUP-2383359,CDM,C1769,HCPCS,0272,RC,,,,both,,,30.14,19.59,,,,,,,,,,,,,
STAPLE BNE FIX SZ 45 X 14 X 11 MM LG TI ALLOY RAPID COMPR,SUP-2908955,CDM,C1713,HCPCS,0278,RC,,,,both,,,11671.38,7586.40,,,,,,,,,,,,,
GRAFT VASC L80CM ID4 7MM PTFE STD WALLED TAPR NONRINGED,SUP-2395786,CDM,C1768,CPT,0278,RC,,,,both,,,6873.46,4467.75,,,,,,,,,,,,,
BUR SURG UNIV TAPR NONFLUTED,SUP-2252816,CDM,C1713,HCPCS,0278,RC,,,,both,,,609.16,395.95,,,,,,,,,,,,,
KIT LAPSCP UTER PROLAPSE SUT PASS LIGMNT GRSP KNOT PUSH,SUP-2171753,CDM,C1713,HCPCS,0278,RC,,,,both,,,2590.50,1683.82,,,,,,,,,,,,,
TUBE TYMPANOSTOMY DIA1.24 MM INNR FLANGE DIA2.65 MM BLU,SUP-2901985,CDM,L8699,HCPCS,0278,RC,,,,both,,,94.55,61.46,,,,,,,,,,,,,
GRAFT VASC GORTX L 10 CM DIA 5 MM EPTFE TW PED SHUNT STRL,SUP-2396686,CDM,C1768,CPT,0278,RC,,,,both,,,879.20,571.48,,,,,,,,,,,,,
BIT DRL CANN 2X115 MM QC,SUP-2221711,CDM,2720000010,LOCAL,0272,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
"HC Gbl Est Pt, E/M Level 3",PX-9829921300,CDM,99213,CPT,0982,RC,,,,inpatient,,,393.00,255.45,,,,,,,,,,,,,
HC So Npm1 Gene Analysis,PX-3108131066,CDM,81310,CPT,0310,RC,,,,both,,,318.00,206.70,,,,,,,,,,,,,
PLATE BLADE ANGL 130 DEG 9H /70MM/152MM,SUP-2547722,CDM,C1713,HCPCS,0278,RC,,,,both,,,2241.52,1456.99,,,,,,,,,,,,,
STRAP SPLNT NYL WHT 2INX14IN ROLYAN D RNG,SUP-2324780,CDM,L3908,HCPCS,0274,RC,,,,both,,,9.11,5.92,,,,,,,,,,,,,
PLATE B1 STP 0 MM CROSSCHECK NS ORTHOLOC 3DI,SUP-2900547,CDM,C1713,HCPCS,0278,RC,,,,both,,,10657.16,6927.15,,,,,,,,,,,,,
STRAP ORTH W3XL4IN STD M FOAM COT MTL TOOTH CLAV BCKL CLSR,SUP-2276601,CDM,L3650,HCPCS,0272,RC,,,,both,,,22.26,14.47,,,,,,,,,,,,,
OSS 7CM OSSEOTI PROX TIB SLV,SUP-2506334,CDM,C1776,CPT,0278,RC,,,,both,,,11934.20,7757.23,,,,,,,,,,,,,
VALVE SHUNT CTRL FLO BUTTON PRESSURE LO,SUP-2628268,CDM,C1889,HCPCS,0278,RC,,,,both,,,2690.35,1748.73,,,,,,,,,,,,,
PLATE BONE SHAFT 146MML HLX10 STRGHT NRRW NON CNTCT BRDGE PO,SUP-2721083,CDM,C1713,HCPCS,0278,RC,,,,both,,,1728.38,1123.45,,,,,,,,,,,,,
PLATE BNE L 43.2 X W 11.4 MM THK 1.6 MM SCREW DIA2/2.3 MM,SUP-2936891,CDM,C1713,HCPCS,0278,RC,,,,both,,,2213.70,1438.90,,,,,,,,,,,,,
PLATE BNE CABLE DBL,SUP-2101216,CDM,C1713,HCPCS,0278,RC,,,,both,,,2363.04,1535.98,,,,,,,,,,,,,
GUIDEWIRE ORTH DIA2 MM FLARE CUSTER LCK NS REUSE,SUP-2885139,CDM,C1769,HCPCS,0272,RC,,,,both,,,1455.39,946.00,,,,,,,,,,,,,
CADDY SCR POLYAX 3.5X34 MM VA VIRAGE,SUP-2684938,CDM,C1713,HCPCS,0278,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
NEEDLE ASPIR 25 GAX80 MM ROUNDED W/O A SIDE HOLE EZ SHOT 3 +,SUP-2460303,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1670.48,1085.81,,,,,,,,,,,,,
CATHETER EXTR DBL LUMN 6FRX14CM,SUP-2260396,CDM,C1887,HCPCS,0272,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
MIKAEEL 10 STRONG SICKLE KNIFE 26CM TTL,SUP-2707305,CDM,2720000010,LOCAL,0272,RC,,,,both,,,844.97,549.23,,,,,,,,,,,,,
GUIDEWIRE ORTH L 16 IN DIA2.8 MM LG TROCAR TIP STRL DISP,SUP-2934252,CDM,C1769,HCPCS,0272,RC,,,,both,,,373.66,242.88,,,,,,,,,,,,,
TRAY EPIDURAL CATH DIA20 GA NDL DIA18 GA CE18TKON 1 FULL,SUP-2936473,CDM,2720000010,LOCAL,0272,RC,,,,both,,,79.22,51.49,,,,,,,,,,,,,
HEAD UPLR DIA38MM 6DEG FEM HIP CO CHROM,SUP-2204170,CDM,C1776,CPT,0278,RC,,,,both,,,1489.93,968.45,,,,,,,,,,,,,
PLATE BN DR 2.4/2.7 VA LCP 2C STD 6H HD 13HSFT 186MM RT STER,SUP-2546049,CDM,C1713,HCPCS,0278,RC,,,,both,,,5128.47,3333.51,,,,,,,,,,,,,
SPLINT FNGR M W075XL18IN ALUMINUM MAL,SUP-2276739,CDM,L3933,HCPCS,0272,RC,,,,both,,,3.01,1.96,,,,,,,,,,,,,
SYNPOR SMOOTH SQUARE SHEET,SUP-2823308,CDM,C1713,HCPCS,0278,RC,,,,both,,,1784.78,1160.11,,,,,,,,,,,,,
SCREW CRNIO MXLFCL 1.5MM DIA 11MML TTNM BMT MCRFXTN,SUP-2587862,CDM,C1713,HCPCS,0278,RC,,,,both,,,1914.11,1244.17,,,,,,,,,,,,,
BLADE SAW 91.2X40.5X0.38 MM RECIP THN EXT STRL PRECIS LTX,SUP-2862503,CDM,2720000010,LOCAL,0272,RC,,,,both,,,398.87,259.27,,,,,,,,,,,,,
NAIL IM L380MM DIA13MM LT GRN L LAT FEM TI CANN LOK CRV,SUP-2179774,CDM,C1713,HCPCS,0278,RC,,,,both,,,5032.82,3271.33,,,,,,,,,,,,,
WIRE GUIDE.FLEXIBLE.F/27090A,SUP-2574042,CDM,C1769,HCPCS,0272,RC,,,,both,,,104.06,67.64,,,,,,,,,,,,,
STEM ULN SZ 4 L75MM RT CEM CONSTRN NEXEL,SUP-2135759,CDM,C1776,CPT,0278,RC,,,,both,,,16227.52,10547.89,,,,,,,,,,,,,
SHELL ACET PRESSFIT PRI 48 MM OD UNIV CLUS H,SUP-2210277,CDM,C1776,CPT,0278,RC,,,,both,,,5939.31,3860.55,,,,,,,,,,,,,
MESH HERN 13.2X10.2 IN ABD W/ ECHO PS POS SYS COMPOSIX L/P,SUP-2126097,CDM,C1781,HCPCS,0278,RC,,,,both,,,5815.28,3779.93,,,,,,,,,,,,,
BUR NEUROSURGICAL CUT RND FLUT S STL TAPR 11MM 160MM,SUP-2284385,CDM,C1713,HCPCS,0278,RC,,,,both,,,279.43,181.63,,,,,,,,,,,,,
ENVELOPE DEFIB BIOENVELOPE 2XL SINGLE PK STRL,SUP-2138482,CDM,C1713,HCPCS,0278,RC,,,,both,,,4239.00,2755.35,,,,,,,,,,,,,
TRAY KYPHOPLASTY SZ 2 BLLN L10MM IBT ADD FRAC KYPHON EXPR,SUP-2293637,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
INSERT SHOE PART FT,SUP-2388200,CDM,L5000,HCPCS,0272,RC,,,,both,,,1465.03,952.27,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY ESOPHASTAR L 125 CM DIA 8 FR BLU,SUP-2248921,CDM,C1732,HCPCS,0278,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
KIT INTRO SHTH DIA9FR PERC HI FLO BONDED ATRAUM VLV,SUP-2272867,CDM,C1894,HCPCS,0272,RC,,,,both,,,129.81,84.38,,,,,,,,,,,,,
VALVE VENT L36MM DIA13MM THK6MM REG PERF LEV 1 DELT,SUP-2284516,CDM,C1889,HCPCS,0278,RC,,,,both,,,3473.56,2257.81,,,,,,,,,,,,,
PLATE BNE L 220 X W 10.2 MM THK 2.8 MM SCREW DIA 3.5 MM 20 HL,SUP-2936833,CDM,C1713,HCPCS,0278,RC,,,,both,,,3444.42,2238.87,,,,,,,,,,,,,
PATCH CV XENOSURE L 14 X W 8 CM BOV PERICARD BIOLOGIC UNIF,SUP-2264302,CDM,C1713,HCPCS,0278,RC,,,,both,,,2540.26,1651.17,,,,,,,,,,,,,
HEAD HUM H15MM DIA40MM CO CHROME ECC PRI GLOB AP,SUP-2249979,CDM,C1776,CPT,0278,RC,,,,both,,,5522.00,3589.30,,,,,,,,,,,,,
KIT PLEUR DRNGE COMPLT INSRT TY CATHETER 5 DRNGE 5 DSG KT,SUP-2301575,CDM,C1729,HCPCS,0272,RC,,,,both,,,3611.00,2347.15,,,,,,,,,,,,,
SOLUTION IV 500ML 20% D,SUP-2106281,CDM,C1713,HCPCS,0278,RC,,,,both,,,533.80,346.97,,,,,,,,,,,,,
SIGMOIDOSCOPE FLX W/ OBTURATOR GRP STRL DISP,SUP-2800975,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1243.44,808.24,,,,,,,,,,,,,
DEFIBRILLATOR CRD BPLR 74X50X14 MM VENTRIC RST ATLAS+ VR,SUP-2356528,CDM,C1722,HCPCS,0275,RC,,,,both,,,67510.00,43881.50,,,,,,,,,,,,,
AUGMENT ACET OD62MM ID64MM THK15MM 6 H TRITANIUM BULK FOAM,SUP-2363289,CDM,C1776,CPT,0278,RC,,,,both,,,5101.87,3316.22,,,,,,,,,,,,,
SCREW BNE L22MM DIA2.7MM MTPHSEAL S STL ST FULL THRD T8,SUP-2177753,CDM,C1713,HCPCS,0278,RC,,,,both,,,139.60,90.74,,,,,,,,,,,,,
RESERVOIR PERF R-14 SEAMLESS BLDR ECMO,SUP-2500318,CDM,2720000010,LOCAL,0272,RC,,,,both,,,847.80,551.07,,,,,,,,,,,,,
PIN FIX HIP AGG PK ODYSSEY,SUP-2304615,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
ALLOGRAFT BNE FEM SHFT 26-50 MMX0.3 CM FRZN,SUP-2717851,CDM,C1762,CPT,0278,RC,,,,both,,,3590.90,2334.08,,,,,,,,,,,,,
GRAFT HUM TISS  164 SQ CM THK0.8-1.2MM THN L PERF CNTOUR ACELLULAR DERM,SUP-2113434,CDM,Q4116,HCPCS,0636,RC,,,,both,,,19744.32,12833.81,,,,,,,,,,,,,
PEG BNE FIX FEM REPL DURAC,SUP-2377156,CDM,C1713,HCPCS,0278,RC,,,,both,,,1077.65,700.47,,,,,,,,,,,,,
SPLINT WR PED M THK1/8IN LT WRP ARND DSGN D RNG STRP ROLYAN,SUP-2324210,CDM,L3809,HCPCS,0274,RC,,,,both,,,51.68,33.59,,,,,,,,,,,,,
PLATE NEURO T 6L 4V TTNM ALLOY ULTRA LOW PRFLE STRGHT WTAB,SUP-2676568,CDM,C1713,HCPCS,0278,RC,,,,both,,,449.49,292.17,,,,,,,,,,,,,
DRILL SURG 2 TRIGGER MOD HALL TITAN,SUP-2607717,CDM,2720000010,LOCAL,0272,RC,,,,both,,,26682.15,17343.40,,,,,,,,,,,,,
STEM FEM L150MM OD12.5MM BOW TI POR IM REV NEUT MOD LNG,SUP-2405742,CDM,C1776,CPT,0278,RC,,,,both,,,5298.75,3444.19,,,,,,,,,,,,,
INTRODUCER SHTH WORLEY-JUMBO 9 FRX50 CM DIL SAFSHTH CSG,SUP-2282364,CDM,C1892,HCPCS,0272,RC,,,,both,,,1208.90,785.78,,,,,,,,,,,,,
RETRACTOR SURG W12XH8MMXL3CM SELF RET MEDL OR LAT BLNT,SUP-2393985,CDM,C1894,HCPCS,0272,RC,,,,both,,,1868.30,1214.39,,,,,,,,,,,,,
CALCAR C BODY 40X55MM STANDARD OFFSET,SUP-2505271,CDM,C1776,CPT,0278,RC,,,,both,,,11228.64,7298.62,,,,,,,,,,,,,
STEM FEM L100MM OD16MM UNIV STD TI KNEE REV CEM FLUT STR,SUP-2406965,CDM,C1776,CPT,0278,RC,,,,both,,,3553.38,2309.70,,,,,,,,,,,,,
TRIAL SHLDR 36MM -4MM YEL TI GLEN HD,SUP-2197202,CDM,2720000010,LOCAL,0272,RC,,,,both,,,580.90,377.58,,,,,,,,,,,,,
CATHETER BLLN DIL L7MM DIA7MM MAX EM SKR NUVENT,SUP-2284351,CDM,C1726,HCPCS,0272,RC,,,,both,,,1647.24,1070.71,,,,,,,,,,,,,
SET CBL GRP SM DIA1.6MM VIT FOR HOWMEDICA OSTEONICS DALL-M,SUP-2377560,CDM,C1776,CPT,0278,RC,,,,both,,,2157.81,1402.58,,,,,,,,,,,,,
PLATE BNE THK 1.4 MM SCREW DIA2.2 MM 8 H MAXILLOFCL CRV,SUP-2909569,CDM,C1713,HCPCS,0278,RC,,,,both,,,979.62,636.75,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED STD FEM TIB FLX OPT CEM SURF,SUP-2212244,CDM,C1776,CPT,0278,RC,,,,both,,,13032.19,8470.92,,,,,,,,,,,,,
METHADONE HCL 5 MG PO TABS,RX-4954,CDM,6370000000,HCPCS,0637,RC,00406-5755-23,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PIN EXT FIX PRE DRL 3X20 MM,SUP-2862038,CDM,C1713,HCPCS,0278,RC,,,,both,,,252.27,163.98,,,,,,,,,,,,,
CYCLOSPORINE MODIFIED 100 MG PO CAPS,RX-28843,CDM,J7502,HCPCS,0636,RC,60505-4632-03,NDC,,both,1,UN,19.80,12.87,,,,,,,,,,,,,
DORZOLAMIDE HCL 2 % OP SOLN,RX-14471,CDM,6370000000,HCPCS,0637,RC,24208-0485-10,NDC,,both,10,ML,153.00,99.45,,,,,,,,,,,,,
PROBE SUCT L45CM DIA5MM OUTER SHTH REPL REPOSABLE DISPOSABLE,SUP-2361203,CDM,C1894,HCPCS,0272,RC,,,,both,,,119.92,77.95,,,,,,,,,,,,,
HC Plmt Biliary Drainage Cath Internal-External,PX-3614753400,CDM,47534,CPT,0361,RC,,,,inpatient,,,6875.00,4468.75,,,,,,,,,,,,,
BROACH GREAT TOE L CANN INSTR KT LPT,SUP-2397196,CDM,C1776,CPT,0278,RC,,,,both,,,1466.38,953.15,,,,,,,,,,,,,
DRILL SURG FOR 1.7MMXL SUTFIX CVD FLEX SUT ANCHR,SUP-2341939,CDM,C1713,HCPCS,0278,RC,,,,both,,,1759.53,1143.69,,,,,,,,,,,,,
CATHETER PICC 4FR GWIRE L70CM POLYUR NIT GWIRE,SUP-2125533,CDM,C1751,HCPCS,0278,RC,,,,both,,,264.23,171.75,,,,,,,,,,,,,
SPACER SPNL 2.5X7-7.5 MM FOR SCR TI MALIBU,SUP-2707656,CDM,C1889,HCPCS,0278,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
MARKER PRB SET 4 PALPATOR XIA,SUP-2734609,CDM,2720000010,LOCAL,0272,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
ADAPTER PACEMKR LD L47CM DIA32MM BPLR IS 1 CONN SIL INSUL LO,SUP-2355668,CDM,C1883,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
BIT DRL DIA10MM HLLW FOR MULTILOC HUM NAILING SYS,SUP-2178934,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1079.16,701.45,,,,,,,,,,,,,
SNARE VASC PET PLT RADPQ MRK BND STRAIN RELF HUB EVAR 1 SNR,SUP-2303142,CDM,C1773,HCPCS,0272,RC,,,,both,,,832.10,540.86,,,,,,,,,,,,,
HC Pt Vasopneumatic Device Therapy|OP PT SERVICES|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS,PX-4209701600,CDM,97016,CPT,0420,RC,,,GP|CQ,outpatient,,,206.00,133.90,,,,,,,,,,,,,
SUPPORT ORTHOT CUST CLUBFOOT WDG,SUP-2435724,CDM,L3380,HCPCS,0274,RC,,,,both,,,140.42,91.27,,,,,,,,,,,,,
ANCHOR SUT NO2 DIA65MM UP EXT TI WDG NDL PRELD W 2 STRND,SUP-2362552,CDM,C1713,HCPCS,0278,RC,,,,both,,,818.03,531.72,,,,,,,,,,,,,
PLATE BNE L 28 MM SCREW DIA2.8 MM MED CP TI MANDIBULAR FULL,SUP-2883713,CDM,C1713,HCPCS,0278,RC,,,,both,,,18882.42,12273.57,,,,,,,,,,,,,
PLATE BONE 3X3 H BILAT MAND ORAL MAXILLOFACIAL TI CRESC LO,SUP-2191434,CDM,C1713,HCPCS,0278,RC,,,,both,,,4771.86,3101.71,,,,,,,,,,,,,
BIT DRL DIA3.5MM METATARSAL CANN FOR FRAC SYS,SUP-2123145,CDM,2720000010,LOCAL,0272,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
CATHETER HD PRECRV AD 15.5 FRX32 CM LT DL SH STRL DURAFLO 2,SUP-2462957,CDM,C1750,HCPCS,0278,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
CASSETTE PHACO W/O TIP MAXVAC,SUP-2109639,CDM,C1713,HCPCS,0278,RC,,,,both,,,464.72,302.07,,,,,,,,,,,,,
ENDOPROSTHESIS VASC FLUENCY + L 40 MM DIA 8 MM CATH L 117 CM,SUP-2128240,CDM,C1874,HCPCS,0278,RC,,,,both,,,5809.00,3775.85,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 80 CM DIA 6 MM L 70CM STR STD WALL,SUP-2396271,CDM,C1768,CPT,0278,RC,,,,both,,,4600.10,2990.06,,,,,,,,,,,,,
LINER APR NEUTRAL STANDARD POLY 22X41MM,SUP-2508858,CDM,C1776,CPT,0278,RC,,,,both,,,2898.22,1883.84,,,,,,,,,,,,,
WASHER ORTHOPEDIC LIGMNT ANCHR W/ SCR,SUP-2449901,CDM,C1713,HCPCS,0278,RC,,,,both,,,3080.34,2002.22,,,,,,,,,,,,,
"HC So Detect, Agnt Mult, Dna Ampli",PX-3068780166,CDM,87801,CPT,0306,RC,,,,inpatient,,,179.00,116.35,,,,,,,,,,,,,
SET INTRO L 45 CM DIA 4 FR SS WIRE MIC SHRT B BVL ECHOGENIC,SUP-2117204,CDM,C1769,HCPCS,0272,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
TRAY TIB SZ 5 R HNG GMK,SUP-2267635,CDM,C1776,CPT,0278,RC,,,,both,,,13250.80,8613.02,,,,,,,,,,,,,
HC Rep Cpx Face H Ft Ea Add 5cm,PX-4501313300,CDM,13133,CPT,0450,RC,,,,both,,,1216.00,790.40,,,,,,,,,,,,,
PLATE BONE MESH SCREEN 1.3X30X40X0.2 MM TITANIUM,SUP-2838350,CDM,C1713,HCPCS,0278,RC,,,,both,,,914.37,594.34,,,,,,,,,,,,,
KIT CATH 20GA L5IN POLYUR W/ INTEGR SUT WNG 0.025X13.75IN,SUP-2383271,CDM,C1751,HCPCS,0278,RC,,,,both,,,85.41,55.52,,,,,,,,,,,,,
PLATE BNE L94MM 8 H BILAT S STL CRV RECON NONLOCKING,SUP-2197681,CDM,C1713,HCPCS,0278,RC,,,,both,,,1169.49,760.17,,,,,,,,,,,,,
CAP ORTH CEPHALOMEDULLARY NAIL TI STRL ZNN,SUP-2862127,CDM,C1713,HCPCS,0278,RC,,,,both,,,2949.59,1917.23,,,,,,,,,,,,,
SCREW INTRF KNEE CANN N ABSRB TI 9MM 25MM,SUP-2256756,CDM,C1713,HCPCS,0278,RC,,,,both,,,763.02,495.96,,,,,,,,,,,,,
CABLE EP CATH L 1.5 M 14 PIN MODEL 1914-SA DIAG CONN SHROUD,SUP-2676240,CDM,2720000010,LOCAL,0272,RC,,,,both,,,891.76,579.64,,,,,,,,,,,,,
PRISMASATE B22GK 4/0 DIALYSIS SOLUTION,RX-40840083,CDM,2580000003,HCPCS,0258,RC,09999-9999-45,NDC,,both,5000,ML,103.50,67.27,,,,,,,,,,,,,
BUNDLE GRFT ENDURANT II NIT POLYESTER 4 PC HELI-FX,SUP-2873749,CDM,C1768,CPT,0278,RC,,,,both,,,87920.00,57148.00,,,,,,,,,,,,,
GRAFT BNE CHIP CRUSH FRZN CANC 1MM 8MM RANG 30CC READIGRFT,SUP-2264735,CDM,C1713,HCPCS,0278,RC,,,,both,,,1316.07,855.45,,,,,,,,,,,,,
BIT DRL CANN 9 MM KNEE SINGLE FLUT MTO,SUP-2849084,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2342.44,1522.59,,,,,,,,,,,,,
HC Collection Venous Blood Venipuncture|ADJ,PX-3003641500,CDM,36415,CPT,0300,RC,,,ADJ,both,,,34.00,22.10,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 80 CM DIA 7MM STR STD WALL SLDE GDS,SUP-2695233,CDM,C1768,CPT,0278,RC,,,,both,,,2852.47,1854.11,,,,,,,,,,,,,
MESH RESTRATA 10.0CM X 12.5CM,SUP-2874127,CDM,A2007,HCPCS,0636,RC,,,,both,,,15543.00,10102.95,,,,,,,,,,,,,
PLATE BNE LCK 5.5X372 MM LT PROX LAT TIB 22 HOLE SS STRL,SUP-2473560,CDM,C1713,HCPCS,0278,RC,,,,both,,,6251.08,4063.20,,,,,,,,,,,,,
PLATE BNE R DST RAD VOLAR TI FOR 1.8/2.4/2.7MM SCR,SUP-2191014,CDM,C1713,HCPCS,0278,RC,,,,both,,,2241.43,1456.93,,,,,,,,,,,,,
PLATE BNE ULN 110 MM LT DORS PROX 8 HOLE BUTTRESS SS STRL,SUP-2471813,CDM,C1713,HCPCS,0278,RC,,,,both,,,2359.68,1533.79,,,,,,,,,,,,,
ANCHOR SUTURE ALLOSYNC PUSHLOCK,SUP-2930455,CDM,C1713,HCPCS,0278,RC,,,,both,,,2802.45,1821.59,,,,,,,,,,,,,
KIT VASC SNR ATRIEVE 90 DEG TIP 15 DEG L 175 CM DIA2-4 MM,SUP-2120066,CDM,C1773,HCPCS,0272,RC,,,,both,,,848.74,551.68,,,,,,,,,,,,,
STABILIT VP FRACTURE KIT WITHOUT NEEDLES,SUP-2699829,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2132.06,1385.84,,,,,,,,,,,,,
PLATE BNE L92MM 7 H LOK 2 COMPR FOR 35MM SCR UNIV LOK SYS,SUP-2199387,CDM,C1713,HCPCS,0278,RC,,,,both,,,941.81,612.18,,,,,,,,,,,,,
PLATE BNE 5MM LAPIDUS STP,SUP-2243210,CDM,C1713,HCPCS,0278,RC,,,,both,,,3485.40,2265.51,,,,,,,,,,,,,
KIT FIX SFT TISS CRSS PIN FOR 3.3MM RIGIDFIX,SUP-2249325,CDM,C1713,HCPCS,0278,RC,,,,both,,,2703.54,1757.30,,,,,,,,,,,,,
SPLINT ORTHOPEDIC CLAV 18-20 IN 2XS PEDIATRIC PROCARE,SUP-2196975,CDM,L3670,HCPCS,0274,RC,,,,both,,,14.57,9.47,,,,,,,,,,,,,
NOREPINEPHRINE-DEXTROSE 4-5 MG/250ML-% IV SOLN,RX-135183,CDM,2500000003,HCPCS,0250,RC,00338-0112-20,NDC,,both,250,ML,129.40,84.11,,,,,,,,,,,,,
NEEDLE BRST LOC L7CM DIA20GA KOPANS-STYLE STIFF PRE-LOADED,SUP-2331832,CDM,C1819,HCPCS,0278,RC,,,,both,,,72.53,47.14,,,,,,,,,,,,,
SYSTEM ANCHR 2 ANCHR ANCHRURE,SUP-2308303,CDM,C1713,HCPCS,0278,RC,,,,both,,,456.43,296.68,,,,,,,,,,,,,
GRAFT BNE CLOWARD DWL FRZN OD 10MM MATRIGRFT,SUP-2264705,CDM,C1713,HCPCS,0278,RC,,,,both,,,1712.59,1113.18,,,,,,,,,,,,,
NEEDLE 25GA ASPIRATION VIZISHOT 2,SUP-2659180,CDM,2720000010,LOCAL,0272,RC,,,,both,,,796.30,517.59,,,,,,,,,,,,,
HC ER Level 5,PX-4509928500,CDM,99285,CPT,0450,RC,,,,outpatient,,,3911.00,2542.15,,,,,,,,,,,,,
ALLOGRAFT BNE STRP 15X40X3-6 MM SPNG FD CANC,SUP-2717783,CDM,C1713,HCPCS,0278,RC,,,,both,,,5165.30,3357.44,,,,,,,,,,,,,
ADAPTER FEM SL +0MM OFFSET MTPHSEAL TI PORCOAT FOR PRESSFIT,SUP-2252607,CDM,C1776,CPT,0278,RC,,,,both,,,1544.41,1003.87,,,,,,,,,,,,,
POSITIONER 2 HRT STARFISH,SUP-2282585,CDM,C1713,HCPCS,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
TRAY CATH PICC LUMENX2 6FR DIA 55CML POLYURETHANE 0.62ML PRI,SUP-2613437,CDM,C1751,HCPCS,0278,RC,,,,both,,,706.81,459.43,,,,,,,,,,,,,
GUIDEWIRE ORTH L9IN DIA2MM S STL SGL TRCR THRD FOR MAYO LOK,SUP-2107902,CDM,C1769,HCPCS,0272,RC,,,,both,,,72.22,46.94,,,,,,,,,,,,,
OBTURATOR SURG LSR CUT TRANSOBT GYNECARE TVT,SUP-2218517,CDM,C1771,HCPCS,0278,RC,,,,both,,,6620.44,4303.29,,,,,,,,,,,,,
SPACER SPNL W12XH18XL50MM 10DEG PEEK OPTMA COROENTXLCT,SUP-2310619,CDM,C1821,HCPCS,0278,RC,,,,both,,,17270.00,11225.50,,,,,,,,,,,,,
RX BURR HOLE COVER 12MM X 1MM,SUP-2669321,CDM,C1713,HCPCS,0278,RC,,,,both,,,942.03,612.32,,,,,,,,,,,,,
SET KNOT PUSH SUT CUT SLT CANN STR DISP FOR FAST FIX MENIS,SUP-2341853,CDM,2720000010,LOCAL,0272,RC,,,,both,,,554.96,360.72,,,,,,,,,,,,,
CEMENT BNE ARTHRPLSTY HI VISC ORTHOPEDIC N MEDICATED,SUP-2156015,CDM,C1713,HCPCS,0278,RC,,,,both,,,169.56,110.21,,,,,,,,,,,,,
PLATE BONE L86MM 2 H RT OLECRANON TI FOR 3.5MM SCR LOQTEQ,SUP-2101273,CDM,C1713,HCPCS,0278,RC,,,,both,,,2725.52,1771.59,,,,,,,,,,,,,
TOOL APPLIER RAPIDPORT EZ,SUP-2119254,CDM,C1713,HCPCS,0278,RC,,,,both,,,810.12,526.58,,,,,,,,,,,,,
BIT DRL SFT BNE 3 MM FOR 4.5/5.5 MM QUATTRO LINK ANCHR REUSE,SUP-2608883,CDM,2720000010,LOCAL,0272,RC,,,,both,,,478.28,310.88,,,,,,,,,,,,,
FORCEP SURG BPLR BI PLR VEO DISP,SUP-2800756,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3925.00,2551.25,,,,,,,,,,,,,
DA VINCI TIBIAL NAIL CASE,SUP-2811246,CDM,C1713,HCPCS,0278,RC,,,,both,,,12544.30,8153.79,,,,,,,,,,,,,
COUNTERSINK SRGCL CNNLTD QUICK CNNCT 35/4MM SCREW,SUP-2462551,CDM,C1713,HCPCS,0278,RC,,,,both,,,1034.94,672.71,,,,,,,,,,,,,
SCREW BONE IMPL KNOTLESS PEEK 6.5MM OPUS SPEEDSCR,SUP-2342100,CDM,C1713,HCPCS,0278,RC,,,,both,,,1378.15,895.80,,,,,,,,,,,,,
CLAMP SPINE OFFSET FOR TENOR,SUP-2289282,CDM,C1713,HCPCS,0278,RC,,,,both,,,1051.90,683.73,,,,,,,,,,,,,
KIT CHST TB INTRO CHLORAPREP 1 STP L GLV ADH BK FEN DRP,SUP-2227360,CDM,C1729,HCPCS,0272,RC,,,,both,,,264.58,171.98,,,,,,,,,,,,,
HC X-Ray Knee Rout Inc Tun Pat Min 4 View,PX-3207356400,CDM,73564,CPT,0320,RC,,,,outpatient,,,616.00,400.40,,,,,,,,,,,,,
STE COMPRESSION FUSION PLT,SUP-2488096,CDM,C1713,HCPCS,0278,RC,,,,both,,,2494.51,1621.43,,,,,,,,,,,,,
GRAFT BONE SUB 30ML CANC CUBE FRZ DRY,SUP-2165553,CDM,C1713,HCPCS,0278,RC,,,,both,,,1328.22,863.34,,,,,,,,,,,,,
PLATE EXT FIX L 65 MM 5 H SHRT CONN OVL SLOT NS DISP ILIZ,SUP-2933853,CDM,2720000010,LOCAL,0272,RC,,,,both,,,585.70,380.70,,,,,,,,,,,,,
CATHETER EP MED CRV 2-5-2 MM 1 MM 7 FRX110 CM,SUP-2867386,CDM,C1730,HCPCS,0272,RC,,,,both,,,2829.14,1838.94,,,,,,,,,,,,,
SHOE ORTHOT ADDITION CONVERT INSTEP VELCRO CLOSURE,SUP-2435742,CDM,L3580,HCPCS,0274,RC,,,,both,,,183.63,119.36,,,,,,,,,,,,,
PLATE BNE L 185 MM SCREW DIA 4.5 MM 10 H SS NAR COMPR NLCK,SUP-2933634,CDM,C1713,HCPCS,0278,RC,,,,both,,,2042.07,1327.35,,,,,,,,,,,,,
SPLINT ORTHOPEDIC CLAV 20-24 IN XS PRNG BCKL PROCARE,SUP-2196976,CDM,L3650,HCPCS,0272,RC,,,,both,,,14.57,9.47,,,,,,,,,,,,,
BIT DRL DIA4MM ANTIROTATION NOTCH FOR PROPHECY INBONE TOT,SUP-2397089,CDM,2720000010,LOCAL,0272,RC,,,,both,,,332.84,216.35,,,,,,,,,,,,,
MESH SURG W15XL20CM OVL FOR TISS SEPARATING AND HERN FIX,SUP-2219761,CDM,C1781,HCPCS,0278,RC,,,,both,,,3009.88,1956.42,,,,,,,,,,,,,
COMPONENT TIB TY W/ 2 TIB AND 2 FEM LO PROF REV KNEE SYS,SUP-2359218,CDM,C1776,CPT,0278,RC,,,,both,,,9498.50,6174.02,,,,,,,,,,,,,
KIT PICC PI 2-L 5FR X 55CM TIPTRACKER,SUP-2855518,CDM,C1751,HCPCS,0278,RC,,,,both,,,631.93,410.75,,,,,,,,,,,,,
TUBE VENT SHEEHY 1.27 MM 1.5 MM 2.75 MM CLLR BUTTON SIL STRL,SUP-2473435,CDM,L8699,HCPCS,0278,RC,,,,both,,,29.55,19.21,,,,,,,,,,,,,
STAPLE BNE FIX W9XL10MM NIT W/ INSTR DYNANITE,SUP-2122338,CDM,C1713,HCPCS,0278,RC,,,,both,,,4694.30,3051.29,,,,,,,,,,,,,
CANNULA SURG CEPHALOMEDULLARY ENTRY ASIA,SUP-2490613,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1466.38,953.15,,,,,,,,,,,,,
HC Rp Loclzj Tum Plnr Whole Body Single Day Imaging,PX-3417880200,CDM,78802,CPT,0341,RC,,,,both,,,2681.00,1742.65,,,,,,,,,,,,,
SUBSTITUTE BONE GRFT 1.7-10MM CHIP CANC FRZ,SUP-2307535,CDM,C1713,HCPCS,0278,RC,,,,both,,,474.14,308.19,,,,,,,,,,,,,
CATHETER BLLN DIL SET 5-15 MM ESOPH GAST SAVARY-GILLIARD,SUP-2759280,CDM,C1769,HCPCS,0272,RC,,,,both,,,5118.20,3326.83,,,,,,,,,,,,,
VALVE CSF PROGRAMMABLE MIC 120 CM W/ RICKHAM RESERVOIR 2 CM,SUP-2863643,CDM,C1889,HCPCS,0278,RC,,,,both,,,16873.07,10967.50,,,,,,,,,,,,,
CONDUIT CV SZ 33MM L10CM ASCEND AORT CARBOMEDICS CARBO SEAL,SUP-2352742,CDM,C1889,HCPCS,0278,RC,,,,both,,,17270.00,11225.50,,,,,,,,,,,,,
DEFIBRILLATOR ICD 2 CHMBR W/ LANDLINE HM LUMAX 740 DR T,SUP-2138199,CDM,C1721,HCPCS,0275,RC,,,,both,,,43960.00,28574.00,,,,,,,,,,,,,
LEAD NEUROSTIMULATOR REACTIV8 L 65 CM SUTURE SLV STRL,SUP-2877968,CDM,C1730,HCPCS,0272,RC,,,,both,,,8945.86,5814.81,,,,,,,,,,,,,
GRAFT SKIN N MESHED CRYOPRESERVED ALLGRFT 232CM2,SUP-2165550,CDM,C1762,CPT,0278,RC,,,,both,,,1406.72,914.37,,,,,,,,,,,,,
PLATE BNE FIBULAR LT 4 HOLE LCK ANAT STRL ALPS LTX,SUP-2861805,CDM,C1713,HCPCS,0278,RC,,,,both,,,2522.68,1639.74,,,,,,,,,,,,,
ALLOGRAFT BNE PTTY 5 CC 42030050] CROSSROADS EXTREMITY SYSTEMS],SUP-2175162,CDM,C1889,HCPCS,0278,RC,,,,both,,,4790.07,3113.55,,,,,,,,,,,,,
FELT SURG W6XL6IN THK1.65MM PTFE FOR THE REP OF SEPT DEFCT,SUP-2127903,CDM,C1768,CPT,0278,RC,,,,both,,,1011.99,657.79,,,,,,,,,,,,,
KIT INFUS PMP 100ML 5IN NONNARCOTIC ELASTOMERIC PMP W/ ON-Q,SUP-2420886,CDM,C9804,HCPCS,0272,RC,,,,both,,,310.86,202.06,,,,,,,,,,,,,
SHUNT SURG L 28 MM RESERVOIR 20 MM CATH L DSTL 600 MM,SUP-2931097,CDM,C1729,HCPCS,0272,RC,,,,both,,,8431.28,5480.33,,,,,,,,,,,,,
COLLAR CERV CNTOUR UNIV 3 IN MED DENS FOAM PROCARE,SUP-2196897,CDM,L0180,HCPCS,0274,RC,,,,both,,,7.82,5.08,,,,,,,,,,,,,
SPLINT WRST XL AD L8IN FOR 85 95IN L NYL LN FOAM PUL ON,SUP-2276660,CDM,L3908,HCPCS,0274,RC,,,,both,,,16.83,10.94,,,,,,,,,,,,,
WIRE FIX THRD 1.25 MM 80 MM SS KIRSCHNER,SUP-2653535,CDM,C1713,HCPCS,0278,RC,,,,both,,,280.87,182.57,,,,,,,,,,,,,
CUP ACET DIA54MM HIP POLY IMPCT FOR 48MM HD BIRMINGHAM,SUP-2350863,CDM,C1776,CPT,0278,RC,,,,both,,,10205.00,6633.25,,,,,,,,,,,,,
SUBSTITUTE BNE GRFT 20X20X4MM DEMIN CANC FILL MTRX CNFRM,SUP-2307023,CDM,C1713,HCPCS,0278,RC,,,,both,,,1866.73,1213.37,,,,,,,,,,,,,
CARBOPLATIN 600 MG/60ML IV SOLN,RX-40055,CDM,J9045,HCPCS,0636,RC,55150-0386-01,NDC,,both,60,ML,144.50,93.92,,,,,,,,,,,,,
PLATE BONE L146MM 12 H POST LAT S STL 1/3 TBLR LCK COMPR FOR,SUP-2349799,CDM,C1713,HCPCS,0278,RC,,,,both,,,3076.26,1999.57,,,,,,,,,,,,,
SCREWDRIVER SURG SD2 FOR BCI 602 IMPL STRL DISP,SUP-2905148,CDM,2720000010,LOCAL,0272,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
KIT EXT FIX WRST SELF DRL RADLUC LO PROF,SUP-2316309,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3826.15,2487.00,,,,,,,,,,,,,
ANCHOR BONE W/ ARTHSCP DEL SYS ADV,SUP-2334700,CDM,C1713,HCPCS,0278,RC,,,,both,,,1813.35,1178.68,,,,,,,,,,,,,
IMPLANT TOE JT SZ 40 SIL FLX FUTURA,SUP-2244043,CDM,C1776,CPT,0278,RC,,,,both,,,4656.87,3026.97,,,,,,,,,,,,,
SCREW BNE L85MM LAG SLDE FOR HIP FRAC SYS CHIMAERA,SUP-2316375,CDM,C1713,HCPCS,0278,RC,,,,both,,,2458.53,1598.04,,,,,,,,,,,,,
DRAIN SURG 24FR BLAK SIL HUBLESS 4 CHANNELED RADPQ EXTN TB,SUP-2218225,CDM,C1729,HCPCS,0272,RC,,,,both,,,348.23,226.35,,,,,,,,,,,,,
VESSEL HARVESTING KIT ENDOSCP ACCS,SUP-2140984,CDM,C1713,HCPCS,0278,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
CANNULA INJ STR 0.8 MM TIP 5 MMX37 CM,SUP-2850979,CDM,2720000010,LOCAL,0272,RC,,,,both,,,336.61,218.80,,,,,,,,,,,,,
WASHER ORTH OD8MM ID3.2MM SPIK FOR 2.7MM SCR,SUP-2184669,CDM,C1713,HCPCS,0278,RC,,,,both,,,195.34,126.97,,,,,,,,,,,,,
CEPHALEXIN 250 MG/5ML PO SUSR,RX-9502,CDM,340b,HCPCS,0637,RC,09999-9903-69,NDC,,both,5,ML,2.70,1.75,,,,,,,,,,,,,
SUPPORT ORTHOT THOR LUMBAR SACR CUST TRIPLANAR CTRL APRON,SUP-2435545,CDM,L0470,HCPCS,0274,RC,,,,both,,,1862.77,1210.80,,,,,,,,,,,,,
PLATE TI VA-LOCKING CALCANEAL LARGE 2.7MM 70MM RGHT STRL,SUP-2547003,CDM,C1713,HCPCS,0278,RC,,,,both,,,3667.99,2384.19,,,,,,,,,,,,,
SCREW BNE L 10 MM DIA 3.2 MM MANDIBULAR XDRV EMER DISP,SUP-2934872,CDM,C1713,HCPCS,0278,RC,,,,both,,,2229.40,1449.11,,,,,,,,,,,,,
LOW PROFILE SCREW CADDY 4.5/6.7MM,SUP-2817599,CDM,C1713,HCPCS,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
GUIDEPIN SURG LESSER 0.71 IN ENCOMPASS,SUP-2319780,CDM,2720000010,LOCAL,0272,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
GUIDEWIRE VASC 145CM 0.035IN TIP 2.5CM RAD 3MM PTFE,SUP-2167602,CDM,C1769,HCPCS,0272,RC,,,,both,,,33.13,21.53,,,,,,,,,,,,,
SCREW SPNL L25MM OD10MM CANN THRD TI IL SI LOK,SUP-2229754,CDM,C1713,HCPCS,0278,RC,,,,both,,,8792.00,5714.80,,,,,,,,,,,,,
CATHETER INTVASC ULTRASOUND ATLNTS SR PRO L 135 CM DIA 3.2,SUP-2139920,CDM,C1753,HCPCS,0278,RC,,,,both,,,2166.60,1408.29,,,,,,,,,,,,,
MOLD BEAD 7MM TOP AND BTM ASSEMB OSTEOSET,SUP-2399035,CDM,C1713,HCPCS,0278,RC,,,,both,,,861.40,559.91,,,,,,,,,,,,,
CARBOPLATIN 10 MG/ML IV SOLN (MIXTURES ONLY),RX-1150452,CDM,J9045,HCPCS,0636,RC,61703-0339-22,NDC,,both,15,ML,67.00,43.55,,,,,,,,,,,,,
PLATE BNE L163.6MM THK3.7MM 0DEG 12 H TI TIM THN LOK COMPR,SUP-2413711,CDM,C1713,HCPCS,0278,RC,,,,both,,,1347.06,875.59,,,,,,,,,,,,,
CATHETER CV SET 035 9 FRX15 CM 3L POLYETH,SUP-2760028,CDM,C1751,HCPCS,0278,RC,,,,both,,,308.69,200.65,,,,,,,,,,,,,
PIN FIX L16MM DIA1.8MM S STL BTTRS,SUP-2183329,CDM,C1713,HCPCS,0278,RC,,,,both,,,176.72,114.87,,,,,,,,,,,,,
PROSTHESIS VOICE 20 FRX10 MM KT IMPL CLASSIC BLOM-SINGER,SUP-2238270,CDM,L8509,HCPCS,0272,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
DRILL SURG L101.6MM DIA2MM TWST CAPTURE,SUP-2419616,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1056.70,686.85,,,,,,,,,,,,,
TRAY CATH HEMODIALYSI SLXACUTE 14FR DIA 30CM STRGHT TAPR TIP,SUP-2610566,CDM,C1752,HCPCS,0278,RC,,,,both,,,530.66,344.93,,,,,,,,,,,,,
TRAY CATH CNTRL VENOU LUMENX3 6FR DIA SUBCLAV W/SHRLCK 3CG S,SUP-2613374,CDM,C1751,HCPCS,0278,RC,,,,both,,,973.40,632.71,,,,,,,,,,,,,
GUIDEWIRE VASC L 260 CM DIA 0.035 IN PTFE J FIX CRV,SUP-2147062,CDM,C1769,HCPCS,0272,RC,,,,both,,,56.96,37.02,,,,,,,,,,,,,
CATHETER PICCS SGL LUMN W/ CLMP IR KT W/ WIRE 130CM 4FR,SUP-2118953,CDM,C1751,HCPCS,0278,RC,,,,both,,,192.45,125.09,,,,,,,,,,,,,
PLATE BONE L147MM 11 H STRL LT LAT DSTL FIBULAR S STL FOR,SUP-2349759,CDM,C1713,HCPCS,0278,RC,,,,both,,,5619.50,3652.67,,,,,,,,,,,,,
GRAFT BIO TISS W6XL8CM THK08 17MM ACELLULAR DERM MTRX THCK,SUP-2307474,CDM,Q4128,HCPCS,0636,RC,,,,both,,,4332.98,2816.44,,,,,,,,,,,,,
ELECTRODE ELECSURG PED 11.5FR HK FOR RESECTSCP,SUP-2332848,CDM,C1713,HCPCS,0278,RC,,,,both,,,437.72,284.52,,,,,,,,,,,,,
IMPLANT SUBTALAR TRUARCH 8 MM,SUP-2586648,CDM,C1776,CPT,0278,RC,,,,both,,,7689.39,4998.10,,,,,,,,,,,,,
PROSTHESIS OTO L5MM OD4MM HA MID EAR OSS PART OFFSET HD FULL,SUP-2284003,CDM,L8613,CPT,0278,RC,,,,both,,,1564.03,1016.62,,,,,,,,,,,,,
TUBE CHST 40FR L20IN POLYVI CHL OPN TIP STR FIRM RADPQ ARGY,SUP-2154971,CDM,C1729,HCPCS,0272,RC,,,,both,,,35.04,22.78,,,,,,,,,,,,,
PLATE BONE L123MM 8 H LT ANTEROLATERAL MEDL DSTL TIB LCK FOR,SUP-2348478,CDM,C1713,HCPCS,0278,RC,,,,both,,,16949.88,11017.42,,,,,,,,,,,,,
COMPONENT HIP CAPPED CEM ENDO HD ST LD/FX,SUP-2212314,CDM,C1776,CPT,0278,RC,,,,both,,,9702.60,6306.69,,,,,,,,,,,,,
BRACE ORTH ABDUCTN CTRL HIP ORTHOSIS FLX,SUP-2388157,CDM,L1620,HCPCS,0274,RC,,,,both,,,397.37,258.29,,,,,,,,,,,,,
GRAFT BNE 4.8 MM 5 CC OSTEOSET XR,SUP-2498595,CDM,C1713,HCPCS,0278,RC,,,,both,,,1833.76,1191.94,,,,,,,,,,,,,
OBTURATOR SHTH 5FRX15CM LUERLOCK,SUP-2355469,CDM,C1894,HCPCS,0272,RC,,,,both,,,19.63,12.76,,,,,,,,,,,,,
COIL NEUROVASCULAR HELIPAQ 18 L 30 CM DIA14 MM WORKING L 190,SUP-2458318,CDM,C1889,HCPCS,0278,RC,,,,both,,,2797.17,1818.16,,,,,,,,,,,,,
DRESSING HUM TISS SZ 2 X 2 CM UMB TISS SKIN LYOPRESERVED,SUP-2905485,CDM,Q4133,HCPCS,0636,RC,,,,both,,,2780.47,1807.31,,,,,,,,,,,,,
PLATE SPNL 3 LEVEL 52 MM ANTR CERV NEO-SL,SUP-2430706,CDM,C1713,HCPCS,0278,RC,,,,both,,,5181.00,3367.65,,,,,,,,,,,,,
TUBE TRACH SZ 11 CLR STRL SER 4200 SAFE-T-TUBE,SUP-2140097,CDM,2720000010,LOCAL,0272,RC,,,,both,,,580.90,377.58,,,,,,,,,,,,,
BIT DRL N CANN 3.7 MM,SUP-2598293,CDM,2720000010,LOCAL,0272,RC,,,,both,,,580.90,377.58,,,,,,,,,,,,,
HC So Quantitative Enzyme Immunoassy,PX-3028631666,CDM,86316,CPT,0302,RC,,,,inpatient,,,177.00,115.05,,,,,,,,,,,,,
SPHERE GLEN REVERSED 42 MM SHLDR CENTERED FOR 29 MM BASEPLT,SUP-2715706,CDM,C1776,CPT,0278,RC,,,,both,,,11738.89,7630.28,,,,,,,,,,,,,
GUIDE MARKING ORTHOGNATHIC MAND IPS,SUP-2433938,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
GLUCOSE 40% PO GEL NEONATAL SYRINGE,RX-4090249,CDM,6370000000,HCPCS,0637,RC,09999-9917-06,NDC,,both,37.5,ML,13.40,8.71,,,,,,,,,,,,,
K WIRE FIX L150MM DIA1.1MM DRL TIP W/O STP NONRADIOPAQUE,SUP-2343041,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1754.38,1140.35,,,,,,,,,,,,,
ALLOGRAFT BNE WDG FD IRRADIATED IL CREST,SUP-2867053,CDM,C1762,CPT,0278,RC,,,,both,,,2496.77,1622.90,,,,,,,,,,,,,
SYSTEM LD DEL ACUITY BREAK-AWAY CORONARY VEN PACE LD SPRL,SUP-2149159,CDM,C1894,HCPCS,0272,RC,,,,both,,,1846.32,1200.11,,,,,,,,,,,,,
SCREW BNE SELF COMPRESSIVE 3.2X16 MM DYNAFIT,SUP-2610267,CDM,C1713,HCPCS,0278,RC,,,,both,,,1497.78,973.56,,,,,,,,,,,,,
STAPLER INT CUT LN 40MM STPL 51MM GRN CRV HD B FRM,SUP-2716240,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1582.03,1028.32,,,,,,,,,,,,,
PLATE BONE STRAIGHT 2 MM 4 HOLE RAPID RESORBABLE STERILE RAP,SUP-2838588,CDM,C1713,HCPCS,0278,RC,,,,both,,,738.53,480.04,,,,,,,,,,,,,
SHAFT FIB TRAD ALLGRFT 20X12 - 13 MM FRZ DRY,SUP-2294106,CDM,C1713,HCPCS,0278,RC,,,,both,,,1199.48,779.66,,,,,,,,,,,,,
KIT INTRO MICROEZ L 35 CM CATH 5 FR NDL L 6 CM SS GUIDEWIRE,SUP-2126204,CDM,C1894,HCPCS,0272,RC,,,,both,,,98.60,64.09,,,,,,,,,,,,,
BIT DRL 3 FLUT W/ QUIK CPL 4.0MMX250MM LEN,SUP-2204931,CDM,2720000010,LOCAL,0272,RC,,,,both,,,584.04,379.63,,,,,,,,,,,,,
TUNNELER SHTH 11GAX8IN ON-Q,SUP-2236801,CDM,C2626,HCPCS,0278,RC,,,,both,,,149.31,97.05,,,,,,,,,,,,,
GRAFT SKIN L220XW60XH0.34-0.51MM MESHED DERM TISS FRZ DRY,SUP-2113070,CDM,C9364,HCPCS,0278,RC,,,,both,,,53.38,34.70,,,,,,,,,,,,,
SCREW SPNL L20MM DIA4MM ANTR CERV TI ST VAR ANG FULL THRD,SUP-2255137,CDM,C1713,HCPCS,0278,RC,,,,both,,,266.90,173.48,,,,,,,,,,,,,
PLATE BNE STD RT 18 HOLE FOR ORTH FIX STRL POLARUS 3,SUP-2518202,CDM,C1713,HCPCS,0278,RC,,,,both,,,6948.82,4516.73,,,,,,,,,,,,,
STAPLE STEP 6MM,SUP-2470706,CDM,C1713,HCPCS,0278,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
MATRIX BIO L 3.5 X W 3.2 IN SZ 73.8 SQCM PORCINE TEND,SUP-2909298,CDM,A2008,HCPCS,0636,RC,,,,both,,,8308.44,5400.49,,,,,,,,,,,,,
CATHETER NEPHROSTOMY MCOT 24 FRX25 CM SIL,SUP-2835743,CDM,C1729,HCPCS,0272,RC,,,,both,,,294.53,191.44,,,,,,,,,,,,,
ADAPTER ORTH 5+ MM FEM KNEE REV SL LIMB PRESERVATION ATTUNE,SUP-2744026,CDM,C1776,CPT,0278,RC,,,,both,,,1544.41,1003.87,,,,,,,,,,,,,
SHUNT SURG L 8.9 MM VENTRICULAR CATH L 180 MM PRESSURE 15 CM FV681T,SUP-2929034,CDM,C1889,HCPCS,0278,RC,,,,both,,,2853.98,1855.09,,,,,,,,,,,,,
PLATE 3.5MM CURVED BROAD LCP 12 HOLE-STERILE,SUP-2546101,CDM,C1713,HCPCS,0278,RC,,,,both,,,2301.37,1495.89,,,,,,,,,,,,,
BETHANECHOL CHLORIDE 25 MG PO TABS,RX-1044,CDM,6370000000,HCPCS,0637,RC,00832-0512-01,NDC,,both,1,UN,4.20,2.73,,,,,,,,,,,,,
MENINGOCOCCAL B RECOMB OMV ADJ IM SUSY,RX-128726,CDM,90620,HCPCS,0636,RC,58160-0976-02,NDC,,both,.5,ML,1067.10,693.61,,,,,,,,,,,,,
COUNTERSINK SURG L 50 MM DIA1.8 MM NS DISP DELT,SUP-2909648,CDM,2720000010,LOCAL,0272,RC,,,,both,,,697.49,453.37,,,,,,,,,,,,,
HC Duplex Av Dialysis Shunt,PX-9219399000,CDM,93990,CPT,0921,RC,,,,outpatient,,,1222.00,794.30,,,,,,,,,,,,,
VALVE HYDROCEPHALUS 35 A WITH CONTROL RESERVOIR SHUNT ASSIST,SUP-2821857,CDM,C1889,HCPCS,0278,RC,,,,both,,,9171.37,5961.39,,,,,,,,,,,,,
GAUGE DEPTH CANN NCB-PH/PT,SUP-2472987,CDM,2720000010,LOCAL,0272,RC,,,,both,,,569.22,369.99,,,,,,,,,,,,,
PLATE BNE W7.5XL61MM THK1.6MM 5X5 H R DST VOLAR RAD TI RIG,SUP-2191022,CDM,C1713,HCPCS,0278,RC,,,,both,,,2672.83,1737.34,,,,,,,,,,,,,
SCREW BNE L58MM DIA6MM CANC FOR TIB FIX WASHERLOC,SUP-2212923,CDM,C1713,HCPCS,0278,RC,,,,both,,,555.78,361.26,,,,,,,,,,,,,
PLATE BNE W10.1XL70MM 6 H BILAT TI LO PROF RIG LOK COMPR,SUP-2191091,CDM,C1713,HCPCS,0278,RC,,,,both,,,1657.04,1077.08,,,,,,,,,,,,,
COIL EMB L22CM OD5MM 10 STRTCH RESIST FRAMING FIL FNSH,SUP-2305174,CDM,C1889,HCPCS,0278,RC,,,,both,,,4898.40,3183.96,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 6X3 CM CRYOPRESERVED UMB CRD NEOX CRD 1K,SUP-2648688,CDM,Q4148,HCPCS,0636,RC,,,,both,,,6358.50,4133.02,,,,,,,,,,,,,
GRAFT BNE SUB 5ML CANC CORT DBM CHIP RM TEMP FRZ DRY,SUP-2223562,CDM,C1762,CPT,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
NUT SPNL STACKABLE LCK SCR BENGAL,SUP-2583126,CDM,C1713,HCPCS,0278,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
COLLAR CERV L13-16IN H2.5IN UNIV TRACH OPN ADJ AD SIERRA,SUP-2123895,CDM,L0172,HCPCS,0272,RC,,,,both,,,39.25,25.51,,,,,,,,,,,,,
BIT DRL TAPR HD 6 MMX9 IN BADGER,SUP-2765765,CDM,2720000010,LOCAL,0272,RC,,,,both,,,594.43,386.38,,,,,,,,,,,,,
BUR SURG SHFT L64MM DIA2.5MM LNG 80000RPM NEURO DMND CARB,SUP-2284217,CDM,2720000010,LOCAL,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
GUIDEWIRE VASC L260CM DIA0.035IN TIP L3MM STD EXCHG PTFE J,SUP-2302722,CDM,C1769,HCPCS,0272,RC,,,,both,,,32.28,20.98,,,,,,,,,,,,,
BODY HUM +10MM OFFSET PROX ELBW TI POR MOSAIC,SUP-2403497,CDM,C1776,CPT,0278,RC,,,,both,,,11580.32,7527.21,,,,,,,,,,,,,
CROSSLINK SPNL M CAPLOX II,SUP-2152469,CDM,C1713,HCPCS,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
PLATE BONE CH BLDE L45MM 6MM OFFSET 100DEG 3 H LT RT S STL,SUP-2318746,CDM,C1713,HCPCS,0278,RC,,,,both,,,5024.00,3265.60,,,,,,,,,,,,,
SPLINT ORTHOPEDIC SLIP ON SM 8 IN RT WRST PLUSH FOAM LNR NYL,SUP-2276664,CDM,L3908,HCPCS,0274,RC,,,,both,,,16.86,10.96,,,,,,,,,,,,,
CLOPIDOGREL BISULFATE 75 MG PO TABS,RX-22142,CDM,6370000000,HCPCS,0637,RC,55111-0196-90,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
COMPONENT PATELLAR ASYM 40X11 MM SUP INFERIOR KNEE BEAD,SUP-2373635,CDM,C1776,CPT,0278,RC,,,,both,,,3011.89,1957.73,,,,,,,,,,,,,
GRAFT HUM TISS BIOINTEGRATIVE 40X30 MM INTRO ANTR TAPESTRY,SUP-2867251,CDM,C1763,HCPCS,0278,RC,,,,both,,,4458.80,2898.22,,,,,,,,,,,,,
RELOAD STPL M SZ 2 THK30MM PUR THCK TRI STPL,SUP-2283350,CDM,C1713,HCPCS,0278,RC,,,,both,,,1608.21,1045.34,,,,,,,,,,,,,
BIT DRILL DIA2MM PERCUTANEOUS QUICK CONNECT,SUP-2478318,CDM,2720000010,LOCAL,0272,RC,,,,both,,,652.02,423.81,,,,,,,,,,,,,
SUPPORT KNEE GEL FORC L PRO-TEC,SUP-2324031,CDM,L1810,HCPCS,0272,RC,,,,both,,,75.71,49.21,,,,,,,,,,,,,
LEAD PACE MYOPORE L 54 CM TI SIL PTIR ATRIOVENTRICULAR IS1,SUP-2356207,CDM,C1898,HCPCS,0275,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
ANCHOR SUTURE L8.5MM OD2.7MM WHITE WITH BLUE STRIPS PRE THRE,SUP-2824806,CDM,C1713,HCPCS,0278,RC,,,,both,,,716.17,465.51,,,,,,,,,,,,,
CATHETER THOR DRNGE 28FR PVC TRCR L10IN PLEUR-EVAC,SUP-2384362,CDM,C1729,HCPCS,0272,RC,,,,both,,,93.20,60.58,,,,,,,,,,,,,
BLADE SURG 11CM 4MM SURG SHV 60DEG AGG ANG,SUP-2363538,CDM,2720000010,LOCAL,0272,RC,,,,both,,,466.57,303.27,,,,,,,,,,,,,
PACEMAKER CARD W 6.68 X H 20.27 CM D 4.14 CM SINGLE CHMBR,SUP-2419405,CDM,2720000010,LOCAL,0272,RC,,,,both,,,12293.41,7990.72,,,,,,,,,,,,,
CALCIUM CARBONATE 1500 (600 CA) MG PO TABS,RX-1301,CDM,6370000000,HCPCS,0637,RC,80681-0005-00,NDC,,both,1,UN,0.30,0.19,,,,,,,,,,,,,
MARKER BRST BX 10GA BARBELL CLP MAMMOSTAR,SUP-2195622,CDM,A4648,CPT,0278,RC,,,,both,,,23.24,15.11,,,,,,,,,,,,,
DILATOR SURG 1 PC SILIC1 REUSE STERILIZABLE USED FOR UP SZ,SUP-2124334,CDM,L8514,HCPCS,0274,RC,,,,both,,,292.02,189.81,,,,,,,,,,,,,
PLATE BNE FIBULAR ANK 4 HOLE TIBIAXYS,SUP-2609016,CDM,C1713,HCPCS,0278,RC,,,,both,,,3558.03,2312.72,,,,,,,,,,,,,
GUIDEWIRE ORTH OLV THRD MAXLOCK EXTRM,SUP-2400238,CDM,C1769,HCPCS,0272,RC,,,,both,,,116.18,75.52,,,,,,,,,,,,,
COMPONENT TOT HIP CEM,SUP-2365521,CDM,C1776,CPT,0278,RC,,,,both,,,10558.69,6863.15,,,,,,,,,,,,,
KIT EEG ELECTRD L 32.5 MM 10 CONTACT STRL DISP EVO,SUP-2936744,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2706.68,1759.34,,,,,,,,,,,,,
INJECTOR INTOCU LENS HNDPC MNRCH II,SUP-2110041,CDM,2720000010,LOCAL,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
SHUNT STERILE COR 375FR L16CM DIA125MM NONPROGRAM REG TAPR PK/5,SUP-2582814,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1591.67,1034.59,,,,,,,,,,,,,
PANITUMUMAB 20 MG/ML IV SOLN (MIXTURES ONLY),RX-1150401,CDM,J9303,HCPCS,0636,RC,55513-0954-01,NDC,,both,5,ML,5217.60,3391.44,,,,,,,,,,,,,
MICRO PLATE STRAIGHT 4 HOLE LNG CP TITANIUM,SUP-2677540,CDM,C1713,HCPCS,0278,RC,,,,both,,,261.03,169.67,,,,,,,,,,,,,
BIT DRL L94MM OD2.5MM FOR 3.5MM SCR,SUP-2243614,CDM,2720000010,LOCAL,0272,RC,,,,both,,,610.92,397.10,,,,,,,,,,,,,
BIT DRILL CANN STD 4.7MM,SUP-2490524,CDM,2720000010,LOCAL,0272,RC,,,,both,,,558.89,363.28,,,,,,,,,,,,,
EXPANDER TISS BRST 9.5 CM PROJCT 11X11 CM 500 CC RND,SUP-2328141,CDM,C1789,HCPCS,0278,RC,,,,both,,,4788.50,3112.52,,,,,,,,,,,,,
DRILL ENDOSCP D6MM 45DEG S STL OSSEOUS TISS POWERPICK,SUP-2122173,CDM,2720000010,LOCAL,0272,RC,,,,both,,,317.14,206.14,,,,,,,,,,,,,
SHELL ACET SZ D DIA46MM STD TI POR SPIK REFLCT,SUP-2345039,CDM,C1776,CPT,0278,RC,,,,both,,,4772.80,3102.32,,,,,,,,,,,,,
AMSCO 7052HP 460 480V 3 PH 60 HZ STEAM HEATED,SUP-2721188,CDM,C1713,HCPCS,0278,RC,,,,both,,,234834.89,152642.68,,,,,,,,,,,,,
ABUTMENT SNAP COUPLING 5.5MM,SUP-2858176,CDM,L8690,HCPCS,0278,RC,,,,both,,,4357.28,2832.23,,,,,,,,,,,,,
SUPPORT ORTHOT HEEL CUST COUNT REINF LTHR,SUP-2435730,CDM,L3440,HCPCS,0272,RC,,,,both,,,216.03,140.42,,,,,,,,,,,,,
WASHER ORTH FOR 35 4MM SCR DART FIRE,SUP-2398286,CDM,C1713,HCPCS,0278,RC,,,,both,,,69.08,44.90,,,,,,,,,,,,,
BLADE RTRCTR BLFR STNDRD 2 5/8NW X 10 3/4NL X 1 5/8ND ABDMNL,SUP-2487735,CDM,2720000010,LOCAL,0272,RC,,,,both,,,461.99,300.29,,,,,,,,,,,,,
SET UROLOGY DIL 8-24FR L37CM POLY SFTY GWIRE,SUP-2171193,CDM,C1769,HCPCS,0272,RC,,,,both,,,1218.32,791.91,,,,,,,,,,,,,
STENT COR 28MM 3.5MM S STL PACLITAXEL DRUG ELUT RAP,SUP-2140748,CDM,C1874,HCPCS,0278,RC,,,,both,,,8267.62,5373.95,,,,,,,,,,,,,
GUIDEWIRE ENDSCPC JGWRE RVLTN 0025N TIP 450CML ANG BX2,SUP-2676535,CDM,C1729,HCPCS,0272,RC,,,,both,,,549.81,357.38,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE 2.5 CC CELLULAR BNE MTRX SYGNACEL CBM,SUP-2929810,CDM,C1713,HCPCS,0278,RC,,,,both,,,4348.90,2826.78,,,,,,,,,,,,,
SHEATH URET PROXIS L 45 CM OD 12 FR ID 10 FR ACCS SHRT DIL,SUP-2655865,CDM,C1894,HCPCS,0272,RC,,,,both,,,507.74,330.03,,,,,,,,,,,,,
ENDOPROSTHESIS VASC VIABAHN L 7.5CM 8MM 120CM 8FR HEPARIN,SUP-2396619,CDM,C1874,HCPCS,0278,RC,,,,both,,,10748.22,6986.34,,,,,,,,,,,,,
OBTURATOR LATCHING BLNT REUSE LNG DA VINCI,SUP-2246608,CDM,C1713,HCPCS,0278,RC,,,,both,,,1852.60,1204.19,,,,,,,,,,,,,
HC Chemo IV Push Initial Drug,PX-3319640900,CDM,96409,CPT,0331,RC,,,,inpatient,,,673.00,437.45,,,,,,,,,,,,,
STRUT EXT FIX W81MM RAD LNG ASSEMB TRAUM FOR TRUELOK RNG,SUP-2316071,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3804.93,2473.20,,,,,,,,,,,,,
RING ANNULPLSTY 24MM RIG FOR MI VALVULOPLASTY CARPENTIER,SUP-2214129,CDM,C1713,HCPCS,0278,RC,,,,both,,,8776.30,5704.59,,,,,,,,,,,,,
SCREW SPNL L35MM OD5.5MM TI CANC ANT THOR PEDCL ST,SUP-2292718,CDM,C1713,HCPCS,0278,RC,,,,both,,,1775.67,1154.19,,,,,,,,,,,,,
KWIRE FIX L4IN DIA11MM SMOOTH DBL TRCR PNT 13463NS] STRYKER CORP],SUP-2361629,CDM,C1713,HCPCS,0278,RC,,,,both,,,15.48,10.06,,,,,,,,,,,,,
STEM HUM CEM 9X210 MM SHLDR REVERSED AEQUALIS,SUP-2715592,CDM,C1776,CPT,0278,RC,,,,both,,,8806.13,5723.98,,,,,,,,,,,,,
PLATE BONE L82MM 7 H STRL S STL 1/3 TBLR LCK FOR 3.5MM SCR,SUP-2419095,CDM,C1713,HCPCS,0278,RC,,,,both,,,1035.57,673.12,,,,,,,,,,,,,
CANNULA ARTHRO ENDOTRAC SLOTTED LASER MARKED,SUP-2461080,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1554.43,1010.38,,,,,,,,,,,,,
CATHETER ANGIO DIA 5 FR COBRA STRL,SUP-2383192,CDM,C1887,HCPCS,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
TRIAL SHELL REV ACET 49906048] ENCORE MEDICAL - DJO SURGICAL],SUP-2217283,CDM,C1776,CPT,0278,RC,,,,both,,,15511.60,10082.54,,,,,,,,,,,,,
HC Rep Cpx Ey/ER/Ns/Lp 1.1-2.5,PX-4501315100,CDM,13151,CPT,0450,RC,,,,both,,,1227.00,797.55,,,,,,,,,,,,,
HC So Phospholipid Antibody,PX-3028614866,CDM,86148,CPT,0302,RC,,,,both,,,27.00,17.55,,,,,,,,,,,,,
SPLINT FNGR L W1XL18IN ALUMINUM MAL,SUP-2276741,CDM,L3933,HCPCS,0274,RC,,,,both,,,2.92,1.90,,,,,,,,,,,,,
HC Excis Nail Matrix Perm Rmvl,PX-4501175000,CDM,11750,CPT,0450,RC,,,,both,,,1216.00,790.40,,,,,,,,,,,,,
PLATE BNE L54MM THK1.2MM 8 H BILAT HINDFT MIDFT S STL,SUP-2186127,CDM,C1713,HCPCS,0278,RC,,,,both,,,2125.25,1381.41,,,,,,,,,,,,,
SEED BRACHYTHERAPY PROST PALLADIUM-103 MICK CART THERASEED,SUP-2129124,CDM,C2640,HCPCS,0278,RC,,,,both,,,153.86,100.01,,,,,,,,,,,,,
MESH CRAN THK 0.6 MM SCREW DIA1.5 MM TI CNTOUR PANEL NS DISP,SUP-2935942,CDM,C1713,HCPCS,0278,RC,,,,both,,,12431.26,8080.32,,,,,,,,,,,,,
PIN APEX HALF 5X120 30 C THRD,SUP-2705299,CDM,2720000010,LOCAL,0272,RC,,,,both,,,638.68,415.14,,,,,,,,,,,,,
KIT PICC 4FR L55CM DBL LUMN INDWL BLU FLEXTIP W GLIDETHRU,SUP-2383373,CDM,C1751,HCPCS,0278,RC,,,,both,,,313.37,203.69,,,,,,,,,,,,,
KIT ART LN L 15 CM DIA18 GA GUIDEWIRE L 40 CM DIA 0.028 IN,SUP-2120113,CDM,C1751,HCPCS,0278,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
PLATE BNE XSM L BRDG MID FUS,SUP-2401174,CDM,C1713,HCPCS,0278,RC,,,,both,,,8810.84,5727.05,,,,,,,,,,,,,
SHEATH INTRO AXS INFIN LS + L 80 CM OD 8 FR ID 0.091 IN LNG,SUP-2551064,CDM,C1766,CPT,0272,RC,,,,both,,,1574.40,1023.36,,,,,,,,,,,,,
DEVICE PAIN CTRL 100ML 2ML/HR W/ 2.5IN FIX HUB CONDUCTION,SUP-2196473,CDM,C1713,HCPCS,0278,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
FRACTURE KIT 7 ML BNE CEMENT SATURATE MIXING SYS STABILIT ER,SUP-2470253,CDM,C1713,HCPCS,0278,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
SUPPORT KNEE THGH CIRC 12 15IN XSM SLIP ON NEOPRENE OPN PAT,SUP-2150846,CDM,L1810,HCPCS,0274,RC,,,,both,,,69.71,45.31,,,,,,,,,,,,,
FORCEP ELECSURG SPETZLER MALIS 1.5 MM 23CM BPLR IRRIGATING,SUP-2859258,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1318.80,857.22,,,,,,,,,,,,,
"HC So2 Antibody Virus, Nos",PX-3028679068,CDM,86790,CPT,0302,RC,,,,both,,,161.00,104.65,,,,,,,,,,,,,
STABILIZER SURG NOT IMPL OCTPS 4.3,SUP-2282583,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3752.30,2438.99,,,,,,,,,,,,,
NAIL IM L150MM DIA9MM UNIV PROX HUM BLU TI CANN LOK RND,SUP-2179631,CDM,C1713,HCPCS,0278,RC,,,,both,,,4735.69,3078.20,,,,,,,,,,,,,
HC Transrectal Ultrasound,PX-4027687200,CDM,76872,CPT,0402,RC,,,,both,,,971.00,631.15,,,,,,,,,,,,,
HC Immunoassay Tumor Antigen Quantitative Ca 125,PX-3028630400,CDM,86304,CPT,0302,RC,,,,both,,,506.00,328.90,,,,,,,,,,,,,
LENS INTOCU SGL PC LENSES OPT DSGN EQCNVX OPT STYL MOD S,SUP-2129720,CDM,V2630,CPT,0276,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
DISK ARTIFICIAL W15XH5XL17MM CERV CO CHROM MOLYBDENUM TI HA,SUP-2415962,CDM,C1889,HCPCS,0278,RC,,,,both,,,13816.00,8980.40,,,,,,,,,,,,,
HC Rep Lac Smp Face 7.6-12.5cm,PX-4501201500,CDM,12015,CPT,0450,RC,,,,both,,,1090.00,708.50,,,,,,,,,,,,,
PLATE BNE 4X8 H BILAT HND S STL T SHP LO PROF RIG NEUT,SUP-2184853,CDM,C1713,HCPCS,0278,RC,,,,both,,,1043.39,678.20,,,,,,,,,,,,,
SUPPORT ORTHOT HIP KNEE ANK CUST UNILAT TORSON BALL BEAR,SUP-2435645,CDM,L2090,HCPCS,0272,RC,,,,both,,,1407.69,915.00,,,,,,,,,,,,,
WIRE BNE FIX L 152 MM DIA 0.9 MM DBL END TROCAR TIP NS LEOS,SUP-2933124,CDM,C1713,HCPCS,0278,RC,,,,both,,,92.94,60.41,,,,,,,,,,,,,
PATCH CV 0.6X10CMX0.4MM,SUP-2395304,CDM,C1768,CPT,0278,RC,,,,both,,,229.22,148.99,,,,,,,,,,,,,
PLATE BNE T 2.7/3.5X20 MM BILATERAL FT ANK 3 HOLE POLYAX LP,SUP-2397463,CDM,C1713,HCPCS,0278,RC,,,,both,,,2760.06,1794.04,,,,,,,,,,,,,
SCREW BONE SELF TAPPING 2.4X10 MM MANDIBULAR LOCKING FOR REC,SUP-2838465,CDM,C1713,HCPCS,0278,RC,,,,both,,,593.46,385.75,,,,,,,,,,,,,
WIRE SURG OD1MM S STL VIT SMOOTH SUT,SUP-2377567,CDM,C1713,HCPCS,0278,RC,,,,both,,,342.89,222.88,,,,,,,,,,,,,
DIREXION/TRANSEND/021/BERN/1RO/155,SUP-2652845,CDM,C1887,HCPCS,0272,RC,,,,both,,,2417.80,1571.57,,,,,,,,,,,,,
STANDOFF EXT FIX 100 MM NS MAXFRAME,SUP-2758004,CDM,2720000010,LOCAL,0272,RC,,,,both,,,410.93,267.10,,,,,,,,,,,,,
CONNECTOR SPNL 4.5/6.35MM L10MM ROD IL CLS LAT CDH,SUP-2286987,CDM,C1713,HCPCS,0278,RC,,,,both,,,2343.07,1523.00,,,,,,,,,,,,,
HC Renal Biopsy Percutaneous|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE PRIOR TO THE ADMINISTRATION OF ANESTHESIA,PX-3615020000,CDM,50200,CPT,0361,RC,,,73,both,,,3707.00,2409.55,,,,,,,,,,,,,
SPLINT SWEDISH AFO WOMAN RT WHT,SUP-2324308,CDM,L4350,HCPCS,0274,RC,,,,both,,,69.87,45.42,,,,,,,,,,,,,
SCREW CONN REPL FOR VALOCKING PPFX GREATER TROCH RNG STRL,SUP-2789948,CDM,C1713,HCPCS,0278,RC,,,,both,,,541.65,352.07,,,,,,,,,,,,,
SCREW BONE EMERGENCY 2.7X14 MM CORTICAL CRUCIFORM RECESS TIT,SUP-2838297,CDM,C1713,HCPCS,0278,RC,,,,both,,,422.02,274.31,,,,,,,,,,,,,
CLIP ANEUR BLDE L8.4MM MAX OPN 6.8MM 70GM STD TEMP PHYNOX,SUP-2108379,CDM,C1889,HCPCS,0278,RC,,,,both,,,1273.05,827.48,,,,,,,,,,,,,
HC Amputation of Finger/Thumb With Flaps,PX-4502695200,CDM,26952,CPT,0450,RC,,,,both,,,3319.00,2157.35,,,,,,,,,,,,,
PLATE BNE L106MM 6 H L LAT DST PERIARTC FIBULAR LOK,SUP-2413023,CDM,C1713,HCPCS,0278,RC,,,,both,,,1987.12,1291.63,,,,,,,,,,,,,
PLATE BNE L96MM 5 H T SHP BTTRS FOR 45MM SCR L FRAG SYS,SUP-2411393,CDM,C1713,HCPCS,0278,RC,,,,both,,,859.01,558.36,,,,,,,,,,,,,
TUBE FEEDING 10FR 36 IRIS ENFIT,SUP-2878018,CDM,2720000010,LOCAL,0272,RC,,,,both,,,686.94,446.51,,,,,,,,,,,,,
ALLOGRAFT BNE COR FRZN HEMI PAT,SUP-2736963,CDM,C1762,CPT,0278,RC,,,,both,,,3377.67,2195.49,,,,,,,,,,,,,
VALVE MITRL CARP EDW TISS ANNULUS 33 MM SEW RNG DIA 42 MM,SUP-2214276,CDM,C1889,HCPCS,0278,RC,,,,both,,,17992.20,11694.93,,,,,,,,,,,,,
HC MRI-Angio Head W Contrast,PX-6157054500,CDM,70545,CPT,0615,RC,,,,outpatient,,,4278.00,2780.70,,,,,,,,,,,,,
HEAD RMR DIA16.5MM MDLLRY,SUP-2188099,CDM,C1713,HCPCS,0278,RC,,,,both,,,727.98,473.19,,,,,,,,,,,,,
BIT DRL L160MM DIA3.5MM ST CANN QUIK CPL NONRADIOLUCENT ADJ,SUP-2187340,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1243.53,808.29,,,,,,,,,,,,,
BRACE ORTH SLD ANK FT,SUP-2388165,CDM,L1960,HCPCS,0272,RC,,,,both,,,1458.81,948.23,,,,,,,,,,,,,
SET GUIDEPIN L FEM ORTH COMP TRUMATCH,SUP-2252967,CDM,C1713,HCPCS,0278,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
CATHETER CV SET 018 6 FRX60 CM 3L SPECTRUM TURBO-JECT,SUP-2759764,CDM,C1751,HCPCS,0278,RC,,,,both,,,375.61,244.15,,,,,,,,,,,,,
BLADE SHAVER DIA5MM SLOTTED WHISKER BLUE HUB,SUP-2589354,CDM,2720000010,LOCAL,0272,RC,,,,both,,,183.75,119.44,,,,,,,,,,,,,
PLATE BONE SM L156MM 12 H STD BILAT COMPR CNTOUR + FOR 3.5MM,SUP-2348999,CDM,C1713,HCPCS,0278,RC,,,,both,,,1745.24,1134.41,,,,,,,,,,,,,
DISTRACTION INTRNL ACT ARM RIGID RMTE DTCH33 MM T 6L 4V QT00,SUP-2669787,CDM,C1713,HCPCS,0278,RC,,,,both,,,2957.66,1922.48,,,,,,,,,,,,,
BLADE RETRACTOR KELLY 2INW X 1.5IND F / UNIVERSAL RING,SUP-2467436,CDM,2720000010,LOCAL,0272,RC,,,,both,,,869.84,565.40,,,,,,,,,,,,,
TUBE TRACH BLUE RHINO G2-MULTI TRAY W/SHILEY FLEX 7.5,SUP-2715854,CDM,C1769,HCPCS,0272,RC,,,,both,,,1362.07,885.35,,,,,,,,,,,,,
GENERATOR PULSE IMPLANTABLE SENZA HFX IQ IPG,SUP-2930186,CDM,C1822,CPT,0278,RC,,,,both,,,58090.00,37758.50,,,,,,,,,,,,,
WAND ARTHSCP WRK L3IN SHFT DIA0.8MM TIP DIA1MM 0DEG SLIM LN,SUP-2341981,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1378.46,896.00,,,,,,,,,,,,,
GRAFT HUM TISS 100MG PARTICULATE INJ MICRONIZED AMNIO MEM,SUP-2305720,CDM,V2790,HCPCS,0274,RC,,,,both,,,4381.87,2848.22,,,,,,,,,,,,,
PATCH VASC HEMGRD L 75 X W 75 MM THK 0.65 MM POLYESTER BOV,SUP-2535430,CDM,C1768,CPT,0278,RC,,,,both,,,532.48,346.11,,,,,,,,,,,,,
COLLAR CERV L H3XL18IN COT M DENS FOAM BRTH ADJ LO-CONTOUR,SUP-2335995,CDM,L0120,HCPCS,0272,RC,,,,both,,,17.68,11.49,,,,,,,,,,,,,
K PL L SUBCONDYLAR FRACT PL10MM LCKNG,SUP-2681867,CDM,C1713,HCPCS,0278,RC,,,,both,,,2842.39,1847.55,,,,,,,,,,,,,
MESH HERN RND 25X20 CM COMP PARIETENE DS,SUP-2430046,CDM,C1781,HCPCS,0278,RC,,,,both,,,5338.44,3469.99,,,,,,,,,,,,,
GRAFT HUM TISS 100MG PARTICULATE INJ MICRONIZED AMNIO MEM,SUP-2305720,CDM,V2790,HCPCS,0278,RC,,,,both,,,4381.87,2848.22,,,,,,,,,,,,,
COMPONENT PATELLOFEMORAL 1 LT KNEE N-K II,SUP-2208961,CDM,C1776,CPT,0278,RC,,,,both,,,14336.30,9318.59,,,,,,,,,,,,,
TUBE VENT BOB 1.02 MM 1 MM 2.7 MM FLROPLAS STRL 520026,SUP-2490416,CDM,L8699,HCPCS,0278,RC,,,,both,,,21.85,14.20,,,,,,,,,,,,,
BLADE SHV L20CM DIA37MM 45DEG BEND LARYN SNUS DISPOSABLE,SUP-2167126,CDM,C1713,HCPCS,0278,RC,,,,both,,,330.14,214.59,,,,,,,,,,,,,
PLATE BONE L104MM 4 H S STL CLVRLF,SUP-2198577,CDM,C1713,HCPCS,0278,RC,,,,both,,,534.08,347.15,,,,,,,,,,,,,
SUPPORT ORTHOT HEEL CUST THMS W/WDG,SUP-2435734,CDM,L3465,HCPCS,0274,RC,,,,both,,,165.73,107.72,,,,,,,,,,,,,
STAPLE ENDOSCP BIOABSORB LN REINF ENDOPATH SEAMGUARD BLK,SUP-2716235,CDM,2720000010,LOCAL,0272,RC,,,,both,,,523.34,340.17,,,,,,,,,,,,,
PLATE BONE 4X10 H CRANIOMAXILLOFACIAL TI Y SHP FOR SCR,SUP-2190610,CDM,C1713,HCPCS,0278,RC,,,,both,,,925.36,601.48,,,,,,,,,,,,,
MESH HERN LG 15.7X10.2 CM W/ POCKET ONFLEX,SUP-2858043,CDM,C1781,HCPCS,0278,RC,,,,both,,,797.78,518.56,,,,,,,,,,,,,
GUIDEWIRE ORTH TRCR PT 1 END 1.4X150 MM STRL,SUP-2789090,CDM,C1769,HCPCS,0272,RC,,,,both,,,1244.19,808.72,,,,,,,,,,,,,
MAGNESIUM HYDROXIDE 400 MG/5ML PO SUSP,RX-28836,CDM,6370000000,HCPCS,0637,RC,00121-0431-30,NDC,,both,5,ML,2.70,1.75,,,,,,,,,,,,,
SPONGE SCLER L5XW2.5MM HALF RND STYL 510 SIL ST,SUP-2213500,CDM,C1784,HCPCS,0278,RC,,,,both,,,150.72,97.97,,,,,,,,,,,,,
PLATE BONE L42MM THK1.4MM SHFT W7.5MM HD 21.5MM 3X5 H STRL T,SUP-2349691,CDM,C1713,HCPCS,0278,RC,,,,both,,,4538.24,2949.86,,,,,,,,,,,,,
SHEATH INTRO DRYSEAL FLX L 33 CM DIA24 FR BODY DIA 8.8 MM,SUP-2395736,CDM,C1894,HCPCS,0272,RC,,,,both,,,2182.30,1418.49,,,,,,,,,,,,,
NEEDLE NUCLEOPLASTY DLR PK CONTAINS DLR SPINEWAND AND,SUP-2342060,CDM,C1713,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
SCREW BNE L 12 MM DIA 3.5 MM TI CANN HDLSS NS LEOS,SUP-2932587,CDM,C1713,HCPCS,0278,RC,,,,both,,,856.25,556.56,,,,,,,,,,,,,
BUR SURG X COARSE DIAMOND 4 MM 12 CM BALL SM BOR MIDAS REX 8,SUP-2664535,CDM,2720000010,LOCAL,0272,RC,,,,both,,,483.56,314.31,,,,,,,,,,,,,
TESTER VENTILATOR CIRC LUNG 05 LT VENTI +,SUP-2352861,CDM,C1713,HCPCS,0278,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
CRIMPER SURG FOR ATLS CBL SYS TSRH 3D MPA,SUP-2289626,CDM,C1713,HCPCS,0278,RC,,,,both,,,3310.41,2151.77,,,,,,,,,,,,,
TRANSDUCER W WNG HSNG 12IN CBL,SUP-2303073,CDM,C1713,HCPCS,0278,RC,,,,both,,,30.36,19.73,,,,,,,,,,,,,
CHEEK RETRACTOR FOR PEDIATRIC,SUP-2823218,CDM,C1713,HCPCS,0278,RC,,,,both,,,347.28,225.73,,,,,,,,,,,,,
STAPLER INT L80MM OPN 3X385MM B SHP CLSR 15MM BLU TI 2 DBL,SUP-2283285,CDM,2720000010,LOCAL,0272,RC,,,,both,,,393.94,256.06,,,,,,,,,,,,,
NEEDLES 2-0 SUTURETAPE MENIS REP MINIMUM ORDER 10 EACH,SUP-2417039,CDM,2720000010,LOCAL,0272,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
TM COLUMN BUTTRESS AUGMENT RT POST LT ANT,SUP-2501831,CDM,C1776,CPT,0278,RC,,,,both,,,5024.00,3265.60,,,,,,,,,,,,,
PATCH CV PERI-GUARD SZ 6 X 8 CM BOV PERICARD FOR SFT TISS,SUP-2129887,CDM,C1763,HCPCS,0278,RC,,,,both,,,2067.85,1344.10,,,,,,,,,,,,,
CATHETER ANGIOPLSTY ENTEER L 135 CM BALLOON L 20 X W 3.75 X,SUP-2280836,CDM,C1887,HCPCS,0272,RC,,,,both,,,6594.00,4286.10,,,,,,,,,,,,,
CONNECTOR SPNL L40-55MM M CROSS BUTTRES ADJ CLMP,SUP-2415665,CDM,C1713,HCPCS,0278,RC,,,,both,,,1145.13,744.33,,,,,,,,,,,,,
GRAFT BNE CERV FIBULAR SPCR LORD FRZ DRY 11MM VERTIGRFT,SUP-2264884,CDM,C1713,HCPCS,0278,RC,,,,both,,,2552.00,1658.80,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY LASSO DIA 7 FR LOOP DIA20 MM SPC,SUP-2248481,CDM,C1730,HCPCS,0272,RC,,,,both,,,3033.24,1971.61,,,,,,,,,,,,,
BIT DRILL 2.0MM EVOLVE EPS,SUP-2822394,CDM,2720000010,LOCAL,0272,RC,,,,both,,,427.04,277.58,,,,,,,,,,,,,
PLEDGET VASC W5/16XL5/16IN THK1.65MM PTFE SQ FELT,SUP-2126673,CDM,C1768,CPT,0278,RC,,,,both,,,37.99,24.69,,,,,,,,,,,,,
MESH SURG L 15 X W 10 CM POLYETHYL TEREPHTHALATE ABD WHT,SUP-2901759,CDM,C1781,HCPCS,0278,RC,,,,both,,,3418.58,2222.08,,,,,,,,,,,,,
EXTENSION NERVE STIM PERC 2.16 MM ISTM QUAD INTERSTIM,SUP-2640136,CDM,C1883,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
GRAFT HUM TISS 1X4CM THN ACELLULAR DERM DERMAMATRIX,SUP-2306889,CDM,C1762,CPT,0278,RC,,,,both,,,489.87,318.42,,,,,,,,,,,,,
PLATE BONE 10 H ANTR BOW LAT PROX FOR 4.5 SCR,SUP-2349066,CDM,C1713,HCPCS,0278,RC,,,,both,,,995.47,647.06,,,,,,,,,,,,,
HYSTEROSCOPIC SET OUTFLO TUBE FOR FLUID MGMT SYS TRUCLEAR,SUP-2172306,CDM,C1713,HCPCS,0278,RC,,,,both,,,406.85,264.45,,,,,,,,,,,,,
VALVE SHUNT W/ PRECHAMBER 4/19 PAEDIGAV,SUP-2846936,CDM,C1889,HCPCS,0278,RC,,,,both,,,5141.91,3342.24,,,,,,,,,,,,,
CATHETER ABLATN STD 2-5 MM 4.5 MM 7.5 FRX110 CM INTELLATIP,SUP-2424671,CDM,C1732,HCPCS,0272,RC,,,,both,,,6123.00,3979.95,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 70 CM DIA 6 MM 50 CM STR STD WALL,SUP-2396268,CDM,C1768,CPT,0278,RC,,,,both,,,4069.44,2645.14,,,,,,,,,,,,,
COIL EMB L60CM DIA28MM NIT STD COMPLX FRME STRTCH RESIST,SUP-2323386,CDM,C1889,HCPCS,0278,RC,,,,both,,,8377.52,5445.39,,,,,,,,,,,,,
NAIL IM L 400 MM DIA13 MM TYP II,SUP-2902167,CDM,C1713,HCPCS,0278,RC,,,,both,,,10466.25,6803.06,,,,,,,,,,,,,
PROBE LAP DIA8GA STEREOTACTIC DISP MAMTOM MR,SUP-2195659,CDM,2720000010,LOCAL,0272,RC,,,,both,,,720.32,468.21,,,,,,,,,,,,,
DEFIBRILLATOR CARD CRT-D BIVENTRICULAR DF4/LV1 CONN DYNAGEN,SUP-2149214,CDM,C1882,HCPCS,0275,RC,,,,both,,,46274.18,30078.22,,,,,,,,,,,,,
GUIDEWIRE ORTH THRD 1.1X150 MM FOR CANN SCREW NS 0333301104,SUP-2789096,CDM,C1769,HCPCS,0272,RC,,,,both,,,1031.93,670.75,,,,,,,,,,,,,
CATHETER URET 4.8FR L70CM 8FR CONE TIP FOR RG PYELOGRAM,SUP-2168891,CDM,C1758,HCPCS,0278,RC,,,,both,,,48.83,31.74,,,,,,,,,,,,,
GRAFT DERM PLIABLE FLD BRST RECON ALLGRFT L12XW4CM THICKNESS,SUP-2307550,CDM,Q4128,HCPCS,0636,RC,,,,both,,,2369.13,1539.93,,,,,,,,,,,,,
CATHETER ABLAT 7FR TIP L5MM 2.5MM SPC QPLR STD CRV AND LEN,SUP-2141281,CDM,C1733,HCPCS,0272,RC,,,,both,,,3011.26,1957.32,,,,,,,,,,,,,
SLING KNOTLESS INCONT MESH,SUP-2308304,CDM,C1781,HCPCS,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
SCREW BNE L12MM DIA2.7MM DST VOLAR RAD LOK FULL THRD SQ DRV,SUP-2411792,CDM,C1713,HCPCS,0278,RC,,,,both,,,411.34,267.37,,,,,,,,,,,,,
PLATE BNE RECON 2.7X40 MM 5 HOLE SS,SUP-2569077,CDM,C1713,HCPCS,0278,RC,,,,both,,,354.04,230.13,,,,,,,,,,,,,
CATHETER CARD ABLATION THERMOCOOL SMARTTOUCH SF 115CM 8FR DD,SUP-2248620,CDM,C1732,HCPCS,0272,RC,,,,both,,,9492.22,6169.94,,,,,,,,,,,,,
STRM MCF PLATE LG RT,SUP-2492549,CDM,C1713,HCPCS,0278,RC,,,,both,,,6869.44,4465.14,,,,,,,,,,,,,
SET LD INTRO DIA12 FR PTFE PEELABLE GUIDEWIRE STRL,SUP-2133597,CDM,C1769,HCPCS,0272,RC,,,,both,,,276.32,179.61,,,,,,,,,,,,,
NEEDLE BRST LOC L5CM OD20GA REPOSIT H STYL,SUP-2174908,CDM,C1819,HCPCS,0278,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
BOLT EXT FIX CANN FOR WIRE ILIZ,SUP-2342270,CDM,C1713,HCPCS,0278,RC,,,,both,,,1535.15,997.85,,,,,,,,,,,,,
KIT REP INCL 3 L PEC BTTN ATTCH INSRT FIBERTAPE SUTS W/ NDL,SUP-2121670,CDM,C1713,HCPCS,0278,RC,,,,both,,,7404.12,4812.68,,,,,,,,,,,,,
PLATE SPNL XSM POST CERV UP THOR MULTIAXIAL VERTEX XLNK,SUP-2289098,CDM,C1713,HCPCS,0278,RC,,,,both,,,1267.78,824.06,,,,,,,,,,,,,
SCREW SPNL L40MM DIA7MM CORT COR DIA6MM CANC COR DIA5.3MM,SUP-2182453,CDM,C1713,HCPCS,0278,RC,,,,both,,,4154.22,2700.24,,,,,,,,,,,,,
ALLOGRAFT BNE WDG 0 DEG 8 MM LORDTC ILLIAC CREST BIO,SUP-2637031,CDM,C1713,HCPCS,0278,RC,,,,both,,,3303.28,2147.13,,,,,,,,,,,,,
LINER ACET DIA32MM 15DEG STD GRP 2 HIP UHMWPE POLYETH,SUP-2304472,CDM,C1776,CPT,0278,RC,,,,both,,,6531.20,4245.28,,,,,,,,,,,,,
GUIDE WIRE 32 MM X 400MM,SUP-2477386,CDM,C1769,HCPCS,0272,RC,,,,both,,,529.88,344.42,,,,,,,,,,,,,
FENTANYL 12 MCG/HR TD PT72,RX-41382,CDM,6370000000,HCPCS,0637,RC,00378-9119-16,NDC,,both,1,UN,73.10,47.51,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.434,SUP-2859998,CDM,C1713,HCPCS,0278,RC,,,,both,,,40544.31,26353.80,,,,,,,,,,,,,
BUR SURG L 7.5 CM DIA1 MM LNG BALL DIAMOND FN DISECT TOOL,SUP-2929992,CDM,2720000010,LOCAL,0272,RC,,,,both,,,659.78,428.86,,,,,,,,,,,,,
CATHETER CARD ABLATION THERMOCOOL SMARTTOUCH SF 115CM 8FR DD,SUP-2248620,CDM,C1732,HCPCS,0278,RC,,,,both,,,9492.22,6169.94,,,,,,,,,,,,,
BUR SURG MTCH HD 1.7 MMX10 CM FLUT SM BOR MIDAS REX LEGEND,SUP-2665009,CDM,2720000010,LOCAL,0272,RC,,,,both,,,294.97,191.73,,,,,,,,,,,,,
CROWN DENT PED SZ LL5 LO LT ANTR CUSPID 1ST PRI M S STL,SUP-2238889,CDM,D6783,CPT,0278,RC,,,,both,,,19.41,12.62,,,,,,,,,,,,,
PIN FIX L40MM OD1.5MM LACTOSORB COPOLYMER ABSRB SGL USE,SUP-2137294,CDM,C1713,HCPCS,0278,RC,,,,both,,,791.28,514.33,,,,,,,,,,,,,
MATRIX BIO SZ 250-540 SQCM FISH SKIN DERMAL MESHED 21,SUP-2909274,CDM,Q4158,HCPCS,0636,RC,,,,both,,,21195.00,13776.75,,,,,,,,,,,,,
SPLINT WR COLLES ALUM W/ FOAM LT M,SUP-2195268,CDM,L3906,HCPCS,0274,RC,,,,both,,,28.54,18.55,,,,,,,,,,,,,
DEVICE RESECTING 3.6MM SYMPHION,SUP-2865687,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2822.86,1834.86,,,,,,,,,,,,,
HOOK SPNL THORLUM TI NEUT BILAT OPN TOP LD FOR 4.5MM ROD,SUP-2287447,CDM,C1713,HCPCS,0278,RC,,,,both,,,3466.03,2252.92,,,,,,,,,,,,,
PLATE BONE COMPRESSION BROAD 324 MM PELVIC 18 HOLE CONTOURED,SUP-2837531,CDM,C1713,HCPCS,0278,RC,,,,both,,,3822.48,2484.61,,,,,,,,,,,,,
COLLAR CERV M AD H225XL13 16IN TRACH CLS 2 PC RIG POLYETH,SUP-2196882,CDM,L0120,HCPCS,0272,RC,,,,both,,,42.01,27.31,,,,,,,,,,,,,
CATHETER NEPHSTMY DIA24FR 2 EYE DRNGE PROPORTIONATE HD DISP,SUP-2128980,CDM,C1729,HCPCS,0272,RC,,,,both,,,25.34,16.47,,,,,,,,,,,,,
BUTTON CBL VIT SYS GRV DALL M,SUP-2377581,CDM,C1713,HCPCS,0278,RC,,,,both,,,692.06,449.84,,,,,,,,,,,,,
ENDCAP ORTH L0MM DIA3.5MM ST TI NAIL SPRL BLDE EXTN HUM,SUP-2192475,CDM,C1713,HCPCS,0278,RC,,,,both,,,442.74,287.78,,,,,,,,,,,,,
SHEATH INTRO PINNACLE L 25 CM 7 FR SS HYDRPHLC PERIPHERAL,SUP-2385676,CDM,C1894,HCPCS,0272,RC,,,,both,,,74.58,48.48,,,,,,,,,,,,,
SET BNE BX NDL 13X16GA L15X22.1CM MURPHY COAX OSTEO SITE,SUP-2170378,CDM,C1713,HCPCS,0278,RC,,,,both,,,370.43,240.78,,,,,,,,,,,,,
PLATE VA-LCKNG CALCANEAL W/TABS 2.7MM LARGE 70MM RGHT-STER,SUP-2546129,CDM,C1713,HCPCS,0278,RC,,,,both,,,3550.27,2307.68,,,,,,,,,,,,,
PLATE BNE ADAPTIVE WIDE LNG 2.5 MM RT 15 HOLE,SUP-2433960,CDM,C1713,HCPCS,0278,RC,,,,both,,,5085.54,3305.60,,,,,,,,,,,,,
CUP HUM H+0MM DIA42MM REV SHLDR POLYETH METALIZED RETENTIVE,SUP-2252983,CDM,C1776,CPT,0278,RC,,,,both,,,5178.02,3365.71,,,,,,,,,,,,,
SPACER SPNL MED 73-88 MM CNTRL BODY STRL XLR,SUP-2592014,CDM,C1889,HCPCS,0278,RC,,,,both,,,11304.00,7347.60,,,,,,,,,,,,,
GRAFT BNE SUB W1.75XL10CM POSTEROLATERAL MAGNIFUSE,SUP-2293961,CDM,C1713,HCPCS,0278,RC,,,,both,,,12560.00,8164.00,,,,,,,,,,,,,
IMPLANT OSS L4MM PIST DIA0.6MM STAP PLAT S STL RBBN LOOP,SUP-2312543,CDM,L8613,CPT,0278,RC,,,,both,,,380.94,247.61,,,,,,,,,,,,,
MICROCATHETER INFUSION MAESTRO 150CM 2.8/2.4FR TRUEFORM,SUP-2462621,CDM,C1887,HCPCS,0272,RC,,,,both,,,1642.06,1067.34,,,,,,,,,,,,,
PROSTHESIS OSS 0.83X7X1.5X1.5 MM GROTE INCUS PARTIALLY CANN,SUP-2648919,CDM,L8613,CPT,0278,RC,,,,both,,,1397.14,908.14,,,,,,,,,,,,,
CROWN DENT LR4 SEC PRI M INDIV SPACE MAINTAINER,SUP-2176710,CDM,D6783,CPT,0278,RC,,,,both,,,25.43,16.53,,,,,,,,,,,,,
ANCHOR SUT OD5.5MM 2 BLK WHT BLU NONABSORBABLE PEEK OPTMA,SUP-2341842,CDM,C1713,HCPCS,0278,RC,,,,both,,,1061.32,689.86,,,,,,,,,,,,,
GUIDEWIRE VASC L150CM DIA0.038IN L3CM STD SM VES NIT,SUP-2385581,CDM,C1769,HCPCS,0272,RC,,,,both,,,100.26,65.17,,,,,,,,,,,,,
GUIDEWIRE SURG 0.062X9 IN HYPRFLX,SUP-2765872,CDM,C1769,HCPCS,0272,RC,,,,both,,,118.16,76.80,,,,,,,,,,,,,
MESH HERN W25.4XL33CM POLYPR PTFE NONABSORBABLE ELLIPSE EXP,SUP-2125911,CDM,C1781,HCPCS,0278,RC,,,,both,,,6188.94,4022.81,,,,,,,,,,,,,
CABLE STRNL TAPR 3 BLNT 1 CUT EDGE NDL SS,SUP-2754810,CDM,C1713,HCPCS,0278,RC,,,,both,,,845.29,549.44,,,,,,,,,,,,,
BURR SURG SWNSN REAMER 5MM DIA HD MED MIC 62MML STL SM BNE M,SUP-2605556,CDM,2720000010,LOCAL,0272,RC,,,,both,,,134.45,87.39,,,,,,,,,,,,,
GRAFT HUM TISS FIB SHFT BNE FRZN ALLGRFT 50MM LEN 8 15MM W,SUP-2264755,CDM,C1713,HCPCS,0278,RC,,,,both,,,1727.19,1122.67,,,,,,,,,,,,,
PLATE BNE W5XL100MM THK1MM 20 H BILAT S STL STR RIG NEUT,SUP-2186151,CDM,C1713,HCPCS,0278,RC,,,,both,,,808.30,525.39,,,,,,,,,,,,,
PLATE BONE 6 H TI 1/3 TBLR,SUP-2319672,CDM,C1713,HCPCS,0278,RC,,,,both,,,2075.54,1349.10,,,,,,,,,,,,,
SCREW KIT CANC STRL GALAXY UNYCO,SUP-2646384,CDM,C1713,HCPCS,0278,RC,,,,both,,,884.26,574.77,,,,,,,,,,,,,
BIT DRILL CALIBRATED 3.5 MM WITH QUICK CONNECT STERILE PERIL,SUP-2837016,CDM,2720000010,LOCAL,0272,RC,,,,both,,,928.97,603.83,,,,,,,,,,,,,
PLATE BONE ORBITAL FLOOR 30X30X0.8 MM POROUS POLYETHYLENE ST,SUP-2837796,CDM,C1713,HCPCS,0278,RC,,,,both,,,1921.05,1248.68,,,,,,,,,,,,,
CANN SCREW WASHER 10.0MM OD X 4.6MM ID,SUP-2639526,CDM,C1713,HCPCS,0278,RC,,,,both,,,248.06,161.24,,,,,,,,,,,,,
PLATE BONE 14 H ANTR BOW LAT PROX FOR 3.5 SCR,SUP-2349062,CDM,C1713,HCPCS,0278,RC,,,,both,,,1035.48,673.06,,,,,,,,,,,,,
FIBER LSR 365UM HOLM,SUP-2225590,CDM,2720000010,LOCAL,0272,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
PHOSPHO-TRIN 250 NEUTRAL 155-852-130 MG PO TABS,RX-137659,CDM,2500000003,HCPCS,0250,RC,39328-0107-10,NDC,,both,1,UN,54.10,35.16,,,,,,,,,,,,,
WALKER PNEUMAT DLX L,SUP-2276721,CDM,L4361,HCPCS,0274,RC,,,,both,,,101.30,65.84,,,,,,,,,,,,,
BETAXOLOL HCL 0.25 % OP SUSP,RX-19703,CDM,6370000000,HCPCS,0637,RC,00078-0729-15,NDC,,both,15,ML,2737.80,1779.57,,,,,,,,,,,,,
HC MRI-Spine Thoracic W Contrast,PX-6127214700,CDM,72147,CPT,0612,RC,,,,inpatient,,,4146.00,2694.90,,,,,,,,,,,,,
PLATE BONE L98MM 7 H RT POST DSTL TIB LCK FOR 3.5MM SCR,SUP-2349805,CDM,C1713,HCPCS,0278,RC,,,,both,,,9518.13,6186.78,,,,,,,,,,,,,
PLATE CRAN THK 0.3 MM SCREW DIA1.5 MM MASTOID NS DISP,SUP-2936857,CDM,C1713,HCPCS,0278,RC,,,,both,,,2885.66,1875.68,,,,,,,,,,,,,
TUBE FEED OD14FR ID9FR SIL JEJUSTMY TRIM DST TIP SUT WNG,SUP-2124616,CDM,2720000010,LOCAL,0272,RC,,,,both,,,597.04,388.08,,,,,,,,,,,,,
LEAD PACE ATTAIN ABIL + MRI SURESCAN L 78 CM DIA 5.3 FR SIL,SUP-2281927,CDM,C1900,HCPCS,0275,RC,,,,both,,,3818.24,2481.86,,,,,,,,,,,,,
FORCEPS ES BPLR VEOA,SUP-2164089,CDM,C1713,HCPCS,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
MARKER TISS W2XL3CM RADIOGRAPHIC BIOABSRB SPCR HLD RADPQ,SUP-2225558,CDM,A4648,CPT,0278,RC,,,,both,,,3061.50,1989.97,,,,,,,,,,,,,
STRIPPER 365 MU SLM LN,SUP-2140359,CDM,2720000010,LOCAL,0272,RC,,,,both,,,675.10,438.81,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.553,SUP-2860070,CDM,C1713,HCPCS,0278,RC,,,,both,,,70944.85,46114.15,,,,,,,,,,,,,
DEFIBRILLATOR IMPL INCEPTA VR W 6.9 X H 6.17 CM D 0.99 CM TI,SUP-2149200,CDM,C1722,HCPCS,0275,RC,,,,both,,,38003.42,24702.22,,,,,,,,,,,,,
PLATE BNE L72MM BRL L38MM 135DEG 3 H ST BILAT PELV HIP S STL,SUP-2186805,CDM,C1713,HCPCS,0278,RC,,,,both,,,1984.64,1290.02,,,,,,,,,,,,,
TRAY CATH PICC GROSH NXT INTERMED 5FR 0.026IN 55CM 2 LUMAN R,SUP-2613425,CDM,C1751,HCPCS,0278,RC,,,,both,,,421.39,273.90,,,,,,,,,,,,,
HC Perq Dev Breast Add Strtctc,PX-3611928400,CDM,19284,CPT,0361,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
SPLINT FRARM AD SM/M RT NEOPRNE TERRY LNR BASE CVA/TBI DGT,SUP-2324472,CDM,L3809,HCPCS,0274,RC,,,,both,,,375.98,244.39,,,,,,,,,,,,,
COMPONENT FEM SZ 4 L KNEE OXINIUM REV CEM LEGION,SUP-2346188,CDM,C1776,CPT,0278,RC,,,,both,,,20070.88,13046.07,,,,,,,,,,,,,
DEVICE URO BLEED CTRL 24FR L54CM 500ML BLLN POSTPARTUM W/,SUP-2169481,CDM,C2628,HCPCS,0272,RC,,,,both,,,1334.56,867.46,,,,,,,,,,,,,
DEVICE REATTACHMENT W22.1XL50.8MM SHT GREATER TROCHANTERIC,SUP-2410261,CDM,C1776,CPT,0278,RC,,,,both,,,2235.49,1453.07,,,,,,,,,,,,,
GRAFT VASC ARTEGRAFT L 30 CM DIA 8 MM CLLGN BOV CAR ART,SUP-2120660,CDM,C1768,CPT,0278,RC,,,,both,,,12054.46,7835.40,,,,,,,,,,,,,
BIT DRL L 400 MM DIA2.5 MM CALIB L 120 MM QC NS DISP,SUP-2905664,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1738.05,1129.73,,,,,,,,,,,,,
HC Convert Nephrostomy Catheter,PX-3615043400,CDM,50434,CPT,0361,RC,,,,outpatient,,,6875.00,4468.75,,,,,,,,,,,,,
STIMULATOR NERVE VAGEL ASPIRE GEN,SUP-2265164,CDM,C1767,HCPCS,0278,RC,,,,both,,,92944.91,60414.19,,,,,,,,,,,,,
CANNULA LAP AUTO VLV 22 MMX12 CM,SUP-2767793,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1970.48,1280.81,,,,,,,,,,,,,
CATHETER CARD ABLATION CELSIUS L 115CM DIA 7FR J SHP BRAIDED,SUP-2257450,CDM,C1733,HCPCS,0272,RC,,,,both,,,2367.56,1538.91,,,,,,,,,,,,,
SCREW BNE ST 1X7 MM CRTX EMGCY W/ FLUT TIP TI MTRX GLD NS LF,SUP-2189079,CDM,C1713,HCPCS,0278,RC,,,,both,,,337.17,219.16,,,,,,,,,,,,,
SCREW CORTICAL 2.5X26MM,SUP-2719777,CDM,C1713,HCPCS,0278,RC,,,,both,,,268.60,174.59,,,,,,,,,,,,,
SCREW BNE LNG THRD 4X26 MM,SUP-2315916,CDM,C1713,HCPCS,0278,RC,,,,both,,,747.32,485.76,,,,,,,,,,,,,
STAPLER 45 SUREFORM CURVED TIP,SUP-2738091,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1632.27,1060.98,,,,,,,,,,,,,
NEEDLE REPROC INTRO 98CM 18G 30DEG BRK1 XS S STL TRANSSEPTAL,SUP-2877985,CDM,C1893,HCPCS,0272,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
ACETYLCYSTEINE 20 % IN SOLN,RX-123,CDM,J7608,HCPCS,0636,RC,00517-7604-01,NDC,,both,3,ML,50.90,33.08,,,,,,,,,,,,,
PLATE BONE L80MM 7 H STRL LT POSTEROLATERAL DSTL FIBULAR S,SUP-2349721,CDM,C1713,HCPCS,0278,RC,,,,both,,,3974.77,2583.60,,,,,,,,,,,,,
SCREW BNE L13MM DIA2.5MM CO CHROM MULTDIR LOK THRD PEGGED,SUP-2421379,CDM,C1713,HCPCS,0278,RC,,,,both,,,524.63,341.01,,,,,,,,,,,,,
PLATE BNE L24MM THK075MM 6 H NONSTERILE HND TI STR LOK FOR,SUP-2180985,CDM,C1713,HCPCS,0278,RC,,,,both,,,1286.58,836.28,,,,,,,,,,,,,
PLATE BNE LG DSTL MEDL TIB SUPRAMALLEOLAR OSTEOTOM NS,SUP-2898977,CDM,C1713,HCPCS,0278,RC,,,,both,,,5163.73,3356.42,,,,,,,,,,,,,
RIBBON RETR 4 X 13,SUP-2244673,CDM,C1713,HCPCS,0278,RC,,,,both,,,68.17,44.31,,,,,,,,,,,,,
HANDLE BLU LT ERGO TI REUSE GRIESHABER RENAISSANCE NG,SUP-2109713,CDM,2720000010,LOCAL,0272,RC,,,,both,,,960.84,624.55,,,,,,,,,,,,,
GUIDEWIRE VASC LUNDERQUIST L 180 CM DIA 0.035 IN TAPR L 11,SUP-2170522,CDM,C1769,HCPCS,0272,RC,,,,both,,,204.92,133.20,,,,,,,,,,,,,
GRAFT HUM TISSUE 200 SQ CM XL THK2.4MM +/-0.4MM CNTOUR PERF RDY TO USE,SUP-2113446,CDM,Q4116,HCPCS,0636,RC,,,,both,,,24077.52,15650.39,,,,,,,,,,,,,
PLATE BONE 135DG 5 HOLE STNLSS STEEL FMRL BLTRL STNDRD TUBE,SUP-2500321,CDM,C1713,HCPCS,0278,RC,,,,both,,,1397.17,908.16,,,,,,,,,,,,,
ANCHOR SUT ETHIB FASTIN RC W/O 2-0,SUP-2525522,CDM,C1713,HCPCS,0278,RC,,,,both,,,1277.98,830.69,,,,,,,,,,,,,
BIT DRL FLUT 5.3X362 MM VERSANAIL,SUP-2606669,CDM,2720000010,LOCAL,0272,RC,,,,both,,,643.57,418.32,,,,,,,,,,,,,
DEVICE SURG 23X121 MM TIV TROCHANTERIC 2 CABLE,SUP-2410260,CDM,C1713,HCPCS,0278,RC,,,,both,,,5050.53,3282.84,,,,,,,,,,,,,
BIT DRILL NAV LONG 3.5MM,SUP-2711623,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1806.63,1174.31,,,,,,,,,,,,,
LEVEL CMF PLATE SMRT3D TRMA ZMC BTTRSS LFT 15 MM SCRW11 HOL,SUP-2667284,CDM,C1713,HCPCS,0278,RC,,,,both,,,1180.20,767.13,,,,,,,,,,,,,
CATHETER DIAG 180DEG FIRM TIP EWC EDGE 180 SDK4000FT] SUPERDIMENSION INC],SUP-2381765,CDM,C1887,HCPCS,0272,RC,,,,both,,,4892.12,3179.88,,,,,,,,,,,,,
TIBIAL NAIL D15XL405,SUP-2703049,CDM,C1776,CPT,0278,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
PLATE BNE L94MM THK3MM 5 H BILAT S STL STR LOK COMPR RECON,SUP-2185333,CDM,C1713,HCPCS,0278,RC,,,,both,,,1297.95,843.67,,,,,,,,,,,,,
BLADE RTRCTR 1 12NW X 2 14ND STNLSS STEEL GRRTT JARIT LATE,SUP-2703326,CDM,2720000010,LOCAL,0272,RC,,,,both,,,718.15,466.80,,,,,,,,,,,,,
BASEPLATE TIB SZ 1 UNIV KNEE PRI CEM MOD KEEL IMP NXGN,SUP-2201004,CDM,C1776,CPT,0278,RC,,,,both,,,3041.09,1976.71,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 3X2 CM AMNIO WND MTRX BIOSKIN,SUP-2759486,CDM,C1762,CPT,0278,RC,,,,both,,,5028.74,3268.68,,,,,,,,,,,,,
NIVOLUMAB-RELATLIMAB-RMBW 240-80 MG/20ML IV SOLN,RX-157838,CDM,J9298,HCPCS,0636,RC,00003-7125-11,NDC,,both,40,ML,88830.70,57739.95,,,,,,,,,,,,,
KIT PEG 20FR NONSAFETY PUSH GWIRE PLCMNT TECH DLX,SUP-2127679,CDM,C1769,HCPCS,0272,RC,,,,both,,,548.09,356.26,,,,,,,,,,,,,
STEM FEM KNEE CONSTRN SCR SUPLMNT,SUP-2210610,CDM,C1713,HCPCS,0278,RC,,,,both,,,2172.88,1412.37,,,,,,,,,,,,,
COMPONENT FEM SM RT KNEE LIBRA,SUP-2442352,CDM,C1776,CPT,0278,RC,,,,both,,,1102.14,716.39,,,,,,,,,,,,,
SUPPORT ORTHOT CUST LEGG PERTHES ORTHOSIS TORONTO TYP,SUP-2435603,CDM,L1700,HCPCS,0274,RC,,,,both,,,4404.76,2863.09,,,,,,,,,,,,,
CONNECTOR SPNL 6.35MM M CORONAL SPINNER TI,SUP-2293328,CDM,C1713,HCPCS,0278,RC,,,,both,,,3290.72,2138.97,,,,,,,,,,,,,
BONE MARROW TRAY STD 8 GAX4 IN W/ BX NDL STRL T-LOK LTX,SUP-2876731,CDM,2720000010,LOCAL,0272,RC,,,,both,,,351.68,228.59,,,,,,,,,,,,,
PLATE BONE THK1.8MM 6 H ANG FOR 2.4MM SCR LORENZ,SUP-2136638,CDM,C1713,HCPCS,0278,RC,,,,both,,,1362.76,885.79,,,,,,,,,,,,,
STAPLE BNE AKIN 10X10 MM,SUP-2223275,CDM,C1713,HCPCS,0278,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
VALVE AORT STENTED LO PROF PORCINE IMP H14MM ID19MM 21MM,SUP-2355763,CDM,C1713,HCPCS,0278,RC,,,,both,,,14130.00,9184.50,,,,,,,,,,,,,
LOOP LAPSCP BPLR EFFECTIVE HEMSTAT CUT ERGO HNDL PKS BILL,SUP-2312971,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
HOOK SPNL BLDE W5.5MM BILAT TI TRNSVRS PROC OFFSET OPN FOR,SUP-2254440,CDM,C1713,HCPCS,0278,RC,,,,both,,,2935.90,1908.33,,,,,,,,,,,,,
SCREW BNE NAIL NAIL HOLDING GTN,SUP-2475646,CDM,C1713,HCPCS,0278,RC,,,,both,,,475.71,309.21,,,,,,,,,,,,,
KIT SPNL CEM 11CC PMMA HI VISC W/ 2 INTRO BX NDL RESVR MIX,SUP-2255657,CDM,C1713,HCPCS,0278,RC,,,,both,,,5809.00,3775.85,,,,,,,,,,,,,
GRAFT BNE 4X4 CM REGENERATIVE TISS MTRX,SUP-2399157,CDM,C1713,HCPCS,0278,RC,,,,both,,,3642.40,2367.56,,,,,,,,,,,,,
PEGFILGRASTIM-CBQV (INF DEV) 6 MG/0.6ML SC SOSY,RX-166563,CDM,Q5111,HCPCS,0636,RC,70114-0130-01,NDC,,both,0.6,ML,12316.30,8005.59,,,,,,,,,,,,,
GRAFT BIO TISS 4X4CM THK04 10MM UNMESHED ACELLULAR DERM,SUP-2362227,CDM,C1763,HCPCS,0278,RC,,,,both,,,4657.25,3027.21,,,,,,,,,,,,,
HC Chemo Infuse Addl Hour Chemo,PX-3359641500,CDM,96415,CPT,0335,RC,,,,both,,,377.00,245.05,,,,,,,,,,,,,
GRAFT HUM TISS W4XL8CM THK08 17MM DERM HUM ACELLULAR,SUP-2307046,CDM,Q4128,HCPCS,0636,RC,,,,both,,,5036.40,3273.66,,,,,,,,,,,,,
SYSTEM PEDCL ACCS INSUL DMND TIP JAMSH I-PASS II,SUP-2310403,CDM,C1713,HCPCS,0278,RC,,,,both,,,1438.12,934.78,,,,,,,,,,,,,
PLATE 3.5MM TI LCP MEDIAL PROXIMAL TIBIA 14H LT 223MM-STER,SUP-2549587,CDM,C1713,HCPCS,0278,RC,,,,both,,,4809.91,3126.44,,,,,,,,,,,,,
HC Urine Pregnancy Test Visual Color Cmprsn Meths,PX-3078102505,CDM,81025,CPT,0307,RC,,,,both,,,356.00,231.40,,,,,,,,,,,,,
HC Rem Int Ureteral Stent,PX-3615038400,CDM,50384,CPT,0361,RC,,,,both,,,8583.00,5578.95,,,,,,,,,,,,,
DUODENOSCOPE FLX RETRO SIDE VIEWING 13.7X11.3X1240 MM ASCOPE,SUP-2659123,CDM,C1748,HCPCS,0278,RC,,,,both,,,43944.30,28563.79,,,,,,,,,,,,,
BRACE WRST M FOR 17.1-19.1CM L PROTCT PD ADJ BAR D RNG CLSR,SUP-2326112,CDM,L3931,HCPCS,0274,RC,,,,both,,,50.77,33.00,,,,,,,,,,,,,
STENT PERIPH L28MM DIA4.5MM INTCRAN ENTERPRISE,SUP-2249134,CDM,C1874,HCPCS,0278,RC,,,,both,,,16328.00,10613.20,,,,,,,,,,,,,
TUBE INNR EAR MYR VENT FLNG W/ TAB 2.03 MM ID SIL BLU,SUP-2312637,CDM,L8699,HCPCS,0278,RC,,,,both,,,45.06,29.29,,,,,,,,,,,,,
BIT DRILL EXTRACTION SZ 7.5 MM SCREW DIA 6.6-7.5 MM STRL,SUP-2913513,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2748.07,1786.25,,,,,,,,,,,,,
WEDGE TIB SZ 7-8 THK10MM FULL STP HNG REV KNEE LEGION,SUP-2346602,CDM,C1776,CPT,0278,RC,,,,both,,,5042.84,3277.85,,,,,,,,,,,,,
SCREW BNE MYOMA 10X320 MM LAP FOR MANIPULATION,SUP-2475554,CDM,C1713,HCPCS,0278,RC,,,,both,,,497.94,323.66,,,,,,,,,,,,,
ROD IM LNG DSTL LCS HP,SUP-2453499,CDM,C1713,HCPCS,0278,RC,,,,both,,,1573.14,1022.54,,,,,,,,,,,,,
SCREW BNE L5MM DIA2.7MM MAND CRANIOMAXILLOFACIAL SIL LOK 5PK,SUP-2366184,CDM,C1713,HCPCS,0278,RC,,,,both,,,387.10,251.61,,,,,,,,,,,,,
RESERVOIR CSF STD MINI 0.14 CC W/O VENTRICULAR CATH,SUP-2852700,CDM,C1729,HCPCS,0272,RC,,,,both,,,1635.59,1063.13,,,,,,,,,,,,,
TWIST DRILL MRRSNKLS MRTN1.5MM X 117 X 25MM STOP CYL 01 100,SUP-2707268,CDM,2720000010,LOCAL,0272,RC,,,,both,,,715.39,465.00,,,,,,,,,,,,,
KNIFE BLADE BAN 3.5 MM,SUP-2399091,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1365.90,887.83,,,,,,,,,,,,,
HC Dna Antibody Native/Double Stranded,PX-3028622500,CDM,86225,CPT,0302,RC,,,,both,,,75.00,48.75,,,,,,,,,,,,,
BARRIER ADH REDUCTION SOLUTION 1.5 LT FLX PVC CLR STRL ADEPT,SUP-2130305,CDM,C1765,HCPCS,0278,RC,,,,both,,,765.53,497.59,,,,,,,,,,,,,
RING EXT FIX DIA 300 MM HALF NS DISP TSF,SUP-2933826,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7847.05,5100.58,,,,,,,,,,,,,
PLATE BONE ANKLE 12 HOLE 1/3 TUBULAR TITANIUM GRIDLOCK VLC PLATING SYSTEM FOR 2.4/3/4MM SCREW,SUP-2878204,CDM,C1713,HCPCS,0278,RC,,,,both,,,2763.20,1796.08,,,,,,,,,,,,,
LEAD NEUROSTIMULATOR L90CM 4 CHMBR PERC PERM QUATTRODE,SUP-2356727,CDM,C1778,HCPCS,0278,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
NITROPRUSSIDE SODIUM 25 MG/ML IV SOLN,RX-18908,CDM,2500000003,HCPCS,0250,RC,72485-0105-01,NDC,,both,2,ML,115.00,74.75,,,,,,,,,,,,,
PLATE 4.5MM TI LCP T 4 HOLES 83MM,SUP-2549652,CDM,C1713,HCPCS,0278,RC,,,,both,,,1789.30,1163.04,,,,,,,,,,,,,
DRAIN SURG W7XL20CM SIL FULL PERF FLAT W/O TRCR,SUP-2198723,CDM,C1729,HCPCS,0272,RC,,,,both,,,64.09,41.66,,,,,,,,,,,,,
PRX HUM HI PLT RT 11H 197MM,SUP-2472710,CDM,C1713,HCPCS,0278,RC,,,,both,,,6079.04,3951.38,,,,,,,,,,,,,
ROD SPNL THORLUM CRV PREBENT TI OD5.5MM L50MM SILVERTON,SUP-2415726,CDM,C1713,HCPCS,0278,RC,,,,both,,,1169.96,760.47,,,,,,,,,,,,,
CONNECTOR SPNL 635-7MM DOMINO CDH,SUP-2631754,CDM,C1713,HCPCS,0278,RC,,,,both,,,2176.02,1414.41,,,,,,,,,,,,,
IMPLANT BIOLOGICAL TISSUE W5XL5CM RS SURGICAL MATRIX MATRISTEM,SUP-2106515,CDM,Q4166,HCPCS,0636,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
PLATE BNE TI ORTHOGNATHIC 8 PLATE CUSTOMIZED FACE ID,SUP-2883700,CDM,C1713,HCPCS,0278,RC,,,,both,,,36293.12,23590.53,,,,,,,,,,,,,
KIT LD ADPT BLV BIS 40,SUP-2282320,CDM,C1883,HCPCS,0278,RC,,,,both,,,1384.30,899.79,,,,,,,,,,,,,
HC Infectious Agent Dna/Rna Vancomycin Resistance,PX-3068750000,CDM,87500,CPT,0306,RC,,,,both,,,91.00,59.15,,,,,,,,,,,,,
HC So Stem Cells Total Count,PX-3028636766,CDM,86367,CPT,0302,RC,,,,both,,,246.00,159.90,,,,,,,,,,,,,
FILTER VASC VENATECH LP L 56 CM DIA 9 FR VENA CAVA CARTRIDGE,SUP-2498261,CDM,C1880,HCPCS,0278,RC,,,,both,,,3579.60,2326.74,,,,,,,,,,,,,
SCREW SACROILIAC 10X30MM JT FIX CANN THRD TI SI-LOK,SUP-2229755,CDM,C1713,HCPCS,0278,RC,,,,both,,,8792.00,5714.80,,,,,,,,,,,,,
PROSTHESIS INDWL VOICE L FLNG T AND E 20F 14MM,SUP-2242419,CDM,L8509,HCPCS,0274,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
BIT REPROC DRL CANN AO CPL 2MM,SUP-2653248,CDM,2720000010,LOCAL,0272,RC,,,,both,,,449.90,292.43,,,,,,,,,,,,,
PLATE SPINE L42.5MM ANT CERV TI ALLY CNVGNT ATLNTS,SUP-2291079,CDM,C1713,HCPCS,0278,RC,,,,both,,,3100.31,2015.20,,,,,,,,,,,,,
PLATE BNE SHT RT PLNTR SYS IMPL INSTRUMENT AXIS,SUP-2610219,CDM,C1713,HCPCS,0278,RC,,,,both,,,7912.80,5143.32,,,,,,,,,,,,,
BIT DRILL PILOT TIP SHORT 3.2 MMX6 IN QUICK CONNECT FOR ANTE,SUP-2837090,CDM,2720000010,LOCAL,0272,RC,,,,both,,,484.28,314.78,,,,,,,,,,,,,
GUIDEWIRE VASC ADX L 180 CM 0.035IN L15CM PTFE WORKHORSE TIP,SUP-2657248,CDM,C1769,HCPCS,0272,RC,,,,both,,,41.45,26.94,,,,,,,,,,,,,
CUBE EXT FIX 5 H RANCHO FEMALE,SUP-2898462,CDM,2720000010,LOCAL,0272,RC,,,,both,,,778.72,506.17,,,,,,,,,,,,,
BETAMETHASONE DIPROPIONATE 0.05 % EX OINT,RX-1029,CDM,6370000000,HCPCS,0637,RC,00168-0056-15,NDC,,both,15,GR,221.40,143.91,,,,,,,,,,,,,
RESVR PROS TI 75ML LCK OUT VLV,SUP-2165355,CDM,C1813,HCPCS,0278,RC,,,,both,,,4144.80,2694.12,,,,,,,,,,,,,
SPLINT DORSAL AFO SPLNT S LF W STRP,SUP-2163833,CDM,L4396,HCPCS,0274,RC,,,,both,,,86.13,55.98,,,,,,,,,,,,,
PLATE BNE JAW FACE 4 ORTHOGNATHIC,SUP-2883355,CDM,C1713,HCPCS,0278,RC,,,,both,,,28651.31,18623.35,,,,,,,,,,,,,
STENT PERIPH 8FR L10CM DIA8MM CATH L120CM 0.035IN FEM ART,SUP-2396490,CDM,C1874,HCPCS,0278,RC,,,,both,,,8415.20,5469.88,,,,,,,,,,,,,
SCREW BNE PART THRD LG 4.3X60 MM STRL PROPELLER HD LTX,SUP-2861175,CDM,C1713,HCPCS,0278,RC,,,,both,,,756.80,491.92,,,,,,,,,,,,,
KIT PICC CATH L 55 CM DIA 4 FR GUIDEWIRE 0.018 IN NDL L 7 CM,SUP-2884238,CDM,C1751,HCPCS,0278,RC,,,,both,,,489.21,317.99,,,,,,,,,,,,,
GRAFT DERMAL PLIABLE THN XS 15X9 CMX0.7-1.4 MM PERF FLEXHD,SUP-2307599,CDM,Q4128,HCPCS,0636,RC,,,,both,,,8607.37,5594.79,,,,,,,,,,,,,
ARCUS 16X13 STAPLE ASSEMBLY STERILE,SUP-2477081,CDM,C1713,HCPCS,0278,RC,,,,both,,,2384.86,1550.16,,,,,,,,,,,,,
CATHETER ANGIOPLSTY NC RANG L 135 CM BALLOON L 9 MM DIA 3 MM,SUP-2140522,CDM,C1725,HCPCS,0272,RC,,,,both,,,703.36,457.18,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 5 CM DIA 5 MM EPTFE STR TW N RING,SUP-2396332,CDM,C1768,CPT,0278,RC,,,,both,,,753.60,489.84,,,,,,,,,,,,,
PLATE BNE XSM L24MM 4 H NONSTERILE BILAT FOREFOOT TI X SHP,SUP-2181208,CDM,C1713,HCPCS,0278,RC,,,,both,,,3375.34,2193.97,,,,,,,,,,,,,
KIT HAMRTOE CORR STP DRL 16 28 35MM PROX MID PHALANX RMR,SUP-2137575,CDM,C1713,HCPCS,0278,RC,,,,both,,,3428.88,2228.77,,,,,,,,,,,,,
ALLOGRAFT HUM TISS FRZN ASEP HEMI BONE-PATELLAR TENDON-BONE,SUP-2867006,CDM,C1762,CPT,0278,RC,,,,both,,,7558.92,4913.30,,,,,,,,,,,,,
PLUG BONE 12MM CEM RESTRIC SWNSN DSGN,SUP-2304516,CDM,C1776,CPT,0278,RC,,,,both,,,398.78,259.21,,,,,,,,,,,,,
GRAFT HUM TISS L 40 MM DIA10 MM FIB SHFT LYOPH STRL,SUP-2913284,CDM,C1762,CPT,0278,RC,,,,both,,,2339.30,1520.54,,,,,,,,,,,,,
GRAFT HUM TISS W4XL7CM REGEN MTRX REPLFRM,SUP-2139390,CDM,C1762,CPT,0278,RC,,,,both,,,3190.59,2073.88,,,,,,,,,,,,,
MESH CRAN L 55 X W 55 MM THK 1 MM SCREW DIA1.7 MM PLLA PDLA,SUP-2883463,CDM,C1713,HCPCS,0278,RC,,,,both,,,5976.11,3884.47,,,,,,,,,,,,,
IMPLANT INSITE FT TI ANCHR 4.5MM W/ NDL,SUP-2388906,CDM,C1713,HCPCS,0278,RC,,,,both,,,1711.30,1112.34,,,,,,,,,,,,,
CATHETER GUID TYP 3DRC USED IN COR ANGIOPLSTY VASC PERIPH,SUP-2158732,CDM,C1887,HCPCS,0272,RC,,,,both,,,419.98,272.99,,,,,,,,,,,,,
PLATE BNE W33XL147MM 10 H R DST MED TIB S STL LOK COMPR NEUT,SUP-2185113,CDM,C1713,HCPCS,0278,RC,,,,both,,,3879.00,2521.35,,,,,,,,,,,,,
HANDPIECE LASER BENT 140 MM STR TIP FIBERLASE HP-R,SUP-2713737,CDM,2720000010,LOCAL,0272,RC,,,,both,,,869.78,565.36,,,,,,,,,,,,,
TIP THRMCPL LG 4 MM CRV,SUP-2357671,CDM,C1733,HCPCS,0272,RC,,,,both,,,2041.00,1326.65,,,,,,,,,,,,,
OSELTAMIVIR PHOSPHATE 6 MG/ML PO SUSR,RX-110204,CDM,340b,HCPCS,0637,RC,00004-0822-05,NDC,,both,5,ML,57.00,37.05,,,,,,,,,,,,,
GRID RAD FAST FIND FOR BX,SUP-2352842,CDM,2720000010,LOCAL,0272,RC,,,,both,,,426.79,277.41,,,,,,,,,,,,,
OBTURATOR ENDOSCP COR BX LG,SUP-2487605,CDM,2720000010,LOCAL,0272,RC,,,,both,,,962.50,625.62,,,,,,,,,,,,,
BUSPIRONE HCL 15 MG PO TABS,RX-17464,CDM,6370000000,HCPCS,0637,RC,51079-0960-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
CLAMP REPROC COMBO MR SAFE LG,SUP-2537966,CDM,2720000010,LOCAL,0272,RC,,,,both,,,550.66,357.93,,,,,,,,,,,,,
STAPLE BNE W18XL16MM NIT SHP MEM COMPRESSIVE FORC DISP,SUP-2399897,CDM,C1713,HCPCS,0278,RC,,,,both,,,4970.62,3230.90,,,,,,,,,,,,,
CATHETER HD STR 14 FRX15 CM SHT TERM 400 XL FULL TY TAPR TIP,SUP-2266959,CDM,C1752,HCPCS,0278,RC,,,,both,,,414.48,269.41,,,,,,,,,,,,,
BIT DRL STR 1.4 MM ICONIX REUSE,SUP-2608470,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1360.94,884.61,,,,,,,,,,,,,
SHEATH INTRO PINNACLE L 10 CM 7 FR GUIDEWIRE PERIPHERAL,SUP-2385674,CDM,C1894,HCPCS,0272,RC,,,,both,,,36.11,23.47,,,,,,,,,,,,,
BALLOON DIL 54 57 60FR L55CM INFLATED DIA18 19 20MM 2 4 6ATM,SUP-2170846,CDM,C1726,HCPCS,0272,RC,,,,both,,,725.34,471.47,,,,,,,,,,,,,
BUR SURG L90MM DIA5MM DMND NONFLUTED RND LEGEND MIDAS REX,SUP-2284660,CDM,C1713,HCPCS,0278,RC,,,,both,,,393.91,256.04,,,,,,,,,,,,,
GRAFT BONE 15ML CANC SUB FOAM FLO B-TCP VITOSS,SUP-2370371,CDM,C1713,HCPCS,0278,RC,,,,both,,,8195.40,5327.01,,,,,,,,,,,,,
SPLINT ORTHOPEDICXSM FNGR DYN WIRE FOAM PIP EXTN ASST AA,SUP-2324550,CDM,L3933,HCPCS,0272,RC,,,,both,,,63.02,40.96,,,,,,,,,,,,,
NEEDLE SURG BVL VITAL JAMSH,SUP-2693463,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
HC Place Cath Subclavian Art,PX-3613622500,CDM,36225,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
PLATE BONE DIA70MM THK1.5MM NONSTERILE CRANIOMAXILLOFACIAL,SUP-2191127,CDM,C1713,HCPCS,0278,RC,,,,both,,,5226.22,3397.04,,,,,,,,,,,,,
FELBAMATE 600 MG PO TABS,RX-10025,CDM,6370000000,HCPCS,0637,RC,00037-0431-01,NDC,,both,1,UN,79.70,51.80,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.443,SUP-2860007,CDM,C1713,HCPCS,0278,RC,,,,both,,,51285.93,33335.85,,,,,,,,,,,,,
PLATE BNE CLAV 3.5X115 MM RT 8 HOLE SS NS,SUP-2177136,CDM,C1713,HCPCS,0278,RC,,,,both,,,2981.24,1937.81,,,,,,,,,,,,,
WIRE FIX L150MM DIA1.25MM CO K 6PK,SUP-2136103,CDM,C1769,HCPCS,0272,RC,,,,both,,,351.68,228.59,,,,,,,,,,,,,
ALLOGRAFT BNE PATELLAR TEND TISS,SUP-2165535,CDM,C1889,HCPCS,0278,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
STAPLE INT 8X8X8MM THK1.5X1.2MM DRL DIA2MM COMPR FOR,SUP-2378850,CDM,C1776,CPT,0278,RC,,,,both,,,2747.50,1785.87,,,,,,,,,,,,,
PLATE BNE L W135XL98MM THK42MM 5 H BILAT TI NAR RIG NEUT,SUP-2190810,CDM,C1713,HCPCS,0278,RC,,,,both,,,1093.69,710.90,,,,,,,,,,,,,
CATHETER PTCA L142CM BLLN L20MM DIA2MM 0.022IN 14ATM,SUP-2298377,CDM,C1725,HCPCS,0272,RC,,,,both,,,188.40,122.46,,,,,,,,,,,,,
COMPONENT TIB L9CM PROX MOD BODY ORTH SALV SYS,SUP-2405794,CDM,C1776,CPT,0278,RC,,,,both,,,17676.63,11489.81,,,,,,,,,,,,,
KIT PT PRGM FOR SPNL CRD STIM SYS PRECIS NOVI,SUP-2138828,CDM,C1713,HCPCS,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
CATHETER CV SET 025 PEDIATRIC 5 FRX5 CM 3L POLYURETHANE,SUP-2759969,CDM,C1751,HCPCS,0278,RC,,,,both,,,234.68,152.54,,,,,,,,,,,,,
DIREXION HI FLO/SINGLE/027/J/1RO/105,SUP-2652834,CDM,C1887,HCPCS,0272,RC,,,,both,,,1695.60,1102.14,,,,,,,,,,,,,
PEG KIT DOBBHOFF 90 DEG BEND 16 FR SAFETY SINGLE PASS PUL,SUP-2852146,CDM,2720000010,LOCAL,0272,RC,,,,both,,,353.25,229.61,,,,,,,,,,,,,
PLATE BONE CONDYLAR 6 HOLE QUARTER TUBULAR STAINLESS STEEL S,SUP-2836701,CDM,C1713,HCPCS,0278,RC,,,,both,,,627.43,407.83,,,,,,,,,,,,,
MATRIX BIO L 8 X W 6 CM FISH SKIN DERMAL INTACT STRL OMEGA3,SUP-2909258,CDM,Q4158,HCPCS,0636,RC,,,,both,,,8449.74,5492.33,,,,,,,,,,,,,
TRAY PICC 6FR L55CM POLYUR NRS DBL LUMN FULL PWR INJ N COAT,SUP-2126709,CDM,C1751,HCPCS,0278,RC,,,,both,,,643.70,418.40,,,,,,,,,,,,,
VORICONAZOLE 200 MG IV SOLR,RX-33010,CDM,J3465,HCPCS,0636,RC,00049-3190-28,NDC,,both,1,UN,106.60,69.29,,,,,,,,,,,,,
DEFIBRILLATOR IMPL CONFIENT RF HE TI 1 LD W/O ATR LD PASS,SUP-2149144,CDM,C1722,HCPCS,0275,RC,,,,both,,,56520.00,36738.00,,,,,,,,,,,,,
ANCHOR SUTURE 4.5MM WITH 3 NO 2 SUTURES HI-FI NEEDLE CROSSFT,SUP-2824425,CDM,C1713,HCPCS,0278,RC,,,,both,,,1774.10,1153.16,,,,,,,,,,,,,
LEAD NERVE STIM 4 MM SPC 90 CM 3 MM PADDLE OCTRODE,SUP-2356730,CDM,C1778,HCPCS,0278,RC,,,,both,,,7223.13,4695.03,,,,,,,,,,,,,
GUIDEWIRE VASC INQWIRE L 80 CM DIA 0.035 IN PTFE PERIPH,SUP-2301915,CDM,C1769,HCPCS,0272,RC,,,,both,,,62.64,40.72,,,,,,,,,,,,,
HC ER Level 4,PX-4509928400,CDM,99284,CPT,0450,RC,,,,outpatient,,,2334.00,1517.10,,,,,,,,,,,,,
DRESSING COMPR CONTOURED ADH FREE FLX STRP W/ COOL CLR,SUP-2880995,CDM,2720000010,LOCAL,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
INSERT TIB SZ 2 THK12MM UNIV UNI KNEE POLYETH UNI PRI NEUT,SUP-2251233,CDM,C1776,CPT,0278,RC,,,,both,,,3868.48,2514.51,,,,,,,,,,,,,
RESERVOIR CEREBROSPINAL 14MM FLUID FLUSHING BOTTOM INLET CON,SUP-2830492,CDM,C1889,HCPCS,0278,RC,,,,both,,,1344.80,874.12,,,,,,,,,,,,,
INSERT ACET SZ F OD54-56MM ID28MM 0DEG UHMWPE CONSTRN,SUP-2344625,CDM,C1776,CPT,0278,RC,,,,both,,,7466.92,4853.50,,,,,,,,,,,,,
DEVICE ENDOSKELETAL SYS PROSTHETIC BK WAIST BELT WEB,SUP-2388212,CDM,L5688,HCPCS,0272,RC,,,,both,,,160.55,104.36,,,,,,,,,,,,,
PLATE HOCKEY 5HOLE LT RS,SUP-2653978,CDM,C1713,HCPCS,0278,RC,,,,both,,,2417.80,1571.57,,,,,,,,,,,,,
TRAY CATH L 13 CM DIA13.5 FR ACUTE 2 LUMEN HI FLO STR EXT IC,SUP-2905035,CDM,C1752,HCPCS,0278,RC,,,,both,,,383.21,249.09,,,,,,,,,,,,,
GRAFT TEND PAT W/ SHTH FRZN ALLGRFT,SUP-2388443,CDM,C1713,HCPCS,0278,RC,,,,both,,,13608.76,8845.69,,,,,,,,,,,,,
TRAY KYPHOPLASTY BLLN 2ML L15MM DIA10.9MM NDL 10GA W/ LOK,SUP-2367063,CDM,C1726,HCPCS,0272,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
EXTENSION ORTHOT LAT THOR CUST,SUP-2435585,CDM,L1210,HCPCS,0272,RC,,,,both,,,692.68,450.24,,,,,,,,,,,,,
CATHETER CTRL VEN AD 9.5FR DBL LUMN SURECUF TISS INGROWTH,SUP-2127899,CDM,C1751,HCPCS,0278,RC,,,,both,,,2666.65,1733.32,,,,,,,,,,,,,
PIN EXT FIX THRD L15MM DIA3MM SHANK L65MM DIA4MM SH TI,SUP-2342885,CDM,2720000010,LOCAL,0272,RC,,,,both,,,776.68,504.84,,,,,,,,,,,,,
EXTRACTOR STONE BSKT 0.6 MM 3 WIR STRL DISP,SUP-2771971,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1011.17,657.26,,,,,,,,,,,,,
CATHETER HD STR EXTN 12.5 FRX16 CM 3L TY MAHRK ELITE,SUP-2283972,CDM,C1752,HCPCS,0278,RC,,,,both,,,595.41,387.02,,,,,,,,,,,,,
PSYLLIUM 58.12 % PO PACK,RX-104606,CDM,6370000000,HCPCS,0637,RC,37000-0024-10,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
GUIDEWIRE ORTHOPEDIC MED CANNULATED F/SMALL JOINT,SUP-2586646,CDM,C1769,HCPCS,0272,RC,,,,both,,,6800.83,4420.54,,,,,,,,,,,,,
HC So Delta Aminolevulinic Acid,PX-3018213566,CDM,82135,CPT,0301,RC,,,,both,,,520.00,338.00,,,,,,,,,,,,,
COMPONENT GLEN FIX L BILAT SHLDR POLYETH KEELED CONSTRN CEM,SUP-2399847,CDM,C1776,CPT,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
CATHETER HEMO DYLS OR HD L15CM 13.5FR AD ADMIN ACUTE BASIC,SUP-2125586,CDM,C1752,HCPCS,0278,RC,,,,both,,,257.48,167.36,,,,,,,,,,,,,
BIT DRILL J LATCH 1.8X88 MM 20 MM WITH STOP TITANIUM NON STE,SUP-2837619,CDM,2720000010,LOCAL,0272,RC,,,,both,,,815.46,530.05,,,,,,,,,,,,,
GRAFT NERVE REP L 2 X W 2 CM AMNIO MEMBRN MULTLYRED MTRX,SUP-2914050,CDM,C1762,CPT,0278,RC,,,,both,,,4631.50,3010.47,,,,,,,,,,,,,
ALLOGRAFT HUM TISS FRZN ASEP SEMITENDINOSUS,SUP-2867229,CDM,C1762,CPT,0278,RC,,,,both,,,5053.20,3284.58,,,,,,,,,,,,,
CATHETER PERI L120CM OD2.2MM ID1MM SIL BA IMPREG MEDOS,SUP-2257150,CDM,C1729,HCPCS,0272,RC,,,,both,,,631.14,410.24,,,,,,,,,,,,,
HC Bone Marrow Aspiration,PX-3613822000,CDM,38220,CPT,0361,RC,,,,both,,,4946.00,3214.90,,,,,,,,,,,,,
SHELL ACET SZ B OD42MM ID22MM TI ALLOY POR NO H REFLCT,SUP-2344928,CDM,C1776,CPT,0278,RC,,,,both,,,6704.69,4358.05,,,,,,,,,,,,,
KIT SHTH Z FLX 270 DIA12 FR STEER SFT TIP STRL,SUP-2141320,CDM,C1894,HCPCS,0272,RC,,,,both,,,4082.00,2653.30,,,,,,,,,,,,,
COMPONENT GLEN 40 MM SHLDR TRABECULAR MTL BIGLIANI/FLATOW,SUP-2436899,CDM,C1776,CPT,0278,RC,,,,both,,,3786.84,2461.45,,,,,,,,,,,,,
COIL EMB L12CM PRI DIA0.020IN 2ND DIA4MM NIT COMPLX SFT,SUP-2323395,CDM,C1889,HCPCS,0278,RC,,,,both,,,7137.22,4639.19,,,,,,,,,,,,,
POST FIX 2 H M,SUP-2197275,CDM,2720000010,LOCAL,0272,RC,,,,both,,,339.12,220.43,,,,,,,,,,,,,
IMMOBILIZER KNEE XL L19IN FOR 20 22IN BLU CANVS T BAR STAY,SUP-2336066,CDM,L1830,CPT,0272,RC,,,,both,,,39.25,25.51,,,,,,,,,,,,,
SHELL ACET OD44MM ID21MM UNIV PPS HIP RECON QUAD SPRNG IMP,SUP-2403681,CDM,C1776,CPT,0278,RC,,,,both,,,5513.84,3584.00,,,,,,,,,,,,,
PROSTHESIS OSS CENTERED 3 MM 4 2 3 TOT HA TI WILDCAT,SUP-2458139,CDM,L8613,CPT,0278,RC,,,,both,,,1144.72,744.07,,,,,,,,,,,,,
HC So Serum Hgb Quantitative,PX-3018305166,CDM,83051,CPT,0301,RC,,,,both,,,75.00,48.75,,,,,,,,,,,,,
PLATE BNE HK 3 HOLE,SUP-2518429,CDM,C1713,HCPCS,0278,RC,,,,both,,,4066.30,2643.09,,,,,,,,,,,,,
PLATE BNE 100 DEG L 3.8 CM THK 1 MM SCREW DIA2 MM 6X8 H TI,SUP-2936471,CDM,C1713,HCPCS,0278,RC,,,,both,,,458.44,297.99,,,,,,,,,,,,,
STRAP ORTHOT HIP KNEE ANK CUST TORSON BILATERAL ROT,SUP-2435640,CDM,L2040,HCPCS,0272,RC,,,,both,,,572.74,372.28,,,,,,,,,,,,,
COUPLER EXT FIX ADD A BAR MRI SAFE JET-X,SUP-2342895,CDM,C1776,CPT,0278,RC,,,,both,,,1221.37,793.89,,,,,,,,,,,,,
IMPLANT CLLR DENT 4.7X4.5X,SUP-2212675,CDM,2780000010,LOCAL,0278,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
PLATE BNE 90 DEG 5 H SCREW DIA1 MM TI CRANIOMAXILLOFACIAL T,SUP-2883139,CDM,C1713,HCPCS,0278,RC,,,,both,,,671.21,436.29,,,,,,,,,,,,,
CATHETER ERCP 5.5-4.5FR L320CM ACCSRY CHAN 2.8MM 0.035IN,SUP-2169432,CDM,C1887,HCPCS,0272,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
CANNULA DRNGE 20DEG W/ DIL EXCORP CIRC BUB TRAP ANGIOVAC,SUP-2420160,CDM,2720000010,LOCAL,0272,RC,,,,both,,,45530.00,29594.50,,,,,,,,,,,,,
BEAM FIX L145MM DIA6.5MM ARTH FOR CHARCOT DEFORMITY AXIS,SUP-2223950,CDM,C1713,HCPCS,0278,RC,,,,both,,,4239.00,2755.35,,,,,,,,,,,,,
GUIDEWIRE HYDROPHILIC ZIP WIRE 0.025IN X 150CM,SUP-2646888,CDM,C1769,HCPCS,0272,RC,,,,both,,,33.25,21.61,,,,,,,,,,,,,
PLATE BNE W63XL40MM THK16MM 90DEG 2X3 H DST RAD TI L SHP,SUP-2191023,CDM,C1713,HCPCS,0278,RC,,,,both,,,1801.10,1170.71,,,,,,,,,,,,,
KIT HEMODLYS L40CM BASIC DLYS CATH 16FR VLV BRKWY INTRO,SUP-2117393,CDM,C1750,HCPCS,0278,RC,,,,both,,,1067.60,693.94,,,,,,,,,,,,,
DEVICE CLOSURE 10 FR PERC VASC SURG SYS PROSTAR XL,SUP-2846208,CDM,C1760,HCPCS,0278,RC,,,,both,,,3092.90,2010.38,,,,,,,,,,,,,
PLATE BNE TIB WIDE 3.5 MM RT MEDL 3 HOLE SS JPS 5434002R,SUP-2645626,CDM,C1713,HCPCS,0278,RC,,,,both,,,12999.60,8449.74,,,,,,,,,,,,,
AWL SURG 52 DEG DIA 6 MM CANN CRV OBTURATOR,SUP-2934623,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1774.10,1153.16,,,,,,,,,,,,,
HEPARIN SOD (PORCINE) IN D5W 100 UNIT/ML IV SOLN,RX-24329,CDM,J1644,HCPCS,0636,RC,00264-9587-20,NDC,,both,250,ML,90.60,58.89,,,,,,,,,,,,,
RETRACTOR SCR 13GA NDL L30CM DIA5MM LAPSCP KT REDDICK SAYE,SUP-2264297,CDM,C1713,HCPCS,0278,RC,,,,both,,,499.26,324.52,,,,,,,,,,,,,
STENT BILI L24MM 6FR 75CM CATH LEN 4MM DIAM AD GEN,SUP-2159196,CDM,C1876,HCPCS,0278,RC,,,,both,,,2778.90,1806.28,,,,,,,,,,,,,
SEED BRACHYTHERAPY PALLADIUM-103 LD MICK CART THERASEED,SUP-2127063,CDM,C2641,HCPCS,0278,RC,,,,both,,,114.61,74.50,,,,,,,,,,,,,
REAMER SURG L20MM MT CUP GENERATION 2,SUP-2398416,CDM,2720000010,LOCAL,0272,RC,,,,both,,,750.46,487.80,,,,,,,,,,,,,
CATHETER DRAINAGE STD LOOP 10 FRX25 CM MULTPURP EXODUS ARRY,SUP-2752492,CDM,C1729,HCPCS,0272,RC,,,,both,,,188.40,122.46,,,,,,,,,,,,,
STAPLER INT CIR XL MED THCK 28 MM 3-4 MM PUR EEA,SUP-2787718,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4865.81,3162.78,,,,,,,,,,,,,
PIN BNE MEMOFIX STPL SYS 2 MM,SUP-2244269,CDM,C1713,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
ELECTRODE ES FOR BOVIE X-10 GENRTR,SUP-2313740,CDM,C1713,HCPCS,0278,RC,,,,both,,,957.70,622.50,,,,,,,,,,,,,
SOLIDLOK HEX TIP 35MM STE,SUP-2724020,CDM,2720000010,LOCAL,0272,RC,,,,both,,,483.56,314.31,,,,,,,,,,,,,
NEOMYCIN-POLYMYXIN-DEXAMETH 3.5-10000-0.1 OP SUSP,RX-103569,CDM,6370000000,HCPCS,0637,RC,61314-0630-06,NDC,,both,5,ML,81.00,52.65,,,,,,,,,,,,,
SCREW HYBRID 3 X 20,SUP-2741739,CDM,C1713,HCPCS,0278,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
CATHETER DRNGE 22FR 2 EYE PROPORTIONATE HD DISP FOR,SUP-2128979,CDM,C1729,HCPCS,0272,RC,,,,both,,,323.86,210.51,,,,,,,,,,,,,
CUBE EXT FIX 2 H RANCHO W/ POST FOR ILIZ TAY SPAT FRME SYS,SUP-2342988,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1260.96,819.62,,,,,,,,,,,,,
PLUG HIP FIX FEN SIZE2,SUP-2377823,CDM,C1776,CPT,0278,RC,,,,both,,,241.78,157.16,,,,,,,,,,,,,
HC Shoulder/Clavicle Strap/Splint,PX-4502924000,CDM,29240,CPT,0450,RC,,,,both,,,214.00,139.10,,,,,,,,,,,,,
PLATE BONE CRANIAL 6 HOLE DOUBLE SQUARE 24X14MM TITANIUM NEU,SUP-2821911,CDM,C1713,HCPCS,0278,RC,,,,both,,,259.68,168.79,,,,,,,,,,,,,
LENS INTOCU +11.0 DIOPT L13MM DIA6MM 118.7 A CONSTANT SLM-2,SUP-2247790,CDM,V2632,HCPCS,0276,RC,,,,both,,,204.10,132.66,,,,,,,,,,,,,
GRAFT HUM TISS CRYOPRESERVED 1 CC FLOWABLE PLCNTA VIAFLOW C,SUP-2759479,CDM,C1762,CPT,0278,RC,,,,both,,,4420.81,2873.53,,,,,,,,,,,,,
SHUNT SURG DELT ASMBLY 2 REG SPNL CEREB FLUID,SUP-2284559,CDM,C1889,HCPCS,0278,RC,,,,both,,,4013.05,2608.48,,,,,,,,,,,,,
CAGE SPNL L14XW14XH30MM 4 LOBE LORDTC END CAP IMP NGAGE,SUP-2317739,CDM,C1889,HCPCS,0278,RC,,,,both,,,13175.44,8564.04,,,,,,,,,,,,,
SCREW FIX L32MM DIA4.3MM TI SELF DRL ST QWIX,SUP-2242825,CDM,C1713,HCPCS,0278,RC,,,,both,,,1208.90,785.78,,,,,,,,,,,,,
INTRODUCER SHTH 6 FRX20 CM 21 GAX15 CM COAX DIL NDL MAK-NV,SUP-2469319,CDM,C1894,HCPCS,0272,RC,,,,both,,,143.44,93.24,,,,,,,,,,,,,
PISTON L4MM DIA0.6MM S STL STAP FOR STAPEDECTOMY MCGEE,SUP-2312540,CDM,L8613,CPT,0278,RC,,,,both,,,244.48,158.91,,,,,,,,,,,,,
CATHETER THORACIC X-LARGE 20FR L26CM EXTENDED LENGTH STRAIGH,SUP-2825233,CDM,C1729,HCPCS,0272,RC,,,,both,,,83.74,54.43,,,,,,,,,,,,,
PLATE BNE L189MM THK3.4MM 14 H BILAT S STL STR LOK COMPR,SUP-2185151,CDM,C1713,HCPCS,0278,RC,,,,both,,,1624.98,1056.24,,,,,,,,,,,,,
PLATE BNE SM W11XL116MM THK3.3MM 0DEG 9 H BILAT TI STR,SUP-2190782,CDM,C1713,HCPCS,0278,RC,,,,both,,,647.44,420.84,,,,,,,,,,,,,
ROD SPNL L140MM DIA5.5MM POST PEDCL TI LORDOSED VIPER 2,SUP-2256307,CDM,C1713,HCPCS,0278,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA PLU MAXBARR 3FR S1193108D4,SUP-2632795,CDM,C1751,HCPCS,0278,RC,,,,both,,,1100.44,715.29,,,,,,,,,,,,,
PLATE BONE RECONSTRUCTION 2.8 MM 20 HOLE TITANIUM MATRIXMAND,SUP-2837766,CDM,C1713,HCPCS,0278,RC,,,,both,,,6455.53,4196.09,,,,,,,,,,,,,
CLIP ANEURYSM 3MM STANDARD PERMANENT YASARGIL  FE942K,SUP-2844504,CDM,C1889,HCPCS,0278,RC,,,,both,,,1118.84,727.25,,,,,,,,,,,,,
HEAD PAT SM SMALL+ LAT LCS MILESTONE,SUP-2454057,CDM,C1776,CPT,0278,RC,,,,both,,,1591.98,1034.79,,,,,,,,,,,,,
KIT THROMCTMY 3MAX WORKING L 160 CM PROX/DSTL OD 4.7,SUP-2323351,CDM,C1887,HCPCS,0272,RC,,,,both,,,6028.80,3918.72,,,,,,,,,,,,,
PLATE BNE STR MINI REG 2 HOLE TI NS LEVEL 1,SUP-2465858,CDM,C1713,HCPCS,0278,RC,,,,both,,,634.75,412.59,,,,,,,,,,,,,
CATHETER CV SET 018 PEDIATRIC 4 FRX5 CM DL J TIP POLYETH,SUP-2760004,CDM,C1751,HCPCS,0278,RC,,,,both,,,278.24,180.86,,,,,,,,,,,,,
PLATE BNE L107MM 3X8 H R S STL T SHP OBLQ ANG LOK COMPR FOR,SUP-2185848,CDM,C1713,HCPCS,0278,RC,,,,both,,,1220.99,793.64,,,,,,,,,,,,,
BLADE SAW OSCLLTNG CLSSC 19MMW X90MML 0.89MM THK INNVTVE TOO,SUP-2605817,CDM,2720000010,LOCAL,0272,RC,,,,both,,,73.19,47.57,,,,,,,,,,,,,
PLATE BNE CLAV CS3 2.7 MM LT VA LCK COMPR SS NS VA-LCP,SUP-2757610,CDM,C1713,HCPCS,0278,RC,,,,both,,,3143.14,2043.04,,,,,,,,,,,,,
PLATE BNE FIBULAR 2.7/3.5X229 MM RT LAT DSTL 15 HOLE SS,SUP-2184167,CDM,C1713,HCPCS,0278,RC,,,,both,,,1940.27,1261.18,,,,,,,,,,,,,
GRAFT VASC GELWEAVE L 30 CM DIA 34 MM POLYESTER GEL,SUP-2385025,CDM,L8670,HCPCS,0278,RC,,,,both,,,2797.74,1818.53,,,,,,,,,,,,,
IMPLANT NSL DORSUM POLYETH SMOOTH RECT,SUP-2242097,CDM,2780000010,LOCAL,0278,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
COMPONENT ARTC SURF UNI 4 8 MM KNEE,SUP-2340775,CDM,C1776,CPT,0278,RC,,,,both,,,5746.20,3735.03,,,,,,,,,,,,,
COUNTERSINK SURG L 50 MM DIA1.3 MM SCREW DIA 3/4 MM NS DISP,SUP-2909578,CDM,2720000010,LOCAL,0272,RC,,,,both,,,752.88,489.37,,,,,,,,,,,,,
ROD REPROC EXT FIX HYBRID 11X150 MM  CARBON FIBER,SUP-2188653,CDM,2720000010,LOCAL,0272,RC,,,,both,,,758.62,493.10,,,,,,,,,,,,,
SPACER TEND NO3 W3XH15XL24MM SIL SWNSN HUNTER,SUP-2397186,CDM,C1713,HCPCS,0278,RC,,,,both,,,3133.72,2036.92,,,,,,,,,,,,,
CATHETER INFUSION BERN 200 CM 2.7/2.4 FRX155 CM FATHOM-16,SUP-2653478,CDM,C1887,HCPCS,0272,RC,,,,both,,,3061.81,1990.18,,,,,,,,,,,,,
PLATE BNE LT MANDIBULAR PRIMARY HEMI W/ TMPLT NS,SUP-2883234,CDM,C1713,HCPCS,0278,RC,,,,both,,,5690.81,3699.03,,,,,,,,,,,,,
SYSTEM EXCHG 12FR L80CM OD0.19IN ID0.16IN 45DEG TIP,SUP-2355722,CDM,C1773,HCPCS,0272,RC,,,,both,,,2152.03,1398.82,,,,,,,,,,,,,
ANCHOR SUT DIA5.5MM TAP IN DSGN FOR SFT TISS FIX FOOTPRINT,SUP-2341862,CDM,C1713,HCPCS,0278,RC,,,,both,,,1358.36,882.93,,,,,,,,,,,,,
MANOMETER ET INFL BLB AIR VENT BTTN CUFFLATOR,SUP-2328646,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1047.03,680.57,,,,,,,,,,,,,
ANCHOR SONIC KIT FORCE FIBER 2.5X10MM 2,SUP-2479334,CDM,C1713,HCPCS,0278,RC,,,,both,,,1016.36,660.63,,,,,,,,,,,,,
SCREW SPNL L45MM DIA7MM TI POLYAX EXT TAB FOR MINIMALLY,SUP-2255045,CDM,C1713,HCPCS,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
DEFIBRILLATOR IMPL LUMAX 300 DR-T 55 X 66MM 12MM 30J BPLR,SUP-2138110,CDM,C1721,HCPCS,0275,RC,,,,both,,,60730.74,39474.98,,,,,,,,,,,,,
KNIFE SURG DACRYOCYSTORHINOSTOMY 5-7/8 INX4.3 MM MICROFRANCE,SUP-2461060,CDM,2720000010,LOCAL,0272,RC,,,,both,,,518.23,336.85,,,,,,,,,,,,,
CATHETER GUIDE EXTN 6 FRX150 CM HYDRPHLC COAT TELSCP,SUP-2416547,CDM,C1887,HCPCS,0272,RC,,,,both,,,1161.80,755.17,,,,,,,,,,,,,
PLATE BONE L17MM THK0.9MM 5MM OFFSET 0DEG 4 H BILAT CHIN,SUP-2191215,CDM,C1713,HCPCS,0278,RC,,,,both,,,975.91,634.34,,,,,,,,,,,,,
CATHETER BLLN DIL 6 FRX320 CM 16 MMX8 CM QUANTUM TTC,SUP-2759284,CDM,C1726,HCPCS,0272,RC,,,,both,,,675.10,438.81,,,,,,,,,,,,,
NERVE STIMULATOR KIT 50 CM TRL INFINION,SUP-2765587,CDM,C1883,HCPCS,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
PLATE BNE L142MM THK3.4MM 11 H BILAT S STL STR LIMIT CNTCT,SUP-2185143,CDM,C1713,HCPCS,0278,RC,,,,both,,,1095.17,711.86,,,,,,,,,,,,,
COLLAR EXTRIC FR 2.5IN FOR 11-23IN NK SHT 1 PC,SUP-2194421,CDM,L0172,HCPCS,0274,RC,,,,both,,,24.46,15.90,,,,,,,,,,,,,
SPLINT WRST SM L8IN L BLK FOAM D RNG CLSR LO PROF MAL,SUP-2336046,CDM,L3809,HCPCS,0272,RC,,,,both,,,19.19,12.47,,,,,,,,,,,,,
STRAP TRAC L6FT UP ARM W PD TRAC TWR,SUP-2166901,CDM,L3660,HCPCS,0274,RC,,,,both,,,415.23,269.90,,,,,,,,,,,,,
KIT ACCS INTRO L10CM DIA4FR GWIRE L40CM DIA0.018IN NDL L7CM,SUP-2302993,CDM,C1894,HCPCS,0272,RC,,,,both,,,76.46,49.70,,,,,,,,,,,,,
PHENOBARBITAL SODIUM 130 MG/ML IJ SOLN,RX-6221,CDM,J2560,HCPCS,0636,RC,42494-0416-25,NDC,,both,0.5,ML,156.30,101.59,,,,,,,,,,,,,
MASK CPAP FULL FACE W/ SIL SEAL FLEXIFOAM CUSH AND HDGEAR,SUP-2224714,CDM,C1713,HCPCS,0278,RC,,,,both,,,486.70,316.35,,,,,,,,,,,,,
INTRODUCER SET INTROFLEX 85F,SUP-2272865,CDM,C1894,HCPCS,0272,RC,,,,both,,,130.94,85.11,,,,,,,,,,,,,
TUBE ET OD11.2/13MM ID7.5MM INFL VOL 40ML SIL FLEX WIRE,SUP-2383582,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1158.66,753.13,,,,,,,,,,,,,
FLUOROURACIL 5 GM/100ML IV SOLN,RX-98157,CDM,J9190,HCPCS,0636,RC,63323-0117-61,NDC,,both,100,ML,84.40,54.86,,,,,,,,,,,,,
APPLICATOR ELECSURG 100 MM RIGID PLASMA COAG FILTER SPATULA,SUP-2762597,CDM,2720000010,LOCAL,0272,RC,,,,both,,,615.28,399.93,,,,,,,,,,,,,
PACEMAKER CARD AZURE XT SR MRI SURESCAN W 50.8 X H 42.6 MM D,SUP-2282506,CDM,C1786,HCPCS,0275,RC,,,,both,,,8164.00,5306.60,,,,,,,,,,,,,
PLATE BONE L53MM 5 H LCK COMPR FOR 2.7MM SCR PEDIFRAG,SUP-2318662,CDM,C1713,HCPCS,0278,RC,,,,both,,,2212.00,1437.80,,,,,,,,,,,,,
HC Alpha-Fetoprotein Serum,PX-3018210500,CDM,82105,CPT,0301,RC,,,,both,,,202.00,131.30,,,,,,,,,,,,,
HC Image Cath Fluid Colxn Visc,PX-3614940500,CDM,49405,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
KIT BLD SALV AUTOTRNS 5 AD CELLSAVER,SUP-2236473,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1167.83,759.09,,,,,,,,,,,,,
SCREW BNE ST 2X18 MM CORTICAL LCK W/ PLUSDRIVE RECESS TI NS,SUP-2189398,CDM,C1713,HCPCS,0278,RC,,,,both,,,503.78,327.46,,,,,,,,,,,,,
KIT ENDOPROS 12FR L15CM SFT W/ TEMPTIP HYDRPHLC TIP,SUP-2147746,CDM,C2617,HCPCS,0278,RC,,,,both,,,259.21,168.49,,,,,,,,,,,,,
GRAFT VASC GELSFT L 30 CM DIA14 MM POLYESTER GEL ABD PERIPH,SUP-2384958,CDM,C1768,CPT,0278,RC,,,,both,,,1028.63,668.61,,,,,,,,,,,,,
BIOPSY SET LIV ACCS 7 FRX60 CM 19 GAX20 MM PRE CRV MECH NDL,SUP-2638571,CDM,C1887,HCPCS,0272,RC,,,,both,,,1753.91,1140.04,,,,,,,,,,,,,
BIT DRL L5.5IN DIA3.5MM OVR QUIK CONN DISP FOR SM FRAG,SUP-2413872,CDM,2720000010,LOCAL,0272,RC,,,,both,,,411.34,267.37,,,,,,,,,,,,,
KIT INTRO 10.5FR L14CM XTW NDL 18GA GWIRE L50CM 0.038IN SYR,SUP-2357066,CDM,C1892,HCPCS,0272,RC,,,,both,,,27.63,17.96,,,,,,,,,,,,,
STEM FEM SEG 9 CM DPHSEAL KNEE TAPR OSS,SUP-2441750,CDM,C1776,CPT,0278,RC,,,,both,,,14356.08,9331.45,,,,,,,,,,,,,
DYNACORD STR BLUE W MO 7 NDLS 12 PK,SUP-2256652,CDM,C1713,HCPCS,0278,RC,,,,both,,,547.30,355.74,,,,,,,,,,,,,
GRAFT BONE MATRIC V92-FC 2.5CC,SUP-2740173,CDM,C1713,HCPCS,0278,RC,,,,both,,,5785.45,3760.54,,,,,,,,,,,,,
PLATE BNE 3.5X196 MM 15 HOLE SS LCP,SUP-2569328,CDM,C1713,HCPCS,0278,RC,,,,both,,,514.65,334.52,,,,,,,,,,,,,
THEOPHYLLINE ER 300 MG PO TB12,RX-12098,CDM,6370000000,HCPCS,0637,RC,00480-3310-01,NDC,,both,1,UN,13.20,8.58,,,,,,,,,,,,,
PACEMAKER CARD DISCOVERY II DR TI 2 CHMBR IS1 COMPATIBLE,SUP-2139586,CDM,C1785,HCPCS,0275,RC,,,,both,,,14597.86,9488.61,,,,,,,,,,,,,
COLLAR EXTRIC FR 2.5IN FOR 11-23IN NK SHT 1 PC,SUP-2194421,CDM,L0172,HCPCS,0272,RC,,,,both,,,24.46,15.90,,,,,,,,,,,,,
ANCHOR SUTURE SFT LNG SINGLE LD WHT BLU JUGGERKNOT,SUP-2745509,CDM,C1776,CPT,0278,RC,,,,both,,,9184.50,5969.92,,,,,,,,,,,,,
GRAFT HUM TISS L 5 X W 4 CM SZ 20 SQCM AMNION-CHORION-AMNION,SUP-2909286,CDM,Q4137,HCPCS,0636,RC,,,,both,,,9764.49,6346.92,,,,,,,,,,,,,
NAIL IM L230MM DIA7.5MM 120DEG ST BLU L/R HUM TI CANN LOK,SUP-2192487,CDM,C1713,HCPCS,0278,RC,,,,both,,,4982.61,3238.70,,,,,,,,,,,,,
PIN FIX L9IN DIA3/32IN BAYNT PT SMOOTH,SUP-2252369,CDM,C1713,HCPCS,0278,RC,,,,both,,,15.70,10.20,,,,,,,,,,,,,
SUPPORT ORTH HIP CIRC 28-48 IN SM MED SZ 2 ALUM,SUP-2915082,CDM,2720000010,LOCAL,0272,RC,,,,both,,,775.52,504.09,,,,,,,,,,,,,
PLATE BONE L94MM 6 HOLE RIGHT LTRL DST PRRTCLR TBL STNLSS ST,SUP-2483830,CDM,C1713,HCPCS,0278,RC,,,,both,,,4263.99,2771.59,,,,,,,,,,,,,
HC Biopsy/Exc Lymph Node Needle,PX-3613850500,CDM,38505,CPT,0361,RC,,,,both,,,5560.00,3614.00,,,,,,,,,,,,,
FIBER LASER 200 MH FLEXSHIELD FLX HOLM ACCUTRAC DISP,SUP-2139425,CDM,C1713,HCPCS,0278,RC,,,,both,,,1417.52,921.39,,,,,,,,,,,,,
DRILL SURG L122MM DIA2.7MM ADD ON OVERDRL FOR VARIAX SYS,SUP-2378005,CDM,2720000010,LOCAL,0272,RC,,,,both,,,879.20,571.48,,,,,,,,,,,,,
KIT STPL BRDG 25MM 4 LEG 20MM MAX CLSR 7.1MM BME ELITE,SUP-2254043,CDM,C1713,HCPCS,0278,RC,,,,both,,,4574.92,2973.70,,,,,,,,,,,,,
BIT DRL TWST 0.25 IN 6.4 MM,SUP-2455477,CDM,2720000010,LOCAL,0272,RC,,,,both,,,819.54,532.70,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH L 124 MM DIA 32 MM SHTH 20 FR RVD,SUP-2170128,CDM,C1874,HCPCS,0278,RC,,,,both,,,32910.34,21391.72,,,,,,,,,,,,,
HEAD BPLR HXL SZ 40 ENCORE MOD,SUP-2216822,CDM,C1776,CPT,0278,RC,,,,both,,,3102.32,2016.51,,,,,,,,,,,,,
TAP SURG DIA3.5MM QUIK CONN FOR DSTL RAD ULN JT PROS,SUP-2119936,CDM,C1776,CPT,0278,RC,,,,both,,,386.22,251.04,,,,,,,,,,,,,
EVOS LARGE TGTR 2.5MM DRILL W/AO QC,SUP-2931251,CDM,C1713,HCPCS,0278,RC,,,,both,,,1648.50,1071.52,,,,,,,,,,,,,
SCREW BONE 2X5 MM LOCKING SELFDRILLING PLUSDRIVE RECESS TITA,SUP-2838327,CDM,C1713,HCPCS,0278,RC,,,,both,,,545.10,354.31,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 10 CM DIA 8 MM RNG L 10 CM EPTFE,SUP-2396299,CDM,C1768,CPT,0278,RC,,,,both,,,763.02,495.96,,,,,,,,,,,,,
SCREW BNE L 60 MM DIA 4 MM SHRT TI CANN HD NS LEOS,SUP-2931493,CDM,C1713,HCPCS,0278,RC,,,,both,,,814.42,529.37,,,,,,,,,,,,,
NARROW PLT STERILIZER 4.5X167 MM 10 HL,SUP-2818129,CDM,C1713,HCPCS,0278,RC,,,,both,,,1632.55,1061.16,,,,,,,,,,,,,
PLATE BNE THK0.6MM 4 H L HND STR NONCOMPRESSION GRID FOR,SUP-2267873,CDM,C1713,HCPCS,0278,RC,,,,both,,,663.17,431.06,,,,,,,,,,,,,
PLATE BURR H L 22.63 DIA18.5 MM SLOT 4.5 MM SCREW DIA1.5 MM,SUP-2936847,CDM,C1713,HCPCS,0278,RC,,,,both,,,945.14,614.34,,,,,,,,,,,,,
CARTRIDGE MENIS REP SZ 2-0 SUT NOVOSTITCH +,SUP-2419748,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1794.26,1166.27,,,,,,,,,,,,,
PLATE BNE RECON 2-2.5X2 MM MAND 36 HOLE FULL MAND LCK TI NS,SUP-2477692,CDM,C1713,HCPCS,0278,RC,,,,both,,,6925.96,4501.87,,,,,,,,,,,,,
IMMOBILIZER ORTH SHLDR SUPP UNIV UNISX STD CUFED AD LN WR,SUP-2306067,CDM,L3650,HCPCS,0274,RC,,,,both,,,56.52,36.74,,,,,,,,,,,,,
RING EXT FIX HALF 120 MM TI NS,SUP-2800190,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1197.31,778.25,,,,,,,,,,,,,
PLATE BONE W8XL26MM THK2.5MM 0DEG 2 H BILAT S STL STR RIG,SUP-2186184,CDM,C1713,HCPCS,0278,RC,,,,both,,,461.67,300.09,,,,,,,,,,,,,
CATHETER VALVULOPLASTY SHFT L110CM SHTH DIA11FR BLLN L3.5CM,SUP-2128491,CDM,C1725,HCPCS,0272,RC,,,,both,,,4553.00,2959.45,,,,,,,,,,,,,
HC Ercp Biliary and Pancreatic,PX-3207433000,CDM,74330,CPT,0320,RC,,,,both,,,2384.00,1549.60,,,,,,,,,,,,,
GUIDEWIRE ENDO L145CM OD0.038IN 14FR INTRO SUP STIFF AMPLTZ,SUP-2141747,CDM,C1769,HCPCS,0272,RC,,,,both,,,111.78,72.66,,,,,,,,,,,,,
SUBSTITUTE BNE GRFT 5CC POLYMER HYALURONIC ACID CONT PSTE,SUP-2247321,CDM,C1713,HCPCS,0278,RC,,,,both,,,3855.92,2506.35,,,,,,,,,,,,,
HC Laryngoscopy W FB Removal,PX-4503153000,CDM,31530,CPT,0450,RC,,,,both,,,1754.00,1140.10,,,,,,,,,,,,,
CATHETER NEPHSTMY DIA20FR 2 EYE DRNGE PROPORTIONATE HD DISP,SUP-2128978,CDM,C1729,HCPCS,0272,RC,,,,both,,,62.49,40.62,,,,,,,,,,,,,
HC N Block Inj Intercost Mlt,PX-3606442100,CDM,64421,CPT,0360,RC,,,,both,,,2895.00,1881.75,,,,,,,,,,,,,
KIT TIB MOD ROT HNG HDP ASSEMB,SUP-2376373,CDM,C1776,CPT,0278,RC,,,,both,,,3881.51,2522.98,,,,,,,,,,,,,
LINER ACET ANTEVERTED 4+ MM 20 DEG 40X58 MM HIP XLPE R3,SUP-2434696,CDM,C1776,CPT,0278,RC,,,,both,,,6116.72,3975.87,,,,,,,,,,,,,
PLATE BNE FUSION RT ANTR ANK 9 HOLE CONSTRUCT,SUP-2609570,CDM,C1713,HCPCS,0278,RC,,,,both,,,6585.55,4280.61,,,,,,,,,,,,,
BIT DRL L50MM DIA1.6MM 7MM STP FOR 2/2.3MM SCR LEIBINGER,SUP-2366417,CDM,2720000010,LOCAL,0272,RC,,,,both,,,405.72,263.72,,,,,,,,,,,,,
WIRE FLTR DEL SUP .014INX315CM BAREWIRE,SUP-2105942,CDM,C1876,HCPCS,0278,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
SCREW BNE L10MM DIA2MM STD CORT CRANIOMAXILLOFACIAL TI ST 400790] DEPUY SYNTHES USA],SUP-2189259,CDM,C1713,HCPCS,0278,RC,,,,both,,,156.59,101.78,,,,,,,,,,,,,
HC Thyroid Metastases Imaging; Whole Body,PX-3417801800,CDM,78018,CPT,0341,RC,,,,both,,,2192.00,1424.80,,,,,,,,,,,,,
BIT DRILL SURG DIA2.5 MM SHRT AO QC STRL DISP EVOS LG,SUP-2931237,CDM,2720000010,LOCAL,0272,RC,,,,both,,,998.21,648.84,,,,,,,,,,,,,
SCREW SPNL L14MM OD4MM CEPHALAD CAUD BIASED ANG POST,SUP-2317654,CDM,C1713,HCPCS,0278,RC,,,,both,,,402.23,261.45,,,,,,,,,,,,,
KIT CATH HEMODIALYSI SFT CELL CHRONIC STD 12.5FR DIA 38CM 19,SUP-2613294,CDM,C1750,HCPCS,0278,RC,,,,both,,,629.73,409.32,,,,,,,,,,,,,
NAIL IM L200MM OD11.5MM FEM RG TRIGEN META-NAIL,SUP-2347402,CDM,C1713,HCPCS,0278,RC,,,,both,,,10888.74,7077.68,,,,,,,,,,,,,
PLATE PHLANG BASE 1.5MM RT TI STRL VAL,SUP-2546894,CDM,C1713,HCPCS,0278,RC,,,,both,,,1878.57,1221.07,,,,,,,,,,,,,
ANCHOR SUTURE DIA2.3 MM SUTURE 1.8 MM HA COAT 2 STRND XBRAID,SUP-2908768,CDM,C1713,HCPCS,0278,RC,,,,both,,,1827.48,1187.86,,,,,,,,,,,,,
PLATE BNE STP 4 H 2 SLOT DISPLC CALCNL TI MATING SCR 35MM,SUP-2243234,CDM,C1713,HCPCS,0278,RC,,,,both,,,4443.10,2888.01,,,,,,,,,,,,,
STEM FEM L260MM DIA15MM STD CLLR R HIP CO CHROME POR REV,SUP-2345245,CDM,C1776,CPT,0278,RC,,,,both,,,18714.40,12164.36,,,,,,,,,,,,,
PROBE ENDOSCP SUCTION 3.5 MM CNTOUR SERFAS,SUP-2361319,CDM,2720000010,LOCAL,0272,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
KIT INTRO L 10 CM DIA 4 FR 40 CM 0.018IN 4CM NIT SHFT STD,SUP-2125283,CDM,C1894,HCPCS,0272,RC,,,,both,,,92.60,60.19,,,,,,,,,,,,,
BLADE OSTEOTOM L 100 MM DIA12 MM GOUGE CRV RND TIP,SUP-2898696,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2060.63,1339.41,,,,,,,,,,,,,
INSERT HUM COMBINATION 9+ MM 42 MM SHLDR 36/42 AEQUALIS,SUP-2715655,CDM,C1776,CPT,0278,RC,,,,both,,,4417.98,2871.69,,,,,,,,,,,,,
COMPONENT ARTC SURF TIB 3-4 10 MM KNEE,SUP-2200805,CDM,C1776,CPT,0278,RC,,,,both,,,87.95,57.17,,,,,,,,,,,,,
EPIFIX 2X2CM 4SQ CM,SUP-2305748,CDM,Q4186,HCPCS,0636,RC,,,,both,,,3340.96,2171.62,,,,,,,,,,,,,
MESH HERN W20XL25CM POLY ABD RECT COMP OPN SKRT PARIETEX,SUP-2172433,CDM,C1781,HCPCS,0278,RC,,,,both,,,5051.51,3283.48,,,,,,,,,,,,,
BIT DRL 3 FLUT 3.2X145 MM MOD W/ QUIK CPL,SUP-2653738,CDM,2720000010,LOCAL,0272,RC,,,,both,,,556.19,361.52,,,,,,,,,,,,,
PLATE BNE THK 0.5 MM 2 X 21 H POLY L-LACTIDE POLY D-LACTIDE,SUP-2883133,CDM,C1713,HCPCS,0278,RC,,,,both,,,11652.41,7574.07,,,,,,,,,,,,,
IMMOBILIZER PREMIER PRO KNEE 3 PNL CANVS 16INCH LTX FREE,SUP-2336075,CDM,L1830,CPT,0274,RC,,,,both,,,45.44,29.54,,,,,,,,,,,,,
BAND SCLER BCKL L 120 MM 3.5 X 0.75 MM SIL TYP 41 SFT ELAS,SUP-2930289,CDM,C1784,HCPCS,0278,RC,,,,both,,,62.80,40.82,,,,,,,,,,,,,
GRAFT HUM TISS L20MM FIBULAR SEG FRZ DRY ALLGRFT MATRIGRFT,SUP-2264767,CDM,C1713,HCPCS,0278,RC,,,,both,,,1447.70,941.00,,,,,,,,,,,,,
PLATE 4.5MM TI LCP T 6 HOLES 115MM,SUP-2549653,CDM,C1713,HCPCS,0278,RC,,,,both,,,2051.27,1333.33,,,,,,,,,,,,,
PLATE BONE COMPRESSION 2 MM MANDIBULAR 8 HOLE INTERMEDIATE L,SUP-2838409,CDM,C1713,HCPCS,0278,RC,,,,both,,,1965.01,1277.26,,,,,,,,,,,,,
SCREW BNE L20MM DIA2.4MM HD DIA3.5MM CORT TI ST FULL THRD,SUP-2189554,CDM,C1713,HCPCS,0278,RC,,,,both,,,223.57,145.32,,,,,,,,,,,,,
BIT DRL L150MM DIA2MM CANN QUIK CPL W/O STP REUSE FOR 3MM,SUP-2187217,CDM,2720000010,LOCAL,0272,RC,,,,both,,,952.64,619.22,,,,,,,,,,,,,
RELOAD STPLR ARTICULATING 4.8 MM UNIV STR SULU DUET TRS 45,SUP-2174660,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1345.24,874.41,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC SOLO 5FR 55CM 2 LUMAN RVS TAPR PWR,SUP-2613394,CDM,C1751,HCPCS,0278,RC,,,,both,,,475.21,308.89,,,,,,,,,,,,,
HC So Hepatitis a Ab Total (Havab),PX-3028670867,CDM,86708,CPT,0302,RC,,,,both,,,21.00,13.65,,,,,,,,,,,,,
IMPLANT SH SIL .040 2X3IN,SUP-2383034,CDM,C1781,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
KIT DRNGE PERI ESSENTIAL ASPIRA,SUP-2126464,CDM,C1729,HCPCS,0272,RC,,,,both,,,3375.50,2194.07,,,,,,,,,,,,,
SCREW BNE L17MM DIA2.7MM LOK FOR R3CON PLATING SYS GORILLA,SUP-2321279,CDM,C1713,HCPCS,0278,RC,,,,both,,,573.84,373.00,,,,,,,,,,,,,
SCREW BNE L30MM OD4.5MM STD CORT LOK,SUP-2342546,CDM,C1713,HCPCS,0278,RC,,,,both,,,94.83,61.64,,,,,,,,,,,,,
PLATE BNE 3.5X194 MM 16 HOLE SS DCP,SUP-2569145,CDM,C1713,HCPCS,0278,RC,,,,both,,,393.76,255.94,,,,,,,,,,,,,
GUIDEWIRE VASC L260CM DIA0.035IN TIP L3IN NIT COR POLYUR,SUP-2385569,CDM,C1769,HCPCS,0272,RC,,,,both,,,155.84,101.30,,,,,,,,,,,,,
DEVICE COMBINATION TISS FIX BIOCOMP 3 SWIVELOCK FIBERTAK,SUP-2882411,CDM,C1713,HCPCS,0278,RC,,,,both,,,8148.30,5296.39,,,,,,,,,,,,,
CEFOXITIN SODIUM 2 G IV SOLR,RX-9463,CDM,J0694,HCPCS,0636,RC,25021-0110-20,NDC,,both,1,UN,57.50,37.37,,,,,,,,,,,,,
CATHETER EP DIAG MAP L CRV OCTAPOLAR 2-2-2MM SPC 2MM TIP,SUP-2356931,CDM,C1730,HCPCS,0272,RC,,,,both,,,1549.59,1007.23,,,,,,,,,,,,,
FILLER BNE GRFT 10 ML GENTAMICIN SULF HA CALCIUM SULF INJ,SUP-2893106,CDM,C1602,HCPCS,0278,RC,,,,both,,,23352.18,15178.92,,,,,,,,,,,,,
CAGE SPNL 60X10MM LORDTC LUM INTBDY FUS DUO,SUP-2418102,CDM,C1889,HCPCS,0278,RC,,,,both,,,23550.00,15307.50,,,,,,,,,,,,,
SLEEVE INSULATING TIP CRYOSURGICAL,SUP-2171528,CDM,C1894,HCPCS,0272,RC,,,,both,,,43.68,28.39,,,,,,,,,,,,,
PLATE BONE W17.5XL214MM THK5.2MM 12 H TI BROAD LIMIT CNTCT,SUP-2190852,CDM,C1713,HCPCS,0278,RC,,,,both,,,2024.99,1316.24,,,,,,,,,,,,,
ALLOGRAFT BNE DWL 9X25-29 MM PRESERVON CANN CANC FLEXIGRAFT,SUP-2421829,CDM,C1762,CPT,0278,RC,,,,both,,,3222.83,2094.84,,,,,,,,,,,,,
CATHETER EP LG 2-8-2 MM 7 FRX95 CM LIVEWIRE,SUP-2355235,CDM,C1731,HCPCS,0278,RC,,,,both,,,4577.18,2975.17,,,,,,,,,,,,,
BLADE SURG 67 MM EZX,SUP-2745652,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3293.70,2140.90,,,,,,,,,,,,,
PLATE DERMATOME 1.5 IN,SUP-2603273,CDM,C1713,HCPCS,0278,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
KIT VENTRICULAR DRAINAGE VENTRICULOSTOMY COMB W/ INS5HND,SUP-2883592,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3590.50,2333.82,,,,,,,,,,,,,
ENDCAP ORTHOPEDIC 0-15 MM EXTN FOR SLD HUM NAIL TI NS,SUP-2192528,CDM,C1713,HCPCS,0278,RC,,,,both,,,699.34,454.57,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 45 CM DIA 4-6 MM SHRT TAPR SLDE GDS,SUP-2461619,CDM,C1768,CPT,0278,RC,,,,both,,,1496.43,972.68,,,,,,,,,,,,,
CATHETER ANGIOPASTY 137CM 40MM OD5FR ODSEC3MM .014IN OTW,SUP-2353068,CDM,C1725,HCPCS,0272,RC,,,,both,,,3061.50,1989.97,,,,,,,,,,,,,
MATRIX BIO L 8 X W 10 CM SZ 144 SQCM FISH SKIN DERMAL,SUP-2909206,CDM,Q4158,HCPCS,0636,RC,,,,both,,,14164.54,9206.95,,,,,,,,,,,,,
PROBE ELECSURG 90DEG BPLR INSUL COOLBACK SHFT JWL CUT NOTCH,SUP-2341623,CDM,2720000010,LOCAL,0272,RC,,,,both,,,593.46,385.75,,,,,,,,,,,,,
INTRODUCER PERI L46CM S STL OBT W/ SUT H BULL SHP TIP REUSE,SUP-2243831,CDM,C1894,HCPCS,0272,RC,,,,both,,,305.71,198.71,,,,,,,,,,,,,
SLING GYN TRNSVAG FIT OD2.7MM ADVNTG,SUP-2141794,CDM,C1771,HCPCS,0278,RC,,,,both,,,2424.71,1576.06,,,,,,,,,,,,,
ALLOGRAFT GRAFTLINK: D=8.0 L=67 MM,SUP-2816062,CDM,C1762,CPT,0278,RC,,,,both,,,6963.26,4526.12,,,,,,,,,,,,,
PLATE BNE RADIAL C1 STD LT VOLAR DSTL SCR ANGLE MOD TI,SUP-2646865,CDM,C1713,HCPCS,0278,RC,,,,both,,,1895.05,1231.78,,,,,,,,,,,,,
PLATE 4.5MM TI LCP TM STRAIGHT RECON 6 HOLES 113MM,SUP-2549506,CDM,C1713,HCPCS,0278,RC,,,,both,,,1525.85,991.80,,,,,,,,,,,,,
CATHETER PICC 4FR L20CM SGL LUMN MAX BARR CT TY MIDLN,SUP-2267041,CDM,C1751,HCPCS,0278,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
CATHETER DIAG L20.25IN OD2.54MM ID1.14MM CUF OD11/32IN COR,SUP-2384405,CDM,C1713,HCPCS,0278,RC,,,,both,,,329.07,213.90,,,,,,,,,,,,,
NAIL IM L240MM OD8.5MM HUM PICCOLO,SUP-2152630,CDM,C1713,HCPCS,0278,RC,,,,both,,,5604.90,3643.18,,,,,,,,,,,,,
CAGE SPNL 16X20MM TI ANT LUM THRD REDUC PROF INTERFIX,SUP-2291788,CDM,C1889,HCPCS,0278,RC,,,,both,,,16029.26,10419.02,,,,,,,,,,,,,
STENT GRFT VASC RELAYPRO L 250 MM CVR L 259 MM DIA 26 MM,SUP-2894603,CDM,C1768,CPT,0278,RC,,,,both,,,68923.00,44799.95,,,,,,,,,,,,,
SCREW BNE ANAT TIGHT REV,SUP-2440686,CDM,C1713,HCPCS,0278,RC,,,,both,,,2091.24,1359.31,,,,,,,,,,,,,
VERSACROSS STEERABLE SHEATH 8.5F 0.035IN ID LG CURL D0 DILATOR CRV,SUP-2857960,CDM,C1766,CPT,0272,RC,,,,both,,,2873.10,1867.51,,,,,,,,,,,,,
PIN FIX L30MM DIA2MM RESRB BIOTRAK,SUP-2106862,CDM,C1713,HCPCS,0278,RC,,,,both,,,703.36,457.18,,,,,,,,,,,,,
APPLIER INT CLP LAP MED 10 MMX33 CM ROT KNOB,SUP-2852432,CDM,C1889,HCPCS,0278,RC,,,,both,,,3243.31,2108.15,,,,,,,,,,,,,
PLATE ULNA 2.5 8 HOLES,SUP-2713863,CDM,C1713,HCPCS,0278,RC,,,,both,,,3255.55,2116.11,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED CUP LNR XLPE G7,SUP-2212417,CDM,C1776,CPT,0278,RC,,,,both,,,6772.98,4402.44,,,,,,,,,,,,,
PLATE EXT FIX LNG 160 MM FT RNG TI NS,SUP-2799580,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2922.93,1899.90,,,,,,,,,,,,,
MESH HERN W10XL10CM MFIL RESRB SQ W/ HYDRGEL BARR PHASIX ST,SUP-2127355,CDM,C1781,HCPCS,0278,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
SCREW BNE 4MMX28MM CANN HI TORQ CAPTURE,SUP-2243994,CDM,C1713,HCPCS,0278,RC,,,,both,,,1170.44,760.79,,,,,,,,,,,,,
GUIDEWIRE VASC L 145 CM DIA 0.035 IN TAPR L 8 CM FLPY TIP L,SUP-2169711,CDM,C1769,HCPCS,0272,RC,,,,both,,,95.02,61.76,,,,,,,,,,,,,
COIL EMB L2CM DIA1MM EXTRA SFT HELIX DETACH AXIUM PRIM,SUP-2295013,CDM,C1889,HCPCS,0278,RC,,,,both,,,4458.80,2898.22,,,,,,,,,,,,,
ORBIT GALAXY DETACH COIL SYS 175CM 35MM 5CM CONTENTS 1,SUP-2249002,CDM,C1713,HCPCS,0278,RC,,,,both,,,7481.58,4863.03,,,,,,,,,,,,,
ADAPTER EXT FIX LNG FOR 3 4 5 6MM APEX PIN HOFFMANN LRF,SUP-2363126,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1350.83,878.04,,,,,,,,,,,,,
NEUROPEN 15.5 CM SHAFT,SUP-2854428,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3177.68,2065.49,,,,,,,,,,,,,
HC So Alkaloids Nos,PX-3018032366,CDM,G0480,CPT,0301,RC,,,,inpatient,,,64.00,41.60,,,,,,,,,,,,,
LEAD NEUROSTIMULATOR L60CM 8 ELECTRD 4MM SPC TUNN TOOL TORQ,SUP-2355955,CDM,C1778,HCPCS,0278,RC,,,,both,,,6751.00,4388.15,,,,,,,,,,,,,
NALBUPHINE HCL 10 MG/ML IJ SOLN,RX-5339,CDM,J2300,HCPCS,0636,RC,00409-1464-61,NDC,,both,0.5,ML,54.10,35.16,,,,,,,,,,,,,
GUIDEWIRE VASC LUNDERQUIST L 180 CM DIA 0.035 IN TAPR L 15,SUP-2170674,CDM,C1769,HCPCS,0272,RC,,,,both,,,145.01,94.26,,,,,,,,,,,,,
STRIPS ILIUM TRICORT TRAD ALLGRFT 22X60 MM FRZ DRY,SUP-2294074,CDM,C1713,HCPCS,0278,RC,,,,both,,,6568.88,4269.77,,,,,,,,,,,,,
PIN GUIDE L 300 MM DIA1.9 MM DRL TIP STRL DISP,SUP-2933130,CDM,2720000010,LOCAL,0272,RC,,,,both,,,255.19,165.87,,,,,,,,,,,,,
ALLOGRAFT BNE FILL 1-8 MM 5 CC FD SPNG CANC READIGRAFT BLX,SUP-2740977,CDM,C1713,HCPCS,0278,RC,,,,both,,,1391.33,904.36,,,,,,,,,,,,,
PLATE BNE L142MM BLDE W5.8XL38MM 145DEG 8 H NONSTERILE,SUP-2186651,CDM,C1713,HCPCS,0278,RC,,,,both,,,2098.62,1364.10,,,,,,,,,,,,,
KIT SHOULDR IMPL CAPPED S4 HEMI S4ZIMMERBIOMET,SUP-2431800,CDM,C1776,CPT,0278,RC,,,,both,,,10990.00,7143.50,,,,,,,,,,,,,
HINGE EXT FIX B FEM SVC PART,SUP-2437342,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2119.50,1377.67,,,,,,,,,,,,,
DYNACLIP FORTE DISPOSABLE PROCEDURE PACK STERILE,SUP-2878960,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1962.50,1275.62,,,,,,,,,,,,,
COMPONENT TIB XSM-XL KNEE POLYETH MOD CEM STEM ROT HNG REV,SUP-2376362,CDM,C1776,CPT,0278,RC,,,,both,,,7104.56,4617.96,,,,,,,,,,,,,
CAGE SPNL MESH 22X28X15 MM LUMBAR INTBDY TI PYRAMESH,SUP-2292040,CDM,C1889,HCPCS,0278,RC,,,,both,,,6452.61,4194.20,,,,,,,,,,,,,
PLATE BNE RADIAL XLN MED LT VOLAR DSTL,SUP-2646871,CDM,C1713,HCPCS,0278,RC,,,,both,,,3045.99,1979.89,,,,,,,,,,,,,
BOLT ORTH FUSION 6.5X155 MM MIDFOOT TI NS,SUP-2799619,CDM,C1713,HCPCS,0278,RC,,,,both,,,1422.26,924.47,,,,,,,,,,,,,
HC Phlebotomy Therapeutic,PX-7619919500,CDM,99195,CPT,0940,RC,,,,outpatient,,,330.00,214.50,,,,,,,,,,,,,
MICROCATHETER INFUSION SUPERCROSS 120 DEG L 130 CM OD,SUP-2605998,CDM,C1887,HCPCS,0272,RC,,,,both,,,1299.96,844.97,,,,,,,,,,,,,
KIT NAVIGATION W/ BX NDL 19GA L105MM FNA NDL 20GA L15CM BX,SUP-2392619,CDM,C1713,HCPCS,0278,RC,,,,both,,,2246.67,1460.34,,,,,,,,,,,,,
SCREW SPNL MULTAXL 4.5X40 MM OCCIPITOCERVICAL UPPER THOR,SUP-2631976,CDM,C1713,HCPCS,0278,RC,,,,both,,,1789.80,1163.37,,,,,,,,,,,,,
DEFIBRILLATOR CARD 2 CHMBR W/O ATR LD TIERED THER ADAPTIVE,SUP-2236355,CDM,C1721,HCPCS,0275,RC,,,,both,,,83900.80,54535.52,,,,,,,,,,,,,
VISE EXT FIX INSUL MINI HM32,SUP-2517252,CDM,2720000010,LOCAL,0272,RC,,,,both,,,503.03,326.97,,,,,,,,,,,,,
GASTROSTOMY SET PUL METHOD 24 FRX150 CM 5.5 FR FEN DRP PEG24,SUP-2738238,CDM,2720000010,LOCAL,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
IMPLANT PIST L4.5MM DIA0.6MM WELL DIA1MM S STL CUP FEN MATTE,SUP-2284058,CDM,L8613,CPT,0278,RC,,,,both,,,433.45,281.74,,,,,,,,,,,,,
KIT REP S STL SYNDESMOSIS TIGHTROPE +,SUP-2122822,CDM,C1713,HCPCS,0278,RC,,,,both,,,2223.12,1445.03,,,,,,,,,,,,,
MESH BIO PORCINE MTRX HERN 4 LAYR ADV TISS ABD 3CM LEN 2CM,SUP-2168862,CDM,C1763,HCPCS,0278,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
NUT ORTH FOR 4.5MM CORT SCR,SUP-2184677,CDM,C1713,HCPCS,0278,RC,,,,both,,,81.42,52.92,,,,,,,,,,,,,
DRILL SURG FOR 1.7MM SUTFIX CVD SHLDR FLEX SUT ANCHR,SUP-2341936,CDM,C1713,HCPCS,0278,RC,,,,both,,,545.01,354.26,,,,,,,,,,,,,
HC Insertion of Chest Tube,PX-4503255100,CDM,32551,CPT,0450,RC,,,,both,,,4942.00,3212.30,,,,,,,,,,,,,
HC Iliac Atherectomy,PX-3610238000,CDM,0238T,CPT,0361,RC,,,,both,,,10136.00,6588.40,,,,,,,,,,,,,
CATHETER GUIDE EXTN 7 FRX150 CM HYDRPHLC COAT TELSCP,SUP-2416548,CDM,C1887,HCPCS,0272,RC,,,,both,,,1161.80,755.17,,,,,,,,,,,,,
GUIDEWIRE ARTHSCP L10IN DIA2.4MM NIT DRL TIP SMOOTH FLX W/O,SUP-2341319,CDM,C1769,HCPCS,0272,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
PLATE SPNL L10MM TI POST CERV LO PROF OPN DOOR BILAT,SUP-2290211,CDM,C1713,HCPCS,0278,RC,,,,both,,,1246.58,810.28,,,,,,,,,,,,,
KIT ELBW JT BUSHING PIN COMP REPL FOR SM ELBW COONRAD/MORREY,SUP-2205947,CDM,C1776,CPT,0278,RC,,,,both,,,2317.32,1506.26,,,,,,,,,,,,,
EXPANDER BRST TISS 500CC W13.5XH13.5CM P6.6CM SIL SMOOTH HI,SUP-2301020,CDM,C1789,HCPCS,0278,RC,,,,both,,,6531.20,4245.28,,,,,,,,,,,,,
HC So Mycophenolate Level,PX-3018018066,CDM,80180,CPT,0301,RC,,,,both,,,129.00,83.85,,,,,,,,,,,,,
DRILL TWIST DIA7MM CANNULATED PROXIMAL,SUP-2878274,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1350.20,877.63,,,,,,,,,,,,,
KIT ASPIR SM VOL BONE MAR,SUP-2163071,CDM,2720000010,LOCAL,0272,RC,,,,both,,,524.38,340.85,,,,,,,,,,,,,
HC Phlebotomy Therapeutic,PX-7619919500,CDM,99195,CPT,0940,RC,,,,inpatient,,,330.00,214.50,,,,,,,,,,,,,
LIDOCAINE HCL (CARDIAC) PF 100 MG/5ML IV SOSY,RX-145137,CDM,J2003,HCPCS,0636,RC,00409-1323-05,NDC,,both,1,ML,54.10,35.16,,,,,,,,,,,,,
COMPRESSOR GRP FOR INSTR SYS TENOR,SUP-2289253,CDM,C1713,HCPCS,0278,RC,,,,both,,,6587.72,4282.02,,,,,,,,,,,,,
HC Echo Cong. Anom - Lmt,PX-4839330400,CDM,93304,CPT,0483,RC,,,,both,,,927.00,602.55,,,,,,,,,,,,,
ALLOGRAFT BNE STRP 3X3X3 MM 15 CC PTTY STRL OSTEOSTRUX,SUP-2731805,CDM,C1713,HCPCS,0278,RC,,,,both,,,3909.30,2541.04,,,,,,,,,,,,,
GUIDEWIRE VASC L 80 CM 0.018 IN L 5CM SS MANDREL STR FIX FLX,SUP-2828289,CDM,C1769,HCPCS,0272,RC,,,,both,,,67.45,43.84,,,,,,,,,,,,,
FRAME EXT FIX BRDG BX ANK DELT STRL GALAXY UNYCO LTX,SUP-2875638,CDM,C1713,HCPCS,0278,RC,,,,both,,,32361.47,21034.96,,,,,,,,,,,,,
WIRE FIX COMPR 1.6X150 MM 25 MM THRD NS,SUP-2863401,CDM,C1713,HCPCS,0278,RC,,,,both,,,144.63,94.01,,,,,,,,,,,,,
SCREW BNE L6MM DIA1MM STD CORT S STL ST NONCANNULATED,SUP-2183135,CDM,C1713,HCPCS,0278,RC,,,,both,,,198.32,128.91,,,,,,,,,,,,,
PLATE BONE 8 H BILAT CRANIOMAXILLOFACIAL TI STRUT LO PROF,SUP-2191330,CDM,C1713,HCPCS,0278,RC,,,,both,,,2233.17,1451.56,,,,,,,,,,,,,
CATHETER CV SET 032 10 FRX25 CM 5 LUMEN QUINT SPECTRUM,SUP-2759769,CDM,C1751,HCPCS,0278,RC,,,,both,,,493.64,320.87,,,,,,,,,,,,,
PLATE 4.5MM TI LCP TM PROX TIBIA 6H 118MM LEFT STERILE,SUP-2549635,CDM,C1713,HCPCS,0278,RC,,,,both,,,5012.66,3258.23,,,,,,,,,,,,,
ALLOGRAFT BNE WDG 20X17 MM FD PAT,SUP-2717925,CDM,C1762,CPT,0278,RC,,,,both,,,6437.00,4184.05,,,,,,,,,,,,,
SLOTTED SCREW F/CONDYLAR HEAD,SUP-2823038,CDM,C1889,HCPCS,0278,RC,,,,both,,,580.27,377.18,,,,,,,,,,,,,
ENDCAP ORTH DIA12MM EXTN 10MM LAT FEM GRY TI CANN T40,SUP-2188987,CDM,C1713,HCPCS,0278,RC,,,,both,,,638.64,415.12,,,,,,,,,,,,,
ELECTRODE EMG L12MM SUBDERM 4 CHN PR SHRP LANC TIP TWISTED,SUP-2279928,CDM,2720000010,LOCAL,0272,RC,,,,both,,,557.82,362.58,,,,,,,,,,,,,
CATHETER DRAINAGE VLV 5 FRX7 CM 20 GA ECHOGENIC NDL ACCEL,SUP-2659250,CDM,C1729,HCPCS,0272,RC,,,,both,,,65.12,42.33,,,,,,,,,,,,,
FORCEPS SURG 23GA TEXT PLATFRM GLARE FRE FINISH ADAPTIVE,SUP-2393140,CDM,2720000010,LOCAL,0272,RC,,,,both,,,308.60,200.59,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.541,SUP-2860058,CDM,C1713,HCPCS,0278,RC,,,,both,,,52400.32,34060.21,,,,,,,,,,,,,
KIT DUAL K2 PROCESSOR W/ TWO KANSO 2 PROCESSORS (CP1150),SUP-2858181,CDM,L8690,HCPCS,0278,RC,,,,both,,,39250.00,25512.50,,,,,,,,,,,,,
SUPPORT ORTHOT LOWER EXTREMITY CUST PER EXTN BAR,SUP-2435695,CDM,L2760,HCPCS,0272,RC,,,,both,,,160.86,104.56,,,,,,,,,,,,,
BONE MATRIX CELLULAR ORIOS 5CC,SUP-2653967,CDM,C1713,HCPCS,0278,RC,,,,both,,,10676.00,6939.40,,,,,,,,,,,,,
MATRIX SURGICAL WOUND 0.030OZ CONNEXT,SUP-2758896,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4662.90,3030.88,,,,,,,,,,,,,
CROWN 6 2ND PERM M LO LT S STL UNITEK,SUP-2238853,CDM,D6783,CPT,0278,RC,,,,both,,,116.31,75.60,,,,,,,,,,,,,
PLATE BNE 130 DEG SHFT L 104 MM BLADE L 50 MM 6 H SS PROX,SUP-2908090,CDM,C1713,HCPCS,0278,RC,,,,both,,,2869.36,1865.08,,,,,,,,,,,,,
STENT URET 5FR L28CM HYDRPHLC SET SFT PGTL STRAIGHTENER POS,SUP-2170695,CDM,C2617,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
DRILL SURG STP 2.4X140 MM CANN,SUP-2749972,CDM,2720000010,LOCAL,0272,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
SUPPORT ORTHOT HND FNGR STRP W/O JT PREFABRICATED INTFACE,SUP-2435783,CDM,L3924,HCPCS,0272,RC,,,,both,,,248.88,161.77,,,,,,,,,,,,,
REMOVER CLP L15CM L APPRX SPAN BEFORE CLSR 1.7MM DISP,SUP-2264251,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7313.06,4753.49,,,,,,,,,,,,,
PLATE BNE L286MM 14 H L LAT DST PERIARTC FEM S STL LOK FOR,SUP-2410724,CDM,C1713,HCPCS,0278,RC,,,,both,,,4533.06,2946.49,,,,,,,,,,,,,
SHEATH TRANSSEPTAL L 72 CM DIA 8.5 FR CRV L 22 MM DIL L 95,SUP-2913158,CDM,C1766,HCPCS,0272,RC,,,,both,,,2873.10,1867.51,,,,,,,,,,,,,
COIL NEUROVASCULAR OPTMA L 47 CM DIA14 MM SZ 0.018 IN PLAT,SUP-2753934,CDM,C1889,HCPCS,0278,RC,,,,both,,,6892.30,4479.99,,,,,,,,,,,,,
GRAFT VASC GELWEAVE L 30 CM DIA 34 MM POLYESTER GEL STR 3,SUP-2894634,CDM,C1889,HCPCS,0278,RC,,,,both,,,3925.00,2551.25,,,,,,,,,,,,,
CANNULA ENDOSCP TERMANIAN ENDOTIP 6 MMX8.5 CM W/ THRD,SUP-2776349,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1906.17,1239.01,,,,,,,,,,,,,
BLOCK TIB AUG 3 5 MM RT LAT LT MEDL NXGN,SUP-2437111,CDM,C1713,HCPCS,0278,RC,,,,both,,,4408.56,2865.56,,,,,,,,,,,,,
MATRIX BIO L 1.6 X W 1.2 IN SZ 12 SQCM PORCINE TEND DERIVED,SUP-2909290,CDM,A2008,HCPCS,0636,RC,,,,both,,,4308.08,2800.25,,,,,,,,,,,,,
SCREW BNE L115MM DIA3.5MM STD CORT S STL ST NONCANNULATED,SUP-2183565,CDM,C1713,HCPCS,0278,RC,,,,both,,,81.42,52.92,,,,,,,,,,,,,
HYDROCORTISONE VALERATE 0.2 % EX CREA,RX-10218,CDM,6370000000,HCPCS,0637,RC,51672-1290-01,NDC,,both,15,GR,322.40,209.56,,,,,,,,,,,,,
BLADE OPHTH 19GA L1.6MM CORNEAL SCLER BLNT DEL STR HNDL,SUP-2110018,CDM,2720000010,LOCAL,0272,RC,,,,both,,,60.29,39.19,,,,,,,,,,,,,
BLADE RTRCTR MCCLLCH 20MMW X 60MML SPNL MSCLE NRRW RGGLS RDM,SUP-2462358,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1624.60,1055.99,,,,,,,,,,,,,
SCREW BNE L32MM DIA4MM STD CANC TI ST LOK FULL THRD BLNT SM,SUP-2413607,CDM,C1713,HCPCS,0278,RC,,,,both,,,536.47,348.71,,,,,,,,,,,,,
INTRODUCER TRANSSEPTAL GUID BRAID SL2 CRV TYP 8FRX8FR W/,SUP-2357255,CDM,C1894,HCPCS,0272,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
TUBING STBL 12 MM FOR DA VINCI S SI ENDOWRIST CLEARFIELD,SUP-2246648,CDM,C1713,HCPCS,0278,RC,,,,both,,,816.40,530.66,,,,,,,,,,,,,
CATHETER VENTRICULAR 14 CM RT ANGLED ADAPTOR BACTISEAL,SUP-2666472,CDM,C1729,HCPCS,0272,RC,,,,both,,,1697.01,1103.06,,,,,,,,,,,,,
SCREW SPNL L28MM DIA5.2MM CORT ANT LUM ST VAR ANG AEGIS,SUP-2255178,CDM,C1713,HCPCS,0278,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
VALVE PRESSURE PROGRAMMABLE CYL 30MM H2O TO 200MM H2O HAKIM,SUP-2666796,CDM,C1889,HCPCS,0278,RC,,,,both,,,18930.46,12304.80,,,,,,,,,,,,,
PLATE LK POLYAXIAL ST,SUP-2495321,CDM,C1713,HCPCS,0278,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 4X4 CM CRYOPRESERVED AMNIOX CLARIX 100,SUP-2648669,CDM,Q4156,HCPCS,0636,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
PACEMAKER CARD 10MM OUTFLOW IDE PMP VENT ASST DEV HEARTWARE,SUP-2282537,CDM,C1768,CPT,0278,RC,,,,both,,,6280.00,4082.00,,,,,,,,,,,,,
INTRODUCER PACE LD L 25 CM DIA 9 FR PERC PEELABLE STRL,SUP-2282127,CDM,C1894,HCPCS,0272,RC,,,,both,,,112.26,72.97,,,,,,,,,,,,,
KNOWLES PIN 1.8X4 1.4,SUP-2818101,CDM,C1713,HCPCS,0278,RC,,,,both,,,1069.08,694.90,,,,,,,,,,,,,
CATHETER ETER DIL FILIFORMS WVN STR TIP 5FR 3175CM REUSE,SUP-2126119,CDM,2720000010,LOCAL,0272,RC,,,,both,,,495.40,322.01,,,,,,,,,,,,,
AMOXICILLIN-POT CLAVULANATE 400-57 MG/5ML PO SUSR,RX-33230,CDM,340b,HCPCS,0637,RC,16714-0293-02,NDC,,both,5,ML,3.50,2.27,,,,,,,,,,,,,
PLATE BNE L194MM THK3.7MM 10 H NONSTERILE L DST MED TIB S,SUP-2185533,CDM,C1713,HCPCS,0278,RC,,,,both,,,3859.31,2508.55,,,,,,,,,,,,,
HC Treat Tibia Fx,PX-4502775000,CDM,27750,CPT,0450,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
BIT DRL SLD 1.5 MM FOR SPIDER LIMIT WRST FUSION,SUP-2852811,CDM,2720000010,LOCAL,0272,RC,,,,both,,,788.17,512.31,,,,,,,,,,,,,
ALLOGRAFT HUMAN TISS AXIOFILL 2000MG,SUP-2865151,CDM,C1762,CPT,0278,RC,,,,both,,,16387.66,10651.98,,,,,,,,,,,,,
IMPLANT COSMETIC SZ 25 X 50 X 3 MM POLYETHYL BLOCK STRL DISP,SUP-2935429,CDM,C1713,HCPCS,0278,RC,,,,both,,,2000.18,1300.12,,,,,,,,,,,,,
SHEATH GUID 11.5X8.5FR L72CM BI DIR SM CRV MOBICATH,SUP-2248640,CDM,C1766,CPT,0272,RC,,,,both,,,2342.44,1522.59,,,,,,,,,,,,,
CATHETER URET PGTL 10 FRX56 CM SOFFLX AQ,SUP-2835786,CDM,C1758,HCPCS,0278,RC,,,,both,,,139.26,90.52,,,,,,,,,,,,,
PROSTHESIS OSS 1.5-5.6 MM 1.5X2.5 MM 1.45 MM PART HA TI SIL,SUP-2483418,CDM,L8613,CPT,0278,RC,,,,both,,,1256.09,816.46,,,,,,,,,,,,,
PLATE BNE FUSION LT FT MEDL CLMN STRL A.L.P.S,SUP-2466806,CDM,C1713,HCPCS,0278,RC,,,,both,,,2881.33,1872.86,,,,,,,,,,,,,
CATHETER CV SET 018 4 FRX60 CM SS TURBO-JECT UPICS40CT1111,SUP-2759820,CDM,C1751,HCPCS,0278,RC,,,,both,,,328.57,213.57,,,,,,,,,,,,,
COIL NEUROVASCULAR GDC-10 L 10 CM DIA 4 MM MICROCATHETER,SUP-2365656,CDM,C1889,HCPCS,0278,RC,,,,both,,,1514.42,984.37,,,,,,,,,,,,,
MELOXICAM 7.5 MG PO TABS,RX-20566,CDM,6370000000,HCPCS,0637,RC,50268-0525-11,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
DEVICE PESSARY SZ 2 RNG W KNOB AND SUPP,SUP-2305664,CDM,A4562,HCPCS,0274,RC,,,,both,,,200.05,130.03,,,,,,,,,,,,,
KIT TISS EXP W/ 10ML LUERLOCK SYR 108CM TRNSF SET 2W CK VLV,SUP-2113308,CDM,C1789,HCPCS,0278,RC,,,,both,,,34.01,22.11,,,,,,,,,,,,,
MICROSPHERE EMB CNTOUR SE DIA 300-500 UM 1 ML PVA PREFIL SYR,SUP-2148447,CDM,C1889,HCPCS,0278,RC,,,,both,,,794.55,516.46,,,,,,,,,,,,,
PLATE EXT FIX BRDG 210 MM FOR 5/8 RNG ALUM NS MAXFRAME,SUP-2800254,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4358.51,2833.03,,,,,,,,,,,,,
PLATE BONE 12 H STOUT STR FOR 2MM SCR VLP MINI-MOD SM BONE,SUP-2351089,CDM,C1713,HCPCS,0278,RC,,,,both,,,5345.38,3474.50,,,,,,,,,,,,,
GUIDEWIRE VASC GLIDEWIRE L 450 CM DIA 0.035 IN TIP 1.5 MM,SUP-2761855,CDM,C1769,HCPCS,0272,RC,,,,both,,,356.08,231.45,,,,,,,,,,,,,
PIN ARTHSCP FLEX FOR FLEX RMR,SUP-2121218,CDM,2720000010,LOCAL,0272,RC,,,,both,,,486.70,316.35,,,,,,,,,,,,,
ALLOGRAFT BNE PWD 30 CC FD IRRADIATED CANC,SUP-2867089,CDM,C1762,CPT,0278,RC,,,,both,,,1369.20,889.98,,,,,,,,,,,,,
SEGMENTAL VSS STEM 15MM X 190MM BOWED,SUP-2502504,CDM,C1776,CPT,0278,RC,,,,both,,,11812.68,7678.24,,,,,,,,,,,,,
GRAFT STRGHT ULTRA THIN WALL NON RNGD PLSTR 6MM DIA 70CM LNG,SUP-2470252,CDM,C1768,CPT,0278,RC,,,,both,,,2113.94,1374.06,,,,,,,,,,,,,
GRAFT VASC HEMGRD L 20 CM DIA 6 MM POLYESTER BOV CLLGN STR,SUP-2227526,CDM,C1768,CPT,0278,RC,,,,both,,,1401.29,910.84,,,,,,,,,,,,,
BRACE THMB IP TO WR CREASE UP TO 3 3/4INXSM COLLUM CMC REG,SUP-2324972,CDM,L3931,HCPCS,0272,RC,,,,both,,,70.08,45.55,,,,,,,,,,,,,
SPACER SPNL W18XH8-11XL45MM LUM INTBDY FUS EXP CTRL DISC HT,SUP-2230738,CDM,C1821,HCPCS,0278,RC,,,,both,,,16485.00,10715.25,,,,,,,,,,,,,
PLATE BNE L148MM 8 H S STL T SHP LOK COMPR FOR 4.5/5MM SCR,SUP-2185758,CDM,C1713,HCPCS,0278,RC,,,,both,,,2153.38,1399.70,,,,,,,,,,,,,
HC Admin Hepatitis B Vaccine,PX-7710001000,CDM,G0010,HCPCS,0771,RC,,,,inpatient,,,116.00,75.40,,,,,,,,,,,,,
BIO-COMPOSITE TRANSFIX 5X40MM,SUP-2811824,CDM,C1713,HCPCS,0278,RC,,,,both,,,1252.86,814.36,,,,,,,,,,,,,
TRAY CV CATH ARW TI PRT SIL CATH NDL SYR FOR VASC ACCS,SUP-2383954,CDM,C1788,HCPCS,0278,RC,,,,both,,,1422.42,924.57,,,,,,,,,,,,,
DRILL SURG 27X36MM PROX SL CANN,SUP-2400092,CDM,2720000010,LOCAL,0272,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
SCREW BNE L 6 MM DIA2.6 MM PLA GLYCOLIDE CRANIOMAXILLOFACIAL,SUP-2883434,CDM,C1713,HCPCS,0278,RC,,,,both,,,581.34,377.87,,,,,,,,,,,,,
COIL EMB L2CM DIA2MM 00115IN INTCRAN MICROFILAMENT DETACH,SUP-2173090,CDM,C1889,HCPCS,0278,RC,,,,both,,,5680.26,3692.17,,,,,,,,,,,,,
GRAFT VASC GORTX L 70 CM DIA 4.5-6.5 MM EPTFE TAPR TW N RING,SUP-2396727,CDM,C1768,CPT,0278,RC,,,,both,,,2128.92,1383.80,,,,,,,,,,,,,
CONNECTOR SPNL L35MM IL TI LO PROF OFFSET FOR DEFORMITY CORR,SUP-2317341,CDM,C1713,HCPCS,0278,RC,,,,both,,,3611.00,2347.15,,,,,,,,,,,,,
SCREW BNE L16MM DIA4.5MM PUR TI CORT ST CANN FULL THRD FOR,SUP-2316383,CDM,C1713,HCPCS,0278,RC,,,,both,,,486.64,316.32,,,,,,,,,,,,,
SYSTEM ACCS WATCHMAN TRUSTEER OD 17 FR ID 12 FR LT ATR DBL,SUP-2895305,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
SUPPORT ORTHOPEDIC ADJ SM LG AD PEDIATRIC RT HND WRST FNGR,SUP-2264312,CDM,L3807,HCPCS,0272,RC,,,,both,,,159.36,103.58,,,,,,,,,,,,,
GENERATOR NEUROSTIMULATOR 304CUCM H219XL195IN THK053IN,SUP-2356746,CDM,C1767,HCPCS,0278,RC,,,,both,,,48670.00,31635.50,,,,,,,,,,,,,
STENT URET 0.038 IN 5 FRX26 CM SET 2 DUROMETER POLARIS ULTRA,SUP-2537712,CDM,C2617,HCPCS,0278,RC,,,,both,,,629.98,409.49,,,,,,,,,,,,,
SHEATH INTRO LIEBERMAN L 37 CM DIA 6.5 FR GUIDEWIRE 0.038 IN,SUP-2168786,CDM,C1894,HCPCS,0272,RC,,,,both,,,127.86,83.11,,,,,,,,,,,,,
BRACE ANKLEXL AD FOR 11.5-13IN UNIV VLY CNTOUR STL STAY,SUP-2197935,CDM,L4350,HCPCS,0272,RC,,,,both,,,30.21,19.64,,,,,,,,,,,,,
WEDGE TIB TY FULL,SUP-2252431,CDM,C1776,CPT,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
PLATE BONE RT DORS DSTL VOLAR RAD WR CROSSLOCK,SUP-2205428,CDM,C1713,HCPCS,0278,RC,,,,both,,,3642.40,2367.56,,,,,,,,,,,,,
PIN FIXATION L10MM DIAMETER 1.1MM PLLA SELF REINFORCED FRACT,SUP-2855235,CDM,C1713,HCPCS,0278,RC,,,,both,,,383.08,249.00,,,,,,,,,,,,,
GRAFT BNE TISS 20X40 MM 0.8-1.8MM DBM PUROS,SUP-2210630,CDM,C1713,HCPCS,0278,RC,,,,both,,,919.39,597.60,,,,,,,,,,,,,
HC Ewho W/O Joint Custom Fab,PX-2740376301,CDM,L3763,HCPCS,0274,RC,,,,both,,,2638.00,1714.70,,,,,,,,,,,,,
SHELL ACET DIA48MM LNR SZ C 2 H MPACT,SUP-2267362,CDM,C1776,CPT,0278,RC,,,,both,,,5912.62,3843.20,,,,,,,,,,,,,
NAIL IM L255MM DIA8.5MM L HUM TAN STR CANN BLU MULTILOC,SUP-2180253,CDM,C1713,HCPCS,0278,RC,,,,both,,,6077.25,3950.21,,,,,,,,,,,,,
CATHETER CV SINGLE LUMEN 0.018 IN 3 FRX50 CM 55 CM SIL,SUP-2168330,CDM,C1751,HCPCS,0278,RC,,,,both,,,248.44,161.49,,,,,,,,,,,,,
DIPHENHYDRAMINE HCL 25 MG PO CAPS,RX-2509,CDM,6370000000,HCPCS,0637,RC,69618-0024-01,NDC,,both,1,UN,0.20,0.13,,,,,,,,,,,,,
CATHETER ANGIO SOFT-VU L 65 CM 5 FR 0.038 IN SOS OMNI2 SFT,SUP-2882719,CDM,C1725,HCPCS,0272,RC,,,,both,,,65.94,42.86,,,,,,,,,,,,,
MATRIX BONE 2ML GRFT SUB DEMIN PASTE INTERGRO +,SUP-2414013,CDM,C1713,HCPCS,0278,RC,,,,both,,,2056.70,1336.85,,,,,,,,,,,,,
LENS IOL BCNVX 16.5+ DIOPT 6X12.5 MM ACRYL ENVISTA,SUP-2129618,CDM,V2632,HCPCS,0276,RC,,,,both,,,414.48,269.41,,,,,,,,,,,,,
VERAPAMIL HCL 2.5 MG/ML IV SOLN,RX-8527,CDM,2500000003,HCPCS,0250,RC,70710-1643-05,NDC,,both,1,ML,54.10,35.16,,,,,,,,,,,,,
BIT DRILL CANNULATED 4.5MM,SUP-2719559,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1430.21,929.64,,,,,,,,,,,,,
GRAFT VASC GORTX L 70 CM DIA 6 MM RNG L 70 CM EPTFE STR STD,SUP-2396097,CDM,C1768,CPT,0278,RC,,,,both,,,2816.58,1830.78,,,,,,,,,,,,,
SCREW BNE L26MM DIA3.5MM PROX HUM NONLOCKING T15 LO PROF 110017726] ZIMMER BIOMET TRAUMA],SUP-2411565,CDM,C1713,HCPCS,0278,RC,,,,both,,,145.95,94.87,,,,,,,,,,,,,
PROSTHESIS OSS SANNA PISTON 0.5X6 MM TRIM FLROPLAS PLAT,SUP-2638117,CDM,L8613,CPT,0278,RC,,,,both,,,631.83,410.69,,,,,,,,,,,,,
CATHETER VENT L35CM OD2.8MM ID1.5MM BA IMPREG EXT DRNGE AND,SUP-2284540,CDM,C1729,HCPCS,0272,RC,,,,both,,,413.98,269.09,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE 2.5 CC DBM CRUNCH,SUP-2913370,CDM,C1713,HCPCS,0278,RC,,,,both,,,2725.52,1771.59,,,,,,,,,,,,,
PLATE PL DSTL HUM LAT SUPP 3.5MM 3H RT 65MM LCP STRL,SUP-2547560,CDM,C1713,HCPCS,0278,RC,,,,both,,,2905.19,1888.37,,,,,,,,,,,,,
SALVATION LIN DISTRACTOR,SUP-2401140,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2945.32,1914.46,,,,,,,,,,,,,
PAD ORTHOT CERV THOR LUMBAR SACR CUST KYPHOSIS,SUP-2435571,CDM,L1020,HCPCS,0274,RC,,,,both,,,305.08,198.30,,,,,,,,,,,,,
GUIDEWIRE ORTH L 285 MM DIA2.5 MM THRD NS DISP,SUP-2900653,CDM,C1769,HCPCS,0272,RC,,,,both,,,528.46,343.50,,,,,,,,,,,,,
GUIDEWIRE ORTH L150MM DIA1.6MM,SUP-2412112,CDM,C1769,HCPCS,0272,RC,,,,both,,,188.40,122.46,,,,,,,,,,,,,
GAUGE MEAS + 0 MM C TAPR NK EXTN,SUP-2368458,CDM,C1776,CPT,0278,RC,,,,both,,,3433.28,2231.63,,,,,,,,,,,,,
SUPPORT ANK XL FOR 14 15IN UNIV NYL STBL NONSTRETCH LACE UP,SUP-2196816,CDM,L4350,HCPCS,0274,RC,,,,both,,,33.03,21.47,,,,,,,,,,,,,
EXTRACTOR SURG UNIV FEM STEM SLAP HAMR,SUP-2252702,CDM,C1713,HCPCS,0278,RC,,,,both,,,636.54,413.75,,,,,,,,,,,,,
SPLINT THMB AD M L BGE L MCP CMC JT PREFRM PERF FLX BASE LAM,SUP-2326182,CDM,L3908,HCPCS,0274,RC,,,,both,,,70.21,45.64,,,,,,,,,,,,,
SET CERV PD4 FOR 35 45IN 2 5YRS PED L89 114CM W REPL PD,SUP-2123894,CDM,L0190,HCPCS,0274,RC,,,,both,,,219.08,142.40,,,,,,,,,,,,,
SUPPORT ANK XL FOR 14 15IN UNIV NYL STBL NONSTRETCH LACE UP,SUP-2196816,CDM,L4350,HCPCS,0272,RC,,,,both,,,33.03,21.47,,,,,,,,,,,,,
ADAPTER CARD PACE L174CM BPLR IS 1 VS 1 CONN SIL INSUL,SUP-2356134,CDM,C1883,HCPCS,0278,RC,,,,both,,,1921.68,1249.09,,,,,,,,,,,,,
SHUNT CV 10FR L31CM POLYUR OUTLYING FLEX KINK RESIST W/ T,SUP-2264212,CDM,C1713,HCPCS,0278,RC,,,,both,,,1786.66,1161.33,,,,,,,,,,,,,
SCREW INTRF L23MM DIA7MM PEEK VENT BIO-TENODESIS,SUP-2121353,CDM,C1713,HCPCS,0278,RC,,,,both,,,989.10,642.91,,,,,,,,,,,,,
PLATE BNE 3 CRPL FOR WRST ARTHROPLAST TI STRL FRDM,SUP-2851941,CDM,C1713,HCPCS,0278,RC,,,,both,,,13902.22,9036.44,,,,,,,,,,,,,
CEFTRIAXONE SODIUM 250 MG IJ SOLR,RX-9489,CDM,J0696,HCPCS,0636,RC,00409-7337-01,NDC,,both,1,UN,54.10,35.16,,,,,,,,,,,,,
CATHETER PICC L55CM DIA4FR SGL LUMN MAX BARR KT W/ PASV VLV,SUP-2118888,CDM,C1751,HCPCS,0278,RC,,,,both,,,555.78,361.26,,,,,,,,,,,,,
STRATTICE RCNSTRCTVE TSSUE MTRX PRFRTD 10 20 FIRM,SUP-2676522,CDM,Q4130,HCPCS,0636,RC,,,,both,,,19800.84,12870.55,,,,,,,,,,,,,
HEAD HUM 4+ MM 42 MM SHLDR DELT EXT,SUP-2456980,CDM,C1776,CPT,0278,RC,,,,both,,,3403.76,2212.44,,,,,,,,,,,,,
RING EXT FIX L160MM 2 H FT FOR SIDEKCK FREE CIR FIX,SUP-2400652,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4845.02,3149.26,,,,,,,,,,,,,
SCREW BNE L 44 MM DIA 4 MM SHRT TI FT ST SD CANN PARTIALLY,SUP-2900621,CDM,C1713,HCPCS,0278,RC,,,,both,,,2339.30,1520.54,,,,,,,,,,,,,
SCREW BONE L12MM OD2.5MM FOREFOOT CANN SH THRD HDLSS SHRP,SUP-2320874,CDM,C1713,HCPCS,0278,RC,,,,both,,,912.17,592.91,,,,,,,,,,,,,
ORTHOPAEDIC INSTRUMENT KIT GEN II STRL DYNABUNION LTX,SUP-2866340,CDM,C1713,HCPCS,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
PLATE BNE 6 H 98DEG SUPCNDYL HIP S STL LOK BILAT RIG SHT BRL,SUP-2370899,CDM,C1713,HCPCS,0278,RC,,,,both,,,3367.34,2188.77,,,,,,,,,,,,,
PLATE BNE W8XL20MM THK2MM 0DEG 2 H BILAT S STL STR RIG DYN,SUP-2186174,CDM,C1713,HCPCS,0278,RC,,,,both,,,384.96,250.22,,,,,,,,,,,,,
STEM HUM CEM SHLDR TOT,SUP-2379210,CDM,C1776,CPT,0278,RC,,,,both,,,10048.00,6531.20,,,,,,,,,,,,,
MESH HERN L35.6XW30.5CM POLYPR ABD ABSRB RECTANG SEPRAMESH,SUP-2125921,CDM,C1781,HCPCS,0278,RC,,,,both,,,4567.13,2968.63,,,,,,,,,,,,,
ALLOGRAFT HUM TISS ACHILLES TEND FRZN W/O BNE NO-RAD,SUP-2321829,CDM,C1762,CPT,0278,RC,,,,both,,,4066.30,2643.09,,,,,,,,,,,,,
GRAFT VASC IMPRA L 70 CM DIA 6 MM EPTFE STR STD WALL N RING,SUP-2127892,CDM,C1768,CPT,0278,RC,,,,both,,,1340.78,871.51,,,,,,,,,,,,,
GENERATOR NEUROSTIMULATOR 25GM 14ML NONRECHARGEABLE PRGMR,SUP-2265160,CDM,C1767,HCPCS,0278,RC,,,,both,,,42864.14,27861.69,,,,,,,,,,,,,
SLEEVE FEM L31MM UNIV MTPHSEAL FULL POR LPS,SUP-2250939,CDM,C1776,CPT,0278,RC,,,,both,,,7900.24,5135.16,,,,,,,,,,,,,
CORD BPLR FTSWCH NONSTERILE REUSE,SUP-2292933,CDM,C1713,HCPCS,0278,RC,,,,both,,,436.27,283.58,,,,,,,,,,,,,
BEAM ANK FUS L110MM DIA7MM 11MM PROX SALVATION,SUP-2400783,CDM,C1713,HCPCS,0278,RC,,,,both,,,4892.12,3179.88,,,,,,,,,,,,,
KIT SCREW ANTR LUMBAR INTERFIXATION APREVO,SUP-2912128,CDM,C1713,HCPCS,0278,RC,,,,both,,,1674.66,1088.53,,,,,,,,,,,,,
DRILL SURG 2 MMX6 IN,SUP-2607264,CDM,2720000010,LOCAL,0272,RC,,,,both,,,507.08,329.60,,,,,,,,,,,,,
HEPATITIS B IMMUNE GLOBULIN 220 UNIT/ML IM SOLN,RX-155582,CDM,90371,HCPCS,0636,RC,13533-0636-01,NDC,,both,3,ML,54.10,35.16,,,,,,,,,,,,,
SET INTRO PERFRMR L 7 CM OD 6 FR ID 2 MM GUIDEWIRE L 25 CM,SUP-2168571,CDM,C1894,HCPCS,0272,RC,,,,both,,,103.59,67.33,,,,,,,,,,,,,
PLATE BONE BLLRD 6MM BRDGE TTNM RIGHT HOOK LATEX FREE ST,SUP-2677533,CDM,C1713,HCPCS,0278,RC,,,,both,,,911.64,592.57,,,,,,,,,,,,,
PLATE BNE TIB RT DP 7 HOLE,SUP-2351455,CDM,C1713,HCPCS,0278,RC,,,,both,,,16280.90,10582.58,,,,,,,,,,,,,
MINOXIDIL 10 MG PO TABS,RX-5114,CDM,6370000000,HCPCS,0637,RC,68084-0205-11,NDC,,both,1,UN,2.90,1.88,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED CEM STEM CHIPBIOCEM] ZIMMER BIOMET INC],SUP-2137372,CDM,C1776,CPT,0278,RC,,,,both,,,10990.00,7143.50,,,,,,,,,,,,,
SCREW SPNL L45MM DIA6.5MM POLYAX ST VAR ANG NONCANNULATED,SUP-2415750,CDM,C1713,HCPCS,0278,RC,,,,both,,,3532.50,2296.12,,,,,,,,,,,,,
ALLOGRAFT DERMAL MED 12X20 CMX1.6/0.4 MM RDY TO USE ALLDERM,SUP-2474881,CDM,Q4116,HCPCS,0636,RC,,,,both,,,28049.62,18232.25,,,,,,,,,,,,,
HC So Microbe Susceptible Disk,PX-3008718466,CDM,87184,CPT,0300,RC,,,,outpatient,,,100.00,65.00,,,,,,,,,,,,,
GRAFT STENT 10X40 MM 9 FRX117 CM,SUP-2126902,CDM,C1874,HCPCS,0278,RC,,,,both,,,7206.30,4684.09,,,,,,,,,,,,,
RESONANCE POSITIONER,SUP-2822058,CDM,2720000010,LOCAL,0272,RC,,,,both,,,441.01,286.66,,,,,,,,,,,,,
KIT EEG ELECTRD L 40.5 MM 12 CONTACT STRL DISP EVO,SUP-2936767,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3388.06,2202.24,,,,,,,,,,,,,
GUIDEWIRE VASC AXIS L 90 CM DIA 0.035 IN TIP L 9 CM PTFE STR,SUP-2120533,CDM,C1769,HCPCS,0272,RC,,,,both,,,119.32,77.56,,,,,,,,,,,,,
GRAFT HUM TISS FEM HD FRZN,SUP-2281651,CDM,C1713,HCPCS,0278,RC,,,,both,,,5187.28,3371.73,,,,,,,,,,,,,
POST EXT FIX 1 H FEM CONN SIDEKCK FREE CIR FIX,SUP-2400618,CDM,C1713,HCPCS,0278,RC,,,,both,,,257.48,167.36,,,,,,,,,,,,,
CANNULA ENDOSCP VERY LO PROF 6 MMX15 CM N THRD SMOOTH BLK,SUP-2768225,CDM,2720000010,LOCAL,0272,RC,,,,both,,,810.31,526.70,,,,,,,,,,,,,
KIT SPLNT CSTNG TCC EZ 4INW FIBERGLAS 1 PC WOVEN OP TCC24005,SUP-2194348,CDM,L4386,HCPCS,0272,RC,,,,both,,,371.96,241.77,,,,,,,,,,,,,
MESH HERN W4XL6IN POLYPR MID WT MFIL RECTANG OVL FLAT SHT,SUP-2227327,CDM,C1781,HCPCS,0278,RC,,,,both,,,119.82,77.88,,,,,,,,,,,,,
LEVEL CMF ST PLATE MDFCE STR WTAB 1.5 MM SCRW4 HOLE T0.6 MM,SUP-2707486,CDM,C1713,HCPCS,0278,RC,,,,both,,,472.88,307.37,,,,,,,,,,,,,
BIT DRL RETROGRADE 5.5 MM CANN W/ SUTURE RETRV ACUFEX TRUNAV,SUP-2849161,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1153.95,750.07,,,,,,,,,,,,,
SPACER TIB MOD 00 MED 4 MM CEM BPLR N-K II,SUP-2449251,CDM,C1776,CPT,0278,RC,,,,both,,,3026.96,1967.52,,,,,,,,,,,,,
PROSTHESIS PENILE 100ML PMP INHIBIZONE IMP ULTREX AMS 700,SUP-2140278,CDM,C1813,HCPCS,0278,RC,,,,both,,,3705.20,2408.38,,,,,,,,,,,,,
GRAFT VASC HEMSHLD PLAT L 15 CM DIA28 MM POLYESTER BOV CLLGN,SUP-2227238,CDM,C1768,CPT,0278,RC,,,,both,,,1389.89,903.43,,,,,,,,,,,,,
PLATE BNE OLECRANON XLN ELBW,SUP-2107786,CDM,C1713,HCPCS,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
BASEPLATE GLEN SZ 8 MM MOD TAPR KT WDG STRL ALTIVATE RVS,SUP-2904158,CDM,C1776,CPT,0278,RC,,,,both,,,24667.84,16034.10,,,,,,,,,,,,,
CONNECTOR SHUNT 1X1.9X11 MM STR SS STRL ACCU-FLO,SUP-2666410,CDM,C1889,HCPCS,0278,RC,,,,both,,,340.56,221.36,,,,,,,,,,,,,
KIT BNE GRFT L RHBMP-2 12MG INJ 10ML CONTAIN NDL 20GA,SUP-2287851,CDM,C1713,HCPCS,0278,RC,,,,both,,,18557.40,12062.31,,,,,,,,,,,,,
DEVICE INFUS 8.5FR L3.5IN EMGCY RADPQ FEP SHTH 17GAX5.5IN,SUP-2383450,CDM,C1894,HCPCS,0272,RC,,,,both,,,96.40,62.66,,,,,,,,,,,,,
FIBER LSR 365MH BLU SUREFLEX,SUP-2141885,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
HC CT Soft Tissue Neck W/ Contrast,PX-3517049100,CDM,70491,CPT,0351,RC,,,,both,,,2388.00,1552.20,,,,,,,,,,,,,
PLATE BNE L33MM THK1MM 2X6 H HND 316L S STL VAR ANG LOK ROT,SUP-2178016,CDM,C1713,HCPCS,0278,RC,,,,both,,,2024.86,1316.16,,,,,,,,,,,,,
PLATE RECON THRDLCK TS ANGLE ANGLE 27 MM SCREW 28 HOLE T30,SUP-2679088,CDM,C1713,HCPCS,0278,RC,,,,both,,,5260.98,3419.64,,,,,,,,,,,,,
COMPONENT TOE SZ 3 4 METATARSAL DCOMPR IMPL BRCH,SUP-2398626,CDM,C1776,CPT,0278,RC,,,,both,,,1318.80,857.22,,,,,,,,,,,,,
PLATE BNE L35MM THK1.3MM 2X4 H L HND TI L SHP LOK TRILOK,SUP-2267942,CDM,C1713,HCPCS,0278,RC,,,,both,,,1738.30,1129.89,,,,,,,,,,,,,
HC MRI-Abdomen W Contrast,PX-6107418200,CDM,74182,CPT,0610,RC,,,,both,,,5019.00,3262.35,,,,,,,,,,,,,
SCREW BNE L18MM DIA3.5MM DST FIBULAR NONLOCKING FULL THRD,SUP-2400175,CDM,C1713,HCPCS,0278,RC,,,,both,,,75.36,48.98,,,,,,,,,,,,,
KIT PERIPH INSRT W/ SCALP NDL SYR GWIRE DIL,SUP-2214619,CDM,C1769,HCPCS,0272,RC,,,,both,,,225.42,146.52,,,,,,,,,,,,,
PLATE BNE L 87 X W 8 MM THK 2.4 MM SCREW DIA2.7 MM 13 H SS 72468913N,SUP-2933399,CDM,C1713,HCPCS,0278,RC,,,,both,,,2676.85,1739.95,,,,,,,,,,,,,
CATHETER THROMCTMY FREECLIMB 54 L 148 CM REPERFUSION TENZING,SUP-2898950,CDM,C1757,HCPCS,0272,RC,,,,both,,,13502.00,8776.30,,,,,,,,,,,,,
PLATE BNE HK 2.7X15 MM RT CLAV BUTTON LCK COMPR NS VA-LCP,SUP-2750828,CDM,C1713,HCPCS,0278,RC,,,,both,,,3809.32,2476.06,,,,,,,,,,,,,
WIRE FIX BLNT 1.4 MM KIRSCHNER,SUP-2211135,CDM,C1713,HCPCS,0278,RC,,,,both,,,172.70,112.25,,,,,,,,,,,,,
IMPLANT OTO L5.8MM HD DIA3.5MM HA MALL CNTR PORP RICHARD,SUP-2312811,CDM,L8613,CPT,0278,RC,,,,both,,,1236.16,803.50,,,,,,,,,,,,,
CATHETER HD PRECRV 15.5 FRX36 CM LT DL FULL SET TITAN HD,SUP-2627364,CDM,C1750,HCPCS,0278,RC,,,,both,,,94.20,61.23,,,,,,,,,,,,,
HC Repair Complex Scalp/Arm/Leg 1.1-2.5 Cm,PX-4501312000,CDM,13120,CPT,0450,RC,,,,outpatient,,,1842.00,1197.30,,,,,,,,,,,,,
SCREW WRIST 15MM,SUP-2706177,CDM,C1776,CPT,0278,RC,,,,both,,,751.72,488.62,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 50 MM FRZN ASEP WHL PATELLAR TEND W/ QUAD,SUP-2866894,CDM,C1762,CPT,0278,RC,,,,both,,,10770.20,7000.63,,,,,,,,,,,,,
SYSTEM EMBOLIC PROTCT FILTERWIRE EZ 3.2FR L190CM VES DIA3.5-5.5MM NIT,SUP-2143662,CDM,C1884,HCPCS,0278,RC,,,,both,,,4286.10,2785.96,,,,,,,,,,,,,
GRAFT VASC L 35 MM ID 5 MM CLLGN BOV CAR ART WOVEN,SUP-2880947,CDM,C1768,CPT,0278,RC,,,,both,,,8474.86,5508.66,,,,,,,,,,,,,
GRAFT BIO TISS W8XL8CM MESHED FET BOV ACELLULAR DERM MTRX,SUP-2243707,CDM,Q4110,HCPCS,0636,RC,,,,both,,,6908.00,4490.20,,,,,,,,,,,,,
HC Inject Tendon Origin/Insert,PX-3612055100,CDM,20551,CPT,0361,RC,,,,outpatient,,,1485.00,965.25,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY LASSO FIX DUODECAPOLAR 20 POLE,SUP-2490042,CDM,C1731,HCPCS,0278,RC,,,,both,,,3846.50,2500.22,,,,,,,,,,,,,
ALLOGRAFT BNE IRRADIATED COSTAL CART NACL,SUP-2867210,CDM,C1762,CPT,0278,RC,,,,both,,,2762.26,1795.47,,,,,,,,,,,,,
TRAY CATH HEMODIALYSI BREVIA ACUTE 11FR DIA 12.5CML 5565120,SUP-2632902,CDM,C1752,HCPCS,0278,RC,,,,both,,,584.04,379.63,,,,,,,,,,,,,
SCREW SYS DEPTH GAUGES DRL 150 MM 4.5 MM OD 6.5 MM SCRS,SUP-2392915,CDM,C1713,HCPCS,0278,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
PLATE BNE L 70 X W 10.7 MM THK 3.4 MM SCREW DIA 3.5 MM 6 H 72440706N,SUP-2932860,CDM,C1713,HCPCS,0278,RC,,,,both,,,1362.16,885.40,,,,,,,,,,,,,
SCREW BNE PEGGED 2.5X14 MM STRL LTX,SUP-2861113,CDM,C1713,HCPCS,0278,RC,,,,both,,,329.89,214.43,,,,,,,,,,,,,
SCREW BNE SHFT PLATE STRL NCB,SUP-2862099,CDM,C1713,HCPCS,0278,RC,,,,both,,,4269.14,2774.94,,,,,,,,,,,,,
SCREW BNE L20MM OD45MM S STL HINDFOOT LOK ADVANSYS SURFIX,SUP-2243405,CDM,C1713,HCPCS,0278,RC,,,,both,,,1154.45,750.39,,,,,,,,,,,,,
TUBE GASTMY W/LMA TUBE 7X70 MM F/LIPPGOLECKI AIRWY SET,SUP-2775409,CDM,2720000010,LOCAL,0272,RC,,,,both,,,916.63,595.81,,,,,,,,,,,,,
COMPONENT FEM M H10MM DSTL SPCR RNG ENDO MOD TILASTAN,SUP-2265088,CDM,C1776,CPT,0278,RC,,,,both,,,876.06,569.44,,,,,,,,,,,,,
CATHETER PTCA L130CM BLLN L20MM DIA6MM 0.035IN PERIPH,SUP-2294968,CDM,C2623,HCPCS,0278,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
HC Rad Exam Upr GI Tract Single Contrast Study,PX-3207424000,CDM,74240,CPT,0320,RC,,,,both,,,1855.00,1205.75,,,,,,,,,,,,,
PLATE BNE W10.2XL91MM THK2.7MM 7 H BILAT S STL STR LO PROF,SUP-2186194,CDM,C1713,HCPCS,0278,RC,,,,both,,,1377.86,895.61,,,,,,,,,,,,,
CAGE SPNL L16XW16XH15MM 4 LOBE MESH NGAGE,SUP-2317742,CDM,C1889,HCPCS,0278,RC,,,,both,,,7909.66,5141.28,,,,,,,,,,,,,
ANCHOR SUT NO2 DIA145MM SHT RIG JUGGERKNOT,SUP-2136094,CDM,C1713,HCPCS,0278,RC,,,,both,,,912.99,593.44,,,,,,,,,,,,,
IMPLANT OPHTH W50XL76MM THK16MM MTB MEDPOR TI,SUP-2366480,CDM,C1713,HCPCS,0278,RC,,,,both,,,4455.22,2895.89,,,,,,,,,,,,,
CAGE SPNL W9XH10XL25MM WDG 0DEG C FBR REINF POLYMER POST,SUP-2255157,CDM,C1889,HCPCS,0278,RC,,,,both,,,9187.64,5971.97,,,,,,,,,,,,,
CAGE SPNL L12XW12XH9MM 4 LOBE MESH L ANAT FOOTPRINT MOD IMP,SUP-2317729,CDM,C1889,HCPCS,0278,RC,,,,both,,,5036.56,3273.76,,,,,,,,,,,,,
KETOTIFEN FUMARATE 0.035 % OP SOLN,RX-165427,CDM,6370000000,HCPCS,0637,RC,00536-1252-40,NDC,,both,5,ML,47.70,31.00,,,,,,,,,,,,,
RING EXT FIX L180MM 2 H FT FOR SIDEKCK FREE CIR FIX,SUP-2400659,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5177.86,3365.61,,,,,,,,,,,,,
FORCEP ALGTR 3 1/2IN DISP,SUP-2340439,CDM,C1776,CPT,0278,RC,,,,both,,,55.77,36.25,,,,,,,,,,,,,
GRAFT BONE GRAN FRZ DRY DEMIN CRUSH CANC CORT 0.5MM-3MM RANG,SUP-2307254,CDM,C1713,HCPCS,0278,RC,,,,both,,,1997.39,1298.30,,,,,,,,,,,,,
SCALPEL HNDPC DISECT HK VAR SZ REPROC HARM,SUP-2219117,CDM,2720000010,LOCAL,0272,RC,,,,both,,,748.89,486.78,,,,,,,,,,,,,
NEEDLE NERVE STIM TROCAR PEDCL ACCS NAV PK,SUP-2764368,CDM,2720000010,LOCAL,0272,RC,,,,both,,,875.59,569.13,,,,,,,,,,,,,
THIAMINE HCL 100 MG PO TABS,RX-7877,CDM,6370000000,HCPCS,0637,RC,00904-7191-06,NDC,,both,1,UN,1.40,0.91,,,,,,,,,,,,,
ROD SPNL 5X60 MM,SUP-2564516,CDM,C1713,HCPCS,0278,RC,,,,both,,,62.17,40.41,,,,,,,,,,,,,
DEFIBRILLATOR CARD 79GM 42CC W50XH76MM THK14MM DF1 IS1 CONN,SUP-2356257,CDM,C1722,HCPCS,0275,RC,,,,both,,,33629.40,21859.11,,,,,,,,,,,,,
PLATE BONE L326MM 20 H BILAT S STL BROAD LO PROF RIG DYN,SUP-2185281,CDM,C1713,HCPCS,0278,RC,,,,both,,,1562.59,1015.68,,,,,,,,,,,,,
PLATE BNE TIB 80 MM LT DSTL,SUP-2265101,CDM,C1713,HCPCS,0278,RC,,,,both,,,2357.36,1532.28,,,,,,,,,,,,,
SET NEPHSTMY PERC ACCS SHTH L20CM OD7FR ID4FR NDL TRCR TIP,SUP-2168359,CDM,C1894,HCPCS,0272,RC,,,,both,,,214.74,139.58,,,,,,,,,,,,,
TARLATAMAB-DLLE 10 MG IV SOLR,RX-167969,CDM,J9026,HCPCS,0636,RC,55513-0077-01,NDC,,both,1,UN,43200.00,28080.00,,,,,,,,,,,,,
ADAPTOR TAPER NEURTRAL LONG 0MM TITANIUM,SUP-2863710,CDM,C1776,CPT,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
TOCILIZUMAB-BAVI 400 MG/20ML IV SOLN,RX-167841,CDM,Q5133,HCPCS,0636,RC,64406-0023-01,NDC,,both,20,ML,6549.00,4256.85,,,,,,,,,,,,,
BURR SURG 6MM DIA HD XLN MIC SM BNE RND DIAMOND HVY COARSE G,SUP-2605576,CDM,2720000010,LOCAL,0272,RC,,,,both,,,161.02,104.66,,,,,,,,,,,,,
PLATE BONE L101MM 8 H TI LT CLAV SHFT FOR 3.5MM SCR LOQTEQ,SUP-2417630,CDM,C1713,HCPCS,0278,RC,,,,both,,,2655.18,1725.87,,,,,,,,,,,,,
HC Abdom Paracentesis Dx/Ther W Imaging Guidance|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE PRIOR TO THE ADMINISTRATION OF ANESTHESIA,PX-4504908300,CDM,49083,CPT,0450,RC,,,73,both,,,3707.00,2409.55,,,,,,,,,,,,,
DEFIBRILLATOR IMPL COGNIS TI CRT 2 CHMBR 2 LD HI ENERGY STRL,SUP-2149056,CDM,C1721,HCPCS,0275,RC,,,,both,,,81640.00,53066.00,,,,,,,,,,,,,
MATRIX BIO DIA 30 MM FISH SKIN SIL DERMAL ADH CIR FEN INTACT,SUP-2909249,CDM,Q4158,HCPCS,0636,RC,,,,both,,,18538.56,12050.06,,,,,,,,,,,,,
KIT BLLN DIL CATH 5.8FR L75CM BLLN 18FR L6CM GWIRE 0.038IN,SUP-2139203,CDM,C1726,HCPCS,0272,RC,,,,both,,,859.07,558.40,,,,,,,,,,,,,
WASHER EXT FIX CPL HOFFMANN,SUP-2457050,CDM,2720000010,LOCAL,0272,RC,,,,both,,,395.64,257.17,,,,,,,,,,,,,
HC MRI - Tmj Unilat or Bilat,PX-6107033600,CDM,70336,CPT,0610,RC,,,,inpatient,,,4365.00,2837.25,,,,,,,,,,,,,
IMPLANT SYS BIOCOMP 2.9MM PUSHLOCK SHRT,SUP-2812591,CDM,C1713,HCPCS,0278,RC,,,,both,,,2213.70,1438.90,,,,,,,,,,,,,
BUR SURG DIAMOND 3 MM MTCH HD FOR MIS NEURO,SUP-2365186,CDM,2720000010,LOCAL,0272,RC,,,,both,,,601.37,390.89,,,,,,,,,,,,,
GRAFT VASC L 40 CM DIA16 X 8 MM POLYESTER BIFURCATE WOVEN,SUP-2265913,CDM,C1768,CPT,0278,RC,,,,both,,,1252.86,814.36,,,,,,,,,,,,,
PLATE BNE STR 1 MM 22 HOLE CONTOURED SM GRID PLLA-PGA STRL,SUP-2489846,CDM,C1713,HCPCS,0278,RC,,,,both,,,957.26,622.22,,,,,,,,,,,,,
PLATE BNE THK0.6MM 5MM BAR 5 H 100DEG UNIV,SUP-2366307,CDM,C1713,HCPCS,0278,RC,,,,both,,,644.01,418.61,,,,,,,,,,,,,
ELECTRODE ELECSURG PED 11.5FR CUT LOOP FOR RESECTSCP,SUP-2332847,CDM,C1713,HCPCS,0278,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
BIT DRL CANN 2X230 MM QC,SUP-2392916,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
MICROCATHETER INFUSION SUPERCROSS 90 XT DEG L 130 CM OD,SUP-2763426,CDM,C1887,HCPCS,0272,RC,,,,both,,,1507.20,979.68,,,,,,,,,,,,,
TI LCP DIA-META VOLAR DISTAL RADIUS PL 5H SHAFT/LT-STERILE,SUP-2546643,CDM,C1713,HCPCS,0278,RC,,,,both,,,4984.56,3239.96,,,,,,,,,,,,,
SCREW BNE 3X16 MM,SUP-2321703,CDM,C1713,HCPCS,0278,RC,,,,both,,,762.71,495.76,,,,,,,,,,,,,
REPAIR KIT 3.5 MM KNOTLESS SYS W/ INSRTR W/O DRL ACU-SINCH,SUP-2857597,CDM,C1713,HCPCS,0278,RC,,,,both,,,2957.88,1922.62,,,,,,,,,,,,,
KIT NEG PRSS 7 DY THER W 250ML ISOLYZER CANSTR AC POWERCORD,SUP-2262385,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2387.03,1551.57,,,,,,,,,,,,,
ALLOGRAFT BNE CHIP 1-8 MM 20 CC PRESERVON CANC READIGRAFT,SUP-2740805,CDM,C1713,HCPCS,0278,RC,,,,both,,,705.40,458.51,,,,,,,,,,,,,
SCREW BNE L 14 MM DIA1.9 MM COMPR FULL THRD SNAP OFF NS,SUP-2930417,CDM,C1713,HCPCS,0278,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
SCREW BNE L50MM DIA4X5MM CORT CANN HDLSS TAPR PROF ACUTRK,SUP-2107223,CDM,C1713,HCPCS,0278,RC,,,,both,,,3413.18,2218.57,,,,,,,,,,,,,
HC IV 1st Hour Init Drug,PX-2609636500,CDM,96365,CPT,0260,RC,,,,both,,,370.00,240.50,,,,,,,,,,,,,
PIN FIX L2.25IN DIA0.125IN TRCR QUIK CONN JOURNEY,SUP-2347043,CDM,C1713,HCPCS,0278,RC,,,,both,,,230.63,149.91,,,,,,,,,,,,,
SET URET STENT MARD L 22 CM DIA 6 FR ZIPWIRE 0.035 IN,SUP-2461119,CDM,C2617,HCPCS,0278,RC,,,,both,,,543.22,353.09,,,,,,,,,,,,,
LCK MAND ANG PL3X3NON COM T25MM CP,SUP-2679064,CDM,C1713,HCPCS,0278,RC,,,,both,,,1870.53,1215.84,,,,,,,,,,,,,
BASEPLATE TIB A UNIV STD PUR PC KNEE PRI CEM STEM NP STRL,SUP-2199597,CDM,C1776,CPT,0278,RC,,,,both,,,11429.60,7429.24,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH ALPHA2 L 147 MM DIA 40 MM SHTH 20 FR,SUP-2912013,CDM,C1768,CPT,0278,RC,,,,both,,,66894.56,43481.46,,,,,,,,,,,,,
SET URET STENT ENDO-SOF L 24 CM DIA 7 FR POLYMER AQ 2 PIGTL,SUP-2835780,CDM,C2617,HCPCS,0278,RC,,,,both,,,395.99,257.39,,,,,,,,,,,,,
PLATE BNE L 47 MM RT DORS DSTL RADIAL NAR SHRT NS VARIAX 2,SUP-2902196,CDM,C1713,HCPCS,0278,RC,,,,both,,,4300.54,2795.35,,,,,,,,,,,,,
ADAPTER  FRACTURE SZ 10-15 SHOULDER IMPLANT,SUP-2751552,CDM,C1776,CPT,0278,RC,,,,both,,,7112.10,4622.86,,,,,,,,,,,,,
FORCEPS SURG 6IN 2MM STR ALGTR MIC CUP PIT RHOT,SUP-2382449,CDM,C1713,HCPCS,0278,RC,,,,both,,,937.48,609.36,,,,,,,,,,,,,
CATHETER ETER EP 7FR L99CM 63MM ELECTRD SPC 10 POLE SYMMETRIC DST,SUP-2357568,CDM,C1731,HCPCS,0278,RC,,,,both,,,5504.42,3577.87,,,,,,,,,,,,,
ROD SPNL REDUCER OCPTL CERV THOR STRL INFIN,SUP-2660092,CDM,C1713,HCPCS,0278,RC,,,,both,,,7420.95,4823.62,,,,,,,,,,,,,
SCREW CORT FT L HEX 45MMX150MM,SUP-2411235,CDM,C1713,HCPCS,0278,RC,,,,both,,,120.07,78.05,,,,,,,,,,,,,
STRUT EXT FIX SHRT MULTAXL CORRECTION SYS HEXAPOD FULL AUTO,SUP-2905657,CDM,C1713,HCPCS,0278,RC,,,,both,,,6720.60,4368.39,,,,,,,,,,,,,
K WIRE FIX DIA1.6MM THRD TIP,SUP-2413866,CDM,C1713,HCPCS,0278,RC,,,,both,,,119.32,77.56,,,,,,,,,,,,,
PLATE BONE THK1.8MM 7 H STRNL TI J SHP LCK,SUP-2262577,CDM,C1713,HCPCS,0278,RC,,,,both,,,2449.20,1591.98,,,,,,,,,,,,,
ALLOGRAFT BNE 1-4 MM 15 CC FD IRRADIATED CORTICAL CANC,SUP-2866827,CDM,C1762,CPT,0278,RC,,,,both,,,671.18,436.27,,,,,,,,,,,,,
PLATE BNE NAR 4.5X199 MM 12 HOLE SS DCP,SUP-2569170,CDM,C1713,HCPCS,0278,RC,,,,both,,,359.22,233.49,,,,,,,,,,,,,
ELECTRODE ELECSURG LOOP CUT 90 DEG PEDIATRIC 10 FR HI FREQ,SUP-2430222,CDM,C1713,HCPCS,0278,RC,,,,both,,,733.50,476.77,,,,,,,,,,,,,
PIN REDUC L180MM OD6MM TRAUM,SUP-2362538,CDM,C1713,HCPCS,0278,RC,,,,both,,,738.53,480.04,,,,,,,,,,,,,
GRAFT BNE SUB HA CLLGN INJ FILL RESRB HEALOS FX,SUP-2255628,CDM,2720000010,LOCAL,0272,RC,,,,both,,,607.59,394.93,,,,,,,,,,,,,
BASEPLATE TIB CEM 1 KNEE,SUP-2391453,CDM,C1776,CPT,0278,RC,,,,both,,,4396.00,2857.40,,,,,,,,,,,,,
SCREW BONE L50MM DIA4MM STD CANC S STL PARTIALLY THRD HEX HD,SUP-2344146,CDM,C1713,HCPCS,0278,RC,,,,both,,,200.11,130.07,,,,,,,,,,,,,
FILTER VASC 6FR INTRO 3MM TEMP NICKEL TI EMBOSHIELD,SUP-2240287,CDM,C1884,HCPCS,0278,RC,,,,both,,,5322.30,3459.49,,,,,,,,,,,,,
HC Peripheral Nerve Neurolysis,PX-3600007519,CDM,3600007519,LOCAL,0360,RC,,,,inpatient,,,9630.00,6259.50,,,,,,,,,,,,,
PROBE SURG PIERCER 10X175 MM NS OSCAR 3 LTX,SUP-2875724,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1695.60,1102.14,,,,,,,,,,,,,
Z DISCONTINUED BIT DRL OD3.8MM CALIB REUSE POLYAX,SUP-2412622,CDM,2720000010,LOCAL,0272,RC,,,,both,,,528.46,343.50,,,,,,,,,,,,,
DRILL ARTHSCP GLEN LATERJET,SUP-2256897,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1852.60,1204.19,,,,,,,,,,,,,
WALKER FT SM M SHOE SZ 3 65 FEM 4 75 STD CLS HEEL ROCK SOLE,SUP-2195218,CDM,L4386,HCPCS,0274,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
PLATE BONE L288MM 12 H LT PROX FEM LCK FOR 4.5MM SCR,SUP-2351171,CDM,C1713,HCPCS,0278,RC,,,,both,,,13614.73,8849.57,,,,,,,,,,,,,
PLATE BNE W22XL66MM STD 6X4 H ST L DST RAD VOLAR TI VAR ANG,SUP-2180850,CDM,C1713,HCPCS,0278,RC,,,,both,,,2735.10,1777.81,,,,,,,,,,,,,
CATHETER INTVASC ULTRASOUND SOUNDSTAR ECO 3D DIA10 FR FOR,SUP-2699992,CDM,C1759,HCPCS,0272,RC,,,,both,,,3596.40,2337.66,,,,,,,,,,,,,
PLATE BNE L 100 MM 7 H SS LT DSTL VOLAR ULN STD STRL EVOS,SUP-2931154,CDM,C1713,HCPCS,0278,RC,,,,both,,,5256.36,3416.63,,,,,,,,,,,,,
GUIDEWIRE VASC L80CM DIA0.018IN TIP L5CM 15DEG ANG NIT,SUP-2172968,CDM,C1769,HCPCS,0272,RC,,,,both,,,162.24,105.46,,,,,,,,,,,,,
CANNULATED 3.0 X 13MM SS PRO TOE  VO NON STERILE,SUP-2496216,CDM,C1776,CPT,0278,RC,,,,both,,,1934.24,1257.26,,,,,,,,,,,,,
CATHETER ANGIOPLSTY POLARCATH L 150 CM BALLOON L 150 MM,SUP-2141971,CDM,C1725,HCPCS,0272,RC,,,,both,,,2979.86,1936.91,,,,,,,,,,,,,
GUIDEWIRE VASC L60CM DIA0.018IN TIP L6CM NIT STR RADPQ IMAG,SUP-2147744,CDM,C1769,HCPCS,0272,RC,,,,both,,,106.16,69.00,,,,,,,,,,,,,
CLAV SUP PLT LT 8H 90MM NS,SUP-2482500,CDM,C1713,HCPCS,0278,RC,,,,both,,,4367.74,2839.03,,,,,,,,,,,,,
ALLOGRAFT HUM TISS HEMI BTB FRZN PRESHAPED NO-RAD,SUP-2321837,CDM,C1762,CPT,0278,RC,,,,both,,,11461.00,7449.65,,,,,,,,,,,,,
CATHETER EP CSL CRV 2-5-2MM 5FRX90CM TORQR,SUP-2281825,CDM,C1730,HCPCS,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
SHEATH INTRO PINNACLE R/O II L 25 CM DIA 4 FR DIL PROTRUDING,SUP-2385178,CDM,C1894,HCPCS,0272,RC,,,,both,,,208.50,135.52,,,,,,,,,,,,,
DAPSONE 100 MG PO TABS,RX-2131,CDM,6370000000,HCPCS,0637,RC,70954-0136-10,NDC,,both,1,UN,5.50,3.57,,,,,,,,,,,,,
ENVELOPE PULSE GENRTR TYRX L 2.9 X W 3.3 IN LG NEURO,SUP-2281262,CDM,C1889,HCPCS,0278,RC,,,,both,,,3124.30,2030.79,,,,,,,,,,,,,
MESH BIO PORCINE HERN 8 LAYR TISS MTRX ABD 20CM LEN 7CM W,SUP-2168853,CDM,C1763,HCPCS,0278,RC,,,,both,,,2276.50,1479.72,,,,,,,,,,,,,
IMMOBILIZER KNEE PREMIER PRO TRI PNL 24INCH FOAM TIETEX PAT,SUP-2336078,CDM,L1830,CPT,0272,RC,,,,both,,,40.41,26.27,,,,,,,,,,,,,
PLATE BNE L 81 MM 7 H LT VOLAR DSTL RADIAL WIDE EXT NS,SUP-2902157,CDM,C1713,HCPCS,0278,RC,,,,both,,,5848.22,3801.34,,,,,,,,,,,,,
GRAFT HERN REP W26XL34CM THK2MM OVL SFT TISS PTCH GOR TX,SUP-2395293,CDM,C1768,CPT,0278,RC,,,,both,,,13608.76,8845.69,,,,,,,,,,,,,
SET GUIDEPIN DIA2.4MM DRL TIP DIA2.4MM GWIRE DIA2.8MM FOR,SUP-2123379,CDM,C1769,HCPCS,0272,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
WIRE FIX L5IN DIA0035IN DBL END SPADE TIP,SUP-2166348,CDM,C1713,HCPCS,0278,RC,,,,both,,,18.43,11.98,,,,,,,,,,,,,
INTRODUCER SHTH 14FR L30CM 0.035IN HEMSTAS VLV SIDEPRT 2,SUP-2355618,CDM,C1894,HCPCS,0272,RC,,,,both,,,89.49,58.17,,,,,,,,,,,,,
ANCHOR SUT DIA5.5MM PEEK OPTMA FOR ARTHSCP ROT CUF REP,SUP-2212879,CDM,C1713,HCPCS,0278,RC,,,,both,,,1223.85,795.50,,,,,,,,,,,,,
GRAFT BONE LT TIB WHL TRAD FRZN,SUP-2294146,CDM,C1713,HCPCS,0278,RC,,,,both,,,15046.88,9780.47,,,,,,,,,,,,,
DEVICE FIX STPL 12MM S STL DISP FOR FT AND ANK PLAPLE SYS,SUP-2122332,CDM,C1713,HCPCS,0278,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
KIT CATH CATH CTRL VEN SET POLYUR SGL LUMN WITHINTEGRAL EXTN,SUP-2120634,CDM,C1751,HCPCS,0278,RC,,,,both,,,46.06,29.94,,,,,,,,,,,,,
PLATE BONE SM THK1.6MM 7 H MAND TI ANG FOR 2/2.3MM SCR,SUP-2136788,CDM,C1713,HCPCS,0278,RC,,,,both,,,2358.14,1532.79,,,,,,,,,,,,,
POR ST/OSS CP/E1 AA DM LN/STD,SUP-2212430,CDM,C1776,CPT,0278,RC,,,,both,,,19665.82,12782.78,,,,,,,,,,,,,
SCREW BONE DIA7MM IL S STL CANC ISOLA,SUP-2255714,CDM,C1713,HCPCS,0278,RC,,,,both,,,2516.71,1635.86,,,,,,,,,,,,,
SCREW BNE SELF RET MIC 1X4 MM MAX SINUS TI CENTRE-DRIVE LF,SUP-2460895,CDM,C1713,HCPCS,0278,RC,,,,both,,,213.46,138.75,,,,,,,,,,,,,
NEEDLE BX L 257 MM DIA2.1 MM PRE CALIB DISP,SUP-2909952,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1957.48,1272.36,,,,,,,,,,,,,
ALLOGRAFT BNE CHIP 15 CC CANC PUROS,SUP-2687381,CDM,C1713,HCPCS,0278,RC,,,,both,,,1739.56,1130.71,,,,,,,,,,,,,
SEALANT HEMOSTATIC POWDER ENDOCLOT 30ML,SUP-2857949,CDM,2720000010,LOCAL,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
PLATE BONE L97MM 4 HOLE TTNM LOW PRFLE LOK CMPRSSN,SUP-2476826,CDM,C1776,CPT,0278,RC,,,,both,,,967.12,628.63,,,,,,,,,,,,,
NAIL IM L420MM DIA13MM UNIV LT GRN PROX TIB TI BEND CANN,SUP-2180451,CDM,C1713,HCPCS,0278,RC,,,,both,,,4592.41,2985.07,,,,,,,,,,,,,
PLATE BONE W14XL132MM THK3.8MM 90DEG 7 H RT TIB L BTTRS LT,SUP-2185769,CDM,C1713,HCPCS,0278,RC,,,,both,,,1887.67,1226.99,,,,,,,,,,,,,
SCREW BNE CORT HND TI L20MM OD1.5MM APTUS HEXADRIVE 4,SUP-2268061,CDM,C1713,HCPCS,0278,RC,,,,both,,,219.55,142.71,,,,,,,,,,,,,
SCREW BNE LCK 3X12 MM DBL STRT THRD SS JPS,SUP-2645499,CDM,C1713,HCPCS,0278,RC,,,,both,,,1068.86,694.76,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 5 CM DIA 4 MM EPTFE STR TW N RING,SUP-2396327,CDM,C1768,CPT,0278,RC,,,,both,,,876.06,569.44,,,,,,,,,,,,,
SYSTEM RENAL INFUS L35CM BENEPHIT XT,SUP-2117234,CDM,C1751,HCPCS,0278,RC,,,,both,,,6210.92,4037.10,,,,,,,,,,,,,
IMMOBILIZER KNEE PREMIER PRO TRI PNL 24INCH FOAM TIETEX PAT,SUP-2336078,CDM,L1830,CPT,0274,RC,,,,both,,,40.41,26.27,,,,,,,,,,,,,
CANNULA OPHTH KRATZ 30 GA LENS MANIP,SUP-2484860,CDM,C1713,HCPCS,0278,RC,,,,both,,,115.96,75.37,,,,,,,,,,,,,
PLATE BONE W8XL64MM THK3.3MM 8 H STRL BILAT PELV S STL,SUP-2186235,CDM,C1713,HCPCS,0278,RC,,,,both,,,1185.60,770.64,,,,,,,,,,,,,
PLATE BNE W17.5XL286MM THK5.2MM 16 H BILAT S STL BROAD,SUP-2185309,CDM,C1713,HCPCS,0278,RC,,,,both,,,2488.92,1617.80,,,,,,,,,,,,,
STEM FEM PRSS FT 2 HIP PRIMARY CEM UPLR/BPLR LNR POLYETH,SUP-2267796,CDM,C1776,CPT,0278,RC,,,,both,,,16014.00,10409.10,,,,,,,,,,,,,
PLATE BONE L55MM THK3.8MM 3 H BILAT S STL NAR DYN COMPR FOR,SUP-2185202,CDM,C1713,HCPCS,0278,RC,,,,both,,,627.37,407.79,,,,,,,,,,,,,
CATHETER CV DL 8.5 FRX20 CM MULT MED HI FLO HEPARIN,SUP-2214563,CDM,C1751,HCPCS,0278,RC,,,,both,,,170.78,111.01,,,,,,,,,,,,,
STEM HUM L205MM DIA10MMXLONG UNIV SHLDR CO CHROM CEM REV,SUP-2193878,CDM,C1776,CPT,0278,RC,,,,both,,,12074.56,7848.46,,,,,,,,,,,,,
GRAFT HUM TISS M W9.2XL19.2CM CORTIVA 1MM TAILORED ALLGRFT,SUP-2335289,CDM,C1762,CPT,0278,RC,,,,both,,,10762.10,6995.36,,,,,,,,,,,,,
PLATE BONE CRANIAL 6 HOLE DOUBLE Y-PLATE 18.8X9.8MM TITANIUM,SUP-2825985,CDM,C1713,HCPCS,0278,RC,,,,both,,,322.79,209.81,,,,,,,,,,,,,
IMPLANT BRST 300-330CC P4.1CM DIA11.9CM NACL STYL 168MP,SUP-2113209,CDM,C1789,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
QUININE SULFATE 324 MG PO CAPS,RX-6781,CDM,6370000000,HCPCS,0637,RC,50742-0238-30,NDC,,both,1,UN,3.10,2.01,,,,,,,,,,,,,
SPLINT ORTH D RNG CLOSURE UNIV 10 IN WRST FOREARM LT,SUP-2336335,CDM,L3809,HCPCS,0272,RC,,,,both,,,27.48,17.86,,,,,,,,,,,,,
SPLINT FNGR M W075XL18IN ALUMINUM MAL,SUP-2276739,CDM,L3933,HCPCS,0274,RC,,,,both,,,3.01,1.96,,,,,,,,,,,,,
NAIL IM ANK ARTH N LCK CANN TI 10MM 180MM,SUP-2412889,CDM,C1713,HCPCS,0278,RC,,,,both,,,3931.28,2555.33,,,,,,,,,,,,,
GUIDEWIRE ORTH L100CM DIA2.4MM BULL TIP FOR SENTNL RMR,SUP-2410250,CDM,C1769,HCPCS,0272,RC,,,,both,,,351.90,228.73,,,,,,,,,,,,,
DRESSING WND FEN 3X7 CM SHT EXTRACELLULAR MTRX MATRISTEM,SUP-2106520,CDM,Q4166,HCPCS,0636,RC,,,,both,,,507.68,329.99,,,,,,,,,,,,,
COUPLING INVERTED PIN ROD,SUP-2678697,CDM,2720000010,LOCAL,0272,RC,,,,both,,,443.18,288.07,,,,,,,,,,,,,
MESH HERN L1.9XW1.6IN L POLYPR INGUINAL NONABSORBABLE,SUP-2125788,CDM,C1781,HCPCS,0278,RC,,,,both,,,492.67,320.24,,,,,,,,,,,,,
DEXTROSE 10 % IV BOLUS,RX-4081995,CDM,2580000003,HCPCS,0258,RC,00338-0023-02,NDC,,both,125,ML,26.60,17.29,,,,,,,,,,,,,
DEXTROSE 10 % IV BOLUS,RX-4081995,CDM,2580000003,HCPCS,0258,RC,63323-0824-76,NDC,,both,125,ML,6.40,4.16,,,,,,,,,,,,,
CATHETER HD STR AD 15.5 FRX20 CM LT DL STACKED DURAMAX LF,SUP-2458764,CDM,C1750,HCPCS,0278,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
SUPPORT ORTHOT THOR LUMBAR SACR CUST SAGITTAL-CORONAL CTRL 3,SUP-2435550,CDM,L0492,HCPCS,0272,RC,,,,both,,,1415.86,920.31,,,,,,,,,,,,,
PLATE BNE ANGLED 2.5 MM LT 7X23 HOLE RECON PT SPEC TI,SUP-2860093,CDM,C1713,HCPCS,0278,RC,,,,both,,,19076.44,12399.69,,,,,,,,,,,,,
STAPLE SPNL 1 H ANTR THORLUM TI EXPEDIUM,SUP-2256340,CDM,C1713,HCPCS,0278,RC,,,,both,,,1224.60,795.99,,,,,,,,,,,,,
CATHETER GUID L45CM L COR 3D INTEGR HEMSTAS ATTAIN COMMND,SUP-2282207,CDM,C1887,HCPCS,0272,RC,,,,both,,,533.80,346.97,,,,,,,,,,,,,
SET INTRO V-STICK DIA 4 FR 7 CM NIT COAX NONECHOGENIC STIFF,SUP-2876223,CDM,C1894,HCPCS,0272,RC,,,,both,,,124.03,80.62,,,,,,,,,,,,,
SCREW BNE LCK 2.7X66 MM ST T8 SS NS,SUP-2183388,CDM,C1713,HCPCS,0278,RC,,,,both,,,392.88,255.37,,,,,,,,,,,,,
HC Repositioning Vad Cath,PX-3613659700,CDM,36597,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
COMPONENT TALAR FLAT CUT 3 LT ANK DBL COAT HINTERMANN SER H3,SUP-2751687,CDM,C1776,CPT,0278,RC,,,,both,,,20096.00,13062.40,,,,,,,,,,,,,
PLATE BNE L9MM THK0.4MM 2 H CRANIOMAXILLOFACIAL BILAT BLU,SUP-2181554,CDM,C1713,HCPCS,0278,RC,,,,both,,,201.59,131.03,,,,,,,,,,,,,
IMPLANT SCLER 2.5X9 MM STYL 279 GROOVED TIRE SIL,SUP-2213509,CDM,C1784,HCPCS,0278,RC,,,,both,,,40.19,26.12,,,,,,,,,,,,,
EPOETIN ALFA-EPBX 10000 UNIT/ML IJ SOLN,RX-142364,CDM,Q5106,HCPCS,0636,RC,00069-1308-10,NDC,,both,1,ML,325.40,211.51,,,,,,,,,,,,,
CLAMP PIN 5 HOLE,SUP-2678695,CDM,2720000010,LOCAL,0272,RC,,,,both,,,422.17,274.41,,,,,,,,,,,,,
GRAFT VASC GORTX L 50 CM DIA 6 MM RNG L 7 CM EPTFE STR STD,SUP-2396037,CDM,C1768,CPT,0278,RC,,,,both,,,2304.76,1498.09,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY SUPREME 120CM 5FR DAMATO QPLR,SUP-2700029,CDM,C1730,HCPCS,0272,RC,,,,both,,,245.64,159.67,,,,,,,,,,,,,
SCREW BNE CORTICAL 2.7X14 MM SS NS,SUP-2183908,CDM,C1713,HCPCS,0278,RC,,,,both,,,804.56,522.96,,,,,,,,,,,,,
GRAFT VASC STR STD WALL N RING EPTFE 8MM DIA 40CM LEN,SUP-2126426,CDM,C1768,CPT,0278,RC,,,,both,,,1497.00,973.05,,,,,,,,,,,,,
SHEATH INTRO TOURGUIDE L 55 CM DIA 6.5 FR DEFLECTION 180 DEG,SUP-2421117,CDM,C1887,HCPCS,0272,RC,,,,both,,,1805.50,1173.57,,,,,,,,,,,,,
TRAY CATH HEMODIALYSI NIAG ACUTE 13.5FR DIA 15CML IN 5766150,SUP-2632924,CDM,C1752,HCPCS,0278,RC,,,,both,,,678.24,440.86,,,,,,,,,,,,,
PLATE STRNL CLOSURE THK 1.5 MM 24 H TI STR LP NS STERNALOCK,SUP-2894481,CDM,C1713,HCPCS,0278,RC,,,,both,,,7366.44,4788.19,,,,,,,,,,,,,
KIT PROCEDURE PROSTATEC CRYO ABL 6X CVA2400,SUP-2855081,CDM,C2618,HCPCS,0272,RC,,,,both,,,17270.00,11225.50,,,,,,,,,,,,,
VALVE AORT PRIMA + DIA25 MM PORCINE WOVEN POLYESTER STNTLSS,SUP-2214045,CDM,C1889,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
PIN FIX L9IN DIA9/64IN S STL DBL END TRCR PT FULL THRD TYP,SUP-2342684,CDM,C1713,HCPCS,0278,RC,,,,both,,,356.36,231.63,,,,,,,,,,,,,
GRAFT VASC 6 MMX70 CM MINI CUF BYPS FLX SM BEAD DISTAFLO,SUP-2432023,CDM,C1768,CPT,0278,RC,,,,both,,,7238.49,4705.02,,,,,,,,,,,,,
GRAFT BNE W8XL110MM FIB FRZN STRUT,SUP-2307389,CDM,C1762,CPT,0278,RC,,,,both,,,3376.07,2194.45,,,,,,,,,,,,,
HC So Platelet Neutralization,PX-3058559766,CDM,85597,CPT,0305,RC,,,,both,,,57.00,37.05,,,,,,,,,,,,,
LOCKING PLATE STRGHT 2X12 24 HLE GRID 10MM THICK T 6L 4V,SUP-2680145,CDM,C1713,HCPCS,0278,RC,,,,both,,,2013.96,1309.07,,,,,,,,,,,,,
SET PERICARDCENT CATH 8.3FR L40CM GWIRE L70CM DIA0.038IN 6,SUP-2167856,CDM,C1729,HCPCS,0272,RC,,,,both,,,459.07,298.40,,,,,,,,,,,,,
PERI SCR 4.0MMX50MM,SUP-2461082,CDM,C1713,HCPCS,0278,RC,,,,both,,,155.24,100.91,,,,,,,,,,,,,
PUMP PAIN 400ML FLO RATE 5ML/HR FIX FOR NRV BLK ON-Q,SUP-2236807,CDM,C9804,HCPCS,0272,RC,,,,both,,,616.88,400.97,,,,,,,,,,,,,
ESTRADIOL 1 MG PO TABS,RX-9967,CDM,6370000000,HCPCS,0637,RC,00555-0886-02,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PLATE VARIAX COMP 7HL 91MM,SUP-2695726,CDM,C1713,HCPCS,0278,RC,,,,both,,,1819.94,1182.96,,,,,,,,,,,,,
HALF PIN 6MMX80MM,SUP-2818307,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1017.30,661.24,,,,,,,,,,,,,
COMPONENT TIB NEUT MOD ROTATIONAL ENDO-MODEL-M,SUP-2265073,CDM,C1776,CPT,0278,RC,,,,both,,,9539.32,6200.56,,,,,,,,,,,,,
SUPPORT ORTHOT KNEE CUST W/ADJACENT FLX EXTN ROT MOLD,SUP-2435614,CDM,L1846,HCPCS,0274,RC,,,,both,,,3312.54,2153.15,,,,,,,,,,,,,
HALF PIN 4X180MM 40MM THR,SUP-2818452,CDM,2720000010,LOCAL,0272,RC,,,,both,,,935.06,607.79,,,,,,,,,,,,,
HC Gastric Lavage/Decomp by Phys,PX-4504375300,CDM,43753,CPT,0450,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
GRAFT HUM TISS POST TIBIALIS TEND >22CM FRZN (FOLDED DIAM,SUP-2307281,CDM,C1762,CPT,0278,RC,,,,both,,,4929.11,3203.92,,,,,,,,,,,,,
BUR SURG L7CM BALL DIA05MM FLUT MIDAS REX MEDNEXT LEGEND,SUP-2279891,CDM,2720000010,LOCAL,0272,RC,,,,both,,,298.83,194.24,,,,,,,,,,,,,
WEDGE RAD TRAD ALLGRFT 6 MM FRZ DRY,SUP-2294088,CDM,C1713,HCPCS,0278,RC,,,,both,,,989.10,642.91,,,,,,,,,,,,,
COIL EMB STRTCH RESIST 0.018 IN 9 MMX33 CM MICRUSFRAME C,SUP-2249242,CDM,C1889,HCPCS,0278,RC,,,,both,,,11108.69,7220.65,,,,,,,,,,,,,
RING EXT FIX RADLUC 2/3 D 175 MM CE MARKED,SUP-2875115,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2715.06,1764.79,,,,,,,,,,,,,
PLATE BNE L112MM 8 H BILAT MTPHSEAL S STL LOK COMPR LO PROF,SUP-2185101,CDM,C1713,HCPCS,0278,RC,,,,both,,,2471.53,1606.49,,,,,,,,,,,,,
SCREW SPNL L 30 MM DIA 5.5 MM FIX ANGLE STRL CD HORZ MODULEX 2PK,SUP-2928495,CDM,C1713,HCPCS,0278,RC,,,,both,,,4263.49,2771.27,,,,,,,,,,,,,
PLATE BNE WIDE MEDL RT 8 HOLE CLMN FUSION SS STRL SOLE MCF,SUP-2875510,CDM,C1713,HCPCS,0278,RC,,,,both,,,12156.51,7901.73,,,,,,,,,,,,,
PLATE BONE METATARSOPHALANGEAL REVISION LEFT TITANIUM ARSENAL FOOT PLATING SYSTEM FOR 2.2/2.7/3.5MM SCREW,SUP-2878217,CDM,C1713,HCPCS,0278,RC,,,,both,,,7488.90,4867.78,,,,,,,,,,,,,
CONNECTOR SPNL L50-60MM YEL TI LUM TRNSVRS LINK CLLT TYP ADJ,SUP-2212638,CDM,C1713,HCPCS,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
PLATE TIBIA EVOS 13H LP 3.5X167MM,SUP-2849004,CDM,C1713,HCPCS,0278,RC,,,,both,,,11482.67,7463.74,,,,,,,,,,,,,
SUPPORT ORTHOT ANK KNEE CUST DBL SLD STIRRUP BND,SUP-2435634,CDM,L2020,HCPCS,0274,RC,,,,both,,,3119.94,2027.96,,,,,,,,,,,,,
HC Endoluminal Bx Biliary Tree,PX-3614754300,CDM,47543,CPT,0361,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
ENDOPROSTHESIS VASC GRAFTMASTER L 19 MM DIA 3.5 MM THK 0.52,SUP-2105202,CDM,C1874,HCPCS,0278,RC,,,,both,,,7520.30,4888.19,,,,,,,,,,,,,
NUT ORTH DIA5MM RESIST SCR BK OUT STBL LOK,SUP-2347061,CDM,C1713,HCPCS,0278,RC,,,,both,,,1891.44,1229.44,,,,,,,,,,,,,
GRAFT VASC IMPRA L 70 CM DIA 8 MM EPTFE FLX STD WALL RING,SUP-2761484,CDM,C1768,CPT,0278,RC,,,,both,,,3228.27,2098.38,,,,,,,,,,,,,
SET INT FIX SCREW DIA1.5 MM 6 H TI NEURO CRV PLATE XDRV 1 PK,SUP-2935492,CDM,C1713,HCPCS,0278,RC,,,,both,,,2194.86,1426.66,,,,,,,,,,,,,
BIT DRILL ARTHROSCOPIC 8MM DIA F/MENISCAL TRANSPLANTATION,SUP-2589297,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2106.94,1369.51,,,,,,,,,,,,,
BIT DRL DIA73MM LNG CANN REUSE,SUP-2319441,CDM,2720000010,LOCAL,0272,RC,,,,both,,,791.28,514.33,,,,,,,,,,,,,
INSTRUMENT SET TOT WRST LT HND,SUP-2490035,CDM,C1776,CPT,0278,RC,,,,both,,,31281.94,20333.26,,,,,,,,,,,,,
SCREW WRIST 18MM,SUP-2500462,CDM,C1713,HCPCS,0278,RC,,,,both,,,633.02,411.46,,,,,,,,,,,,,
PLATE END RETRACTOR,SUP-2587575,CDM,C1713,HCPCS,0278,RC,,,,both,,,776.74,504.88,,,,,,,,,,,,,
INDWELLING VOICE PROS L FLNG T,SUP-2242343,CDM,L8509,HCPCS,0274,RC,,,,both,,,935.72,608.22,,,,,,,,,,,,,
COMPONENT FEM MCK RESTORIS,SUP-2407398,CDM,C1713,HCPCS,0278,RC,,,,both,,,580.90,377.58,,,,,,,,,,,,,
SCREW SPNL MULTAXL 7.5X80 MM CANC CD HORZ TCS,SUP-2628366,CDM,C1713,HCPCS,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
DEVICE CRYOTHERAPY W/ CRYO CANSTR CLARIFIX GEN II,SUP-2423335,CDM,C2618,HCPCS,0272,RC,,,,both,,,5604.90,3643.18,,,,,,,,,,,,,
IMPLANT BRST 620 650CC P59CM W145XH15CM SIL STYL 468 FULL HT,SUP-2113355,CDM,C1789,HCPCS,0278,RC,,,,both,,,1617.10,1051.11,,,,,,,,,,,,,
PROBE SRGCL SKLLRN 65NL SINUS BDD GRDTD W/MRKR,SUP-2706954,CDM,2720000010,LOCAL,0272,RC,,,,both,,,458.66,298.13,,,,,,,,,,,,,
COMPONENT OP TBL CLARK SOCK,SUP-2360618,CDM,C1776,CPT,0278,RC,,,,both,,,1381.60,898.04,,,,,,,,,,,,,
PROSTHESIS OSS GROTE SM 13X12X16 MM CNL WALL POROUS HA,SUP-2637868,CDM,L8613,CPT,0278,RC,,,,both,,,1429.80,929.37,,,,,,,,,,,,,
SPLINT HND AD L115IN L DK BLU HEADLINER BROAD CLTH REST,SUP-2165488,CDM,L3807,HCPCS,0274,RC,,,,both,,,211.04,137.18,,,,,,,,,,,,,
CAGE ACET OD64MM TI PPS LT HIP REV IMP MALLORY-HEAD,SUP-2405110,CDM,C1776,CPT,0278,RC,,,,both,,,11643.12,7568.03,,,,,,,,,,,,,
INTRODUCER SHTH PERC KT W BONDED HEM AND CHLORAPREP,SUP-2272866,CDM,C1894,HCPCS,0272,RC,,,,both,,,769.30,500.04,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA IR 3FR 55CM PED 1 S3173355P,SUP-2632836,CDM,C1751,HCPCS,0278,RC,,,,both,,,445.53,289.59,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED 28D/32E/32F INSRT ALUM TRIDENT,SUP-2364444,CDM,C1776,CPT,0278,RC,,,,both,,,20410.00,13266.50,,,,,,,,,,,,,
IMPLANT HEARING 12MM THK8-9MM HA ABUTMENT IMPL HEARINGABLE,SUP-2164983,CDM,L8613,CPT,0278,RC,,,,both,,,10487.60,6816.94,,,,,,,,,,,,,
PLATE BNE W24.4XL56.6MM STD R DST DORS VOLAR RAD FAST GUID,SUP-2414023,CDM,C1713,HCPCS,0278,RC,,,,both,,,2938.13,1909.78,,,,,,,,,,,,,
GUIDEWIRE VASC ADX L 260 CM DIA 0.025 IN TIP L 3 MM PTFE,SUP-2752481,CDM,C1769,HCPCS,0272,RC,,,,both,,,41.45,26.94,,,,,,,,,,,,,
STRM CC PLATE LG RT,SUP-2471503,CDM,C1713,HCPCS,0278,RC,,,,both,,,4793.08,3115.50,,,,,,,,,,,,,
PLATE SPINAL 9 MM 2 HOLE LOW PROFILE STRAIGHT CONTOURABLE NE,SUP-2838352,CDM,C1713,HCPCS,0278,RC,,,,both,,,178.98,116.34,,,,,,,,,,,,,
VALVULOTOME ANGIOSCOPIC PILLING L 15 CM CUT 2 MM CUT HD AG,SUP-2384630,CDM,C1713,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
BIT DRL QC 2.5X170 MM 80 MM CALIB STRL,SUP-2563751,CDM,2720000010,LOCAL,0272,RC,,,,both,,,462.68,300.74,,,,,,,,,,,,,
PLATE BNE L 131 MM SCREW DIA 4.5 MM 7 H SS NAR COMPR NLCK,SUP-2932849,CDM,C1713,HCPCS,0278,RC,,,,both,,,1734.47,1127.41,,,,,,,,,,,,,
PIN EXT FIX L 50 MM DIA 5 MM LNG TI HALF STRL DISP JET-X,SUP-2933290,CDM,2720000010,LOCAL,0272,RC,,,,both,,,438.31,284.90,,,,,,,,,,,,,
HOOK OBT ACET MOD SCR FOR CUP FIX PAR 5,SUP-2403455,CDM,C1713,HCPCS,0278,RC,,,,both,,,2763.20,1796.08,,,,,,,,,,,,,
BIT DRL DIA1.7MM PREDRLING H FOR DISTR PIN CASPR,SUP-2108441,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1755.04,1140.78,,,,,,,,,,,,,
BIT DRL DIA14MM SGL FLX FOR SFT SUT ANCHR JUGGERKNOT,SUP-2137231,CDM,2720000010,LOCAL,0272,RC,,,,both,,,327.06,212.59,,,,,,,,,,,,,
NEEDLE PARACENTESIS YUEH 5 FRX15 CM 19 GA PGTL PERC ASPIR,SUP-2168539,CDM,C1729,HCPCS,0272,RC,,,,both,,,73.82,47.98,,,,,,,,,,,,,
HA CONT ACT RECONS RG 46MM RT,SUP-2822563,CDM,C1776,CPT,0278,RC,,,,both,,,6393.04,4155.48,,,,,,,,,,,,,
PROBE LASER CRV 23 GA ENDO OCU W/ SMA906 CONN LUMEPROBE,SUP-2713784,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4072.58,2647.18,,,,,,,,,,,,,
CYLINDER MED GAS 20ML SULPHUR HEXAFLUORIDE W/O REG ACCURUS,SUP-2109993,CDM,C1784,HCPCS,0278,RC,,,,both,,,3677.82,2390.58,,,,,,,,,,,,,
DEVICE INFLATION NS QUANTUM DISP,SUP-2738153,CDM,2720000010,LOCAL,0272,RC,,,,both,,,417.62,271.45,,,,,,,,,,,,,
TUBE ARMSTRONG 1.14X2.5X3.8MM,SUP-2736735,CDM,L8699,HCPCS,0278,RC,,,,both,,,18.53,12.04,,,,,,,,,,,,,
SCREW BNE FT 8X75 MM CANN STRL,SUP-2501041,CDM,C1713,HCPCS,0278,RC,,,,both,,,785.82,510.78,,,,,,,,,,,,,
PIN ORTH L9IN OD5/64IN SMOOTH TRCR DBL SHRP TIP STRL S STL,SUP-2342705,CDM,C1713,HCPCS,0278,RC,,,,both,,,182.75,118.79,,,,,,,,,,,,,
ELECTRODE LOOP LINA G 200MM X100MM,SUP-2265060,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1153.95,750.07,,,,,,,,,,,,,
SET INT FIX SCREW DIA1.5 MM 2 H TI NEURO STR PLT XDRV 1 PK,SUP-2935200,CDM,C1713,HCPCS,0278,RC,,,,both,,,763.02,495.96,,,,,,,,,,,,,
SLEEVE CNTR L9MM DIA1.5MM PMMA FOR OUTSIDE STEM RX90,SUP-2405679,CDM,C1776,CPT,0278,RC,,,,both,,,879.20,571.48,,,,,,,,,,,,,
HC So West Nile Ab,PX-3028678966,CDM,86789,CPT,0302,RC,,,,both,,,49.00,31.85,,,,,,,,,,,,,
PACK VITRCTMY 20GA STR ENDOILLUMINATOR CONSTELLATION TOT +,SUP-2109924,CDM,C1713,HCPCS,0278,RC,,,,both,,,1620.24,1053.16,,,,,,,,,,,,,
PLATE BONE MIC THK0.4MM 8 H BILAT CRANIOMAXILLOFACIAL SLV TI,SUP-2181663,CDM,C1713,HCPCS,0278,RC,,,,both,,,1255.06,815.79,,,,,,,,,,,,,
PLATE BNE L292MM 16 H R ANTEROMEDIAL DST TIB S STL VAR ANG,SUP-2177664,CDM,C1713,HCPCS,0278,RC,,,,both,,,7233.37,4701.69,,,,,,,,,,,,,
CATHETER TRAY PORT-A-CATH,SUP-2175842,CDM,C1788,HCPCS,0278,RC,,,,both,,,30.93,20.10,,,,,,,,,,,,,
SCREW BNE L28MM OD4.5MM TI CANN SHT THRD HD COMPR DARCO,SUP-2401015,CDM,C1713,HCPCS,0278,RC,,,,both,,,759.88,493.92,,,,,,,,,,,,,
UNIPOLAR HIP-FITMORE POR ST/ ENDO HD,SUP-2417654,CDM,C1776,CPT,0278,RC,,,,both,,,9420.00,6123.00,,,,,,,,,,,,,
SPHERE GLEN OD 42 MM ID 24.5 MM TI NIOBIUM NITRIDE LAT STRL,SUP-2888630,CDM,C1776,CPT,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
PLATE BNE L58MM THK1.3MM 2X8 H L HND TI L SHP LOK TRILOK,SUP-2267944,CDM,C1713,HCPCS,0278,RC,,,,both,,,1838.78,1195.21,,,,,,,,,,,,,
PASSER SUT SHUTTLE J HK STRL ACCU-PASS,SUP-2341082,CDM,C1713,HCPCS,0278,RC,,,,both,,,418.72,272.17,,,,,,,,,,,,,
PLATE BNE L W20XL36MM NONSTERILE BILAT S STL X SHP LO PROF,SUP-2186323,CDM,C1713,HCPCS,0278,RC,,,,both,,,2363.51,1536.28,,,,,,,,,,,,,
GRAFT FEM SHFT ALLGRFT FRZN GREATER THAN 11.0CM,SUP-2165574,CDM,C1762,CPT,0278,RC,,,,both,,,3124.30,2030.79,,,,,,,,,,,,,
RING SPNL STD 6 LOBE SCREW,SUP-2602104,CDM,C1713,HCPCS,0278,RC,,,,both,,,113.04,73.48,,,,,,,,,,,,,
INTRODUCER TUBE SET PERC CIAGLIA BLU RHINO G2,SUP-2759773,CDM,C1769,HCPCS,0272,RC,,,,both,,,444.53,288.94,,,,,,,,,,,,,
GRAFT VASC DIA22MM GREATER AORT HRT VLV CARDIOGRFT,SUP-2264800,CDM,C1762,CPT,0278,RC,,,,both,,,43374.01,28193.11,,,,,,,,,,,,,
SNARE SHT THROW STIFF JUMBO,SUP-2148788,CDM,C1892,HCPCS,0272,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
TRAVASOL 10 % IV SOLN,RX-8074,CDM,2500000003,HCPCS,0250,RC,00338-0644-06,NDC,,both,2000,ML,322.00,209.30,,,,,,,,,,,,,
SYSTEM LOCATING NERVE CHECKPOINT GEMINI BIPOLAR,SUP-2854484,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2185.44,1420.54,,,,,,,,,,,,,
HC Ftl Fibronectin Cervicovag Secretions Semi-Quan,PX-3018273100,CDM,82731,CPT,0301,RC,,,,both,,,771.00,501.15,,,,,,,,,,,,,
BRAIN STIMULATOR KIT REMOT CTRL 3 VERCISE,SUP-2845267,CDM,C1787,HCPCS,0278,RC,,,,both,,,2025.30,1316.44,,,,,,,,,,,,,
MOD FEMORAL PROX LOCKING SCREW,SUP-2506000,CDM,C1776,CPT,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
BRACE ORTHOPEDIC MED RT WRST LTHR,SUP-2194367,CDM,L3931,HCPCS,0274,RC,,,,both,,,25.94,16.86,,,,,,,,,,,,,
PLATE BNE L145MM 8 H ST L MED PROX TIB S STL LOK COMPR LO,SUP-2185641,CDM,C1713,HCPCS,0278,RC,,,,both,,,4260.82,2769.53,,,,,,,,,,,,,
FOUNDATION FOUNDATION PS INSRT SZ 2 9 MM,SUP-2216363,CDM,C1776,CPT,0278,RC,,,,both,,,3268.74,2124.68,,,,,,,,,,,,,
GRAFT BNE W22XL20MM THK35X8MM BICORT EVANS WDG FOR OSTEOTMY,SUP-2399094,CDM,C1713,HCPCS,0278,RC,,,,both,,,6204.64,4033.02,,,,,,,,,,,,,
CATHETER GUID L 100 CM OD 5 FR ID 0.056 IN PTFE LNR XB 3.5,SUP-2910577,CDM,C1887,HCPCS,0272,RC,,,,both,,,127.17,82.66,,,,,,,,,,,,,
NEEDLE SUT NIT W WIRE LOOP END,SUP-2120933,CDM,2720000010,LOCAL,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
MESH PELV Y SHP ARTISYN,SUP-2257355,CDM,C1781,HCPCS,0278,RC,,,,both,,,4305.32,2798.46,,,,,,,,,,,,,
DRAIN SURG 19FR SIL RND HUBLESS W/ 0.25IN BEND TRCR BLAK,SUP-2256705,CDM,C1729,HCPCS,0272,RC,,,,both,,,410.62,266.90,,,,,,,,,,,,,
STEM FEM L130MM OD10MM STD BODY NK OFFSET CO CHROM HIP PRI,SUP-2203076,CDM,C1776,CPT,0278,RC,,,,both,,,24554.80,15960.62,,,,,,,,,,,,,
GUIDEWIRE VASC L150CM DIA0.035IN L10CM DIA3MM J TIP PTFE,SUP-2142708,CDM,C1769,HCPCS,0272,RC,,,,both,,,36.42,23.67,,,,,,,,,,,,,
HC So Tissue Cult of Neoplastic Dis,PX-3118823766,CDM,88237,CPT,0311,RC,,,,inpatient,,,185.00,120.25,,,,,,,,,,,,,
IMPLANT TIB L30MM DIA9MM CANN DRVR FIX DEV APERFIX II,SUP-2402622,CDM,C1776,CPT,0278,RC,,,,both,,,1645.86,1069.81,,,,,,,,,,,,,
SHOE ORTHOT ADDITION CONVERT INSTEP VELCRO CLOSURE,SUP-2435742,CDM,L3580,HCPCS,0272,RC,,,,both,,,183.63,119.36,,,,,,,,,,,,,
STOP DRL DIA45 65MM TI CANN STP BIT FOR LAT ENTRY FEM,SUP-2178866,CDM,2720000010,LOCAL,0272,RC,,,,both,,,775.52,504.09,,,,,,,,,,,,,
VALVE AORT CARP EDW PERIMT MAGNA MT 29MM 28MM 34MM 19MM BOV,SUP-2214110,CDM,C1889,HCPCS,0278,RC,,,,both,,,17113.00,11123.45,,,,,,,,,,,,,
NEEDLE BX ASPIR 1.6 MMX47 CM ANGLED,SUP-2771791,CDM,2720000010,LOCAL,0272,RC,,,,both,,,546.36,355.13,,,,,,,,,,,,,
CAP HIP POR W/ EPOCH STEM TM CUPXLPE LG HD,SUP-2212324,CDM,C1776,CPT,0278,RC,,,,both,,,17524.37,11390.84,,,,,,,,,,,,,
WHEEL SURG DIA254MM GRIT 150MM MTL CUT CEBOTOME,SUP-2166350,CDM,2720000010,LOCAL,0272,RC,,,,both,,,536.53,348.74,,,,,,,,,,,,,
PLATE BONE DUAL CMPRSSN HLX16 TTNM CNTRD F/2.7MM SCREW UNVRS,SUP-2498034,CDM,C1713,HCPCS,0278,RC,,,,both,,,1190.19,773.62,,,,,,,,,,,,,
SET SUPRPUB CATH 14FR L30CM NDL 15GA W/ MCOT CONN TUBE 1 W,SUP-2171109,CDM,C2627,HCPCS,0272,RC,,,,both,,,268.16,174.30,,,,,,,,,,,,,
MESH CRAN L 60 X W 60 MM THK 0.3 MM SCREW DIA1.5/1.7 MM SM,SUP-2883537,CDM,C1713,HCPCS,0278,RC,,,,both,,,4466.71,2903.36,,,,,,,,,,,,,
PLATE SPNL 43 MM ANTR LUMBAR 4 HOLE PYRAMID +4,SUP-2631828,CDM,C1713,HCPCS,0278,RC,,,,both,,,12481.50,8112.97,,,,,,,,,,,,,
PLATE BNE LCK 3.5X66 MM 5 HOLE CNTOUR 2 COMPR SS STRL,SUP-2463043,CDM,C1713,HCPCS,0278,RC,,,,both,,,848.68,551.64,,,,,,,,,,,,,
BIT DRL L 173 MM DIA 3.8 MM SLD FOR A.L.P.S. PLATING SYS,SUP-2882084,CDM,2720000010,LOCAL,0272,RC,,,,both,,,949.85,617.40,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY LASSO L 115 CM 7FR 4.5MM DACRON D,SUP-2538039,CDM,C1730,HCPCS,0272,RC,,,,both,,,756.55,491.76,,,,,,,,,,,,,
PIN DRL 12 PIN STRL DISP,SUP-2420173,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2890.37,1878.74,,,,,,,,,,,,,
PLATE BNE STR 2-2.5X1 MM 20 HOLE TI LEVEL 1 THREADLOCK TS,SUP-2474570,CDM,C1713,HCPCS,0278,RC,,,,both,,,2505.75,1628.74,,,,,,,,,,,,,
HC Intrvasc US Noncoronary Addl,PX-4023725300,CDM,37253,CPT,0402,RC,,,,both,,,1485.00,965.25,,,,,,,,,,,,,
PLATE EXT FIX DIA140MM ANK FT FOR TRUELOK FRME ASSEMB,SUP-2316188,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1502.24,976.46,,,,,,,,,,,,,
SCREW CRTX FT SELF TAP HEX HD 4.5MM DIA 44MML,SUP-2342661,CDM,C1713,HCPCS,0278,RC,,,,both,,,53.63,34.86,,,,,,,,,,,,,
ACETAMINOPHEN 80 MG RE SUPP,RX-8946,CDM,6370000000,HCPCS,0637,RC,51672-2114-00,NDC,,both,1,UN,8.00,5.20,,,,,,,,,,,,,
SCREW BONE L90/85MM LAG COMPR INTEGR KT META-TAN,SUP-2340868,CDM,C1713,HCPCS,0278,RC,,,,both,,,4096.60,2662.79,,,,,,,,,,,,,
PLATE BNE L97MM 12 H NONSTERILE STR RECON FOR 27MM SCR UNIV,SUP-2402650,CDM,C1713,HCPCS,0278,RC,,,,both,,,1304.04,847.63,,,,,,,,,,,,,
PLATE BNE SCREW DIA2.7 MM LG PATELLAR MESH STRL EVOS,SUP-2932791,CDM,C1713,HCPCS,0278,RC,,,,both,,,6669.36,4335.08,,,,,,,,,,,,,
WIRE BNE FIX L 229 MM DIA1.6 MM NS LEOS KIRSCHNER,SUP-2933119,CDM,C1713,HCPCS,0278,RC,,,,both,,,137.09,89.11,,,,,,,,,,,,,
PLATE BNE ORBIT FLR 30X0.6 MM TRIANG PLLA-PGA STRL RESORB XG,SUP-2460045,CDM,C1713,HCPCS,0278,RC,,,,both,,,2747.09,1785.61,,,,,,,,,,,,,
WEDGE HEEL 3/4 2.5X9/16 HAPAD,SUP-2325445,CDM,L3350,HCPCS,0272,RC,,,,both,,,12.91,8.39,,,,,,,,,,,,,
GUIDE NDL BX 2 PURP FOR 14L3E TRANSDUCER 4 IN-PLANE INSRT,SUP-2835413,CDM,2720000010,LOCAL,0272,RC,,,,both,,,777.15,505.15,,,,,,,,,,,,,
SET URET STENT UTHANE L 28 CM DIA 6-9.5 FR PROX SEG L 13 CM,SUP-2835748,CDM,C2617,HCPCS,0278,RC,,,,both,,,374.88,243.67,,,,,,,,,,,,,
SCREW BNE LCK 6.5X24 MM ANK FUSION CONSTRUCT,SUP-2609802,CDM,C1713,HCPCS,0278,RC,,,,both,,,1099.22,714.49,,,,,,,,,,,,,
STEM HUM METAPHYSIS 13 MM SHLDR ADJ REVERSED AEQUALIS,SUP-2715405,CDM,C1776,CPT,0278,RC,,,,both,,,11938.28,7759.88,,,,,,,,,,,,,
CATHETER ANGIO GLIDECATH L 120 CM DIA 4 FR 0.038 IN ANGLED,SUP-2385514,CDM,C1887,HCPCS,0272,RC,,,,both,,,173.33,112.66,,,,,,,,,,,,,
STENT DUODENAL L90MM DIA22MM CATH L230CM 10FR 0.035IN NIT,SUP-2149758,CDM,C1876,HCPCS,0278,RC,,,,both,,,7968.44,5179.49,,,,,,,,,,,,,
GRAFT BNE 4-10 MM 60 CC CORTICAL CANC,SUP-2766766,CDM,C1713,HCPCS,0278,RC,,,,both,,,2724.26,1770.77,,,,,,,,,,,,,
HC Treat Wrist Bone Fx,PX-4502562200,CDM,25622,CPT,0450,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
DRILL SUT ANCHR MICRORAPTOR HIP,SUP-2418767,CDM,2720000010,LOCAL,0272,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
GRAFT HUM TISS L MED FEM CONDYLE HEMI FRSH,SUP-2264743,CDM,C1713,HCPCS,0278,RC,,,,both,,,36168.09,23509.26,,,,,,,,,,,,,
BIT DRL L170MM DIA3.2MM CANN QUIK CPL ADJ STP REUSE FOR,SUP-2187331,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1039.25,675.51,,,,,,,,,,,,,
GRAFT BONE SUBSTITUTE 10CC GEL INJECTABLE DBM REVERSE PHASE M STIMUBLAST,SUP-2120748,CDM,C1713,HCPCS,0278,RC,,,,both,,,3391.20,2204.28,,,,,,,,,,,,,
GRAFT BNE 2.5 CC OSTEOSURGE 100,SUP-2641797,CDM,C1713,HCPCS,0278,RC,,,,both,,,1203.41,782.22,,,,,,,,,,,,,
PLATE BNE L 75.2 X W 31 MM THK 1 MM SCREW DIA2 MM TI,SUP-2936170,CDM,C1713,HCPCS,0278,RC,,,,both,,,2684.70,1745.05,,,,,,,,,,,,,
NAIL IM 8.25X225MM TIB HUM N LCK SLD TI ALTA,SUP-2363488,CDM,C1713,HCPCS,0278,RC,,,,both,,,1992.17,1294.91,,,,,,,,,,,,,
ANCHOR SUTURE XL 2-0 1.7 MM BLU SUTUREFIX ULTRA ULTRABRAID,SUP-2848639,CDM,C1713,HCPCS,0278,RC,,,,both,,,1180.33,767.21,,,,,,,,,,,,,
SAW SURG HOLE 10.8X33 MM 9 CM LG BOR MIDAS REX 8,SUP-2664882,CDM,2720000010,LOCAL,0272,RC,,,,both,,,567.96,369.17,,,,,,,,,,,,,
PLATE BNE RIBBON UNIV 3.5X45 MM FOR RECON SYS NS LTX DISP,SUP-2861124,CDM,C1713,HCPCS,0278,RC,,,,both,,,1241.93,807.25,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED FEM TIB GUIDEPIN K3AMEDACTA] MEDACTA USA],SUP-2267793,CDM,C1776,CPT,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
PLATE BNE Y SM NS LTX,SUP-2861123,CDM,C1713,HCPCS,0278,RC,,,,both,,,756.80,491.92,,,,,,,,,,,,,
PLATE 54MM RECON 9 H REAR FT,SUP-2243225,CDM,C1713,HCPCS,0278,RC,,,,both,,,6583.51,4279.28,,,,,,,,,,,,,
CLIP ANEUR PERM 9/14.1 MM YASRG,SUP-2108621,CDM,C1889,HCPCS,0278,RC,,,,both,,,989.60,643.24,,,,,,,,,,,,,
MICROCATHETER DIAG FASTRACKER 325 TRANSEND L 135 CM DIA 3 FR,SUP-2148476,CDM,C1887,HCPCS,0272,RC,,,,both,,,1843.24,1198.11,,,,,,,,,,,,,
MESH SURG MXLFCL 85X50 MM SM GRID FOR 1.5 MM SCREW TI,SUP-2461550,CDM,C1713,HCPCS,0278,RC,,,,both,,,2694.06,1751.14,,,,,,,,,,,,,
GUIDE SURG ACET CUST BONE MOD SET SIGN,SUP-2206141,CDM,C1713,HCPCS,0278,RC,,,,both,,,2637.60,1714.44,,,,,,,,,,,,,
GUIDEWIRE VASC L145CM L7CM OD0035IN L25CM OD3MM S STL PTFE,SUP-2167708,CDM,C1769,HCPCS,0272,RC,,,,both,,,37.59,24.43,,,,,,,,,,,,,
SUPPORT ORTHOT THOR LUMBAR SACR CUST TRIPLANAR CTRL APRON,SUP-2435545,CDM,L0470,HCPCS,0272,RC,,,,both,,,1862.77,1210.80,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 160 MM DIA 7 MM DEL SHTH,SUP-2934162,CDM,C1713,HCPCS,0278,RC,,,,both,,,11925.72,7751.72,,,,,,,,,,,,,
EXPANDER BRST TISS W14XH11.2CM P6-7.3CM 460-550CC SMOOTH,SUP-2339901,CDM,C1789,HCPCS,0278,RC,,,,both,,,5181.00,3367.65,,,,,,,,,,,,,
SCREW BNE L 7 MM DIA2.3 MM TI TEMPOROMANDIBULAR JT FOSSA,SUP-2934764,CDM,C1713,HCPCS,0278,RC,,,,both,,,341.00,221.65,,,,,,,,,,,,,
GUIDEWIRE ORTH 1.5 MMX40 CM NIT NS DISP,SUP-2599295,CDM,C1769,HCPCS,0272,RC,,,,both,,,174.36,113.33,,,,,,,,,,,,,
HC Intro Catheter Aorta,PX-3613620000,CDM,36200,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
CATHETER ABLAT SPC M SWP DSTL REACH L4MM BIDIR QPLR THRMCPL,SUP-2357501,CDM,C1730,HCPCS,0272,RC,,,,both,,,4631.50,3010.47,,,,,,,,,,,,,
HEAD FEM OD32MM -5MM NK OFFSET C TAPR CO CHROM MTL ON POLY,SUP-2408736,CDM,C1776,CPT,0278,RC,,,,both,,,4521.60,2939.04,,,,,,,,,,,,,
DRESSING NSL EPISTAXIS L 4 X W 2.4 CM THK 0.3 CM POLYETHYL,SUP-2900166,CDM,2720000010,LOCAL,0272,RC,,,,both,,,431.75,280.64,,,,,,,,,,,,,
BONE MARROW KIT 5 PRT 11 GAX4 CM 10 CC W/ ASPIR NDL BMAX,SUP-2759688,CDM,2720000010,LOCAL,0272,RC,,,,both,,,141.30,91.84,,,,,,,,,,,,,
GRAFT HUM TISS W2XL4CM CRYOPRESERVED PLCNTA TISS UMB AMNION,SUP-2319184,CDM,Q4133,HCPCS,0636,RC,,,,both,,,5369.40,3490.11,,,,,,,,,,,,,
COMPONENT TIB TY L69MM A/P56MM M/L75MM STD TIV L KNEE PRI,SUP-2208444,CDM,C1776,CPT,0278,RC,,,,both,,,2906.13,1888.98,,,,,,,,,,,,,
WIRE FIXATION THREADED 15X150 MM CALIBRATED TROCAR POINT 1 E,SUP-2837833,CDM,C1713,HCPCS,0278,RC,,,,both,,,112.76,73.29,,,,,,,,,,,,,
DRILL SURG CANN 2.65 MM PATENT PENDING HAMMERTUBE,SUP-2749757,CDM,2720000010,LOCAL,0272,RC,,,,both,,,370.52,240.84,,,,,,,,,,,,,
DRILL SURG OD39MM SALVATION,SUP-2401154,CDM,2720000010,LOCAL,0272,RC,,,,both,,,474.14,308.19,,,,,,,,,,,,,
GRAFT HUM TISS PLAS NAT DUMMY DENOVO,SUP-2200263,CDM,C1762,CPT,0278,RC,,,,both,,,13659.00,8878.35,,,,,,,,,,,,,
BASEPLATE TIB L47MM SH MEDL LAT KNEE CO CHROM RESURF,SUP-2406477,CDM,C1776,CPT,0278,RC,,,,both,,,8322.57,5409.67,,,,,,,,,,,,,
CATHETER CV DL 018 5 FRX135 CM FLX POWERPICC,SUP-2126385,CDM,C1751,HCPCS,0278,RC,,,,both,,,337.11,219.12,,,,,,,,,,,,,
STEM FEM L MOD HIP REMEDY,SUP-2319837,CDM,C1776,CPT,0278,RC,,,,both,,,7065.00,4592.25,,,,,,,,,,,,,
BIT DRILL AO 2.6X220MM,SUP-2737603,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2116.36,1375.63,,,,,,,,,,,,,
COIL EMB L2CM LOOP DIA2MM 0.018IN PLAT HYDRGEL POLYMER HELI,SUP-2385379,CDM,C1889,HCPCS,0278,RC,,,,both,,,499.26,324.52,,,,,,,,,,,,,
PLATE BNE X 2.3X1.5 MM THOR RIB 20 HOLE LCK LEVEL 1,SUP-2869165,CDM,C1713,HCPCS,0278,RC,,,,both,,,4271.03,2776.17,,,,,,,,,,,,,
GUIDEWIRE VASC STR 0.014 INX200 CM 14 CM SFT TRAXCESS 14,SUP-2305455,CDM,C1769,HCPCS,0272,RC,,,,both,,,1540.17,1001.11,,,,,,,,,,,,,
PIN FIX L9IN DIA48MM ST S STL 2 SIDE SGL DMND 1 END PNT,SUP-2150531,CDM,C1713,HCPCS,0278,RC,,,,both,,,25.84,16.80,,,,,,,,,,,,,
SCREW INTRF CANN 7X35 MM 2 MM GUIDEWIRE 8 MM HD STD TI RCI,SUP-2878045,CDM,C1713,HCPCS,0278,RC,,,,both,,,461.58,300.03,,,,,,,,,,,,,
PLATE BNE MESHED SM 0.6 MM MXLFCL NEURO STD PAT OUSIDE HOLE,SUP-2525645,CDM,C1713,HCPCS,0278,RC,,,,both,,,5094.96,3311.72,,,,,,,,,,,,,
KIT INTRO 14FR SHTH DIL GWIRE PUNC NDL IMPELLA CP,SUP-2106268,CDM,C1894,HCPCS,0272,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
FEM TRL LT SZ4 N-K,SUP-2209579,CDM,C1713,HCPCS,0278,RC,,,,both,,,2609.34,1696.07,,,,,,,,,,,,,
CATHETER ABLATION L 35 MM DIA12 FR CARD PULSED FLD STRL DISP,SUP-2930291,CDM,C1732,HCPCS,0272,RC,,,,both,,,26533.00,17246.45,,,,,,,,,,,,,
PIN DRL L12MM KNEE GUID RG RMR DISP FLIPCUTTER II,SUP-2120811,CDM,C1713,HCPCS,0278,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
ALLOGRAFT HUMAN TISS MAXXEUS SEMIT FZ,SUP-2875993,CDM,C1762,CPT,0278,RC,,,,both,,,5533.47,3596.76,,,,,,,,,,,,,
SET PICC 3L 6FR X 55CM W TEG CHG,SUP-2887058,CDM,C1751,HCPCS,0278,RC,,,,both,,,1849.46,1202.15,,,,,,,,,,,,,
HC Gbl Office/OP Consltj New/Est Pt Low Mdm 30 Minutes,PX-9829924301,CDM,99243,CPT,0982,RC,,,,outpatient,,,565.00,367.25,,,,,,,,,,,,,
CLAMP EXT FIX PROCALLUS LRS,SUP-2570730,CDM,2720000010,LOCAL,0272,RC,,,,both,,,860.36,559.23,,,,,,,,,,,,,
BIT DRL L50MM FLEX FOR ACET SCR,SUP-2345718,CDM,2720000010,LOCAL,0272,RC,,,,both,,,446.51,290.23,,,,,,,,,,,,,
SCREW BNE SD SHT THRD 7X80 MM CANN MAXTORQUE,SUP-2315912,CDM,C1713,HCPCS,0278,RC,,,,both,,,1080.16,702.10,,,,,,,,,,,,,
BRACE BK SUMMIT 456 1 SZ ADJ,SUP-2123906,CDM,L0456,HCPCS,0274,RC,,,,both,,,993.81,645.98,,,,,,,,,,,,,
BIT DRL L70MM DIA3.5MM CANN NONRADIOPAQUE W/O STP DISP,SUP-2413876,CDM,2720000010,LOCAL,0272,RC,,,,both,,,798.82,519.23,,,,,,,,,,,,,
PLATE D32MM W9MM 115DEG BIFURCATED BLADE SPHER HOLES CLAMP ALTDORF,SUP-2108879,CDM,C1713,HCPCS,0278,RC,,,,both,,,348.41,226.47,,,,,,,,,,,,,
PLATE BNE 2 X 32 H STR DBL STRP NS,SUP-2883276,CDM,C1713,HCPCS,0278,RC,,,,both,,,4731.45,3075.44,,,,,,,,,,,,,
SCREW SPNL 7.5X45 MM 4.75 MM FOR ROD CD HORZ SOLERA VOYAGER,SUP-2422086,CDM,C1713,HCPCS,0278,RC,,,,both,,,3355.88,2181.32,,,,,,,,,,,,,
SPHERE GLEN DIA36MM CO CHROM CNTR FOR 25MM GLEN BASEPLT,SUP-2388676,CDM,C1776,CPT,0278,RC,,,,both,,,11318.13,7356.78,,,,,,,,,,,,,
LEAD PACE AD 8.6FR L65CM VENT SIL EPTFE DF1 CONN ACT FIX,SUP-2282248,CDM,C1777,HCPCS,0275,RC,,,,both,,,8769.83,5700.39,,,,,,,,,,,,,
INTRODUCER TUBE SET 8.5/9/10 MM MULTI PERC TY W/ PHAR,SUP-2759711,CDM,C1769,HCPCS,0272,RC,,,,both,,,1738.93,1130.30,,,,,,,,,,,,,
PLATE BONE SM L65MM 8 H S STL STR ECT,SUP-2198583,CDM,C1713,HCPCS,0278,RC,,,,both,,,318.62,207.10,,,,,,,,,,,,,
SCREW BNE CRTX 2.7X75 MM ST T8 STARDRV RECESS TI NS,SUP-2758221,CDM,C1713,HCPCS,0278,RC,,,,both,,,158.07,102.75,,,,,,,,,,,,,
BRACE ANK SPRAIN AND TRAUM AND CHRONIC DISORD 1 SZ FIT MOST,SUP-2319275,CDM,L4350,HCPCS,0274,RC,,,,both,,,41.67,27.09,,,,,,,,,,,,,
NEEDLE SUTURE L 48 MM LOOP 10 MM CTX TAPR PT 1/2 CIR SHUTTLE,SUP-2906016,CDM,C1713,HCPCS,0278,RC,,,,both,,,207.24,134.71,,,,,,,,,,,,,
IMPLANT BONE ANCHORED BAHA AD UNILAT W/SLEEPER,SUP-2165010,CDM,L8614,HCPCS,0278,RC,,,,both,,,20535.60,13348.14,,,,,,,,,,,,,
IMPLANT HUM TISS DIA22 MM LG PULM VLV REDUC THROMBOSIS,SUP-2933269,CDM,C1762,CPT,0278,RC,,,,both,,,43374.01,28193.11,,,,,,,,,,,,,
CROWN DENT 5 UP RT SEC PRI M S STL GLD PREFABRICATED REPL,SUP-2238933,CDM,D6783,CPT,0278,RC,,,,both,,,21.98,14.29,,,,,,,,,,,,,
CURVED PLATE,SUP-2820656,CDM,C1713,HCPCS,0278,RC,,,,both,,,1324.92,861.20,,,,,,,,,,,,,
REAMER SURG 27MM CALIB TENFUSE,SUP-2401437,CDM,2720000010,LOCAL,0272,RC,,,,both,,,703.36,457.18,,,,,,,,,,,,,
KIT VASC ACCS GWIRE L210CM ELITE,SUP-2227330,CDM,C1769,HCPCS,0272,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
GRAFT VSCLR 20CMW X 30CML 2MM THK EPTFE AORTA RCTNGLR NON AB,SUP-2676131,CDM,C1768,CPT,0278,RC,,,,both,,,8361.82,5435.18,,,,,,,,,,,,,
CATHETER PULM ART 5FR INFL 0.75CC L110CM BAL DIA8MM SGL WDG,SUP-2383931,CDM,C1887,HCPCS,0272,RC,,,,both,,,244.92,159.20,,,,,,,,,,,,,
ALLOGRAFT HUM TISS SM 0.25 CC FRZN AMNIO FLUID ALLOGEN,SUP-2393044,CDM,C1713,HCPCS,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
BIT DRL CANN SHT 2.5 MM FOR SCREW NS VIS DE BAROUK LTX,SUP-2861959,CDM,2720000010,LOCAL,0272,RC,,,,both,,,582.16,378.40,,,,,,,,,,,,,
HOOD O2 M-L INF NK DISP DISPOSA-HOOD,SUP-2391750,CDM,C1769,HCPCS,0272,RC,,,,both,,,28.54,18.55,,,,,,,,,,,,,
GRAFT VASC GORTX L 80 CM DIA 6 MM RNG L 20 CM EPTFE STR TW,SUP-2396155,CDM,C1768,CPT,0278,RC,,,,both,,,3551.34,2308.37,,,,,,,,,,,,,
COVER BUR H DIA15MM TI FOR CRAN CLSR SYS,SUP-2243977,CDM,C1713,HCPCS,0278,RC,,,,both,,,344.83,224.14,,,,,,,,,,,,,
KIT SPEC CART BX TRNSPRT CARTICEL 80006] VERICEL CORP],SUP-2392682,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1934.24,1257.26,,,,,,,,,,,,,
GUIDEWIRE VASC ADX L 150 CM DIA 0.035 IN TIP L 3.5 CM PTFE,SUP-2118916,CDM,C1769,HCPCS,0272,RC,,,,both,,,28.86,18.76,,,,,,,,,,,,,
RING EXT FIX MED 200 MM SET RX STRUT STRL TRUELOK EVO LTX,SUP-2875590,CDM,2720000010,LOCAL,0272,RC,,,,both,,,30569.38,19870.10,,,,,,,,,,,,,
UNIT RECV ENTRL ACCS SYS CORTRAK,SUP-2764716,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2953.17,1919.56,,,,,,,,,,,,,
CISPLATIN 200 MG/200ML IV SOLN,RX-88378,CDM,J9060,HCPCS,0636,RC,63323-0103-64,NDC,,both,200,ML,237.40,154.31,,,,,,,,,,,,,
VALVE CSF REG PERF LEVEL 2 W/ BIOGLDE DELT,SUP-2631431,CDM,C1889,HCPCS,0278,RC,,,,both,,,4271.03,2776.17,,,,,,,,,,,,,
PROBE ABLATN SING 15 MM OPTABLATE,SUP-2877226,CDM,C1886,HCPCS,0278,RC,,,,both,,,11853.50,7704.77,,,,,,,,,,,,,
SUMMIT 6/7 STD NK SEG W/COLLAR,SUP-2515382,CDM,C1776,CPT,0278,RC,,,,both,,,1946.80,1265.42,,,,,,,,,,,,,
SCREW BNE L 3 MM DIA1.7 MM CRANIOMAXILLOFACIAL ST 5PK,SUP-2884113,CDM,C1713,HCPCS,0278,RC,,,,both,,,1276.72,829.87,,,,,,,,,,,,,
DEVICE THROMCTMY ALPHAVAC 20 DEG CANN L 77 CM DIA22 FR ACCS,SUP-2862979,CDM,C1757,HCPCS,0272,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
PACKING NASAL SINUS FRM SINGLE USE,SUP-2866534,CDM,2720000010,LOCAL,0272,RC,,,,both,,,600.05,390.03,,,,,,,,,,,,,
WAND ABLAT TIP DIA0.81MM 45DEG BALL ELECTRD SM JT COOLCUT,SUP-2123446,CDM,2720000010,LOCAL,0272,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
DARIFENACIN HYDROBROMIDE ER 15 MG PO TB24,RX-40403,CDM,6370000000,HCPCS,0637,RC,33342-0277-07,NDC,,both,1,UN,5.00,3.25,,,,,,,,,,,,,
TRANSILLUMINATOR OPHTH 25GA EXAM W ANG DISP SAPPHIRE FOR,SUP-2109943,CDM,2720000010,LOCAL,0272,RC,,,,both,,,559.74,363.83,,,,,,,,,,,,,
TRAY PICC MAXIMAL BARR 5FR 2 LUMN CATHETER W BIOPATCH PROTCT,SUP-2125698,CDM,C1751,HCPCS,0278,RC,,,,both,,,1015.66,660.18,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE 15 CC CELLULAR BNE MTRX SYGNACEL CBM,SUP-2929817,CDM,C1713,HCPCS,0278,RC,,,,both,,,21571.80,14021.67,,,,,,,,,,,,,
PIN SURG DRL TRNSVRS XLN 64 MM COMPRESS,SUP-2441834,CDM,C1713,HCPCS,0278,RC,,,,both,,,178.98,116.34,,,,,,,,,,,,,
BRACE WALKING EMBEDDED SOLE SM SHT ANK ROCKER BTM INLINE,SUP-2336131,CDM,L4361,HCPCS,0272,RC,,,,both,,,78.75,51.19,,,,,,,,,,,,,
STEM FEM L115MM OD10MM 12/14 131DEG CEM + STD OFFSET PRI,SUP-2222334,CDM,C1776,CPT,0278,RC,,,,both,,,8949.00,5816.85,,,,,,,,,,,,,
BIT DRL TAPR 4.3X16 MM GUID TWST REG PLATFORM,SUP-2430147,CDM,2720000010,LOCAL,0272,RC,,,,both,,,661.76,430.14,,,,,,,,,,,,,
DRIVER PLT ASMBLY SNOWCAP ANTR CERV LANX,SUP-2136802,CDM,2720000010,LOCAL,0272,RC,,,,both,,,204.10,132.66,,,,,,,,,,,,,
BOLT REPROC CANN WIRE FIX,SUP-2482606,CDM,C1713,HCPCS,0278,RC,,,,both,,,58.40,37.96,,,,,,,,,,,,,
PLATE BNE 24 H CRANIOMAXILLOFACIAL TI ADPT FOR 1.3MM,SUP-2190625,CDM,C1713,HCPCS,0278,RC,,,,both,,,2587.05,1681.58,,,,,,,,,,,,,
SUPPORT ORTHOT HEEL CUST COUNT REINF LTHR,SUP-2435730,CDM,L3440,HCPCS,0274,RC,,,,both,,,216.03,140.42,,,,,,,,,,,,,
SCREW BNE L18MM DIA4MM DST CANC TIB TI NONCANNULATED,SUP-2413451,CDM,C1713,HCPCS,0278,RC,,,,both,,,172.70,112.25,,,,,,,,,,,,,
PLATE BNE L 159 MM SCREW DIA 3.5 MM 9 H SS PROX HUM STR STRL,SUP-2933589,CDM,C1713,HCPCS,0278,RC,,,,both,,,7787.20,5061.68,,,,,,,,,,,,,
PLATE BNE FIBULAR 2.7X105 MM RT LAT DSTL 5 HOLE STRL VALCP,SUP-2789393,CDM,C1713,HCPCS,0278,RC,,,,both,,,2942.31,1912.50,,,,,,,,,,,,,
INTRODUCER THERMOABLATION STARBURST XL L 6 CM HRD COAX ACCS,SUP-2752607,CDM,C1894,HCPCS,0272,RC,,,,both,,,342.26,222.47,,,,,,,,,,,,,
PLATE EXT FIX L45MM SH 3 H CONN S STL FOR ILIZ TAY SPAT FRME,SUP-2340709,CDM,2720000010,LOCAL,0272,RC,,,,both,,,727.95,473.17,,,,,,,,,,,,,
PROBE TEMP SINGLE LUMEN COMPLETE BRAIN PRB KT LICOX,SUP-2666701,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1675.98,1089.39,,,,,,,,,,,,,
BRACE WALKING EMBEDDED SOLE SM SHT ANK ROCKER BTM INLINE,SUP-2336131,CDM,L4361,HCPCS,0274,RC,,,,both,,,78.75,51.19,,,,,,,,,,,,,
CATHETER INFUSION STR TIP 1.9 FRX165 CM PROGREAT LAMBDA,SUP-2852404,CDM,C1887,HCPCS,0272,RC,,,,both,,,2380.12,1547.08,,,,,,,,,,,,,
GEMTUZUMAB OZOGAMICIN 4.5 MG IV SOLR,RX-139611,CDM,J9203,HCPCS,0636,RC,00008-4510-01,NDC,,both,1,UN,29363.60,19086.34,,,,,,,,,,,,,
PROBE ABLAT 90DEG MPLR ABLAT,SUP-2341620,CDM,2720000010,LOCAL,0272,RC,,,,both,,,452.16,293.90,,,,,,,,,,,,,
CATHETER CTRL VEN 9.6FR 1.8ML L90CM SIL SGL LUMN OD3.2MM,SUP-2127699,CDM,C1751,HCPCS,0278,RC,,,,both,,,948.31,616.40,,,,,,,,,,,,,
POST FIX 1 H M,SUP-2197266,CDM,2720000010,LOCAL,0272,RC,,,,both,,,326.56,212.26,,,,,,,,,,,,,
JOINT TOE CANN 0 DEG LG HAMRTOE PHALINX,SUP-2397782,CDM,C1776,CPT,0278,RC,,,,both,,,1548.02,1006.21,,,,,,,,,,,,,
CURETTE SURG RHOTON 14 7.5 IN ANGLED TI NS,SUP-2473498,CDM,2720000010,LOCAL,0272,RC,,,,both,,,562.63,365.71,,,,,,,,,,,,,
HC Blood Count Platelet Automated,PX-3058504900,CDM,85049,CPT,0305,RC,,,,both,,,139.00,90.35,,,,,,,,,,,,,
DISPENSER GRFT DEL SYS X1,SUP-2740846,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
HALOPERIDOL 0.5 MG PO TABS,RX-3578,CDM,6370000000,HCPCS,0637,RC,51079-0733-20,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
GUIDEWIRE ARTHSCP L381MM DIA24MM SMOOTH DRL TIP,SUP-2137215,CDM,C1769,HCPCS,0272,RC,,,,both,,,914.37,594.34,,,,,,,,,,,,,
FILTER SMK EVAC SMARTFLTR,SUP-2166751,CDM,2720000010,LOCAL,0272,RC,,,,both,,,470.12,305.58,,,,,,,,,,,,,
PLATE BNE 14 H SS RT PELV ACET SUPRAPECTINEAL FLX ANAT STRL,SUP-2902660,CDM,C1713,HCPCS,0278,RC,,,,both,,,10605.04,6893.28,,,,,,,,,,,,,
PLUG TIB TI KNEE HNG STRL MOST OPTIONS,SUP-2208388,CDM,C1713,HCPCS,0278,RC,,,,both,,,587.81,382.08,,,,,,,,,,,,,
HC Glucose Blood Test,PX-3008296200,CDM,82962,CPT,0300,RC,,,,both,,,11.00,7.15,,,,,,,,,,,,,
GRAFT BNE W10 16XL30 40MM IL CREST WDG FRZN,SUP-2307417,CDM,C1713,HCPCS,0278,RC,,,,both,,,3278.16,2130.80,,,,,,,,,,,,,
GRAFT BNE SPNG 25X20X7 MM DBM CANC,SUP-2641784,CDM,C1713,HCPCS,0278,RC,,,,both,,,4364.29,2836.79,,,,,,,,,,,,,
BIT DRL CANN 1.6X95 MM QC,SUP-2432236,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1221.46,793.95,,,,,,,,,,,,,
INSERT TIB SM DIA4MM KNEE S STL FRAG AXSOS,SUP-2371464,CDM,C1713,HCPCS,0278,RC,,,,both,,,353.25,229.61,,,,,,,,,,,,,
TOBRAMYCIN 0.3 % OP OINT,RX-19769,CDM,6370000000,HCPCS,0637,RC,00078-0813-01,NDC,,both,3.5,GR,1260.00,819.00,,,,,,,,,,,,,
DEVICE PRESSURE MONITOR INT ABD STRL LF,SUP-2427953,CDM,C1713,HCPCS,0278,RC,,,,both,,,383.80,249.47,,,,,,,,,,,,,
KIT STYL STEERING CAP PRECIS L70CM,SUP-2141935,CDM,2720000010,LOCAL,0272,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
BIT DRL L150MM OD32MM N RADLUC CANN W O STP ORTHOFIX,SUP-2315979,CDM,2720000010,LOCAL,0272,RC,,,,both,,,432.57,281.17,,,,,,,,,,,,,
BUR SURG DIA 4 MM HUB XLI DIAMOND STRL DISP HI-LINE XS,SUP-2929233,CDM,2720000010,LOCAL,0272,RC,,,,both,,,565.42,367.52,,,,,,,,,,,,,
TROSPIUM CHLORIDE ER 60 MG PO CP24,RX-89385,CDM,6370000000,HCPCS,0637,RC,00574-0118-30,NDC,,both,1,UN,17.80,11.57,,,,,,,,,,,,,
PIN KUNTSCH FEM GUID W/O FLAG 2.8MM DIA - 2.8MM DIAM,SUP-2362262,CDM,2720000010,LOCAL,0272,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
BENDING IRON FOR 3.5MM LCP(TM) PILON PLATES,SUP-2548471,CDM,C1713,HCPCS,0278,RC,,,,both,,,2523.37,1640.19,,,,,,,,,,,,,
EVOS 3.5/4.5 PP DIS FEM PLATE L 14 HOLE 297MM,SUP-2931221,CDM,C1713,HCPCS,0278,RC,,,,both,,,19256.05,12516.43,,,,,,,,,,,,,
BLADE SEAL L31CM DIA5MM ULTRASONIC BALL TIP HARM,SUP-2219113,CDM,2720000010,LOCAL,0272,RC,,,,both,,,575.09,373.81,,,,,,,,,,,,,
DRILL SURG TWST 0.25 IN MRI,SUP-2439953,CDM,2720000010,LOCAL,0272,RC,,,,both,,,690.80,449.02,,,,,,,,,,,,,
SCREW BNE L 48 MM DIA2.4 MM TI CORTICAL ST T7 DRV NS VLP,SUP-2931509,CDM,C1713,HCPCS,0278,RC,,,,both,,,212.77,138.30,,,,,,,,,,,,,
HC Ot Adl Training 15 Min|OP PT SERVICES|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS,PX-4309753500,CDM,97535,CPT,0430,RC,,,GP|CQ,both,,,131.00,85.15,,,,,,,,,,,,,
BRACE ORTH LACE CLOSURE SM 5.5X6.25 IN WRST LT SPECTR,SUP-2319267,CDM,L3906,HCPCS,0272,RC,,,,both,,,26.75,17.39,,,,,,,,,,,,,
BRACE TRACTION HALO VEST 2XL,SUP-2328124,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2684.70,1745.05,,,,,,,,,,,,,
MESH SURG W30XL30CM DIA5MM POLYPR SQ FLAT FOR SFT TISS REP,SUP-2219797,CDM,C1781,HCPCS,0278,RC,,,,both,,,1161.39,754.90,,,,,,,,,,,,,
PARADIGM EZ SWITCH SYSTEM UNIVERSAL,SUP-2824687,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3579.60,2326.74,,,,,,,,,,,,,
BOLT IM L52MM DIA3.9MM BLU TI ALUM NIOBIUM TRCR TIP ST LCK,SUP-2192207,CDM,C1713,HCPCS,0278,RC,,,,both,,,573.68,372.89,,,,,,,,,,,,,
PLATE BNE W10XL97MM THK1.5MM 90DEG 8X3 H BILAT S STL T SHP,SUP-2185879,CDM,C1713,HCPCS,0278,RC,,,,both,,,1681.25,1092.81,,,,,,,,,,,,,
PLATE CRAN L 52 X W 40 MM THK 0.6 MM SCREW DIA1.5 MM SM TI,SUP-2936415,CDM,C1713,HCPCS,0278,RC,,,,both,,,2706.68,1759.34,,,,,,,,,,,,,
BALLOON KYPHOPLASTY 10GA 10MM VERTEBRAL IVAS ELITE,SUP-2876066,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3535.14,2297.84,,,,,,,,,,,,,
CATHETER INFUSION PULSE SPRY PRO L 135 CM 5FR SLT 50CM FLX Y,SUP-2117020,CDM,C1757,HCPCS,0272,RC,,,,both,,,273.18,177.57,,,,,,,,,,,,,
RESTRICTOR CEM DIA10MM SILAS FEM CNL UNIV SWNSN,SUP-2304515,CDM,C1713,HCPCS,0278,RC,,,,both,,,398.78,259.21,,,,,,,,,,,,,
NEEDLE VENTRICULAR DERRICO 12 GAX3.75 IN 1 HOLE LUER LCK HUB,SUP-2666381,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1035.38,673.00,,,,,,,,,,,,,
SCREW BNE L 20 MM DIA 3.5 MM LCK VA NS LEOS,SUP-2931362,CDM,C1713,HCPCS,0278,RC,,,,both,,,503.97,327.58,,,,,,,,,,,,,
FAMOTIDINE 10 MG PO TABS,RX-15065,CDM,6370000000,HCPCS,0637,RC,16837-0872-30,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
SET URET STENT SOFFLX POLYUR RADIOPAQUE SFT MLTI LEN STRL,SUP-2835717,CDM,C2617,HCPCS,0278,RC,,,,both,,,466.01,302.91,,,,,,,,,,,,,
CATHETER TRAY 5 FRX70 CM DL PEEL AWAY SHTH SELD,SUP-2384057,CDM,C1751,HCPCS,0278,RC,,,,both,,,206.42,134.17,,,,,,,,,,,,,
GUIDE SURG TRUMATCH STEPTECH,SUP-2421899,CDM,C1776,CPT,0278,RC,,,,both,,,2041.00,1326.65,,,,,,,,,,,,,
ALLOGRAFT HUM TISS CRYOPRESERVED ACHILLES TEND,SUP-2867087,CDM,C1762,CPT,0278,RC,,,,both,,,4322.37,2809.54,,,,,,,,,,,,,
CATHETER IV DL 5 FR DOT KT MBP BIOP PC POWERMIDLINE,SUP-2626739,CDM,C1751,HCPCS,0278,RC,,,,both,,,505.54,328.60,,,,,,,,,,,,,
SET INT FIX SCREW DIA1.5 MM TI NEURO Y DBL PLATE XDRV 1 PK,SUP-2935470,CDM,C1713,HCPCS,0278,RC,,,,both,,,2329.88,1514.42,,,,,,,,,,,,,
BASKET SPEC RETRV HELCL POLYP 2X4 CM 7 FR NS MEM BSKT,SUP-2737566,CDM,2720000010,LOCAL,0272,RC,,,,both,,,948.28,616.38,,,,,,,,,,,,,
NUT ORTH LCK NS,SUP-2902572,CDM,C1713,HCPCS,0278,RC,,,,both,,,2441.66,1587.08,,,,,,,,,,,,,
SCREW BONE L26MM DIA4.5MM CORT ST FULL THRD HEX HD,SUP-2342652,CDM,C1713,HCPCS,0278,RC,,,,both,,,26.22,17.04,,,,,,,,,,,,,
GRAFT MESHED W5XL5CM PRIMATRIX DERM REP SCAFFOLD,SUP-2243704,CDM,Q4110,HCPCS,0636,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
MESH HERN RECTANGULAR 10X16 CM INTRAPERITONEAL ENFORM,SUP-2539548,CDM,C1781,HCPCS,0278,RC,,,,both,,,9291.26,6039.32,,,,,,,,,,,,,
CATHETER DRNGE 75FR OD 250CML NTNL NSBLRY SNGLE PGTL W/CNNC,SUP-2676504,CDM,C2625,HCPCS,0278,RC,,,,both,,,333.12,216.53,,,,,,,,,,,,,
CATHETER SET 12 FRX25 CM SUPRAPUBIC MAC-LOC SCALPEL UTHANE,SUP-2169838,CDM,C2627,HCPCS,0272,RC,,,,both,,,251.64,163.57,,,,,,,,,,,,,
CATHETER ETER EP 5FR L120CM 5MM SPC 1MM BND QPLR TORQ CTRL,SUP-2355229,CDM,C1730,HCPCS,0272,RC,,,,both,,,401.70,261.10,,,,,,,,,,,,,
CAGE SPNL 15 DEG L 43 X W 30 X H 16 MM 2 H 3D PRNT NO PROF,SUP-2884670,CDM,C1889,HCPCS,0278,RC,,,,both,,,18997.00,12348.05,,,,,,,,,,,,,
ELECTRODE PLSM WANDS INTEGR SUCT PRT NACL DEL DURABLE ACT,SUP-2342032,CDM,C1713,HCPCS,0278,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
RING EXT FIX DIA140 MM 5/8 MONK RING,SUP-2898982,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3713.05,2413.48,,,,,,,,,,,,,
GRAFT BIO TISS 18MM DISC DERM REP MESHED SCAFFOLD PRIMATRIX,SUP-2243698,CDM,Q4110,HCPCS,0636,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
BLADE ELECSURG 5.5 MM COMPATIBLE W/ ERBE GENRTR,SUP-2848550,CDM,2720000010,LOCAL,0272,RC,,,,both,,,741.83,482.19,,,,,,,,,,,,,
ALLOGRAFT HUM TISS STD 4X2 CM REGENERATIVE GRAFTJACKET NOW,SUP-2759443,CDM,Q4107,HCPCS,0636,RC,,,,both,,,6449.47,4192.16,,,,,,,,,,,,,
BRACE ORTH CARBON FIBER FRME RT KNEE PCL L/TH S/CF ADJ OA,SUP-2914958,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1467.98,954.19,,,,,,,,,,,,,
PATCH CV L 15 X W 10 CM THK 0.6 MM EPTFE RW RECTANGULAR STRL,SUP-2761225,CDM,C1768,CPT,0278,RC,,,,both,,,3893.60,2530.84,,,,,,,,,,,,,
NAIL IM RETROGRADE 5 DEG 14X360 MM FEM BEND RFNADVANCED,SUP-2789418,CDM,C1713,HCPCS,0278,RC,,,,both,,,5628.20,3658.33,,,,,,,,,,,,,
FENTANYL-BUPIVACAINE-NACL 0.5-0.125-0.9 MG/250ML-% EP SOLN,RX-139976,CDM,J7999,HCPCS,0636,RC,71286-2082-02,NDC,,both,250,ML,122.20,79.43,,,,,,,,,,,,,
GRAFT DERM L16XW6CM THCKNESS 8-1.7MM ACELLULAR DERM,SUP-2307476,CDM,C1713,HCPCS,0278,RC,,,,both,,,7196.88,4677.97,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 20 CM DIA 8 MM EPTFE STR STD WALL,SUP-2396197,CDM,C1768,CPT,0278,RC,,,,both,,,744.18,483.72,,,,,,,,,,,,,
SET TRACH PERC,SUP-2168327,CDM,C1713,HCPCS,0278,RC,,,,both,,,656.26,426.57,,,,,,,,,,,,,
BROAD PLATE 4.5MM 26X423MM,SUP-2818486,CDM,C1713,HCPCS,0278,RC,,,,both,,,6076.37,3949.64,,,,,,,,,,,,,
HEAD FEM DIA32MM +5MM OFFSET 14/16 TAPR CO CHROM MTL ON,SUP-2249718,CDM,C1776,CPT,0278,RC,,,,both,,,2113.85,1374.00,,,,,,,,,,,,,
SLEEVE TROCAR L110MM DIAMETER 12MM SMOOTH DISPOSABLE WITH TA,SUP-2809464,CDM,2720000010,LOCAL,0272,RC,,,,both,,,711.27,462.33,,,,,,,,,,,,,
DISTRACTION INTRNL DIST ALVLR TRACK 15 END DRV 15 18 MM S,SUP-2680407,CDM,C1713,HCPCS,0278,RC,,,,both,,,2976.22,1934.54,,,,,,,,,,,,,
SPACER FEM XL THK5MM L MED DST DURAC,SUP-2377208,CDM,C1776,CPT,0278,RC,,,,both,,,2483.11,1614.02,,,,,,,,,,,,,
PLATE 4.5MM LCP CONDYLAR 10 HOLES 242MM RIGHT STERILE,SUP-2547438,CDM,C1713,HCPCS,0278,RC,,,,both,,,4586.47,2981.21,,,,,,,,,,,,,
CATHETER CARD ABLATION QDOT MIC L 115 CM 8 FR 3.5 MM J SHP,SUP-2880102,CDM,C1732,HCPCS,0272,RC,,,,both,,,15813.04,10278.48,,,,,,,,,,,,,
CONNECTOR SPNL INLINE 6.25 MM ROD ASF16T ARMDA,SUP-2562367,CDM,C1713,HCPCS,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
CARTRIDGE SAW W1.33MM THK1.05MM D18.3MM S STL PRECIS OSC,SUP-2367670,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1239.92,805.95,,,,,,,,,,,,,
MASK CPAP M/L FULL FACE HDGEAR FORMA,SUP-2224716,CDM,C1713,HCPCS,0278,RC,,,,both,,,226.08,146.95,,,,,,,,,,,,,
WIRE FIX TRCR PT 0.28 MMX4 IN NS KIRSCHNER,SUP-2361628,CDM,C1713,HCPCS,0278,RC,,,,both,,,5.90,3.83,,,,,,,,,,,,,
GRAFT ENDOVASC L40MM DIAM 8MM TRNSJUG INTRAHEPATIC VIATORR,SUP-2395920,CDM,C1874,HCPCS,0278,RC,,,,both,,,14202.22,9231.44,,,,,,,,,,,,,
SCREW BNE L34MM DIA2.7MM STD CORT S STL HEX SOCK,SUP-2183351,CDM,C1713,HCPCS,0278,RC,,,,both,,,53.98,35.09,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED STD FEM TIB PERSONA,SUP-2212216,CDM,C1776,CPT,0278,RC,,,,both,,,13502.00,8776.30,,,,,,,,,,,,,
OCCLUDER CV WATCHMAN FLX PRO DIA 35 MM DEL SYS DIA12 FR NIT,SUP-2882252,CDM,C1889,HCPCS,0278,RC,,,,both,,,54950.00,35717.50,,,,,,,,,,,,,
PLATE BNE L183MM 14 H NONSTERILE CNTOUR LOK 2 COMPR FOR 35MM,SUP-2199392,CDM,C1713,HCPCS,0278,RC,,,,both,,,1283.35,834.18,,,,,,,,,,,,,
HC MRI Breast W/O Contrast Bilateral,PX-6107704700,CDM,77047,CPT,0610,RC,,,,outpatient,,,5019.00,3262.35,,,,,,,,,,,,,
LEAD PACE SENTUS PROMRI L 85 CM DIA16 MM TIP 49 CM L85/49,SUP-2138463,CDM,C1900,HCPCS,0275,RC,,,,both,,,5011.44,3257.44,,,,,,,,,,,,,
IPRATROPIUM BROMIDE 0.06 % NA SOLN,RX-16071,CDM,6370000000,HCPCS,0637,RC,00054-0046-41,NDC,,both,15,ML,162.00,105.30,,,,,,,,,,,,,
PLATE BONE L37MM 7 H S STL 1/3 TBLR ECT,SUP-2198533,CDM,C1713,HCPCS,0278,RC,,,,both,,,135.24,87.91,,,,,,,,,,,,,
BIT DRILL DIAMETER 4MM SHOULDER DISPOSABLE FOR KNOTLESS SUTU,SUP-2825106,CDM,2720000010,LOCAL,0272,RC,,,,both,,,731.93,475.75,,,,,,,,,,,,,
IMMOBILIZER KNEE SIZED CANVS 16 IN L,SUP-2336062,CDM,L1830,CPT,0274,RC,,,,both,,,35.76,23.24,,,,,,,,,,,,,
BIT DRL DIA2.9MM FOR SFT ANCHR SHT SHFT PK JUGGERKNOT,SUP-2212783,CDM,2720000010,LOCAL,0272,RC,,,,both,,,379.94,246.96,,,,,,,,,,,,,
SHEATH INTRO DIA 9 FR HEMOSTATIC VLV,SUP-2125359,CDM,C1894,HCPCS,0272,RC,,,,both,,,69.96,45.47,,,,,,,,,,,,,
LOCKING CORTICAL PEG BLUE 2.3MMX36MM,SUP-2841822,CDM,C1713,HCPCS,0278,RC,,,,both,,,353.25,229.61,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 1.5 CC ADIPOSE MTRX RENUVA HD,SUP-2761880,CDM,C1762,CPT,0278,RC,,,,both,,,1469.52,955.19,,,,,,,,,,,,,
HC So Aldolase,PX-3078208566,CDM,82085,CPT,0307,RC,,,,both,,,201.00,130.65,,,,,,,,,,,,,
CATHETER DIAG L150CM DST L10CM MIC NEURO RENEGADE HI FLO,SUP-2367869,CDM,C1887,HCPCS,0272,RC,,,,both,,,2337.67,1519.49,,,,,,,,,,,,,
GRAFT TISS SPCR CERV CANC FRZ DRY ALLGRFT 10MM,SUP-2307225,CDM,C1713,HCPCS,0278,RC,,,,both,,,2895.08,1881.80,,,,,,,,,,,,,
STIMULATOR NERVE 2 QUATTRODE LAMITRODE S-8 EPIDUCER PRODIGY,SUP-2862952,CDM,C1767,HCPCS,0278,RC,,,,both,,,50240.00,32656.00,,,,,,,,,,,,,
VALVE SHUNT L23.7MM 15CM H2O PRSS TI 2 CONN GRAVITATIONAL,SUP-2108715,CDM,C1729,HCPCS,0272,RC,,,,both,,,4341.65,2822.07,,,,,,,,,,,,,
KNIFE SURG STR 500 MH LRI STRL LSREDG + DISP,SUP-2469193,CDM,2720000010,LOCAL,0272,RC,,,,both,,,128.11,83.27,,,,,,,,,,,,,
BIT DRL 230/200MM CALIB DIA2.5MM 3 FLUT QUIK CPL,SUP-2187615,CDM,2720000010,LOCAL,0272,RC,,,,both,,,513.55,333.81,,,,,,,,,,,,,
PROCHLORPERAZINE EDISYLATE 10 MG/2ML IJ SOLN,RX-145108,CDM,J0780,HCPCS,0636,RC,72266-0204-10,NDC,,both,1,ML,54.10,35.16,,,,,,,,,,,,,
SCREW BNE L65MM DIA8MM THRD L22MM DIA12.7MM CANC CNDYL S,SUP-2186549,CDM,C1713,HCPCS,0278,RC,,,,both,,,939.77,610.85,,,,,,,,,,,,,
PACEMAKER CARD PHILOS SR TI POLYUR SIL SINGLE CHMBR IS1 UPLR,SUP-2138488,CDM,C1786,HCPCS,0275,RC,,,,both,,,8333.56,5416.81,,,,,,,,,,,,,
ENDOSCOPE NEURO 8X100 MM STRL AURORA SURGISCOPE LTX DISP,SUP-2863638,CDM,2720000010,LOCAL,0272,RC,,,,both,,,21195.00,13776.75,,,,,,,,,,,,,
MATRIX BIO MED SZ 147 SQCM FISH SKIN LT DORSUM RT PALMAR 10/BX,SUP-2909427,CDM,Q4158,HCPCS,0636,RC,,,,both,,,12827.21,8337.69,,,,,,,,,,,,,
SHEATH INTRO PERFRMR L 63 CM OD 12 FR ID 4 MM GUIDEWIRE,SUP-2633271,CDM,C1894,HCPCS,0272,RC,,,,both,,,111.91,72.74,,,,,,,,,,,,,
CABLE ORTH L559MM DIA1.8MM HIP S STL W/ CERCLAGE CBL-READY,SUP-2410258,CDM,C1713,HCPCS,0278,RC,,,,both,,,1097.05,713.08,,,,,,,,,,,,,
STEM HUM L74MM 3C 135DEG TI SHLDR ANAT MONOLITHIC AEQUALIS,SUP-2388549,CDM,C1776,CPT,0278,RC,,,,both,,,5771.32,3751.36,,,,,,,,,,,,,
BIT DRL STR 14-16X250 MM,SUP-2440891,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5750.91,3738.09,,,,,,,,,,,,,
BRAIN STIM IMPL BRAINSENSE TECHNOLOGY RECHARGEABLE MRI,SUP-2883003,CDM,C1820,HCPCS,0278,RC,,,,both,,,97135.90,63138.33,,,,,,,,,,,,,
SCREW BNE LCK 3 MM VA TI KREULOCK,SUP-2845745,CDM,C1713,HCPCS,0278,RC,,,,both,,,10095.10,6561.81,,,,,,,,,,,,,
SIGMA HP UNI FEM FIN BLK SZ 2,SUP-2513378,CDM,C1776,CPT,0278,RC,,,,both,,,6283.14,4084.04,,,,,,,,,,,,,
JOINT EXT FIX MOD BALL ASMBLY NS DISP MONK RING,SUP-2881065,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1545.67,1004.69,,,,,,,,,,,,,
RETRACTOR NEUROSURGICAL 20 MM DOCKING PIN MARS 3V SYS,SUP-2232227,CDM,C1713,HCPCS,0278,RC,,,,both,,,1303.10,847.01,,,,,,,,,,,,,
PROBE LAP AR 2.3X2200 MM AX GASTRO/COLO,SUP-2466379,CDM,2720000010,LOCAL,0272,RC,,,,both,,,666.18,433.02,,,,,,,,,,,,,
GRAFT BNE PTTY 10 CC DBM OPTIUM,SUP-2264864,CDM,C1713,HCPCS,0278,RC,,,,both,,,2549.05,1656.88,,,,,,,,,,,,,
SUPPORT ORTHOT HEEL CUST STD RUBBER,SUP-2435733,CDM,L3460,HCPCS,0274,RC,,,,both,,,97.28,63.23,,,,,,,,,,,,,
GOLIMUMAB 50 MG/4ML IV SOLN,RX-122988,CDM,J1602,HCPCS,0636,RC,57894-0350-01,NDC,,both,4,ML,5897.70,3833.50,,,,,,,,,,,,,
GRAFT HUM TISS TEND 10.5X80 MM FRZN TERMINALLY GRAFTLINK,SUP-2123476,CDM,C1713,HCPCS,0278,RC,,,,both,,,7300.50,4745.32,,,,,,,,,,,,,
INSTRUMENT 25MM IMPLANT TO TRIAL ADAPTER,SUP-2515580,CDM,C1776,CPT,0278,RC,,,,both,,,1438.12,934.78,,,,,,,,,,,,,
SCREW BONE L55MM DIA6.5MM CORT TI ALLOY ST FT VERSANAIL,SUP-2411529,CDM,C1713,HCPCS,0278,RC,,,,both,,,599.77,389.85,,,,,,,,,,,,,
SHUNT SURG 4 MM LUMBO-PERITONEAL,SUP-2666434,CDM,C1729,HCPCS,0272,RC,,,,both,,,1649.13,1071.93,,,,,,,,,,,,,
BUR SURG DIA 3.1 MM HUB II NEURO CUT STRL DISP HI-LINE XS GE555SU,SUP-2928830,CDM,2720000010,LOCAL,0272,RC,,,,both,,,343.42,223.22,,,,,,,,,,,,,
SHELL ACET DIA50MM TI ALLY POR HA CALCICOAT CERAMIC MH PRI,SUP-2210228,CDM,C1776,CPT,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
BETAMETHASONE VALERATE 0.1 % EX CREA,RX-1031,CDM,6370000000,HCPCS,0637,RC,00713-0326-15,NDC,,both,15,GR,80.60,52.39,,,,,,,,,,,,,
TRIAL NERVE STIM KT STIM BLDR ADV,SUP-2435500,CDM,C1778,HCPCS,0278,RC,,,,both,,,12246.00,7959.90,,,,,,,,,,,,,
CUP ACET DIA60MM 5 H STD PROF GRIPTION REV PINN,SUP-2250138,CDM,C1776,CPT,0278,RC,,,,both,,,9074.60,5898.49,,,,,,,,,,,,,
TRAY VERTPLSTY BNE ACCS AND PREP W INJ OSTEO FORCE,SUP-2168831,CDM,C1713,HCPCS,0278,RC,,,,both,,,793.73,515.92,,,,,,,,,,,,,
SCREW BNE L42MM OD4MM TI CANC CANN PARTIALLY THRD FOR EXT,SUP-2107617,CDM,C1713,HCPCS,0278,RC,,,,both,,,690.80,449.02,,,,,,,,,,,,,
RESERVOIR PENILE PROS 700 AMS 65 ML,SUP-2138963,CDM,C1813,HCPCS,0278,RC,,,,both,,,6462.12,4200.38,,,,,,,,,,,,,
PASSER SUT CRESC MGR REACH NANOPASS,SUP-2366744,CDM,2720000010,LOCAL,0272,RC,,,,both,,,962.98,625.94,,,,,,,,,,,,,
HC Doppler Veloc Fetal Mid Cereb,PX-4027682100,CDM,76821,CPT,0402,RC,,,,both,,,516.00,335.40,,,,,,,,,,,,,
HC Dilation Stricture/Obst S&I,PX-3207436000,CDM,74360,CPT,0320,RC,,,,inpatient,,,1253.00,814.45,,,,,,,,,,,,,
SUPPORT ORTHOT KNEE CUST W/ADJACENT JT ROT CNTRL MOLD,SUP-2435613,CDM,L1844,LOCAL,0274,RC,,,,both,,,4311.38,2802.40,,,,,,,,,,,,,
PLATE BNE CRV NAR 4.5 MM 18 HOLE SS NS LCP,SUP-2178063,CDM,C1713,HCPCS,0278,RC,,,,both,,,3562.27,2315.48,,,,,,,,,,,,,
NECK FEM SZ 0 1 STD OFFSET SEG FOR TAPR HIP SYS SUMMIT,SUP-2436176,CDM,C1776,CPT,0278,RC,,,,both,,,1865.16,1212.35,,,,,,,,,,,,,
KIT INTRO ARW FLX SHTH L 10 CM DIA 8.5 FR POLYUR INTEGR,SUP-2763349,CDM,C1892,HCPCS,0272,RC,,,,both,,,238.64,155.12,,,,,,,,,,,,,
SHAFT FIB TRAD ALLGRFT 80 MM FRZN,SUP-2294143,CDM,C1713,HCPCS,0278,RC,,,,both,,,1821.20,1183.78,,,,,,,,,,,,,
GUIDEWIRE VASC L260CM OD0.035IN TIP L9CM STR PTFE HEP EXTRA,SUP-2157303,CDM,C1769,HCPCS,0272,RC,,,,both,,,130.94,85.11,,,,,,,,,,,,,
BENZTROPINE MESYLATE 2 MG PO TABS,RX-1000,CDM,6370000000,HCPCS,0637,RC,69315-0138-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
GRAFT HUM TISS W20MM QUAD L6CM WHL PAT W EXTRA QUAD FRZN,SUP-2264794,CDM,C1713,HCPCS,0278,RC,,,,both,,,11990.37,7793.74,,,,,,,,,,,,,
SHEATH INTRO TORFLEX 90 DEG L 63 CM DIA 8 FR GUIDEWIRE L 180,SUP-2131516,CDM,C1893,HCPCS,0272,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
KIT DRN 600ML 1/4IN 6IN POST AUTOTRNS PVC TRCR HEMVAC,SUP-2205662,CDM,2720000010,LOCAL,0272,RC,,,,both,,,428.99,278.84,,,,,,,,,,,,,
CATHETER EP CRD 1 CM SPC 5 FRX100 CM NBIH,SUP-2871492,CDM,C1730,HCPCS,0272,RC,,,,both,,,127.45,82.84,,,,,,,,,,,,,
SCREW BNE L36MM OD3.5MM TI FT ANK CANN SHT THRD HD COMPR,SUP-2400883,CDM,C1713,HCPCS,0278,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
SHEARS ENDOSCP L36CM DIA5MM ULTRASONIC CRV TIP HARM,SUP-2219112,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8183.63,5319.36,,,,,,,,,,,,,
ENDCAP ORTH L10MM DIA12MM ST GRN FEM TI NAIL EXTN LOK HD,SUP-2192364,CDM,C1713,HCPCS,0278,RC,,,,both,,,744.90,484.18,,,,,,,,,,,,,
GUIDEWIRE VASC L180CM DIA0.016IN TIP L10CM NIT HYDRPHLC STR,SUP-2148345,CDM,C1769,HCPCS,0272,RC,,,,both,,,910.60,591.89,,,,,,,,,,,,,
CAGE SPNL W15.5XH9XL12MM PEEK ANT CERV INTBDY FUS LORD,SUP-2416003,CDM,C1889,HCPCS,0278,RC,,,,both,,,6247.50,4060.87,,,,,,,,,,,,,
ROD FOR GALAXY FIXATION SYSTEM 12MM 400MM,SUP-2633889,CDM,C1713,HCPCS,0278,RC,,,,both,,,858.54,558.05,,,,,,,,,,,,,
CATHETER ART LN IRRIGATION 6 FRX80 CM FOGARTY,SUP-2214042,CDM,C1757,HCPCS,0272,RC,,,,both,,,69.55,45.21,,,,,,,,,,,,,
SCISSOR SURG 1619 MM 2.8 MM STRL LF DISP,SUP-2865651,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1927.02,1252.56,,,,,,,,,,,,,
RESERVOIR 100ML PC,SUP-2138964,CDM,C1813,HCPCS,0278,RC,,,,both,,,6462.12,4200.38,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.543,SUP-2860060,CDM,C1713,HCPCS,0278,RC,,,,both,,,57750.25,37537.66,,,,,,,,,,,,,
BLADE RETRACTOR RICHARDSON 1X1.25 IN BOOKWALTER,SUP-2468019,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1026.40,667.16,,,,,,,,,,,,,
STYLET 24MM,SUP-2722365,CDM,C1713,HCPCS,0278,RC,,,,both,,,241.78,157.16,,,,,,,,,,,,,
GUIDEWIRE ORTH L5IN DIA0.059IN S STL SGL TRCR FOR MOD HND,SUP-2107897,CDM,C1769,HCPCS,0272,RC,,,,both,,,47.10,30.61,,,,,,,,,,,,,
PLATE BNE PROF THK 0.6 MM 5 X 3 H SCREW DIA1 MM RT CMF L SHP,SUP-2883729,CDM,C1713,HCPCS,0278,RC,,,,both,,,461.58,300.03,,,,,,,,,,,,,
KNIFE 3722040 TYMPAN 7MM CVD BLADE,SUP-2702665,CDM,2720000010,LOCAL,0272,RC,,,,both,,,401.54,261.00,,,,,,,,,,,,,
PLATE BNE L62MM LNG 2X2 H NONSTERILE R BILAT 1ST MTP FUS S,SUP-2184838,CDM,C1713,HCPCS,0278,RC,,,,both,,,3007.02,1954.56,,,,,,,,,,,,,
GAUGE DEPTH DISPOSABLE SONOMA CRX,SUP-2431210,CDM,2720000010,LOCAL,0272,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
BLADE SAW 54.6MMW X 40MML F/REPEAT STERNOTOMY HALL STERILE,SUP-2586285,CDM,2720000010,LOCAL,0272,RC,,,,both,,,84.28,54.78,,,,,,,,,,,,,
JOINT FNGR CARPOMETACARPAL 1X1X1 CM ARTHRPLSTY ARTELON CMC,SUP-2365447,CDM,C1776,CPT,0278,RC,,,,both,,,5868.66,3814.63,,,,,,,,,,,,,
HC Superselective Renal Art Bil,PX-3233625400,CDM,36254,CPT,0323,RC,,,,both,,,10063.00,6540.95,,,,,,,,,,,,,
PLATE BONE LOK DUAL CMPRSSN 118MML HLX9 STNLSS STEEL CNTRD S,SUP-2588603,CDM,C1713,HCPCS,0278,RC,,,,both,,,1001.66,651.08,,,,,,,,,,,,,
PLATE BONE 6X17X6 H LT MAND SEC HMSPHR TI RECON LEIBINGER,SUP-2363753,CDM,C1713,HCPCS,0278,RC,,,,both,,,4880.35,3172.23,,,,,,,,,,,,,
SCREW BNE PART THRD 3X18 MM CANN STRL,SUP-2460883,CDM,C1713,HCPCS,0278,RC,,,,both,,,517.79,336.56,,,,,,,,,,,,,
HC So Ethylene Glycol,PX-3018269366,CDM,82693,CPT,0301,RC,,,,both,,,106.00,68.90,,,,,,,,,,,,,
SLEEVE LIG SZ 1.8 MM STRL,SUP-2616249,CDM,2720000010,LOCAL,0272,RC,,,,both,,,46.32,30.11,,,,,,,,,,,,,
SCREW BNE FUSION 2X40 MM DIGITAL CAPTURE,SUP-2419201,CDM,C1713,HCPCS,0278,RC,,,,both,,,997.30,648.24,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED CUP HD LNR ST TRAB MTL XLPE CERM,SUP-2212327,CDM,C1776,CPT,0278,RC,,,,both,,,17838.37,11594.94,,,,,,,,,,,,,
HC Echo Cong. Anom - Lmt W/Ctrst,PX-4839330401,CDM,C8922,HCPCS,0483,RC,,,,both,,,870.00,565.50,,,,,,,,,,,,,
PROBE SUCT DIA35MM CNTOUR W INTEGR CBL HND CTRL SERFAS,SUP-2367325,CDM,2720000010,LOCAL,0272,RC,,,,both,,,404.24,262.76,,,,,,,,,,,,,
DART PIP L30MM DIA25MM 10DEG PEEK,SUP-2420293,CDM,C1713,HCPCS,0278,RC,,,,both,,,1868.30,1214.39,,,,,,,,,,,,,
MESH SURG W200XL200MM THK0.4MM NONSTERILE BLU CRANIOFACIAL,SUP-2181573,CDM,C1781,HCPCS,0278,RC,,,,both,,,26545.56,17254.61,,,,,,,,,,,,,
HC NM Bowel Imaging,PX-3417829000,CDM,78290,CPT,0341,RC,,,,both,,,3272.00,2126.80,,,,,,,,,,,,,
BLADE SHAVER CRV 40 DEG 4.8 MM SERRATED HEMOSTATIC CONCV,SUP-2648915,CDM,2720000010,LOCAL,0272,RC,,,,both,,,600.02,390.01,,,,,,,,,,,,,
INTRO SHEATH CATH LOCK 7FRX12CM,SUP-2698824,CDM,C1894,HCPCS,0272,RC,,,,both,,,43.08,28.00,,,,,,,,,,,,,
PLATE BNE CONN 2 HOLE +,SUP-2484660,CDM,C1713,HCPCS,0278,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
CLAMP EXT FIX M CLP ON SELF HLD,SUP-2188527,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1277.20,830.18,,,,,,,,,,,,,
SYSTEM UROLIFT2 ATC W/IMPLANT,SUP-2895948,CDM,C1889,HCPCS,0278,RC,,,,both,,,3689.50,2398.17,,,,,,,,,,,,,
SHEATH INTRO PROTRIEVE L 38 CM OD 26 FR ID 20 FR DEPLOYED,SUP-2862339,CDM,C1894,HCPCS,0272,RC,,,,both,,,12560.00,8164.00,,,,,,,,,,,,,
NEOMYCIN-POLYMYXIN-DEXAMETH 3.5-10000-0.1 OP OINT,RX-103568,CDM,6370000000,HCPCS,0637,RC,61314-0631-36,NDC,,both,3.5,GR,81.10,52.71,,,,,,,,,,,,,
SCREW BNE LCK 6.5X290 MM CONCL,SUP-2349806,CDM,C1713,HCPCS,0278,RC,,,,both,,,744.18,483.72,,,,,,,,,,,,,
ALLOGRAFT SPEEDSPIRAL CMC 13X13,SUP-2419421,CDM,C1776,CPT,0278,RC,,,,both,,,7536.00,4898.40,,,,,,,,,,,,,
COUNTERSINK SURG FOR 4.5/6.5MM SCR,SUP-2187361,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1059.66,688.78,,,,,,,,,,,,,
DRILL SURG 20MM J SLOT PILOT LUHR,SUP-2364951,CDM,2720000010,LOCAL,0272,RC,,,,both,,,345.90,224.83,,,,,,,,,,,,,
PLATE BNE CLAV STD 3.5X140 MM ANTR 13 HOLE NS A.L.P.S,SUP-2457874,CDM,C1713,HCPCS,0278,RC,,,,both,,,4731.98,3075.79,,,,,,,,,,,,,
CAGE SPNL 25X12X9MM LO PROF BONE GRFT CHAMBERS TANT MRK,SUP-2354700,CDM,C1889,HCPCS,0278,RC,,,,both,,,9420.00,6123.00,,,,,,,,,,,,,
PLATE BNE L158MM 6 H R DST EXTRAARTICULAR HUM S STL LOK,SUP-2184042,CDM,C1713,HCPCS,0278,RC,,,,both,,,3729.50,2424.17,,,,,,,,,,,,,
PLATE BNE ANGLED 2 MM LT 7X23 HOLE RECON PT SPEC TI,SUP-2860076,CDM,C1713,HCPCS,0278,RC,,,,both,,,17726.87,11522.47,,,,,,,,,,,,,
HC Pt Neuro Facilitation Ea 15 Min|OP PT SERVICES|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS|UNUSUAL NON-OVERLAPPING SERVICE,PX-4209711200,CDM,97112,CPT,0420,RC,,,GP|CQ|XU,both,,,159.00,103.35,,,,,,,,,,,,,
KIT PLT CONC SYS BLD BNE MAR ASPIRATE RESVR AUTOTRNS BIOCUE,SUP-2402592,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4851.30,3153.34,,,,,,,,,,,,,
NEEDLE OPHTH DIX SPUD FB W/ REVERSIBLE SCREW HNDL SS,SUP-2486999,CDM,2720000010,LOCAL,0272,RC,,,,both,,,486.95,316.52,,,,,,,,,,,,,
CATHETER INTVASC OCCL PRUITT L 27 CM 4 FR 9 MM STR PLIABLE,SUP-2264225,CDM,C2628,HCPCS,0272,RC,,,,both,,,1252.86,814.36,,,,,,,,,,,,,
CATHETER PTCA L135CM BLLN L40MM DIA4MM GWIRE 0.014IN CHOC,SUP-2280610,CDM,C1725,HCPCS,0272,RC,,,,both,,,2339.30,1520.54,,,,,,,,,,,,,
ACETYLCHOLINE CHLORIDE 20 MG IO SOLR,RX-76641,CDM,2500000003,HCPCS,0250,RC,24208-0539-20,NDC,,both,1,UN,750.80,488.02,,,,,,,,,,,,,
PLATE BNE L 367 MM SCREW DIA 3.5/4.5 MM 16 H LT TROCHANTERIC 72586116N,SUP-2932742,CDM,C1713,HCPCS,0278,RC,,,,both,,,21760.20,14144.13,,,,,,,,,,,,,
DIREXION HI-FLO/FATHOM/027/BERN/1RO/155,SUP-2652843,CDM,C1887,HCPCS,0272,RC,,,,both,,,2731.80,1775.67,,,,,,,,,,,,,
PLATE BNE STR 45 MM TCP,SUP-2535871,CDM,C1713,HCPCS,0278,RC,,,,both,,,3523.08,2290.00,,,,,,,,,,,,,
CAPTOPRIL 25 MG PO TABS,RX-9402,CDM,6370000000,HCPCS,0637,RC,60687-0315-11,NDC,,both,1,UN,7.00,4.55,,,,,,,,,,,,,
KIT TENODESIS WITH 5MM TENOLOK ANCHOR AND ONE NO2 HI FI SUTU,SUP-2825210,CDM,C1713,HCPCS,0278,RC,,,,both,,,3817.93,2481.65,,,,,,,,,,,,,
GRAFT HUM TISS INJ FLUID THN 12X2 CM AMNIO PLCNTA PRO3-P,SUP-2742038,CDM,C1762,CPT,0278,RC,,,,both,,,5914.98,3844.74,,,,,,,,,,,,,
MESH SYN ABD BIOMATERIAL N ABSRB EXP POLYTETRAFLUROETHYLENE 1DLMCP203] WL GORE AND ASSOCIATES INC],SUP-2395347,CDM,C1781,HCPCS,0278,RC,,,,both,,,8098.06,5263.74,,,,,,,,,,,,,
SHUNT CAR ART 3X5MM L30CM SGL USE EXT INTEGRA SUNDT,SUP-2244281,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4971.56,3231.51,,,,,,,,,,,,,
PLATE SPNL BURR HOLE CVR CRAN GRDIAN,SUP-2637196,CDM,C1713,HCPCS,0278,RC,,,,both,,,2563.87,1666.52,,,,,,,,,,,,,
COIL NEUROVASCULAR TRUFILL L 2 MM MICROCATHETER 0.021 IN,SUP-2699374,CDM,C1889,HCPCS,0278,RC,,,,both,,,1523.21,990.09,,,,,,,,,,,,,
BUR DENT 1 MM CARBIDE ORNG STRL OSSEO STAP,SUP-2134833,CDM,C1713,HCPCS,0278,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
SYSTEM BNE BX 11 GAX10 CM WESTBROOK,SUP-2477883,CDM,2720000010,LOCAL,0272,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
RESTRICTOR CEM DIA14MM UNIV FEM CNL UHMWPE BIOSTP G,SUP-2253101,CDM,C1776,CPT,0278,RC,,,,both,,,172.70,112.25,,,,,,,,,,,,,
ENDCAP ORTH TI FOR SLD TIB IM NAIL,SUP-2192162,CDM,C1713,HCPCS,0278,RC,,,,both,,,428.89,278.78,,,,,,,,,,,,,
GRAFT BNE SUB 25CC PTTY DBM FIBERS AND GLYC FRZ DRY OPTIUM,SUP-2264862,CDM,C1713,HCPCS,0278,RC,,,,both,,,808.71,525.66,,,,,,,,,,,,,
STENT PERIPH EPIC L 120 MM DIA 7 MM CATH L 120 CM NOM DIA,SUP-2145788,CDM,C1876,HCPCS,0278,RC,,,,both,,,2983.00,1938.95,,,,,,,,,,,,,
SCREW BNE L70MM DIA3.5MM STD CORT TI ST LOK LO PROF AXSOS 3,SUP-2704637,CDM,C1713,HCPCS,0278,RC,,,,both,,,138.47,90.01,,,,,,,,,,,,,
TOTAL ELBW,SUP-2212312,CDM,C1776,CPT,0278,RC,,,,both,,,29830.00,19389.50,,,,,,,,,,,,,
SYSTEM BULKING PRC BULKAMID URETHRAL,SUP-2717685,CDM,L8606,HCPCS,0278,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
PLATE BNE RECON 3.5 MM PELV 8 HOLE,SUP-2518363,CDM,C1713,HCPCS,0278,RC,,,,both,,,3212.22,2087.94,,,,,,,,,,,,,
RAIL EXT FIX STR 5.5X500 MM 4D COBALT CHROM,SUP-2517553,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6343.05,4122.98,,,,,,,,,,,,,
HANDPIECE IRRIG DIA2.2MM FRONTAL SNUS FIX 80 ARTC DISP,SUP-2284173,CDM,2720000010,LOCAL,0272,RC,,,,both,,,977.64,635.47,,,,,,,,,,,,,
CATHETER CHOLANGIOGRAM PTC 14 GAX4 IN 20 IN PMI DISP,SUP-2330478,CDM,C1713,HCPCS,0278,RC,,,,both,,,75.17,48.86,,,,,,,,,,,,,
GRAFT BNE PTTY 2.5 CC CLLGN MOZAIK,SUP-2431102,CDM,C9359,HCPCS,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
PLATE BONE L165MM 8 H RT LAT PROX TIB S STL LCK FOR 4.5MM,SUP-2348229,CDM,C1713,HCPCS,0278,RC,,,,both,,,15015.79,9760.26,,,,,,,,,,,,,
DIGOXIN 0.25 MG/ML IJ SOLN,RX-2442,CDM,J1160,HCPCS,0636,RC,00641-1410-35,NDC,,both,0.5,ML,54.10,35.16,,,,,,,,,,,,,
COIL EMB L20CM DIA6MM HELI DETACH TARGET XL,SUP-2365817,CDM,C1889,HCPCS,0278,RC,,,,both,,,5929.11,3853.92,,,,,,,,,,,,,
PORT VEN ACCS SGL LUMN TI 84FRX76CM L SIL CATHETER 9FR INTRO,SUP-2351856,CDM,C1788,HCPCS,0278,RC,,,,both,,,865.79,562.76,,,,,,,,,,,,,
COIL LD EXTRACTION ONE-TIE L 14 CM DIA 6 MM GUIDEWIRE 0.018,SUP-2170095,CDM,C1889,HCPCS,0278,RC,,,,both,,,699.59,454.73,,,,,,,,,,,,,
PLATE BNE L 18 MM THK 0.6 MM 4 H SCREW DIA1. 5 MM LNG TI,SUP-2883946,CDM,C1713,HCPCS,0278,RC,,,,both,,,467.86,304.11,,,,,,,,,,,,,
SET CATHETER DRAINAGE FUHRMAN PNEUMOTHORAX CPPD850WCEIMH,SUP-2759699,CDM,C1729,HCPCS,0272,RC,,,,both,,,462.84,300.85,,,,,,,,,,,,,
WASHER 3.5/4.5MM STRL,SUP-2547540,CDM,C1713,HCPCS,0278,RC,,,,both,,,303.42,197.22,,,,,,,,,,,,,
STENT COR 30MM OD3MM BARE MTL OTW S STL S670,SUP-2281443,CDM,C1876,HCPCS,0278,RC,,,,both,,,521.24,338.81,,,,,,,,,,,,,
KIT TRACH TB AD L80MM OD10MM ID7MM SIL W/ OBT SIDEPRT,SUP-2352053,CDM,2720000010,LOCAL,0272,RC,,,,both,,,310.01,201.51,,,,,,,,,,,,,
PASTE BONE GRAFT GRAFTON PLUS ALLOGRAFT 1ML MOLDABLE SYRINGE DBM,SUP-2293916,CDM,C1713,HCPCS,0278,RC,,,,both,,,432.06,280.84,,,,,,,,,,,,,
GRAFT TISS FRZN ALLGRFT RIB SEG 50 300MM LX5 30MM W,SUP-2307297,CDM,C1713,HCPCS,0278,RC,,,,both,,,1787.48,1161.86,,,,,,,,,,,,,
MESH HERN 20CM WHT COMP RND MFIL POLY W/ ABSRB CLLGN FLM,SUP-2173620,CDM,C1781,HCPCS,0278,RC,,,,both,,,4415.53,2870.09,,,,,,,,,,,,,
NERVE STIMULATOR KIT PROC EMG/NMJ SURFACE/SSEP SURF ELECTRD,SUP-2725217,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
GRAFT STENT THOR 46X46X200 MM 25 FR PROX FREEFLO STR VALIANT,SUP-2298558,CDM,C1768,CPT,0278,RC,,,,both,,,61214.30,39789.29,,,,,,,,,,,,,
CAGE SPNL STACKABLE 4 DEG 9 MM BTM BENGAL,SUP-2530169,CDM,C1889,HCPCS,0278,RC,,,,both,,,7614.50,4949.42,,,,,,,,,,,,,
MESH SURG 30X30CM PREPERI ENFORM,SUP-2419665,CDM,C1781,HCPCS,0278,RC,,,,both,,,37601.50,24440.97,,,,,,,,,,,,,
BRACE ORTH CUST FABRICATED RIGID W/O INTFACE LNR TLSO,SUP-2388143,CDM,L0450,HCPCS,0274,RC,,,,both,,,4930.40,3204.76,,,,,,,,,,,,,
CATHETER HEMO DYLS OR HD AD 12FR L24CM INSRTN 13.5FR ADMIN,SUP-2125585,CDM,C1752,HCPCS,0278,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
LANOLIN EX OINT,RX-4346,CDM,6370000000,HCPCS,0637,RC,09999-9906-93,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
REAMER SURG 4.5 MM FLX,SUP-2362047,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
BIVALIRUDIN TRIFLUOROACETATE 250 MG IV SOLR,RX-141224,CDM,J0583,HCPCS,0636,RC,67457-0256-10,NDC,,both,1,UN,575.00,373.75,,,,,,,,,,,,,
PLATE CRAN W38XL45MM TI RECTANG MALL CNTOUR MESH FOR 1.3MM,SUP-2190619,CDM,C1713,HCPCS,0278,RC,,,,both,,,4598.84,2989.25,,,,,,,,,,,,,
CATHETER HD DL 11.5 FRX15 CM RAULERSON INT JUG DUOFLO,SUP-2269577,CDM,C1751,HCPCS,0278,RC,,,,both,,,109.90,71.43,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED UPCHARGE OXIN XLPE,SUP-2351338,CDM,C1776,CPT,0278,RC,,,,both,,,1045.62,679.65,,,,,,,,,,,,,
DEFIBRILLATOR CARD 82GM 43CC W50XH81MM THK14MM IS1 DF1 CONN,SUP-2356310,CDM,C1882,HCPCS,0275,RC,,,,both,,,51810.00,33676.50,,,,,,,,,,,,,
WAVE CALCANEAL FRACTURE PLATE DRILL MODEL 2.7X160MM,SUP-2830339,CDM,C1713,HCPCS,0278,RC,,,,both,,,288.88,187.77,,,,,,,,,,,,,
PLATE BONE LOCKING MINI 2 MM MANDIBULAR 8 HOLE STRUT MALLEAB,SUP-2838413,CDM,C1713,HCPCS,0278,RC,,,,both,,,2349.66,1527.28,,,,,,,,,,,,,
SPACER SPNL 6DEG H10MM 55X22MM LAT TRUSS SYS,SUP-2101173,CDM,C1889,HCPCS,0278,RC,,,,both,,,19468.00,12654.20,,,,,,,,,,,,,
COIL EMB L15CM OD5MM HELI LOOP REG DEL SYS 2 TIP MRK,SUP-2305172,CDM,C1889,HCPCS,0278,RC,,,,both,,,2402.10,1561.36,,,,,,,,,,,,,
K WIRE FIX L280MM DIA2MM W/ TRCR TIP FOR NCB PLATING SYS,SUP-2412825,CDM,C1713,HCPCS,0278,RC,,,,both,,,66.25,43.06,,,,,,,,,,,,,
RING TRAC M 19-22IN CERV CLOSE BK W/ 2.5IN SKULL AND POS PIN,SUP-2328119,CDM,L0810,HCPCS,0274,RC,,,,both,,,3375.50,2194.07,,,,,,,,,,,,,
BRACE WRST M FOR 17.1-19.1CM L PROTCT PD ADJ BAR D RNG CLSR,SUP-2326112,CDM,L3931,HCPCS,0272,RC,,,,both,,,50.77,33.00,,,,,,,,,,,,,
STENT PERIPH OMLNK ELITE L 29 MM DIA 9 MM CATH L 80 CM SHTH,SUP-2105239,CDM,C1876,HCPCS,0278,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
LINER REPL SZ REG,SUP-2197117,CDM,L4396,HCPCS,0274,RC,,,,both,,,31.49,20.47,,,,,,,,,,,,,
PLATE BONE L77MM 6 H FIB TI STR LCK W/ SYNDESMOTIC SLOT FOR,SUP-2225368,CDM,C1713,HCPCS,0278,RC,,,,both,,,3263.09,2121.01,,,,,,,,,,,,,
BLADE SHV XL L180MM DIA5.5MM 8 FLUT HIP BRL BUR FOR ARTHRO,SUP-2366594,CDM,2720000010,LOCAL,0272,RC,,,,both,,,241.21,156.79,,,,,,,,,,,,,
PLATE BONE L119MM 7 H STR SEMITUBULAR FOR 4.5MM,SUP-2343805,CDM,C1713,HCPCS,0278,RC,,,,both,,,639.62,415.75,,,,,,,,,,,,,
NIACIN ER 500 MG PO TBCR,RX-5545,CDM,6370000000,HCPCS,0637,RC,80681-0090-00,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
GRAFT VASC IMPRA L 30 CM DIA 6 MM EPTFE FLX STD WALL RING,SUP-2761437,CDM,C1768,CPT,0278,RC,,,,both,,,1694.75,1101.59,,,,,,,,,,,,,
INSERT HUM DIA36MM THK+9MM LAT SHLDR POLYETH AEQUALIS,SUP-2388686,CDM,C1776,CPT,0278,RC,,,,both,,,5066.39,3293.15,,,,,,,,,,,,,
PLATE BNE L 159 MM 18 H SCREW DIA2.7 MM TI ALLOY MINI FRAG,SUP-2902359,CDM,C1713,HCPCS,0278,RC,,,,both,,,4255.42,2766.02,,,,,,,,,,,,,
REAMER SURG DIA2.7MM HLLW FOR 2.4/3MM SCR,SUP-2187143,CDM,2720000010,LOCAL,0272,RC,,,,both,,,871.70,566.60,,,,,,,,,,,,,
CATHETER EP ASYM 2-5 MM 5 MM 8 FRX110 CM HTD,SUP-2424670,CDM,C1733,HCPCS,0272,RC,,,,both,,,3309.56,2151.21,,,,,,,,,,,,,
WASHER LCK M6 INBONE,SUP-2494978,CDM,C1713,HCPCS,0278,RC,,,,both,,,34.54,22.45,,,,,,,,,,,,,
ATTACHMENT TOOL L8CM RED STR SM BOR MTCH HD DMND LEGEND,SUP-2284667,CDM,C1713,HCPCS,0278,RC,,,,both,,,2994.74,1946.58,,,,,,,,,,,,,
KIT INSTR MIS LAT STRL DISP MINMN,SUP-2911990,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2747.50,1785.87,,,,,,,,,,,,,
IMPLANT ANK JT HYBRID SUBTALAR TI AND POLYETH HORZ 9MM,SUP-2137775,CDM,C1776,CPT,0278,RC,,,,both,,,5181.00,3367.65,,,,,,,,,,,,,
SHELL HUM DIA52MM SHLDR CO CHROM BPLR ABS,SUP-2404522,CDM,C1776,CPT,0278,RC,,,,both,,,5350.56,3477.86,,,,,,,,,,,,,
PLATE BNE L W10.1XL112MM THK3.5MM 8 H BILAT S STL STR RIG,SUP-2186214,CDM,C1713,HCPCS,0278,RC,,,,both,,,1466.63,953.31,,,,,,,,,,,,,
BUR SURG CUT 23MM DIA SIZEIII F AESCULAP HILAN XS,SUP-2108776,CDM,C1713,HCPCS,0278,RC,,,,both,,,314.38,204.35,,,,,,,,,,,,,
WEDGE TIB SZ 1-2 15MM KNEE REV FULL STP LEGION,SUP-2346595,CDM,C1776,CPT,0278,RC,,,,both,,,3799.40,2469.61,,,,,,,,,,,,,
TOCILIZUMAB 80 MG/4ML IV SOLN,RX-104370,CDM,J3262,HCPCS,0636,RC,50242-0135-01,NDC,,both,4,ML,1567.00,1018.55,,,,,,,,,,,,,
POST EXT FIX 5DEG DSTL RAD KICKSTAND FOR ACU-LOC,SUP-2107133,CDM,2720000010,LOCAL,0272,RC,,,,both,,,596.60,387.79,,,,,,,,,,,,,
MICROCATHETER GUID TREVO PRO 14 L 157 CM PROX/DSTL OD,SUP-2367794,CDM,C1887,HCPCS,0272,RC,,,,both,,,2195.49,1427.07,,,,,,,,,,,,,
ALLOGRAFT BNE CUBE 14X14X14 MM FD SPNG CANC READIGRAFT BLX,SUP-2740885,CDM,C1713,HCPCS,0278,RC,,,,both,,,1791.34,1164.37,,,,,,,,,,,,,
ALLOGRAFT BNE PLATE MED FD IRRADIATED TIB,SUP-2867176,CDM,C1762,CPT,0278,RC,,,,both,,,2818.94,1832.31,,,,,,,,,,,,,
GUIDEWIRE ORTHOPEDIC 65321] CONVENTUS ORTHOPAEDICS],SUP-2167403,CDM,C1769,HCPCS,0272,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
GRAFT HUM TISS W8XL260MM STRUT SEMITENDINOSUS W/ GRACILIS,SUP-2137076,CDM,C1713,HCPCS,0278,RC,,,,both,,,5410.22,3516.64,,,,,,,,,,,,,
GUIDEWIRE 21038 TEFLON COATED 100CM,SUP-2277902,CDM,C1769,HCPCS,0272,RC,,,,both,,,205.51,133.58,,,,,,,,,,,,,
BLADE SAW W9XL31MM THK038MM CUT THK064MM REPL S STL SAG,SUP-2150759,CDM,2720000010,LOCAL,0272,RC,,,,both,,,27.19,17.67,,,,,,,,,,,,,
CATHETER INTVASC OCCL FOGARTY L 40 CM DIA 3 FR BALLOON DIA,SUP-2214267,CDM,C2628,HCPCS,0272,RC,,,,both,,,153.23,99.60,,,,,,,,,,,,,
GUIDEWIRE VASC SION L 300 CM DIA 0.014 IN RADIOPAQUE L 3 CM,SUP-2123809,CDM,C1769,HCPCS,0272,RC,,,,both,,,417.62,271.45,,,,,,,,,,,,,
STEM FEM SZ 4 L165MM DIA15MM HIP CO CHROME CLLRD PRESSFIT,SUP-2252027,CDM,C1776,CPT,0278,RC,,,,both,,,3500.47,2275.31,,,,,,,,,,,,,
CRIMP SPNL 2 PK ASCNT POCT,SUP-2601976,CDM,C1713,HCPCS,0278,RC,,,,both,,,496.12,322.48,,,,,,,,,,,,,
CATHETER DLYS 13.5FR 13CM KT CVD EXTN MAHRK ELITE,SUP-2174258,CDM,C1752,HCPCS,0278,RC,,,,both,,,288.10,187.26,,,,,,,,,,,,,
CATHETER CV 3L 6 FRX55 CM SAFETY INTRO NDL XCELA,SUP-2118819,CDM,C1751,HCPCS,0278,RC,,,,both,,,741.83,482.19,,,,,,,,,,,,,
SEED BRACHYTHERAPY PRELD CARTRIDGE NS MICK DISP,SUP-2247306,CDM,C2643,HCPCS,0278,RC,,,,both,,,207.24,134.71,,,,,,,,,,,,,
PLATE BNE W7XL57MM THK1.5MM 7 H L CNDYL TI FOR 2.7MM SCR,SUP-2191039,CDM,C1713,HCPCS,0278,RC,,,,both,,,1141.17,741.76,,,,,,,,,,,,,
ANCHOR SUTURE MAG,SUP-2342073,CDM,C1713,HCPCS,0278,RC,,,,both,,,2260.80,1469.52,,,,,,,,,,,,,
SYSTEM ORTH REV MOD TIB TAPE 83 OSS,SUP-2441796,CDM,C1776,CPT,0278,RC,,,,both,,,9339.93,6070.95,,,,,,,,,,,,,
SYSTEM VES HARVESTING KT ENDOSCP VASOVIEW 6,SUP-2227298,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1821.20,1183.78,,,,,,,,,,,,,
NEEDLE INJ L12.5CM DIA12GA BNE CEM DEL NORIAN,SUP-2194178,CDM,2720000010,LOCAL,0272,RC,,,,both,,,646.75,420.39,,,,,,,,,,,,,
RELOAD STPL L100MM OPN H4.5MM CLS H2MM WIRE DIA0.23MM THCK,SUP-2220070,CDM,2720000010,LOCAL,0272,RC,,,,both,,,343.89,223.53,,,,,,,,,,,,,
GRAFT DURA 1.57IN 1.57IN BOV PERICARD ENDURA,SUP-2244038,CDM,C1763,HCPCS,0278,RC,,,,both,,,703.36,457.18,,,,,,,,,,,,,
STEM FEM L165MM DIA15MM 12/14 TAPR HIP 5/8 POR TRIANG STD,SUP-2252068,CDM,C1776,CPT,0278,RC,,,,both,,,5435.34,3532.97,,,,,,,,,,,,,
MESH SPNL H50XL12MM TI RND,SUP-2254464,CDM,C1713,HCPCS,0278,RC,,,,both,,,13420.36,8723.23,,,,,,,,,,,,,
SCREW BONE L8MM OD1.3MM CRANIOMAXILLOFACIAL VIT LUHR PAN FIX,SUP-2364633,CDM,C1713,HCPCS,0278,RC,,,,both,,,122.65,79.72,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH FLX L 82 MM DIA24 MM SHTH 18 FR RVD,SUP-2170612,CDM,C1768,CPT,0278,RC,,,,both,,,24021.00,15613.65,,,,,,,,,,,,,
RING EXT FIX COMP FT 140MM INT DIAM 160MM LEN,SUP-2342278,CDM,C1713,HCPCS,0278,RC,,,,both,,,8695.76,5652.24,,,,,,,,,,,,,
PROSTHESIS OSS L 5 MM SHFT DIA1.14 MM HD DIA2 X 4.4 MM TI HA,SUP-2901929,CDM,L8613,CPT,0278,RC,,,,both,,,1726.69,1122.35,,,,,,,,,,,,,
PACEMAKER CARD ATTESTA S DR MRI SURESCAN W 42.9 X H 44.7 X D,SUP-2665247,CDM,C1785,HCPCS,0275,RC,,,,both,,,8007.00,5204.55,,,,,,,,,,,,,
BUR 45MMX19CM SPHR HPS,SUP-2167161,CDM,2720000010,LOCAL,0272,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
CATHETER EMB FOGARTY L 40 CM DIA 6 FR BALLOON DIA,SUP-2214018,CDM,C1757,HCPCS,0272,RC,,,,both,,,279.18,181.47,,,,,,,,,,,,,
RING EXT FIX DIA180 210MM L LNG ROCK SHOE HOFFMANN LRF,SUP-2363188,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
CATHETER VENTRICULAR STRP STD 1.3X2.5 MMX18 CM GRAD PUDENZ,SUP-2852582,CDM,C1729,HCPCS,0272,RC,,,,both,,,442.05,287.33,,,,,,,,,,,,,
PLATE BNE L 234 MM SCREW DIA 3.5 MM 18 SHFT H TI MTPHSEAL NS,SUP-2907836,CDM,C1713,HCPCS,0278,RC,,,,both,,,4614.17,2999.21,,,,,,,,,,,,,
DRIVER SURG OD3MM M HEX FOR EVOLUTION C CERV IMPL REM SYS,SUP-2293607,CDM,C1713,HCPCS,0278,RC,,,,both,,,159.42,103.62,,,,,,,,,,,,,
MANIPULATOR SURG MICRO-CHOP 90 DEG 120 MM LENS FOR CHOPPING,SUP-2484866,CDM,C1713,HCPCS,0278,RC,,,,both,,,689.86,448.41,,,,,,,,,,,,,
PLATE BONE L94MM 7 H T SHP LCK 3 HD FOR 3.5MM SCR,SUP-2318683,CDM,C1713,HCPCS,0278,RC,,,,both,,,2389.85,1553.40,,,,,,,,,,,,,
PLATE BNE L303MM THK3MM 16 H BILAT S STL STR LOK COMPR RECON,SUP-2185353,CDM,C1713,HCPCS,0278,RC,,,,both,,,2166.66,1408.33,,,,,,,,,,,,,
DEXTROSE-SODIUM CHLORIDE 5-0.9 % IV SOLN,RX-15882,CDM,J7042,HCPCS,0258,RC,00264-7610-00,NDC,,both,1000,ML,34.00,22.10,,,,,,,,,,,,,
PROBE LITHO OD3.3FR REINF ST DISP,SUP-2332792,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3595.30,2336.94,,,,,,,,,,,,,
HOOK SPNL DIA6.5MM BILAT PEDCL TI NEUT THRT W BLDE OPN FOR,SUP-2254523,CDM,C1713,HCPCS,0278,RC,,,,both,,,2034.72,1322.57,,,,,,,,,,,,,
CABLE LT,SUP-2310428,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
PLATE BNE STR 3.5X36.2 MM 3 HOLE RECON FOR SM FRAG SYS TI NS,SUP-2463023,CDM,C1713,HCPCS,0278,RC,,,,both,,,737.40,479.31,,,,,,,,,,,,,
PLATE BONE LOCKING HOLEX6 T SHAPED LEFT DORSAL DISTAL,SUP-2721275,CDM,C1713,HCPCS,0278,RC,,,,both,,,3066.02,1992.91,,,,,,,,,,,,,
KIT BNE GRFT SUB 3CC SIDE DEL CANN L60MM NDL 15GA COMPLT FT,SUP-2208438,CDM,C1713,HCPCS,0278,RC,,,,both,,,9608.40,6245.46,,,,,,,,,,,,,
BLADE SHAVER ARTHSCP AGRSSVE PLU 5MM DIA LNG HIP STRGHT FORM,SUP-2605873,CDM,2720000010,LOCAL,0272,RC,,,,both,,,191.07,124.20,,,,,,,,,,,,,
HC Placement Central Venous Cath,PX-3613655600,CDM,36556,CPT,0361,RC,,,,outpatient,,,9955.00,6470.75,,,,,,,,,,,,,
BAND ANNULPLSTY DURAN ANCORE L 63 X 33.8 MM ORIFICE L 27.8 X,SUP-2282715,CDM,C1889,HCPCS,0278,RC,,,,both,,,3061.50,1989.97,,,,,,,,,,,,,
INTRODUCER SHTH 8FR L63CM DIL L67CM CRV TYP SL4 SUP STIFF,SUP-2357259,CDM,C1894,HCPCS,0272,RC,,,,both,,,580.90,377.58,,,,,,,,,,,,,
WIRE FIX TROCAR PT 2 END 0.049 INX150 MM TI MAG KIRSCHNER,SUP-2476935,CDM,C1713,HCPCS,0278,RC,,,,both,,,42.39,27.55,,,,,,,,,,,,,
PROSTHESIS OSS 0.4X5.25 MM PISTON NIT/FLROPLAS SMRT 360,SUP-2651574,CDM,L8613,CPT,0278,RC,,,,both,,,1004.96,653.22,,,,,,,,,,,,,
GUIDEWIRE VASC J 3 MM 0.035 INX200 CM STD FIX COR SAFE T-J,SUP-2167688,CDM,C1769,HCPCS,0272,RC,,,,both,,,56.14,36.49,,,,,,,,,,,,,
PLATE BONE L18MM THK1.5MM 2X2 H MINI TI RT,SUP-2319359,CDM,C1713,HCPCS,0278,RC,,,,both,,,339.12,220.43,,,,,,,,,,,,,
PERFORATOR CRAN AD PED 14/11MM DGR O ROUNDED CUT EDGE DISP,SUP-2106556,CDM,C1713,HCPCS,0278,RC,,,,both,,,697.08,453.10,,,,,,,,,,,,,
CATHETER CTRL VEN L12CM OD5FR PED DBL LUMN N TUNNELED BASIC,SUP-2167978,CDM,C1751,HCPCS,0278,RC,,,,both,,,296.42,192.67,,,,,,,,,,,,,
LINER ACET PRSS FT HIP POROUS POLYETH MTL,SUP-2223614,CDM,C1776,CPT,0278,RC,,,,both,,,16014.00,10409.10,,,,,,,,,,,,,
ENDPLATE SPNL DISK 14X16MM FOOTPRINT 0DEG CO CHROM,SUP-2232285,CDM,C1713,HCPCS,0278,RC,,,,both,,,10990.00,7143.50,,,,,,,,,,,,,
ROD SPNL L120MM DIA5.5MM RT ANTR TI ALLOY SMOOTH MOSS MIAMI,SUP-2254457,CDM,C1713,HCPCS,0278,RC,,,,both,,,800.70,520.45,,,,,,,,,,,,,
VALVE SHUNT SINGLE OPENING PRESSURE 30CM H2O WITH NO CONNECT,SUP-2825629,CDM,C1889,HCPCS,0278,RC,,,,both,,,4341.65,2822.07,,,,,,,,,,,,,
SCREW SPNL POLYAX 10X100 MM POST IL 2 COR REDUCTION STRL,SUP-2566431,CDM,C1713,HCPCS,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
CONNECTOR 7 MM 7.5 DEG TEAL TI FOR IMPLATE SYS,SUP-2340251,CDM,C1713,HCPCS,0278,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
DEVICE ENDOSKELETAL SYS PROSTHETIC BK WAIST BELT WEB,SUP-2388212,CDM,L5688,HCPCS,0274,RC,,,,both,,,160.55,104.36,,,,,,,,,,,,,
GUIDEWIRE ORTH,SUP-2247391,CDM,C1769,HCPCS,0272,RC,,,,both,,,25.12,16.33,,,,,,,,,,,,,
SODIUM ACETATE 2 MEQ/ML IV SOLN,RX-7301,CDM,2500000003,HCPCS,0250,RC,00409-7299-83,NDC,,both,20,ML,64.40,41.86,,,,,,,,,,,,,
HC So Antibody; Mumps,PX-3028673566,CDM,86735,CPT,0302,RC,,,,both,,,104.00,67.60,,,,,,,,,,,,,
ALLOGRAFT BNE MOLD 10 CC VIABLE BNE MTRX VIBONE,SUP-2731791,CDM,C1762,CPT,0278,RC,,,,both,,,10990.00,7143.50,,,,,,,,,,,,,
PLATE BNE L100MM 130DEG 4 H PELVIS BILAT S STL STD BRL RIG,SUP-2342580,CDM,C1713,HCPCS,0278,RC,,,,both,,,3639.73,2365.82,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP L150CM DIA0.035IN TIP L3CM PTFE STR FLX,SUP-2139325,CDM,C1769,HCPCS,0272,RC,,,,both,,,36.86,23.96,,,,,,,,,,,,,
NEEDLE SUTURE L8.75IN HEAVY CURVED REVERDIN,SUP-2803391,CDM,2720000010,LOCAL,0272,RC,,,,both,,,778.78,506.21,,,,,,,,,,,,,
CEMENT KIT CALCIUM PHOSPHATE 8 CC QUICKSET,SUP-2845379,CDM,C1713,HCPCS,0278,RC,,,,both,,,4945.50,3214.57,,,,,,,,,,,,,
HC So2 Complement C-3/C-4,PX-3028616068,CDM,86160,CPT,0302,RC,,,,both,,,41.00,26.65,,,,,,,,,,,,,
STEM FEM L155MM DIA105MM L HIP 12 14 TAPR POR SM STAT SHT,SUP-2251908,CDM,C1776,CPT,0278,RC,,,,both,,,14239.27,9255.53,,,,,,,,,,,,,
CATHETER EP CRD 5/5/5 MM 6 FRX110 CM SOLOIST,SUP-2749538,CDM,C2630,CPT,0272,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
TUBE VENT 1.14 MM 0.76 MM 2.3 MM DONALDSON FLROPLAS 525051,SUP-2462379,CDM,L8699,HCPCS,0278,RC,,,,both,,,23.68,15.39,,,,,,,,,,,,,
GRAFT VASC IMPRA L 10 CM DIA 3 MM EPTFE STR TW N RING HEMO,SUP-2761229,CDM,C1768,CPT,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
PLATE BNE L W10.1XL252MM THK3.5MM 18 H BILAT S STL STR RIG,SUP-2186229,CDM,C1713,HCPCS,0278,RC,,,,both,,,2148.92,1396.80,,,,,,,,,,,,,
TRAY CATH 5FR 3 LUMN MAX BARR SHERLOCK 3CG TPS STYL PWR,SUP-2125516,CDM,C1751,HCPCS,0278,RC,,,,both,,,990.23,643.65,,,,,,,,,,,,,
PLATE BNE STR 9 HOLE LCK PRECONTOURED DYN COMPR TOT WRST NS,SUP-2851920,CDM,C1713,HCPCS,0278,RC,,,,both,,,3772.33,2452.01,,,,,,,,,,,,,
SHEATH INTRO PERFRMR L 98 CM OD 7 FR ID 2.3 MM GUIDEWIRE,SUP-2168591,CDM,C1894,HCPCS,0272,RC,,,,both,,,177.44,115.34,,,,,,,,,,,,,
NEEDLE TRANSSEPTAL 21GA L71CM FOR L HRT ACCS,SUP-2167852,CDM,C1713,HCPCS,0278,RC,,,,both,,,339.12,220.43,,,,,,,,,,,,,
ARM EXT FIX ACTIVATION 53 MM RIGID,SUP-2463580,CDM,C1713,HCPCS,0278,RC,,,,both,,,2841.32,1846.86,,,,,,,,,,,,,
SCREW BNE L85MM DIA6MM HD DIA27MM CANC TI ALLY PARTIALLY,SUP-2207995,CDM,C1713,HCPCS,0278,RC,,,,both,,,641.69,417.10,,,,,,,,,,,,,
FOOTPLATE EXT FIX L 155 MM LNG GRN NS DISP SPAT FRME TSF,SUP-2933233,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5406.61,3514.30,,,,,,,,,,,,,
LASER CATH EXTRM II OTW 2.3MM,SUP-2353067,CDM,C1725,HCPCS,0272,RC,,,,both,,,4867.00,3163.55,,,,,,,,,,,,,
BAND GAST ADJ DISECT REALIZE C,SUP-2219868,CDM,C1889,HCPCS,0278,RC,,,,both,,,9043.20,5878.08,,,,,,,,,,,,,
CATHETER PICC 4FR SGL LUMN W/ MICEZ SFTY MIC INTRO FULL,SUP-2125613,CDM,C1751,HCPCS,0278,RC,,,,both,,,536.37,348.64,,,,,,,,,,,,,
IMPLANT BIO SZ 250 SQCM FISH SKIN DERMAL SLD INTACT FLAT DRY,SUP-2909272,CDM,Q4158,HCPCS,0636,RC,,,,both,,,23314.50,15154.42,,,,,,,,,,,,,
PLATE BNE W12XL142MM THK3.7MM LNG 5 H NONSTERILE PROX HUM S,SUP-2186015,CDM,C1713,HCPCS,0278,RC,,,,both,,,4379.23,2846.50,,,,,,,,,,,,,
CATHETER PICC 5FR L55CM 2 LUMN W/ PASV VLV TECHNOLOGY,SUP-2118889,CDM,C1751,HCPCS,0278,RC,,,,both,,,810.12,526.58,,,,,,,,,,,,,
COIL VASC AZUR HYDROCOIL L 4 CM DIA 3 MM MICROCATHETER 0.018,SUP-2385381,CDM,C1889,HCPCS,0278,RC,,,,both,,,628.03,408.22,,,,,,,,,,,,,
NEEDLE SUTURE L8IN HEAVY CURVED LIGATURE KOCHER,SUP-2809005,CDM,2720000010,LOCAL,0272,RC,,,,both,,,366.97,238.53,,,,,,,,,,,,,
WASHER ORTH SCREW DIA 4.5 MM DBL NS EVOS,SUP-2933074,CDM,C1713,HCPCS,0278,RC,,,,both,,,715.92,465.35,,,,,,,,,,,,,
BIT DRL 230/200MM CALIB DIA3.2MM 3 FLUT QUIK CPL,SUP-2187618,CDM,2720000010,LOCAL,0272,RC,,,,both,,,682.29,443.49,,,,,,,,,,,,,
COMPONENT TIB SZ 4 RT MEDL LT LAT MOB BEAR CEM PRESERVATION,SUP-2251290,CDM,C1776,CPT,0278,RC,,,,both,,,4873.28,3167.63,,,,,,,,,,,,,
STEM FEM L140MM DIA12MM HIP L MTPHSEAL BODY STR NK TIV,SUP-2210352,CDM,C1776,CPT,0278,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
ROD SPNL L95MM PEEK POST THORACOLUMBOSACRAL PERC APPRCH CDH,SUP-2279684,CDM,C1713,HCPCS,0278,RC,,,,both,,,1640.65,1066.42,,,,,,,,,,,,,
DEVICE MENIS REP STR NDL ALL-SUTURE CROSSFIX II,SUP-2402629,CDM,C1713,HCPCS,0278,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
FEM FULL AGMT BLK 59X25,SUP-2205982,CDM,C1776,CPT,0278,RC,,,,both,,,24391.52,15854.49,,,,,,,,,,,,,
SCREW INTFR L23MM DIA10MM POLY L LACTIC ACID KNEE CANN,SUP-2249498,CDM,C1713,HCPCS,0278,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
BLADE RETRACTOR 2 12IND SOLID LATERAL,SUP-2671275,CDM,2720000010,LOCAL,0272,RC,,,,both,,,256.44,166.69,,,,,,,,,,,,,
BIT DRL FLX CENTERING SL DISP,SUP-2608596,CDM,2720000010,LOCAL,0272,RC,,,,both,,,422.02,274.31,,,,,,,,,,,,,
PLATE BNE LCK 237 MM LT DSTL LAT TIB PERIARTICULAR 18 HOLE,SUP-2475092,CDM,C1713,HCPCS,0278,RC,,,,both,,,4615.86,3000.31,,,,,,,,,,,,,
GRAFT VASC IMPRA L 10 CM DIA 3 MM EPTFE STR STD WALL N RING,SUP-2761227,CDM,C1768,CPT,0278,RC,,,,both,,,480.73,312.47,,,,,,,,,,,,,
TI LCP WRIST FUSION STANDARD BEND PLATE-STERILE,SUP-2546649,CDM,C1713,HCPCS,0278,RC,,,,both,,,5520.31,3588.20,,,,,,,,,,,,,
MESH SURG W9XL13CM POLY 3 DIM RECTANG PARIETEX,SUP-2174799,CDM,C1781,HCPCS,0278,RC,,,,both,,,264.55,171.96,,,,,,,,,,,,,
HC Drain Arm Bursa,PX-4502393100,CDM,23931,CPT,0450,RC,,,,both,,,1649.00,1071.85,,,,,,,,,,,,,
RING EXT FIX 180 MM TRAUM CLMP SIDE,SUP-2197264,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4239.00,2755.35,,,,,,,,,,,,,
SCREW CRANIO MAXILLOFACIAL CNTR DRV HD TI 2.0MMDIA 9MML,SUP-2262649,CDM,C1713,HCPCS,0278,RC,,,,both,,,122.46,79.60,,,,,,,,,,,,,
KIT SPNL ROD PT SPEC EXP ANY LEVEL UNID,SUP-2926536,CDM,C1713,HCPCS,0278,RC,,,,both,,,16642.00,10817.30,,,,,,,,,,,,,
PLATE BONE W10XL16MM THK0.3MM 4 H TI BX ULT LO PROF,SUP-2181544,CDM,C1713,HCPCS,0278,RC,,,,both,,,795.05,516.78,,,,,,,,,,,,,
INSERT SCRDRVR TORX STARDRV T10 FOR SCREW STRL DISP OPERACE,SUP-2913519,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2199.10,1429.41,,,,,,,,,,,,,
AVELUMAB 200 MG/10ML IV SOLN,RX-137785,CDM,J9023,HCPCS,0636,RC,44087-3535-01,NDC,,both,10,ML,6030.80,3920.02,,,,,,,,,,,,,
BAR EXT FIX 11X300 MM CARBON,SUP-2749997,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1591.98,1034.79,,,,,,,,,,,,,
MESH HERN W8XH6IN INT ABD OMEGA 3 FATTY ACID POLYPR OBLONG,SUP-2265985,CDM,C1781,HCPCS,0278,RC,,,,both,,,2025.30,1316.44,,,,,,,,,,,,,
PLATE SPNL L30MM CEPHALIC TO CAUD 22MM 5 H GLD ANTR BILAT,SUP-2193034,CDM,C1713,HCPCS,0278,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
HC Debride/Musc/Fasc First 20 Sq Cm,PX-3611104300,CDM,11043,CPT,0361,RC,,,,both,,,625.00,406.25,,,,,,,,,,,,,
DEFIBRILLATOR CRD BPLR ATR VENTRIC 2 CHMBR ROPT ATLS DR,SUP-2356547,CDM,C1721,HCPCS,0275,RC,,,,both,,,42955.20,27920.88,,,,,,,,,,,,,
RHS RADIAMETERL HEAD DIAMETER 22MM,SUP-2822289,CDM,C1776,CPT,0278,RC,,,,both,,,4813.62,3128.85,,,,,,,,,,,,,
GRAFT BNE SUB W25MMXL25CM FASC LATA FRZN,SUP-2307102,CDM,C1762,CPT,0278,RC,,,,both,,,1711.71,1112.61,,,,,,,,,,,,,
SPHINCTEROTOME ENDOSCP 4X25 MM V-SYSTEM 3 LUMEN,SUP-2313220,CDM,2720000010,LOCAL,0272,RC,,,,both,,,354.82,230.63,,,,,,,,,,,,,
TUBE VENT L2.50MM ID1.27MM SIL MICROGEL DISP FOR MYR GRMMT,SUP-2284011,CDM,L8699,HCPCS,0278,RC,,,,both,,,101.39,65.90,,,,,,,,,,,,,
SCREW BNE SELF DRL CANN COMPR TI L19MM L5MM OD3MM APTUS,SUP-2268332,CDM,C1713,HCPCS,0278,RC,,,,both,,,1446.91,940.49,,,,,,,,,,,,,
PIN EXT FIX HALF 6X110 MM 50 MM THRD SS RINGFIX,SUP-2461217,CDM,2720000010,LOCAL,0272,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 10 CM DIA 7 MM EPTFE STR TW N RING,SUP-2396345,CDM,C1768,CPT,0278,RC,,,,both,,,602.88,391.87,,,,,,,,,,,,,
SPLINT ORTH 3 1 2 4 1 4 M L L WRST THMB LTWT SFT INNR LINING,SUP-2194733,CDM,L3931,HCPCS,0272,RC,,,,both,,,84.78,55.11,,,,,,,,,,,,,
POST EXT FIX 2 HOLE STRL TRUELOK EVO LTX,SUP-2875628,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1453.19,944.57,,,,,,,,,,,,,
CANNULA ENDO L90MM OD7MM HIP COMPLT THRD DISP CLEAR-TRAC,SUP-2341064,CDM,2720000010,LOCAL,0272,RC,,,,both,,,574.62,373.50,,,,,,,,,,,,,
COLLAR CERV AD COT LN PD HT ADJ TECHNOLOGY W/ REPL PDS,SUP-2124227,CDM,L0180,HCPCS,0272,RC,,,,both,,,122.59,79.68,,,,,,,,,,,,,
ANCHOR SUT 4.5MM NO 2 W/ NDL MORPHIX,SUP-2277452,CDM,C1713,HCPCS,0278,RC,,,,both,,,2339.30,1520.54,,,,,,,,,,,,,
ANCHOR SUTURE PRSS FIT,SUP-2663508,CDM,C1776,CPT,0278,RC,,,,both,,,204.10,132.66,,,,,,,,,,,,,
PLATE BNE FIBULAR 2.7X131 MM RT LAT DSTL 7 HOLE NS VA-LCP,SUP-2758199,CDM,C1713,HCPCS,0278,RC,,,,both,,,2974.96,1933.72,,,,,,,,,,,,,
SURFACE ARTC 1-2 AB THK17MM AP40MM ML58MM PUR PROLONG KNEE,SUP-2211957,CDM,C1776,CPT,0278,RC,,,,both,,,4633.07,3011.50,,,,,,,,,,,,,
PLATE BNE L17MM 2 H R S STL L SHP RIG NEUT NONCOMPRESSION,SUP-2186157,CDM,C1713,HCPCS,0278,RC,,,,both,,,189.78,123.36,,,,,,,,,,,,,
MESH HERN FLAT SHT 8X10 IN RECT OVL KNITTED PROLITE ULTRA,SUP-2227248,CDM,C1781,HCPCS,0278,RC,,,,both,,,259.14,168.44,,,,,,,,,,,,,
DISSECTOR ENDOSCP CRV JAW 26 CM CRDLSS FOR US SONICISION,SUP-2422350,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1224.60,795.99,,,,,,,,,,,,,
GUIDE SURG PLN TI LP DISTRCTN CUSTOMIZABLE UNILAT VSP,SUP-2883942,CDM,2720000010,LOCAL,0272,RC,,,,both,,,17554.96,11410.72,,,,,,,,,,,,,
HC Direct Referral Observation Surcharge,PX-7620037900,CDM,G0379,CPT,0762,RC,,,,both,,,460.00,299.00,,,,,,,,,,,,,
PLATE BNE THK1.7MM STD 2X2 H MIDFACE G 3D,SUP-2366291,CDM,C1713,HCPCS,0278,RC,,,,both,,,726.34,472.12,,,,,,,,,,,,,
GUIDEWIRE VASC L180CM DIA0.018IN TIP L3MM PTFE J TIP FIX,SUP-2421132,CDM,C1769,HCPCS,0272,RC,,,,both,,,38.62,25.10,,,,,,,,,,,,,
PLATE 3.5MM TI LCP TM CLAVICLE 5H RT-15MM HOOK DEPTH-STER,SUP-2549664,CDM,C1713,HCPCS,0278,RC,,,,both,,,3620.01,2353.01,,,,,,,,,,,,,
"HC So2 Ag Detect Nos, Eia Multi Step",PX-3068744968,CDM,87449,CPT,0306,RC,,,,both,,,173.00,112.45,,,,,,,,,,,,,
GUIDEWIRE VASC GLIDEWIRE ADVANTAGE TRK L 300 CM DIA 0.014 IN,SUP-2880693,CDM,C1769,HCPCS,0272,RC,,,,both,,,1083.30,704.14,,,,,,,,,,,,,
BUNDLE CVC L 16 CM DIA 7 FR MAX BARR 3 LUMEN TEGDERM,SUP-2930819,CDM,C1751,HCPCS,0278,RC,,,,both,,,329.98,214.49,,,,,,,,,,,,,
KYPHOPLASTY KIT 1ST FRAC 10/3 IBT KYPHON 1 STP,SUP-2743784,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8164.00,5306.60,,,,,,,,,,,,,
MESH CRAN W38XL50MM THK1MM TIIUM POLYETH POR MTRX 1 SIDE,SUP-2366477,CDM,C1713,HCPCS,0278,RC,,,,both,,,3675.75,2389.24,,,,,,,,,,,,,
PIN EXT FIX CASE 3-6 MM APEX,SUP-2494304,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5521.38,3588.90,,,,,,,,,,,,,
PATCH HERN W15.5XL20.5CM 28-35MM STOMA OPN POLYPR W/ EXP,SUP-2126078,CDM,C1781,HCPCS,0278,RC,,,,both,,,3600.48,2340.31,,,,,,,,,,,,,
DISTAL LATERAL TIBIA PLATE JIG LEFT,SUP-2726642,CDM,C1713,HCPCS,0278,RC,,,,both,,,1272.99,827.44,,,,,,,,,,,,,
ALLOGRACT HUM TISS AMNIOBAND MEMBRANE 14MM DISK,SUP-2905493,CDM,Q4151,HCPCS,0636,RC,,,,both,,,800.64,520.42,,,,,,,,,,,,,
PLATE 3.5MM TI LCP TM CLAVICLE 4H RT-15MM HOOK DEPTH-STER,SUP-2549658,CDM,C1713,HCPCS,0278,RC,,,,both,,,3461.63,2250.06,,,,,,,,,,,,,
NAIL EBA ONE LONG 130DEG LEFT 36MM,SUP-2717572,CDM,C1713,HCPCS,0278,RC,,,,both,,,5143.32,3343.16,,,,,,,,,,,,,
PLATE BNE W17.5XL300MM THK5.2MM 16 H ST BILAT S STL BROAD,SUP-2185312,CDM,C1713,HCPCS,0278,RC,,,,both,,,2848.95,1851.82,,,,,,,,,,,,,
CATHETER HEMO DYLS OR HD L19CM ODSEC14.5MM MTL CHRONIC,SUP-2118958,CDM,C1751,HCPCS,0278,RC,,,,both,,,1175.96,764.37,,,,,,,,,,,,,
PHYTONADIONE 1 MG/0.5ML IJ SOLN,RX-118346,CDM,J3430,HCPCS,0636,RC,76329-1240-01,NDC,,both,0.25,ML,71.10,46.21,,,,,,,,,,,,,
BASKET STONE RETRV 1.9FR L120CM NIT PARACHUTE 4 WIR DISP,SUP-2139282,CDM,2720000010,LOCAL,0272,RC,,,,both,,,842.59,547.68,,,,,,,,,,,,,
WIRE SPINAL FIXATION KIRSCHNER 0.45IN DIA 500MML BLUNT TIP,SUP-2232217,CDM,C1713,HCPCS,0278,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 6X2 CM BLOCKADE AMNIO PROTCT BARR,SUP-2538795,CDM,C1762,CPT,0278,RC,,,,both,,,9347.78,6076.06,,,,,,,,,,,,,
HC Imrt Planning,PX-3337730100,CDM,77301,CPT,0333,RC,,,,both,,,14532.00,9445.80,,,,,,,,,,,,,
SCORPION NEEDLE HIP LENGTH,SUP-2812253,CDM,2720000010,LOCAL,0272,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
GRAFT HUM TISS W8XL16CM THK2.3-3.3MM ULT THCK REGENERATIVE,SUP-2113417,CDM,Q4116,HCPCS,0636,RC,,,,both,,,14685.78,9545.76,,,,,,,,,,,,,
PLATE BNE 20 H ST BILAT S STL NAR CRV LOK COMPR FOR 45MM SCR,SUP-2178066,CDM,C1713,HCPCS,0278,RC,,,,both,,,4630.81,3010.03,,,,,,,,,,,,,
GUIDE BLOCK F/LCP(TM) PROXIMAL LATERAL TIBIA PLATES-RIGHT,SUP-2548287,CDM,C1713,HCPCS,0278,RC,,,,both,,,1352.68,879.24,,,,,,,,,,,,,
BRUSH RUST RNG REMOVER MED BATTERY OPERATED BUR HNDL DIAMOND,SUP-2478531,CDM,2720000010,LOCAL,0272,RC,,,,both,,,344.93,224.20,,,,,,,,,,,,,
GRAFT BONE 5X11X11MM LMASR HUM TISS TRICORT SPCR MECHANISM,SUP-2293951,CDM,C1713,HCPCS,0278,RC,,,,both,,,3764.86,2447.16,,,,,,,,,,,,,
PLATE BNE L 150.62 X W 8.25 MM THK 2.8 MM 20 H TI STR NS,SUP-2936949,CDM,C1713,HCPCS,0278,RC,,,,both,,,6135.56,3988.11,,,,,,,,,,,,,
CANNULA ART L10MM HEMSHLD,SUP-2106278,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2496.30,1622.59,,,,,,,,,,,,,
STIMULATOR COCHLEAR BILATERAL PEDIATRIC SLEEPER BAHA,SUP-2165016,CDM,L8614,HCPCS,0278,RC,,,,both,,,34665.60,22532.64,,,,,,,,,,,,,
HEAD FEM DIA36MM -3.5MM SHT NK CO CHROM SUFIKITA SUP FINISH,SUP-2304426,CDM,C1776,CPT,0278,RC,,,,both,,,4388.15,2852.30,,,,,,,,,,,,,
INSERT HUM DIA36MM THK+9MM 7.5DEG REVERSED SHLDR FOR CONV,SUP-2388716,CDM,C1776,CPT,0278,RC,,,,both,,,6572.02,4271.81,,,,,,,,,,,,,
SCREW BONE JONES 5.5MM,SUP-2719494,CDM,C1713,HCPCS,0278,RC,,,,both,,,6512.36,4233.03,,,,,,,,,,,,,
BUPRENORPHINE HCL-NALOXONE HCL 2-0.5 MG SL FILM,RX-106574,CDM,J0572,HCPCS,0636,RC,47781-0355-03,NDC,,both,1,UN,10.10,6.56,,,,,,,,,,,,,
DEVICE PESSARY 3 IN INCONT RNG,SUP-2171747,CDM,A4562,HCPCS,0274,RC,,,,both,,,181.90,118.23,,,,,,,,,,,,,
PIN FIX DIAMOND PT 2 END 1/8X9 IN 4 PT STYL SMOOTH PLN STRL,SUP-2150488,CDM,C1713,HCPCS,0278,RC,,,,both,,,15.45,10.04,,,,,,,,,,,,,
PLATE BNE L306MM BLDE W48XL25MM 95DEG 18 H ST HIP S STL RIG,SUP-2186765,CDM,C1713,HCPCS,0278,RC,,,,both,,,4611.59,2997.53,,,,,,,,,,,,,
PLATE 1ST MTCRPL 2MM DORS SS STRL VAL,SUP-2546097,CDM,C1713,HCPCS,0278,RC,,,,both,,,2268.74,1474.68,,,,,,,,,,,,,
GRAFT SHFT FEM STRUCTURAL ALLGRFT FRZN 200MM,SUP-2307349,CDM,C1713,HCPCS,0278,RC,,,,both,,,5699.26,3704.52,,,,,,,,,,,,,
GRAFT HUM TISS W1.5XL2CM THK35UN AMNIO MEMBRN DEHYDR SGL,SUP-2247193,CDM,V2790,HCPCS,0274,RC,,,,both,,,1428.70,928.65,,,,,,,,,,,,,
MATRIX HUM TISS L 3 X W 2 CM DECELL PLCNTA MEMBRN,SUP-2909312,CDM,Q4201,HCPCS,0636,RC,,,,both,,,1381.60,898.04,,,,,,,,,,,,,
PLATE BNE 130 DEG PEDIATRIC 5X111 MM 23/15 MM HIP 5 HOLE LCP,SUP-2799111,CDM,C1713,HCPCS,0278,RC,,,,both,,,2625.48,1706.56,,,,,,,,,,,,,
PLATE SPNL ANCHR 45 MM OCPTL ASCNT POCT,SUP-2601972,CDM,C1713,HCPCS,0278,RC,,,,both,,,3529.36,2294.08,,,,,,,,,,,,,
GRAFT HUM TISS W1.5XL2CM THK35UN AMNIO MEMBRN DEHYDR SGL,SUP-2247193,CDM,V2790,HCPCS,0278,RC,,,,both,,,1428.70,928.65,,,,,,,,,,,,,
CATHETER HEMODIALYSI TRI FLO ACTE 11.5FR DIA 20CM PCED TAPR,SUP-2610638,CDM,C1752,HCPCS,0278,RC,,,,both,,,122.49,79.62,,,,,,,,,,,,,
MAXFRAME RING MOUNT FOR 5-6MM,SUP-2752092,CDM,2720000010,LOCAL,0272,RC,,,,both,,,512.95,333.42,,,,,,,,,,,,,
DEVICE SUCTION 5 MM CAUT SPATULA TIP W/O TBNG SURGIWAND II,SUP-2787742,CDM,2720000010,LOCAL,0272,RC,,,,both,,,423.12,275.03,,,,,,,,,,,,,
PARTICLE EMB BEAR NSPVA DIA150-250 UM 100 MG PVA HYDRPHLC,SUP-2482241,CDM,C1889,HCPCS,0278,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
BAR EXT FIX L75MM DIA6MM COMP FOR JET-X FIX SYS,SUP-2342911,CDM,2720000010,LOCAL,0272,RC,,,,both,,,730.99,475.14,,,,,,,,,,,,,
HC Irradiation Service Charge,PX-3008694500,CDM,86945,CPT,0300,RC,,,,outpatient,,,364.00,236.60,,,,,,,,,,,,,
DEXAMETHASONE SODIUM PHOSPHATE 100 MG/10ML IJ SOLN,RX-125411,CDM,J1100,HCPCS,0636,RC,63323-0516-10,NDC,,both,0.5,ML,54.10,35.16,,,,,,,,,,,,,
PLATE BNE L422MM 20 H ST R CNDYL S STL LOK COMPR CRV FOR,SUP-2177093,CDM,C1713,HCPCS,0278,RC,,,,both,,,5111.79,3322.66,,,,,,,,,,,,,
TIP VITRCTMY CUT HI SPD DISP 25GA,SUP-2129350,CDM,2720000010,LOCAL,0272,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
HC Repr Smp Not Face 12.6-20cm,PX-4501200500,CDM,12005,CPT,0450,RC,,,,both,,,1216.00,790.40,,,,,,,,,,,,,
CURETTE CERV SZ 4 0 VIO ANG 254MM OVL CUP,SUP-2162120,CDM,2720000010,LOCAL,0272,RC,,,,both,,,687.00,446.55,,,,,,,,,,,,,
PI PICC 3-LUMEN: 6FRX55CM WITH 130CM SS,SUP-2826705,CDM,C1751,HCPCS,0278,RC,,,,both,,,342.89,222.88,,,,,,,,,,,,,
POSITIONER RADIOTHERAPY HYDRGEL SPCR SYN ABSRB DEL SYS,SUP-2124544,CDM,C1889,HCPCS,0278,RC,,,,both,,,10362.00,6735.30,,,,,,,,,,,,,
SHUNT CAR KT W/O RESVR N PROGRAMMABLE 8FR 13CM,SUP-2264222,CDM,C1713,HCPCS,0278,RC,,,,both,,,938.86,610.26,,,,,,,,,,,,,
HC So Assay Other Fluid Chorides,PX-3018243866,CDM,82438,CPT,0301,RC,,,,outpatient,,,32.00,20.80,,,,,,,,,,,,,
BASKET RETRV W10XL1150MM MIN WRK CHN 1.2MM 3 WIR FOR GRSP,SUP-2313148,CDM,2720000010,LOCAL,0272,RC,,,,both,,,703.99,457.59,,,,,,,,,,,,,
CONNECTOR SPNL THORLUM TI PARA SM STAT FOR 5MM ROD USS II,SUP-2193432,CDM,C1713,HCPCS,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
ANCHOR SUTURE WITH THREE NO 2 HI FI SUTURES WITH NEEDLES 5.0,SUP-2828569,CDM,C1713,HCPCS,0278,RC,,,,both,,,1157.03,752.07,,,,,,,,,,,,,
ELECTRODE LOOP 27FR WIRE DIA0.35MM BRN CUT ANG 1 STEM W/,SUP-2261182,CDM,2720000010,LOCAL,0272,RC,,,,both,,,629.04,408.88,,,,,,,,,,,,,
CLIP DYN STIM L,SUP-2310409,CDM,E0749,HCPCS,0278,RC,,,,both,,,989.10,642.91,,,,,,,,,,,,,
FIBER LSR FLEXIVA PULSE 242,SUP-2717687,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1244.29,808.79,,,,,,,,,,,,,
SCREW BNE L20MM DIA27MM LOK,SUP-2315954,CDM,C1713,HCPCS,0278,RC,,,,both,,,731.78,475.66,,,,,,,,,,,,,
SCREW INTFR L20MM DIA8MM TAPR 7.5-8.3MM KNEE CANN RND THRD,SUP-2341574,CDM,C1713,HCPCS,0278,RC,,,,both,,,687.66,446.98,,,,,,,,,,,,,
SPLINT WRST FA UNIV L 8 IN,SUP-2276643,CDM,L3809,HCPCS,0272,RC,,,,both,,,14.22,9.24,,,,,,,,,,,,,
SEALANT SURG 13 YR DURA AUTOSPRAY ADHERUS,SUP-2381862,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2437.64,1584.47,,,,,,,,,,,,,
BLADE SHAVER SMOOTH BITE 3.5MM,SUP-2659168,CDM,2720000010,LOCAL,0272,RC,,,,both,,,287.09,186.61,,,,,,,,,,,,,
PLATE BONE LG 20MMD TI LEGX2 SINGLE STERNAL TALON ST FOOT,SUP-2873680,CDM,C1713,HCPCS,0278,RC,,,,both,,,3464.96,2252.22,,,,,,,,,,,,,
GRAFT HUM TISS W35XL35MM THK1.5MM ACELLULAR DERM RM TEMP,SUP-2264600,CDM,Q4125,HCPCS,0636,RC,,,,both,,,5995.26,3896.92,,,,,,,,,,,,,
STEM VERSYS CEM/REV/CALCAR 13X170MM,SUP-2504507,CDM,C1776,CPT,0278,RC,,,,both,,,11366.80,7388.42,,,,,,,,,,,,,
NAIL IM L380MM DIA11MM UNIV FEM GRN TI AG RG CANN LOK SLOT,SUP-2192619,CDM,C1713,HCPCS,0278,RC,,,,both,,,5278.97,3431.33,,,,,,,,,,,,,
HEAD RAD DIA22MM CO CHROM W/ LOK SCR ALIGN,SUP-2340138,CDM,C1776,CPT,0278,RC,,,,both,,,7379.00,4796.35,,,,,,,,,,,,,
PACEMAKER CARD REVO MRI SURESCAN W 51 X H 45 MM D 8 MM 12.7,SUP-2282478,CDM,C1785,HCPCS,0275,RC,,,,both,,,11779.87,7656.92,,,,,,,,,,,,,
INTRODUCER TUBE CATH 8 FRX35 CM STIFFENING STYL INTUB FROVA,SUP-2760026,CDM,2720000010,LOCAL,0272,RC,,,,both,,,341.22,221.79,,,,,,,,,,,,,
COMPONENT PAT KINEMATIC KNEE IMPL L,SUP-2376465,CDM,C1776,CPT,0278,RC,,,,both,,,2138.34,1389.92,,,,,,,,,,,,,
GRAFT VASC IMPRA L 25 CM DIA19 MM EPTFE FLEXLG DIAMETER RING,SUP-2761436,CDM,C1768,CPT,0278,RC,,,,both,,,1922.97,1249.93,,,,,,,,,,,,,
HC Analyze/Program Spine Inf Pump,PX-5106236800,CDM,62368,CPT,0510,RC,,,,both,,,961.00,624.65,,,,,,,,,,,,,
ANCHOR SUT ORTHOCORD SZ 2 L36IN COMP BRAID CP-2 ARMED NDL,SUP-2249447,CDM,C1713,HCPCS,0278,RC,,,,both,,,3067.78,1994.06,,,,,,,,,,,,,
ELECTRODE DEFIB EMBLEM MRI L 45 CM SHFT DIA 7 FR DSTL TIP,SUP-2148624,CDM,C1896,HCPCS,0275,RC,,,,both,,,12230.30,7949.69,,,,,,,,,,,,,
SCREW SPNL DBL LD 4X36 MM THRD,SUP-2414777,CDM,C1713,HCPCS,0278,RC,,,,both,,,766.16,498.00,,,,,,,,,,,,,
GRAFT VASC HEMSHLD PLAT L 30 CM 8 MM POLYESTER BOV CLLGN STR,SUP-2265921,CDM,C1768,CPT,0278,RC,,,,both,,,1981.56,1288.01,,,,,,,,,,,,,
PROBE OPHTH DIA0.3MM S STL REUSE RITLENG,SUP-2224375,CDM,2720000010,LOCAL,0272,RC,,,,both,,,580.90,377.58,,,,,,,,,,,,,
SCREW BONE SELFTAPPING 2X10 MM CORTICAL HEXAGONAL HEAD STAIN,SUP-2836715,CDM,C1713,HCPCS,0278,RC,,,,both,,,242.00,157.30,,,,,,,,,,,,,
ANCHOR SUT 25MM LOOP VERSITOMIC G LOK,SUP-2366633,CDM,C1713,HCPCS,0278,RC,,,,both,,,1413.22,918.59,,,,,,,,,,,,,
HC Repeat Control Nosebleed,PX-4503090600,CDM,30906,CPT,0450,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
SAW SURG HOLE 5.4X48 3 MM 9 CM LG BOR MIDAS REX 8,SUP-2664884,CDM,2720000010,LOCAL,0272,RC,,,,both,,,473.01,307.46,,,,,,,,,,,,,
TAP SURGICAL RESORB-X 2.1MM 70MM 11MM ADJUSTMENT DRILL-FREE F/BOS EA,SUP-2681418,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1305.27,848.43,,,,,,,,,,,,,
Z DISCONTINUED USE 2903995 CATHETER GUID AD 7FR L100CM COR PERIPH ORNG NYL PTFE XB L,SUP-2158386,CDM,C1887,HCPCS,0272,RC,,,,both,,,112.10,72.86,,,,,,,,,,,,,
PROBE VITRCTMY 23GA ANT CHMBR CENTURION ULTRAVIT,SUP-2109971,CDM,2720000010,LOCAL,0272,RC,,,,both,,,690.58,448.88,,,,,,,,,,,,,
BARRIER AND CVR SZ 2 SORDEX OPTIME,SUP-2238672,CDM,C1713,HCPCS,0278,RC,,,,both,,,361.07,234.70,,,,,,,,,,,,,
SCREW BONE L36MM DIA4MM HEADLESS COMPRESSION,SUP-2633879,CDM,C1713,HCPCS,0278,RC,,,,both,,,992.24,644.96,,,,,,,,,,,,,
PLATE BNE L120MM 6 H RIG SPN FOR 45MM SCR L FRAG SYS,SUP-2411402,CDM,C1713,HCPCS,0278,RC,,,,both,,,703.77,457.45,,,,,,,,,,,,,
ALLOGRAFT HUM TISS ACHILLES TEND PRESHAPED,SUP-2321866,CDM,C1713,HCPCS,0278,RC,,,,both,,,15386.00,10000.90,,,,,,,,,,,,,
PILLAR EXT FIX L 120 MM THRD MONK RING,SUP-2899190,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1467.95,954.17,,,,,,,,,,,,,
KIT PRSS MON ICP MICROSENSOR BASIC FOR SUBDURAL,SUP-2243820,CDM,C1713,HCPCS,0278,RC,,,,both,,,3092.90,2010.38,,,,,,,,,,,,,
BLADE BLUNT 20MM MIS W/SHTH AND TUBE SET NEXUS,SUP-2716354,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2321.46,1508.95,,,,,,,,,,,,,
FELT SURG W1XL1IN THK1.65MM SQ PTFE STRL,SUP-2126674,CDM,C1781,HCPCS,0278,RC,,,,both,,,186.96,121.52,,,,,,,,,,,,,
COMPONENT FEM SZ 6 R REV POST STBL GMK,SUP-2267613,CDM,C1776,CPT,0278,RC,,,,both,,,19866.78,12913.41,,,,,,,,,,,,,
INTRODUCER SHTH FLPY TIP 0.021 IN 6 FRX11 CM 21 GAX4 CM,SUP-2430074,CDM,C1893,HCPCS,0272,RC,,,,both,,,184.63,120.01,,,,,,,,,,,,,
MESH GYN POLYPR ULT LTWT SMARTMESH TECHNOLOGY FOR POST PELV,SUP-2165312,CDM,C1781,HCPCS,0278,RC,,,,both,,,4819.90,3132.93,,,,,,,,,,,,,
"HC So1 Enzyme Activity,Cells/Tissue",PX-3018265767,CDM,82657,CPT,0301,RC,,,,both,,,53.00,34.45,,,,,,,,,,,,,
IMPLANT HUM TISS L 7 X W 7 CM PLCNTA MEMBRN MTRX FLX FOR WND,SUP-2905483,CDM,Q4151,HCPCS,0636,RC,,,,both,,,22620.06,14703.04,,,,,,,,,,,,,
CATHETER SUPP 3.1FR L90CM DIA0.050X0.063IN 0.035IN GWIRE,SUP-2353128,CDM,C1887,HCPCS,0272,RC,,,,both,,,501.52,325.99,,,,,,,,,,,,,
ROD SPNL STR PRECUT TI OD3.5MM L125MM VAIL,SUP-2415753,CDM,C1713,HCPCS,0278,RC,,,,both,,,1287.40,836.81,,,,,,,,,,,,,
ALLOGRAFT HUM TISS WHL BTB FRZN NO-RAD,SUP-2321841,CDM,C1762,CPT,0278,RC,,,,both,,,10974.30,7133.29,,,,,,,,,,,,,
LINER ACET OD48-52MM ID28MM 10DEG TOT UHMWPE PFC,SUP-2253281,CDM,C1776,CPT,0278,RC,,,,both,,,2696.63,1752.81,,,,,,,,,,,,,
PLATE FUSION VA LCK 2.4/2.7MM 2H TI STRL,SUP-2546996,CDM,C1713,HCPCS,0278,RC,,,,both,,,2981.81,1938.18,,,,,,,,,,,,,
PLATE BONE 15 H ANAT FIBULAR ANK L SHP GORILLA,SUP-2321565,CDM,C1713,HCPCS,0278,RC,,,,both,,,5484.01,3564.61,,,,,,,,,,,,,
BIT DRILL CALIBRATED 4.2MM EXTRA LONG,SUP-2739157,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2454.16,1595.20,,,,,,,,,,,,,
GRAFT HUM TISS L W13XL22CM THK07 14MM THN ACELLULAR,SUP-2307616,CDM,Q4128,HCPCS,0636,RC,,,,both,,,30573.08,19872.50,,,,,,,,,,,,,
PLATE BNE L145MM 8 H NONSTERILE L PROX TIB S STL,SUP-2185701,CDM,C1713,HCPCS,0278,RC,,,,both,,,3734.09,2427.16,,,,,,,,,,,,,
BIO MEDICUS 17FR,SUP-2726347,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1023.58,665.33,,,,,,,,,,,,,
OCCLUDER CV 14X33 MM STENT GRFT LP W/ DEL SYS TALENT,SUP-2429838,CDM,C1768,CPT,0278,RC,,,,both,,,7771.50,5051.47,,,,,,,,,,,,,
LINER ACET ECC 32X66 MM HIP,SUP-2202296,CDM,C1776,CPT,0278,RC,,,,both,,,3486.78,2266.41,,,,,,,,,,,,,
PIN EXT FIX L95MM DIA4MM THRD L30MM SH ORTH RECON HALF S,SUP-2342905,CDM,C1713,HCPCS,0278,RC,,,,both,,,855.87,556.32,,,,,,,,,,,,,
MATRIX BIO L 12 X W 8 CM FET BOV DERM IONIC SLV DERMAL SLD,SUP-2909232,CDM,Q4110,HCPCS,0636,RC,,,,both,,,10399.68,6759.79,,,,,,,,,,,,,
CANNULA VOID FIL DEL L 450 MM DIA 7.8 MM ERGO T HNDL UNIV LL,SUP-2893104,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3124.30,2030.79,,,,,,,,,,,,,
BUR SURG DIA3MM NEURO PRECIS,SUP-2365188,CDM,2720000010,LOCAL,0272,RC,,,,both,,,375.26,243.92,,,,,,,,,,,,,
SCREW BNE CANC 6.5X35 MM FT TI NS ISO,SUP-2460481,CDM,C1713,HCPCS,0278,RC,,,,both,,,73.79,47.96,,,,,,,,,,,,,
AWL SURG SQ TAPR,SUP-2934604,CDM,2720000010,LOCAL,0272,RC,,,,both,,,697.08,453.10,,,,,,,,,,,,,
INTRODUCER INFUSION PMP 23 FR KT SHTH INSRTN DIL IMPELLA RP,SUP-2431909,CDM,C1894,HCPCS,0272,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
PLATE BNE L100MM 5 H T SHP FOR 45MM SCR L FRAG SYS,SUP-2411392,CDM,C1713,HCPCS,0278,RC,,,,both,,,620.97,403.63,,,,,,,,,,,,,
PLATE L 2.4MM 2H,SUP-2843930,CDM,C1713,HCPCS,0278,RC,,,,both,,,2182.30,1418.49,,,,,,,,,,,,,
GLYBURIDE 5 MG PO TABS,RX-3489,CDM,6370000000,HCPCS,0637,RC,00093-8344-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
GUIDEWIRE UROLOGICAL STR 0.038 IN X150 CM MOVABLE COR FLX,SUP-2500963,CDM,C1769,HCPCS,0272,RC,,,,both,,,84.37,54.84,,,,,,,,,,,,,
BIT DRL L91MM DIA1.9MM STP 35MM TWST QUIK NONRADIOLUCENT,SUP-2267850,CDM,2720000010,LOCAL,0272,RC,,,,both,,,306.46,199.20,,,,,,,,,,,,,
NUT SPINE BRK OFF SACR FIX ANTR SPNL SYS TI COLORADO 2,SUP-2290606,CDM,C1713,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
PLATE BNE L148MM 8 H T SHP FOR 45MM SCR L FRAG SYS,SUP-2411409,CDM,C1713,HCPCS,0278,RC,,,,both,,,931.45,605.44,,,,,,,,,,,,,
KIT CATH L16CM DIA8FR CTRL VEN POLYUR DBL LUMN NONTUNNELED,SUP-2120583,CDM,C1751,HCPCS,0278,RC,,,,both,,,133.14,86.54,,,,,,,,,,,,,
CATHETER PH MON INF 6FR 0CM PH CHAN W/ 7 IMPED RNG DISP ZNIS,SUP-2227938,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3567.04,2318.58,,,,,,,,,,,,,
SYSTEM GRFT PREP 30MM LNG WHT W HI STRENGTH SUT FOR KNEE,SUP-2256712,CDM,2720000010,LOCAL,0272,RC,,,,both,,,305.37,198.49,,,,,,,,,,,,,
NAIL IM L360MM DIA10MM R FEM PIRIFORMIS FOSSA ENTRY LT GRN,SUP-2180374,CDM,C1713,HCPCS,0278,RC,,,,both,,,5684.44,3694.89,,,,,,,,,,,,,
PLATE BONE 32MML STNLSS STEEL L SHPD RIGHT F/2.7MM SCREW MIN,SUP-2493338,CDM,C1713,HCPCS,0278,RC,,,,both,,,173.89,113.03,,,,,,,,,,,,,
BEVACIZUMAB 25 MG/ML IV SOLN (MIXTURES ONLY),RX-1150416,CDM,J9035,HCPCS,0636,RC,50242-0060-01,NDC,,both,4,ML,2295.20,1491.88,,,,,,,,,,,,,
NAIL LONG LEFT D 10X340 MM,SUP-2854225,CDM,C1713,HCPCS,0278,RC,,,,both,,,8888.02,5777.21,,,,,,,,,,,,,
IMPLANT OP RM LAPIDUS PLT 5 AND 8MM GRA,SUP-2321487,CDM,C1713,HCPCS,0278,RC,,,,both,,,4074.15,2648.20,,,,,,,,,,,,,
TRAY CATH MIDLN POWERMIDLINE 3FR 20CM 1 LUMAN RVRSE TAPR PWR P4153108,SUP-2613515,CDM,C1751,HCPCS,0278,RC,,,,both,,,357.96,232.67,,,,,,,,,,,,,
SPHERE GLEN DIA41MM +6MM OFFSET CO CHROM SHLDR REV SYS,SUP-2404724,CDM,C1776,CPT,0278,RC,,,,both,,,4703.72,3057.42,,,,,,,,,,,,,
HC Peripheral Block - Peribulbar or Retrobulbar,PX-3606750000,CDM,67500,CPT,0360,RC,,,,both,,,920.00,598.00,,,,,,,,,,,,,
PLATE BONE 4 HOLE 2X24 MM SAGITTAL SPLIT STRAIGHT TITANIUM,SUP-2838397,CDM,C1713,HCPCS,0278,RC,,,,both,,,995.69,647.20,,,,,,,,,,,,,
PLATE BNE W6.3XL49MM THK1.6MM -90DEG 2X4 H DST RAD VOLAR S,SUP-2186111,CDM,C1713,HCPCS,0278,RC,,,,both,,,1715.29,1114.94,,,,,,,,,,,,,
PLATE BONE L97MM 8 H RT SUP MEDL CLAV LCK FOR 3.5MM SCR,SUP-2348753,CDM,C1713,HCPCS,0278,RC,,,,both,,,6441.87,4187.22,,,,,,,,,,,,,
INSERT HUM REVERSED 7.5 DEG 42X+9 MM SHLDR RETENTIVE TI,SUP-2421801,CDM,C1776,CPT,0278,RC,,,,both,,,5270.49,3425.82,,,,,,,,,,,,,
CATHETER ANGIOPLSTY AVTR L 142 CM BALLOON L 20 MM DIA 4 MM,SUP-2156427,CDM,C1725,HCPCS,0272,RC,,,,both,,,166.42,108.17,,,,,,,,,,,,,
SPHINCTEROTOME ENDOSCP CANN 3.9 FRX260 CM 0.025 IN JAGTOME,SUP-2420156,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1303.07,847.00,,,,,,,,,,,,,
CATHETER OPHTH BLLN L15MM DIA3MM BILAT DCP LACRICATH,SUP-2330966,CDM,C1726,HCPCS,0272,RC,,,,both,,,914.93,594.70,,,,,,,,,,,,,
MARKER BRST BX 8GA BOWTIE SHP MAMTOM,SUP-2195651,CDM,A4648,CPT,0278,RC,,,,both,,,358.27,232.88,,,,,,,,,,,,,
MICONAZOLE NITRATE 2 % EX POWD,RX-10599,CDM,2500000003,HCPCS,0250,RC,00316-0225-30,NDC,,both,85,GR,24.90,16.18,,,,,,,,,,,,,
GRAFT DERM HUM TISS HYDRATED THCK ACELLULAR DERM IMPL,SUP-2307459,CDM,Q4128,HCPCS,0636,RC,,,,both,,,2315.81,1505.28,,,,,,,,,,,,,
PLATE BONE SM L25MM 3 H S STL STR ECT,SUP-2198581,CDM,C1713,HCPCS,0278,RC,,,,both,,,215.47,140.06,,,,,,,,,,,,,
CATHETER THROMCTMY FETCH ASPIR STRL,SUP-2277426,CDM,C1729,HCPCS,0272,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
COIL EMB L10CM OD0.020IN LOOP OD6MM STD NIT COMPLX FRME,SUP-2323359,CDM,C1889,HCPCS,0278,RC,,,,both,,,7065.00,4592.25,,,,,,,,,,,,,
IMMOBILIZER SHLDR SLNG L,SUP-2276606,CDM,L3660,HCPCS,0274,RC,,,,both,,,10.80,7.02,,,,,,,,,,,,,
PLATE BONE L48MM 3 H T SHP LCK 2 HD FOR 3.5MM SCR,SUP-2318679,CDM,C1713,HCPCS,0278,RC,,,,both,,,1737.74,1129.53,,,,,,,,,,,,,
SHEATH URO 11 13FRX38CM UROPS,SUP-2312756,CDM,C1894,HCPCS,0272,RC,,,,both,,,2243.78,1458.46,,,,,,,,,,,,,
CATHETER THOR 24FR L22IN PVC 5 EYELET STR ATRAUM,SUP-2227431,CDM,C1729,HCPCS,0272,RC,,,,both,,,22.95,14.92,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.522,SUP-2860039,CDM,C1713,HCPCS,0278,RC,,,,both,,,39174.95,25463.72,,,,,,,,,,,,,
PLATE BNE L78MM BLDE W5.8XL38MM 130DEG 4 H NONSTERILE BILAT,SUP-2186597,CDM,C1713,HCPCS,0278,RC,,,,both,,,1579.11,1026.42,,,,,,,,,,,,,
HC NM Kidney Image W/O Pharmacologic,PX-3417870700,CDM,78707,CPT,0341,RC,,,,both,,,2078.00,1350.70,,,,,,,,,,,,,
BRACE LUMBAR TLSO BODY JACKET,SUP-2388144,CDM,L0486,HCPCS,0274,RC,,,,both,,,5013.48,3258.76,,,,,,,,,,,,,
SPLINT ORTHOPEDIC PADDED LG 9X4.5 IN LT PRE MOLD PROCARE,SUP-2196717,CDM,L3809,HCPCS,0274,RC,,,,both,,,13.69,8.90,,,,,,,,,,,,,
WAND ARTHSCP 90DEG ABLAT COBLATION MEGAVAC AMBIENT,SUP-2342009,CDM,2720000010,LOCAL,0272,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
STENT BILI XPERT L 40 MM DIA 4 MM DEL SYS L 135 CM INTRO 4,SUP-2105963,CDM,C1876,HCPCS,0278,RC,,,,both,,,6908.00,4490.20,,,,,,,,,,,,,
BIT DRL CANN 6 MM 4.5 MM CALIB FOR 6.5 MM HDLSS COMPR SCREW,SUP-2863414,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1035.92,673.35,,,,,,,,,,,,,
PLUG ORTH THRD 3.5 MM STARDRV NS LCP,SUP-2863373,CDM,C1713,HCPCS,0278,RC,,,,both,,,298.96,194.32,,,,,,,,,,,,,
HEAD FEM ADV MTL W/BFH TECHNOLOGY 52MM LNG A CLASS,SUP-2304512,CDM,C1776,CPT,0278,RC,,,,both,,,9694.75,6301.59,,,,,,,,,,,,,
CATHETER CV KT AD 14 GAX16 CM SINGLE LUMEN N TUNNELED,SUP-2763391,CDM,C1751,HCPCS,0278,RC,,,,both,,,69.71,45.31,,,,,,,,,,,,,
BUR SURG ACORN 6X7.7 MM 7 CM FLUT SM BOR LEGEND MEDNEXT,SUP-2630994,CDM,2720000010,LOCAL,0272,RC,,,,both,,,314.38,204.35,,,,,,,,,,,,,
PLATE BNE L 112 MM SCREW DIA 3.5/4.5 MM 1 H SS RT,SUP-2931280,CDM,C1713,HCPCS,0278,RC,,,,both,,,20110.92,13072.10,,,,,,,,,,,,,
PROX ULNAR PLT PROV RT,SUP-2724312,CDM,C1713,HCPCS,0278,RC,,,,both,,,1666.27,1083.08,,,,,,,,,,,,,
INTRODUCER IV CATH NEOMAGIC L 40 CM CATH 1.9 FR SIL PICC 1,SUP-2874154,CDM,C1751,HCPCS,0278,RC,,,,both,,,212.89,138.38,,,,,,,,,,,,,
BIT DRL L300MM DIA4.3MM QUIK CPL PERC CALIB W/O STP REUSE,SUP-2187852,CDM,2720000010,LOCAL,0272,RC,,,,both,,,515.02,334.76,,,,,,,,,,,,,
SLIDER SPINE DEV TI GIC54,SUP-2293363,CDM,2780000010,LOCAL,0278,RC,,,,both,,,358.09,232.76,,,,,,,,,,,,,
TI TOMOFIX MEDIAL DISTAL FEMUR PL/4 HOLES/RIGHT-STERILE,SUP-2546832,CDM,C1713,HCPCS,0278,RC,,,,both,,,3846.44,2500.19,,,,,,,,,,,,,
NAIL IM L200MM DIA4.8MM FEM HIP S STL CANN NONLOCKING RUSH,SUP-2362427,CDM,C1713,HCPCS,0278,RC,,,,both,,,671.18,436.27,,,,,,,,,,,,,
CATHETER CRICOTHYROTOMY SET 5X7.2 MMX9 CM EMGCY CUF MELK,SUP-2759806,CDM,C1769,HCPCS,0272,RC,,,,both,,,623.60,405.34,,,,,,,,,,,,,
DEVICE PESSARY CUBE 4 DRN,SUP-2119333,CDM,A4562,HCPCS,0274,RC,,,,both,,,103.49,67.27,,,,,,,,,,,,,
SCREW BNE L4MM DIA2MM MAND CRANIOMAXILLOFACIAL GRN ST MINI 5PK,SUP-2366138,CDM,C1713,HCPCS,0278,RC,,,,both,,,199.67,129.79,,,,,,,,,,,,,
SPEEDGUIDE DRILL AO 20MM 70MM,SUP-2704787,CDM,2720000010,LOCAL,0272,RC,,,,both,,,868.21,564.34,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.537,SUP-2860054,CDM,C1713,HCPCS,0278,RC,,,,both,,,48778.02,31705.71,,,,,,,,,,,,,
GRAFT STENT 6X15 MM HEPARIN,SUP-2396648,CDM,C1874,HCPCS,0278,RC,,,,both,,,11837.80,7694.57,,,,,,,,,,,,,
HC Declotting Central Vad,PX-3613659300,CDM,36593,CPT,0361,RC,,,,outpatient,,,1120.00,728.00,,,,,,,,,,,,,
TUBE ENDOTRACHEAL L 34 CM OD 11 MM ID 7.5 MM SIL DUALCUFF,SUP-2891629,CDM,2720000010,LOCAL,0272,RC,,,,both,,,796.84,517.95,,,,,,,,,,,,,
BUR SURG RND LNG 1.5X1.5 MM 48 MM 6 FLUT OTO SS,SUP-2761063,CDM,2720000010,LOCAL,0272,RC,,,,both,,,348.67,226.64,,,,,,,,,,,,,
CUBE EXT FIX 1 H S STL RANCHO FOR ILIZ TAY SPAT FRME EXT,SUP-2342332,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1084.30,704.79,,,,,,,,,,,,,
COMPONENT ARTC SURF TIB 5-6 EF 14 MM KNEE GRN NXGN LPS,SUP-2208735,CDM,C1776,CPT,0278,RC,,,,both,,,1381.60,898.04,,,,,,,,,,,,,
HC N Block Paravert Thoracic 3+,PX-3606449200,CDM,64492,CPT,0360,RC,,,,both,,,3113.00,2023.45,,,,,,,,,,,,,
TITANIUM MESH TRAY SYMPHYSIS MANDIBLE CP TITANIUM,SUP-2669724,CDM,C1713,HCPCS,0278,RC,,,,both,,,6533.40,4246.71,,,,,,,,,,,,,
PLATE BNE T 4.5X199 MM 10 HOLE LCP,SUP-2569412,CDM,C1713,HCPCS,0278,RC,,,,both,,,694.25,451.26,,,,,,,,,,,,,
CATHETER BLLN DIL L17MM DIA6MM FRONTAL EM SKR NUVENT,SUP-2284114,CDM,C1726,HCPCS,0272,RC,,,,both,,,3389.00,2202.85,,,,,,,,,,,,,
CATHETER HD STR 20 CM 15 CM SINGLE VLV BASIC KT BIOFLO,SUP-2457748,CDM,C1750,HCPCS,0278,RC,,,,both,,,1089.58,708.23,,,,,,,,,,,,,
GRAFT EVAR L70MM DIA28X28MM C DST DSGN FOR ABD AORT ANEUR,SUP-2295272,CDM,C1768,CPT,0278,RC,,,,both,,,23785.50,15460.57,,,,,,,,,,,,,
STEM HUM OD8MM HYDROXYAPETITE SHLDR IMPL REUNION,SUP-2379010,CDM,C1776,CPT,0278,RC,,,,both,,,14157.63,9202.46,,,,,,,,,,,,,
DRESSING BIO 300 SQ CM FISH SKIN MESHED 21 STRL DISP,SUP-2909183,CDM,Q4158,HCPCS,0636,RC,,,,both,,,35748.90,23236.78,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 280 MM DIA15 MM DEL SHTH 49ML,SUP-2937085,CDM,C1713,HCPCS,0278,RC,,,,both,,,15778.50,10256.02,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 45 CM DIA 5-8 MM SHRT TAPR SLDE GDS,SUP-2525447,CDM,C1768,CPT,0278,RC,,,,both,,,1124.94,731.21,,,,,,,,,,,,,
DEVICE PESSARY SZ 2 RNG W KNOB AND SUPP,SUP-2305664,CDM,A4562,HCPCS,0272,RC,,,,both,,,200.05,130.03,,,,,,,,,,,,,
MESH SURG W6XL8IN OMEGA 3 FATTY ACIDS NAT BIORESORBABLE,SUP-2265966,CDM,C1781,HCPCS,0278,RC,,,,both,,,2163.46,1406.25,,,,,,,,,,,,,
DRILL SURG STR 55 MM INTERCONTINENTAL,SUP-2585621,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1491.50,969.47,,,,,,,,,,,,,
PLATE BNE SQ MINI 2X0.6 MM 3X2 HOLE FOR SCREW TI NS LEVEL 1,SUP-2472563,CDM,C1713,HCPCS,0278,RC,,,,both,,,701.04,455.68,,,,,,,,,,,,,
PLATE SPNL 5.5X30-34 MM SS CROSSLINK MULTI-SPAN,SUP-2630569,CDM,C1713,HCPCS,0278,RC,,,,both,,,5071.10,3296.21,,,,,,,,,,,,,
PASSER SUTURE ERGO DESIGN 150 MM LT SS NS REUSE,SUP-2762075,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4898.40,3183.96,,,,,,,,,,,,,
HEAD FEM SZ 38MM CO CHROM ALLOY HIP RESURF CEM RECAP,SUP-2409290,CDM,C1776,CPT,0278,RC,,,,both,,,10126.50,6582.22,,,,,,,,,,,,,
GRAFT VASC HEMSHLD VANTAGE L 40 CM DIA 7 MM POLYESTER BOV,SUP-2266060,CDM,C1768,CPT,0278,RC,,,,both,,,1291.11,839.22,,,,,,,,,,,,,
KIT CATH 2 LUMN 7 F,SUP-2120581,CDM,C1751,HCPCS,0278,RC,,,,both,,,119.32,77.56,,,,,,,,,,,,,
ACCESS KIT ECHO ENHANCED TIP MINI 5 FRX10 CM COAX INTRO MAX,SUP-2303004,CDM,C1894,HCPCS,0272,RC,,,,both,,,76.46,49.70,,,,,,,,,,,,,
PLATE BNE TBLR 2.7X65 MM 8 HOLE 1/4 SS,SUP-2536111,CDM,C1713,HCPCS,0278,RC,,,,both,,,433.01,281.46,,,,,,,,,,,,,
SHEATH NEPHSTMY L17CM DIA10MM RENAL ACCS BVL END GWIRE NOTCH,SUP-2126726,CDM,C1894,HCPCS,0272,RC,,,,both,,,124.75,81.09,,,,,,,,,,,,,
SYSTEM OCCL DEL L80CM SHTH 6FR 180DEG CRV EXCHG WIRE HEMSTAS,SUP-2355719,CDM,C1713,HCPCS,0278,RC,,,,both,,,2152.03,1398.82,,,,,,,,,,,,,
CATHETER ETER DRNGE 038IN LOK LOOP MULT PURP GWIRE 5 SIDEPRT,SUP-2168355,CDM,C1713,HCPCS,0278,RC,,,,both,,,320.12,208.08,,,,,,,,,,,,,
KIT LD L60CM TIP 3MM ELECTRD 4MM SPC 8 ELECTRD,SUP-2356726,CDM,C1778,HCPCS,0278,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
WIRE SURG BLNT 0.64X160 MM 22 GA KNEE LIG,SUP-2361096,CDM,C1713,HCPCS,0278,RC,,,,both,,,53.57,34.82,,,,,,,,,,,,,
BLOCK CUT TIB,SUP-2392667,CDM,2720000010,LOCAL,0272,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
COLLAR CERV PROGLIDE UNIV,SUP-2276573,CDM,L0172,HCPCS,0272,RC,,,,both,,,219.55,142.71,,,,,,,,,,,,,
CATHETER EP 5FR L100CM 5MM SPC TIP 5MM DIAG MAP F CRV QPLR,SUP-2140168,CDM,C1730,HCPCS,0272,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
STEM FEM REV 0+ MM LNG 19 MM LT HIP POLISHED BOW EMPERION,SUP-2434543,CDM,C1776,CPT,0278,RC,,,,both,,,14293.28,9290.63,,,,,,,,,,,,,
LEAD PACE UPLR/BPLR 80 CM 2 ELECTRD PASS FIX IS-1 EASYTRAK 2,SUP-2148690,CDM,C1900,HCPCS,0275,RC,,,,both,,,3617.28,2351.23,,,,,,,,,,,,,
DRILL SURG DIA11MM DISK DISP FOR ULTRASONIC REV SYS UDRV 3,SUP-2408564,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1227.80,798.07,,,,,,,,,,,,,
CATHETER PICC ARROW TAPERFREE 5FR 55CM 2-LUMEN,SUP-2887046,CDM,C1751,HCPCS,0278,RC,,,,both,,,571.48,371.46,,,,,,,,,,,,,
GUIDEWIRE ORTH L6IN DIA1.6MM PART THRD TIP FOR CANN SCR,SUP-2410065,CDM,2720000010,LOCAL,0272,RC,,,,both,,,51.75,33.64,,,,,,,,,,,,,
SCREW BNE L50MM DIA3.5MM PROX FEM CANN T15 HEXALOBE PEDILOC,SUP-2318568,CDM,C1713,HCPCS,0278,RC,,,,both,,,1548.02,1006.21,,,,,,,,,,,,,
HOOK SPNL BLDE W5.5MM BILAT TI TRNSVRS PROC OFFSET OPN REDUC,SUP-2254442,CDM,C1713,HCPCS,0278,RC,,,,both,,,3171.40,2061.41,,,,,,,,,,,,,
SHUNT PERI 7FR 90CM M SM W O RESVR CSF ASSEMB FLOW CTRL VLV,SUP-2278386,CDM,C1889,HCPCS,0278,RC,,,,both,,,2447.66,1590.98,,,,,,,,,,,,,
IMPLANT ANK FT TARSOMETATARSAL STD FUSION REFLX HYBRID,SUP-2897071,CDM,C1713,HCPCS,0278,RC,,,,both,,,7532.86,4896.36,,,,,,,,,,,,,
BLADE REPROC SAW MAKO NARROW 2MM,SUP-2653056,CDM,2720000010,LOCAL,0272,RC,,,,both,,,214.96,139.72,,,,,,,,,,,,,
DEVICE SUT QUIK LOAD PK COR-KNOT,SUP-2265302,CDM,2720000010,LOCAL,0272,RC,,,,both,,,894.90,581.68,,,,,,,,,,,,,
BIT DRL OVR T6 2X122 MM 2 MM FOR SCR VARIAX,SUP-2613647,CDM,2720000010,LOCAL,0272,RC,,,,both,,,913.74,593.93,,,,,,,,,,,,,
HC Nursery Level I R&B,PX-1710000000,CDM,1710000000,LOCAL,0171,RC,,,,inpatient,,,4500.00,2925.00,,,,,,,,,,,,,
HC Wound Vac >50 Sq Cm Dme,PX-7619760600,CDM,97606,CPT,0761,RC,,,,both,,,461.00,299.65,,,,,,,,,,,,,
RAMUS TRNSPRT DVCE 20MM MDDLE DRVN BODY WTWO PLTS T 6L 4V,SUP-2669790,CDM,C1713,HCPCS,0278,RC,,,,both,,,16971.89,11031.73,,,,,,,,,,,,,
SUPPORT ORTHOT HND FNGR STRP W/O JT PREFABRICATED INTFACE,SUP-2435783,CDM,L3924,HCPCS,0274,RC,,,,both,,,248.88,161.77,,,,,,,,,,,,,
HC Cta Upper Extremity W & W/O Cont,PX-3527320600,CDM,73206,CPT,0352,RC,,,,outpatient,,,2630.00,1709.50,,,,,,,,,,,,,
PIN BNE FIX DIA5MM LOK LNR S-ROM,SUP-2253106,CDM,C1713,HCPCS,0278,RC,,,,both,,,404.43,262.88,,,,,,,,,,,,,
BIT DRL L145MM DIA4.2MM ST 3 FLUT NDL PNT QUIK CPL FOR FEM,SUP-2178879,CDM,2720000010,LOCAL,0272,RC,,,,both,,,641.35,416.88,,,,,,,,,,,,,
GUIDEWIRE VASC ROTAWIRE WIRECLIP L 325 CM DIA 0.014 IN FLPY,SUP-2140975,CDM,C1769,HCPCS,0272,RC,,,,both,,,584.98,380.24,,,,,,,,,,,,,
IMMOBILIZER KNEE WRP II W PAT UNIV,SUP-2196844,CDM,L1810,HCPCS,0272,RC,,,,both,,,40.47,26.31,,,,,,,,,,,,,
BOLT IM L38MM DIA4.9MM GRN TI SELF CUT TRCR TIP LOK FULL,SUP-2192383,CDM,C1713,HCPCS,0278,RC,,,,both,,,562.09,365.36,,,,,,,,,,,,,
DRESSING BIO 95 SQ CM FISH SKIN MIC STRL DISP SURGICLOSE,SUP-2909165,CDM,Q4158,HCPCS,0636,RC,,,,both,,,12858.30,8357.89,,,,,,,,,,,,,
COLLAR CERV TRACHEOTOMY LG AD 3.25 IN 16-19 IN PHILADELPHIA,SUP-2319293,CDM,L0172,HCPCS,0274,RC,,,,both,,,39.60,25.74,,,,,,,,,,,,,
GUIDEWIRE ORTH TROCAR PT 1 END 0.062X8 IN ACUTRK 2,SUP-2657754,CDM,C1769,HCPCS,0272,RC,,,,both,,,47.10,30.61,,,,,,,,,,,,,
SCREW FIX L190MM DIA6MM S STL SPADE PNT MR CONDITIONAL FOR,SUP-2186962,CDM,C1713,HCPCS,0278,RC,,,,both,,,242.31,157.50,,,,,,,,,,,,,
PLATE BNE L103MM 6 H BILAT S STL BROAD LO PROF RIG DYN,SUP-2185272,CDM,C1713,HCPCS,0278,RC,,,,both,,,1081.51,702.98,,,,,,,,,,,,,
GRAFT CANC CUBE 30CC,SUP-2115982,CDM,C1713,HCPCS,0278,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
PLATE BNE CONTOURED LT SUBMUSCULAR 14 HOLE SMPLE,SUP-2490494,CDM,C1713,HCPCS,0278,RC,,,,both,,,4125.96,2681.87,,,,,,,,,,,,,
BRACE LS M FOR 35 41IN HIP COT POLYAMIDE LYCRA AVG SUPP 2,SUP-2325578,CDM,L0625,HCPCS,0272,RC,,,,both,,,207.81,135.08,,,,,,,,,,,,,
TIB RET CCK 58WX15HGT,SUP-2199948,CDM,C1776,CPT,0278,RC,,,,both,,,5963.49,3876.27,,,,,,,,,,,,,
SET NDL DISCOGRAM FOR PAIN MGMT DOCKING,SUP-2353382,CDM,C1713,HCPCS,0278,RC,,,,both,,,1805.50,1173.57,,,,,,,,,,,,,
CATHETER HD STR EXTN 13.5 FRX16 CM DL HI FLO MAHRK ELITE,SUP-2626876,CDM,C1752,HCPCS,0278,RC,,,,both,,,209.75,136.34,,,,,,,,,,,,,
SROM NRH TIB PLAT ASSY SM 12MM,SUP-2515637,CDM,C1776,CPT,0278,RC,,,,both,,,8479.26,5511.52,,,,,,,,,,,,,
BRACE THMB IP TO WR CREASE UP TO 3 3/4INXSM COLLUM CMC REG,SUP-2324972,CDM,L3931,HCPCS,0274,RC,,,,both,,,70.08,45.55,,,,,,,,,,,,,
PLANER BONE 8MM,SUP-2419452,CDM,2720000010,LOCAL,0272,RC,,,,both,,,648.41,421.47,,,,,,,,,,,,,
TITANIUM 3D MESH 120MM X 120MM 10MM 15MM SSTM CP TTNM,SUP-2681440,CDM,C1713,HCPCS,0278,RC,,,,both,,,7459.57,4848.72,,,,,,,,,,,,,
GRAFT HUM TISS SZ >80CM SAPH VEIN CRYOPRESERVED ANGIOGRFT,SUP-2264714,CDM,C1762,CPT,0278,RC,,,,both,,,34569.92,22470.45,,,,,,,,,,,,,
SPLINT ORTHOPEDIC MED LT MTCRPL,SUP-2124892,CDM,L3808,HCPCS,0272,RC,,,,both,,,32.97,21.43,,,,,,,,,,,,,
SLEEVE SURG THRD,SUP-2484449,CDM,C1713,HCPCS,0278,RC,,,,both,,,1469.65,955.27,,,,,,,,,,,,,
EXPANDER BRST 375CC W12XH12CM P6.4CM SIL TEXT HI PROF,SUP-2301031,CDM,C1889,HCPCS,0278,RC,,,,both,,,6248.60,4061.59,,,,,,,,,,,,,
CATHETER INFUSION OCCL 5 FRX135 CM 30 CM 1 CC 20 CC FOUNTAIN,SUP-2302568,CDM,C1751,HCPCS,0278,RC,,,,both,,,262.82,170.83,,,,,,,,,,,,,
PLATE BNE L 14 MM THK 0.6 MM 4 H SCREW DIA1. 5 MM MED TI,SUP-2883917,CDM,C1713,HCPCS,0278,RC,,,,both,,,524.38,340.85,,,,,,,,,,,,,
PEG BONE FIX L ANG SUBTALAR IMP STA-PEG,SUP-2397148,CDM,C1713,HCPCS,0278,RC,,,,both,,,4835.60,3143.14,,,,,,,,,,,,,
GUIDEWIRE UROLOGICAL ULTRATRACK L 150 CM 0.038IN ANGLED TAPR,SUP-2539338,CDM,C1769,HCPCS,0272,RC,,,,both,,,128.24,83.36,,,,,,,,,,,,,
TRUSS ANK OSTEOTMY 22X18X5.5 MM 10D SYS,SUP-2101136,CDM,C1713,HCPCS,0278,RC,,,,both,,,11088.75,7207.69,,,,,,,,,,,,,
CATHETER ANGIO MARINER L 130 CM DIA 5 FR 0.035 IN H1 BRAIDED,SUP-2118115,CDM,C1887,HCPCS,0272,RC,,,,both,,,254.72,165.57,,,,,,,,,,,,,
PACK BTTRY FOR PWR SCRDRVR QUICKDRIVE MINI,SUP-2366439,CDM,C1713,HCPCS,0278,RC,,,,both,,,644.52,418.94,,,,,,,,,,,,,
PLATE BNE L 1.71 IN MED TI ALLOY LT FT STBL LP LISFRANC NS,SUP-2912912,CDM,C1713,HCPCS,0278,RC,,,,both,,,6236.04,4053.43,,,,,,,,,,,,,
PERTUZUMAB 420 MG/14ML IV SOLN,RX-116751,CDM,J9306,HCPCS,0636,RC,50242-0145-01,NDC,,both,14,ML,19643.10,12768.01,,,,,,,,,,,,,
EVOS 1.8MMX26MM LOCKING PEG T7,SUP-2819366,CDM,C1713,HCPCS,0278,RC,,,,both,,,615.25,399.91,,,,,,,,,,,,,
SCREW BNE L22MM DIA3.5MM EL TI POLYAX NONLOCKING COMPR FOR,SUP-2340299,CDM,C1713,HCPCS,0278,RC,,,,both,,,409.77,266.35,,,,,,,,,,,,,
STRUT C D 60 80MM SALVATION,SUP-2401127,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3221.64,2094.07,,,,,,,,,,,,,
PLATE BNE STR 1.5X0.4 MM MIDFACE 4 HOLE W/ TAB FOR SCREW NS,SUP-2494849,CDM,C1713,HCPCS,0278,RC,,,,both,,,455.93,296.35,,,,,,,,,,,,,
HEAD FEM 28MM DIA 12/14 TAPR + 7 NK LEN PRI MTL ON POLY CO,SUP-2203691,CDM,C1776,CPT,0278,RC,,,,both,,,2769.48,1800.16,,,,,,,,,,,,,
PLATE BNE L 167 MM SCREW DIA 4.5 MM 9 H SS NAR COMPR NLCK,SUP-2933779,CDM,C1713,HCPCS,0278,RC,,,,both,,,1939.58,1260.73,,,,,,,,,,,,,
SCREW BNE L35MM DIA4.7MM CORT TI HDLSS COMPR ACUTRK 2,SUP-2106805,CDM,C1713,HCPCS,0278,RC,,,,both,,,1447.54,940.90,,,,,,,,,,,,,
GRAFT HUMAN TISSUE 40X20 CM BIOLOGIC TISSUE MATRIX STERILE X,SUP-2838620,CDM,C1763,HCPCS,0278,RC,,,,both,,,74241.85,48257.20,,,,,,,,,,,,,
PLATE BNE 3 H LAT S STL FOR ANK FRAC MGMT,SUP-2123043,CDM,C1713,HCPCS,0278,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
KIT DRL DIA2MM CONT COMPR IMPL W/O STP SPD,SUP-2194183,CDM,C1713,HCPCS,0278,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
GUIDEWIRE VASC SPLASHWIRE L 180 CM DIA 0.018 IN STD STR,SUP-2665480,CDM,C1769,HCPCS,0272,RC,,,,both,,,160.45,104.29,,,,,,,,,,,,,
CLAMP ABLAT JAW L65MM L CRV 2 ELECTRD BPLR,SUP-2124466,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8321.00,5408.65,,,,,,,,,,,,,
COIL NEUROVASCULAR HYDROFILL 10 L 6 CM LOOP DIA2 MM,SUP-2305308,CDM,C1889,HCPCS,0278,RC,,,,both,,,6280.00,4082.00,,,,,,,,,,,,,
DEVICE INFLATION 22 ATM 12 ML ARIA GA STRL,SUP-2149336,CDM,C2625,HCPCS,0278,RC,,,,both,,,279.46,181.65,,,,,,,,,,,,,
PLATE BNE LCK 2X6X1 MM 4 HOLE CRV FOR SCREW TI BLU NS,SUP-2424094,CDM,C1713,HCPCS,0278,RC,,,,both,,,799.51,519.68,,,,,,,,,,,,,
PLATE BNE L 149 MM SCREW DIA 4.5 MM 8 H SS NAR COMPR NLCK,SUP-2932850,CDM,C1713,HCPCS,0278,RC,,,,both,,,1649.29,1072.04,,,,,,,,,,,,,
D-RAD VOLAR PLATE 5H RIGHT WIDE TI,SUP-2818635,CDM,C1713,HCPCS,0278,RC,,,,both,,,3776.79,2454.91,,,,,,,,,,,,,
DIAZEPAM 2 MG PO TABS,RX-2404,CDM,6370000000,HCPCS,0637,RC,51079-0284-20,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
BRACE LS M FOR 35 41IN HIP COT POLYAMIDE LYCRA AVG SUPP 2,SUP-2325578,CDM,L0625,HCPCS,0274,RC,,,,both,,,207.81,135.08,,,,,,,,,,,,,
SHELL ACET OD46MM ID40MM UNIV HIP CEMENTLESS PRI BHR 74121146] SMITH AND NEPHEW ORTHOPAEDICS],SUP-2350856,CDM,C1776,CPT,0278,RC,,,,both,,,10833.00,7041.45,,,,,,,,,,,,,
IMPLANT SZ 10 HEMI PHLANG GREAT TOE MOV,SUP-2244246,CDM,C1776,CPT,0278,RC,,,,both,,,7441.89,4837.23,,,,,,,,,,,,,
HC Ewho W/O Joint Custom Fab,PX-2740376301,CDM,L3763,HCPCS,0272,RC,,,,both,,,2638.00,1714.70,,,,,,,,,,,,,
WAND ABLAT FOR TNSLCTMY ADENOIDECTOMY PROCISE EZ,SUP-2342047,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1058.97,688.33,,,,,,,,,,,,,
OPHTHALMOLOGY EQUIP CRWFRD/BELLAN PGTL PRB THE CRWFRD/BELLAN,SUP-2247575,CDM,C1784,HCPCS,0278,RC,,,,both,,,266.90,173.48,,,,,,,,,,,,,
ROD SPNL L50MM DIA6.35MM R POST TI ALLY CRV SMOOTH LEG,SUP-2289186,CDM,C1713,HCPCS,0278,RC,,,,both,,,1796.08,1167.45,,,,,,,,,,,,,
SCREW INTRF 5X10 MM PEEK GRAPPLER TENODESIS,SUP-2749764,CDM,C1713,HCPCS,0278,RC,,,,both,,,1686.18,1096.02,,,,,,,,,,,,,
REAMER SURG DIA4.6MM FOR INTOSS FIX IOFIX PLUSX-POST,SUP-2223757,CDM,2720000010,LOCAL,0272,RC,,,,both,,,781.86,508.21,,,,,,,,,,,,,
CAGE SPNL W23XH10-12XL27MM POST THORLUM TI INTBDY FUS OVL,SUP-2254465,CDM,C1889,HCPCS,0278,RC,,,,both,,,11143.86,7243.51,,,,,,,,,,,,,
CATHETER CV FULL SAFETY TY 025 5 FRX15 CM 3L STD,SUP-2759988,CDM,C1751,HCPCS,0278,RC,,,,both,,,383.83,249.49,,,,,,,,,,,,,
PLATE BNE T 2.7X32 MM 3 HOLE SS,SUP-2569102,CDM,C1713,HCPCS,0278,RC,,,,both,,,162.34,105.52,,,,,,,,,,,,,
CATHETER PULM ART 8.3FR ENDOVENT MINIMAL INCIS VLV ENDOVENT,SUP-2214477,CDM,C1725,HCPCS,0272,RC,,,,both,,,4242.14,2757.39,,,,,,,,,,,,,
GRFT CHIPS CORT CANC 1-4MM 4.59MM 15CC PUROS,SUP-2693919,CDM,C1713,HCPCS,0278,RC,,,,both,,,2119.50,1377.67,,,,,,,,,,,,,
CATHETER GUID CXI L 90 CM DIA 2.3 FR 0.014 IN SS STR TIP,SUP-2168959,CDM,C1887,HCPCS,0272,RC,,,,both,,,609.38,396.10,,,,,,,,,,,,,
DRESSING WND FEN 3X3 CM SHT EXTRACELLULAR MTRX MATRISTEM,SUP-2106519,CDM,Q4166,HCPCS,0636,RC,,,,both,,,253.84,165.00,,,,,,,,,,,,,
DEVICE KYPHOPLASTY BNE ACCS OSTEO INTRO ADV KYPHON EXPRESS,SUP-2665002,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1102.52,716.64,,,,,,,,,,,,,
HC Echocardiogram Ltd Doppler,PX-4839332100,CDM,93321,CPT,0483,RC,,,,both,,,1077.00,700.05,,,,,,,,,,,,,
ARTHROSCOPIC SET HIP,SUP-2123487,CDM,C1769,HCPCS,0272,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
PLATE BONE L49MM 4 H S STL 1/3 TBLR ECT,SUP-2198531,CDM,C1713,HCPCS,0278,RC,,,,both,,,130.66,84.93,,,,,,,,,,,,,
ELECTRODE RF SUCT HND CTRL DISPOSABLE VAPR COOLPULSE 90,SUP-2256748,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1541.74,1002.13,,,,,,,,,,,,,
BUR SURG OD30MM DMND RND EXTRA COARSE TAPR N FLUT ST FOR,SUP-2364026,CDM,2720000010,LOCAL,0272,RC,,,,both,,,364.77,237.10,,,,,,,,,,,,,
GRAFT BONE SUB 10ML PUTTY CA PHOS SYNTH GRAN BIOABSRB ATTRAX,SUP-2310454,CDM,C1763,HCPCS,0278,RC,,,,both,,,4082.00,2653.30,,,,,,,,,,,,,
CIPROFLOXACIN HCL 0.3 % OP OINT,RX-23234,CDM,6370000000,HCPCS,0637,RC,66758-0071-38,NDC,,both,3.5,GR,1223.40,795.21,,,,,,,,,,,,,
GRAFT VASC GORTX L 100 CM DIA 8 MM RNG L 80 CM EPTFE STR TW,SUP-2396141,CDM,C1768,CPT,0278,RC,,,,both,,,3121.16,2028.75,,,,,,,,,,,,,
SCREW BNE L30MM DIA3.5MM STD ANK S STL LOK FIX ANG SYS,SUP-2243360,CDM,C1713,HCPCS,0278,RC,,,,both,,,927.96,603.17,,,,,,,,,,,,,
BRACE ANK L H10IN RIG THERMOPLASTIC SHELL ADJ HEEL STRP W/,SUP-2197171,CDM,L4350,HCPCS,0272,RC,,,,both,,,40.41,26.27,,,,,,,,,,,,,
RELOAD STPL 2.5MM L60MM 0DEG VASC TISS TAN TI 6 ROW LIN,SUP-2283265,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1188.24,772.36,,,,,,,,,,,,,
SCREW BONE 1.7X18 MM EMERGENCY RECESS TITANIUM NON STERILE P,SUP-2838180,CDM,C1713,HCPCS,0278,RC,,,,both,,,300.25,195.16,,,,,,,,,,,,,
DILATOR UTER 185MM SGL END HEG,SUP-2245454,CDM,C1713,HCPCS,0278,RC,,,,both,,,133.95,87.07,,,,,,,,,,,,,
CATHETER GUID MICROGUIDE TOT L 82 CM L 76 CM SHTH 6 FR,SUP-2158735,CDM,C1887,HCPCS,0272,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
PROSTHESIS OTO L6MM SHFT DIA0.4MM LOOP 0.6MM MID EAR STAP,SUP-2284065,CDM,L8613,CPT,0278,RC,,,,both,,,245.55,159.61,,,,,,,,,,,,,
DISC BIOLOGIC ABSRB SCAFFOLD BIOFIBER 8MM,SUP-2388577,CDM,C1781,HCPCS,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
PLATE BNE W12XL119MM THK1MM 7 H BILAT S STL SEMI TBLR LO,SUP-2184868,CDM,C1713,HCPCS,0278,RC,,,,both,,,103.62,67.35,,,,,,,,,,,,,
CUP HIP PT SPEC,SUP-2165898,CDM,C1776,CPT,0278,RC,,,,both,,,3708.34,2410.42,,,,,,,,,,,,,
GRAFT BONE PUTTY SYR FRZ DRY DEMIN BONE MTRX 1CC,SUP-2136835,CDM,C1713,HCPCS,0278,RC,,,,both,,,452.79,294.31,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE L 10 MM DIA 7.5 MM CART ARAGONITE 5PK,SUP-2913425,CDM,C1763,HCPCS,0278,RC,,,,both,,,21509.00,13980.85,,,,,,,,,,,,,
CATHETER INTRAAORTIC BLLN 10.5 FR 50 CC,SUP-2227269,CDM,C1725,HCPCS,0272,RC,,,,both,,,2041.00,1326.65,,,,,,,,,,,,,
HC So1 T Cell Total,PX-3028635967,CDM,86359,CPT,0302,RC,,,,both,,,81.00,52.65,,,,,,,,,,,,,
CAGE SPINE CERV ANTR RECT GEO 9X9X21,SUP-2414456,CDM,C1889,HCPCS,0278,RC,,,,both,,,9881.58,6423.03,,,,,,,,,,,,,
GRAFT HUM TISS PROX R TIB W BTB FRZN,SUP-2307301,CDM,C1713,HCPCS,0278,RC,,,,both,,,17581.11,11427.72,,,,,,,,,,,,,
IMPLANT TIB POST STBL UNIV PRI PEG CEM SZ 8 E/F 10MM THCK,SUP-2200761,CDM,C1776,CPT,0278,RC,,,,both,,,14474.77,9408.60,,,,,,,,,,,,,
DEVICE ORTH L8.5MM OD3.5MM KNEE ACL PCL RETRODRILL,SUP-2120841,CDM,C1713,HCPCS,0278,RC,,,,both,,,894.90,581.68,,,,,,,,,,,,,
GRAFT BNE MTRX LG 12.5 CC STRL FIBERGRAFT AERIDYAN 59000125,SUP-2874925,CDM,C1713,HCPCS,0278,RC,,,,both,,,12434.40,8082.36,,,,,,,,,,,,,
HC So Quantitative Enzyme Immunoassy|NOT REASONABLE AND NECESSARY,PX-3028631666,CDM,86316,CPT,0302,RC,,,GZ,outpatient,,,177.00,115.05,,,,,,,,,,,,,
SCREW BNE PEGGED 2.5X14 MM DSTL RADIAL VOLAR FT LCK FT COCR,SUP-2476040,CDM,C1713,HCPCS,0278,RC,,,,both,,,229.03,148.87,,,,,,,,,,,,,
SHEATH TRANSSEPTAL 45 DEG L 63 CM DIA 8.5 FR GUIDEWIRE L 180 D0,SUP-2913659,CDM,C1893,HCPCS,0272,RC,,,,both,,,3045.80,1979.77,,,,,,,,,,,,,
WIRE EXT FIX BAYNT 370X1.8 MM TRUELOK,SUP-2316139,CDM,2720000010,LOCAL,0272,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
RING EXT FIX HALF 80 MM TI NS,SUP-2799520,CDM,2720000010,LOCAL,0272,RC,,,,both,,,972.33,632.01,,,,,,,,,,,,,
COIL NEUROVASCULAR DELTAPAQ L 10 CM DIA 4 MM PRIMARY DIA,SUP-2460951,CDM,C1889,HCPCS,0278,RC,,,,both,,,4828.13,3138.28,,,,,,,,,,,,,
SLING URETH BLDR FIX MESH POLYPR BIOARC SP,SUP-2140250,CDM,C1771,HCPCS,0278,RC,,,,both,,,5350.56,3477.86,,,,,,,,,,,,,
ANCHOR SUT DIA2.8MM MAG KNOTLESS FIX,SUP-2342076,CDM,C1713,HCPCS,0278,RC,,,,both,,,1096.27,712.58,,,,,,,,,,,,,
NEEDLE BX COR 16 GAX16 CM SEMI AUTO COAX PUR COR MISSION,SUP-2127780,CDM,C1713,HCPCS,0278,RC,,,,both,,,127.17,82.66,,,,,,,,,,,,,
SPLINT ORTH L4IN STD PLAS FNGR MLLT W/O PD STAX,SUP-2205660,CDM,L3913,HCPCS,0274,RC,,,,both,,,5.28,3.43,,,,,,,,,,,,,
HC So Hla II Low Resolution One Antigen Equivalent Ea,PX-3108137766,CDM,81377,CPT,0310,RC,,,,both,,,233.00,151.45,,,,,,,,,,,,,
OSTEOTOME 4MM 8.1IN LEN LT CVD W/ GRD ANDRSN NEIVERT,SUP-2129697,CDM,2720000010,LOCAL,0272,RC,,,,both,,,467.86,304.11,,,,,,,,,,,,,
CUP ACET DIA58MM RT HIP POR PRI PRESSFIT ASR,SUP-2254023,CDM,C1776,CPT,0278,RC,,,,both,,,16017.14,10411.14,,,,,,,,,,,,,
PLATE BNE DSTL C1 STD RT VOLAR RAD TI,SUP-2646874,CDM,C1713,HCPCS,0278,RC,,,,both,,,1432.28,930.98,,,,,,,,,,,,,
PIN FIX SINGLE DIAMOND 0.156X9 IN SHANK END SS NS STEINMANN,SUP-2791377,CDM,C1713,HCPCS,0278,RC,,,,both,,,55.33,35.96,,,,,,,,,,,,,
PLATE CRAN 160X40X40 MM PT SPEC IMPL PEEK,SUP-2860127,CDM,C1713,HCPCS,0278,RC,,,,both,,,27562.92,17915.90,,,,,,,,,,,,,
PLATE BNE L 27.31 X W 5.08 MM THK 0.6 MM SCREW DIA2 MM 4 H,SUP-2936564,CDM,C1713,HCPCS,0278,RC,,,,both,,,1617.10,1051.11,,,,,,,,,,,,,
TUBE SUCTION ROSEN 16 GAX2-3/8 IN W/ OBTURATOR,SUP-2484778,CDM,C1713,HCPCS,0278,RC,,,,both,,,34.10,22.16,,,,,,,,,,,,,
LEVEL NEURO ST PLATE ULTRNE DBL Y SHP NEURO SCRW6 HOLE 16 MM,SUP-2681850,CDM,C1713,HCPCS,0278,RC,,,,both,,,905.95,588.87,,,,,,,,,,,,,
TRAY EPIDURAL CATH DIA19 GA NDL DIA17 GA CE17TKFN CONT NRFIT,SUP-2936781,CDM,2720000010,LOCAL,0272,RC,,,,both,,,91.31,59.35,,,,,,,,,,,,,
GRAFT SFT TISS FLOWABLE 0.6 CC 100 MG TISS MTRX INTERFYL,SUP-2651384,CDM,Q4171,HCPCS,0636,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
RELOAD STPL 10 TACK STD PURCH ARTC RELIATACK,SUP-2283328,CDM,2720000010,LOCAL,0272,RC,,,,both,,,422.80,274.82,,,,,,,,,,,,,
PLATE BNE HK LNG 2.7X9 MM LT CLAV VA LCK COMPR NS VA-LCP,SUP-2757614,CDM,C1713,HCPCS,0278,RC,,,,both,,,3482.76,2263.79,,,,,,,,,,,,,
DEFIBRILLATOR CARD 2 CHMBR ATLS II + DR,SUP-2357756,CDM,C1721,HCPCS,0275,RC,,,,both,,,54950.00,35717.50,,,,,,,,,,,,,
ALLOGRAFT BNE CHIP 1-8 MM 20 CC FD CRUSH CANC READIGRAFT,SUP-2741031,CDM,C1713,HCPCS,0278,RC,,,,both,,,840.83,546.54,,,,,,,,,,,,,
MTOSCR INTRF NON-CANN 9X30 STER,SUP-2341297,CDM,C1713,HCPCS,0278,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
PLATE BNE T 3.5X57 MM 3X4 HOLE RT ANGLED SS LCP,SUP-2569404,CDM,C1713,HCPCS,0278,RC,,,,both,,,445.57,289.62,,,,,,,,,,,,,
GUIDEWIRE VASC L80CM DIA0018IN NIT PLAT TIP FOR COAX INTRO,SUP-2302989,CDM,C1769,HCPCS,0272,RC,,,,both,,,91.69,59.60,,,,,,,,,,,,,
HC Remove Tun Cath Vad W/Port,PX-3613659000,CDM,36590,CPT,0361,RC,,,,outpatient,,,3707.00,2409.55,,,,,,,,,,,,,
RONGEUR SURG CLEVELAND 4 5.5 IN AUTOCLV SS HIS,SUP-2238355,CDM,2720000010,LOCAL,0272,RC,,,,both,,,452.13,293.88,,,,,,,,,,,,,
WIRE PL REDUCTION WIRE 1.25MM /THRDD TIP W/SM STOP/150MM-ST,SUP-2546046,CDM,C1713,HCPCS,0278,RC,,,,both,,,171.44,111.44,,,,,,,,,,,,,
COLLAR CERV PD REG INF BK PANEL REPL,SUP-2124226,CDM,L0174,HCPCS,0274,RC,,,,both,,,56.14,36.49,,,,,,,,,,,,,
ALLOGRAFT BNE 100 MM PRESERVON FIBULAR SHFT MATRIGRAFT,SUP-2740897,CDM,C1762,CPT,0278,RC,,,,both,,,1995.53,1297.09,,,,,,,,,,,,,
HC So Anti Striated Antibody,PX-3028625566,CDM,86255,CPT,0302,RC,,,,outpatient,,,96.00,62.40,,,,,,,,,,,,,
CLAMP REPROC FIX PIN 6 POS MR SAFE MED,SUP-2477358,CDM,2720000010,LOCAL,0272,RC,,,,both,,,498.04,323.73,,,,,,,,,,,,,
GRAFT VASC DISTAFLO L 90 CM DIA 6 MM EPTFE CARBON PERIPH,SUP-2128086,CDM,C1768,CPT,0278,RC,,,,both,,,9865.88,6412.82,,,,,,,,,,,,,
GUIDEWIRE UROLOGICAL STR 3 CM 0.038 IN X150 CM FIX STIFF LF,SUP-2498415,CDM,C1769,HCPCS,0272,RC,,,,both,,,39.60,25.74,,,,,,,,,,,,,
GUIDEWIRE CATH J STR 0.035 INX70 CM SS STRL,SUP-2626779,CDM,C1769,HCPCS,0272,RC,,,,both,,,31.34,20.37,,,,,,,,,,,,,
HC So Anti Striated Antibody,PX-3028625566,CDM,86255,CPT,0302,RC,,,,inpatient,,,96.00,62.40,,,,,,,,,,,,,
MARKER FIDUCIAL GOLD DELIVERY NEEDLES 1.2MM X 3MM (3EA) IZI,SUP-2848835,CDM,A4648,CPT,0278,RC,,,,both,,,189.62,123.25,,,,,,,,,,,,,
GUIDE DRL DIA3-4MM DISP FOR PONTO SYS,SUP-2319871,CDM,C1713,HCPCS,0278,RC,,,,both,,,675.10,438.81,,,,,,,,,,,,,
SHEATH INTRO PINNACLE R/O II L 10 CM DIA 5 FR 2.5CM 0.038 IN,SUP-2385185,CDM,C1894,HCPCS,0272,RC,,,,both,,,200.65,130.42,,,,,,,,,,,,,
SUPPORT ORTHOT ANK KNEE GAUNTLET PREFABRICATED OFF THE SHLF,SUP-2435622,CDM,L1902,HCPCS,0274,RC,,,,both,,,211.32,137.36,,,,,,,,,,,,,
BOX JUNCTION 5DEG FEM BAL REV SYS,SUP-2315543,CDM,C1776,CPT,0278,RC,,,,both,,,665.68,432.69,,,,,,,,,,,,,
PERI-LOC VLP 3.5MM S-T LOCK SCREW 26MM,SUP-2818974,CDM,C1713,HCPCS,0278,RC,,,,both,,,1014.25,659.26,,,,,,,,,,,,,
IMPLANT COCHLEAR HEARING STRL NUCLS,SUP-2140411,CDM,L8614,HCPCS,0278,RC,,,,both,,,61500.83,39975.54,,,,,,,,,,,,,
PLATE BNE L236MM 9 H NONSTERILE R DST FEM TI LOK COMPR FOR,SUP-2190725,CDM,C1713,HCPCS,0278,RC,,,,both,,,4937.21,3209.19,,,,,,,,,,,,,
PATCH HERN L W5.4XL7IN UNCOATED MFIL PROPYLENE OVL ABSRB,SUP-2125898,CDM,C1781,HCPCS,0278,RC,,,,both,,,2984.88,1940.17,,,,,,,,,,,,,
PLATE BNE BROAD 4.5X215 MM 12 HOLE SS LCP,SUP-2569365,CDM,C1713,HCPCS,0278,RC,,,,both,,,720.16,468.10,,,,,,,,,,,,,
PLATE BNE L50MM 6 H BILAT ORAL MAXILLOFACIAL TI CRESC SHP,SUP-2191403,CDM,C1713,HCPCS,0278,RC,,,,both,,,2811.24,1827.31,,,,,,,,,,,,,
BRACE ORTH CIRC THGH 23.5-26.5 IN CTR 17-19 IN CALF 18-20 IN,SUP-2914921,CDM,2720000010,LOCAL,0272,RC,,,,both,,,905.89,588.83,,,,,,,,,,,,,
STENT GRFT VASC POWERLINK XL INTUITRAK EXPRESS L 100 MM CVR,SUP-2217583,CDM,C1768,CPT,0278,RC,,,,both,,,13172.30,8561.99,,,,,,,,,,,,,
DISC NEUROSURGICAL LOW WITHOUT RESERVOIR NON PROGRAMMABLE PR,SUP-2826743,CDM,C1889,HCPCS,0278,RC,,,,both,,,1271.42,826.42,,,,,,,,,,,,,
WIRE BNE FIX L 150 MM DIA2.5 MM SS TRCR PT NS KIRSCHNER,SUP-2900580,CDM,C1713,HCPCS,0278,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
PIN EXTRNL FXTN L100MM D4MM THRD L20MM BLUE HALF XTRFX SSTM,SUP-2458511,CDM,2720000010,LOCAL,0272,RC,,,,both,,,403.65,262.37,,,,,,,,,,,,,
COMPONENT FEM KNEE CUT COORDINATES TOT KNEE REPL PIGALILEO +,SUP-2450906,CDM,C1776,CPT,0278,RC,,,,both,,,91.19,59.27,,,,,,,,,,,,,
GRAFT BONE SUB 10CC DEMIN BONE MTRX RM TEMP OPTEFORM,SUP-2223560,CDM,C1713,HCPCS,0278,RC,,,,both,,,4867.00,3163.55,,,,,,,,,,,,,
RESORB X TEMPLATE MANDIBULAR FORMING DEVICE,SUP-2679364,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1173.61,762.85,,,,,,,,,,,,,
CATHETER PULM ART 8.5FR L20CM SAFT OXMTR 3 LUMN W/ INTEGR,SUP-2214765,CDM,C1751,HCPCS,0278,RC,,,,both,,,1670.48,1085.81,,,,,,,,,,,,,
GUIDE NDL BX FOR TRANSDUCER DISP,SUP-2835416,CDM,2720000010,LOCAL,0272,RC,,,,both,,,131.88,85.72,,,,,,,,,,,,,
INTRA-AORTIC PUMP KIT ADPT 7.5 FR 40 CC BLLN CATH LINEAR,SUP-2525609,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2543.31,1653.15,,,,,,,,,,,,,
ALLOGRAFT BNE FLOWABLE 5 CC OSTEOAMP,SUP-2731798,CDM,C1776,CPT,0278,RC,,,,both,,,5268.67,3424.64,,,,,,,,,,,,,
STAPLE BONE LEG W1.8XL18MM INTERAXIS L15MM CLP THK2.7MM BRDG,SUP-2175181,CDM,C1713,HCPCS,0278,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
PLATE 2 CLMN DSTL VLR RAD 2.4MM 7H HD 4H SHFT LT STRL TI,SUP-2546712,CDM,C1713,HCPCS,0278,RC,,,,both,,,2738.52,1780.04,,,,,,,,,,,,,
STRAP CLAV FOAM PADDED 42-48 IN X LG BCKL CLOSURE PROCARE,SUP-2195760,CDM,L3650,HCPCS,0274,RC,,,,both,,,15.57,10.12,,,,,,,,,,,,,
HEAD HUM FX RT ANAT SHLDR SYS 40MM,SUP-2204878,CDM,C1776,CPT,0278,RC,,,,both,,,4917.24,3196.21,,,,,,,,,,,,,
AM PICC SET: 1-L 4.5FRX55CM 130CM HYDR,SUP-2822097,CDM,C1751,HCPCS,0278,RC,,,,both,,,425.31,276.45,,,,,,,,,,,,,
HC Reposition Gastric Tube Duod,PX-3614376100,CDM,43761,CPT,0361,RC,,,,both,,,1485.00,965.25,,,,,,,,,,,,,
KIT CATH HEMODIALYSI HEMOSTAR CHRONIC STD 14.5FR DIA 20CM 15,SUP-2613296,CDM,C1750,HCPCS,0278,RC,,,,both,,,1362.76,885.79,,,,,,,,,,,,,
PLATE BONE L201MM 10 H RT LAT PROX TIB S STL LCK FOR 4.5MM,SUP-2348230,CDM,C1713,HCPCS,0278,RC,,,,both,,,15168.08,9859.25,,,,,,,,,,,,,
SCREW SCHANZ BLUNTED POINT 4.5MM 125MM/HA COATING-STERILE,SUP-2547735,CDM,C1713,HCPCS,0278,RC,,,,both,,,532.80,346.32,,,,,,,,,,,,,
PLATE BNE DBL ANGLED LG 2 MM RECON PT SPEC TI,SUP-2860088,CDM,C1713,HCPCS,0278,RC,,,,both,,,22828.43,14838.48,,,,,,,,,,,,,
DRIVER SHFT SURG NONCANNULATED CROSS PIN QUIK CPL UNIV NEURO,SUP-2364404,CDM,2720000010,LOCAL,0272,RC,,,,both,,,959.62,623.75,,,,,,,,,,,,,
AUGMENT FEM SZ D THK5MM STD UNIV POST KNEE TRABECULAR MTL,SUP-2200230,CDM,C1776,CPT,0278,RC,,,,both,,,4408.56,2865.56,,,,,,,,,,,,,
PLATE BNE SM 6 H CRANIOMAXILLOFACIAL TI LO PROF GAP FOR,SUP-2366209,CDM,C1713,HCPCS,0278,RC,,,,both,,,879.73,571.82,,,,,,,,,,,,,
HANDPIECE ABLAT DIA6MM ENDOMET IMPED CTRL DEV DISP NOVASURE,SUP-2239893,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3332.58,2166.18,,,,,,,,,,,,,
WIRE SURG 0.045X6 IN TRCR PT NS KIRSCHNER LTX,SUP-2862421,CDM,C1713,HCPCS,0278,RC,,,,both,,,11.24,7.31,,,,,,,,,,,,,
ROD EXT FIX L200MM S STL CIR THRD TELSCP ORIG ILIZ,SUP-2342304,CDM,C1713,HCPCS,0278,RC,,,,both,,,1599.05,1039.38,,,,,,,,,,,,,
SEPARATOR 7,SUP-2655666,CDM,C1757,HCPCS,0272,RC,,,,both,,,5275.20,3428.88,,,,,,,,,,,,,
STIMULATOR NERVE CHARGER MOB EON,SUP-2355969,CDM,C1713,HCPCS,0278,RC,,,,both,,,4239.00,2755.35,,,,,,,,,,,,,
SET PICC 1L 4.5FR X 55CM BP,SUP-2887066,CDM,C1751,HCPCS,0278,RC,,,,both,,,1019.46,662.65,,,,,,,,,,,,,
PLATE BNE 2.7X60 MM 7 HOLE SS DCP,SUP-2569129,CDM,C1713,HCPCS,0278,RC,,,,both,,,284.96,185.22,,,,,,,,,,,,,
BIT DRL L30MM DIA2.8MM FOR GLEN SHLDR SYS BIO MOD,SUP-2408384,CDM,2720000010,LOCAL,0272,RC,,,,both,,,355.13,230.83,,,,,,,,,,,,,
CAP RIB LCK X DRV NS ADVANTAGERIB,SUP-2908963,CDM,C1713,HCPCS,0278,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
FIBER LASER 365 MH 100 W FLEXSHIELD OUTPT TIP ETFE SIL,SUP-2141811,CDM,2720000010,LOCAL,0272,RC,,,,both,,,974.84,633.65,,,,,,,,,,,,,
PLATE BNE CRV BROAD PEDIATRIC 3.5 MM 20 HOLE SS NS LCP,SUP-2799222,CDM,C1713,HCPCS,0278,RC,,,,both,,,2906.64,1889.32,,,,,,,,,,,,,
GRAFT BNE SUB 5CC FOAM PK VERSATILE COMPR RESIST VITOSS 21021905] STRYKER CORP],SUP-2361882,CDM,C1713,HCPCS,0278,RC,,,,both,,,3692.64,2400.22,,,,,,,,,,,,,
MESH HERN CIR 15 CM W/ ECHO 2 POS SYS POLYPR VENTRALIGHT ST,SUP-2126500,CDM,C1781,HCPCS,0278,RC,,,,both,,,2336.16,1518.50,,,,,,,,,,,,,
PATCH CV 20CMX140CMX04MM,SUP-2395306,CDM,C1768,CPT,0278,RC,,,,both,,,1105.28,718.43,,,,,,,,,,,,,
APPLIER INT CLP REMOVER 12.5 MMX35 CM ARTICULATING BULLDOG,SUP-2852476,CDM,C1889,HCPCS,0278,RC,,,,both,,,6810.94,4427.11,,,,,,,,,,,,,
PLATE BONE 5 H TI LCK 3RD TBLR,SUP-2419534,CDM,C1713,HCPCS,0278,RC,,,,both,,,737.90,479.63,,,,,,,,,,,,,
CATHETER EP 8FR L105CM LOOP DIA15MM 3-3-3MM SPC D CRV CIR,SUP-2357571,CDM,C1732,HCPCS,0278,RC,,,,both,,,5290.90,3439.08,,,,,,,,,,,,,
SET SCR 130DEG TI FOR TROCHANTERIC FIX NAIL,SUP-2180358,CDM,C1713,HCPCS,0278,RC,,,,both,,,476.56,309.76,,,,,,,,,,,,,
GRAFT DURA W1XL1IN CLLGN SUTURELESS HIGHLY CNFRM RESTR,SUP-2165123,CDM,C1763,HCPCS,0278,RC,,,,both,,,703.77,457.45,,,,,,,,,,,,,
KIT HEMO DYLS OR HD 11FR INSRTN L15CM POLYUR BODYSOFT CATH,SUP-2126494,CDM,C1752,HCPCS,0278,RC,,,,both,,,358.71,233.16,,,,,,,,,,,,,
GENII CONST ART ISRT SZ3-4 9MM,SUP-2822791,CDM,C1776,CPT,0278,RC,,,,both,,,2442.92,1587.90,,,,,,,,,,,,,
NOZZLE SPRY FOR 2 RNG HNDPC L17 STRL DISP ELAN 4,SUP-2929101,CDM,2720000010,LOCAL,0272,RC,,,,both,,,344.33,223.81,,,,,,,,,,,,,
BRACE KNEE HNG WRP M,SUP-2276701,CDM,L1820,HCPCS,0274,RC,,,,both,,,53.73,34.92,,,,,,,,,,,,,
SCREW INTFR L25MM OD9MM LACTOSORB POLYMER CORT KNEE CANN,SUP-2212862,CDM,C1713,HCPCS,0278,RC,,,,both,,,865.13,562.33,,,,,,,,,,,,,
ALLOGRAFT BNE RNG 13X14X11 MM,SUP-2787595,CDM,C1713,HCPCS,0278,RC,,,,both,,,2798.53,1819.04,,,,,,,,,,,,,
BUR SURG OD8.0MM LNG DMND ECOURSE RND N FLUT STRL FOR TPS,SUP-2363384,CDM,2720000010,LOCAL,0272,RC,,,,both,,,256.35,166.63,,,,,,,,,,,,,
"HC Pt Therapeutic Exercise,Ea 15 Min|OP OCCUPATIONAL THERAPY SERV|SERVICES PROVIDED IN WHOLE OR IN PARTY BY AN OTA FOR MEDICARE PATIENTS|DOCUMENTATION ON FILE",PX-4209711000,CDM,97110,CPT,0420,RC,,,GO|CO|KX,both,,,195.00,126.75,,,,,,,,,,,,,
GRAFT BNE L16MM DIA10MM CANC PLUG W CART FRZN FLEXIGRFT,SUP-2264630,CDM,C1713,HCPCS,0278,RC,,,,both,,,1265.58,822.63,,,,,,,,,,,,,
"HC So Concentratn ,Any, Infect Agent",PX-3008701566,CDM,87015,CPT,0300,RC,,,,outpatient,,,79.00,51.35,,,,,,,,,,,,,
CATHETER HD TWO LUMEN PEDIATRIC 8 FRX4 3/8 IN KT ARW,SUP-2627028,CDM,C1752,HCPCS,0278,RC,,,,both,,,228.59,148.58,,,,,,,,,,,,,
BLADE SAW OSCILLATING 95X21X1.27 MM 1.27 MM HALL,SUP-2607471,CDM,2720000010,LOCAL,0272,RC,,,,both,,,188.40,122.46,,,,,,,,,,,,,
COVER BUR H DIA20MM 7 H W/ TAB CNTOUR NONCOMPRESSION LO PROF,SUP-2363634,CDM,C1713,HCPCS,0278,RC,,,,both,,,864.69,562.05,,,,,,,,,,,,,
PLATE BNE DBL Y 2-2.5X1 MM 10 MM GENIOPLASTY W/ TAB STP TI,SUP-2539565,CDM,C1713,HCPCS,0278,RC,,,,both,,,712.84,463.35,,,,,,,,,,,,,
BEARING HUM STD 40 MM SHLDR VIVACIT-E PROLONG COMPHSVE,SUP-2418152,CDM,C1776,CPT,0278,RC,,,,both,,,3246.76,2110.39,,,,,,,,,,,,,
BLADE SAW LAPIPLASTY 11X40MM,SUP-2389094,CDM,2720000010,LOCAL,0272,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
CLIP ANEUR W5XL6MM CO CHROM ALLY TEMP STD TYP STR SUGITA,SUP-2305976,CDM,C1889,HCPCS,0278,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
MARKER BRST BX 7 CM NDL MAGSEED,SUP-2427296,CDM,A4648,CPT,0278,RC,,,,both,,,1786.97,1161.53,,,,,,,,,,,,,
FEEDING TUBE KIT LP 18 FRX2.3 CM BLLN BUTTON SIL MINI 1,SUP-2754578,CDM,2720000010,LOCAL,0272,RC,,,,both,,,691.71,449.61,,,,,,,,,,,,,
CATH REPROC EP SUPREME FIX JSN 4POL 5MM 6FR,SUP-2526066,CDM,C1730,HCPCS,0272,RC,,,,both,,,120.64,78.42,,,,,,,,,,,,,
STAPLER INT SZ 23MM H1.5-2.2MM OPN LEG L5.2MM PWR ADJ HT W/,SUP-2218868,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1430.62,929.90,,,,,,,,,,,,,
GUIDEWIRE VASC VASSALLO GT L 300 CM DIA 0.014 IN TIP LOAD 3,SUP-2909280,CDM,C1769,HCPCS,0272,RC,,,,both,,,441.01,286.66,,,,,,,,,,,,,
SYSTEM KNEE LT STRL MISHA,SUP-2930733,CDM,C1776,CPT,0278,RC,,,,both,,,49455.00,32145.75,,,,,,,,,,,,,
NAIL IM L160MM DIA9MM STRL AQUA L/R DSTL FEM TI LCK SLD DYN,SUP-2191690,CDM,C1713,HCPCS,0278,RC,,,,both,,,5458.14,3547.79,,,,,,,,,,,,,
SET DRNGE 12FR 30CM 038IN 14FR SUMP GUID WIRE J TIP CONN,SUP-2168235,CDM,C1713,HCPCS,0278,RC,,,,both,,,550.38,357.75,,,,,,,,,,,,,
DRESSING BIO CIRC 14 MM ACELLULAR FISH SKIN OMEGA 3 SLD CIR,SUP-2883716,CDM,Q4158,HCPCS,0636,RC,,,,both,,,9812.50,6378.12,,,,,,,,,,,,,
GRAFT HUM TISS RT TALUS OSTEOCHNDRL REFRIGERATED CART RECON,SUP-2307434,CDM,C1713,HCPCS,0278,RC,,,,both,,,12936.80,8408.92,,,,,,,,,,,,,
DRILL SURG QR CHK VANGUARD GLOB,SUP-2441422,CDM,2720000010,LOCAL,0272,RC,,,,both,,,748.89,486.78,,,,,,,,,,,,,
HC Pbb Carpal Tunnel Inj Pmc|BILATERAL PROCEDURE,PX-5102052600,CDM,20526,CPT,0510,RC,,,50,outpatient,,,775.00,503.75,,,,,,,,,,,,,
GRAFT BONE SUB W1XH10XL0.8CM DEMIN MTRX GRFTON,SUP-2281665,CDM,C9362,HCPCS,0278,RC,,,,both,,,3506.60,2279.29,,,,,,,,,,,,,
GRAFT BNE STRP 100 MM 10 CC,SUP-2430787,CDM,C1713,HCPCS,0278,RC,,,,both,,,7457.50,4847.37,,,,,,,,,,,,,
SYSTEM REPAIR ANCHOR  ACL IMPLANT,SUP-2754752,CDM,C1713,HCPCS,0278,RC,,,,both,,,6735.30,4377.94,,,,,,,,,,,,,
ALLOGRAFT BNE WDG 23 MM FRZN ILIUM TRICORT,SUP-2717923,CDM,C1762,CPT,0278,RC,,,,both,,,5712.32,3713.01,,,,,,,,,,,,,
HC Bladder Instillation Anticarcinogenic of Agent,PX-3615172000,CDM,51720,CPT,0361,RC,,,,both,,,2644.00,1718.60,,,,,,,,,,,,,
TRAY BNE MAR CPRP BMA PLT SENS 1 BTTN AUTOMATION USED TO,SUP-2120732,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2769.48,1800.16,,,,,,,,,,,,,
GRAFT TISS FRZN ALLGRFT WDG IL CREST 9MM,SUP-2307415,CDM,C1713,HCPCS,0278,RC,,,,both,,,2320.46,1508.30,,,,,,,,,,,,,
GRAFT HUM TISS 9X73 MM QUADRICEPS TEND FLEXIGRAFT QUADLINK,SUP-2845910,CDM,C1762,CPT,0278,RC,,,,both,,,7421.08,4823.70,,,,,,,,,,,,,
SPLINT WR AD L GREATER THAN W4IN LT MCP DLX KAY-SPLNT III,SUP-2324563,CDM,L3906,HCPCS,0272,RC,,,,both,,,87.95,57.17,,,,,,,,,,,,,
PHENOBARBITAL 32.4 MG PO TABS,RX-6217,CDM,6370000000,HCPCS,0637,RC,00904-6575-61,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
STAPLE BNE COMPR 16 X 10 X 10MM,SUP-2401352,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2923.34,1900.17,,,,,,,,,,,,,
GRAFT BNE 85X17.5 MM DBM BLLST,SUP-2641774,CDM,C1713,HCPCS,0278,RC,,,,both,,,13753.20,8939.58,,,,,,,,,,,,,
HEAD FEM OD32MM +7MM XLN NK CO CHROM HIP SLOT TAPR N,SUP-2304434,CDM,C1776,CPT,0278,RC,,,,both,,,4624.91,3006.19,,,,,,,,,,,,,
NAIL INTRMDLLRY CNNLTD 20MM DIA 100 POLY L LCTC ACID HELI RS,SUP-2639522,CDM,C1713,HCPCS,0278,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
WIRE FIXATION .9MM 22.9CM TROCAR POINT,SUP-2474399,CDM,2720000010,LOCAL,0272,RC,,,,both,,,35.61,23.15,,,,,,,,,,,,,
GUIDEWIRE VASC NEUROSCOUT 14 L 205 CM DSTL TIP L 42 CM DIA,SUP-2676242,CDM,C1769,HCPCS,0272,RC,,,,both,,,2315.72,1505.22,,,,,,,,,,,,,
FIBER ENT HOLM LSR 200 MIC STRL LTX FRE,SUP-2417255,CDM,2720000010,LOCAL,0272,RC,,,,both,,,690.80,449.02,,,,,,,,,,,,,
GUIDEWIRE ORTH TROCAR PT 1 END 2.8X300 MM NS,SUP-2789102,CDM,C1769,HCPCS,0272,RC,,,,both,,,1719.34,1117.57,,,,,,,,,,,,,
HC Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/O Img Gdn|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE PRIOR TO THE ADMINISTRATION OF ANESTHESIA,PX-3606232200,CDM,62322,CPT,0360,RC,,,73,both,,,2230.00,1449.50,,,,,,,,,,,,,
DRESSING WND SURG MTRX THCK 10X15 CM MATRISTEM,SUP-2106498,CDM,Q4166,HCPCS,0636,RC,,,,both,,,14836.50,9643.72,,,,,,,,,,,,,
PUMP INFUSION ELASTOMERIC 100 CC 2 ML/HR 2 FIX FLO STRL ON-Q,SUP-2424458,CDM,C9804,HCPCS,0272,RC,,,,both,,,222.94,144.91,,,,,,,,,,,,,
SCREW BNE L32MM DIA4MM THRD L14MM CANC TI SELF DRL ST,SUP-2189939,CDM,C1713,HCPCS,0278,RC,,,,both,,,58.62,38.10,,,,,,,,,,,,,
ALLOGRAFT HUM TISS AMNIO MEMBRN 4X8 CM DRY ALLOWRAP DRY,SUP-2717793,CDM,Q4150,HCPCS,0636,RC,,,,both,,,15599.52,10139.69,,,,,,,,,,,,,
PATIENT PRGRMMR KIT INCLDS RMTE CNTRL RMTE CNTRL HLSTR PTNT,SUP-2679260,CDM,C1787,HCPCS,0278,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
SPACER M 54X5MM LT CEM,SUP-2209026,CDM,C1776,CPT,0278,RC,,,,both,,,11366.17,7388.01,,,,,,,,,,,,,
CATHETER PERITONEAL LAVAGE SET 038X40 CM 9 FRX20 CM 90,SUP-2760072,CDM,C1892,HCPCS,0272,RC,,,,both,,,290.36,188.73,,,,,,,,,,,,,
PLATE BNE RECON 3.5X190 MM 16 HOLE SS,SUP-2569091,CDM,C1713,HCPCS,0278,RC,,,,both,,,502.56,326.66,,,,,,,,,,,,,
SCREW CORTEX ST 2.4X7MM W/3.5MM HD,SUP-2547196,CDM,C1713,HCPCS,0278,RC,,,,both,,,171.66,111.58,,,,,,,,,,,,,
SCREW BONE L26MM D2.7MM CRTCL DST RDL LOK FLLY THRDD SQRE DR,SUP-2496977,CDM,C1713,HCPCS,0278,RC,,,,both,,,499.26,324.52,,,,,,,,,,,,,
ROD REPROC EXT FIX 11X650 MM MR CARBON FIBER NS,SUP-2188678,CDM,2720000010,LOCAL,0272,RC,,,,both,,,593.46,385.75,,,,,,,,,,,,,
PLATE BONE CRANIAL 10 HOLE STRAIGHT 43.9X3.4MM TITANIUM NEUR,SUP-2821912,CDM,C1713,HCPCS,0278,RC,,,,both,,,143.18,93.07,,,,,,,,,,,,,
CATHETER HD STR 13.5 FRX13 CM DL HI FLO PASS TY MAHRK ELITE,SUP-2626886,CDM,C1752,HCPCS,0278,RC,,,,both,,,417.81,271.58,,,,,,,,,,,,,
TRIAL NERVE STIM LD 90 CM KT AXIUM SLIMTIP,SUP-2357676,CDM,C1778,HCPCS,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
NAIL ORTH DUMMY,SUP-2563945,CDM,C1713,HCPCS,0278,RC,,,,both,,,1457.78,947.56,,,,,,,,,,,,,
STEM FEM SZ 15 L150MM HIP CO CHROM STD OFFSET CEMENTLESS,SUP-2344546,CDM,C1776,CPT,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
IMPLANT BIO TISS W5XL5CM PORCINE DERM MTRX RECON THINNER,SUP-2388573,CDM,C1763,HCPCS,0278,RC,,,,both,,,8305.30,5398.44,,,,,,,,,,,,,
PEG BONE L14MM DIA3.5MM ANK FT ANTI ROT,SUP-2321067,CDM,C1713,HCPCS,0278,RC,,,,both,,,824.25,535.76,,,,,,,,,,,,,
DEVICE DRIVE ROTAWIRE EXTRA SUPPORT,SUP-2743276,CDM,C1769,HCPCS,0272,RC,,,,both,,,866.64,563.32,,,,,,,,,,,,,
RETRACTABLE SCR IN J,SUP-2236353,CDM,C1883,HCPCS,0278,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
HC Trach Change,PX-7613150200,CDM,31502,CPT,0761,RC,,,,inpatient,,,694.00,451.10,,,,,,,,,,,,,
HC Myelogram Thoracic,PX-3616230300,CDM,62303,CPT,0361,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
HC Tmj Open/Closed Mouth Unilateral,PX-3207032800,CDM,70328,CPT,0320,RC,,,,outpatient,,,96.00,62.40,,,,,,,,,,,,,
CYTAL WOUND MATRIX 3 LAYER LAWD 16X35CM,SUP-2909167,CDM,Q4166,HCPCS,0636,RC,,,,both,,,24190.56,15723.86,,,,,,,,,,,,,
MESH SYN ABD N ABSRB RECT POLYPR W EXP,SUP-2126098,CDM,C1781,HCPCS,0278,RC,,,,both,,,6053.92,3935.05,,,,,,,,,,,,,
OSTEOTOME SURG W44XL205MM RT CVD RT W/ GRD ANDERSON-NEIVERT,SUP-2129696,CDM,2720000010,LOCAL,0272,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
BUR SURG DIAMOND 1.5 MMX16 CM MTCH HD BRN STRL LTX,SUP-2859541,CDM,2720000010,LOCAL,0272,RC,,,,both,,,584.04,379.63,,,,,,,,,,,,,
PLATE 2 CLMN DSTL VLR RAD 2.4MM 7H HD 5H SHFT LT STRL TI,SUP-2546714,CDM,C1713,HCPCS,0278,RC,,,,both,,,2842.55,1847.66,,,,,,,,,,,,,
HC Immunoassay Tumor Antigen Quantitative Ca 15-3,PX-3028630000,CDM,86300,CPT,0302,RC,,,,both,,,140.00,91.00,,,,,,,,,,,,,
HC Tmj Open/Closed Mouth Unilateral,PX-3207032800,CDM,70328,CPT,0320,RC,,,,inpatient,,,96.00,62.40,,,,,,,,,,,,,
TRAY EPIDURAL TUOHY NDL DIA20 GA SGL SHT LIDO NACL SYR CLR,SUP-2936485,CDM,2720000010,LOCAL,0272,RC,,,,both,,,51.12,33.23,,,,,,,,,,,,,
MESH HERN 15X10CM L POLY CLLGN COAT ANAT W LAT SLT,SUP-2752159,CDM,C1781,HCPCS,0278,RC,,,,both,,,716.64,465.82,,,,,,,,,,,,,
SPADE TIP DRILL FOR 2.9MM PUSHLOCK,SUP-2812459,CDM,2720000010,LOCAL,0272,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
COMPRESSOR SURG OPN FOR SM EXT FIX,SUP-2188699,CDM,C1713,HCPCS,0278,RC,,,,both,,,1987.62,1291.95,,,,,,,,,,,,,
CATHETER IV SINGLE LEMEN 4 FR DOT KT MBP POWERMIDLINE,SUP-2626733,CDM,C1751,HCPCS,0278,RC,,,,both,,,449.02,291.86,,,,,,,,,,,,,
PACEMAKER CARD PERM SGL CHMBR STD UPLR BPLR SSIR IS 1 CONN,SUP-2357332,CDM,C1786,HCPCS,0275,RC,,,,both,,,11618.00,7551.70,,,,,,,,,,,,,
KIT REPL INDWL LO PRSS VOICE PROSTHESES SER 6MM BLOM SINGER,SUP-2246403,CDM,L8509,HCPCS,0274,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
CROWN DENT D7 PEDIATRIC 1ST PRIMARY M UPPER RT SS,SUP-2239041,CDM,D6783,CPT,0278,RC,,,,both,,,18.81,12.23,,,,,,,,,,,,,
PLATE BNE TI ORTHOGNATHIC 5 PLATE CUSTOMIZED FACE ID,SUP-2883698,CDM,C1713,HCPCS,0278,RC,,,,both,,,30561.78,19865.16,,,,,,,,,,,,,
CATHETER CV 3 LUMEN MED 7 FRX16 CM MULT MED,SUP-2214688,CDM,C1751,HCPCS,0278,RC,,,,both,,,137.66,89.48,,,,,,,,,,,,,
SEALANT TISS FIBRIN 5 CC W/ CTRL TIP EVICEL,SUP-2738904,CDM,2720000010,LOCAL,0272,RC,,,,both,,,14149.31,9197.05,,,,,,,,,,,,,
CHOLANGIOGRAM KIT RX AUTOTOME UTOM XL SPHINTOM JAGWIRE 7519,SUP-2525324,CDM,C1769,HCPCS,0272,RC,,,,both,,,656.26,426.57,,,,,,,,,,,,,
IRON SUCROSE 400 MG IN NS 270 ML IVPB,RX-4081282,CDM,J1756,HCPCS,0636,RC,99999-9008-30,NDC,,both,270,ML,876.20,569.53,,,,,,,,,,,,,
HC CT Pelvis W/WO Contrast,PX-3527219400,CDM,72194,CPT,0352,RC,,,,inpatient,,,2630.00,1709.50,,,,,,,,,,,,,
SCREWDRIVER SURG T6 LIN DRVR SHFT W/ AO QUIK CPLR,SUP-2417067,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1400.44,910.29,,,,,,,,,,,,,
GRAFT HUM TISS ARTC CART NAT DENOVO,SUP-2200262,CDM,C1762,CPT,0278,RC,,,,both,,,14638.68,9515.14,,,,,,,,,,,,,
STENT PANCREATIC ELECTROCAUTERY 24X15X10 MM 10.8 FRX138 CM,SUP-2459413,CDM,C1874,HCPCS,0278,RC,,,,both,,,12289.96,7988.47,,,,,,,,,,,,,
DILATOR SHTH OUTER L33CM OD14FR ID11.2FR INNR L43CM OD10.9FR,SUP-2353159,CDM,C1894,HCPCS,0272,RC,,,,both,,,810.12,526.58,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 10 CM DIA 3 MM EPTFE STR TW N RING,SUP-2396325,CDM,C1768,CPT,0278,RC,,,,both,,,1136.68,738.84,,,,,,,,,,,,,
HC Dx Bone Marrow Bx & Aspir,PX-7613822200,CDM,38222,CPT,0761,RC,,,,both,,,8633.00,5611.45,,,,,,,,,,,,,
SET URET CATH 5FR L130CM PLUG L80CM ILLUMINATING SGL LUMN,SUP-2171299,CDM,C1758,HCPCS,0278,RC,,,,both,,,607.40,394.81,,,,,,,,,,,,,
RISPERIDONE 1 MG PO TABS,RX-18313,CDM,6370000000,HCPCS,0637,RC,68084-0272-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
GRAFT VASC IMPRA L 15 CM DIA 3-6 MM EPTFE STP STD WALL N,SUP-2761527,CDM,C1768,CPT,0278,RC,,,,both,,,814.36,529.33,,,,,,,,,,,,,
KIT REPL INDWL LO PRSS VOICE PROSTHESES SER 6MM BLOM SINGER,SUP-2246403,CDM,L8509,HCPCS,0272,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
SCREW BNE L75MM DIA5MM CANN LOK,SUP-2184919,CDM,C1713,HCPCS,0278,RC,,,,both,,,613.87,399.02,,,,,,,,,,,,,
DILATOR PENILE PROS 9-12MM DISP,SUP-2138906,CDM,C1713,HCPCS,0278,RC,,,,both,,,838.79,545.21,,,,,,,,,,,,,
GRAFT BNE FOAM 50X10X5 MM 5 CC 2 STRP STRL BI-OSTETIC,SUP-2134724,CDM,C1713,HCPCS,0278,RC,,,,both,,,4450.95,2893.12,,,,,,,,,,,,,
SCREW BONE SELFTAPPING 4X58 MM CORTICAL HUMERAL TITANIUM NON,SUP-2837144,CDM,C1713,HCPCS,0278,RC,,,,both,,,1002.07,651.35,,,,,,,,,,,,,
PLATE BNE L4.5MM 6 H TI FOR 4.5/5.5/6.5MM SCR L FRAG,SUP-2412040,CDM,C1713,HCPCS,0278,RC,,,,both,,,741.04,481.68,,,,,,,,,,,,,
HC So Hla Class I&II Antibody Qual,PX-3028682866,CDM,86828,CPT,0302,RC,,,,both,,,168.00,109.20,,,,,,,,,,,,,
BLADE REPROC CUTTER RESECT FORUMLA 3.5MM,SUP-2653123,CDM,2720000010,LOCAL,0272,RC,,,,both,,,63.90,41.53,,,,,,,,,,,,,
INSERT SYS 12 10DEG DURATN P3 28MM,SUP-2376145,CDM,C1776,CPT,0278,RC,,,,both,,,2004.11,1302.67,,,,,,,,,,,,,
CHIPS BNE GRFT 15CC 1-4MM ALLGRFT CANC FRZ DRY PRESERVATION,SUP-2293747,CDM,C1713,HCPCS,0278,RC,,,,both,,,1169.96,760.47,,,,,,,,,,,,,
PLATE BONE L220MM THK3.7MM 12 H LT DSTL MEDL TIB TI LCK,SUP-2190884,CDM,C1713,HCPCS,0278,RC,,,,both,,,4488.00,2917.20,,,,,,,,,,,,,
PS TIBIAL BEARING SIZE 10 16MM VIT E,SUP-2813227,CDM,C1776,CPT,0278,RC,,,,both,,,6386.76,4151.39,,,,,,,,,,,,,
SHEATH INTRO PINNACLE L 10 CM 9 FR GUIDEWIRE PERIPHERAL,SUP-2385684,CDM,C1894,HCPCS,0272,RC,,,,both,,,18.06,11.74,,,,,,,,,,,,,
PLATE BURR H L 54.8 MM DIA 48 MM THK 0.51 MM TI NS DISP,SUP-2935927,CDM,C1713,HCPCS,0278,RC,,,,both,,,2191.72,1424.62,,,,,,,,,,,,,
SEGMENTAL FEM/TIB MALE-FEMALE 30MM,SUP-2502403,CDM,C1776,CPT,0278,RC,,,,both,,,9269.28,6025.03,,,,,,,,,,,,,
DEVICE INFLATION BALLOON L 5 CM DIA24/18 FR PACLITAXEL COAT,SUP-2881839,CDM,C1889,HCPCS,0278,RC,,,,both,,,11775.00,7653.75,,,,,,,,,,,,,
SCREW BONE L20MM DIA3.5MM CORT S STL ST SELF DRL CANN,SUP-2183897,CDM,C1713,HCPCS,0278,RC,,,,both,,,754.29,490.29,,,,,,,,,,,,,
STENT PANCREATIC ZMMN L 40 MM DIA 7 FR CHANNEL 3.2 MM,SUP-2675680,CDM,C2617,HCPCS,0278,RC,,,,both,,,172.70,112.25,,,,,,,,,,,,,
PLATE BNE W17.5XL350MM THK5.2MM 16 H NONSTERILE R CNDYL FEM,SUP-2185047,CDM,C1713,HCPCS,0278,RC,,,,both,,,4998.69,3249.15,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED STD H1 HD COCR,SUP-2419697,CDM,C1776,CPT,0278,RC,,,,both,,,10362.00,6735.30,,,,,,,,,,,,,
BIT DRL TIP DIA3.1MM TAPR DIA4.6MM CANN REG DENS BNE ACUTRK,SUP-2107225,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2493.16,1620.55,,,,,,,,,,,,,
ARTISS FROZEN SOLUTION 2ML,SUP-2827667,CDM,C9250,HCPCS,0636,RC,,,,both,,,580.40,377.26,,,,,,,,,,,,,
SLEEVE SURG HOLDING 3.5-4X123 MM,SUP-2472916,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1491.50,969.47,,,,,,,,,,,,,
PLATE BONE 4 H STR MOTOBAND CP,SUP-2174979,CDM,C1713,HCPCS,0278,RC,,,,both,,,5920.47,3848.31,,,,,,,,,,,,,
BIT DRL MED 3.5 MM POWEREASE,SUP-2628251,CDM,2720000010,LOCAL,0272,RC,,,,both,,,998.71,649.16,,,,,,,,,,,,,
CRYOABLATION KIT PROST ICEPEARL 2.1 CX 10891] FORTEC MEDICAL INC],SUP-2225694,CDM,2720000010,LOCAL,0272,RC,,,,both,,,12073.30,7847.64,,,,,,,,,,,,,
SYSTEM INFL BAL L16MM DIA6MM MAX M-110C F-70 S-0 PRECIS SGL,SUP-2106364,CDM,C1729,HCPCS,0272,RC,,,,both,,,6123.00,3979.95,,,,,,,,,,,,,
HANDPIECE PHACO FRAGMENTATION STELLARIS PC LF,SUP-2472660,CDM,2720000010,LOCAL,0272,RC,,,,both,,,15429.96,10029.47,,,,,,,,,,,,,
VALVE CSF FLO CTRL REG CONTOURED MED PRESSURE W/ BIOGLDE,SUP-2631417,CDM,C1889,HCPCS,0278,RC,,,,both,,,2599.92,1689.95,,,,,,,,,,,,,
COMPONENT KNEE CEM W/ PSI,SUP-2212346,CDM,C1776,CPT,0278,RC,,,,both,,,10833.00,7041.45,,,,,,,,,,,,,
STENT URET STR 0.038 IN 7 FRX28 CM 6 FR DBL PGTL SFT CNTOUR,SUP-2465699,CDM,C2617,HCPCS,0278,RC,,,,both,,,564.57,366.97,,,,,,,,,,,,,
SYSTEM OCCL DEL AMPLATZER 180 DEG L 80 CM SHTH 6 FR NIT MESH,SUP-2116315,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1821.20,1183.78,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 12X12X12 MM FUSIONFLEX,SUP-2759431,CDM,C1713,HCPCS,0278,RC,,,,both,,,2203.28,1432.13,,,,,,,,,,,,,
DEFIBRILLATOR IMPL VISIA AF MRI S VR SURESCAN W 51 X H 66 MM,SUP-2421054,CDM,C1722,HCPCS,0275,RC,,,,both,,,38264.32,24871.81,,,,,,,,,,,,,
PLATE BNE SM W11XL111MM THK34MM 8 H BILAT TI RIG NEUT LOK,SUP-2190781,CDM,C1713,HCPCS,0278,RC,,,,both,,,1007.88,655.12,,,,,,,,,,,,,
PLATE BNE STR LG 1.5X28X1 MM MIDFACE 6 HOLE W/ TAB NS,SUP-2493927,CDM,C1713,HCPCS,0278,RC,,,,both,,,502.81,326.83,,,,,,,,,,,,,
PROBE COAG 6.9FR L3M CONVENIENT BLT IN FLTR 3000A FIAPC,SUP-2217946,CDM,2720000010,LOCAL,0272,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
SCREW BONE L50MM DIA6MM CORT TI ST CANN LCK FULL THRD HEX HD,SUP-2191836,CDM,C1713,HCPCS,0278,RC,,,,both,,,631.05,410.18,,,,,,,,,,,,,
MOST FEMORAL SEGMENT 42.5MM,SUP-2509220,CDM,C1776,CPT,0278,RC,,,,both,,,7276.95,4730.02,,,,,,,,,,,,,
SYSTEM EMBOLIC PROTCT FILTERWIRE EZ L 300 CM RVD 3.5 - 5.5,SUP-2143664,CDM,C1769,HCPCS,0272,RC,,,,both,,,4286.10,2785.96,,,,,,,,,,,,,
BOWL BONE CEM MX OPTITWIST,SUP-2196560,CDM,2720000010,LOCAL,0272,RC,,,,both,,,414.48,269.41,,,,,,,,,,,,,
DRAINAGE SET STD INTEGR 1 PC M LL CONN CLP EXAFLOW,SUP-2666669,CDM,C1729,HCPCS,0272,RC,,,,both,,,571.20,371.28,,,,,,,,,,,,,
STAPLE BONE FIX OFFSET 5MM FOR OSTEOTMY,SUP-2342734,CDM,C1713,HCPCS,0278,RC,,,,both,,,2357.45,1532.34,,,,,,,,,,,,,
CATHETER INFUSION STR 200 CM 2.7/2.4 FRX155 CM FATHOM-16,SUP-2653477,CDM,C1887,HCPCS,0272,RC,,,,both,,,2499.44,1624.64,,,,,,,,,,,,,
PLATE BNE MISC BIN FRAG SYS NS F3 LTX,SUP-2861300,CDM,C1713,HCPCS,0278,RC,,,,both,,,1047.88,681.12,,,,,,,,,,,,,
SCREW BNE CANN SHT THRD HD MINI MONSTER 3.5 X 28MM,SUP-2320502,CDM,C1713,HCPCS,0278,RC,,,,both,,,769.30,500.04,,,,,,,,,,,,,
PLATE BNE L385MM 16 H ST PROX FEM S STL HK LO PROF LOK COMPR,SUP-2186067,CDM,C1713,HCPCS,0278,RC,,,,both,,,5742.31,3732.50,,,,,,,,,,,,,
COMPONENT TIB EXT X LG 3 ANK COCR SALTO TALARIS,SUP-2244191,CDM,C1776,CPT,0278,RC,,,,both,,,19527.03,12692.57,,,,,,,,,,,,,
KIT DRL BIT OD2.10MM FOR MDLLRY CNL HAMMERLOCK 2,SUP-2194166,CDM,2720000010,LOCAL,0272,RC,,,,both,,,759.69,493.80,,,,,,,,,,,,,
SEALANT TISS 4 CC TISSEEL KT,SUP-2129851,CDM,2720000010,LOCAL,0272,RC,,,,both,,,689.07,447.90,,,,,,,,,,,,,
"HC Insert Picc Cath, 5/> Yrs - Anes",PX-3613656901,CDM,36569,CPT,0361,RC,,,,both,,,4942.00,3212.30,,,,,,,,,,,,,
CUPRIC CHLORIDE 0.4 MG/ML IV SOLN,RX-1985,CDM,J3490,HCPCS,0636,RC,00409-4092-01,NDC,,both,10,ML,182.40,118.56,,,,,,,,,,,,,
NAIL IM L330MM DIA11MM STD TIB TI CANN LOK CEPHALOMEDULLARY,SUP-2368787,CDM,C1713,HCPCS,0278,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY AFOCUS L 110 CM DIA 5 FR TIP L 20,SUP-2141326,CDM,C1730,HCPCS,0272,RC,,,,both,,,3124.30,2030.79,,,,,,,,,,,,,
SCREW BNE L 14 MM DIA2.2 MM SM CANN STRL QFX,SUP-2932858,CDM,C1713,HCPCS,0278,RC,,,,both,,,736.52,478.74,,,,,,,,,,,,,
PROSTHESIS OSS PISTON 0.6X4.75 MM SHEA CUP PLAT FLROPLAS,SUP-2637821,CDM,L8613,CPT,0278,RC,,,,both,,,418.03,271.72,,,,,,,,,,,,,
TROCAR SURG TRANSFIXING PIN FIX SYS BLK XTRAFIX,SUP-2199736,CDM,2720000010,LOCAL,0272,RC,,,,both,,,362.23,235.45,,,,,,,,,,,,,
STENT URET L 24 CM DIA 4.8 FR PERCFLX 2 PIGTL LP FIRM SHFT,SUP-2722599,CDM,C2617,HCPCS,0278,RC,,,,both,,,260.87,169.57,,,,,,,,,,,,,
CATHETER ANGIOPLSTY OTW 4 FRX130 CM 4X200 MM PACIFIC+,SUP-2281330,CDM,C1725,HCPCS,0272,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
SUPPORT ORTHOT THOR LUMBAR SACR CUST SAGITTAL-CORONAL CTRL 3,SUP-2435550,CDM,L0492,HCPCS,0274,RC,,,,both,,,1415.86,920.31,,,,,,,,,,,,,
INDAPAMIDE 2.5 MG PO TABS,RX-3879,CDM,6370000000,HCPCS,0637,RC,62559-0511-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
NEOMYCIN-POLYMYXIN-HC 3.5-10000-1 OT SUSP,RX-28810,CDM,6370000000,HCPCS,0637,RC,24208-0635-62,NDC,,both,10,ML,377.60,245.44,,,,,,,,,,,,,
BUR SURG DIAMOND 1 MM 9 CM BALL CRV MIDAS REX LEGEND,SUP-2631891,CDM,2720000010,LOCAL,0272,RC,,,,both,,,897.82,583.58,,,,,,,,,,,,,
SHEATH INTRO PRELUDE ROADSTER L 90 CM DIA 6 FR COAT L 35 CM,SUP-2911979,CDM,C1894,HCPCS,0272,RC,,,,both,,,386.22,251.04,,,,,,,,,,,,,
SPACER SPNL 10 MM COR POST FUSION OCTAVE,SUP-2264524,CDM,C1889,HCPCS,0278,RC,,,,both,,,10990.00,7143.50,,,,,,,,,,,,,
BASKET STONE REMV W1.5XL3.5CM SHTH 7FR 4 WIR ROT PIN VISE,SUP-2169281,CDM,2720000010,LOCAL,0272,RC,,,,both,,,753.60,489.84,,,,,,,,,,,,,
PROSTHESIS OSS L8MM TRIM L57MM HD W4MM FLNG DIA4MM SHFT,SUP-2312571,CDM,L8613,CPT,0278,RC,,,,both,,,1209.21,785.99,,,,,,,,,,,,,
PIN LOCATING DIA2MM,SUP-2878596,CDM,2720000010,LOCAL,0272,RC,,,,both,,,596.60,387.79,,,,,,,,,,,,,
BUR SURG TOT L 82 MM CUT L 30 MM DIA 3 MM SHANNON-STYLE STR AO,SUP-2881148,CDM,2720000010,LOCAL,0272,RC,,,,both,,,728.64,473.62,,,,,,,,,,,,,
SET INTRO MICROEZ L 35 CM CATH 5 FR NDL L 5 CM SS GUIDEWIRE,SUP-2125497,CDM,C1751,HCPCS,0278,RC,,,,both,,,100.48,65.31,,,,,,,,,,,,,
KIT CATH LOCATABLE GUID OLY,SUP-2381759,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3476.77,2259.90,,,,,,,,,,,,,
DENOSUMAB 120 MG/1.7ML SC SOLN,RX-107208,CDM,J0897,HCPCS,0636,RC,55513-0730-01,NDC,,both,1.7,ML,10176.80,6614.92,,,,,,,,,,,,,
BUR SURG L98MM DIA1MM S STL CRV FLUT CUT VISAO,SUP-2284225,CDM,C1713,HCPCS,0278,RC,,,,both,,,740.16,481.10,,,,,,,,,,,,,
BUTTON FIX DIA17MM SUT ACL PCL FOR GRFT DELRIN,SUP-2341304,CDM,C1713,HCPCS,0278,RC,,,,both,,,227.15,147.65,,,,,,,,,,,,,
DEFIBRILLATOR IMPL LUMAX 30 J TI EPOXY RESIN SIL SINGLE,SUP-2138115,CDM,C1722,HCPCS,0275,RC,,,,both,,,62583.34,40679.17,,,,,,,,,,,,,
BEAM FIX L130MM DIA4.5MM ARTH,SUP-2223933,CDM,C1713,HCPCS,0278,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
MOLD CEMENT SPACER STEM DIA10 MM HD DIA 48 MM OFFSET 18 MM,SUP-2898430,CDM,C1713,HCPCS,0278,RC,,,,both,,,11570.90,7521.08,,,,,,,,,,,,,
GRAFT BNE W14XL24MM THK25X6MM BICORT COT WDG FOR OSTEOTMY,SUP-2399092,CDM,C1713,HCPCS,0278,RC,,,,both,,,5105.64,3318.67,,,,,,,,,,,,,
HC Hdr Brachy Seed IR 192,PX-2780171701,CDM,C1717,HCPCS,0278,RC,,,,both,,,1859.00,1208.35,,,,,,,,,,,,,
METFORMIN HCL ER 500 MG PO TB24,RX-28995,CDM,6370000000,HCPCS,0637,RC,50268-0550-15,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
REDAPT 300MM SLV REV STEM SZ 19 STD OFFSET,SUP-2419251,CDM,C1776,CPT,0278,RC,,,,both,,,18212.00,11837.80,,,,,,,,,,,,,
DRILL SURG SM DIA4-5.5MM STP,SUP-2417457,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1531.28,995.33,,,,,,,,,,,,,
BUR SURG BALL 4 MM FLUT,SUP-2848214,CDM,2720000010,LOCAL,0272,RC,,,,both,,,531.35,345.38,,,,,,,,,,,,,
PLATE BNE SCREW DIA2.8 MM TI MANDIBULAR FULL CUSTOMIZED,SUP-2883222,CDM,C1713,HCPCS,0278,RC,,,,both,,,32467.60,21103.94,,,,,,,,,,,,,
ALLOGRAFT BNE BLOCK 8X15 MM IL TRICORT CORNERSTONE,SUP-2293822,CDM,C1713,HCPCS,0278,RC,,,,both,,,1877.72,1220.52,,,,,,,,,,,,,
SLEEVE POS DIA15MM UNIV SHLDR CO CHROM CEM PRI FOR HUM FRAC,SUP-2404537,CDM,C1776,CPT,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
PLATE 3.5MM CURVED BROAD LCP 28 HOLE-STERILE,SUP-2546109,CDM,C1713,HCPCS,0278,RC,,,,both,,,3924.91,2551.19,,,,,,,,,,,,,
PLATE BNE SM W11XL38MM THK3.3MM 0DEG 3 H BILAT TI STR RIG,SUP-2190772,CDM,C1713,HCPCS,0278,RC,,,,both,,,476.28,309.58,,,,,,,,,,,,,
GUIDEWIRE W/ THRD TIP FOR CERV SCR SMOOTH BLNT TIP L2.0MM,SUP-2204929,CDM,C1769,HCPCS,0272,RC,,,,both,,,84.78,55.11,,,,,,,,,,,,,
SALVATION L BRKT NEW GEN,SUP-2401141,CDM,2720000010,LOCAL,0272,RC,,,,both,,,967.12,628.63,,,,,,,,,,,,,
BAND EXT FIX ACUTE ADJ NS DISP SMRT TSF,SUP-2933829,CDM,2720000010,LOCAL,0272,RC,,,,both,,,247.37,160.79,,,,,,,,,,,,,
PLATE EXT FIX L75MM S STL 6 H SH CONN IMP ILIZ,SUP-2342294,CDM,C1713,HCPCS,0278,RC,,,,both,,,727.95,473.17,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA FT PLU MAXBARR S1295108FD3,SUP-2632816,CDM,C1751,HCPCS,0278,RC,,,,both,,,1037.71,674.51,,,,,,,,,,,,,
COIL EMB L40CM DIA002IN LOOP DIA7MM COMPLX STD FRME RUBY,SUP-2323667,CDM,C1889,HCPCS,0278,RC,,,,both,,,4050.60,2632.89,,,,,,,,,,,,,
SLEEVE TIB L7CM TI POR PROX KNEE REDUC SZ OSS MARTI VIERZON,SUP-2406487,CDM,C1776,CPT,0278,RC,,,,both,,,11770.29,7650.69,,,,,,,,,,,,,
NEEDLE BRONCH TREE BRONCH INTACT HLTH NAKHOSTEEN BRONCHSCP,SUP-2772833,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2348.22,1526.34,,,,,,,,,,,,,
HC So Neo Gsap Dna Mcrstl Ins,PX-3108145766,CDM,81457,CPT,0310,RC,,,,outpatient,,,5225.00,3396.25,,,,,,,,,,,,,
SCREW BNE 3.5X14 MM TI,SUP-2321690,CDM,C1713,HCPCS,0278,RC,,,,both,,,433.01,281.46,,,,,,,,,,,,,
MIDAZOLAM-SODIUM CHLORIDE 100-0.9 MG/100ML-% IV SOLN,RX-153672,CDM,J2251,HCPCS,0636,RC,44567-0611-10,NDC,,both,100,ML,172.50,112.12,,,,,,,,,,,,,
SPACER SPNL W20XH12XL55MM 18DEG LORD OBLQ LAT LUM INTBDY FUS,SUP-2421108,CDM,C1889,HCPCS,0278,RC,,,,both,,,16365.68,10637.69,,,,,,,,,,,,,
KIT SUT ANCHR BTTN PLT OPT ASMBLY,SUP-2401368,CDM,C1713,HCPCS,0278,RC,,,,both,,,2386.40,1551.16,,,,,,,,,,,,,
ANCHOR STRE 1.4MML PRLDD IMPLNT W/ NDLE/1.4MM DRILL SHRT SRL,SUP-2589288,CDM,C1713,HCPCS,0278,RC,,,,both,,,1301.22,845.79,,,,,,,,,,,,,
IMPLANT BIO TISS SZ 4 X 5 CM NOM THK 0.15-0.25 MM BOV,SUP-2894046,CDM,C1768,CPT,0278,RC,,,,both,,,816.40,530.66,,,,,,,,,,,,,
MATRIX BIO L 2 X W 2 CM SZ 7 SQCM FISH SKIN DERMAL PREMESHED,SUP-2909222,CDM,Q4158,HCPCS,0636,RC,,,,both,,,2835.42,1843.02,,,,,,,,,,,,,
BAR SUPP ANK DISTRACTOR SYS,SUP-2340727,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
STEM HUM FRAC R 7MM EQUINOXE,SUP-2223294,CDM,C1776,CPT,0278,RC,,,,both,,,7181.18,4667.77,,,,,,,,,,,,,
SCREW SPNL L30MM OD5.5MM S STL CANC PEDCL ST FIX ANG,SUP-2288872,CDM,C1713,HCPCS,0278,RC,,,,both,,,2398.18,1558.82,,,,,,,,,,,,,
KIT INSRTN INTRO L 6 IN CATH DIA 7.5 FR 40 CC PACKAGED STRL,SUP-2908666,CDM,C1894,HCPCS,0272,RC,,,,both,,,486.57,316.27,,,,,,,,,,,,,
SCREW SET 0.25-32 IN FLSH BRK STRL CD HORZ,SUP-2629305,CDM,C1713,HCPCS,0278,RC,,,,both,,,109.90,71.43,,,,,,,,,,,,,
CATHETER SUPRAPUBIC MUSHRM 2 36 FR PEZ,SUP-2126756,CDM,C2627,HCPCS,0272,RC,,,,both,,,31.56,20.51,,,,,,,,,,,,,
GRAFT DURA L 3 X W 3 IN TYP I CLLGN BOV ACHILLES TEND RESRB,SUP-2889756,CDM,C1763,HCPCS,0278,RC,,,,both,,,2463.55,1601.31,,,,,,,,,,,,,
IMMOBILIZER SHLDR W ABD SM,SUP-2276608,CDM,L3670,HCPCS,0272,RC,,,,both,,,75.74,49.23,,,,,,,,,,,,,
SUPPORT ORTH SM NYL LEG LTWT XCELTRAX AIR,SUP-2197147,CDM,L4370,HCPCS,0272,RC,,,,both,,,78.06,50.74,,,,,,,,,,,,,
SPLINT ORTHOPEDIC CLAV 18-20 IN 2XS PEDIATRIC PROCARE,SUP-2196975,CDM,L3670,HCPCS,0272,RC,,,,both,,,14.57,9.47,,,,,,,,,,,,,
FILLER BONE VOID 3ML PUTTY HA NORIAN SRS,SUP-2341402,CDM,C1713,HCPCS,0278,RC,,,,both,,,263.76,171.44,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 70 CM DIA 4-7 MM SHRT TAPR REINF,SUP-2669626,CDM,C1768,CPT,0278,RC,,,,both,,,1481.45,962.94,,,,,,,,,,,,,
GUIDEWIRE VASC L150CM DIA0.035IN TIP L3MM PTFE J CRV FIX,SUP-2302704,CDM,C1769,HCPCS,0272,RC,,,,both,,,22.20,14.43,,,,,,,,,,,,,
CLAMP SURG DIA16MM CRAN TI RAP SAFE HEALING LO PROF,SUP-2108414,CDM,C1713,HCPCS,0278,RC,,,,both,,,503.59,327.33,,,,,,,,,,,,,
APPLIER CLIP 8.75IN ANEURYSM VARIO MINI BAYONET SWIVEL REUSA,SUP-2821710,CDM,C1889,HCPCS,0278,RC,,,,both,,,6032.41,3921.07,,,,,,,,,,,,,
BIT DRL 16 MM DISP,SUP-2243020,CDM,2720000010,LOCAL,0272,RC,,,,both,,,521.24,338.81,,,,,,,,,,,,,
SCREW 3.5MMX44MM HEADLESS DART-FIRE,SUP-2857922,CDM,C1713,HCPCS,0278,RC,,,,both,,,2458.62,1598.10,,,,,,,,,,,,,
VALVULOTOME ANGIOSCOPIC L 9 7/8 IN RETROGRADE NS,SUP-2436427,CDM,2720000010,LOCAL,0272,RC,,,,both,,,344.21,223.74,,,,,,,,,,,,,
SPACER SPNL 24 DEG 42X30X18 MM SOVEREIGN,SUP-2424001,CDM,C1821,HCPCS,0278,RC,,,,both,,,13423.50,8725.27,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC IR 6FR 55CM 2 LUMAN RVS TAP 3276335,SUP-2632673,CDM,C1751,HCPCS,0278,RC,,,,both,,,417.93,271.65,,,,,,,,,,,,,
DRILL TWST L 7 MM DIA1.5 MM STP 5 MM SCREW DIA2 MM CONTRA,SUP-2883878,CDM,2720000010,LOCAL,0272,RC,,,,both,,,292.02,189.81,,,,,,,,,,,,,
PATCH CV HEMGRD L 120 X W 6 MM POLYESTER BOV CLLGN CAR ART,SUP-2266051,CDM,C1768,CPT,0278,RC,,,,both,,,480.70,312.45,,,,,,,,,,,,,
PLATE BNE L 28 MM SCREW DIA2.8 MM MED CP TI RT MANDIBULAR,SUP-2883705,CDM,C1713,HCPCS,0278,RC,,,,both,,,16105.59,10468.63,,,,,,,,,,,,,
GRAFT BNE SUB 5ML HCT P IN CORTICOCANCELLOUS CELLULAR BNE,SUP-2194156,CDM,C1713,HCPCS,0278,RC,,,,both,,,6813.80,4428.97,,,,,,,,,,,,,
DEFIBRILLATOR IMPL LUMAX 500 DR-T TI EPOXY RESIN SIL 2 CHMBR,SUP-2138127,CDM,C1721,HCPCS,0275,RC,,,,both,,,33284.00,21634.60,,,,,,,,,,,,,
LENS IO +28.0 DIOPT L10.5MM,SUP-2392376,CDM,V2632,HCPCS,0276,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
PLATE SPNL ANTR CSPN TI,SUP-2280000,CDM,C1713,HCPCS,0278,RC,,,,both,,,3143.14,2043.04,,,,,,,,,,,,,
CATHETER DIAG L155CM OD2.6X2FR ID0.015IN 0.012IN MIC,SUP-2367849,CDM,C1887,HCPCS,0272,RC,,,,both,,,2892.57,1880.17,,,,,,,,,,,,,
SHELL ACET DIA58MM LNR SZ F 2 H MPACT,SUP-2267377,CDM,C1776,CPT,0278,RC,,,,both,,,4547.98,2956.19,,,,,,,,,,,,,
GRAFT VASC STR STD WALL RING STRTCH 6MM DIA 20CM LEN GORTX,SUP-2396000,CDM,C1768,CPT,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
ROD EXT FIX L200MM THRD STR SIDEKCK FREE CIR FIX,SUP-2400599,CDM,2720000010,LOCAL,0272,RC,,,,both,,,178.98,116.34,,,,,,,,,,,,,
SURGICAL PROCEDURE KIT ENDOSCP OUTPT CUST,SUP-2217545,CDM,C1729,HCPCS,0272,RC,,,,both,,,21.07,13.70,,,,,,,,,,,,,
ALLOGRAFT PLACENTAL MATRIX 4CM X 6CM AMNIOBAND,SUP-2877946,CDM,C1762,CPT,0278,RC,,,,both,,,8049.20,5231.98,,,,,,,,,,,,,
HC Observation per Hour,PX-7620037800,CDM,G0378,CPT,0762,RC,,,,both,,,78.00,50.70,,,,,,,,,,,,,
PIN EXTRACTOR,SUP-2136768,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4898.40,3183.96,,,,,,,,,,,,,
PLATE LK POLYAXIAL LT SHRT T10,SUP-2704905,CDM,C1713,HCPCS,0278,RC,,,,both,,,5171.89,3361.73,,,,,,,,,,,,,
ROD SPNL 50 MM,SUP-2415851,CDM,C1713,HCPCS,0278,RC,,,,both,,,913.74,593.93,,,,,,,,,,,,,
CATHETER DRAINAGE PIG 0.025 IN 6 FRX25 CM BILI SET UTHANE,SUP-2168619,CDM,C1729,HCPCS,0272,RC,,,,both,,,248.53,161.54,,,,,,,,,,,,,
PLATE BNE LCK 3.5X130 MM RT DSTL MEDL HUM 7 HOLE FIX ANGLE,SUP-2525041,CDM,C1713,HCPCS,0278,RC,,,,both,,,2918.57,1897.07,,,,,,,,,,,,,
SCREW BNE ST 1.3X10 MM CRTX W/ FLUT TIP TI MTRX GLD NS LF,SUP-2189184,CDM,C1713,HCPCS,0278,RC,,,,both,,,274.75,178.59,,,,,,,,,,,,,
HC Dialysis Other Than Hemo (Crt/Peritoneal),PX-8029094500,CDM,90945,CPT,0802,RC,,,,inpatient,,,1278.00,830.70,,,,,,,,,,,,,
STAPLE BNE W10XL10MM NIT SHP MEM COMPRESSIVE FORC DISP,SUP-2399892,CDM,C1713,HCPCS,0278,RC,,,,both,,,3598.44,2338.99,,,,,,,,,,,,,
HEAD FEM DIA36MM +1MM OFFSET CERAMIC DELT U-MOTION II,SUP-2391366,CDM,C1776,CPT,0278,RC,,,,both,,,4282.96,2783.92,,,,,,,,,,,,,
BUR SURG L9CM DIA254MM MTL WHL MIDAS REX LEGEND,SUP-2280239,CDM,2720000010,LOCAL,0272,RC,,,,both,,,479.73,311.82,,,,,,,,,,,,,
HC Assay of Glutamyltrase Gamma,PX-3018297700,CDM,82977,CPT,0301,RC,,,,both,,,140.00,91.00,,,,,,,,,,,,,
ALLOGRAFT BNE 250-1000 MH 1.20 CC FD MINERALIZED ORAGRAFT,SUP-2740966,CDM,C1713,HCPCS,0278,RC,,,,both,,,217.95,141.67,,,,,,,,,,,,,
PLATE BNE W12XL151MM THK1MM 9 H BILAT S STL SEMI TBLR LO,SUP-2184870,CDM,C1713,HCPCS,0278,RC,,,,both,,,283.26,184.12,,,,,,,,,,,,,
PLATE STRNL CLOSURE THK 1.5 MM 4 H TI BX LP NS STERNALOCK EZ,SUP-2894461,CDM,C1713,HCPCS,0278,RC,,,,both,,,1460.10,949.06,,,,,,,,,,,,,
CUSHION HEEL W/ BLU DOT S,SUP-2151867,CDM,L3334,HCPCS,0274,RC,,,,both,,,48.36,31.43,,,,,,,,,,,,,
DRILL SURG DIA3MM CRWN FOR UNIV SCR EXTR,SUP-2368624,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2219.98,1442.99,,,,,,,,,,,,,
BUR SURG 4.1X13 MM FOR WDG MICA,SUP-2431609,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1290.54,838.85,,,,,,,,,,,,,
SCREW BONE L13MM DIA3.5MM NONLOCKING HEXALOBE FOR ACU-LOC 2,SUP-2106640,CDM,C1713,HCPCS,0278,RC,,,,both,,,219.80,142.87,,,,,,,,,,,,,
CATHETER SZ PTS-X L 110 CM BALLOON L 3 CM DIA25 MM INTRO 8,SUP-2659789,CDM,C1725,HCPCS,0272,RC,,,,both,,,989.10,642.91,,,,,,,,,,,,,
PLATE BONE COMPRESSION SMALL 208 MM PELVIC 16 HOLE CONTOURED,SUP-2837527,CDM,C1713,HCPCS,0278,RC,,,,both,,,4583.93,2979.55,,,,,,,,,,,,,
HC So T3 Reverse,PX-3018448266,CDM,84482,CPT,0301,RC,,,,inpatient,,,181.00,117.65,,,,,,,,,,,,,
PROBE ELECSURG FLX 1.3 MMX2.2 MR ERBEJET 2 DISP,SUP-2734129,CDM,2720000010,LOCAL,0272,RC,,,,both,,,876.06,569.44,,,,,,,,,,,,,
GRAFT VASC IMPRA L 45 CM DIA 5-8 MM EPTFE STP STD WALL N,SUP-2127037,CDM,C1768,CPT,0278,RC,,,,both,,,1150.53,747.84,,,,,,,,,,,,,
SCREW BONE 2MM DIA 16MML TTNM ALLOY CROSS DRIVE 12MM THRDD S,SUP-2677471,CDM,C1713,HCPCS,0278,RC,,,,both,,,316.04,205.43,,,,,,,,,,,,,
BRACE KNEE SM FOR 115 13IN UNIV BUTTERESS NEOPRENE W STBL,SUP-2319243,CDM,L1810,HCPCS,0272,RC,,,,both,,,54.13,35.18,,,,,,,,,,,,,
PIN TENS BND DIA15MM L50MM S STL SMOOTH,SUP-2107849,CDM,C1713,HCPCS,0278,RC,,,,both,,,725.34,471.47,,,,,,,,,,,,,
DYNANITE 1.1 DBL TIP NITI G-WIRE 2 ZONE,SUP-2812885,CDM,C1769,HCPCS,0272,RC,,,,both,,,436.46,283.70,,,,,,,,,,,,,
KIT INSTR DEL COR DCOMPR FOR IO BIOPLASTY,SUP-2120743,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1624.95,1056.22,,,,,,,,,,,,,
SPLINT ORTHOPEDIC CLAV 20-24 IN XS PRNG BCKL PROCARE,SUP-2196976,CDM,L3650,HCPCS,0274,RC,,,,both,,,14.57,9.47,,,,,,,,,,,,,
ALIGNRITE WRIST BLK LNG RGHT XS,SUP-2458402,CDM,L3906,HCPCS,0274,RC,,,,both,,,55.95,36.37,,,,,,,,,,,,,
BIT DRL PAT STP W/ MOD AO FIT N-K II,SUP-2449173,CDM,2720000010,LOCAL,0272,RC,,,,both,,,466.29,303.09,,,,,,,,,,,,,
ELECTRODE ES 24X26FR DIA3MM YEL COAG BRL SHP FOR 24/28FR,SUP-2261198,CDM,C1713,HCPCS,0278,RC,,,,both,,,440.45,286.29,,,,,,,,,,,,,
PACK BONE MAR ASPIR 30ML CONC,SUP-2384781,CDM,C1713,HCPCS,0278,RC,,,,both,,,7520.30,4888.19,,,,,,,,,,,,,
GUIDEWIRE URO L150CM DIA0.035IN STR PTFE MOV COR,SUP-2139327,CDM,C1769,HCPCS,0272,RC,,,,both,,,46.75,30.39,,,,,,,,,,,,,
COLLAR CERV CNTOUR UNIV 3 IN MED DENS FOAM PROCARE,SUP-2196897,CDM,L0180,HCPCS,0272,RC,,,,both,,,7.82,5.08,,,,,,,,,,,,,
PLATE BNE RND 1.5X70 MM CRANIOFACIAL MESH MALL CONTOURABLE,SUP-2191124,CDM,C1713,HCPCS,0278,RC,,,,both,,,5447.90,3541.13,,,,,,,,,,,,,
BONE GRFT SUB GRFT PSTE 10ML,SUP-2293918,CDM,C1713,HCPCS,0278,RC,,,,both,,,2920.20,1898.13,,,,,,,,,,,,,
ELECTRODE ENDO MPLR DISP RL CUT 24FR,SUP-2261188,CDM,2720000010,LOCAL,0272,RC,,,,both,,,473.61,307.85,,,,,,,,,,,,,
STEM FEM SEG 11 CM DPHSEAL KNEE SMOOTH OSS,SUP-2449810,CDM,C1776,CPT,0278,RC,,,,both,,,11424.11,7425.67,,,,,,,,,,,,,
IMPLANT BIO TISS W13XL23MM TEND LIGMNT CLLGN STRP ABSRB,SUP-2388569,CDM,C1781,HCPCS,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
GRAFT VASC GORTX L 30 CM DIA 4-7 MM RNG L 5 CM EPTFE TAPR,SUP-2396103,CDM,C1768,CPT,0278,RC,,,,both,,,1865.16,1212.35,,,,,,,,,,,,,
COMPONENT TIB SZ 4 RT MEDL LT LAT FIX BEAR CEM PRESERVATION,SUP-2251284,CDM,C1776,CPT,0278,RC,,,,both,,,5856.10,3806.46,,,,,,,,,,,,,
SYSTEM LD DEL PACE INTRO,SUP-2149190,CDM,C1898,HCPCS,0275,RC,,,,both,,,2260.80,1469.52,,,,,,,,,,,,,
PLATE BNE 95 DEG SHFT L 156 MM BLADE L 50 MM 9 H SS CNDYL,SUP-2908528,CDM,C1713,HCPCS,0278,RC,,,,both,,,3395.34,2206.97,,,,,,,,,,,,,
PLATE BNE W17.5XL134MM THK5.2MM 7 H BILAT S STL BROAD LOK,SUP-2185288,CDM,C1713,HCPCS,0278,RC,,,,both,,,1192.85,775.35,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 70 CM DIA 4 MM STR STD WALL REINF,SUP-2486471,CDM,C1768,CPT,0278,RC,,,,both,,,1723.17,1120.06,,,,,,,,,,,,,
SLEEVE IM NAIL DIA 8-13 MM LNG TIB RIGID PROTCT STRL DISP,SUP-2908074,CDM,2720000010,LOCAL,0272,RC,,,,both,,,698.27,453.88,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY LASSO NAV ECO L 115 CM 7/15 FR,SUP-2248626,CDM,C1730,HCPCS,0272,RC,,,,both,,,4527.88,2943.12,,,,,,,,,,,,,
STEM HUM L122MM DIA6MM SHLDR PPS FOR FRAC SYS COMPHSVE,SUP-2404912,CDM,C1776,CPT,0278,RC,,,,both,,,7787.20,5061.68,,,,,,,,,,,,,
"HC Transluminal Peripheral Atherectomy, Abdominal Aorta",PX-3610236000,CDM,0236T,HCPCS,0361,RC,,,,both,,,10136.00,6588.40,,,,,,,,,,,,,
BRACE ORTHOPEDIC AFO ANK PREFABRICATED SPRL,SUP-2265016,CDM,L1951,HCPCS,0272,RC,,,,both,,,3240.48,2106.31,,,,,,,,,,,,,
GUIDEWIRE VASC L150CM DIA0.035IN L8CM LNG TAPR SM VES NIT,SUP-2385572,CDM,C1769,HCPCS,0272,RC,,,,both,,,116.02,75.41,,,,,,,,,,,,,
ROPIVACAINE ELASTOMERIC INFUSION 0.2%,RX-4081819201,CDM,C9804,HCPCS,0636,RC,09999-9917-29,NDC,,both,100,ML,75.40,49.01,,,,,,,,,,,,,
WIRE FIX 2X150 MM TI NS KIRSCHNER,SUP-2432340,CDM,C1713,HCPCS,0278,RC,,,,both,,,30.62,19.90,,,,,,,,,,,,,
ROD SPNL L70MM DIA5.5MM SAG THOR LUM TI CDH,SUP-2289156,CDM,C1713,HCPCS,0278,RC,,,,both,,,3098.24,2013.86,,,,,,,,,,,,,
GUIDEWIRE 1.5MMX12IN FOR CANNFLX SCR,SUP-2341355,CDM,C1769,HCPCS,0272,RC,,,,both,,,153.33,99.66,,,,,,,,,,,,,
MESH HERN OVL 12X6 IN POCKETED BIORESORBABLE PHASIX ST,SUP-2855272,CDM,C1781,HCPCS,0278,RC,,,,both,,,25057.20,16287.18,,,,,,,,,,,,,
COIL NEUROVASCULAR WEB SL W 3-7 X H 3 MM DIA 5 MM,SUP-2836311,CDM,C1889,HCPCS,0278,RC,,,,both,,,51794.30,33666.29,,,,,,,,,,,,,
CAGE SPNL L10XW10XH10MM 4 LOBE MESH ANAT FOOTPRINT MOD IMP,SUP-2317725,CDM,C1889,HCPCS,0278,RC,,,,both,,,4747.68,3085.99,,,,,,,,,,,,,
GRAFT BNE CUBE FRZ DRY CANC L 10MMXW 10MMXH 10MM 40CC,SUP-2264687,CDM,C1713,HCPCS,0278,RC,,,,both,,,1556.00,1011.40,,,,,,,,,,,,,
LASER SURG 1CM INDIGO DIFFUSER TIP FBROPT TEMP SENS OPT,SUP-2257669,CDM,C1713,HCPCS,0278,RC,,,,both,,,2747.50,1785.87,,,,,,,,,,,,,
ROD EXT FIX CARBON FIBER,SUP-2362751,CDM,C1713,HCPCS,0278,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
HC Thyroid Stimulating Hormone,PX-3018444300,CDM,84443,CPT,0301,RC,,,,both,,,293.00,190.45,,,,,,,,,,,,,
SCREW BONE L70MM DIA3.5MM CORT DSTL TIB TI NONCANNULATED,SUP-2413384,CDM,C1713,HCPCS,0278,RC,,,,both,,,167.05,108.58,,,,,,,,,,,,,
GRAFT PSTE SYN CA PHSPTE BONESOURCE BVF 10GM,SUP-2374936,CDM,C1713,HCPCS,0278,RC,,,,both,,,2962.59,1925.68,,,,,,,,,,,,,
ROD EXT FIX L220MM WRST C FBR W 4 25MM SCHNZ SCR,SUP-2179122,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2980.65,1937.42,,,,,,,,,,,,,
ELECTRODE ES RESECT W HF CBL PLSM RLER,SUP-2419640,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1673.21,1087.59,,,,,,,,,,,,,
STEM TIB SM-XL L3IN OD10MM KNEE FIN ADVTM,SUP-2304377,CDM,C1776,CPT,0278,RC,,,,both,,,2939.04,1910.38,,,,,,,,,,,,,
PLATE TI LOCKING 1.3MM STRUT 8 HOLES OBLIQUE RT-STERILE,SUP-2546885,CDM,C1713,HCPCS,0278,RC,,,,both,,,1224.35,795.83,,,,,,,,,,,,,
KIT HAD CATH L45CM INSRT L28CM CARBOTHANE SYMMETRIC TIP 2,SUP-2283952,CDM,C1881,HCPCS,0278,RC,,,,both,,,917.76,596.54,,,,,,,,,,,,,
PLATE BNE HEVANS LNG 24MM L,SUP-2321481,CDM,C1713,HCPCS,0278,RC,,,,both,,,5077.38,3300.30,,,,,,,,,,,,,
GUIDEWIRE VASC SYNCHRO 215CM 0.014IN SEG 35CM SOFR PRESHAPED,SUP-2717702,CDM,C1769,HCPCS,0272,RC,,,,both,,,2474.32,1608.31,,,,,,,,,,,,,
STENT CORONARY VERIFLEX L 28 MM DIA 4 MM SS OTW BALLOON,SUP-2144550,CDM,C1876,HCPCS,0278,RC,,,,both,,,3061.50,1989.97,,,,,,,,,,,,,
CROWN DENT LR6 1ST PRI M INDIV SPACE MAINTAINER,SUP-2176684,CDM,D6783,CPT,0278,RC,,,,both,,,25.91,16.84,,,,,,,,,,,,,
ENDOPROSTHESIS VASC VIABAHN VBX L 15 MM 5/8 MM 80 CM 6 FR,SUP-2892859,CDM,C1874,HCPCS,0278,RC,,,,both,,,8587.90,5582.13,,,,,,,,,,,,,
PLATE BONE L40MM SH STRL LT ANTEROLATERAL CALCNL S STL VAR,SUP-2178428,CDM,C1713,HCPCS,0278,RC,,,,both,,,3076.01,1999.41,,,,,,,,,,,,,
IMPLANT HUM TISS L 2 X W 2 CM PLCNTA MEMBRN TRILAYER,SUP-2905510,CDM,Q4278,HCPCS,0636,RC,,,,both,,,4271.40,2776.41,,,,,,,,,,,,,
PIN FIX KNEE PRI LOK AMK,SUP-2252438,CDM,C1776,CPT,0278,RC,,,,both,,,1051.27,683.33,,,,,,,,,,,,,
HC Tips,PX-3613718200,CDM,37182,CPT,0361,RC,,,,outpatient,,,15457.00,10047.05,,,,,,,,,,,,,
SCREW BNE L70MM DIA4.5MM CORT TI ST DBL LD THRD FOR PHOENIX,SUP-2412116,CDM,C1713,HCPCS,0278,RC,,,,both,,,656.26,426.57,,,,,,,,,,,,,
ECLIPSE CAGE SCREW M 35MM,SUP-2817809,CDM,C1713,HCPCS,0278,RC,,,,both,,,9420.00,6123.00,,,,,,,,,,,,,
SCREW INTRF 8X40 MM TI CROSS-SCREW,SUP-2608260,CDM,C1713,HCPCS,0278,RC,,,,both,,,413.98,269.09,,,,,,,,,,,,,
GRAFT SURG W7.5XL11IN RECT ANTIBACT COAT REGEN CLLGN MTRX,SUP-2125840,CDM,C1781,HCPCS,0278,RC,,,,both,,,57955.61,37671.15,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA MAXBARR 4FR 55CM S9294108D,SUP-2632877,CDM,C1751,HCPCS,0278,RC,,,,both,,,702.76,456.79,,,,,,,,,,,,,
PLATE H EXT 1.5MM RT W/GUIDES STRL TI LCP,SUP-2546743,CDM,C1713,HCPCS,0278,RC,,,,both,,,1497.75,973.54,,,,,,,,,,,,,
BRACE ORTHOPEDIC LBR AFO ADJ,SUP-2265018,CDM,L4205,HCPCS,0274,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
STEM FEM L195MM DIA18MM DST HIP TI HA STR CONIC CEM MOD REV,SUP-2375829,CDM,C1776,CPT,0278,RC,,,,both,,,7441.80,4837.17,,,,,,,,,,,,,
PLATE BNE FIBULAR 2.7/3.5X51 MM LT PL 2 HOLE BUTTRESS SS,SUP-2522056,CDM,C1713,HCPCS,0278,RC,,,,both,,,1503.90,977.53,,,,,,,,,,,,,
GUIDEWIRE VASC L260CM DIA0035IN S STL PTFE HEP STR AMPLATZ,SUP-2167927,CDM,C1769,HCPCS,0272,RC,,,,both,,,85.63,55.66,,,,,,,,,,,,,
SHEATH ARTHSCP 6MM DIA STD LEN N THRD N OPT VW BLDELSS OBLQ,SUP-2341421,CDM,C1713,HCPCS,0278,RC,,,,both,,,2443.08,1588.00,,,,,,,,,,,,,
BUR SURG ACORN 5 MMX10 CM FLUT SM BOR MIDAS REX LEGEND,SUP-2627608,CDM,2720000010,LOCAL,0272,RC,,,,both,,,325.99,211.89,,,,,,,,,,,,,
LINER ACET OD60MM ID28MM 0DEG MARATHON HIP REV LIP PINN,SUP-2250377,CDM,C1776,CPT,0278,RC,,,,both,,,2362.54,1535.65,,,,,,,,,,,,,
COMPONENT FEM PROX KNEE STD NEUT V40 TAPR GLOB MOD REPL SYS,SUP-2376504,CDM,C1776,CPT,0278,RC,,,,both,,,12003.44,7802.24,,,,,,,,,,,,,
BASEPLATE TIB SZ 0/1 THK14MM STD POR LT STEM PRESSFIT REV,SUP-2209327,CDM,C1776,CPT,0278,RC,,,,both,,,10010.32,6506.71,,,,,,,,,,,,,
ANCHOR SUTURE PRE LD 2-0 6.5 MM TWO STRND POLYESTER,SUP-2608438,CDM,C1713,HCPCS,0278,RC,,,,both,,,435.46,283.05,,,,,,,,,,,,,
HC Injection for Ductogram,PX-3611903000,CDM,19030,CPT,0361,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
GRAFT VASC HEMSHLD PLAT L 30 CM DIA24 MM POLYESTER BOV CLLGN,SUP-2499321,CDM,C1768,CPT,0278,RC,,,,both,,,2009.44,1306.14,,,,,,,,,,,,,
MESH SURG 15CM OMEGA 3 FATTY ACID FIL POLYPR SEE THRU,SUP-2265980,CDM,C1781,HCPCS,0278,RC,,,,both,,,1547.99,1006.19,,,,,,,,,,,,,
ETOPOSIDE 20 MG/ML IV SOLN (MIXTURES ONLY),RX-430002,CDM,J9181,HCPCS,0636,RC,16729-0114-08,NDC,,both,25,ML,148.40,96.46,,,,,,,,,,,,,
STENT URET UNIVERSA FIRM L 24 CM DIA 6 FR POLYUR AQ BRAIDED,SUP-2171437,CDM,C2617,HCPCS,0278,RC,,,,both,,,389.61,253.25,,,,,,,,,,,,,
BALLOON EXTRCTN 1900MML X 15MM DIA 28MM MNMM CHNNL SIZE 3 L,SUP-2679325,CDM,C1726,HCPCS,0272,RC,,,,both,,,714.76,464.59,,,,,,,,,,,,,
SCREW BNE MAXILLOMANDIBULAR 2X12 MM 8 MM SS MAXDRIVE,SUP-2469567,CDM,C1713,HCPCS,0278,RC,,,,both,,,367.69,239.00,,,,,,,,,,,,,
SCREW SS REVERE SM DIAM,SUP-2232364,CDM,C1713,HCPCS,0278,RC,,,,both,,,8116.90,5275.98,,,,,,,,,,,,,
PROSTHESIS OSS EAR 3X6.9 MM BOJRAB,SUP-2313859,CDM,L8613,CPT,0278,RC,,,,both,,,1122.55,729.66,,,,,,,,,,,,,
FRAME EXT FIX 220 MM SALVATION,SUP-2538205,CDM,2720000010,LOCAL,0272,RC,,,,both,,,26652.32,17324.01,,,,,,,,,,,,,
KIT TRACH AD TB L98MM OD12.3MM ID9MM SIL W/ OBT SIDEPRT,SUP-2352055,CDM,2720000010,LOCAL,0272,RC,,,,both,,,331.18,215.27,,,,,,,,,,,,,
PLATE SPNL L5.5MM UNIV S STL ILLIOSACRAL POST LCK BILAT,SUP-2290568,CDM,C1713,HCPCS,0278,RC,,,,both,,,524.38,340.85,,,,,,,,,,,,,
PLATE BNE 100DEG 4 H L SHP STERNALOCK BLU PRI CLSR SYS,SUP-2403029,CDM,C1713,HCPCS,0278,RC,,,,both,,,1230.88,800.07,,,,,,,,,,,,,
STEM FEM L125MM DIA14MM CLLR H20MM 38MM OFFSET 135DEG NEUT,SUP-2252660,CDM,C1776,CPT,0278,RC,,,,both,,,10385.55,6750.61,,,,,,,,,,,,,
EXPANDER BRST TISS 375CC W12XH12CM P6.4CM SIL SMOOTH HI,SUP-2421120,CDM,C1789,HCPCS,0278,RC,,,,both,,,5887.50,3826.87,,,,,,,,,,,,,
TISS HUM IMPL W6XL6CM AMNIO MEMBRN ALLGRFT BIOVANCE,SUP-2113889,CDM,Q4154,HCPCS,0636,RC,,,,both,,,11852.24,7703.96,,,,,,,,,,,,,
BAND SURG ADJ DISECT INJ PRT APPL REALIZE,SUP-2257754,CDM,2780000010,LOCAL,0278,RC,,,,both,,,9043.20,5878.08,,,,,,,,,,,,,
SERENGETI MINIMALLY INVASIVE RETRCT QTY 2,SUP-2258073,CDM,C1713,HCPCS,0278,RC,,,,both,,,1224.60,795.99,,,,,,,,,,,,,
VALVE ENDOSCP WSH CASE - SUCTION,SUP-2457314,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1067.29,693.74,,,,,,,,,,,,,
PROBE VITRCTMY 23GA UNIV STR SGL END,SUP-2109902,CDM,C1713,HCPCS,0278,RC,,,,both,,,649.98,422.49,,,,,,,,,,,,,
ALLOGRAFT BNE FIBULAR SHFT 26-50 MMX0.1 CM FD,SUP-2717855,CDM,C1762,CPT,0278,RC,,,,both,,,2392.24,1554.96,,,,,,,,,,,,,
PACK INSTR MENIS ROOT REP,SUP-2340964,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1067.60,693.94,,,,,,,,,,,,,
TEMPLATE SURG ANCHR SHT CASPIAN,SUP-2873698,CDM,2720000010,LOCAL,0272,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
PG PRO 18 GAUGE 8CM RT BASIC BIOPATCH,SUP-2613504,CDM,C1751,HCPCS,0278,RC,,,,both,,,244.92,159.20,,,,,,,,,,,,,
ENTRADA NEEDLE 15CM 60 IN,SUP-2700479,CDM,2720000010,LOCAL,0272,RC,,,,both,,,486.70,316.35,,,,,,,,,,,,,
GRAFT CORMATRIX EXTRACELLULAR MATRIX  2CM X 10CM,SUP-2848900,CDM,C1768,CPT,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED H6 RESURF CORMET,SUP-2365404,CDM,C1776,CPT,0278,RC,,,,both,,,26690.00,17348.50,,,,,,,,,,,,,
CHOICE INTERMEDIATE 182CM MAG J 5PK,SUP-2664363,CDM,C1729,HCPCS,0272,RC,,,,both,,,210.38,136.75,,,,,,,,,,,,,
COMPONENT FEM AP55MM ML65MM POLYETH BEAD CRUCE RET DURAC,SUP-2377033,CDM,C1776,CPT,0278,RC,,,,both,,,6007.51,3904.88,,,,,,,,,,,,,
BIT DRL L160MM DIA27MM QUIK CPL CANN FOR 4MM SCR,SUP-2179010,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1266.86,823.46,,,,,,,,,,,,,
MARKER BRST BX FOR 11GA MAMTOM PRB MAMMOMARK2 11,SUP-2195639,CDM,A4648,CPT,0278,RC,,,,both,,,260.62,169.40,,,,,,,,,,,,,
CATHETER HF 3 LUMN BASIC KT 70CM NIT GWIRE W/ RADSTIC,SUP-2125558,CDM,C1751,HCPCS,0278,RC,,,,both,,,603.82,392.48,,,,,,,,,,,,,
MATRIX SURGICAL WOUND 0.045OZ CONNEXT,SUP-2863796,CDM,C1763,HCPCS,0278,RC,,,,both,,,6201.50,4030.97,,,,,,,,,,,,,
ROD EXT FIX THRD 150 MM UNIV HINGE,SUP-2517346,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1939.26,1260.52,,,,,,,,,,,,,
SCREW SPNL MULTAXL STD 5.5X40 MM FIREBIRD,SUP-2658646,CDM,C1889,HCPCS,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
SNARE NSL KRAUSE 10.25 IN 4-1/3 IN SATIN FINISH STD SMOOTH,SUP-2161593,CDM,C1713,HCPCS,0278,RC,,,,both,,,432.32,281.01,,,,,,,,,,,,,
HC Hemoglobin F Fetal Qualitative,PX-3018303300,CDM,83033,CPT,0301,RC,,,,both,,,269.00,174.85,,,,,,,,,,,,,
SET INT FIX SCREW DIA1.5 MM TI NEURO 1 DBL Y SHP XLN PLATE,SUP-2936611,CDM,C1713,HCPCS,0278,RC,,,,both,,,30304.14,19697.69,,,,,,,,,,,,,
GRAFT DERM L7CMXW4CM PORCINE IMPL IMPLABLE INTEXEN LP,SUP-2140304,CDM,C1781,HCPCS,0278,RC,,,,both,,,1774.89,1153.68,,,,,,,,,,,,,
DINOPROSTONE 10 MG VA INST,RX-27467,CDM,6370000000,HCPCS,0637,RC,55566-2800-01,NDC,,both,1,UN,2475.90,1609.33,,,,,,,,,,,,,
SCREW BNE MAXILLOFACIAL CORT CENTRE-DRIVE 2.3 25085091] KLS MARTIN LP],SUP-2262627,CDM,C1713,HCPCS,0278,RC,,,,both,,,106.76,69.39,,,,,,,,,,,,,
HC Lyr Clos Sc Tk Ext 7.6-12cm,PX-4501203400,CDM,12034,CPT,0450,RC,,,,inpatient,,,1445.00,939.25,,,,,,,,,,,,,
STEM FEM SZ 0 TI PREMIER NATURAL-HIP,SUP-2210717,CDM,C1776,CPT,0278,RC,,,,both,,,13941.60,9062.04,,,,,,,,,,,,,
GRAFT BIO TISS W5.9XL7.9IN PORCINE DERM RIFAMPIN,SUP-2125838,CDM,C1781,HCPCS,0278,RC,,,,both,,,22498.10,14623.76,,,,,,,,,,,,,
PLATE PROMO RT SZ 3,SUP-2321423,CDM,C1713,HCPCS,0278,RC,,,,both,,,6352.22,4128.94,,,,,,,,,,,,,
CATHETER PICC L90CM 0.035IN 30DEG ANG TIP S STL DBL BRAID,SUP-2385620,CDM,C1887,HCPCS,0272,RC,,,,both,,,700.53,455.34,,,,,,,,,,,,,
KIT OPHTH 7ML PERFLUOROCARBON LIQ PROC PERFLUORON,SUP-2110016,CDM,C1784,HCPCS,0278,RC,,,,both,,,4475.38,2909.00,,,,,,,,,,,,,
CATHETER DRAINAGE LCK PIG 10 FRX40 CM POLYURETHANE,SUP-2303561,CDM,C1729,HCPCS,0272,RC,,,,both,,,229.22,148.99,,,,,,,,,,,,,
PIN BNE FIX L16MM DIA15MM PLA BIORESORBABLE NONCOLLAGENOUS,SUP-2166732,CDM,C1713,HCPCS,0278,RC,,,,both,,,594.43,386.38,,,,,,,,,,,,,
HC Collection Venous Blood Venipuncture,PX-3003641500,CDM,36415,CPT,0300,RC,,,,both,,,34.00,22.10,,,,,,,,,,,,,
MICROFREE HIGH SPEED DRILL,SUP-2605742,CDM,2720000010,LOCAL,0272,RC,,,,both,,,23480.29,15262.19,,,,,,,,,,,,,
CATHETER ULTRASOUND NAVIGATIONAL 10 FRX90 CM VIVID I ACUNAV,SUP-2248451,CDM,C1759,HCPCS,0272,RC,,,,both,,,7862.56,5110.66,,,,,,,,,,,,,
WASHER ORTH DIA10MM S STL FOR 4.5MM CANN SCR,SUP-2184668,CDM,C1713,HCPCS,0278,RC,,,,both,,,65.50,42.57,,,,,,,,,,,,,
INSTRUMENT CUP REM 60MM FINISH BLDE FIX HNDL INOMED ACET,SUP-2363414,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
PLATE BNE L263MM 16 H BILAT S STL BROAD LO PROF RIG DYN,SUP-2185280,CDM,C1713,HCPCS,0278,RC,,,,both,,,1249.09,811.91,,,,,,,,,,,,,
RING EXT FIX ID155MM ALUM FULL FOR TAY SPAT FRME ILIZ,SUP-2342961,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6198.20,4028.83,,,,,,,,,,,,,
CATHETER ANGIO MULTI-TRACK L 100 CM DIA 5 FR INTRO 7 FR,SUP-2125287,CDM,C1725,HCPCS,0272,RC,,,,both,,,185.26,120.42,,,,,,,,,,,,,
COLLAR CERV L13-16IN H2.5IN UNIV TRACH OPN ADJ AD SIERRA,SUP-2123895,CDM,L0172,HCPCS,0274,RC,,,,both,,,39.25,25.51,,,,,,,,,,,,,
GRAFT HUM TISS 11MM TEND PAT BNE FRZN,SUP-2335535,CDM,C1762,CPT,0278,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
CAP END TIB TI NAIL LO PROF UNIFLEX,SUP-2412893,CDM,C1713,HCPCS,0278,RC,,,,both,,,496.12,322.48,,,,,,,,,,,,,
BIT DRL CANN,SUP-2218773,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1566.20,1018.03,,,,,,,,,,,,,
KIT TUBE RETEN SYS CONVENIENCE L43IN OD12FR NG CORTRAK,SUP-2236655,CDM,2720000010,LOCAL,0272,RC,,,,both,,,420.70,273.45,,,,,,,,,,,,,
GRAFT BNE W5XL60MM FIB FRZN SHFT,SUP-2307378,CDM,C1713,HCPCS,0278,RC,,,,both,,,2071.24,1346.31,,,,,,,,,,,,,
TUBE EXT FIX L400MM OD25MM RED C FOR UNILAT MONOTB TRIAX SYS,SUP-2372619,CDM,C1713,HCPCS,0278,RC,,,,both,,,604.89,393.18,,,,,,,,,,,,,
PACEMAKER CARD ADAPTA VDD W 42.9 X H 44.7 MM D 7.5 MM TI 2,SUP-2282317,CDM,C2619,HCPCS,0275,RC,,,,both,,,9812.50,6378.12,,,,,,,,,,,,,
HIGH DMD SYS W/TBL(LG HD,SUP-2212093,CDM,C1776,CPT,0278,RC,,,,both,,,15175.62,9864.15,,,,,,,,,,,,,
GUIDEWIRE VASC THRUWAY L 130 CM DIA 0.014 IN SS SIL J LNG,SUP-2148330,CDM,C1769,HCPCS,0272,RC,,,,both,,,329.54,214.20,,,,,,,,,,,,,
PLATE BNE T 50 MM 3X9 HOLE COMPR,SUP-2435431,CDM,C1713,HCPCS,0278,RC,,,,both,,,548.53,356.54,,,,,,,,,,,,,
GRAFT DURA 2X7 CM SUTURABLE BIO TISS BOV PERICARD DURAGN,SUP-2468366,CDM,C1763,HCPCS,0278,RC,,,,both,,,1106.72,719.37,,,,,,,,,,,,,
PLATE 4.5MM TI LCP TM STRAIGHT RECON 3 HOLES 56MM,SUP-2549503,CDM,C1713,HCPCS,0278,RC,,,,both,,,964.95,627.22,,,,,,,,,,,,,
RETRACTOR ENDOSCP L 2350 MM DIA2.6 MM CLP SZ 16 MM CHANNEL,SUP-2909397,CDM,C1889,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
ARM EXT FIX SHT REAR FT ARTC 3 ARTH SIDEKCK,SUP-2400622,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1504.06,977.64,,,,,,,,,,,,,
ALLOGRAFT HUM TISS SHT 3X2 CM PLCNTA BASE MEMBRN AMNIOEFFECT,SUP-2872719,CDM,C1762,CPT,0278,RC,,,,both,,,3177.68,2065.49,,,,,,,,,,,,,
GUIDEWIRE VASC ROTAWIRE ROT L 325 CM DIA 0.009 IN SPRING TIP,SUP-2142055,CDM,C1769,HCPCS,0272,RC,,,,both,,,992.24,644.96,,,,,,,,,,,,,
GRAFT HUM TISS FRZN ALLGRFT MENIS W/ HEMI PLATEAU MED HUM,SUP-2307290,CDM,C1762,CPT,0278,RC,,,,both,,,18103.83,11767.49,,,,,,,,,,,,,
EXTENSION LD 25 CM SPNL CRD PRECIS,SUP-2138800,CDM,C1883,HCPCS,0278,RC,,,,both,,,1956.22,1271.54,,,,,,,,,,,,,
ANCHOR SUT DIA6.8MM SUT SZ 2 MAXBRAID LACTOSORB L15,SUP-2137200,CDM,C1713,HCPCS,0278,RC,,,,both,,,904.32,587.81,,,,,,,,,,,,,
PANEL DS RESORB BLNK 55X55MM,SUP-2364987,CDM,C1713,HCPCS,0278,RC,,,,both,,,2245.23,1459.40,,,,,,,,,,,,,
PLATE BONE REDUCTION INSTRUMENT 27/35MM,SUP-2497339,CDM,C1713,HCPCS,0278,RC,,,,both,,,1697.33,1103.26,,,,,,,,,,,,,
DRAIN SURG 19FR SIL RND HUBLESS RADPQ W/O TRCR BLAK,SUP-2218223,CDM,C1729,HCPCS,0272,RC,,,,both,,,306.53,199.24,,,,,,,,,,,,,
BUR SURG L98MM OD5MM RND DMND CRV NONFLUTED VISAO,SUP-2284231,CDM,C1713,HCPCS,0278,RC,,,,both,,,775.49,504.07,,,,,,,,,,,,,
PACEMAKER CARD EDORA HF-T SENTUS TI HSNG EPOXY RESIN HEADER,SUP-2138475,CDM,C2621,HCPCS,0275,RC,,,,both,,,30772.00,20001.80,,,,,,,,,,,,,
COLLAR CERV 4 MONTH-10YR CH FOR TORTICOLLIS TREAT TOT,SUP-2324278,CDM,L0180,HCPCS,0274,RC,,,,both,,,131.06,85.19,,,,,,,,,,,,,
SET SCR SPNL N BRK OFF TI STRL 6.35MM DIA,SUP-2415640,CDM,C1713,HCPCS,0278,RC,,,,both,,,1247.58,810.93,,,,,,,,,,,,,
NEEDLE ENDO KNEE STRL SCORPION,SUP-2121201,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
STENT PERIPHERAL L50MM DIAMETER 6MM VASCULAR ARTERIOVENOUS STRAIGHT FLAIR,SUP-2128226,CDM,C1874,HCPCS,0278,RC,,,,both,,,7065.00,4592.25,,,,,,,,,,,,,
RAIL EXT FIX SM 250 MM,SUP-2467791,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3557.62,2312.45,,,,,,,,,,,,,
PORT INFUS 8FR ATTCH GROSH CATHETER TI W SIL FILL SUT H AND,SUP-2126311,CDM,C1788,HCPCS,0278,RC,,,,both,,,1617.10,1051.11,,,,,,,,,,,,,
CANNULA ENDOSCP 6 MMX10.5 CM W/O INSUFFLATION STOPCOCK,SUP-2767776,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1322.85,859.85,,,,,,,,,,,,,
IMPLANT CAPSULAR TENS RNG COMPR 12-10 MM PMMA PRELD INJ FLX,SUP-2884216,CDM,L8699,HCPCS,0278,RC,,,,both,,,581.69,378.10,,,,,,,,,,,,,
BLADE RETRACTOR 10 CM LT INT PIN MAST QUAD,SUP-2631624,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1728.73,1123.67,,,,,,,,,,,,,
SCREW BNE L10MM DIA2.7MM STD CORT TI ST NONLOCKING FULL,SUP-2189542,CDM,C1713,HCPCS,0278,RC,,,,both,,,204.10,132.66,,,,,,,,,,,,,
DEVICE PESSARY NO5 DIA1.75IN SIL CUBE VAULT TRIMO SAN JEL,SUP-2171732,CDM,A4562,HCPCS,0272,RC,,,,both,,,112.79,73.31,,,,,,,,,,,,,
STAPLER INT L30MM DIA48MM TI STPL RELD DISPOSABLE DST SER TA,SUP-2283410,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1173.58,762.83,,,,,,,,,,,,,
PLATE BNE,SUP-2499640,CDM,C1713,HCPCS,0278,RC,,,,both,,,891.76,579.64,,,,,,,,,,,,,
MESH SURG DIA15CM OPTIMIZED COMP W O FIX SUT RND PARIETEX,SUP-2174709,CDM,C1781,HCPCS,0278,RC,,,,both,,,1771.62,1151.55,,,,,,,,,,,,,
BEVACIZUMAB-AWWB 100 MG/4ML IV SOLN,RX-146509,CDM,Q5107,HCPCS,0636,RC,55513-0206-01,NDC,,both,4,ML,2009.50,1306.17,,,,,,,,,,,,,
BUR SURG DIA1.4 MM HUB II DIAMOND STRL REUSE HI-LINE,SUP-2929234,CDM,2720000010,LOCAL,0272,RC,,,,both,,,622.00,404.30,,,,,,,,,,,,,
LINER ACET HOOD HIP METASUL EPSILON,SUP-2448624,CDM,C1776,CPT,0278,RC,,,,both,,,50486.49,32816.22,,,,,,,,,,,,,
CAGE SPNL MESH 15X12X10 MM 6 LOBE,SUP-2602069,CDM,C1889,HCPCS,0278,RC,,,,both,,,6766.70,4398.35,,,,,,,,,,,,,
PLATE BNE RECON 2-2.5X2 MM MAND 34 HOLE FULL MAND LCK STRL,SUP-2486611,CDM,C1713,HCPCS,0278,RC,,,,both,,,8266.65,5373.32,,,,,,,,,,,,,
PLATE BNE W10XL77MM THK1.5MM 90DEG 6X3 H BILAT S STL T SHP,SUP-2185874,CDM,C1713,HCPCS,0278,RC,,,,both,,,1152.88,749.37,,,,,,,,,,,,,
COMPONENT HUM SM L8IN ELBW INTERCHANGEABLE LNG FLNG ASMBLY,SUP-2205926,CDM,C1776,CPT,0278,RC,,,,both,,,12490.92,8119.10,,,,,,,,,,,,,
PLATE BNE STR MINI REG 2X0.6 MM 8 HOLE LP FOR SCR TI STRL,SUP-2497344,CDM,C1713,HCPCS,0278,RC,,,,both,,,356.26,231.57,,,,,,,,,,,,,
BENDING TEMPLATE FOR LOCKING TROCHANTER STABILIZATION PLATE,SUP-2548476,CDM,C1713,HCPCS,0278,RC,,,,both,,,532.80,346.32,,,,,,,,,,,,,
HEAD FEM DIA32MM NK L-3.5MM ALUMINA CERAMIC ON CERAMIC 12/14,SUP-2202657,CDM,C1776,CPT,0278,RC,,,,both,,,6050.78,3933.01,,,,,,,,,,,,,
PLATE BNE BROAD 3.5X172 MM 13 HOLE SS LCP,SUP-2569339,CDM,C1713,HCPCS,0278,RC,,,,both,,,516.37,335.64,,,,,,,,,,,,,
HC Procalcitonin (Pct),PX-3018414500,CDM,84145,CPT,0301,RC,,,,both,,,139.00,90.35,,,,,,,,,,,,,
SPLINT SWEDISH AFO WOMAN RT WHT,SUP-2324308,CDM,L4350,HCPCS,0272,RC,,,,both,,,69.87,45.42,,,,,,,,,,,,,
GRAFT HUM TISS DIA16MM AMNIO TISS MEM DISK SHT AMNIOFIX,SUP-2305722,CDM,V2790,HCPCS,0278,RC,,,,both,,,1193.20,775.58,,,,,,,,,,,,,
LINER ACET DIA28MM 0DEG STD GRP 1 HIP UHMPE POLYETH POR,SUP-2304440,CDM,C1776,CPT,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
WIRE FIX L80MM OD0.86MM K,SUP-2122279,CDM,C1769,HCPCS,0278,RC,,,,both,,,47.10,30.61,,,,,,,,,,,,,
HALF RNG 200MM FRDM CIR FIX,SUP-2400665,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2285.92,1485.85,,,,,,,,,,,,,
SCREW BNE L90MM DIA10.5MM ST LAG SQ DRVR SOCK FOR AFFIXUS,SUP-2413329,CDM,C1713,HCPCS,0278,RC,,,,both,,,2847.98,1851.19,,,,,,,,,,,,,
SPACER SPNL 45X10X10 MM INTBDY FUSION DEV CRESCENT,SUP-2281752,CDM,C1889,HCPCS,0278,RC,,,,both,,,9106.00,5918.90,,,,,,,,,,,,,
NEEDLE HURD CLEFT PALATE TONSIL 21CM 8 14IN LEFT,SUP-2681809,CDM,2720000010,LOCAL,0272,RC,,,,both,,,336.64,218.82,,,,,,,,,,,,,
STEM BPLR HIP POR SYS,SUP-2212079,CDM,C1776,CPT,0278,RC,,,,both,,,8143.06,5292.99,,,,,,,,,,,,,
GENTAMICIN IN SALINE 2-0.9 MG/ML-% IV SOLN,RX-15912,CDM,J1580,HCPCS,0636,RC,00338-0511-41,NDC,,both,50,ML,54.10,35.16,,,,,,,,,,,,,
HC Fetal Eval Follow-Up/Repeat,PX-4027681600,CDM,76816,CPT,0402,RC,,,,both,,,1269.00,824.85,,,,,,,,,,,,,
ALLOGRAFT CHIP CORT CANC DEMIN 2MM - 4MM RANG 15CC,SUP-2414281,CDM,C1889,HCPCS,0278,RC,,,,both,,,760.67,494.44,,,,,,,,,,,,,
JOINT TOE 9.5 MM STS,SUP-2318976,CDM,C1776,CPT,0278,RC,,,,both,,,4317.50,2806.37,,,,,,,,,,,,,
MOLD TIB SPCR M AP45MM ML70MM PMMA URETHANE GENT KASM,SUP-2315778,CDM,C1776,CPT,0278,RC,,,,both,,,4082.00,2653.30,,,,,,,,,,,,,
CATHETER ABLAT 7FR L115CM TIP 4MM 2-5-2MM SPC 4 ELECTRD D,SUP-2248806,CDM,C1733,HCPCS,0272,RC,,,,both,,,2367.56,1538.91,,,,,,,,,,,,,
VALVE FACEPLT BODY AND DIAPH ATSV II,SUP-2242325,CDM,L8501,HCPCS,0272,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
GUIDEWIRE ORTH L150MM DIA16MM NONCOLORED S STL W SPADE PNT,SUP-2186900,CDM,C1769,HCPCS,0272,RC,,,,both,,,72.16,46.90,,,,,,,,,,,,,
GUIDEWIRE ORTHOPEDIC 2.5X220 MM GLEN AEQUALIS PERFORM,SUP-2390579,CDM,C1769,HCPCS,0272,RC,,,,both,,,662.54,430.65,,,,,,,,,,,,,
HC Assay of Prostate Specific Antigen Free,PX-3018415400,CDM,84154,CPT,0301,RC,,,,outpatient,,,267.00,173.55,,,,,,,,,,,,,
SPACER FEM 5 MM DSTL RT LAT,SUP-2364851,CDM,C1776,CPT,0278,RC,,,,both,,,2922.56,1899.66,,,,,,,,,,,,,
PLATE BNE 5DEG SHT L MTPHSEAL,SUP-2321451,CDM,C1713,HCPCS,0278,RC,,,,both,,,5196.70,3377.85,,,,,,,,,,,,,
HC So1 Chemiluminescent Assay,PX-3018239767,CDM,82397,CPT,0301,RC,,,,both,,,84.00,54.60,,,,,,,,,,,,,
PROBE BX 14 GAX138 MM W/ INTEGR COAX CANN VACORA,SUP-2759180,CDM,2720000010,LOCAL,0272,RC,,,,both,,,593.93,386.05,,,,,,,,,,,,,
CRANIAL ACCESS KIT W/ NO DRUG 2 DRL BIT NO RAZOR,SUP-2852688,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1308.19,850.32,,,,,,,,,,,,,
SCREW BONE L3MM DIA1.6MM TI SELF DRL FOR CRAN CLSR SYS,SUP-2243981,CDM,C1713,HCPCS,0278,RC,,,,both,,,153.04,99.48,,,,,,,,,,,,,
NAIL FEM TROCHANTERIC 10MM DIA 130 DEG 360MML RT STRL TI,SUP-2349038,CDM,C1713,HCPCS,0278,RC,,,,both,,,9237.88,6004.62,,,,,,,,,,,,,
CATHETER ELECHEMSTAS 7FR L210CM NDL OD0.51MM ID0.24MM MIN,SUP-2149701,CDM,2720000010,LOCAL,0272,RC,,,,both,,,679.37,441.59,,,,,,,,,,,,,
PLATE BONE DELTA 1X21-HOLE 0.5MM THK PLLA PDLA PGA,SUP-2883363,CDM,C1713,HCPCS,0278,RC,,,,both,,,8926.83,5802.44,,,,,,,,,,,,,
BIT DRL DIA 4.3 MM LNG AO QC STRL DISP TRIGEN MAX,SUP-2932881,CDM,2720000010,LOCAL,0272,RC,,,,both,,,851.57,553.52,,,,,,,,,,,,,
CANNULA ENDOSCP W/ STOPCOCK,SUP-2747296,CDM,2720000010,LOCAL,0272,RC,,,,both,,,693.06,450.49,,,,,,,,,,,,,
ROD CONN CONT THRD 21 MM,SUP-2862041,CDM,C1713,HCPCS,0278,RC,,,,both,,,232.86,151.36,,,,,,,,,,,,,
SHELL ACET OD65MM UNIV CSTI HIP RIM FLARE MULTIH REV,SUP-2208487,CDM,C1776,CPT,0278,RC,,,,both,,,9137.40,5939.31,,,,,,,,,,,,,
PLATE SPNL L37.5MM UNIV TI ANT CERV LOK ALLY ATLNTS,SUP-2293160,CDM,C1713,HCPCS,0278,RC,,,,both,,,2585.60,1680.64,,,,,,,,,,,,,
CATHETER PA L 80 CM DIA 5.3 FR BALLOON DIA10 MM GUIDEWIRE,SUP-2168609,CDM,C2628,HCPCS,0272,RC,,,,both,,,215.53,140.09,,,,,,,,,,,,,
RING SPNL L TI ALLOY CLS HALF FOR RIB SUPP VEPTR,SUP-2193302,CDM,C1713,HCPCS,0278,RC,,,,both,,,3290.72,2138.97,,,,,,,,,,,,,
PROBE SURG 6.9FR L18CM ES GAST INT REF INFUSED 6 IMPED 2 PH,SUP-2336766,CDM,2720000010,LOCAL,0272,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
ENDCAP ORTH DIA25MM 0MM EXTN ST STARDRV T25 RECESS FOR HUM,SUP-2179611,CDM,C1713,HCPCS,0278,RC,,,,both,,,530.19,344.62,,,,,,,,,,,,,
DEFIBRILLATOR IMPL LUMAX 500 HF-T 59X 66MM 12MM 30J LANDLINE,SUP-2138409,CDM,C1882,HCPCS,0275,RC,,,,both,,,79285.00,51535.25,,,,,,,,,,,,,
NEXFIX NCP SCORED GUID  NCPSGW062,SUP-2844032,CDM,C1769,HCPCS,0272,RC,,,,both,,,31.40,20.41,,,,,,,,,,,,,
SCREW BNE L76MM OD7MM THRD L17MM PUR HINDFOOT ANK CANN SHT,SUP-2320765,CDM,C1713,HCPCS,0278,RC,,,,both,,,1338.90,870.28,,,,,,,,,,,,,
INTRODUCER HEMSTAS FAST CATH 7FRX12CM SHTH W/ LUER LCK 0.032,SUP-2355391,CDM,C1894,HCPCS,0272,RC,,,,both,,,66.73,43.37,,,,,,,,,,,,,
PLATE BNE L154MM 9 H NONSTERILE R DST RAD VOLAR DPHSEAL,SUP-2184058,CDM,C1713,HCPCS,0278,RC,,,,both,,,4358.51,2833.03,,,,,,,,,,,,,
GRAFT BNE STRP LG 90X25X7 MM 1-2 MM 15.8 CC ACTIFUSE ABX,SUP-2130293,CDM,C1713,HCPCS,0278,RC,,,,both,,,10190.56,6623.86,,,,,,,,,,,,,
IMPLANT CRAN L PEEK PRIORITY CUSTOMIZED,SUP-2365150,CDM,C1713,HCPCS,0278,RC,,,,both,,,54847.70,35651.00,,,,,,,,,,,,,
TRUMATCH MIDFACE/MANDIBLE TI 3D PRNT GUIDE/ ORBIT,SUP-2194247,CDM,C1713,HCPCS,0278,RC,,,,both,,,9655.81,6276.28,,,,,,,,,,,,,
GUIDEWIRE ORTH L98CM DIA3MM S STL BEAD TIP DISP FOR UNIFLEX,SUP-2412676,CDM,C1769,HCPCS,0272,RC,,,,both,,,356.70,231.85,,,,,,,,,,,,,
NERVE STIMULATOR KIT LD PERIPH NERVE SYS CHANNEL B STIMQ,SUP-2423764,CDM,C1778,HCPCS,0278,RC,,,,both,,,6280.00,4082.00,,,,,,,,,,,,,
SOCKET PROS TST,SUP-2388206,CDM,L5620,HCPCS,0274,RC,,,,both,,,730.74,474.98,,,,,,,,,,,,,
BRACE KNEE CUST W/ ADJ HNG FUSIONXT OA,SUP-2150833,CDM,L1810,HCPCS,0274,RC,,,,both,,,1709.73,1111.32,,,,,,,,,,,,,
SHEATH INTRO PINNACLE TIF TIP L 10 CM DIA 5 FR 0.038 IN,SUP-2384798,CDM,C1894,HCPCS,0272,RC,,,,both,,,41.07,26.70,,,,,,,,,,,,,
SPACER SPNL W14XH11XL8MM 4DEG PEEK OPTMA ANT CERV INTBDY,SUP-2286397,CDM,C1821,HCPCS,0278,RC,,,,both,,,2009.60,1306.24,,,,,,,,,,,,,
CANNULA INJ LL 3.5 MM FOR POS PRESSURE ASST VENT SYS LF,SUP-2772363,CDM,2720000010,LOCAL,0272,RC,,,,both,,,370.17,240.61,,,,,,,,,,,,,
SYSTEM STENT INTRO CATH PUSH 8.5FR GUID 5FR L195CM 0.035IN,SUP-2170075,CDM,C1894,HCPCS,0272,RC,,,,both,,,351.68,228.59,,,,,,,,,,,,,
TUBING SET VERSICON FOR JOIMAX SPINE PUMP,SUP-2848823,CDM,2720000010,LOCAL,0272,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
SCREW BNE PART THRD 5X40 MM CANN STRL,SUP-2471330,CDM,C1713,HCPCS,0278,RC,,,,both,,,551.29,358.34,,,,,,,,,,,,,
DEFIBRILLATOR IMPL EVERA MRI XT SURESCAN W 51 X H 66 MM D 13,SUP-2282398,CDM,C1721,HCPCS,0275,RC,,,,both,,,35042.40,22777.56,,,,,,,,,,,,,
HC Breath Hydrogen/Met Test,PX-9209106500,CDM,91065,CPT,0920,RC,,,,outpatient,,,362.00,235.30,,,,,,,,,,,,,
PLATE BNE PROF THK 0.6 MM 7 H SCREW DIA1 MM CMF DBL Y SHP NS,SUP-2883803,CDM,C1713,HCPCS,0278,RC,,,,both,,,536.94,349.01,,,,,,,,,,,,,
PLEDGET SURGICAL W3XL7MM THK15MM SOFT PRE PUNCHED,SUP-2425487,CDM,C1768,CPT,0278,RC,,,,both,,,81.92,53.25,,,,,,,,,,,,,
NEEDLE BX ASPIR 1 MMX48 CM,SUP-2772738,CDM,2720000010,LOCAL,0272,RC,,,,both,,,738.43,479.98,,,,,,,,,,,,,
STEM FEM L200MM OD16MM NO CEM MOD,SUP-2265080,CDM,C1776,CPT,0278,RC,,,,both,,,8179.89,5316.93,,,,,,,,,,,,,
SUPPORT ORTHOT LOWER EXTREMITY CUST FT PLATE STIRRUP ATTCH,SUP-2435655,CDM,L2250,HCPCS,0274,RC,,,,both,,,945.67,614.69,,,,,,,,,,,,,
HC Dilation Stricture/Obst S&I,PX-3207436000,CDM,74360,CPT,0320,RC,,,,outpatient,,,1253.00,814.45,,,,,,,,,,,,,
GRAFT BNE SM 2.5 CC DBM STRND +,SUP-2641767,CDM,C1713,HCPCS,0278,RC,,,,both,,,4050.60,2632.89,,,,,,,,,,,,,
HC MRI-Brain WO & W Contrast,PX-6117055300,CDM,70553,CPT,0611,RC,,,,both,,,3486.00,2265.90,,,,,,,,,,,,,
GUIDEWIRE ORTH L320MM DIA3.2MM ENTRY DISP FOR ANK ARTH NAIL,SUP-2412145,CDM,C1769,HCPCS,0272,RC,,,,both,,,357.96,232.67,,,,,,,,,,,,,
ASCOPE 5 BRONCHO HD 5.6/2.8 SAMPLER SET,SUP-2882182,CDM,C1601,HCPCS,0272,RC,,,,both,,,1014.22,659.24,,,,,,,,,,,,,
PLATE BONE ANGLED 2 MM LEFT 7X23 HOLE RECONSTRUCTION PRECONT,SUP-2837754,CDM,C1713,HCPCS,0278,RC,,,,both,,,7270.98,4726.14,,,,,,,,,,,,,
INBONE  POLY SZ 6 11MM SULCUS,SUP-2470049,CDM,C1776,CPT,0278,RC,,,,both,,,3865.34,2512.47,,,,,,,,,,,,,
PLATE BNE THK13MM 6 H LOK COMPR BILAT NEUT MAL ROTATIONAL,SUP-2107088,CDM,C1713,HCPCS,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
BLADE ARTHSCP 4.2MM DIA 30DEG 10.5CML SINUS BNDBLE TIP RHNTC,SUP-2586409,CDM,2720000010,LOCAL,0272,RC,,,,both,,,271.01,176.16,,,,,,,,,,,,,
SPLINT ORTHOPEDIC W/ ABDUCTED SM 8 IN LT WRST FOREARM THMB,SUP-2276634,CDM,L3809,HCPCS,0272,RC,,,,both,,,21.92,14.25,,,,,,,,,,,,,
SET BILI STENT ZMMN L 12 CM DIA 7 FR PUSH L 170 CM GUIDEWIRE,SUP-2738159,CDM,C2625,HCPCS,0278,RC,,,,both,,,430.18,279.62,,,,,,,,,,,,,
HC Arterial Line Insertion,PX-7613662001,CDM,36620,CPT,0370,RC,,,,inpatient,,,789.00,512.85,,,,,,,,,,,,,
PLATE BNE CALCANEAL LG 2.7X70 MM LT LCK VA TAB SS NS VA-LCP,SUP-2799245,CDM,C1713,HCPCS,0278,RC,,,,both,,,3227.35,2097.78,,,,,,,,,,,,,
IMPLANT BRST MOD PROF SIL 510 CC FILL VOL 155 CM PROJCT,SUP-2113103,CDM,C1789,HCPCS,0278,RC,,,,both,,,2245.10,1459.31,,,,,,,,,,,,,
SEED BRACHYTHERAPY LOOSE 2.01-3.0 MCI NS ADVANTAGE,SUP-2247265,CDM,C2643,HCPCS,0278,RC,,,,both,,,219.80,142.87,,,,,,,,,,,,,
MESH CRAN CUSTOMIZED + MED MEDPOR PTERIONAL +,SUP-2862745,CDM,C1713,HCPCS,0278,RC,,,,both,,,48861.98,31760.29,,,,,,,,,,,,,
DEVICE REVASCULARIZATION EMBOTRAP II L 33 MM DIA 5 MM NIT 2,SUP-2163307,CDM,C1889,HCPCS,0278,RC,,,,both,,,21352.00,13878.80,,,,,,,,,,,,,
PLATE BNE 3D PRNT LG MIDFACE MAND TI TRUMATCH,SUP-2860368,CDM,C1713,HCPCS,0278,RC,,,,both,,,27035.40,17573.01,,,,,,,,,,,,,
STEM HUM L 107 MM DSTL DIA10 MM CLLR DIA 38 MM SZ 3 TYP,SUP-2894282,CDM,C1776,CPT,0278,RC,,,,both,,,16016.14,10410.49,,,,,,,,,,,,,
FIB NAIL 1503185,SUP-2843405,CDM,C1713,HCPCS,0278,RC,,,,both,,,8321.00,5408.65,,,,,,,,,,,,,
NEPHROSTOMY SET 0.038 IN 12 FRX35 CM LCK ALL PURP SKATER,SUP-2269627,CDM,C1729,HCPCS,0272,RC,,,,both,,,285.74,185.73,,,,,,,,,,,,,
SHEATH ENDOSCP 10-12 FRX54 CM ACCS VARI-PASS,SUP-2497201,CDM,C1894,HCPCS,0278,RC,,,,both,,,169.56,110.21,,,,,,,,,,,,,
CATHETER INFUSION 0.035 IN 5 FRX35 CM 10 CM 20 SH MEWISSEN,SUP-2141163,CDM,C1725,HCPCS,0272,RC,,,,both,,,237.16,154.15,,,,,,,,,,,,,
RASP SURG SINGLE SIDE SAW STRYKR IO FRDM CARTILAGINATOR,SUP-2865104,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2232.54,1451.15,,,,,,,,,,,,,
IMPL KNEE FEM NAIL CEPHALOMEDULLARY SHRT BL LFT,SUP-2489869,CDM,C1776,CPT,0278,RC,,,,both,,,4450.26,2892.67,,,,,,,,,,,,,
SET ORTH FOR INT BRAC TECH STRL DISP AUTOGRFT GRAFTLINK,SUP-2882291,CDM,C1713,HCPCS,0278,RC,,,,both,,,6829.50,4439.17,,,,,,,,,,,,,
KIT 210CM TBNG 1 TRNSDUC MON PRSS TRUWAVE,SUP-2214652,CDM,2720000010,LOCAL,0272,RC,,,,both,,,120.86,78.56,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA PLU MAXBARR 5FR S1385108D3,SUP-2632822,CDM,C1751,HCPCS,0278,RC,,,,both,,,1131.81,735.68,,,,,,,,,,,,,
KETOROLAC TROMETHAMINE 0.5 % OP SOLN,RX-19733,CDM,6370000000,HCPCS,0637,RC,70512-0790-05,NDC,,both,5,ML,27.00,17.55,,,,,,,,,,,,,
SCREW BONE L16MM THRD DIA2MM HD DIA3.3MM COR DIA1.3MM PITCH,SUP-2349378,CDM,C1713,HCPCS,0278,RC,,,,both,,,645.71,419.71,,,,,,,,,,,,,
GRAFT HUMAN TSSUE SGMNT LG 6MML BRCHMTTRSL FRZE DRIED IRRDTD,SUP-2726036,CDM,C1762,CPT,0278,RC,,,,both,,,3733.15,2426.55,,,,,,,,,,,,,
CATHETER PERF 5FR L136CM 0.054IN PROX WRK POS CONT ASPIR,SUP-2323624,CDM,C1757,HCPCS,0272,RC,,,,both,,,4553.00,2959.45,,,,,,,,,,,,,
MESH SURG 19CM LEN 15CM W THK1MM SYN ABD N ABSRB OVL EXP,SUP-2125769,CDM,C1781,HCPCS,0278,RC,,,,both,,,1827.48,1187.86,,,,,,,,,,,,,
TOCILIZUMAB 20 MG/ML IV SOLN (MIXTURES ONLY),RX-430062,CDM,J3262,HCPCS,0636,RC,50242-0136-01,NDC,,both,10,ML,3917.40,2546.31,,,,,,,,,,,,,
HC Revise/Remove Spinal Cord Stim,PX-3600007521,CDM,3600007521,LOCAL,0360,RC,,,,both,,,482.00,313.30,,,,,,,,,,,,,
GRAFT HUM TISS L69MM DIA9.5MM FRZN FLEXIGRFT GRFTLINK,SUP-2264635,CDM,C1762,CPT,0278,RC,,,,both,,,7033.91,4572.04,,,,,,,,,,,,,
KIT NEUROSURGICAL DEV MILD TISS SCULPTER TROCAR HNDL PORTAL,SUP-2927636,CDM,2720000010,LOCAL,0272,RC,,,,both,,,9263.00,6020.95,,,,,,,,,,,,,
POST EXT FIX PIN MT MULTIPARALLEL 4 HI NS MAXFRAME,SUP-2758001,CDM,2720000010,LOCAL,0272,RC,,,,both,,,564.70,367.05,,,,,,,,,,,,,
PLATE BNE MED RT POST FIB NS UNITE,SUP-2896533,CDM,C1713,HCPCS,0278,RC,,,,both,,,3281.30,2132.84,,,,,,,,,,,,,
BIT DRL CANN 2 IN 1 2 X 65 MM,SUP-2243023,CDM,2720000010,LOCAL,0272,RC,,,,both,,,743.83,483.49,,,,,,,,,,,,,
SET IMPL PELV INT FIX W/ ST SCR,SUP-2183094,CDM,C1713,HCPCS,0278,RC,,,,both,,,175289.21,113937.99,,,,,,,,,,,,,
KIT CRAN ACCS INCLUDE SYR 5CC NDL RAZ POVIDONE IOD SWAB LIDO,SUP-2244116,CDM,2720000010,LOCAL,0272,RC,,,,both,,,973.53,632.79,,,,,,,,,,,,,
TUBE T SURG DRAIN 10F SIL STRL,SUP-2752236,CDM,C1729,HCPCS,0272,RC,,,,both,,,1263.63,821.36,,,,,,,,,,,,,
COMPONENT CRPL SM STD BILAT WRST JT TI POR PRI PRSS FIT,SUP-2243197,CDM,C1776,CPT,0278,RC,,,,both,,,3141.98,2042.29,,,,,,,,,,,,,
PROBE LSR 20GA STR ENDO,SUP-2109736,CDM,2720000010,LOCAL,0272,RC,,,,both,,,379.31,246.55,,,,,,,,,,,,,
DEVICE INT FIX W ZIPLOOP INLINE TECHNOLOGY FOR ACL RECON,SUP-2136091,CDM,C1713,HCPCS,0278,RC,,,,both,,,1758.40,1142.96,,,,,,,,,,,,,
ALLOGRAFT BNE WDG 23 MM FD ILIUM TRICORT,SUP-2717917,CDM,C1713,HCPCS,0278,RC,,,,both,,,5837.70,3794.50,,,,,,,,,,,,,
TRANSDUCER PRESSURE MONITOR SET W/ VENT TRUWAVE DISP,SUP-2214636,CDM,C1713,HCPCS,0278,RC,,,,both,,,39.19,25.47,,,,,,,,,,,,,
CATHETER INFUSION PULSE SPRY PRO L 90 CM 5 FR SLT 5 CM FLX Y,SUP-2117005,CDM,C1751,HCPCS,0278,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
HC Intraosseous Needle Placement,PX-7613668000,CDM,36680,CPT,0761,RC,,,,outpatient,,,954.00,620.10,,,,,,,,,,,,,
ANCHOR SUT DIA6.5MM BIOCRYL RAPIDE ABSRB 3 DYNACORD SZ 2,SUP-2256651,CDM,C1713,HCPCS,0278,RC,,,,both,,,1695.60,1102.14,,,,,,,,,,,,,
SCREW BNE DISTRCTN 14 MM STRL,SUP-2430771,CDM,C1713,HCPCS,0278,RC,,,,both,,,141.30,91.84,,,,,,,,,,,,,
TRAY GLEN SM SHLDR POR MOD BIOMOD,SUP-2404669,CDM,C1776,CPT,0278,RC,,,,both,,,4465.08,2902.30,,,,,,,,,,,,,
HEAD FEM DIA28MM +10MM OFFSET 10/12 TAPR CO CHROM SKIRTED,SUP-2253273,CDM,C1776,CPT,0278,RC,,,,both,,,2093.75,1360.94,,,,,,,,,,,,,
SPLINT WR COLLES ALUM W/ FOAM LT M,SUP-2195268,CDM,L3906,HCPCS,0272,RC,,,,both,,,28.54,18.55,,,,,,,,,,,,,
PROCESSOR HEARING AID BLK KT SND LT INCL ABUTMENT CVR BTTRY,SUP-2164945,CDM,L8614,HCPCS,0278,RC,,,,both,,,9263.00,6020.95,,,,,,,,,,,,,
CATHETER INFUSION 4 FRX90 CM 40 CM OCCL WIRE FOUNTAIN,SUP-2302768,CDM,C1751,HCPCS,0278,RC,,,,both,,,372.09,241.86,,,,,,,,,,,,,
PLATE BONE W5XL39MM THK1.2MM 7 H RT CNDYL S STL,SUP-2343842,CDM,C1713,HCPCS,0278,RC,,,,both,,,2272.17,1476.91,,,,,,,,,,,,,
SET INTRO L 14 CM DIA 9 FR GUIDEWIRE 0.038 IN PTFE TEARWY,SUP-2226016,CDM,C1892,HCPCS,0272,RC,,,,both,,,60.29,39.19,,,,,,,,,,,,,
EXTENSION STEM L120MM DIA11MM NK L75MM TIB KNEE TIV FLUT,SUP-2208711,CDM,C1776,CPT,0278,RC,,,,both,,,2529.27,1644.03,,,,,,,,,,,,,
GUIDEWIRE ORTH TROCAR PT 1 END 15 DEG 1.2X150 MM TI,SUP-2751496,CDM,C1769,HCPCS,0272,RC,,,,both,,,288.88,187.77,,,,,,,,,,,,,
SET LD EXTRACTION BYRD WORKSTATION INTRO 16 FR SHTH 12 FR,SUP-2169003,CDM,C1773,HCPCS,0272,RC,,,,both,,,3035.69,1973.20,,,,,,,,,,,,,
LEVEL NEURO PLATE ULTRNE STR NEURO SCRW2 HOLE 12 MM T06 MM,SUP-2677496,CDM,C1713,HCPCS,0278,RC,,,,both,,,298.33,193.91,,,,,,,,,,,,,
ELEVATOR SURG TIP 3.5 MM MOD OBWEGESER,SUP-2936983,CDM,2720000010,LOCAL,0272,RC,,,,both,,,609.16,395.95,,,,,,,,,,,,,
RING EXT FIX DIA120 MM FULL TAB MONK RING,SUP-2898981,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4654.27,3025.28,,,,,,,,,,,,,
PIN EXT FIX HALF 3X70 MM 12 MM SD ST NS LTX,SUP-2862039,CDM,C1713,HCPCS,0278,RC,,,,both,,,271.67,176.59,,,,,,,,,,,,,
NEEDLE ASPIR 22GA L2.4MM SHTH DIA1.52MM ENDO US EXPECT SLM,SUP-2418158,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2546.54,1655.25,,,,,,,,,,,,,
WASHER ORTH L25MM FOR SIDEKCK EZ FRME EXT FIX,SUP-2400674,CDM,2720000010,LOCAL,0272,RC,,,,both,,,135.02,87.76,,,,,,,,,,,,,
PLATE BNE FEM 236 MM RT DSTL 9 HOLE TI STRL LCP,SUP-2549451,CDM,C1713,HCPCS,0278,RC,,,,both,,,5385.60,3500.64,,,,,,,,,,,,,
PLATE BNE L233MM 15 H NONSTERILE L POSTEROLATERAL DST,SUP-2177408,CDM,C1713,HCPCS,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
LEAD PACEMKR OPTISENSE OPTIM 40CM,SUP-2356692,CDM,C1898,HCPCS,0275,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
NEEDLE ENDOSCP 30678ND MANHES MONOPOLAR FOR 30678ND REPL,SUP-2767361,CDM,2720000010,LOCAL,0272,RC,,,,both,,,470.37,305.74,,,,,,,,,,,,,
BLADE RTRCTR MCCLLCH 7CMD STNLSS STEEL SPNL MSCLE NRRW BLACK,SUP-2494782,CDM,2720000010,LOCAL,0272,RC,,,,both,,,414.79,269.61,,,,,,,,,,,,,
PLATE BNE W14XL24MM 2X3 H CRANIOMAXILLOFACIAL BILAT BLU TI,SUP-2181567,CDM,C1713,HCPCS,0278,RC,,,,both,,,1337.64,869.47,,,,,,,,,,,,,
TUBE ORTH OD8MM IM FLR EXCHG NONSTERILE M/DN,SUP-2410448,CDM,C1713,HCPCS,0278,RC,,,,both,,,294.97,191.73,,,,,,,,,,,,,
SCREW SPNL REDUCTION 4.5X25 MM THORLUM PEDCL TRPL LD PREF 2,SUP-2175469,CDM,C1713,HCPCS,0278,RC,,,,both,,,5416.50,3520.72,,,,,,,,,,,,,
GRAFT VASC EXXCEL SFT L 40 CM DIA 4-7 MM SZ 5 CM EPTFE SFT,SUP-2266064,CDM,C1768,CPT,0278,RC,,,,both,,,1714.44,1114.39,,,,,,,,,,,,,
HC Eeg Awake & Drowsy,PX-7409581600,CDM,95816,CPT,0740,RC,,,,both,,,1811.00,1177.15,,,,,,,,,,,,,
BLADE LARYNSCP L90MM SZ 2 PED MACINTOSH FBROPT MRI REUSE S,SUP-2309346,CDM,2720000010,LOCAL,0272,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
SYSTEM MENIS REP 12DEG BRAID ABSRB 2-0 PNCRYL SUT CRV NDL,SUP-2249488,CDM,C1713,HCPCS,0278,RC,,,,both,,,888.62,577.60,,,,,,,,,,,,,
BURR SURG 5MM DIA HD LNG MIC 70MML SM BNE RND DIAMOND MICROP,SUP-2605569,CDM,2720000010,LOCAL,0272,RC,,,,both,,,67.64,43.97,,,,,,,,,,,,,
PIN FIX L65MM DIA1.2MM ANK FT SMOOTH TRCR TIP OLV DISP FOR,SUP-2379280,CDM,2720000010,LOCAL,0272,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC SOLO2 PLU MAXBARR 4FR 55C 1194108D5,SUP-2632633,CDM,C1751,HCPCS,0278,RC,,,,both,,,990.23,643.65,,,,,,,,,,,,,
CATHETER SUBCLAV 8FRX20CM W/ REM Y ADPT,SUP-2267029,CDM,C1751,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
CATHETER THERMOABLAT DIA18-31MM BLLN L8CM ELECTRD L4CM 16,SUP-2172284,CDM,C1888,HCPCS,0272,RC,,,,both,,,8003.86,5202.51,,,,,,,,,,,,,
CATHETER URET PED 3FR L70CM,SUP-2168914,CDM,C1758,HCPCS,0278,RC,,,,both,,,189.66,123.28,,,,,,,,,,,,,
HC Allo Fresh Infusion,PX-3623824000,CDM,38240,CPT,0362,RC,,,,both,,,1411.00,917.15,,,,,,,,,,,,,
PLATE BNE THK 1 MM SCREW DIA2 MM 2 X 2 H MINI 3D TRAP,SUP-2883194,CDM,C1713,HCPCS,0278,RC,,,,both,,,1535.71,998.21,,,,,,,,,,,,,
TIP FLO PHACO 30DEG CVD INF SL 20GA LAM,SUP-2247715,CDM,C1713,HCPCS,0278,RC,,,,both,,,1130.40,734.76,,,,,,,,,,,,,
VALVE AORT SUTURELESS PERCEVAL,SUP-2352662,CDM,C1889,HCPCS,0278,RC,,,,both,,,28888.00,18777.20,,,,,,,,,,,,,
STEM HUMERAL L SHOULDER MODULAR PMMA GENTAMICIN BASE,SUP-2718070,CDM,C1776,CPT,0278,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
TOCILIZUMAB 200 MG/10ML IV SOLN,RX-104371,CDM,J3262,HCPCS,0636,RC,50242-0136-01,NDC,,both,10,ML,3917.40,2546.31,,,,,,,,,,,,,
PLATE BNE LG FT LAT CLMN STRL A.L.P.S,SUP-2486267,CDM,C1713,HCPCS,0278,RC,,,,both,,,2378.77,1546.20,,,,,,,,,,,,,
PIN ALIGN KNEE HOWMED PCA UNIV LNG,SUP-2364946,CDM,C1713,HCPCS,0278,RC,,,,both,,,253.08,164.50,,,,,,,,,,,,,
BUR SHV L19CM DIA5MM 8 FLUT HIP LEN RND COOLCUT,SUP-2121983,CDM,2720000010,LOCAL,0272,RC,,,,both,,,122.46,79.60,,,,,,,,,,,,,
PLATE SLIM STR 3 HL T8,SUP-2702873,CDM,C1713,HCPCS,0278,RC,,,,both,,,3362.94,2185.91,,,,,,,,,,,,,
KIT PICC MAX BARRIER PRLOADED 4FR X 55CM 1L,SUP-2864579,CDM,C1751,HCPCS,0278,RC,,,,both,,,700.22,455.14,,,,,,,,,,,,,
RING EXT FIX ID140MM COMP C HALF FOR ILIZ,SUP-2342280,CDM,C1713,HCPCS,0278,RC,,,,both,,,6776.91,4404.99,,,,,,,,,,,,,
NAIL IM SHT HINDFOOT SHOULDERED END CAP PHANTOM,SUP-2743165,CDM,C1713,HCPCS,0278,RC,,,,both,,,923.16,600.05,,,,,,,,,,,,,
SCREW INTRF 9MM 20MM 35MM 2MM DIA GWIRE FIX KNEE CANN N,SUP-2340987,CDM,C1713,HCPCS,0278,RC,,,,both,,,684.52,444.94,,,,,,,,,,,,,
RELOAD STPL H35XL60MM BLU REG B FORM NAT ARTC ECHELON,SUP-2218989,CDM,2720000010,LOCAL,0272,RC,,,,both,,,516.25,335.56,,,,,,,,,,,,,
SPACER SPNL W11XH9XL14MM 4DEG PEEK ANT CERV INTBDY FUS LORD,SUP-2286353,CDM,C1713,HCPCS,0278,RC,,,,both,,,2009.60,1306.24,,,,,,,,,,,,,
NEEDLE ASPIR INJ 15 GAX32 CM NS ENDOLAP LTX REUSE,SUP-2868232,CDM,2720000010,LOCAL,0272,RC,,,,both,,,457.00,297.05,,,,,,,,,,,,,
CAP KNEE W/ VE SURF AND PAT PERSONA,SUP-2212228,CDM,C1776,CPT,0278,RC,,,,both,,,15112.82,9823.33,,,,,,,,,,,,,
TRIAL KNEE SPACER SM MED LG SZ SET STRL DISP COPAL EXCHANGE,SUP-2905435,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1224.60,795.99,,,,,,,,,,,,,
CEFAZOLIN SODIUM-DEXTROSE 2-3 GM-%(50ML) IV SOLR,RX-143625,CDM,J0690,HCPCS,0636,RC,00264-3105-11,NDC,,both,1,UN,84.90,55.18,,,,,,,,,,,,,
HC Ot Ultrasound 15 Min,PX-4309703500,CDM,97035,CPT,0430,RC,,,,outpatient,,,194.00,126.10,,,,,,,,,,,,,
CATHETER PICC 5FR L55CM GWIRE L70CM 0.018IN POLYUR S STL,SUP-2125529,CDM,C1751,HCPCS,0278,RC,,,,both,,,293.02,190.46,,,,,,,,,,,,,
STENT GRFT VASC TAG L 10 CM DIA26 MM SHTH 20 FR AORT,SUP-2396365,CDM,C1713,HCPCS,0278,RC,,,,both,,,40035.00,26022.75,,,,,,,,,,,,,
STEM HUM L125MM DIA10MM UNIV DST SHLDR TI PRI REV CEM FOR,SUP-2372853,CDM,C1776,CPT,0278,RC,,,,both,,,12971.34,8431.37,,,,,,,,,,,,,
PLATE BNE STR LG 1.5X28X1 MM MIDFACE 6 HOLE W/ TAB STRL,SUP-2518114,CDM,C1713,HCPCS,0278,RC,,,,both,,,531.29,345.34,,,,,,,,,,,,,
ALBUTEROL SULFATE 2 MG/5ML PO SYRP,RX-252,CDM,340b,HCPCS,0637,RC,70752-0102-12,NDC,,both,5,ML,2.70,1.75,,,,,,,,,,,,,
SUPPORT ORTHOT HEEL CUST STD NEW LTHR,SUP-2435732,CDM,L3455,HCPCS,0272,RC,,,,both,,,115.24,74.91,,,,,,,,,,,,,
PLATE BNE TIB 202 MM LAT 9 HOLE BUTTRESS HD TI NS LC-DCP,SUP-2569063,CDM,C1713,HCPCS,0278,RC,,,,both,,,2614.87,1699.67,,,,,,,,,,,,,
COIL DETACH NXT HELIX STD 10 7 MMX10 CM,SUP-2173054,CDM,C1889,HCPCS,0278,RC,,,,both,,,1924.82,1251.13,,,,,,,,,,,,,
SCREW BNE L8MM DIA1.5MM CO CHROM CORT ST NONLOCKING FULL,SUP-2411776,CDM,C1713,HCPCS,0278,RC,,,,both,,,312.27,202.98,,,,,,,,,,,,,
FELT SURG W2XL2IN THK1.65MM PTFE FOR THE REP OF SEPT DEFCT,SUP-2127906,CDM,C1768,CPT,0278,RC,,,,both,,,246.74,160.38,,,,,,,,,,,,,
FORCEPS BX 3.3FR L115CM CUP 0.85CUMM OVL TO OBTAIN TISS,SUP-2171270,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1144.53,743.94,,,,,,,,,,,,,
STENT URET 0.038 IN 8 FRX22 CM 6 FR FLX FIRM PERCFLX +,SUP-2460000,CDM,C2617,HCPCS,0278,RC,,,,both,,,510.72,331.97,,,,,,,,,,,,,
GRAFT VASC L10CM DIA37MM THOR NIT EPTFE STR GORE-TAG,SUP-2396373,CDM,C1713,HCPCS,0278,RC,,,,both,,,40035.00,26022.75,,,,,,,,,,,,,
PLATE BNE L85MM THK3.3MM 7 H BILAT S STL RIG STR DYN COMPR,SUP-2186331,CDM,C1713,HCPCS,0278,RC,,,,both,,,974.78,633.61,,,,,,,,,,,,,
STEM HUM SZ 1 L137MM DIA10MM STD SHLDR CO CHROM HA CEM,SUP-2250980,CDM,C1776,CPT,0278,RC,,,,both,,,9853.32,6404.66,,,,,,,,,,,,,
PORT IMPL INFUSION 9.6 FR PRE ATTCH SIL CATH POWERPORT MRI,SUP-2126333,CDM,C1788,HCPCS,0278,RC,,,,both,,,1287.40,836.81,,,,,,,,,,,,,
PLATE BNE L37MM THK1.3MM 2X4 H L MTCRPL TI L SHP COMPR FOR,SUP-2267918,CDM,C1713,HCPCS,0278,RC,,,,both,,,673.22,437.59,,,,,,,,,,,,,
DILATOR ENDOSCP 54FR L180CM BLLN L8CM ES DISP ELIM PET,SUP-2166036,CDM,C1726,HCPCS,0272,RC,,,,both,,,232.36,151.03,,,,,,,,,,,,,
PROSTHESIS OSS PISTON 0.8X1.02X4.5 MM 0.97 MM RT EAR SHEA,SUP-2637805,CDM,L8613,CPT,0278,RC,,,,both,,,455.58,296.13,,,,,,,,,,,,,
CLONAZEPAM 1 MG PO TABS,RX-9638,CDM,6370000000,HCPCS,0637,RC,16729-0137-00,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PLATE BONE L202MM 16 H STRL S STL COMPR FOR 3.5MM SCR EVOS,SUP-2349642,CDM,C1713,HCPCS,0278,RC,,,,both,,,2923.97,1900.58,,,,,,,,,,,,,
JOURNEY II BCSXLPE ART ISRT SZ 5-6 RT 1,SUP-2340967,CDM,C1776,CPT,0278,RC,,,,both,,,20410.00,13266.50,,,,,,,,,,,,,
LEAD NERVE STIM 50 CM PADDLE KT ARTISAN,SUP-2138834,CDM,C1778,HCPCS,0278,RC,,,,both,,,12961.92,8425.25,,,,,,,,,,,,,
COIL EMB L35CM OD0.020IN LOOP OD9MM STD NIT COMPLX FRME,SUP-2323369,CDM,C1889,HCPCS,0278,RC,,,,both,,,7149.78,4647.36,,,,,,,,,,,,,
BRACE ORTH CUST FABRICATED RIGID W/O INTFACE LNR TLSO,SUP-2388143,CDM,L0450,HCPCS,0272,RC,,,,both,,,4930.40,3204.76,,,,,,,,,,,,,
INTRODUCER SHTH HEMSTAS 7FRX23CM W/ .038IN GWIRE 7FR DILATO,SUP-2355393,CDM,C1894,HCPCS,0272,RC,,,,both,,,76.93,50.00,,,,,,,,,,,,,
SHEETING SIL TRNSLUC REINF FOR APPL ON BODY,SUP-2134688,CDM,2720000010,LOCAL,0272,RC,,,,both,,,932.58,606.18,,,,,,,,,,,,,
CANNULA IRRIGATION SIMCOE 23 GAX15 MM DOUBLE-BARRELED RVS,SUP-2475629,CDM,2720000010,LOCAL,0272,RC,,,,both,,,316.36,205.63,,,,,,,,,,,,,
SHEATH INTRO PRELUDE L 4 CM DIA 5 FR GUIDEWIRE L 50 CM DIA,SUP-2476900,CDM,C1894,HCPCS,0272,RC,,,,both,,,81.51,52.98,,,,,,,,,,,,,
SCREW BNE L 10 MM DIA2 MM MANDIBULAR ST LCK NS UNIV AXS,SUP-2909470,CDM,C1713,HCPCS,0278,RC,,,,both,,,474.20,308.23,,,,,,,,,,,,,
VALVE AORT CARP EDW PERIMT MAGNA EASE MT OD 19 MM ID 18 MM,SUP-2214116,CDM,C1889,HCPCS,0278,RC,,,,both,,,19678.38,12790.95,,,,,,,,,,,,,
NAIL INTRAMEDULLARYXL L36CM DIA7MM RT ANTR POST FEM LCK,SUP-2318897,CDM,C1713,HCPCS,0278,RC,,,,both,,,12501.34,8125.87,,,,,,,,,,,,,
GRAFT VASC L80CM ID8MM STRTCH THN WALLED INTERING,SUP-2395853,CDM,C1768,CPT,0278,RC,,,,both,,,5089.94,3308.46,,,,,,,,,,,,,
PROSTHESIS PENILE L18CM CYL MALL 600M,SUP-2138932,CDM,C1813,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
SYSTEM SHLDR ARTHRPLSTY GLEN PT SPEC MTCH PT,SUP-2197200,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
LEAD NEUROSTIMULATOR 35CM WIRE INTRAMUSCULAR NEUROSTIM,SUP-2281931,CDM,C1778,HCPCS,0278,RC,,,,both,,,8242.50,5357.62,,,,,,,,,,,,,
SCREW BNE L95MM DIA12.7MM SUBTROCHANTERIC HIP CANN,SUP-2347919,CDM,C1713,HCPCS,0278,RC,,,,both,,,1089.08,707.90,,,,,,,,,,,,,
ELECTRODE ES VPR FRONTLOADING PK PLASMABUTTON,SUP-2313936,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1704.64,1108.02,,,,,,,,,,,,,
PATCH SFT TISS W15X20CM THK1MM EPTFE MICROPOROUS FOR,SUP-2395297,CDM,C1781,HCPCS,0278,RC,,,,both,,,3331.54,2165.50,,,,,,,,,,,,,
CONNECTOR SPNL W51-70MM DIA5.5MM TRNSVRS ADJ VITALITY,SUP-2402701,CDM,C1713,HCPCS,0278,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
DRIVER SURG T10 TORX HEX FOR EVOLUTION C CERV IMPL REM SYS,SUP-2293611,CDM,C1713,HCPCS,0278,RC,,,,both,,,239.11,155.42,,,,,,,,,,,,,
STEM FEM L165MM DIA15MM 12/14 TAPR HIP 5/8 POR STD NK AML,SUP-2252057,CDM,C1776,CPT,0278,RC,,,,both,,,11655.68,7576.19,,,,,,,,,,,,,
SYSTEM VARICOSE VEIN CLOSURE VENASEAL,SUP-2717590,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6088.46,3957.50,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 25X25 MM FD PERIO FASC LATA ORAGRAFT,SUP-2741085,CDM,C1762,CPT,0278,RC,,,,both,,,349.95,227.47,,,,,,,,,,,,,
NEEDLE SURG TONSIL 30 DEG 23 GAX13 MM ANGLED LL,SUP-2484855,CDM,C1713,HCPCS,0278,RC,,,,both,,,154.55,100.46,,,,,,,,,,,,,
ANCHOR SUTURE LOOPED CRV NDL BLU,SUP-2848967,CDM,C1713,HCPCS,0278,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
BLADE SAW SAG 96 MM CLMN STRL LTX,SUP-2862419,CDM,2720000010,LOCAL,0272,RC,,,,both,,,344.21,223.74,,,,,,,,,,,,,
STEM FEM SZ 11 L200MM NK L40MM DST DIA155MM LNG L HIP CEM,SUP-2374745,CDM,C1776,CPT,0278,RC,,,,both,,,12453.24,8094.61,,,,,,,,,,,,,
CATHETER HD CRV EXTN 12 FRX16 CM ACUTE DL TY MAHRK ELITE,SUP-2283963,CDM,C1752,HCPCS,0278,RC,,,,both,,,301.06,195.69,,,,,,,,,,,,,
TRIAL BONE PLT 3 H T SHP TC-100 SM FRAG SYS,SUP-2343726,CDM,C1713,HCPCS,0278,RC,,,,both,,,1184.82,770.13,,,,,,,,,,,,,
COMPRESSION SCREW 40MM,SUP-2819501,CDM,C1713,HCPCS,0278,RC,,,,both,,,1532.04,995.83,,,,,,,,,,,,,
PLATE BNE L 2.7 MM RT LCK 5 HOLE SHFT NS LTX,SUP-2861509,CDM,C1713,HCPCS,0278,RC,,,,both,,,1203.12,782.03,,,,,,,,,,,,,
ENDCAP ORTH L10MM DIA12MM NONSTERILE GRN FEM TI NAIL EXTN,SUP-2192363,CDM,C1713,HCPCS,0278,RC,,,,both,,,609.19,395.97,,,,,,,,,,,,,
GRAFT BNE SCAFFOLD 20X20X4 MM MOLD DBM FUSIONFLEX,SUP-2859709,CDM,C1713,HCPCS,0278,RC,,,,both,,,4427.09,2877.61,,,,,,,,,,,,,
VALVE PRESSURE FIX 120 CM PV RR UNTZ D CATH,SUP-2666781,CDM,C1889,HCPCS,0278,RC,,,,both,,,3422.66,2224.73,,,,,,,,,,,,,
KCL IN DEXTROSE-NACL 20-5-0.2 MEQ/L-%-% IV SOLN,RX-102357,CDM,2500000003,HCPCS,0250,RC,00338-0663-04,NDC,,both,1000,ML,54.10,35.16,,,,,,,,,,,,,
KIT INTRO MAK L 10 CM DIA 4 FR 40 CM 0.018 IN PLAT ECHO COAX,SUP-2303000,CDM,C1713,HCPCS,0278,RC,,,,both,,,81.48,52.96,,,,,,,,,,,,,
BEVACIZUMAB 400 MG/16ML IV SOLN,RX-104375,CDM,J9035,HCPCS,0636,RC,50242-0061-01,NDC,,both,16,ML,9180.80,5967.52,,,,,,,,,,,,,
GRAFT VASC STD WALL 5-8 MMX45 CM SHT TAPR STR ADVANTA VXT,SUP-2464340,CDM,C1768,CPT,0278,RC,,,,both,,,1496.43,972.68,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP L150CM OD0038IN OD14FR INTRO 3MM J TIP MOV,SUP-2141740,CDM,C1769,HCPCS,0272,RC,,,,both,,,60.54,39.35,,,,,,,,,,,,,
INTRODUCER MIC KT VSI 5FR NIT MANDREL TUNGSTEN SFT TIP,SUP-2383174,CDM,C1894,HCPCS,0272,RC,,,,both,,,56.36,36.63,,,,,,,,,,,,,
HAND CONTROL ELECSURG SINGLE FUNC,SUP-2225598,CDM,2720000010,LOCAL,0272,RC,,,,both,,,741.83,482.19,,,,,,,,,,,,,
PLATE BNE SM W11XL64MM THK3.3MM 0DEG 5 H BILAT TI STR RIG,SUP-2190776,CDM,C1713,HCPCS,0278,RC,,,,both,,,513.48,333.76,,,,,,,,,,,,,
PLATE BNE MED TI MANDIBULAR 3D PRNT NS DISP ACCUPLATE,SUP-2934721,CDM,C1713,HCPCS,0278,RC,,,,both,,,29032.44,18871.09,,,,,,,,,,,,,
COIL VASC 10MM DIA 30CM LEN 018IN GWIRE STRTCH DETACH HELI,SUP-2365710,CDM,C1889,HCPCS,0278,RC,,,,both,,,1828.74,1188.68,,,,,,,,,,,,,
SCREW SPNL L45MM DIA6.25MM PEDCL TI POLYAX MNRCH,SUP-2254491,CDM,C1713,HCPCS,0278,RC,,,,both,,,2961.02,1924.66,,,,,,,,,,,,,
HC So1 Drg Scrn Class List A,PX-3018030767,CDM,80307,CPT,0301,RC,,,,outpatient,,,147.00,95.55,,,,,,,,,,,,,
ANCHOR SUTURE DIA 4.75 MM BIOCOMP STRL HD SCORPION LNT,SUP-2910030,CDM,C1713,HCPCS,0278,RC,,,,both,,,2370.70,1540.95,,,,,,,,,,,,,
HEAD PAT STD LG LAT LCS MILESTONE,SUP-2454059,CDM,C1776,CPT,0278,RC,,,,both,,,2304.76,1498.09,,,,,,,,,,,,,
MESH HERN W15XL15CM POLYGLACTIN 910 WVN FLAT VCRL,SUP-2220358,CDM,C1781,HCPCS,0278,RC,,,,both,,,1539.60,1000.74,,,,,,,,,,,,,
PLATE BNE L 185 X W 10.7 MM THK 3.4 MM SCREW DIA 3.5 MM 16 H,SUP-2933363,CDM,C1713,HCPCS,0278,RC,,,,both,,,3037.01,1974.06,,,,,,,,,,,,,
TUBE TRACH CUF AD 7X10.6X120 MM SIL BIVONA TTS HYPRFLX,SUP-2352023,CDM,2720000010,LOCAL,0272,RC,,,,both,,,542.72,352.77,,,,,,,,,,,,,
PLATE BNE L166MM 14 H BILAT S STL LO PROF RIG LIMIT CNTCT,SUP-2186206,CDM,C1713,HCPCS,0278,RC,,,,both,,,1891.41,1229.42,,,,,,,,,,,,,
DISTALDORSO-ULNARDORSO-RADIALL-PLATESR4H,SUP-2816178,CDM,C1713,HCPCS,0278,RC,,,,both,,,2716.10,1765.46,,,,,,,,,,,,,
SUPPORT ORTHOT ANK KNEE TIB CUST FRAC SFT,SUP-2435648,CDM,L2112,HCPCS,0274,RC,,,,both,,,1428.32,928.41,,,,,,,,,,,,,
KIT ELBW JT ULN PIN BUSHING COONRAD/MORREY,SUP-2205923,CDM,C1776,CPT,0278,RC,,,,both,,,1902.21,1236.44,,,,,,,,,,,,,
CORTICAL BONE SCR 5.0MM X 20MM,SUP-2588707,CDM,C1713,HCPCS,0278,RC,,,,both,,,534.65,347.52,,,,,,,,,,,,,
DRILL SURG LATCH 2.7 MM USED FOR DENS BNE,SUP-2608734,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1244.95,809.22,,,,,,,,,,,,,
PLATE BNE GAP 25 MM NEURO LORENZ,SUP-2402911,CDM,C1713,HCPCS,0278,RC,,,,both,,,678.24,440.86,,,,,,,,,,,,,
MATRIX BIO L 3 X W 3 CM SZ 16 SQCM FISH SKIN DERMAL 5/BX,SUP-2909362,CDM,Q4158,HCPCS,0636,RC,,,,both,,,4069.44,2645.14,,,,,,,,,,,,,
CAGE SPNL 11 MM BENGAL,SUP-2256188,CDM,C1889,HCPCS,0278,RC,,,,both,,,6867.18,4463.67,,,,,,,,,,,,,
PSEUDOEPHEDRINE HCL ER 120 MG PO TB12,RX-6716,CDM,6370000000,HCPCS,0637,RC,00081-0670-20,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
HUMERAL LINER 40MM +2.5,SUP-2512475,CDM,C1776,CPT,0278,RC,,,,both,,,2276.50,1479.72,,,,,,,,,,,,,
PUSHER KNOT CLARKE REICH 5-0 5 MMX45 CM FOR LAP,SUP-2421588,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1664.70,1082.05,,,,,,,,,,,,,
OSELTAMIVIR PHOSPHATE 6 MG/ML PO SUSR,RX-110204,CDM,340b,HCPCS,0637,RC,09999-9909-42,NDC,,both,5,ML,33.70,21.90,,,,,,,,,,,,,
CATHETER GUID TURNPIKE LP L 150 CM SHFT DIA PROX/DSTL,SUP-2383148,CDM,C1887,HCPCS,0272,RC,,,,both,,,1924.82,1251.13,,,,,,,,,,,,,
CONNECTOR SHUNT OD1.9MM YOUTH SHAPED TITANIUM 3 WAYOUTH MIET,SUP-2825579,CDM,C1889,HCPCS,0278,RC,,,,both,,,737.99,479.69,,,,,,,,,,,,,
BIT DRL SLD 3.8X127 MM SS ALPS,SUP-2487351,CDM,2720000010,LOCAL,0272,RC,,,,both,,,379.94,246.96,,,,,,,,,,,,,
NUT ORTH L17MM DIA5MM TI FOR CNDYL SCR T2,SUP-2369862,CDM,C1713,HCPCS,0278,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
COMPONENT IMPLANT SHLDR CAP S2 HEMI,SUP-2797210,CDM,C1776,CPT,0278,RC,,,,both,,,6908.00,4490.20,,,,,,,,,,,,,
LEAD DEFIB 5.6FR 65CM TRNSVEN ACT FIX BPLR PERM STEROID ELUT,SUP-2356669,CDM,C1895,HCPCS,0275,RC,,,,both,,,13345.00,8674.25,,,,,,,,,,,,,
PLATE LOQTEQ PROXIMAL HUMERUS 3.5 4H,SUP-2858202,CDM,C1713,HCPCS,0278,RC,,,,both,,,7605.77,4943.75,,,,,,,,,,,,,
CATHETER HD STR 11.5 FRX20 CM SHT TERM DL TAPR TIP DUOFLO,SUP-2627389,CDM,C1752,HCPCS,0278,RC,,,,both,,,131.88,85.72,,,,,,,,,,,,,
SPHINCTEROTOME ENDOSCP 5 MM 4.4 FRX20 MM TRUTOME 8316,SUP-2467574,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1245.17,809.36,,,,,,,,,,,,,
DISC BNE SCREW DIA 5.5 MM NIT DYN REFLX,SUP-2897281,CDM,C1713,HCPCS,0278,RC,,,,both,,,4706.86,3059.46,,,,,,,,,,,,,
PIN FIX TEMP,SUP-2379520,CDM,C1713,HCPCS,0278,RC,,,,both,,,219.80,142.87,,,,,,,,,,,,,
PACK ARTHSCP B DRL TIP GWIRE PASS PIN BONE TUNN PLUG,SUP-2341854,CDM,C1713,HCPCS,0278,RC,,,,both,,,844.03,548.62,,,,,,,,,,,,,
HEAD HUM STEMLESS SHT 41 MM SHLDR ALPHA EQUINOXE,SUP-2451396,CDM,C1776,CPT,0278,RC,,,,both,,,4266.63,2773.31,,,,,,,,,,,,,
BIT DRL FOR SH 2.9MM PUSHLOCK,SUP-2121760,CDM,2720000010,LOCAL,0272,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
BIT DRL CANN 5.5 MM KNEE SINGLE FLUT MTO,SUP-2849077,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2411.52,1567.49,,,,,,,,,,,,,
PIN FIX DISP SM FRAG PLATING SYS L12MM,SUP-2413865,CDM,C1713,HCPCS,0278,RC,,,,both,,,481.36,312.88,,,,,,,,,,,,,
SCREW EXT FIX L200MM DIA6MM THRD L80MM S STL HA SELF DRL MR,SUP-2186996,CDM,2720000010,LOCAL,0272,RC,,,,both,,,913.11,593.52,,,,,,,,,,,,,
TWIST DRILL ANGULUS 1.9 X 19MM,SUP-2495883,CDM,2720000010,LOCAL,0272,RC,,,,both,,,750.59,487.88,,,,,,,,,,,,,
DRILL SURG 7.5MM CANN DISP FOR CHARCOT DEFORMITY AXIS,SUP-2223917,CDM,2720000010,LOCAL,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
INTRODUCER MIC KT VSI 5FR S STL MANDREL TUNGSTEN SFT TIP,SUP-2383173,CDM,C1894,HCPCS,0272,RC,,,,both,,,180.55,117.36,,,,,,,,,,,,,
PLATE BONE L31MM 2 HOLE BLTRL STNLSS STEEL STRGHT NNCMPRSSN,SUP-2492489,CDM,C1713,HCPCS,0278,RC,,,,both,,,765.88,497.82,,,,,,,,,,,,,
MESH SURGICAL A TYPE 1.5 MM FOOT FOR CMF DISTRACTOR MANDIBLE,SUP-2842166,CDM,C1713,HCPCS,0278,RC,,,,both,,,3286.01,2135.91,,,,,,,,,,,,,
PIN EXT FIX HALF 6X250 MM 85 MM GRY XTRAFIX,SUP-2534566,CDM,2720000010,LOCAL,0272,RC,,,,both,,,568.34,369.42,,,,,,,,,,,,,
GRAFT BONE SUB 5ML PASTE DEMIN BONE OPTECURE,SUP-2223574,CDM,C1713,HCPCS,0278,RC,,,,both,,,3187.10,2071.61,,,,,,,,,,,,,
PLATE BONE W14XL181MM THK3.8MM 90DEG 10 H RT TIB L BTTRS LT,SUP-2185772,CDM,C1713,HCPCS,0278,RC,,,,both,,,1952.83,1269.34,,,,,,,,,,,,,
STENT URET L 90 CM DIA 7 FR SIL BRAIDED DIV HYDRO-GLIDE,SUP-2128997,CDM,C2617,HCPCS,0278,RC,,,,both,,,315.60,205.14,,,,,,,,,,,,,
CATHETER DIAG EP STEER 5MM ELECTRD SPC QPLR LONGEST CRV,SUP-2141295,CDM,C1725,HCPCS,0272,RC,,,,both,,,1439.38,935.60,,,,,,,,,,,,,
MARKER TISS 17X10CM RBBN5/CS,SUP-2127911,CDM,A4648,CPT,0278,RC,,,,both,,,204.04,132.63,,,,,,,,,,,,,
RING EXT FIX DIA160 MM FT SPEEDWIRE ANAT,SUP-2898537,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4317.50,2806.37,,,,,,,,,,,,,
SET INTRO S-MAK L 10 CM DIA 5 FR L 40 CM NIT COR PLAT TIP,SUP-2475724,CDM,C1894,HCPCS,0272,RC,,,,both,,,72.22,46.94,,,,,,,,,,,,,
NAIL IM 10X34 CM,SUP-2196674,CDM,C1713,HCPCS,0278,RC,,,,both,,,4898.40,3183.96,,,,,,,,,,,,,
GUIDEWIRE ENDO L450CM DIA0.018IN EXCHG SHP STIFF SHFT,SUP-2140156,CDM,C1769,HCPCS,0272,RC,,,,both,,,359.31,233.55,,,,,,,,,,,,,
DRILL HAND HUDSON BRACE STANDARD JARIT STERILE,SUP-2705660,CDM,2720000010,LOCAL,0272,RC,,,,both,,,964.48,626.91,,,,,,,,,,,,,
PLATE BONE L46MM 4 H STRL S STL 1/3 TBLR LCK FOR 3.5MM SCR,SUP-2349627,CDM,C1713,HCPCS,0278,RC,,,,both,,,1407.16,914.65,,,,,,,,,,,,,
STENT CORONARY L 14 MM DIA 4 MM SS OTW STRL,SUP-2140495,CDM,C1876,HCPCS,0278,RC,,,,both,,,4107.12,2669.63,,,,,,,,,,,,,
CORKSCREW SPNL MINI HK CD HORZ M8,SUP-2290029,CDM,C1713,HCPCS,0278,RC,,,,both,,,3155.70,2051.20,,,,,,,,,,,,,
CATHETER DIL 6FR L180CM BLLN INFLATED 36-40.5-45FR L8CM ES,SUP-2149683,CDM,C1726,HCPCS,0272,RC,,,,both,,,539.42,350.62,,,,,,,,,,,,,
CATHETER SUPP RUBICON 35 L 90 CM DIA 5 FR TIP 2.84 FR PROX,SUP-2140835,CDM,C1725,HCPCS,0272,RC,,,,both,,,477.91,310.64,,,,,,,,,,,,,
NAIL RFNA 12MMX 320MM 5 DEG BEND/ ST,SUP-2718125,CDM,C1713,HCPCS,0278,RC,,,,both,,,5181.35,3367.88,,,,,,,,,,,,,
BIT DRL QC 4X245 MM FEM PERIPROSTHETIC NCB,SUP-2862215,CDM,2720000010,LOCAL,0272,RC,,,,both,,,407.51,264.88,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.533,SUP-2860050,CDM,C1713,HCPCS,0278,RC,,,,both,,,40093.72,26060.92,,,,,,,,,,,,,
HEAD ULN 19 WRST MOD COCR 1ST CHOICE,SUP-2852860,CDM,C1776,CPT,0278,RC,,,,both,,,5751.91,3738.74,,,,,,,,,,,,,
STENT BILI PALMAZ XL L 30 MM DIA10 MM SHTH 10 FR SS TRNSHEP,SUP-2158990,CDM,C1877,HCPCS,0278,RC,,,,both,,,4879.56,3171.71,,,,,,,,,,,,,
GUIDEPIN SURG L300MM DIA2.8MM DISP FOR DRL TIP,SUP-2411556,CDM,2720000010,LOCAL,0272,RC,,,,both,,,417.71,271.51,,,,,,,,,,,,,
BAND LAPAROSCOPY GASTRIC ADJUSTABLE ACCESS PORT II STERILE LAP-BAND VG,SUP-2119233,CDM,C1889,HCPCS,0278,RC,,,,both,,,9828.20,6388.33,,,,,,,,,,,,,
PLATE BONE L THK1.5MM RT TI MEDL CLMN ARCH GORILLA,SUP-2321509,CDM,C1713,HCPCS,0278,RC,,,,both,,,6583.01,4278.96,,,,,,,,,,,,,
GUIDEPIN FIX DIA1.5MM TOEMOTION HEMICAP,SUP-2123617,CDM,2720000010,LOCAL,0272,RC,,,,both,,,731.62,475.55,,,,,,,,,,,,,
DILATOR ENDOSCP L180CM CATH 6FR BLLN L8CM INFLATED M00558360,SUP-2420683,CDM,2720000010,LOCAL,0272,RC,,,,both,,,605.89,393.83,,,,,,,,,,,,,
SHELL ACET SZ H DIA66MM 13 H HIP TRITANIUM HMSPHR TRIDENT,SUP-2419423,CDM,C1776,CPT,0278,RC,,,,both,,,7630.20,4959.63,,,,,,,,,,,,,
CAST ORTHOT ANK KNEE FEM CUST FRAC SEMI RIGID,SUP-2435651,CDM,L2134,HCPCS,0272,RC,,,,both,,,3262.59,2120.68,,,,,,,,,,,,,
GRAFT BNE SUB 20CC 1 8MM CANC CRUSH CHIP READIGRFT,SUP-2264814,CDM,C1713,HCPCS,0278,RC,,,,both,,,776.37,504.64,,,,,,,,,,,,,
PLATE BNE L151MM 9 H ST R LAT DST FIBULAR S STL LOK COMPR,SUP-2177422,CDM,C1713,HCPCS,0278,RC,,,,both,,,2077.86,1350.61,,,,,,,,,,,,,
GUIDEWIRE VASC L125CM DIA0032IN FOR QUATTRO,SUP-2416133,CDM,C1769,HCPCS,0272,RC,,,,both,,,60.66,39.43,,,,,,,,,,,,,
GRAFT BNE SUB W9.5-10XL8-13MM THK30-53MM PAT TEND HEMI SHP,SUP-2307266,CDM,C1713,HCPCS,0278,RC,,,,both,,,8171.94,5311.76,,,,,,,,,,,,,
HC Placement Central Venous Cath,PX-3613655600,CDM,36556,CPT,0361,RC,,,,inpatient,,,9955.00,6470.75,,,,,,,,,,,,,
CEMENT BNE 10 CC STRL FORTERA LTX,SUP-2855703,CDM,C1713,HCPCS,0278,RC,,,,both,,,17879.16,11621.45,,,,,,,,,,,,,
BUTTON SUTURE DIA14 MM OUTER THK 1.6 MM TUNN SZ 7-9 MM TI,SUP-2905794,CDM,C1713,HCPCS,0278,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
STAPLER INT L75MM CUT LN L73MM STPL LN L77MM BLU B FRM 8,SUP-2220040,CDM,2720000010,LOCAL,0272,RC,,,,both,,,427.89,278.13,,,,,,,,,,,,,
CANNULA INJ 8.5 CM F/POS PRESSURE VENT LARYNGOSCOPE 8587K,SUP-2775140,CDM,2720000010,LOCAL,0272,RC,,,,both,,,492.82,320.33,,,,,,,,,,,,,
RING EXT FIX HALF 140 MM CARBON FIBER NS,SUP-2799574,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1434.10,932.16,,,,,,,,,,,,,
MESH SURG 50X16 MM 1007703,SUP-2565359,CDM,C1781,HCPCS,0278,RC,,,,both,,,11304.00,7347.60,,,,,,,,,,,,,
PLATE BNE W22XL75MM STD 6X5 H ST R DST RAD VOLAR S STL VAR,SUP-2177305,CDM,C1713,HCPCS,0278,RC,,,,both,,,2603.66,1692.38,,,,,,,,,,,,,
CUTTER ENDOPATH ETS45 COMP FLX 45MM ENDOSCP LIN CTS45NK,SUP-2218888,CDM,C1713,HCPCS,0278,RC,,,,both,,,621.72,404.12,,,,,,,,,,,,,
GRAFT BONE FEM SHFT SPL FRZ DRY,SUP-2165576,CDM,C1713,HCPCS,0278,RC,,,,both,,,1617.10,1051.11,,,,,,,,,,,,,
PLATE BNE CLAV 2.7 MM RT MEDL VA LCK COMPR TI STRL VALCP,SUP-2789635,CDM,C1713,HCPCS,0278,RC,,,,both,,,4800.43,3120.28,,,,,,,,,,,,,
PROBE NERVE MONITORING CNTRL BLADE STRL DISP,SUP-2711123,CDM,C1713,HCPCS,0278,RC,,,,both,,,3956.40,2571.66,,,,,,,,,,,,,
HC So Assay of Psa Total,PX-3018415366,CDM,84153,CPT,0301,RC,,,,outpatient,,,338.00,219.70,,,,,,,,,,,,,
IMPLANT BRST DIA14.4CM P4.4CM 550CC SIL GEL FILL SHELL RND,SUP-2300619,CDM,C1789,HCPCS,0278,RC,,,,both,,,2857.40,1857.31,,,,,,,,,,,,,
GENERATOR NERVE STIM PULSE IMPL DBS INFIN,SUP-2637203,CDM,C1767,HCPCS,0278,RC,,,,both,,,34372.67,22342.24,,,,,,,,,,,,,
PLATE BNE SM L42MM 0DEG 6 H NONSTERILE R 1ST MTP FUS S STL,SUP-2184815,CDM,C1713,HCPCS,0278,RC,,,,both,,,3213.92,2089.05,,,,,,,,,,,,,
MATRIX BIO L 8 X W 6 CM FISH SKIN DERMAL INTACT STRL OMEGA3 10/BX,SUP-2909453,CDM,Q4158,HCPCS,0636,RC,,,,both,,,7184.32,4669.81,,,,,,,,,,,,,
PIN TEMP FIX L 14 MM DIA 3. 5MM LG TARGETER PROV STRL DISP,SUP-2931142,CDM,C1713,HCPCS,0278,RC,,,,both,,,1648.50,1071.52,,,,,,,,,,,,,
IMPLANT BIO L 3 X W 7 CM FISH SKIN DERMAL SLD INTACT FLAT,SUP-2909282,CDM,Q4158,HCPCS,0636,RC,,,,both,,,3218.50,2092.02,,,,,,,,,,,,,
CARPENTER- LO PRSS PORCINE MITRL BIOPROSTHESIS - SZ 27MM,SUP-2214279,CDM,C1713,HCPCS,0278,RC,,,,both,,,14915.00,9694.75,,,,,,,,,,,,,
GENTAMICIN SULFATE 0.3 % OP SOLN,RX-3428,CDM,6370000000,HCPCS,0637,RC,60758-0188-05,NDC,,both,5,ML,19.70,12.80,,,,,,,,,,,,,
BUR SURG RND 3 MM 93 MM CRV FLUT HI SPD FOR DRL SYS SS VISAO,SUP-2628957,CDM,2720000010,LOCAL,0272,RC,,,,both,,,788.33,512.41,,,,,,,,,,,,,
KIT MICROPUNCTURE MINISTICK MAX  4FR X 10CM STIFF .018 NITINOL ECHOGENIC NEEDLE 2.75IN,SUP-2849609,CDM,C1894,HCPCS,0272,RC,,,,both,,,71.91,46.74,,,,,,,,,,,,,
ANCHOR SUT L17.9MM DIA5MM W/ TWO SZ 2 FIBERWIRE AND NDL FOR,SUP-2121499,CDM,C1713,HCPCS,0278,RC,,,,both,,,675.10,438.81,,,,,,,,,,,,,
PACEMAKER CARD CONFIENT RF HE TI W/O ATR LD STRL,SUP-2149140,CDM,C1721,HCPCS,0275,RC,,,,both,,,56520.00,36738.00,,,,,,,,,,,,,
PLATE BONE SM 138MML HLX10 STNLSS STEEL DELTA BTTRSS ST RIGH,SUP-2725823,CDM,C1713,HCPCS,0278,RC,,,,both,,,2852.56,1854.16,,,,,,,,,,,,,
NEEDLE INSUFFLATION VERES 2.1X120 MM 1.6 MM DSTL TIP,SUP-2850635,CDM,2720000010,LOCAL,0272,RC,,,,both,,,314.91,204.69,,,,,,,,,,,,,
BRACE ORTH SAGITAL LUMBAR CORONAL CTRL PREFABRICATED,SUP-2388152,CDM,L0640,HCPCS,0272,RC,,,,both,,,2694.81,1751.63,,,,,,,,,,,,,
SCREW SPNL MULTAXL 6.5X30 MM CANN EXT TAB VOYAGER 4.75,SUP-2629439,CDM,C1713,HCPCS,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
INJECTOR MONARCH IV IOL,SUP-2859221,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5288.67,3437.64,,,,,,,,,,,,,
IMPLANT BRST DIA95CM P3CM 125 150CC SIL NACL FILL SHELL RND,SUP-2300541,CDM,C1789,HCPCS,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
MORCELLATOR ENDOSCP BPLR DURABLE FOR PK G400 GENRTR PKS,SUP-2313950,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
ATTUNE SOLO PINNING SYSTEM,SUP-2514810,CDM,2720000010,LOCAL,0272,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
BUTTON CERCLAGE 25MM TI HEX T15 STARDRV FOR ORTH CBL SYS,SUP-2181296,CDM,C1713,HCPCS,0278,RC,,,,both,,,497.28,323.23,,,,,,,,,,,,,
BIT DRL L45MM DIA1.1MM ST TI JCBS CHK NONRADIOPAQUE W/O STP,SUP-2187169,CDM,2720000010,LOCAL,0272,RC,,,,both,,,363.30,236.14,,,,,,,,,,,,,
WEDGE OSTEOTOM ORTH FOR TIB SYS,SUP-2121032,CDM,C1713,HCPCS,0278,RC,,,,both,,,4270.40,2775.76,,,,,,,,,,,,,
BRACE ORTH SAGITAL LUMBAR CORONAL CTRL PREFABRICATED,SUP-2388152,CDM,L0640,HCPCS,0274,RC,,,,both,,,2694.81,1751.63,,,,,,,,,,,,,
BIT DRL L300MM DIA3.2MM PERC QUIK CPL CALIB W/O STP REUSE,SUP-2187851,CDM,2720000010,LOCAL,0272,RC,,,,both,,,553.52,359.79,,,,,,,,,,,,,
TUBING SUCTION 15 FRX3 MM 32 CM SIL,SUP-2394845,CDM,C1713,HCPCS,0278,RC,,,,both,,,76.93,50.00,,,,,,,,,,,,,
SCREW BNE L14MM DIA2.5MM S STL ST LOK FULL THRD SM HEX HD,SUP-2348661,CDM,C1713,HCPCS,0278,RC,,,,both,,,840.64,546.42,,,,,,,,,,,,,
K WIRE FIX L152MM DIA2MM S STL SGL END SMOOTH BAYNT TIP 3PK,SUP-2251209,CDM,C1713,HCPCS,0278,RC,,,,both,,,354.98,230.74,,,,,,,,,,,,,
GRIP CBL SM L185MM TROCHANTERIC HIP 3 CBL ACCORD,SUP-2345202,CDM,C1776,CPT,0278,RC,,,,both,,,6738.44,4379.99,,,,,,,,,,,,,
SYSTEM LD DEL SELECTRA CORONARY SINUS STRL,SUP-2138088,CDM,C1893,HCPCS,0272,RC,,,,both,,,989.10,642.91,,,,,,,,,,,,,
SHELL ACET TOT HIP PRI PRESSFIT SLD UNIV POR TI 42MM OD,SUP-2403407,CDM,C1776,CPT,0278,RC,,,,both,,,4527.88,2943.12,,,,,,,,,,,,,
FIBER LASER HOLMIUM 1S0 SUREFLEE,SUP-2885274,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1180.64,767.42,,,,,,,,,,,,,
PROBE PENCIL 8MHZ CONTOURED  RSFH ONLY,SUP-2862967,CDM,2720000010,LOCAL,0272,RC,,,,both,,,675.10,438.81,,,,,,,,,,,,,
PLATE STRNL 12 H TI ANGLED NS MATRIXSTERNUM,SUP-2904200,CDM,C1713,HCPCS,0278,RC,,,,both,,,3434.72,2232.57,,,,,,,,,,,,,
INSERT TIB XL THK13MM AP58MM ML82MM UNIV CNDYL KNEE NEUT,SUP-2377421,CDM,C1776,CPT,0278,RC,,,,both,,,1957.35,1272.28,,,,,,,,,,,,,
PLATE BNE L363MM 18 H R PROX PERIPROSTHETIC FEM TI NCB,SUP-2205041,CDM,C1713,HCPCS,0278,RC,,,,both,,,4553.75,2959.94,,,,,,,,,,,,,
GRAFT HUMAN TSSUE 4CMW X 4CML 08 17MM THK ACLLLR DRMS ULTR,SUP-2727660,CDM,Q4128,HCPCS,0636,RC,,,,both,,,4425.20,2876.38,,,,,,,,,,,,,
NEEDLE PROC CRV PEDIATRIC 19/22 GAX56 CM BRCKNBRGH,SUP-2749550,CDM,2720000010,LOCAL,0272,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
SCREW BNE 2X27 MM 7 MM TI,SUP-2484022,CDM,C1713,HCPCS,0278,RC,,,,both,,,404.18,262.72,,,,,,,,,,,,,
HC Assay of Prolactin,PX-3018414600,CDM,84146,CPT,0301,RC,,,,both,,,194.00,126.10,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE 15 CC SYR VIABLE MTRX OSTEOCONDUCTIVE,SUP-2916780,CDM,C1713,HCPCS,0278,RC,,,,both,,,16485.00,10715.25,,,,,,,,,,,,,
HC Perq Dilation Xst Trc Endourologic Px W/Img,PX-3615043600,CDM,50436,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
BONE CEMENT SURG 40 GM PMMA STD VISC RADIOPAQUE STRL G1 40,SUP-2898467,CDM,C1713,HCPCS,0278,RC,,,,both,,,204.10,132.66,,,,,,,,,,,,,
PLATE BNE BURR HOLE CVR 12X1 MM CONTOURED PDLLA STRL,SUP-2460733,CDM,C1713,HCPCS,0278,RC,,,,both,,,902.53,586.64,,,,,,,,,,,,,
COIL NEUROVASCULAR L 6 CM DIA 0.135 IN MICROCATHETER DIA,SUP-2896851,CDM,C1889,HCPCS,0278,RC,,,,both,,,4364.60,2836.99,,,,,,,,,,,,,
PLATE BNE W11XL86MM THK3.3MM 6 H BILAT MTPHSEAL TI LOK,SUP-2190760,CDM,C1713,HCPCS,0278,RC,,,,both,,,2628.43,1708.48,,,,,,,,,,,,,
MESH CRAN L 122.58 X W 67.28 MM THK 0.6 MM SCREW DIA1.5 MM,SUP-2935809,CDM,C1713,HCPCS,0278,RC,,,,both,,,4446.24,2890.06,,,,,,,,,,,,,
STABILIZER PECTUS BAR TI OFFSET NS PECTUS BLU,SUP-2895736,CDM,C1713,HCPCS,0278,RC,,,,both,,,10927.20,7102.68,,,,,,,,,,,,,
PLATE ADAPTER DIST LAT FEMUR LEFT,SUP-2704703,CDM,C1713,HCPCS,0278,RC,,,,both,,,4548.29,2956.39,,,,,,,,,,,,,
TUBING ASPIR ZOOM STROKE SOLUTION STRL,SUP-2739215,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1114.70,724.55,,,,,,,,,,,,,
BASKET EXTR L6CM DIA3CM CATH L208CM SHTH 10FR ACC CHN 4.2MM,SUP-2170590,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1036.20,673.53,,,,,,,,,,,,,
"HC Gbl Est Pt, E/M Level 4|MULTIPLE OUTPATIENT HOSPITAL E/M ENCOUNTERS ON THE SAME DATE",PX-9829921400,CDM,99214,CPT,0982,RC,,,27,outpatient,,,522.00,339.30,,,,,,,,,,,,,
IMPLANT PROST NIT TEMPORARILY IMPLD SNR MINIMALLY INVASIVE,SUP-2915763,CDM,C1889,HCPCS,0278,RC,,,,both,,,9090.30,5908.69,,,,,,,,,,,,,
HC Neutralizing Antibody Sars-Cov-2 Screen,PX-3008640866,CDM,86408,CPT,0300,RC,,,,both,,,82.00,53.30,,,,,,,,,,,,,
SPLINT ORTH 3 1 2 4 1 4 M L L WRST THMB LTWT SFT INNR LINING,SUP-2194733,CDM,L3931,HCPCS,0274,RC,,,,both,,,84.78,55.11,,,,,,,,,,,,,
SIZER SURG GEL BRST RND ULTRA HI RESTERILIZABLE MEMORYSHAPE,SUP-2748639,CDM,2720000010,LOCAL,0272,RC,,,,both,,,722.20,469.43,,,,,,,,,,,,,
"HC So Hiv-1, Quantification",PX-3068753666,CDM,87536,CPT,0306,RC,,,,both,,,621.00,403.65,,,,,,,,,,,,,
BIT DRL L50MM DIA19MM TWST J NOTCH ARNETT STYL INSRT W O,SUP-2262754,CDM,2720000010,LOCAL,0272,RC,,,,both,,,430.78,280.01,,,,,,,,,,,,,
PLATE BNE SM 8 H NONSTERILE MANUBRIUM STRNL TI H SHP RIG,SUP-2192435,CDM,C1713,HCPCS,0278,RC,,,,both,,,2998.07,1948.75,,,,,,,,,,,,,
PLATE TOT WR FUS STD LT,SUP-2107017,CDM,C1713,HCPCS,0278,RC,,,,both,,,5859.24,3808.51,,,,,,,,,,,,,
SCREW BNE L34MM DIA5MM TIB TI DBL LD FOR PHOENIX NAIL SYS,SUP-2412120,CDM,C1713,HCPCS,0278,RC,,,,both,,,904.32,587.81,,,,,,,,,,,,,
VALVE CSF REG PERF LEVEL 1.5 W/ BIOGLDE DELT,SUP-2631430,CDM,C1889,HCPCS,0278,RC,,,,both,,,4271.03,2776.17,,,,,,,,,,,,,
CATHETER EMB 6FR EPS CTRL FLO PROXIS,SUP-2356604,CDM,C1751,HCPCS,0278,RC,,,,both,,,4239.00,2755.35,,,,,,,,,,,,,
PLATE 3.5MM TI LCP PERIARTIC PROX HUM 5 HOLE 145MM LT STRL,SUP-2546858,CDM,C1713,HCPCS,0278,RC,,,,both,,,5912.46,3843.10,,,,,,,,,,,,,
GLIDEWIRE ENDO L450CM OD0.035IN ANG NO REPL BILI DEV,SUP-2141516,CDM,C1769,HCPCS,0272,RC,,,,both,,,720.94,468.61,,,,,,,,,,,,,
TAP NAV2001 SOLERA AWLTIPTAP 40MM,SUP-2281193,CDM,C1713,HCPCS,0278,RC,,,,both,,,1683.83,1094.49,,,,,,,,,,,,,
ALLOGRAFT HUM TISS MESHED 16X8 CMX0.3 MM PERITONEUM MESO,SUP-2486980,CDM,C1763,HCPCS,0278,RC,,,,both,,,5802.72,3771.77,,,,,,,,,,,,,
HOLDER NDL MCPHER 3-7/8 IN CRV FLAT HNDL W/CTCH MICROSURGERY,SUP-2494986,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1257.76,817.54,,,,,,,,,,,,,
ROCURONIUM BROMIDE 100 MG/10ML IV SOLN,RX-95812,CDM,340b,HCPCS,0250,RC,67457-0228-10,NDC,,both,10,ML,54.10,35.16,,,,,,,,,,,,,
BUTTON SUT DIA19MM POLY FOR PCL AND MULT KNEE LIG RECON,SUP-2212823,CDM,C1713,HCPCS,0278,RC,,,,both,,,169.56,110.21,,,,,,,,,,,,,
CATHETER TRAY THORACENTESIS 14 GA 17 GAX6 IN NDL TEF CURITY,SUP-2153994,CDM,C1729,HCPCS,0272,RC,,,,both,,,125.69,81.70,,,,,,,,,,,,,
GRAFT SPNL W12XL36MM CORT FRZ DRY CAPSTONE,SUP-2293994,CDM,C1713,HCPCS,0278,RC,,,,both,,,17298.26,11243.87,,,,,,,,,,,,,
GUIDEWIRE VASC L180CM DIA0.035IN TIP L3CM NIT COR HYDRPHLC,SUP-2421308,CDM,C1769,HCPCS,0272,RC,,,,both,,,146.39,95.15,,,,,,,,,,,,,
CLAMP REPROC PIN 4 HOLE,SUP-2484024,CDM,2720000010,LOCAL,0272,RC,,,,both,,,379.72,246.82,,,,,,,,,,,,,
COVER BUR H DIA17MM BILAT TI CNTOUR RIG NONCOMPRESSION LO,SUP-2190645,CDM,C1713,HCPCS,0278,RC,,,,both,,,844.66,549.03,,,,,,,,,,,,,
PLATE BNE L76MM 4 H ST L PROX BILAT TIB S STL NEUT LOK,SUP-2177831,CDM,C1713,HCPCS,0278,RC,,,,both,,,4167.60,2708.94,,,,,,,,,,,,,
PLATE BNE L 109 X W 8.5 MM THK 2.4 MM SCREW DIA2.7 MM 7 H SS 72468807,SUP-2932776,CDM,C1713,HCPCS,0278,RC,,,,both,,,2618.45,1701.99,,,,,,,,,,,,,
BLADE SAW 11.5X7X0.64 MM INT ORAL OSCILLATING SAW THN STRL,SUP-2862528,CDM,2720000010,LOCAL,0272,RC,,,,both,,,328.41,213.47,,,,,,,,,,,,,
BRACE WALKING MED LT LOWER LEG AIRSEL ACHILLES,SUP-2914932,CDM,2720000010,LOCAL,0272,RC,,,,both,,,327.09,212.61,,,,,,,,,,,,,
CATHETER ETER HAD KT LNG TERM ACCS 32 15FRX27CM CANNON II +,SUP-2762958,CDM,C1750,HCPCS,0278,RC,,,,both,,,178.98,116.34,,,,,,,,,,,,,
CABLE SPNL DBL LOOP TI,SUP-2430775,CDM,C1713,HCPCS,0278,RC,,,,both,,,4691.16,3049.25,,,,,,,,,,,,,
PLATE BONE DOUBLE BEND 2 MM 6 MM LEFT CHIN 4 HOLE ADVANCEMEN,SUP-2838393,CDM,C1713,HCPCS,0278,RC,,,,both,,,1002.29,651.49,,,,,,,,,,,,,
NAIL RFNA 10DEG BEND 10X200MM STERILE,SUP-2744545,CDM,C1713,HCPCS,0278,RC,,,,both,,,5975.92,3884.35,,,,,,,,,,,,,
CEMENT BONE TRCE ADTV,SUP-2342072,CDM,C1713,HCPCS,0278,RC,,,,both,,,53.38,34.70,,,,,,,,,,,,,
PLATE BNE LCK 1.5X23 MM 4 HOLE TI NS LCP,SUP-2799632,CDM,C1713,HCPCS,0278,RC,,,,both,,,667.47,433.86,,,,,,,,,,,,,
DRILL SURG L25MM FLEX PEG R3,SUP-2345727,CDM,C1713,HCPCS,0278,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
MESH SURG W3.5XL6IN POLY SELF FIXATING RECT W/ RESRB PLA,SUP-2174793,CDM,C1781,HCPCS,0278,RC,,,,both,,,739.25,480.51,,,,,,,,,,,,,
TAN {} ROSE {} 10X32 RT,SUP-2818884,CDM,C1713,HCPCS,0278,RC,,,,both,,,15899.08,10334.40,,,,,,,,,,,,,
SHEATH INTRO FLX RAABE L 90 CM OD 8 FR GUIDEWIRE 0.038 IN,SUP-2168691,CDM,C1894,HCPCS,0272,RC,,,,both,,,1161.80,755.17,,,,,,,,,,,,,
ANCHOR SUT L16.3MM DIA5.5MM TI W/ TWO SZ 2 FIBERWIRE CRKSCR,SUP-2121570,CDM,C1713,HCPCS,0278,RC,,,,both,,,722.20,469.43,,,,,,,,,,,,,
MATRIX BIO SZ 300 SQCM FISH SKIN DERMAL SLD INTACT STRL,SUP-2909288,CDM,Q4158,HCPCS,0636,RC,,,,both,,,27977.40,18185.31,,,,,,,,,,,,,
CUP ACET OD56MM ID48MM HA FOR DYSPLASIA BIRMINGHAM,SUP-2350869,CDM,C1776,CPT,0278,RC,,,,both,,,12795.50,8317.07,,,,,,,,,,,,,
GUIDEWIRE VASC L 60 CM 0.035 IN CRV RAD 3 MM HVY DBL FLX TIP,SUP-2760020,CDM,C1769,HCPCS,0272,RC,,,,both,,,172.48,112.11,,,,,,,,,,,,,
SCREW SPNL L12MM DIA32MM CORT TI STR NONCANNULATED ST,SUP-2189827,CDM,C1713,HCPCS,0278,RC,,,,both,,,226.08,146.95,,,,,,,,,,,,,
CATHETER GUID ANGLED 018IN 5 FRX135 CM TRAILBLAZER,SUP-2280517,CDM,C1887,HCPCS,0272,RC,,,,both,,,477.28,310.23,,,,,,,,,,,,,
NAIL IM L28CM DIA7.5-9MM LNG PROX HUM LOK AG BEND TRIGEN,SUP-2348198,CDM,C1713,HCPCS,0278,RC,,,,both,,,11787.25,7661.71,,,,,,,,,,,,,
VALVE CSF FLO BUTTON CONTOURED REG MED PRESSURE STRATA,SUP-2640142,CDM,C1889,HCPCS,0278,RC,,,,both,,,2083.30,1354.14,,,,,,,,,,,,,
ALLOGRAFT BNE CHIP 0.5-3 MM 30 CC FD CRUSH CORTICAL CANC,SUP-2743408,CDM,C1713,HCPCS,0278,RC,,,,both,,,1698.74,1104.18,,,,,,,,,,,,,
PIN FIX L9IN DIA4MM ST S STL 2 SIDE SGL DMND 1 END PNT STYL,SUP-2150480,CDM,C1713,HCPCS,0278,RC,,,,both,,,18.53,12.04,,,,,,,,,,,,,
SEALER TISSUE X1 37CM STRAIGHT JAW,SUP-2749483,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1353.34,879.67,,,,,,,,,,,,,
SET ID BND FOR STRUT MAXFRAME,SUP-2179162,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1148.46,746.50,,,,,,,,,,,,,
STEM FEM L250MM OD11MM TI HA 80% POR DST CALCAR HIP DPHSEAL,SUP-2408335,CDM,C1776,CPT,0278,RC,,,,both,,,8264.48,5371.91,,,,,,,,,,,,,
ARMSTRONG R VENT TUBE 114MM BLUE FLPL,SUP-2669498,CDM,L8699,HCPCS,0278,RC,,,,both,,,45.88,29.82,,,,,,,,,,,,,
KIT DISPOSABLES BIO-SUTURETAK,SUP-2121596,CDM,C1713,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
COMPONENT HUM 50X46 MM SHLDR OVOMOTION,SUP-2423632,CDM,C1776,CPT,0278,RC,,,,both,,,18249.68,11862.29,,,,,,,,,,,,,
CATHETER INTVASC OCCL ECLIPSE 2L L 160 CM 0.016IN L 15MM 6MM,SUP-2717626,CDM,C2628,HCPCS,0272,RC,,,,both,,,5648.86,3671.76,,,,,,,,,,,,,
GRAFT HUM TISS W8XL20CM THK1.04-2.28MM THCK REGEN TISS MTRX,SUP-2112989,CDM,Q4116,HCPCS,0636,RC,,,,both,,,18362.72,11935.77,,,,,,,,,,,,,
PINN GRIP TF REV SHIM 5 DEG,SUP-2512731,CDM,C1776,CPT,0278,RC,,,,both,,,2219.35,1442.58,,,,,,,,,,,,,
SURGICAL PROCEDURE KIT MANIFOLD CUST RICHMOND,SUP-2117307,CDM,C1713,HCPCS,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
HC Irradiation Service Charge,PX-3008694500,CDM,86945,CPT,0300,RC,,,,inpatient,,,364.00,236.60,,,,,,,,,,,,,
TUBE TRACH L40CM DIA8MM WHT SFT RUB LSR RESIST LSRTUBUS,SUP-2265588,CDM,2720000010,LOCAL,0272,RC,,,,both,,,724.56,470.96,,,,,,,,,,,,,
HC Iadna S Aureus Methicillin Resist Amp Probe Tq,PX-3068764100,CDM,87641,CPT,0306,RC,,,,both,,,135.00,87.75,,,,,,,,,,,,,
SPLINT SLD BGE 3/32IN TAILORSPLNT,SUP-2324804,CDM,L4350,HCPCS,0274,RC,,,,both,,,132.79,86.31,,,,,,,,,,,,,
VALVE MITRL CARP EDW TISS ANNULUS 29 MM SEW RNG DIA 38 MM,SUP-2214274,CDM,C1889,HCPCS,0278,RC,,,,both,,,10990.00,7143.50,,,,,,,,,,,,,
SET NASOLACHRYMAL INTUB LOOP DIA 0.64 MM WIDER SEG DIA 0.94,SUP-2911953,CDM,A4263,CPT,0278,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
PIN FIX 0.213X9 IN PARTIALLY THRD NS FPS STEINMAN,SUP-2856434,CDM,C1713,HCPCS,0278,RC,,,,both,,,175.84,114.30,,,,,,,,,,,,,
HC Drug Screen Quantitative Lithium,PX-3018017800,CDM,80178,CPT,0301,RC,,,,both,,,267.00,173.55,,,,,,,,,,,,,
PROSTHESIS OSS MCGEE 0.8X52X7 MM 3 MM MALL WIRE REINF SHFT,SUP-2637881,CDM,L8613,CPT,0278,RC,,,,both,,,1369.89,890.43,,,,,,,,,,,,,
VALVE MITRL ATS OPN PVT AP DIA24 MM ORIFICE 22.8 MM TISS,SUP-2282676,CDM,C1889,HCPCS,0278,RC,,,,both,,,10048.00,6531.20,,,,,,,,,,,,,
PLATE BNE W15XL88MM THK2MM 3 H BILAT S STL COVERLEAF RIG,SUP-2186005,CDM,C1713,HCPCS,0278,RC,,,,both,,,414.48,269.41,,,,,,,,,,,,,
GRAFT EVAR L10CM DIA5MM CATH L120CM BLLN DIA5MM 0.035IN HEP,SUP-2396542,CDM,C1874,HCPCS,0278,RC,,,,both,,,12318.22,8006.84,,,,,,,,,,,,,
SCREW SPNL 5.5/8.2X60 MM TP OH,SUP-2175727,CDM,C1713,HCPCS,0278,RC,,,,both,,,5937.74,3859.53,,,,,,,,,,,,,
CATHETER VENTRICULAR STD 1.5 MMX35 CM INTCRAN BA STRIPE CLR,SUP-2851441,CDM,C1729,HCPCS,0272,RC,,,,both,,,414.26,269.27,,,,,,,,,,,,,
TROCAR ENDOSCP L100MM DIA11MM STBL SL BLDELSS DISP ENDOPATH,SUP-2218781,CDM,2720000010,LOCAL,0272,RC,,,,both,,,650.86,423.06,,,,,,,,,,,,,
TWIST DRILL 15MM DIA X 20MM 5MM STOP DNTL LATCH SNGLE USE,SUP-2669770,CDM,2720000010,LOCAL,0272,RC,,,,both,,,467.99,304.19,,,,,,,,,,,,,
BUR SURG DIA12MM 6 H TI CVR H W/O TAB CNTOUR LO PROF,SUP-2191186,CDM,C1781,HCPCS,0278,RC,,,,both,,,514.96,334.72,,,,,,,,,,,,,
PLATE BNE L W13.5XL88MM THK4.2MM 5 H BILAT TI STR RIG LIMIT,SUP-2190809,CDM,C1713,HCPCS,0278,RC,,,,both,,,553.96,360.07,,,,,,,,,,,,,
HC So1 Beta 2 Glycoprotein 1 Ab,PX-3028614667,CDM,86146,CPT,0302,RC,,,,both,,,30.00,19.50,,,,,,,,,,,,,
PROSTHESIS FEN NAR STR 1 PC HIP 38MM ASTN MOORE,SUP-2377813,CDM,C1776,CPT,0278,RC,,,,both,,,2466.16,1603.00,,,,,,,,,,,,,
NEEDLE ASPIR ENDOSCP ULTRASOUND 25 GA 2.4 MM MIN CHANNEL,SUP-2141500,CDM,2720000010,LOCAL,0272,RC,,,,both,,,675.10,438.81,,,,,,,,,,,,,
CATHETER VENTRICULAR 13X25 MMX15 CM STD STR BA IMPREG,SUP-2277969,CDM,C1729,HCPCS,0272,RC,,,,both,,,483.47,314.26,,,,,,,,,,,,,
CATHETER HD DL 10 FRX15 CM VLV INTRO GLIDEPATH AIRGUARD,SUP-2627018,CDM,C1750,HCPCS,0278,RC,,,,both,,,2027.66,1317.98,,,,,,,,,,,,,
HC MRI-Spine Lumbar W Contrast,PX-6127214900,CDM,72149,CPT,0612,RC,,,,outpatient,,,4146.00,2694.90,,,,,,,,,,,,,
AMOXICILLIN-POT CLAVULANATE ER 1000-62.5 MG PO TB12,RX-33862,CDM,6370000000,HCPCS,0637,RC,00781-1943-82,NDC,,both,1,UN,30.40,19.76,,,,,,,,,,,,,
PLATE BNE L MINI REG 0.6 MM RT MXLFCL MULDER STYL LP TI LF,SUP-2463536,CDM,C1713,HCPCS,0278,RC,,,,both,,,620.59,403.38,,,,,,,,,,,,,
ADAPTER LD FOR ILINK-BIS-10 PULSE GENRTR,SUP-2138033,CDM,C1883,HCPCS,0278,RC,,,,both,,,1736.42,1128.67,,,,,,,,,,,,,
PROBE ENDOSCP BPLR 7 FR 2 GENRTR PLUG QUICKSILVER,SUP-2737102,CDM,2720000010,LOCAL,0272,RC,,,,both,,,543.22,353.09,,,,,,,,,,,,,
INSERT TIB REV KNEE SYS POLYETH SZ 2 17MM PROVEN,SUP-2359242,CDM,C1776,CPT,0278,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
HC Manual Spirometry 1 Time,PX-4609415000,CDM,94150,CPT,0460,RC,,,,both,,,46.00,29.90,,,,,,,,,,,,,
ANCHOR SUTURE 4.5MM WITH 2 SUTURES HI-FI NEEDLE GENESYS CROS,SUP-2825102,CDM,C1713,HCPCS,0278,RC,,,,both,,,1570.09,1020.56,,,,,,,,,,,,,
SCREW BNE DRILL-FREE 1.5X13 MM 8 MM 2 MM CLLR ORTHOANCHOR,SUP-2458349,CDM,C1713,HCPCS,0278,RC,,,,both,,,342.57,222.67,,,,,,,,,,,,,
PATCH VASC HEMGRD L 150 X W 25 MM THK 0.65 MM POLYESTER BOV,SUP-2266050,CDM,C1768,CPT,0278,RC,,,,both,,,451.69,293.60,,,,,,,,,,,,,
FERROUS GLUCONATE 324 (38 FE) MG PO TABS,RX-3066,CDM,6370000000,HCPCS,0637,RC,00574-0508-01,NDC,,both,1,UN,0.50,0.32,,,,,,,,,,,,,
SPLINT KNEE L12IN UNIV PERF FOAM HK AND LOOP CLSR QUICK-FIT,SUP-2197151,CDM,L1851,HCPCS,0272,RC,,,,both,,,31.34,20.37,,,,,,,,,,,,,
IMPLANT CRANIOMAXILLOFACIAL W43XH6XL44MM RT PTERIONAL SMER,SUP-2365351,CDM,C1889,HCPCS,0278,RC,,,,both,,,3659.04,2378.38,,,,,,,,,,,,,
SHEATH ENDO DIA4MM 15DEG LENS KARL STORZ DISP ENDO-SCRUB,SUP-2277880,CDM,C1894,HCPCS,0272,RC,,,,both,,,161.58,105.03,,,,,,,,,,,,,
MESH HERN SQ 1 20X20 CM MONOFILAMENT 3D TEXTILE VERSATEX,SUP-2752219,CDM,C1781,HCPCS,0278,RC,,,,both,,,749.46,487.15,,,,,,,,,,,,,
COIL NEUROVASCULAR L 70 CM DIA10 CM MICROCATHETER DIA,SUP-2898089,CDM,C1889,HCPCS,0278,RC,,,,both,,,4019.20,2612.48,,,,,,,,,,,,,
DEVICE VENT BIPAP AIRWY RESP VPAP III ST,SUP-2331930,CDM,C1713,HCPCS,0278,RC,,,,both,,,7379.00,4796.35,,,,,,,,,,,,,
SUPPORT ORTHOT ANK KNEE CUST ROCKER BTM CONTACT,SUP-2435654,CDM,L2232,HCPCS,0274,RC,,,,both,,,275.03,178.77,,,,,,,,,,,,,
HC 2d Echo Without Contrast - Without Dop/Color Flow,PX-4839330701,CDM,93307,CPT,0483,RC,,,,both,,,1896.00,1232.40,,,,,,,,,,,,,
SPACER SPNL 17X14 MM VALEO,SUP-2391432,CDM,C1821,HCPCS,0278,RC,,,,both,,,9671.20,6286.28,,,,,,,,,,,,,
HC Intubation/Endotracheal/Emerg,PX-4503150000,CDM,31500,CPT,0450,RC,,,,outpatient,,,403.00,261.95,,,,,,,,,,,,,
SCREW BNE CANN 7.5X45 MM COMPR FT TI NS,SUP-2787838,CDM,C1713,HCPCS,0278,RC,,,,both,,,1074.38,698.35,,,,,,,,,,,,,
PROTAMINE SULFATE 10 MG/ML IV SOLN,RX-6677,CDM,J2720,HCPCS,0636,RC,63323-0229-30,NDC,,both,1,ML,54.10,35.16,,,,,,,,,,,,,
ENDOPROSTHESIS VASC VIABAHN L 10CM 11MM 120CM EPTFE,SUP-2719588,CDM,C1768,HCPCS,0278,RC,,,,both,,,8650.70,5622.95,,,,,,,,,,,,,
SPLINT WRST L L10IN R FA LN CIRCUMFERENTIAL STRP SLIP ON,SUP-2276629,CDM,L3809,HCPCS,0272,RC,,,,both,,,22.29,14.49,,,,,,,,,,,,,
PLATE BONE 6X21 H RT MAND TI LCK FOR 2MM SCR,SUP-2191235,CDM,C1713,HCPCS,0278,RC,,,,both,,,7644.64,4969.02,,,,,,,,,,,,,
SPLINT KNEE L12IN UNIV PERF FOAM HK AND LOOP CLSR QUICK-FIT,SUP-2197151,CDM,L1851,HCPCS,0274,RC,,,,both,,,31.34,20.37,,,,,,,,,,,,,
PLATE BNE L31MM 4 H BILAT S STL LOK COMPR LO PROF FOR 2MM,SUP-2186302,CDM,C1713,HCPCS,0278,RC,,,,both,,,688.19,447.32,,,,,,,,,,,,,
SUPPORT ORTHOT ANK KNEE CUST ROCKER BTM CONTACT,SUP-2435654,CDM,L2232,HCPCS,0272,RC,,,,both,,,275.03,178.77,,,,,,,,,,,,,
CATHETER SURG RETRV OD7-6FR BAL OD9-12MM GWIRE 0.035IN INJ,SUP-2141491,CDM,2720000010,LOCAL,0272,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
FUROSEMIDE 8 MG/ML PO SOLN,RX-3293,CDM,340b,HCPCS,0637,RC,68094-0867-59,NDC,,both,1.25,ML,2.70,1.75,,,,,,,,,,,,,
GUIDE GLEN REVERSED BLUEPRINT,SUP-2388828,CDM,2720000010,LOCAL,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
HC X-Ray Exam Entire Spine 2/3 Vw,PX-3207208200,CDM,72082,CPT,0320,RC,,,,both,,,969.00,629.85,,,,,,,,,,,,,
CATHETER CV SINGLE LUMEN 4 FRX55 CM FULL TY POWERPICC,SUP-2126368,CDM,C1751,HCPCS,0278,RC,,,,both,,,494.96,321.72,,,,,,,,,,,,,
ENFORTUMAB VEDOTIN-EJFV 30 MG IV SOLR,RX-148581,CDM,J9177,HCPCS,0636,RC,51144-0030-01,NDC,,both,1,UN,12134.90,7887.68,,,,,,,,,,,,,
GRAFT VASC DISTAFLO L 60 CM DIA 6 MM EPTFE CARBON PERIPH STR,SUP-2126811,CDM,C1768,CPT,0278,RC,,,,both,,,3925.00,2551.25,,,,,,,,,,,,,
STEM TIB L16MM KNEE MTPHSEAL PROFIX,SUP-2347006,CDM,C1776,CPT,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
HC Cardiac Rehab Phase 3 - 45 Visits,PX-9900000041,CDM,9900000041,LOCAL,0990,RC,,,,both,,,113.00,73.45,,,,,,,,,,,,,
SEED BRACHYTHERAPY I-125 LOOSE PROST BRACHYSOURCE,SUP-2129115,CDM,C2638,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
HC So1 Drg Scrn Class List A|NOT REASONABLE AND NECESSARY,PX-3018030767,CDM,80307,CPT,0301,RC,,,GZ,outpatient,,,147.00,95.55,,,,,,,,,,,,,
HC Cryoprecipitate Reduced Plasma,PX-3900904400,CDM,P9044,HCPCS,0390,RC,,,,both,,,526.00,341.90,,,,,,,,,,,,,
HC Flouro X-Ray Barium Enema,PX-3207427000,CDM,74270,CPT,0320,RC,,,,both,,,1401.00,910.65,,,,,,,,,,,,,
CATHETER THORACENTESIS SET 9 FRX20 CM PNEUMOTHORAX PETERS,SUP-2760076,CDM,C1729,HCPCS,0272,RC,,,,both,,,600.12,390.08,,,,,,,,,,,,,
CATHETER PUSH 8.5FR L170CM 0.035IN MINI ACCSRY CHAN L3.2MM,SUP-2169109,CDM,C1729,HCPCS,0272,RC,,,,both,,,122.46,79.60,,,,,,,,,,,,,
CATHETER CV 3L 5 FRX135 CM NIT GUIDEWIRE POWERPICC PROVENA,SUP-2127011,CDM,C1751,HCPCS,0278,RC,,,,both,,,525.32,341.46,,,,,,,,,,,,,
IMMOBILIZER KNEE PREMIER PRO TRI PNL 22INCH FOAM TIETEX PAT,SUP-2336077,CDM,L1830,CPT,0272,RC,,,,both,,,38.78,25.21,,,,,,,,,,,,,
PLATE BNE THK0.6MM 4X6 H BILAT HND T SHP NONCOMPRESSION,SUP-2267880,CDM,C1713,HCPCS,0278,RC,,,,both,,,660.66,429.43,,,,,,,,,,,,,
HC Monkeypox Dna (R),PX-3008759366,CDM,87593,CPT,0300,RC,,,,both,,,113.00,73.45,,,,,,,,,,,,,
PLATE BNE H0.6MM 6X2 H UP FACE G TI 3D LEIBINGER UNIV 2,SUP-2366269,CDM,C1713,HCPCS,0278,RC,,,,both,,,1211.57,787.52,,,,,,,,,,,,,
PLATE BNE L47MM 7X2 H L VOLAR DST RAD S STL VAR ANG LOK,SUP-2184122,CDM,C1713,HCPCS,0278,RC,,,,both,,,2114.48,1374.41,,,,,,,,,,,,,
SIZER IMPL MAMM SMOOTH MOD PROF SIL GEL 275 ML RND,SUP-2300910,CDM,2720000010,LOCAL,0272,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
CATHETER HD DL 14 FRX20 CM KT ANTIMICROBIAL ARROWG+ARD BLU,SUP-2435359,CDM,C1752,HCPCS,0278,RC,,,,both,,,433.95,282.07,,,,,,,,,,,,,
GUIDEPIN ORTH L18IN DIA2.4MM SMOOTH SGL BAYNT TIP W/ EYELET,SUP-2249398,CDM,C1769,HCPCS,0272,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
TIBIA TRIAL SIZE 5 4,SUP-2473186,CDM,2720000010,LOCAL,0272,RC,,,,both,,,701.38,455.90,,,,,,,,,,,,,
ZINC SULFATE 1 MG/ML IV SOLN,RX-8878,CDM,J3490,HCPCS,0636,RC,00517-6101-01,NDC,,both,10,ML,176.60,114.79,,,,,,,,,,,,,
BRACE ORTH THGH CIRC 21-29.5 IN 3XL C-6 TECHNOLOGY RT MEDL,SUP-2915204,CDM,2720000010,LOCAL,0272,RC,,,,both,,,699.25,454.51,,,,,,,,,,,,,
PLATE BNE MIC THK06MM 5X7 H BILAT CRANIOMAXILLOFACIAL TI,SUP-2262729,CDM,C1713,HCPCS,0278,RC,,,,both,,,543.00,352.95,,,,,,,,,,,,,
ALLOGRAFT BNE CHIP 1-9.5 MM 15 CC FD CORTICAL CANC,SUP-2717788,CDM,C1713,HCPCS,0278,RC,,,,both,,,647.63,420.96,,,,,,,,,,,,,
SCREW BONE EMERGENCY 2.7X10 MM TITANIUM,SUP-2838295,CDM,C1713,HCPCS,0278,RC,,,,both,,,422.02,274.31,,,,,,,,,,,,,
ANCHOR SUTURE 3 2 5 MM TI MAXBRAID ALLTHREAD,SUP-2194148,CDM,C1713,HCPCS,0278,RC,,,,both,,,1042.48,677.61,,,,,,,,,,,,,
IMPL CAPPED KNEE LPS FXTICMFMTBPRLSRPATPLG,SUP-2212334,CDM,C1776,CPT,0278,RC,,,,both,,,17421.54,11324.00,,,,,,,,,,,,,
PACEMAKER CARD PERCEPTA QUAD MRI SURESCAN W 46.5 X H 59 MM D,SUP-2282510,CDM,C2621,HCPCS,0275,RC,,,,both,,,15072.00,9796.80,,,,,,,,,,,,,
BUR SURG L 125 MM DIA2.35 MM HD DIA 4 MM DIAMOND NS REUSE,SUP-2929276,CDM,2720000010,LOCAL,0272,RC,,,,both,,,336.70,218.85,,,,,,,,,,,,,
FORCEP ENDOSCP BX AD 4 MMX180 CM 2 MM GI SPEC RETRV STD FEN,SUP-2865645,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1679.43,1091.63,,,,,,,,,,,,,
PLATE SPNL 37 MM ANTR LUMBAR 4 HOLE PYRAMID +4,SUP-2631825,CDM,C1713,HCPCS,0278,RC,,,,both,,,12481.50,8112.97,,,,,,,,,,,,,
CONNECTOR SPNL L40MM STD TI XLNK ASMBLY FIX TRNSVRS W/ CLOSE,SUP-2254508,CDM,C1713,HCPCS,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
ANCHOR SUT TI WDG W TWO STRANDS OF FORCEFIBER AND NDL 5MM,SUP-2362551,CDM,C1713,HCPCS,0278,RC,,,,both,,,819.04,532.38,,,,,,,,,,,,,
LINER ACET OD57-60MM ID28MM UNIV,SUP-2342600,CDM,C1776,CPT,0278,RC,,,,both,,,236.60,153.79,,,,,,,,,,,,,
STEREOTACTIC SET KNEE ROBOTIC-ASSISTED SOLUTION ARRY VELYS,SUP-2749617,CDM,2720000010,LOCAL,0272,RC,,,,both,,,995.38,647.00,,,,,,,,,,,,,
NAIL IM L180MM OD11MM 125DEG S STL TROCHANTERIC LOK CANN,SUP-2371033,CDM,C1713,HCPCS,0278,RC,,,,both,,,1940.52,1261.34,,,,,,,,,,,,,
SCREW BNE L22MM DIA35MM RAREFT LOK PLT FOR TOT FT SYS 2,SUP-2243296,CDM,C1713,HCPCS,0278,RC,,,,both,,,812.76,528.29,,,,,,,,,,,,,
GRAFT BNE MATCHSTICK 3-6X60 MM CANC CORTICAL PUREBONE,SUP-2424610,CDM,C1713,HCPCS,0278,RC,,,,both,,,2299.89,1494.93,,,,,,,,,,,,,
CATHETER DLYS ADOL 15FR L59CM TWO CUF SWAN NK RADPQ STRP,SUP-2174279,CDM,C1751,HCPCS,0278,RC,,,,both,,,321.44,208.94,,,,,,,,,,,,,
HC Dexa Appendicular Skeleton,PX-3207708100,CDM,77081,CPT,0320,RC,,,,outpatient,,,649.00,421.85,,,,,,,,,,,,,
WASHER ORTH FOR 3.5MM SCR,SUP-2609149,CDM,C1713,HCPCS,0278,RC,,,,both,,,565.61,367.65,,,,,,,,,,,,,
BUR SURG MED WAVED SPRL FOR CRANIOTOME HNDPC STRL DISP,SUP-2937167,CDM,2720000010,LOCAL,0272,RC,,,,both,,,800.70,520.45,,,,,,,,,,,,,
REVISION TIB BUSHING 4 MM OFFSET,SUP-2359214,CDM,C1776,CPT,0278,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
METHYLNALTREXONE BROMIDE 12 MG/0.6ML SC SOLN|DISCARDED DRUG NOT ADMINISTE,RX-91651,CDM,J2212,HCPCS,0636,RC,65649-0551-02,NDC,JW,both,0.4,ML,651.40,423.41,,,,,,,,,,,,,
ANCHOR SUTURE W/ INSRTR 1.4 MM NANOTACK,SUP-2608554,CDM,C1713,HCPCS,0278,RC,,,,both,,,1271.26,826.32,,,,,,,,,,,,,
GRAFT STENT 36X180 MM 6 FR DISECT ENDOVASC ZENITH,SUP-2423996,CDM,C1768,CPT,0278,RC,,,,both,,,47542.74,30902.78,,,,,,,,,,,,,
STENT BILI S.M.A.R.T. CTRL L 20 MM DIA12 MM DEL SYS L 80 CM,SUP-2158636,CDM,C1876,HCPCS,0278,RC,,,,both,,,2559.10,1663.41,,,,,,,,,,,,,
KIT INTRO ARW THMS DIA 8.5 FR GUIDEWIRE 0.025 IN POLYUR PERC,SUP-2383286,CDM,C1894,HCPCS,0272,RC,,,,both,,,82.61,53.70,,,,,,,,,,,,,
PLATE BNE FIBULAR 3.5X103 MM LT LAT DSTL 7 HOLE EVOS,SUP-2349743,CDM,C1713,HCPCS,0278,RC,,,,both,,,4614.39,2999.35,,,,,,,,,,,,,
PLATE BONE W14.9XL74MM THK1.2MM 4 H DSTL TIB S STL SCALLOPED,SUP-2185733,CDM,C1713,HCPCS,0278,RC,,,,both,,,844.13,548.68,,,,,,,,,,,,,
SPLINT WRST COCK UP UNIV R,SUP-2205498,CDM,L3931,HCPCS,0274,RC,,,,both,,,57.15,37.15,,,,,,,,,,,,,
RESORB XG ST MESH SPCLTY SUN PTTRN PRTL SM GRD101 X 101 MM T,SUP-2679391,CDM,C1713,HCPCS,0278,RC,,,,both,,,19860.56,12909.36,,,,,,,,,,,,,
PLATE BNE L262MM 16 H NONSTERILE R ANTLAT DST TIB S STL VAR,SUP-2177690,CDM,C1713,HCPCS,0278,RC,,,,both,,,7001.29,4550.84,,,,,,,,,,,,,
SCREW BNE CORTICAL 5X22 MM STRL,SUP-2463013,CDM,C1713,HCPCS,0278,RC,,,,both,,,568.34,369.42,,,,,,,,,,,,,
PLATE BNE SM W11XL56MM THK15MM 90DEG 4X4 H TI T SHP R ANG,SUP-2190929,CDM,C1713,HCPCS,0278,RC,,,,both,,,963.45,626.24,,,,,,,,,,,,,
ALLOGRAFT HUM TISS SM VIABLE AMNION MTRX ESSENCE,SUP-2538797,CDM,C1762,CPT,0278,RC,,,,both,,,4289.24,2788.01,,,,,,,,,,,,,
PACEMAKER CARD DISCOVERY II DR W 44 X H 47 MM THK 7 MM 24.9,SUP-2148604,CDM,C1785,HCPCS,0275,RC,,,,both,,,16996.82,11047.93,,,,,,,,,,,,,
PLATE BNE CRV 2.3X35 MM FRAC COMPR FOR SCR TI LEVEL 1,SUP-2498880,CDM,C1713,HCPCS,0278,RC,,,,both,,,856.18,556.52,,,,,,,,,,,,,
DEFIBRILLATOR IMPL RIVACOR 7 DR-T PROMRI W 60 X H 66.5 MM D,SUP-2739234,CDM,C1898,HCPCS,0275,RC,,,,both,,,58278.40,37880.96,,,,,,,,,,,,,
PROBE LAP L28CM DIA10MM W/ CRD L10FT ABC,SUP-2166156,CDM,C1713,HCPCS,0278,RC,,,,both,,,317.61,206.45,,,,,,,,,,,,,
HC Paracentesis WO Img Gd,PX-4504908200,CDM,49082,CPT,0450,RC,,,,both,,,2844.00,1848.60,,,,,,,,,,,,,
PLATE BNE RADIAL C1 LNG LT VOLAR DSTL SCR ANGLE MOD TI,SUP-2646866,CDM,C1713,HCPCS,0278,RC,,,,both,,,2142.23,1392.45,,,,,,,,,,,,,
CATHETER CV MAXIMAL BARR TY 7 FRX15 CM 3L RIFAMPIN SPECTRUM,SUP-2759874,CDM,C1751,HCPCS,0278,RC,,,,both,,,478.35,310.93,,,,,,,,,,,,,
PLATE BNE H1.5MM 14 H MAND G TI LO PROF FRAC FOR 2/2.3MM,SUP-2366366,CDM,C1713,HCPCS,0278,RC,,,,both,,,2102.80,1366.82,,,,,,,,,,,,,
DEVICE VENTRICULAR EMGCY PWR PK,SUP-2356040,CDM,C1713,HCPCS,0278,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
SET O2 FLO MODULATOR 6FR L7.5CM ID2MM TRANSTRACHEAL KINK,SUP-2168722,CDM,2720000010,LOCAL,0272,RC,,,,both,,,416.93,271.00,,,,,,,,,,,,,
CATHETER URET L65CM DIA5FR BERN IMAGER II,SUP-2139303,CDM,C1758,HCPCS,0278,RC,,,,both,,,61.17,39.76,,,,,,,,,,,,,
SPLINT WRST COCK UP UNIV R,SUP-2205498,CDM,L3931,HCPCS,0272,RC,,,,both,,,57.15,37.15,,,,,,,,,,,,,
TUBE GASTMY W/LMA 75 MM LIPPGOLECKI DIFFICULT AIRWY SET,SUP-2775169,CDM,2720000010,LOCAL,0272,RC,,,,both,,,798.31,518.90,,,,,,,,,,,,,
GUIDEWIRE ORTHOPEDIC 440 MM NEWPORT MIS,SUP-2245926,CDM,C1769,HCPCS,0272,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
PLATE BNE L349MM 14 H ST PROX FEM S STL HK LO PROF LOK,SUP-2186065,CDM,C1713,HCPCS,0278,RC,,,,both,,,5558.77,3613.20,,,,,,,,,,,,,
IPILIMUMAB 200 MG/40ML IV SOLN,RX-104774,CDM,J9228,HCPCS,0636,RC,00003-2328-22,NDC,,both,40,ML,104310.40,67801.76,,,,,,,,,,,,,
WASHER ORTH DIA20 MM SPIK STRL TRIGEN MAX,SUP-2932749,CDM,C1713,HCPCS,0278,RC,,,,both,,,1139.82,740.88,,,,,,,,,,,,,
ROD SPNL REDUCTION STATIONARY TEMP CD HORZ,SUP-2630474,CDM,C1713,HCPCS,0278,RC,,,,both,,,1541.27,1001.83,,,,,,,,,,,,,
MATRIX BIO SZ 114 SQCM FISH SKIN DERMAL MIC STRL GRAFTGUIDE 10/BX,SUP-2909431,CDM,Q4158,HCPCS,0636,RC,,,,both,,,13115.78,8525.26,,,,,,,,,,,,,
IMMOBILIZER SHLDR SLNG L,SUP-2276606,CDM,L3660,HCPCS,0272,RC,,,,both,,,10.80,7.02,,,,,,,,,,,,,
HC Aspiration of Corpora Cavernos,PX-4505422000,CDM,54220,CPT,0450,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
SFS PROV FIXATION PIN LNG STE,SUP-2724034,CDM,C1725,HCPCS,0272,RC,,,,both,,,326.56,212.26,,,,,,,,,,,,,
GRAFT HUM TISS 05CC FLOWABLE PLCNTA TISS MTRX VIAFLX,SUP-2417202,CDM,C1713,HCPCS,0278,RC,,,,both,,,3425.74,2226.73,,,,,,,,,,,,,
TIRE SCLER SIL CONVX STYL 287,SUP-2213515,CDM,C1784,HCPCS,0278,RC,,,,both,,,53.38,34.70,,,,,,,,,,,,,
GLUCOSE 4 G PO CHEW,RX-16050,CDM,6370000000,HCPCS,0637,RC,09999-9916-34,NDC,,both,1,UN,0.60,0.39,,,,,,,,,,,,,
HOOK DISECT 10MM HARM,SUP-2257471,CDM,2720000010,LOCAL,0272,RC,,,,both,,,562.94,365.91,,,,,,,,,,,,,
HC Drain External Ear Lesion,PX-4506900500,CDM,69005,CPT,0450,RC,,,,both,,,1649.00,1071.85,,,,,,,,,,,,,
K-WIRE 2.0MM X 350MM TROCAR TIP,SUP-2931155,CDM,C1713,HCPCS,0278,RC,,,,both,,,459.60,298.74,,,,,,,,,,,,,
CATHETER ANGIOPLSTY SMASH L 80 CM DIA 5 FR BALLOON L 2 CM,SUP-2118776,CDM,C1725,HCPCS,0272,RC,,,,both,,,750.46,487.80,,,,,,,,,,,,,
COMPONENT TIB UNI UHMWPE LT RT 37MM ANTR POST 7.5MM REPPICI,SUP-2403268,CDM,C1776,CPT,0278,RC,,,,both,,,3761.72,2445.12,,,,,,,,,,,,,
SCREW BNE L 6 MM DIA2.7 MM SS CORTICAL T8 RECESS FOR MINI,SUP-2905581,CDM,C1713,HCPCS,0278,RC,,,,both,,,382.45,248.59,,,,,,,,,,,,,
MESH SURG M PTCH ONLAY W6XL12CM UNDERLAY 7.5CM HERN SYS,SUP-2220101,CDM,C1781,HCPCS,0278,RC,,,,both,,,984.30,639.79,,,,,,,,,,,,,
TI LCP DIA-META VOLAR DISTAL RADIUS PL 7H SHAFT/LT-STERILE,SUP-2546644,CDM,C1713,HCPCS,0278,RC,,,,both,,,5107.37,3319.79,,,,,,,,,,,,,
PLATE BNE RECON 2.4X184 MM LCK TI,SUP-2569455,CDM,C1713,HCPCS,0278,RC,,,,both,,,550.91,358.09,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP ANGLED 025X260 GLIDEWIRE,SUP-2385607,CDM,C1769,HCPCS,0272,RC,,,,both,,,2213.70,1438.90,,,,,,,,,,,,,
GUIDEWIRE DYNANITE 1.6DBL TIP NITI 2ZONE (MULTIPLES OF FIVE),SUP-2657205,CDM,C1769,HCPCS,0272,RC,,,,both,,,436.46,283.70,,,,,,,,,,,,,
RETRACTOR ENDOSCOPIC HAND FREE INTRACORPOREAL DUO,SUP-2880419,CDM,2720000010,LOCAL,0272,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
PIN FIX ENDOBROW 2.1X5 MM STRL SONICWELD RX,SUP-2487082,CDM,C1713,HCPCS,0278,RC,,,,both,,,334.28,217.28,,,,,,,,,,,,,
KIT NOVASURE V5 THERMOABLATION DEVICE,SUP-2718088,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4141.66,2692.08,,,,,,,,,,,,,
LEAD NERVE STIM KT 3 MM ELECTRD 4 MM SPC 60 CM QUATTRODE,SUP-2615498,CDM,C1778,HCPCS,0278,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
SCREW INTRF KNEE CANN N ABSRB TI 7MM 20MM,SUP-2249496,CDM,C1713,HCPCS,0278,RC,,,,both,,,693.94,451.06,,,,,,,,,,,,,
PACK VITRCTMY 25GA 5000CPM STR ENDOILLUMINATOR W/ VLV CANN,SUP-2109966,CDM,C1713,HCPCS,0278,RC,,,,both,,,2132.06,1385.84,,,,,,,,,,,,,
KNIFE ULTRASND SONOPET 12CM IQ APEX 360,SUP-2719504,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3069.92,1995.45,,,,,,,,,,,,,
PEG IM NAIL L 26 MM DIA2.7 MM TI FIBULAR DSTL THRD HDLSS NS,SUP-2909006,CDM,C1713,HCPCS,0278,RC,,,,both,,,777.15,505.15,,,,,,,,,,,,,
SCREW BNE CANN 10.35X115 MM TI GLD NS TFN-ADVANCED 04038115,SUP-2799599,CDM,C1713,HCPCS,0278,RC,,,,both,,,1748.60,1136.59,,,,,,,,,,,,,
DEVICE PESSARY CUBE 4 DRN,SUP-2119333,CDM,A4562,HCPCS,0272,RC,,,,both,,,103.49,67.27,,,,,,,,,,,,,
SCREW SPNL L34MM OD4MM ANTR CERV CANN CANC LAG TI UCSS,SUP-2417481,CDM,C1713,HCPCS,0278,RC,,,,both,,,3777.42,2455.32,,,,,,,,,,,,,
HC So Onc Pan-Tumor Dna&Rna Next-Generation Sequencing,PX-3100211066,CDM,0211U,CPT,0310,RC,,,,both,,,8878.00,5770.70,,,,,,,,,,,,,
CATHETER EP MAP DIAG 6FR 110CM LEN XL CRV DECAPOLAR 5MM SPC,SUP-2357625,CDM,C1730,HCPCS,0272,RC,,,,both,,,1598.26,1038.87,,,,,,,,,,,,,
BAR EXT FIX L350MM DIA11MM FBR GLS FOR XTRAFIX SYS,SUP-2199713,CDM,2720000010,LOCAL,0272,RC,,,,both,,,714.13,464.18,,,,,,,,,,,,,
BLADE REPROC SHV SERRAT STR SHAFT 11CM W/O TUBE 4MM,SUP-2653215,CDM,2720000010,LOCAL,0272,RC,,,,both,,,263.51,171.28,,,,,,,,,,,,,
ELECTRODE ENDOSCP VES SEAL SPR DISPOSABLE PK SUPERPULSE,SUP-2312848,CDM,2720000010,LOCAL,0272,RC,,,,both,,,792.22,514.94,,,,,,,,,,,,,
GUIDEWIRE ORTH MULT HOLE,SUP-2644805,CDM,C1769,HCPCS,0272,RC,,,,both,,,2595.90,1687.33,,,,,,,,,,,,,
DEVICE FIX 5 MM KNOT PUSH SUTURE CUT STRL TWINFIX QUICK-T,SUP-2341073,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1102.14,716.39,,,,,,,,,,,,,
HC MRI Lower Ext Jnt W/ Cont,PX-6107372200,CDM,73722,CPT,0610,RC,,,,inpatient,,,5019.00,3262.35,,,,,,,,,,,,,
MANIPULATOR SURG NUCLS KELMAN,SUP-2484800,CDM,C1713,HCPCS,0278,RC,,,,both,,,444.94,289.21,,,,,,,,,,,,,
SHEATH INTRO FLX RAABE L 55 CM OD 6 FR GUIDEWIRE 0.038 IN,SUP-2168680,CDM,C1894,HCPCS,0272,RC,,,,both,,,121.83,79.19,,,,,,,,,,,,,
HC 3d Echo Img&Pst-Pxessing Tee/Tte Cgen Car Anomal,PX-4839331900,CDM,93319,CPT,0483,RC,,,,inpatient,,,1225.00,796.25,,,,,,,,,,,,,
AMOXICILLIN-POT CLAVULANATE 400-57 MG/5ML PO SUSR,RX-33230,CDM,340b,HCPCS,0637,RC,16714-0293-01,NDC,,both,5,ML,4.90,3.18,,,,,,,,,,,,,
PLATE BNE TALAR 5 LNG 3 MM LT ANK PEGGED PROPHECY INVISION,SUP-2459965,CDM,C1713,HCPCS,0278,RC,,,,both,,,9570.72,6220.97,,,,,,,,,,,,,
PLATE BNE LG 4 H STRNL BX SHP NS,SUP-2909889,CDM,C1713,HCPCS,0278,RC,,,,both,,,1348.76,876.69,,,,,,,,,,,,,
COMPONENT FEM NP HIP CRUCE RET HI FLX LEGION,SUP-2348020,CDM,C1776,CPT,0278,RC,,,,both,,,9420.00,6123.00,,,,,,,,,,,,,
GRAFT HUM TISS DIA21MM THK5MM MT LENGTHENING DISC,SUP-2321679,CDM,C1776,CPT,0278,RC,,,,both,,,7693.00,5000.45,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED LNR HD E1 POLYETH CERM H1AZIMMER] ZIMMER BIOMET INC],SUP-2212569,CDM,C1776,CPT,0278,RC,,,,both,,,17584.00,11429.60,,,,,,,,,,,,,
EQUINOXE REVERSE 36MM HUMERAL LINER +2.5,SUP-2512471,CDM,C1776,CPT,0278,RC,,,,both,,,2276.50,1479.72,,,,,,,,,,,,,
SHUNT SURG L 6.5 CM SNAP INNR W/ VENTRICULAR CATH,SUP-2628509,CDM,C1729,HCPCS,0272,RC,,,,both,,,824.72,536.07,,,,,,,,,,,,,
PLATE BNE HK LNG 2.7X12 MM RT CLAV VA LCK STRL VALCP,SUP-2789385,CDM,C1713,HCPCS,0278,RC,,,,both,,,4214.26,2739.27,,,,,,,,,,,,,
SHEATH INTRO PERFRMR L 75 CM OD 5 FR ID 1.7 MM 0.025IN,SUP-2633273,CDM,C1894,HCPCS,0272,RC,,,,both,,,234.53,152.44,,,,,,,,,,,,,
BASKET STONE RETRV L90CM DIA12MM SHTH 2.4FR NIT POLYIMIDE,SUP-2139277,CDM,2720000010,LOCAL,0272,RC,,,,both,,,640.94,416.61,,,,,,,,,,,,,
STEM FEM L150MM DIA9MM HIP CO CHROM INTLOK PRI CEM TAPR,SUP-2403346,CDM,C1776,CPT,0278,RC,,,,both,,,6323.96,4110.57,,,,,,,,,,,,,
APPLIER CLP ENDOSCP MED LG 10 MMX18 IN LIG HORZ MTL LIG SYS,SUP-2656781,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5055.40,3286.01,,,,,,,,,,,,,
HC MRI Lower Ext Jnt W/ Cont,PX-6107372200,CDM,73722,CPT,0610,RC,,,,outpatient,,,5019.00,3262.35,,,,,,,,,,,,,
CATHETER EP DAMATO CRV 5 MM SPC 6 FR INQUIRY,SUP-2357415,CDM,C1730,HCPCS,0272,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
SCREW CRAN L 4 MM DIA1.7 MM 10PK PLLA PGA PDLA RESRB STRL DEL,SUP-2883348,CDM,C1713,HCPCS,0278,RC,,,,both,,,2533.98,1647.09,,,,,,,,,,,,,
PLATE BONE 3 H RT PROX TIB TIM L CRV LCK ALPS,SUP-2413720,CDM,C1713,HCPCS,0278,RC,,,,both,,,3963.47,2576.26,,,,,,,,,,,,,
PROSTHESIS PENILE 18 CM INFPUB APPRCH PRECONN AMS 700 CXR MS,SUP-2139002,CDM,C1813,HCPCS,0278,RC,,,,both,,,27446.74,17840.38,,,,,,,,,,,,,
MINI PLATE CUTTER DISTRACTORS,SUP-2680280,CDM,C1713,HCPCS,0278,RC,,,,both,,,4081.15,2652.75,,,,,,,,,,,,,
PRESS SURG L75IN 23X31MM PLT FASC SHEEHY,SUP-2382504,CDM,2720000010,LOCAL,0272,RC,,,,both,,,399.09,259.41,,,,,,,,,,,,,
HC Cytp Smrs Any Oth Src Extnd Std > 5 Slides,PX-3118816200,CDM,88162,CPT,0311,RC,,,,both,,,182.00,118.30,,,,,,,,,,,,,
KIT THROMCTMY STROKE FAST PK CATH AXS VECTA 46 VECTA 71,SUP-2878080,CDM,C1757,HCPCS,0272,RC,,,,both,,,12566.28,8168.08,,,,,,,,,,,,,
"HC So Encephalitis, Eastern Equine",PX-3028665266,CDM,86652,CPT,0302,RC,,,,both,,,34.00,22.10,,,,,,,,,,,,,
PLATE BNE ULN TI RAYHACK,SUP-2535896,CDM,C1713,HCPCS,0278,RC,,,,both,,,2888.80,1877.72,,,,,,,,,,,,,
CABLE SPNL DBL LOOP,SUP-2327660,CDM,C1713,HCPCS,0278,RC,,,,both,,,4694.30,3051.29,,,,,,,,,,,,,
ANKLE FUSION PLATE ANTERIOR TT RIGHT 5H STRL,SUP-2815095,CDM,C1713,HCPCS,0278,RC,,,,both,,,9420.00,6123.00,,,,,,,,,,,,,
PLATE BNE L436MM 19 H R DST FEM S STL LOK COMPR FOR 45MM SCR,SUP-2177828,CDM,C1713,HCPCS,0278,RC,,,,both,,,5209.48,3386.16,,,,,,,,,,,,,
GRAFT SPNL 10MM26MM26MM 8DEG ANTR FRZN PRECIS,SUP-2293921,CDM,C1713,HCPCS,0278,RC,,,,both,,,12154.94,7900.71,,,,,,,,,,,,,
BLADE SURG L75MM ST S STL HELIX FOR LCP DHHS SYS,SUP-2186778,CDM,C1713,HCPCS,0278,RC,,,,both,,,1172.13,761.88,,,,,,,,,,,,,
CHIPS BONE GRAFT CANC MORS 30CC 1-4MM FD ASP,SUP-2875980,CDM,C1713,HCPCS,0278,RC,,,,both,,,1288.66,837.63,,,,,,,,,,,,,
SHELL ACET OD65MM UNIV CO CHROM HIP REV PRESSFIT MULTIH,SUP-2199985,CDM,C1776,CPT,0278,RC,,,,both,,,4785.36,3110.48,,,,,,,,,,,,,
TRAY BX L152MM OD11GA S STL NDL PWR BNE ACCS ARW ONCONTROL,SUP-2383231,CDM,C1830,HCPCS,0278,RC,,,,both,,,461.05,299.68,,,,,,,,,,,,,
HC So Bacterium Antibody,PX-3028660966,CDM,86609,CPT,0302,RC,,,,both,,,83.00,53.95,,,,,,,,,,,,,
GRAFT DERM HYDRATED THCK ACELLULAR DERM IMPL ALLGRFT L7XW2CM,SUP-2307457,CDM,Q4128,HCPCS,0636,RC,,,,both,,,1674.00,1088.10,,,,,,,,,,,,,
BLADE RETRACTOR ABH 5X1 IN RENAL ALUM,SUP-2472281,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1374.72,893.57,,,,,,,,,,,,,
ANCHOR SUT 45MM DIA NO 2 ABSRB SFT TISS BRAID POLY TWO,SUP-2362543,CDM,C1713,HCPCS,0278,RC,,,,both,,,722.99,469.94,,,,,,,,,,,,,
IMPLANT ENDO FIX 6.5MM PEEK KNOTLESS,SUP-2341229,CDM,C1713,HCPCS,0278,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
GRAFT BONE PARTICULATE SYNTH OSTEOCONDUCTIVE CLLGN 10GM 10CC,SUP-2288536,CDM,C1713,HCPCS,0278,RC,,,,both,,,1818.63,1182.11,,,,,,,,,,,,,
SCREW BNE L80MM DIA7.3MM CORT S STL ST CANN LOK FULL THRD,SUP-2184940,CDM,C1713,HCPCS,0278,RC,,,,both,,,898.67,584.14,,,,,,,,,,,,,
SCREW BONE L90MM DIA7.3MM CORT S STL ST CANN LCK PARTIALLY,SUP-2185012,CDM,C1713,HCPCS,0278,RC,,,,both,,,4477.07,2910.10,,,,,,,,,,,,,
GRAFT BONE POST LUM SPCR IRRADIATED FRZ DRY H 7MM SM GRFTECH,SUP-2294232,CDM,C1713,HCPCS,0278,RC,,,,both,,,5815.28,3779.93,,,,,,,,,,,,,
DRILL HND OD12MM,SUP-2354594,CDM,2720000010,LOCAL,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
PLATE BNE L9MM 4 H S STL H SHP FOR 1.5MM SCR MINI FRAG SYS,SUP-2411307,CDM,C1713,HCPCS,0278,RC,,,,both,,,434.70,282.55,,,,,,,,,,,,,
SET DRNGE DBL LUMN SUMP W WIRE GUID AND CONN TB COOK COPE,SUP-2168259,CDM,C1729,HCPCS,0272,RC,,,,both,,,503.19,327.07,,,,,,,,,,,,,
DILATOR SHTH 11FR L47.5CM ID3.7MM ROT LD EXTR TIGHTRAIL,SUP-2353157,CDM,C1894,HCPCS,0272,RC,,,,both,,,7865.70,5112.70,,,,,,,,,,,,,
PLATE EXT FIX BRDG 150 MM FOR 5/8 RNG ALUM NS MAXFRAME,SUP-2799531,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3821.29,2483.84,,,,,,,,,,,,,
SCREW BONE SM L40MM DIA3MM CANN HDLSS COMPR QFX,SUP-2343147,CDM,C1713,HCPCS,0278,RC,,,,both,,,1985.86,1290.81,,,,,,,,,,,,,
HC Tx Spinal Pnxr Drainage CSF W/Fluor/CT,PX-3616232900,CDM,62329,CPT,0361,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
BAR EXT FIX CALIB TOMAHAWK MINI FIX SIDEKCK,SUP-2400615,CDM,2720000010,LOCAL,0272,RC,,,,both,,,668.82,434.73,,,,,,,,,,,,,
ENDOPROSTHESIS VASC ICAST L 22 MM DIA 6 MM CATH L 80 CM,SUP-2884894,CDM,C1874,HCPCS,0278,RC,,,,both,,,9429.73,6129.32,,,,,,,,,,,,,
INTRODUCER SHTH L11CM OD5FR DIL L17CM 0.038IN GRY SIL,SUP-2294510,CDM,C1894,HCPCS,0272,RC,,,,both,,,91.19,59.27,,,,,,,,,,,,,
NEEDLE INTRO TRANSSEPTAL 19GA 56CM LEN BRK 2 CRV STYL,SUP-2357225,CDM,C1713,HCPCS,0278,RC,,,,both,,,659.40,428.61,,,,,,,,,,,,,
HC Operative Cholangiogram,PX-3207430000,CDM,74300,CPT,0320,RC,,,,both,,,1415.00,919.75,,,,,,,,,,,,,
CATHETER CARD ABLATION THERMOCOOL SF L 115 CM 8 FR B CRV RED,SUP-2492474,CDM,C1732,HCPCS,0272,RC,,,,both,,,7762.08,5045.35,,,,,,,,,,,,,
ENDCAP ORTH S STL HI COMPR G-BEAM FUS BEAMING SYS,SUP-2417458,CDM,2720000010,LOCAL,0272,RC,,,,both,,,540.08,351.05,,,,,,,,,,,,,
PLATE BNE L MINI 2X17 MM OBLQ ANGLED TI,SUP-2536098,CDM,C1713,HCPCS,0278,RC,,,,both,,,250.57,162.87,,,,,,,,,,,,,
ASSY SHIP GAMMA STER A 0.9 MM,SUP-2916662,CDM,2720000010,LOCAL,0272,RC,,,,both,,,264.51,171.93,,,,,,,,,,,,,
DRIVER SURG MULTPURP N CANN FOR TRIGEN PERC SYS,SUP-2347051,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1022.38,664.55,,,,,,,,,,,,,
PLEDGET SURG DEVICE HAART AORTIC ANNULOPLASTY POLYESTER,SUP-2878063,CDM,C1768,CPT,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
SPACER SPNL W18XH8MM D15MM 7DEG ANT CERV INTBDY FUS INTEGR,SUP-2231402,CDM,C1821,HCPCS,0278,RC,,,,both,,,7536.00,4898.40,,,,,,,,,,,,,
BRACE ORTH CARBON FIBER FRME RT KNEE PCL L/TH S/CF CUST,SUP-2915011,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1295.03,841.77,,,,,,,,,,,,,
VALVE MITRL CARP EDW DURAFLEX DIA 35 MM SEW RNG DIA 44 MM,SUP-2214285,CDM,C1713,HCPCS,0278,RC,,,,both,,,13973.00,9082.45,,,,,,,,,,,,,
TRAY GLEN M SHLDR HA POR MOD BIOMOD,SUP-2404646,CDM,C1776,CPT,0278,RC,,,,both,,,4870.14,3165.59,,,,,,,,,,,,,
BIT DRILL SURG L 130 MM DIA 4.2 MM FREEHAND STRL LF DISP T2,SUP-2900504,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1125.78,731.76,,,,,,,,,,,,,
SET INTRO 14FR L70CM GWIRE 0038IN STNT POS COOK Z,SUP-2168375,CDM,C1713,HCPCS,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
SPLINT WRST L INSTABILITY INJ LACE W STAY COCK UP FIRM SUPP,SUP-2197063,CDM,L3908,HCPCS,0272,RC,,,,both,,,27.41,17.82,,,,,,,,,,,,,
PLATE BNE L54MM 2X8 H BILAT S STL T SHP LO PROF RIG NEUT,SUP-2186368,CDM,C1713,HCPCS,0278,RC,,,,both,,,1738.96,1130.32,,,,,,,,,,,,,
CATHETER IV REINF TIP 20 GAX10 CM PWR INJ POWERGLIDE PRO F320108PT,SUP-2125671,CDM,C1751,HCPCS,0278,RC,,,,both,,,379.44,246.64,,,,,,,,,,,,,
PLATE BNE TIB UNIV ANTR 3 HOLE TI NS LTX,SUP-2856995,CDM,C1713,HCPCS,0278,RC,,,,both,,,5862.38,3810.55,,,,,,,,,,,,,
CLAMP EXT FIX TUBE TO TUBE MED LG 20/25 MM BLU RED TRIAX,SUP-2501292,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3149.73,2047.32,,,,,,,,,,,,,
CAP END 5MM ANKLE ARTHRODESIS NAIL SYSTEM PHOENIX,SUP-2500913,CDM,C1889,HCPCS,0278,RC,,,,both,,,483.56,314.31,,,,,,,,,,,,,
TROCAR SURG DBL SL 4X120 MM ASMBLY,SUP-2517246,CDM,2720000010,LOCAL,0272,RC,,,,both,,,618.58,402.08,,,,,,,,,,,,,
GUIDEWIRE VASC PULSE SPRY L 154 CM DIA 0.035 IN FLPY TIP L 2,SUP-2118469,CDM,C1769,HCPCS,0272,RC,,,,both,,,241.15,156.75,,,,,,,,,,,,,
HC So T Helper/Supressor Lymph,PX-3028636067,CDM,86360,CPT,0302,RC,,,,both,,,64.00,41.60,,,,,,,,,,,,,
TITANIUM SCRN MESH PANEL 80MM X 80MM1MM10MM SSTM CP TTNM,SUP-2677463,CDM,C1713,HCPCS,0278,RC,,,,both,,,3079.96,2001.97,,,,,,,,,,,,,
ANKLE FUSION PLATE ANTERIOR TT RIGHT 5H,SUP-2815299,CDM,C1713,HCPCS,0278,RC,,,,both,,,9106.00,5918.90,,,,,,,,,,,,,
CLAMP REPROC FIX EXT PIN 4 POS MR SAFE LG,SUP-2467409,CDM,2720000010,LOCAL,0272,RC,,,,both,,,419.94,272.96,,,,,,,,,,,,,
STEM FEM PRSS FT 12X100 MM REV N SLT GEN II,SUP-2435042,CDM,C1776,CPT,0278,RC,,,,both,,,3579.60,2326.74,,,,,,,,,,,,,
GRAFT BONE PRO DENS 40CC,SUP-2399151,CDM,C1713,HCPCS,0278,RC,,,,both,,,16921.55,10999.01,,,,,,,,,,,,,
PLATE BNE W5XL22MM THK1MM 4 H BILAT TI STR RIG NEUT DYN,SUP-2191041,CDM,C1713,HCPCS,0278,RC,,,,both,,,833.48,541.76,,,,,,,,,,,,,
HC Echo Cong Anom Complete W/Ctrst,PX-4839330301,CDM,C8921,HCPCS,0483,RC,,,,both,,,1724.00,1120.60,,,,,,,,,,,,,
KIT GRAFTMAG GRAFT DELIVERY SYSTEM DISPOSABLE EX,SUP-2934650,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4694.30,3051.29,,,,,,,,,,,,,
HC CT Perc Asp Disc Para Vent Tis,PX-3616226700,CDM,62267,CPT,0361,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
PLATE BONE L94MM 4 H NONSTERILE RT LAT PROX TIB LCK FOR,SUP-2348466,CDM,C1713,HCPCS,0278,RC,,,,both,,,11391.29,7404.34,,,,,,,,,,,,,
STAPLER INT AD L45MM STD THCK TISS GRN TI LIN NONCUTTING 2,SUP-2283416,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1310.35,851.73,,,,,,,,,,,,,
PACK PENILE PROS INSRTN INFL STR BLDE RNG HNDL AMS 800,SUP-2138912,CDM,C1713,HCPCS,0278,RC,,,,both,,,676.98,440.04,,,,,,,,,,,,,
INSERT TIB L THK9MM UNIV CNDYL KNEE NEUT PRI STBL DURAC,SUP-2377414,CDM,C1776,CPT,0278,RC,,,,both,,,1921.18,1248.77,,,,,,,,,,,,,
STEM FEM SZ 9 L155MM DIA15MM -5MM OFFSET DST HIP TI ALLY HA,SUP-2379090,CDM,C1776,CPT,0278,RC,,,,both,,,12426.86,8077.46,,,,,,,,,,,,,
DEVICE PAIN CTRL 100ML 2ML/HR W/ FIX HUB CATH,SUP-2196472,CDM,E0783,HCPCS,0278,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
SHUNT PERI W OUT RESVR PROGRAMMABLE SYS ASSEMB STRATA VLV,SUP-2277981,CDM,C1889,HCPCS,0278,RC,,,,both,,,13135.91,8538.34,,,,,,,,,,,,,
KIT INTRO GLIDESHEATH SLENDER L 10 CM DIA 7 FR 0.025IN PLAS,SUP-2420179,CDM,C1894,HCPCS,0272,RC,,,,both,,,372.88,242.37,,,,,,,,,,,,,
GRAFT HUM TISS 9SQCM EPIFIX AMNIO MEM ALLGRFT DEHYDR N VIABLE,SUP-2305752,CDM,Q4186,HCPCS,0636,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
PLATE BNE L140MM 13 H OLECRANON TIM LO PROF MULTIPLANAR ARM,SUP-2411729,CDM,C1713,HCPCS,0278,RC,,,,both,,,3987.49,2591.87,,,,,,,,,,,,,
HC Fna Bx W/Fluor Gdn 1st Les,PX-3611000700,CDM,10007,CPT,0361,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
STENT PERIPH EVERFLEX L 120 MM DIA 6 MM CATH L 80 CM SHTH 5,SUP-2866784,CDM,C1876,HCPCS,0278,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
PLATE BNE L52MM THK2.3MM 8 H NONCOMPRESSION FRAC,SUP-2262990,CDM,C1713,HCPCS,0278,RC,,,,both,,,1175.15,763.85,,,,,,,,,,,,,
BUR DIAMONDS 811 037 MAXIMA,SUP-2238962,CDM,2720000010,LOCAL,0272,RC,,,,both,,,95.30,61.94,,,,,,,,,,,,,
SET INT FIX SCREW DIA1.5 MM 6 H XLN TI NEURO DBL Y SHP PLATE,SUP-2935833,CDM,C1713,HCPCS,0278,RC,,,,both,,,21879.52,14221.69,,,,,,,,,,,,,
ALLOGRAFT BNE SPACER 22-24X27-32X9 MM FD ALIF ANTR APPRCH,SUP-2736757,CDM,C1713,HCPCS,0278,RC,,,,both,,,14184.95,9220.22,,,,,,,,,,,,,
SET INTUB LACR PRB SIL TBNG CRWFRD,SUP-2247574,CDM,C1783,HCPCS,0278,RC,,,,both,,,307.72,200.02,,,,,,,,,,,,,
COIL EMB L15CM DIA10MM 0.018IN PERIPH HYDRGEL DETACH 18 SYS,SUP-2385421,CDM,C1889,HCPCS,0278,RC,,,,both,,,3048.85,1981.75,,,,,,,,,,,,,
CONNECTOR PENILE PROS QC PENPRO,SUP-2138931,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1978.20,1285.83,,,,,,,,,,,,,
SHEPARD GROMMET VENT TUBE 102MM ID FLUOROPLASTIC 60 PACK,SUP-2681458,CDM,L8699,HCPCS,0278,RC,,,,both,,,24.52,15.94,,,,,,,,,,,,,
RING ANNULPLSTY CARP EDW PHY DIA 36 MM TI ALLOY POLYESTER,SUP-2214266,CDM,C1889,HCPCS,0278,RC,,,,both,,,7834.30,5092.29,,,,,,,,,,,,,
DEFIBRILLATOR IMPL ILIVIA DR-T 2 CHMBR DF4 CONN STRL,SUP-2138474,CDM,C1721,HCPCS,0275,RC,,,,both,,,68216.50,44340.72,,,,,,,,,,,,,
DRIVER SURG HEX 3.8 MM CANN,SUP-2423055,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1824.34,1185.82,,,,,,,,,,,,,
PIN FIX L150MM DIA6MM THRD L55MM S STL HA HALF CORT BULL,SUP-2343020,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1260.96,819.62,,,,,,,,,,,,,
PLATE BNE L18MM THK0.4MM 7 H CRANIOMAXILLOFACIAL BILAT BLU,SUP-2181564,CDM,C1713,HCPCS,0278,RC,,,,both,,,859.10,558.41,,,,,,,,,,,,,
BIT DRILL TWIST 2.1MM FOR SUTURE ANCHORS,SUP-2828539,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1096.58,712.78,,,,,,,,,,,,,
HANDPIECE LASER MALL CLN KT FIBERLASE,SUP-2713735,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3912.44,2543.09,,,,,,,,,,,,,
CATHETER DIAG ZOOM 88-T L 110 CM DIA 0.088 IN HYDRPHLC LG,SUP-2739214,CDM,C1757,HCPCS,0272,RC,,,,both,,,9404.30,6112.79,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 40 MM DIA 4 MM DEL SHTH 1.5ML,SUP-2937069,CDM,C1713,HCPCS,0278,RC,,,,both,,,4873.28,3167.63,,,,,,,,,,,,,
PLATE BONE L214MM 6X23 H LT MAND TI ANG LCK COMPR FOR 2.4MM,SUP-2191429,CDM,C1713,HCPCS,0278,RC,,,,both,,,8299.65,5394.77,,,,,,,,,,,,,
SHEATH INTRO PINNACLE L 10 CM 4 FR GUIDEWIRE PERIPHERAL,SUP-2385661,CDM,C1894,HCPCS,0272,RC,,,,both,,,37.18,24.17,,,,,,,,,,,,,
BLADE SHV DIA3MM STR AGG TURB HEMSTAT W/ PK TECHNOLOGY FOR,SUP-2313841,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3326.01,2161.91,,,,,,,,,,,,,
PLATE 9HL 2.7X107MM,SUP-2477304,CDM,C1713,HCPCS,0278,RC,,,,both,,,952.17,618.91,,,,,,,,,,,,,
ENDCAP ORTH LCK 4.5 MM WRST FOR FRDM 4.5 MM SCR STRL,SUP-2851947,CDM,C1889,HCPCS,0278,RC,,,,both,,,533.74,346.93,,,,,,,,,,,,,
PLATE BNE RECON 2-2.5X182X2 MM RT MAND 26 HOLE ANGLED STRL,SUP-2478108,CDM,C1713,HCPCS,0278,RC,,,,both,,,6238.11,4054.77,,,,,,,,,,,,,
GRAFT TISS REGEN MATRIX 4X4CM GRAFTJACKET,SUP-2262293,CDM,Q4107,HCPCS,0636,RC,,,,both,,,3758.58,2443.08,,,,,,,,,,,,,
COLLAR CERV L H4.25IN FOR 16-19IN PLASTAZOTE FOAM 2 PC L,SUP-2336006,CDM,L0140,HCPCS,0272,RC,,,,both,,,30.87,20.07,,,,,,,,,,,,,
VALVE HEMOSTAS GRDIAN POLYCARB GUIDEWIRE INSRTN TOOL STRL,SUP-2383195,CDM,C1713,HCPCS,0278,RC,,,,both,,,4317.50,2806.37,,,,,,,,,,,,,
CATHETER HD DL 14.5X23 CM ADMIN BASIC KT LT STR HEMOSTAR,SUP-2126528,CDM,C1750,HCPCS,0278,RC,,,,both,,,1513.48,983.76,,,,,,,,,,,,,
BIT DRL L305MM DIA4MM TIB REUSE RUSS TAY,SUP-2342369,CDM,2720000010,LOCAL,0272,RC,,,,both,,,337.64,219.47,,,,,,,,,,,,,
CUP 1 PC ACET NEUT POR W/ SCR H TI ALLOY ULT HI MOL POLYETH,SUP-2202894,CDM,C1776,CPT,0278,RC,,,,both,,,8123.18,5280.07,,,,,,,,,,,,,
GRAFT HUM TISS W1.5XL1.5CM AMNIO MEMBRN FOR WND COVERING IN,SUP-2135264,CDM,Q4148,HCPCS,0636,RC,,,,both,,,3202.80,2081.82,,,,,,,,,,,,,
NKII +4MM MOD NP TIBIAL BASEPLATE-CONST RT SIZE 2,SUP-2510148,CDM,C1776,CPT,0278,RC,,,,both,,,7988.16,5192.30,,,,,,,,,,,,,
CATHETER ANGIO ARW BERMAN L 80 CM DIA 5 FR BALLOON DIA12 MM,SUP-2383927,CDM,C1725,HCPCS,0272,RC,,,,both,,,910.60,591.89,,,,,,,,,,,,,
KIT TKR CEM FEM CEM TIB STD SURF AND NO PAT PERSONA,SUP-2212215,CDM,C1776,CPT,0278,RC,,,,both,,,11972.82,7782.33,,,,,,,,,,,,,
BLADE SCRWDRVR 2MM2.3MM DIA 80MML QUICK CPLNG CNTRE DRIVE,SUP-2676901,CDM,2720000010,LOCAL,0272,RC,,,,both,,,331.71,215.61,,,,,,,,,,,,,
OBTURATOR VERSPRT + RT 12MM BLUNTPORT OBT W/ 5MM + SEAL AND,SUP-2283210,CDM,2720000010,LOCAL,0272,RC,,,,both,,,334.25,217.26,,,,,,,,,,,,,
HC I&D Abcess Complic Multiple,PX-4501006100,CDM,10061,CPT,0450,RC,,,,inpatient,,,405.00,263.25,,,,,,,,,,,,,
SCREW BNE L10MM DIA2MM PUR TI ALLY THRD AND ROUNDED CONIC HD,SUP-2181024,CDM,C1713,HCPCS,0278,RC,,,,both,,,412.06,267.84,,,,,,,,,,,,,
SHUNT SURG CORONARY 3X12 MM VES BLB TIP RADIOPAQUE TAB SIL,SUP-2159485,CDM,C1889,HCPCS,0278,RC,,,,both,,,141.30,91.84,,,,,,,,,,,,,
CATHETER HD 3L 11.5 FRX20 CM STR TRIFLO,SUP-2433955,CDM,C1752,HCPCS,0278,RC,,,,both,,,150.72,97.97,,,,,,,,,,,,,
FIBER LASER 600 MH 1.8 MM,SUP-2427799,CDM,C1713,HCPCS,0278,RC,,,,both,,,6594.00,4286.10,,,,,,,,,,,,,
PLATE CRAN L 31 MM DIA25 MM THK 0.5 MM SCREW DIA1.5 MM TI,SUP-2937029,CDM,C1713,HCPCS,0278,RC,,,,both,,,872.92,567.40,,,,,,,,,,,,,
ALLOGRAFT BNE SPACER 12X14X7 MM CERV FD PARL CANC,SUP-2736852,CDM,C1713,HCPCS,0278,RC,,,,both,,,2782.04,1808.33,,,,,,,,,,,,,
MESH HERN W3XL6IN OMEGA 3 FATTY ACID COAT POLYPR,SUP-2265981,CDM,C1781,HCPCS,0278,RC,,,,both,,,857.22,557.19,,,,,,,,,,,,,
PLATE BONE L301MM 16 H LCK COMPR FOR 4.5MM SCR PERI-LOC L,SUP-2348445,CDM,C1713,HCPCS,0278,RC,,,,both,,,7812.48,5078.11,,,,,,,,,,,,,
GRAFT DURA SUTURABLE 1X1 IN REGEN MTRX DURAGN + EACH=5 UNITS,SUP-2922527,CDM,C1763,HCPCS,0278,RC,,,,both,,,812.66,528.23,,,,,,,,,,,,,
GRAFT VASC HEMSHLD GLD L 30 CM ID DIA MM BRANCH SZ 10 MM,SUP-2763176,CDM,C1768,CPT,0278,RC,,,,both,,,4635.86,3013.31,,,,,,,,,,,,,
MESH CRAN SZ 120 X 175 X 80 MM THK 1 MM SCREW DIA1.5/1.7 MM,SUP-2883398,CDM,C1713,HCPCS,0278,RC,,,,both,,,41542.20,27002.43,,,,,,,,,,,,,
HC So Protoporphyrin RBC Quant,PX-3018420266,CDM,84202,CPT,0301,RC,,,,both,,,132.00,85.80,,,,,,,,,,,,,
THROMBIN (RECOMBINANT) 5000 UNITS EX SOLR,RX-89570,CDM,6370000000,HCPCS,0637,RC,00338-0322-01,NDC,,both,1,UN,494.50,321.42,,,,,,,,,,,,,
MATRIX HEMSTAT 5ML FULL FLOSEAL,SUP-2130321,CDM,2720000010,LOCAL,0272,RC,,,,both,,,793.70,515.90,,,,,,,,,,,,,
TUBE TRACH 7MM REPL PERC CUF W OBT DIL AND INNR CANN PER FIT,SUP-2351977,CDM,2720000010,LOCAL,0272,RC,,,,both,,,375.17,243.86,,,,,,,,,,,,,
SCREW BNE HD SHT THRD 4X42 MM CANN MINI-MONSTER,SUP-2320562,CDM,C1713,HCPCS,0278,RC,,,,both,,,741.83,482.19,,,,,,,,,,,,,
STEM HUM L125MM OD6.5MM UNIV CO CHROM SHLDR PRI CEM IMP,SUP-2404713,CDM,C1776,CPT,0278,RC,,,,both,,,15583.82,10129.48,,,,,,,,,,,,,
PLATE BONE 9 H RT BOARDER SCAPULA,SUP-2107834,CDM,C1713,HCPCS,0278,RC,,,,both,,,5419.64,3522.77,,,,,,,,,,,,,
CONNECTOR SPNL M SZ 6 L32-37MM STD POST LUM THOR TI SCR,SUP-2254361,CDM,C1713,HCPCS,0278,RC,,,,both,,,4242.14,2757.39,,,,,,,,,,,,,
PLATE BNE W10XL57MM THK1.5MM 4X5 H BILAT S STL T SHP R ANG,SUP-2185871,CDM,C1713,HCPCS,0278,RC,,,,both,,,991.58,644.53,,,,,,,,,,,,,
X FUSE IMPLANT STANDARD 0 DEGREE,SUP-2704846,CDM,C1713,HCPCS,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
PLATE BONE THK2.6MM 7 H MAND TI CVD FOR 2/2.3MM SCR SYS,SUP-2137629,CDM,C1713,HCPCS,0278,RC,,,,both,,,3428.88,2228.77,,,,,,,,,,,,,
PLATE BONE 12 H STOUT STR FOR 2.4MM SCR VLP MINI-MOD SM BONE,SUP-2351102,CDM,C1713,HCPCS,0278,RC,,,,both,,,4553.47,2959.76,,,,,,,,,,,,,
STAPLER INT L21MM 48MM STPL GI TI CIR CUT LN 2 ROW,SUP-2283253,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1028.13,668.28,,,,,,,,,,,,,
PLATE BONE 10 H TI LCK STR,SUP-2123457,CDM,C1713,HCPCS,0278,RC,,,,both,,,1868.30,1214.39,,,,,,,,,,,,,
CATHETER CV SET 032 REG 8 FRX20 CM 12 GA DL J TIP SPECTRUM,SUP-2759724,CDM,C1751,HCPCS,0278,RC,,,,both,,,439.88,285.92,,,,,,,,,,,,,
GUIDEWIRE VASC PRIMEWIRE PRESTIGE L 185 CM SS GLYDX HYDRPHLC,SUP-2393125,CDM,C1769,HCPCS,0272,RC,,,,both,,,2025.30,1316.44,,,,,,,,,,,,,
GRAFT SHFT HUM CRSS SECT SPNL ALLGRFT FRZ DRY 10MM,SUP-2264983,CDM,C1713,HCPCS,0278,RC,,,,both,,,4810.98,3127.14,,,,,,,,,,,,,
CATHETER THROMCTMY L 100 CM DIA 5 FR INFUSION L 5 CM,SUP-2141147,CDM,C1751,HCPCS,0278,RC,,,,both,,,237.16,154.15,,,,,,,,,,,,,
AUGMENT FEMORALXSM THK4MM STD RT POST KNEE TI CEM BLK,SUP-2406979,CDM,C1776,CPT,0278,RC,,,,both,,,1956.22,1271.54,,,,,,,,,,,,,
GUIDEWIRE ORTHOPEDIC TIB,SUP-2366800,CDM,C1769,HCPCS,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
WIRE FIX 250 MM KIRSCHNER,SUP-2243647,CDM,C1713,HCPCS,0278,RC,,,,both,,,128.74,83.68,,,,,,,,,,,,,
EXPANDER PUPIL 7 MM STRL MALYUGIN RNG,SUP-2304866,CDM,2720000010,LOCAL,0272,RC,,,,both,,,470.47,305.81,,,,,,,,,,,,,
SPLINT WRST AND THMB BLK FOAM XS 8 IN R,SUP-2336034,CDM,L3809,HCPCS,0272,RC,,,,both,,,21.35,13.88,,,,,,,,,,,,,
SET INTRO SELECTRA STRL,SUP-2418817,CDM,C1893,HCPCS,0272,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
PACEMAKER CARD W/ LD ULT VR INSIGNIA,SUP-2236360,CDM,C1786,HCPCS,0275,RC,,,,both,,,18855.70,12256.20,,,,,,,,,,,,,
NEEDLE ENDOSCP 25GA L4MM WRK L230CM MIN CHN 28MM UP GI MID,SUP-2313417,CDM,C1713,HCPCS,0278,RC,,,,both,,,138.82,90.23,,,,,,,,,,,,,
CATHETER ANGIOPLSTY THRDR L 150 CM BALLOON L 12 MM DIA1.2 MM,SUP-2140839,CDM,C1725,HCPCS,0272,RC,,,,both,,,3215.36,2089.98,,,,,,,,,,,,,
PLATE BNE RECON 2-2.7X193X3 MM RT MAND 26 HOLE ANGLED STRL,SUP-2482449,CDM,C1713,HCPCS,0278,RC,,,,both,,,6948.38,4516.45,,,,,,,,,,,,,
PLATE 5HL 2.7X65MM,SUP-2464249,CDM,C1713,HCPCS,0278,RC,,,,both,,,962.50,625.62,,,,,,,,,,,,,
GUIDEWIRE VASC LUNDERQUIST L 90 CM DIA 0.035 IN TAPR L 15 CM,SUP-2638728,CDM,C1769,HCPCS,0272,RC,,,,both,,,176.03,114.42,,,,,,,,,,,,,
GUIDEWIRE VASC L 80 CM DIA 0.035 IN TAPR L 6 CM FLPY TIP L 2,SUP-2167663,CDM,C1769,HCPCS,0272,RC,,,,both,,,26.28,17.08,,,,,,,,,,,,,
SET BX NDL 13GA L10CM INFUS CANN W/ RATCH UNIDIR DRL ACT,SUP-2169482,CDM,2720000010,LOCAL,0272,RC,,,,both,,,433.32,281.66,,,,,,,,,,,,,
CHOPPER OPHTH NUCLS NAGAHARA LT,SUP-2472918,CDM,2720000010,LOCAL,0272,RC,,,,both,,,409.27,266.03,,,,,,,,,,,,,
CUBE EXT FIX 3 H RANCHO FEMALE,SUP-2898424,CDM,2720000010,LOCAL,0272,RC,,,,both,,,606.02,393.91,,,,,,,,,,,,,
CATHETER ETER TY 2 ST MAXIMAL BARR IPA 4FR POWERPICC,SUP-2126383,CDM,C1751,HCPCS,0278,RC,,,,both,,,625.68,406.69,,,,,,,,,,,,,
TUBING ASPIR MILLIPEDE 070 FLX BRAIDED ROTATING M LL CONN,SUP-2929966,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
ALLOGRAFT BNE LORDTC 0 DEGREE 12X14X6 MM OPTIO-C,SUP-2402681,CDM,C1713,HCPCS,0278,RC,,,,both,,,9420.00,6123.00,,,,,,,,,,,,,
SET INTRO PERFRMR L 13 CM DIA12 FR TIP 3 MM GUIDEWIRE 0.038,SUP-2168216,CDM,C1894,HCPCS,0272,RC,,,,both,,,132.41,86.07,,,,,,,,,,,,,
PLATE BNE L69MM 6 H S STL 1/3 TBLR LOK COMPR W/ CLLR FOR,SUP-2185930,CDM,C1713,HCPCS,0278,RC,,,,both,,,454.36,295.33,,,,,,,,,,,,,
PLATE BONE L334MM 18 H LT PROX TIB S STL LCK COMPR LO PROF,SUP-2419194,CDM,C1713,HCPCS,0278,RC,,,,both,,,4768.47,3099.51,,,,,,,,,,,,,
PLATE L FUSION VA LCP 2.4/2.7MM LNG RT TI STRL,SUP-2546994,CDM,C1713,HCPCS,0278,RC,,,,both,,,3609.12,2345.93,,,,,,,,,,,,,
MESH HERN OPTIMIZED COMP 37X28 CM RND POLYESTER PARIETEX,SUP-2752186,CDM,C1781,HCPCS,0278,RC,,,,both,,,8994.47,5846.41,,,,,,,,,,,,,
TI LCP VOLAR COLUMN DISTAL RADIUS PL 8H HEAD/5H SHAFT/LT,SUP-2549121,CDM,C1713,HCPCS,0278,RC,,,,both,,,2898.94,1884.31,,,,,,,,,,,,,
COMPONENT TIB L240MM THK11MM PROX 1 PC NONMODULAR OSS,SUP-2405863,CDM,C1776,CPT,0278,RC,,,,both,,,18821.16,12233.75,,,,,,,,,,,,,
EXTENSION STEM XSM L80MM KNEE CO CHROM CEM MOD MONOGRAM,SUP-2376293,CDM,C1776,CPT,0278,RC,,,,both,,,1972.27,1281.98,,,,,,,,,,,,,
HC Mod Sed Same Phys/Qhp 5/>Yrs,PX-3729915200,CDM,99152,CPT,0372,RC,,,,inpatient,,,297.00,193.05,,,,,,,,,,,,,
SLEEVE FEM 61MM LATERAL MEDIAL FULL COAT REV PORCOAT ATTUNE,SUP-2251471,CDM,C1776,CPT,0278,RC,,,,both,,,8297.14,5393.14,,,,,,,,,,,,,
ORTHO ANCHRGE C TUBE PLATE RIGHT HOOK STRGHT 4 HOLE 6MM BRG,SUP-2676797,CDM,C1713,HCPCS,0278,RC,,,,both,,,1154.77,750.60,,,,,,,,,,,,,
"HC So Concentratn ,Any, Infect Agent",PX-3008701566,CDM,87015,CPT,0300,RC,,,,inpatient,,,79.00,51.35,,,,,,,,,,,,,
ROD SPNL L110MM DIA5.5MM POST R STR SMOOTH TI ALLY SEXTANT,SUP-2288459,CDM,C1713,HCPCS,0278,RC,,,,both,,,2016.51,1310.73,,,,,,,,,,,,,
TRAY ART LN CATH 3FR L8CM 0.018IN NDL 20GA POLYETH BASEPLT,SUP-2167868,CDM,C1751,HCPCS,0278,RC,,,,both,,,166.73,108.37,,,,,,,,,,,,,
HC So Elution Procedure,PX-3028686066,CDM,86860,CPT,0302,RC,,,,both,,,282.00,183.30,,,,,,,,,,,,,
COMPONENT XVS STERILE COMPONENTS,SUP-2756517,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4553.00,2959.45,,,,,,,,,,,,,
KIT INTRO VSI RADIAL SHTH L 12 CM DIA 6 FR GUIDEWIRE L 45 CM,SUP-2383182,CDM,C1894,HCPCS,0272,RC,,,,both,,,70.65,45.92,,,,,,,,,,,,,
PLATE BNE BSSO 2X35 MM SLIDING COLOGNE FOR SCR TI NS LEVEL 1,SUP-2475338,CDM,C1713,HCPCS,0278,RC,,,,both,,,1640.52,1066.34,,,,,,,,,,,,,
AUGMENT TIB THK 5 MM SZ 6 RT MEDL LL KNEE REV HINGE STRL,SUP-2889813,CDM,C1776,CPT,0278,RC,,,,both,,,4869.83,3165.39,,,,,,,,,,,,,
TRANSMITTER SND PROC HEARING AID STREAMER REMOT CTRL WHT,SUP-2319868,CDM,C1713,HCPCS,0278,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
"HC Pt Therapeutic Exercise,Ea 15 Min|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS",PX-4209711000,CDM,97110,CPT,0420,RC,,,CQ,both,,,195.00,126.75,,,,,,,,,,,,,
BUR SURG L21CM DIA9MM BALL FLUT L BOR MIDAS REX LEGEND,SUP-2277906,CDM,2720000010,LOCAL,0272,RC,,,,both,,,399.75,259.84,,,,,,,,,,,,,
DEVICE CLIPPING HEMSTAT 155CM,SUP-2141393,CDM,2720000010,LOCAL,0272,RC,,,,both,,,522.46,339.60,,,,,,,,,,,,,
ALLOGRAFT BNE PTTY 1 CC LECITHIN CARR DBM NS REGENEROSS +,SUP-2862036,CDM,C1713,HCPCS,0278,RC,,,,both,,,520.71,338.46,,,,,,,,,,,,,
GRAFT VASC INTERGARD L 60 CM DIA22 MM THK 0.38 MM POLYESTER,SUP-2694162,CDM,C1768,CPT,0278,RC,,,,both,,,1805.94,1173.86,,,,,,,,,,,,,
KIT BAL KYPHOPLASTY NDL 10GA L15MM SGL IVAS ELITE,SUP-2361506,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4264.31,2771.80,,,,,,,,,,,,,
GRAFT VASC STD WALL 4 MMX10 CM STR REINF DEL SYS ADVANTA VXT,SUP-2472522,CDM,C1768,CPT,0278,RC,,,,both,,,356.30,231.59,,,,,,,,,,,,,
BACITRACIN 500 UNIT/GM EX OINT,RX-850,CDM,6370000000,HCPCS,0637,RC,00904-7402-67,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PLASMAX PLSM CONC SYS PLSMX DISP KT,SUP-2402601,CDM,C1713,HCPCS,0278,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
RAIL L300MM AD STD COMP FOR LIMB RECON SYS,SUP-2316078,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3826.15,2487.00,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 80 CM DIA10 MM EPTFE STR TW N RING,SUP-2396359,CDM,C1768,CPT,0278,RC,,,,both,,,3702.06,2406.34,,,,,,,,,,,,,
ALLOGRAFT BNE STRP 35X60 MM FRZN TRICORT ILIUM MATRIGRAFT,SUP-2740789,CDM,C1713,HCPCS,0278,RC,,,,both,,,7809.90,5076.43,,,,,,,,,,,,,
NAIL IM L160MM DIA10MM NONSTERILE AQUA L/R DSTL FEM TI LCK,SUP-2191706,CDM,C1713,HCPCS,0278,RC,,,,both,,,5612.94,3648.41,,,,,,,,,,,,,
KIT EXT FIX DST RAD FRME W/ TI SELF DRL SCHNZ SCR L200MM C,SUP-2179168,CDM,C1713,HCPCS,0278,RC,,,,both,,,7978.52,5186.04,,,,,,,,,,,,,
ALLOGRAFT BNE REFRIGERATED RT ANK TALUS,SUP-2740840,CDM,C1762,CPT,0278,RC,,,,both,,,20671.84,13436.70,,,,,,,,,,,,,
ALLOGRAFT BNE GEL 10 CC DBM,SUP-2636992,CDM,C1713,HCPCS,0278,RC,,,,both,,,2920.20,1898.13,,,,,,,,,,,,,
BUTTON SUTURE DIA11 MM ABS 3 H BUTTON RND CONCV FOR INT BRAC,SUP-2882170,CDM,C1713,HCPCS,0278,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
CEMENT BONE POLYMETHYLMETHACRYLATE W/ TOBRA M VISC RADPQ LNG,SUP-2364374,CDM,C1713,HCPCS,0278,RC,,,,both,,,924.73,601.07,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.531,SUP-2860048,CDM,C1713,HCPCS,0278,RC,,,,both,,,45470.03,29555.52,,,,,,,,,,,,,
INSERT TIB SZ 5 THK17.5MM GVF POLYETH ROT PLATFRM STBL PFC,SUP-2253727,CDM,C1776,CPT,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
GUIDEWIRE VASC IQ L 185 CM DIA 0.014 IN SIL WORKHORSE J W/,SUP-2140695,CDM,C1769,HCPCS,0272,RC,,,,both,,,260.62,169.40,,,,,,,,,,,,,
CATHETER CTRL VEN 5.5FR 20CM LEN SGL LUMN N TUNNELED BASIC,SUP-2383312,CDM,C1751,HCPCS,0278,RC,,,,both,,,86.04,55.93,,,,,,,,,,,,,
SCREW BNE L 4 MM DIA1.8 MM TI NEURO XDRV EMER 12 PK STRL,SUP-2935285,CDM,C1713,HCPCS,0278,RC,,,,both,,,3045.80,1979.77,,,,,,,,,,,,,
COVER BUR H DIA20MM SHUNT LO PROF W/ TAB FOR 1.5MM SCR CRAN,SUP-2363639,CDM,C1713,HCPCS,0278,RC,,,,both,,,961.66,625.08,,,,,,,,,,,,,
NAIL IM L380MM OD11MM 125DEG LNG TIM RT HIP AG CANN LCK,SUP-2211476,CDM,C1713,HCPCS,0278,RC,,,,both,,,4515.32,2934.96,,,,,,,,,,,,,
NEEDLE LOC L7.5CM OD20GA BRST REPOSITIONABLE PATENTED SIDE,SUP-2269616,CDM,C1819,HCPCS,0278,RC,,,,both,,,116.18,75.52,,,,,,,,,,,,,
SCREW BNE CORTICAL 4X42 MM PROX HUM CANN SD HEX DRV NS NCB,SUP-2459937,CDM,C1713,HCPCS,0278,RC,,,,both,,,496.78,322.91,,,,,,,,,,,,,
STENT PERIPH EXPRESS LD L 37 MM DIA 8 MM CATH L 75 CM DIA 6,SUP-2144315,CDM,C1876,HCPCS,0278,RC,,,,both,,,3532.50,2296.12,,,,,,,,,,,,,
CATHETER INT AORT BLLN 9.5FX340,SUP-2227308,CDM,C1713,HCPCS,0278,RC,,,,both,,,2088.10,1357.26,,,,,,,,,,,,,
GUIDEWIRE URO L145CM DIA0038IN PTFE S STL SGL END FIX COR J,SUP-2126213,CDM,C1769,HCPCS,0272,RC,,,,both,,,55.33,35.96,,,,,,,,,,,,,
WASHER ORTH STR FOR DARCO 7MM HDLSS COMPR SCR,SUP-2399606,CDM,C1713,HCPCS,0278,RC,,,,both,,,113.04,73.48,,,,,,,,,,,,,
GRAFT BONE STRP 2.5CMX5CM GRFTON,SUP-2293900,CDM,C1713,HCPCS,0278,RC,,,,both,,,2213.70,1438.90,,,,,,,,,,,,,
SHEATH INTRO 8FR L63CM TRANSSEPTAL SL2 CRV BRAID HEMSTAS,SUP-2357254,CDM,C1893,HCPCS,0272,RC,,,,both,,,562.06,365.34,,,,,,,,,,,,,
ANCHOR SUT SUP REVO PRE LD ON A DISP DRVR 5.0MMX14MM W/ TWO,SUP-2166968,CDM,C1713,HCPCS,0278,RC,,,,both,,,576.44,374.69,,,,,,,,,,,,,
KIT INTRO ELITE HV SHTH L 7 CM DIA 5 FR GUIDEWIRE L 45 CM,SUP-2615932,CDM,C1894,HCPCS,0272,RC,,,,both,,,63.96,41.57,,,,,,,,,,,,,
INSERT TIB L59MM THK12MM UNIV KNEE PRI POST STBL NEUT ASCNT,SUP-2407029,CDM,C1776,CPT,0278,RC,,,,both,,,3234.20,2102.23,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 0.5 CC INJ AMNIO FLUID STRATOGEN FLO,SUP-2777565,CDM,C1762,CPT,0278,RC,,,,both,,,5369.40,3490.11,,,,,,,,,,,,,
SCREW BNE L 3.5 MM DIA1.8 MM MIDFACE EMER CNTR DRV NS DISP,SUP-2934705,CDM,C1713,HCPCS,0278,RC,,,,both,,,184.00,119.60,,,,,,,,,,,,,
IFIX INTERFERENCE SCR 7X25MM,SUP-2589274,CDM,C1713,HCPCS,0278,RC,,,,both,,,1139.44,740.64,,,,,,,,,,,,,
PLATE BNE MESHED 26X26X0.6 MM SM GRID PLLA-PGA STRL,SUP-2468007,CDM,C1713,HCPCS,0278,RC,,,,both,,,1487.79,967.06,,,,,,,,,,,,,
BODY HUM L30MM STD PROX SHLDR MOD FOR FX PROMOS +,SUP-2351245,CDM,C1776,CPT,0278,RC,,,,both,,,2888.80,1877.72,,,,,,,,,,,,,
INSERT TIB SZ 1 L10MM LT MEDL RT LAT ALL POLY UNI,SUP-2342208,CDM,C1776,CPT,0278,RC,,,,both,,,4918.81,3197.23,,,,,,,,,,,,,
NEEDLE BONE CEMENT DELIVERY 12 GAX10 CM STERILE,SUP-2838510,CDM,2720000010,LOCAL,0272,RC,,,,both,,,270.35,175.73,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 180 MM DIA17 MM DEL SHTH,SUP-2934269,CDM,C1713,HCPCS,0278,RC,,,,both,,,20642.11,13417.37,,,,,,,,,,,,,
KNIFE SURG JANNETTA SM 7.5 IN ANGLED LF,SUP-2485564,CDM,2720000010,LOCAL,0272,RC,,,,both,,,329.86,214.41,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY L 92 CM DIA 6 FR TIP 1 MM SPC 10,SUP-2248671,CDM,C1733,HCPCS,0272,RC,,,,both,,,954.56,620.46,,,,,,,,,,,,,
CATHETER THROMCTMY FOGARTY L 80 CM DIA 6 FR MEMBRN DIA,SUP-2214029,CDM,C1757,HCPCS,0272,RC,,,,both,,,1156.09,751.46,,,,,,,,,,,,,
CATHETER BLLN 1.25 X 6MM SPRINTER OTW,SUP-2282975,CDM,C1725,HCPCS,0272,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
HC Abd Paracentesis W Guide,PX-3614908300,CDM,49083,CPT,0361,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
BLADE OSTEOTOM SZ 10 RAD DISP,SUP-2345748,CDM,C1713,HCPCS,0278,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
RING AND DRL GUID ASSEMB 35 MM PEEK,SUP-2400391,CDM,C1776,CPT,0278,RC,,,,both,,,178.98,116.34,,,,,,,,,,,,,
STIMULATOR NERVE STRL DISP NSS IB-STIM,SUP-2898795,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3752.30,2438.99,,,,,,,,,,,,,
SACUBITRIL-VALSARTAN 49-51 MG PO TABS,RX-130695,CDM,6370000000,HCPCS,0637,RC,43598-0644-60,NDC,,both,1,UN,23.90,15.53,,,,,,,,,,,,,
PIN FIX L4MM DIA1.7MM AUTO PILOT,SUP-2363539,CDM,C1713,HCPCS,0278,RC,,,,both,,,108.14,70.29,,,,,,,,,,,,,
SLEEVE PROTECTION 8MM/11MM -,SUP-2896469,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1124.34,730.82,,,,,,,,,,,,,
FAM-TRASTUZUMAB DERUXTEC-NXKI 100 MG IV SOLR,RX-148610,CDM,J9358,HCPCS,0636,RC,65597-0406-01,NDC,,both,1,UN,8889.10,5777.91,,,,,,,,,,,,,
ILLUMINATOR OPHTH DIA35GA RFID STR SMOOTH ROUNDED DSTL TIP,SUP-2109914,CDM,2720000010,LOCAL,0272,RC,,,,both,,,373.75,242.94,,,,,,,,,,,,,
K WIRE FIX L150MM DIA2MM TI TRCR PNT,SUP-2193149,CDM,C1713,HCPCS,0278,RC,,,,both,,,284.14,184.69,,,,,,,,,,,,,
GUIDEWIRE URLGCL 0032N DIA 150CML 18CML TIP CTD STRGHT TIP,SUP-2729842,CDM,C1769,HCPCS,0272,RC,,,,both,,,97.59,63.43,,,,,,,,,,,,,
PHYTONADIONE 1 MG/ML ORAL SOLUTION,RX-4082399,CDM,6370000000,HCPCS,0637,RC,09999-9158-25,NDC,,both,2.5,ML,35.40,23.01,,,,,,,,,,,,,
HEAD HUM H12MM OD40MM THK12MM CONCENTRIC TOT SHLDR SOLAR,SUP-2378990,CDM,C1776,CPT,0278,RC,,,,both,,,6048.90,3931.78,,,,,,,,,,,,,
PORT IMPL INFUSION 7.2 FR VORT,SUP-2165210,CDM,C1788,HCPCS,0278,RC,,,,both,,,1632.80,1061.32,,,,,,,,,,,,,
KIT CATHETER AD 7FR L30CM CTRL VEN POLYUR NONCOATED 3 LUMN,SUP-2120585,CDM,C1751,HCPCS,0278,RC,,,,both,,,141.30,91.84,,,,,,,,,,,,,
GRAFT FEM CORT STRUT THIRDS 20CM,SUP-2307356,CDM,C1713,HCPCS,0278,RC,,,,both,,,4391.79,2854.66,,,,,,,,,,,,,
PLATE BNE BROAD 4.5X394 MM 22 HOLE TI NS LC-DCP,SUP-2568786,CDM,C1713,HCPCS,0278,RC,,,,both,,,3970.22,2580.64,,,,,,,,,,,,,
CROWN DENT LR5 SEC PRI M INDIV SPACE MAINTAINER,SUP-2176711,CDM,D6783,CPT,0278,RC,,,,both,,,22.67,14.74,,,,,,,,,,,,,
SEAT SPNL 6.35MM TI ALIGNING VAR ANG LCK,SUP-2415646,CDM,C1713,HCPCS,0278,RC,,,,both,,,1231.76,800.64,,,,,,,,,,,,,
BIT DRL QC 4.3X230 MM PROX TIB NCB,SUP-2457075,CDM,2720000010,LOCAL,0272,RC,,,,both,,,848.68,551.64,,,,,,,,,,,,,
CATHETER PERI PED L42CM LT SWAN NK CURLE CATH 2 CUF ARGY,SUP-2174282,CDM,C1750,HCPCS,0278,RC,,,,both,,,518.60,337.09,,,,,,,,,,,,,
SEED BRACHYTHERAPY LOAD 6.01-7.0 MCI STRL ADVANTAGE,SUP-2247276,CDM,C2642,HCPCS,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
GRAFT VASC WOVN DBL VELR STR 20MMX30CM,SUP-2469691,CDM,C1768,CPT,0278,RC,,,,both,,,2009.44,1306.14,,,,,,,,,,,,,
SPONGE GRV SIL 4.0MMX12.0MMX80MM,SUP-2213498,CDM,C1784,HCPCS,0278,RC,,,,both,,,166.42,108.17,,,,,,,,,,,,,
TAP BNE SPNL POST 12MM DIA,SUP-2291532,CDM,C1713,HCPCS,0278,RC,,,,both,,,2518.25,1636.86,,,,,,,,,,,,,
ANCHOR SUTURE 5.5MM WITH 3 NO 2 SUTURES HI-FI NEEDLE CROSSFT,SUP-2824898,CDM,C1713,HCPCS,0278,RC,,,,both,,,1545.32,1004.46,,,,,,,,,,,,,
PLATE BNE CLAV CS2 2.7 MM LT VA LCK COMPR SS STRL VA-LCP,SUP-2750793,CDM,C1713,HCPCS,0278,RC,,,,both,,,3397.86,2208.61,,,,,,,,,,,,,
COMPONENT FEM SZ 8 L POST KNEE NP PRI BICRUCIATE CEM STBL,SUP-2350309,CDM,C1776,CPT,0278,RC,,,,both,,,10487.60,6816.94,,,,,,,,,,,,,
ABLYSINOL IA SOLN,RX-145355,CDM,2500000003,HCPCS,0250,RC,54288-0105-02,NDC,,both,1,ML,1144.30,743.79,,,,,,,,,,,,,
DEVICE ABLAT HIFU EMITTING TRANSDUCERS LO CELL PROF,SUP-2355880,CDM,C1713,HCPCS,0278,RC,,,,both,,,11775.00,7653.75,,,,,,,,,,,,,
CONNECTOR SPNL S STL THORLUM LO PROF PARA W FOR 5.5/5.5MM,SUP-2230978,CDM,C1713,HCPCS,0278,RC,,,,both,,,920.02,598.01,,,,,,,,,,,,,
SLEEVE FEM DIA13MM HIP MALLORY-HEAD PMMA CNTR CEM BIPLANAR,SUP-2406640,CDM,C1776,CPT,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
ALLOGRAFT BNE HEMI MAND FD,SUP-2321822,CDM,C1713,HCPCS,0278,RC,,,,both,,,5196.70,3377.85,,,,,,,,,,,,,
PROSTHESIS OSS L 2 MM DIA1.1 MM HD DIA 3.25 MM TI HA PART DP,SUP-2902095,CDM,L8613,CPT,0278,RC,,,,both,,,1585.57,1030.62,,,,,,,,,,,,,
BIT DRL CALIB W/ SPIK FOR SURTAC II JCBS CHK,SUP-2341330,CDM,2720000010,LOCAL,0272,RC,,,,both,,,388.07,252.25,,,,,,,,,,,,,
GRAFT BNE SUB 1CC DEMIN BNE MTRX OSTEOCONDUCTIVE STRATOFUSE,SUP-2164153,CDM,C1713,HCPCS,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
STRAP SPLNT NYL WHT 2INX14IN ROLYAN D RNG,SUP-2324780,CDM,L3908,HCPCS,0272,RC,,,,both,,,9.11,5.92,,,,,,,,,,,,,
VALVE AORT FREESTYLE H 9 MM DIA19 MM PORCINE PRESTYLED,SUP-2429932,CDM,C1713,HCPCS,0278,RC,,,,both,,,18840.00,12246.00,,,,,,,,,,,,,
WIRE FIX L100MM OD.9MM SM FOR 2-2.5MM SCR 1 END TRCR PIN K,SUP-2392808,CDM,C1713,HCPCS,0278,RC,,,,both,,,29.05,18.88,,,,,,,,,,,,,
MICROPOWER OSCILLATING SAW,SUP-2605738,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8906.11,5788.97,,,,,,,,,,,,,
GRAFT HUM TISS W26XH7MM D9-11MM TRANSFORAMINAL POST LUM,SUP-2306940,CDM,C1713,HCPCS,0278,RC,,,,both,,,13903.17,9037.06,,,,,,,,,,,,,
RING EXT FIX HALF 170 MM CARBON FIBER RINGFIX,SUP-2365280,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3413.18,2218.57,,,,,,,,,,,,,
PLATE BNE THK0.6MM 6X2 H STD UNIV CRANIOMAXILLOFACIAL TI 3D,SUP-2366292,CDM,C1713,HCPCS,0278,RC,,,,both,,,1312.33,853.01,,,,,,,,,,,,,
BIT DRL DIA4.3MM CALIB ANK COMPR NAILING SYS,SUP-2316003,CDM,2720000010,LOCAL,0272,RC,,,,both,,,687.47,446.86,,,,,,,,,,,,,
GUIDEWIRE ORTH L28IN DIA2.2MM S STL DISP FOR VERSANAIL HUM,SUP-2413205,CDM,C1769,HCPCS,0272,RC,,,,both,,,430.18,279.62,,,,,,,,,,,,,
HC Lum Discogram/Inj Each Level,PX-3616229000,CDM,62290,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
STEM FEM SZ 1 POR HIP 12/14 TAPR PRESSFIT RESTORIS Z,SUP-2370439,CDM,C1776,CPT,0278,RC,,,,both,,,4018.89,2612.28,,,,,,,,,,,,,
PLATE BNE W10XL214MM THK3.6MM 18 H BILAT S STL CRV RIG CLLR,SUP-2186260,CDM,C1713,HCPCS,0278,RC,,,,both,,,3076.85,1999.95,,,,,,,,,,,,,
ASSEMBLY SHUNT OPN END STD 120 CM BURR HOLE WALL SLT STRATA,SUP-2664459,CDM,C1889,HCPCS,0278,RC,,,,both,,,17088.70,11107.65,,,,,,,,,,,,,
CATHETER ANGIOPLSTY 23 MMX5 CM ZMED II,SUP-2309687,CDM,C1725,HCPCS,0272,RC,,,,both,,,2089.76,1358.34,,,,,,,,,,,,,
STENT BILI SENTINOL L 40 MM DIA 6 MM CATH L 75 CM SHTH 6 FR,SUP-2140675,CDM,C1876,HCPCS,0278,RC,,,,both,,,2276.50,1479.72,,,,,,,,,,,,,
STENT NSL 370UG MOMETASONE FUROATE BIOABSRB IMPL W/ DEL SYS,SUP-2246417,CDM,C2625,HCPCS,0278,RC,,,,both,,,3830.80,2490.02,,,,,,,,,,,,,
EXTRACTOR SURG L2-2.5 MMXTRACT ALL DISP FOR 2-2.5 MM,SUP-2337710,CDM,C1713,HCPCS,0278,RC,,,,both,,,675.10,438.81,,,,,,,,,,,,,
PLATE BNE FIBULAR 2.7X105 MM LT LAT DSTL 5 HOLE NS VA-LCP,SUP-2758196,CDM,C1713,HCPCS,0278,RC,,,,both,,,2681.06,1742.69,,,,,,,,,,,,,
LENS INTOCU PMMA +15 D L12.5 MM OD6 MM EQCNVX ANTR CHMBR,SUP-2129478,CDM,V2630,CPT,0276,RC,,,,both,,,160.71,104.46,,,,,,,,,,,,,
VALVE SHUNT FLO CTRL SM CONTOURED W/ BIOGLDE MED PRESSURE,SUP-2631414,CDM,C1889,HCPCS,0278,RC,,,,both,,,2599.92,1689.95,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY ENSITE L 110 CM MAP ARRY,SUP-2516514,CDM,C1731,HCPCS,0278,RC,,,,both,,,10462.48,6800.61,,,,,,,,,,,,,
HC X-Ray Ac Joints,PX-3207305000,CDM,73050,CPT,0320,RC,,,,both,,,675.00,438.75,,,,,,,,,,,,,
PROBE ACTIVE FIBER PTEYE,SUP-2716312,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1822.93,1184.90,,,,,,,,,,,,,
MICROCATHETER GUID MARATHON TOT L 170 CM L 165 CM,SUP-2172482,CDM,C1887,HCPCS,0272,RC,,,,both,,,2847.98,1851.19,,,,,,,,,,,,,
CATHETER CV KT PEDIATRIC 5.5 FRX8 CM 3L STR SFT TIP,SUP-2763364,CDM,C1751,HCPCS,0278,RC,,,,both,,,416.36,270.63,,,,,,,,,,,,,
PACEMAKER CARD ACCOLADE MRI W 4.45 X H 4.81 CM THK 0.75 CM,SUP-2149250,CDM,C1786,HCPCS,0275,RC,,,,both,,,8650.70,5622.95,,,,,,,,,,,,,
ROD SPNL L90MM OD5.5MM POST LUM SMOOTH PRE CUT REVOLVE,SUP-2230518,CDM,C1713,HCPCS,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
KIT PROTCT SYS EMBOL-X GLIDE L 11 IN LG 2 FILTER 1 ART CANN,SUP-2214493,CDM,C1713,HCPCS,0278,RC,,,,both,,,1507.42,979.82,,,,,,,,,,,,,
SCREW SET FITBONE,SUP-2645706,CDM,C1713,HCPCS,0278,RC,,,,both,,,643.79,418.46,,,,,,,,,,,,,
CAGE ACET DIA50MM RT TOT HIP TI REV CEM BURCH-SCHNEIDER,SUP-2212040,CDM,C1776,CPT,0278,RC,,,,both,,,8458.85,5498.25,,,,,,,,,,,,,
SCREW BNE L45MM OD5MM TI LO PROF IMPL FOR BASEPLT VERSO,SUP-2404643,CDM,C1713,HCPCS,0278,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
COVER BUR H DIA10MM CRANIOMAXILLOFACIAL PLT LO PROF W/ TAB,SUP-2366205,CDM,C1713,HCPCS,0278,RC,,,,both,,,671.49,436.47,,,,,,,,,,,,,
UCL INTERNAL BRACE IMPLANT SYSTEM,SUP-2814081,CDM,C1713,HCPCS,0278,RC,,,,both,,,3702.06,2406.34,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL PEEK SD800.531,SUP-2860212,CDM,C1713,HCPCS,0278,RC,,,,both,,,37581.40,24427.91,,,,,,,,,,,,,
COIL NEUROVASCULAR L 10 CM DIA 5 MM PLATINUM/TUNGSTEN,SUP-2895582,CDM,C1889,HCPCS,0278,RC,,,,both,,,6892.30,4479.99,,,,,,,,,,,,,
EXTRACTOR SURG FEM PROS ADPT,SUP-2252759,CDM,C1713,HCPCS,0278,RC,,,,both,,,1007.94,655.16,,,,,,,,,,,,,
BLADE SAW W12.5MM D70MM CUT THK0.94MM BRASSELER HUB RECIP,SUP-2244432,CDM,2720000010,LOCAL,0272,RC,,,,both,,,272.55,177.16,,,,,,,,,,,,,
STAPLE BNE FIX BRDG W7MM LEG L5X5MM WIRE DIA1.5X1.5MM NIT,SUP-2194210,CDM,C1713,HCPCS,0278,RC,,,,both,,,1130.40,734.76,,,,,,,,,,,,,
STENT BILI AD L120MM DIA7MM CATH 6FR L80CM SHTH 0.035IN,SUP-2170734,CDM,C1876,HCPCS,0278,RC,,,,both,,,3026.80,1967.42,,,,,,,,,,,,,
HEAD HUM H24MM DIA46MM CO CHROM OFFSET PRI NECKLESS FOR TOT,SUP-2344306,CDM,C1776,CPT,0278,RC,,,,both,,,3147.85,2046.10,,,,,,,,,,,,,
TRAY CHST TB 14FR L41CM 4 SIDEPRT SGL LUMN INTRO J TIP,SUP-2168192,CDM,C1729,HCPCS,0272,RC,,,,both,,,721.26,468.82,,,,,,,,,,,,,
STEM RADIAL DIA 6.5 MM PEEK TI ALLOY ELBW CEM TOT ARTHPLSTY,SUP-2902231,CDM,C1776,CPT,0278,RC,,,,both,,,9225.32,5996.46,,,,,,,,,,,,,
PIN FIX REFLX,SUP-2362936,CDM,2720000010,LOCAL,0272,RC,,,,both,,,372.37,242.04,,,,,,,,,,,,,
CHEST TUBE KIT W/O LIDO PLEURAGUIDE DISP,SUP-2227301,CDM,C1729,HCPCS,0272,RC,,,,both,,,241.47,156.96,,,,,,,,,,,,,
KIT SUTURE ANCHR L 15 MM DIA 4.5 MM PEEK KNOTLESS TENSIONING,SUP-2899054,CDM,C1713,HCPCS,0278,RC,,,,both,,,1424.78,926.11,,,,,,,,,,,,,
SHEATH INTRO CLOSUREFAST L 7 CM DIA 6 FR SS POLYMER AD STRL,SUP-2393090,CDM,C1894,HCPCS,0272,RC,,,,both,,,56.05,36.43,,,,,,,,,,,,,
GRAFT SURG PROC HUM DERM CLLGN RECTANG 1MM 4CMX12CM ALLOMAX,SUP-2126255,CDM,C1781,HCPCS,0278,RC,,,,both,,,3364.20,2186.73,,,,,,,,,,,,,
GRAFT HUM TISS 1CC LIQ FLOWABLE AMNION,SUP-2120777,CDM,C1776,CPT,0278,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
BIOPROSTHESIS VASC PROCOL L 40 CM DIA 6 MM BOV MESENTERIC,SUP-2175239,CDM,C1768,CPT,0278,RC,,,,both,,,6123.00,3979.95,,,,,,,,,,,,,
HC So Macroscopic Exam Arthropod,PX-3008716866,CDM,87168,CPT,0300,RC,,,,both,,,75.00,48.75,,,,,,,,,,,,,
IMMOBILIZER SHLDR L L9X19.5IN R/L CANVS W/ WAIST STRP THMB,SUP-2336104,CDM,L3660,HCPCS,0272,RC,,,,both,,,20.88,13.57,,,,,,,,,,,,,
WASHER ORTH L L13MM DIA6.6MM BONE FIX RND,SUP-2198347,CDM,C1713,HCPCS,0278,RC,,,,both,,,45.84,29.80,,,,,,,,,,,,,
NAIL IM LNG 130 DEG 15X320 MM RT HIP AFFIXUS,SUP-2460703,CDM,C1713,HCPCS,0278,RC,,,,both,,,7771.50,5051.47,,,,,,,,,,,,,
BIT DRL L225MM DIA3.2MM NONSTERILE QUIK CPL NONRADIOPAQUE,SUP-2187166,CDM,2720000010,LOCAL,0272,RC,,,,both,,,455.83,296.29,,,,,,,,,,,,,
SHEATH INTRO AFX L 45 CM GUIDEWIRE 0.035 IN PTFE 55D PEBAX,SUP-2217717,CDM,C1894,HCPCS,0272,RC,,,,both,,,1328.22,863.34,,,,,,,,,,,,,
FIBER LASER 600 MH FOR USE W/ KTP/YAG,SUP-2225628,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1271.70,826.60,,,,,,,,,,,,,
DEVICE REVASCULARIZATION EMBOTRAP II L 21 MM DIA 5 MM NIT 2,SUP-2163306,CDM,C1889,HCPCS,0278,RC,,,,both,,,21352.00,13878.80,,,,,,,,,,,,,
CATHETER ANGIO MARINER L 100 CM 5 FR 0.035 IN HN2 BRAIDED,SUP-2116844,CDM,C1887,HCPCS,0272,RC,,,,both,,,124.66,81.03,,,,,,,,,,,,,
RESERVOIR 20MM 15 WITH SHUNT ASSISTANT HYDRO VORKAMMER PROGA,SUP-2821841,CDM,C1889,HCPCS,0278,RC,,,,both,,,7988.51,5192.53,,,,,,,,,,,,,
PLATE BNE L 29.08 X W 5.72 MM THK 1.6 MM 4 H GRD III TI MOD,SUP-2936985,CDM,C1713,HCPCS,0278,RC,,,,both,,,1249.72,812.32,,,,,,,,,,,,,
METAPHYSEAL FEMORAL CONE LARGE H52MM,SUP-2511512,CDM,C1776,CPT,0278,RC,,,,both,,,10143.77,6593.45,,,,,,,,,,,,,
TESTER VENTILATOR CIRC LUNG 1 LT VENTI +,SUP-2352860,CDM,C1713,HCPCS,0278,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
SPLINT WR PED M THK1/8IN LT WRP ARND DSGN D RNG STRP ROLYAN,SUP-2324210,CDM,L3809,HCPCS,0272,RC,,,,both,,,51.68,33.59,,,,,,,,,,,,,
SET PUNCTURE PROVOX VEGA 22.5FR X 8MM,SUP-2741941,CDM,L8501,HCPCS,0278,RC,,,,both,,,1260.68,819.44,,,,,,,,,,,,,
HC Clsd Tx Trimall Fx W Manip,PX-4502781800,CDM,27818,CPT,0450,RC,,,,inpatient,,,1633.00,1061.45,,,,,,,,,,,,,
SCREW INTFR L8MM DIA3MM BIOCOMPOSITE W/ HNDL INSRT,SUP-2121327,CDM,C1713,HCPCS,0278,RC,,,,both,,,1271.70,826.60,,,,,,,,,,,,,
ANCHOR SUTURE BRAID 2-0 MO-6 6.5 MM NDL TI WHT BLU V-LOX,SUP-2762303,CDM,C1713,HCPCS,0278,RC,,,,both,,,888.62,577.60,,,,,,,,,,,,,
PATCH CV HEMACAROTID L 120 X W 6 MM THK 0.41 MM POLYESTER,SUP-2227498,CDM,C1768,CPT,0278,RC,,,,both,,,454.01,295.11,,,,,,,,,,,,,
DEVICE ARTOTMY CLOSURE CATLYST III DIA 5.7 FR FEM ART MANUAL,SUP-2159549,CDM,C1760,HCPCS,0278,RC,,,,both,,,607.59,394.93,,,,,,,,,,,,,
DEVICE CLSR TRCR PRT,SUP-2171688,CDM,2720000010,LOCAL,0272,RC,,,,both,,,272.55,177.16,,,,,,,,,,,,,
CLIP ANEUR MIC STR 9MM TEMP - 9MM,SUP-2243952,CDM,C1889,HCPCS,0278,RC,,,,both,,,1164.94,757.21,,,,,,,,,,,,,
TIGECYCLINE 50 MG IV SOLR,RX-41652,CDM,J3244,HCPCS,0636,RC,00781-3481-92,NDC,,both,1,UN,345.00,224.25,,,,,,,,,,,,,
PLATE BNE L157MM 9 H ST L DST LAT FIBULAR S STL VAR ANG LOK,SUP-2177732,CDM,C1713,HCPCS,0278,RC,,,,both,,,3052.46,1984.10,,,,,,,,,,,,,
HANDPIECE LASER 300 MM MALL FIBERLASE ACUPULSE,SUP-2713714,CDM,2720000010,LOCAL,0272,RC,,,,both,,,882.34,573.52,,,,,,,,,,,,,
SCREW SPNL L30MM DIA6.25MM CANC ANTR PEDCL TI MNRCH,SUP-2254476,CDM,C1713,HCPCS,0278,RC,,,,both,,,1670.48,1085.81,,,,,,,,,,,,,
HC Endoscopy Nasal Diagnostic,PX-4503123100,CDM,31231,CPT,0450,RC,,,,both,,,779.00,506.35,,,,,,,,,,,,,
WASHER ORTHOPEDIC SMOOTH GRIDLOCK,SUP-2878257,CDM,C1713,HCPCS,0278,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
PPICC PROVENA 4F DL BASIC TL,SUP-2613557,CDM,C1751,HCPCS,0278,RC,,,,both,,,615.50,400.07,,,,,,,,,,,,,
PLATE BONE L W13.5XL250MM THK4.2MM 14 H BILAT TI STR RIG,SUP-2190827,CDM,C1713,HCPCS,0278,RC,,,,both,,,2010.76,1306.99,,,,,,,,,,,,,
PLATE BONE L54MM THK3.4MM 3 H BILAT NONLOCKING COMPR FOR,SUP-2348946,CDM,C1713,HCPCS,0278,RC,,,,both,,,1209.18,785.97,,,,,,,,,,,,,
BLADE IM L110MM DIA11MM ST G TI HNDL HELI FOR TROCHANTERIC,SUP-2191909,CDM,C1713,HCPCS,0278,RC,,,,both,,,1900.30,1235.19,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL PEEK SD800.522,SUP-2860203,CDM,C1713,HCPCS,0278,RC,,,,both,,,35383.40,22999.21,,,,,,,,,,,,,
COMPONENT GLEN PEGGED SHLDR ANTI ROT,SUP-2388566,CDM,C1776,CPT,0278,RC,,,,both,,,195.94,127.36,,,,,,,,,,,,,
COMPONENT FEM 7X3MM OFFSET UNICAP,SUP-2123702,CDM,C1776,CPT,0278,RC,,,,both,,,17427.00,11327.55,,,,,,,,,,,,,
GUIDEWIRE 1.0MMX14IN ACL INTRF SCR SYS NIT,SUP-2362048,CDM,C1769,HCPCS,0272,RC,,,,both,,,72.22,46.94,,,,,,,,,,,,,
DISC ARTIFICIAL SZ 5 H10.5MM UNIV INTERVERTEBRAL LUM UHMWPE,SUP-2255759,CDM,C1889,HCPCS,0278,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
KIT PAINBUSTER SIL SOAK 270ML X4ML HR 2 2ML HR PER SITE ON Q,SUP-2236847,CDM,C9804,HCPCS,0272,RC,,,,both,,,769.30,500.04,,,,,,,,,,,,,
CATHETER HEMO DYLS OR HD AD 8FR L15CM ADMIN BASIC KT DBL,SUP-2174128,CDM,C1750,HCPCS,0278,RC,,,,both,,,204.10,132.66,,,,,,,,,,,,,
ALLOGRAFT BNE PTTY 5 CC DBM ALLOSYNC,SUP-2431987,CDM,C1889,HCPCS,0278,RC,,,,both,,,2317.32,1506.26,,,,,,,,,,,,,
ANCHOR SUTURE DIA 3.9 MM PEEK DBL KNOTLESS SYS STRL OMEGA,SUP-2908722,CDM,C1713,HCPCS,0278,RC,,,,both,,,2631.32,1710.36,,,,,,,,,,,,,
CILOSTAZOL 100 MG PO TABS,RX-24474,CDM,6370000000,HCPCS,0637,RC,00093-2064-06,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
BUR SURG 6MM BALL,SUP-2361579,CDM,2720000010,LOCAL,0272,RC,,,,both,,,168.15,109.30,,,,,,,,,,,,,
PLATE BNE X ARTC 2.4 MM RT DSTL RADIAL VOLAR 5X5 HOLE VA NS,SUP-2549104,CDM,C1713,HCPCS,0278,RC,,,,both,,,2562.52,1665.64,,,,,,,,,,,,,
MESH GYN M W10XL15CM FLAT FLR POLYPR FOR TRANSABDOMINAL,SUP-2165307,CDM,C1781,HCPCS,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
SHEATH ACCESS SHORT 12FR 10FR 25CM PROXIS URETERAL,SUP-2655863,CDM,C1894,HCPCS,0272,RC,,,,both,,,466.29,303.09,,,,,,,,,,,,,
BETAMETHASONE SOD PHOS & ACET 6 (3-3) MG/ML IJ SUSP,RX-9266,CDM,J0702,HCPCS,0636,RC,00517-0720-01,NDC,,both,1,ML,63.30,41.14,,,,,,,,,,,,,
GRAFT VASC HEMSHLD PLAT L 50 CM DIA28 MM BRANCH SZ 12/10/8/8,SUP-2499699,CDM,C1768,CPT,0278,RC,,,,both,,,5563.36,3616.18,,,,,,,,,,,,,
LEAD PACE CAPSUR VDD2 L 52 CM DIA 9 FR SIL INSUL STEROID RT,SUP-2281960,CDM,C1779,HCPCS,0275,RC,,,,both,,,1130.40,734.76,,,,,,,,,,,,,
PROSTHESIS TESTICULAR L W2.9XL4.5CM NACL MENTR,SUP-2165398,CDM,C1713,HCPCS,0278,RC,,,,both,,,4553.00,2959.45,,,,,,,,,,,,,
INSTRUMENT SET HOFFMANN3 MILITARY EXTERNAL FIXATOR,SUP-2705836,CDM,C1713,HCPCS,0278,RC,,,,both,,,105142.90,68342.88,,,,,,,,,,,,,
HC Immunoassay Analyte Quantitative Nos,PX-3018352000,CDM,83520,CPT,0301,RC,,,,both,,,93.00,60.45,,,,,,,,,,,,,
STEM HUM SZ 0 L144MM DIA12MM STD SHLDR CO CHROM HA,SUP-2250984,CDM,C1776,CPT,0278,RC,,,,both,,,4553.00,2959.45,,,,,,,,,,,,,
SPINE CATH XL,SUP-2341605,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3683.22,2394.09,,,,,,,,,,,,,
PTFE LINER LNG TERM VENT TUBE,SUP-2680303,CDM,L8699,HCPCS,0278,RC,,,,both,,,83.71,54.41,,,,,,,,,,,,,
SPACER KNEE L 74X54X80X48X18MM HI REL INTERSPACE,SUP-2223696,CDM,C1776,CPT,0278,RC,,,,both,,,10205.00,6633.25,,,,,,,,,,,,,
CATHETER INFUS 27FR L31CM 0.375IN CONN 2 LUMN BI CAVAL 701063537] GETINGE USA MAQUET MED SYS],SUP-2227419,CDM,C1713,HCPCS,0278,RC,,,,both,,,7903.69,5137.40,,,,,,,,,,,,,
PLATE BNE L59MM 12 H NONSTERILE S STL ADPT LOK COMPR W/ SHT,SUP-2177474,CDM,C1713,HCPCS,0278,RC,,,,both,,,1229.84,799.40,,,,,,,,,,,,,
CATHETER GUID L100CM OD7FR JUDKINS L 4 W/ SIDE H W/OUT,SUP-2103712,CDM,C1887,HCPCS,0272,RC,,,,both,,,185.26,120.42,,,,,,,,,,,,,
BIT DRL SHT 4X90 MM S3 FAST GUIDE,SUP-2606606,CDM,2720000010,LOCAL,0272,RC,,,,both,,,796.15,517.50,,,,,,,,,,,,,
SUTURE NONABSORBABLE BRAID 1/2 CIR TAPR PT WHT BLU 39IN OM9054,SUP-2342109,CDM,C1769,HCPCS,0272,RC,,,,both,,,82.90,53.88,,,,,,,,,,,,,
RASP SURG PYRAMETRIX ADV,SUP-2292624,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1798.34,1168.92,,,,,,,,,,,,,
PLATE BNE CONTOURABLE MESH 100X0.6 MM RIGID TI SLV STRL,SUP-2859916,CDM,C1713,HCPCS,0278,RC,,,,both,,,5900.69,3835.45,,,,,,,,,,,,,
CATHETER URET FLX TIP 0.038 IN 7 FRX70 CM OPN END SET C FLX,SUP-2467894,CDM,C1758,HCPCS,0278,RC,,,,both,,,123.59,80.33,,,,,,,,,,,,,
CATHETER KIT PICC LN NEONATAL,SUP-2431429,CDM,C1751,HCPCS,0278,RC,,,,both,,,158.57,103.07,,,,,,,,,,,,,
CATHETER NEPHSTMY L30CM OD16FR ODSEC6FR 2 FLX STYL CONN TB,SUP-2139310,CDM,C1729,HCPCS,0272,RC,,,,both,,,208.03,135.22,,,,,,,,,,,,,
NYSTATIN 100000 UNIT/GM EX CREA,RX-5749,CDM,6370000000,HCPCS,0637,RC,45802-0059-35,NDC,,both,15,GR,63.00,40.95,,,,,,,,,,,,,
LINER ACET B 0 DEG 28 MM HIP X3 POLYETH TRIDENT,SUP-2364434,CDM,C1776,CPT,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
CATHETER DRAIN 14F 25CM STD LOOP W/ RADIOPAQUE MRKR BND PG,SUP-2659162,CDM,C1729,HCPCS,0272,RC,,,,both,,,224.20,145.73,,,,,,,,,,,,,
HC Drainage Ext Ear Abscess,PX-4506900000,CDM,69000,CPT,0450,RC,,,,both,,,730.00,474.50,,,,,,,,,,,,,
SULFASALAZINE 500 MG PO TABS,RX-7562,CDM,6370000000,HCPCS,0637,RC,59762-5000-05,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PLATE BNE L107MM 6 H NONSTERILE L LAT PROX TIB S STL LOK,SUP-2185608,CDM,C1713,HCPCS,0278,RC,,,,both,,,3836.08,2493.45,,,,,,,,,,,,,
IMMOBILIZER SHLDR W ABD SM,SUP-2276608,CDM,L3670,HCPCS,0274,RC,,,,both,,,75.74,49.23,,,,,,,,,,,,,
PLATE BONE 5 H MAND TI CRESC SHP LIMIT CNTCT DYN COMPR FOR,SUP-2191402,CDM,C1713,HCPCS,0278,RC,,,,both,,,2034.72,1322.57,,,,,,,,,,,,,
SCREW BNE L28MM DIA4MM DST FIBULAR NONLOCKING PARTIALLY THRD,SUP-2400216,CDM,C1713,HCPCS,0278,RC,,,,both,,,514.96,334.72,,,,,,,,,,,,,
CATHETER EP SM 2-7-2 MM 7 FRX95 CM ORBITER ST,SUP-2487169,CDM,C1730,HCPCS,0272,RC,,,,both,,,3086.62,2006.30,,,,,,,,,,,,,
BRACE WRST LACER W O ABDUCTED THMB X L UNIV R,SUP-2276647,CDM,L3931,HCPCS,0274,RC,,,,both,,,28.42,18.47,,,,,,,,,,,,,
STENT URETH KOYLE DIAP L 50 CM DIA 8 FR,SUP-2835761,CDM,C2617,HCPCS,0278,RC,,,,both,,,127.33,82.76,,,,,,,,,,,,,
VALVE MI OD31MM ID26.1MM 5.18SQCM 85DEG PYROLYTIC C,SUP-2355159,CDM,C1889,HCPCS,0278,RC,,,,both,,,13062.40,8490.56,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 50 CM DIA 5 MM STR STD WALL HELIX,SUP-2669692,CDM,C1768,CPT,0278,RC,,,,both,,,2034.31,1322.30,,,,,,,,,,,,,
PLATE BONE PRECONTOURED 2.8 MM RIGHT 7X23 HOLE RECONSTRUCTIO,SUP-2837768,CDM,C1713,HCPCS,0278,RC,,,,both,,,9587.68,6231.99,,,,,,,,,,,,,
CYLINDER PENILE PROS L16CM DIA12MM CONCEALABLE MAL SPECTR,SUP-2138901,CDM,C1813,HCPCS,0278,RC,,,,both,,,36101.21,23465.79,,,,,,,,,,,,,
HC Dialysis Other Than Hemo (Crt/Peritoneal),PX-8029094500,CDM,90945,CPT,0881,RC,,,,outpatient,,,1278.00,830.70,,,,,,,,,,,,,
LEADWIRE EKG HOLTER 24 IN SEER 1000 AHA 3 LD 3 CHANNEL,SUP-2713577,CDM,C1713,HCPCS,0278,RC,,,,both,,,921.78,599.16,,,,,,,,,,,,,
PLATE BNE L86MM 4 H ST R LAT DST FIBULAR S STL LOK COMPR,SUP-2177414,CDM,C1713,HCPCS,0278,RC,,,,both,,,1898.82,1234.23,,,,,,,,,,,,,
MESH HERN PTCH 14 MMX8 CM NYL SUPRAMESH,SUP-2335982,CDM,C1781,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
FIBER LASER BALL TIP 1000 MH FOR USE W/ KTP/YAG,SUP-2225627,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1325.08,861.30,,,,,,,,,,,,,
SILVER SULFADIAZINE 1 % EX CREA,RX-7224,CDM,2500000003,HCPCS,0250,RC,43598-0210-25,NDC,,both,25,GR,33.80,21.97,,,,,,,,,,,,,
PLATE BONE 3.5X230MM LCP X ARTC DSTL HUM 10 H RT TI,SUP-2419610,CDM,C1713,HCPCS,0278,RC,,,,both,,,4542.64,2952.72,,,,,,,,,,,,,
HC Pain Intermediate,PX-3600007515,CDM,3600007515,LOCAL,0360,RC,,,,both,,,2485.00,1615.25,,,,,,,,,,,,,
ROD SPNL ANTR SMOOTH TI ALLOY 5.5MM DIA 100MM LEN,SUP-2289284,CDM,C1713,HCPCS,0278,RC,,,,both,,,1353.34,879.67,,,,,,,,,,,,,
SNARE ENDO W25XL40MM SHTH DIA3MM NDL 25GA L5MM HEX DISP FOR,SUP-2360307,CDM,2720000010,LOCAL,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL PEEK SD800.552,SUP-2860233,CDM,C1713,HCPCS,0278,RC,,,,both,,,57759.04,37543.38,,,,,,,,,,,,,
CATHETER GUID CXI L 135 CM DIA 2.6 FR 0.018 IN SS STR TIP,SUP-2638642,CDM,C1887,HCPCS,0272,RC,,,,both,,,690.77,449.00,,,,,,,,,,,,,
METHOTREXATE SODIUM PF 25 MG/ML IJ SOLN (MIXTURES ONLY),RX-1150418,CDM,J9260,HCPCS,0636,RC,61703-0408-41,NDC,,both,0.5,ML,54.10,35.16,,,,,,,,,,,,,
HC Otoacoutstic Emission Testing,PX-4719258700,CDM,92587,CPT,0471,RC,,,,inpatient,,,179.00,116.35,,,,,,,,,,,,,
PROBE CRYOSURGERY L 1.1 MM W/ OVERSHEATH SLIM LIGHT STRL (MUST ORDER MULTIPLES OF 5 EACH),SUP-2890320,CDM,C2618,HCPCS,0272,RC,,,,both,,,1470.15,955.60,,,,,,,,,,,,,
SPECULUM VAG PETERSON,SUP-2155550,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1575.50,1024.07,,,,,,,,,,,,,
ALLOGRAFT BNE FRZN LT ANK TALUS,SUP-2740764,CDM,C1762,CPT,0278,RC,,,,both,,,9381.54,6098.00,,,,,,,,,,,,,
ALLODERM SELECT RESTORE LARGEPERFORATED - MEDIUM 1.6 0.4MM,SUP-2827484,CDM,Q4116,HCPCS,0636,RC,,,,both,,,45470.34,29555.72,,,,,,,,,,,,,
SCREW BNE SCHNZ 6X100 MM SD HA STRL,SUP-2563698,CDM,C1713,HCPCS,0278,RC,,,,both,,,472.10,306.86,,,,,,,,,,,,,
PROBE SUCT DIA3.5MM 90-S AGG W/ INTEGR CBL HND CTRL SERFAS,SUP-2366833,CDM,2720000010,LOCAL,0272,RC,,,,both,,,527.43,342.83,,,,,,,,,,,,,
TRACHEOSTOMY KIT PEDIATRIC 17 GA 5 MMX5.8 CM CRICOTHYROTOMY,SUP-2846610,CDM,2720000010,LOCAL,0272,RC,,,,both,,,551.45,358.44,,,,,,,,,,,,,
PLATE BONE THK2MM 0DEG 20 H MAND ORAL MAXILLOFACIAL TI,SUP-2191272,CDM,C1713,HCPCS,0278,RC,,,,both,,,3764.86,2447.16,,,,,,,,,,,,,
TRAY PICC MAXIMAL BARR 5FR 3 LUMN CATHETER W BIOPATCH PROTCT S1395108D5,SUP-2125700,CDM,C1751,HCPCS,0278,RC,,,,both,,,1138.60,740.09,,,,,,,,,,,,,
HC So Diphtheria Antibody,PX-3028664866,CDM,86648,CPT,0302,RC,,,,outpatient,,,202.00,131.30,,,,,,,,,,,,,
TREMELIMUMAB-ACTL 20 MG/ML (MIXTURES ONLY),RX-4082533,CDM,J9347,HCPCS,0636,RC,00310-4535-30,NDC,,both,3.75,ML,29798.80,19369.22,,,,,,,,,,,,,
TRAY CATH PICC LUMENX2 6FR DIA 60CML POLYURETHANE 0.69ML PRI,SUP-2613393,CDM,C1751,HCPCS,0278,RC,,,,both,,,252.14,163.89,,,,,,,,,,,,,
DRILL TWST 3.5MM DIA 120MML,SUP-2413873,CDM,C1713,HCPCS,0278,RC,,,,both,,,336.29,218.59,,,,,,,,,,,,,
KIT THROMCTMY INDIGO SYS LIGHTNING L 115 CM DIA,SUP-2550575,CDM,C1757,HCPCS,0272,RC,,,,both,,,21006.60,13654.29,,,,,,,,,,,,,
SYSTEM TOT KNEE NAVIGATION INST RENTAL,SUP-2361518,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1879.29,1221.54,,,,,,,,,,,,,
BASEPLATE TIB XL SZ 1 AP58MM ML82MM UNIV KNEE HA POR CEM,SUP-2377190,CDM,C1776,CPT,0278,RC,,,,both,,,3321.87,2159.22,,,,,,,,,,,,,
STEM FEM L127MM DIA14MM DST HIP TI ALLY PLSM SPRAYED HA STR,SUP-2375620,CDM,C1776,CPT,0278,RC,,,,both,,,7720.63,5018.41,,,,,,,,,,,,,
GUIDE WIRE AND DRL L230 DIAM 20 SGL TRCR OPT FOR 65 SCR,SUP-2392814,CDM,C1769,HCPCS,0272,RC,,,,both,,,80.07,52.05,,,,,,,,,,,,,
INBONE  POLY SZ 6 13MM SULCUS,SUP-2483515,CDM,C1776,CPT,0278,RC,,,,both,,,5221.82,3394.18,,,,,,,,,,,,,
NAIL IM L170MM DIA11MM 130DEG SHT FEM GRN TI CANN ANAT,SUP-2180536,CDM,C1713,HCPCS,0278,RC,,,,both,,,3997.22,2598.19,,,,,,,,,,,,,
CAGE SPNL 10 DEG 45X22X10 MM COHERE XLW,SUP-2736463,CDM,C1889,HCPCS,0278,RC,,,,both,,,15543.00,10102.95,,,,,,,,,,,,,
CAGE SPNL 8X18X40MM PEEK LLIF ZEUS,SUP-2115633,CDM,C1889,HCPCS,0278,RC,,,,both,,,13345.00,8674.25,,,,,,,,,,,,,
PLATE BNE W11XL125MM THK33MM 9 H BILAT MTPHSEAL TI LOK COMPR,SUP-2190763,CDM,C1713,HCPCS,0278,RC,,,,both,,,2766.06,1797.94,,,,,,,,,,,,,
CANNULA ENDOSCP LT 10X41 MM STRL MONTGOMERY DISP,SUP-2139783,CDM,2720000010,LOCAL,0272,RC,,,,both,,,357.96,232.67,,,,,,,,,,,,,
PLATE BNE CLAV 2.7 MM LT VA LCK COMPR TI NS VA-LCP,SUP-2758171,CDM,C1713,HCPCS,0278,RC,,,,both,,,4364.47,2836.91,,,,,,,,,,,,,
HC X-Ray Knee Rout Inc Tun Pat Min 4 View,PX-3207356400,CDM,73564,CPT,0320,RC,,,,inpatient,,,616.00,400.40,,,,,,,,,,,,,
CAGE SPNL L14XW14XH13MM 4 LOBE MESH L ANAT FOOTPRINT MOD,SUP-2317736,CDM,C1889,HCPCS,0278,RC,,,,both,,,6732.16,4375.90,,,,,,,,,,,,,
DRILL ENDOSCP 2.5 MM 4 5,SUP-2877962,CDM,2720000010,LOCAL,0272,RC,,,,both,,,844.66,549.03,,,,,,,,,,,,,
SHEATH INTRO PERFRMR L 30 CM OD 6 FR ID 2 MM GUIDEWIRE 0.038,SUP-2168358,CDM,C1894,HCPCS,0272,RC,,,,both,,,72.35,47.03,,,,,,,,,,,,,
ALIGNRITE WRIST BLK LNG RGHT XS,SUP-2458402,CDM,L3906,HCPCS,0272,RC,,,,both,,,55.95,36.37,,,,,,,,,,,,,
SCREW BONE L16MM DIA2.4MM CORT TI ST NONCANNULATED,SUP-2189552,CDM,C1713,HCPCS,0278,RC,,,,both,,,215.81,140.28,,,,,,,,,,,,,
THREADED BM RECOVERY SYSTEM 13G,SUP-2816416,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1059.75,688.84,,,,,,,,,,,,,
PROBE LITHO PNEUMATIC 0.89X940 MM FLX SWISS LITHOCLAST DISP,SUP-2457040,CDM,2720000010,LOCAL,0272,RC,,,,both,,,790.12,513.58,,,,,,,,,,,,,
PLATE BNE VOLAR NAR RT DSTL RADIAL 1 HOLE NS LTX,SUP-2857369,CDM,C1713,HCPCS,0278,RC,,,,both,,,4791.64,3114.57,,,,,,,,,,,,,
WAND ARTHSCP ABLAT SHFT 2.3MM 35DEG SHT BVL SM JT RF FOR,SUP-2341979,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1541.74,1002.13,,,,,,,,,,,,,
HC CT Colonography Screening,PX-3507426300,CDM,74263,CPT,0350,RC,,,,outpatient,,,2769.00,1799.85,,,,,,,,,,,,,
BRACE ORTHOPEDIC AFO ANK PREFABRICATED SPRL,SUP-2265016,CDM,L1951,HCPCS,0274,RC,,,,both,,,3240.48,2106.31,,,,,,,,,,,,,
COIL EMB 10 L6CM OD2MM HELCL STRTCH RESIST FNSH HYDRGEL,SUP-2305144,CDM,C1889,HCPCS,0278,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
ALLOGRAFT BNE CORTICAL 1-4 MM 1-9.5 MM 100 CC FRZN ASEP CANC,SUP-2717969,CDM,C1713,HCPCS,0278,RC,,,,both,,,5887.50,3826.87,,,,,,,,,,,,,
HEAD FEM 12/14 TAPR PRI MTL ON POLY S STL 22MM DIA -3.5 NK,SUP-2205782,CDM,C1776,CPT,0278,RC,,,,both,,,1877.72,1220.52,,,,,,,,,,,,,
CARTILAGE ALLOGRAFT MATRIX CAM,SUP-2726033,CDM,C1762,CPT,0278,RC,,,,both,,,1975.37,1283.99,,,,,,,,,,,,,
RING ALUMINUM 6 TAB 160MM,SUP-2853243,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
SYSTEM INTRO SHTH 6FR L13CM GRN HUB W O SIDEPRT SPLITTABLE,SUP-2303228,CDM,C1892,HCPCS,0272,RC,,,,both,,,102.21,66.44,,,,,,,,,,,,,
STENT CORONARY XIENCE SKYPOINT L 38 MM DIA 3.5 MM SYS L 145,SUP-2845184,CDM,C1874,HCPCS,0278,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
DRILL TWST L48MM OD1.2MM 4MM W/O STP N RADLUC,SUP-2365235,CDM,2720000010,LOCAL,0272,RC,,,,both,,,979.68,636.79,,,,,,,,,,,,,
WEDGE FEM SZ 3 THK20MM DSTL KNEE FOR HNG SYS LEGION,SUP-2346405,CDM,C1776,CPT,0278,RC,,,,both,,,4270.40,2775.76,,,,,,,,,,,,,
CALCIUM CITRATE-VITAMIN D 315-6.25 MG-MCG PO TABS,RX-160015,CDM,6370000000,HCPCS,0637,RC,77333-0113-10,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PLATE BNE FIBULAR LT LAT ANK 11 HOLE STRL,SUP-2518407,CDM,C1713,HCPCS,0278,RC,,,,both,,,6258.02,4067.71,,,,,,,,,,,,,
CLAMP EXT FIX SQ T-MAX,SUP-2849123,CDM,2720000010,LOCAL,0272,RC,,,,both,,,361.67,235.09,,,,,,,,,,,,,
HC Bx Breast Add Lesion US Img,PX-3611908400,CDM,19084,CPT,0361,RC,,,,inpatient,,,3707.00,2409.55,,,,,,,,,,,,,
GRAFT VASC W6MMXL80CM BYPS SM CUF DISTAFLO,SUP-2128084,CDM,C1768,CPT,0278,RC,,,,both,,,15631.74,10160.63,,,,,,,,,,,,,
KIT ROBOTIC ORTHOPAEDIC X-SCAN PLAN DISP MAZORX,SUP-2266518,CDM,C1713,HCPCS,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
CATHETER FIST WAVELINQ ENDOAVF L ART VEN 50/43 CM DIA 4 FR,SUP-2133516,CDM,C1887,HCPCS,0272,RC,,,,both,,,21980.00,14287.00,,,,,,,,,,,,,
BIT DRILL FOR 2.8MM SCREW DISP,SUP-2864790,CDM,2720000010,LOCAL,0272,RC,,,,both,,,763.02,495.96,,,,,,,,,,,,,
CEPHALEXIN 250 MG/5ML PO SUSR,RX-9502,CDM,340b,HCPCS,0637,RC,00093-4177-73,NDC,,both,5,ML,5.20,3.38,,,,,,,,,,,,,
PLATE BONE SHAFT 230MML HLX16 STRGHT NRRW F/PRPRSTHTC FRAC N,SUP-2469446,CDM,C1713,HCPCS,0278,RC,,,,both,,,1800.82,1170.53,,,,,,,,,,,,,
GRAFT SFT TISS 2CC SCAFFOLD FLOWABLE CLLGN FOR HRD TO ACC DP,SUP-2399102,CDM,Q4113,HCPCS,0636,RC,,,,both,,,4668.49,3034.52,,,,,,,,,,,,,
MICRO PLATE 4 X 4 HOLES RCTNGLR SGMNTS 6MM 15MM SSTM CP TT,SUP-2677442,CDM,C1713,HCPCS,0278,RC,,,,both,,,1209.59,786.23,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 50 CM DIA 7 MM EPTFE STR TW N RING,SUP-2396347,CDM,C1768,CPT,0278,RC,,,,both,,,2006.46,1304.20,,,,,,,,,,,,,
BIT DRL OD2MM LNG PILOT QUIK REL,SUP-2319579,CDM,2720000010,LOCAL,0272,RC,,,,both,,,339.12,220.43,,,,,,,,,,,,,
STAPLER INT L100MM THK38MM TI RELD TWO DBL STAGGERED ROW,SUP-2283275,CDM,2720000010,LOCAL,0272,RC,,,,both,,,615.82,400.28,,,,,,,,,,,,,
PLATE BONE LT DSTL FIB TI LCK,SUP-2419540,CDM,C1713,HCPCS,0278,RC,,,,both,,,2433.50,1581.77,,,,,,,,,,,,,
HEAD FEM MED 32 MM HIP,SUP-2364576,CDM,C1776,CPT,0278,RC,,,,both,,,2749.07,1786.90,,,,,,,,,,,,,
WIRE FIX L230MM OD2.3MM NICKEL CHROM SMOOTH SGL END TRCR,SUP-2321630,CDM,C1713,HCPCS,0278,RC,,,,both,,,263.76,171.44,,,,,,,,,,,,,
PLATE BNE 1.5/2X27X1.2 MM 4 HOLE SS LCP,SUP-2569284,CDM,C1713,HCPCS,0278,RC,,,,both,,,307.41,199.82,,,,,,,,,,,,,
PROGRAMMER PT FOR NEUROSTIM SYS,SUP-2284641,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2810.30,1826.69,,,,,,,,,,,,,
SCREW SPNL POLYAX 6X30 MM POST THORLUM SELF RET TI PRECEPT,SUP-2568255,CDM,C1713,HCPCS,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
BIT DRILL NAV LONG 4.0MM,SUP-2711624,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1806.63,1174.31,,,,,,,,,,,,,
BEARING TIB L63/67MM THK24MM KNEE SUP STBL POST STBL CNDYL 183874] ZIMMER BIOMET ORTHOPEDICS],SUP-2407728,CDM,C1776,CPT,0278,RC,,,,both,,,6510.79,4232.01,,,,,,,,,,,,,
CURETTE SURG W10MMXL17IN FOR CEMENTLESS HIP REV SYS MORELAND,SUP-2253224,CDM,C1713,HCPCS,0278,RC,,,,both,,,3611.00,2347.15,,,,,,,,,,,,,
KIT CATH W/ 4X20 TREVO XP RETRV AND CATLYST 6 CATH STROKE,SUP-2367910,CDM,C1757,HCPCS,0272,RC,,,,both,,,28295.80,18392.27,,,,,,,,,,,,,
BASEPLATE TIB 42X66 MM KNEE PRE COAT,SUP-2205578,CDM,C1776,CPT,0278,RC,,,,both,,,5881.19,3822.77,,,,,,,,,,,,,
PLATE BNE THK1MM LNG 6 H TI CRV LOK MINI FOR 27MM SCR,SUP-2262966,CDM,C1713,HCPCS,0278,RC,,,,both,,,1267.52,823.89,,,,,,,,,,,,,
POINTER NAVIGATION PRB FOR STEREOTACTIC SURG SYS AXIEM DISP,SUP-2284346,CDM,C1713,HCPCS,0278,RC,,,,both,,,1601.40,1040.91,,,,,,,,,,,,,
COLLAR CERV ADJ XL 20X3 IN COTTON MED DENS PREMIERPRO,SUP-2335997,CDM,L0120,HCPCS,0274,RC,,,,both,,,22.55,14.66,,,,,,,,,,,,,
COMPONENT FEM SZ 3 RT POST STBL CEM GMK,SUP-2267593,CDM,C1776,CPT,0278,RC,,,,both,,,8439.85,5485.90,,,,,,,,,,,,,
PLATE BNE RECTANGULAR MIC 1X0.6 MM CRANIOMAXILLOFACIAL 4X2,SUP-2472521,CDM,C1713,HCPCS,0278,RC,,,,both,,,838.95,545.32,,,,,,,,,,,,,
DEVICE PESSARY OD2 1/2IN GELLHORN FLEX IMP,SUP-2171735,CDM,A4562,HCPCS,0272,RC,,,,both,,,119.32,77.56,,,,,,,,,,,,,
BRACE ORTHOPEDIC LBR AFO ADJ,SUP-2265018,CDM,L4205,HCPCS,0272,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
IMPLANT TIGHTROPE II ABS,SUP-2749481,CDM,C1713,HCPCS,0278,RC,,,,both,,,894.90,581.68,,,,,,,,,,,,,
CATHETER URODYN 5FR L30CM 2 LUMN,SUP-2168936,CDM,C1726,HCPCS,0272,RC,,,,both,,,70.68,45.94,,,,,,,,,,,,,
WIRE ORTH SURG L280MM DIA1.25MM S STL CERCLAGE PRECUT,SUP-2186837,CDM,C1713,HCPCS,0278,RC,,,,both,,,229.41,149.12,,,,,,,,,,,,,
CATHETER HD SET 0.035 INX60 CM 12 FRX13 CM DL ACUTE YOU-BEND,SUP-2763037,CDM,C1752,HCPCS,0278,RC,,,,both,,,192.73,125.27,,,,,,,,,,,,,
CAPTIVATOR EMR LG SCOPE,SUP-2679161,CDM,2720000010,LOCAL,0272,RC,,,,both,,,963.79,626.46,,,,,,,,,,,,,
PLATE BONE STRAIGHT 1.5X26X6 MM 4 HOLE RAPID RESORBABLE STER,SUP-2838545,CDM,C1713,HCPCS,0278,RC,,,,both,,,705.56,458.61,,,,,,,,,,,,,
GRAFT BONE PUTTY 10CC GRFTON,SUP-2319848,CDM,C9359,HCPCS,0278,RC,,,,both,,,2935.90,1908.33,,,,,,,,,,,,,
"HC New Pt, E/M Level 2|UNUSUAL NON-OVERLAPPING SERVICE",PX-5109920200,CDM,99202,CPT,0510,RC,,,XU,both,,,296.00,192.40,,,,,,,,,,,,,
PLATE BNE RECON SM 2-2.3X2.8 MM LT PRESHAPED SMRT TI NS,SUP-2457935,CDM,C1713,HCPCS,0278,RC,,,,both,,,9513.67,6183.89,,,,,,,,,,,,,
GRAFT HUM TISS 500 MG PURAPLY MZ,SUP-2849177,CDM,C1763,HCPCS,0278,RC,,,,both,,,3642.40,2367.56,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC IR 6FR 55CM 3 LUMAN RVS TAPR PWR IN,SUP-2613398,CDM,C1751,HCPCS,0278,RC,,,,both,,,512.76,333.29,,,,,,,,,,,,,
SYSTEM BONE CEMENT SPINAL HIGHV+ TEKNIMED,SUP-2717562,CDM,C1713,HCPCS,0278,RC,,,,both,,,6123.00,3979.95,,,,,,,,,,,,,
HC Gbl Office/OP Consltj New/Est Pt Low Mdm 30 Minutes,PX-9829924301,CDM,99243,CPT,0982,RC,,,,inpatient,,,565.00,367.25,,,,,,,,,,,,,
WASHER ORTH DIA31X40MM HIP TROCH FOR MOD SYS S ROM,SUP-2257042,CDM,C1713,HCPCS,0278,RC,,,,both,,,953.30,619.64,,,,,,,,,,,,,
SHELL ACET SLD POR CONSERVE + TOT 6 MM OFFSET 36 MM 42 MM,SUP-2304473,CDM,C1776,CPT,0278,RC,,,,both,,,5809.00,3775.85,,,,,,,,,,,,,
INSERT TIB SZ 2 THK10MM R ANK FIX BEAR VANTAGE,SUP-2420827,CDM,C1776,CPT,0278,RC,,,,both,,,4402.91,2861.89,,,,,,,,,,,,,
SPACER HUM GLEN 36X+9 MM SHLDR AEQUALIS RVS,SUP-2431491,CDM,C1776,CPT,0278,RC,,,,both,,,4443.10,2888.01,,,,,,,,,,,,,
PLATE BONE LOK 124MML HLX7 YELLW ST RIGHT PSTRLTRL DST HMRL,SUP-2481713,CDM,C1713,HCPCS,0278,RC,,,,both,,,2835.77,1843.25,,,,,,,,,,,,,
SCREW GLEN FIX SHLDR LCK RVS CNTRL BASEPLT EQUINOXE,SUP-2908865,CDM,C1713,HCPCS,0278,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
BINDER ABD 12 IN HK,SUP-2691242,CDM,C1713,HCPCS,0278,RC,,,,both,,,35.67,23.19,,,,,,,,,,,,,
TROCAR ENDOSCP L100MM DIA12MM DIL TIP OBT RADLUC STBL SL,SUP-2218274,CDM,2720000010,LOCAL,0272,RC,,,,both,,,635.38,413.00,,,,,,,,,,,,,
SUPPORT ORTHOT KNEE RATCH LCK FOR ACTIVE,SUP-2435670,CDM,L2430,HCPCS,0274,RC,,,,both,,,405.85,263.80,,,,,,,,,,,,,
CATHETER BLLN OCCL 0.010 IN 2.2FRX150MM 5X30MM HYPERGLIDE,SUP-2172479,CDM,C2628,HCPCS,0272,RC,,,,both,,,4772.80,3102.32,,,,,,,,,,,,,
SET INTRO SHTH L 15 CM DIA 7 FR TEARWY VLV PEELABLE STRL,SUP-2627272,CDM,C1894,HCPCS,0272,RC,,,,both,,,12.56,8.16,,,,,,,,,,,,,
GUN BX 14 GAX115 MM AUTO,SUP-2327305,CDM,2720000010,LOCAL,0272,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
SCREW BNE CORTICAL LNG 4X70 MM TI TIBIAXYS,SUP-2243008,CDM,C1713,HCPCS,0278,RC,,,,both,,,900.99,585.64,,,,,,,,,,,,,
STENT BILI L80MM DIA6MM CATH L80CM LIFESTNT,SUP-2420395,CDM,C1876,HCPCS,0278,RC,,,,both,,,10346.30,6725.09,,,,,,,,,,,,,
RAIL EXT FIX 2.75IN MINI RX-FIX,SUP-2396840,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8107.48,5269.86,,,,,,,,,,,,,
SUPPORT KNEE GEL FORC L PRO-TEC,SUP-2324031,CDM,L1810,HCPCS,0274,RC,,,,both,,,75.71,49.21,,,,,,,,,,,,,
PLATE BNE W11XL226MM THK4.2MM 14 H MTPHSEAL S STL LOK COMPR,SUP-2185267,CDM,C1713,HCPCS,0278,RC,,,,both,,,3460.15,2249.10,,,,,,,,,,,,,
"HC Est Pt, E/M Level 5|RESIDENT/TEACHING PHYS SERV",PX-5109921500,CDM,99215,CPT,0510,RC,,,GC,outpatient,,,369.00,239.85,,,,,,,,,,,,,
PLATE BNE L 55 MM 4 H LT VOLAR DSTL RADIAL WIDE NS VARIAX,SUP-2902150,CDM,C1713,HCPCS,0278,RC,,,,both,,,4332.01,2815.81,,,,,,,,,,,,,
CATHETER ABLATN LG CRV 2-5-2 MM 4 MM TIP 7 FRX110 CM THER,SUP-2102283,CDM,C1733,HCPCS,0272,RC,,,,both,,,1890.28,1228.68,,,,,,,,,,,,,
SCREW BNE L50MM DIA6MM CORT ST NONCANNULATED NONLOCKING,SUP-2377556,CDM,C1713,HCPCS,0278,RC,,,,both,,,869.78,565.36,,,,,,,,,,,,,
CANNULA ARTHSCP HIP SHLDR MOD HNDL OBTURATOR HYDRODAM REUSE,SUP-2745447,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2055.76,1336.24,,,,,,,,,,,,,
PLATE BNE L48MM 3X8 H TI Y SHP FOR 2MM SCR,SUP-2191309,CDM,C1713,HCPCS,0278,RC,,,,both,,,1592.45,1035.09,,,,,,,,,,,,,
SURGICAL LEAD KIT 70 CM 32 ELECTRD COVE EDGE 32,SUP-2141959,CDM,C1778,HCPCS,0278,RC,,,,both,,,20410.00,13266.50,,,,,,,,,,,,,
BLADE SCREWDRIVER 2MM/2.3MM DIA STAINLESS STEEL MAXDRIVE,SUP-2494082,CDM,2720000010,LOCAL,0272,RC,,,,both,,,644.33,418.81,,,,,,,,,,,,,
COIL NEUROVASCULAR TARGET L 2.5 CM DIA2 MM PLATINUM/TUNGSTEN,SUP-2866251,CDM,C1889,HCPCS,0278,RC,,,,both,,,7225.14,4696.34,,,,,,,,,,,,,
SHUNT SURG INF 11.5FR L30CM REG DBL VLV 2 SWCH PMP CHMBR,SUP-2133689,CDM,C1889,HCPCS,0278,RC,,,,both,,,6513.21,4233.59,,,,,,,,,,,,,
SHEATH INTRO FLX ANSEL L 55 CM OD 7 FR ID 2.54 MM DIL 56.5,SUP-2169824,CDM,C1894,HCPCS,0272,RC,,,,both,,,181.81,118.18,,,,,,,,,,,,,
BLADE SHAVER 4.2 MMX10.5 CM IRRIG STRL LYNX,SUP-2607700,CDM,2720000010,LOCAL,0272,RC,,,,both,,,323.92,210.55,,,,,,,,,,,,,
BIT DRL DIA2MM CANN FOR QUICKFIX SCR AND COMPHSVE FT SYS,SUP-2122860,CDM,2720000010,LOCAL,0272,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
ALLOGRAFT BNE CRUSH 2-10 MM 60 CC FD IRRADIATED CANC,SUP-2867140,CDM,C1762,CPT,0278,RC,,,,both,,,2640.74,1716.48,,,,,,,,,,,,,
EVOS 3.5 MM 1/3 TUBULAR PL 7H 82MM,SUP-2820015,CDM,C1713,HCPCS,0278,RC,,,,both,,,533.02,346.46,,,,,,,,,,,,,
VALVE HYDROCEPHALUS WITH PEDIATRIC PRECHAMBER PROGRAM 2.0,SUP-2826122,CDM,C1889,HCPCS,0278,RC,,,,both,,,7764.75,5047.09,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA PLU MAXBARR 3FR S1193108D1,SUP-2632792,CDM,C1751,HCPCS,0278,RC,,,,both,,,831.03,540.17,,,,,,,,,,,,,
COMPONENT FEM KNEE POST STABILIZING LT UNISX REV CEM STEM,SUP-2199876,CDM,C1776,CPT,0278,RC,,,,both,,,30731.81,19975.68,,,,,,,,,,,,,
CATHETER ETER NEPHSTMY 8FR L25CM COMB STNT PERCFLX,SUP-2141727,CDM,C1729,HCPCS,0272,RC,,,,both,,,280.75,182.49,,,,,,,,,,,,,
MESH SURG W6XL8IN ELLIPSE SEPRA TECHNOLOGY VENTRALIGHT,SUP-2125908,CDM,C1781,HCPCS,0278,RC,,,,both,,,2047.28,1330.73,,,,,,,,,,,,,
PLATE BONE 12 H TI STR LCK COMPR BILAT NEUT LO PROF FOR,SUP-2319665,CDM,C1713,HCPCS,0278,RC,,,,both,,,1340.78,871.51,,,,,,,,,,,,,
POST EXT FIX TALL WIRE PREASSEMBLED FOR SALVATION EXT FIX,SUP-2401119,CDM,2720000010,LOCAL,0272,RC,,,,both,,,957.70,622.50,,,,,,,,,,,,,
SPLINT FNGR 9CM L 3.5IN 4 PRNG PROTCT ALUMINIUM NONPADDED,SUP-2197320,CDM,L3933,HCPCS,0272,RC,,,,both,,,126.35,82.13,,,,,,,,,,,,,
GRAFT BNE CHIP 1-4 MM 60 CC CANC PUREBONE,SUP-2424602,CDM,C1713,HCPCS,0278,RC,,,,both,,,1681.66,1093.08,,,,,,,,,,,,,
INSERTER SURG STR IN 28 CM SHFT,SUP-2140253,CDM,C2631,HCPCS,0278,RC,,,,both,,,364.24,236.76,,,,,,,,,,,,,
CROWN DENT PRI M S STL,SUP-2238885,CDM,D6783,CPT,0278,RC,,,,both,,,1700.28,1105.18,,,,,,,,,,,,,
PROSTHESIS KNEE M W65MM LT FEM TIB ENDODUR POREX MOD,SUP-2265093,CDM,C1776,CPT,0278,RC,,,,both,,,81734.20,53127.23,,,,,,,,,,,,,
EXTENSION DRL BIT LNG DIA6MM CARB REUSE,SUP-2179280,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1111.43,722.43,,,,,,,,,,,,,
CANNULA KYPHOPLASTY ACC 13GA BONE FOR IVAS,SUP-2361357,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1591.41,1034.42,,,,,,,,,,,,,
BASEPLATE TIB SM SZ 1 AP42MM ML67MM UNIV KNEE HA POR CEM,SUP-2377184,CDM,C1776,CPT,0278,RC,,,,both,,,3673.80,2387.97,,,,,,,,,,,,,
GUIDEWIRE VASC L 60 CM DIA 0.032 IN TIP CRV RAD 0.3 MM FIX,SUP-2759849,CDM,C1769,HCPCS,0272,RC,,,,both,,,85.28,55.43,,,,,,,,,,,,,
HC Duplex Av Dialysis Shunt,PX-9219399000,CDM,93990,CPT,0921,RC,,,,inpatient,,,1222.00,794.30,,,,,,,,,,,,,
KIT INTRO ARROWG+ARD BLU SHTH L 10 CM DIA 9 FR GUIDEWIRE L,SUP-2763327,CDM,C1892,HCPCS,0272,RC,,,,both,,,162.02,105.31,,,,,,,,,,,,,
GRAFT BONE THICKNESS 10MM PAT TEND PRESHAPED,SUP-2335260,CDM,C1713,HCPCS,0278,RC,,,,both,,,11304.00,7347.60,,,,,,,,,,,,,
PLATE BNE L56MM 4 H R RAD HD RIM S STL RIG LOK COMPR FOR,SUP-2186000,CDM,C1713,HCPCS,0278,RC,,,,both,,,1833.67,1191.89,,,,,,,,,,,,,
SHELL ACET OD56MM ID23MM UNIV TI PPS HIP MH LCK RNG PRI IMP,SUP-2403458,CDM,C1776,CPT,0278,RC,,,,both,,,12255.42,7966.02,,,,,,,,,,,,,
FOOT PLATE EXT FIX DIA200 MM SHRT NS DISP MONK RING,SUP-2881090,CDM,C1769,HCPCS,0272,RC,,,,both,,,4999.67,3249.79,,,,,,,,,,,,,
SCREW BONE L30MM OD2MM ST LAG CROSS PIN SLD LO PROF 5PK,SUP-2363611,CDM,C1713,HCPCS,0278,RC,,,,both,,,198.98,129.34,,,,,,,,,,,,,
LENS IOL HYDROPHOBIC ACRYL POST CHMBR EXT VISION CLR,SUP-2880950,CDM,V2788,HCPCS,0276,RC,,,,both,,,915.00,594.75,,,,,,,,,,,,,
DEVICE PESSARY NO5 DIA1.75IN SIL CUBE VAULT TRIMO SAN JEL,SUP-2171732,CDM,A4562,HCPCS,0274,RC,,,,both,,,112.79,73.31,,,,,,,,,,,,,
GUAIFENESIN 200 MG PO TABS,RX-10144,CDM,6370000000,HCPCS,0637,RC,00904-5154-60,NDC,,both,1,UN,0.30,0.19,,,,,,,,,,,,,
PIN EXT FIX L300MM DIA4MM TRANSFIXING FOR SIDEKCK STLTH,SUP-2400691,CDM,2720000010,LOCAL,0272,RC,,,,both,,,558.92,363.30,,,,,,,,,,,,,
HC External Ecg Rec>7d<15d Scanning Alys W/Report,PX-7309324700,CDM,93247,CPT,0731,RC,,,,inpatient,,,387.00,251.55,,,,,,,,,,,,,
STEM TIB SMOOTH MID 12 MM TOT ANK COAT INBONE II,SUP-2472121,CDM,C1776,CPT,0278,RC,,,,both,,,1428.70,928.65,,,,,,,,,,,,,
KNIFE SRGCL YASRGL MICRO 7 14NL 2 14NL WRKNG 3MMW TIP ARCH,SUP-2669630,CDM,2720000010,LOCAL,0272,RC,,,,both,,,304.33,197.81,,,,,,,,,,,,,
PIN FIX DIA12MM TEMP COMPR FOR CERV PLT,SUP-2255611,CDM,C1713,HCPCS,0278,RC,,,,both,,,219.80,142.87,,,,,,,,,,,,,
GUIDEWIRE VASC AQUALINER 150CM 0.035IN TIP 3CM ANGLED STIFF,SUP-2118698,CDM,C1769,HCPCS,0272,RC,,,,both,,,263.76,171.44,,,,,,,,,,,,,
PLATE ORTHO C TUBE X SH15MM BRG T15MM CP TITANIUM,SUP-2681868,CDM,C1713,HCPCS,0278,RC,,,,both,,,1808.11,1175.27,,,,,,,,,,,,,
SCREW BNE LCK 2.7X7 MM MAXDRIVE LEVEL 1 258870791,SUP-2464242,CDM,C1713,HCPCS,0278,RC,,,,both,,,453.73,294.92,,,,,,,,,,,,,
HC Removal Iud,PX-4505830100,CDM,58301,CPT,0450,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
DEVICE PESSARY DSH 2 60 MM W/ SUPP,SUP-2273824,CDM,A4562,HCPCS,0274,RC,,,,both,,,94.45,61.39,,,,,,,,,,,,,
GRAFT HUM TISS 2X3CM THN AMNION,SUP-2120772,CDM,C1762,CPT,0278,RC,,,,both,,,2708.25,1760.36,,,,,,,,,,,,,
INSERT TIB SULCUS 2+ LG 16 MM TOT ANK POLYETH INBONE II,SUP-2519592,CDM,C1776,CPT,0278,RC,,,,both,,,5743.06,3732.99,,,,,,,,,,,,,
PROBE PEDCL L165MM CANN W/ MOD JAMSH NDL NO2 MOD MOD,SUP-2354607,CDM,2720000010,LOCAL,0272,RC,,,,both,,,499.26,324.52,,,,,,,,,,,,,
"HC Coombs,Direct",PX-3028688000,CDM,86880,CPT,0302,RC,,,,both,,,328.00,213.20,,,,,,,,,,,,,
PLATE BNE L142MM 6 H ST R MED DST TIB S STL LOK COMPR FOR,SUP-2185583,CDM,C1713,HCPCS,0278,RC,,,,both,,,4991.00,3244.15,,,,,,,,,,,,,
HC Assay of Iron|NOT REASONABLE AND NECESSARY,PX-3018354000,CDM,83540,CPT,0301,RC,,,GZ,both,,,105.00,68.25,,,,,,,,,,,,,
SYSTEM THR PART CO CHROM R3,SUP-2348016,CDM,C1776,CPT,0278,RC,,,,both,,,11932.00,7755.80,,,,,,,,,,,,,
"HC So Alpha-1,Antitrypsin,Phenotype",PX-3018210466,CDM,82104,CPT,0301,RC,,,,both,,,156.00,101.40,,,,,,,,,,,,,
PLATE BNE L215MM 12 H NONSTERILE R OLECRANON S STL LOK,SUP-2185432,CDM,C1713,HCPCS,0278,RC,,,,both,,,3340.27,2171.18,,,,,,,,,,,,,
IMPLANT BRST SIL SHELL COHESIVE SMOOTH RND MOD PROF 600CC,SUP-2300429,CDM,C1789,HCPCS,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
PLATE CRAN 120X20X40 MM PT SPEC IMPL PEEK,SUP-2860117,CDM,C1713,HCPCS,0278,RC,,,,both,,,23461.45,15249.94,,,,,,,,,,,,,
"HC Chlamydia Amp Probe Tech, 1",PX-3068749100,CDM,87491,CPT,0306,RC,,,,both,,,208.00,135.20,,,,,,,,,,,,,
BURR SURG 5.5MM DIA HD XLN MIC 10MML CARBIDE SM BNE OVL FLUT,SUP-2605580,CDM,2720000010,LOCAL,0272,RC,,,,both,,,71.25,46.31,,,,,,,,,,,,,
KIT IMPL DST BICEPS BTTN INSRT W/ NO2 FIBERLOOP SUT,SUP-2121662,CDM,C1713,HCPCS,0278,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
ACETAMINOPHEN 160 MG/5ML PO SUSP,RX-8943,CDM,340b,HCPCS,0637,RC,68094-0231-61,NDC,,both,10.15,ML,15.80,10.27,,,,,,,,,,,,,
GUIDE SURG PLN NYL LP DISTRCTN CUSTOMIZABLE BILATERAL VSP,SUP-2883943,CDM,2720000010,LOCAL,0272,RC,,,,both,,,19986.10,12990.96,,,,,,,,,,,,,
STEM FEM L160MM DIA13.5MM 12/14 TAPR HIP 5/8 POR TRIANG STD,SUP-2252067,CDM,C1776,CPT,0278,RC,,,,both,,,11008.84,7155.75,,,,,,,,,,,,,
LINER ACET 24 10 DEG 36 MM FEM HIP POLYETH RINGLOK,SUP-2136080,CDM,C1776,CPT,0278,RC,,,,both,,,4615.80,3000.27,,,,,,,,,,,,,
GUIDEPIN ORTH DIA3MM FOR OPN WDG OSTEOTMY,SUP-2121036,CDM,C1769,HCPCS,0272,RC,,,,both,,,100.48,65.31,,,,,,,,,,,,,
KIT SURG BNE CEMENT 120 GM SYR MIXING DEL SYS DISP PICOMIX,SUP-2898586,CDM,2720000010,LOCAL,0272,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
PLATE BNE W4XL44MM THK1MM 3X8 H BILAT S STL T SHP LO PROF,SUP-2186290,CDM,C1713,HCPCS,0278,RC,,,,both,,,1166.20,758.03,,,,,,,,,,,,,
INSERT TIB M L SZ 2/2 DIA13MM MOD ROT HNG MONOGRAM,SUP-2376384,CDM,C1776,CPT,0278,RC,,,,both,,,2768.07,1799.25,,,,,,,,,,,,,
HEAD FEM BPLR 22X38 MM HIP RINGLOK,SUP-2449889,CDM,C1776,CPT,0278,RC,,,,both,,,4069.44,2645.14,,,,,,,,,,,,,
HC So Chromosome Anal 15-20,PX-3118826266,CDM,88262,CPT,0311,RC,,,,both,,,463.00,300.95,,,,,,,,,,,,,
GRAFT VASC GELSFT L 15 CM DIA14 MM POLYESTER GEL ABD PERIPH,SUP-2384932,CDM,C1768,CPT,0278,RC,,,,both,,,774.39,503.35,,,,,,,,,,,,,
PUMP INFUS 100ML 2ML/HR PAINPMP,SUP-2361459,CDM,C2626,HCPCS,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
GUIDEWIRE ENDO L145CM 0.035IN FIX COR STR TIP,SUP-2128989,CDM,C1769,HCPCS,0272,RC,,,,both,,,34.54,22.45,,,,,,,,,,,,,
BIT DRILL SURG DIA 5.5/4.75 MM STRL REUSE ALPHAVENT OMEGA,SUP-2906519,CDM,2720000010,LOCAL,0272,RC,,,,both,,,973.40,632.71,,,,,,,,,,,,,
GLIPIZIDE 10 MG PO TABS,RX-10116,CDM,6370000000,HCPCS,0637,RC,60505-0142-00,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PLATE STR 2MM 12H TI STRL VAL,SUP-2546908,CDM,C1713,HCPCS,0278,RC,,,,both,,,1972.74,1282.28,,,,,,,,,,,,,
COLLAR CERV PADDED SM SHT 2X10X20 IN COMFORT ADJ MIAMI J,SUP-2434341,CDM,L0174,HCPCS,0272,RC,,,,both,,,150.66,97.93,,,,,,,,,,,,,
ANCHOR SUTURE L14MM DIAMETER 5MM TITANIUM SELF PUNCHING SELF,SUP-2824260,CDM,C1713,HCPCS,0278,RC,,,,both,,,826.35,537.13,,,,,,,,,,,,,
COVER BUR H L10MM DIA0.6MM DOMED W/ TAB,SUP-2365227,CDM,C1713,HCPCS,0278,RC,,,,both,,,1224.91,796.19,,,,,,,,,,,,,
GRAFT HUM TISS DIA16MM AMNIO TISS MEM DISK SHT AMNIOFIX,SUP-2305722,CDM,V2790,HCPCS,0274,RC,,,,both,,,1193.20,775.58,,,,,,,,,,,,,
CATHETER ETER CTRL VEN L90CM OD96FR ODSEC32MM ID16MM 1 LUMN,SUP-2126549,CDM,C1751,HCPCS,0278,RC,,,,both,,,433.32,281.66,,,,,,,,,,,,,
SET PROC W/ 250ML BOWL 30UM FLTR RESVR BRAT 2,SUP-2352646,CDM,2720000010,LOCAL,0272,RC,,,,both,,,301.44,195.94,,,,,,,,,,,,,
SUPPORT KNEE THGH CIRC 12 15IN XSM SLIP ON NEOPRENE OPN PAT,SUP-2150846,CDM,L1810,HCPCS,0272,RC,,,,both,,,69.71,45.31,,,,,,,,,,,,,
GUIDEWIRE UROLOGY L150CM OD.035IN 3CM TIP NIT HYDRPHLC TAPR,SUP-2385304,CDM,C1769,HCPCS,0272,RC,,,,both,,,172.51,112.13,,,,,,,,,,,,,
PLATE BNE FUSION STD NAR LT ANTR ANK ALIGNX,SUP-2610037,CDM,C1713,HCPCS,0278,RC,,,,both,,,9118.56,5927.06,,,,,,,,,,,,,
GRAFT HUM TISS W12XL20CM THK07 14MM THN ACELLULAR HYDRATED,SUP-2307556,CDM,Q4128,HCPCS,0636,RC,,,,both,,,23967.62,15578.95,,,,,,,,,,,,,
SCREW SPNL MULTAXL 4.5X20 MM CANN FOR 4.5 MM ROD SHILLA,SUP-2630589,CDM,C1713,HCPCS,0278,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
SUPPORT ORTHOT HIP KNEE ANK CUST UNILAT TORSON BALL BEAR,SUP-2435645,CDM,L2090,HCPCS,0274,RC,,,,both,,,1407.69,915.00,,,,,,,,,,,,,
SCREW BONE L4MM DIA1.5MM SLV CORT TI SELF DRL NONCANNULATED,SUP-2181628,CDM,C1713,HCPCS,0278,RC,,,,both,,,330.14,214.59,,,,,,,,,,,,,
CATHETER GUID BOBBY L 95 CM OD 8.4 FR ID 2.18 MM BALLOON L,SUP-2915969,CDM,C1887,HCPCS,0272,RC,,,,both,,,6782.40,4408.56,,,,,,,,,,,,,
DISTAL TIB CLOSING WEDG OSTEOTOME PLT,SUP-2811863,CDM,C1713,HCPCS,0278,RC,,,,both,,,1632.80,1061.32,,,,,,,,,,,,,
SCREW BONE SELFTAPPING 2.4X16 MM MANDIBULAR 20/PK TITANIUM N,SUP-2842293,CDM,C1713,HCPCS,0278,RC,,,,both,,,322.35,209.53,,,,,,,,,,,,,
GRAFT HUM TISS PTCH 6X1 CM ROUNDED BOV PERICARD PHOTOFIX LTX,SUP-2859715,CDM,C1768,CPT,0278,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
BOLT EXT FIX SPEEDWIRE,SUP-2898509,CDM,2720000010,LOCAL,0272,RC,,,,both,,,433.32,281.66,,,,,,,,,,,,,
PLATE BONE 4X20X4 H BILAT TI DBL ANG RIG NONCOMPRESSION,SUP-2191422,CDM,C1713,HCPCS,0278,RC,,,,both,,,11256.90,7316.98,,,,,,,,,,,,,
BLADE RETRACTOR LNG TEETH 45X15X MM SPNL SELF RET BLK,SUP-2457502,CDM,2720000010,LOCAL,0272,RC,,,,both,,,773.95,503.07,,,,,,,,,,,,,
MYCOPHENOLATE MOFETIL 200 MG/ML PO SUSR,RX-25005,CDM,J7528,HCPCS,0636,RC,00004-0261-29,NDC,,both,1.25,ML,48.60,31.59,,,,,,,,,,,,,
WEDGE TIB SZ 3-4 15MM L MED R LAT KNEE HEMI STP LEGION,SUP-2346584,CDM,C1776,CPT,0278,RC,,,,both,,,3399.05,2209.38,,,,,,,,,,,,,
INTRODUCER SHTH 22FR L25CM 0.035IN HEMSTAS VLV SIDEPRT 2,SUP-2355622,CDM,C1894,HCPCS,0272,RC,,,,both,,,88.71,57.66,,,,,,,,,,,,,
IMPLANT OP RM MINI-MONSTER 3.5 X 36MM HD CANN SHT THRD SCR,SUP-2320510,CDM,C1713,HCPCS,0278,RC,,,,both,,,753.60,489.84,,,,,,,,,,,,,
GRAFT VASC HEMGRD L 70 CM DIA 6 MM RNG L 20 CM THK 0.49 MM,SUP-2484216,CDM,C1768,CPT,0278,RC,,,,both,,,2882.68,1873.74,,,,,,,,,,,,,
INBONE  POLY SZ 5 20MM SULCUS TOTAL ANKLE,SUP-2492608,CDM,C1776,CPT,0278,RC,,,,both,,,5743.06,3732.99,,,,,,,,,,,,,
VINORELBINE TARTRATE 10 MG/ML IV SOLN,RX-14203,CDM,J9390,HCPCS,0636,RC,25021-0204-01,NDC,,both,1,ML,72.00,46.80,,,,,,,,,,,,,
POROUS TOT CNDYL FEM COMP MED R,SUP-2397049,CDM,C1776,CPT,0278,RC,,,,both,,,16390.80,10654.02,,,,,,,,,,,,,
TAP SURG L 65 MM DIA1.7 MM SD HEX FOR 3 MM SCREW DELT,SUP-2883333,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1690.67,1098.94,,,,,,,,,,,,,
SCREW BNE M3.5X0.6 MM 2X12 MM LCK MIC-THRD TI CONTOURS VPS-3,SUP-2646763,CDM,C1713,HCPCS,0278,RC,,,,both,,,272.93,177.40,,,,,,,,,,,,,
SYSTEM NAVIGATION 180DEG FIRM EXT WRK CHAN EDGE,SUP-2381740,CDM,C1713,HCPCS,0278,RC,,,,both,,,1397.30,908.24,,,,,,,,,,,,,
CONNECTOR CATH 3 WAY PUDENZ,SUP-2847006,CDM,C1889,HCPCS,0278,RC,,,,both,,,379.09,246.41,,,,,,,,,,,,,
INSERT TIB THK8MM BEAR ONLAY X3,SUP-2368702,CDM,C1776,CPT,0278,RC,,,,both,,,2620.33,1703.21,,,,,,,,,,,,,
KYPHOPLASTY TRAY 20/2 OSTEO INTRO BNDL KYPHOPAK EXPRESS II,SUP-2665109,CDM,C1713,HCPCS,0278,RC,,,,both,,,8415.20,5469.88,,,,,,,,,,,,,
LCK FRAC PL6 H43MM NON COM T 25MM CP,SUP-2694249,CDM,C1713,HCPCS,0278,RC,,,,both,,,1533.89,997.03,,,,,,,,,,,,,
SOCKET PROS TST,SUP-2388206,CDM,L5620,HCPCS,0272,RC,,,,both,,,730.74,474.98,,,,,,,,,,,,,
CATHETER ART 0.025 IN 7 FRX110 CM STD 4 LUMEN HEPCOAT LTX,SUP-2662679,CDM,C1751,HCPCS,0278,RC,,,,both,,,261.25,169.81,,,,,,,,,,,,,
GUIDEWIRE ORTH L9MM DIA1MM 15DEG D9MM BNE CHN NIT DISP FOR,SUP-2123633,CDM,C1769,HCPCS,0272,RC,,,,both,,,979.68,636.79,,,,,,,,,,,,,
COMPONENT ARTC SURF TIB 5-6 CD 12 MM KNEE STRP GRN NXGN LPS,SUP-2201961,CDM,C1776,CPT,0278,RC,,,,both,,,2411.52,1567.49,,,,,,,,,,,,,
BLADE SAW W165MM D20MM CUT THK6MM FOR L BNE GRFT HARV HALL,SUP-2166096,CDM,C1713,HCPCS,0278,RC,,,,both,,,359.22,233.49,,,,,,,,,,,,,
WASHER ORTH DIA14MM 1.3MM TI RND LO PROF,SUP-2166861,CDM,C1713,HCPCS,0278,RC,,,,both,,,226.96,147.52,,,,,,,,,,,,,
GRAFT HUM TISS 3X7CM ACELLULAR HYDRATED DERMA MTRX,SUP-2306893,CDM,C1762,CPT,0278,RC,,,,both,,,1603.25,1042.11,,,,,,,,,,,,,
SHEARS ENDOSCP L36CM DIA5MM ULTRASONIC CRV TIP ADAPTIVE,SUP-2219101,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4208.82,2735.73,,,,,,,,,,,,,
STEM FEM L150MM DIA13.5MM TI POR IM REV BOW NEUT MOD LNG,SUP-2405743,CDM,C1776,CPT,0278,RC,,,,both,,,5298.75,3444.19,,,,,,,,,,,,,
STEM HUM INTERCALARY 60 MM SHLDR REV SEG W/ SCREW COMPHSVE,SUP-2442426,CDM,C1776,CPT,0278,RC,,,,both,,,17266.86,11223.46,,,,,,,,,,,,,
SCREW BNE COMPR FUS NAIL WICH,SUP-2377550,CDM,C1713,HCPCS,0278,RC,,,,both,,,5739.14,3730.44,,,,,,,,,,,,,
ROD PUSH DIA5.5MM,SUP-2211165,CDM,C1713,HCPCS,0278,RC,,,,both,,,237.38,154.30,,,,,,,,,,,,,
DRIVER SHFT SURG UNIV NONCANNULATED NEURO 1.5MM,SUP-2365253,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1212.95,788.42,,,,,,,,,,,,,
BRACE KNEE SM HNG PAT STBL BILAT AD PUL ON STRP CLSR,SUP-2196833,CDM,L1810,HCPCS,0272,RC,,,,both,,,56.99,37.04,,,,,,,,,,,,,
PLATE BONE L153MM 11 H STRL LT ANTEROLATERAL DSTL TIB S STL,SUP-2349732,CDM,C1713,HCPCS,0278,RC,,,,both,,,12792.36,8315.03,,,,,,,,,,,,,
CATHETER CV DL 26 FRX60 CM 20 GA N COAT L-CATH,SUP-2133178,CDM,C1751,HCPCS,0278,RC,,,,both,,,249.44,162.14,,,,,,,,,,,,,
CATHETER HEMODIALYSI TRI FLO ACTE 11.5FR DIA 15CM STRGHT TAP,SUP-2610548,CDM,C1752,HCPCS,0278,RC,,,,both,,,122.46,79.60,,,,,,,,,,,,,
ALLOSYNC COTTON WEDGE 16MMX5.5MM,SUP-2811230,CDM,C1713,HCPCS,0278,RC,,,,both,,,4521.60,2939.04,,,,,,,,,,,,,
SHAVER SURG HD W1.8XH1.3MM MIC HK W/ TIP SHT EXTN SIL SL,SUP-2305946,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1185.66,770.68,,,,,,,,,,,,,
COMPONENT CRPL 3 STD WRST POLYETH FRDM,SUP-2610399,CDM,C1776,CPT,0278,RC,,,,both,,,4070.82,2646.03,,,,,,,,,,,,,
LENS IOL BCNVX 18.5+ DIOPT 6X13 MM TORIC,SUP-2102633,CDM,V2788,HCPCS,0276,RC,,,,both,,,985.00,640.25,,,,,,,,,,,,,
CATHETER VENTRICULAR MED CLS PRESSURE 91 CM SHUNT ACCU-FLO,SUP-2243780,CDM,C1729,HCPCS,0272,RC,,,,both,,,768.01,499.21,,,,,,,,,,,,,
BRACE KNEE CUST W/ ADJ HNG FUSIONXT OA,SUP-2150833,CDM,L1810,HCPCS,0272,RC,,,,both,,,1709.73,1111.32,,,,,,,,,,,,,
TUBE TRACH JACKSON 4 8 MMX2.75 IN REG LEN 3 PC SET DBL ACT,SUP-2867585,CDM,2720000010,LOCAL,0272,RC,,,,both,,,343.83,223.49,,,,,,,,,,,,,
KIT PERC DILATIONAL TRACH TUBE DIA 8 MM CONN 15 MM DIL ERGO,SUP-2887140,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1183.81,769.48,,,,,,,,,,,,,
SCREW BNE ST 2X11 MM LCK W/ STARDRV RECESS SS NS LCP,SUP-2183311,CDM,C1713,HCPCS,0278,RC,,,,both,,,308.91,200.79,,,,,,,,,,,,,
HC So Collagen Cross-Link N-Telopep,PX-3018252366,CDM,82523,CPT,0301,RC,,,,outpatient,,,139.00,90.35,,,,,,,,,,,,,
WIRE FIX TROCAR PT 2 END 0.045X12 IN SS NS KIRSCHNER,SUP-2791815,CDM,C1713,HCPCS,0278,RC,,,,both,,,13.25,8.61,,,,,,,,,,,,,
PLATE 13 TUB 3HL L35MM,SUP-2695629,CDM,C1713,HCPCS,0278,RC,,,,both,,,1189.12,772.93,,,,,,,,,,,,,
BIT DRILL DIA5.5MM CANNULATED PILOT,SUP-2878723,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1350.20,877.63,,,,,,,,,,,,,
ALLOGRAFT BNE SPNG 2X5X0.5 CM 10 CC CRBNT APATITE VENADO,SUP-2718019,CDM,C1713,HCPCS,0278,RC,,,,both,,,1993.87,1296.02,,,,,,,,,,,,,
PACK DEL SYS ANCHR SUT L15MM DIA4.5MM CONVENIENCE ACHILLES,SUP-2122830,CDM,C1713,HCPCS,0278,RC,,,,both,,,3893.60,2530.84,,,,,,,,,,,,,
HYDROCODONE-ACETAMINOPHEN 5-325 MG PO TABS,RX-34505,CDM,6370000000,HCPCS,0637,RC,00406-0123-23,NDC,,both,1,UN,2.80,1.82,,,,,,,,,,,,,
RHINO-LARYNGOSCOPE FLX L 350 MM OD 5 MM ID 2 MM INTERVENTION,SUP-2882909,CDM,2720000010,LOCAL,0272,RC,,,,both,,,737.90,479.63,,,,,,,,,,,,,
SHUNT SURG L 8.9 MM VENTRICULAR CATH L 250 MM PRESSURE 10 CM,SUP-2931051,CDM,C1729,HCPCS,0272,RC,,,,both,,,4178.74,2716.18,,,,,,,,,,,,,
BLADE SURG MULT XL 4.2 MM + STRL FMS VUE DISP,SUP-2624802,CDM,2720000010,LOCAL,0272,RC,,,,both,,,320.28,208.18,,,,,,,,,,,,,
BIT DRL TWST 1X30 MM 5 MM W/ STP DENT SS SONICWELD RX,SUP-2461242,CDM,2720000010,LOCAL,0272,RC,,,,both,,,416.30,270.59,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.447,SUP-2860011,CDM,C1713,HCPCS,0278,RC,,,,both,,,55233.54,35901.80,,,,,,,,,,,,,
SCREW BONE 4X40MM ANKLE CANNULATED ARSENAL,SUP-2878141,CDM,C1713,HCPCS,0278,RC,,,,both,,,1130.40,734.76,,,,,,,,,,,,,
DRILL ENDO OD10MM STD LEN CANN BIT RMR HD FEM TUNN ARTHSCP,SUP-2342263,CDM,2720000010,LOCAL,0272,RC,,,,both,,,946.24,615.06,,,,,,,,,,,,,
ANCHOR SPNL FIX 15 MM COALITION MIS,SUP-2663503,CDM,C1889,HCPCS,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
TRIAL PIN L25MM DIA2MM PROV FOR TEMP FIX,SUP-2344024,CDM,C1713,HCPCS,0278,RC,,,,both,,,865.01,562.26,,,,,,,,,,,,,
BASEPLATE TIB M SZ 2 AP50MM ML74MM UNIV KNEE HA POR CEM,SUP-2377187,CDM,C1776,CPT,0278,RC,,,,both,,,3259.57,2118.72,,,,,,,,,,,,,
CLONIDINE 0.2 MG/24HR TD PTWK,RX-143502,CDM,6370000000,HCPCS,0637,RC,00378-0872-16,NDC,,both,1,UN,200.80,130.52,,,,,,,,,,,,,
CATHETER DRNGE 18FR L40CM GWIRE 0.038IN 6 SIDEPRT STD,SUP-2168761,CDM,C1729,HCPCS,0272,RC,,,,both,,,265.02,172.26,,,,,,,,,,,,,
BLADE SURG OMNI CUT 4.2 MM RESECT STRL FMS VUE DISP,SUP-2624799,CDM,2720000010,LOCAL,0272,RC,,,,both,,,373.66,242.88,,,,,,,,,,,,,
KIT INSTR CAPITAL FRAG CTRL GUIDE STRL DISP MINIBUNION,SUP-2893288,CDM,2720000010,LOCAL,0272,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
SPLINT HND M ULN DEVIATION RT NEOPRNE WRP ARND W/ THMB H ADJ,SUP-2324909,CDM,L3906,HCPCS,0274,RC,,,,both,,,28.01,18.21,,,,,,,,,,,,,
SCREW BONE LOCKING 3.5/2.7MM DIA 48MML STERILE,SUP-2588235,CDM,C1713,HCPCS,0278,RC,,,,both,,,300.15,195.10,,,,,,,,,,,,,
GRAFT TISS FRZN ALLGRFT FEM DST VARIES MATRIGRFT,SUP-2264748,CDM,C1713,HCPCS,0278,RC,,,,both,,,11380.80,7397.52,,,,,,,,,,,,,
COMPONENT FEM THK10MM STD KNEE BUMPER HNG ROT KINEMATIC,SUP-2376453,CDM,C1776,CPT,0278,RC,,,,both,,,1489.30,968.04,,,,,,,,,,,,,
PLATE BONE STRL L SHP LT VAR LCK 2.7MM SCR VLP FT PERC,SUP-2349925,CDM,C1713,HCPCS,0278,RC,,,,both,,,2878.28,1870.88,,,,,,,,,,,,,
BURR SURG 5MM DIA HD XLN 95MML SM BNE RND DIAMOND MICROPOWER,SUP-2605841,CDM,2720000010,LOCAL,0272,RC,,,,both,,,340.94,221.61,,,,,,,,,,,,,
HC Blood Occult Peroxidase Actv Qual Feces 1-3 Spec,PX-3018227200,CDM,82272,CPT,0301,RC,,,,both,,,87.00,56.55,,,,,,,,,,,,,
BUR SURG DIA5MM TI RND CUT NONFLUTED,SUP-2363803,CDM,2720000010,LOCAL,0272,RC,,,,both,,,588.75,382.69,,,,,,,,,,,,,
LEAD DEFIB ENDOTK RELIANCE GS L 64 CM ENDOCARD STEROID ELUT,SUP-2139495,CDM,C1895,HCPCS,0275,RC,,,,both,,,20410.00,13266.50,,,,,,,,,,,,,
PANEL KIT 25.39X25.59X45.67 IN MOD W/ TIERX4 WM-NP1/WM-WP1,SUP-2484812,CDM,C1713,HCPCS,0278,RC,,,,both,,,2416.23,1570.55,,,,,,,,,,,,,
CAGE SPNL W21XH20 25XL22MM 5DEG MIDTHORACIC INTBDY FUS TI,SUP-2182810,CDM,C1889,HCPCS,0278,RC,,,,both,,,20410.00,13266.50,,,,,,,,,,,,,
PLATE PL DSTL HUM 2.7/3.5MM 3H LT 75MM SHRT STRL TI VA LCP,SUP-2546788,CDM,C1713,HCPCS,0278,RC,,,,both,,,4503.83,2927.49,,,,,,,,,,,,,
IMPLANT COSMETIC SZ 50 X 76 X 0.85 MM POLYETHYL ORBIT FLR,SUP-2935301,CDM,C1713,HCPCS,0278,RC,,,,both,,,1595.12,1036.83,,,,,,,,,,,,,
BIT DRL 1.2X87 MM 6 MM STP TPS END NS UNIV NEURO III LTX,SUP-2862796,CDM,2720000010,LOCAL,0272,RC,,,,both,,,657.26,427.22,,,,,,,,,,,,,
CURETTE KYPHOPLASTY SZ 2 DIA7MM T TIP N RADPQ FOR VERTPLSTY,SUP-2293449,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
SIZER BRST 620CC W14XH13.2CM P6.9CM COHESIVE III SIL GEL HI,SUP-2300824,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1287.40,836.81,,,,,,,,,,,,,
PLATE BNE STR MINI SM 2-2.5X1 MM 7 MM 4 HOLE LCK TLTS TI,SUP-2459206,CDM,C1713,HCPCS,0278,RC,,,,both,,,1668.56,1084.56,,,,,,,,,,,,,
VANCOMYCIN HCL 5 G IV SOLR,RX-143506,CDM,J3373,HCPCS,0636,RC,00409-6509-01,NDC,,both,1,UN,519.00,337.35,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP L480CM DIA0.021IN TIP L5CM HYDRPHLC COAT,SUP-2169615,CDM,C1769,HCPCS,0272,RC,,,,both,,,474.14,308.19,,,,,,,,,,,,,
SYSTEM DRAINAGE VENTRICULAR CATH SHUNT FOR EDS III,SUP-2308153,CDM,C1729,HCPCS,0272,RC,,,,both,,,954.34,620.32,,,,,,,,,,,,,
CONNECTOR VLV METERING LN DIA 0.5 MM SPEC INFUSION STRL DISP,SUP-2930212,CDM,2720000010,LOCAL,0272,RC,,,,both,,,366.75,238.39,,,,,,,,,,,,,
CARTRIDGE BNE CEM MIX UNIV TWR VAC ROTOR BRK OFF NOZ W/O,SUP-2253063,CDM,C1713,HCPCS,0278,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
LINER ACET OD39MM ID22MM HIPXLPE BPLR TNDM,SUP-2344605,CDM,C1776,CPT,0278,RC,,,,both,,,3692.64,2400.22,,,,,,,,,,,,,
STIMULATOR NERVE 7.5 AMP IMPL PULSE GENRTR DL QUAT PROCLAIM,SUP-2355965,CDM,C1767,HCPCS,0278,RC,,,,both,,,47100.00,30615.00,,,,,,,,,,,,,
BLADE SAW OSCILLATING 9.5MMW X25MML FLUORIDEFSTRYKER,SUP-2605445,CDM,2720000010,LOCAL,0272,RC,,,,both,,,72.91,47.39,,,,,,,,,,,,,
BRUSH CYTO L2.5CM DIA3MM CATH 6FR ACCSRY CHAN 3.2MM 0.035IN,SUP-2170661,CDM,2720000010,LOCAL,0272,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
PLATE BNE L23MM 4 H NONSTERILE TI LOK COMPR W SHT THRD DRL,SUP-2180909,CDM,C1713,HCPCS,0278,RC,,,,both,,,797.69,518.50,,,,,,,,,,,,,
PIN ABSORBABLE 3.2X50.0MM STERILE F / ARTHROTEK,SUP-2498686,CDM,C1713,HCPCS,0278,RC,,,,both,,,719.06,467.39,,,,,,,,,,,,,
PLATE BNE 2 X 2 H CRANIOMAXILLOFACIAL 3D BX LP NS UNIV NEURO,SUP-2883186,CDM,C1713,HCPCS,0278,RC,,,,both,,,884.63,575.01,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED ULTRA HI DEMAND 1 FIX BEAR BIOMETK1FIX] ZIMMER BIOMET INC],SUP-2137339,CDM,C1776,CPT,0278,RC,,,,both,,,19468.00,12654.20,,,,,,,,,,,,,
CATHETER CV MAXIMAL BARR TY 032 9 FRX15 CM 11 GA 3L SPECTRUM,SUP-2759741,CDM,C1751,HCPCS,0278,RC,,,,both,,,605.58,393.63,,,,,,,,,,,,,
NEEDLE BX LIV ACCS 19 GAX20 CM,SUP-2432216,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1504.06,977.64,,,,,,,,,,,,,
TRAY CTRL VEN AD 9.5FR L5CM 0.018IN NDL 19GA DIL C5 SYR DBL,SUP-2127768,CDM,C1751,HCPCS,0278,RC,,,,both,,,2430.05,1579.53,,,,,,,,,,,,,
GUIDEWIRE VASC EMERALD L 125 CM DIA 0.032 IN CRV RAD 3 MM,SUP-2157272,CDM,C1769,HCPCS,0272,RC,,,,both,,,86.35,56.13,,,,,,,,,,,,,
Z INACTIVE PER BARD CARTRIDGE IMPL 30 Q-RING SALUTE 18CM,SUP-2126057,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 8X240 MM FRZN GAM PERONEUS LONGUS TEND,SUP-2866907,CDM,C1762,CPT,0278,RC,,,,both,,,3066.52,1993.24,,,,,,,,,,,,,
STEM NONCEMENTED FEM/TIB 12X80MM,SUP-2359181,CDM,C1776,CPT,0278,RC,,,,both,,,3611.00,2347.15,,,,,,,,,,,,,
PLATE BONE THK0.8MM HND H LCK COMPR BILAT MALL FOR 1.5/2.3MM,SUP-2107079,CDM,C1713,HCPCS,0278,RC,,,,both,,,681.38,442.90,,,,,,,,,,,,,
IMPLANT BIO TISS L2.5CM ID4MM PERIPH NRV CLLGN,SUP-2378819,CDM,C9353,HCPCS,0278,RC,,,,both,,,3849.64,2502.27,,,,,,,,,,,,,
SCREW BNE NLCK 3X26 MM DBL STRT THRD STRL JPS LTX,SUP-2875249,CDM,C1713,HCPCS,0278,RC,,,,both,,,335.35,217.98,,,,,,,,,,,,,
DEVICE FIX 5MM BTTN DIR W/O LOOP FEM ENDOBTTN,SUP-2341083,CDM,C1713,HCPCS,0278,RC,,,,both,,,910.60,591.89,,,,,,,,,,,,,
SCREW BNE CANN 7X110 MM 16 MM CAPTURE HIGH-TORQUE,SUP-2609029,CDM,C1713,HCPCS,0278,RC,,,,both,,,1409.29,916.04,,,,,,,,,,,,,
KIT CATH MIC VENT BOLT INTCRAN PRSS MON CAMINO,SUP-2308098,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2577.44,1675.34,,,,,,,,,,,,,
GRAFT BNE LG 10 CC DBM STRND +,SUP-2641769,CDM,C1713,HCPCS,0278,RC,,,,both,,,13282.20,8633.43,,,,,,,,,,,,,
PLATE BNE L81MM 7 H S STL 1/3 TBLR LOK COMPR W/ CLLR FOR,SUP-2185932,CDM,C1713,HCPCS,0278,RC,,,,both,,,461.77,300.15,,,,,,,,,,,,,
GRAFT BNE SUB 16X10MM DBM MTRX PLUG GRFTON,SUP-2278335,CDM,C1713,HCPCS,0278,RC,,,,both,,,2064.61,1342.00,,,,,,,,,,,,,
DRILL SRGCL TWIST MRRSN STYLE 22MM DIA 105MML CLNDRCL F/LVL,SUP-2681045,CDM,2720000010,LOCAL,0272,RC,,,,both,,,637.83,414.59,,,,,,,,,,,,,
CD BONE SCR 2.3X18MM,SUP-2494495,CDM,C1713,HCPCS,0278,RC,,,,both,,,204.92,133.20,,,,,,,,,,,,,
COLLAR CERV M AD H225XL13 16IN TRACH CLS 2 PC RIG POLYETH,SUP-2196882,CDM,L0120,HCPCS,0274,RC,,,,both,,,42.01,27.31,,,,,,,,,,,,,
SHEATH RADIAL LONG 106F-071-100,SUP-2854131,CDM,C1887,HCPCS,0272,RC,,,,both,,,4082.00,2653.30,,,,,,,,,,,,,
HC So1 Creatinine Urine/Other,PX-3018257067,CDM,82570,CPT,0301,RC,,,,both,,,186.00,120.90,,,,,,,,,,,,,
HC Intraosseous Needle Placement,PX-7613668000,CDM,36680,CPT,0761,RC,,,,inpatient,,,954.00,620.10,,,,,,,,,,,,,
CATHETER INTVASC OCCL FOGARTY L 40 CM DIA 8 MM BALLOON DIA,SUP-2214269,CDM,C2628,HCPCS,0272,RC,,,,both,,,421.07,273.70,,,,,,,,,,,,,
ADAPTER LD L 15 CM DF1 CONN TO TERM,SUP-2148908,CDM,C1883,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
CROMOLYN SODIUM 5.2 MG/ACT NA AERS,RX-24325,CDM,6370000000,HCPCS,0637,RC,14832-0011-01,NDC,,both,26,ML,62.60,40.69,,,,,,,,,,,,,
WIRE FIX L229MM DIA2.5MM S STL PARTIALLY THRD DBL SHRP TIP,SUP-2409763,CDM,C1713,HCPCS,0278,RC,,,,both,,,41.39,26.90,,,,,,,,,,,,,
SCREW BNE 4.2X50 MM,SUP-2198076,CDM,C1713,HCPCS,0278,RC,,,,both,,,452.66,294.23,,,,,,,,,,,,,
PLATE BNE L 1.5X0.8 MM 4 MM MIDFACE 3X3 HOLE W/ TAB TI NS,SUP-2518111,CDM,C1713,HCPCS,0278,RC,,,,both,,,919.39,597.60,,,,,,,,,,,,,
COIL EMB L50CM DIA14MM HELI LSR ABLATED DARKER RADPQ MRK,SUP-2367741,CDM,C1889,HCPCS,0278,RC,,,,both,,,5467.21,3553.69,,,,,,,,,,,,,
SCREW SPNL L35MM DIA4.75MM CANC PEDCL S STL NO CUT ISOLA VSP,SUP-2256907,CDM,C1713,HCPCS,0278,RC,,,,both,,,1883.06,1223.99,,,,,,,,,,,,,
SET NEUROSURGICAL TISS SCULPTURE TRCR DISP LUM DCOMPR PROC,SUP-2392706,CDM,C1889,HCPCS,0278,RC,,,,both,,,13659.00,8878.35,,,,,,,,,,,,,
SCREW BNE L16MM DIA3.5MM CORT TI SELF DRL ST NONCANNULATED,SUP-2189865,CDM,C1713,HCPCS,0278,RC,,,,both,,,69.74,45.33,,,,,,,,,,,,,
STAPLER ROBOT L 30 MM DIA 8 MM CRV TIP STRL DISP SUREFORM DA,SUP-2908883,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1714.44,1114.39,,,,,,,,,,,,,
CAP NAIL H0MM TIB NAT NAIL,SUP-2413038,CDM,C1713,HCPCS,0278,RC,,,,both,,,620.97,403.63,,,,,,,,,,,,,
PLATE BNE NAR L VOLAR DST RAD WRST LOK ACU-LOC,SUP-2107768,CDM,C1713,HCPCS,0278,RC,,,,both,,,2606.20,1694.03,,,,,,,,,,,,,
HEAD FEM OD36MM CO CHROM MTL ON MTL HIP CEM CONSERVE +,SUP-2304497,CDM,C1776,CPT,0278,RC,,,,both,,,15700.00,10205.00,,,,,,,,,,,,,
STEM HUM STD 9 MM SHLDR NP AFFINITI,SUP-2715299,CDM,C1776,CPT,0278,RC,,,,both,,,15440.95,10036.62,,,,,,,,,,,,,
PUTTY T50106 GRFT DBF 6CC,SUP-2281670,CDM,C1713,HCPCS,0278,RC,,,,both,,,3265.60,2122.64,,,,,,,,,,,,,
GRAFT BNE L100MM FRZN TIB SEG IMPL ALLGRFT MATRIGRFT,SUP-2264791,CDM,C1713,HCPCS,0278,RC,,,,both,,,2422.35,1574.53,,,,,,,,,,,,,
SUBSTITUTE BONE GRFT 5ML DBM PUTTY IMP DYNAGRFT D,SUP-2242678,CDM,C9359,HCPCS,0278,RC,,,,both,,,1844.81,1199.13,,,,,,,,,,,,,
CATHETER EXT LUM L80CM OD1.5MM ID0.7MM CLS TIP BA IMPREG,SUP-2284544,CDM,C1729,HCPCS,0272,RC,,,,both,,,564.16,366.70,,,,,,,,,,,,,
FILLER BNE VOID 5 CC CORTICAL BNE SODIUM HYALURONATE KOLOSIS,SUP-2927230,CDM,C1713,HCPCS,0278,RC,,,,both,,,1827.48,1187.86,,,,,,,,,,,,,
NEEDLE BX 8 GA ASPIR BNE MAR TARGET,SUP-2430778,CDM,2720000010,LOCAL,0272,RC,,,,both,,,662.54,430.65,,,,,,,,,,,,,
SCREW BNE L11MM DIA2.3MM THOR STRNL TI LOK DRL FREE LEV 1,SUP-2262555,CDM,C1713,HCPCS,0278,RC,,,,both,,,80.04,52.03,,,,,,,,,,,,,
SET CLLR AD H3IN FOR 13-21IN NK REG ORNG PLAS HK AND LOOP,SUP-2124216,CDM,L0172,HCPCS,0274,RC,,,,both,,,90.87,59.07,,,,,,,,,,,,,
TUBE LO PROF GASTSTMY 20FR 3.4CM,SUP-2169496,CDM,2720000010,LOCAL,0272,RC,,,,both,,,596.60,387.79,,,,,,,,,,,,,
HC Fetal Eval 2-3 Trim @ Addl Gest,PX-4027681000,CDM,76810,CPT,0402,RC,,,,both,,,793.00,515.45,,,,,,,,,,,,,
PLATE BNE STR SHT CRANIOFACIAL NEURO 2 HOLE LP STRL LEVEL 1,SUP-2487703,CDM,C1713,HCPCS,0278,RC,,,,both,,,208.81,135.73,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED HYBRID CKNEESNEPHHYB] SMITH AND NEPHEW ORTHOPAEDICS],SUP-2351342,CDM,C1776,CPT,0278,RC,,,,both,,,12613.38,8198.70,,,,,,,,,,,,,
HC ED Clsd Tx Mcp Disl WO Anesth,PX-4502670000,CDM,26700,CPT,0450,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
BAR EXT FIX L 300 MM DIA 6 MM NS DISP MAV MINI,SUP-2932852,CDM,2720000010,LOCAL,0272,RC,,,,both,,,652.81,424.33,,,,,,,,,,,,,
GRAFT BONE 5 CC,SUP-2424592,CDM,C1713,HCPCS,0278,RC,,,,both,,,4671.38,3036.40,,,,,,,,,,,,,
GUIDEWIRE GLDEWIRE .018INX150CM,SUP-2140128,CDM,C1769,HCPCS,0272,RC,,,,both,,,879.70,571.80,,,,,,,,,,,,,
INTERNAL FIXATION KIT 1X4 MM STRL SPEEDBUTTON LTX,SUP-2866392,CDM,C1713,HCPCS,0278,RC,,,,both,,,1664.20,1081.73,,,,,,,,,,,,,
HC MRI-Spine Thoracic W Contrast,PX-6127214700,CDM,72147,CPT,0612,RC,,,,outpatient,,,4146.00,2694.90,,,,,,,,,,,,,
FORCEP TISS MICRO-TYING LG 23 GAX10 MM AHMED CRV DISP,SUP-2304861,CDM,C1713,HCPCS,0278,RC,,,,both,,,327.09,212.61,,,,,,,,,,,,,
COMPONENT TOT SHLDR CAPPED S3WRIGHT] WRIGHT MEDICAL TECHNOLOGY INC],SUP-2400713,CDM,C1776,CPT,0278,RC,,,,both,,,21980.00,14287.00,,,,,,,,,,,,,
PLATE BNE L77MM THK3MM 5 H BILAT S STL STR LIMIT CNTCT DYN,SUP-2185332,CDM,C1713,HCPCS,0278,RC,,,,both,,,1495.77,972.25,,,,,,,,,,,,,
SET CATH CATH L 20 CM DIA 5 FR GUIDEWIRE 0.018 IN NDL L 7 CM,SUP-2884236,CDM,C1751,HCPCS,0278,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
PLATE BONE 12 H BILAT MAND TI STR RIG NONCOMPRESSION,SUP-2191406,CDM,C1713,HCPCS,0278,RC,,,,both,,,2521.42,1638.92,,,,,,,,,,,,,
KIT BLLN KYPHOPLASTY 8GA 20MM,SUP-2863096,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8450.02,5492.51,,,,,,,,,,,,,
"HC So Lipoprotein,Bld,by Nmr",PX-3018370466,CDM,83704,CPT,0301,RC,,,,inpatient,,,76.00,49.40,,,,,,,,,,,,,
SUPPORT EXT FIX OBLQ CONN RINGFIX,SUP-2472830,CDM,2720000010,LOCAL,0272,RC,,,,both,,,301.44,195.94,,,,,,,,,,,,,
HC Pt Neuro Facilitation Ea 15 Min,PX-4209711200,CDM,97112,CPT,0420,RC,,,,both,,,159.00,103.35,,,,,,,,,,,,,
KIT ABLATION RF MULTI-COOLED 17GA 5CM,SUP-2236770,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4082.00,2653.30,,,,,,,,,,,,,
POST TAPR L31MM DIA8.5MM HEMICAP,SUP-2123529,CDM,C1776,CPT,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
GUIDEWIRE ARTHSCP L 3.2MM DISP FOR 4.5/8.5MM BEAMING SYS,SUP-2223913,CDM,C1769,HCPCS,0272,RC,,,,both,,,84.78,55.11,,,,,,,,,,,,,
HC So Tiagubine,PX-3018019966,CDM,80199,CPT,0301,RC,,,,both,,,92.00,59.80,,,,,,,,,,,,,
PLATE SPNL FIX 5.5X28 MM SS CROSSLINK,SUP-2660208,CDM,C1713,HCPCS,0278,RC,,,,both,,,5071.10,3296.21,,,,,,,,,,,,,
ANCHOR SUT WHT BLU W/ 1.3MM SUTTAPE FIBERTAK,SUP-2121775,CDM,C1713,HCPCS,0278,RC,,,,both,,,1114.70,724.55,,,,,,,,,,,,,
PLATE BNE T 4.5X116 MM 6 HOLE TI NS LCP,SUP-2569055,CDM,C1713,HCPCS,0278,RC,,,,both,,,2216.15,1440.50,,,,,,,,,,,,,
IMPLANT CRAN CUST PEEK,SUP-2431413,CDM,C1889,HCPCS,0278,RC,,,,both,,,23762.58,15445.68,,,,,,,,,,,,,
SCREW INTFR L20MM OD8MM TTNM ACL CNNLTD BLUNT THRDD NNBSRBBL,SUP-2589300,CDM,C1713,HCPCS,0278,RC,,,,both,,,313.31,203.65,,,,,,,,,,,,,
KIT CANN W 8MM REDUC STPLR INTEGR DA VINCI SYS GUID INSTR,SUP-2246681,CDM,C1713,HCPCS,0278,RC,,,,both,,,9891.00,6429.15,,,,,,,,,,,,,
MATRIX BIO L 25 X W 10 CM FET BOV DERM DERMAL SLD STRL,SUP-2909300,CDM,Q4110,HCPCS,0636,RC,,,,both,,,14130.00,9184.50,,,,,,,,,,,,,
STEM FEM L300MM OD13MM POR DSTL HIP MOD SLOT RL HARDENED,SUP-2404202,CDM,C1776,CPT,0278,RC,,,,both,,,10063.70,6541.40,,,,,,,,,,,,,
PLATE BONE W14XL74MM THK3.8MM 4 H RT TIB L BTTRS LT ANG S,SUP-2185766,CDM,C1713,HCPCS,0278,RC,,,,both,,,1768.10,1149.26,,,,,,,,,,,,,
CATHETER EP L110CM OD4FR 2-5-2MM SPC L DECAPOLAR STEER,SUP-2357644,CDM,C1730,HCPCS,0272,RC,,,,both,,,1610.82,1047.03,,,,,,,,,,,,,
FOLIC ACID 1 MG PO TABS,RX-3233,CDM,6370000000,HCPCS,0637,RC,69315-0127-10,NDC,,both,1,UN,0.60,0.39,,,,,,,,,,,,,
PLUG FIST TUBE L9CM OD16MM DISK FOR MULT TISS DEFCT REP,SUP-2395749,CDM,C1781,HCPCS,0278,RC,,,,both,,,2643.88,1718.52,,,,,,,,,,,,,
VALVE MITRL CARP EDW PERIMT + DIA27 MM SEW RNG DIA 36 MM,SUP-2214292,CDM,C1889,HCPCS,0278,RC,,,,both,,,15197.60,9878.44,,,,,,,,,,,,,
PLATE BONE 4 H STD RT DSTL VOLAR RAD D-RAD SMRT PK,SUP-2343909,CDM,C1713,HCPCS,0278,RC,,,,both,,,3563.59,2316.33,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP STR 0.035 INX260 CM STIFF RND JAGWIRE,SUP-2141543,CDM,C1769,HCPCS,0272,RC,,,,both,,,402.99,261.94,,,,,,,,,,,,,
GRAFT BNE SUB W10XH125XL125MM B TRICALCIUM PHSPTE GRAN SYN,SUP-2194020,CDM,C1713,HCPCS,0278,RC,,,,both,,,930.88,605.07,,,,,,,,,,,,,
SPLINT THMB AD FOR 4.5-9.5IN REG KUHL PERF NEOPRNE WRP ARND,SUP-2324315,CDM,L3931,HCPCS,0272,RC,,,,both,,,73.70,47.90,,,,,,,,,,,,,
CATHETER DRNGE L25CM OD8FR NEPHSTMY TIGHT PGTL,SUP-2118772,CDM,C1729,HCPCS,0272,RC,,,,both,,,221.06,143.69,,,,,,,,,,,,,
TRIAL SPNL 14MM IMPL ALLGRFT DANEK,SUP-2292301,CDM,C1713,HCPCS,0278,RC,,,,both,,,1029.39,669.10,,,,,,,,,,,,,
K WIRE FIX L6IN THK0.045IN FOR FT PLATING SYS EXTREMILOCK,SUP-2319433,CDM,C1769,HCPCS,0272,RC,,,,both,,,69.08,44.90,,,,,,,,,,,,,
SUPPORT ORTHOPEDIC FLX SM AD LT FNGR ORTHOSIS FLX BRAC,SUP-2325138,CDM,L3807,HCPCS,0272,RC,,,,both,,,243.51,158.28,,,,,,,,,,,,,
HC Ot Therapeutic Activities 15 Min|OP OCCUPATIONAL THERAPY SERV|DOCUMENTATION ON FILE|SERVICES PROVIDED IN WHOLE OR IN PARTY BY AN OTA FOR MEDICARE PATIENTS|UNUSUAL NON-OVERLAPPING SERVICE,PX-4309753000,CDM,97530,CPT,0430,RC,,,GO|KX|CO|XU,both,,,144.00,93.60,,,,,,,,,,,,,
SCREW BNE LAG 10.5X70 MM FOR CEPHALOMEDULLARY NAIL,SUP-2463591,CDM,C1713,HCPCS,0278,RC,,,,both,,,1542.09,1002.36,,,,,,,,,,,,,
PROGUIDE 28CM BASIC KIT HOLES 16F PLWAY SHTH 18 G INTRDCR ND,SUP-2701766,CDM,C1894,HCPCS,0272,RC,,,,both,,,753.60,489.84,,,,,,,,,,,,,
IMMUNE GLOBULIN (HUMAN) 20 GM/200ML IV SOLN,RX-104398,CDM,J1459,HCPCS,0636,RC,44206-0438-20,NDC,,both,200,ML,11319.80,7357.87,,,,,,,,,,,,,
"HC So1 Cytomegalovirus, Igg Antibody",PX-3028664467,CDM,86644,CPT,0302,RC,,,,both,,,49.00,31.85,,,,,,,,,,,,,
BIT DRL L157MM DIA2MM SH FOR VAR ANG LOCKED PLATING SYS,SUP-2344012,CDM,2720000010,LOCAL,0272,RC,,,,both,,,910.69,591.95,,,,,,,,,,,,,
CANNULA CHOPPER 23GA VISCO PAREKH LATEX FREE,SUP-2493345,CDM,2720000010,LOCAL,0272,RC,,,,both,,,602.10,391.36,,,,,,,,,,,,,
SPACER SPNL 4 MM MONOTUBE,SUP-2476623,CDM,C1821,HCPCS,0278,RC,,,,both,,,50.55,32.86,,,,,,,,,,,,,
GRAFT HUM TISS W5XL5CM NOM THK1.1MM STD HUM DERM REGEN TISS,SUP-2399063,CDM,Q4107,HCPCS,0636,RC,,,,both,,,6116.72,3975.87,,,,,,,,,,,,,
BRACE ORTHOPEDIC POST OPERATIVE UNIV KNEE WARRIOR RECOVERY,SUP-2336061,CDM,L1810,HCPCS,0274,RC,,,,both,,,210.22,136.64,,,,,,,,,,,,,
PLATE BONE 70MML STNLSS STEEL F3.5MM SCREW SM FRGMNT SSTM N,SUP-2721912,CDM,C1713,HCPCS,0278,RC,,,,both,,,1272.99,827.44,,,,,,,,,,,,,
SUPPORT ORTHOT HEEL CUST STD NEW LTHR,SUP-2435732,CDM,L3455,HCPCS,0274,RC,,,,both,,,115.24,74.91,,,,,,,,,,,,,
FILTER SHUNT ID1.5MM 3.9U LN OUTLT PRT 2 HOLTER,SUP-2243796,CDM,C1729,HCPCS,0272,RC,,,,both,,,1369.04,889.88,,,,,,,,,,,,,
ANCHOR BNE FOR REGENETEN BIOINDUCTIVE IMPL,SUP-2341377,CDM,C1713,HCPCS,0278,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
DEFIBRILLATOR CARD ATLS II HF,SUP-2357759,CDM,C1882,HCPCS,0275,RC,,,,both,,,69080.00,44902.00,,,,,,,,,,,,,
SHEATH INTRO PINNACLE DESTINATION 65CM 8FR COAT L 35CM XCUT,SUP-2385458,CDM,C1894,HCPCS,0272,RC,,,,both,,,386.09,250.96,,,,,,,,,,,,,
KIT INTRO GLIDESHEATH L 25 CM OD 6FR ID 0.087IN 0.021IN,SUP-2384836,CDM,C1894,HCPCS,0272,RC,,,,both,,,280.09,182.06,,,,,,,,,,,,,
PIN FIXATION 4.5MM THREADED CANCELLOUS,SUP-2498971,CDM,2720000010,LOCAL,0272,RC,,,,both,,,350.27,227.68,,,,,,,,,,,,,
BLADE SAW OSCILLATING CLASSIC 19MM/13MMW X90MML 1.37MM THK I,SUP-2605832,CDM,2720000010,LOCAL,0272,RC,,,,both,,,81.99,53.29,,,,,,,,,,,,,
PROBE PALPATION 5MM 33CM DEPTH MRK,SUP-2361235,CDM,2720000010,LOCAL,0272,RC,,,,both,,,404.28,262.78,,,,,,,,,,,,,
ALLOGRAFT BNE LG PARTICULATE 1-4 MM 5 CC FD GRND ORAGRAFT,SUP-2740856,CDM,C1713,HCPCS,0278,RC,,,,both,,,601.56,391.01,,,,,,,,,,,,,
MESH HERN M DIA6.4CM VENTRAL POLYPR EPTFE CIR SELF EXP PTCH,SUP-2125720,CDM,C1781,HCPCS,0278,RC,,,,both,,,1798.28,1168.88,,,,,,,,,,,,,
OSTEOTOME CVD .50MMX120MM HRIS,SUP-2364384,CDM,2720000010,LOCAL,0272,RC,,,,both,,,785.79,510.76,,,,,,,,,,,,,
PROSTHESIS OSS L15MM HD L3MM DST END DIA117MM HA FRISBEE PAR,SUP-2436531,CDM,L8613,CPT,0278,RC,,,,both,,,1138.88,740.27,,,,,,,,,,,,,
ROPIVACAINE HCL 2 MG/ML IJ SOLN,RX-18192,CDM,J2795,HCPCS,0636,RC,09999-9912-65,NDC,,both,100,ML,140.30,91.19,,,,,,,,,,,,,
HC Drain/Inject Joint/Bursa|PBB CHARGE,PX-4502060000,CDM,20600,CPT,0450,RC,,,PBB,both,,,358.00,232.70,,,,,,,,,,,,,
ELECTRODE SUBDERM NDL L 38 MM CABLE L 1 M PRASS PR 2 CHANNEL,SUP-2902080,CDM,2720000010,LOCAL,0272,RC,,,,both,,,534.87,347.67,,,,,,,,,,,,,
ROD IM T HNDL VANGUARD MICROPLASTY,SUP-2446402,CDM,C1713,HCPCS,0278,RC,,,,both,,,876.06,569.44,,,,,,,,,,,,,
BUR SURG DIA5MM SIL S STL CRNRSTN MIC HVY DUTY DISPOSABLE,SUP-2363369,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1197.63,778.46,,,,,,,,,,,,,
IMPLANT PIP SZ 30 SIL ELASTMR PK,SUP-2365881,CDM,C1776,CPT,0278,RC,,,,both,,,3138.12,2039.78,,,,,,,,,,,,,
HC Ot Ultrasound 15 Min,PX-4309703500,CDM,97035,CPT,0430,RC,,,,inpatient,,,194.00,126.10,,,,,,,,,,,,,
SCREW INTFR 9MM 30MM 1MM KNEE FIX CANN N ABSRB TI TAPR HD,SUP-2341315,CDM,C1713,HCPCS,0278,RC,,,,both,,,540.71,351.46,,,,,,,,,,,,,
PLATE BNE THK 1.4 MM SCREW DIA2.2 MM 1 X 21 H PLL,SUP-2883206,CDM,C1713,HCPCS,0278,RC,,,,both,,,12848.66,8351.63,,,,,,,,,,,,,
BUTTON SUT L12MM DIA2.6MM TI FOR TENS SLDE TECH DST BICEPS,SUP-2121663,CDM,C1713,HCPCS,0278,RC,,,,both,,,926.30,602.09,,,,,,,,,,,,,
SYSTEM NEUROSTIMULATOR W 1.1 CM 2 CHANNEL ADAPTIVESTIM,SUP-2883485,CDM,C1767,HCPCS,0278,RC,,,,both,,,49612.00,32247.80,,,,,,,,,,,,,
SCREW ACET LCK 28/32/36 MM PROV APCL,SUP-2440986,CDM,C1713,HCPCS,0278,RC,,,,both,,,28.26,18.37,,,,,,,,,,,,,
PATCH MEMBRN CRAN SPNL,SUP-2365424,CDM,C1763,HCPCS,0278,RC,,,,both,,,5052.98,3284.44,,,,,,,,,,,,,
ZOLEDRONIC ACID 5 MG/100ML IV SOLN,RX-81434,CDM,J3489,HCPCS,0636,RC,55111-0688-52,NDC,,both,100,ML,73.20,47.58,,,,,,,,,,,,,
PIN EXT FIX L30MM OD5MM HA SALVATION,SUP-2401150,CDM,C1713,HCPCS,0278,RC,,,,both,,,574.62,373.50,,,,,,,,,,,,,
RETAINER IMPL NOSTRIL 3,SUP-2352032,CDM,2720000010,LOCAL,0272,RC,,,,both,,,568.34,369.42,,,,,,,,,,,,,
ALLOGRAFT BNE CUBE 5 CC FD IRRADIATED CANC,SUP-2867097,CDM,C1762,CPT,0278,RC,,,,both,,,590.63,383.91,,,,,,,,,,,,,
KIT PERI DRNGE CATHETER 155FR SIL CUF 1 INSRT TY ASPIRA,SUP-2301569,CDM,C1729,HCPCS,0272,RC,,,,both,,,3293.33,2140.66,,,,,,,,,,,,,
ROD EXT FIX GRAD 60 MM,SUP-2464594,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
KNIFE ELECSURG 3 MM ORISE PROKNIFE,SUP-2754410,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2668.22,1734.34,,,,,,,,,,,,,
SCREW INTRF L28MM DIA10MM KNEE PLLA CANN BIOABSRB THRD WDG,SUP-2362045,CDM,C1713,HCPCS,0278,RC,,,,both,,,463.15,301.05,,,,,,,,,,,,,
LEAD PACE ATTAIN ABIL MRI SURESCAN L 88 CM DIA 6 FR SIL,SUP-2281923,CDM,C1900,HCPCS,0275,RC,,,,both,,,4450.10,2892.56,,,,,,,,,,,,,
CATHETER US 5FR L150CM GWIRE 0.014IN PLAT GLYDX HYDRPHLC,SUP-2327228,CDM,C1753,HCPCS,0278,RC,,,,both,,,2469.61,1605.25,,,,,,,,,,,,,
NAIL IM FEM STD SHT SET ITST,SUP-2861288,CDM,C1713,HCPCS,0278,RC,,,,both,,,24217.69,15741.50,,,,,,,,,,,,,
TUBE TRACH STD 10 MM CLR MONTGOMERY SAFE-T-TUBE,SUP-2138747,CDM,2720000010,LOCAL,0272,RC,,,,both,,,514.96,334.72,,,,,,,,,,,,,
GRAFT SFT TISS BOV CLLGN 2.0 RECT 16CMX20CM SURGIMEND,SUP-2243682,CDM,C9360,HCPCS,0278,RC,,,,both,,,18086.40,11756.16,,,,,,,,,,,,,
BLADE SURG W10MM CASPR,SUP-2363308,CDM,2720000010,LOCAL,0272,RC,,,,both,,,546.86,355.46,,,,,,,,,,,,,
BRACE ORTH JEWETT,SUP-2138672,CDM,L0472,HCPCS,0274,RC,,,,both,,,1563.72,1016.42,,,,,,,,,,,,,
DEFIBRILLATOR IMPL UNIFY QUADRA W 41 X H 75 MM THK 14 MM 45,SUP-2357559,CDM,C1900,HCPCS,0275,RC,,,,both,,,62800.00,40820.00,,,,,,,,,,,,,
COMPONENT TIB UNI 8 MM KNEE,SUP-2205996,CDM,C1776,CPT,0278,RC,,,,both,,,4477.64,2910.47,,,,,,,,,,,,,
DRILL SURG PATELLO FEM JT PEG TAIL GENDER SOL,SUP-2437891,CDM,2720000010,LOCAL,0272,RC,,,,both,,,452.16,293.90,,,,,,,,,,,,,
SET PICC 2L 5FR X 55CM W TEGADERM,SUP-2887045,CDM,C1751,HCPCS,0278,RC,,,,both,,,723.24,470.11,,,,,,,,,,,,,
INSTRUMENT KIT PLN PT SPEC LINEAR DISTRCTN,SUP-2860258,CDM,2720000010,LOCAL,0272,RC,,,,both,,,11930.74,7754.98,,,,,,,,,,,,,
HC So Liver Ds Alys 3 Bmrk Srm Alg,PX-3108151766,CDM,81517,CPT,0310,RC,,,,both,,,465.00,302.25,,,,,,,,,,,,,
GUIDEWIRE ORTH 600 MM STRL,SUP-2609518,CDM,C1769,HCPCS,0272,RC,,,,both,,,335.57,218.12,,,,,,,,,,,,,
NAIL FEM RG 13.5MMX380MM,SUP-2405541,CDM,C1713,HCPCS,0278,RC,,,,both,,,6961.38,4524.90,,,,,,,,,,,,,
PLATE BONE 10 H ANTR BOW LAT PROX FOR 3.5 SCR,SUP-2349060,CDM,C1713,HCPCS,0278,RC,,,,both,,,930.85,605.05,,,,,,,,,,,,,
PLATE IMPL 4.5MM LCPTM MEDL PROX TIB,SUP-2177070,CDM,C1713,HCPCS,0278,RC,,,,both,,,68903.53,44787.29,,,,,,,,,,,,,
PLATE BNE THK 0.6 MM SCREW DIA2 MM TI RT CRANIOMAXILLOFACIAL,SUP-2935828,CDM,C1713,HCPCS,0278,RC,,,,both,,,668.82,434.73,,,,,,,,,,,,,
PLATE BONE L73MM 6 H LT SUP MEDL CLAV LCK PERI-LOC,SUP-2348754,CDM,C1713,HCPCS,0278,RC,,,,both,,,6533.24,4246.61,,,,,,,,,,,,,
HC Tprnl Plmt Biodegrdabl Matrl,PX-3615587400,CDM,55874,CPT,0361,RC,,,,both,,,5169.00,3359.85,,,,,,,,,,,,,
PACK VENT ASST L SHLDR BG PT PERS SUPP,SUP-2282574,CDM,Q0498,HCPCS,0274,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
PLATE BNE H0.5MM 18 H UP FACE BLU TI STR MAL LEIBINGER UNIV,SUP-2366231,CDM,C1713,HCPCS,0278,RC,,,,both,,,1568.68,1019.64,,,,,,,,,,,,,
WIRE FIX L350MM DIA1.8MM S STL SGL END SMOOTH SHRP TIP SPRD,SUP-2186869,CDM,C1713,HCPCS,0278,RC,,,,both,,,217.54,141.40,,,,,,,,,,,,,
ALLOGRAFT BNE GRND 30 CC FD ASEP CANC,SUP-2867039,CDM,C1762,CPT,0278,RC,,,,both,,,1288.66,837.63,,,,,,,,,,,,,
STEM FEM L170MM OD18MM 7.5IN BEAD 20MM BUILDUP CALCAR REV,SUP-2203258,CDM,C1776,CPT,0278,RC,,,,both,,,18715.97,12165.38,,,,,,,,,,,,,
GRAFT BNE MPJ SEG 14 MM,SUP-2107947,CDM,C1713,HCPCS,0278,RC,,,,both,,,15684.30,10194.79,,,,,,,,,,,,,
ALLOGRAFT BNE 4X8X16 MM BIOEXPAND,SUP-2636999,CDM,C1713,HCPCS,0278,RC,,,,both,,,2782.29,1808.49,,,,,,,,,,,,,
GRAFT BNE L201 270MM L PROX HUM FRZN,SUP-2335591,CDM,C1713,HCPCS,0278,RC,,,,both,,,8289.60,5388.24,,,,,,,,,,,,,
BRACE ORTH JEWETT,SUP-2138672,CDM,L0472,HCPCS,0272,RC,,,,both,,,1563.72,1016.42,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED ADV OXIN NP JOURNEY II,SUP-2348066,CDM,C1776,CPT,0278,RC,,,,both,,,11932.00,7755.80,,,,,,,,,,,,,
KIT KYPHOPLASTY L 12 CM DIA10 GA LNG ACCSRY DIAMOND BVL TIP,SUP-2930354,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
NKII REV CSTI POROUS FEMORAL LT SIZE 00,SUP-2509648,CDM,C1776,CPT,0278,RC,,,,both,,,20008.08,13005.25,,,,,,,,,,,,,
SPACER SPNL SM 12 DEG 32X23X18 MM,SUP-2630947,CDM,C1889,HCPCS,0278,RC,,,,both,,,13423.50,8725.27,,,,,,,,,,,,,
COMPONENT TIB TY 6 7 MM LT ANK HINTERMANN SER H2,SUP-2751905,CDM,C1776,CPT,0278,RC,,,,both,,,18212.00,11837.80,,,,,,,,,,,,,
SHUNT LP L87CM OD15MM ID07MM OD20GA BLNT NDL CSF LO PRSS,SUP-2277930,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2205.72,1433.72,,,,,,,,,,,,,
DRIVER SURG SCR ADJ TORQ,SUP-2328121,CDM,2720000010,LOCAL,0272,RC,,,,both,,,489.84,318.40,,,,,,,,,,,,,
COMPLETION REV FM SHIM MD/STD+,SUP-2513631,CDM,C1776,CPT,0278,RC,,,,both,,,3582.74,2328.78,,,,,,,,,,,,,
PLATE BNE L112MM 4 H ST L MED DST TIB S STL VAR ANG LOK,SUP-2177632,CDM,C1713,HCPCS,0278,RC,,,,both,,,5247.16,3410.65,,,,,,,,,,,,,
SCREW SET MULTAXL SS STRL CD HORZ MODULEX,SUP-2849984,CDM,C1713,HCPCS,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
KIT CATH HEMODIALYSI HEMOSPLIT XK CHRONIC STD 16FR D 5685270,SUP-2632960,CDM,C1750,HCPCS,0278,RC,,,,both,,,1425.56,926.61,,,,,,,,,,,,,
PLATE BNE THK1.4MM HND ARTH TRILOK 4 FUS CORNER FOR,SUP-2267955,CDM,C1713,HCPCS,0278,RC,,,,both,,,3799.40,2469.61,,,,,,,,,,,,,
LEVEL NEURO SCREWDRIVER BLADE ULTRAONE80 MM QTY001 EA,SUP-2677980,CDM,2720000010,LOCAL,0272,RC,,,,both,,,692.06,449.84,,,,,,,,,,,,,
CATHETER HAD ADMIN BASIC KT DBL LUMN SIL CRV SPL TIP CUF N,SUP-2267087,CDM,C1881,HCPCS,0278,RC,,,,both,,,715.92,465.35,,,,,,,,,,,,,
SCREW BONE 5X80MM THRD LO PROF TI,SUP-2316512,CDM,C1713,HCPCS,0278,RC,,,,both,,,674.60,438.49,,,,,,,,,,,,,
GRAFT VASC FUSION BIOLINE L 60 CM DIA 6 MM EXTERNALLY SUPP,SUP-2266009,CDM,L8670,HCPCS,0278,RC,,,,both,,,4662.90,3030.88,,,,,,,,,,,,,
CANNULA SUCTION DIAMETER 2MM 0DEG STRAIGHT TIP BLUNT FOR MIN,SUP-2825704,CDM,2720000010,LOCAL,0272,RC,,,,both,,,977.26,635.22,,,,,,,,,,,,,
MOD DMND KNEE SYS W/O PAT,SUP-2212167,CDM,C1776,CPT,0278,RC,,,,both,,,9971.23,6481.30,,,,,,,,,,,,,
REPAIR KIT CRUC BUTTON PK,SUP-2121320,CDM,C1713,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
"HC X-Ray, Thoracic Spine/4 V",PX-3207207400,CDM,72074,CPT,0320,RC,,,,inpatient,,,795.00,516.75,,,,,,,,,,,,,
RING FIX OVL 180MM IMP DNE,SUP-2197263,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3815.10,2479.81,,,,,,,,,,,,,
NAIL IM PERITROCHANTERIC PTN,SUP-2606675,CDM,C1713,HCPCS,0278,RC,,,,both,,,1896.56,1232.76,,,,,,,,,,,,,
SCREW BNE LCK STARDRV RECESS FOR CONN ATTCH PLATE TI NS LCP,SUP-2800002,CDM,C1713,HCPCS,0278,RC,,,,both,,,522.43,339.58,,,,,,,,,,,,,
GRAFT VASC 6MM DIA 40CM LEN 4CM STR STRTCH STD WALL N RNGD,SUP-2395841,CDM,C1768,CPT,0278,RC,,,,both,,,1742.70,1132.75,,,,,,,,,,,,,
VALVE PULM HOMOGRAFT SZ 21 MM X 7.9 CM CONDUIT STRL,SUP-2175242,CDM,2720000010,LOCAL,0272,RC,,,,both,,,36251.30,23563.34,,,,,,,,,,,,,
GUIDEPIN SURG CANN SCREE +,SUP-2398608,CDM,C1713,HCPCS,0278,RC,,,,both,,,103.62,67.35,,,,,,,,,,,,,
PLATE BONE THICKNESS 1.5MM TI SAG CVD X LNG PLATTEN PROF,SUP-2262968,CDM,C1713,HCPCS,0278,RC,,,,both,,,1218.76,792.19,,,,,,,,,,,,,
NEEDLE SPNL Y 100 MM ES2 LT,SUP-2532842,CDM,2720000010,LOCAL,0272,RC,,,,both,,,678.62,441.10,,,,,,,,,,,,,
CUP ACET MLRY HD 26X62 MM 3 HOLE HIP SYS,SUP-2449900,CDM,C1776,CPT,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
SUPPORT ORTHOT ANK KNEE TIB CUST FRAC SFT,SUP-2435648,CDM,L2112,HCPCS,0272,RC,,,,both,,,1428.32,928.41,,,,,,,,,,,,,
GRAFT BNE SPNG 20X15X5 MM DBM CANC,SUP-2641782,CDM,C1713,HCPCS,0278,RC,,,,both,,,2742.16,1782.40,,,,,,,,,,,,,
PLATE NEURO ULTRA LOW PRFLE STRGHT W/TAB HLX18 LATEX FREE,SUP-2492847,CDM,C1713,HCPCS,0278,RC,,,,both,,,1024.58,665.98,,,,,,,,,,,,,
KNIFE SRGCL JRDN 45DG ANGLD TPRD BLADE FSTPDCTMY LATEX FREE,SUP-2673269,CDM,2720000010,LOCAL,0272,RC,,,,both,,,321.47,208.96,,,,,,,,,,,,,
PLATE BONE L67MM THK3.4MM 4 H BILAT NONLOCKING COMPR FOR,SUP-2348947,CDM,C1713,HCPCS,0278,RC,,,,both,,,1260.96,819.62,,,,,,,,,,,,,
ALLOGRAFT DERMAL 25X30 MM MATRACELL DECELL DERM ARTHROFLEX,SUP-2740767,CDM,Q4125,HCPCS,0636,RC,,,,both,,,3758.58,2443.08,,,,,,,,,,,,,
DRILL SURG MOD 4-6 15 MM TIB CEM SPEC,SUP-2456582,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1466.38,953.15,,,,,,,,,,,,,
SURGICAL KIT PERIARTICULAR 5 MM REDUC AXSOS,SUP-2484856,CDM,C1713,HCPCS,0278,RC,,,,both,,,10033.43,6521.73,,,,,,,,,,,,,
PLATE BONE L22MM 2 H STRL S STL 1/3 TBLR FOR 3.5MM SCR EVOS,SUP-2349634,CDM,C1713,HCPCS,0278,RC,,,,both,,,551.29,358.34,,,,,,,,,,,,,
BRACE WALKING N PNEUMATIC PRE FABRIC,SUP-2388198,CDM,L4386,HCPCS,0274,RC,,,,both,,,440.07,286.05,,,,,,,,,,,,,
ALLOGRAFT BNE PASTE 3 CC CANC PUROS,SUP-2692417,CDM,C1713,HCPCS,0278,RC,,,,both,,,1186.92,771.50,,,,,,,,,,,,,
STENT NEURO SURPS EVOLVE L 12 MM DIA 5 MM COCR PLAT FLO,SUP-2745358,CDM,C1889,HCPCS,0278,RC,,,,both,,,42898.68,27884.14,,,,,,,,,,,,,
MESH HERN M W1.3XL1.6IN INGUINAL POLYPR NONABSORBABLE,SUP-2125790,CDM,C1781,HCPCS,0278,RC,,,,both,,,479.16,311.45,,,,,,,,,,,,,
FIBER LASER HOLM 10608] FORTEC MEDICAL INC],SUP-2225648,CDM,2720000010,LOCAL,0272,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
VEDOLIZUMAB 300 MG IV SOLR,RX-126214,CDM,J3380,HCPCS,0636,RC,64764-0300-20,NDC,,both,1,UN,27611.80,17947.67,,,,,,,,,,,,,
ALLOGRAFT BNE BLOCK 10X25X8 MM UNICORTICAL IL ORAGRAFT,SUP-2740924,CDM,C1713,HCPCS,0278,RC,,,,both,,,824.25,535.76,,,,,,,,,,,,,
PLATE BNE LCK UNIV 3.5 MM 4 HOLE CONTOURED 2 COMPR FOR SCR,SUP-2479199,CDM,C1713,HCPCS,0278,RC,,,,both,,,1148.80,746.72,,,,,,,,,,,,,
PIN FIX L229MM OD2.8MM S STL SMOOTH SGL SHRP TIP TRCR PT 1,SUP-2304042,CDM,C1713,HCPCS,0278,RC,,,,both,,,16.70,10.85,,,,,,,,,,,,,
PLATE BNE L25MM THK33MM 2 H BILAT S STL STR LIMIT CNTCT DYN,SUP-2185123,CDM,C1713,HCPCS,0278,RC,,,,both,,,753.32,489.66,,,,,,,,,,,,,
STEM FEM SZ 12 L300MM STD OFFSET MONOLITHIC SLVLSS REV,SUP-2345609,CDM,C1776,CPT,0278,RC,,,,both,,,19122.60,12429.69,,,,,,,,,,,,,
PLATE BNE LAPIDUS STD 1.3 MM LT MEDL 4 HOLE W/ COMPR GORILLA,SUP-2321485,CDM,C1713,HCPCS,0278,RC,,,,both,,,4275.11,2778.82,,,,,,,,,,,,,
AIRWAY LARYN MASK SGL USE SZ 3 SYR AND LUB 7MM CUF ET TUBE,SUP-2384107,CDM,C1713,HCPCS,0278,RC,,,,both,,,1500.92,975.60,,,,,,,,,,,,,
PLATE BNE DBL Y LG 1.5X19X1 MM MIDFACE 6 HOLE W/ TAB TI NS,SUP-2478356,CDM,C1713,HCPCS,0278,RC,,,,both,,,884.91,575.19,,,,,,,,,,,,,
SCREW BNE 1.5X17 MM SS NS,SUP-2183168,CDM,C1713,HCPCS,0278,RC,,,,both,,,67.13,43.63,,,,,,,,,,,,,
RING EXT FIX DIA150MM FULL FOR RNG FIX SYS TRUELOK,SUP-2316170,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3033.37,1971.69,,,,,,,,,,,,,
PLATE BNE BRIM W 10.5 MM THK 2.5 MM H SPC 12 MM 14 H SCREW,SUP-2902402,CDM,C1713,HCPCS,0278,RC,,,,both,,,6479.70,4211.80,,,,,,,,,,,,,
ANCHOR SUTURE KNOTLESS 2 1.8 MM HIP FIBERTAK,SUP-2423106,CDM,C1713,HCPCS,0278,RC,,,,both,,,1397.30,908.24,,,,,,,,,,,,,
DOBUTAMINE-DEXTROSE 2-5 MG/ML-% IV SOLN,RX-18315,CDM,J1250,HCPCS,0636,RC,00409-2347-31,NDC,,both,250,ML,224.30,145.79,,,,,,,,,,,,,
PLATE BNE W8XL144MM THK3.3MM 18 H NONSTERILE BILAT PELV S,SUP-2186245,CDM,C1713,HCPCS,0278,RC,,,,both,,,2481.23,1612.80,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY L 115 CM DIA 6 FR SPC 2-5-2 MM D,SUP-2248677,CDM,C1732,HCPCS,0278,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
CANNULATED CHISEL FOR TODDLER OSTEOTOMY PLATES,SUP-2548626,CDM,C1713,HCPCS,0278,RC,,,,both,,,3026.52,1967.24,,,,,,,,,,,,,
HC Pelvis Arteriogram,PX-3237573600,CDM,75736,CPT,0323,RC,,,,both,,,6773.00,4402.45,,,,,,,,,,,,,
SYSTEM HARV DISECT HARV ROD TRCR ENDOSCP VES VIRTUOSAPH +,SUP-2385220,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3193.38,2075.70,,,,,,,,,,,,,
BUR SURG BALL MED 3 MM FLUT EXT,SUP-2848202,CDM,2720000010,LOCAL,0272,RC,,,,both,,,473.32,307.66,,,,,,,,,,,,,
PIN GUID DIA2MM TG SGL HEMICAP,SUP-2123526,CDM,2720000010,LOCAL,0272,RC,,,,both,,,279.46,181.65,,,,,,,,,,,,,
STENT URET L 24 CM DIA 8 FR PERCFLX GLDEX USGK DBL PIGTL,SUP-2147803,CDM,C2617,HCPCS,0278,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
TREPHINE BONE BX L8IN DIA19MM RMR FOR FEM REV PROC,SUP-2136786,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2009.60,1306.24,,,,,,,,,,,,,
KIT BNE CEM 5CC CA PHSPTE MACROPOROUS INJ 2 CHAMBERED SYR W,SUP-2120761,CDM,C1713,HCPCS,0278,RC,,,,both,,,4352.04,2828.83,,,,,,,,,,,,,
STEM HUM L110MM DIA12MM 135DEG CO CHROM MOLYBDENUM CEM STD,SUP-2204826,CDM,C1776,CPT,0278,RC,,,,both,,,8025.84,5216.80,,,,,,,,,,,,,
PLATE BONE STR CRANIOMAXILLOFACIAL 2X34 H 2 STRP NONSTERILE,SUP-2363721,CDM,C1713,HCPCS,0278,RC,,,,both,,,2654.40,1725.36,,,,,,,,,,,,,
PIN TEMP FIX ASSURE,SUP-2232043,CDM,C1713,HCPCS,0278,RC,,,,both,,,219.80,142.87,,,,,,,,,,,,,
PLATE VA LCP CLAV SHAFT XL LT 2.7MM ST,SUP-2740107,CDM,C1713,HCPCS,0278,RC,,,,both,,,3517.05,2286.08,,,,,,,,,,,,,
PUMP INFUSION ELASTOMERIC 270 CC 2 ML/HR FIX FLO STRL ON-Q,SUP-2424459,CDM,C9804,HCPCS,0272,RC,,,,both,,,248.06,161.24,,,,,,,,,,,,,
SIZER BRST 700CC DIA15.8CM P4.9CM SIL GEL MOD + PROF RND,SUP-2300897,CDM,2720000010,LOCAL,0272,RC,,,,both,,,973.40,632.71,,,,,,,,,,,,,
PLATE BNE L370MM BLDE W48XL25MM 95DEG 22 H NONSTERILE HIP S,SUP-2186775,CDM,C1713,HCPCS,0278,RC,,,,both,,,4524.27,2940.78,,,,,,,,,,,,,
IMPLANT FACE L 102 X W 4 MM THK 3.6 MM L 102 X W 4.6 MM THK,SUP-2883454,CDM,C1713,HCPCS,0278,RC,,,,both,,,1119.10,727.41,,,,,,,,,,,,,
PLATE BONE 13 H RT DSTL MEDL TIB LCK W/O TAB FOR 3.5MM SCR,SUP-2349087,CDM,C1713,HCPCS,0278,RC,,,,both,,,3128.98,2033.84,,,,,,,,,,,,,
MESH HERN M CLR PLUG AND PTCH SURGPRO HERN-MATE,SUP-2173557,CDM,C1781,HCPCS,0278,RC,,,,both,,,563.41,366.22,,,,,,,,,,,,,
PLATE BNE L MIC XLN EXT 1.5 MM 12 MM LT BAR TI NS LEVEL 1,SUP-2458674,CDM,C1713,HCPCS,0278,RC,,,,both,,,494.17,321.21,,,,,,,,,,,,,
MITOMYCIN 20 MG IV SOLR,RX-10630,CDM,J9280,HCPCS,0636,RC,72819-0153-02,NDC,,both,1,UN,389.40,253.11,,,,,,,,,,,,,
TRAY CATH HEMODIALYSI TRI FLO ACTE 11.5FR DIA SM LUMAN 12CM,SUP-2610530,CDM,C1752,HCPCS,0278,RC,,,,both,,,260.62,169.40,,,,,,,,,,,,,
DISTRACTOR SURG L 30 MM 3 X 3 H RT MANDIBULAR PED NS,SUP-2883396,CDM,C1713,HCPCS,0278,RC,,,,both,,,23612.80,15348.32,,,,,,,,,,,,,
CLAMP 3 D LG BL,SUP-2460235,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1749.07,1136.90,,,,,,,,,,,,,
CAGE SPNL W9XH11XL27MM 0DEG C FBR REINF POLYMER POST LUM,SUP-2255223,CDM,C1889,HCPCS,0278,RC,,,,both,,,53.38,34.70,,,,,,,,,,,,,
MESH CRANIOMAXILLOFACIAL M W90XL90MM THK0.3MM MALL UPGRADED,SUP-2419459,CDM,C1713,HCPCS,0278,RC,,,,both,,,5188.82,3372.73,,,,,,,,,,,,,
SPLINT POLYCENTRIC ULN DEVIATION RT SM,SUP-2324606,CDM,L3906,HCPCS,0272,RC,,,,both,,,177.35,115.28,,,,,,,,,,,,,
PROCESSOR SOUND COCHLEAR IMPL UNILAT KT FOR OSI300 IMPL OSIA2I,SUP-2882740,CDM,L8614,HCPCS,0278,RC,,,,both,,,22789.74,14813.33,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP ANGLED 0.038 INX150 CM GLIDEWIRE UWS6038,SUP-2462933,CDM,C1769,HCPCS,0272,RC,,,,both,,,150.78,98.01,,,,,,,,,,,,,
ALLOGRAFT PUTTY DBM PUROS 5CC SYR,SUP-2414587,CDM,C9359,HCPCS,0278,RC,,,,both,,,2656.44,1726.69,,,,,,,,,,,,,
HC So Hiv-1antibody,PX-3028670166,CDM,86701,CPT,0302,RC,,,,both,,,109.00,70.85,,,,,,,,,,,,,
PLATE BNE TWST 2 HOLE,SUP-2481110,CDM,C1713,HCPCS,0278,RC,,,,both,,,344.14,223.69,,,,,,,,,,,,,
PEG BONE FXTN L24MM D2.5MM FLLY THRDD ALPS HAND FRAC SSTM,SUP-2458480,CDM,C1713,HCPCS,0278,RC,,,,both,,,276.32,179.61,,,,,,,,,,,,,
STOP ORTH HNG KNEE HYPEREXTENSION AX PLUG LEGION,SUP-2346319,CDM,C1776,CPT,0278,RC,,,,both,,,2700.40,1755.26,,,,,,,,,,,,,
SCREW BNE CRTX 3.5X38 MM LP ST HD T15 STARDRV RECESS TI NS,SUP-2758267,CDM,C1713,HCPCS,0278,RC,,,,both,,,102.62,66.70,,,,,,,,,,,,,
NAIL IM L400MM DIA8MM FEM TIB TI SLD LOK AG UNREAMED ENDCAP,SUP-2192765,CDM,C1713,HCPCS,0278,RC,,,,both,,,5329.84,3464.40,,,,,,,,,,,,,
HC Culture Type Immunolog,PX-3008714700,CDM,87147,CPT,0300,RC,,,,both,,,40.00,26.00,,,,,,,,,,,,,
GRAFT TISS FRZ DRY ALLGRFT FASC LATA 15CMX3MM,SUP-2307103,CDM,C1762,CPT,0278,RC,,,,both,,,778.28,505.88,,,,,,,,,,,,,
KIT INSTR DRL AND SPEAR TRCR DISP FOR 3MM SUTURETAK,SUP-2121597,CDM,C1713,HCPCS,0278,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
CATHETER BRONCHSCP L 145 CM WORKING L 72 CM BALLOON DIA13 MM,SUP-2930256,CDM,C2628,HCPCS,0272,RC,,,,both,,,3909.30,2541.04,,,,,,,,,,,,,
BEAM FIX L80MM DIA5.5MM ARTH FOR CHARCOT DEFORMITY AXIS,SUP-2223939,CDM,C1776,CPT,0278,RC,,,,both,,,4050.60,2632.89,,,,,,,,,,,,,
DRESSING WOUND SURGICAL MATRIX XSMALL 10X15 CM PLASTIC MATRISTEM,SUP-2106512,CDM,Q4166,HCPCS,0636,RC,,,,both,,,12611.03,8197.17,,,,,,,,,,,,,
CAGE SPNL 7 DEG 16X14 MM 12 MM UPPER ENDPLATE FOOTPRINT TI,SUP-2230024,CDM,C1889,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
PLATE CNDYL 1.5MM 2H HD 6H SHFT TI STRL VAL,SUP-2546893,CDM,C1713,HCPCS,0278,RC,,,,both,,,1797.84,1168.60,,,,,,,,,,,,,
BIT DRILL 2.3MM TIGON,SUP-2842564,CDM,2720000010,LOCAL,0272,RC,,,,both,,,461.58,300.03,,,,,,,,,,,,,
GRAFT BONE DISC AND CHIP DEMIN BONE MTRX FRZN CANC CORT 32CC,SUP-2223556,CDM,C1762,CPT,0278,RC,,,,both,,,10205.00,6633.25,,,,,,,,,,,,,
CONFORMER EYE DIA25 X 22 MM THK 5.6 MM LG ACRYL NVENT CUP,SUP-2883164,CDM,2720000010,LOCAL,0272,RC,,,,both,,,192.54,125.15,,,,,,,,,,,,,
KIT SURG PWR MINIMALLY INVASIVE IRRIGATION STRL LF DISP,SUP-2881112,CDM,2720000010,LOCAL,0272,RC,,,,both,,,362.67,235.74,,,,,,,,,,,,,
SYRINGE MED 11 N BCA ETHIODIZED OIL NEUROVASC EMB LIQ FOR,SUP-2249001,CDM,C1713,HCPCS,0278,RC,,,,both,,,979.68,636.79,,,,,,,,,,,,,
LEAD PACE COROX OTW-L L 87 CM DIA1.8 MM POLYUR IRIDIUM OXIDE,SUP-2138260,CDM,C1900,HCPCS,0275,RC,,,,both,,,5011.44,3257.44,,,,,,,,,,,,,
SHEATH URET ACC 12FR 35CML W/ DIL,SUP-2119490,CDM,C1894,HCPCS,0272,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
COIL VASC AZUR L 26 CM DIA10 MM MICROCATHETER 0.035 IN LOOP,SUP-2385431,CDM,C1889,HCPCS,0278,RC,,,,both,,,3959.54,2573.70,,,,,,,,,,,,,
DRILL SURG QR 2.8 MM STRL LTX,SUP-2857677,CDM,2720000010,LOCAL,0272,RC,,,,both,,,405.06,263.29,,,,,,,,,,,,,
MATERIAL RESTORATIVE 38GM PWD 14ML LIQ IVRY POLYMER REINF ZN,SUP-2238586,CDM,C1713,HCPCS,0278,RC,,,,both,,,392.59,255.18,,,,,,,,,,,,,
PROBE DOPP 20MHZ 280MML 2MM TIP MALEABLE DISP BIONET HNDL,SUP-2305970,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1277.98,830.69,,,,,,,,,,,,,
CATHETER SUPRPUB 12FR L54CM LO PROF TRCR STYL DRNGE SET,SUP-2171298,CDM,C2627,HCPCS,0272,RC,,,,both,,,236.63,153.81,,,,,,,,,,,,,
PLATE BONE L165MM 9 H RT PROX HUM LCK FOR 3.5MM SCR PERI-LOC,SUP-2348556,CDM,C1713,HCPCS,0278,RC,,,,both,,,13919.31,9047.55,,,,,,,,,,,,,
DOCETAXEL 20 MG/ML IV CONC,RX-106841,CDM,J9171,HCPCS,0636,RC,16729-0267-63,NDC,,both,1,ML,77.80,50.57,,,,,,,,,,,,,
GRAFT BNE SUB W1XL5CM POSTEROLATERAL CERV DEMIN BNE MTRX,SUP-2293965,CDM,C1713,HCPCS,0278,RC,,,,both,,,3956.40,2571.66,,,,,,,,,,,,,
SHEATH URO L55CM ID12FR HYDRPHLC URIN TRACT URET ACCS FLX,SUP-2171319,CDM,C1894,HCPCS,0272,RC,,,,both,,,444.62,289.00,,,,,,,,,,,,,
PIN EXT FIX HALF LNG 6X180 MM 25 MM THRD TIN SIDEKCK FRDM,SUP-2851273,CDM,2720000010,LOCAL,0272,RC,,,,both,,,430.18,279.62,,,,,,,,,,,,,
STENT PERIPH LIFESTENT L 120 MM DIA 5 MM CATH L 80 CM DIA 5,SUP-2541389,CDM,C1876,HCPCS,0278,RC,,,,both,,,7222.00,4694.30,,,,,,,,,,,,,
CATHETER PERITONEAL DLYS TENCK INF 31 CM 2 CUF SIL QUINT,SUP-2754738,CDM,C1752,HCPCS,0278,RC,,,,both,,,217.66,141.48,,,,,,,,,,,,,
LENS TORIC ACRYSOF IQ 30.0,SUP-2112046,CDM,V2787,HCPCS,0276,RC,,,,both,,,435.00,282.75,,,,,,,,,,,,,
COMPONENT SHLDR CAPPED HUM GLEN REVERSED STEM HD ASCEND FLX,SUP-2424092,CDM,C1776,CPT,0278,RC,,,,both,,,27632.00,17960.80,,,,,,,,,,,,,
POST AUG BLK SZ 1 5MM,SUP-2220859,CDM,C1776,CPT,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
SCREW BNE L54MM L17MM OD5.5MM SHT THRD IMPL MONSTER,SUP-2320681,CDM,C1713,HCPCS,0278,RC,,,,both,,,1208.90,785.78,,,,,,,,,,,,,
IMPLANT ANK JT TIB COMP CO CHROM SALTO TALARIS SZ 0,SUP-2244135,CDM,C1776,CPT,0278,RC,,,,both,,,12393.58,8055.83,,,,,,,,,,,,,
COIL VASC NEST EMBOLUS L 14 CM DIA20 MM CATH DIA 0.035 IN,SUP-2638554,CDM,C1889,HCPCS,0278,RC,,,,both,,,380.57,247.37,,,,,,,,,,,,,
PLATE BONE DUAL CMPRSSN HLX5 TTNM 14 TBLR F2.7MM SCREW UNV,SUP-2721009,CDM,C1713,HCPCS,0278,RC,,,,both,,,796.93,518.00,,,,,,,,,,,,,
PLATE BNE L131MM 6 H POSTEROMEDIAL PROX TIB S STL LOK COMPR,SUP-2177797,CDM,C1713,HCPCS,0278,RC,,,,both,,,3449.82,2242.38,,,,,,,,,,,,,
BONE GRAFTING KIT UNILAT CELLULAR BNE MTRX VIVIGEN MIS,SUP-2740944,CDM,C1713,HCPCS,0278,RC,,,,both,,,11099.02,7214.36,,,,,,,,,,,,,
SET IRR ARTHSCP FLD PMP,SUP-2166212,CDM,C1713,HCPCS,0278,RC,,,,both,,,1381.60,898.04,,,,,,,,,,,,,
PLATE BNE 12 H ST BILAT S STL NAR CRV LOK COMPR FOR 35MM SCR,SUP-2178044,CDM,C1713,HCPCS,0278,RC,,,,both,,,2132.63,1386.21,,,,,,,,,,,,,
COIL VASC RETRACTA CATH 0.035 IN PLAT INCONEL DETACHABLE,SUP-2570697,CDM,C1889,HCPCS,0278,RC,,,,both,,,2097.27,1363.23,,,,,,,,,,,,,
LGN CONST INSRT SZ3-4 TIB SZ4-5 FEM 13MM,SUP-2822788,CDM,C1776,CPT,0278,RC,,,,both,,,6939.40,4510.61,,,,,,,,,,,,,
CLAMP L6 MULT PIN POS,SUP-2188488,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1394.16,906.20,,,,,,,,,,,,,
Z DISCONTINUED USE 2149666 GUIDEWIRE BILI ENDO JAGWIRE RX 0.025 INX260 CM,SUP-2141538,CDM,C1769,HCPCS,0272,RC,,,,both,,,322.35,209.53,,,,,,,,,,,,,
GRAFT BIO TISS MARIGEN EXPANSE 2X2CM MESHED,SUP-2909358,CDM,Q4158,HCPCS,0636,RC,,,,both,,,3149.42,2047.12,,,,,,,,,,,,,
PLATE BNE L267MM THK34MM 20 H BILAT S STL STR LIMIT CNTCT,SUP-2185157,CDM,C1713,HCPCS,0278,RC,,,,both,,,2181.48,1417.96,,,,,,,,,,,,,
PLATE BNE W101XL252MM 18 H BILAT TI STR LO PROF RIG LOK,SUP-2191095,CDM,C1713,HCPCS,0278,RC,,,,both,,,2362.03,1535.32,,,,,,,,,,,,,
SYSTEM ENDOSCP VES HARV VASOVIEW 6 PRO,SUP-2266079,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2402.63,1561.71,,,,,,,,,,,,,
PATCH BIOLOGICAL BOVINE PERICARDIUM NERVE 10CM LENGTH 2CM WI,SUP-2821558,CDM,C1763,HCPCS,0278,RC,,,,both,,,326.62,212.30,,,,,,,,,,,,,
GRAFT BNE SCAFFOLD 1 CC OSTEOINDUCTIVE DBM EXPONENT,SUP-2424596,CDM,C1713,HCPCS,0278,RC,,,,both,,,328.13,213.28,,,,,,,,,,,,,
BONE GRAFTING KIT CELLULAR BNE MTRX,SUP-2741916,CDM,C1713,HCPCS,0278,RC,,,,both,,,4869.17,3164.96,,,,,,,,,,,,,
GUIDEWIRE SURG 0.062X14 IN HYPRFLX,SUP-2765744,CDM,C1769,HCPCS,0272,RC,,,,both,,,112.63,73.21,,,,,,,,,,,,,
SPACER SPNL 7 DEG 14X12 MM 12 MM UPPER ENDPLATE FORTIFY I,SUP-2584699,CDM,C1889,HCPCS,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
SIGMA HP UNI FEM DEFCT SHM 1MM,SUP-2513393,CDM,C1776,CPT,0278,RC,,,,both,,,3871.62,2516.55,,,,,,,,,,,,,
CAGE SPNL W15XH15XL25MM C FBR REINF POLYMER POST LUM INTBDY,SUP-2252405,CDM,C1889,HCPCS,0278,RC,,,,both,,,9737.14,6329.14,,,,,,,,,,,,,
ROD EXT FIX L200MM DIA5MM C CONN YEL HOFFMANN II MRI,SUP-2372488,CDM,2720000010,LOCAL,0272,RC,,,,both,,,188.40,122.46,,,,,,,,,,,,,
NEEDLE SURGICAL L6 3/8IN 20DEG PERFORATING MCGEE,SUP-2810175,CDM,2720000010,LOCAL,0272,RC,,,,both,,,450.24,292.66,,,,,,,,,,,,,
ANCHOR SUTURE DIA 3.9 MM BIOCOMP FLAG STRL SWIVELOCK,SUP-2910470,CDM,C1713,HCPCS,0278,RC,,,,both,,,1681.47,1092.96,,,,,,,,,,,,,
URETEROSCOPE FLX DIGITAL 3.6 FRX670 MM 8.6 FR STD WISCOPE,SUP-2653928,CDM,C1747,HCPCS,0272,RC,,,,both,,,4003.50,2602.27,,,,,,,,,,,,,
PLATE BONE 8 H ORBIT CRANIOMAXILLOFACIAL CVD FOR 1MM SCR,SUP-2402921,CDM,C1713,HCPCS,0278,RC,,,,both,,,480.42,312.27,,,,,,,,,,,,,
LOCKING MNDBLR ANGLE PLATE 4X4 NON CMPRSSN 20MM THICK T 6L,SUP-2694219,CDM,C1713,HCPCS,0278,RC,,,,both,,,2614.08,1699.15,,,,,,,,,,,,,
WIRE FIX 2 MM KIRSCHNER ANC600] PROGRESSIVE MEDICAL],SUP-2330465,CDM,C1713,HCPCS,0278,RC,,,,both,,,47.10,30.61,,,,,,,,,,,,,
CATHETER ANGIOPLSTY ADV 18LP L 170 CM BALLOON L 8 CM DIA 6,SUP-2169885,CDM,C1725,HCPCS,0272,RC,,,,both,,,350.11,227.57,,,,,,,,,,,,,
DRILL SURG CTRL MBT LCS COMPLETE,SUP-2453458,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1369.04,889.88,,,,,,,,,,,,,
HANDPIECE 9GAX12MMX12CM BX BRST MAMMO ATEC MINIMALLY,SUP-2239990,CDM,2720000010,LOCAL,0272,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY REFLEXION SPRL L 99 CM 7FR 6.3 MM,SUP-2678547,CDM,C1730,HCPCS,0272,RC,,,,both,,,1427.22,927.69,,,,,,,,,,,,,
SCREW COMPR 4.5X28MM HEADLESS TI SHRT THRD STRL,SUP-2547064,CDM,C1713,HCPCS,0278,RC,,,,both,,,917.10,596.11,,,,,,,,,,,,,
PACEMAKER CARD SINGLE CHMBR TEMP PULSE GENRTR DDDDDD,SUP-2138029,CDM,C1713,HCPCS,0278,RC,,,,both,,,5871.80,3816.67,,,,,,,,,,,,,
LEUPROLIDE ACETATE (4 MONTH) 30 MG IM KIT,RX-21108,CDM,J9217,HCPCS,0636,RC,00074-3683-03,NDC,,both,1,UN,2627.40,1707.81,,,,,,,,,,,,,
NITROGLYCERIN 0.4 MG/SPRAY TL SOLN,RX-27096,CDM,6370000000,HCPCS,0637,RC,45802-0210-01,NDC,,both,4.9,GR,841.80,547.17,,,,,,,,,,,,,
DEFIBRILLATOR 2 CHMBR CARDIOVERTER ADV 7.40CM HT 4.00CM W 40,SUP-2356289,CDM,C1721,HCPCS,0275,RC,,,,both,,,49926.00,32451.90,,,,,,,,,,,,,
CHISEL SURG EXTRACTION SHFT NS,SUP-2799545,CDM,C1713,HCPCS,0278,RC,,,,both,,,1521.42,988.92,,,,,,,,,,,,,
CANNULA SRGCL PRCTNS 4.5/5.5MM SCREW NON ST,SUP-2484113,CDM,2720000010,LOCAL,0272,RC,,,,both,,,994.75,646.59,,,,,,,,,,,,,
PLEDGET CV L 2.5 X W 2.5 CM THK 1.85 MM PTFE FELT LO,SUP-2761316,CDM,C1768,CPT,0278,RC,,,,both,,,54.76,35.59,,,,,,,,,,,,,
STEM FEM PRSS FT 10X150 MM REV SLT GEN II,SUP-2435045,CDM,C1776,CPT,0278,RC,,,,both,,,4220.16,2743.10,,,,,,,,,,,,,
GRAFT VASC IMPRA L 10 CM DIA 8 MM EPTFE FLX TW SM BEAD RING,SUP-2761428,CDM,C1768,CPT,0278,RC,,,,both,,,1141.01,741.66,,,,,,,,,,,,,
SCREW BONE L24MM DIA1.5MM CO CHROM CORT ST NONLOCKING FULL,SUP-2411775,CDM,C1713,HCPCS,0278,RC,,,,both,,,271.30,176.34,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.433,SUP-2859997,CDM,C1713,HCPCS,0278,RC,,,,both,,,38649.63,25122.26,,,,,,,,,,,,,
PROSTHESIS OTO L8MM DIA0.8-1MM POLYCEL TOT OVL HD SHEEHY,SUP-2284068,CDM,L8613,CPT,0278,RC,,,,both,,,739.53,480.69,,,,,,,,,,,,,
HC So Triglycerides,PX-3018447866,CDM,84478,CPT,0301,RC,,,,both,,,38.00,24.70,,,,,,,,,,,,,
ALLOGRAFT BNE DEMINERALIZED CORTICAL 125-710 MIC 3 CC FD,SUP-2717747,CDM,C1713,HCPCS,0278,RC,,,,both,,,729.58,474.23,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 40 CM DIA 6 MM TRMPT TAPR STD HELIX,SUP-2483747,CDM,C1768,CPT,0278,RC,,,,both,,,2383.26,1549.12,,,,,,,,,,,,,
GRAFT HUM TISS 9X67 MM QUADRICEPS TEND FLEXIGRAFT QUADLINK,SUP-2845904,CDM,C1762,CPT,0278,RC,,,,both,,,8245.64,5359.67,,,,,,,,,,,,,
PLATE EXT FIX LNG REAR FT FOR SIDEKCK STLTH,SUP-2400639,CDM,2720000010,LOCAL,0272,RC,,,,both,,,335.98,218.39,,,,,,,,,,,,,
SHEATH TG0854522 85F 22MM 45CM,SUP-2298503,CDM,C1887,HCPCS,0272,RC,,,,both,,,1805.50,1173.57,,,,,,,,,,,,,
PROBE DTECT MARGIN F/LUMPECTOMY,SUP-2213366,CDM,C1713,HCPCS,0278,RC,,,,both,,,3124.30,2030.79,,,,,,,,,,,,,
LEAD PACE 7FR L58CM ULTRATHIN CARD SIL STEROID TI NITRIDE,SUP-2356101,CDM,C1898,HCPCS,0275,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
PROSTHESIS OSS STAP 0.4X5.5 MM PISTON TI,SUP-2457610,CDM,L8613,CPT,0278,RC,,,,both,,,540.24,351.16,,,,,,,,,,,,,
BIT DRL L 360 MM DIA 3.5 MM LCK STRL DISP,SUP-2902137,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1103.11,717.02,,,,,,,,,,,,,
GRAFT BNE 10ML CA PHSPTE DRILLABLE SYN CALLOS,SUP-2106909,CDM,C1713,HCPCS,0278,RC,,,,both,,,9294.40,6041.36,,,,,,,,,,,,,
STAPLE BNE FIX 25X7MM BRDG 4 20MM LEG Y SHP IMPL,SUP-2194191,CDM,C1713,HCPCS,0278,RC,,,,both,,,5420.24,3523.16,,,,,,,,,,,,,
CATHETER CARD ABLATION NAVISTAR RMT L 125 CM DIA 7 FR TIP 8,SUP-2248933,CDM,C1732,HCPCS,0272,RC,,,,both,,,7912.80,5143.32,,,,,,,,,,,,,
PIN FIX TRCR PT 5/64X9 IN PLN STEINMANN,SUP-2362521,CDM,C1713,HCPCS,0278,RC,,,,both,,,32.81,21.33,,,,,,,,,,,,,
SCREW BONE L36MM CORT S STL ST NONCANNULATED NONLOCKING FULL,SUP-2186583,CDM,C1713,HCPCS,0278,RC,,,,both,,,1670.17,1085.61,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 40 CM DIA10 MM EPTFE STR STD WALL,SUP-2396203,CDM,C1768,CPT,0278,RC,,,,both,,,1752.12,1138.88,,,,,,,,,,,,,
KIT CATH HEMODIALYSI DECATHLON DF CHRONIC EXCHANGE DF19IT24K,SUP-2632977,CDM,C1750,HCPCS,0278,RC,,,,both,,,1134.17,737.21,,,,,,,,,,,,,
TREPHINE ORTH DIA5MM CRWN DRL FOR UNIV SCR EXTR,SUP-2368626,CDM,C1713,HCPCS,0278,RC,,,,both,,,2240.39,1456.25,,,,,,,,,,,,,
BONE MATRIX CELLULAR VIAFORM MOLDABLE 1CC,SUP-2854489,CDM,C1713,HCPCS,0278,RC,,,,both,,,1538.60,1000.09,,,,,,,,,,,,,
FIBER LASER 272UM EXCALIBUR DUST THULIUM,SUP-2885332,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
STENT BILI LIFESTENT L 40 MM DIA 9 MM CATH L 80 CM DIA 6 FR,SUP-2128201,CDM,C1876,HCPCS,0278,RC,,,,both,,,5338.00,3469.70,,,,,,,,,,,,,
SCREW BONE 100X130MM LAG PEAK FX,SUP-2137044,CDM,C1713,HCPCS,0278,RC,,,,both,,,1507.20,979.68,,,,,,,,,,,,,
FORCEPS SURG L215X115MM L12FT 15MM TIP BPLR INSUL CRD TIP (EACH = 10),SUP-2243380,CDM,C1713,HCPCS,0278,RC,,,,both,,,2086.62,1356.30,,,,,,,,,,,,,
SCREW CRAN 10PK L 4 MM DIA2.2 MM PLLA PGA PDLA RESRB STRL DELT,SUP-2883350,CDM,C1713,HCPCS,0278,RC,,,,both,,,2660.84,1729.55,,,,,,,,,,,,,
DEFIBRILLATOR IMPL ACTICOR 7 PROMRI VR-T W 66.5 X H 60 MM D,SUP-2739243,CDM,C1882,HCPCS,0275,RC,,,,both,,,55590.56,36133.86,,,,,,,,,,,,,
PLATE BNE TALAR 3 MM TRL,SUP-2498025,CDM,C1713,HCPCS,0278,RC,,,,both,,,1698.74,1104.18,,,,,,,,,,,,,
PREGABALIN 25 MG PO CAPS,RX-42162,CDM,6370000000,HCPCS,0637,RC,60687-0473-01,NDC,,both,1,UN,6.10,3.96,,,,,,,,,,,,,
BAND ANNULPLSTY COSGROVE-EDWARDS SZ 26 MM L 57.9 MM OD 33.6,SUP-2214191,CDM,C1713,HCPCS,0278,RC,,,,both,,,8446.91,5490.49,,,,,,,,,,,,,
CATHETER ANGIOPLSTY OPTA LP L 80 CM BALLOON L 40 MM DIA 6 MM,SUP-2156111,CDM,C1725,HCPCS,0272,RC,,,,both,,,509.25,331.01,,,,,,,,,,,,,
PLATE SPNL 4 LEVEL WIDE 64 MM ANTR CERV ARCHON,SUP-2563427,CDM,C1713,HCPCS,0278,RC,,,,both,,,2590.50,1683.82,,,,,,,,,,,,,
SCREW BNE HALLUX VALGUS 3X14 MM PROSTEP,SUP-2400016,CDM,C1713,HCPCS,0278,RC,,,,both,,,1353.34,879.67,,,,,,,,,,,,,
GRAFT BNE SUB 25CC 50X10X5MM STRP STRATOFUSE,SUP-2164171,CDM,C1713,HCPCS,0278,RC,,,,both,,,981.25,637.81,,,,,,,,,,,,,
BIT DRL 12 MM,SUP-2420187,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3733.46,2426.75,,,,,,,,,,,,,
COIL VASC AZUR CX L 24 CM DIA13 MM MICROCATHETER 0.035 IN,SUP-2385444,CDM,C1889,HCPCS,0278,RC,,,,both,,,4308.08,2800.25,,,,,,,,,,,,,
IMPLANT COCHLEAR SLIM STR ELECTRD NUCLS CI422,SUP-2165045,CDM,L8614,HCPCS,0278,RC,,,,both,,,67845.98,44099.89,,,,,,,,,,,,,
NEEDLE BRONCHSCP 21GA HNDL SHTH NDL STYL PERIVIEW FLX,SUP-2418795,CDM,2720000010,LOCAL,0272,RC,,,,both,,,947.84,616.10,,,,,,,,,,,,,
DRILL SURG 6 ANTIROTATION NOTCH INBONE,SUP-2850356,CDM,2720000010,LOCAL,0272,RC,,,,both,,,332.84,216.35,,,,,,,,,,,,,
PLATE BNE VOLAR CLMN RT DSTL RADIAL 9 HOLE SS NS LCP,SUP-2183197,CDM,C1713,HCPCS,0278,RC,,,,both,,,2405.55,1563.61,,,,,,,,,,,,,
SPLINT WRST L L10IN R FA LN CIRCUMFERENTIAL STRP SLIP ON,SUP-2276629,CDM,L3809,HCPCS,0274,RC,,,,both,,,22.29,14.49,,,,,,,,,,,,,
STENT URET POLARIS L 10 CM DIA 5 FR SENSOR GUIDEWIRE L 150,SUP-2461922,CDM,C2617,HCPCS,0278,RC,,,,both,,,561.49,364.97,,,,,,,,,,,,,
FOUNDATION NP STEM TIB SZ 3 LT **SPECIAL ORD ONLY,SUP-2215824,CDM,C1776,CPT,0278,RC,,,,both,,,5846.68,3800.34,,,,,,,,,,,,,
CATHETER HEMO DYLS OR HD ADMIN BASIC KT DBL LUMN POLYUR STR,SUP-2116540,CDM,C1752,HCPCS,0278,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
PLATE BONE L49MM 4 H S STL SELF COMPR FOR 3.5MM SCR ECT,SUP-2198563,CDM,C1713,HCPCS,0278,RC,,,,both,,,231.51,150.48,,,,,,,,,,,,,
KIT INTRODUCER 9F INTROFLEX MAX BARRIER,SUP-2866712,CDM,2720000010,LOCAL,0272,RC,,,,both,,,545.45,354.54,,,,,,,,,,,,,
DEFIBRILLATOR CRD 40 J 2 CHMBR SJ4 CONN UNIFY DR,SUP-2356313,CDM,C1882,HCPCS,0275,RC,,,,both,,,47145.03,30644.27,,,,,,,,,,,,,
DOPAMINE HCL 40 MG/ML IV SOLN,RX-2595,CDM,J1265,HCPCS,0636,RC,00409-9104-21,NDC,,both,10,ML,54.10,35.16,,,,,,,,,,,,,
HEAD FEMORAL COCR 12/14 36MM +0,SUP-2504653,CDM,C1776,CPT,0278,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
HC So Ptt,PX-3058573066,CDM,85730,CPT,0305,RC,,,,both,,,47.00,30.55,,,,,,,,,,,,,
IMMOBILIZER ORTH SHLDR SUPP UNIV UNISX STD CUFED AD LN WR,SUP-2306067,CDM,L3650,HCPCS,0272,RC,,,,both,,,56.52,36.74,,,,,,,,,,,,,
LEAD PACE SELUTE PICOTIP L 45 CM POLYUR SIL ENDOCARD RT,SUP-2148629,CDM,C1898,HCPCS,0275,RC,,,,both,,,2656.44,1726.69,,,,,,,,,,,,,
GUIDEWIRE UROLOGY DBL FLX 0.035 INX145 CM 5 CM RDRUN PC,SUP-2835783,CDM,C1769,HCPCS,0272,RC,,,,both,,,153.48,99.76,,,,,,,,,,,,,
GUIDEWIRE ORTH BALL TIP 3X800 MM,SUP-2760195,CDM,C1769,HCPCS,0272,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
HC Ribs Bilat 3 Vw W/O Chest,PX-3207111000,CDM,71110,CPT,0320,RC,,,,outpatient,,,732.00,475.80,,,,,,,,,,,,,
MESH SURG DIA10-15CM WHT POLY CLLGN FLM RECT MFIL BIOABSRB,SUP-2283399,CDM,C1781,HCPCS,0278,RC,,,,both,,,1218.48,792.01,,,,,,,,,,,,,
MILRINONE LACTATE 10 MG/10ML IV SOLN|DISCARDED DRUG NOT ADMINISTE,RX-123636,CDM,J2260,HCPCS,0636,RC,00143-9710-01,NDC,JW,both,10,ML,54.10,35.16,,,,,,,,,,,,,
BIT DRL TWST 1.5X22 MM 9 MM W/ STP DENT LATCH LEVEL 1 DISP,SUP-2459583,CDM,2720000010,LOCAL,0272,RC,,,,both,,,446.70,290.35,,,,,,,,,,,,,
MESH HERN W6XL13.5CM SYNTH ABD N ABSRB PRESHAPED KEYHOLE,SUP-2265908,CDM,C1781,HCPCS,0278,RC,,,,both,,,130.18,84.62,,,,,,,,,,,,,
CATHETER CV SET 018 4 FRX60 CM 1LUMEN RAD PWR INJ TURBO-JECT,SUP-2759822,CDM,C1751,HCPCS,0278,RC,,,,both,,,403.02,261.96,,,,,,,,,,,,,
STENT URTRL 8FR DIA 26CML PRCFLX DBLE PGTL STRGHT TIP FLXBLE,SUP-2726052,CDM,C2617,HCPCS,0278,RC,,,,both,,,630.32,409.71,,,,,,,,,,,,,
BIT DRL ADJ STRL ZEVO,SUP-2628870,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1109.68,721.29,,,,,,,,,,,,,
BUR SURG COARSE DIAMOND MED 60 K 3 MM HI SPD UNIDRIVE DISP,SUP-2599312,CDM,2720000010,LOCAL,0272,RC,,,,both,,,624.04,405.63,,,,,,,,,,,,,
ARTHROSCOPIC KIT 2 MM PIN STRL INION FREEDOMPIN LTX DISP,SUP-2857899,CDM,C1713,HCPCS,0278,RC,,,,both,,,1686.18,1096.02,,,,,,,,,,,,,
CATHETER ANGIO ACCU-VU L 70 CM DIA 5 FR GUIDEWIRE 0.035 IN,SUP-2117054,CDM,C1887,HCPCS,0272,RC,,,,both,,,98.91,64.29,,,,,,,,,,,,,
PLATE BNE RECON 2.7X3 MM 36 HOLE ANGLED-ANGLED LCK TI STRL,SUP-2539592,CDM,C1713,HCPCS,0278,RC,,,,both,,,10421.13,6773.73,,,,,,,,,,,,,
PLATE BNE W12XL90MM THK2.5MM 3 H BILAT PROX HUM TI RIG LOK,SUP-2190988,CDM,C1713,HCPCS,0278,RC,,,,both,,,4624.91,3006.19,,,,,,,,,,,,,
PLEDGET 3X3MM TEFLON FIRM,SUP-2425484,CDM,C1768,CPT,0278,RC,,,,both,,,69.17,44.96,,,,,,,,,,,,,
CATHETER REPROC BW HALO XP DIAP EP 7FR,SUP-2473832,CDM,C1731,HCPCS,0278,RC,,,,both,,,1092.78,710.31,,,,,,,,,,,,,
BALLOON KYPHOPLASTY AUG SYS SZ 2 L15MM W/ 10GA NDL IVAS,SUP-2367064,CDM,C1727,CPT,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
GRAFT BONE VIABLE CELL BONE MTRX 15CC CELLENTRA,SUP-2402616,CDM,C1713,HCPCS,0278,RC,,,,both,,,17687.62,11496.95,,,,,,,,,,,,,
CATHETER CARD ABLATION BLZR PRIM XP L 110 CM DIA 7 FR TIP L,SUP-2141339,CDM,C1731,HCPCS,0278,RC,,,,both,,,5181.00,3367.65,,,,,,,,,,,,,
SET SCR SPNL S STL PEDCL W/O BRK OFF FOR 6.35MM ROD CDH LEG,SUP-2288808,CDM,C1713,HCPCS,0278,RC,,,,both,,,453.10,294.51,,,,,,,,,,,,,
BIT DRL SM DIA2MM SH W/ AO QUIK CONN DISP FOR EVOS SM,SUP-2344043,CDM,2720000010,LOCAL,0272,RC,,,,both,,,600.02,390.01,,,,,,,,,,,,,
PLATE BNE L22MM THK1.5MM 8MM SPCR TI REARFOOT LAT CLMN,SUP-2399636,CDM,C1713,HCPCS,0278,RC,,,,both,,,3086.62,2006.30,,,,,,,,,,,,,
CEMENT BONE 80GM DBL DOSE CA PHOS W/ GENTMYCN HI VISC N,SUP-2222169,CDM,C1713,HCPCS,0278,RC,,,,both,,,2150.90,1398.08,,,,,,,,,,,,,
CATHETER BAL DIL 7FR L40CM SHTH 10-12FR TMS,SUP-2141079,CDM,C1725,HCPCS,0272,RC,,,,both,,,753.60,489.84,,,,,,,,,,,,,
GENERATOR NEUROSTIMULATOR W/SINGLE LEAD FOR MODEL 1000,SUP-2175903,CDM,C1767,HCPCS,0278,RC,,,,both,,,129766.78,84348.41,,,,,,,,,,,,,
WASHER ORTH 2 MM EXIT FOR CABLE STRL,SUP-2563697,CDM,C1713,HCPCS,0278,RC,,,,both,,,449.90,292.43,,,,,,,,,,,,,
BLADE 279MM 11IN DISPOSABLE BAN HIP PRESERVATION SYS,SUP-2167157,CDM,2720000010,LOCAL,0272,RC,,,,both,,,790.87,514.07,,,,,,,,,,,,,
GUIDEWIRE ORTH VAR ANG,SUP-2187444,CDM,C1769,HCPCS,0272,RC,,,,both,,,2575.90,1674.33,,,,,,,,,,,,,
WIRE ORTH POLYETHYL KT CERCLAGE FOR GLEN BNE LOSS IMPL STRL,SUP-2882281,CDM,C1713,HCPCS,0278,RC,,,,both,,,2530.84,1645.05,,,,,,,,,,,,,
ENDOTRACHEAL TUBE KIT 35 FR LT DL BLT IN VID CAM VIVASIGHT 2,SUP-2752982,CDM,2720000010,LOCAL,0272,RC,,,,both,,,844.66,549.03,,,,,,,,,,,,,
CONNECTOR SPNL L40MM TRNSVRS LO PROF CLP ON DSGN OASYS,SUP-2362942,CDM,C1713,HCPCS,0278,RC,,,,both,,,1491.50,969.47,,,,,,,,,,,,,
ELECTRODE MONOPOLAR COAG 24 FR PT FOR COLLIN KNIFE YEL STRL,SUP-2360969,CDM,C1713,HCPCS,0278,RC,,,,both,,,401.92,261.25,,,,,,,,,,,,,
PHENYLEPHRINE-MINERAL OIL-PET 0.25-14-74.9 % RE OINT,RX-124243,CDM,6370000000,HCPCS,0637,RC,45802-0188-16,NDC,,both,57,GR,11.80,7.67,,,,,,,,,,,,,
HC Hcg Quantitative,PX-3018470200,CDM,84702,CPT,0301,RC,,,,both,,,393.00,255.45,,,,,,,,,,,,,
PLATE BNE CLAV CS2 2.7 MM LT VA LCK COMPR SS NS VA-LCP,SUP-2750792,CDM,C1713,HCPCS,0278,RC,,,,both,,,3089.26,2008.02,,,,,,,,,,,,,
CONNECTOR ROD PARL 3.5/5.5 MM SINGLE SIERRA,SUP-2245455,CDM,C1713,HCPCS,0278,RC,,,,both,,,3438.30,2234.89,,,,,,,,,,,,,
GRAFT BNE SUB 5CC CA PHSPTE ROTARY MIX PTTY VOID FILL INJ,SUP-2194289,CDM,C9359,HCPCS,0278,RC,,,,both,,,4270.40,2775.76,,,,,,,,,,,,,
PLATE BNE W12XL114MM THK25MM 5 H BILAT PROX HUM TI RIG LOK,SUP-2190989,CDM,C1713,HCPCS,0278,RC,,,,both,,,4769.94,3100.46,,,,,,,,,,,,,
MESH SURG DIA4.5IN CIR SEPRA TECHNOLOGY VENTRALIGHT,SUP-2125905,CDM,C1781,HCPCS,0278,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
KIT SHUNT W CLS TIP LUM CATHETER STRATA,SUP-2278370,CDM,C1729,HCPCS,0272,RC,,,,both,,,15707.60,10209.94,,,,,,,,,,,,,
MICROCATHETER ETER ANGIO 29FR L130CM 0021IN SWAN NK TIP NYL,SUP-2301442,CDM,C1887,HCPCS,0272,RC,,,,both,,,857.06,557.09,,,,,,,,,,,,,
KIT INSTR INTERNALBRACE LIG AUG REP CLLGN COAT FBR TAPE W/,SUP-2121456,CDM,C1713,HCPCS,0278,RC,,,,both,,,3375.50,2194.07,,,,,,,,,,,,,
HC So1 Chromosome Analysis 20-25,PX-3118826467,CDM,88264,CPT,0311,RC,,,,outpatient,,,227.00,147.55,,,,,,,,,,,,,
NAIL FEMORAL RETROGRADE 13X360MM,SUP-2718056,CDM,C1713,HCPCS,0278,RC,,,,both,,,11195.10,7276.81,,,,,,,,,,,,,
SHUNT CV L14MM DIA1.75MM IC SIL BLB TIP RADPQ CLRVW,SUP-2282639,CDM,C1889,HCPCS,0278,RC,,,,both,,,248.06,161.24,,,,,,,,,,,,,
LINER ACET D OD46 48MM ID28MM THK79MM 0DEG POLYETH HA HIP,SUP-2374955,CDM,C1776,CPT,0278,RC,,,,both,,,2390.80,1554.02,,,,,,,,,,,,,
NERVE STIMULATOR KIT PT PRGMR,SUP-2141945,CDM,C1787,HCPCS,0278,RC,,,,both,,,2743.73,1783.42,,,,,,,,,,,,,
RELOAD STPLR L 5 MM ARTICULATING RELD FIX DEV 10 STD VIO,SUP-2913726,CDM,C1713,HCPCS,0278,RC,,,,both,,,802.11,521.37,,,,,,,,,,,,,
GUIDEWIRE VASC MIC KT ACCS STRL,SUP-2117208,CDM,C1769,HCPCS,0272,RC,,,,both,,,1124.12,730.68,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 30 CM DIA24 MM EPTFE STR STD WALL,SUP-2396234,CDM,C1768,CPT,0278,RC,,,,both,,,1981.34,1287.87,,,,,,,,,,,,,
BUTTON GASTRONOMY 18FR L17CM LO PROF ENDOVIVE,SUP-2149740,CDM,C1713,HCPCS,0278,RC,,,,both,,,363.74,236.43,,,,,,,,,,,,,
BUTTON SUTURE BNE TUNN TUNNELPRO,SUP-2908824,CDM,C1713,HCPCS,0278,RC,,,,both,,,847.80,551.07,,,,,,,,,,,,,
FIXATION KIT KNOTLESS TENSIONABLE BICEPS DRL GUIDE FIBERTAK,SUP-2859830,CDM,C1713,HCPCS,0278,RC,,,,both,,,3108.60,2020.59,,,,,,,,,,,,,
PLATE BNE TIB NEUT 2.7/3.5X232 MM RT DSTL 12 HOLE VA LP SS,SUP-2177662,CDM,C1713,HCPCS,0278,RC,,,,both,,,5908.13,3840.28,,,,,,,,,,,,,
ANCHOR SFT TISS L16MM DIA1.1MM KNEE COPOLYMER SGL SELF REINF,SUP-2166731,CDM,C1776,CPT,0278,RC,,,,both,,,380.88,247.57,,,,,,,,,,,,,
CATHETER THROMCTMY PRONTO LP L 140 CM DIA 6 FR GUIDEWIRE,SUP-2383130,CDM,C1757,HCPCS,0272,RC,,,,both,,,715.92,465.35,,,,,,,,,,,,,
GUIDEWIRE VASC INQWIRE L 150 CM 0.035 IN TIP 3 MM N CRV LNG,SUP-2301909,CDM,C1769,HCPCS,0272,RC,,,,both,,,32.50,21.12,,,,,,,,,,,,,
GRAFT HUM TISS ANT TIBIALIS TEND >22CM FRZN (FOLDED DIAM,SUP-2307279,CDM,C1713,HCPCS,0278,RC,,,,both,,,5495.00,3571.75,,,,,,,,,,,,,
KIT INTRO AVNT + DIA 5 FR CANN L 11 CM MINI GUIDEWIRE L 70,SUP-2157388,CDM,C1894,HCPCS,0272,RC,,,,both,,,58.09,37.76,,,,,,,,,,,,,
CUTTER PIN HRCLS 3MM MAX CPCTY LG 8 1/2NL TNGSTN CRBDE BLADE,SUP-2484805,CDM,C1713,HCPCS,0278,RC,,,,both,,,2875.83,1869.29,,,,,,,,,,,,,
PLATE BNE L63MM 3X4 H OBLQ T SHP FOR 35MM SCR,SUP-2199382,CDM,C1713,HCPCS,0278,RC,,,,both,,,558.89,363.28,,,,,,,,,,,,,
JOINT TALAR ANK TOT SYS SALTO TALARIS XL,SUP-2244040,CDM,C1713,HCPCS,0278,RC,,,,both,,,25512.50,16583.12,,,,,,,,,,,,,
TROCAR ENDOSCP DIA12 MM SZ 5/ 7/8 MM POLYUR BALLOON BLNT TIP,SUP-2896154,CDM,2720000010,LOCAL,0272,RC,,,,both,,,685.68,445.69,,,,,,,,,,,,,
HC Assay of Magnesium,PX-3018373500,CDM,83735,CPT,0301,RC,,,,both,,,122.00,79.30,,,,,,,,,,,,,
TROCAR SURG DIA8MM FOR 8X11MM PROTCT SL,SUP-2188183,CDM,C1713,HCPCS,0278,RC,,,,both,,,390.71,253.96,,,,,,,,,,,,,
HOLDER HK OFFSET,SUP-2232087,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2216.84,1440.95,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE 15 CC CORTICOCANCELLOUS ALLGRFT FRZN,SUP-2933867,CDM,C1762,CPT,0278,RC,,,,both,,,13683.34,8894.17,,,,,,,,,,,,,
GUIDEWIRE VASC 145CM 0.025IN TAPR 7 CM FLPY TIP 2 CM,SUP-2167651,CDM,C1769,HCPCS,0272,RC,,,,both,,,34.26,22.27,,,,,,,,,,,,,
HC Aaa Screening Ultrasound,PX-4027670600,CDM,76706,CPT,0402,RC,,,,outpatient,,,881.00,572.65,,,,,,,,,,,,,
SYSTEM STENT DEL SFT 14X7 MMX5X4 CM 4.5 CM NUDEL CP,SUP-2257078,CDM,C1769,HCPCS,0272,RC,,,,both,,,1108.42,720.47,,,,,,,,,,,,,
BASKET STONE RETRV SUR CATCH 11MM 3X2 BSKT 24 FR X 120 CM,SUP-2312750,CDM,2720000010,LOCAL,0272,RC,,,,both,,,608.34,395.42,,,,,,,,,,,,,
GRAFT EVAR DST BODY L76MM LEG L28MM IPSILATERAL DIA12MM SHTH,SUP-2170129,CDM,C1874,HCPCS,0278,RC,,,,both,,,18839.97,12245.98,,,,,,,,,,,,,
ROD EXT FIX L214MM DIA8MM SPAN L207MM 45DEG C FBR CRV,SUP-2188721,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1105.53,718.59,,,,,,,,,,,,,
HC Replac Central Tun Cath W/Pump,PX-3613658300,CDM,36583,CPT,0361,RC,,,,outpatient,,,8583.00,5578.95,,,,,,,,,,,,,
HC So Alkaloids Nos,PX-3018032366,CDM,G0480,CPT,0301,RC,,,,outpatient,,,64.00,41.60,,,,,,,,,,,,,
STIMULATOR NERVE IMPL PULSE GENRTR INFIN 6 DBS,SUP-2431903,CDM,C1767,HCPCS,0278,RC,,,,both,,,53380.00,34697.00,,,,,,,,,,,,,
ELEMENT WORKING BPLR IGLESIAS,SUP-2313972,CDM,C1713,HCPCS,0278,RC,,,,both,,,6962.13,4525.38,,,,,,,,,,,,,
COIL EMB L5CM DIA0.02IN LOOP DIA3MM COMPLX EXTRA SFT FILL,SUP-2323430,CDM,C1889,HCPCS,0278,RC,,,,both,,,6458.98,4198.34,,,,,,,,,,,,,
LEVOFLOXACIN 5 MG/ML IVPB (PED) >/= 50 ML,RX-4090161,CDM,J1956,HCPCS,0250,RC,00143-9720-01,NDC,,both,50,ML,54.10,35.16,,,,,,,,,,,,,
SYSTEM AUTOTRNS 3/16IN 600ML DBL TRCR W/ PVC DRN HEMVAC,SUP-2198715,CDM,2720000010,LOCAL,0272,RC,,,,both,,,451.56,293.51,,,,,,,,,,,,,
KIT PICC 5FR L55CM GWIRE L80CM CARBOTHANE NIT 2 LUMN INSRT,SUP-2116977,CDM,C1751,HCPCS,0278,RC,,,,both,,,468.96,304.82,,,,,,,,,,,,,
LEAD PACE SIL ENDOCARD RT ATRIOVENTRICULAR SCREW FIX SWEET,SUP-2148541,CDM,C1895,HCPCS,0275,RC,,,,both,,,7049.30,4582.04,,,,,,,,,,,,,
SHEATH INTRO PINNACLE DESTINATION 45CM 6FR COAT L 5CM LIMA,SUP-2385280,CDM,C1894,HCPCS,0272,RC,,,,both,,,268.47,174.51,,,,,,,,,,,,,
PIN FIX L 60 MM DIA 3.5 MM PROV COMPR STRL EVOS,SUP-2933621,CDM,C1713,HCPCS,0278,RC,,,,both,,,679.65,441.77,,,,,,,,,,,,,
PLATE BONE L31MM 4 H S STL 1/4 TBLR QTR SLGHT CONCV W/O CLLR,SUP-2186070,CDM,C1713,HCPCS,0278,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
SCREW BNE L 105 MM DIA 3.5 MM ST LCK STRL EVOS,SUP-2931816,CDM,C1713,HCPCS,0278,RC,,,,both,,,526.14,341.99,,,,,,,,,,,,,
PLATE BNE L 163 X W 115 MM THK 0.3 MM SCREW DIA1.5 MM TI CMF,SUP-2883720,CDM,C1713,HCPCS,0278,RC,,,,both,,,6251.74,4063.63,,,,,,,,,,,,,
CATHETER PTCA L130CM BLLN L150MM DIA4MM PACLITAXEL OVR THE,SUP-2280381,CDM,C2623,HCPCS,0278,RC,,,,both,,,4615.80,3000.27,,,,,,,,,,,,,
FILTER VASC OPTEASE L 55 CM NIT FEM ACCS OBTURATOR BRT TIP,SUP-2157005,CDM,C1880,HCPCS,0278,RC,,,,both,,,4012.92,2608.40,,,,,,,,,,,,,
PLATE 4.5MM TI LCP TM STRAIGHT RECON 15 HOLES 284MM,SUP-2549515,CDM,C1713,HCPCS,0278,RC,,,,both,,,1775.95,1154.37,,,,,,,,,,,,,
INFUSION PUMP KIT PAIN 10 IN CTRL CATH PAINBUSTER SOAK ON-Q,SUP-2236848,CDM,C1713,HCPCS,0278,RC,,,,both,,,973.40,632.71,,,,,,,,,,,,,
LOCKING SCR T8 FT 2.7MM / L15MM,SUP-2364743,CDM,C1713,HCPCS,0278,RC,,,,both,,,606.02,393.91,,,,,,,,,,,,,
HANDPIECE PHACO ULTRASONIC USED W/ INFIN VISION SYS,SUP-2109879,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
HC So Dna Antibody|ADJ,PX-3028622566,CDM,86225,CPT,0302,RC,,,ADJ,both,,,397.00,258.05,,,,,,,,,,,,,
BOLT BNE FIX L165MM DIA65MM PROX L10MM DST L24MM MIDFOOT,SUP-2400772,CDM,C1713,HCPCS,0278,RC,,,,both,,,5184.14,3369.69,,,,,,,,,,,,,
GRAFT HUM TISS SEMITENDINOSUS ASEP,SUP-2418650,CDM,C1762,CPT,0278,RC,,,,both,,,4204.46,2732.90,,,,,,,,,,,,,
CATHETER BI-CAVAL 2 LUMN 23FR ELITE,SUP-2124558,CDM,C1729,HCPCS,0272,RC,,,,both,,,7379.00,4796.35,,,,,,,,,,,,,
LOCK DIST TIB MED RT 12H STE,SUP-2501034,CDM,C1713,HCPCS,0278,RC,,,,both,,,4404.23,2862.75,,,,,,,,,,,,,
POROUS FINN STEM 152MMX17.5MM,SUP-2510737,CDM,C1776,CPT,0278,RC,,,,both,,,4448.12,2891.28,,,,,,,,,,,,,
STEM HUM 11MM MINI SHLDR CO CHROM COMPHSVE REV PRI CEM,SUP-2404564,CDM,C1776,CPT,0278,RC,,,,both,,,10990.00,7143.50,,,,,,,,,,,,,
VANCOMYCIN HCL 1 G IV SOLR,RX-143505,CDM,J3373,HCPCS,0636,RC,63323-0284-20,NDC,,both,1,UN,91.50,59.47,,,,,,,,,,,,,
GRAFT BNE 20 MM DISC HA,SUP-2651597,CDM,C1713,HCPCS,0278,RC,,,,both,,,2423.89,1575.53,,,,,,,,,,,,,
TUBES SOUND ABR EARTIP SANIBEL,SUP-2719737,CDM,2720000010,LOCAL,0272,RC,,,,both,,,135.02,87.76,,,,,,,,,,,,,
BRACE ORTH POST LUMBAR BK PREFABRICATED LSO,SUP-2388149,CDM,L0630,HCPCS,0272,RC,,,,both,,,417.09,271.11,,,,,,,,,,,,,
NAIL IM L150MM OD10MM TI LO EXT FOR RECON SURG PANTA,SUP-2243605,CDM,C1713,HCPCS,0278,RC,,,,both,,,12842.51,8347.63,,,,,,,,,,,,,
TUBE INNR EAR MYR VENT FLNG W/ TAB 1.14 MM ID SIL STRL,SUP-2277568,CDM,L8699,HCPCS,0278,RC,,,,both,,,245.86,159.81,,,,,,,,,,,,,
SEALANT SURG 8ML SYN HYDRGEL DESIGNED REDUC POST SURG,SUP-2130351,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3697.98,2403.69,,,,,,,,,,,,,
KIT PICC CATH TRAY 4 FR WITHOUT CHG WITH VPS,SUP-2120612,CDM,C1751,HCPCS,0278,RC,,,,both,,,837.44,544.34,,,,,,,,,,,,,
TRABECTEDIN 1 MG IV SOLR,RX-131640,CDM,J9352,HCPCS,0636,RC,59676-0610-01,NDC,,both,1,UN,10625.30,6906.44,,,,,,,,,,,,,
SYSTEM STENT GRFT OVATION IX L 80 MM DIA20 MM DEL CATH 14 FR,SUP-2217718,CDM,C1874,HCPCS,0278,RC,,,,both,,,33280.86,21632.56,,,,,,,,,,,,,
MESH HERN SQ 16X16 IN FULL RESRB FOR SFT TISS PHASIX,SUP-2855257,CDM,C1781,HCPCS,0278,RC,,,,both,,,66599.40,43289.61,,,,,,,,,,,,,
NEEDLE SPNL BVL 11 GAX6 IN FOR PEDCL ACCS SERENGETI,SUP-2855001,CDM,2720000010,LOCAL,0272,RC,,,,both,,,652.81,424.33,,,,,,,,,,,,,
IMPL BREAST GEL BOOST SMTH MOD + PROF 290CC,SUP-2738067,CDM,C1789,HCPCS,0278,RC,,,,both,,,3658.10,2377.76,,,,,,,,,,,,,
SUTURE D-SPECIAL 3 EBOND GRN BRD D9261,SUP-2218947,CDM,C1713,HCPCS,0278,RC,,,,both,,,1441.26,936.82,,,,,,,,,,,,,
SLEEVE SURG 100DEG ST LT BLU TI LOK FOR 9-12MM FEM NAIL,SUP-2191877,CDM,C1713,HCPCS,0278,RC,,,,both,,,1370.70,890.95,,,,,,,,,,,,,
SYSTEM TARGETING 10MM PRECIS SYS W/ PERPENDICULARITY ROD FOR,SUP-2256811,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6352.22,4128.94,,,,,,,,,,,,,
FORCEPS BX L230CM DIA32MM BLU ALGTR CUP NDL FEN DISPOSABLE,SUP-2313108,CDM,C1713,HCPCS,0278,RC,,,,both,,,52.94,34.41,,,,,,,,,,,,,
CRYOABLATION PROC KT - VAR (4X CVA2400 4X CRYO-55-F 1X,SUP-2885357,CDM,2720000010,LOCAL,0272,RC,,,,both,,,12324.50,8010.92,,,,,,,,,,,,,
PLATE BNE 1ST MTP 10 DEG 2.7 MM RT NS LTX,SUP-2857041,CDM,C1713,HCPCS,0278,RC,,,,both,,,3529.36,2294.08,,,,,,,,,,,,,
BASEPLATE GLEN 29 MM SHLDR W/ LNG POST AEQUALIS REVERSED II,SUP-2715609,CDM,C1776,CPT,0278,RC,,,,both,,,6030.37,3919.74,,,,,,,,,,,,,
BOLT EXT FIX SHLDR NS DISP SMRT TSF,SUP-2932922,CDM,2720000010,LOCAL,0272,RC,,,,both,,,195.90,127.33,,,,,,,,,,,,,
FIBER LASER 550 MH 2 WVLNGTH SIDE FIRING FOR BPH XPEEDA HOLM,SUP-2417492,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3673.55,2387.81,,,,,,,,,,,,,
PLATE BONE L72.6MM SM THK3.7MM 0DEG 5 H TI HYBRID LCK COMPR,SUP-2421386,CDM,C1713,HCPCS,0278,RC,,,,both,,,862.09,560.36,,,,,,,,,,,,,
KNIFE SURG ANNULOTOMY BAYNT DISP MAXCESS,SUP-2310424,CDM,2720000010,LOCAL,0272,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
CATHETER SHUNT PERI L27CM OD15.5FR FOR DENV ASCITES,SUP-2133692,CDM,C1729,HCPCS,0272,RC,,,,both,,,75.99,49.39,,,,,,,,,,,,,
CONNECTOR SPNL L20MM CROSS REVERE,SUP-2229619,CDM,C1713,HCPCS,0278,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
SHUNT KIT FLO CTRL SM SHUNT CONTOURED HI PRESSURE,SUP-2631351,CDM,C1729,HCPCS,0272,RC,,,,both,,,1067.60,693.94,,,,,,,,,,,,,
GUIDEWIRE ORTH L450MM DIA2.8MM CALIB L300MM TRCR PNT THRD,SUP-2194147,CDM,C1769,HCPCS,0272,RC,,,,both,,,193.20,125.58,,,,,,,,,,,,,
KIT CATH HEMODIALYSI PWR TRIALYSI SLIM CATH ACTE 12FR DIA 12,SUP-2613259,CDM,C1752,HCPCS,0278,RC,,,,both,,,886.89,576.48,,,,,,,,,,,,,
BALLOON ULTRASONIC FOR BF-UC160F E,SUP-2313245,CDM,C1725,HCPCS,0272,RC,,,,both,,,90.62,58.90,,,,,,,,,,,,,
MESH HERN LG 4.1X6.3 IN ANAT O3FA FIL COAT C-QUR CENTRIFX,SUP-2227254,CDM,C1781,HCPCS,0278,RC,,,,both,,,477.28,310.23,,,,,,,,,,,,,
PLATE BNE L 156 X W 11 MM THK 3 MM SCREW DIA2.7/3.5 MM 13 H 72466013N,SUP-2933194,CDM,C1713,HCPCS,0278,RC,,,,both,,,5694.39,3701.35,,,,,,,,,,,,,
STAPLER INT EXTRA THICK 60 MM W/ TRI-STAPLE BLK GIA,SUP-2787697,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1525.76,991.74,,,,,,,,,,,,,
KIT REP SM PRELD 2-0 FIBERWIRE A SM KNOT PUSH DISP MENIS,SUP-2121189,CDM,C1713,HCPCS,0278,RC,,,,both,,,973.40,632.71,,,,,,,,,,,,,
COMPONENT TIB LNG KNEE STEM REMEDY,SUP-2424083,CDM,C1776,CPT,0278,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
HEPARIN SODIUM (PORCINE) PF 5000 UNIT/0.5ML IJ SOLN,RX-120978,CDM,J1644,HCPCS,0636,RC,71839-0118-25,NDC,,both,0.5,ML,54.10,35.16,,,,,,,,,,,,,
SCREW BNE CONN SHT CANN FOR TIB NAIL NS,SUP-2799671,CDM,C1713,HCPCS,0278,RC,,,,both,,,1568.78,1019.71,,,,,,,,,,,,,
BIT DRL DIA2.75MM 0.066 CANN FOR GLEN BNE LOSS SET,SUP-2122055,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
COUPLER FLO DIA2.5MM 20MHZ DOPP,SUP-2382621,CDM,C1889,HCPCS,0278,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
BIT DRL CANN 9 MM KNEE FOR ACL/PCL STRL DISP,SUP-2849070,CDM,2720000010,LOCAL,0272,RC,,,,both,,,700.22,455.14,,,,,,,,,,,,,
IMMOBILIZER KNEE WRP II W PAT UNIV,SUP-2196844,CDM,L1810,HCPCS,0274,RC,,,,both,,,40.47,26.31,,,,,,,,,,,,,
PULSE OXIMETER KIT STRT AD PEDIATRIC 12 FT CRD LNOP DCI,SUP-2265856,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1155.52,751.09,,,,,,,,,,,,,
TUBE TRACH PED L40MM OD53MM ID35MM SIL CUF STR NK FLNG FLX,SUP-2352325,CDM,2720000010,LOCAL,0272,RC,,,,both,,,593.52,385.79,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE 5 CC CORTICOCANCELLOUS ALLGRFT,SUP-2932761,CDM,C1762,CPT,0278,RC,,,,both,,,22608.00,14695.20,,,,,,,,,,,,,
HC So Targeted Genomic Seq Analys,PX-3108145566,CDM,81455,CPT,0310,RC,,,,both,,,3287.00,2136.55,,,,,,,,,,,,,
ANCHOR SUT NO 0 2.5MM W/ 1 USP DBL ARMED MORPHIX,SUP-2277450,CDM,C1713,HCPCS,0278,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
PLATE BNE W10XL100MM THK1.5MM 90DEG 8X4 H BILAT S STL T SHP,SUP-2185880,CDM,C1713,HCPCS,0278,RC,,,,both,,,1675.32,1088.96,,,,,,,,,,,,,
ALLOGRAFT BNE SPACER 6 DEG 10 MM FRZN ALIF BIGFOOT,SUP-2731733,CDM,C1713,HCPCS,0278,RC,,,,both,,,12246.00,7959.90,,,,,,,,,,,,,
PLATE BNE L26.6MM THK1.7MM CLP 15MM SLOT L15MM Z B,SUP-2175178,CDM,C1713,HCPCS,0278,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 4X4 CM BLOCKADE AMNIO PROTCT BARR,SUP-2538796,CDM,C1762,CPT,0278,RC,,,,both,,,13404.66,8713.03,,,,,,,,,,,,,
VALVE HEMSTAS W/ GWIRE INSRTN TOOL GRDIAN II NC,SUP-2120549,CDM,C1894,HCPCS,0272,RC,,,,both,,,69.08,44.90,,,,,,,,,,,,,
STENT URET 0.038 IN 6 FRX26 CM SENSOR 2 FLX SET POLARIS LOOP,SUP-2473659,CDM,C2617,HCPCS,0278,RC,,,,both,,,507.42,329.82,,,,,,,,,,,,,
PLATE BNE 3 H RAD WRST S STL CLMN PIN,SUP-2389682,CDM,C1713,HCPCS,0278,RC,,,,both,,,1679.90,1091.93,,,,,,,,,,,,,
SPLINT ANK M SHOE SZ 9-10.5 IN LG POLYPRO PLAS LT FT,SUP-2930190,CDM,L1930,HCPCS,0272,RC,,,,both,,,182.15,118.40,,,,,,,,,,,,,
CUBE EXT FIX 4 HOLE RANCHO,SUP-2749949,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1281.12,832.73,,,,,,,,,,,,,
COLLAR CERV TRACHEOTOMY LG AD 3.25 IN 16-19 IN PHILADELPHIA,SUP-2319293,CDM,L0172,HCPCS,0272,RC,,,,both,,,39.60,25.74,,,,,,,,,,,,,
BLADE SAW 8MM CUT W 70MML 127MM THICKNESS ST UNI,SUP-2253193,CDM,C1713,HCPCS,0278,RC,,,,both,,,335.35,217.98,,,,,,,,,,,,,
ADAPTER LD L 40 CM SIL INSUL UPLR 5 MM RECEPTACLE IS1 CONN,SUP-2616257,CDM,C1883,HCPCS,0278,RC,,,,both,,,684.52,444.94,,,,,,,,,,,,,
NUT ORTH DIA6MM S STL HEX FOR SACR BAR FIX,SUP-2187003,CDM,C1713,HCPCS,0278,RC,,,,both,,,328.54,213.55,,,,,,,,,,,,,
SCREW CANN COMPR 22MM 10MM,SUP-2268244,CDM,C1713,HCPCS,0278,RC,,,,both,,,1033.63,671.86,,,,,,,,,,,,,
SURFACE ARTC 3-4 CH THK10MM AP42MM ML66MM REG YEL UHMWPE,SUP-2201354,CDM,C1776,CPT,0278,RC,,,,both,,,3683.22,2394.09,,,,,,,,,,,,,
CATHETER ANGIOPLSTY RANG L 150 CM BALLOON L 120 MM DIA 5 MM,SUP-2754437,CDM,C2623,HCPCS,0278,RC,,,,both,,,4694.30,3051.29,,,,,,,,,,,,,
PLATE BNE Y,SUP-2315932,CDM,C1713,HCPCS,0278,RC,,,,both,,,3720.90,2418.58,,,,,,,,,,,,,
MONITOR CARD MNL AUTOACTIVATED TRIG CLS BOR CYL MAG MR,SUP-2356337,CDM,C1764,HCPCS,0278,RC,,,,both,,,8923.88,5800.52,,,,,,,,,,,,,
CABLE LIGHT PLIF MAS STRL MAXCESS,SUP-2434164,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
HC Cta Upper Extremity W & W/O Cont,PX-3527320600,CDM,73206,CPT,0352,RC,,,,inpatient,,,2630.00,1709.50,,,,,,,,,,,,,
COLLAR CERV ATLS REG PD5 PEDIATRIC 3-6 YR OCPTL SUPP STRP,SUP-2420905,CDM,L0172,HCPCS,0272,RC,,,,both,,,149.09,96.91,,,,,,,,,,,,,
JIG SURG REDUCTION ACCS N GUID LP,SUP-2167401,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
PLATE BONE L25MM HUM S STL LCK BLDE EQUINOXE,SUP-2223414,CDM,C1713,HCPCS,0278,RC,,,,both,,,353.25,229.61,,,,,,,,,,,,,
GRAFT BONE SUB 30CC PARTIC 1-4MM CANC FRZ DRY CRUSH,SUP-2113912,CDM,C1713,HCPCS,0278,RC,,,,both,,,1398.18,908.82,,,,,,,,,,,,,
DILATOR SURG TUNN GENTLE THREADS 905651,SUP-2745480,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2650.79,1723.01,,,,,,,,,,,,,
CATHETER CV KT 7 FRX30 CM 3L INTRO NDL SHRP SAFETY,SUP-2763325,CDM,C1751,HCPCS,0278,RC,,,,both,,,305.21,198.39,,,,,,,,,,,,,
TUBE TRACH AD L100MM OD9.2MM ID6MM SIL UNCUF EXTRA LEN FIX,SUP-2352033,CDM,2720000010,LOCAL,0272,RC,,,,both,,,852.64,554.22,,,,,,,,,,,,,
HC Inj/Asp Maj Jnt or Bursa,PX-7612061000,CDM,20610,CPT,0761,RC,,,,outpatient,,,1092.00,709.80,,,,,,,,,,,,,
NAIL RFNA 10MMX 360MM 10 DEG BEND/ ST,SUP-2720091,CDM,C1713,HCPCS,0278,RC,,,,both,,,5751.76,3738.64,,,,,,,,,,,,,
BRACE KNEE 17 27IN R L UNIV FIT UPTO 305IN THGH T SCP,SUP-2150870,CDM,L1810,HCPCS,0274,RC,,,,both,,,290.23,188.65,,,,,,,,,,,,,
SYSTEM EXTR BG 3400ML RNG DIA14CM BLLN L100MM DIA12MM,SUP-2119763,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA 5FR 55CM 3 LUMAN R S9385108,SUP-2632878,CDM,C1751,HCPCS,0278,RC,,,,both,,,695.64,452.17,,,,,,,,,,,,,
ASSEMBLY DIL MORPHEUS DIA 4 FR SPLITTABLE SHTH STRL,SUP-2734843,CDM,C1894,HCPCS,0272,RC,,,,both,,,6.59,4.28,,,,,,,,,,,,,
PLATE BONE 1.5MM 8 H STR UNIV NEURO III,SUP-2363642,CDM,C1713,HCPCS,0278,RC,,,,both,,,569.16,369.95,,,,,,,,,,,,,
GRAFT BNE SUB 1CC CELLULAR MTRX OSTEOCEL +,SUP-2310448,CDM,C1713,HCPCS,0278,RC,,,,both,,,1193.20,775.58,,,,,,,,,,,,,
PLATE BNE L230MM 10 H ST R DST HUM EXTRA ARTC S STL LOK,SUP-2177170,CDM,C1713,HCPCS,0278,RC,,,,both,,,4610.12,2996.58,,,,,,,,,,,,,
PLUG MESH M ANCHR 4CM RIM 5CM 3D THERMOFORMED FLAT,SUP-2220111,CDM,C1781,HCPCS,0278,RC,,,,both,,,704.87,458.17,,,,,,,,,,,,,
SCREW BNE CORTICAL 2.7X16 MM FUSION HEX DRV YEL WRST SS NS,SUP-2851923,CDM,C1713,HCPCS,0278,RC,,,,both,,,668.69,434.65,,,,,,,,,,,,,
GUIDEWIRE ORTH OD5MM 3 3.5 4 4 M KT CANN SCRDRVR 2IN 1 DRL,SUP-2225502,CDM,C1769,HCPCS,0272,RC,,,,both,,,562.37,365.54,,,,,,,,,,,,,
BLADE ULTRASONIC L25MM STD BNE BLNT DISP BNE SCALP,SUP-2305943,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1255.50,816.07,,,,,,,,,,,,,
BIT DRILL 4.3X125MM SGL USE STRL,SUP-2152549,CDM,2720000010,LOCAL,0272,RC,,,,both,,,175.40,114.01,,,,,,,,,,,,,
ANCHOR SUT L24.5MM DIA4.75MM SELF PUNCHING BIO-SWIVELOCK SP,SUP-2121700,CDM,C1713,HCPCS,0278,RC,,,,both,,,1193.20,775.58,,,,,,,,,,,,,
PI PICC: 2-L 5FRX50CM WITH 80CM HYDRO NI,SUP-2826702,CDM,C1751,HCPCS,0278,RC,,,,both,,,336.61,218.80,,,,,,,,,,,,,
GUIDEWIRE VASC TEFCOR L 145 CM 0.038 IN 10 CM CRV RAD 3 MM,SUP-2167805,CDM,C1769,HCPCS,0272,RC,,,,both,,,45.66,29.68,,,,,,,,,,,,,
PROBE SUCT BLU ANG TACS DYONIC,SUP-2341611,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1051.90,683.73,,,,,,,,,,,,,
FORCEPS BNE CUT L 131 MM NAR LNG RATCH REDUCTION NS DISP,SUP-2908153,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4263.02,2770.96,,,,,,,,,,,,,
KIT CATHETER 14FR L9IN PERC CAV DRNGE ASSEMB CRV BLU FLEXTIP,SUP-2383258,CDM,C1729,HCPCS,0272,RC,,,,both,,,716.89,465.98,,,,,,,,,,,,,
KIT LD DEL ACCSRY IS1 CTRL HEMOSTAS VLV INTRO TORQUE 3 W,SUP-2149006,CDM,C1887,HCPCS,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
LINER ACET CUP FINISHING B 37 MM EZX,SUP-2745661,CDM,C1776,CPT,0278,RC,,,,both,,,529.88,344.42,,,,,,,,,,,,,
COMPONENT TOE DIA12MM 1X1.5MM OFFSET MT CE ARTC HEMICAP,SUP-2123595,CDM,C1776,CPT,0278,RC,,,,both,,,6280.00,4082.00,,,,,,,,,,,,,
ANCHOR SUTURE STRL CITREFIX,SUP-2900523,CDM,C1713,HCPCS,0278,RC,,,,both,,,2034.72,1322.57,,,,,,,,,,,,,
ELEVATOR SURG L11IN TIP W25MM S STL SATIN FINISH COBB DAWSON,SUP-2160986,CDM,C1713,HCPCS,0278,RC,,,,both,,,341.91,222.24,,,,,,,,,,,,,
SCREW CONN HUM TI NAIL CANN EXPERT SYS,SUP-2178847,CDM,C1713,HCPCS,0278,RC,,,,both,,,1528.83,993.74,,,,,,,,,,,,,
GRAFT HUM TISS W4XL7CM THK0.23-0.51MM THN REGENERATIVE TISS,SUP-2113074,CDM,Q4116,HCPCS,0636,RC,,,,both,,,1538.60,1000.09,,,,,,,,,,,,,
GUIDEWIRE VASC L 145 CM 0.035 IN TIP L 3 MM PTFE J MOVEABLE,SUP-2118928,CDM,C1769,HCPCS,0272,RC,,,,both,,,18.87,12.27,,,,,,,,,,,,,
SODIUM CHLORIDE 3% IV BOLUS,RX-4082505,CDM,J7131,HCPCS,0250,RC,00264-7805-10,NDC,,both,100,ML,9.40,6.11,,,,,,,,,,,,,
TUBE COMPRSS DISTRACTION,SUP-2468926,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
SHUNT KIT FLO CTRL SM SHUNT CONTOURED MED PRESSURE,SUP-2631350,CDM,C1729,HCPCS,0272,RC,,,,both,,,1067.60,693.94,,,,,,,,,,,,,
PLATE BNE CONN 8 HOLE,SUP-2472597,CDM,C1713,HCPCS,0278,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
HC So1 Serotonin,PX-3018426067,CDM,84260,CPT,0301,RC,,,,both,,,436.00,283.40,,,,,,,,,,,,,
BIT DRILL QC 3.8X180MM,SUP-2749486,CDM,2720000010,LOCAL,0272,RC,,,,both,,,622.63,404.71,,,,,,,,,,,,,
COMPONENT HIP P5 ENDO PROS,SUP-2351400,CDM,C1776,CPT,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
FIBER LASER HOLMIUM 272 LONG,SUP-2885396,CDM,2720000010,LOCAL,0272,RC,,,,both,,,769.30,500.04,,,,,,,,,,,,,
PROBE LASER PRECIS 20 GA FIBER HND PC CRV PLAS EYELITE,SUP-2109737,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2509.49,1631.17,,,,,,,,,,,,,
BRACE KNEE POSTOP LNG UNIV UNISX WRP ARND HNG T SCP 10DEG,SUP-2150857,CDM,L1845,HCPCS,0274,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
HC Unlisted Procedure Small Intestine,PX-3614479901,CDM,44799,CPT,0361,RC,,,,both,,,2846.00,1849.90,,,,,,,,,,,,,
KIT STPL FIX BRDG L9MM LEG L12/10MM WIRE 1.3X1.5MM IDEAL,SUP-2194250,CDM,C1713,HCPCS,0278,RC,,,,both,,,2641.31,1716.85,,,,,,,,,,,,,
GRAFT VASC INTERGARD L 85 CM DIA 8 MM RNG L 45 CM,SUP-2495572,CDM,C1768,CPT,0278,RC,,,,both,,,3162.92,2055.90,,,,,,,,,,,,,
CATHETER GUID SOFIA L 115 CM DIA 5 FR ID 0.55 IN OD 0.067 IN,SUP-2305413,CDM,C1887,HCPCS,0272,RC,,,,both,,,4407.30,2864.74,,,,,,,,,,,,,
SEED BRACHYTHERAPY LOOSE 8.01-9.0 MCI NS ADVANTAGE,SUP-2247283,CDM,C2643,HCPCS,0278,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
LIGATOR ENDOSCP DIA8.6-11.5MM MULT DISP SPDBND LIGATOR SUP,SUP-2149563,CDM,2720000010,LOCAL,0272,RC,,,,both,,,452.98,294.44,,,,,,,,,,,,,
TAP SCREW STANDARD LOCKING 24 MM PERIARTICULAR,SUP-2460233,CDM,C1713,HCPCS,0278,RC,,,,both,,,455.39,296.00,,,,,,,,,,,,,
HANDLE DETACH PENUMBRA COIL DH5] PENUMBRA INC],SUP-2323582,CDM,C1713,HCPCS,0278,RC,,,,both,,,747.32,485.76,,,,,,,,,,,,,
PLATE BNE L159MM 6 H L CNDYL S STL VAR ANG LOK COMPR,SUP-2184325,CDM,C1713,HCPCS,0278,RC,,,,both,,,5380.04,3497.03,,,,,,,,,,,,,
DRILL SURGICAL 4.5MM CANNULATED VERSITOMIC,SUP-2589312,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1192.79,775.31,,,,,,,,,,,,,
CATHETER ETER PICC DIA3FR POLYUR SGL LUMN INTMED TY W SFTY,SUP-2125524,CDM,C1751,HCPCS,0278,RC,,,,both,,,254.65,165.52,,,,,,,,,,,,,
BASEPLATE TIB L SZ 1 AP53MM ML77MM UNIV KNEE HA POR CEM,SUP-2377188,CDM,C1776,CPT,0278,RC,,,,both,,,4309.21,2800.99,,,,,,,,,,,,,
BINDER MAMM SURG 3XL X SFT CUP,SUP-2113433,CDM,L8000,HCPCS,0274,RC,,,,both,,,132.82,86.33,,,,,,,,,,,,,
PLATE BNE THK0.8MM BAR L8MM 6 H CRANIOMAXILLOFACIAL GRY TI,SUP-2366263,CDM,C1713,HCPCS,0278,RC,,,,both,,,756.87,491.97,,,,,,,,,,,,,
PLATE BNE W17.5XL178MM THK5.2MM 10 H BILAT S STL BROAD,SUP-2185293,CDM,C1713,HCPCS,0278,RC,,,,both,,,1630.82,1060.03,,,,,,,,,,,,,
SNARE VASC 1 SNR L 100 CM DIA 4 FR TUNGSTEN NIT GLD PLT STRL,SUP-2677173,CDM,C1773,HCPCS,0272,RC,,,,both,,,109.90,71.43,,,,,,,,,,,,,
SCREW BNE L20MM DIA3MM BLU TI ST SELF DRL CANN COMPR CONIC,SUP-2242805,CDM,C1713,HCPCS,0278,RC,,,,both,,,940.05,611.03,,,,,,,,,,,,,
GRAFT BNE L16MM OD27MM PARTIALLY DEMIN TENFUSE NAIL,SUP-2401374,CDM,C1713,HCPCS,0278,RC,,,,both,,,4229.58,2749.23,,,,,,,,,,,,,
SYSTEM PLT PREP FOR CASCADE AUTOLGS MEMBRN,SUP-2307545,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2185.44,1420.54,,,,,,,,,,,,,
CATHETER ENDOBRONCHIAL BLK SET PEDIATRIC 5 FRX50 CM 4.5 MM,SUP-2759865,CDM,2720000010,LOCAL,0272,RC,,,,both,,,614.62,399.50,,,,,,,,,,,,,
BIT DRL L180MM OD1.8-4.2MM FOR 5.5MM SCR,SUP-2242912,CDM,2720000010,LOCAL,0272,RC,,,,both,,,819.07,532.40,,,,,,,,,,,,,
INSERT TIB SZ 4 THK16MM STD UNIV PRI CONSTRN NEUT ANAT MOD,SUP-2252397,CDM,C1776,CPT,0278,RC,,,,both,,,4178.71,2716.16,,,,,,,,,,,,,
IMPLANT FACE L 50 X W 38 MM THK 1.5 MM POLYETHYL EMBEDDED TI,SUP-2883378,CDM,C1713,HCPCS,0278,RC,,,,both,,,3218.53,2092.04,,,,,,,,,,,,,
SCREW BNE ST 1.3X7 MM MXLFCL CRTX CRUCFRM HD W/ FLUT TIP TI,SUP-2189179,CDM,C1713,HCPCS,0278,RC,,,,both,,,320.91,208.59,,,,,,,,,,,,,
GRAFT HUM (see comments)  TISS BIOINTEGRATIVE 30X30 MM STRL TAPESTRY LF,SUP-2867239,CDM,C1763,HCPCS,0278,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
CLOVERLEAF PLT STERILIZER 88 MM 3 HL,SUP-2820744,CDM,C1713,HCPCS,0278,RC,,,,both,,,2266.08,1472.95,,,,,,,,,,,,,
COMPONENT ACET TRIFLANGED LT HIP,SUP-2137602,CDM,C1776,CPT,0278,RC,,,,both,,,5469.88,3555.42,,,,,,,,,,,,,
GRAFT BIO TISS MARIGEN EXPANSE 4X4CM MESHED,SUP-2909363,CDM,Q4158,HCPCS,0636,RC,,,,both,,,5243.80,3408.47,,,,,,,,,,,,,
PLATE BNE CRV MIC 1.5X0.6 MM 3X2 HOLE SQ SEG W/ CROSS BAR TI,SUP-2459657,CDM,C1713,HCPCS,0278,RC,,,,both,,,960.37,624.24,,,,,,,,,,,,,
BEVACIZUMAB-ADCD 400 MG/16ML IV SOLN,RX-161517,CDM,Q5129,HCPCS,0636,RC,72606-0012-01,NDC,,both,16,ML,7803.70,5072.40,,,,,,,,,,,,,
GLYCOPYRROLATE PF 0.4 MG/2ML IJ SOSY,RX-145385,CDM,J1596,HCPCS,0636,RC,70121-1699-01,NDC,,both,0.5,ML,54.10,35.16,,,,,,,,,,,,,
PLATE DERMTOM W4IN STD BLDE GRD AIR ACCURATE ARTC SIMP,SUP-2204023,CDM,C1713,HCPCS,0278,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
BIT DRL CALIB 4.8X180 MM QC,SUP-2315869,CDM,2720000010,LOCAL,0272,RC,,,,both,,,435.14,282.84,,,,,,,,,,,,,
WIRE FIX L270MM DIA25MM LNG MIDFT HD THRD FOR ORTHOLOC 3DI,SUP-2398612,CDM,C1776,CPT,0278,RC,,,,both,,,69.08,44.90,,,,,,,,,,,,,
BIT DRL L 120/50 MM DIA1.5 MM SCREW DIA2 MM CALIB AO QC CLR,SUP-2908280,CDM,2720000010,LOCAL,0272,RC,,,,both,,,771.50,501.47,,,,,,,,,,,,,
PLATE BNE HK 2.7X12 MM RT CLAV VA LCK COMPR STRL VALCP,SUP-2789377,CDM,C1713,HCPCS,0278,RC,,,,both,,,4609.39,2996.10,,,,,,,,,,,,,
SCREW SPNL L45MM DIA7MM TI SGL INNR POLYAX FOR 5.5MM ROD,SUP-2254635,CDM,C1713,HCPCS,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
LEAD DEFIB RIATA ST OPTIM TI POLYUR SIL BPLR SINGLE COIL,SUP-2357372,CDM,C1777,HCPCS,0275,RC,,,,both,,,14915.00,9694.75,,,,,,,,,,,,,
PLATE BNE 1.5/2X73X1.5 MM 12 HOLE SS LC-DCP,SUP-2569201,CDM,C1713,HCPCS,0278,RC,,,,both,,,329.86,214.41,,,,,,,,,,,,,
STEM FEM STD OFFSET EF MAG NK W/ TRUNNION ARCOS,SUP-2443218,CDM,C1776,CPT,0278,RC,,,,both,,,2176.02,1414.41,,,,,,,,,,,,,
SCREW INTRF 8X50 MM TI CROSS-SCREW,SUP-2608261,CDM,C1713,HCPCS,0278,RC,,,,both,,,443.09,288.01,,,,,,,,,,,,,
GUIDEWIRE ZGR CRM HYD J 180CM,SUP-2282460,CDM,C1769,HCPCS,0272,RC,,,,both,,,356.86,231.96,,,,,,,,,,,,,
NEEDLE SUTURE 20 SPECTRUM AUTOPASS,SUP-2765862,CDM,2720000010,LOCAL,0272,RC,,,,both,,,996.89,647.98,,,,,,,,,,,,,
BLADE SHV L18CM DIA3.5MM 15DEG AIRWY NONROTATABLE ANG TIP,SUP-2284140,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1632.80,1061.32,,,,,,,,,,,,,
SCREW BNE ST 2.7X16 MM CORTICAL PERI ARTC,SUP-2177058,CDM,C1713,HCPCS,0278,RC,,,,both,,,39.97,25.98,,,,,,,,,,,,,
MICROSPHERE EMB EMBOSPHERE DIA100-300 UM 1 CC 20 CC SYR YEL,SUP-2303399,CDM,C1889,HCPCS,0278,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
MESH HERN W10XL15CM PET PLA 70% CLLGN 30% GLYC LAP SELF,SUP-2174686,CDM,C1781,HCPCS,0278,RC,,,,both,,,953.90,620.03,,,,,,,,,,,,,
PLATE BONE 8 H LT CLAV LCK J,SUP-2107751,CDM,C1713,HCPCS,0278,RC,,,,both,,,3061.50,1989.97,,,,,,,,,,,,,
STENT URETH 7FR L24MM SIL CLS END DBL J,SUP-2313759,CDM,C2617,HCPCS,0278,RC,,,,both,,,391.34,254.37,,,,,,,,,,,,,
KIT BX DIA2.2MM PASS NDL DISP,SUP-2284363,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2058.21,1337.84,,,,,,,,,,,,,
COMPONENT FEM L7CM 1/3 RT PROX HIP TYP 1 TAPR FINN,SUP-2407261,CDM,C1776,CPT,0278,RC,,,,both,,,12082.72,7853.77,,,,,,,,,,,,,
AUGMENT FEM 3.5MM KNEE TI FLNG OSS,SUP-2405803,CDM,C1776,CPT,0278,RC,,,,both,,,2218.41,1441.97,,,,,,,,,,,,,
CATHETER INFUSION FASTRACKER 325 L 135 CM OD PROX/DSTL,SUP-2147320,CDM,C1887,HCPCS,0272,RC,,,,both,,,1288.50,837.52,,,,,,,,,,,,,
TUBE NASOENT AD 20FR L8IN BLLN L1.5IN DISP BLAKMR,SUP-2127131,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1165.79,757.76,,,,,,,,,,,,,
COMPONENT GLEN SM 4MM SHLDR POLY KEELED MOD NONCONSTRAINED,SUP-2404637,CDM,C1776,CPT,0278,RC,,,,both,,,3884.02,2524.61,,,,,,,,,,,,,
BIT DRILL FLEXIBLE 12MM LONG,SUP-2718099,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2977.19,1935.17,,,,,,,,,,,,,
CANNULA ARTHSCP L55MM ID8.2MM STRL DISP CAPS-LOCK,SUP-2341366,CDM,2720000010,LOCAL,0272,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
VALVE AORT INTUITY ELITE BOV PERICARD COCR POLYESTER SIL,SUP-2214325,CDM,C1713,HCPCS,0278,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
PASSER SUTURE CAPSULESTITCH,SUP-2859832,CDM,2720000010,LOCAL,0272,RC,,,,both,,,926.30,602.09,,,,,,,,,,,,,
ROD EXT FIX L60MM S STL THRD TELSCP ORIG CIR FOR TAY SPAT,SUP-2342299,CDM,2720000010,LOCAL,0272,RC,,,,both,,,183.97,119.58,,,,,,,,,,,,,
PLATE BNE 130 DEG SHFT L 60 MM BLADE L 50 MM SCREW DIA 3.5,SUP-2908315,CDM,C1713,HCPCS,0278,RC,,,,both,,,1648.69,1071.65,,,,,,,,,,,,,
TUBE SET 2.6 MM MACR ST NEXUS SONASTAR,SUP-2748598,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2571.66,1671.58,,,,,,,,,,,,,
CATHETER ETER ACCURACY FULL BA VENT INTRODUCING ROD 15CM,SUP-2243869,CDM,2720000010,LOCAL,0272,RC,,,,both,,,9122.55,5929.66,,,,,,,,,,,,,
CLAMP REPROC TUBE TUBE MRI SAFE FIXATION,SUP-2679119,CDM,2720000010,LOCAL,0272,RC,,,,both,,,440.64,286.42,,,,,,,,,,,,,
BASEPLATE TIB SZ 3 AP48MM ML68MM THK5.5MM L KNEE TI ALLY NP,SUP-2346726,CDM,C1776,CPT,0278,RC,,,,both,,,8025.84,5216.80,,,,,,,,,,,,,
PLATE BNE SM LT LAPIDUS STRATUM,SUP-2607234,CDM,C1713,HCPCS,0278,RC,,,,both,,,4155.63,2701.16,,,,,,,,,,,,,
HC Ua Auto W/O Micro-Ref Lab,PX-3008100366,CDM,81003,CPT,0300,RC,,,,both,,,11.00,7.15,,,,,,,,,,,,,
SCREW BONE CORTEX 1.5X6 MM RAPID RESORBABLE STERILE RAPIDSOR,SUP-2838540,CDM,C1713,HCPCS,0278,RC,,,,both,,,317.61,206.45,,,,,,,,,,,,,
BURR SURG 10MM DIA HD LG BNE BRL FLUTEX6 FLFRVSNS SURG CEBOT,SUP-2605417,CDM,2720000010,LOCAL,0272,RC,,,,both,,,593.46,385.75,,,,,,,,,,,,,
SPLINT ELBW STRP W 0.625 IN SM FOAM INF PADDED HK LOOP,SUP-2930100,CDM,2720000010,LOCAL,0272,RC,,,,both,,,15.67,10.19,,,,,,,,,,,,,
PLATE BNE L23MM 4 H ST S STL LOK COMPR W SHT THRD DRL GUID,SUP-2177470,CDM,C1713,HCPCS,0278,RC,,,,both,,,870.22,565.64,,,,,,,,,,,,,
GRAFT BONE SUB 22X45MM ILIUM TRICORT STRP,SUP-2281639,CDM,C1762,CPT,0278,RC,,,,both,,,5986.57,3891.27,,,,,,,,,,,,,
HC So Microbe Susceptible Disk,PX-3008718466,CDM,87184,CPT,0300,RC,,,,inpatient,,,100.00,65.00,,,,,,,,,,,,,
CATHETER HD CRV EXTN 12 FRX20 CM CATH NDL DUOFLO,SUP-2627073,CDM,C1752,HCPCS,0278,RC,,,,both,,,343.52,223.29,,,,,,,,,,,,,
LAT TIB HEAD BUTT PLT STERILIZER 9HL 181 MM LT,SUP-2818115,CDM,C1713,HCPCS,0278,RC,,,,both,,,5802.25,3771.46,,,,,,,,,,,,,
SCREW BNE CANN 7.3X60 MM 32 MM PART THRD TI STRL TRAUM FIX,SUP-2861362,CDM,C1713,HCPCS,0278,RC,,,,both,,,912.04,592.83,,,,,,,,,,,,,
SCREW BONE L11MM DIA1.5MM TI TRILOK HEXADRIVE 4 APTUS,SUP-2268081,CDM,C1713,HCPCS,0278,RC,,,,both,,,439.98,285.99,,,,,,,,,,,,,
PIN FIX DBL TROCAR 0.141X9 IN SS NS STEINMANN,SUP-2791275,CDM,C1713,HCPCS,0278,RC,,,,both,,,31.65,20.57,,,,,,,,,,,,,
KIT PT SAFETY MED POSTFREE HIP DISTRACTOR STRL DISP PVT,SUP-2907464,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2562.24,1665.46,,,,,,,,,,,,,
SET TBNG INTEGR DISPOSABLE FOR ARTHRO PMP,SUP-2361368,CDM,2720000010,LOCAL,0272,RC,,,,both,,,345.46,224.55,,,,,,,,,,,,,
CATHETER DRIANAGE SUMP PERCFLX MAT N COAT 12FR 30CM,SUP-2147732,CDM,C1729,HCPCS,0272,RC,,,,both,,,294.31,191.30,,,,,,,,,,,,,
BLADE SCREWDRIVER 15MM DIA 40MML CROSS DRIVE,SUP-2681046,CDM,2720000010,LOCAL,0272,RC,,,,both,,,613.30,398.64,,,,,,,,,,,,,
SYSTEM BLLN DIL L16MM DIA6MM FOR EUSTACHIAN TB,SUP-2106342,CDM,C1726,HCPCS,0272,RC,,,,both,,,8280.81,5382.53,,,,,,,,,,,,,
PLATE BNE W10.2XL182MM THK2.7MM 14 H BILAT S STL STR LO,SUP-2186201,CDM,C1713,HCPCS,0278,RC,,,,both,,,1762.64,1145.72,,,,,,,,,,,,,
SYSTEM TISS GLUE 4 ML KT BIOLOGIC FBRN SEAL TISSEEL VALUPAK,SUP-2129971,CDM,C9250,HCPCS,0636,RC,,,,both,,,677.67,440.49,,,,,,,,,,,,,
PLATE BNE TBLR 2.7X49 MM 6 HOLE 1/4 SS,SUP-2536107,CDM,C1713,HCPCS,0278,RC,,,,both,,,382.45,248.59,,,,,,,,,,,,,
PLATE BONE L40-50MM TROCHANTERIC HIP MALLORY-HEAD TI 2 PC,SUP-2405215,CDM,C1713,HCPCS,0278,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
DEVICE BNE FILL SZ 3,SUP-2279566,CDM,2720000010,LOCAL,0272,RC,,,,both,,,901.49,585.97,,,,,,,,,,,,,
CATHETER DRAINAGE SINGLE LUMEN 14 FRX30 CM MP UTHANE,SUP-2168201,CDM,C1729,HCPCS,0272,RC,,,,both,,,550.38,357.75,,,,,,,,,,,,,
PACK VITRCTMY PRB 25+GA CASS EXTRUSION LN INFUS CANN PLUG,SUP-2109944,CDM,C1713,HCPCS,0278,RC,,,,both,,,1723.86,1120.51,,,,,,,,,,,,,
SHEATH INTRO PRELUDE ROADSTER L 45 CM DIA 5 FR COAT L 35 CM,SUP-2900367,CDM,C1894,HCPCS,0272,RC,,,,both,,,320.28,208.18,,,,,,,,,,,,,
GUIDEWIRE VASC GLIDEWIRE 150CM 0.038IN TIP L 3 CM STIFF STR,SUP-2385593,CDM,C1769,HCPCS,0272,RC,,,,both,,,155.24,100.91,,,,,,,,,,,,,
NAIL IM CCD ANGLE 130 DEG L 170 MM DIA12 MM TROCHANTERIC,SUP-2900581,CDM,C1713,HCPCS,0278,RC,,,,both,,,7134.24,4637.26,,,,,,,,,,,,,
TRANSFER SET 6 LD VENTED PREASSEMBLED BARCODED STRL PINNACLE,SUP-2774377,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1520.07,988.05,,,,,,,,,,,,,
IMP SYS BTB T-ROPE W/10.0MM FLIPCUTR II,SUP-2811951,CDM,C1713,HCPCS,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
STAPLER INT CIR 45 MM RELD BIOABSORBABLE REINF LN SEAMGRD,SUP-2485991,CDM,2720000010,LOCAL,0272,RC,,,,both,,,923.16,600.05,,,,,,,,,,,,,
TUBE VNTLTN MRTZ 076MM ID LUMEN 086MM OD FLNGE 1MM DIA INN,SUP-2680276,CDM,L8699,HCPCS,0278,RC,,,,both,,,66.54,43.25,,,,,,,,,,,,,
GRAFT BNE SUB L40MM OD7MM PLUG FRZ DRY,SUP-2306983,CDM,C1713,HCPCS,0278,RC,,,,both,,,2896.24,1882.56,,,,,,,,,,,,,
DEVICE NEUROSTIMULATOR 13.9CC W1.9XH2.2IN 29.1GM RECHRG,SUP-2284637,CDM,C1820,HCPCS,0278,RC,,,,both,,,58356.90,37931.98,,,,,,,,,,,,,
CANNULA SUCTION COHEN ACORN 260X3.2X55 MM UTER SPRING MT NS,SUP-2465989,CDM,2720000010,LOCAL,0272,RC,,,,both,,,940.12,611.08,,,,,,,,,,,,,
SCREW BNE CRTX 2.7X90 MM ST T8 STARDRV RECESS TI NS,SUP-2758224,CDM,C1713,HCPCS,0278,RC,,,,both,,,172.42,112.07,,,,,,,,,,,,,
FIBER LASER DIA200UM FLEXSHIELD COAT HOLM HI PWR TRAC TIP,SUP-2141781,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1298.83,844.24,,,,,,,,,,,,,
GRAFT BNE SUB W25XL100MM THK3MM B TCP SYN TISS STRP CHRONOS,SUP-2182832,CDM,C1713,HCPCS,0278,RC,,,,both,,,3845.72,2499.72,,,,,,,,,,,,,
SHEETS NON-WOVEN WEB 35MMX35MM 1.4X1.4,SUP-2826683,CDM,C1763,HCPCS,0278,RC,,,,both,,,266.90,173.48,,,,,,,,,,,,,
GRAFT HUM TISS 5X5CM THK0.4-1MM MESHED REMODELABLE ACELLULAR,SUP-2225421,CDM,C1713,HCPCS,0278,RC,,,,both,,,9341.50,6071.97,,,,,,,,,,,,,
SPACER TIB H5MM L PROX ENDO MOD M IMPL,SUP-2265092,CDM,C1776,CPT,0278,RC,,,,both,,,3262.46,2120.60,,,,,,,,,,,,,
KIT TESSYS ACCESS DISP JOIMAX,SUP-2848833,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2496.30,1622.59,,,,,,,,,,,,,
HEAD FEM DIA32MM +5MM OFFSET 10/12 TAPR CO CHROM SKIRTED,SUP-2253276,CDM,C1776,CPT,0278,RC,,,,both,,,2071.14,1346.24,,,,,,,,,,,,,
SHEATH LD INTRO SAFSHTH L 13 CM DIA 8 FR GUIDEWIRE 0.038 IN,SUP-2137992,CDM,C1892,HCPCS,0272,RC,,,,both,,,204.10,132.66,,,,,,,,,,,,,
RETRACTOR THMB 15DEG A CRV TAB THMBLE ACCSRY NANOFX,SUP-2123632,CDM,C1713,HCPCS,0278,RC,,,,both,,,131.88,85.72,,,,,,,,,,,,,
NEEDLE BRST LOC L10CM OD20GA N REPOSITIONABLE W/ FLEXSTRAND,SUP-2269621,CDM,C1819,HCPCS,0278,RC,,,,both,,,97.34,63.27,,,,,,,,,,,,,
COMPONENT GLEN CAGED SHLDR MTL-BK,SUP-2223617,CDM,C1776,CPT,0278,RC,,,,both,,,15700.00,10205.00,,,,,,,,,,,,,
STRAP CLAV M HVY DUTY BCKL CLSR,SUP-2194646,CDM,L3650,HCPCS,0274,RC,,,,both,,,18.12,11.78,,,,,,,,,,,,,
DEFIBRILLATOR IMPL VENTAK PRIZM 2 VR DEL ENERGY 31 J TI,SUP-2148620,CDM,C1722,HCPCS,0275,RC,,,,both,,,62784.30,40809.79,,,,,,,,,,,,,
GUIDEWIRE VASC ADX L 150 CM DIA 0.035 IN TIP L 15 CM PTFE,SUP-2752483,CDM,C1769,HCPCS,0272,RC,,,,both,,,43.65,28.37,,,,,,,,,,,,,
KIT CVC AD 9FR L10CM POLYUR DBL LUMN NONTUNNELED AMLESS,SUP-2120578,CDM,C1751,HCPCS,0278,RC,,,,both,,,254.97,165.73,,,,,,,,,,,,,
COMPONENT FEM 190 MM RT DSTL KNEE GRW,SUP-2452033,CDM,C1776,CPT,0278,RC,,,,both,,,71475.19,46458.87,,,,,,,,,,,,,
GUIDEWIRE BLUNT TIP NIT 18 INCH INVICTUS,SUP-2114057,CDM,C1769,HCPCS,0272,RC,,,,both,,,169.56,110.21,,,,,,,,,,,,,
SUPPORT ORTHOPEDIC LOOP LCK 5.5-6.5 IN SM 7.5 IN LT PROCARE,SUP-2197046,CDM,L3931,HCPCS,0272,RC,,,,both,,,20.44,13.29,,,,,,,,,,,,,
PLATE BONE 5 H LT MIDFOOT NAVICULAR CUNEIFORM TI FOR,SUP-2225435,CDM,C1713,HCPCS,0278,RC,,,,both,,,6823.22,4435.09,,,,,,,,,,,,,
DEVICE LASER DEL LNG ENT ANGLED OTOPROBE 10706] FORTEC MEDICAL INC],SUP-2225657,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1059.75,688.84,,,,,,,,,,,,,
HEAD FEM ROTARY BALL MED 32 MM HIP WEBER,SUP-2440883,CDM,C1776,CPT,0278,RC,,,,both,,,1144.53,743.94,,,,,,,,,,,,,
VALVE VENT PUR TRACH TBNG SWALLOING LO PROF DISP PASSY MUIR,SUP-2322024,CDM,L8501,HCPCS,0272,RC,,,,both,,,231.10,150.21,,,,,,,,,,,,,
KIT IMPL L450MM DIA3MM TIM IM AND ENDCAP THE NANCY NAIL,SUP-2253251,CDM,C1713,HCPCS,0278,RC,,,,both,,,659.40,428.61,,,,,,,,,,,,,
ROD SPNL ANTR RT SMOOTH 5.5MM DIA 110MM LEN LEG,SUP-2289285,CDM,C1713,HCPCS,0278,RC,,,,both,,,1284.26,834.77,,,,,,,,,,,,,
BRACE KNEE HNG WRP M,SUP-2276701,CDM,L1820,HCPCS,0272,RC,,,,both,,,53.73,34.92,,,,,,,,,,,,,
CABAZITAXEL 60 MG/1.5ML IV SOLN,RX-105769,CDM,J9043,HCPCS,0636,RC,00024-5824-11,NDC,,both,1,UN,27982.30,18188.49,,,,,,,,,,,,,
PASSER SUT 10/12-15MM DISP CARTER-THOMASON CLOSESURE SYS XL,SUP-2171694,CDM,2720000010,LOCAL,0272,RC,,,,both,,,499.26,324.52,,,,,,,,,,,,,
CLIP NERVE STIM STIMULATING SAFEOP,SUP-2725218,CDM,2720000010,LOCAL,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
PLATE BNE W12XL196MM THK3.7MM LNG 8 H NONSTERILE PROX HUM S,SUP-2186019,CDM,C1713,HCPCS,0278,RC,,,,both,,,4728.49,3073.52,,,,,,,,,,,,,
ADAPTER PACE LD OSCOR L 10 CM SIL INSUL 2 BPLR IS1 CONN,SUP-2356411,CDM,C1883,HCPCS,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
PLATE BNE W5XL39MM THK1.2MM 7 H L CNDYL TI RIG LOK FOR 2MM,SUP-2191063,CDM,C1713,HCPCS,0278,RC,,,,both,,,1128.67,733.64,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED ARTC SURF KNEE UPCHARGE HXLPE,SUP-2212682,CDM,C1776,CPT,0278,RC,,,,both,,,480.42,312.27,,,,,,,,,,,,,
PLATE BNE T 100 MM 5 HOLE SS,SUP-2569107,CDM,C1713,HCPCS,0278,RC,,,,both,,,350.58,227.88,,,,,,,,,,,,,
PROBE ELECSURG SUCTION REG 133 MM 50-S SWP RF N BEND SERFAS,SUP-2435284,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1194.64,776.52,,,,,,,,,,,,,
HC Assay of Urea Nitrogen Urine,PX-3018454000,CDM,84540,CPT,0301,RC,,,,inpatient,,,194.00,126.10,,,,,,,,,,,,,
PROSTHETIC KIT IMPL PT DISP,SUP-2304849,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
CHOLANGIOGRAM KIT RX AUTOTOME UTOM XL SPHINTOM JAGWIRE 7608,SUP-2525342,CDM,C1769,HCPCS,0272,RC,,,,both,,,781.86,508.21,,,,,,,,,,,,,
SCREW SPNL TRANSITION RAIL 4.5X500 MM TI MESA RAIL 4D,SUP-2538576,CDM,C1713,HCPCS,0278,RC,,,,both,,,6929.51,4504.18,,,,,,,,,,,,,
BIT DRL L125MM OD1.6MM PILOT TWST CHK END DISP FOR 2MM LAG,SUP-2366419,CDM,2720000010,LOCAL,0272,RC,,,,both,,,511.04,332.18,,,,,,,,,,,,,
"HC Office/OP Consltj New/Est Pt High Mdm 55 Minutes|SIGNIFICANT, SEPARATELY IDENTIFIABLE EVALUATION AND MANAGEMENT SERVICE BY THE SAME PHYSICIAN ON THE SAME DAY OF THE PROCEDURE OR OTHER SERVICE",PX-5109924500,CDM,99245,CPT,0510,RC,,,25,both,,,439.00,285.35,,,,,,,,,,,,,
MESH HERN REP DIA8CM P4HB MFIL RESRB RND W/ HYDRGEL BARR,SUP-2125879,CDM,C1781,HCPCS,0278,RC,,,,both,,,4019.20,2612.48,,,,,,,,,,,,,
PLATE BNE FIBULAR 3.5X169 MM LT LAT DSTL 13 HOLE EVOS,SUP-2349746,CDM,C1713,HCPCS,0278,RC,,,,both,,,5726.10,3721.96,,,,,,,,,,,,,
PLATE BNE LCK UNIV 131 MM TROCHANTERIC STBL COMPR SS NS DHHS,SUP-2863370,CDM,C1713,HCPCS,0278,RC,,,,both,,,2549.96,1657.47,,,,,,,,,,,,,
HC MRI - Tmj Unilat or Bilat,PX-6107033600,CDM,70336,CPT,0610,RC,,,,outpatient,,,4365.00,2837.25,,,,,,,,,,,,,
"HC Gbl Est Pt, E/M Level 3|MULTIPLE OUTPATIENT HOSPITAL E/M ENCOUNTERS ON THE SAME DATE",PX-9829921300,CDM,99213,CPT,0982,RC,,,27,outpatient,,,393.00,255.45,,,,,,,,,,,,,
BIT DRL TWST 1.5X100 MM MORRISON W/ NOTCH LEVEL 1 DISP,SUP-2463124,CDM,2720000010,LOCAL,0272,RC,,,,both,,,476.93,310.00,,,,,,,,,,,,,
ENDOPROSTHESIS VASC ICAST L 59 MM DIA 6 MM CATH L 80 CM,SUP-2884907,CDM,C1874,HCPCS,0278,RC,,,,both,,,9800.25,6370.16,,,,,,,,,,,,,
SPINDLE INT FIX SM 12MM 800LB M FORC FEM POR INTFACE CPS,SUP-2406898,CDM,C1713,HCPCS,0278,RC,,,,both,,,9806.22,6374.04,,,,,,,,,,,,,
INTRODUCER EP 6 FR 45CM LEN HEMSTAT VLV AD,SUP-2357050,CDM,C1894,HCPCS,0272,RC,,,,both,,,188.40,122.46,,,,,,,,,,,,,
GRAFT HUM TISS L W10.2XL21.1CM CORTIVA 1MM TAILORED ALLGRFT,SUP-2335288,CDM,C1762,CPT,0278,RC,,,,both,,,13068.30,8494.39,,,,,,,,,,,,,
STENT ENDOVASC L29MM DIA5-8MM CATH L80CM INTRO SHTH 7FR,SUP-2395638,CDM,C1874,HCPCS,0278,RC,,,,both,,,9200.20,5980.13,,,,,,,,,,,,,
PLATE BNE 0MM LAT CLMN LENGTHENING LOK POLYAX,SUP-2363893,CDM,C1713,HCPCS,0278,RC,,,,both,,,5530.48,3594.81,,,,,,,,,,,,,
TRAY CATH PICC POLY Q CATH 3FR 0.024IN 60CM 1 LUMAN 3153107,SUP-2632641,CDM,C1751,HCPCS,0278,RC,,,,both,,,314.94,204.71,,,,,,,,,,,,,
CAP L HIP VIT E LNR CERCAP PRICING,SUP-2212078,CDM,C1776,CPT,0278,RC,,,,both,,,18840.00,12246.00,,,,,,,,,,,,,
KIT INTRO L 5 CM DIA 4.5 FR GUIDEWIRE L 40 CM DIA 0.018 IN,SUP-2226021,CDM,C1769,HCPCS,0272,RC,,,,both,,,109.90,71.43,,,,,,,,,,,,,
RELOAD STPL H41X2MM DIA45MM GRN THCK TISS NAT ARTC B FORM,SUP-2218987,CDM,2720000010,LOCAL,0272,RC,,,,both,,,368.13,239.28,,,,,,,,,,,,,
GRAFT BONE SUB 1CC DEMIN BONE MTRX ALLOSYNC PURE,SUP-2120752,CDM,C1713,HCPCS,0278,RC,,,,both,,,847.80,551.07,,,,,,,,,,,,,
HC So Fungus Culture Skin,PX-3008710166,CDM,87101,CPT,0300,RC,,,,inpatient,,,112.00,72.80,,,,,,,,,,,,,
SPLINT ANK FT M L POST LEAF LTWT SEMI RIG ROLYAN,SUP-2326013,CDM,L4396,HCPCS,0274,RC,,,,both,,,98.22,63.84,,,,,,,,,,,,,
INSERT HUM 32 MM SHLDR SOCKET RSP,SUP-2217310,CDM,C1776,CPT,0278,RC,,,,both,,,2590.50,1683.82,,,,,,,,,,,,,
CONNECTOR SPNL TRNSVRS CROSS CONN,SUP-2415585,CDM,C1713,HCPCS,0278,RC,,,,both,,,1088.17,707.31,,,,,,,,,,,,,
CATHETER CHOLGM L50CM L52CM OD5FR 0.035IN GWIRE DISP FOR,SUP-2168432,CDM,C1894,HCPCS,0272,RC,,,,both,,,169.56,110.21,,,,,,,,,,,,,
ALLOGRAFT BNE FRZN ASEP BONE-PATELLAR TENDON-BONE TRU-ARC,SUP-2867219,CDM,C1762,CPT,0278,RC,,,,both,,,12298.91,7994.29,,,,,,,,,,,,,
MESH ORBIT THK0.6MM MIC 22 H CRANIOMAXILLOFACIAL TI PROF,SUP-2262587,CDM,C1713,HCPCS,0278,RC,,,,both,,,635.91,413.34,,,,,,,,,,,,,
NEEDLE PUNC LL 2 MM TIP 5 MMX33 CM,SUP-2852224,CDM,2720000010,LOCAL,0272,RC,,,,both,,,350.08,227.55,,,,,,,,,,,,,
CATHETER CV SINGLE LUMEN 2 FRX30 CM PER-Q-CATH,SUP-2126427,CDM,C1751,HCPCS,0278,RC,,,,both,,,154.49,100.42,,,,,,,,,,,,,
GRAFT HUM TISS W3-10MMX20-38CM GRACILIS TEND FRZN,SUP-2307278,CDM,C1713,HCPCS,0278,RC,,,,both,,,3568.39,2319.45,,,,,,,,,,,,,
SCREW BNE L 150 MM DIA 3.5 MM SS CORTICAL ST STRL EVOS,SUP-2932525,CDM,C1713,HCPCS,0278,RC,,,,both,,,258.42,167.97,,,,,,,,,,,,,
GRAFT BNE H15XL25MM TRICORT PAT WDG FRZ DRY MATRIGRFT,SUP-2264809,CDM,C1713,HCPCS,0278,RC,,,,both,,,2183.46,1419.25,,,,,,,,,,,,,
SET INTRO L 15 CM CATH 5/7.5 FR REINF HEMOSTATIC VLV DIL FOR,SUP-2517605,CDM,C1894,HCPCS,0272,RC,,,,both,,,124.85,81.15,,,,,,,,,,,,,
CATHETER BERN 4FR 100CM,SUP-2116854,CDM,2720000010,LOCAL,0272,RC,,,,both,,,108.64,70.62,,,,,,,,,,,,,
BLADE SHV L22.5CM DIA4MM 1500RPM LNG DBL CRV ANG TIP,SUP-2284158,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1651.23,1073.30,,,,,,,,,,,,,
INTRODUCER SHTH 8FR L81CM 0.038IN TRANSSEPTAL SR0 CRV,SUP-2357245,CDM,C1893,HCPCS,0272,RC,,,,both,,,618.58,402.08,,,,,,,,,,,,,
SCREW IM NAIL L 120 MM DIA10.5 MM HIP LAG STRL GAMMA4,SUP-2900568,CDM,C1713,HCPCS,0278,RC,,,,both,,,2124.87,1381.17,,,,,,,,,,,,,
GUIDEWIRE VASC L 30 CM DIA 0.015 IN CRV RAD 2 MM SS SAFE-T-J,SUP-2760092,CDM,C1769,HCPCS,0272,RC,,,,both,,,92.50,60.12,,,,,,,,,,,,,
DRILL SURG DIA2.52 MM MINI STRL REUSE ACUTRK 3,SUP-2912760,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1623.38,1055.20,,,,,,,,,,,,,
STAPLE SPNL ANTR THORACO LUM PRNG TI COLORADO 2,SUP-2290577,CDM,C1713,HCPCS,0278,RC,,,,both,,,1692.46,1100.10,,,,,,,,,,,,,
HC Peripheral Nerve Neurolysis,PX-3600007519,CDM,3600007519,LOCAL,0360,RC,,,,outpatient,,,9630.00,6259.50,,,,,,,,,,,,,
ANCHOR SUTURE UHMWPE POLYESTER TI BTTN WASHER EXTRATHORACIC,SUP-2905458,CDM,C1713,HCPCS,0278,RC,,,,both,,,11178.40,7265.96,,,,,,,,,,,,,
FOSPHENYTOIN SODIUM 500 MG PE/10ML IJ SOLN,RX-88010,CDM,Q2009,HCPCS,0636,RC,00069-6001-21,NDC,,both,2,ML,139.50,90.67,,,,,,,,,,,,,
SUPPORT ORTHOPEDIC ADJ LG AD PEDIATRIC LT HND WRST FNGR SEP,SUP-2264311,CDM,L3807,HCPCS,0274,RC,,,,both,,,171.92,111.75,,,,,,,,,,,,,
BUR SURG 57X40MM RND DMND STD NONFLUTED ST POWERFORMA,SUP-2284213,CDM,C1713,HCPCS,0278,RC,,,,both,,,489.18,317.97,,,,,,,,,,,,,
LENS IOL 5 MM POST CHMBR,SUP-2110268,CDM,V2632,HCPCS,0276,RC,,,,both,,,3752.30,2438.99,,,,,,,,,,,,,
INTRODUCER LD 5 FRX13 CM 20 CM HEMOSTATIC VLV SAFSHTH TEARWY,SUP-2302616,CDM,C1893,HCPCS,0272,RC,,,,both,,,143.81,93.48,,,,,,,,,,,,,
PLATE BNE CRV 3.5X213 MM 18 HOLE RECON FOR SCR SS NS,SUP-2482146,CDM,C1713,HCPCS,0278,RC,,,,both,,,1635.22,1062.89,,,,,,,,,,,,,
PLATE BNE LCK 2.7X141 MM 12 HOLE CNTOUR 2 COMPR SS STRL,SUP-2461862,CDM,C1713,HCPCS,0278,RC,,,,both,,,1117.75,726.54,,,,,,,,,,,,,
PLATE BONE L226MM 12 H LT MEDL DSTL TIB TIM LCK COMPR FOR,SUP-2137062,CDM,C1713,HCPCS,0278,RC,,,,both,,,5879.78,3821.86,,,,,,,,,,,,,
ENDCAP SPNL DIA20MM 0DEG SM H1.5MM TEETH THORLUM GRY TI,SUP-2390810,CDM,C1889,HCPCS,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED H1B FOREVER,SUP-2212570,CDM,C1776,CPT,0278,RC,,,,both,,,15229.00,9898.85,,,,,,,,,,,,,
FLEXIGRAFT GRAFTLINK TS: D=10.5 L= 88 MM,SUP-2816261,CDM,C1762,CPT,0278,RC,,,,both,,,7033.91,4572.04,,,,,,,,,,,,,
HC Dx Bone Marrow Bx & Aspir,PX-3613822200,CDM,38222,CPT,0361,RC,,,,both,,,8633.00,5611.45,,,,,,,,,,,,,
MARKER BRST BX FOR CELERO,SUP-2240047,CDM,A4648,CPT,0278,RC,,,,both,,,251.20,163.28,,,,,,,,,,,,,
CROWN DENT 6 S STL PRETRIMMED BELLED CRIMPED 6 LO LT PERM M,SUP-2100247,CDM,D6783,CPT,0278,RC,,,,both,,,35.48,23.06,,,,,,,,,,,,,
SET INSTR SM EXT FIX GRPHC CA W/ S STL SELF DRL SCHNZ SCR,SUP-2183086,CDM,2720000010,LOCAL,0272,RC,,,,both,,,45414.17,29519.21,,,,,,,,,,,,,
PLATE BNE SM W10XL97MM THK15MM 90DEG 3X8 H TI T SHP R ANG,SUP-2190939,CDM,C1713,HCPCS,0278,RC,,,,both,,,1849.96,1202.47,,,,,,,,,,,,,
HC Hepatitis B Core Antibody Hbcab Igm Antibody,PX-3028670500,CDM,86705,CPT,0302,RC,,,,both,,,763.00,495.95,,,,,,,,,,,,,
PLATE BONE MAND PRI CRANIO FACE MAND RECON TI STR 17 H FOR,SUP-2363732,CDM,C1713,HCPCS,0278,RC,,,,both,,,1696.86,1102.96,,,,,,,,,,,,,
HEAD FEM OD28MM -3.5MM 12/14 TAPR LO WR FRAC TOUGH PLT TYP,SUP-2222423,CDM,C1776,CPT,0278,RC,,,,both,,,4644.69,3019.05,,,,,,,,,,,,,
EGR XPRESS DISPOSABLE,SUP-2465174,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1758.40,1142.96,,,,,,,,,,,,,
COOLCUT 45 BALL ELECTRODE SJ,SUP-2817908,CDM,2720000010,LOCAL,0272,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
SYSTEM CRAN FIX LG 16 MM STRL LOOP,SUP-2430764,CDM,C1713,HCPCS,0278,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
STENT BILI COT-LNG L 9 CM DIA10 FR 0.035 IN SOFFLX CRV,SUP-2737215,CDM,C2617,HCPCS,0278,RC,,,,both,,,197.82,128.58,,,,,,,,,,,,,
PLATE BNE L 130 MM SCREW DIA2.7/3.5 MM 9 H SS MEDL DSTL TIB,SUP-2931319,CDM,C1713,HCPCS,0278,RC,,,,both,,,4637.15,3014.15,,,,,,,,,,,,,
CATHETER ANGIOPLSTY FOX SV L 135 CM BALLOON L 100 MM DIA10,SUP-2106194,CDM,C1874,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
INTRODUCER SHTH J 10 FRX11 CM ENHANCED DIL DBL DSTL INPUT TS,SUP-2294413,CDM,C1894,HCPCS,0272,RC,,,,both,,,30.14,19.59,,,,,,,,,,,,,
GRAFT BNE MTRX XL 20 CC FIBERGRAFT BG,SUP-2736522,CDM,C1713,HCPCS,0278,RC,,,,both,,,16014.00,10409.10,,,,,,,,,,,,,
HANDPIECE INCIS FOC 0.2 MM LENS CELL BRL,SUP-2713596,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4772.74,3102.28,,,,,,,,,,,,,
STIMULATOR BNE GROWTH PHYSIO-STIM,SUP-2316032,CDM,E0749,HCPCS,0278,RC,,,,both,,,7840.58,5096.38,,,,,,,,,,,,,
SCREW BNE SD 1.5X4 MM CRAN STARDRV RECESS TI NS,SUP-2189245,CDM,C1713,HCPCS,0278,RC,,,,both,,,100.48,65.31,,,,,,,,,,,,,
PLATE BNE CERV SM 2.7X52 MM 6 HOLE TI,SUP-2464010,CDM,C1713,HCPCS,0278,RC,,,,both,,,380.25,247.16,,,,,,,,,,,,,
PACK PHACO RND ABS 30DEG 9MM,SUP-2109876,CDM,C1713,HCPCS,0278,RC,,,,both,,,1444.09,938.66,,,,,,,,,,,,,
PLATE BONE L THK0.3MM MULT H ORBIT FLR TI MESH PREFRM FOR,SUP-2135900,CDM,C1713,HCPCS,0278,RC,,,,both,,,2285.92,1485.85,,,,,,,,,,,,,
WIRE FIX TRCAR PT 1 END 1.5 MMX9 IN SMTH/PLAIN KIRSCHNER 6PK,SUP-2476700,CDM,C1713,HCPCS,0278,RC,,,,both,,,182.75,118.79,,,,,,,,,,,,,
GUIDEWIRE VASC NEOMAGIC L 60 CM DIA 0.010 IN HYDRPHLC REPOS,SUP-2874179,CDM,C1769,HCPCS,0272,RC,,,,both,,,119.95,77.97,,,,,,,,,,,,,
VALVULOTOME LEMAITRE 3MM 3 1/2IN 051481D30] LEMAITRE VASCULAR INC],SUP-2264155,CDM,2720000010,LOCAL,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
TIP MACRO SHORT 2.6MM,SUP-2741123,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2571.66,1671.58,,,,,,,,,,,,,
SLEEVE FEM L31MM UNIV MTPHSEAL TI PORCOAT DST POR LPS,SUP-2250938,CDM,C1776,CPT,0278,RC,,,,both,,,6703.27,4357.13,,,,,,,,,,,,,
SHEATH GUID 8FR L77CM DIA0.11IN MP CRV LO FRIC OBLQ CUT VLV,SUP-2248483,CDM,C1892,HCPCS,0272,RC,,,,both,,,480.42,312.27,,,,,,,,,,,,,
NEEDLE INTRO L98CM OD18GA 30DEG BRK-1 XS S STL TRANSSEPTAL,SUP-2357594,CDM,C1893,HCPCS,0272,RC,,,,both,,,697.08,453.10,,,,,,,,,,,,,
SPACER KNEE 5MM SM-ML DSTL POST DURAC,SUP-2364866,CDM,C1776,CPT,0278,RC,,,,both,,,1896.09,1232.46,,,,,,,,,,,,,
CATHETER HEMO DYLS L 33 CM DIA14.5 FR PRECIS SI SLV,SUP-2905042,CDM,C1750,HCPCS,0278,RC,,,,both,,,1250.38,812.75,,,,,,,,,,,,,
TRAY CATH MIDLN POWERMIDLINE MAXBARR 5FR 20CM 2 LUMAN RVS TA,SUP-2613520,CDM,C1751,HCPCS,0278,RC,,,,both,,,508.68,330.64,,,,,,,,,,,,,
ELECTRODE EMG GRND PD STIMULUS RET NDL NONSTERILE DISPOSABLE,SUP-2292835,CDM,C1713,HCPCS,0278,RC,,,,both,,,1647.87,1071.12,,,,,,,,,,,,,
PLATE SPNL L40MM THORLUM TRUSS,SUP-2230316,CDM,C1713,HCPCS,0278,RC,,,,both,,,13407.80,8715.07,,,,,,,,,,,,,
MESH MIDFACIAL CUSTOMIZED KT AUG HOST MEDPOR,SUP-2862743,CDM,C1713,HCPCS,0278,RC,,,,both,,,23302.03,15146.32,,,,,,,,,,,,,
CANNULA SURG 25GA 41GA AT TIP 0.10MM DBL END SUBRETINAL INJ,SUP-2129187,CDM,2720000010,LOCAL,0272,RC,,,,both,,,382.55,248.66,,,,,,,,,,,,,
GRAFT HUM TISS HAMSTRING 50R503] ZIMMER BIOMET INC],SUP-2208435,CDM,C1762,CPT,0278,RC,,,,both,,,6735.30,4377.94,,,,,,,,,,,,,
PLATE BONE L28MM THK0.3MM 6 H CRANIOMAXILLOFACIAL TI STR FOR,SUP-2136520,CDM,C1713,HCPCS,0278,RC,,,,both,,,320.28,208.18,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED CONSTRN PS VIVACIT-E PERSONA,SUP-2212504,CDM,C1776,CPT,0278,RC,,,,both,,,15464.50,10051.92,,,,,,,,,,,,,
GUIDEWIRE VASC L180CM DIA0.035IN S STL PULM STR JAGWIRE,SUP-2149399,CDM,C1769,HCPCS,0272,RC,,,,both,,,386.53,251.24,,,,,,,,,,,,,
HC So Targ Geonomic Seq Analy,PX-3108144566,CDM,81445,CPT,0310,RC,,,,both,,,2715.00,1764.75,,,,,,,,,,,,,
CYSTOSCOPE RIGID 0 DEGREE 2.7X113 MM,SUP-2862635,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6264.30,4071.79,,,,,,,,,,,,,
RING SPNL SM STAT 5.5X50 MM CLOSED MESA,SUP-2531762,CDM,C1713,HCPCS,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
PLATE BNE L49MM 4 H BILAT S STL 1/3 TBLR FOR 3.5MM SCR,SUP-2411333,CDM,C1713,HCPCS,0278,RC,,,,both,,,194.59,126.48,,,,,,,,,,,,,
DALBAVANCIN HCL 500 MG IV SOLR,RX-126580,CDM,J0875,HCPCS,0636,RC,57970-0100-01,NDC,,both,1,UN,5248.50,3411.52,,,,,,,,,,,,,
COMPONENT TOE JT L15MM 0DEG NEUT PROX INTERPHALANGEAL YEL STO15P] STRYKER CORP],SUP-2365953,CDM,C1713,HCPCS,0278,RC,,,,both,,,2576.06,1674.44,,,,,,,,,,,,,
NKII REV/CONS FEM NP DISTAL SPCR RTSZ 0 4MM LAT,SUP-2509694,CDM,C1776,CPT,0278,RC,,,,both,,,2939.04,1910.38,,,,,,,,,,,,,
PLATE BONE STRAIGHT 1.5 MM 3X3 HOLE PRECONTOURED TITANIUM SI,SUP-2837748,CDM,C1713,HCPCS,0278,RC,,,,both,,,2661.78,1730.16,,,,,,,,,,,,,
COIL NEUROVASCULAR L 15 CM DIA 0.135 IN MICROCATHETER DIA,SUP-2896835,CDM,C1889,HCPCS,0278,RC,,,,both,,,5306.60,3449.29,,,,,,,,,,,,,
RING EXT FIX 5/8 150 MM NS TRUELOK LTX,SUP-2875077,CDM,2720000010,LOCAL,0272,RC,,,,both,,,958.55,623.06,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP JAGWIRE REVOLUTION L 500 CM TIP L 5 CM,SUP-2419661,CDM,C1769,HCPCS,0272,RC,,,,both,,,549.81,357.38,,,,,,,,,,,,,
GRAFT BNE SUB 10ML DEMIN MTRX STERIFUSE,SUP-2138660,CDM,C9359,HCPCS,0278,RC,,,,both,,,6264.30,4071.79,,,,,,,,,,,,,
GRAFT BNE SUB 10CC CA PHSPTE HA PTTY INJ HYDROSET,SUP-2366072,CDM,C1713,HCPCS,0278,RC,,,,both,,,10077.52,6550.39,,,,,,,,,,,,,
ENDO FUSE  FUSION BEAM 25X25MM,SUP-2473271,CDM,C1713,HCPCS,0278,RC,,,,both,,,6644.24,4318.76,,,,,,,,,,,,,
SHEATH INTRO L10CM ID7FR 2.5CM DIL .038IN MINI GWIRE MRK,SUP-2385191,CDM,C1894,HCPCS,0272,RC,,,,both,,,100.32,65.21,,,,,,,,,,,,,
GRAFT HUM TISS W2XL2CM THN SGL LAYR AMNION SOLO CYGNUS,SUP-2393054,CDM,Q4170,HCPCS,0636,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
NAIL IM L400MM DIA10MM 130DEG LNG R PROX FEM GRN TI CANN,SUP-2180498,CDM,C1713,HCPCS,0278,RC,,,,both,,,6454.80,4195.62,,,,,,,,,,,,,
GRAFT BNE H10MM IL CREST WDG FRZ DRY MATRIGRFT,SUP-2264642,CDM,C1762,CPT,0278,RC,,,,both,,,2061.98,1340.29,,,,,,,,,,,,,
DYNAFORCE IS A NIT SUPERELASTIC BONE STPL FOR USE IN SURG,SUP-2175163,CDM,C1713,HCPCS,0278,RC,,,,both,,,2041.00,1326.65,,,,,,,,,,,,,
K WIRE FIX L110MM DIA2.8MM FOR PHLANG PROS ANATOEMIC,SUP-2123380,CDM,C1776,CPT,0278,RC,,,,both,,,21.98,14.29,,,,,,,,,,,,,
BIT DRL L 195 MM DIA 6 MM 3 FLUT FOR QC FOR RADLUC DRV NS,SUP-2907751,CDM,2720000010,LOCAL,0272,RC,,,,both,,,562.28,365.48,,,,,,,,,,,,,
SCREW EXT FIX L100MM DIA6MM THRD L30MM S STL SELF DRL MR,SUP-2186991,CDM,C1713,HCPCS,0278,RC,,,,both,,,492.60,320.19,,,,,,,,,,,,,
GRAFT HUM TISS BNE TEND BNE HEMI W/ QUADRICEPS W10-13MM,SUP-2307265,CDM,C1713,HCPCS,0278,RC,,,,both,,,7330.08,4764.55,,,,,,,,,,,,,
PERFORATOR SURGICAL L14MM OD11MM CRANIAL HIGH PERFORMANCE DISPOSABLE KIT ACRA CUT DGR II,SUP-2106553,CDM,C1713,HCPCS,0278,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
KIT ROBOTIC SPINE DISP MAZORX,SUP-2266519,CDM,C1713,HCPCS,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
COVER BUR H L14MM DIA0.6MM DOMED W/ TAB,SUP-2365228,CDM,C1713,HCPCS,0278,RC,,,,both,,,1042.48,677.61,,,,,,,,,,,,,
DEXTROSE 10 % IV BOLUS,RX-4081995,CDM,2580000003,HCPCS,0250,RC,00338-0023-02,NDC,,both,125,ML,26.60,17.29,,,,,,,,,,,,,
COMPONENT TOT KNEE CAPPED UNI OXIN,SUP-2351430,CDM,C1776,CPT,0278,RC,,,,both,,,11775.00,7653.75,,,,,,,,,,,,,
IMPLANT FACE 40 X 40 MM THK 8.45 MM POLYETHYL LL ORBIT RIM,SUP-2883315,CDM,C1713,HCPCS,0278,RC,,,,both,,,2144.24,1393.76,,,,,,,,,,,,,
GUIDEWIRE VASC COPE L 60 CM DIA 0.018 IN TAPR L 3.25 CM FLPY,SUP-2168436,CDM,C1769,HCPCS,0272,RC,,,,both,,,94.58,61.48,,,,,,,,,,,,,
SCREW SPNL 4.5X22 MM SYM,SUP-2539618,CDM,C1713,HCPCS,0278,RC,,,,both,,,3545.06,2304.29,,,,,,,,,,,,,
PLATE EXT FIX SHT 200 MM FT RNG TI NS,SUP-2800130,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3143.45,2043.24,,,,,,,,,,,,,
GRAFT BLK CERV CORT ALLGRFT 7MMX14MMX11MM,SUP-2289235,CDM,C1763,HCPCS,0278,RC,,,,both,,,2815.80,1830.27,,,,,,,,,,,,,
COIL VASC INTERLOCK-18 L 20 CM DIA10 MM GUIDEWIRE 0.018 IN,SUP-2142384,CDM,C1889,HCPCS,0278,RC,,,,both,,,1303.10,847.01,,,,,,,,,,,,,
SPHERE GLEN INFERIOR 2.5+ MM 24X36 MM TI,SUP-2845833,CDM,C1776,CPT,0278,RC,,,,both,,,11932.00,7755.80,,,,,,,,,,,,,
PLATE BONE L70MM THK3.1MM 6 H BILAT S STL LCK COMPR RECON,SUP-2348688,CDM,C1713,HCPCS,0278,RC,,,,both,,,4690.53,3048.84,,,,,,,,,,,,,
GRAFT VASC INTERGARD L 70 CM DIA 8 MM RNG L 15 CM UTHN,SUP-2914831,CDM,C1762,CPT,0278,RC,,,,both,,,3149.58,2047.23,,,,,,,,,,,,,
IMMOBILIZER SHLDR L L9X19.5IN R/L CANVS W/ WAIST STRP THMB,SUP-2336104,CDM,L3660,HCPCS,0274,RC,,,,both,,,20.88,13.57,,,,,,,,,,,,,
APPLIER CLP SM L54.5CM JAW L1.1CM VERY HI CLS VERY LO OPN,SUP-2246602,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6594.00,4286.10,,,,,,,,,,,,,
SCREW BNE L4MM DIA2.3MM MAND CRANIOMAXILLOFACIAL SIL LOK 5PK,SUP-2366161,CDM,C1713,HCPCS,0278,RC,,,,both,,,347.13,225.63,,,,,,,,,,,,,
SPLINT ORTH D RNG CLOSURE UNIV 10 IN WRST FOREARM LT,SUP-2336335,CDM,L3809,HCPCS,0274,RC,,,,both,,,27.48,17.86,,,,,,,,,,,,,
HC Doppler Echo,PX-4839332000,CDM,93320,CPT,0483,RC,,,,outpatient,,,2133.00,1386.45,,,,,,,,,,,,,
PLATE BNE HUM 166 MM RT DSTL MEDL 17 HOLE STRL A.L.P.S,SUP-2463056,CDM,C1713,HCPCS,0278,RC,,,,both,,,3143.14,2043.04,,,,,,,,,,,,,
PACEMAKER CARD 23GM 11CC H42XL52MM THK6MM TI PARYLENE EPOXY,SUP-2356209,CDM,C1786,HCPCS,0275,RC,,,,both,,,8792.00,5714.80,,,,,,,,,,,,,
GRAFT VASC IMPRA L 40 CM DIA 6 MM EPTFE STR STD WALL N RING,SUP-2761278,CDM,C1768,CPT,0278,RC,,,,both,,,1411.81,917.68,,,,,,,,,,,,,
RING EXT FIX DIA180 MM LNG FT NS DISP SMRT TSF,SUP-2933201,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5135.47,3338.06,,,,,,,,,,,,,
COMPONENT FEM AP43MM ML68MM RT KNEE CO CHROM NONBEADED NP,SUP-2252372,CDM,C1776,CPT,0278,RC,,,,both,,,8980.40,5837.26,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY ESOPHASTAR L 125 CM DIA 8 FR BLU,SUP-2248921,CDM,C1732,HCPCS,0272,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
INTRODUCER SHTH TRANSSEPTAL 032 8 FRX61 CM 67 CM MULLINS,SUP-2463416,CDM,C1893,HCPCS,0272,RC,,,,both,,,238.64,155.12,,,,,,,,,,,,,
FRAME EXT FIX L155MM ASSEMB FT ILIZ,SUP-2343004,CDM,2720000010,LOCAL,0272,RC,,,,both,,,36595.29,23786.94,,,,,,,,,,,,,
COMPONENT TIB SZ G R MED CEM FOR PART KNEE SYS PERSONA,SUP-2402770,CDM,C1776,CPT,0278,RC,,,,both,,,11586.60,7531.29,,,,,,,,,,,,,
HC Anaerobic ID,PX-3008707600,CDM,87076,CPT,0300,RC,,,,both,,,95.00,61.75,,,,,,,,,,,,,
GRAFT HUM TISS W4XL8CM AMNIO MEMBRN AXOGRFT,SUP-2125455,CDM,C1762,CPT,0278,RC,,,,both,,,10048.00,6531.20,,,,,,,,,,,,,
COLLAR CERV DEFINITIVE PEDIATRIC 8-11X2 IN 2 PC,SUP-2428148,CDM,L0172,HCPCS,0272,RC,,,,both,,,173.83,112.99,,,,,,,,,,,,,
RING EXT FIX DIA155 MM FULL RED NS DISP SMRT TSF,SUP-2932915,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4820.03,3133.02,,,,,,,,,,,,,
CATHETER GUID 5FR L100CM ID0.056IN NYL POLYUR S STL BRAID,SUP-2248993,CDM,C1887,HCPCS,0272,RC,,,,both,,,1480.13,962.08,,,,,,,,,,,,,
ENVELOPE DEFIB BIOENVELOPE 2XL FIVE PK STRL,SUP-2138486,CDM,C1713,HCPCS,0278,RC,,,,both,,,21195.00,13776.75,,,,,,,,,,,,,
AUTOTRANSFUSION KIT 120 MH FAST STRT AT1 FOR CATS +,SUP-2429401,CDM,2720000010,LOCAL,0272,RC,,,,both,,,551.07,358.20,,,,,,,,,,,,,
EXTENSION NEUROSTIMULATOR L30CM SGL 8 3383] ST JUDE MEDICAL INC],SUP-2356742,CDM,C1883,HCPCS,0278,RC,,,,both,,,2810.30,1826.69,,,,,,,,,,,,,
CATHETER HD MAXIMAL BARR TY 035 12 FRX15 CM DL TURBO-FLO HD,SUP-2759842,CDM,C1752,HCPCS,0278,RC,,,,both,,,522.31,339.50,,,,,,,,,,,,,
HC So Neo Gsap Dna Mcrstl Ins,PX-3108145766,CDM,81457,CPT,0310,RC,,,,inpatient,,,5225.00,3396.25,,,,,,,,,,,,,
ROD DISTRACTOR MAXILLOFCL SHRT ACTIVATION FLX NS,SUP-2883555,CDM,C1713,HCPCS,0278,RC,,,,both,,,2415.16,1569.85,,,,,,,,,,,,,
ELECTRODE NDL CANN L15CM ARRY DIA5CM FOR OPN AND PERC RF,SUP-2149340,CDM,C1713,HCPCS,0278,RC,,,,both,,,7912.80,5143.32,,,,,,,,,,,,,
STENT ES L7CM DIA18MM PROX FLARE DIA23MM NONCOVERED DST REL,SUP-2149379,CDM,C1876,HCPCS,0278,RC,,,,both,,,5110.04,3321.53,,,,,,,,,,,,,
PLATE BNE L 32 X W 8 MM THK 3.2 MM SCREW DIA2.7 MM 4 H SS 72440104N,SUP-2933303,CDM,C1713,HCPCS,0278,RC,,,,both,,,1890.53,1228.84,,,,,,,,,,,,,
SELENIUM SULFIDE 2.5 % EX LOTN,RX-37630,CDM,6370000000,HCPCS,0637,RC,45802-0040-64,NDC,,both,120,ML,44.90,29.18,,,,,,,,,,,,,
GUIDEWIRE VASC L 200 CM 0.035IN L 6CM 2.5CM SAFE-T-J FIX COR,SUP-2167606,CDM,C1769,HCPCS,0272,RC,,,,both,,,66.60,43.29,,,,,,,,,,,,,
HC So Molec Cytogenics,PX-3118827166,CDM,88271,CPT,0311,RC,,,,both,,,74.00,48.10,,,,,,,,,,,,,
EXTRACTOR STONE HELCL 4.5 FRX65 CM TIPLSS NIT NCIRCLE,SUP-2835777,CDM,2720000010,LOCAL,0272,RC,,,,both,,,434.92,282.70,,,,,,,,,,,,,
DRILL TWST L 54 MM DIA1.4 MM STP 1.7 MM DENT SHFT NS DISP,SUP-2883323,CDM,2720000010,LOCAL,0272,RC,,,,both,,,373.31,242.65,,,,,,,,,,,,,
HC Assay of Gammaglobulin Iga Igd Igg Igm Each,PX-3018278400,CDM,82784,CPT,0301,RC,,,,both,,,204.00,132.60,,,,,,,,,,,,,
BASKET STONE ERCP FLOWER BSKT 20MM,SUP-2313155,CDM,2720000010,LOCAL,0272,RC,,,,both,,,734.76,477.59,,,,,,,,,,,,,
SET HEMOFILTER W THE AN 69 DLYZR MEM FOR CRRT M150,SUP-2129951,CDM,2720000010,LOCAL,0272,RC,,,,both,,,843.34,548.17,,,,,,,,,,,,,
INSERT TIB SM 9 MM CAS ELIBRA UNIV,SUP-2442363,CDM,C1776,CPT,0278,RC,,,,both,,,240.21,156.14,,,,,,,,,,,,,
PUMP PAIN MGMT SYS 400ML 2 SEL A FLO,SUP-2236747,CDM,C9804,HCPCS,0272,RC,,,,both,,,989.10,642.91,,,,,,,,,,,,,
TIP IRRIG FEM CNL BRSH W SUCT 9IN PULSAVAC,SUP-2199679,CDM,C1713,HCPCS,0278,RC,,,,both,,,1058.18,687.82,,,,,,,,,,,,,
CUP ACET DIA66MM UNIV HIP TI POR PRESSFIT PRI CEMENTLESS MH,SUP-2250732,CDM,C1776,CPT,0278,RC,,,,both,,,6864.04,4461.63,,,,,,,,,,,,,
GUIDEWIRE VASC IMAG L190CM DIA0.014IN STR TIP OCCL HYDRPHLC,SUP-2148712,CDM,C1769,HCPCS,0272,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
NEEDLE ENDOSCP FNA 19 GA NIT,SUP-2427167,CDM,C1713,HCPCS,0278,RC,,,,both,,,1372.18,891.92,,,,,,,,,,,,,
PLATE BNE OFFSET SYNDESMOSIS ANK ORTHOLOC 3DI,SUP-2398374,CDM,C1713,HCPCS,0278,RC,,,,both,,,1478.94,961.31,,,,,,,,,,,,,
GRAFT VASC HEMSHLD GLD L 15 CM 10 MM POLYESTER BOV CLLGN STR,SUP-2266032,CDM,L8670,HCPCS,0278,RC,,,,both,,,1004.80,653.12,,,,,,,,,,,,,
MIXER BNE CEM ROTARY ELECTR PWR FOR MAXILLOFACIAL SURG,SUP-2194208,CDM,C1713,HCPCS,0278,RC,,,,both,,,6045.66,3929.68,,,,,,,,,,,,,
IMPLANT HUM TISS H 10 MM CALC-CUBOID PRO-SPEC WDG,SUP-2932788,CDM,C1762,CPT,0278,RC,,,,both,,,4328.49,2813.52,,,,,,,,,,,,,
HC Drain Perirenal/Renal Abscess,PX-3615002000,CDM,50020,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
GRAFT BONE SUB DIA6CM CIR SHP DEMIN BONE MTRX GRFTON A-FLEX,SUP-2293902,CDM,C1713,HCPCS,0278,RC,,,,both,,,3987.02,2591.56,,,,,,,,,,,,,
GUIDEWIRE VASC SAFARI L 260 CM DIA 0.035 IN SS LUBRIGREEN,SUP-2140840,CDM,C1769,HCPCS,0272,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
HC Clsd Tx Trimall Fx W Manip,PX-4502781800,CDM,27818,CPT,0450,RC,,,,outpatient,,,1633.00,1061.45,,,,,,,,,,,,,
IMPLANT BONE STRP MOLD HUM TISS MTRX 50MMX17MMX4MM FRZN,SUP-2284710,CDM,C1713,HCPCS,0278,RC,,,,both,,,4571.84,2971.70,,,,,,,,,,,,,
WIRE FIX TROCAR PT 2 END 0.035X9 IN SS NS KIRSCHNER,SUP-2791242,CDM,C1713,HCPCS,0278,RC,,,,both,,,9.11,5.92,,,,,,,,,,,,,
PIN FIX 20 MM A.L.P.S,SUP-2467719,CDM,2720000010,LOCAL,0272,RC,,,,both,,,449.02,291.86,,,,,,,,,,,,,
CURETTE SURG CUP STR AQ/AC,SUP-2897555,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1221.46,793.95,,,,,,,,,,,,,
PLATE BNE DELT SM 117 MM LT DSTL DORS RADIAL 8 HOLE BUTTRESS,SUP-2458845,CDM,C1713,HCPCS,0278,RC,,,,both,,,2157.21,1402.19,,,,,,,,,,,,,
CANNULA INJ 3.5 MMX30 CM KOH ULTRAMICRO NDL,SUP-2766999,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1127.64,732.97,,,,,,,,,,,,,
BLADE OSTEO W16MM S STL MRI RAD DISPOSABLE,SUP-2435929,CDM,2720000010,LOCAL,0272,RC,,,,both,,,367.38,238.80,,,,,,,,,,,,,
PLATE BONE W13.5XL358MM THK4.2MM 20 H BILAT S STL NAR LIMIT,SUP-2185258,CDM,C1713,HCPCS,0278,RC,,,,both,,,3526.31,2292.10,,,,,,,,,,,,,
WIRE BNE FIX METATRSL SHORTNG PILOT H 2.25 NS,SUP-2899209,CDM,2720000010,LOCAL,0272,RC,,,,both,,,320.28,208.18,,,,,,,,,,,,,
KIT STRNL CLOSURE NDL CUT L CONVENTIONAL 36 IN FREE 60 MM,SUP-2930413,CDM,C1713,HCPCS,0278,RC,,,,both,,,3061.50,1989.97,,,,,,,,,,,,,
TUBE EXT FIX DIA20MM BLU DYN FOR MONOTB TRIAX SYS,SUP-2372604,CDM,C1713,HCPCS,0278,RC,,,,both,,,8964.70,5827.05,,,,,,,,,,,,,
NAIL IM 10.7X245 MM KNEE PRECICE,SUP-2309822,CDM,C1713,HCPCS,0278,RC,,,,both,,,50937.08,33109.10,,,,,,,,,,,,,
BLADE RTRCTR RVL SHRT TOOTH 50MML VLT F/ANTRR CRVCL FSN RMVL,SUP-2468708,CDM,2720000010,LOCAL,0272,RC,,,,both,,,473.14,307.54,,,,,,,,,,,,,
BUR ENDOSCP RND MED 4.2X120 MM GRY ORNG STRL UNIDRIVE DISP,SUP-2585885,CDM,2720000010,LOCAL,0272,RC,,,,both,,,136.46,88.70,,,,,,,,,,,,,
AMPICILLIN SODIUM 1 G IJ SOLR (MIXTURES ONLY),RX-430024,CDM,J0290,HCPCS,0636,RC,00781-3412-92,NDC,,both,1,UN,82.40,53.56,,,,,,,,,,,,,
PIN DISTRACTOR L14MM FOR SECURE-C CERV ARTIFICIAL,SUP-2232197,CDM,C1713,HCPCS,0278,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
BLADE SURG 7 LT MIDLN,SUP-2631600,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1122.55,729.66,,,,,,,,,,,,,
SHEATH INTRO STR 8 FRX60 CM SMOOTH TAPR SS PTFE BLU COMPASS,SUP-2846737,CDM,C1894,HCPCS,0272,RC,,,,both,,,292.08,189.85,,,,,,,,,,,,,
BRACE WRST LACER W O ABDUCTED THMB X L UNIV R,SUP-2276647,CDM,L3931,HCPCS,0272,RC,,,,both,,,28.42,18.47,,,,,,,,,,,,,
PLATE BNE RECON NAR,SUP-2363457,CDM,C1713,HCPCS,0278,RC,,,,both,,,2054.69,1335.55,,,,,,,,,,,,,
UNIT DRNGE INF 2000ML SGL COLL WET SUCT WET SEAL REGULATED,SUP-2384317,CDM,C1729,HCPCS,0272,RC,,,,both,,,645.87,419.82,,,,,,,,,,,,,
CATHETER ETER DIAG OD7FR 2 10 2 SPC STABLEMAPR SM,SUP-2281831,CDM,C1731,HCPCS,0278,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
MESH SURG L 40 X W 20 CM D 1.5 MM PORCINE DERMAL CLLGN ABD,SUP-2901739,CDM,C9364,HCPCS,0278,RC,,,,both,,,58572.65,38072.22,,,,,,,,,,,,,
BUR SURG DIA5MM LNG S STL RND CUT FLUT ELITE TPS,SUP-2363476,CDM,2720000010,LOCAL,0272,RC,,,,both,,,312.93,203.40,,,,,,,,,,,,,
SCREWDRIVER SURG MINI QUIKDRIVE REUSE,SUP-2435307,CDM,C1713,HCPCS,0278,RC,,,,both,,,14887.05,9676.58,,,,,,,,,,,,,
CATHETER EP 1 MM 7 FRX110 10 MM STEER INQUIRY,SUP-2473019,CDM,C1730,HCPCS,0272,RC,,,,both,,,3356.66,2181.83,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED BPLR UPLR CEM STEM H4DEPUY] JNJ HEALTHCARE],SUP-2257616,CDM,C1776,CPT,0278,RC,,,,both,,,7222.00,4694.30,,,,,,,,,,,,,
SET INTRO NEFF SHTH L 20 CM OD 7 FR ID 4 FR GUIDEWIRE 0.018,SUP-2168031,CDM,C1894,HCPCS,0272,RC,,,,both,,,195.90,127.33,,,,,,,,,,,,,
PLATE BONE L120MM THK2MM 6 H SPN FOR 4.5MM SCR TC-100 L FRAG,SUP-2343815,CDM,C1713,HCPCS,0278,RC,,,,both,,,2528.01,1643.21,,,,,,,,,,,,,
HC Replc Centrl Tun Cath W/O Port,PX-3613658100,CDM,36581,CPT,0361,RC,,,,inpatient,,,4893.00,3180.45,,,,,,,,,,,,,
OBTURATOR ENDOSCP 0.057 INX11 MM CORONARY INTRO SHTH GRY,SUP-2294579,CDM,C1894,HCPCS,0272,RC,,,,both,,,17.27,11.23,,,,,,,,,,,,,
BLADE SURGICAL L65MM TONGUE PLAIN FOR MOUTH GAG DAVIS-BOYLE,SUP-2808624,CDM,2720000010,LOCAL,0272,RC,,,,both,,,317.27,206.23,,,,,,,,,,,,,
PLATE BNE 22 H ST BILAT S STL NAR CRV LOK COMPR FOR 45MM SCR,SUP-2178068,CDM,C1713,HCPCS,0278,RC,,,,both,,,5165.11,3357.32,,,,,,,,,,,,,
WIRE EXT FIX L100MM DIA2MM THRD L15MM THRDED,SUP-2316466,CDM,C1713,HCPCS,0278,RC,,,,both,,,327.00,212.55,,,,,,,,,,,,,
KIT HUM COMP SZ 4 ELBW ARTC NEXEL,SUP-2135761,CDM,C1776,CPT,0278,RC,,,,both,,,4069.44,2645.14,,,,,,,,,,,,,
SUPPORT ORTHOT CUST CLUBFOOT WDG,SUP-2435724,CDM,L3380,HCPCS,0272,RC,,,,both,,,140.42,91.27,,,,,,,,,,,,,
PLATE PL LAT SUPP 2.7/3.5MM 9H RT 153MM XLNG TI DHP STRL,SUP-2546773,CDM,C1713,HCPCS,0278,RC,,,,both,,,4683.78,3044.46,,,,,,,,,,,,,
SCREW SPNL LOK SPHERX,SUP-2311149,CDM,C1713,HCPCS,0278,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
ALLOGRAFT DERMAL UNMESHED 6X16 CMX0.75-1.5 MM DERMACELL,SUP-2264718,CDM,Q4122,HCPCS,0636,RC,,,,both,,,8083.93,5254.55,,,,,,,,,,,,,
HC So Sgpt (Alt),PX-3018446066,CDM,84460,CPT,0301,RC,,,,both,,,37.00,24.05,,,,,,,,,,,,,
KIT INTRO PERFRMR L 40 CM DIA 8 FR GUIDEWIRE 0.038 IN PERIPH,SUP-2168617,CDM,C1894,HCPCS,0272,RC,,,,both,,,389.36,253.08,,,,,,,,,,,,,
SCREW BNE L10MM OD27MM TI CORT DST RAD LOK FULL THRD CRSS,SUP-2372700,CDM,C1713,HCPCS,0278,RC,,,,both,,,567.08,368.60,,,,,,,,,,,,,
PLATE BONEXL STRL LT CALCNL FOR 3.5MM SCR VLP,SUP-2349963,CDM,C1713,HCPCS,0278,RC,,,,both,,,6594.16,4286.20,,,,,,,,,,,,,
INSERT TIB L THK9MM AP55MM ML80MM STD L R KNEE ARTC CONSTRN,SUP-2377541,CDM,C1776,CPT,0278,RC,,,,both,,,5233.50,3401.77,,,,,,,,,,,,,
WASHER ORTH OD13.5MM ID5.5MM SPIK FOR 4.5/6.5MM CANC SCR,SUP-2184673,CDM,C1713,HCPCS,0278,RC,,,,both,,,322.64,209.72,,,,,,,,,,,,,
VALVE PERITONEAL L90CM OD1.4MM 30CM VERTICAL WATER PRESSURE,SUP-2821786,CDM,C1889,HCPCS,0278,RC,,,,both,,,7301.00,4745.65,,,,,,,,,,,,,
GUIDEWIRE ORTH SMOOTH 0.062X4 IN FOR SM JT,SUP-2609663,CDM,C1769,HCPCS,0272,RC,,,,both,,,203.79,132.46,,,,,,,,,,,,,
GRAFT HUM TISS L 4 X W 3 CM SZ 12 SQCM AMNION-CHORION-AMNION,SUP-2909294,CDM,Q4137,HCPCS,0636,RC,,,,both,,,6543.67,4253.39,,,,,,,,,,,,,
CUSHION HEEL W/ BLU DOT S,SUP-2151867,CDM,L3334,HCPCS,0272,RC,,,,both,,,48.36,31.43,,,,,,,,,,,,,
SCREW BNE 2X15 MM 10 MM HEX X DRV DRILL-FREE TI LEVEL 1,SUP-2460275,CDM,C1713,HCPCS,0278,RC,,,,both,,,361.63,235.06,,,,,,,,,,,,,
SET INTRO PEELWY L 15.5 CM DIA16 FR DIL L 20 CM GUIDEWIRE,SUP-2168022,CDM,C1892,HCPCS,0272,RC,,,,both,,,155.40,101.01,,,,,,,,,,,,,
SEMI-TUB PLT STERILIZER 71 MM LENGTH 4 HL,SUP-2818125,CDM,C1713,HCPCS,0278,RC,,,,both,,,487.33,316.76,,,,,,,,,,,,,
SCREW BNE LCK 2.7X60 MM ST PERI-LOC,SUP-2348654,CDM,C1713,HCPCS,0278,RC,,,,both,,,837.60,544.44,,,,,,,,,,,,,
PHENOBARBITAL 100 MG PO TABS,RX-6213,CDM,6370000000,HCPCS,0637,RC,00143-1458-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
BEARING ANK JT H9MM TIB TALAR UHMWPE SLDE COR STAR,SUP-2340544,CDM,C1776,CPT,0278,RC,,,,both,,,4406.99,2864.54,,,,,,,,,,,,,
HC Otoacoutstic Emission Testing,PX-4719258700,CDM,92587,CPT,0471,RC,,,,outpatient,,,179.00,116.35,,,,,,,,,,,,,
SET DRNGE 5FR 0.035IN NSL PANCREAS STR W/ FLAP FOR TEMP,SUP-2169040,CDM,C1729,HCPCS,0272,RC,,,,both,,,417.62,271.45,,,,,,,,,,,,,
CLINIMIX/DEXTROSE (5/15) 5 % IV SOLN,RX-25752,CDM,2500000003,HCPCS,0250,RC,00338-1099-04,NDC,,both,2000,ML,460.00,299.00,,,,,,,,,,,,,
ANCHOR SUT 0 DIA3.7MM PLLA ABSRB DBL ARMED W/ NDL RAPTORMITE,SUP-2341796,CDM,C1713,HCPCS,0278,RC,,,,both,,,867.93,564.15,,,,,,,,,,,,,
INSERTION KIT 2.4 MM PERC PUSHLOCK ANCHR,SUP-2423443,CDM,C1713,HCPCS,0278,RC,,,,both,,,690.80,449.02,,,,,,,,,,,,,
PLATE BNE SM L214MM 18 H BILAT S STL LO PROF RIG LIMIT,SUP-2186213,CDM,C1713,HCPCS,0278,RC,,,,both,,,2147.41,1395.82,,,,,,,,,,,,,
HC Repair of Vagina,PX-4505720000,CDM,57200,CPT,0450,RC,,,,both,,,3074.00,1998.10,,,,,,,,,,,,,
ROD SPNL L48CM DIA4MM RT ANTR S STL PRECRV SMOOTH MOSS,SUP-2254426,CDM,C1713,HCPCS,0278,RC,,,,both,,,1083.30,704.14,,,,,,,,,,,,,
BASEPLATE 26 MM TM RVS 15M,SUP-2501801,CDM,C1713,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
SCREW BNE LCK 5X51 MM TI NS,SUP-2192330,CDM,C1713,HCPCS,0278,RC,,,,both,,,529.91,344.44,,,,,,,,,,,,,
INSERT FEM NK L-6MM TAPR HIP CO CHROM MOLYBDENUM ALLY ENDO,SUP-2405247,CDM,C1776,CPT,0278,RC,,,,both,,,222.31,144.50,,,,,,,,,,,,,
BRACE ORTHOPEDIC MED RT WRST LTHR,SUP-2194367,CDM,L3931,HCPCS,0272,RC,,,,both,,,25.94,16.86,,,,,,,,,,,,,
POST EXTERNAL FIXATION 11MM 30DEG ANGLED XTRAFIX SYSTEM,SUP-2479018,CDM,2720000010,LOCAL,0272,RC,,,,both,,,393.29,255.64,,,,,,,,,,,,,
GRAFT BNE 14 MM DISC HA,SUP-2651596,CDM,C1713,HCPCS,0278,RC,,,,both,,,2497.40,1623.31,,,,,,,,,,,,,
CATHETER BASIC DWELL ENDURNC KIT ARROW 22GAX8,SUP-2744559,CDM,C1751,HCPCS,0278,RC,,,,both,,,244.92,159.20,,,,,,,,,,,,,
DRILL SURG CANN 10 MM HND JCBS CHK UNIV SS NS REUSE,SUP-2491113,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2981.37,1937.89,,,,,,,,,,,,,
RELOAD STPLR D 30 MM DIA 8 MM SZ 3.5 MM CRV TIP 4 ROW BLU,SUP-2908900,CDM,2720000010,LOCAL,0272,RC,,,,both,,,659.40,428.61,,,,,,,,,,,,,
CLOBETASOL PROPIONATE 0.05 % EX SOLN,RX-9632,CDM,6370000000,HCPCS,0637,RC,51672-1293-03,NDC,,both,50,ML,189.00,122.85,,,,,,,,,,,,,
GUIDEWIRE URO L150CM DIA0035IN STR TIP REG BODY ULTRATRACK,SUP-2313185,CDM,C1769,HCPCS,0272,RC,,,,both,,,128.24,83.36,,,,,,,,,,,,,
PLATE STRNL 4 H TI STR NS MATRIXSTERNUM,SUP-2904256,CDM,C1713,HCPCS,0278,RC,,,,both,,,1778.43,1155.98,,,,,,,,,,,,,
HC So Ptt / Thromboplastin Subs,PX-3058573266,CDM,85732,CPT,0305,RC,,,,both,,,99.00,64.35,,,,,,,,,,,,,
CABLE SPNL LAT LIGHT TIMBERLINE,SUP-2690629,CDM,C1713,HCPCS,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
IMPLANT ANK SZ 1 TOT FIX BEAR VANTAGE,SUP-2223473,CDM,C1776,CPT,0278,RC,,,,both,,,345.40,224.51,,,,,,,,,,,,,
STEM FEM L235MM DIA20MM BOW CONIC TI ALLY HA DST HIP REV,SUP-2375861,CDM,C1776,CPT,0278,RC,,,,both,,,8266.99,5373.54,,,,,,,,,,,,,
HC Treat Wrist Bone Fx,PX-4502563500,CDM,25635,CPT,0450,RC,,,,both,,,1633.00,1061.45,,,,,,,,,,,,,
STENT PERIPH SMRT RADIANZ L 60 MM DIA 8 MM DEL SYS L 150 CM,SUP-2866180,CDM,C1876,HCPCS,0278,RC,,,,both,,,3730.07,2424.55,,,,,,,,,,,,,
PLATE BNE 12 H TI STR FOR 1.3MM SCR,SUP-2190688,CDM,C1713,HCPCS,0278,RC,,,,both,,,1124.78,731.11,,,,,,,,,,,,,
PATCH CV 5X75CMX08MM,SUP-2395309,CDM,C1768,CPT,0278,RC,,,,both,,,1400.44,910.29,,,,,,,,,,,,,
BUR SURG L10CM DIA4MM BALL FLUT SM BOR MIDAS REX LEGEND,SUP-2277611,CDM,2720000010,LOCAL,0272,RC,,,,both,,,347.35,225.78,,,,,,,,,,,,,
GRAFT BNE PTTY 2 CC,SUP-2335248,CDM,C9359,HCPCS,0278,RC,,,,both,,,979.68,636.79,,,,,,,,,,,,,
CATHETER INFUS SOLEX OD9.3 FRXL25 CM 3 LUMN DISP FOR INT JUG,SUP-2416146,CDM,C1751,HCPCS,0278,RC,,,,both,,,2597.03,1688.07,,,,,,,,,,,,,
HC Bx Breast Add Lesion US Img,PX-3611908400,CDM,19084,CPT,0361,RC,,,,outpatient,,,3707.00,2409.55,,,,,,,,,,,,,
CHLORHEXIDINE GLUCONATE 0.12 % MT SOLN,RX-9516,CDM,340b,HCPCS,0637,RC,63739-0052-74,NDC,,both,15,ML,7.70,5.00,,,,,,,,,,,,,
SCREW ST 1.5X6MM UN3,SUP-2363854,CDM,C1713,HCPCS,0278,RC,,,,both,,,233.18,151.57,,,,,,,,,,,,,
HC So1 Antithyroglobulin Antibody,PX-3028680067,CDM,86800,CPT,0302,RC,,,,both,,,163.00,105.95,,,,,,,,,,,,,
SHEATH GUID AD L45CM OD7FR ID2.5MM 0.018/0.038IN MP POLYUR,SUP-2169817,CDM,C1894,HCPCS,0272,RC,,,,both,,,151.07,98.20,,,,,,,,,,,,,
LINER ACET OD50MM ID28MM +4MM ENDRN HIP CONSTRN LCK RNG PRI,SUP-2250690,CDM,C1776,CPT,0278,RC,,,,both,,,8291.48,5389.46,,,,,,,,,,,,,
GRAFT BNE PERONEOUS LONGUS SM,SUP-2307292,CDM,C1713,HCPCS,0278,RC,,,,both,,,4150.83,2698.04,,,,,,,,,,,,,
QUADLINK IMPLANT SYSTEM 9MM,SUP-2811463,CDM,C1713,HCPCS,0278,RC,,,,both,,,6829.50,4439.17,,,,,,,,,,,,,
CATHETER HAD AD L40CM INSRT L23CM DIA14.5FR POLYUR PRE CRV,SUP-2174241,CDM,C1881,HCPCS,0278,RC,,,,both,,,2173.60,1412.84,,,,,,,,,,,,,
IMPLANT OSS M L3.9MM DIA1.17MM SHT INCUS STAP HA FULL CANN,SUP-2313672,CDM,L8613,CPT,0278,RC,,,,both,,,905.26,588.42,,,,,,,,,,,,,
CARBOPLATIN 10 MG/ML IV SOLN (MIXTURES ONLY),RX-1150452,CDM,J9045,HCPCS,0636,RC,61703-0339-56,NDC,,both,60,ML,170.40,110.76,,,,,,,,,,,,,
CATHETER ANGIOPLSTY L150CM 7X20 BAL MRAIL ULT SFT SV,SUP-2140571,CDM,C1725,HCPCS,0272,RC,,,,both,,,1279.71,831.81,,,,,,,,,,,,,
SCREW BNE L8MM DIA1.2MM STD CORT CRANIOMAXILLOFACIAL TI ST,SUP-2189160,CDM,C1713,HCPCS,0278,RC,,,,both,,,351.68,228.59,,,,,,,,,,,,,
CATHETER THOR 28FR L20IN PVC R ANG RADPQ SENTNL LN SENTNL,SUP-2154972,CDM,C1729,HCPCS,0272,RC,,,,both,,,34.73,22.57,,,,,,,,,,,,,
TAPESTRY RC BIOINTEGRATIVE 30X30 MM LAT TAPESTRY LF,SUP-2867250,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4301.80,2796.17,,,,,,,,,,,,,
FIBER LASER HOLM 365 M MULTI-USE W/ SMA-905 BLU SMARTSYNC,SUP-2835959,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1394.57,906.47,,,,,,,,,,,,,
STENT THOR L100MM DIA26X26MM W CAPTIVIA DEL SYS VALIANT,SUP-2603421,CDM,C1768,CPT,0278,RC,,,,both,,,53364.30,34686.79,,,,,,,,,,,,,
MULTIGEN 70 MG PO TABS,RX-93008,CDM,6370000000,HCPCS,0637,RC,51991-0543-90,NDC,,both,1,UN,4.30,2.79,,,,,,,,,,,,,
ALLOGRACT HUM TISS AMNIOBAND MEMBRANE 16MM DISK,SUP-2905491,CDM,Q4151,HCPCS,0636,RC,,,,both,,,1371.43,891.43,,,,,,,,,,,,,
CATHETERIZATION KIT ART 025 20 GAX12 CM 18/25 GA 5 CC FEP LF,SUP-2865584,CDM,C1751,HCPCS,0278,RC,,,,both,,,316.51,205.73,,,,,,,,,,,,,
PATCH VASC VASCU-GUARD L 8 X W 0.8 CM BOV PERICARD FOR,SUP-2130383,CDM,C1768,CPT,0278,RC,,,,both,,,771.12,501.23,,,,,,,,,,,,,
CATHETER CARD ABLATION CELSIUS FLTR L 115 CM 7.5 FR TIP 8 MM,SUP-2248634,CDM,C1733,HCPCS,0272,RC,,,,both,,,2383.26,1549.12,,,,,,,,,,,,,
MESH GORE SYNECOR 30CM X 30CM RECTANGLE,SUP-2763179,CDM,C1781,HCPCS,0278,RC,,,,both,,,21832.42,14191.07,,,,,,,,,,,,,
BLADE IM L80MM DIA12.5MM ST CANC TI SPRL NTHREADED CANN N,SUP-2192132,CDM,C1713,HCPCS,0278,RC,,,,both,,,2402.98,1561.94,,,,,,,,,,,,,
GRAFT VASC TW 4-7 MMX80 CM STR XLN W/ SLDE GDS ADVANTA VXT,SUP-2463137,CDM,C1768,CPT,0278,RC,,,,both,,,3931.69,2555.60,,,,,,,,,,,,,
CATHETER ABLAT 7FR L115CM SPC 2-5-2MM TIP 3.5MM CRV 75MM,SUP-2357693,CDM,C1733,HCPCS,0272,RC,,,,both,,,9106.00,5918.90,,,,,,,,,,,,,
SCREW BNE ST 1.3X7 MM CRTX W/ FLUT TIP TI MTRX GLD NS LF,SUP-2189178,CDM,C1713,HCPCS,0278,RC,,,,both,,,322.23,209.45,,,,,,,,,,,,,
DEVICE PESSARY OD2 1/2IN GELLHORN FLEX IMP,SUP-2171735,CDM,A4562,HCPCS,0274,RC,,,,both,,,119.32,77.56,,,,,,,,,,,,,
RESERVOIR VENTCULSTMY S STL W/ BASE FOR 6MM BUR H,SUP-2243790,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1155.52,751.09,,,,,,,,,,,,,
CATHETER URET 3FR 70CM LEN WVN OLV TIP REUSE,SUP-2129048,CDM,C1729,HCPCS,0272,RC,,,,both,,,197.82,128.58,,,,,,,,,,,,,
SEGMENT FEM SZ 1 H20MM LT LAT TILASTAN FOR W60MM COMP,SUP-2265082,CDM,C1776,CPT,0278,RC,,,,both,,,5680.26,3692.17,,,,,,,,,,,,,
AUGMENT FEM 3 4 MM POST,SUP-2610720,CDM,C1776,CPT,0278,RC,,,,both,,,3067.15,1993.65,,,,,,,,,,,,,
MICROCATHETER INFUSION PROGREAT L 130 CM DIA2.7 FR COAT 70,SUP-2385153,CDM,C1887,HCPCS,0272,RC,,,,both,,,1862.96,1210.92,,,,,,,,,,,,,
GRAFT HUM TISS W5XL5CM THK4-5MM EXTRA ULT THCK HYDRATED,SUP-2307503,CDM,Q4128,HCPCS,0636,RC,,,,both,,,5159.18,3353.47,,,,,,,,,,,,,
SET INTRO PEELWY L 15.5 CM DIA10.5 FR MULTPURP STRL,SUP-2168536,CDM,C1892,HCPCS,0272,RC,,,,both,,,147.58,95.93,,,,,,,,,,,,,
BOOT ORTHOT M SMOOTH IN BD AFO SOFTPRO,SUP-2324237,CDM,L4387,HCPCS,0274,RC,,,,both,,,128.11,83.27,,,,,,,,,,,,,
PLATE BONE SZ 10 DSTL RADIOULNAR JT LCK ASMBLY,SUP-2119921,CDM,C1713,HCPCS,0278,RC,,,,both,,,15502.18,10076.42,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.545,SUP-2860062,CDM,C1713,HCPCS,0278,RC,,,,both,,,52738.81,34280.23,,,,,,,,,,,,,
BUR SURG DIA4MM RND PRECIS RIM GLDE TECHNOLOGY RAP SMOOTH,SUP-2363785,CDM,2720000010,LOCAL,0272,RC,,,,both,,,437.65,284.47,,,,,,,,,,,,,
KETOROLAC-ROPIV-KETAMINE 15-100-30 MG/50ML IJ SOSY,RX-146777,CDM,2500000003,HCPCS,0250,RC,69374-0519-50,NDC,,both,50,ML,287.50,186.87,,,,,,,,,,,,,
KIT INTRO ENDOAVF CV CATH SHTH STRL,SUP-2859464,CDM,C1894,HCPCS,0272,RC,,,,both,,,248.06,161.24,,,,,,,,,,,,,
MICROSPHERE EMB CNTOUR SE DIA 900-1200 UM 2 ML PVA PREFIL,SUP-2148452,CDM,C1713,HCPCS,0278,RC,,,,both,,,794.55,516.46,,,,,,,,,,,,,
BOOT ORTHOT M SMOOTH IN BD AFO SOFTPRO,SUP-2324237,CDM,L4387,HCPCS,0272,RC,,,,both,,,128.11,83.27,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED CEM STEM H3SN] SMITH AND NEPHEW ORTHOPAEDICS],SUP-2351358,CDM,C1776,CPT,0278,RC,,,,both,,,11618.00,7551.70,,,,,,,,,,,,,
MICROSPONGE DRUG DELIVERY VECTRA F,SUP-2848998,CDM,2720000010,LOCAL,0272,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
GRAFT VASC IMPRA CARBOFLO L 40 CM DIA 8 MM EPTFE CARBON FLX,SUP-2761448,CDM,C1768,CPT,0278,RC,,,,both,,,1977.73,1285.52,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY L115CM 6FR 1MM 10MM FIX L CRV,SUP-2462747,CDM,C1730,HCPCS,0272,RC,,,,both,,,825.82,536.78,,,,,,,,,,,,,
CHLORPHENIRAMINE MALEATE 4 MG PO TABS,RX-1645,CDM,6370000000,HCPCS,0637,RC,00904-0012-61,NDC,,both,1,UN,0.60,0.39,,,,,,,,,,,,,
SADDLE SPNL OPEN/OPEN 4.75 POLARIS 5.5/5.5,SUP-2136369,CDM,C1713,HCPCS,0278,RC,,,,both,,,1648.50,1071.52,,,,,,,,,,,,,
BLADE SAW OSCLLTNG 19MMW X90MML 1.47MM THK LG BNE COARSE MID,SUP-2605800,CDM,2720000010,LOCAL,0272,RC,,,,both,,,207.96,135.17,,,,,,,,,,,,,
PLATE BONE THK1MM 8 H CRANIOMAXILLOFACIAL ORAL GRN SLV TI,SUP-2181765,CDM,C1713,HCPCS,0278,RC,,,,both,,,2116.67,1375.84,,,,,,,,,,,,,
ALLOGRAFT BNE FD IRRADIATED FEM SHFT,SUP-2867204,CDM,C1762,CPT,0278,RC,,,,both,,,5014.42,3259.37,,,,,,,,,,,,,
CATHETER CTRL VEN 5FR L60CM PERIPHERALLY INSERTED STD 2 LUMN,SUP-2168839,CDM,C1751,HCPCS,0278,RC,,,,both,,,279.46,181.65,,,,,,,,,,,,,
MESH SURG W25XL45IN POLY NONABSORBABLE RECT MERS,SUP-2219872,CDM,C1781,HCPCS,0278,RC,,,,both,,,502.31,326.50,,,,,,,,,,,,,
COIL NEUROVASCULAR AXIUM PRIM L 30 CM SECONDARY DIA12 MM,SUP-2429568,CDM,C1889,HCPCS,0278,RC,,,,both,,,6578.30,4275.89,,,,,,,,,,,,,
CLAMP SURG VASOVASOSTOMY SET SILBER,SUP-2160639,CDM,2720000010,LOCAL,0272,RC,,,,both,,,896.69,582.85,,,,,,,,,,,,,
CATHETER BLLN EXTRACTION 4.5 FR 15X20 MM MULT 3V +,SUP-2312992,CDM,C1726,HCPCS,0272,RC,,,,both,,,499.61,324.75,,,,,,,,,,,,,
IMPLANT HUM TISS L 5 X W 5 CM AMNIO MEMBRN LYOPRESERVED,SUP-2905514,CDM,Q4133,HCPCS,0636,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
SYSTEM DRNGE 50ML W BAXTER INTLNK NDLLSS INJECTIN SITES CRD,SUP-2277977,CDM,C1729,HCPCS,0272,RC,,,,both,,,502.93,326.90,,,,,,,,,,,,,
PLATE BNE W16XL156MM BLDE L60MM THK4.8MM 95DEG 9 H,SUP-2185517,CDM,C1713,HCPCS,0278,RC,,,,both,,,2964.38,1926.85,,,,,,,,,,,,,
PLATE BNE Z MINI REG RT NO SPACE BTWN HOLE TI LEVEL 1 LF,SUP-2468855,CDM,C1713,HCPCS,0278,RC,,,,both,,,543.00,352.95,,,,,,,,,,,,,
GUIDEWIRE VASC 014X300 SPECTR WAVEWRITER,SUP-2240283,CDM,C1769,HCPCS,0272,RC,,,,both,,,1868.30,1214.39,,,,,,,,,,,,,
CATH BLLN STENT GRAFT 10 50MMX65CM,SUP-2700281,CDM,C2628,HCPCS,0278,RC,,,,both,,,1444.40,938.86,,,,,,,,,,,,,
GUIDEPIN ORTH L431MM DIA2.4MM TRCR TIP PASS LSR MRK,SUP-2341539,CDM,2720000010,LOCAL,0272,RC,,,,both,,,364.24,236.76,,,,,,,,,,,,,
BIT DRILL 3.5MM DIA WRIST LATEXFREEDOM,SUP-2605907,CDM,2720000010,LOCAL,0272,RC,,,,both,,,830.78,540.01,,,,,,,,,,,,,
PROSTHESIS VOICE 20 FRX10 MM KT IMPL CLASSIC BLOM-SINGER,SUP-2238270,CDM,L8509,HCPCS,0274,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
LEVEL NEURO MESH 3D NEURO SCRW170 X 138 MM T10 MM CP TTNM Q,SUP-2681434,CDM,C1713,HCPCS,0278,RC,,,,both,,,12870.55,8365.86,,,,,,,,,,,,,
PROBE VITRCTMY 27GA L27MM 10000CPM CONSTELLATION ULTRAVIT,SUP-2109977,CDM,2720000010,LOCAL,0272,RC,,,,both,,,736.90,478.98,,,,,,,,,,,,,
STENT CORONARY XIENCE PRIM LL L 28 MM DIA2.25 MM SYS L 143,SUP-2104685,CDM,C1874,HCPCS,0278,RC,,,,both,,,5181.00,3367.65,,,,,,,,,,,,,
SET SCR SPNL L25MM DIA5.5MM TI FOR 5.5MM ROD EXPEDIUM,SUP-2254610,CDM,C1713,HCPCS,0278,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
SLING GYN TVT EXACT CONTINENCE SYS POLYPR BLU DESARA,SUP-2152278,CDM,C1771,HCPCS,0278,RC,,,,both,,,2508.86,1630.76,,,,,,,,,,,,,
WIRE FIX REDUCTION 1.5 MM HALF PT TIP NS,SUP-2799566,CDM,C1713,HCPCS,0278,RC,,,,both,,,668.95,434.82,,,,,,,,,,,,,
SCREW BNE L95MM DIA11MM FEM G TI CANN FOR TROCHANTERIC NAIL,SUP-2180366,CDM,C1713,HCPCS,0278,RC,,,,both,,,1805.56,1173.61,,,,,,,,,,,,,
LENS IOL TECNIS 1-PIECE ACRYLIC DCB0000220,SUP-2853105,CDM,V2632,HCPCS,0276,RC,,,,both,,,310.86,202.06,,,,,,,,,,,,,
TRAY DRNGE CATH 5FR THORA-PARA,SUP-2133921,CDM,C1729,HCPCS,0272,RC,,,,both,,,194.68,126.54,,,,,,,,,,,,,
HC Image Cath Fluid Peri/Retro,PX-3614940600,CDM,49406,CPT,0361,RC,,,,inpatient,,,6875.00,4468.75,,,,,,,,,,,,,
PROTECTOR PLT SM M PAT TRIATHLON,SUP-2364729,CDM,C1713,HCPCS,0278,RC,,,,both,,,833.67,541.89,,,,,,,,,,,,,
CAGE SPNL PARL 9X7X23 MM LUMBAR CONCORDE,SUP-2255217,CDM,C1889,HCPCS,0278,RC,,,,both,,,11704.35,7607.83,,,,,,,,,,,,,
GRAFT HUM TISS L 150 MM FIB SHFT LYOPH,SUP-2913308,CDM,C1762,CPT,0278,RC,,,,both,,,5115.06,3324.79,,,,,,,,,,,,,
CAGE SPNL H16-25MM DIA14MM 6DEG ANT TI VBR DISTR DEV ADD,SUP-2390793,CDM,C1889,HCPCS,0278,RC,,,,both,,,23393.00,15205.45,,,,,,,,,,,,,
COLLAR SPNL TI SM STAT FOR VAR AXIS SCR USS,SUP-2193308,CDM,C1713,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
STEM FEM L240MM DIA16MM 135DEG STD OFFSET DST HIP BILAT,SUP-2252570,CDM,C1776,CPT,0278,RC,,,,both,,,9472.75,6157.29,,,,,,,,,,,,,
KIT INTRO ARW SHTH L 10 CM DIA 9 FR DIL L 17.75 IN DIA 0.035,SUP-2120577,CDM,C1894,HCPCS,0272,RC,,,,both,,,160.77,104.50,,,,,,,,,,,,,
PROPRANOLOL HCL 20 MG PO TABS,RX-6657,CDM,6370000000,HCPCS,0637,RC,69238-2078-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
HYDROMORPHONE HCL 1 MG/ML IV SOLN,RX-156956,CDM,2500000003,HCPCS,0250,RC,71266-9115-01,NDC,,both,30,ML,123.20,80.08,,,,,,,,,,,,,
ANCHOR 6.8MM PEEK,SUP-2589139,CDM,C1713,HCPCS,0278,RC,,,,both,,,1223.85,795.50,,,,,,,,,,,,,
LEAD PACE 6FR L58CM VENT SIL INSUL BPLR TI NITRIDE STEROID,SUP-2281981,CDM,C1898,HCPCS,0275,RC,,,,both,,,1332.87,866.37,,,,,,,,,,,,,
STEM FEM VERSYS 7.5 IN BEADED FC +20 CALCAR 15.0X170MM STR,SUP-2504255,CDM,C1776,CPT,0278,RC,,,,both,,,13376.40,8694.66,,,,,,,,,,,,,
LO-PRO SCRW SYS CS 2.0/2.3/3.0MM,SUP-2814763,CDM,C1713,HCPCS,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
GRAFT BONE SUBSTITUTEXSM SZ 0.5-0.7MM 0.5ML B TRICALCIUM,SUP-2194005,CDM,C1713,HCPCS,0278,RC,,,,both,,,281.34,182.87,,,,,,,,,,,,,
HC Myelography 2+ Regions S&I,PX-3207227000,CDM,72270,CPT,0320,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
TRIHEXYPHENIDYL HCL 2 MG PO TABS,RX-8166,CDM,6370000000,HCPCS,0637,RC,70954-0212-10,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
PLATE BNE ORBIT FLR 30X50X0.4 MM CRAN,SUP-2352051,CDM,C1713,HCPCS,0278,RC,,,,both,,,1635.94,1063.36,,,,,,,,,,,,,
HC Pt Therapeutic Activities 15 Min|OP PT SERVICES|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS|DOCUMENTATION ON FILE,PX-4209753000,CDM,97530,CPT,0420,RC,,,GP|CQ|KX,both,,,144.00,93.60,,,,,,,,,,,,,
SHEATH INTRO 4FR L12CM GWIRE 0.035IN ACT W/ SMOOTH TAPERS,SUP-2355635,CDM,C1894,HCPCS,0272,RC,,,,both,,,25.12,16.33,,,,,,,,,,,,,
HC So Chimerism Anal No Cell Selec,PX-3018126766,CDM,81267,CPT,0301,RC,,,,both,,,258.00,167.70,,,,,,,,,,,,,
SPLINT CLAV L AD W2.75XL34.5IN BCKL CLSR PD MCLEOD,SUP-2197365,CDM,L3650,HCPCS,0274,RC,,,,both,,,25.12,16.33,,,,,,,,,,,,,
HC Image Cath Fluid Peri/Retro,PX-3614940600,CDM,49406,CPT,0361,RC,,,,outpatient,,,6875.00,4468.75,,,,,,,,,,,,,
PROSTHESIS STAP L425MM DIA05MM BND LOOP W05MM PURE TI MTRX,SUP-2263282,CDM,L8613,CPT,0278,RC,,,,both,,,835.24,542.91,,,,,,,,,,,,,
PLATE BNE COMPR LNG 3.5/4 MM 3 HOLE STR NS LTX,SUP-2857067,CDM,C1713,HCPCS,0278,RC,,,,both,,,5598.62,3639.10,,,,,,,,,,,,,
SPLINT CLAV L AD W2.75XL34.5IN BCKL CLSR PD MCLEOD,SUP-2197365,CDM,L3650,HCPCS,0272,RC,,,,both,,,25.12,16.33,,,,,,,,,,,,,
GRAFT VASC GELWEAVE L 30 CM DIA20 MM POLYESTER GEL,SUP-2385018,CDM,C1768,CPT,0278,RC,,,,both,,,1445.44,939.54,,,,,,,,,,,,,
CLAMP EXT FIX STR MRI SAFE FOR MULT PIN JET-X,SUP-2342894,CDM,2720000010,LOCAL,0272,RC,,,,both,,,715.76,465.24,,,,,,,,,,,,,
GUIDEWIRE VASC ANGLED 3 CM 035X260 STD COR CANALIZER,SUP-2120020,CDM,C1769,HCPCS,0272,RC,,,,both,,,143.18,93.07,,,,,,,,,,,,,
LIFT HEEL LG ADJLFT,SUP-2394116,CDM,L3334,HCPCS,0272,RC,,,,both,,,40.66,26.43,,,,,,,,,,,,,
SCREW BNE XL L75MM DIA7MM HDLSS COMPR FULL THRD,SUP-2122591,CDM,C1713,HCPCS,0278,RC,,,,both,,,2182.30,1418.49,,,,,,,,,,,,,
HARNESS CERV VIS PD33600] PROVIDENCE MEDICAL TECHNOLOGY],SUP-2330585,CDM,2720000010,LOCAL,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
OVITEX PRS PERMANENT POLYMER 11.5X22CM 3 LAYERS,SUP-2914475,CDM,C1781,HCPCS,0278,RC,,,,both,,,13285.34,8635.47,,,,,,,,,,,,,
DRILL SUT ANCHR MICRORAPTOR SHLDR,SUP-2419183,CDM,2720000010,LOCAL,0272,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
HC So Infectious Agent Ab Quant,PX-3028631766,CDM,86317,CPT,0302,RC,,,,both,,,118.00,76.70,,,,,,,,,,,,,
BURR FLUTED MATCHSTICK 3.0MM ANSPACH MA158NS,SUP-2843305,CDM,2720000010,LOCAL,0272,RC,,,,both,,,612.83,398.34,,,,,,,,,,,,,
MARKER RAD 0.9X3MM SFT TISS GLD PRELOAD,SUP-2418127,CDM,A4648,CPT,0278,RC,,,,both,,,171.66,111.58,,,,,,,,,,,,,
Z DISCONTINUED NO SUB IDED CANNULA PERF 25FR L30IN MULTISTAGE FEM VEN W/ INSRT KT,SUP-2282887,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1291.67,839.59,,,,,,,,,,,,,
PLATE BNE L390MM 24 H BROAD COMPR RIG FOR 45MM SCR L FRAG,SUP-2411435,CDM,C1713,HCPCS,0278,RC,,,,both,,,1366.15,888.00,,,,,,,,,,,,,
PLATE BONE TITANIUMXSHAPED ULT LO PROF MATRIXNEURO,SUP-2181543,CDM,C1713,HCPCS,0278,RC,,,,both,,,834.61,542.50,,,,,,,,,,,,,
HC External Ecg Rec>7d<15d Scanning Alys W/Report,PX-7309324700,CDM,93247,CPT,0731,RC,,,,outpatient,,,387.00,251.55,,,,,,,,,,,,,
HC Donor Lymphocyte Infusion,PX-3623824200,CDM,38242,CPT,0362,RC,,,,both,,,1519.00,987.35,,,,,,,,,,,,,
SCREW BNE L24MM DIA2.5MM CO CHROM LOK SQ DRV MULTDIR PEGGED,SUP-2411666,CDM,C1713,HCPCS,0278,RC,,,,both,,,521.24,338.81,,,,,,,,,,,,,
TRACKER NAVIGATION SPINE NONINVASIVE SPINEMASK,SUP-2364165,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1135.86,738.31,,,,,,,,,,,,,
PIN CLMP L72MM 2 BAR FOR XTRAFIX FIX SYS,SUP-2199705,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4139.78,2690.86,,,,,,,,,,,,,
APIXABAN 5 MG PO TABS,RX-120104,CDM,6370000000,HCPCS,0637,RC,00003-0894-31,NDC,,both,1,UN,45.50,29.57,,,,,,,,,,,,,
PLATE BNE L 46 MM TI RT DSTL VOLAR RADIAL NAR NS VARIAX,SUP-2900750,CDM,C1713,HCPCS,0278,RC,,,,both,,,6331.40,4115.41,,,,,,,,,,,,,
VALVE PRESSURE PROGRAMMABLE 100 MM H2O MED HI RANG BACTISEAL,SUP-2666825,CDM,C1889,HCPCS,0278,RC,,,,both,,,5659.32,3678.56,,,,,,,,,,,,,
PROBE BRST BX DIA10GA VERTICAL ENCOR,SUP-2126859,CDM,2720000010,LOCAL,0272,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
DEVICE FIX RND 2 HOLE SS STRL ENDOBUTTON LTX,SUP-2877791,CDM,C1713,HCPCS,0278,RC,,,,both,,,696.48,452.71,,,,,,,,,,,,,
GRAFT DERMAL PLIABLE THN MED 20X11 CMX0.7-1.4 MM BRST FLEXHD,SUP-2307605,CDM,Q4128,HCPCS,0636,RC,,,,both,,,22378.15,14545.80,,,,,,,,,,,,,
TRIAL BONE PLT 5 H 1/3 TBLR W/ CLLR FOR 3.5MM SCR TC-100 SM,SUP-2343721,CDM,C1713,HCPCS,0278,RC,,,,both,,,737.08,479.10,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 80 CM DIA 6 MM EPTFE TRMPT TAPR TW,SUP-2227381,CDM,C1768,CPT,0278,RC,,,,both,,,4807.25,3124.71,,,,,,,,,,,,,
MESH CRAN L 121 X W 125 MM SCREW DIA2 MM TI PANEL NS DISP,SUP-2936559,CDM,C1713,HCPCS,0278,RC,,,,both,,,4097.70,2663.50,,,,,,,,,,,,,
HC Gas Dilution or Washout,PX-4609472700,CDM,94727,CPT,0460,RC,,,,both,,,411.00,267.15,,,,,,,,,,,,,
DRILL TWST 90 DEG L 21 MM DIA1.5 MM STP 8 MM DENT SHFT NS,SUP-2883271,CDM,2720000010,LOCAL,0272,RC,,,,both,,,362.86,235.86,,,,,,,,,,,,,
KIT ARTHSCP 7X15MM DISP BICEPTOR FOR BICEPS TENODESIS REP,SUP-2341824,CDM,C1713,HCPCS,0278,RC,,,,both,,,1186.92,771.50,,,,,,,,,,,,,
PROSTHESIS OSS 4.5 MM 0.2 MM 1.45 MM PRECIS OWENS ASSURE TI,SUP-2468524,CDM,L8613,CPT,0278,RC,,,,both,,,1287.81,837.08,,,,,,,,,,,,,
NEEDLE BRST LOC TAG 7 CM,SUP-2433839,CDM,A4648,CPT,0278,RC,,,,both,,,860.36,559.23,,,,,,,,,,,,,
PROBE ENDOSCP 90 DEG HI PROF SAPHYRE,SUP-2848576,CDM,2720000010,LOCAL,0272,RC,,,,both,,,590.07,383.55,,,,,,,,,,,,,
WIRE EXT FIX L 546 MM DIA1.8 MM XL OLV NS DISP ILIZ,SUP-2932755,CDM,C1713,HCPCS,0278,RC,,,,both,,,599.27,389.53,,,,,,,,,,,,,
ALLOSYNC DBM STRIP 19X26X7MM,SUP-2811276,CDM,C1713,HCPCS,0278,RC,,,,both,,,4903.11,3187.02,,,,,,,,,,,,,
CROWN DENT AD SZ DUL4 LT UP 1ST PRI M S STL REST PRETRIMMED,SUP-2238909,CDM,D6783,CPT,0278,RC,,,,both,,,27.98,18.19,,,,,,,,,,,,,
SUTURE ANCHR TI ANCHR TWINFIX TI 6.5 MM SUT ANCHR W/ TWO NO,SUP-2341052,CDM,C1713,HCPCS,0278,RC,,,,both,,,886.89,576.48,,,,,,,,,,,,,
VALVE SWALLOING AND SPEAK OD23MM ID15MM CLR LO PROF LTWT,SUP-2322023,CDM,L8501,HCPCS,0274,RC,,,,both,,,365.68,237.69,,,,,,,,,,,,,
KIT FIX W/ CANN DRL GUID PIN MRK PEN SURG RUL MAXBRAID SUT,SUP-2212941,CDM,C1776,CPT,0278,RC,,,,both,,,4775.81,3104.28,,,,,,,,,,,,,
LINER ACET CUP OD51MM ID32MM STD MTL ON POLY THCK PRI CEM,SUP-2406737,CDM,C1776,CPT,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
SPLINT FNGR L L3.25IN ALUM PD LTWT COT,SUP-2196692,CDM,L3809,HCPCS,0274,RC,,,,both,,,2.32,1.51,,,,,,,,,,,,,
PROCESSOR SND SUPERPOWER LT DIAMOND BLK PONTO 3,SUP-2430354,CDM,L8690,HCPCS,0278,RC,,,,both,,,12858.30,8357.89,,,,,,,,,,,,,
GRAFT MTRX DERM HUM TISS ACELLULAR FRZN 2CMX4CM M HMTRX,SUP-2125440,CDM,Q4134,HCPCS,0636,RC,,,,both,,,753.60,489.84,,,,,,,,,,,,,
BOOT WLK LO XS NOAIR EA,SUP-2319305,CDM,L4386,HCPCS,0274,RC,,,,both,,,72.97,47.43,,,,,,,,,,,,,
KIT BNE ACCS PRB 13GA L100CM W/O SPCR DISP FOR VERTPLSTY,SUP-2293681,CDM,C1894,HCPCS,0272,RC,,,,both,,,1424.30,925.79,,,,,,,,,,,,,
GRASPER SURG 3 PRNG 2.8 FRX115 CM CAPT,SUP-2835969,CDM,2720000010,LOCAL,0272,RC,,,,both,,,693.22,450.59,,,,,,,,,,,,,
HARVESTER SURG W2.5XL2.5CM EPIDERMAL AUTO PRECIS CELLUTOME,SUP-2262291,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1271.70,826.60,,,,,,,,,,,,,
PLATE BONE SHFT L204MM BLDE L50MM THK4.8MM 95DEG 12 H STRL,SUP-2185460,CDM,C1713,HCPCS,0278,RC,,,,both,,,3550.46,2307.80,,,,,,,,,,,,,
HANDPIECE BX VAC ASST SPR LD COR DEV,SUP-2240007,CDM,2720000010,LOCAL,0272,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
BASE CALIB REUSE VIP 5D,SUP-2123499,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
SET HAD CATHETER 125FR L32CM W INJ CAP SCALP SHTH NDL GWIRE,SUP-2267083,CDM,C1750,HCPCS,0278,RC,,,,both,,,533.80,346.97,,,,,,,,,,,,,
HYDROCORTISONE 2.5 % EX OINT,RX-3732,CDM,6370000000,HCPCS,0637,RC,45802-0014-05,NDC,,both,454,GR,157.40,102.31,,,,,,,,,,,,,
GRAFT VASC EXXCEL SFT L 10 CM DIA 6 MM EPTFE STR STD WALL,SUP-2227639,CDM,C1768,CPT,0278,RC,,,,both,,,371.56,241.51,,,,,,,,,,,,,
GRAFT BNE PTTY 5 CC DBM BEAST +,SUP-2742046,CDM,C1713,HCPCS,0278,RC,,,,both,,,3626.70,2357.35,,,,,,,,,,,,,
SENSOR PULSE OXMTR CABLE L 90 CM FNGR SPO2 CLP AD NS LF,SUP-2929795,CDM,2720000010,LOCAL,0272,RC,,,,both,,,198.86,129.26,,,,,,,,,,,,,
CABLE NAVIGATION TRUDI,SUP-2418308,CDM,2720000010,LOCAL,0272,RC,,,,both,,,697.08,453.10,,,,,,,,,,,,,
GRAFT TIB SHFT FRZ DRY ALLGRFT,SUP-2165589,CDM,C1762,CPT,0278,RC,,,,both,,,1890.28,1228.68,,,,,,,,,,,,,
LINER ACET OD48MM ID28MM +4MM OFFSET 10DEG HIP GVF POLYETH,SUP-2250247,CDM,C1776,CPT,0278,RC,,,,both,,,9693.81,6300.98,,,,,,,,,,,,,
PLATE 4 HL TWST ALUM RINGFIX SYS,SUP-2473213,CDM,C1713,HCPCS,0278,RC,,,,both,,,452.16,293.90,,,,,,,,,,,,,
BRACE ORTH LACE CLOSURE SM 5.5X6.25 IN WRST LT SPECTR,SUP-2319267,CDM,L3906,HCPCS,0274,RC,,,,both,,,26.75,17.39,,,,,,,,,,,,,
KIT LD L75CM 8 ELECTRD PERC COMP CONTAIN LD ANCHR GWIRE NDL,SUP-2284648,CDM,2780000010,LOCAL,0278,RC,,,,both,,,7529.72,4894.32,,,,,,,,,,,,,
PLATE BNE W10XL21MM THK13MM 6 H GRID LOK TI FOR 2 23MM SCR,SUP-2267950,CDM,C1713,HCPCS,0278,RC,,,,both,,,3083.04,2003.98,,,,,,,,,,,,,
HC MRI-Angio Head W Contrast,PX-6157054500,CDM,70545,CPT,0615,RC,,,,inpatient,,,4278.00,2780.70,,,,,,,,,,,,,
PLATE BNE L41MM THK13MM 2X6 H HND 316L S STL VAR ANG LOK ROT,SUP-2178040,CDM,C1713,HCPCS,0278,RC,,,,both,,,2288.93,1487.80,,,,,,,,,,,,,
IMPLANT GYN W6XL8CM FASC LATA TUTOPLAST PROC ALLGRFT TISS,SUP-2421127,CDM,C1762,CPT,0278,RC,,,,both,,,5702.24,3706.46,,,,,,,,,,,,,
PLATE BNE 3.5X183 MM 14 HOLE SS LCP,SUP-2569327,CDM,C1713,HCPCS,0278,RC,,,,both,,,499.10,324.41,,,,,,,,,,,,,
IMPLANT HUM TISS CARDIOGRAFT DIA23 MM LG AORT VLV,SUP-2866796,CDM,C1762,CPT,0278,RC,,,,both,,,31846.51,20700.23,,,,,,,,,,,,,
PIN DRL DIA3MM W/ SPADE TIP FOR KNEE LIG RECON RETROBUTTON,SUP-2121403,CDM,2720000010,LOCAL,0272,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
GUIDEWIRE VASC L 145 CM DIA 0.035 IN PTFE MOVABLE COR,SUP-2147064,CDM,C1769,HCPCS,0272,RC,,,,both,,,36.33,23.61,,,,,,,,,,,,,
DRIVER CAP THRD REDUC,SUP-2232114,CDM,2780000010,LOCAL,0278,RC,,,,both,,,3045.80,1979.77,,,,,,,,,,,,,
HC Level III Surg Pathology Gross&Microscopic Exam,PX-3128830400,CDM,88304,CPT,0312,RC,,,,both,,,433.00,281.45,,,,,,,,,,,,,
NUT EXT FIX SPD STRL TRUELOK EVO LTX,SUP-2875632,CDM,2720000010,LOCAL,0272,RC,,,,both,,,204.63,133.01,,,,,,,,,,,,,
ALLOGRAFT BNE FRZN ASEP RT PROX HUM,SUP-2867026,CDM,C1762,CPT,0278,RC,,,,both,,,15812.88,10278.37,,,,,,,,,,,,,
PLATE BONE L142MM THK3.7MM 6 H LT DSTL MEDL TIB TI LCK COMPR,SUP-2190882,CDM,C1713,HCPCS,0278,RC,,,,both,,,4351.41,2828.42,,,,,,,,,,,,,
DRILL SURG OD4.4MM CALIB NONSTERILE JCBS,SUP-2412781,CDM,C1713,HCPCS,0278,RC,,,,both,,,307.72,200.02,,,,,,,,,,,,,
BIT DRL CANN 2 MM AO SHFT STRL DISP,SUP-2469804,CDM,2720000010,LOCAL,0272,RC,,,,both,,,651.80,423.67,,,,,,,,,,,,,
GUIDEWIRE SUPP L185CM DIA0014IN STR TIP SAVION FLX,SUP-2140938,CDM,C1769,HCPCS,0272,RC,,,,both,,,634.28,412.28,,,,,,,,,,,,,
SURGICAL PROCEDURE PACK EYE DR BELLIAPPA,SUP-2110979,CDM,C1713,HCPCS,0278,RC,,,,both,,,747.70,486.00,,,,,,,,,,,,,
SCREW CORTEX ST 2.4X22MM TI W/T8 STARDRV STRL,SUP-2548981,CDM,C1713,HCPCS,0278,RC,,,,both,,,216.09,140.46,,,,,,,,,,,,,
CONE TIB W29MM MTPHSEAL OPTETRAK LOGIC,SUP-2435970,CDM,C1776,CPT,0278,RC,,,,both,,,8394.16,5456.20,,,,,,,,,,,,,
SCREW BNE ST 5X16 MM PERIPROSTHETIC VA LCK OPTILINK STRL,SUP-2789484,CDM,C1713,HCPCS,0278,RC,,,,both,,,956.95,622.02,,,,,,,,,,,,,
BIT DRL 5 MM XO BUTTON,SUP-2765786,CDM,2720000010,LOCAL,0272,RC,,,,both,,,571.79,371.66,,,,,,,,,,,,,
HEPATITIS B VAC RECOMBINANT 10 MCG/0.5ML IJ SUSY,RX-159680,CDM,90744,HCPCS,0636,RC,58160-0820-52,NDC,,both,.5,ML,0.10,0.06,,,,,,,,,,,,,
IMPLANT BRST W15 145XH127 125CM P66 82CM 650 780CC NACL,SUP-2300540,CDM,C1789,HCPCS,0278,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
SCREW SPNL 6.5X40 MM PEDCL,SUP-2211275,CDM,C1713,HCPCS,0278,RC,,,,both,,,3925.00,2551.25,,,,,,,,,,,,,
SCISSOR SURG CASTANARES 6.25 IN FACELIFT NS LTX,SUP-2872583,CDM,C1889,HCPCS,0278,RC,,,,both,,,282.07,183.35,,,,,,,,,,,,,
WRENCH SURG FIX BOLT ILIZ,SUP-2340712,CDM,C1898,HCPCS,0275,RC,,,,both,,,4411.70,2867.60,,,,,,,,,,,,,
PROTECTOR TISS 8 MM FOR DRL,SUP-2167397,CDM,2720000010,LOCAL,0272,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
CATHETER EP MED CRV 7 FR THER COOL PATH,SUP-2459519,CDM,C2630,CPT,0272,RC,,,,both,,,4361.46,2834.95,,,,,,,,,,,,,
CONNECTOR SPNL TI POST THOR LUM ADJ LAT CONN CLS SIDELOAD,SUP-2289155,CDM,C1713,HCPCS,0278,RC,,,,both,,,3583.18,2329.07,,,,,,,,,,,,,
SEALER TISS L35CM DIA5MM ARTC ADV BPLR STR TIP LAP APPRCH,SUP-2219735,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4187.44,2721.84,,,,,,,,,,,,,
CATHETER URO L20CM OD1FR NDL OD28GA SPL INTRO PREEMIECATH,SUP-2394007,CDM,C1751,HCPCS,0278,RC,,,,both,,,494.55,321.46,,,,,,,,,,,,,
PROSTHESIS OSS STAP 0.5X4.5 MM 0.6 MM PISTON FLROPLAS,SUP-2459454,CDM,L8613,CPT,0278,RC,,,,both,,,286.18,186.02,,,,,,,,,,,,,
PLATE X LCK 2.4/2.7MM LG 36X20MM TI,SUP-2549728,CDM,C1713,HCPCS,0278,RC,,,,both,,,2600.30,1690.19,,,,,,,,,,,,,
GRAFT BNE CHIP 2-5 MM 60 CC FRZN FN CORTICAL CANC,SUP-2307427,CDM,C1713,HCPCS,0278,RC,,,,both,,,5724.60,3720.99,,,,,,,,,,,,,
PLATE BONE 1.5MM MESH NEURO SCR DIA7.5X7.5CM ISOGRID TI,SUP-2277536,CDM,C1713,HCPCS,0278,RC,,,,both,,,1899.70,1234.80,,,,,,,,,,,,,
CATHETER VENTRICULAR RT ANGLE 30 CM BA ACCU-FLO,SUP-2666402,CDM,C1729,HCPCS,0272,RC,,,,both,,,832.16,540.90,,,,,,,,,,,,,
ELECTRODE ENDO 24FR MPLR LOOP ELECTRD REUSE CUT STR,SUP-2361450,CDM,2720000010,LOCAL,0272,RC,,,,both,,,306.90,199.48,,,,,,,,,,,,,
PLATE BNE RECON 3.5X214 MM 18 HOLE SS,SUP-2569092,CDM,C1713,HCPCS,0278,RC,,,,both,,,557.82,362.58,,,,,,,,,,,,,
SET SCR SPNL DIA5.5MM IL TI HEX BRK OFF CDH SOLERA,SUP-2287852,CDM,C1713,HCPCS,0278,RC,,,,both,,,109.90,71.43,,,,,,,,,,,,,
PLATE BNE LCK 2.7 MM 8 HOLE CNTOUR 2 COMPR FOR SCR TI STRL,SUP-2499602,CDM,C1713,HCPCS,0278,RC,,,,both,,,890.06,578.54,,,,,,,,,,,,,
METHYLPREDNISOLONE SODIUM SUCC 500 MG IJ SOLR (MIXTURES ONLY),RX-430069,CDM,J2919,HCPCS,0636,RC,00009-0758-01,NDC,,both,1,UN,139.70,90.80,,,,,,,,,,,,,
SPHINCTEROTOME ENDSCPC 39FR DIA 20MML CUT WIRE BLRY W/0025,SUP-2707100,CDM,C1769,HCPCS,0272,RC,,,,both,,,902.34,586.52,,,,,,,,,,,,,
KIT TKR TRABECULAR MTL FEM TIB PAT AND VIT E SURF PERSONA,SUP-2212239,CDM,C1776,CPT,0278,RC,,,,both,,,19154.00,12450.10,,,,,,,,,,,,,
STEM FEM SZ 13MM L140MM STD BODY EXT NK VERSYS,SUP-2210336,CDM,C1776,CPT,0278,RC,,,,both,,,26752.80,17389.32,,,,,,,,,,,,,
SHEATH INTRO L 23 CM DIA 9 FR PEELWY STRL,SUP-2148845,CDM,C1894,HCPCS,0272,RC,,,,both,,,204.10,132.66,,,,,,,,,,,,,
GRAFT BONE CHIP IRRADIATED FRZ DRY CANC CORT 15CC,SUP-2113892,CDM,C1713,HCPCS,0278,RC,,,,both,,,1318.80,857.22,,,,,,,,,,,,,
BUTTON FIX L14MM CLLR 7MM RND CONCAVE TWO PC FOR ACL RECON,SUP-2121396,CDM,C1713,HCPCS,0278,RC,,,,both,,,703.36,457.18,,,,,,,,,,,,,
STEM FEM L300MM OD11MM BOW TI POR IM REV CEM NEUT MOD LNG,SUP-2405728,CDM,C1776,CPT,0278,RC,,,,both,,,5016.15,3260.50,,,,,,,,,,,,,
AMOXICILLIN-POT CLAVULANATE 500-125 MG PO TABS,RX-33227,CDM,6370000000,HCPCS,0637,RC,65862-0502-20,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
BLADE SAW KNEE 19.5MM CUT EDGE 90MM CUT DEPTH 1.2MM CUT THCK,SUP-2586313,CDM,2720000010,LOCAL,0272,RC,,,,both,,,111.85,72.70,,,,,,,,,,,,,
"HC Est Pt, E/M Level 5",PX-5109921500,CDM,99215,CPT,0510,RC,,,,inpatient,,,369.00,239.85,,,,,,,,,,,,,
KIT CEMENT AND MIXING SYSTEM COMBO,SUP-2823660,CDM,C1713,HCPCS,0278,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
TRAY KYPHOPLASTY SZ 2 BLLN L10MM BNE FILL DEV SYR IBT KYPHON,SUP-2293623,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8031.08,5220.20,,,,,,,,,,,,,
PLATE BNE TBLR 100 DEG 5 HOLE STRL LTX,SUP-2861630,CDM,C1713,HCPCS,0278,RC,,,,both,,,291.08,189.20,,,,,,,,,,,,,
CATHETER CV SINGLE LUMEN 018 IN 4 FRX55 CM 135 CM POWERPICC,SUP-2126369,CDM,C1751,HCPCS,0278,RC,,,,both,,,330.80,215.02,,,,,,,,,,,,,
K WIRE FIX L285MM DIA2.5MM S STL W/ TRCR PNT,SUP-2186866,CDM,C1713,HCPCS,0278,RC,,,,both,,,306.34,199.12,,,,,,,,,,,,,
NAIL IM L 210 MM DIA10.5 MM HINDFOOT STRL DUALCOMPRESSION,SUP-2930406,CDM,C1713,HCPCS,0278,RC,,,,both,,,37680.00,24492.00,,,,,,,,,,,,,
PACK PROC 6FT IVTM DISP STRT UP KT ICY,SUP-2416138,CDM,C1751,HCPCS,0278,RC,,,,both,,,12803.16,8322.05,,,,,,,,,,,,,
FIBER LASER 550 MICRON 3/PKG STERILE INCLUDES 1,SUP-2574064,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1169.74,760.33,,,,,,,,,,,,,
PLATE WDG OPN VA LCK 2.4/2.7MM 5MM SPACER TI STRL,SUP-2546960,CDM,C1713,HCPCS,0278,RC,,,,both,,,3593.98,2336.09,,,,,,,,,,,,,
PIN FIX STD UP EXT AXLE MRS,SUP-2372334,CDM,C1713,HCPCS,0278,RC,,,,both,,,6975.45,4534.04,,,,,,,,,,,,,
IMPLANT BLGCL TSSUE SHEET 100SQCM 10CMW X 10CML PRCNE TSSUE,SUP-2707153,CDM,Q4130,HCPCS,0636,RC,,,,both,,,9614.68,6249.54,,,,,,,,,,,,,
VALVE SHUNT SYSTEM WITH NO DIFFERENTIAL PRESSURE UNIT WITH F,SUP-2825719,CDM,C1889,HCPCS,0278,RC,,,,both,,,11337.91,7369.64,,,,,,,,,,,,,
GRAFT HUM TISS W16XL20CM THK1.04-2.28MM THCK REGEN TISS,SUP-2113002,CDM,Q4116,HCPCS,0636,RC,,,,both,,,36716.02,23865.41,,,,,,,,,,,,,
FEMORAL HD COCR 22MM +0,SUP-2359091,CDM,C1776,CPT,0278,RC,,,,both,,,1271.70,826.60,,,,,,,,,,,,,
COMPONENT FEM SZ 3 CO CHROM L KNEE REV STEMLESS POST STBL,SUP-2346124,CDM,C1776,CPT,0278,RC,,,,both,,,23513.11,15283.52,,,,,,,,,,,,,
NEEDLE PUNC SPNL 0 DEG 17 MMX18 CM NEURO W/O BITE WIDTH,SUP-2770066,CDM,2720000010,LOCAL,0272,RC,,,,both,,,382.11,248.37,,,,,,,,,,,,,
CROWN DENT NODLL4 1ST PRI M LO L S STL REFIL,SUP-2322193,CDM,D6783,CPT,0278,RC,,,,both,,,32.22,20.94,,,,,,,,,,,,,
PIN FIX 2X50 MM STRL INION OTPS LTX DISP,SUP-2857901,CDM,C1713,HCPCS,0278,RC,,,,both,,,458.44,297.99,,,,,,,,,,,,,
PLATE BNE MESHED MED 1.5X26X0.8 MM MIDFACE 6X2 W/ TAB STRL,SUP-2518107,CDM,C1713,HCPCS,0278,RC,,,,both,,,1070.11,695.57,,,,,,,,,,,,,
LINER ACET OD58MM ID32MM 10DEG 6MM OFFSET ECC HIP POLYETH,SUP-2379047,CDM,C1776,CPT,0278,RC,,,,both,,,1371.14,891.24,,,,,,,,,,,,,
JOINT PHALANX 0 DEG 2 MM DIGIFUSE,SUP-2609620,CDM,C1713,HCPCS,0278,RC,,,,both,,,5736.84,3728.95,,,,,,,,,,,,,
SPLINT ORTHOPEDIC W/ ABDUCTED SM 8 IN LT WRST FOREARM THMB,SUP-2276634,CDM,L3809,HCPCS,0274,RC,,,,both,,,21.92,14.25,,,,,,,,,,,,,
ROD REPROC EXT FIX HYBRID CARBN 11X400MM,SUP-2489330,CDM,2720000010,LOCAL,0272,RC,,,,both,,,238.58,155.08,,,,,,,,,,,,,
KIT BNE GRFT HARVESTING SZ 10 MM PER PASS 1.7 CC TREPHINE,SUP-2913165,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3739.74,2430.83,,,,,,,,,,,,,
SCREW BONE L28MM OD4MM SELF DRL CANN LNG THRD MAXTORQUE,SUP-2315917,CDM,C1713,HCPCS,0278,RC,,,,both,,,708.86,460.76,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL PEEK SD800.529,SUP-2860210,CDM,C1713,HCPCS,0278,RC,,,,both,,,38271.58,24876.53,,,,,,,,,,,,,
HC Njx Px Cntrst Kne Arthg Cntrst Enhncd CT/MRI Kne,PX-3612736900,CDM,27369,CPT,0361,RC,,,,inpatient,,,3707.00,2409.55,,,,,,,,,,,,,
STEM FEM SZ 12 L225MM HIP CO CHROM STD CLLR CEM NEUT REV,SUP-2344470,CDM,C1776,CPT,0278,RC,,,,both,,,13439.20,8735.48,,,,,,,,,,,,,
CANNULA EXTN 20 CM FOR UNIV HNDL STR,SUP-2470940,CDM,2720000010,LOCAL,0272,RC,,,,both,,,746.88,485.47,,,,,,,,,,,,,
PLATE BONE 10 H LT DSTL MEDL TIB LCK W/O TAB FOR 3.5MM SCR,SUP-2349082,CDM,C1713,HCPCS,0278,RC,,,,both,,,3376.60,2194.79,,,,,,,,,,,,,
SPLINT WR AD SM UPTO W3.5IN LT MCP DLX KAY-SPLNT III,SUP-2324559,CDM,L3906,HCPCS,0272,RC,,,,both,,,79.41,51.62,,,,,,,,,,,,,
PLATE BNE L171MM SHT WRST SPANNING ACU LOC,SUP-2416950,CDM,C1713,HCPCS,0278,RC,,,,both,,,6744.72,4384.07,,,,,,,,,,,,,
NEEDLE LOCALIZATION HAWKINS II 20GA 12.5CM 29.4CM WIRE,SUP-2875915,CDM,A4648,CPT,0278,RC,,,,both,,,119.32,77.56,,,,,,,,,,,,,
PLATE BONE L25MM BLDE L15MM THK0.9MM 3X3 H RT MAX TI L SHP,SUP-2191199,CDM,C1713,HCPCS,0278,RC,,,,both,,,719.06,467.39,,,,,,,,,,,,,
SCREW BNE LCK 2.7X22 MM RADIAL LCK TI,SUP-2363473,CDM,C1713,HCPCS,0278,RC,,,,both,,,296.92,193.00,,,,,,,,,,,,,
MESH HERN W30XL30CM SQ PARTIALLY ABSRB LTWT ULTRAPRO,SUP-2220104,CDM,C1781,HCPCS,0278,RC,,,,both,,,1075.54,699.10,,,,,,,,,,,,,
KIT EEG ELECTRD L 54.5 MM 16 CONTACT RF PRB STRL DISP EVO,SUP-2936420,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3720.90,2418.58,,,,,,,,,,,,,
SCREW INTRF BIOABSORBABLE 2.7X24 MM FT,SUP-2166519,CDM,C1713,HCPCS,0278,RC,,,,both,,,441.20,286.78,,,,,,,,,,,,,
INFLIXIMAB 100 MG IV SOLR,RX-23796,CDM,J1745,HCPCS,0636,RC,57894-0030-01,NDC,,both,1,UN,3445.10,2239.31,,,,,,,,,,,,,
HC Njx Px Cntrst Kne Arthg Cntrst Enhncd CT/MRI Kne,PX-3612736900,CDM,27369,CPT,0361,RC,,,,outpatient,,,3707.00,2409.55,,,,,,,,,,,,,
KIT CATH 14FR L9IN PERC CAV DRNGE ASMBLY CVD BLU FLEXTIP,SUP-2383257,CDM,C1729,HCPCS,0272,RC,,,,both,,,378.68,246.14,,,,,,,,,,,,,
SCREW BNE 4/PK L 8 MM DIA2.2 MM PLA GLYCOLIDE CRANIOMAXILLOFACIAL,SUP-2884156,CDM,C1713,HCPCS,0278,RC,,,,both,,,1289.79,838.36,,,,,,,,,,,,,
SET INT FIX SCREW DIA1.5 MM 6 H TI NEURO STR REG PLATE SD HI,SUP-2936065,CDM,C1713,HCPCS,0278,RC,,,,both,,,17835.20,11592.88,,,,,,,,,,,,,
HEAD FEM 26 MM HIP COCR,SUP-2449387,CDM,C1776,CPT,0278,RC,,,,both,,,2303.19,1497.07,,,,,,,,,,,,,
PLATE BNE PED W23XL127MM 90DEG 5 H ST DST CNDYL FEM S STL LO,SUP-2177213,CDM,C1713,HCPCS,0278,RC,,,,both,,,2887.42,1876.82,,,,,,,,,,,,,
PLATE BUR H L 17 MM THK 0.5 MM SZ 24.2 X 21.2 MM TI RT,SUP-2934753,CDM,C1713,HCPCS,0278,RC,,,,both,,,511.82,332.68,,,,,,,,,,,,,
MESH CRAN CUSTOMIZED XL PRIORITY STRL MEDPOR,SUP-2862753,CDM,C1713,HCPCS,0278,RC,,,,both,,,72157.86,46902.61,,,,,,,,,,,,,
GUIDEWIRE VASC TORX L 80 CM DIA 0.018 IN TIP 5 CM NIT PERIPH,SUP-2226011,CDM,C1769,HCPCS,0272,RC,,,,both,,,311.68,202.59,,,,,,,,,,,,,
ROD SPNL 5.5X500 MM 50 MM MESA RAIL 811H55500T50,SUP-2732253,CDM,C1713,HCPCS,0278,RC,,,,both,,,7338.18,4769.82,,,,,,,,,,,,,
HC So Vip(Vasoact.Intest.Polypept.),PX-3018458666,CDM,84586,CPT,0301,RC,,,,outpatient,,,2406.00,1563.90,,,,,,,,,,,,,
MESH PREPERITONEAL BIOMATERIAL 9CM CIRCULAR SYNECOR,SUP-2752386,CDM,C1781,HCPCS,0278,RC,,,,both,,,1309.38,851.10,,,,,,,,,,,,,
MINI L PLATE 2.0 OBLIQUE L 4 HOLES,SUP-2496554,CDM,C1713,HCPCS,0278,RC,,,,both,,,254.97,165.73,,,,,,,,,,,,,
SCREW BNE FOR TOT HIP POSTEROLATERAL APPRCH MAKO,SUP-2368442,CDM,C1713,HCPCS,0278,RC,,,,both,,,644.33,418.81,,,,,,,,,,,,,
HC So Iadna Sars-Cov-2-19 Amp Probe Tq,PX-3068763566,CDM,87635,CPT,0306,RC,,,,both,,,176.00,114.40,,,,,,,,,,,,,
SPLINT ORTHOPEDIC W/ ABDUCTED MED 8 IN RT WRST FOREARM THMB,SUP-2276638,CDM,L3809,HCPCS,0274,RC,,,,both,,,22.61,14.70,,,,,,,,,,,,,
CONNECTOR ROD L50 MM OD6 MM SPINETUNE TL STR STRL FEATURING,SUP-2416059,CDM,C1713,HCPCS,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
BUR SURG HOLE SAW 10.8X24.1 MM 9 CM LG BOR MIDAS REX LEGEND,SUP-2631877,CDM,2720000010,LOCAL,0272,RC,,,,both,,,485.13,315.33,,,,,,,,,,,,,
PLATE BONE THK0.5MM 6 H NEURO DBL Y,SUP-2365075,CDM,C1713,HCPCS,0278,RC,,,,both,,,1730.01,1124.51,,,,,,,,,,,,,
KNEE IMMOB 22IN QUAL + S,SUP-2195531,CDM,L1830,CPT,0272,RC,,,,both,,,46.66,30.33,,,,,,,,,,,,,
GRAFT BONE FEMORAL HD W/ TROCH FZ IRR,SUP-2875985,CDM,C1762,CPT,0278,RC,,,,both,,,3973.36,2582.68,,,,,,,,,,,,,
NAIL IM TIB STD 8X345 MM,SUP-2552326,CDM,C1713,HCPCS,0278,RC,,,,both,,,3680.27,2392.18,,,,,,,,,,,,,
CLAMP EXT FIX M OD20MM BLU FOR MONOTUBE RNG HYBRID TRIAX SYS,SUP-2372627,CDM,C1713,HCPCS,0278,RC,,,,both,,,5011.75,3257.64,,,,,,,,,,,,,
SCREW SPNL 5.5X30 MM,SUP-2402798,CDM,C1713,HCPCS,0278,RC,,,,both,,,2072.40,1347.06,,,,,,,,,,,,,
PLATE BNE 3.5X76 MM CLAV RT 6 HOLE SHFT TI LOQTEQ,SUP-2431898,CDM,C1713,HCPCS,0278,RC,,,,both,,,4678.60,3041.09,,,,,,,,,,,,,
JOINT FNGR 50 MP SIL,SUP-2852976,CDM,C1776,CPT,0278,RC,,,,both,,,4812.40,3128.06,,,,,,,,,,,,,
EPIFIX MESHED 4.5X4.5CM  11SQ CM,SUP-2305743,CDM,Q4186,HCPCS,0636,RC,,,,both,,,4694.30,3051.29,,,,,,,,,,,,,
DRONABINOL 2.5 MG PO CAPS,RX-9904,CDM,Q0167,HCPCS,0637,RC,67877-0753-60,NDC,,both,1,UN,8.40,5.46,,,,,,,,,,,,,
CATHETER ANGIO MARINER L 65 CM 5 FR 0.038 IN RIM NONBRAIDED,SUP-2116923,CDM,C1725,HCPCS,0272,RC,,,,both,,,151.98,98.79,,,,,,,,,,,,,
HC So1 Cardiolipin Antibody,PX-3028614767,CDM,86147,CPT,0302,RC,,,,both,,,58.00,37.70,,,,,,,,,,,,,
PLATE BNE L316MM 13 H L DST FEM TI LOK COMPR LO PROF RIG,SUP-2190745,CDM,C1713,HCPCS,0278,RC,,,,both,,,4151.71,2698.61,,,,,,,,,,,,,
NAIL IM L30CM DIA8.5MM TIB KNEE GRY TI CANN LOK RG BEND,SUP-2347075,CDM,C1713,HCPCS,0278,RC,,,,both,,,3738.80,2430.22,,,,,,,,,,,,,
PROBE RF STR 22 GAX100 MM NIT DISP,SUP-2753309,CDM,2720000010,LOCAL,0272,RC,,,,both,,,279.46,181.65,,,,,,,,,,,,,
BALLOON RETRV BILI DBL LUMN 11.5MM,SUP-2149637,CDM,C1726,HCPCS,0272,RC,,,,both,,,266.90,173.48,,,,,,,,,,,,,
INTRODUCER REPROC SHTH SM CURL 0.032 IN 8.5 FRX71 CM AGILIS NXT,SUP-2357284,CDM,C1766,CPT,0272,RC,,,,both,,,1821.20,1183.78,,,,,,,,,,,,,
PLATE SPNL L28MM UNIV CERV ANT 2 LEV TI STD REFLX,SUP-2380860,CDM,C1713,HCPCS,0278,RC,,,,both,,,5761.90,3745.23,,,,,,,,,,,,,
GRAFT BIO TISS 5X5CM THK04-10MM MESHED 1:1 ACELLULAR DERM,SUP-2632332,CDM,C1763,HCPCS,0278,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
HC So1 Immunofixation Serum,PX-3028633467,CDM,86334,CPT,0302,RC,,,,both,,,225.00,146.25,,,,,,,,,,,,,
SYSTEM CLOSURE PK SHTH VENASEAL,SUP-2883969,CDM,C1888,HCPCS,0272,RC,,,,both,,,2464.90,1602.18,,,,,,,,,,,,,
MESH HERN W12XL15CM OPN TISS SEPARATING PHYSIOMESH,SUP-2219745,CDM,C1781,HCPCS,0278,RC,,,,both,,,2099.94,1364.96,,,,,,,,,,,,,
HC Leukored Platelet Pheres Irrad,PX-3900903700,CDM,P9037,CPT,0390,RC,,,,both,,,2828.00,1838.20,,,,,,,,,,,,,
HC Antb Severe Aqt Respir Synd Sars-Cov-2 Covid-19,PX-3028676900,CDM,86769,CPT,0302,RC,,,,both,,,82.00,53.30,,,,,,,,,,,,,
BIT DRL DIA7MM ENTRY FOR ANK COMPR NAILING SYS,SUP-2316004,CDM,2720000010,LOCAL,0272,RC,,,,both,,,934.65,607.52,,,,,,,,,,,,,
IMMOBILIZER SHLDR M STRP 39IN,SUP-2324218,CDM,L3650,HCPCS,0274,RC,,,,both,,,19.12,12.43,,,,,,,,,,,,,
CATHETER EP 6FR L125CM 5MM SPC POLYUR QPLR FIX 200574,SUP-2142208,CDM,C1725,HCPCS,0272,RC,,,,both,,,722.20,469.43,,,,,,,,,,,,,
CATHETER CV DL 5 FRX45 CM SHERLOCK STYL GROSH NXT,SUP-2126722,CDM,C1751,HCPCS,0278,RC,,,,both,,,712.78,463.31,,,,,,,,,,,,,
SET URET STENT SOFFLX L 14 CM DIA 6 FR POS L 46 CM DIA 7 FR,SUP-2168899,CDM,C2617,HCPCS,0278,RC,,,,both,,,468.24,304.36,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 30 CM DIA 8 MM STR TW STRL,SUP-2396318,CDM,C1768,CPT,0278,RC,,,,both,,,2358.14,1532.79,,,,,,,,,,,,,
CATHETER CV DL 10 FR CUT DN PROC TY LNRD,SUP-2626324,CDM,C1751,HCPCS,0278,RC,,,,both,,,504.13,327.68,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED SH2] STELKAST CO],SUP-2359391,CDM,C1776,CPT,0278,RC,,,,both,,,12246.00,7959.90,,,,,,,,,,,,,
COMPONENT TOT SHLDR CAPPED REVERSED S4FHORTHO] FH ORTHO INC],SUP-2224562,CDM,C1776,CPT,0278,RC,,,,both,,,21038.00,13674.70,,,,,,,,,,,,,
VALVE HYDROCEPHALUS 10 PED W/ SHUNT ASST AND BUR H RESVR,SUP-2108747,CDM,C1729,HCPCS,0272,RC,,,,both,,,8990.95,5844.12,,,,,,,,,,,,,
STENT URET STR 0.038 IN 3 CM 7 FRX20 CM 6 FR POLARIS ULTRA,SUP-2478060,CDM,C2617,HCPCS,0278,RC,,,,both,,,427.64,277.97,,,,,,,,,,,,,
CATHETER EP 6FR L115CM 5MM SPC 4 ELECTRD A CRV NYL PROTCT,SUP-2248898,CDM,C1730,HCPCS,0272,RC,,,,both,,,342.26,222.47,,,,,,,,,,,,,
PLATE BONE SM THK2MM TI BLU MAND DBL ANG STR MID GRD 2,SUP-2136807,CDM,C1713,HCPCS,0278,RC,,,,both,,,5906.34,3839.12,,,,,,,,,,,,,
SUTURE LASSO NDL QTY 5 AR4560,SUP-2121866,CDM,2720000010,LOCAL,0272,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
MESH HERN 5X10CM POLYPR W/ POLYDIOXANONE PROCEED RECT TISS,SUP-2219759,CDM,C1781,HCPCS,0278,RC,,,,both,,,875.21,568.89,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC PROVENA PLU MAXBARR 5FR S1395108D2,SUP-2632827,CDM,C1751,HCPCS,0278,RC,,,,both,,,1166.57,758.27,,,,,,,,,,,,,
CATHETER VASC DIAG COBRA 2 PERIPH .038 W/O HYDRPHLC COAT AD,SUP-2141098,CDM,C1887,HCPCS,0272,RC,,,,both,,,154.77,100.60,,,,,,,,,,,,,
CRADLE SPNL RAD 220MM SUP CRAN GLD TI ALLOY NEUT FOR RIB,SUP-2193283,CDM,C1889,HCPCS,0278,RC,,,,both,,,5915.76,3845.24,,,,,,,,,,,,,
SCREW SPNL MULTAXL 4.5X40 MM FEN SOLERA 5.5/6,SUP-2629693,CDM,C1713,HCPCS,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
SUPPORT ORTHOT HIP JT LOWER EXTREMITY PELV CTRL CLEVIS TYP,SUP-2435680,CDM,L2570,HCPCS,0274,RC,,,,both,,,1260.90,819.58,,,,,,,,,,,,,
SCREW BNE LOK MINI TI NONSTERILE 20MMX5MM MAXDRIVE,SUP-2262884,CDM,C1713,HCPCS,0278,RC,,,,both,,,366.50,238.22,,,,,,,,,,,,,
INSERTER SLNG TRNSVAG DISP,SUP-2140288,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2073.19,1347.57,,,,,,,,,,,,,
SPACER SPNL 10X22X50 MM,SUP-2310600,CDM,C1821,HCPCS,0278,RC,,,,both,,,18055.00,11735.75,,,,,,,,,,,,,
DEVICE SUT CAPT L25CM DIA12MM OPN ACCS W/O SLNG FOR,SUP-2139398,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2186.92,1421.50,,,,,,,,,,,,,
BAR EXT FIX SM 1,SUP-2460173,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3622.30,2354.49,,,,,,,,,,,,,
PUSHER STENT ADVANIX SZ 4/5 FR PANCREATIC OTW STRL,SUP-2141440,CDM,C1889,HCPCS,0278,RC,,,,both,,,157.69,102.50,,,,,,,,,,,,,
DRIVER SHFT SURG FLAT BLDE NCANNULATED N STRL REUSE 2.0MM,SUP-2364196,CDM,2720000010,LOCAL,0272,RC,,,,both,,,812.98,528.44,,,,,,,,,,,,,
PEN ABLAT ELECTRD L30MM BPLR LIN COOLRAIL,SUP-2124462,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8964.70,5827.05,,,,,,,,,,,,,
CANNULA ENDOSCP LFRIC 10 CM CARVALHO LP W/O LUER LCK CONN,SUP-2767949,CDM,2720000010,LOCAL,0272,RC,,,,both,,,723.42,470.22,,,,,,,,,,,,,
STAPLER INT L100MM CUT LN L98MM STPL LN L102MM BLU B FRM 8,SUP-2220038,CDM,2720000010,LOCAL,0272,RC,,,,both,,,653.56,424.81,,,,,,,,,,,,,
GRAFT HUM TISS PTCH 14X8 CM RECT BOV PERICARD PHOTOFIX LTX,SUP-2859717,CDM,C1768,CPT,0278,RC,,,,both,,,6751.00,4388.15,,,,,,,,,,,,,
PLATE BNE THK 1.4 MM SCREW DIA2.2 MM 3 X 21 H PLL STRUT,SUP-2883361,CDM,C1713,HCPCS,0278,RC,,,,both,,,19273.01,12527.46,,,,,,,,,,,,,
STENT DUODENAL HANAROSTENT LOWAX L 12 CM DIA22 MM DEL SYS L,SUP-2675384,CDM,C1874,HCPCS,0278,RC,,,,both,,,9843.90,6398.53,,,,,,,,,,,,,
GRAFT HUM TISS INJ FLUID THN 3X2 CM AMNIO PLCNTA PRO3-P,SUP-2742037,CDM,C1762,CPT,0278,RC,,,,both,,,2676.85,1739.95,,,,,,,,,,,,,
"HC So Lipoprotein,Bld,by Nmr",PX-3018370466,CDM,83704,CPT,0301,RC,,,,outpatient,,,76.00,49.40,,,,,,,,,,,,,
PLATE BNE 16 H CRANIOMAXILLOFACIAL TI STR LO PROF W/O BAR,SUP-2366198,CDM,C1713,HCPCS,0278,RC,,,,both,,,918.58,597.08,,,,,,,,,,,,,
KIT INTRO INTROFLEX L 10 CM DIA 7 FR DETACHABLE AUTO VLV,SUP-2214540,CDM,C1894,HCPCS,0272,RC,,,,both,,,69.08,44.90,,,,,,,,,,,,,
PIN EXT FIX BLNT 6X250 MM 90 MM THRD HA SS STRL APEX,SUP-2460751,CDM,2720000010,LOCAL,0272,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
PLATE BONE NONSTERILE CRANIOMAXILLOFACIAL TEAL TI SM ARC,SUP-2191109,CDM,C1713,HCPCS,0278,RC,,,,both,,,2631.32,1710.36,,,,,,,,,,,,,
BIT DRL L6-18MM DIA3.5MM ST GRY CORT DISP FOR VERTEX MAX,SUP-2286798,CDM,2720000010,LOCAL,0272,RC,,,,both,,,883.75,574.44,,,,,,,,,,,,,
SET CATH 5FR 200CM GWIRE .018IN 1MM MRK WIRE GUID BILI,SUP-2169240,CDM,C1713,HCPCS,0278,RC,,,,both,,,748.73,486.67,,,,,,,,,,,,,
BIT DRILL 2.4MM DIAMETER FOR ULTRA FIX MINIMITE ANCHOR,SUP-2824090,CDM,2720000010,LOCAL,0272,RC,,,,both,,,504.54,327.95,,,,,,,,,,,,,
SHEET CRAN W50XL50MM THK0.5MM RAP RESRB FOR 1.5MM SCR FIX,SUP-2194075,CDM,C1781,HCPCS,0278,RC,,,,both,,,3426.68,2227.34,,,,,,,,,,,,,
SPACER SPNL W11XH7XL14MM 0DEG LORDTC CORT CANC LIFEGRAFT,SUP-2353351,CDM,C1713,HCPCS,0278,RC,,,,both,,,2637.60,1714.44,,,,,,,,,,,,,
GRAFT BNE SUB 1CC H5MM DIA16MM DBM SHP BIO,SUP-2364716,CDM,C1713,HCPCS,0278,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
RELOAD STPL H2X0.75MM DIA45MM GRY MESENTERY/THIN TISS NAT,SUP-2218988,CDM,2720000010,LOCAL,0272,RC,,,,both,,,591.83,384.69,,,,,,,,,,,,,
BUR SURG RND 3X80 MM W/ LAT PROTCT GOLF BLU STRL DISP,SUP-2599840,CDM,2720000010,LOCAL,0272,RC,,,,both,,,394.04,256.13,,,,,,,,,,,,,
REMOVABLE END CAP,SUP-2823037,CDM,C1889,HCPCS,0278,RC,,,,both,,,1549.59,1007.23,,,,,,,,,,,,,
CONNECTOR SPNL L30.5-43MM OD4.5MM LO PROF CROSS,SUP-2228097,CDM,C1713,HCPCS,0278,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
FILTER VENA CAVA FEM SHTH DIL SET SIMN NIT,SUP-2127813,CDM,C1880,HCPCS,0278,RC,,,,both,,,276.32,179.61,,,,,,,,,,,,,
SHEATH INTRO L 90 CM DIA 6 FR SS COIL NYL OUTER PTFE INNR,SUP-2139613,CDM,C1894,HCPCS,0272,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
MESH HERN SQ 4X4 IN FULL RESRB FOR SFT TISS RECON PHASIX,SUP-2855249,CDM,C1781,HCPCS,0278,RC,,,,both,,,5212.40,3388.06,,,,,,,,,,,,,
PLATE BNE L155MM 6 H NONSTERILE L DST FEM LOK FOR 4.5MM SCR,SUP-2348454,CDM,C1713,HCPCS,0278,RC,,,,both,,,10020.68,6513.44,,,,,,,,,,,,,
PLATE SPNL 2 LEVEL 46 MM ANTR CERV,SUP-2414259,CDM,C1713,HCPCS,0278,RC,,,,both,,,4882.76,3173.79,,,,,,,,,,,,,
HC NM Quant Lung Perfusion,PX-3417859700,CDM,78597,CPT,0341,RC,,,,both,,,2923.00,1899.95,,,,,,,,,,,,,
TAP SURG 4-5X30 MM ACUTRK,SUP-2107227,CDM,C1713,HCPCS,0278,RC,,,,both,,,265.42,172.52,,,,,,,,,,,,,
RASP DISTAL SMART TOE,SUP-2495619,CDM,2720000010,LOCAL,0272,RC,,,,both,,,591.89,384.73,,,,,,,,,,,,,
MESH CRAN L 85 X W 53 MM THK 0.8 MM SCREW DIA1.5 MM SM TI,SUP-2936898,CDM,C1713,HCPCS,0278,RC,,,,both,,,5055.40,3286.01,,,,,,,,,,,,,
STEM FEM L140MM DIA14MM 135DEG STD OFFSET DST HIP BILAT,SUP-2252552,CDM,C1776,CPT,0278,RC,,,,both,,,8947.74,5816.03,,,,,,,,,,,,,
OXYBUTYNIN CHLORIDE 5 MG PO TABS,RX-5938,CDM,6370000000,HCPCS,0637,RC,00832-0038-00,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
CATHETER BRACHYTHERAPY MULT LUMEN 4.5 CM BLNT CONTURAFLEX,SUP-2239954,CDM,C1725,HCPCS,0272,RC,,,,both,,,8375.95,5444.37,,,,,,,,,,,,,
CATHETER PLCMNT KT,SUP-2126777,CDM,C1751,HCPCS,0278,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
STENT PANCREATIC ZMMN L 15 CM DIA 4 FR GUIDEWIRE 0.021 IN,SUP-2738124,CDM,C2617,HCPCS,0278,RC,,,,both,,,245.71,159.71,,,,,,,,,,,,,
DA VINCI TIBIAL NAIL 12MMX31.5CM,SUP-2828941,CDM,C1713,HCPCS,0278,RC,,,,both,,,6578.30,4275.89,,,,,,,,,,,,,
PROCESSOR HEARING AID CHROMA BGE RT EAR SND PROC CHAN WIND,SUP-2319863,CDM,L8690,HCPCS,0278,RC,,,,both,,,10048.00,6531.20,,,,,,,,,,,,,
HOOK SPNL RT LAM S STL OPN ANG FOR 4MM ROD MOSS MIAMI SYS,SUP-2254425,CDM,C1713,HCPCS,0278,RC,,,,both,,,1516.62,985.80,,,,,,,,,,,,,
CATHETER ABLATN MED CRV XLS 4/8 MM 2-5-2 MM 7 FRX115 CM,SUP-2356982,CDM,C1733,HCPCS,0272,RC,,,,both,,,1868.30,1214.39,,,,,,,,,,,,,
PLATE BNE W33XL173MM 12 H R DST MED TIB S STL LOK COMPR NEUT,SUP-2185115,CDM,C1713,HCPCS,0278,RC,,,,both,,,4331.88,2815.72,,,,,,,,,,,,,
PLATE BNE MIC THK0.4MM 18 H BILAT CRANIOMAXILLOFACIAL BLU,SUP-2181676,CDM,C1713,HCPCS,0278,RC,,,,both,,,2384.83,1550.14,,,,,,,,,,,,,
ANCHOR SUT SZ 4.5MM WHT BLU PEEK UHMWPE BRAID FLAT PERMATAPE,SUP-2417594,CDM,C1713,HCPCS,0278,RC,,,,both,,,1720.72,1118.47,,,,,,,,,,,,,
FILGRASTIM-SNDZ 480 MCG/0.8ML IJ SOSY,RX-131188,CDM,Q5101,HCPCS,0636,RC,61314-0326-01,NDC,,both,0.8,ML,1295.00,841.75,,,,,,,,,,,,,
VALVE VENT DRNGE L120CM CEREB LN PROGRAMMABLE UNITZ,SUP-2194064,CDM,C1889,HCPCS,0278,RC,,,,both,,,14281.94,9283.26,,,,,,,,,,,,,
SCREW BNE L20MM DIA3.5MM S STL LOK WSHR SURFIX,SUP-2243392,CDM,C1713,HCPCS,0278,RC,,,,both,,,1109.46,721.15,,,,,,,,,,,,,
CUP ACET DIA58MM LT HIPX3 MOB BEAR FOR 28MM HD REST ADM,SUP-2361604,CDM,C1776,CPT,0278,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
MESH WND DERM REP FET BOV DERM PRIMATRIX FEN 20X25,SUP-2243691,CDM,Q4110,HCPCS,0636,RC,,,,both,,,43960.00,28574.00,,,,,,,,,,,,,
SCR DF ZURICH HEXMD1.2X7MM5MM THD,SUP-2678357,CDM,C1713,HCPCS,0278,RC,,,,both,,,509.50,331.17,,,,,,,,,,,,,
GUIDEWIRE FIX 24MMX70CM HUM BULL TIP S STL M DN,SUP-2410450,CDM,C1769,HCPCS,0272,RC,,,,both,,,132.48,86.11,,,,,,,,,,,,,
MESH HERN W15XL30CM VENTRAL SYN POLY CLLGN POLYLACTIC ACID,SUP-2174796,CDM,C1781,HCPCS,0278,RC,,,,both,,,1286.24,836.06,,,,,,,,,,,,,
PIN EXT FIX L300MM OD4MM TI NITRIDE WIRE H TIP TRANSFIXING,SUP-2400695,CDM,2720000010,LOCAL,0272,RC,,,,both,,,715.92,465.35,,,,,,,,,,,,,
RING TRAC M 19-22IN CERV CLOSE BK W/ 2.5IN SKULL AND POS PIN,SUP-2328119,CDM,L0810,HCPCS,0272,RC,,,,both,,,3375.50,2194.07,,,,,,,,,,,,,
PIN DRL 13MM ACL PCL KNEE ALL IN 1 GUID RG RMR DISP,SUP-2120835,CDM,2720000010,LOCAL,0272,RC,,,,both,,,894.90,581.68,,,,,,,,,,,,,
PROSTHESIS INDWL VOICE L FLNG T AND E 20F 14MM,SUP-2242419,CDM,L8509,HCPCS,0272,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
VITAMIN D (ERGOCALCIFEROL) 1.25 MG (50000 UT) PO CAPS,RX-100998,CDM,6370000000,HCPCS,0637,RC,50268-0297-15,NDC,,both,1,UN,6.30,4.09,,,,,,,,,,,,,
MESH HERN RECT 16X8 IN FULL RESRB FOR SFT TISS PHASIX,SUP-2855255,CDM,C1781,HCPCS,0278,RC,,,,both,,,33786.40,21961.16,,,,,,,,,,,,,
STENT BILI PALMAZ GEN L 25 MM EXPANSION DIA10-12 MM SHTH 8,SUP-2159233,CDM,C1877,HCPCS,0278,RC,,,,both,,,3749.16,2436.95,,,,,,,,,,,,,
TRAY ADPT FX SHLDR SYS,SUP-2223411,CDM,C1776,CPT,0278,RC,,,,both,,,8792.00,5714.80,,,,,,,,,,,,,
PIN FIX L225MM DIA6MM S STL FOR L EXT FIX SET,SUP-2187000,CDM,C1713,HCPCS,0278,RC,,,,both,,,350.90,228.08,,,,,,,,,,,,,
SYSTEM FIX ORTHO BOLT WIRE EXT LNG LRF,SUP-2472243,CDM,2720000010,LOCAL,0272,RC,,,,both,,,295.69,192.20,,,,,,,,,,,,,
CLOBETASOL PROPIONATE 0.05 % EX OINT,RX-9631,CDM,6370000000,HCPCS,0637,RC,51672-1259-01,NDC,,both,15,GR,22.50,14.62,,,,,,,,,,,,,
INSTRUMENT TEMP FIX 2.3 MM RIB 69 MM SCR TI LEVEL 1 MAXDRIVE,SUP-2869185,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1060.06,689.04,,,,,,,,,,,,,
WIRE EXT FIX DIA2MM FOR SALVATION EXT FIX,SUP-2401142,CDM,C1713,HCPCS,0278,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
URETEROSCOPE DGT FLX SHTH GLOB STD MOB CART CMSO IMAGER,SUP-2139385,CDM,C1747,HCPCS,0272,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
GUIDEWIRE VASC L 150 CM DIA 0.035 IN TIP L 1.5 MM SS PTFE,SUP-2120090,CDM,C1769,HCPCS,0272,RC,,,,both,,,48.89,31.78,,,,,,,,,,,,,
BIT DRL SLD LNG 2X115 MM,SUP-2321710,CDM,2720000010,LOCAL,0272,RC,,,,both,,,384.65,250.02,,,,,,,,,,,,,
NAIL IM L235MM DIA11MM 130DEG SHT GRN R PROX FEM TI,SUP-2180538,CDM,C1713,HCPCS,0278,RC,,,,both,,,4957.93,3222.65,,,,,,,,,,,,,
PLATE BNE L316MM 13 H NONSTERILE R DST FEM S STL LOK COMPR,SUP-2184903,CDM,C1713,HCPCS,0278,RC,,,,both,,,4661.90,3030.23,,,,,,,,,,,,,
PLANER SURG STANDARD STANDARD+ PAT BSKT PLT REPL LCS,SUP-2252798,CDM,C1713,HCPCS,0278,RC,,,,both,,,722.20,469.43,,,,,,,,,,,,,
PLATE BONE DIA70MM NONSTERILE CRAN TI RND CNTOUR MESH MALL,SUP-2190637,CDM,C1713,HCPCS,0278,RC,,,,both,,,5717.94,3716.66,,,,,,,,,,,,,
BIT DRL CANN 2.7X145 MM QC FOR 3.5-4 MM SCREW BLU GRN NS,SUP-2423900,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1347.06,875.59,,,,,,,,,,,,,
PLATE BONE 3 H 7 PEG NAR LT VOLAR S STL BEAR,SUP-2389747,CDM,C1713,HCPCS,0278,RC,,,,both,,,3563.90,2316.53,,,,,,,,,,,,,
BLADE ULTRSNC ASPIR WORKING L 100 MM L 10 X W 5 MM THK 0.5,SUP-2889546,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1745.84,1134.80,,,,,,,,,,,,,
SCREW BONE L48MM DIA4MM SM DK BLU TI ST SELF DRL CANN,SUP-2399816,CDM,C1713,HCPCS,0278,RC,,,,both,,,766.16,498.00,,,,,,,,,,,,,
ANCHOR SUTURE 5.0 MM KNOTLESS HEALICOIL,SUP-2653383,CDM,C1713,HCPCS,0278,RC,,,,both,,,1350.20,877.63,,,,,,,,,,,,,
CUP ACET 10 DEG 32X70 MM FEM HIP,SUP-2202591,CDM,C1776,CPT,0278,RC,,,,both,,,2139.28,1390.53,,,,,,,,,,,,,
CATHETER NPHRSTMY DLTN 30FR OD 55CML 15CML BLLN PRCTNS FADER,SUP-2721797,CDM,C1729,HCPCS,0272,RC,,,,both,,,842.24,547.46,,,,,,,,,,,,,
FILTER VASC OPT ELITE SHTH L 70 CM DIA 5 FR CAVA DIA 30 MM,SUP-2120059,CDM,C1880,HCPCS,0278,RC,,,,both,,,5392.01,3504.81,,,,,,,,,,,,,
SCREW SYS DEPTH G DRL 100 MM 2.7 MM OD 4.5 MM SCRS,SUP-2392913,CDM,2720000010,LOCAL,0272,RC,,,,both,,,916.10,595.46,,,,,,,,,,,,,
ELECTRODE ES 6FR BUGBEE,SUP-2436271,CDM,2720000010,LOCAL,0272,RC,,,,both,,,496.75,322.89,,,,,,,,,,,,,
ALLOGRAFT BNE 9X220 MM POST TIBIALIS,SUP-2866886,CDM,C1762,CPT,0278,RC,,,,both,,,4176.20,2714.53,,,,,,,,,,,,,
SYSTEM EUSTACHIAN DIL L 20 MM DIA 5 MM BALLOON INFLATION SYR,SUP-2900137,CDM,C1726,HCPCS,0272,RC,,,,both,,,5102.50,3316.62,,,,,,,,,,,,,
BLADE SCRDRVR 1.2 CROSS PIN,SUP-2419549,CDM,2720000010,LOCAL,0272,RC,,,,both,,,705.87,458.82,,,,,,,,,,,,,
SYSTEM DETACH NXT,SUP-2173075,CDM,C1713,HCPCS,0278,RC,,,,both,,,693.94,451.06,,,,,,,,,,,,,
TRAY TIB REV MOD 4T4F PROVEN,SUP-2359299,CDM,C1776,CPT,0278,RC,,,,both,,,4749.25,3087.01,,,,,,,,,,,,,
CATHETER HD STR 12 FRX20 CM SHT TERM 3L TY SLIM-CATH,SUP-2427950,CDM,C1752,HCPCS,0278,RC,,,,both,,,2818.12,1831.78,,,,,,,,,,,,,
GRAFT HUM TISS W2XL4CM THN AMNIO BARR MEM CHORION FREE,SUP-2399185,CDM,C1762,CPT,0278,RC,,,,both,,,4355.18,2830.87,,,,,,,,,,,,,
CATH GD MP1 SH 7FR 100CM WSGD,SUP-2142141,CDM,C1887,HCPCS,0272,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
RELOAD STPL L100MM REG TISS BLU TI FOR PROX LIN CUT DST SER,SUP-2283274,CDM,2720000010,LOCAL,0272,RC,,,,both,,,320.91,208.59,,,,,,,,,,,,,
PLATE BONE DUAL CMPRSSN HLX8 TTNM 1/3 TBLR F/3.5MM LOK SCREW,SUP-2588615,CDM,C1713,HCPCS,0278,RC,,,,both,,,587.18,381.67,,,,,,,,,,,,,
PROSTHESIS OSS WEHRS II AVG 6.3X5.2X2.5 MM SINGLE NOTCH HA,SUP-2638123,CDM,L8613,CPT,0278,RC,,,,both,,,1165.63,757.66,,,,,,,,,,,,,
SCREW SPNL L25MM OD6.5MM 5.5MM ROD MONOAX LO PROF DBL LD,SUP-2229329,CDM,C1713,HCPCS,0278,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
SCREW BNE L32MM DIA4.7MM S STL CORT N ST DRL NCANNULATED,SUP-2412997,CDM,C1713,HCPCS,0278,RC,,,,both,,,206.99,134.54,,,,,,,,,,,,,
PLATE BONE W15XL200MM THK2MM 10 H BILAT TI THN BLDE RIG,SUP-2190987,CDM,C1713,HCPCS,0278,RC,,,,both,,,1808.45,1175.49,,,,,,,,,,,,,
PLATE BNE NAR 3.5X197 MM 11 HOLE SS LCP,SUP-2569355,CDM,C1713,HCPCS,0278,RC,,,,both,,,585.45,380.54,,,,,,,,,,,,,
CATHETER HD DL 15.5 FRX12 CM PRECRV TAPR TIP DUOFLO,SUP-2267102,CDM,C1750,HCPCS,0278,RC,,,,both,,,109.90,71.43,,,,,,,,,,,,,
CATHETER THOR 32FR L20IN CLR PVC THERMOSENSITIVE STR RADPQ,SUP-2154969,CDM,C1729,HCPCS,0272,RC,,,,both,,,28.10,18.26,,,,,,,,,,,,,
GRAFT VASC STR WVN DBL VEL 22MM DIAX15CM L HEMSHLD PLAT,SUP-2227696,CDM,C1768,CPT,0278,RC,,,,both,,,1446.13,939.98,,,,,,,,,,,,,
DILATOR UTER HEG 1-26 MM 7.5 IN SET SINGLE END IN CANVS RL,SUP-2472815,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2093.22,1360.59,,,,,,,,,,,,,
MESH BIO BOV MTRX WND TISS N PERF 6CM LEN 6CM W 1MM,SUP-2364669,CDM,C9359,HCPCS,0278,RC,,,,both,,,5610.05,3646.53,,,,,,,,,,,,,
GRAFT PUTTY NOVABONE,SUP-2307532,CDM,C9359,HCPCS,0278,RC,,,,both,,,1193.20,775.58,,,,,,,,,,,,,
TEMPLATE SURG LO PROF FIX STD POST XLNK PLT,SUP-2290317,CDM,C1713,HCPCS,0278,RC,,,,both,,,416.46,270.70,,,,,,,,,,,,,
CLAMP EXT FIX L MULTIPIN 4 POS,SUP-2188492,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2037.92,1324.65,,,,,,,,,,,,,
PLATE BONE L99MM 2 H LT PROX FEM LCK FOR 4.5MM SCR PERI-LOC,SUP-2351167,CDM,C1713,HCPCS,0278,RC,,,,both,,,11254.23,7315.25,,,,,,,,,,,,,
SET PICC CONV FOR 5FR CATH SELD,SUP-2384043,CDM,C1751,HCPCS,0278,RC,,,,both,,,73.79,47.96,,,,,,,,,,,,,
SHEATH INTRO PRELUDE L 4 CM DIA 6 FR GUIDEWIRE L 40 CM DIA,SUP-2303309,CDM,C1894,HCPCS,0272,RC,,,,both,,,87.92,57.15,,,,,,,,,,,,,
SET KNEE REPL POLY MOST OPTIONS,SUP-2208301,CDM,C1776,CPT,0278,RC,,,,both,,,4069.44,2645.14,,,,,,,,,,,,,
COIL EMB L30CM DIA12MM 00135IN SFT HELI DETACH STRTCH,SUP-2173301,CDM,C1889,HCPCS,0278,RC,,,,both,,,3686.36,2396.13,,,,,,,,,,,,,
KIT INTRO MINI STK II L 5 CM DIA 3 FR GUIDEWIRE L 45 CM DIA,SUP-2734848,CDM,C1894,HCPCS,0272,RC,,,,both,,,24.49,15.92,,,,,,,,,,,,,
SET INTRO SUP ARW FLX SHTH L 45 CM DIA 8 FR HYDRPHLC,SUP-2383414,CDM,C1894,HCPCS,0272,RC,,,,both,,,375.42,244.02,,,,,,,,,,,,,
ENDCAP SPNL 16 MM T2 STRATOSPHERE,SUP-2432046,CDM,C1889,HCPCS,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
SCREW BNE L 4.6 MM DIA2.5 MM TI MAND CNDYL PROS FIX AXS NS,SUP-2909586,CDM,C1713,HCPCS,0278,RC,,,,both,,,644.99,419.24,,,,,,,,,,,,,
KIT INTRO OD5FR MIC VSI NIT MANDREL S STL SFT TIP L60CM,SUP-2383167,CDM,C1894,HCPCS,0272,RC,,,,both,,,133.45,86.74,,,,,,,,,,,,,
PASSER SUT 45DEG LT ARTHSCP SLINGSHOT,SUP-2365418,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1139.38,740.60,,,,,,,,,,,,,
PLATE BNE L 233 MM SCREW DIA 4.5 MM 11 H SS LT DSTL FEM 72574111N,SUP-2932746,CDM,C1713,HCPCS,0278,RC,,,,both,,,11501.82,7476.18,,,,,,,,,,,,,
COMPACTOR SURG SZ 7/9 UNIV FOR NOTCH/PATELLA GRV PREP SCORP,SUP-2378559,CDM,C1776,CPT,0278,RC,,,,both,,,1711.30,1112.34,,,,,,,,,,,,,
BUR SURG COARSE DIAMOND 6 MM RND UPWR,SUP-2166789,CDM,2720000010,LOCAL,0272,RC,,,,both,,,228.59,148.58,,,,,,,,,,,,,
VALVE WITH MCLANAHAN RESERVOIR AND MININAV 0 PROSA,SUP-2826814,CDM,C1889,HCPCS,0278,RC,,,,both,,,10665.20,6932.38,,,,,,,,,,,,,
GUIDEWIRE VASC L 260 CM 0.035IN L 7CM 2.5CM SAFE-T-J HVY DTY,SUP-2638691,CDM,C1769,HCPCS,0272,RC,,,,both,,,54.76,35.59,,,,,,,,,,,,,
SCREW BNE 1.5X13 MM 5 MM X DRV DRILL-FREE TI LEVEL1 10771391,SUP-2478720,CDM,C1713,HCPCS,0278,RC,,,,both,,,190.69,123.95,,,,,,,,,,,,,
ALLOGRAFT BNE BLOCK 10X10X10 MM SPNG FD CANC,SUP-2717779,CDM,C1713,HCPCS,0278,RC,,,,both,,,2088.10,1357.26,,,,,,,,,,,,,
SCREW BNE L36MM DIA3.5MM EL TI LOK MULTDIR FOR ALPS FRAC,SUP-2413772,CDM,C1713,HCPCS,0278,RC,,,,both,,,624.86,406.16,,,,,,,,,,,,,
GRAFT VASC GORTX L 60 CM DIA 6 MM EPTFE STR TW N RING STRL,SUP-2396697,CDM,C1768,CPT,0278,RC,,,,both,,,2037.86,1324.61,,,,,,,,,,,,,
PLATE BONE L249MM THK6MM 11 H LT FEM CNDYL TI BTTRS RIG CLLR,SUP-2190903,CDM,C1713,HCPCS,0278,RC,,,,both,,,3120.31,2028.20,,,,,,,,,,,,,
DEXTROSE-SODIUM CHLORIDE 5-0.9 % IV SOLN,RX-15882,CDM,J7042,HCPCS,0258,RC,00338-0089-03,NDC,,both,500,ML,38.30,24.89,,,,,,,,,,,,,
MICRO PLATE 3 X 2 HOLES SQRE SGMNTS 6MM 15MM SSTM CP TTNM,SUP-2681100,CDM,C1713,HCPCS,0278,RC,,,,both,,,644.89,419.18,,,,,,,,,,,,,
BASEPLATE TIB L63MM KNEE CO CHROME MOD ORTH SALV SYS,SUP-2435905,CDM,C1776,CPT,0278,RC,,,,both,,,9339.93,6070.95,,,,,,,,,,,,,
HC Allergy Skin Tests,PX-9249502800,CDM,95028,CPT,0924,RC,,,,both,,,219.00,142.35,,,,,,,,,,,,,
INSERT TIB SZ 2 THK9.5MM RT MEDL LT LAT KNEE FIX BEAR,SUP-2251271,CDM,C1776,CPT,0278,RC,,,,both,,,2530.84,1645.05,,,,,,,,,,,,,
CATHETER CV 3L 6 FR STYL BASIC TY POLY RADPICC,SUP-2126398,CDM,C1751,HCPCS,0278,RC,,,,both,,,373.66,242.88,,,,,,,,,,,,,
MATRIX BIO L 7 X W 7 CM BOV CLLGN CHONDROITIN-6-SULFATE,SUP-2909259,CDM,Q4105,HCPCS,0636,RC,,,,both,,,9178.85,5966.25,,,,,,,,,,,,,
BONE BIOPSY KIT HUNTINGTON GUID 18 GAX10 CM MADISON MINI,SUP-2472852,CDM,2720000010,LOCAL,0272,RC,,,,both,,,800.70,520.45,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY L 115 CM DIA 6 FR SPC 2-5-2 MM D,SUP-2248677,CDM,C1732,HCPCS,0272,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
KIT NEUROSTIMULATOR L 45 CM DIA1.35 MM PERIPH TRL 4 CONTACT 1 CHAN,SUP-2925122,CDM,C1897,HCPCS,0278,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
BURR BALL FLUTED 3.0MM W/ MED ATTACHMENT,SUP-2843301,CDM,2720000010,LOCAL,0272,RC,,,,both,,,402.36,261.53,,,,,,,,,,,,,
BIT DRL L44.5MM DIA1.4MM L8MM STP J LATCH NONRADIOPAQUE,SUP-2179239,CDM,2720000010,LOCAL,0272,RC,,,,both,,,602.25,391.46,,,,,,,,,,,,,
SHEATH INTRO PERFRMR CKFLO L 13 CM DIA 5 FR 0.035 IN,SUP-2642114,CDM,C1894,HCPCS,0272,RC,,,,both,,,160.11,104.07,,,,,,,,,,,,,
GUIDEWIRE VASC HYDRPHLC L180 CM OD.035 IN STR STIFF ZIPWIRE,SUP-2141155,CDM,C1769,HCPCS,0272,RC,,,,both,,,178.35,115.93,,,,,,,,,,,,,
PLATE 2H LOCKING 2.7/3.0/3.5/4.0MM,SUP-2752088,CDM,C1713,HCPCS,0278,RC,,,,both,,,1715.70,1115.20,,,,,,,,,,,,,
BUR SURG HOLE MAKER 9.5 MMX14 CM LG BOR MIDAS REX LEGEND,SUP-2627700,CDM,2720000010,LOCAL,0272,RC,,,,both,,,440.51,286.33,,,,,,,,,,,,,
SENSOR PPG YELLOW RSFH ONLY,SUP-2862969,CDM,2720000010,LOCAL,0272,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
CATHETER ANGIOPLSTY SAPPHIRE II PRO L 150 CM BALLOON L 10 MM,SUP-2636322,CDM,C1725,HCPCS,0272,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
STRAP ORTHOT HIP KNEE ANK CUST TORSON BILATERAL ROT,SUP-2435640,CDM,L2040,HCPCS,0274,RC,,,,both,,,572.74,372.28,,,,,,,,,,,,,
NAIL IM 130 DEG 10 MMX40 CM RT IMHS,SUP-2349039,CDM,C1713,HCPCS,0278,RC,,,,both,,,6066.48,3943.21,,,,,,,,,,,,,
GRAFT HUM TISS W14 18XL25MM FRZ DRY ALLGRFT FIB SHFT BNE,SUP-2307189,CDM,C1713,HCPCS,0278,RC,,,,both,,,1707.91,1110.14,,,,,,,,,,,,,
NUT SPNL DIA5/16IN S STL TAPR LCK VSP,SUP-2255575,CDM,C1713,HCPCS,0278,RC,,,,both,,,241.78,157.16,,,,,,,,,,,,,
SUPPORT ORTHOT CUST LIFT ELEVATION INSIDE SHOE UP TO 1 HALF,SUP-2435718,CDM,L3332,HCPCS,0274,RC,,,,both,,,208.81,135.73,,,,,,,,,,,,,
EXTENSION STEM L180MM OD13MM HIP FEM MOD PLSM SPRY IMP,SUP-2217204,CDM,C1776,CPT,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
GUIDEWIRE ORTH L24IN CANN THRD,SUP-2290861,CDM,C1769,HCPCS,0272,RC,,,,both,,,221.94,144.26,,,,,,,,,,,,,
TADALAFIL 20 MG PO TABS,RX-36986,CDM,6370000000,HCPCS,0637,RC,29300-0289-13,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
CATHETER ATHRCTMY DIAMONDBACK PREDATOR 360 L 145 CM DIA1.75,SUP-2159496,CDM,C1724,HCPCS,0278,RC,,,,both,,,10032.30,6520.99,,,,,,,,,,,,,
LOCK SCREW SQ DRIVE 2.7MM X 24MM STER,SUP-2587130,CDM,C1713,HCPCS,0278,RC,,,,both,,,362.67,235.74,,,,,,,,,,,,,
CALCITONIN (SALMON) 200 UNIT/ML IJ SOLN,RX-9347,CDM,J0630,HCPCS,0636,RC,67457-0675-02,NDC,,both,0.5,ML,737.50,479.37,,,,,,,,,,,,,
HC Leg Bones Lengthening Study,PX-3207707300,CDM,77073,CPT,0320,RC,,,,outpatient,,,802.00,521.30,,,,,,,,,,,,,
PLATE BNE MID FUS RECON SM L ST,SUP-2401268,CDM,C1713,HCPCS,0278,RC,,,,both,,,8478.00,5510.70,,,,,,,,,,,,,
SCREW BNE CANN 9X65 MM FEN TI STRL FIREBIRD SI,SUP-2738376,CDM,C1713,HCPCS,0278,RC,,,,both,,,9812.50,6378.12,,,,,,,,,,,,,
SPLINT POLYCENTRIC ULN DEVIATION RT SM,SUP-2324606,CDM,L3906,HCPCS,0274,RC,,,,both,,,177.35,115.28,,,,,,,,,,,,,
IMETELSTAT SODIUM 47 MG IV SOLR,RX-168240,CDM,J0870,HCPCS,0636,RC,82959-0112-01,NDC,,both,1.5,ML,11242.40,7307.56,,,,,,,,,,,,,
HC Speech Gen Device Eval 1 Hr,PX-4449260700,CDM,92607,CPT,0444,RC,,,,both,,,698.00,453.70,,,,,,,,,,,,,
FIBER LASER HOLMIUM SIDE FIRE  LOW POWER,SUP-2885369,CDM,2720000010,LOCAL,0272,RC,,,,both,,,791.28,514.33,,,,,,,,,,,,,
BUR SURG OVL 3.5X130 MM W/ LAT PROTCT VIO STRL DISP,SUP-2599841,CDM,2720000010,LOCAL,0272,RC,,,,both,,,404.59,262.98,,,,,,,,,,,,,
SCREW BONE 5X20MM PERIPH SYS FT STRL TRABECULAR MTL,SUP-2202926,CDM,C1713,HCPCS,0278,RC,,,,both,,,416.99,271.04,,,,,,,,,,,,,
DEVICE THROMCTMY ARROW-TREROTOLA PTD L 120 CM DIA 7 FR,SUP-2384059,CDM,C1724,HCPCS,0278,RC,,,,both,,,2810.30,1826.69,,,,,,,,,,,,,
CLAMP ROD TO ROD SPNL 5.5MM TO 5.5MM 18MM WID,SUP-2230104,CDM,C1713,HCPCS,0278,RC,,,,both,,,1036.20,673.53,,,,,,,,,,,,,
PLEDGET CV DEBAKEY L 15.2 X W 15.2 CM THK 0.57 MM POLYESTER,SUP-2761343,CDM,C1768,CPT,0278,RC,,,,both,,,366.09,237.96,,,,,,,,,,,,,
CATHETER DRNGE 8FR L25CM FLEXIMA GLDEX ALL PURP LOOP RADPQ,SUP-2147781,CDM,C1729,HCPCS,0272,RC,,,,both,,,298.30,193.89,,,,,,,,,,,,,
SCREW BNE L8MM THRD 17MM HD 24MM TI LNG THRD CANN HDLESS,SUP-2389486,CDM,C1713,HCPCS,0278,RC,,,,both,,,2062.98,1340.94,,,,,,,,,,,,,
HC Leg Bones Lengthening Study,PX-3207707300,CDM,77073,CPT,0320,RC,,,,inpatient,,,802.00,521.30,,,,,,,,,,,,,
PLATE SPNL L22MM UNIV TI ANTR CERV BILAT CNVGNT KT ZEPHIR,SUP-2291236,CDM,C1713,HCPCS,0278,RC,,,,both,,,7331.90,4765.73,,,,,,,,,,,,,
SCREW BNE L 95 MM DIA 4 MM SS CANC PART THRD T15 STARDRV,SUP-2905725,CDM,C1713,HCPCS,0278,RC,,,,both,,,662.70,430.75,,,,,,,,,,,,,
HC Chemo Im Inject Hormonal,PX-3319640200,CDM,96402,CPT,0331,RC,,,,both,,,279.00,181.35,,,,,,,,,,,,,
GRAFT HUM TISS L 3 X W 2 CM AMNIO MEMBRN RESRB AIR DRY STRL,SUP-2913449,CDM,Q4173,HCPCS,0636,RC,,,,both,,,5843.54,3798.30,,,,,,,,,,,,,
GUIDEWIRE VASC L300CM DIA0.018IN TIP L3CM 45DEG GLD HYDRPHLC,SUP-2385556,CDM,C1769,HCPCS,0272,RC,,,,both,,,600.53,390.34,,,,,,,,,,,,,
BIT DRL TWST 1.5X115 MM AO ATTCH LEVEL 1 DISP,SUP-2467329,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1005.59,653.63,,,,,,,,,,,,,
HC MRI Face Neck Eye W & WO Cont,PX-6107054300,CDM,70543,CPT,0610,RC,,,,outpatient,,,5040.00,3276.00,,,,,,,,,,,,,
BIT DRL L115MM DIA1.6MM SKINNY RAINBOW INCORPORATED DEPTH,SUP-2365252,CDM,2720000010,LOCAL,0272,RC,,,,both,,,632.08,410.85,,,,,,,,,,,,,
GRAFT UMBILICAL CORD 3X6 CRYOPRESERVED CRYO-CORD,SUP-2664296,CDM,C1762,CPT,0278,RC,,,,both,,,6264.30,4071.79,,,,,,,,,,,,,
GUIDEPIN SURG DIA32MM N FORCE,SUP-2414093,CDM,C1713,HCPCS,0278,RC,,,,both,,,316.51,205.73,,,,,,,,,,,,,
PLATE BONE 5 H LCK GLDE ANK IMP,SUP-2107793,CDM,C1713,HCPCS,0278,RC,,,,both,,,2879.38,1871.60,,,,,,,,,,,,,
GUIDE WIRE 1.2 MMX100 MM STRL,SUP-2814085,CDM,C1769,HCPCS,0272,RC,,,,both,,,69.08,44.90,,,,,,,,,,,,,
GRAFT BONE SUB W5XL5CM GRFTON,SUP-2293901,CDM,C1713,HCPCS,0278,RC,,,,both,,,3054.59,1985.48,,,,,,,,,,,,,
PLATE BNE L63MM 4 H BILAT S STL STR NONCOMPRESSION RECON,SUP-2410175,CDM,C1713,HCPCS,0278,RC,,,,both,,,900.43,585.28,,,,,,,,,,,,,
ENDPLATE SPNL FUSION WNG ANGLE 60 DEG L 12 MM HA COAT MIS,SUP-2912001,CDM,C1713,HCPCS,0278,RC,,,,both,,,28260.00,18369.00,,,,,,,,,,,,,
PLATE BNE CNDYL 1.5X37 MM RT 7 HOLE FOR MINI FRAG SYS SS NS,SUP-2470482,CDM,C1713,HCPCS,0278,RC,,,,both,,,745.18,484.37,,,,,,,,,,,,,
HC Cath Urethral Simple,PX-7615170200,CDM,51702,CPT,0761,RC,,,,both,,,204.00,132.60,,,,,,,,,,,,,
EXTENSION STEM REV 175X6X14 MM TIB KNEE OFFSET OFFSET,SUP-2508656,CDM,C1776,CPT,0278,RC,,,,both,,,6405.60,4163.64,,,,,,,,,,,,,
MASK CPAP SM NSL 2 FLAP CUSH CMFRT FULL 2 W/ PREM HDGEAR,SUP-2326709,CDM,C1713,HCPCS,0278,RC,,,,both,,,634.28,412.28,,,,,,,,,,,,,
MIS TRAB METAL FLEX SCREW,SUP-2822709,CDM,C1713,HCPCS,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
HC Heinz Bodies Direct,PX-3058544100,CDM,85441,CPT,0305,RC,,,,both,,,328.00,213.20,,,,,,,,,,,,,
HC Elbow 2 Views,PX-3207307000,CDM,73070,CPT,0320,RC,,,,both,,,496.00,322.40,,,,,,,,,,,,,
CATHETER GUID CXI L 150 CM DIA 2.6 FR 0.018 IN SS STR TIP,SUP-2170701,CDM,C1887,HCPCS,0272,RC,,,,both,,,1541.74,1002.13,,,,,,,,,,,,,
TRAY THOR VENT PROC 13FR L13CM TRU-CLOSE,SUP-2391585,CDM,C1729,HCPCS,0272,RC,,,,both,,,703.36,457.18,,,,,,,,,,,,,
GRAFT VASC GORTX L 50 CM DIA 5 MM RNG L 30 CM EPTFE STR TW,SUP-2396109,CDM,C1768,CPT,0278,RC,,,,both,,,2276.50,1479.72,,,,,,,,,,,,,
ALLOGRAFT BNE 4-10 MM 60 CC FD DEMINERALIZED CORTICAL CANC,SUP-2866846,CDM,C1762,CPT,0278,RC,,,,both,,,1736.42,1128.67,,,,,,,,,,,,,
EPIFIX 2X4CM 8SQ CM,SUP-2305751,CDM,Q4186,HCPCS,0636,RC,,,,both,,,4571.84,2971.70,,,,,,,,,,,,,
PROSTHESIS OSS 141402ENT,SUP-2648903,CDM,L8613,CPT,0278,RC,,,,both,,,440.07,286.05,,,,,,,,,,,,,
STENT GRFT VASC AFX BODY L 90 MM DIA25 MM LIMB L 30 MM DIA20,SUP-2217641,CDM,C1768,CPT,0278,RC,,,,both,,,34398.70,22359.15,,,,,,,,,,,,,
CATH REPROC EP SUPREME FIX CRD 4POL 2/5/2 5FR,SUP-2526067,CDM,C1730,HCPCS,0272,RC,,,,both,,,180.49,117.32,,,,,,,,,,,,,
POST EXT FIX 12MM 4 H ASSEMB BOLT FLEX ANK FT NONSTERILE,SUP-2316111,CDM,2720000010,LOCAL,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
STYLET PACE 86 CM LT HRT LD DEL SYS CPS DUO,SUP-2357580,CDM,C1769,HCPCS,0272,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
WAND ELECSURG OD0.8MM 45DEG TENDONS FASC EPF MICRODEBRIDER,SUP-2342116,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1196.34,777.62,,,,,,,,,,,,,
TRUMATCH TRAY FEM 2.0,SUP-2513273,CDM,C1776,CPT,0278,RC,,,,both,,,2420.94,1573.61,,,,,,,,,,,,,
SPACER SPNL W37XH14MM D28MM 12DEG GRFT 3.3ML PEEK CERV,SUP-2317133,CDM,C1821,HCPCS,0278,RC,,,,both,,,15857.00,10307.05,,,,,,,,,,,,,
TRAY CATH HEMODIALYSI NIAG ACUTE 13.5FR DIA 20CML IN 5575200,SUP-2632905,CDM,C1752,HCPCS,0278,RC,,,,both,,,608.53,395.54,,,,,,,,,,,,,
MESH HERN ANAT LG 15X10 CM RT PRESHAPED MONOFILAMENT DEXTILE,SUP-2752175,CDM,C1781,HCPCS,0278,RC,,,,both,,,827.30,537.74,,,,,,,,,,,,,
TUBE MYR ID127MM VENT TI MORETZ,SUP-2313694,CDM,L8699,HCPCS,0278,RC,,,,both,,,92.63,60.21,,,,,,,,,,,,,
LENS INTOCU +33.0 DIOPT L13MM DIA6MM 0DEG HAPTIC ANG A,SUP-2111085,CDM,V2632,HCPCS,0276,RC,,,,both,,,421.11,273.72,,,,,,,,,,,,,
PLATE BONE DOUBLE ANGLE LARGE 1.5 MM PRECONTOURED RECONSTRUC,SUP-2842355,CDM,C1713,HCPCS,0278,RC,,,,both,,,8708.48,5660.51,,,,,,,,,,,,,
BIT DRL TWST 1.1X105 MM CYL LEVEL 1 DISP,SUP-2483493,CDM,2720000010,LOCAL,0272,RC,,,,both,,,422.33,274.51,,,,,,,,,,,,,
CATHETER ETER URET 5FR WHSTL TIP WVN L DRNGE LUMN REUSE,SUP-2126130,CDM,C1758,HCPCS,0278,RC,,,,both,,,292.02,189.81,,,,,,,,,,,,,
GRAFT BONE SUB 7.5CC W25XH12XL25MM HA POR BLK PRO OSTEON 500,SUP-2413074,CDM,C1713,HCPCS,0278,RC,,,,both,,,5221.82,3394.18,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.442,SUP-2860006,CDM,C1713,HCPCS,0278,RC,,,,both,,,48716.47,31665.71,,,,,,,,,,,,,
CLIP LIG M BLU TI HRT SHP WIRE HORZ 6 CLIPS PER PK,SUP-2855136,CDM,C1889,HCPCS,0278,RC,,,,both,,,9.11,5.92,,,,,,,,,,,,,
GRAFT HUM TISS 15ML FRMBL CELLULAR BNE MTRX CRYOPRESERVED,SUP-2264616,CDM,C1713,HCPCS,0278,RC,,,,both,,,20103.03,13066.97,,,,,,,,,,,,,
ANGIOGRAPHY KIT,SUP-2302859,CDM,C1713,HCPCS,0278,RC,,,,both,,,46.41,30.17,,,,,,,,,,,,,
GRAFT BNE SUB 15CC 1 8MM CANC CRUSH CHIP READIGRFT,SUP-2264815,CDM,C1713,HCPCS,0278,RC,,,,both,,,701.44,455.94,,,,,,,,,,,,,
WASHER ORTH BRNZ BTTN FOR DSTL ELBW PLATING SYS,SUP-2340389,CDM,C1713,HCPCS,0278,RC,,,,both,,,133.45,86.74,,,,,,,,,,,,,
SCREW EXT FIX L100MM DIA4MM THRD L30MM S STL HA SELF DRL MR,SUP-2186978,CDM,C1713,HCPCS,0278,RC,,,,both,,,781.42,507.92,,,,,,,,,,,,,
PSN REV TM TIB CENTRAL CONE SZ MED,SUP-2508667,CDM,C1776,CPT,0278,RC,,,,both,,,12874.00,8368.10,,,,,,,,,,,,,
SCREW BNE FIX ANGLE 4X14 MM,SUP-2391497,CDM,C1713,HCPCS,0278,RC,,,,both,,,1146.73,745.37,,,,,,,,,,,,,
ALLOGRAFT BNE REFRIGERATED RT WHL DSTL CONDYLE,SUP-2740771,CDM,C1762,CPT,0278,RC,,,,both,,,62964.82,40927.13,,,,,,,,,,,,,
SCREW BNE L14MM DIA4MM CORT S STL ST FIX ANG NONCANNULATED,SUP-2184697,CDM,C1713,HCPCS,0278,RC,,,,both,,,384.78,250.11,,,,,,,,,,,,,
HYDROCORTISONE 2 MG/ML PO SUSP,RX-4081168,CDM,6370000000,HCPCS,0637,RC,09999-9920-11,NDC,,both,2.5,ML,11.30,7.34,,,,,,,,,,,,,
ANCHOR SUT PEEK W/ ORTHOCORD GRYPHON,SUP-2249323,CDM,C1713,HCPCS,0278,RC,,,,both,,,1190.06,773.54,,,,,,,,,,,,,
PLATE BONE L203MM 95DEG 10 SLOT STD SUPCNDYL,SUP-2412161,CDM,C1713,HCPCS,0278,RC,,,,both,,,1736.42,1128.67,,,,,,,,,,,,,
SCREW INTFR L25MM DIA9MM RND HD STAR DRV FOR ACL RECON,SUP-2212841,CDM,C1713,HCPCS,0278,RC,,,,both,,,1350.45,877.79,,,,,,,,,,,,,
ALLOGRAFT BNE STRP 15X20 MM FD STRUCTURAL ILIUM ORAGRAFT,SUP-2740880,CDM,C1713,HCPCS,0278,RC,,,,both,,,1153.32,749.66,,,,,,,,,,,,,
NEEDLE BX 25GA ADJ EXTN 0-8CM SHTH 5.2FR ACC CHN 2.8MM STYL,SUP-2171106,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1114.70,724.55,,,,,,,,,,,,,
SCREW BNE L13MM OD2MM TI CORT ST SELF DRL NONLOCKING FULL,SUP-2242874,CDM,C1713,HCPCS,0278,RC,,,,both,,,1139.47,740.66,,,,,,,,,,,,,
PIN FIX L14MM DIA2MM PROV FOR EVOS SM PLATING SYS,SUP-2344052,CDM,C1713,HCPCS,0278,RC,,,,both,,,776.68,504.84,,,,,,,,,,,,,
PLUG IM OD10MM FEM CNL BNE CEM RESTRIC EXETER X CHANGE,SUP-2368342,CDM,C1713,HCPCS,0278,RC,,,,both,,,117.09,76.11,,,,,,,,,,,,,
CAP END DIA15MM EXTN 0MM TI CANN HD FOR LOK SL 13-15MM FEM,SUP-2192716,CDM,C1713,HCPCS,0278,RC,,,,both,,,1020.19,663.12,,,,,,,,,,,,,
STEM FEM SEG 17 CM DPHSEAL KNEE SMOOTH OSS,SUP-2449813,CDM,C1776,CPT,0278,RC,,,,both,,,11945.50,7764.57,,,,,,,,,,,,,
PLATE TI VA-LOCKING CALCANEAL 2.7MM SMALL 58MM RGHT STRL,SUP-2546999,CDM,C1713,HCPCS,0278,RC,,,,both,,,3614.17,2349.21,,,,,,,,,,,,,
PLATE BNE L319MM 12 H ST L PROX FEM S STL LO PROF LOK COMPR,SUP-2186048,CDM,C1713,HCPCS,0278,RC,,,,both,,,5064.44,3291.89,,,,,,,,,,,,,
SHELL ACET BPLR 22X45 MM HIP RINGLOK,SUP-2449897,CDM,C1776,CPT,0278,RC,,,,both,,,3574.89,2323.68,,,,,,,,,,,,,
SCREW BONE L10MM DIA2MM STD TI LCK FULL THRD ANG FOR HND,SUP-2319612,CDM,C1713,HCPCS,0278,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
GRAFT BNE STRP 30 MM FIRM DBM,SUP-2134704,CDM,C1713,HCPCS,0278,RC,,,,both,,,1924.82,1251.13,,,,,,,,,,,,,
POST EXT FIX 4 HOLE W/O THRD ATTCH,SUP-2749943,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1365.90,887.83,,,,,,,,,,,,,
DEFIBRILLATOR IMPL CONTAK RENEWAL III HE W 2.48 X H 3.25 IN,SUP-2149225,CDM,C1722,HCPCS,0275,RC,,,,both,,,77558.00,50412.70,,,,,,,,,,,,,
SCREW INTERFERENCE L35MM DIAMETER 9MM CANNULATED,SUP-2842784,CDM,C1713,HCPCS,0278,RC,,,,both,,,414.29,269.29,,,,,,,,,,,,,
GRAFT VASC HEMSHLD PLAT L 15 CM 22MM POLYESTER BOV CLLGN STR,SUP-2265916,CDM,C1768,CPT,0278,RC,,,,both,,,1014.09,659.16,,,,,,,,,,,,,
SPACER SPNL MED 29-39 MM CNTRL BODY STRL XLR,SUP-2592008,CDM,C1889,HCPCS,0278,RC,,,,both,,,11304.00,7347.60,,,,,,,,,,,,,
GUIDE PIN ORTH TROCAR PT 1 END 3.2X330 MM AOS,SUP-2766034,CDM,2720000010,LOCAL,0272,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
DRILL SURG L120-200MM DIA2MM TWST,SUP-2194235,CDM,2720000010,LOCAL,0272,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
GRAFT HUM TISS ACELLULAR DERM THK.4-.8 MM OD4 CM N MESHED,SUP-2366752,CDM,Q4126,HCPCS,0636,RC,,,,both,,,4490.20,2918.63,,,,,,,,,,,,,
SYS K ORBITAL T04MM,SUP-2681107,CDM,C1713,HCPCS,0278,RC,,,,both,,,2011.14,1307.24,,,,,,,,,,,,,
LEAD DEFIB 9 FRX59 CM TINED DF4-LLHO ENDOTK RELIANCE S 0272,SUP-2457472,CDM,C1777,HCPCS,0275,RC,,,,both,,,7536.00,4898.40,,,,,,,,,,,,,
SET CATH RAD C-PMS-400-RA,SUP-2167838,CDM,C1751,HCPCS,0278,RC,,,,both,,,114.45,74.39,,,,,,,,,,,,,
PLATE BNE 1/4 TBLR 6 HOLE W/ CLLRD NS LTX,SUP-2861936,CDM,C1713,HCPCS,0278,RC,,,,both,,,232.86,151.36,,,,,,,,,,,,,
NEEDLE LOC BRST REPOSITIONAL HOMER FLX J CRV WIRE 20 G X 3,SUP-2120040,CDM,C1819,HCPCS,0278,RC,,,,both,,,106.76,69.39,,,,,,,,,,,,,
HC Glb Dx Bone Marrow Bx & Aspir,PX-9823822200,CDM,38222,CPT,0982,RC,,,,both,,,8736.00,5678.40,,,,,,,,,,,,,
STENT PERIPH HERCLNK ELITE L 12 MM DIA 6 MM CATH L 135 CM,SUP-2104664,CDM,C1876,HCPCS,0278,RC,,,,both,,,2182.30,1418.49,,,,,,,,,,,,,
ACETAMINOPHEN CHILDRENS 160 MG PO CHEW,RX-141402,CDM,2500000003,HCPCS,0250,RC,00904-6645-24,NDC,,both,1,UN,54.10,35.16,,,,,,,,,,,,,
CARTRIDGE HAD EXPR ACUTE DISPOSABLE,SUP-2312275,CDM,2720000010,LOCAL,0272,RC,,,,both,,,570.44,370.79,,,,,,,,,,,,,
TRAY PICC 5FR L55CM SIL NRS SGL LUMN FULL PWR INJ N COAT CT,SUP-2126723,CDM,C1751,HCPCS,0278,RC,,,,both,,,790.65,513.92,,,,,,,,,,,,,
GUIDEWIRE ORTH THRD 24 IN BLNT CD HORZ,SUP-2628256,CDM,C1769,HCPCS,0272,RC,,,,both,,,221.94,144.26,,,,,,,,,,,,,
EXPEL NEPH 12/25 K,SUP-2652778,CDM,C1729,HCPCS,0272,RC,,,,both,,,514.96,334.72,,,,,,,,,,,,,
GUIDEWIRE VASC L200CM OD0.012IN ID0.014IN TIP L3CM HYDRPHLC,SUP-2305454,CDM,C1769,HCPCS,0272,RC,,,,both,,,1215.18,789.87,,,,,,,,,,,,,
SYSTEM EMBOLIC PROTCT EMBOL-X SLIM DIA24 FR OBTURATOR SM,SUP-2214484,CDM,C1884,HCPCS,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
BEARING TIB SZ 1 LT ANK POLYETH FIX VANTAGE,SUP-2223476,CDM,C1776,CPT,0278,RC,,,,both,,,13188.00,8572.20,,,,,,,,,,,,,
FIXATION EXT 4 H FN WIRE RNG CLMP KT,SUP-2316279,CDM,2720000010,LOCAL,0272,RC,,,,both,,,661.72,430.12,,,,,,,,,,,,,
GRAFT VASC GELWEAVE L 60 CM DIA26 MM POLYESTER GEL,SUP-2385478,CDM,L8670,HCPCS,0278,RC,,,,both,,,3532.50,2296.12,,,,,,,,,,,,,
BLADE REPROC SAW SAGITTAL SYS 4 AND 2000 29X0.89X73MM,SUP-2525942,CDM,C1776,CPT,0278,RC,,,,both,,,60.88,39.57,,,,,,,,,,,,,
PLATE PL LAT SUPP 2.7/3.5MM 9H LT 153MM XLNG TI DHP STRL,SUP-2546779,CDM,C1713,HCPCS,0278,RC,,,,both,,,4646.79,3020.41,,,,,,,,,,,,,
SPLINT WRST SM L8IN L BLK FOAM D RNG CLSR LO PROF MAL,SUP-2336046,CDM,L3809,HCPCS,0274,RC,,,,both,,,19.19,12.47,,,,,,,,,,,,,
GRAFT VASC GORTX L 45 CM DIA 4-7 MM OFFSET RNG L 5 CM EPTFE,SUP-2396104,CDM,C1768,CPT,0278,RC,,,,both,,,2000.18,1300.12,,,,,,,,,,,,,
NEEDLE PERC L7CM DIA18GA ART VEN RADPQ CATHETER THN WALL,SUP-2169616,CDM,C1894,HCPCS,0272,RC,,,,both,,,21.20,13.78,,,,,,,,,,,,,
CATHETER DRAINAGE VLV 6 FRX10 CM 51 IN KT SPIN-LOCK ACCEL,SUP-2659259,CDM,C1729,HCPCS,0272,RC,,,,both,,,131.50,85.47,,,,,,,,,,,,,
STRAP TRAC L6FT UP ARM W PD TRAC TWR,SUP-2166901,CDM,L3660,HCPCS,0272,RC,,,,both,,,415.23,269.90,,,,,,,,,,,,,
HC MRI-Spine Lumbar W Contrast,PX-6127214900,CDM,72149,CPT,0612,RC,,,,inpatient,,,4146.00,2694.90,,,,,,,,,,,,,
CATHETER DRNGE SIL RUB FOR BARTH CYST ABSC,SUP-2171591,CDM,C1729,HCPCS,0272,RC,,,,both,,,69.43,45.13,,,,,,,,,,,,,
IMPLANT SYNDESMOTIC SCREW L 47 MM DIA 4.2 MM NOTCH 14 MM,SUP-2899006,CDM,C1713,HCPCS,0278,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
NEEDLE PROC TRANSSEPTAL 86 DEG 18 GAX71 CM HEARTSPAN,SUP-2472120,CDM,2720000010,LOCAL,0272,RC,,,,both,,,527.52,342.89,,,,,,,,,,,,,
CATHETER ABLATN DD CRV CONTACT FORC BIDIR TACTICATH,SUP-2470992,CDM,C2630,CPT,0272,RC,,,,both,,,8771.02,5701.16,,,,,,,,,,,,,
PROBE CRYOSURGICAL GRN MALL SHFT ANG FOR RESECT ABLAT,SUP-2341617,CDM,C1713,HCPCS,0278,RC,,,,both,,,491.25,319.31,,,,,,,,,,,,,
ANCHOR SUT DIA4.5MM SUT SZ 2 COBRAID PEEK OPTMA BLK BLU,SUP-2341850,CDM,C1713,HCPCS,0278,RC,,,,both,,,1007.94,655.16,,,,,,,,,,,,,
PLATE BONE LOK SHAFT 289MML PRTSL 64 CRVD NON CNTCT BRDGE PO,SUP-2721986,CDM,C1713,HCPCS,0278,RC,,,,both,,,2038.86,1325.26,,,,,,,,,,,,,
IMPLANT GYN W4XL12CM FASC LATA TUTOPLAST PROC ALLGRFT TISS,SUP-2300760,CDM,C1762,CPT,0278,RC,,,,both,,,3158.84,2053.25,,,,,,,,,,,,,
CATHETER IV NEOMAGIC L 25 CM DIA1.9 FR SIL PICC 1 LUMEN STYL,SUP-2874155,CDM,C1751,HCPCS,0278,RC,,,,both,,,123.09,80.01,,,,,,,,,,,,,
ORA-PLUS PO LIQD,RX-5851,CDM,340b,HCPCS,0637,RC,00574-0303-16,NDC,,both,473,ML,78.80,51.22,,,,,,,,,,,,,
HINGE HALF,SUP-2488353,CDM,2720000010,LOCAL,0272,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
HC Fetal Bio W/O Nonstress Test,PX-4027681900,CDM,76819,CPT,0402,RC,,,,both,,,904.00,587.60,,,,,,,,,,,,,
HC Debride Skin and Subcu,PX-4501104200,CDM,11042,CPT,0450,RC,,,,both,,,1247.00,810.55,,,,,,,,,,,,,
TRIAL KNEE IMPL SZ 4 LT FEM NS REUSE N-K,SUP-2209388,CDM,C1713,HCPCS,0278,RC,,,,both,,,2398.96,1559.32,,,,,,,,,,,,,
"HC So F8,Vw Factor Antigen",PX-3058524666,CDM,85246,CPT,0305,RC,,,,both,,,196.00,127.40,,,,,,,,,,,,,
LINER ACET OD68MM ID32MM +4MM OFFSET 10DEG HIP MARATHON,SUP-2250425,CDM,C1776,CPT,0278,RC,,,,both,,,4797.92,3118.65,,,,,,,,,,,,,
LEAD PACE CAPSURFIX NOVUS MRI SURESCAN L 58 CM DIA 6 FR SIL,SUP-2281974,CDM,C1898,HCPCS,0275,RC,,,,both,,,1130.40,734.76,,,,,,,,,,,,,
CANNULA PERF 21FR FEM VEN NVENT PERC BIO MEDICUS,SUP-2282877,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1291.67,839.59,,,,,,,,,,,,,
ALLOGRAFT BNE FLOWABLE 2.5 CC OSTEOAMP,SUP-2731797,CDM,C1776,CPT,0278,RC,,,,both,,,3430.92,2230.10,,,,,,,,,,,,,
BAR SPNL SZ 12 L116.5MM RAD 220MM SUP INFERIOR CRAN GLD TI,SUP-2193298,CDM,C1713,HCPCS,0278,RC,,,,both,,,7501.46,4875.95,,,,,,,,,,,,,
PLATE BNE W11XL220MM THK37MM 12 H ST R MED DST TIB S STL LOK,SUP-2185595,CDM,C1713,HCPCS,0278,RC,,,,both,,,5143.98,3343.59,,,,,,,,,,,,,
RING EXT FIX HALF 140 MM CARBON FIBER RINGFIX,SUP-2365277,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3161.98,2055.29,,,,,,,,,,,,,
ALLOGRAFT BNE CUBE 8X8X8 MM FD DEMINERALIZED CANC FLEXIGRAFT,SUP-2740768,CDM,C1713,HCPCS,0278,RC,,,,both,,,1276.35,829.63,,,,,,,,,,,,,
FIBER LASER L12IN DIA0.4MM SMARTCONNECTOR TECHNOLOGY FOR FLEX,SUP-2138859,CDM,C1713,HCPCS,0278,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
CATHETER CARD ABLATION EZ STEER THERMOCOOL L 115 CM D-D CRV,SUP-2248505,CDM,C2630,CPT,0272,RC,,,,both,,,4301.80,2796.17,,,,,,,,,,,,,
GUIDEWIRE VASC L 300 CM DIA 0.018 IN RADIOPAQUE TIP L 2 CM,SUP-2101938,CDM,C1769,HCPCS,0272,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
IMPLANT BRST 525CC P5.8CM W14.5XH13.2CM HIGHLY COHESIVE SIL,SUP-2113497,CDM,C1789,HCPCS,0278,RC,,,,both,,,3438.30,2234.89,,,,,,,,,,,,,
GRAFT BNE SUB 10CC 15% HYDROXYAPATITE/85% B-TCP GRAN POR,SUP-2288532,CDM,C1713,HCPCS,0278,RC,,,,both,,,1401.23,910.80,,,,,,,,,,,,,
CARPEL ORTH TRAPEZIUM 20 MM AVANTA CMC,SUP-2469007,CDM,C1776,CPT,0278,RC,,,,both,,,4553.00,2959.45,,,,,,,,,,,,,
HC Intubation/Endotracheal/Emerg,PX-4503150000,CDM,31500,CPT,0450,RC,,,,inpatient,,,403.00,261.95,,,,,,,,,,,,,
PLATE BNE W24.4XL89.5MM STD L DST VOLAR RAD EXT ANAT FAST,SUP-2414030,CDM,C1713,HCPCS,0278,RC,,,,both,,,4455.66,2896.18,,,,,,,,,,,,,
HC Fat Stain Feces Urine/Respir Secretions,PX-3008912500,CDM,89125,CPT,0300,RC,,,,both,,,246.00,159.90,,,,,,,,,,,,,
INTRODUCER SHTH 0.018 IN 5 FRX11 CM 21 GAX4 CM GRY PRELUDE,SUP-2303267,CDM,C1894,HCPCS,0272,RC,,,,both,,,134.55,87.46,,,,,,,,,,,,,
GRAFT VASC ULTRAMAX L 40 CM DIA14 X 7 MM POLYESTER GEL,SUP-2265941,CDM,C1768,CPT,0278,RC,,,,both,,,1496.78,972.91,,,,,,,,,,,,,
PLATE BNE L 257 MM SCREW DIA 4.5 MM 14 H LT PROX LAT TIB NS,SUP-2932855,CDM,C1713,HCPCS,0278,RC,,,,both,,,10638.32,6914.91,,,,,,,,,,,,,
CATHETER HD DL 14 FRX24 CM PRECRV STP TIP HEMO-FLOW,SUP-2266976,CDM,C1750,HCPCS,0278,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
BIT DRL L 140/45 MM DIA2.8 MM CALIB AO QC NS REUSE V,SUP-2908552,CDM,2720000010,LOCAL,0272,RC,,,,both,,,675.89,439.33,,,,,,,,,,,,,
OVERTUBE ENDOSCP 50 CM GAST GUARDUS DISP,SUP-2847340,CDM,2720000010,LOCAL,0272,RC,,,,both,,,708.86,460.76,,,,,,,,,,,,,
SPACER SPNL W26XH10MM PEEK-OPTIMA 1 LEV ANTR INTERVERTEBRAL,SUP-2385988,CDM,C1889,HCPCS,0278,RC,,,,both,,,10701.12,6955.73,,,,,,,,,,,,,
SCREW SPNL ST 4.2X10 MM FIX,SUP-2414364,CDM,C1713,HCPCS,0278,RC,,,,both,,,883.13,574.03,,,,,,,,,,,,,
PROSTHESIS PENILE KT,SUP-2140116,CDM,C1769,HCPCS,0272,RC,,,,both,,,2062.98,1340.94,,,,,,,,,,,,,
WASHER EXT FIX OD14MM ID7MM THK2MM SPC FOR ILIZ TAY SPAT,SUP-2342313,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1291.17,839.26,,,,,,,,,,,,,
DEXAMETHASONE SODIUM PHOSPHATE 120 MG/30ML IJ SOLN,RX-125410,CDM,J1100,HCPCS,0636,RC,55150-0239-30,NDC,,both,0.5,ML,54.10,35.16,,,,,,,,,,,,,
PIN EXTRNL FXTN L200MM D5MM TRBCLR METAL TOTAL ANKLE SSTM,SUP-2720915,CDM,2720000010,LOCAL,0272,RC,,,,both,,,424.53,275.94,,,,,,,,,,,,,
PLATE BNE RECON 2-2.5X2 MM RT MAND 26 HOLE ANGLED NS LEVEL 1,SUP-2489282,CDM,C1713,HCPCS,0278,RC,,,,both,,,5134.47,3337.41,,,,,,,,,,,,,
PROBE SPNL DCOMPR DISCECTOMY 15GA L6IN LUM STR LORD KT,SUP-2367000,CDM,C1713,HCPCS,0278,RC,,,,both,,,4396.00,2857.40,,,,,,,,,,,,,
CATHETER EP CSL 2-4-5 MM 6 FRX120 CM SUPREME,SUP-2356973,CDM,C1730,HCPCS,0272,RC,,,,both,,,2706.68,1759.34,,,,,,,,,,,,,
PLATE EXT FIX SHT 100 MM FT RNG TI NS,SUP-2799578,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2526.29,1642.09,,,,,,,,,,,,,
AUGMENT FEM SZ 2 THK5MM POST KNEE REV SPCR BLK FOUNDATION,SUP-2215550,CDM,C1776,CPT,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
INTRODUCER SUPRPUB CATH 16FR SHTH 20FR L17CM TRCR L20CM FOR,SUP-2171356,CDM,C1894,HCPCS,0272,RC,,,,both,,,400.98,260.64,,,,,,,,,,,,,
KIT INFLATION DEV PRIORITY PK INFLATED 30 ATM VLV ID 0.096,SUP-2103552,CDM,C1894,HCPCS,0272,RC,,,,both,,,204.10,132.66,,,,,,,,,,,,,
MESH SURG 100X100X1 MM 3D TI LEVEL 1 NEURO,SUP-2465193,CDM,C1713,HCPCS,0278,RC,,,,both,,,5758.07,3742.75,,,,,,,,,,,,,
SHEATH INTRO PERFRMR L 13 CM DIA 6 FR GUIDEWIRE 0.035 IN,SUP-2168285,CDM,C1894,HCPCS,0272,RC,,,,both,,,72.47,47.11,,,,,,,,,,,,,
PLATE BNE L84MM 4 H BILAT S STL T SHP LO PROF NEUT,SUP-2185752,CDM,C1713,HCPCS,0278,RC,,,,both,,,1565.35,1017.48,,,,,,,,,,,,,
POLARCUP Anchoring Peg (2 each),SUP-2511217,CDM,C1776,CPT,0278,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL PEEK SD800.556,SUP-2860237,CDM,C1713,HCPCS,0278,RC,,,,both,,,24450.55,15892.86,,,,,,,,,,,,,
COIL NEUROVASCULAR L 1.5 MM DIA1 MM DIA 0.01 IN DEL CATH,SUP-2894578,CDM,C1889,HCPCS,0278,RC,,,,both,,,4788.50,3112.52,,,,,,,,,,,,,
GRAFT BONE M CELLULAR MTRX OSTEOCEL PRO,SUP-2310456,CDM,C1762,CPT,0278,RC,,,,both,,,5871.80,3816.67,,,,,,,,,,,,,
PLATE BNE BROAD 4.5X124 MM 7 HOLE SS LC-DCP,SUP-2569266,CDM,C1713,HCPCS,0278,RC,,,,both,,,367.85,239.10,,,,,,,,,,,,,
FERRIC CARBOXYMALTOSE 750 MG/15ML IV SOLN,RX-123010,CDM,J1439,HCPCS,0636,RC,00517-0650-01,NDC,,both,15,ML,4344.20,2823.73,,,,,,,,,,,,,
BLADE SAW SAG 18.5X10X0.4 MM 0.6 MM FN TOOTH MICROPOWER,SUP-2607449,CDM,2720000010,LOCAL,0272,RC,,,,both,,,79.50,51.67,,,,,,,,,,,,,
IMMOBILIZER PREMIER PRO KNEE 3 PNL CANVS 16INCH LTX FREE,SUP-2336075,CDM,L1830,CPT,0272,RC,,,,both,,,45.44,29.54,,,,,,,,,,,,,
PLATE BONE L242MM THK3.3MM 20 H BILAT S STL RIG STR DYN,SUP-2186339,CDM,C1713,HCPCS,0278,RC,,,,both,,,1696.45,1102.69,,,,,,,,,,,,,
STAPLE INT CARTRIDGE 16X15 MM TI SS DISP,SUP-2100301,CDM,2720000010,LOCAL,0272,RC,,,,both,,,423.90,275.53,,,,,,,,,,,,,
MATRIX 1.4MM BIT DRILL W/14MM,SUP-2823234,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1361.22,884.79,,,,,,,,,,,,,
TRAY CATH PICC Q CATH PLU INTERMED 5FR 65CM 1 LUMAN W/ACCSSR,SUP-2613414,CDM,C1751,HCPCS,0278,RC,,,,both,,,145.70,94.70,,,,,,,,,,,,,
SHEARS SURG L36CM DIA5MM CRV BLDE W/ PSTL HNDLE HND CTRL,SUP-2257348,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1308.60,850.59,,,,,,,,,,,,,
IMPLANT HUM TISS W20CMXL25MM FASC LATA FRZ DRY TUTOPLAST,SUP-2307101,CDM,C1762,CPT,0278,RC,,,,both,,,1309.85,851.40,,,,,,,,,,,,,
SCREW BNE L36MM DIA4.2MM NONLOCKING COMPR FOR PLATING SYS,SUP-2321257,CDM,C1713,HCPCS,0278,RC,,,,both,,,600.53,390.34,,,,,,,,,,,,,
GRAFT HUM TISS L100MM FRZN SHFT HUM STRUCTURAL ALLGRFT,SUP-2307375,CDM,C1713,HCPCS,0278,RC,,,,both,,,2731.61,1775.55,,,,,,,,,,,,,
TUBE ENTRL FEED GASTRO-JEJUNAL 22 FRX45 CM 7-10 CC FOR SURG,SUP-2764470,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1080.69,702.45,,,,,,,,,,,,,
PIN FXTN RSRBBLE 16MM DIA 4MML POLY DL LCTC ACID FLAT HEAD,SUP-2681198,CDM,C1713,HCPCS,0278,RC,,,,both,,,269.38,175.10,,,,,,,,,,,,,
HC So1 Chromosome Analysis 20-25,PX-3118826467,CDM,88264,CPT,0311,RC,,,,inpatient,,,227.00,147.55,,,,,,,,,,,,,
CATHETER NEPHROSTOMY SET 10 FRX19.5 CM COPE LOOP,SUP-2835666,CDM,C1729,HCPCS,0272,RC,,,,both,,,840.89,546.58,,,,,,,,,,,,,
SET DRN RND SIL TRCR 10FRX6IN FULL CHANNELS 10FRX20CM,SUP-2155580,CDM,C1729,HCPCS,0272,RC,,,,both,,,41.92,27.25,,,,,,,,,,,,,
HALOPERIDOL LACTATE 5 MG/ML IJ SOLN,RX-3584,CDM,J1630,HCPCS,0636,RC,63323-0474-00,NDC,,both,0.2,ML,54.10,35.16,,,,,,,,,,,,,
CATHETER INTVASC OCCL PRUITT L 23 CM DIA 9 FR DL STOPCOCK LL,SUP-2264272,CDM,C2628,HCPCS,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
MESH SURG L10XW8INXL POLYPR ABD OBLONG BIOABSRB OVL IMP,SUP-2265969,CDM,C1781,HCPCS,0278,RC,,,,both,,,3632.98,2361.44,,,,,,,,,,,,,
GRAFT VASC EXXCEL SFT L 20 CM DIA 8 MM EPTFE STR STD WALL,SUP-2227641,CDM,C1768,CPT,0278,RC,,,,both,,,679.90,441.93,,,,,,,,,,,,,
SPACER HLD CHMBR TEAL VLV COLLAPSIBLE FLUT BREATHERITE,SUP-2389314,CDM,C1713,HCPCS,0278,RC,,,,both,,,580.90,377.58,,,,,,,,,,,,,
PLATE BNE MINI 4 X 2 HOLE STRUT SLD END THCK MID POST CP TI,SUP-2465522,CDM,C1713,HCPCS,0278,RC,,,,both,,,1295.75,842.24,,,,,,,,,,,,,
CATHETER GUID VISTA BRT TIP L 55 CM OD 7 FR ID 0.078 IN TIP,SUP-2158733,CDM,C1887,HCPCS,0272,RC,,,,both,,,563.79,366.46,,,,,,,,,,,,,
INSERTER SURG LNR RVS TRABECULAR MTL,SUP-2436883,CDM,C1776,CPT,0278,RC,,,,both,,,4309.65,2801.27,,,,,,,,,,,,,
PLATE BONE 1.3X100X100 MM CONTOURABLE MESH RIGID TITANIUM GO,SUP-2838347,CDM,C1713,HCPCS,0278,RC,,,,both,,,7366.44,4788.19,,,,,,,,,,,,,
HC So Antigen Typing,PX-3008690566,CDM,86905,CPT,0300,RC,,,,both,,,160.00,104.00,,,,,,,,,,,,,
ADAPTER HUM 1 FOR REVERSIBLE SHLDR SYS TI HUMELOCK II,SUP-2741780,CDM,C1776,CPT,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
PLATE 3.5MM TI LCP EXTRA-ARTICLR DSTL HUM 10H/RT 230MM-STER,SUP-2546621,CDM,C1713,HCPCS,0278,RC,,,,both,,,5027.45,3267.84,,,,,,,,,,,,,
GRAFT HUM TISS 40MG AMNIO MEM PARTICULATE DEHYDR AMNIOFIX,SUP-2305719,CDM,V2790,HCPCS,0278,RC,,,,both,,,2278.07,1480.75,,,,,,,,,,,,,
ALLOGRAFT BNE DBM 2 CC FIBER VESUVIUS,SUP-2717976,CDM,C1713,HCPCS,0278,RC,,,,both,,,1036.83,673.94,,,,,,,,,,,,,
EPINEPHRINE PF 1 MG/ML IJ SOLN,RX-139548,CDM,J0166,HCPCS,0636,RC,54288-0103-10,NDC,,both,0.1,ML,54.10,35.16,,,,,,,,,,,,,
PLATE BONE DUAL CMPRSSN HLX9 TTNM RCNSTRCTN F3.5MM LOK SCRE,SUP-2724005,CDM,C1713,HCPCS,0278,RC,,,,both,,,1630.04,1059.53,,,,,,,,,,,,,
IMMOBILIZER KNEE PREMIER PRO TRI PNL 22INCH FOAM TIETEX PAT,SUP-2336077,CDM,L1830,CPT,0274,RC,,,,both,,,38.78,25.21,,,,,,,,,,,,,
HC So Cmv Culture,PX-3008725466,CDM,87254,CPT,0300,RC,,,,both,,,151.00,98.15,,,,,,,,,,,,,
ALLOGRAFT BNE DWL 11X25-29 MM PRESERVON CANN CANC FLEXIGRAFT,SUP-2264644,CDM,C1762,CPT,0278,RC,,,,both,,,3222.83,2094.84,,,,,,,,,,,,,
SPLINT ORTHOPEDIC PADDED LG 9X4.5 IN LT PRE MOLD PROCARE,SUP-2196717,CDM,L3809,HCPCS,0272,RC,,,,both,,,13.69,8.90,,,,,,,,,,,,,
SET SCR SPNL LOK N BRK OFF TI 4MM DIA TSRH 3D SPNL SYS,SUP-2289648,CDM,C1713,HCPCS,0278,RC,,,,both,,,109.90,71.43,,,,,,,,,,,,,
PLATE BNE 2.7X76 MM 9 HOLE SS DCP,SUP-2569131,CDM,C1713,HCPCS,0278,RC,,,,both,,,317.77,206.55,,,,,,,,,,,,,
PLATE BNE H0.6MM 7 H UP FACE G TI T LEIBINGER UNIV 2,SUP-2366277,CDM,C1713,HCPCS,0278,RC,,,,both,,,549.34,357.07,,,,,,,,,,,,,
CATHETER HD LT 14 FRX28 CM ADMIN BASIC SET SPLIT STRM,SUP-2267086,CDM,C1750,HCPCS,0278,RC,,,,both,,,715.92,465.35,,,,,,,,,,,,,
HC Replac Central Tun Cath W/Pump,PX-3613658300,CDM,36583,CPT,0361,RC,,,,inpatient,,,8583.00,5578.95,,,,,,,,,,,,,
TUBE MYR 1.02MM DIAM WHT RED BLK REUT BOB FLROPLAS ST,SUP-2284045,CDM,L8699,HCPCS,0278,RC,,,,both,,,42.20,27.43,,,,,,,,,,,,,
STOCKING ORTHOT SUPP GRP CUST PREFABRICATED OFF THE SHLF,SUP-2435567,CDM,L0982,HCPCS,0274,RC,,,,both,,,44.27,28.78,,,,,,,,,,,,,
EMR KIT 18 MMX165 CM FOR ENDOSCP MUCOSAL RESECT UPPER GI,SUP-2313210,CDM,C1713,HCPCS,0278,RC,,,,both,,,658.05,427.73,,,,,,,,,,,,,
GRAFT BONE CRUSH FRZ DRY DEMIN CANC 0.1MM-4MM RANG 60CC,SUP-2294026,CDM,C1713,HCPCS,0278,RC,,,,both,,,3008.12,1955.28,,,,,,,,,,,,,
SCREW SPNL L40MM DIA65MM AWL TAP HI STRENGTH LO PROF,SUP-2278778,CDM,C1713,HCPCS,0278,RC,,,,both,,,3355.88,2181.32,,,,,,,,,,,,,
HC Dexa Appendicular Skeleton,PX-3207708100,CDM,77081,CPT,0320,RC,,,,inpatient,,,649.00,421.85,,,,,,,,,,,,,
INSERT SURG 0.3 MM TETH TRANSLACE,SUP-2732730,CDM,C1776,CPT,0278,RC,,,,both,,,1802.36,1171.53,,,,,,,,,,,,,
TAP SURG DIA2.2 MM DELT,SUP-2883303,CDM,2720000010,LOCAL,0272,RC,,,,both,,,562.12,365.38,,,,,,,,,,,,,
CUTTER ENDOSCP L340MM LIN ARTC SGL STROKE FIRING ENDOPATH,SUP-2218776,CDM,2720000010,LOCAL,0272,RC,,,,both,,,766.32,498.11,,,,,,,,,,,,,
SCREW BNE CANN 4X44 MM FT TI STRL ASNS III,SUP-2374569,CDM,C1713,HCPCS,0278,RC,,,,both,,,533.80,346.97,,,,,,,,,,,,,
SPACER SPNL L W10XH10XL25MM 5DEG PEEK THORLUM OBLQ COROENT,SUP-2310885,CDM,C1821,HCPCS,0278,RC,,,,both,,,7614.50,4949.42,,,,,,,,,,,,,
VALVE CSF PRESSURE STD HI ULTRAVS,SUP-2666748,CDM,C1889,HCPCS,0278,RC,,,,both,,,1657.29,1077.24,,,,,,,,,,,,,
BURR SURG 4MM DIA HD XLN MIC 8MML HD CARBIDE SM BNE OVL FLUT,SUP-2605579,CDM,2720000010,LOCAL,0272,RC,,,,both,,,64.06,41.64,,,,,,,,,,,,,
CATH REPROC EP JSN 2-5-2 MM 6FR 120CM SUPREME,SUP-2877821,CDM,C1730,HCPCS,0272,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
SLING GYN OUTPT PROSPECTIVE PAYMENT IN FAST,SUP-2140294,CDM,C1771,HCPCS,0278,RC,,,,both,,,4698.23,3053.85,,,,,,,,,,,,,
PLATE BNE STR 3.5X209 MM 16 HOLE RECON LCK SS STRL,SUP-2483471,CDM,C1713,HCPCS,0278,RC,,,,both,,,1976.76,1284.89,,,,,,,,,,,,,
CAGE SPNL 0 DEG 25X11X8 MM POST LUMBAR INTBDY PEEK CEZANNE,SUP-2578160,CDM,C1889,HCPCS,0278,RC,,,,both,,,6229.76,4049.34,,,,,,,,,,,,,
ELECTRODE LOOP L W CBL FOR 30DEG TELSCP 0112041] MEDACTA USA],SUP-2267192,CDM,C1776,CPT,0278,RC,,,,both,,,5526.40,3592.16,,,,,,,,,,,,,
PROSTHESIS VOICE L10MM OD16FR TRACHEOESOPHAGEAL INDWL CLASS,SUP-2242366,CDM,L8509,HCPCS,0272,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
KNIFE OPHTH WEINSTOCK BIMANUAL 19 GA DIAMOND BVL LF,SUP-2491683,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5302.52,3446.64,,,,,,,,,,,,,
CATH BLLN SCORING 2X10MM X 139CM OTW PTCA ANGIOSCULPT,SUP-2353175,CDM,C1725,HCPCS,0272,RC,,,,both,,,2590.50,1683.82,,,,,,,,,,,,,
MESH SPNL W26XH50XL33MM TI OVL,SUP-2256179,CDM,C1781,HCPCS,0278,RC,,,,both,,,12289.96,7988.47,,,,,,,,,,,,,
SURGICAL PROCEDURE SET SINGLE STRL GENESYS HTA PROCERVE LTX,SUP-2864515,CDM,C1886,HCPCS,0278,RC,,,,both,,,6232.90,4051.38,,,,,,,,,,,,,
HC Potassium 24hr Urine,PX-3018413300,CDM,84133,CPT,0301,RC,,,,outpatient,,,119.00,77.35,,,,,,,,,,,,,
SET URET STENT SOFFLX L 8 CM DIA 3.0 FR GUIDEWIRE L 60 CM,SUP-2707491,CDM,C2617,HCPCS,0278,RC,,,,both,,,573.05,372.48,,,,,,,,,,,,,
PLATE BONE W8XL60MM THK2MM 0DEG 7 H BILAT TI STR RIG DYN,SUP-2191071,CDM,C1713,HCPCS,0278,RC,,,,both,,,1442.39,937.55,,,,,,,,,,,,,
PACEMAKER CARD ALTRUA 40 W 42 X H 42 MM THK 8 MM 23.4 GM,SUP-2149273,CDM,C1786,HCPCS,0275,RC,,,,both,,,16007.72,10405.02,,,,,,,,,,,,,
CUBE EXT FIX 2 HOLE RANCHO,SUP-2749947,CDM,2720000010,LOCAL,0272,RC,,,,both,,,913.74,593.93,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 150 GM AMNIO MEMBRN PARTICULATE NEOX FLO,SUP-2648691,CDM,Q4155,HCPCS,0636,RC,,,,both,,,5887.50,3826.87,,,,,,,,,,,,,
SCREW BONE L12MM OD3.5MM CORT DSTL VOLAR RAD PRECIS SELF DRL,SUP-2361530,CDM,C1713,HCPCS,0278,RC,,,,both,,,298.83,194.24,,,,,,,,,,,,,
CLAMP CRAN L 12 MM NEURO CRANIOTOMY LN STRL DISP LORENZ,SUP-2935329,CDM,C1713,HCPCS,0278,RC,,,,both,,,860.36,559.23,,,,,,,,,,,,,
EXTRACTOR SURG SZ 1.6 MM SCREW DIA 3.4-4 MM STRL DISP,SUP-2913642,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1923.82,1250.48,,,,,,,,,,,,,
GUIDEWIRE ENDO L250CM S STL PROG FLEX TIP TO INTRODUCE DIL,SUP-2169222,CDM,C1769,HCPCS,0272,RC,,,,both,,,769.30,500.04,,,,,,,,,,,,,
PLATE BONE L201MM 10 H LT LAT PROX TIB S STL LCK FOR 4.5MM,SUP-2348224,CDM,C1713,HCPCS,0278,RC,,,,both,,,12929.42,8404.12,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 50 CM DIA 8 MM STR STD WALL HELIX,SUP-2494777,CDM,C1768,CPT,0278,RC,,,,both,,,1026.56,667.26,,,,,,,,,,,,,
SCREW BNE L100MM DIA12MM HIP NAIL LAG FOR TRAUM GAM,SUP-2370992,CDM,C1713,HCPCS,0278,RC,,,,both,,,924.73,601.07,,,,,,,,,,,,,
CATHETER THERMODILUTION 7.5 FRX110 CM CO SVO2 SWN GZ,SUP-2214318,CDM,C1751,HCPCS,0278,RC,,,,both,,,623.51,405.28,,,,,,,,,,,,,
HEAD FEM STD 42 MM COCR,SUP-2217242,CDM,C1776,CPT,0278,RC,,,,both,,,2386.40,1551.16,,,,,,,,,,,,,
HC CT Heart No Contrast Quant Eval Coronry Calcium|SELF-PAY CT CALCIUM SCORING,PX-3507557100,CDM,75571,CPT,0350,RC,,,CTC,outpatient,,,175.00,175.00,,,,,,,,,,,,,
TRAY CATH HEMODIALYSI NIAG SLIM CATH ACTE 12FR DIA 2 5755240,SUP-2632921,CDM,C1752,HCPCS,0278,RC,,,,both,,,615.44,400.04,,,,,,,,,,,,,
PLATE SPNL L24MM 2 LEV STR BILAT LCK ANTR CERV TI VUELOCK,SUP-2415768,CDM,C1713,HCPCS,0278,RC,,,,both,,,4669.18,3034.97,,,,,,,,,,,,,
GUIDEWIRE VASC L 60 CM 0.035 IN CRV RAD 3MM HVY DBL FLX STRL,SUP-2760022,CDM,C1769,HCPCS,0272,RC,,,,both,,,97.69,63.50,,,,,,,,,,,,,
PLATE BNE L 131 X W 11.4 MM THK 3.5 MM SCREW DIA 3.5 MM 9 H 72464509,SUP-2933336,CDM,C1713,HCPCS,0278,RC,,,,both,,,3366.39,2188.15,,,,,,,,,,,,,
BRACE ORTH POST LUMBAR BK PREFABRICATED LSO,SUP-2388149,CDM,L0630,HCPCS,0274,RC,,,,both,,,417.09,271.11,,,,,,,,,,,,,
PLATE 1.0MM THCK 20 H STRNL LCK STR CP TI,SUP-2262566,CDM,C1713,HCPCS,0278,RC,,,,both,,,2735.63,1778.16,,,,,,,,,,,,,
ANCHOR SUT L14.7MM DIA5.5MM BIOCOMPOSITE FULL THRD W/ 2,SUP-2121547,CDM,C1713,HCPCS,0278,RC,,,,both,,,1051.90,683.73,,,,,,,,,,,,,
CATHETER DRNGE L25CM DIA10.2FR 0.038IN 3 H CRV UTHANE,SUP-2168614,CDM,C1729,HCPCS,0272,RC,,,,both,,,186.58,121.28,,,,,,,,,,,,,
KIT CATH HEMODIALYSI RELIANCE XK CHRONIC STD 16FR DIA 24CM 1,SUP-2613277,CDM,C1750,HCPCS,0278,RC,,,,both,,,1483.65,964.37,,,,,,,,,,,,,
SUPPORT ORTHOT LOWER EXTREMITY CUST PER EXTN BAR,SUP-2435695,CDM,L2760,HCPCS,0274,RC,,,,both,,,160.86,104.56,,,,,,,,,,,,,
PLATE BNE FEM 120 DEG 240 MM ARCHED MR SAFE NS,SUP-2863419,CDM,C1713,HCPCS,0278,RC,,,,both,,,3174.51,2063.43,,,,,,,,,,,,,
PROBE LAP 5 MM W/ HANDSWITCH,SUP-2225599,CDM,2720000010,LOCAL,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
KIT ART LN CATHETER 20GA L3IN NDL 21GA L1IN GWIRE L25CM,SUP-2120114,CDM,C1751,HCPCS,0278,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
SPHINCTEROTOME ENDOSCP DIA55FR CATHETER  L200CM WIRE L30MM T,SUP-2436453,CDM,2720000010,LOCAL,0272,RC,,,,both,,,320.19,208.12,,,,,,,,,,,,,
PLATE BNE MESHED 1 MM MXLFCL 12 HOLE LF,SUP-2469443,CDM,C1713,HCPCS,0278,RC,,,,both,,,5111.32,3322.36,,,,,,,,,,,,,
BIT DRILL L7IN OD2MM TRK,SUP-2249399,CDM,2720000010,LOCAL,0272,RC,,,,both,,,954.56,620.46,,,,,,,,,,,,,
KIT INTRO BILI STNT 10FR,SUP-2149476,CDM,C1894,HCPCS,0272,RC,,,,both,,,230.19,149.62,,,,,,,,,,,,,
STENT PERIPH LIFESTENT L 80 MM DIA 7 MM CATH L 130 CM DIA 6,SUP-2128192,CDM,C1876,HCPCS,0278,RC,,,,both,,,5338.00,3469.70,,,,,,,,,,,,,
PLATE BNE L249MM 12 H NONSTERILE CRV FEM SHFT TI NCB,SUP-2411493,CDM,C1713,HCPCS,0278,RC,,,,both,,,1873.26,1217.62,,,,,,,,,,,,,
DEMINERALIZED CORT OSTEOCONDUCTIVE FRZ DRY 5CC FIBEROS,SUP-2314098,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1884.00,1224.60,,,,,,,,,,,,,
PLATE 60MM INTERPEDICULAR GIC59,SUP-2293978,CDM,C1713,HCPCS,0278,RC,,,,both,,,6361.64,4135.07,,,,,,,,,,,,,
SYSTEM POS STD 36X55 IN PREVALON GLIDE SHT REPOS AIRTAP,SUP-2336480,CDM,C1713,HCPCS,0278,RC,,,,both,,,1040.91,676.59,,,,,,,,,,,,,
HEAD RMR DIA8.5MM MDLLRY FR CUT,SUP-2188127,CDM,2720000010,LOCAL,0272,RC,,,,both,,,879.11,571.42,,,,,,,,,,,,,
RING EXT FIX DIA 300 MM FULL NS DISP TSF,SUP-2933274,CDM,2720000010,LOCAL,0272,RC,,,,both,,,9158.60,5953.09,,,,,,,,,,,,,
KIT PICC MAX BARR ANTIMICR/ANITTHROM PRELOAD 6FR X 55CM 3L,SUP-2864583,CDM,C1751,HCPCS,0278,RC,,,,both,,,907.46,589.85,,,,,,,,,,,,,
CUTTER SURG L MED R LAT FEM ACCURIS ST,SUP-2344211,CDM,2720000010,LOCAL,0272,RC,,,,both,,,916.41,595.67,,,,,,,,,,,,,
ANCHOR SUT KNOTLESS CINCHLOCK 2.4 MM,SUP-2378803,CDM,C1713,HCPCS,0278,RC,,,,both,,,2929.62,1904.25,,,,,,,,,,,,,
GRAFT BONE SUB 1-10MM 10ML CRUSH CANC FRZ DRY,SUP-2165597,CDM,C1713,HCPCS,0278,RC,,,,both,,,599.74,389.83,,,,,,,,,,,,,
ALLOGRAFT BNE STRP 20X25X6 MM FD SPNG CANC READIGRAFT BLX,SUP-2740890,CDM,C1713,HCPCS,0278,RC,,,,both,,,3821.54,2484.00,,,,,,,,,,,,,
HC So Von Wille Brand Factor,PX-3058524566,CDM,85245,CPT,0305,RC,,,,both,,,204.00,132.60,,,,,,,,,,,,,
GRAFT BONE L16MM DIA11MM CANC PLUG W/O CART FLEXIGRFT,SUP-2264647,CDM,C1713,HCPCS,0278,RC,,,,both,,,1972.92,1282.40,,,,,,,,,,,,,
GRAFT DERM L12CM W3CM THK.8-1.7MM THCK DERMAMATRIX ACELLULAR,SUP-2306910,CDM,C1762,CPT,0278,RC,,,,both,,,3282.49,2133.62,,,,,,,,,,,,,
CATHETER EP 4 MM 7 FRX110 4 FRX20 MM INQUIRY,SUP-2538007,CDM,C1731,HCPCS,0278,RC,,,,both,,,5133.90,3337.03,,,,,,,,,,,,,
PLATE RAD HD RIM 2.4MM 4H RT TI LCP,SUP-2549710,CDM,C1713,HCPCS,0278,RC,,,,both,,,2017.20,1311.18,,,,,,,,,,,,,
COLLAR CERV ATLS REG PD5 PEDIATRIC 3-6 YR OCPTL SUPP STRP,SUP-2420905,CDM,L0172,HCPCS,0274,RC,,,,both,,,149.09,96.91,,,,,,,,,,,,,
BIT DRL DIA24MM OCCIPITOCERVICAL UP THOR NAVIGATED INFIN,SUP-2293677,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1938.95,1260.32,,,,,,,,,,,,,
CAGE SPNL MESH 17X13X9 MM 6 LOBE,SUP-2602077,CDM,C1889,HCPCS,0278,RC,,,,both,,,7617.64,4951.47,,,,,,,,,,,,,
CATHETER HD DL 12 FRX16 CM ARROWG+ARD BLU BLU FLEXTIP,SUP-2763039,CDM,C1752,HCPCS,0278,RC,,,,both,,,189.00,122.85,,,,,,,,,,,,,
ANCHOR SUTURE ZIP 5-0 4.5X38 MM BRAIDED POLYESTER,SUP-2608407,CDM,C1713,HCPCS,0278,RC,,,,both,,,552.58,359.18,,,,,,,,,,,,,
LINER ACET HIP ARCM FOR KM3,SUP-2136660,CDM,C1776,CPT,0278,RC,,,,both,,,5275.20,3428.88,,,,,,,,,,,,,
KIT INTRO VSI L 10 CM DIA 4 FR SS 7 CM 21 GA MANDREL TIP SIL,SUP-2763442,CDM,C1894,HCPCS,0272,RC,,,,both,,,63.74,41.43,,,,,,,,,,,,,
CANN SCREW THD 5.0X44MM,SUP-2586818,CDM,C1713,HCPCS,0278,RC,,,,both,,,468.65,304.62,,,,,,,,,,,,,
GUIDEWIRE ORTHOPEDIC BULL TIP 3 MMX100 CM SMOOTH IM FIX ZMS,SUP-2207940,CDM,C1769,HCPCS,0272,RC,,,,both,,,224.20,145.73,,,,,,,,,,,,,
MESH CRAN W41XL42MM D0.5MM THK1MM R ORBIT FLR WALL TIIUM,SUP-2366483,CDM,C1713,HCPCS,0278,RC,,,,both,,,4799.05,3119.38,,,,,,,,,,,,,
BLADE RTRCTR RVL MICRO 14MMW X 35MML SHRT TOOTH BLUE F/ANTRR,SUP-2493096,CDM,2720000010,LOCAL,0272,RC,,,,both,,,473.17,307.56,,,,,,,,,,,,,
AMOXICILLIN-POT CLAVULANATE 400-57 MG/5ML PO SUSR,RX-33230,CDM,340b,HCPCS,0637,RC,09999-9911-17,NDC,,both,5,ML,2.70,1.75,,,,,,,,,,,,,
LANOLIN-PETROLATUM 15.5-53.4 % EX OINT,RX-134282,CDM,6370000000,HCPCS,0637,RC,65197-0400-10,NDC,,both,42.5,GR,12.10,7.86,,,,,,,,,,,,,
SPLINT ANK M SHOE SZ 9-10.5 IN LG POLYPRO PLAS LT FT,SUP-2930190,CDM,L1930,HCPCS,0274,RC,,,,both,,,182.15,118.40,,,,,,,,,,,,,
GUIDEWIRE ORTHOPEDIC 3MM X 800MM BEAD TIP FOR TIBIOTALOCALCANEAL FUSION DYNANAIL,SUP-2878463,CDM,C1769,HCPCS,0272,RC,,,,both,,,1177.50,765.37,,,,,,,,,,,,,
HEAD HUM OD56MM THK21MM YEL CO CHROM STD MORSE TAPR AFFINITI,SUP-2396770,CDM,C1776,HCPCS,0278,RC,,,,both,,,7075.68,4599.19,,,,,,,,,,,,,
CAGE SPNL W10XH9XL27MM 5-10DEG LUM PEEK INTBDY SELF EXP POR,SUP-2353372,CDM,C1889,HCPCS,0278,RC,,,,both,,,10990.00,7143.50,,,,,,,,,,,,,
IMPLANT OSS L5.5MM DIA1.14MM HA CAP FULL CANN CONSERVATIVE,SUP-2313680,CDM,L8613,CPT,0278,RC,,,,both,,,915.18,594.87,,,,,,,,,,,,,
KIT CATH HEMODIALYSI HEMOSPLIT CHRONIC STD 14.5FR DIA LG LUM,SUP-2613295,CDM,C1750,HCPCS,0278,RC,,,,both,,,1486.95,966.52,,,,,,,,,,,,,
ROD EXT FIX THRD 100 MM RINGFIX,SUP-2365334,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1727.00,1122.55,,,,,,,,,,,,,
LEAD DEFIB SIL BPLR,SUP-2357723,CDM,C1895,HCPCS,0275,RC,,,,both,,,7065.00,4592.25,,,,,,,,,,,,,
BLADE IM L46MM ST G TI SPRL FOR HUM NAIL,SUP-2192465,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1645.52,1069.59,,,,,,,,,,,,,
KIT THR TRABECULAR MTL STEM CUP XLPE LNR,SUP-2212129,CDM,C1776,CPT,0278,RC,,,,both,,,16745.62,10884.65,,,,,,,,,,,,,
ANCHOR SUT ABSRB W/ NDL QUICKANCHR + PANALOK RC,SUP-2249365,CDM,C1713,HCPCS,0278,RC,,,,both,,,1391.02,904.16,,,,,,,,,,,,,
SCREW 4X38MM,SUP-2678040,CDM,C1713,HCPCS,0278,RC,,,,both,,,746.54,485.25,,,,,,,,,,,,,
SCREW BNE LCK 2.3X12 MM,SUP-2691426,CDM,C1713,HCPCS,0278,RC,,,,both,,,491.10,319.21,,,,,,,,,,,,,
DISPOSABLES KIT FOR 3.5 MM HIP PUSHLOCK,SUP-2812329,CDM,2720000010,LOCAL,0272,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
REAMER SURG CUP OD24MM,SUP-2400254,CDM,2720000010,LOCAL,0272,RC,,,,both,,,929.44,604.14,,,,,,,,,,,,,
PLATE BNE THK0.6MM 3X3 H L HND NONCOMPRESSION GRID FOR,SUP-2267891,CDM,C1713,HCPCS,0278,RC,,,,both,,,728.48,473.51,,,,,,,,,,,,,
TIP INSTRUMENT LASER 20 DEG OMNITIP,SUP-2225652,CDM,2720000010,LOCAL,0272,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
PACK NEUROSURGICAL SHTH L 95 X W 13.5 MM MYRIAD HNDPC L 13 NN-3010,SUP-2930304,CDM,2720000010,LOCAL,0272,RC,,,,both,,,22705.03,14758.27,,,,,,,,,,,,,
MTOSCRINTF.NON-CANN 5.5X30 N/S,SUP-2341308,CDM,C1713,HCPCS,0278,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
SCREW CANNULATED 7.3X135MM SS FULL THRD STRL,SUP-2547277,CDM,C1713,HCPCS,0278,RC,,,,both,,,749.46,487.15,,,,,,,,,,,,,
KIT CATH HEMODIALYSI GLIDEPATH CHRONIC STD 14.5FR DIA 39CM 3,SUP-2613291,CDM,C1750,HCPCS,0278,RC,,,,both,,,800.70,520.45,,,,,,,,,,,,,
SCREW BONE L25MM DIA5MM CANC S STL PERIPH REFLCT,SUP-2344769,CDM,C1713,HCPCS,0278,RC,,,,both,,,410.24,266.66,,,,,,,,,,,,,
CAP SCR FOR EXT FIX SYS,SUP-2263011,CDM,C1713,HCPCS,0278,RC,,,,both,,,607.78,395.06,,,,,,,,,,,,,
PLATE BNE L142MM 6 H NONSTERILE R MED PROX TIB S STL LOK,SUP-2185670,CDM,C1713,HCPCS,0278,RC,,,,both,,,4176.48,2714.71,,,,,,,,,,,,,
SCREW BNE REPL BEAL TYP,SUP-2466960,CDM,C1713,HCPCS,0278,RC,,,,both,,,173.89,113.03,,,,,,,,,,,,,
PLATE BIFUR 115 DEG 30MM/5MM STRL,SUP-2547478,CDM,C1713,HCPCS,0278,RC,,,,both,,,1437.05,934.08,,,,,,,,,,,,,
ROD SPNL THORLUM CRV PREBENT TI OD5.5MM L65MM SILVERTON,SUP-2415729,CDM,C1713,HCPCS,0278,RC,,,,both,,,1168.08,759.25,,,,,,,,,,,,,
BRONCHOSCOPE EXALT MODEL B REGULAR,SUP-2855172,CDM,C1601,HCPCS,0272,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
PENTAMIDINE ISETHIONATE 300 MG IN SOLR,RX-28235,CDM,J2545,HCPCS,0636,RC,13925-0522-01,NDC,,both,1,UN,830.90,540.08,,,,,,,,,,,,,
GRAFT BNE SUB 15CC CELLULAR DBM VIVIGEN,SUP-2264615,CDM,C1713,HCPCS,0278,RC,,,,both,,,13683.34,8894.17,,,,,,,,,,,,,
SCREW BONE L10MM DIA2.7MM MAG MAND NONLOCKINGXDRIVE FOR,SUP-2136765,CDM,C1713,HCPCS,0278,RC,,,,both,,,222.94,144.91,,,,,,,,,,,,,
HEAD FEM BALL 12/14 LNG 32 MM ANTR POST,SUP-2440890,CDM,C1776,CPT,0278,RC,,,,both,,,2176.02,1414.41,,,,,,,,,,,,,
SCREW BNE MAXILLOMANDIBULAR 2X16 MM 12 MM X DRV DRILL-FREE,SUP-2457030,CDM,C1713,HCPCS,0278,RC,,,,both,,,312.40,203.06,,,,,,,,,,,,,
DEVICE ENDART L44CM OD5MM TRANSECTION MOLLRING CUT,SUP-2264256,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6144.98,3994.24,,,,,,,,,,,,,
SCREW BONE L80MM DIA13MM THRD L22MM STRL CANC S STL ST CANN,SUP-2186573,CDM,C1713,HCPCS,0278,RC,,,,both,,,853.01,554.46,,,,,,,,,,,,,
COMPONENT FEM DIA3.5MM HIP CKPT RESTORIS MCK,SUP-2368441,CDM,C1776,CPT,0278,RC,,,,both,,,276.32,179.61,,,,,,,,,,,,,
CORTICAL BONE SCR 2.7X16MM,SUP-2397913,CDM,C1713,HCPCS,0278,RC,,,,both,,,220.43,143.28,,,,,,,,,,,,,
TROCAR ENDOSCP DIA2/3 MM DIL RADIALLY EXPANDABLE SLV STRL,SUP-2896341,CDM,2720000010,LOCAL,0272,RC,,,,both,,,404.24,262.76,,,,,,,,,,,,,
GRAFT HUM TISS W3XL6CM MINIMALLY PROC UMB CRD SFT TISS MEM,SUP-2124870,CDM,C1762,CPT,0278,RC,,,,both,,,11853.50,7704.77,,,,,,,,,,,,,
MATRIX BIO L 4 X W 6 CM SZ 43 SQCM FISH SKIN DERMAL MESHED,SUP-2909241,CDM,Q4158,HCPCS,0636,RC,,,,both,,,4154.22,2700.24,,,,,,,,,,,,,
BIT DRL DIA9MM ENTRY FOR ANK COMPR NAILING SYS,SUP-2316005,CDM,2720000010,LOCAL,0272,RC,,,,both,,,948.66,616.63,,,,,,,,,,,,,
TUBE EXT FIX L300MM OD20MM BLU C FOR UNILAT MONOTB TRIAX SYS,SUP-2372610,CDM,C1713,HCPCS,0278,RC,,,,both,,,560.18,364.12,,,,,,,,,,,,,
CATHETER IV NEOMAGIC L 8 CM DIA1.9 FR SIL PICC 1 LUMEN EPIV,SUP-2874832,CDM,C1751,HCPCS,0278,RC,,,,both,,,91.53,59.49,,,,,,,,,,,,,
LACOSAMIDE 200 MG/20ML IV SOLN,RX-96886,CDM,C9254,HCPCS,0636,RC,70069-0471-01,NDC,,both,5,ML,56.80,36.92,,,,,,,,,,,,,
GRIP CBL M TROCH VIT W/ 2/2MM CBL DALL-M,SUP-2377569,CDM,C1713,HCPCS,0278,RC,,,,both,,,2721.75,1769.14,,,,,,,,,,,,,
HC Counseling Visit for Ldct-Pbb,PX-5100029600,CDM,G0296,CPT,0510,RC,,,,inpatient,,,254.00,165.10,,,,,,,,,,,,,
CABLE SPNL DBL LOOP 1.1 MM W/ 2 CRMP SS STRL LENTUR,SUP-2685267,CDM,C1713,HCPCS,0278,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
GUIDEWIRE VASC L 150 CM DIA 0.035 IN PTFE N CRV TAPR LL TIP,SUP-2301907,CDM,C1769,HCPCS,0272,RC,,,,both,,,31.24,20.31,,,,,,,,,,,,,
PLATE BNE L300MM 13 H NONSTERILE R PROX LAT TIB S STL LOK,SUP-2184885,CDM,C1713,HCPCS,0278,RC,,,,both,,,4151.33,2698.36,,,,,,,,,,,,,
PIN FIX DBL TROCAR 0.141X9 IN THRD SS NS STEINMANN,SUP-2791295,CDM,C1713,HCPCS,0278,RC,,,,both,,,81.67,53.09,,,,,,,,,,,,,
GRAFT VSCLR STRGHT WOVEN DBLE VLR 28MM DX15CM L HMSHLD PLTNM,SUP-2464174,CDM,C1768,CPT,0278,RC,,,,both,,,1418.28,921.88,,,,,,,,,,,,,
SUPPORT ORTHOPEDIC ADJ SM LG AD PEDIATRIC RT HND WRST FNGR,SUP-2264312,CDM,L3807,HCPCS,0274,RC,,,,both,,,159.36,103.58,,,,,,,,,,,,,
CATHETER CARD ABLATION THERMOCOOL SF L 115 CM 8 FR B CRV RED,SUP-2492474,CDM,C1732,HCPCS,0278,RC,,,,both,,,7762.08,5045.35,,,,,,,,,,,,,
NEEDLE SUTURE KNOTLESS SWIVELOCK C SCORPION AR2600SBS10,SUP-2845508,CDM,C1713,HCPCS,0278,RC,,,,both,,,6751.00,4388.15,,,,,,,,,,,,,
URETEROSCOPE (see item comments) DIGITAL URS FLX SU MODEL E NORM DEFL AXIS II,SUP-2882439,CDM,C1747,HCPCS,0272,RC,,,,both,,,2665.86,1732.81,,,,,,,,,,,,,
FIBER LASER HOLM SUREFLEX 10812] FORTEC MEDICAL INC],SUP-2225689,CDM,C1713,HCPCS,0278,RC,,,,both,,,675.10,438.81,,,,,,,,,,,,,
SHELL ACET 48 MM HIP CERM REFLECTION,SUP-2434646,CDM,C1776,CPT,0278,RC,,,,both,,,6914.28,4494.28,,,,,,,,,,,,,
HC N Block Inj Intercost Sng,PX-3606442000,CDM,64420,CPT,0360,RC,,,,both,,,2230.00,1449.50,,,,,,,,,,,,,
PLATE SURFACE 3.5MM QUADRILATERAL SHORT STERILE,SUP-2546017,CDM,C1713,HCPCS,0278,RC,,,,both,,,1638.04,1064.73,,,,,,,,,,,,,
PLATE BNE L141MM THK3MM 9 H BILAT S STL STR LIMIT CNTCT DYN,SUP-2185340,CDM,C1713,HCPCS,0278,RC,,,,both,,,1872.23,1216.95,,,,,,,,,,,,,
SHEATH INTRO GLIDESHEATH L 10 CM OD 4 FR ID 0.061 IN TIP DIA,SUP-2384846,CDM,C1894,HCPCS,0272,RC,,,,both,,,131.88,85.72,,,,,,,,,,,,,
BIT DRL CANN 8 MM FULL FLUT FOR LARDING WIRE,SUP-2767543,CDM,2720000010,LOCAL,0272,RC,,,,both,,,906.33,589.11,,,,,,,,,,,,,
REAMER SURG DIA7MM PILOTED HD FOR ALL ARTHSCP PROX BICEP,SUP-2121314,CDM,C1713,HCPCS,0278,RC,,,,both,,,643.70,418.40,,,,,,,,,,,,,
GRAFT BNE SUB 1 8MM 20ML CANC CHIP FRZN ALLGRFT,SUP-2264731,CDM,C1713,HCPCS,0278,RC,,,,both,,,893.36,580.68,,,,,,,,,,,,,
ALLOGRAFT DISC DBM AND CORT CANC BONE CHIP FRZN OPTEFORM,SUP-2223554,CDM,C1762,CPT,0278,RC,,,,both,,,1208.90,785.78,,,,,,,,,,,,,
SYSTEM SPEC RETRV EXTRACTION 12 MM 16 MMX4 CM 6500 CC ALEXIS,SUP-2119764,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1208.90,785.78,,,,,,,,,,,,,
CATHETER DIAG 5FR 100CM LEN 5MM SPC 5MM TIP MAP EP ABLAT,SUP-2141289,CDM,C1730,HCPCS,0272,RC,,,,both,,,483.56,314.31,,,,,,,,,,,,,
PLATE BNE 90 DEG THK 0.6 MM 7 X 7 H SCREW DIA1.5 MM TI,SUP-2883846,CDM,C1713,HCPCS,0278,RC,,,,both,,,778.72,506.17,,,,,,,,,,,,,
STENT OPHTH MINI SIL FOR CANALICULAR LAC MONOKA,SUP-2224378,CDM,C1783,HCPCS,0278,RC,,,,both,,,272.11,176.87,,,,,,,,,,,,,
DEVICE REM 183GM W7.1XH11.4CM D5.1CM TRAK BK II,SUP-2326855,CDM,2720000010,LOCAL,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
MINI PLATE STRAIGHT 20 HOLE ADAPTION 10MM CP TITANIUM,SUP-2675815,CDM,C1713,HCPCS,0278,RC,,,,both,,,442.46,287.60,,,,,,,,,,,,,
HC Retro Urethrocystography S&I,PX-3207445000,CDM,74450,CPT,0320,RC,,,,inpatient,,,911.00,592.15,,,,,,,,,,,,,
SCREW BNE L46MM DIA6MM CANC TIB TI NONCANNULATED NONLOCKING,SUP-2212917,CDM,C1713,HCPCS,0278,RC,,,,both,,,685.78,445.76,,,,,,,,,,,,,
ANCHOR SUT L16.3MM D5.5MM TI NO2 FIBERWIRE ORDER MULT OF 5EA,SUP-2121574,CDM,C1713,HCPCS,0278,RC,,,,both,,,800.70,520.45,,,,,,,,,,,,,
WASHER SPNL 7X18 MM FOR SCREW TI NS,SUP-2592002,CDM,C1713,HCPCS,0278,RC,,,,both,,,693.94,451.06,,,,,,,,,,,,,
GRAFT BONE SUB W25XH8XL50MM 10CC STRP BIOACTIVE BIOLOGIC,SUP-2232307,CDM,C9362,HCPCS,0278,RC,,,,both,,,4490.20,2918.63,,,,,,,,,,,,,
BUR SURG L8CM DIA1.1MM HD L6.4MM TAPR SIDE CUT L BALL FLUT,SUP-2284628,CDM,2720000010,LOCAL,0272,RC,,,,both,,,250.32,162.71,,,,,,,,,,,,,
PROGRAMMER PT HANDHELD REMOT FOR 7427 SYNERGY EZ,SUP-2284582,CDM,C1787,HCPCS,0278,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
STEM HUM L122MM DIA14MM STD CO CHROM POR PRI PRESSFIT CEM,SUP-2404596,CDM,C1776,CPT,0278,RC,,,,both,,,13109.50,8521.17,,,,,,,,,,,,,
HC Chloride Urine,PX-3018243600,CDM,82436,CPT,0301,RC,,,,outpatient,,,195.00,126.75,,,,,,,,,,,,,
ALLOGRAFT DERMAL 1.5X2 CMX0.76-1.25 MM DECELL DERM ORACELL,SUP-2740796,CDM,C1762,CPT,0278,RC,,,,both,,,452.79,294.31,,,,,,,,,,,,,
KNIFE SURG ROYCE 7.5 INX8 MM EAR BAYNT DN CUT MICROFRANCE,SUP-2498047,CDM,2720000010,LOCAL,0272,RC,,,,both,,,464.85,302.15,,,,,,,,,,,,,
DEFIBRILLATOR CRD 40 J 2 CHMBR UNIFY DR,SUP-2356312,CDM,C1882,HCPCS,0275,RC,,,,both,,,53851.00,35003.15,,,,,,,,,,,,,
STENT TRACHBRONCH WGRFT L 30 MM DIA10 MM CATH L 116 CM,SUP-2140222,CDM,C1874,HCPCS,0278,RC,,,,both,,,6672.50,4337.12,,,,,,,,,,,,,
PLATE BONE DUAL CMPRSSN HLX12 TTNM CNTRD F3.5MM LOK SCREW S,SUP-2724799,CDM,C1713,HCPCS,0278,RC,,,,both,,,1901.71,1236.11,,,,,,,,,,,,,
CANNULA ARTHSCP 7 MM HIP SHLDR ADJ SHFT HYDRODAM REUSE,SUP-2745448,CDM,2720000010,LOCAL,0272,RC,,,,both,,,773.70,502.90,,,,,,,,,,,,,
CEMENT BONE 20ML 40GM FULL DOSE POLYMETHYLMETHACRYLATE,SUP-2197441,CDM,C1713,HCPCS,0278,RC,,,,both,,,211.38,137.40,,,,,,,,,,,,,
ANCHOR SUTURE 5.5 MM PEEK-OPTIMA,SUP-2399112,CDM,C1713,HCPCS,0278,RC,,,,both,,,1230.88,800.07,,,,,,,,,,,,,
HC OB ER Level 1,PX-4509928101,CDM,99281,CPT,0450,RC,,,,both,,,660.00,429.00,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY L 110 CM DIA 4 FR SPC 5 MM D CRV,SUP-2248642,CDM,C1730,HCPCS,0272,RC,,,,both,,,876.06,569.44,,,,,,,,,,,,,
CATHETER EP L125CM OD6FR TEMP BPLR PACE SFT TIP GOETZ,SUP-2126151,CDM,2720000010,LOCAL,0272,RC,,,,both,,,127.45,82.84,,,,,,,,,,,,,
BRACE WLK XL 13+ M 15+ WOM ANK FOAM PNEUMAT SEMI RIG SHELL,SUP-2196362,CDM,L4361,HCPCS,0272,RC,,,,both,,,138.16,89.80,,,,,,,,,,,,,
IMPLANT SPNL MOD TULIP PRECEPT,SUP-2312140,CDM,C1713,HCPCS,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
ROD SPNL L400MM DIA5.5MM POST TI STR SMOOTH SILVERTON-D,SUP-2211121,CDM,C1713,HCPCS,0278,RC,,,,both,,,881.71,573.11,,,,,,,,,,,,,
PLATE BNE L 185 MM SCREW DIA 4.5 MM 10 H NAR COMPR NLCK NS,SUP-2933931,CDM,C1713,HCPCS,0278,RC,,,,both,,,1761.54,1145.00,,,,,,,,,,,,,
WASHER ORTH DIA 5.5 MM NS LEOS,SUP-2932966,CDM,C1713,HCPCS,0278,RC,,,,both,,,324.14,210.69,,,,,,,,,,,,,
ELECTRODE ECG MEDI-TRACE 5,SUP-2835249,CDM,2720000010,LOCAL,0272,RC,,,,both,,,440.39,286.25,,,,,,,,,,,,,
CARBIDOPA-LEVODOPA 25-250 MG PO TABS,RX-9408,CDM,6370000000,HCPCS,0637,RC,60687-0836-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
GUIDEWIRE VASC GLIDEWIRE 150CM 0.018IN TIP L 3 CM STR,SUP-2385545,CDM,C1769,HCPCS,0272,RC,,,,both,,,174.65,113.52,,,,,,,,,,,,,
HEPATITIS B IMMUNE GLOBULIN 220 UNIT/ML IM SOLN,RX-155582,CDM,90371,HCPCS,0636,RC,13533-0636-05,NDC,,both,3,ML,1416.50,920.72,,,,,,,,,,,,,
SHUNT KIT EDW BARBARO SYRINGO LUMPERITON T TUBE FOLTZ CSF,SUP-2838800,CDM,C1889,HCPCS,0278,RC,,,,both,,,3686.71,2396.36,,,,,,,,,,,,,
ELECTRODE ELECSURG L 30.2 CM INSUL DIA1.72 MM TIP DIA1.37 MM,SUP-2936945,CDM,2720000010,LOCAL,0272,RC,,,,both,,,887.84,577.10,,,,,,,,,,,,,
HC Intro Long Gastro Tube - 15202,PX-3614450000,CDM,44500,CPT,0361,RC,,,,both,,,2461.00,1599.65,,,,,,,,,,,,,
PLATE BNE L 107 X W 10.5 MM THK 3 MM SCREW DIA2.7/3.5 MM 5 H 72467705,SUP-2932769,CDM,C1713,HCPCS,0278,RC,,,,both,,,3202.49,2081.62,,,,,,,,,,,,,
SYSTEM IMPL 4.75MM SWIVELOCK C ANCHR W/ SCORPION NDL 1 PRELD,SUP-2121719,CDM,C1713,HCPCS,0278,RC,,,,both,,,5997.40,3898.31,,,,,,,,,,,,,
IMPLANT HUM TISS L 6 X W 5 CM PLCNTA MTRX MEMBRN MINIMALLY,SUP-2905497,CDM,C1762,CPT,0278,RC,,,,both,,,8949.00,5816.85,,,,,,,,,,,,,
CATHETER DRNGE 8.5FR CANN 18GA L15CM DIA0.038IN UTHANE,SUP-2168646,CDM,C1729,HCPCS,0272,RC,,,,both,,,200.46,130.30,,,,,,,,,,,,,
CANN DRIVER BIT HEX 25MM AO,SUP-2724774,CDM,2720000010,LOCAL,0272,RC,,,,both,,,536.06,348.44,,,,,,,,,,,,,
CATHETER PERI DLYS 15FR L46CM UNIV STR LIN RADPQ STRP TENCK,SUP-2283895,CDM,C1750,HCPCS,0278,RC,,,,both,,,131.50,85.47,,,,,,,,,,,,,
MESH SURG L ARC THK0.4MM SLV CRANIOFACIAL TI MALL CNTOUR LO,SUP-2181575,CDM,C1781,HCPCS,0278,RC,,,,both,,,3990.31,2593.70,,,,,,,,,,,,,
CEMENT BNE PASTE 25 GM SOURC,SUP-2371940,CDM,C1713,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
CATHETER THORACENTESIS SET 14 FRX29 CM PNEUMOTHORAX WAYNE,SUP-2759796,CDM,C1729,HCPCS,0272,RC,,,,both,,,600.02,390.01,,,,,,,,,,,,,
GUIDEWIRE VASC L300CM DIA0.014IN TIP L5CM 15DEG G TUNGSTEN,SUP-2172962,CDM,C1769,HCPCS,0272,RC,,,,both,,,308.76,200.69,,,,,,,,,,,,,
ALLOGRAFT DERMAL 3X4 CM DERMAPURE,SUP-2388442,CDM,Q4152,HCPCS,0636,RC,,,,both,,,3611.00,2347.15,,,,,,,,,,,,,
"HC So TB Test, Cell Immun Measure",PX-3028648066,CDM,86480,CPT,0302,RC,,,,both,,,400.00,260.00,,,,,,,,,,,,,
MESH SCAFFOLD GALAFLEX 10CMX20CM BIORESRB,SUP-2903931,CDM,C1781,HCPCS,0278,RC,,,,both,,,8792.00,5714.80,,,,,,,,,,,,,
MESH HERN SM DIA7.6CM VENTRAL POLYPR EPTFE CIR SELF EXP,SUP-2125712,CDM,C1781,HCPCS,0278,RC,,,,both,,,1166.20,758.03,,,,,,,,,,,,,
CATHETER CV DL 4 FR INTERMED NURSING TY PWR INJ,SUP-2125536,CDM,C1751,HCPCS,0278,RC,,,,both,,,320.28,208.18,,,,,,,,,,,,,
GRAFT HUM TISS W40XL70MM THK1MM ACELLULAR ARTHROFLEX,SUP-2264666,CDM,C1762,CPT,0278,RC,,,,both,,,6305.53,4098.59,,,,,,,,,,,,,
BATTERY SACRAL NERVE R20,SUP-2858719,CDM,C1820,HCPCS,0278,RC,,,,both,,,32031.14,20820.24,,,,,,,,,,,,,
CATHETER THROMCTMY INDIGO L 50 CM DIA 7 FR PERIPH ART VEIN,SUP-2714064,CDM,C1887,HCPCS,0272,RC,,,,both,,,8195.40,5327.01,,,,,,,,,,,,,
PROPRANOLOL HCL ER 80 MG PO CP24,RX-38225,CDM,6370000000,HCPCS,0637,RC,00527-4117-37,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
NAIL IM L360MM DIA10MM UNIV L R DST FEM TI CANN LOK RG DYN,SUP-2191721,CDM,C1713,HCPCS,0278,RC,,,,both,,,6646.75,4320.39,,,,,,,,,,,,,
HB Gbl Visit to Discuss Lung Ca Screen W Ldct|PBB CHARGE,PX-9820029600,CDM,G0296,CPT,0982,RC,,,PBB,both,,,363.00,235.95,,,,,,,,,,,,,
GRAFT BNE BIO DBM BOAT SHT SGL UNIT,SUP-2364714,CDM,C1713,HCPCS,0278,RC,,,,both,,,2417.80,1571.57,,,,,,,,,,,,,
ALLOSYNC INJECTABLE FIBERS 1CC,SUP-2816377,CDM,C1713,HCPCS,0278,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
GRAFT BNE SUB 05CC DEMIN BNE MTRX PRIM HD,SUP-2307260,CDM,C1713,HCPCS,0278,RC,,,,both,,,182.12,118.38,,,,,,,,,,,,,
RETRACTOR SURG BLNT 25 MMX4 CM SPNL MEDL LAT DIL HLLW SS,SUP-2293011,CDM,C1713,HCPCS,0278,RC,,,,both,,,4108.53,2670.54,,,,,,,,,,,,,
GRAFT BNE SUB 5CC 1 4MM DEMIN CANC SPNG CHIP FLEXIGRFT,SUP-2264611,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1592.45,1035.09,,,,,,,,,,,,,
FORCEPS OPHTH 25GA + BLNT DST END MIC TEXT BROAD GRSP SURF,SUP-2109691,CDM,2720000010,LOCAL,0272,RC,,,,both,,,580.24,377.16,,,,,,,,,,,,,
PLATE BNE L17MM THK0.6MM 4MM OFFSET 5 H BILAT CHIN ORAL,SUP-2191217,CDM,C1713,HCPCS,0278,RC,,,,both,,,1149.55,747.21,,,,,,,,,,,,,
MESH CRANIAL 2X78X78X1.2 MM RAPID RESORBABLE STERILE RAPIDSO,SUP-2838598,CDM,C1713,HCPCS,0278,RC,,,,both,,,8257.89,5367.63,,,,,,,,,,,,,
CATHETER CV FULL SAFETY TY 7 FRX20 CM 3L DRY POLYURETHANE,SUP-2759878,CDM,C1751,HCPCS,0278,RC,,,,both,,,341.95,222.27,,,,,,,,,,,,,
AGENT HEMSTAT 3GM PURIFIED PLNT STARCH PWD ABSRB ARISTA AH,SUP-2125941,CDM,2720000010,LOCAL,0272,RC,,,,both,,,485.13,315.33,,,,,,,,,,,,,
DEVICE PROSTHETIC SHRINKER BK 5] SOUTHERN PROSTHETIC SUPPLY],SUP-2352853,CDM,L8440,HCPCS,0274,RC,,,,both,,,168.18,109.32,,,,,,,,,,,,,
PLATE BONE SM LT HEVANS,SUP-2321670,CDM,C1713,HCPCS,0278,RC,,,,both,,,3789.35,2463.08,,,,,,,,,,,,,
PLATE 4.5MM LCP CONDYLAR 14 HOLES 314MM RIGHT STERILE,SUP-2547442,CDM,C1713,HCPCS,0278,RC,,,,both,,,4933.69,3206.90,,,,,,,,,,,,,
COMPONENT CLMP EXT FIX STR CLMP JET-X,SUP-2342858,CDM,C1776,CPT,0278,RC,,,,both,,,2595.21,1686.89,,,,,,,,,,,,,
MARKER ENDO TISS 5ML BLK C LUERLOCK TIP PREFIL SYR SPOT,SUP-2227804,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1193.20,775.58,,,,,,,,,,,,,
GRAFT DURA W2XL2IN CLLGN DURAFOAM 1 PER CA,SUP-2243765,CDM,2780000010,LOCAL,0278,RC,,,,both,,,1478.94,961.31,,,,,,,,,,,,,
BLADE SHV DIA2.5MM FULL RAD CUT GRY HUB FOR SM JT,SUP-2366887,CDM,2720000010,LOCAL,0272,RC,,,,both,,,249.66,162.28,,,,,,,,,,,,,
ALLOGRAFT CHIP CANC CRUSH FRZN 1.7MM - 10MM RANG 60CC,SUP-2307395,CDM,C1713,HCPCS,0278,RC,,,,both,,,3365.45,2187.54,,,,,,,,,,,,,
NAIL IM L34.5CM OD10MM TIB CANN LCK DELT RUSS TAY,SUP-2342519,CDM,C1713,HCPCS,0278,RC,,,,both,,,1855.74,1206.23,,,,,,,,,,,,,
PLATE BNE L180MM 7 H NONSTERILE R PROX LAT TIB S STL LOK,SUP-2184879,CDM,C1713,HCPCS,0278,RC,,,,both,,,3911.56,2542.51,,,,,,,,,,,,,
GRAFT BNE GRAN 15X15X1-2 MM 2.6 CC SUBSTITUTE SHP ACTIFUSE,SUP-2129869,CDM,C1713,HCPCS,0278,RC,,,,both,,,3061.50,1989.97,,,,,,,,,,,,,
DEVICE PESSARY RNG W/ SUPP FLD 3IN,SUP-2171843,CDM,A4562,HCPCS,0272,RC,,,,both,,,172.70,112.25,,,,,,,,,,,,,
PLATE BONE W30XL30MM THK0.5MM CRAN ORBIT FLR RAP RESRB W/,SUP-2194081,CDM,C1713,HCPCS,0278,RC,,,,both,,,3004.67,1953.04,,,,,,,,,,,,,
SCREW BNE L32MM DIA6.5MM SHLDR CNTR FOR RSA REUNION,SUP-2373752,CDM,C1713,HCPCS,0278,RC,,,,both,,,431.75,280.64,,,,,,,,,,,,,
RHINOLARYNGOSCOPE VID INTERVENTION 130 DEG 5X350 MM ASCOPE 4,SUP-2752985,CDM,2720000010,LOCAL,0272,RC,,,,both,,,898.04,583.73,,,,,,,,,,,,,
SIZER GRFT L7-15MM ORNG DISP CHONDROFIX,SUP-2200251,CDM,2720000010,LOCAL,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
GRAFT BLGCL TSSUE W16XL20CM PRCNE DRMS MTRX RCNSTRCTVE PLBLE,SUP-2675761,CDM,C1781,HCPCS,0278,RC,,,,both,,,30765.72,19997.72,,,,,,,,,,,,,
CATHETER VENTRICULAR F 9 CM SNAP SHUNT ENDOVENT INNERVISION,SUP-2628505,CDM,C1729,HCPCS,0272,RC,,,,both,,,639.15,415.45,,,,,,,,,,,,,
PLATE BNE 20 H ST BILAT S STL NAR CRV LOK COMPR FOR 35MM SCR,SUP-2178052,CDM,C1713,HCPCS,0278,RC,,,,both,,,3331.41,2165.42,,,,,,,,,,,,,
HMDIAL SET 24CM 14.5FR PU HMFL BSC PRECURVE,SUP-2633005,CDM,C1750,HCPCS,0278,RC,,,,both,,,270.04,175.53,,,,,,,,,,,,,
KIT ANK CARE AD H95IN UNIV BILAT W BRAC WRP CLD PK EXER,SUP-2196372,CDM,L4350,HCPCS,0272,RC,,,,both,,,53.91,35.04,,,,,,,,,,,,,
CATHETER PTCA L150CM 0.018IN BLLN L12CM DIA3MM 15ATM PERIPH,SUP-2156646,CDM,C1725,HCPCS,0272,RC,,,,both,,,904.32,587.81,,,,,,,,,,,,,
CEMENT BONE RADPQ HALF DOSE VERTAPLEX,SUP-2361427,CDM,C1713,HCPCS,0278,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
BLADE LARYNSCP SZ 3 FBR OPT CLD LT CARR INCORPORATED,SUP-2261367,CDM,2720000010,LOCAL,0272,RC,,,,both,,,523.12,340.03,,,,,,,,,,,,,
FERROUS SULFATE 300 (60 FE) MG/5ML PO SOLN,RX-165426,CDM,6370000000,HCPCS,0637,RC,58526-0005-59,NDC,,both,5,ML,29.50,19.17,,,,,,,,,,,,,
PLATE BNE L239MM 14 H NONSTERILE L MED DST TIB S STL LOK,SUP-2184177,CDM,C1713,HCPCS,0278,RC,,,,both,,,3904.15,2537.70,,,,,,,,,,,,,
HANDPIECE IRRIGATION COAX STR LUER LCK SS CAPSULEGUARD IA,SUP-2476374,CDM,2720000010,LOCAL,0272,RC,,,,both,,,56.14,36.49,,,,,,,,,,,,,
PROSTHESIS PENILE 12CM SNAP FIT RT CX MS INHIBIZONE,SUP-2138965,CDM,C1813,HCPCS,0278,RC,,,,both,,,24774.60,16103.49,,,,,,,,,,,,,
ORTHOPAEDIC KIT 12X3.2 MM TI SYND-EZ,SUP-2761960,CDM,C1713,HCPCS,0278,RC,,,,both,,,3428.88,2228.77,,,,,,,,,,,,,
ANCHOR SUT 2.8 MM DIA NO 2 SUT TI TWINFIX,SUP-2318502,CDM,C1713,HCPCS,0278,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
WEDGE ALLGRFT FIBULAR STRUT 40MM,SUP-2293969,CDM,C1713,HCPCS,0278,RC,,,,both,,,2370.70,1540.95,,,,,,,,,,,,,
SUPPORT ORTHOT ANK KNEE GAUNTLET PREFABRICATED OFF THE SHLF,SUP-2435622,CDM,L1902,HCPCS,0272,RC,,,,both,,,211.32,137.36,,,,,,,,,,,,,
CATHETERIZATION KIT 8.5 FRX16 CM CV BNDL VANTEX,SUP-2744705,CDM,C1751,HCPCS,0278,RC,,,,both,,,423.87,275.52,,,,,,,,,,,,,
COUNTERSINK SURG DIA4X45MM CANN BITE COMPR SCR QUIK CONN,SUP-2315944,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1178.82,766.23,,,,,,,,,,,,,
DEVICE ENDOSCP SUTURING 12 MM STD W/O SUTURE CAPIO,SUP-2139400,CDM,C1713,HCPCS,0278,RC,,,,both,,,2186.92,1421.50,,,,,,,,,,,,,
TOPIRAMATE 25 MG PO TABS,RX-18920,CDM,6370000000,HCPCS,0637,RC,69097-0122-03,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
WEDGE FEM SZ 5-6 THK5MM LNG STD UNIV POST PRI CEM LEGION,SUP-2346387,CDM,C1776,CPT,0278,RC,,,,both,,,3479.12,2261.43,,,,,,,,,,,,,
ANCHOR BNE SINGLE 6.5 MM KNOTLESS ANCHR SYS OMEGA,SUP-2660823,CDM,C1713,HCPCS,0278,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
ALLOGRAFT BNE SPACER 7 DEG 28X10X8 MM TLIF MONOLITHIC CRV,SUP-2538528,CDM,C1889,HCPCS,0278,RC,,,,both,,,8504.63,5528.01,,,,,,,,,,,,,
PLATE BNE HUM 127 MM RT DSTL MEDL 13 HOLE STRL A.L.P.S,SUP-2463649,CDM,C1713,HCPCS,0278,RC,,,,both,,,2847.98,1851.19,,,,,,,,,,,,,
CATHETER INFUSION 2.7 FRX165 CM 20 CM MAGIC SPIF FLO COIL,SUP-2424286,CDM,C1887,HCPCS,0272,RC,,,,both,,,2279.64,1481.77,,,,,,,,,,,,,
CENTRALIZER STEM 8 MM DSTL FEM HIP MTRX,SUP-2450934,CDM,C1776,CPT,0278,RC,,,,both,,,244.92,159.20,,,,,,,,,,,,,
TRIAL BONE PLT 5 H T SHP OBLQ TC-100 SM FRAG SYS,SUP-2343731,CDM,C1713,HCPCS,0278,RC,,,,both,,,2159.47,1403.66,,,,,,,,,,,,,
NAIL IM L26CM DIA12MM TIBIOTALOCALCANEAL NIT DYNANAILXL,SUP-2277458,CDM,C1713,HCPCS,0278,RC,,,,both,,,58859.30,38258.54,,,,,,,,,,,,,
PLATE BNE STR 1 MM 3 HOLE C-TUBE FOR 12MM BRIDGE ORTHOANCHOR,SUP-2457414,CDM,C1713,HCPCS,0278,RC,,,,both,,,574.34,373.32,,,,,,,,,,,,,
COIL VASC TORNADO EMBOLUS L 14 CM DIA 6 MM CATH DIA 0.035 IN,SUP-2168828,CDM,C1889,HCPCS,0278,RC,,,,both,,,326.56,212.26,,,,,,,,,,,,,
HANDPIECE ULTRSNC SYS 11 MM CEMENT REMOVAL HELIX TIP STRL,SUP-2883822,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1329.35,864.08,,,,,,,,,,,,,
SHUNT NEUROSURGICAL ADJ PROSA,SUP-2108730,CDM,C1889,HCPCS,0278,RC,,,,both,,,15433.10,10031.51,,,,,,,,,,,,,
SET CARDPLG PERF 4:1 W/ HEAT EXCHG W/ RIDGE BUB TRAP FLTR,SUP-2384917,CDM,C1713,HCPCS,0278,RC,,,,both,,,333.63,216.86,,,,,,,,,,,,,
BIT DRILL 18/4X24 MM J LATCH COUPLING STOP NON STERILE MATRI,SUP-2837607,CDM,2720000010,LOCAL,0272,RC,,,,both,,,819.85,532.90,,,,,,,,,,,,,
SUPPORT ORTHOT FT METATRSL ARCH ATTCH TO SHOE LONGITUDINAL,SUP-2435709,CDM,L3090,HCPCS,0274,RC,,,,both,,,115.24,74.91,,,,,,,,,,,,,
GRAFT BIO TISS RECON FIRM CRUC INCIS STRATTICE PORCINE IMP,SUP-2113359,CDM,Q4116,HCPCS,0636,RC,,,,both,,,3271.88,2126.72,,,,,,,,,,,,,
SPLINT WRST AND THMB BLK FOAM XS 8 IN R,SUP-2336034,CDM,L3809,HCPCS,0274,RC,,,,both,,,21.35,13.88,,,,,,,,,,,,,
KIT MULT LUMN CTRL VEN,SUP-2120609,CDM,C1751,HCPCS,0278,RC,,,,both,,,403.80,262.47,,,,,,,,,,,,,
GUIDEWIRE VASC L600MM DIA3.2MM FOR IMPL NAIL PANTA 2,SUP-2244338,CDM,C1769,HCPCS,0272,RC,,,,both,,,687.19,446.67,,,,,,,,,,,,,
STRAP CLAV M HVY DUTY BCKL CLSR,SUP-2194646,CDM,L3650,HCPCS,0272,RC,,,,both,,,18.12,11.78,,,,,,,,,,,,,
PLATE BNE CRV 4.5X439 MM RT CNDYL 22 HOLE VA LCK COMPR SS,SUP-2177872,CDM,C1713,HCPCS,0278,RC,,,,both,,,8967.27,5828.73,,,,,,,,,,,,,
PLATE BNE BAR L8MM THK1MM 4 H L CRANIOMAXILLOFACIAL TI MINI,SUP-2366320,CDM,C1713,HCPCS,0278,RC,,,,both,,,638.99,415.34,,,,,,,,,,,,,
CANNULA UTER KAHN TRIG L7 3/8IN 2 FLX,SUP-2160514,CDM,C1713,HCPCS,0278,RC,,,,both,,,1622.31,1054.50,,,,,,,,,,,,,
BOOT CAST OPN TOE 2XS 5.5X3 IN OPN HEEL PROCARE,SUP-2196779,CDM,L4387,HCPCS,0274,RC,,,,both,,,15.42,10.02,,,,,,,,,,,,,
ROD SPNL 4.5X500 MM SS SHILLA,SUP-2630594,CDM,C1713,HCPCS,0278,RC,,,,both,,,2147.76,1396.04,,,,,,,,,,,,,
BOUGIE SURG 40FR TIP L13MM BLU SIL TAPR MLNY TIP ULT FLX,SUP-2277361,CDM,2720000010,LOCAL,0272,RC,,,,both,,,869.78,565.36,,,,,,,,,,,,,
GRAFT BNE CHIP FRZ DRY CANC CORT 1MM 8MM RANG 10CC READIGRFT,SUP-2264692,CDM,C1713,HCPCS,0278,RC,,,,both,,,366.03,237.92,,,,,,,,,,,,,
ISOSORBIDE MONONITRATE ER 30 MG PO TB24,RX-24521,CDM,6370000000,HCPCS,0637,RC,00904-6449-61,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
DEFIBRILLATOR IMPL LUMOS DR-T W 67 X H 55 MM D 12 MM 32 CC,SUP-2138067,CDM,C1721,HCPCS,0275,RC,,,,both,,,47100.00,30615.00,,,,,,,,,,,,,
LP PLATE L SH RT LNG EXTENDED BAYS STY,SUP-2676715,CDM,C1713,HCPCS,0278,RC,,,,both,,,410.84,267.05,,,,,,,,,,,,,
PLATE SPNL L68MM STD ANTR CERV TI LEV 4 FIX LCK MAXAN,SUP-2205443,CDM,C1713,HCPCS,0278,RC,,,,both,,,2590.50,1683.82,,,,,,,,,,,,,
KIT SHUNT T TB CSF CATH RESVR SYR PERI EDWARDS-BARBARO,SUP-2308211,CDM,C1713,HCPCS,0278,RC,,,,both,,,2855.55,1856.11,,,,,,,,,,,,,
DEVICE MICRO COR KNOT PRELOADED,SUP-2752112,CDM,C1889,HCPCS,0278,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
CETUXIMAB 100 MG/50ML IV SOLN,RX-37989,CDM,J9055,HCPCS,0636,RC,66733-0948-23,NDC,,both,50,ML,2409.20,1565.98,,,,,,,,,,,,,
CLIP EXT FIX DYNAMIZATION FOR LG COMBINATION CLMP,SUP-2188497,CDM,2720000010,LOCAL,0272,RC,,,,both,,,434.32,282.31,,,,,,,,,,,,,
GRAFT FRZ DRY ALLGRFT 100-150CM2,SUP-2165570,CDM,C1713,HCPCS,0278,RC,,,,both,,,1444.40,938.86,,,,,,,,,,,,,
KIT BNE FIX STPL BRIDGE L 20 X 20 MM ULTRA NIT ANK FT ULTRA,SUP-2896847,CDM,C1713,HCPCS,0278,RC,,,,both,,,5648.86,3671.76,,,,,,,,,,,,,
GUIDEWIRE VASC L 260 CM DIA 0.035 IN TAPR L 6 CM FLX TIP L,SUP-2167608,CDM,C1769,HCPCS,0272,RC,,,,both,,,57.52,37.39,,,,,,,,,,,,,
INVISION  TIBIAL TRAY TRIAL SZ 3 4MM,SUP-2469798,CDM,C1776,CPT,0278,RC,,,,both,,,1557.44,1012.34,,,,,,,,,,,,,
DOBUTAMINE-DEXTROSE 1-5 MG/ML-% IV SOLN,RX-15981,CDM,J1250,HCPCS,0636,RC,00409-2346-32,NDC,,both,250,ML,126.50,82.22,,,,,,,,,,,,,
PLATE BNE SS NS LCP,SUP-2178460,CDM,C1713,HCPCS,0278,RC,,,,both,,,1543.69,1003.40,,,,,,,,,,,,,
BURR SURG 2.1MM DIA HD 5MML HD CARBIDE TAPR FISS MICROPOWER,SUP-2605539,CDM,2720000010,LOCAL,0272,RC,,,,both,,,114.20,74.23,,,,,,,,,,,,,
SCREW BNE L65MM DIA7.3MM PROX FEM S STL SELF DRL ST CONIC,SUP-2184760,CDM,C1713,HCPCS,0278,RC,,,,both,,,768.73,499.67,,,,,,,,,,,,,
BB-TAK MTP THREADED,SUP-2811921,CDM,C1713,HCPCS,0278,RC,,,,both,,,266.90,173.48,,,,,,,,,,,,,
BUR DENT 1.8 MM CARBIDE BRN STRL OSSEO STAP,SUP-2134835,CDM,C1713,HCPCS,0278,RC,,,,both,,,675.10,438.81,,,,,,,,,,,,,
CATHETER DRAINAGE VLV 5 FRX15 CM 51 IN SPIN-LOCK ACCEL,SUP-2659276,CDM,C1729,HCPCS,0272,RC,,,,both,,,136.72,88.87,,,,,,,,,,,,,
COIL NEUROVASCULAR HYDROFRAME 18 L 19 CM LOOP DIA 6 MM,SUP-2305269,CDM,C1889,HCPCS,0278,RC,,,,both,,,8540.80,5551.52,,,,,,,,,,,,,
COMPONENT HUM SHOULDERXLPE CONSTRUCT COMPHSVE,SUP-2408804,CDM,C1776,CPT,0278,RC,,,,both,,,25905.00,16838.25,,,,,,,,,,,,,
HC Pt Estim-Manual Each 15 Min,PX-4209703200,CDM,97032,CPT,0420,RC,,,,inpatient,,,206.00,133.90,,,,,,,,,,,,,
HC Assay of Urea Nitrogen Urine,PX-3018454000,CDM,84540,CPT,0301,RC,,,,outpatient,,,194.00,126.10,,,,,,,,,,,,,
TUBE SUCTION BARON 3.3 MMX19 CM,SUP-2473711,CDM,2720000010,LOCAL,0272,RC,,,,both,,,809.27,526.03,,,,,,,,,,,,,
ALLOGRAFT BNE FEM HD 4.7 CM FRZN W/O CART,SUP-2717884,CDM,C1762,CPT,0278,RC,,,,both,,,5667.20,3683.68,,,,,,,,,,,,,
SYSTEM INT FIX PEEK PELV APPL ANCHR PP SUT F,SUP-2308302,CDM,C1713,HCPCS,0278,RC,,,,both,,,1523.31,990.15,,,,,,,,,,,,,
FIBER LASER SLIMLINE SIS 365,SUP-2525910,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1409.20,915.98,,,,,,,,,,,,,
VALVE HYDROCEPHALUS 15 PED W/ SHUNT ASST AND BUR H RESVR,SUP-2108748,CDM,C1729,HCPCS,0272,RC,,,,both,,,7918.42,5146.97,,,,,,,,,,,,,
GRAFT DERMAL ANTIMICROBIAL 4.91X4.91 CM 24.1 SC PURAPLYAM XT,SUP-2866270,CDM,Q4197,HCPCS,0636,RC,,,,both,,,8870.50,5765.82,,,,,,,,,,,,,
GRAFT HUM TISS W2XL2CM CRYOPRESERVED AMNIO MEM LO PROF FOR,SUP-2116284,CDM,Q4148,HCPCS,0636,RC,,,,both,,,1868.30,1214.39,,,,,,,,,,,,,
STEM RADIAL SM ELBW SIG NOTCH,SUP-2478595,CDM,C1776,CPT,0278,RC,,,,both,,,5416.50,3520.72,,,,,,,,,,,,,
CANNULA SUCTION 2 MMX23 CM INSUL MONOPOLAR LARYNGEAL,SUP-2775025,CDM,2720000010,LOCAL,0272,RC,,,,both,,,512.92,333.40,,,,,,,,,,,,,
INSERT TIB THK 17 MM SZ 3 POLYETHYL LT ANK FIX XT REV STRL,SUP-2932764,CDM,C1776,CPT,0278,RC,,,,both,,,8271.07,5376.20,,,,,,,,,,,,,
KIT ART CATH INTEGR 1 3 4IN LF,SUP-2384037,CDM,C1894,HCPCS,0272,RC,,,,both,,,105.50,68.57,,,,,,,,,,,,,
CEMIPLIMAB-RWLC 350 MG/7ML IV SOLN,RX-143863,CDM,J9119,HCPCS,0636,RC,61755-0008-01,NDC,,both,7,ML,31463.90,20451.53,,,,,,,,,,,,,
MESH SURG L55MM W55MM OD5MM DELT LP,SUP-2364976,CDM,C1781,HCPCS,0278,RC,,,,both,,,8248.78,5361.71,,,,,,,,,,,,,
HC Blood Occult Peroxidase Actv Qual Feces 1 Deter,PX-3018227000,CDM,82270,CPT,0301,RC,,,,both,,,87.00,56.55,,,,,,,,,,,,,
SCREW BNE SHT THRD 9 MM,SUP-2315914,CDM,C1713,HCPCS,0278,RC,,,,both,,,920.02,598.01,,,,,,,,,,,,,
CATHETER SET SALIVARY DUCT 0.014 IN 20 MMX2 CM ADV,SUP-2422285,CDM,C1726,HCPCS,0272,RC,,,,both,,,1381.60,898.04,,,,,,,,,,,,,
CATHETER ANGIO ZOOM L 143 CM DIA 6 FR DSTL OD 5 FR PROX ID,SUP-2913641,CDM,C1887,HCPCS,0272,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
CLIP ANEUR BAYNT FEN L TYP SUGITA,SUP-2305999,CDM,C1889,HCPCS,0278,RC,,,,both,,,361.10,234.71,,,,,,,,,,,,,
PIN EXT FIX SELF TAPPING 5X300 MM THRD TRANSFIX,SUP-2362754,CDM,C1713,HCPCS,0278,RC,,,,both,,,266.90,173.48,,,,,,,,,,,,,
STEM FEM L150MM DIA13MM KNEE CO CHROME BOW CEM MOD M TAPR,SUP-2252630,CDM,C1776,CPT,0278,RC,,,,both,,,10386.96,6751.52,,,,,,,,,,,,,
HC Rep Lac Smp Not Face <2.5cm,PX-4501200100,CDM,12001,CPT,0450,RC,,,,outpatient,,,421.00,273.65,,,,,,,,,,,,,
KNEE TOTAL PERSONA ZIMMER BIOMET,SUP-2909906,CDM,C1776,CPT,0278,RC,,,,both,,,11461.00,7449.65,,,,,,,,,,,,,
COMPONENT PATELLAR DOMED 35 MM KNEE W/ CENTER PEG,SUP-2253967,CDM,C1776,CPT,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
SUTURE NOVAFIL SZ 0 L18IN NONABSORBABLE BLU HSG-22 L27MM 8886446063,SUP-2174602,CDM,C1713,HCPCS,0278,RC,,,,both,,,239.30,155.54,,,,,,,,,,,,,
CATHETER INFUS L135CM OD1.8FR .014IN RADPQ GLD MRK BND DSTL,SUP-2327205,CDM,C1887,HCPCS,0272,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
LINER ACET OD56MM ID32MM +4MM OFFSET HIP GVF POLYETH TI NEUT,SUP-2250251,CDM,C1776,CPT,0278,RC,,,,both,,,10561.70,6865.10,,,,,,,,,,,,,
ROD SPNL S STL OD45 MM X L200 MM SAG,SUP-2279841,CDM,C1713,HCPCS,0278,RC,,,,both,,,2361.28,1534.83,,,,,,,,,,,,,
SCREW SET CANN 3.5 MM,SUP-2183052,CDM,C1713,HCPCS,0278,RC,,,,both,,,41626.10,27056.96,,,,,,,,,,,,,
HC Dx Bone Marrow Bx & Aspir,PX-5103822200,CDM,38222,CPT,0510,RC,,,,both,,,8633.00,5611.45,,,,,,,,,,,,,
HEAD HUM OD22.2MM +4MM SHLDR BPLR INNR IMP FOR SHLDR,SUP-2404518,CDM,C1776,CPT,0278,RC,,,,both,,,5146.46,3345.20,,,,,,,,,,,,,
GUIDEWIRE VASC STR 0.035 INX50 CM STD FIX COR TAPR PTFE SS,SUP-2167661,CDM,C1769,HCPCS,0272,RC,,,,both,,,27.10,17.61,,,,,,,,,,,,,
GRAFT HUM TISS W5XL12CM THCK ALLDERM,SUP-2113078,CDM,Q4116,HCPCS,0636,RC,,,,both,,,5793.30,3765.64,,,,,,,,,,,,,
SCREW BNE L16MM DIA45MM PUR CANN GUID GROWTH EIGHT PLATE,SUP-2316384,CDM,C1713,HCPCS,0278,RC,,,,both,,,502.90,326.88,,,,,,,,,,,,,
GRAFT BNE SUB 10CC B TRICALCIUM PHSPTE VERSATILE ULT POR,SUP-2370374,CDM,C1713,HCPCS,0278,RC,,,,both,,,9127.98,5933.19,,,,,,,,,,,,,
GRAFT BIO TISS W3.9XL5.9IN PORCINE DERM RIFAMPIN,SUP-2125835,CDM,C1781,HCPCS,0278,RC,,,,both,,,11256.90,7316.98,,,,,,,,,,,,,
STAPLE BNE FIX W11XH10-10MM WIRE W1.5XL1.5MM SMOOTH OSSTPL,SUP-2194214,CDM,C1713,HCPCS,0278,RC,,,,both,,,1051.90,683.73,,,,,,,,,,,,,
HC So Pretx Serum RBC Antibody Incubation Drugs Each,PX-3028697566,CDM,86975,CPT,0302,RC,,,,both,,,204.00,132.60,,,,,,,,,,,,,
DRILL SURG ANGLED INDEPENDENCE,SUP-2598869,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
PLATE BONE L31MM 100DEG 3X4 H LT CRANIOMAXILLOFACIAL TI L,SUP-2191287,CDM,C1713,HCPCS,0278,RC,,,,both,,,936.35,608.63,,,,,,,,,,,,,
TRIAL PAT OD29MM ULTEM NXGN,SUP-2201312,CDM,C1776,CPT,0278,RC,,,,both,,,81.64,53.07,,,,,,,,,,,,,
TROCAR ENDO BLADELESS 2/3MM 65MM NON-OPTI W/ SMOOTH SLV,SUP-2855493,CDM,2720000010,LOCAL,0272,RC,,,,both,,,521.05,338.68,,,,,,,,,,,,,
NAIL COMPR L200MM DIA12MM ANK TI CANN,SUP-2316335,CDM,C1713,HCPCS,0278,RC,,,,both,,,8343.61,5423.35,,,,,,,,,,,,,
GRAFT BIO TISS W6XL6CM FEN FET BOV ACELLULAR DERM MTRX,SUP-2243694,CDM,Q4110,HCPCS,0636,RC,,,,both,,,4239.00,2755.35,,,,,,,,,,,,,
RAIL EXT FIX STR 5.5X500 MM 4D TI,SUP-2517545,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5770.32,3750.71,,,,,,,,,,,,,
TUBE DYNAMIZATION DISTRACTION,SUP-2494737,CDM,2720000010,LOCAL,0272,RC,,,,both,,,9310.73,6051.97,,,,,,,,,,,,,
WASHER BNE ANK MED MALL SLED,SUP-2389601,CDM,C1713,HCPCS,0278,RC,,,,both,,,486.70,316.35,,,,,,,,,,,,,
BURR ARTHSCP AGGRSSVE 5.5MM DIA 120MML BONE BRRL DARK GRAY P,SUP-2574098,CDM,2720000010,LOCAL,0272,RC,,,,both,,,136.46,88.70,,,,,,,,,,,,,
MODIFIED CLLR BTTN VENT TUBE 127MM ID PC SLCNE 30 PACK,SUP-2680284,CDM,L8699,HCPCS,0278,RC,,,,both,,,34.79,22.61,,,,,,,,,,,,,
SUPPORT PROSTHETIC JT KNEE TORSION CTRL STRL,SUP-2388181,CDM,L2380,HCPCS,0272,RC,,,,both,,,303.73,197.42,,,,,,,,,,,,,
VALVE ANGIO HEMSTAS TORQ DEV GWIRE INTRO TUOHY BORST HONOR,SUP-2303049,CDM,C1713,HCPCS,0278,RC,,,,both,,,62.64,40.72,,,,,,,,,,,,,
CATHETER ETER HAD STD KT 145FRX42CM GLIDEPATH,SUP-2126476,CDM,C1881,HCPCS,0278,RC,,,,both,,,1309.38,851.10,,,,,,,,,,,,,
GRANULES BONE GRAFT OSTEOSOURCE 1-4MM ALLOGRAFT 30ML,SUP-2137586,CDM,C1734,HCPCS,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
DRILL REAMER COMBINATION,SUP-2475333,CDM,C1713,HCPCS,0278,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
GRAFT BNE FEN 15X100 MM DEMINERALIZED CORTICAL FENFLEX,SUP-2742006,CDM,C1713,HCPCS,0278,RC,,,,both,,,3151.78,2048.66,,,,,,,,,,,,,
GRAFT HUMAN TSSUE FIRM 16X10 CM RCNSTRCTVE TSSUE MTRX STRTTC,SUP-2483681,CDM,Q4130,HCPCS,0636,RC,,,,both,,,15844.44,10298.89,,,,,,,,,,,,,
CATHETERIZATION KIT 7 FRX30 CM CV 3L NDL HOWES,SUP-2120584,CDM,C1894,HCPCS,0272,RC,,,,both,,,206.61,134.30,,,,,,,,,,,,,
HC Trach Change,PX-7613150200,CDM,31502,CPT,0761,RC,,,,outpatient,,,694.00,451.10,,,,,,,,,,,,,
CATHETER DRNGE 20FR L40CM 0.038IN L BOR 6 SIDEPRT FLX RIG,SUP-2168762,CDM,C1729,HCPCS,0272,RC,,,,both,,,269.51,175.18,,,,,,,,,,,,,
SCREW BNE L20MM DIA6.5MM CTRL FOR REV SHLDR SYS COMPHSVE,SUP-2404735,CDM,C1713,HCPCS,0278,RC,,,,both,,,405.06,263.29,,,,,,,,,,,,,
CAGE SPNL 3D 10 DEG 40X18X10 MM LAT WAVEFORM L,SUP-2711319,CDM,C1889,HCPCS,0278,RC,,,,both,,,11461.00,7449.65,,,,,,,,,,,,,
FIBER LASER 200 MH SHTH SCP SAFE FLEXG STRL CALCULASE DISP,SUP-2778002,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1186.70,771.35,,,,,,,,,,,,,
RING EXT FIX DIA140 MM 5/6 TAB NS DISP MONK RING,SUP-2881098,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3272.67,2127.24,,,,,,,,,,,,,
SHEATH INTRO HEARTSPAN 150 DEG L 63 CM DIA 8.5 FR NDL L 71,SUP-2701795,CDM,C1893,HCPCS,0272,RC,,,,both,,,494.55,321.46,,,,,,,,,,,,,
"HC Gbl Est Pt, E/M Level 3",PX-9829921300,CDM,99213,CPT,0982,RC,,,,outpatient,,,393.00,255.45,,,,,,,,,,,,,
ECULIZUMAB 300 MG/30ML IV SOLN|DISCARDED DRUG NOT ADMINISTE,RX-81696,CDM,J1299,HCPCS,0636,RC,25682-0001-01,NDC,JW,both,30,ML,19242.90,12507.88,,,,,,,,,,,,,
SPHINCTEROTOME ENDSCPC 45FR DIA DST TIP 15MML TIP 20MML CUT,SUP-2707127,CDM,2720000010,LOCAL,0272,RC,,,,both,,,581.69,378.10,,,,,,,,,,,,,
DISTRACTION INTRNL DIST ALVLR TRACK 1.0 END DRV 1.0 1.2 MM S,SUP-2488046,CDM,C1713,HCPCS,0278,RC,,,,both,,,2807.76,1825.04,,,,,,,,,,,,,
CATHETER KT CTRL VEN PWR INJ 4 LUMN 8.5FRX8IN 20CM,SUP-2120604,CDM,C1751,HCPCS,0278,RC,,,,both,,,244.92,159.20,,,,,,,,,,,,,
ALLOGRAFT BNE BLOCK 40X12X5 MM 2.4 CC PRO OSTEON 500R,SUP-2684311,CDM,C1713,HCPCS,0278,RC,,,,both,,,1975.06,1283.79,,,,,,,,,,,,,
INSERT TIB SULCUS 4+ 16 MM LT RT TOT ANK POLYETH INBONE II,SUP-2850358,CDM,C1776,CPT,0278,RC,,,,both,,,5221.82,3394.18,,,,,,,,,,,,,
CATHETER THORACIC 20FR L20IN SILICONE 5 EYELET STRAIGHT SOFT,SUP-2825067,CDM,C1729,HCPCS,0272,RC,,,,both,,,34.54,22.45,,,,,,,,,,,,,
ENDOSCOPE RIGID STRL,SUP-2225633,CDM,2720000010,LOCAL,0272,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
SCREW BNE THMB NS REUSE,SUP-2489723,CDM,C1713,HCPCS,0278,RC,,,,both,,,464.72,302.07,,,,,,,,,,,,,
IMPLANT ORBIT SM W32XH13XL35MM THK1.2MM LT 3D FLR W/,SUP-2365169,CDM,C1713,HCPCS,0278,RC,,,,both,,,7488.90,4867.78,,,,,,,,,,,,,
STEM FEM L50MM DIA14MM KNEE CEM REV ATTUNE,SUP-2251474,CDM,C1776,CPT,0278,RC,,,,both,,,2380.12,1547.08,,,,,,,,,,,,,
BASEPLATE TIB SZ 5 THK10MM UNIV KNEE POLYETH NP CRUCE RET,SUP-2253589,CDM,C1776,CPT,0278,RC,,,,both,,,4082.00,2653.30,,,,,,,,,,,,,
PLATE BONE W10XL70MM THK2.8MM 6 H S STL STR NONCOMPRESSION,SUP-2343763,CDM,C1713,HCPCS,0278,RC,,,,both,,,3441.75,2237.14,,,,,,,,,,,,,
SCREW BONE L52MM DIA4.9MM NONSTERILE CORT S STL,SUP-2186392,CDM,C1713,HCPCS,0278,RC,,,,both,,,535.43,348.03,,,,,,,,,,,,,
SCREW BNE L14MM DOA2.7MM NONLOCKING FOR TUFFNEK TECHNOLOGY,SUP-2321176,CDM,C1713,HCPCS,0278,RC,,,,both,,,626.43,407.18,,,,,,,,,,,,,
BUR SURG DIA 6 MM HUB I DIAMOND STRL REUSE HI-LINE,SUP-2929280,CDM,2720000010,LOCAL,0272,RC,,,,both,,,406.38,264.15,,,,,,,,,,,,,
PLATE BNE 3.5X288 MM 22 HOLE SS LC-DCP,SUP-2569240,CDM,C1713,HCPCS,0278,RC,,,,both,,,481.83,313.19,,,,,,,,,,,,,
SPHERE GLEN DIA38MM REG STD SHLDR CO CHROM LOK SCR PRI REV,SUP-2223371,CDM,C1776,CPT,0278,RC,,,,both,,,4266.63,2773.31,,,,,,,,,,,,,
IMPLANT MANDIBULAR SZ 50 MM TI ALLOY LT TEMPOROMANDIBULAR JT,SUP-2934178,CDM,C1713,HCPCS,0278,RC,,,,both,,,20639.22,13415.49,,,,,,,,,,,,,
MARKER SURG FIDUCIAL 2X3X1 CM SPACER CLP SFT TISS BIOZORB,SUP-2716283,CDM,A4648,CPT,0278,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
SHELL ACET PRESSFIT REV 54 MM OD UNIV CLUS H FLR PLSM SPRY,SUP-2359356,CDM,C1776,CPT,0278,RC,,,,both,,,4728.84,3073.75,,,,,,,,,,,,,
GRAFT VASC SZ 26 MM SPEC SINGLE BRANCH,SUP-2535441,CDM,C1768,CPT,0278,RC,,,,both,,,5553.12,3609.53,,,,,,,,,,,,,
GRAFT HUM TISS FN PARTICULATE 200 MG MICRONIZED MICROMATRIX,SUP-2106477,CDM,Q4118,HCPCS,0636,RC,,,,both,,,2191.72,1424.62,,,,,,,,,,,,,
CATHETER GUID OD7FR ID5.4FR L40CM C315,SUP-2282340,CDM,C1894,HCPCS,0272,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
PLATE BNE L 44 X W 10.2 MM THK 2.8 MM SCREW DIA 3.5 MM 4 H 72440604N,SUP-2932879,CDM,C1713,HCPCS,0278,RC,,,,both,,,1837.03,1194.07,,,,,,,,,,,,,
ANCHOR SUT W/ ORTHOCORD SZ 3-0 L18IN COMP BRAID V-4 L5MM,SUP-2249375,CDM,C1713,HCPCS,0278,RC,,,,both,,,3055.22,1985.89,,,,,,,,,,,,,
CATHETER HD CATH ON OFF,SUP-2263924,CDM,C1752,HCPCS,0278,RC,,,,both,,,8.35,5.43,,,,,,,,,,,,,
NAIL IM L32CM DIA10MM 2MM POST BOW LNG RT HINDFOOT FUS,SUP-2340957,CDM,C1713,HCPCS,0278,RC,,,,both,,,12585.59,8180.63,,,,,,,,,,,,,
SCREW BONE SLD SH THRD BLNT TIP PRECIS JMF 5.5MMX56MM,SUP-2321008,CDM,C1713,HCPCS,0278,RC,,,,both,,,2582.65,1678.72,,,,,,,,,,,,,
PLATE BNE SZ 2.6 MM TI MANDIBULAR HEMI NS DISP ACCUPLATE,SUP-2934735,CDM,C1713,HCPCS,0278,RC,,,,both,,,52004.68,33803.04,,,,,,,,,,,,,
CLAMP EXT FIX L25MM RED TB TO TB FOR MONOTB TRIAX SYS,SUP-2372626,CDM,C1713,HCPCS,0278,RC,,,,both,,,3149.73,2047.32,,,,,,,,,,,,,
ENFORTUMAB VEDOTIN-EJFV 20 MG IV SOLR,RX-148580,CDM,J9177,HCPCS,0636,RC,51144-0020-01,NDC,,both,1,UN,8090.00,5258.50,,,,,,,,,,,,,
BIT DRL TWST 1.9X115 MM 9 MM W/ STP NOTCH LEVEL 1 DISP,SUP-2470020,CDM,2720000010,LOCAL,0272,RC,,,,both,,,511.38,332.40,,,,,,,,,,,,,
HC So Hemochromatosis Gene Analysis,PX-3108125666,CDM,81256,CPT,0310,RC,,,,both,,,349.00,226.85,,,,,,,,,,,,,
ZINC SULFATE 220 (50 ZN) MG PO CAPS,RX-8880,CDM,6370000000,HCPCS,0637,RC,77333-0983-25,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
CARFILZOMIB 30 MG IV SOLR,RX-134235,CDM,J9047,HCPCS,0636,RC,76075-0102-01,NDC,,both,1,UN,5093.60,3310.84,,,,,,,,,,,,,
GUIDEWIRE VASC PULSE SPRY L 109 CM DIA 0.035 IN FLPY TIP L 2,SUP-2118468,CDM,C1757,HCPCS,0272,RC,,,,both,,,241.15,156.75,,,,,,,,,,,,,
INSERT SHOE PART FT,SUP-2388200,CDM,L5000,HCPCS,0274,RC,,,,both,,,1465.03,952.27,,,,,,,,,,,,,
GUIDEWIRE VASC XCELA L 70 CM DIA 0.018 IN NIT TUNGSTEN,SUP-2118820,CDM,C1769,HCPCS,0272,RC,,,,both,,,227.56,147.91,,,,,,,,,,,,,
SCREW SPNL 2PK SD 4X11 MM FIX ANGLE STRL ATLNTS ESSENTIALS,SUP-2632022,CDM,C1713,HCPCS,0278,RC,,,,both,,,722.20,469.43,,,,,,,,,,,,,
ROD SPNL L300MM DIA5.5MM STR MULT ANG PERC SNIPER,SUP-2354878,CDM,C1713,HCPCS,0278,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
BLADE ARTHRO OD4.5MM ENDOSCP SHV BOXED INCIS CUT AGG + STR,SUP-2351476,CDM,2720000010,LOCAL,0272,RC,,,,both,,,172.70,112.25,,,,,,,,,,,,,
POST EXT FIX ANK FT 4 H FOR TRUELOK FRME ASSEMB HEXAPOD SYS,SUP-2316132,CDM,2720000010,LOCAL,0272,RC,,,,both,,,509.50,331.17,,,,,,,,,,,,,
DEXTROSE 10 % IV BOLUS,RX-4081995,CDM,2580000003,HCPCS,0250,RC,00338-0023-03,NDC,,both,125,ML,12.80,8.32,,,,,,,,,,,,,
CATHETER INFUSION 5 FRX90 CM 5 CM OCCL WIRE FOUNTAIN,SUP-2302779,CDM,C1751,HCPCS,0278,RC,,,,both,,,262.82,170.83,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY SPC 3 MM ATRAUM FIX COURNAND CRV,SUP-2641813,CDM,C1730,HCPCS,0272,RC,,,,both,,,3088.66,2007.63,,,,,,,,,,,,,
APPLIER INT CLP MULT FIRE SM MED 5X205 MM CHALLENGER REUSE,SUP-2852445,CDM,C1889,HCPCS,0278,RC,,,,both,,,9270.10,6025.56,,,,,,,,,,,,,
HC Thoracic Fascial Plane Block Bi Injection,PX-3606446800,CDM,64468,CPT,0360,RC,,,,both,,,1238.00,804.70,,,,,,,,,,,,,
HC Antibody Varicella-Zoster,PX-3028678700,CDM,86787,CPT,0302,RC,,,,both,,,139.00,90.35,,,,,,,,,,,,,
HC Portogram W/O Hemo S&I,PX-3207588700,CDM,75887,CPT,0320,RC,,,,both,,,7130.00,4634.50,,,,,,,,,,,,,
INTRAAORTIC PUMP KIT 7.5 FR 30/40 CC INSRTN SHTH MEGA,SUP-2534220,CDM,C1894,HCPCS,0272,RC,,,,both,,,388.83,252.74,,,,,,,,,,,,,
STEM FEM 13 155 MM HIP POROUS SYNERGY,SUP-2344408,CDM,C1776,CPT,0278,RC,,,,both,,,5966.00,3877.90,,,,,,,,,,,,,
PERI-LOC 2.5MM T7 LOCK SCREW 30MM S-T,SUP-2820439,CDM,C1713,HCPCS,0278,RC,,,,both,,,965.52,627.59,,,,,,,,,,,,,
PHENYTOIN SODIUM 50 MG/ML IJ SOLN,RX-6256,CDM,J1165,HCPCS,0636,RC,00641-0493-21,NDC,,both,2,ML,54.10,35.16,,,,,,,,,,,,,
SHEATH GUID SUBLIME L 150 CM 5 FR 2.3 MM ID 1.9 MM 0.035 IN,SUP-2913951,CDM,C1894,HCPCS,0272,RC,,,,both,,,973.40,632.71,,,,,,,,,,,,,
ISOSULFAN BLUE 1 % SC SOLN,RX-10358,CDM,Q9968,HCPCS,0636,RC,67457-0220-05,NDC,,both,0.5,ML,698.20,453.83,,,,,,,,,,,,,
SCREW INTRF CANN 7X40 MM 2 MM BLNT THREADS ENLARGED HD RCI,SUP-2877906,CDM,C1713,HCPCS,0278,RC,,,,both,,,511.04,332.18,,,,,,,,,,,,,
VALVE PROGRAMMABLE INLINE SM W/ SIPHONGUARD DEV CERTAS +,SUP-2558675,CDM,C1889,HCPCS,0278,RC,,,,both,,,13375.90,8694.33,,,,,,,,,,,,,
TISSUE BIO MATRIDERM 10.5 X 14.8CM 1MM MED,SUP-2866498,CDM,A2027,HCPCS,0636,RC,,,,both,,,15793.23,10265.60,,,,,,,,,,,,,
ALLOGRAFT BNE WDG SM 18-25X9X7-14 MM FD IRRADIATED IL CREST,SUP-2866876,CDM,C1762,CPT,0278,RC,,,,both,,,1930.00,1254.50,,,,,,,,,,,,,
BIT DRL DIA3.8MM TIM CANN DISP,SUP-2412627,CDM,2720000010,LOCAL,0272,RC,,,,both,,,948.28,616.38,,,,,,,,,,,,,
PIN FIXATION DISPOSABLE SM FRAGMENT PLATING SYSTEM L26MM,SUP-2462661,CDM,2720000010,LOCAL,0272,RC,,,,both,,,414.48,269.41,,,,,,,,,,,,,
GRAFT BNE SUB 15ML TRICALCIUM PHSPTE GRAN CONT RESRB,SUP-2255616,CDM,C1713,HCPCS,0278,RC,,,,both,,,2515.14,1634.84,,,,,,,,,,,,,
BEAM FIX 4.5X140 MM,SUP-2422262,CDM,C1713,HCPCS,0278,RC,,,,both,,,3768.00,2449.20,,,,,,,,,,,,,
PADDLE NEUROSTIMULATOR SPNL CRD BLNK WIDE FOR COVEREDGE X,SUP-2138811,CDM,C1778,HCPCS,0278,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
COLLAR PREMIER PRO UNIV ADJ CLS CELL FOAM LNR L TRACH OPN,SUP-2336009,CDM,L0140,HCPCS,0274,RC,,,,both,,,14.32,9.31,,,,,,,,,,,,,
SCREW INTFR L35MM DIA9MM KNEE PLLA CANN ABSRB RND HD,SUP-2249523,CDM,C1713,HCPCS,0278,RC,,,,both,,,675.10,438.81,,,,,,,,,,,,,
DRILL SURG CANN SM 5 MM HUDSON,SUP-2766114,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1774.10,1153.16,,,,,,,,,,,,,
DEVICE TORQ WIRE GUID HYDROSTEER,SUP-2357057,CDM,C1894,HCPCS,0272,RC,,,,both,,,15.70,10.20,,,,,,,,,,,,,
NAIL IM L34.5CM OD11MM TIB CANN LCK DELT RUSS TAY,SUP-2342521,CDM,C1713,HCPCS,0278,RC,,,,both,,,961.75,625.14,,,,,,,,,,,,,
PERI SCR 40MMX10MM,SUP-2720896,CDM,C1713,HCPCS,0278,RC,,,,both,,,155.24,100.91,,,,,,,,,,,,,
DILATOR ENDOSCP THRD 6.5 MM SUTURE ANCHR STRL TWINFIX AB LTX,SUP-2879125,CDM,2720000010,LOCAL,0272,RC,,,,both,,,461.58,300.03,,,,,,,,,,,,,
ALLOGRAFT BNE CRYOPRESERVED LT CLAV,SUP-2740853,CDM,C1762,CPT,0278,RC,,,,both,,,15105.91,9818.84,,,,,,,,,,,,,
TILENE GRD LT 20CMX14 3PK,SUP-2402563,CDM,C1781,HCPCS,0278,RC,,,,both,,,1579.42,1026.62,,,,,,,,,,,,,
SCREW BONE FINE PITCH 2X4 MM MANDIBULAR SELFTAPPING 5/PK TIT,SUP-2842316,CDM,C1713,HCPCS,0278,RC,,,,both,,,232.55,151.16,,,,,,,,,,,,,
HC Nras/Kras Gene Analys,PX-3000111066,CDM,0111U,CPT,0300,RC,,,,both,,,797.00,518.05,,,,,,,,,,,,,
KIT POS BEACH CHAIR DISP ADAPTABLE,SUP-2908606,CDM,2720000010,LOCAL,0272,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
HC Replace of Peg Tube Flu Guid,PX-4504945000,CDM,49450,CPT,0450,RC,,,,both,,,1056.00,686.40,,,,,,,,,,,,,
SPACER SPNL W35XH27MM THICKNESS 14MM TI ANT THORLUM FUS,SUP-2244711,CDM,C1713,HCPCS,0278,RC,,,,both,,,5495.00,3571.75,,,,,,,,,,,,,
BIT DRILL L305MM DIA25MM QUICK CONNECTOR CALIBRATOR,SUP-2468551,CDM,2720000010,LOCAL,0272,RC,,,,both,,,507.14,329.64,,,,,,,,,,,,,
SUPPORT ORTHOT ANK KNEE CUST DBL SLD STIRRUP BND,SUP-2435634,CDM,L2020,HCPCS,0272,RC,,,,both,,,3119.94,2027.96,,,,,,,,,,,,,
GRAFT EVAR L14CM AORT DIA23MM IL DIA12MM INFRARENAL TRUNK,SUP-2396039,CDM,C1768,CPT,0278,RC,,,,both,,,32342.00,21022.30,,,,,,,,,,,,,
SET PNEUMOTHOR CATHETER 63FR L20CM NDL 18GA PGTL TRUNER,SUP-2167918,CDM,C1729,HCPCS,0272,RC,,,,both,,,245.30,159.44,,,,,,,,,,,,,
CATHETER REPERFUSION PROX 4.7FR ID0.043IN DST OD1.27MM,SUP-2323350,CDM,C1725,HCPCS,0272,RC,,,,both,,,4710.00,3061.50,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 45 CM DIA 4-7 MM SHRT TAPR HELIX,SUP-2763161,CDM,C1768,CPT,0278,RC,,,,both,,,1803.05,1171.98,,,,,,,,,,,,,
GUIDEWIRE SURG L735MM DIA1MM ELECTROMAGNETIC SENS ALWAYS-ON,SUP-2392605,CDM,C1769,HCPCS,0272,RC,,,,both,,,635.85,413.30,,,,,,,,,,,,,
HC So Hiv1 Probe,PX-3068753568,CDM,87535,CPT,0306,RC,,,,both,,,118.00,76.70,,,,,,,,,,,,,
INTRODUCER TUBE COUDE TIP AD 15 FRX70 CM CALIB POLYETH DISP,SUP-2381630,CDM,C1894,HCPCS,0272,RC,,,,both,,,23.58,15.33,,,,,,,,,,,,,
LINER ACET OD54MM ID32MM +4MM OFFSET HIP GVF POLYETH TI,SUP-2250250,CDM,C1776,CPT,0278,RC,,,,both,,,10459.97,6798.98,,,,,,,,,,,,,
DEFIBRILLATOR CARD 76GM 35CC W40XH74MM THK14MM PARYLENE,SUP-2356295,CDM,C1721,HCPCS,0275,RC,,,,both,,,37994.00,24696.10,,,,,,,,,,,,,
INDWELLING VOICE PROS L FLNG T,SUP-2242343,CDM,L8509,HCPCS,0272,RC,,,,both,,,935.72,608.22,,,,,,,,,,,,,
PLATE BONE 10 H RT SCAPULA LAT BORD,SUP-2107833,CDM,C1713,HCPCS,0278,RC,,,,both,,,5837.26,3794.22,,,,,,,,,,,,,
WASHER FIX DIA65MM TI FOR ORTHOLOC 3DI ANK FUS PLATING SYS,SUP-2398621,CDM,C1713,HCPCS,0278,RC,,,,both,,,81.64,53.07,,,,,,,,,,,,,
CATHETER DIL 5.8FR L75CM BLLN L4CM INFLATED DIA5MM 0.038IN,SUP-2139198,CDM,C1726,HCPCS,0272,RC,,,,both,,,919.08,597.40,,,,,,,,,,,,,
OSS ARCOS IM FEMUR ROD 20CM,SUP-2506346,CDM,C1776,CPT,0278,RC,,,,both,,,7714.98,5014.74,,,,,,,,,,,,,
TUBE VENT ID1.14MM SIL DONALDSON,SUP-2284009,CDM,L8699,HCPCS,0278,RC,,,,both,,,49.52,32.19,,,,,,,,,,,,,
SCREW SPNL THRD 2X12 MM 8 MM SS MAXDRIVE MMF LF,SUP-2483529,CDM,C1713,HCPCS,0278,RC,,,,both,,,316.04,205.43,,,,,,,,,,,,,
VENLAFAXINE HCL 50 MG PO TABS,RX-12204,CDM,6370000000,HCPCS,0637,RC,23155-0248-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE 3 CC CORTICOCANCELLOUS KT CELLULAR BNE,SUP-2932945,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8914.46,5794.40,,,,,,,,,,,,,
BLADE SURG 48MM ACET REV SYS EZOUT,SUP-2365134,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3454.00,2245.10,,,,,,,,,,,,,
STEM FEM CEM LO OFFSET FORGED CO CHROM C SER SZ 3 ACUMATCH,SUP-2221725,CDM,C1776,CPT,0278,RC,,,,both,,,10676.00,6939.40,,,,,,,,,,,,,
ALLOGRAFT BNE FD MEDL TO LAT WHL FEM CONDYLE,SUP-2866851,CDM,C1762,CPT,0278,RC,,,,both,,,6473.11,4207.52,,,,,,,,,,,,,
PLATE BNE W11XL112MM THK3.3MM 8 H BILAT MTPHSEAL TI LOK,SUP-2190762,CDM,C1713,HCPCS,0278,RC,,,,both,,,2718.71,1767.16,,,,,,,,,,,,,
CONNECTOR SPNL L20MM OD5.5MM S STL THORLUM OFFSET REVERE,SUP-2230984,CDM,C1713,HCPCS,0278,RC,,,,both,,,920.02,598.01,,,,,,,,,,,,,
CATHETER THORACENTESIS TY 9 FRX29 CM PNEUMOTHORAX 20 SIDEPRT,SUP-2760152,CDM,C1729,HCPCS,0272,RC,,,,both,,,785.47,510.56,,,,,,,,,,,,,
PLATE BNE RECON 3.5 MM 6 HOLE 2 COMPR LCK FOR SCR TI STRL,SUP-2459238,CDM,C1713,HCPCS,0278,RC,,,,both,,,1335.10,867.81,,,,,,,,,,,,,
LOCKNUT POS HDRST 0.375 IN NEUROSURGICAL,SUP-2336996,CDM,C1713,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED ADD ON CERM BIOLOX,SUP-2365430,CDM,C1776,CPT,0278,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
MESH HERN M 45X10CM ONLAY 7CM UNDERLAY 19X13CM CONN,SUP-2219792,CDM,C1781,HCPCS,0278,RC,,,,both,,,984.30,639.79,,,,,,,,,,,,,
IMPLANT COSMETIC SZ 35 X 53 MM POLYETHYL RT EAR BASE EXT,SUP-2935177,CDM,C1713,HCPCS,0278,RC,,,,both,,,4458.80,2898.22,,,,,,,,,,,,,
IMPLANT GLEN SM PEGGED ALPHA EQUINOXE,SUP-2223348,CDM,C1776,CPT,0278,RC,,,,both,,,3918.72,2547.17,,,,,,,,,,,,,
FORCEPS SURG UNIV PLT,SUP-2364410,CDM,2720000010,LOCAL,0272,RC,,,,both,,,634.12,412.18,,,,,,,,,,,,,
PISTON OTOLARYN L3.75MM OD.6MM S STL FLROPLAS INCUS PIST,SUP-2312534,CDM,L8613,CPT,0278,RC,,,,both,,,300.03,195.02,,,,,,,,,,,,,
SHEATH INTRO STEADYSHEATH EVOLUTION L 11.2 CM DIA 9 FR,SUP-2170084,CDM,C1893,HCPCS,0272,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
PLATE 2 23 3+3 H GRID 6 TRILOK,SUP-2267951,CDM,C1713,HCPCS,0278,RC,,,,both,,,2685.42,1745.52,,,,,,,,,,,,,
PLATE BNE W10XL190MM THK3.6MM 16 H BILAT S STL CRV RIG CLLR,SUP-2186259,CDM,C1713,HCPCS,0278,RC,,,,both,,,2853.38,1854.70,,,,,,,,,,,,,
CATHETER EP JSN 2-5-2 MM 6 FRX120 CM SUPREME,SUP-2355185,CDM,C1730,HCPCS,0272,RC,,,,both,,,373.66,242.88,,,,,,,,,,,,,
SCREW BNE L120MM OD75MM PUR TI LO EXT ST SELF DRL CANN NO,SUP-2242951,CDM,C1713,HCPCS,0278,RC,,,,both,,,1753.53,1139.79,,,,,,,,,,,,,
KIT BNE MAR ASPIR J NDL SYR,SUP-2399065,CDM,2720000010,LOCAL,0272,RC,,,,both,,,505.54,328.60,,,,,,,,,,,,,
RING EXT FIX DIA160MM FULL FOR RNG FIX SYS TRUELOK,SUP-2316171,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3062.25,1990.46,,,,,,,,,,,,,
GRAFT HUM TISS W2XL7CM SFT REGEN MTRX REP REPLFRM,SUP-2139388,CDM,C1762,CPT,0278,RC,,,,both,,,2378.42,1545.97,,,,,,,,,,,,,
PATCH CV 1X7 CM FOR PERICARD SHELHIGH,SUP-2424961,CDM,C1768,CPT,0278,RC,,,,both,,,376.80,244.92,,,,,,,,,,,,,
LINER EXT FIX STD EZ FRAME,SUP-2500212,CDM,2720000010,LOCAL,0272,RC,,,,both,,,822.68,534.74,,,,,,,,,,,,,
BOLT WIRE OFFSET ADAPT SHRT,SUP-2702991,CDM,2720000010,LOCAL,0272,RC,,,,both,,,864.76,562.09,,,,,,,,,,,,,
EYE WASH OP SOLN,RX-3000,CDM,6370000000,HCPCS,0637,RC,00536-1224-97,NDC,,both,118,ML,13.90,9.03,,,,,,,,,,,,,
LENS INTOCU +10.5 DIOPT L13MM DIA6MM 0DEG HAPTIC ANG A,SUP-2111162,CDM,V2632,HCPCS,0276,RC,,,,both,,,1554.30,1010.29,,,,,,,,,,,,,
PLATE BNE MESHED 51X51X1.5 MM SM GRID PLLA-PGA STRL,SUP-2480459,CDM,C1713,HCPCS,0278,RC,,,,both,,,3591.91,2334.74,,,,,,,,,,,,,
GRAFT VASC GORTX L 110 CM DIA 8 MM RNG L 70 CM EPTFE STR TW,SUP-2396139,CDM,C1768,CPT,0278,RC,,,,both,,,4264.12,2771.68,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 30 CM DIA 8 MM RNG L 12 CM EPTFE,SUP-2396317,CDM,C1768,CPT,0278,RC,,,,both,,,2166.60,1408.29,,,,,,,,,,,,,
ALLOGRAFT OATS DISPOSABLE KIT 20MM,SUP-2811232,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3391.20,2204.28,,,,,,,,,,,,,
LEAD NEUROSTIMULATOR L45CM DIA13MM ELECTRD L6MM SPC 18MM,SUP-2278244,CDM,C1778,HCPCS,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
APPLIER ANEURYSM CLIP L8IN STANDARD BAYONET STRAIGHT REUSABL,SUP-2825295,CDM,C1889,HCPCS,0278,RC,,,,both,,,4702.62,3056.70,,,,,,,,,,,,,
BASEPLATE GLEN DIA25MM POST 15MM FOR CONV SHLDR SYS,SUP-2388675,CDM,C1776,CPT,0278,RC,,,,both,,,6389.59,4153.23,,,,,,,,,,,,,
ALLOGRAFT HUM TISS HEMI BTB FRZN LO-RAD,SUP-2321875,CDM,C1762,CPT,0278,RC,,,,both,,,7379.00,4796.35,,,,,,,,,,,,,
PLATE BNE L262MM 19 H NONSTERILE R ANTLAT DST TIB S STL LO,SUP-2185970,CDM,C1713,HCPCS,0278,RC,,,,both,,,4454.72,2895.57,,,,,,,,,,,,,
HC Thyroglobulin Antibody,PX-3028680000,CDM,86800,CPT,0302,RC,,,,both,,,86.00,55.90,,,,,,,,,,,,,
PIN POS THRD 1.2X63 MM POS,SUP-2321705,CDM,2720000010,LOCAL,0272,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
RELOAD STPLR 45 MM WHT SUREFORM DAVINCI XI,SUP-2422167,CDM,2720000010,LOCAL,0272,RC,,,,both,,,659.40,428.61,,,,,,,,,,,,,
CATHETER ANGIO ACCU-VU L 70 CM DIA 5 FR 0.035 IN 20 CM PIG,SUP-2117060,CDM,C1887,HCPCS,0272,RC,,,,both,,,300.18,195.12,,,,,,,,,,,,,
PROBE SRGCL MCCLLCH 9 12NL 4MM TIP ANGLD FMNPLTN,SUP-2676451,CDM,2720000010,LOCAL,0272,RC,,,,both,,,327.47,212.86,,,,,,,,,,,,,
BLADE SHV L11CM DIA3.5MM 3000RPM CRV SHFT M4 ROT TIP,SUP-2284137,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1093.57,710.82,,,,,,,,,,,,,
DISTRACTION INTRNL DIST MNDBLE ZRCH 2 TLTS TRANS HRFRD RGHT,SUP-2694402,CDM,C1713,HCPCS,0278,RC,,,,both,,,18127.38,11782.80,,,,,,,,,,,,,
DEVICE STRNL CLOSUREXSM D11MM TI TWO LEG SGL VERSION TALON,SUP-2262515,CDM,C1713,HCPCS,0278,RC,,,,both,,,4066.30,2643.09,,,,,,,,,,,,,
PLATE BONE BAR L11.9MM THK0.6MM SH 2X2 H RT,SUP-2191304,CDM,C1713,HCPCS,0278,RC,,,,both,,,819.85,532.90,,,,,,,,,,,,,
POST EXT FIX M DIA8MM STR CLMP OUTRIG,SUP-2188516,CDM,2720000010,LOCAL,0272,RC,,,,both,,,340.41,221.27,,,,,,,,,,,,,
AUGMENT FEM CO CHROM R DST KNEE SL RESURF OSS,SUP-2405804,CDM,C1776,CPT,0278,RC,,,,both,,,2359.71,1533.81,,,,,,,,,,,,,
PLATE BNE L131MM 6 H NONSTERILE POST MED PROX TIB S STL LOK,SUP-2177796,CDM,C1713,HCPCS,0278,RC,,,,both,,,3136.04,2038.43,,,,,,,,,,,,,
KNIFE URETHROTOME CLD SERR BLDE FOR USA ELITE SYSTEM/USA,SUP-2313990,CDM,2720000010,LOCAL,0272,RC,,,,both,,,620.97,403.63,,,,,,,,,,,,,
SYSTEM THROMCTMY POUNCE L 14 CM DIA12 FR GUIDEWIRE 0.035 IN,SUP-2914010,CDM,C1894,HCPCS,0272,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
PLATE BONE L36MM THK0.9MM 4 H S STL H SHP NONCOMPRESSION FOR,SUP-2343831,CDM,C1713,HCPCS,0278,RC,,,,both,,,1236.59,803.78,,,,,,,,,,,,,
CAGE SPNL 3D 7 DEG 15X5X20 MM WAVEFORM C,SUP-2710166,CDM,C1889,HCPCS,0278,RC,,,,both,,,4553.00,2959.45,,,,,,,,,,,,,
GENERATOR NEUROSTIMULATOR 25GM 14ML THK7MM L VAGUS NRV SGL,SUP-2265163,CDM,C1767,HCPCS,0278,RC,,,,both,,,77124.68,50131.04,,,,,,,,,,,,,
GRAFT BIO TISS W15XL10CM THK1MM NONDENATURED CLLGN BOV,SUP-2383080,CDM,C1781,HCPCS,0278,RC,,,,both,,,10362.00,6735.30,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE 1 CC DBM,SUP-2913398,CDM,C1713,HCPCS,0278,RC,,,,both,,,2282.78,1483.81,,,,,,,,,,,,,
HC US Transvaginal Obsetrical,PX-4027681700,CDM,76817,CPT,0402,RC,,,,both,,,1263.00,820.95,,,,,,,,,,,,,
GRAFT BNE 1 CC CELLULAR BNE MTRX V92,SUP-2434349,CDM,C1889,HCPCS,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
SCREW BONE SELFTAPPING 1.3X10 MM CORTEX CRANIOMAXILLOFACIAL,SUP-2838149,CDM,C1713,HCPCS,0278,RC,,,,both,,,323.11,210.02,,,,,,,,,,,,,
STEM HUM L200MM DIA8MM 135DEG LNG STD SHLDR TI ARTHROPLASTY,SUP-2250042,CDM,C1776,CPT,0278,RC,,,,both,,,12089.00,7857.85,,,,,,,,,,,,,
COLLAR EXTRIC 1 PC RIG INF PERFIT,SUP-2389135,CDM,L0190,HCPCS,0274,RC,,,,both,,,18.81,12.23,,,,,,,,,,,,,
PLATE BNE CLAV CS2 2.7 MM LT LAT VA LCK COMPR TI STRL VALCP,SUP-2789608,CDM,C1713,HCPCS,0278,RC,,,,both,,,3985.66,2590.68,,,,,,,,,,,,,
CLIP INT M L POLYMER LOK LIG HEM O LOK,SUP-2641839,CDM,C1889,HCPCS,0278,RC,,,,both,,,107.42,69.82,,,,,,,,,,,,,
BEAM FUS 7X90MM PROX FT SALVATION,SUP-2400744,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4892.12,3179.88,,,,,,,,,,,,,
KNIFE ELECSURG 0.9X3.9 MM 2.8X230 MM 2.8 MM ITKNIFE NANO,SUP-2477916,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2208.21,1435.34,,,,,,,,,,,,,
CANNULA KYPHOPLASTY BVL TIP W/ INTRO PREMIER AFFIRM,SUP-2232189,CDM,C1894,HCPCS,0272,RC,,,,both,,,1758.40,1142.96,,,,,,,,,,,,,
SCREW BONE L10MM OD2.7MM S STL CORT ST NONCANNULATED LCK,SUP-2348300,CDM,C1713,HCPCS,0278,RC,,,,both,,,999.02,649.36,,,,,,,,,,,,,
GUIDEWIRE VASC L 180 CM 0.025 IN L 7 CM 3 CM AMPLTZ X STIFF,SUP-2638700,CDM,C1769,HCPCS,0272,RC,,,,both,,,249.32,162.06,,,,,,,,,,,,,
SUPPORT ORTHOT WRST HND FNGR CUST W/NONTORSION JT,SUP-2435788,CDM,L3931,HCPCS,0274,RC,,,,both,,,537.22,349.19,,,,,,,,,,,,,
DEVICE ORTHOT ADDITION TO LO EXT LIMIT ANK MOTN EA JT,SUP-2388175,CDM,L2200,HCPCS,0274,RC,,,,both,,,117.31,76.25,,,,,,,,,,,,,
HC So Tissue Cult of Neoplastic Dis,PX-3118823766,CDM,88237,CPT,0311,RC,,,,outpatient,,,185.00,120.25,,,,,,,,,,,,,
DEXAMETHASONE 0.5 MG PO TABS,RX-2322,CDM,J8540,HCPCS,0636,RC,00054-8179-25,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
SHANK SPNL SCR 4.5MMX55MM RELINE MAS MOD,SUP-2310255,CDM,C1713,HCPCS,0278,RC,,,,both,,,1805.50,1173.57,,,,,,,,,,,,,
HEAD FEM OD36MM +0MM 12/14 MTL ON MTL PRI TAPR HIP CO CHROM,SUP-2222058,CDM,C1776,CPT,0278,RC,,,,both,,,2763.20,1796.08,,,,,,,,,,,,,
GRAFT HUM TISS W10-20MMXL19.5-20CM ACHILLES TEND FRZN,SUP-2307275,CDM,C1762,CPT,0278,RC,,,,both,,,5943.80,3863.47,,,,,,,,,,,,,
SCREW KIT MED PEDIATRIC 5 MM STRL GALAXY,SUP-2646381,CDM,C1713,HCPCS,0278,RC,,,,both,,,10055.10,6535.81,,,,,,,,,,,,,
ALLOGRAFT HUM TISS PTCH THN 4X8 CM AMNIO TISS MEMBRN CYGNUS,SUP-2422824,CDM,Q4170,HCPCS,0636,RC,,,,both,,,5181.00,3367.65,,,,,,,,,,,,,
Z DISCONTINUED NO SUB IDED SET INTRO 8FR HYDRPHLC PERC FOR TRACH CIAGLIA BLU RHINO,SUP-2168708,CDM,C1769,HCPCS,0272,RC,,,,both,,,1161.80,755.17,,,,,,,,,,,,,
BRACE ORTHOPEDIC TLSO XL BK SPK COMPLETE PANEL QUICKDRAW,SUP-2124228,CDM,L1620,HCPCS,0274,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
MESH HERN SQ 1 15X15 CM W/ ORIENTATION MARKING VERSATEX,SUP-2752216,CDM,C1781,HCPCS,0278,RC,,,,both,,,717.58,466.43,,,,,,,,,,,,,
CPT 12/14 COCR REVISION SIZE 3 180MM,SUP-2504692,CDM,C1776,CPT,0278,RC,,,,both,,,11329.12,7363.93,,,,,,,,,,,,,
PLATE BNE W38XL50MM THK09MM 3X9 H BILAT S STL T SHP RIG,SUP-2186289,CDM,C1713,HCPCS,0278,RC,,,,both,,,1226.67,797.34,,,,,,,,,,,,,
GRAFT HUM TISS DIA44MM FEM HD FRZN,SUP-2307304,CDM,C1713,HCPCS,0278,RC,,,,both,,,3959.51,2573.68,,,,,,,,,,,,,
NEEDLE TRANSSEPTAL KT AND STYL 18GA 71CM 50 DEG CRV ANG,SUP-2302570,CDM,2720000010,LOCAL,0272,RC,,,,both,,,412.13,267.88,,,,,,,,,,,,,
ROPIVACAINE ELASTOMERIC INFUSION 0.2%,RX-4081819201,CDM,J2795,HCPCS,0636,RC,63323-0285-23,NDC,,both,100,ML,317.40,206.31,,,,,,,,,,,,,
SHELL ACET SLD BK COCR ALLOY 46MM VITALOCK,SUP-2364624,CDM,C1776,CPT,0278,RC,,,,both,,,3264.69,2122.05,,,,,,,,,,,,,
CATHETER ANGIO OD4FR L65CM 0.035IN AD FLUSHED PGTL RADPQ,SUP-2116581,CDM,C1887,HCPCS,0272,RC,,,,both,,,325.93,211.85,,,,,,,,,,,,,
SPACER SPNL LORDTC 5 DEG 11 MM LUMBAR OBLQ VERTIGRAFT II,SUP-2264977,CDM,C1713,HCPCS,0278,RC,,,,both,,,9878.38,6420.95,,,,,,,,,,,,,
SEALER TISS L35CM DIA5MM CRV JAW ARTC ADV BPLR ENSEAL G2,SUP-2219729,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4287.39,2786.80,,,,,,,,,,,,,
INTRODUCER KYPHOPLASTY SZ 3 8GA 4.2MM TRCR AND DMND OSTEO,SUP-2293706,CDM,C1894,HCPCS,0272,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
DISSECTOR ELECSURG SHFT L 27 CM LUMITIP PEN ABLATION,SUP-2124420,CDM,C1713,HCPCS,0278,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
EXPANDER BRST 700CC W13.5XH13.5CM P8.3CM SIL TEXT ULT HI,SUP-2301036,CDM,C1789,HCPCS,0278,RC,,,,both,,,6248.60,4061.59,,,,,,,,,,,,,
MARKER BRST BX TI UND MRI TRIMARK,SUP-2382009,CDM,A4648,CPT,0278,RC,,,,both,,,178.98,116.34,,,,,,,,,,,,,
PLATE BNE TBLR 100 DEG 2 HOLE STRL LTX,SUP-2861627,CDM,C1713,HCPCS,0278,RC,,,,both,,,271.67,176.59,,,,,,,,,,,,,
CABLE SPNL FLAT BAR ATLS 2PK,SUP-2289638,CDM,C1713,HCPCS,0278,RC,,,,both,,,357.96,232.67,,,,,,,,,,,,,
CATHETER ANGIOPLSTY ANGIOSCULPT L 137 CM 20 MM 4 MM,SUP-2353194,CDM,C1725,HCPCS,0272,RC,,,,both,,,3022.25,1964.46,,,,,,,,,,,,,
PROBE NERVE STIM BPLR CONCENTRIC STRL DISP,SUP-2901971,CDM,2720000010,LOCAL,0272,RC,,,,both,,,471.35,306.38,,,,,,,,,,,,,
ENDO FUSE  FUSION BEAM 25X20MM,SUP-2466274,CDM,C1713,HCPCS,0278,RC,,,,both,,,6644.24,4318.76,,,,,,,,,,,,,
TWIST DRILL 1.9MM DIA X 115MM 6MM STOP W/NTCH LEVEL SSTM SNG,SUP-2498808,CDM,2720000010,LOCAL,0272,RC,,,,both,,,425.22,276.39,,,,,,,,,,,,,
HC Intrvasc US Noncoronary Addl,PX-3613725300,CDM,37253,CPT,0361,RC,,,,both,,,1485.00,965.25,,,,,,,,,,,,,
ISONIAZID 300 MG PO TABS,RX-4027,CDM,6370000000,HCPCS,0637,RC,51079-0083-01,NDC,,both,1,UN,4.70,3.05,,,,,,,,,,,,,
KIT HUM COMP SZ 5 6 EL VIVACIT E ARTC NEXEL,SUP-2402661,CDM,C1776,CPT,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
SCREW BNE LCK 14 MM AIRLOCK,SUP-2309315,CDM,C1713,HCPCS,0278,RC,,,,both,,,527.99,343.19,,,,,,,,,,,,,
SPLINT WRST XL AD L8IN FOR 85 95IN L NYL LN FOAM PUL ON,SUP-2276660,CDM,L3908,HCPCS,0272,RC,,,,both,,,16.83,10.94,,,,,,,,,,,,,
HC Smoking Cessatn 10/More Mins Symptomatic Pt,PX-9429940700,CDM,99407,CPT,0942,RC,,,,both,,,88.00,57.20,,,,,,,,,,,,,
SYRINGE MED CONE TIP 100 CC CLMP 3 RNG AUTOCLV FOR UROLOGY,SUP-2747411,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1440.82,936.53,,,,,,,,,,,,,
MEGESTROL ACETATE 40 MG/ML PO SUSP,RX-10521,CDM,6370000000,HCPCS,0637,RC,00121-0945-10,NDC,,both,5,ML,9.50,6.17,,,,,,,,,,,,,
GUIDEWIRE ORTH LAIN DIA0.062IN LNG DISP,SUP-2122967,CDM,C1769,HCPCS,0272,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
WEDGE HEEL 3/4 2.5X9/16 HAPAD,SUP-2325445,CDM,L3350,HCPCS,0274,RC,,,,both,,,12.91,8.39,,,,,,,,,,,,,
SCREW BNE FT LG 5X20 MM COMPR,SUP-2122526,CDM,C1713,HCPCS,0278,RC,,,,both,,,2132.06,1385.84,,,,,,,,,,,,,
CATHETER GUID VERIPATH L 50 CM OD 7 FR ID 0.078 IN INNR PTFE,SUP-2101521,CDM,C1887,HCPCS,0272,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
GUIDEWIRE VASC L200CM DIA0.014IN DST SEG L35CM NIT HYDRPHLC,SUP-2367901,CDM,C1769,HCPCS,0272,RC,,,,both,,,2088.10,1357.26,,,,,,,,,,,,,
IMPLANT BRST 420 450CC P45CM DIA134CM NACL STYL 68MP SMOOTH,SUP-2113377,CDM,C1789,HCPCS,0278,RC,,,,both,,,1494.64,971.52,,,,,,,,,,,,,
IMPLANT SYNTH 93 X 74 MM THK 20 MM MED POLYETHYL RT TEMPORAL,SUP-2883542,CDM,C1713,HCPCS,0278,RC,,,,both,,,4963.96,3226.57,,,,,,,,,,,,,
CAGE SPNL MESH 17X13X20 MM 6 LOBE,SUP-2602081,CDM,C1889,HCPCS,0278,RC,,,,both,,,11002.56,7151.66,,,,,,,,,,,,,
PLATE BNE 2X2 H CRANIOMAXILLOFACIAL TI 3D BX LO PROF FOR,SUP-2366201,CDM,C1713,HCPCS,0278,RC,,,,both,,,574.12,373.18,,,,,,,,,,,,,
MANIPULATOR UTER 3 CM FOR HARM SCALPEL/LASER SS NS KOH CUP,SUP-2756069,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1836.02,1193.41,,,,,,,,,,,,,
POST EXT FIX SHT WIRE MR CONDITIONAL FOR DISTR OSTEOGENESIS,SUP-2179141,CDM,2720000010,LOCAL,0272,RC,,,,both,,,591.98,384.79,,,,,,,,,,,,,
STRUT EXT FIX L 195- 310 MM LNG UNIV HEX,SUP-2898453,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4578.12,2975.78,,,,,,,,,,,,,
SET PICC L 1 9/16 IN DIA18 GA SHTH L 1 1/4 IN DIA 5 FR,SUP-2887113,CDM,C1769,HCPCS,0272,RC,,,,both,,,70.02,45.51,,,,,,,,,,,,,
BIT DRL DIA2.5MM LNG W/ AO QUIK CONN DISP FOR SM PLATING,SUP-2344044,CDM,2720000010,LOCAL,0272,RC,,,,both,,,712.72,463.27,,,,,,,,,,,,,
SCREW BNE L 10 MM DIA 3.5 MM TI ST LCK T15 DRV NS EVOS,SUP-2931551,CDM,C1713,HCPCS,0278,RC,,,,both,,,404.93,263.20,,,,,,,,,,,,,
PIN FIX PROV SM FRAG SYS 2.7MMX18MM,SUP-2343972,CDM,C1713,HCPCS,0278,RC,,,,both,,,1245.73,809.72,,,,,,,,,,,,,
GRAFT FEM PROX W/ HD FRZN ALLGRFT,SUP-2165579,CDM,C1713,HCPCS,0278,RC,,,,both,,,6876.60,4469.79,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 30 CM DIA 6 MM EPTFE STR STD WALL,SUP-2396184,CDM,C1768,CPT,0278,RC,,,,both,,,1419.28,922.53,,,,,,,,,,,,,
CLIP EASY FIX DEV 18X12X12,SUP-2696123,CDM,C1713,HCPCS,0278,RC,,,,both,,,3172.37,2062.04,,,,,,,,,,,,,
STAPLER INT L28CM DIA29MM CLS STPL H10-2.5MM OPN LEG L5.5MM,SUP-2218995,CDM,2720000010,LOCAL,0272,RC,,,,both,,,824.69,536.05,,,,,,,,,,,,,
BIT OVERDRILL DIA 3.5 MM AO QC SM TARGETER SYS STRL DISP,SUP-2932962,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1316.45,855.69,,,,,,,,,,,,,
INSERT TIB SZ 7 THICKNESS 10MM UHMWPE KNEE PRI NEUT UNIV,SUP-2365103,CDM,C1776,CPT,0278,RC,,,,both,,,2150.15,1397.60,,,,,,,,,,,,,
TRIAL ARTC SURF UNI HI FLX PROV SZ 3 8MM,SUP-2200485,CDM,2720000010,LOCAL,0272,RC,,,,both,,,510.25,331.66,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL PEEK SD800.537,SUP-2860218,CDM,C1713,HCPCS,0278,RC,,,,both,,,40080.53,26052.34,,,,,,,,,,,,,
HC N Block Paravert Lumbar 3+,PX-3606449500,CDM,64495,CPT,0360,RC,,,,both,,,3113.00,2023.45,,,,,,,,,,,,,
NEXEL TOT ELBW,SUP-2212313,CDM,C1776,CPT,0278,RC,,,,both,,,30144.00,19593.60,,,,,,,,,,,,,
FIBER LSR .6MM DISP KTP/YAG,SUP-2225625,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1171.22,761.29,,,,,,,,,,,,,
CATHETER BLLN DIL L23CM OD9FR 2ML IU,SUP-2169837,CDM,2720000010,LOCAL,0272,RC,,,,both,,,201.62,131.05,,,,,,,,,,,,,
PLATE BONE INF BLDE L35MM 5MM OFFSET 90DEG 3 H LT RT LCK,SUP-2318745,CDM,C1713,HCPCS,0278,RC,,,,both,,,5024.53,3265.94,,,,,,,,,,,,,
SHEATH INTRO GLIDESHEATH L 25CM 5FR 0.074IN SPRING WALL PUNC,SUP-2384823,CDM,C1894,HCPCS,0272,RC,,,,both,,,150.72,97.97,,,,,,,,,,,,,
VALVE CSF CRAN IMPL HYDROCEPHALUS OSV II 9OS702,SUP-2666688,CDM,C1889,HCPCS,0278,RC,,,,both,,,10289.97,6688.48,,,,,,,,,,,,,
COLLAR CERV ADJ XL 20X3 IN COTTON MED DENS PREMIERPRO,SUP-2335997,CDM,L0120,HCPCS,0272,RC,,,,both,,,22.55,14.66,,,,,,,,,,,,,
HC RBC Deglycerolized,PX-3900903900,CDM,P9039,CPT,0390,RC,,,,both,,,2154.00,1400.10,,,,,,,,,,,,,
REPLACEMENT PD F VISTA CERV CLLR ADLT,SUP-2196894,CDM,L0120,HCPCS,0272,RC,,,,both,,,52.19,33.92,,,,,,,,,,,,,
SCREW BNE L34MM DIA3.5MM NONLOCKING FOR R3CON PLATING SYS,SUP-2321371,CDM,C1713,HCPCS,0278,RC,,,,both,,,444.62,289.00,,,,,,,,,,,,,
GRAFT HUM TISS W4XL6CM THK0.1MM PERICARD BIOCOMPATIBLE,SUP-2395372,CDM,C1768,CPT,0278,RC,,,,both,,,354.82,230.63,,,,,,,,,,,,,
HC So1 Infectious Agent Ab Quant,PX-3028631767,CDM,86317,CPT,0302,RC,,,,inpatient,,,44.00,28.60,,,,,,,,,,,,,
ANCHOR SFT TISS OPN ADJ CORT 4 PNT KNOTLESS FIX SYS,SUP-2121400,CDM,C1713,HCPCS,0278,RC,,,,both,,,609.16,395.95,,,,,,,,,,,,,
SCREW POLYAX 3.5X14MM 7902-3514,SUP-2211408,CDM,C1713,HCPCS,0278,RC,,,,both,,,3168.26,2059.37,,,,,,,,,,,,,
COMPONENT HIP CAPPED BPLR SH1] STELKAST CO],SUP-2359390,CDM,C1776,CPT,0278,RC,,,,both,,,8478.00,5510.70,,,,,,,,,,,,,
PROSTHESIS OSS 1.80X3 MM 1.45X37 MM DSTL END CUP TI HA ALTO,SUP-2232499,CDM,L8613,CPT,0278,RC,,,,both,,,1159.98,753.99,,,,,,,,,,,,,
PLATE BONE L145MM THK3.3MM 12 H BILAT S STL RIG STR DYN,SUP-2186335,CDM,C1713,HCPCS,0278,RC,,,,both,,,1211.00,787.15,,,,,,,,,,,,,
EXTENSION STEM 2MM OFFSET CPLR,SUP-2221223,CDM,C1776,CPT,0278,RC,,,,both,,,1208.90,785.78,,,,,,,,,,,,,
PLATE BNE W12.9XL43.7MM 8 H Y HI STRENGTH FOR FLX FRAG FIX,SUP-2411673,CDM,C1713,HCPCS,0278,RC,,,,both,,,1902.84,1236.85,,,,,,,,,,,,,
BLADE SURG KNF L11MM PARA GRFT,SUP-2121679,CDM,2720000010,LOCAL,0272,RC,,,,both,,,147.58,95.93,,,,,,,,,,,,,
CATHETER ANGIOPLSTY L 90 CM BALLOON L 250 MM DIA2 MM SHTH 4,SUP-2909705,CDM,C1725,HCPCS,0272,RC,,,,both,,,793.76,515.94,,,,,,,,,,,,,
HC Cortisol Total,PX-3018253300,CDM,82533,CPT,0301,RC,,,,both,,,212.00,137.80,,,,,,,,,,,,,
CATHETER NASOBILIARY 8.5FR L250CM STL TEF W/ GWIRE DISP,SUP-2148628,CDM,C1898,HCPCS,0275,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
SHUNT MICRO STENT WITH APPLIERS CYPASS ULTRA,SUP-2109981,CDM,C1783,HCPCS,0278,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
SUPPORT ORTHOT CUST HEEL WDG SACH,SUP-2435720,CDM,L3340,HCPCS,0274,RC,,,,both,,,241.31,156.85,,,,,,,,,,,,,
BIT DRL CANN 2.7 MM PERC,SUP-2862252,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1047.88,681.12,,,,,,,,,,,,,
CANNULA SURG LNG 95 DEG 4.3 MM SCR NCB,SUP-2458046,CDM,2720000010,LOCAL,0272,RC,,,,both,,,538.20,349.83,,,,,,,,,,,,,
CATHETER HD 15 FRX27 CM 21 GA ARROW-CLARK NEXTSTEP,SUP-2627054,CDM,C1750,HCPCS,0278,RC,,,,both,,,973.40,632.71,,,,,,,,,,,,,
WASHER ORTH OD35MM S STL MTP LOK SURFIX,SUP-2243052,CDM,C1713,HCPCS,0278,RC,,,,both,,,503.94,327.56,,,,,,,,,,,,,
SET SCR DBL HEX TI,SUP-2415553,CDM,C1713,HCPCS,0278,RC,,,,both,,,400.92,260.60,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED BPLR PRSS FT STEM,SUP-2365426,CDM,C1776,CPT,0278,RC,,,,both,,,7850.00,5102.50,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY INTELLAMAP ORION 180 DEG L 115 CM,SUP-2141350,CDM,2720000010,LOCAL,0272,RC,,,,both,,,9263.00,6020.95,,,,,,,,,,,,,
SCREW BNE L20MM OD2MM THRD L15MM TI BRK OFF MONSTER BITE,SUP-2321005,CDM,C1713,HCPCS,0278,RC,,,,both,,,671.80,436.67,,,,,,,,,,,,,
TRAY CATH PICC GROSH NXT CLEARVUE BASIC 4FR 0.033N 6 9617405,SUP-2632706,CDM,C1751,HCPCS,0278,RC,,,,both,,,342.26,222.47,,,,,,,,,,,,,
PLATE BNE SZ 2.8 MM TI MANDIBULAR FULL NS DISP ACCUPLATE,SUP-2934819,CDM,C1713,HCPCS,0278,RC,,,,both,,,65767.30,42748.74,,,,,,,,,,,,,
CAGE GLENOID SHOULDER BETA EQUINOXE LG CEMENTED,SUP-2880193,CDM,C1776,CPT,0278,RC,,,,both,,,3925.00,2551.25,,,,,,,,,,,,,
HYOSCYAMINE SULFATE 0.125 MG/ML PO SOLN,RX-3782,CDM,340b,HCPCS,0637,RC,54838-0506-15,NDC,,both,0.125,ML,2.70,1.75,,,,,,,,,,,,,
SPHERE EMB ONCOZENE DIA100 UM SM 3 ML PREFIL SYR HYDRGEL WHT,SUP-2717592,CDM,C1889,HCPCS,0278,RC,,,,both,,,13423.50,8725.27,,,,,,,,,,,,,
SUPPORT ORTHOT CUST HEEL WDG SACH,SUP-2435720,CDM,L3340,HCPCS,0272,RC,,,,both,,,241.31,156.85,,,,,,,,,,,,,
RING EXT FIX LNG 180 MM SET RX STRUT STRL TRUELOK EVO LTX,SUP-2875587,CDM,2720000010,LOCAL,0272,RC,,,,both,,,29668.98,19284.84,,,,,,,,,,,,,
DEVICE SUCT 70DEG CRV,SUP-2364158,CDM,2720000010,LOCAL,0272,RC,,,,both,,,804.22,522.74,,,,,,,,,,,,,
CINACALCET HCL 30 MG PO TABS,RX-38100,CDM,6370000000,HCPCS,0637,RC,16729-0440-15,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
STENT PERIPH EXPRESS SD MR L 15 MM DIA 5 MM CATH L 90 CM,SUP-2142389,CDM,C1876,HCPCS,0278,RC,,,,both,,,3846.50,2500.22,,,,,,,,,,,,,
BENDING IRON FOR 3.5MM,SUP-2548469,CDM,C1713,HCPCS,0278,RC,,,,both,,,1552.51,1009.13,,,,,,,,,,,,,
SCREW BNE L16MM DIA35MM RAREFT LOK PLT FOR TOT FT SYS 2,SUP-2243293,CDM,C1713,HCPCS,0278,RC,,,,both,,,951.80,618.67,,,,,,,,,,,,,
DEVICE FIX SFT TISS 2.9 MM W/O NDL W/ ZIPLOOP TOGGLELOC,SUP-2663990,CDM,C1713,HCPCS,0278,RC,,,,both,,,1920.17,1248.11,,,,,,,,,,,,,
IMPLANT COSMETIC SZ 80.5 X 61.5 X 2 MM LG POLYETHYL OCCPTL,SUP-2935439,CDM,C1713,HCPCS,0278,RC,,,,both,,,4374.02,2843.11,,,,,,,,,,,,,
ALLOGRAFT HUM TISS 8X8X8 MM FUSIONFLEX,SUP-2759441,CDM,C1713,HCPCS,0278,RC,,,,both,,,1382.67,898.74,,,,,,,,,,,,,
LEUCOVORIN CALCIUM 350 MG IJ SOLR,RX-4393,CDM,J0640,HCPCS,0636,RC,71288-0163-30,NDC,,both,1,UN,76.70,49.85,,,,,,,,,,,,,
NEEDLE ASPIR 700X2 MM W/O SYRINGE DISP,SUP-2482118,CDM,2720000010,LOCAL,0272,RC,,,,both,,,814.36,529.33,,,,,,,,,,,,,
SYSTEM VLV REP TRICLIP G4 TRICSP VLV TRANSCATHETER EDGE TO,SUP-2895994,CDM,C1889,HCPCS,0278,RC,,,,both,,,122460.00,79599.00,,,,,,,,,,,,,
SCREW BNE SD 2.7X12 MM TI SNAP-OFF,SUP-2608913,CDM,C1713,HCPCS,0278,RC,,,,both,,,1394.91,906.69,,,,,,,,,,,,,
RETRACTOR MICRODISCECTOMY 18MM DIA TBLR MTRX,SUP-2292888,CDM,C1713,HCPCS,0278,RC,,,,both,,,1156.24,751.56,,,,,,,,,,,,,
EXTRACTOR PRO RX S 9 12MM ABV,SUP-2141495,CDM,2720000010,LOCAL,0272,RC,,,,both,,,468.96,304.82,,,,,,,,,,,,,
SCREW SYS PARTIALLY THRD LAG 316 L VM S THRD 2.5MM CANN,SUP-2392883,CDM,C1713,HCPCS,0278,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
PLATE BNE L68MM 3X5 H T SHP FOR 3.5MM SCR,SUP-2411363,CDM,C1713,HCPCS,0278,RC,,,,both,,,372.59,242.18,,,,,,,,,,,,,
GUIDEWIRE VASC L 180 CM DIA 0.038 IN TAPR L 9.5 CM FLPY TIP,SUP-2167904,CDM,C1769,HCPCS,0272,RC,,,,both,,,61.67,40.09,,,,,,,,,,,,,
ADAPTER KIT 55 CM M8 TORQUE WRENCH VERCISE,SUP-2836336,CDM,C1883,HCPCS,0278,RC,,,,both,,,3140.00,2041.00,,,,,,,,,,,,,
WASHER ORTHOPEDIC SPC 4 MM FOR MR SAFE TI NS,SUP-2179143,CDM,C1713,HCPCS,0278,RC,,,,both,,,28.10,18.26,,,,,,,,,,,,,
PLATE EXT FIX 30 MM STP OFF NS DISP SMRT TSF,SUP-2932868,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2125.03,1381.27,,,,,,,,,,,,,
KIT CUT GUID R FEM KNEE NYLON-12 VISIONAIRE JOURNEY II,SUP-2351444,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
COLLAR CERV 4 MONTH-10YR CH FOR TORTICOLLIS TREAT TOT,SUP-2324278,CDM,L0180,HCPCS,0272,RC,,,,both,,,131.06,85.19,,,,,,,,,,,,,
PLUG MTRX 14X10MM 42314,SUP-2278334,CDM,C1713,HCPCS,0278,RC,,,,both,,,2064.61,1342.00,,,,,,,,,,,,,
BAND GASTRIC STANDARD ADULT FOR ADJUSTABLE SYSTEM LAP BAND AP RAPIDPORT OMNIFORM,SUP-2119250,CDM,C1713,HCPCS,0278,RC,,,,both,,,10880.10,7072.06,,,,,,,,,,,,,
CATHETER ATHRCTMY L 9.5 CM BUR 2.25 MM EXCHG STRL,SUP-2147779,CDM,C1724,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
ROSUVASTATIN CALCIUM 5 MG PO TABS,RX-36612,CDM,6370000000,HCPCS,0637,RC,67877-0439-90,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
GUIDEWIRE VASC L185CM SHT PRSS STR TIP PRIMEWIRE PRESTIGE,SUP-2327224,CDM,C1769,HCPCS,0272,RC,,,,both,,,1962.50,1275.62,,,,,,,,,,,,,
GRAFT HUM TISS W2XL2CM THN MTRX ANAT BARR FOR ORTH APPL,SUP-2120771,CDM,C1762,CPT,0278,RC,,,,both,,,2237.25,1454.21,,,,,,,,,,,,,
SCREW BONE L125MM DIA7MM S STL SELF DRL ST CANN FULL THRD LO,SUP-2340800,CDM,C1713,HCPCS,0278,RC,,,,both,,,1614.27,1049.28,,,,,,,,,,,,,
PLATE BNE 5 H R DST FIB ANK S STL LOK FOR FRAC MGMT SYS,SUP-2123023,CDM,C1713,HCPCS,0278,RC,,,,both,,,2041.00,1326.65,,,,,,,,,,,,,
SPACER SPNL RND 5 DEG MED 21 MM ENDPLATE STRL XLR,SUP-2592019,CDM,C1889,HCPCS,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
PLATE BNE L114MM THK3MM 6 H TI TIM R DST ANTLAT TIB LOK,SUP-2413679,CDM,C1713,HCPCS,0278,RC,,,,both,,,4851.30,3153.34,,,,,,,,,,,,,
SPACER ORTH HUM 9+ MM 42 MM,SUP-2715590,CDM,C1776,CPT,0278,RC,,,,both,,,4443.10,2888.01,,,,,,,,,,,,,
EXTRACTOR STONE 1.5FR L115CM BSKT DIA1CM NIT TIPLSS UNIDEX,SUP-2170513,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1144.22,743.74,,,,,,,,,,,,,
DISP KIT DX SWIVELOCK CANN 4.75 MM,SUP-2815107,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1648.50,1071.52,,,,,,,,,,,,,
PLATE BNE L194MM 12 H NAR 2 COMPR FOR 4.5MM SCR L FRAG SYS,SUP-2411426,CDM,C1713,HCPCS,0278,RC,,,,both,,,517.47,336.36,,,,,,,,,,,,,
SET INTRO PERFRMR L 13 CM OD 11 FR ID 3.6 MM GUIDEWIRE 0.038,SUP-2168232,CDM,C1894,HCPCS,0272,RC,,,,both,,,127.92,83.15,,,,,,,,,,,,,
VALVE SWALLOING AND SPEAK OD23MM ID15MM CLR LO PROF LTWT,SUP-2322023,CDM,L8501,HCPCS,0272,RC,,,,both,,,365.68,237.69,,,,,,,,,,,,,
INSTRUMENT OPHTH 20GA W/ BRSH NDL PASS ASPIR DISP,SUP-2213460,CDM,C1713,HCPCS,0278,RC,,,,both,,,341.63,222.06,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.426,SUP-2859990,CDM,C1713,HCPCS,0278,RC,,,,both,,,35546.06,23104.94,,,,,,,,,,,,,
RESERVOIR 20MM W/ HYDR SPRUNG PROGAV 2.0,SUP-2108739,CDM,C1729,HCPCS,0272,RC,,,,both,,,7388.26,4802.37,,,,,,,,,,,,,
SCREW SPNL TIGHTENER FOR MIS SPNL FIX SYS TELLURIDE,SUP-2211187,CDM,C1713,HCPCS,0278,RC,,,,both,,,467.86,304.11,,,,,,,,,,,,,
DRILL SURG STP 3.2X165 MM CANN,SUP-2749973,CDM,2720000010,LOCAL,0272,RC,,,,both,,,395.64,257.17,,,,,,,,,,,,,
HC So Thyroid Stim Immunoglobulin,PX-3018444566,CDM,84445,CPT,0301,RC,,,,both,,,289.00,187.85,,,,,,,,,,,,,
HC Incision of Lingual Frenum (Frenotomy),PX-3614101000,CDM,41010,CPT,0361,RC,,,,outpatient,,,4755.00,3090.75,,,,,,,,,,,,,
CATHETER CV 3L 7 FRX20 CM KT SAFETY VANTEX,SUP-2277021,CDM,C1751,HCPCS,0278,RC,,,,both,,,192.17,124.91,,,,,,,,,,,,,
MESH COMPOSIX LP ELP 8.2IN X 10.2IN W/ INTRO,SUP-2125818,CDM,C1781,HCPCS,0278,RC,,,,both,,,3606.60,2344.29,,,,,,,,,,,,,
PLATE BONE L W12XL71MM THK1MM 4 H BILAT TI SEMI TBLR LO PROF,SUP-2190702,CDM,C1713,HCPCS,0278,RC,,,,both,,,243.13,158.03,,,,,,,,,,,,,
HC Plmt Nephroureteral Catheter,PX-3615043300,CDM,50433,CPT,0361,RC,,,,both,,,8583.00,5578.95,,,,,,,,,,,,,
GUIDE DRL BUSHING 25 DEG 8 MM,SUP-2167405,CDM,2720000010,LOCAL,0272,RC,,,,both,,,706.50,459.22,,,,,,,,,,,,,
ROD THRD RINGFIX SYS 80MM,SUP-2460077,CDM,2720000010,LOCAL,0272,RC,,,,both,,,109.90,71.43,,,,,,,,,,,,,
CATHETER BLLN DIL 16-17-18 MM FIX WIRE EZDILATE,SUP-2865617,CDM,C1726,HCPCS,0272,RC,,,,both,,,7379.00,4796.35,,,,,,,,,,,,,
SCREW BNE CANC 4.5X48 MM FT NCB,SUP-2861255,CDM,C1713,HCPCS,0278,RC,,,,both,,,523.94,340.56,,,,,,,,,,,,,
SYSTEM BNE CEMENT DEL HYDRLC OSSEOFLEX CD-H,SUP-2460813,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1648.50,1071.52,,,,,,,,,,,,,
STEM HUM 8 MM SHLDR AFFINITI PC,SUP-2715287,CDM,C1776,CPT,0278,RC,,,,both,,,13169.16,8559.95,,,,,,,,,,,,,
SET THROMCTMY ANGIOJET XVG L 140 CM DIA 5 FR SHTH 5 FR,SUP-2142033,CDM,C1757,HCPCS,0272,RC,,,,both,,,5118.20,3326.83,,,,,,,,,,,,,
CATHETER DRAINAGE LCK PIG 8 FRX40 CM BILI SFT POLYURETHANE,SUP-2303560,CDM,C1729,HCPCS,0272,RC,,,,both,,,244.92,159.20,,,,,,,,,,,,,
BIT DRILL 1.5X75 MM STRYKER J LATCH NON STERILE PROPAK,SUP-2837898,CDM,2720000010,LOCAL,0272,RC,,,,both,,,584.67,380.04,,,,,,,,,,,,,
COIL EMB L2CM DIA0.02IN LOOP DIA2MM CRV EXTRA SFT FILL,SUP-2323439,CDM,C1889,HCPCS,0278,RC,,,,both,,,5259.50,3418.67,,,,,,,,,,,,,
PLATE BNE L 238 MM SCREW DIA 3.5 MM 20 H SS RECON NS,SUP-2908372,CDM,C1713,HCPCS,0278,RC,,,,both,,,2776.83,1804.94,,,,,,,,,,,,,
GRAFT BNE PELLET INJ 5 CC OSTEOSET XR,SUP-2759439,CDM,C1713,HCPCS,0278,RC,,,,both,,,1252.86,814.36,,,,,,,,,,,,,
LEAD SENSING RESPIRATORY INSPIRE,SUP-2664097,CDM,C1778,HCPCS,0278,RC,,,,both,,,10914.64,7094.52,,,,,,,,,,,,,
PLATE BONE 9 H RT FIB ANAT FOR ANK FX GORILLA,SUP-2321566,CDM,C1713,HCPCS,0278,RC,,,,both,,,7834.30,5092.29,,,,,,,,,,,,,
PLATE BNE W10.1XL58MM 5 H BILAT TI LO PROF RIG LOK COMPR,SUP-2191090,CDM,C1713,HCPCS,0278,RC,,,,both,,,1436.27,933.58,,,,,,,,,,,,,
ROD EXTERNAL FIXATION L200MM STAINLESS STEEL THREADED,SUP-2586508,CDM,2720000010,LOCAL,0272,RC,,,,both,,,434.98,282.74,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 160 MM DIA 9 MM DEL SHTH 11ML,SUP-2937081,CDM,C1713,HCPCS,0278,RC,,,,both,,,12622.80,8204.82,,,,,,,,,,,,,
CATHETER ANGIO SLIP-CATH L 100 CM DIA 3 FR GUIDEWIRE 0.025,SUP-2168702,CDM,C1751,HCPCS,0278,RC,,,,both,,,157.00,102.05,,,,,,,,,,,,,
IMPLANT HUM TISS W6MMXL25CM WHL CLLGN TEND STR KNOB END PASS,SUP-2400582,CDM,C1776,CPT,0278,RC,,,,both,,,3554.48,2310.41,,,,,,,,,,,,,
BUR SURG FLUT BALL 1 MMX7 CM SM BOR MIDAS REX LEGEND,SUP-2422253,CDM,2720000010,LOCAL,0272,RC,,,,both,,,349.92,227.45,,,,,,,,,,,,,
CATH BLLN SCORING 2.5X10MM X 137CM OTW PTCA ANGIOSCULPT,SUP-2353066,CDM,C1725,HCPCS,0272,RC,,,,both,,,138.16,89.80,,,,,,,,,,,,,
HANDPIECE ULTRSNC SYS 5 DEG L 180 MM M/F TIP EXT CRV DRVR,SUP-2883740,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2931.69,1905.60,,,,,,,,,,,,,
IMMUNE GLOBULIN (HUMAN) 10 GM/200ML IV SOLN,RX-104392,CDM,J1568,HCPCS,0636,RC,68982-0840-04,NDC,,both,200,ML,5730.70,3724.95,,,,,,,,,,,,,
COLLAR CERV PADDED SM SHT 2X10X20 IN COMFORT ADJ MIAMI J,SUP-2434341,CDM,L0174,HCPCS,0274,RC,,,,both,,,150.66,97.93,,,,,,,,,,,,,
VALVE FACEPLT BODY AND DIAPH ATSV II,SUP-2242325,CDM,L8501,HCPCS,0274,RC,,,,both,,,612.30,397.99,,,,,,,,,,,,,
ROCKER SPNL FOR OD4.5MM SCR ROD REDUC CD HORZ LEG,SUP-2290304,CDM,C1713,HCPCS,0278,RC,,,,both,,,3155.86,2051.31,,,,,,,,,,,,,
HC Incision of Lingual Frenum (Frenotomy),PX-3614101000,CDM,41010,CPT,0361,RC,,,,inpatient,,,4755.00,3090.75,,,,,,,,,,,,,
DISTRACTOR SURG MIC 25 MM 1 MM TOP RATCH ZURICH II,SUP-2473898,CDM,2720000010,LOCAL,0272,RC,,,,both,,,19582.20,12728.43,,,,,,,,,,,,,
KIT FRACTURE OMNICURVE 11GA 15 MM,SUP-2864548,CDM,2720000010,LOCAL,0272,RC,,,,both,,,8087.07,5256.60,,,,,,,,,,,,,
CATHETER CV DL 7.8 FR KT ACCS W/ INTEGR HEMSTAS VLV,SUP-2383945,CDM,C1751,HCPCS,0278,RC,,,,both,,,317.77,206.55,,,,,,,,,,,,,
CABLE ORTHPDC 1.3MM DIA 889MML CBLT CHRMM W/NDLE CRIMP CABLE,SUP-2500488,CDM,C1713,HCPCS,0278,RC,,,,both,,,869.37,565.09,,,,,,,,,,,,,
HC Assay of Prostate Specific Antigen Free,PX-3018415400,CDM,84154,CPT,0301,RC,,,,inpatient,,,267.00,173.55,,,,,,,,,,,,,
KNIFE ACCUTOME 600 550 OR 500UM 6MM POLISHED WNG FTPLT FULL,SUP-2106443,CDM,C1713,HCPCS,0278,RC,,,,both,,,1491.50,969.47,,,,,,,,,,,,,
BRACE ORTH SLD ANK FT,SUP-2388165,CDM,L1960,HCPCS,0274,RC,,,,both,,,1458.81,948.23,,,,,,,,,,,,,
SET PNEUMOTHOR LESS TRAUMATIC FOR PERC ASPIR,SUP-2383243,CDM,C1729,HCPCS,0272,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
KIT INTRO L 14CM DIA 9FR GUIDEWIRE L 50 CM DIA 0.038 IN PTFE,SUP-2125277,CDM,C1892,HCPCS,0272,RC,,,,both,,,103.34,67.17,,,,,,,,,,,,,
GUIDEWIRE VASC GLIDEWIRE 260CM 0.035IN TIP 3 CM STIFF ANGLED,SUP-2385591,CDM,C1769,HCPCS,0272,RC,,,,both,,,180.55,117.36,,,,,,,,,,,,,
SCREW BNE L65MM OD7MM SELF DRL CANN LNG THRD MAXTORQUE,SUP-2400319,CDM,C1713,HCPCS,0278,RC,,,,both,,,700.22,455.14,,,,,,,,,,,,,
LEAD NEUROSTIMULATOR L43CM DIA3MM VAGUS NRV SIL BPLR HELCL,SUP-2175912,CDM,C1767,HCPCS,0278,RC,,,,both,,,26690.00,17348.50,,,,,,,,,,,,,
SPACER FEM +0MM OFFSET 12/14 TAPR HIP MOD CATHCART UPLR,SUP-2251027,CDM,C1776,CPT,0278,RC,,,,both,,,235.50,153.07,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED UPCHARGE MOD CUP TRAB MEL,SUP-2212692,CDM,C1776,CPT,0278,RC,,,,both,,,1142.08,742.35,,,,,,,,,,,,,
SYSTEM EMB LIQ 1GM N BCA TANT PWD 10CC ETHIODIZED OIL VI,SUP-2257886,CDM,C1889,HCPCS,0278,RC,,,,both,,,13464.32,8751.81,,,,,,,,,,,,,
CANNULATED SCREW 8.0X75MM,SUP-2900832,CDM,C1713,HCPCS,0278,RC,,,,both,,,997.95,648.67,,,,,,,,,,,,,
PSYLLIUM 51.7 % PO PACK,RX-137582,CDM,6370000000,HCPCS,0637,RC,37000-0024-04,NDC,,both,1,UN,4.00,2.60,,,,,,,,,,,,,
HC Breath Hydrogen/Met Test,PX-9209106500,CDM,91065,CPT,0920,RC,,,,inpatient,,,362.00,235.30,,,,,,,,,,,,,
BIT DRL DIA3.3MM EQUINOXE FX,SUP-2223460,CDM,2720000010,LOCAL,0272,RC,,,,both,,,370.52,240.84,,,,,,,,,,,,,
BIT DRILL CROSSPIN PINN-ACL,SUP-2825126,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1365.46,887.55,,,,,,,,,,,,,
GRAFT VASC L30CM ID10MM RNGD SECT L30CM STD WALLED STR GOR,SUP-2396023,CDM,C1768,CPT,0278,RC,,,,both,,,2986.14,1940.99,,,,,,,,,,,,,
CARTRIDGE GRFT DEL GEL 5 CC STRL INSTAFILL SIGNIFY LTX,SUP-2865332,CDM,C1713,HCPCS,0278,RC,,,,both,,,5746.20,3735.03,,,,,,,,,,,,,
NAIL CPHLMDLLRY L215CM OD115MM 130DG SM SHRT TTNM RIGHT CCD,SUP-2462052,CDM,C1713,HCPCS,0278,RC,,,,both,,,4450.26,2892.67,,,,,,,,,,,,,
INTRODUCER SHTH TRANSSEPTAL 032 8 FRX60 CM 67 CM MULLINS,SUP-2464325,CDM,C1893,HCPCS,0272,RC,,,,both,,,323.42,210.22,,,,,,,,,,,,,
PLATE BNE H MINI LNG TI,SUP-2466582,CDM,C1713,HCPCS,0278,RC,,,,both,,,497.06,323.09,,,,,,,,,,,,,
CABLE SPNL DIA11MM ST TI SGL LOOP W BAR CRMP SONGER,SUP-2420957,CDM,C1713,HCPCS,0278,RC,,,,both,,,2452.34,1594.02,,,,,,,,,,,,,
"HC Est Pt, E/M Level 5",PX-5109921500,CDM,99215,CPT,0510,RC,,,,outpatient,,,369.00,239.85,,,,,,,,,,,,,
STEM FEM L120MM MOD CEM POREX ENDO MOD,SUP-2265094,CDM,C1776,CPT,0278,RC,,,,both,,,15282.38,9933.55,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY DYN XT L 65 CM DIA 6 FR SPC 5 MM,SUP-2142738,CDM,C1730,HCPCS,0272,RC,,,,both,,,1099.00,714.35,,,,,,,,,,,,,
SYSTEM BNE BX 11 GAX15 CM WESTBROOK,SUP-2479659,CDM,2720000010,LOCAL,0272,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
PARTICLE EMB EMBOCUBE HYDRATED SZ 5 MM CATH 0.04 IN 50MG,SUP-2501105,CDM,C1889,HCPCS,0278,RC,,,,both,,,172.70,112.25,,,,,,,,,,,,,
PLATE BONE L68MM LT CALCNL LCK FOR 3.5MM SCR PERI-LOC,SUP-2348512,CDM,C1713,HCPCS,0278,RC,,,,both,,,5391.07,3504.20,,,,,,,,,,,,,
PIMECROLIMUS 1 % EX CREA,RX-32052,CDM,6370000000,HCPCS,0637,RC,00187-5100-01,NDC,,both,30,GR,1345.70,874.70,,,,,,,,,,,,,
GRAFT HUM TISS 1CC PLCNTA TISS MTRX ALLGRFT FLOWERFLO,SUP-2225378,CDM,C1713,HCPCS,0278,RC,,,,both,,,7065.00,4592.25,,,,,,,,,,,,,
SYSTEM ENDOSCP VES HARV W/ TOOL CANN SEAL SHT PRT BLNT TIP,SUP-2227791,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4021.15,2613.75,,,,,,,,,,,,,
INSERTER SURG CRV FLX STRL FAST-FIX LTX,SUP-2880223,CDM,C1713,HCPCS,0278,RC,,,,both,,,1711.14,1112.24,,,,,,,,,,,,,
BLADE SURG TISSUE LIBERATOR UP BEND,SUP-2745478,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1318.80,857.22,,,,,,,,,,,,,
DILATOR ENDOSCP ADV L 80 CM DIA 5 FR BALLOON L 4 CM DIA 8 MM,SUP-2880206,CDM,C1726,HCPCS,0272,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
PLATE BNE L 8 H R MIDSHAFT CLAV LO PROF,SUP-2106986,CDM,C1713,HCPCS,0278,RC,,,,both,,,2791.46,1814.45,,,,,,,,,,,,,
AUGMENT FEM M THK10MM STD UNIV DST BLK PRI PRESSFIT ROT HNG,SUP-2253242,CDM,C1776,CPT,0278,RC,,,,both,,,1857.62,1207.45,,,,,,,,,,,,,
CROWN DENT 4 PLAS PRI UP LT CTRL PREFABRICATED TRNSPAR ANTR,SUP-2100384,CDM,D6783,CPT,0278,RC,,,,both,,,23.27,15.13,,,,,,,,,,,,,
PLATE BNE L90MM 4 H L LAT PROX PERIARTC HUM LOK COMPR,SUP-2410730,CDM,C1713,HCPCS,0278,RC,,,,both,,,4201.89,2731.23,,,,,,,,,,,,,
CATHETER ABLATN D CRV 2-5-2 MM SPC 6 FRX120 CM CRD QPLR RF,SUP-2356801,CDM,C1730,HCPCS,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
BRACE KNEE SM HNG PAT STBL BILAT AD PUL ON STRP CLSR,SUP-2196833,CDM,L1810,HCPCS,0274,RC,,,,both,,,56.99,37.04,,,,,,,,,,,,,
COMPONENT TIB UNI RM/LL 9MM SM EIUS,SUP-2364886,CDM,C1776,CPT,0278,RC,,,,both,,,8729.20,5673.98,,,,,,,,,,,,,
PROSTHESIS OSS DE LA CRUZ PISTON 0.6X3.50 MM SS FLROPLAS,SUP-2638112,CDM,L8613,CPT,0278,RC,,,,both,,,501.02,325.66,,,,,,,,,,,,,
HC Arthrogram Wrist S&I,PX-3227311500,CDM,73115,CPT,0322,RC,,,,outpatient,,,601.00,390.65,,,,,,,,,,,,,
KIT CATH TWO LUMN CTRL VEN ACCS SUP W/ ARROWG+ARD BLU ACCS,SUP-2383303,CDM,C1894,HCPCS,0272,RC,,,,both,,,188.09,122.26,,,,,,,,,,,,,
INSTRUMENT OP RM DRILLS 1.7X110MM DRIL,SUP-2321598,CDM,2720000010,LOCAL,0272,RC,,,,both,,,692.37,450.04,,,,,,,,,,,,,
ALLOGRAFT HUM TISS FEN 20X9 CM SHT AMNION/CHORION AMNIOFIX,SUP-2871493,CDM,C1762,CPT,0278,RC,,,,both,,,40568.80,26369.72,,,,,,,,,,,,,
GRAFT HUM TISS R MED FEM HEMICONDYLE FRSH REFRIGERATED,SUP-2264628,CDM,C1762,CPT,0278,RC,,,,both,,,36168.09,23509.26,,,,,,,,,,,,,
RING DIA140MM ALUM,SUP-2701755,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4535.73,2948.22,,,,,,,,,,,,,
DISTRACTOR SURG NO4 L60MM S STL DTT,SUP-2280176,CDM,C1713,HCPCS,0278,RC,,,,both,,,1267.78,824.06,,,,,,,,,,,,,
SCREW SPNL HEX 2X17 MM ETCHED DRL FREE TI MMF,SUP-2468626,CDM,C1713,HCPCS,0278,RC,,,,both,,,595.63,387.16,,,,,,,,,,,,,
CATHETER IRR SINUS RELIEVA VORT,SUP-2106359,CDM,C1729,HCPCS,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
SUPPORT ORTHOT HEEL CUST STD RUBBER,SUP-2435733,CDM,L3460,HCPCS,0272,RC,,,,both,,,97.28,63.23,,,,,,,,,,,,,
PLATE BNE STR MINI LNG 2X1 MM 12 MM 4 HOLE BRIDGE TI LEVEL 1,SUP-2483177,CDM,C1713,HCPCS,0278,RC,,,,both,,,531.51,345.48,,,,,,,,,,,,,
MARKER SITE SECURMARK FOR 12GA BX DEV ATEC,SUP-2240041,CDM,A4648,CPT,0278,RC,,,,both,,,218.86,142.26,,,,,,,,,,,,,
PLATE BNE W135XL368MM THK42MM 20 H BILAT S STL NAR LOK,SUP-2185259,CDM,C1713,HCPCS,0278,RC,,,,both,,,3429.07,2228.90,,,,,,,,,,,,,
GUIDE WIRE PERC 2.5MM F/5MM LCK SCR,SUP-2548437,CDM,C1769,HCPCS,0272,RC,,,,both,,,1901.74,1236.13,,,,,,,,,,,,,
SCREW BNE L60MM DIA3.7MM CORT S STL ST DRL CANN LOK FULL,SUP-2178754,CDM,C1713,HCPCS,0278,RC,,,,both,,,496.31,322.60,,,,,,,,,,,,,
COUNTERSINK SURG CONDYLE T2 ALPHA SYS STRL DISP,SUP-2902692,CDM,2720000010,LOCAL,0272,RC,,,,both,,,750.46,487.80,,,,,,,,,,,,,
SPHERE GLEN 2X25 MM ECC FOR AEQUALIS COCR,SUP-2431493,CDM,C1776,CPT,0278,RC,,,,both,,,9628.81,6258.73,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY WEBST L 110 CM DIA 5 FR TIP 1 MM,SUP-2248859,CDM,C1730,HCPCS,0272,RC,,,,both,,,323.42,210.22,,,,,,,,,,,,,
HEAD FEM 28 MM HIP CERM 111152012] PAXEON RECONSTRUCTION],SUP-2322446,CDM,C1776,CPT,0278,RC,,,,both,,,628.00,408.20,,,,,,,,,,,,,
GRAFT VASC W1XL6IN ULT THN FAB PLAT KNIT DBL VEL NONTAPERED,SUP-2265860,CDM,C1768,CPT,0278,RC,,,,both,,,395.64,257.17,,,,,,,,,,,,,
SPLINT WR AD SM UPTO W3.5IN LT MCP DLX KAY-SPLNT III,SUP-2324559,CDM,L3906,HCPCS,0274,RC,,,,both,,,79.41,51.62,,,,,,,,,,,,,
BRACE KNEE POSTOP UNIV UNISX FASTEN ON HNG ROM STRP CLSR AD,SUP-2196449,CDM,L1832,HCPCS,0272,RC,,,,both,,,401.45,260.94,,,,,,,,,,,,,
ALLOGRAFT HUM TISS SPACER 14X12.5X8.22 MM PARL VERTIGRAFT,SUP-2264959,CDM,C1713,HCPCS,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
HC Arterial Line Insertion,PX-7613662001,CDM,36620,CPT,0370,RC,,,,outpatient,,,789.00,512.85,,,,,,,,,,,,,
MESH SURG W4.3XL4.3CM CIR VENTRAL PTCH FOR TISS SEPARATING,SUP-2219821,CDM,C1781,HCPCS,0278,RC,,,,both,,,1326.90,862.48,,,,,,,,,,,,,
PLATE BNE L241MM 8 H NONSTERILE PROX FEM S STL HK LO PROF,SUP-2186058,CDM,C1713,HCPCS,0278,RC,,,,both,,,4599.75,2989.84,,,,,,,,,,,,,
PLATE BNE TIB LT DSTL POSTEROLATERAL ANK 4 HOLE NS,SUP-2518423,CDM,C1713,HCPCS,0278,RC,,,,both,,,5237.52,3404.39,,,,,,,,,,,,,
GUIDEWIRE ORTH DIA2MM SMOOTH INSRT FOR FEM NAIL PEDINAIL,SUP-2318960,CDM,C1769,HCPCS,0272,RC,,,,both,,,1240.93,806.60,,,,,,,,,,,,,
SCREW BNE ST 1.55X3 MM CRANIOFACIAL TI BRNZ NS MATRIXMIDFACE,SUP-2181607,CDM,C1713,HCPCS,0278,RC,,,,both,,,319.15,207.45,,,,,,,,,,,,,
MODULUS XLW 8X22X60MM 10 DEG INDIV ST PKG,SUP-2421140,CDM,C1889,HCPCS,0278,RC,,,,both,,,13345.00,8674.25,,,,,,,,,,,,,
DEVICE SPEC RETRV MAXI ESOPH SWIRLNET,SUP-2490688,CDM,2720000010,LOCAL,0272,RC,,,,both,,,442.02,287.31,,,,,,,,,,,,,
MESH CRAN CUSTOMIZED + XL MEDPOR PTERIONAL +,SUP-2862747,CDM,C1713,HCPCS,0278,RC,,,,both,,,68297.32,44393.26,,,,,,,,,,,,,
ANCHOR SUT DIA4.75MM BIOCRYL RAPIDE ABSRB KNOTLESS HEALIX,SUP-2249438,CDM,C1713,HCPCS,0278,RC,,,,both,,,2957.88,1922.62,,,,,,,,,,,,,
CATHETER SPHINTOM DBL LUMN SIZE: 6F,SUP-2169383,CDM,C1713,HCPCS,0278,RC,,,,both,,,555.78,361.26,,,,,,,,,,,,,
SCREW KIT LNG CANC SCR STRL GALAXY UNYCO,SUP-2646396,CDM,C1713,HCPCS,0278,RC,,,,both,,,533.36,346.68,,,,,,,,,,,,,
BUR SURG BUD DMND N FLUT,SUP-2227829,CDM,2720000010,LOCAL,0272,RC,,,,both,,,46.63,30.31,,,,,,,,,,,,,
HC Obstetrical Care,PX-4505940900,CDM,59409,CPT,0450,RC,,,,both,,,3074.00,1998.10,,,,,,,,,,,,,
PIN HALF THRD 6X200 MM 80 MM EXT FIX SS HA,SUP-2343025,CDM,C1713,HCPCS,0278,RC,,,,both,,,1260.96,819.62,,,,,,,,,,,,,
SET CLLR AD H3IN FOR 13-21IN NK REG ORNG PLAS HK AND LOOP,SUP-2124216,CDM,L0172,HCPCS,0272,RC,,,,both,,,90.87,59.07,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP STR 0.025 INX260 CM HYDRPHLC COAT NAVIPRO,SUP-2141537,CDM,C1769,HCPCS,0272,RC,,,,both,,,322.76,209.79,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 30 CM DIA 4-7 MM SHRT TAPR REINF,SUP-2669625,CDM,C1768,CPT,0278,RC,,,,both,,,607.18,394.67,,,,,,,,,,,,,
SPLINT ORTHOPEDIC W/ ABDUCTED MED 8 IN RT WRST FOREARM THMB,SUP-2276638,CDM,L3809,HCPCS,0272,RC,,,,both,,,22.61,14.70,,,,,,,,,,,,,
PACEMAKER CARD INSIGNIA I ENTRA TI 2 CHMBR IS1 CONN UPLR,SUP-2148609,CDM,C1785,HCPCS,0275,RC,,,,both,,,17009.38,11056.10,,,,,,,,,,,,,
SCREW BNE L4MM DIA1MM CORT TI ST FULL THRD CRUCFRM RECESS,SUP-2189074,CDM,C1713,HCPCS,0278,RC,,,,both,,,337.17,219.16,,,,,,,,,,,,,
FRACTURE KIT 10 ML BNE CEMENT SATURATE MIXING STABILIT ER,SUP-2457092,CDM,C1713,HCPCS,0278,RC,,,,both,,,2232.54,1451.15,,,,,,,,,,,,,
GASTROSTOMY SET PUL METHOD 24 FRX150 CM 0.035 260 CM PEG24,SUP-2738239,CDM,C1769,HCPCS,0272,RC,,,,both,,,533.80,346.97,,,,,,,,,,,,,
LENS IOL 16.5 DIOPT DIA12.5 MM A CONSTANT BLK,SUP-2882613,CDM,V2787,HCPCS,0276,RC,,,,both,,,950.00,617.50,,,,,,,,,,,,,
BRONCHOSCOPE L600MM DIA22MM FLX VID REG DISPOSABLE ASCOPE 3,SUP-2115186,CDM,2720000010,LOCAL,0272,RC,,,,both,,,844.66,549.03,,,,,,,,,,,,,
COIL NEUROVASCULAR TRUFILL L 5 MM MICROCATHETER 0.021 IN,SUP-2482185,CDM,C1768,CPT,0278,RC,,,,both,,,1523.21,990.09,,,,,,,,,,,,,
BUR SHV OD55MM HPS PREBENT SPHR,SUP-2167163,CDM,2720000010,LOCAL,0272,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
MARKER RAD 1X5MM NDL L20CM OD18GA GLD FIDUCIAL PROST SEED,SUP-2164652,CDM,A4648,CPT,0278,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
DRILL SURG 0.25 IN STR JCBS CHK W/ KEY HI TORQUE BSPMAX II,SUP-2745857,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2003.32,1302.16,,,,,,,,,,,,,
SCREW BNE L 46 MM DIA 4.5 MM CORTICAL ST STRL EVOS,SUP-2931158,CDM,C1713,HCPCS,0278,RC,,,,both,,,177.16,115.15,,,,,,,,,,,,,
PLATE BNE THK0.6MM 7 H STD CRANIOMAXILLOFACIAL G TI DBL Y,SUP-2366272,CDM,C1713,HCPCS,0278,RC,,,,both,,,558.51,363.03,,,,,,,,,,,,,
SURGICAL PROCEDURE KIT 55 CM SPOTLT OPS SHTH VENACURE EVLT,SUP-2752487,CDM,C1888,HCPCS,0272,RC,,,,both,,,886.61,576.30,,,,,,,,,,,,,
PLATE BNE L 125 MM 14 H SCREW DIA2.7 MM BROAD LCK MINI FRAG,SUP-2902344,CDM,C1713,HCPCS,0278,RC,,,,both,,,4928.54,3203.55,,,,,,,,,,,,,
PLATE BNE LP 1.5X0.6 MM NEURO 4X2 HOLE LADDER SQ SEG TI NS,SUP-2468727,CDM,C1713,HCPCS,0278,RC,,,,both,,,829.18,538.97,,,,,,,,,,,,,
STENT BILI OMLNK L 38 MM DIA 7 MM CATH L 135 CM GUIDEWIRE,SUP-2101584,CDM,C1876,HCPCS,0278,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
SPRAY PULSE 2 CK VLV,SUP-2117035,CDM,C1751,HCPCS,0278,RC,,,,both,,,602.88,391.87,,,,,,,,,,,,,
PLATE BNE ANTR BRIM LT PELV 12 HOLE,SUP-2518350,CDM,C1713,HCPCS,0278,RC,,,,both,,,4587.54,2981.90,,,,,,,,,,,,,
CANNULA TRACH ID8MM INNR FOR 9MM PERC TB PER FIT PORTEX,SUP-2352318,CDM,C1713,HCPCS,0278,RC,,,,both,,,500.36,325.23,,,,,,,,,,,,,
PLATE BNE L MED NAR 0.6 MM RT LP WEB TI,SUP-2473225,CDM,C1713,HCPCS,0278,RC,,,,both,,,476.93,310.00,,,,,,,,,,,,,
IMPLANT SUBTALAR L12MM DIA7MM ANK JT FOR ARTHROERESIS,SUP-2121852,CDM,C1713,HCPCS,0278,RC,,,,both,,,4694.30,3051.29,,,,,,,,,,,,,
SOD CITRATE-CITRIC ACID 500-334 MG/5ML PO SOLN,RX-11394,CDM,340b,HCPCS,0637,RC,00121-1190-00,NDC,,both,15,ML,11.50,7.47,,,,,,,,,,,,,
HC Declot Vascular Device,PX-5103659300,CDM,36593,CPT,0510,RC,,,,both,,,1120.00,728.00,,,,,,,,,,,,,
SUTURE ANCHR TI ANCHR TWINFIX TI 5.0 MM SUT ANCHR W/ TWO,SUP-2341673,CDM,C1713,HCPCS,0278,RC,,,,both,,,767.38,498.80,,,,,,,,,,,,,
PLATE BONE 29X47MM THK0.3MM TEMPORAL SKULL BASE MALL FOR,SUP-2363573,CDM,C1713,HCPCS,0278,RC,,,,both,,,2627.36,1707.78,,,,,,,,,,,,,
GUIDEWIRE ORTH L6IN DIA0.035IN DBL TRCR FOR MIC COMPR SCR,SUP-2107169,CDM,C1769,HCPCS,0272,RC,,,,both,,,56.52,36.74,,,,,,,,,,,,,
CATHETER EMB 7FR CTRL FLO EPS PROXIS,SUP-2356605,CDM,C1884,HCPCS,0278,RC,,,,both,,,4239.00,2755.35,,,,,,,,,,,,,
INSERT TIB THK 7 MM SZ 1 UHMWPE RT ANK TOT ANAT NEUT STRL,SUP-2931410,CDM,C1776,CPT,0278,RC,,,,both,,,8102.93,5266.90,,,,,,,,,,,,,
TOCILIZUMAB 20 MG/ML IV SOLN (MIXTURES ONLY),RX-430062,CDM,J3262,HCPCS,0636,RC,50242-0137-01,NDC,,both,20,ML,7834.70,5092.55,,,,,,,,,,,,,
GRAFT OTO 0.4-0.6CM POR PORCINE SM INTEST SUBMUCOSA LAM,SUP-2170504,CDM,C1763,HCPCS,0278,RC,,,,both,,,659.40,428.61,,,,,,,,,,,,,
SHUNT SURG PLEUR EFFUS DENV,SUP-2133700,CDM,C1889,HCPCS,0278,RC,,,,both,,,5007.26,3254.72,,,,,,,,,,,,,
WIRE BNE FIX L 152 MM DIA 0.9 MM SINGLE END TROCAR TIP NS,SUP-2933571,CDM,C1713,HCPCS,0278,RC,,,,both,,,81.33,52.86,,,,,,,,,,,,,
COIL NEUROVASCULAR L 27 CM DIA 98 MM DIA 0.0135 IN DEL CATH,SUP-2894689,CDM,C1889,HCPCS,0278,RC,,,,both,,,5495.00,3571.75,,,,,,,,,,,,,
SHEATH INTRO FAST-CATH L 75 CM DIA12 FR GUIDEWIRE 0.038 IN,SUP-2355526,CDM,C1894,HCPCS,0272,RC,,,,both,,,86.35,56.13,,,,,,,,,,,,,
PLATE BONE L74MM 6 H POST LAT S STL 1/3 TBLR LCK COMPR FOR,SUP-2349795,CDM,C1713,HCPCS,0278,RC,,,,both,,,2119.88,1377.92,,,,,,,,,,,,,
IMMOBILIZER SHLDR M STRP 39IN,SUP-2324218,CDM,L3650,HCPCS,0272,RC,,,,both,,,19.12,12.43,,,,,,,,,,,,,
DRILL SURG N CANN LNG FOR 3.5 MM SCREW,SUP-2598342,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2081.82,1353.18,,,,,,,,,,,,,
PLATE BONE L86MM 7 H LT POSTEROLATERAL DSTL FIBULAR VAR ANG,SUP-2349821,CDM,C1713,HCPCS,0278,RC,,,,both,,,5299.69,3444.80,,,,,,,,,,,,,
PLATE BNE L129MM 7 H NONSTERILE R POSTEROLATERAL DST FIBULAR,SUP-2177391,CDM,C1713,HCPCS,0278,RC,,,,both,,,1781.89,1158.23,,,,,,,,,,,,,
STAPLER INT AD L30MM DIA4.8MM TI STR PRELD DISP ROTIC,SUP-2283031,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1920.36,1248.23,,,,,,,,,,,,,
WIRE FIX 150MM 1.6MM TI K,SUP-2193147,CDM,C1713,HCPCS,0278,RC,,,,both,,,24.65,16.02,,,,,,,,,,,,,
SALVATION  C WASHER 2.5MM 6PK MULTIPACK,SUP-2493481,CDM,C1713,HCPCS,0278,RC,,,,both,,,480.42,312.27,,,,,,,,,,,,,
LINER ACETABULAR CONSTR E1 SIZE H 36MM,SUP-2505370,CDM,C1776,CPT,0278,RC,,,,both,,,2669.00,1734.85,,,,,,,,,,,,,
PLATE BNE L 161 MM SCREW DIA 4.5 MM 8 H LT PROX LAT TIB NS,SUP-2933304,CDM,C1713,HCPCS,0278,RC,,,,both,,,9792.09,6364.86,,,,,,,,,,,,,
ANCHOR SUT 5.5MM 3 SUT W/O NDL ROPH BIOSTEON INTRALINE,SUP-2366672,CDM,C1713,HCPCS,0278,RC,,,,both,,,788.14,512.29,,,,,,,,,,,,,
CATHETER EP TPLR DAMATO FIX CRV WVN POLYUR SHFT 7FRX110CM,SUP-2142011,CDM,C1730,HCPCS,0272,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
TROCAR ENDOSCP L 70 MM DIA 5 MM LAPSCP SHRT BLADED SMTH CANN,SUP-2896368,CDM,2720000010,LOCAL,0272,RC,,,,both,,,381.38,247.90,,,,,,,,,,,,,
PLATE BNE L79MM 5 H R MED DST HUM LOK FOR 2.7/3.5MM SCR,SUP-2348596,CDM,C1713,HCPCS,0278,RC,,,,both,,,10081.60,6553.04,,,,,,,,,,,,,
IMPLANT HUM TISS L 15 X W 7.5 CM AMNIO MEMBRN LYOPRESERVED,SUP-2905504,CDM,Q4133,HCPCS,0636,RC,,,,both,,,27318.00,17756.70,,,,,,,,,,,,,
STIMULATOR BONE GROWTH SPINALOGIC,SUP-2196349,CDM,2780000010,LOCAL,0278,RC,,,,both,,,9435.70,6133.20,,,,,,,,,,,,,
STEM FEM SZ 1 LT N CLLRD POR NAT HIP,SUP-2210732,CDM,C1776,CPT,0278,RC,,,,both,,,14225.77,9246.75,,,,,,,,,,,,,
NAIL IM L360MM DIA10MM NK ANG 130DEG LT FEM TI CANN LCK,SUP-2347148,CDM,C1713,HCPCS,0278,RC,,,,both,,,12487.78,8117.06,,,,,,,,,,,,,
NEEDLE PEDCL ACCS PK1002,SUP-2660653,CDM,2720000010,LOCAL,0272,RC,,,,both,,,574.81,373.63,,,,,,,,,,,,,
PLATE BONE L21MM THK1.2MM SHFT W5MM 4 H STRL FLX FOR 2MM SCR,SUP-2349649,CDM,C1713,HCPCS,0278,RC,,,,both,,,3350.38,2177.75,,,,,,,,,,,,,
MORCELLATOR HYSTEROSCOPIC DEV DST MRK 5MM FOR USE W 5C SYS,SUP-2172304,CDM,C1782,HCPCS,0272,RC,,,,both,,,1411.27,917.33,,,,,,,,,,,,,
ROD SPNL ANTR RT CVD SMOOTH S STL 5.0MM DIA 110MM LEN,SUP-2290505,CDM,C1713,HCPCS,0278,RC,,,,both,,,1748.98,1136.84,,,,,,,,,,,,,
IMPLANT TOE JT PHLANG KGTI SZ 2,SUP-2242675,CDM,C1776,CPT,0278,RC,,,,both,,,6458.98,4198.34,,,,,,,,,,,,,
PLATE BONE L132MM THK3.4MM 9 H BILAT NONLOCKING COMPR FOR,SUP-2348952,CDM,C1713,HCPCS,0278,RC,,,,both,,,1577.72,1025.52,,,,,,,,,,,,,
BODY FEM SZ 16.5 LNG L HA DST TEXT APR,SUP-2211011,CDM,C1776,CPT,0278,RC,,,,both,,,29170.60,18960.89,,,,,,,,,,,,,
HC So Detect Agent Nos Dna Amp,PX-3068779866,CDM,87798,CPT,0306,RC,,,,both,,,192.00,124.80,,,,,,,,,,,,,
FIXED ANGLE GUIDE 135 DEG,SUP-2704816,CDM,C1713,HCPCS,0278,RC,,,,both,,,740.29,481.19,,,,,,,,,,,,,
COMPONENT HIP BPLR HA PART LO DEMAND,SUP-2249605,CDM,C1776,CPT,0278,RC,,,,both,,,8164.00,5306.60,,,,,,,,,,,,,
ALLOGRAFT DERMAL 1X4 CMX0.76-1.25 MM DECELL DERM ORACELL,SUP-2741069,CDM,C1713,HCPCS,0278,RC,,,,both,,,517.47,336.36,,,,,,,,,,,,,
BUTTON SUT L10.9MM DIA2.6MM FOR PECTORALIS REP,SUP-2121667,CDM,C1776,CPT,0278,RC,,,,both,,,926.30,602.09,,,,,,,,,,,,,
ROD FOR GALAXY FIX SYS 12MM 250MM,SUP-2316297,CDM,2720000010,LOCAL,0272,RC,,,,both,,,858.54,558.05,,,,,,,,,,,,,
CATHETER PERITONEAL OPN END 91 CM FULL BA W/ SLT,SUP-2851309,CDM,C1729,HCPCS,0272,RC,,,,both,,,475.55,309.11,,,,,,,,,,,,,
HC Convert Nephrostomy Catheter,PX-3615043400,CDM,50434,CPT,0361,RC,,,,inpatient,,,6875.00,4468.75,,,,,,,,,,,,,
HC Sel Cath Thor/Brachioceph 1st,PX-3613621500,CDM,36215,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
SET URET STENT SOFFLX L 28 CM DIA10 FR INSRTR L 40 CM DIA10,SUP-2171262,CDM,C2617,HCPCS,0278,RC,,,,both,,,437.09,284.11,,,,,,,,,,,,,
LOCK SFS 27/40 NL CADDY LIDS,SUP-2724038,CDM,C1725,HCPCS,0272,RC,,,,both,,,1144.91,744.19,,,,,,,,,,,,,
WIRE FIX TROCAR PT 1 END 1X150 MM SS NS KIRSCHNER,SUP-2905650,CDM,C1713,HCPCS,0278,RC,,,,both,,,28.10,18.26,,,,,,,,,,,,,
CATHETER NEPHSTMY 8FR L25CM FLEXIMA KT REG PGTL TIP RADPQ,SUP-2147848,CDM,C1729,HCPCS,0272,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
SCREW BNE L74MM DIA4.5MM CORT PROX FEM ANK S STL ST FULL,SUP-2350222,CDM,C1713,HCPCS,0278,RC,,,,both,,,386.82,251.43,,,,,,,,,,,,,
GRAFT HUM TISS TIB CORT STRUT BNE FRZ DRY ALLGRFT 100MM LEN,SUP-2264713,CDM,C1713,HCPCS,0278,RC,,,,both,,,2274.24,1478.26,,,,,,,,,,,,,
HC Peripheral Block - Tap Bilateral Infusion,PX-3606448900,CDM,64489,CPT,0360,RC,,,,both,,,1238.00,804.70,,,,,,,,,,,,,
HC Path Consltj Surg Cytologic Exam Each Addl Site,PX-3118833400,CDM,88334,CPT,0311,RC,,,,both,,,227.00,147.55,,,,,,,,,,,,,
CATHETER THERMOABLATION CLOSUREPLUS DIA 8 FR GUIDEWIRE 0.025,SUP-2393082,CDM,C1760,HCPCS,0278,RC,,,,both,,,2339.30,1520.54,,,,,,,,,,,,,
AIRWAY LARYNGEAL CHILDREN 30-50KG MASK SIZE 3 OROGASTRIC TUB,SUP-2824818,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1303.10,847.01,,,,,,,,,,,,,
BUTTON SUT L45MM DIA12MM LOOP RETROBTTN,SUP-2121380,CDM,2720000010,LOCAL,0272,RC,,,,both,,,737.90,479.63,,,,,,,,,,,,,
SCREW BONE L6MM DIA3.5MM STRL CORT S STL ST FOR SM PLATING,SUP-2349331,CDM,C1713,HCPCS,0278,RC,,,,both,,,155.02,100.76,,,,,,,,,,,,,
TRAY PERICARDCENT CATH 5FR L20CM 0.025IN 7 SIDEPRT TO,SUP-2168549,CDM,C1769,HCPCS,0272,RC,,,,both,,,552.64,359.22,,,,,,,,,,,,,
GRAFT BNE 3 CC AUG,SUP-2759480,CDM,C1734,HCPCS,0278,RC,,,,both,,,10424.80,6776.12,,,,,,,,,,,,,
SET IMPL 3.5MM LO PROF PELV SYS,SUP-2177061,CDM,C1713,HCPCS,0278,RC,,,,both,,,136236.06,88553.44,,,,,,,,,,,,,
SCREW BONE 3.5MMX65MM LCK T20 ST PERI-LOC,SUP-2349993,CDM,C1713,HCPCS,0278,RC,,,,both,,,1297.51,843.38,,,,,,,,,,,,,
ORTHOPAEDIC INSTRUMENT KIT IM IMPL SCR STRL MINIBUNION LTX,SUP-2866375,CDM,C1713,HCPCS,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
SCREW INTRF L 15 MM DIA 7 PM STRL CITRELOCK XPRESS,SUP-2900560,CDM,C1713,HCPCS,0278,RC,,,,both,,,5127.62,3332.95,,,,,,,,,,,,,
NAIL IM ZCKL II SUBTROCHANTERIC 95MM NAIL,SUP-2364783,CDM,C1713,HCPCS,0278,RC,,,,both,,,1030.39,669.75,,,,,,,,,,,,,
PLATFORM SUT ANCHR DIA2.3MM W/ NO2 TWO STRND FORC FBR,SUP-2366693,CDM,C1713,HCPCS,0278,RC,,,,both,,,1407.69,915.00,,,,,,,,,,,,,
BLADE RETRACTOR HARRINGTON UNIV 2/3X2.25 IN ABD RNG,SUP-2458924,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1251.73,813.62,,,,,,,,,,,,,
SEGMENTAL DISTAL FEMUR SIZE C-RT,SUP-2502381,CDM,C1776,CPT,0278,RC,,,,both,,,21406.95,13914.52,,,,,,,,,,,,,
BONE MECH GIC58 6X14X11 CANC BLK,SUP-2293805,CDM,C1713,HCPCS,0278,RC,,,,both,,,2496.30,1622.59,,,,,,,,,,,,,
DEFIBRILLATOR CARDIOVERTER SGL CHMBR 30J PECTORAL BPLR VVEV,SUP-2357749,CDM,C1722,HCPCS,0275,RC,,,,both,,,52124.00,33880.60,,,,,,,,,,,,,
BIT DRL L 115 MM DIA2.4 MM LAG QC NS DISP,SUP-2936421,CDM,2720000010,LOCAL,0272,RC,,,,both,,,700.22,455.14,,,,,,,,,,,,,
GRAFT VASC W6XL6CM THK0.4MM CV PTCH GOR TX,SUP-2395308,CDM,C1768,CPT,0278,RC,,,,both,,,697.08,453.10,,,,,,,,,,,,,
TERBINAFINE HCL 250 MG PO TABS,RX-12724,CDM,6370000000,HCPCS,0637,RC,69097-0859-02,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
STIMULATOR IMPL FUS,SUP-2414469,CDM,E0749,HCPCS,0278,RC,,,,both,,,17725.30,11521.44,,,,,,,,,,,,,
HC Ot Elec Stim Unattended,PX-4309701400,CDM,97014,CPT,0430,RC,,,,both,,,206.00,133.90,,,,,,,,,,,,,
BOLT ORTH L34MM DIA6.9MM LAT TROCHANTERIC HIP CO CHROM MOD,SUP-2404492,CDM,C1713,HCPCS,0278,RC,,,,both,,,1381.60,898.04,,,,,,,,,,,,,
KIT DRNGE SUMP J TIP CATH TRCR STYL .038IN GUIDWIRE CANN,SUP-2147873,CDM,C1729,HCPCS,0272,RC,,,,both,,,471.47,306.46,,,,,,,,,,,,,
KIT RETRCT SHIM DISP FOR MINIMAL ACCS SYS MAXCESS 4,SUP-2310431,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4396.00,2857.40,,,,,,,,,,,,,
SHELL ACET PRESSFIT PRI 48 MM OD UNIV MULT H TRABECULAR MTL,SUP-2202626,CDM,C1776,CPT,0278,RC,,,,both,,,5204.55,3382.96,,,,,,,,,,,,,
MARKER SFT TISS L3MM DIA0.9MM GLD FIDUCIAL W/ 18GA L12CM ETW,SUP-2164654,CDM,A4648,CPT,0278,RC,,,,both,,,222.94,144.91,,,,,,,,,,,,,
PLATE BONE STRAIGHT 2 MM RAPID RESORBABLE STERILE RAPIDSORB,SUP-2838587,CDM,C1713,HCPCS,0278,RC,,,,both,,,498.95,324.32,,,,,,,,,,,,,
GRAFT BIO TISS 2X4CM THK04 10MM PROLAYER,SUP-2362226,CDM,C1763,HCPCS,0278,RC,,,,both,,,2587.36,1681.78,,,,,,,,,,,,,
ROD EXT FIX JT UNIV GRV,SUP-2491187,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2085.90,1355.83,,,,,,,,,,,,,
DRILL W/QC 2.0MM,SUP-2841805,CDM,2720000010,LOCAL,0272,RC,,,,both,,,319.81,207.88,,,,,,,,,,,,,
SHUNT CAR 8FR L31CM REG TEMP W/O RESVR T PRT,SUP-2264219,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4078.86,2651.26,,,,,,,,,,,,,
KIT AIRFLOW SENS PRSS TRNSDUC PTAF LT FOR ALICE 5 PRO TECH,SUP-2327534,CDM,C1713,HCPCS,0278,RC,,,,both,,,926.30,602.09,,,,,,,,,,,,,
PLATE BNE PANCARPAL 2/2.7 MM 11 HOLE ARTH SS LCP,SUP-2569398,CDM,C1713,HCPCS,0278,RC,,,,both,,,538.82,350.23,,,,,,,,,,,,,
SCREW BNE CORTICAL 6X20-70 MM 2.5-3 MM SD THRD SHFT,SUP-2874953,CDM,C1713,HCPCS,0278,RC,,,,both,,,340.66,221.43,,,,,,,,,,,,,
PLATE BNE CRV 10 MM 4 HOLE SAG,SUP-2417588,CDM,C1713,HCPCS,0278,RC,,,,both,,,1568.90,1019.78,,,,,,,,,,,,,
CATHETER VENTRICULAR STR SM 2.2 MMX18 CM TANTALUM PUDENZ,SUP-2852593,CDM,C1729,HCPCS,0272,RC,,,,both,,,477.41,310.32,,,,,,,,,,,,,
STRUT EXT FIX 80-120 MM C/D SALVATION,SUP-2463765,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3312.70,2153.25,,,,,,,,,,,,,
KIT INTRO FLUENT L 10 CM DIA 5 FR GUIDEWIRE L 40 CM NDL L 7,SUP-2164807,CDM,C1894,HCPCS,0272,RC,,,,both,,,59.66,38.78,,,,,,,,,,,,,
STENT BILI HANAROSTENT L 50 MM DIA 8 MM L 1800 MM SHRT WIRE,SUP-2461954,CDM,C1876,HCPCS,0278,RC,,,,both,,,5369.40,3490.11,,,,,,,,,,,,,
LEVEL NEURO ST PLATE MICRO LDDR 15 MM SCRW2 X 2 HOLES 12 MM,SUP-2707406,CDM,C1713,HCPCS,0278,RC,,,,both,,,559.83,363.89,,,,,,,,,,,,,
TRAY CATH 4FR SGL LUMN NONCOATED VLV COMPATIBLE TRIM LEN,SUP-2125635,CDM,C1751,HCPCS,0278,RC,,,,both,,,698.59,454.08,,,,,,,,,,,,,
STEM FEM L13MM DIA6MM EXT HIP CEM ENCOMPASS,SUP-2314454,CDM,C1776,CPT,0278,RC,,,,both,,,6079.04,3951.38,,,,,,,,,,,,,
PLATE BNE DBL ANGLED MED 2 MM RECON PT SPEC,SUP-2860083,CDM,C1713,HCPCS,0278,RC,,,,both,,,26989.24,17543.01,,,,,,,,,,,,,
CATHETER HEMO DYLS OR HD L15CM ADMIN ACUTE BASIC KT 8 FR AD,SUP-2267028,CDM,C1751,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
PROSTHESIS OSS VENT TUBE 1.27 MM W/ TAB PAPARELLA FLROPLAS,SUP-2312785,CDM,L8699,HCPCS,0278,RC,,,,both,,,49.36,32.08,,,,,,,,,,,,,
COMPONENT GLENOSPHERE XTEND 42MM PLUS 6MM,SUP-2427755,CDM,C1776,CPT,0278,RC,,,,both,,,4396.00,2857.40,,,,,,,,,,,,,
CATHETER EP SINGLE 2-5-2MM 7FRX90CM MARINR,SUP-2281836,CDM,C1731,HCPCS,0278,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
SCREW BNE 1.5X8 MM HEXADRIVE 4 TI SPEEDTIP,SUP-2423807,CDM,C1713,HCPCS,0278,RC,,,,both,,,429.24,279.01,,,,,,,,,,,,,
BIT DRL L 155/60 MM DIA2.5 MM CALIB AO QC STRL DISP V,SUP-2907658,CDM,2720000010,LOCAL,0272,RC,,,,both,,,893.49,580.77,,,,,,,,,,,,,
HC Voice Prosthesis Eval,PX-4449259700,CDM,92597,CPT,0444,RC,,,,outpatient,,,478.00,310.70,,,,,,,,,,,,,
KIT INTRO VSI DE-CLOT SHTH L 4 CM DIA 7 FR GUIDEWIRE L 40 CM,SUP-2120538,CDM,C1757,HCPCS,0272,RC,,,,both,,,141.30,91.84,,,,,,,,,,,,,
HC Cyclic Citrullinated Peptide Antibody,PX-3028620000,CDM,86200,CPT,0302,RC,,,,both,,,70.00,45.50,,,,,,,,,,,,,
BAG TISS CLSR DIA10CM TRNSPAR SIL SILO SPR LD PROX OPN SFT,SUP-2134675,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1560.58,1014.38,,,,,,,,,,,,,
STENT PERIPH 6FR L170MM DIA7MM CATH L80CM 0.035IN NIT SELF,SUP-2420404,CDM,C1876,HCPCS,0278,RC,,,,both,,,6123.00,3979.95,,,,,,,,,,,,,
RING FIX 11-13MM CAPSULAR TENS REFORM,SUP-2110079,CDM,L8610,HCPCS,0278,RC,,,,both,,,675.79,439.26,,,,,,,,,,,,,
PIN EXT FIX HALF 4X34 MM 120 MM SD SHANK HA COAT STRL,SUP-2749900,CDM,2720000010,LOCAL,0272,RC,,,,both,,,847.80,551.07,,,,,,,,,,,,,
GRAFT HUM TISS W8XL20CM THK07 14MM THN ACELLULAR HYDRATED,SUP-2307555,CDM,Q4128,HCPCS,0636,RC,,,,both,,,13588.35,8832.43,,,,,,,,,,,,,
GRAFT BNE VIABLE 5CC TIM MTRX FIBERCEL,SUP-2422146,CDM,C1762,CPT,0278,RC,,,,both,,,9592.70,6235.25,,,,,,,,,,,,,
RING SPNL STD 28X22 MM 6 LOBE,SUP-2602108,CDM,C1713,HCPCS,0278,RC,,,,both,,,938.86,610.26,,,,,,,,,,,,,
GRAFT VASC ALBOGRAFT L 100 CM DIA 8 MM POLYESTER STR KNITTED,SUP-2601079,CDM,C1768,CPT,0278,RC,,,,both,,,2119.50,1377.67,,,,,,,,,,,,,
PACEMAKER CRD UPLR/BPLR SINGLE CHMBR IS-1 CONN LEGEND SR,SUP-2236359,CDM,C1721,HCPCS,0275,RC,,,,both,,,92221.80,59944.17,,,,,,,,,,,,,
SCREW BNE L130MM 140DEG HIP CAPT ASSEMB,SUP-2251194,CDM,C1713,HCPCS,0278,RC,,,,both,,,1120.98,728.64,,,,,,,,,,,,,
SHEATH INTRO FLX SHUTTLE L 110 CM OD 7 FR GUIDEWIRE 0.038 IN,SUP-2170726,CDM,C1894,HCPCS,0272,RC,,,,both,,,364.24,236.76,,,,,,,,,,,,,
SYSTEM RETRV RECOVERY CONE VENA CAVA ENDOSCP FB REMOVAL STRL,SUP-2126999,CDM,C1880,HCPCS,0278,RC,,,,both,,,1868.30,1214.39,,,,,,,,,,,,,
PLATE SPNL 2 LEVEL 40 MM ANTR CERV NEO-SL,SUP-2430719,CDM,C1713,HCPCS,0278,RC,,,,both,,,7771.50,5051.47,,,,,,,,,,,,,
GRAFT VASC IMPRA L 50 CM DIA 5-8 MM EPTFE STP STD WALL N,SUP-2127041,CDM,C1768,CPT,0278,RC,,,,both,,,1297.92,843.65,,,,,,,,,,,,,
PLATE BNE STR 2.7X113 MM 14 HOLE RECON LCK SS STRL,SUP-2472691,CDM,C1713,HCPCS,0278,RC,,,,both,,,1707.66,1109.98,,,,,,,,,,,,,
SCREW DIA1.7MM L3MM ABSRB FOR STRYKR LEIBINGER 2/EA,SUP-2364990,CDM,C1713,HCPCS,0278,RC,,,,both,,,336.04,218.43,,,,,,,,,,,,,
ALLOGRAFT HUM TISS FRZN ASEP SEMITENDINOSUS W/ GRACILIS,SUP-2867231,CDM,C1762,CPT,0278,RC,,,,both,,,6848.97,4451.83,,,,,,,,,,,,,
PIN EXT FIX L65MM OD5MM TI CIR HALF HEX FIX RANCHO,SUP-2342566,CDM,C1713,HCPCS,0278,RC,,,,both,,,1081.26,702.82,,,,,,,,,,,,,
COMPOUND CEM GLS IONOMER LUTING GC FUJI I,SUP-2226108,CDM,C1713,HCPCS,0278,RC,,,,both,,,226.68,147.34,,,,,,,,,,,,,
BIT DRL OD2.7MM CALCLOCK,SUP-2399236,CDM,2720000010,LOCAL,0272,RC,,,,both,,,348.54,226.55,,,,,,,,,,,,,
NAIL IM 11.5X200 MM PHANTOM ACTIVCORE P312152000S,SUP-2743184,CDM,C1713,HCPCS,0278,RC,,,,both,,,21666.00,14082.90,,,,,,,,,,,,,
ALLOGRAFT HUM TISS FD ASEP WHL FASC LATA,SUP-2867004,CDM,C1762,CPT,0278,RC,,,,both,,,3299.20,2144.48,,,,,,,,,,,,,
COMPONENT HIP PRSS FT H7 HD X3 MTL CERM MDM,SUP-2379154,CDM,C1776,CPT,0278,RC,,,,both,,,20096.00,13062.40,,,,,,,,,,,,,
TRIAL NERVE STIM EXT,SUP-2568742,CDM,2720000010,LOCAL,0272,RC,,,,both,,,690.80,449.02,,,,,,,,,,,,,
GRAFT BONE ALLGRFT DEMIN 1CC MTRX GRFTON,SUP-2115989,CDM,C9359,HCPCS,0278,RC,,,,both,,,464.72,302.07,,,,,,,,,,,,,
TRAY EPIDURAL NDL TUOHY DIA20 GA HYPO L 1.5 IN DIA18 GA SGL,SUP-2936580,CDM,2720000010,LOCAL,0272,RC,,,,both,,,56.52,36.74,,,,,,,,,,,,,
CATHETER MIDLINE AGBA PI 1-L 4.5FR X 15CM,SUP-2850034,CDM,C1751,HCPCS,0278,RC,,,,both,,,536.94,349.01,,,,,,,,,,,,,
MARKER BRST BX OD10GA PET BARBELL CLP MAMMOSTAR,SUP-2195624,CDM,A4648,CPT,0278,RC,,,,both,,,232.42,151.07,,,,,,,,,,,,,
CATHETER INFUSION 2.7 FRX165 CM 3 CM MAGIC SPIF FLO COIL,SUP-2424284,CDM,C1887,HCPCS,0272,RC,,,,both,,,2502.58,1626.68,,,,,,,,,,,,,
MATRIX DURA MATER CLLGN 4X5IN SUTURABLE,SUP-2244026,CDM,C1763,HCPCS,0278,RC,,,,both,,,1001.88,651.22,,,,,,,,,,,,,
COIL EMB L1CM DIA0.02IN LOOP DIA2MM COMPLX EXTRA SFT FILL,SUP-2323438,CDM,C1889,HCPCS,0278,RC,,,,both,,,4954.92,3220.70,,,,,,,,,,,,,
BUR SURG TAPR 1.5X13.1 MM 7 CM FOOTED SM BOR MIDAS REX 8,SUP-2664897,CDM,2720000010,LOCAL,0272,RC,,,,both,,,596.60,387.79,,,,,,,,,,,,,
CATHETER URET 10FR 2 LUMN,SUP-2313814,CDM,C1726,HCPCS,0272,RC,,,,both,,,144.13,93.68,,,,,,,,,,,,,
PISTON OTO FUNC L4.25MM DIA0.6MM HASH MRK 0.5MM,SUP-2312545,CDM,L8613,CPT,0278,RC,,,,both,,,402.86,261.86,,,,,,,,,,,,,
CATHETER INFUSION UNI-FUSE L 90 CM DIA 4 FR SLT PAT L 50 CM,SUP-2117145,CDM,C1889,HCPCS,0278,RC,,,,both,,,659.40,428.61,,,,,,,,,,,,,
CRANIAL ACCESS KIT 3.97 MM 5.31X6.35 MM MULTIPLE DRL BITS,SUP-2666729,CDM,2720000010,LOCAL,0272,RC,,,,both,,,902.81,586.83,,,,,,,,,,,,,
BOLT EXT FIX AUG STEM HSNG COCR VANGUARD,SUP-2441906,CDM,2720000010,LOCAL,0272,RC,,,,both,,,477.28,310.23,,,,,,,,,,,,,
LINER ACET OD68MM ID36MM +4MM OFFSET 10DEG HIP MARATHON,SUP-2250477,CDM,C1776,CPT,0278,RC,,,,both,,,5105.64,3318.67,,,,,,,,,,,,,
PLATE BNE W22XL75MM STD 6X5 H NONSTERILE R DST RAD VOLAR S,SUP-2184119,CDM,C1713,HCPCS,0278,RC,,,,both,,,2367.06,1538.59,,,,,,,,,,,,,
KIT AUTOTRASFUSION DIA4.8MM QUIK DC AND PVC DRN BLD CONSERV,SUP-2361131,CDM,C1729,HCPCS,0272,RC,,,,both,,,524.69,341.05,,,,,,,,,,,,,
BURR SURG 1MM DIA HD SHRT 26MML HD CTTNG MICROPOWER MCR100 S,SUP-2605534,CDM,2720000010,LOCAL,0272,RC,,,,both,,,68.36,44.43,,,,,,,,,,,,,
PLATE BNE W10.2XL78MM THK2.7MM 6 H BILAT S STL STR LO PROF,SUP-2186193,CDM,C1713,HCPCS,0278,RC,,,,both,,,1314.22,854.24,,,,,,,,,,,,,
PROSTHESIS PENILE INCL BLNT TIP STAY HK DEAVER M WILSON,SUP-2165464,CDM,C1713,HCPCS,0278,RC,,,,both,,,1353.34,879.67,,,,,,,,,,,,,
CONNECTOR SPNL 1/4 STD POST S STL UNTHREADED TRNSVRS CONN,SUP-2255598,CDM,C1713,HCPCS,0278,RC,,,,both,,,703.36,457.18,,,,,,,,,,,,,
BOOT CAST ASMBLY ROCKER BTM,SUP-2162677,CDM,L4361,HCPCS,0272,RC,,,,both,,,4220.16,2743.10,,,,,,,,,,,,,
CAST ORTHOT ANK KNEE FEM CUST FRAC SEMI RIGID,SUP-2435651,CDM,L2134,HCPCS,0274,RC,,,,both,,,3262.59,2120.68,,,,,,,,,,,,,
SYSTEM PHACO L09MM 45DEG TIPLSS ULT FMS ACT CENTURION,SUP-2109973,CDM,C1713,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
PLATE BNE LCK SHT 178 MM LT DSTL MEDL HUM 11 HOLE PUR STRL,SUP-2469482,CDM,C1713,HCPCS,0278,RC,,,,both,,,3104.83,2018.14,,,,,,,,,,,,,
CATHETER HD STR 13.5 FRX15 CM 3L BASIC SET TRIO-CT,SUP-2433953,CDM,C1752,HCPCS,0278,RC,,,,both,,,370.52,240.84,,,,,,,,,,,,,
COLLAR CERV CNTOUR SM 18.5X3 IN 11-16 IN MED FOAM PROCARE,SUP-2196858,CDM,L0180,HCPCS,0274,RC,,,,both,,,10.71,6.96,,,,,,,,,,,,,
SCREW BNE CANN MED THRD 7.2X80 MM HDLSS SHRP TIP BEAM JOUSTA,SUP-2742955,CDM,C1713,HCPCS,0278,RC,,,,both,,,3739.74,2430.83,,,,,,,,,,,,,
GRAFT VASC SZ 24 MM SPEC 3 BRANCH,SUP-2535444,CDM,C1768,CPT,0278,RC,,,,both,,,6206.43,4034.18,,,,,,,,,,,,,
PLUG RMR DIA 14MM SPNL LUM TAPR FUS SGL BRL L CAGE,SUP-2291611,CDM,C1713,HCPCS,0278,RC,,,,both,,,297.48,193.36,,,,,,,,,,,,,
SCREW BONE L4MM DIA1.5MM CRANIOMAXILLOFACIAL SELF DRL CROSS,SUP-2363330,CDM,C1713,HCPCS,0278,RC,,,,both,,,167.58,108.93,,,,,,,,,,,,,
SHEATH ENDO OD2.7MM EXCHG FOR 30DEG TELSCP 8672.422,SUP-2332865,CDM,C1894,HCPCS,0272,RC,,,,both,,,2747.50,1785.87,,,,,,,,,,,,,
ELECTRODE LAP L32CM DIA5MM PIN 4MM L HK EXT INSUL NONCOATED,SUP-2166743,CDM,2720000010,LOCAL,0272,RC,,,,both,,,461.20,299.78,,,,,,,,,,,,,
PLATE MEDL CLMN FUSION 78MM RT STRL VA LCP,SUP-2546131,CDM,C1713,HCPCS,0278,RC,,,,both,,,5285.88,3435.82,,,,,,,,,,,,,
CATHETER HD SYMMETRICAL 14.5 FRX23 CM PALINDROMIC EMERALD,SUP-2174237,CDM,C1750,HCPCS,0278,RC,,,,both,,,2314.37,1504.34,,,,,,,,,,,,,
GRAFT DURA W1XL1IN ULTRAPURE CLLGN ADH BARR MTRX DURAGN +,SUP-2244004,CDM,C1763,HCPCS,0278,RC,,,,both,,,928.25,603.36,,,,,,,,,,,,,
GRAFT BNE MEDL VERSAGRAFT,SUP-2257912,CDM,C1776,CPT,0278,RC,,,,both,,,4050.60,2632.89,,,,,,,,,,,,,
GRAFT BONE SUB 5GM CA PHOS CLASS BONESOURCE,SUP-2365152,CDM,C1713,HCPCS,0278,RC,,,,both,,,1868.30,1214.39,,,,,,,,,,,,,
CAGE SPNL W9.5XH10XL22MM TI LORDTC LUM TIRBOLOX-L LUM,SUP-2152429,CDM,C1889,HCPCS,0278,RC,,,,both,,,7222.00,4694.30,,,,,,,,,,,,,
BRACE WALKING N PNEUMATIC PRE FABRIC,SUP-2388198,CDM,L4386,HCPCS,0272,RC,,,,both,,,440.07,286.05,,,,,,,,,,,,,
GRAFT VASC GORTX L 10 CM DIA 4 MM RNG L 2.5 CM EPTFE STR TW,SUP-2396145,CDM,C1768,CPT,0278,RC,,,,both,,,1199.48,779.66,,,,,,,,,,,,,
CATHETER HD TENCK 46 CM UNIV 1 PREPERITONEAL CUF KT ARGY,SUP-2626783,CDM,C1750,HCPCS,0278,RC,,,,both,,,219.17,142.46,,,,,,,,,,,,,
BIT DRL DIA2MM CANN COMPR,SUP-2122159,CDM,2720000010,LOCAL,0272,RC,,,,both,,,436.46,283.70,,,,,,,,,,,,,
TROCAR SURG DBL SL 5X180 MM ASMBLY,SUP-2517250,CDM,2720000010,LOCAL,0272,RC,,,,both,,,720.63,468.41,,,,,,,,,,,,,
SCREW SPNL L25MM DIA7.5MM THORLUM LO PROF N THRD LOK REVERE,SUP-2229417,CDM,C1713,HCPCS,0278,RC,,,,both,,,1899.70,1234.80,,,,,,,,,,,,,
GRAFT PASTE SYNTH CLLGN 1CC COPIOS BVF,SUP-2197451,CDM,C1713,HCPCS,0278,RC,,,,both,,,989.10,642.91,,,,,,,,,,,,,
TUBING IRRGTN 0.104N ID 0.192N OD 14.6FR 10FTL SLSTC SLCNE N,SUP-2492551,CDM,2720000010,LOCAL,0272,RC,,,,both,,,340.85,221.55,,,,,,,,,,,,,
DEXTROSE-SODIUM CHLORIDE 5-0.9 % IV SOLN,RX-15882,CDM,J7042,HCPCS,0250,RC,00264-7610-00,NDC,,both,1000,ML,34.00,22.10,,,,,,,,,,,,,
ANCHOR SUTURE L11MM DIAMETER 3.5MM WITH 1 NO2 HI-FI SUTURE P,SUP-2824900,CDM,C1713,HCPCS,0278,RC,,,,both,,,1642.82,1067.83,,,,,,,,,,,,,
SCREW BNE L65MM DIA5MM CORT TI SELF DRL LOK HEX RECESS,SUP-2190751,CDM,C1713,HCPCS,0278,RC,,,,both,,,589.00,382.85,,,,,,,,,,,,,
SLING SHLDR PCH 13X19IN SWTH 5X54IN UNIV FOAM ADJ STRP,SUP-2195491,CDM,L3660,HCPCS,0272,RC,,,,both,,,30.33,19.71,,,,,,,,,,,,,
ROD SPNL PRE-BENT 5.5X35 MM TI STRL CD HORZ ESSENTIALS,SUP-2629471,CDM,C1713,HCPCS,0278,RC,,,,both,,,1002.13,651.38,,,,,,,,,,,,,
TUBE VENT 1.02 MM 1.6 MM 2.3 MM SHEP GRMMT W/ TAB SIL 510022,SUP-2535077,CDM,L8699,HCPCS,0278,RC,,,,both,,,32.25,20.96,,,,,,,,,,,,,
PLATE BNE W13.5XL206MM THK4.2MM 11 H BILAT S STL NAR LIMIT,SUP-2185246,CDM,C1713,HCPCS,0278,RC,,,,both,,,1622.28,1054.48,,,,,,,,,,,,,
METRONIDAZOLE 0.75 % EX GEL,RX-19741,CDM,6370000000,HCPCS,0637,RC,51672-4116-06,NDC,,both,45,GR,441.10,286.71,,,,,,,,,,,,,
OXYGENATOR PERFSN BARB CONN SZ 3/8 IN BLD FLO RATE 0.5-4,SUP-2895279,CDM,2720000010,LOCAL,0272,RC,,,,both,,,6908.00,4490.20,,,,,,,,,,,,,
MESH HERN OVL 10X6 IN W/ ECHO2 POS SYS POLYPR PHASIX ST,SUP-2855263,CDM,C1781,HCPCS,0278,RC,,,,both,,,20331.50,13215.47,,,,,,,,,,,,,
MESH HERN W5XL10CM POLYPR FLAT L PORE MFIL SFT KNIT LTWT,SUP-2125777,CDM,C1781,HCPCS,0278,RC,,,,both,,,203.47,132.26,,,,,,,,,,,,,
PROBE TEMP SM,SUP-2308193,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1342.13,872.38,,,,,,,,,,,,,
PLATE BNE FIBULAR 2.7X79 MM RT LAT DSTL 3 HOLE NS VA-LCP,SUP-2758191,CDM,C1713,HCPCS,0278,RC,,,,both,,,2455.73,1596.22,,,,,,,,,,,,,
STENT TRACH L30MM DIA12MM WRK L62CM 16FR POLYUR OVR THE WIRE,SUP-2302396,CDM,C1874,HCPCS,0278,RC,,,,both,,,7536.00,4898.40,,,,,,,,,,,,,
GUIDEWIRE UROLOGICAL ULTRATRACK HYBRID L 150 CM DIA 0.035 IN,SUP-2539336,CDM,C1769,HCPCS,0272,RC,,,,both,,,124.63,81.01,,,,,,,,,,,,,
SCREW SPNL L14MM OD4MM VAR ANG SELF DRL TI SNOWCAP,SUP-2136813,CDM,C1713,HCPCS,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
PLATE BONE L61MM 14MM 4 H DYN COMPR FOR 4.5MM SCR,SUP-2185204,CDM,C1713,HCPCS,0278,RC,,,,both,,,1450.59,942.88,,,,,,,,,,,,,
SCREW BNE L14MM DIA2.4MM S STL CORT PERIARTC CONIC ST,SUP-2410748,CDM,C1713,HCPCS,0278,RC,,,,both,,,248.41,161.47,,,,,,,,,,,,,
BRACE ORTH CIRC THGH 29.5-32 IN CTR 21-23 IN CALF 22-24 IN 3XL LT,SUP-2916744,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1127.45,732.84,,,,,,,,,,,,,
MESH HERN W25.9XL36CM VENTRAL HERN POLYPR EPTFE RECTANG,SUP-2125812,CDM,C1781,HCPCS,0278,RC,,,,both,,,4798.86,3119.26,,,,,,,,,,,,,
HC Conversion Ext Bil Drng Cath to Intrnl/Extrnl,PX-3614753500,CDM,47535,CPT,0361,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 20 CM DIA 7 MM EPTFE STR TW,SUP-2492849,CDM,C1768,CPT,0278,RC,,,,both,,,776.11,504.47,,,,,,,,,,,,,
BLADE FULL RAD BYONICS BONECUTTER 3.5 MM,SUP-2340786,CDM,2720000010,LOCAL,0272,RC,,,,both,,,596.76,387.89,,,,,,,,,,,,,
SIZER BRST DIA12.6CM P3.8CM 350CC GEL RND SMOOTH MOD + PROF,SUP-2300855,CDM,2720000010,LOCAL,0272,RC,,,,both,,,926.30,602.09,,,,,,,,,,,,,
PROBE ABLAT 17GA L15CM CBL L1.4M STD PERC ACT ZONE DISPLAY 3,SUP-2219809,CDM,2720000010,LOCAL,0272,RC,,,,both,,,12484.64,8115.02,,,,,,,,,,,,,
ALLODERM THIN FENESTRATED 4X8,SUP-2827478,CDM,Q4116,HCPCS,0636,RC,,,,both,,,8644.42,5618.87,,,,,,,,,,,,,
SLEEVE SURG DIA12MM STR OUTER PROTCT DISPOSABLE FOR 8 11MM,SUP-2178904,CDM,2720000010,LOCAL,0272,RC,,,,both,,,334.72,217.57,,,,,,,,,,,,,
CATHETER ANGIOPLSTY L 150 CM BALLOON L 200 MM DIA 3.5 MM,SUP-2909693,CDM,C1725,HCPCS,0272,RC,,,,both,,,830.84,540.05,,,,,,,,,,,,,
CATHETER HD STR 20 CM 15 CM BIOFLO DURAMAX,SUP-2487143,CDM,C1750,HCPCS,0278,RC,,,,both,,,872.92,567.40,,,,,,,,,,,,,
SCREW HD POS,SUP-2232095,CDM,2780000010,LOCAL,0278,RC,,,,both,,,2493.16,1620.55,,,,,,,,,,,,,
STEM FEM L225MM DIA11MM KNEE STR CEM OSS,SUP-2405840,CDM,C1776,CPT,0278,RC,,,,both,,,4761.81,3095.18,,,,,,,,,,,,,
ASSEMBLY SCR HLD ENT BIPHASE,SUP-2135871,CDM,C1713,HCPCS,0278,RC,,,,both,,,910.60,591.89,,,,,,,,,,,,,
ZIEGLER KNIFE NEEDLE 7MM,SUP-2482096,CDM,2720000010,LOCAL,0272,RC,,,,both,,,430.18,279.62,,,,,,,,,,,,,
BLADE RETRACTOR HOHMN 12 CMX29 MM OLIF,SUP-2627604,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2436.36,1583.63,,,,,,,,,,,,,
PLATE BNE 7 H L CNDYL TI FOR 2MM SCR MOD HND SYS,SUP-2191064,CDM,C1713,HCPCS,0278,RC,,,,both,,,2276.19,1479.52,,,,,,,,,,,,,
PLATE SPNL L28MM ANT CERV TI ALLY LEV 2 XTEND,SUP-2230260,CDM,C1713,HCPCS,0278,RC,,,,both,,,2041.00,1326.65,,,,,,,,,,,,,
WIRE BNE FIX L 152 MM DIA1.1 MM DBL END TROCAR TIP NS LEOS,SUP-2933896,CDM,C1713,HCPCS,0278,RC,,,,both,,,124.31,80.80,,,,,,,,,,,,,
SCREW BONE L90MM DIA4.5MM ST CRTX LCK L FRAG SET,SUP-2348904,CDM,C1713,HCPCS,0278,RC,,,,both,,,1172.63,762.21,,,,,,,,,,,,,
SHEATH ENDOSCP CYSTOURETHROSCOPE 17 FRX20.6 CM FOR CHANNELX1,SUP-2313967,CDM,C1894,HCPCS,0272,RC,,,,both,,,2263.63,1471.36,,,,,,,,,,,,,
JACKET ORTHOT CUST BODY MOLD TO PT,SUP-2435593,CDM,L1300,HCPCS,0272,RC,,,,both,,,4879.40,3171.61,,,,,,,,,,,,,
SYSTEM PROTCT L INT AORT FLTR,SUP-2214487,CDM,C1884,HCPCS,0278,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
KIT VASC SNR ATRIEVE 90 DEG TIP 15 DEG L 120 CM DIA18-30 MM,SUP-2120070,CDM,C1773,HCPCS,0272,RC,,,,both,,,1240.30,806.19,,,,,,,,,,,,,
INBONE  POLY SZ 4 20MM SULCUS TOTAL ANKLE,SUP-2465176,CDM,C1776,CPT,0278,RC,,,,both,,,5743.06,3732.99,,,,,,,,,,,,,
IVERMECTIN 3 MG PO TABS,RX-25820,CDM,6370000000,HCPCS,0637,RC,42799-0806-01,NDC,,both,1,UN,18.70,12.15,,,,,,,,,,,,,
"Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral)",PX-3008718600,CDM,87186,CPT,0300,RC,,,,both,,,102.00,66.30,,,,,,,,,,,,,
SCREW EXT FIX LCK ANAT DNP,SUP-2477708,CDM,2720000010,LOCAL,0272,RC,,,,both,,,671.96,436.77,,,,,,,,,,,,,
SYSTEM NEUROSTIMULATOR 16 CHAN NONRECHARGEABLE EONC,SUP-2356749,CDM,C1778,HCPCS,0278,RC,,,,both,,,34540.00,22451.00,,,,,,,,,,,,,
NEEDLE SPNL TARGETING TELLURIDE,SUP-2687388,CDM,2720000010,LOCAL,0272,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
BUDESONIDE-FORMOTEROL FUMARATE 160-4.5 MCG/ACT IN AERO,RX-81454,CDM,6370000000,HCPCS,0637,RC,00186-0370-28,NDC,,both,6,GR,716.40,465.66,,,,,,,,,,,,,
HOOK SPNL 3 MM 4.5X8 MM OFFSET BLADE TI EXPEDIUM,SUP-2583496,CDM,C1713,HCPCS,0278,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
SYSTEM BILI STENT DEL NAVIFLEX L 202.5 CM DIA 8.5 FR PLAS,SUP-2141421,CDM,C1889,HCPCS,0278,RC,,,,both,,,258.64,168.12,,,,,,,,,,,,,
DRILL COUNTSINK 2.5MM MINI HCS MASTORQUE K,SUP-2400009,CDM,C1713,HCPCS,0278,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
TRAY CATH PICC POWERPICC SOLO2 MAXBARR 6FR 55CM 3 LUMAN RVS,SUP-2613401,CDM,C1751,HCPCS,0278,RC,,,,both,,,815.46,530.05,,,,,,,,,,,,,
MAGNESIUM SULFATE 4000 MG/100ML IVPB PREMIX (OB USE ONLY),RX-4081101,CDM,J3475,HCPCS,0636,RC,44567-0421-24,NDC,,both,100,ML,54.10,35.16,,,,,,,,,,,,,
SPLINT ORTH SUPP MED YTH WRST FOREARM RT ALUM FOAM,SUP-2194488,CDM,L3808,HCPCS,0274,RC,,,,both,,,12.15,7.90,,,,,,,,,,,,,
GRAFT HUM TISS 2CC PLCNTA TISS MTRX FLOWERFLO,SUP-2225379,CDM,C1713,HCPCS,0278,RC,,,,both,,,17144.40,11143.86,,,,,,,,,,,,,
GRAFT EVAR L49MM DIA36X36MM EXTN FREE FLO CLS WEB FOR ABD,SUP-2295234,CDM,C1768,CPT,0278,RC,,,,both,,,14679.50,9541.67,,,,,,,,,,,,,
PLATE BNE THK1MM 0DEG M MINI TI ORAL MAXILLOFACIAL 4 H,SUP-2262737,CDM,C1713,HCPCS,0278,RC,,,,both,,,1022.38,664.55,,,,,,,,,,,,,
REPAIR KIT KNOTLESS ARTHSCP AC SYS STRL LTX,SUP-2859827,CDM,C1713,HCPCS,0278,RC,,,,both,,,5887.50,3826.87,,,,,,,,,,,,,
STENT BILI AD L140MM DIA7MM CATH L125CM SHTH 6FR 0.035IN,SUP-2170735,CDM,C1876,HCPCS,0278,RC,,,,both,,,3314.80,2154.62,,,,,,,,,,,,,
GRAFT BONE L50XW5XH5MM 1.25ML CANC DEMIN STRP STRL,SUP-2125419,CDM,C1713,HCPCS,0278,RC,,,,both,,,490.63,318.91,,,,,,,,,,,,,
COIL EMB L20CM DIA8MM 0.018IN PERIPH HYDRGEL DETACH 18 SYS,SUP-2385419,CDM,C1889,HCPCS,0278,RC,,,,both,,,3216.36,2090.63,,,,,,,,,,,,,
PLATE BNE T 3.5X64 MM DSTL TIB 3 HOLE SS NS LCP,SUP-2184168,CDM,C1713,HCPCS,0278,RC,,,,both,,,2008.31,1305.40,,,,,,,,,,,,,
COIL EMB L10CM DIA4MM 00115IN DETACH SFT STRTCH RESIST,SUP-2173105,CDM,C1889,HCPCS,0278,RC,,,,both,,,4804.20,3122.73,,,,,,,,,,,,,
STENT BILI WALLFLEX L 100 MM DIA10 MM CATH L 194 CM DIA 9 FR,SUP-2889595,CDM,C1874,HCPCS,0278,RC,,,,both,,,8313.31,5403.65,,,,,,,,,,,,,
SYSTEM CLP DEL MITRACLIP NTR L 109.5 CM DIA16 FR BALLOON L,SUP-2102259,CDM,C1889,HCPCS,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
CATHETER NEPHROSTOMY HYDRPHLC TIP 10 FRX25 CM KT REG TEMPTIP,SUP-2147905,CDM,C1729,HCPCS,0272,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
PIN EXTERNAL FIXATION HALF SHORT 3X10 MM RADIAL DISTAL STAIN,SUP-2836762,CDM,2720000010,LOCAL,0272,RC,,,,both,,,776.68,504.84,,,,,,,,,,,,,
"HC So Sodium,Urine Spot",PX-3018430066,CDM,84300,CPT,0301,RC,,,,both,,,25.00,16.25,,,,,,,,,,,,,
RING ACET OD53MM ID49MM MTL REINF CNTOUR,SUP-2345094,CDM,C1776,CPT,0278,RC,,,,both,,,5545.24,3604.41,,,,,,,,,,,,,
SCREW BNE SD 1.5X5 MM CRTX W/ PLUSDRIVE RECESS TI MTRX SLV,SUP-2188937,CDM,C1713,HCPCS,0278,RC,,,,both,,,279.15,181.45,,,,,,,,,,,,,
PLATE SPNL L35MM UNIV TI POST LUM STR STD OFFSET BILAT CD,SUP-2293334,CDM,C1713,HCPCS,0278,RC,,,,both,,,4286.10,2785.96,,,,,,,,,,,,,
VALVE CSF PROGRAMMABLE IN-LINE VENTRICULAR CATH CERTAS +,SUP-2666571,CDM,C1889,HCPCS,0278,RC,,,,both,,,12086.77,7856.40,,,,,,,,,,,,,
BUR SURG SPHR 4.5 MMX10.8 CM UNHOODED RHINOTEC,SUP-2607705,CDM,2720000010,LOCAL,0272,RC,,,,both,,,287.94,187.16,,,,,,,,,,,,,
STEM FEM REV 0+ MM LNG 11 MM LT HIP POLISHED BOW EMPERION,SUP-2434535,CDM,C1776,CPT,0278,RC,,,,both,,,13483.16,8764.05,,,,,,,,,,,,,
GRAFT VASC GORTX L 70 CM DIA 3 MM EPTFE STR STD WALL N RING,SUP-2396413,CDM,C1768,CPT,0278,RC,,,,both,,,1855.74,1206.23,,,,,,,,,,,,,
LEAD NEUROSTIMULATOR L50CM LIN SPNL CRD DISP PHASE III,SUP-2141901,CDM,C1778,HCPCS,0278,RC,,,,both,,,5024.00,3265.60,,,,,,,,,,,,,
SCREW BONE L130MM OD7MM THRD L33MM PUR HINDFOOT ANK CANN LNG,SUP-2320958,CDM,C1713,HCPCS,0278,RC,,,,both,,,2787.06,1811.59,,,,,,,,,,,,,
SPACER SPNL TRAPEZIUM 10X10X10 MM MTCRPL CMC,SUP-2120681,CDM,C1821,HCPCS,0278,RC,,,,both,,,5199.84,3379.90,,,,,,,,,,,,,
SCREW INTRF 10X20 MM 1.5 MM GUIDEWIRE MTO STRL SOFTSILK LTX,SUP-2879282,CDM,C1713,HCPCS,0278,RC,,,,both,,,1295.72,842.22,,,,,,,,,,,,,
PLATE BONE L84MM 4 H T SHP FOR 4.5MM CORTEX/MALLEOLAR/SHAFT,SUP-2343816,CDM,C1713,HCPCS,0278,RC,,,,both,,,2129.01,1383.86,,,,,,,,,,,,,
CATHETER INTVASC OCCL FOGARTY L 80 CM DIA 8 FR BALLON DIA,SUP-2214270,CDM,C2628,HCPCS,0272,RC,,,,both,,,229.85,149.40,,,,,,,,,,,,,
SCREW BONE L5MM PAN FIX LUHR,SUP-2364706,CDM,C1713,HCPCS,0278,RC,,,,both,,,117.22,76.19,,,,,,,,,,,,,
CATHETER CTRL VEN OD5FR PICC TRIM LEN 2 LUMN INTMED TY NRS,SUP-2125537,CDM,C1894,HCPCS,0272,RC,,,,both,,,483.87,314.52,,,,,,,,,,,,,
CLINIMIX E/DEXTROSE (8/14) 8 % IV SOLN,RX-151970,CDM,2500000003,HCPCS,0250,RC,00338-0206-04,NDC,,both,2000,ML,690.00,448.50,,,,,,,,,,,,,
PLATE BNE BURR HOLE CVR 22X1 MM SLGHT CONTOURED PDLLA STRL,SUP-2462761,CDM,C1713,HCPCS,0278,RC,,,,both,,,1087.88,707.12,,,,,,,,,,,,,
RING FIX LO EXT TEF PANTSA NAIL SYS,SUP-2243642,CDM,C1713,HCPCS,0278,RC,,,,both,,,405.06,263.29,,,,,,,,,,,,,
DEFIBRILLATOR CRD BPLR 14 MM 33 CC 77 GM RST ATLS II VR,SUP-2356517,CDM,C1722,HCPCS,0275,RC,,,,both,,,56206.00,36533.90,,,,,,,,,,,,,
BUR SURG OD3MM SHANK L13CM LILAC COARSE DMND MTCH HD MIS,SUP-2365192,CDM,2720000010,LOCAL,0272,RC,,,,both,,,589.16,382.95,,,,,,,,,,,,,
GUIDEWIRE VASC L 180 CM DIA 0.035 IN TAPR L 4.5 CM FLPY TIP,SUP-2167777,CDM,C1769,HCPCS,0272,RC,,,,both,,,41.39,26.90,,,,,,,,,,,,,
SCREW BNE HDLSS 3X30 MM COMPR FT STRL HCS LTX,SUP-2860987,CDM,C1713,HCPCS,0278,RC,,,,both,,,1144.91,744.19,,,,,,,,,,,,,
ALLOGRAFT BNE CHIP 1-4 MM 5 CC PRESERVON CANC READIGRAFT,SUP-2740975,CDM,C1713,HCPCS,0278,RC,,,,both,,,422.71,274.76,,,,,,,,,,,,,
STEM HUM REVERSED LNG 11X180 MM SHLDR FRAC AEQUALIS REVERSED,SUP-2715635,CDM,C1776,CPT,0278,RC,,,,both,,,17224.47,11195.91,,,,,,,,,,,,,
SHEATH INTRO 5FR L10CM 21/19GA ECHOGENIC TAPR NDL W/ NIT,SUP-2385251,CDM,C1894,HCPCS,0272,RC,,,,both,,,190.22,123.64,,,,,,,,,,,,,
SUPPORT ORTHOT KNEE CUST SUPCNDYL SOCKET MOLD,SUP-2435620,CDM,L1860,HCPCS,0274,RC,,,,both,,,3530.36,2294.73,,,,,,,,,,,,,
SCREW BNE CANN 7X8 MM,SUP-2315921,CDM,C1713,HCPCS,0278,RC,,,,both,,,1023.64,665.37,,,,,,,,,,,,,
VALVE PRESSURE PROGRAMMABLE CYL W/ INTEGR CONN HAKIM,SUP-2666808,CDM,C1889,HCPCS,0278,RC,,,,both,,,16069.58,10445.23,,,,,,,,,,,,,
GUIDEWIRE ORTH SM L160MM DIA0.8MM CO CHROM RDY FOR SURG,SUP-2418951,CDM,C1769,HCPCS,0272,RC,,,,both,,,295.16,191.85,,,,,,,,,,,,,
TUBE TRACH 5.5 MM PEDIATRIC 5.5X8X46 MM STRL BIVONA AIRE-CUF,SUP-2352008,CDM,2720000010,LOCAL,0272,RC,,,,both,,,623.95,405.57,,,,,,,,,,,,,
PROVENTM REV KNEE SYS MOD FEM SZ 1 THRU 6,SUP-2359350,CDM,C1776,CPT,0278,RC,,,,both,,,13973.00,9082.45,,,,,,,,,,,,,
INSERT SURG 18MM INTERSPINOUS FUS TI UNILINK,SUP-2205259,CDM,C1713,HCPCS,0278,RC,,,,both,,,4082.00,2653.30,,,,,,,,,,,,,
WIRE FIX 1.6 MM SS NS KIRSCHNER,SUP-2432332,CDM,C1713,HCPCS,0278,RC,,,,both,,,439.73,285.82,,,,,,,,,,,,,
SYSTEM FIX OPTIFIX ABSORB 30 FASTENERS W/ART TECH,SUP-2731836,CDM,C1713,HCPCS,0278,RC,,,,both,,,1507.20,979.68,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED STEM XLPE,SUP-2212518,CDM,C1776,CPT,0278,RC,,,,both,,,10996.28,7147.58,,,,,,,,,,,,,
CLIP ANEUR BLDE L8.3MM MAX OPN 6.8MM 180GM PERM PHYNOX STD,SUP-2108378,CDM,C1889,HCPCS,0278,RC,,,,both,,,1588.15,1032.30,,,,,,,,,,,,,
PLATE BNE RECON UNIV 3.5 MM 8 HOLE 2 COMPR FOR SCR TI NS,SUP-2472100,CDM,C1713,HCPCS,0278,RC,,,,both,,,1448.92,941.80,,,,,,,,,,,,,
STENT BILI E-LUMINEXX L 120 MM DIA 6 MM CATH L 135 CM DIA 6,SUP-2128907,CDM,C1876,HCPCS,0278,RC,,,,both,,,4392.86,2855.36,,,,,,,,,,,,,
PLATE BONE M W11XL162MM THK3.7MM 12 H TI STR REV FOR,SUP-2225498,CDM,C1713,HCPCS,0278,RC,,,,both,,,1733.28,1126.63,,,,,,,,,,,,,
STEM FEM L150MM OD9MM STR CLLRD TI IM OSS,SUP-2405835,CDM,C1776,CPT,0278,RC,,,,both,,,4352.04,2828.83,,,,,,,,,,,,,
PLATE BNE CRV BROAD PEDIATRIC 3.5 MM 12 HOLE SS NS LCP,SUP-2799220,CDM,C1713,HCPCS,0278,RC,,,,both,,,2092.65,1360.22,,,,,,,,,,,,,
STEM FEM L225MM DIA15X20MM NK L36+8MM LNG HIP NEUT STR BOW,SUP-2253203,CDM,C1776,CPT,0278,RC,,,,both,,,12091.51,7859.48,,,,,,,,,,,,,
REAMER SURG FOR UP EXT SYS STRT,SUP-2372565,CDM,C1713,HCPCS,0278,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
NYSTATIN-TRIAMCINOLONE 100000-0.1 UNIT/GM-% EX CREA,RX-5754,CDM,6370000000,HCPCS,0637,RC,51672-1263-01,NDC,,both,15,GR,94.30,61.29,,,,,,,,,,,,,
PLATE BNE L 179 X W 11 MM THK 3 MM SCREW DIA2.7/3.5 MM 12 H 72465612N,SUP-2933213,CDM,C1713,HCPCS,0278,RC,,,,both,,,5908.54,3840.55,,,,,,,,,,,,,
SUTURE TENSIONER CUTTER FOR KNEE,SUP-2121949,CDM,2720000010,LOCAL,0272,RC,,,,both,,,549.50,357.17,,,,,,,,,,,,,
PLATE BONE DIA100MM THK1.5MM NONSTERILE CRANIOMAXILLOFACIAL,SUP-2191128,CDM,C1713,HCPCS,0278,RC,,,,both,,,6524.29,4240.79,,,,,,,,,,,,,
SHEATH INTRO SUPER SHTH L 7 CM DIA 4.5 FR GUIDEWIRE L 70 CM,SUP-2269574,CDM,C1892,HCPCS,0272,RC,,,,both,,,45.53,29.59,,,,,,,,,,,,,
PLATE SPNL L75MM TI ANT CERV LOK LO PROF ATLNTS VISN,SUP-2293175,CDM,C1713,HCPCS,0278,RC,,,,both,,,3263.06,2120.99,,,,,,,,,,,,,
GUIDEWIRE VASC HI TORQ SUP COR L 300 CM DIA 0.035 IN,SUP-2103530,CDM,C1769,HCPCS,0272,RC,,,,both,,,226.08,146.95,,,,,,,,,,,,,
SCREW BNE CORTICAL 3.5X20 MM FUSION HEX DRV YEL WRST SS NS,SUP-2851928,CDM,C1713,HCPCS,0278,RC,,,,both,,,711.15,462.25,,,,,,,,,,,,,
SPLINT WRST FA UNIV L 8 IN,SUP-2276643,CDM,L3809,HCPCS,0274,RC,,,,both,,,14.22,9.24,,,,,,,,,,,,,
CLIP SPNL SPR STIM FOR REVERE STBL SYS TRANSCONTINENTAL,SUP-2417901,CDM,2720000010,LOCAL,0272,RC,,,,both,,,942.00,612.30,,,,,,,,,,,,,
PLATE BNE H MIC 140 DEG 1.5 MM CRANIOMAXILLOFACIAL 12 NS,SUP-2493025,CDM,C1713,HCPCS,0278,RC,,,,both,,,531.51,345.48,,,,,,,,,,,,,
PLATE BNE ANGLED 2 MM LT 7X23 HOLE RECON MAXILLA PT SPEC,SUP-2860075,CDM,C1713,HCPCS,0278,RC,,,,both,,,23755.98,15441.39,,,,,,,,,,,,,
BUR SURG MIC 0.8 MM FOR SALIVARY TELSCP,SUP-2771970,CDM,2720000010,LOCAL,0272,RC,,,,both,,,907.59,589.93,,,,,,,,,,,,,
PROSTHESIS OSS WEHRS INCUS AVG 2.7X1.5X1.6X3.5 MM DBL NOTCH,SUP-2637893,CDM,L8613,CPT,0278,RC,,,,both,,,1348.10,876.26,,,,,,,,,,,,,
LEUPROLIDE MESYLATE (6 MONTH) 42 MG SC PRSY,RX-158160,CDM,J1952,HCPCS,0636,RC,69448-0023-63,NDC,,both,1,UN,12297.90,7993.63,,,,,,,,,,,,,
CATHETER CV MAXIMAL BARR TY 018 5 FRX15 CM DL J TIP STRL,SUP-2759913,CDM,C1751,HCPCS,0278,RC,,,,both,,,452.00,293.80,,,,,,,,,,,,,
PLATE BNE BAR L16MM 2 H CRANIOMAXILLOFACIAL TI LO PROF FOR,SUP-2366200,CDM,C1713,HCPCS,0278,RC,,,,both,,,425.25,276.41,,,,,,,,,,,,,
STENT URET STR 0.038 IN 3 CM 7 FRX22 CM DBL PGTL PERCFLX,SUP-2493656,CDM,C2617,HCPCS,0278,RC,,,,both,,,398.40,258.96,,,,,,,,,,,,,
CATHETER THORACENTHESIS STR 32 FRX52 CM FLARED END 6 HOLE,SUP-2265219,CDM,C1729,HCPCS,0272,RC,,,,both,,,17.90,11.63,,,,,,,,,,,,,
HC So Assay Other Fluid Chorides,PX-3018243866,CDM,82438,CPT,0301,RC,,,,inpatient,,,32.00,20.80,,,,,,,,,,,,,
CATHETER HD DL 15.5 FRX32 CM STACKED TIP CHRONIC DURAMAX,SUP-2117417,CDM,C1750,HCPCS,0278,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
HC Remove Tun Catheter W/O Port,PX-5103658900,CDM,36589,CPT,0510,RC,,,,both,,,1901.00,1235.65,,,,,,,,,,,,,
ROD EXT FIX L120MM DIA8MM DSTL RAD ELBW C FBR REUSE,SUP-2188736,CDM,2720000010,LOCAL,0272,RC,,,,both,,,304.58,197.98,,,,,,,,,,,,,
SCREW BNE L25MM DIA4.75MM CORT FIX ANG NONCANNULATED,SUP-2407396,CDM,C1713,HCPCS,0278,RC,,,,both,,,483.56,314.31,,,,,,,,,,,,,
PLATE BNE THK 1.4 MM SCREW DIA2.2 MM 3 X 21 H PLL,SUP-2883163,CDM,C1713,HCPCS,0278,RC,,,,both,,,17478.62,11361.10,,,,,,,,,,,,,
BIT DRL STP 3 MMX8 IN NS VERSANAIL,SUP-2486351,CDM,2720000010,LOCAL,0272,RC,,,,both,,,552.64,359.22,,,,,,,,,,,,,
PLATE BNE LCK UNIV 2.3X1.5 MM THOR RIB 14 HOLE LEVEL 1,SUP-2869213,CDM,C1713,HCPCS,0278,RC,,,,both,,,4417.98,2871.69,,,,,,,,,,,,,
TUBE VENT 0.76 MM 1 MM 2/1.5 MM TINY TEF FLROPLAS 520152,SUP-2535143,CDM,L8699,HCPCS,0278,RC,,,,both,,,29.20,18.98,,,,,,,,,,,,,
COMPONENT PART KNEE CEM PATELLOFEMORAL TROCH UPLR,SUP-2249578,CDM,C1776,CPT,0278,RC,,,,both,,,12403.00,8061.95,,,,,,,,,,,,,
BLOCK FEM SZ 9 THK10MM UNIV DST KNEE CO CHROM TOT STBL FULL,SUP-2378530,CDM,C1776,CPT,0278,RC,,,,both,,,3696.41,2402.67,,,,,,,,,,,,,
EXTRACTOR STONE 12FR L38CM NIT COR HYDRPHLC TIPLSS PERC,SUP-2171357,CDM,C1713,HCPCS,0278,RC,,,,both,,,697.71,453.51,,,,,,,,,,,,,
GRAFT BNE PTTY 3 CC MOLD DBM XEMPLIFI +,SUP-2423062,CDM,C9359,HCPCS,0278,RC,,,,both,,,1654.78,1075.61,,,,,,,,,,,,,
GUIDEWIRE ORTH L150MM DIA2MM 6.5MM OLV 45MM THRD GEN INSTRMT,SUP-2318882,CDM,C1769,HCPCS,0272,RC,,,,both,,,732.25,475.96,,,,,,,,,,,,,
HC Blood Gases Any Combination Ph Pco2 Po2 Co2 Hco3,PX-3018280300,CDM,82803,CPT,0301,RC,,,,outpatient,,,301.00,195.65,,,,,,,,,,,,,
CATHETER EMB REINF 4 FRX40 CM SMOOTH SIL SS LF,SUP-2214227,CDM,C1757,HCPCS,0272,RC,,,,both,,,243.13,158.03,,,,,,,,,,,,,
PROSTHESIS VOICE 16 FRX20 CM DUCKBILL SIL,SUP-2242272,CDM,L8509,HCPCS,0274,RC,,,,both,,,277.58,180.43,,,,,,,,,,,,,
VALVE HYDROCEPHALUS PROGAV 2.0,SUP-2825851,CDM,C1889,HCPCS,0278,RC,,,,both,,,8274.50,5378.42,,,,,,,,,,,,,
DILATOR TRANSSEPTAL L 67 CM GUIDEWIRE L 230 CM HDPE HYPOTUBE,SUP-2913159,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3297.00,2143.05,,,,,,,,,,,,,
BUR SURG DIAMOND 4 MM OVL,SUP-2521576,CDM,2720000010,LOCAL,0272,RC,,,,both,,,970.26,630.67,,,,,,,,,,,,,
PROVENTM POST STBL KNEE SYS M/L 55 MM A/P 53 MM,SUP-2359094,CDM,C1776,CPT,0278,RC,,,,both,,,6939.40,4510.61,,,,,,,,,,,,,
PLATE BNE 4 H 130DEG HIP S STL LOK BILAT COMPR RIG STD BRL,SUP-2370872,CDM,C1713,HCPCS,0278,RC,,,,both,,,2258.45,1467.99,,,,,,,,,,,,,
PROBE NERVE STIM MONOPOLAR STD PRASS HNDL FLSH TIP STRL DISP,SUP-2902005,CDM,2720000010,LOCAL,0272,RC,,,,both,,,421.70,274.10,,,,,,,,,,,,,
ALLOGRAFT BNE 2 CC DEMINERALIZED BONE MTRX ALLOCRAFT,SUP-2636995,CDM,C1713,HCPCS,0278,RC,,,,both,,,1126.07,731.95,,,,,,,,,,,,,
MESH CRANIAL CONTOURABLE 1.5X150X150X0.5 MM RAPID RESORBABLE,SUP-2838568,CDM,C1713,HCPCS,0278,RC,,,,both,,,18454.41,11995.37,,,,,,,,,,,,,
GRAFT VASC GORTX L 30 CM DIA 6 MM RNG L 12 CM EPTFE STR TW,SUP-2396151,CDM,C1768,CPT,0278,RC,,,,both,,,1915.40,1245.01,,,,,,,,,,,,,
PLATE BNE L79MM 6 H STR LOK RECON FOR 3.5MM SCR UNIV LOK,SUP-2411371,CDM,C1713,HCPCS,0278,RC,,,,both,,,1386.84,901.45,,,,,,,,,,,,,
HC Iadna Sars-Cov-2-19 Amp Probe Tq,PX-3068763500,CDM,87635,CPT,0306,RC,,,,inpatient,,,110.00,71.50,,,,,,,,,,,,,
STEM HUM L190MM OD7MM UNIV TI REV CEM RVS TOT IMP BIOMOD,SUP-2403972,CDM,C1776,CPT,0278,RC,,,,both,,,12365.32,8037.46,,,,,,,,,,,,,
PLATE BNE L265MM THK3MM 14 H BILAT S STL STR LOK COMPR RECON,SUP-2185351,CDM,C1713,HCPCS,0278,RC,,,,both,,,2026.09,1316.96,,,,,,,,,,,,,
SET INTRO SUP ARW FLX SHTH L 35 CM DIA 6 FR HYDRPHLC,SUP-2383979,CDM,C1894,HCPCS,0272,RC,,,,both,,,225.99,146.89,,,,,,,,,,,,,
PLUG BNE DIA10MM SM DIAM CEM,SUP-2408548,CDM,C1713,HCPCS,0278,RC,,,,both,,,337.55,219.41,,,,,,,,,,,,,
CAGE SPINE IMPL AVS ANCHOR-C CERV 14 X 16 FOOTPRINT TI 6 X,SUP-2380431,CDM,C1889,HCPCS,0278,RC,,,,both,,,5416.50,3520.72,,,,,,,,,,,,,
GRAFT HUMAN TISSUE 40X25 CM BIOLOGIC TISSUE MATRIX STERILE X,SUP-2838622,CDM,C1763,HCPCS,0278,RC,,,,both,,,92803.96,60322.57,,,,,,,,,,,,,
GRAFT HUM TISS L 4 X W 2 CM AMNIO MEMBRN RESRB STRL PALINGEN,SUP-2913452,CDM,Q4173,HCPCS,0636,RC,,,,both,,,6427.58,4177.93,,,,,,,,,,,,,
SCREW BNE L 105 MM DIA 3.5 MM SS CORTICAL ST NS EVOS,SUP-2931556,CDM,C1713,HCPCS,0278,RC,,,,both,,,171.82,111.68,,,,,,,,,,,,,
BIT DRL DIA1.8MM LNG AO QUIK CONN DISP,SUP-2344031,CDM,2720000010,LOCAL,0272,RC,,,,both,,,694.44,451.39,,,,,,,,,,,,,
NEXGEN LEGACY 3 DEG FLUTED TIBIAL 7D FULL WDG SZ2,SUP-2503474,CDM,C1776,CPT,0278,RC,,,,both,,,2411.52,1567.49,,,,,,,,,,,,,
ANCHOR SUTURE 5.5MM WITH 2 SUTURES HI-FI NEEDLE GENESYS CROS,SUP-2824354,CDM,C1713,HCPCS,0278,RC,,,,both,,,1792.94,1165.41,,,,,,,,,,,,,
CLIP INT LIG ALLIGATOR,SUP-2266677,CDM,C1889,HCPCS,0278,RC,,,,both,,,486.70,316.35,,,,,,,,,,,,,
LINER ACET SZ Q OD70MM ID32MM HIP HGP II CUP ELEV RIM,SUP-2202761,CDM,C1776,CPT,0278,RC,,,,both,,,2306.33,1499.11,,,,,,,,,,,,,
PLATE BNE FEM LNG 3.5X152 MM RT DSTL PROX 4 HOLE STRL VALCP,SUP-2789586,CDM,C1713,HCPCS,0278,RC,,,,both,,,4157.23,2702.20,,,,,,,,,,,,,
PROSTHESIS VOICE 16 FRX20 CM DUCKBILL SIL,SUP-2242272,CDM,L8509,HCPCS,0272,RC,,,,both,,,277.58,180.43,,,,,,,,,,,,,
COIL EMB 10 L1CM OD2MM COMPLX STRTCH RESIST FNSH V-TRAK SFT,SUP-2305134,CDM,C1889,HCPCS,0278,RC,,,,both,,,3045.80,1979.77,,,,,,,,,,,,,
BOLT IM L48MM DIA3.9MM HD DIA8MM TI ST LOK HEX RECESS TRCR,SUP-2192202,CDM,C1713,HCPCS,0278,RC,,,,both,,,591.51,384.48,,,,,,,,,,,,,
DEFIBRILLATOR IMPL IFORIA 7 VR-T DX W 55 X H 65 MM D 11 MM,SUP-2138360,CDM,C1722,HCPCS,0275,RC,,,,both,,,50868.00,33064.20,,,,,,,,,,,,,
PLATE BNE L 125 MM SCREW DIA2.4 MM 20 SHFT H TI ADPT MINI,SUP-2908062,CDM,C1713,HCPCS,0278,RC,,,,both,,,4604.24,2992.76,,,,,,,,,,,,,
CYCLOPENTOLATE HCL 1 % OP SOLN,RX-2025,CDM,6370000000,HCPCS,0637,RC,61314-0396-01,NDC,,both,2,ML,53.80,34.97,,,,,,,,,,,,,
GRAFT DERMAL N FEN 4X4 CMX1-2 MM DERMAL MTRX PARADERM,SUP-2742063,CDM,C1763,HCPCS,0278,RC,,,,both,,,4930.59,3204.88,,,,,,,,,,,,,
GRAFT VASC MAXIFLO L 50 CM DIA 7 MM EPTFE SEAL PTFE TW STRL,SUP-2392564,CDM,C1768,CPT,0278,RC,,,,both,,,1403.58,912.33,,,,,,,,,,,,,
INSERT TIB CR 2.5 10 MM KNEE HI FLX EXP POLYETH VIT E,SUP-2390440,CDM,C1776,CPT,0278,RC,,,,both,,,5840.40,3796.26,,,,,,,,,,,,,
HC So1 Immunoglobulin,PX-3018278467,CDM,82784,CPT,0301,RC,,,,both,,,456.00,296.40,,,,,,,,,,,,,
PLATE BONE 4 H CRANIOMAXILLOFACIAL TI STR FOR 1.3MM SCR,SUP-2190644,CDM,C1713,HCPCS,0278,RC,,,,both,,,175.21,113.89,,,,,,,,,,,,,
PLATE BNE 130 DEG PEDIATRIC 5X175 MM 23/15 MM HIP 9 HOLE LCP,SUP-2799112,CDM,C1713,HCPCS,0278,RC,,,,both,,,2967.36,1928.78,,,,,,,,,,,,,
GRAFT VASC INTERGARD L 70 CM DIA 8 MM RNG L 20 CM UTHN,SUP-2227616,CDM,C1768,CPT,0278,RC,,,,both,,,3149.58,2047.23,,,,,,,,,,,,,
LEAD PACE RENEWAL TR EASYTRAK 2/3 STRL,SUP-2149120,CDM,C1895,HCPCS,0275,RC,,,,both,,,25434.00,16532.10,,,,,,,,,,,,,
"HC So1 Ag Detect Nos, Eia Multi Step",PX-3068744967,CDM,87449,CPT,0306,RC,,,,both,,,384.00,249.60,,,,,,,,,,,,,
CATHETER ANGIOPLSTY OVR THE WIRE 0.018 IN 150 CM 2.5X220 MM,SUP-2140761,CDM,C1725,HCPCS,0272,RC,,,,both,,,538.51,350.03,,,,,,,,,,,,,
CAP END IMPING 5 MM HUM UNIV NAILING SYS 2ND SCREW VERSANAIL,SUP-2497878,CDM,C1889,HCPCS,0278,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
PLATE BNE DPHSEAL-MTPHSEAL RT VOLAR DSTL RADIAL 13 HOLE STRL,SUP-2546641,CDM,C1713,HCPCS,0278,RC,,,,both,,,5384.13,3499.68,,,,,,,,,,,,,
BRACE KNEE HNG WRP X L,SUP-2276703,CDM,L1820,HCPCS,0272,RC,,,,both,,,50.11,32.57,,,,,,,,,,,,,
SPLINT ANK FT 3-6 SM ORTHOSIS AD UNISX WMN SHOE R STRP CLSR,SUP-2326061,CDM,L4350,HCPCS,0274,RC,,,,both,,,123.59,80.33,,,,,,,,,,,,,
DEFIBRILLATOR PECTORAL 2 CHMBR BPLR RENEWAL,SUP-2236368,CDM,C1882,HCPCS,0275,RC,,,,both,,,81640.00,53066.00,,,,,,,,,,,,,
BUR SURG L10CM DIA2MM BALL DMND SM BOR MIDAS REX LEGEND,SUP-2277608,CDM,2720000010,LOCAL,0272,RC,,,,both,,,327.94,213.16,,,,,,,,,,,,,
SCREW BNE ANTIROTATION 95 MM FOR FEM NK SYS TI NS,SUP-2181061,CDM,C1713,HCPCS,0278,RC,,,,both,,,817.40,531.31,,,,,,,,,,,,,
HC CT L-Spine W/WO Contrast,PX-3527213300,CDM,72133,CPT,0352,RC,,,,both,,,2630.00,1709.50,,,,,,,,,,,,,
INTRODUCER HEMSTAS 8FRX45CM 30 DEG CRV .038IN GWIRE FAST,SUP-2355586,CDM,C1894,HCPCS,0272,RC,,,,both,,,127.96,83.17,,,,,,,,,,,,,
PIN DISTRCTN 14 MM,SUP-2136803,CDM,C1713,HCPCS,0278,RC,,,,both,,,690.80,449.02,,,,,,,,,,,,,
CEMENT BNE 20 GM RADIOPAQUE N RADLUC FORTRESS CONCORD,SUP-2231422,CDM,C1713,HCPCS,0278,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
PACEMAKER CARD 2 CHMBR PHILOS II DR,SUP-2138035,CDM,C1785,HCPCS,0275,RC,,,,both,,,15866.42,10313.17,,,,,,,,,,,,,
WIRE FIX TROCAR PT 1 END 0.062X9 IN RND END SS NS KIRSCHNER,SUP-2791259,CDM,C1713,HCPCS,0278,RC,,,,both,,,8.60,5.59,,,,,,,,,,,,,
PROBE DOPP 8.2MHZ FLO DTECT PNCL,SUP-2321978,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2826.00,1836.90,,,,,,,,,,,,,
GRAFT VASC HEMSHLD GLD L 100 CM DIA10 MM POLYESTER BOV CLLGN,SUP-2265898,CDM,C1768,CPT,0278,RC,,,,both,,,1500.07,975.05,,,,,,,,,,,,,
PLATE BNE SM TI MANDIBULAR 3D PRNT NS DISP ACCUPLATE,SUP-2934959,CDM,C1713,HCPCS,0278,RC,,,,both,,,24391.52,15854.49,,,,,,,,,,,,,
DILATOR ENDOSCP CATHETER  L2400MM BLLN L55MM DIA18 20MM ES P,SUP-2436500,CDM,2720000010,LOCAL,0272,RC,,,,both,,,876.06,569.44,,,,,,,,,,,,,
CONE FEM AUG 6 LT KNEE CTRL TRITANIUM TRIATHLON,SUP-2422247,CDM,C1776,CPT,0278,RC,,,,both,,,10847.98,7051.19,,,,,,,,,,,,,
INTRODUCER SHTH L12CM 13FR AD .038IN GWIRE W/ L LUMN,SUP-2355410,CDM,C1894,HCPCS,0272,RC,,,,both,,,44.75,29.09,,,,,,,,,,,,,
DRILL ENDOSCP 7.5 MM,SUP-2849104,CDM,2720000010,LOCAL,0272,RC,,,,both,,,734.76,477.59,,,,,,,,,,,,,
CANNULA 96670 115 BIO MEDICUS 15FR EA,SUP-2725857,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1119.10,727.41,,,,,,,,,,,,,
ENDCAP ORTH DIA10 MM THRD T15 STRL FLEX-THREAD,SUP-2900408,CDM,C1889,HCPCS,0278,RC,,,,both,,,282.60,183.69,,,,,,,,,,,,,
STEM FEMORAL SOL SYS 10/15.0 R LRG STAT,SUP-2513075,CDM,C1776,CPT,0278,RC,,,,both,,,19643.84,12768.50,,,,,,,,,,,,,
CLAMP EXT FIX 10.5MM BAR TO RNG FRDM JET-X,SUP-2342880,CDM,2720000010,LOCAL,0272,RC,,,,both,,,5132.17,3335.91,,,,,,,,,,,,,
ELECTRODE ELECSURG CUT LOOP 3 FRX115 CM MONOPOLAR RITECUT,SUP-2313511,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1222.50,794.62,,,,,,,,,,,,,
RING EXT FIX ID140MM TI C FBR HYBRID 3/4 FOR DST TIB FRME,SUP-2188609,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1292.02,839.81,,,,,,,,,,,,,
STOCKING ORTHOT SUPP GRP CUST PREFABRICATED OFF THE SHLF,SUP-2435567,CDM,L0982,HCPCS,0272,RC,,,,both,,,44.27,28.78,,,,,,,,,,,,,
CATHETER VENTRICULAR W/ FEMALE LUER LCK CONN TRANSPARENT,SUP-2666384,CDM,C1729,HCPCS,0272,RC,,,,both,,,979.81,636.88,,,,,,,,,,,,,
INSERT TIB THK 10 MM SZ 3 UHMWPE RT ANK NEUT STRL CADENCE,SUP-2932828,CDM,C1776,CPT,0278,RC,,,,both,,,9478.25,6160.86,,,,,,,,,,,,,
INSERT TIB SZ 1 THICKNESS 8MM KNEE POST STBL INSRT IMP SCORP,SUP-2365109,CDM,C1776,CPT,0278,RC,,,,both,,,2000.21,1300.14,,,,,,,,,,,,,
CATHETER CTRL VEN 7FR L6IN POLYUR 2 LUMN W/ BLU FLEXTIP AND,SUP-2120645,CDM,C1751,HCPCS,0278,RC,,,,both,,,75.36,48.98,,,,,,,,,,,,,
COMPONENT RADIAL IM 4 DSTL WRST MICRONAIL,SUP-2538185,CDM,C1776,CPT,0278,RC,,,,both,,,6983.36,4539.18,,,,,,,,,,,,,
CANNULA RF L 150 MM DIA18 GA TIP L 5 MM LNG HYBRID ACTIVE,SUP-2917886,CDM,2720000010,LOCAL,0272,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
COIL NEUROVASCULAR MICROPLEX L 15 CM LOOP DIA 6 MM,SUP-2305207,CDM,C1889,HCPCS,0278,RC,,,,both,,,1814.92,1179.70,,,,,,,,,,,,,
ELECTRODE ES WIDE FRONTLOADING SURF LOOP SUPERSECT,SUP-2313935,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1796.99,1168.04,,,,,,,,,,,,,
LUBIPROSTONE 24 MCG PO CAPS,RX-70472,CDM,6370000000,HCPCS,0637,RC,00480-4138-06,NDC,,both,1,UN,8.00,5.20,,,,,,,,,,,,,
HC Ot Ultrasound 15 Min|DOCUMENTATION ON FILE|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS,PX-4309703500,CDM,97035,CPT,0430,RC,,,KX|CQ,outpatient,,,194.00,126.10,,,,,,,,,,,,,
DOPPLER VASC W 8MHZ PRB DGT DISPLAY ALK BATTERIES ART PRSS,SUP-2308197,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3047.84,1981.10,,,,,,,,,,,,,
CLIP INT USE W 11 MM WORKING CHANNEL 136 MM DIA2.5 MM CAP D,SUP-2881910,CDM,C1889,HCPCS,0278,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
BODY FEM L13.5MM HIP MOD ENCORE,SUP-2217197,CDM,C1776,CPT,0278,RC,,,,both,,,10314.90,6704.68,,,,,,,,,,,,,
CATHETER EP 7 MM 7 FRX110 1525 MM INQUIRY,SUP-2538005,CDM,C1730,HCPCS,0272,RC,,,,both,,,4785.36,3110.48,,,,,,,,,,,,,
SHEATH GUID 8FR L65CM HYDRPHLC COAT L35CM S STL COIL STR,SUP-2384898,CDM,C1894,HCPCS,0272,RC,,,,both,,,364.24,236.76,,,,,,,,,,,,,
DEFIBRILLATOR IMPL IFORIA DX TI EPOXY RESIN SIL HYBRID MR,SUP-2138445,CDM,C1722,HCPCS,0275,RC,,,,both,,,54008.00,35105.20,,,,,,,,,,,,,
KIT INTRO L 7 CM DIA 5 FR GUIDEWIRE L 45 CM DIA 0.018 IN,SUP-2615918,CDM,C1894,HCPCS,0272,RC,,,,both,,,151.35,98.38,,,,,,,,,,,,,
KIT PROC UNILAT W/ 5MM BAL DCR,SUP-2330968,CDM,C1726,HCPCS,0272,RC,,,,both,,,1193.20,775.58,,,,,,,,,,,,,
BLADE ENDOSCP SHAVER 60 DEG L 11 CM DIA 3.5 MM SPD 5000 RPM,SUP-2900136,CDM,2720000010,LOCAL,0272,RC,,,,both,,,505.79,328.76,,,,,,,,,,,,,
DISC SCREW SD 1.5X4 MM NS UNIV NEURO III LTX,SUP-2862732,CDM,C1713,HCPCS,0278,RC,,,,both,,,21426.01,13926.91,,,,,,,,,,,,,
HC Aaa Screening Ultrasound,PX-4027670600,CDM,76706,CPT,0402,RC,,,,inpatient,,,881.00,572.65,,,,,,,,,,,,,
FORCEP ELECSURG BPLR STD 1.2MM 15 CM SEMKIN NS SILVERGLIDE,SUP-2859571,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1400.22,910.14,,,,,,,,,,,,,
PAD BED SENSOR ALARM 30 DAY,SUP-2529125,CDM,C1776,CPT,0278,RC,,,,both,,,41.39,26.90,,,,,,,,,,,,,
PIN FIX DBL DIAMOND 0.141X9 IN SS NS STEINMANN,SUP-2791822,CDM,C1713,HCPCS,0278,RC,,,,both,,,33.35,21.68,,,,,,,,,,,,,
ANCHOR SUTURE DIA1.4 MM SUTURE 1.2 MM HA COAT 1 STRND XBRAID,SUP-2908699,CDM,C1713,HCPCS,0278,RC,,,,both,,,1770.96,1151.12,,,,,,,,,,,,,
BLADE SHV L22CM OD2.9MM DST BEND 15DEG 60-500RPM DBL CRV,SUP-2284128,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2029.70,1319.30,,,,,,,,,,,,,
COMPONENT TIB MOD PROX 130MM LGTH FINN - 130MM LEN,SUP-2406135,CDM,C1776,CPT,0278,RC,,,,both,,,16811.56,10927.51,,,,,,,,,,,,,
STAPLE BONE FIX 8MM WIRE 1.6X1.3MM ASMBLY SNIPER,SUP-2390573,CDM,C1713,HCPCS,0278,RC,,,,both,,,4396.00,2857.40,,,,,,,,,,,,,
JOINT TOE 10 DEG 3.7 MM 5 MM INTER-PHALANGEAL FUSION PK,SUP-2423827,CDM,C1713,HCPCS,0278,RC,,,,both,,,4995.11,3246.82,,,,,,,,,,,,,
PROSTHESIS VOICE L10MM OD16FR TRACHEOESOPHAGEAL INDWL CLASS,SUP-2242366,CDM,L8509,HCPCS,0274,RC,,,,both,,,863.50,561.27,,,,,,,,,,,,,
SET ATHRCTMY ROTAREX L 135 CM DIA 6 FR GUIDEWIRE L 320 CM,SUP-2739179,CDM,C1724,HCPCS,0278,RC,,,,both,,,10990.00,7143.50,,,,,,,,,,,,,
TRAY CATH MIDLN PROVENA MAXBARR 3FR 20CM 1 LUMAN S4153108DGP,SUP-2632861,CDM,C1751,HCPCS,0278,RC,,,,both,,,587.40,381.81,,,,,,,,,,,,,
PLATE BONE RECONSTRUCTION 3.5X58 MM 5 HOLE FOR SCREW STERILE,SUP-2836650,CDM,C1713,HCPCS,0278,RC,,,,both,,,2476.24,1609.56,,,,,,,,,,,,,
RING EXT FIX FULL 120 MM CIR,SUP-2400625,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2665.86,1732.81,,,,,,,,,,,,,
SCREW INTRF L35MM DIA11MM KNEE PLLA HA BIOABSRB FOR ACL PCL,SUP-2341582,CDM,C1713,HCPCS,0278,RC,,,,both,,,926.46,602.20,,,,,,,,,,,,,
PROSTHESIS CEM FEM W/ COCR HD AND XLPE LNR,SUP-2347944,CDM,C1776,CPT,0278,RC,,,,both,,,10990.00,7143.50,,,,,,,,,,,,,
TRANSDUCER KIT PROC,SUP-2302909,CDM,C1713,HCPCS,0278,RC,,,,both,,,36.58,23.78,,,,,,,,,,,,,
DEFIBRILLATOR IMPL LIVIAN HE TI BATTERY PWR ACUITY ENDOTK A,SUP-2149048,CDM,C1882,HCPCS,0275,RC,,,,both,,,78500.00,51025.00,,,,,,,,,,,,,
PLATE BNE W16XL190MM THK5MM 9 H R CNDYL FEM S STL BTTRS DYN,SUP-2185806,CDM,C1713,HCPCS,0278,RC,,,,both,,,2560.14,1664.09,,,,,,,,,,,,,
LASER SURG SELECTA TRIO,SUP-2713770,CDM,2720000010,LOCAL,0272,RC,,,,both,,,298300.00,193895.00,,,,,,,,,,,,,
GUIDE WIRE .052IN X 55CM SAFE-T-J TEFLON COATED FIXED CORE,SUP-2718702,CDM,C1769,HCPCS,0272,RC,,,,both,,,109.90,71.43,,,,,,,,,,,,,
SCREW BNE L 4 MM DIA2.6 MM EMER STRL DELT,SUP-2909658,CDM,C1713,HCPCS,0278,RC,,,,both,,,1230.57,799.87,,,,,,,,,,,,,
MESH HERN RECT 8X4 IN FULL RESRB FOR SFT TISS PHASIX,SUP-2855250,CDM,C1781,HCPCS,0278,RC,,,,both,,,8901.90,5786.23,,,,,,,,,,,,,
RING EXT FIX 105MM 2/3 TAY SPAT FRME,SUP-2342974,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7309.92,4751.45,,,,,,,,,,,,,
ROD EXT FIX L300MM DIA11MM C FBR MR CONDITIONAL,SUP-2188659,CDM,2720000010,LOCAL,0272,RC,,,,both,,,637.77,414.55,,,,,,,,,,,,,
CHLORTHALIDONE 25 MG PO TABS,RX-1661,CDM,6370000000,HCPCS,0637,RC,70756-0011-11,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
INTRODUCER SHTH STR 0.021 IN 6 FRX11 CM 21 GAX4 CM PRELUDE,SUP-2303223,CDM,C1893,HCPCS,0272,RC,,,,both,,,126.60,82.29,,,,,,,,,,,,,
STEM TIB DIA14MM BILAT ANK PLSM TOP CEM PROPHECY INBONE,SUP-2397070,CDM,C1776,CPT,0278,RC,,,,both,,,1337.64,869.47,,,,,,,,,,,,,
NAIL IM TIB 13.5X240 MM PHOENIX,SUP-2534608,CDM,C1713,HCPCS,0278,RC,,,,both,,,4851.30,3153.34,,,,,,,,,,,,,
HC CT Heart No Contrast Quant Eval Coronry Calcium|SELF-PAY CT CALCIUM SCORING,PX-3507557100,CDM,75571,CPT,0350,RC,,,CTC,inpatient,,,175.00,175.00,,,,,,,,,,,,,
BEARING HUM DIA44MM +5MM OFFSET TI FOR RVS SHLDR SYS,SUP-2404730,CDM,C1776,CPT,0278,RC,,,,both,,,4352.04,2828.83,,,,,,,,,,,,,
CATHETER ANGIO GLIDECATH L 70 CM DIA 4 FR SHFT DIA1.05 MM,SUP-2385515,CDM,C1887,HCPCS,0272,RC,,,,both,,,131.88,85.72,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED STD CEM STEM,SUP-2267788,CDM,C1776,CPT,0278,RC,,,,both,,,13545.96,8804.87,,,,,,,,,,,,,
BLADE BNE M THK5MM PARTICULATE MILL,SUP-2367526,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1019.90,662.93,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY L 92 CM DIA 6 FR SPC 2-5-2 MM E,SUP-2248676,CDM,C1730,HCPCS,0272,RC,,,,both,,,2241.96,1457.27,,,,,,,,,,,,,
PLATE BNE RECON 2-2.5X2.5 MM MAND 36 HOLE ANGLED-ANGLED STRL,SUP-2539584,CDM,C1713,HCPCS,0278,RC,,,,both,,,9010.17,5856.61,,,,,,,,,,,,,
STENT BILI S.M.A.R.T. FLX L 40 MM DIA10 MM DEL SYS L 120 CM,SUP-2159361,CDM,C1876,HCPCS,0278,RC,,,,both,,,2041.00,1326.65,,,,,,,,,,,,,
PLATE BNE Z MIC MED 100 1.5X0.6 MM LT CRANIOMAXILLOFACIAL,SUP-2467507,CDM,C1713,HCPCS,0278,RC,,,,both,,,543.00,352.95,,,,,,,,,,,,,
ELECTRODE DEFIB Q-TRAK L 45 CM DIA 7 FR COIL DIA 9FR 59.5 CC,SUP-2148623,CDM,C1896,HCPCS,0275,RC,,,,both,,,14130.00,9184.50,,,,,,,,,,,,,
HC Ot Orthotic Fit/Train per 15 Min,PX-4309776000,CDM,97760,CPT,0430,RC,,,,both,,,206.00,133.90,,,,,,,,,,,,,
KIT CATH HEMODIALYSI SAFETY 12FR DIA 20CM 3 LUMAN INDWL BLU,SUP-2613322,CDM,C1751,HCPCS,0278,RC,,,,both,,,352.31,229.00,,,,,,,,,,,,,
ALLOGRAFT HUM TISS ALLOPATCH PLIABLE 4X4CM,SUP-2307619,CDM,Q4128,HCPCS,0636,RC,,,,both,,,2728.66,1773.63,,,,,,,,,,,,,
BEARING HUM DIA36-44MM STD ARCOMXL FOR COMPHSVE REV SHLDR,SUP-2409553,CDM,C1776,CPT,0278,RC,,,,both,,,2983.00,1938.95,,,,,,,,,,,,,
CROSSLINK MECH GIC55 TRNSVRS LINK W/ 100MM BAR806LT55L100T,SUP-2289276,CDM,C1713,HCPCS,0278,RC,,,,both,,,2672.14,1736.89,,,,,,,,,,,,,
DRILL PLATING 2.5X14MM CERV SPIDER,SUP-2402185,CDM,2720000010,LOCAL,0272,RC,,,,both,,,753.60,489.84,,,,,,,,,,,,,
TROCAR SURG DIA2.8MM FOR 6.5/7.3MM CANN SCR,SUP-2177036,CDM,2720000010,LOCAL,0272,RC,,,,both,,,525.17,341.36,,,,,,,,,,,,,
KIT BONE MAR ASPIRATE 10ML,SUP-2384754,CDM,2720000010,LOCAL,0272,RC,,,,both,,,7834.30,5092.29,,,,,,,,,,,,,
LENS IOL TORIC PANOPTIX CLAREON CNWTT3 13.0D,SUP-2754345,CDM,V2788,HCPCS,0276,RC,,,,both,,,1121.25,728.81,,,,,,,,,,,,,
RASP SURG 16MM CONE DISP FOR MTP FUS PLATING SYS OMNI,SUP-2223753,CDM,2720000010,LOCAL,0272,RC,,,,both,,,725.34,471.47,,,,,,,,,,,,,
SHEATH INTRO PERFRMR L 30 CM DIA16 FR GUIDEWIRE 0.038 IN,SUP-2168488,CDM,C1894,HCPCS,0272,RC,,,,both,,,176.22,114.54,,,,,,,,,,,,,
POROUS STEM W/STD HD,SUP-2212342,CDM,C1776,CPT,0278,RC,,,,both,,,6772.98,4402.44,,,,,,,,,,,,,
TRIAL KNEE DIA38MM THK11MM ASYM TOT STBL TRIATHLON,SUP-2363808,CDM,C1776,CPT,0278,RC,,,,both,,,395.95,257.37,,,,,,,,,,,,,
CATHETER GUID PTFE S STL BRAIDING JL 3.5 ECOPAC COR SHP,SUP-2158348,CDM,C1887,HCPCS,0272,RC,,,,both,,,557.35,362.28,,,,,,,,,,,,,
SCREW BNE L50MM DIA5MM CANC TI ST CANN LOK FULL THRD TRIGEN,SUP-2348149,CDM,C1713,HCPCS,0278,RC,,,,both,,,1407.16,914.65,,,,,,,,,,,,,
TRAY DRAINAGE CATH RESOLV DIA14 FR STAYFIX SECUREMENT DEV,SUP-2461755,CDM,C1729,HCPCS,0272,RC,,,,both,,,455.30,295.94,,,,,,,,,,,,,
BASEPLATE TIB SZ 1-2 KNEE PRI CEM STEM MOD IMP,SUP-2201006,CDM,C1776,CPT,0278,RC,,,,both,,,3016.60,1960.79,,,,,,,,,,,,,
PLATE BNE L24MM THK1.5MM S STL O SHP CENTRE H FOR 4.5MM SCR,SUP-2318690,CDM,C1713,HCPCS,0278,RC,,,,both,,,2030.45,1319.79,,,,,,,,,,,,,
GRAFT HUM TISS W3XL3CM THN MTRX ANAT BARR FOR ORTH APPL,SUP-2120773,CDM,C1762,CPT,0278,RC,,,,both,,,3709.13,2410.93,,,,,,,,,,,,,
PLATE BNE L67MM BLDE W9.2XL30MM 90DEG 5 H BILAT S STL LOK,SUP-2185363,CDM,C1713,HCPCS,0278,RC,,,,both,,,3356.25,2181.56,,,,,,,,,,,,,
PROBE BRST BX 11GA TI SHP 3 FLX DEL SYS MAMTOM HYDROMARK,SUP-2195593,CDM,A4648,CPT,0278,RC,,,,both,,,270.04,175.53,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP L145CM OD0038IN 35CM TIP PTFE AMPLATZ SUP,SUP-2139357,CDM,C1769,HCPCS,0272,RC,,,,both,,,88.14,57.29,,,,,,,,,,,,,
PLATE BONE L12MM 4 H CRANIOFACIAL VIT FOR 1.3MM SCR PANFIX,SUP-2364702,CDM,C1713,HCPCS,0278,RC,,,,both,,,335.98,218.39,,,,,,,,,,,,,
KIT ATHRCTMY PHOENIX L 130 CM INTRO 7 FR GUIDEWIRE 0.014 IN,SUP-2859708,CDM,C1885,CPT,0278,RC,,,,both,,,9106.00,5918.90,,,,,,,,,,,,,
CAGE HUM STEMLESS 3 EQUINOXE,SUP-2606123,CDM,C1889,HCPCS,0278,RC,,,,both,,,11932.00,7755.80,,,,,,,,,,,,,
AFFINITI CORTILOC PEGGED GLENOID SIZE: 56,SUP-2713890,CDM,C1776,CPT,0278,RC,,,,both,,,6287.85,4087.10,,,,,,,,,,,,,
COLLAR SPNL UNIV TI W/ GRV SM STAT USS,SUP-2193400,CDM,2780000010,LOCAL,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
GEMCITABINE HCL 200 MG/5.26ML IV SOLN,RX-111496,CDM,J9201,HCPCS,0636,RC,00409-0183-01,NDC,,both,5.26,ML,54.10,35.16,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.548,SUP-2860065,CDM,C1713,HCPCS,0278,RC,,,,both,,,55917.12,36346.13,,,,,,,,,,,,,
SPLINT ORTHOT CUST HALLUS VALGUS NT DYN,SUP-2435710,CDM,L3100,HCPCS,0274,RC,,,,both,,,122.49,79.62,,,,,,,,,,,,,
PLATE BNE X 2.3X1.5 MM THOR RIB 10 HOLE LCK SLD SEMI LEVEL 1,SUP-2869173,CDM,C1713,HCPCS,0278,RC,,,,both,,,3398.74,2209.18,,,,,,,,,,,,,
HC So Hepatic Function Panel,PX-3018007666,CDM,80076,CPT,0301,RC,,,,both,,,30.00,19.50,,,,,,,,,,,,,
RAMIPRIL 2.5 MG PO CAPS,RX-11260,CDM,6370000000,HCPCS,0637,RC,65862-0475-01,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
ANCHOR SUT 15MM PRELD W 2 0 AND NDL MICROMITE STITCHPAK,SUP-2166461,CDM,C1713,HCPCS,0278,RC,,,,both,,,681.16,442.75,,,,,,,,,,,,,
SPACER ORTH TALAR PT SPEC PK,SUP-2742003,CDM,C1776,CPT,0278,RC,,,,both,,,41369.50,26890.17,,,,,,,,,,,,,
HC So Hepatitis Delta Agent Ab,PX-3028669266,CDM,86692,CPT,0302,RC,,,,both,,,108.00,70.20,,,,,,,,,,,,,
HC So Gabapentin Neurontin,PX-3018017166,CDM,80171,CPT,0301,RC,,,,both,,,49.00,31.85,,,,,,,,,,,,,
KNEE VNGD TI FEM SSK 70MM RT,SUP-2510699,CDM,C1713,HCPCS,0278,RC,,,,both,,,17671.92,11486.75,,,,,,,,,,,,,
CAP SPNL LCK RAD,SUP-2543612,CDM,C1713,HCPCS,0278,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
HC Iadna Mycoplasma Genitalium Amplified Probe Tech,PX-3068756300,CDM,87563,CPT,0306,RC,,,,both,,,120.00,78.00,,,,,,,,,,,,,
RECON PLATE 5X77MM 4.5MM,SUP-2818427,CDM,C1713,HCPCS,0278,RC,,,,both,,,3061.03,1989.67,,,,,,,,,,,,,
SCREW BONE L8MM DIA2MM HND VAR ANG LCK FLOWERCUBE,SUP-2225440,CDM,C1713,HCPCS,0278,RC,,,,both,,,373.97,243.08,,,,,,,,,,,,,
SCREW BNE HD 6.5X105 MM 16 MM,SUP-2398634,CDM,C1713,HCPCS,0278,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
COLLAR CERV PROGLIDE UNIV,SUP-2276573,CDM,L0172,HCPCS,0274,RC,,,,both,,,219.55,142.71,,,,,,,,,,,,,
BIT DRL TWST 0.8X4 MM 7 CM SM BOR MIDAS REX 8 LEGEND,SUP-2664811,CDM,2720000010,LOCAL,0272,RC,,,,both,,,473.01,307.46,,,,,,,,,,,,,
PLATE BNE THK0.6MM 6 H MAND TI DBL Y LO PROF FOR 2MM SCR,SUP-2262946,CDM,C1713,HCPCS,0278,RC,,,,both,,,571.48,371.46,,,,,,,,,,,,,
PLATE BNE L161MM 8 H NONSTERILE R MED DST TIB S STL LOK,SUP-2184172,CDM,C1713,HCPCS,0278,RC,,,,both,,,3773.93,2453.05,,,,,,,,,,,,,
HIP BIP PRSFT SYST 98000100601,SUP-2212080,CDM,C1776,CPT,0278,RC,,,,both,,,5499.02,3574.36,,,,,,,,,,,,,
BIT DRL L 300 MM DIA13 MM STRL DISP PICCOLO COMP,SUP-2930823,CDM,2720000010,LOCAL,0272,RC,,,,both,,,420.51,273.33,,,,,,,,,,,,,
LEVOTHYROXINE SODIUM 112 MCG PO TABS,RX-10404,CDM,6370000000,HCPCS,0637,RC,00074-9296-90,NDC,,both,1,UN,7.50,4.87,,,,,,,,,,,,,
CATHETER CV DL PEDIATRIC 7 FRX65 CM CUF W/ STYL BRVC,SUP-2126157,CDM,C1751,HCPCS,0278,RC,,,,both,,,926.30,602.09,,,,,,,,,,,,,
NEEDLE ENDOSCP 21 MMX15 CM LL SPRING LD ADIPOSE PT EMPLOYING,SUP-2769559,CDM,2720000010,LOCAL,0272,RC,,,,both,,,730.33,474.71,,,,,,,,,,,,,
PASSER SUTURE DRAGON TNGE DEV COSURE CAPSULAR,SUP-2745457,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1023.64,665.37,,,,,,,,,,,,,
HC Dx Bone Marrow Aspirations,PX-5103822000,CDM,38220,CPT,0510,RC,,,,both,,,4946.00,3214.90,,,,,,,,,,,,,
GUIDEWIRE ENDOSCP STR 0.032 INX150 CM REG FLX TIP GLIDEWIRE,SUP-2478880,CDM,C1769,HCPCS,0272,RC,,,,both,,,137.09,89.11,,,,,,,,,,,,,
GRAFT VASC GORTX L 30 CM DIA 6 MM RNG L 20 CM EPTFE STR STD,SUP-2396092,CDM,C1768,CPT,0278,RC,,,,both,,,1535.46,998.05,,,,,,,,,,,,,
BRACE KNEE 17 27IN R L UNIV FIT UPTO 305IN THGH T SCP,SUP-2150870,CDM,L1810,HCPCS,0272,RC,,,,both,,,290.23,188.65,,,,,,,,,,,,,
IMPLANT CRANIAL M CUSTOMIZED MEDPOR,SUP-2862613,CDM,C1713,HCPCS,0278,RC,,,,both,,,45661.69,29680.10,,,,,,,,,,,,,
PLATE BONE DUAL CMPRSSN UNVRSL 3.5X157 MM 12 HOLE LOK,SUP-2488500,CDM,C1713,HCPCS,0278,RC,,,,both,,,1138.44,739.99,,,,,,,,,,,,,
TAP SURG L180MM D110MM FOR 4.5MM CORT AND SHFT SCR,SUP-2187416,CDM,C1713,HCPCS,0278,RC,,,,both,,,723.68,470.39,,,,,,,,,,,,,
"HC So Systemic Lupus a, Dna Ab",PX-3028622567,CDM,86225,CPT,0302,RC,,,,both,,,28.00,18.20,,,,,,,,,,,,,
MORPHINE SULFATE (PF) 1 MG/ML IJ SOLN,RX-15852,CDM,J2274,HCPCS,0636,RC,00641-6019-01,NDC,,both,10,ML,166.60,108.29,,,,,,,,,,,,,
CUP ACET DIA62MM UNIV HIP TI POR PRESSFIT PRI CEMENTLESS MH,SUP-2250728,CDM,C1776,CPT,0278,RC,,,,both,,,4967.48,3228.86,,,,,,,,,,,,,
KNIFE SRGCL SCHKNCHT 7MM BLADE 6 14NL SCKLE ANGLD LATEX FRE,SUP-2673272,CDM,2720000010,LOCAL,0272,RC,,,,both,,,335.85,218.30,,,,,,,,,,,,,
LINER ACET OD42MM ID28MM +3MM NEUT XLPE ESCALADE,SUP-2315257,CDM,C1776,CPT,0278,RC,,,,both,,,2863.68,1861.39,,,,,,,,,,,,,
PROBE NERVE STIM DIA2.3 MM MONOPOLAR BALL TIP HNDL STRL DISP,SUP-2902085,CDM,2720000010,LOCAL,0272,RC,,,,both,,,525.79,341.76,,,,,,,,,,,,,
HC So1 Lipid Panel|NOT REASONABLE AND NECESSARY,PX-3018006167,CDM,80061,CPT,0301,RC,,,GZ,both,,,55.00,35.75,,,,,,,,,,,,,
STEM TIB L150MM DIA14MM KNEE EXTN STABILIZING PRI FLUT,SUP-2253323,CDM,C1713,HCPCS,0278,RC,,,,both,,,3815.10,2479.81,,,,,,,,,,,,,
STENT CORONARY EXPRESS 2 L 16 MM DIA2.25 MM GUIDE CATH 5 FR,SUP-2144260,CDM,C1876,HCPCS,0278,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
ROD EXT FIX L550MM DIA11MM UNIV C FBR RADLUC CONN,SUP-2188672,CDM,2720000010,LOCAL,0272,RC,,,,both,,,755.48,491.06,,,,,,,,,,,,,
HC Cervical Myelogram S&I,PX-3207224000,CDM,72240,CPT,0320,RC,,,,both,,,3707.00,2409.55,,,,,,,,,,,,,
KIT BNE FIX 43MM SBT 14X3.5MM LPS SCR 2.5MM PIN TIP DRL,SUP-2123091,CDM,C1713,HCPCS,0278,RC,,,,both,,,3218.50,2092.02,,,,,,,,,,,,,
CATHETER CV DL 4 FR FULL TY PER-Q-CATH,SUP-2126382,CDM,C1894,HCPCS,0272,RC,,,,both,,,503.97,327.58,,,,,,,,,,,,,
MEMBRANE CLLGN DURA REP DURAMATRIX SUTURABLE 1IN X 1IN,SUP-2165128,CDM,C1763,HCPCS,0278,RC,,,,both,,,920.55,598.36,,,,,,,,,,,,,
SCREW BNE L 5 MM DIA1.7 MM POLY L-LACTIDE POLY D-LACTIDE 10PK,SUP-2883349,CDM,C1713,HCPCS,0278,RC,,,,both,,,2533.98,1647.09,,,,,,,,,,,,,
GRAFT HUM TISS L155MM DIA4 5MM LAT ANK TEND SUTURED FRZN,SUP-2264638,CDM,C1713,HCPCS,0278,RC,,,,both,,,4295.83,2792.29,,,,,,,,,,,,,
CLIP ANEUR BLDE MIC L1.0MM 10GM NO1 S STL GRFT SLIM-LINE,SUP-2243091,CDM,C1889,HCPCS,0278,RC,,,,both,,,1500.92,975.60,,,,,,,,,,,,,
ALLOGRAFT BNE 4X8X13 MM BIOEXPAND,SUP-2636998,CDM,C1713,HCPCS,0278,RC,,,,both,,,2608.40,1695.46,,,,,,,,,,,,,
CATHETER CV TY STRL LTX,SUP-2876536,CDM,C1751,HCPCS,0278,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
GRAFT VASC DURAGN SECUR L 1 X W 1 IN DURA REGEN MTRX STRL,SUP-2500914,CDM,C1763,HCPCS,0278,RC,,,,both,,,1021.10,663.71,,,,,,,,,,,,,
PLATE EXT FIX L50MM ANK FT FOR TRUELOK FRME ASSEMB HEXAPOD,SUP-2316157,CDM,2720000010,LOCAL,0272,RC,,,,both,,,412.31,268.00,,,,,,,,,,,,,
CUP ACET OD38MM ID22MM UHMWPE COMPR MOLD PVT BPLR,SUP-2314493,CDM,C1776,CPT,0278,RC,,,,both,,,2135.20,1387.88,,,,,,,,,,,,,
STEM TAPER 18X185MM,SUP-2505147,CDM,C1776,CPT,0278,RC,,,,both,,,7724.40,5020.86,,,,,,,,,,,,,
STENT CORONARY MAGIC WSTNT DIA 6 MM LNG STRL,SUP-2141825,CDM,C1876,HCPCS,0278,RC,,,,both,,,6511.58,4232.53,,,,,,,,,,,,,
COIL VASC I-ED COIL PRIMARY L 30 CM DIA 0.012 IN SECONDARY,SUP-2865311,CDM,C1889,HCPCS,0278,RC,,,,both,,,5824.70,3786.05,,,,,,,,,,,,,
SHEATH INTRO FLX SHUTTLE L 90 CM OD 5 FR GUIDEWIRE 0.038 IN,SUP-2170003,CDM,C1894,HCPCS,0272,RC,,,,both,,,341.13,221.73,,,,,,,,,,,,,
HC Inj/Asp Maj Jnt or Bursa,PX-7612061000,CDM,20610,CPT,0761,RC,,,,inpatient,,,1092.00,709.80,,,,,,,,,,,,,
GRAFT HUM TISS W2XL2CM AMNIO MEMBRN TRNSLUC GRID PAT,SUP-2113883,CDM,Q4154,HCPCS,0636,RC,,,,both,,,2684.70,1745.05,,,,,,,,,,,,,
ROD SPNL THRD LNG 400 MM MR SAFE NS,SUP-2863418,CDM,C1713,HCPCS,0278,RC,,,,both,,,313.75,203.94,,,,,,,,,,,,,
SCREW SPNL FT 3.5X36 MM CORRIDOR,SUP-2593534,CDM,C1713,HCPCS,0278,RC,,,,both,,,1196.34,777.62,,,,,,,,,,,,,
GRAFT VASC IMPRA L 40 CM DIA 8 MM EPTFE FLX STD WALL SM BEAD,SUP-2761449,CDM,C1768,CPT,0278,RC,,,,both,,,2069.01,1344.86,,,,,,,,,,,,,
COMPONENT FEM SZ 7 CO CHROM LT KNEE REV STEMLESS POST STBL,SUP-2346128,CDM,C1776,CPT,0278,RC,,,,both,,,19430.32,12629.71,,,,,,,,,,,,,
BINDER MAMM SURG 3XL X SFT CUP,SUP-2113433,CDM,L8000,HCPCS,0272,RC,,,,both,,,132.82,86.33,,,,,,,,,,,,,
CATHETER LD DEL ACUITY PRO 90 DEG L 60 CM DIA 7 FR SS PTFE,SUP-2149030,CDM,C1887,HCPCS,0272,RC,,,,both,,,769.30,500.04,,,,,,,,,,,,,
DRILL SURG ORAL MXLFCL STRGHT HGH SPD PRMNNT LEVER FLFSMLL B,SUP-2605596,CDM,2720000010,LOCAL,0272,RC,,,,both,,,17285.83,11235.79,,,,,,,,,,,,,
WASHER ORTH 0 DEG 86-130 MM,SUP-2609262,CDM,C1713,HCPCS,0278,RC,,,,both,,,524.73,341.07,,,,,,,,,,,,,
PLATE BNE CANC 3.5 MM RT,SUP-2349952,CDM,C1713,HCPCS,0278,RC,,,,both,,,3155.70,2051.20,,,,,,,,,,,,,
COIL EMB L1CM DIA1MM HELI DETACH TARGET NANO,SUP-2367948,CDM,C1889,HCPCS,0278,RC,,,,both,,,4286.10,2785.96,,,,,,,,,,,,,
GRAFT HUM TISS L230MM MIN DIA75MM PERONEUS LONGUS TEND FRZN,SUP-2264785,CDM,C1762,CPT,0278,RC,,,,both,,,5422.75,3524.79,,,,,,,,,,,,,
VEST PT CERV HALO,SUP-2322423,CDM,L0112,HCPCS,0274,RC,,,,both,,,19625.00,12756.25,,,,,,,,,,,,,
PLATE BNE STR 2.3X45X1.5 MM 6 HOLE COMPR FRAC TI LEVEL 1,SUP-2469290,CDM,C1713,HCPCS,0278,RC,,,,both,,,859.04,558.38,,,,,,,,,,,,,
MESH HERN M W4.3XL5.5IN POLYPR EPTFE OVL SELF EXP PTCH,SUP-2125714,CDM,C1781,HCPCS,0278,RC,,,,both,,,2192.98,1425.44,,,,,,,,,,,,,
CARTRIDGE SAW W25XH1.27XL105MM STD OSC TIP FALC EVOLVE,SUP-2367669,CDM,2720000010,LOCAL,0272,RC,,,,both,,,894.90,581.68,,,,,,,,,,,,,
ASSEMBLY GWIRE DIA0035IN PARA FOR MIC ACUTRK 2,SUP-2107280,CDM,C1769,HCPCS,0272,RC,,,,both,,,850.94,553.11,,,,,,,,,,,,,
COIL SZ 1 OL1000 SGL ELECTR BNE ST,SUP-2196350,CDM,E0749,HCPCS,0278,RC,,,,both,,,7959.90,5173.93,,,,,,,,,,,,,
ALLOGRAFT BNE BI-COMPARTMENT REFRIGERATED LT MEDL TROCHLEA,SUP-2740878,CDM,C1762,CPT,0278,RC,,,,both,,,57907.91,37640.14,,,,,,,,,,,,,
SYSTEM EXT DRNGE VOL LIMITING W/ 30ML BURET LIMITORR,SUP-2244113,CDM,C1713,HCPCS,0278,RC,,,,both,,,812.95,528.42,,,,,,,,,,,,,
ISAVUCONAZONIUM SULFATE 186 MG PO CAPS,RX-129589,CDM,6370000000,HCPCS,0637,RC,00469-0520-01,NDC,,both,1,UN,481.70,313.10,,,,,,,,,,,,,
NOREPINEPHRINE-SODIUM CHLORIDE 32-0.9 MG/250ML-% IV SOLN,RX-144802,CDM,2500000003,HCPCS,0250,RC,69194-0117-10,NDC,,both,250,ML,237.20,154.18,,,,,,,,,,,,,
PAD ORTHOT CERV THOR LUMBAR SACR CUST KYPHOSIS,SUP-2435571,CDM,L1020,HCPCS,0272,RC,,,,both,,,305.08,198.30,,,,,,,,,,,,,
BRACE EL R ROM TELSCP 4 CUF X ACT,SUP-2196500,CDM,L3702,HCPCS,0274,RC,,,,both,,,294.38,191.35,,,,,,,,,,,,,
PLATE BONE L46MM THK2.8MM 4 H BILAT S STL NONCOMPRESSION,SUP-2348976,CDM,C1713,HCPCS,0278,RC,,,,both,,,2978.79,1936.21,,,,,,,,,,,,,
BIT CANNULATED DIA 4.9MM/L240,SUP-2718093,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1384.74,900.08,,,,,,,,,,,,,
ROD SPNL L100MM OD5.5MM S STL STR THORLUM REVERE,SUP-2185220,CDM,C1713,HCPCS,0278,RC,,,,both,,,4154.28,2700.28,,,,,,,,,,,,,
PLATE BONE SHFT L397MM BLDE L60MM THK4.8MM 95DEG 24 H BILAT,SUP-2185466,CDM,C1713,HCPCS,0278,RC,,,,both,,,3642.78,2367.81,,,,,,,,,,,,,
PLATE BNE L111MM 8 H NONSTERILE R PROX TIB S STL LO PROF,SUP-2185813,CDM,C1713,HCPCS,0278,RC,,,,both,,,3619.79,2352.86,,,,,,,,,,,,,
RETRACTOR SURG L8CM DIA26MM TB DISP FOR MICRODISCECTOMY,SUP-2293061,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1109.68,721.29,,,,,,,,,,,,,
GENERATOR EXT PULSE DRG W/ 2 PRT HD,SUP-2357373,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
SPLINT THMB AD M L BGE L MCP CMC JT PREFRM PERF FLX BASE LAM,SUP-2326182,CDM,L3908,HCPCS,0272,RC,,,,both,,,70.21,45.64,,,,,,,,,,,,,
SHEATH INTRO PRELUDEEASE 16CM 6FR 80CM NDL 4CM NIT PLAT,SUP-2483446,CDM,C1894,HCPCS,0272,RC,,,,both,,,151.66,98.58,,,,,,,,,,,,,
INTRODUCER LD L12CM OD5FR 0.038IN PLCMNT N PEEL AWAY N COR,SUP-2356158,CDM,C1894,HCPCS,0272,RC,,,,both,,,37.68,24.49,,,,,,,,,,,,,
BIT DRL L140MM OD2MM LNG SLD MEAS AO,SUP-2321587,CDM,2720000010,LOCAL,0272,RC,,,,both,,,494.55,321.46,,,,,,,,,,,,,
NAIL IM TIB 7.5X290 MM PHOENIX,SUP-2472772,CDM,C1713,HCPCS,0278,RC,,,,both,,,4954.92,3220.70,,,,,,,,,,,,,
PLATE BNE LCK 2.4X45 MM RT DSTL RADIAL 7X3 HOLE COMPR CLMN,SUP-2190182,CDM,C1713,HCPCS,0278,RC,,,,both,,,2731.23,1775.30,,,,,,,,,,,,,
SPLINT ORTH L4IN STD PLAS FNGR MLLT W/O PD STAX,SUP-2205660,CDM,L3913,HCPCS,0272,RC,,,,both,,,5.28,3.43,,,,,,,,,,,,,
DRILL SURG PEG TROCHANTERIC HI PERF SIG,SUP-2453117,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1199.48,779.66,,,,,,,,,,,,,
CATHETER CV SET 035 PEDIATRIC 5 FRX5 CM 1 LUMEN J TIP,SUP-2760011,CDM,C1751,HCPCS,0278,RC,,,,both,,,143.00,92.95,,,,,,,,,,,,,
DACARBAZINE 100 MG IV SOLR,RX-2090,CDM,J9130,HCPCS,0636,RC,63323-0127-10,NDC,,both,1,UN,71.30,46.34,,,,,,,,,,,,,
EXTERNAL FIXATION SET LG SELF DRL SCHNZ SCREW SS,SUP-2183084,CDM,2720000010,LOCAL,0272,RC,,,,both,,,63940.57,41561.37,,,,,,,,,,,,,
PLATE BNE METATARSOPHALANGEAL SM RT TCP,SUP-2485258,CDM,C1713,HCPCS,0278,RC,,,,both,,,4248.42,2761.47,,,,,,,,,,,,,
NAIL INTRAMEDULLARY SUBTALAR MEDIAL COLUMN 8MM X 80MM NITINOL DYNANAIL MINI,SUP-2878181,CDM,C1713,HCPCS,0278,RC,,,,both,,,17788.10,11562.26,,,,,,,,,,,,,
LEAD PACE SIL ENDOCARD RT VENTRICULAR PASS FIX IS1 BPLR CONN,SUP-2148540,CDM,C1898,HCPCS,0275,RC,,,,both,,,2835.42,1843.02,,,,,,,,,,,,,
DRILL BNE ACCS 10 GA STRL SYNFLATE,SUP-2758541,CDM,2720000010,LOCAL,0272,RC,,,,both,,,353.25,229.61,,,,,,,,,,,,,
GRIPPER SURGICAL RETRACTOR DISP,SUP-2427782,CDM,C1713,HCPCS,0278,RC,,,,both,,,401.92,261.25,,,,,,,,,,,,,
MEPIVACAINE HCL (PF) 1.5 % IJ SOLN,RX-155558,CDM,J0670,HCPCS,0636,RC,63323-0293-37,NDC,,both,1.333333333333333333,ML,54.10,35.16,,,,,,,,,,,,,
HC So Hep B Ultraquant,PX-3068751766,CDM,87517,CPT,0306,RC,,,,both,,,306.00,198.90,,,,,,,,,,,,,
GRAFT BNE STRP 5 CC BIOACTIVE GLS,SUP-2860950,CDM,C1713,HCPCS,0278,RC,,,,both,,,6248.60,4061.59,,,,,,,,,,,,,
CATHETER DRNGE 28FR 4 WNG DISP FOR NEPHSTMY MALECOTS,SUP-2129077,CDM,C2627,HCPCS,0272,RC,,,,both,,,37.02,24.06,,,,,,,,,,,,,
SCREW BNE L18MM DIA4MM PERIARTC S STL ST LOK FULL THRD FOR,SUP-2184949,CDM,C1713,HCPCS,0278,RC,,,,both,,,415.86,270.31,,,,,,,,,,,,,
UNIVERSAL HUM NAIL 8X160MM,SUP-2587503,CDM,C1713,HCPCS,0278,RC,,,,both,,,4196.89,2727.98,,,,,,,,,,,,,
MESH HERN CIR 20 CM W/ ECHO 2 POS SYS POLYPR VENTRALIGHT ST,SUP-2126501,CDM,C1781,HCPCS,0278,RC,,,,both,,,3736.60,2428.79,,,,,,,,,,,,,
HC Phase II Recovery - Addtl 15 Min,PX-7100000011,CDM,7100000011,LOCAL,0710,RC,,,,both,,,305.00,198.25,,,,,,,,,,,,,
WASHER ORTH SH FIX TI ALLOY,SUP-2208302,CDM,C1713,HCPCS,0278,RC,,,,both,,,1449.74,942.33,,,,,,,,,,,,,
PLATE BNE CRV 4.5X266 MM RT CNDYL 12 HOLE VA LCK STRL VALCP,SUP-2789641,CDM,C1713,HCPCS,0278,RC,,,,both,,,6515.22,4234.89,,,,,,,,,,,,,
DEVICE FIX DIA10MM TIB PRELD TUNNELOC,SUP-2137205,CDM,C1713,HCPCS,0278,RC,,,,both,,,1874.45,1218.39,,,,,,,,,,,,,
FIXATION BEAM 7.5 X 105 MM,SUP-2586671,CDM,C1713,HCPCS,0278,RC,,,,both,,,4380.30,2847.19,,,,,,,,,,,,,
DEVICE COAG 3 CM GUID 6140 EPISENSE,SUP-2424448,CDM,2720000010,LOCAL,0272,RC,,,,both,,,40820.00,26533.00,,,,,,,,,,,,,
PROBE ES L75MM OD17GA THERACOOL,SUP-2237208,CDM,C1713,HCPCS,0278,RC,,,,both,,,2433.50,1581.77,,,,,,,,,,,,,
CAGE SPNL 22X9X8MM 15DEG LO PROF LORDTC EXP W/ TANT MRK,SUP-2354698,CDM,C1889,HCPCS,0278,RC,,,,both,,,17332.80,11266.32,,,,,,,,,,,,,
BIT DRILL MINI AO 2.0MM,SUP-2745252,CDM,2720000010,LOCAL,0272,RC,,,,both,,,502.40,326.56,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL TI NS SD420.423,SUP-2859987,CDM,C1713,HCPCS,0278,RC,,,,both,,,37598.99,24439.34,,,,,,,,,,,,,
CATHETER EP L120CM DIA6FR ELECTRD SPC 2-2-2MM JSN CRV MAP,SUP-2356819,CDM,C1730,HCPCS,0272,RC,,,,both,,,800.70,520.45,,,,,,,,,,,,,
SPACER SPNL W11XH8XL14MM 0DEG PEEK TI MRK PARA ANT THORLUM,SUP-2286240,CDM,C1821,HCPCS,0278,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
TOOL EXT FIX T MINI RAIL SYS RX-FIX,SUP-2517154,CDM,2720000010,LOCAL,0272,RC,,,,both,,,960.84,624.55,,,,,,,,,,,,,
STAPLER SURG L60MM BLU RELD DISP W/ 3.5MM TI STPL DST SER,SUP-2283417,CDM,2720000010,LOCAL,0272,RC,,,,both,,,567.93,369.15,,,,,,,,,,,,,
PLATE BONE W12XL71MM THK4MM 4 H S STL STR NAR COMPR FOR,SUP-2343806,CDM,C1713,HCPCS,0278,RC,,,,both,,,1233.55,801.81,,,,,,,,,,,,,
CATHETER CCOMBO VINCLUDES SVO2 AND EDV VIP W/ AMC THROMSHLD,SUP-2214323,CDM,C1751,HCPCS,0278,RC,,,,both,,,793.64,515.87,,,,,,,,,,,,,
PLATE BNE STRUT 1.3X43 MM CRANIOMAXILLOFACIAL 18 HOLE TI NS,SUP-2190670,CDM,C1713,HCPCS,0278,RC,,,,both,,,1478.94,961.31,,,,,,,,,,,,,
CLAMP REPROC COMBO MR SAFE MED,SUP-2466315,CDM,2720000010,LOCAL,0272,RC,,,,both,,,356.64,231.82,,,,,,,,,,,,,
COLLAR CERV FOAM PADDING XTALL ADLT 4.5 IN TRNS ATLS PROCARE,SUP-2195753,CDM,L0180,HCPCS,0272,RC,,,,both,,,74.51,48.43,,,,,,,,,,,,,
PLATE BNE DBL ANGLED SM 2.5 MM RECON PT SPEC TI,SUP-2860099,CDM,C1713,HCPCS,0278,RC,,,,both,,,22092.10,14359.86,,,,,,,,,,,,,
CATHETER DRNGE 5FR OD 250CML NTNL NSBLRY SNGLE PGTL WCNNCTN,SUP-2679097,CDM,C2617,HCPCS,0278,RC,,,,both,,,333.12,216.53,,,,,,,,,,,,,
BLADE SAW D 31 MM CUT EDGE 9 MM CUT THK 0.5 MM MATERIAL THK,SUP-2898831,CDM,2720000010,LOCAL,0272,RC,,,,both,,,157.06,102.09,,,,,,,,,,,,,
NEEDLE ASPIR DIA25GA SHTH DIA1.52MM WRK CHAN 2.4MM STD HNDL,SUP-2141501,CDM,2720000010,LOCAL,0272,RC,,,,both,,,662.54,430.65,,,,,,,,,,,,,
COMPONENT ULN L3.5IN REG R EL TIV PLSM INTERCHANGEABLE CEM,SUP-2205939,CDM,C1776,CPT,0278,RC,,,,both,,,18758.36,12192.93,,,,,,,,,,,,,
STEM FEM SZ 4 L149MM DIA14MM STD CO CHROM MOD STANMORE,SUP-2405087,CDM,C1776,CPT,0278,RC,,,,both,,,6637.96,4314.67,,,,,,,,,,,,,
ENALAPRIL-HYDROCHLOROTHIAZIDE 10-25 MG PO TABS,RX-9928,CDM,6370000000,HCPCS,0637,RC,51672-4046-01,NDC,,both,1,UN,54.10,35.16,,,,,,,,,,,,,
RESERVOIR PERF VEN BG W/ RECIRC LN AFFIN RV,SUP-2473177,CDM,2720000010,LOCAL,0272,RC,,,,both,,,244.92,159.20,,,,,,,,,,,,,
PROSTHESIS OSS MCGEE 1.22X4.5 MM 4.75 MM STAPE MALL SS,SUP-2637817,CDM,L8613,CPT,0278,RC,,,,both,,,495.65,322.17,,,,,,,,,,,,,
STABILIZER SURG MECH AXIUS,SUP-2141846,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3124.30,2030.79,,,,,,,,,,,,,
BAR SACRAL THRD 6X260MM,SUP-2547746,CDM,C1713,HCPCS,0278,RC,,,,both,,,1851.44,1203.44,,,,,,,,,,,,,
TREPHINE BONE BX L8IN DIA11MM RMR FOR FEM REV PROC,SUP-2136782,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1868.30,1214.39,,,,,,,,,,,,,
GRAFT BNE 30CC 1 4MM CANC CRUSH CHIP READIGRFT,SUP-2264820,CDM,C1713,HCPCS,0278,RC,,,,both,,,1333.24,866.61,,,,,,,,,,,,,
K WIRE 07X152MM TROCAR STE,SUP-2721585,CDM,C1713,HCPCS,0278,RC,,,,both,,,167.52,108.89,,,,,,,,,,,,,
INTRODUCER SHTH L62CM OD0.12IN ID0.09IN LAT VEIN RENAL CRV,SUP-2303511,CDM,C1892,HCPCS,0272,RC,,,,both,,,1224.60,795.99,,,,,,,,,,,,,
CATHETER THROMCTMY AXS VECTA 71 L 125 CM ID 1.8 MM,SUP-2551061,CDM,C1757,HCPCS,0272,RC,,,,both,,,7799.76,5069.84,,,,,,,,,,,,,
GRAFT BIO TISS W7.9XL7.9IN PORCINE DERM RIFAMPIN,SUP-2125842,CDM,C1781,HCPCS,0278,RC,,,,both,,,43610.83,28347.04,,,,,,,,,,,,,
STAPLER INT REG 60-3.8 IN KNIFELESS SINGLE RELD W/ DST SER,SUP-2787703,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1261.87,820.22,,,,,,,,,,,,,
IMPLANT HUM TISS RT PAT OSTEOCHNDRL,SUP-2884879,CDM,C1762,CPT,0278,RC,,,,both,,,38653.40,25124.71,,,,,,,,,,,,,
BASKET SPEC RETRV ACCORDIAN,SUP-2225715,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1020.50,663.32,,,,,,,,,,,,,
GRAFT VASC W7XL10CM THK01MM PERICARD EPTFE MEM PRECL,SUP-2395367,CDM,C1781,HCPCS,0278,RC,,,,both,,,1036.20,673.53,,,,,,,,,,,,,
HALF PIN 6MMX90MM,SUP-2820673,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1197.00,778.05,,,,,,,,,,,,,
TUBE ENDOTRACHEAL 5 MM CHANGING,SUP-2242618,CDM,2720000010,LOCAL,0272,RC,,,,both,,,32.94,21.41,,,,,,,,,,,,,
BASEPLATE TIB L51MM LNG MED LAT KNEE CO CHROM RESURF,SUP-2406482,CDM,C1713,HCPCS,0278,RC,,,,both,,,8633.43,5611.73,,,,,,,,,,,,,
POST ORTHOPEDIC 4 HOLE W/ 12MM BOLT TRUELOK,SUP-2316112,CDM,2720000010,LOCAL,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
GRAFT BNE SUB 10CC SZ 0212 0850MM DEMIN CORT PWD FRZ DRY,SUP-2307257,CDM,C1713,HCPCS,0278,RC,,,,both,,,886.58,576.28,,,,,,,,,,,,,
AMPHOTERICIN B LIPOSOME 50 MG IV SUSR,RX-21900,CDM,J0289,HCPCS,0636,RC,00469-3051-30,NDC,,both,1,UN,938.50,610.02,,,,,,,,,,,,,
BRACE SHLDR L RT UNILAT LYCRA SPANDEX ORTHOSIS MFC II ROLYAN,SUP-2324867,CDM,L3660,HCPCS,0272,RC,,,,both,,,114.74,74.58,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY DYN TIP L 110 CM DIA 6 FR SPC,SUP-2141316,CDM,C1730,HCPCS,0272,RC,,,,both,,,1774.10,1153.16,,,,,,,,,,,,,
TRAY CATH MIDLN PROVENA PLU 3FR 20CM 1 LUMAN RVRSE TAPR PWR,SUP-2613547,CDM,C1751,HCPCS,0278,RC,,,,both,,,464.72,302.07,,,,,,,,,,,,,
STEM FEM L267MM OD13MM BOW TRI SLOT PLSM SPRAYED HA DST HIP,SUP-2375898,CDM,C1776,CPT,0278,RC,,,,both,,,9397.39,6108.30,,,,,,,,,,,,,
STENT PERIPH FORMULA 418 L 12 MM DIA 5 MM CATH L 80 CM DIA 6,SUP-2171177,CDM,C1876,HCPCS,0278,RC,,,,both,,,2774.98,1803.74,,,,,,,,,,,,,
BRA SURG SUPP LG 38-40 IN ZIPPER,SUP-2213721,CDM,L8000,HCPCS,0272,RC,,,,both,,,125.41,81.52,,,,,,,,,,,,,
GRAFT BONE 30ML CORT CANC CRUSH CHIP FRZN,SUP-2294136,CDM,C1713,HCPCS,0278,RC,,,,both,,,1230.88,800.07,,,,,,,,,,,,,
GUIDEWIRE ORTH DIA2.5MM LOK SMOOTH DRL TIP FLX THRD FOR,SUP-2187225,CDM,C1769,HCPCS,0272,RC,,,,both,,,179.07,116.40,,,,,,,,,,,,,
PLATE VARIAX HAND 17 6 HOLE L ANG,SUP-2695489,CDM,C1713,HCPCS,0278,RC,,,,both,,,1051.59,683.53,,,,,,,,,,,,,
SYSTEM CATH DEL 145CM GUID INTRO PEEL AWAY INTRO APEEL CS +,SUP-2357280,CDM,C1894,HCPCS,0272,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
KIT THR POR STEM TRABECULAR MTL CUP L VIT E LNR AND L 98000100580] ZIMMER BIOMET INC],SUP-2212077,CDM,C1776,CPT,0278,RC,,,,both,,,18055.00,11735.75,,,,,,,,,,,,,
ANCHOR SUT 65MM DIA W NDL PEEK INTRALINE,SUP-2417097,CDM,C1713,HCPCS,0278,RC,,,,both,,,767.42,498.82,,,,,,,,,,,,,
PLATE BNE SM L97MM THK1MM 6 H BILAT S STL 1/3 TBLR NEUT DYN,SUP-2185847,CDM,C1713,HCPCS,0278,RC,,,,both,,,3701.31,2405.85,,,,,,,,,,,,,
BLADE RTRCTR MRDNG MED 1INW X 3 1/3NL TTNM F / UNVRSL RING U,SUP-2498731,CDM,2720000010,LOCAL,0272,RC,,,,both,,,976.13,634.48,,,,,,,,,,,,,
GRAFT VASC GORTX STRTCH L 40 CM DIA 14 X 7 MM STD WALL TRUNK,SUP-2396238,CDM,C1768,CPT,0278,RC,,,,both,,,2634.46,1712.40,,,,,,,,,,,,,
WIRE FIX COUNTSINK FOR INTROSSEOUS SYS,SUP-2400067,CDM,C1713,HCPCS,0278,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
PAROXETINE HCL 20 MG PO TABS,RX-10855,CDM,6370000000,HCPCS,0637,RC,68084-0045-11,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
SCREW BONE L6MM DIA2MM HND VAR ANG LCK FLOWERCUBE,SUP-2225439,CDM,C1713,HCPCS,0278,RC,,,,both,,,842.15,547.40,,,,,,,,,,,,,
BRONCHOSCOPE FLX L 600 MM OD 4.2 MM ID 2.2 MM STRL DISP,SUP-2882948,CDM,C1601,HCPCS,0272,RC,,,,both,,,989.10,642.91,,,,,,,,,,,,,
CATHETER LAPSCP L13IN DISP CHOLGM FOR PRT INSRTN,SUP-2330476,CDM,C1713,HCPCS,0278,RC,,,,both,,,856.34,556.62,,,,,,,,,,,,,
ANCHOR SUTURE 4MM KNOTLESS CROSSFT,SUP-2824383,CDM,C1713,HCPCS,0278,RC,,,,both,,,2031.89,1320.73,,,,,,,,,,,,,
SUPPORT ANK XL FOR 14-15IN BLK BALLISTIC NYL L R FT STBL LO,SUP-2269721,CDM,L1930,HCPCS,0274,RC,,,,both,,,64.87,42.17,,,,,,,,,,,,,
SCREW BONE L4MM DIA1.7MM SELF DRL LO PROF HD HT AXS 5PK,SUP-2363866,CDM,C1713,HCPCS,0278,RC,,,,both,,,312.74,203.28,,,,,,,,,,,,,
ANCHOR SUT OD2.9MM PEEK OPTMA POLYMER PRETIED KNOT ST KINSA,SUP-2341712,CDM,C1713,HCPCS,0278,RC,,,,both,,,1362.76,885.79,,,,,,,,,,,,,
SUPPORT ANK XL FOR 14-15IN BLK BALLISTIC NYL L R FT STBL LO,SUP-2269721,CDM,L1930,HCPCS,0272,RC,,,,both,,,64.87,42.17,,,,,,,,,,,,,
HC Inject Tendon Origin/Insert,PX-3612055100,CDM,20551,CPT,0361,RC,,,,inpatient,,,1485.00,965.25,,,,,,,,,,,,,
NAIL IM 125 DEG SHT 10 MMX21.5 CM LT CEPHALOMEDULLARY FEM TI,SUP-2208131,CDM,C1713,HCPCS,0278,RC,,,,both,,,4450.26,2892.67,,,,,,,,,,,,,
SCREW BONE L10MM DIA4MM STD CANC S STL FULL THRD HEX HD,SUP-2344113,CDM,C1713,HCPCS,0278,RC,,,,both,,,207.27,134.73,,,,,,,,,,,,,
PLATE BNE 2X5 H TI CRV MTRX NS DISP TRAUMAONE,SUP-2936012,CDM,C1713,HCPCS,0278,RC,,,,both,,,2766.34,1798.12,,,,,,,,,,,,,
CANNULA ENDOSCP LUER LCK CONN 3.9 MMX5 CM LIGHTWEIGHT RED,SUP-2767463,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1543.31,1003.15,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 40 CM DIA 4 MM STR STD WALL REINF,SUP-2695223,CDM,C1768,CPT,0278,RC,,,,both,,,1109.02,720.86,,,,,,,,,,,,,
COIL EMB 6.70MM L10CM PRI DIA0.0115IN 2ND DIA6MM INTCRAN,SUP-2295056,CDM,C1889,HCPCS,0278,RC,,,,both,,,3771.14,2451.24,,,,,,,,,,,,,
CATHETER IV SINGLE LEMEN 4 FR DOT KT GIVA PC NG POWERMIDLINE,SUP-2626737,CDM,C1751,HCPCS,0278,RC,,,,both,,,508.68,330.64,,,,,,,,,,,,,
INTRODUCER SHTH LAMP 90 CRV AD 8.5 FRX81 CM ACCS PEELWY,SUP-2357231,CDM,C1893,HCPCS,0272,RC,,,,both,,,806.98,524.54,,,,,,,,,,,,,
KIT LD INTRO SAFSHTH ULTRA L 13 CM DIA 9 FR GUIDEWIRE L 50,SUP-2707589,CDM,C1892,HCPCS,0272,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
ALLOGRAFT BNE FLOWABLE 10 CC OSTEOAMP,SUP-2731799,CDM,C1776,CPT,0278,RC,,,,both,,,8471.09,5506.21,,,,,,,,,,,,,
PLATE BNE L57MM 6X5 H NONSTERILE L DST RAD VOLAR RIM S STL,SUP-2177523,CDM,C1713,HCPCS,0278,RC,,,,both,,,2684.13,1744.68,,,,,,,,,,,,,
BASEPLATE TIB UNI UNIV PRI PEG CEM NP SZ 1 NAT KNEE II,SUP-2208934,CDM,C1776,CPT,0278,RC,,,,both,,,4408.56,2865.56,,,,,,,,,,,,,
HC X-Ray Exam Chest 1 View,PX-3247104500,CDM,71045,CPT,0324,RC,,,,both,,,270.00,175.50,,,,,,,,,,,,,
HC So2 Heparin Assoc Platelet Antibo,PX-3028602268,CDM,86022,CPT,0302,RC,,,,both,,,728.00,473.20,,,,,,,,,,,,,
SUPPORT ORTHOPEDIC LOOP LCK 5.5-6.5 IN SM 7.5 IN LT PROCARE,SUP-2197046,CDM,L3931,HCPCS,0274,RC,,,,both,,,20.44,13.29,,,,,,,,,,,,,
GRAFT BONE 10.0ML ALLGRFT PUTTY DBM MAXXEUS,SUP-2165614,CDM,C9359,HCPCS,0278,RC,,,,both,,,4239.00,2755.35,,,,,,,,,,,,,
PLATE FT 120MM DBL H FOR CIR FIX FRDM SIDEKCK,SUP-2400632,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2665.86,1732.81,,,,,,,,,,,,,
BLADE SHAVER CLOSED STD TYP A,SUP-2648982,CDM,2720000010,LOCAL,0272,RC,,,,both,,,430.18,279.62,,,,,,,,,,,,,
COIL EMB L25CM OD0.020IN LOOP OD9MM STD NIT COMPLX FRME,SUP-2323368,CDM,C1889,HCPCS,0278,RC,,,,both,,,6933.12,4506.53,,,,,,,,,,,,,
RASP SURG W9.5XL30.5MM RND SHANK RECIP FOR SM BNE,SUP-2166365,CDM,2720000010,LOCAL,0272,RC,,,,both,,,651.74,423.63,,,,,,,,,,,,,
COMPONENT TIB DIA12MM CANN FUS NAIL NONLOCKING WICH,SUP-2377549,CDM,C1776,CPT,0278,RC,,,,both,,,8153.01,5299.46,,,,,,,,,,,,,
SPLINT ORTH PLASTALUME 5.25X5.25 IN FNGR W/ BLB RADLUC,SUP-2276774,CDM,L3933,HCPCS,0272,RC,,,,both,,,5.21,3.39,,,,,,,,,,,,,
STAPLE BONE FIX W20XL20X20MM 2X2MM WIRE FIX BARB IMPL OSSTPL,SUP-2191866,CDM,C1713,HCPCS,0278,RC,,,,both,,,3124.30,2030.79,,,,,,,,,,,,,
SCREW BONE L65MM DIA6.5MM THRD L20MM CANN EXTREMFIX,SUP-2319559,CDM,C1713,HCPCS,0278,RC,,,,both,,,1287.40,836.81,,,,,,,,,,,,,
STAPLE CART W4MM L60MM 0DEG GRN RELD ENDO UNIV THCK TISS 4,SUP-2257587,CDM,2720000010,LOCAL,0272,RC,,,,both,,,424.31,275.80,,,,,,,,,,,,,
CANNULA ENDOSCP L 55 MM DIA 4.5 MM STRL DISP PARALLELPORTAL,SUP-2908738,CDM,2720000010,LOCAL,0272,RC,,,,both,,,910.60,591.89,,,,,,,,,,,,,
BUR SURG TREPHINE 13.5 MM CARBIDE UPWR,SUP-2166770,CDM,2720000010,LOCAL,0272,RC,,,,both,,,439.60,285.74,,,,,,,,,,,,,
GROMMET VENT TB ID1.27MM FLNG ID2.75MM TI MICROPOLISHED,SUP-2284042,CDM,L8699,HCPCS,0278,RC,,,,both,,,65.06,42.29,,,,,,,,,,,,,
CATHETER ANGIO L54CM OD8FR COR SINUS MPL LV1 EASYTRAK,SUP-2148861,CDM,C1887,HCPCS,0272,RC,,,,both,,,329.70,214.30,,,,,,,,,,,,,
GRAFT VASC STR STD WALL RING 6MM DIA 70CM LEN GORTX,SUP-2396009,CDM,C1768,CPT,0278,RC,,,,both,,,3805.68,2473.69,,,,,,,,,,,,,
CAGE SPNL 14X12X6 MM AVS AS,SUP-2362858,CDM,C1889,HCPCS,0278,RC,,,,both,,,5733.39,3726.70,,,,,,,,,,,,,
WASHER SPNL 6 MM SFS,SUP-2582940,CDM,C1713,HCPCS,0278,RC,,,,both,,,204.10,132.66,,,,,,,,,,,,,
GRAFT BNE FIBER LG 10 CC SYR DBM,SUP-2431098,CDM,C1889,HCPCS,0278,RC,,,,both,,,6688.20,4347.33,,,,,,,,,,,,,
SHELL ACET OD54MM CLUS H CERAMIC POR REFLCT FSO,SUP-2344700,CDM,C1776,CPT,0278,RC,,,,both,,,4278.25,2780.86,,,,,,,,,,,,,
LEAD PACE 9FR L58CM QPLR IS 1 CONN A SENSE V PACE SENSE R,SUP-2421028,CDM,C1779,HCPCS,0275,RC,,,,both,,,1305.39,848.50,,,,,,,,,,,,,
PLATE CRAN PT SPEC IMPL PEEK SD800.547,SUP-2860228,CDM,C1713,HCPCS,0278,RC,,,,both,,,50072.64,32547.22,,,,,,,,,,,,,
SCREW BNE L16MM OD45MM S STL CANN,SUP-2316413,CDM,C1713,HCPCS,0278,RC,,,,both,,,537.19,349.17,,,,,,,,,,,,,
DEVICE LAPSCP L DIA9CM HND ASST LAP-DISC,SUP-2257668,CDM,C1788,HCPCS,0278,RC,,,,both,,,1648.50,1071.52,,,,,,,,,,,,,
HC NM Sest. Rest Stress Mult,PX-3407845200,CDM,78452,CPT,0340,RC,,,,both,,,4883.00,3173.95,,,,,,,,,,,,,
GRAFT BNE VOID FILL 10 CC MG,SUP-2742076,CDM,C1713,HCPCS,0278,RC,,,,both,,,11209.80,7286.37,,,,,,,,,,,,,
K WIRE FIX L9IN DIA0.9MM NONSTERILE S STL 2 SIDE DBL DMND,SUP-2150683,CDM,C1713,HCPCS,0278,RC,,,,both,,,20.19,13.12,,,,,,,,,,,,,
HC Pt Estim-Manual Each 15 Min,PX-4209703200,CDM,97032,CPT,0420,RC,,,,outpatient,,,206.00,133.90,,,,,,,,,,,,,
NAIL IM L320MM DIA11X11.5MM TIB FOR COMP NAILING SYS,SUP-2152504,CDM,C1713,HCPCS,0278,RC,,,,both,,,5809.31,3776.05,,,,,,,,,,,,,
CATHETER ANGIOPLSTY FOX CROSS L 135 CM BALLOON L 20 MM DIA 8,SUP-2101861,CDM,C1725,HCPCS,0272,RC,,,,both,,,540.08,351.05,,,,,,,,,,,,,
TUBE VENT ID1.14MM INNR FLNG OD2.4MM INTERFLNG DISTANCE,SUP-2277574,CDM,L8699,HCPCS,0278,RC,,,,both,,,70.87,46.07,,,,,,,,,,,,,
COMPONENT FEM 2 CT-MRI ROTATING NS MYKNEE LBS,SUP-2575560,CDM,C1776,CPT,0278,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
STENT BILI L80MM DIA10MM PARTIALLY CVR L70MM CATH L194CM,SUP-2149799,CDM,C1874,HCPCS,0278,RC,,,,both,,,5250.17,3412.61,,,,,,,,,,,,,
KIT MRK DEL NAVIGATION CATH L125CM OD0.070IN ID0.040IN,SUP-2381771,CDM,C1769,HCPCS,0272,RC,,,,both,,,435.20,282.88,,,,,,,,,,,,,
BRACE ORTH BILATERAL SM AD ANK WALKING MAXTRAX AIR,SUP-2427326,CDM,L4360,HCPCS,0274,RC,,,,both,,,93.76,60.94,,,,,,,,,,,,,
SPLINT WR AD L GREATER THAN W4IN LT MCP DLX KAY-SPLNT III,SUP-2324563,CDM,L3906,HCPCS,0274,RC,,,,both,,,87.95,57.17,,,,,,,,,,,,,
AUGMENT TIB SM CONE SYMM STRL EMPOWR,SUP-2929661,CDM,C1776,CPT,0278,RC,,,,both,,,18515.95,12035.37,,,,,,,,,,,,,
PATCH CV HEMSHLD L 6 X W 2 IN THK 0.46 MM POLYESTER BOV,SUP-2484252,CDM,C1768,CPT,0278,RC,,,,both,,,1115.83,725.29,,,,,,,,,,,,,
TUBE TYMPANOSTOMY L 6 MM DIA1.14 MM FLANGE L 6 MM SIL FIRM,SUP-2902088,CDM,L8699,HCPCS,0278,RC,,,,both,,,77.06,50.09,,,,,,,,,,,,,
GUIDEWIRE SOLO HYDRO 0.035 WITH STRAIGHT TIP,SUP-2655879,CDM,C1769,HCPCS,0272,RC,,,,both,,,101.55,66.01,,,,,,,,,,,,,
IMPLANT PHOTODYNAMIC STBL BALLOON L 180 MM DIA 9 MM DEL SHTH,SUP-2934164,CDM,C1713,HCPCS,0278,RC,,,,both,,,12789.22,8312.99,,,,,,,,,,,,,
ALLOGRAFT DERM 0.4-1.0MM THIN: L8.0XW6.0CM MESHED MTRX,SUP-2420217,CDM,C1781,HCPCS,0278,RC,,,,both,,,6769.84,4400.40,,,,,,,,,,,,,
SCREW BONE L75MM DIA4.5MM THRD L34MM MALL S STL ST SELF DRL,SUP-2184558,CDM,C1713,HCPCS,0278,RC,,,,both,,,104.47,67.91,,,,,,,,,,,,,
SYSTEM ENDOSCP ULTRASOUND DEL 19 GA PRE LD NDL BEAC F1905] MEDTRONIC COVIDIEN GIVEN IMAGING],SUP-2173693,CDM,C1713,HCPCS,0278,RC,,,,both,,,332.84,216.35,,,,,,,,,,,,,
PLATE BONE W22XL51MM THK1.6MM 12 H LT DSTL RAD VOLAR TI NAR,SUP-2267963,CDM,C1713,HCPCS,0278,RC,,,,both,,,3315.31,2154.95,,,,,,,,,,,,,
EXTRACTOR SURG HK FOR HINDFOOT TTC/TC NAIL SYS NS DISP,SUP-2909097,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2355.00,1530.75,,,,,,,,,,,,,
DRIVER SURG RET STAR 20 FOR ANK FUS PLATING SYS ORTHOLOC,SUP-2398591,CDM,2720000010,LOCAL,0272,RC,,,,both,,,684.52,444.94,,,,,,,,,,,,,
STEM FEM SZ 0 132DEG HIP FORGED VIT POR CLLRD TAPR CEM,SUP-2375347,CDM,C1776,CPT,0278,RC,,,,both,,,13680.98,8892.64,,,,,,,,,,,,,
WALKER FT SM M SHOE SZ 3 65 FEM 4 75 STD CLS HEEL ROCK SOLE,SUP-2195218,CDM,L4386,HCPCS,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
PATCH VASC W15XL10CM THK0.5MM BIO TISS BOV MTRX PERICARD,SUP-2214210,CDM,C1768,CPT,0278,RC,,,,both,,,2198.00,1428.70,,,,,,,,,,,,,
HYDROCOD POLI-CHLORPHE POLI ER 10-8 MG/5ML PO SUER,RX-161224,CDM,340b,HCPCS,0637,RC,09999-9900-59,NDC,,both,5,ML,11.30,7.34,,,,,,,,,,,,,
HEAD FEM 12/14 TAPR PRI CERAMIC ON CERAMIC 28MM DIA -3.5 NK,SUP-2202658,CDM,C1776,CPT,0278,RC,,,,both,,,4898.40,3183.96,,,,,,,,,,,,,
ALLOGRAFT HUM TISS FRZN ASEP PT MATCHED LT MEDL HALF MENIS,SUP-2866992,CDM,C1762,CPT,0278,RC,,,,both,,,8304.67,5398.04,,,,,,,,,,,,,
SUTURE ORTHOCORD SZ 2-0 W/ DBL ARM MENIS NDL 228144,SUP-2256746,CDM,C1713,HCPCS,0278,RC,,,,both,,,689.54,448.20,,,,,,,,,,,,,
CATHETER THERMOABLATION DIA 6 FR SUPERFICIAL VEIN RF,SUP-2883975,CDM,C1888,HCPCS,0272,RC,,,,both,,,894.90,581.68,,,,,,,,,,,,,
SHEATH INTRO FLX L 45 CM OD 5 FR GUIDEWIRE 0.038 IN SM CKFLO,SUP-2633289,CDM,C1894,HCPCS,0272,RC,,,,both,,,144.69,94.05,,,,,,,,,,,,,
CIPROFLOXACIN IN D5W 200 MG/100ML IV SOLN,RX-104407,CDM,J0744,HCPCS,0636,RC,25021-0114-82,NDC,,both,100,ML,54.10,35.16,,,,,,,,,,,,,
STENT CORONARY TAXUS LIBERTE L 8 MM DIA2.5 MM DEL SYS L 144,SUP-2140620,CDM,C1874,HCPCS,0278,RC,,,,both,,,6437.00,4184.05,,,,,,,,,,,,,
ALLOGRAFT BNE 250-1000 MH 0.70 CC FD MINERALIZED ORAGRAFT,SUP-2741057,CDM,C1713,HCPCS,0278,RC,,,,both,,,185.64,120.67,,,,,,,,,,,,,
HC So Haptoglobin,PX-3018301066,CDM,83010,CPT,0301,RC,,,,both,,,38.00,24.70,,,,,,,,,,,,,
STENT ENDOPROS L5CM DIA8MM CATH 8FR L75CM BAL DIA8MM,SUP-2396563,CDM,C1874,HCPCS,0278,RC,,,,both,,,9200.20,5980.13,,,,,,,,,,,,,
COMPONENT FEM SZ 4 R KNEE CO CHROM MOLYBDENUM CEM W/ ASYM,SUP-2251380,CDM,C1776,CPT,0278,RC,,,,both,,,15009.20,9755.98,,,,,,,,,,,,,
KIT INDIR DCOMPR 10MM SUPERION,SUP-2392703,CDM,C1821,HCPCS,0278,RC,,,,both,,,28888.00,18777.20,,,,,,,,,,,,,
SLEEVE FEM SM SZ 11 TI STIKTITE HA HIP REV MOD REDAPT,SUP-2345436,CDM,C1776,CPT,0278,RC,,,,both,,,8143.59,5293.33,,,,,,,,,,,,,
SPHERE GLEN +3 40 MM SHLDR COMPHSVE VERSE-DIAL,SUP-2418153,CDM,C1776,CPT,0278,RC,,,,both,,,4239.00,2755.35,,,,,,,,,,,,,
KIT STEREOTACTIC BRAIN INT BX TRAJECTORY GUID FRAMELESS,SUP-2284362,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4152.08,2698.85,,,,,,,,,,,,,
ALLOGRAFT BNE STRP 10X20X3-6 MM SPNG FD CANC,SUP-2717782,CDM,C1713,HCPCS,0278,RC,,,,both,,,2586.10,1680.96,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 70 CM DIA 8 MM EPTFE STR TW REINF 2,SUP-2681202,CDM,C1768,CPT,0278,RC,,,,both,,,2189.21,1422.99,,,,,,,,,,,,,
PLATE BNE TIB LT PROX TARGETING ARM,SUP-2766313,CDM,C1713,HCPCS,0278,RC,,,,both,,,16940.30,11011.19,,,,,,,,,,,,,
GRAFT VASC L 5 CM DIA20 MM WOVEN EXTRALUMINAL STRL,SUP-2139654,CDM,C1768,CPT,0278,RC,,,,both,,,276.32,179.61,,,,,,,,,,,,,
PLATE BNE L147MM 8 H R PROX TIB S STL VAR ANG LOK COMPR SM,SUP-2177915,CDM,C1713,HCPCS,0278,RC,,,,both,,,5855.97,3806.38,,,,,,,,,,,,,
CUP HUM DIA39MM NEUT OFFSET SHLDR CAP UNIVERS REVERS,SUP-2123339,CDM,C1776,CPT,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
WAND ABLAT CROSS 50 DYONICS RFS,SUP-2341117,CDM,2720000010,LOCAL,0272,RC,,,,both,,,609.16,395.95,,,,,,,,,,,,,
PROBE SPNL STR ANTR COLORADO 2,SUP-2290554,CDM,C1713,HCPCS,0278,RC,,,,both,,,2819.72,1832.82,,,,,,,,,,,,,
DOXORUBICIN HCL 50 MG IV SOLR|DISCARDED DRUG NOT ADMINISTE,RX-2619,CDM,J9000,HCPCS,0636,RC,00143-9093-01,NDC,JW,both,1,UN,757.60,492.44,,,,,,,,,,,,,
CATHETER HD STR 13 FRX20 CM SHT TERM 3L TY SLIM-CATH,SUP-2125594,CDM,C1752,HCPCS,0278,RC,,,,both,,,638.64,415.12,,,,,,,,,,,,,
DEVICE ATHRCTMY SHFT L 145 CM DIA 0.063 IN CRWN 1.5 MM NOSE,SUP-2892898,CDM,C1724,HCPCS,0278,RC,,,,both,,,6280.00,4082.00,,,,,,,,,,,,,
KIT BLWRMSTR CRNRY WTBNG SET F  PUMP BPSS CLRVW,SUP-2722937,CDM,2720000010,LOCAL,0272,RC,,,,both,,,515.65,335.17,,,,,,,,,,,,,
ANCHOR SUT OD4.5MM BIOCRYL RAPIDE ORTHOCORD HEALIX ADV BR,SUP-2256656,CDM,C1713,HCPCS,0278,RC,,,,both,,,1400.44,910.29,,,,,,,,,,,,,
HC So Hepatitis Be Antibody,PX-3028670766,CDM,86707,CPT,0302,RC,,,,outpatient,,,106.00,68.90,,,,,,,,,,,,,
BUR SURG OD5.5MM BLK SHTH BRL HI VISIBILITY DYONICS,SUP-2341869,CDM,C1713,HCPCS,0278,RC,,,,both,,,392.34,255.02,,,,,,,,,,,,,
NUSHIELD 1.6CM DISC 2SQ CM,SUP-2314106,CDM,Q4160,HCPCS,0636,RC,,,,both,,,545.73,354.72,,,,,,,,,,,,,
CLOTRIMAZOLE 1 % EX CREA,RX-1767,CDM,6370000000,HCPCS,0637,RC,51672-2002-01,NDC,,both,15,GR,23.00,14.95,,,,,,,,,,,,,
Bronchoscopy W/Cptr-Asst Image-Guided Navigation,CASE-31627,LOCAL,31627,CPT,,,,,,outpatient,,,40954.75,24572.85,,,,,,,,,,,,,
Submucous Rescj Inferior Turbinate Prtl/Compl|BILATERAL PROCEDURE,CASE-30140,LOCAL,30140,CPT,,,,,50,outpatient,,,51135.30,30681.18,,,,,,,,,,,,,
Excision Tumor Soft Tis Back/Flank Subq 3 Cm/>,CASE-21931,LOCAL,21931,CPT,0360,RC,,,,outpatient,,,19170.78,11502.47,,,,,,,,,,,,,
HC N Block Inj Intercost Sng|LEFT SIDE,CASE-64420,LOCAL,64420,CPT,0360,RC,,,LT,outpatient,,,4274.93,2564.96,,,,,,,,,,,,,
Excision Tumor Soft Tis Back/Flank Subq 3 Cm/>,CASE-21931,LOCAL,21931,CPT,,,,,,outpatient,,,19170.78,11502.47,,,,,,,,,,,,,
"Capsulectomy/Capsulotomy Iphal Joint Each|LEFT HAND, SECOND DIGIT",CASE-26525,LOCAL,26525,CPT,0360,RC,,,F1,outpatient,,,21530.25,12918.15,,,,,,,,,,,,,
Submucous Rescj Inferior Turbinate Prtl/Compl|RIGHT SIDE,CASE-30140,LOCAL,30140,CPT,0360,RC,,,RT,outpatient,,,98006.38,58803.83,,,,,,,,,,,,,
"Capsulectomy/Capsulotomy Iphal Joint Each|LEFT HAND, SECOND DIGIT",CASE-26525,LOCAL,26525,CPT,,,,,F1,outpatient,,,21530.25,12918.15,,,,,,,,,,,,,
Bronchoscopy W/Cptr-Asst Image-Guided Navigation,CASE-31627,LOCAL,31627,CPT,0360,RC,,,,outpatient,,,40954.75,24572.85,,,,,,,,,,,,,
Submucous Rescj Inferior Turbinate Prtl/Compl|BILATERAL PROCEDURE,CASE-30140,LOCAL,30140,CPT,0360,RC,,,50,outpatient,,,51135.30,30681.18,,,,,,,,,,,,,
HC N Block Inj Suprascapular Nerv|RIGHT SIDE,CASE-64418,LOCAL,64418,CPT,0360,RC,,,RT,outpatient,,,3998.58,2399.15,,,,,,,,,,,,,
Submucous Rescj Inferior Turbinate Prtl/Compl|RIGHT SIDE,CASE-30140,LOCAL,30140,CPT,,,,,RT,outpatient,,,98006.38,58803.83,,,,,,,,,,,,,
DEXTROSE 10 % IV BOLUS,RX-4081995,CDM,2580000003,HCPCS,0258,RC,00338-0023-03,NDC,,both,125,ML,12.80,8.32,,,,,,,,,,,,,
DEVICE VASC CLOSURE CELT ACD + L 15 CM LUMEN DIA2.4 MM SHTH,SUP-2931108,CDM,C1760,HCPCS,0278,RC,,,,both,,,656.26,426.57,,,,,,,,,,,,,
SCREW SPNL 4X20 MM ANTR CERV,SUP-2205440,CDM,C1713,HCPCS,0278,RC,,,,both,,,763.02,495.96,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH TX2 L 162 MM DIA 32/28 MM SHTH 20 FR,SUP-2751307,CDM,C1874,HCPCS,0278,RC,,,,both,,,56641.52,36816.99,,,,,,,,,,,,,
CEFTRIAXONE SODIUM 2 G IJ SOLR,RX-9488,CDM,J0696,HCPCS,0636,RC,60505-6149-00,NDC,,both,1,UN,54.10,35.16,,,,,,,,,,,,,
GRAFT HUM TISS W3XL6CM CRYOPRESERVED PLCNTA TISS UMB AMNION,SUP-2319186,CDM,Q4133,HCPCS,0636,RC,,,,both,,,9325.80,6061.77,,,,,,,,,,,,,
MIS LOCK CALC PLT LG EXD 2H RT,SUP-2586881,CDM,C1713,HCPCS,0278,RC,,,,both,,,2780.56,1807.36,,,,,,,,,,,,,
NEEDLE BRST LOC REPOSITIONAL DISP 20GA 5CM KOP,SUP-2331831,CDM,C1819,HCPCS,0278,RC,,,,both,,,747.32,485.76,,,,,,,,,,,,,
Bx/Exc Lymph Node Open Deep Axillary Node|RIGHT SIDE,CASE-38525,LOCAL,38525,CPT,,,,,RT,outpatient,,,46974.72,28184.83,,,,,,,,,,,,,
Exc B9 Lesion Mrgn Xcp Sk Tg T/a/L >4.0 Cm,CASE-11406,LOCAL,11406,CPT,,,,,,outpatient,,,40102.92,24061.75,,,,,,,,,,,,,
"Amputation Toe Metatarsophalangeal Joint|LEFT FOOT, GREAT TOE",CASE-28820,LOCAL,28820,CPT,,,,,TA,outpatient,,,19493.90,11696.34,,,,,,,,,,,,,
Bx/Exc Lymph Node Open Deep Axillary Node|RIGHT SIDE,CASE-38525,LOCAL,38525,CPT,0360,RC,,,RT,outpatient,,,46974.72,28184.83,,,,,,,,,,,,,
Exc B9 Lesion Mrgn Xcp Sk Tg T/a/L >4.0 Cm,CASE-11406,LOCAL,11406,CPT,0360,RC,,,,outpatient,,,40102.92,24061.75,,,,,,,,,,,,,
Unlisted Laparoscopy Px Intestine Xcp Rectum,CASE-44238,LOCAL,44238,CPT,,,,,,outpatient,,,25770.85,15462.51,,,,,,,,,,,,,
Unlisted Laparoscopy Px Intestine Xcp Rectum,CASE-44238,LOCAL,44238,CPT,0360,RC,,,,outpatient,,,25770.85,15462.51,,,,,,,,,,,,,
"Amputation Toe Metatarsophalangeal Joint|LEFT FOOT, GREAT TOE",CASE-28820,LOCAL,28820,CPT,0360,RC,,,TA,outpatient,,,19493.90,11696.34,,,,,,,,,,,,,
PACEMAKER CARD PHILOS DR 2 CHMBR IS1 UPLR BPLR CONN DDDR,SUP-2137960,CDM,C1785,HCPCS,0275,RC,,,,both,,,9316.38,6055.65,,,,,,,,,,,,,
HC Pt Adl Training 15mn|OP OCCUPATIONAL THERAPY SERV|SERVICES PROVIDED IN WHOLE OR IN PARTY BY AN OTA FOR MEDICARE PATIENTS,PX-4209753500,CDM,97535,CPT,0420,RC,,,GO|CO,outpatient,,,174.00,113.10,,,,,,,,,,,,,
RESERVOIR VENTRICULAR SINGLE FLAT ACCU-FLO,SUP-2666409,CDM,C1889,HCPCS,0278,RC,,,,both,,,1131.53,735.49,,,,,,,,,,,,,
DRILL SURG MOD 1.5-3 13 MM TIB NP SPEC 2,SUP-2456603,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1438.12,934.78,,,,,,,,,,,,,
HC Treat Kneecap Fx,PX-4502752000,CDM,27520,CPT,0450,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
PLATE BNE SM W10.1XL106MM THK3.5MM 8 H BILAT S STL CRV RIG,SUP-2186262,CDM,C1713,HCPCS,0278,RC,,,,both,,,2086.18,1356.02,,,,,,,,,,,,,
PROX TIB LOCK PLATE RT 15H ST,SUP-2587100,CDM,C1713,HCPCS,0278,RC,,,,both,,,2806.41,1824.17,,,,,,,,,,,,,
Lamnotmy Incl W/Dcmprsn Nrv Root 1 Intrspc Lumbr|BILATERAL PROCEDURE,CASE-63030,LOCAL,63030,CPT,,,,,50,outpatient,,,47426.42,28455.85,,,,,,,,,,,,,
Laps Gastric Restrictive Px Remove Device & Port,CASE-43774,LOCAL,43774,CPT,0360,RC,,,,outpatient,,,36087.93,21652.76,,,,,,,,,,,,,
Trachelectomy Cervicectomy Amp Cervix Spx,CASE-57530,LOCAL,57530,CPT,,,,,,outpatient,,,23222.00,13933.20,,,,,,,,,,,,,
Lamnotmy Incl W/Dcmprsn Nrv Root 1 Intrspc Lumbr|BILATERAL PROCEDURE,CASE-63030,LOCAL,63030,CPT,0360,RC,,,50,outpatient,,,47426.42,28455.85,,,,,,,,,,,,,
Laps Gastric Restrictive Px Remove Device & Port,CASE-43774,LOCAL,43774,CPT,,,,,,outpatient,,,36087.93,21652.76,,,,,,,,,,,,,
"Inj Dx/Ther Agnt Paravert Facet Joint, Cerv/Thorac, 2nd Level",CASE-64491,LOCAL,64491,CPT,0360,RC,,,,outpatient,,,4392.15,2635.29,,,,,,,,,,,,,
Trachelectomy Cervicectomy Amp Cervix Spx,CASE-57530,LOCAL,57530,CPT,0360,RC,,,,outpatient,,,23222.00,13933.20,,,,,,,,,,,,,
"Inj Dx/Ther Agnt Paravert Facet Joint, Cerv/Thorac, 2nd Level",CASE-64491,LOCAL,64491,CPT,,,,,,outpatient,,,4392.15,2635.29,,,,,,,,,,,,,
BIT DRL QC LG LNG 5 MM FOR CANN SCREW NS,SUP-2789109,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1609.94,1046.46,,,,,,,,,,,,,
DRESSING NSL L 4 CM POLYMER X FIRM BIORESORBABLE STRL DISP,SUP-2900104,CDM,2720000010,LOCAL,0272,RC,,,,both,,,576.03,374.42,,,,,,,,,,,,,
PLATE BNE LG TI MANDIBULAR 3D PRNT NS DISP ACCUPLATE,SUP-2935024,CDM,C1713,HCPCS,0278,RC,,,,both,,,35720.64,23218.42,,,,,,,,,,,,,
TUBING IRR DISP FOR ULTSONIC REV SYS ULT DRV 3,SUP-2408553,CDM,2720000010,LOCAL,0272,RC,,,,both,,,326.56,212.26,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY L 110 CM DIA 7 FR SPC 1-7-1 MM H,SUP-2141324,CDM,C1730,HCPCS,0272,RC,,,,both,,,3314.58,2154.48,,,,,,,,,,,,,
HC ED Clsd Tx Distal Fib Fx Manip,PX-4502778800,CDM,27788,CPT,0450,RC,,,,both,,,383.00,248.95,,,,,,,,,,,,,
KIT INTRO L 10 CM DIA 5 FR 7 CM NIT SHFT PLAT TIP STIFF DIL,SUP-2615875,CDM,C1894,HCPCS,0272,RC,,,,both,,,139.42,90.62,,,,,,,,,,,,,
SLEEVE SM KNEE W/ PD,SUP-2351387,CDM,C1776,CPT,0278,RC,,,,both,,,13188.00,8572.20,,,,,,,,,,,,,
MESH CRAN CUSTOMIZED MED PRIORITY STRL MEDPOR,SUP-2862751,CDM,C1713,HCPCS,0278,RC,,,,both,,,53294.18,34641.22,,,,,,,,,,,,,
"HC So Detect, Agnt Mult, Dna Ampli",PX-3068780166,CDM,87801,CPT,0306,RC,,,,outpatient,,,179.00,116.35,,,,,,,,,,,,,
PLATE BONE L35MM THK0.9MM 8 H BILAT TI STRUT RIG NEUT SAG,SUP-2191224,CDM,C1713,HCPCS,0278,RC,,,,both,,,1532.01,995.81,,,,,,,,,,,,,
BIT DRL OD2.4MM DISP FOR VERTEX MAX SYS,SUP-2280206,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2207.42,1434.82,,,,,,,,,,,,,
WASHER ORTH 1 MM,SUP-2749959,CDM,2720000010,LOCAL,0272,RC,,,,both,,,555.78,361.26,,,,,,,,,,,,,
GRFT CHIPS CANC 4-9.5MM 5CC PUROS,SUP-2693922,CDM,C1713,HCPCS,0278,RC,,,,both,,,1017.36,661.28,,,,,,,,,,,,,
Lithotripsy Xtrcorp Shock Wave|LEFT SIDE,CASE-50590,LOCAL,50590,CPT,,,,,LT,outpatient,,,21914.62,13148.77,,,,,,,,,,,,,
Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE,CASE-62323,LOCAL,62323,CPT,0360,RC,,,XU,outpatient,,,7691.12,4614.67,,,,,,,,,,,,,
Colon Ca Scrn Not Hi Rsk Ind|DOCUMENTATION ON FILE,CASE-G0121,LOCAL,G0121,CPT,,,,,KX,outpatient,,,9632.35,5779.41,,,,,,,,,,,,,
Injection Aa&/Strd Genicular Nrv Branches W/Img|RIGHT SIDE,CASE-64454,LOCAL,64454,CPT,0360,RC,,,RT,outpatient,,,4376.67,2626.00,,,,,,,,,,,,,
Arthroplasty Patella W/O Prosthesis,CASE-27437,LOCAL,27437,CPT,0360,RC,,,,outpatient,,,50593.62,30356.17,,,,,,,,,,,,,
Exc B9 Lesion Mrgn Xcp Sk Tg S/N/H/F/G 0.6-1.0cm,CASE-11421,LOCAL,11421,CPT,0360,RC,,,,outpatient,,,8630.67,5178.40,,,,,,,,,,,,,
Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE,CASE-62323,LOCAL,62323,CPT,,,,,XU,outpatient,,,7691.12,4614.67,,,,,,,,,,,,,
Exc B9 Lesion Mrgn Xcp Sk Tg S/N/H/F/G 0.6-1.0cm,CASE-11421,LOCAL,11421,CPT,,,,,,outpatient,,,8630.67,5178.40,,,,,,,,,,,,,
Arthroplasty Patella W/O Prosthesis,CASE-27437,LOCAL,27437,CPT,,,,,,outpatient,,,50593.62,30356.17,,,,,,,,,,,,,
Lithotripsy Xtrcorp Shock Wave|LEFT SIDE,CASE-50590,LOCAL,50590,CPT,0360,RC,,,LT,outpatient,,,21914.62,13148.77,,,,,,,,,,,,,
Colon Ca Scrn Not Hi Rsk Ind|DOCUMENTATION ON FILE,CASE-G0121,LOCAL,G0121,CPT,0360,RC,,,KX,outpatient,,,9632.35,5779.41,,,,,,,,,,,,,
Injection Aa&/Strd Genicular Nrv Branches W/Img|RIGHT SIDE,CASE-64454,LOCAL,64454,CPT,,,,,RT,outpatient,,,4376.67,2626.00,,,,,,,,,,,,,
PLATE BONE L22MM 110DEG MINI LT L LHR,SUP-2364916,CDM,C1713,HCPCS,0278,RC,,,,both,,,386.60,251.29,,,,,,,,,,,,,
CATHETER CHOLANGIOGRAM 4.5 FRX3 IN W/ 20018M55 TAUT INTRO,SUP-2384044,CDM,C1894,HCPCS,0272,RC,,,,both,,,64.65,42.02,,,,,,,,,,,,,
COLLAR EXTRIC 1 PC RIG INF PERFIT,SUP-2389135,CDM,L0190,HCPCS,0272,RC,,,,both,,,18.81,12.23,,,,,,,,,,,,,
MICROPHONE HEARING AID CONN LN,SUP-2430270,CDM,2720000010,LOCAL,0272,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
DISC ARTIFICIAL SZ 4 7.5DEG UNIV INTERVERTEBRAL LUM MTL ON,SUP-2255736,CDM,C1889,HCPCS,0278,RC,,,,both,,,16108.20,10470.33,,,,,,,,,,,,,
PLATE SPINE L65MM ANT CERV TI ALLY CNVGNT ATLNTS,SUP-2291088,CDM,C1713,HCPCS,0278,RC,,,,both,,,3977.50,2585.37,,,,,,,,,,,,,
PLATE BNE RECON LG 2-2.3X176X2.8 MM RT 24 HOLE SMRT TI STRL,SUP-2460372,CDM,C1713,HCPCS,0278,RC,,,,both,,,10543.65,6853.37,,,,,,,,,,,,,
STENT GRFT VASC AFX L 80 MM UNCOVERED L 20 MM DIA,SUP-2217613,CDM,C1768,CPT,0278,RC,,,,both,,,15558.70,10113.15,,,,,,,,,,,,,
AMPICILLIN SODIUM 250 MG IJ SOLR|DISCARDED DRUG NOT ADMINISTE,RX-473,CDM,J0290,HCPCS,0636,RC,65219-0014-01,NDC,JW,both,1,UN,54.10,35.16,,,,,,,,,,,,,
DEVICE MENIS REP STR ZIPLOOP TECHNOLOGY MAXFIRE MARXMEN,SUP-2212786,CDM,C1776,CPT,0278,RC,,,,both,,,1136.68,738.84,,,,,,,,,,,,,
MORPHINE SULFATE-NACL 30-0.9 MG/30ML-% IV SOSY,RX-143809,CDM,2500000003,HCPCS,0250,RC,70092-1519-48,NDC,,both,30,ML,57.00,37.05,,,,,,,,,,,,,
GENERATOR FLO BIPAP AIR TBNG CONN PWR CRD SULLIVAN COMFORT,SUP-2331922,CDM,C1713,HCPCS,0278,RC,,,,both,,,2794.60,1816.49,,,,,,,,,,,,,
Surgical Arthroscopy Shoulder Xtnsv Dbrdmt 3+|RIGHT SIDE,CASE-29823,LOCAL,29823,CPT,,,,,RT,outpatient,,,55001.43,33000.86,,,,,,,,,,,,,
Rpr Recrt Ingun Hernia Any Age Incarcerated|LEFT SIDE,CASE-49521,LOCAL,49521,CPT,,,,,LT,outpatient,,,30633.38,18380.03,,,,,,,,,,,,,
Rpr 1st Ingun Hrna Age 5 Yrs/> Incarcerated|RIGHT SIDE,CASE-49507,LOCAL,49507,CPT,,,,,RT,outpatient,,,24078.98,14447.39,,,,,,,,,,,,,
"HC I&D Finger Abscess Simple|RIGHT HAND, THUMB",CASE-26010,LOCAL,26010,CPT,0450,RC,,,F5,outpatient,,,11822.28,7093.37,,,,,,,,,,,,,
Rpr Recrt Ingun Hernia Any Age Incarcerated|LEFT SIDE,CASE-49521,LOCAL,49521,CPT,0360,RC,,,LT,outpatient,,,30633.38,18380.03,,,,,,,,,,,,,
Rpr 1st Ingun Hrna Age 5 Yrs/> Incarcerated|RIGHT SIDE,CASE-49507,LOCAL,49507,CPT,0360,RC,,,RT,outpatient,,,24078.98,14447.39,,,,,,,,,,,,,
Excision Tumor Soft Tissue Foot/Toe Subq <1.5cm|LEFT SIDE,CASE-28043,LOCAL,28043,CPT,,,,,LT,outpatient,,,13980.07,8388.04,,,,,,,,,,,,,
Excision Tumor Soft Tissue Foot/Toe Subq <1.5cm|LEFT SIDE,CASE-28043,LOCAL,28043,CPT,0360,RC,,,LT,outpatient,,,13980.07,8388.04,,,,,,,,,,,,,
Surgical Arthroscopy Shoulder Xtnsv Dbrdmt 3+|RIGHT SIDE,CASE-29823,LOCAL,29823,CPT,0360,RC,,,RT,outpatient,,,55001.43,33000.86,,,,,,,,,,,,,
GUIDE LT 5MM UNIV NONTRANSPARENT,SUP-2166954,CDM,2720000010,LOCAL,0272,RC,,,,both,,,585.04,380.28,,,,,,,,,,,,,
PLATE BONE L252MM 20 H STRL S STL COMPR FOR 3.5MM SCR EVOS,SUP-2349644,CDM,C1713,HCPCS,0278,RC,,,,both,,,3609.27,2346.03,,,,,,,,,,,,,
GRAFT BIO TISS W2.4XL6.3IN PORCINE DERM RIFAMPIN,SUP-2125832,CDM,C1781,HCPCS,0278,RC,,,,both,,,10173.60,6612.84,,,,,,,,,,,,,
CATHETER PICC DIA4FR PLCMNT WIRE INTEGR NDL PROTCT SHRP SAFT,SUP-2383475,CDM,C1751,HCPCS,0278,RC,,,,both,,,236.25,153.56,,,,,,,,,,,,,
PLATE BNE TI RT POST TTC FUSION NS,SUP-2896800,CDM,C1713,HCPCS,0278,RC,,,,both,,,6433.86,4182.01,,,,,,,,,,,,,
GRAFT HUM TISS 4X4CM THN THK0.4-1MM REGENERATIVE TISS MTRX,SUP-2399079,CDM,C1713,HCPCS,0278,RC,,,,both,,,5460.46,3549.30,,,,,,,,,,,,,
Arthrd Ant Interbody Min Dsc Lumbar,CASE-22558,LOCAL,22558,CPT,0360,RC,,,,outpatient,,,87850.75,52710.45,,,,,,,,,,,,,
Mastectomy Partial W/Axillary Lymphadenectomy|LEFT SIDE,CASE-19302,LOCAL,19302,CPT,,,,,LT,outpatient,,,56947.80,34168.68,,,,,,,,,,,,,
Nipple/Areola Reconstruction|BILATERAL PROCEDURE,CASE-19350,LOCAL,19350,CPT,0360,RC,,,50,outpatient,,,131721.93,79033.16,,,,,,,,,,,,,
Arthrd Ant Interbody Min Dsc Lumbar,CASE-22558,LOCAL,22558,CPT,,,,,,outpatient,,,87850.75,52710.45,,,,,,,,,,,,,
Mastectomy Partial W/Axillary Lymphadenectomy|LEFT SIDE,CASE-19302,LOCAL,19302,CPT,0360,RC,,,LT,outpatient,,,56947.80,34168.68,,,,,,,,,,,,,
Nipple/Areola Reconstruction|BILATERAL PROCEDURE,CASE-19350,LOCAL,19350,CPT,,,,,50,outpatient,,,131721.93,79033.16,,,,,,,,,,,,,
KIT CTRL CATH 5.5FRX20CM PRSS INJ DBL LUMN ANTIMIC AND,SUP-2120620,CDM,C1751,HCPCS,0278,RC,,,,both,,,763.96,496.57,,,,,,,,,,,,,
CATH REPROC EP 5FRX120CM JSN 6-ELECTRD 5-5-5-175-175MM,SUP-2653048,CDM,C1730,HCPCS,0272,RC,,,,both,,,177.57,115.42,,,,,,,,,,,,,
GRAFT VASC FUSION BIOLINE L 80 CM DIA 5 MM AX COMPLIANCE,SUP-2694231,CDM,C1768,CPT,0278,RC,,,,both,,,6230.61,4049.90,,,,,,,,,,,,,
PLATE BNE LAPIDUS LG RT STRATUM,SUP-2423338,CDM,C1713,HCPCS,0278,RC,,,,both,,,5840.97,3796.63,,,,,,,,,,,,,
SCREW BNE CANN SHT THRD 3.5X32 MM HD MINI-MONSTER,SUP-2320506,CDM,C1713,HCPCS,0278,RC,,,,both,,,670.39,435.75,,,,,,,,,,,,,
POUCH MESH GRFT DEL OPTIMESH 23X2MM YELLO,SUP-2354628,CDM,C1781,HCPCS,0278,RC,,,,both,,,10990.00,7143.50,,,,,,,,,,,,,
CATHETER IVUS VISIONS PV .014P L 150 CM GLYDX HYDRPHLC,SUP-2900240,CDM,C1753,HCPCS,0278,RC,,,,both,,,1675.13,1088.83,,,,,,,,,,,,,
GRAFT BNE SUBSTITUTE MATERIAL 3 CC PREFILL STRL ACCUFILL LF,SUP-2866847,CDM,C1713,HCPCS,0278,RC,,,,both,,,8000.41,5200.27,,,,,,,,,,,,,
NEEDLE BRACHYTHERAPY L20CM OD18G 5X10 PREWAXED SEED,SUP-2129061,CDM,C1715,HCPCS,0272,RC,,,,both,,,25.12,16.33,,,,,,,,,,,,,
PLATE BNE MESHED 6 STD 0.6 MM CRAN PRECONTR TI STRL LF,SUP-2479676,CDM,C1713,HCPCS,0278,RC,,,,both,,,8732.43,5676.08,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH FLX L 55 MM PROX/DSTL 20 MM SHTH,SUP-2171050,CDM,C1768,CPT,0278,RC,,,,both,,,6101.02,3965.66,,,,,,,,,,,,,
Brnchsc Brushing/Protected Brushings,CASE-31623,LOCAL,31623,CPT,0360,RC,,,,outpatient,,,43649.75,26189.85,,,,,,,,,,,,,
"Amputation Toe Interphalangeal Joint|LEFT FOOT, THIRD DIGIT",CASE-28825,LOCAL,28825,CPT,0360,RC,,,T2,outpatient,,,18574.07,11144.44,,,,,,,,,,,,,
Ercp Destruction/Lithotripsy Calculi Any Method,CASE-43265,LOCAL,43265,CPT,,,,,,outpatient,,,45353.77,27212.26,,,,,,,,,,,,,
Brnchsc Brushing/Protected Brushings,CASE-31623,LOCAL,31623,CPT,,,,,,outpatient,,,43649.75,26189.85,,,,,,,,,,,,,
HC App Skin Sub Other Tot <100 1st 25,CASE-15275,LOCAL,15275,CPT,0361,RC,,,,outpatient,,,24836.20,14901.72,,,,,,,,,,,,,
Ercp Destruction/Lithotripsy Calculi Any Method,CASE-43265,LOCAL,43265,CPT,0360,RC,,,,outpatient,,,45353.77,27212.26,,,,,,,,,,,,,
Laps Vaginal Hysterect > 250 Gm Rmvl Tube&/Ovar,CASE-58554,LOCAL,58554,CPT,0360,RC,,,,outpatient,,,59672.98,35803.79,,,,,,,,,,,,,
Laps Vaginal Hysterect > 250 Gm Rmvl Tube&/Ovar,CASE-58554,LOCAL,58554,CPT,,,,,,outpatient,,,59672.98,35803.79,,,,,,,,,,,,,
"Amputation Toe Interphalangeal Joint|LEFT FOOT, THIRD DIGIT",CASE-28825,LOCAL,28825,CPT,,,,,T2,outpatient,,,18574.07,11144.44,,,,,,,,,,,,,
GRAFT PASTE SYNTHETIC CALCIUM PHOSPHATE 5G BONESOURCE BVF,SUP-2431338,CDM,C1713,HCPCS,0278,RC,,,,both,,,2119.50,1377.67,,,,,,,,,,,,,
ALLOGRAFT BNE PTTY 2.5 CC DBM BIO,SUP-2637040,CDM,C1713,HCPCS,0278,RC,,,,both,,,753.60,489.84,,,,,,,,,,,,,
PLATE BONE DUAL CMPRSSN HLX14 TTNM CNTRD F3.5MM SCREW UNVRS,SUP-2720368,CDM,C1713,HCPCS,0278,RC,,,,both,,,1604.16,1042.70,,,,,,,,,,,,,
WEDGE TIB L59MM 10DEG MEDL LAT KNEE TI HALF PRI CEM 2 SCR,SUP-2405475,CDM,C1776,CPT,0278,RC,,,,both,,,2449.20,1591.98,,,,,,,,,,,,,
PLATE BNE DSTL RAD OPTILOCK,SUP-2606601,CDM,C1713,HCPCS,0278,RC,,,,both,,,85.78,55.76,,,,,,,,,,,,,
BOLT ORTH L 50 MM DIA 4.9 MM TI ST LCK NS,SUP-2907996,CDM,C1713,HCPCS,0278,RC,,,,both,,,555.00,360.75,,,,,,,,,,,,,
NAIL IM CANN 10X340 MM LT TROCHANTERIC SS STRL,SUP-2186378,CDM,C1713,HCPCS,0278,RC,,,,both,,,4100.84,2665.55,,,,,,,,,,,,,
SUPPORT PROSTHETIC JT KNEE GTT LCK L2182] TIDEWATER PROSTHETICS],SUP-2388173,CDM,L2182,HCPCS,0274,RC,,,,both,,,245.23,159.40,,,,,,,,,,,,,
NAIL IM HUM 8 7MMX30CM,SUP-2348164,CDM,C1713,HCPCS,0278,RC,,,,both,,,3952.00,2568.80,,,,,,,,,,,,,
PLATE BNE T 2.3 MM LT 6 HOLE COMPR OBLQ PROFYLE-L,SUP-2691429,CDM,C1713,HCPCS,0278,RC,,,,both,,,1273.11,827.52,,,,,,,,,,,,,
Optx Dstl Radl I-Artic Fx/Epiphysl Sep 3 Frag|RIGHT SIDE,CASE-25609,LOCAL,25609,CPT,0360,RC,,,RT,outpatient,,,36892.98,22135.79,,,,,,,,,,,,,
Transurethral Resection Bladder Neck,CASE-52500,LOCAL,52500,CPT,0360,RC,,,,outpatient,,,18831.58,11298.95,,,,,,,,,,,,,
Optx Dstl Radl I-Artic Fx/Epiphysl Sep 3 Frag|RIGHT SIDE,CASE-25609,LOCAL,25609,CPT,,,,,RT,outpatient,,,36892.98,22135.79,,,,,,,,,,,,,
Transurethral Resection Bladder Neck,CASE-52500,LOCAL,52500,CPT,,,,,,outpatient,,,18831.58,11298.95,,,,,,,,,,,,,
Lamnotmy Incl W/Dcmprsn Nrv Root 1 Intrspc Lumbr,CASE-63030,LOCAL,63030,CPT,,,,,,outpatient,,,44691.43,26814.86,,,,,,,,,,,,,
Lamnotmy Incl W/Dcmprsn Nrv Root 1 Intrspc Lumbr,CASE-63030,LOCAL,63030,CPT,0360,RC,,,,outpatient,,,44691.43,26814.86,,,,,,,,,,,,,
STEM TIB EXTN L30MM DIA15MM STR NXGN,SUP-2402750,CDM,C1776,CPT,0278,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
PLATE BNE L TIM L CALCNL LNG LOK ALPS,SUP-2413698,CDM,C1713,HCPCS,0278,RC,,,,both,,,3400.62,2210.40,,,,,,,,,,,,,
CURETTE SURG 4 6.75 IN 10.8X7.6 MM STR NS RUGGLES-REDMOND,SUP-2473280,CDM,2720000010,LOCAL,0272,RC,,,,both,,,500.89,325.58,,,,,,,,,,,,,
MINI PLATE T SHAPE EXTENDED,SUP-2694758,CDM,C1713,HCPCS,0278,RC,,,,both,,,617.73,401.52,,,,,,,,,,,,,
DA VINCI TIBIAL NAIL SCREW CASE,SUP-2816347,CDM,C1713,HCPCS,0278,RC,,,,both,,,1051.90,683.73,,,,,,,,,,,,,
PLATE BNE THK1MM REG 8 H TI FOR 2MM MINI MOD,SUP-2262766,CDM,C1713,HCPCS,0278,RC,,,,both,,,133.76,86.94,,,,,,,,,,,,,
PLATE BNE W12XL199MM THK1MM 11 H BILAT S STL SEMI TBLR LO,SUP-2184873,CDM,C1713,HCPCS,0278,RC,,,,both,,,313.00,203.45,,,,,,,,,,,,,
PLATE BNE T 148 MM 8 HOLE SS,SUP-2569109,CDM,C1713,HCPCS,0278,RC,,,,both,,,383.39,249.20,,,,,,,,,,,,,
COIL VASC VORTX-18 L 58 MM UNRESTRAINED L 5.5 MM DIA 5 MM,SUP-2148150,CDM,C1889,HCPCS,0278,RC,,,,both,,,238.64,155.12,,,,,,,,,,,,,
SYSTEM EXT CSF DRNGE HERM II,SUP-2244302,CDM,C1729,HCPCS,0272,RC,,,,both,,,498.10,323.76,,,,,,,,,,,,,
Laser Vaporization of Prostate for Urine Flow,CASE-52648,LOCAL,52648,CPT,0360,RC,,,,outpatient,,,35074.93,21044.96,,,,,,,,,,,,,
Laps Abd Prtm&Omentum Dx W/WO Spec Br/Wa Spx,CASE-49320,LOCAL,49320,CPT,,,,,,outpatient,,,25613.57,15368.14,,,,,,,,,,,,,
"HC ED Avulsion Nail Plate Single|RIGHT HAND, THUMB",CASE-11730,LOCAL,11730,CPT,0450,RC,,,F5,outpatient,,,11822.28,7093.37,,,,,,,,,,,,,
Laps Abd Prtm&Omentum Dx W/WO Spec Br/Wa Spx,CASE-49320,LOCAL,49320,CPT,0360,RC,,,,outpatient,,,25613.57,15368.14,,,,,,,,,,,,,
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 1 Level|BILATERAL PROCEDURE,CASE-64493,LOCAL,64493,CPT,,,,,50,outpatient,,,3988.28,2392.97,,,,,,,,,,,,,
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 1 Level|BILATERAL PROCEDURE,CASE-64493,LOCAL,64493,CPT,0360,RC,,,50,outpatient,,,3988.28,2392.97,,,,,,,,,,,,,
Transection/Avulsion Oth Spinal Nrv Xdrl,CASE-64772,LOCAL,64772,CPT,0360,RC,,,,outpatient,,,26472.32,15883.39,,,,,,,,,,,,,
Laser Vaporization of Prostate for Urine Flow,CASE-52648,LOCAL,52648,CPT,,,,,,outpatient,,,35074.93,21044.96,,,,,,,,,,,,,
Transection/Avulsion Oth Spinal Nrv Xdrl,CASE-64772,LOCAL,64772,CPT,,,,,,outpatient,,,26472.32,15883.39,,,,,,,,,,,,,
GRAFT HUM TISS L 20X40MM PERICARD FRZ DRY READIGRFT,SUP-2264834,CDM,C1713,HCPCS,0278,RC,,,,both,,,539.04,350.38,,,,,,,,,,,,,
KT CTRL VEN CATH L20CM OD7FR SFTY 3 LUM,SUP-2927790,CDM,C1751,HCPCS,0278,RC,,,,both,,,209.97,136.48,,,,,,,,,,,,,
RING EXT FIX SZ 5 8 DIA150MM FT C FBR COMP ILIZ,SUP-2342284,CDM,C1713,HCPCS,0278,RC,,,,both,,,8162.74,5305.78,,,,,,,,,,,,,
TAPE 24IN FIXATION NEEDLE WITH PASSING ENDOBUTTON,SUP-2880373,CDM,2720000010,LOCAL,0272,RC,,,,both,,,323.42,210.22,,,,,,,,,,,,,
CATHETER INFUSION UNI-FUSE + L 135 CM 4.3 FR SLT 15 CM BALL,SUP-2752573,CDM,C1751,HCPCS,0278,RC,,,,both,,,785.00,510.25,,,,,,,,,,,,,
COIL EMB L6CM DIA0.02IN LOOP DIA3MM COMPLX EXTRA SFT FILL,SUP-2323446,CDM,C1889,HCPCS,0278,RC,,,,both,,,6471.54,4206.50,,,,,,,,,,,,,
COIL VASC EMBOLUS L 1 CM DIA2 MM GUIDEWIRE 0.035 IN STRTCH,SUP-2167992,CDM,C1889,HCPCS,0278,RC,,,,both,,,274.44,178.39,,,,,,,,,,,,,
CAP ORTH WSHR FOR 27MM STD LOK SURFIX SCR HALLU LOCK MTP,SUP-2243051,CDM,C1713,HCPCS,0278,RC,,,,both,,,460.48,299.31,,,,,,,,,,,,,
SCREW BNE L90MM DIA13MM THRD L22MM STD HIP S STL LAG CANN,SUP-2370957,CDM,C1713,HCPCS,0278,RC,,,,both,,,1397.30,908.24,,,,,,,,,,,,,
PLATE BNE T 3.5X78X1.2 MM 4X6 HOLE FOR SCR SM FRAG SYS SS NS,SUP-2470183,CDM,C1713,HCPCS,0278,RC,,,,both,,,424.34,275.82,,,,,,,,,,,,,
GRAFT BIO TISS STD PORCINE MTRX PEYRONIES REP BIODESIGN,SUP-2170533,CDM,C1763,HCPCS,0278,RC,,,,both,,,1548.02,1006.21,,,,,,,,,,,,,
DRILL SURG CANN 2.2 MM STRL LTX DISP,SUP-2860993,CDM,2720000010,LOCAL,0272,RC,,,,both,,,426.91,277.49,,,,,,,,,,,,,
HC Injection Small Joint/Bursa|LEFT SIDE,CASE-20600,LOCAL,20600,CPT,0361,RC,,,LT,outpatient,,,18796.78,11278.07,,,,,,,,,,,,,
Insj Inflatable Urethral/Bladder Neck Sphincter,CASE-53445,LOCAL,53445,CPT,,,,,,outpatient,,,104791.43,62874.86,,,,,,,,,,,,,
Laps W/Vag Hysterect 250 Gm/&Rmvl Tube&/Ovaries,CASE-58552,LOCAL,58552,CPT,,,,,,outpatient,,,47558.33,28535.00,,,,,,,,,,,,,
Nsl/Sinus Ndsc Max Antrost W/Rmvl Tiss Max Sinus|LEFT SIDE,CASE-31267,LOCAL,31267,CPT,0360,RC,,,LT,outpatient,,,35348.32,21208.99,,,,,,,,,,,,,
Hysteroscopy Removal Leiomyomata,CASE-58561,LOCAL,58561,CPT,0360,RC,,,,outpatient,,,29214.00,17528.40,,,,,,,,,,,,,
Unlisted Laparoscopic Procedure Liver,CASE-47379,LOCAL,47379,CPT,,,,,,outpatient,,,31108.03,18664.82,,,,,,,,,,,,,
Unlisted Laparoscopic Procedure Liver,CASE-47379,LOCAL,47379,CPT,0360,RC,,,,outpatient,,,31108.03,18664.82,,,,,,,,,,,,,
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|LEFT HAND, THIRD DIGIT",CASE-26160,LOCAL,26160,CPT,0360,RC,,,F2,outpatient,,,10989.42,6593.65,,,,,,,,,,,,,
Laps W/Vag Hysterect 250 Gm/&Rmvl Tube&/Ovaries,CASE-58552,LOCAL,58552,CPT,0360,RC,,,,outpatient,,,47558.33,28535.00,,,,,,,,,,,,,
Insj Inflatable Urethral/Bladder Neck Sphincter,CASE-53445,LOCAL,53445,CPT,0360,RC,,,,outpatient,,,104791.43,62874.86,,,,,,,,,,,,,
Hysteroscopy Removal Leiomyomata,CASE-58561,LOCAL,58561,CPT,,,,,,outpatient,,,29214.00,17528.40,,,,,,,,,,,,,
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|LEFT HAND, THIRD DIGIT",CASE-26160,LOCAL,26160,CPT,,,,,F2,outpatient,,,10989.42,6593.65,,,,,,,,,,,,,
Nsl/Sinus Ndsc Max Antrost W/Rmvl Tiss Max Sinus|LEFT SIDE,CASE-31267,LOCAL,31267,CPT,,,,,LT,outpatient,,,35348.32,21208.99,,,,,,,,,,,,,
PLATE BNE BURR HOLE CVR 22X0.5X1 MM SLGHT CONTOURED STRL,SUP-2479093,CDM,C1713,HCPCS,0278,RC,,,,both,,,1224.66,796.03,,,,,,,,,,,,,
KIT STRNL CLOSURE AUXILIARY CABLE PLATE STRL,SUP-2894345,CDM,C1713,HCPCS,0278,RC,,,,both,,,3595.30,2336.94,,,,,,,,,,,,,
RETRACTOR SURG L152MM HND HELD DBL END BLNT FARABEUF,SUP-2244666,CDM,C1713,HCPCS,0278,RC,,,,both,,,51.81,33.68,,,,,,,,,,,,,
EPOCH POR ST/HA CUP/LGXLPE LINER/LG STD HD,SUP-2212321,CDM,C1776,CPT,0278,RC,,,,both,,,15754.29,10240.29,,,,,,,,,,,,,
CATHETER CARD ABLATION QDOT MIC L 115 CM 8 FR 3.5 MM J SHP,SUP-2880102,CDM,C1732,HCPCS,0278,RC,,,,both,,,15813.04,10278.48,,,,,,,,,,,,,
COMPONENT ARTC SURF CR 1-2 AB 9 MM TIB KNEE PUR NXGN,SUP-2201339,CDM,C1776,CPT,0278,RC,,,,both,,,3682.59,2393.68,,,,,,,,,,,,,
SCREW INTRF L8MM DIA3MM W/ HNDL INSRTR BIO-TENODESIS,SUP-2121326,CDM,C1713,HCPCS,0278,RC,,,,both,,,1051.90,683.73,,,,,,,,,,,,,
COMPONENT FEM SZ 1 LT KNEE NP PRI CEM STEM ROT HNG MEDL PVT,SUP-2304625,CDM,C1776,CPT,0278,RC,,,,both,,,14732.88,9576.37,,,,,,,,,,,,,
VENLAFAXINE HCL ER 75 MG PO CP24,RX-27858,CDM,6370000000,HCPCS,0637,RC,68084-0709-11,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
GRAFT BNE SPNG 20X15X7 MM DBM CANC,SUP-2641783,CDM,C1713,HCPCS,0278,RC,,,,both,,,2819.41,1832.62,,,,,,,,,,,,,
Hysteroscopy Bx Endometrium&/Polypc W/WO D&C,CASE-58558,LOCAL,58558,CPT,,,,,,outpatient,,,22238.80,13343.28,,,,,,,,,,,,,
"Neuroplasty Sciatic Nerve,Open",CASE-64712,LOCAL,64712,CPT,0360,RC,,,,outpatient,,,34242.53,20545.52,,,,,,,,,,,,,
Laryngoscopy Direct Operative W/Biopsy|UNUSUAL NON-OVERLAPPING SERVICE,CASE-31535,LOCAL,31535,CPT,,,,,XU,outpatient,,,21137.88,12682.73,,,,,,,,,,,,,
Mastectomy Simple Complete|BILATERAL PROCEDURE,CASE-19303,LOCAL,19303,CPT,,,,,50,outpatient,,,76885.10,46131.06,,,,,,,,,,,,,
Arthrd Ant Interbody Decompress Cervical Belw C2,CASE-22551,LOCAL,22551,CPT,,,,,,outpatient,,,63567.22,38140.33,,,,,,,,,,,,,
HC Breath Hydrogen/Met Test,CASE-91065,LOCAL,91065,CPT,0920,RC,,,,outpatient,,,392.17,235.30,,,,,,,,,,,,,
Arthrd Ant Interbody Decompress Cervical Belw C2,CASE-22551,LOCAL,22551,CPT,0360,RC,,,,outpatient,,,63567.22,38140.33,,,,,,,,,,,,,
HC Lyr Clos Sc Tk Ext 2.6-7 Cm|SEPARATE STRUCTURE,CASE-12032,LOCAL,12032,CPT,0450,RC,,,XS,outpatient,,,27843.83,16706.30,,,,,,,,,,,,,
Hysteroscopy Bx Endometrium&/Polypc W/WO D&C,CASE-58558,LOCAL,58558,CPT,0360,RC,,,,outpatient,,,22238.80,13343.28,,,,,,,,,,,,,
Laryngoscopy Direct Operative W/Biopsy|UNUSUAL NON-OVERLAPPING SERVICE,CASE-31535,LOCAL,31535,CPT,0360,RC,,,XU,outpatient,,,21137.88,12682.73,,,,,,,,,,,,,
Aspiration Bladder Insert Suprapubic Catheter,CASE-51102,LOCAL,51102,CPT,0360,RC,,,,outpatient,,,13240.87,7944.52,,,,,,,,,,,,,
"Neuroplasty Sciatic Nerve,Open",CASE-64712,LOCAL,64712,CPT,,,,,,outpatient,,,34242.53,20545.52,,,,,,,,,,,,,
Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|RIGHT SIDE,CASE-26160,LOCAL,26160,CPT,0360,RC,,,RT,outpatient,,,13272.10,7963.26,,,,,,,,,,,,,
Mastectomy Simple Complete|BILATERAL PROCEDURE,CASE-19303,LOCAL,19303,CPT,0360,RC,,,50,outpatient,,,76885.10,46131.06,,,,,,,,,,,,,
Aspiration Bladder Insert Suprapubic Catheter,CASE-51102,LOCAL,51102,CPT,,,,,,outpatient,,,13240.87,7944.52,,,,,,,,,,,,,
Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|RIGHT SIDE,CASE-26160,LOCAL,26160,CPT,,,,,RT,outpatient,,,13272.10,7963.26,,,,,,,,,,,,,
BONE VOID FILLERS MORSELIZED ALLOGRAFTS CANC MILLED CANC,SUP-2307071,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2096.89,1362.98,,,,,,,,,,,,,
BRACE KNEE POSTOP UNIV UNISX FASTEN ON HNG ROM STRP CLSR AD,SUP-2196449,CDM,L1832,HCPCS,0274,RC,,,,both,,,401.45,260.94,,,,,,,,,,,,,
STENT EVAR L29MM DIA8-16MM CATH L135CM 0.035IN PROX DST IL,SUP-2395708,CDM,C1874,HCPCS,0278,RC,,,,both,,,9862.74,6410.78,,,,,,,,,,,,,
CATHETER DRNGE 10FR L35CM GWIRE 0.038IN BILI FLEXIMA REG,SUP-2147832,CDM,C1729,HCPCS,0272,RC,,,,both,,,248.06,161.24,,,,,,,,,,,,,
HC Renal Cyst Study Contrast S&I,PX-3207447000,CDM,74470,CPT,0320,RC,,,,both,,,6875.00,4468.75,,,,,,,,,,,,,
HC So Testosterone Total,PX-3018440366,CDM,84403,CPT,0301,RC,,,,both,,,118.00,76.70,,,,,,,,,,,,,
GRAFT HUM TISS DISC 15 MM AMNION-CHORION-AMNION LAYR PLCNTA,SUP-2909246,CDM,Q4140,HCPCS,0636,RC,,,,both,,,2800.57,1820.37,,,,,,,,,,,,,
BIT DRL DIA145MM SHT RIG FOR SFT SUT ANCHR JUGGERKNOT,SUP-2136095,CDM,2720000010,LOCAL,0272,RC,,,,both,,,239.05,155.38,,,,,,,,,,,,,
CALCIUM GLUCONATE-NACL 2-0.675 GM/100ML-% IV SOLN,RX-146762,CDM,J0613,HCPCS,0636,RC,44567-0621-01,NDC,,both,100,ML,227.20,147.68,,,,,,,,,,,,,
PATCH CV W2XL9CM THK0.4MM EPTFE CNFRM GORE TEX,SUP-2395305,CDM,C1768,CPT,0278,RC,,,,both,,,687.66,446.98,,,,,,,,,,,,,
KIT HEMODLYS L24CM BASIC DLYS CATH 16FR VLV BRKWY INTRO,SUP-2117389,CDM,C1750,HCPCS,0278,RC,,,,both,,,1191.98,774.79,,,,,,,,,,,,,
HC IV Inf Ea Add Hour,PX-2609636600,CDM,96366,CPT,0260,RC,,,,both,,,87.00,56.55,,,,,,,,,,,,,
STAPLE EASYCLIP 20 16 16,SUP-2696124,CDM,C1713,HCPCS,0278,RC,,,,both,,,5385.73,3500.72,,,,,,,,,,,,,
TOOL INSRTN STRL FURLOW LTX DISP,SUP-2862194,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1644.10,1068.66,,,,,,,,,,,,,
STUD FIX L18.5MM DIA7.5MM PATELLOFEMORAL JT HEMICAP,SUP-2123693,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1937.38,1259.30,,,,,,,,,,,,,
SCREW BONE L34MM DIA3.5MM CORT PERIARTC S STL ST,SUP-2205644,CDM,C1713,HCPCS,0278,RC,,,,both,,,266.15,173.00,,,,,,,,,,,,,
Tympanostomy General Anesthesia|RIGHT SIDE,CASE-69436,LOCAL,69436,CPT,0360,RC,,,RT,outpatient,,,19111.78,11467.07,,,,,,,,,,,,,
Laps Gstr Rstcv Px W/Byp Roux-en-Y Limb <150 Cm,CASE-43644,LOCAL,43644,CPT,,,,,,outpatient,,,101835.25,61101.15,,,,,,,,,,,,,
Esophagoscopy Flexible Transoral Ultrasound Exam,CASE-43231,LOCAL,43231,CPT,,,,,,outpatient,,,11176.00,6705.60,,,,,,,,,,,,,
Laps Gstr Rstcv Px W/Byp Roux-en-Y Limb <150 Cm,CASE-43644,LOCAL,43644,CPT,0360,RC,,,,outpatient,,,101835.25,61101.15,,,,,,,,,,,,,
"Tendon Sheath Incision|UNUSUAL NON-OVERLAPPING SERVICE|LEFT HAND, THUMB",CASE-26055,LOCAL,26055,CPT,,,,,XU|FA,outpatient,,,24147.52,14488.51,,,,,,,,,,,,,
Blepharoplasty Upper Eyelid W/Excessive Skin|BILATERAL PROCEDURE,CASE-15823,LOCAL,15823,CPT,,,,,50,outpatient,,,24154.00,14492.40,,,,,,,,,,,,,
"Hallux Rigidus W/Cheilectomy 1st Mp Jt W/O Implt|RIGHT FOOT, GREAT TOE",CASE-28289,LOCAL,28289,CPT,,,,,T5,outpatient,,,24528.12,14716.87,,,,,,,,,,,,,
Esophagoscopy Flexible Transoral Ultrasound Exam,CASE-43231,LOCAL,43231,CPT,0360,RC,,,,outpatient,,,11176.00,6705.60,,,,,,,,,,,,,
HC Blood Occult Peroxidase Actv Qual Feces 1-3 Spec,CASE-82272,LOCAL,82272,CPT,0301,RC,,,,outpatient,,,1122.33,673.40,,,,,,,,,,,,,
Tympanostomy General Anesthesia|RIGHT SIDE,CASE-69436,LOCAL,69436,CPT,,,,,RT,outpatient,,,19111.78,11467.07,,,,,,,,,,,,,
Blepharoplasty Upper Eyelid W/Excessive Skin|BILATERAL PROCEDURE,CASE-15823,LOCAL,15823,CPT,0360,RC,,,50,outpatient,,,24154.00,14492.40,,,,,,,,,,,,,
"Tendon Sheath Incision|UNUSUAL NON-OVERLAPPING SERVICE|LEFT HAND, THUMB",CASE-26055,LOCAL,26055,CPT,0360,RC,,,XU|FA,outpatient,,,24147.52,14488.51,,,,,,,,,,,,,
"Hallux Rigidus W/Cheilectomy 1st Mp Jt W/O Implt|RIGHT FOOT, GREAT TOE",CASE-28289,LOCAL,28289,CPT,0360,RC,,,T5,outpatient,,,24528.12,14716.87,,,,,,,,,,,,,
SCREW BNE L 28 MM DIA 3 MM TI CANN HD NS LEOS,SUP-2932613,CDM,C1713,HCPCS,0278,RC,,,,both,,,715.67,465.19,,,,,,,,,,,,,
DEVICE FIXATION 35MM NONSUTURE FOR SOFT TISSUE CONTINUOUS LO,SUP-2824701,CDM,C1713,HCPCS,0278,RC,,,,both,,,702.54,456.65,,,,,,,,,,,,,
GRAFT VASC HEMSHLD GLD L 60 CM DIA12 MM POLYESTER BOV CLLGN,SUP-2227684,CDM,C1768,CPT,0278,RC,,,,both,,,1897.35,1233.28,,,,,,,,,,,,,
CATHETER EP DECAPOLAR 2-5-2 MM LG 7 FR STEER,SUP-2102302,CDM,C1730,HCPCS,0272,RC,,,,both,,,2512.00,1632.80,,,,,,,,,,,,,
DIMENHYDRINATE 50 MG PO TABS,RX-2485,CDM,6370000000,HCPCS,0637,RC,00904-2051-59,NDC,,both,1,UN,0.20,0.13,,,,,,,,,,,,,
PROBE LASER 23GA 40DEG NIT TIP EZ INSRTN DISP,SUP-2109925,CDM,2720000010,LOCAL,0272,RC,,,,both,,,685.05,445.28,,,,,,,,,,,,,
MGII KNEE POR STEM TIB.E+/GRE BLK LT/M RT/L,SUP-2199639,CDM,C1776,CPT,0278,RC,,,,both,,,15659.81,10178.88,,,,,,,,,,,,,
GRAFT BNE PARTICULATE 250-1000 M UM 2 CC CANC PUROS,SUP-2860955,CDM,C1713,HCPCS,0278,RC,,,,both,,,216.03,140.42,,,,,,,,,,,,,
SCREW BNE 16 MM TIP 2-3/4 IN DISTRCTN FOR RUGGLES REDMOND NS,SUP-2460932,CDM,C1713,HCPCS,0278,RC,,,,both,,,400.35,260.23,,,,,,,,,,,,,
BLADE SHV OD4.5MM STR CUT BOXED ARTHROBLDE SYNOVATOR,SUP-2341398,CDM,2720000010,LOCAL,0272,RC,,,,both,,,184.95,120.22,,,,,,,,,,,,,
PLATE TUB 8H 95MM,SUP-2695655,CDM,C1713,HCPCS,0278,RC,,,,both,,,1281.43,832.93,,,,,,,,,,,,,
Revision Peri-Implant Capsule Breast|RIGHT SIDE,CASE-19370,LOCAL,19370,CPT,,,,,RT,outpatient,,,104951.48,62970.89,,,,,,,,,,,,,
"Open Tx Articular Fracture Mcp/IP Joint Ea|LEFT HAND, FIFTH DIGIT",CASE-26746,LOCAL,26746,CPT,,,,,F4,outpatient,,,25299.60,15179.76,,,,,,,,,,,,,
"Open Tx Articular Fracture Mcp/IP Joint Ea|LEFT HAND, FIFTH DIGIT",CASE-26746,LOCAL,26746,CPT,0360,RC,,,F4,outpatient,,,25299.60,15179.76,,,,,,,,,,,,,
Revision Peri-Implant Capsule Breast|RIGHT SIDE,CASE-19370,LOCAL,19370,CPT,0360,RC,,,RT,outpatient,,,104951.48,62970.89,,,,,,,,,,,,,
Arthrd Ant Interbody Decompress Cervical Belw C2|SEPARATE STRUCTURE,CASE-22551,LOCAL,22551,CPT,,,,,XS,outpatient,,,91252.22,54751.33,,,,,,,,,,,,,
Arthrd Ant Interbody Decompress Cervical Belw C2|SEPARATE STRUCTURE,CASE-22551,LOCAL,22551,CPT,0360,RC,,,XS,outpatient,,,91252.22,54751.33,,,,,,,,,,,,,
HC MRI-Pelvis WO Contrast,PX-6147219500,CDM,72195,CPT,0614,RC,,,,both,,,4626.00,3006.90,,,,,,,,,,,,,
HYOSCYAMINE SULFATE ER 0.375 MG PO TB12,RX-17010,CDM,6370000000,HCPCS,0637,RC,51525-0115-01,NDC,,both,1,UN,3.60,2.34,,,,,,,,,,,,,
KIT INTRO ELITE HV SHTH L 7 CM DIA 3 FR GUIDEWIRE L 40 CM,SUP-2615930,CDM,C1894,HCPCS,0272,RC,,,,both,,,96.05,62.43,,,,,,,,,,,,,
SPLINT THMB AD FOR 4.5-9.5IN REG KUHL PERF NEOPRNE WRP ARND,SUP-2324315,CDM,L3931,HCPCS,0274,RC,,,,both,,,73.70,47.90,,,,,,,,,,,,,
VALVE CSF CRAN 2PC HYDROCEPHALUS OSV II,SUP-2666689,CDM,C1889,HCPCS,0278,RC,,,,both,,,9293.24,6040.61,,,,,,,,,,,,,
HC Debride Infected Skin,PX-4501100000,CDM,11000,CPT,0450,RC,,,,both,,,1842.00,1197.30,,,,,,,,,,,,,
DRILL SURG ANGLED STAND ALONE NO-P INTBDY CAGE DIVERGENCE,SUP-2630132,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2488.70,1617.65,,,,,,,,,,,,,
ATEZOLIZUMAB 840 MG/14ML IV SOLN,RX-145415,CDM,J9022,HCPCS,0636,RC,50242-0918-01,NDC,,both,14,ML,23364.20,15186.73,,,,,,,,,,,,,
DEVICE GREATER TROCHANT REATTACHMENT EXT,SUP-2469176,CDM,C1713,HCPCS,0278,RC,,,,both,,,11405.11,7413.32,,,,,,,,,,,,,
SIZER SURG W14XH14.6CM 555ML P5.9CM SIL GEL BRST 332 STYL,SUP-2300828,CDM,2720000010,LOCAL,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
CATHETER CNTRL VNOU LUMENX1 5FR DIA 34CML SIL 0.3ML JUG SUBC,SUP-2613071,CDM,C1751,HCPCS,0278,RC,,,,both,,,266.90,173.48,,,,,,,,,,,,,
ANCHOR SUTURE L 12 MM DIA 3 MM TI STRL GRAPPLER,SUP-2881102,CDM,C1713,HCPCS,0278,RC,,,,both,,,1112.97,723.43,,,,,,,,,,,,,
PLATE BONE LOK HLX6 3MM THK TTNM 120DG ANGLD LVLX1 RCNSTRCTN,SUP-2679063,CDM,C1713,HCPCS,0278,RC,,,,both,,,3383.95,2199.57,,,,,,,,,,,,,
Egd Intrmural Needle Aspir/Biop Altered Anatomy,CASE-43242,LOCAL,43242,CPT,0360,RC,,,,outpatient,,,20239.12,12143.47,,,,,,,,,,,,,
Egd Intrmural Needle Aspir/Biop Altered Anatomy,CASE-43242,LOCAL,43242,CPT,,,,,,outpatient,,,20239.12,12143.47,,,,,,,,,,,,,
HC Inj Aa&/Strd Other Peripheral Nerve/Branch|RIGHT SIDE,CASE-64450,LOCAL,64450,CPT,0450,RC,,,RT,outpatient,,,3976.05,2385.63,,,,,,,,,,,,,
Esophagogastroduodenoscopy Submucosal Injection|UNUSUAL NON-OVERLAPPING SERVICE,CASE-43236,LOCAL,43236,CPT,0360,RC,,,XU,outpatient,,,12699.80,7619.88,,,,,,,,,,,,,
Esophagogastroduodenoscopy Submucosal Injection|UNUSUAL NON-OVERLAPPING SERVICE,CASE-43236,LOCAL,43236,CPT,,,,,XU,outpatient,,,12699.80,7619.88,,,,,,,,,,,,,
VALVE SHUNT SM EXTRACTED STRATA II,SUP-2628591,CDM,C1729,HCPCS,0272,RC,,,,both,,,13380.89,8697.58,,,,,,,,,,,,,
GUIDEWIRE ORTH OFFSET BLOCK AIMING DEV NS,SUP-2799290,CDM,C1769,HCPCS,0272,RC,,,,both,,,1176.56,764.76,,,,,,,,,,,,,
PLATE STRNL LG 10 H TI LADDER NS MATRIXSTERNUM,SUP-2904259,CDM,C1713,HCPCS,0278,RC,,,,both,,,2936.69,1908.85,,,,,,,,,,,,,
SEED BRACHYTHERAPY LOAD 8.01-9.0 MCI STRL ADVANTAGE 2029ILS2] ISOAID LLC],SUP-2247282,CDM,C2642,HCPCS,0278,RC,,,,both,,,565.20,367.38,,,,,,,,,,,,,
ENALAPRILAT 1.25 MG/ML IV SOLN,RX-169136,CDM,2500000003,HCPCS,0250,RC,00143-9787-01,NDC,,both,1,ML,54.10,35.16,,,,,,,,,,,,,
BIT DRL LNG 1.1X60 MM 4 MM W/ STP STRYKR QUIK CPL,SUP-2653745,CDM,2720000010,LOCAL,0272,RC,,,,both,,,780.35,507.23,,,,,,,,,,,,,
SYSTEM EMBOLIC PROTCT L180CM DIA6MM 0014IN 8 NIT STRUT GWIRE,SUP-2158106,CDM,C1884,HCPCS,0278,RC,,,,both,,,5652.00,3673.80,,,,,,,,,,,,,
SHOE ORTHOT MEN CUST OXFORD INTEGR PART OF BRAC,SUP-2435715,CDM,L3225,HCPCS,0272,RC,,,,both,,,208.97,135.83,,,,,,,,,,,,,
MICROCATHETER INFUSION PROWLER SEL LP-ES L 150CM 5CM STR TIP,SUP-2499396,CDM,C1887,HCPCS,0272,RC,,,,both,,,4134.19,2687.22,,,,,,,,,,,,,
HC Surgery Level 1 Base,PX-3600000001,CDM,3600000001,LOCAL,0360,RC,,,,both,,,1052.00,683.80,,,,,,,,,,,,,
MASK CPAP MED ELBW CAPSTRAP,SUP-2429260,CDM,C1713,HCPCS,0278,RC,,,,both,,,353.60,229.84,,,,,,,,,,,,,
Nasal/Sinus Ndsc W/Rmvl Tiss From Frontal Sinus|BILATERAL PROCEDURE,CASE-31276,LOCAL,31276,CPT,0360,RC,,,50,outpatient,,,60525.53,36315.32,,,,,,,,,,,,,
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|LEFT HAND, FIFTH DIGIT",CASE-26160,LOCAL,26160,CPT,0360,RC,,,F4,outpatient,,,8772.70,5263.62,,,,,,,,,,,,,
Laparoscopy Urethral Suspension Stress Incont,CASE-51990,LOCAL,51990,CPT,,,,,,outpatient,,,110869.92,66521.95,,,,,,,,,,,,,
Open Treatment Ulnar Fracture Proximal End|LEFT SIDE,CASE-24685,LOCAL,24685,CPT,0360,RC,,,LT,outpatient,,,54970.60,32982.36,,,,,,,,,,,,,
Revision of Reconstructed Breast,CASE-19380,LOCAL,19380,CPT,,,,,,outpatient,,,71706.43,43023.86,,,,,,,,,,,,,
Mastopexy|RIGHT SIDE,CASE-19316,LOCAL,19316,CPT,,,,,RT,outpatient,,,48312.63,28987.58,,,,,,,,,,,,,
Open Treatment Ulnar Fracture Proximal End|LEFT SIDE,CASE-24685,LOCAL,24685,CPT,,,,,LT,outpatient,,,54970.60,32982.36,,,,,,,,,,,,,
Laparoscopy Surg Partial Nephrectomy|LEFT SIDE,CASE-50543,LOCAL,50543,CPT,,,,,LT,outpatient,,,102475.95,61485.57,,,,,,,,,,,,,
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|LEFT HAND, FIFTH DIGIT",CASE-26160,LOCAL,26160,CPT,,,,,F4,outpatient,,,8772.70,5263.62,,,,,,,,,,,,,
Revision of Reconstructed Breast,CASE-19380,LOCAL,19380,CPT,0360,RC,,,,outpatient,,,71706.43,43023.86,,,,,,,,,,,,,
Nasal/Sinus Ndsc W/Rmvl Tiss From Frontal Sinus|BILATERAL PROCEDURE,CASE-31276,LOCAL,31276,CPT,,,,,50,outpatient,,,60525.53,36315.32,,,,,,,,,,,,,
Laparoscopy Surg Partial Nephrectomy|LEFT SIDE,CASE-50543,LOCAL,50543,CPT,0360,RC,,,LT,outpatient,,,102475.95,61485.57,,,,,,,,,,,,,
Laparoscopy Urethral Suspension Stress Incont,CASE-51990,LOCAL,51990,CPT,0360,RC,,,,outpatient,,,110869.92,66521.95,,,,,,,,,,,,,
Mastopexy|RIGHT SIDE,CASE-19316,LOCAL,19316,CPT,0360,RC,,,RT,outpatient,,,48312.63,28987.58,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED CERM ON CERM STEJH5] STRYKER CORP],SUP-2365939,CDM,C1776,CPT,0278,RC,,,,both,,,16029.70,10419.30,,,,,,,,,,,,,
PLATE BNE L36MM THK1MM 2X6 H CNDYL HND 316L S STL VAR ANG,SUP-2178010,CDM,C1713,HCPCS,0278,RC,,,,both,,,1520.33,988.21,,,,,,,,,,,,,
"HC Phlebotomy,Tx",PX-9409919500,CDM,99195,CPT,0940,RC,,,,outpatient,,,330.00,214.50,,,,,,,,,,,,,
PLATE BNE L 163 X W 11.4 MM THK 3.5 MM SCREW DIA 3.5 MM 12 H 72464512N,SUP-2932863,CDM,C1713,HCPCS,0278,RC,,,,both,,,3567.04,2318.58,,,,,,,,,,,,,
PIN EXT FIX 240X5 MM APEX SD,SUP-2517219,CDM,2720000010,LOCAL,0272,RC,,,,both,,,250.57,162.87,,,,,,,,,,,,,
PLATE BONE L71MM 6 H FIB TI STR LCK FOR 2.7/3/3.5/4MM SCR,SUP-2225374,CDM,C1713,HCPCS,0278,RC,,,,both,,,3325.89,2161.83,,,,,,,,,,,,,
PLATE BONE L23MM LNG DBL Y SPEC LORENZ,SUP-2137628,CDM,C1713,HCPCS,0278,RC,,,,both,,,810.12,526.58,,,,,,,,,,,,,
GRAFTON MTRX 2.5CMX10CM 2 EA,SUP-2307031,CDM,C1713,HCPCS,0278,RC,,,,both,,,3951.69,2568.60,,,,,,,,,,,,,
PSN REV STRAIGHT SPLINE STEM EXT 15X175MM,SUP-2508792,CDM,C1776,CPT,0278,RC,,,,both,,,4333.20,2816.58,,,,,,,,,,,,,
OSTEOTOME SURG OD 8MM LNG BLDE THN FLX,SUP-2408600,CDM,2720000010,LOCAL,0272,RC,,,,both,,,518.10,336.76,,,,,,,,,,,,,
GRAFT SOFT TISSUE CANN 11X30 MM TIB WITH DRIVER APERFIX II,SUP-2664013,CDM,C1713,HCPCS,0278,RC,,,,both,,,1927.96,1253.17,,,,,,,,,,,,,
WIRE TEMP FIX 3 MM DIAM S STL DBL END SMOOTH DBL SHRP TIP,SUP-2342718,CDM,C1713,HCPCS,0278,RC,,,,both,,,210.16,136.60,,,,,,,,,,,,,
PLATE BNE L185MM 12 H NONSTERILE R LAT PROX TIB S STL LOK,SUP-2185618,CDM,C1713,HCPCS,0278,RC,,,,both,,,3973.70,2582.90,,,,,,,,,,,,,
BLADE SAW SZ 7 UNIV WIDE SAG FOR PROPHECY INBONE TOT ANK,SUP-2397086,CDM,2720000010,LOCAL,0272,RC,,,,both,,,367.38,238.80,,,,,,,,,,,,,
COVER BURR H DIA18.5 MM PROF THK 0.3 MM CRAN NS THINFLAP,SUP-2883901,CDM,C1713,HCPCS,0278,RC,,,,both,,,662.54,430.65,,,,,,,,,,,,,
Chemodenervation Muscle Neck Unilat for Dystonia,CASE-64616,LOCAL,64616,CPT,0360,RC,,,,outpatient,,,5512.65,3307.59,,,,,,,,,,,,,
Mastectomy Simple Complete,CASE-19303,LOCAL,19303,CPT,0360,RC,,,,outpatient,,,61102.52,36661.51,,,,,,,,,,,,,
Nasal/Sinus Ndsc W/Rmvl Tiss From Frontal Sinus|LEFT SIDE,CASE-31276,LOCAL,31276,CPT,,,,,LT,outpatient,,,35240.75,21144.45,,,,,,,,,,,,,
Nasal/Sinus Ndsc W/Rmvl Tiss From Frontal Sinus|LEFT SIDE,CASE-31276,LOCAL,31276,CPT,0360,RC,,,LT,outpatient,,,35240.75,21144.45,,,,,,,,,,,,,
Excision Inferior Turbinate Partial/Complete|BILATERAL PROCEDURE,CASE-30130,LOCAL,30130,CPT,0360,RC,,,50,outpatient,,,29867.82,17920.69,,,,,,,,,,,,,
Mastectomy Simple Complete,CASE-19303,LOCAL,19303,CPT,,,,,,outpatient,,,61102.52,36661.51,,,,,,,,,,,,,
Chemodenervation Muscle Neck Unilat for Dystonia,CASE-64616,LOCAL,64616,CPT,,,,,,outpatient,,,5512.65,3307.59,,,,,,,,,,,,,
Excision Inferior Turbinate Partial/Complete|BILATERAL PROCEDURE,CASE-30130,LOCAL,30130,CPT,,,,,50,outpatient,,,29867.82,17920.69,,,,,,,,,,,,,
IMPLANT MALAR SUP PET 50X19X3MM RT DSGN RZ MEDPOR,SUP-2365283,CDM,C1713,HCPCS,0278,RC,,,,both,,,1500.92,975.60,,,,,,,,,,,,,
ALBUTEROL SULFATE HFA 108 (90 BASE) MCG/ACT IN AERS,RX-17837,CDM,6370000000,HCPCS,0637,RC,68180-0963-01,NDC,,both,8.5,GR,116.90,75.98,,,,,,,,,,,,,
INSTRUMENT TRAY 11 GA W/ INFLATABLE BNE TAMP KYPHON XPANDER,SUP-2293647,CDM,C1894,HCPCS,0272,RC,,,,both,,,8949.00,5816.85,,,,,,,,,,,,,
PACEMAKER CARD 24GM 14CC W59XH55MM THK6MM RESYNCH THER IS1,SUP-2356470,CDM,C2621,HCPCS,0275,RC,,,,both,,,16328.00,10613.20,,,,,,,,,,,,,
TAP SURG 35MM SCR LOK QUIK CONN PERIARTC,SUP-2198526,CDM,C1713,HCPCS,0278,RC,,,,both,,,517.47,336.36,,,,,,,,,,,,,
DEFIBRILLATOR CRD BPLR ATR VENTRIC 2 CHMBR ATLS DR V242ROPTSYS] ST JUDE MED CARDIAC RHYM MGMT],SUP-2356548,CDM,C1721,HCPCS,0275,RC,,,,both,,,58319.22,37907.49,,,,,,,,,,,,,
IMPLANT SELF REINFORCED CROSSPIN STERILE 45MM,SUP-2824428,CDM,C1713,HCPCS,0278,RC,,,,both,,,835.84,543.30,,,,,,,,,,,,,
MESH SURG 30CM LEN 5CM W 0.5MM THICKNESS STD SH SYNTH ABD,SUP-2265903,CDM,C1781,HCPCS,0278,RC,,,,both,,,117.22,76.19,,,,,,,,,,,,,
NAIL IM L255MM DIA8MM NONSTERILE DK BLU TIB TI LCK UNREAMED,SUP-2192746,CDM,C1713,HCPCS,0278,RC,,,,both,,,4211.87,2737.72,,,,,,,,,,,,,
"HC Culture Typing,Dna/Rna Sequencing",PX-3008715300,CDM,87153,CPT,0300,RC,,,,both,,,364.00,236.60,,,,,,,,,,,,,
INTRODUCER SHTH 10.5FR L12CM 0.038IN L50CM L LUMN HEMSTAS,SUP-2355412,CDM,C1894,HCPCS,0272,RC,,,,both,,,42.39,27.55,,,,,,,,,,,,,
SET INTRO PERFRMR L 13 CM DIA 9 FR DIL 20 CM GUIDEWIRE 0.038,SUP-2168241,CDM,C1894,HCPCS,0272,RC,,,,both,,,67.92,44.15,,,,,,,,,,,,,
CATHETER ATHRCTMY ROTAPRO L 135 CM BUR DIA1.25 MM CORONARY,SUP-2140853,CDM,C1724,HCPCS,0278,RC,,,,both,,,6264.30,4071.79,,,,,,,,,,,,,
PLATE BNE L63MM 3X4 H S STL T LOK COMPR OBLQ L ANG FOR,SUP-2186026,CDM,C1713,HCPCS,0278,RC,,,,both,,,996.01,647.41,,,,,,,,,,,,,
Tenolysis Extensor Tendon Hand/Finger Each,CASE-26445,LOCAL,26445,CPT,,,,,,outpatient,,,16467.32,9880.39,,,,,,,,,,,,,
Vaginal Hysterectomy Uterus 250 Gm/<,CASE-58260,LOCAL,58260,CPT,0360,RC,,,,outpatient,,,41231.12,24738.67,,,,,,,,,,,,,
Nasal/Sinus Ndsc Tot W/Frnt Sins Expl Tiss Rmvl|LEFT SIDE,CASE-31253,LOCAL,31253,CPT,0360,RC,,,LT,outpatient,,,35348.32,21208.99,,,,,,,,,,,,,
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|RIGHT HAND, FOURTH DIGIT",CASE-26160,LOCAL,26160,CPT,0360,RC,,,F8,outpatient,,,8598.17,5158.90,,,,,,,,,,,,,
Nasal/Sinus Ndsc Tot W/Frnt Sins Expl Tiss Rmvl|LEFT SIDE,CASE-31253,LOCAL,31253,CPT,,,,,LT,outpatient,,,35348.32,21208.99,,,,,,,,,,,,,
Tenolysis Extensor Tendon Hand/Finger Each,CASE-26445,LOCAL,26445,CPT,0360,RC,,,,outpatient,,,16467.32,9880.39,,,,,,,,,,,,,
Egd Transoral Biopsy Single/Multiple,CASE-43239,LOCAL,43239,CPT,0360,RC,,,,outpatient,,,10996.48,6597.89,,,,,,,,,,,,,
Egd Transoral Biopsy Single/Multiple,CASE-43239,LOCAL,43239,CPT,,,,,,outpatient,,,10996.48,6597.89,,,,,,,,,,,,,
Amputation Metatarsal W/Toe Single,CASE-28810,LOCAL,28810,CPT,0360,RC,,,,outpatient,,,28867.77,17320.66,,,,,,,,,,,,,
Egd Balloon Dilation Esophagus <30 Mm Diam,CASE-43249,LOCAL,43249,CPT,0360,RC,,,,outpatient,,,12911.92,7747.15,,,,,,,,,,,,,
Egd Balloon Dilation Esophagus <30 Mm Diam,CASE-43249,LOCAL,43249,CPT,,,,,,outpatient,,,12911.92,7747.15,,,,,,,,,,,,,
Amputation Metatarsal W/Toe Single,CASE-28810,LOCAL,28810,CPT,,,,,,outpatient,,,28867.77,17320.66,,,,,,,,,,,,,
Vaginal Hysterectomy Uterus 250 Gm/<,CASE-58260,LOCAL,58260,CPT,,,,,,outpatient,,,41231.12,24738.67,,,,,,,,,,,,,
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|RIGHT HAND, FOURTH DIGIT",CASE-26160,LOCAL,26160,CPT,,,,,F8,outpatient,,,8598.17,5158.90,,,,,,,,,,,,,
GUIDEWIRE STRAIGHT .035IN NITINOL FLEXIBLE SOLO,SUP-2655878,CDM,C1769,HCPCS,0272,RC,,,,both,,,249.03,161.87,,,,,,,,,,,,,
BUR SURG M L8MM DIA3MM RND FLUT CARB ELITE TPS,SUP-2367418,CDM,2720000010,LOCAL,0272,RC,,,,both,,,271.36,176.38,,,,,,,,,,,,,
POLARUS 3 SCREW CADDY 4.3 MM 18 46 MM,SUP-2639808,CDM,C1713,HCPCS,0278,RC,,,,both,,,1419.28,922.53,,,,,,,,,,,,,
CATHETER URET 6-10FR L50CM 2 LUMN STD ACCS W/ AQ FLEXI-TIP,SUP-2171303,CDM,C1758,HCPCS,0278,RC,,,,both,,,219.80,142.87,,,,,,,,,,,,,
ALLOGRAFT BNE CORTICAL 109X10 MM FRZN STRUT,SUP-2717909,CDM,C1762,CPT,0278,RC,,,,both,,,3831.62,2490.55,,,,,,,,,,,,,
CATHETER ANGIO STR PIG AD 4 FRX65 CM SH TEF,SUP-2301519,CDM,C1713,HCPCS,0278,RC,,,,both,,,33.76,21.94,,,,,,,,,,,,,
COLLAR CERV CNTOUR SM 18.5X3 IN 11-16 IN MED FOAM PROCARE,SUP-2196858,CDM,L0180,HCPCS,0272,RC,,,,both,,,10.71,6.96,,,,,,,,,,,,,
RELOAD REPROC STPLR REINF ENDO GIA,SUP-2365470,CDM,2720000010,LOCAL,0272,RC,,,,both,,,878.26,570.87,,,,,,,,,,,,,
CARBAMIDE PEROXIDE 6.5 % OT SOLN,RX-1359,CDM,6370000000,HCPCS,0637,RC,00904-7478-35,NDC,,both,15,ML,8.60,5.59,,,,,,,,,,,,,
DEXTROSE-SODIUM CHLORIDE 5-0.9 % IV SOLN,RX-15882,CDM,J7042,HCPCS,0250,RC,00338-0089-03,NDC,,both,500,ML,38.30,24.89,,,,,,,,,,,,,
BUR SURG CYL 4X11.3 MM 10 CM BRL SM BOR MIDAS REX 8 LEGEND,SUP-2664510,CDM,2720000010,LOCAL,0272,RC,,,,both,,,432.57,281.17,,,,,,,,,,,,,
PLATE BNE 3X8 H TI T SHP ADPT DYN COMPR FOR 1.3MM SCR,SUP-2190692,CDM,C1713,HCPCS,0278,RC,,,,both,,,1117.40,726.31,,,,,,,,,,,,,
SET INTRO FLX L 13 CM OD 7 FR ID 2.5 MM GUIDEWIRE L 40 CM,SUP-2168669,CDM,C1894,HCPCS,0272,RC,,,,both,,,138.47,90.01,,,,,,,,,,,,,
OBTURATOR ENDOSCP DISECT NS ECTRA II LTX,SUP-2877788,CDM,2720000010,LOCAL,0272,RC,,,,both,,,900.08,585.05,,,,,,,,,,,,,
SYSTEM PAIN RELF 600ML W/ SEL A FLO 2-14ML/HR ON-Q,SUP-2236813,CDM,C9804,HCPCS,0272,RC,,,,both,,,989.10,642.91,,,,,,,,,,,,,
BIT DRL OD42MM CALIB FOR RADLUC TARGET DEV,SUP-2371642,CDM,2720000010,LOCAL,0272,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
Enteroscopy > 2nd Prtn W/Control Bleeding,CASE-44366,LOCAL,44366,CPT,0360,RC,,,,outpatient,,,11795.50,7077.30,,,,,,,,,,,,,
Enteroscopy > 2nd Prtn W/Control Bleeding,CASE-44366,LOCAL,44366,CPT,,,,,,outpatient,,,11795.50,7077.30,,,,,,,,,,,,,
Arthrd Ant Interdy Cervcl Belw C2 Ea Addl Ntrspc,CASE-22552,LOCAL,22552,CPT,,,,,,outpatient,,,75684.82,45410.89,,,,,,,,,,,,,
Insj Biomchn Dev Intervertebral Dsc Spc W/Arthrd,CASE-22853,LOCAL,22853,CPT,0360,RC,,,,outpatient,,,76377.03,45826.22,,,,,,,,,,,,,
Insj Biomchn Dev Intervertebral Dsc Spc W/Arthrd,CASE-22853,LOCAL,22853,CPT,,,,,,outpatient,,,76377.03,45826.22,,,,,,,,,,,,,
Arthrd Ant Interdy Cervcl Belw C2 Ea Addl Ntrspc,CASE-22552,LOCAL,22552,CPT,0360,RC,,,,outpatient,,,75684.82,45410.89,,,,,,,,,,,,,
LEVEL 1 THOR STERILEPLATE RIB LCK Z SHP2.3 MM SCREW12 H,SUP-2262531,CDM,C1713,HCPCS,0278,RC,,,,both,,,2778.59,1806.08,,,,,,,,,,,,,
SCREW BONE L20MM KNEE TIB M/G,SUP-2200344,CDM,C1713,HCPCS,0278,RC,,,,both,,,630.51,409.83,,,,,,,,,,,,,
HC Iaadiadoo Influenza,PX-3068780400,CDM,87804,CPT,0306,RC,,,,both,,,225.00,146.25,,,,,,,,,,,,,
CATHETER ELECTROPHYSIOLOGY SUPREME 120CM 4FR COURNAND QPLR,SUP-2487482,CDM,C1730,HCPCS,0272,RC,,,,both,,,168.87,109.77,,,,,,,,,,,,,
COMPONENT TOT HIP CAPPED UPCHARGE STEM EPOCH II,SUP-2212678,CDM,C1776,CPT,0278,RC,,,,both,,,2511.97,1632.78,,,,,,,,,,,,,
TUBE TRACH AD L80MM OD10MM ID7MM SIL CUF W TLK ATTCH MID,SUP-2352453,CDM,2720000010,LOCAL,0272,RC,,,,both,,,408.20,265.33,,,,,,,,,,,,,
PACK PROC 6FT IVTM DISPOSABLE STRT UP KT COOL LN,SUP-2416137,CDM,C1751,HCPCS,0278,RC,,,,both,,,8932.17,5805.91,,,,,,,,,,,,,
COVER BUR H DIA22MM TI FOR CRAN CLSR SYS,SUP-2243979,CDM,C1713,HCPCS,0278,RC,,,,both,,,540.27,351.18,,,,,,,,,,,,,
SUBSTITUTE BONE GRFT 2.5ML 100 DEMIN BONE MTRX PUTTY,SUP-2319808,CDM,C9359,HCPCS,0278,RC,,,,both,,,2778.90,1806.28,,,,,,,,,,,,,
PORT IMPL INFUSION LIFEPORT 11.4 FR TI,SUP-2332934,CDM,C1788,HCPCS,0278,RC,,,,both,,,2562.24,1665.46,,,,,,,,,,,,,
CATHETER ETER THOR 12FR L16IN POLYVI CHL 4 EYELET STR ATRAUM,SUP-2266021,CDM,C1729,HCPCS,0272,RC,,,,both,,,233.33,151.66,,,,,,,,,,,,,
CONNECTOR SPNL HD OFFSET 36 MM CREO 5.5,SUP-2731844,CDM,C1713,HCPCS,0278,RC,,,,both,,,1334.50,867.42,,,,,,,,,,,,,
SCREW BONE PED L14MM DIA4.5MM LT RT CORT PROX FEM S STL ST,SUP-2318573,CDM,C1713,HCPCS,0278,RC,,,,both,,,218.61,142.10,,,,,,,,,,,,,
Rpr Aa Hernia Recr 3-10 Cm Reducible,CASE-49615,LOCAL,49615,CPT,,,,,,outpatient,,,73864.80,44318.88,,,,,,,,,,,,,
Colsc Flexible W/Transendoscopic Balloon Dilat,CASE-45386,LOCAL,45386,CPT,0360,RC,,,,outpatient,,,11387.78,6832.67,,,,,,,,,,,,,
Laps Tx Ectopic Preg W/Salping&/Oophorectomy,CASE-59151,LOCAL,59151,CPT,0360,RC,,,,outpatient,,,27645.47,16587.28,,,,,,,,,,,,,
Allograft for Spine Surgery Only Morselized,CASE-20930,LOCAL,20930,CPT,,,,,,outpatient,,,77624.35,46574.61,,,,,,,,,,,,,
Unlisted Laparoscopy Procedure Oviduct Ovary,CASE-58679,LOCAL,58679,CPT,0360,RC,,,,outpatient,,,43914.88,26348.93,,,,,,,,,,,,,
Colsc Flexible W/Transendoscopic Balloon Dilat,CASE-45386,LOCAL,45386,CPT,,,,,,outpatient,,,11387.78,6832.67,,,,,,,,,,,,,
Sphincterotomy Anal Division Sphincter Spx,CASE-46080,LOCAL,46080,CPT,0360,RC,,,,outpatient,,,10656.32,6393.79,,,,,,,,,,,,,
Sphincterotomy Anal Division Sphincter Spx,CASE-46080,LOCAL,46080,CPT,,,,,,outpatient,,,10656.32,6393.79,,,,,,,,,,,,,
Laps Tx Ectopic Preg W/Salping&/Oophorectomy,CASE-59151,LOCAL,59151,CPT,,,,,,outpatient,,,27645.47,16587.28,,,,,,,,,,,,,
Allograft for Spine Surgery Only Morselized,CASE-20930,LOCAL,20930,CPT,0360,RC,,,,outpatient,,,77624.35,46574.61,,,,,,,,,,,,,
Rpr Aa Hernia Recr 3-10 Cm Reducible,CASE-49615,LOCAL,49615,CPT,0360,RC,,,,outpatient,,,73864.80,44318.88,,,,,,,,,,,,,
Unlisted Laparoscopy Procedure Oviduct Ovary,CASE-58679,LOCAL,58679,CPT,,,,,,outpatient,,,43914.88,26348.93,,,,,,,,,,,,,
DRESSING WND BIO FISH SKIN FENSTRTED 3CM X 3.5CM RSFH ONLY,SUP-2859689,CDM,Q4158,HCPCS,0636,RC,,,,both,,,2103.49,1367.27,,,,,,,,,,,,,
PIN BNE FIX DIA 0.125 IN HDD THRD NS VANGUARD XP 2/PK,SUP-2887772,CDM,2720000010,LOCAL,0272,RC,,,,both,,,353.25,229.61,,,,,,,,,,,,,
SIMETHICONE 125 MG PO CHEW,RX-7226,CDM,6370000000,HCPCS,0637,RC,69618-0032-06,NDC,,both,1,UN,0.50,0.32,,,,,,,,,,,,,
PLATE BNE RECON 2.7X3 MM 36 HOLE ANGLED-ANGLED LCK TI NS,SUP-2486414,CDM,C1713,HCPCS,0278,RC,,,,both,,,7792.44,5065.09,,,,,,,,,,,,,
SPHINCTEROTOME ENDO L200CM OD7FR 4.2MM MFIL PUR CONN DOME,SUP-2170077,CDM,2720000010,LOCAL,0272,RC,,,,both,,,747.32,485.76,,,,,,,,,,,,,
PASSER SUT 45DEG L W/ SM PUNC FOOTPRINT SGL PORTAL PVT,SUP-2366736,CDM,2720000010,LOCAL,0272,RC,,,,both,,,857.22,557.19,,,,,,,,,,,,,
ROD EXT FIX L200MM DIA11MM C FBR MAG RESONANCE CONDITIONAL,SUP-2188654,CDM,2720000010,LOCAL,0272,RC,,,,both,,,594.34,386.32,,,,,,,,,,,,,
KIT DISINFECTION NOW TEST,SUP-2765073,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1271.70,826.60,,,,,,,,,,,,,
Egd Percutaneous Placement Gastrostomy Tube,CASE-43246,LOCAL,43246,CPT,,,,,,outpatient,,,11157.78,6694.67,,,,,,,,,,,,,
Tnot Elbow Lateral/Medial Debride Open Tdn Rpr|LEFT SIDE,CASE-24359,LOCAL,24359,CPT,,,,,LT,outpatient,,,17937.10,10762.26,,,,,,,,,,,,,
Surgical Arthroscopy Shoulder Biceps Tenodesis|RIGHT SIDE,CASE-29828,LOCAL,29828,CPT,,,,,RT,outpatient,,,55001.43,33000.86,,,,,,,,,,,,,
Tnot Elbow Lateral/Medial Debride Open Tdn Rpr|LEFT SIDE,CASE-24359,LOCAL,24359,CPT,0360,RC,,,LT,outpatient,,,17937.10,10762.26,,,,,,,,,,,,,
Egd Percutaneous Placement Gastrostomy Tube,CASE-43246,LOCAL,43246,CPT,0360,RC,,,,outpatient,,,11157.78,6694.67,,,,,,,,,,,,,
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 1 Level,CASE-64493,LOCAL,64493,CPT,,,,,,outpatient,,,3988.28,2392.97,,,,,,,,,,,,,
Surgical Arthroscopy Shoulder Biceps Tenodesis|RIGHT SIDE,CASE-29828,LOCAL,29828,CPT,0360,RC,,,RT,outpatient,,,55001.43,33000.86,,,,,,,,,,,,,
Conization Cervix W/WO D&C Rpr Eltrd Exc,CASE-57522,LOCAL,57522,CPT,,,,,,outpatient,,,18118.53,10871.12,,,,,,,,,,,,,
Conization Cervix W/WO D&C Rpr Eltrd Exc,CASE-57522,LOCAL,57522,CPT,0360,RC,,,,outpatient,,,18118.53,10871.12,,,,,,,,,,,,,
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 1 Level,CASE-64493,LOCAL,64493,CPT,0360,RC,,,,outpatient,,,3988.28,2392.97,,,,,,,,,,,,,
HC Joint Injection/Aspir Large WO US|DISTINCT PROCEDURAL SERVICE|RIGHT SIDE|PBB CHARGE,CASE-20610,LOCAL,20610,CPT,0510,RC,,,59|RT|PBB,outpatient,,,3935.75,2361.45,,,,,,,,,,,,,
RELOAD STPL L60MM EXTRA THCK REINF FOR SIGNIA STPLR,SUP-2283377,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1877.06,1220.09,,,,,,,,,,,,,
PLATE 3.5MM TI CURVED NARROW LCP 16 HOLE-STERILE,SUP-2546921,CDM,C1713,HCPCS,0278,RC,,,,both,,,2911.09,1892.21,,,,,,,,,,,,,
ELECTRODE ELECSURG BND 30 DEG 24 FR HF RESECT CLINCH UROLOGY,SUP-2478335,CDM,2720000010,LOCAL,0272,RC,,,,both,,,828.71,538.66,,,,,,,,,,,,,
CATHETER ATRSEPTSTMY Z-5 L 50 CM DIA 5 FR BALLOON L 1.35 CM,SUP-2125231,CDM,C1725,HCPCS,0272,RC,,,,both,,,994.85,646.65,,,,,,,,,,,,,
ENDOGRAFT VASC ZENITH ALPHA L 217 MM DIA 38 MM SHTH 18 FR,SUP-2170244,CDM,C1874,HCPCS,0278,RC,,,,both,,,48670.00,31635.50,,,,,,,,,,,,,
NAIL IM L180MM DIA11MM 130DEG LNG HIP TIM CANN LOK FOR AG,SUP-2413331,CDM,C1713,HCPCS,0278,RC,,,,both,,,3127.44,2032.84,,,,,,,,,,,,,
CATHETER REPROC EP 4FRX120CM JSN 4-ELECTRD 5-5-5MM,SUP-2653049,CDM,C1730,HCPCS,0272,RC,,,,both,,,146.20,95.03,,,,,,,,,,,,,
Rpr Aa Hernia Recr > 10 Cm Reducible,CASE-49617,LOCAL,49617,CPT,,,,,,outpatient,,,109529.25,65717.55,,,,,,,,,,,,,
Rpr Aa Hernia Recr > 10 Cm Reducible,CASE-49617,LOCAL,49617,CPT,0360,RC,,,,outpatient,,,109529.25,65717.55,,,,,,,,,,,,,
Prq Impltj Neurostim Eltrd Sacral Nrve W/Imaging,CASE-64561,LOCAL,64561,CPT,0360,RC,,,,outpatient,,,38683.77,23210.26,,,,,,,,,,,,,
Esophagogastroduodenoscopy Submucosal Injection|SEPARATE STRUCTURE,CASE-43236,LOCAL,43236,CPT,,,,,XS,outpatient,,,13005.62,7803.37,,,,,,,,,,,,,
Prq Impltj Neurostim Eltrd Sacral Nrve W/Imaging,CASE-64561,LOCAL,64561,CPT,,,,,,outpatient,,,38683.77,23210.26,,,,,,,,,,,,,
Esophagogastroduodenoscopy Submucosal Injection|SEPARATE STRUCTURE,CASE-43236,LOCAL,43236,CPT,0360,RC,,,XS,outpatient,,,13005.62,7803.37,,,,,,,,,,,,,
"Arthrodesis Interphalangeal Jt W/WO Int Fixj|LEFT HAND, FOURTH DIGIT",CASE-26860,LOCAL,26860,CPT,,,,,F3,outpatient,,,20970.25,12582.15,,,,,,,,,,,,,
Cysto Bladder W/Ureteral Catheterization|UNUSUAL NON-OVERLAPPING SERVICE,CASE-52005,LOCAL,52005,CPT,0360,RC,,,XU,outpatient,,,36825.12,22095.07,,,,,,,,,,,,,
"Open Tx Distal Phalangeal Fracture Each|LEFT HAND, FIFTH DIGIT",CASE-26765,LOCAL,26765,CPT,,,,,F4,outpatient,,,15892.37,9535.42,,,,,,,,,,,,,
Cysto Bladder W/Ureteral Catheterization|UNUSUAL NON-OVERLAPPING SERVICE,CASE-52005,LOCAL,52005,CPT,,,,,XU,outpatient,,,36825.12,22095.07,,,,,,,,,,,,,
HC Injection Small Joint/Bursa|PBB CHARGE,CASE-20600,LOCAL,20600,CPT,0361,RC,,,PBB,outpatient,,,677.08,406.25,,,,,,,,,,,,,
"Arthrodesis Interphalangeal Jt W/WO Int Fixj|LEFT HAND, FOURTH DIGIT",CASE-26860,LOCAL,26860,CPT,0360,RC,,,F3,outpatient,,,20970.25,12582.15,,,,,,,,,,,,,
"Open Tx Distal Phalangeal Fracture Each|LEFT HAND, FIFTH DIGIT",CASE-26765,LOCAL,26765,CPT,0360,RC,,,F4,outpatient,,,15892.37,9535.42,,,,,,,,,,,,,
Arthrs Kne Surg W/Meniscectomy Med/Lat W/Shvg|RIGHT SIDE,CASE-29881,LOCAL,29881,CPT,0360,RC,,,RT,outpatient,,,26636.02,15981.61,,,,,,,,,,,,,
Arthrs Kne Surg W/Meniscectomy Med/Lat W/Shvg|RIGHT SIDE,CASE-29881,LOCAL,29881,CPT,,,,,RT,outpatient,,,26636.02,15981.61,,,,,,,,,,,,,
ALLOGRAFT BNE SPACER 8 23-27X11 MM FRZN NAR LORDTC ANTR FRA,SUP-2736759,CDM,C1713,HCPCS,0278,RC,,,,both,,,11740.15,7631.10,,,,,,,,,,,,,
GUIDEWIRE VASC HIWIRE L 260 CM DIA 0.038 IN TAPR L 22 CM,SUP-2170352,CDM,C1769,HCPCS,0272,RC,,,,both,,,584.29,379.79,,,,,,,,,,,,,
CATHETER GUID MERCI V 2.0 L 180 CM BALLOON L 5 MM DIA2 MM SS,SUP-2367776,CDM,C1773,HCPCS,0272,RC,,,,both,,,9734.00,6327.10,,,,,,,,,,,,,
SHELL ACET OD60MM UNIV HA POR PLSM SPRY HIP REV PRESSFIT,SUP-2408351,CDM,C1776,CPT,0278,RC,,,,both,,,12409.28,8066.03,,,,,,,,,,,,,
PLATE BNE W15XL120MM THK2MM 5 H BILAT S STL COVERLEAF RIG,SUP-2186007,CDM,C1713,HCPCS,0278,RC,,,,both,,,1582.62,1028.70,,,,,,,,,,,,,
PROCEDURE KIT PRB KNOT PUSH SUTURE CUT INTRO CROSSFIX II,SUP-2402628,CDM,C1713,HCPCS,0278,RC,,,,both,,,392.50,255.12,,,,,,,,,,,,,
PLATE BONE L34MM 4 H RIG EDC FOR 2.4MM SCR,SUP-2319391,CDM,C1713,HCPCS,0278,RC,,,,both,,,734.76,477.59,,,,,,,,,,,,,
HC Strapping of Toes,PX-4502955000,CDM,29550,CPT,0450,RC,,,,both,,,109.00,70.85,,,,,,,,,,,,,
HEAD FEM REV MTL ON POLY CO CHROM 32MM DIA +16 NK LEN LFIT,SUP-2364463,CDM,C1776,CPT,0278,RC,,,,both,,,1170.59,760.88,,,,,,,,,,,,,
GRAFT HUM TISS OD43MM FEM HD OSTEOARTC ALLGRFT FRZN,SUP-2264751,CDM,C1713,HCPCS,0278,RC,,,,both,,,3444.11,2238.67,,,,,,,,,,,,,
PLATE BNE TBLR 2.7X65 MM 8 HOLE 1/4 TI,SUP-2536112,CDM,C1713,HCPCS,0278,RC,,,,both,,,446.19,290.02,,,,,,,,,,,,,
PLATE BNE 3.5X157 MM 12 HOLE SS LCP,SUP-2569325,CDM,C1713,HCPCS,0278,RC,,,,both,,,466.29,303.09,,,,,,,,,,,,,
Laparoscopy W/Rmvl Adnexal Structures|RIGHT SIDE,CASE-58661,LOCAL,58661,CPT,,,,,RT,outpatient,,,39086.40,23451.84,,,,,,,,,,,,,
"Amputation Toe Interphalangeal Joint|RIGHT FOOT, SECOND DIGIT",CASE-28825,LOCAL,28825,CPT,0360,RC,,,T6,outpatient,,,14858.67,8915.20,,,,,,,,,,,,,
Revision of Reconstructed Breast|BILATERAL PROCEDURE,CASE-19380,LOCAL,19380,CPT,0360,RC,,,50,outpatient,,,45815.47,27489.28,,,,,,,,,,,,,
Laparoscopy W/Rmvl Adnexal Structures|RIGHT SIDE,CASE-58661,LOCAL,58661,CPT,0360,RC,,,RT,outpatient,,,39086.40,23451.84,,,,,,,,,,,,,
"Amputation Toe Interphalangeal Joint|RIGHT FOOT, SECOND DIGIT",CASE-28825,LOCAL,28825,CPT,,,,,T6,outpatient,,,14858.67,8915.20,,,,,,,,,,,,,
Revision of Reconstructed Breast|BILATERAL PROCEDURE,CASE-19380,LOCAL,19380,CPT,,,,,50,outpatient,,,45815.47,27489.28,,,,,,,,,,,,,
STAPLE BNE FIX W18XL18MM LEG L18MM SPD TI W/O STP,SUP-2194267,CDM,C1713,HCPCS,0278,RC,,,,both,,,3186.16,2071.00,,,,,,,,,,,,,
GRAFT CV 1525X1525MM PLEDG PTFE SFT ST,SUP-2384072,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1043.01,677.96,,,,,,,,,,,,,
RELOAD STPL LD UNIT 30 MM 2 MM VASC TISS TRISTAPLE DISP,SUP-2283351,CDM,C1713,HCPCS,0278,RC,,,,both,,,1570.00,1020.50,,,,,,,,,,,,,
GRAFT EVAR L70MM DIA23X23MM C DST DSGN FOR ABD AORT ANEUR,SUP-2295270,CDM,C1768,CPT,0278,RC,,,,both,,,23471.50,15256.47,,,,,,,,,,,,,
GRAFT BNE 150X11 MM BLLST 021100000,SUP-2644295,CDM,C1713,HCPCS,0278,RC,,,,both,,,7536.00,4898.40,,,,,,,,,,,,,
PROTAMINE SULFATE 10 MG/ML IV SOLN,RX-6677,CDM,J2720,HCPCS,0636,RC,63323-0229-05,NDC,,both,1,ML,54.10,35.16,,,,,,,,,,,,,
FIBER LASER HOLM 273 M FOR USE W/ H-30 RED SMARTSYNC DISP,SUP-2835945,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1232.04,800.83,,,,,,,,,,,,,
PLATE BONE L40MM THK0.3MM 10 H CRANIOMAXILLOFACIAL TI CVD,SUP-2136523,CDM,C1713,HCPCS,0278,RC,,,,both,,,449.02,291.86,,,,,,,,,,,,,
LIGATOR OD8.5-9.2MM 122CMXSM TAMP TRIG CRD MULT BND BRL,SUP-2169551,CDM,C1713,HCPCS,0278,RC,,,,both,,,874.02,568.11,,,,,,,,,,,,,
NAIL IM 8X300 MM TIB TI STRL EXPERT,SUP-2179812,CDM,C1713,HCPCS,0278,RC,,,,both,,,3809.45,2476.14,,,,,,,,,,,,,
NAIL GAM 3 LNG 120DEG 10X360MM ST,SUP-2703241,CDM,C1713,HCPCS,0278,RC,,,,both,,,8694.66,5651.53,,,,,,,,,,,,,
CATHETER CARD ABLATION NAVISTAR L 115 CM 7FR 4MM C CRV SFT,SUP-2248471,CDM,C1732,HCPCS,0272,RC,,,,both,,,0.03,0.02,,,,,,,,,,,,,
HC Biopsy/Exc Lymph Node Needle,CASE-38505,LOCAL,38505,CPT,0361,RC,,,,outpatient,,,10382.77,6229.66,,,,,,,,,,,,,
Brnschsc Tndsc Ebus Dx/Tx Intervention Perph Les,CASE-31654,LOCAL,31654,CPT,,,,,,outpatient,,,40321.40,24192.84,,,,,,,,,,,,,
Brnschsc Tndsc Ebus Dx/Tx Intervention Perph Les,CASE-31654,LOCAL,31654,CPT,0360,RC,,,,outpatient,,,40321.40,24192.84,,,,,,,,,,,,,
ROD SPNL L500MM DIA6.35MM S STL HEX LINKED,SUP-2293084,CDM,C1713,HCPCS,0278,RC,,,,both,,,1181.74,768.13,,,,,,,,,,,,,
REAMER CONIC 1 STP FOR GAM 3 NAILING SYS,SUP-2361609,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2577.31,1675.25,,,,,,,,,,,,,
TISSUE CLOSURE KIT 4.5 MM PNCH PROX,SUP-2102275,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1413.00,918.45,,,,,,,,,,,,,
JOINT TOE INSTRUMENT KT MED K WIRE MARKED DRL BIT OSSIOFIBER,SUP-2641890,CDM,2720000010,LOCAL,0272,RC,,,,both,,,471.00,306.15,,,,,,,,,,,,,
INSERT TIB SZ 1 THICKNESS 11MM KNEE SL IMP MOST OPTIONS,SUP-2208281,CDM,C1776,CPT,0278,RC,,,,both,,,6415.02,4169.76,,,,,,,,,,,,,
PLATE BNE L155MM 9 H L PROX PERIARTC ULNA LOK,SUP-2198454,CDM,C1713,HCPCS,0278,RC,,,,both,,,2504.59,1627.98,,,,,,,,,,,,,
ANCHOR SUT L7.5MM DIA2.4MM W/ 2-0 FIBERWIRE 17.4MM 3/8 CIR,SUP-2121010,CDM,C1713,HCPCS,0278,RC,,,,both,,,832.10,540.86,,,,,,,,,,,,,
HC So B Burgdorferi Amplified Probe,PX-3068747666,CDM,87476,CPT,0306,RC,,,,both,,,201.00,130.65,,,,,,,,,,,,,
PLATE BNE L109MM 9 H S STL 1/3 TBLR W/ CLLR LIMIT CNTCT DYN,SUP-2185935,CDM,C1713,HCPCS,0278,RC,,,,both,,,509.12,330.93,,,,,,,,,,,,,
BUR SURG DIA 3.1 MM HUB XLII DIAMOND STRL REUSE HI-LINE,SUP-2928897,CDM,2720000010,LOCAL,0272,RC,,,,both,,,774.07,503.15,,,,,,,,,,,,,
WASHER SFT TISS OD35MM 6.25MM BIO-POST,SUP-2121117,CDM,C1713,HCPCS,0278,RC,,,,both,,,1212.04,787.83,,,,,,,,,,,,,
CATHETER CV SET 032 7 FRX25 CM 3L POLYETH,SUP-2760144,CDM,C1751,HCPCS,0278,RC,,,,both,,,234.93,152.70,,,,,,,,,,,,,
Revj/Rmvl Perph Neurostimulator Electrode Array,CASE-64585,LOCAL,64585,CPT,0360,RC,,,,outpatient,,,58501.13,35100.68,,,,,,,,,,,,,
Rpr Aa Hernia 1st > 10 Cm Ncrc8/Strangulated,CASE-49596,LOCAL,49596,CPT,0360,RC,,,,outpatient,,,79132.93,47479.76,,,,,,,,,,,,,
Revj/Rmvl Perph Neurostimulator Electrode Array,CASE-64585,LOCAL,64585,CPT,,,,,,outpatient,,,58501.13,35100.68,,,,,,,,,,,,,
Open Tx Metacarpal Fracture Single Ea Bone|RIGHT SIDE,CASE-26615,LOCAL,26615,CPT,,,,,RT,outpatient,,,23867.32,14320.39,,,,,,,,,,,,,
Laps Surg W/Aspir Cavity/Cyst Single/Multiple,CASE-49322,LOCAL,49322,CPT,,,,,,outpatient,,,29815.45,17889.27,,,,,,,,,,,,,
Laps Surg W/Aspir Cavity/Cyst Single/Multiple,CASE-49322,LOCAL,49322,CPT,0360,RC,,,,outpatient,,,29815.45,17889.27,,,,,,,,,,,,,
HC Inj Anesth Celiac Plexus,CASE-64530,LOCAL,64530,CPT,0361,RC,,,,outpatient,,,7853.18,4711.91,,,,,,,,,,,,,
Rpr Aa Hernia 1st > 10 Cm Ncrc8/Strangulated,CASE-49596,LOCAL,49596,CPT,,,,,,outpatient,,,79132.93,47479.76,,,,,,,,,,,,,
Open Tx Metacarpal Fracture Single Ea Bone|RIGHT SIDE,CASE-26615,LOCAL,26615,CPT,0360,RC,,,RT,outpatient,,,23867.32,14320.39,,,,,,,,,,,,,
HEAD HUM DIA50MM THK21MM SHLDR CO CHROM PRI STD OFFSET NK,SUP-2372842,CDM,C1776,CPT,0278,RC,,,,both,,,2904.69,1888.05,,,,,,,,,,,,,
PLATE BONE THK1.25MM 12 H CRANIOMAXILLOFACIAL ORAL SLV TI,SUP-2181778,CDM,C1713,HCPCS,0278,RC,,,,both,,,2642.00,1717.30,,,,,,,,,,,,,
HANDPIECE SEAL 44X5CM VES PSTL GRP LIGASURE ADV,SUP-2174894,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1938.95,1260.32,,,,,,,,,,,,,
CLIP ANEURYSM SUNDTKEES 15MM BAYONET 201659,SUP-2844598,CDM,C1889,HCPCS,0278,RC,,,,both,,,656.26,426.57,,,,,,,,,,,,,
SCREW BNE HDLSS TH SER 3 X 16 MM TI,SUP-2244461,CDM,C1713,HCPCS,0278,RC,,,,both,,,1023.73,665.42,,,,,,,,,,,,,
MESH CRAN L 81.28 X W 72.39 MM THK 0.3 MM SCREW DIA1.5 MM SZ,SUP-2936145,CDM,C1713,HCPCS,0278,RC,,,,both,,,15725.12,10221.33,,,,,,,,,,,,,
HC So Thyroglobin Ab,PX-3028680068,CDM,86800,CPT,0302,RC,,,,both,,,32.00,20.80,,,,,,,,,,,,,
DEFIBRILLATOR IMPL IPERIA 7 HF-T W 56 X H 65 MM D 11 MM 40 J,SUP-2138368,CDM,C1882,HCPCS,0275,RC,,,,both,,,53380.00,34697.00,,,,,,,,,,,,,
LEVOFLOXACIN 5 MG/ML IVPB (PED) >/= 50 ML,RX-4090161,CDM,2500000003,HCPCS,0250,RC,00143-9721-24,NDC,,both,50,ML,54.10,35.16,,,,,,,,,,,,,
PORT INFUS 8FR PWR INJ CT FOR VASC ACCS CATH,SUP-2126607,CDM,C1788,HCPCS,0278,RC,,,,both,,,558.92,363.30,,,,,,,,,,,,,
GRAFT BONE SUB 10ML DBM PUTTY IRRADIATED SYR,SUP-2293910,CDM,C1713,HCPCS,0278,RC,,,,both,,,2719.24,1767.51,,,,,,,,,,,,,
"Arthrt Expl Drg/Rmvl Loose/FB Iphal Jt Ea|RIGHT HAND, THIRD DIGIT",CASE-26080,LOCAL,26080,CPT,,,,,F7,outpatient,,,15095.27,9057.16,,,,,,,,,,,,,
"Arthrt Expl Drg/Rmvl Loose/FB Iphal Jt Ea|RIGHT HAND, THIRD DIGIT",CASE-26080,LOCAL,26080,CPT,0360,RC,,,F7,outpatient,,,15095.27,9057.16,,,,,,,,,,,,,
Colpopexy Vaginal Intraperitoneal Approach|UNUSUAL NON-OVERLAPPING SERVICE,CASE-57283,LOCAL,57283,CPT,,,,,XU,outpatient,,,30376.43,18225.86,,,,,,,,,,,,,
Cysto W/Insert Ureteral Stent,CASE-52332,LOCAL,52332,CPT,,,,,,outpatient,,,13647.70,8188.62,,,,,,,,,,,,,
Cysto W/Insert Ureteral Stent,CASE-52332,LOCAL,52332,CPT,0360,RC,,,,outpatient,,,13647.70,8188.62,,,,,,,,,,,,,
Arthrs Aid Tibial Fx Prox Unicondylar Bicondylar,CASE-29856,LOCAL,29856,CPT,,,,,,outpatient,,,53650.95,32190.57,,,,,,,,,,,,,
"Prq Skel Fixj Phlngl Shft Fx Prox/Middle Px/F/T|RIGHT HAND, FIFTH DIGIT",CASE-26727,LOCAL,26727,CPT,0360,RC,,,F9,outpatient,,,13007.85,7804.71,,,,,,,,,,,,,
"Prq Skel Fixj Phlngl Shft Fx Prox/Middle Px/F/T|RIGHT HAND, FIFTH DIGIT",CASE-26727,LOCAL,26727,CPT,,,,,F9,outpatient,,,13007.85,7804.71,,,,,,,,,,,,,
Arthrs Aid Tibial Fx Prox Unicondylar Bicondylar,CASE-29856,LOCAL,29856,CPT,0360,RC,,,,outpatient,,,53650.95,32190.57,,,,,,,,,,,,,
Bx/Exc Lymph Node Open Deep Cervical Node|LEFT SIDE,CASE-38510,LOCAL,38510,CPT,0360,RC,,,LT,outpatient,,,41644.80,24986.88,,,,,,,,,,,,,
Laparoscopy Surg W/Bx Single/Multiple,CASE-49321,LOCAL,49321,CPT,,,,,,outpatient,,,34689.30,20813.58,,,,,,,,,,,,,
Bx/Exc Lymph Node Open Deep Cervical Node|LEFT SIDE,CASE-38510,LOCAL,38510,CPT,,,,,LT,outpatient,,,41644.80,24986.88,,,,,,,,,,,,,
Laparoscopy Surg W/Bx Single/Multiple,CASE-49321,LOCAL,49321,CPT,0360,RC,,,,outpatient,,,34689.30,20813.58,,,,,,,,,,,,,
Arthrs Wrst Exc&/Rpr Triang Fibrocart&/Joint,CASE-29846,LOCAL,29846,CPT,0360,RC,,,,outpatient,,,26472.32,15883.39,,,,,,,,,,,,,
Arthrs Wrst Exc&/Rpr Triang Fibrocart&/Joint,CASE-29846,LOCAL,29846,CPT,,,,,,outpatient,,,26472.32,15883.39,,,,,,,,,,,,,
HC Joint Injection/Aspir Large WO US|LEFT SIDE|PBB CHARGE,CASE-20610,LOCAL,20610,CPT,0510,RC,,,LT|PBB,outpatient,,,1504.75,902.85,,,,,,,,,,,,,
Colpopexy Vaginal Intraperitoneal Approach|UNUSUAL NON-OVERLAPPING SERVICE,CASE-57283,LOCAL,57283,CPT,0360,RC,,,XU,outpatient,,,30376.43,18225.86,,,,,,,,,,,,,
HC Declotting Central Vad,PX-3613659300,CDM,36593,CPT,0361,RC,,,,inpatient,,,1120.00,728.00,,,,,,,,,,,,,
BUR SURG TOT L 72 MM CUT L 13 MM DIA 4.3 MM WDG AO STRL LF,SUP-2881101,CDM,2720000010,LOCAL,0272,RC,,,,both,,,832.73,541.27,,,,,,,,,,,,,
KWIRE FIX L230MM DIA23MM SMOOTH SGL END TRCR,SUP-2321625,CDM,C1713,HCPCS,0278,RC,,,,both,,,87.04,56.58,,,,,,,,,,,,,
PATCH AMNION 2 LAYR PROTCT 4 X 8CM STERISHIELD II,SUP-2138666,CDM,C1762,CPT,0278,RC,,,,both,,,7366.44,4788.19,,,,,,,,,,,,,
PLATE BNE L 117 MM SCREW DIA 3.5 MM 8 H RT MEDL PROX TIB,SUP-2931258,CDM,C1713,HCPCS,0278,RC,,,,both,,,8802.36,5721.53,,,,,,,,,,,,,
PLATE BONE L120MM 5 H BILAT TI SPN LCK COMPR LO PROF RIG FOR,SUP-2190888,CDM,C1713,HCPCS,0278,RC,,,,both,,,1164.25,756.76,,,,,,,,,,,,,
INTRODUCER SHTH 6FR L5CM DBL DSTL GWIRE L50CM 0.038IN,SUP-2355427,CDM,C1894,HCPCS,0272,RC,,,,both,,,32.97,21.43,,,,,,,,,,,,,
BUR SURG DIA3MM RND FLUT CUT ELITE,SUP-2367545,CDM,C1713,HCPCS,0278,RC,,,,both,,,408.45,265.49,,,,,,,,,,,,,
CATHETER HD LT 10 FRX52 CM 22-25 CM ART CUF SET STYL TESIO,SUP-2627151,CDM,C1750,HCPCS,0278,RC,,,,both,,,929.44,604.14,,,,,,,,,,,,,
INFINITY EVERLAST SZ 2 8MM TOTAL ANKLE,SUP-2822432,CDM,C1776,CPT,0278,RC,,,,both,,,5878.08,3820.75,,,,,,,,,,,,,
Tr/Trnspl Tdn Carp/Mtcrpl Hand W/O Fr Grf Ea Tdn,CASE-26480,LOCAL,26480,CPT,0360,RC,,,,outpatient,,,27877.25,16726.35,,,,,,,,,,,,,
Arthrs Knee Abrasion Arthrp/Mlt Drlg/Microfx|LEFT SIDE,CASE-29879,LOCAL,29879,CPT,0360,RC,,,LT,outpatient,,,26225.77,15735.46,,,,,,,,,,,,,
Arthrs Knee Abrasion Arthrp/Mlt Drlg/Microfx|LEFT SIDE,CASE-29879,LOCAL,29879,CPT,,,,,LT,outpatient,,,26225.77,15735.46,,,,,,,,,,,,,
Tr/Trnspl Tdn Carp/Mtcrpl Hand W/O Fr Grf Ea Tdn,CASE-26480,LOCAL,26480,CPT,,,,,,outpatient,,,27877.25,16726.35,,,,,,,,,,,,,
HC Drain/Inj Joint/Bursa W/US Large|LEFT SIDE,CASE-20611,LOCAL,20611,CPT,0510,RC,,,LT,outpatient,,,4089.47,2453.68,,,,,,,,,,,,,
HC Anterior Epitaxis Simple|RIGHT SIDE,CASE-30901,LOCAL,30901,CPT,0450,RC,,,RT,outpatient,,,15328.73,9197.24,,,,,,,,,,,,,
SYSTEM IMPL FOREFOOT PEEK W/ 3X8MM TENODESIS SCR OBLONG,SUP-2121329,CDM,C1776,CPT,0278,RC,,,,both,,,4380.30,2847.19,,,,,,,,,,,,,
HC Inject Tendon Sheath Ligament,PX-3612055000,CDM,20550,CPT,0361,RC,,,,both,,,1485.00,965.25,,,,,,,,,,,,,
GRAFT HUM TISS W2XL2CM THK45UM AMNIO MEMBRN DEHYDR OMNI DIR,SUP-2340451,CDM,C1762,CPT,0278,RC,,,,both,,,1256.00,816.40,,,,,,,,,,,,,
LENS IOL 10.0 TO 30.0 DIOPT IOL PLANE 3.0 CORNEAL,SUP-2880953,CDM,V2787,HCPCS,0276,RC,,,,both,,,415.00,269.75,,,,,,,,,,,,,
TUBE ET LASERTUBUS 6MM STRL DISPOSAB,SUP-2265587,CDM,2720000010,LOCAL,0272,RC,,,,both,,,367.00,238.55,,,,,,,,,,,,,
PLATE EXT FIX 90 DEG 180 MM FEM ARCH CARBON FIBER NS,SUP-2800127,CDM,2720000010,LOCAL,0272,RC,,,,both,,,2626.96,1707.52,,,,,,,,,,,,,
NEEDLE ASPRTN ENDBRNCHL 052MM DIA ULTRSND TRNSBRNCHL ST SNG,SUP-2676540,CDM,2720000010,LOCAL,0272,RC,,,,both,,,679.18,441.47,,,,,,,,,,,,,
COIL EMB L12CM DIA4MM 0.0115IN INTCRAN 3D MICROFILAMENT,SUP-2295050,CDM,C1889,HCPCS,0278,RC,,,,both,,,4527.88,2943.12,,,,,,,,,,,,,
HC Nerve Neurolysis,PX-3600007520,CDM,3600007520,LOCAL,0360,RC,,,,both,,,6487.00,4216.55,,,,,,,,,,,,,
GUIDEWIRE VASC L 70 CM DIA 0.018 IN NIT MARKED RADIOPAQUE,SUP-2269549,CDM,C1769,HCPCS,0272,RC,,,,both,,,109.90,71.43,,,,,,,,,,,,,
GRAFT DURA W1XL1IN REABSORBABLE MTRX SUB FOR SFT TISS REP ID1105] INTEGRA LIFESCIENCES CORP],SUP-2244078,CDM,C1763,HCPCS,0278,RC,,,,both,,,396.52,257.74,,,,,,,,,,,,,
STRAP LCK NS SIDEKCK EZ FRAME,SUP-2850513,CDM,2720000010,LOCAL,0272,RC,,,,both,,,3055.22,1985.89,,,,,,,,,,,,,
OXYGENATOR PERF HPRN QUADROX ID BIOLINE,SUP-2266018,CDM,2720000010,LOCAL,0272,RC,,,,both,,,4135.38,2688.00,,,,,,,,,,,,,
PLATE BONE THK2.5MM 12 H CRANIOMAXILLOFACIAL ORAL LT BLU TI,SUP-2181774,CDM,C1713,HCPCS,0278,RC,,,,both,,,3756.38,2441.65,,,,,,,,,,,,,
SUPPORT ORTHOT THOR LUMBAR SACR CUST TRIPLANAR CTRL MOD,SUP-2435540,CDM,L0458,HCPCS,0274,RC,,,,both,,,2524.97,1641.23,,,,,,,,,,,,,
GRAFT DURA W2XL2IN PURIFIED CLLGN MTRX REGEN DURAGN SECUR,SUP-2244019,CDM,C1713,HCPCS,0278,RC,,,,both,,,1770.33,1150.71,,,,,,,,,,,,,
Ostectomy Complete Other Metatarsal Head 2/3/4|RIGHT SIDE,CASE-28112,LOCAL,28112,CPT,0360,RC,,,RT,outpatient,,,34933.33,20960.00,,,,,,,,,,,,,
Cysto Bladder W/Ureteral Catheterization|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-52005,LOCAL,52005,CPT,,,,,LT|XU,outpatient,,,21914.62,13148.77,,,,,,,,,,,,,
Dstr Nrolytc Agnt Parverteb Fct Addl Crvcl/Thora,CASE-64634,LOCAL,64634,CPT,,,,,,outpatient,,,11775.07,7065.04,,,,,,,,,,,,,
"Rpr/Advmnt Flxr Tdn Zone 2 W/O Fr Grft Ea Tendon|RIGHT HAND, FOURTH DIGIT",CASE-26356,LOCAL,26356,CPT,0360,RC,,,F8,outpatient,,,29367.62,17620.57,,,,,,,,,,,,,
Ostectomy Complete Other Metatarsal Head 2/3/4|RIGHT SIDE,CASE-28112,LOCAL,28112,CPT,,,,,RT,outpatient,,,34933.33,20960.00,,,,,,,,,,,,,
Dstrj Lesion Anus Simple Surg Excision,CASE-46922,LOCAL,46922,CPT,0360,RC,,,,outpatient,,,13474.60,8084.76,,,,,,,,,,,,,
HC Nursery Level I R&B,PX-1710000000,CDM,1710000000,LOCAL,,,,,,outpatient,,,4875.00,2925.00,,,,,,,,,,,,,
Esophagogastroduodenoscopy Submucosal Injection|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-43236,LOCAL,43236,CPT,,,,,74,outpatient,,,11359.40,6815.64,,,,,,,,,,,,,
Dstr Nrolytc Agnt Parverteb Fct Addl Crvcl/Thora,CASE-64634,LOCAL,64634,CPT,0360,RC,,,,outpatient,,,11775.07,7065.04,,,,,,,,,,,,,
Esophagogastroduodenoscopy Submucosal Injection|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-43236,LOCAL,43236,CPT,0360,RC,,,74,outpatient,,,11359.40,6815.64,,,,,,,,,,,,,
Cysto Bladder W/Ureteral Catheterization|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-52005,LOCAL,52005,CPT,0360,RC,,,LT|XU,outpatient,,,21914.62,13148.77,,,,,,,,,,,,,
Dstrj Lesion Anus Simple Surg Excision,CASE-46922,LOCAL,46922,CPT,,,,,,outpatient,,,13474.60,8084.76,,,,,,,,,,,,,
"Rpr/Advmnt Flxr Tdn Zone 2 W/O Fr Grft Ea Tendon|RIGHT HAND, FOURTH DIGIT",CASE-26356,LOCAL,26356,CPT,,,,,F8,outpatient,,,29367.62,17620.57,,,,,,,,,,,,,
KIT INTRODUCER TRACH BLUE RHINO,SUP-2640126,CDM,C1769,HCPCS,0272,RC,,,,both,,,2001.75,1301.14,,,,,,,,,,,,,
HC Counseling Visit for Ldct-Pbb,PX-5100029600,CDM,G0296,CPT,0510,RC,,,,outpatient,,,254.00,165.10,,,,,,,,,,,,,
PLATE BONE W9XL73MM THK1.1MM 6 H DSTL ULN FIBULAR S STL 1/3,SUP-2343777,CDM,C1713,HCPCS,0278,RC,,,,both,,,593.93,386.05,,,,,,,,,,,,,
WASHER SPNL SS XIA,SUP-2379903,CDM,C1713,HCPCS,0278,RC,,,,both,,,314.00,204.10,,,,,,,,,,,,,
PROSTHESIS PENILE L16CM 0DEG BIOFLX SIL INFPUB INFL SELF,SUP-2165448,CDM,C1813,HCPCS,0278,RC,,,,both,,,23298.80,15144.22,,,,,,,,,,,,,
SYSTEM IMPLANT BICEPS DISTAL TWO INCISION,SUP-2750916,CDM,C1713,HCPCS,0278,RC,,,,both,,,4066.30,2643.09,,,,,,,,,,,,,
NAIL 8.0 MM STP DRL SALVATION MIDFOOT,SUP-2417603,CDM,C1713,HCPCS,0278,RC,,,,both,,,763.02,495.96,,,,,,,,,,,,,
NEEDLE ASPIR 19GA L80MM WRK L1400MM INSRT PORTION DIA185MM,SUP-2313397,CDM,2720000010,LOCAL,0272,RC,,,,both,,,683.83,444.49,,,,,,,,,,,,,
HC Wheelchair Training per 15 Min|OP PT SERVICES|SERVICES PROVIDED IN WHOLE OR IN PART BY A PTA FOR MEDICARE PAIENTS,PX-4209754200,CDM,97542,CPT,0420,RC,,,GP|CQ,outpatient,,,154.00,100.10,,,,,,,,,,,,,
PLATE BONE L42MM 6 H BILAT MAXILLOFACIAL MAND ORAL TI STR,SUP-2191325,CDM,C1713,HCPCS,0278,RC,,,,both,,,1415.51,920.08,,,,,,,,,,,,,
Cmbnd Anterpost Colporraphy W/Cysto W/Ntrcl Rpr,CASE-57265,LOCAL,57265,CPT,,,,,,outpatient,,,86694.32,52016.59,,,,,,,,,,,,,
Neuroplasty &/Transpos Median Nrv Carpal Tunne|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64721,LOCAL,64721,CPT,,,,,LT|XU,outpatient,,,34139.12,20483.47,,,,,,,,,,,,,
Cysto Bladder W/Ureteral Catheterization|BILATERAL PROCEDURE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-52005,LOCAL,52005,CPT,,,,,50|XU,outpatient,,,23692.90,14215.74,,,,,,,,,,,,,
Optx Dstl Radl I-Artic Fx/Epiphysl Sep 3 Frag|LEFT SIDE,CASE-25609,LOCAL,25609,CPT,0360,RC,,,LT,outpatient,,,34340.88,20604.53,,,,,,,,,,,,,
Neuroplasty &/Transpos Median Nrv Carpal Tunne|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64721,LOCAL,64721,CPT,0360,RC,,,LT|XU,outpatient,,,34139.12,20483.47,,,,,,,,,,,,,
Optx Dstl Radl I-Artic Fx/Epiphysl Sep 3 Frag|LEFT SIDE,CASE-25609,LOCAL,25609,CPT,,,,,LT,outpatient,,,34340.88,20604.53,,,,,,,,,,,,,
HC N Block Inj Intercost Sng,CASE-64420,LOCAL,64420,CPT,0360,RC,,,,outpatient,,,4008.43,2405.06,,,,,,,,,,,,,
Cmbnd Anterpost Colporraphy W/Cysto W/Ntrcl Rpr,CASE-57265,LOCAL,57265,CPT,0360,RC,,,,outpatient,,,86694.32,52016.59,,,,,,,,,,,,,
"Amputation Toe Interphalangeal Joint|RIGHT FOOT, THIRD DIGIT",CASE-28825,LOCAL,28825,CPT,0360,RC,,,T7,outpatient,,,12525.72,7515.43,,,,,,,,,,,,,
Cysto Bladder W/Ureteral Catheterization|BILATERAL PROCEDURE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-52005,LOCAL,52005,CPT,0360,RC,,,50|XU,outpatient,,,23692.90,14215.74,,,,,,,,,,,,,
"Amputation Toe Interphalangeal Joint|RIGHT FOOT, THIRD DIGIT",CASE-28825,LOCAL,28825,CPT,,,,,T7,outpatient,,,12525.72,7515.43,,,,,,,,,,,,,
CATHETERIZATION TRAY 3 FR SINGLE LUMEN POWERPICC PROVENA,SUP-2127009,CDM,C1751,HCPCS,0278,RC,,,,both,,,382.73,248.77,,,,,,,,,,,,,
HEAD RAD STD SZ 24 W24XL13MM BILAT EL JT CO CHROME NONCOATED,SUP-2244261,CDM,C1776,CPT,0278,RC,,,,both,,,6543.76,4253.44,,,,,,,,,,,,,
PLATE BNE DBL ANGLED LG 2 MM RECON PT SPEC,SUP-2860086,CDM,C1713,HCPCS,0278,RC,,,,both,,,26791.42,17414.42,,,,,,,,,,,,,
TUBE FEED 16FR 3 5ML STOMA L15CM JEJU L22CM SIL INT RETEN,SUP-2236569,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1102.27,716.48,,,,,,,,,,,,,
PLATE BNE L 154 X W 10.2 MM THK 2.8 MM SCREW DIA 3.5 MM 14 HL,SUP-2936832,CDM,C1713,HCPCS,0278,RC,,,,both,,,2853.63,1854.86,,,,,,,,,,,,,
GRAFT HUM TISS XSM W9XL15CM THK15 22MM THCK PERF FLEXHD,SUP-2436520,CDM,Q4128,HCPCS,0636,RC,,,,both,,,7431.75,4830.64,,,,,,,,,,,,,
CATHETER ELECHEMSTAS STRL ENDOSTAT II LF DISP,SUP-2125961,CDM,2720000010,LOCAL,0272,RC,,,,both,,,486.70,316.35,,,,,,,,,,,,,
HC So Lidocaine,PX-3018017666,CDM,80176,CPT,0301,RC,,,,both,,,387.00,251.55,,,,,,,,,,,,,
HC Retro Urethrocystography S&I,PX-3207445000,CDM,74450,CPT,0320,RC,,,,outpatient,,,911.00,592.15,,,,,,,,,,,,,
Peri-Implant Capsulectomy Breast Complete|BILATERAL PROCEDURE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-19371,LOCAL,19371,CPT,0360,RC,,,50|XU,outpatient,,,64271.73,38563.04,,,,,,,,,,,,,
Dstr Nrolytc Agnt Parverteb Fct Sngl Lmbr/Sacral|BILATERAL PROCEDURE,CASE-64635,LOCAL,64635,CPT,0360,RC,,,50,outpatient,,,11983.28,7189.97,,,,,,,,,,,,,
"Hallux Rigidus W/Cheilectomy 1st Mp Jt W/O Implt|LEFT FOOT, GREAT TOE",CASE-28289,LOCAL,28289,CPT,,,,,TA,outpatient,,,27989.30,16793.58,,,,,,,,,,,,,
Exc Lesion Eyelid W/O Clsr/W/Simple Dir Closure,CASE-67840,LOCAL,67840,CPT,0360,RC,,,,outpatient,,,18581.43,11148.86,,,,,,,,,,,,,
Exc Lesion Eyelid W/O Clsr/W/Simple Dir Closure,CASE-67840,LOCAL,67840,CPT,,,,,,outpatient,,,18581.43,11148.86,,,,,,,,,,,,,
Cystoscopy prostatic imp 1-3,CASE-C9739,LOCAL,C9739,CPT,0360,RC,,,,outpatient,,,23654.32,14192.59,,,,,,,,,,,,,
Blepharoplasty Upper Eyelid W/Excessive Skin,CASE-15823,LOCAL,15823,CPT,,,,,,outpatient,,,24154.00,14492.40,,,,,,,,,,,,,
Blepharoplasty Upper Eyelid W/Excessive Skin,CASE-15823,LOCAL,15823,CPT,0360,RC,,,,outpatient,,,24154.00,14492.40,,,,,,,,,,,,,
"Hallux Rigidus W/Cheilectomy 1st Mp Jt W/O Implt|LEFT FOOT, GREAT TOE",CASE-28289,LOCAL,28289,CPT,0360,RC,,,TA,outpatient,,,27989.30,16793.58,,,,,,,,,,,,,
Dstr Nrolytc Agnt Parverteb Fct Sngl Lmbr/Sacral|BILATERAL PROCEDURE,CASE-64635,LOCAL,64635,CPT,,,,,50,outpatient,,,11983.28,7189.97,,,,,,,,,,,,,
Cystoscopy prostatic imp 1-3,CASE-C9739,LOCAL,C9739,CPT,,,,,,outpatient,,,23654.32,14192.59,,,,,,,,,,,,,
"Open Tx Metacarpal Fracture Single Ea Bone|LEFT HAND, FOURTH DIGIT",CASE-26615,LOCAL,26615,CPT,0360,RC,,,F3,outpatient,,,29346.28,17607.77,,,,,,,,,,,,,
Peri-Implant Capsulectomy Breast Complete|BILATERAL PROCEDURE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-19371,LOCAL,19371,CPT,,,,,50|XU,outpatient,,,64271.73,38563.04,,,,,,,,,,,,,
"Open Tx Metacarpal Fracture Single Ea Bone|LEFT HAND, FOURTH DIGIT",CASE-26615,LOCAL,26615,CPT,,,,,F3,outpatient,,,29346.28,17607.77,,,,,,,,,,,,,
GRAFT VASC ADVANTA VXT L 80 CM DIA 5 MM STR STD WALL HELIX,SUP-2496134,CDM,C1768,CPT,0278,RC,,,,both,,,2791.99,1814.79,,,,,,,,,,,,,
ROD SPNL L300MM DIA3.5MM POST CERVICOTHORACIC TI SMOOTH,SUP-2289082,CDM,C1713,HCPCS,0278,RC,,,,both,,,1193.99,776.09,,,,,,,,,,,,,
GLYCERIN (LAXATIVE) 2 G RE SUPP,RX-41003,CDM,6370000000,HCPCS,0637,RC,00132-0075-12,NDC,,both,1,UN,2.70,1.75,,,,,,,,,,,,,
MESH HERN XL W5XL7IN L INGUINAL POLYPR REP CRV SHP SEAL,SUP-2125773,CDM,C1781,HCPCS,0278,RC,,,,both,,,631.14,410.24,,,,,,,,,,,,,
BLADE SURG W225XL105IN MATTE FINISH CNTR MAL S STL DIXON,SUP-2162005,CDM,2720000010,LOCAL,0272,RC,,,,both,,,579.74,376.83,,,,,,,,,,,,,
BIT DRILL 42 X 300,SUP-2700664,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1808.64,1175.62,,,,,,,,,,,,,
SCREW BONE L6MM DIA1.5MM STD CORT S STL ST FULL THRD HEX HD,SUP-2343856,CDM,C1713,HCPCS,0278,RC,,,,both,,,260.43,169.28,,,,,,,,,,,,,
SCREW BNE L 20 MM DIA2 MM TI CANN HDLSS NS LEOS,SUP-2932618,CDM,C1713,HCPCS,0278,RC,,,,both,,,817.91,531.64,,,,,,,,,,,,,
PLATE BONE MED RIGHT F/METATARSOPHALANGEAL FUSION JOINT,SUP-2586521,CDM,C1713,HCPCS,0278,RC,,,,both,,,6388.90,4152.78,,,,,,,,,,,,,
ELECTRODE SUBDERM NDL L 22 MM 4 CHANNEL TWISTED PR GRN WHT,SUP-2902010,CDM,2720000010,LOCAL,0272,RC,,,,both,,,504.44,327.89,,,,,,,,,,,,,
PLATE BNE TBLR 145 MM 12-HOLE 1/3,SUP-2518446,CDM,C1713,HCPCS,0278,RC,,,,both,,,2527.70,1643.00,,,,,,,,,,,,,
Excision Interdigital Morton Neuroma Single Each|LEFT SIDE,CASE-28080,LOCAL,28080,CPT,0360,RC,,,LT,outpatient,,,24836.20,14901.72,,,,,,,,,,,,,
Mastectomy Partial|LEFT SIDE|SEPARATE PRACTITIONER,CASE-19301,LOCAL,19301,CPT,0360,RC,,,LT|XP,outpatient,,,113631.43,68178.86,,,,,,,,,,,,,
Excision Interdigital Morton Neuroma Single Each|LEFT SIDE,CASE-28080,LOCAL,28080,CPT,,,,,LT,outpatient,,,24836.20,14901.72,,,,,,,,,,,,,
Lithotripsy Xtrcorp Shock Wave|BILATERAL PROCEDURE,CASE-50590,LOCAL,50590,CPT,,,,,50,outpatient,,,30397.12,18238.27,,,,,,,,,,,,,
Lithotripsy Xtrcorp Shock Wave|BILATERAL PROCEDURE,CASE-50590,LOCAL,50590,CPT,0360,RC,,,50,outpatient,,,30397.12,18238.27,,,,,,,,,,,,,
Mastectomy Partial|LEFT SIDE|SEPARATE PRACTITIONER,CASE-19301,LOCAL,19301,CPT,,,,,LT|XP,outpatient,,,113631.43,68178.86,,,,,,,,,,,,,
CAGE SPNL MESH 17X13X10 MM 6 LOBE,SUP-2602078,CDM,C1889,HCPCS,0278,RC,,,,both,,,7787.20,5061.68,,,,,,,,,,,,,
VARIAX CLAV - TRIAL- ANT LAT / 7 H,SUP-2377995,CDM,C1713,HCPCS,0278,RC,,,,both,,,406.19,264.02,,,,,,,,,,,,,
COVER BUR H L14MM W/ SHUNT,SUP-2365244,CDM,C1713,HCPCS,0278,RC,,,,both,,,831.25,540.31,,,,,,,,,,,,,
PROSTHESIS 4MM DIAM 7MM LEN RND HD PLASTIPORE TORP CAUSSE,SUP-2312527,CDM,L8613,CPT,0278,RC,,,,both,,,568.40,369.46,,,,,,,,,,,,,
SURGICAL PREPARATION PACK SCAPHOLUNATE INT CRPL SLIC SCREW,SUP-2106423,CDM,C1713,HCPCS,0278,RC,,,,both,,,2596.78,1687.91,,,,,,,,,,,,,
SCREW INTFR L20MM DIA7MM KNEE TI RND BIOABSRB BLNT THRD,SUP-2341569,CDM,C1713,HCPCS,0278,RC,,,,both,,,621.72,404.12,,,,,,,,,,,,,
CATHETER CARD ABLATION CELSIUS FLTR L 115 CM 7.5 FR TIP 4 MM,SUP-2248636,CDM,C1733,HCPCS,0272,RC,,,,both,,,2615.62,1700.15,,,,,,,,,,,,,
SCREW BONE L110MM DIA5MM THRD L16MM 3.5MM HD HEX RECESS GLD,SUP-2192150,CDM,C1713,HCPCS,0278,RC,,,,both,,,885.67,575.69,,,,,,,,,,,,,
SCREW BNE COMPR 4.5X36 MM HIP CORTICAL TALON,SUP-2391512,CDM,C1713,HCPCS,0278,RC,,,,both,,,104.09,67.66,,,,,,,,,,,,,
PLATE BONE LOK 287MML HLX22 STRGHT RCNSTRCTN ST,SUP-2588611,CDM,C1713,HCPCS,0278,RC,,,,both,,,2538.69,1650.15,,,,,,,,,,,,,
TREPHINE SURG DIA8MM CRWN DRL,SUP-2368636,CDM,C1713,HCPCS,0278,RC,,,,both,,,2014.31,1309.30,,,,,,,,,,,,,
SCREW BONE SELFTAPPING 1X4 MM CRANIOMAXILLOFACIAL EMERGENCY,SUP-2837651,CDM,C1713,HCPCS,0278,RC,,,,both,,,604.01,392.61,,,,,,,,,,,,,
SHEATH INTRO GLIDESHEATH L 25 CM OD 4 FR ID 0.061 IN TIP DIA,SUP-2384848,CDM,C1894,HCPCS,0272,RC,,,,both,,,125.60,81.64,,,,,,,,,,,,,
Destruction Neurolytic Agt Genicular Nerve W/Img,CASE-64624,LOCAL,64624,CPT,,,,,,outpatient,,,12041.90,7225.14,,,,,,,,,,,,,
Dstr Nrolytc Agnt Parverteb Fct Sngl Crvcl/Thora|RIGHT SIDE,CASE-64633,LOCAL,64633,CPT,,,,,RT,outpatient,,,11822.95,7093.77,,,,,,,,,,,,,
Destruction Neurolytic Agt Genicular Nerve W/Img,CASE-64624,LOCAL,64624,CPT,0360,RC,,,,outpatient,,,12041.90,7225.14,,,,,,,,,,,,,
HC Remove Tun Cath Vad W/Port,CASE-36590,LOCAL,36590,CPT,0361,RC,,,,outpatient,,,6839.52,4103.71,,,,,,,,,,,,,
Dstr Nrolytc Agnt Parverteb Fct Sngl Crvcl/Thora|RIGHT SIDE,CASE-64633,LOCAL,64633,CPT,0360,RC,,,RT,outpatient,,,11822.95,7093.77,,,,,,,,,,,,,
"Corrj Hallux Valgus W/Sesmdc W/Dist Metar Osteot|RIGHT FOOT, GREAT TOE",CASE-28296,LOCAL,28296,CPT,,,,,T5,outpatient,,,26417.38,15850.43,,,,,,,,,,,,,
"Corrj Hallux Valgus W/Sesmdc W/Dist Metar Osteot|RIGHT FOOT, GREAT TOE",CASE-28296,LOCAL,28296,CPT,0360,RC,,,T5,outpatient,,,26417.38,15850.43,,,,,,,,,,,,,
PACK PROC HALF SHT W3XL5IN SOD HYALURONATE,SUP-2154016,CDM,C1765,HCPCS,0278,RC,,,,both,,,2950.94,1918.11,,,,,,,,,,,,,
BUR SURG MATCHSTICK LNG 2.3 MM FLUT FOR QD14-S/QD14-G1/QD14,SUP-2848154,CDM,2720000010,LOCAL,0272,RC,,,,both,,,365.94,237.86,,,,,,,,,,,,,
THREADLOCK TRNSPRT DSTRCTR 60MM T 6L 4V SNGLE USE,SUP-2499166,CDM,C1713,HCPCS,0278,RC,,,,both,,,17385.14,11300.34,,,,,,,,,,,,,
SEALER VES DIA8MM ENDOWRIST DA VINCI SI,SUP-2246595,CDM,2720000010,LOCAL,0272,RC,,,,both,,,1868.30,1214.39,,,,,,,,,,,,,
FIBER LASER FLAT TIP 400 MH ASMBLY HOLM MF400BH] GALLAGHER MEDICAL PRODUCTS LLC],SUP-2225999,CDM,2720000010,LOCAL,0272,RC,,,,both,,,894.90,581.68,,,,,,,,,,,,,
TUBE SUCTION POOLE 23FR DIA 8 3/4INL CURVED ANGLED,SUP-2501227,CDM,2720000010,LOCAL,0272,RC,,,,both,,,78.85,51.25,,,,,,,,,,,,,
NEEDLE BRST LOC BLNT 20 GAX5 CM STRL HAWK3 LTX,SUP-2876181,CDM,C1819,HCPCS,0278,RC,,,,both,,,160.14,104.09,,,,,,,,,,,,,
TRAY EPIDURAL TUOHY NDL L 3.5 IN DIA17 GA SGL SHT LIDO NACL,SUP-2936441,CDM,2720000010,LOCAL,0272,RC,,,,both,,,47.60,30.94,,,,,,,,,,,,,
TRAY CHST TB 28FR L41CM 4 SIDEPRT THAL QUIK W/ 80CM GWIRE,SUP-2167997,CDM,C1729,HCPCS,0272,RC,,,,both,,,725.65,471.67,,,,,,,,,,,,,
HC So Hpv Dna Amp Probe,PX-3068762466,CDM,87624,CPT,0306,RC,,,,both,,,44.00,28.60,,,,,,,,,,,,,
BRACE ANK DORSIFLEXION ASST PLNTR,SUP-2388176,CDM,L2210,HCPCS,0274,RC,,,,both,,,169.78,110.36,,,,,,,,,,,,,
STRAP CLAV FOAM PADDED 42-48 IN X LG BCKL CLOSURE PROCARE,SUP-2195760,CDM,L3650,HCPCS,0272,RC,,,,both,,,15.57,10.12,,,,,,,,,,,,,
GUIDEPIN ORTH 1.6X3.5 MM DRL TIP SS NS,SUP-2485885,CDM,C1769,HCPCS,0272,RC,,,,both,,,178.04,115.73,,,,,,,,,,,,,
Cysto impl 4 or more,CASE-C9740,LOCAL,C9740,CPT,,,,,,outpatient,,,39911.73,23947.04,,,,,,,,,,,,,
HC Biopsy/Exc Lymph Node Needle|TECHNICAL COMPONENT,CASE-38505,LOCAL,38505,CPT,0361,RC,,,TC,outpatient,,,13091.53,7854.92,,,,,,,,,,,,,
Fasct Palm W/WO Z-Plasty Tissue Reargmt/Skn Grft|LEFT SIDE,CASE-26121,LOCAL,26121,CPT,,,,,LT,outpatient,,,10900.58,6540.35,,,,,,,,,,,,,
Cysto impl 4 or more,CASE-C9740,LOCAL,C9740,CPT,0360,RC,,,,outpatient,,,39911.73,23947.04,,,,,,,,,,,,,
Brnchsc Incl Fluor Gdnce Dx W/Cell Washg Spx,CASE-31622,LOCAL,31622,CPT,,,,,,outpatient,,,13796.25,8277.75,,,,,,,,,,,,,
Brnchsc Incl Fluor Gdnce Dx W/Cell Washg Spx,CASE-31622,LOCAL,31622,CPT,0360,RC,,,,outpatient,,,13796.25,8277.75,,,,,,,,,,,,,
Fasct Palm W/WO Z-Plasty Tissue Reargmt/Skn Grft|LEFT SIDE,CASE-26121,LOCAL,26121,CPT,0360,RC,,,LT,outpatient,,,10900.58,6540.35,,,,,,,,,,,,,
AMIODARONE HCL 150 MG/3ML IV SOLN,RX-93084,CDM,J0282,HCPCS,0636,RC,70436-0232-52,NDC,,both,3,ML,54.10,35.16,,,,,,,,,,,,,
EXTENSION STEM TIB STABILIZING PRI Y 14MM DIA 145MM,SUP-2199616,CDM,C1776,CPT,0278,RC,,,,both,,,4923.52,3200.29,,,,,,,,,,,,,
SCREW INTRF BIO ABSORBABLE 9X22.5 MM KNEE CANN THRD WEDGED,SUP-2608089,CDM,C1713,HCPCS,0278,RC,,,,both,,,548.59,356.58,,,,,,,,,,,,,
PLUG VASC MED 8 MM AZUR,SUP-2853096,CDM,C1889,HCPCS,0278,RC,,,,both,,,6790.25,4413.66,,,,,,,,,,,,,
GRAFT VASC IMPRA L 30 CM DIA 6 MM EPTFE STR TW N RING HEMO,SUP-2761264,CDM,C1768,CPT,0278,RC,,,,both,,,1490.90,969.08,,,,,,,,,,,,,
PLATE BONE LOK 36MML HLX3 STNLSS STEEL 14 TBLR ST,SUP-2726489,CDM,C1713,HCPCS,0278,RC,,,,both,,,601.56,391.01,,,,,,,,,,,,,
HC Advncd Care Plan 30 Min,PX-5109949700,CDM,99497,CPT,0510,RC,,,,both,,,254.00,165.10,,,,,,,,,,,,,
NAIL IM L150MM DIA10MM ANK TI COR LOK TECHNOLOGY 2 STG ARTH,SUP-2412146,CDM,C1713,HCPCS,0278,RC,,,,both,,,8107.92,5270.15,,,,,,,,,,,,,
PLATE BNE CLAV 3.5X86 MM LT SUP MIDSHAFT 8 HOLE EVOS,SUP-2424108,CDM,C1713,HCPCS,0278,RC,,,,both,,,2959.14,1923.44,,,,,,,,,,,,,
BRACE ORTH BILATERAL SM AD ANK WALKING MAXTRAX AIR,SUP-2427326,CDM,L4360,HCPCS,0272,RC,,,,both,,,93.76,60.94,,,,,,,,,,,,,
POWDER MED TALCUM FOR TREAT OF MALIG PLEUR EFFUS,SUP-2138763,CDM,2720000010,LOCAL,0272,RC,,,,both,,,613.87,399.02,,,,,,,,,,,,,
HC Rsf Lab Ecmc - Autopsy,PX-9900000125,CDM,9900000125,LOCAL,0990,RC,,,,both,,,503.00,326.95,,,,,,,,,,,,,
PLATE BONE L117MM 10 HOLE BLTRL STNLSS STEEL STRGHT RCNSTRCT,SUP-2499132,CDM,C1713,HCPCS,0278,RC,,,,both,,,1128.11,733.27,,,,,,,,,,,,,
PLATE BNE L75MM THK3MM 4 H BILAT S STL STR LOK COMPR RECON,SUP-2185331,CDM,C1713,HCPCS,0278,RC,,,,both,,,1203.22,782.09,,,,,,,,,,,,,
ANCHOR SUTURE 4.5X11MM KNOTLESS DEPLOYED POPLOK,SUP-2828588,CDM,C1713,HCPCS,0278,RC,,,,both,,,1677.07,1090.10,,,,,,,,,,,,,
Laps Tx Ectopic Preg W/Salping&/Oophorectomy|RIGHT SIDE,CASE-59151,LOCAL,59151,CPT,,,,,RT,outpatient,,,30460.58,18276.35,,,,,,,,,,,,,
Egd Transoral Biopsy Single/Multiple|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-43239,LOCAL,43239,CPT,0360,RC,,,74,outpatient,,,10365.77,6219.46,,,,,,,,,,,,,
Egd Transoral Biopsy Single/Multiple|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-43239,LOCAL,43239,CPT,,,,,74,outpatient,,,10365.77,6219.46,,,,,,,,,,,,,
HC Pbb Carpal Tunnel Inj Pmc|BILATERAL PROCEDURE,CASE-20526,LOCAL,20526,CPT,0510,RC,,,50,outpatient,,,3560.05,2136.03,,,,,,,,,,,,,
Laps Tx Ectopic Preg W/Salping&/Oophorectomy|RIGHT SIDE,CASE-59151,LOCAL,59151,CPT,0360,RC,,,RT,outpatient,,,30460.58,18276.35,,,,,,,,,,,,,
Cysto/Pyeloscopy Bx&/Fulguration Pelivc Lesion|LEFT SIDE,CASE-52354,LOCAL,52354,CPT,0360,RC,,,LT,outpatient,,,17985.30,10791.18,,,,,,,,,,,,,
Cysto/Pyeloscopy Bx&/Fulguration Pelivc Lesion|LEFT SIDE,CASE-52354,LOCAL,52354,CPT,,,,,LT,outpatient,,,17985.30,10791.18,,,,,,,,,,,,,
SCREW BNE 4.25X14MM CERV VAR SPIDER,SUP-2402174,CDM,C1713,HCPCS,0278,RC,,,,both,,,5286.03,3435.92,,,,,,,,,,,,,
BASKET STONE ERCP 4W FLOWER BSKT ROT 22 MMX195 CM,SUP-2313154,CDM,C1713,HCPCS,0278,RC,,,,both,,,458.44,297.99,,,,,,,,,,,,,
ALLOGRAFT HUM TISS STD 12X2 CM REGENERATIVE GRAFTJACKET NOW,SUP-2759533,CDM,Q4107,HCPCS,0636,RC,,,,both,,,6535.53,4248.09,,,,,,,,,,,,,
GRAFT BNE SUB 2.5CC DEMIN BNE MTRX PTTY,SUP-2306995,CDM,C9359,HCPCS,0278,RC,,,,both,,,1201.99,781.29,,,,,,,,,,,,,
MESH CRAN L 85 X W 55 MM THK 0.3 MM SCREW DIA1.5 MM TI,SUP-2936475,CDM,C1713,HCPCS,0278,RC,,,,both,,,1946.80,1265.42,,,,,,,,,,,,,
CATHETER CV MAXIMAL BARR TY 018 4 FRX15 CM DL J TIP STRL,SUP-2759909,CDM,C1751,HCPCS,0278,RC,,,,both,,,436.30,283.59,,,,,,,,,,,,,
NAIL TIBIAL -ADVANCED 9MMX 345MM ST,SUP-2718104,CDM,C1713,HCPCS,0278,RC,,,,both,,,4336.47,2818.71,,,,,,,,,,,,,
PROCESSOR SND KT MAG 345 AD,SUP-2165019,CDM,L8691,HCPCS,0274,RC,,,,both,,,580.90,377.58,,,,,,,,,,,,,
BOOT CAST L TOT CNTCT SYS TCC-EZ,SUP-2244448,CDM,L4387,HCPCS,0272,RC,,,,both,,,355.39,231.00,,,,,,,,,,,,,
CATHETER INFUSION TEGTMEYER DIA 30 GA LYMPHATIC DUCT STRL,SUP-2118901,CDM,2720000010,LOCAL,0272,RC,,,,both,,,370.52,240.84,,,,,,,,,,,,,
CATHETER PICC 4FR L55CM LUMN 17GA GWIRE L45CM TAPE L92CM SGL,SUP-2118965,CDM,C1751,HCPCS,0278,RC,,,,both,,,427.04,277.58,,,,,,,,,,,,,
Nasal/Sinus Ndsc Surg W/Concha Bullosa Resection|LEFT SIDE,CASE-31240,LOCAL,31240,CPT,,,,,LT,outpatient,,,49144.77,29486.86,,,,,,,,,,,,,
Nasal/Sinus Ndsc Surg W/Concha Bullosa Resection|LEFT SIDE,CASE-31240,LOCAL,31240,CPT,0360,RC,,,LT,outpatient,,,49144.77,29486.86,,,,,,,,,,,,,
Excision Pilonidal Cyst/Sinus Complicated,CASE-11772,LOCAL,11772,CPT,,,,,,outpatient,,,26281.88,15769.13,,,,,,,,,,,,,
Excision Pilonidal Cyst/Sinus Complicated,CASE-11772,LOCAL,11772,CPT,0360,RC,,,,outpatient,,,26281.88,15769.13,,,,,,,,,,,,,
Bronchoscopy W/Cptr-Asst Image-Guided Navigation,CASE-31627,APC,31627,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6936.25,,"APC Price ($6,605.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6605.95,6936.25,OPPS APC
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],7017.54,,"Case rate ($6,683.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,353, add-ons for qualifying new technology services are included. If operating cost exceeds $41,224.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,106.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,391.86 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,408.05 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $346.56. The transfer capital threshold is the transfer adjustment factor * $346.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6683.37,14699.43,Inpatient DRG
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],38517.10,,"Fee schedule rate ($38,517.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,16897.01,43444.85,There are no additional notes associated with this service or procedure.
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],23216.87,,"Fee schedule rate ($23,216.87). Adds an outlier to normal pricing equal to the per diem rate ($51,531) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.7), with a minimum of zero.",,,,0,other,10311.17,24308.97,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],81353.66,,"Fee schedule rate ($81,353.66). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,27256.92,81353.66,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,167,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],14865.60,,"Case rate ($14,157.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,306.21, add-ons for qualifying new technology services are included. If operating cost exceeds $48,177.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,653.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $11,319.53 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,361.26 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $893.22. The transfer capital threshold is the transfer adjustment factor * $893.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,14157.71,43522.37,Inpatient DRG
Lithotripsy Xtrcorp Shock Wave|BILATERAL PROCEDURE,CASE-50590,APC,50590,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3299.47,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3299.47,3464.44,OPPS APC
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],19604.30,,"Fee schedule rate ($19,604.30). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9446.38,21796.21,There are no additional notes associated with this service or procedure.
"NEONATE BIRTH WEIGHT > 2499 GRAMS NORMAL NEWBORN OR NEONATE WITH OTHER PROBLEM,MAJOR",640,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],2898.84,,"Case rate ($2,898.84). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,2898.84,3043.78,There are no additional notes associated with this service or procedure.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,025,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],13351.00,,"Per diem ($13,351). If length of stay < 6.4, first 1 days paid at a per diem of $26,702 instead. Capped at $85,446.13.",,,,0,other,13351.00,91631.33,Estimated amount calculated based on 4 day length of stay.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],14699.43,,"Fee schedule rate ($14,699.43). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6683.37,14699.43,There are no additional notes associated with this service or procedure.
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],14625.55,,"Fee schedule rate ($14,625.55). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7438.45,15961.98,There are no additional notes associated with this service or procedure.
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],8379.44,,"Case rate ($7,980.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,570.88, add-ons for qualifying new technology services are included. If operating cost exceeds $42,441.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,190.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,604.68 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,625.93 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $430.79. The transfer capital threshold is the transfer adjustment factor * $430.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8163.06,18067.42,Inpatient DRG
KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,689,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],10050.37,,"Case rate ($9,571.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,054.26, add-ons for qualifying new technology services are included. If operating cost exceeds $43,925.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,304.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $7,082.45 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,109.31 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $544.37. The transfer capital threshold is the transfer adjustment factor * $544.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9802.58,22831.22,Inpatient DRG
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],37768.77,,"Fee schedule rate ($37,768.77). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7453.00,42138.30,There are no additional notes associated with this service or procedure.
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],10311.17,,"Case rate ($10,311.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,727.87, add-ons for qualifying new technology services are included. If operating cost exceeds $44,598.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,371.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $7,754.32 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,782.91 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $611.89. The transfer capital threshold is the transfer adjustment factor * $611.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10311.17,24308.97,Inpatient DRG
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,306,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],29614.01,,"Fee schedule rate ($29,614.01). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12616.37,31007.02,There are no additional notes associated with this service or procedure.
Largsc Exc Tum&/Strpg Cords/Epigl Mcrscp/Tlscp,CASE-31541,APC,31541,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3489.82,,"APC Price ($3,489.82). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3489.82,3664.31,OPPS APC
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],6659.57,,"Fee schedule rate ($6,659.57). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5415.00,17575.50,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],34272.79,,"Fee schedule rate ($34,272.79). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,14295.18,42768.36,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],19535.15,,"Case rate ($19,152.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,952.40, add-ons for qualifying new technology services are included. If operating cost exceeds $52,823.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,018.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $15,948.65 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $16,007.45 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,258.51. The transfer capital threshold is the transfer adjustment factor * $1,258.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,19152.11,53152.12,Inpatient DRG
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,690,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],7575.48,,"Case rate ($7,426.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,044.73, add-ons for qualifying new technology services are included. If operating cost exceeds $41,915.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,160.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,081.05 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,099.78 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $400.94. The transfer capital threshold is the transfer adjustment factor * $400.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,7426.94,15928.53,Inpatient DRG
TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC,087,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],8424.24,,"Case rate ($8,139.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,707.48, add-ons for qualifying new technology services are included. If operating cost exceeds $42,578.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,213.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $5,741.36 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,762.53 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $453.05. The transfer capital threshold is the transfer adjustment factor * $453.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,8139.36,22679.07,Inpatient DRG
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5778.62,,"Case rate ($5,778.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,511.33, add-ons for qualifying new technology services are included. If operating cost exceeds $40,382.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,040.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $3,553.28 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,566.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $280.39. The transfer capital threshold is the transfer adjustment factor * $280.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,5778.62,11681.49,Inpatient DRG
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC",514,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],8868.04,,"Case rate ($8,868.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,385.35, add-ons for qualifying new technology services are included. If operating cost exceeds $43,256.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,266.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $6,416.74 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,440.40 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $506.34. The transfer capital threshold is the transfer adjustment factor * $506.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8868.04,22699.91,Inpatient DRG
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],35528.17,,"Fee schedule rate ($35,528.17). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,14747.55,37899.49,There are no additional notes associated with this service or procedure.
CHOLECYSTECTOMY WITH C.D.E. WITH MCC,411,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],88615.28,,"Fee schedule rate ($88,615.28). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,24315.13,88615.28,There are no additional notes associated with this service or procedure.
OTHER MENTAL DISORDER DIAGNOSES,887,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],2070.00,,,,,,0,other,2070.00,21072.10,Estimated amount calculated based on 1 day length of stay.
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],35474.53,,"Fee schedule rate ($35,474.53). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,16428.39,42083.20,There are no additional notes associated with this service or procedure.
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],16055.90,,"Fee schedule rate ($16,055.90). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8163.06,18067.42,There are no additional notes associated with this service or procedure.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],23520.23,,"Fee schedule rate ($23,520.23). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10517.71,24909.11,There are no additional notes associated with this service or procedure.
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],14525.56,,,,,,0,other,5068.21,14525.56,There are no additional notes associated with this service or procedure.
Post Colporrhaphy Rectocele W/WO Perineorrhaphy,CASE-57250,APC,57250,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],10447.27,,"APC Price ($9,949.78). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,9949.78,10447.27,OPPS APC
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],15802.03,,"Fee schedule rate ($15,802.03). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7566.45,16333.88,There are no additional notes associated with this service or procedure.
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],26391.01,,"Fee schedule rate ($26,391.01). Adds an outlier to normal pricing equal to the per diem rate ($77,296.48) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,11454.97,28394.78,There are no additional notes associated with this service or procedure.
MAJOR ESOPHAGEAL DISORDERS WITH CC,369,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],8892.75,,"Case rate ($8,718.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,246.12, add-ons for qualifying new technology services are included. If operating cost exceeds $43,117.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,255.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,278.03 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,301.17 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $495.40. The transfer capital threshold is the transfer adjustment factor * $495.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6965.00,19680.94,Inpatient DRG
Nsl/Sinus Ndsc Max Antrost W/Rmvl Tiss Max Sinus|RIGHT SIDE,CASE-31267,APC,31267,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6605.95,,"APC Price ($6,605.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6605.95,6936.25,OPPS APC
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,093,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],19011.32,,"Fee schedule rate ($19,011.32). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,19011.32,There are no additional notes associated with this service or procedure.
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC",758,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],16323.02,,"Fee schedule rate ($16,323.02). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8574.80,19263.78,There are no additional notes associated with this service or procedure.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC",156,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],6757.62,,"Case rate ($6,625.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,298.82, add-ons for qualifying new technology services are included. If operating cost exceeds $41,169.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,102.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $4,337.88 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,353.87 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $342.30. The transfer capital threshold is the transfer adjustment factor * $342.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6625.12,13598.77,Inpatient DRG
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],23239.84,,"Fee schedule rate ($23,239.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8543.64,23239.84,There are no additional notes associated with this service or procedure.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,352,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],21946.47,,"Fee schedule rate ($21,946.47). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,9853.37,26528.70,There are no additional notes associated with this service or procedure.
HC Drain/Inj Joint/Bursa W/US Large|RIGHT SIDE,CASE-20611,APC,20611,CPT,0510,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],40714.72,,"Fee schedule rate ($40,714.72). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,17356.15,44778.95,There are no additional notes associated with this service or procedure.
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],11281.44,,"Fee schedule rate ($11,281.44). Adds an outlier to normal pricing equal to the per diem rate ($62,521.14) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,6010.23,12246.05,There are no additional notes associated with this service or procedure.
Cysto W/Urtroscopy&/Pyeloscopy Dx|RIGHT SIDE,CASE-52351,APC,52351,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3464.44,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3299.47,3464.44,OPPS APC
INFLAMMATORY BOWEL DISEASE WITH CC,386,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],8556.53,,"Case rate ($8,556.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,095.56, add-ons for qualifying new technology services are included. If operating cost exceeds $42,966.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,243.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,128.01 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,150.61 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $483.56. The transfer capital threshold is the transfer adjustment factor * $483.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8556.53,19879.00,Inpatient DRG
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],45157.33,,"Fee schedule rate ($45,157.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,10733.06,45157.33,There are no additional notes associated with this service or procedure.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC,192,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6512.87,,"Case rate ($6,292.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,989.50, add-ons for qualifying new technology services are included. If operating cost exceeds $40,860.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,077.96, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,029.69 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,044.54 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $317.98. The transfer capital threshold is the transfer adjustment factor * $317.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6292.63,12753.78,Inpatient DRG
CHEST PAIN,313,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],15377.66,,"Fee schedule rate ($15,377.66). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,6820.84,15377.66,There are no additional notes associated with this service or procedure.
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC,807,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],12670.24,,"Fee schedule rate ($12,670.24). Adds an outlier to normal pricing equal to the per diem rate ($29,637.88) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,5354.25,13266.23,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC,817,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],44895.04,,,,,,0,other,17396.11,44895.04,There are no additional notes associated with this service or procedure.
CERVICAL SPINAL FUSION WITHOUT CC/MCC,473,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],18477.61,,"Case rate ($18,477.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,324.93, add-ons for qualifying new technology services are included. If operating cost exceeds $52,195.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,969.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.6. The base transfer operating payment is the transfer adjustment factor * $15,323.48 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,379.98 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,209.17. The transfer capital threshold is the transfer adjustment factor * $1,209.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,18477.61,62077.11,Inpatient DRG
Ostc Prtl Exostc/Condylc Metar Head|RIGHT SIDE|SEPARATE STRUCTURE,CASE-28288,APC,28288,CPT,0360,RC,,,RT|XS,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],31533.97,,"Fee schedule rate ($31,533.97). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8563.30,31533.97,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],16129.04,,"Case rate ($16,129.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,140.12, add-ons for qualifying new technology services are included. If operating cost exceeds $50,011.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,797.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $13,146.70 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,195.17 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,037.40. The transfer capital threshold is the transfer adjustment factor * $1,037.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,16129.04,59610.47,Inpatient DRG
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],16333.88,,,,,,0,other,7566.45,16333.88,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,448,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],94077.13,,"Fee schedule rate ($94,077.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,30663.95,94077.13,There are no additional notes associated with this service or procedure.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,988,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],13729.30,,"Case rate ($13,075.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,299.49, add-ons for qualifying new technology services are included. If operating cost exceeds $47,170.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,574.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $10,316.50 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,354.54 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $814.07. The transfer capital threshold is the transfer adjustment factor * $814.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13075.52,42425.46,Inpatient DRG
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],15808.67,,"Fee schedule rate ($15,808.67). Adds an outlier to normal pricing equal to the per diem rate ($67,650.85) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,7641.61,19371.27,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],8963.19,,"Case rate ($8,787.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,310.38, add-ons for qualifying new technology services are included. If operating cost exceeds $43,181.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,260.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,342.05 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,365.43 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $500.45. The transfer capital threshold is the transfer adjustment factor * $500.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6965.00,32293.66,Inpatient DRG
Nasal/Sinus Ndsc W/Partial Ethmoidectomy,CASE-31254,APC,31254,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6605.95,,"APC Price ($6,605.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6605.95,6936.25,OPPS APC
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],20170.75,,"Fee schedule rate ($20,170.75). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10048.39,23545.50,There are no additional notes associated with this service or procedure.
"LIMB REATTACHMENT, HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA",956,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],148259.86,,"Fee schedule rate ($148,259.86). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,27428.25,148259.86,There are no additional notes associated with this service or procedure.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],5778.62,,"Case rate ($5,778.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,511.33, add-ons for qualifying new technology services are included. If operating cost exceeds $40,382.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,040.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $3,553.28 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,566.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $280.39. The transfer capital threshold is the transfer adjustment factor * $280.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,5778.62,11681.49,Inpatient DRG
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],24511.94,,"Case rate ($23,344.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $21,852.68, add-ons for qualifying new technology services are included. If operating cost exceeds $56,723.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,325.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $19,834.60 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $19,907.73 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,565.15. The transfer capital threshold is the transfer adjustment factor * $1,565.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,23344.70,62179.32,Inpatient DRG
HC External Version,CASE-59412,APC,59412,CPT,0720,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3181.53,,"APC Price ($3,030.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3030.03,3181.53,OPPS APC
Ostc Prtl Exostc/Condylc Metar Head|RIGHT SIDE,CASE-28288,APC,28288,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
"Prq Skel Fixj Phlngl Shft Fx Prox/Middle Px/F/T|LEFT HAND, FIFTH DIGIT",CASE-26727,APC,26727,CPT,0360,RC,,,F4,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],47123.82,,"Fee schedule rate ($47,123.82). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,12696.97,47123.82,There are no additional notes associated with this service or procedure.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],63499.65,,,,,,0,other,23799.09,63499.65,There are no additional notes associated with this service or procedure.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,479,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],14533.55,,"Case rate ($14,533.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,655.86, add-ons for qualifying new technology services are included. If operating cost exceeds $48,526.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,680.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $11,667.89 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,710.91 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $920.71. The transfer capital threshold is the transfer adjustment factor * $920.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10586.00,50518.76,Inpatient DRG
Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE,CASE-62323,APC,62323,CPT,0360,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],660.72,,"APC Price ($660.72). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,660.72,693.76,OPPS APC
INFLAMMATORY BOWEL DISEASE WITH CC,386,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],8556.53,,"Case rate ($8,556.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,095.56, add-ons for qualifying new technology services are included. If operating cost exceeds $42,966.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,243.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,128.01 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,150.61 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $483.56. The transfer capital threshold is the transfer adjustment factor * $483.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8556.53,19879.00,Inpatient DRG
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],8318.14,,"Case rate ($8,318.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,873.80, add-ons for qualifying new technology services are included. If operating cost exceeds $42,744.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,226.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,907.07 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,928.85 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $466.13. The transfer capital threshold is the transfer adjustment factor * $466.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8318.14,19763.43,Inpatient DRG
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6122.64,,"Case rate ($6,122.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,831.37, add-ons for qualifying new technology services are included. If operating cost exceeds $40,702.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,065.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $3,872.14 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,886.42 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $305.55. The transfer capital threshold is the transfer adjustment factor * $305.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,1188.00,12138.74,Inpatient DRG
"LIMB REATTACHMENT, HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA",956,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],74044.55,,,,,,0,other,27428.25,148259.86,There are no additional notes associated with this service or procedure.
Colsc Flexible W/Transendoscopic Balloon Dilat|COLORECTAL CANCER SCREEN,CASE-45386,APC,45386,CPT,0360,RC,,,PT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1159.29,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1120.09,1176.09,OPPS APC
Rpr Aa Hernia 1st 3-10 Cm Reducible,CASE-49593,APC,49593,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6059.65,,"APC Price ($6,059.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6059.65,6362.63,OPPS APC
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],16489.07,,"Case rate ($15,703.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,770.26, add-ons for qualifying new technology services are included. If operating cost exceeds $49,641.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,742.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $12,776.86 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,825.31 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $982.06. The transfer capital threshold is the transfer adjustment factor * $982.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,16120.25,41187.90,Inpatient DRG
Unlisted Px Female Genital System Nonobstetrical,CASE-58999,APC,58999,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],198.70,,"APC Price ($189.24). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,189.24,198.70,OPPS APC
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],41187.90,,,,,,0,other,16120.25,41187.90,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],67794.72,,"Fee schedule rate ($67,794.72). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,10862.00,86437.13,There are no additional notes associated with this service or procedure.
"NEONATE BIRTH WEIGHT > 2499 GRAMS WITH RESPIRATORY DISTRESS SYNDROME OR OTHER MAJOR RESPIRATORY CONDITION,MINOR",634,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],5919.50,,"Case rate ($5,637.62). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5637.62,5919.50,There are no additional notes associated with this service or procedure.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],21455.22,,"Fee schedule rate ($21,455.22). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,9097.60,21455.22,There are no additional notes associated with this service or procedure.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],45845.03,,"Fee schedule rate ($45,845.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,18598.83,48389.68,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],94787.57,,"Fee schedule rate ($94,787.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,23526.87,94787.57,There are no additional notes associated with this service or procedure.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,073,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],13114.77,,"Case rate ($12,490.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,774.70, add-ons for qualifying new technology services are included. If operating cost exceeds $46,645.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,512.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $9,792.62 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,829.75 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $752.68. The transfer capital threshold is the transfer adjustment factor * $752.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12809.38,43475.01,Inpatient DRG
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,479,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],10586.00,,"Per diem ($10,586). If length of stay < 3.3, first 1 days paid at a per diem of $21,172 instead. Capped at $34,934.31.",,,,0,other,10586.00,50518.76,Estimated amount calculated based on 2 day length of stay.
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC,939,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],97674.79,,"Fee schedule rate ($97,674.79). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,26517.40,97674.79,There are no additional notes associated with this service or procedure.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],15309.46,,"Fee schedule rate ($15,309.46). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6965.00,15340.19,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],36008.91,,,,,,0,other,14337.84,52803.53,There are no additional notes associated with this service or procedure.
"NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY",789,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],3054.00,,,,,,0,other,3054.00,14857.05,Estimated amount calculated based on 1 day length of stay.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],7921.00,,"Per diem ($7,921). If length of stay < 4.1, first 1 days paid at a per diem of $15,842 instead. Capped at $32,474.30.",,,,0,other,7921.00,45706.73,Estimated amount calculated based on 2 day length of stay.
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],27832.43,,"Fee schedule rate ($27,832.43). Adds an outlier to normal pricing equal to the per diem rate ($62,521.14) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.7), with a minimum of zero.",,,,0,other,11974.38,29141.64,There are no additional notes associated with this service or procedure.
Laparoscopy Urethral Suspension Stress Incont,CASE-51990,APC,51990,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],9949.78,,"APC Price ($9,949.78). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,9949.78,10447.27,OPPS APC
SINGLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL,402,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],30630.65,,"Case rate ($29,172.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $27,273.75, add-ons for qualifying new technology services are included. If operating cost exceeds $62,144.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,751.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $25,235.76 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $25,328.80 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,991.35. The transfer capital threshold is the transfer adjustment factor * $1,991.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,29172.05,124455.45,Inpatient DRG
BRONCHITIS AND ASTHMA WITH CC/MCC,202,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],8948.08,,"Case rate ($8,521.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,063.43, add-ons for qualifying new technology services are included. If operating cost exceeds $42,934.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,241.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,096.00 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,118.48 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $481.03. The transfer capital threshold is the transfer adjustment factor * $481.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7606.34,19110.30,Inpatient DRG
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],6965.00,,,,,,0,other,6965.00,34422.94,There are no additional notes associated with this service or procedure.
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],10136.44,,"Case rate ($10,136.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,565.33, add-ons for qualifying new technology services are included. If operating cost exceeds $44,436.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,359.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $7,592.38 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,620.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $599.11. The transfer capital threshold is the transfer adjustment factor * $599.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10136.44,24444.75,Inpatient DRG
Egd Intrmural US Needle Aspirate/Biopsy Esophags,CASE-43238,APC,43238,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1885.95,,"APC Price ($1,796.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1796.14,1885.95,OPPS APC
Nasal/Sinus Ndsc Total With Sphenoidotomy|BILATERAL PROCEDURE,CASE-31257,APC,31257,CPT,0360,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6837.16,,"APC Price ($6,605.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6605.95,6936.25,OPPS APC
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],38508.74,,"Fee schedule rate ($38,508.74). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.6), with a minimum of zero.",,,,0,other,15821.59,40320.14,There are no additional notes associated with this service or procedure.
Bronchoscopy Needle Bx Trachea Main Stem&/Bron,CASE-31629,APC,31629,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6837.16,,"APC Price ($6,605.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6605.95,6936.25,OPPS APC
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],8165.30,,"Fee schedule rate ($8,165.30). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4341.01,12882.53,There are no additional notes associated with this service or procedure.
Prep Site Trunk/Arm/Leg 1st 100 Sq Cm/1pct,CASE-15002,APC,15002,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],691.79,,"APC Price ($691.79). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,691.79,726.38,OPPS APC
PREMATURITY WITHOUT MAJOR PROBLEMS,792,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],2074.00,,,,,,0,other,1956.00,19457.66,Estimated amount calculated based on 3 day length of stay.
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5628.97,,"Case rate ($5,628.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,372.11, add-ons for qualifying new technology services are included. If operating cost exceeds $40,243.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,029.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,414.56 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,427.15 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $269.44. The transfer capital threshold is the transfer adjustment factor * $269.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,5628.97,12272.58,Inpatient DRG
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],6886.69,,"Case rate ($6,558.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,237.08, add-ons for qualifying new technology services are included. If operating cost exceeds $41,108.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,097.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $4,276.36 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,292.13 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $337.45. The transfer capital threshold is the transfer adjustment factor * $337.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6558.75,14871.83,Inpatient DRG
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,097,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],27724.54,,"Case rate ($26,404.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $24,698.97, add-ons for qualifying new technology services are included. If operating cost exceeds $59,569.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,548.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.7. The base transfer operating payment is the transfer adjustment factor * $22,670.44 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $22,754.03 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,788.92. The transfer capital threshold is the transfer adjustment factor * $1,788.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,26404.32,79915.74,Inpatient DRG
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,451,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],94077.13,,"Fee schedule rate ($94,077.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,23821.44,94077.13,There are no additional notes associated with this service or procedure.
RESPIRATORY NEOPLASMS WITH CC,181,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],9519.76,,"Case rate ($9,197.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,692.16, add-ons for qualifying new technology services are included. If operating cost exceeds $43,563.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,290.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,722.42 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,747.21 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $530.47. The transfer capital threshold is the transfer adjustment factor * $530.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,9197.84,21074.07,Inpatient DRG
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITH MCC,429,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],64217.75,,"Case rate ($62,958.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $58,704.65, add-ons for qualifying new technology services are included. If operating cost exceeds $93,575.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $6,222.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.6. The base transfer operating payment is the transfer adjustment factor * $56,551.19 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $56,759.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,462.45. The transfer capital threshold is the transfer adjustment factor * $4,462.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,62958.58,177294.98,Inpatient DRG
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITHOUT CC/MCC,816,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],6965.00,,,,,,0,other,6224.90,14733.53,There are no additional notes associated with this service or procedure.
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,094,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],67889.44,,"Fee schedule rate ($67,889.44). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,25778.58,67889.44,There are no additional notes associated with this service or procedure.
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],16804.22,,"Fee schedule rate ($16,804.22). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7238.69,16804.22,There are no additional notes associated with this service or procedure.
HC Repair Tun or Non Cath W/Port,CASE-36576,APC,36576,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1473.45,,"APC Price ($1,473.45). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1473.45,1547.12,OPPS APC
NERVOUS SYSTEM NEOPLASMS WITH MCC,054,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],6965.00,,,,,,0,other,6965.00,30044.81,There are no additional notes associated with this service or procedure.
Laryngoscopy Exc Tum&/Stripping Cords/Epiglott,CASE-31540,APC,31540,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3489.82,,"APC Price ($3,489.82). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3489.82,3664.31,OPPS APC
Arthrs Wrst Exc&/Rpr Triang Fibrocart&/Joint|RIGHT SIDE,CASE-29846,APC,29846,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
GASTROINTESTINAL HEMORRHAGE WITH MCC,377,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],31575.65,,"Fee schedule rate ($31,575.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,7634.00,35969.56,There are no additional notes associated with this service or procedure.
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],24308.97,,,,,,0,other,10311.17,24308.97,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITH CC,386,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],19210.66,,,,,,0,other,8556.53,19879.00,There are no additional notes associated with this service or procedure.
HC Inj Anes/Steroid C/D Facet Sg|BILATERAL PROCEDURE,CASE-64490,APC,64490,CPT,0361,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],827.89,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,827.89,869.28,OPPS APC
HC Plcmt Tunnel Pleural Drain Cat,CASE-32550,APC,32550,CPT,0361,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3468.64,,"APC Price ($3,351.34). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3351.34,3518.91,OPPS APC
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",062,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],23554.26,,"Fee schedule rate ($23,554.26). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,13844.84,44304.80,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS WITH MCC,947,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],23855.83,,"Fee schedule rate ($23,855.83). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10541.41,30414.32,There are no additional notes associated with this service or procedure.
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],24092.63,,"Fee schedule rate ($24,092.63). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10626.74,25225.91,There are no additional notes associated with this service or procedure.
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],29216.99,,"Fee schedule rate ($29,216.99). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9755.86,29216.99,There are no additional notes associated with this service or procedure.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],16829.13,,"Fee schedule rate ($16,829.13). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,8009.34,19877.10,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],32795.66,,"Fee schedule rate ($32,795.66). Adds an outlier to normal pricing equal to the per diem rate ($69,146.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,1188.00,34338.33,There are no additional notes associated with this service or procedure.
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],26204.74,,"Fee schedule rate ($26,204.74). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10120.20,26204.74,There are no additional notes associated with this service or procedure.
CERVICAL SPINAL FUSION WITH CC,472,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],70198.84,,"Fee schedule rate ($70,198.84). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,21896.13,70198.84,There are no additional notes associated with this service or procedure.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC",156,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],6997.20,,"Fee schedule rate ($6,997.20). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6625.12,13598.77,There are no additional notes associated with this service or procedure.
APPENDIX PROCEDURES WITH MCC,397,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],45007.36,,"Fee schedule rate ($45,007.36). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.5), with a minimum of zero.",,,,0,other,18163.37,51558.84,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],23851.92,,"Case rate ($23,851.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $22,324.54, add-ons for qualifying new technology services are included. If operating cost exceeds $57,195.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,362.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.8. The base transfer operating payment is the transfer adjustment factor * $20,304.73 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $20,379.59 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,602.24. The transfer capital threshold is the transfer adjustment factor * $1,602.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,23851.92,63653.13,Inpatient DRG
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,761,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],11946.72,,"Fee schedule rate ($11,946.72). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,5808.41,11946.72,There are no additional notes associated with this service or procedure.
Exc Rct Procidentia W/Anast Perineal Approach,CASE-45130,APC,45130,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],51.22,,"APC Price ($48.78). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,48.78,51.22,OPPS APC
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],26391.01,,"Fee schedule rate ($26,391.01). Adds an outlier to normal pricing equal to the per diem rate ($77,296.48) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,11454.97,28394.78,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],16433.85,,"Case rate ($15,651.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,721.24, add-ons for qualifying new technology services are included. If operating cost exceeds $49,592.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,738.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $12,728.03 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,776.29 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $978.31. The transfer capital threshold is the transfer adjustment factor * $978.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,41030.48,Inpatient DRG
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC",442,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],18157.80,,"Fee schedule rate ($18,157.80). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6607.45,19011.92,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC,084,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],19445.16,,"Fee schedule rate ($19,445.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,6965.00,19445.16,There are no additional notes associated with this service or procedure.
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],12509.83,,"Case rate ($11,914.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,219.06, add-ons for qualifying new technology services are included. If operating cost exceeds $46,090.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,489.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $9,240.03 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,274.10 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $729.13. The transfer capital threshold is the transfer adjustment factor * $729.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,11914.12,40426.76,Inpatient DRG
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],34032.82,,"Fee schedule rate ($34,032.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,15233.11,38610.21,There are no additional notes associated with this service or procedure.
COMPLICATIONS OF TREATMENT WITH CC,920,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],18836.22,,"Fee schedule rate ($18,836.22). Adds an outlier to normal pricing equal to the per diem rate ($49,808.13) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,8732.59,20731.52,There are no additional notes associated with this service or procedure.
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],27553.62,,"Fee schedule rate ($27,553.62). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12305.53,30103.84,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],81353.66,,"Fee schedule rate ($81,353.66). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,27256.92,81353.66,There are no additional notes associated with this service or procedure.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],75579.22,,"Fee schedule rate ($75,579.22). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,25162.32,75579.22,There are no additional notes associated with this service or procedure.
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],8480.00,,"Per diem ($8,480). If length of stay < 5.5, first 1 days paid at a per diem of $16,960 instead. Capped at $46,638.59.",,,,0,other,8480.00,59081.91,Estimated amount calculated based on 3 day length of stay.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITHOUT CC/MCC,816,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6224.90,,"Case rate ($6,224.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,926.50, add-ons for qualifying new technology services are included. If operating cost exceeds $40,797.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,073.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $3,966.92 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,981.55 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $313.03. The transfer capital threshold is the transfer adjustment factor * $313.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6224.90,14733.53,Inpatient DRG
SPINAL PROCEDURES WITH MCC,028,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],43510.34,,"Case rate ($41,438.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $38,758.58, add-ons for qualifying new technology services are included. If operating cost exceeds $73,629.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,578.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.5. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 9.5)) / 2. The base transfer operating payment is the transfer adjustment factor * $36,674.58 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $36,813.63 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,818.89. The transfer capital threshold is the transfer adjustment factor * $2,818.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,42633.57,120982.83,Inpatient DRG
"RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT > 96 HOURS,MAJOR",130,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],47720.91,,"Case rate ($45,448.49). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,45448.49,47720.91,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],18585.05,,"Fee schedule rate ($18,585.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8859.23,20090.22,There are no additional notes associated with this service or procedure.
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC,520,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],39786.42,,"Fee schedule rate ($39,786.42). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12061.74,39786.42,There are no additional notes associated with this service or procedure.
Laps Tx Ectopic Preg W/Salping&/Oophorectomy,CASE-59151,APC,59151,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5658.76,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5658.76,5941.70,OPPS APC
"KNEE AND LOWER LEG PROCEDURES EXCEPT FOOT,MODERATE",313,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],19210.88,,"Case rate ($19,210.88). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,19210.88,20171.42,There are no additional notes associated with this service or procedure.
PERIPHERAL VASCULAR DISORDERS WITH CC,300,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],20331.78,,"Fee schedule rate ($20,331.78). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,9174.14,21005.20,There are no additional notes associated with this service or procedure.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,191,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],8832.09,,"Fee schedule rate ($8,832.09). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6965.00,16612.88,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],27256.92,,"Case rate ($27,256.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $25,492.14, add-ons for qualifying new technology services are included. If operating cost exceeds $60,363.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,611.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. The base transfer operating payment is the transfer adjustment factor * $23,460.69 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $23,547.19 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,851.28. The transfer capital threshold is the transfer adjustment factor * $1,851.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,27256.92,81353.66,Inpatient DRG
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,098,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],38799.38,,"Fee schedule rate ($38,799.38). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,6965.00,45156.75,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],86235.79,,"Fee schedule rate ($86,235.79). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,32296.02,88188.38,There are no additional notes associated with this service or procedure.
Suture Infrapatellar Tendon Primary|BILATERAL PROCEDURE,CASE-27380,APC,27380,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,056,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],18075.78,,"Case rate ($17,215.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,178.88, add-ons for qualifying new technology services are included. If operating cost exceeds $51,049.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,849.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $14,180.17 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,233.93 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,089.92. The transfer capital threshold is the transfer adjustment factor * $1,089.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7659.00,59328.19,Inpatient DRG
NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,601,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],11904.59,,,,,,0,other,6042.05,12359.72,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,690,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],14625.55,,"Fee schedule rate ($14,625.55). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7426.94,15928.53,There are no additional notes associated with this service or procedure.
"Rpr Coltrl Ligm Mtcarphlngl/Iphal Jt|RIGHT HAND, THUMB",CASE-26540,APC,26540,CPT,0360,RC,,,F5,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],19119.59,,"Case rate ($19,119.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,922.16, add-ons for qualifying new technology services are included. If operating cost exceeds $52,793.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,016.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $15,918.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,977.21 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,256.13. The transfer capital threshold is the transfer adjustment factor * $1,256.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,11348.00,62454.12,Inpatient DRG
Cysto/Uretero W/Lithotripsy &Indwell Stent Insrt|SEPARATE STRUCTURE|RIGHT SIDE,CASE-52356,APC,52356,CPT,0360,RC,,,XS|RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5269.71,,"APC Price ($5,018.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5018.77,5269.71,OPPS APC
Rpr Aa Hernia 1st 3-10 Cm Reducible,CASE-49593,APC,49593,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6362.63,,"APC Price ($6,059.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6059.65,6362.63,OPPS APC
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],25534.84,,,,,,0,other,10733.06,45157.33,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],14086.54,,"Case rate ($13,415.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,637.40, add-ons for qualifying new technology services are included. If operating cost exceeds $47,508.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,578.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $10,652.07 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,692.45 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $818.74. The transfer capital threshold is the transfer adjustment factor * $818.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,1188.00,34338.33,Inpatient DRG
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",623,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],14093.37,,"Case rate ($14,093.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,246.37, add-ons for qualifying new technology services are included. If operating cost exceeds $48,117.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,648.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $11,259.90 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,301.42 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $888.52. The transfer capital threshold is the transfer adjustment factor * $888.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,14093.37,33712.76,Inpatient DRG
Enteroscopy > 2nd Prtn W/Control Bleeding,CASE-44366,APC,44366,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1859.01,,"APC Price ($1,796.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1796.14,1885.95,OPPS APC
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],22626.77,,"Fee schedule rate ($22,626.77). Adds an outlier to normal pricing equal to the per diem rate ($36,883.74) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.5), with a minimum of zero.",,,,0,other,10098.51,24259.09,There are no additional notes associated with this service or procedure.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],39820.52,,"Fee schedule rate ($39,820.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,15273.74,39820.52,There are no additional notes associated with this service or procedure.
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],7842.75,,"Case rate ($7,842.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,431.55, add-ons for qualifying new technology services are included. If operating cost exceeds $42,302.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,191.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $5,466.44 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,486.60 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $431.36. The transfer capital threshold is the transfer adjustment factor * $431.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,5280.00,17136.70,Inpatient DRG
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],27222.08,,"Fee schedule rate ($27,222.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7389.00,37134.43,There are no additional notes associated with this service or procedure.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],105091.76,,"Fee schedule rate ($105,091.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,35719.96,105091.76,There are no additional notes associated with this service or procedure.
HC Injection Small Joint/Bursa|PBB CHARGE,CASE-20600,APC,20600,CPT,0361,RC,,,PBB,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],287.31,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,085,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],57443.16,,"Fee schedule rate ($57,443.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,9282.00,57443.16,There are no additional notes associated with this service or procedure.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],16120.25,,"Case rate ($16,120.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,131.93, add-ons for qualifying new technology services are included. If operating cost exceeds $50,002.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,796.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $13,138.54 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,186.98 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,036.76. The transfer capital threshold is the transfer adjustment factor * $1,036.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,16120.25,41187.90,Inpatient DRG
Open Tx Metacarpal Fracture Single Ea Bone|LEFT SIDE,CASE-26615,APC,26615,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3169.86,3215.80,OPPS APC
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],36094.03,,"Fee schedule rate ($36,094.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11194.25,36094.03,There are no additional notes associated with this service or procedure.
Posterior Non-Segmental Instrumentation,CASE-22840,APC,22840,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],26287.03,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,25398.09,26287.03,OPPS APC
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],12696.11,,"Case rate ($12,091.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,384.11, add-ons for qualifying new technology services are included. If operating cost exceeds $46,255.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,502.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $9,404.49 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,439.16 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $742.11. The transfer capital threshold is the transfer adjustment factor * $742.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,29482.05,Inpatient DRG
Exc B9 Lesion Mrgn Xcp Sk Tg T/a/L 0.6-1.0 Cm,CASE-11401,APC,11401,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],399.53,,"APC Price ($380.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,380.51,399.53,OPPS APC
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],21354.82,,"Fee schedule rate ($21,354.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6834.39,21354.82,There are no additional notes associated with this service or procedure.
HYPERTENSION WITHOUT MCC,305,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],14190.59,,"Fee schedule rate ($14,190.59). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,7058.55,17230.49,There are no additional notes associated with this service or procedure.
FULL TERM NEONATE WITH MAJOR PROBLEMS,793,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],78359.29,,"Fee schedule rate ($78,359.29). Adds an outlier to normal pricing equal to the per diem rate ($27,082.03) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.7), with a minimum of zero.",,,,0,other,4302.90,82045.22,There are no additional notes associated with this service or procedure.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC",156,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],11593.96,,"Case rate ($6,625.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,298.82, add-ons for qualifying new technology services are included. If operating cost exceeds $41,169.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,102.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $4,337.88 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,353.87 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $342.30. The transfer capital threshold is the transfer adjustment factor * $342.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,6625.12,13598.77,All Other Inpatient
"NEONATE BIRTH WEIGHT 2000-2499 GRAMS NORMAL NEWBORN OR NEONATE WITH OTHER PROBLEM,MAJOR",626,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],7399.95,,"Case rate ($7,047.57). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7047.57,7399.95,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF THE EYE WITHOUT MCC,125,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],9949.80,,"Fee schedule rate ($9,949.80). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (6), with a minimum of zero.",,,,0,other,7144.54,17952.29,There are no additional notes associated with this service or procedure.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,479,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],36577.58,,,,,,0,other,10586.00,50518.76,There are no additional notes associated with this service or procedure.
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],15600.07,,"Fee schedule rate ($15,600.07). Adds an outlier to normal pricing equal to the per diem rate ($180,117.98) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,7566.45,16333.88,There are no additional notes associated with this service or procedure.
PERIPHERAL VASCULAR DISORDERS WITH CC,300,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],9174.14,,"Case rate ($9,174.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,670.11, add-ons for qualifying new technology services are included. If operating cost exceeds $43,541.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,288.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,700.45 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,725.16 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $528.73. The transfer capital threshold is the transfer adjustment factor * $528.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9174.14,21005.20,Inpatient DRG
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],19877.10,,"Fee schedule rate ($19,877.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8009.34,19877.10,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],28821.04,,"Fee schedule rate ($28,821.04). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,10347.06,28821.04,There are no additional notes associated with this service or procedure.
VENTRICULAR SHUNT PROCEDURES WITH MCC,031,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],62406.76,,"Fee schedule rate ($62,406.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,32287.20,88162.80,There are no additional notes associated with this service or procedure.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC,434,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],13280.45,,"Fee schedule rate ($13,280.45). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6770.05,14019.86,There are no additional notes associated with this service or procedure.
PERITONEAL ADHESIOLYSIS WITH CC,336,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],53705.31,,"Fee schedule rate ($53,705.31). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,16225.22,53705.31,There are no additional notes associated with this service or procedure.
"VAGINAL DELIVERY,MODERATE",560,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],4534.59,,"Case rate ($4,318.66). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4318.66,4534.59,There are no additional notes associated with this service or procedure.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],25052.97,,"Fee schedule rate ($25,052.97). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,12696.97,47123.82,There are no additional notes associated with this service or procedure.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,477,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],64922.30,,"Fee schedule rate ($64,922.30). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16.6), with a minimum of zero.",,,,0,other,25339.74,67976.16,There are no additional notes associated with this service or procedure.
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],38839.49,,"Fee schedule rate ($38,839.49). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.6), with a minimum of zero.",,,,0,other,15940.79,53275.26,There are no additional notes associated with this service or procedure.
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],35419.59,,"Fee schedule rate ($35,419.59). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,7086.00,57872.02,There are no additional notes associated with this service or procedure.
Removal Cerclage Suture Under Anesthesia,CASE-59871,APC,59871,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3030.03,,"APC Price ($3,030.03). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3030.03,3181.53,OPPS APC
Peri-Implant Capsulectomy Breast Complete|BILATERAL PROCEDURE,CASE-19371,APC,19371,CPT,0360,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],8033.01,,"APC Price ($7,650.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,7918.25,8033.01,OPPS APC
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH CC,026,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],23000.66,,"Case rate ($23,000.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $21,532.64, add-ons for qualifying new technology services are included. If operating cost exceeds $56,403.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,299.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $19,515.74 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $19,587.69 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,539.98. The transfer capital threshold is the transfer adjustment factor * $1,539.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,23000.66,63202.45,Inpatient DRG
GASTROINTESTINAL HEMORRHAGE WITH MCC,377,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],14324.29,,"Case rate ($14,324.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,461.19, add-ons for qualifying new technology services are included. If operating cost exceeds $48,332.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,665.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $11,473.94 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,516.24 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $905.41. The transfer capital threshold is the transfer adjustment factor * $905.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7634.00,35969.56,Inpatient DRG
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],27589.62,,"Fee schedule rate ($27,589.62). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12566.28,30861.41,There are no additional notes associated with this service or procedure.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],47123.82,,"Fee schedule rate ($47,123.82). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,12696.97,47123.82,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,086,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],30728.81,,"Fee schedule rate ($30,728.81). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8442.00,30728.81,There are no additional notes associated with this service or procedure.
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC",011,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],107320.33,,,,,,0,other,38880.49,150008.48,There are no additional notes associated with this service or procedure.
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],39359.90,,,,,,0,other,15491.11,54180.83,There are no additional notes associated with this service or procedure.
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC,939,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],51927.95,,"Fee schedule rate ($51,927.95). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,26517.40,97674.79,There are no additional notes associated with this service or procedure.
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],62990.26,,"Fee schedule rate ($62,990.26). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,16787.98,62990.26,There are no additional notes associated with this service or procedure.
VENTRICULAR SHUNT PROCEDURES WITH MCC,031,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],84202.04,,"Fee schedule rate ($84,202.04). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16.6), with a minimum of zero.",,,,0,other,32287.20,88162.80,There are no additional notes associated with this service or procedure.
Excision Tumor Soft Tissue Shoulder Subq 3 Cm/>,CASE-23071,APC,23071,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5856.81,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5658.76,5941.70,OPPS APC
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,394,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],18411.77,,,,,,0,other,8281.56,20909.61,There are no additional notes associated with this service or procedure.
UNGROUPABLE,999,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],136003.49,,,,,,0,other,10228.00,161307.29,There are no additional notes associated with this service or procedure.
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],23385.72,,"Fee schedule rate ($23,385.72). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,23385.72,There are no additional notes associated with this service or procedure.
DIABETES WITHOUT CC/MCC,639,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],6965.00,,,,,,0,other,6151.76,12223.35,There are no additional notes associated with this service or procedure.
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],12858.35,,"Case rate ($12,606.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,862.91, add-ons for qualifying new technology services are included. If operating cost exceeds $46,733.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,539.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $9,881.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,917.95 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $779.75. The transfer capital threshold is the transfer adjustment factor * $779.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,12606.23,36868.88,Inpatient DRG
CESAREAN SECTION WITHOUT STERILIZATION WITH CC,787,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],23722.94,,"Fee schedule rate ($23,722.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9508.01,23722.94,There are no additional notes associated with this service or procedure.
"Amputation Metatarsal W/Toe Single|RIGHT FOOT, FIFTH DIGIT",CASE-28810,APC,28810,CPT,0360,RC,,,T9,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
"NEONATE BIRTH WEIGHT > 2499 GRAMS WITH MAJOR ANOMALY,MAJOR",633,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],22319.13,,"Case rate ($22,319.13). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,22319.13,23435.09,There are no additional notes associated with this service or procedure.
OSTEOMYELITIS WITHOUT CC/MCC,541,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],11429.52,,"Fee schedule rate ($11,429.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5103.00,15493.67,There are no additional notes associated with this service or procedure.
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,307,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7694.89,,"Case rate ($7,434.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $7,017.68, add-ons for qualifying new technology services are included. If operating cost exceeds $45,662.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $3,170.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $5,632.79 + an uncompensated DSH payment of $1,359.91. The transfer operating threshold is the transfer adjustment factor * $5,657.77 + an uncompensated DSH payment of $1,359.91. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $441.98. The transfer capital threshold is the transfer adjustment factor * $441.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6335.27,18228.77,Inpatient DRG
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],16587.74,,"Case rate ($16,026.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,044.99, add-ons for qualifying new technology services are included. If operating cost exceeds $49,916.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,789.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $13,051.92 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,100.04 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,029.93. The transfer capital threshold is the transfer adjustment factor * $1,029.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,11165.00,61234.06,Inpatient DRG
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],13435.63,,"Case rate ($12,795.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,039.30, add-ons for qualifying new technology services are included. If operating cost exceeds $46,910.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,553.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $10,057.27 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,094.35 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $793.62. The transfer capital threshold is the transfer adjustment factor * $793.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12795.84,41944.25,Inpatient DRG
Surgical Arthroscopy Shoulder Dstl Claviculc|LEFT SIDE,CASE-29824,APC,29824,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],6965.00,,,,,,0,other,6340.03,15076.44,There are no additional notes associated with this service or procedure.
RESPIRATORY NEOPLASMS WITHOUT CC/MCC,182,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],23037.13,,"Fee schedule rate ($23,037.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6965.00,23037.13,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],59610.47,,"Fee schedule rate ($59,610.47). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,16129.04,59610.47,There are no additional notes associated with this service or procedure.
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],19997.63,,"Fee schedule rate ($19,997.63). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,9151.11,30245.71,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,447,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],156646.82,,"Fee schedule rate ($156,646.82). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,47193.21,156646.82,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],30372.64,,"Fee schedule rate ($30,372.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,13260.40,32878.30,There are no additional notes associated with this service or procedure.
INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC,198,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],6931.02,,"Case rate ($6,795.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,456.95, add-ons for qualifying new technology services are included. If operating cost exceeds $41,327.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,114.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,495.42 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,512.00 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $354.73. The transfer capital threshold is the transfer adjustment factor * $354.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6795.12,23505.07,Inpatient DRG
"Tendon Sheath Incision|RIGHT HAND, SECOND DIGIT",CASE-26055,APC,26055,CPT,0360,RC,,,F6,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1505.12,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1505.12,1580.37,OPPS APC
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],13064.19,,"Case rate ($12,808.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,050.64, add-ons for qualifying new technology services are included. If operating cost exceeds $46,921.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,554.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $10,068.57 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,105.69 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $794.51. The transfer capital threshold is the transfer adjustment factor * $794.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,7353.00,33398.16,Inpatient DRG
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],24838.71,,"Fee schedule rate ($24,838.71). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,10895.60,35192.25,There are no additional notes associated with this service or procedure.
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],42767.23,,"Fee schedule rate ($42,767.23). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,17356.15,44778.95,There are no additional notes associated with this service or procedure.
"Tendon Sheath Incision|RIGHT HAND, FOURTH DIGIT",CASE-26055,APC,26055,CPT,0360,RC,,,F8,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1505.12,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1505.12,1580.37,OPPS APC
CERVICAL SPINAL FUSION WITH CC,472,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],22375.61,,"Case rate ($21,310.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $19,996.08, add-ons for qualifying new technology services are included. If operating cost exceeds $54,867.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,142.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $17,982.95 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,051.13 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,382.21. The transfer capital threshold is the transfer adjustment factor * $1,382.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,21896.13,70198.84,Inpatient DRG
Laparoscopy Surg Partial Nephrectomy|LEFT SIDE,CASE-50543,APC,50543,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],9949.78,,"APC Price ($9,949.78). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,9949.78,10447.27,OPPS APC
HC Peripheral Block - Femoral Single or Saphenous W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE|RIGHT SIDE,CASE-64447,APC,64447,CPT,0360,RC,,,XU|RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1557.80,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1505.12,1580.37,OPPS APC
Laps Surg Rpr Recurrent Inguinal Hernia|BILATERAL PROCEDURE,CASE-49651,APC,49651,CPT,0360,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5941.70,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5658.76,5941.70,OPPS APC
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],32168.63,,"Fee schedule rate ($32,168.63). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,13904.43,34749.58,There are no additional notes associated with this service or procedure.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],19604.30,,"Fee schedule rate ($19,604.30). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9446.38,21796.21,There are no additional notes associated with this service or procedure.
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],14845.26,,"Case rate ($14,343.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,478.83, add-ons for qualifying new technology services are included. If operating cost exceeds $48,349.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,666.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $11,491.51 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,533.88 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $906.79. The transfer capital threshold is the transfer adjustment factor * $906.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,14343.25,36024.65,Inpatient DRG
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],2070.00,,,,,,0,other,1188.00,34338.33,Estimated amount calculated based on 6 day length of stay.
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],34032.82,,"Fee schedule rate ($34,032.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,15233.11,38610.21,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],25293.50,,"Fee schedule rate ($25,293.50). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11059.47,28423.20,There are no additional notes associated with this service or procedure.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],22664.58,,"Case rate ($21,585.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,215.96, add-ons for qualifying new technology services are included. If operating cost exceeds $55,086.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,196.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $18,203.89 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,271.01 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,436.47. The transfer capital threshold is the transfer adjustment factor * $1,436.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,21585.31,73588.10,Inpatient DRG
SINGLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL,402,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],75557.26,,"Fee schedule rate ($75,557.26). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.9), with a minimum of zero.",,,,0,other,29172.05,124455.45,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],25609.86,,"Fee schedule rate ($25,609.86). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,12775.53,31469.43,There are no additional notes associated with this service or procedure.
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH CC",457,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],160549.49,,"Fee schedule rate ($160,549.49). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,42327.47,160549.49,There are no additional notes associated with this service or procedure.
HC Drain/Inj Joint/Bursa W/US Large|RIGHT SIDE,CASE-20611,APC,20611,CPT,0510,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
Arthroscopy Knee W/Meniscus Rpr Medial/Lateral,CASE-29882,APC,29882,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],12017.31,,"APC Price ($12,017.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12017.31,12618.18,OPPS APC
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 2nd Level|RIGHT SIDE,CASE-64494,APC,64494,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],856.86,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,827.89,869.28,OPPS APC
Laps Rpr Paraesphgl Hrna Incl Fundplsty W/O Mesh,CASE-43281,APC,43281,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],10447.27,,"APC Price ($9,949.78). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,9949.78,10447.27,OPPS APC
"HYPOVOLEMIA AND RELATED ELECTROLYTE DISORDERS,MODERATE",422,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],1923.79,,"Case rate for a one day stay ($1,923.79). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,1923.79,2019.98,There are no additional notes associated with this service or procedure.
Cystourethroscopy Inj Chemodenervation Bladder|UNUSUAL NON-OVERLAPPING SERVICE,CASE-52287,APC,52287,CPT,0360,RC,,,XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3464.44,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3299.47,3464.44,OPPS APC
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],41740.86,,"Case rate ($23,851.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $22,324.54, add-ons for qualifying new technology services are included. If operating cost exceeds $57,195.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,362.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.8. The base transfer operating payment is the transfer adjustment factor * $20,304.73 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $20,379.59 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,602.24. The transfer capital threshold is the transfer adjustment factor * $1,602.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,23851.92,63653.13,All Other Inpatient
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],13244.49,,"Case rate ($12,984.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,215.07, add-ons for qualifying new technology services are included. If operating cost exceeds $47,086.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,567.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $10,232.39 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,270.12 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $807.44. The transfer capital threshold is the transfer adjustment factor * $807.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,12984.79,32077.45,Inpatient DRG
Prq Skel Fixj Dstl Phlngl Fx Fngr/Thmb Ea,CASE-26756,APC,26756,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],13447.65,,"Case rate ($12,992.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,222.63, add-ons for qualifying new technology services are included. If operating cost exceeds $47,093.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,568.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $10,239.92 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,277.68 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $808.03. The transfer capital threshold is the transfer adjustment factor * $808.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,7665.00,40737.46,Inpatient DRG
RADIOTHERAPY,849,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],43523.92,,"Fee schedule rate ($43,523.92). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,20293.88,81867.07,There are no additional notes associated with this service or procedure.
Tx Missed Abortion First Trimester Surgical,CASE-59820,APC,59820,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3136.08,,"APC Price ($3,030.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3030.03,3181.53,OPPS APC
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],16035.06,,"Fee schedule rate ($16,035.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,7396.47,16035.06,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],32364.15,,"Fee schedule rate ($32,364.15). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,9370.00,65732.99,There are no additional notes associated with this service or procedure.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC,858,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],33794.11,,"Fee schedule rate ($33,794.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11377.76,33794.11,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],18905.23,,"Fee schedule rate ($18,905.23). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6963.00,18954.85,There are no additional notes associated with this service or procedure.
"Tendon Sheath Incision|RIGHT HAND, FIFTH DIGIT",CASE-26055,APC,26055,CPT,0360,RC,,,F9,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1505.12,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1505.12,1580.37,OPPS APC
VENTRICULAR SHUNT PROCEDURES WITH CC,032,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],46275.08,,"Fee schedule rate ($46,275.08). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,16376.22,46275.08,There are no additional notes associated with this service or procedure.
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,095,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],48575.01,,"Fee schedule rate ($48,575.01). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,19411.47,50750.92,There are no additional notes associated with this service or procedure.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],20782.85,,,,,,0,other,9097.60,21455.22,There are no additional notes associated with this service or procedure.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],24259.09,,"Fee schedule rate ($24,259.09). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10098.51,24259.09,There are no additional notes associated with this service or procedure.
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC,519,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],50780.20,,"Fee schedule rate ($50,780.20). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,15490.44,50780.20,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],13405.94,,,,,,0,other,6558.75,14871.83,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,690,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],15212.93,,"Fee schedule rate ($15,212.93). Adds an outlier to normal pricing equal to the per diem rate ($36,758.78) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,7426.94,15928.53,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],9389.48,,"Case rate ($9,389.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,870.44, add-ons for qualifying new technology services are included. If operating cost exceeds $43,741.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,304.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,900.05 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,925.50 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $544.48. The transfer capital threshold is the transfer adjustment factor * $544.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9389.48,22358.90,Inpatient DRG
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],13872.99,,"Fee schedule rate ($13,872.99). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.8), with a minimum of zero.",,,,0,other,5068.21,14525.56,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],29241.62,,"Fee schedule rate ($29,241.62). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,12984.79,32077.45,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH CC,427,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],135659.15,,"Fee schedule rate ($135,659.15). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.8), with a minimum of zero.",,,,0,other,50829.82,142040.39,There are no additional notes associated with this service or procedure.
HC Joint Injection/Aspir Large WO US|PBB CHARGE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-20610,APC,20610,CPT,0510,RC,,,PBB|XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],297.37,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,287.31,301.68,OPPS APC
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],13486.95,,"Fee schedule rate ($13,486.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6915.64,14442.92,There are no additional notes associated with this service or procedure.
CERVICAL SPINAL FUSION WITH MCC,471,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],111337.93,,"Fee schedule rate ($111,337.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,34645.26,111337.93,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],22358.90,,"Fee schedule rate ($22,358.90). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9389.48,22358.90,There are no additional notes associated with this service or procedure.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],43888.01,,"Fee schedule rate ($43,888.01). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11717.72,43888.01,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITH MCC,385,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],11967.90,,"Fee schedule rate ($11,967.90). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11480.01,31134.92,There are no additional notes associated with this service or procedure.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],22071.25,,"Case rate ($21,020.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $19,725.88, add-ons for qualifying new technology services are included. If operating cost exceeds $54,596.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,121.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $17,713.77 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $17,780.93 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,361.52. The transfer capital threshold is the transfer adjustment factor * $1,361.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,21597.50,67790.93,Inpatient DRG
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],12795.84,,"Case rate ($12,795.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,039.30, add-ons for qualifying new technology services are included. If operating cost exceeds $46,910.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,553.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $10,057.27 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,094.35 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $793.62. The transfer capital threshold is the transfer adjustment factor * $793.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12795.84,41944.25,Inpatient DRG
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],40108.48,,"Fee schedule rate ($40,108.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,5569.00,40108.48,There are no additional notes associated with this service or procedure.
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],17033.98,,"Fee schedule rate ($17,033.98). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.8), with a minimum of zero.",,,,0,other,7884.32,17835.23,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC,084,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],19445.16,,"Fee schedule rate ($19,445.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,6965.00,19445.16,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],9492.76,,"Case rate ($9,040.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,546, add-ons for qualifying new technology services are included. If operating cost exceeds $43,417.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,278.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,576.80 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,601.05 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $518.97. The transfer capital threshold is the transfer adjustment factor * $518.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9040.72,26966.33,Inpatient DRG
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,094,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],66140.08,,"Fee schedule rate ($66,140.08). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16.5), with a minimum of zero.",,,,0,other,25778.58,67889.44,There are no additional notes associated with this service or procedure.
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],48961.48,,"Fee schedule rate ($48,961.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11575.50,48961.48,There are no additional notes associated with this service or procedure.
Injection Aa&/Strd Genicular Nrv Branches W/Img|RIGHT SIDE,CASE-64454,APC,64454,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],683.85,,"APC Price ($660.72). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,660.72,693.76,OPPS APC
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],14705.65,,"Case rate ($14,005.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,187.01, add-ons for qualifying new technology services are included. If operating cost exceeds $48,058.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,620.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $11,199.59 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,242.06 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $860.83. The transfer capital threshold is the transfer adjustment factor * $860.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,14370.36,38378.80,Inpatient DRG
Laparoscopy Surg Rpr Initial Inguinal Hernia|BILATERAL PROCEDURE,CASE-49650,APC,49650,CPT,0360,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5941.70,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5658.76,5941.70,OPPS APC
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],57305.33,,,,,,0,other,8972.00,81524.17,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],81353.66,,"Fee schedule rate ($81,353.66). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,27256.92,81353.66,There are no additional notes associated with this service or procedure.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],9238.95,,"Fee schedule rate ($9,238.95). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8767.81,19824.58,There are no additional notes associated with this service or procedure.
CELLULITIS WITH MCC,602,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],26710.49,,"Fee schedule rate ($26,710.49). Adds an outlier to normal pricing equal to the per diem rate ($28,488.06) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.8), with a minimum of zero.",,,,0,other,11570.10,28349.31,There are no additional notes associated with this service or procedure.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],37768.77,,"Fee schedule rate ($37,768.77). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7453.00,42138.30,There are no additional notes associated with this service or procedure.
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],16498.72,,"Case rate ($15,940.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,964.98, add-ons for qualifying new technology services are included. If operating cost exceeds $49,835.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,783.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $12,972.20 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,020.03 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,023.63. The transfer capital threshold is the transfer adjustment factor * $1,023.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,15940.79,53275.26,Inpatient DRG
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],21195.68,,"Fee schedule rate ($21,195.68). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,6965.00,21195.68,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],7923.33,,"Case rate ($7,923.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,506.51, add-ons for qualifying new technology services are included. If operating cost exceeds $42,377.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,197.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $5,541.13 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,561.56 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $437.25. The transfer capital threshold is the transfer adjustment factor * $437.25. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,1188.00,17370.86,Inpatient DRG
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],21854.96,,"Fee schedule rate ($21,854.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10638.94,25261.33,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,555,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],42290.95,,"Fee schedule rate ($42,290.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10896.27,42290.95,There are no additional notes associated with this service or procedure.
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],10201.52,,"Case rate ($9,715.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,188.44, add-ons for qualifying new technology services are included. If operating cost exceeds $44,059.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,314.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $7,216.13 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,243.49 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $554.65. The transfer capital threshold is the transfer adjustment factor * $554.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7243.75,23262.15,Inpatient DRG
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,451,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],94077.13,,"Fee schedule rate ($94,077.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,23821.44,94077.13,There are no additional notes associated with this service or procedure.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],17365.00,,"Fee schedule rate ($17,365.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5683.00,19635.68,There are no additional notes associated with this service or procedure.
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],23870.71,,"Fee schedule rate ($23,870.71). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10626.74,25225.91,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC,817,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],42878.11,,"Fee schedule rate ($42,878.11). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.5), with a minimum of zero.",,,,0,other,17396.11,44895.04,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],85305.59,,"Fee schedule rate ($85,305.59). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,21719.40,85305.59,There are no additional notes associated with this service or procedure.
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],12526.44,,"Fee schedule rate ($12,526.44). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5415.00,17575.50,There are no additional notes associated with this service or procedure.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],51656.32,,"Fee schedule rate ($51,656.32). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,20559.34,54086.17,There are no additional notes associated with this service or procedure.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,057,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],11254.78,,"Case rate ($10,718.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,107.12, add-ons for qualifying new technology services are included. If operating cost exceeds $44,978.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,401.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,132.18 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,162.17 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $641.71. The transfer capital threshold is the transfer adjustment factor * $641.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10718.84,39884.93,Inpatient DRG
CELLULITIS WITH MCC,602,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],26710.49,,"Fee schedule rate ($26,710.49). Adds an outlier to normal pricing equal to the per diem rate ($28,488.06) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.8), with a minimum of zero.",,,,0,other,11570.10,28349.31,There are no additional notes associated with this service or procedure.
NONTRAUMATIC STUPOR AND COMA WITH MCC,080,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],30179.40,,"Fee schedule rate ($30,179.40). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,14202.39,35615.37,There are no additional notes associated with this service or procedure.
SPINAL PROCEDURES WITH MCC,028,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],120982.83,,"Fee schedule rate ($120,982.83). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,42633.57,120982.83,There are no additional notes associated with this service or procedure.
Aspiration Bladder Insert Suprapubic Catheter,CASE-51102,APC,51102,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],2054.48,,"APC Price ($1,956.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1956.65,2054.48,OPPS APC
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],13361.69,,"Case rate ($12,725.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,973.79, add-ons for qualifying new technology services are included. If operating cost exceeds $46,844.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,548.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $9,991.99 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,028.83 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $788.47. The transfer capital threshold is the transfer adjustment factor * $788.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12725.42,34245.00,Inpatient DRG
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC",458,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],30806.13,,"Case rate ($30,202.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $28,231.97, add-ons for qualifying new technology services are included. If operating cost exceeds $63,102.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,826.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $26,190.45 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $26,287.02 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,066.69. The transfer capital threshold is the transfer adjustment factor * $2,066.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,30202.09,132827.25,Inpatient DRG
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC,806,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],13416.00,,,,,,0,other,5354.25,13416.00,There are no additional notes associated with this service or procedure.
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],29594.00,,"Fee schedule rate ($29,594.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,13571.25,33781.47,There are no additional notes associated with this service or procedure.
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],14625.55,,"Fee schedule rate ($14,625.55). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7438.45,15961.98,There are no additional notes associated with this service or procedure.
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],45017.13,,"Fee schedule rate ($45,017.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,14603.31,45017.13,There are no additional notes associated with this service or procedure.
NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,601,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],12359.72,,"Fee schedule rate ($12,359.72). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6042.05,12359.72,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],8787.35,,"Case rate ($8,368.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,932.99, add-ons for qualifying new technology services are included. If operating cost exceeds $42,804.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,218.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $5,965.43 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,988.04 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $458.52. The transfer capital threshold is the transfer adjustment factor * $458.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8563.30,31533.97,Inpatient DRG
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],42138.30,,,,,,0,other,7453.00,42138.30,There are no additional notes associated with this service or procedure.
INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC,198,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],23505.07,,"Fee schedule rate ($23,505.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6795.12,23505.07,There are no additional notes associated with this service or procedure.
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],16048.10,,"Case rate ($15,283.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,353.89, add-ons for qualifying new technology services are included. If operating cost exceeds $49,224.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,735.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.2. The base transfer operating payment is the transfer adjustment factor * $12,363.36 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,408.94 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $975.59. The transfer capital threshold is the transfer adjustment factor * $975.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,15283.90,38757.79,Inpatient DRG
OTHER CEREBROVASCULAR DISORDERS WITH MCC,070,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],37774.46,,"Fee schedule rate ($37,774.46). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,13219.09,37774.46,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC,833,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],10289.10,,,,,,0,other,3041.73,10289.10,There are no additional notes associated with this service or procedure.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],9252.42,,"Case rate ($8,811.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,333.06, add-ons for qualifying new technology services are included. If operating cost exceeds $43,204.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,262.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,364.65 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,388.11 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $502.23. The transfer capital threshold is the transfer adjustment factor * $502.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,20401.88,Inpatient DRG
Parathyroidectomy/Exploration Parathyroids|SEPARATE STRUCTURE|RIGHT SIDE,CASE-60500,APC,60500,CPT,0360,RC,,,XS|RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],10298.02,,"APC Price ($9,949.78). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,9949.78,10447.27,OPPS APC
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],29474.94,,"Fee schedule rate ($29,474.94). Adds an outlier to normal pricing equal to the per diem rate ($65,448.99) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.4), with a minimum of zero.",,,,0,other,12566.28,30861.41,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],16343.72,,,,,,0,other,7569.84,21892.85,There are no additional notes associated with this service or procedure.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,345,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],33616.03,,"Fee schedule rate ($33,616.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12134.89,33616.03,There are no additional notes associated with this service or procedure.
Ndsc Dcmprn Spinal Cord 1 W/Lamot Ntrspc Lumbar,CASE-62380,APC,62380,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7029.71,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6791.99,7131.59,OPPS APC
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],59521.43,,"Fee schedule rate ($59,521.43). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,16689.78,59521.43,There are no additional notes associated with this service or procedure.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],16669.71,,"Fee schedule rate ($16,669.71). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8767.81,19824.58,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],2070.00,,,,,,0,other,1188.00,12138.74,Estimated amount calculated based on 1 day length of stay.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],5683.00,,"Per diem ($5,683). If length of stay < 3.3, first 1 days paid at a per diem of $11,366 instead. Capped at $18,753.53.",,,,0,other,5683.00,19635.68,Estimated amount calculated based on 3 day length of stay.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,988,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],42425.46,,"Fee schedule rate ($42,425.46). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,13075.52,42425.46,There are no additional notes associated with this service or procedure.
Rpr 1st Ingun Hrna Age 5 Yrs/> Incarcerated|RIGHT SIDE,CASE-49507,APC,49507,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3518.91,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3351.34,3518.91,OPPS APC
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],19952.48,,,,,,0,other,6965.00,20401.88,There are no additional notes associated with this service or procedure.
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],19371.27,,"Fee schedule rate ($19,371.27). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8643.20,19462.52,There are no additional notes associated with this service or procedure.
DIABETES WITH CC,638,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],8014.07,,"Case rate ($8,014.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,590.93, add-ons for qualifying new technology services are included. If operating cost exceeds $42,461.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,203.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,625.24 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,645.98 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $443.89. The transfer capital threshold is the transfer adjustment factor * $443.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8014.07,17634.53,Inpatient DRG
Autograft Spine Surgery Local From Same Incision,CASE-20936,APC,20936,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],16412.07,,"APC Price ($16,412.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,16412.07,17232.68,OPPS APC
"NEONATE BIRTH WEIGHT 1500-1999 GRAMS WITH RESPIRATORY DISTRESS SYNDROME OR OTHER MAJOR RESPIRATORY CONDITION,MODERATE",612,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],10963.86,,"Case rate ($10,963.86). Base payment rate plus any adjustments related to outliers.",,,,0,other,10963.86,11512.05,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],27049.03,,"Case rate ($15,456.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,514.54, add-ons for qualifying new technology services are included. If operating cost exceeds $49,385.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,748.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $12,523.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,569.59 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $988.22. The transfer capital threshold is the transfer adjustment factor * $988.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,15456.59,41402.42,All Other Inpatient
FRACTURES OF FEMUR WITH MCC,533,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],6852.00,,"Per diem ($6,852). If length of stay < 4.3, first 1 days paid at a per diem of $13,704 instead. Capped at $29,461.79.",,,,0,other,6852.00,49490.05,Estimated amount calculated based on 2 day length of stay.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,167,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],43522.37,,"Fee schedule rate ($43,522.37). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,14157.71,43522.37,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITH CC,164,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],19703.98,,"Case rate ($19,037.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,845.93, add-ons for qualifying new technology services are included. If operating cost exceeds $52,716.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,010.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $15,842.57 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,900.98 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,250.14. The transfer capital threshold is the transfer adjustment factor * $1,250.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,19037.66,77058.83,Inpatient DRG
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],41402.42,,"Fee schedule rate ($41,402.42). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,15456.59,41402.42,There are no additional notes associated with this service or procedure.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],17620.75,,,,,,0,other,8009.34,19877.10,There are no additional notes associated with this service or procedure.
OTHER CEREBROVASCULAR DISORDERS WITH CC,071,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],9204.36,,"Case rate ($8,893.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,408.66, add-ons for qualifying new technology services are included. If operating cost exceeds $43,279.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,268.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,439.97 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,463.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $508.18. The transfer capital threshold is the transfer adjustment factor * $508.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,5843.00,29215.10,Inpatient DRG
Insj Biomchn Dev Vrt Corpectomy Defect W/Arthrd,CASE-22854,APC,22854,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12618.18,,"APC Price ($12,017.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,12017.31,12618.18,OPPS APC
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],31577.54,,"Fee schedule rate ($31,577.54). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,15453.88,39251.68,There are no additional notes associated with this service or procedure.
"Amputation Toe Interphalangeal Joint|LEFT FOOT, THIRD DIGIT",CASE-28825,APC,28825,CPT,0360,RC,,,T2,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
Injection Aa&/Strd Ilioinguinal Ih Nerves,CASE-64425,APC,64425,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],660.72,,"APC Price ($660.72). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,660.72,693.76,OPPS APC
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],10638.94,,"Case rate ($10,638.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,032.78, add-ons for qualifying new technology services are included. If operating cost exceeds $44,903.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,395.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,058.12 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,087.83 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $635.87. The transfer capital threshold is the transfer adjustment factor * $635.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10638.94,25261.33,Inpatient DRG
INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC,198,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],23505.07,,"Fee schedule rate ($23,505.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6795.12,23505.07,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6340.03,,"Case rate ($6,340.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,033.60, add-ons for qualifying new technology services are included. If operating cost exceeds $40,904.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,081.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $4,073.62 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,088.64 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $321.45. The transfer capital threshold is the transfer adjustment factor * $321.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6340.03,15076.44,Inpatient DRG
DIABETES WITHOUT CC/MCC,639,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6329.61,,"Case rate ($6,028.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,751.12, add-ons for qualifying new technology services are included. If operating cost exceeds $40,622.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,051.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $3,791.80 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,806.17 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $291.45. The transfer capital threshold is the transfer adjustment factor * $291.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6151.76,12223.35,Inpatient DRG
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],39337.51,,"Fee schedule rate ($39,337.51). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,16120.25,41187.90,There are no additional notes associated with this service or procedure.
"Excis Intrasp Lesn,Xdural,Lumbar",CASE-63267,APC,63267,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],7665.00,,"Per diem ($7,665). If length of stay < 4, first 1 days paid at a per diem of $15,330 instead. Capped at $30,658.90.",,,,0,other,7665.00,40737.46,Estimated amount calculated based on 5 day length of stay.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],11606.06,,"Case rate ($11,053.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,418.34, add-ons for qualifying new technology services are included. If operating cost exceeds $45,289.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,426.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $8,442.26 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,473.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $666.18. The transfer capital threshold is the transfer adjustment factor * $666.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,11053.39,36776.05,Inpatient DRG
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],8269.74,,"Case rate ($7,875.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,462.42, add-ons for qualifying new technology services are included. If operating cost exceeds $42,333.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,193.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $5,497.20 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,517.46 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $433.78. The transfer capital threshold is the transfer adjustment factor * $433.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7875.94,17233.12,Inpatient DRG
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],6010.23,,"Case rate ($6,010.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,726.79, add-ons for qualifying new technology services are included. If operating cost exceeds $40,597.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,057.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,767.95 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,781.84 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $297.33. The transfer capital threshold is the transfer adjustment factor * $297.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6010.23,12246.05,Inpatient DRG
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],10284.89,,"Case rate ($9,795.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,247.81, add-ons for qualifying new technology services are included. If operating cost exceeds $44,118.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,334.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $7,276.03 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,302.86 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $574.15. The transfer capital threshold is the transfer adjustment factor * $574.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9795.13,23899.13,Inpatient DRG
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC",758,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],16323.02,,"Fee schedule rate ($16,323.02). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8574.80,19263.78,There are no additional notes associated with this service or procedure.
VAGINAL DELIVERY WITH O.R. PROCEDURES EXCEPT STERILIZATION AND/OR D&C,768,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],9662.00,,"Case rate ($9,201.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,695.94, add-ons for qualifying new technology services are included. If operating cost exceeds $43,566.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,290.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $6,726.19 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,750.99 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $530.76. The transfer capital threshold is the transfer adjustment factor * $530.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6426.91,13416.00,Inpatient DRG
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,057,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],21204.48,,"Fee schedule rate ($21,204.48). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,10718.84,39884.93,There are no additional notes associated with this service or procedure.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH CC,026,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],58431.20,,"Fee schedule rate ($58,431.20). Adds an outlier to normal pricing equal to the per diem rate ($112,420.62) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,23000.66,63202.45,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],67794.72,,"Fee schedule rate ($67,794.72). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,10862.00,86437.13,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC,832,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],13561.03,,"Fee schedule rate ($13,561.03). Adds an outlier to normal pricing equal to the per diem rate ($18,253.69) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,4803.31,14198.92,There are no additional notes associated with this service or procedure.
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],38508.74,,"Fee schedule rate ($38,508.74). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.6), with a minimum of zero.",,,,0,other,15821.59,40320.14,There are no additional notes associated with this service or procedure.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],17194.49,,"Fee schedule rate ($17,194.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8554.50,19204.75,There are no additional notes associated with this service or procedure.
"NERVOUS SYSTEM MALIGNANCY,MODERATE",041,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],9704.66,,"Case rate ($9,242.53). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9242.53,9704.66,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],10358.84,,"Case rate ($9,865.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,313.33, add-ons for qualifying new technology services are included. If operating cost exceeds $44,184.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,339.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $7,341.31 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,368.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $579.30. The transfer capital threshold is the transfer adjustment factor * $579.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9865.56,37914.65,Inpatient DRG
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12263.78,,"Case rate ($11,679.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,019.23, add-ons for qualifying new technology services are included. If operating cost exceeds $45,890.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,454.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $9,040.00 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,074.28 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $694.84. The transfer capital threshold is the transfer adjustment factor * $694.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,11974.38,29141.64,Inpatient DRG
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],13610.32,,"Case rate ($12,962.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,214.63, add-ons for qualifying new technology services are included. If operating cost exceeds $47,085.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,546.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $10,230.89 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,269.68 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $786.37. The transfer capital threshold is the transfer adjustment factor * $786.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7000.00,33835.79,Inpatient DRG
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],16900.84,,"Fee schedule rate ($16,900.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8151.55,18033.97,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],7698.44,,"Case rate ($7,547.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,156.87, add-ons for qualifying new technology services are included. If operating cost exceeds $42,027.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,169.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $5,192.77 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,211.92 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $409.76. The transfer capital threshold is the transfer adjustment factor * $409.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6965.00,19126.88,Inpatient DRG
Replacement Tissue Expander W/Permanent Implant,CASE-11970,APC,11970,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7029.71,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6791.99,7131.59,OPPS APC
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",759,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],6438.90,,"Case rate ($6,438.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,125.57, add-ons for qualifying new technology services are included. If operating cost exceeds $40,996.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,088.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,165.27 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,180.62 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $328.68. The transfer capital threshold is the transfer adjustment factor * $328.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6190.22,13057.66,Inpatient DRG
PSYCHOSES,885,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],2070.00,,,,,,0,other,2070.00,27484.83,Estimated amount calculated based on 3 day length of stay.
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],59494.91,,"Fee schedule rate ($59,494.91). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,18594.09,59494.91,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],59021.28,,"Fee schedule rate ($59,021.28). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,23851.92,63653.13,There are no additional notes associated with this service or procedure.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",062,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],44304.80,,"Fee schedule rate ($44,304.80). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,13844.84,44304.80,There are no additional notes associated with this service or procedure.
"POISONING OF MEDICINAL AGENTS,MODERATE",812,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],6200.39,,"Case rate ($5,905.13). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5905.13,6200.39,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],17651.07,,"Fee schedule rate ($17,651.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,6564.18,17651.07,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],11677.97,,"Fee schedule rate ($11,677.97). Adds an outlier to normal pricing equal to the per diem rate ($67,650.85) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.7), with a minimum of zero.",,,,0,other,6153.12,13947.32,There are no additional notes associated with this service or procedure.
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],24092.63,,"Fee schedule rate ($24,092.63). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10626.74,25225.91,There are no additional notes associated with this service or procedure.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],54764.34,,"Fee schedule rate ($54,764.34). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,18178.96,54764.34,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],9356.31,,"Case rate ($9,356.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,839.58, add-ons for qualifying new technology services are included. If operating cost exceeds $43,710.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,302.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $6,869.30 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,894.63 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $542.06. The transfer capital threshold is the transfer adjustment factor * $542.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9356.31,25026.36,Inpatient DRG
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],8165.30,,"Fee schedule rate ($8,165.30). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4341.01,12882.53,There are no additional notes associated with this service or procedure.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],47797.26,,"Case rate ($45,521.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $42,483.01, add-ons for qualifying new technology services are included. If operating cost exceeds $77,354.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,947.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 12.5. The base transfer operating payment is the transfer adjustment factor * $40,389.14 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $40,538.06 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,187.10. The transfer capital threshold is the transfer adjustment factor * $3,187.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,45521.20,142438.06,Inpatient DRG
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],28756.63,,"Fee schedule rate ($28,756.63). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,13148.66,32553.63,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,690,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7629.22,,"Case rate ($7,265.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,904.86, add-ons for qualifying new technology services are included. If operating cost exceeds $41,775.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,139.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $4,941.18 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,959.91 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $379.79. The transfer capital threshold is the transfer adjustment factor * $379.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7426.94,15928.53,Inpatient DRG
Sigmoidoscopy Flx Dx W/Collj Spec Br/Wa if Pfrmd,CASE-45330,APC,45330,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],900.93,,"APC Price ($870.46). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,870.46,913.99,OPPS APC
Cystoscopy prostatic imp 1-3,CASE-C9739,APC,C9739,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5018.77,,"APC Price ($5,018.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5018.77,5269.71,OPPS APC
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7229.61,,"Case rate ($6,885.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,550.10, add-ons for qualifying new technology services are included. If operating cost exceeds $41,421.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,112.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $4,587.76 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,605.15 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $352.63. The transfer capital threshold is the transfer adjustment factor * $352.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,21089.59,Inpatient DRG
HEADACHES WITHOUT MCC,103,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],13314.75,,"Case rate ($7,608.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,213.57, add-ons for qualifying new technology services are included. If operating cost exceeds $42,084.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,174.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $5,249.26 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,268.62 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $414.22. The transfer capital threshold is the transfer adjustment factor * $414.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,6965.00,20883.08,All Other Inpatient
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],12246.05,,"Fee schedule rate ($12,246.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6010.23,12246.05,There are no additional notes associated with this service or procedure.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],34800.15,,"Case rate ($33,623.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $31,414.68, add-ons for qualifying new technology services are included. If operating cost exceeds $66,285.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,076.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.4. The base transfer operating payment is the transfer adjustment factor * $29,361.48 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $29,469.74 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,316.91. The transfer capital threshold is the transfer adjustment factor * $2,316.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,33623.33,133270.57,Inpatient DRG
INFLAMMATORY BOWEL DISEASE WITH MCC,385,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],21593.52,,"Fee schedule rate ($21,593.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11480.01,31134.92,There are no additional notes associated with this service or procedure.
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],26204.74,,"Fee schedule rate ($26,204.74). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10120.20,26204.74,There are no additional notes associated with this service or procedure.
Prq Impltj Neurostimulator Eltrd Peripheral Nrv,CASE-64555,APC,64555,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5965.28,,"APC Price ($5,965.28). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5965.28,6263.54,OPPS APC
"Amputation Metatarsal W/Toe Single|RIGHT FOOT, FIFTH DIGIT",CASE-28810,APC,28810,CPT,0360,RC,,,T9,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],17033.98,,"Fee schedule rate ($17,033.98). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.8), with a minimum of zero.",,,,0,other,7884.32,17835.23,There are no additional notes associated with this service or procedure.
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],8454.94,,"Case rate ($8,454.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,001.06, add-ons for qualifying new technology services are included. If operating cost exceeds $42,872.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,236.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,033.86 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,056.11 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $476.13. The transfer capital threshold is the transfer adjustment factor * $476.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6230.00,22762.43,Inpatient DRG
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],128358.13,,"Fee schedule rate ($128,358.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,40542.37,128358.13,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,064,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],15874.85,,"Case rate ($15,563.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,614.08, add-ons for qualifying new technology services are included. If operating cost exceeds $49,485.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,756.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $12,622.59 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,669.13 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $996.05. The transfer capital threshold is the transfer adjustment factor * $996.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,15563.58,41838.16,Inpatient DRG
"NEONATE BIRTH WEIGHT > 2499 GRAMS WITH OTHER SIGNIFICANT CONDITION,MODERATE",639,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],4769.28,,"Case rate ($4,769.28). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,4769.28,5007.74,There are no additional notes associated with this service or procedure.
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],27222.08,,"Fee schedule rate ($27,222.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7389.00,37134.43,There are no additional notes associated with this service or procedure.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],73588.10,,"Fee schedule rate ($73,588.10). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,21585.31,73588.10,There are no additional notes associated with this service or procedure.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],11681.49,,"Fee schedule rate ($11,681.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5778.62,11681.49,There are no additional notes associated with this service or procedure.
SALIVARY GLAND PROCEDURES,139,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],30690.92,,"Fee schedule rate ($30,690.92). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,10313.19,30690.92,There are no additional notes associated with this service or procedure.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],9570.98,,"Case rate ($9,570.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,039.28, add-ons for qualifying new technology services are included. If operating cost exceeds $43,910.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,317.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $7,068.27 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,094.33 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $557.76. The transfer capital threshold is the transfer adjustment factor * $557.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,5569.00,40108.48,Inpatient DRG
"VAGINAL DELIVERY WITH O.R. PROCEDURE EXCEPT STERILIZATION AND/OR D&C,MAJOR",542,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],8518.92,,"Case rate ($8,518.92). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,8518.92,8944.87,There are no additional notes associated with this service or procedure.
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC",514,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],20115.80,,,,,,0,other,8868.04,22699.91,There are no additional notes associated with this service or procedure.
CERVICAL SPINAL FUSION WITH CC,472,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],22375.61,,"Case rate ($21,310.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $19,996.08, add-ons for qualifying new technology services are included. If operating cost exceeds $54,867.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,142.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $17,982.95 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,051.13 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,382.21. The transfer capital threshold is the transfer adjustment factor * $1,382.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,21896.13,70198.84,Inpatient DRG
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],19232.01,,"Case rate ($10,989.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,359.11, add-ons for qualifying new technology services are included. If operating cost exceeds $45,230.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,421.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $8,383.26 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,414.17 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $661.52. The transfer capital threshold is the transfer adjustment factor * $661.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,10989.72,26280.60,All Other Inpatient
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],7332.00,,"Per diem ($7,332). If length of stay < 4.6, first 1 days paid at a per diem of $14,664 instead. Capped at $33,727.80.",,,,0,other,7332.00,35314.31,Estimated amount calculated based on 3 day length of stay.
OTHER CEREBROVASCULAR DISORDERS WITH MCC,070,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],37774.46,,"Fee schedule rate ($37,774.46). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,13219.09,37774.46,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],13923.42,,"Case rate ($13,260.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,471.48, add-ons for qualifying new technology services are included. If operating cost exceeds $47,342.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,587.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $10,487.86 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,526.53 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $827.60. The transfer capital threshold is the transfer adjustment factor * $827.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13260.40,32878.30,Inpatient DRG
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITHOUT CC/MCC",630,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],12242.79,,"Case rate ($11,828.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,139.67, add-ons for qualifying new technology services are included. If operating cost exceeds $46,010.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,482.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $9,160.95 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,194.72 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $722.89. The transfer capital threshold is the transfer adjustment factor * $722.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,11828.78,42541.02,Inpatient DRG
Open Tx Metacarpal Fracture Single Ea Bone|RIGHT SIDE,CASE-26615,APC,26615,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC,862,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],35884.94,,,,,,0,other,6855.00,35884.94,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,448,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],32197.15,,"Case rate ($30,663.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $28,661.63, add-ons for qualifying new technology services are included. If operating cost exceeds $63,532.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,860.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $26,618.53 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $26,716.68 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,100.47. The transfer capital threshold is the transfer adjustment factor * $2,100.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,30663.95,94077.13,Inpatient DRG
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH CC,427,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],134742.59,,"Fee schedule rate ($134,742.59). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,50829.82,142040.39,There are no additional notes associated with this service or procedure.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],18598.83,,"Case rate ($18,598.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,437.70, add-ons for qualifying new technology services are included. If operating cost exceeds $52,308.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,978.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 5.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $15,435.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,492.75 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,218.04. The transfer capital threshold is the transfer adjustment factor * $1,218.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,18598.83,48389.68,Inpatient DRG
"Arthrodesis Interphalangeal Jt W/WO Int Fixj|RIGHT HAND, FIFTH DIGIT",CASE-26860,APC,26860,CPT,0360,RC,,,F9,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3062.67,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
Total Thyroid Lobectomy Uni W/WO Isthmusectomy|RIGHT SIDE,CASE-60220,APC,60220,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5658.76,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5658.76,5941.70,OPPS APC
Tnot Elbow Lateral/Medial Debride Open Tdn Rpr|LEFT SIDE,CASE-24359,APC,24359,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH CC",457,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],42327.47,,"Case rate ($42,327.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $39,511.96, add-ons for qualifying new technology services are included. If operating cost exceeds $74,382.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,713.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $37,429.01 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $37,567.02 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,953.52. The transfer capital threshold is the transfer adjustment factor * $2,953.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,42327.47,160549.49,Inpatient DRG
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],40192.59,,"Fee schedule rate ($40,192.59). Adds an outlier to normal pricing equal to the per diem rate ($235,324.88) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.6), with a minimum of zero.",,,,0,other,16428.39,42083.20,There are no additional notes associated with this service or procedure.
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],8945.71,,"Case rate ($8,643.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,176.19, add-ons for qualifying new technology services are included. If operating cost exceeds $43,047.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,249.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $6,208.35 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,231.24 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $489.90. The transfer capital threshold is the transfer adjustment factor * $489.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,8643.20,19462.52,Inpatient DRG
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],31477.13,,"Fee schedule rate ($31,477.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9648.19,31477.13,There are no additional notes associated with this service or procedure.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH CC,354,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],33472.54,,,,,,0,other,11633.13,33472.54,There are no additional notes associated with this service or procedure.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,479,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],50518.76,,"Fee schedule rate ($50,518.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,10586.00,50518.76,There are no additional notes associated with this service or procedure.
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],27222.08,,"Fee schedule rate ($27,222.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7389.00,37134.43,There are no additional notes associated with this service or procedure.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC",156,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],12624.95,,"Fee schedule rate ($12,624.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6625.12,13598.77,There are no additional notes associated with this service or procedure.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],38246.19,,"Fee schedule rate ($38,246.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,19435.86,50821.76,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],30063.84,,"Fee schedule rate ($30,063.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13891.57,34712.20,There are no additional notes associated with this service or procedure.
SALIVARY GLAND PROCEDURES,139,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],30690.92,,"Fee schedule rate ($30,690.92). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,10313.19,30690.92,There are no additional notes associated with this service or procedure.
Arthrs Kne Surg W/Meniscectomy Med/Lat W/Shvg|RIGHT SIDE|SEPARATE STRUCTURE,CASE-29881,APC,29881,CPT,0360,RC,,,RT|XS,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6791.99,7131.59,OPPS APC
INFLAMMATORY BOWEL DISEASE WITH CC,386,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],8780.45,,"Case rate ($8,362.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,926.87, add-ons for qualifying new technology services are included. If operating cost exceeds $42,797.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,218.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $5,959.32 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,981.92 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $458.05. The transfer capital threshold is the transfer adjustment factor * $458.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8556.53,19879.00,Inpatient DRG
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],7238.69,,"Case rate ($7,238.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,869.60, add-ons for qualifying new technology services are included. If operating cost exceeds $41,740.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,147.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,906.55 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,924.64 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $387.18. The transfer capital threshold is the transfer adjustment factor * $387.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7238.69,16804.22,Inpatient DRG
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC,058,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],23663.15,,"Case rate ($13,521.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,714.66, add-ons for qualifying new technology services are included. If operating cost exceeds $47,585.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,606.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $10,730.14 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,769.70 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $846.71. The transfer capital threshold is the transfer adjustment factor * $846.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,13521.80,40853.02,All Other Inpatient
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],27665.18,,"Fee schedule rate ($27,665.18). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,11914.12,40426.76,There are no additional notes associated with this service or procedure.
Cysto/Pyeloscopy Bx&/Fulguration Pelivc Lesion|LEFT SIDE,CASE-52354,APC,52354,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5194.43,,"APC Price ($5,018.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5018.77,5269.71,OPPS APC
"CARDIAC ARREST, UNEXPLAINED WITH MCC",296,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],13148.36,,"Case rate ($12,522.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,784.78, add-ons for qualifying new technology services are included. If operating cost exceeds $46,655.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,533.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $9,803.69 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,839.84 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $773.61. The transfer capital threshold is the transfer adjustment factor * $773.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12522.25,36459.67,Inpatient DRG
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],86235.79,,"Fee schedule rate ($86,235.79). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,32296.02,88188.38,There are no additional notes associated with this service or procedure.
NON-MALIGNANT BREAST DISORDERS WITH CC/MCC,600,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],15046.13,,"Fee schedule rate ($15,046.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7999.14,20495.56,There are no additional notes associated with this service or procedure.
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],46202.59,,"Fee schedule rate ($46,202.59). Adds an outlier to normal pricing equal to the per diem rate ($126,777.34) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,18594.09,59494.91,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],8972.00,,"Per diem ($8,972). If length of stay < 6.1, first 1 days paid at a per diem of $17,944 instead. Capped at $54,730.85.",,,,0,other,8972.00,81524.17,Estimated amount calculated based on 4 day length of stay.
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],6338.33,,"Case rate ($6,214.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,916.41, add-ons for qualifying new technology services are included. If operating cost exceeds $40,787.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,072.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $3,956.88 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,971.47 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $312.24. The transfer capital threshold is the transfer adjustment factor * $312.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6214.05,15318.94,Inpatient DRG
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],16935.49,,"Case rate ($16,129.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,140.12, add-ons for qualifying new technology services are included. If operating cost exceeds $50,011.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,797.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $13,146.70 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,195.17 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,037.40. The transfer capital threshold is the transfer adjustment factor * $1,037.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,16129.04,59610.47,Inpatient DRG
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITHOUT CC/MCC,428,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],118904.57,,"Fee schedule rate ($118,904.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,40017.53,118904.57,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL HEMORRHAGE WITH CC,378,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],20845.19,,"Fee schedule rate ($20,845.19). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8586.33,20845.19,There are no additional notes associated with this service or procedure.
Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq|COLORECTAL CANCER SCREEN|UNUSUAL NON-OVERLAPPING SERVICE,CASE-45385,APC,45385,CPT,0360,RC,,,PT|XU,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1120.09,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1120.09,1176.09,OPPS APC
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],12558.65,,"Fee schedule rate ($12,558.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5065.00,12558.65,There are no additional notes associated with this service or procedure.
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,450,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],146009.19,,"Fee schedule rate ($146,009.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,38037.38,146009.19,There are no additional notes associated with this service or procedure.
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],17501.40,,"Fee schedule rate ($17,501.40). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,15453.88,39251.68,There are no additional notes associated with this service or procedure.
SEIZURES WITH MCC,100,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],36398.28,,"Fee schedule rate ($36,398.28). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,15061.09,38110.41,There are no additional notes associated with this service or procedure.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],38246.19,,"Fee schedule rate ($38,246.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,19435.86,50821.76,There are no additional notes associated with this service or procedure.
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],7733.72,,"Case rate ($7,733.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,330.12, add-ons for qualifying new technology services are included. If operating cost exceeds $42,201.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,183.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,365.38 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,385.17 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $423.38. The transfer capital threshold is the transfer adjustment factor * $423.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7733.72,18043.23,Inpatient DRG
Excision Interdigital Morton Neuroma Single Each|RIGHT SIDE,CASE-28080,APC,28080,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1580.37,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1505.12,1580.37,OPPS APC
Tonsillectomy & Adenoidectomy Age 12/>,CASE-42821,APC,42821,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3211.97,,"APC Price ($3,103.35). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.35,3258.52,OPPS APC
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,345,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],12134.89,,"Case rate ($12,134.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,424.43, add-ons for qualifying new technology services are included. If operating cost exceeds $46,295.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,505.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $9,444.66 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,479.48 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $745.28. The transfer capital threshold is the transfer adjustment factor * $745.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12134.89,33616.03,Inpatient DRG
Dstr Nrolytc Agnt Parverteb Fct Sngl Crvcl/Thora,CASE-64633,APC,64633,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1827.80,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1827.80,1919.19,OPPS APC
"CARDIAC ARREST, UNEXPLAINED WITH MCC",296,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],12522.25,,"Case rate ($12,522.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,784.78, add-ons for qualifying new technology services are included. If operating cost exceeds $46,655.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,533.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $9,803.69 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,839.84 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $773.61. The transfer capital threshold is the transfer adjustment factor * $773.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12522.25,36459.67,Inpatient DRG
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,025,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],89465.42,,,,,,0,other,13351.00,91631.33,There are no additional notes associated with this service or procedure.
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH CC",457,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],42327.47,,"Case rate ($42,327.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $39,511.96, add-ons for qualifying new technology services are included. If operating cost exceeds $74,382.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,713.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $37,429.01 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $37,567.02 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,953.52. The transfer capital threshold is the transfer adjustment factor * $2,953.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,42327.47,160549.49,Inpatient DRG
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],28966.51,,,,,,0,other,11914.12,40426.76,There are no additional notes associated with this service or procedure.
ALLERGIC REACTIONS WITH MCC,915,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],13332.86,,"Case rate ($13,332.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,538.89, add-ons for qualifying new technology services are included. If operating cost exceeds $47,409.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,592.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $10,555.02 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,593.94 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $832.90. The transfer capital threshold is the transfer adjustment factor * $832.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,13332.86,33088.84,Inpatient DRG
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,056,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],32881.80,,"Fee schedule rate ($32,881.80). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (44), with a minimum of zero.",,,,0,other,7659.00,59328.19,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC,817,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],30443.19,,"Case rate ($17,396.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,318.84, add-ons for qualifying new technology services are included. If operating cost exceeds $51,189.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,890.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $14,321.08 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,373.88 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,130.07. The transfer capital threshold is the transfer adjustment factor * $1,130.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,17396.11,44895.04,All Other Inpatient
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],10890.32,,"Case rate ($10,371.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,799.93, add-ons for qualifying new technology services are included. If operating cost exceeds $44,670.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,361.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $7,825.31 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,854.98 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $601.47. The transfer capital threshold is the transfer adjustment factor * $601.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10626.74,25225.91,Inpatient DRG
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],13625.25,,"Fee schedule rate ($13,625.25). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7243.75,23262.15,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],19173.27,,,,,,0,other,8543.64,23239.84,There are no additional notes associated with this service or procedure.
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],13236.54,,"Case rate ($12,606.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,862.91, add-ons for qualifying new technology services are included. If operating cost exceeds $46,733.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,539.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $9,881.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,917.95 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $779.75. The transfer capital threshold is the transfer adjustment factor * $779.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12606.23,36868.88,Inpatient DRG
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],15283.90,,"Case rate ($15,283.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,353.89, add-ons for qualifying new technology services are included. If operating cost exceeds $49,224.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,735.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.2. The base transfer operating payment is the transfer adjustment factor * $12,363.36 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,408.94 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $975.59. The transfer capital threshold is the transfer adjustment factor * $975.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,15283.90,38757.79,Inpatient DRG
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],17760.46,,,,,,0,other,6524.00,17760.46,There are no additional notes associated with this service or procedure.
Cystourethroscopy Inj Chemodenervation Bladder,CASE-52287,APC,52287,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],2025.13,,"APC Price ($1,956.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1956.65,2054.48,OPPS APC
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],7366.00,,"Case rate ($7,366). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,988.03, add-ons for qualifying new technology services are included. If operating cost exceeds $41,859.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,156.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,024.55 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,043.08 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $396.49. The transfer capital threshold is the transfer adjustment factor * $396.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,21195.68,Inpatient DRG
"Surg Implnt Neuroelect,Epidural",CASE-63655,APC,63655,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],29894.47,,"APC Price ($28,883.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,28883.55,30327.72,OPPS APC
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC,058,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],14197.89,,"Case rate ($13,521.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,714.66, add-ons for qualifying new technology services are included. If operating cost exceeds $47,585.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,606.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $10,730.14 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,769.70 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $846.71. The transfer capital threshold is the transfer adjustment factor * $846.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13521.80,40853.02,Inpatient DRG
Cysto W/Insert Ureteral Stent,CASE-52332,APC,52332,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3299.47,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3299.47,3464.44,OPPS APC
Surgical Arthroscopy Shoulder Biceps Tenodesis|RIGHT SIDE,CASE-29828,APC,29828,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,6791.99,OPPS APC
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],52794.06,,"Fee schedule rate ($52,794.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (37), with a minimum of zero.",,,,0,other,13907.80,52794.06,There are no additional notes associated with this service or procedure.
CHOLECYSTECTOMY WITH C.D.E. WITH MCC,411,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],88615.28,,"Fee schedule rate ($88,615.28). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,24315.13,88615.28,There are no additional notes associated with this service or procedure.
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],43225.79,,"Fee schedule rate ($43,225.79). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,20846.48,81306.30,There are no additional notes associated with this service or procedure.
RESPIRATORY NEOPLASMS WITHOUT CC/MCC,182,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7296.48,,"Case rate ($7,049.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,693.83, add-ons for qualifying new technology services are included. If operating cost exceeds $41,564.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,133.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,731.43 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,748.88 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $373.36. The transfer capital threshold is the transfer adjustment factor * $373.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6965.00,23037.13,Inpatient DRG
Sigmoidoscopy Flx Control Bleeding,CASE-45334,APC,45334,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1159.29,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1120.09,1176.09,OPPS APC
Hysteroscopy Diagnostic Separate Procedure,CASE-58555,APC,58555,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3136.08,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3030.03,3181.53,OPPS APC
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],32101.06,,,,,,0,other,7665.00,40737.46,There are no additional notes associated with this service or procedure.
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],10626.21,,"Case rate ($10,120.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,550.21, add-ons for qualifying new technology services are included. If operating cost exceeds $44,421.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,357.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $7,577.32 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,605.26 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $597.93. The transfer capital threshold is the transfer adjustment factor * $597.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10120.20,26204.74,Inpatient DRG
Chromotubation Oviduct W/Materials|UNUSUAL NON-OVERLAPPING SERVICE,CASE-58350,APC,58350,CPT,0360,RC,,,XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5941.70,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5658.76,5941.70,OPPS APC
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],45706.73,,"Fee schedule rate ($45,706.73). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,7921.00,45706.73,There are no additional notes associated with this service or procedure.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],15808.32,,"Case rate ($15,273.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,344.45, add-ons for qualifying new technology services are included. If operating cost exceeds $49,215.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,734.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $12,353.94 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,399.49 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $974.85. The transfer capital threshold is the transfer adjustment factor * $974.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,15273.74,39820.52,Inpatient DRG
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],38246.19,,"Fee schedule rate ($38,246.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,19435.86,50821.76,There are no additional notes associated with this service or procedure.
COMPLICATIONS OF TREATMENT WITH CC,920,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],20731.52,,"Fee schedule rate ($20,731.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8732.59,20731.52,There are no additional notes associated with this service or procedure.
Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq,CASE-45385,APC,45385,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1159.29,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1120.09,1176.09,OPPS APC
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],7944.77,,"Case rate ($7,566.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,174.51, add-ons for qualifying new technology services are included. If operating cost exceeds $42,045.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,171.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,210.35 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,229.56 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $411.15. The transfer capital threshold is the transfer adjustment factor * $411.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7566.45,16333.88,Inpatient DRG
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],16433.85,,"Case rate ($15,651.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,721.24, add-ons for qualifying new technology services are included. If operating cost exceeds $49,592.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,738.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $12,728.03 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,776.29 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $978.31. The transfer capital threshold is the transfer adjustment factor * $978.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,41030.48,Inpatient DRG
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],22762.43,,"Fee schedule rate ($22,762.43). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6230.00,22762.43,There are no additional notes associated with this service or procedure.
Adjnt Tis Trnsfr/Reargmt Any Area 30.1-60 Sq Cm,CASE-14301,APC,14301,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3317.01,,"APC Price ($3,317.01). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3317.01,3317.01,OPPS APC
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],9439.43,,"Fee schedule rate ($9,439.43). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7847.50,17755.26,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],33398.16,,"Fee schedule rate ($33,398.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,7353.00,33398.16,There are no additional notes associated with this service or procedure.
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],11168.08,,"Fee schedule rate ($11,168.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5937.41,12366.99,There are no additional notes associated with this service or procedure.
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],13625.25,,"Fee schedule rate ($13,625.25). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7243.75,23262.15,There are no additional notes associated with this service or procedure.
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],53275.26,,"Fee schedule rate ($53,275.26). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,15940.79,53275.26,There are no additional notes associated with this service or procedure.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,097,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],79915.74,,"Fee schedule rate ($79,915.74). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,26404.32,79915.74,There are no additional notes associated with this service or procedure.
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],14670.87,,"Case rate ($14,383.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,516, add-ons for qualifying new technology services are included. If operating cost exceeds $48,387.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,669.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,528.54 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,571.05 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $909.72. The transfer capital threshold is the transfer adjustment factor * $909.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6965.00,36140.75,Inpatient DRG
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC,831,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],10088.35,,"Case rate ($10,088.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,520.59, add-ons for qualifying new technology services are included. If operating cost exceeds $44,391.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,355.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $7,547.82 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,575.65 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $595.60. The transfer capital threshold is the transfer adjustment factor * $595.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,4941.30,23661.59,Inpatient DRG
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,057,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],24348.21,,"Fee schedule rate ($24,348.21). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.9), with a minimum of zero.",,,,0,other,10718.84,39884.93,There are no additional notes associated with this service or procedure.
OTHER MENTAL DISORDER DIAGNOSES,887,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],9197.17,,"Case rate ($9,197.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,691.53, add-ons for qualifying new technology services are included. If operating cost exceeds $43,562.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,290.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,721.79 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,746.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $530.42. The transfer capital threshold is the transfer adjustment factor * $530.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,2070.00,21072.10,Inpatient DRG
Vulvectomy Simple Partial,CASE-56620,APC,56620,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3136.08,,"APC Price ($3,030.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3030.03,3181.53,OPPS APC
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC,806,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],13416.00,,,,,,0,other,5354.25,13416.00,There are no additional notes associated with this service or procedure.
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC",011,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],39685.35,,"Case rate ($37,795.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $35,362.92, add-ons for qualifying new technology services are included. If operating cost exceeds $70,233.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,318.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 11.4. The base transfer operating payment is the transfer adjustment factor * $33,291.75 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $33,417.97 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,558.88. The transfer capital threshold is the transfer adjustment factor * $2,558.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,38880.49,150008.48,Inpatient DRG
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],55463.28,,"Case rate ($31,693.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $29,619.21, add-ons for qualifying new technology services are included. If operating cost exceeds $64,490.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,935.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. The base transfer operating payment is the transfer adjustment factor * $27,572.60 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $27,674.26 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,175.75. The transfer capital threshold is the transfer adjustment factor * $2,175.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,10862.00,86437.13,All Other Inpatient
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],32263.82,,"Fee schedule rate ($32,263.82). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13571.25,33781.47,There are no additional notes associated with this service or procedure.
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level|RIGHT SIDE,CASE-64483,APC,64483,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],869.28,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,827.89,869.28,OPPS APC
CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC,788,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],20142.33,,"Fee schedule rate ($20,142.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8438.02,20142.33,There are no additional notes associated with this service or procedure.
HC Remove Tun Cath Vad W/Port,CASE-36590,APC,36590,CPT,0361,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1547.12,,"APC Price ($1,473.45). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1473.45,1547.12,OPPS APC
MAJOR BLADDER PROCEDURES WITH MCC,653,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],125343.98,,"Fee schedule rate ($125,343.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,10280.00,125343.98,There are no additional notes associated with this service or procedure.
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],29585.82,,"Fee schedule rate ($29,585.82). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12606.23,36868.88,There are no additional notes associated with this service or procedure.
VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC,033,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],23364.60,,"Fee schedule rate ($23,364.60). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,13206.23,42156.44,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],6965.00,,,,,,0,other,6965.00,19126.88,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],25427.61,,"Case rate ($24,567.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $22,990.45, add-ons for qualifying new technology services are included. If operating cost exceeds $57,861.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,414.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.7. The base transfer operating payment is the transfer adjustment factor * $20,968.18 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $21,045.49 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,654.60. The transfer capital threshold is the transfer adjustment factor * $1,654.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,9370.00,65732.99,Inpatient DRG
CESAREAN SECTION WITHOUT STERILIZATION WITH MCC,786,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],13426.74,,"Case rate ($12,787.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,051.65, add-ons for qualifying new technology services are included. If operating cost exceeds $46,922.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,533.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $10,068.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,106.70 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $773.89. The transfer capital threshold is the transfer adjustment factor * $773.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12612.10,23722.94,Inpatient DRG
Exploration Penetrating Wound Spx Extremity|LEFT SIDE,CASE-20103,APC,20103,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3215.80,3215.80,OPPS APC
"DORSAL AND LUMBAR FUSION PROCEDURE EXCEPT FOR CURVATURE OF BACK,MODERATE",304,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],8008.99,,"Case rate for a one day stay ($7,627.61). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7627.61,8008.99,There are no additional notes associated with this service or procedure.
"HC Aerosol, Hhn, Mdi, Ippb",CASE-94640,APC,94640,CPT,0410,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3464.44,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3299.47,3464.44,OPPS APC
HC Inj Lympho for Sentinal Node,CASE-38792,APC,38792,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6215.36,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6215.36,6526.12,OPPS APC
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],18105.81,,"Case rate ($18,105.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,979.06, add-ons for qualifying new technology services are included. If operating cost exceeds $51,850.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,941.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $14,978.89 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,034.11 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,181.98. The transfer capital threshold is the transfer adjustment factor * $1,181.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,18105.81,52699.33,Inpatient DRG
PREMATURITY WITHOUT MAJOR PROBLEMS,792,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],19179.69,,"Case rate ($18,531.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,374.70, add-ons for qualifying new technology services are included. If operating cost exceeds $52,245.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,973.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. The base transfer operating payment is the transfer adjustment factor * $15,373.07 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,429.75 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,213.09. The transfer capital threshold is the transfer adjustment factor * $1,213.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,1956.00,19457.66,Inpatient DRG
CESAREAN SECTION WITH STERILIZATION WITH CC,784,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],9443.35,,"Case rate ($9,124.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,623.49, add-ons for qualifying new technology services are included. If operating cost exceeds $43,494.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,285.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,654.00 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,678.54 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $525.07. The transfer capital threshold is the transfer adjustment factor * $525.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,9124.01,23722.94,Inpatient DRG
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],28038.61,,"Fee schedule rate ($28,038.61). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12126.09,29582.40,There are no additional notes associated with this service or procedure.
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],29216.99,,"Fee schedule rate ($29,216.99). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9755.86,29216.99,There are no additional notes associated with this service or procedure.
POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES,769,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],29791.03,,"Fee schedule rate ($29,791.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,13388.39,33250.19,There are no additional notes associated with this service or procedure.
Mastopexy|BILATERAL PROCEDURE,CASE-19316,APC,19316,CPT,0360,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6432.89,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6432.89,6526.12,OPPS APC
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,057,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],10718.84,,"Case rate ($10,718.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,107.12, add-ons for qualifying new technology services are included. If operating cost exceeds $44,978.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,401.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,132.18 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,162.17 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $641.71. The transfer capital threshold is the transfer adjustment factor * $641.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10718.84,39884.93,Inpatient DRG
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC",641,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],7575.73,,"Case rate ($7,214.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,847.54, add-ons for qualifying new technology services are included. If operating cost exceeds $41,718.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,145.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $4,884.58 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,902.59 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $385.44. The transfer capital threshold is the transfer adjustment factor * $385.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7214.98,15312.64,Inpatient DRG
Bronchoscopy W/Transbroncl Ndl Aspir Bx Ea Lobe,CASE-31633,APC,31633,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6605.95,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6605.95,6936.25,OPPS APC
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],40426.76,,"Fee schedule rate ($40,426.76). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,11914.12,40426.76,There are no additional notes associated with this service or procedure.
CERVICAL SPINAL FUSION WITHOUT CC/MCC,473,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],32335.82,,"Case rate ($18,477.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,324.93, add-ons for qualifying new technology services are included. If operating cost exceeds $52,195.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,969.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.6. The base transfer operating payment is the transfer adjustment factor * $15,323.48 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,379.98 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,209.17. The transfer capital threshold is the transfer adjustment factor * $1,209.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,18477.61,62077.11,All Other Inpatient
CESAREAN SECTION WITH STERILIZATION WITH CC,784,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],23722.94,,"Fee schedule rate ($23,722.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9124.01,23722.94,There are no additional notes associated with this service or procedure.
Tenodesis Long Tendon Biceps|LEFT SIDE,CASE-23430,APC,23430,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7029.71,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6791.99,7131.59,OPPS APC
CESAREAN SECTION WITHOUT STERILIZATION WITH CC,787,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],16639.02,,"Case rate ($9,508.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,980.70, add-ons for qualifying new technology services are included. If operating cost exceeds $43,851.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,313.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $7,009.90 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,035.74 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $553.15. The transfer capital threshold is the transfer adjustment factor * $553.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,9508.01,23722.94,All Other Inpatient
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],36464.27,,"Case rate ($34,727.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $32,503.39, add-ons for qualifying new technology services are included. If operating cost exceeds $67,374.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,099.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.9. The base transfer operating payment is the transfer adjustment factor * $30,443.02 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $30,558.44 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,339.92. The transfer capital threshold is the transfer adjustment factor * $2,339.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,35719.96,105091.76,Inpatient DRG
Gastroenterology Procedure,CASE-91299,APC,91299,CPT,0750,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],120.44,,"APC Price ($120.44). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,120.44,126.46,OPPS APC
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,394,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],20909.61,,"Fee schedule rate ($20,909.61). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8281.56,20909.61,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITHOUT STERILIZATION WITH MCC,786,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],23722.94,,"Fee schedule rate ($23,722.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12612.10,23722.94,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,065,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],25681.86,,"Fee schedule rate ($25,681.86). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,8786.76,25681.86,There are no additional notes associated with this service or procedure.
Egd Intrmural Needle Aspir/Biop Altered Anatomy,CASE-43242,APC,43242,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3735.12,,"APC Price ($3,608.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3608.81,3789.26,OPPS APC
Exc B9 Lesion Mrgn Xcp Sk Tg S/N/H/F/G 0.6-1.0cm,CASE-11421,APC,11421,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],662.83,,"APC Price ($662.83). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,662.83,695.97,OPPS APC
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],32101.06,,,,,,0,other,7665.00,40737.46,There are no additional notes associated with this service or procedure.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC,099,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],11171.21,,"Case rate ($11,171.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,527.95, add-ons for qualifying new technology services are included. If operating cost exceeds $45,398.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,434.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,551.47 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,583.00 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $674.80. The transfer capital threshold is the transfer adjustment factor * $674.80. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,11171.21,26807.94,Inpatient DRG
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],34409.98,,"Fee schedule rate ($34,409.98). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,14344.60,36028.59,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITH MCC,385,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],12962.93,,"Case rate ($12,345.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,639.91, add-ons for qualifying new technology services are included. If operating cost exceeds $46,510.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,502.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $9,658.34 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,694.96 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $742.36. The transfer capital threshold is the transfer adjustment factor * $742.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,11480.01,31134.92,Inpatient DRG
TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC,087,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],17189.96,,"Fee schedule rate ($17,189.96). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,8139.36,22679.07,There are no additional notes associated with this service or procedure.
"HC Excis Nail Matrix Perm Rmvl|LEFT FOOT, GREAT TOE|UNUSUAL NON-OVERLAPPING SERVICE",CASE-11750,APC,11750,CPT,0450,RC,,,TA|XU,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3169.86,OPPS APC
Fissurectomy Incl Sphincterotomy When Performed,CASE-46200,APC,46200,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],2598.08,,"APC Price ($2,598.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2598.08,2727.99,OPPS APC
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],6965.00,,,,,,0,other,6965.00,21404.64,There are no additional notes associated with this service or procedure.
Laps W/Vag Hysterect 250 Gm/&Rmvl Tube&/Ovaries,CASE-58552,APC,58552,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],9949.78,,"APC Price ($9,949.78). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,9949.78,10298.02,OPPS APC
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],85305.59,,"Fee schedule rate ($85,305.59). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,21719.40,85305.59,There are no additional notes associated with this service or procedure.
OTHER MENTAL DISORDER DIAGNOSES,887,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],21072.10,,,,,,0,other,2070.00,21072.10,There are no additional notes associated with this service or procedure.
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],8122.16,,"Case rate ($7,847.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,435.96, add-ons for qualifying new technology services are included. If operating cost exceeds $42,306.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,191.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,470.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,491.01 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $431.70. The transfer capital threshold is the transfer adjustment factor * $431.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,7847.50,17755.26,Inpatient DRG
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,095,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],20382.04,,"Case rate ($19,411.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $18,193.69, add-ons for qualifying new technology services are included. If operating cost exceeds $53,064.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,037.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.6. The base transfer operating payment is the transfer adjustment factor * $16,189.05 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $16,248.74 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,277.48. The transfer capital threshold is the transfer adjustment factor * $1,277.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,19411.47,50750.92,Inpatient DRG
MAJOR CHEST TRAUMA WITHOUT CC/MCC,185,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],14780.69,,"Fee schedule rate ($14,780.69). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.7), with a minimum of zero.",,,,0,other,7271.19,21771.61,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],29241.62,,"Fee schedule rate ($29,241.62). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,12984.79,32077.45,There are no additional notes associated with this service or procedure.
OSTEOMYELITIS WITH CC,540,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],25507.30,,,,,,0,other,9809.07,25507.30,There are no additional notes associated with this service or procedure.
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],36801.89,,,,,,0,other,6277.00,36801.89,There are no additional notes associated with this service or procedure.
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,095,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],48470.91,,"Fee schedule rate ($48,470.91). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.8), with a minimum of zero.",,,,0,other,19411.47,50750.92,There are no additional notes associated with this service or procedure.
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC",514,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],9045.40,,"Case rate ($8,868.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,385.35, add-ons for qualifying new technology services are included. If operating cost exceeds $43,256.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,266.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $6,416.74 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,440.40 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $506.34. The transfer capital threshold is the transfer adjustment factor * $506.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,8868.04,22699.91,Inpatient DRG
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],23078.81,,"Fee schedule rate ($23,078.81). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10311.17,24308.97,There are no additional notes associated with this service or procedure.
COAGULATION DISORDERS,813,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],12274.39,,"Case rate ($12,274.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,554.21, add-ons for qualifying new technology services are included. If operating cost exceeds $46,425.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,515.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $9,573.96 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,609.26 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $755.48. The transfer capital threshold is the transfer adjustment factor * $755.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12274.39,30013.33,Inpatient DRG
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC",605,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],17131.97,,"Fee schedule rate ($17,131.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8148.17,18024.13,There are no additional notes associated with this service or procedure.
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],15381.51,,,,,,0,other,7238.69,16804.22,There are no additional notes associated with this service or procedure.
PREMATURITY WITHOUT MAJOR PROBLEMS,792,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],11512.88,,"Fee schedule rate ($11,512.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,1956.00,19457.66,There are no additional notes associated with this service or procedure.
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC",011,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],150008.48,,"Fee schedule rate ($150,008.48). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (44), with a minimum of zero.",,,,0,other,38880.49,150008.48,There are no additional notes associated with this service or procedure.
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC,807,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],12670.24,,"Fee schedule rate ($12,670.24). Adds an outlier to normal pricing equal to the per diem rate ($29,637.88) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,5354.25,13266.23,There are no additional notes associated with this service or procedure.
HC >= 12 Lead Ekg,CASE-93005,APC,93005,CPT,0730,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],57.98,,"APC Price ($55.22). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,55.22,57.98,OPPS APC
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,544,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],23207.64,,"Fee schedule rate ($23,207.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,7055.15,23207.64,There are no additional notes associated with this service or procedure.
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITHOUT CC/MCC",630,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],42541.02,,"Fee schedule rate ($42,541.02). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11828.78,42541.02,There are no additional notes associated with this service or procedure.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],45706.73,,"Fee schedule rate ($45,706.73). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,7921.00,45706.73,There are no additional notes associated with this service or procedure.
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],16737.83,,"Case rate ($15,940.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,964.98, add-ons for qualifying new technology services are included. If operating cost exceeds $49,835.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,783.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $12,972.20 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,020.03 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,023.63. The transfer capital threshold is the transfer adjustment factor * $1,023.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,15940.79,53275.26,Inpatient DRG
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],39337.51,,"Fee schedule rate ($39,337.51). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,16120.25,41187.90,There are no additional notes associated with this service or procedure.
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],19523.79,,"Case rate ($18,594.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,433.29, add-ons for qualifying new technology services are included. If operating cost exceeds $52,304.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,977.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $15,431.44 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,488.34 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,217.69. The transfer capital threshold is the transfer adjustment factor * $1,217.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,18594.09,59494.91,Inpatient DRG
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6640.88,,"Case rate ($6,324.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,027.46, add-ons for qualifying new technology services are included. If operating cost exceeds $40,898.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,072.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $4,067.09 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,082.51 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $312.61. The transfer capital threshold is the transfer adjustment factor * $312.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5139.72,13110.79,Inpatient DRG
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],39820.52,,"Fee schedule rate ($39,820.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,15273.74,39820.52,There are no additional notes associated with this service or procedure.
BRONCHITIS AND ASTHMA WITH CC/MCC,202,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],18251.76,,"Fee schedule rate ($18,251.76). Adds an outlier to normal pricing equal to the per diem rate ($45,948.49) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,7606.34,19110.30,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],25026.36,,"Fee schedule rate ($25,026.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9356.31,25026.36,There are no additional notes associated with this service or procedure.
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],23262.15,,,,,,0,other,7243.75,23262.15,There are no additional notes associated with this service or procedure.
VENTRICULAR SHUNT PROCEDURES WITH CC,032,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],40047.88,,"Fee schedule rate ($40,047.88). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,16376.22,46275.08,There are no additional notes associated with this service or procedure.
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],28966.51,,,,,,0,other,11914.12,40426.76,There are no additional notes associated with this service or procedure.
Sigmoidoscopy Flx Control Bleeding,CASE-45334,APC,45334,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1159.29,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1120.09,1176.09,OPPS APC
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],25013.10,,"Fee schedule rate ($25,013.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10846.16,25863.45,There are no additional notes associated with this service or procedure.
HC Inj Anes/Steroid C/D Facet Sg|LEFT SIDE|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-64490,APC,64490,CPT,0361,RC,,,LT|74,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],856.86,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,827.89,869.28,OPPS APC
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,555,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],19068.47,,"Case rate ($10,896.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,272.18, add-ons for qualifying new technology services are included. If operating cost exceeds $45,143.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,414.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,296.64 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,327.23 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $654.69. The transfer capital threshold is the transfer adjustment factor * $654.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,10896.27,42290.95,All Other Inpatient
"Inj Dx/Ther Agnt Paravert Facet Joint, Cerv/Thorac, Add Level",CASE-64492,APC,64492,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],869.28,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,827.89,869.28,OPPS APC
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,544,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],23207.64,,"Fee schedule rate ($23,207.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,7055.15,23207.64,There are no additional notes associated with this service or procedure.
TRAUMATIC INJURY WITH MCC,913,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],42838.46,,"Fee schedule rate ($42,838.46). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13014.58,42838.46,There are no additional notes associated with this service or procedure.
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC,519,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],15490.44,,"Case rate ($15,490.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,546.03, add-ons for qualifying new technology services are included. If operating cost exceeds $49,417.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,750.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $12,554.80 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,601.09 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $990.70. The transfer capital threshold is the transfer adjustment factor * $990.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,15490.44,50780.20,Inpatient DRG
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],12907.72,,"Case rate ($12,293.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,590.89, add-ons for qualifying new technology services are included. If operating cost exceeds $46,461.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,498.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $9,609.50 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,645.94 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $738.61. The transfer capital threshold is the transfer adjustment factor * $738.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12606.23,36868.88,Inpatient DRG
MINOR BLADDER PROCEDURES WITHOUT CC/MCC,664,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],31876.87,,"Fee schedule rate ($31,876.87). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9034.63,31876.87,There are no additional notes associated with this service or procedure.
"Suture Digital Nerve Hand/Foot 1 Nerve|RIGHT HAND, THUMB",CASE-64831,APC,64831,CPT,0360,RC,,,F5,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1891.77,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1827.80,1919.19,OPPS APC
HC Joint Injection/Aspir Large WO US|LEFT SIDE|PBB CHARGE,CASE-20610,APC,20610,CPT,0510,RC,,,LT|PBB,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],15283.90,,"Case rate ($15,283.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,353.89, add-ons for qualifying new technology services are included. If operating cost exceeds $49,224.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,735.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.2. The base transfer operating payment is the transfer adjustment factor * $12,363.36 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,408.94 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $975.59. The transfer capital threshold is the transfer adjustment factor * $975.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,15283.90,38757.79,Inpatient DRG
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],36776.05,,"Fee schedule rate ($36,776.05). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11053.39,36776.05,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF NERVOUS SYSTEM WITH CC,092,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],26765.51,,"Fee schedule rate ($26,765.51). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8872.78,26765.51,There are no additional notes associated with this service or procedure.
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],31477.13,,"Fee schedule rate ($31,477.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9648.19,31477.13,There are no additional notes associated with this service or procedure.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],17185.35,,"Fee schedule rate ($17,185.35). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,16120.25,41187.90,There are no additional notes associated with this service or procedure.
PSYCHOSES,885,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],26250.06,,"Fee schedule rate ($26,250.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15.8), with a minimum of zero.",,,,0,other,2070.00,27484.83,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],9370.00,,"Per diem ($9,370). If length of stay < 6.7, first 1 days paid at a per diem of $18,740 instead. Capped at $62,779.90.",,,,0,other,9370.00,65732.99,Estimated amount calculated based on 3 day length of stay.
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],15090.08,,"Case rate ($14,371.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,528.29, add-ons for qualifying new technology services are included. If operating cost exceeds $48,399.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,646.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $11,539.59 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,583.34 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $886.96. The transfer capital threshold is the transfer adjustment factor * $886.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,14747.55,37899.49,Inpatient DRG
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC",458,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],31259.16,,"Case rate ($30,202.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $28,231.97, add-ons for qualifying new technology services are included. If operating cost exceeds $63,102.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,826.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $26,190.45 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $26,287.02 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,066.69. The transfer capital threshold is the transfer adjustment factor * $2,066.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,30202.09,132827.25,Inpatient DRG
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],34245.00,,"Fee schedule rate ($34,245.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,12725.42,34245.00,There are no additional notes associated with this service or procedure.
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],15484.93,,"Case rate ($14,747.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,854.94, add-ons for qualifying new technology services are included. If operating cost exceeds $48,725.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,696.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $11,866.24 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,909.99 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $936.36. The transfer capital threshold is the transfer adjustment factor * $936.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,14747.55,37899.49,Inpatient DRG
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,329,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],86631.74,,"Fee schedule rate ($86,631.74). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (38), with a minimum of zero.",,,,0,other,33072.77,90445.33,There are no additional notes associated with this service or procedure.
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],25100.69,,"Case rate ($14,343.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,478.83, add-ons for qualifying new technology services are included. If operating cost exceeds $48,349.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,666.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $11,491.51 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,533.88 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $906.79. The transfer capital threshold is the transfer adjustment factor * $906.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,14343.25,36024.65,All Other Inpatient
BRONCHITIS AND ASTHMA WITH CC/MCC,202,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],14307.27,,"Fee schedule rate ($14,307.27). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7606.34,19110.30,There are no additional notes associated with this service or procedure.
HC Breath Hydrogen/Met Test,CASE-91065,APC,91065,CPT,0920,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],209.18,,"APC Price ($202.11). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,202.11,212.21,OPPS APC
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],40714.72,,"Fee schedule rate ($40,714.72). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,17356.15,44778.95,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,082,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],17771.67,,"Case rate ($17,423.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,344.04, add-ons for qualifying new technology services are included. If operating cost exceeds $51,215.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,892.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $14,346.19 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,399.08 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,132.06. The transfer capital threshold is the transfer adjustment factor * $1,132.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,17423.21,56223.11,Inpatient DRG
Cysto W/Ureteroscopy W/Rmvl/Manj Stones,CASE-52352,APC,52352,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3464.44,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3299.47,3464.44,OPPS APC
Reconstruction Nail Bed W/Graft,CASE-11762,APC,11762,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],2027.84,,"APC Price ($1,931.28). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1931.28,2027.84,OPPS APC
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],36855.62,,"Fee schedule rate ($36,855.62). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,15821.59,40320.14,There are no additional notes associated with this service or procedure.
Exc B9 Lesion Mrgn Xcp Sk Tg S/N/H/F/G 0.5 Cm/<,CASE-11420,APC,11420,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1623.23,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1545.93,1623.23,OPPS APC
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH MCC",722,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],56869.13,,"Fee schedule rate ($56,869.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,14200.37,56869.13,There are no additional notes associated with this service or procedure.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",063,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],35701.87,,"Fee schedule rate ($35,701.87). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,35701.87,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],81524.17,,"Fee schedule rate ($81,524.17). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,8972.00,81524.17,There are no additional notes associated with this service or procedure.
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],6965.00,,,,,,0,other,5883.03,17111.12,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,426,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],177294.98,,"Fee schedule rate ($177,294.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,76581.29,216864.15,There are no additional notes associated with this service or procedure.
RESPIRATORY NEOPLASMS WITHOUT CC/MCC,182,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],7049.74,,"Case rate ($7,049.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,693.83, add-ons for qualifying new technology services are included. If operating cost exceeds $41,564.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,133.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,731.43 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,748.88 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $373.36. The transfer capital threshold is the transfer adjustment factor * $373.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,23037.13,Inpatient DRG
TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC,087,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],17189.96,,"Fee schedule rate ($17,189.96). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,8139.36,22679.07,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,085,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],17330.41,,"Case rate ($17,330.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,257.72, add-ons for qualifying new technology services are included. If operating cost exceeds $51,128.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,885.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $14,260.20 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,312.77 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,125.27. The transfer capital threshold is the transfer adjustment factor * $1,125.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9282.00,57443.16,Inpatient DRG
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,418,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],13400.58,,"Case rate ($13,400.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,601.88, add-ons for qualifying new technology services are included. If operating cost exceeds $47,472.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,597.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $10,617.79 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,656.93 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $837.85. The transfer capital threshold is the transfer adjustment factor * $837.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,13400.58,39884.93,Inpatient DRG
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC",494,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],39945.55,,"Fee schedule rate ($39,945.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,15533.10,39945.55,There are no additional notes associated with this service or procedure.
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],34406.22,,"Fee schedule rate ($34,406.22). Adds an outlier to normal pricing equal to the per diem rate ($49,808.13) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,14343.25,36024.65,There are no additional notes associated with this service or procedure.
Biopsy Floor Mouth,CASE-41108,APC,41108,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1600.04,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1545.93,1623.23,OPPS APC
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,450,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],38037.38,,"Case rate ($38,037.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $35,520.98, add-ons for qualifying new technology services are included. If operating cost exceeds $70,391.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,399.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $33,452.68 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $33,576.02 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,639.75. The transfer capital threshold is the transfer adjustment factor * $2,639.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,38037.38,146009.19,Inpatient DRG
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],26721.94,,"Fee schedule rate ($26,721.94). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6965.00,34422.94,There are no additional notes associated with this service or procedure.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],23799.09,,"Case rate ($23,799.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $22,275.40, add-ons for qualifying new technology services are included. If operating cost exceeds $57,146.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,358.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.1. The base transfer operating payment is the transfer adjustment factor * $20,255.77 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $20,330.45 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,598.38. The transfer capital threshold is the transfer adjustment factor * $1,598.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,23799.09,63499.65,Inpatient DRG
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],19407.49,,"Case rate ($18,751.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,579.45, add-ons for qualifying new technology services are included. If operating cost exceeds $52,450.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,989.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $15,577.06 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,634.50 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,229.18. The transfer capital threshold is the transfer adjustment factor * $1,229.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,8480.00,59081.91,Inpatient DRG
GASTROINTESTINAL HEMORRHAGE WITH MCC,377,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],7634.00,,"Per diem ($7,634). If length of stay < 4.5, first 1 days paid at a per diem of $15,268 instead. Capped at $34,353.60.",,,,0,other,7634.00,35969.56,Estimated amount calculated based on 3 day length of stay.
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH MCC",510,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],10710.00,,"Per diem ($10,710). If length of stay < 5.3, first 1 days paid at a per diem of $21,420 instead. Capped at $56,764.26.",,,,0,other,10710.00,89863.76,Estimated amount calculated based on 6 day length of stay.
Septoplasty/Submucous Resecj W/WO Cartilage Grf|BILATERAL PROCEDURE,CASE-30520,APC,30520,CPT,0360,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6837.16,,"APC Price ($6,605.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6605.95,6936.25,OPPS APC
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],20553.44,,"Fee schedule rate ($20,553.44). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8874.81,20553.44,There are no additional notes associated with this service or procedure.
"HYPOVOLEMIA AND RELATED ELECTROLYTE DISORDERS,MODERATE",422,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],2019.98,,"Case rate for a one day stay ($1,923.79). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,1923.79,2019.98,There are no additional notes associated with this service or procedure.
Dstr Nrolytc Agnt Parverteb Fct Addl Crvcl/Thora|LEFT SIDE,CASE-64634,APC,64634,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1891.77,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1827.80,1919.19,OPPS APC
Cysto/Uretero W/Lithotripsy &Indwell Stent Insrt|LEFT SIDE,CASE-52356,APC,52356,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5018.77,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5018.77,5269.71,OPPS APC
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],2070.00,,,,,,0,other,1188.00,12138.74,Estimated amount calculated based on 1 day length of stay.
"NEONATE BIRTH WEIGHT > 2499 GRAMS WITH OTHER SIGNIFICANT CONDITION,MODERATE",639,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],5007.74,,"Case rate ($4,769.28). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4769.28,5007.74,There are no additional notes associated with this service or procedure.
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],22955.40,,"Case rate ($21,862.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,473.63, add-ons for qualifying new technology services are included. If operating cost exceeds $55,344.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,216.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. The base transfer operating payment is the transfer adjustment factor * $18,460.61 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,528.68 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,456.72. The transfer capital threshold is the transfer adjustment factor * $1,456.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7086.00,57872.02,Inpatient DRG
Repair Brow Ptosis|BILATERAL PROCEDURE,CASE-67900,APC,67900,CPT,0360,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],2336.65,,"APC Price ($2,225.38). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2225.38,2336.65,OPPS APC
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],75725.96,,"Fee schedule rate ($75,725.96). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (40), with a minimum of zero.",,,,0,other,45521.20,142438.06,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],8991.47,,"Case rate ($8,563.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,101.85, add-ons for qualifying new technology services are included. If operating cost exceeds $42,972.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,244.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $6,134.29 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,156.91 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $484.06. The transfer capital threshold is the transfer adjustment factor * $484.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8563.30,31533.97,Inpatient DRG
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,307,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],7434.68,,"Case rate ($7,434.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $7,017.68, add-ons for qualifying new technology services are included. If operating cost exceeds $45,662.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $3,170.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $5,632.79 + an uncompensated DSH payment of $1,359.91. The transfer operating threshold is the transfer adjustment factor * $5,657.77 + an uncompensated DSH payment of $1,359.91. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $441.98. The transfer capital threshold is the transfer adjustment factor * $441.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6335.27,18228.77,Inpatient DRG
PERITONEAL ADHESIOLYSIS WITH CC,336,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],28551.96,,"Fee schedule rate ($28,551.96). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,16225.22,53705.31,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL OBSTRUCTION WITH CC,389,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],7658.22,,"Case rate ($7,293.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,920.63, add-ons for qualifying new technology services are included. If operating cost exceeds $41,791.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,151.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $4,957.39 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,975.67 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $391.19. The transfer capital threshold is the transfer adjustment factor * $391.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5118.00,16423.43,Inpatient DRG
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],30245.71,,"Fee schedule rate ($30,245.71). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9151.11,30245.71,There are no additional notes associated with this service or procedure.
Exc Rct Procidentia W/Anast Perineal Approach,CASE-45130,APC,45130,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],51.22,,"APC Price ($48.78). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,48.78,51.22,OPPS APC
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],32323.20,,"Fee schedule rate ($32,323.20). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,16286.16,58320.32,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],46523.26,,"Fee schedule rate ($46,523.26). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,17782.11,46523.26,There are no additional notes associated with this service or procedure.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC,099,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],22084.20,,"Fee schedule rate ($22,084.20). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11171.21,26807.94,There are no additional notes associated with this service or procedure.
SPINAL PROCEDURES WITHOUT CC/MCC,030,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],17651.54,,"Case rate ($16,810.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,774.52, add-ons for qualifying new technology services are included. If operating cost exceeds $50,645.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,847.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $13,778.77 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,829.57 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,087.28. The transfer capital threshold is the transfer adjustment factor * $1,087.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,16810.99,44714.01,Inpatient DRG
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],23618.74,,"Fee schedule rate ($23,618.74). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10533.95,24956.34,There are no additional notes associated with this service or procedure.
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],68942.79,,"Fee schedule rate ($68,942.79). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,21489.15,68942.79,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7032.89,,"Case rate ($6,697.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,375.48, add-ons for qualifying new technology services are included. If operating cost exceeds $41,246.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,099.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $4,413.79 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,430.53 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $339.25. The transfer capital threshold is the transfer adjustment factor * $339.25. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6841.83,21167.26,Inpatient DRG
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],5791.49,,"Fee schedule rate ($5,791.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,3079.00,10940.41,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],9036.41,,"Case rate ($8,859.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,377.16, add-ons for qualifying new technology services are included. If operating cost exceeds $43,248.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,265.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $6,408.58 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,432.21 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $505.70. The transfer capital threshold is the transfer adjustment factor * $505.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,8859.23,20090.22,Inpatient DRG
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",062,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],44304.80,,"Fee schedule rate ($44,304.80). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,13844.84,44304.80,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],23954.07,,"Fee schedule rate ($23,954.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,6167.00,29058.99,There are no additional notes associated with this service or procedure.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],20401.88,,"Fee schedule rate ($20,401.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,20401.88,There are no additional notes associated with this service or procedure.
Septoplasty/Submucous Resecj W/WO Cartilage Grf|BILATERAL PROCEDURE,CASE-30520,APC,30520,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6605.95,,"APC Price ($6,605.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6605.95,6936.25,OPPS APC
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],19691.31,,"Fee schedule rate ($19,691.31). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,9040.72,26966.33,There are no additional notes associated with this service or procedure.
Wmhc Perc Implant Stim Lead Ea,CASE-63650,APC,63650,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6174.06,,"APC Price ($5,965.28). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5965.28,6263.54,OPPS APC
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],8269.74,,"Case rate ($7,875.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,462.42, add-ons for qualifying new technology services are included. If operating cost exceeds $42,333.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,193.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $5,497.20 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,517.46 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $433.78. The transfer capital threshold is the transfer adjustment factor * $433.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7875.94,17233.12,Inpatient DRG
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],9629.35,,"Case rate ($9,170.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,680.50, add-ons for qualifying new technology services are included. If operating cost exceeds $43,551.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,275.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,710.11 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,735.55 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $515.75. The transfer capital threshold is the transfer adjustment factor * $515.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9389.48,22358.90,Inpatient DRG
CESAREAN SECTION WITH STERILIZATION WITH MCC,783,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],18571.05,,"Case rate ($18,571.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,411.86, add-ons for qualifying new technology services are included. If operating cost exceeds $52,282.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,975.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $15,410.10 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,466.92 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,216.01. The transfer capital threshold is the transfer adjustment factor * $1,216.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12612.10,23722.94,Inpatient DRG
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,091,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],34556.75,,,,,,0,other,13838.06,40030.81,There are no additional notes associated with this service or procedure.
"NEONATE TRANSFERRED < 5 DAYS OLD BORN HERE,MODERATE",581,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],1604.01,,"The inlier payment is calculated as the lesser of the standard DRG payment $1,604.01 and the transfer payment, which is a per diem of $1,253.13. If cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,1604.01,1684.21,Estimated amount calculated based on 1 day length of stay.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],42569.49,,"Case rate ($40,542.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $37,851.31, add-ons for qualifying new technology services are included. If operating cost exceeds $72,722.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,582.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.6. The base transfer operating payment is the transfer adjustment factor * $35,774.45 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $35,906.36 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,822.96. The transfer capital threshold is the transfer adjustment factor * $2,822.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,40542.37,128358.13,Inpatient DRG
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],31577.54,,"Fee schedule rate ($31,577.54). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,15453.88,39251.68,There are no additional notes associated with this service or procedure.
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH MCC",510,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],22399.99,,"Case rate ($22,399.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,973.84, add-ons for qualifying new technology services are included. If operating cost exceeds $55,844.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,256.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.3. The base transfer operating payment is the transfer adjustment factor * $18,958.99 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $19,028.89 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,496.05. The transfer capital threshold is the transfer adjustment factor * $1,496.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10710.00,89863.76,Inpatient DRG
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],2070.00,,,,,,0,other,1188.00,12138.74,Estimated amount calculated based on 1 day length of stay.
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",759,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],11643.60,,"Fee schedule rate ($11,643.60). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6190.22,13057.66,There are no additional notes associated with this service or procedure.
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],10626.74,,"Case rate ($10,626.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,021.44, add-ons for qualifying new technology services are included. If operating cost exceeds $44,892.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,394.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $8,046.82 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,076.49 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $634.97. The transfer capital threshold is the transfer adjustment factor * $634.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10626.74,25225.91,Inpatient DRG
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],14098.78,,"Case rate ($14,098.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,251.41, add-ons for qualifying new technology services are included. If operating cost exceeds $48,122.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,648.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $11,264.92 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,306.46 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $888.91. The transfer capital threshold is the transfer adjustment factor * $888.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7332.00,35314.31,Inpatient DRG
Exc Cyst/Aberrant Breast Tissue Open 1/> Lesion|BILATERAL PROCEDURE,CASE-19120,APC,19120,CPT,0360,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3848.19,,"APC Price ($3,664.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3793.21,3848.19,OPPS APC
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",623,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],14423.36,,"Case rate ($13,736.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,936.41, add-ons for qualifying new technology services are included. If operating cost exceeds $47,807.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,601.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $10,949.94 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,991.46 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $841.64. The transfer capital threshold is the transfer adjustment factor * $841.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,14093.37,33712.76,Inpatient DRG
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],19371.27,,"Fee schedule rate ($19,371.27). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7641.61,19371.27,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],6965.00,,,,,,0,other,6965.00,41030.48,There are no additional notes associated with this service or procedure.
Cysto W/Rescj/Fulg Orthopic Ureterocele Uni/Bi,CASE-52300,APC,52300,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3299.47,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3299.47,3464.44,OPPS APC
Tx Incomplete Abortion Any Trimester Surgical,CASE-59812,APC,59812,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3030.03,,"APC Price ($3,030.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3030.03,3181.53,OPPS APC
OTHER DISORDERS OF THE EYE WITHOUT MCC,125,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],7501.77,,"Case rate ($7,144.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,782.02, add-ons for qualifying new technology services are included. If operating cost exceeds $41,653.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,140.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,819.30 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,837.07 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $380.29. The transfer capital threshold is the transfer adjustment factor * $380.29. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7144.54,17952.29,Inpatient DRG
Nasal/Sinus Ndsc Total With Sphenoidotomy|BILATERAL PROCEDURE,CASE-31257,APC,31257,CPT,0360,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6837.16,,"APC Price ($6,605.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6605.95,6936.25,OPPS APC
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],31973.49,,"Fee schedule rate ($31,973.49). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,13386.36,33244.29,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],21892.85,,"Fee schedule rate ($21,892.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7569.84,21892.85,There are no additional notes associated with this service or procedure.
Surgical Arthroscopy Shoulder Repair Slap Lesion|LEFT SIDE,CASE-29807,APC,29807,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6791.99,7131.59,OPPS APC
"DIVERTICULITIS AND DIVERTICULOSIS,MAJOR",244,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],11068.02,,"Case rate ($11,068.02). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,11068.02,11621.42,There are no additional notes associated with this service or procedure.
Septoplasty/Submucous Resecj W/WO Cartilage Grf,CASE-30520,APC,30520,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3211.97,,"APC Price ($3,103.35). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.35,3258.52,OPPS APC
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],7383.46,,"Case rate ($7,238.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,869.60, add-ons for qualifying new technology services are included. If operating cost exceeds $41,740.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,147.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,906.55 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,924.64 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $387.18. The transfer capital threshold is the transfer adjustment factor * $387.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,7238.69,16804.22,Inpatient DRG
Cystourethroscopy,CASE-52000,APC,52000,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],652.69,,"APC Price ($652.69). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,652.69,685.32,OPPS APC
Surgical Arthroscopy Shoulder Repair Slap Lesion|RIGHT SIDE,CASE-29807,APC,29807,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6791.99,7131.59,OPPS APC
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],7587.22,,"Case rate ($7,438.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,055.44, add-ons for qualifying new technology services are included. If operating cost exceeds $41,926.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,161.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,091.72 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,110.49 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $401.79. The transfer capital threshold is the transfer adjustment factor * $401.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,7438.45,15961.98,Inpatient DRG
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],29216.99,,"Fee schedule rate ($29,216.99). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9755.86,29216.99,There are no additional notes associated with this service or procedure.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,270,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],96464.47,,"Fee schedule rate ($96,464.47). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,34720.90,101002.04,There are no additional notes associated with this service or procedure.
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,069,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],6965.00,,,,,,0,other,6965.00,20333.68,There are no additional notes associated with this service or procedure.
ALLERGIC REACTIONS WITH MCC,915,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],33088.84,,,,,,0,other,13332.86,33088.84,There are no additional notes associated with this service or procedure.
HC Rep Cpx Sc Arm Lg 2.6-7.5cm,CASE-13121,APC,13121,CPT,0450,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1600.04,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1545.93,1623.23,OPPS APC
Osteoplasty Radius/Ulna Shortening,CASE-25390,APC,25390,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7029.71,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6791.99,7131.59,OPPS APC
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,450,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],100159.17,,"Fee schedule rate ($100,159.17). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15), with a minimum of zero.",,,,0,other,38037.38,146009.19,There are no additional notes associated with this service or procedure.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],8767.81,,"Case rate ($8,767.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,292.11, add-ons for qualifying new technology services are included. If operating cost exceeds $43,163.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,258.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,323.85 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,347.16 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $499.01. The transfer capital threshold is the transfer adjustment factor * $499.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8767.81,19824.58,Inpatient DRG
Hysteroscopy Bx Endometrium&/Polypc W/WO D&C,CASE-58558,APC,58558,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3136.08,,"APC Price ($3,030.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3030.03,3181.53,OPPS APC
DIABETES WITH CC,638,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],17634.53,,,,,,0,other,8014.07,17634.53,There are no additional notes associated with this service or procedure.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],9097.60,,"Case rate ($9,097.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,598.92, add-ons for qualifying new technology services are included. If operating cost exceeds $43,469.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,283.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,629.53 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,653.97 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $523.14. The transfer capital threshold is the transfer adjustment factor * $523.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9097.60,21455.22,Inpatient DRG
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],19877.10,,"Fee schedule rate ($19,877.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8009.34,19877.10,There are no additional notes associated with this service or procedure.
NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,601,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],12359.72,,"Fee schedule rate ($12,359.72). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6042.05,12359.72,There are no additional notes associated with this service or procedure.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],17100.47,,"Case rate ($16,286.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,286.28, add-ons for qualifying new technology services are included. If operating cost exceeds $50,157.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,808.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $13,292.32 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,341.33 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,048.90. The transfer capital threshold is the transfer adjustment factor * $1,048.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,16286.16,58320.32,Inpatient DRG
TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC,087,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],22679.07,,"Fee schedule rate ($22,679.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,8139.36,22679.07,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,064,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],16108.31,,"Case rate ($15,563.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,614.08, add-ons for qualifying new technology services are included. If operating cost exceeds $49,485.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,756.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $12,622.59 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,669.13 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $996.05. The transfer capital threshold is the transfer adjustment factor * $996.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,15563.58,41838.16,Inpatient DRG
Surg Tx Anal Fistula Intersphincteric,CASE-46275,APC,46275,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],2727.99,,"APC Price ($2,598.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2598.08,2727.99,OPPS APC
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,074,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],20919.08,,"Fee schedule rate ($20,919.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8925.60,20919.08,There are no additional notes associated with this service or procedure.
"SEPTICEMIA AND DISSEMINATED INFECTIONS,MODERATE",720,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],2046.25,,"Case rate for a one day stay ($1,948.81). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,1948.81,2046.25,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,447,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],49552.87,,"Case rate ($47,193.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $44,038.45, add-ons for qualifying new technology services are included. If operating cost exceeds $78,909.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $5,069.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $41,938.87 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $42,093.51 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,309.39. The transfer capital threshold is the transfer adjustment factor * $3,309.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,47193.21,156646.82,Inpatient DRG
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],142438.06,,"Fee schedule rate ($142,438.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (40), with a minimum of zero.",,,,0,other,45521.20,142438.06,There are no additional notes associated with this service or procedure.
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],15461.47,,"Case rate ($14,725.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,834.15, add-ons for qualifying new technology services are included. If operating cost exceeds $48,705.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,694.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,845.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,889.20 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $934.73. The transfer capital threshold is the transfer adjustment factor * $934.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7389.00,37134.43,Inpatient DRG
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],25026.36,,"Fee schedule rate ($25,026.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9356.31,25026.36,There are no additional notes associated with this service or procedure.
Esophageal Motility Study W/Interp&Rpt,CASE-91010,APC,91010,CPT,0750,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],361.51,,"APC Price ($349.28). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,349.28,366.75,OPPS APC
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],26028.48,,"Case rate ($26,028.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $24,349.34, add-ons for qualifying new technology services are included. If operating cost exceeds $59,220.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,521.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $22,322.08 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $22,404.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,761.43. The transfer capital threshold is the transfer adjustment factor * $1,761.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,26028.48,80635.65,Inpatient DRG
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],21862.29,,"Case rate ($21,862.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,473.63, add-ons for qualifying new technology services are included. If operating cost exceeds $55,344.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,216.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. The base transfer operating payment is the transfer adjustment factor * $18,460.61 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,528.68 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,456.72. The transfer capital threshold is the transfer adjustment factor * $1,456.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7086.00,57872.02,Inpatient DRG
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],20362.22,,"Fee schedule rate ($20,362.22). Adds an outlier to normal pricing equal to the per diem rate ($66,744.74) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.8), with a minimum of zero.",,,,0,other,9282.47,21320.03,There are no additional notes associated with this service or procedure.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],52794.06,,"Fee schedule rate ($52,794.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (37), with a minimum of zero.",,,,0,other,13907.80,52794.06,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITH CC,164,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],47433.53,,"Fee schedule rate ($47,433.53). Adds an outlier to normal pricing equal to the per diem rate ($158,028.38) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,19037.66,77058.83,There are no additional notes associated with this service or procedure.
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],35474.53,,"Fee schedule rate ($35,474.53). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,16428.39,42083.20,There are no additional notes associated with this service or procedure.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC",156,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],12624.95,,"Fee schedule rate ($12,624.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6625.12,13598.77,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC,832,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],9034.88,,"Fee schedule rate ($9,034.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4803.31,14198.92,There are no additional notes associated with this service or procedure.
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],27109.44,,"Case rate ($15,491.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,546.67, add-ons for qualifying new technology services are included. If operating cost exceeds $49,417.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,750.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $12,555.42 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,601.72 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $990.75. The transfer capital threshold is the transfer adjustment factor * $990.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,15491.11,54180.83,All Other Inpatient
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],37768.77,,"Fee schedule rate ($37,768.77). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7453.00,42138.30,There are no additional notes associated with this service or procedure.
HYPERTENSION WITHOUT MCC,305,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],17230.49,,"Fee schedule rate ($17,230.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7058.55,17230.49,There are no additional notes associated with this service or procedure.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],22353.41,,"Case rate ($21,597.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,227.30, add-ons for qualifying new technology services are included. If operating cost exceeds $55,098.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,197.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $18,215.19 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,282.35 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,437.36. The transfer capital threshold is the transfer adjustment factor * $1,437.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,21597.50,67790.93,Inpatient DRG
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,690,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],7575.48,,"Case rate ($7,426.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,044.73, add-ons for qualifying new technology services are included. If operating cost exceeds $41,915.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,160.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,081.05 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,099.78 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $400.94. The transfer capital threshold is the transfer adjustment factor * $400.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,7426.94,15928.53,Inpatient DRG
HC Inj Lympho for Sentinal Node|UNUSUAL NON-OVERLAPPING SERVICE,CASE-38792,APC,38792,CPT,0361,RC,,,XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6526.12,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6215.36,6526.12,OPPS APC
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],23520.23,,"Fee schedule rate ($23,520.23). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10517.71,24909.11,There are no additional notes associated with this service or procedure.
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],9950.89,,"Case rate ($9,950.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,392.71, add-ons for qualifying new technology services are included. If operating cost exceeds $44,263.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,345.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $7,420.40 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,447.76 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $585.54. The transfer capital threshold is the transfer adjustment factor * $585.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7243.75,23262.15,Inpatient DRG
CERVICAL SPINAL FUSION WITH CC,472,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],70198.84,,"Fee schedule rate ($70,198.84). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,21896.13,70198.84,There are no additional notes associated with this service or procedure.
Nsl/Sinus Ndsc Max Antrost W/Rmvl Tiss Max Sinus|BILATERAL PROCEDURE,CASE-31267,APC,31267,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6605.95,,"APC Price ($6,605.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6605.95,6936.25,OPPS APC
FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,748,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],25601.70,,"Fee schedule rate ($25,601.70). Adds an outlier to normal pricing equal to the per diem rate ($21,136.29) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9316.20,26805.98,There are no additional notes associated with this service or procedure.
HC Biopsy/Exc Lymph Node Needle|LEFT SIDE,CASE-38505,APC,38505,CPT,0361,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1545.93,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1545.93,1600.04,OPPS APC
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC,807,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],10071.17,,"Fee schedule rate ($10,071.17). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5354.25,13266.23,There are no additional notes associated with this service or procedure.
"CVA AND PRECEREBRAL OCCLUSION WITH INFARCTION,EXTREME",045,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],21474.91,,"Case rate ($21,474.91). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $45,251, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,21474.91,22548.66,There are no additional notes associated with this service or procedure.
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],11565.93,,"Fee schedule rate ($11,565.93). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6148.93,15887.21,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],39259.55,,,,,,0,other,15456.59,41402.42,There are no additional notes associated with this service or procedure.
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],35061.53,,"Fee schedule rate ($35,061.53). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,9696.93,35061.53,There are no additional notes associated with this service or procedure.
HC Joint Injection/Aspir Large WO US|RIGHT SIDE,CASE-20610,APC,20610,CPT,0510,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],297.37,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,287.31,301.68,OPPS APC
Bx/Exc Lymph Node Open Deep Axillary Node|RIGHT SIDE,CASE-38525,APC,38525,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6526.12,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6215.36,6526.12,OPPS APC
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],9520.30,,"Case rate ($9,066.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,583.69, add-ons for qualifying new technology services are included. If operating cost exceeds $43,454.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,268.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,613.67 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,638.74 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $508.34. The transfer capital threshold is the transfer adjustment factor * $508.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9282.47,21320.03,Inpatient DRG
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],16066.07,,"Case rate ($16,066.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,081.53, add-ons for qualifying new technology services are included. If operating cost exceeds $49,952.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,792.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $13,088.32 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,136.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,032.80. The transfer capital threshold is the transfer adjustment factor * $1,032.80. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,41030.48,Inpatient DRG
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH CC",457,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],160549.49,,"Fee schedule rate ($160,549.49). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,42327.47,160549.49,There are no additional notes associated with this service or procedure.
Carpectomy All Bones Proximal Row|RIGHT SIDE,CASE-25215,APC,25215,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3062.67,OPPS APC
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],12509.83,,"Case rate ($11,914.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,219.06, add-ons for qualifying new technology services are included. If operating cost exceeds $46,090.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,489.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $9,240.03 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,274.10 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $729.13. The transfer capital threshold is the transfer adjustment factor * $729.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,11914.12,40426.76,Inpatient DRG
VAGINAL DELIVERY WITH O.R. PROCEDURES EXCEPT STERILIZATION AND/OR D&C,768,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],9438.18,,"Case rate ($8,988.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,510.78, add-ons for qualifying new technology services are included. If operating cost exceeds $43,381.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,262.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $6,541.03 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,565.83 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $502.76. The transfer capital threshold is the transfer adjustment factor * $502.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6426.91,13416.00,Inpatient DRG
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,761,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6011.70,,"Case rate ($5,808.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,539.05, add-ons for qualifying new technology services are included. If operating cost exceeds $40,410.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,042.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $3,580.90 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,594.10 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $282.57. The transfer capital threshold is the transfer adjustment factor * $282.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,5808.41,11946.72,Inpatient DRG
Colonoscopy Flx Dx W/Collj Spec When Pfrmd,CASE-45378,APC,45378,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],913.99,,"APC Price ($870.46). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,870.46,913.99,OPPS APC
OTHER DISORDERS OF THE EYE WITHOUT MCC,125,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],14429.27,,"Fee schedule rate ($14,429.27). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.9), with a minimum of zero.",,,,0,other,7144.54,17952.29,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],8714.51,,"Case rate ($8,543.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,083.58, add-ons for qualifying new technology services are included. If operating cost exceeds $42,954.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,242.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,116.09 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,138.64 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $482.62. The transfer capital threshold is the transfer adjustment factor * $482.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,8543.64,23239.84,Inpatient DRG
Arthroscopy Knee W/Meniscus Rpr Medial/Lateral|LEFT SIDE,CASE-29882,APC,29882,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6791.99,7131.59,OPPS APC
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,068,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],12849.90,,"Fee schedule rate ($12,849.90). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,23184.90,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC,817,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],43874.75,,"Fee schedule rate ($43,874.75). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,17396.11,44895.04,There are no additional notes associated with this service or procedure.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],75579.22,,"Fee schedule rate ($75,579.22). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,25162.32,75579.22,There are no additional notes associated with this service or procedure.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,329,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],86631.74,,"Fee schedule rate ($86,631.74). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (38), with a minimum of zero.",,,,0,other,33072.77,90445.33,There are no additional notes associated with this service or procedure.
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],33890.73,,"Fee schedule rate ($33,890.73). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6277.00,36801.89,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITHOUT CC/MCC,428,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],105654.25,,"Fee schedule rate ($105,654.25). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,40017.53,118904.57,There are no additional notes associated with this service or procedure.
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],20362.22,,"Fee schedule rate ($20,362.22). Adds an outlier to normal pricing equal to the per diem rate ($66,744.74) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.8), with a minimum of zero.",,,,0,other,9282.47,21320.03,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL HEMORRHAGE WITH MCC,377,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],7634.00,,"Per diem ($7,634). If length of stay < 4.5, first 1 days paid at a per diem of $15,268 instead. Capped at $34,353.60.",,,,0,other,7634.00,35969.56,Estimated amount calculated based on 3 day length of stay.
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],11168.08,,"Fee schedule rate ($11,168.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5937.41,12366.99,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC,084,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],8638.95,,"Case rate ($8,227.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,801.26, add-ons for qualifying new technology services are included. If operating cost exceeds $42,672.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,208.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $5,834.19 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,856.31 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $448.43. The transfer capital threshold is the transfer adjustment factor * $448.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,19445.16,Inpatient DRG
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],53569.45,,"Fee schedule rate ($53,569.45). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14.8), with a minimum of zero.",,,,0,other,21248.73,56089.29,There are no additional notes associated with this service or procedure.
CHEST PAIN,313,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],15377.66,,"Fee schedule rate ($15,377.66). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,6820.84,15377.66,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],11059.47,,"Case rate ($11,059.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,424, add-ons for qualifying new technology services are included. If operating cost exceeds $45,295.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,426.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $8,447.91 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,479.05 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $666.62. The transfer capital threshold is the transfer adjustment factor * $666.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,11059.47,28423.20,Inpatient DRG
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],10704.29,,,,,,0,other,5628.97,12272.58,There are no additional notes associated with this service or procedure.
Bronchoscopy W/Transbroncl Ndl Aspir Bx Ea Lobe,CASE-31633,APC,31633,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6605.95,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6605.95,6936.25,OPPS APC
OSTEOMYELITIS WITH CC,540,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],11259.77,,"Case rate ($10,723.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,111.53, add-ons for qualifying new technology services are included. If operating cost exceeds $44,982.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,402.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $8,136.58 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,166.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $642.06. The transfer capital threshold is the transfer adjustment factor * $642.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9809.07,25507.30,Inpatient DRG
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC,817,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],17396.11,,"Case rate ($17,396.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,318.84, add-ons for qualifying new technology services are included. If operating cost exceeds $51,189.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,890.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $14,321.08 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,373.88 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,130.07. The transfer capital threshold is the transfer adjustment factor * $1,130.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,17396.11,44895.04,Inpatient DRG
CERVICAL SPINAL FUSION WITH MCC,471,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],95014.33,,,,,,0,other,34645.26,111337.93,There are no additional notes associated with this service or procedure.
Laparoscopy W/Rmvl Adnexal Structures|BILATERAL PROCEDURE,CASE-58661,APC,58661,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5658.76,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5658.76,5856.81,OPPS APC
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],9718.11,,"Case rate ($9,389.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,870.44, add-ons for qualifying new technology services are included. If operating cost exceeds $43,741.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,304.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,900.05 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,925.50 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $544.48. The transfer capital threshold is the transfer adjustment factor * $544.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,9389.48,22358.90,Inpatient DRG
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC",641,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],15312.64,,,,,,0,other,7214.98,15312.64,There are no additional notes associated with this service or procedure.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],18933.95,,"Fee schedule rate ($18,933.95). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.8), with a minimum of zero.",,,,0,other,8767.81,19824.58,There are no additional notes associated with this service or procedure.
Optx Dstl Radl I-Artic Fx/Epiphysl Sep 2 Frag|RIGHT SIDE,CASE-25608,APC,25608,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7029.71,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6791.99,7029.71,OPPS APC
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],75579.22,,"Fee schedule rate ($75,579.22). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,25162.32,75579.22,There are no additional notes associated with this service or procedure.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH CC,026,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],23501.30,,"Case rate ($22,382.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,995.42, add-ons for qualifying new technology services are included. If operating cost exceeds $55,866.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,218.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $18,978.51 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $19,050.47 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,458.73. The transfer capital threshold is the transfer adjustment factor * $1,458.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,23000.66,63202.45,Inpatient DRG
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],9570.98,,"Case rate ($9,570.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,039.28, add-ons for qualifying new technology services are included. If operating cost exceeds $43,910.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,317.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $7,068.27 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,094.33 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $557.76. The transfer capital threshold is the transfer adjustment factor * $557.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,5569.00,40108.48,Inpatient DRG
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],36988.38,,"Fee schedule rate ($36,988.38). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.7), with a minimum of zero.",,,,0,other,15273.74,39820.52,There are no additional notes associated with this service or procedure.
CERVICAL SPINAL FUSION WITHOUT CC/MCC,473,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],33002.76,,"Fee schedule rate ($33,002.76). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,18477.61,62077.11,There are no additional notes associated with this service or procedure.
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],16347.34,,"Case rate ($16,026.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,044.99, add-ons for qualifying new technology services are included. If operating cost exceeds $49,916.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,789.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $13,051.92 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,100.04 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,029.93. The transfer capital threshold is the transfer adjustment factor * $1,029.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,11165.00,61234.06,Inpatient DRG
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,069,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],7354.47,,"Case rate ($7,354.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,977.32, add-ons for qualifying new technology services are included. If operating cost exceeds $41,848.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,155.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $5,013.88 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,032.37 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $395.65. The transfer capital threshold is the transfer adjustment factor * $395.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,20333.68,Inpatient DRG
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],12455.21,,"Case rate ($12,455.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,722.41, add-ons for qualifying new technology services are included. If operating cost exceeds $46,593.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,528.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $9,741.55 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,777.47 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $768.70. The transfer capital threshold is the transfer adjustment factor * $768.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12455.21,37149.27,Inpatient DRG
SEIZURES WITH MCC,100,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],15362.31,,"Case rate ($15,061.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,146.62, add-ons for qualifying new technology services are included. If operating cost exceeds $49,017.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,719.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $12,156.85 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,201.67 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $959.30. The transfer capital threshold is the transfer adjustment factor * $959.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,15061.09,38110.41,Inpatient DRG
Egd Percutaneous Placement Gastrostomy Tube,CASE-43246,APC,43246,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1796.14,,"APC Price ($1,796.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1796.14,1885.95,OPPS APC
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],20170.75,,"Fee schedule rate ($20,170.75). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10048.39,23545.50,There are no additional notes associated with this service or procedure.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,477,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],26606.73,,"Case rate ($25,339.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $23,708.63, add-ons for qualifying new technology services are included. If operating cost exceeds $58,579.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,471.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 8.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $21,683.73 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $21,763.68 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,711.06. The transfer capital threshold is the transfer adjustment factor * $1,711.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,25339.74,67976.16,Inpatient DRG
RADIOTHERAPY,849,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],20293.88,,"Case rate ($20,293.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $19,014.57, add-ons for qualifying new technology services are included. If operating cost exceeds $53,885.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,101.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $17,006.91 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $17,069.62 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,342.01. The transfer capital threshold is the transfer adjustment factor * $1,342.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,20293.88,81867.07,Inpatient DRG
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],22732.01,,"Fee schedule rate ($22,732.01). Adds an outlier to normal pricing equal to the per diem rate ($114,196.66) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.5), with a minimum of zero.",,,,0,other,10136.44,24444.75,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],41580.51,,"Fee schedule rate ($41,580.51). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,13783.20,41580.51,There are no additional notes associated with this service or procedure.
HC Joint Injection/Aspir Large WO US|BILATERAL PROCEDURE|PBB CHARGE,CASE-20610,APC,20610,CPT,0510,RC,,,50|PBB,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH MCC",722,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],14697.38,,"Case rate ($14,200.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,345.91, add-ons for qualifying new technology services are included. If operating cost exceeds $48,216.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,656.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $11,359.07 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,400.95 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $896.34. The transfer capital threshold is the transfer adjustment factor * $896.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,14200.37,56869.13,Inpatient DRG
Laps Gstr Rstcv Px W/Byp Roux-en-Y Limb <150 Cm,CASE-43644,APC,43644,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],297.37,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,287.31,301.68,OPPS APC
PERITONEAL ADHESIOLYSIS WITH CC,336,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],39628.80,,"Fee schedule rate ($39,628.80). Adds an outlier to normal pricing equal to the per diem rate ($54,966.40) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,16225.22,53705.31,There are no additional notes associated with this service or procedure.
Colonoscopy W/Biopsy Single/Multiple|SEPARATE STRUCTURE,CASE-45380,APC,45380,CPT,0360,RC,,,XS,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1176.09,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1120.09,1176.09,OPPS APC
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],19319.20,,"Fee schedule rate ($19,319.20). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8906.63,28434.57,There are no additional notes associated with this service or procedure.
"NEONATE BIRTH WEIGHT 2000-2499 GRAMS WITH OTHER SIGNIFICANT CONDITION,MINOR",625,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],9296.26,,"Case rate ($9,296.26). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,9296.26,9761.07,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],33398.16,,"Fee schedule rate ($33,398.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,7353.00,33398.16,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],70242.60,,"Fee schedule rate ($70,242.60). Adds an outlier to normal pricing equal to the per diem rate ($137,416) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16.5), with a minimum of zero.",,,,0,other,27256.92,81353.66,There are no additional notes associated with this service or procedure.
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],6524.00,,"Per diem ($6,524). If length of stay < 2.6, first 1 days paid at a per diem of $13,048 instead. Capped at $16,962.56.",,,,0,other,6524.00,17760.46,Estimated amount calculated based on 2 day length of stay.
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],54180.83,,"Fee schedule rate ($54,180.83). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,15491.11,54180.83,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,093,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],19011.32,,"Fee schedule rate ($19,011.32). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,19011.32,There are no additional notes associated with this service or procedure.
"Arthrodesis Interphalangeal Jt W/WO Int Fixj|LEFT HAND, FIFTH DIGIT",CASE-26860,APC,26860,CPT,0360,RC,,,F4,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7029.71,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6791.99,7131.59,OPPS APC
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,069,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],20333.68,,"Fee schedule rate ($20,333.68). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,20333.68,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],6965.00,,,,,,0,other,6558.75,14871.83,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],24675.88,,"Fee schedule rate ($24,675.88). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10834.64,25830.00,There are no additional notes associated with this service or procedure.
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],19170.43,,"Case rate ($18,257.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,150.65, add-ons for qualifying new technology services are included. If operating cost exceeds $52,021.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,924.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $15,148.26 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,205.70 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,164.33. The transfer capital threshold is the transfer adjustment factor * $1,164.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8480.00,59081.91,Inpatient DRG
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC,099,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],22084.20,,"Fee schedule rate ($22,084.20). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11171.21,26807.94,There are no additional notes associated with this service or procedure.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],8988.07,,"Case rate ($8,811.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,333.06, add-ons for qualifying new technology services are included. If operating cost exceeds $43,204.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,262.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,364.65 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,388.11 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $502.23. The transfer capital threshold is the transfer adjustment factor * $502.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6965.00,20401.88,Inpatient DRG
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],20297.68,,"Fee schedule rate ($20,297.68). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6965.00,21404.64,There are no additional notes associated with this service or procedure.
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],11565.93,,"Fee schedule rate ($11,565.93). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6148.93,15887.21,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6564.18,,"Case rate ($6,564.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,242.12, add-ons for qualifying new technology services are included. If operating cost exceeds $41,113.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,097.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $4,281.39 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,297.17 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $337.84. The transfer capital threshold is the transfer adjustment factor * $337.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6564.18,17651.07,Inpatient DRG
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],13149.46,,"Fee schedule rate ($13,149.46). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.9), with a minimum of zero.",,,,0,other,6683.37,14699.43,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],22750.61,,"Case rate ($21,667.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,292.19, add-ons for qualifying new technology services are included. If operating cost exceeds $55,163.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,202.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $18,279.84 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,347.24 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,442.46. The transfer capital threshold is the transfer adjustment factor * $1,442.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8972.00,81524.17,Inpatient DRG
Laps Surg W/Aspir Cavity/Cyst Single/Multiple,CASE-49322,APC,49322,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5856.81,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5658.76,5941.70,OPPS APC
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],17672.39,,"Case rate ($10,098.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,530.04, add-ons for qualifying new technology services are included. If operating cost exceeds $44,401.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,356.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $7,557.23 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,585.10 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $596.34. The transfer capital threshold is the transfer adjustment factor * $596.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,10098.51,24259.09,All Other Inpatient
Laps Gastric Restrictive Px Remove Device & Port,CASE-43774,APC,43774,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3608.81,,"APC Price ($3,608.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3608.81,3789.26,OPPS APC
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC,807,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6510.67,,"Case rate ($6,510.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,192.35, add-ons for qualifying new technology services are included. If operating cost exceeds $41,063.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,093.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $4,231.80 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,247.40 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $333.93. The transfer capital threshold is the transfer adjustment factor * $333.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,5354.25,13266.23,Inpatient DRG
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],9446.38,,"Case rate ($9,446.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,923.36, add-ons for qualifying new technology services are included. If operating cost exceeds $43,794.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,308.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,952.78 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,978.41 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $548.64. The transfer capital threshold is the transfer adjustment factor * $548.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9446.38,21796.21,Inpatient DRG
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC,520,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],39786.42,,"Fee schedule rate ($39,786.42). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12061.74,39786.42,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],8863.02,,"Case rate ($8,563.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,101.85, add-ons for qualifying new technology services are included. If operating cost exceeds $42,972.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,244.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $6,134.29 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,156.91 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $484.06. The transfer capital threshold is the transfer adjustment factor * $484.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,8563.30,31533.97,Inpatient DRG
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC,434,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],13280.45,,"Fee schedule rate ($13,280.45). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6770.05,14019.86,There are no additional notes associated with this service or procedure.
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],8743.15,,"Case rate ($8,447.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,994.13, add-ons for qualifying new technology services are included. If operating cost exceeds $42,865.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,235.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,026.96 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,049.18 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $475.59. The transfer capital threshold is the transfer adjustment factor * $475.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,1188.00,18893.86,Inpatient DRG
TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC,084,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],8838.59,,"Case rate ($8,417.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,966.41, add-ons for qualifying new technology services are included. If operating cost exceeds $42,837.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,233.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $5,999.34 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,021.46 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $473.41. The transfer capital threshold is the transfer adjustment factor * $473.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,19445.16,Inpatient DRG
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],31091.14,,"Fee schedule rate ($31,091.14). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13148.66,32553.63,There are no additional notes associated with this service or procedure.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",062,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],33023.06,,"Fee schedule rate ($33,023.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,13844.84,44304.80,There are no additional notes associated with this service or procedure.
"Tendon Sheath Incision|LEFT FOOT, GREAT TOE",CASE-26055,APC,26055,CPT,0360,RC,,,TA,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1919.19,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1827.80,1919.19,OPPS APC
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],9318.55,,"Case rate ($8,874.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,391.65, add-ons for qualifying new technology services are included. If operating cost exceeds $43,262.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,266.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $6,423.02 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,446.70 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $506.84. The transfer capital threshold is the transfer adjustment factor * $506.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8874.81,20553.44,Inpatient DRG
"Rpr/Advmnt Flxr Tdn Zone 2 W/O Fr Grft Ea Tendon|LEFT HAND, FOURTH DIGIT",CASE-26356,APC,26356,CPT,0360,RC,,,F3,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
Chemodenervation Muscle Neck Unilat for Dystonia,CASE-64616,APC,64616,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],297.37,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,287.31,301.68,OPPS APC
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],6965.00,,,,,,0,other,6965.00,32293.66,There are no additional notes associated with this service or procedure.
PREMATURITY WITH MAJOR PROBLEMS,791,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],30904.42,,"Case rate ($29,432.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $27,516.30, add-ons for qualifying new technology services are included. If operating cost exceeds $62,387.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,770.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 13.3. The base transfer operating payment is the transfer adjustment factor * $25,477.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $25,571.35 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,010.42. The transfer capital threshold is the transfer adjustment factor * $2,010.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,3048.21,30904.42,Inpatient DRG
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],12573.10,,"Case rate ($11,974.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,275.12, add-ons for qualifying new technology services are included. If operating cost exceeds $46,146.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,493.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $9,295.90 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,330.17 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $733.54. The transfer capital threshold is the transfer adjustment factor * $733.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,11974.38,29141.64,Inpatient DRG
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],5741.55,,"Case rate ($5,628.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,372.11, add-ons for qualifying new technology services are included. If operating cost exceeds $40,243.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,029.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,414.56 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,427.15 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $269.44. The transfer capital threshold is the transfer adjustment factor * $269.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,5628.97,12272.58,Inpatient DRG
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],19354.07,,"Case rate ($11,059.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,424, add-ons for qualifying new technology services are included. If operating cost exceeds $45,295.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,426.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $8,447.91 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,479.05 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $666.62. The transfer capital threshold is the transfer adjustment factor * $666.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,11059.47,28423.20,All Other Inpatient
HC Peripheral Block - Femoral Single or Saphenous W/Img Gdn|LEFT SIDE,CASE-64447,APC,64447,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],660.72,,"APC Price ($660.72). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,660.72,693.76,OPPS APC
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",759,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],6760.85,,"Case rate ($6,438.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,125.57, add-ons for qualifying new technology services are included. If operating cost exceeds $40,996.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,088.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,165.27 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,180.62 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $328.68. The transfer capital threshold is the transfer adjustment factor * $328.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6190.22,13057.66,Inpatient DRG
HC Joint Injection/Aspir Large WO US|PBB CHARGE|RIGHT SIDE,CASE-20610,APC,20610,CPT,0510,RC,,,PBB|RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],57456.84,,,,,,0,other,21719.40,85305.59,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],37149.27,,"Fee schedule rate ($37,149.27). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,12455.21,37149.27,There are no additional notes associated with this service or procedure.
Exc Tumor Soft Tissue Abdl Wall Subfascial 5cm/>,CASE-22901,APC,22901,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],2718.88,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2718.88,2854.83,OPPS APC
Mastectomy Simple Complete,CASE-19303,APC,19303,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6432.89,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6432.89,6432.89,OPPS APC
HC Bx Breast 1st Lesion US Img|LEFT SIDE,CASE-19083,APC,19083,CPT,0361,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1623.23,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1545.93,1623.23,OPPS APC
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],32974.74,,"Case rate ($31,404.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $29,405.52, add-ons for qualifying new technology services are included. If operating cost exceeds $64,276.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,862.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $27,356.84 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $27,460.57 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,102.71. The transfer capital threshold is the transfer adjustment factor * $2,102.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,32296.02,88188.38,Inpatient DRG
Anoscopy Dx W/HRA &Chem Agnts Enhancement W/Bx,CASE-46607,APC,46607,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1120.09,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1120.09,1176.09,OPPS APC
Laps Vaginal Hysterect > 250 Gm Rmvl Tube&/Ovar,CASE-58554,APC,58554,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],10447.27,,"APC Price ($9,949.78). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,9949.78,10447.27,OPPS APC
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,447,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],156646.82,,"Fee schedule rate ($156,646.82). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,47193.21,156646.82,There are no additional notes associated with this service or procedure.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,329,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],86631.74,,"Fee schedule rate ($86,631.74). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (38), with a minimum of zero.",,,,0,other,33072.77,90445.33,There are no additional notes associated with this service or procedure.
COAGULATION DISORDERS,813,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],30013.33,,,,,,0,other,12274.39,30013.33,There are no additional notes associated with this service or procedure.
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC,497,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],37761.19,,"Fee schedule rate ($37,761.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10127.65,37761.19,There are no additional notes associated with this service or procedure.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],54503.46,,"Fee schedule rate ($54,503.46). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.9), with a minimum of zero.",,,,0,other,21585.31,73588.10,There are no additional notes associated with this service or procedure.
Laps Surg W/Aspir Cavity/Cyst Single/Multiple,CASE-49322,APC,49322,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5658.76,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5658.76,5941.70,OPPS APC
HC Inj Aa&/Strd Other Peripheral Nerve/Branch|RIGHT SIDE,CASE-64450,APC,64450,CPT,0450,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],660.72,,"APC Price ($660.72). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,660.72,683.85,OPPS APC
UNGROUPABLE,999,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],49727.19,,"Case rate ($48,752.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $45,488.70, add-ons for qualifying new technology services are included. If operating cost exceeds $80,359.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $5,183.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 12.7. The base transfer operating payment is the transfer adjustment factor * $43,383.78 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $43,543.75 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,423.41. The transfer capital threshold is the transfer adjustment factor * $3,423.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,10228.00,161307.29,Inpatient DRG
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],15802.03,,"Fee schedule rate ($15,802.03). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7566.45,16333.88,There are no additional notes associated with this service or procedure.
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],37591.64,,"Fee schedule rate ($37,591.64). Adds an outlier to normal pricing equal to the per diem rate ($51,531) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.1), with a minimum of zero.",,,,0,other,15491.11,54180.83,There are no additional notes associated with this service or procedure.
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],7784.77,,"Case rate ($7,414.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,032.76, add-ons for qualifying new technology services are included. If operating cost exceeds $41,903.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,159.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,069.12 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,087.81 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $400.00. The transfer capital threshold is the transfer adjustment factor * $400.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7414.07,18217.52,Inpatient DRG
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],41493.06,,"Fee schedule rate ($41,493.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,16897.01,43444.85,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],41402.42,,"Fee schedule rate ($41,402.42). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,15456.59,41402.42,There are no additional notes associated with this service or procedure.
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],19997.63,,"Fee schedule rate ($19,997.63). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,9151.11,30245.71,There are no additional notes associated with this service or procedure.
HC Inj Aa&/Strd Other Peripheral Nerve/Branch|LEFT SIDE,CASE-64450,APC,64450,CPT,0450,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],660.72,,"APC Price ($660.72). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,660.72,693.76,OPPS APC
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],26587.11,,"Case rate ($25,321.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $23,734.86, add-ons for qualifying new technology services are included. If operating cost exceeds $58,605.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,428.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $21,707.60 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $21,789.91 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,668.50. The transfer capital threshold is the transfer adjustment factor * $1,668.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,26028.48,80635.65,Inpatient DRG
"CARDIAC ARREST, UNEXPLAINED WITH MCC",296,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],29352.79,,"Fee schedule rate ($29,352.79). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.2), with a minimum of zero.",,,,0,other,12522.25,36459.67,There are no additional notes associated with this service or procedure.
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],8106.18,,"Case rate ($8,106.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,676.61, add-ons for qualifying new technology services are included. If operating cost exceeds $42,547.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,210.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,710.61 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,731.66 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $450.62. The transfer capital threshold is the transfer adjustment factor * $450.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8106.18,18245.94,Inpatient DRG
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],80635.65,,"Fee schedule rate ($80,635.65). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,26028.48,80635.65,There are no additional notes associated with this service or procedure.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,025,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],34372.30,,"Case rate ($32,735.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $30,588.77, add-ons for qualifying new technology services are included. If operating cost exceeds $65,459.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,011.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.4. The base transfer operating payment is the transfer adjustment factor * $28,538.59 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $28,643.82 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,251.98. The transfer capital threshold is the transfer adjustment factor * $2,251.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,13351.00,91631.33,Inpatient DRG
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,761,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],6098.83,,"Case rate ($5,808.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,539.05, add-ons for qualifying new technology services are included. If operating cost exceeds $40,410.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,042.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $3,580.90 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,594.10 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $282.57. The transfer capital threshold is the transfer adjustment factor * $282.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5808.41,11946.72,Inpatient DRG
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,345,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],21236.06,,"Case rate ($12,134.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,424.43, add-ons for qualifying new technology services are included. If operating cost exceeds $46,295.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,505.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $9,444.66 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,479.48 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $745.28. The transfer capital threshold is the transfer adjustment factor * $745.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,12134.89,33616.03,All Other Inpatient
Cystostomy Cystotomy W/Drainage,CASE-51040,APC,51040,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1956.65,,"APC Price ($1,956.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1956.65,2054.48,OPPS APC
"Corrj Hallux Valgus W/Sesmdc W/Dist Metar Osteot|RIGHT FOOT, GREAT TOE",CASE-28296,APC,28296,CPT,0360,RC,,,T5,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],52453.14,,"Fee schedule rate ($52,453.14). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14.9), with a minimum of zero.",,,,0,other,20846.48,81306.30,There are no additional notes associated with this service or procedure.
"DIVERTICULITIS AND DIVERTICULOSIS,MINOR",244,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],1867.19,,"Case rate for a one day stay ($1,867.19). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,1867.19,1960.55,There are no additional notes associated with this service or procedure.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,352,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],26528.70,,"Fee schedule rate ($26,528.70). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,9853.37,26528.70,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],16869.37,,"Case rate ($16,066.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,081.53, add-ons for qualifying new technology services are included. If operating cost exceeds $49,952.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,792.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $13,088.32 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,136.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,032.80. The transfer capital threshold is the transfer adjustment factor * $1,032.80. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,41030.48,Inpatient DRG
VAGINAL DELIVERY WITH O.R. PROCEDURES EXCEPT STERILIZATION AND/OR D&C,768,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],12088.81,,"Fee schedule rate ($12,088.81). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6426.91,13416.00,There are no additional notes associated with this service or procedure.
Ligamentous Reconstruction Knee Extra-Articular|RIGHT SIDE,CASE-27427,APC,27427,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],12618.18,,"APC Price ($12,017.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,12017.31,12618.18,OPPS APC
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],23870.71,,"Fee schedule rate ($23,870.71). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10626.74,25225.91,There are no additional notes associated with this service or procedure.
HC Inj Proc Cysto or Void,CASE-51600,APC,51600,CPT,0361,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6837.16,,"APC Price ($6,605.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6605.95,6936.25,OPPS APC
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],81524.17,,"Fee schedule rate ($81,524.17). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,8972.00,81524.17,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],13923.42,,"Case rate ($13,260.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,471.48, add-ons for qualifying new technology services are included. If operating cost exceeds $47,342.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,587.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $10,487.86 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,526.53 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $827.60. The transfer capital threshold is the transfer adjustment factor * $827.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13260.40,32878.30,Inpatient DRG
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],27120.18,,"Fee schedule rate ($27,120.18). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,11717.72,43888.01,There are no additional notes associated with this service or procedure.
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC,797,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],9155.71,,"Case rate ($8,719.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,247.38, add-ons for qualifying new technology services are included. If operating cost exceeds $43,118.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,255.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $6,279.28 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,302.43 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $495.50. The transfer capital threshold is the transfer adjustment factor * $495.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8719.72,20928.55,Inpatient DRG
Laparoscopy Surg Rpr Initial Inguinal Hernia|BILATERAL PROCEDURE,CASE-49650,APC,49650,CPT,0360,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5856.81,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5658.76,5941.70,OPPS APC
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC",494,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],16076.76,,"Case rate ($15,533.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,585.72, add-ons for qualifying new technology services are included. If operating cost exceeds $49,456.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,753.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $12,594.34 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,640.78 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $993.82. The transfer capital threshold is the transfer adjustment factor * $993.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,15533.10,39945.55,Inpatient DRG
"NEONATE BIRTH WEIGHT > 2499 GRAMS WITH RESPIRATORY DISTRESS SYNDROME OR OTHER MAJOR RESPIRATORY CONDITION,MAJOR",634,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],22128.47,,"Case rate ($21,074.73). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,21074.73,22128.47,There are no additional notes associated with this service or procedure.
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],28334.16,,"Fee schedule rate ($28,334.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,7868.00,32126.64,There are no additional notes associated with this service or procedure.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],20116.12,,"Case rate ($19,435.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $18,216.37, add-ons for qualifying new technology services are included. If operating cost exceeds $53,087.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,039.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.9. The base transfer operating payment is the transfer adjustment factor * $16,211.64 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $16,271.42 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,279.26. The transfer capital threshold is the transfer adjustment factor * $1,279.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,19435.86,50821.76,Inpatient DRG
PERIPHERAL VASCULAR DISORDERS WITH CC,300,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],9495.23,,"Case rate ($9,174.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,670.11, add-ons for qualifying new technology services are included. If operating cost exceeds $43,541.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,288.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,700.45 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,725.16 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $528.73. The transfer capital threshold is the transfer adjustment factor * $528.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,9174.14,21005.20,Inpatient DRG
"HYPERTENSION,MODERATE",199,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],6738.39,,"The inlier payment is calculated as the lesser of the standard DRG payment $6,738.39 and the transfer payment, which is a per diem of $2,315.60. If cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,6738.39,7075.31,Estimated amount calculated based on 2 day length of stay.
HEART FAILURE AND SHOCK WITH CC,292,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],7694.43,,"Case rate ($7,694.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,293.57, add-ons for qualifying new technology services are included. If operating cost exceeds $42,164.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,180.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,328.98 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,348.63 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $420.51. The transfer capital threshold is the transfer adjustment factor * $420.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,5502.00,16705.77,Inpatient DRG
Surgical Arthroscopy Shoulder Biceps Tenodesis,CASE-29828,APC,29828,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],38248.08,,"Fee schedule rate ($38,248.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11593.79,38248.08,There are no additional notes associated with this service or procedure.
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],24701.52,,"Fee schedule rate ($24,701.52). Adds an outlier to normal pricing equal to the per diem rate ($51,462.28) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,10846.16,25863.45,There are no additional notes associated with this service or procedure.
VAGINAL DELIVERY WITH O.R. PROCEDURES EXCEPT STERILIZATION AND/OR D&C,768,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],13416.00,,,,,,0,other,6426.91,13416.00,There are no additional notes associated with this service or procedure.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC,027,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],56363.30,,"Fee schedule rate ($56,363.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,19030.20,56363.30,There are no additional notes associated with this service or procedure.
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],10851.72,,"Case rate ($10,638.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,032.78, add-ons for qualifying new technology services are included. If operating cost exceeds $44,903.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,395.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,058.12 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,087.83 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $635.87. The transfer capital threshold is the transfer adjustment factor * $635.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,10638.94,25261.33,Inpatient DRG
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],13051.76,,"Case rate ($12,795.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,039.30, add-ons for qualifying new technology services are included. If operating cost exceeds $46,910.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,553.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $10,057.27 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,094.35 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $793.62. The transfer capital threshold is the transfer adjustment factor * $793.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,12795.84,41944.25,Inpatient DRG
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,025,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],91631.33,,"Fee schedule rate ($91,631.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,13351.00,91631.33,There are no additional notes associated with this service or procedure.
"ALCOHOL ABUSE AND DEPENDENCE,EXTREME",775,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],25694.91,,"Case rate ($24,471.34). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,24471.34,25694.91,There are no additional notes associated with this service or procedure.
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,069,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7611.88,,"Case rate ($7,354.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,977.32, add-ons for qualifying new technology services are included. If operating cost exceeds $41,848.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,155.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $5,013.88 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,032.37 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $395.65. The transfer capital threshold is the transfer adjustment factor * $395.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6965.00,20333.68,Inpatient DRG
GASTROINTESTINAL HEMORRHAGE WITH MCC,377,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],31575.65,,"Fee schedule rate ($31,575.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,7634.00,35969.56,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],34272.79,,"Fee schedule rate ($34,272.79). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,14295.18,42768.36,There are no additional notes associated with this service or procedure.
PERITONEAL ADHESIOLYSIS WITH CC,336,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],16225.22,,"Case rate ($16,225.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,229.58, add-ons for qualifying new technology services are included. If operating cost exceeds $50,100.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,804.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $13,235.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,284.63 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,044.44. The transfer capital threshold is the transfer adjustment factor * $1,044.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,16225.22,53705.31,Inpatient DRG
Exc Prtd Tum/Prtd Glnd Lat Dsj&Prsrv Facial Nr|RIGHT SIDE,CASE-42415,APC,42415,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5818.16,,"APC Price ($5,541.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5541.10,5818.16,OPPS APC
MAJOR CHEST TRAUMA WITHOUT CC/MCC,185,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],14780.69,,"Fee schedule rate ($14,780.69). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.7), with a minimum of zero.",,,,0,other,7271.19,21771.61,There are no additional notes associated with this service or procedure.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],8151.55,,"Case rate ($8,151.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,718.82, add-ons for qualifying new technology services are included. If operating cost exceeds $42,589.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,213.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,752.66 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,773.87 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $453.94. The transfer capital threshold is the transfer adjustment factor * $453.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8151.55,18033.97,Inpatient DRG
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],20373.57,,,,,,0,other,8956.76,28983.97,There are no additional notes associated with this service or procedure.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],60646.89,,"Fee schedule rate ($60,646.89). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15.6), with a minimum of zero.",,,,0,other,23799.09,63499.65,There are no additional notes associated with this service or procedure.
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],9151.11,,"Case rate ($9,151.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,648.69, add-ons for qualifying new technology services are included. If operating cost exceeds $43,519.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,287.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,679.11 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,703.74 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $527.05. The transfer capital threshold is the transfer adjustment factor * $527.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9151.11,30245.71,Inpatient DRG
Arthrs Knee W/Meniscectomy Med&Lat W/Shaving|RIGHT SIDE,CASE-29880,APC,29880,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
SPINAL PROCEDURES WITH MCC,028,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],120982.83,,"Fee schedule rate ($120,982.83). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,42633.57,120982.83,There are no additional notes associated with this service or procedure.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],42586.49,,"Fee schedule rate ($42,586.49). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,13341.67,42586.49,There are no additional notes associated with this service or procedure.
"INFECTIOUS AND PARASITIC DISEASES INCLUDING HIV WITH O.R. PROCEDURE,MINOR",710,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],12749.87,,"Case rate ($12,749.87). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,12749.87,13387.36,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],51903.64,,"Fee schedule rate ($51,903.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,16017.99,51903.64,There are no additional notes associated with this service or procedure.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],92045.07,,,,,,0,other,33623.33,133270.57,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,091,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],14114.82,,"Case rate ($13,838.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,008.86, add-ons for qualifying new technology services are included. If operating cost exceeds $47,879.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,629.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $11,023.26 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,063.91 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $869.84. The transfer capital threshold is the transfer adjustment factor * $869.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,13838.06,40030.81,Inpatient DRG
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,093,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],19011.32,,"Fee schedule rate ($19,011.32). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,19011.32,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],32327.17,,"Case rate ($31,693.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $29,619.21, add-ons for qualifying new technology services are included. If operating cost exceeds $64,490.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,935.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. The base transfer operating payment is the transfer adjustment factor * $27,572.60 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $27,674.26 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,175.75. The transfer capital threshold is the transfer adjustment factor * $2,175.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,10862.00,86437.13,Inpatient DRG
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,082,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],18294.37,,"Case rate ($17,423.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,344.04, add-ons for qualifying new technology services are included. If operating cost exceeds $51,215.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,892.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $14,346.19 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,399.08 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,132.06. The transfer capital threshold is the transfer adjustment factor * $1,132.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,17423.21,56223.11,Inpatient DRG
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],20156.99,,"Fee schedule rate ($20,156.99). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9865.56,37914.65,There are no additional notes associated with this service or procedure.
HC Breath Hydrogen/Met Test,CASE-91065,APC,91065,CPT,0920,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],202.11,,"APC Price ($202.11). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,202.11,212.21,OPPS APC
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],30935.16,,"Fee schedule rate ($30,935.16). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13092.47,33159.45,There are no additional notes associated with this service or procedure.
HC Inj Trigger Pt 1-2 Musc Grps|PBB CHARGE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-20552,APC,20552,CPT,0510,RC,,,PBB|XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],301.68,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,287.31,301.68,OPPS APC
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],16900.84,,"Fee schedule rate ($16,900.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8151.55,18033.97,There are no additional notes associated with this service or procedure.
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],25099.93,,"Fee schedule rate ($25,099.93). Adds an outlier to normal pricing equal to the per diem rate ($40,783.87) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10989.72,26280.60,There are no additional notes associated with this service or procedure.
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC,939,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],97674.79,,"Fee schedule rate ($97,674.79). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,26517.40,97674.79,There are no additional notes associated with this service or procedure.
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],7705.04,,"Fee schedule rate ($7,705.04). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6503.90,14492.93,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],13148.66,,"Case rate ($13,148.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,367.53, add-ons for qualifying new technology services are included. If operating cost exceeds $47,238.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,579.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $10,384.29 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,422.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $819.42. The transfer capital threshold is the transfer adjustment factor * $819.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,13148.66,32553.63,Inpatient DRG
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],25829.63,,"Fee schedule rate ($25,829.63). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6965.00,29482.05,There are no additional notes associated with this service or procedure.
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],8750.86,,"Case rate ($8,454.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,001.06, add-ons for qualifying new technology services are included. If operating cost exceeds $42,872.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,236.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,033.86 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,056.11 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $476.13. The transfer capital threshold is the transfer adjustment factor * $476.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6230.00,22762.43,Inpatient DRG
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],24669.57,,"Fee schedule rate ($24,669.57). Adds an outlier to normal pricing equal to the per diem rate ($34,856.52) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.7), with a minimum of zero.",,,,0,other,10834.64,25830.00,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],128358.13,,"Fee schedule rate ($128,358.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,40542.37,128358.13,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],46523.26,,"Fee schedule rate ($46,523.26). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,17782.11,46523.26,There are no additional notes associated with this service or procedure.
Hrhc Ntrnl & Xtrnl 2/> Column/Group W/Fissu,CASE-46261,APC,46261,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],2689.02,,"APC Price ($2,598.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2598.08,2727.99,OPPS APC
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],17755.26,,"Fee schedule rate ($17,755.26). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7847.50,17755.26,There are no additional notes associated with this service or procedure.
Cysto/Uretero W/Lithotripsy &Indwell Stent Insrt|LEFT SIDE,CASE-52356,APC,52356,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5194.43,,"APC Price ($5,018.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5018.77,5269.71,OPPS APC
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],33398.16,,"Fee schedule rate ($33,398.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,7353.00,33398.16,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],6276.18,,"Case rate ($6,153.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,859.72, add-ons for qualifying new technology services are included. If operating cost exceeds $40,730.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,067.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,900.39 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,914.77 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $307.78. The transfer capital threshold is the transfer adjustment factor * $307.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6153.12,13947.32,Inpatient DRG
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC",514,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],9311.44,,"Case rate ($8,868.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,385.35, add-ons for qualifying new technology services are included. If operating cost exceeds $43,256.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,266.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $6,416.74 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,440.40 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $506.34. The transfer capital threshold is the transfer adjustment factor * $506.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8868.04,22699.91,Inpatient DRG
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],81524.17,,"Fee schedule rate ($81,524.17). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,8972.00,81524.17,There are no additional notes associated with this service or procedure.
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],14206.79,,,,,,0,other,6834.39,21354.82,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC",281,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],23859.35,,"Fee schedule rate ($23,859.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8169.15,23859.35,There are no additional notes associated with this service or procedure.
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,450,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],146009.19,,"Fee schedule rate ($146,009.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,38037.38,146009.19,There are no additional notes associated with this service or procedure.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],16037.43,,"Case rate ($15,273.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,344.45, add-ons for qualifying new technology services are included. If operating cost exceeds $49,215.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,734.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $12,353.94 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,399.49 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $974.85. The transfer capital threshold is the transfer adjustment factor * $974.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,15273.74,39820.52,Inpatient DRG
Dstr Nrolytc Agnt Parverteb Fct Sngl Lmbr/Sacral|BILATERAL PROCEDURE,CASE-64635,APC,64635,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1827.80,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1827.80,1919.19,OPPS APC
CERVICAL SPINAL FUSION WITH CC,472,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],22334.05,,"Case rate ($21,896.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,505.12, add-ons for qualifying new technology services are included. If operating cost exceeds $55,376.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,219.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $18,491.99 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,560.18 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,459.20. The transfer capital threshold is the transfer adjustment factor * $1,459.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,21896.13,70198.84,Inpatient DRG
Colpopexy Vaginal Intraperitoneal Approach|UNUSUAL NON-OVERLAPPING SERVICE,CASE-57283,APC,57283,CPT,0360,RC,,,XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7183.96,,"APC Price ($6,941.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6941.03,7288.08,OPPS APC
Int Hrhc by Ligation Single Hroid W/O Img Gdn,CASE-46945,APC,46945,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],2598.08,,"APC Price ($2,598.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2598.08,2727.99,OPPS APC
Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|RIGHT SIDE,CASE-26160,APC,26160,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1891.77,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1827.80,1919.19,OPPS APC
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],39359.90,,,,,,0,other,15491.11,54180.83,There are no additional notes associated with this service or procedure.
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],22524.26,,,,,,0,other,9696.93,35061.53,There are no additional notes associated with this service or procedure.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],54537.29,,"Fee schedule rate ($54,537.29). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.7), with a minimum of zero.",,,,0,other,21597.50,67790.93,There are no additional notes associated with this service or procedure.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],26949.28,,"Fee schedule rate ($26,949.28). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9977.99,26949.28,There are no additional notes associated with this service or procedure.
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC,497,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],22707.58,,"Fee schedule rate ($22,707.58). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7.8), with a minimum of zero.",,,,0,other,10127.65,37761.19,There are no additional notes associated with this service or procedure.
GI Tract Imaging Intraluminal Colon I&R,CASE-91113,APC,91113,CPT,0750,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],913.99,,"APC Price ($870.46). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,870.46,913.99,OPPS APC
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],30055.64,,"Fee schedule rate ($30,055.64). Adds an outlier to normal pricing equal to the per diem rate ($74,094.67) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.9), with a minimum of zero.",,,,0,other,12775.53,31469.43,There are no additional notes associated with this service or procedure.
HYPERTENSION WITHOUT MCC,305,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],14858.10,,,,,,0,other,7058.55,17230.49,There are no additional notes associated with this service or procedure.
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],11168.08,,"Fee schedule rate ($11,168.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5937.41,12366.99,There are no additional notes associated with this service or procedure.
Hemorrhoidectomy Int & Xtrnl 2/> Column/Gro,CASE-46260,APC,46260,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],2727.99,,"APC Price ($2,598.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2598.08,2727.99,OPPS APC
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,167,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],14653.23,,"Case rate ($14,157.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,306.21, add-ons for qualifying new technology services are included. If operating cost exceeds $48,177.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,653.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $11,319.53 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,361.26 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $893.22. The transfer capital threshold is the transfer adjustment factor * $893.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,14157.71,43522.37,Inpatient DRG
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],11612.44,,"Case rate ($11,059.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,424, add-ons for qualifying new technology services are included. If operating cost exceeds $45,295.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,426.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $8,447.91 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,479.05 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $666.62. The transfer capital threshold is the transfer adjustment factor * $666.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,11059.47,28423.20,Inpatient DRG
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],58320.32,,"Fee schedule rate ($58,320.32). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,16286.16,58320.32,There are no additional notes associated with this service or procedure.
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],16306.17,,"Case rate ($15,529.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,607.89, add-ons for qualifying new technology services are included. If operating cost exceeds $49,478.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,729.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $12,615.11 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,662.94 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $969.63. The transfer capital threshold is the transfer adjustment factor * $969.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,15940.79,53275.26,Inpatient DRG
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],41006.47,,"Fee schedule rate ($41,006.47). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12268.97,41006.47,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],24195.39,,"Case rate ($23,377.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $21,882.92, add-ons for qualifying new technology services are included. If operating cost exceeds $56,753.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,327.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $19,864.72 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $19,937.97 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,567.52. The transfer capital threshold is the transfer adjustment factor * $1,567.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,23377.19,96365.69,Inpatient DRG
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,095,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],48470.91,,"Fee schedule rate ($48,470.91). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.8), with a minimum of zero.",,,,0,other,19411.47,50750.92,There are no additional notes associated with this service or procedure.
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC",758,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],19263.78,,,,,,0,other,8574.80,19263.78,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],12992.90,,"Case rate ($12,992.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,222.63, add-ons for qualifying new technology services are included. If operating cost exceeds $47,093.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,568.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $10,239.92 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,277.68 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $808.03. The transfer capital threshold is the transfer adjustment factor * $808.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7665.00,40737.46,Inpatient DRG
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],6963.00,,"Per diem ($6,963). If length of stay < 2.6, first 1 days paid at a per diem of $13,926 instead. Capped at $18,103.30.",,,,0,other,6963.00,18954.85,Estimated amount calculated based on 3 day length of stay.
INFLAMMATORY BOWEL DISEASE WITH CC,386,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],19879.00,,"Fee schedule rate ($19,879.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8556.53,19879.00,There are no additional notes associated with this service or procedure.
Septoplasty/Submucous Resecj W/WO Cartilage Grf|BILATERAL PROCEDURE,CASE-30520,APC,30520,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6605.95,,"APC Price ($6,605.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6605.95,6936.25,OPPS APC
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],66833.55,,"Fee schedule rate ($66,833.55). Adds an outlier to normal pricing equal to the per diem rate ($141,521.30) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,26028.48,80635.65,There are no additional notes associated with this service or procedure.
PREMATURITY WITHOUT MAJOR PROBLEMS,792,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],18531.10,,"Case rate ($18,531.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,374.70, add-ons for qualifying new technology services are included. If operating cost exceeds $52,245.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,973.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. The base transfer operating payment is the transfer adjustment factor * $15,373.07 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,429.75 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,213.09. The transfer capital threshold is the transfer adjustment factor * $1,213.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,1956.00,19457.66,Inpatient DRG
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],54764.34,,"Fee schedule rate ($54,764.34). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,18178.96,54764.34,There are no additional notes associated with this service or procedure.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH CC,354,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],31968.77,,"Fee schedule rate ($31,968.77). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11633.13,33472.54,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],23014.22,,,,,,0,other,9865.56,37914.65,There are no additional notes associated with this service or procedure.
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],24444.75,,"Fee schedule rate ($24,444.75). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10136.44,24444.75,There are no additional notes associated with this service or procedure.
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],34032.82,,"Fee schedule rate ($34,032.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,15233.11,38610.21,There are no additional notes associated with this service or procedure.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC",156,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6857.00,,"Case rate ($6,625.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,298.82, add-ons for qualifying new technology services are included. If operating cost exceeds $41,169.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,102.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $4,337.88 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,353.87 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $342.30. The transfer capital threshold is the transfer adjustment factor * $342.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6625.12,13598.77,Inpatient DRG
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],34759.42,,,,,,0,other,13907.80,52794.06,There are no additional notes associated with this service or procedure.
Injection Aa&/Strd Intercostal Nrv Ea Addl Lvl|RIGHT SIDE,CASE-64421,APC,64421,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],856.86,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,827.89,869.28,OPPS APC
O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC,621,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],36669.96,,"Fee schedule rate ($36,669.96). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,12159.94,36669.96,There are no additional notes associated with this service or procedure.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,329,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],86631.74,,"Fee schedule rate ($86,631.74). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (38), with a minimum of zero.",,,,0,other,33072.77,90445.33,There are no additional notes associated with this service or procedure.
VENTRICULAR SHUNT PROCEDURES WITH MCC,031,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],84202.04,,"Fee schedule rate ($84,202.04). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16.6), with a minimum of zero.",,,,0,other,32287.20,88162.80,There are no additional notes associated with this service or procedure.
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],26721.94,,"Fee schedule rate ($26,721.94). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6965.00,34422.94,There are no additional notes associated with this service or procedure.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],17269.71,,"Case rate ($16,447.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,436.22, add-ons for qualifying new technology services are included. If operating cost exceeds $50,307.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,820.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $13,441.70 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,491.27 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,060.68. The transfer capital threshold is the transfer adjustment factor * $1,060.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7453.00,42138.30,Inpatient DRG
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],9313.50,,"Fee schedule rate ($9,313.50). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7238.69,16804.22,There are no additional notes associated with this service or procedure.
COAGULATION DISORDERS,813,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],29046.49,,"Fee schedule rate ($29,046.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12274.39,30013.33,There are no additional notes associated with this service or procedure.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],133270.57,,"Fee schedule rate ($133,270.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,33623.33,133270.57,There are no additional notes associated with this service or procedure.
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,307,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],6965.00,,,,,,0,other,6335.27,18228.77,There are no additional notes associated with this service or procedure.
Inj for Sacroiliac Jt Anesth|BILATERAL PROCEDURE,CASE-G0260,APC,G0260,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],660.72,,"APC Price ($660.72). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,660.72,693.76,OPPS APC
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],45017.13,,"Fee schedule rate ($45,017.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,14603.31,45017.13,There are no additional notes associated with this service or procedure.
Ndsc Dcmprn Spinal Cord 1 W/Lamot Ntrspc Lumbar,CASE-62380,APC,62380,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7029.71,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6791.99,7131.59,OPPS APC
OTHER MENTAL DISORDER DIAGNOSES,887,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],2070.00,,,,,,0,other,2070.00,21072.10,Estimated amount calculated based on 1 day length of stay.
CESAREAN SECTION WITH STERILIZATION WITH MCC,783,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],18571.05,,"Case rate ($18,571.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,411.86, add-ons for qualifying new technology services are included. If operating cost exceeds $52,282.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,975.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $15,410.10 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,466.92 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,216.01. The transfer capital threshold is the transfer adjustment factor * $1,216.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12612.10,23722.94,Inpatient DRG
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],22686.91,,"Fee schedule rate ($22,686.91). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,10120.20,26204.74,There are no additional notes associated with this service or procedure.
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,094,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],67889.44,,"Fee schedule rate ($67,889.44). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,25778.58,67889.44,There are no additional notes associated with this service or procedure.
Anoscopy Dx W/HRA &Chem Agnts Enhancement W/Bx|SEPARATE STRUCTURE,CASE-46607,APC,46607,CPT,0360,RC,,,XS,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],2727.99,,"APC Price ($2,598.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2598.08,2727.99,OPPS APC
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],25225.91,,,,,,0,other,10626.74,25225.91,There are no additional notes associated with this service or procedure.
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],17111.12,,,,,,0,other,5883.03,17111.12,There are no additional notes associated with this service or procedure.
"Neuroplasty Other Arm/Leg Nerve,Open|LEFT SIDE",CASE-64708,APC,64708,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6791.99,7131.59,OPPS APC
ALLERGIC REACTIONS WITH MCC,915,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],27385.01,,"Fee schedule rate ($27,385.01). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,13332.86,33088.84,There are no additional notes associated with this service or procedure.
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],34032.82,,"Fee schedule rate ($34,032.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,15233.11,38610.21,There are no additional notes associated with this service or procedure.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC,192,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],7068.60,,"Fee schedule rate ($7,068.60). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6292.63,12753.78,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],13252.76,,"Case rate ($12,992.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,222.63, add-ons for qualifying new technology services are included. If operating cost exceeds $47,093.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,568.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $10,239.92 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,277.68 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $808.03. The transfer capital threshold is the transfer adjustment factor * $808.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,7665.00,40737.46,Inpatient DRG
NONTRAUMATIC STUPOR AND COMA WITH MCC,080,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],24854.18,,"Case rate ($14,202.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,347.79, add-ons for qualifying new technology services are included. If operating cost exceeds $48,218.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,656.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $11,360.96 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,402.84 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $896.49. The transfer capital threshold is the transfer adjustment factor * $896.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,14202.39,35615.37,All Other Inpatient
HC Inj Tendon Sheath/Ligament|PBB CHARGE|RIGHT SIDE,CASE-20550,APC,20550,CPT,0510,RC,,,PBB|RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],301.68,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,287.31,301.68,OPPS APC
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],62084.69,,"Fee schedule rate ($62,084.69). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (35), with a minimum of zero.",,,,0,other,30398.48,82674.88,There are no additional notes associated with this service or procedure.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],80635.65,,"Fee schedule rate ($80,635.65). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,26028.48,80635.65,There are no additional notes associated with this service or procedure.
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,068,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],8008.12,,"Case rate ($7,626.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,241.24, add-ons for qualifying new technology services are included. If operating cost exceeds $42,112.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,165.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $5,276.29 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,296.29 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $405.55. The transfer capital threshold is the transfer adjustment factor * $405.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,23184.90,Inpatient DRG
HEART FAILURE AND SHOCK WITH CC,292,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],15550.06,,"Fee schedule rate ($15,550.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5502.00,16705.77,There are no additional notes associated with this service or procedure.
Peri-Implant Capsulectomy Breast Complete,CASE-19371,APC,19371,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7918.25,,"APC Price ($7,650.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,7918.25,8033.01,OPPS APC
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,068,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],23184.90,,"Fee schedule rate ($23,184.90). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,23184.90,There are no additional notes associated with this service or procedure.
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],6378.61,,"Case rate ($6,378.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,069.50, add-ons for qualifying new technology services are included. If operating cost exceeds $40,940.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,084.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,109.40 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,124.55 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $324.27. The transfer capital threshold is the transfer adjustment factor * $324.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,4341.01,12882.53,Inpatient DRG
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],21489.15,,"Case rate ($21,489.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,126.50, add-ons for qualifying new technology services are included. If operating cost exceeds $54,997.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,189.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.6. The base transfer operating payment is the transfer adjustment factor * $18,114.76 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,181.55 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,429.43. The transfer capital threshold is the transfer adjustment factor * $1,429.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,21489.15,68942.79,Inpatient DRG
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],85305.59,,"Fee schedule rate ($85,305.59). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,21719.40,85305.59,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],27944.96,,"Case rate ($27,944.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $26,132.21, add-ons for qualifying new technology services are included. If operating cost exceeds $61,003.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,661.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.8. The base transfer operating payment is the transfer adjustment factor * $24,098.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $24,187.26 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,901.60. The transfer capital threshold is the transfer adjustment factor * $1,901.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,27944.96,86252.84,Inpatient DRG
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,098,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],45156.75,,,,,,0,other,6965.00,45156.75,There are no additional notes associated with this service or procedure.
Anoscopy Dx W/HRA &Chem Agnts Enhancement W/Bx|SEPARATE STRUCTURE,CASE-46607,APC,46607,CPT,0360,RC,,,XS,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],2598.08,,"APC Price ($2,598.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2598.08,2727.99,OPPS APC
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],24701.52,,"Fee schedule rate ($24,701.52). Adds an outlier to normal pricing equal to the per diem rate ($51,462.28) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,10846.16,25863.45,There are no additional notes associated with this service or procedure.
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH MCC",510,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],89863.76,,"Fee schedule rate ($89,863.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10710.00,89863.76,There are no additional notes associated with this service or procedure.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],73588.10,,"Fee schedule rate ($73,588.10). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,21585.31,73588.10,There are no additional notes associated with this service or procedure.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],37768.77,,"Fee schedule rate ($37,768.77). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7453.00,42138.30,There are no additional notes associated with this service or procedure.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],42787.31,,"Fee schedule rate ($42,787.31). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,15476.23,42787.31,There are no additional notes associated with this service or procedure.
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],22762.43,,"Fee schedule rate ($22,762.43). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6230.00,22762.43,There are no additional notes associated with this service or procedure.
DIABETES WITHOUT CC/MCC,639,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],11899.36,,"Fee schedule rate ($11,899.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6151.76,12223.35,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],63653.13,,,,,,0,other,23851.92,63653.13,There are no additional notes associated with this service or procedure.
PREMATURITY WITHOUT MAJOR PROBLEMS,792,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],18531.10,,"Case rate ($18,531.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,374.70, add-ons for qualifying new technology services are included. If operating cost exceeds $52,245.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,973.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. The base transfer operating payment is the transfer adjustment factor * $15,373.07 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,429.75 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,213.09. The transfer capital threshold is the transfer adjustment factor * $1,213.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,1956.00,19457.66,Inpatient DRG
HC Blood Occult Peroxidase Actv Qual Feces 1-3 Spec,CASE-82272,APC,82272,CPT,0301,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],4.38,,,,,,0,other,4.23,4.44,There are no additional notes associated with this service or procedure.
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],7474.95,,"Fee schedule rate ($7,474.95). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6915.64,14442.92,There are no additional notes associated with this service or procedure.
RADIOTHERAPY,849,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],81867.07,,"Fee schedule rate ($81,867.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,20293.88,81867.07,There are no additional notes associated with this service or procedure.
HC Biopsy Liver Percutan Needle,CASE-47000,APC,47000,CPT,0361,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1600.04,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1545.93,1623.23,OPPS APC
HC Inj Aa&/Strd Greater Occipital Nerve|BILATERAL PROCEDURE,CASE-64405,APC,64405,CPT,0450,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
Xpedicul Decompress Throacic Cord,CASE-63055,APC,63055,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
VAGINAL DELIVERY WITH O.R. PROCEDURES EXCEPT STERILIZATION AND/OR D&C,768,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],12088.81,,"Fee schedule rate ($12,088.81). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6426.91,13416.00,There are no additional notes associated with this service or procedure.
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC,939,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],27445.51,,"Case rate ($26,517.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $24,804.19, add-ons for qualifying new technology services are included. If operating cost exceeds $59,675.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,557.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $22,775.26 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $22,859.24 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,797.19. The transfer capital threshold is the transfer adjustment factor * $1,797.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,26517.40,97674.79,Inpatient DRG
"FEVER AND INFLAMMATORY CONDITIONS,MODERATE",722,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],2150.10,,"Case rate for a one day stay ($2,047.71). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,2047.71,2150.10,There are no additional notes associated with this service or procedure.
PSYCHOSES,885,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],27484.83,,,,,,0,other,2070.00,27484.83,There are no additional notes associated with this service or procedure.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],24259.09,,"Fee schedule rate ($24,259.09). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10098.51,24259.09,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],10600.80,,"Fee schedule rate ($10,600.80). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,19126.88,There are no additional notes associated with this service or procedure.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],6965.00,,,,,,0,other,6965.00,15340.19,There are no additional notes associated with this service or procedure.
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],33890.73,,"Fee schedule rate ($33,890.73). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6277.00,36801.89,There are no additional notes associated with this service or procedure.
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],36855.62,,"Fee schedule rate ($36,855.62). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,15821.59,40320.14,There are no additional notes associated with this service or procedure.
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],10136.44,,"Case rate ($10,136.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,565.33, add-ons for qualifying new technology services are included. If operating cost exceeds $44,436.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,359.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $7,592.38 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,620.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $599.11. The transfer capital threshold is the transfer adjustment factor * $599.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10136.44,24444.75,Inpatient DRG
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],58394.20,,"Fee schedule rate ($58,394.20). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,9370.00,65732.99,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],2070.00,,,,,,0,other,1188.00,34338.33,Estimated amount calculated based on 6 day length of stay.
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,555,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],10896.27,,"Case rate ($10,896.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,272.18, add-ons for qualifying new technology services are included. If operating cost exceeds $45,143.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,414.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,296.64 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,327.23 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $654.69. The transfer capital threshold is the transfer adjustment factor * $654.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10896.27,42290.95,Inpatient DRG
PERIPHERAL VASCULAR DISORDERS WITH CC,300,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],21005.20,,,,,,0,other,9174.14,21005.20,There are no additional notes associated with this service or procedure.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITHOUT CC/MCC,816,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],14733.53,,"Fee schedule rate ($14,733.53). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6224.90,14733.53,There are no additional notes associated with this service or procedure.
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],18245.94,,"Fee schedule rate ($18,245.94). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8106.18,18245.94,There are no additional notes associated with this service or procedure.
Dstr Nrolytc Agnt Parverteb Fct Addl Lmbr/Sacral|LEFT SIDE,CASE-64636,APC,64636,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1891.77,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1827.80,1919.19,OPPS APC
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,309,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],14547.21,,,,,,0,other,5055.77,14547.21,There are no additional notes associated with this service or procedure.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],15116.99,,"Fee schedule rate ($15,116.99). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,8906.63,28434.57,There are no additional notes associated with this service or procedure.
UNGROUPABLE,999,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],51189.76,,"Case rate ($48,752.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $45,488.70, add-ons for qualifying new technology services are included. If operating cost exceeds $80,359.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $5,183.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 12.7. The base transfer operating payment is the transfer adjustment factor * $43,383.78 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $43,543.75 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,423.41. The transfer capital threshold is the transfer adjustment factor * $3,423.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10228.00,161307.29,Inpatient DRG
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],11684.07,,"Case rate ($11,454.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,791.92, add-ons for qualifying new technology services are included. If operating cost exceeds $45,662.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,455.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $8,814.47 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,846.97 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $695.55. The transfer capital threshold is the transfer adjustment factor * $695.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,11454.97,28394.78,Inpatient DRG
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],49717.39,,"Fee schedule rate ($49,717.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,14908.05,49717.39,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],59610.47,,"Fee schedule rate ($59,610.47). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,16129.04,59610.47,There are no additional notes associated with this service or procedure.
O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC,621,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],36669.96,,"Fee schedule rate ($36,669.96). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,12159.94,36669.96,There are no additional notes associated with this service or procedure.
Replacement Tissue Expander W/Permanent Implant|BILATERAL PROCEDURE,CASE-11970,APC,11970,CPT,0360,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,7029.71,7131.59,OPPS APC
Arthrs Knee Abrasion Arthrp/Mlt Drlg/Microfx|RIGHT SIDE,CASE-29879,APC,29879,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
HC Inject Tendon Origin/Insert|RIGHT SIDE,CASE-20551,APC,20551,CPT,0361,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],301.68,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,287.31,301.68,OPPS APC
OTHER MENTAL DISORDER DIAGNOSES,887,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],6965.00,,,,,,0,other,2070.00,21072.10,There are no additional notes associated with this service or procedure.
CELLULITIS WITH MCC,602,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],11570.10,,"Case rate ($11,570.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,899.02, add-ons for qualifying new technology services are included. If operating cost exceeds $45,770.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,463.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $8,921.17 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,954.07 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $703.97. The transfer capital threshold is the transfer adjustment factor * $703.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,11570.10,28349.31,Inpatient DRG
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,097,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],67876.56,,"Fee schedule rate ($67,876.56). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17.7), with a minimum of zero.",,,,0,other,26404.32,79915.74,There are no additional notes associated with this service or procedure.
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 2nd Level,CASE-64494,APC,64494,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],827.89,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,827.89,869.28,OPPS APC
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],22946.70,,"Fee schedule rate ($22,946.70). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,15456.59,41402.42,There are no additional notes associated with this service or procedure.
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH CC",457,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],43198.38,,"Case rate ($41,141.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $38,481.63, add-ons for qualifying new technology services are included. If operating cost exceeds $73,352.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,557.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $36,398.68 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $36,536.68 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,797.69. The transfer capital threshold is the transfer adjustment factor * $2,797.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,42327.47,160549.49,Inpatient DRG
"MAJOR RESPIRATORY INFECTIONS AND INFLAMMATIONS,EXTREME",137,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],18845.78,,"Case rate ($18,845.78). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,18845.78,19788.07,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],24037.59,,"Case rate ($22,892.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $21,471.50, add-ons for qualifying new technology services are included. If operating cost exceeds $56,342.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,255.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.7. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.7)) / 2. The base transfer operating payment is the transfer adjustment factor * $19,452.79 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $19,526.55 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,495.19. The transfer capital threshold is the transfer adjustment factor * $1,495.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,23526.87,94787.57,Inpatient DRG
Cervical Lymphadec Modified Radical Neck Dsj|RIGHT SIDE,CASE-38724,APC,38724,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],199.10,,"APC Price ($199.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,199.10,209.05,OPPS APC
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],26204.74,,"Fee schedule rate ($26,204.74). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10120.20,26204.74,There are no additional notes associated with this service or procedure.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],21585.31,,"Case rate ($21,585.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,215.96, add-ons for qualifying new technology services are included. If operating cost exceeds $55,086.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,196.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $18,203.89 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,271.01 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,436.47. The transfer capital threshold is the transfer adjustment factor * $1,436.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,21585.31,73588.10,Inpatient DRG
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],13486.95,,"Fee schedule rate ($13,486.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6915.64,14442.92,There are no additional notes associated with this service or procedure.
Laparoscopy Surg Rpr Initial Inguinal Hernia|RIGHT SIDE,CASE-49650,APC,49650,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5658.76,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5658.76,5941.70,OPPS APC
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],6965.00,,,,,,0,other,5778.62,11681.49,There are no additional notes associated with this service or procedure.
PREMATURITY WITHOUT MAJOR PROBLEMS,792,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],11512.88,,"Fee schedule rate ($11,512.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,1956.00,19457.66,There are no additional notes associated with this service or procedure.
SALIVARY GLAND PROCEDURES,139,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],30690.92,,"Fee schedule rate ($30,690.92). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,10313.19,30690.92,There are no additional notes associated with this service or procedure.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],13341.67,,"Case rate ($13,341.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,547.08, add-ons for qualifying new technology services are included. If operating cost exceeds $47,418.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,593.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $10,563.18 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,602.13 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $833.54. The transfer capital threshold is the transfer adjustment factor * $833.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,13341.67,42586.49,Inpatient DRG
Egd Transoral Biopsy Single/Multiple|SEPARATE STRUCTURE,CASE-43239,APC,43239,CPT,0360,RC,,,XS,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1796.14,,"APC Price ($1,796.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1796.14,1885.95,OPPS APC
"INFECTIOUS AND PARASITIC DISEASES INCLUDING HIV WITH O.R. PROCEDURE,EXTREME",710,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],46781.69,,"Case rate ($46,781.69). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $48,300, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,46781.69,49120.77,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,066,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],13466.94,,,,,,0,other,6579.76,20083.61,There are no additional notes associated with this service or procedure.
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12601.27,,"Case rate ($12,001.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,318.84, add-ons for qualifying new technology services are included. If operating cost exceeds $46,189.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,477.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $9,338.49 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,373.89 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $717.78. The transfer capital threshold is the transfer adjustment factor * $717.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12305.53,30103.84,Inpatient DRG
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],40890.77,,,,,,0,other,16017.99,51903.64,There are no additional notes associated with this service or procedure.
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],14789.23,,,,,,0,other,6965.00,21089.59,There are no additional notes associated with this service or procedure.
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7957.73,,"Case rate ($7,578.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,196.51, add-ons for qualifying new technology services are included. If operating cost exceeds $42,067.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,162.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,231.73 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,251.56 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $402.12. The transfer capital threshold is the transfer adjustment factor * $402.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6711.00,16865.16,Inpatient DRG
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC",629,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],40946.19,,"Fee schedule rate ($40,946.19). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,16699.94,44657.18,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,373,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],13780.60,,"Fee schedule rate ($13,780.60). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6870.94,14313.05,There are no additional notes associated with this service or procedure.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,098,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],17835.89,,"Case rate ($17,486.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,402.62, add-ons for qualifying new technology services are included. If operating cost exceeds $51,273.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,896.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $14,404.56 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,457.67 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,136.66. The transfer capital threshold is the transfer adjustment factor * $1,136.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6965.00,45156.75,Inpatient DRG
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,057,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],11254.78,,"Case rate ($10,718.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,107.12, add-ons for qualifying new technology services are included. If operating cost exceeds $44,978.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,401.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,132.18 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,162.17 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $641.71. The transfer capital threshold is the transfer adjustment factor * $641.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10718.84,39884.93,Inpatient DRG
"OTHER COMPLICATIONS OF TREATMENT,MODERATE",813,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],7551.91,,"Case rate ($7,551.91). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,7551.91,7929.51,There are no additional notes associated with this service or procedure.
Excision Hydrocele Unilateral|RIGHT SIDE,CASE-55040,APC,55040,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3468.64,,"APC Price ($3,351.34). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3351.34,3518.91,OPPS APC
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,394,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],11588.85,,"Fee schedule rate ($11,588.85). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8281.56,20909.61,There are no additional notes associated with this service or procedure.
HC Biopsy/Exc Lymph Node Needle,CASE-38505,APC,38505,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1545.93,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1545.93,1623.23,OPPS APC
Ercp Remove Calculi/Debris Biliary/Pancreas Duct,CASE-43264,APC,43264,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5682.51,,"APC Price ($5,682.51). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5682.51,5966.63,OPPS APC
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],42787.31,,"Fee schedule rate ($42,787.31). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,15476.23,42787.31,There are no additional notes associated with this service or procedure.
Arthrs Kne Surg W/Meniscectomy Med/Lat W/Shvg|RIGHT SIDE|SEPARATE STRUCTURE,CASE-29881,APC,29881,CPT,0360,RC,,,RT|XS,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
HC Gastroesophag Reflx Test W/Tel Ph Eltrd|REDUCED SERVICES,CASE-91035,APC,91035,CPT,0750,RC,,,52,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],803.80,,"APC Price ($803.80). Discounted by 50%. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,803.80,843.99,OPPS APC
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],35389.50,,"Case rate ($35,389.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $33,057.71, add-ons for qualifying new technology services are included. If operating cost exceeds $67,928.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,206.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.3. The base transfer operating payment is the transfer adjustment factor * $30,998.46 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $31,112.76 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,446.08. The transfer capital threshold is the transfer adjustment factor * $2,446.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,35389.50,101083.00,Inpatient DRG
Lithotripsy Xtrcorp Shock Wave|RIGHT SIDE,CASE-50590,APC,50590,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3414.95,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3299.47,3464.44,OPPS APC
HC Joint Injection/Aspir Large WO US|LEFT SIDE|PBB CHARGE,CASE-20610,APC,20610,CPT,0510,RC,,,LT|PBB,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],301.68,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,287.31,301.68,OPPS APC
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],25830.00,,,,,,0,other,10834.64,25830.00,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,091,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],13838.06,,"Case rate ($13,838.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,008.86, add-ons for qualifying new technology services are included. If operating cost exceeds $47,879.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,629.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $11,023.26 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,063.91 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $869.84. The transfer capital threshold is the transfer adjustment factor * $869.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,13838.06,40030.81,Inpatient DRG
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],13947.32,,"Fee schedule rate ($13,947.32). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6153.12,13947.32,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],28235.64,,"Fee schedule rate ($28,235.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,14344.60,36028.59,There are no additional notes associated with this service or procedure.
NEONATE WITH OTHER SIGNIFICANT PROBLEMS,794,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],11939.84,,"Case rate ($11,939.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,242.99, add-ons for qualifying new technology services are included. If operating cost exceeds $46,114.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,490.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $9,263.89 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,298.04 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $731.01. The transfer capital threshold is the transfer adjustment factor * $731.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,1798.85,12536.83,Inpatient DRG
BRONCHITIS AND ASTHMA WITH CC/MCC,202,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],19110.30,,,,,,0,other,7606.34,19110.30,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],16935.49,,"Case rate ($16,129.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,140.12, add-ons for qualifying new technology services are included. If operating cost exceeds $50,011.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,797.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $13,146.70 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,195.17 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,037.40. The transfer capital threshold is the transfer adjustment factor * $1,037.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,16129.04,59610.47,Inpatient DRG
"Correction Hammertoe|RIGHT FOOT, FIFTH DIGIT",CASE-28285,APC,28285,CPT,0360,RC,,,T9,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],43703.12,,"Fee schedule rate ($43,703.12). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.7), with a minimum of zero.",,,,0,other,17693.40,52449.26,There are no additional notes associated with this service or procedure.
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],8268.30,,"Case rate ($8,106.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,676.61, add-ons for qualifying new technology services are included. If operating cost exceeds $42,547.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,210.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,710.61 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,731.66 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $450.62. The transfer capital threshold is the transfer adjustment factor * $450.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,8106.18,18245.94,Inpatient DRG
COMPLICATIONS OF TREATMENT WITH CC,920,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],18836.22,,"Fee schedule rate ($18,836.22). Adds an outlier to normal pricing equal to the per diem rate ($49,808.13) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,8732.59,20731.52,There are no additional notes associated with this service or procedure.
Nsl/Sinus Ndsc Max Antrost W/Rmvl Tiss Max Sinus|RIGHT SIDE,CASE-31267,APC,31267,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6605.95,,"APC Price ($6,605.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6605.95,6936.25,OPPS APC
SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS,029,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],26300.97,,"Case rate ($25,048.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $23,437.73, add-ons for qualifying new technology services are included. If operating cost exceeds $58,308.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,449.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.7)) / 2. The base transfer operating payment is the transfer adjustment factor * $21,413.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $21,492.79 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,689.76. The transfer capital threshold is the transfer adjustment factor * $1,689.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13641.00,67130.05,Inpatient DRG
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12564.01,,"Case rate ($11,965.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,285.76, add-ons for qualifying new technology services are included. If operating cost exceeds $46,156.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,475.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,305.53 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,340.81 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $715.24. The transfer capital threshold is the transfer adjustment factor * $715.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12268.97,41006.47,Inpatient DRG
"ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",770,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],17800.73,,"Fee schedule rate ($17,800.73). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,8735.30,19730.13,There are no additional notes associated with this service or procedure.
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],59494.91,,"Fee schedule rate ($59,494.91). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,18594.09,59494.91,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],41402.42,,"Fee schedule rate ($41,402.42). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,15456.59,41402.42,There are no additional notes associated with this service or procedure.
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],26721.94,,"Fee schedule rate ($26,721.94). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6965.00,34422.94,There are no additional notes associated with this service or procedure.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],38248.08,,"Fee schedule rate ($38,248.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11593.79,38248.08,There are no additional notes associated with this service or procedure.
Laps Rpr Paraesphgl Hrna Incl Fundplsty W/O Mesh,CASE-43281,APC,43281,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],9949.78,,"APC Price ($9,949.78). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,9949.78,10447.27,OPPS APC
Surgical Arthroscopy Shoulder Dstl Claviculc|LEFT SIDE,CASE-29824,APC,29824,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
PREMATURITY WITHOUT MAJOR PROBLEMS,792,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],11512.88,,"Fee schedule rate ($11,512.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,1956.00,19457.66,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC,788,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],8733.35,,"Case rate ($8,438.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,985.31, add-ons for qualifying new technology services are included. If operating cost exceeds $42,856.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,234.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,018.17 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,040.36 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $474.89. The transfer capital threshold is the transfer adjustment factor * $474.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,8438.02,20142.33,Inpatient DRG
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC,519,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],50780.20,,"Fee schedule rate ($50,780.20). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,15490.44,50780.20,There are no additional notes associated with this service or procedure.
"HC Injection Small Joint/Bursa|RIGHT HAND, FOURTH DIGIT",CASE-20600,APC,20600,CPT,0361,RC,,,F8,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1557.80,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1505.12,1580.37,OPPS APC
DIABETES WITH CC,638,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],15195.79,,"Fee schedule rate ($15,195.79). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8014.07,17634.53,There are no additional notes associated with this service or procedure.
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],14747.55,,"Case rate ($14,747.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,854.94, add-ons for qualifying new technology services are included. If operating cost exceeds $48,725.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,696.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $11,866.24 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,909.99 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $936.36. The transfer capital threshold is the transfer adjustment factor * $936.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,14747.55,37899.49,Inpatient DRG
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],11065.78,,"Fee schedule rate ($11,065.78). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5883.03,17111.12,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],21195.68,,"Fee schedule rate ($21,195.68). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,6965.00,21195.68,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],43949.31,,"Fee schedule rate ($43,949.31). Adds an outlier to normal pricing equal to the per diem rate ($149,567.78) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,17782.11,46523.26,There are no additional notes associated with this service or procedure.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC",156,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],12624.95,,"Fee schedule rate ($12,624.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6625.12,13598.77,There are no additional notes associated with this service or procedure.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],14699.43,,"Fee schedule rate ($14,699.43). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6683.37,14699.43,There are no additional notes associated with this service or procedure.
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",004,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],10715.36,,,,,,0,other,10249.47,272554.00,Estimated amount calculated based on 6 day length of stay.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],19230.88,,"Fee schedule rate ($19,230.88). Adds an outlier to normal pricing equal to the per diem rate ($71,679.63) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8874.81,20553.44,There are no additional notes associated with this service or procedure.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC",061,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],62315.82,,"Fee schedule rate ($62,315.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,20616.23,62315.82,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],6965.00,,,,,,0,other,6558.75,14871.83,There are no additional notes associated with this service or procedure.
HC Inj Lympho for Sentinal Node|RIGHT SIDE,CASE-38792,APC,38792,CPT,0361,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6526.12,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6215.36,6526.12,OPPS APC
Cystoscopy prostatic imp 1-3,CASE-C9739,APC,C9739,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5194.43,,"APC Price ($5,018.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5018.77,5269.71,OPPS APC
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH CC,427,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],135659.15,,"Fee schedule rate ($135,659.15). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.8), with a minimum of zero.",,,,0,other,50829.82,142040.39,There are no additional notes associated with this service or procedure.
CHOLECYSTECTOMY WITH C.D.E. WITH MCC,411,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],24315.13,,"Case rate ($24,315.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $22,755.46, add-ons for qualifying new technology services are included. If operating cost exceeds $57,626.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,396.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $20,734.06 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $20,810.51 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,636.12. The transfer capital threshold is the transfer adjustment factor * $1,636.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,24315.13,88615.28,Inpatient DRG
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH CC",457,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],44443.84,,"Case rate ($42,327.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $39,511.96, add-ons for qualifying new technology services are included. If operating cost exceeds $74,382.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,713.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $37,429.01 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $37,567.02 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,953.52. The transfer capital threshold is the transfer adjustment factor * $2,953.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,42327.47,160549.49,Inpatient DRG
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],16828.14,,"Case rate ($16,026.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,044.99, add-ons for qualifying new technology services are included. If operating cost exceeds $49,916.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,789.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $13,051.92 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,100.04 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,029.93. The transfer capital threshold is the transfer adjustment factor * $1,029.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,11165.00,61234.06,Inpatient DRG
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],5791.49,,"Fee schedule rate ($5,791.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,3079.00,10940.41,There are no additional notes associated with this service or procedure.
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],7560.98,,"Case rate ($7,412.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,031.50, add-ons for qualifying new technology services are included. If operating cost exceeds $41,902.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,159.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $5,067.86 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,086.55 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $399.90. The transfer capital threshold is the transfer adjustment factor * $399.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6148.93,15887.21,Inpatient DRG
"Suture Digital Nerve Hand/Foot 1 Nerve|LEFT HAND, THUMB",CASE-64831,APC,64831,CPT,0360,RC,,,FA,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC,087,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],17998.55,,,,,,0,other,8139.36,22679.07,There are no additional notes associated with this service or procedure.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],16829.13,,"Fee schedule rate ($16,829.13). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,8009.34,19877.10,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],30063.84,,"Fee schedule rate ($30,063.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13891.57,34712.20,There are no additional notes associated with this service or procedure.
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],15145.28,,"Fee schedule rate ($15,145.28). Adds an outlier to normal pricing equal to the per diem rate ($54,966.40) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7402.56,16438.59,There are no additional notes associated with this service or procedure.
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],22557.82,,"Fee schedule rate ($22,557.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6801.88,22557.82,There are no additional notes associated with this service or procedure.
VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC,033,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],42156.44,,"Fee schedule rate ($42,156.44). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,13206.23,42156.44,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],32852.04,,"Fee schedule rate ($32,852.04). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,13783.20,41580.51,There are no additional notes associated with this service or procedure.
"MAJOR ESOPHAGEAL DISORDERS,EXTREME",242,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],23025.20,,"Case rate ($23,025.20). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,23025.20,24176.46,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,083,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],28680.85,,"Fee schedule rate ($28,680.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,28680.85,There are no additional notes associated with this service or procedure.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],23835.16,,"Fee schedule rate ($23,835.16). Adds an outlier to normal pricing equal to the per diem rate ($63,133.20) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10533.95,24956.34,There are no additional notes associated with this service or procedure.
Esophagogastroduodenoscopy Transoral Diagnostic,CASE-43235,APC,43235,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],878.67,,"APC Price ($848.96). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,848.96,891.41,OPPS APC
VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC,033,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],13206.23,,"Case rate ($13,206.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,421.07, add-ons for qualifying new technology services are included. If operating cost exceeds $47,292.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,583.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $10,437.64 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,476.13 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $823.63. The transfer capital threshold is the transfer adjustment factor * $823.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,13206.23,42156.44,Inpatient DRG
DIABETES WITH CC,638,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],8227.59,,"Case rate ($7,835.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,436.08, add-ons for qualifying new technology services are included. If operating cost exceeds $42,307.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,180.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,470.39 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,491.13 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $420.47. The transfer capital threshold is the transfer adjustment factor * $420.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8014.07,17634.53,Inpatient DRG
Rpr Aa Hernia 1st > 10 Cm Ncrc8/Strangulated|UNUSUAL NON-OVERLAPPING SERVICE,CASE-49596,APC,49596,CPT,0360,RC,,,XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5856.81,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5658.76,5941.70,OPPS APC
MINOR BLADDER PROCEDURES WITHOUT CC/MCC,664,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],31876.87,,"Fee schedule rate ($31,876.87). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9034.63,31876.87,There are no additional notes associated with this service or procedure.
"POISONING OF MEDICINAL AGENTS,MAJOR",812,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],9754.16,,"Case rate ($9,289.68). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9289.68,9754.16,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITH CC,386,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],18347.61,,"Fee schedule rate ($18,347.61). Adds an outlier to normal pricing equal to the per diem rate ($111,650.51) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8556.53,19879.00,There are no additional notes associated with this service or procedure.
INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC,198,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],7134.88,,"Case rate ($6,795.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,456.95, add-ons for qualifying new technology services are included. If operating cost exceeds $41,327.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,114.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,495.42 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,512.00 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $354.73. The transfer capital threshold is the transfer adjustment factor * $354.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6795.12,23505.07,Inpatient DRG
Neuroplasty &/Transposition Ulnar Nerve Elbow|RIGHT SIDE,CASE-64718,APC,64718,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1827.80,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1827.80,1919.19,OPPS APC
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],33152.73,,"Fee schedule rate ($33,152.73). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13891.57,34712.20,There are no additional notes associated with this service or procedure.
Bronchoscopy W/Cptr-Asst Image-Guided Navigation,CASE-31627,APC,31627,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6605.95,,"APC Price ($6,605.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6605.95,6936.25,OPPS APC
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],7412.73,,"Case rate ($7,412.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,031.50, add-ons for qualifying new technology services are included. If operating cost exceeds $41,902.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,159.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $5,067.86 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,086.55 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $399.90. The transfer capital threshold is the transfer adjustment factor * $399.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6148.93,15887.21,Inpatient DRG
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],8083.15,,"Case rate ($8,083.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,655.19, add-ons for qualifying new technology services are included. If operating cost exceeds $42,526.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,208.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,689.27 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,710.24 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $448.94. The transfer capital threshold is the transfer adjustment factor * $448.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7884.32,17835.23,Inpatient DRG
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,097,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],67876.56,,"Fee schedule rate ($67,876.56). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17.7), with a minimum of zero.",,,,0,other,26404.32,79915.74,There are no additional notes associated with this service or procedure.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],19230.88,,"Fee schedule rate ($19,230.88). Adds an outlier to normal pricing equal to the per diem rate ($71,679.63) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8874.81,20553.44,There are no additional notes associated with this service or procedure.
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITH MCC,429,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],66106.51,,"Case rate ($62,958.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $58,704.65, add-ons for qualifying new technology services are included. If operating cost exceeds $93,575.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $6,222.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.6. The base transfer operating payment is the transfer adjustment factor * $56,551.19 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $56,759.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,462.45. The transfer capital threshold is the transfer adjustment factor * $4,462.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,62958.58,177294.98,Inpatient DRG
Exc B9 Lesion Mrgn Xcp Sk Tg T/a/L 3.1-4.0 Cm,CASE-11404,APC,11404,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1600.04,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1545.93,1623.23,OPPS APC
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],14908.05,,"Case rate ($14,908.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,004.25, add-ons for qualifying new technology services are included. If operating cost exceeds $48,875.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,708.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $12,014.99 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,059.30 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $948.10. The transfer capital threshold is the transfer adjustment factor * $948.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,14908.05,49717.39,Inpatient DRG
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],18245.94,,"Fee schedule rate ($18,245.94). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8106.18,18245.94,There are no additional notes associated with this service or procedure.
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],14343.25,,"Case rate ($14,343.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,478.83, add-ons for qualifying new technology services are included. If operating cost exceeds $48,349.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,666.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $11,491.51 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,533.88 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $906.79. The transfer capital threshold is the transfer adjustment factor * $906.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,14343.25,36024.65,Inpatient DRG
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],11247.07,,"Case rate ($11,247.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,598.51, add-ons for qualifying new technology services are included. If operating cost exceeds $45,469.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,440.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,621.77 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,653.56 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $680.34. The transfer capital threshold is the transfer adjustment factor * $680.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,11247.07,27028.33,Inpatient DRG
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],33159.45,,"Fee schedule rate ($33,159.45). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,13092.47,33159.45,There are no additional notes associated with this service or procedure.
CERVICAL SPINAL FUSION WITHOUT CC/MCC,473,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],19124.33,,"Case rate ($18,477.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,324.93, add-ons for qualifying new technology services are included. If operating cost exceeds $52,195.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,969.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.6. The base transfer operating payment is the transfer adjustment factor * $15,323.48 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,379.98 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,209.17. The transfer capital threshold is the transfer adjustment factor * $1,209.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,18477.61,62077.11,Inpatient DRG
PLEURAL EFFUSION WITH MCC,186,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],29692.94,,"Fee schedule rate ($29,692.94). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10804.96,31089.66,There are no additional notes associated with this service or procedure.
"MAJOR BILIARY TRACT PROCEDURES,MODERATE",261,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],22379.43,,"Case rate ($22,379.43). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,22379.43,23498.40,There are no additional notes associated with this service or procedure.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],9206.20,,"Case rate ($8,767.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,292.11, add-ons for qualifying new technology services are included. If operating cost exceeds $43,163.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,258.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,323.85 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,347.16 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $499.01. The transfer capital threshold is the transfer adjustment factor * $499.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8767.81,19824.58,Inpatient DRG
Exc Bartholins Gland/Cyst|LEFT SIDE,CASE-56740,APC,56740,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3030.03,,"APC Price ($3,030.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3030.03,3136.08,OPPS APC
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],37914.65,,"Fee schedule rate ($37,914.65). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9865.56,37914.65,There are no additional notes associated with this service or procedure.
"Arthrodesis Interphalangeal Jt W/WO Int Fixj|LEFT HAND, THUMB",CASE-26860,APC,26860,CPT,0360,RC,,,FA,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],38378.80,,"Fee schedule rate ($38,378.80). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,14370.36,38378.80,There are no additional notes associated with this service or procedure.
"Repair Extensor Tendon Finger W/O Graft Each|LEFT HAND, THIRD DIGIT",CASE-26418,APC,26418,CPT,0360,RC,,,F2,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1505.12,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1505.12,1580.37,OPPS APC
"CELLULITIS AND OTHER SKIN INFECTIONS,MODERATE",383,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],6811.69,,"Case rate ($6,487.32). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6487.32,6811.69,There are no additional notes associated with this service or procedure.
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],18043.23,,"Fee schedule rate ($18,043.23). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7733.72,18043.23,There are no additional notes associated with this service or procedure.
Dstr Nrolytc Agnt Parverteb Fct Addl Lmbr/Sacral,CASE-64636,APC,64636,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1919.19,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1827.80,1919.19,OPPS APC
BRONCHITIS AND ASTHMA WITHOUT CC/MCC,203,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],4763.76,,"Case rate ($4,536.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $4,234.32, add-ons for qualifying new technology services are included. If operating cost exceeds $43,804.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $3,112.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,215.08. The transfer operating threshold is the transfer adjustment factor * $4,234.32 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $321.83. The transfer capital threshold is the transfer adjustment factor * $321.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,4763.76,13707.00,Inpatient DRG
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITH MCC OR ANTINEOPLASTIC IMPLANT OR EPILEPSY WITH NEUROSTIMULATOR,023,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],112755.11,,,,,,0,other,15168.00,136379.44,There are no additional notes associated with this service or procedure.
Laparoscopy Surg W/Bx Single/Multiple|UNUSUAL NON-OVERLAPPING SERVICE,CASE-49321,APC,49321,CPT,0360,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],9949.78,,"APC Price ($9,949.78). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,9949.78,9949.78,OPPS APC
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],51903.64,,"Fee schedule rate ($51,903.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,16017.99,51903.64,There are no additional notes associated with this service or procedure.
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],81306.30,,"Fee schedule rate ($81,306.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,20846.48,81306.30,There are no additional notes associated with this service or procedure.
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],30245.71,,"Fee schedule rate ($30,245.71). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9151.11,30245.71,There are no additional notes associated with this service or procedure.
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],5791.49,,"Fee schedule rate ($5,791.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,3079.00,10940.41,There are no additional notes associated with this service or procedure.
Dilation Esoph Unguided Sound/Bougie 1/Mult Pass,CASE-43450,APC,43450,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],848.96,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,848.96,891.41,OPPS APC
GASTROINTESTINAL HEMORRHAGE WITH MCC,377,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],14658.70,,"Case rate ($13,960.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,145.34, add-ons for qualifying new technology services are included. If operating cost exceeds $48,016.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,617.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $11,158.09 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,200.39 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $857.64. The transfer capital threshold is the transfer adjustment factor * $857.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7634.00,35969.56,Inpatient DRG
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],21089.59,,"Fee schedule rate ($21,089.59). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,6965.00,21089.59,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],86252.84,,"Fee schedule rate ($86,252.84). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,27944.96,86252.84,There are no additional notes associated with this service or procedure.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],42586.49,,"Fee schedule rate ($42,586.49). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,13341.67,42586.49,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,448,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],94077.13,,"Fee schedule rate ($94,077.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,30663.95,94077.13,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC,087,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],22679.07,,"Fee schedule rate ($22,679.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,8139.36,22679.07,There are no additional notes associated with this service or procedure.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],10098.51,,"Case rate ($10,098.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,530.04, add-ons for qualifying new technology services are included. If operating cost exceeds $44,401.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,356.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $7,557.23 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,585.10 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $596.34. The transfer capital threshold is the transfer adjustment factor * $596.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10098.51,24259.09,Inpatient DRG
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],67790.93,,"Fee schedule rate ($67,790.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,21597.50,67790.93,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],6965.00,,,,,,0,other,1188.00,12138.74,There are no additional notes associated with this service or procedure.
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],7291.31,,"Case rate ($6,944.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,595.55, add-ons for qualifying new technology services are included. If operating cost exceeds $41,466.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,125.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,633.51 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,650.60 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $365.63. The transfer capital threshold is the transfer adjustment factor * $365.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5068.21,14525.56,Inpatient DRG
CHOLECYSTECTOMY WITH C.D.E. WITH MCC,411,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],62078.92,,"Fee schedule rate ($62,078.92). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15), with a minimum of zero.",,,,0,other,24315.13,88615.28,There are no additional notes associated with this service or procedure.
"Prq Skel Fixj Phlngl Shft Fx Prox/Middle Px/F/T|RIGHT HAND, FIFTH DIGIT",CASE-26727,APC,26727,CPT,0360,RC,,,F9,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],8790.94,,"Case rate ($8,372.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,924.20, add-ons for qualifying new technology services are included. If operating cost exceeds $42,795.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,230.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,957.28 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,979.25 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $470.09. The transfer capital threshold is the transfer adjustment factor * $470.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,23385.72,Inpatient DRG
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],39820.52,,"Fee schedule rate ($39,820.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,15273.74,39820.52,There are no additional notes associated with this service or procedure.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC,862,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],6855.00,,"Per diem ($6,855). If length of stay < 5, first 1 days paid at a per diem of $13,710 instead. Capped at $34,272.79.",,,,0,other,6855.00,35884.94,Estimated amount calculated based on 3 day length of stay.
Arthrodesis Posterior/Pstlat Tq 1ntrspc Lumbar,CASE-22612,APC,22612,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],17232.68,,"APC Price ($16,412.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,16986.50,17232.68,OPPS APC
Rpr 1st Ingun Hrna Age 5 Yrs/> Reducible|LEFT SIDE,CASE-49505,APC,49505,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3351.34,,"APC Price ($3,351.34). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3351.34,3518.91,OPPS APC
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],9950.98,,"Case rate ($9,755.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,211.27, add-ons for qualifying new technology services are included. If operating cost exceeds $44,082.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,331.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $7,239.63 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,266.32 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $571.28. The transfer capital threshold is the transfer adjustment factor * $571.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,9755.86,29216.99,Inpatient DRG
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],22557.82,,"Fee schedule rate ($22,557.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6801.88,22557.82,There are no additional notes associated with this service or procedure.
HC N Block Inj Suprascapular Nerv|RIGHT SIDE,CASE-64418,APC,64418,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],693.76,,"APC Price ($660.72). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,660.72,693.76,OPPS APC
INFLAMMATORY BOWEL DISEASE WITH CC,386,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],8984.36,,"Case rate ($8,556.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,095.56, add-ons for qualifying new technology services are included. If operating cost exceeds $42,966.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,243.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,128.01 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,150.61 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $483.56. The transfer capital threshold is the transfer adjustment factor * $483.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8556.53,19879.00,Inpatient DRG
OSTEOMYELITIS WITH CC,540,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],18450.55,,"Fee schedule rate ($18,450.55). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,9809.07,25507.30,There are no additional notes associated with this service or procedure.
Laps Tx Ectopic Preg W/Salping&/Oophorectomy|RIGHT SIDE,CASE-59151,APC,59151,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5658.76,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5658.76,5941.70,OPPS APC
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,097,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],26404.32,,"Case rate ($26,404.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $24,698.97, add-ons for qualifying new technology services are included. If operating cost exceeds $59,569.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,548.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.7. The base transfer operating payment is the transfer adjustment factor * $22,670.44 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $22,754.03 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,788.92. The transfer capital threshold is the transfer adjustment factor * $1,788.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,26404.32,79915.74,Inpatient DRG
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],12566.28,,"Case rate ($12,566.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,825.74, add-ons for qualifying new technology services are included. If operating cost exceeds $46,696.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,536.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $9,844.49 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,880.79 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $776.83. The transfer capital threshold is the transfer adjustment factor * $776.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12566.28,30861.41,Inpatient DRG
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],19230.33,,,,,,0,other,8563.30,31533.97,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC,084,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],6965.00,,,,,,0,other,6965.00,19445.16,There are no additional notes associated with this service or procedure.
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],26301.36,,"Fee schedule rate ($26,301.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11247.07,27028.33,There are no additional notes associated with this service or procedure.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],42787.31,,"Fee schedule rate ($42,787.31). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,15476.23,42787.31,There are no additional notes associated with this service or procedure.
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC,964,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],12940.01,,"Case rate ($12,323.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,600.20, add-ons for qualifying new technology services are included. If operating cost exceeds $46,471.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,519.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $9,619.78 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,655.25 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $759.10. The transfer capital threshold is the transfer adjustment factor * $759.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12323.82,34154.06,Inpatient DRG
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],18045.04,,"Fee schedule rate ($18,045.04). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,1188.00,18893.86,There are no additional notes associated with this service or procedure.
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],23385.72,,"Fee schedule rate ($23,385.72). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,23385.72,There are no additional notes associated with this service or procedure.
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],7566.45,,"Case rate ($7,566.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,174.51, add-ons for qualifying new technology services are included. If operating cost exceeds $42,045.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,171.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,210.35 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,229.56 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $411.15. The transfer capital threshold is the transfer adjustment factor * $411.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7566.45,16333.88,Inpatient DRG
CELLULITIS WITH MCC,602,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],11570.10,,"Case rate ($11,570.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,899.02, add-ons for qualifying new technology services are included. If operating cost exceeds $45,770.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,463.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $8,921.17 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,954.07 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $703.97. The transfer capital threshold is the transfer adjustment factor * $703.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,11570.10,28349.31,Inpatient DRG
Injection Aa&/Strd Ilioinguinal Ih Nerves,CASE-64425,APC,64425,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],683.85,,"APC Price ($660.72). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,660.72,693.76,OPPS APC
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],26178.21,,"Fee schedule rate ($26,178.21). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,13917.42,34889.29,There are no additional notes associated with this service or procedure.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],105091.76,,"Fee schedule rate ($105,091.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,35719.96,105091.76,There are no additional notes associated with this service or procedure.
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral Ea Addl|LEFT SIDE,CASE-64484,APC,64484,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],869.28,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,827.89,869.28,OPPS APC
Sphincterotomy Anal Division Sphincter Spx,CASE-46080,APC,46080,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],2727.99,,"APC Price ($2,598.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2598.08,2727.99,OPPS APC
PLEURAL EFFUSION WITH MCC,186,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],29692.94,,"Fee schedule rate ($29,692.94). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10804.96,31089.66,There are no additional notes associated with this service or procedure.
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],5068.21,,"Fee schedule rate ($5,068.21). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5068.21,14525.56,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,699,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],8818.60,,"Case rate ($8,818.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,339.37, add-ons for qualifying new technology services are included. If operating cost exceeds $43,210.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,262.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $6,370.92 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,394.41 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $502.73. The transfer capital threshold is the transfer adjustment factor * $502.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,5961.00,19972.16,Inpatient DRG
Excision Hydrocele Unilateral|LEFT SIDE,CASE-55040,APC,55040,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3351.34,,"APC Price ($3,351.34). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3351.34,3518.91,OPPS APC
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],31577.54,,"Fee schedule rate ($31,577.54). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,15453.88,39251.68,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC,817,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],18004.97,,"Case rate ($17,396.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,318.84, add-ons for qualifying new technology services are included. If operating cost exceeds $51,189.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,890.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $14,321.08 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,373.88 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,130.07. The transfer capital threshold is the transfer adjustment factor * $1,130.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,17396.11,44895.04,Inpatient DRG
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],27041.80,,"Case rate ($26,127.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $24,441.31, add-ons for qualifying new technology services are included. If operating cost exceeds $59,312.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,528.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. The base transfer operating payment is the transfer adjustment factor * $22,413.72 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $22,496.36 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,768.66. The transfer capital threshold is the transfer adjustment factor * $1,768.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,26127.34,90333.60,Inpatient DRG
HC Inj Tendon Sheath/Ligament|PBB CHARGE,CASE-20550,APC,20550,CPT,0510,RC,,,PBB,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],287.31,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],53152.12,,"Fee schedule rate ($53,152.12). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,19152.11,53152.12,There are no additional notes associated with this service or procedure.
INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC,198,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],23505.07,,"Fee schedule rate ($23,505.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6795.12,23505.07,There are no additional notes associated with this service or procedure.
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],22762.43,,"Fee schedule rate ($22,762.43). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6230.00,22762.43,There are no additional notes associated with this service or procedure.
HC Biopsy/Exc Lymph Node Needle|TECHNICAL COMPONENT|RIGHT SIDE,CASE-38505,APC,38505,CPT,0361,RC,,,TC|RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1545.93,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1545.93,1623.23,OPPS APC
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6336.93,,"Case rate ($6,122.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,831.37, add-ons for qualifying new technology services are included. If operating cost exceeds $40,702.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,065.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $3,872.14 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,886.42 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $305.55. The transfer capital threshold is the transfer adjustment factor * $305.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,1188.00,12138.74,Inpatient DRG
"Open Tx Distal Phalangeal Fracture Each|LEFT HAND, FIFTH DIGIT",CASE-26765,APC,26765,CPT,0360,RC,,,F4,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],12818.71,,"Fee schedule rate ($12,818.71). Adds an outlier to normal pricing equal to the per diem rate ($42,942.49) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,6564.18,17651.07,There are no additional notes associated with this service or procedure.
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],45157.33,,"Fee schedule rate ($45,157.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,10733.06,45157.33,There are no additional notes associated with this service or procedure.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC,858,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],11377.76,,"Case rate ($11,377.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,720.10, add-ons for qualifying new technology services are included. If operating cost exceeds $45,591.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,449.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $8,742.91 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,775.15 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $689.90. The transfer capital threshold is the transfer adjustment factor * $689.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,11377.76,33794.11,Inpatient DRG
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],18043.23,,"Fee schedule rate ($18,043.23). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7733.72,18043.23,There are no additional notes associated with this service or procedure.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,097,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],67876.56,,"Fee schedule rate ($67,876.56). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17.7), with a minimum of zero.",,,,0,other,26404.32,79915.74,There are no additional notes associated with this service or procedure.
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],25253.70,,"Fee schedule rate ($25,253.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11974.38,29141.64,There are no additional notes associated with this service or procedure.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],33623.33,,"Case rate ($33,623.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $31,414.68, add-ons for qualifying new technology services are included. If operating cost exceeds $66,285.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,076.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.4. The base transfer operating payment is the transfer adjustment factor * $29,361.48 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $29,469.74 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,316.91. The transfer capital threshold is the transfer adjustment factor * $2,316.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,33623.33,133270.57,Inpatient DRG
Hysteroscopy Removal Impacted Foreign Body,CASE-58562,APC,58562,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3030.03,,"APC Price ($3,030.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3030.03,3136.08,OPPS APC
Insj Inflatable Urethral/Bladder Neck Sphincter,CASE-53445,APC,53445,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],20079.15,,"APC Price ($19,400.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,19400.15,20370.16,OPPS APC
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],40853.23,,"Case rate ($23,344.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $21,852.68, add-ons for qualifying new technology services are included. If operating cost exceeds $56,723.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,325.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $19,834.60 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $19,907.73 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,565.15. The transfer capital threshold is the transfer adjustment factor * $1,565.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,23344.70,62179.32,All Other Inpatient
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],26809.29,,"Case rate ($26,809.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $25,075.72, add-ons for qualifying new technology services are included. If operating cost exceeds $59,946.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,578.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $23,045.79 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $23,130.76 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,818.54. The transfer capital threshold is the transfer adjustment factor * $1,818.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,26809.29,97015.50,Inpatient DRG
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR,518,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],27836.34,,"Case rate ($26,510.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $24,843.87, add-ons for qualifying new technology services are included. If operating cost exceeds $59,714.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,513.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 5.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $22,812.43 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $22,898.92 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,753.42. The transfer capital threshold is the transfer adjustment factor * $1,753.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13252.00,89342.77,Inpatient DRG
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITH MCC OR ANTINEOPLASTIC IMPLANT OR EPILEPSY WITH NEUROSTIMULATOR,023,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],136379.44,,"Fee schedule rate ($136,379.44). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,15168.00,136379.44,There are no additional notes associated with this service or procedure.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],97015.50,,"Fee schedule rate ($97,015.50). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,26809.29,97015.50,There are no additional notes associated with this service or procedure.
Arthrs Knee Debridement/Shaving Artclr Crtlg|RIGHT SIDE,CASE-29877,APC,29877,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],32584.77,,"Fee schedule rate ($32,584.77). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,23799.09,63499.65,There are no additional notes associated with this service or procedure.
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],16035.06,,"Fee schedule rate ($16,035.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,7396.47,16035.06,There are no additional notes associated with this service or procedure.
Dstr Nrolytc Agnt Parverteb Fct Sngl Crvcl/Thora|RIGHT SIDE,CASE-64633,APC,64633,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1891.77,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1827.80,1919.19,OPPS APC
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],10851.72,,"Case rate ($10,638.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,032.78, add-ons for qualifying new technology services are included. If operating cost exceeds $44,903.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,395.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,058.12 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,087.83 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $635.87. The transfer capital threshold is the transfer adjustment factor * $635.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,10638.94,25261.33,Inpatient DRG
Mast Modf Rad W/Ax Lymph Nod W/WO Pect/Alis Min|RIGHT SIDE,CASE-19307,APC,19307,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6215.36,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6215.36,6526.12,OPPS APC
Musc Myocutaneous/Fasciocutaneous Flap Trunk,CASE-15734,APC,15734,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5658.76,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5658.76,5941.70,OPPS APC
CERVICAL SPINAL FUSION WITHOUT CC/MCC,473,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],18477.61,,"Case rate ($18,477.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,324.93, add-ons for qualifying new technology services are included. If operating cost exceeds $52,195.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,969.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.6. The base transfer operating payment is the transfer adjustment factor * $15,323.48 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,379.98 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,209.17. The transfer capital threshold is the transfer adjustment factor * $1,209.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,18477.61,62077.11,Inpatient DRG
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],7175.55,,"Case rate ($7,034.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,679.97, add-ons for qualifying new technology services are included. If operating cost exceeds $41,550.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,132.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $4,717.62 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,735.02 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $372.27. The transfer capital threshold is the transfer adjustment factor * $372.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6965.00,21089.59,Inpatient DRG
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC",458,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],78415.67,,"Fee schedule rate ($78,415.67). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.8), with a minimum of zero.",,,,0,other,30202.09,132827.25,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],7353.00,,"Per diem ($7,353). If length of stay < 4.1, first 1 days paid at a per diem of $14,706 instead. Capped at $30,145.85.",,,,0,other,7353.00,33398.16,Estimated amount calculated based on 4 day length of stay.
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC,939,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],97674.79,,"Fee schedule rate ($97,674.79). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,26517.40,97674.79,There are no additional notes associated with this service or procedure.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",063,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],11680.61,,"Case rate ($11,451.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,788.77, add-ons for qualifying new technology services are included. If operating cost exceeds $45,659.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,455.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $8,811.33 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,843.82 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $695.30. The transfer capital threshold is the transfer adjustment factor * $695.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6965.00,35701.87,Inpatient DRG
HC Joint Injection/Aspir Large WO US|LEFT SIDE,CASE-20610,APC,20610,CPT,0510,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],297.37,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,287.31,301.68,OPPS APC
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],13639.70,,"Case rate ($12,990.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,220.11, add-ons for qualifying new technology services are included. If operating cost exceeds $47,091.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,567.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $10,237.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,275.16 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $807.83. The transfer capital threshold is the transfer adjustment factor * $807.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9888.00,43399.23,Inpatient DRG
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH CC,427,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],50829.82,,"Case rate ($50,829.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $47,421.51, add-ons for qualifying new technology services are included. If operating cost exceeds $82,292.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $5,335.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $45,309.50 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $45,476.56 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,575.37. The transfer capital threshold is the transfer adjustment factor * $3,575.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,50829.82,142040.39,Inpatient DRG
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],5791.49,,"Fee schedule rate ($5,791.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,3079.00,10940.41,There are no additional notes associated with this service or procedure.
HC I&D Ischio Perirectal Abs,CASE-46040,APC,46040,CPT,0450,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1176.09,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1120.09,1176.09,OPPS APC
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC,099,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],25603.58,,"Fee schedule rate ($25,603.58). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.7), with a minimum of zero.",,,,0,other,11171.21,26807.94,There are no additional notes associated with this service or procedure.
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],16055.90,,"Fee schedule rate ($16,055.90). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8163.06,18067.42,There are no additional notes associated with this service or procedure.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],9104.82,,"Case rate ($8,671.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,214.84, add-ons for qualifying new technology services are included. If operating cost exceeds $43,085.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,240.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $6,246.21 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,269.89 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $480.10. The transfer capital threshold is the transfer adjustment factor * $480.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8874.81,20553.44,Inpatient DRG
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],57872.02,,,,,,0,other,7086.00,57872.02,There are no additional notes associated with this service or procedure.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,761,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5808.41,,"Case rate ($5,808.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,539.05, add-ons for qualifying new technology services are included. If operating cost exceeds $40,410.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,042.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $3,580.90 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,594.10 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $282.57. The transfer capital threshold is the transfer adjustment factor * $282.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,5808.41,11946.72,Inpatient DRG
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],32980.62,,,,,,0,other,7000.00,33835.79,There are no additional notes associated with this service or procedure.
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],8004.40,,"Case rate ($7,733.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,330.12, add-ons for qualifying new technology services are included. If operating cost exceeds $42,201.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,183.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,365.38 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,385.17 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $423.38. The transfer capital threshold is the transfer adjustment factor * $423.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,7733.72,18043.23,Inpatient DRG
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,085,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],30539.16,,"Fee schedule rate ($30,539.16). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,9282.00,57443.16,There are no additional notes associated with this service or procedure.
Incision & Removal Foreign Body Subq Tiss Compl,CASE-10121,APC,10121,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1623.23,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1545.93,1623.23,OPPS APC
Ercp Biliary/Panc Duct Stent Exchange W/Dil&Wire,CASE-43276,APC,43276,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5881.39,,"APC Price ($5,682.51). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5682.51,5966.63,OPPS APC
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],27028.33,,,,,,0,other,11247.07,27028.33,There are no additional notes associated with this service or procedure.
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],28445.08,,"Fee schedule rate ($28,445.08). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.8), with a minimum of zero.",,,,0,other,12195.15,39424.57,There are no additional notes associated with this service or procedure.
Prq Skeletal Fixj Metacarpal Fx Each Bone|RIGHT SIDE,CASE-26608,APC,26608,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
Cysto Bladder W/Ureteral Catheterization|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-52005,APC,52005,CPT,0360,RC,,,LT|XU,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3299.47,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3299.47,3464.44,OPPS APC
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],18671.22,,"Case rate ($17,782.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,677.93, add-ons for qualifying new technology services are included. If operating cost exceeds $51,548.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,918.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $14,678.86 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,732.98 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,158.31. The transfer capital threshold is the transfer adjustment factor * $1,158.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,17782.11,46523.26,Inpatient DRG
MAJOR BLADDER PROCEDURES WITH MCC,653,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],10280.00,,"Per diem ($10,280). If length of stay < 9.5, first 1 days paid at a per diem of $20,560 instead. Capped at $97,655.95.",,,,0,other,10280.00,125343.98,Estimated amount calculated based on 10 day length of stay.
Cysto W/Urtroscopy&/Pyeloscopy Dx|UNUSUAL NON-OVERLAPPING SERVICE,CASE-52351,APC,52351,CPT,0360,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3299.47,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3299.47,3464.44,OPPS APC
POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES,769,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],23429.68,,"Case rate ($13,388.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,590.54, add-ons for qualifying new technology services are included. If operating cost exceeds $47,461.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,596.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $10,606.49 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,645.59 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $836.96. The transfer capital threshold is the transfer adjustment factor * $836.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,13388.39,33250.19,All Other Inpatient
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],46453.28,,"Case rate ($44,241.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $41,371.19, add-ons for qualifying new technology services are included. If operating cost exceeds $76,242.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,778.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 12.5. The base transfer operating payment is the transfer adjustment factor * $39,277.32 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $39,426.24 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,018.95. The transfer capital threshold is the transfer adjustment factor * $3,018.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,45521.20,142438.06,Inpatient DRG
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",623,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],14798.04,,"Case rate ($14,093.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,246.37, add-ons for qualifying new technology services are included. If operating cost exceeds $48,117.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,648.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $11,259.90 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,301.42 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $888.52. The transfer capital threshold is the transfer adjustment factor * $888.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,14093.37,33712.76,Inpatient DRG
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC,434,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],13390.01,,"Fee schedule rate ($13,390.01). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6770.05,14019.86,There are no additional notes associated with this service or procedure.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],21585.31,,"Case rate ($21,585.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,215.96, add-ons for qualifying new technology services are included. If operating cost exceeds $55,086.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,196.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $18,203.89 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,271.01 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,436.47. The transfer capital threshold is the transfer adjustment factor * $1,436.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,21585.31,73588.10,Inpatient DRG
"Tendon Sheath Incision|UNUSUAL NON-OVERLAPPING SERVICE|LEFT HAND, THUMB",CASE-26055,APC,26055,CPT,0360,RC,,,XU|FA,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
"ANTEPARTUM WITHOUT O.R. PROCEDURE,MINOR",566,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],2613.78,,"The inlier payment is calculated as the lesser of the standard DRG payment $2,613.78 and the transfer payment, which is a per diem of $1,281.27. If cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,2613.78,2744.47,Estimated amount calculated based on 1 day length of stay.
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],6965.00,,,,,,0,other,6965.00,16400.70,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],6923.41,,"Case rate ($6,787.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,450.02, add-ons for qualifying new technology services are included. If operating cost exceeds $41,321.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,114.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,488.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,505.07 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $354.19. The transfer capital threshold is the transfer adjustment factor * $354.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6164.03,14071.02,Inpatient DRG
DIABETES WITH CC,638,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],17634.53,,,,,,0,other,8014.07,17634.53,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,167,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],14157.71,,"Case rate ($14,157.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,306.21, add-ons for qualifying new technology services are included. If operating cost exceeds $48,177.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,653.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $11,319.53 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,361.26 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $893.22. The transfer capital threshold is the transfer adjustment factor * $893.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,14157.71,43522.37,Inpatient DRG
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],11133.98,,"Fee schedule rate ($11,133.98). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5919.29,13545.65,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],16278.78,,,,,,0,other,6965.00,19126.88,There are no additional notes associated with this service or procedure.
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],10181.78,,"Case rate ($9,696.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,156.46, add-ons for qualifying new technology services are included. If operating cost exceeds $44,027.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,326.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $7,185.02 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,211.51 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $566.97. The transfer capital threshold is the transfer adjustment factor * $566.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9696.93,35061.53,Inpatient DRG
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],42768.36,,"Fee schedule rate ($42,768.36). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,14295.18,42768.36,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,086,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],8442.00,,"Per diem ($8,442). If length of stay < 2.9, first 1 days paid at a per diem of $16,884 instead. Capped at $24,481.64.",,,,0,other,8442.00,30728.81,Estimated amount calculated based on 2 day length of stay.
"OTHER DIGESTIVE SYSTEM DIAGNOSES,MINOR",254,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],5522.50,,"Case rate ($5,522.50). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,5522.50,5798.63,There are no additional notes associated with this service or procedure.
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC,964,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],28802.15,,"Fee schedule rate ($28,802.15). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,12323.82,34154.06,There are no additional notes associated with this service or procedure.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,479,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],50518.76,,"Fee schedule rate ($50,518.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,10586.00,50518.76,There are no additional notes associated with this service or procedure.
HC N Block Inj Suprascapular Nerv|RIGHT SIDE,CASE-64418,APC,64418,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],660.72,,"APC Price ($660.72). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,660.72,693.76,OPPS APC
SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS,870,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],161307.29,,"Fee schedule rate ($161,307.29). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (41), with a minimum of zero.",,,,0,other,161307.29,161307.29,There are no additional notes associated with this service or procedure.
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],9696.93,,"Case rate ($9,696.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,156.46, add-ons for qualifying new technology services are included. If operating cost exceeds $44,027.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,326.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $7,185.02 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,211.51 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $566.97. The transfer capital threshold is the transfer adjustment factor * $566.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9696.93,35061.53,Inpatient DRG
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],6965.00,,,,,,0,other,6965.00,19126.88,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],28756.63,,"Fee schedule rate ($28,756.63). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,13148.66,32553.63,There are no additional notes associated with this service or procedure.
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],18043.23,,"Fee schedule rate ($18,043.23). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7733.72,18043.23,There are no additional notes associated with this service or procedure.
PERITONEAL ADHESIOLYSIS WITH CC,336,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],53705.31,,"Fee schedule rate ($53,705.31). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,16225.22,53705.31,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],59021.28,,"Fee schedule rate ($59,021.28). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,23851.92,63653.13,There are no additional notes associated with this service or procedure.
ALLERGIC REACTIONS WITH MCC,915,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],13999.50,,"Case rate ($13,332.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,538.89, add-ons for qualifying new technology services are included. If operating cost exceeds $47,409.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,592.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $10,555.02 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,593.94 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $832.90. The transfer capital threshold is the transfer adjustment factor * $832.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13332.86,33088.84,Inpatient DRG
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH CC",457,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],44443.84,,"Case rate ($42,327.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $39,511.96, add-ons for qualifying new technology services are included. If operating cost exceeds $74,382.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,713.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $37,429.01 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $37,567.02 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,953.52. The transfer capital threshold is the transfer adjustment factor * $2,953.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,42327.47,160549.49,Inpatient DRG
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],16400.70,,"Fee schedule rate ($16,400.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,16400.70,There are no additional notes associated with this service or procedure.
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],31973.49,,"Fee schedule rate ($31,973.49). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,13386.36,33244.29,There are no additional notes associated with this service or procedure.
Sigmoidoscopy Flx Control Bleeding,CASE-45334,APC,45334,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1120.09,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1120.09,1176.09,OPPS APC
TRAUMATIC INJURY WITH MCC,913,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],13274.87,,"Case rate ($13,014.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,242.79, add-ons for qualifying new technology services are included. If operating cost exceeds $47,113.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,569.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $10,260.01 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,297.84 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $809.62. The transfer capital threshold is the transfer adjustment factor * $809.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,13014.58,42838.46,Inpatient DRG
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],80635.65,,"Fee schedule rate ($80,635.65). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,26028.48,80635.65,There are no additional notes associated with this service or procedure.
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],68942.79,,"Fee schedule rate ($68,942.79). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,21489.15,68942.79,There are no additional notes associated with this service or procedure.
OSTEOMYELITIS WITHOUT CC/MCC,541,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7531.98,,"Case rate ($7,277.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,905.50, add-ons for qualifying new technology services are included. If operating cost exceeds $41,776.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,149.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $4,942.33 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,960.55 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $390.00. The transfer capital threshold is the transfer adjustment factor * $390.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,5103.00,15493.67,Inpatient DRG
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],11565.93,,"Fee schedule rate ($11,565.93). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6148.93,15887.21,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],10605.28,,"Case rate ($10,100.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,546.88, add-ons for qualifying new technology services are included. If operating cost exceeds $44,417.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,342.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $7,573.22 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,601.93 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $582.10. The transfer capital threshold is the transfer adjustment factor * $582.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10347.06,28821.04,Inpatient DRG
"Tenolysis Extensor Tendon Hand/Finger Each|LEFT HAND, SECOND DIGIT",CASE-26445,APC,26445,CPT,0360,RC,,,F1,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3169.86,OPPS APC
CERVICAL SPINAL FUSION WITH CC,472,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],70198.84,,"Fee schedule rate ($70,198.84). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,21896.13,70198.84,There are no additional notes associated with this service or procedure.
HC Biopsy Liver Percutan Needle,CASE-47000,APC,47000,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1545.93,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1545.93,1623.23,OPPS APC
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],16804.22,,"Fee schedule rate ($16,804.22). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7238.69,16804.22,There are no additional notes associated with this service or procedure.
Nasal/Sinus Ndsc W/Rmvl Tiss From Frontal Sinus,CASE-31276,APC,31276,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6936.25,,"APC Price ($6,605.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6605.95,6936.25,OPPS APC
RADIOTHERAPY,849,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],53314.83,,,,,,0,other,20293.88,81867.07,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],28038.61,,"Fee schedule rate ($28,038.61). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12126.09,29582.40,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITH MCC,385,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],29736.16,,"Fee schedule rate ($29,736.16). Adds an outlier to normal pricing equal to the per diem rate ($112,108.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.5), with a minimum of zero.",,,,0,other,11480.01,31134.92,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],21892.85,,"Fee schedule rate ($21,892.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7569.84,21892.85,There are no additional notes associated with this service or procedure.
Insj/Rplcmt Perq Eltrd Ra Pn W/Int Nstim 1st Ra,CASE-64596,APC,64596,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],10429.83,,"APC Price ($10,429.83). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,10429.83,10951.32,OPPS APC
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],11348.00,,"Per diem ($11,348). If length of stay < 4.2, first 1 days paid at a per diem of $22,696 instead. Capped at $47,660.93.",,,,0,other,11348.00,62454.12,Estimated amount calculated based on 5 day length of stay.
SINGLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL,402,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],75557.26,,"Fee schedule rate ($75,557.26). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.9), with a minimum of zero.",,,,0,other,29172.05,124455.45,There are no additional notes associated with this service or procedure.
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 2nd Level|RIGHT SIDE,CASE-64494,APC,64494,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],827.89,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,827.89,869.28,OPPS APC
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],8239.88,,"Case rate ($7,847.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,435.96, add-ons for qualifying new technology services are included. If operating cost exceeds $42,306.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,191.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,470.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,491.01 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $431.70. The transfer capital threshold is the transfer adjustment factor * $431.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7847.50,17755.26,Inpatient DRG
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],13361.69,,"Case rate ($12,725.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,973.79, add-ons for qualifying new technology services are included. If operating cost exceeds $46,844.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,548.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $9,991.99 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,028.83 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $788.47. The transfer capital threshold is the transfer adjustment factor * $788.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12725.42,34245.00,Inpatient DRG
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC,497,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],37761.19,,"Fee schedule rate ($37,761.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10127.65,37761.19,There are no additional notes associated with this service or procedure.
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITH MCC,429,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],177294.98,,"Fee schedule rate ($177,294.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,62958.58,177294.98,There are no additional notes associated with this service or procedure.
Colsc Flexible W/Transendoscopic Balloon Dilat,CASE-45386,APC,45386,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1159.29,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1120.09,1176.09,OPPS APC
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC",061,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],62315.82,,"Fee schedule rate ($62,315.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,20616.23,62315.82,There are no additional notes associated with this service or procedure.
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],33159.45,,"Fee schedule rate ($33,159.45). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,13092.47,33159.45,There are no additional notes associated with this service or procedure.
"Tendon Sheath Incision|LEFT HAND, THUMB",CASE-26055,APC,26055,CPT,0360,RC,,,FA,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1580.37,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1505.12,1580.37,OPPS APC
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],7569.84,,"Case rate ($7,569.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,177.66, add-ons for qualifying new technology services are included. If operating cost exceeds $42,048.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,171.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,213.49 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,232.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $411.40. The transfer capital threshold is the transfer adjustment factor * $411.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7569.84,21892.85,Inpatient DRG
PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,337,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],38926.31,,"Fee schedule rate ($38,926.31). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,12340.08,38926.31,There are no additional notes associated with this service or procedure.
HEART FAILURE AND SHOCK WITH CC,292,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7901.83,,"Case rate ($7,525.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,146.88, add-ons for qualifying new technology services are included. If operating cost exceeds $42,017.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,158.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,182.28 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,201.93 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $398.32. The transfer capital threshold is the transfer adjustment factor * $398.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5502.00,16705.77,Inpatient DRG
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC,807,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],13266.23,,,,,,0,other,5354.25,13266.23,There are no additional notes associated with this service or procedure.
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],10003.71,,"Case rate ($10,003.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,441.84, add-ons for qualifying new technology services are included. If operating cost exceeds $44,312.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,349.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $7,469.36 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,496.90 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $589.41. The transfer capital threshold is the transfer adjustment factor * $589.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10003.71,23415.63,Inpatient DRG
Mastectomy Partial|LEFT SIDE,CASE-19301,APC,19301,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6526.12,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6215.36,6526.12,OPPS APC
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC,058,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],33637.83,,,,,,0,other,13521.80,40853.02,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC,832,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],6968.31,,"Case rate ($6,831.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,490.97, add-ons for qualifying new technology services are included. If operating cost exceeds $41,361.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,117.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $4,529.32 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,546.02 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $357.41. The transfer capital threshold is the transfer adjustment factor * $357.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,4803.31,14198.92,Inpatient DRG
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC,519,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],15847.20,,"Case rate ($15,092.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,200.43, add-ons for qualifying new technology services are included. If operating cost exceeds $49,071.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,698.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $12,209.19 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,255.48 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $938.43. The transfer capital threshold is the transfer adjustment factor * $938.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,15490.44,50780.20,Inpatient DRG
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],23954.07,,"Fee schedule rate ($23,954.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,6167.00,29058.99,There are no additional notes associated with this service or procedure.
Arthroscopy Knee W/Meniscus Rpr Medial&Lateral|RIGHT SIDE,CASE-29883,APC,29883,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3169.86,OPPS APC
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],13236.54,,"Case rate ($12,606.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,862.91, add-ons for qualifying new technology services are included. If operating cost exceeds $46,733.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,539.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $9,881.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,917.95 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $779.75. The transfer capital threshold is the transfer adjustment factor * $779.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12606.23,36868.88,Inpatient DRG
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],6965.00,,,,,,0,other,6965.00,34422.94,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],2070.00,,,,,,0,other,1188.00,34338.33,Estimated amount calculated based on 6 day length of stay.
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],27944.96,,"Case rate ($27,944.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $26,132.21, add-ons for qualifying new technology services are included. If operating cost exceeds $61,003.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,661.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.8. The base transfer operating payment is the transfer adjustment factor * $24,098.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $24,187.26 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,901.60. The transfer capital threshold is the transfer adjustment factor * $1,901.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,27944.96,86252.84,Inpatient DRG
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],30963.45,,"Case rate ($17,693.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,595.40, add-ons for qualifying new technology services are included. If operating cost exceeds $51,466.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,911.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $14,596.63 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,650.45 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,151.82. The transfer capital threshold is the transfer adjustment factor * $1,151.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,17693.40,52449.26,All Other Inpatient
Chemodenervation Internal Anal Sphincter,CASE-46505,APC,46505,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],2689.02,,"APC Price ($2,598.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2598.08,2727.99,OPPS APC
Hysteroscopy Removal Leiomyomata,CASE-58561,APC,58561,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],4916.53,,"APC Price ($4,682.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,4682.41,4916.53,OPPS APC
Dstr Nrolytc Agnt Parverteb Fct Addl Crvcl/Thora|RIGHT SIDE,CASE-64634,APC,64634,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1919.19,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1891.77,1919.19,OPPS APC
"RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT > 96 HOURS,MAJOR",130,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],45448.49,,"Case rate ($45,448.49). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,45448.49,47720.91,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,689,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],9802.58,,"Case rate ($9,802.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,254.74, add-ons for qualifying new technology services are included. If operating cost exceeds $44,125.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,334.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $7,282.94 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,309.79 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $574.70. The transfer capital threshold is the transfer adjustment factor * $574.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9802.58,22831.22,Inpatient DRG
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],38757.79,,,,,,0,other,15283.90,38757.79,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,689,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],9802.58,,"Case rate ($9,802.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,254.74, add-ons for qualifying new technology services are included. If operating cost exceeds $44,125.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,334.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $7,282.94 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,309.79 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $574.70. The transfer capital threshold is the transfer adjustment factor * $574.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9802.58,22831.22,Inpatient DRG
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],30245.71,,"Fee schedule rate ($30,245.71). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9151.11,30245.71,There are no additional notes associated with this service or procedure.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],11468.70,,"Case rate ($10,922.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,313.38, add-ons for qualifying new technology services are included. If operating cost exceeds $45,184.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,400.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $8,336.82 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,368.43 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $640.79. The transfer capital threshold is the transfer adjustment factor * $640.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,11194.25,36094.03,Inpatient DRG
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC",494,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],39481.90,,,,,,0,other,15533.10,39945.55,There are no additional notes associated with this service or procedure.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],39820.52,,"Fee schedule rate ($39,820.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,15273.74,39820.52,There are no additional notes associated with this service or procedure.
CERVICAL SPINAL FUSION WITH CC,472,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],38318.23,,"Case rate ($21,896.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,505.12, add-ons for qualifying new technology services are included. If operating cost exceeds $55,376.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,219.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $18,491.99 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,560.18 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,459.20. The transfer capital threshold is the transfer adjustment factor * $1,459.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,21896.13,70198.84,All Other Inpatient
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],23870.71,,"Fee schedule rate ($23,870.71). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10626.74,25225.91,There are no additional notes associated with this service or procedure.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],23691.11,,,,,,0,other,10098.51,24259.09,There are no additional notes associated with this service or procedure.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],36434.36,,"Case rate ($35,719.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $33,365.14, add-ons for qualifying new technology services are included. If operating cost exceeds $68,236.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,230.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.9. The base transfer operating payment is the transfer adjustment factor * $31,304.77 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $31,420.19 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,470.26. The transfer capital threshold is the transfer adjustment factor * $2,470.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,35719.96,105091.76,Inpatient DRG
HEADACHES WITHOUT MCC,103,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],16455.88,,,,,,0,other,6965.00,20883.08,There are no additional notes associated with this service or procedure.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC",442,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],19011.92,,,,,,0,other,6607.45,19011.92,There are no additional notes associated with this service or procedure.
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],31477.13,,"Fee schedule rate ($31,477.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9648.19,31477.13,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],25609.86,,"Fee schedule rate ($25,609.86). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,12775.53,31469.43,There are no additional notes associated with this service or procedure.
DIABETES WITH CC,638,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],16842.29,,"Fee schedule rate ($16,842.29). Adds an outlier to normal pricing equal to the per diem rate ($39,561.63) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,8014.07,17634.53,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],33910.82,,"Case rate ($32,296.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $30,179.91, add-ons for qualifying new technology services are included. If operating cost exceeds $65,050.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,979.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $28,131.23 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $28,234.95 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,219.83. The transfer capital threshold is the transfer adjustment factor * $2,219.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,32296.02,88188.38,Inpatient DRG
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],36875.62,,"Fee schedule rate ($36,875.62). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.7), with a minimum of zero.",,,,0,other,15233.11,38610.21,There are no additional notes associated with this service or procedure.
HYPERTENSION WITHOUT MCC,305,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],7058.55,,"Case rate ($7,058.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,702.02, add-ons for qualifying new technology services are included. If operating cost exceeds $41,573.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,133.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,739.59 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,757.07 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $374.00. The transfer capital threshold is the transfer adjustment factor * $374.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7058.55,17230.49,Inpatient DRG
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,085,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],18196.93,,"Case rate ($17,330.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,257.72, add-ons for qualifying new technology services are included. If operating cost exceeds $51,128.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,885.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $14,260.20 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,312.77 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,125.27. The transfer capital threshold is the transfer adjustment factor * $1,125.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9282.00,57443.16,Inpatient DRG
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],58320.32,,"Fee schedule rate ($58,320.32). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,16286.16,58320.32,There are no additional notes associated with this service or procedure.
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],18245.94,,"Fee schedule rate ($18,245.94). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8106.18,18245.94,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],12990.19,,"Case rate ($12,990.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,220.11, add-ons for qualifying new technology services are included. If operating cost exceeds $47,091.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,567.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $10,237.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,275.16 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $807.83. The transfer capital threshold is the transfer adjustment factor * $807.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9888.00,43399.23,Inpatient DRG
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],19458.27,,"Fee schedule rate ($19,458.27). Adds an outlier to normal pricing equal to the per diem rate ($75,355.48) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,8956.76,28983.97,There are no additional notes associated with this service or procedure.
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC",514,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],22699.91,,"Fee schedule rate ($22,699.91). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8868.04,22699.91,There are no additional notes associated with this service or procedure.
NERVOUS SYSTEM NEOPLASMS WITH MCC,054,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],6965.00,,,,,,0,other,6965.00,30044.81,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,083,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],28680.85,,"Fee schedule rate ($28,680.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,28680.85,There are no additional notes associated with this service or procedure.
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],54180.83,,"Fee schedule rate ($54,180.83). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,15491.11,54180.83,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,064,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],16341.76,,"Case rate ($15,563.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,614.08, add-ons for qualifying new technology services are included. If operating cost exceeds $49,485.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,756.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $12,622.59 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,669.13 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $996.05. The transfer capital threshold is the transfer adjustment factor * $996.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,15563.58,41838.16,Inpatient DRG
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],17898.30,,"Fee schedule rate ($17,898.30). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,32293.66,There are no additional notes associated with this service or procedure.
Sigmoidoscopy Flx Dx W/Collj Spec Br/Wa if Pfrmd,CASE-45330,APC,45330,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],870.46,,"APC Price ($870.46). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,870.46,913.99,OPPS APC
NERVOUS SYSTEM NEOPLASMS WITH MCC,054,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],25589.03,,"Fee schedule rate ($25,589.03). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,6965.00,30044.81,There are no additional notes associated with this service or procedure.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],45050.58,,"Fee schedule rate ($45,050.58). Adds an outlier to normal pricing equal to the per diem rate ($120,238.99) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,18178.96,54764.34,There are no additional notes associated with this service or procedure.
UNGROUPABLE,999,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],161307.29,,"Fee schedule rate ($161,307.29). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (41), with a minimum of zero.",,,,0,other,10228.00,161307.29,There are no additional notes associated with this service or procedure.
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],8057.43,,"Case rate ($8,057.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,631.26, add-ons for qualifying new technology services are included. If operating cost exceeds $42,502.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,207.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,665.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,686.30 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $447.06. The transfer capital threshold is the transfer adjustment factor * $447.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6524.00,17760.46,Inpatient DRG
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],8354.35,,"Case rate ($7,956.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,537.38, add-ons for qualifying new technology services are included. If operating cost exceeds $42,408.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,199.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,571.89 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,592.43 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $439.68. The transfer capital threshold is the transfer adjustment factor * $439.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,17467.27,Inpatient DRG
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,479,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],27999.30,,"Fee schedule rate ($27,999.30). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,10586.00,50518.76,There are no additional notes associated with this service or procedure.
CERVICAL SPINAL FUSION WITH MCC,471,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],34645.26,,"Case rate ($34,645.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $32,365.35, add-ons for qualifying new technology services are included. If operating cost exceeds $67,236.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,151.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $30,308.64 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $30,420.39 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,391.65. The transfer capital threshold is the transfer adjustment factor * $2,391.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,34645.26,111337.93,Inpatient DRG
HC Inj Tendon Sheath/Ligament|PBB CHARGE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-20550,APC,20550,CPT,0510,RC,,,PBB|XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],301.68,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,287.31,301.68,OPPS APC
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],12972.28,,"Case rate ($7,412.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,031.50, add-ons for qualifying new technology services are included. If operating cost exceeds $41,902.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,159.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $5,067.86 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,086.55 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $399.90. The transfer capital threshold is the transfer adjustment factor * $399.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,6148.93,15887.21,All Other Inpatient
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],16235.87,,"Fee schedule rate ($16,235.87). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6524.00,17760.46,There are no additional notes associated with this service or procedure.
Lamnotmy Incl W/Dcmprsn Nrv Root 1 Intrspc Lumbr|LEFT SIDE|SEPARATE STRUCTURE,CASE-63030,APC,63030,CPT,0360,RC,,,LT|XS,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC,858,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],33794.11,,"Fee schedule rate ($33,794.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11377.76,33794.11,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,093,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],7337.55,,"Case rate ($7,337.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,961.57, add-ons for qualifying new technology services are included. If operating cost exceeds $41,832.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,154.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,998.19 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,016.62 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $394.41. The transfer capital threshold is the transfer adjustment factor * $394.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,19011.32,Inpatient DRG
"Open Tx Phalangeal Shaft Fracture Prox/Middle Ea|LEFT HAND, THIRD DIGIT",CASE-26735,APC,26735,CPT,0360,RC,,,F2,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,337,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],38926.31,,"Fee schedule rate ($38,926.31). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,12340.08,38926.31,There are no additional notes associated with this service or procedure.
CERVICAL SPINAL FUSION WITH MCC,471,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],36377.52,,"Case rate ($34,645.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $32,365.35, add-ons for qualifying new technology services are included. If operating cost exceeds $67,236.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,151.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $30,308.64 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $30,420.39 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,391.65. The transfer capital threshold is the transfer adjustment factor * $2,391.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,34645.26,111337.93,Inpatient DRG
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],13092.47,,"Case rate ($13,092.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,315.24, add-ons for qualifying new technology services are included. If operating cost exceeds $47,186.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,575.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $10,332.19 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,370.29 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $815.31. The transfer capital threshold is the transfer adjustment factor * $815.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,13092.47,33159.45,Inpatient DRG
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],53152.12,,"Fee schedule rate ($53,152.12). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,19152.11,53152.12,There are no additional notes associated with this service or procedure.
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],12974.62,,"Case rate ($7,414.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,032.76, add-ons for qualifying new technology services are included. If operating cost exceeds $41,903.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,159.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,069.12 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,087.81 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $400.00. The transfer capital threshold is the transfer adjustment factor * $400.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,7414.07,18217.52,All Other Inpatient
Ercp W/Biopsy Single/Multiple|UNUSUAL NON-OVERLAPPING SERVICE,CASE-43261,APC,43261,CPT,0360,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5682.51,,"APC Price ($5,682.51). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5682.51,5966.63,OPPS APC
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],8117.25,,"Case rate ($7,842.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,431.55, add-ons for qualifying new technology services are included. If operating cost exceeds $42,302.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,191.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $5,466.44 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,486.60 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $431.36. The transfer capital threshold is the transfer adjustment factor * $431.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,5280.00,17136.70,Inpatient DRG
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],8571.21,,"Case rate ($8,163.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,729.53, add-ons for qualifying new technology services are included. If operating cost exceeds $42,600.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,214.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,763.33 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,784.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $454.78. The transfer capital threshold is the transfer adjustment factor * $454.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8163.06,18067.42,Inpatient DRG
BRONCHITIS AND ASTHMA WITHOUT CC/MCC,203,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],6046.34,,"Case rate ($5,927.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $5,614.23, add-ons for qualifying new technology services are included. If operating cost exceeds $44,258.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $3,061.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,235.54 + an uncompensated DSH payment of $1,359.91. The transfer operating threshold is the transfer adjustment factor * $4,254.32 + an uncompensated DSH payment of $1,359.91. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $332.34. The transfer capital threshold is the transfer adjustment factor * $332.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,4763.76,13707.00,Inpatient DRG
Removal Intact Breast Implant|BILATERAL PROCEDURE,CASE-19328,APC,19328,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6215.36,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6215.36,6215.36,OPPS APC
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],12642.79,,"Case rate ($7,224.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,856.36, add-ons for qualifying new technology services are included. If operating cost exceeds $41,727.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,146.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $4,893.37 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,911.41 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $386.14. The transfer capital threshold is the transfer adjustment factor * $386.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,6965.00,15340.19,All Other Inpatient
INFLAMMATORY BOWEL DISEASE WITH MCC,385,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],13293.42,,"Case rate ($12,660.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,913.31, add-ons for qualifying new technology services are included. If operating cost exceeds $46,784.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,543.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $9,931.73 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,968.35 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $783.71. The transfer capital threshold is the transfer adjustment factor * $783.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,11480.01,31134.92,Inpatient DRG
SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS,029,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],25048.54,,"Case rate ($25,048.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $23,437.73, add-ons for qualifying new technology services are included. If operating cost exceeds $58,308.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,449.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.7)) / 2. The base transfer operating payment is the transfer adjustment factor * $21,413.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $21,492.79 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,689.76. The transfer capital threshold is the transfer adjustment factor * $1,689.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,13641.00,67130.05,Inpatient DRG
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],29594.00,,"Fee schedule rate ($29,594.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,13571.25,33781.47,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITH CC,386,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],18347.61,,"Fee schedule rate ($18,347.61). Adds an outlier to normal pricing equal to the per diem rate ($111,650.51) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8556.53,19879.00,There are no additional notes associated with this service or procedure.
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],21089.59,,"Fee schedule rate ($21,089.59). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,6965.00,21089.59,There are no additional notes associated with this service or procedure.
Egd Endoscopic Stent Placement W/Wire& Dilation,CASE-43266,APC,43266,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5966.63,,"APC Price ($5,682.51). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5682.51,5966.63,OPPS APC
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC,833,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],5760.37,,"Case rate ($5,486.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,239.18, add-ons for qualifying new technology services are included. If operating cost exceeds $40,110.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,018.96, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $3,282.12 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,294.23 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $258.99. The transfer capital threshold is the transfer adjustment factor * $258.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,3041.73,10289.10,Inpatient DRG
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],16048.10,,"Case rate ($15,283.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,353.89, add-ons for qualifying new technology services are included. If operating cost exceeds $49,224.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,735.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.2. The base transfer operating payment is the transfer adjustment factor * $12,363.36 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,408.94 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $975.59. The transfer capital threshold is the transfer adjustment factor * $975.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,15283.90,38757.79,Inpatient DRG
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],60646.89,,"Fee schedule rate ($60,646.89). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15.6), with a minimum of zero.",,,,0,other,23799.09,63499.65,There are no additional notes associated with this service or procedure.
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],17150.47,,,,,,0,other,7847.50,17755.26,There are no additional notes associated with this service or procedure.
NEONATE WITH OTHER SIGNIFICANT PROBLEMS,794,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],3383.58,,"Fee schedule rate ($3,383.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,1798.85,12536.83,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6122.64,,"Case rate ($6,122.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,831.37, add-ons for qualifying new technology services are included. If operating cost exceeds $40,702.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,065.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $3,872.14 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,886.42 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $305.55. The transfer capital threshold is the transfer adjustment factor * $305.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,1188.00,12138.74,Inpatient DRG
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,329,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],90445.33,,,,,,0,other,33072.77,90445.33,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],28423.20,,"Fee schedule rate ($28,423.20). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11059.47,28423.20,There are no additional notes associated with this service or procedure.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],10451.96,,"Case rate ($10,098.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,530.04, add-ons for qualifying new technology services are included. If operating cost exceeds $44,401.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,356.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $7,557.23 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,585.10 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $596.34. The transfer capital threshold is the transfer adjustment factor * $596.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,10098.51,24259.09,Inpatient DRG
"ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",770,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],17800.73,,"Fee schedule rate ($17,800.73). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,8735.30,19730.13,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],81353.66,,"Fee schedule rate ($81,353.66). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,27256.92,81353.66,There are no additional notes associated with this service or procedure.
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],8739.43,,"Fee schedule rate ($8,739.43). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7402.56,16438.59,There are no additional notes associated with this service or procedure.
HC Joint Injection/Aspir Large WO US|DISTINCT PROCEDURAL SERVICE|RIGHT SIDE|PBB CHARGE,CASE-20610,APC,20610,CPT,0510,RC,,,59|RT|PBB,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],301.68,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,287.31,301.68,OPPS APC
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],37899.49,,"Fee schedule rate ($37,899.49). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,14747.55,37899.49,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],12543.25,,"Case rate ($11,945.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,248.66, add-ons for qualifying new technology services are included. If operating cost exceeds $46,119.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,491.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $9,269.54 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,303.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $731.46. The transfer capital threshold is the transfer adjustment factor * $731.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6167.00,29058.99,Inpatient DRG
INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,352,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],26528.70,,"Fee schedule rate ($26,528.70). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,9853.37,26528.70,There are no additional notes associated with this service or procedure.
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],6277.00,,"Per diem ($6,277). If length of stay < 5.6, first 1 days paid at a per diem of $12,554 instead. Capped at $35,148.55.",,,,0,other,6277.00,36801.89,Estimated amount calculated based on 4 day length of stay.
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],54180.83,,"Fee schedule rate ($54,180.83). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,15491.11,54180.83,There are no additional notes associated with this service or procedure.
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],33835.79,,"Fee schedule rate ($33,835.79). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,7000.00,33835.79,There are no additional notes associated with this service or procedure.
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH MCC",722,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],56869.13,,"Fee schedule rate ($56,869.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,14200.37,56869.13,There are no additional notes associated with this service or procedure.
FRACTURES OF FEMUR WITH MCC,533,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],49490.05,,"Fee schedule rate ($49,490.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,6852.00,49490.05,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],62084.69,,"Fee schedule rate ($62,084.69). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (35), with a minimum of zero.",,,,0,other,30398.48,82674.88,There are no additional notes associated with this service or procedure.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,270,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],34720.90,,"Case rate ($34,720.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $32,431.98, add-ons for qualifying new technology services are included. If operating cost exceeds $71,076.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $5,156.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.4. The base transfer operating payment is the transfer adjustment factor * $30,933.64 + an uncompensated DSH payment of $1,359.91. The transfer operating threshold is the transfer adjustment factor * $31,072.08 + an uncompensated DSH payment of $1,359.91. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,427.36. The transfer capital threshold is the transfer adjustment factor * $2,427.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,34720.90,101002.04,Inpatient DRG
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],16129.04,,"Case rate ($16,129.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,140.12, add-ons for qualifying new technology services are included. If operating cost exceeds $50,011.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,797.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $13,146.70 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,195.17 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,037.40. The transfer capital threshold is the transfer adjustment factor * $1,037.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,16129.04,59610.47,Inpatient DRG
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",063,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],6965.00,,,,,,0,other,6965.00,35701.87,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],28983.97,,"Fee schedule rate ($28,983.97). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8956.76,28983.97,There are no additional notes associated with this service or procedure.
"ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",770,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],18843.74,,"Fee schedule rate ($18,843.74). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,8735.30,19730.13,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITH STERILIZATION WITH CC,784,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],9580.21,,"Case rate ($9,124.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,623.49, add-ons for qualifying new technology services are included. If operating cost exceeds $43,494.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,285.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,654.00 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,678.54 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $525.07. The transfer capital threshold is the transfer adjustment factor * $525.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9124.01,23722.94,Inpatient DRG
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],9635.31,,"Case rate ($9,446.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,923.36, add-ons for qualifying new technology services are included. If operating cost exceeds $43,794.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,308.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,952.78 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,978.41 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $548.64. The transfer capital threshold is the transfer adjustment factor * $548.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,9446.38,21796.21,Inpatient DRG
Laps Surg Rpr Recurrent Inguinal Hernia|RIGHT SIDE,CASE-49651,APC,49651,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5941.70,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5658.76,5941.70,OPPS APC
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],29342.21,,"Case rate ($27,944.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $26,132.21, add-ons for qualifying new technology services are included. If operating cost exceeds $61,003.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,661.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.8. The base transfer operating payment is the transfer adjustment factor * $24,098.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $24,187.26 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,901.60. The transfer capital threshold is the transfer adjustment factor * $1,901.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,27944.96,86252.84,Inpatient DRG
Cysto W/Removal of Lesions Small,CASE-52224,APC,52224,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3414.95,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3299.47,3464.44,OPPS APC
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],24838.71,,"Fee schedule rate ($24,838.71). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,10895.60,35192.25,There are no additional notes associated with this service or procedure.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],21013.21,,"Case rate ($20,012.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $18,786.59, add-ons for qualifying new technology services are included. If operating cost exceeds $53,657.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,049.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $16,778.03 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $16,841.64 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,289.60. The transfer capital threshold is the transfer adjustment factor * $1,289.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,20559.34,54086.17,Inpatient DRG
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],14329.44,,"Case rate ($13,647.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,831.20, add-ons for qualifying new technology services are included. If operating cost exceeds $47,702.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,615.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $10,846.26 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,886.25 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $855.88. The transfer capital threshold is the transfer adjustment factor * $855.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7921.00,45706.73,Inpatient DRG
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],16484.76,,"Fee schedule rate ($16,484.76). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,16120.25,41187.90,There are no additional notes associated with this service or procedure.
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],22382.59,,,,,,0,other,9648.19,31477.13,There are no additional notes associated with this service or procedure.
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],10485.30,,"Fee schedule rate ($10,485.30). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9282.47,21320.03,There are no additional notes associated with this service or procedure.
NORMAL NEWBORN,795,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3298.01,,"Case rate ($3,298.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $3,203.67, add-ons for qualifying new technology services are included. If operating cost exceeds $38,074.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $1,858.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $1,254.10 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $1,258.72 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $98.96. The transfer capital threshold is the transfer adjustment factor * $98.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,1369.79,5771.52,Inpatient DRG
Rpr 1st Ingun Hrna Age 5 Yrs/> Reducible|RIGHT SIDE,CASE-49505,APC,49505,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3518.91,,"APC Price ($3,351.34). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3351.34,3518.91,OPPS APC
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6503.90,,"Case rate ($6,503.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,186.05, add-ons for qualifying new technology services are included. If operating cost exceeds $41,057.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,093.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $4,225.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,241.10 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $333.44. The transfer capital threshold is the transfer adjustment factor * $333.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6503.90,14492.93,Inpatient DRG
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],39424.57,,"Fee schedule rate ($39,424.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12195.15,39424.57,There are no additional notes associated with this service or procedure.
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],7261.42,,"Case rate ($6,915.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,569.08, add-ons for qualifying new technology services are included. If operating cost exceeds $41,440.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,123.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,607.15 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,624.14 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $363.55. The transfer capital threshold is the transfer adjustment factor * $363.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6915.64,14442.92,Inpatient DRG
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],31577.54,,"Fee schedule rate ($31,577.54). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,15453.88,39251.68,There are no additional notes associated with this service or procedure.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],12696.97,,"Case rate ($12,696.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,947.32, add-ons for qualifying new technology services are included. If operating cost exceeds $46,818.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,546.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,965.63 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,002.37 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $786.39. The transfer capital threshold is the transfer adjustment factor * $786.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12696.97,47123.82,Inpatient DRG
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC,520,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],12061.74,,"Case rate ($12,061.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,356.39, add-ons for qualifying new technology services are included. If operating cost exceeds $46,227.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,499.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $9,376.87 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,411.44 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $739.93. The transfer capital threshold is the transfer adjustment factor * $739.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12061.74,39786.42,Inpatient DRG
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],15484.93,,"Case rate ($14,747.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,854.94, add-ons for qualifying new technology services are included. If operating cost exceeds $48,725.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,696.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $11,866.24 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,909.99 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $936.36. The transfer capital threshold is the transfer adjustment factor * $936.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,14747.55,37899.49,Inpatient DRG
Excision Inferior Turbinate Partial/Complete|BILATERAL PROCEDURE,CASE-30130,APC,30130,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.35,,"APC Price ($3,103.35). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.35,3103.35,OPPS APC
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],48538.56,,"Fee schedule rate ($48,538.56). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,19435.86,50821.76,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC,087,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],17189.96,,"Fee schedule rate ($17,189.96). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,8139.36,22679.07,There are no additional notes associated with this service or procedure.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],19877.10,,"Fee schedule rate ($19,877.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8009.34,19877.10,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],67794.72,,"Fee schedule rate ($67,794.72). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,10862.00,86437.13,There are no additional notes associated with this service or procedure.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITHOUT CC/MCC,816,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6442.77,,"Case rate ($6,224.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,926.50, add-ons for qualifying new technology services are included. If operating cost exceeds $40,797.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,073.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $3,966.92 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,981.55 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $313.03. The transfer capital threshold is the transfer adjustment factor * $313.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6224.90,14733.53,Inpatient DRG
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],45017.13,,"Fee schedule rate ($45,017.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,14603.31,45017.13,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],62084.69,,"Fee schedule rate ($62,084.69). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (35), with a minimum of zero.",,,,0,other,30398.48,82674.88,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],14839.66,,"Case rate ($14,337.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,473.80, add-ons for qualifying new technology services are included. If operating cost exceeds $48,344.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,666.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $11,486.49 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,528.84 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $906.40. The transfer capital threshold is the transfer adjustment factor * $906.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,14337.84,52803.53,Inpatient DRG
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],35528.17,,"Fee schedule rate ($35,528.17). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,14747.55,37899.49,There are no additional notes associated with this service or procedure.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,098,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],18360.48,,"Case rate ($17,486.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,402.62, add-ons for qualifying new technology services are included. If operating cost exceeds $51,273.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,896.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $14,404.56 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,457.67 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,136.66. The transfer capital threshold is the transfer adjustment factor * $1,136.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,45156.75,Inpatient DRG
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],26966.33,,"Fee schedule rate ($26,966.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,9040.72,26966.33,There are no additional notes associated with this service or procedure.
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],57872.02,,,,,,0,other,7086.00,57872.02,There are no additional notes associated with this service or procedure.
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],7176.11,,"Case rate ($6,834.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,493.49, add-ons for qualifying new technology services are included. If operating cost exceeds $41,364.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,117.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $4,531.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,548.54 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $357.61. The transfer capital threshold is the transfer adjustment factor * $357.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6834.39,21354.82,Inpatient DRG
CESAREAN SECTION WITHOUT STERILIZATION WITH CC,787,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],9508.01,,"Case rate ($9,508.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,980.70, add-ons for qualifying new technology services are included. If operating cost exceeds $43,851.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,313.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $7,009.90 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,035.74 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $553.15. The transfer capital threshold is the transfer adjustment factor * $553.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9508.01,23722.94,Inpatient DRG
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH CC,427,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],134742.59,,"Fee schedule rate ($134,742.59). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,50829.82,142040.39,There are no additional notes associated with this service or procedure.
Rpr/Advmnt Flxr Tdn Zone 2 W/O Fr Grft Ea Tendon,CASE-26356,APC,26356,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],9918.70,,"Case rate ($9,446.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,923.36, add-ons for qualifying new technology services are included. If operating cost exceeds $43,794.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,308.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,952.78 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,978.41 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $548.64. The transfer capital threshold is the transfer adjustment factor * $548.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9446.38,21796.21,Inpatient DRG
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],87909.90,,"Fee schedule rate ($87,909.90). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,33623.33,133270.57,There are no additional notes associated with this service or procedure.
HEADACHES WITHOUT MCC,103,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],20883.08,,"Fee schedule rate ($20,883.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,20883.08,There are no additional notes associated with this service or procedure.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],59521.43,,"Fee schedule rate ($59,521.43). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,16689.78,59521.43,There are no additional notes associated with this service or procedure.
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],19010.30,,"Case rate ($18,105.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,008.50, add-ons for qualifying new technology services are included. If operating cost exceeds $51,879.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,913.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $15,006.65 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,063.55 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,153.45. The transfer capital threshold is the transfer adjustment factor * $1,153.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,18594.09,59494.91,Inpatient DRG
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],6965.00,,,,,,0,other,6965.00,21089.59,There are no additional notes associated with this service or procedure.
FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,748,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],26805.98,,,,,,0,other,9316.20,26805.98,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITH MCC,385,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],21593.52,,"Fee schedule rate ($21,593.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11480.01,31134.92,There are no additional notes associated with this service or procedure.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,988,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],13729.30,,"Case rate ($13,075.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,299.49, add-ons for qualifying new technology services are included. If operating cost exceeds $47,170.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,574.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $10,316.50 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,354.54 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $814.07. The transfer capital threshold is the transfer adjustment factor * $814.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13075.52,42425.46,Inpatient DRG
HYPERTENSION WITHOUT MCC,305,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],7411.48,,"Case rate ($7,058.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,702.02, add-ons for qualifying new technology services are included. If operating cost exceeds $41,573.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,133.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,739.59 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,757.07 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $374.00. The transfer capital threshold is the transfer adjustment factor * $374.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7058.55,17230.49,Inpatient DRG
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],39361.94,,"Fee schedule rate ($39,361.94). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.8), with a minimum of zero.",,,,0,other,16129.04,59610.47,There are no additional notes associated with this service or procedure.
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH MCC",510,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],39199.98,,"Case rate ($22,399.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,973.84, add-ons for qualifying new technology services are included. If operating cost exceeds $55,844.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,256.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.3. The base transfer operating payment is the transfer adjustment factor * $18,958.99 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $19,028.89 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,496.05. The transfer capital threshold is the transfer adjustment factor * $1,496.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,10710.00,89863.76,All Other Inpatient
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],9302.19,,"Case rate ($8,859.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,377.16, add-ons for qualifying new technology services are included. If operating cost exceeds $43,248.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,265.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $6,408.58 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,432.21 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $505.70. The transfer capital threshold is the transfer adjustment factor * $505.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8859.23,20090.22,Inpatient DRG
Laps Fulg/Exc Ovary Viscera/Peritoneal Surface|LEFT SIDE,CASE-58662,APC,58662,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5941.70,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5658.76,5941.70,OPPS APC
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],39797.94,,"Fee schedule rate ($39,797.94). Adds an outlier to normal pricing equal to the per diem rate ($75,578.79) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.5), with a minimum of zero.",,,,0,other,16286.16,58320.32,There are no additional notes associated with this service or procedure.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,477,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],62359.39,,"Fee schedule rate ($62,359.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,25339.74,67976.16,There are no additional notes associated with this service or procedure.
"CHRONIC OBSTRUCTIVE PULMONARY DISEASE,MAJOR",140,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],9390.55,,"Case rate ($9,390.55). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,9390.55,9860.08,There are no additional notes associated with this service or procedure.
Arthrs Knee W/Meniscectomy Med&Lat W/Shaving|RIGHT SIDE,CASE-29880,APC,29880,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
HEART FAILURE AND SHOCK WITH CC,292,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],7694.43,,"Case rate ($7,694.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,293.57, add-ons for qualifying new technology services are included. If operating cost exceeds $42,164.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,180.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,328.98 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,348.63 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $420.51. The transfer capital threshold is the transfer adjustment factor * $420.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,5502.00,16705.77,Inpatient DRG
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],39797.94,,"Fee schedule rate ($39,797.94). Adds an outlier to normal pricing equal to the per diem rate ($75,578.79) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.5), with a minimum of zero.",,,,0,other,16286.16,58320.32,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITHOUT STERILIZATION WITH MCC,786,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],13115.49,,"Case rate ($13,115.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,336.66, add-ons for qualifying new technology services are included. If operating cost exceeds $47,207.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,576.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $10,353.53 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,391.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $817.00. The transfer capital threshold is the transfer adjustment factor * $817.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12612.10,23722.94,Inpatient DRG
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],37199.37,,,,,,0,other,14747.55,37899.49,There are no additional notes associated with this service or procedure.
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],16804.22,,"Fee schedule rate ($16,804.22). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7238.69,16804.22,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],8023.69,,"Case rate ($7,641.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,244.44, add-ons for qualifying new technology services are included. If operating cost exceeds $42,115.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,176.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,280.02 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,299.49 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $416.65. The transfer capital threshold is the transfer adjustment factor * $416.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7641.61,19371.27,Inpatient DRG
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,448,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],94077.13,,"Fee schedule rate ($94,077.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,30663.95,94077.13,There are no additional notes associated with this service or procedure.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],105091.76,,"Fee schedule rate ($105,091.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,35719.96,105091.76,There are no additional notes associated with this service or procedure.
Exc B9 Lesion Mrgn Xcp Sk Tg T/a/L 0.6-1.0 Cm,CASE-11401,APC,11401,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],393.83,,"APC Price ($380.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,380.51,399.53,OPPS APC
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],45144.75,,"Fee schedule rate ($45,144.75). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,10078.00,81454.07,There are no additional notes associated with this service or procedure.
Rpr 1st Ingun Hrna Age 5 Yrs/> Reducible|LEFT SIDE,CASE-49505,APC,49505,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3468.64,,"APC Price ($3,351.34). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3351.34,3518.91,OPPS APC
HC Trigger Point 3 or More,CASE-20553,APC,20553,CPT,0510,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],287.31,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
HC Gastric Procedure Unlisted,CASE-43999,APC,43999,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],848.96,,"APC Price ($848.96). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,848.96,891.41,OPPS APC
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],42021.93,,"Fee schedule rate ($42,021.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,21248.73,56089.29,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],22805.37,,"Case rate ($21,719.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,340.70, add-ons for qualifying new technology services are included. If operating cost exceeds $55,211.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,206.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.2. The base transfer operating payment is the transfer adjustment factor * $18,328.17 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,395.75 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,446.27. The transfer capital threshold is the transfer adjustment factor * $1,446.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,21719.40,85305.59,Inpatient DRG
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],13341.67,,"Case rate ($13,341.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,547.08, add-ons for qualifying new technology services are included. If operating cost exceeds $47,418.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,593.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $10,563.18 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,602.13 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $833.54. The transfer capital threshold is the transfer adjustment factor * $833.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,13341.67,42586.49,Inpatient DRG
CHEST PAIN,313,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],15377.66,,"Fee schedule rate ($15,377.66). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,6820.84,15377.66,There are no additional notes associated with this service or procedure.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],133270.57,,"Fee schedule rate ($133,270.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,33623.33,133270.57,There are no additional notes associated with this service or procedure.
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],37488.28,,"Fee schedule rate ($37,488.28). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.5), with a minimum of zero.",,,,0,other,15453.88,39251.68,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,086,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],11143.76,,"Case rate ($10,766.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,151.85, add-ons for qualifying new technology services are included. If operating cost exceeds $45,022.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,405.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $8,176.75 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,206.90 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $645.23. The transfer capital threshold is the transfer adjustment factor * $645.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,8442.00,30728.81,Inpatient DRG
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,329,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],86382.02,,"Fee schedule rate ($86,382.02). Adds an outlier to normal pricing equal to the per diem rate ($147,722.18) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,33072.77,90445.33,There are no additional notes associated with this service or procedure.
Autograft Spine Surgery Local From Same Incision,CASE-20936,APC,20936,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],17232.68,,"APC Price ($16,412.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,16412.07,17232.68,OPPS APC
"LYMPHATIC AND OTHER MALIGNANCIES AND NEOPLASMS OF UNCERTAIN BEHAVIOR,MODERATE",694,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],2179.51,,"Case rate for a one day stay ($2,075.72). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,2075.72,2179.51,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],18092.36,,"Case rate ($17,230.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,193.59, add-ons for qualifying new technology services are included. If operating cost exceeds $51,064.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,851.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $14,194.82 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,248.64 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,091.05. The transfer capital threshold is the transfer adjustment factor * $1,091.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,17693.40,52449.26,Inpatient DRG
Sigmoidoscopy Flx Dx W/Collj Spec Br/Wa if Pfrmd|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-45330,APC,45330,CPT,0360,RC,,,74,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],870.46,,"APC Price ($870.46). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,870.46,913.99,OPPS APC
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,394,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],20909.61,,"Fee schedule rate ($20,909.61). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8281.56,20909.61,There are no additional notes associated with this service or procedure.
Esophagogastroduodenoscopy Submucosal Injection|UNUSUAL NON-OVERLAPPING SERVICE,CASE-43236,APC,43236,CPT,0360,RC,,,XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],878.67,,"APC Price ($848.96). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,848.96,891.41,OPPS APC
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],25013.10,,"Fee schedule rate ($25,013.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10846.16,25863.45,There are no additional notes associated with this service or procedure.
"VAGINAL DELIVERY,MODERATE",560,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],4318.66,,"Case rate ($4,318.66). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,4318.66,4534.59,There are no additional notes associated with this service or procedure.
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],10503.90,,"Case rate ($10,003.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,441.84, add-ons for qualifying new technology services are included. If operating cost exceeds $44,312.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,349.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $7,469.36 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,496.90 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $589.41. The transfer capital threshold is the transfer adjustment factor * $589.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10003.71,23415.63,Inpatient DRG
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],52794.06,,"Fee schedule rate ($52,794.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (37), with a minimum of zero.",,,,0,other,13907.80,52794.06,There are no additional notes associated with this service or procedure.
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],15961.98,,,,,,0,other,7438.45,15961.98,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],27839.09,,"Case rate ($26,513.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $24,846.32, add-ons for qualifying new technology services are included. If operating cost exceeds $59,717.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,513.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. The base transfer operating payment is the transfer adjustment factor * $22,814.87 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $22,901.37 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,753.60. The transfer capital threshold is the transfer adjustment factor * $1,753.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,27256.92,81353.66,Inpatient DRG
"CESAREAN SECTION WITH STERILIZATION,MODERATE",539,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],7813.94,,"Case rate ($7,813.94). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,7813.94,8204.64,There are no additional notes associated with this service or procedure.
"ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",770,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],17800.73,,"Fee schedule rate ($17,800.73). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,8735.30,19730.13,There are no additional notes associated with this service or procedure.
ENDOCRINE DISORDERS WITH CC,644,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],8237.82,,"Case rate ($8,076.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $7,615.48, add-ons for qualifying new technology services are included. If operating cost exceeds $46,260.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $3,217.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $6,227.71 + an uncompensated DSH payment of $1,359.91. The transfer operating threshold is the transfer adjustment factor * $6,255.58 + an uncompensated DSH payment of $1,359.91. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $488.69. The transfer capital threshold is the transfer adjustment factor * $488.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,7066.99,20334.21,Inpatient DRG
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],48094.52,,,,,,0,other,18497.24,62041.12,There are no additional notes associated with this service or procedure.
Arthroscopy Knee W/Meniscus Rpr Medial&Lateral|LEFT SIDE,CASE-29883,APC,29883,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],86235.79,,"Fee schedule rate ($86,235.79). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,32296.02,88188.38,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,373,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],7214.49,,"Case rate ($6,870.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,527.50, add-ons for qualifying new technology services are included. If operating cost exceeds $41,398.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,120.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $4,565.72 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,582.56 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $360.28. The transfer capital threshold is the transfer adjustment factor * $360.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6870.94,14313.05,Inpatient DRG
"LIMB REATTACHMENT, HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA",956,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],148259.86,,"Fee schedule rate ($148,259.86). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,27428.25,148259.86,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITHOUT STERILIZATION WITH CC,787,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],23722.94,,"Fee schedule rate ($23,722.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9508.01,23722.94,There are no additional notes associated with this service or procedure.
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|RIGHT HAND, THIRD DIGIT",CASE-26160,APC,26160,CPT,0360,RC,,,F7,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1505.12,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1505.12,1580.37,OPPS APC
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],14217.69,,"Case rate ($13,540.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,753.82, add-ons for qualifying new technology services are included. If operating cost exceeds $47,624.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,587.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $10,768.04 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,808.87 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $827.66. The transfer capital threshold is the transfer adjustment factor * $827.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13891.57,34712.20,Inpatient DRG
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC,434,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],13280.45,,"Fee schedule rate ($13,280.45). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6770.05,14019.86,There are no additional notes associated with this service or procedure.
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],48832.41,,,,,,0,other,8480.00,59081.91,There are no additional notes associated with this service or procedure.
"ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",770,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],17800.73,,"Fee schedule rate ($17,800.73). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,8735.30,19730.13,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],13260.40,,"Case rate ($13,260.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,471.48, add-ons for qualifying new technology services are included. If operating cost exceeds $47,342.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,587.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $10,487.86 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,526.53 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $827.60. The transfer capital threshold is the transfer adjustment factor * $827.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,13260.40,32878.30,Inpatient DRG
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],6965.00,,,,,,0,other,6965.00,36140.75,There are no additional notes associated with this service or procedure.
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],10474.41,,"Case rate ($10,120.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,550.21, add-ons for qualifying new technology services are included. If operating cost exceeds $44,421.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,357.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $7,577.32 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,605.26 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $597.93. The transfer capital threshold is the transfer adjustment factor * $597.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,10120.20,26204.74,Inpatient DRG
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],19435.86,,"Case rate ($19,435.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $18,216.37, add-ons for qualifying new technology services are included. If operating cost exceeds $53,087.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,039.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.9. The base transfer operating payment is the transfer adjustment factor * $16,211.64 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $16,271.42 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,279.26. The transfer capital threshold is the transfer adjustment factor * $1,279.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,19435.86,50821.76,Inpatient DRG
HC Perq Vert Agmntj Cavity Crtj Uni/Bi Cannulation,CASE-22513,APC,22513,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6791.99,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
"Suture Digital Nerve Hand/Foot 1 Nerve|RIGHT HAND, SECOND DIGIT",CASE-64831,APC,64831,CPT,0360,RC,,,F6,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC",494,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],39481.90,,,,,,0,other,15533.10,39945.55,There are no additional notes associated with this service or procedure.
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],33890.73,,"Fee schedule rate ($33,890.73). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6277.00,36801.89,There are no additional notes associated with this service or procedure.
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC,797,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],8719.72,,"Case rate ($8,719.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,247.38, add-ons for qualifying new technology services are included. If operating cost exceeds $43,118.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,255.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $6,279.28 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,302.43 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $495.50. The transfer capital threshold is the transfer adjustment factor * $495.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8719.72,20928.55,Inpatient DRG
Allograft for Spine Surgery Only Structural,CASE-20931,APC,20931,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],12017.31,,"APC Price ($12,017.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12017.31,12017.31,OPPS APC
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],20170.75,,"Fee schedule rate ($20,170.75). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10048.39,23545.50,There are no additional notes associated with this service or procedure.
Colonoscopy Flx Dx W/Collj Spec When Pfrmd|COLORECTAL CANCER SCREEN,CASE-45378,APC,45378,CPT,0360,RC,,,PT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],900.93,,"APC Price ($870.46). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,870.46,913.99,OPPS APC
"NEONATE BIRTH WEIGHT > 2499 GRAMS WITH OTHER SIGNIFICANT CONDITION,MODERATE",639,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],4769.28,,"Case rate ($4,769.28). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,4769.28,5007.74,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITH MCC,385,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12962.93,,"Case rate ($12,345.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,639.91, add-ons for qualifying new technology services are included. If operating cost exceeds $46,510.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,502.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $9,658.34 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,694.96 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $742.36. The transfer capital threshold is the transfer adjustment factor * $742.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,11480.01,31134.92,Inpatient DRG
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],7994.00,,"Per diem ($7,994). If length of stay < 1.7, first 1 days paid at a per diem of $15,988 instead. Capped at $13,589.22.",,,,0,other,6841.83,21167.26,Estimated amount calculated based on 1 day length of stay.
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],11945.95,,"Case rate ($11,945.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,248.66, add-ons for qualifying new technology services are included. If operating cost exceeds $46,119.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,491.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $9,269.54 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,303.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $731.46. The transfer capital threshold is the transfer adjustment factor * $731.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6167.00,29058.99,Inpatient DRG
CHEST PAIN,313,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],15377.66,,"Fee schedule rate ($15,377.66). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,6820.84,15377.66,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],11213.85,,"Case rate ($10,834.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,214.84, add-ons for qualifying new technology services are included. If operating cost exceeds $45,085.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,410.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $8,239.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,269.90 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $650.18. The transfer capital threshold is the transfer adjustment factor * $650.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,10834.64,25830.00,Inpatient DRG
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH CC,427,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],135659.15,,"Fee schedule rate ($135,659.15). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.8), with a minimum of zero.",,,,0,other,50829.82,142040.39,There are no additional notes associated with this service or procedure.
"Suture Digital Nerve Hand/Foot 1 Nerve|RIGHT HAND, SECOND DIGIT",CASE-64831,APC,64831,CPT,0360,RC,,,F6,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,450,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],146009.19,,"Fee schedule rate ($146,009.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,38037.38,146009.19,There are no additional notes associated with this service or procedure.
VAGINAL DELIVERY WITH O.R. PROCEDURES EXCEPT STERILIZATION AND/OR D&C,768,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],9385.94,,"Case rate ($9,201.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,695.94, add-ons for qualifying new technology services are included. If operating cost exceeds $43,566.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,290.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $6,726.19 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,750.99 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $530.76. The transfer capital threshold is the transfer adjustment factor * $530.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6426.91,13416.00,Inpatient DRG
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],13747.09,,"Case rate ($13,092.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,315.24, add-ons for qualifying new technology services are included. If operating cost exceeds $47,186.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,575.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $10,332.19 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,370.29 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $815.31. The transfer capital threshold is the transfer adjustment factor * $815.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13092.47,33159.45,Inpatient DRG
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,066,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],6711.36,,"Case rate ($6,579.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,256.61, add-ons for qualifying new technology services are included. If operating cost exceeds $41,127.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,098.96, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $4,295.82 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,311.66 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $338.98. The transfer capital threshold is the transfer adjustment factor * $338.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6579.76,20083.61,Inpatient DRG
Exc Rct Tum Incl Muscularis Propria,CASE-45172,APC,45172,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],2727.99,,"APC Price ($2,598.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2598.08,2727.99,OPPS APC
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],10327.22,,"Case rate ($9,977.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,417.91, add-ons for qualifying new technology services are included. If operating cost exceeds $44,288.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,347.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $7,445.51 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,472.96 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $587.52. The transfer capital threshold is the transfer adjustment factor * $587.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,9977.99,26949.28,Inpatient DRG
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],12272.58,,"Fee schedule rate ($12,272.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5628.97,12272.58,There are no additional notes associated with this service or procedure.
Unlisted Procedure Hemic or Lymphatic System,CASE-38999,APC,38999,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],12899.30,,"APC Price ($12,899.30). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12899.30,13544.27,OPPS APC
Ndsc Eval Intstinal Pouch Dx W/Collj Spec Spx,CASE-44385,APC,44385,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],900.93,,"APC Price ($870.46). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,870.46,913.99,OPPS APC
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],67107.92,,"Fee schedule rate ($67,107.92). Adds an outlier to normal pricing equal to the per diem rate ($118,521.29) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16.7), with a minimum of zero.",,,,0,other,26127.34,90333.60,There are no additional notes associated with this service or procedure.
Biopsy Floor Mouth,CASE-41108,APC,41108,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1600.04,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1545.93,1623.23,OPPS APC
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC,939,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],97674.79,,"Fee schedule rate ($97,674.79). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,26517.40,97674.79,There are no additional notes associated with this service or procedure.
Injection Aa&/Strd Intercostal Nrv Ea Addl Lvl|RIGHT SIDE,CASE-64421,APC,64421,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],827.89,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,827.89,869.28,OPPS APC
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],30372.64,,"Fee schedule rate ($30,372.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,13260.40,32878.30,There are no additional notes associated with this service or procedure.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],19604.30,,"Fee schedule rate ($19,604.30). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9446.38,21796.21,There are no additional notes associated with this service or procedure.
HEADACHES WITHOUT MCC,103,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],20883.08,,"Fee schedule rate ($20,883.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,20883.08,There are no additional notes associated with this service or procedure.
PREMATURITY WITH MAJOR PROBLEMS,791,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],3054.00,,,,,,0,other,3048.21,30904.42,Estimated amount calculated based on 5 day length of stay.
HC Inj Lympho for Sentinal Node|SEPARATE PRACTITIONER,CASE-38792,APC,38792,CPT,0361,RC,,,XP,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6432.89,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6215.36,6526.12,OPPS APC
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],18217.52,,"Fee schedule rate ($18,217.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7414.07,18217.52,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],13947.32,,"Fee schedule rate ($13,947.32). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6153.12,13947.32,There are no additional notes associated with this service or procedure.
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],18378.15,,"Fee schedule rate ($18,378.15). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,13092.47,33159.45,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],14265.61,,"Case rate ($13,783.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,957.83, add-ons for qualifying new technology services are included. If operating cost exceeds $47,828.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,625.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $10,972.42 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,012.88 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $865.83. The transfer capital threshold is the transfer adjustment factor * $865.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,13783.20,41580.51,Inpatient DRG
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],6965.00,,,,,,0,other,6965.00,17467.27,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],32878.30,,,,,,0,other,13260.40,32878.30,There are no additional notes associated with this service or procedure.
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],22341.11,,"Case rate ($21,277.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $19,965.45, add-ons for qualifying new technology services are included. If operating cost exceeds $54,836.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,139.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. The base transfer operating payment is the transfer adjustment factor * $17,952.43 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,020.50 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,379.87. The transfer capital threshold is the transfer adjustment factor * $1,379.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7086.00,57872.02,Inpatient DRG
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],26204.74,,"Fee schedule rate ($26,204.74). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10120.20,26204.74,There are no additional notes associated with this service or procedure.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],41944.25,,"Fee schedule rate ($41,944.25). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12795.84,41944.25,There are no additional notes associated with this service or procedure.
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],40714.72,,"Fee schedule rate ($40,714.72). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,17356.15,44778.95,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,064,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],15921.74,,"Case rate ($15,163.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,266.61, add-ons for qualifying new technology services are included. If operating cost exceeds $49,137.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,703.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $12,275.12 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,321.66 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $943.49. The transfer capital threshold is the transfer adjustment factor * $943.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,15563.58,41838.16,Inpatient DRG
"VERTIGO AND OTHER LABYRINTH DISORDERS,MODERATE",111,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],2611.05,,"Case rate for a one day stay ($2,611.05). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,2611.05,2741.60,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],41580.51,,"Fee schedule rate ($41,580.51). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,13783.20,41580.51,There are no additional notes associated with this service or procedure.
PERITONEAL ADHESIOLYSIS WITH CC,336,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],17036.48,,"Case rate ($16,225.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,229.58, add-ons for qualifying new technology services are included. If operating cost exceeds $50,100.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,804.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $13,235.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,284.63 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,044.44. The transfer capital threshold is the transfer adjustment factor * $1,044.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,16225.22,53705.31,Inpatient DRG
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],12154.28,,"Case rate ($11,575.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,904.06, add-ons for qualifying new technology services are included. If operating cost exceeds $45,775.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,464.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $8,926.20 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,959.11 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $704.37. The transfer capital threshold is the transfer adjustment factor * $704.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,11575.50,48961.48,Inpatient DRG
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],7389.00,,"Per diem ($7,389). If length of stay < 4.8, first 1 days paid at a per diem of $14,778 instead. Capped at $35,466.15.",,,,0,other,7389.00,37134.43,Estimated amount calculated based on 6 day length of stay.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],13149.46,,"Fee schedule rate ($13,149.46). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.9), with a minimum of zero.",,,,0,other,6683.37,14699.43,There are no additional notes associated with this service or procedure.
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],14690.49,,"Fee schedule rate ($14,690.49). Adds an outlier to normal pricing equal to the per diem rate ($54,770.58) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.7), with a minimum of zero.",,,,0,other,7238.69,16804.22,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,066,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],11514.58,,"Case rate ($6,579.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,256.61, add-ons for qualifying new technology services are included. If operating cost exceeds $41,127.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,098.96, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $4,295.82 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,311.66 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $338.98. The transfer capital threshold is the transfer adjustment factor * $338.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,6579.76,20083.61,All Other Inpatient
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],62041.12,,"Fee schedule rate ($62,041.12). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,18497.24,62041.12,There are no additional notes associated with this service or procedure.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],53939.67,,"Fee schedule rate ($53,939.67). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,21382.16,85466.62,There are no additional notes associated with this service or procedure.
Repair Intermediate S/a/T/E >30.0 Cm|SEPARATE STRUCTURE,CASE-12037,APC,12037,CPT,0360,RC,,,XS,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1600.04,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1545.93,1623.23,OPPS APC
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],17100.47,,"Case rate ($16,286.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,286.28, add-ons for qualifying new technology services are included. If operating cost exceeds $50,157.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,808.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $13,292.32 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,341.33 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,048.90. The transfer capital threshold is the transfer adjustment factor * $1,048.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,16286.16,58320.32,Inpatient DRG
Ostectomy Complete Other Metatarsal Head 2/3/4|RIGHT SIDE,CASE-28112,APC,28112,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
OTHER DISORDERS OF NERVOUS SYSTEM WITH CC,092,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],26765.51,,"Fee schedule rate ($26,765.51). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8872.78,26765.51,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,086,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],8442.00,,"Per diem ($8,442). If length of stay < 2.9, first 1 days paid at a per diem of $16,884 instead. Capped at $24,481.64.",,,,0,other,8442.00,30728.81,Estimated amount calculated based on 2 day length of stay.
PSYCHOSES,885,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],11404.17,,"Case rate ($11,404.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,744.67, add-ons for qualifying new technology services are included. If operating cost exceeds $45,615.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,451.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.5. The base transfer operating payment is the transfer adjustment factor * $8,767.39 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,799.72 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $691.83. The transfer capital threshold is the transfer adjustment factor * $691.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,2070.00,27484.83,Inpatient DRG
Sigmoidoscopy Flx Dx W/Collj Spec Br/Wa if Pfrmd|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-45330,APC,45330,CPT,0360,RC,,,74,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],870.46,,"APC Price ($870.46). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,870.46,913.99,OPPS APC
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],10862.00,,"Per diem ($10,862). If length of stay < 7.6, first 1 days paid at a per diem of $21,724 instead. Capped at $82,553.89.",,,,0,other,10862.00,86437.13,Estimated amount calculated based on 6 day length of stay.
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC,832,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],9034.88,,"Fee schedule rate ($9,034.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4803.31,14198.92,There are no additional notes associated with this service or procedure.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],51656.32,,"Fee schedule rate ($51,656.32). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,20559.34,54086.17,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],14231.57,,"Case rate ($13,952.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,115.33, add-ons for qualifying new technology services are included. If operating cost exceeds $47,986.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,638.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $11,129.34 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,170.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $878.22. The transfer capital threshold is the transfer adjustment factor * $878.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,13917.42,34889.29,Inpatient DRG
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],19371.27,,"Fee schedule rate ($19,371.27). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8643.20,19462.52,There are no additional notes associated with this service or procedure.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],9687.34,,"Case rate ($9,226.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,731.97, add-ons for qualifying new technology services are included. If operating cost exceeds $43,602.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,279.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,761.38 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,787.02 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $519.70. The transfer capital threshold is the transfer adjustment factor * $519.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9446.38,21796.21,Inpatient DRG
Ndsc Eval Intstinal Pouch Dx W/Collj Spec Spx,CASE-44385,APC,44385,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],913.99,,"APC Price ($870.46). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,870.46,913.99,OPPS APC
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],67794.72,,"Fee schedule rate ($67,794.72). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,10862.00,86437.13,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],15076.44,,"Fee schedule rate ($15,076.44). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6340.03,15076.44,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,447,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],83279.92,,"Fee schedule rate ($83,279.92). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,47193.21,156646.82,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],107110.70,,"Fee schedule rate ($107,110.70). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (21), with a minimum of zero.",,,,0,other,40542.37,128358.13,There are no additional notes associated with this service or procedure.
"Prq Skel Fixj Phlngl Shft Fx Prox/Middle Px/F/T|RIGHT HAND, THUMB",CASE-26727,APC,26727,CPT,0360,RC,,,F5,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],13421.68,,,,,,0,other,6564.18,17651.07,There are no additional notes associated with this service or procedure.
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITHOUT MCC,430,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],41000.16,,"Case rate ($41,000.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $38,277.19, add-ons for qualifying new technology services are included. If operating cost exceeds $73,148.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,616.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $36,198.76 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $36,332.23 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,856.44. The transfer capital threshold is the transfer adjustment factor * $2,856.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,41000.16,133156.90,Inpatient DRG
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,448,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],94077.13,,"Fee schedule rate ($94,077.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,30663.95,94077.13,There are no additional notes associated with this service or procedure.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],13907.80,,"Case rate ($13,907.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,073.74, add-ons for qualifying new technology services are included. If operating cost exceeds $47,944.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,634.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $11,087.92 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,128.80 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $874.95. The transfer capital threshold is the transfer adjustment factor * $874.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,13907.80,52794.06,Inpatient DRG
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],10862.00,,"Per diem ($10,862). If length of stay < 7.6, first 1 days paid at a per diem of $21,724 instead. Capped at $82,553.89.",,,,0,other,10862.00,86437.13,Estimated amount calculated based on 6 day length of stay.
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,448,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],79697.35,,"Fee schedule rate ($79,697.35). Adds an outlier to normal pricing equal to the per diem rate ($108,215.07) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,30663.95,94077.13,There are no additional notes associated with this service or procedure.
HC Plcmt Tunnel Pleural Drain Cat,CASE-32550,APC,32550,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3351.34,,"APC Price ($3,351.34). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3351.34,3518.91,OPPS APC
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],22363.67,,"Fee schedule rate ($22,363.67). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10003.71,23415.63,There are no additional notes associated with this service or procedure.
Cysto W/Urtroscopy&/Pyeloscopy Dx|UNUSUAL NON-OVERLAPPING SERVICE,CASE-52351,APC,52351,CPT,0360,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3299.47,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3299.47,3464.44,OPPS APC
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],59081.91,,"Fee schedule rate ($59,081.91). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,8480.00,59081.91,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,426,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],207121.41,,"Fee schedule rate ($207,121.41). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,76581.29,216864.15,There are no additional notes associated with this service or procedure.
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],42767.23,,"Fee schedule rate ($42,767.23). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,17356.15,44778.95,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],19371.27,,"Fee schedule rate ($19,371.27). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7641.61,19371.27,There are no additional notes associated with this service or procedure.
"Tendon Sheath Incision|LEFT HAND, FIFTH DIGIT",CASE-26055,APC,26055,CPT,0360,RC,,,F4,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1505.12,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1505.12,1580.37,OPPS APC
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level|RIGHT SIDE,CASE-64483,APC,64483,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],827.89,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,827.89,869.28,OPPS APC
FULL TERM NEONATE WITH MAJOR PROBLEMS,793,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],30181.78,,"Case rate ($30,181.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $28,213.07, add-ons for qualifying new technology services are included. If operating cost exceeds $63,084.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,825.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $26,171.62 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $26,268.12 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,065.20. The transfer capital threshold is the transfer adjustment factor * $2,065.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,4302.90,82045.22,Inpatient DRG
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],31401.22,,"Fee schedule rate ($31,401.22). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.7), with a minimum of zero.",,,,0,other,13260.40,32878.30,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITH CC,386,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],19210.66,,,,,,0,other,8556.53,19879.00,There are no additional notes associated with this service or procedure.
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],23415.63,,,,,,0,other,10003.71,23415.63,There are no additional notes associated with this service or procedure.
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],16400.70,,"Fee schedule rate ($16,400.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,16400.70,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],13448.43,,"Case rate ($12,808.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,050.64, add-ons for qualifying new technology services are included. If operating cost exceeds $46,921.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,554.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $10,068.57 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,105.69 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $794.51. The transfer capital threshold is the transfer adjustment factor * $794.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7353.00,33398.16,Inpatient DRG
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],26483.27,,,,,,0,other,11059.47,28423.20,There are no additional notes associated with this service or procedure.
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH CC",457,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],42327.47,,"Case rate ($42,327.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $39,511.96, add-ons for qualifying new technology services are included. If operating cost exceeds $74,382.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,713.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $37,429.01 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $37,567.02 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,953.52. The transfer capital threshold is the transfer adjustment factor * $2,953.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,42327.47,160549.49,Inpatient DRG
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],41944.25,,"Fee schedule rate ($41,944.25). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12795.84,41944.25,There are no additional notes associated with this service or procedure.
VAGINAL DELIVERY WITH O.R. PROCEDURES EXCEPT STERILIZATION AND/OR D&C,768,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],9662.00,,"Case rate ($9,201.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,695.94, add-ons for qualifying new technology services are included. If operating cost exceeds $43,566.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,290.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $6,726.19 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,750.99 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $530.76. The transfer capital threshold is the transfer adjustment factor * $530.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6426.91,13416.00,Inpatient DRG
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,306,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],13057.94,,"Case rate ($12,616.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,872.35, add-ons for qualifying new technology services are included. If operating cost exceeds $46,743.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,540.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $9,890.94 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,927.40 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $780.49. The transfer capital threshold is the transfer adjustment factor * $780.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,12616.37,31007.02,Inpatient DRG
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,309,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5055.77,,"Case rate ($4,815.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $4,493.87, add-ons for qualifying new technology services are included. If operating cost exceeds $44,063.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $3,132.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,473.46. The transfer operating threshold is the transfer adjustment factor * $4,493.87 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $341.56. The transfer capital threshold is the transfer adjustment factor * $341.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5055.77,14547.21,Inpatient DRG
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6153.12,,"Case rate ($6,153.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,859.72, add-ons for qualifying new technology services are included. If operating cost exceeds $40,730.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,067.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,900.39 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,914.77 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $307.78. The transfer capital threshold is the transfer adjustment factor * $307.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6153.12,13947.32,Inpatient DRG
OTHER DISORDERS OF THE EYE WITHOUT MCC,125,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],14429.27,,"Fee schedule rate ($14,429.27). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.9), with a minimum of zero.",,,,0,other,7144.54,17952.29,There are no additional notes associated with this service or procedure.
HC Inj Aa&/Strd Other Peripheral Nerve/Branch|LEFT SIDE,CASE-64450,APC,64450,CPT,0450,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],683.85,,"APC Price ($660.72). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,660.72,693.76,OPPS APC
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,093,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7538.11,,"Case rate ($7,179.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,823.98, add-ons for qualifying new technology services are included. If operating cost exceeds $41,694.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,133.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,860.60 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,879.03 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $373.60. The transfer capital threshold is the transfer adjustment factor * $373.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,19011.32,Inpatient DRG
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],36434.36,,"Case rate ($35,719.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $33,365.14, add-ons for qualifying new technology services are included. If operating cost exceeds $68,236.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,230.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.9. The base transfer operating payment is the transfer adjustment factor * $31,304.77 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $31,420.19 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,470.26. The transfer capital threshold is the transfer adjustment factor * $2,470.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,35719.96,105091.76,Inpatient DRG
Arthrodesis Combined Tq 1ntrspc Lumbar,CASE-22633,APC,22633,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],26287.03,,"APC Price ($25,398.09). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,25398.09,26668.00,OPPS APC
SEIZURES WITH MCC,100,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],38110.41,,,,,,0,other,15061.09,38110.41,There are no additional notes associated with this service or procedure.
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 1 Level|BILATERAL PROCEDURE,CASE-64493,APC,64493,CPT,0360,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],869.28,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,827.89,869.28,OPPS APC
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],26687.87,,"Case rate ($25,417.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $23,824.31, add-ons for qualifying new technology services are included. If operating cost exceeds $58,695.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,435.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. The base transfer operating payment is the transfer adjustment factor * $21,796.72 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $21,879.36 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,675.35. The transfer capital threshold is the transfer adjustment factor * $1,675.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,26127.34,90333.60,Inpatient DRG
SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS,029,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],26300.97,,"Case rate ($25,048.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $23,437.73, add-ons for qualifying new technology services are included. If operating cost exceeds $58,308.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,449.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.7)) / 2. The base transfer operating payment is the transfer adjustment factor * $21,413.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $21,492.79 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,689.76. The transfer capital threshold is the transfer adjustment factor * $1,689.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13641.00,67130.05,Inpatient DRG
"Arthrodesis Great Toe Metatarsophalangeal Joint|LEFT FOOT, GREAT TOE",CASE-28750,APC,28750,CPT,0360,RC,,,TA,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6791.99,7131.59,OPPS APC
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],25609.86,,"Fee schedule rate ($25,609.86). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,12775.53,31469.43,There are no additional notes associated with this service or procedure.
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],40426.76,,"Fee schedule rate ($40,426.76). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,11914.12,40426.76,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,091,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],33004.27,,"Fee schedule rate ($33,004.27). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13838.06,40030.81,There are no additional notes associated with this service or procedure.
Lamnotmy Incl W/Dcmprsn Nrv Root 1 Intrspc Lumbr|RIGHT SIDE,CASE-63030,APC,63030,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7029.71,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6791.99,7131.59,OPPS APC
POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES,769,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],29791.03,,"Fee schedule rate ($29,791.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,13388.39,33250.19,There are no additional notes associated with this service or procedure.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],42586.49,,"Fee schedule rate ($42,586.49). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,13341.67,42586.49,There are no additional notes associated with this service or procedure.
MAJOR BLADDER PROCEDURES WITH MCC,653,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],37906.76,,"Case rate ($36,101.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $33,783.96, add-ons for qualifying new technology services are included. If operating cost exceeds $68,654.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,197.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.5. The base transfer operating payment is the transfer adjustment factor * $31,718.75 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $31,839.01 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,437.98. The transfer capital threshold is the transfer adjustment factor * $2,437.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10280.00,125343.98,Inpatient DRG
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],31973.49,,"Fee schedule rate ($31,973.49). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,13386.36,33244.29,There are no additional notes associated with this service or procedure.
Arthrodesis Pst/Pstlat Tq 1ntrspc Ea Addl Ntrspc,CASE-22614,APC,22614,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],16986.50,,"APC Price ($16,412.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,16412.07,17232.68,OPPS APC
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],34570.85,,"Fee schedule rate ($34,570.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,6965.00,36140.75,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],6965.00,,,,,,0,other,1188.00,12138.74,There are no additional notes associated with this service or procedure.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],22292.26,,"Fee schedule rate ($22,292.26). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9977.99,26949.28,There are no additional notes associated with this service or procedure.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC",061,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],62315.82,,"Fee schedule rate ($62,315.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,20616.23,62315.82,There are no additional notes associated with this service or procedure.
NONTRAUMATIC STUPOR AND COMA WITH MCC,080,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],34015.33,,"Fee schedule rate ($34,015.33). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.5), with a minimum of zero.",,,,0,other,14202.39,35615.37,There are no additional notes associated with this service or procedure.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],53939.67,,"Fee schedule rate ($53,939.67). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,21382.16,85466.62,There are no additional notes associated with this service or procedure.
HC Injection Small Joint/Bursa|LEFT SIDE,CASE-20600,APC,20600,CPT,0361,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],15318.94,,"Fee schedule rate ($15,318.94). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6214.05,15318.94,There are no additional notes associated with this service or procedure.
UNGROUPABLE,999,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],49727.19,,"Case rate ($48,752.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $45,488.70, add-ons for qualifying new technology services are included. If operating cost exceeds $80,359.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $5,183.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 12.7. The base transfer operating payment is the transfer adjustment factor * $43,383.78 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $43,543.75 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,423.41. The transfer capital threshold is the transfer adjustment factor * $3,423.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,10228.00,161307.29,Inpatient DRG
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],25253.70,,"Fee schedule rate ($25,253.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11974.38,29141.64,There are no additional notes associated with this service or procedure.
Mastectomy Simple Complete|RIGHT SIDE,CASE-19303,APC,19303,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6215.36,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6215.36,6432.89,OPPS APC
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],33197.83,,"Fee schedule rate ($33,197.83). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.8), with a minimum of zero.",,,,0,other,13907.80,52794.06,There are no additional notes associated with this service or procedure.
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],6230.00,,"Per diem ($6,230). If length of stay < 2.9, first 1 days paid at a per diem of $12,460 instead. Capped at $18,065.71.",,,,0,other,6230.00,22762.43,Estimated amount calculated based on 3 day length of stay.
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],19601.02,,"Fee schedule rate ($19,601.02). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12606.23,36868.88,There are no additional notes associated with this service or procedure.
"ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",770,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],17800.73,,"Fee schedule rate ($17,800.73). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,8735.30,19730.13,There are no additional notes associated with this service or procedure.
Exploration Penetrating Wound Spx Extremity|LEFT SIDE,CASE-20103,APC,20103,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3215.80,3215.80,OPPS APC
"MAJOR ESOPHAGEAL DISORDERS,EXTREME",242,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],24176.46,,"Case rate ($23,025.20). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,23025.20,24176.46,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],10042.78,,"Case rate ($9,564.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,047.52, add-ons for qualifying new technology services are included. If operating cost exceeds $43,918.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,303.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $7,075.74 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,102.57 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $543.86. The transfer capital threshold is the transfer adjustment factor * $543.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9795.13,23899.13,Inpatient DRG
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],22340.59,,"Fee schedule rate ($22,340.59). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,21248.73,56089.29,There are no additional notes associated with this service or procedure.
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],8393.44,,"Case rate ($7,993.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,572.03, add-ons for qualifying new technology services are included. If operating cost exceeds $42,443.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,202.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $5,606.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,627.08 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $442.40. The transfer capital threshold is the transfer adjustment factor * $442.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5415.00,17575.50,Inpatient DRG
HYPERTENSION WITHOUT MCC,305,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],14190.59,,"Fee schedule rate ($14,190.59). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,7058.55,17230.49,There are no additional notes associated with this service or procedure.
Cysto Bladder W/Ureteral Catheterization|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-52005,APC,52005,CPT,0360,RC,,,LT|XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3464.44,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3299.47,3464.44,OPPS APC
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],60793.48,,"Fee schedule rate ($60,793.48). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15.7), with a minimum of zero.",,,,0,other,23851.92,63653.13,There are no additional notes associated with this service or procedure.
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,450,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],39939.25,,"Case rate ($38,037.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $35,520.98, add-ons for qualifying new technology services are included. If operating cost exceeds $70,391.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,399.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $33,452.68 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $33,576.02 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,639.75. The transfer capital threshold is the transfer adjustment factor * $2,639.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,38037.38,146009.19,Inpatient DRG
Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|RIGHT SIDE,CASE-26160,APC,26160,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1919.19,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1827.80,1919.19,OPPS APC
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],32745.30,,"Fee schedule rate ($32,745.30). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,8480.00,59081.91,There are no additional notes associated with this service or procedure.
HC Bx Breast 1st Lesion US Img|RIGHT SIDE,CASE-19083,APC,19083,CPT,0361,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1600.04,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1545.93,1623.23,OPPS APC
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],19579.01,,"Case rate ($18,646.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,513.37, add-ons for qualifying new technology services are included. If operating cost exceeds $52,384.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,952.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $15,509.62 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,568.42 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,192.11. The transfer capital threshold is the transfer adjustment factor * $1,192.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,19152.11,53152.12,Inpatient DRG
"Amputation Toe Metatarsophalangeal Joint|LEFT FOOT, GREAT TOE",CASE-28820,APC,28820,CPT,0360,RC,,,TA,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3169.86,OPPS APC
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC,807,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],13266.23,,,,,,0,other,5354.25,13266.23,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],12272.58,,"Fee schedule rate ($12,272.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5628.97,12272.58,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],27256.92,,"Case rate ($27,256.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $25,492.14, add-ons for qualifying new technology services are included. If operating cost exceeds $60,363.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,611.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. The base transfer operating payment is the transfer adjustment factor * $23,460.69 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $23,547.19 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,851.28. The transfer capital threshold is the transfer adjustment factor * $1,851.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,27256.92,81353.66,Inpatient DRG
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,085,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],44704.18,,,,,,0,other,9282.00,57443.16,There are no additional notes associated with this service or procedure.
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],22762.43,,"Fee schedule rate ($22,762.43). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6230.00,22762.43,There are no additional notes associated with this service or procedure.
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC,964,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],34154.06,,"Fee schedule rate ($34,154.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12323.82,34154.06,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITH MCC,385,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],21593.52,,"Fee schedule rate ($21,593.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11480.01,31134.92,There are no additional notes associated with this service or procedure.
Surg Nasopharyngoscopy Dilat Eustachian Tube Bi,CASE-69706,APC,69706,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5735.04,,"APC Price ($5,541.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5541.10,5818.16,OPPS APC
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],13460.55,,"Case rate ($12,819.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,081.67, add-ons for qualifying new technology services are included. If operating cost exceeds $46,952.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,536.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $10,098.43 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,136.72 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $776.19. The transfer capital threshold is the transfer adjustment factor * $776.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13148.66,32553.63,Inpatient DRG
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],13625.25,,"Fee schedule rate ($13,625.25). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7243.75,23262.15,There are no additional notes associated with this service or procedure.
TRAUMATIC INJURY WITH MCC,913,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],30719.04,,"Fee schedule rate ($30,719.04). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.5), with a minimum of zero.",,,,0,other,13014.58,42838.46,There are no additional notes associated with this service or procedure.
"ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",770,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],8910.01,,"Case rate ($8,735.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,261.87, add-ons for qualifying new technology services are included. If operating cost exceeds $43,132.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,256.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $6,293.72 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,316.92 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $496.64. The transfer capital threshold is the transfer adjustment factor * $496.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,8735.30,19730.13,Inpatient DRG
Laparoscopy W/Rmvl Adnexal Structures,CASE-58661,APC,58661,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5941.70,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5658.76,5941.70,OPPS APC
O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC,621,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],36669.96,,"Fee schedule rate ($36,669.96). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,12159.94,36669.96,There are no additional notes associated with this service or procedure.
"Inj Dx/Ther Agnt Paravert Facet Joint, Cerv/Thorac, Add Level|RIGHT SIDE",CASE-64492,APC,64492,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],827.89,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,827.89,869.28,OPPS APC
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],8297.99,,"Case rate ($7,902.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,498.58, add-ons for qualifying new technology services are included. If operating cost exceeds $42,369.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,185.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,532.65 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,553.63 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $425.25. The transfer capital threshold is the transfer adjustment factor * $425.25. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7884.32,17835.23,Inpatient DRG
HC Lyr Clos Sc Tk Ext 2.6-7 Cm|SEPARATE STRUCTURE,CASE-12032,APC,12032,CPT,0450,RC,,,XS,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],2718.88,,"APC Price ($2,718.88). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2718.88,2854.83,OPPS APC
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],25609.86,,"Fee schedule rate ($25,609.86). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,12775.53,31469.43,There are no additional notes associated with this service or procedure.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],97015.50,,"Fee schedule rate ($97,015.50). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,26809.29,97015.50,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,091,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],40030.81,,"Fee schedule rate ($40,030.81). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,13838.06,40030.81,There are no additional notes associated with this service or procedure.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],14699.43,,"Fee schedule rate ($14,699.43). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6683.37,14699.43,There are no additional notes associated with this service or procedure.
INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC,198,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],13459.55,,"Fee schedule rate ($13,459.55). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.7), with a minimum of zero.",,,,0,other,6795.12,23505.07,There are no additional notes associated with this service or procedure.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],9084.76,,"Case rate ($8,906.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,421.26, add-ons for qualifying new technology services are included. If operating cost exceeds $43,292.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,269.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $6,452.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,476.31 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $509.17. The transfer capital threshold is the transfer adjustment factor * $509.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,8906.63,28434.57,Inpatient DRG
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],16235.87,,"Fee schedule rate ($16,235.87). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6524.00,17760.46,There are no additional notes associated with this service or procedure.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],18970.81,,"Case rate ($18,598.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,437.70, add-ons for qualifying new technology services are included. If operating cost exceeds $52,308.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,978.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 5.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $15,435.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,492.75 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,218.04. The transfer capital threshold is the transfer adjustment factor * $1,218.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,18598.83,48389.68,Inpatient DRG
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC,862,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],28705.48,,"Fee schedule rate ($28,705.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (42), with a minimum of zero.",,,,0,other,6855.00,35884.94,There are no additional notes associated with this service or procedure.
Rpr Recrt Ingun Hernia Any Age Incarcerated|LEFT SIDE,CASE-49521,APC,49521,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6362.63,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6059.65,6362.63,OPPS APC
Marsupialization Bartholins Gland Cyst,CASE-56440,APC,56440,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3030.03,,"APC Price ($3,030.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3030.03,3181.53,OPPS APC
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],14603.31,,"Case rate ($14,603.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,720.75, add-ons for qualifying new technology services are included. If operating cost exceeds $48,591.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,685.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $11,732.54 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,775.80 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $925.81. The transfer capital threshold is the transfer adjustment factor * $925.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,14603.31,45017.13,Inpatient DRG
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,418,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],31790.24,,"Fee schedule rate ($31,790.24). Adds an outlier to normal pricing equal to the per diem rate ($79,031.36) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.9), with a minimum of zero.",,,,0,other,13400.58,39884.93,There are no additional notes associated with this service or procedure.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],8009.34,,"Case rate ($8,009.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,586.52, add-ons for qualifying new technology services are included. If operating cost exceeds $42,457.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,203.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $5,620.85 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,641.57 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $443.54. The transfer capital threshold is the transfer adjustment factor * $443.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8009.34,19877.10,Inpatient DRG
Hallux Rigidus W/Cheilectomy 1st Mp Jt W/O Implt,CASE-28289,APC,28289,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
ENDOCRINE DISORDERS WITH CC,644,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],8358.96,,"Case rate ($8,076.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $7,615.48, add-ons for qualifying new technology services are included. If operating cost exceeds $46,260.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $3,217.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $6,227.71 + an uncompensated DSH payment of $1,359.91. The transfer operating threshold is the transfer adjustment factor * $6,255.58 + an uncompensated DSH payment of $1,359.91. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $488.69. The transfer capital threshold is the transfer adjustment factor * $488.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,7066.99,20334.21,Inpatient DRG
CHEST PAIN,313,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],8175.40,,"Fee schedule rate ($8,175.40). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,6820.84,15377.66,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],2070.00,,,,,,0,other,1188.00,12138.74,Estimated amount calculated based on 1 day length of stay.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,097,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],79915.74,,"Fee schedule rate ($79,915.74). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,26404.32,79915.74,There are no additional notes associated with this service or procedure.
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],12606.23,,"Case rate ($12,606.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,862.91, add-ons for qualifying new technology services are included. If operating cost exceeds $46,733.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,539.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $9,881.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,917.95 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $779.75. The transfer capital threshold is the transfer adjustment factor * $779.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12606.23,36868.88,Inpatient DRG
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,085,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],57443.16,,"Fee schedule rate ($57,443.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,9282.00,57443.16,There are no additional notes associated with this service or procedure.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],52699.33,,"Fee schedule rate ($52,699.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,18105.81,52699.33,There are no additional notes associated with this service or procedure.
"Partical Excision Bone Phalanx Toe|LEFT FOOT, THIRD DIGIT",CASE-28124,APC,28124,CPT,0360,RC,,,T2,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
"Tendon Sheath Incision|RIGHT HAND, FIFTH DIGIT",CASE-26055,APC,26055,CPT,0360,RC,,,F9,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1557.80,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1505.12,1580.37,OPPS APC
SPINAL PROCEDURES WITH MCC,028,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],120982.83,,"Fee schedule rate ($120,982.83). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,42633.57,120982.83,There are no additional notes associated with this service or procedure.
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",623,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],32096.64,,"Fee schedule rate ($32,096.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,14093.37,33712.76,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,064,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],37792.72,,"Fee schedule rate ($37,792.72). Adds an outlier to normal pricing equal to the per diem rate ($115,085.88) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,15563.58,41838.16,There are no additional notes associated with this service or procedure.
"CHRONIC OBSTRUCTIVE PULMONARY DISEASE,MINOR",140,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],5836.06,,"Case rate ($5,836.06). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,5836.06,6127.86,There are no additional notes associated with this service or procedure.
RESPIRATORY NEOPLASMS WITH CC,181,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],17609.39,,"Fee schedule rate ($17,609.39). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9197.84,21074.07,There are no additional notes associated with this service or procedure.
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC,805,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],9438.43,,"Case rate ($9,253.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,743.82, add-ons for qualifying new technology services are included. If operating cost exceeds $43,614.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,294.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $6,773.89 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,798.87 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $534.53. The transfer capital threshold is the transfer adjustment factor * $534.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,9253.36,21235.42,Inpatient DRG
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],7847.50,,"Case rate ($7,847.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,435.96, add-ons for qualifying new technology services are included. If operating cost exceeds $42,306.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,191.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,470.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,491.01 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $431.70. The transfer capital threshold is the transfer adjustment factor * $431.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7847.50,17755.26,Inpatient DRG
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],18512.68,,"Case rate ($17,631.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,566.73, add-ons for qualifying new technology services are included. If operating cost exceeds $51,437.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,879.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $14,566.55 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,621.78 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,119.62. The transfer capital threshold is the transfer adjustment factor * $1,119.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,18105.81,52699.33,Inpatient DRG
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],23239.84,,"Fee schedule rate ($23,239.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8543.64,23239.84,There are no additional notes associated with this service or procedure.
ALLERGIC REACTIONS WITH MCC,915,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],27385.01,,"Fee schedule rate ($27,385.01). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,13332.86,33088.84,There are no additional notes associated with this service or procedure.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],13768.00,,,,,,0,other,6683.37,14699.43,There are no additional notes associated with this service or procedure.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],52909.62,,"Fee schedule rate ($52,909.62). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,23344.70,62179.32,There are no additional notes associated with this service or procedure.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],22292.26,,"Fee schedule rate ($22,292.26). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9977.99,26949.28,There are no additional notes associated with this service or procedure.
Arthrs Wrst Exc&/Rpr Triang Fibrocart&/Joint,CASE-29846,APC,29846,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],14651.56,,"Case rate ($8,372.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,924.20, add-ons for qualifying new technology services are included. If operating cost exceeds $42,795.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,230.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,957.28 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,979.25 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $470.09. The transfer capital threshold is the transfer adjustment factor * $470.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,6965.00,23385.72,All Other Inpatient
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],62454.12,,"Fee schedule rate ($62,454.12). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11348.00,62454.12,There are no additional notes associated with this service or procedure.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],45845.03,,"Fee schedule rate ($45,845.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,18598.83,48389.68,There are no additional notes associated with this service or procedure.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],12778.21,,"Case rate ($12,527.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,789.82, add-ons for qualifying new technology services are included. If operating cost exceeds $46,660.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,533.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $9,808.71 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,844.88 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $774.00. The transfer capital threshold is the transfer adjustment factor * $774.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,12527.66,29917.96,Inpatient DRG
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],19824.58,,,,,,0,other,8767.81,19824.58,There are no additional notes associated with this service or procedure.
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],6310.74,,"Case rate ($6,010.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,726.79, add-ons for qualifying new technology services are included. If operating cost exceeds $40,597.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,057.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,767.95 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,781.84 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $297.33. The transfer capital threshold is the transfer adjustment factor * $297.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6010.23,12246.05,Inpatient DRG
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6749.91,,"Case rate ($6,428.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,124.26, add-ons for qualifying new technology services are included. If operating cost exceeds $40,995.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,079.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $4,163.53 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,179.31 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $320.02. The transfer capital threshold is the transfer adjustment factor * $320.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6564.18,17651.07,Inpatient DRG
Neuroplasty &/Transpos Median Nrv Carpal Tunne|RIGHT SIDE|SEPARATE STRUCTURE,CASE-64721,APC,64721,CPT,0360,RC,,,RT|XS,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7029.71,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6791.99,7131.59,OPPS APC
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC",494,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],15890.67,,"Case rate ($15,133.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,239.03, add-ons for qualifying new technology services are included. If operating cost exceeds $49,110.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,701.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $12,247.65 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,294.08 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $941.38. The transfer capital threshold is the transfer adjustment factor * $941.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,15533.10,39945.55,Inpatient DRG
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],8151.60,,"Case rate ($7,875.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,462.42, add-ons for qualifying new technology services are included. If operating cost exceeds $42,333.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,193.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $5,497.20 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,517.46 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $433.78. The transfer capital threshold is the transfer adjustment factor * $433.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,7875.94,17233.12,Inpatient DRG
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],46523.26,,"Fee schedule rate ($46,523.26). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,17782.11,46523.26,There are no additional notes associated with this service or procedure.
HC Biopsy Liver Percutan Needle,CASE-47000,APC,47000,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1545.93,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1545.93,1623.23,OPPS APC
Dstr Nrolytc Agnt Parverteb Fct Sngl Lmbr/Sacral|RIGHT SIDE,CASE-64635,APC,64635,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1827.80,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1827.80,1919.19,OPPS APC
COMPLICATIONS OF TREATMENT WITH CC,920,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],20731.52,,"Fee schedule rate ($20,731.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8732.59,20731.52,There are no additional notes associated with this service or procedure.
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],6066.84,,"Case rate ($5,777.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,510.70, add-ons for qualifying new technology services are included. If operating cost exceeds $40,381.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,040.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $3,552.65 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,565.75 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $280.34. The transfer capital threshold is the transfer adjustment factor * $280.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5065.00,12558.65,Inpatient DRG
VENTRICULAR SHUNT PROCEDURES WITH MCC,031,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],84202.04,,"Fee schedule rate ($84,202.04). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16.6), with a minimum of zero.",,,,0,other,32287.20,88162.80,There are no additional notes associated with this service or procedure.
Bx/Exc Lymph Node Open Deep Axillary Node|BILATERAL PROCEDURE,CASE-38525,APC,38525,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6215.36,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6215.36,6526.12,OPPS APC
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR,518,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],27836.34,,"Case rate ($26,510.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $24,843.87, add-ons for qualifying new technology services are included. If operating cost exceeds $59,714.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,513.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 5.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $22,812.43 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $22,898.92 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,753.42. The transfer capital threshold is the transfer adjustment factor * $1,753.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13252.00,89342.77,Inpatient DRG
INFLAMMATORY BOWEL DISEASE WITH CC,386,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],19879.00,,"Fee schedule rate ($19,879.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8556.53,19879.00,There are no additional notes associated with this service or procedure.
Excision Hydrocele Unilateral|RIGHT SIDE,CASE-55040,APC,55040,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3351.34,,"APC Price ($3,351.34). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3351.34,3518.91,OPPS APC
SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS,029,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],61889.56,,"Fee schedule rate ($61,889.56). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13641.00,67130.05,There are no additional notes associated with this service or procedure.
COMPLICATIONS OF TREATMENT WITH CC,920,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],19722.26,,,,,,0,other,8732.59,20731.52,There are no additional notes associated with this service or procedure.
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC",011,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],38880.49,,"Case rate ($38,880.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $36,305.31, add-ons for qualifying new technology services are included. If operating cost exceeds $71,176.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,461.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 11.4. The base transfer operating payment is the transfer adjustment factor * $34,234.14 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $34,360.36 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,701.41. The transfer capital threshold is the transfer adjustment factor * $2,701.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,38880.49,150008.48,Inpatient DRG
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],39337.51,,"Fee schedule rate ($39,337.51). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,16120.25,41187.90,There are no additional notes associated with this service or procedure.
SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS,029,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],61889.56,,"Fee schedule rate ($61,889.56). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13641.00,67130.05,There are no additional notes associated with this service or procedure.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],9416.02,,"Case rate ($9,097.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,598.92, add-ons for qualifying new technology services are included. If operating cost exceeds $43,469.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,283.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,629.53 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,653.97 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $523.14. The transfer capital threshold is the transfer adjustment factor * $523.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,9097.60,21455.22,Inpatient DRG
HC Inj Anes/Steroid C/D Facet Sg|RIGHT SIDE,CASE-64490,APC,64490,CPT,0361,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],827.89,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,827.89,869.28,OPPS APC
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],37768.77,,"Fee schedule rate ($37,768.77). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7453.00,42138.30,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],34892.92,,"Fee schedule rate ($34,892.92). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,6965.00,41030.48,There are no additional notes associated with this service or procedure.
"NEONATE TRANSFERRED < 5 DAYS OLD BORN HERE,EXTREME",581,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],5011.20,,"The inlier payment is calculated as the lesser of the standard DRG payment $4,772.57 and the transfer payment, which is a per diem of $3,615.58. If cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4772.57,5011.20,Estimated amount calculated based on 1 day length of stay.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],14038.14,,"Case rate ($13,762.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,938.93, add-ons for qualifying new technology services are included. If operating cost exceeds $47,809.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,624.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $10,953.59 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,993.98 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $864.35. The transfer capital threshold is the transfer adjustment factor * $864.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,1188.00,34338.33,Inpatient DRG
HC Lyr Clos Nk Hnd Ft 2.6-5 Cm,CASE-12042,APC,12042,CPT,0450,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1600.04,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1545.93,1623.23,OPPS APC
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],6963.00,,"Per diem ($6,963). If length of stay < 2.6, first 1 days paid at a per diem of $13,926 instead. Capped at $18,103.30.",,,,0,other,6963.00,18954.85,Estimated amount calculated based on 3 day length of stay.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],5894.19,,"Case rate ($5,778.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,511.33, add-ons for qualifying new technology services are included. If operating cost exceeds $40,382.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,040.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $3,553.28 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,566.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $280.39. The transfer capital threshold is the transfer adjustment factor * $280.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,5778.62,11681.49,Inpatient DRG
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],8448.77,,"Case rate ($8,163.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,729.53, add-ons for qualifying new technology services are included. If operating cost exceeds $42,600.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,214.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,763.33 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,784.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $454.78. The transfer capital threshold is the transfer adjustment factor * $454.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,8163.06,18067.42,Inpatient DRG
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC,858,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],19911.08,,"Case rate ($11,377.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,720.10, add-ons for qualifying new technology services are included. If operating cost exceeds $45,591.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,449.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $8,742.91 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,775.15 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $689.90. The transfer capital threshold is the transfer adjustment factor * $689.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,11377.76,33794.11,All Other Inpatient
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],16037.43,,"Case rate ($15,273.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,344.45, add-ons for qualifying new technology services are included. If operating cost exceeds $49,215.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,734.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $12,353.94 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,399.49 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $974.85. The transfer capital threshold is the transfer adjustment factor * $974.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,15273.74,39820.52,Inpatient DRG
NEONATE WITH OTHER SIGNIFICANT PROBLEMS,794,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],3383.58,,"Fee schedule rate ($3,383.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,1798.85,12536.83,There are no additional notes associated with this service or procedure.
Egd Insert Guide Wire Dilator Passage Esophagus,CASE-43248,APC,43248,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],848.96,,"APC Price ($848.96). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,848.96,891.41,OPPS APC
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],12705.76,,"Fee schedule rate ($12,705.76). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9795.13,23899.13,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,082,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],56223.11,,"Fee schedule rate ($56,223.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,17423.21,56223.11,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC,788,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],8859.92,,"Case rate ($8,438.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,985.31, add-ons for qualifying new technology services are included. If operating cost exceeds $42,856.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,234.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,018.17 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,040.36 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $474.89. The transfer capital threshold is the transfer adjustment factor * $474.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8438.02,20142.33,Inpatient DRG
TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC,084,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],19445.16,,"Fee schedule rate ($19,445.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,6965.00,19445.16,There are no additional notes associated with this service or procedure.
NEONATE WITH OTHER SIGNIFICANT PROBLEMS,794,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],3383.58,,"Fee schedule rate ($3,383.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,1798.85,12536.83,There are no additional notes associated with this service or procedure.
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],14442.92,,,,,,0,other,6915.64,14442.92,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC,832,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],6968.31,,"Case rate ($6,831.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,490.97, add-ons for qualifying new technology services are included. If operating cost exceeds $41,361.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,117.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $4,529.32 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,546.02 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $357.41. The transfer capital threshold is the transfer adjustment factor * $357.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,4803.31,14198.92,Inpatient DRG
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITH MCC,429,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],62958.58,,"Case rate ($62,958.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $58,704.65, add-ons for qualifying new technology services are included. If operating cost exceeds $93,575.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $6,222.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.6. The base transfer operating payment is the transfer adjustment factor * $56,551.19 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $56,759.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,462.45. The transfer capital threshold is the transfer adjustment factor * $4,462.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,62958.58,177294.98,Inpatient DRG
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|RIGHT HAND, FOURTH DIGIT",CASE-26160,APC,26160,CPT,0360,RC,,,F8,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1505.12,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1505.12,1580.37,OPPS APC
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH MCC",722,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],56869.13,,"Fee schedule rate ($56,869.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,14200.37,56869.13,There are no additional notes associated with this service or procedure.
VAGINAL DELIVERY WITH O.R. PROCEDURES EXCEPT STERILIZATION AND/OR D&C,768,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],9201.90,,"Case rate ($9,201.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,695.94, add-ons for qualifying new technology services are included. If operating cost exceeds $43,566.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,290.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $6,726.19 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,750.99 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $530.76. The transfer capital threshold is the transfer adjustment factor * $530.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6426.91,13416.00,Inpatient DRG
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITHOUT MCC,430,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],41820.16,,"Case rate ($41,000.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $38,277.19, add-ons for qualifying new technology services are included. If operating cost exceeds $73,148.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,616.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $36,198.76 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $36,332.23 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,856.44. The transfer capital threshold is the transfer adjustment factor * $2,856.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,41000.16,133156.90,Inpatient DRG
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],40737.46,,"Fee schedule rate ($40,737.46). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,7665.00,40737.46,There are no additional notes associated with this service or procedure.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],101083.00,,"Fee schedule rate ($101,083.00). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,35389.50,101083.00,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],8991.47,,"Case rate ($8,563.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,101.85, add-ons for qualifying new technology services are included. If operating cost exceeds $42,972.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,244.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $6,134.29 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,156.91 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $484.06. The transfer capital threshold is the transfer adjustment factor * $484.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8563.30,31533.97,Inpatient DRG
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],81454.07,,"Fee schedule rate ($81,454.07). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,10078.00,81454.07,There are no additional notes associated with this service or procedure.
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],23870.71,,"Fee schedule rate ($23,870.71). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10626.74,25225.91,There are no additional notes associated with this service or procedure.
Edg US Exam Surgical Alter Stom Duodenum/Jejunum,CASE-43259,APC,43259,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1885.95,,"APC Price ($1,796.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1796.14,1885.95,OPPS APC
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,086,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],30728.81,,"Fee schedule rate ($30,728.81). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8442.00,30728.81,There are no additional notes associated with this service or procedure.
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],37899.49,,"Fee schedule rate ($37,899.49). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,14747.55,37899.49,There are no additional notes associated with this service or procedure.
HC Trigger Point 3 or More|PBB CHARGE,CASE-20553,APC,20553,CPT,0510,RC,,,PBB,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,555,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],10896.27,,"Case rate ($10,896.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,272.18, add-ons for qualifying new technology services are included. If operating cost exceeds $45,143.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,414.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,296.64 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,327.23 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $654.69. The transfer capital threshold is the transfer adjustment factor * $654.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10896.27,42290.95,Inpatient DRG
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],81353.66,,"Fee schedule rate ($81,353.66). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,27256.92,81353.66,There are no additional notes associated with this service or procedure.
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],16235.87,,"Fee schedule rate ($16,235.87). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6524.00,17760.46,There are no additional notes associated with this service or procedure.
Nasal/Sinus Ndsc Surg W/Dilation Frontal Sinus|BILATERAL PROCEDURE,CASE-31296,APC,31296,CPT,0360,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6837.16,,"APC Price ($6,605.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6605.95,6936.25,OPPS APC
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],31658.33,,,,,,0,other,1188.00,31658.33,There are no additional notes associated with this service or procedure.
Arthrs Aided Ant Cruciate Ligm Rpr/Agmntj/Rcnstj|RIGHT SIDE,CASE-29888,APC,29888,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7029.71,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6791.99,7029.71,OPPS APC
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],27222.08,,"Fee schedule rate ($27,222.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7389.00,37134.43,There are no additional notes associated with this service or procedure.
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],24387.68,,"Fee schedule rate ($24,387.68). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10733.06,45157.33,There are no additional notes associated with this service or procedure.
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],27433.71,,"Case rate ($26,127.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $24,441.31, add-ons for qualifying new technology services are included. If operating cost exceeds $59,312.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,528.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. The base transfer operating payment is the transfer adjustment factor * $22,413.72 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $22,496.36 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,768.66. The transfer capital threshold is the transfer adjustment factor * $1,768.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,26127.34,90333.60,Inpatient DRG
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],21089.59,,"Fee schedule rate ($21,089.59). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,6965.00,21089.59,There are no additional notes associated with this service or procedure.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],13907.80,,"Case rate ($13,907.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,073.74, add-ons for qualifying new technology services are included. If operating cost exceeds $47,944.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,634.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $11,087.92 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,128.80 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $874.95. The transfer capital threshold is the transfer adjustment factor * $874.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,13907.80,52794.06,Inpatient DRG
Repair Each Addnl Digit Nerve,CASE-64832,APC,64832,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],45845.03,,"Fee schedule rate ($45,845.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,18598.83,48389.68,There are no additional notes associated with this service or procedure.
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC,497,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],10634.03,,"Case rate ($10,127.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,557.14, add-ons for qualifying new technology services are included. If operating cost exceeds $44,428.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,358.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 1.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $7,584.22 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,612.19 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $598.47. The transfer capital threshold is the transfer adjustment factor * $598.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10127.65,37761.19,Inpatient DRG
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,097,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],71069.39,,,,,,0,other,26404.32,79915.74,There are no additional notes associated with this service or procedure.
Suction Assisted Lipectomy Upper Extremity|BILATERAL PROCEDURE,CASE-15878,APC,15878,CPT,0360,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],2027.84,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1998.87,2027.84,OPPS APC
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],12488.77,,"Case rate ($11,894.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,218.97, add-ons for qualifying new technology services are included. If operating cost exceeds $46,089.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,470.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,238.99 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,274.02 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $710.13. The transfer capital threshold is the transfer adjustment factor * $710.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12195.15,39424.57,Inpatient DRG
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,690,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],14625.55,,"Fee schedule rate ($14,625.55). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7426.94,15928.53,There are no additional notes associated with this service or procedure.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],38246.19,,"Fee schedule rate ($38,246.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,19435.86,50821.76,There are no additional notes associated with this service or procedure.
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC,805,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],16193.38,,"Case rate ($9,253.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,743.82, add-ons for qualifying new technology services are included. If operating cost exceeds $43,614.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,294.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $6,773.89 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,798.87 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $534.53. The transfer capital threshold is the transfer adjustment factor * $534.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,9253.36,21235.42,All Other Inpatient
INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC,198,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6795.12,,"Case rate ($6,795.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,456.95, add-ons for qualifying new technology services are included. If operating cost exceeds $41,327.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,114.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,495.42 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,512.00 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $354.73. The transfer capital threshold is the transfer adjustment factor * $354.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6795.12,23505.07,Inpatient DRG
Cmbnd Anterpost Colporraphy W/Cysto,CASE-57260,APC,57260,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],4846.30,,"APC Price ($4,682.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,4682.41,4916.53,OPPS APC
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],28821.04,,"Fee schedule rate ($28,821.04). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,10347.06,28821.04,There are no additional notes associated with this service or procedure.
Surg Tx Anal Fistula Intersphincteric,CASE-46275,APC,46275,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],2598.08,,"APC Price ($2,598.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2598.08,2727.99,OPPS APC
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC,831,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],10592.77,,"Case rate ($10,088.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,520.59, add-ons for qualifying new technology services are included. If operating cost exceeds $44,391.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,355.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $7,547.82 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,575.65 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $595.60. The transfer capital threshold is the transfer adjustment factor * $595.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,4941.30,23661.59,Inpatient DRG
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH MCC",510,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],10710.00,,"Per diem ($10,710). If length of stay < 5.3, first 1 days paid at a per diem of $21,420 instead. Capped at $56,764.26.",,,,0,other,10710.00,89863.76,Estimated amount calculated based on 6 day length of stay.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],133270.57,,"Fee schedule rate ($133,270.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,33623.33,133270.57,There are no additional notes associated with this service or procedure.
"CARDIAC ARREST, UNEXPLAINED WITH MCC",296,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],29352.79,,"Fee schedule rate ($29,352.79). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.2), with a minimum of zero.",,,,0,other,12522.25,36459.67,There are no additional notes associated with this service or procedure.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC",061,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],62315.82,,"Fee schedule rate ($62,315.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,20616.23,62315.82,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,093,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7594.36,,"Case rate ($7,337.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,961.57, add-ons for qualifying new technology services are included. If operating cost exceeds $41,832.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,154.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,998.19 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,016.62 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $394.41. The transfer capital threshold is the transfer adjustment factor * $394.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6965.00,19011.32,Inpatient DRG
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC",281,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],8332.53,,"Case rate ($8,169.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,735.20, add-ons for qualifying new technology services are included. If operating cost exceeds $42,606.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,215.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $5,768.98 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,790.25 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $455.23. The transfer capital threshold is the transfer adjustment factor * $455.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,8169.15,23859.35,Inpatient DRG
"CARDIAC ARREST, UNEXPLAINED WITH MCC",296,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],12522.25,,"Case rate ($12,522.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,784.78, add-ons for qualifying new technology services are included. If operating cost exceeds $46,655.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,533.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $9,803.69 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,839.84 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $773.61. The transfer capital threshold is the transfer adjustment factor * $773.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12522.25,36459.67,Inpatient DRG
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],46957.19,,,,,,0,other,18105.81,52699.33,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],62084.69,,"Fee schedule rate ($62,084.69). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (35), with a minimum of zero.",,,,0,other,30398.48,82674.88,There are no additional notes associated with this service or procedure.
Laparoscopy Surg Rpr Initial Inguinal Hernia|LEFT SIDE,CASE-49650,APC,49650,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5941.70,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5658.76,5941.70,OPPS APC
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],43399.23,,"Fee schedule rate ($43,399.23). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9888.00,43399.23,There are no additional notes associated with this service or procedure.
HC Joint Injection/Aspir Large WO US|PBB CHARGE|BILATERAL PROCEDURE,CASE-20610,APC,20610,CPT,0510,RC,,,PBB|50,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC,964,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],34154.06,,"Fee schedule rate ($34,154.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12323.82,34154.06,There are no additional notes associated with this service or procedure.
Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq|COLORECTAL CANCER SCREEN,CASE-45385,APC,45385,CPT,0360,RC,,,PT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1120.09,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1120.09,1176.09,OPPS APC
"Neuroplasty Other Arm/Leg Nerve,Open|LEFT SIDE",CASE-64708,APC,64708,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],23520.23,,"Fee schedule rate ($23,520.23). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10517.71,24909.11,There are no additional notes associated with this service or procedure.
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],16379.98,,"Fee schedule rate ($16,379.98). Adds an outlier to normal pricing equal to the per diem rate ($46,377.87) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7847.50,17755.26,There are no additional notes associated with this service or procedure.
Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq|SEPARATE STRUCTURE|COLORECTAL CANCER SCREEN,CASE-45385,APC,45385,CPT,0360,RC,,,XS|PT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1176.09,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1120.09,1176.09,OPPS APC
"DIABETES,MINOR",420,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],5146.44,,"Case rate ($5,146.44). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,5146.44,5403.76,There are no additional notes associated with this service or procedure.
DIABETES WITH CC,638,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],16842.29,,"Fee schedule rate ($16,842.29). Adds an outlier to normal pricing equal to the per diem rate ($39,561.63) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,8014.07,17634.53,There are no additional notes associated with this service or procedure.
Cysto W/Ureteroscopy W/Lithotripsy,CASE-52353,APC,52353,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5269.71,,"APC Price ($5,018.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5018.77,5269.71,OPPS APC
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],81454.07,,"Fee schedule rate ($81,454.07). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,10078.00,81454.07,There are no additional notes associated with this service or procedure.
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],33835.79,,"Fee schedule rate ($33,835.79). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,7000.00,33835.79,There are no additional notes associated with this service or procedure.
NON-MALIGNANT BREAST DISORDERS WITH CC/MCC,600,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],9178.71,,"Case rate ($8,998.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,506.94, add-ons for qualifying new technology services are included. If operating cost exceeds $43,377.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,275.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $6,537.88 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,561.99 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $515.90. The transfer capital threshold is the transfer adjustment factor * $515.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,7999.14,20495.56,Inpatient DRG
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],39153.65,,"Fee schedule rate ($39,153.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,7605.00,39153.65,There are no additional notes associated with this service or procedure.
Egd Transoral Biopsy Single/Multiple|SEPARATE STRUCTURE,CASE-43239,APC,43239,CPT,0360,RC,,,XS,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1796.14,,"APC Price ($1,796.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1796.14,1885.95,OPPS APC
Conization Cervix W/WO D&C Rpr Eltrd Exc,CASE-57522,APC,57522,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3181.53,,"APC Price ($3,030.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3030.03,3181.53,OPPS APC
RADIOTHERAPY,849,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],20742.66,,"Case rate ($19,754.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $18,546.41, add-ons for qualifying new technology services are included. If operating cost exceeds $53,417.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,031.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $16,538.75 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $16,601.46 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,271.21. The transfer capital threshold is the transfer adjustment factor * $1,271.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,20293.88,81867.07,Inpatient DRG
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],12126.09,,"Case rate ($12,126.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,416.25, add-ons for qualifying new technology services are included. If operating cost exceeds $46,287.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,504.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $9,436.50 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,471.29 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $744.63. The transfer capital threshold is the transfer adjustment factor * $744.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12126.09,29582.40,Inpatient DRG
Tr/Trnspl Tdn Carp/Mtcrpl Hand W/O Fr Grf Ea Tdn,CASE-26480,APC,26480,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC,832,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6831.68,,"Case rate ($6,831.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,490.97, add-ons for qualifying new technology services are included. If operating cost exceeds $41,361.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,117.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $4,529.32 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,546.02 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $357.41. The transfer capital threshold is the transfer adjustment factor * $357.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,4803.31,14198.92,Inpatient DRG
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],37899.49,,"Fee schedule rate ($37,899.49). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,14747.55,37899.49,There are no additional notes associated with this service or procedure.
SEIZURES WITH MCC,100,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],32323.98,,"Fee schedule rate ($32,323.98). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,15061.09,38110.41,There are no additional notes associated with this service or procedure.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],7605.00,,"Per diem ($7,605). If length of stay < 4.8, first 1 days paid at a per diem of $15,210 instead. Capped at $36,505.40.",,,,0,other,7605.00,39153.65,Estimated amount calculated based on 3 day length of stay.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC,192,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],12753.78,,"Fee schedule rate ($12,753.78). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6292.63,12753.78,There are no additional notes associated with this service or procedure.
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,069,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],20333.68,,"Fee schedule rate ($20,333.68). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,20333.68,There are no additional notes associated with this service or procedure.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],10728.06,,"Case rate ($10,517.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,920.01, add-ons for qualifying new technology services are included. If operating cost exceeds $44,791.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,386.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $7,945.76 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,975.06 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $627.00. The transfer capital threshold is the transfer adjustment factor * $627.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,10517.71,24909.11,Inpatient DRG
HC Lyr Clos Sc Tk Ext 2.6-7 Cm,CASE-12032,APC,12032,CPT,0450,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1545.93,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1545.93,1623.23,OPPS APC
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC,964,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],12323.82,,"Case rate ($12,323.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,600.20, add-ons for qualifying new technology services are included. If operating cost exceeds $46,471.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,519.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $9,619.78 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,655.25 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $759.10. The transfer capital threshold is the transfer adjustment factor * $759.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12323.82,34154.06,Inpatient DRG
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],142438.06,,"Fee schedule rate ($142,438.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (40), with a minimum of zero.",,,,0,other,45521.20,142438.06,There are no additional notes associated with this service or procedure.
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],14630.12,,"Case rate ($14,343.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,478.83, add-ons for qualifying new technology services are included. If operating cost exceeds $48,349.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,666.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $11,491.51 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,533.88 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $906.79. The transfer capital threshold is the transfer adjustment factor * $906.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,14343.25,36024.65,Inpatient DRG
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,064,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],27236.27,,"Case rate ($15,563.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,614.08, add-ons for qualifying new technology services are included. If operating cost exceeds $49,485.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,756.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $12,622.59 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,669.13 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $996.05. The transfer capital threshold is the transfer adjustment factor * $996.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,15563.58,41838.16,All Other Inpatient
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],23344.70,,"Case rate ($23,344.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $21,852.68, add-ons for qualifying new technology services are included. If operating cost exceeds $56,723.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,325.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $19,834.60 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $19,907.73 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,565.15. The transfer capital threshold is the transfer adjustment factor * $1,565.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,23344.70,62179.32,Inpatient DRG
Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn,CASE-62323,APC,62323,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],693.76,,"APC Price ($660.72). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,660.72,693.76,OPPS APC
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],21354.82,,"Fee schedule rate ($21,354.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6834.39,21354.82,There are no additional notes associated with this service or procedure.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],37505.96,,"Case rate ($35,719.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $33,365.14, add-ons for qualifying new technology services are included. If operating cost exceeds $68,236.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,230.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.9. The base transfer operating payment is the transfer adjustment factor * $31,304.77 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $31,420.19 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,470.26. The transfer capital threshold is the transfer adjustment factor * $2,470.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,35719.96,105091.76,Inpatient DRG
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],33159.45,,"Fee schedule rate ($33,159.45). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,13092.47,33159.45,There are no additional notes associated with this service or procedure.
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],21354.82,,"Fee schedule rate ($21,354.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6834.39,21354.82,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,699,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],19570.20,,"Fee schedule rate ($19,570.20). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5961.00,19972.16,There are no additional notes associated with this service or procedure.
Surgical Arthroscopy Sho W/Coracoacrm Ligm Rls|RIGHT SIDE,CASE-29826,APC,29826,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7029.71,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6791.99,7131.59,OPPS APC
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],67460.63,,,,,,0,other,25162.32,75579.22,There are no additional notes associated with this service or procedure.
Arthroscopy Knee W/Meniscus Rpr Medial/Lateral|LEFT SIDE,CASE-29882,APC,29882,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],32293.66,,"Fee schedule rate ($32,293.66). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,32293.66,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],54875.56,,"Fee schedule rate ($54,875.56). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,21719.40,85305.59,There are no additional notes associated with this service or procedure.
Optx Dstl Radl I-Artic Fx/Epiphysl Sep 3 Frag|RIGHT SIDE,CASE-25609,APC,25609,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6791.99,7131.59,OPPS APC
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],17686.09,,"Fee schedule rate ($17,686.09). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8318.14,19763.43,There are no additional notes associated with this service or procedure.
Prep Site Trunk/Arm/Leg 1st 100 Sq Cm/1pct,CASE-15002,APC,15002,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],716.00,,"APC Price ($691.79). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,691.79,726.38,OPPS APC
"POISONING OF MEDICINAL AGENTS,MODERATE",812,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],5905.13,,"Case rate ($5,905.13). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,5905.13,6200.39,There are no additional notes associated with this service or procedure.
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],17760.46,,,,,,0,other,6524.00,17760.46,There are no additional notes associated with this service or procedure.
INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC,198,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],13459.55,,"Fee schedule rate ($13,459.55). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.7), with a minimum of zero.",,,,0,other,6795.12,23505.07,There are no additional notes associated with this service or procedure.
"Open Tx Phalangeal Shaft Fracture Prox/Middle Ea|LEFT HAND, FOURTH DIGIT",CASE-26735,APC,26735,CPT,0360,RC,,,F3,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],29594.00,,"Fee schedule rate ($29,594.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,13571.25,33781.47,There are no additional notes associated with this service or procedure.
CHEST PAIN,313,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],15377.66,,"Fee schedule rate ($15,377.66). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,6820.84,15377.66,There are no additional notes associated with this service or procedure.
Tonsillectomy & Adenoidectomy Age 12/>,CASE-42821,APC,42821,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.35,,"APC Price ($3,103.35). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.35,3258.52,OPPS APC
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],33608.45,,"Fee schedule rate ($33,608.45). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,7332.00,35314.31,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC,084,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],6965.00,,,,,,0,other,6965.00,19445.16,There are no additional notes associated with this service or procedure.
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],16804.22,,"Fee schedule rate ($16,804.22). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7238.69,16804.22,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,085,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],9282.00,,"Per diem ($9,282). If length of stay < 4.6, first 1 days paid at a per diem of $18,564 instead. Capped at $42,695.82.",,,,0,other,9282.00,57443.16,Estimated amount calculated based on 2 day length of stay.
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],19126.88,,"Fee schedule rate ($19,126.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,19126.88,There are no additional notes associated with this service or procedure.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],22677.38,,"Case rate ($21,597.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,227.30, add-ons for qualifying new technology services are included. If operating cost exceeds $55,098.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,197.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $18,215.19 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,282.35 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,437.36. The transfer capital threshold is the transfer adjustment factor * $1,437.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,21597.50,67790.93,Inpatient DRG
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],142438.06,,"Fee schedule rate ($142,438.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (40), with a minimum of zero.",,,,0,other,45521.20,142438.06,There are no additional notes associated with this service or procedure.
PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,337,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],38926.31,,"Fee schedule rate ($38,926.31). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,12340.08,38926.31,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC,817,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],24316.95,,"Fee schedule rate ($24,316.95). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,17396.11,44895.04,There are no additional notes associated with this service or procedure.
"Tendon Sheath Incision|RIGHT HAND, THIRD DIGIT",CASE-26055,APC,26055,CPT,0360,RC,,,F7,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1557.80,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1505.12,1580.37,OPPS APC
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],7990.62,,"Case rate ($7,833.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,423.35, add-ons for qualifying new technology services are included. If operating cost exceeds $42,294.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,190.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,458.28 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,478.41 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $430.71. The transfer capital threshold is the transfer adjustment factor * $430.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,5883.03,17111.12,Inpatient DRG
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],10322.60,,"Case rate ($10,120.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,550.21, add-ons for qualifying new technology services are included. If operating cost exceeds $44,421.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,357.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $7,577.32 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,605.26 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $597.93. The transfer capital threshold is the transfer adjustment factor * $597.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,10120.20,26204.74,Inpatient DRG
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],28149.75,,"Case rate ($26,809.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $25,075.72, add-ons for qualifying new technology services are included. If operating cost exceeds $59,946.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,578.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $23,045.79 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $23,130.76 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,818.54. The transfer capital threshold is the transfer adjustment factor * $1,818.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,26809.29,97015.50,Inpatient DRG
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],33890.73,,"Fee schedule rate ($33,890.73). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6277.00,36801.89,There are no additional notes associated with this service or procedure.
Laps Surg Bilateral Total Pelvic Lmphadectomy,CASE-38571,APC,38571,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],10447.27,,"APC Price ($9,949.78). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,9949.78,10447.27,OPPS APC
HC Inj Anesth Celiac Plexus|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64530,APC,64530,CPT,0361,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],827.89,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,827.89,869.28,OPPS APC
Inj for Sacroiliac Jt Anesth|BILATERAL PROCEDURE,CASE-G0260,APC,G0260,CPT,0360,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],693.76,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,660.72,693.76,OPPS APC
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],17100.47,,"Case rate ($16,286.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,286.28, add-ons for qualifying new technology services are included. If operating cost exceeds $50,157.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,808.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $13,292.32 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,341.33 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,048.90. The transfer capital threshold is the transfer adjustment factor * $1,048.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,16286.16,58320.32,Inpatient DRG
Parathyroidectomy/Exploration Parathyroids|LEFT SIDE,CASE-60500,APC,60500,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5541.10,,"APC Price ($5,541.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5541.10,5818.16,OPPS APC
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],14442.92,,,,,,0,other,6915.64,14442.92,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],14871.83,,"Fee schedule rate ($14,871.83). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6558.75,14871.83,There are no additional notes associated with this service or procedure.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],24259.09,,"Fee schedule rate ($24,259.09). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10098.51,24259.09,There are no additional notes associated with this service or procedure.
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC",011,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],102498.90,,"Fee schedule rate ($102,498.90). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,38880.49,150008.48,There are no additional notes associated with this service or procedure.
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],61234.06,,"Fee schedule rate ($61,234.06). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11165.00,61234.06,There are no additional notes associated with this service or procedure.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],38248.08,,"Fee schedule rate ($38,248.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11593.79,38248.08,There are no additional notes associated with this service or procedure.
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6838.09,,"Case rate ($6,606.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,281.82, add-ons for qualifying new technology services are included. If operating cost exceeds $41,152.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,100.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,320.93 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,336.86 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $340.96. The transfer capital threshold is the transfer adjustment factor * $340.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,5919.29,13545.65,Inpatient DRG
"NON-EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,EXTREME",952,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],40306.00,,"Case rate ($38,386.67). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,38386.67,40306.00,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],8318.14,,"Case rate ($8,318.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,873.80, add-ons for qualifying new technology services are included. If operating cost exceeds $42,744.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,226.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,907.07 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,928.85 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $466.13. The transfer capital threshold is the transfer adjustment factor * $466.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8318.14,19763.43,Inpatient DRG
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],25253.70,,"Fee schedule rate ($25,253.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11974.38,29141.64,There are no additional notes associated with this service or procedure.
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],6277.00,,"Per diem ($6,277). If length of stay < 5.6, first 1 days paid at a per diem of $12,554 instead. Capped at $35,148.55.",,,,0,other,6277.00,36801.89,Estimated amount calculated based on 4 day length of stay.
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],54875.56,,"Fee schedule rate ($54,875.56). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,21719.40,85305.59,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],32293.66,,"Fee schedule rate ($32,293.66). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,32293.66,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],13574.43,,"Case rate ($12,928.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,182.77, add-ons for qualifying new technology services are included. If operating cost exceeds $47,053.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,543.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $10,199.15 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,237.82 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $783.93. The transfer capital threshold is the transfer adjustment factor * $783.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13260.40,32878.30,Inpatient DRG
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,555,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],11165.01,,"Case rate ($10,633.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,043.79, add-ons for qualifying new technology services are included. If operating cost exceeds $44,914.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,380.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,068.25 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,098.84 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $620.14. The transfer capital threshold is the transfer adjustment factor * $620.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10896.27,42290.95,Inpatient DRG
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],13808.63,,"Case rate ($13,341.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,547.08, add-ons for qualifying new technology services are included. If operating cost exceeds $47,418.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,593.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $10,563.18 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,602.13 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $833.54. The transfer capital threshold is the transfer adjustment factor * $833.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,13341.67,42586.49,Inpatient DRG
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,082,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],56223.11,,"Fee schedule rate ($56,223.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,17423.21,56223.11,There are no additional notes associated with this service or procedure.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],36094.03,,"Fee schedule rate ($36,094.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11194.25,36094.03,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],81524.17,,"Fee schedule rate ($81,524.17). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,8972.00,81524.17,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],10834.64,,"Case rate ($10,834.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,214.84, add-ons for qualifying new technology services are included. If operating cost exceeds $45,085.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,410.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $8,239.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,269.90 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $650.18. The transfer capital threshold is the transfer adjustment factor * $650.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10834.64,25830.00,Inpatient DRG
MINOR BLADDER PROCEDURES WITHOUT CC/MCC,664,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],19674.39,,"Fee schedule rate ($19,674.39). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,9034.63,31876.87,There are no additional notes associated with this service or procedure.
Exc Lesion Eyelid W/O Clsr/W/Simple Dir Closure,CASE-67840,APC,67840,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],965.76,,"APC Price ($933.10). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,933.10,979.76,OPPS APC
BRONCHITIS AND ASTHMA WITH CC/MCC,202,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],14307.27,,"Fee schedule rate ($14,307.27). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7606.34,19110.30,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],21195.68,,"Fee schedule rate ($21,195.68). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,6965.00,21195.68,There are no additional notes associated with this service or procedure.
HC Remove Tun Cath Vad W/Port,CASE-36590,APC,36590,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1473.45,,"APC Price ($1,473.45). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1473.45,1547.12,OPPS APC
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],9282.47,,"Case rate ($9,282.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,770.90, add-ons for qualifying new technology services are included. If operating cost exceeds $43,641.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,296.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,800.88 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,825.96 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $536.66. The transfer capital threshold is the transfer adjustment factor * $536.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9282.47,21320.03,Inpatient DRG
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],43444.85,,,,,,0,other,16897.01,43444.85,There are no additional notes associated with this service or procedure.
ALLERGIC REACTIONS WITH MCC,915,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],27385.01,,"Fee schedule rate ($27,385.01). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,13332.86,33088.84,There are no additional notes associated with this service or procedure.
"CHRONIC OBSTRUCTIVE PULMONARY DISEASE,MODERATE",140,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],2031.65,,"Case rate for a one day stay ($2,031.65). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,2031.65,2133.23,There are no additional notes associated with this service or procedure.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],17741.86,,"Case rate ($16,897.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,854.53, add-ons for qualifying new technology services are included. If operating cost exceeds $50,725.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,853.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $13,858.48 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,909.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,093.57. The transfer capital threshold is the transfer adjustment factor * $1,093.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,16897.01,43444.85,Inpatient DRG
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],13486.95,,"Fee schedule rate ($13,486.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6915.64,14442.92,There are no additional notes associated with this service or procedure.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],24275.07,,"Case rate ($23,799.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $22,275.40, add-ons for qualifying new technology services are included. If operating cost exceeds $57,146.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,358.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.1. The base transfer operating payment is the transfer adjustment factor * $20,255.77 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $20,330.45 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,598.38. The transfer capital threshold is the transfer adjustment factor * $1,598.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,23799.09,63499.65,Inpatient DRG
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC,817,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],43874.75,,"Fee schedule rate ($43,874.75). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,17396.11,44895.04,There are no additional notes associated with this service or procedure.
SALIVARY GLAND PROCEDURES,139,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],10674.15,,"Case rate ($10,313.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,729.75, add-ons for qualifying new technology services are included. If operating cost exceeds $44,600.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,372.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $7,756.21 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,784.80 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $612.04. The transfer capital threshold is the transfer adjustment factor * $612.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,10313.19,30690.92,Inpatient DRG
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],10846.16,,"Case rate ($10,846.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,225.56, add-ons for qualifying new technology services are included. If operating cost exceeds $45,096.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,410.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $8,250.19 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,280.61 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $651.02. The transfer capital threshold is the transfer adjustment factor * $651.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10846.16,25863.45,Inpatient DRG
MAJOR CHEST PROCEDURES WITH CC,164,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],19418.41,,"Case rate ($19,037.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,845.93, add-ons for qualifying new technology services are included. If operating cost exceeds $52,716.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,010.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $15,842.57 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,900.98 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,250.14. The transfer capital threshold is the transfer adjustment factor * $1,250.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,19037.66,77058.83,Inpatient DRG
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],25796.13,,"Case rate ($24,567.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $22,990.45, add-ons for qualifying new technology services are included. If operating cost exceeds $57,861.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,414.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.7. The base transfer operating payment is the transfer adjustment factor * $20,968.18 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $21,045.49 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,654.60. The transfer capital threshold is the transfer adjustment factor * $1,654.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9370.00,65732.99,Inpatient DRG
VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC,033,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],42156.44,,"Fee schedule rate ($42,156.44). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,13206.23,42156.44,There are no additional notes associated with this service or procedure.
"DIGESTIVE MALIGNANCY,MAJOR",240,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],13537.02,,"The inlier payment is calculated as the lesser of the standard DRG payment $12,892.40 and the transfer payment, which is a per diem of $1,879.36. If cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12892.40,13537.02,Estimated amount calculated based on 4 day length of stay.
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],8269.74,,"Case rate ($7,875.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,462.42, add-ons for qualifying new technology services are included. If operating cost exceeds $42,333.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,193.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $5,497.20 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,517.46 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $433.78. The transfer capital threshold is the transfer adjustment factor * $433.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7875.94,17233.12,Inpatient DRG
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],17100.47,,"Case rate ($16,286.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,286.28, add-ons for qualifying new technology services are included. If operating cost exceeds $50,157.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,808.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $13,292.32 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,341.33 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,048.90. The transfer capital threshold is the transfer adjustment factor * $1,048.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,16286.16,58320.32,Inpatient DRG
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],34614.30,,"Fee schedule rate ($34,614.30). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11348.00,62454.12,There are no additional notes associated with this service or procedure.
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],15857.69,,,,,,0,other,7402.56,16438.59,There are no additional notes associated with this service or procedure.
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],13040.15,,"Fee schedule rate ($13,040.15). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10989.72,26280.60,There are no additional notes associated with this service or procedure.
"MODERATELY EXTENSIVE O.R. PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,MODERATE",793,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],15307.57,,"Case rate ($14,578.64). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,14578.64,15307.57,There are no additional notes associated with this service or procedure.
Cysto W/Urtroscopy&/Pyeloscopy Dx|RIGHT SIDE,CASE-52351,APC,52351,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3464.44,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3299.47,3464.44,OPPS APC
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,306,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],12616.37,,"Case rate ($12,616.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,872.35, add-ons for qualifying new technology services are included. If operating cost exceeds $46,743.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,540.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $9,890.94 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,927.40 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $780.49. The transfer capital threshold is the transfer adjustment factor * $780.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12616.37,31007.02,Inpatient DRG
HC N Block Inj Intercost Sng|RIGHT SIDE,CASE-64420,APC,64420,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],660.72,,"APC Price ($660.72). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,660.72,693.76,OPPS APC
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],7368.94,,"Case rate ($7,224.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,856.36, add-ons for qualifying new technology services are included. If operating cost exceeds $41,727.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,146.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $4,893.37 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,911.41 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $386.14. The transfer capital threshold is the transfer adjustment factor * $386.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6965.00,15340.19,Inpatient DRG
CESAREAN SECTION WITH STERILIZATION WITH CC,784,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],23722.94,,"Fee schedule rate ($23,722.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9124.01,23722.94,There are no additional notes associated with this service or procedure.
Exc Lesion Eyelid W/O Clsr/W/Simple Dir Closure,CASE-67840,APC,67840,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],979.76,,"APC Price ($933.10). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,933.10,979.76,OPPS APC
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|LEFT HAND, FIFTH DIGIT",CASE-26160,APC,26160,CPT,0360,RC,,,F4,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1580.37,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1505.12,1580.37,OPPS APC
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],11440.38,,"Case rate ($10,895.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,271.55, add-ons for qualifying new technology services are included. If operating cost exceeds $45,142.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,414.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $8,296.01 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,326.60 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $654.64. The transfer capital threshold is the transfer adjustment factor * $654.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10895.60,35192.25,Inpatient DRG
SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS,029,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],13641.00,,"Per diem ($13,641). If length of stay < 4.7, first 1 days paid at a per diem of $27,282 instead. Capped at $64,114.20.",,,,0,other,13641.00,67130.05,Estimated amount calculated based on 5 day length of stay.
SALIVARY GLAND PROCEDURES,139,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],30690.92,,"Fee schedule rate ($30,690.92). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,10313.19,30690.92,There are no additional notes associated with this service or procedure.
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC",758,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],19263.78,,,,,,0,other,8574.80,19263.78,There are no additional notes associated with this service or procedure.
FRACTURES OF FEMUR WITH MCC,533,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],49490.05,,"Fee schedule rate ($49,490.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,6852.00,49490.05,There are no additional notes associated with this service or procedure.
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],14391.09,,"Case rate ($13,904.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,070.60, add-ons for qualifying new technology services are included. If operating cost exceeds $47,941.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,634.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,084.78 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,125.65 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $874.70. The transfer capital threshold is the transfer adjustment factor * $874.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,13904.43,34749.58,Inpatient DRG
DIABETES WITHOUT CC/MCC,639,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],6151.76,,"Case rate ($6,151.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,858.45, add-ons for qualifying new technology services are included. If operating cost exceeds $40,729.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,067.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $3,899.13 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,913.51 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $307.68. The transfer capital threshold is the transfer adjustment factor * $307.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6151.76,12223.35,Inpatient DRG
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],15318.94,,"Fee schedule rate ($15,318.94). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6214.05,15318.94,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],27555.15,,"Fee schedule rate ($27,555.15). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,14908.05,49717.39,There are no additional notes associated with this service or procedure.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,544,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],14181.20,,"Fee schedule rate ($14,181.20). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7055.15,23207.64,There are no additional notes associated with this service or procedure.
"ANTEPARTUM WITH O.R. PROCEDURE,MAJOR",547,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],15235.38,,"Case rate ($15,235.38). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,15235.38,15997.15,There are no additional notes associated with this service or procedure.
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],13386.36,,"Case rate ($13,386.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,588.65, add-ons for qualifying new technology services are included. If operating cost exceeds $47,459.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,596.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $10,604.60 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,643.70 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $836.81. The transfer capital threshold is the transfer adjustment factor * $836.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,13386.36,33244.29,Inpatient DRG
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],16612.67,,"Case rate ($15,821.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,854.10, add-ons for qualifying new technology services are included. If operating cost exceeds $49,725.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,774.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $12,861.73 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,909.15 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,014.92. The transfer capital threshold is the transfer adjustment factor * $1,014.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,15821.59,40320.14,Inpatient DRG
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC,520,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],39786.42,,"Fee schedule rate ($39,786.42). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12061.74,39786.42,There are no additional notes associated with this service or procedure.
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],12558.65,,"Fee schedule rate ($12,558.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5065.00,12558.65,There are no additional notes associated with this service or procedure.
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC,497,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],37761.19,,"Fee schedule rate ($37,761.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10127.65,37761.19,There are no additional notes associated with this service or procedure.
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH MCC",722,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],35609.47,,,,,,0,other,14200.37,56869.13,There are no additional notes associated with this service or procedure.
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],59081.91,,"Fee schedule rate ($59,081.91). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,8480.00,59081.91,There are no additional notes associated with this service or procedure.
Vulvectomy Simple Partial,CASE-56620,APC,56620,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3136.08,,"APC Price ($3,030.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3030.03,3181.53,OPPS APC
HC Layer Closure Face <2.5 Cm,CASE-12051,APC,12051,CPT,0450,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1600.04,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1600.04,1600.04,OPPS APC
"SEPTICEMIA AND DISSEMINATED INFECTIONS,EXTREME",720,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],26098.98,,"The inlier payment is calculated as the lesser of the standard DRG payment $24,856.17 and the transfer payment, which is a per diem of $2,401.56. If cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,24856.17,26098.98,Estimated amount calculated based on 2 day length of stay.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],42768.36,,"Fee schedule rate ($42,768.36). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,14295.18,42768.36,There are no additional notes associated with this service or procedure.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],60646.89,,"Fee schedule rate ($60,646.89). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15.6), with a minimum of zero.",,,,0,other,23799.09,63499.65,There are no additional notes associated with this service or procedure.
Ercp W/Sphincterotomy/Papillotomy,CASE-43262,APC,43262,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3735.12,,"APC Price ($3,608.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3608.81,3789.26,OPPS APC
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],30636.35,,"Fee schedule rate ($30,636.35). Adds an outlier to normal pricing equal to the per diem rate ($67,650.85) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12984.79,32077.45,There are no additional notes associated with this service or procedure.
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],18245.94,,"Fee schedule rate ($18,245.94). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8106.18,18245.94,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,085,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],17330.41,,"Case rate ($17,330.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,257.72, add-ons for qualifying new technology services are included. If operating cost exceeds $51,128.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,885.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $14,260.20 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,312.77 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,125.27. The transfer capital threshold is the transfer adjustment factor * $1,125.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9282.00,57443.16,Inpatient DRG
Colon Ca Scrn Not Hi Rsk Ind,CASE-G0121,APC,G0121,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],913.99,,"APC Price ($870.46). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,870.46,913.99,OPPS APC
BRONCHITIS AND ASTHMA WITH CC/MCC,202,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],19110.30,,,,,,0,other,7606.34,19110.30,There are no additional notes associated with this service or procedure.
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC,497,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],20928.60,,"Fee schedule rate ($20,928.60). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10127.65,37761.19,There are no additional notes associated with this service or procedure.
Implnt Bio Implnt for Soft Tissue Reinforcement,CASE-15777,APC,15777,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],13544.27,,"APC Price ($12,899.30). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,13544.27,13544.27,OPPS APC
MAJOR BLADDER PROCEDURES WITH MCC,653,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],125343.98,,"Fee schedule rate ($125,343.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,10280.00,125343.98,There are no additional notes associated with this service or procedure.
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC",629,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],44657.18,,"Fee schedule rate ($44,657.18). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,16699.94,44657.18,There are no additional notes associated with this service or procedure.
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],23870.71,,"Fee schedule rate ($23,870.71). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10626.74,25225.91,There are no additional notes associated with this service or procedure.
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],6606.85,,"Case rate ($6,606.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,281.82, add-ons for qualifying new technology services are included. If operating cost exceeds $41,152.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,100.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,320.93 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,336.86 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $340.96. The transfer capital threshold is the transfer adjustment factor * $340.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,5919.29,13545.65,Inpatient DRG
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],35192.25,,"Fee schedule rate ($35,192.25). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,10895.60,35192.25,There are no additional notes associated with this service or procedure.
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITH MCC OR ANTINEOPLASTIC IMPLANT OR EPILEPSY WITH NEUROSTIMULATOR,023,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],42788.50,,"Case rate ($40,750.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $38,045.35, add-ons for qualifying new technology services are included. If operating cost exceeds $72,916.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,598.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $35,967.78 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $36,100.40 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,838.21. The transfer capital threshold is the transfer adjustment factor * $2,838.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,15168.00,136379.44,Inpatient DRG
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],32814.60,,"Case rate ($18,751.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,579.45, add-ons for qualifying new technology services are included. If operating cost exceeds $52,450.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,989.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $15,577.06 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,634.50 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,229.18. The transfer capital threshold is the transfer adjustment factor * $1,229.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,8480.00,59081.91,All Other Inpatient
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC,099,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],11171.21,,"Case rate ($11,171.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,527.95, add-ons for qualifying new technology services are included. If operating cost exceeds $45,398.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,434.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,551.47 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,583.00 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $674.80. The transfer capital threshold is the transfer adjustment factor * $674.80. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,11171.21,26807.94,Inpatient DRG
COMPLICATIONS OF TREATMENT WITH CC,920,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],8959.88,,"Case rate ($8,533.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,086.17, add-ons for qualifying new technology services are included. If operating cost exceeds $42,957.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,230.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,118.02 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,141.22 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $470.25. The transfer capital threshold is the transfer adjustment factor * $470.25. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8732.59,20731.52,Inpatient DRG
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],34892.92,,"Fee schedule rate ($34,892.92). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,6965.00,41030.48,There are no additional notes associated with this service or procedure.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,025,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],33390.23,,"Case rate ($32,735.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $30,588.77, add-ons for qualifying new technology services are included. If operating cost exceeds $65,459.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,011.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.4. The base transfer operating payment is the transfer adjustment factor * $28,538.59 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $28,643.82 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,251.98. The transfer capital threshold is the transfer adjustment factor * $2,251.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 102%.",,,,0,other,13351.00,91631.33,Inpatient DRG
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,699,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],5961.00,,"Per diem ($5,961). If length of stay < 3.2, first 1 days paid at a per diem of $11,922 instead. Capped at $19,074.90.",,,,0,other,5961.00,19972.16,Estimated amount calculated based on 3 day length of stay.
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",004,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],10715.36,,,,,,0,other,10249.47,272554.00,Estimated amount calculated based on 6 day length of stay.
HYPERTENSION WITHOUT MCC,305,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],9160.44,,"Fee schedule rate ($9,160.44). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7058.55,17230.49,There are no additional notes associated with this service or procedure.
"Tendon Sheath Incision|RIGHT HAND, THUMB",CASE-26055,APC,26055,CPT,0360,RC,,,F5,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1580.37,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1505.12,1580.37,OPPS APC
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],40918.00,,"Fee schedule rate ($40,918.00). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,16689.78,59521.43,There are no additional notes associated with this service or procedure.
Peri-Implant Capsulectomy Breast Complete|BILATERAL PROCEDURE,CASE-19371,APC,19371,CPT,0360,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7918.25,,"APC Price ($7,650.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,7918.25,8033.01,OPPS APC
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],31658.33,,,,,,0,other,1188.00,31658.33,There are no additional notes associated with this service or procedure.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC",494,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],39945.55,,"Fee schedule rate ($39,945.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,15533.10,39945.55,There are no additional notes associated with this service or procedure.
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],16235.87,,"Fee schedule rate ($16,235.87). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6524.00,17760.46,There are no additional notes associated with this service or procedure.
PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,337,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],30204.20,,,,,,0,other,12340.08,38926.31,There are no additional notes associated with this service or procedure.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",062,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],44304.80,,"Fee schedule rate ($44,304.80). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,13844.84,44304.80,There are no additional notes associated with this service or procedure.
"ASTHMA,MODERATE",141,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],2101.28,,"Case rate for a one day stay ($2,101.28). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,2101.28,2206.34,There are no additional notes associated with this service or procedure.
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],2070.00,,,,,,0,other,1188.00,18893.86,Estimated amount calculated based on 3 day length of stay.
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],11170.89,,"Case rate ($10,638.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,032.78, add-ons for qualifying new technology services are included. If operating cost exceeds $44,903.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,395.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,058.12 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,087.83 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $635.87. The transfer capital threshold is the transfer adjustment factor * $635.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10638.94,25261.33,Inpatient DRG
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],7944.77,,"Case rate ($7,566.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,174.51, add-ons for qualifying new technology services are included. If operating cost exceeds $42,045.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,171.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,210.35 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,229.56 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $411.15. The transfer capital threshold is the transfer adjustment factor * $411.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7566.45,16333.88,Inpatient DRG
Lithotripsy Xtrcorp Shock Wave|LEFT SIDE,CASE-50590,APC,50590,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3299.47,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3299.47,3414.95,OPPS APC
Arthrd Ant Ntrbd Min Dsc Ea Addl Interspace,CASE-22585,APC,22585,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],12437.92,,"APC Price ($12,017.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,12437.92,12618.18,OPPS APC
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC",011,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],150008.48,,"Fee schedule rate ($150,008.48). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (44), with a minimum of zero.",,,,0,other,38880.49,150008.48,There are no additional notes associated with this service or procedure.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],58320.32,,"Fee schedule rate ($58,320.32). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,16286.16,58320.32,There are no additional notes associated with this service or procedure.
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],12091.53,,"Case rate ($12,091.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,384.11, add-ons for qualifying new technology services are included. If operating cost exceeds $46,255.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,502.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $9,404.49 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,439.16 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $742.11. The transfer capital threshold is the transfer adjustment factor * $742.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,29482.05,Inpatient DRG
CESAREAN SECTION WITH STERILIZATION WITHOUT CC/MCC,785,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],20142.33,,"Fee schedule rate ($20,142.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8431.24,20142.33,There are no additional notes associated with this service or procedure.
VENTRICULAR SHUNT PROCEDURES WITH MCC,031,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],84202.04,,"Fee schedule rate ($84,202.04). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16.6), with a minimum of zero.",,,,0,other,32287.20,88162.80,There are no additional notes associated with this service or procedure.
"EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME, NEONATE",790,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],43038.65,,"Case rate ($42,194.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $39,388.49, add-ons for qualifying new technology services are included. If operating cost exceeds $74,259.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,703.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 17.9. The base transfer operating payment is the transfer adjustment factor * $37,305.99 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $37,443.54 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,943.81. The transfer capital threshold is the transfer adjustment factor * $2,943.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,3054.00,44304.49,Inpatient DRG
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,098,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],38799.38,,"Fee schedule rate ($38,799.38). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,6965.00,45156.75,There are no additional notes associated with this service or procedure.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,073,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],43475.01,,"Fee schedule rate ($43,475.01). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,12809.38,43475.01,There are no additional notes associated with this service or procedure.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC",061,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],51814.18,,"Fee schedule rate ($51,814.18). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,20616.23,62315.82,There are no additional notes associated with this service or procedure.
HYPERTENSION WITHOUT MCC,305,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],17230.49,,"Fee schedule rate ($17,230.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7058.55,17230.49,There are no additional notes associated with this service or procedure.
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],37899.49,,"Fee schedule rate ($37,899.49). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,14747.55,37899.49,There are no additional notes associated with this service or procedure.
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC,497,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],10634.03,,"Case rate ($10,127.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,557.14, add-ons for qualifying new technology services are included. If operating cost exceeds $44,428.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,358.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 1.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $7,584.22 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,612.19 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $598.47. The transfer capital threshold is the transfer adjustment factor * $598.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10127.65,37761.19,Inpatient DRG
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],22732.01,,"Fee schedule rate ($22,732.01). Adds an outlier to normal pricing equal to the per diem rate ($114,196.66) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.5), with a minimum of zero.",,,,0,other,10136.44,24444.75,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],62084.69,,"Fee schedule rate ($62,084.69). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (35), with a minimum of zero.",,,,0,other,30398.48,82674.88,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],34338.33,,,,,,0,other,1188.00,34338.33,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],107110.70,,"Fee schedule rate ($107,110.70). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (21), with a minimum of zero.",,,,0,other,40542.37,128358.13,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],34409.98,,"Fee schedule rate ($34,409.98). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,14344.60,36028.59,There are no additional notes associated with this service or procedure.
MAJOR CHEST TRAUMA WITHOUT CC/MCC,185,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],7634.75,,"Case rate ($7,271.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,899.84, add-ons for qualifying new technology services are included. If operating cost exceeds $41,770.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,149.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,936.68 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,954.88 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $389.55. The transfer capital threshold is the transfer adjustment factor * $389.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7271.19,21771.61,Inpatient DRG
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],31973.49,,"Fee schedule rate ($31,973.49). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,13386.36,33244.29,There are no additional notes associated with this service or procedure.
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH CC",457,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],43174.02,,"Case rate ($42,327.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $39,511.96, add-ons for qualifying new technology services are included. If operating cost exceeds $74,382.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,713.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $37,429.01 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $37,567.02 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,953.52. The transfer capital threshold is the transfer adjustment factor * $2,953.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,42327.47,160549.49,Inpatient DRG
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],8665.35,,"Case rate ($8,372.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,924.20, add-ons for qualifying new technology services are included. If operating cost exceeds $42,795.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,230.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,957.28 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,979.25 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $470.09. The transfer capital threshold is the transfer adjustment factor * $470.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6965.00,23385.72,Inpatient DRG
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],14871.83,,"Fee schedule rate ($14,871.83). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6558.75,14871.83,There are no additional notes associated with this service or procedure.
Laparoscopic Appendectomy,CASE-44970,APC,44970,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5658.76,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5658.76,5941.70,OPPS APC
DIABETES WITH MCC,637,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],27368.25,,"Fee schedule rate ($27,368.25). Adds an outlier to normal pricing equal to the per diem rate ($39,561.63) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,9959.03,28655.62,There are no additional notes associated with this service or procedure.
TRAUMATIC INJURY WITH MCC,913,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],23742.60,,"Fee schedule rate ($23,742.60). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13014.58,42838.46,There are no additional notes associated with this service or procedure.
HC Debride Subq First 20 Sq Cm|SEPARATE STRUCTURE,CASE-11042,APC,11042,CPT,0361,RC,,,XS,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3169.86,3215.80,OPPS APC
"NEONATE BIRTH WEIGHT > 2499 GRAMS WITH RESPIRATORY DISTRESS SYNDROME OR OTHER MAJOR RESPIRATORY CONDITION,MINOR",634,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],5637.62,,"Case rate ($5,637.62). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,5637.62,5919.50,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],23954.07,,"Fee schedule rate ($23,954.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,6167.00,29058.99,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],19763.43,,"Fee schedule rate ($19,763.43). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,8318.14,19763.43,There are no additional notes associated with this service or procedure.
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],14455.04,,"Fee schedule rate ($14,455.04). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5280.00,17136.70,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],12272.58,,"Fee schedule rate ($12,272.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5628.97,12272.58,There are no additional notes associated with this service or procedure.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],10476.89,,"Case rate ($9,977.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,417.91, add-ons for qualifying new technology services are included. If operating cost exceeds $44,288.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,347.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $7,445.51 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,472.96 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $587.52. The transfer capital threshold is the transfer adjustment factor * $587.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9977.99,26949.28,Inpatient DRG
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC,099,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],11562.20,,"Case rate ($11,171.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,527.95, add-ons for qualifying new technology services are included. If operating cost exceeds $45,398.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,434.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,551.47 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,583.00 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $674.80. The transfer capital threshold is the transfer adjustment factor * $674.80. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,11171.21,26807.94,Inpatient DRG
Injection Aa&/Strd Ilioinguinal Ih Nerves,CASE-64425,APC,64425,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],693.76,,"APC Price ($660.72). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,660.72,693.76,OPPS APC
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],28115.62,,"Case rate ($16,066.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,081.53, add-ons for qualifying new technology services are included. If operating cost exceeds $49,952.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,792.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $13,088.32 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,136.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,032.80. The transfer capital threshold is the transfer adjustment factor * $1,032.80. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,6965.00,41030.48,All Other Inpatient
SIGNS AND SYMPTOMS WITH MCC,947,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],30414.32,,"Fee schedule rate ($30,414.32). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,10541.41,30414.32,There are no additional notes associated with this service or procedure.
RESPIRATORY NEOPLASMS WITHOUT CC/MCC,182,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],7402.23,,"Case rate ($7,049.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,693.83, add-ons for qualifying new technology services are included. If operating cost exceeds $41,564.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,133.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,731.43 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,748.88 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $373.36. The transfer capital threshold is the transfer adjustment factor * $373.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,23037.13,Inpatient DRG
INFLAMMATORY BOWEL DISEASE WITH MCC,385,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],12660.40,,"Case rate ($12,660.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,913.31, add-ons for qualifying new technology services are included. If operating cost exceeds $46,784.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,543.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $9,931.73 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,968.35 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $783.71. The transfer capital threshold is the transfer adjustment factor * $783.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,11480.01,31134.92,Inpatient DRG
Lam Facetec/Foramot Drg Arthrd Lumbar 1 Vrt Sgm,CASE-63052,APC,63052,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],25398.09,,"APC Price ($25,398.09). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,25398.09,25398.09,OPPS APC
"Repair Extensor Tendon Finger W/O Graft Each|LEFT HAND, THUMB",CASE-26418,APC,26418,CPT,0360,RC,,,FA,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1505.12,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1505.12,1580.37,OPPS APC
Tissue Expander Placement Breast Reconstruction|BILATERAL PROCEDURE,CASE-19357,APC,19357,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],12899.30,,"APC Price ($12,899.30). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12899.30,13350.78,OPPS APC
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],24632.06,,"Case rate ($23,799.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $22,275.40, add-ons for qualifying new technology services are included. If operating cost exceeds $57,146.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,358.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.1. The base transfer operating payment is the transfer adjustment factor * $20,255.77 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $20,330.45 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,598.38. The transfer capital threshold is the transfer adjustment factor * $1,598.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,23799.09,63499.65,Inpatient DRG
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],17194.49,,"Fee schedule rate ($17,194.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8554.50,19204.75,There are no additional notes associated with this service or procedure.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],8811.83,,"Case rate ($8,811.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,333.06, add-ons for qualifying new technology services are included. If operating cost exceeds $43,204.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,262.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,364.65 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,388.11 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $502.23. The transfer capital threshold is the transfer adjustment factor * $502.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,20401.88,Inpatient DRG
Arthrs Wrst Exc&/Rpr Triang Fibrocart&/Joint|RIGHT SIDE,CASE-29846,APC,29846,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],41944.25,,"Fee schedule rate ($41,944.25). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12795.84,41944.25,There are no additional notes associated with this service or procedure.
CERVICAL SPINAL FUSION WITH CC,472,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],70198.84,,"Fee schedule rate ($70,198.84). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,21896.13,70198.84,There are no additional notes associated with this service or procedure.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",062,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],34576.42,,,,,,0,other,13844.84,44304.80,There are no additional notes associated with this service or procedure.
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],14690.49,,"Fee schedule rate ($14,690.49). Adds an outlier to normal pricing equal to the per diem rate ($54,770.58) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.7), with a minimum of zero.",,,,0,other,7238.69,16804.22,There are no additional notes associated with this service or procedure.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],24956.34,,,,,,0,other,10533.95,24956.34,There are no additional notes associated with this service or procedure.
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITH MCC OR ANTINEOPLASTIC IMPLANT OR EPILEPSY WITH NEUROSTIMULATOR,023,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],40750.95,,"Case rate ($40,750.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $38,045.35, add-ons for qualifying new technology services are included. If operating cost exceeds $72,916.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,598.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $35,967.78 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $36,100.40 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,838.21. The transfer capital threshold is the transfer adjustment factor * $2,838.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,15168.00,136379.44,Inpatient DRG
Egd Transoral Biopsy Single/Multiple|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-43239,APC,43239,CPT,0360,RC,,,74,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],848.96,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,848.96,891.41,OPPS APC
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],8319.50,,"Case rate ($7,923.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,506.51, add-ons for qualifying new technology services are included. If operating cost exceeds $42,377.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,197.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $5,541.13 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,561.56 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $437.25. The transfer capital threshold is the transfer adjustment factor * $437.25. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,1188.00,17370.86,Inpatient DRG
Tx Missed Abortion First Trimester Surgical,CASE-59820,APC,59820,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3030.03,,"APC Price ($3,030.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3030.03,3181.53,OPPS APC
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],81454.07,,"Fee schedule rate ($81,454.07). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,10078.00,81454.07,There are no additional notes associated with this service or procedure.
"Prq Skel Fixj Phlngl Shft Fx Prox/Middle Px/F/T|LEFT HAND, FIFTH DIGIT",CASE-26727,APC,26727,CPT,0360,RC,,,F4,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],8970.82,,"Case rate ($8,543.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,083.58, add-ons for qualifying new technology services are included. If operating cost exceeds $42,954.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,242.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,116.09 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,138.64 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $482.62. The transfer capital threshold is the transfer adjustment factor * $482.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8543.64,23239.84,Inpatient DRG
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC,058,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],40853.02,,"Fee schedule rate ($40,853.02). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,13521.80,40853.02,There are no additional notes associated with this service or procedure.
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],39424.57,,"Fee schedule rate ($39,424.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12195.15,39424.57,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF THE EYE WITHOUT MCC,125,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],14429.27,,"Fee schedule rate ($14,429.27). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.9), with a minimum of zero.",,,,0,other,7144.54,17952.29,There are no additional notes associated with this service or procedure.
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],45157.33,,"Fee schedule rate ($45,157.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,10733.06,45157.33,There are no additional notes associated with this service or procedure.
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH MCC",722,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],56869.13,,"Fee schedule rate ($56,869.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,14200.37,56869.13,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],30636.35,,"Fee schedule rate ($30,636.35). Adds an outlier to normal pricing equal to the per diem rate ($67,650.85) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12984.79,32077.45,There are no additional notes associated with this service or procedure.
"ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",770,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],19730.13,,,,,,0,other,8735.30,19730.13,There are no additional notes associated with this service or procedure.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],5569.00,,"Per diem ($5,569). If length of stay < 3.8, first 1 days paid at a per diem of $11,138 instead. Capped at $21,162.80.",,,,0,other,5569.00,40108.48,Estimated amount calculated based on 2 day length of stay.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],20135.47,,,,,,0,other,8874.81,20553.44,There are no additional notes associated with this service or procedure.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,309,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],8103.90,,"Fee schedule rate ($8,103.90). Adds an outlier to normal pricing equal to the per diem rate ($3,770.33) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5055.77,14547.21,There are no additional notes associated with this service or procedure.
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],20170.75,,"Fee schedule rate ($20,170.75). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10048.39,23545.50,There are no additional notes associated with this service or procedure.
HC N Block Inj Suprascapular Nerv|LEFT SIDE,CASE-64418,APC,64418,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],660.72,,"APC Price ($660.72). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,660.72,693.76,OPPS APC
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],17194.49,,"Fee schedule rate ($17,194.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8554.50,19204.75,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITHOUT CC/MCC,428,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],118904.57,,"Fee schedule rate ($118,904.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,40017.53,118904.57,There are no additional notes associated with this service or procedure.
Surgical Arthroscopy Shoulder Biceps Tenodesis,CASE-29828,APC,29828,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,555,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],26009.06,,,,,,0,other,10896.27,42290.95,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6299.93,,"Case rate ($5,999.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,724.78, add-ons for qualifying new technology services are included. If operating cost exceeds $40,595.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,049.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $3,765.55 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,779.83 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $289.43. The transfer capital threshold is the transfer adjustment factor * $289.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,1188.00,12138.74,Inpatient DRG
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,056,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],7659.00,,"Per diem ($7,659). If length of stay < 5.7, first 1 days paid at a per diem of $15,318 instead. Capped at $43,658.02.",,,,0,other,7659.00,59328.19,Estimated amount calculated based on 3 day length of stay.
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],10181.78,,"Case rate ($9,696.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,156.46, add-ons for qualifying new technology services are included. If operating cost exceeds $44,027.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,326.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $7,185.02 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,211.51 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $566.97. The transfer capital threshold is the transfer adjustment factor * $566.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9696.93,35061.53,Inpatient DRG
Hysteroscopy Removal Impacted Foreign Body,CASE-58562,APC,58562,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3136.08,,"APC Price ($3,030.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3030.03,3136.08,OPPS APC
SPINAL PROCEDURES WITH MCC,028,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],112913.98,,"Fee schedule rate ($112,913.98). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,42633.57,120982.83,There are no additional notes associated with this service or procedure.
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],15177.23,,"Fee schedule rate ($15,177.23). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,7414.07,18217.52,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITH STERILIZATION WITH MCC,783,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],18571.05,,"Case rate ($18,571.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,411.86, add-ons for qualifying new technology services are included. If operating cost exceeds $52,282.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,975.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $15,410.10 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,466.92 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,216.01. The transfer capital threshold is the transfer adjustment factor * $1,216.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12612.10,23722.94,Inpatient DRG
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC,434,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],13390.01,,"Fee schedule rate ($13,390.01). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6770.05,14019.86,There are no additional notes associated with this service or procedure.
HC Bx Breast 1st Lesion US Img|RIGHT SIDE,CASE-19083,APC,19083,CPT,0361,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1545.93,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1545.93,1623.23,OPPS APC
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],22425.60,,"Case rate ($21,667.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,292.19, add-ons for qualifying new technology services are included. If operating cost exceeds $55,163.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,202.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $18,279.84 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,347.24 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,442.46. The transfer capital threshold is the transfer adjustment factor * $1,442.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,8972.00,81524.17,Inpatient DRG
Egd Ablate Tumor Polyp/Lesion W/Dilation& Wire,CASE-43270,APC,43270,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1885.95,,"APC Price ($1,796.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1796.14,1885.95,OPPS APC
"CVA AND PRECEREBRAL OCCLUSION WITH INFARCTION,MODERATE",045,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],10746.50,,"Case rate ($10,234.76). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10234.76,10746.50,There are no additional notes associated with this service or procedure.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC",156,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],12624.95,,"Fee schedule rate ($12,624.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6625.12,13598.77,There are no additional notes associated with this service or procedure.
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH CC",457,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],160549.49,,"Fee schedule rate ($160,549.49). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,42327.47,160549.49,There are no additional notes associated with this service or procedure.
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],24528.10,,"Fee schedule rate ($24,528.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10989.72,26280.60,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,555,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],11441.08,,"Case rate ($10,896.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,272.18, add-ons for qualifying new technology services are included. If operating cost exceeds $45,143.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,414.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,296.64 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,327.23 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $654.69. The transfer capital threshold is the transfer adjustment factor * $654.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10896.27,42290.95,Inpatient DRG
CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC,788,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],19006.00,,,,,,0,other,8438.02,20142.33,There are no additional notes associated with this service or procedure.
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],17755.26,,"Fee schedule rate ($17,755.26). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7847.50,17755.26,There are no additional notes associated with this service or procedure.
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],16235.87,,"Fee schedule rate ($16,235.87). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6524.00,17760.46,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],10709.21,,"Case rate ($10,347.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,761.25, add-ons for qualifying new technology services are included. If operating cost exceeds $44,632.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,374.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $7,787.59 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,816.30 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $614.52. The transfer capital threshold is the transfer adjustment factor * $614.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,10347.06,28821.04,Inpatient DRG
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,095,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],48575.01,,"Fee schedule rate ($48,575.01). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,19411.47,50750.92,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC,087,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],8139.36,,"Case rate ($8,139.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,707.48, add-ons for qualifying new technology services are included. If operating cost exceeds $42,578.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,213.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $5,741.36 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,762.53 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $453.05. The transfer capital threshold is the transfer adjustment factor * $453.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8139.36,22679.07,Inpatient DRG
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],37016.57,,"Fee schedule rate ($37,016.57). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15), with a minimum of zero.",,,,0,other,15283.90,38757.79,There are no additional notes associated with this service or procedure.
COMPLICATIONS OF TREATMENT WITH CC,920,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],9038.23,,"Case rate ($8,732.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,259.35, add-ons for qualifying new technology services are included. If operating cost exceeds $43,130.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,256.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,291.21 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,314.40 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $496.44. The transfer capital threshold is the transfer adjustment factor * $496.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,8732.59,20731.52,Inpatient DRG
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC,797,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],8719.72,,"Case rate ($8,719.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,247.38, add-ons for qualifying new technology services are included. If operating cost exceeds $43,118.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,255.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $6,279.28 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,302.43 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $495.50. The transfer capital threshold is the transfer adjustment factor * $495.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8719.72,20928.55,Inpatient DRG
CERVICAL SPINAL FUSION WITH CC,472,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],55366.06,,"Fee schedule rate ($55,366.06). Adds an outlier to normal pricing equal to the per diem rate ($66,990.29) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,21896.13,70198.84,There are no additional notes associated with this service or procedure.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],29837.65,,"Fee schedule rate ($29,837.65). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,12696.97,47123.82,There are no additional notes associated with this service or procedure.
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",004,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],10715.36,,,,,,0,other,10249.47,272554.00,Estimated amount calculated based on 6 day length of stay.
Tx Incomplete Abortion Any Trimester Surgical,CASE-59812,APC,59812,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3030.03,,"APC Price ($3,030.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3030.03,3181.53,OPPS APC
RESPIRATORY NEOPLASMS WITH CC,181,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],9361.88,,"Fee schedule rate ($9,361.88). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9197.84,21074.07,There are no additional notes associated with this service or procedure.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,329,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],33734.23,,"Case rate ($33,072.77). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $30,902.51, add-ons for qualifying new technology services are included. If operating cost exceeds $65,773.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,036.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.4. The base transfer operating payment is the transfer adjustment factor * $28,851.18 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $28,957.55 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,276.64. The transfer capital threshold is the transfer adjustment factor * $2,276.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,33072.77,90445.33,Inpatient DRG
"SICKLE CELL ANEMIA CRISIS,MODERATE",662,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],8059.59,,"Case rate ($7,675.80). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7675.80,8059.59,There are no additional notes associated with this service or procedure.
Tx Missed Abortion First Trimester Surgical,CASE-59820,APC,59820,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3136.08,,"APC Price ($3,030.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3030.03,3181.53,OPPS APC
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],2070.00,,,,,,0,other,1188.00,31658.33,Estimated amount calculated based on 16 day length of stay.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],28619.77,,"Case rate ($27,256.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $25,492.14, add-ons for qualifying new technology services are included. If operating cost exceeds $60,363.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,611.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. The base transfer operating payment is the transfer adjustment factor * $23,460.69 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $23,547.19 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,851.28. The transfer capital threshold is the transfer adjustment factor * $1,851.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,27256.92,81353.66,Inpatient DRG
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],45933.85,,"Fee schedule rate ($45,933.85). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,18497.24,62041.12,There are no additional notes associated with this service or procedure.
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],17662.17,,"Fee schedule rate ($17,662.17). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (47), with a minimum of zero.",,,,0,other,15283.90,38757.79,There are no additional notes associated with this service or procedure.
Perq Nl/Pl Lithotrp Simple Up to 2 Cm 1 Location|RIGHT SIDE,CASE-50080,APC,50080,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],9170.96,,"APC Price ($8,860.83). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,8860.83,9303.88,OPPS APC
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],14525.56,,,,,,0,other,5068.21,14525.56,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],33398.16,,"Fee schedule rate ($33,398.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,7353.00,33398.16,There are no additional notes associated with this service or procedure.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC",494,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],39945.55,,"Fee schedule rate ($39,945.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,15533.10,39945.55,There are no additional notes associated with this service or procedure.
NON-MALIGNANT BREAST DISORDERS WITH CC/MCC,600,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],15046.13,,"Fee schedule rate ($15,046.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7999.14,20495.56,There are no additional notes associated with this service or procedure.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],33608.45,,"Fee schedule rate ($33,608.45). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,7332.00,35314.31,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],13299.05,,"Case rate ($12,665.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,938.30, add-ons for qualifying new technology services are included. If operating cost exceeds $46,809.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,525.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $9,955.60 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,993.35 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $765.21. The transfer capital threshold is the transfer adjustment factor * $765.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9888.00,43399.23,Inpatient DRG
Cysto Bladder W/Ureteral Catheterization|BILATERAL PROCEDURE,CASE-52005,APC,52005,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1956.65,,"APC Price ($1,956.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1956.65,2054.48,OPPS APC
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,093,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],19011.32,,"Fee schedule rate ($19,011.32). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,19011.32,There are no additional notes associated with this service or procedure.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,098,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],17486.17,,"Case rate ($17,486.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,402.62, add-ons for qualifying new technology services are included. If operating cost exceeds $51,273.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,896.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $14,404.56 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,457.67 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,136.66. The transfer capital threshold is the transfer adjustment factor * $1,136.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,45156.75,Inpatient DRG
"Fasct Prtl Palmar 1 Dgt Prox Iphal Jt W/WO Rpr|RIGHT HAND, THUMB",CASE-26123,APC,26123,CPT,0360,RC,,,F5,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3169.86,OPPS APC
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,699,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],19570.20,,"Fee schedule rate ($19,570.20). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5961.00,19972.16,There are no additional notes associated with this service or procedure.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],20289.13,,"Case rate ($11,593.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,921.06, add-ons for qualifying new technology services are included. If operating cost exceeds $45,792.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,465.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $8,943.14 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,976.12 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $705.70. The transfer capital threshold is the transfer adjustment factor * $705.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,11593.79,38248.08,All Other Inpatient
CHEST PAIN,313,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],15377.66,,"Fee schedule rate ($15,377.66). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,6820.84,15377.66,There are no additional notes associated with this service or procedure.
Neuroplasty &/Transposition Ulnar Nerve Elbow|LEFT SIDE|SEPARATE STRUCTURE,CASE-64718,APC,64718,CPT,0360,RC,,,LT|XS,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC,805,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],11584.65,,"Fee schedule rate ($11,584.65). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9253.36,21235.42,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,086,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],8442.00,,"Per diem ($8,442). If length of stay < 2.9, first 1 days paid at a per diem of $16,884 instead. Capped at $24,481.64.",,,,0,other,8442.00,30728.81,Estimated amount calculated based on 2 day length of stay.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],45845.03,,"Fee schedule rate ($45,845.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,18598.83,48389.68,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],14169.40,,"Case rate ($13,891.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,058.63, add-ons for qualifying new technology services are included. If operating cost exceeds $47,929.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,633.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,072.85 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,113.68 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $873.76. The transfer capital threshold is the transfer adjustment factor * $873.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,13891.57,34712.20,Inpatient DRG
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],85466.62,,"Fee schedule rate ($85,466.62). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,21382.16,85466.62,There are no additional notes associated with this service or procedure.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],9206.20,,"Case rate ($8,767.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,292.11, add-ons for qualifying new technology services are included. If operating cost exceeds $43,163.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,258.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,323.85 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,347.16 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $499.01. The transfer capital threshold is the transfer adjustment factor * $499.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8767.81,19824.58,Inpatient DRG
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,690,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],8106.00,,"Fee schedule rate ($8,106). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7426.94,15928.53,There are no additional notes associated with this service or procedure.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],7605.00,,"Per diem ($7,605). If length of stay < 4.8, first 1 days paid at a per diem of $15,210 instead. Capped at $36,505.40.",,,,0,other,7605.00,39153.65,Estimated amount calculated based on 3 day length of stay.
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],37149.27,,"Fee schedule rate ($37,149.27). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,12455.21,37149.27,There are no additional notes associated with this service or procedure.
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC",011,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],150008.48,,"Fee schedule rate ($150,008.48). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (44), with a minimum of zero.",,,,0,other,38880.49,150008.48,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],28235.64,,"Fee schedule rate ($28,235.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,14344.60,36028.59,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,373,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6870.94,,"Case rate ($6,870.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,527.50, add-ons for qualifying new technology services are included. If operating cost exceeds $41,398.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,120.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $4,565.72 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,582.56 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $360.28. The transfer capital threshold is the transfer adjustment factor * $360.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6870.94,14313.05,Inpatient DRG
NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,601,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],11369.77,,"Fee schedule rate ($11,369.77). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,6042.05,12359.72,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],24669.57,,"Fee schedule rate ($24,669.57). Adds an outlier to normal pricing equal to the per diem rate ($34,856.52) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.7), with a minimum of zero.",,,,0,other,10834.64,25830.00,There are no additional notes associated with this service or procedure.
Cysto/Uretero W/Lithotripsy &Indwell Stent Insrt|SEPARATE STRUCTURE|RIGHT SIDE,CASE-52356,APC,52356,CPT,0360,RC,,,XS|RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5018.77,,"APC Price ($5,018.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5018.77,5269.71,OPPS APC
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",004,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],10715.36,,,,,,0,other,10249.47,272554.00,Estimated amount calculated based on 6 day length of stay.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],9977.99,,"Case rate ($9,977.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,417.91, add-ons for qualifying new technology services are included. If operating cost exceeds $44,288.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,347.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $7,445.51 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,472.96 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $587.52. The transfer capital threshold is the transfer adjustment factor * $587.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9977.99,26949.28,Inpatient DRG
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],39424.57,,"Fee schedule rate ($39,424.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12195.15,39424.57,There are no additional notes associated with this service or procedure.
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],22487.70,,"Fee schedule rate ($22,487.70). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10048.39,23545.50,There are no additional notes associated with this service or procedure.
HC Bx Breast 1st Lesion US Img|LEFT SIDE,CASE-19083,APC,19083,CPT,0361,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1545.93,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1545.93,1623.23,OPPS APC
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],62708.63,,,,,,0,other,23526.87,94787.57,There are no additional notes associated with this service or procedure.
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],12725.42,,"Case rate ($12,725.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,973.79, add-ons for qualifying new technology services are included. If operating cost exceeds $46,844.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,548.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $9,991.99 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,028.83 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $788.47. The transfer capital threshold is the transfer adjustment factor * $788.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12725.42,34245.00,Inpatient DRG
CERVICAL SPINAL FUSION WITH CC,472,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],55366.06,,"Fee schedule rate ($55,366.06). Adds an outlier to normal pricing equal to the per diem rate ($66,990.29) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,21896.13,70198.84,There are no additional notes associated with this service or procedure.
MAJOR THUMB OR JOINT PROCEDURES,506,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],25355.52,,"Fee schedule rate ($25,355.52). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.5), with a minimum of zero.",,,,0,other,11081.83,26548.21,There are no additional notes associated with this service or procedure.
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC",605,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],8555.58,,"Case rate ($8,148.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,715.67, add-ons for qualifying new technology services are included. If operating cost exceeds $42,586.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,213.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,749.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,770.72 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $453.69. The transfer capital threshold is the transfer adjustment factor * $453.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8148.17,18024.13,Inpatient DRG
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],29916.58,,"Fee schedule rate ($29,916.58). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12725.42,34245.00,There are no additional notes associated with this service or procedure.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],58320.32,,"Fee schedule rate ($58,320.32). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,16286.16,58320.32,There are no additional notes associated with this service or procedure.
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 2nd Level|LEFT SIDE,CASE-64494,APC,64494,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],827.89,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,827.89,869.28,OPPS APC
"CARDIAC ARREST, UNEXPLAINED WITH MCC",296,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],12960.53,,"Case rate ($12,522.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,784.78, add-ons for qualifying new technology services are included. If operating cost exceeds $46,655.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,533.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $9,803.69 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,839.84 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $773.61. The transfer capital threshold is the transfer adjustment factor * $773.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,12522.25,36459.67,Inpatient DRG
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],25148.13,,"Case rate ($14,370.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,504.04, add-ons for qualifying new technology services are included. If operating cost exceeds $48,375.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,668.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $11,516.62 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,559.08 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $908.78. The transfer capital threshold is the transfer adjustment factor * $908.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,14370.36,38378.80,All Other Inpatient
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH CC",457,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],160549.49,,"Fee schedule rate ($160,549.49). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,42327.47,160549.49,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6977.68,,"Case rate ($6,645.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,326.46, add-ons for qualifying new technology services are included. If operating cost exceeds $41,197.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,095.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,364.96 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,381.51 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $335.50. The transfer capital threshold is the transfer adjustment factor * $335.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6164.03,14071.02,Inpatient DRG
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],14492.93,,"Fee schedule rate ($14,492.93). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6503.90,14492.93,There are no additional notes associated with this service or procedure.
FRACTURES OF FEMUR WITH MCC,533,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],13001.18,,"Case rate ($12,561.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,821.33, add-ons for qualifying new technology services are included. If operating cost exceeds $46,692.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,536.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $9,840.09 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,876.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $776.48. The transfer capital threshold is the transfer adjustment factor * $776.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6852.00,49490.05,Inpatient DRG
"Inj Dx/Ther Agnt Paravert Facet Joint, Cerv/Thorac, 2nd Level|LEFT SIDE",CASE-64491,APC,64491,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],856.86,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,827.89,869.28,OPPS APC
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,699,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],19570.20,,"Fee schedule rate ($19,570.20). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5961.00,19972.16,There are no additional notes associated with this service or procedure.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],52699.33,,"Fee schedule rate ($52,699.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,18105.81,52699.33,There are no additional notes associated with this service or procedure.
Total Thyroid Lobectomy Uni W/WO Isthmusectomy|RIGHT SIDE,CASE-60220,APC,60220,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5941.70,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5658.76,5941.70,OPPS APC
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],16926.26,,"Case rate ($16,120.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,131.93, add-ons for qualifying new technology services are included. If operating cost exceeds $50,002.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,796.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $13,138.54 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,186.98 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,036.76. The transfer capital threshold is the transfer adjustment factor * $1,036.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,16120.25,41187.90,Inpatient DRG
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],24838.71,,"Fee schedule rate ($24,838.71). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,10895.60,35192.25,There are no additional notes associated with this service or procedure.
RESPIRATORY NEOPLASMS WITH CC,181,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],20127.30,,"Fee schedule rate ($20,127.30). Adds an outlier to normal pricing equal to the per diem rate ($54,966.40) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,9197.84,21074.07,There are no additional notes associated with this service or procedure.
"Amputation Toe Interphalangeal Joint|LEFT FOOT, THIRD DIGIT",CASE-28825,APC,28825,CPT,0360,RC,,,T2,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,097,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],27724.54,,"Case rate ($26,404.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $24,698.97, add-ons for qualifying new technology services are included. If operating cost exceeds $59,569.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,548.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.7. The base transfer operating payment is the transfer adjustment factor * $22,670.44 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $22,754.03 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,788.92. The transfer capital threshold is the transfer adjustment factor * $1,788.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,26404.32,79915.74,Inpatient DRG
INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC,198,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],23505.07,,"Fee schedule rate ($23,505.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6795.12,23505.07,There are no additional notes associated with this service or procedure.
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],37199.37,,,,,,0,other,14747.55,37899.49,There are no additional notes associated with this service or procedure.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],37505.96,,"Case rate ($35,719.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $33,365.14, add-ons for qualifying new technology services are included. If operating cost exceeds $68,236.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,230.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.9. The base transfer operating payment is the transfer adjustment factor * $31,304.77 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $31,420.19 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,470.26. The transfer capital threshold is the transfer adjustment factor * $2,470.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,35719.96,105091.76,Inpatient DRG
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],11260.25,,"Case rate ($10,724.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,128.34, add-ons for qualifying new technology services are included. If operating cost exceeds $44,999.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,386.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $8,152.48 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,183.39 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $626.62. The transfer capital threshold is the transfer adjustment factor * $626.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10989.72,26280.60,Inpatient DRG
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],14674.80,,"Fee schedule rate ($14,674.80). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6711.00,16865.16,There are no additional notes associated with this service or procedure.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],9351.96,,"Case rate ($8,906.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,421.26, add-ons for qualifying new technology services are included. If operating cost exceeds $43,292.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,269.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $6,452.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,476.31 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $509.17. The transfer capital threshold is the transfer adjustment factor * $509.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8906.63,28434.57,Inpatient DRG
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],34245.00,,"Fee schedule rate ($34,245.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,12725.42,34245.00,There are no additional notes associated with this service or procedure.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],19877.10,,"Fee schedule rate ($19,877.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8009.34,19877.10,There are no additional notes associated with this service or procedure.
MAJOR ESOPHAGEAL DISORDERS WITH CC,369,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],6965.00,,,,,,0,other,6965.00,19680.94,There are no additional notes associated with this service or procedure.
HC Non Stress Test|UNUSUAL NON-OVERLAPPING SERVICE,CASE-59025,APC,59025,CPT,0920,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],189.24,,"APC Price ($189.24). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,189.24,198.70,OPPS APC
"Corrj Hallux Valgus W/Sesmdc W/Rescj Prox Phal|LEFT FOOT, GREAT TOE",CASE-28292,APC,28292,CPT,0360,RC,,,TA,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
RADIOTHERAPY,849,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],20293.88,,"Case rate ($20,293.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $19,014.57, add-ons for qualifying new technology services are included. If operating cost exceeds $53,885.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,101.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $17,006.91 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $17,069.62 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,342.01. The transfer capital threshold is the transfer adjustment factor * $1,342.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,20293.88,81867.07,Inpatient DRG
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],39797.94,,"Fee schedule rate ($39,797.94). Adds an outlier to normal pricing equal to the per diem rate ($75,578.79) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.5), with a minimum of zero.",,,,0,other,16286.16,58320.32,There are no additional notes associated with this service or procedure.
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],30236.06,,"Fee schedule rate ($30,236.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.8), with a minimum of zero.",,,,0,other,1188.00,31658.33,There are no additional notes associated with this service or procedure.
FRACTURES OF FEMUR WITH MCC,533,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],49490.05,,"Fee schedule rate ($49,490.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,6852.00,49490.05,There are no additional notes associated with this service or procedure.
Tx Incomplete Abortion Any Trimester Surgical,CASE-59812,APC,59812,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3181.53,,"APC Price ($3,030.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3030.03,3181.53,OPPS APC
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],12154.28,,"Case rate ($11,575.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,904.06, add-ons for qualifying new technology services are included. If operating cost exceeds $45,775.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,464.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $8,926.20 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,959.11 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $704.37. The transfer capital threshold is the transfer adjustment factor * $704.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,11575.50,48961.48,Inpatient DRG
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],35192.25,,"Fee schedule rate ($35,192.25). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,10895.60,35192.25,There are no additional notes associated with this service or procedure.
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],16379.98,,"Fee schedule rate ($16,379.98). Adds an outlier to normal pricing equal to the per diem rate ($46,377.87) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7847.50,17755.26,There are no additional notes associated with this service or procedure.
HEART FAILURE AND SHOCK WITH CC,292,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7901.83,,"Case rate ($7,525.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,146.88, add-ons for qualifying new technology services are included. If operating cost exceeds $42,017.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,158.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,182.28 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,201.93 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $398.32. The transfer capital threshold is the transfer adjustment factor * $398.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5502.00,16705.77,Inpatient DRG
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],56476.93,,,,,,0,other,21382.16,85466.62,There are no additional notes associated with this service or procedure.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,477,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],62359.39,,"Fee schedule rate ($62,359.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,25339.74,67976.16,There are no additional notes associated with this service or procedure.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],85466.62,,"Fee schedule rate ($85,466.62). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,21382.16,85466.62,There are no additional notes associated with this service or procedure.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],75579.22,,"Fee schedule rate ($75,579.22). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,25162.32,75579.22,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],25609.86,,"Fee schedule rate ($25,609.86). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,12775.53,31469.43,There are no additional notes associated with this service or procedure.
"NEONATE BIRTH WEIGHT > 2499 GRAMS WITH MAJOR ANOMALY,MAJOR",633,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],23435.09,,"Case rate ($22,319.13). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,22319.13,23435.09,There are no additional notes associated with this service or procedure.
RADIOTHERAPY,849,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],81867.07,,"Fee schedule rate ($81,867.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,20293.88,81867.07,There are no additional notes associated with this service or procedure.
Injection Aa&/Strd Genicular Nrv Branches W/Img|RIGHT SIDE,CASE-64454,APC,64454,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],693.76,,"APC Price ($660.72). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,660.72,693.76,OPPS APC
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],18905.23,,"Fee schedule rate ($18,905.23). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6963.00,18954.85,There are no additional notes associated with this service or procedure.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],37768.77,,"Fee schedule rate ($37,768.77). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7453.00,42138.30,There are no additional notes associated with this service or procedure.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],20553.44,,"Fee schedule rate ($20,553.44). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8874.81,20553.44,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],31533.97,,"Fee schedule rate ($31,533.97). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8563.30,31533.97,There are no additional notes associated with this service or procedure.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],17365.00,,"Fee schedule rate ($17,365.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5683.00,19635.68,There are no additional notes associated with this service or procedure.
HYPERTENSION WITHOUT MCC,305,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],17230.49,,"Fee schedule rate ($17,230.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7058.55,17230.49,There are no additional notes associated with this service or procedure.
"OTHER COMPLICATIONS OF TREATMENT,MODERATE",813,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],7929.51,,"Case rate ($7,551.91). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7551.91,7929.51,There are no additional notes associated with this service or procedure.
Bronchoscopy Needle Bx Trachea Main Stem&/Bron,CASE-31629,APC,31629,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6605.95,,"APC Price ($6,605.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6605.95,6936.25,OPPS APC
"NEONATE BIRTH WEIGHT 2000-2499 GRAMS WITH OTHER SIGNIFICANT CONDITION,MODERATE",625,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],14740.04,,"Case rate ($14,038.13). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,14038.13,14740.04,There are no additional notes associated with this service or procedure.
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],14603.31,,"Case rate ($14,603.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,720.75, add-ons for qualifying new technology services are included. If operating cost exceeds $48,591.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,685.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $11,732.54 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,775.80 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $925.81. The transfer capital threshold is the transfer adjustment factor * $925.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,14603.31,45017.13,Inpatient DRG
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],52699.33,,"Fee schedule rate ($52,699.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,18105.81,52699.33,There are no additional notes associated with this service or procedure.
"Repair Extensor Tendon Finger W/O Graft Each|LEFT HAND, THUMB",CASE-26418,APC,26418,CPT,0360,RC,,,FA,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1580.37,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1505.12,1580.37,OPPS APC
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],21167.26,,"Fee schedule rate ($21,167.26). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,6841.83,21167.26,There are no additional notes associated with this service or procedure.
CHOLECYSTECTOMY WITH C.D.E. WITH MCC,411,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],88615.28,,"Fee schedule rate ($88,615.28). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,24315.13,88615.28,There are no additional notes associated with this service or procedure.
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],13732.10,,"Fee schedule rate ($13,732.10). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6965.00,29482.05,There are no additional notes associated with this service or procedure.
SEIZURES WITH MCC,100,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],15061.09,,"Case rate ($15,061.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,146.62, add-ons for qualifying new technology services are included. If operating cost exceeds $49,017.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,719.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $12,156.85 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,201.67 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $959.30. The transfer capital threshold is the transfer adjustment factor * $959.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,15061.09,38110.41,Inpatient DRG
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],13448.43,,"Case rate ($12,808.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,050.64, add-ons for qualifying new technology services are included. If operating cost exceeds $46,921.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,554.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $10,068.57 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,105.69 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $794.51. The transfer capital threshold is the transfer adjustment factor * $794.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7353.00,33398.16,Inpatient DRG
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],24259.09,,"Fee schedule rate ($24,259.09). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10098.51,24259.09,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITH STERILIZATION WITH CC,784,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],19922.46,,"Fee schedule rate ($19,922.46). Adds an outlier to normal pricing equal to the per diem rate ($39,437.39) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,9124.01,23722.94,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],13947.32,,"Fee schedule rate ($13,947.32). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6153.12,13947.32,There are no additional notes associated with this service or procedure.
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],35061.53,,"Fee schedule rate ($35,061.53). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,9696.93,35061.53,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITH STERILIZATION WITH CC,784,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],23722.94,,"Fee schedule rate ($23,722.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9124.01,23722.94,There are no additional notes associated with this service or procedure.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],23340.86,,,,,,0,other,9977.99,26949.28,There are no additional notes associated with this service or procedure.
SEIZURES WITH MCC,100,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],38110.41,,,,,,0,other,15061.09,38110.41,There are no additional notes associated with this service or procedure.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],39153.65,,"Fee schedule rate ($39,153.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,7605.00,39153.65,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,086,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],30728.81,,"Fee schedule rate ($30,728.81). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8442.00,30728.81,There are no additional notes associated with this service or procedure.
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],11065.78,,"Fee schedule rate ($11,065.78). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5883.03,17111.12,There are no additional notes associated with this service or procedure.
CERVICAL SPINAL FUSION WITH CC,472,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],22990.94,,"Case rate ($21,896.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,505.12, add-ons for qualifying new technology services are included. If operating cost exceeds $55,376.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,219.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $18,491.99 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,560.18 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,459.20. The transfer capital threshold is the transfer adjustment factor * $1,459.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,21896.13,70198.84,Inpatient DRG
HC Inj Tendon Sheath/Ligament|PBB CHARGE|RIGHT SIDE,CASE-20550,APC,20550,CPT,0510,RC,,,PBB|RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],297.37,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,287.31,301.68,OPPS APC
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],7291.31,,"Case rate ($6,944.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,595.55, add-ons for qualifying new technology services are included. If operating cost exceeds $41,466.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,125.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,633.51 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,650.60 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $365.63. The transfer capital threshold is the transfer adjustment factor * $365.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5068.21,14525.56,Inpatient DRG
"Fasct Prtl Palmr Addl Dgt Prox Iphal Jt W/WO Rpr|RIGHT HAND, FOURTH DIGIT",CASE-26125,APC,26125,CPT,0360,RC,,,F8,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],25276.59,,"Fee schedule rate ($25,276.59). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,11053.39,36776.05,There are no additional notes associated with this service or procedure.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],23618.74,,"Fee schedule rate ($23,618.74). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10533.95,24956.34,There are no additional notes associated with this service or procedure.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],10476.89,,"Case rate ($9,977.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,417.91, add-ons for qualifying new technology services are included. If operating cost exceeds $44,288.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,347.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $7,445.51 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,472.96 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $587.52. The transfer capital threshold is the transfer adjustment factor * $587.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9977.99,26949.28,Inpatient DRG
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,373,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],7326.34,,"Fee schedule rate ($7,326.34). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6870.94,14313.05,There are no additional notes associated with this service or procedure.
Colsc Flexible W/Transendoscopic Balloon Dilat|COLORECTAL CANCER SCREEN,CASE-45386,APC,45386,CPT,0360,RC,,,PT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1120.09,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1120.09,1176.09,OPPS APC
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],19126.88,,"Fee schedule rate ($19,126.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,19126.88,There are no additional notes associated with this service or procedure.
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH MCC",722,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],14200.37,,"Case rate ($14,200.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,345.91, add-ons for qualifying new technology services are included. If operating cost exceeds $48,216.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,656.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $11,359.07 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,400.95 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $896.34. The transfer capital threshold is the transfer adjustment factor * $896.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,14200.37,56869.13,Inpatient DRG
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],13006.10,,"Case rate ($12,566.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,825.74, add-ons for qualifying new technology services are included. If operating cost exceeds $46,696.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,536.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $9,844.49 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,880.79 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $776.83. The transfer capital threshold is the transfer adjustment factor * $776.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,12566.28,30861.41,Inpatient DRG
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC,805,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],20281.41,,"Fee schedule rate ($20,281.41). Adds an outlier to normal pricing equal to the per diem rate ($31,438.44) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.5), with a minimum of zero.",,,,0,other,9253.36,21235.42,There are no additional notes associated with this service or procedure.
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],16438.59,,"Fee schedule rate ($16,438.59). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7402.56,16438.59,There are no additional notes associated with this service or procedure.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC,099,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],22084.20,,"Fee schedule rate ($22,084.20). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11171.21,26807.94,There are no additional notes associated with this service or procedure.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,097,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],27328.47,,"Case rate ($26,404.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $24,698.97, add-ons for qualifying new technology services are included. If operating cost exceeds $59,569.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,548.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.7. The base transfer operating payment is the transfer adjustment factor * $22,670.44 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $22,754.03 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,788.92. The transfer capital threshold is the transfer adjustment factor * $1,788.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,26404.32,79915.74,Inpatient DRG
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],26204.74,,"Fee schedule rate ($26,204.74). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10120.20,26204.74,There are no additional notes associated with this service or procedure.
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],24092.63,,"Fee schedule rate ($24,092.63). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10626.74,25225.91,There are no additional notes associated with this service or procedure.
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],9607.36,,"Case rate ($9,282.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,770.90, add-ons for qualifying new technology services are included. If operating cost exceeds $43,641.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,296.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,800.88 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,825.96 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $536.66. The transfer capital threshold is the transfer adjustment factor * $536.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,9282.47,21320.03,Inpatient DRG
Corrj Hallux Valgus W/Sesmdc W/Dist Metar Osteot|RIGHT SIDE,CASE-28296,APC,28296,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
"HEART FAILURE,MODERATE",194,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],7591.38,,"The inlier payment is calculated as the lesser of the standard DRG payment $7,591.38 and the transfer payment, which is a per diem of $1,820.47. If cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,7591.38,7970.95,Estimated amount calculated based on 4 day length of stay.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],46431.62,,"Case rate ($45,521.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $42,483.01, add-ons for qualifying new technology services are included. If operating cost exceeds $77,354.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,947.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 12.5. The base transfer operating payment is the transfer adjustment factor * $40,389.14 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $40,538.06 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,187.10. The transfer capital threshold is the transfer adjustment factor * $3,187.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,45521.20,142438.06,Inpatient DRG
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],11681.49,,"Fee schedule rate ($11,681.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5778.62,11681.49,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],30063.84,,"Fee schedule rate ($30,063.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13891.57,34712.20,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITH STERILIZATION WITHOUT CC/MCC,785,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],20142.33,,"Fee schedule rate ($20,142.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8431.24,20142.33,There are no additional notes associated with this service or procedure.
OTHER CEREBROVASCULAR DISORDERS WITH MCC,070,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],37774.46,,"Fee schedule rate ($37,774.46). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,13219.09,37774.46,There are no additional notes associated with this service or procedure.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],80635.65,,"Fee schedule rate ($80,635.65). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,26028.48,80635.65,There are no additional notes associated with this service or procedure.
RADIOTHERAPY,849,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],81867.07,,"Fee schedule rate ($81,867.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,20293.88,81867.07,There are no additional notes associated with this service or procedure.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH CC,354,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],12514.68,,"Case rate ($12,514.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $11,748.98, add-ons for qualifying new technology services are included. If operating cost exceeds $50,393.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $3,540.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $10,343.20 + an uncompensated DSH payment of $1,359.91. The transfer operating threshold is the transfer adjustment factor * $10,389.07 + an uncompensated DSH payment of $1,359.91. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $811.58. The transfer capital threshold is the transfer adjustment factor * $811.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,11633.13,33472.54,Inpatient DRG
Litholapaxy Comp/Lg > 2.5 Cm,CASE-52318,APC,52318,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3464.44,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3299.47,3464.44,OPPS APC
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],29141.64,,,,,,0,other,11974.38,29141.64,There are no additional notes associated with this service or procedure.
HC >= 12 Lead Ekg,CASE-93005,APC,93005,CPT,0730,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],57.98,,"APC Price ($55.22). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,55.22,57.98,OPPS APC
"Arthrodesis Interphalangeal Jt W/WO Int Fixj|LEFT HAND, FIFTH DIGIT",CASE-26860,APC,26860,CPT,0360,RC,,,F4,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],52449.26,,"Fee schedule rate ($52,449.26). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,17693.40,52449.26,There are no additional notes associated with this service or procedure.
Egd Transoral Biopsy Single/Multiple|UNUSUAL NON-OVERLAPPING SERVICE,CASE-43239,APC,43239,CPT,0360,RC,,,XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1885.95,,"APC Price ($1,796.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1796.14,1885.95,OPPS APC
Cysto W/Insert Ureteral Stent|BILATERAL PROCEDURE,CASE-52332,APC,52332,CPT,0360,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3464.44,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3299.47,3464.44,OPPS APC
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],6524.00,,"Per diem ($6,524). If length of stay < 2.6, first 1 days paid at a per diem of $13,048 instead. Capped at $16,962.56.",,,,0,other,6524.00,17760.46,Estimated amount calculated based on 2 day length of stay.
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,095,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],50750.92,,,,,,0,other,19411.47,50750.92,There are no additional notes associated with this service or procedure.
"Suture Digital Nerve Hand/Foot 1 Nerve|RIGHT HAND, THUMB",CASE-64831,APC,64831,CPT,0360,RC,,,F5,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1827.80,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1827.80,1919.19,OPPS APC
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],6738.99,,"Case rate ($6,606.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,281.82, add-ons for qualifying new technology services are included. If operating cost exceeds $41,152.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,100.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,320.93 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,336.86 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $340.96. The transfer capital threshold is the transfer adjustment factor * $340.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,5919.29,13545.65,Inpatient DRG
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],15067.30,,"Case rate ($14,349.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,508.07, add-ons for qualifying new technology services are included. If operating cost exceeds $48,379.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,645.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,519.44 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,563.12 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $885.41. The transfer capital threshold is the transfer adjustment factor * $885.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7389.00,37134.43,Inpatient DRG
Colpocleisis Le Fort Type,CASE-57120,APC,57120,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],4846.30,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,4682.41,4916.53,OPPS APC
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC,817,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],18265.92,,"Case rate ($17,396.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,318.84, add-ons for qualifying new technology services are included. If operating cost exceeds $51,189.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,890.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $14,321.08 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,373.88 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,130.07. The transfer capital threshold is the transfer adjustment factor * $1,130.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,17396.11,44895.04,Inpatient DRG
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],13149.46,,"Fee schedule rate ($13,149.46). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.9), with a minimum of zero.",,,,0,other,6683.37,14699.43,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],12368.61,,"Case rate ($12,126.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,416.25, add-ons for qualifying new technology services are included. If operating cost exceeds $46,287.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,504.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $9,436.50 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,471.29 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $744.63. The transfer capital threshold is the transfer adjustment factor * $744.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,12126.09,29582.40,Inpatient DRG
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],43949.31,,"Fee schedule rate ($43,949.31). Adds an outlier to normal pricing equal to the per diem rate ($149,567.78) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,17782.11,46523.26,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,065,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],18986.57,,"Fee schedule rate ($18,986.57). Adds an outlier to normal pricing equal to the per diem rate ($85,884.96) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,8786.76,25681.86,There are no additional notes associated with this service or procedure.
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],34570.85,,"Fee schedule rate ($34,570.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,6965.00,36140.75,There are no additional notes associated with this service or procedure.
"NEONATE BIRTH WEIGHT > 2499 GRAMS WITH MAJOR ANOMALY,MODERATE",633,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],6626.56,,"Case rate ($6,626.56). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,6626.56,6957.89,There are no additional notes associated with this service or procedure.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],28434.57,,"Fee schedule rate ($28,434.57). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,8906.63,28434.57,There are no additional notes associated with this service or procedure.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],28434.57,,"Fee schedule rate ($28,434.57). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,8906.63,28434.57,There are no additional notes associated with this service or procedure.
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|LEFT HAND, THUMB",CASE-26160,APC,26160,CPT,0360,RC,,,FA,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1505.12,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1505.12,1580.37,OPPS APC
INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,352,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],10346.04,,"Case rate ($9,853.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,301.99, add-ons for qualifying new technology services are included. If operating cost exceeds $44,173.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,338.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $7,330.01 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,357.04 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $578.41. The transfer capital threshold is the transfer adjustment factor * $578.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9853.37,26528.70,Inpatient DRG
Esophagoscopy Flexible Transoral With Biopsy,CASE-43202,APC,43202,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1885.95,,"APC Price ($1,796.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1796.14,1885.95,OPPS APC
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],5791.49,,"Fee schedule rate ($5,791.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,3079.00,10940.41,There are no additional notes associated with this service or procedure.
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],14067.85,,"Case rate ($13,792.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,966.02, add-ons for qualifying new technology services are included. If operating cost exceeds $47,837.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,626.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $10,980.58 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,021.07 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $866.48. The transfer capital threshold is the transfer adjustment factor * $866.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6965.00,34422.94,Inpatient DRG
"NEONATE BIRTH WEIGHT > 2499 GRAMS WITH OTHER MAJOR PROCEDURE,MINOR",631,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],4484.22,,"Case rate ($4,484.22). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,4484.22,4708.43,There are no additional notes associated with this service or procedure.
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],40426.76,,"Fee schedule rate ($40,426.76). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,11914.12,40426.76,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],7641.61,,"Case rate ($7,641.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,244.44, add-ons for qualifying new technology services are included. If operating cost exceeds $42,115.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,176.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,280.02 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,299.49 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $416.65. The transfer capital threshold is the transfer adjustment factor * $416.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7641.61,19371.27,Inpatient DRG
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC",494,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],15533.10,,"Case rate ($15,533.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,585.72, add-ons for qualifying new technology services are included. If operating cost exceeds $49,456.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,753.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $12,594.34 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,640.78 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $993.82. The transfer capital threshold is the transfer adjustment factor * $993.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,15533.10,39945.55,Inpatient DRG
"BRONCHIOLITIS AND RSV PNEUMONIA,MODERATE",138,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],4858.09,,"Case rate ($4,858.09). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,4858.09,5100.99,There are no additional notes associated with this service or procedure.
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC,939,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],26517.40,,"Case rate ($26,517.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $24,804.19, add-ons for qualifying new technology services are included. If operating cost exceeds $59,675.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,557.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $22,775.26 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $22,859.24 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,797.19. The transfer capital threshold is the transfer adjustment factor * $1,797.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,26517.40,97674.79,Inpatient DRG
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,699,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],8818.60,,"Case rate ($8,818.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,339.37, add-ons for qualifying new technology services are included. If operating cost exceeds $43,210.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,262.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $6,370.92 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,394.41 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $502.73. The transfer capital threshold is the transfer adjustment factor * $502.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,5961.00,19972.16,Inpatient DRG
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,097,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],26404.32,,"Case rate ($26,404.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $24,698.97, add-ons for qualifying new technology services are included. If operating cost exceeds $59,569.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,548.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.7. The base transfer operating payment is the transfer adjustment factor * $22,670.44 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $22,754.03 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,788.92. The transfer capital threshold is the transfer adjustment factor * $1,788.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,26404.32,79915.74,Inpatient DRG
Revj/Rmvl Perph Neurostimulator Electrode Array,CASE-64585,APC,64585,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],18158.97,,"APC Price ($18,158.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,18158.97,19066.92,OPPS APC
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],20075.57,,"Case rate ($19,119.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,922.16, add-ons for qualifying new technology services are included. If operating cost exceeds $52,793.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,016.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $15,918.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,977.21 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,256.13. The transfer capital threshold is the transfer adjustment factor * $1,256.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,11348.00,62454.12,Inpatient DRG
"OTHER DIGESTIVE SYSTEM DIAGNOSES,MAJOR",254,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],10956.19,,"Case rate ($10,956.19). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,10956.19,11504.00,There are no additional notes associated with this service or procedure.
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],34032.82,,"Fee schedule rate ($34,032.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,15233.11,38610.21,There are no additional notes associated with this service or procedure.
CERVICAL SPINAL FUSION WITH CC,472,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],22334.05,,"Case rate ($21,896.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,505.12, add-ons for qualifying new technology services are included. If operating cost exceeds $55,376.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,219.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $18,491.99 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,560.18 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,459.20. The transfer capital threshold is the transfer adjustment factor * $1,459.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,21896.13,70198.84,Inpatient DRG
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,544,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],7407.91,,"Case rate ($7,055.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,698.86, add-ons for qualifying new technology services are included. If operating cost exceeds $41,569.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,133.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $4,736.45 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,753.92 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $373.75. The transfer capital threshold is the transfer adjustment factor * $373.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7055.15,23207.64,Inpatient DRG
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],8033.46,,"Case rate ($7,875.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,462.42, add-ons for qualifying new technology services are included. If operating cost exceeds $42,333.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,193.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $5,497.20 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,517.46 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $433.78. The transfer capital threshold is the transfer adjustment factor * $433.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,7875.94,17233.12,Inpatient DRG
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],11681.49,,"Fee schedule rate ($11,681.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5778.62,11681.49,There are no additional notes associated with this service or procedure.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],17223.78,,"Fee schedule rate ($17,223.78). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,8151.55,18033.97,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,689,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],22417.63,,"Fee schedule rate ($22,417.63). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,9802.58,22831.22,There are no additional notes associated with this service or procedure.
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],24528.10,,"Fee schedule rate ($24,528.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10989.72,26280.60,There are no additional notes associated with this service or procedure.
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],7993.75,,"Case rate ($7,993.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,572.03, add-ons for qualifying new technology services are included. If operating cost exceeds $42,443.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,202.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $5,606.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,627.08 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $442.40. The transfer capital threshold is the transfer adjustment factor * $442.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,5415.00,17575.50,Inpatient DRG
Laps Gastric Restrictive Px Remove Device & Port,CASE-43774,APC,43774,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3735.12,,"APC Price ($3,608.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3608.81,3789.26,OPPS APC
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,345,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],33616.03,,"Fee schedule rate ($33,616.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12134.89,33616.03,There are no additional notes associated with this service or procedure.
HC Inj Aa&/Strd Other Peripheral Nerve/Branch|LEFT SIDE,CASE-64450,APC,64450,CPT,0450,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],693.76,,"APC Price ($660.72). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,660.72,693.76,OPPS APC
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC,027,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],19030.20,,"Case rate ($19,030.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,839, add-ons for qualifying new technology services are included. If operating cost exceeds $52,710.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,009.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $15,835.66 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,894.05 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,249.59. The transfer capital threshold is the transfer adjustment factor * $1,249.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,19030.20,56363.30,Inpatient DRG
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],12920.81,,"Case rate ($12,305.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,583.18, add-ons for qualifying new technology services are included. If operating cost exceeds $46,454.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,517.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $9,602.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,638.24 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $757.76. The transfer capital threshold is the transfer adjustment factor * $757.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12305.53,30103.84,Inpatient DRG
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],14674.80,,"Fee schedule rate ($14,674.80). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6711.00,16865.16,There are no additional notes associated with this service or procedure.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,191,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],16612.88,,"Fee schedule rate ($16,612.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6965.00,16612.88,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITHOUT CC/MCC,428,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],118904.57,,"Fee schedule rate ($118,904.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,40017.53,118904.57,There are no additional notes associated with this service or procedure.
NONTRAUMATIC STUPOR AND COMA WITH MCC,080,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],30179.40,,"Fee schedule rate ($30,179.40). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,14202.39,35615.37,There are no additional notes associated with this service or procedure.
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],25829.63,,"Fee schedule rate ($25,829.63). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6965.00,29482.05,There are no additional notes associated with this service or procedure.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],14185.96,,"Case rate ($13,907.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,073.74, add-ons for qualifying new technology services are included. If operating cost exceeds $47,944.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,634.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $11,087.92 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,128.80 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $874.95. The transfer capital threshold is the transfer adjustment factor * $874.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,13907.80,52794.06,Inpatient DRG
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],39820.52,,"Fee schedule rate ($39,820.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,15273.74,39820.52,There are no additional notes associated with this service or procedure.
"OTHER SKIN SUBCUTANEOUS TISSUE AND BREAST DISORDERS,MINOR",385,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],4972.05,,"Case rate ($4,735.29). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4735.29,4972.05,There are no additional notes associated with this service or procedure.
HC >= 12 Lead Ekg|PBB CHARGE,CASE-93005,APC,93005,CPT,0730,RC,,,PBB,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],57.15,,"APC Price ($55.22). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,55.22,57.98,OPPS APC
PSYCHOSES,885,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],11404.17,,"Case rate ($11,404.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,744.67, add-ons for qualifying new technology services are included. If operating cost exceeds $45,615.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,451.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.5. The base transfer operating payment is the transfer adjustment factor * $8,767.39 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,799.72 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $691.83. The transfer capital threshold is the transfer adjustment factor * $691.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,2070.00,27484.83,Inpatient DRG
NONTRAUMATIC STUPOR AND COMA WITH MCC,080,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],14912.51,,"Case rate ($14,202.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,347.79, add-ons for qualifying new technology services are included. If operating cost exceeds $48,218.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,656.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $11,360.96 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,402.84 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $896.49. The transfer capital threshold is the transfer adjustment factor * $896.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,14202.39,35615.37,Inpatient DRG
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC,027,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],56363.30,,"Fee schedule rate ($56,363.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,19030.20,56363.30,There are no additional notes associated with this service or procedure.
BRONCHITIS AND ASTHMA WITH CC/MCC,202,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],8948.08,,"Case rate ($8,521.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,063.43, add-ons for qualifying new technology services are included. If operating cost exceeds $42,934.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,241.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,096.00 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,118.48 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $481.03. The transfer capital threshold is the transfer adjustment factor * $481.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7606.34,19110.30,Inpatient DRG
"POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT PROCEDURE,MAJOR",561,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],2074.03,,"Case rate for a one day stay ($1,975.27). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,1975.27,2074.03,There are no additional notes associated with this service or procedure.
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],37591.64,,"Fee schedule rate ($37,591.64). Adds an outlier to normal pricing equal to the per diem rate ($51,531) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.1), with a minimum of zero.",,,,0,other,15491.11,54180.83,There are no additional notes associated with this service or procedure.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],22664.58,,"Case rate ($21,585.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,215.96, add-ons for qualifying new technology services are included. If operating cost exceeds $55,086.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,196.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $18,203.89 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,271.01 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,436.47. The transfer capital threshold is the transfer adjustment factor * $1,436.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,21585.31,73588.10,Inpatient DRG
"CHRONIC OBSTRUCTIVE PULMONARY DISEASE,MAJOR",140,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],9390.55,,"Case rate ($9,390.55). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,9390.55,9860.08,There are no additional notes associated with this service or procedure.
Parathyroidectomy/Exploration Parathyroids|LEFT SIDE,CASE-60500,APC,60500,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5818.16,,"APC Price ($5,541.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5541.10,5818.16,OPPS APC
UNGROUPABLE,999,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],136003.49,,,,,,0,other,10228.00,161307.29,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],28983.97,,"Fee schedule rate ($28,983.97). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8956.76,28983.97,There are no additional notes associated with this service or procedure.
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC,058,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],40853.02,,"Fee schedule rate ($40,853.02). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,13521.80,40853.02,There are no additional notes associated with this service or procedure.
UNGROUPABLE,999,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],161307.29,,"Fee schedule rate ($161,307.29). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (41), with a minimum of zero.",,,,0,other,10228.00,161307.29,There are no additional notes associated with this service or procedure.
"LIMB REATTACHMENT, HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA",956,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],28799.66,,"Case rate ($27,428.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $25,651.53, add-ons for qualifying new technology services are included. If operating cost exceeds $60,522.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,623.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $23,619.49 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $23,706.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,863.81. The transfer capital threshold is the transfer adjustment factor * $1,863.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,27428.25,148259.86,Inpatient DRG
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],8354.35,,"Case rate ($7,956.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,537.38, add-ons for qualifying new technology services are included. If operating cost exceeds $42,408.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,199.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,571.89 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,592.43 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $439.68. The transfer capital threshold is the transfer adjustment factor * $439.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,17467.27,Inpatient DRG
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,074,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],20919.08,,"Fee schedule rate ($20,919.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8925.60,20919.08,There are no additional notes associated with this service or procedure.
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],54920.47,,,,,,0,other,20846.48,81306.30,There are no additional notes associated with this service or procedure.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,345,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],33616.03,,"Fee schedule rate ($33,616.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12134.89,33616.03,There are no additional notes associated with this service or procedure.
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5948.62,,"Case rate ($5,665.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,412.90, add-ons for qualifying new technology services are included. If operating cost exceeds $40,283.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,025.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $3,454.86 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,467.95 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $265.55. The transfer capital threshold is the transfer adjustment factor * $265.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5065.00,12558.65,Inpatient DRG
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],41402.42,,"Fee schedule rate ($41,402.42). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,15456.59,41402.42,There are no additional notes associated with this service or procedure.
PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,337,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],21595.14,,"Case rate ($12,340.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,615.32, add-ons for qualifying new technology services are included. If operating cost exceeds $46,486.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,520.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $9,634.84 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,670.37 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $760.28. The transfer capital threshold is the transfer adjustment factor * $760.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,12340.08,38926.31,All Other Inpatient
NEONATE WITH OTHER SIGNIFICANT PROBLEMS,794,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],2074.00,,,,,,0,other,1798.85,12536.83,Estimated amount calculated based on 2 day length of stay.
Cysto Bladder W/Ureteral Catheterization|BILATERAL PROCEDURE,CASE-52005,APC,52005,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1956.65,,"APC Price ($1,956.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1956.65,2054.48,OPPS APC
VENTRICULAR SHUNT PROCEDURES WITH MCC,031,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],62406.76,,"Fee schedule rate ($62,406.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,32287.20,88162.80,There are no additional notes associated with this service or procedure.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],22664.58,,"Case rate ($21,585.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,215.96, add-ons for qualifying new technology services are included. If operating cost exceeds $55,086.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,196.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $18,203.89 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,271.01 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,436.47. The transfer capital threshold is the transfer adjustment factor * $1,436.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,21585.31,73588.10,Inpatient DRG
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],29917.96,,"Fee schedule rate ($29,917.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,12527.66,29917.96,There are no additional notes associated with this service or procedure.
TRAUMATIC INJURY WITH MCC,913,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],42838.46,,"Fee schedule rate ($42,838.46). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13014.58,42838.46,There are no additional notes associated with this service or procedure.
O.R. PROCEDURES FOR OBESITY WITH CC,620,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],43753.50,,"Fee schedule rate ($43,753.50). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12782.30,43753.50,There are no additional notes associated with this service or procedure.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],41006.47,,"Fee schedule rate ($41,006.47). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12268.97,41006.47,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],34892.92,,"Fee schedule rate ($34,892.92). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,6965.00,41030.48,There are no additional notes associated with this service or procedure.
MAJOR BLADDER PROCEDURES WITH MCC,653,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],125343.98,,"Fee schedule rate ($125,343.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,10280.00,125343.98,There are no additional notes associated with this service or procedure.
PSYCHOSES,885,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],11974.38,,"Case rate ($11,404.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,744.67, add-ons for qualifying new technology services are included. If operating cost exceeds $45,615.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,451.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.5. The base transfer operating payment is the transfer adjustment factor * $8,767.39 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,799.72 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $691.83. The transfer capital threshold is the transfer adjustment factor * $691.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,2070.00,27484.83,Inpatient DRG
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],9687.34,,"Case rate ($9,226.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,731.97, add-ons for qualifying new technology services are included. If operating cost exceeds $43,602.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,279.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,761.38 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,787.02 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $519.70. The transfer capital threshold is the transfer adjustment factor * $519.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9446.38,21796.21,Inpatient DRG
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],62084.69,,"Fee schedule rate ($62,084.69). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (35), with a minimum of zero.",,,,0,other,30398.48,82674.88,There are no additional notes associated with this service or procedure.
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],14670.87,,"Case rate ($14,383.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,516, add-ons for qualifying new technology services are included. If operating cost exceeds $48,387.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,669.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,528.54 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,571.05 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $909.72. The transfer capital threshold is the transfer adjustment factor * $909.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6965.00,36140.75,Inpatient DRG
Chemodenervation Muscle Neck Unilat for Dystonia|BILATERAL PROCEDURE,CASE-64616,APC,64616,CPT,0360,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],301.68,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,287.31,301.68,OPPS APC
SIGNS AND SYMPTOMS WITH MCC,947,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],30414.32,,"Fee schedule rate ($30,414.32). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,10541.41,30414.32,There are no additional notes associated with this service or procedure.
SEIZURES WITH MCC,100,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],36398.28,,"Fee schedule rate ($36,398.28). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,15061.09,38110.41,There are no additional notes associated with this service or procedure.
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],29594.00,,"Fee schedule rate ($29,594.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,13571.25,33781.47,There are no additional notes associated with this service or procedure.
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],16283.24,,"Fee schedule rate ($16,283.24). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7875.94,17233.12,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],23239.84,,"Fee schedule rate ($23,239.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8543.64,23239.84,There are no additional notes associated with this service or procedure.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,418,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],33285.61,,,,,,0,other,13400.58,39884.93,There are no additional notes associated with this service or procedure.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH CC,026,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],63202.45,,"Fee schedule rate ($63,202.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,23000.66,63202.45,There are no additional notes associated with this service or procedure.
Perq Nl/Pl Lithotrp Complex >2 Cm Mlt Locations|RIGHT SIDE,CASE-50081,APC,50081,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],9303.88,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,8860.83,9303.88,OPPS APC
Colsc Flexible W/Transendoscopic Balloon Dilat,CASE-45386,APC,45386,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1159.29,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1120.09,1176.09,OPPS APC
SALIVARY GLAND PROCEDURES,139,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],30690.92,,"Fee schedule rate ($30,690.92). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,10313.19,30690.92,There are no additional notes associated with this service or procedure.
MAJOR CHEST TRAUMA WITHOUT CC/MCC,185,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],12066.60,,"Fee schedule rate ($12,066.60). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7271.19,21771.61,There are no additional notes associated with this service or procedure.
"NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY",789,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],6759.90,,,,,,0,other,3054.00,14857.05,Estimated amount calculated based on 1 day length of stay.
Surgical Arthroscopy Sho W/Coracoacrm Ligm Rls|RIGHT SIDE,CASE-29826,APC,29826,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6791.99,7131.59,OPPS APC
"LIMB REATTACHMENT, HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA",956,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],70718.06,,"Fee schedule rate ($70,718.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,27428.25,148259.86,There are no additional notes associated with this service or procedure.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,191,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],6965.00,,,,,,0,other,6965.00,16612.88,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],15318.94,,"Fee schedule rate ($15,318.94). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6214.05,15318.94,There are no additional notes associated with this service or procedure.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],23811.59,,"Case rate ($23,344.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $21,852.68, add-ons for qualifying new technology services are included. If operating cost exceeds $56,723.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,325.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $19,834.60 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $19,907.73 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,565.15. The transfer capital threshold is the transfer adjustment factor * $1,565.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,23344.70,62179.32,Inpatient DRG
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],27028.33,,,,,,0,other,11247.07,27028.33,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,167,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],14157.71,,"Case rate ($14,157.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,306.21, add-ons for qualifying new technology services are included. If operating cost exceeds $48,177.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,653.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $11,319.53 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,361.26 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $893.22. The transfer capital threshold is the transfer adjustment factor * $893.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,14157.71,43522.37,Inpatient DRG
OTHER CEREBROVASCULAR DISORDERS WITH MCC,070,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],37774.46,,"Fee schedule rate ($37,774.46). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,13219.09,37774.46,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],11102.21,,"Case rate ($10,573.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,988.03, add-ons for qualifying new technology services are included. If operating cost exceeds $44,859.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,375.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $8,012.70 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,043.08 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $615.88. The transfer capital threshold is the transfer adjustment factor * $615.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10834.64,25830.00,Inpatient DRG
COAGULATION DISORDERS,813,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],29046.49,,"Fee schedule rate ($29,046.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12274.39,30013.33,There are no additional notes associated with this service or procedure.
"CHRONIC OBSTRUCTIVE PULMONARY DISEASE,MINOR",140,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],5836.06,,"Case rate ($5,836.06). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,5836.06,6127.86,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],9370.00,,"Per diem ($9,370). If length of stay < 6.7, first 1 days paid at a per diem of $18,740 instead. Capped at $62,779.90.",,,,0,other,9370.00,65732.99,Estimated amount calculated based on 3 day length of stay.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],17693.40,,"Case rate ($17,693.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,595.40, add-ons for qualifying new technology services are included. If operating cost exceeds $51,466.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,911.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $14,596.63 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,650.45 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,151.82. The transfer capital threshold is the transfer adjustment factor * $1,151.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,17693.40,52449.26,Inpatient DRG
SALIVARY GLAND PROCEDURES,139,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],16316.56,,"Fee schedule rate ($16,316.56). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,10313.19,30690.92,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],19371.27,,"Fee schedule rate ($19,371.27). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7641.61,19371.27,There are no additional notes associated with this service or procedure.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],62041.12,,"Fee schedule rate ($62,041.12). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,18497.24,62041.12,There are no additional notes associated with this service or procedure.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],49902.84,,,,,,0,other,11348.00,62454.12,There are no additional notes associated with this service or procedure.
Egd Band Ligation Esophgeal/Gastric Varices,CASE-43244,APC,43244,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1796.14,,"APC Price ($1,796.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1796.14,1885.95,OPPS APC
"LIMB REATTACHMENT, HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA",956,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],148259.86,,"Fee schedule rate ($148,259.86). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,27428.25,148259.86,There are no additional notes associated with this service or procedure.
Esophagoscopy Flexible Transoral With Biopsy,CASE-43202,APC,43202,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1796.14,,"APC Price ($1,796.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1796.14,1885.95,OPPS APC
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],18092.36,,"Case rate ($17,230.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,193.59, add-ons for qualifying new technology services are included. If operating cost exceeds $51,064.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,851.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $14,194.82 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,248.64 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,091.05. The transfer capital threshold is the transfer adjustment factor * $1,091.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,17693.40,52449.26,Inpatient DRG
"ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",770,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],18843.74,,"Fee schedule rate ($18,843.74). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,8735.30,19730.13,There are no additional notes associated with this service or procedure.
SINGLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL,402,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],124455.45,,"Fee schedule rate ($124,455.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,29172.05,124455.45,There are no additional notes associated with this service or procedure.
CERVICAL SPINAL FUSION WITH CC,472,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],70198.84,,"Fee schedule rate ($70,198.84). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,21896.13,70198.84,There are no additional notes associated with this service or procedure.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],38248.08,,"Fee schedule rate ($38,248.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11593.79,38248.08,There are no additional notes associated with this service or procedure.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,025,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],91631.33,,"Fee schedule rate ($91,631.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,13351.00,91631.33,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],51231.98,,"Fee schedule rate ($51,231.98). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,23377.19,96365.69,There are no additional notes associated with this service or procedure.
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],8511.49,,"Case rate ($8,106.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,676.61, add-ons for qualifying new technology services are included. If operating cost exceeds $42,547.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,210.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,710.61 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,731.66 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $450.62. The transfer capital threshold is the transfer adjustment factor * $450.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8106.18,18245.94,Inpatient DRG
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],14783.11,,"Case rate ($8,447.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,994.13, add-ons for qualifying new technology services are included. If operating cost exceeds $42,865.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,235.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,026.96 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,049.18 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $475.59. The transfer capital threshold is the transfer adjustment factor * $475.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,1188.00,18893.86,All Other Inpatient
"Tendon Sheath Incision|LEFT HAND, THUMB|UNUSUAL NON-OVERLAPPING SERVICE",CASE-26055,APC,26055,CPT,0360,RC,,,FA|XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
ALLERGIC REACTIONS WITH MCC,915,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],27385.01,,"Fee schedule rate ($27,385.01). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,13332.86,33088.84,There are no additional notes associated with this service or procedure.
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],12246.05,,"Fee schedule rate ($12,246.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6010.23,12246.05,There are no additional notes associated with this service or procedure.
HC Inj Tendon Sheath/Ligament|PBB CHARGE|RIGHT SIDE,CASE-20550,APC,20550,CPT,0510,RC,,,PBB|RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],301.68,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,287.31,301.68,OPPS APC
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],27589.62,,"Fee schedule rate ($27,589.62). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12566.28,30861.41,There are no additional notes associated with this service or procedure.
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],16026.80,,"Case rate ($16,026.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,044.99, add-ons for qualifying new technology services are included. If operating cost exceeds $49,916.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,789.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $13,051.92 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,100.04 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,029.93. The transfer capital threshold is the transfer adjustment factor * $1,029.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,11165.00,61234.06,Inpatient DRG
Hrv Skin for Skin Cell Ssp Agrft 1st 25 Sq Cm/<,CASE-15011,APC,15011,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1931.28,,"APC Price ($1,931.28). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1931.28,1998.87,OPPS APC
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],20905.41,,"Case rate ($11,945.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,248.66, add-ons for qualifying new technology services are included. If operating cost exceeds $46,119.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,491.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $9,269.54 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,303.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $731.46. The transfer capital threshold is the transfer adjustment factor * $731.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,6167.00,29058.99,All Other Inpatient
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],10223.39,,"Fee schedule rate ($10,223.39). Adds an outlier to normal pricing equal to the per diem rate ($48,095.58) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,5628.97,12272.58,There are no additional notes associated with this service or procedure.
Suction Assisted Lipectomy Upper Extremity|BILATERAL PROCEDURE,CASE-15878,APC,15878,CPT,0360,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1998.87,,"APC Price ($1,931.28). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1998.87,2027.84,OPPS APC
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],10902.64,,"Case rate ($10,533.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,935.13, add-ons for qualifying new technology services are included. If operating cost exceeds $44,806.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,388.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $7,960.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,990.18 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $628.19. The transfer capital threshold is the transfer adjustment factor * $628.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,10533.95,24956.34,Inpatient DRG
"SPINAL PROCEDURES,MINOR",023,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],4703.06,,"Case rate for a one day stay ($4,703.06). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,4703.06,4938.21,There are no additional notes associated with this service or procedure.
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITH MCC OR ANTINEOPLASTIC IMPLANT OR EPILEPSY WITH NEUROSTIMULATOR,023,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],15168.00,,"Per diem ($15,168). If length of stay < 7.1, first 1 days paid at a per diem of $30,336 instead. Capped at $107,689.53.",,,,0,other,15168.00,136379.44,Estimated amount calculated based on 6 day length of stay.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],133270.57,,"Fee schedule rate ($133,270.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,33623.33,133270.57,There are no additional notes associated with this service or procedure.
NON-MALIGNANT BREAST DISORDERS WITH CC/MCC,600,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],19574.79,,"Fee schedule rate ($19,574.79). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7999.14,20495.56,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,083,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],11397.40,,"Case rate ($11,397.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,738.37, add-ons for qualifying new technology services are included. If operating cost exceeds $45,609.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,451.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $8,761.12 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,793.42 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $691.34. The transfer capital threshold is the transfer adjustment factor * $691.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,28680.85,Inpatient DRG
NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,601,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],12359.72,,"Fee schedule rate ($12,359.72). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6042.05,12359.72,There are no additional notes associated with this service or procedure.
"Open Tx Articular Fracture Mcp/IP Joint Ea|LEFT HAND, FOURTH DIGIT",CASE-26746,APC,26746,CPT,0360,RC,,,F3,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3169.86,OPPS APC
"OPIOID ABUSE AND DEPENDENCE,MODERATE",773,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],4673.89,,"Case rate ($4,673.89). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,4673.89,4907.58,There are no additional notes associated with this service or procedure.
Tx Incomplete Abortion Any Trimester Surgical,CASE-59812,APC,59812,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3136.08,,"APC Price ($3,030.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3030.03,3181.53,OPPS APC
Nasal/Sinus Ndsc Tot W/Sphendt W/Sphen Tiss Rmvl|RIGHT SIDE,CASE-31259,APC,31259,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6936.25,,"APC Price ($6,605.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6605.95,6936.25,OPPS APC
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7698.80,,"Case rate ($7,438.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,055.44, add-ons for qualifying new technology services are included. If operating cost exceeds $41,926.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,161.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,091.72 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,110.49 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $401.79. The transfer capital threshold is the transfer adjustment factor * $401.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,7438.45,15961.98,Inpatient DRG
NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,601,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6217.80,,"Case rate ($5,921.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,651.86, add-ons for qualifying new technology services are included. If operating cost exceeds $40,522.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,043.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $3,692.91 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,706.91 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $283.85. The transfer capital threshold is the transfer adjustment factor * $283.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6042.05,12359.72,Inpatient DRG
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],5683.00,,"Per diem ($5,683). If length of stay < 3.3, first 1 days paid at a per diem of $11,366 instead. Capped at $18,753.53.",,,,0,other,5683.00,19635.68,Estimated amount calculated based on 3 day length of stay.
PSYCHOSES,885,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],11404.17,,"Case rate ($11,404.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,744.67, add-ons for qualifying new technology services are included. If operating cost exceeds $45,615.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,451.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.5. The base transfer operating payment is the transfer adjustment factor * $8,767.39 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,799.72 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $691.83. The transfer capital threshold is the transfer adjustment factor * $691.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,2070.00,27484.83,Inpatient DRG
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,450,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],146009.19,,"Fee schedule rate ($146,009.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,38037.38,146009.19,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],12543.25,,"Case rate ($11,945.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,248.66, add-ons for qualifying new technology services are included. If operating cost exceeds $46,119.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,491.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $9,269.54 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,303.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $731.46. The transfer capital threshold is the transfer adjustment factor * $731.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6167.00,29058.99,Inpatient DRG
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],37768.77,,"Fee schedule rate ($37,768.77). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7453.00,42138.30,There are no additional notes associated with this service or procedure.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],22292.26,,"Fee schedule rate ($22,292.26). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9977.99,26949.28,There are no additional notes associated with this service or procedure.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC,858,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],33794.11,,"Fee schedule rate ($33,794.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11377.76,33794.11,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,373,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],13780.60,,"Fee schedule rate ($13,780.60). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6870.94,14313.05,There are no additional notes associated with this service or procedure.
Gastroenterology Procedure,CASE-91299,APC,91299,CPT,0750,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],124.66,,"APC Price ($120.44). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,120.44,126.46,OPPS APC
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],13486.95,,"Fee schedule rate ($13,486.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6915.64,14442.92,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],34338.33,,,,,,0,other,1188.00,34338.33,There are no additional notes associated with this service or procedure.
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,451,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],94077.13,,"Fee schedule rate ($94,077.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,23821.44,94077.13,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,093,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],10107.20,,"Fee schedule rate ($10,107.20). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,19011.32,There are no additional notes associated with this service or procedure.
"NEONATE BIRTH WEIGHT 2000-2499 GRAMS WITH RESPIRATORY DISTRESS SYNDROME OR OTHER MAJOR RESPIRATORY CONDITION,MODERATE",622,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],20988.12,,"Case rate ($20,988.12). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,20988.12,22037.53,There are no additional notes associated with this service or procedure.
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,450,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],38798.13,,"Case rate ($38,037.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $35,520.98, add-ons for qualifying new technology services are included. If operating cost exceeds $70,391.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,399.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $33,452.68 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $33,576.02 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,639.75. The transfer capital threshold is the transfer adjustment factor * $2,639.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,38037.38,146009.19,Inpatient DRG
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],12268.97,,"Case rate ($12,268.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,549.17, add-ons for qualifying new technology services are included. If operating cost exceeds $46,420.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,515.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,568.94 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,604.22 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $755.08. The transfer capital threshold is the transfer adjustment factor * $755.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12268.97,41006.47,Inpatient DRG
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],16033.30,,"Case rate ($15,491.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,546.67, add-ons for qualifying new technology services are included. If operating cost exceeds $49,417.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,750.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $12,555.42 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,601.72 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $990.75. The transfer capital threshold is the transfer adjustment factor * $990.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,15491.11,54180.83,Inpatient DRG
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],12526.44,,"Fee schedule rate ($12,526.44). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5415.00,17575.50,There are no additional notes associated with this service or procedure.
Esophagogastroduodenoscopy US Scope W/Adj Strxrs,CASE-43237,APC,43237,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1859.01,,"APC Price ($1,796.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1796.14,1885.95,OPPS APC
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,448,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],30663.95,,"Case rate ($30,663.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $28,661.63, add-ons for qualifying new technology services are included. If operating cost exceeds $63,532.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,860.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $26,618.53 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $26,716.68 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,100.47. The transfer capital threshold is the transfer adjustment factor * $2,100.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,30663.95,94077.13,Inpatient DRG
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,073,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],13449.85,,"Case rate ($12,809.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,051.90, add-ons for qualifying new technology services are included. If operating cost exceeds $46,922.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,554.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $10,069.82 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,106.95 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $794.61. The transfer capital threshold is the transfer adjustment factor * $794.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12809.38,43475.01,Inpatient DRG
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",004,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],260309.36,,"Fee schedule rate ($260,309.36). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (35), with a minimum of zero.",,,,0,other,10249.47,272554.00,There are no additional notes associated with this service or procedure.
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,069,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],20333.68,,"Fee schedule rate ($20,333.68). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,20333.68,There are no additional notes associated with this service or procedure.
Surg Tx Anal Fistula Intersphincteric,CASE-46275,APC,46275,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],2689.02,,"APC Price ($2,598.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2598.08,2727.99,OPPS APC
Sgmdsc Flx Rmvl Tum Polyp/Oth Les Snare Tq|COLORECTAL CANCER SCREEN,CASE-45338,APC,45338,CPT,0360,RC,,,PT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1120.09,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1120.09,1176.09,OPPS APC
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],68942.79,,"Fee schedule rate ($68,942.79). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,21489.15,68942.79,There are no additional notes associated with this service or procedure.
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],12027.72,,"Case rate ($11,454.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,791.92, add-ons for qualifying new technology services are included. If operating cost exceeds $45,662.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,455.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $8,814.47 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,846.97 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $695.55. The transfer capital threshold is the transfer adjustment factor * $695.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,11454.97,28394.78,Inpatient DRG
Revj/Rmvl Perph Neurostimulator Electrode Array,CASE-64585,APC,64585,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],18794.54,,"APC Price ($18,158.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,18158.97,19066.92,OPPS APC
UNGROUPABLE,999,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],161307.29,,"Fee schedule rate ($161,307.29). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (41), with a minimum of zero.",,,,0,other,10228.00,161307.29,There are no additional notes associated with this service or procedure.
Excision Ganglion Wrist Dorsal/Volar Primary|RIGHT SIDE,CASE-25111,APC,25111,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
Arthroscopy Knee W/Meniscus Rpr Medial/Lateral|LEFT SIDE,CASE-29882,APC,29882,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7029.71,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6791.99,7131.59,OPPS APC
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITHOUT CC/MCC,428,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],118904.57,,"Fee schedule rate ($118,904.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,40017.53,118904.57,There are no additional notes associated with this service or procedure.
"DIABETES,MAJOR",420,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],10364.30,,"Case rate ($9,870.76). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9870.76,10364.30,There are no additional notes associated with this service or procedure.
Dstr Nrolytc Agnt Parverteb Fct Sngl Crvcl/Thora|BILATERAL PROCEDURE,CASE-64633,APC,64633,CPT,0360,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1891.77,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1827.80,1891.77,OPPS APC
NEONATE WITH OTHER SIGNIFICANT PROBLEMS,794,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],2074.00,,,,,,0,other,1798.85,12536.83,Estimated amount calculated based on 2 day length of stay.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,074,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],19371.82,,"Fee schedule rate ($19,371.82). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,8925.60,20919.08,There are no additional notes associated with this service or procedure.
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC",629,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],44657.18,,"Fee schedule rate ($44,657.18). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,16699.94,44657.18,There are no additional notes associated with this service or procedure.
DIABETES WITH CC,638,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],15195.79,,"Fee schedule rate ($15,195.79). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8014.07,17634.53,There are no additional notes associated with this service or procedure.
SALIVARY GLAND PROCEDURES,139,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],10828.85,,"Case rate ($10,313.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,729.75, add-ons for qualifying new technology services are included. If operating cost exceeds $44,600.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,372.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $7,756.21 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,784.80 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $612.04. The transfer capital threshold is the transfer adjustment factor * $612.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10313.19,30690.92,Inpatient DRG
"Repair Extensor Tendon Finger W/O Graft Each|LEFT HAND, THIRD DIGIT",CASE-26418,APC,26418,CPT,0360,RC,,,F2,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1580.37,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1505.12,1580.37,OPPS APC
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC,805,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],9490.62,,"Case rate ($9,038.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,557.35, add-ons for qualifying new technology services are included. If operating cost exceeds $43,428.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,266.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $6,587.42 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,612.40 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $506.32. The transfer capital threshold is the transfer adjustment factor * $506.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9253.36,21235.42,Inpatient DRG
DIABETES WITHOUT CC/MCC,639,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],6595.05,,"Fee schedule rate ($6,595.05). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6151.76,12223.35,There are no additional notes associated with this service or procedure.
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral Ea Addl,CASE-64484,APC,64484,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],856.86,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,827.89,869.28,OPPS APC
TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC,087,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],8355.28,,"Case rate ($7,957.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,549.43, add-ons for qualifying new technology services are included. If operating cost exceeds $42,420.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,189.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $5,583.32 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,604.48 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $429.15. The transfer capital threshold is the transfer adjustment factor * $429.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8139.36,22679.07,Inpatient DRG
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],13806.09,,"Case rate ($13,148.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,367.53, add-ons for qualifying new technology services are included. If operating cost exceeds $47,238.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,579.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $10,384.29 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,422.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $819.42. The transfer capital threshold is the transfer adjustment factor * $819.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13148.66,32553.63,Inpatient DRG
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,307,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],7583.37,,"Case rate ($7,434.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $7,017.68, add-ons for qualifying new technology services are included. If operating cost exceeds $45,662.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $3,170.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $5,632.79 + an uncompensated DSH payment of $1,359.91. The transfer operating threshold is the transfer adjustment factor * $5,657.77 + an uncompensated DSH payment of $1,359.91. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $441.98. The transfer capital threshold is the transfer adjustment factor * $441.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6335.27,18228.77,Inpatient DRG
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],81524.17,,"Fee schedule rate ($81,524.17). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,8972.00,81524.17,There are no additional notes associated with this service or procedure.
"Open Tx Phalangeal Shaft Fracture Prox/Middle Ea|RIGHT HAND, SECOND DIGIT",CASE-26735,APC,26735,CPT,0360,RC,,,F6,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],11753.96,,"Case rate ($11,194.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,549.37, add-ons for qualifying new technology services are included. If operating cost exceeds $45,420.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,436.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $8,572.81 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,604.42 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $676.48. The transfer capital threshold is the transfer adjustment factor * $676.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,11194.25,36094.03,Inpatient DRG
Dilation Esoph Unguided Sound/Bougie 1/Mult Pass,CASE-43450,APC,43450,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],848.96,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,848.96,891.41,OPPS APC
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],21305.84,,"Case rate ($20,291.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $19,046.38, add-ons for qualifying new technology services are included. If operating cost exceeds $53,917.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,069.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $17,036.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $17,101.43 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,309.49. The transfer capital threshold is the transfer adjustment factor * $1,309.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,20846.48,81306.30,Inpatient DRG
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],11095.05,,"Case rate ($6,340.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,033.60, add-ons for qualifying new technology services are included. If operating cost exceeds $40,904.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,081.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $4,073.62 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,088.64 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $321.45. The transfer capital threshold is the transfer adjustment factor * $321.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,6340.03,15076.44,All Other Inpatient
PSYCHOSES,885,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],26250.06,,"Fee schedule rate ($26,250.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15.8), with a minimum of zero.",,,,0,other,2070.00,27484.83,There are no additional notes associated with this service or procedure.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],34001.86,,,,,,0,other,7921.00,45706.73,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],14906.49,,"Fee schedule rate ($14,906.49). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12126.09,29582.40,There are no additional notes associated with this service or procedure.
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC",758,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],16323.02,,"Fee schedule rate ($16,323.02). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8574.80,19263.78,There are no additional notes associated with this service or procedure.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],62041.12,,"Fee schedule rate ($62,041.12). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,18497.24,62041.12,There are no additional notes associated with this service or procedure.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],37158.98,,"Case rate ($35,389.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $33,057.71, add-ons for qualifying new technology services are included. If operating cost exceeds $67,928.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,206.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.3. The base transfer operating payment is the transfer adjustment factor * $30,998.46 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $31,112.76 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,446.08. The transfer capital threshold is the transfer adjustment factor * $2,446.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,35389.50,101083.00,Inpatient DRG
Trachelectomy Cervicectomy Amp Cervix Spx,CASE-57530,APC,57530,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],4916.53,,"APC Price ($4,682.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,4682.41,4916.53,OPPS APC
NONTRAUMATIC STUPOR AND COMA WITH MCC,080,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],34015.33,,"Fee schedule rate ($34,015.33). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.5), with a minimum of zero.",,,,0,other,14202.39,35615.37,There are no additional notes associated with this service or procedure.
HC Inj Tendon Sheath/Ligament|PBB CHARGE|SEPARATE STRUCTURE,CASE-20550,APC,20550,CPT,0510,RC,,,PBB|XS,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],301.68,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,287.31,301.68,OPPS APC
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,690,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],7798.29,,"Case rate ($7,426.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,044.73, add-ons for qualifying new technology services are included. If operating cost exceeds $41,915.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,160.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,081.05 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,099.78 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $400.94. The transfer capital threshold is the transfer adjustment factor * $400.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7426.94,15928.53,Inpatient DRG
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,447,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],125567.31,,"Fee schedule rate ($125,567.31). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15.7), with a minimum of zero.",,,,0,other,47193.21,156646.82,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],53152.12,,"Fee schedule rate ($53,152.12). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,19152.11,53152.12,There are no additional notes associated with this service or procedure.
Cystourethroscopy W/Dest &/Rmvl Tumor Large,CASE-52240,APC,52240,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5018.77,,"APC Price ($5,018.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5018.77,5269.71,OPPS APC
DIABETES WITH CC,638,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],15195.79,,"Fee schedule rate ($15,195.79). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8014.07,17634.53,There are no additional notes associated with this service or procedure.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],20817.01,,"Fee schedule rate ($20,817.01). Adds an outlier to normal pricing equal to the per diem rate ($37,789.38) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,9446.38,21796.21,There are no additional notes associated with this service or procedure.
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],18044.55,,"Case rate ($10,311.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,727.87, add-ons for qualifying new technology services are included. If operating cost exceeds $44,598.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,371.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $7,754.32 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,782.91 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $611.89. The transfer capital threshold is the transfer adjustment factor * $611.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,10311.17,24308.97,All Other Inpatient
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6731.54,,"Case rate ($6,503.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,186.05, add-ons for qualifying new technology services are included. If operating cost exceeds $41,057.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,093.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $4,225.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,241.10 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $333.44. The transfer capital threshold is the transfer adjustment factor * $333.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6503.90,14492.93,Inpatient DRG
MAJOR CHEST TRAUMA WITHOUT CC/MCC,185,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],21771.61,,"Fee schedule rate ($21,771.61). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7271.19,21771.61,There are no additional notes associated with this service or procedure.
HEADACHES WITHOUT MCC,103,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],20883.08,,"Fee schedule rate ($20,883.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,20883.08,There are no additional notes associated with this service or procedure.
NONTRAUMATIC STUPOR AND COMA WITH MCC,080,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],16044.62,,"Fee schedule rate ($16,044.62). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,14202.39,35615.37,There are no additional notes associated with this service or procedure.
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],34245.00,,"Fee schedule rate ($34,245.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,12725.42,34245.00,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],34409.98,,"Fee schedule rate ($34,409.98). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,14344.60,36028.59,There are no additional notes associated with this service or procedure.
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],7396.47,,"Case rate ($7,396.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,016.38, add-ons for qualifying new technology services are included. If operating cost exceeds $41,887.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,158.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,052.80 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,071.43 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $398.72. The transfer capital threshold is the transfer adjustment factor * $398.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7396.47,16035.06,Inpatient DRG
Arthrs Knee W/Meniscectomy Med&Lat W/Shaving|LEFT SIDE,CASE-29880,APC,29880,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],32360.46,,"Case rate ($30,819.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $28,860.20, add-ons for qualifying new technology services are included. If operating cost exceeds $63,731.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,820.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. The base transfer operating payment is the transfer adjustment factor * $26,813.59 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $26,915.25 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,060.96. The transfer capital threshold is the transfer adjustment factor * $2,060.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10862.00,86437.13,Inpatient DRG
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],34422.94,,,,,,0,other,6965.00,34422.94,There are no additional notes associated with this service or procedure.
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],21354.82,,"Fee schedule rate ($21,354.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6834.39,21354.82,There are no additional notes associated with this service or procedure.
HC Injection Small Joint/Bursa|LEFT SIDE,CASE-20600,APC,20600,CPT,0361,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,690,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],15928.53,,,,,,0,other,7426.94,15928.53,There are no additional notes associated with this service or procedure.
Unlisted Laparoscopic Procedure Liver,CASE-47379,APC,47379,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5941.70,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5658.76,5941.70,OPPS APC
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITHOUT CC/MCC",630,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],42541.02,,"Fee schedule rate ($42,541.02). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11828.78,42541.02,There are no additional notes associated with this service or procedure.
"Inj Dx/Ther Agnt Paravert Facet Joint, Cerv/Thorac, Add Level|RIGHT SIDE",CASE-64492,APC,64492,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],856.86,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,827.89,869.28,OPPS APC
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],43399.23,,"Fee schedule rate ($43,399.23). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9888.00,43399.23,There are no additional notes associated with this service or procedure.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],9552.48,,"Case rate ($9,097.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,598.92, add-ons for qualifying new technology services are included. If operating cost exceeds $43,469.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,283.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,629.53 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,653.97 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $523.14. The transfer capital threshold is the transfer adjustment factor * $523.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9097.60,21455.22,Inpatient DRG
Nsl/Sinus Ndsc Max Antrost W/Rmvl Tiss Max Sinus|LEFT SIDE,CASE-31267,APC,31267,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6605.95,,"APC Price ($6,605.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6605.95,6936.25,OPPS APC
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],23870.71,,"Fee schedule rate ($23,870.71). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10626.74,25225.91,There are no additional notes associated with this service or procedure.
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],25013.10,,"Fee schedule rate ($25,013.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10846.16,25863.45,There are no additional notes associated with this service or procedure.
Exc B9 Lesion Mrgn Xcp Sk Tg T/a/L 2.1-3.0 Cm,CASE-11403,APC,11403,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],2718.88,,"APC Price ($2,718.88). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2718.88,2854.83,OPPS APC
Cerclage Cervix Pregnancy Vaginal,CASE-59320,APC,59320,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3136.08,,"APC Price ($3,030.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3030.03,3181.53,OPPS APC
Split Agrft F/S/N/H/F/G/M/D Gt 1st 100 Cm/</1 %,CASE-15120,APC,15120,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3317.01,,"APC Price ($3,317.01). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3317.01,3482.86,OPPS APC
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],8787.44,,"Case rate ($8,787.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,310.38, add-ons for qualifying new technology services are included. If operating cost exceeds $43,181.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,260.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,342.05 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,365.43 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $500.45. The transfer capital threshold is the transfer adjustment factor * $500.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,32293.66,Inpatient DRG
Insj Multi-Component Inflatable Penile Prosth,CASE-54405,APC,54405,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],20079.15,,"APC Price ($19,400.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,19400.15,20370.16,OPPS APC
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],10733.06,,"Case rate ($10,733.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,120.35, add-ons for qualifying new technology services are included. If operating cost exceeds $44,991.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,402.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $8,145.37 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,175.40 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $642.75. The transfer capital threshold is the transfer adjustment factor * $642.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10733.06,45157.33,Inpatient DRG
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,544,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],14181.20,,"Fee schedule rate ($14,181.20). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7055.15,23207.64,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],17755.84,,"Fee schedule rate ($17,755.84). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,7353.00,33398.16,There are no additional notes associated with this service or procedure.
GI Tract Imaging Intraluminal Colon I&R,CASE-91113,APC,91113,CPT,0750,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],870.46,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,870.46,913.99,OPPS APC
"Amp F/Th 1/2 Jt/Phalanx W/Neurect W/Dir Clsr|RIGHT HAND, SECOND DIGIT",CASE-26951,APC,26951,CPT,0360,RC,,,F6,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],27589.62,,"Fee schedule rate ($27,589.62). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12566.28,30861.41,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],22358.90,,"Fee schedule rate ($22,358.90). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9389.48,22358.90,There are no additional notes associated with this service or procedure.
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH MCC",510,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],89863.76,,"Fee schedule rate ($89,863.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10710.00,89863.76,There are no additional notes associated with this service or procedure.
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],22311.17,,"Case rate ($21,248.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $19,902.85, add-ons for qualifying new technology services are included. If operating cost exceeds $54,773.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,171.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.3. The base transfer operating payment is the transfer adjustment factor * $17,891.94 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $17,957.90 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,411.85. The transfer capital threshold is the transfer adjustment factor * $1,411.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,21248.73,56089.29,Inpatient DRG
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,544,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],7407.91,,"Case rate ($7,055.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,698.86, add-ons for qualifying new technology services are included. If operating cost exceeds $41,569.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,133.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $4,736.45 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,753.92 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $373.75. The transfer capital threshold is the transfer adjustment factor * $373.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7055.15,23207.64,Inpatient DRG
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],21455.22,,"Fee schedule rate ($21,455.22). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,9097.60,21455.22,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],94787.57,,"Fee schedule rate ($94,787.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,23526.87,94787.57,There are no additional notes associated with this service or procedure.
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],20170.75,,"Fee schedule rate ($20,170.75). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10048.39,23545.50,There are no additional notes associated with this service or procedure.
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITHOUT MCC,430,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],108381.11,,"Fee schedule rate ($108,381.11). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.6), with a minimum of zero.",,,,0,other,41000.16,133156.90,There are no additional notes associated with this service or procedure.
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],23385.72,,"Fee schedule rate ($23,385.72). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,23385.72,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],53152.12,,"Fee schedule rate ($53,152.12). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,19152.11,53152.12,There are no additional notes associated with this service or procedure.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,056,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],45711.64,,,,,,0,other,7659.00,59328.19,There are no additional notes associated with this service or procedure.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],45933.85,,"Fee schedule rate ($45,933.85). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,18497.24,62041.12,There are no additional notes associated with this service or procedure.
Lamnotmy Incl W/Dcmprsn Nrv Root 1 Intrspc Lumbr|LEFT SIDE|SEPARATE STRUCTURE,CASE-63030,APC,63030,CPT,0360,RC,,,LT|XS,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7029.71,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6791.99,7131.59,OPPS APC
HC Drain/Inj Joint/Bursa W/US Large,CASE-20611,APC,20611,CPT,0510,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],297.37,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,287.31,301.68,OPPS APC
Colonoscopy Flx W/Endoscopic Mucosal Resection|UNUSUAL NON-OVERLAPPING SERVICE|COLORECTAL CANCER SCREEN,CASE-45390,APC,45390,CPT,0360,RC,,,XU|PT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],2689.02,,"APC Price ($2,598.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2598.08,2727.99,OPPS APC
NON-MALIGNANT BREAST DISORDERS WITH CC/MCC,600,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],9178.71,,"Case rate ($8,998.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,506.94, add-ons for qualifying new technology services are included. If operating cost exceeds $43,377.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,275.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $6,537.88 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,561.99 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $515.90. The transfer capital threshold is the transfer adjustment factor * $515.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,7999.14,20495.56,Inpatient DRG
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],142438.06,,"Fee schedule rate ($142,438.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (40), with a minimum of zero.",,,,0,other,45521.20,142438.06,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITHOUT STERILIZATION WITH CC,787,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],9840.79,,"Case rate ($9,508.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,980.70, add-ons for qualifying new technology services are included. If operating cost exceeds $43,851.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,313.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $7,009.90 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,035.74 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $553.15. The transfer capital threshold is the transfer adjustment factor * $553.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,9508.01,23722.94,Inpatient DRG
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],29917.96,,"Fee schedule rate ($29,917.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,12527.66,29917.96,There are no additional notes associated with this service or procedure.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC,434,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],13390.01,,"Fee schedule rate ($13,390.01). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6770.05,14019.86,There are no additional notes associated with this service or procedure.
Amputation Metatarsal W/Toe Single,CASE-28810,APC,28810,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3062.67,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
MAJOR BLADDER PROCEDURES WITH MCC,653,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],10280.00,,"Per diem ($10,280). If length of stay < 9.5, first 1 days paid at a per diem of $20,560 instead. Capped at $97,655.95.",,,,0,other,10280.00,125343.98,Estimated amount calculated based on 10 day length of stay.
CESAREAN SECTION WITH STERILIZATION WITH CC,784,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],23722.94,,"Fee schedule rate ($23,722.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9124.01,23722.94,There are no additional notes associated with this service or procedure.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,098,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],17881.16,,"Case rate ($17,029.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,006.10, add-ons for qualifying new technology services are included. If operating cost exceeds $50,877.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,836.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $14,008.04 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,061.15 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,076.69. The transfer capital threshold is the transfer adjustment factor * $1,076.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,45156.75,Inpatient DRG
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7081.29,,"Case rate ($6,841.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,500.42, add-ons for qualifying new technology services are included. If operating cost exceeds $41,371.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,118.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $4,538.73 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,555.47 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $358.15. The transfer capital threshold is the transfer adjustment factor * $358.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6841.83,21167.26,Inpatient DRG
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],37550.29,,"Fee schedule rate ($37,550.29). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,15476.23,42787.31,There are no additional notes associated with this service or procedure.
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITH MCC,429,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],64224.74,,"Case rate ($61,166.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $57,147.93, add-ons for qualifying new technology services are included. If operating cost exceeds $92,018.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $5,986.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.6. The base transfer operating payment is the transfer adjustment factor * $54,994.47 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $55,202.98 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,227.00. The transfer capital threshold is the transfer adjustment factor * $4,227.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,62958.58,177294.98,Inpatient DRG
"Remove Spinal Neurostim Electrode Plate/Paddle, Incl Fluoro",CASE-63662,APC,63662,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3386.97,,"APC Price ($3,272.44). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3272.44,3436.06,OPPS APC
"Open Tx Metacarpal Fracture Single Ea Bone|LEFT HAND, FOURTH DIGIT",CASE-26615,APC,26615,CPT,0360,RC,,,F3,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],36868.88,,"Fee schedule rate ($36,868.88). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12606.23,36868.88,There are no additional notes associated with this service or procedure.
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],16400.70,,"Fee schedule rate ($16,400.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,16400.70,There are no additional notes associated with this service or procedure.
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],26204.74,,"Fee schedule rate ($26,204.74). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10120.20,26204.74,There are no additional notes associated with this service or procedure.
Laparoscopy W/Rmvl Adnexal Structures|RIGHT SIDE,CASE-58661,APC,58661,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5856.81,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5658.76,5941.70,OPPS APC
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],12152.40,,"Case rate ($11,914.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,219.06, add-ons for qualifying new technology services are included. If operating cost exceeds $46,090.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,489.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $9,240.03 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,274.10 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $729.13. The transfer capital threshold is the transfer adjustment factor * $729.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,11914.12,40426.76,Inpatient DRG
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],2070.00,,,,,,0,other,1188.00,18893.86,Estimated amount calculated based on 3 day length of stay.
CESAREAN SECTION WITHOUT STERILIZATION WITH CC,787,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],20988.02,,"Fee schedule rate ($20,988.02). Adds an outlier to normal pricing equal to the per diem rate ($39,437.39) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,9508.01,23722.94,There are no additional notes associated with this service or procedure.
ALLERGIC REACTIONS WITH MCC,915,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],14559.00,,"Fee schedule rate ($14,559.00). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,13332.86,33088.84,There are no additional notes associated with this service or procedure.
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",759,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],13057.66,,,,,,0,other,6190.22,13057.66,There are no additional notes associated with this service or procedure.
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],33890.73,,"Fee schedule rate ($33,890.73). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6277.00,36801.89,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],14871.83,,"Fee schedule rate ($14,871.83). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6558.75,14871.83,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC,833,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5486.07,,"Case rate ($5,486.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,239.18, add-ons for qualifying new technology services are included. If operating cost exceeds $40,110.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,018.96, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $3,282.12 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,294.23 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $258.99. The transfer capital threshold is the transfer adjustment factor * $258.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,3041.73,10289.10,Inpatient DRG
Nasal/Sinus Ndsc Tot W/Frnt Sins Expl Tiss Rmvl|LEFT SIDE,CASE-31253,APC,31253,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6605.95,,"APC Price ($6,605.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6605.95,6936.25,OPPS APC
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,082,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],42953.28,,"Fee schedule rate ($42,953.28). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.6), with a minimum of zero.",,,,0,other,17423.21,56223.11,There are no additional notes associated with this service or procedure.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],19849.17,,"Fee schedule rate ($19,849.17). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,9097.60,21455.22,There are no additional notes associated with this service or procedure.
Dstr Nrolytc Agnt Parverteb Fct Addl Lmbr/Sacral|LEFT SIDE,CASE-64636,APC,64636,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1827.80,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1827.80,1919.19,OPPS APC
Nasal/Sinus Ndsc Surg W/Dilation Frontal Sinus|BILATERAL PROCEDURE,CASE-31296,APC,31296,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6605.95,,"APC Price ($6,605.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6605.95,6936.25,OPPS APC
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],16283.24,,"Fee schedule rate ($16,283.24). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7875.94,17233.12,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,082,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],42953.28,,"Fee schedule rate ($42,953.28). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.6), with a minimum of zero.",,,,0,other,17423.21,56223.11,There are no additional notes associated with this service or procedure.
Sgmdsc Flx Rmvl Tum Polyp/Oth Les Snare Tq|COLORECTAL CANCER SCREEN,CASE-45338,APC,45338,CPT,0360,RC,,,PT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1120.09,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1120.09,1176.09,OPPS APC
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,167,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],24121.65,,"Fee schedule rate ($24,121.65). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,14157.71,43522.37,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC,831,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],17654.61,,"Case rate ($10,088.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,520.59, add-ons for qualifying new technology services are included. If operating cost exceeds $44,391.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,355.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $7,547.82 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,575.65 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $595.60. The transfer capital threshold is the transfer adjustment factor * $595.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,4941.30,23661.59,All Other Inpatient
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],10448.91,,"Fee schedule rate ($10,448.91). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,3079.00,10940.41,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],2070.00,,,,,,0,other,1188.00,17370.86,Estimated amount calculated based on 3 day length of stay.
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,083,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],28680.85,,"Fee schedule rate ($28,680.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,28680.85,There are no additional notes associated with this service or procedure.
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC",458,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],132827.25,,"Fee schedule rate ($132,827.25). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,30202.09,132827.25,There are no additional notes associated with this service or procedure.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],42586.49,,"Fee schedule rate ($42,586.49). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,13341.67,42586.49,There are no additional notes associated with this service or procedure.
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],12840.52,,"Case rate ($12,840.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,080.88, add-ons for qualifying new technology services are included. If operating cost exceeds $46,951.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,556.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $10,098.70 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,135.93 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $796.89. The transfer capital threshold is the transfer adjustment factor * $796.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,1188.00,31658.33,Inpatient DRG
CERVICAL SPINAL FUSION WITHOUT CC/MCC,473,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],45879.35,,"Fee schedule rate ($45,879.35). Adds an outlier to normal pricing equal to the per diem rate ($58,401.78) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,18477.61,62077.11,There are no additional notes associated with this service or procedure.
SINGLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL,402,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],124455.45,,"Fee schedule rate ($124,455.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,29172.05,124455.45,There are no additional notes associated with this service or procedure.
HC >= 12 Lead Ekg|PBB CHARGE,CASE-93005,APC,93005,CPT,0730,RC,,,PBB,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],55.22,,"APC Price ($55.22). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,55.22,57.98,OPPS APC
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],6965.00,,,,,,0,other,5778.62,11681.49,There are no additional notes associated with this service or procedure.
Neuroplasty &/Transposition Ulnar Nerve Elbow|LEFT SIDE,CASE-64718,APC,64718,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1891.77,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1827.80,1919.19,OPPS APC
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],23954.07,,"Fee schedule rate ($23,954.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,6167.00,29058.99,There are no additional notes associated with this service or procedure.
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],10048.39,,"Case rate ($10,048.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,483.42, add-ons for qualifying new technology services are included. If operating cost exceeds $44,354.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,352.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,510.78 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,538.48 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $592.68. The transfer capital threshold is the transfer adjustment factor * $592.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10048.39,23545.50,Inpatient DRG
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,191,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],8036.50,,"Case rate ($7,653.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,255.78, add-ons for qualifying new technology services are included. If operating cost exceeds $42,126.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,177.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,291.32 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,310.83 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $417.54. The transfer capital threshold is the transfer adjustment factor * $417.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,16612.88,Inpatient DRG
"Prq Skel Fixj Phlngl Shft Fx Prox/Middle Px/F/T|LEFT HAND, FIFTH DIGIT",CASE-26727,APC,26727,CPT,0360,RC,,,F4,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
"OTHER EAR NOSE MOUTH THROAT AND CRANIAL OR FACIAL DIAGNOSES,MINOR",115,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],4810.94,,"Case rate ($4,810.94). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,4810.94,5051.49,There are no additional notes associated with this service or procedure.
Realignment Extensor Tendon Hand Each Tendon,CASE-26437,APC,26437,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
"Remove Spinal Neurostim Electrode Plate/Paddle, Incl Fluoro",CASE-63662,APC,63662,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3436.06,,"APC Price ($3,272.44). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3272.44,3436.06,OPPS APC
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,057,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],39884.93,,"Fee schedule rate ($39,884.93). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,10718.84,39884.93,There are no additional notes associated with this service or procedure.
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],9607.36,,"Case rate ($9,282.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,770.90, add-ons for qualifying new technology services are included. If operating cost exceeds $43,641.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,296.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,800.88 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,825.96 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $536.66. The transfer capital threshold is the transfer adjustment factor * $536.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,9282.47,21320.03,Inpatient DRG
Surgical Arthroscopy Shoulder Removal Loose/FB|SEPARATE STRUCTURE|RIGHT SIDE,CASE-29819,APC,29819,CPT,0360,RC,,,XS|RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7029.71,OPPS APC
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],35474.53,,"Fee schedule rate ($35,474.53). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,16428.39,42083.20,There are no additional notes associated with this service or procedure.
Transection/Avulsion Oth Spinal Nrv Xdrl,CASE-64772,APC,64772,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
Perq Nl/Pl Lithotrp Simple Up to 2 Cm 1 Location|RIGHT SIDE,CASE-50080,APC,50080,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],8860.83,,"APC Price ($8,860.83). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,8860.83,9303.88,OPPS APC
Tnot Elbow Lateral/Medial Debride Open Tdn Rpr|RIGHT SIDE,CASE-24359,APC,24359,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
"Tendon Sheath Incision|UNUSUAL NON-OVERLAPPING SERVICE|LEFT HAND, THIRD DIGIT",CASE-26055,APC,26055,CPT,0360,RC,,,XU|F2,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1505.12,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1505.12,1557.80,OPPS APC
Aspiration Bladder Insert Suprapubic Catheter,CASE-51102,APC,51102,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1956.65,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1956.65,2054.48,OPPS APC
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],15461.47,,"Case rate ($14,725.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,834.15, add-ons for qualifying new technology services are included. If operating cost exceeds $48,705.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,694.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,845.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,889.20 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $934.73. The transfer capital threshold is the transfer adjustment factor * $934.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7389.00,37134.43,Inpatient DRG
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],27044.29,,"Case rate ($15,453.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,512.02, add-ons for qualifying new technology services are included. If operating cost exceeds $49,383.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,747.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $12,520.90 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,567.07 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $988.02. The transfer capital threshold is the transfer adjustment factor * $988.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,15453.88,39251.68,All Other Inpatient
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,309,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],6518.19,,"Case rate ($6,207.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $5,875.02, add-ons for qualifying new technology services are included. If operating cost exceeds $44,519.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $3,081.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,495.17 + an uncompensated DSH payment of $1,359.91. The transfer operating threshold is the transfer adjustment factor * $4,515.10 + an uncompensated DSH payment of $1,359.91. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $352.72. The transfer capital threshold is the transfer adjustment factor * $352.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5055.77,14547.21,Inpatient DRG
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],33608.45,,"Fee schedule rate ($33,608.45). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,7332.00,35314.31,There are no additional notes associated with this service or procedure.
Insertion Breast Implant Same Day of Mastectomy,CASE-19340,APC,19340,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],7650.49,,"APC Price ($7,650.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,7650.49,8033.01,OPPS APC
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],11133.98,,"Fee schedule rate ($11,133.98). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5919.29,13545.65,There are no additional notes associated with this service or procedure.
"Suture Digital Nerve Hand/Foot 1 Nerve|LEFT HAND, FOURTH DIGIT",CASE-64831,APC,64831,CPT,0360,RC,,,F3,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3169.86,3215.80,OPPS APC
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC",629,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],16699.94,,"Case rate ($16,699.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,671.20, add-ons for qualifying new technology services are included. If operating cost exceeds $50,542.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,839.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $13,675.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,726.25 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,079.16. The transfer capital threshold is the transfer adjustment factor * $1,079.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,16699.94,44657.18,Inpatient DRG
Ercp Stent Placement Biliary/Pancreatic Duct,CASE-43274,APC,43274,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5682.51,,"APC Price ($5,682.51). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5682.51,5966.63,OPPS APC
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH CC,026,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],63202.45,,"Fee schedule rate ($63,202.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,23000.66,63202.45,There are no additional notes associated with this service or procedure.
Mastectomy Partial|RIGHT SIDE,CASE-19301,APC,19301,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3848.19,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3664.94,3848.19,OPPS APC
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],39153.65,,"Fee schedule rate ($39,153.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,7605.00,39153.65,There are no additional notes associated with this service or procedure.
"Inj Dx/Ther Agnt Paravert Facet Joint, Cerv/Thorac, 2nd Level|LEFT SIDE|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA",CASE-64491,APC,64491,CPT,0360,RC,,,LT|74,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],827.89,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,827.89,869.28,OPPS APC
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],6965.00,,,,,,0,other,6965.00,23385.72,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],26007.09,,,,,,0,other,10895.60,35192.25,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],2070.00,,,,,,0,other,1188.00,17370.86,Estimated amount calculated based on 3 day length of stay.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],31241.17,,,,,,0,other,12696.97,47123.82,There are no additional notes associated with this service or procedure.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],35304.50,,"Case rate ($33,623.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $31,414.68, add-ons for qualifying new technology services are included. If operating cost exceeds $66,285.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,076.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.4. The base transfer operating payment is the transfer adjustment factor * $29,361.48 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $29,469.74 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,316.91. The transfer capital threshold is the transfer adjustment factor * $2,316.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,33623.33,133270.57,Inpatient DRG
"NEONATE BIRTH WEIGHT > 2499 GRAMS NORMAL NEWBORN OR NEONATE WITH OTHER PROBLEM,MINOR",640,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],1186.89,,"Case rate ($1,130.37). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,1130.37,1186.89,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,083,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],28680.85,,"Fee schedule rate ($28,680.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,28680.85,There are no additional notes associated with this service or procedure.
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC,519,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],50780.20,,"Fee schedule rate ($50,780.20). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,15490.44,50780.20,There are no additional notes associated with this service or procedure.
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],31973.49,,"Fee schedule rate ($31,973.49). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,13386.36,33244.29,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],6657.03,,"Case rate ($6,340.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,033.60, add-ons for qualifying new technology services are included. If operating cost exceeds $40,904.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,081.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $4,073.62 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,088.64 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $321.45. The transfer capital threshold is the transfer adjustment factor * $321.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6340.03,15076.44,Inpatient DRG
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],19119.59,,"Case rate ($19,119.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,922.16, add-ons for qualifying new technology services are included. If operating cost exceeds $52,793.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,016.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $15,918.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,977.21 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,256.13. The transfer capital threshold is the transfer adjustment factor * $1,256.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,11348.00,62454.12,Inpatient DRG
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],6277.00,,"Per diem ($6,277). If length of stay < 5.6, first 1 days paid at a per diem of $12,554 instead. Capped at $35,148.55.",,,,0,other,6277.00,36801.89,Estimated amount calculated based on 4 day length of stay.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,086,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],11143.76,,"Case rate ($10,766.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,151.85, add-ons for qualifying new technology services are included. If operating cost exceeds $45,022.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,405.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $8,176.75 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,206.90 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $645.23. The transfer capital threshold is the transfer adjustment factor * $645.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,8442.00,30728.81,Inpatient DRG
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,167,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],43522.37,,"Fee schedule rate ($43,522.37). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,14157.71,43522.37,There are no additional notes associated with this service or procedure.
HC Biopsy/Exc Lymph Node Needle|TECHNICAL COMPONENT,CASE-38505,APC,38505,CPT,0361,RC,,,TC,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1600.04,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1545.93,1623.23,OPPS APC
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],15042.50,,"Case rate ($14,747.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,854.94, add-ons for qualifying new technology services are included. If operating cost exceeds $48,725.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,696.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $11,866.24 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,909.99 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $936.36. The transfer capital threshold is the transfer adjustment factor * $936.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,14747.55,37899.49,Inpatient DRG
Rpr Recrt Ingun Hernia Any Age Incarcerated|LEFT SIDE,CASE-49521,APC,49521,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6059.65,,"APC Price ($6,059.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6059.65,6362.63,OPPS APC
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],28225.82,,"Case rate ($16,129.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,140.12, add-ons for qualifying new technology services are included. If operating cost exceeds $50,011.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,797.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $13,146.70 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,195.17 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,037.40. The transfer capital threshold is the transfer adjustment factor * $1,037.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,16129.04,59610.47,All Other Inpatient
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],19343.43,,"Case rate ($11,053.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,418.34, add-ons for qualifying new technology services are included. If operating cost exceeds $45,289.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,426.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $8,442.26 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,473.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $666.18. The transfer capital threshold is the transfer adjustment factor * $666.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,11053.39,36776.05,All Other Inpatient
Egd Insert Guide Wire Dilator Passage Esophagus,CASE-43248,APC,43248,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],891.41,,"APC Price ($848.96). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,848.96,891.41,OPPS APC
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,098,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],38799.38,,"Fee schedule rate ($38,799.38). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,6965.00,45156.75,There are no additional notes associated with this service or procedure.
ALLERGIC REACTIONS WITH MCC,915,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],33088.84,,,,,,0,other,13332.86,33088.84,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],11059.47,,"Case rate ($11,059.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,424, add-ons for qualifying new technology services are included. If operating cost exceeds $45,295.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,426.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $8,447.91 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,479.05 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $666.62. The transfer capital threshold is the transfer adjustment factor * $666.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,11059.47,28423.20,Inpatient DRG
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],14895.38,,"Case rate ($14,603.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,720.75, add-ons for qualifying new technology services are included. If operating cost exceeds $48,591.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,685.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $11,732.54 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,775.80 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $925.81. The transfer capital threshold is the transfer adjustment factor * $925.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,14603.31,45017.13,Inpatient DRG
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],9635.31,,"Case rate ($9,446.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,923.36, add-ons for qualifying new technology services are included. If operating cost exceeds $43,794.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,308.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,952.78 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,978.41 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $548.64. The transfer capital threshold is the transfer adjustment factor * $548.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,9446.38,21796.21,Inpatient DRG
CERVICAL SPINAL FUSION WITH MCC,471,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],111337.93,,"Fee schedule rate ($111,337.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,34645.26,111337.93,There are no additional notes associated with this service or procedure.
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],75976.83,,,,,,0,other,10078.00,81454.07,There are no additional notes associated with this service or procedure.
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],28334.16,,"Fee schedule rate ($28,334.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,7868.00,32126.64,There are no additional notes associated with this service or procedure.
HC Blood Occult Peroxidase Actv Qual Feces 1-3 Spec,CASE-82272,APC,82272,CPT,0301,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],4.44,,,,,,0,other,4.23,4.44,There are no additional notes associated with this service or procedure.
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],45017.13,,"Fee schedule rate ($45,017.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,14603.31,45017.13,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL OBSTRUCTION WITH CC,389,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],16423.43,,"Fee schedule rate ($16,423.43). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5118.00,16423.43,There are no additional notes associated with this service or procedure.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,191,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],16612.88,,"Fee schedule rate ($16,612.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6965.00,16612.88,There are no additional notes associated with this service or procedure.
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],11168.08,,"Fee schedule rate ($11,168.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5937.41,12366.99,There are no additional notes associated with this service or procedure.
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC,520,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],39786.42,,"Fee schedule rate ($39,786.42). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12061.74,39786.42,There are no additional notes associated with this service or procedure.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],7224.45,,"Case rate ($7,224.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,856.36, add-ons for qualifying new technology services are included. If operating cost exceeds $41,727.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,146.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $4,893.37 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,911.41 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $386.14. The transfer capital threshold is the transfer adjustment factor * $386.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,15340.19,Inpatient DRG
Repair Intermediate S/a/T/E >30.0 Cm,CASE-12037,APC,12037,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1623.23,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1545.93,1623.23,OPPS APC
Egd Balloon Dilation Esophagus <30 Mm Diam,CASE-43249,APC,43249,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1796.14,,"APC Price ($1,796.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1796.14,1885.95,OPPS APC
CHEST PAIN,313,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],6965.00,,,,,,0,other,6820.84,15377.66,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,091,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],14114.82,,"Case rate ($13,838.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,008.86, add-ons for qualifying new technology services are included. If operating cost exceeds $47,879.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,629.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $11,023.26 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,063.91 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $869.84. The transfer capital threshold is the transfer adjustment factor * $869.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,13838.06,40030.81,Inpatient DRG
Lamnotmy Incl W/Dcmprsn Nrv Root 1 Intrspc Lumbr|LEFT SIDE|SEPARATE STRUCTURE,CASE-63030,APC,63030,CPT,0360,RC,,,LT|XS,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6791.99,7131.59,OPPS APC
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],9667.64,,"Fee schedule rate ($9,667.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,5139.72,13110.79,There are no additional notes associated with this service or procedure.
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],7993.75,,"Case rate ($7,993.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,572.03, add-ons for qualifying new technology services are included. If operating cost exceeds $42,443.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,202.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $5,606.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,627.08 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $442.40. The transfer capital threshold is the transfer adjustment factor * $442.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,5415.00,17575.50,Inpatient DRG
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],7734.30,,"Case rate ($7,366). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,988.03, add-ons for qualifying new technology services are included. If operating cost exceeds $41,859.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,156.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,024.55 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,043.08 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $396.49. The transfer capital threshold is the transfer adjustment factor * $396.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,21195.68,Inpatient DRG
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],21980.29,,"Fee schedule rate ($21,980.29). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9865.56,37914.65,There are no additional notes associated with this service or procedure.
Excision Inferior Turbinate Partial/Complete|BILATERAL PROCEDURE,CASE-30130,APC,30130,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.35,,"APC Price ($3,103.35). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.35,3103.35,OPPS APC
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],27329.90,,"Case rate ($26,028.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $24,349.34, add-ons for qualifying new technology services are included. If operating cost exceeds $59,220.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,521.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $22,322.08 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $22,404.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,761.43. The transfer capital threshold is the transfer adjustment factor * $1,761.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,26028.48,80635.65,Inpatient DRG
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,091,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],13838.06,,"Case rate ($13,838.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,008.86, add-ons for qualifying new technology services are included. If operating cost exceeds $47,879.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,629.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $11,023.26 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,063.91 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $869.84. The transfer capital threshold is the transfer adjustment factor * $869.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,13838.06,40030.81,Inpatient DRG
Laps Supracrv Hysterect 250 Gm/< Rmvl Tube/Ovar,CASE-58542,APC,58542,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],10298.02,,"APC Price ($9,949.78). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,9949.78,10298.02,OPPS APC
SPINAL PROCEDURES WITHOUT CC/MCC,030,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],44714.01,,"Fee schedule rate ($44,714.01). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,16810.99,44714.01,There are no additional notes associated with this service or procedure.
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],11640.72,,"Case rate ($11,247.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,598.51, add-ons for qualifying new technology services are included. If operating cost exceeds $45,469.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,440.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,621.77 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,653.56 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $680.34. The transfer capital threshold is the transfer adjustment factor * $680.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,11247.07,27028.33,Inpatient DRG
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],58394.20,,"Fee schedule rate ($58,394.20). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,9370.00,65732.99,There are no additional notes associated with this service or procedure.
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],13017.29,,"Case rate ($7,438.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,055.44, add-ons for qualifying new technology services are included. If operating cost exceeds $41,926.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,161.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,091.72 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,110.49 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $401.79. The transfer capital threshold is the transfer adjustment factor * $401.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,7438.45,15961.98,All Other Inpatient
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC,519,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],15800.25,,"Case rate ($15,490.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,546.03, add-ons for qualifying new technology services are included. If operating cost exceeds $49,417.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,750.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $12,554.80 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,601.09 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $990.70. The transfer capital threshold is the transfer adjustment factor * $990.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,15490.44,50780.20,Inpatient DRG
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,083,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],11967.27,,"Case rate ($11,397.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,738.37, add-ons for qualifying new technology services are included. If operating cost exceeds $45,609.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,451.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $8,761.12 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,793.42 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $691.34. The transfer capital threshold is the transfer adjustment factor * $691.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,28680.85,Inpatient DRG
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],19868.19,,"Case rate ($18,922.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,770.10, add-ons for qualifying new technology services are included. If operating cost exceeds $52,641.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,971.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.9. The base transfer operating payment is the transfer adjustment factor * $15,765.37 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,825.15 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,211.76. The transfer capital threshold is the transfer adjustment factor * $1,211.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,19435.86,50821.76,Inpatient DRG
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH MCC",510,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],23519.99,,"Case rate ($22,399.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,973.84, add-ons for qualifying new technology services are included. If operating cost exceeds $55,844.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,256.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.3. The base transfer operating payment is the transfer adjustment factor * $18,958.99 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $19,028.89 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,496.05. The transfer capital threshold is the transfer adjustment factor * $1,496.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10710.00,89863.76,Inpatient DRG
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7477.31,,"Case rate ($7,224.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,856.36, add-ons for qualifying new technology services are included. If operating cost exceeds $41,727.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,146.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $4,893.37 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,911.41 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $386.14. The transfer capital threshold is the transfer adjustment factor * $386.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6965.00,15340.19,Inpatient DRG
"CESAREAN SECTION WITHOUT STERILIZATION,MAJOR",540,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],11325.56,,"Case rate ($10,786.25). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10786.25,11325.56,There are no additional notes associated with this service or procedure.
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],14481.61,,"Case rate ($13,792.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,966.02, add-ons for qualifying new technology services are included. If operating cost exceeds $47,837.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,626.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $10,980.58 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,021.07 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $866.48. The transfer capital threshold is the transfer adjustment factor * $866.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,34422.94,Inpatient DRG
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC,434,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],13390.01,,"Fee schedule rate ($13,390.01). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6770.05,14019.86,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC,832,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],13561.03,,"Fee schedule rate ($13,561.03). Adds an outlier to normal pricing equal to the per diem rate ($18,253.69) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,4803.31,14198.92,There are no additional notes associated with this service or procedure.
Egd US Guided Transmural Injxn/Fiducial Marker,CASE-43253,APC,43253,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1859.01,,"APC Price ($1,796.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1796.14,1885.95,OPPS APC
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],10422.45,,"Fee schedule rate ($10,422.45). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9446.38,21796.21,There are no additional notes associated with this service or procedure.
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],13486.95,,"Fee schedule rate ($13,486.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6915.64,14442.92,There are no additional notes associated with this service or procedure.
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],14902.97,,"Case rate ($14,610.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,727.68, add-ons for qualifying new technology services are included. If operating cost exceeds $48,598.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,686.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.6. The base transfer operating payment is the transfer adjustment factor * $11,739.44 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,782.73 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $926.36. The transfer capital threshold is the transfer adjustment factor * $926.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6277.00,36801.89,Inpatient DRG
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],6066.84,,"Case rate ($5,777.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,510.70, add-ons for qualifying new technology services are included. If operating cost exceeds $40,381.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,040.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $3,552.65 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,565.75 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $280.34. The transfer capital threshold is the transfer adjustment factor * $280.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5065.00,12558.65,Inpatient DRG
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],42768.36,,"Fee schedule rate ($42,768.36). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,14295.18,42768.36,There are no additional notes associated with this service or procedure.
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],59081.91,,"Fee schedule rate ($59,081.91). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,8480.00,59081.91,There are no additional notes associated with this service or procedure.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],20382.60,,"Fee schedule rate ($20,382.60). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11053.39,36776.05,There are no additional notes associated with this service or procedure.
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC,807,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],11163.60,,"Fee schedule rate ($11,163.60). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5354.25,13266.23,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS WITH MCC,947,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],16169.51,,"Fee schedule rate ($16,169.51). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,10541.41,30414.32,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC,087,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],12569.55,,"Fee schedule rate ($12,569.55). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,8139.36,22679.07,There are no additional notes associated with this service or procedure.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],73588.10,,"Fee schedule rate ($73,588.10). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,21585.31,73588.10,There are no additional notes associated with this service or procedure.
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],15994.77,,"Case rate ($15,233.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,306.64, add-ons for qualifying new technology services are included. If operating cost exceeds $49,177.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,731.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $12,316.28 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,361.69 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $971.88. The transfer capital threshold is the transfer adjustment factor * $971.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,15233.11,38610.21,Inpatient DRG
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],8862.31,,"Fee schedule rate ($8,862.31). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8767.81,19824.58,There are no additional notes associated with this service or procedure.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],15309.46,,"Fee schedule rate ($15,309.46). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6965.00,15340.19,There are no additional notes associated with this service or procedure.
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],22524.26,,,,,,0,other,9696.93,35061.53,There are no additional notes associated with this service or procedure.
Excision Pilonidal Cyst/Sinus Simple,CASE-11770,APC,11770,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],2814.04,,"APC Price ($2,718.88). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2718.88,2814.04,OPPS APC
TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC,084,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],19445.16,,"Fee schedule rate ($19,445.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,6965.00,19445.16,There are no additional notes associated with this service or procedure.
Suction Assisted Lipectomy Lower Extremity|BILATERAL PROCEDURE,CASE-15879,APC,15879,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6215.36,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6215.36,6526.12,OPPS APC
HC Drain/Inj Joint/Bursa W/US Large|PBB CHARGE,CASE-20611,APC,20611,CPT,0510,RC,,,PBB,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],301.68,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,287.31,301.68,OPPS APC
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],28038.61,,"Fee schedule rate ($28,038.61). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12126.09,29582.40,There are no additional notes associated with this service or procedure.
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],21854.96,,"Fee schedule rate ($21,854.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10638.94,25261.33,There are no additional notes associated with this service or procedure.
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH MCC",722,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],14200.37,,"Case rate ($14,200.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,345.91, add-ons for qualifying new technology services are included. If operating cost exceeds $48,216.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,656.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $11,359.07 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,400.95 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $896.34. The transfer capital threshold is the transfer adjustment factor * $896.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,14200.37,56869.13,Inpatient DRG
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],7730.10,,"Fee schedule rate ($7,730.10). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6153.12,13947.32,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],84226.47,,"Fee schedule rate ($84,226.47). Adds an outlier to normal pricing equal to the per diem rate ($75,906.87) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14.7), with a minimum of zero.",,,,0,other,32296.02,88188.38,There are no additional notes associated with this service or procedure.
HC Joint Injection/Aspir Large WO US|LEFT SIDE,CASE-20610,APC,20610,CPT,0510,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],301.68,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,287.31,301.68,OPPS APC
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],20407.65,,"Case rate ($19,435.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $18,216.37, add-ons for qualifying new technology services are included. If operating cost exceeds $53,087.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,039.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.9. The base transfer operating payment is the transfer adjustment factor * $16,211.64 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $16,271.42 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,279.26. The transfer capital threshold is the transfer adjustment factor * $1,279.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,19435.86,50821.76,Inpatient DRG
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,085,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],57443.16,,"Fee schedule rate ($57,443.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,9282.00,57443.16,There are no additional notes associated with this service or procedure.
Laps Vaginal Hysterect > 250 Gm Rmvl Tube&/Ovar,CASE-58554,APC,58554,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],9949.78,,"APC Price ($9,949.78). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,9949.78,10447.27,OPPS APC
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",063,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],35701.87,,"Fee schedule rate ($35,701.87). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,35701.87,There are no additional notes associated with this service or procedure.
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],31750.77,,"Fee schedule rate ($31,750.77). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13386.36,33244.29,There are no additional notes associated with this service or procedure.
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],8945.71,,"Case rate ($8,643.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,176.19, add-ons for qualifying new technology services are included. If operating cost exceeds $43,047.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,249.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $6,208.35 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,231.24 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $489.90. The transfer capital threshold is the transfer adjustment factor * $489.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,8643.20,19462.52,Inpatient DRG
"OTHER DISORDERS OF NERVOUS SYSTEM,MAJOR",058,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],1244.31,,"Case rate for a one day stay ($1,185.06). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,1185.06,1244.31,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],25026.36,,"Fee schedule rate ($25,026.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9356.31,25026.36,There are no additional notes associated with this service or procedure.
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],81306.30,,"Fee schedule rate ($81,306.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,20846.48,81306.30,There are no additional notes associated with this service or procedure.
UNGROUPABLE,999,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],50458.48,,"Case rate ($48,752.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $45,488.70, add-ons for qualifying new technology services are included. If operating cost exceeds $80,359.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $5,183.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 12.7. The base transfer operating payment is the transfer adjustment factor * $43,383.78 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $43,543.75 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,423.41. The transfer capital threshold is the transfer adjustment factor * $3,423.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,10228.00,161307.29,Inpatient DRG
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC,807,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],6510.67,,"Case rate ($6,510.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,192.35, add-ons for qualifying new technology services are included. If operating cost exceeds $41,063.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,093.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $4,231.80 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,247.40 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $333.93. The transfer capital threshold is the transfer adjustment factor * $333.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,5354.25,13266.23,Inpatient DRG
Nasal/Sinus Ndsc W/Partial Ethmoidectomy,CASE-31254,APC,31254,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6605.95,,"APC Price ($6,605.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6605.95,6936.25,OPPS APC
PSYCHOSES,885,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],11803.32,,"Case rate ($11,404.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,744.67, add-ons for qualifying new technology services are included. If operating cost exceeds $45,615.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,451.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.5. The base transfer operating payment is the transfer adjustment factor * $8,767.39 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,799.72 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $691.83. The transfer capital threshold is the transfer adjustment factor * $691.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,2070.00,27484.83,Inpatient DRG
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITHOUT CC/MCC,816,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],14733.53,,"Fee schedule rate ($14,733.53). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6224.90,14733.53,There are no additional notes associated with this service or procedure.
Mastectomy Simple Complete|BILATERAL PROCEDURE,CASE-19303,APC,19303,CPT,0360,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6526.12,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6526.12,6526.12,OPPS APC
Dstr Nrolytc Agnt Parverteb Fct Addl Crvcl/Thora,CASE-64634,APC,64634,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1827.80,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1827.80,1919.19,OPPS APC
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,068,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],6965.00,,,,,,0,other,6965.00,23184.90,There are no additional notes associated with this service or procedure.
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],16055.90,,"Fee schedule rate ($16,055.90). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8163.06,18067.42,There are no additional notes associated with this service or procedure.
ENDOCRINE DISORDERS WITH CC,644,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],19420.69,,"Fee schedule rate ($19,420.69). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7066.99,20334.21,There are no additional notes associated with this service or procedure.
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC,497,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],37761.19,,"Fee schedule rate ($37,761.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10127.65,37761.19,There are no additional notes associated with this service or procedure.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],44691.15,,"Fee schedule rate ($44,691.15). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,26028.48,80635.65,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],6338.33,,"Case rate ($6,214.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,916.41, add-ons for qualifying new technology services are included. If operating cost exceeds $40,787.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,072.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $3,956.88 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,971.47 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $312.24. The transfer capital threshold is the transfer adjustment factor * $312.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6214.05,15318.94,Inpatient DRG
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],11043.60,,"Case rate ($10,517.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,920.01, add-ons for qualifying new technology services are included. If operating cost exceeds $44,791.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,386.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $7,945.76 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,975.06 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $627.00. The transfer capital threshold is the transfer adjustment factor * $627.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10517.71,24909.11,Inpatient DRG
PERITONEAL ADHESIOLYSIS WITH CC,336,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],28394.14,,"Case rate ($16,225.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,229.58, add-ons for qualifying new technology services are included. If operating cost exceeds $50,100.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,804.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $13,235.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,284.63 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,044.44. The transfer capital threshold is the transfer adjustment factor * $1,044.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,16225.22,53705.31,All Other Inpatient
Arthrs Wrst Exc&/Rpr Triang Fibrocart&/Joint,CASE-29846,APC,29846,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,447,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],156646.82,,"Fee schedule rate ($156,646.82). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,47193.21,156646.82,There are no additional notes associated with this service or procedure.
UNGROUPABLE,999,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],51189.76,,"Case rate ($48,752.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $45,488.70, add-ons for qualifying new technology services are included. If operating cost exceeds $80,359.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $5,183.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 12.7. The base transfer operating payment is the transfer adjustment factor * $43,383.78 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $43,543.75 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,423.41. The transfer capital threshold is the transfer adjustment factor * $3,423.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10228.00,161307.29,Inpatient DRG
O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC,621,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],12452.88,,"Case rate ($11,859.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,187.11, add-ons for qualifying new technology services are included. If operating cost exceeds $46,058.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,467.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $9,207.25 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,242.16 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $707.69. The transfer capital threshold is the transfer adjustment factor * $707.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12159.94,36669.96,Inpatient DRG
Laparoscopy Surg Partial Nephrectomy|LEFT SIDE,CASE-50543,APC,50543,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],9949.78,,"APC Price ($9,949.78). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,9949.78,10447.27,OPPS APC
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],23385.72,,"Fee schedule rate ($23,385.72). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,23385.72,There are no additional notes associated with this service or procedure.
"COAGULATION AND PLATELET DISORDERS,MODERATE",661,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],9779.76,,"Case rate ($9,779.76). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,9779.76,10268.75,There are no additional notes associated with this service or procedure.
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],8869.86,,"Case rate ($8,447.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,994.13, add-ons for qualifying new technology services are included. If operating cost exceeds $42,865.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,235.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,026.96 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,049.18 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $475.59. The transfer capital threshold is the transfer adjustment factor * $475.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,1188.00,18893.86,Inpatient DRG
CESAREAN SECTION WITH STERILIZATION WITH MCC,783,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],23722.94,,"Fee schedule rate ($23,722.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12612.10,23722.94,There are no additional notes associated with this service or procedure.
"ALCOHOLIC LIVER DISEASE,EXTREME",280,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],24390.20,,"Case rate ($24,390.20). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,24390.20,25609.71,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],9226.81,,"Case rate ($8,787.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,310.38, add-ons for qualifying new technology services are included. If operating cost exceeds $43,181.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,260.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,342.05 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,365.43 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $500.45. The transfer capital threshold is the transfer adjustment factor * $500.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,32293.66,Inpatient DRG
PSYCHOSES,885,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],2070.00,,,,,,0,other,2070.00,27484.83,Estimated amount calculated based on 3 day length of stay.
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],35419.59,,"Fee schedule rate ($35,419.59). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,7086.00,57872.02,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],23239.84,,"Fee schedule rate ($23,239.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8543.64,23239.84,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],6460.78,,"Case rate ($6,153.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,859.72, add-ons for qualifying new technology services are included. If operating cost exceeds $40,730.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,067.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,900.39 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,914.77 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $307.78. The transfer capital threshold is the transfer adjustment factor * $307.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6153.12,13947.32,Inpatient DRG
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],19824.58,,,,,,0,other,8767.81,19824.58,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,064,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],41838.16,,"Fee schedule rate ($41,838.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,15563.58,41838.16,There are no additional notes associated with this service or procedure.
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],21576.11,,"Case rate ($20,846.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $19,528.64, add-ons for qualifying new technology services are included. If operating cost exceeds $54,399.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,142.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $17,519.09 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $17,583.69 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,382.43. The transfer capital threshold is the transfer adjustment factor * $1,382.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,20846.48,81306.30,Inpatient DRG
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],6965.00,,,,,,0,other,6965.00,32293.66,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,690,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],15212.93,,"Fee schedule rate ($15,212.93). Adds an outlier to normal pricing equal to the per diem rate ($36,758.78) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,7426.94,15928.53,There are no additional notes associated with this service or procedure.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,988,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],42425.46,,"Fee schedule rate ($42,425.46). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,13075.52,42425.46,There are no additional notes associated with this service or procedure.
"Tendon Sheath Incision|LEFT HAND, FIFTH DIGIT",CASE-26055,APC,26055,CPT,0360,RC,,,F4,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1580.37,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1505.12,1580.37,OPPS APC
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,097,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],67876.56,,"Fee schedule rate ($67,876.56). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17.7), with a minimum of zero.",,,,0,other,26404.32,79915.74,There are no additional notes associated with this service or procedure.
SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS,029,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],25588.42,,"Case rate ($24,369.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $22,848.26, add-ons for qualifying new technology services are included. If operating cost exceeds $57,719.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,360.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.7)) / 2. The base transfer operating payment is the transfer adjustment factor * $20,824.36 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $20,903.31 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,600.61. The transfer capital threshold is the transfer adjustment factor * $1,600.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13641.00,67130.05,Inpatient DRG
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],16669.71,,"Fee schedule rate ($16,669.71). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8767.81,19824.58,There are no additional notes associated with this service or procedure.
HC Peripheral Block - Femoral Single or Saphenous W/Img Gdn|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64447,APC,64447,CPT,0360,RC,,,LT|XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7029.71,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,7029.71,7131.59,OPPS APC
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,091,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],14163.16,,"Case rate ($13,488.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,705.41, add-ons for qualifying new technology services are included. If operating cost exceeds $47,576.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,583.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $10,719.82 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,760.46 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $823.95. The transfer capital threshold is the transfer adjustment factor * $823.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13838.06,40030.81,Inpatient DRG
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],86252.84,,"Fee schedule rate ($86,252.84). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,27944.96,86252.84,There are no additional notes associated with this service or procedure.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],101083.00,,"Fee schedule rate ($101,083.00). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,35389.50,101083.00,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF THE EYE WITHOUT MCC,125,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],17952.29,,"Fee schedule rate ($17,952.29). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (6), with a minimum of zero.",,,,0,other,7144.54,17952.29,There are no additional notes associated with this service or procedure.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC,434,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7007.00,,"Case rate ($6,770.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,433.64, add-ons for qualifying new technology services are included. If operating cost exceeds $41,304.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,112.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,472.20 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,488.69 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $352.90. The transfer capital threshold is the transfer adjustment factor * $352.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6770.05,14019.86,Inpatient DRG
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6841.83,,"Case rate ($6,841.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,500.42, add-ons for qualifying new technology services are included. If operating cost exceeds $41,371.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,118.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $4,538.73 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,555.47 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $358.15. The transfer capital threshold is the transfer adjustment factor * $358.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6841.83,21167.26,Inpatient DRG
Fasct Palm W/WO Z-Plasty Tissue Reargmt/Skn Grft|LEFT SIDE,CASE-26121,APC,26121,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3169.86,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6944.10,,"Case rate ($6,944.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,595.55, add-ons for qualifying new technology services are included. If operating cost exceeds $41,466.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,125.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,633.51 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,650.60 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $365.63. The transfer capital threshold is the transfer adjustment factor * $365.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,5068.21,14525.56,Inpatient DRG
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],8972.00,,"Per diem ($8,972). If length of stay < 6.1, first 1 days paid at a per diem of $17,944 instead. Capped at $54,730.85.",,,,0,other,8972.00,81524.17,Estimated amount calculated based on 4 day length of stay.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITHOUT CC/MCC,517,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],11705.53,,"Case rate ($11,148.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $10,476.23, add-ons for qualifying new technology services are included. If operating cost exceeds $49,120.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $3,441.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $9,076.06 + an uncompensated DSH payment of $1,359.91. The transfer operating threshold is the transfer adjustment factor * $9,116.32 + an uncompensated DSH payment of $1,359.91. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $712.16. The transfer capital threshold is the transfer adjustment factor * $712.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10207.96,29371.86,Inpatient DRG
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],11388.47,,"Case rate ($10,846.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,225.56, add-ons for qualifying new technology services are included. If operating cost exceeds $45,096.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,410.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $8,250.19 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,280.61 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $651.02. The transfer capital threshold is the transfer adjustment factor * $651.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10846.16,25863.45,Inpatient DRG
NONTRAUMATIC STUPOR AND COMA WITH MCC,080,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],30179.40,,"Fee schedule rate ($30,179.40). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,14202.39,35615.37,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],128358.13,,"Fee schedule rate ($128,358.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,40542.37,128358.13,There are no additional notes associated with this service or procedure.
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC",629,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],44657.18,,"Fee schedule rate ($44,657.18). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,16699.94,44657.18,There are no additional notes associated with this service or procedure.
Excision Olecranon Bursa|LEFT SIDE,CASE-24105,APC,24105,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6791.99,7131.59,OPPS APC
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],33159.45,,"Fee schedule rate ($33,159.45). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,13092.47,33159.45,There are no additional notes associated with this service or procedure.
CELLULITIS WITH MCC,602,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],20247.68,,"Case rate ($11,570.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,899.02, add-ons for qualifying new technology services are included. If operating cost exceeds $45,770.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,463.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $8,921.17 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,954.07 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $703.97. The transfer capital threshold is the transfer adjustment factor * $703.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,11570.10,28349.31,All Other Inpatient
Arthroscopy Knee W/Meniscus Rpr Medial&Lateral|LEFT SIDE,CASE-29883,APC,29883,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],13256.31,,"Case rate ($12,808.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,050.64, add-ons for qualifying new technology services are included. If operating cost exceeds $46,921.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,554.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $10,068.57 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,105.69 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $794.51. The transfer capital threshold is the transfer adjustment factor * $794.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,7353.00,33398.16,Inpatient DRG
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],26178.21,,"Fee schedule rate ($26,178.21). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,13917.42,34889.29,There are no additional notes associated with this service or procedure.
"UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY EXCEPT LEIOMYOMA,MINOR",513,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],5701.99,,"Case rate for a one day stay ($5,430.47). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5430.47,5701.99,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITH MCC,385,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],12660.40,,"Case rate ($12,660.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,913.31, add-ons for qualifying new technology services are included. If operating cost exceeds $46,784.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,543.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $9,931.73 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,968.35 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $783.71. The transfer capital threshold is the transfer adjustment factor * $783.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,11480.01,31134.92,Inpatient DRG
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],59521.43,,"Fee schedule rate ($59,521.43). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,16689.78,59521.43,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,091,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],40030.81,,"Fee schedule rate ($40,030.81). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,13838.06,40030.81,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6977.68,,"Case rate ($6,645.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,326.46, add-ons for qualifying new technology services are included. If operating cost exceeds $41,197.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,095.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,364.96 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,381.51 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $335.50. The transfer capital threshold is the transfer adjustment factor * $335.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6164.03,14071.02,Inpatient DRG
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],8106.18,,"Case rate ($8,106.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,676.61, add-ons for qualifying new technology services are included. If operating cost exceeds $42,547.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,210.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,710.61 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,731.66 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $450.62. The transfer capital threshold is the transfer adjustment factor * $450.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8106.18,18245.94,Inpatient DRG
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],24528.10,,"Fee schedule rate ($24,528.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10989.72,26280.60,There are no additional notes associated with this service or procedure.
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],15484.93,,"Case rate ($14,747.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,854.94, add-ons for qualifying new technology services are included. If operating cost exceeds $48,725.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,696.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $11,866.24 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,909.99 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $936.36. The transfer capital threshold is the transfer adjustment factor * $936.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,14747.55,37899.49,Inpatient DRG
SPINAL PROCEDURES WITHOUT CC/MCC,030,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],17193.04,,"Case rate ($16,374.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,395.22, add-ons for qualifying new technology services are included. If operating cost exceeds $50,266.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,789.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $13,399.47 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,450.27 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,029.91. The transfer capital threshold is the transfer adjustment factor * $1,029.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,16810.99,44714.01,Inpatient DRG
RESPIRATORY NEOPLASMS WITH CC,181,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],17609.39,,"Fee schedule rate ($17,609.39). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9197.84,21074.07,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,064,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],41838.16,,"Fee schedule rate ($41,838.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,15563.58,41838.16,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],10347.06,,"Case rate ($10,347.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,761.25, add-ons for qualifying new technology services are included. If operating cost exceeds $44,632.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,374.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $7,787.59 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,816.30 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $614.52. The transfer capital threshold is the transfer adjustment factor * $614.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10347.06,28821.04,Inpatient DRG
MAJOR CHEST PROCEDURES WITH CC,164,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],49664.75,,,,,,0,other,19037.66,77058.83,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],82674.88,,,,,,0,other,30398.48,82674.88,There are no additional notes associated with this service or procedure.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],28649.93,,"Fee schedule rate ($28,649.93). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,12268.97,41006.47,There are no additional notes associated with this service or procedure.
"Capsulectomy/Capsulotomy Iphal Joint Each|RIGHT HAND, FOURTH DIGIT",CASE-26525,APC,26525,CPT,0360,RC,,,F8,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
Laparoscopy W/Rmvl Adnexal Structures,CASE-58661,APC,58661,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5658.76,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5658.76,5941.70,OPPS APC
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],9667.64,,"Fee schedule rate ($9,667.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,5139.72,13110.79,There are no additional notes associated with this service or procedure.
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],42021.93,,"Fee schedule rate ($42,021.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,21248.73,56089.29,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],49997.29,,,,,,0,other,19152.11,53152.12,There are no additional notes associated with this service or procedure.
Surgical Arthroscopy Shoulder Removal Loose/FB,CASE-29819,APC,29819,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7029.71,OPPS APC
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],27747.62,,"Case rate ($26,809.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $25,075.72, add-ons for qualifying new technology services are included. If operating cost exceeds $59,946.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,578.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $23,045.79 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $23,130.76 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,818.54. The transfer capital threshold is the transfer adjustment factor * $1,818.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,26809.29,97015.50,Inpatient DRG
Egd Balloon Dilation Esophagus <30 Mm Diam,CASE-43249,APC,43249,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1859.01,,"APC Price ($1,796.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1796.14,1885.95,OPPS APC
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",063,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],35701.87,,"Fee schedule rate ($35,701.87). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,35701.87,There are no additional notes associated with this service or procedure.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],23618.74,,"Fee schedule rate ($23,618.74). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10533.95,24956.34,There are no additional notes associated with this service or procedure.
HC Cv Cath Plac W/Port Tun >5,CASE-36561,APC,36561,CPT,0361,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3058.92,,"APC Price ($2,955.48). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2955.48,3103.25,OPPS APC
HYPERTENSION WITHOUT MCC,305,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],14190.59,,"Fee schedule rate ($14,190.59). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,7058.55,17230.49,There are no additional notes associated with this service or procedure.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],75579.22,,"Fee schedule rate ($75,579.22). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,25162.32,75579.22,There are no additional notes associated with this service or procedure.
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],20981.60,,"Fee schedule rate ($20,981.60). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,10003.71,23415.63,There are no additional notes associated with this service or procedure.
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],11914.12,,"Case rate ($11,914.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,219.06, add-ons for qualifying new technology services are included. If operating cost exceeds $46,090.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,489.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $9,240.03 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,274.10 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $729.13. The transfer capital threshold is the transfer adjustment factor * $729.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,11914.12,40426.76,Inpatient DRG
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],42787.31,,"Fee schedule rate ($42,787.31). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,15476.23,42787.31,There are no additional notes associated with this service or procedure.
Vulvectomy Simple Partial|BILATERAL PROCEDURE,CASE-56620,APC,56620,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3030.03,,"APC Price ($3,030.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3030.03,3181.53,OPPS APC
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],25609.86,,"Fee schedule rate ($25,609.86). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,12775.53,31469.43,There are no additional notes associated with this service or procedure.
Ndsc Njx Implt Matrl Urt&/Bldr Nck,CASE-51715,APC,51715,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3464.44,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3299.47,3464.44,OPPS APC
COAGULATION DISORDERS,813,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],29046.49,,"Fee schedule rate ($29,046.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12274.39,30013.33,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],81353.66,,"Fee schedule rate ($81,353.66). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,27256.92,81353.66,There are no additional notes associated with this service or procedure.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC",156,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],12624.95,,"Fee schedule rate ($12,624.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6625.12,13598.77,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,426,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],177294.98,,"Fee schedule rate ($177,294.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,76581.29,216864.15,There are no additional notes associated with this service or procedure.
NONTRAUMATIC STUPOR AND COMA WITH MCC,080,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],30179.40,,"Fee schedule rate ($30,179.40). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,14202.39,35615.37,There are no additional notes associated with this service or procedure.
POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES,769,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],13856.98,,"Case rate ($13,388.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,590.54, add-ons for qualifying new technology services are included. If operating cost exceeds $47,461.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,596.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $10,606.49 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,645.59 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $836.96. The transfer capital threshold is the transfer adjustment factor * $836.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,13388.39,33250.19,Inpatient DRG
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC,807,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],13266.23,,,,,,0,other,5354.25,13266.23,There are no additional notes associated with this service or procedure.
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",004,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],95747.60,,"Case rate ($95,747.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $89,207.57, add-ons for qualifying new technology services are included. If operating cost exceeds $124,078.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $8,620.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 22.4. The base transfer operating payment is the transfer adjustment factor * $86,942.06 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $87,262.63 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $6,860.59. The transfer capital threshold is the transfer adjustment factor * $6,860.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10249.47,272554.00,Inpatient DRG
UNGROUPABLE,999,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],48752.15,,"Case rate ($48,752.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $45,488.70, add-ons for qualifying new technology services are included. If operating cost exceeds $80,359.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $5,183.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 12.7. The base transfer operating payment is the transfer adjustment factor * $43,383.78 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $43,543.75 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,423.41. The transfer capital threshold is the transfer adjustment factor * $3,423.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10228.00,161307.29,Inpatient DRG
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],17356.15,,"Case rate ($17,356.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,281.67, add-ons for qualifying new technology services are included. If operating cost exceeds $51,152.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,887.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $14,284.05 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,336.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,127.15. The transfer capital threshold is the transfer adjustment factor * $1,127.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,17356.15,44778.95,Inpatient DRG
"SICKLE CELL ANEMIA CRISIS,MODERATE",662,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],8059.59,,"Case rate ($7,675.80). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7675.80,8059.59,There are no additional notes associated with this service or procedure.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],5683.00,,"Per diem ($5,683). If length of stay < 3.3, first 1 days paid at a per diem of $11,366 instead. Capped at $18,753.53.",,,,0,other,5683.00,19635.68,Estimated amount calculated based on 3 day length of stay.
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,095,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],48575.01,,"Fee schedule rate ($48,575.01). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,19411.47,50750.92,There are no additional notes associated with this service or procedure.
"Amp F/Th 1/2 Jt/Phalanx W/Neurect W/Dir Clsr|RIGHT HAND, SECOND DIGIT",CASE-26951,APC,26951,CPT,0360,RC,,,F6,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,074,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],9371.88,,"Case rate ($8,925.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,438.90, add-ons for qualifying new technology services are included. If operating cost exceeds $43,309.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,270.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,470.10 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,493.95 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $510.55. The transfer capital threshold is the transfer adjustment factor * $510.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8925.60,20919.08,Inpatient DRG
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],14603.19,,"Case rate ($13,907.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,073.74, add-ons for qualifying new technology services are included. If operating cost exceeds $47,944.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,634.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $11,087.92 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,128.80 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $874.95. The transfer capital threshold is the transfer adjustment factor * $874.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13907.80,52794.06,Inpatient DRG
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],22557.82,,"Fee schedule rate ($22,557.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6801.88,22557.82,There are no additional notes associated with this service or procedure.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,352,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],10102.12,,"Case rate ($9,621.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,100.21, add-ons for qualifying new technology services are included. If operating cost exceeds $43,971.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,307.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $7,128.23 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,155.26 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $547.89. The transfer capital threshold is the transfer adjustment factor * $547.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9853.37,26528.70,Inpatient DRG
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],22405.95,,"Fee schedule rate ($22,405.95). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,11914.12,40426.76,There are no additional notes associated with this service or procedure.
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6457.19,,"Case rate ($6,457.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,142.59, add-ons for qualifying new technology services are included. If operating cost exceeds $41,013.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,089.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $4,182.21 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,197.63 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $330.02. The transfer capital threshold is the transfer adjustment factor * $330.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,5139.72,13110.79,Inpatient DRG
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],29241.62,,"Fee schedule rate ($29,241.62). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,12984.79,32077.45,There are no additional notes associated with this service or procedure.
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],25829.63,,"Fee schedule rate ($25,829.63). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6965.00,29482.05,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],28983.97,,"Fee schedule rate ($28,983.97). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8956.76,28983.97,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],9370.00,,"Per diem ($9,370). If length of stay < 6.7, first 1 days paid at a per diem of $18,740 instead. Capped at $62,779.90.",,,,0,other,9370.00,65732.99,Estimated amount calculated based on 3 day length of stay.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],41944.25,,"Fee schedule rate ($41,944.25). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12795.84,41944.25,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],21667.25,,"Case rate ($21,667.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,292.19, add-ons for qualifying new technology services are included. If operating cost exceeds $55,163.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,202.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $18,279.84 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,347.24 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,442.46. The transfer capital threshold is the transfer adjustment factor * $1,442.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8972.00,81524.17,Inpatient DRG
"EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME, NEONATE",790,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],3054.00,,,,,,0,other,3054.00,44304.49,Estimated amount calculated based on 17 day length of stay.
Trurl Electrosurg Rescj Prostate Bleed Complete,CASE-52601,APC,52601,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5269.71,,"APC Price ($5,018.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5018.77,5269.71,OPPS APC
PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,337,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],12340.08,,"Case rate ($12,340.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,615.32, add-ons for qualifying new technology services are included. If operating cost exceeds $46,486.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,520.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $9,634.84 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,670.37 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $760.28. The transfer capital threshold is the transfer adjustment factor * $760.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12340.08,38926.31,Inpatient DRG
"Open Tx Metacarpal Fracture Single Ea Bone|RIGHT HAND, THIRD DIGIT",CASE-26615,APC,26615,CPT,0360,RC,,,F7,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,098,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],17486.17,,"Case rate ($17,486.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,402.62, add-ons for qualifying new technology services are included. If operating cost exceeds $51,273.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,896.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $14,404.56 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,457.67 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,136.66. The transfer capital threshold is the transfer adjustment factor * $1,136.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,45156.75,Inpatient DRG
COMPLICATIONS OF TREATMENT WITH CC,920,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],15282.03,,"Case rate ($8,732.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,259.35, add-ons for qualifying new technology services are included. If operating cost exceeds $43,130.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,256.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,291.21 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,314.40 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $496.44. The transfer capital threshold is the transfer adjustment factor * $496.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,8732.59,20731.52,All Other Inpatient
SALIVARY GLAND PROCEDURES,139,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],23222.51,,"Fee schedule rate ($23,222.51). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.9), with a minimum of zero.",,,,0,other,10313.19,30690.92,There are no additional notes associated with this service or procedure.
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC,058,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],40853.02,,"Fee schedule rate ($40,853.02). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,13521.80,40853.02,There are no additional notes associated with this service or procedure.
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],10448.91,,"Fee schedule rate ($10,448.91). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,3079.00,10940.41,There are no additional notes associated with this service or procedure.
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],17829.00,,"Fee schedule rate ($17,829). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,13904.43,34749.58,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITH STERILIZATION WITHOUT CC/MCC,785,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],10708.50,,"Fee schedule rate ($10,708.50). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8431.24,20142.33,There are no additional notes associated with this service or procedure.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,352,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],21946.47,,"Fee schedule rate ($21,946.47). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,9853.37,26528.70,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],22750.61,,"Case rate ($21,667.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,292.19, add-ons for qualifying new technology services are included. If operating cost exceeds $55,163.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,202.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $18,279.84 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,347.24 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,442.46. The transfer capital threshold is the transfer adjustment factor * $1,442.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8972.00,81524.17,Inpatient DRG
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],28038.61,,"Fee schedule rate ($28,038.61). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12126.09,29582.40,There are no additional notes associated with this service or procedure.
Orchiectomy Radical Tumor Inguinal Approach|LEFT SIDE,CASE-54530,APC,54530,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3468.64,,"APC Price ($3,351.34). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3351.34,3518.91,OPPS APC
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],51903.64,,"Fee schedule rate ($51,903.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,16017.99,51903.64,There are no additional notes associated with this service or procedure.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],11681.49,,"Fee schedule rate ($11,681.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5778.62,11681.49,There are no additional notes associated with this service or procedure.
OSTEOMYELITIS WITHOUT CC/MCC,541,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],6334.65,,"Fee schedule rate ($6,334.65). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5103.00,15493.67,There are no additional notes associated with this service or procedure.
Tenodesis Long Tendon Biceps|RIGHT SIDE,CASE-23430,APC,23430,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6791.99,7131.59,OPPS APC
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],23078.81,,"Fee schedule rate ($23,078.81). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10311.17,24308.97,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],18311.90,,"Fee schedule rate ($18,311.90). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8543.64,23239.84,There are no additional notes associated with this service or procedure.
APPENDIX PROCEDURES WITH MCC,397,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],28575.75,,"Fee schedule rate ($28,575.75). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,18163.37,51558.84,There are no additional notes associated with this service or procedure.
O.R. PROCEDURES FOR OBESITY WITH CC,620,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],31489.10,,,,,,0,other,12782.30,43753.50,There are no additional notes associated with this service or procedure.
Rpr Aa Hernia 1st > 10 Cm Reducible,CASE-49595,APC,49595,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6059.65,,"APC Price ($6,059.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6059.65,6362.63,OPPS APC
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],81306.30,,"Fee schedule rate ($81,306.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,20846.48,81306.30,There are no additional notes associated with this service or procedure.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],12527.66,,"Case rate ($12,527.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,789.82, add-ons for qualifying new technology services are included. If operating cost exceeds $46,660.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,533.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $9,808.71 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,844.88 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $774.00. The transfer capital threshold is the transfer adjustment factor * $774.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12527.66,29917.96,Inpatient DRG
Rpr Nonunion/Malunion Radius/Ulna W/O Autograft,CASE-25400,APC,25400,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7029.71,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6791.99,7029.71,OPPS APC
CESAREAN SECTION WITH STERILIZATION WITH CC,784,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],23722.94,,"Fee schedule rate ($23,722.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9124.01,23722.94,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,085,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],57443.16,,"Fee schedule rate ($57,443.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,9282.00,57443.16,There are no additional notes associated with this service or procedure.
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC,520,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],28074.86,,"Fee schedule rate ($28,074.86). Adds an outlier to normal pricing equal to the per diem rate ($68,872.56) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,12061.74,39786.42,There are no additional notes associated with this service or procedure.
"Arthrodesis Interphalangeal Jt W/WO Int Fixj|LEFT HAND, FOURTH DIGIT",CASE-26860,APC,26860,CPT,0360,RC,,,F3,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
"UTERINE AND ADNEXA PROCEDURES FOR LEIOMYOMA,MODERATE",519,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],4637.07,,"Case rate for a one day stay ($4,637.07). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,4637.07,4868.92,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],24675.88,,"Fee schedule rate ($24,675.88). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10834.64,25830.00,There are no additional notes associated with this service or procedure.
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,450,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],38037.38,,"Case rate ($38,037.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $35,520.98, add-ons for qualifying new technology services are included. If operating cost exceeds $70,391.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,399.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $33,452.68 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $33,576.02 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,639.75. The transfer capital threshold is the transfer adjustment factor * $2,639.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,38037.38,146009.19,Inpatient DRG
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],6965.00,,,,,,0,other,5883.03,17111.12,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITH CC,386,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],18347.61,,"Fee schedule rate ($18,347.61). Adds an outlier to normal pricing equal to the per diem rate ($111,650.51) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8556.53,19879.00,There are no additional notes associated with this service or procedure.
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],11170.89,,"Case rate ($10,638.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,032.78, add-ons for qualifying new technology services are included. If operating cost exceeds $44,903.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,395.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,058.12 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,087.83 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $635.87. The transfer capital threshold is the transfer adjustment factor * $635.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10638.94,25261.33,Inpatient DRG
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],11914.12,,"Case rate ($11,914.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,219.06, add-ons for qualifying new technology services are included. If operating cost exceeds $46,090.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,489.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $9,240.03 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,274.10 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $729.13. The transfer capital threshold is the transfer adjustment factor * $729.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,11914.12,40426.76,Inpatient DRG
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,098,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],38799.38,,"Fee schedule rate ($38,799.38). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,6965.00,45156.75,There are no additional notes associated with this service or procedure.
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],14383.21,,"Case rate ($14,383.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,516, add-ons for qualifying new technology services are included. If operating cost exceeds $48,387.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,669.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,528.54 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,571.05 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $909.72. The transfer capital threshold is the transfer adjustment factor * $909.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,36140.75,Inpatient DRG
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],15751.44,,,,,,0,other,6965.00,21195.68,There are no additional notes associated with this service or procedure.
Cystourethroscopy Inj Chemodenervation Bladder|SEPARATE STRUCTURE,CASE-52287,APC,52287,CPT,0360,RC,,,XS,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3464.44,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3299.47,3464.44,OPPS APC
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level|RIGHT SIDE,CASE-64483,APC,64483,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],869.28,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,827.89,869.28,OPPS APC
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],59021.28,,"Fee schedule rate ($59,021.28). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,23851.92,63653.13,There are no additional notes associated with this service or procedure.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],24315.03,,"Case rate ($23,157.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $21,717.81, add-ons for qualifying new technology services are included. If operating cost exceeds $56,588.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,274.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.1. The base transfer operating payment is the transfer adjustment factor * $19,698.17 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $19,772.86 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,514.05. The transfer capital threshold is the transfer adjustment factor * $1,514.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,23799.09,63499.65,Inpatient DRG
Egd Intrmural Needle Aspir/Biop Altered Anatomy,CASE-43242,APC,43242,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3789.26,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3608.81,3789.26,OPPS APC
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,065,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],9094.30,,"Case rate ($8,786.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,309.75, add-ons for qualifying new technology services are included. If operating cost exceeds $43,180.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,260.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,341.42 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,364.80 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $500.40. The transfer capital threshold is the transfer adjustment factor * $500.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,8786.76,25681.86,Inpatient DRG
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],17782.11,,"Case rate ($17,782.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,677.93, add-ons for qualifying new technology services are included. If operating cost exceeds $51,548.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,918.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $14,678.86 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,732.98 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,158.31. The transfer capital threshold is the transfer adjustment factor * $1,158.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,17782.11,46523.26,Inpatient DRG
HC Peripheral Block - Femoral Single or Saphenous W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE|RIGHT SIDE,CASE-64447,APC,64447,CPT,0360,RC,,,XU|RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1505.12,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1505.12,1580.37,OPPS APC
SPINAL PROCEDURES WITHOUT CC/MCC,030,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],17147.21,,"Case rate ($16,810.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,774.52, add-ons for qualifying new technology services are included. If operating cost exceeds $50,645.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,847.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $13,778.77 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,829.57 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,087.28. The transfer capital threshold is the transfer adjustment factor * $1,087.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,16810.99,44714.01,Inpatient DRG
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],15891.15,,,,,,0,other,7414.07,18217.52,There are no additional notes associated with this service or procedure.
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],28334.16,,"Fee schedule rate ($28,334.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,7868.00,32126.64,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],19152.11,,"Case rate ($19,152.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,952.40, add-ons for qualifying new technology services are included. If operating cost exceeds $52,823.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,018.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $15,948.65 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $16,007.45 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,258.51. The transfer capital threshold is the transfer adjustment factor * $1,258.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,19152.11,53152.12,Inpatient DRG
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],40714.72,,"Fee schedule rate ($40,714.72). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,17356.15,44778.95,There are no additional notes associated with this service or procedure.
"PULMONARY EMBOLISM,MAJOR",134,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],2442.79,,"Case rate for a one day stay ($2,326.47). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,2326.47,2442.79,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,065,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],25681.86,,"Fee schedule rate ($25,681.86). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,8786.76,25681.86,There are no additional notes associated with this service or procedure.
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],22732.01,,"Fee schedule rate ($22,732.01). Adds an outlier to normal pricing equal to the per diem rate ($114,196.66) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.5), with a minimum of zero.",,,,0,other,10136.44,24444.75,There are no additional notes associated with this service or procedure.
HC N Block Inj Suprascapular Nerv|LEFT SIDE,CASE-64418,APC,64418,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],693.76,,"APC Price ($660.72). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,660.72,693.76,OPPS APC
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],6834.39,,"Case rate ($6,834.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,493.49, add-ons for qualifying new technology services are included. If operating cost exceeds $41,364.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,117.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $4,531.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,548.54 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $357.61. The transfer capital threshold is the transfer adjustment factor * $357.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6834.39,21354.82,Inpatient DRG
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],9302.19,,"Case rate ($8,859.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,377.16, add-ons for qualifying new technology services are included. If operating cost exceeds $43,248.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,265.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $6,408.58 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,432.21 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $505.70. The transfer capital threshold is the transfer adjustment factor * $505.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8859.23,20090.22,Inpatient DRG
GASTROINTESTINAL OBSTRUCTION WITH CC,389,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],7293.54,,"Case rate ($7,293.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,920.63, add-ons for qualifying new technology services are included. If operating cost exceeds $41,791.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,151.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $4,957.39 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,975.67 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $391.19. The transfer capital threshold is the transfer adjustment factor * $391.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,5118.00,16423.43,Inpatient DRG
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],33221.97,,"Fee schedule rate ($33,221.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (47), with a minimum of zero.",,,,0,other,15283.90,38757.79,There are no additional notes associated with this service or procedure.
"LIMB REATTACHMENT, HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA",956,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],70718.06,,"Fee schedule rate ($70,718.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,27428.25,148259.86,There are no additional notes associated with this service or procedure.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],52909.62,,"Fee schedule rate ($52,909.62). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,23344.70,62179.32,There are no additional notes associated with this service or procedure.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],24259.09,,"Fee schedule rate ($24,259.09). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10098.51,24259.09,There are no additional notes associated with this service or procedure.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],101083.00,,"Fee schedule rate ($101,083.00). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,35389.50,101083.00,There are no additional notes associated with this service or procedure.
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],8133.30,,"Fee schedule rate ($8,133.30). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6711.00,16865.16,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL HEMORRHAGE WITH MCC,377,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],31575.65,,"Fee schedule rate ($31,575.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,7634.00,35969.56,There are no additional notes associated with this service or procedure.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],37768.77,,"Fee schedule rate ($37,768.77). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7453.00,42138.30,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],6466.83,,"Case rate ($6,340.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,033.60, add-ons for qualifying new technology services are included. If operating cost exceeds $40,904.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,081.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $4,073.62 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,088.64 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $321.45. The transfer capital threshold is the transfer adjustment factor * $321.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6340.03,15076.44,Inpatient DRG
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],8758.05,,"Fee schedule rate ($8,758.05). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7566.45,16333.88,There are no additional notes associated with this service or procedure.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC,434,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6770.05,,"Case rate ($6,770.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,433.64, add-ons for qualifying new technology services are included. If operating cost exceeds $41,304.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,112.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,472.20 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,488.69 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $352.90. The transfer capital threshold is the transfer adjustment factor * $352.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6770.05,14019.86,Inpatient DRG
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,066,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6810.05,,"Case rate ($6,579.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,256.61, add-ons for qualifying new technology services are included. If operating cost exceeds $41,127.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,098.96, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $4,295.82 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,311.66 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $338.98. The transfer capital threshold is the transfer adjustment factor * $338.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6579.76,20083.61,Inpatient DRG
Cysto impl 4 or more,CASE-C9740,APC,C9740,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],8860.83,,"APC Price ($8,860.83). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,8860.83,9303.88,OPPS APC
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,086,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],30728.81,,"Fee schedule rate ($30,728.81). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8442.00,30728.81,There are no additional notes associated with this service or procedure.
Rpr 1st Ingun Hrna Age 5 Yrs/> Incarcerated|RIGHT SIDE,CASE-49507,APC,49507,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3468.64,,"APC Price ($3,351.34). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3351.34,3518.91,OPPS APC
BRONCHITIS AND ASTHMA WITHOUT CC/MCC,203,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],10373.62,,"Case rate ($5,927.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $5,614.23, add-ons for qualifying new technology services are included. If operating cost exceeds $44,258.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $3,061.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,235.54 + an uncompensated DSH payment of $1,359.91. The transfer operating threshold is the transfer adjustment factor * $4,254.32 + an uncompensated DSH payment of $1,359.91. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $332.34. The transfer capital threshold is the transfer adjustment factor * $332.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,4763.76,13707.00,All Other Inpatient
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],42787.31,,"Fee schedule rate ($42,787.31). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,15476.23,42787.31,There are no additional notes associated with this service or procedure.
HC Blood Occult Peroxidase Actv Qual Feces 1-3 Spec,CASE-82272,APC,82272,CPT,0301,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],4.23,,,,,,0,other,4.23,4.44,There are no additional notes associated with this service or procedure.
Septoplasty/Submucous Resecj W/WO Cartilage Grf,CASE-30520,APC,30520,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.52,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.35,3258.52,OPPS APC
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],19877.10,,"Fee schedule rate ($19,877.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8009.34,19877.10,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],12984.79,,"Case rate ($12,984.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,215.07, add-ons for qualifying new technology services are included. If operating cost exceeds $47,086.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,567.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $10,232.39 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,270.12 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $807.44. The transfer capital threshold is the transfer adjustment factor * $807.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12984.79,32077.45,Inpatient DRG
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],12753.81,,"Case rate ($12,146.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,454.25, add-ons for qualifying new technology services are included. If operating cost exceeds $46,325.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,488.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $9,473.39 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,509.30 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $728.15. The transfer capital threshold is the transfer adjustment factor * $728.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12455.21,37149.27,Inpatient DRG
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,690,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],14625.55,,"Fee schedule rate ($14,625.55). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7426.94,15928.53,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],27839.09,,"Case rate ($26,513.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $24,846.32, add-ons for qualifying new technology services are included. If operating cost exceeds $59,717.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,513.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. The base transfer operating payment is the transfer adjustment factor * $22,814.87 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $22,901.37 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,753.60. The transfer capital threshold is the transfer adjustment factor * $1,753.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,27256.92,81353.66,Inpatient DRG
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,073,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],12809.38,,"Case rate ($12,809.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,051.90, add-ons for qualifying new technology services are included. If operating cost exceeds $46,922.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,554.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $10,069.82 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,106.95 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $794.61. The transfer capital threshold is the transfer adjustment factor * $794.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12809.38,43475.01,Inpatient DRG
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],11194.25,,"Case rate ($11,194.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,549.37, add-ons for qualifying new technology services are included. If operating cost exceeds $45,420.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,436.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $8,572.81 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,604.42 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $676.48. The transfer capital threshold is the transfer adjustment factor * $676.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,11194.25,36094.03,Inpatient DRG
O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC,621,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],28347.36,,"Fee schedule rate ($28,347.36). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12159.94,36669.96,There are no additional notes associated with this service or procedure.
FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,748,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],10293.04,,"Case rate ($10,293.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $9,679.84, add-ons for qualifying new technology services are included. If operating cost exceeds $48,324.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $3,378.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.4. The base transfer operating payment is the transfer adjustment factor * $8,283.19 + an uncompensated DSH payment of $1,359.91. The transfer operating threshold is the transfer adjustment factor * $8,319.93 + an uncompensated DSH payment of $1,359.91. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $649.94. The transfer capital threshold is the transfer adjustment factor * $649.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9316.20,26805.98,Inpatient DRG
SEIZURES WITH MCC,100,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],32323.98,,"Fee schedule rate ($32,323.98). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,15061.09,38110.41,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITH MCC,385,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],21593.52,,"Fee schedule rate ($21,593.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11480.01,31134.92,There are no additional notes associated with this service or procedure.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],36094.03,,"Fee schedule rate ($36,094.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11194.25,36094.03,There are no additional notes associated with this service or procedure.
TRAUMATIC INJURY WITH MCC,913,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],42838.46,,"Fee schedule rate ($42,838.46). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13014.58,42838.46,There are no additional notes associated with this service or procedure.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],11717.72,,"Case rate ($11,717.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,036.36, add-ons for qualifying new technology services are included. If operating cost exceeds $45,907.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,474.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $9,058.01 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,091.41 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $714.77. The transfer capital threshold is the transfer adjustment factor * $714.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,11717.72,43888.01,Inpatient DRG
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],42767.23,,"Fee schedule rate ($42,767.23). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,17356.15,44778.95,There are no additional notes associated with this service or procedure.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],8853.91,,"Case rate ($8,554.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,093.67, add-ons for qualifying new technology services are included. If operating cost exceeds $42,964.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,243.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,126.13 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,148.72 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $483.41. The transfer capital threshold is the transfer adjustment factor * $483.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,8554.50,19204.75,Inpatient DRG
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],40426.76,,"Fee schedule rate ($40,426.76). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,11914.12,40426.76,There are no additional notes associated with this service or procedure.
"OTHER DIGESTIVE SYSTEM AND ABDOMINAL PROCEDURES,EXTREME",229,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],43070.04,,"Case rate ($41,019.09). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,41019.09,43070.04,There are no additional notes associated with this service or procedure.
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],7550.61,,"Case rate ($7,402.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,022.05, add-ons for qualifying new technology services are included. If operating cost exceeds $41,893.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,159.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,058.45 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,077.10 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $399.16. The transfer capital threshold is the transfer adjustment factor * $399.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,7402.56,16438.59,Inpatient DRG
PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,337,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],38926.31,,"Fee schedule rate ($38,926.31). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,12340.08,38926.31,There are no additional notes associated with this service or procedure.
OTHER CEREBROVASCULAR DISORDERS WITH MCC,070,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],31286.59,,"Fee schedule rate ($31,286.59). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13219.09,37774.46,There are no additional notes associated with this service or procedure.
RADIOTHERAPY,849,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],20699.76,,"Case rate ($20,293.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $19,014.57, add-ons for qualifying new technology services are included. If operating cost exceeds $53,885.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,101.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $17,006.91 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $17,069.62 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,342.01. The transfer capital threshold is the transfer adjustment factor * $1,342.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,20293.88,81867.07,Inpatient DRG
"MAJOR STOMACH ESOPHAGEAL AND DUODENAL PROCEDURES,MINOR",220,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],15220.03,,"Case rate ($15,220.03). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,15220.03,15981.03,There are no additional notes associated with this service or procedure.
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],13960.40,,"Case rate ($13,295.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,504.24, add-ons for qualifying new technology services are included. If operating cost exceeds $47,375.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,590.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $10,520.50 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,559.29 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $830.17. The transfer capital threshold is the transfer adjustment factor * $830.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7000.00,33835.79,Inpatient DRG
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],8643.20,,"Case rate ($8,643.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,176.19, add-ons for qualifying new technology services are included. If operating cost exceeds $43,047.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,249.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $6,208.35 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,231.24 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $489.90. The transfer capital threshold is the transfer adjustment factor * $489.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8643.20,19462.52,Inpatient DRG
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],35474.53,,"Fee schedule rate ($35,474.53). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,16428.39,42083.20,There are no additional notes associated with this service or procedure.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC,862,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],14795.51,,"Case rate ($14,295.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,434.11, add-ons for qualifying new technology services are included. If operating cost exceeds $48,305.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,663.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $11,446.95 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,489.15 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $903.28. The transfer capital threshold is the transfer adjustment factor * $903.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6855.00,35884.94,Inpatient DRG
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],32168.63,,"Fee schedule rate ($32,168.63). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,13904.43,34749.58,There are no additional notes associated with this service or procedure.
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC,520,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],12483.90,,"Case rate ($12,061.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,356.39, add-ons for qualifying new technology services are included. If operating cost exceeds $46,227.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,499.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $9,376.87 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,411.44 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $739.93. The transfer capital threshold is the transfer adjustment factor * $739.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,12061.74,39786.42,Inpatient DRG
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],14803.72,,"Case rate ($14,098.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,251.41, add-ons for qualifying new technology services are included. If operating cost exceeds $48,122.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,648.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $11,264.92 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,306.46 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $888.91. The transfer capital threshold is the transfer adjustment factor * $888.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7332.00,35314.31,Inpatient DRG
Blepharoplasty Upper Eyelid W/Excessive Skin,CASE-15823,APC,15823,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],2027.84,,"APC Price ($1,931.28). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1931.28,2027.84,OPPS APC
Rpr Aa Hernia 1st > 10 Cm Reducible,CASE-49595,APC,49595,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6362.63,,"APC Price ($6,059.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6059.65,6362.63,OPPS APC
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],23526.87,,"Case rate ($23,526.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $22,022.15, add-ons for qualifying new technology services are included. If operating cost exceeds $56,893.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,338.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.7. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.7)) / 2. The base transfer operating payment is the transfer adjustment factor * $20,003.44 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $20,077.20 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,578.47. The transfer capital threshold is the transfer adjustment factor * $1,578.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,23526.87,94787.57,Inpatient DRG
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],20401.88,,"Fee schedule rate ($20,401.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,20401.88,There are no additional notes associated with this service or procedure.
RESPIRATORY NEOPLASMS WITH CC,181,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],17609.39,,"Fee schedule rate ($17,609.39). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9197.84,21074.07,There are no additional notes associated with this service or procedure.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],33608.45,,"Fee schedule rate ($33,608.45). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,7332.00,35314.31,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC,087,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],14243.88,,"Case rate ($8,139.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,707.48, add-ons for qualifying new technology services are included. If operating cost exceeds $42,578.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,213.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $5,741.36 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,762.53 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $453.05. The transfer capital threshold is the transfer adjustment factor * $453.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,8139.36,22679.07,All Other Inpatient
HC Drain/Inj Joint/Bursa W/US Large|PBB CHARGE,CASE-20611,APC,20611,CPT,0510,RC,,,PBB,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],287.31,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
Peri-Implant Capsulectomy Breast Complete|BILATERAL PROCEDURE,CASE-19371,APC,19371,CPT,0360,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],8033.01,,"APC Price ($7,650.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,7918.25,8033.01,OPPS APC
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],59021.28,,"Fee schedule rate ($59,021.28). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,23851.92,63653.13,There are no additional notes associated with this service or procedure.
Lam Facetectomy&Foramot 1 Vrt Sgm Ea Addl Sgm,CASE-63048,APC,63048,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,7029.71,7131.59,OPPS APC
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITH MCC OR ANTINEOPLASTIC IMPLANT OR EPILEPSY WITH NEUROSTIMULATOR,023,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],42788.50,,"Case rate ($40,750.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $38,045.35, add-ons for qualifying new technology services are included. If operating cost exceeds $72,916.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,598.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $35,967.78 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $36,100.40 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,838.21. The transfer capital threshold is the transfer adjustment factor * $2,838.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,15168.00,136379.44,Inpatient DRG
HC Joint Injection/Aspir Medium WO US|PBB CHARGE,CASE-20605,APC,20605,CPT,0510,RC,,,PBB,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],287.31,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,064,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],41838.16,,"Fee schedule rate ($41,838.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,15563.58,41838.16,There are no additional notes associated with this service or procedure.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],69977.32,,,,,,0,other,26028.48,80635.65,There are no additional notes associated with this service or procedure.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,097,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],26932.41,,"Case rate ($26,404.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $24,698.97, add-ons for qualifying new technology services are included. If operating cost exceeds $59,569.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,548.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.7. The base transfer operating payment is the transfer adjustment factor * $22,670.44 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $22,754.03 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,788.92. The transfer capital threshold is the transfer adjustment factor * $1,788.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,26404.32,79915.74,Inpatient DRG
"Partical Excision Bone Phalanx Toe|LEFT FOOT, THIRD DIGIT",CASE-28124,APC,28124,CPT,0360,RC,,,T2,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],10839.27,,"Case rate ($10,626.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,021.44, add-ons for qualifying new technology services are included. If operating cost exceeds $44,892.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,394.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $8,046.82 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,076.49 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $634.97. The transfer capital threshold is the transfer adjustment factor * $634.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,10626.74,25225.91,Inpatient DRG
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],19126.88,,"Fee schedule rate ($19,126.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,19126.88,There are no additional notes associated with this service or procedure.
Sigmoidoscopy Flx W/Biopsy Single/Multiple,CASE-45331,APC,45331,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],900.93,,"APC Price ($870.46). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,870.46,913.99,OPPS APC
HC Inj Proc Cysto or Void,CASE-51600,APC,51600,CPT,0361,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6936.25,,"APC Price ($6,605.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6605.95,6936.25,OPPS APC
CHEST PAIN,313,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],8522.85,,"Fee schedule rate ($8,522.85). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,6820.84,15377.66,There are no additional notes associated with this service or procedure.
Egd Percutaneous Placement Gastrostomy Tube,CASE-43246,APC,43246,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1885.95,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1796.14,1885.95,OPPS APC
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,447,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],125567.31,,"Fee schedule rate ($125,567.31). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15.7), with a minimum of zero.",,,,0,other,47193.21,156646.82,There are no additional notes associated with this service or procedure.
Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq|SEPARATE STRUCTURE|COLORECTAL CANCER SCREEN,CASE-45385,APC,45385,CPT,0360,RC,,,XS|PT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1120.09,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1120.09,1176.09,OPPS APC
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],15802.03,,"Fee schedule rate ($15,802.03). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7566.45,16333.88,There are no additional notes associated with this service or procedure.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC",494,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],15533.10,,"Case rate ($15,533.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,585.72, add-ons for qualifying new technology services are included. If operating cost exceeds $49,456.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,753.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $12,594.34 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,640.78 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $993.82. The transfer capital threshold is the transfer adjustment factor * $993.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,15533.10,39945.55,Inpatient DRG
VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC,033,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],13668.45,,"Case rate ($13,206.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,421.07, add-ons for qualifying new technology services are included. If operating cost exceeds $47,292.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,583.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $10,437.64 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,476.13 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $823.63. The transfer capital threshold is the transfer adjustment factor * $823.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,13206.23,42156.44,Inpatient DRG
VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC,033,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],13470.35,,"Case rate ($13,206.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,421.07, add-ons for qualifying new technology services are included. If operating cost exceeds $47,292.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,583.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $10,437.64 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,476.13 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $823.63. The transfer capital threshold is the transfer adjustment factor * $823.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,13206.23,42156.44,Inpatient DRG
"Inj Dx/Ther Agnt Paravert Facet Joint, Cerv/Thorac, 2nd Level|LEFT SIDE",CASE-64491,APC,64491,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],869.28,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,827.89,869.28,OPPS APC
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],15318.94,,"Fee schedule rate ($15,318.94). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6214.05,15318.94,There are no additional notes associated with this service or procedure.
SEIZURES WITH MCC,100,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],15061.09,,"Case rate ($15,061.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,146.62, add-ons for qualifying new technology services are included. If operating cost exceeds $49,017.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,719.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $12,156.85 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,201.67 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $959.30. The transfer capital threshold is the transfer adjustment factor * $959.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,15061.09,38110.41,Inpatient DRG
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],86235.79,,"Fee schedule rate ($86,235.79). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,32296.02,88188.38,There are no additional notes associated with this service or procedure.
Sphincterotomy Anal Division Sphincter Spx,CASE-46080,APC,46080,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],2727.99,,"APC Price ($2,598.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2598.08,2727.99,OPPS APC
Bronchoscopy W/Plmt Fiducial Markers Single/Mult,CASE-31626,APC,31626,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6605.95,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6605.95,6936.25,OPPS APC
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],26874.85,,,,,,0,other,11194.25,36094.03,There are no additional notes associated with this service or procedure.
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",759,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],6438.90,,"Case rate ($6,438.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,125.57, add-ons for qualifying new technology services are included. If operating cost exceeds $40,996.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,088.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,165.27 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,180.62 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $328.68. The transfer capital threshold is the transfer adjustment factor * $328.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6190.22,13057.66,Inpatient DRG
Xpedicul Decompress Throacic Cord|RIGHT SIDE,CASE-63055,APC,63055,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7029.71,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6791.99,7131.59,OPPS APC
Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq|COLORECTAL CANCER SCREEN,CASE-45385,APC,45385,CPT,0360,RC,,,PT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1176.09,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1120.09,1176.09,OPPS APC
Cervical Lymphadec Modified Radical Neck Dsj|RIGHT SIDE,CASE-38724,APC,38724,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],199.10,,"APC Price ($199.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,199.10,209.05,OPPS APC
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC",605,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],18024.13,,,,,,0,other,8148.17,18024.13,There are no additional notes associated with this service or procedure.
Exc B9 Lesion Mrgn Xcp Sk Tg S/N/H/F/G 3.1-4.0cm,CASE-11424,APC,11424,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1919.19,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1827.80,1919.19,OPPS APC
Colonoscopy W/Biopsy Single/Multiple|COLORECTAL CANCER SCREEN,CASE-45380,APC,45380,CPT,0360,RC,,,PT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1176.09,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1120.09,1176.09,OPPS APC
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],57305.33,,,,,,0,other,8972.00,81524.17,There are no additional notes associated with this service or procedure.
"NEONATE BIRTH WEIGHT > 2499 GRAMS WITH RESPIRATORY DISTRESS SYNDROME OR OTHER MAJOR RESPIRATORY CONDITION,MODERATE",634,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],9899.21,,"Case rate ($9,427.82). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9427.82,9899.21,There are no additional notes associated with this service or procedure.
"Open Tx Metacarpal Fracture Single Ea Bone|LEFT HAND, FOURTH DIGIT",CASE-26615,APC,26615,CPT,0360,RC,,,F3,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
HC Trigger Point 3 or More,CASE-20553,APC,20553,CPT,0510,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],301.68,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,287.31,301.68,OPPS APC
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR,518,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],89342.77,,"Fee schedule rate ($89,342.77). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,13252.00,89342.77,There are no additional notes associated with this service or procedure.
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,306,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],12616.37,,"Case rate ($12,616.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,872.35, add-ons for qualifying new technology services are included. If operating cost exceeds $46,743.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,540.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $9,890.94 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,927.40 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $780.49. The transfer capital threshold is the transfer adjustment factor * $780.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12616.37,31007.02,Inpatient DRG
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],13444.85,,"Case rate ($12,990.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,220.11, add-ons for qualifying new technology services are included. If operating cost exceeds $47,091.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,567.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $10,237.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,275.16 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $807.83. The transfer capital threshold is the transfer adjustment factor * $807.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,9888.00,43399.23,Inpatient DRG
Rmvl & Rplcmt Inflatable Penile Prosth Same Sess,CASE-54410,APC,54410,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],19400.15,,"APC Price ($19,400.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,19400.15,20370.16,OPPS APC
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],17651.07,,"Fee schedule rate ($17,651.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,6564.18,17651.07,There are no additional notes associated with this service or procedure.
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5879.61,,"Case rate ($5,599.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,351.63, add-ons for qualifying new technology services are included. If operating cost exceeds $40,222.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,020.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $3,393.82 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,406.68 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $260.86. The transfer capital threshold is the transfer adjustment factor * $260.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,3079.00,10940.41,Inpatient DRG
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],8318.14,,"Case rate ($8,318.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,873.80, add-ons for qualifying new technology services are included. If operating cost exceeds $42,744.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,226.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,907.07 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,928.85 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $466.13. The transfer capital threshold is the transfer adjustment factor * $466.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8318.14,19763.43,Inpatient DRG
Exc B9 Lesion Mrgn Xcp Sk Tg S/N/H/F/G 3.1-4.0cm,CASE-11424,APC,11424,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1891.77,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1827.80,1919.19,OPPS APC
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,085,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],9282.00,,"Per diem ($9,282). If length of stay < 4.6, first 1 days paid at a per diem of $18,564 instead. Capped at $42,695.82.",,,,0,other,9282.00,57443.16,Estimated amount calculated based on 2 day length of stay.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],38728.27,,,,,,0,other,15273.74,39820.52,There are no additional notes associated with this service or procedure.
POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES,769,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],14057.81,,"Case rate ($13,388.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,590.54, add-ons for qualifying new technology services are included. If operating cost exceeds $47,461.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,596.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $10,606.49 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,645.59 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $836.96. The transfer capital threshold is the transfer adjustment factor * $836.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13388.39,33250.19,Inpatient DRG
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6201.19,,"Case rate ($6,201.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,904.45, add-ons for qualifying new technology services are included. If operating cost exceeds $40,775.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,071.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,944.95 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,959.50 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $311.30. The transfer capital threshold is the transfer adjustment factor * $311.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,5937.41,12366.99,Inpatient DRG
Exc B9 Lesion Mrgn Xcp Sk Tg S/N/H/F/G 0.6-1.0cm,CASE-11421,APC,11421,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],695.97,,"APC Price ($662.83). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,662.83,695.97,OPPS APC
"Inj Dx/Ther Agnt Paravert Facet Joint, Cerv/Thorac, Add Level",CASE-64492,APC,64492,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],856.86,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,827.89,869.28,OPPS APC
Removal Implant Deep|LEFT SIDE,CASE-20680,APC,20680,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],2718.88,,"APC Price ($2,718.88). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2718.88,2854.83,OPPS APC
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,329,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],86631.74,,"Fee schedule rate ($86,631.74). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (38), with a minimum of zero.",,,,0,other,33072.77,90445.33,There are no additional notes associated with this service or procedure.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],41944.25,,"Fee schedule rate ($41,944.25). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12795.84,41944.25,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],25026.36,,"Fee schedule rate ($25,026.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9356.31,25026.36,There are no additional notes associated with this service or procedure.
BRONCHITIS AND ASTHMA WITH CC/MCC,202,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],8521.98,,"Case rate ($8,521.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,063.43, add-ons for qualifying new technology services are included. If operating cost exceeds $42,934.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,241.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,096.00 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,118.48 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $481.03. The transfer capital threshold is the transfer adjustment factor * $481.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7606.34,19110.30,Inpatient DRG
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH CC,427,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],53371.31,,"Case rate ($50,829.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $47,421.51, add-ons for qualifying new technology services are included. If operating cost exceeds $82,292.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $5,335.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $45,309.50 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $45,476.56 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,575.37. The transfer capital threshold is the transfer adjustment factor * $3,575.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,50829.82,142040.39,Inpatient DRG
CERVICAL SPINAL FUSION WITH CC,472,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],70198.84,,"Fee schedule rate ($70,198.84). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,21896.13,70198.84,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],8242.50,,"Fee schedule rate ($8,242.50). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6558.75,14871.83,There are no additional notes associated with this service or procedure.
"Partical Excision Bone Phalanx Toe|LEFT FOOT, THIRD DIGIT",CASE-28124,APC,28124,CPT,0360,RC,,,T2,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7029.71,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6791.99,7131.59,OPPS APC
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC,807,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],10071.17,,"Fee schedule rate ($10,071.17). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5354.25,13266.23,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],38378.80,,"Fee schedule rate ($38,378.80). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,14370.36,38378.80,There are no additional notes associated with this service or procedure.
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],11281.44,,"Fee schedule rate ($11,281.44). Adds an outlier to normal pricing equal to the per diem rate ($62,521.14) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,6010.23,12246.05,There are no additional notes associated with this service or procedure.
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],10826.73,,"Case rate ($10,311.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,727.87, add-ons for qualifying new technology services are included. If operating cost exceeds $44,598.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,371.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $7,754.32 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,782.91 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $611.89. The transfer capital threshold is the transfer adjustment factor * $611.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10311.17,24308.97,Inpatient DRG
OSTEOMYELITIS WITHOUT CC/MCC,541,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7476.68,,"Case rate ($7,120.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,769.45, add-ons for qualifying new technology services are included. If operating cost exceeds $41,640.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,129.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $4,806.28 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,824.50 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $369.42. The transfer capital threshold is the transfer adjustment factor * $369.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5103.00,15493.67,Inpatient DRG
OSTEOMYELITIS WITHOUT CC/MCC,541,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],11429.52,,"Fee schedule rate ($11,429.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5103.00,15493.67,There are no additional notes associated with this service or procedure.
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],24444.75,,"Fee schedule rate ($24,444.75). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10136.44,24444.75,There are no additional notes associated with this service or procedure.
"Hallux Rigidus W/Cheilectomy 1st Mp Jt W/O Implt|LEFT FOOT, GREAT TOE",CASE-28289,APC,28289,CPT,0360,RC,,,TA,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC,805,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],20902.03,,"Fee schedule rate ($20,902.03). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9253.36,21235.42,There are no additional notes associated with this service or procedure.
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC,964,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],34154.06,,"Fee schedule rate ($34,154.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12323.82,34154.06,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6330.99,,"Case rate ($6,029.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,752.35, add-ons for qualifying new technology services are included. If operating cost exceeds $40,623.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,051.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,793.02 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,807.40 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $291.54. The transfer capital threshold is the transfer adjustment factor * $291.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6153.12,13947.32,Inpatient DRG
"ANTEPARTUM WITHOUT O.R. PROCEDURE,MINOR",566,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],2744.47,,"The inlier payment is calculated as the lesser of the standard DRG payment $2,613.78 and the transfer payment, which is a per diem of $1,281.27. If cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,2613.78,2744.47,Estimated amount calculated based on 1 day length of stay.
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],13276.20,,"Fee schedule rate ($13,276.20). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,6167.00,29058.99,There are no additional notes associated with this service or procedure.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],21597.50,,"Case rate ($21,597.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,227.30, add-ons for qualifying new technology services are included. If operating cost exceeds $55,098.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,197.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $18,215.19 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,282.35 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,437.36. The transfer capital threshold is the transfer adjustment factor * $1,437.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,21597.50,67790.93,Inpatient DRG
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],31533.97,,"Fee schedule rate ($31,533.97). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8563.30,31533.97,There are no additional notes associated with this service or procedure.
MAJOR BLADDER PROCEDURES WITH MCC,653,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],38992.11,,"Case rate ($37,135.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $34,681.82, add-ons for qualifying new technology services are included. If operating cost exceeds $69,552.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,333.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.5. The base transfer operating payment is the transfer adjustment factor * $32,616.61 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $32,736.87 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,573.77. The transfer capital threshold is the transfer adjustment factor * $2,573.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10280.00,125343.98,Inpatient DRG
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",062,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],44304.80,,"Fee schedule rate ($44,304.80). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,13844.84,44304.80,There are no additional notes associated with this service or procedure.
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],10255.35,,"Case rate ($9,767). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,236.23, add-ons for qualifying new technology services are included. If operating cost exceeds $44,107.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,318.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $7,263.74 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,291.28 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $558.31. The transfer capital threshold is the transfer adjustment factor * $558.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10003.71,23415.63,Inpatient DRG
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC",758,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],9003.54,,"Case rate ($8,574.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,112.57, add-ons for qualifying new technology services are included. If operating cost exceeds $42,983.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,244.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $6,144.96 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,167.62 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $484.90. The transfer capital threshold is the transfer adjustment factor * $484.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8574.80,19263.78,Inpatient DRG
OTHER CEREBROVASCULAR DISORDERS WITH MCC,070,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],13219.09,,"Case rate ($13,219.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,433.04, add-ons for qualifying new technology services are included. If operating cost exceeds $47,304.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,584.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $10,449.57 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,488.10 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $824.57. The transfer capital threshold is the transfer adjustment factor * $824.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,13219.09,37774.46,Inpatient DRG
"CHOLECYSTECTOMY,MODERATE",263,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],15882.03,,"Case rate ($15,125.74). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,15125.74,15882.03,There are no additional notes associated with this service or procedure.
Destruction Neurolytic Agt Genicular Nerve W/Img|BILATERAL PROCEDURE,CASE-64624,APC,64624,CPT,0360,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1891.77,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1827.80,1919.19,OPPS APC
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],10003.71,,"Case rate ($10,003.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,441.84, add-ons for qualifying new technology services are included. If operating cost exceeds $44,312.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,349.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $7,469.36 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,496.90 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $589.41. The transfer capital threshold is the transfer adjustment factor * $589.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10003.71,23415.63,Inpatient DRG
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],22292.26,,"Fee schedule rate ($22,292.26). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9977.99,26949.28,There are no additional notes associated with this service or procedure.
Laparoscopy Colpopexy Suspension Vaginal Apex,CASE-57425,APC,57425,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],10447.27,,"APC Price ($9,949.78). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,9949.78,10447.27,OPPS APC
"Repair Each Addnl Digit Nerve|LEFT HAND, THUMB",CASE-64832,APC,64832,CPT,0360,RC,,,FA,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3215.80,3215.80,OPPS APC
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],13301.81,,"Case rate ($12,668.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,940.75, add-ons for qualifying new technology services are included. If operating cost exceeds $46,811.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,525.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $9,958.04 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,995.80 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $765.40. The transfer capital threshold is the transfer adjustment factor * $765.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7665.00,40737.46,Inpatient DRG
PERIPHERAL VASCULAR DISORDERS WITH CC,300,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],20061.53,,"Fee schedule rate ($20,061.53). Adds an outlier to normal pricing equal to the per diem rate ($49,296.97) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.9), with a minimum of zero.",,,,0,other,9174.14,21005.20,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF NERVOUS SYSTEM WITH CC,092,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],19225.24,,"Fee schedule rate ($19,225.24). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8872.78,26765.51,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],19691.31,,"Fee schedule rate ($19,691.31). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,9040.72,26966.33,There are no additional notes associated with this service or procedure.
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6731.54,,"Case rate ($6,503.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,186.05, add-ons for qualifying new technology services are included. If operating cost exceeds $41,057.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,093.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $4,225.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,241.10 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $333.44. The transfer capital threshold is the transfer adjustment factor * $333.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6503.90,14492.93,Inpatient DRG
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],26721.94,,"Fee schedule rate ($26,721.94). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6965.00,34422.94,There are no additional notes associated with this service or procedure.
Ercp Remove Foreign Body/Stent Biliary/Panc Duct,CASE-43275,APC,43275,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3608.81,,"APC Price ($3,608.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3608.81,3789.26,OPPS APC
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],18905.23,,"Fee schedule rate ($18,905.23). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6963.00,18954.85,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],59891.41,,"Fee schedule rate ($59,891.41). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15), with a minimum of zero.",,,,0,other,23526.87,94787.57,There are no additional notes associated with this service or procedure.
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],20297.68,,"Fee schedule rate ($20,297.68). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6965.00,21404.64,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],32293.66,,"Fee schedule rate ($32,293.66). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,32293.66,There are no additional notes associated with this service or procedure.
Optx Dstl Radl I-Artic Fx/Epiphysl Sep 3 Frag|RIGHT SIDE,CASE-25609,APC,25609,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],13194.59,,"Case rate ($12,566.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,825.74, add-ons for qualifying new technology services are included. If operating cost exceeds $46,696.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,536.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $9,844.49 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,880.79 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $776.83. The transfer capital threshold is the transfer adjustment factor * $776.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12566.28,30861.41,Inpatient DRG
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],31533.97,,"Fee schedule rate ($31,533.97). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8563.30,31533.97,There are no additional notes associated with this service or procedure.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,025,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],32735.52,,"Case rate ($32,735.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $30,588.77, add-ons for qualifying new technology services are included. If operating cost exceeds $65,459.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,011.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.4. The base transfer operating payment is the transfer adjustment factor * $28,538.59 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $28,643.82 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,251.98. The transfer capital threshold is the transfer adjustment factor * $2,251.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,13351.00,91631.33,Inpatient DRG
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],80635.65,,"Fee schedule rate ($80,635.65). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,26028.48,80635.65,There are no additional notes associated with this service or procedure.
HC Remove Tun Cath Vad W/Port,CASE-36590,APC,36590,CPT,0361,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1525.02,,"APC Price ($1,473.45). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1473.45,1547.12,OPPS APC
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,451,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],23821.44,,"Case rate ($23,821.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $22,296.19, add-ons for qualifying new technology services are included. If operating cost exceeds $57,167.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,359.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $20,276.48 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $20,351.24 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,600.01. The transfer capital threshold is the transfer adjustment factor * $1,600.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,23821.44,94077.13,Inpatient DRG
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],7923.33,,"Case rate ($7,923.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,506.51, add-ons for qualifying new technology services are included. If operating cost exceeds $42,377.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,197.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $5,541.13 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,561.56 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $437.25. The transfer capital threshold is the transfer adjustment factor * $437.25. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,1188.00,17370.86,Inpatient DRG
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],42993.55,,"Case rate ($24,567.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $22,990.45, add-ons for qualifying new technology services are included. If operating cost exceeds $57,861.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,414.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.7. The base transfer operating payment is the transfer adjustment factor * $20,968.18 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $21,045.49 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,654.60. The transfer capital threshold is the transfer adjustment factor * $1,654.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,9370.00,65732.99,All Other Inpatient
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],12195.15,,"Case rate ($12,195.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,480.50, add-ons for qualifying new technology services are included. If operating cost exceeds $46,351.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,509.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,500.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,535.55 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $749.68. The transfer capital threshold is the transfer adjustment factor * $749.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12195.15,39424.57,Inpatient DRG
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],12566.28,,"Case rate ($12,566.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,825.74, add-ons for qualifying new technology services are included. If operating cost exceeds $46,696.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,536.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $9,844.49 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,880.79 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $776.83. The transfer capital threshold is the transfer adjustment factor * $776.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12566.28,30861.41,Inpatient DRG
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],12002.19,,"Case rate ($11,430.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,787.01, add-ons for qualifying new technology services are included. If operating cost exceeds $45,658.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,437.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $8,808.66 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,842.06 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $677.05. The transfer capital threshold is the transfer adjustment factor * $677.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,11717.72,43888.01,Inpatient DRG
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],53152.12,,"Fee schedule rate ($53,152.12). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,19152.11,53152.12,There are no additional notes associated with this service or procedure.
SPINAL PROCEDURES WITHOUT CC/MCC,030,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],41254.39,,"Fee schedule rate ($41,254.39). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,16810.99,44714.01,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL HEMORRHAGE WITH MCC,377,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],15040.50,,"Case rate ($14,324.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,461.19, add-ons for qualifying new technology services are included. If operating cost exceeds $48,332.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,665.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $11,473.94 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,516.24 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $905.41. The transfer capital threshold is the transfer adjustment factor * $905.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7634.00,35969.56,Inpatient DRG
HC Joint Injection/Aspir Large WO US,CASE-20610,APC,20610,CPT,0510,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
Injection Aa&/Strd Genicular Nrv Branches W/Img|LEFT SIDE,CASE-64454,APC,64454,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],693.76,,"APC Price ($660.72). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,660.72,693.76,OPPS APC
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],14124.74,,"Case rate ($13,647.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,831.20, add-ons for qualifying new technology services are included. If operating cost exceeds $47,702.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,615.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $10,846.26 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,886.25 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $855.88. The transfer capital threshold is the transfer adjustment factor * $855.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,7921.00,45706.73,Inpatient DRG
Esophagogastroduodenoscopy Submucosal Injection,CASE-43236,APC,43236,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],891.41,,"APC Price ($848.96). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,848.96,891.41,OPPS APC
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],19249.79,,"Case rate ($18,598.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,437.70, add-ons for qualifying new technology services are included. If operating cost exceeds $52,308.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,978.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 5.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $15,435.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,492.75 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,218.04. The transfer capital threshold is the transfer adjustment factor * $1,218.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,18598.83,48389.68,Inpatient DRG
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7492.04,,"Case rate ($7,238.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,869.60, add-ons for qualifying new technology services are included. If operating cost exceeds $41,740.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,147.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,906.55 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,924.64 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $387.18. The transfer capital threshold is the transfer adjustment factor * $387.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,7238.69,16804.22,Inpatient DRG
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],42586.49,,"Fee schedule rate ($42,586.49). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,13341.67,42586.49,There are no additional notes associated with this service or procedure.
Anterior Instrumentation 2-3 Vertebral Segments|UNUSUAL NON-OVERLAPPING SERVICE,CASE-22845,APC,22845,CPT,0360,RC,,,XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],12437.92,,"APC Price ($12,017.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,12437.92,12618.18,OPPS APC
"NEONATE BIRTH WEIGHT 2000-2499 GRAMS WITH OTHER SIGNIFICANT CONDITION,MINOR",625,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],9761.07,,"Case rate ($9,296.26). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9296.26,9761.07,There are no additional notes associated with this service or procedure.
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],17575.50,,,,,,0,other,5415.00,17575.50,There are no additional notes associated with this service or procedure.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],42842.73,,,,,,0,other,16689.78,59521.43,There are no additional notes associated with this service or procedure.
"Arthrodesis Interphalangeal Jt W/WO Int Fixj|LEFT HAND, FOURTH DIGIT",CASE-26860,APC,26860,CPT,0360,RC,,,F3,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3062.67,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],75579.22,,"Fee schedule rate ($75,579.22). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,25162.32,75579.22,There are no additional notes associated with this service or procedure.
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],28394.78,,"Fee schedule rate ($28,394.78). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11454.97,28394.78,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,373,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],7637.70,,"Fee schedule rate ($7,637.70). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6870.94,14313.05,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],33398.16,,"Fee schedule rate ($33,398.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,7353.00,33398.16,There are no additional notes associated with this service or procedure.
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC,807,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6738.54,,"Case rate ($6,510.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,192.35, add-ons for qualifying new technology services are included. If operating cost exceeds $41,063.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,093.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $4,231.80 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,247.40 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $333.93. The transfer capital threshold is the transfer adjustment factor * $333.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,5354.25,13266.23,Inpatient DRG
"NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY",789,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],14149.57,,"Case rate ($14,149.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,298.65, add-ons for qualifying new technology services are included. If operating cost exceeds $48,169.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,652.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $11,312.00 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,353.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $892.63. The transfer capital threshold is the transfer adjustment factor * $892.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,3054.00,14857.05,Inpatient DRG
CERVICAL SPINAL FUSION WITH MCC,471,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],111337.93,,"Fee schedule rate ($111,337.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,34645.26,111337.93,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],24686.74,,"Case rate ($23,851.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $22,324.54, add-ons for qualifying new technology services are included. If operating cost exceeds $57,195.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,362.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.8. The base transfer operating payment is the transfer adjustment factor * $20,304.73 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $20,379.59 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,602.24. The transfer capital threshold is the transfer adjustment factor * $1,602.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,23851.92,63653.13,Inpatient DRG
RESPIRATORY NEOPLASMS WITHOUT CC/MCC,182,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],23037.13,,"Fee schedule rate ($23,037.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6965.00,23037.13,There are no additional notes associated with this service or procedure.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,329,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],86631.74,,"Fee schedule rate ($86,631.74). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (38), with a minimum of zero.",,,,0,other,33072.77,90445.33,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],12808.03,,"Case rate ($12,808.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,050.64, add-ons for qualifying new technology services are included. If operating cost exceeds $46,921.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,554.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $10,068.57 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,105.69 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $794.51. The transfer capital threshold is the transfer adjustment factor * $794.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7353.00,33398.16,Inpatient DRG
Osteoplasty Radius/Ulna Shortening|LEFT SIDE,CASE-25390,APC,25390,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7029.71,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,7029.71,7029.71,OPPS APC
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],54537.29,,"Fee schedule rate ($54,537.29). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.7), with a minimum of zero.",,,,0,other,21597.50,67790.93,There are no additional notes associated with this service or procedure.
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC",758,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],16323.02,,"Fee schedule rate ($16,323.02). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8574.80,19263.78,There are no additional notes associated with this service or procedure.
Revj/Rmvl Impl Spi Npg/Rcvr Dtch Connj Eltrd Ra,CASE-63688,APC,63688,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3386.97,,"APC Price ($3,272.44). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3272.44,3436.06,OPPS APC
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,095,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],19411.47,,"Case rate ($19,411.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $18,193.69, add-ons for qualifying new technology services are included. If operating cost exceeds $53,064.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,037.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.6. The base transfer operating payment is the transfer adjustment factor * $16,189.05 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $16,248.74 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,277.48. The transfer capital threshold is the transfer adjustment factor * $1,277.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,19411.47,50750.92,Inpatient DRG
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],16669.71,,"Fee schedule rate ($16,669.71). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8767.81,19824.58,There are no additional notes associated with this service or procedure.
SALIVARY GLAND PROCEDURES,139,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],10313.19,,"Case rate ($10,313.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,729.75, add-ons for qualifying new technology services are included. If operating cost exceeds $44,600.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,372.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $7,756.21 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,784.80 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $612.04. The transfer capital threshold is the transfer adjustment factor * $612.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10313.19,30690.92,Inpatient DRG
Cysto W/Ureteroscopy W/Lithotripsy|RIGHT SIDE,CASE-52353,APC,52353,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5269.71,,"APC Price ($5,018.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5269.71,5269.71,OPPS APC
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],28253.40,,"Fee schedule rate ($28,253.40). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,12126.09,29582.40,There are no additional notes associated with this service or procedure.
Lamnotmy Incl W/Dcmprsn Nrv Root 1 Intrspc Lumbr,CASE-63030,APC,63030,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],81306.30,,"Fee schedule rate ($81,306.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,20846.48,81306.30,There are no additional notes associated with this service or procedure.
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC",458,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],30202.09,,"Case rate ($30,202.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $28,231.97, add-ons for qualifying new technology services are included. If operating cost exceeds $63,102.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,826.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $26,190.45 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $26,287.02 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,066.69. The transfer capital threshold is the transfer adjustment factor * $2,066.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,30202.09,132827.25,Inpatient DRG
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,690,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],12997.15,,"Case rate ($7,426.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,044.73, add-ons for qualifying new technology services are included. If operating cost exceeds $41,915.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,160.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,081.05 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,099.78 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $400.94. The transfer capital threshold is the transfer adjustment factor * $400.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,7426.94,15928.53,All Other Inpatient
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],16869.37,,"Case rate ($16,066.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,081.53, add-ons for qualifying new technology services are included. If operating cost exceeds $49,952.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,792.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $13,088.32 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,136.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,032.80. The transfer capital threshold is the transfer adjustment factor * $1,032.80. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,41030.48,Inpatient DRG
O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC,621,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12452.88,,"Case rate ($11,859.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,187.11, add-ons for qualifying new technology services are included. If operating cost exceeds $46,058.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,467.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $9,207.25 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,242.16 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $707.69. The transfer capital threshold is the transfer adjustment factor * $707.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12159.94,36669.96,Inpatient DRG
Arthrt Expl Drg/Rmvl Loose/FB Iphal Jt Ea,CASE-26080,APC,26080,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1505.12,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1505.12,1557.80,OPPS APC
PSYCHOSES,885,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],11632.25,,"Case rate ($11,404.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,744.67, add-ons for qualifying new technology services are included. If operating cost exceeds $45,615.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,451.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.5. The base transfer operating payment is the transfer adjustment factor * $8,767.39 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,799.72 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $691.83. The transfer capital threshold is the transfer adjustment factor * $691.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,2070.00,27484.83,Inpatient DRG
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,098,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],18098.19,,"Case rate ($17,486.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,402.62, add-ons for qualifying new technology services are included. If operating cost exceeds $51,273.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,896.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $14,404.56 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,457.67 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,136.66. The transfer capital threshold is the transfer adjustment factor * $1,136.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6965.00,45156.75,Inpatient DRG
Prq Impltj Neurostimulator Eltrd Peripheral Nrv|LEFT SIDE,CASE-64555,APC,64555,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6174.06,,"APC Price ($5,965.28). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5965.28,6263.54,OPPS APC
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,065,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],25681.86,,"Fee schedule rate ($25,681.86). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,8786.76,25681.86,There are no additional notes associated with this service or procedure.
Insertion Breast Implant Same Day of Mastectomy,CASE-19340,APC,19340,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],8033.01,,"APC Price ($7,650.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,7650.49,8033.01,OPPS APC
"NON-EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,EXTREME",952,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],40306.00,,"Case rate ($38,386.67). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,38386.67,40306.00,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],6460.78,,"Case rate ($6,153.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,859.72, add-ons for qualifying new technology services are included. If operating cost exceeds $40,730.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,067.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,900.39 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,914.77 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $307.78. The transfer capital threshold is the transfer adjustment factor * $307.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6153.12,13947.32,Inpatient DRG
"Amputation Toe Interphalangeal Joint|LEFT FOOT, SECOND DIGIT",CASE-28825,APC,28825,CPT,0360,RC,,,T1,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],10503.90,,"Case rate ($10,003.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,441.84, add-ons for qualifying new technology services are included. If operating cost exceeds $44,312.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,349.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $7,469.36 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,496.90 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $589.41. The transfer capital threshold is the transfer adjustment factor * $589.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10003.71,23415.63,Inpatient DRG
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],9384.04,,"Fee schedule rate ($9,384.04). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,6564.18,17651.07,There are no additional notes associated with this service or procedure.
NORMAL NEWBORN,795,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],5771.52,,"Case rate ($3,298.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $3,203.67, add-ons for qualifying new technology services are included. If operating cost exceeds $38,074.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $1,858.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $1,254.10 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $1,258.72 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $98.96. The transfer capital threshold is the transfer adjustment factor * $98.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,1369.79,5771.52,All Other Inpatient
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],36868.88,,"Fee schedule rate ($36,868.88). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12606.23,36868.88,There are no additional notes associated with this service or procedure.
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],30103.84,,,,,,0,other,12305.53,30103.84,There are no additional notes associated with this service or procedure.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],47123.82,,"Fee schedule rate ($47,123.82). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,12696.97,47123.82,There are no additional notes associated with this service or procedure.
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|RIGHT HAND, FOURTH DIGIT",CASE-26160,APC,26160,CPT,0360,RC,,,F8,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1580.37,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1505.12,1580.37,OPPS APC
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,191,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],16612.88,,"Fee schedule rate ($16,612.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6965.00,16612.88,There are no additional notes associated with this service or procedure.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,191,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],16612.88,,"Fee schedule rate ($16,612.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6965.00,16612.88,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],19763.43,,"Fee schedule rate ($19,763.43). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,8318.14,19763.43,There are no additional notes associated with this service or procedure.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],9318.55,,"Case rate ($8,874.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,391.65, add-ons for qualifying new technology services are included. If operating cost exceeds $43,262.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,266.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $6,423.02 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,446.70 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $506.84. The transfer capital threshold is the transfer adjustment factor * $506.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8874.81,20553.44,Inpatient DRG
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITHOUT CC/MCC",630,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],42541.02,,"Fee schedule rate ($42,541.02). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11828.78,42541.02,There are no additional notes associated with this service or procedure.
Edg US Exam Surgical Alter Stom Duodenum/Jejunum,CASE-43259,APC,43259,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1859.01,,"APC Price ($1,796.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1796.14,1885.95,OPPS APC
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],20815.70,,"Fee schedule rate ($20,815.70). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,7605.00,39153.65,There are no additional notes associated with this service or procedure.
INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC,198,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],13459.55,,"Fee schedule rate ($13,459.55). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.7), with a minimum of zero.",,,,0,other,6795.12,23505.07,There are no additional notes associated with this service or procedure.
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6220.59,,"Case rate ($6,010.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,726.79, add-ons for qualifying new technology services are included. If operating cost exceeds $40,597.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,057.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,767.95 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,781.84 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $297.33. The transfer capital threshold is the transfer adjustment factor * $297.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6010.23,12246.05,Inpatient DRG
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],26721.94,,"Fee schedule rate ($26,721.94). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6965.00,34422.94,There are no additional notes associated with this service or procedure.
Esophagogastroduodenoscopy Submucosal Injection,CASE-43236,APC,43236,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],848.96,,"APC Price ($848.96). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,848.96,891.41,OPPS APC
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],8972.00,,"Per diem ($8,972). If length of stay < 6.1, first 1 days paid at a per diem of $17,944 instead. Capped at $54,730.85.",,,,0,other,8972.00,81524.17,Estimated amount calculated based on 4 day length of stay.
OTHER DISORDERS OF NERVOUS SYSTEM WITH CC,092,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],20129.57,,,,,,0,other,8872.78,26765.51,There are no additional notes associated with this service or procedure.
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITHOUT MCC,430,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],113479.23,,,,,,0,other,41000.16,133156.90,There are no additional notes associated with this service or procedure.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],26809.29,,"Case rate ($26,809.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $25,075.72, add-ons for qualifying new technology services are included. If operating cost exceeds $59,946.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,578.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $23,045.79 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $23,130.76 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,818.54. The transfer capital threshold is the transfer adjustment factor * $1,818.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,26809.29,97015.50,Inpatient DRG
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],51630.84,,"Fee schedule rate ($51,630.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,20559.34,54086.17,There are no additional notes associated with this service or procedure.
HC Inj Anes/Steroid C/D Facet Sg|RIGHT SIDE,CASE-64490,APC,64490,CPT,0361,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],869.28,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,827.89,869.28,OPPS APC
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],38610.21,,,,,,0,other,15233.11,38610.21,There are no additional notes associated with this service or procedure.
"ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",770,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],17800.73,,"Fee schedule rate ($17,800.73). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,8735.30,19730.13,There are no additional notes associated with this service or procedure.
Rcnstj Mndblr Rami&/Bdy Sgtl Splt W/Int Rgd Fi,CASE-21196,APC,21196,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5541.10,,"APC Price ($5,541.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5541.10,5541.10,OPPS APC
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],73588.10,,"Fee schedule rate ($73,588.10). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,21585.31,73588.10,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,394,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],8571.41,,"Case rate ($8,281.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,839.77, add-ons for qualifying new technology services are included. If operating cost exceeds $42,710.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,223.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,873.17 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,894.83 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $463.45. The transfer capital threshold is the transfer adjustment factor * $463.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,8281.56,20909.61,Inpatient DRG
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],19126.88,,"Fee schedule rate ($19,126.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,19126.88,There are no additional notes associated with this service or procedure.
Ndsc Dcmprn Spinal Cord 1 W/Lamot Ntrspc Lumbar,CASE-62380,APC,62380,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],15145.28,,"Fee schedule rate ($15,145.28). Adds an outlier to normal pricing equal to the per diem rate ($54,966.40) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7402.56,16438.59,There are no additional notes associated with this service or procedure.
Egd Ablate Tumor Polyp/Lesion W/Dilation& Wire,CASE-43270,APC,43270,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1796.14,,"APC Price ($1,796.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1796.14,1885.95,OPPS APC
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],42768.36,,"Fee schedule rate ($42,768.36). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,14295.18,42768.36,There are no additional notes associated with this service or procedure.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],44847.62,,"Fee schedule rate ($44,847.62). Adds an outlier to normal pricing equal to the per diem rate ($79,031.36) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,18105.81,52699.33,There are no additional notes associated with this service or procedure.
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],29216.99,,"Fee schedule rate ($29,216.99). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9755.86,29216.99,There are no additional notes associated with this service or procedure.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC",156,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],12624.95,,"Fee schedule rate ($12,624.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6625.12,13598.77,There are no additional notes associated with this service or procedure.
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],23385.72,,"Fee schedule rate ($23,385.72). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,23385.72,There are no additional notes associated with this service or procedure.
CERVICAL SPINAL FUSION WITHOUT CC/MCC,473,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],62077.11,,"Fee schedule rate ($62,077.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,18477.61,62077.11,There are no additional notes associated with this service or procedure.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],8702.79,,"Case rate ($8,702.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,231.63, add-ons for qualifying new technology services are included. If operating cost exceeds $43,102.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,254.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,263.59 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,286.68 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $494.26. The transfer capital threshold is the transfer adjustment factor * $494.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,5683.00,19635.68,Inpatient DRG
POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES,769,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],29791.03,,"Fee schedule rate ($29,791.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,13388.39,33250.19,There are no additional notes associated with this service or procedure.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],22292.26,,"Fee schedule rate ($22,292.26). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9977.99,26949.28,There are no additional notes associated with this service or procedure.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],36988.38,,"Fee schedule rate ($36,988.38). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.7), with a minimum of zero.",,,,0,other,15273.74,39820.52,There are no additional notes associated with this service or procedure.
HC Inj Aa&/Strd Greater Occipital Nerve|RIGHT SIDE,CASE-64405,APC,64405,CPT,0450,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],297.37,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,287.31,301.68,OPPS APC
"EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME, NEONATE",790,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],43063.10,,"Case rate ($41,012.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $38,361.54, add-ons for qualifying new technology services are included. If operating cost exceeds $73,232.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,548.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 17.9. The base transfer operating payment is the transfer adjustment factor * $36,279.04 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $36,416.59 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,788.49. The transfer capital threshold is the transfer adjustment factor * $2,788.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,3054.00,44304.49,Inpatient DRG
SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS,029,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],25549.51,,"Case rate ($25,048.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $23,437.73, add-ons for qualifying new technology services are included. If operating cost exceeds $58,308.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,449.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.7)) / 2. The base transfer operating payment is the transfer adjustment factor * $21,413.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $21,492.79 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,689.76. The transfer capital threshold is the transfer adjustment factor * $1,689.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,13641.00,67130.05,Inpatient DRG
Egd Removal Tumor Polyp/Other Lesion Snare Tech,CASE-43251,APC,43251,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1859.01,,"APC Price ($1,796.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1796.14,1885.95,OPPS APC
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],8460.30,,"Case rate ($8,057.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,631.26, add-ons for qualifying new technology services are included. If operating cost exceeds $42,502.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,207.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,665.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,686.30 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $447.06. The transfer capital threshold is the transfer adjustment factor * $447.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6524.00,17760.46,Inpatient DRG
Osteot W/WO Lngth Shrt/Corrj Metar Xcp 1st Ea|RIGHT SIDE,CASE-28308,APC,28308,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
INFLAMMATORY BOWEL DISEASE WITH CC,386,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],8727.66,,"Case rate ($8,556.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,095.56, add-ons for qualifying new technology services are included. If operating cost exceeds $42,966.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,243.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,128.01 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,150.61 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $483.56. The transfer capital threshold is the transfer adjustment factor * $483.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,8556.53,19879.00,Inpatient DRG
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC,964,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],34154.06,,"Fee schedule rate ($34,154.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12323.82,34154.06,There are no additional notes associated with this service or procedure.
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],10339.17,,"Case rate ($10,136.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,565.33, add-ons for qualifying new technology services are included. If operating cost exceeds $44,436.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,359.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $7,592.38 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,620.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $599.11. The transfer capital threshold is the transfer adjustment factor * $599.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,10136.44,24444.75,Inpatient DRG
Surgical Arthroscopy Sho W/Coracoacrm Ligm Rls|RIGHT SIDE,CASE-29826,APC,29826,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],47123.82,,"Fee schedule rate ($47,123.82). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,12696.97,47123.82,There are no additional notes associated with this service or procedure.
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],6230.00,,"Per diem ($6,230). If length of stay < 2.9, first 1 days paid at a per diem of $12,460 instead. Capped at $18,065.71.",,,,0,other,6230.00,22762.43,Estimated amount calculated based on 3 day length of stay.
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],12366.99,,,,,,0,other,5937.41,12366.99,There are no additional notes associated with this service or procedure.
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC",605,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],17131.97,,"Fee schedule rate ($17,131.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8148.17,18024.13,There are no additional notes associated with this service or procedure.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC",494,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],37708.15,,"Fee schedule rate ($37,708.15). Adds an outlier to normal pricing equal to the per diem rate ($63,554.89) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,15533.10,39945.55,There are no additional notes associated with this service or procedure.
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],11269.71,,"Case rate ($10,733.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,120.35, add-ons for qualifying new technology services are included. If operating cost exceeds $44,991.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,402.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $8,145.37 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,175.40 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $642.75. The transfer capital threshold is the transfer adjustment factor * $642.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10733.06,45157.33,Inpatient DRG
NERVOUS SYSTEM NEOPLASMS WITH MCC,054,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],25589.03,,"Fee schedule rate ($25,589.03). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,6965.00,30044.81,There are no additional notes associated with this service or procedure.
Xpedicul Decompress Throacic Cord|RIGHT SIDE,CASE-63055,APC,63055,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7029.71,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6791.99,7131.59,OPPS APC
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,418,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],39884.93,,"Fee schedule rate ($39,884.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,13400.58,39884.93,There are no additional notes associated with this service or procedure.
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],33835.79,,"Fee schedule rate ($33,835.79). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,7000.00,33835.79,There are no additional notes associated with this service or procedure.
HC Joint Injection/Aspir Large WO US|PBB CHARGE|RIGHT SIDE,CASE-20610,APC,20610,CPT,0510,RC,,,PBB|RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],19087.91,,"Case rate ($18,178.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,047.10, add-ons for qualifying new technology services are included. If operating cost exceeds $51,918.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,947.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $15,046.67 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,102.15 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,187.33. The transfer capital threshold is the transfer adjustment factor * $1,187.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,18178.96,54764.34,Inpatient DRG
"HC Debrid,Subq Ea Addt'l 20sqcm",CASE-11045,APC,11045,CPT,0361,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],399.53,,"APC Price ($380.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,380.51,399.53,OPPS APC
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],40426.76,,"Fee schedule rate ($40,426.76). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,11914.12,40426.76,There are no additional notes associated with this service or procedure.
HC >= 12 Lead Ekg|ADJ,CASE-93005,APC,93005,CPT,0730,RC,,,ADJ,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],124.62,,"APC Price ($124.62). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,124.62,130.85,OPPS APC
"NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY",789,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],14149.57,,"Case rate ($14,149.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,298.65, add-ons for qualifying new technology services are included. If operating cost exceeds $48,169.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,652.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $11,312.00 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,353.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $892.63. The transfer capital threshold is the transfer adjustment factor * $892.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,3054.00,14857.05,Inpatient DRG
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],6965.00,,,,,,0,other,6558.75,14871.83,There are no additional notes associated with this service or procedure.
Hysteroscopy Lysis Intrauterine Adhesions,CASE-58559,APC,58559,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],4682.41,,"APC Price ($4,682.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,4682.41,4916.53,OPPS APC
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITH MCC OR ANTINEOPLASTIC IMPLANT OR EPILEPSY WITH NEUROSTIMULATOR,023,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],41565.97,,"Case rate ($40,750.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $38,045.35, add-ons for qualifying new technology services are included. If operating cost exceeds $72,916.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,598.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $35,967.78 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $36,100.40 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,838.21. The transfer capital threshold is the transfer adjustment factor * $2,838.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 102%.",,,,0,other,15168.00,136379.44,Inpatient DRG
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC,027,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],33302.85,,"Case rate ($19,030.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,839, add-ons for qualifying new technology services are included. If operating cost exceeds $52,710.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,009.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $15,835.66 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,894.05 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,249.59. The transfer capital threshold is the transfer adjustment factor * $1,249.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 175%.",,,,0,other,19030.20,56363.30,All Other Inpatient
"HC Aerosol, Hhn, Mdi, Ippb",CASE-94640,APC,94640,CPT,0410,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3299.47,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3299.47,3464.44,OPPS APC
VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC,033,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],32720.88,,,,,,0,other,13206.23,42156.44,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],19126.88,,"Fee schedule rate ($19,126.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,19126.88,There are no additional notes associated with this service or procedure.
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],6503.90,,"Case rate ($6,503.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,186.05, add-ons for qualifying new technology services are included. If operating cost exceeds $41,057.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,093.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $4,225.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,241.10 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $333.44. The transfer capital threshold is the transfer adjustment factor * $333.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6503.90,14492.93,Inpatient DRG
Bx/Exc Lymph Node Open Deep Cervical Node|LEFT SIDE,CASE-38510,APC,38510,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5735.04,,"APC Price ($5,541.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5541.10,5818.16,OPPS APC
HC Injection Small Joint/Bursa|LEFT SIDE,CASE-20600,APC,20600,CPT,0361,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
"DIABETES,MAJOR",420,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],9870.76,,"Case rate ($9,870.76). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,9870.76,10364.30,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],23899.13,,"Fee schedule rate ($23,899.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9795.13,23899.13,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITH STERILIZATION WITH MCC,783,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],23722.94,,"Fee schedule rate ($23,722.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12612.10,23722.94,There are no additional notes associated with this service or procedure.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],18341.97,,"Fee schedule rate ($18,341.97). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.9), with a minimum of zero.",,,,0,other,8554.50,19204.75,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITHOUT CC/MCC,428,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],118904.57,,"Fee schedule rate ($118,904.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,40017.53,118904.57,There are no additional notes associated with this service or procedure.
Insj Biomchn Dev Intervertebral Dsc Spc W/Arthrd,CASE-22853,APC,22853,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],12437.92,,"APC Price ($12,017.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,12017.31,12618.18,OPPS APC
HC Gastric Procedure Unlisted,CASE-43999,APC,43999,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],848.96,,"APC Price ($848.96). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,848.96,891.41,OPPS APC
Esophagogastroduodenoscopy Transoral Diagnostic|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-43235,APC,43235,CPT,0360,RC,,,74,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],848.96,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,848.96,891.41,OPPS APC
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],11348.00,,"Per diem ($11,348). If length of stay < 4.2, first 1 days paid at a per diem of $22,696 instead. Capped at $47,660.93.",,,,0,other,11348.00,62454.12,Estimated amount calculated based on 5 day length of stay.
COMPLICATIONS OF TREATMENT WITH CC,920,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],8732.59,,"Case rate ($8,732.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,259.35, add-ons for qualifying new technology services are included. If operating cost exceeds $43,130.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,256.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,291.21 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,314.40 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $496.44. The transfer capital threshold is the transfer adjustment factor * $496.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8732.59,20731.52,Inpatient DRG
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH CC",457,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],117335.92,,,,,,0,other,42327.47,160549.49,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],17651.07,,"Fee schedule rate ($17,651.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,6564.18,17651.07,There are no additional notes associated with this service or procedure.
Rpr Coltrl Ligm Mtcarphlngl/Iphal Jt,CASE-26540,APC,26540,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
HC External Version,CASE-59412,APC,59412,CPT,0720,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3030.03,,"APC Price ($3,030.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3030.03,3181.53,OPPS APC
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH CC,354,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],13140.41,,"Case rate ($12,514.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $11,748.98, add-ons for qualifying new technology services are included. If operating cost exceeds $50,393.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $3,540.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $10,343.20 + an uncompensated DSH payment of $1,359.91. The transfer operating threshold is the transfer adjustment factor * $10,389.07 + an uncompensated DSH payment of $1,359.91. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $811.58. The transfer capital threshold is the transfer adjustment factor * $811.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,11633.13,33472.54,Inpatient DRG
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC",514,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],22699.91,,"Fee schedule rate ($22,699.91). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8868.04,22699.91,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],28821.04,,"Fee schedule rate ($28,821.04). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,10347.06,28821.04,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],15318.94,,"Fee schedule rate ($15,318.94). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6214.05,15318.94,There are no additional notes associated with this service or procedure.
BRONCHITIS AND ASTHMA WITH CC/MCC,202,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],14307.27,,"Fee schedule rate ($14,307.27). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7606.34,19110.30,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC,831,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],9294.42,,"Fee schedule rate ($9,294.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,4941.30,23661.59,There are no additional notes associated with this service or procedure.
NERVOUS SYSTEM NEOPLASMS WITH MCC,054,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],25589.03,,"Fee schedule rate ($25,589.03). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,6965.00,30044.81,There are no additional notes associated with this service or procedure.
"CHRONIC OBSTRUCTIVE PULMONARY DISEASE,MINOR",140,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],6127.86,,"Case rate ($5,836.06). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5836.06,6127.86,There are no additional notes associated with this service or procedure.
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC",458,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],78415.67,,"Fee schedule rate ($78,415.67). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.8), with a minimum of zero.",,,,0,other,30202.09,132827.25,There are no additional notes associated with this service or procedure.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,309,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],6965.00,,,,,,0,other,5055.77,14547.21,There are no additional notes associated with this service or procedure.
NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,601,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],11904.59,,,,,,0,other,6042.05,12359.72,There are no additional notes associated with this service or procedure.
"Open Tx Phalangeal Shaft Fracture Prox/Middle Ea|RIGHT HAND, SECOND DIGIT",CASE-26735,APC,26735,CPT,0360,RC,,,F6,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],21404.64,,,,,,0,other,6965.00,21404.64,There are no additional notes associated with this service or procedure.
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],13425.91,,"Fee schedule rate ($13,425.91). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11974.38,29141.64,There are no additional notes associated with this service or procedure.
Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq|SEPARATE STRUCTURE|COLORECTAL CANCER SCREEN,CASE-45385,APC,45385,CPT,0360,RC,,,XS|PT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1120.09,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1120.09,1176.09,OPPS APC
TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC,087,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],22679.07,,"Fee schedule rate ($22,679.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,8139.36,22679.07,There are no additional notes associated with this service or procedure.
Ostectomy Complete Other Metatarsal Head 2/3/4|RIGHT SIDE,CASE-28112,APC,28112,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
Carpectomy All Bones Proximal Row|RIGHT SIDE,CASE-25215,APC,25215,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3062.67,OPPS APC
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,306,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],29614.01,,"Fee schedule rate ($29,614.01). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12616.37,31007.02,There are no additional notes associated with this service or procedure.
CERVICAL SPINAL FUSION WITHOUT CC/MCC,473,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],18891.59,,"Case rate ($17,991.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,903.11, add-ons for qualifying new technology services are included. If operating cost exceeds $51,774.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,905.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.6. The base transfer operating payment is the transfer adjustment factor * $14,901.66 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,958.16 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,145.38. The transfer capital threshold is the transfer adjustment factor * $1,145.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,18477.61,62077.11,Inpatient DRG
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITH MCC OR ANTINEOPLASTIC IMPLANT OR EPILEPSY WITH NEUROSTIMULATOR,023,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],136379.44,,"Fee schedule rate ($136,379.44). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,15168.00,136379.44,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],59021.28,,"Fee schedule rate ($59,021.28). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,23851.92,63653.13,There are no additional notes associated with this service or procedure.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],16900.84,,"Fee schedule rate ($16,900.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8151.55,18033.97,There are no additional notes associated with this service or procedure.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],12795.84,,"Case rate ($12,795.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,039.30, add-ons for qualifying new technology services are included. If operating cost exceeds $46,910.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,553.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $10,057.27 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,094.35 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $793.62. The transfer capital threshold is the transfer adjustment factor * $793.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12795.84,41944.25,Inpatient DRG
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],68942.79,,"Fee schedule rate ($68,942.79). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,21489.15,68942.79,There are no additional notes associated with this service or procedure.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITHOUT CC/MCC,816,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],6965.00,,,,,,0,other,6224.90,14733.53,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],18585.05,,"Fee schedule rate ($18,585.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8859.23,20090.22,There are no additional notes associated with this service or procedure.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC",442,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6607.45,,"Case rate ($6,292.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $5,873.10, add-ons for qualifying new technology services are included. If operating cost exceeds $45,442.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $3,237.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $5,846.42. The transfer operating threshold is the transfer adjustment factor * $5,873.10 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $446.39. The transfer capital threshold is the transfer adjustment factor * $446.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6607.45,19011.92,Inpatient DRG
NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,601,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],6570.94,,"Fee schedule rate ($6,570.94). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6042.05,12359.72,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],28038.61,,"Fee schedule rate ($28,038.61). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12126.09,29582.40,There are no additional notes associated with this service or procedure.
Mastopexy,CASE-19316,APC,19316,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],7650.49,,"APC Price ($7,650.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,7650.49,7918.25,OPPS APC
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],13947.32,,"Fee schedule rate ($13,947.32). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6153.12,13947.32,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],17782.11,,"Case rate ($17,782.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,677.93, add-ons for qualifying new technology services are included. If operating cost exceeds $51,548.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,918.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $14,678.86 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,732.98 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,158.31. The transfer capital threshold is the transfer adjustment factor * $1,158.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,17782.11,46523.26,Inpatient DRG
"OSTEOMYELITIS SEPTIC ARTHRITIS AND OTHER MUSCULOSKELETAL INFECTIONS,MODERATE",344,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],9448.65,,"Case rate ($9,448.65). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,9448.65,9921.08,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC,788,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],8659.65,,"Case rate ($8,247.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,819.64, add-ons for qualifying new technology services are included. If operating cost exceeds $42,690.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,209.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,852.50 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,874.69 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $449.84. The transfer capital threshold is the transfer adjustment factor * $449.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8438.02,20142.33,Inpatient DRG
COMPLICATIONS OF TREATMENT WITH CC,920,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],8732.59,,"Case rate ($8,732.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,259.35, add-ons for qualifying new technology services are included. If operating cost exceeds $43,130.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,256.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,291.21 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,314.40 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $496.44. The transfer capital threshold is the transfer adjustment factor * $496.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8732.59,20731.52,Inpatient DRG
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],80635.65,,"Fee schedule rate ($80,635.65). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,26028.48,80635.65,There are no additional notes associated with this service or procedure.
CELLULITIS WITH MCC,602,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],26710.49,,"Fee schedule rate ($26,710.49). Adds an outlier to normal pricing equal to the per diem rate ($28,488.06) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.8), with a minimum of zero.",,,,0,other,11570.10,28349.31,There are no additional notes associated with this service or procedure.
Arthrodesis Posterior/Pstlat Tq 1ntrspc Lumbar,CASE-22612,APC,22612,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],16986.50,,"APC Price ($16,412.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,16986.50,17232.68,OPPS APC
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,307,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],7434.68,,"Case rate ($7,434.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $7,017.68, add-ons for qualifying new technology services are included. If operating cost exceeds $45,662.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $3,170.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $5,632.79 + an uncompensated DSH payment of $1,359.91. The transfer operating threshold is the transfer adjustment factor * $5,657.77 + an uncompensated DSH payment of $1,359.91. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $441.98. The transfer capital threshold is the transfer adjustment factor * $441.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6335.27,18228.77,Inpatient DRG
Colorectal Scrn; Hi Risk Ind,CASE-G0105,APC,G0105,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],870.46,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,870.46,913.99,OPPS APC
CESAREAN SECTION WITH STERILIZATION WITHOUT CC/MCC,785,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],20142.33,,"Fee schedule rate ($20,142.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8431.24,20142.33,There are no additional notes associated with this service or procedure.
CERVICAL SPINAL FUSION WITHOUT CC/MCC,473,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],45879.35,,"Fee schedule rate ($45,879.35). Adds an outlier to normal pricing equal to the per diem rate ($58,401.78) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,18477.61,62077.11,There are no additional notes associated with this service or procedure.
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],32168.63,,"Fee schedule rate ($32,168.63). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,13904.43,34749.58,There are no additional notes associated with this service or procedure.
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC",629,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],40946.19,,"Fee schedule rate ($40,946.19). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,16699.94,44657.18,There are no additional notes associated with this service or procedure.
Excision Tumor Soft Tis Back/Flank Subq 3 Cm/>,CASE-21931,APC,21931,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1600.04,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1545.93,1600.04,OPPS APC
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],28334.16,,"Fee schedule rate ($28,334.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,7868.00,32126.64,There are no additional notes associated with this service or procedure.
MAJOR ESOPHAGEAL DISORDERS WITH CC,369,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],8892.75,,"Case rate ($8,718.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,246.12, add-ons for qualifying new technology services are included. If operating cost exceeds $43,117.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,255.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,278.03 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,301.17 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $495.40. The transfer capital threshold is the transfer adjustment factor * $495.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6965.00,19680.94,Inpatient DRG
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,447,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],47193.21,,"Case rate ($47,193.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $44,038.45, add-ons for qualifying new technology services are included. If operating cost exceeds $78,909.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $5,069.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $41,938.87 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $42,093.51 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,309.39. The transfer capital threshold is the transfer adjustment factor * $3,309.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,47193.21,156646.82,Inpatient DRG
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],9950.89,,"Case rate ($9,950.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,392.71, add-ons for qualifying new technology services are included. If operating cost exceeds $44,263.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,345.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $7,420.40 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,447.76 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $585.54. The transfer capital threshold is the transfer adjustment factor * $585.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7243.75,23262.15,Inpatient DRG
"OTHER BACK AND NECK DISORDERS FRACTURES AND INJURIES,MODERATE",347,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],2095.36,,"Case rate for a one day stay ($1,995.58). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,1995.58,2095.36,There are no additional notes associated with this service or procedure.
Insj Multi-Component Inflatable Penile Prosth,CASE-54405,APC,54405,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],19400.15,,"APC Price ($19,400.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,19400.15,20370.16,OPPS APC
Cysto W/Insert Ureteral Stent|RIGHT SIDE,CASE-52332,APC,52332,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3299.47,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3299.47,3464.44,OPPS APC
Cysto W/Ureteroscopy W/Lithotripsy|LEFT SIDE,CASE-52353,APC,52353,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5269.71,,"APC Price ($5,018.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5018.77,5269.71,OPPS APC
"Inj Dx/Ther Agnt Paravert Facet Joint, Cerv/Thorac, 2nd Level|BILATERAL PROCEDURE",CASE-64491,APC,64491,CPT,0360,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],856.86,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,827.89,856.86,OPPS APC
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],45845.03,,"Fee schedule rate ($45,845.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,18598.83,48389.68,There are no additional notes associated with this service or procedure.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],11194.25,,"Case rate ($11,194.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,549.37, add-ons for qualifying new technology services are included. If operating cost exceeds $45,420.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,436.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $8,572.81 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,604.42 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $676.48. The transfer capital threshold is the transfer adjustment factor * $676.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,11194.25,36094.03,Inpatient DRG
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH CC,427,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],135659.15,,"Fee schedule rate ($135,659.15). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.8), with a minimum of zero.",,,,0,other,50829.82,142040.39,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],35973.56,,"Fee schedule rate ($35,973.56). Adds an outlier to normal pricing equal to the per diem rate ($68,707.98) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,14908.05,49717.39,There are no additional notes associated with this service or procedure.
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],11811.40,,"Fee schedule rate ($11,811.40). Adds an outlier to normal pricing equal to the per diem rate ($53,248.69) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.7), with a minimum of zero.",,,,0,other,5937.41,12366.99,There are no additional notes associated with this service or procedure.
INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC,198,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6795.12,,"Case rate ($6,795.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,456.95, add-ons for qualifying new technology services are included. If operating cost exceeds $41,327.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,114.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,495.42 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,512.00 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $354.73. The transfer capital threshold is the transfer adjustment factor * $354.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6795.12,23505.07,Inpatient DRG
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],15802.03,,"Fee schedule rate ($15,802.03). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7566.45,16333.88,There are no additional notes associated with this service or procedure.
O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC,621,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],28347.36,,"Fee schedule rate ($28,347.36). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12159.94,36669.96,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],10347.06,,"Case rate ($10,347.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,761.25, add-ons for qualifying new technology services are included. If operating cost exceeds $44,632.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,374.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $7,787.59 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,816.30 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $614.52. The transfer capital threshold is the transfer adjustment factor * $614.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10347.06,28821.04,Inpatient DRG
FRACTURES OF FEMUR WITH MCC,533,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],6852.00,,"Per diem ($6,852). If length of stay < 4.3, first 1 days paid at a per diem of $13,704 instead. Capped at $29,461.79.",,,,0,other,6852.00,49490.05,Estimated amount calculated based on 2 day length of stay.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],40890.77,,,,,,0,other,16017.99,51903.64,There are no additional notes associated with this service or procedure.
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],48961.48,,"Fee schedule rate ($48,961.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11575.50,48961.48,There are no additional notes associated with this service or procedure.
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],39424.57,,"Fee schedule rate ($39,424.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12195.15,39424.57,There are no additional notes associated with this service or procedure.
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],11168.08,,"Fee schedule rate ($11,168.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5937.41,12366.99,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],16129.04,,"Case rate ($16,129.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,140.12, add-ons for qualifying new technology services are included. If operating cost exceeds $50,011.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,797.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $13,146.70 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,195.17 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,037.40. The transfer capital threshold is the transfer adjustment factor * $1,037.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,16129.04,59610.47,Inpatient DRG
Rpr Ingun Hernia Sliding Any Age,CASE-49525,APC,49525,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3351.34,,"APC Price ($3,351.34). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3351.34,3518.91,OPPS APC
INFLAMMATORY BOWEL DISEASE WITH MCC,385,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],29736.16,,"Fee schedule rate ($29,736.16). Adds an outlier to normal pricing equal to the per diem rate ($112,108.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.5), with a minimum of zero.",,,,0,other,11480.01,31134.92,There are no additional notes associated with this service or procedure.
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],20170.75,,"Fee schedule rate ($20,170.75). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10048.39,23545.50,There are no additional notes associated with this service or procedure.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],26949.28,,"Fee schedule rate ($26,949.28). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9977.99,26949.28,There are no additional notes associated with this service or procedure.
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],9777.20,,"Case rate ($9,311.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,798, add-ons for qualifying new technology services are included. If operating cost exceeds $43,669.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,298.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $6,827.87 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,853.05 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $538.79. The transfer capital threshold is the transfer adjustment factor * $538.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,21404.64,Inpatient DRG
"OPIOID ABUSE AND DEPENDENCE,MODERATE",773,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],4907.58,,"Case rate ($4,673.89). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4673.89,4907.58,There are no additional notes associated with this service or procedure.
HC Joint Injection/Aspir Large WO US|PBB CHARGE|RIGHT SIDE,CASE-20610,APC,20610,CPT,0510,RC,,,PBB|RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
HC Inj Anes/Steroid C/D Facet Sg|LEFT SIDE|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-64490,APC,64490,CPT,0361,RC,,,LT|74,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],827.89,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,827.89,869.28,OPPS APC
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,074,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],19371.82,,"Fee schedule rate ($19,371.82). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,8925.60,20919.08,There are no additional notes associated with this service or procedure.
HC Remove Tun Cath Vad W/Port,CASE-36590,APC,36590,CPT,0361,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1525.02,,"APC Price ($1,473.45). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1473.45,1547.12,OPPS APC
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],24126.45,,"Fee schedule rate ($24,126.45). Adds an outlier to normal pricing equal to the per diem rate ($62,306.11) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10638.94,25261.33,There are no additional notes associated with this service or procedure.
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR,518,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],13252.00,,"Per diem ($13,252). If length of stay < 5.3, first 1 days paid at a per diem of $26,504 instead. Capped at $70,235.08.",,,,0,other,13252.00,89342.77,Estimated amount calculated based on 1 day length of stay.
Revise Ulnar Nerve at Wrist,CASE-64719,APC,64719,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3357.48,,"APC Price ($3,197.60). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3357.48,3357.48,OPPS APC
Neuroplasty &/Transposition Ulnar Nerve Elbow|LEFT SIDE,CASE-64718,APC,64718,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1919.19,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1827.80,1919.19,OPPS APC
ALLERGIC REACTIONS WITH MCC,915,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],13999.50,,"Case rate ($13,332.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,538.89, add-ons for qualifying new technology services are included. If operating cost exceeds $47,409.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,592.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $10,555.02 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,593.94 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $832.90. The transfer capital threshold is the transfer adjustment factor * $832.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13332.86,33088.84,Inpatient DRG
CHEST PAIN,313,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],7161.88,,"Case rate ($6,820.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,480.89, add-ons for qualifying new technology services are included. If operating cost exceeds $41,351.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,116.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $4,519.27 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,535.94 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $356.62. The transfer capital threshold is the transfer adjustment factor * $356.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6820.84,15377.66,Inpatient DRG
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],120927.32,,"Fee schedule rate ($120,927.32). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,45521.20,142438.06,There are no additional notes associated with this service or procedure.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],16658.16,,"Case rate ($15,864.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,920.37, add-ons for qualifying new technology services are included. If operating cost exceeds $49,791.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,753.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $12,926.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,975.42 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $993.55. The transfer capital threshold is the transfer adjustment factor * $993.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,16286.16,58320.32,Inpatient DRG
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],54764.34,,"Fee schedule rate ($54,764.34). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,18178.96,54764.34,There are no additional notes associated with this service or procedure.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,479,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],10586.00,,"Per diem ($10,586). If length of stay < 3.3, first 1 days paid at a per diem of $21,172 instead. Capped at $34,934.31.",,,,0,other,10586.00,50518.76,Estimated amount calculated based on 2 day length of stay.
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],15253.64,,"Case rate ($14,527.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,673.50, add-ons for qualifying new technology services are included. If operating cost exceeds $48,544.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,658.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $11,684.25 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,728.55 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $898.08. The transfer capital threshold is the transfer adjustment factor * $898.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,14908.05,49717.39,Inpatient DRG
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],33835.79,,"Fee schedule rate ($33,835.79). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,7000.00,33835.79,There are no additional notes associated with this service or procedure.
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC",641,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],14928.67,,"Fee schedule rate ($14,928.67). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7214.98,15312.64,There are no additional notes associated with this service or procedure.
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],14309.17,,"Fee schedule rate ($14,309.17). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,17467.27,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],15009.94,,"Case rate ($14,295.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,434.11, add-ons for qualifying new technology services are included. If operating cost exceeds $48,305.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,663.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $11,446.95 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,489.15 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $903.28. The transfer capital threshold is the transfer adjustment factor * $903.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,14295.18,42768.36,Inpatient DRG
OTHER CEREBROVASCULAR DISORDERS WITH CC,071,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],5843.00,,"Per diem ($5,843). If length of stay < 3.3, first 1 days paid at a per diem of $11,686 instead. Capped at $19,281.62.",,,,0,other,5843.00,29215.10,Estimated amount calculated based on 3 day length of stay.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,418,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],13668.59,,"Case rate ($13,400.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,601.88, add-ons for qualifying new technology services are included. If operating cost exceeds $47,472.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,597.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $10,617.79 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,656.93 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $837.85. The transfer capital threshold is the transfer adjustment factor * $837.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,13400.58,39884.93,Inpatient DRG
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],9841.15,,"Case rate ($9,648.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,111.10, add-ons for qualifying new technology services are included. If operating cost exceeds $43,982.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,323.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $7,139.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,166.15 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $563.40. The transfer capital threshold is the transfer adjustment factor * $563.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,9648.19,31477.13,Inpatient DRG
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],16612.67,,"Case rate ($15,821.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,854.10, add-ons for qualifying new technology services are included. If operating cost exceeds $49,725.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,774.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $12,861.73 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,909.15 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,014.92. The transfer capital threshold is the transfer adjustment factor * $1,014.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,15821.59,40320.14,Inpatient DRG
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH CC,026,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],63202.45,,"Fee schedule rate ($63,202.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,23000.66,63202.45,There are no additional notes associated with this service or procedure.
CHOLECYSTECTOMY WITH C.D.E. WITH MCC,411,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],25530.89,,"Case rate ($24,315.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $22,755.46, add-ons for qualifying new technology services are included. If operating cost exceeds $57,626.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,396.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $20,734.06 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $20,810.51 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,636.12. The transfer capital threshold is the transfer adjustment factor * $1,636.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,24315.13,88615.28,Inpatient DRG
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12867.00,,"Case rate ($12,254.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,554.74, add-ons for qualifying new technology services are included. If operating cost exceeds $46,425.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,495.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $9,573.49 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,609.79 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $735.84. The transfer capital threshold is the transfer adjustment factor * $735.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12566.28,30861.41,Inpatient DRG
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH CC,026,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],23805.68,,"Case rate ($23,000.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $21,532.64, add-ons for qualifying new technology services are included. If operating cost exceeds $56,403.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,299.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $19,515.74 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $19,587.69 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,539.98. The transfer capital threshold is the transfer adjustment factor * $1,539.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103.5%.",,,,0,other,23000.66,63202.45,Inpatient DRG
"COCAINE ABUSE AND DEPENDENCE,MAJOR",774,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],7555.20,,"Case rate ($7,555.20). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,7555.20,7932.96,There are no additional notes associated with this service or procedure.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],51577.45,,"Fee schedule rate ($51,577.45). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,26809.29,97015.50,There are no additional notes associated with this service or procedure.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],41006.47,,"Fee schedule rate ($41,006.47). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12268.97,41006.47,There are no additional notes associated with this service or procedure.
Arthrp Intercarpal/Carp/Mtcrpl Jt Suspension|LEFT SIDE,CASE-25448,APC,25448,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
NONTRAUMATIC STUPOR AND COMA WITH MCC,080,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],30179.40,,"Fee schedule rate ($30,179.40). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,14202.39,35615.37,There are no additional notes associated with this service or procedure.
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],33835.79,,"Fee schedule rate ($33,835.79). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,7000.00,33835.79,There are no additional notes associated with this service or procedure.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],52909.62,,"Fee schedule rate ($52,909.62). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,23344.70,62179.32,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6787.66,,"Case rate ($6,787.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,450.02, add-ons for qualifying new technology services are included. If operating cost exceeds $41,321.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,114.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,488.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,505.07 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $354.19. The transfer capital threshold is the transfer adjustment factor * $354.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6164.03,14071.02,Inpatient DRG
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],25253.70,,"Fee schedule rate ($25,253.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11974.38,29141.64,There are no additional notes associated with this service or procedure.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],33623.33,,"Case rate ($33,623.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $31,414.68, add-ons for qualifying new technology services are included. If operating cost exceeds $66,285.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,076.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.4. The base transfer operating payment is the transfer adjustment factor * $29,361.48 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $29,469.74 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,316.91. The transfer capital threshold is the transfer adjustment factor * $2,316.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,33623.33,133270.57,Inpatient DRG
Cystourethroscopy Inj Chemodenervation Bladder,CASE-52287,APC,52287,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],2054.48,,"APC Price ($1,956.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1956.65,2054.48,OPPS APC
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],93728.21,,"Fee schedule rate ($93,728.21). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,35719.96,105091.76,There are no additional notes associated with this service or procedure.
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],23754.07,,,,,,0,other,10120.20,26204.74,There are no additional notes associated with this service or procedure.
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],6066.84,,"Case rate ($5,777.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,510.70, add-ons for qualifying new technology services are included. If operating cost exceeds $40,381.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,040.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $3,552.65 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,565.75 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $280.34. The transfer capital threshold is the transfer adjustment factor * $280.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5065.00,12558.65,Inpatient DRG
NONTRAUMATIC STUPOR AND COMA WITH MCC,080,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],16726.50,,"Fee schedule rate ($16,726.50). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,14202.39,35615.37,There are no additional notes associated with this service or procedure.
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],6965.00,,,,,,0,other,6148.93,15887.21,There are no additional notes associated with this service or procedure.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],15420.70,,"Case rate ($8,811.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,333.06, add-ons for qualifying new technology services are included. If operating cost exceeds $43,204.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,262.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,364.65 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,388.11 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $502.23. The transfer capital threshold is the transfer adjustment factor * $502.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,6965.00,20401.88,All Other Inpatient
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,479,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],10586.00,,"Per diem ($10,586). If length of stay < 3.3, first 1 days paid at a per diem of $21,172 instead. Capped at $34,934.31.",,,,0,other,10586.00,50518.76,Estimated amount calculated based on 2 day length of stay.
Aspiration Bladder Insert Suprapubic Catheter,CASE-51102,APC,51102,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1956.65,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1956.65,2054.48,OPPS APC
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,761,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],6965.00,,,,,,0,other,5808.41,11946.72,There are no additional notes associated with this service or procedure.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],16684.46,,"Case rate ($16,120.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,131.93, add-ons for qualifying new technology services are included. If operating cost exceeds $50,002.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,796.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $13,138.54 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,186.98 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,036.76. The transfer capital threshold is the transfer adjustment factor * $1,036.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,16120.25,41187.90,Inpatient DRG
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],21089.59,,"Fee schedule rate ($21,089.59). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,6965.00,21089.59,There are no additional notes associated with this service or procedure.
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH MCC",510,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],23183.99,,"Case rate ($22,399.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,973.84, add-ons for qualifying new technology services are included. If operating cost exceeds $55,844.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,256.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.3. The base transfer operating payment is the transfer adjustment factor * $18,958.99 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $19,028.89 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,496.05. The transfer capital threshold is the transfer adjustment factor * $1,496.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,10710.00,89863.76,Inpatient DRG
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,699,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],5961.00,,"Per diem ($5,961). If length of stay < 3.2, first 1 days paid at a per diem of $11,922 instead. Capped at $19,074.90.",,,,0,other,5961.00,19972.16,Estimated amount calculated based on 3 day length of stay.
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],37899.49,,"Fee schedule rate ($37,899.49). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,14747.55,37899.49,There are no additional notes associated with this service or procedure.
Cysto W/Ureteroscopy W/Lithotripsy,CASE-52353,APC,52353,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5018.77,,"APC Price ($5,018.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5018.77,5269.71,OPPS APC
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],31533.97,,"Fee schedule rate ($31,533.97). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8563.30,31533.97,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],19126.88,,"Fee schedule rate ($19,126.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,19126.88,There are no additional notes associated with this service or procedure.
ALLERGIC REACTIONS WITH MCC,915,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],31602.31,,"Fee schedule rate ($31,602.31). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.8), with a minimum of zero.",,,,0,other,13332.86,33088.84,There are no additional notes associated with this service or procedure.
Excision Interdigital Morton Neuroma Single Each|LEFT SIDE,CASE-28080,APC,28080,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1505.12,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1505.12,1557.80,OPPS APC
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],43888.01,,"Fee schedule rate ($43,888.01). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11717.72,43888.01,There are no additional notes associated with this service or procedure.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],11348.00,,"Per diem ($11,348). If length of stay < 4.2, first 1 days paid at a per diem of $22,696 instead. Capped at $47,660.93.",,,,0,other,11348.00,62454.12,Estimated amount calculated based on 5 day length of stay.
Arthroplasty Patella W/O Prosthesis,CASE-27437,APC,27437,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,6791.99,OPPS APC
VENTRICULAR SHUNT PROCEDURES WITH CC,032,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],16703.74,,"Case rate ($16,376.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,370.06, add-ons for qualifying new technology services are included. If operating cost exceeds $50,241.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,815.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $13,375.80 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,425.12 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,055.48. The transfer capital threshold is the transfer adjustment factor * $1,055.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,16376.22,46275.08,Inpatient DRG
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],18105.81,,"Case rate ($18,105.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,979.06, add-ons for qualifying new technology services are included. If operating cost exceeds $51,850.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,941.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $14,978.89 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,034.11 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,181.98. The transfer capital threshold is the transfer adjustment factor * $1,181.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,18105.81,52699.33,Inpatient DRG
Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq,CASE-45385,APC,45385,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1120.09,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1120.09,1176.09,OPPS APC
HC Pbb Carpal Tunnel Inj Pmc|BILATERAL PROCEDURE,CASE-20526,APC,20526,CPT,0510,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,297.37,OPPS APC
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,988,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],30888.17,,"Fee schedule rate ($30,888.17). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.5), with a minimum of zero.",,,,0,other,13075.52,42425.46,There are no additional notes associated with this service or procedure.
Osteoplasty Radius/Ulna Shortening,CASE-25390,APC,25390,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7131.59,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6791.99,7131.59,OPPS APC
VENTRICULAR SHUNT PROCEDURES WITH MCC,031,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],62406.76,,"Fee schedule rate ($62,406.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,32287.20,88162.80,There are no additional notes associated with this service or procedure.
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],12213.87,,"Case rate ($11,974.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,275.12, add-ons for qualifying new technology services are included. If operating cost exceeds $46,146.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,493.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $9,295.90 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,330.17 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $733.54. The transfer capital threshold is the transfer adjustment factor * $733.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,11974.38,29141.64,Inpatient DRG
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH CC,026,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],23000.66,,"Case rate ($23,000.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $21,532.64, add-ons for qualifying new technology services are included. If operating cost exceeds $56,403.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,299.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $19,515.74 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $19,587.69 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,539.98. The transfer capital threshold is the transfer adjustment factor * $1,539.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,23000.66,63202.45,Inpatient DRG
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],67790.93,,"Fee schedule rate ($67,790.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,21597.50,67790.93,There are no additional notes associated with this service or procedure.
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],16458.91,,"Fee schedule rate ($16,458.91). Adds an outlier to normal pricing equal to the per diem rate ($62,521.14) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,7875.94,17233.12,There are no additional notes associated with this service or procedure.
HC Remove Tun Cath Vad W/Port,CASE-36590,APC,36590,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1473.45,,"APC Price ($1,473.45). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1473.45,1547.12,OPPS APC
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],11331.34,,"Case rate ($10,791.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,191.45, add-ons for qualifying new technology services are included. If operating cost exceeds $45,062.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,391.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $8,215.35 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,246.50 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $631.45. The transfer capital threshold is the transfer adjustment factor * $631.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,11059.47,28423.20,Inpatient DRG
HC >= 12 Lead Ekg|UNUSUAL NON-OVERLAPPING SERVICE,CASE-93005,APC,93005,CPT,0730,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3489.82,,"APC Price ($3,489.82). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3489.82,3611.96,OPPS APC
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,699,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],19570.20,,"Fee schedule rate ($19,570.20). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5961.00,19972.16,There are no additional notes associated with this service or procedure.
RESPIRATORY NEOPLASMS WITHOUT CC/MCC,182,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],12247.49,,"Fee schedule rate ($12,247.49). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6965.00,23037.13,There are no additional notes associated with this service or procedure.
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],16235.87,,"Fee schedule rate ($16,235.87). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6524.00,17760.46,There are no additional notes associated with this service or procedure.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],48389.68,,,,,,0,other,18598.83,48389.68,There are no additional notes associated with this service or procedure.
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,095,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],20382.04,,"Case rate ($19,411.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $18,193.69, add-ons for qualifying new technology services are included. If operating cost exceeds $53,064.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,037.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.6. The base transfer operating payment is the transfer adjustment factor * $16,189.05 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $16,248.74 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,277.48. The transfer capital threshold is the transfer adjustment factor * $1,277.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,19411.47,50750.92,Inpatient DRG
Tissue Expander Placement Breast Reconstruction|BILATERAL PROCEDURE,CASE-19357,APC,19357,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],12899.30,,"APC Price ($12,899.30). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12899.30,13350.78,OPPS APC
"OPIOID ABUSE AND DEPENDENCE,MODERATE",773,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],4673.89,,"Case rate ($4,673.89). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,4673.89,4907.58,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],13724.51,,"Case rate ($13,260.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,471.48, add-ons for qualifying new technology services are included. If operating cost exceeds $47,342.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,587.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $10,487.86 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,526.53 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $827.60. The transfer capital threshold is the transfer adjustment factor * $827.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,13260.40,32878.30,Inpatient DRG
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],62179.32,,,,,,0,other,23344.70,62179.32,There are no additional notes associated with this service or procedure.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],62454.12,,"Fee schedule rate ($62,454.12). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11348.00,62454.12,There are no additional notes associated with this service or procedure.
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],17255.73,,"Fee schedule rate ($17,255.73). Adds an outlier to normal pricing equal to the per diem rate ($43,191.57) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,8163.06,18067.42,There are no additional notes associated with this service or procedure.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],85466.62,,"Fee schedule rate ($85,466.62). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,21382.16,85466.62,There are no additional notes associated with this service or procedure.
OTHER CEREBROVASCULAR DISORDERS WITH CC,071,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],29215.10,,"Fee schedule rate ($29,215.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5843.00,29215.10,There are no additional notes associated with this service or procedure.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],45845.03,,"Fee schedule rate ($45,845.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,18598.83,48389.68,There are no additional notes associated with this service or procedure.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],51656.32,,"Fee schedule rate ($51,656.32). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,20559.34,54086.17,There are no additional notes associated with this service or procedure.
HC Inj Proc Cysto or Void,CASE-51600,APC,51600,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6605.95,,"APC Price ($6,605.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6605.95,6936.25,OPPS APC
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],96365.69,,"Fee schedule rate ($96,365.69). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,23377.19,96365.69,There are no additional notes associated with this service or procedure.
Excision Hydrocele Unilateral|LEFT SIDE,CASE-55040,APC,55040,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3468.64,,"APC Price ($3,351.34). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3351.34,3518.91,OPPS APC
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],59610.47,,"Fee schedule rate ($59,610.47). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,16129.04,59610.47,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],12732.39,,"Case rate ($12,126.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,416.25, add-ons for qualifying new technology services are included. If operating cost exceeds $46,287.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,504.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $9,436.50 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,471.29 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $744.63. The transfer capital threshold is the transfer adjustment factor * $744.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12126.09,29582.40,Inpatient DRG
DIABETES WITHOUT CC/MCC,639,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],11899.36,,"Fee schedule rate ($11,899.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6151.76,12223.35,There are no additional notes associated with this service or procedure.
"LIMB REATTACHMENT, HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA",956,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],28388.24,,"Case rate ($27,428.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $25,651.53, add-ons for qualifying new technology services are included. If operating cost exceeds $60,522.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,623.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $23,619.49 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $23,706.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,863.81. The transfer capital threshold is the transfer adjustment factor * $1,863.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,27428.25,148259.86,Inpatient DRG
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],13931.52,,"Fee schedule rate ($13,931.52). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10120.20,26204.74,There are no additional notes associated with this service or procedure.
HC Inj Tendon Sheath/Ligament|PBB CHARGE,CASE-20550,APC,20550,CPT,0510,RC,,,PBB,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],297.37,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,287.31,301.68,OPPS APC
"COCAINE ABUSE AND DEPENDENCE,MAJOR",774,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],7932.96,,"Case rate ($7,555.20). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7555.20,7932.96,There are no additional notes associated with this service or procedure.
POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES,769,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],29791.03,,"Fee schedule rate ($29,791.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,13388.39,33250.19,There are no additional notes associated with this service or procedure.
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],15233.11,,"Case rate ($15,233.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,306.64, add-ons for qualifying new technology services are included. If operating cost exceeds $49,177.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,731.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $12,316.28 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,361.69 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $971.88. The transfer capital threshold is the transfer adjustment factor * $971.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,15233.11,38610.21,Inpatient DRG
O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC,621,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],21279.90,,"Case rate ($12,159.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,447.74, add-ons for qualifying new technology services are included. If operating cost exceeds $46,318.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,507.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $9,467.88 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,502.79 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $747.11. The transfer capital threshold is the transfer adjustment factor * $747.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,12159.94,36669.96,All Other Inpatient
SPINAL PROCEDURES WITH MCC,028,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],120982.83,,"Fee schedule rate ($120,982.83). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,42633.57,120982.83,There are no additional notes associated with this service or procedure.
Lamnotmy Incl W/Dcmprsn Nrv Root 1 Intrspc Lumbr|LEFT SIDE|SEPARATE STRUCTURE,CASE-63030,APC,63030,CPT,0360,RC,,,LT|XS,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7029.71,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6791.99,7131.59,OPPS APC
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],61290.90,,"Fee schedule rate ($61,290.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,23799.09,63499.65,There are no additional notes associated with this service or procedure.
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],18067.42,,,,,,0,other,8163.06,18067.42,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,555,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],26009.06,,,,,,0,other,10896.27,42290.95,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITH STERILIZATION WITH MCC,783,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],23722.94,,"Fee schedule rate ($23,722.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12612.10,23722.94,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],26966.33,,"Fee schedule rate ($26,966.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,9040.72,26966.33,There are no additional notes associated with this service or procedure.
HC Inj Anes/Steroid C/D Facet Sg,CASE-64490,APC,64490,CPT,0361,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],856.86,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,827.89,869.28,OPPS APC
"EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME, NEONATE",790,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],42194.75,,"Case rate ($42,194.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $39,388.49, add-ons for qualifying new technology services are included. If operating cost exceeds $74,259.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,703.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 17.9. The base transfer operating payment is the transfer adjustment factor * $37,305.99 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $37,443.54 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,943.81. The transfer capital threshold is the transfer adjustment factor * $2,943.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,3054.00,44304.49,Inpatient DRG
MAJOR CHEST PROCEDURES WITH CC,164,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],77058.83,,"Fee schedule rate ($77,058.83). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,19037.66,77058.83,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],85305.59,,"Fee schedule rate ($85,305.59). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,21719.40,85305.59,There are no additional notes associated with this service or procedure.
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC",514,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],22699.91,,"Fee schedule rate ($22,699.91). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8868.04,22699.91,There are no additional notes associated with this service or procedure.
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC",458,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],132827.25,,"Fee schedule rate ($132,827.25). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,30202.09,132827.25,There are no additional notes associated with this service or procedure.
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR,518,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],89342.77,,"Fee schedule rate ($89,342.77). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,13252.00,89342.77,There are no additional notes associated with this service or procedure.
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC,797,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],20928.55,,"Fee schedule rate ($20,928.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8719.72,20928.55,There are no additional notes associated with this service or procedure.
PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,337,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],38926.31,,"Fee schedule rate ($38,926.31). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,12340.08,38926.31,There are no additional notes associated with this service or procedure.
OSTEOMYELITIS WITHOUT CC/MCC,541,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],5103.00,,"Per diem ($5,103). If length of stay < 2.9, first 1 days paid at a per diem of $10,206 instead. Capped at $14,797.61.",,,,0,other,5103.00,15493.67,Estimated amount calculated based on 1 day length of stay.
Cysto W/Ureteroscopy W/Rmvl/Manj Stones|BILATERAL PROCEDURE,CASE-52352,APC,52352,CPT,0360,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3414.95,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3299.47,3464.44,OPPS APC
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],11594.35,,"Fee schedule rate ($11,594.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6164.03,14071.02,There are no additional notes associated with this service or procedure.
Prtl Exc B1 Tarsal/Metar B1 Xcp Talus/Calcaneus|LEFT SIDE,CASE-28122,APC,28122,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3169.86,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],46523.26,,"Fee schedule rate ($46,523.26). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,17782.11,46523.26,There are no additional notes associated with this service or procedure.
PREMATURITY WITHOUT MAJOR PROBLEMS,792,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],18531.10,,"Case rate ($18,531.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,374.70, add-ons for qualifying new technology services are included. If operating cost exceeds $52,245.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,973.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. The base transfer operating payment is the transfer adjustment factor * $15,373.07 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,429.75 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,213.09. The transfer capital threshold is the transfer adjustment factor * $1,213.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,1956.00,19457.66,Inpatient DRG
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],23078.81,,"Fee schedule rate ($23,078.81). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10311.17,24308.97,There are no additional notes associated with this service or procedure.
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITHOUT CC/MCC",630,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],12420.22,,"Case rate ($11,828.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,139.67, add-ons for qualifying new technology services are included. If operating cost exceeds $46,010.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,482.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $9,160.95 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,194.72 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $722.89. The transfer capital threshold is the transfer adjustment factor * $722.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,11828.78,42541.02,Inpatient DRG
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITH MCC OR ANTINEOPLASTIC IMPLANT OR EPILEPSY WITH NEUROSTIMULATOR,023,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],136379.44,,"Fee schedule rate ($136,379.44). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,15168.00,136379.44,There are no additional notes associated with this service or procedure.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,479,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],14871.97,,"Case rate ($14,163.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,334.67, add-ons for qualifying new technology services are included. If operating cost exceeds $48,205.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,632.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $11,346.70 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,389.72 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $872.13. The transfer capital threshold is the transfer adjustment factor * $872.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10586.00,50518.76,Inpatient DRG
OSTEOMYELITIS WITH CC,540,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],10723.59,,"Case rate ($10,723.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,111.53, add-ons for qualifying new technology services are included. If operating cost exceeds $44,982.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,402.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $8,136.58 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,166.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $642.06. The transfer capital threshold is the transfer adjustment factor * $642.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9809.07,25507.30,Inpatient DRG
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],8009.34,,"Case rate ($8,009.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,586.52, add-ons for qualifying new technology services are included. If operating cost exceeds $42,457.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,203.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $5,620.85 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,641.57 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $443.54. The transfer capital threshold is the transfer adjustment factor * $443.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8009.34,19877.10,Inpatient DRG
"DISORDERS OF PANCREAS EXCEPT MALIGNANCY,MODERATE",282,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],2016.06,,"Case rate for a one day stay ($1,920.06). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,1920.06,2016.06,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],14871.83,,"Fee schedule rate ($14,871.83). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6558.75,14871.83,There are no additional notes associated with this service or procedure.
Implant Neurostim/Receiver,CASE-64590,APC,64590,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],18794.54,,"APC Price ($18,158.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,18158.97,19066.92,OPPS APC
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],52449.26,,"Fee schedule rate ($52,449.26). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,17693.40,52449.26,There are no additional notes associated with this service or procedure.
Exc Tum/Vasc Mal Sft Tiss Hand/Fngr Subq <1.5cm|RIGHT SIDE,CASE-26115,APC,26115,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1600.04,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1545.93,1623.23,OPPS APC
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],49717.39,,"Fee schedule rate ($49,717.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,14908.05,49717.39,There are no additional notes associated with this service or procedure.
"Rpr/Advmnt Flxr Tdn Zone 2 W/O Fr Grft Ea Tendon|LEFT HAND, FOURTH DIGIT",CASE-26356,APC,26356,CPT,0360,RC,,,F3,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],20297.68,,"Fee schedule rate ($20,297.68). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6965.00,21404.64,There are no additional notes associated with this service or procedure.
Cmbnd Anterpost Colporraphy W/Cysto,CASE-57260,APC,57260,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],4916.53,,"APC Price ($4,682.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,4682.41,4916.53,OPPS APC
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],20109.72,,"Case rate ($19,152.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,952.40, add-ons for qualifying new technology services are included. If operating cost exceeds $52,823.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,018.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $15,948.65 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $16,007.45 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,258.51. The transfer capital threshold is the transfer adjustment factor * $1,258.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,19152.11,53152.12,Inpatient DRG
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],6167.00,,"Per diem ($6,167). If length of stay < 4.5, first 1 days paid at a per diem of $12,334 instead. Capped at $27,753.50.",,,,0,other,6167.00,29058.99,Estimated amount calculated based on 3 day length of stay.
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],15857.69,,,,,,0,other,7402.56,16438.59,There are no additional notes associated with this service or procedure.
"DIABETES,MODERATE",420,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],2103.71,,"Case rate for a one day stay ($2,103.71). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,2103.71,2208.90,There are no additional notes associated with this service or procedure.
HYPERTENSION WITHOUT MCC,305,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],14190.59,,"Fee schedule rate ($14,190.59). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,7058.55,17230.49,There are no additional notes associated with this service or procedure.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],58320.32,,"Fee schedule rate ($58,320.32). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,16286.16,58320.32,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],128358.13,,"Fee schedule rate ($128,358.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,40542.37,128358.13,There are no additional notes associated with this service or procedure.
"Correction Hammertoe|RIGHT FOOT, SECOND DIGIT",CASE-28285,APC,28285,CPT,0360,RC,,,T6,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,068,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],6965.00,,,,,,0,other,6965.00,23184.90,There are no additional notes associated with this service or procedure.
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],16998.43,,"Fee schedule rate ($16,998.43). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,13386.36,33244.29,There are no additional notes associated with this service or procedure.
Nasal/Sinus Ndsc W/Partial Ethmoidectomy,CASE-31254,APC,31254,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6936.25,,"APC Price ($6,605.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6605.95,6936.25,OPPS APC
Redo Excis Lumbar Disk|LEFT SIDE,CASE-63042,APC,63042,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,191,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],6965.00,,,,,,0,other,6965.00,16612.88,There are no additional notes associated with this service or procedure.
Post Colporrhaphy Rectocele W/WO Perineorrhaphy,CASE-57250,APC,57250,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],9949.78,,"APC Price ($9,949.78). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,9949.78,10447.27,OPPS APC
INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC,198,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],23505.07,,"Fee schedule rate ($23,505.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6795.12,23505.07,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,085,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],9282.00,,"Per diem ($9,282). If length of stay < 4.6, first 1 days paid at a per diem of $18,564 instead. Capped at $42,695.82.",,,,0,other,9282.00,57443.16,Estimated amount calculated based on 2 day length of stay.
Exc Cyst/Aberrant Breast Tissue Open 1/> Lesion|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-19120,APC,19120,CPT,0360,RC,,,RT|XU,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6215.36,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6215.36,6526.12,OPPS APC
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,066,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],13466.94,,,,,,0,other,6579.76,20083.61,There are no additional notes associated with this service or procedure.
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],16438.59,,"Fee schedule rate ($16,438.59). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7402.56,16438.59,There are no additional notes associated with this service or procedure.
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],59494.91,,"Fee schedule rate ($59,494.91). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,18594.09,59494.91,There are no additional notes associated with this service or procedure.
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH MCC",510,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],89863.76,,"Fee schedule rate ($89,863.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10710.00,89863.76,There are no additional notes associated with this service or procedure.
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],20170.75,,"Fee schedule rate ($20,170.75). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10048.39,23545.50,There are no additional notes associated with this service or procedure.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],23520.23,,"Fee schedule rate ($23,520.23). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10517.71,24909.11,There are no additional notes associated with this service or procedure.
"COCAINE ABUSE AND DEPENDENCE,MAJOR",774,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],7932.96,,"Case rate ($7,555.20). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7555.20,7932.96,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],21167.26,,"Fee schedule rate ($21,167.26). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,6841.83,21167.26,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,373,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],13670.03,,"Fee schedule rate ($13,670.03). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6870.94,14313.05,There are no additional notes associated with this service or procedure.
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],19371.27,,"Fee schedule rate ($19,371.27). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8643.20,19462.52,There are no additional notes associated with this service or procedure.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,056,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],59328.19,,"Fee schedule rate ($59,328.19). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (44), with a minimum of zero.",,,,0,other,7659.00,59328.19,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],23899.13,,"Fee schedule rate ($23,899.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9795.13,23899.13,There are no additional notes associated with this service or procedure.
Colonoscopy W/Biopsy Single/Multiple|SEPARATE STRUCTURE,CASE-45380,APC,45380,CPT,0360,RC,,,XS,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1120.09,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1120.09,1176.09,OPPS APC
"Remv Vert Body,Cerv,One Sgmt",CASE-63081,APC,63081,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],12437.92,,"APC Price ($12,017.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,12017.31,12437.92,OPPS APC
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC,519,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],37589.76,,"Fee schedule rate ($37,589.76). Adds an outlier to normal pricing equal to the per diem rate ($123,674.40) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,15490.44,50780.20,There are no additional notes associated with this service or procedure.
PERIPHERAL VASCULAR DISORDERS WITH CC,300,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],20331.78,,"Fee schedule rate ($20,331.78). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,9174.14,21005.20,There are no additional notes associated with this service or procedure.
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],21354.82,,"Fee schedule rate ($21,354.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6834.39,21354.82,There are no additional notes associated with this service or procedure.
Cysto W/Rescj/Fulg Orthopic Ureterocele Uni/Bi,CASE-52300,APC,52300,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3299.47,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3299.47,3464.44,OPPS APC
Marsupialization Bartholins Gland Cyst,CASE-56440,APC,56440,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3181.53,,"APC Price ($3,030.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3030.03,3181.53,OPPS APC
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC,058,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],40853.02,,"Fee schedule rate ($40,853.02). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,13521.80,40853.02,There are no additional notes associated with this service or procedure.
RESPIRATORY NEOPLASMS WITH CC,181,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],17609.39,,"Fee schedule rate ($17,609.39). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9197.84,21074.07,There are no additional notes associated with this service or procedure.
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],29243.52,,"Fee schedule rate ($29,243.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,14343.25,36024.65,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],13260.40,,"Case rate ($13,260.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,471.48, add-ons for qualifying new technology services are included. If operating cost exceeds $47,342.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,587.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $10,487.86 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,526.53 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $827.60. The transfer capital threshold is the transfer adjustment factor * $827.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,13260.40,32878.30,Inpatient DRG
HC Joint Injection/Aspir Medium WO US|PBB CHARGE|RIGHT SIDE,CASE-20605,APC,20605,CPT,0510,RC,,,PBB|RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],29243.52,,"Fee schedule rate ($29,243.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,14343.25,36024.65,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],15009.94,,"Case rate ($14,295.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,434.11, add-ons for qualifying new technology services are included. If operating cost exceeds $48,305.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,663.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $11,446.95 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,489.15 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $903.28. The transfer capital threshold is the transfer adjustment factor * $903.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,14295.18,42768.36,Inpatient DRG
Ligamentous Reconstruction Knee Extra-Articular|LEFT SIDE,CASE-27427,APC,27427,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7029.71,OPPS APC
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],68942.79,,"Fee schedule rate ($68,942.79). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,21489.15,68942.79,There are no additional notes associated with this service or procedure.
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],11065.78,,"Fee schedule rate ($11,065.78). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5883.03,17111.12,There are no additional notes associated with this service or procedure.
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],7999.61,,"Case rate ($7,842.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,431.55, add-ons for qualifying new technology services are included. If operating cost exceeds $42,302.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,191.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $5,466.44 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,486.60 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $431.36. The transfer capital threshold is the transfer adjustment factor * $431.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,5280.00,17136.70,Inpatient DRG
Laparoscopy W/Rmvl Adnexal Structures|LEFT SIDE,CASE-58661,APC,58661,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5941.70,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5658.76,5941.70,OPPS APC
Vaginal Hysterectomy Uterus 250 Gm/<,CASE-58260,APC,58260,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],4916.53,,"APC Price ($4,682.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,4682.41,4916.53,OPPS APC
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],24567.74,,"Case rate ($24,567.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $22,990.45, add-ons for qualifying new technology services are included. If operating cost exceeds $57,861.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,414.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.7. The base transfer operating payment is the transfer adjustment factor * $20,968.18 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $21,045.49 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,654.60. The transfer capital threshold is the transfer adjustment factor * $1,654.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9370.00,65732.99,Inpatient DRG
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],19630.80,,"Fee schedule rate ($19,630.80). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,7086.00,57872.02,There are no additional notes associated with this service or procedure.
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],16438.59,,"Fee schedule rate ($16,438.59). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7402.56,16438.59,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],13414.31,,"Case rate ($12,775.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,020.41, add-ons for qualifying new technology services are included. If operating cost exceeds $46,891.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,552.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $10,038.44 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,075.45 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $792.13. The transfer capital threshold is the transfer adjustment factor * $792.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12775.53,31469.43,Inpatient DRG
Injection Aa&/Strd Ilioinguinal Ih Nerves,CASE-64425,APC,64425,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],660.72,,"APC Price ($660.72). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,660.72,693.76,OPPS APC
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],37149.27,,"Fee schedule rate ($37,149.27). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,12455.21,37149.27,There are no additional notes associated with this service or procedure.
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],17710.35,,"Case rate ($10,120.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,550.21, add-ons for qualifying new technology services are included. If operating cost exceeds $44,421.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,357.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $7,577.32 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,605.26 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $597.93. The transfer capital threshold is the transfer adjustment factor * $597.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,10120.20,26204.74,All Other Inpatient
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],37488.28,,"Fee schedule rate ($37,488.28). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.5), with a minimum of zero.",,,,0,other,15453.88,39251.68,There are no additional notes associated with this service or procedure.
Surg Tx Anal Fistula Intersphincteric,CASE-46275,APC,46275,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],2598.08,,"APC Price ($2,598.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2598.08,2727.99,OPPS APC
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],8637.85,,"Case rate ($8,468.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,013.65, add-ons for qualifying new technology services are included. If operating cost exceeds $42,884.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,237.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,046.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,068.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $477.12. The transfer capital threshold is the transfer adjustment factor * $477.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6963.00,18954.85,Inpatient DRG
"Arthrodesis Great Toe Metatarsophalangeal Joint|LEFT FOOT, GREAT TOE",CASE-28750,APC,28750,CPT,0360,RC,,,TA,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR,518,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],89342.77,,"Fee schedule rate ($89,342.77). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,13252.00,89342.77,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],10168.64,,"Fee schedule rate ($10,168.64). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,19126.88,There are no additional notes associated with this service or procedure.
ENDOCRINE DISORDERS WITH CC,644,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],19420.69,,"Fee schedule rate ($19,420.69). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7066.99,20334.21,There are no additional notes associated with this service or procedure.
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],21512.35,,"Fee schedule rate ($21,512.35). Adds an outlier to normal pricing equal to the per diem rate ($37,521.53) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,9696.93,35061.53,There are no additional notes associated with this service or procedure.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],53939.67,,"Fee schedule rate ($53,939.67). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,21382.16,85466.62,There are no additional notes associated with this service or procedure.
OTHER CEREBROVASCULAR DISORDERS WITH MCC,070,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],13532.33,,"Case rate ($12,887.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,145.39, add-ons for qualifying new technology services are included. If operating cost exceeds $47,016.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,541.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $10,161.92 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,200.44 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $781.07. The transfer capital threshold is the transfer adjustment factor * $781.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13219.09,37774.46,Inpatient DRG
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,073,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],43475.01,,"Fee schedule rate ($43,475.01). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,12809.38,43475.01,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,373,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],13670.03,,"Fee schedule rate ($13,670.03). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6870.94,14313.05,There are no additional notes associated with this service or procedure.
HC Non Stress Test|UNUSUAL NON-OVERLAPPING SERVICE,CASE-59025,APC,59025,CPT,0920,RC,,,XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],198.70,,"APC Price ($189.24). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,189.24,198.70,OPPS APC
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],43703.12,,"Fee schedule rate ($43,703.12). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.7), with a minimum of zero.",,,,0,other,17693.40,52449.26,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],23239.84,,"Fee schedule rate ($23,239.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8543.64,23239.84,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6787.66,,"Case rate ($6,787.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,450.02, add-ons for qualifying new technology services are included. If operating cost exceeds $41,321.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,114.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,488.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,505.07 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $354.19. The transfer capital threshold is the transfer adjustment factor * $354.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6164.03,14071.02,Inpatient DRG
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],16387.39,,"Case rate ($16,066.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,081.53, add-ons for qualifying new technology services are included. If operating cost exceeds $49,952.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,792.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $13,088.32 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,136.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,032.80. The transfer capital threshold is the transfer adjustment factor * $1,032.80. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6965.00,41030.48,Inpatient DRG
"OTHER PNEUMONIA,MAJOR",139,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],10665.92,,"Case rate ($10,158.02). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10158.02,10665.92,There are no additional notes associated with this service or procedure.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",063,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],11451.58,,"Case rate ($11,451.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,788.77, add-ons for qualifying new technology services are included. If operating cost exceeds $45,659.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,455.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $8,811.33 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,843.82 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $695.30. The transfer capital threshold is the transfer adjustment factor * $695.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,35701.87,Inpatient DRG
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],13447.65,,"Case rate ($12,992.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,222.63, add-ons for qualifying new technology services are included. If operating cost exceeds $47,093.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,568.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $10,239.92 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,277.68 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $808.03. The transfer capital threshold is the transfer adjustment factor * $808.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,7665.00,40737.46,Inpatient DRG
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,066,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],6965.00,,,,,,0,other,6579.76,20083.61,There are no additional notes associated with this service or procedure.
Mastectomy Partial W/Axillary Lymphadenectomy|LEFT SIDE,CASE-19302,APC,19302,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6432.89,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6215.36,6432.89,OPPS APC
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],8487.31,,"Case rate ($8,083.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,655.19, add-ons for qualifying new technology services are included. If operating cost exceeds $42,526.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,208.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,689.27 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,710.24 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $448.94. The transfer capital threshold is the transfer adjustment factor * $448.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7884.32,17835.23,Inpatient DRG
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],11945.95,,"Case rate ($11,945.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,248.66, add-ons for qualifying new technology services are included. If operating cost exceeds $46,119.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,491.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $9,269.54 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,303.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $731.46. The transfer capital threshold is the transfer adjustment factor * $731.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6167.00,29058.99,Inpatient DRG
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],30372.64,,"Fee schedule rate ($30,372.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,13260.40,32878.30,There are no additional notes associated with this service or procedure.
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],36024.65,,,,,,0,other,14343.25,36024.65,There are no additional notes associated with this service or procedure.
Arthroscopy Knee W/Meniscus Rpr Medial/Lateral|LEFT SIDE,CASE-29882,APC,29882,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6791.99,7131.59,OPPS APC
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],16828.14,,"Case rate ($16,026.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,044.99, add-ons for qualifying new technology services are included. If operating cost exceeds $49,916.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,789.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $13,051.92 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,100.04 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,029.93. The transfer capital threshold is the transfer adjustment factor * $1,029.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,11165.00,61234.06,Inpatient DRG
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],40426.76,,"Fee schedule rate ($40,426.76). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,11914.12,40426.76,There are no additional notes associated with this service or procedure.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],39797.94,,"Fee schedule rate ($39,797.94). Adds an outlier to normal pricing equal to the per diem rate ($75,578.79) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.5), with a minimum of zero.",,,,0,other,16286.16,58320.32,There are no additional notes associated with this service or procedure.
"ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",770,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],17800.73,,"Fee schedule rate ($17,800.73). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,8735.30,19730.13,There are no additional notes associated with this service or procedure.
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],2070.00,,,,,,0,other,1188.00,18893.86,Estimated amount calculated based on 3 day length of stay.
POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES,769,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],29791.03,,"Fee schedule rate ($29,791.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,13388.39,33250.19,There are no additional notes associated with this service or procedure.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC,858,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],33794.11,,"Fee schedule rate ($33,794.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11377.76,33794.11,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],29458.80,,"Fee schedule rate ($29,458.80). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,19152.11,53152.12,There are no additional notes associated with this service or procedure.
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC,964,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],12323.82,,"Case rate ($12,323.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,600.20, add-ons for qualifying new technology services are included. If operating cost exceeds $46,471.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,519.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $9,619.78 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,655.25 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $759.10. The transfer capital threshold is the transfer adjustment factor * $759.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12323.82,34154.06,Inpatient DRG
Injection Aa&/Strd Genicular Nrv Branches W/Img|RIGHT SIDE,CASE-64454,APC,64454,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],660.72,,"APC Price ($660.72). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,660.72,693.76,OPPS APC
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],2070.00,,,,,,0,other,1188.00,17370.86,Estimated amount calculated based on 3 day length of stay.
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],16438.59,,"Fee schedule rate ($16,438.59). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7402.56,16438.59,There are no additional notes associated with this service or procedure.
HEADACHES WITHOUT MCC,103,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],6965.00,,,,,,0,other,6965.00,20883.08,There are no additional notes associated with this service or procedure.
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,450,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],146009.19,,"Fee schedule rate ($146,009.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,38037.38,146009.19,There are no additional notes associated with this service or procedure.
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITHOUT MCC,430,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],133156.90,,"Fee schedule rate ($133,156.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,41000.16,133156.90,There are no additional notes associated with this service or procedure.
Neuroplasty &/Transpos Median Nrv Carpal Tunne|LEFT SIDE,CASE-64721,APC,64721,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1827.80,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1827.80,1919.19,OPPS APC
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],39820.52,,"Fee schedule rate ($39,820.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,15273.74,39820.52,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],34892.92,,"Fee schedule rate ($34,892.92). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,6965.00,41030.48,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,555,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],42290.95,,"Fee schedule rate ($42,290.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10896.27,42290.95,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL HEMORRHAGE WITH CC,378,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],20845.19,,"Fee schedule rate ($20,845.19). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8586.33,20845.19,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],7366.00,,"Case rate ($7,366). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,988.03, add-ons for qualifying new technology services are included. If operating cost exceeds $41,859.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,156.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,024.55 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,043.08 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $396.49. The transfer capital threshold is the transfer adjustment factor * $396.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,21195.68,Inpatient DRG
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],9533.13,,"Fee schedule rate ($9,533.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5068.21,14525.56,There are no additional notes associated with this service or procedure.
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],36652.83,,"Fee schedule rate ($36,652.83). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,21489.15,68942.79,There are no additional notes associated with this service or procedure.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH CC,354,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],31968.77,,"Fee schedule rate ($31,968.77). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11633.13,33472.54,There are no additional notes associated with this service or procedure.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],23347.92,,"Case rate ($13,341.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,547.08, add-ons for qualifying new technology services are included. If operating cost exceeds $47,418.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,593.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $10,563.18 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,602.13 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $833.54. The transfer capital threshold is the transfer adjustment factor * $833.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,13341.67,42586.49,All Other Inpatient
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],13907.80,,"Case rate ($13,907.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,073.74, add-ons for qualifying new technology services are included. If operating cost exceeds $47,944.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,634.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $11,087.92 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,128.80 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $874.95. The transfer capital threshold is the transfer adjustment factor * $874.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,13907.80,52794.06,Inpatient DRG
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],28394.78,,"Fee schedule rate ($28,394.78). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11454.97,28394.78,There are no additional notes associated with this service or procedure.
"Hallux Rigidus W/Cheilectomy 1st Mp Jt W/O Implt|RIGHT FOOT, GREAT TOE",CASE-28289,APC,28289,CPT,0360,RC,,,T5,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],27345.48,,"Case rate ($26,809.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $25,075.72, add-ons for qualifying new technology services are included. If operating cost exceeds $59,946.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,578.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $23,045.79 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $23,130.76 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,818.54. The transfer capital threshold is the transfer adjustment factor * $1,818.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,26809.29,97015.50,Inpatient DRG
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],16064.26,,"Fee schedule rate ($16,064.26). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7733.72,18043.23,There are no additional notes associated with this service or procedure.
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],7238.69,,"Case rate ($7,238.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,869.60, add-ons for qualifying new technology services are included. If operating cost exceeds $41,740.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,147.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,906.55 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,924.64 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $387.18. The transfer capital threshold is the transfer adjustment factor * $387.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7238.69,16804.22,Inpatient DRG
Enteroscopy > 2nd Prtn W/Control Bleeding,CASE-44366,APC,44366,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1796.14,,"APC Price ($1,796.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1796.14,1885.95,OPPS APC
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],58394.20,,"Fee schedule rate ($58,394.20). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,9370.00,65732.99,There are no additional notes associated with this service or procedure.
"CARDIAC ARREST, UNEXPLAINED WITH MCC",296,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],12772.70,,"Case rate ($12,522.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,784.78, add-ons for qualifying new technology services are included. If operating cost exceeds $46,655.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,533.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $9,803.69 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,839.84 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $773.61. The transfer capital threshold is the transfer adjustment factor * $773.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,12522.25,36459.67,Inpatient DRG
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],31462.43,,"Case rate ($30,398.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $28,414.67, add-ons for qualifying new technology services are included. If operating cost exceeds $63,285.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,841.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.2. The base transfer operating payment is the transfer adjustment factor * $26,372.48 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $26,469.72 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,081.05. The transfer capital threshold is the transfer adjustment factor * $2,081.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,30398.48,82674.88,Inpatient DRG
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],8563.30,,"Case rate ($8,563.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,101.85, add-ons for qualifying new technology services are included. If operating cost exceeds $42,972.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,244.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $6,134.29 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,156.91 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $484.06. The transfer capital threshold is the transfer adjustment factor * $484.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8563.30,31533.97,Inpatient DRG
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],142438.06,,"Fee schedule rate ($142,438.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (40), with a minimum of zero.",,,,0,other,45521.20,142438.06,There are no additional notes associated with this service or procedure.
Rmvl & Rplcmt Inflatable Penile Prosth Same Sess,CASE-54410,APC,54410,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],20079.15,,"APC Price ($19,400.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,19400.15,20370.16,OPPS APC
Revision Peri-Implant Capsule Breast,CASE-19370,APC,19370,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7918.25,,"APC Price ($7,650.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,7918.25,8033.01,OPPS APC
VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC,033,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],31250.88,,"Fee schedule rate ($31,250.88). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7.9), with a minimum of zero.",,,,0,other,13206.23,42156.44,There are no additional notes associated with this service or procedure.
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],33244.29,,,,,,0,other,13386.36,33244.29,There are no additional notes associated with this service or procedure.
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],8592.71,,"Case rate ($8,183.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,760.21, add-ons for qualifying new technology services are included. If operating cost exceeds $42,631.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,205.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,793.29 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,815.26 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $445.29. The transfer capital threshold is the transfer adjustment factor * $445.29. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,23385.72,Inpatient DRG
DIABETES WITHOUT CC/MCC,639,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],6274.80,,"Case rate ($6,151.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,858.45, add-ons for qualifying new technology services are included. If operating cost exceeds $40,729.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,067.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $3,899.13 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,913.51 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $307.68. The transfer capital threshold is the transfer adjustment factor * $307.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6151.76,12223.35,Inpatient DRG
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],81454.07,,"Fee schedule rate ($81,454.07). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,10078.00,81454.07,There are no additional notes associated with this service or procedure.
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],31973.49,,"Fee schedule rate ($31,973.49). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,13386.36,33244.29,There are no additional notes associated with this service or procedure.
CHEST PAIN,313,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],7161.88,,"Case rate ($6,820.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,480.89, add-ons for qualifying new technology services are included. If operating cost exceeds $41,351.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,116.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $4,519.27 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,535.94 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $356.62. The transfer capital threshold is the transfer adjustment factor * $356.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6820.84,15377.66,Inpatient DRG
"NEONATE BIRTH WEIGHT 2000-2499 GRAMS NORMAL NEWBORN OR NEONATE WITH OTHER PROBLEM,MAJOR",626,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],7399.95,,"Case rate ($7,047.57). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7047.57,7399.95,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITHOUT STERILIZATION WITH CC,787,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],23722.94,,"Fee schedule rate ($23,722.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9508.01,23722.94,There are no additional notes associated with this service or procedure.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],28149.75,,"Case rate ($26,809.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $25,075.72, add-ons for qualifying new technology services are included. If operating cost exceeds $59,946.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,578.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $23,045.79 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $23,130.76 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,818.54. The transfer capital threshold is the transfer adjustment factor * $1,818.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,26809.29,97015.50,Inpatient DRG
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],25829.63,,"Fee schedule rate ($25,829.63). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6965.00,29482.05,There are no additional notes associated with this service or procedure.
Enteroscopy > 2nd Prtn Abltj Lesion,CASE-44369,APC,44369,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1796.14,,"APC Price ($1,796.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1796.14,1885.95,OPPS APC
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],22677.38,,"Case rate ($21,597.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,227.30, add-ons for qualifying new technology services are included. If operating cost exceeds $55,098.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,197.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $18,215.19 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,282.35 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,437.36. The transfer capital threshold is the transfer adjustment factor * $1,437.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,21597.50,67790.93,Inpatient DRG
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],38222.57,,,,,,0,other,7605.00,39153.65,There are no additional notes associated with this service or procedure.
OSTEOMYELITIS WITH CC,540,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],18450.55,,"Fee schedule rate ($18,450.55). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,9809.07,25507.30,There are no additional notes associated with this service or procedure.
CHOLECYSTECTOMY WITH C.D.E. WITH MCC,411,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],88615.28,,"Fee schedule rate ($88,615.28). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,24315.13,88615.28,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],8609.27,,"Case rate ($8,318.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,873.80, add-ons for qualifying new technology services are included. If operating cost exceeds $42,744.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,226.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,907.07 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,928.85 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $466.13. The transfer capital threshold is the transfer adjustment factor * $466.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,8318.14,19763.43,Inpatient DRG
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],10605.28,,"Case rate ($10,100.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,546.88, add-ons for qualifying new technology services are included. If operating cost exceeds $44,417.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,342.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $7,573.22 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,601.93 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $582.10. The transfer capital threshold is the transfer adjustment factor * $582.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10347.06,28821.04,Inpatient DRG
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],70242.60,,"Fee schedule rate ($70,242.60). Adds an outlier to normal pricing equal to the per diem rate ($137,416) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16.5), with a minimum of zero.",,,,0,other,27256.92,81353.66,There are no additional notes associated with this service or procedure.
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],54236.60,,"Fee schedule rate ($54,236.60). Adds an outlier to normal pricing equal to the per diem rate ($122,612.56) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,21489.15,68942.79,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],6965.00,,,,,,0,other,6965.00,19126.88,There are no additional notes associated with this service or procedure.
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],11807.01,,"Case rate ($11,575.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,904.06, add-ons for qualifying new technology services are included. If operating cost exceeds $45,775.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,464.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $8,926.20 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,959.11 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $704.37. The transfer capital threshold is the transfer adjustment factor * $704.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,11575.50,48961.48,Inpatient DRG
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],24511.94,,"Case rate ($23,344.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $21,852.68, add-ons for qualifying new technology services are included. If operating cost exceeds $56,723.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,325.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $19,834.60 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $19,907.73 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,565.15. The transfer capital threshold is the transfer adjustment factor * $1,565.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,23344.70,62179.32,Inpatient DRG
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],26725.53,,"Fee schedule rate ($26,725.53). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.6), with a minimum of zero.",,,,0,other,11575.50,48961.48,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],11847.11,,"Fee schedule rate ($11,847.11). Adds an outlier to normal pricing equal to the per diem rate ($62,538.40) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,6214.05,15318.94,There are no additional notes associated with this service or procedure.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],54537.29,,"Fee schedule rate ($54,537.29). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.7), with a minimum of zero.",,,,0,other,21597.50,67790.93,There are no additional notes associated with this service or procedure.
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],27665.18,,"Fee schedule rate ($27,665.18). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,11914.12,40426.76,There are no additional notes associated with this service or procedure.
Suction Assisted Lipectomy Trunk,CASE-15877,APC,15877,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1600.04,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1600.04,1623.23,OPPS APC
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC",442,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],8080.45,,"Case rate ($7,695.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $7,260.76, add-ons for qualifying new technology services are included. If operating cost exceeds $45,905.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $3,189.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $5,874.79 + an uncompensated DSH payment of $1,359.91. The transfer operating threshold is the transfer adjustment factor * $5,900.84 + an uncompensated DSH payment of $1,359.91. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $460.97. The transfer capital threshold is the transfer adjustment factor * $460.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6607.45,19011.92,Inpatient DRG
"SEIZURE,MINOR",053,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],2119.21,,"Case rate for a one day stay ($2,119.21). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,2119.21,2225.17,There are no additional notes associated with this service or procedure.
"NEONATE BIRTH WEIGHT 1500-1999 GRAMS WITH OR WITHOUT OTHER SIGNIFICANT CONDITION,MODERATE",614,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],11512.05,,"Case rate ($10,963.86). Base payment rate plus any adjustments related to outliers.",,,,0,other,10963.86,11512.05,There are no additional notes associated with this service or procedure.
Biopsy Vaginal Mucosa Simple|UNUSUAL NON-OVERLAPPING SERVICE,CASE-57100,APC,57100,CPT,0360,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5658.76,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5658.76,5941.70,OPPS APC
OTHER CEREBROVASCULAR DISORDERS WITH MCC,070,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],37774.46,,"Fee schedule rate ($37,774.46). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,13219.09,37774.46,There are no additional notes associated with this service or procedure.
"MAJOR STOMACH ESOPHAGEAL AND DUODENAL PROCEDURES,MINOR",220,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],15981.03,,"Case rate ($15,220.03). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,15220.03,15981.03,There are no additional notes associated with this service or procedure.
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],52453.14,,"Fee schedule rate ($52,453.14). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14.9), with a minimum of zero.",,,,0,other,20846.48,81306.30,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],17168.65,,"Fee schedule rate ($17,168.65). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,32293.66,There are no additional notes associated with this service or procedure.
Laparoscopy Surg Cholecystectomy,CASE-47562,APC,47562,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5856.81,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5658.76,5941.70,OPPS APC
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],8165.30,,"Fee schedule rate ($8,165.30). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4341.01,12882.53,There are no additional notes associated with this service or procedure.
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],13794.06,,"Fee schedule rate ($13,794.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,6915.64,14442.92,There are no additional notes associated with this service or procedure.
Rmvl Noninfct Mesh/Prosth Aa/Parastomal Hrna Rpr,CASE-49623,APC,49623,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],199.10,,"APC Price ($199.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,199.10,209.05,OPPS APC
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],13295.62,,"Case rate ($13,295.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,504.24, add-ons for qualifying new technology services are included. If operating cost exceeds $47,375.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,590.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $10,520.50 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,559.29 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $830.17. The transfer capital threshold is the transfer adjustment factor * $830.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7000.00,33835.79,Inpatient DRG
"Open Tx Distal Phalangeal Fracture Each|RIGHT HAND, SECOND DIGIT",CASE-26765,APC,26765,CPT,0360,RC,,,F6,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],14830.15,,"Fee schedule rate ($14,830.15). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,7884.32,17835.23,There are no additional notes associated with this service or procedure.
Open Biopsy/Excision Inguinofemoral Nodes|RIGHT SIDE,CASE-38531,APC,38531,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6526.12,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6215.36,6526.12,OPPS APC
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],49717.39,,"Fee schedule rate ($49,717.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,14908.05,49717.39,There are no additional notes associated with this service or procedure.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],19422.10,,"Case rate ($18,497.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,343.20, add-ons for qualifying new technology services are included. If operating cost exceeds $52,214.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,970.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $15,341.68 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,398.25 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,210.61. The transfer capital threshold is the transfer adjustment factor * $1,210.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,18497.24,62041.12,Inpatient DRG
GASTROINTESTINAL OBSTRUCTION WITH CC,389,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],5118.00,,"Per diem ($5,118). If length of stay < 2.9, first 1 days paid at a per diem of $10,236 instead. Capped at $14,842.71.",,,,0,other,5118.00,16423.43,Estimated amount calculated based on 2 day length of stay.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,479,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],50518.76,,"Fee schedule rate ($50,518.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,10586.00,50518.76,There are no additional notes associated with this service or procedure.
Corrj Hallux Valgus W/Sesmdc W/Dist Metar Osteot|RIGHT SIDE,CASE-28296,APC,28296,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
NERVOUS SYSTEM NEOPLASMS WITH MCC,054,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],12899.48,,"Case rate ($12,285.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,564.29, add-ons for qualifying new technology services are included. If operating cost exceeds $46,435.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,516.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $9,584.00 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,619.34 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $756.27. The transfer capital threshold is the transfer adjustment factor * $756.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,30044.81,Inpatient DRG
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],35192.25,,"Fee schedule rate ($35,192.25). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,10895.60,35192.25,There are no additional notes associated with this service or procedure.
Neuroplasty &/Transpos Median Nrv Carpal Tunne|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64721,APC,64721,CPT,0360,RC,,,LT|XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7029.71,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6791.99,7131.59,OPPS APC
Cysto W/Urtroscopy&/Pyeloscopy Dx|RIGHT SIDE,CASE-52351,APC,52351,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3299.47,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3299.47,3464.44,OPPS APC
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],26721.94,,"Fee schedule rate ($26,721.94). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6965.00,34422.94,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],13865.83,,"Case rate ($7,923.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,506.51, add-ons for qualifying new technology services are included. If operating cost exceeds $42,377.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,197.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $5,541.13 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,561.56 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $437.25. The transfer capital threshold is the transfer adjustment factor * $437.25. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,1188.00,17370.86,All Other Inpatient
APPENDIX PROCEDURES WITH MCC,397,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],51558.84,,"Fee schedule rate ($51,558.84). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,18163.37,51558.84,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],13947.32,,"Fee schedule rate ($13,947.32). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6153.12,13947.32,There are no additional notes associated with this service or procedure.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],11681.49,,"Fee schedule rate ($11,681.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5778.62,11681.49,There are no additional notes associated with this service or procedure.
"CARDIAC ARREST, UNEXPLAINED WITH MCC",296,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],36459.67,,"Fee schedule rate ($36,459.67). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12522.25,36459.67,There are no additional notes associated with this service or procedure.
NON-MALIGNANT BREAST DISORDERS WITH CC/MCC,600,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],15046.13,,"Fee schedule rate ($15,046.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7999.14,20495.56,There are no additional notes associated with this service or procedure.
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],34406.22,,"Fee schedule rate ($34,406.22). Adds an outlier to normal pricing equal to the per diem rate ($49,808.13) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,14343.25,36024.65,There are no additional notes associated with this service or procedure.
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],27665.18,,"Fee schedule rate ($27,665.18). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,11914.12,40426.76,There are no additional notes associated with this service or procedure.
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],13625.25,,"Fee schedule rate ($13,625.25). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7243.75,23262.15,There are no additional notes associated with this service or procedure.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,761,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],11946.72,,"Fee schedule rate ($11,946.72). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,5808.41,11946.72,There are no additional notes associated with this service or procedure.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITHOUT CC/MCC,816,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],6965.00,,,,,,0,other,6224.90,14733.53,There are no additional notes associated with this service or procedure.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],40108.48,,"Fee schedule rate ($40,108.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,5569.00,40108.48,There are no additional notes associated with this service or procedure.
HC Rt Bronch Dx Clear Airway,CASE-31645,APC,31645,CPT,0361,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3664.31,,"APC Price ($3,489.82). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3489.82,3664.31,OPPS APC
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH CC",457,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],44443.84,,"Case rate ($42,327.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $39,511.96, add-ons for qualifying new technology services are included. If operating cost exceeds $74,382.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,713.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $37,429.01 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $37,567.02 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,953.52. The transfer capital threshold is the transfer adjustment factor * $2,953.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,42327.47,160549.49,Inpatient DRG
Marsupialization Bartholins Gland Cyst|LEFT SIDE,CASE-56440,APC,56440,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3181.53,,"APC Price ($3,030.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3030.03,3181.53,OPPS APC
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],2070.00,,,,,,0,other,1188.00,31658.33,Estimated amount calculated based on 16 day length of stay.
NON-MALIGNANT BREAST DISORDERS WITH CC/MCC,600,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],15046.13,,"Fee schedule rate ($15,046.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7999.14,20495.56,There are no additional notes associated with this service or procedure.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,191,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7860.43,,"Case rate ($7,486.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,110.12, add-ons for qualifying new technology services are included. If operating cost exceeds $41,981.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,155.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,145.66 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,165.17 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $395.51. The transfer capital threshold is the transfer adjustment factor * $395.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,16612.88,Inpatient DRG
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],12305.53,,"Case rate ($12,305.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,583.18, add-ons for qualifying new technology services are included. If operating cost exceeds $46,454.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,517.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $9,602.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,638.24 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $757.76. The transfer capital threshold is the transfer adjustment factor * $757.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12305.53,30103.84,Inpatient DRG
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,083,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],28680.85,,"Fee schedule rate ($28,680.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,28680.85,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC,817,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],17396.11,,"Case rate ($17,396.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,318.84, add-ons for qualifying new technology services are included. If operating cost exceeds $51,189.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,890.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $14,321.08 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,373.88 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,130.07. The transfer capital threshold is the transfer adjustment factor * $1,130.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,17396.11,44895.04,Inpatient DRG
VENTRICULAR SHUNT PROCEDURES WITH CC,032,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],46275.08,,"Fee schedule rate ($46,275.08). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,16376.22,46275.08,There are no additional notes associated with this service or procedure.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],29837.65,,"Fee schedule rate ($29,837.65). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,12696.97,47123.82,There are no additional notes associated with this service or procedure.
SEIZURES WITH MCC,100,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],15409.62,,"Case rate ($14,675.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,811.97, add-ons for qualifying new technology services are included. If operating cost exceeds $48,682.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,668.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $11,822.20 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,867.02 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $908.68. The transfer capital threshold is the transfer adjustment factor * $908.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,15061.09,38110.41,Inpatient DRG
HEART FAILURE AND SHOCK WITH CC,292,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],15550.06,,"Fee schedule rate ($15,550.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5502.00,16705.77,There are no additional notes associated with this service or procedure.
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],53569.45,,"Fee schedule rate ($53,569.45). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14.8), with a minimum of zero.",,,,0,other,21248.73,56089.29,There are no additional notes associated with this service or procedure.
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC",758,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],8746.30,,"Case rate ($8,574.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,112.57, add-ons for qualifying new technology services are included. If operating cost exceeds $42,983.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,244.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $6,144.96 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,167.62 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $484.90. The transfer capital threshold is the transfer adjustment factor * $484.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,8574.80,19263.78,Inpatient DRG
HC Inj Trigger Pt 1-2 Musc Grps|PBB CHARGE|SEPARATE STRUCTURE,CASE-20552,APC,20552,CPT,0510,RC,,,PBB|XS,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],301.68,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,287.31,301.68,OPPS APC
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],7784.77,,"Case rate ($7,414.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,032.76, add-ons for qualifying new technology services are included. If operating cost exceeds $41,903.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,159.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,069.12 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,087.81 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $400.00. The transfer capital threshold is the transfer adjustment factor * $400.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7414.07,18217.52,Inpatient DRG
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],33516.19,,"Case rate ($19,152.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,952.40, add-ons for qualifying new technology services are included. If operating cost exceeds $52,823.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,018.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $15,948.65 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $16,007.45 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,258.51. The transfer capital threshold is the transfer adjustment factor * $1,258.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,19152.11,53152.12,All Other Inpatient
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,066,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],6965.00,,,,,,0,other,6579.76,20083.61,There are no additional notes associated with this service or procedure.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],69977.32,,,,,,0,other,26028.48,80635.65,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],8200.65,,"Case rate ($7,923.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,506.51, add-ons for qualifying new technology services are included. If operating cost exceeds $42,377.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,197.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $5,541.13 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,561.56 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $437.25. The transfer capital threshold is the transfer adjustment factor * $437.25. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,1188.00,17370.86,Inpatient DRG
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],10036.32,,"Case rate ($9,696.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,156.46, add-ons for qualifying new technology services are included. If operating cost exceeds $44,027.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,326.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $7,185.02 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,211.51 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $566.97. The transfer capital threshold is the transfer adjustment factor * $566.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,9696.93,35061.53,Inpatient DRG
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,450,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],39939.25,,"Case rate ($38,037.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $35,520.98, add-ons for qualifying new technology services are included. If operating cost exceeds $70,391.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,399.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $33,452.68 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $33,576.02 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,639.75. The transfer capital threshold is the transfer adjustment factor * $2,639.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,38037.38,146009.19,Inpatient DRG
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],15887.21,,,,,,0,other,6148.93,15887.21,There are no additional notes associated with this service or procedure.
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],53569.45,,"Fee schedule rate ($53,569.45). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14.8), with a minimum of zero.",,,,0,other,21248.73,56089.29,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC,831,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],10341.62,,"Case rate ($9,849.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,312.82, add-ons for qualifying new technology services are included. If operating cost exceeds $44,183.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,324.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $7,340.04 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,367.87 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $564.17. The transfer capital threshold is the transfer adjustment factor * $564.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,4941.30,23661.59,Inpatient DRG
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],26178.21,,"Fee schedule rate ($26,178.21). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,13917.42,34889.29,There are no additional notes associated with this service or procedure.
MINOR BLADDER PROCEDURES WITHOUT CC/MCC,664,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],9267.70,,"Case rate ($8,826.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,359.44, add-ons for qualifying new technology services are included. If operating cost exceeds $43,230.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,251.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $6,390.26 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,414.49 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $491.17. The transfer capital threshold is the transfer adjustment factor * $491.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9034.63,31876.87,Inpatient DRG
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],58320.32,,"Fee schedule rate ($58,320.32). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,16286.16,58320.32,There are no additional notes associated with this service or procedure.
Sgmdsc Flx Rmvl Tum Polyp/Oth Les Snare Tq|COLORECTAL CANCER SCREEN,CASE-45338,APC,45338,CPT,0360,RC,,,PT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1120.09,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1120.09,1176.09,OPPS APC
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],17365.00,,"Fee schedule rate ($17,365.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5683.00,19635.68,There are no additional notes associated with this service or procedure.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,352,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],10050.44,,"Case rate ($9,853.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,301.99, add-ons for qualifying new technology services are included. If operating cost exceeds $44,173.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,338.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $7,330.01 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,357.04 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $578.41. The transfer capital threshold is the transfer adjustment factor * $578.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,9853.37,26528.70,Inpatient DRG
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC",061,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],62315.82,,"Fee schedule rate ($62,315.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,20616.23,62315.82,There are no additional notes associated with this service or procedure.
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],30245.71,,"Fee schedule rate ($30,245.71). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9151.11,30245.71,There are no additional notes associated with this service or procedure.
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],15994.77,,"Case rate ($15,233.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,306.64, add-ons for qualifying new technology services are included. If operating cost exceeds $49,177.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,731.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $12,316.28 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,361.69 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $971.88. The transfer capital threshold is the transfer adjustment factor * $971.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,15233.11,38610.21,Inpatient DRG
"Corrj Hallux Valgus W/Sesmdc W/Rescj Prox Phal|LEFT FOOT, GREAT TOE",CASE-28292,APC,28292,CPT,0360,RC,,,TA,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3062.67,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],19126.88,,"Fee schedule rate ($19,126.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,19126.88,There are no additional notes associated with this service or procedure.
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],10078.00,,"Per diem ($10,078). If length of stay < 7.2, first 1 days paid at a per diem of $20,156 instead. Capped at $72,563.53.",,,,0,other,10078.00,81454.07,Estimated amount calculated based on 15 day length of stay.
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],22695.45,,,,,,0,other,9755.86,29216.99,There are no additional notes associated with this service or procedure.
HC Lyr Clos Nk Hnd Ft <2.6cm,CASE-12041,APC,12041,CPT,0450,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1623.23,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1545.93,1623.23,OPPS APC
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],19458.27,,"Fee schedule rate ($19,458.27). Adds an outlier to normal pricing equal to the per diem rate ($75,355.48) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,8956.76,28983.97,There are no additional notes associated with this service or procedure.
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,068,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],23184.90,,"Fee schedule rate ($23,184.90). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,23184.90,There are no additional notes associated with this service or procedure.
SPINAL PROCEDURES WITH MCC,028,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],112913.98,,"Fee schedule rate ($112,913.98). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,42633.57,120982.83,There are no additional notes associated with this service or procedure.
Exc Tum/Vasc Mal Sft Tiss Hand/Fngr Subq <1.5cm|RIGHT SIDE,CASE-26115,APC,26115,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1623.23,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1545.93,1623.23,OPPS APC
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],14234.24,,"Case rate ($13,556.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,768.52, add-ons for qualifying new technology services are included. If operating cost exceeds $47,639.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,588.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $10,782.69 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,823.57 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $828.78. The transfer capital threshold is the transfer adjustment factor * $828.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13907.80,52794.06,Inpatient DRG
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],25609.86,,"Fee schedule rate ($25,609.86). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,12775.53,31469.43,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],60793.48,,"Fee schedule rate ($60,793.48). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15.7), with a minimum of zero.",,,,0,other,23851.92,63653.13,There are no additional notes associated with this service or procedure.
Dstrj Lesion Penis Simple Laser,CASE-54057,APC,54057,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],675.53,,"APC Price ($652.69). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,652.69,685.32,OPPS APC
Brnchsc Ebus Guided Sampl 3/> Node Station/Strux,CASE-31653,APC,31653,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6936.25,,"APC Price ($6,605.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6605.95,6936.25,OPPS APC
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],28445.08,,"Fee schedule rate ($28,445.08). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.8), with a minimum of zero.",,,,0,other,12195.15,39424.57,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],11594.35,,"Fee schedule rate ($11,594.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6164.03,14071.02,There are no additional notes associated with this service or procedure.
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",623,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],32096.64,,"Fee schedule rate ($32,096.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,14093.37,33712.76,There are no additional notes associated with this service or procedure.
Secondary Closure Surg Wound/Dehsn Extsv/Complic,CASE-13160,APC,13160,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3433.11,,"APC Price ($3,317.01). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3317.01,3433.11,OPPS APC
HC Joint Injection/Aspir Large WO US|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-20610,APC,20610,CPT,0510,RC,,,LT|XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],301.68,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,287.31,301.68,OPPS APC
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],9052.31,,"Case rate ($8,874.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,391.65, add-ons for qualifying new technology services are included. If operating cost exceeds $43,262.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,266.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $6,423.02 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,446.70 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $506.84. The transfer capital threshold is the transfer adjustment factor * $506.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,8874.81,20553.44,Inpatient DRG
Placement Seton,CASE-46020,APC,46020,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],2598.08,,"APC Price ($2,598.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2598.08,2727.99,OPPS APC
Colonoscopy Flx Dx W/Collj Spec When Pfrmd,CASE-45378,APC,45378,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],870.46,,"APC Price ($870.46). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,870.46,913.99,OPPS APC
Peri-Implant Capsulectomy Breast Complete|RIGHT SIDE,CASE-19371,APC,19371,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6432.89,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6215.36,6432.89,OPPS APC
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],59021.28,,"Fee schedule rate ($59,021.28). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,23851.92,63653.13,There are no additional notes associated with this service or procedure.
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],9648.19,,"Case rate ($9,648.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,111.10, add-ons for qualifying new technology services are included. If operating cost exceeds $43,982.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,323.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $7,139.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,166.15 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $563.40. The transfer capital threshold is the transfer adjustment factor * $563.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9648.19,31477.13,Inpatient DRG
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],36855.62,,"Fee schedule rate ($36,855.62). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,15821.59,40320.14,There are no additional notes associated with this service or procedure.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC,192,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6512.87,,"Case rate ($6,292.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,989.50, add-ons for qualifying new technology services are included. If operating cost exceeds $40,860.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,077.96, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,029.69 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,044.54 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $317.98. The transfer capital threshold is the transfer adjustment factor * $317.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6292.63,12753.78,Inpatient DRG
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],52909.62,,"Fee schedule rate ($52,909.62). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,23344.70,62179.32,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH CC,427,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],134742.59,,"Fee schedule rate ($134,742.59). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,50829.82,142040.39,There are no additional notes associated with this service or procedure.
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITHOUT MCC,430,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],133156.90,,"Fee schedule rate ($133,156.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,41000.16,133156.90,There are no additional notes associated with this service or procedure.
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],12979.93,,"Case rate ($12,725.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,973.79, add-ons for qualifying new technology services are included. If operating cost exceeds $46,844.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,548.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $9,991.99 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,028.83 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $788.47. The transfer capital threshold is the transfer adjustment factor * $788.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,12725.42,34245.00,Inpatient DRG
"SEPTICEMIA AND DISSEMINATED INFECTIONS,MAJOR",720,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],14333.66,,"Case rate ($13,651.10). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13651.10,14333.66,There are no additional notes associated with this service or procedure.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,056,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],7659.00,,"Per diem ($7,659). If length of stay < 5.7, first 1 days paid at a per diem of $15,318 instead. Capped at $43,658.02.",,,,0,other,7659.00,59328.19,Estimated amount calculated based on 3 day length of stay.
"Tendon Sheath Incision|LEFT FOOT, GREAT TOE",CASE-26055,APC,26055,CPT,0360,RC,,,TA,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1827.80,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1827.80,1919.19,OPPS APC
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,448,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],79697.35,,"Fee schedule rate ($79,697.35). Adds an outlier to normal pricing equal to the per diem rate ($108,215.07) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,30663.95,94077.13,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC,788,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],8859.92,,"Case rate ($8,438.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,985.31, add-ons for qualifying new technology services are included. If operating cost exceeds $42,856.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,234.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,018.17 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,040.36 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $474.89. The transfer capital threshold is the transfer adjustment factor * $474.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8438.02,20142.33,Inpatient DRG
INFLAMMATORY BOWEL DISEASE WITH CC,386,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],8856.01,,"Case rate ($8,556.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,095.56, add-ons for qualifying new technology services are included. If operating cost exceeds $42,966.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,243.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,128.01 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,150.61 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $483.56. The transfer capital threshold is the transfer adjustment factor * $483.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,8556.53,19879.00,Inpatient DRG
HC Drain/Inj Joint/Bursa W/US Large|PBB CHARGE|LEFT SIDE,CASE-20611,APC,20611,CPT,0510,RC,,,PBB|LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],297.37,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,287.31,301.68,OPPS APC
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],14678.03,,"Case rate ($13,979.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,162.50, add-ons for qualifying new technology services are included. If operating cost exceeds $48,033.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,618.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $11,175.18 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,217.55 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $858.95. The transfer capital threshold is the transfer adjustment factor * $858.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,14343.25,36024.65,Inpatient DRG
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC,058,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],40853.02,,"Fee schedule rate ($40,853.02). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,13521.80,40853.02,There are no additional notes associated with this service or procedure.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],19824.58,,,,,,0,other,8767.81,19824.58,There are no additional notes associated with this service or procedure.
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],13092.47,,"Case rate ($13,092.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,315.24, add-ons for qualifying new technology services are included. If operating cost exceeds $47,186.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,575.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $10,332.19 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,370.29 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $815.31. The transfer capital threshold is the transfer adjustment factor * $815.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,13092.47,33159.45,Inpatient DRG
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],90333.60,,"Fee schedule rate ($90,333.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,26127.34,90333.60,There are no additional notes associated with this service or procedure.
Neuroplasty &/Transpos Median Nrv Carpal Tunne|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64721,APC,64721,CPT,0360,RC,,,RT|XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1891.77,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1827.80,1919.19,OPPS APC
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],41493.06,,"Fee schedule rate ($41,493.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,16897.01,43444.85,There are no additional notes associated with this service or procedure.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC,434,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],13280.45,,"Fee schedule rate ($13,280.45). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6770.05,14019.86,There are no additional notes associated with this service or procedure.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC",061,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],62315.82,,"Fee schedule rate ($62,315.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,20616.23,62315.82,There are no additional notes associated with this service or procedure.
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],8868.77,,"Case rate ($8,446.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,005.29, add-ons for qualifying new technology services are included. If operating cost exceeds $42,876.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,224.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $6,037.45 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,060.34 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $464.05. The transfer capital threshold is the transfer adjustment factor * $464.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8643.20,19462.52,Inpatient DRG
GASTROINTESTINAL HEMORRHAGE WITH MCC,377,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],14324.29,,"Case rate ($14,324.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,461.19, add-ons for qualifying new technology services are included. If operating cost exceeds $48,332.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,665.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $11,473.94 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,516.24 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $905.41. The transfer capital threshold is the transfer adjustment factor * $905.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7634.00,35969.56,Inpatient DRG
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],25013.10,,"Fee schedule rate ($25,013.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10846.16,25863.45,There are no additional notes associated with this service or procedure.
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],13361.69,,"Case rate ($12,725.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,973.79, add-ons for qualifying new technology services are included. If operating cost exceeds $46,844.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,548.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $9,991.99 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,028.83 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $788.47. The transfer capital threshold is the transfer adjustment factor * $788.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12725.42,34245.00,Inpatient DRG
UNGROUPABLE,999,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],161307.29,,"Fee schedule rate ($161,307.29). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (41), with a minimum of zero.",,,,0,other,10228.00,161307.29,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],20567.06,,"Fee schedule rate ($20,567.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,9356.31,25026.36,There are no additional notes associated with this service or procedure.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],24956.34,,,,,,0,other,10533.95,24956.34,There are no additional notes associated with this service or procedure.
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],23870.71,,"Fee schedule rate ($23,870.71). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10626.74,25225.91,There are no additional notes associated with this service or procedure.
Enteroscopy > 2nd Prtn W/Control Bleeding,CASE-44366,APC,44366,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1796.14,,"APC Price ($1,796.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1796.14,1885.95,OPPS APC
"NERVOUS SYSTEM MALIGNANCY,MAJOR",041,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],12460.43,,"Case rate ($12,460.43). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,12460.43,13083.45,There are no additional notes associated with this service or procedure.
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITHOUT CC/MCC",630,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],12115.38,,"Case rate ($11,538.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,887.49, add-ons for qualifying new technology services are included. If operating cost exceeds $45,758.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,444.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $8,908.77 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,942.54 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $684.75. The transfer capital threshold is the transfer adjustment factor * $684.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,11828.78,42541.02,Inpatient DRG
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC,833,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],6965.00,,,,,,0,other,3041.73,10289.10,There are no additional notes associated with this service or procedure.
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITHOUT CC/MCC",630,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],42541.02,,"Fee schedule rate ($42,541.02). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11828.78,42541.02,There are no additional notes associated with this service or procedure.
MAJOR CHEST TRAUMA WITHOUT CC/MCC,185,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],21771.61,,"Fee schedule rate ($21,771.61). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7271.19,21771.61,There are no additional notes associated with this service or procedure.
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITH MCC OR ANTINEOPLASTIC IMPLANT OR EPILEPSY WITH NEUROSTIMULATOR,023,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],15168.00,,"Per diem ($15,168). If length of stay < 7.1, first 1 days paid at a per diem of $30,336 instead. Capped at $107,689.53.",,,,0,other,15168.00,136379.44,Estimated amount calculated based on 6 day length of stay.
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],37149.27,,"Fee schedule rate ($37,149.27). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,12455.21,37149.27,There are no additional notes associated with this service or procedure.
"Tendon Sheath Incision|LEFT HAND, FIFTH DIGIT",CASE-26055,APC,26055,CPT,0360,RC,,,F4,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1505.12,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1505.12,1580.37,OPPS APC
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],12550.50,,"Case rate ($12,126.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,416.25, add-ons for qualifying new technology services are included. If operating cost exceeds $46,287.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,504.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $9,436.50 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,471.29 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $744.63. The transfer capital threshold is the transfer adjustment factor * $744.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,12126.09,29582.40,Inpatient DRG
DIABETES WITH MCC,637,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],10909.44,,"Case rate ($10,909.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $10,253.93, add-ons for qualifying new technology services are included. If operating cost exceeds $48,898.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $3,423.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $8,854.74 + an uncompensated DSH payment of $1,359.91. The transfer operating threshold is the transfer adjustment factor * $8,894.02 + an uncompensated DSH payment of $1,359.91. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $694.79. The transfer capital threshold is the transfer adjustment factor * $694.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9959.03,28655.62,Inpatient DRG
Tnot Elbow Lateral/Medial Debride Open Tdn Rpr|RIGHT SIDE,CASE-24359,APC,24359,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],10097.32,,"Case rate ($9,755.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,211.27, add-ons for qualifying new technology services are included. If operating cost exceeds $44,082.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,331.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $7,239.63 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,266.32 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $571.28. The transfer capital threshold is the transfer adjustment factor * $571.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,9755.86,29216.99,Inpatient DRG
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],11454.97,,"Case rate ($11,454.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,791.92, add-ons for qualifying new technology services are included. If operating cost exceeds $45,662.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,455.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $8,814.47 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,846.97 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $695.55. The transfer capital threshold is the transfer adjustment factor * $695.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,11454.97,28394.78,Inpatient DRG
HC Drain/Inj Joint/Bursa W/US Large,CASE-20611,APC,20611,CPT,0510,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
Episiotomy/Vag Rpr Oth/Thn Attending,CASE-59300,APC,59300,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3030.03,,"APC Price ($3,030.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3030.03,3181.53,OPPS APC
OTHER CEREBROVASCULAR DISORDERS WITH CC,071,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],5843.00,,"Per diem ($5,843). If length of stay < 3.3, first 1 days paid at a per diem of $11,686 instead. Capped at $19,281.62.",,,,0,other,5843.00,29215.10,Estimated amount calculated based on 3 day length of stay.
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],17033.98,,"Fee schedule rate ($17,033.98). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.8), with a minimum of zero.",,,,0,other,7884.32,17835.23,There are no additional notes associated with this service or procedure.
Exc Rct Procidentia W/Anast Perineal Approach,CASE-45130,APC,45130,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],48.78,,"APC Price ($48.78). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,48.78,51.22,OPPS APC
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],12246.05,,"Fee schedule rate ($12,246.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6010.23,12246.05,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,064,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],41838.16,,"Fee schedule rate ($41,838.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,15563.58,41838.16,There are no additional notes associated with this service or procedure.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],12127.84,,"Case rate ($11,717.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,036.36, add-ons for qualifying new technology services are included. If operating cost exceeds $45,907.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,474.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $9,058.01 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,091.41 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $714.77. The transfer capital threshold is the transfer adjustment factor * $714.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,11717.72,43888.01,Inpatient DRG
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],15060.41,,"Case rate ($14,343.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,478.83, add-ons for qualifying new technology services are included. If operating cost exceeds $48,349.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,666.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $11,491.51 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,533.88 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $906.79. The transfer capital threshold is the transfer adjustment factor * $906.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,14343.25,36024.65,Inpatient DRG
Prq Skel Fixj Dstl Phlngl Fx Fngr/Thmb Ea,CASE-26756,APC,26756,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
NERVOUS SYSTEM NEOPLASMS WITH MCC,054,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],25589.03,,"Fee schedule rate ($25,589.03). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,6965.00,30044.81,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],85305.59,,"Fee schedule rate ($85,305.59). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,21719.40,85305.59,There are no additional notes associated with this service or procedure.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC,862,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],28705.48,,"Fee schedule rate ($28,705.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (42), with a minimum of zero.",,,,0,other,6855.00,35884.94,There are no additional notes associated with this service or procedure.
NEONATE WITH OTHER SIGNIFICANT PROBLEMS,794,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],1956.00,,,,,,0,other,1798.85,12536.83,Estimated amount calculated based on 2 day length of stay.
Arthrd Ant Interbody Min Dsc Crv Below C2|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-22554,APC,22554,CPT,0360,RC,,,74,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],12437.92,,"APC Price ($12,017.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,12437.92,12618.18,OPPS APC
"Suture Digital Nerve Hand/Foot 1 Nerve|RIGHT HAND, THUMB",CASE-64831,APC,64831,CPT,0360,RC,,,F5,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1891.77,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1827.80,1919.19,OPPS APC
HC Joint Injection/Aspir Medium WO US|PBB CHARGE,CASE-20605,APC,20605,CPT,0510,RC,,,PBB,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],301.68,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,287.31,301.68,OPPS APC
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],11063.08,,"Case rate ($10,846.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,225.56, add-ons for qualifying new technology services are included. If operating cost exceeds $45,096.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,410.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $8,250.19 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,280.61 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $651.02. The transfer capital threshold is the transfer adjustment factor * $651.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,10846.16,25863.45,Inpatient DRG
MAJOR BLADDER PROCEDURES WITH MCC,653,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],10280.00,,"Per diem ($10,280). If length of stay < 9.5, first 1 days paid at a per diem of $20,560 instead. Capped at $97,655.95.",,,,0,other,10280.00,125343.98,Estimated amount calculated based on 10 day length of stay.
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],24675.88,,"Fee schedule rate ($24,675.88). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10834.64,25830.00,There are no additional notes associated with this service or procedure.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],29917.96,,"Fee schedule rate ($29,917.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,12527.66,29917.96,There are no additional notes associated with this service or procedure.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],11717.72,,"Case rate ($11,717.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,036.36, add-ons for qualifying new technology services are included. If operating cost exceeds $45,907.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,474.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $9,058.01 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,091.41 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $714.77. The transfer capital threshold is the transfer adjustment factor * $714.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,11717.72,43888.01,Inpatient DRG
"FEMALE REPRODUCTIVE SYSTEM INFECTIONS,MODERATE",531,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],7220.36,,"Case rate ($6,876.53). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6876.53,7220.36,There are no additional notes associated with this service or procedure.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC,858,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],33794.11,,"Fee schedule rate ($33,794.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11377.76,33794.11,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],19763.43,,"Fee schedule rate ($19,763.43). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,8318.14,19763.43,There are no additional notes associated with this service or procedure.
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],7141.97,,"Case rate ($6,801.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,463.25, add-ons for qualifying new technology services are included. If operating cost exceeds $41,334.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,115.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,501.70 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,518.30 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $355.23. The transfer capital threshold is the transfer adjustment factor * $355.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6801.88,22557.82,Inpatient DRG
Optx Patllr Fx W/Int Fixj/Patllc&Soft Tiss Rpr,CASE-27524,APC,27524,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC,832,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6831.68,,"Case rate ($6,831.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,490.97, add-ons for qualifying new technology services are included. If operating cost exceeds $41,361.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,117.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $4,529.32 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,546.02 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $357.41. The transfer capital threshold is the transfer adjustment factor * $357.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,4803.31,14198.92,Inpatient DRG
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,479,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],50518.76,,"Fee schedule rate ($50,518.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,10586.00,50518.76,There are no additional notes associated with this service or procedure.
Neuroplasty &/Transposition Ulnar Nerve Elbow,CASE-64718,APC,64718,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1827.80,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1827.80,1919.19,OPPS APC
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],26721.94,,"Fee schedule rate ($26,721.94). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6965.00,34422.94,There are no additional notes associated with this service or procedure.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,057,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],39884.93,,"Fee schedule rate ($39,884.93). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,10718.84,39884.93,There are no additional notes associated with this service or procedure.
Brnschsc Tndsc Ebus Dx/Tx Intervention Perph Les,CASE-31654,APC,31654,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6605.95,,"APC Price ($6,605.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6605.95,6936.25,OPPS APC
HC Breath Hydrogen/Met Test,CASE-91065,APC,91065,CPT,0920,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],209.18,,"APC Price ($202.11). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,202.11,212.21,OPPS APC
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],2070.00,,,,,,0,other,1188.00,17370.86,Estimated amount calculated based on 3 day length of stay.
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC,832,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],7173.26,,"Case rate ($6,831.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,490.97, add-ons for qualifying new technology services are included. If operating cost exceeds $41,361.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,117.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $4,529.32 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,546.02 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $357.41. The transfer capital threshold is the transfer adjustment factor * $357.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,4803.31,14198.92,Inpatient DRG
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],8787.44,,"Case rate ($8,787.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,310.38, add-ons for qualifying new technology services are included. If operating cost exceeds $43,181.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,260.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,342.05 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,365.43 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $500.45. The transfer capital threshold is the transfer adjustment factor * $500.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,32293.66,Inpatient DRG
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],14217.69,,"Case rate ($13,540.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,753.82, add-ons for qualifying new technology services are included. If operating cost exceeds $47,624.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,587.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $10,768.04 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,808.87 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $827.66. The transfer capital threshold is the transfer adjustment factor * $827.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13891.57,34712.20,Inpatient DRG
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],25044.52,,"Case rate ($23,851.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $22,324.54, add-ons for qualifying new technology services are included. If operating cost exceeds $57,195.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,362.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.8. The base transfer operating payment is the transfer adjustment factor * $20,304.73 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $20,379.59 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,602.24. The transfer capital threshold is the transfer adjustment factor * $1,602.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,23851.92,63653.13,Inpatient DRG
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6558.75,,"Case rate ($6,558.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,237.08, add-ons for qualifying new technology services are included. If operating cost exceeds $41,108.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,097.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $4,276.36 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,292.13 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $337.45. The transfer capital threshold is the transfer adjustment factor * $337.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6558.75,14871.83,Inpatient DRG
NONTRAUMATIC STUPOR AND COMA WITH MCC,080,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],34015.33,,"Fee schedule rate ($34,015.33). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.5), with a minimum of zero.",,,,0,other,14202.39,35615.37,There are no additional notes associated with this service or procedure.
Marsupialization Bartholins Gland Cyst,CASE-56440,APC,56440,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3030.03,,"APC Price ($3,030.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3030.03,3181.53,OPPS APC
OSTEOMYELITIS WITH CC,540,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],18450.55,,"Fee schedule rate ($18,450.55). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,9809.07,25507.30,There are no additional notes associated with this service or procedure.
Arthrs Knee W/Meniscectomy Med&Lat W/Shaving|RIGHT SIDE,CASE-29880,APC,29880,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH CC,026,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],63202.45,,"Fee schedule rate ($63,202.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,23000.66,63202.45,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],43399.23,,"Fee schedule rate ($43,399.23). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9888.00,43399.23,There are no additional notes associated with this service or procedure.
FRACTURES OF FEMUR WITH MCC,533,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],49490.05,,"Fee schedule rate ($49,490.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,6852.00,49490.05,There are no additional notes associated with this service or procedure.
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],12651.45,,"Fee schedule rate ($12,651.45). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,6503.90,14492.93,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,066,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],20083.61,,"Fee schedule rate ($20,083.61). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6579.76,20083.61,There are no additional notes associated with this service or procedure.
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],12246.05,,"Fee schedule rate ($12,246.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6010.23,12246.05,There are no additional notes associated with this service or procedure.
HC Injection Small Joint/Bursa,CASE-20600,APC,20600,CPT,0361,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],297.37,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,287.31,301.68,OPPS APC
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],25667.48,,"Fee schedule rate ($25,667.48). Adds an outlier to normal pricing equal to the per diem rate ($77,296.48) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,11194.25,36094.03,There are no additional notes associated with this service or procedure.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],40108.48,,"Fee schedule rate ($40,108.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,5569.00,40108.48,There are no additional notes associated with this service or procedure.
MAJOR CHEST TRAUMA WITHOUT CC/MCC,185,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7525.68,,"Case rate ($7,271.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,899.84, add-ons for qualifying new technology services are included. If operating cost exceeds $41,770.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,149.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,936.68 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,954.88 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $389.55. The transfer capital threshold is the transfer adjustment factor * $389.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,7271.19,21771.61,Inpatient DRG
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,447,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],49552.87,,"Case rate ($47,193.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $44,038.45, add-ons for qualifying new technology services are included. If operating cost exceeds $78,909.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $5,069.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $41,938.87 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $42,093.51 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,309.39. The transfer capital threshold is the transfer adjustment factor * $3,309.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,47193.21,156646.82,Inpatient DRG
INFLAMMATORY BOWEL DISEASE WITH CC,386,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],19879.00,,"Fee schedule rate ($19,879.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8556.53,19879.00,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITH STERILIZATION WITH MCC,783,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],18986.82,,"Case rate ($18,082.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,987.66, add-ons for qualifying new technology services are included. If operating cost exceeds $51,858.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,911.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $14,985.90 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,042.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,151.85. The transfer capital threshold is the transfer adjustment factor * $1,151.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12612.10,23722.94,Inpatient DRG
"Surg Implnt Neuroelect,Epidural",CASE-63655,APC,63655,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],30327.72,,"APC Price ($28,883.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,28883.55,30327.72,OPPS APC
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],9991.03,,"Case rate ($9,795.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,247.81, add-ons for qualifying new technology services are included. If operating cost exceeds $44,118.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,334.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $7,276.03 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,302.86 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $574.15. The transfer capital threshold is the transfer adjustment factor * $574.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,9795.13,23899.13,Inpatient DRG
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,447,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],48844.97,,"Case rate ($47,193.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $44,038.45, add-ons for qualifying new technology services are included. If operating cost exceeds $78,909.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $5,069.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $41,938.87 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $42,093.51 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,309.39. The transfer capital threshold is the transfer adjustment factor * $3,309.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,47193.21,156646.82,Inpatient DRG
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],86252.84,,"Fee schedule rate ($86,252.84). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,27944.96,86252.84,There are no additional notes associated with this service or procedure.
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],5791.49,,"Fee schedule rate ($5,791.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,3079.00,10940.41,There are no additional notes associated with this service or procedure.
Tonsillectomy & Adenoidectomy Age 12/>,CASE-42821,APC,42821,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.35,,"APC Price ($3,103.35). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.35,3258.52,OPPS APC
HC >= 12 Lead Ekg|PBB CHARGE,CASE-93005,APC,93005,CPT,0730,RC,,,PBB,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],55.22,,"APC Price ($55.22). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,55.22,57.98,OPPS APC
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],13006.10,,"Case rate ($12,566.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,825.74, add-ons for qualifying new technology services are included. If operating cost exceeds $46,696.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,536.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $9,844.49 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,880.79 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $776.83. The transfer capital threshold is the transfer adjustment factor * $776.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,12566.28,30861.41,Inpatient DRG
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],48961.48,,"Fee schedule rate ($48,961.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11575.50,48961.48,There are no additional notes associated with this service or procedure.
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],15244.88,,"Fee schedule rate ($15,244.88). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,7438.45,15961.98,There are no additional notes associated with this service or procedure.
"Tendon Sheath Incision|RIGHT HAND, THIRD DIGIT|UNUSUAL NON-OVERLAPPING SERVICE",CASE-26055,APC,26055,CPT,0360,RC,,,F7|XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1557.80,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1505.12,1580.37,OPPS APC
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],21489.15,,"Case rate ($21,489.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,126.50, add-ons for qualifying new technology services are included. If operating cost exceeds $54,997.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,189.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.6. The base transfer operating payment is the transfer adjustment factor * $18,114.76 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,181.55 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,429.43. The transfer capital threshold is the transfer adjustment factor * $1,429.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,21489.15,68942.79,Inpatient DRG
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC",442,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],8080.45,,"Case rate ($7,695.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $7,260.76, add-ons for qualifying new technology services are included. If operating cost exceeds $45,905.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $3,189.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $5,874.79 + an uncompensated DSH payment of $1,359.91. The transfer operating threshold is the transfer adjustment factor * $5,900.84 + an uncompensated DSH payment of $1,359.91. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $460.97. The transfer capital threshold is the transfer adjustment factor * $460.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6607.45,19011.92,Inpatient DRG
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5778.62,,"Case rate ($5,778.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,511.33, add-ons for qualifying new technology services are included. If operating cost exceeds $40,382.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,040.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $3,553.28 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,566.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $280.39. The transfer capital threshold is the transfer adjustment factor * $280.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,5778.62,11681.49,Inpatient DRG
Egd Transoral Control Bleeding Any Method|UNUSUAL NON-OVERLAPPING SERVICE,CASE-43255,APC,43255,CPT,0360,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1796.14,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1796.14,1885.95,OPPS APC
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],36776.05,,"Fee schedule rate ($36,776.05). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11053.39,36776.05,There are no additional notes associated with this service or procedure.
Optx Dstl Radl X-Artic Fx/Epiphysl Sep|RIGHT SIDE,CASE-25607,APC,25607,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7029.71,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6791.99,7131.59,OPPS APC
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],12393.48,,"Case rate ($11,974.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,275.12, add-ons for qualifying new technology services are included. If operating cost exceeds $46,146.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,493.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $9,295.90 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,330.17 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $733.54. The transfer capital threshold is the transfer adjustment factor * $733.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,11974.38,29141.64,Inpatient DRG
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],21534.51,,,,,,0,other,9356.31,25026.36,There are no additional notes associated with this service or procedure.
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC",923,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],6965.00,,,,,,0,other,6965.00,20068.57,There are no additional notes associated with this service or procedure.
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],30245.71,,"Fee schedule rate ($30,245.71). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9151.11,30245.71,There are no additional notes associated with this service or procedure.
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],21645.63,,"Fee schedule rate ($21,645.63). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,17356.15,44778.95,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,167,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],14157.71,,"Case rate ($14,157.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,306.21, add-ons for qualifying new technology services are included. If operating cost exceeds $48,177.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,653.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $11,319.53 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,361.26 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $893.22. The transfer capital threshold is the transfer adjustment factor * $893.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,14157.71,43522.37,Inpatient DRG
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],37149.27,,"Fee schedule rate ($37,149.27). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,12455.21,37149.27,There are no additional notes associated with this service or procedure.
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],15087.45,,"Fee schedule rate ($15,087.45). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7389.00,37134.43,There are no additional notes associated with this service or procedure.
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,069,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],7354.47,,"Case rate ($7,354.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,977.32, add-ons for qualifying new technology services are included. If operating cost exceeds $41,848.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,155.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $5,013.88 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,032.37 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $395.65. The transfer capital threshold is the transfer adjustment factor * $395.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,20333.68,Inpatient DRG
Colorectal Scrn; Hi Risk Ind,CASE-G0105,APC,G0105,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],913.99,,"APC Price ($870.46). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,870.46,913.99,OPPS APC
Esophagoscopy Flexible Transoral Ultrasound Exam,CASE-43231,APC,43231,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1885.95,,"APC Price ($1,796.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1796.14,1885.95,OPPS APC
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],35474.53,,"Fee schedule rate ($35,474.53). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,16428.39,42083.20,There are no additional notes associated with this service or procedure.
HC >= 12 Lead Ekg|ADJ,CASE-93005,APC,93005,CPT,0730,RC,,,ADJ,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],130.85,,"APC Price ($124.62). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,124.62,130.85,OPPS APC
PSYCHOSES,885,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],2070.00,,,,,,0,other,2070.00,27484.83,Estimated amount calculated based on 3 day length of stay.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],2070.00,,,,,,0,other,1188.00,12138.74,Estimated amount calculated based on 1 day length of stay.
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],15802.03,,"Fee schedule rate ($15,802.03). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7566.45,16333.88,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],23885.04,,"Case rate ($22,747.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $21,336.09, add-ons for qualifying new technology services are included. If operating cost exceeds $56,207.10 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,244.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $19,317.89 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $19,391.14 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,484.82. The transfer capital threshold is the transfer adjustment factor * $1,484.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,23377.19,96365.69,Inpatient DRG
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],25784.85,,"Fee schedule rate ($25,784.85). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,17782.11,46523.26,There are no additional notes associated with this service or procedure.
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],10940.41,,,,,,0,other,3079.00,10940.41,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],37495.79,,"Fee schedule rate ($37,495.79). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.8), with a minimum of zero.",,,,0,other,15456.59,41402.42,There are no additional notes associated with this service or procedure.
"HERNIA PROCEDURES EXCEPT INGUINAL FEMORAL AND UMBILICAL,EXTREME",227,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],42217.00,,"Case rate ($40,206.67). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,40206.67,42217.00,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,394,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],8281.56,,"Case rate ($8,281.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,839.77, add-ons for qualifying new technology services are included. If operating cost exceeds $42,710.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,223.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,873.17 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,894.83 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $463.45. The transfer capital threshold is the transfer adjustment factor * $463.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8281.56,20909.61,Inpatient DRG
Removal Implant Deep,CASE-20680,APC,20680,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1827.80,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1827.80,1919.19,OPPS APC
"Tx Open Tendon Flexor Toe 1 Tendon Spx|RIGHT FOOT, SECOND DIGIT",CASE-28232,APC,28232,CPT,0360,RC,,,T6,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1505.12,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1505.12,1580.37,OPPS APC
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],7923.33,,"Case rate ($7,923.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,506.51, add-ons for qualifying new technology services are included. If operating cost exceeds $42,377.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,197.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $5,541.13 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,561.56 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $437.25. The transfer capital threshold is the transfer adjustment factor * $437.25. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,1188.00,17370.86,Inpatient DRG
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],23618.74,,"Fee schedule rate ($23,618.74). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10533.95,24956.34,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC,831,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],9294.42,,"Fee schedule rate ($9,294.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,4941.30,23661.59,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,447,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],156646.82,,"Fee schedule rate ($156,646.82). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,47193.21,156646.82,There are no additional notes associated with this service or procedure.
NONTRAUMATIC STUPOR AND COMA WITH MCC,080,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],14202.39,,"Case rate ($14,202.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,347.79, add-ons for qualifying new technology services are included. If operating cost exceeds $48,218.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,656.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $11,360.96 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,402.84 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $896.49. The transfer capital threshold is the transfer adjustment factor * $896.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,14202.39,35615.37,Inpatient DRG
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],8887.20,,"Fee schedule rate ($8,887.20). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,7396.47,16035.06,There are no additional notes associated with this service or procedure.
MINOR BLADDER PROCEDURES WITHOUT CC/MCC,664,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],31876.87,,"Fee schedule rate ($31,876.87). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9034.63,31876.87,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF NERVOUS SYSTEM WITH CC,092,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],14834.40,,"Fee schedule rate ($14,834.40). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8872.78,26765.51,There are no additional notes associated with this service or procedure.
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],16226.57,,"Case rate ($15,453.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,512.02, add-ons for qualifying new technology services are included. If operating cost exceeds $49,383.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,747.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $12,520.90 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,567.07 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $988.02. The transfer capital threshold is the transfer adjustment factor * $988.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,15453.88,39251.68,Inpatient DRG
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],30063.84,,"Fee schedule rate ($30,063.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13891.57,34712.20,There are no additional notes associated with this service or procedure.
FULL TERM NEONATE WITH MAJOR PROBLEMS,793,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],30785.42,,"Case rate ($30,181.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $28,213.07, add-ons for qualifying new technology services are included. If operating cost exceeds $63,084.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,825.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $26,171.62 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $26,268.12 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,065.20. The transfer capital threshold is the transfer adjustment factor * $2,065.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,4302.90,82045.22,Inpatient DRG
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC,939,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],97674.79,,"Fee schedule rate ($97,674.79). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,26517.40,97674.79,There are no additional notes associated with this service or procedure.
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],14309.17,,"Fee schedule rate ($14,309.17). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,17467.27,There are no additional notes associated with this service or procedure.
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],16048.10,,"Case rate ($15,283.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,353.89, add-ons for qualifying new technology services are included. If operating cost exceeds $49,224.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,735.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.2. The base transfer operating payment is the transfer adjustment factor * $12,363.36 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,408.94 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $975.59. The transfer capital threshold is the transfer adjustment factor * $975.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,15283.90,38757.79,Inpatient DRG
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],29367.82,,"Fee schedule rate ($29,367.82). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.7), with a minimum of zero.",,,,0,other,12527.66,29917.96,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],45758.86,,,,,,0,other,17693.40,52449.26,There are no additional notes associated with this service or procedure.
NONTRAUMATIC STUPOR AND COMA WITH MCC,080,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],35615.37,,,,,,0,other,14202.39,35615.37,There are no additional notes associated with this service or procedure.
Cysto impl 4 or more,CASE-C9740,APC,C9740,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],9170.96,,"APC Price ($8,860.83). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,8860.83,9303.88,OPPS APC
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],6965.00,,,,,,0,other,6965.00,21404.64,There are no additional notes associated with this service or procedure.
"HC Repair Nail Bed|RIGHT HAND, FIFTH DIGIT",CASE-11760,APC,11760,CPT,0450,RC,,,F9,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],7944.77,,"Case rate ($7,566.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,174.51, add-ons for qualifying new technology services are included. If operating cost exceeds $42,045.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,171.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,210.35 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,229.56 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $411.15. The transfer capital threshold is the transfer adjustment factor * $411.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7566.45,16333.88,Inpatient DRG
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],21980.29,,"Fee schedule rate ($21,980.29). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9865.56,37914.65,There are no additional notes associated with this service or procedure.
Biopsy Floor Mouth,CASE-41108,APC,41108,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1545.93,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1545.93,1623.23,OPPS APC
Exc B9 Lesion Mrgn Xcp Sk Tg T/a/L >4.0 Cm,CASE-11406,APC,11406,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1623.23,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1545.93,1623.23,OPPS APC
Colonoscopy W/Biopsy Single/Multiple|UNUSUAL NON-OVERLAPPING SERVICE,CASE-45380,APC,45380,CPT,0360,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1120.09,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1120.09,1176.09,OPPS APC
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],19126.88,,"Fee schedule rate ($19,126.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,19126.88,There are no additional notes associated with this service or procedure.
OTHER CEREBROVASCULAR DISORDERS WITH CC,071,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],29215.10,,"Fee schedule rate ($29,215.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5843.00,29215.10,There are no additional notes associated with this service or procedure.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],15309.46,,"Fee schedule rate ($15,309.46). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6965.00,15340.19,There are no additional notes associated with this service or procedure.
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],34032.82,,"Fee schedule rate ($34,032.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,15233.11,38610.21,There are no additional notes associated with this service or procedure.
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITH MCC,429,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],177294.98,,"Fee schedule rate ($177,294.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,62958.58,177294.98,There are no additional notes associated with this service or procedure.
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],12804.91,,"Case rate ($12,195.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,480.50, add-ons for qualifying new technology services are included. If operating cost exceeds $46,351.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,509.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,500.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,535.55 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $749.68. The transfer capital threshold is the transfer adjustment factor * $749.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12195.15,39424.57,Inpatient DRG
VENTRICULAR SHUNT PROCEDURES WITH CC,032,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],46275.08,,"Fee schedule rate ($46,275.08). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,16376.22,46275.08,There are no additional notes associated with this service or procedure.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],38517.10,,"Fee schedule rate ($38,517.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,16897.01,43444.85,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],128358.13,,"Fee schedule rate ($128,358.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,40542.37,128358.13,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],21784.85,,"Fee schedule rate ($21,784.85). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.4), with a minimum of zero.",,,,0,other,9795.13,23899.13,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,555,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],24840.59,,"Fee schedule rate ($24,840.59). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10896.27,42290.95,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],14871.83,,"Fee schedule rate ($14,871.83). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6558.75,14871.83,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],32360.46,,"Case rate ($30,819.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $28,860.20, add-ons for qualifying new technology services are included. If operating cost exceeds $63,731.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,820.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. The base transfer operating payment is the transfer adjustment factor * $26,813.59 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $26,915.25 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,060.96. The transfer capital threshold is the transfer adjustment factor * $2,060.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10862.00,86437.13,Inpatient DRG
Vaginal Hysterectomy Uterus 250 Gm/<,CASE-58260,APC,58260,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],4846.30,,"APC Price ($4,682.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,4682.41,4916.53,OPPS APC
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],25667.48,,"Fee schedule rate ($25,667.48). Adds an outlier to normal pricing equal to the per diem rate ($77,296.48) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,11194.25,36094.03,There are no additional notes associated with this service or procedure.
Laps Fulg/Exc Ovary Viscera/Peritoneal Surface|BILATERAL PROCEDURE,CASE-58662,APC,58662,CPT,0360,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5856.81,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5658.76,5941.70,OPPS APC
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],12725.42,,"Case rate ($12,725.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,973.79, add-ons for qualifying new technology services are included. If operating cost exceeds $46,844.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,548.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $9,991.99 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,028.83 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $788.47. The transfer capital threshold is the transfer adjustment factor * $788.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12725.42,34245.00,Inpatient DRG
O.R. PROCEDURES FOR OBESITY WITH CC,620,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],43753.50,,"Fee schedule rate ($43,753.50). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12782.30,43753.50,There are no additional notes associated with this service or procedure.
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],13625.25,,"Fee schedule rate ($13,625.25). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7243.75,23262.15,There are no additional notes associated with this service or procedure.
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITHOUT MCC,430,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],43050.17,,"Case rate ($41,000.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $38,277.19, add-ons for qualifying new technology services are included. If operating cost exceeds $73,148.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,616.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $36,198.76 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $36,332.23 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,856.44. The transfer capital threshold is the transfer adjustment factor * $2,856.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,41000.16,133156.90,Inpatient DRG
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,448,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],30663.95,,"Case rate ($30,663.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $28,661.63, add-ons for qualifying new technology services are included. If operating cost exceeds $63,532.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,860.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $26,618.53 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $26,716.68 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,100.47. The transfer capital threshold is the transfer adjustment factor * $2,100.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,30663.95,94077.13,Inpatient DRG
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],14674.80,,"Fee schedule rate ($14,674.80). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6711.00,16865.16,There are no additional notes associated with this service or procedure.
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],10998.68,,"Case rate ($10,626.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,021.44, add-ons for qualifying new technology services are included. If operating cost exceeds $44,892.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,394.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $8,046.82 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,076.49 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $634.97. The transfer capital threshold is the transfer adjustment factor * $634.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,10626.74,25225.91,Inpatient DRG
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],28434.57,,"Fee schedule rate ($28,434.57). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,8906.63,28434.57,There are no additional notes associated with this service or procedure.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,479,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],14533.55,,"Case rate ($14,533.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,655.86, add-ons for qualifying new technology services are included. If operating cost exceeds $48,526.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,680.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $11,667.89 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,710.91 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $920.71. The transfer capital threshold is the transfer adjustment factor * $920.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10586.00,50518.76,Inpatient DRG
INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC,198,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],23505.07,,"Fee schedule rate ($23,505.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6795.12,23505.07,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],20109.72,,"Case rate ($19,152.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,952.40, add-ons for qualifying new technology services are included. If operating cost exceeds $52,823.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,018.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $15,948.65 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $16,007.45 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,258.51. The transfer capital threshold is the transfer adjustment factor * $1,258.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,19152.11,53152.12,Inpatient DRG
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],29474.94,,"Fee schedule rate ($29,474.94). Adds an outlier to normal pricing equal to the per diem rate ($65,448.99) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.4), with a minimum of zero.",,,,0,other,12566.28,30861.41,There are no additional notes associated with this service or procedure.
HC Trigger Point 3 or More|PBB CHARGE,CASE-20553,APC,20553,CPT,0510,RC,,,PBB,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
MAJOR CHEST PROCEDURES WITH CC,164,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],77058.83,,"Fee schedule rate ($77,058.83). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,19037.66,77058.83,There are no additional notes associated with this service or procedure.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],59521.43,,"Fee schedule rate ($59,521.43). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,16689.78,59521.43,There are no additional notes associated with this service or procedure.
HC Joint Injection/Aspir Large WO US,CASE-20610,APC,20610,CPT,0510,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],301.68,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,287.31,301.68,OPPS APC
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],21990.99,,"Case rate ($12,566.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,825.74, add-ons for qualifying new technology services are included. If operating cost exceeds $46,696.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,536.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $9,844.49 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,880.79 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $776.83. The transfer capital threshold is the transfer adjustment factor * $776.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,12566.28,30861.41,All Other Inpatient
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],7868.00,,"Per diem ($7,868). If length of stay < 3.9, first 1 days paid at a per diem of $15,736 instead. Capped at $30,683.33.",,,,0,other,7868.00,32126.64,Estimated amount calculated based on 3 day length of stay.
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],37899.49,,"Fee schedule rate ($37,899.49). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,14747.55,37899.49,There are no additional notes associated with this service or procedure.
Egd Removal Tumor Polyp/Other Lesion Snare Tech,CASE-43251,APC,43251,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1859.01,,"APC Price ($1,796.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1796.14,1885.95,OPPS APC
Destruction Neurolytic Agt Genicular Nerve W/Img|BILATERAL PROCEDURE,CASE-64624,APC,64624,CPT,0360,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1891.77,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1827.80,1919.19,OPPS APC
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7492.04,,"Case rate ($7,238.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,869.60, add-ons for qualifying new technology services are included. If operating cost exceeds $41,740.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,147.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,906.55 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,924.64 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $387.18. The transfer capital threshold is the transfer adjustment factor * $387.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,7238.69,16804.22,Inpatient DRG
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC,099,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],22084.20,,"Fee schedule rate ($22,084.20). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11171.21,26807.94,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],8543.64,,"Case rate ($8,543.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,083.58, add-ons for qualifying new technology services are included. If operating cost exceeds $42,954.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,242.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,116.09 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,138.64 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $482.62. The transfer capital threshold is the transfer adjustment factor * $482.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8543.64,23239.84,Inpatient DRG
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC,806,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],10071.17,,"Fee schedule rate ($10,071.17). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5354.25,13416.00,There are no additional notes associated with this service or procedure.
OSTEOMYELITIS WITH CC,540,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],25507.30,,,,,,0,other,9809.07,25507.30,There are no additional notes associated with this service or procedure.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",062,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],44304.80,,"Fee schedule rate ($44,304.80). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,13844.84,44304.80,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],11477.81,,"Case rate ($6,558.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,237.08, add-ons for qualifying new technology services are included. If operating cost exceeds $41,108.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,097.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $4,276.36 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,292.13 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $337.45. The transfer capital threshold is the transfer adjustment factor * $337.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,6558.75,14871.83,All Other Inpatient
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],13904.43,,"Case rate ($13,904.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,070.60, add-ons for qualifying new technology services are included. If operating cost exceeds $47,941.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,634.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,084.78 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,125.65 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $874.70. The transfer capital threshold is the transfer adjustment factor * $874.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,13904.43,34749.58,Inpatient DRG
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],27832.43,,"Fee schedule rate ($27,832.43). Adds an outlier to normal pricing equal to the per diem rate ($62,521.14) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.7), with a minimum of zero.",,,,0,other,11974.38,29141.64,There are no additional notes associated with this service or procedure.
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],29594.00,,"Fee schedule rate ($29,594.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,13571.25,33781.47,There are no additional notes associated with this service or procedure.
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],9667.64,,"Fee schedule rate ($9,667.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,5139.72,13110.79,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,699,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],8818.60,,"Case rate ($8,818.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,339.37, add-ons for qualifying new technology services are included. If operating cost exceeds $43,210.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,262.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $6,370.92 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,394.41 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $502.73. The transfer capital threshold is the transfer adjustment factor * $502.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,5961.00,19972.16,Inpatient DRG
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],43399.23,,"Fee schedule rate ($43,399.23). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9888.00,43399.23,There are no additional notes associated with this service or procedure.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],16286.16,,"Case rate ($16,286.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,286.28, add-ons for qualifying new technology services are included. If operating cost exceeds $50,157.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,808.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $13,292.32 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,341.33 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,048.90. The transfer capital threshold is the transfer adjustment factor * $1,048.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,16286.16,58320.32,Inpatient DRG
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],59891.41,,"Fee schedule rate ($59,891.41). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15), with a minimum of zero.",,,,0,other,23526.87,94787.57,There are no additional notes associated with this service or procedure.
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],59081.91,,"Fee schedule rate ($59,081.91). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,8480.00,59081.91,There are no additional notes associated with this service or procedure.
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC",923,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6974.68,,"Case rate ($6,642.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $6,199.52, add-ons for qualifying new technology services are included. If operating cost exceeds $45,769.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $3,262.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,171.35. The transfer operating threshold is the transfer adjustment factor * $6,199.52 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $471.20. The transfer capital threshold is the transfer adjustment factor * $471.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,20068.57,Inpatient DRG
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],19604.30,,"Fee schedule rate ($19,604.30). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9446.38,21796.21,There are no additional notes associated with this service or procedure.
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],27222.08,,"Fee schedule rate ($27,222.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7389.00,37134.43,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,064,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],41838.16,,"Fee schedule rate ($41,838.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,15563.58,41838.16,There are no additional notes associated with this service or procedure.
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR,518,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],13252.00,,"Per diem ($13,252). If length of stay < 5.3, first 1 days paid at a per diem of $26,504 instead. Capped at $70,235.08.",,,,0,other,13252.00,89342.77,Estimated amount calculated based on 1 day length of stay.
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITHOUT CC/MCC,428,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],118904.57,,"Fee schedule rate ($118,904.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,40017.53,118904.57,There are no additional notes associated with this service or procedure.
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC,807,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],10071.17,,"Fee schedule rate ($10,071.17). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5354.25,13266.23,There are no additional notes associated with this service or procedure.
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],6633.98,,"Case rate ($6,503.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,186.05, add-ons for qualifying new technology services are included. If operating cost exceeds $41,057.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,093.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $4,225.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,241.10 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $333.44. The transfer capital threshold is the transfer adjustment factor * $333.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6503.90,14492.93,Inpatient DRG
Unlisted Px Female Genital System Nonobstetrical,CASE-58999,APC,58999,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],189.24,,"APC Price ($189.24). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,189.24,198.70,OPPS APC
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],41187.90,,,,,,0,other,16120.25,41187.90,There are no additional notes associated with this service or procedure.
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,095,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],48575.01,,"Fee schedule rate ($48,575.01). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,19411.47,50750.92,There are no additional notes associated with this service or procedure.
Colonoscopy Flx Dx W/Collj Spec When Pfrmd|COLORECTAL CANCER SCREEN,CASE-45378,APC,45378,CPT,0360,RC,,,PT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],913.99,,"APC Price ($870.46). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,870.46,913.99,OPPS APC
Inject Rx Other Periph Nerve|LEFT SIDE,CASE-64640,APC,64640,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],827.89,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,827.89,869.28,OPPS APC
Laparoscopy Surg Rpr Initial Inguinal Hernia|RIGHT SIDE,CASE-49650,APC,49650,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5856.81,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5658.76,5941.70,OPPS APC
"NEONATE BIRTH WEIGHT > 2499 GRAMS NORMAL NEWBORN OR NEONATE WITH OTHER PROBLEM,MODERATE",640,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],1551.39,,"Case rate ($1,551.39). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,1551.39,1628.96,There are no additional notes associated with this service or procedure.
"ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",770,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],17800.73,,"Fee schedule rate ($17,800.73). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,8735.30,19730.13,There are no additional notes associated with this service or procedure.
"Open Tx Articular Fracture Mcp/IP Joint Ea|LEFT HAND, FIFTH DIGIT",CASE-26746,APC,26746,CPT,0360,RC,,,F4,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC,832,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],14198.92,,,,,,0,other,4803.31,14198.92,There are no additional notes associated with this service or procedure.
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],20981.60,,"Fee schedule rate ($20,981.60). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,10003.71,23415.63,There are no additional notes associated with this service or procedure.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],105091.76,,"Fee schedule rate ($105,091.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,35719.96,105091.76,There are no additional notes associated with this service or procedure.
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR,518,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],27799.30,,"Case rate ($27,254.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $25,489.62, add-ons for qualifying new technology services are included. If operating cost exceeds $60,360.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,611.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 5.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $23,458.18 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $23,544.67 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,851.08. The transfer capital threshold is the transfer adjustment factor * $1,851.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,13252.00,89342.77,Inpatient DRG
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],26280.60,,,,,,0,other,10989.72,26280.60,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],8563.30,,"Case rate ($8,563.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,101.85, add-ons for qualifying new technology services are included. If operating cost exceeds $42,972.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,244.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $6,134.29 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,156.91 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $484.06. The transfer capital threshold is the transfer adjustment factor * $484.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8563.30,31533.97,Inpatient DRG
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],20846.48,,"Case rate ($20,846.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $19,528.64, add-ons for qualifying new technology services are included. If operating cost exceeds $54,399.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,142.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $17,519.09 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $17,583.69 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,382.43. The transfer capital threshold is the transfer adjustment factor * $1,382.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,20846.48,81306.30,Inpatient DRG
"NEONATE BIRTH WEIGHT > 2499 GRAMS WITH OTHER SIGNIFICANT CONDITION,MAJOR",639,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],17657.19,,"Case rate ($16,816.37). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,16816.37,17657.19,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC,833,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],5760.37,,"Case rate ($5,486.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,239.18, add-ons for qualifying new technology services are included. If operating cost exceeds $40,110.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,018.96, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $3,282.12 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,294.23 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $258.99. The transfer capital threshold is the transfer adjustment factor * $258.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,3041.73,10289.10,Inpatient DRG
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],23262.15,,,,,,0,other,7243.75,23262.15,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],7353.00,,"Per diem ($7,353). If length of stay < 4.1, first 1 days paid at a per diem of $14,706 instead. Capped at $30,145.85.",,,,0,other,7353.00,33398.16,Estimated amount calculated based on 4 day length of stay.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],20401.88,,"Fee schedule rate ($20,401.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,20401.88,There are no additional notes associated with this service or procedure.
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],17003.38,,"Case rate ($16,428.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,418.58, add-ons for qualifying new technology services are included. If operating cost exceeds $50,289.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,819.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $13,424.13 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,473.63 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,059.30. The transfer capital threshold is the transfer adjustment factor * $1,059.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,16428.39,42083.20,Inpatient DRG
MAJOR CHEST TRAUMA WITHOUT CC/MCC,185,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],7271.19,,"Case rate ($7,271.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,899.84, add-ons for qualifying new technology services are included. If operating cost exceeds $41,770.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,149.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,936.68 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,954.88 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $389.55. The transfer capital threshold is the transfer adjustment factor * $389.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7271.19,21771.61,Inpatient DRG
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],15751.44,,,,,,0,other,6965.00,21195.68,There are no additional notes associated with this service or procedure.
PREMATURITY WITH MAJOR PROBLEMS,791,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],3186.77,,,,,,0,other,3048.21,30904.42,Estimated amount calculated based on 5 day length of stay.
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],27433.71,,"Case rate ($26,127.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $24,441.31, add-ons for qualifying new technology services are included. If operating cost exceeds $59,312.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,528.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. The base transfer operating payment is the transfer adjustment factor * $22,413.72 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $22,496.36 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,768.66. The transfer capital threshold is the transfer adjustment factor * $1,768.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,26127.34,90333.60,Inpatient DRG
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],11059.47,,"Case rate ($11,059.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,424, add-ons for qualifying new technology services are included. If operating cost exceeds $45,295.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,426.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $8,447.91 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,479.05 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $666.62. The transfer capital threshold is the transfer adjustment factor * $666.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,11059.47,28423.20,Inpatient DRG
Tenodesis Long Tendon Biceps|LEFT SIDE,CASE-23430,APC,23430,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
Mastopexy,CASE-19316,APC,19316,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7918.25,,"APC Price ($7,650.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,7650.49,7918.25,OPPS APC
NORMAL NEWBORN,795,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],2576.52,,"Fee schedule rate ($2,576.52). Adds an outlier to normal pricing equal to the per diem rate ($414) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,1369.79,5771.52,There are no additional notes associated with this service or procedure.
HC Biopsy/Exc Lymph Node Needle|TECHNICAL COMPONENT|RIGHT SIDE,CASE-38505,APC,38505,CPT,0361,RC,,,TC|RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1623.23,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1545.93,1623.23,OPPS APC
"HEART FAILURE,EXTREME",194,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],22266.50,,"Case rate ($22,266.50). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,22266.50,23379.83,There are no additional notes associated with this service or procedure.
NONTRAUMATIC STUPOR AND COMA WITH MCC,080,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],14699.47,,"Case rate ($14,202.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,347.79, add-ons for qualifying new technology services are included. If operating cost exceeds $48,218.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,656.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $11,360.96 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,402.84 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $896.49. The transfer capital threshold is the transfer adjustment factor * $896.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,14202.39,35615.37,Inpatient DRG
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH MCC",722,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],30233.98,,"Fee schedule rate ($30,233.98). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,14200.37,56869.13,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],28038.61,,"Fee schedule rate ($28,038.61). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12126.09,29582.40,There are no additional notes associated with this service or procedure.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC,027,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],56363.30,,"Fee schedule rate ($56,363.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,19030.20,56363.30,There are no additional notes associated with this service or procedure.
COMPLICATIONS OF TREATMENT WITH CC,920,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],18836.22,,"Fee schedule rate ($18,836.22). Adds an outlier to normal pricing equal to the per diem rate ($49,808.13) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,8732.59,20731.52,There are no additional notes associated with this service or procedure.
"PULMONARY EMBOLISM,MAJOR",134,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],2326.47,,"Case rate for a one day stay ($2,326.47). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,2326.47,2442.79,There are no additional notes associated with this service or procedure.
Egd Balloon Dilation Esophagus <30 Mm Diam,CASE-43249,APC,43249,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1885.95,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1796.14,1885.95,OPPS APC
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],27982.66,,,,,,0,other,11575.50,48961.48,There are no additional notes associated with this service or procedure.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],22158.27,,,,,,0,other,5569.00,40108.48,There are no additional notes associated with this service or procedure.
Laparoscopy W/Rmvl Adnexal Structures|LEFT SIDE,CASE-58661,APC,58661,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5658.76,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5658.76,5941.70,OPPS APC
FRACTURES OF FEMUR WITH MCC,533,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],49490.05,,"Fee schedule rate ($49,490.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,6852.00,49490.05,There are no additional notes associated with this service or procedure.
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],2070.00,,,,,,0,other,1188.00,18893.86,Estimated amount calculated based on 3 day length of stay.
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],2070.00,,,,,,0,other,1188.00,18893.86,Estimated amount calculated based on 3 day length of stay.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],31006.45,,"Case rate ($30,398.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $28,414.67, add-ons for qualifying new technology services are included. If operating cost exceeds $63,285.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,841.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.2. The base transfer operating payment is the transfer adjustment factor * $26,372.48 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $26,469.72 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,081.05. The transfer capital threshold is the transfer adjustment factor * $2,081.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,30398.48,82674.88,Inpatient DRG
UNGROUPABLE,999,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],49746.13,,"Case rate ($47,377.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $44,294.44, add-ons for qualifying new technology services are included. If operating cost exceeds $79,165.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $5,002.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 12.7. The base transfer operating payment is the transfer adjustment factor * $42,189.53 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $42,349.49 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,242.79. The transfer capital threshold is the transfer adjustment factor * $3,242.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10228.00,161307.29,Inpatient DRG
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,025,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],91631.33,,"Fee schedule rate ($91,631.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,13351.00,91631.33,There are no additional notes associated with this service or procedure.
Ercp Destruction/Lithotripsy Calculi Any Method,CASE-43265,APC,43265,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5966.63,,"APC Price ($5,682.51). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5682.51,5966.63,OPPS APC
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC,817,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],43874.75,,"Fee schedule rate ($43,874.75). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,17396.11,44895.04,There are no additional notes associated with this service or procedure.
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],13486.95,,"Fee schedule rate ($13,486.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6915.64,14442.92,There are no additional notes associated with this service or procedure.
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],16438.59,,"Fee schedule rate ($16,438.59). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7402.56,16438.59,There are no additional notes associated with this service or procedure.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],52794.06,,"Fee schedule rate ($52,794.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (37), with a minimum of zero.",,,,0,other,13907.80,52794.06,There are no additional notes associated with this service or procedure.
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],12621.98,,"Case rate ($12,195.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,480.50, add-ons for qualifying new technology services are included. If operating cost exceeds $46,351.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,509.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,500.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,535.55 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $749.68. The transfer capital threshold is the transfer adjustment factor * $749.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,12195.15,39424.57,Inpatient DRG
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],28394.78,,"Fee schedule rate ($28,394.78). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11454.97,28394.78,There are no additional notes associated with this service or procedure.
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],9471.40,,"Case rate ($9,151.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,648.69, add-ons for qualifying new technology services are included. If operating cost exceeds $43,519.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,287.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,679.11 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,703.74 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $527.05. The transfer capital threshold is the transfer adjustment factor * $527.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,9151.11,30245.71,Inpatient DRG
Laps Vaginal Hysterectomy Uterus 250 Gm/<,CASE-58550,APC,58550,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5941.70,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5658.76,5941.70,OPPS APC
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],87909.90,,"Fee schedule rate ($87,909.90). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,33623.33,133270.57,There are no additional notes associated with this service or procedure.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],61290.90,,"Fee schedule rate ($61,290.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,23799.09,63499.65,There are no additional notes associated with this service or procedure.
OTHER CEREBROVASCULAR DISORDERS WITH MCC,070,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],37774.46,,"Fee schedule rate ($37,774.46). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,13219.09,37774.46,There are no additional notes associated with this service or procedure.
"Arthrodesis Interphalangeal Jt W/WO Int Fixj|LEFT HAND, THUMB",CASE-26860,APC,26860,CPT,0360,RC,,,FA,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],21492.53,,"Fee schedule rate ($21,492.53). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,11914.12,40426.76,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],30055.64,,"Fee schedule rate ($30,055.64). Adds an outlier to normal pricing equal to the per diem rate ($74,094.67) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.9), with a minimum of zero.",,,,0,other,12775.53,31469.43,There are no additional notes associated with this service or procedure.
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],41190.50,,"Fee schedule rate ($41,190.50). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,16787.98,62990.26,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITHOUT STERILIZATION WITH CC,787,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],9983.41,,"Case rate ($9,508.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,980.70, add-ons for qualifying new technology services are included. If operating cost exceeds $43,851.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,313.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $7,009.90 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,035.74 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $553.15. The transfer capital threshold is the transfer adjustment factor * $553.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9508.01,23722.94,Inpatient DRG
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC,519,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],50780.20,,"Fee schedule rate ($50,780.20). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,15490.44,50780.20,There are no additional notes associated with this service or procedure.
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],31477.13,,"Fee schedule rate ($31,477.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9648.19,31477.13,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],29241.62,,"Fee schedule rate ($29,241.62). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,12984.79,32077.45,There are no additional notes associated with this service or procedure.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC,862,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],6855.00,,"Per diem ($6,855). If length of stay < 5, first 1 days paid at a per diem of $13,710 instead. Capped at $34,272.79.",,,,0,other,6855.00,35884.94,Estimated amount calculated based on 3 day length of stay.
CESAREAN SECTION WITHOUT STERILIZATION WITH MCC,786,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],23722.94,,"Fee schedule rate ($23,722.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12612.10,23722.94,There are no additional notes associated with this service or procedure.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC",442,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],18157.80,,"Fee schedule rate ($18,157.80). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6607.45,19011.92,There are no additional notes associated with this service or procedure.
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITH MCC,429,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],169317.41,,"Fee schedule rate ($169,317.41). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,62958.58,177294.98,There are no additional notes associated with this service or procedure.
DIABETES WITH CC,638,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],8414.77,,"Case rate ($8,014.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,590.93, add-ons for qualifying new technology services are included. If operating cost exceeds $42,461.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,203.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,625.24 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,645.98 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $443.89. The transfer capital threshold is the transfer adjustment factor * $443.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8014.07,17634.53,Inpatient DRG
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],19822.43,,"Case rate ($19,152.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,952.40, add-ons for qualifying new technology services are included. If operating cost exceeds $52,823.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,018.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $15,948.65 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $16,007.45 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,258.51. The transfer capital threshold is the transfer adjustment factor * $1,258.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,19152.11,53152.12,Inpatient DRG
Vulvectomy Simple Partial,CASE-56620,APC,56620,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3030.03,,"APC Price ($3,030.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3030.03,3181.53,OPPS APC
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,095,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],48575.01,,"Fee schedule rate ($48,575.01). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,19411.47,50750.92,There are no additional notes associated with this service or procedure.
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],22217.08,,"Fee schedule rate ($22,217.08). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.4), with a minimum of zero.",,,,0,other,7243.75,23262.15,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,083,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],6965.00,,,,,,0,other,6965.00,28680.85,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],14871.83,,"Fee schedule rate ($14,871.83). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6558.75,14871.83,There are no additional notes associated with this service or procedure.
Marsupialization Bartholins Gland Cyst|LEFT SIDE,CASE-56440,APC,56440,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3136.08,,"APC Price ($3,030.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3030.03,3181.53,OPPS APC
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],18245.94,,"Fee schedule rate ($18,245.94). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8106.18,18245.94,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],51903.64,,"Fee schedule rate ($51,903.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,16017.99,51903.64,There are no additional notes associated with this service or procedure.
Nasal/Sinus Ndsc Total With Sphenoidotomy|BILATERAL PROCEDURE,CASE-31257,APC,31257,CPT,0360,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6936.25,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6605.95,6936.25,OPPS APC
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],33159.45,,"Fee schedule rate ($33,159.45). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,13092.47,33159.45,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITH MCC,385,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],21593.52,,"Fee schedule rate ($21,593.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11480.01,31134.92,There are no additional notes associated with this service or procedure.
"HC Repair Nail Bed|LEFT HAND, THIRD DIGIT",CASE-11760,APC,11760,CPT,0450,RC,,,F2,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],691.79,,"APC Price ($691.79). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,691.79,726.38,OPPS APC
Egd Transoral Biopsy Single/Multiple,CASE-43239,APC,43239,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],848.96,,"APC Price ($848.96). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,848.96,878.67,OPPS APC
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],62041.12,,"Fee schedule rate ($62,041.12). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,18497.24,62041.12,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],18905.23,,"Fee schedule rate ($18,905.23). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6963.00,18954.85,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],59610.47,,"Fee schedule rate ($59,610.47). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,16129.04,59610.47,There are no additional notes associated with this service or procedure.
"NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY",789,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],6663.33,,,,,,0,other,3054.00,14857.05,Estimated amount calculated based on 1 day length of stay.
Exc B9 Lesion Mrgn Xcp Sk Tg S/N/H/F/G 0.6-1.0cm,CASE-11421,APC,11421,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],686.03,,"APC Price ($662.83). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,662.83,695.97,OPPS APC
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],14699.43,,"Fee schedule rate ($14,699.43). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6683.37,14699.43,There are no additional notes associated with this service or procedure.
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],15177.23,,"Fee schedule rate ($15,177.23). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,7414.07,18217.52,There are no additional notes associated with this service or procedure.
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],40426.76,,"Fee schedule rate ($40,426.76). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,11914.12,40426.76,There are no additional notes associated with this service or procedure.
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],35419.59,,"Fee schedule rate ($35,419.59). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,7086.00,57872.02,There are no additional notes associated with this service or procedure.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],14699.43,,"Fee schedule rate ($14,699.43). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6683.37,14699.43,There are no additional notes associated with this service or procedure.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],9977.99,,"Case rate ($9,977.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,417.91, add-ons for qualifying new technology services are included. If operating cost exceeds $44,288.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,347.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $7,445.51 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,472.96 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $587.52. The transfer capital threshold is the transfer adjustment factor * $587.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9977.99,26949.28,Inpatient DRG
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],34406.22,,"Fee schedule rate ($34,406.22). Adds an outlier to normal pricing equal to the per diem rate ($49,808.13) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,14343.25,36024.65,There are no additional notes associated with this service or procedure.
Transurethral Resection Bladder Neck,CASE-52500,APC,52500,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3414.95,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3299.47,3464.44,OPPS APC
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],18245.94,,"Fee schedule rate ($18,245.94). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8106.18,18245.94,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,064,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],16341.76,,"Case rate ($15,563.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,614.08, add-ons for qualifying new technology services are included. If operating cost exceeds $49,485.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,756.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $12,622.59 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,669.13 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $996.05. The transfer capital threshold is the transfer adjustment factor * $996.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,15563.58,41838.16,Inpatient DRG
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],23078.81,,"Fee schedule rate ($23,078.81). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10311.17,24308.97,There are no additional notes associated with this service or procedure.
HC Joint Injection/Aspir Large WO US|RIGHT SIDE|PBB CHARGE,CASE-20610,APC,20610,CPT,0510,RC,,,RT|PBB,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],297.37,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,287.31,301.68,OPPS APC
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7344.86,,"Case rate ($6,995.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,652.42, add-ons for qualifying new technology services are included. If operating cost exceeds $41,523.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,120.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $4,689.69 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,707.47 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $360.46. The transfer capital threshold is the transfer adjustment factor * $360.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,16400.70,Inpatient DRG
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],80635.65,,"Fee schedule rate ($80,635.65). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,26028.48,80635.65,There are no additional notes associated with this service or procedure.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],8876.85,,"Case rate ($8,702.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,231.63, add-ons for qualifying new technology services are included. If operating cost exceeds $43,102.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,254.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,263.59 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,286.68 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $494.26. The transfer capital threshold is the transfer adjustment factor * $494.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,5683.00,19635.68,Inpatient DRG
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],2070.00,,,,,,0,other,1188.00,18893.86,Estimated amount calculated based on 3 day length of stay.
VAGINAL DELIVERY WITH O.R. PROCEDURES EXCEPT STERILIZATION AND/OR D&C,768,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],12088.81,,"Fee schedule rate ($12,088.81). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6426.91,13416.00,There are no additional notes associated with this service or procedure.
Rpr Recrt Ingun Hernia Any Age Incarcerated,CASE-49521,APC,49521,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6059.65,,"APC Price ($6,059.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6059.65,6362.63,OPPS APC
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,073,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],31567.81,,,,,,0,other,12809.38,43475.01,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],40737.46,,"Fee schedule rate ($40,737.46). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,7665.00,40737.46,There are no additional notes associated with this service or procedure.
NORMAL NEWBORN,795,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3413.44,,"Case rate ($3,298.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $3,203.67, add-ons for qualifying new technology services are included. If operating cost exceeds $38,074.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $1,858.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $1,254.10 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $1,258.72 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $98.96. The transfer capital threshold is the transfer adjustment factor * $98.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,1369.79,5771.52,Inpatient DRG
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC,519,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],50780.20,,"Fee schedule rate ($50,780.20). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,15490.44,50780.20,There are no additional notes associated with this service or procedure.
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],36024.65,,,,,,0,other,14343.25,36024.65,There are no additional notes associated with this service or procedure.
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC",011,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],83140.05,,"Fee schedule rate ($83,140.05). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (44), with a minimum of zero.",,,,0,other,38880.49,150008.48,There are no additional notes associated with this service or procedure.
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],9696.93,,"Case rate ($9,696.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,156.46, add-ons for qualifying new technology services are included. If operating cost exceeds $44,027.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,326.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $7,185.02 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,211.51 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $566.97. The transfer capital threshold is the transfer adjustment factor * $566.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9696.93,35061.53,Inpatient DRG
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,069,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],7722.19,,"Case rate ($7,354.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,977.32, add-ons for qualifying new technology services are included. If operating cost exceeds $41,848.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,155.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $5,013.88 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,032.37 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $395.65. The transfer capital threshold is the transfer adjustment factor * $395.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,20333.68,Inpatient DRG
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC",011,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],150008.48,,"Fee schedule rate ($150,008.48). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (44), with a minimum of zero.",,,,0,other,38880.49,150008.48,There are no additional notes associated with this service or procedure.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],41648.41,,"Case rate ($23,799.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $22,275.40, add-ons for qualifying new technology services are included. If operating cost exceeds $57,146.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,358.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.1. The base transfer operating payment is the transfer adjustment factor * $20,255.77 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $20,330.45 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,598.38. The transfer capital threshold is the transfer adjustment factor * $1,598.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,23799.09,63499.65,All Other Inpatient
MAJOR THUMB OR JOINT PROCEDURES,506,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],11354.12,,"Case rate ($10,813.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,211.67, add-ons for qualifying new technology services are included. If operating cost exceeds $45,082.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,392.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $8,235.50 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,266.72 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $633.00. The transfer capital threshold is the transfer adjustment factor * $633.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,11081.83,26548.21,Inpatient DRG
HEADACHES WITHOUT MCC,103,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],7608.43,,"Case rate ($7,608.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,213.57, add-ons for qualifying new technology services are included. If operating cost exceeds $42,084.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,174.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $5,249.26 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,268.62 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $414.22. The transfer capital threshold is the transfer adjustment factor * $414.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,20883.08,Inpatient DRG
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],40918.00,,"Fee schedule rate ($40,918.00). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,16689.78,59521.43,There are no additional notes associated with this service or procedure.
Chemodenervation Muscle Neck Unilat for Dystonia|BILATERAL PROCEDURE,CASE-64616,APC,64616,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC,087,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],8302.15,,"Case rate ($8,139.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,707.48, add-ons for qualifying new technology services are included. If operating cost exceeds $42,578.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,213.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $5,741.36 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,762.53 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $453.05. The transfer capital threshold is the transfer adjustment factor * $453.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,8139.36,22679.07,Inpatient DRG
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],18341.97,,"Fee schedule rate ($18,341.97). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.9), with a minimum of zero.",,,,0,other,8554.50,19204.75,There are no additional notes associated with this service or procedure.
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],15800.93,,"Case rate ($15,491.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,546.67, add-ons for qualifying new technology services are included. If operating cost exceeds $49,417.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,750.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $12,555.42 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,601.72 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $990.75. The transfer capital threshold is the transfer adjustment factor * $990.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,15491.11,54180.83,Inpatient DRG
HC Drain/Inj Joint/Bursa W/US Large|PBB CHARGE|LEFT SIDE,CASE-20611,APC,20611,CPT,0510,RC,,,PBB|LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],297.37,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,287.31,301.68,OPPS APC
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,690,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],14625.55,,"Fee schedule rate ($14,625.55). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7426.94,15928.53,There are no additional notes associated with this service or procedure.
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",004,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],10715.36,,,,,,0,other,10249.47,272554.00,Estimated amount calculated based on 6 day length of stay.
Hemorrhoid Ntrnl & Xtrnl 1 Column W/Fissurecto,CASE-46257,APC,46257,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],2598.08,,"APC Price ($2,598.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2598.08,2727.99,OPPS APC
"Correction Hammertoe|RIGHT FOOT, SECOND DIGIT",CASE-28285,APC,28285,CPT,0360,RC,,,T6,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
HC Injection Small Joint/Bursa|PBB CHARGE,CASE-20600,APC,20600,CPT,0361,RC,,,PBB,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],297.37,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,287.31,301.68,OPPS APC
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITH MCC OR ANTINEOPLASTIC IMPLANT OR EPILEPSY WITH NEUROSTIMULATOR,023,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],41565.97,,"Case rate ($40,750.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $38,045.35, add-ons for qualifying new technology services are included. If operating cost exceeds $72,916.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,598.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $35,967.78 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $36,100.40 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,838.21. The transfer capital threshold is the transfer adjustment factor * $2,838.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 102%.",,,,0,other,15168.00,136379.44,Inpatient DRG
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],22557.82,,"Fee schedule rate ($22,557.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6801.88,22557.82,There are no additional notes associated with this service or procedure.
"ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",770,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],18843.74,,"Fee schedule rate ($18,843.74). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,8735.30,19730.13,There are no additional notes associated with this service or procedure.
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],33188.44,,"Fee schedule rate ($33,188.44). Adds an outlier to normal pricing equal to the per diem rate ($84,167.29) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.5), with a minimum of zero.",,,,0,other,13904.43,34749.58,There are no additional notes associated with this service or procedure.
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],6965.00,,,,,,0,other,5139.72,13110.79,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITHOUT CC/MCC,428,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],110624.09,,,,,,0,other,40017.53,118904.57,There are no additional notes associated with this service or procedure.
"Exc Tum/Vasc Mal Sft Tiss Hand/Fngr Subq <1.5cm|RIGHT HAND, THIRD DIGIT",CASE-26115,APC,26115,CPT,0360,RC,,,F7,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1600.04,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1545.93,1623.23,OPPS APC
RESPIRATORY NEOPLASMS WITH CC,181,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],17609.39,,"Fee schedule rate ($17,609.39). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9197.84,21074.07,There are no additional notes associated with this service or procedure.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC",061,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],21071.18,,"Case rate ($20,067.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $18,838.06, add-ons for qualifying new technology services are included. If operating cost exceeds $53,709.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,053.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $16,829.30 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $16,893.11 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,293.54. The transfer capital threshold is the transfer adjustment factor * $1,293.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,20616.23,62315.82,Inpatient DRG
HC Inj Lympho for Sentinal Node,CASE-38792,APC,38792,CPT,0361,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6432.89,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6215.36,6526.12,OPPS APC
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC,797,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],9155.71,,"Case rate ($8,719.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,247.38, add-ons for qualifying new technology services are included. If operating cost exceeds $43,118.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,255.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $6,279.28 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,302.43 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $495.50. The transfer capital threshold is the transfer adjustment factor * $495.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8719.72,20928.55,Inpatient DRG
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],42021.93,,"Fee schedule rate ($42,021.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,21248.73,56089.29,There are no additional notes associated with this service or procedure.
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],38839.49,,"Fee schedule rate ($38,839.49). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.6), with a minimum of zero.",,,,0,other,15940.79,53275.26,There are no additional notes associated with this service or procedure.
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],17123.74,,"Case rate ($16,787.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,753.10, add-ons for qualifying new technology services are included. If operating cost exceeds $50,624.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,845.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $13,757.43 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,808.15 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,085.60. The transfer capital threshold is the transfer adjustment factor * $1,085.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,16787.98,62990.26,Inpatient DRG
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],16283.24,,"Fee schedule rate ($16,283.24). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7875.94,17233.12,There are no additional notes associated with this service or procedure.
PREMATURITY WITHOUT MAJOR PROBLEMS,792,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],11512.88,,"Fee schedule rate ($11,512.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,1956.00,19457.66,There are no additional notes associated with this service or procedure.
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC",458,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],132827.25,,"Fee schedule rate ($132,827.25). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,30202.09,132827.25,There are no additional notes associated with this service or procedure.
"Corrj Hallux Valgus W/Sesmdc W/Dist Metar Osteot|RIGHT FOOT, GREAT TOE",CASE-28296,APC,28296,CPT,0360,RC,,,T5,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],46523.26,,"Fee schedule rate ($46,523.26). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,17782.11,46523.26,There are no additional notes associated with this service or procedure.
HC Incis/Drain Scrotum/Testis Epididym,CASE-54700,APC,54700,CPT,0450,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],2025.13,,"APC Price ($1,956.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1956.65,2054.48,OPPS APC
Cystourethroscopy Inj Chemodenervation Bladder|SEPARATE STRUCTURE,CASE-52287,APC,52287,CPT,0360,RC,,,XS,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3299.47,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3299.47,3464.44,OPPS APC
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],62990.26,,"Fee schedule rate ($62,990.26). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,16787.98,62990.26,There are no additional notes associated with this service or procedure.
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],28804.77,,"Fee schedule rate ($28,804.77). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,15491.11,54180.83,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],41402.42,,"Fee schedule rate ($41,402.42). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,15456.59,41402.42,There are no additional notes associated with this service or procedure.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,191,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],13394.17,,"Case rate ($7,653.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,255.78, add-ons for qualifying new technology services are included. If operating cost exceeds $42,126.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,177.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,291.32 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,310.83 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $417.54. The transfer capital threshold is the transfer adjustment factor * $417.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,6965.00,16612.88,All Other Inpatient
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],6965.00,,,,,,0,other,6164.03,14071.02,There are no additional notes associated with this service or procedure.
"HYPOVOLEMIA AND RELATED ELECTROLYTE DISORDERS,MODERATE",422,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],1923.79,,"Case rate for a one day stay ($1,923.79). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,1923.79,2019.98,There are no additional notes associated with this service or procedure.
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],5280.00,,"Per diem ($5,280). If length of stay < 3.1, first 1 days paid at a per diem of $10,560 instead. Capped at $16,366.82.",,,,0,other,5280.00,17136.70,Estimated amount calculated based on 3 day length of stay.
GASTROINTESTINAL HEMORRHAGE WITH MCC,377,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],31575.65,,"Fee schedule rate ($31,575.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,7634.00,35969.56,There are no additional notes associated with this service or procedure.
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],14492.93,,"Fee schedule rate ($14,492.93). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6503.90,14492.93,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],43703.12,,"Fee schedule rate ($43,703.12). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.7), with a minimum of zero.",,,,0,other,17693.40,52449.26,There are no additional notes associated with this service or procedure.
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6683.19,,"Case rate ($6,457.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,142.59, add-ons for qualifying new technology services are included. If operating cost exceeds $41,013.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,089.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $4,182.21 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,197.63 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $330.02. The transfer capital threshold is the transfer adjustment factor * $330.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,5139.72,13110.79,Inpatient DRG
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],18918.49,,"Fee schedule rate ($18,918.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9282.47,21320.03,There are no additional notes associated with this service or procedure.
OTHER CEREBROVASCULAR DISORDERS WITH CC,071,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],29215.10,,"Fee schedule rate ($29,215.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5843.00,29215.10,There are no additional notes associated with this service or procedure.
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC",629,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],40946.19,,"Fee schedule rate ($40,946.19). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,16699.94,44657.18,There are no additional notes associated with this service or procedure.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,056,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],59328.19,,"Fee schedule rate ($59,328.19). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (44), with a minimum of zero.",,,,0,other,7659.00,59328.19,There are no additional notes associated with this service or procedure.
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],24308.97,,,,,,0,other,10311.17,24308.97,There are no additional notes associated with this service or procedure.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],41669.98,,,,,,0,other,16286.16,58320.32,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],47751.13,,"Fee schedule rate ($47,751.13). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.7), with a minimum of zero.",,,,0,other,19152.11,53152.12,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],19458.27,,"Fee schedule rate ($19,458.27). Adds an outlier to normal pricing equal to the per diem rate ($75,355.48) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,8956.76,28983.97,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],18311.90,,"Fee schedule rate ($18,311.90). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8543.64,23239.84,There are no additional notes associated with this service or procedure.
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],25863.45,,,,,,0,other,10846.16,25863.45,There are no additional notes associated with this service or procedure.
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],6965.00,,,,,,0,other,6965.00,17467.27,There are no additional notes associated with this service or procedure.
Injection Aa&/Strd Genicular Nrv Branches W/Img|BILATERAL PROCEDURE,CASE-64454,APC,64454,CPT,0360,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],683.85,,"APC Price ($660.72). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,660.72,693.76,OPPS APC
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],16428.39,,"Case rate ($16,428.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,418.58, add-ons for qualifying new technology services are included. If operating cost exceeds $50,289.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,819.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $13,424.13 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,473.63 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,059.30. The transfer capital threshold is the transfer adjustment factor * $1,059.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,16428.39,42083.20,Inpatient DRG
MINOR BLADDER PROCEDURES WITHOUT CC/MCC,664,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],9350.84,,"Case rate ($9,034.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,540.33, add-ons for qualifying new technology services are included. If operating cost exceeds $43,411.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,278.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $6,571.15 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,595.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $518.53. The transfer capital threshold is the transfer adjustment factor * $518.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,9034.63,31876.87,Inpatient DRG
VENTRICULAR SHUNT PROCEDURES WITH CC,032,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],17195.03,,"Case rate ($16,376.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,370.06, add-ons for qualifying new technology services are included. If operating cost exceeds $50,241.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,815.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $13,375.80 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,425.12 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,055.48. The transfer capital threshold is the transfer adjustment factor * $1,055.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,16376.22,46275.08,Inpatient DRG
HC Bx Breast 1st Lesion US Img|LEFT SIDE,CASE-19083,APC,19083,CPT,0361,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1545.93,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1545.93,1623.23,OPPS APC
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],90333.60,,"Fee schedule rate ($90,333.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,26127.34,90333.60,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,065,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],8786.76,,"Case rate ($8,786.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,309.75, add-ons for qualifying new technology services are included. If operating cost exceeds $43,180.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,260.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,341.42 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,364.80 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $500.40. The transfer capital threshold is the transfer adjustment factor * $500.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8786.76,25681.86,Inpatient DRG
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],8268.30,,"Case rate ($8,106.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,676.61, add-ons for qualifying new technology services are included. If operating cost exceeds $42,547.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,210.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,710.61 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,731.66 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $450.62. The transfer capital threshold is the transfer adjustment factor * $450.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,8106.18,18245.94,Inpatient DRG
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],19371.27,,"Fee schedule rate ($19,371.27). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8643.20,19462.52,There are no additional notes associated with this service or procedure.
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],59494.91,,"Fee schedule rate ($59,494.91). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,18594.09,59494.91,There are no additional notes associated with this service or procedure.
Exc Prtd Tum/Prtd Glnd Lat Dsj&Prsrv Facial Nr|RIGHT SIDE,CASE-42415,APC,42415,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5541.10,,"APC Price ($5,541.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5541.10,5818.16,OPPS APC
NON-MALIGNANT BREAST DISORDERS WITH CC/MCC,600,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],8339.10,,"Fee schedule rate ($8,339.10). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7999.14,20495.56,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,085,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],31837.05,,"Fee schedule rate ($31,837.05). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,9282.00,57443.16,There are no additional notes associated with this service or procedure.
"ALCOHOL ABUSE AND DEPENDENCE,EXTREME",775,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],25694.91,,"Case rate ($24,471.34). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,24471.34,25694.91,There are no additional notes associated with this service or procedure.
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC",923,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],6965.00,,,,,,0,other,6965.00,20068.57,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],17651.07,,"Fee schedule rate ($17,651.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,6564.18,17651.07,There are no additional notes associated with this service or procedure.
"Tendon Sheath Incision|LEFT HAND, THIRD DIGIT",CASE-26055,APC,26055,CPT,0360,RC,,,F2,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1827.80,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1827.80,1919.19,OPPS APC
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],9218.36,,"Case rate ($8,906.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,421.26, add-ons for qualifying new technology services are included. If operating cost exceeds $43,292.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,269.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $6,452.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,476.31 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $509.17. The transfer capital threshold is the transfer adjustment factor * $509.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,8906.63,28434.57,Inpatient DRG
VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC,033,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],13206.23,,"Case rate ($13,206.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,421.07, add-ons for qualifying new technology services are included. If operating cost exceeds $47,292.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,583.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $10,437.64 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,476.13 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $823.63. The transfer capital threshold is the transfer adjustment factor * $823.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,13206.23,42156.44,Inpatient DRG
DIABETES WITH CC,638,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],15195.79,,"Fee schedule rate ($15,195.79). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8014.07,17634.53,There are no additional notes associated with this service or procedure.
Unlisted Laparoscopic Procedure Liver,CASE-47379,APC,47379,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5941.70,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5658.76,5941.70,OPPS APC
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],10638.94,,"Case rate ($10,638.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,032.78, add-ons for qualifying new technology services are included. If operating cost exceeds $44,903.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,395.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,058.12 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,087.83 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $635.87. The transfer capital threshold is the transfer adjustment factor * $635.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10638.94,25261.33,Inpatient DRG
HC Bx Breast 1st Lesion US Img|BILATERAL PROCEDURE,CASE-19083,APC,19083,CPT,0361,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],2854.83,,"APC Price ($2,718.88). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2718.88,2854.83,OPPS APC
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],32553.63,,,,,,0,other,13148.66,32553.63,There are no additional notes associated with this service or procedure.
Posterior Segmental Instrumentation 3-6 Vrt Seg,CASE-22842,APC,22842,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],16412.07,,"APC Price ($16,412.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,16412.07,16986.50,OPPS APC
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],8842.67,,"Case rate ($8,543.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,083.58, add-ons for qualifying new technology services are included. If operating cost exceeds $42,954.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,242.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,116.09 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,138.64 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $482.62. The transfer capital threshold is the transfer adjustment factor * $482.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,8543.64,23239.84,Inpatient DRG
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],34245.00,,"Fee schedule rate ($34,245.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,12725.42,34245.00,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],24675.88,,"Fee schedule rate ($24,675.88). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10834.64,25830.00,There are no additional notes associated with this service or procedure.
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC",629,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],44657.18,,"Fee schedule rate ($44,657.18). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,16699.94,44657.18,There are no additional notes associated with this service or procedure.
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],15341.29,,"Case rate ($14,610.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,727.68, add-ons for qualifying new technology services are included. If operating cost exceeds $48,598.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,686.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.6. The base transfer operating payment is the transfer adjustment factor * $11,739.44 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,782.73 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $926.36. The transfer capital threshold is the transfer adjustment factor * $926.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6277.00,36801.89,Inpatient DRG
"RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT > 96 HOURS,MAJOR",130,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],45448.49,,"Case rate ($45,448.49). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,45448.49,47720.91,There are no additional notes associated with this service or procedure.
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],27222.08,,"Fee schedule rate ($27,222.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7389.00,37134.43,There are no additional notes associated with this service or procedure.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],19849.17,,"Fee schedule rate ($19,849.17). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,9097.60,21455.22,There are no additional notes associated with this service or procedure.
Arthrodesis Combined Tq 1ntrspc Lumbar,CASE-22633,APC,22633,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],25398.09,,"APC Price ($25,398.09). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,25398.09,26668.00,OPPS APC
Nasal/Sinus Ndsc Tot W/Sphendt W/Sphen Tiss Rmvl|RIGHT SIDE,CASE-31259,APC,31259,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6605.95,,"APC Price ($6,605.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6605.95,6936.25,OPPS APC
NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,601,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],6344.15,,"Case rate ($6,042.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,756.39, add-ons for qualifying new technology services are included. If operating cost exceeds $40,627.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,059.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $3,797.45 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,811.45 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $299.66. The transfer capital threshold is the transfer adjustment factor * $299.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6042.05,12359.72,Inpatient DRG
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],33159.45,,"Fee schedule rate ($33,159.45). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,13092.47,33159.45,There are no additional notes associated with this service or procedure.
Nasal/Sinus Ndsc Tot W/Sphendt W/Sphen Tiss Rmvl|RIGHT SIDE,CASE-31259,APC,31259,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6936.25,,"APC Price ($6,605.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6605.95,6936.25,OPPS APC
"NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY",789,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],14149.57,,"Case rate ($14,149.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,298.65, add-ons for qualifying new technology services are included. If operating cost exceeds $48,169.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,652.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $11,312.00 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,353.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $892.63. The transfer capital threshold is the transfer adjustment factor * $892.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,3054.00,14857.05,Inpatient DRG
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],20170.75,,"Fee schedule rate ($20,170.75). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10048.39,23545.50,There are no additional notes associated with this service or procedure.
"INFECTIOUS AND PARASITIC DISEASES INCLUDING HIV WITH O.R. PROCEDURE,MAJOR",710,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],30930.59,,"Case rate ($29,457.70). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,29457.70,30930.59,There are no additional notes associated with this service or procedure.
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],7990.62,,"Case rate ($7,833.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,423.35, add-ons for qualifying new technology services are included. If operating cost exceeds $42,294.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,190.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,458.28 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,478.41 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $430.71. The transfer capital threshold is the transfer adjustment factor * $430.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,5883.03,17111.12,Inpatient DRG
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC",514,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],22699.91,,"Fee schedule rate ($22,699.91). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8868.04,22699.91,There are no additional notes associated with this service or procedure.
"CARDIAC ARREST, UNEXPLAINED WITH MCC",296,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],29352.79,,"Fee schedule rate ($29,352.79). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.2), with a minimum of zero.",,,,0,other,12522.25,36459.67,There are no additional notes associated with this service or procedure.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],45845.03,,"Fee schedule rate ($45,845.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,18598.83,48389.68,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,065,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],13653.54,,"Fee schedule rate ($13,653.54). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,8786.76,25681.86,There are no additional notes associated with this service or procedure.
FULL TERM NEONATE WITH MAJOR PROBLEMS,793,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],78359.29,,"Fee schedule rate ($78,359.29). Adds an outlier to normal pricing equal to the per diem rate ($27,082.03) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.7), with a minimum of zero.",,,,0,other,4302.90,82045.22,There are no additional notes associated with this service or procedure.
SKIN ULCERS WITH MCC,592,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],38644.05,,"Fee schedule rate ($38,644.05). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15), with a minimum of zero.",,,,0,other,15116.17,38644.05,There are no additional notes associated with this service or procedure.
HC N Block Inj Suprascapular Nerv|RIGHT SIDE,CASE-64418,APC,64418,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],683.85,,"APC Price ($660.72). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,660.72,693.76,OPPS APC
Correction Hammertoe|LEFT SIDE,CASE-28285,APC,28285,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
Nasal/Sinus Ndsc Tot W/Sphendt W/Sphen Tiss Rmvl|RIGHT SIDE,CASE-31259,APC,31259,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6605.95,,"APC Price ($6,605.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6605.95,6936.25,OPPS APC
NORMAL NEWBORN,795,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],3462.91,,"Case rate ($3,298.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $3,203.67, add-ons for qualifying new technology services are included. If operating cost exceeds $38,074.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $1,858.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $1,254.10 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $1,258.72 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $98.96. The transfer capital threshold is the transfer adjustment factor * $98.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,1369.79,5771.52,Inpatient DRG
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],18043.23,,"Fee schedule rate ($18,043.23). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7733.72,18043.23,There are no additional notes associated with this service or procedure.
Neuroplasty &/Transpos Median Nrv Carpal Tunne|BILATERAL PROCEDURE,CASE-64721,APC,64721,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1827.80,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1827.80,1919.19,OPPS APC
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],11586.05,,"Case rate ($11,194.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,549.37, add-ons for qualifying new technology services are included. If operating cost exceeds $45,420.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,436.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $8,572.81 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,604.42 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $676.48. The transfer capital threshold is the transfer adjustment factor * $676.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,11194.25,36094.03,Inpatient DRG
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],16804.22,,"Fee schedule rate ($16,804.22). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7238.69,16804.22,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,555,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],26009.06,,,,,,0,other,10896.27,42290.95,There are no additional notes associated with this service or procedure.
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC",629,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],44657.18,,"Fee schedule rate ($44,657.18). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,16699.94,44657.18,There are no additional notes associated with this service or procedure.
Ercp W/Biopsy Single/Multiple,CASE-43261,APC,43261,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3789.26,,"APC Price ($3,608.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3608.81,3789.26,OPPS APC
MAJOR BLADDER PROCEDURES WITH MCC,653,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],66638.04,,"Fee schedule rate ($66,638.04). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,10280.00,125343.98,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,065,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],25681.86,,"Fee schedule rate ($25,681.86). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,8786.76,25681.86,There are no additional notes associated with this service or procedure.
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC,520,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],28074.86,,"Fee schedule rate ($28,074.86). Adds an outlier to normal pricing equal to the per diem rate ($68,872.56) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,12061.74,39786.42,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],31044.77,,"Fee schedule rate ($31,044.77). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,9370.00,65732.99,There are no additional notes associated with this service or procedure.
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],10638.94,,"Case rate ($10,638.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,032.78, add-ons for qualifying new technology services are included. If operating cost exceeds $44,903.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,395.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,058.12 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,087.83 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $635.87. The transfer capital threshold is the transfer adjustment factor * $635.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10638.94,25261.33,Inpatient DRG
"Tendon Sheath Incision|LEFT HAND, THUMB|UNUSUAL NON-OVERLAPPING SERVICE",CASE-26055,APC,26055,CPT,0360,RC,,,FA|XU,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
"VAGINAL DELIVERY,MINOR",560,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],3720.04,,"Case rate ($3,720.04). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,3720.04,3906.04,There are no additional notes associated with this service or procedure.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],35389.50,,"Case rate ($35,389.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $33,057.71, add-ons for qualifying new technology services are included. If operating cost exceeds $67,928.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,206.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.3. The base transfer operating payment is the transfer adjustment factor * $30,998.46 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $31,112.76 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,446.08. The transfer capital threshold is the transfer adjustment factor * $2,446.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,35389.50,101083.00,Inpatient DRG
Unlisted Laparoscopic Procedure Liver,CASE-47379,APC,47379,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5658.76,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5658.76,5941.70,OPPS APC
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC,832,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],13561.03,,"Fee schedule rate ($13,561.03). Adds an outlier to normal pricing equal to the per diem rate ($18,253.69) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,4803.31,14198.92,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],6340.03,,"Case rate ($6,340.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,033.60, add-ons for qualifying new technology services are included. If operating cost exceeds $40,904.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,081.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $4,073.62 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,088.64 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $321.45. The transfer capital threshold is the transfer adjustment factor * $321.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6340.03,15076.44,Inpatient DRG
"POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT PROCEDURE,MINOR",561,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],1349.01,,"Case rate for a one day stay ($1,349.01). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,1349.01,1416.46,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],11945.95,,"Case rate ($11,945.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,248.66, add-ons for qualifying new technology services are included. If operating cost exceeds $46,119.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,491.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $9,269.54 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,303.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $731.46. The transfer capital threshold is the transfer adjustment factor * $731.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6167.00,29058.99,Inpatient DRG
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],6965.00,,,,,,0,other,6965.00,20401.88,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITHOUT STERILIZATION WITH MCC,786,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],23722.94,,"Fee schedule rate ($23,722.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12612.10,23722.94,There are no additional notes associated with this service or procedure.
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],21534.68,,"Case rate ($12,305.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,583.18, add-ons for qualifying new technology services are included. If operating cost exceeds $46,454.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,517.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $9,602.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,638.24 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $757.76. The transfer capital threshold is the transfer adjustment factor * $757.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,12305.53,30103.84,All Other Inpatient
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH CC,427,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],142040.39,,,,,,0,other,50829.82,142040.39,There are no additional notes associated with this service or procedure.
NEONATE WITH OTHER SIGNIFICANT PROBLEMS,794,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],3383.58,,"Fee schedule rate ($3,383.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,1798.85,12536.83,There are no additional notes associated with this service or procedure.
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],35419.59,,"Fee schedule rate ($35,419.59). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,7086.00,57872.02,There are no additional notes associated with this service or procedure.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],62454.12,,"Fee schedule rate ($62,454.12). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11348.00,62454.12,There are no additional notes associated with this service or procedure.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH CC,026,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],33601.03,,"Fee schedule rate ($33,601.03). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,23000.66,63202.45,There are no additional notes associated with this service or procedure.
NEONATE WITH OTHER SIGNIFICANT PROBLEMS,794,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],12357.73,,"Case rate ($11,939.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,242.99, add-ons for qualifying new technology services are included. If operating cost exceeds $46,114.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,490.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $9,263.89 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,298.04 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $731.01. The transfer capital threshold is the transfer adjustment factor * $731.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,1798.85,12536.83,Inpatient DRG
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],52699.33,,"Fee schedule rate ($52,699.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,18105.81,52699.33,There are no additional notes associated with this service or procedure.
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],16804.22,,"Fee schedule rate ($16,804.22). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7238.69,16804.22,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],84226.47,,"Fee schedule rate ($84,226.47). Adds an outlier to normal pricing equal to the per diem rate ($75,906.87) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14.7), with a minimum of zero.",,,,0,other,32296.02,88188.38,There are no additional notes associated with this service or procedure.
CHOLECYSTECTOMY WITH C.D.E. WITH MCC,411,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],88615.28,,"Fee schedule rate ($88,615.28). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,24315.13,88615.28,There are no additional notes associated with this service or procedure.
Wmhc Perc Implant Stim Lead Ea,CASE-63650,APC,63650,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5965.28,,"APC Price ($5,965.28). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5965.28,6263.54,OPPS APC
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],18815.22,,"Case rate ($18,178.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,047.10, add-ons for qualifying new technology services are included. If operating cost exceeds $51,918.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,947.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $15,046.67 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,102.15 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,187.33. The transfer capital threshold is the transfer adjustment factor * $1,187.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,18178.96,54764.34,Inpatient DRG
SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS,029,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],13641.00,,"Per diem ($13,641). If length of stay < 4.7, first 1 days paid at a per diem of $27,282 instead. Capped at $64,114.20.",,,,0,other,13641.00,67130.05,Estimated amount calculated based on 5 day length of stay.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC",281,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],23859.35,,"Fee schedule rate ($23,859.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8169.15,23859.35,There are no additional notes associated with this service or procedure.
OTHER CEREBROVASCULAR DISORDERS WITH CC,071,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],5843.00,,"Per diem ($5,843). If length of stay < 3.3, first 1 days paid at a per diem of $11,686 instead. Capped at $19,281.62.",,,,0,other,5843.00,29215.10,Estimated amount calculated based on 3 day length of stay.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,098,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],38799.38,,"Fee schedule rate ($38,799.38). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,6965.00,45156.75,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],41030.48,,,,,,0,other,6965.00,41030.48,There are no additional notes associated with this service or procedure.
NORMAL NEWBORN,795,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],2576.52,,"Fee schedule rate ($2,576.52). Adds an outlier to normal pricing equal to the per diem rate ($414) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,1369.79,5771.52,There are no additional notes associated with this service or procedure.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC",494,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],39945.55,,"Fee schedule rate ($39,945.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,15533.10,39945.55,There are no additional notes associated with this service or procedure.
DIABETES WITHOUT CC/MCC,639,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6329.61,,"Case rate ($6,028.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,751.12, add-ons for qualifying new technology services are included. If operating cost exceeds $40,622.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,051.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $3,791.80 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,806.17 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $291.45. The transfer capital threshold is the transfer adjustment factor * $291.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6151.76,12223.35,Inpatient DRG
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],20297.68,,"Fee schedule rate ($20,297.68). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6965.00,21404.64,There are no additional notes associated with this service or procedure.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,761,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],5808.41,,"Case rate ($5,808.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,539.05, add-ons for qualifying new technology services are included. If operating cost exceeds $40,410.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,042.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $3,580.90 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,594.10 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $282.57. The transfer capital threshold is the transfer adjustment factor * $282.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,5808.41,11946.72,Inpatient DRG
Hemorrhoidectomy Int & Xtrnl 2/> Column/Gro,CASE-46260,APC,46260,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],2598.08,,"APC Price ($2,598.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2598.08,2727.99,OPPS APC
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,426,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],78112.92,,"Case rate ($76,581.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $71,377.56, add-ons for qualifying new technology services are included. If operating cost exceeds $106,248.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $7,218.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $69,177.55 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $69,432.61 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $5,458.79. The transfer capital threshold is the transfer adjustment factor * $5,458.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,76581.29,216864.15,Inpatient DRG
"SEPTICEMIA AND DISSEMINATED INFECTIONS,EXTREME",720,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],24856.17,,"The inlier payment is calculated as the lesser of the standard DRG payment $24,856.17 and the transfer payment, which is a per diem of $2,401.56. If cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,24856.17,26098.98,Estimated amount calculated based on 2 day length of stay.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],17620.75,,,,,,0,other,8009.34,19877.10,There are no additional notes associated with this service or procedure.
FULL TERM NEONATE WITH MAJOR PROBLEMS,793,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],78359.29,,"Fee schedule rate ($78,359.29). Adds an outlier to normal pricing equal to the per diem rate ($27,082.03) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.7), with a minimum of zero.",,,,0,other,4302.90,82045.22,There are no additional notes associated with this service or procedure.
VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC,033,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],31250.88,,"Fee schedule rate ($31,250.88). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7.9), with a minimum of zero.",,,,0,other,13206.23,42156.44,There are no additional notes associated with this service or procedure.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],20817.01,,"Fee schedule rate ($20,817.01). Adds an outlier to normal pricing equal to the per diem rate ($37,789.38) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,9446.38,21796.21,There are no additional notes associated with this service or procedure.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],13435.63,,"Case rate ($12,795.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,039.30, add-ons for qualifying new technology services are included. If operating cost exceeds $46,910.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,553.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $10,057.27 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,094.35 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $793.62. The transfer capital threshold is the transfer adjustment factor * $793.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12795.84,41944.25,Inpatient DRG
Ostc Prtl Exostc/Condylc Metar Head|RIGHT SIDE,CASE-28288,APC,28288,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
CESAREAN SECTION WITH STERILIZATION WITH CC,784,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],9443.35,,"Case rate ($9,124.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,623.49, add-ons for qualifying new technology services are included. If operating cost exceeds $43,494.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,285.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,654.00 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,678.54 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $525.07. The transfer capital threshold is the transfer adjustment factor * $525.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,9124.01,23722.94,Inpatient DRG
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,093,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],19011.32,,"Fee schedule rate ($19,011.32). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,19011.32,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,690,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],7426.94,,"Case rate ($7,426.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,044.73, add-ons for qualifying new technology services are included. If operating cost exceeds $41,915.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,160.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,081.05 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,099.78 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $400.94. The transfer capital threshold is the transfer adjustment factor * $400.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7426.94,15928.53,Inpatient DRG
PSYCHOSES,885,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],27484.83,,,,,,0,other,2070.00,27484.83,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,064,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],37792.72,,"Fee schedule rate ($37,792.72). Adds an outlier to normal pricing equal to the per diem rate ($115,085.88) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,15563.58,41838.16,There are no additional notes associated with this service or procedure.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],9331.88,,"Case rate ($8,887.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,416.42, add-ons for qualifying new technology services are included. If operating cost exceeds $43,287.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,255.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,447.03 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,471.47 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $495.53. The transfer capital threshold is the transfer adjustment factor * $495.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9097.60,21455.22,Inpatient DRG
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],6817.04,,"Case rate ($6,683.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,353, add-ons for qualifying new technology services are included. If operating cost exceeds $41,224.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,106.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,391.86 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,408.05 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $346.56. The transfer capital threshold is the transfer adjustment factor * $346.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6683.37,14699.43,Inpatient DRG
TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC,087,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],22679.07,,"Fee schedule rate ($22,679.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,8139.36,22679.07,There are no additional notes associated with this service or procedure.
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC,058,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],14197.89,,"Case rate ($13,521.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,714.66, add-ons for qualifying new technology services are included. If operating cost exceeds $47,585.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,606.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $10,730.14 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,769.70 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $846.71. The transfer capital threshold is the transfer adjustment factor * $846.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13521.80,40853.02,Inpatient DRG
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],28766.85,,"Fee schedule rate ($28,766.85). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,16017.99,51903.64,There are no additional notes associated with this service or procedure.
BRONCHITIS AND ASTHMA WITH CC/MCC,202,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],18251.76,,"Fee schedule rate ($18,251.76). Adds an outlier to normal pricing equal to the per diem rate ($45,948.49) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,7606.34,19110.30,There are no additional notes associated with this service or procedure.
NERVOUS SYSTEM NEOPLASMS WITH MCC,054,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],12580.56,,"Case rate ($11,981.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,300.46, add-ons for qualifying new technology services are included. If operating cost exceeds $46,171.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,476.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $9,320.18 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,355.51 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $716.37. The transfer capital threshold is the transfer adjustment factor * $716.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,30044.81,Inpatient DRG
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],21667.25,,"Case rate ($21,667.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,292.19, add-ons for qualifying new technology services are included. If operating cost exceeds $55,163.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,202.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $18,279.84 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,347.24 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,442.46. The transfer capital threshold is the transfer adjustment factor * $1,442.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8972.00,81524.17,Inpatient DRG
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],23316.48,,"Fee schedule rate ($23,316.48). Adds an outlier to normal pricing equal to the per diem rate ($44,995.76) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7.7), with a minimum of zero.",,,,0,other,10347.06,28821.04,There are no additional notes associated with this service or procedure.
NORMAL NEWBORN,795,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],2576.52,,"Fee schedule rate ($2,576.52). Adds an outlier to normal pricing equal to the per diem rate ($414) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,1369.79,5771.52,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],7569.84,,"Case rate ($7,569.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,177.66, add-ons for qualifying new technology services are included. If operating cost exceeds $42,048.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,171.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,213.49 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,232.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $411.40. The transfer capital threshold is the transfer adjustment factor * $411.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7569.84,21892.85,Inpatient DRG
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],27329.90,,"Case rate ($26,028.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $24,349.34, add-ons for qualifying new technology services are included. If operating cost exceeds $59,220.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,521.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $22,322.08 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $22,404.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,761.43. The transfer capital threshold is the transfer adjustment factor * $1,761.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,26028.48,80635.65,Inpatient DRG
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],31693.30,,"Case rate ($31,693.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $29,619.21, add-ons for qualifying new technology services are included. If operating cost exceeds $64,490.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,935.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. The base transfer operating payment is the transfer adjustment factor * $27,572.60 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $27,674.26 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,175.75. The transfer capital threshold is the transfer adjustment factor * $2,175.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10862.00,86437.13,Inpatient DRG
HC Breath Hydrogen/Met Test,CASE-91065,APC,91065,CPT,0920,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],202.11,,"APC Price ($202.11). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,202.11,212.21,OPPS APC
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],10298.57,,"Fee schedule rate ($10,298.57). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7641.61,19371.27,There are no additional notes associated with this service or procedure.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],47123.82,,"Fee schedule rate ($47,123.82). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,12696.97,47123.82,There are no additional notes associated with this service or procedure.
Rmvl & Rplcmt Inflatable Penile Prosth Same Sess,CASE-54410,APC,54410,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],20370.16,,"APC Price ($19,400.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,19400.15,20370.16,OPPS APC
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],86235.79,,"Fee schedule rate ($86,235.79). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,32296.02,88188.38,There are no additional notes associated with this service or procedure.
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC",458,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],30202.09,,"Case rate ($30,202.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $28,231.97, add-ons for qualifying new technology services are included. If operating cost exceeds $63,102.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,826.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $26,190.45 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $26,287.02 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,066.69. The transfer capital threshold is the transfer adjustment factor * $2,066.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,30202.09,132827.25,Inpatient DRG
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],23714.25,,"Fee schedule rate ($23,714.25). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,15476.23,42787.31,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],14440.86,,"Case rate ($13,952.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,115.33, add-ons for qualifying new technology services are included. If operating cost exceeds $47,986.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,638.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $11,129.34 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,170.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $878.22. The transfer capital threshold is the transfer adjustment factor * $878.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,13917.42,34889.29,Inpatient DRG
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],34406.22,,"Fee schedule rate ($34,406.22). Adds an outlier to normal pricing equal to the per diem rate ($49,808.13) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,14343.25,36024.65,There are no additional notes associated with this service or procedure.
HYPERTENSION WITHOUT MCC,305,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7305.60,,"Case rate ($7,058.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,702.02, add-ons for qualifying new technology services are included. If operating cost exceeds $41,573.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,133.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,739.59 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,757.07 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $374.00. The transfer capital threshold is the transfer adjustment factor * $374.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,7058.55,17230.49,Inpatient DRG
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,329,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],33734.23,,"Case rate ($33,072.77). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $30,902.51, add-ons for qualifying new technology services are included. If operating cost exceeds $65,773.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,036.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.4. The base transfer operating payment is the transfer adjustment factor * $28,851.18 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $28,957.55 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,276.64. The transfer capital threshold is the transfer adjustment factor * $2,276.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,33072.77,90445.33,Inpatient DRG
Laparoscopy Surg Partial Nephrectomy|LEFT SIDE,CASE-50543,APC,50543,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],9949.78,,"APC Price ($9,949.78). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,9949.78,10447.27,OPPS APC
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],22358.90,,"Fee schedule rate ($22,358.90). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9389.48,22358.90,There are no additional notes associated with this service or procedure.
"MAJOR GASTROINTESTINAL AND PERITONEAL INFECTIONS,MAJOR",248,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],11267.56,,"Case rate ($11,267.56). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,11267.56,11830.94,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITH STERILIZATION WITH CC,784,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],9124.01,,"Case rate ($9,124.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,623.49, add-ons for qualifying new technology services are included. If operating cost exceeds $43,494.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,285.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,654.00 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,678.54 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $525.07. The transfer capital threshold is the transfer adjustment factor * $525.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9124.01,23722.94,Inpatient DRG
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],52803.53,,"Fee schedule rate ($52,803.53). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,14337.84,52803.53,There are no additional notes associated with this service or procedure.
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH MCC",722,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],34009.69,,"Fee schedule rate ($34,009.69). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,14200.37,56869.13,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],34272.79,,"Fee schedule rate ($34,272.79). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,14295.18,42768.36,There are no additional notes associated with this service or procedure.
Dilation Esoph Unguided Sound/Bougie 1/Mult Pass,CASE-43450,APC,43450,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],878.67,,"APC Price ($848.96). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,848.96,891.41,OPPS APC
RESPIRATORY NEOPLASMS WITH CC,181,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],21074.07,,,,,,0,other,9197.84,21074.07,There are no additional notes associated with this service or procedure.
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,451,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],23821.44,,"Case rate ($23,821.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $22,296.19, add-ons for qualifying new technology services are included. If operating cost exceeds $57,167.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,359.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $20,276.48 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $20,351.24 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,600.01. The transfer capital threshold is the transfer adjustment factor * $1,600.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,23821.44,94077.13,Inpatient DRG
Excision Tumor Soft Tissue Shoulder Subq 3 Cm/>,CASE-23071,APC,23071,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5658.76,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5658.76,5941.70,OPPS APC
OTHER MENTAL DISORDER DIAGNOSES,887,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],2070.00,,,,,,0,other,2070.00,21072.10,Estimated amount calculated based on 1 day length of stay.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],33608.45,,"Fee schedule rate ($33,608.45). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,7332.00,35314.31,There are no additional notes associated with this service or procedure.
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],23870.71,,"Fee schedule rate ($23,870.71). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10626.74,25225.91,There are no additional notes associated with this service or procedure.
SPINAL PROCEDURES WITHOUT CC/MCC,030,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],44714.01,,"Fee schedule rate ($44,714.01). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,16810.99,44714.01,There are no additional notes associated with this service or procedure.
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],23385.72,,"Fee schedule rate ($23,385.72). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,23385.72,There are no additional notes associated with this service or procedure.
Rpr Aa Hernia 1st 3-10 Cm Reducible,CASE-49593,APC,49593,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6271.74,,"APC Price ($6,059.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6059.65,6362.63,OPPS APC
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|LEFT HAND, FIFTH DIGIT",CASE-26160,APC,26160,CPT,0360,RC,,,F4,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1557.80,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1505.12,1580.37,OPPS APC
TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC,084,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],19445.16,,"Fee schedule rate ($19,445.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,6965.00,19445.16,There are no additional notes associated with this service or procedure.
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,095,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],48575.01,,"Fee schedule rate ($48,575.01). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,19411.47,50750.92,There are no additional notes associated with this service or procedure.
VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC,033,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],13866.54,,"Case rate ($13,206.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,421.07, add-ons for qualifying new technology services are included. If operating cost exceeds $47,292.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,583.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $10,437.64 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,476.13 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $823.63. The transfer capital threshold is the transfer adjustment factor * $823.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13206.23,42156.44,Inpatient DRG
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6220.59,,"Case rate ($6,010.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,726.79, add-ons for qualifying new technology services are included. If operating cost exceeds $40,597.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,057.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,767.95 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,781.84 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $297.33. The transfer capital threshold is the transfer adjustment factor * $297.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6010.23,12246.05,Inpatient DRG
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],13301.81,,"Case rate ($12,668.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,940.75, add-ons for qualifying new technology services are included. If operating cost exceeds $46,811.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,525.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $9,958.04 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,995.80 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $765.40. The transfer capital threshold is the transfer adjustment factor * $765.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7665.00,40737.46,Inpatient DRG
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],40542.37,,"Case rate ($40,542.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $37,851.31, add-ons for qualifying new technology services are included. If operating cost exceeds $72,722.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,582.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.6. The base transfer operating payment is the transfer adjustment factor * $35,774.45 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $35,906.36 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,822.96. The transfer capital threshold is the transfer adjustment factor * $2,822.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,40542.37,128358.13,Inpatient DRG
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],16865.16,,,,,,0,other,6711.00,16865.16,There are no additional notes associated with this service or procedure.
"CARDIAC ARREST, UNEXPLAINED WITH MCC",296,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],36459.67,,"Fee schedule rate ($36,459.67). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12522.25,36459.67,There are no additional notes associated with this service or procedure.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,056,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],18561.00,,"Case rate ($17,677.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,580.28, add-ons for qualifying new technology services are included. If operating cost exceeds $51,451.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,910.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $14,581.57 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,635.33 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,150.63. The transfer capital threshold is the transfer adjustment factor * $1,150.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7659.00,59328.19,Inpatient DRG
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC,858,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],33794.11,,"Fee schedule rate ($33,794.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11377.76,33794.11,There are no additional notes associated with this service or procedure.
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],22686.91,,"Fee schedule rate ($22,686.91). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,10120.20,26204.74,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITH CC,386,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],19210.66,,,,,,0,other,8556.53,19879.00,There are no additional notes associated with this service or procedure.
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],14789.23,,,,,,0,other,6965.00,21089.59,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],62084.69,,"Fee schedule rate ($62,084.69). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (35), with a minimum of zero.",,,,0,other,30398.48,82674.88,There are no additional notes associated with this service or procedure.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],38246.19,,"Fee schedule rate ($38,246.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,19435.86,50821.76,There are no additional notes associated with this service or procedure.
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],16400.70,,"Fee schedule rate ($16,400.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,16400.70,There are no additional notes associated with this service or procedure.
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],56089.29,,,,,,0,other,21248.73,56089.29,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],35192.25,,"Fee schedule rate ($35,192.25). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,10895.60,35192.25,There are no additional notes associated with this service or procedure.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],26028.48,,"Case rate ($26,028.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $24,349.34, add-ons for qualifying new technology services are included. If operating cost exceeds $59,220.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,521.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $22,322.08 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $22,404.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,761.43. The transfer capital threshold is the transfer adjustment factor * $1,761.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,26028.48,80635.65,Inpatient DRG
CERVICAL SPINAL FUSION WITHOUT CC/MCC,473,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],45879.35,,"Fee schedule rate ($45,879.35). Adds an outlier to normal pricing equal to the per diem rate ($58,401.78) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,18477.61,62077.11,There are no additional notes associated with this service or procedure.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],40918.00,,"Fee schedule rate ($40,918.00). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,16689.78,59521.43,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,426,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],76581.29,,"Case rate ($76,581.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $71,377.56, add-ons for qualifying new technology services are included. If operating cost exceeds $106,248.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $7,218.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $69,177.55 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $69,432.61 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $5,458.79. The transfer capital threshold is the transfer adjustment factor * $5,458.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,76581.29,216864.15,Inpatient DRG
"ASTHMA,MINOR",141,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],4318.17,,"Case rate ($4,112.54). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4318.17,4318.17,There are no additional notes associated with this service or procedure.
Posterior Segmental Instrumentation 3-6 Vrt Seg,CASE-22842,APC,22842,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],16986.50,,"APC Price ($16,412.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,16412.07,16986.50,OPPS APC
INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,352,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],21946.47,,"Fee schedule rate ($21,946.47). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,9853.37,26528.70,There are no additional notes associated with this service or procedure.
Dilation Esoph Unguided Sound/Bougie 1/Mult Pass,CASE-43450,APC,43450,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],878.67,,"APC Price ($848.96). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,848.96,891.41,OPPS APC
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],14795.51,,"Case rate ($14,295.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,434.11, add-ons for qualifying new technology services are included. If operating cost exceeds $48,305.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,663.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $11,446.95 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,489.15 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $903.28. The transfer capital threshold is the transfer adjustment factor * $903.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,14295.18,42768.36,Inpatient DRG
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITH MCC OR ANTINEOPLASTIC IMPLANT OR EPILEPSY WITH NEUROSTIMULATOR,023,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],136379.44,,"Fee schedule rate ($136,379.44). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,15168.00,136379.44,There are no additional notes associated with this service or procedure.
PERIPHERAL VASCULAR DISORDERS WITH CC,300,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],9409.88,,"Case rate ($8,961.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,485.66, add-ons for qualifying new technology services are included. If operating cost exceeds $43,356.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,260.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,516.00 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,540.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $500.84. The transfer capital threshold is the transfer adjustment factor * $500.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9174.14,21005.20,Inpatient DRG
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],18596.80,,"Case rate ($10,626.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,021.44, add-ons for qualifying new technology services are included. If operating cost exceeds $44,892.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,394.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $8,046.82 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,076.49 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $634.97. The transfer capital threshold is the transfer adjustment factor * $634.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,10626.74,25225.91,All Other Inpatient
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],51630.84,,"Fee schedule rate ($51,630.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,20559.34,54086.17,There are no additional notes associated with this service or procedure.
Ligamentous Reconstruction Knee Extra-Articular|LEFT SIDE,CASE-27427,APC,27427,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7029.71,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6791.99,7029.71,OPPS APC
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],19371.27,,"Fee schedule rate ($19,371.27). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8643.20,19462.52,There are no additional notes associated with this service or procedure.
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC",011,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],102498.90,,"Fee schedule rate ($102,498.90). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,38880.49,150008.48,There are no additional notes associated with this service or procedure.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC",061,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],21337.80,,"Case rate ($20,616.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $19,314.45, add-ons for qualifying new technology services are included. If operating cost exceeds $54,185.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,125.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $17,305.68 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $17,369.49 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,365.59. The transfer capital threshold is the transfer adjustment factor * $1,365.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,20616.23,62315.82,Inpatient DRG
Nerve Repair W/Nerve Allograft First Strand|LEFT SIDE,CASE-64912,APC,64912,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],8501.91,,"APC Price ($8,214.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,8214.41,8625.13,OPPS APC
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC,797,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],13416.00,,,,,,0,other,8719.72,20928.55,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF THE EYE WITHOUT MCC,125,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],15108.00,,,,,,0,other,7144.54,17952.29,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,082,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],18294.37,,"Case rate ($17,423.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,344.04, add-ons for qualifying new technology services are included. If operating cost exceeds $51,215.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,892.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $14,346.19 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,399.08 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,132.06. The transfer capital threshold is the transfer adjustment factor * $1,132.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,17423.21,56223.11,Inpatient DRG
FRACTURES OF FEMUR WITH MCC,533,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],49490.05,,"Fee schedule rate ($49,490.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,6852.00,49490.05,There are no additional notes associated with this service or procedure.
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],21850.50,,"Fee schedule rate ($21,850.50). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12195.15,39424.57,There are no additional notes associated with this service or procedure.
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],12937.10,,"Fee schedule rate ($12,937.10). Adds an outlier to normal pricing equal to the per diem rate ($49,808.13) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.5), with a minimum of zero.",,,,0,other,5919.29,13545.65,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],33398.16,,"Fee schedule rate ($33,398.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,7353.00,33398.16,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],12992.90,,"Case rate ($12,992.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,222.63, add-ons for qualifying new technology services are included. If operating cost exceeds $47,093.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,568.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $10,239.92 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,277.68 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $808.03. The transfer capital threshold is the transfer adjustment factor * $808.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7665.00,40737.46,Inpatient DRG
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],31462.43,,"Case rate ($30,398.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $28,414.67, add-ons for qualifying new technology services are included. If operating cost exceeds $63,285.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,841.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.2. The base transfer operating payment is the transfer adjustment factor * $26,372.48 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $26,469.72 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,081.05. The transfer capital threshold is the transfer adjustment factor * $2,081.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,30398.48,82674.88,Inpatient DRG
Destruction Neurolytic Agt Genicular Nerve W/Img|BILATERAL PROCEDURE,CASE-64624,APC,64624,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1827.80,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1827.80,1919.19,OPPS APC
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,097,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],79915.74,,"Fee schedule rate ($79,915.74). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,26404.32,79915.74,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],12734.97,,"Fee schedule rate ($12,734.97). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,6167.00,29058.99,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,082,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],56223.11,,"Fee schedule rate ($56,223.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,17423.21,56223.11,There are no additional notes associated with this service or procedure.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],45050.58,,"Fee schedule rate ($45,050.58). Adds an outlier to normal pricing equal to the per diem rate ($120,238.99) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,18178.96,54764.34,There are no additional notes associated with this service or procedure.
Dstr Nrolytc Agnt Parverteb Fct Addl Lmbr/Sacral|RIGHT SIDE,CASE-64636,APC,64636,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1919.19,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1827.80,1919.19,OPPS APC
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],33910.82,,"Case rate ($32,296.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $30,179.91, add-ons for qualifying new technology services are included. If operating cost exceeds $65,050.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,979.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $28,131.23 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $28,234.95 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,219.83. The transfer capital threshold is the transfer adjustment factor * $2,219.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,32296.02,88188.38,Inpatient DRG
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],28038.61,,"Fee schedule rate ($28,038.61). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12126.09,29582.40,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,065,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],8786.76,,"Case rate ($8,786.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,309.75, add-ons for qualifying new technology services are included. If operating cost exceeds $43,180.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,260.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,341.42 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,364.80 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $500.40. The transfer capital threshold is the transfer adjustment factor * $500.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8786.76,25681.86,Inpatient DRG
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],9762.40,,"Case rate ($9,570.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,039.28, add-ons for qualifying new technology services are included. If operating cost exceeds $43,910.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,317.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $7,068.27 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,094.33 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $557.76. The transfer capital threshold is the transfer adjustment factor * $557.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,5569.00,40108.48,Inpatient DRG
FRACTURES OF FEMUR WITH MCC,533,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],13189.61,,"Case rate ($12,561.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,821.33, add-ons for qualifying new technology services are included. If operating cost exceeds $46,692.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,536.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $9,840.09 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,876.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $776.48. The transfer capital threshold is the transfer adjustment factor * $776.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6852.00,49490.05,Inpatient DRG
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],14908.05,,"Case rate ($14,908.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,004.25, add-ons for qualifying new technology services are included. If operating cost exceeds $48,875.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,708.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $12,014.99 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,059.30 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $948.10. The transfer capital threshold is the transfer adjustment factor * $948.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,14908.05,49717.39,Inpatient DRG
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],18043.23,,"Fee schedule rate ($18,043.23). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7733.72,18043.23,There are no additional notes associated with this service or procedure.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],35719.96,,"Case rate ($35,719.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $33,365.14, add-ons for qualifying new technology services are included. If operating cost exceeds $68,236.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,230.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.9. The base transfer operating payment is the transfer adjustment factor * $31,304.77 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $31,420.19 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,470.26. The transfer capital threshold is the transfer adjustment factor * $2,470.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,35719.96,105091.76,Inpatient DRG
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],16900.84,,"Fee schedule rate ($16,900.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8151.55,18033.97,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,083,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],6965.00,,,,,,0,other,6965.00,28680.85,There are no additional notes associated with this service or procedure.
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],35061.53,,"Fee schedule rate ($35,061.53). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,9696.93,35061.53,There are no additional notes associated with this service or procedure.
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],22487.70,,"Fee schedule rate ($22,487.70). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10048.39,23545.50,There are no additional notes associated with this service or procedure.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,761,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],11946.72,,"Fee schedule rate ($11,946.72). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,5808.41,11946.72,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC,831,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],10088.35,,"Case rate ($10,088.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,520.59, add-ons for qualifying new technology services are included. If operating cost exceeds $44,391.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,355.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $7,547.82 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,575.65 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $595.60. The transfer capital threshold is the transfer adjustment factor * $595.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,4941.30,23661.59,Inpatient DRG
SALIVARY GLAND PROCEDURES,139,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],23222.51,,"Fee schedule rate ($23,222.51). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.9), with a minimum of zero.",,,,0,other,10313.19,30690.92,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],26966.33,,"Fee schedule rate ($26,966.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,9040.72,26966.33,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],26178.21,,"Fee schedule rate ($26,178.21). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,13917.42,34889.29,There are no additional notes associated with this service or procedure.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],23790.06,,"Fee schedule rate ($23,790.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10517.71,24909.11,There are no additional notes associated with this service or procedure.
Hemorrhoidectomy Ntrnl & Xtrnl 1 Column/Group,CASE-46255,APC,46255,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],2689.02,,"APC Price ($2,598.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2598.08,2727.99,OPPS APC
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],41379.07,,"Case rate ($39,408.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $36,866.52, add-ons for qualifying new technology services are included. If operating cost exceeds $71,737.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,433.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.6. The base transfer operating payment is the transfer adjustment factor * $34,789.67 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $34,921.57 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,674.02. The transfer capital threshold is the transfer adjustment factor * $2,674.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,40542.37,128358.13,Inpatient DRG
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],16489.07,,"Case rate ($15,703.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,770.26, add-ons for qualifying new technology services are included. If operating cost exceeds $49,641.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,742.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $12,776.86 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,825.31 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $982.06. The transfer capital threshold is the transfer adjustment factor * $982.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,16120.25,41187.90,Inpatient DRG
Nasal/Sinus Ndsc Total With Sphenoidotomy|BILATERAL PROCEDURE,CASE-31257,APC,31257,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6605.95,,"APC Price ($6,605.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6605.95,6936.25,OPPS APC
SALIVARY GLAND PROCEDURES,139,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],30690.92,,"Fee schedule rate ($30,690.92). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,10313.19,30690.92,There are no additional notes associated with this service or procedure.
SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS,029,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],13641.00,,"Per diem ($13,641). If length of stay < 4.7, first 1 days paid at a per diem of $27,282 instead. Capped at $64,114.20.",,,,0,other,13641.00,67130.05,Estimated amount calculated based on 5 day length of stay.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],27120.18,,"Fee schedule rate ($27,120.18). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,11717.72,43888.01,There are no additional notes associated with this service or procedure.
Arthrd Ant Interbody Min Dsc Crv Below C2|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-22554,APC,22554,CPT,0360,RC,,,74,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12618.18,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,12437.92,12618.18,OPPS APC
CHOLECYSTECTOMY WITH C.D.E. WITH MCC,411,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],25166.16,,"Case rate ($24,315.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $22,755.46, add-ons for qualifying new technology services are included. If operating cost exceeds $57,626.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,396.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $20,734.06 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $20,810.51 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,636.12. The transfer capital threshold is the transfer adjustment factor * $1,636.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,24315.13,88615.28,Inpatient DRG
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC",494,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],39945.55,,"Fee schedule rate ($39,945.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,15533.10,39945.55,There are no additional notes associated with this service or procedure.
Gastroenterology Procedure,CASE-91299,APC,91299,CPT,0750,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],126.46,,"APC Price ($120.44). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,120.44,126.46,OPPS APC
OTHER CEREBROVASCULAR DISORDERS WITH MCC,070,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],37774.46,,"Fee schedule rate ($37,774.46). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,13219.09,37774.46,There are no additional notes associated with this service or procedure.
POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES,769,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],13388.39,,"Case rate ($13,388.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,590.54, add-ons for qualifying new technology services are included. If operating cost exceeds $47,461.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,596.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $10,606.49 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,645.59 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $836.96. The transfer capital threshold is the transfer adjustment factor * $836.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,13388.39,33250.19,Inpatient DRG
Bx/Exc Lymph Node Open Deep Axillary Node|LEFT SIDE,CASE-38525,APC,38525,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6432.89,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6215.36,6526.12,OPPS APC
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],33890.73,,"Fee schedule rate ($33,890.73). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6277.00,36801.89,There are no additional notes associated with this service or procedure.
Rpr Aa Hernia Recr > 10 Cm Reducible,CASE-49617,APC,49617,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],209.05,,"APC Price ($199.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,199.10,209.05,OPPS APC
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],22217.08,,"Fee schedule rate ($22,217.08). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.4), with a minimum of zero.",,,,0,other,7243.75,23262.15,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],19187.65,,"Fee schedule rate ($19,187.65). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8859.23,20090.22,There are no additional notes associated with this service or procedure.
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],12573.10,,"Case rate ($11,974.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,275.12, add-ons for qualifying new technology services are included. If operating cost exceeds $46,146.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,493.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $9,295.90 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,330.17 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $733.54. The transfer capital threshold is the transfer adjustment factor * $733.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,11974.38,29141.64,Inpatient DRG
HC Drain/Inj Joint/Bursa W/US Large|BILATERAL PROCEDURE,CASE-20611,APC,20611,CPT,0510,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],301.68,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,287.31,301.68,OPPS APC
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],6965.00,,,,,,0,other,6148.93,15887.21,There are no additional notes associated with this service or procedure.
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],9667.64,,"Fee schedule rate ($9,667.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,5139.72,13110.79,There are no additional notes associated with this service or procedure.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],93728.21,,"Fee schedule rate ($93,728.21). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,35719.96,105091.76,There are no additional notes associated with this service or procedure.
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],16026.80,,"Case rate ($16,026.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,044.99, add-ons for qualifying new technology services are included. If operating cost exceeds $49,916.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,789.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $13,051.92 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,100.04 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,029.93. The transfer capital threshold is the transfer adjustment factor * $1,029.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,11165.00,61234.06,Inpatient DRG
Egd Intrmural US Needle Aspirate/Biopsy Esophags,CASE-43238,APC,43238,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1796.14,,"APC Price ($1,796.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1796.14,1885.95,OPPS APC
CESAREAN SECTION WITH STERILIZATION WITH MCC,783,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],18571.05,,"Case rate ($18,571.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,411.86, add-ons for qualifying new technology services are included. If operating cost exceeds $52,282.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,975.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $15,410.10 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,466.92 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,216.01. The transfer capital threshold is the transfer adjustment factor * $1,216.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12612.10,23722.94,Inpatient DRG
Neuroplasty &/Transpos Median Nrv Carpal Tunne|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64721,APC,64721,CPT,0360,RC,,,LT|XU,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
"Tendon Sheath Incision|RIGHT HAND, FIFTH DIGIT|UNUSUAL NON-OVERLAPPING SERVICE",CASE-26055,APC,26055,CPT,0360,RC,,,F9|XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
PSYCHOSES,885,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],11404.17,,"Case rate ($11,404.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,744.67, add-ons for qualifying new technology services are included. If operating cost exceeds $45,615.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,451.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.5. The base transfer operating payment is the transfer adjustment factor * $8,767.39 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,799.72 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $691.83. The transfer capital threshold is the transfer adjustment factor * $691.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,2070.00,27484.83,Inpatient DRG
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],59476.09,,"Fee schedule rate ($59,476.09). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15.9), with a minimum of zero.",,,,0,other,23377.19,96365.69,There are no additional notes associated with this service or procedure.
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],29594.00,,"Fee schedule rate ($29,594.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,13571.25,33781.47,There are no additional notes associated with this service or procedure.
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],18675.44,,,,,,0,other,6965.00,23385.72,There are no additional notes associated with this service or procedure.
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",759,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],11643.60,,"Fee schedule rate ($11,643.60). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6190.22,13057.66,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL OBSTRUCTION WITH CC,389,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],16423.43,,"Fee schedule rate ($16,423.43). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5118.00,16423.43,There are no additional notes associated with this service or procedure.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],7453.00,,"Per diem ($7,453). If length of stay < 5.4, first 1 days paid at a per diem of $14,906 instead. Capped at $40,245.21.",,,,0,other,7453.00,42138.30,Estimated amount calculated based on 3 day length of stay.
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],9386.41,,"Case rate ($8,939.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,464.83, add-ons for qualifying new technology services are included. If operating cost exceeds $43,335.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,259.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,495.25 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,519.88 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $499.24. The transfer capital threshold is the transfer adjustment factor * $499.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9151.11,30245.71,Inpatient DRG
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],26465.57,,,,,,0,other,11053.39,36776.05,There are no additional notes associated with this service or procedure.
"FOOT AND TOE PROCEDURES,MINOR",314,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],10777.59,,"Case rate ($10,264.37). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10264.37,10777.59,There are no additional notes associated with this service or procedure.
SEIZURES WITH MCC,100,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],15061.09,,"Case rate ($15,061.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,146.62, add-ons for qualifying new technology services are included. If operating cost exceeds $49,017.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,719.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $12,156.85 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,201.67 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $959.30. The transfer capital threshold is the transfer adjustment factor * $959.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,15061.09,38110.41,Inpatient DRG
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],17755.26,,"Fee schedule rate ($17,755.26). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7847.50,17755.26,There are no additional notes associated with this service or procedure.
MINOR BLADDER PROCEDURES WITHOUT CC/MCC,664,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],9350.84,,"Case rate ($9,034.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,540.33, add-ons for qualifying new technology services are included. If operating cost exceeds $43,411.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,278.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $6,571.15 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,595.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $518.53. The transfer capital threshold is the transfer adjustment factor * $518.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,9034.63,31876.87,Inpatient DRG
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],6167.00,,"Per diem ($6,167). If length of stay < 4.5, first 1 days paid at a per diem of $12,334 instead. Capped at $27,753.50.",,,,0,other,6167.00,29058.99,Estimated amount calculated based on 3 day length of stay.
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],86252.84,,"Fee schedule rate ($86,252.84). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,27944.96,86252.84,There are no additional notes associated with this service or procedure.
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],9942.69,,"Case rate ($9,469.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,958.67, add-ons for qualifying new technology services are included. If operating cost exceeds $43,829.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,297.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $6,987.23 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,013.72 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $537.06. The transfer capital threshold is the transfer adjustment factor * $537.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9696.93,35061.53,Inpatient DRG
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,086,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],17031.00,,"Fee schedule rate ($17,031). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8442.00,30728.81,There are no additional notes associated with this service or procedure.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC",156,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],12987.84,,"Fee schedule rate ($12,987.84). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,6625.12,13598.77,There are no additional notes associated with this service or procedure.
Chemodenervation Muscle Neck Unilat for Dystonia|BILATERAL PROCEDURE,CASE-64616,APC,64616,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
Excision Ganglion Wrist Dorsal/Volar Primary|RIGHT SIDE,CASE-25111,APC,25111,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
CESAREAN SECTION WITH STERILIZATION WITH CC,784,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],13148.10,,"Fee schedule rate ($13,148.10). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9124.01,23722.94,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITH STERILIZATION WITHOUT CC/MCC,785,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],20142.33,,"Fee schedule rate ($20,142.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8431.24,20142.33,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],19187.65,,"Fee schedule rate ($19,187.65). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8859.23,20090.22,There are no additional notes associated with this service or procedure.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC,434,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],13390.01,,"Fee schedule rate ($13,390.01). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6770.05,14019.86,There are no additional notes associated with this service or procedure.
MAJOR CHEST TRAUMA WITHOUT CC/MCC,185,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],14780.69,,"Fee schedule rate ($14,780.69). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.7), with a minimum of zero.",,,,0,other,7271.19,21771.61,There are no additional notes associated with this service or procedure.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,191,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],6965.00,,,,,,0,other,6965.00,16612.88,There are no additional notes associated with this service or procedure.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],9007.39,,"Case rate ($8,702.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,231.63, add-ons for qualifying new technology services are included. If operating cost exceeds $43,102.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,254.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,263.59 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,286.68 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $494.26. The transfer capital threshold is the transfer adjustment factor * $494.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,5683.00,19635.68,Inpatient DRG
"Repair Extensor Tendon Finger W/O Graft Each|LEFT HAND, FOURTH DIGIT",CASE-26418,APC,26418,CPT,0360,RC,,,F3,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],16379.98,,"Fee schedule rate ($16,379.98). Adds an outlier to normal pricing equal to the per diem rate ($46,377.87) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7847.50,17755.26,There are no additional notes associated with this service or procedure.
"LIMB REATTACHMENT, HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA",956,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],78821.07,,"Fee schedule rate ($78,821.07). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,27428.25,148259.86,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],8563.30,,"Case rate ($8,563.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,101.85, add-ons for qualifying new technology services are included. If operating cost exceeds $42,972.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,244.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $6,134.29 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,156.91 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $484.06. The transfer capital threshold is the transfer adjustment factor * $484.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8563.30,31533.97,Inpatient DRG
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC",923,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],6965.00,,,,,,0,other,6965.00,20068.57,There are no additional notes associated with this service or procedure.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],11586.05,,"Case rate ($11,194.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,549.37, add-ons for qualifying new technology services are included. If operating cost exceeds $45,420.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,436.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $8,572.81 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,604.42 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $676.48. The transfer capital threshold is the transfer adjustment factor * $676.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,11194.25,36094.03,Inpatient DRG
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC",514,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],9178.42,,"Case rate ($8,868.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,385.35, add-ons for qualifying new technology services are included. If operating cost exceeds $43,256.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,266.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $6,416.74 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,440.40 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $506.34. The transfer capital threshold is the transfer adjustment factor * $506.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,8868.04,22699.91,Inpatient DRG
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],59521.43,,"Fee schedule rate ($59,521.43). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,16689.78,59521.43,There are no additional notes associated with this service or procedure.
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],16035.06,,"Fee schedule rate ($16,035.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,7396.47,16035.06,There are no additional notes associated with this service or procedure.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],42586.49,,"Fee schedule rate ($42,586.49). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,13341.67,42586.49,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],45758.86,,,,,,0,other,17693.40,52449.26,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITH CC,386,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],18347.61,,"Fee schedule rate ($18,347.61). Adds an outlier to normal pricing equal to the per diem rate ($111,650.51) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8556.53,19879.00,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],46523.26,,"Fee schedule rate ($46,523.26). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,17782.11,46523.26,There are no additional notes associated with this service or procedure.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],29917.96,,"Fee schedule rate ($29,917.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,12527.66,29917.96,There are no additional notes associated with this service or procedure.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],25408.95,,"Fee schedule rate ($25,408.95). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,18598.83,48389.68,There are no additional notes associated with this service or procedure.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],38246.19,,"Fee schedule rate ($38,246.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,19435.86,50821.76,There are no additional notes associated with this service or procedure.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC",061,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],51814.18,,"Fee schedule rate ($51,814.18). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,20616.23,62315.82,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],18585.05,,"Fee schedule rate ($18,585.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8859.23,20090.22,There are no additional notes associated with this service or procedure.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],29917.96,,"Fee schedule rate ($29,917.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,12527.66,29917.96,There are no additional notes associated with this service or procedure.
SALIVARY GLAND PROCEDURES,139,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],23222.51,,"Fee schedule rate ($23,222.51). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.9), with a minimum of zero.",,,,0,other,10313.19,30690.92,There are no additional notes associated with this service or procedure.
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITH MCC OR ANTINEOPLASTIC IMPLANT OR EPILEPSY WITH NEUROSTIMULATOR,023,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],40750.95,,"Case rate ($40,750.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $38,045.35, add-ons for qualifying new technology services are included. If operating cost exceeds $72,916.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,598.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $35,967.78 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $36,100.40 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,838.21. The transfer capital threshold is the transfer adjustment factor * $2,838.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,15168.00,136379.44,Inpatient DRG
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,988,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],42425.46,,"Fee schedule rate ($42,425.46). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,13075.52,42425.46,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL HEMORRHAGE WITH MCC,377,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],31575.65,,"Fee schedule rate ($31,575.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,7634.00,35969.56,There are no additional notes associated with this service or procedure.
Prtl Exc B1 Tarsal/Metar B1 Xcp Talus/Calcaneus|RIGHT SIDE,CASE-28122,APC,28122,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3169.86,OPPS APC
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",062,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],33023.06,,"Fee schedule rate ($33,023.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,13844.84,44304.80,There are no additional notes associated with this service or procedure.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7422.85,,"Case rate ($7,069.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,721.66, add-ons for qualifying new technology services are included. If operating cost exceeds $41,592.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,125.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $4,758.67 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,776.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $365.76. The transfer capital threshold is the transfer adjustment factor * $365.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,15340.19,Inpatient DRG
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],40910.08,,"Case rate ($23,377.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $21,882.92, add-ons for qualifying new technology services are included. If operating cost exceeds $56,753.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,327.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $19,864.72 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $19,937.97 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,567.52. The transfer capital threshold is the transfer adjustment factor * $1,567.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,23377.19,96365.69,All Other Inpatient
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],14830.15,,"Fee schedule rate ($14,830.15). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,7884.32,17835.23,There are no additional notes associated with this service or procedure.
HC Repair Tun or Non Cath W/Port,CASE-36576,APC,36576,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1473.45,,"APC Price ($1,473.45). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1473.45,1547.12,OPPS APC
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],13952.52,,"Case rate ($13,952.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,115.33, add-ons for qualifying new technology services are included. If operating cost exceeds $47,986.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,638.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $11,129.34 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,170.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $878.22. The transfer capital threshold is the transfer adjustment factor * $878.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,13917.42,34889.29,Inpatient DRG
MAJOR CHEST TRAUMA WITHOUT CC/MCC,185,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],21771.61,,"Fee schedule rate ($21,771.61). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7271.19,21771.61,There are no additional notes associated with this service or procedure.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,073,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],24095.40,,"Fee schedule rate ($24,095.40). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,12809.38,43475.01,There are no additional notes associated with this service or procedure.
Marsupialization Bartholins Gland Cyst,CASE-56440,APC,56440,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3136.08,,"APC Price ($3,030.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3030.03,3181.53,OPPS APC
INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,352,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],10346.04,,"Case rate ($9,853.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,301.99, add-ons for qualifying new technology services are included. If operating cost exceeds $44,173.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,338.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $7,330.01 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,357.04 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $578.41. The transfer capital threshold is the transfer adjustment factor * $578.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9853.37,26528.70,Inpatient DRG
Surgical Arthroscopy Shoulder W/Rotator Cuff Rpr|RIGHT SIDE,CASE-29827,APC,29827,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6791.99,7131.59,OPPS APC
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],35389.50,,"Case rate ($35,389.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $33,057.71, add-ons for qualifying new technology services are included. If operating cost exceeds $67,928.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,206.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.3. The base transfer operating payment is the transfer adjustment factor * $30,998.46 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $31,112.76 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,446.08. The transfer capital threshold is the transfer adjustment factor * $2,446.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,35389.50,101083.00,Inpatient DRG
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,065,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],18986.57,,"Fee schedule rate ($18,986.57). Adds an outlier to normal pricing equal to the per diem rate ($85,884.96) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,8786.76,25681.86,There are no additional notes associated with this service or procedure.
"Amputation Toe Metatarsophalangeal Joint|RIGHT HAND, FOURTH DIGIT",CASE-28820,APC,28820,CPT,0360,RC,,,F8,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
VENTRICULAR SHUNT PROCEDURES WITH MCC,031,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],62406.76,,"Fee schedule rate ($62,406.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,32287.20,88162.80,There are no additional notes associated with this service or procedure.
Unlisted Laparoscopy Procedure Stomach,CASE-43659,APC,43659,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5941.70,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5658.76,5941.70,OPPS APC
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],46523.26,,"Fee schedule rate ($46,523.26). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,17782.11,46523.26,There are no additional notes associated with this service or procedure.
Osteot W/WO Lngth Shrt/Corrj Metar Xcp 1st Ea|LEFT SIDE,CASE-28308,APC,28308,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
Sigmoidoscopy Flx Dx W/Collj Spec Br/Wa if Pfrmd|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-45330,APC,45330,CPT,0360,RC,,,74,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],913.99,,"APC Price ($870.46). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,870.46,913.99,OPPS APC
CESAREAN SECTION WITH STERILIZATION WITH CC,784,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],23722.94,,"Fee schedule rate ($23,722.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9124.01,23722.94,There are no additional notes associated with this service or procedure.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,056,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],18295.84,,"Case rate ($17,677.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,580.28, add-ons for qualifying new technology services are included. If operating cost exceeds $51,451.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,910.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $14,581.57 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,635.33 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,150.63. The transfer capital threshold is the transfer adjustment factor * $1,150.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,7659.00,59328.19,Inpatient DRG
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC,519,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],15800.25,,"Case rate ($15,490.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,546.03, add-ons for qualifying new technology services are included. If operating cost exceeds $49,417.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,750.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $12,554.80 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,601.09 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $990.70. The transfer capital threshold is the transfer adjustment factor * $990.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,15490.44,50780.20,Inpatient DRG
"FEVER AND INFLAMMATORY CONDITIONS,MODERATE",722,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],2150.10,,"Case rate for a one day stay ($2,047.71). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,2047.71,2150.10,There are no additional notes associated with this service or procedure.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,479,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],50518.76,,"Fee schedule rate ($50,518.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,10586.00,50518.76,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],16017.99,,"Case rate ($16,017.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,036.80, add-ons for qualifying new technology services are included. If operating cost exceeds $49,907.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,789.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $13,043.76 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,091.85 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,029.28. The transfer capital threshold is the transfer adjustment factor * $1,029.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,16017.99,51903.64,Inpatient DRG
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],7000.00,,"Per diem ($7,000). If length of stay < 4.5, first 1 days paid at a per diem of $14,000 instead. Capped at $31,498.95.",,,,0,other,7000.00,33835.79,Estimated amount calculated based on 2 day length of stay.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],47123.82,,"Fee schedule rate ($47,123.82). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,12696.97,47123.82,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,083,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],28680.85,,"Fee schedule rate ($28,680.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,28680.85,There are no additional notes associated with this service or procedure.
Nasal/Sinus Ndsc Surg W/Concha Bullosa Resection|LEFT SIDE,CASE-31240,APC,31240,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.35,,"APC Price ($3,103.35). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.35,3211.97,OPPS APC
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,555,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],11441.08,,"Case rate ($10,896.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,272.18, add-ons for qualifying new technology services are included. If operating cost exceeds $45,143.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,414.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,296.64 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,327.23 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $654.69. The transfer capital threshold is the transfer adjustment factor * $654.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10896.27,42290.95,Inpatient DRG
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC,192,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6292.63,,"Case rate ($6,292.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,989.50, add-ons for qualifying new technology services are included. If operating cost exceeds $40,860.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,077.96, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,029.69 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,044.54 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $317.98. The transfer capital threshold is the transfer adjustment factor * $317.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6292.63,12753.78,Inpatient DRG
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],21377.04,,"Fee schedule rate ($21,377.04). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,9648.19,31477.13,There are no additional notes associated with this service or procedure.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],18033.97,,,,,,0,other,8151.55,18033.97,There are no additional notes associated with this service or procedure.
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC,797,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],11599.35,,"Fee schedule rate ($11,599.35). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8719.72,20928.55,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6558.75,,"Case rate ($6,558.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,237.08, add-ons for qualifying new technology services are included. If operating cost exceeds $41,108.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,097.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $4,276.36 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,292.13 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $337.45. The transfer capital threshold is the transfer adjustment factor * $337.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6558.75,14871.83,Inpatient DRG
CESAREAN SECTION WITH STERILIZATION WITHOUT CC/MCC,785,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],20142.33,,"Fee schedule rate ($20,142.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8431.24,20142.33,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,426,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],177294.98,,"Fee schedule rate ($177,294.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,76581.29,216864.15,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,065,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],25681.86,,"Fee schedule rate ($25,681.86). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,8786.76,25681.86,There are no additional notes associated with this service or procedure.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],54764.34,,"Fee schedule rate ($54,764.34). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,18178.96,54764.34,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,689,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],22417.63,,"Fee schedule rate ($22,417.63). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,9802.58,22831.22,There are no additional notes associated with this service or procedure.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],23835.16,,"Fee schedule rate ($23,835.16). Adds an outlier to normal pricing equal to the per diem rate ($63,133.20) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10533.95,24956.34,There are no additional notes associated with this service or procedure.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC,099,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],12239.85,,"Fee schedule rate ($12,239.85). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11171.21,26807.94,There are no additional notes associated with this service or procedure.
Open Tx Distal Fibular Fracture Lat Malleolus|RIGHT SIDE,CASE-27792,APC,27792,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7029.71,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6791.99,7131.59,OPPS APC
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],97015.50,,"Fee schedule rate ($97,015.50). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,26809.29,97015.50,There are no additional notes associated with this service or procedure.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC,027,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],56363.30,,"Fee schedule rate ($56,363.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,19030.20,56363.30,There are no additional notes associated with this service or procedure.
UNGROUPABLE,999,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],161307.29,,"Fee schedule rate ($161,307.29). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (41), with a minimum of zero.",,,,0,other,10228.00,161307.29,There are no additional notes associated with this service or procedure.
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],13486.95,,"Fee schedule rate ($13,486.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6915.64,14442.92,There are no additional notes associated with this service or procedure.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,057,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],10984.18,,"Case rate ($10,461.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,883.26, add-ons for qualifying new technology services are included. If operating cost exceeds $44,754.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,367.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $7,908.32 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,938.31 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $607.85. The transfer capital threshold is the transfer adjustment factor * $607.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10718.84,39884.93,Inpatient DRG
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],18585.05,,"Fee schedule rate ($18,585.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8859.23,20090.22,There are no additional notes associated with this service or procedure.
HEADACHES WITHOUT MCC,103,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],20883.08,,"Fee schedule rate ($20,883.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,20883.08,There are no additional notes associated with this service or procedure.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],16037.43,,"Case rate ($15,273.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,344.45, add-ons for qualifying new technology services are included. If operating cost exceeds $49,215.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,734.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $12,353.94 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,399.49 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $974.85. The transfer capital threshold is the transfer adjustment factor * $974.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,15273.74,39820.52,Inpatient DRG
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],40108.48,,"Fee schedule rate ($40,108.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,5569.00,40108.48,There are no additional notes associated with this service or procedure.
COMPLICATIONS OF TREATMENT WITH CC,920,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],8959.88,,"Case rate ($8,533.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,086.17, add-ons for qualifying new technology services are included. If operating cost exceeds $42,957.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,230.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,118.02 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,141.22 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $470.25. The transfer capital threshold is the transfer adjustment factor * $470.25. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8732.59,20731.52,Inpatient DRG
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],66833.55,,"Fee schedule rate ($66,833.55). Adds an outlier to normal pricing equal to the per diem rate ($141,521.30) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,26028.48,80635.65,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],14873.32,,"Case rate ($14,370.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,504.04, add-ons for qualifying new technology services are included. If operating cost exceeds $48,375.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,668.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $11,516.62 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,559.08 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $908.78. The transfer capital threshold is the transfer adjustment factor * $908.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,14370.36,38378.80,Inpatient DRG
ALLERGIC REACTIONS WITH MCC,915,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],31602.31,,"Fee schedule rate ($31,602.31). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.8), with a minimum of zero.",,,,0,other,13332.86,33088.84,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],18585.05,,"Fee schedule rate ($18,585.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8859.23,20090.22,There are no additional notes associated with this service or procedure.
VENTRICULAR SHUNT PROCEDURES WITH MCC,031,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],62406.76,,"Fee schedule rate ($62,406.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,32287.20,88162.80,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC,817,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],43874.75,,"Fee schedule rate ($43,874.75). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,17396.11,44895.04,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],9302.19,,"Case rate ($8,859.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,377.16, add-ons for qualifying new technology services are included. If operating cost exceeds $43,248.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,265.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $6,408.58 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,432.21 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $505.70. The transfer capital threshold is the transfer adjustment factor * $505.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8859.23,20090.22,Inpatient DRG
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],16283.24,,"Fee schedule rate ($16,283.24). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7875.94,17233.12,There are no additional notes associated with this service or procedure.
SEIZURES WITH MCC,100,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],15061.09,,"Case rate ($15,061.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,146.62, add-ons for qualifying new technology services are included. If operating cost exceeds $49,017.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,719.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $12,156.85 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,201.67 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $959.30. The transfer capital threshold is the transfer adjustment factor * $959.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,15061.09,38110.41,Inpatient DRG
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC",641,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],14928.67,,"Fee schedule rate ($14,928.67). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7214.98,15312.64,There are no additional notes associated with this service or procedure.
Bronchoscopy Needle Bx Trachea Main Stem&/Bron,CASE-31629,APC,31629,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6605.95,,"APC Price ($6,605.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6605.95,6936.25,OPPS APC
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5910.09,,"Case rate ($5,710.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,447.70, add-ons for qualifying new technology services are included. If operating cost exceeds $40,318.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,035.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $3,489.88 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,502.75 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $275.39. The transfer capital threshold is the transfer adjustment factor * $275.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,3079.00,10940.41,Inpatient DRG
HC Gastroesophag Reflx Test W/Tel Ph Eltrd|REDUCED SERVICES,CASE-91035,APC,91035,CPT,0750,RC,,,52,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],831.93,,"APC Price ($803.80). Discounted by 50%. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,803.80,843.99,OPPS APC
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC,519,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],37589.76,,"Fee schedule rate ($37,589.76). Adds an outlier to normal pricing equal to the per diem rate ($123,674.40) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,15490.44,50780.20,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],94787.57,,"Fee schedule rate ($94,787.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,23526.87,94787.57,There are no additional notes associated with this service or procedure.
"NEONATE BIRTH WEIGHT 2000-2499 GRAMS NORMAL NEWBORN OR NEONATE WITH OTHER PROBLEM,MODERATE",626,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],2489.89,,"Case rate ($2,489.89). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,2489.89,2614.38,There are no additional notes associated with this service or procedure.
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR,518,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],89342.77,,"Fee schedule rate ($89,342.77). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,13252.00,89342.77,There are no additional notes associated with this service or procedure.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,073,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],23113.11,,"Fee schedule rate ($23,113.11). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,12809.38,43475.01,There are no additional notes associated with this service or procedure.
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],11165.00,,"Per diem ($11,165). If length of stay < 3.5, first 1 days paid at a per diem of $22,330 instead. Capped at $39,078.16.",,,,0,other,11165.00,61234.06,Estimated amount calculated based on 3 day length of stay.
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],17467.27,,,,,,0,other,6965.00,17467.27,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],20567.06,,"Fee schedule rate ($20,567.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,9356.31,25026.36,There are no additional notes associated with this service or procedure.
Arthroscopy Knee W/Meniscus Rpr Medial&Lateral|RIGHT SIDE,CASE-29883,APC,29883,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3169.86,OPPS APC
NEONATE WITH OTHER SIGNIFICANT PROBLEMS,794,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],11939.84,,"Case rate ($11,939.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,242.99, add-ons for qualifying new technology services are included. If operating cost exceeds $46,114.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,490.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $9,263.89 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,298.04 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $731.01. The transfer capital threshold is the transfer adjustment factor * $731.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,1798.85,12536.83,Inpatient DRG
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],52794.06,,"Fee schedule rate ($52,794.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (37), with a minimum of zero.",,,,0,other,13907.80,52794.06,There are no additional notes associated with this service or procedure.
INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC,198,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],23505.07,,"Fee schedule rate ($23,505.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6795.12,23505.07,There are no additional notes associated with this service or procedure.
Excision Inferior Turbinate Partial/Complete|LEFT SIDE,CASE-30130,APC,30130,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6605.95,,"APC Price ($6,605.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6605.95,6936.25,OPPS APC
NEONATE WITH OTHER SIGNIFICANT PROBLEMS,794,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],1956.00,,,,,,0,other,1798.85,12536.83,Estimated amount calculated based on 2 day length of stay.
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",004,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],97662.55,,"Case rate ($95,747.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $89,207.57, add-ons for qualifying new technology services are included. If operating cost exceeds $124,078.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $8,620.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 22.4. The base transfer operating payment is the transfer adjustment factor * $86,942.06 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $87,262.63 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $6,860.59. The transfer capital threshold is the transfer adjustment factor * $6,860.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,10249.47,272554.00,Inpatient DRG
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],41493.06,,"Fee schedule rate ($41,493.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,16897.01,43444.85,There are no additional notes associated with this service or procedure.
"SEIZURE,MINOR",053,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],2119.21,,"Case rate for a one day stay ($2,119.21). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,2119.21,2225.17,There are no additional notes associated with this service or procedure.
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,069,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],11269.65,,"Fee schedule rate ($11,269.65). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,20333.68,There are no additional notes associated with this service or procedure.
"VAGINAL DELIVERY WITH O.R. PROCEDURE EXCEPT STERILIZATION AND/OR D&C,MINOR",542,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],4303.32,,"Case rate ($4,303.32). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,4303.32,4518.49,There are no additional notes associated with this service or procedure.
"LIMB REATTACHMENT, HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA",956,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],74044.55,,,,,,0,other,27428.25,148259.86,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],49717.39,,"Fee schedule rate ($49,717.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,14908.05,49717.39,There are no additional notes associated with this service or procedure.
SEIZURES WITH MCC,100,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],15588.23,,"Case rate ($15,061.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,146.62, add-ons for qualifying new technology services are included. If operating cost exceeds $49,017.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,719.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $12,156.85 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,201.67 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $959.30. The transfer capital threshold is the transfer adjustment factor * $959.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,15061.09,38110.41,Inpatient DRG
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],33398.16,,"Fee schedule rate ($33,398.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,7353.00,33398.16,There are no additional notes associated with this service or procedure.
HEADACHES WITHOUT MCC,103,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],6965.00,,,,,,0,other,6965.00,20883.08,There are no additional notes associated with this service or procedure.
Cysto Bladder W/Ureteral Catheterization|BILATERAL PROCEDURE,CASE-52005,APC,52005,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1956.65,,"APC Price ($1,956.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1956.65,2054.48,OPPS APC
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],21597.50,,"Case rate ($21,597.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,227.30, add-ons for qualifying new technology services are included. If operating cost exceeds $55,098.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,197.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $18,215.19 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,282.35 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,437.36. The transfer capital threshold is the transfer adjustment factor * $1,437.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,21597.50,67790.93,Inpatient DRG
CHEST PAIN,313,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],6965.00,,,,,,0,other,6820.84,15377.66,There are no additional notes associated with this service or procedure.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],64429.92,,"Fee schedule rate ($64,429.92). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,25162.32,75579.22,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],39361.94,,"Fee schedule rate ($39,361.94). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.8), with a minimum of zero.",,,,0,other,16129.04,59610.47,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],9135.90,,"Case rate ($8,956.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,467.88, add-ons for qualifying new technology services are included. If operating cost exceeds $43,338.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,272.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $6,498.97 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,522.93 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $512.83. The transfer capital threshold is the transfer adjustment factor * $512.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,8956.76,28983.97,Inpatient DRG
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral Ea Addl,CASE-64484,APC,64484,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],856.86,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,827.89,869.28,OPPS APC
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],7721.24,,"Case rate ($7,569.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,177.66, add-ons for qualifying new technology services are included. If operating cost exceeds $42,048.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,171.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,213.49 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,232.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $411.40. The transfer capital threshold is the transfer adjustment factor * $411.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,7569.84,21892.85,Inpatient DRG
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,988,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],42425.46,,"Fee schedule rate ($42,425.46). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,13075.52,42425.46,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,085,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],9282.00,,"Per diem ($9,282). If length of stay < 4.6, first 1 days paid at a per diem of $18,564 instead. Capped at $42,695.82.",,,,0,other,9282.00,57443.16,Estimated amount calculated based on 2 day length of stay.
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],7000.00,,"Per diem ($7,000). If length of stay < 4.5, first 1 days paid at a per diem of $14,000 instead. Capped at $31,498.95.",,,,0,other,7000.00,33835.79,Estimated amount calculated based on 2 day length of stay.
TRAUMATIC INJURY WITH MCC,913,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],13665.31,,"Case rate ($13,014.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,242.79, add-ons for qualifying new technology services are included. If operating cost exceeds $47,113.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,569.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $10,260.01 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,297.84 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $809.62. The transfer capital threshold is the transfer adjustment factor * $809.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13014.58,42838.46,Inpatient DRG
Transection/Avulsion Oth Spinal Nrv Xdrl|RIGHT SIDE,CASE-64772,APC,64772,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],25830.00,,,,,,0,other,10834.64,25830.00,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],72151.96,,"Fee schedule rate ($72,151.96). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,27944.96,86252.84,There are no additional notes associated with this service or procedure.
Lithotripsy Xtrcorp Shock Wave|RIGHT SIDE,CASE-50590,APC,50590,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3299.47,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3299.47,3464.44,OPPS APC
"Remove Spinal Neurostim Electrode Plate/Paddle, Incl Fluoro",CASE-63662,APC,63662,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3272.44,,"APC Price ($3,272.44). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3272.44,3436.06,OPPS APC
Cystourethroscopy|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-52000,APC,52000,CPT,0360,RC,,,74,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],652.69,,"APC Price ($652.69). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,652.69,685.32,OPPS APC
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|RIGHT HAND, FIFTH DIGIT",CASE-26160,APC,26160,CPT,0360,RC,,,F9,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1505.12,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1505.12,1580.37,OPPS APC
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITHOUT CC/MCC,816,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],14733.53,,"Fee schedule rate ($14,733.53). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6224.90,14733.53,There are no additional notes associated with this service or procedure.
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH CC",457,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],160549.49,,"Fee schedule rate ($160,549.49). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,42327.47,160549.49,There are no additional notes associated with this service or procedure.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],75579.22,,"Fee schedule rate ($75,579.22). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,25162.32,75579.22,There are no additional notes associated with this service or procedure.
MINOR BLADDER PROCEDURES WITHOUT CC/MCC,664,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],31876.87,,"Fee schedule rate ($31,876.87). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9034.63,31876.87,There are no additional notes associated with this service or procedure.
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC,807,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],10071.17,,"Fee schedule rate ($10,071.17). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5354.25,13266.23,There are no additional notes associated with this service or procedure.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],35719.96,,"Case rate ($35,719.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $33,365.14, add-ons for qualifying new technology services are included. If operating cost exceeds $68,236.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,230.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.9. The base transfer operating payment is the transfer adjustment factor * $31,304.77 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $31,420.19 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,470.26. The transfer capital threshold is the transfer adjustment factor * $2,470.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,35719.96,105091.76,Inpatient DRG
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC,192,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6473.17,,"Case rate ($6,164.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,878.57, add-ons for qualifying new technology services are included. If operating cost exceeds $40,749.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,061.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $3,918.76 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,933.62 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $301.20. The transfer capital threshold is the transfer adjustment factor * $301.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6292.63,12753.78,Inpatient DRG
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC",758,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],16323.02,,"Fee schedule rate ($16,323.02). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8574.80,19263.78,There are no additional notes associated with this service or procedure.
NON-MALIGNANT BREAST DISORDERS WITH CC/MCC,600,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],19574.79,,"Fee schedule rate ($19,574.79). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7999.14,20495.56,There are no additional notes associated with this service or procedure.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,097,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],79915.74,,"Fee schedule rate ($79,915.74). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,26404.32,79915.74,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7623.81,,"Case rate ($7,366). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,988.03, add-ons for qualifying new technology services are included. If operating cost exceeds $41,859.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,156.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,024.55 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,043.08 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $396.49. The transfer capital threshold is the transfer adjustment factor * $396.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6965.00,21195.68,Inpatient DRG
Nsl/Sinus Ndsc Max Antrost W/Rmvl Tiss Max Sinus|LEFT SIDE,CASE-31267,APC,31267,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6605.95,,"APC Price ($6,605.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6605.95,6936.25,OPPS APC
"Arthrodesis Interphalangeal Jt W/WO Int Fixj|LEFT HAND, THUMB",CASE-26860,APC,26860,CPT,0360,RC,,,FA,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],17194.49,,"Fee schedule rate ($17,194.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8554.50,19204.75,There are no additional notes associated with this service or procedure.
Transurethral Resection Bladder Neck,CASE-52500,APC,52500,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3464.44,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3299.47,3464.44,OPPS APC
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],20170.75,,"Fee schedule rate ($20,170.75). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10048.39,23545.50,There are no additional notes associated with this service or procedure.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC",442,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],7849.58,,"Case rate ($7,695.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $7,260.76, add-ons for qualifying new technology services are included. If operating cost exceeds $45,905.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $3,189.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $5,874.79 + an uncompensated DSH payment of $1,359.91. The transfer operating threshold is the transfer adjustment factor * $5,900.84 + an uncompensated DSH payment of $1,359.91. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $460.97. The transfer capital threshold is the transfer adjustment factor * $460.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6607.45,19011.92,Inpatient DRG
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],18245.94,,"Fee schedule rate ($18,245.94). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8106.18,18245.94,There are no additional notes associated with this service or procedure.
"Tx Open Tendon Flexor Toe 1 Tendon Spx|LEFT FOOT, SECOND DIGIT",CASE-28232,APC,28232,CPT,0360,RC,,,T1,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1505.12,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1505.12,1580.37,OPPS APC
NEONATE WITH OTHER SIGNIFICANT PROBLEMS,794,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],1798.85,,"Fee schedule rate ($1,798.85). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,1798.85,12536.83,There are no additional notes associated with this service or procedure.
DIABETES WITHOUT CC/MCC,639,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],6274.80,,"Case rate ($6,151.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,858.45, add-ons for qualifying new technology services are included. If operating cost exceeds $40,729.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,067.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $3,899.13 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,913.51 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $307.68. The transfer capital threshold is the transfer adjustment factor * $307.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6151.76,12223.35,Inpatient DRG
Exc Tumor Soft Tiss Face&Scalp Subfascial 2 Cm/>,CASE-21014,APC,21014,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],2854.83,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2718.88,2854.83,OPPS APC
"Rpr Coltrl Ligm Mtcarphlngl/Iphal Jt|LEFT HAND, SECOND DIGIT",CASE-26540,APC,26540,CPT,0360,RC,,,F1,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3169.86,OPPS APC
BRONCHITIS AND ASTHMA WITH CC/MCC,202,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],8948.08,,"Case rate ($8,521.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,063.43, add-ons for qualifying new technology services are included. If operating cost exceeds $42,934.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,241.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,096.00 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,118.48 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $481.03. The transfer capital threshold is the transfer adjustment factor * $481.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7606.34,19110.30,Inpatient DRG
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR,518,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],89342.77,,"Fee schedule rate ($89,342.77). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,13252.00,89342.77,There are no additional notes associated with this service or procedure.
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],52453.14,,"Fee schedule rate ($52,453.14). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14.9), with a minimum of zero.",,,,0,other,20846.48,81306.30,There are no additional notes associated with this service or procedure.
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],5065.00,,"Per diem ($5,065). If length of stay < 2.1, first 1 days paid at a per diem of $10,130 instead. Capped at $10,636.84.",,,,0,other,5065.00,12558.65,Estimated amount calculated based on 2 day length of stay.
"OTHER ESOPHAGEAL DISORDERS,EXTREME",243,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],20146.09,,"Case rate ($20,146.09). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,20146.09,21153.39,There are no additional notes associated with this service or procedure.
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],17627.38,,"Case rate ($16,787.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,753.10, add-ons for qualifying new technology services are included. If operating cost exceeds $50,624.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,845.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $13,757.43 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,808.15 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,085.60. The transfer capital threshold is the transfer adjustment factor * $1,085.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,16787.98,62990.26,Inpatient DRG
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],23377.19,,"Case rate ($23,377.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $21,882.92, add-ons for qualifying new technology services are included. If operating cost exceeds $56,753.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,327.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $19,864.72 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $19,937.97 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,567.52. The transfer capital threshold is the transfer adjustment factor * $1,567.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,23377.19,96365.69,Inpatient DRG
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,074,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],8925.60,,"Case rate ($8,925.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,438.90, add-ons for qualifying new technology services are included. If operating cost exceeds $43,309.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,270.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,470.10 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,493.95 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $510.55. The transfer capital threshold is the transfer adjustment factor * $510.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8925.60,20919.08,Inpatient DRG
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,095,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],48575.01,,"Fee schedule rate ($48,575.01). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,19411.47,50750.92,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],81353.66,,"Fee schedule rate ($81,353.66). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,27256.92,81353.66,There are no additional notes associated with this service or procedure.
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC",605,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],17131.97,,"Fee schedule rate ($17,131.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8148.17,18024.13,There are no additional notes associated with this service or procedure.
POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES,769,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],31756.41,,"Fee schedule rate ($31,756.41). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.7), with a minimum of zero.",,,,0,other,13388.39,33250.19,There are no additional notes associated with this service or procedure.
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],12840.52,,"Case rate ($12,840.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,080.88, add-ons for qualifying new technology services are included. If operating cost exceeds $46,951.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,556.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $10,098.70 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,135.93 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $796.89. The transfer capital threshold is the transfer adjustment factor * $796.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,1188.00,31658.33,Inpatient DRG
Colpopexy Vaginal Intraperitoneal Approach|UNUSUAL NON-OVERLAPPING SERVICE,CASE-57283,APC,57283,CPT,0360,RC,,,XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7288.08,,"APC Price ($6,941.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6941.03,7288.08,OPPS APC
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],6965.00,,,,,,0,other,6965.00,32293.66,There are no additional notes associated with this service or procedure.
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,069,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],6965.00,,,,,,0,other,6965.00,20333.68,There are no additional notes associated with this service or procedure.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],15273.74,,"Case rate ($15,273.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,344.45, add-ons for qualifying new technology services are included. If operating cost exceeds $49,215.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,734.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $12,353.94 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,399.49 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $974.85. The transfer capital threshold is the transfer adjustment factor * $974.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,15273.74,39820.52,Inpatient DRG
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,074,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],19371.82,,"Fee schedule rate ($19,371.82). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,8925.60,20919.08,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL HEMORRHAGE WITH CC,378,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],18430.30,,"Fee schedule rate ($18,430.30). Adds an outlier to normal pricing equal to the per diem rate ($75,427.18) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,8586.33,20845.19,There are no additional notes associated with this service or procedure.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],61290.90,,"Fee schedule rate ($61,290.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,23799.09,63499.65,There are no additional notes associated with this service or procedure.
VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC,033,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],31250.88,,"Fee schedule rate ($31,250.88). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7.9), with a minimum of zero.",,,,0,other,13206.23,42156.44,There are no additional notes associated with this service or procedure.
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC",641,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],14624.71,,"Fee schedule rate ($14,624.71). Adds an outlier to normal pricing equal to the per diem rate ($38,755.52) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7214.98,15312.64,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12753.81,,"Case rate ($12,146.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,454.25, add-ons for qualifying new technology services are included. If operating cost exceeds $46,325.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,488.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $9,473.39 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,509.30 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $728.15. The transfer capital threshold is the transfer adjustment factor * $728.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12455.21,37149.27,Inpatient DRG
"NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY",789,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],6663.33,,,,,,0,other,3054.00,14857.05,Estimated amount calculated based on 1 day length of stay.
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],36868.88,,"Fee schedule rate ($36,868.88). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12606.23,36868.88,There are no additional notes associated with this service or procedure.
INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC,198,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],6795.12,,"Case rate ($6,795.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,456.95, add-ons for qualifying new technology services are included. If operating cost exceeds $41,327.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,114.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,495.42 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,512.00 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $354.73. The transfer capital threshold is the transfer adjustment factor * $354.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6795.12,23505.07,Inpatient DRG
CHOLECYSTECTOMY WITH C.D.E. WITH MCC,411,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],24840.95,,"Case rate ($23,658.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $22,184.70, add-ons for qualifying new technology services are included. If operating cost exceeds $57,055.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,309.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $20,163.30 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $20,239.75 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,549.80. The transfer capital threshold is the transfer adjustment factor * $1,549.80. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,24315.13,88615.28,Inpatient DRG
SIGNS AND SYMPTOMS WITH MCC,947,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],23855.83,,"Fee schedule rate ($23,855.83). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10541.41,30414.32,There are no additional notes associated with this service or procedure.
DIABETES WITH CC,638,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],15195.79,,"Fee schedule rate ($15,195.79). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8014.07,17634.53,There are no additional notes associated with this service or procedure.
"Inj Dx/Ther Agnt Paravert Facet Joint, Cerv/Thorac, 2nd Level|LEFT SIDE|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA",CASE-64491,APC,64491,CPT,0360,RC,,,LT|74,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],856.86,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,827.89,869.28,OPPS APC
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC,806,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],10071.17,,"Fee schedule rate ($10,071.17). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5354.25,13416.00,There are no additional notes associated with this service or procedure.
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],26721.94,,"Fee schedule rate ($26,721.94). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6965.00,34422.94,There are no additional notes associated with this service or procedure.
Chemodenervation Internal Anal Sphincter,CASE-46505,APC,46505,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],2689.02,,"APC Price ($2,598.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2598.08,2727.99,OPPS APC
"Repair Extensor Tendon Finger W/O Graft Each|LEFT HAND, THIRD DIGIT",CASE-26418,APC,26418,CPT,0360,RC,,,F2,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1557.80,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1505.12,1580.37,OPPS APC
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],32852.04,,"Fee schedule rate ($32,852.04). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,13783.20,41580.51,There are no additional notes associated with this service or procedure.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],10451.96,,"Case rate ($10,098.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,530.04, add-ons for qualifying new technology services are included. If operating cost exceeds $44,401.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,356.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $7,557.23 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,585.10 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $596.34. The transfer capital threshold is the transfer adjustment factor * $596.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,10098.51,24259.09,Inpatient DRG
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC,807,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],11393.67,,"Case rate ($6,510.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,192.35, add-ons for qualifying new technology services are included. If operating cost exceeds $41,063.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,093.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $4,231.80 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,247.40 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $333.93. The transfer capital threshold is the transfer adjustment factor * $333.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,5354.25,13266.23,All Other Inpatient
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC,497,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],22707.58,,"Fee schedule rate ($22,707.58). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7.8), with a minimum of zero.",,,,0,other,10127.65,37761.19,There are no additional notes associated with this service or procedure.
HC Joint Injection/Aspir Large WO US|RIGHT SIDE,CASE-20610,APC,20610,CPT,0510,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],301.68,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,287.31,301.68,OPPS APC
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC,805,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],9490.62,,"Case rate ($9,038.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,557.35, add-ons for qualifying new technology services are included. If operating cost exceeds $43,428.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,266.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $6,587.42 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,612.40 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $506.32. The transfer capital threshold is the transfer adjustment factor * $506.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9253.36,21235.42,Inpatient DRG
PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,337,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],28847.26,,"Fee schedule rate ($28,847.26). Adds an outlier to normal pricing equal to the per diem rate ($89,320.38) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.8), with a minimum of zero.",,,,0,other,12340.08,38926.31,There are no additional notes associated with this service or procedure.
MAJOR CHEST TRAUMA WITHOUT CC/MCC,185,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],21771.61,,"Fee schedule rate ($21,771.61). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7271.19,21771.61,There are no additional notes associated with this service or procedure.
"POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS,MAJOR",721,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],1958.12,,"Case rate for a one day stay ($1,864.88). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,1864.88,1958.12,There are no additional notes associated with this service or procedure.
Dstrj Lesion Anus Simple Surg Excision,CASE-46922,APC,46922,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],2598.08,,"APC Price ($2,598.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2598.08,2727.99,OPPS APC
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],12526.44,,"Fee schedule rate ($12,526.44). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5415.00,17575.50,There are no additional notes associated with this service or procedure.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],39337.51,,"Fee schedule rate ($39,337.51). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,16120.25,41187.90,There are no additional notes associated with this service or procedure.
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],33890.73,,"Fee schedule rate ($33,890.73). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6277.00,36801.89,There are no additional notes associated with this service or procedure.
Laps Gstrc Rstrictiv Px Longitudinal Gastrectomy,CASE-43775,APC,43775,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],43.83,,"APC Price ($43.83). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,43.83,46.02,OPPS APC
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],13792.01,,"Case rate ($13,792.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,966.02, add-ons for qualifying new technology services are included. If operating cost exceeds $47,837.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,626.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $10,980.58 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,021.07 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $866.48. The transfer capital threshold is the transfer adjustment factor * $866.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,34422.94,Inpatient DRG
Cysto/Uretero W/Lithotripsy &Indwell Stent Insrt|SEPARATE STRUCTURE|RIGHT SIDE,CASE-52356,APC,52356,CPT,0360,RC,,,XS|RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5018.77,,"APC Price ($5,018.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5018.77,5269.71,OPPS APC
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],17703.27,,"Case rate ($17,356.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,281.67, add-ons for qualifying new technology services are included. If operating cost exceeds $51,152.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,887.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $14,284.05 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,336.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,127.15. The transfer capital threshold is the transfer adjustment factor * $1,127.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,17356.15,44778.95,Inpatient DRG
"VERTIGO AND OTHER LABYRINTH DISORDERS,MODERATE",111,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],2741.60,,"Case rate for a one day stay ($2,611.05). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,2611.05,2741.60,There are no additional notes associated with this service or procedure.
O.R. PROCEDURES FOR OBESITY WITH CC,620,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],30074.44,,"Fee schedule rate ($30,074.44). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7.8), with a minimum of zero.",,,,0,other,12782.30,43753.50,There are no additional notes associated with this service or procedure.
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC,520,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],39786.42,,"Fee schedule rate ($39,786.42). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12061.74,39786.42,There are no additional notes associated with this service or procedure.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,057,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],10718.84,,"Case rate ($10,718.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,107.12, add-ons for qualifying new technology services are included. If operating cost exceeds $44,978.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,401.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,132.18 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,162.17 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $641.71. The transfer capital threshold is the transfer adjustment factor * $641.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10718.84,39884.93,Inpatient DRG
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],18588.16,,"Fee schedule rate ($18,588.16). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.8), with a minimum of zero.",,,,0,other,8643.20,19462.52,There are no additional notes associated with this service or procedure.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],38246.19,,"Fee schedule rate ($38,246.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,19435.86,50821.76,There are no additional notes associated with this service or procedure.
Exc Tum/Vasc Mal Sft Tiss Hand/Fngr Subq <1.5cm|RIGHT SIDE,CASE-26115,APC,26115,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1545.93,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1545.93,1623.23,OPPS APC
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],75579.22,,"Fee schedule rate ($75,579.22). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,25162.32,75579.22,There are no additional notes associated with this service or procedure.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],24909.11,,,,,,0,other,10517.71,24909.11,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6744.39,,"Case rate ($6,423.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,119.36, add-ons for qualifying new technology services are included. If operating cost exceeds $40,990.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,079.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $4,158.65 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,174.41 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $319.64. The transfer capital threshold is the transfer adjustment factor * $319.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6558.75,14871.83,Inpatient DRG
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],17755.26,,"Fee schedule rate ($17,755.26). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7847.50,17755.26,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITH STERILIZATION WITH CC,784,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],9358.80,,"Case rate ($8,913.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,440.32, add-ons for qualifying new technology services are included. If operating cost exceeds $43,311.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,257.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,470.84 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,495.37 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $497.36. The transfer capital threshold is the transfer adjustment factor * $497.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9124.01,23722.94,Inpatient DRG
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,097,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],79915.74,,"Fee schedule rate ($79,915.74). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,26404.32,79915.74,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH CC,427,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],74679.15,,"Fee schedule rate ($74,679.15). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,50829.82,142040.39,There are no additional notes associated with this service or procedure.
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC,497,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],23775.72,,,,,,0,other,10127.65,37761.19,There are no additional notes associated with this service or procedure.
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],13923.91,,"Case rate ($7,956.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,537.38, add-ons for qualifying new technology services are included. If operating cost exceeds $42,408.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,199.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,571.89 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,592.43 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $439.68. The transfer capital threshold is the transfer adjustment factor * $439.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,6965.00,17467.27,All Other Inpatient
CESAREAN SECTION WITH STERILIZATION WITH CC,784,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],23722.94,,"Fee schedule rate ($23,722.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9124.01,23722.94,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,064,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],37792.72,,"Fee schedule rate ($37,792.72). Adds an outlier to normal pricing equal to the per diem rate ($115,085.88) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,15563.58,41838.16,There are no additional notes associated with this service or procedure.
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],33159.45,,"Fee schedule rate ($33,159.45). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,13092.47,33159.45,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],59610.47,,"Fee schedule rate ($59,610.47). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,16129.04,59610.47,There are no additional notes associated with this service or procedure.
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],39424.57,,"Fee schedule rate ($39,424.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12195.15,39424.57,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC,788,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],20142.33,,"Fee schedule rate ($20,142.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8438.02,20142.33,There are no additional notes associated with this service or procedure.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],49902.84,,,,,,0,other,11348.00,62454.12,There are no additional notes associated with this service or procedure.
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],11522.52,,"Case rate ($10,973.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,361.17, add-ons for qualifying new technology services are included. If operating cost exceeds $45,232.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,404.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,384.43 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,416.22 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $644.45. The transfer capital threshold is the transfer adjustment factor * $644.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,11247.07,27028.33,Inpatient DRG
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],18905.23,,"Fee schedule rate ($18,905.23). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6963.00,18954.85,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],13245.75,,"Fee schedule rate ($13,245.75). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9795.13,23899.13,There are no additional notes associated with this service or procedure.
"Tendon Sheath Incision|RIGHT HAND, FIFTH DIGIT",CASE-26055,APC,26055,CPT,0360,RC,,,F9,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1580.37,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1505.12,1580.37,OPPS APC
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],14428.87,,"Case rate ($13,741.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,941.31, add-ons for qualifying new technology services are included. If operating cost exceeds $47,812.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,601.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $10,954.82 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,996.36 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $842.01. The transfer capital threshold is the transfer adjustment factor * $842.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7332.00,35314.31,Inpatient DRG
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],73588.10,,"Fee schedule rate ($73,588.10). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,21585.31,73588.10,There are no additional notes associated with this service or procedure.
Excision Ganglion Wrist Dorsal/Volar Primary|LEFT SIDE,CASE-25111,APC,25111,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1505.12,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1505.12,1580.37,OPPS APC
Episiotomy/Vag Rpr Oth/Thn Attending,CASE-59300,APC,59300,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3030.03,,"APC Price ($3,030.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3030.03,3181.53,OPPS APC
OSTEOMYELITIS WITHOUT CC/MCC,541,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],7277.28,,"Case rate ($7,277.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,905.50, add-ons for qualifying new technology services are included. If operating cost exceeds $41,776.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,149.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $4,942.33 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,960.55 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $390.00. The transfer capital threshold is the transfer adjustment factor * $390.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,5103.00,15493.67,Inpatient DRG
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH MCC",510,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],22399.99,,"Case rate ($22,399.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,973.84, add-ons for qualifying new technology services are included. If operating cost exceeds $55,844.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,256.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.3. The base transfer operating payment is the transfer adjustment factor * $18,958.99 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $19,028.89 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,496.05. The transfer capital threshold is the transfer adjustment factor * $1,496.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10710.00,89863.76,Inpatient DRG
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],15818.84,,"Case rate ($15,283.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,353.89, add-ons for qualifying new technology services are included. If operating cost exceeds $49,224.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,735.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.2. The base transfer operating payment is the transfer adjustment factor * $12,363.36 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,408.94 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $975.59. The transfer capital threshold is the transfer adjustment factor * $975.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,15283.90,38757.79,Inpatient DRG
Orchiectomy Radical Tumor Inguinal Approach|LEFT SIDE,CASE-54530,APC,54530,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3351.34,,"APC Price ($3,351.34). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3351.34,3518.91,OPPS APC
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],26204.74,,"Fee schedule rate ($26,204.74). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10120.20,26204.74,There are no additional notes associated with this service or procedure.
Rpr Xtnsr Tdn Cntrl Slip Tiss W/Lat Band Ea Fngr,CASE-26426,APC,26426,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],81524.17,,"Fee schedule rate ($81,524.17). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,8972.00,81524.17,There are no additional notes associated with this service or procedure.
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],29216.99,,"Fee schedule rate ($29,216.99). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9755.86,29216.99,There are no additional notes associated with this service or procedure.
CERVICAL SPINAL FUSION WITHOUT CC/MCC,473,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],62077.11,,"Fee schedule rate ($62,077.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,18477.61,62077.11,There are no additional notes associated with this service or procedure.
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],14747.55,,"Case rate ($14,747.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,854.94, add-ons for qualifying new technology services are included. If operating cost exceeds $48,725.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,696.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $11,866.24 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,909.99 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $936.36. The transfer capital threshold is the transfer adjustment factor * $936.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,14747.55,37899.49,Inpatient DRG
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],9608.67,,"Case rate ($9,151.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,648.69, add-ons for qualifying new technology services are included. If operating cost exceeds $43,519.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,287.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,679.11 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,703.74 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $527.05. The transfer capital threshold is the transfer adjustment factor * $527.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9151.11,30245.71,Inpatient DRG
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC",442,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],13467.42,,"Case rate ($7,695.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $7,260.76, add-ons for qualifying new technology services are included. If operating cost exceeds $45,905.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $3,189.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $5,874.79 + an uncompensated DSH payment of $1,359.91. The transfer operating threshold is the transfer adjustment factor * $5,900.84 + an uncompensated DSH payment of $1,359.91. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $460.97. The transfer capital threshold is the transfer adjustment factor * $460.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,6607.45,19011.92,All Other Inpatient
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],14970.38,,"Case rate ($8,554.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,093.67, add-ons for qualifying new technology services are included. If operating cost exceeds $42,964.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,243.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,126.13 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,148.72 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $483.41. The transfer capital threshold is the transfer adjustment factor * $483.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,8554.50,19204.75,All Other Inpatient
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],105091.76,,"Fee schedule rate ($105,091.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,35719.96,105091.76,There are no additional notes associated with this service or procedure.
Exc Tumor Soft Tiss Face&Scalp Subfascial 2 Cm/>,CASE-21014,APC,21014,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],2854.83,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2718.88,2854.83,OPPS APC
MINOR BLADDER PROCEDURES WITHOUT CC/MCC,664,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],9034.63,,"Case rate ($9,034.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,540.33, add-ons for qualifying new technology services are included. If operating cost exceeds $43,411.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,278.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $6,571.15 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,595.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $518.53. The transfer capital threshold is the transfer adjustment factor * $518.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9034.63,31876.87,Inpatient DRG
HC Bx Breast 1st Lesion US Img|BILATERAL PROCEDURE,CASE-19083,APC,19083,CPT,0361,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],2814.04,,"APC Price ($2,718.88). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2718.88,2854.83,OPPS APC
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,329,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],33072.77,,"Case rate ($33,072.77). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $30,902.51, add-ons for qualifying new technology services are included. If operating cost exceeds $65,773.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,036.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.4. The base transfer operating payment is the transfer adjustment factor * $28,851.18 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $28,957.55 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,276.64. The transfer capital threshold is the transfer adjustment factor * $2,276.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,33072.77,90445.33,Inpatient DRG
Cystourethroscopy W/Dest &/Rmvl Tumor Large,CASE-52240,APC,52240,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5194.43,,"APC Price ($5,018.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5018.77,5269.71,OPPS APC
OTHER CEREBROVASCULAR DISORDERS WITH MCC,070,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],13219.09,,"Case rate ($13,219.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,433.04, add-ons for qualifying new technology services are included. If operating cost exceeds $47,304.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,584.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $10,449.57 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,488.10 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $824.57. The transfer capital threshold is the transfer adjustment factor * $824.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,13219.09,37774.46,Inpatient DRG
SPINAL PROCEDURES WITH MCC,028,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],43486.24,,"Case rate ($42,633.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $39,796.72, add-ons for qualifying new technology services are included. If operating cost exceeds $74,667.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,735.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.5. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 9.5)) / 2. The base transfer operating payment is the transfer adjustment factor * $37,712.72 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $37,851.77 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,975.91. The transfer capital threshold is the transfer adjustment factor * $2,975.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,42633.57,120982.83,Inpatient DRG
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],39820.52,,"Fee schedule rate ($39,820.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,15273.74,39820.52,There are no additional notes associated with this service or procedure.
Lithotripsy Xtrcorp Shock Wave|BILATERAL PROCEDURE,CASE-50590,APC,50590,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3299.47,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3299.47,3464.44,OPPS APC
Colsc Flexible W/Transendoscopic Balloon Dilat,CASE-45386,APC,45386,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1176.09,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1120.09,1176.09,OPPS APC
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],51903.64,,"Fee schedule rate ($51,903.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,16017.99,51903.64,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],30063.84,,"Fee schedule rate ($30,063.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13891.57,34712.20,There are no additional notes associated with this service or procedure.
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],12937.10,,"Fee schedule rate ($12,937.10). Adds an outlier to normal pricing equal to the per diem rate ($49,808.13) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.5), with a minimum of zero.",,,,0,other,5919.29,13545.65,There are no additional notes associated with this service or procedure.
Mastectomy Partial,CASE-19301,APC,19301,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3793.21,,"APC Price ($3,664.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3793.21,3793.21,OPPS APC
HC Joint Injection/Aspir Large WO US|PBB CHARGE|LEFT SIDE,CASE-20610,APC,20610,CPT,0510,RC,,,PBB|LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],287.31,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
Thyroidectomy Total/Complete,CASE-60240,APC,60240,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5941.70,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5658.76,5941.70,OPPS APC
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],14274.73,,"Case rate ($13,792.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,966.02, add-ons for qualifying new technology services are included. If operating cost exceeds $47,837.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,626.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $10,980.58 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,021.07 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $866.48. The transfer capital threshold is the transfer adjustment factor * $866.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6965.00,34422.94,Inpatient DRG
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC,797,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],20928.55,,"Fee schedule rate ($20,928.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8719.72,20928.55,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],67794.72,,"Fee schedule rate ($67,794.72). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,10862.00,86437.13,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],12732.39,,"Case rate ($12,126.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,416.25, add-ons for qualifying new technology services are included. If operating cost exceeds $46,287.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,504.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $9,436.50 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,471.29 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $744.63. The transfer capital threshold is the transfer adjustment factor * $744.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12126.09,29582.40,Inpatient DRG
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC,434,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],6905.45,,"Case rate ($6,770.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,433.64, add-ons for qualifying new technology services are included. If operating cost exceeds $41,304.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,112.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,472.20 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,488.69 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $352.90. The transfer capital threshold is the transfer adjustment factor * $352.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6770.05,14019.86,Inpatient DRG
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",062,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],13844.84,,"Case rate ($13,844.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,015.16, add-ons for qualifying new technology services are included. If operating cost exceeds $47,886.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,630.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $11,029.54 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,070.21 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $870.34. The transfer capital threshold is the transfer adjustment factor * $870.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,13844.84,44304.80,Inpatient DRG
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],97015.50,,"Fee schedule rate ($97,015.50). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,26809.29,97015.50,There are no additional notes associated with this service or procedure.
Laryngoscopy Exc Tum&/Stripping Cords/Epiglott,CASE-31540,APC,31540,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3664.31,,"APC Price ($3,489.82). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3489.82,3664.31,OPPS APC
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],29241.62,,"Fee schedule rate ($29,241.62). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,12984.79,32077.45,There are no additional notes associated with this service or procedure.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],16749.22,,"Case rate ($9,570.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,039.28, add-ons for qualifying new technology services are included. If operating cost exceeds $43,910.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,317.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $7,068.27 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,094.33 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $557.76. The transfer capital threshold is the transfer adjustment factor * $557.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,5569.00,40108.48,All Other Inpatient
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,083,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],11967.27,,"Case rate ($11,397.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,738.37, add-ons for qualifying new technology services are included. If operating cost exceeds $45,609.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,451.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $8,761.12 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,793.42 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $691.34. The transfer capital threshold is the transfer adjustment factor * $691.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,28680.85,Inpatient DRG
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],7453.00,,"Per diem ($7,453). If length of stay < 5.4, first 1 days paid at a per diem of $14,906 instead. Capped at $40,245.21.",,,,0,other,7453.00,42138.30,Estimated amount calculated based on 3 day length of stay.
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],6965.00,,,,,,0,other,6965.00,21089.59,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITH CC,386,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],14973.93,,"Case rate ($8,556.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,095.56, add-ons for qualifying new technology services are included. If operating cost exceeds $42,966.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,243.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,128.01 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,150.61 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $483.56. The transfer capital threshold is the transfer adjustment factor * $483.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,8556.53,19879.00,All Other Inpatient
PREMATURITY WITHOUT MAJOR PROBLEMS,792,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],2074.00,,,,,,0,other,1956.00,19457.66,Estimated amount calculated based on 3 day length of stay.
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC",458,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],73617.60,,"Fee schedule rate ($73,617.60). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,30202.09,132827.25,There are no additional notes associated with this service or procedure.
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],21512.35,,"Fee schedule rate ($21,512.35). Adds an outlier to normal pricing equal to the per diem rate ($37,521.53) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,9696.93,35061.53,There are no additional notes associated with this service or procedure.
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],14455.04,,"Fee schedule rate ($14,455.04). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5280.00,17136.70,There are no additional notes associated with this service or procedure.
POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES,769,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],13656.16,,"Case rate ($13,388.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,590.54, add-ons for qualifying new technology services are included. If operating cost exceeds $47,461.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,596.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $10,606.49 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,645.59 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $836.96. The transfer capital threshold is the transfer adjustment factor * $836.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,13388.39,33250.19,Inpatient DRG
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],75976.83,,,,,,0,other,10078.00,81454.07,There are no additional notes associated with this service or procedure.
OSTEOMYELITIS WITHOUT CC/MCC,541,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],11429.52,,"Fee schedule rate ($11,429.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5103.00,15493.67,There are no additional notes associated with this service or procedure.
ALLERGIC REACTIONS WITH MCC,915,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],13332.86,,"Case rate ($13,332.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,538.89, add-ons for qualifying new technology services are included. If operating cost exceeds $47,409.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,592.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $10,555.02 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,593.94 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $832.90. The transfer capital threshold is the transfer adjustment factor * $832.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,13332.86,33088.84,Inpatient DRG
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],11348.00,,"Per diem ($11,348). If length of stay < 4.2, first 1 days paid at a per diem of $22,696 instead. Capped at $47,660.93.",,,,0,other,11348.00,62454.12,Estimated amount calculated based on 5 day length of stay.
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],23377.19,,"Case rate ($23,377.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $21,882.92, add-ons for qualifying new technology services are included. If operating cost exceeds $56,753.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,327.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $19,864.72 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $19,937.97 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,567.52. The transfer capital threshold is the transfer adjustment factor * $1,567.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,23377.19,96365.69,Inpatient DRG
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,057,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],39884.93,,"Fee schedule rate ($39,884.93). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,10718.84,39884.93,There are no additional notes associated with this service or procedure.
Intraop Sentinel Lymph Node ID W/Dye Injection|RIGHT SIDE,CASE-38900,APC,38900,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6432.89,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6215.36,6526.12,OPPS APC
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],45706.73,,"Fee schedule rate ($45,706.73). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,7921.00,45706.73,There are no additional notes associated with this service or procedure.
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],11133.98,,"Fee schedule rate ($11,133.98). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5919.29,13545.65,There are no additional notes associated with this service or procedure.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],28395.88,,,,,,0,other,11717.72,43888.01,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,064,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],41838.16,,"Fee schedule rate ($41,838.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,15563.58,41838.16,There are no additional notes associated with this service or procedure.
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",004,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],95747.60,,"Case rate ($95,747.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $89,207.57, add-ons for qualifying new technology services are included. If operating cost exceeds $124,078.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $8,620.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 22.4. The base transfer operating payment is the transfer adjustment factor * $86,942.06 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $87,262.63 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $6,860.59. The transfer capital threshold is the transfer adjustment factor * $6,860.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10249.47,272554.00,Inpatient DRG
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],33221.97,,"Fee schedule rate ($33,221.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (47), with a minimum of zero.",,,,0,other,15283.90,38757.79,There are no additional notes associated with this service or procedure.
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7108.12,,"Case rate ($6,769.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,442.26, add-ons for qualifying new technology services are included. If operating cost exceeds $41,313.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,104.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,480.33 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,497.31 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $344.37. The transfer capital threshold is the transfer adjustment factor * $344.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6915.64,14442.92,Inpatient DRG
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],25276.59,,"Fee schedule rate ($25,276.59). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,11053.39,36776.05,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],128358.13,,"Fee schedule rate ($128,358.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,40542.37,128358.13,There are no additional notes associated with this service or procedure.
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",004,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],10870.65,,,,,,0,other,10249.47,272554.00,Estimated amount calculated based on 6 day length of stay.
HEART FAILURE AND SHOCK WITH CC,292,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],7694.43,,"Case rate ($7,694.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,293.57, add-ons for qualifying new technology services are included. If operating cost exceeds $42,164.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,180.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,328.98 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,348.63 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $420.51. The transfer capital threshold is the transfer adjustment factor * $420.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,5502.00,16705.77,Inpatient DRG
PERITONEAL ADHESIOLYSIS WITH CC,336,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],53705.31,,"Fee schedule rate ($53,705.31). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,16225.22,53705.31,There are no additional notes associated with this service or procedure.
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],10002.75,,"Case rate ($9,526.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,011.98, add-ons for qualifying new technology services are included. If operating cost exceeds $43,882.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,301.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $7,040.34 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,067.03 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $541.14. The transfer capital threshold is the transfer adjustment factor * $541.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9755.86,29216.99,Inpatient DRG
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],7141.97,,"Case rate ($6,801.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,463.25, add-ons for qualifying new technology services are included. If operating cost exceeds $41,334.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,115.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,501.70 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,518.30 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $355.23. The transfer capital threshold is the transfer adjustment factor * $355.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6801.88,22557.82,Inpatient DRG
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],101083.00,,"Fee schedule rate ($101,083.00). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,35389.50,101083.00,There are no additional notes associated with this service or procedure.
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],27222.08,,"Fee schedule rate ($27,222.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7389.00,37134.43,There are no additional notes associated with this service or procedure.
Arthrs Aided Ant Cruciate Ligm Rpr/Agmntj/Rcnstj|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-29888,APC,29888,CPT,0360,RC,,,RT|XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],12437.92,,"APC Price ($12,017.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,12017.31,12437.92,OPPS APC
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],22358.90,,"Fee schedule rate ($22,358.90). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9389.48,22358.90,There are no additional notes associated with this service or procedure.
"MAJOR RESPIRATORY INFECTIONS AND INFLAMMATIONS,MODERATE",137,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],7130.89,,"Case rate ($7,130.89). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,7130.89,7487.43,There are no additional notes associated with this service or procedure.
SPINAL PROCEDURES WITH MCC,028,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],42633.57,,"Case rate ($42,633.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $39,796.72, add-ons for qualifying new technology services are included. If operating cost exceeds $74,667.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,735.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.5. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 9.5)) / 2. The base transfer operating payment is the transfer adjustment factor * $37,712.72 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $37,851.77 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,975.91. The transfer capital threshold is the transfer adjustment factor * $2,975.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,42633.57,120982.83,Inpatient DRG
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7598.16,,"Case rate ($7,236.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,877.29, add-ons for qualifying new technology services are included. If operating cost exceeds $41,748.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,137.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,913.71 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,932.34 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $377.68. The transfer capital threshold is the transfer adjustment factor * $377.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7396.47,16035.06,Inpatient DRG
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC",156,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],12987.84,,"Fee schedule rate ($12,987.84). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,6625.12,13598.77,There are no additional notes associated with this service or procedure.
Cysto W/Removal of Tumors Small,CASE-52234,APC,52234,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3299.47,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3299.47,3464.44,OPPS APC
HC >= 12 Lead Ekg|ADJ,CASE-93005,APC,93005,CPT,0730,RC,,,ADJ,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],124.62,,"APC Price ($124.62). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,124.62,130.85,OPPS APC
Amputation Metatarsal W/Toe Single,CASE-28810,APC,28810,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3062.67,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],22695.45,,,,,,0,other,9755.86,29216.99,There are no additional notes associated with this service or procedure.
MINOR BLADDER PROCEDURES WITHOUT CC/MCC,664,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],31876.87,,"Fee schedule rate ($31,876.87). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9034.63,31876.87,There are no additional notes associated with this service or procedure.
"Repair Extensor Tendon Finger W/O Graft Each|LEFT HAND, THIRD DIGIT",CASE-26418,APC,26418,CPT,0360,RC,,,F2,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1557.80,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1505.12,1580.37,OPPS APC
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],8874.81,,"Case rate ($8,874.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,391.65, add-ons for qualifying new technology services are included. If operating cost exceeds $43,262.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,266.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $6,423.02 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,446.70 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $506.84. The transfer capital threshold is the transfer adjustment factor * $506.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8874.81,20553.44,Inpatient DRG
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],8702.79,,"Case rate ($8,702.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,231.63, add-ons for qualifying new technology services are included. If operating cost exceeds $43,102.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,254.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,263.59 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,286.68 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $494.26. The transfer capital threshold is the transfer adjustment factor * $494.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,5683.00,19635.68,Inpatient DRG
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],16756.96,,"Case rate ($16,428.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,418.58, add-ons for qualifying new technology services are included. If operating cost exceeds $50,289.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,819.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $13,424.13 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,473.63 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,059.30. The transfer capital threshold is the transfer adjustment factor * $1,059.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,16428.39,42083.20,Inpatient DRG
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],30935.16,,"Fee schedule rate ($30,935.16). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13092.47,33159.45,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],34892.92,,"Fee schedule rate ($34,892.92). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,6965.00,41030.48,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],32795.66,,"Fee schedule rate ($32,795.66). Adds an outlier to normal pricing equal to the per diem rate ($69,146.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,1188.00,34338.33,There are no additional notes associated with this service or procedure.
DIABETES WITHOUT CC/MCC,639,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6151.76,,"Case rate ($6,151.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,858.45, add-ons for qualifying new technology services are included. If operating cost exceeds $40,729.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,067.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $3,899.13 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,913.51 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $307.68. The transfer capital threshold is the transfer adjustment factor * $307.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6151.76,12223.35,Inpatient DRG
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],25276.59,,"Fee schedule rate ($25,276.59). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,11053.39,36776.05,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,448,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],31311.40,,"Case rate ($29,820.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $27,928.88, add-ons for qualifying new technology services are included. If operating cost exceeds $62,799.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,749.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $25,885.78 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $25,983.93 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,989.64. The transfer capital threshold is the transfer adjustment factor * $1,989.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,30663.95,94077.13,Inpatient DRG
NEONATE WITH OTHER SIGNIFICANT PROBLEMS,794,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],11939.84,,"Case rate ($11,939.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,242.99, add-ons for qualifying new technology services are included. If operating cost exceeds $46,114.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,490.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $9,263.89 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,298.04 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $731.01. The transfer capital threshold is the transfer adjustment factor * $731.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,1798.85,12536.83,Inpatient DRG
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],20401.88,,"Fee schedule rate ($20,401.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,20401.88,There are no additional notes associated with this service or procedure.
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],15122.13,,"Case rate ($14,610.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,727.68, add-ons for qualifying new technology services are included. If operating cost exceeds $48,598.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,686.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.6. The base transfer operating payment is the transfer adjustment factor * $11,739.44 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,782.73 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $926.36. The transfer capital threshold is the transfer adjustment factor * $926.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6277.00,36801.89,Inpatient DRG
"HEART FAILURE,EXTREME",194,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],22266.50,,"Case rate ($22,266.50). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,22266.50,23379.83,There are no additional notes associated with this service or procedure.
COMPLICATIONS OF TREATMENT WITH CC,920,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],11021.73,,"Fee schedule rate ($11,021.73). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8732.59,20731.52,There are no additional notes associated with this service or procedure.
COAGULATION DISORDERS,813,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],28664.96,,"Fee schedule rate ($28,664.96). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.7), with a minimum of zero.",,,,0,other,12274.39,30013.33,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],15997.57,,"Case rate ($15,456.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,514.54, add-ons for qualifying new technology services are included. If operating cost exceeds $49,385.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,748.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $12,523.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,569.59 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $988.22. The transfer capital threshold is the transfer adjustment factor * $988.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,15456.59,41402.42,Inpatient DRG
CELLULITIS WITH MCC,602,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],26710.49,,"Fee schedule rate ($26,710.49). Adds an outlier to normal pricing equal to the per diem rate ($28,488.06) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.8), with a minimum of zero.",,,,0,other,11570.10,28349.31,There are no additional notes associated with this service or procedure.
Rpr/Advmnt Flxr Tdn Zone 2 W/O Fr Grft Ea Tendon,CASE-26356,APC,26356,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7909.07,,"Case rate ($7,641.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,244.44, add-ons for qualifying new technology services are included. If operating cost exceeds $42,115.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,176.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,280.02 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,299.49 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $416.65. The transfer capital threshold is the transfer adjustment factor * $416.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,7641.61,19371.27,Inpatient DRG
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],17988.50,,"Fee schedule rate ($17,988.50). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,7000.00,33835.79,There are no additional notes associated with this service or procedure.
VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC,033,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],42156.44,,"Fee schedule rate ($42,156.44). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,13206.23,42156.44,There are no additional notes associated with this service or procedure.
HC N Block Inj Intercost Sng|RIGHT SIDE,CASE-64420,APC,64420,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],660.72,,"APC Price ($660.72). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,660.72,693.76,OPPS APC
SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS,029,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],25925.24,,"Case rate ($25,048.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $23,437.73, add-ons for qualifying new technology services are included. If operating cost exceeds $58,308.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,449.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.7)) / 2. The base transfer operating payment is the transfer adjustment factor * $21,413.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $21,492.79 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,689.76. The transfer capital threshold is the transfer adjustment factor * $1,689.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,13641.00,67130.05,Inpatient DRG
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],6965.00,,,,,,0,other,6148.93,15887.21,There are no additional notes associated with this service or procedure.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],7453.00,,"Per diem ($7,453). If length of stay < 5.4, first 1 days paid at a per diem of $14,906 instead. Capped at $40,245.21.",,,,0,other,7453.00,42138.30,Estimated amount calculated based on 3 day length of stay.
POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES,769,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],33250.19,,,,,,0,other,13388.39,33250.19,There are no additional notes associated with this service or procedure.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],39316.61,,,,,,0,other,15476.23,42787.31,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],52449.26,,"Fee schedule rate ($52,449.26). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,17693.40,52449.26,There are no additional notes associated with this service or procedure.
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],11168.08,,"Fee schedule rate ($11,168.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5937.41,12366.99,There are no additional notes associated with this service or procedure.
RADIOTHERAPY,849,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],81867.07,,"Fee schedule rate ($81,867.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,20293.88,81867.07,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],13260.40,,"Case rate ($13,260.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,471.48, add-ons for qualifying new technology services are included. If operating cost exceeds $47,342.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,587.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $10,487.86 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,526.53 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $827.60. The transfer capital threshold is the transfer adjustment factor * $827.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,13260.40,32878.30,Inpatient DRG
"CARDIAC ARREST, UNEXPLAINED WITH MCC",296,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],12522.25,,"Case rate ($12,522.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,784.78, add-ons for qualifying new technology services are included. If operating cost exceeds $46,655.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,533.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $9,803.69 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,839.84 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $773.61. The transfer capital threshold is the transfer adjustment factor * $773.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12522.25,36459.67,Inpatient DRG
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],9075.36,,"Case rate ($8,643.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,176.19, add-ons for qualifying new technology services are included. If operating cost exceeds $43,047.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,249.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $6,208.35 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,231.24 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $489.90. The transfer capital threshold is the transfer adjustment factor * $489.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8643.20,19462.52,Inpatient DRG
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],11886.92,,"Fee schedule rate ($11,886.92). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9389.48,22358.90,There are no additional notes associated with this service or procedure.
Egd Transoral Control Bleeding Any Method|UNUSUAL NON-OVERLAPPING SERVICE,CASE-43255,APC,43255,CPT,0360,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1796.14,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1796.14,1885.95,OPPS APC
GASTROINTESTINAL OBSTRUCTION WITH CC,389,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],9102.45,,"Fee schedule rate ($9,102.45). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5118.00,16423.43,There are no additional notes associated with this service or procedure.
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],18093.25,,"Fee schedule rate ($18,093.25). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,15233.11,38610.21,There are no additional notes associated with this service or procedure.
"HC Repair Nail Bed|RIGHT HAND, FIFTH DIGIT",CASE-11760,APC,11760,CPT,0450,RC,,,F9,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,056,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],59328.19,,"Fee schedule rate ($59,328.19). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (44), with a minimum of zero.",,,,0,other,7659.00,59328.19,There are no additional notes associated with this service or procedure.
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],8816.06,,"Case rate ($8,643.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,176.19, add-ons for qualifying new technology services are included. If operating cost exceeds $43,047.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,249.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $6,208.35 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,231.24 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $489.90. The transfer capital threshold is the transfer adjustment factor * $489.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,8643.20,19462.52,Inpatient DRG
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,066,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],20083.61,,"Fee schedule rate ($20,083.61). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6579.76,20083.61,There are no additional notes associated with this service or procedure.
Tenodesis Long Tendon Biceps|LEFT SIDE,CASE-23430,APC,23430,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6791.99,7131.59,OPPS APC
"OSTEOMYELITIS SEPTIC ARTHRITIS AND OTHER MUSCULOSKELETAL INFECTIONS,MODERATE",344,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],9921.08,,"Case rate ($9,448.65). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9448.65,9921.08,There are no additional notes associated with this service or procedure.
SPINAL PROCEDURES WITHOUT CC/MCC,030,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],43194.95,,,,,,0,other,16810.99,44714.01,There are no additional notes associated with this service or procedure.
PREMATURITY WITHOUT MAJOR PROBLEMS,792,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],11512.88,,"Fee schedule rate ($11,512.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,1956.00,19457.66,There are no additional notes associated with this service or procedure.
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC",605,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],17131.97,,"Fee schedule rate ($17,131.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8148.17,18024.13,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],6965.00,,,,,,0,other,6965.00,19126.88,There are no additional notes associated with this service or procedure.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],23799.09,,"Case rate ($23,799.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $22,275.40, add-ons for qualifying new technology services are included. If operating cost exceeds $57,146.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,358.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.1. The base transfer operating payment is the transfer adjustment factor * $20,255.77 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $20,330.45 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,598.38. The transfer capital threshold is the transfer adjustment factor * $1,598.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,23799.09,63499.65,Inpatient DRG
Rpr 1st Ingun Hrna Age 5 Yrs/> Reducible|LEFT SIDE,CASE-49505,APC,49505,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3468.64,,"APC Price ($3,351.34). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3351.34,3518.91,OPPS APC
Ercp Destruction/Lithotripsy Calculi Any Method,CASE-43265,APC,43265,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5881.39,,"APC Price ($5,682.51). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5682.51,5966.63,OPPS APC
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],8778.37,,"Case rate ($8,360.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,925.03, add-ons for qualifying new technology services are included. If operating cost exceeds $42,796.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,217.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $5,957.49 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,980.08 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $457.91. The transfer capital threshold is the transfer adjustment factor * $457.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8554.50,19204.75,Inpatient DRG
COMPLICATIONS OF TREATMENT WITH CC,920,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],20731.52,,"Fee schedule rate ($20,731.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8732.59,20731.52,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],70242.60,,"Fee schedule rate ($70,242.60). Adds an outlier to normal pricing equal to the per diem rate ($137,416) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16.5), with a minimum of zero.",,,,0,other,27256.92,81353.66,There are no additional notes associated with this service or procedure.
Cystourethroscopy|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-52000,APC,52000,CPT,0360,RC,,,74,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],675.53,,"APC Price ($652.69). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,652.69,685.32,OPPS APC
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC",011,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],150008.48,,"Fee schedule rate ($150,008.48). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (44), with a minimum of zero.",,,,0,other,38880.49,150008.48,There are no additional notes associated with this service or procedure.
HC >= 12 Lead Ekg|PBB CHARGE,CASE-93005,APC,93005,CPT,0730,RC,,,PBB,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],57.15,,"APC Price ($55.22). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,55.22,57.98,OPPS APC
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],2070.00,,,,,,0,other,1188.00,34338.33,Estimated amount calculated based on 6 day length of stay.
DIABETES WITHOUT CC/MCC,639,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6367.07,,"Case rate ($6,151.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,858.45, add-ons for qualifying new technology services are included. If operating cost exceeds $40,729.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,067.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $3,899.13 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,913.51 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $307.68. The transfer capital threshold is the transfer adjustment factor * $307.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6151.76,12223.35,Inpatient DRG
Exc B9 Lesion Mrgn Xcp Sk Tg T/a/L 3.1-4.0 Cm,CASE-11404,APC,11404,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1545.93,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1545.93,1623.23,OPPS APC
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],40426.76,,"Fee schedule rate ($40,426.76). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,11914.12,40426.76,There are no additional notes associated with this service or procedure.
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",759,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],11643.60,,"Fee schedule rate ($11,643.60). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6190.22,13057.66,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],13031.04,,"Case rate ($12,775.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,020.41, add-ons for qualifying new technology services are included. If operating cost exceeds $46,891.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,552.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $10,038.44 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,075.45 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $792.13. The transfer capital threshold is the transfer adjustment factor * $792.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,12775.53,31469.43,Inpatient DRG
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],15381.51,,,,,,0,other,7238.69,16804.22,There are no additional notes associated with this service or procedure.
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],24126.45,,"Fee schedule rate ($24,126.45). Adds an outlier to normal pricing equal to the per diem rate ($62,306.11) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10638.94,25261.33,There are no additional notes associated with this service or procedure.
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC,939,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],97674.79,,"Fee schedule rate ($97,674.79). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,26517.40,97674.79,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],12990.19,,"Case rate ($12,990.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,220.11, add-ons for qualifying new technology services are included. If operating cost exceeds $47,091.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,567.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $10,237.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,275.16 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $807.83. The transfer capital threshold is the transfer adjustment factor * $807.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9888.00,43399.23,Inpatient DRG
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC,831,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],9294.42,,"Fee schedule rate ($9,294.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,4941.30,23661.59,There are no additional notes associated with this service or procedure.
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC",514,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],20115.80,,,,,,0,other,8868.04,22699.91,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],52803.53,,"Fee schedule rate ($52,803.53). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,14337.84,52803.53,There are no additional notes associated with this service or procedure.
Revision of Spinal Shunt,CASE-63744,APC,63744,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3357.48,,"APC Price ($3,197.60). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3197.60,3357.48,OPPS APC
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],142438.06,,"Fee schedule rate ($142,438.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (40), with a minimum of zero.",,,,0,other,45521.20,142438.06,There are no additional notes associated with this service or procedure.
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],23078.81,,"Fee schedule rate ($23,078.81). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10311.17,24308.97,There are no additional notes associated with this service or procedure.
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],53275.26,,"Fee schedule rate ($53,275.26). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,15940.79,53275.26,There are no additional notes associated with this service or procedure.
Arthrs Wrst Exc&/Rpr Triang Fibrocart&/Joint,CASE-29846,APC,29846,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],20959.73,,"Fee schedule rate ($20,959.73). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12195.15,39424.57,There are no additional notes associated with this service or procedure.
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITH MCC OR ANTINEOPLASTIC IMPLANT OR EPILEPSY WITH NEUROSTIMULATOR,023,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],136379.44,,"Fee schedule rate ($136,379.44). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,15168.00,136379.44,There are no additional notes associated with this service or procedure.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],46215.75,,"Fee schedule rate ($46,215.75). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.7), with a minimum of zero.",,,,0,other,18598.83,48389.68,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],21167.26,,"Fee schedule rate ($21,167.26). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,6841.83,21167.26,There are no additional notes associated with this service or procedure.
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],6586.33,,"Case rate ($6,457.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,142.59, add-ons for qualifying new technology services are included. If operating cost exceeds $41,013.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,089.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $4,182.21 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,197.63 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $330.02. The transfer capital threshold is the transfer adjustment factor * $330.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,5139.72,13110.79,Inpatient DRG
HEADACHES WITHOUT MCC,103,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],20883.08,,"Fee schedule rate ($20,883.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,20883.08,There are no additional notes associated with this service or procedure.
Colonoscopy W/Biopsy Single/Multiple|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-45380,APC,45380,CPT,0360,RC,,,74,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1159.29,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1120.09,1176.09,OPPS APC
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC,099,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],22084.20,,"Fee schedule rate ($22,084.20). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11171.21,26807.94,There are no additional notes associated with this service or procedure.
POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES,769,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],14057.81,,"Case rate ($13,388.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,590.54, add-ons for qualifying new technology services are included. If operating cost exceeds $47,461.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,596.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $10,606.49 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,645.59 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $836.96. The transfer capital threshold is the transfer adjustment factor * $836.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13388.39,33250.19,Inpatient DRG
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC",758,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],8574.80,,"Case rate ($8,574.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,112.57, add-ons for qualifying new technology services are included. If operating cost exceeds $42,983.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,244.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $6,144.96 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,167.62 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $484.90. The transfer capital threshold is the transfer adjustment factor * $484.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8574.80,19263.78,Inpatient DRG
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],30063.84,,"Fee schedule rate ($30,063.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13891.57,34712.20,There are no additional notes associated with this service or procedure.
HC N Block Inj Suprascapular Nerv|LEFT SIDE,CASE-64418,APC,64418,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],683.85,,"APC Price ($660.72). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,660.72,693.76,OPPS APC
Exc B9 Lesion Mrgn Xcp Sk Tg S/N/H/F/G 0.5 Cm/<,CASE-11420,APC,11420,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1545.93,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1545.93,1623.23,OPPS APC
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],10311.17,,"Case rate ($10,311.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,727.87, add-ons for qualifying new technology services are included. If operating cost exceeds $44,598.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,371.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $7,754.32 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,782.91 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $611.89. The transfer capital threshold is the transfer adjustment factor * $611.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10311.17,24308.97,Inpatient DRG
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC,964,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],12323.82,,"Case rate ($12,323.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,600.20, add-ons for qualifying new technology services are included. If operating cost exceeds $46,471.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,519.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $9,619.78 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,655.25 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $759.10. The transfer capital threshold is the transfer adjustment factor * $759.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12323.82,34154.06,Inpatient DRG
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],13405.94,,,,,,0,other,6558.75,14871.83,There are no additional notes associated with this service or procedure.
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],25829.63,,"Fee schedule rate ($25,829.63). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6965.00,29482.05,There are no additional notes associated with this service or procedure.
Brnchsc Removal Bronchial Valve Initial,CASE-31648,APC,31648,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3611.96,,"APC Price ($3,489.82). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3489.82,3664.31,OPPS APC
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],13154.04,,"Case rate ($12,527.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,789.82, add-ons for qualifying new technology services are included. If operating cost exceeds $46,660.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,533.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $9,808.71 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,844.88 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $774.00. The transfer capital threshold is the transfer adjustment factor * $774.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12527.66,29917.96,Inpatient DRG
Cysto W/Ureteroscopy W/Lithotripsy|LEFT SIDE,CASE-52353,APC,52353,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5018.77,,"APC Price ($5,018.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5018.77,5269.71,OPPS APC
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],7034.85,,"Case rate ($7,034.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,679.97, add-ons for qualifying new technology services are included. If operating cost exceeds $41,550.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,132.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $4,717.62 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,735.02 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $372.27. The transfer capital threshold is the transfer adjustment factor * $372.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,21089.59,Inpatient DRG
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],2070.00,,,,,,0,other,1188.00,17370.86,Estimated amount calculated based on 3 day length of stay.
"HC Debrid,Subq Ea Addt'l 20sqcm",CASE-11045,APC,11045,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],380.51,,"APC Price ($380.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,380.51,399.53,OPPS APC
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC",061,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],51814.18,,"Fee schedule rate ($51,814.18). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,20616.23,62315.82,There are no additional notes associated with this service or procedure.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],9137.93,,"Case rate ($8,702.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,231.63, add-ons for qualifying new technology services are included. If operating cost exceeds $43,102.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,254.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,263.59 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,286.68 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $494.26. The transfer capital threshold is the transfer adjustment factor * $494.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5683.00,19635.68,Inpatient DRG
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],23526.87,,"Case rate ($23,526.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $22,022.15, add-ons for qualifying new technology services are included. If operating cost exceeds $56,893.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,338.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.7. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.7)) / 2. The base transfer operating payment is the transfer adjustment factor * $20,003.44 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $20,077.20 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,578.47. The transfer capital threshold is the transfer adjustment factor * $1,578.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,23526.87,94787.57,Inpatient DRG
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],22557.82,,"Fee schedule rate ($22,557.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6801.88,22557.82,There are no additional notes associated with this service or procedure.
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,069,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],7722.19,,"Case rate ($7,354.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,977.32, add-ons for qualifying new technology services are included. If operating cost exceeds $41,848.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,155.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $5,013.88 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,032.37 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $395.65. The transfer capital threshold is the transfer adjustment factor * $395.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,20333.68,Inpatient DRG
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],10223.39,,"Fee schedule rate ($10,223.39). Adds an outlier to normal pricing equal to the per diem rate ($48,095.58) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,5628.97,12272.58,There are no additional notes associated with this service or procedure.
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6379.98,,"Case rate ($6,076.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,795.85, add-ons for qualifying new technology services are included. If operating cost exceeds $40,666.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,054.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,836.36 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,850.90 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $294.87. The transfer capital threshold is the transfer adjustment factor * $294.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5937.41,12366.99,Inpatient DRG
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],6167.00,,"Per diem ($6,167). If length of stay < 4.5, first 1 days paid at a per diem of $12,334 instead. Capped at $27,753.50.",,,,0,other,6167.00,29058.99,Estimated amount calculated based on 3 day length of stay.
Revj/Rmvl Impl Spi Npg/Rcvr Dtch Connj Eltrd Ra,CASE-63688,APC,63688,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3272.44,,"APC Price ($3,272.44). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3272.44,3436.06,OPPS APC
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],13561.53,,"Case rate ($13,295.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,504.24, add-ons for qualifying new technology services are included. If operating cost exceeds $47,375.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,590.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $10,520.50 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,559.29 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $830.17. The transfer capital threshold is the transfer adjustment factor * $830.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,7000.00,33835.79,Inpatient DRG
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH MCC",722,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],14697.38,,"Case rate ($14,200.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,345.91, add-ons for qualifying new technology services are included. If operating cost exceeds $48,216.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,656.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $11,359.07 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,400.95 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $896.34. The transfer capital threshold is the transfer adjustment factor * $896.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,14200.37,56869.13,Inpatient DRG
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],17194.49,,"Fee schedule rate ($17,194.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8554.50,19204.75,There are no additional notes associated with this service or procedure.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,056,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],17677.14,,"Case rate ($17,677.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,580.28, add-ons for qualifying new technology services are included. If operating cost exceeds $51,451.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,910.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $14,581.57 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,635.33 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,150.63. The transfer capital threshold is the transfer adjustment factor * $1,150.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7659.00,59328.19,Inpatient DRG
HC Non Stress Test|UNUSUAL NON-OVERLAPPING SERVICE,CASE-59025,APC,59025,CPT,0920,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],189.24,,"APC Price ($189.24). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,189.24,198.70,OPPS APC
NEONATE WITH OTHER SIGNIFICANT PROBLEMS,794,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],3383.58,,"Fee schedule rate ($3,383.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,1798.85,12536.83,There are no additional notes associated with this service or procedure.
MAJOR CHEST TRAUMA WITHOUT CC/MCC,185,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],14780.69,,"Fee schedule rate ($14,780.69). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.7), with a minimum of zero.",,,,0,other,7271.19,21771.61,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],13947.32,,"Fee schedule rate ($13,947.32). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6153.12,13947.32,There are no additional notes associated with this service or procedure.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],28395.88,,,,,,0,other,11717.72,43888.01,There are no additional notes associated with this service or procedure.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,098,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],6965.00,,,,,,0,other,6965.00,45156.75,There are no additional notes associated with this service or procedure.
Ercp W/Biopsy Single/Multiple,CASE-43261,APC,43261,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3735.12,,"APC Price ($3,608.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3608.81,3789.26,OPPS APC
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",062,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],44304.80,,"Fee schedule rate ($44,304.80). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,13844.84,44304.80,There are no additional notes associated with this service or procedure.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],8906.63,,"Case rate ($8,906.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,421.26, add-ons for qualifying new technology services are included. If operating cost exceeds $43,292.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,269.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $6,452.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,476.31 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $509.17. The transfer capital threshold is the transfer adjustment factor * $509.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8906.63,28434.57,Inpatient DRG
NON-MALIGNANT BREAST DISORDERS WITH CC/MCC,600,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],9448.68,,"Case rate ($8,998.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,506.94, add-ons for qualifying new technology services are included. If operating cost exceeds $43,377.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,275.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $6,537.88 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,561.99 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $515.90. The transfer capital threshold is the transfer adjustment factor * $515.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7999.14,20495.56,Inpatient DRG
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],142438.06,,"Fee schedule rate ($142,438.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (40), with a minimum of zero.",,,,0,other,45521.20,142438.06,There are no additional notes associated with this service or procedure.
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],30977.50,,,,,,0,other,12606.23,36868.88,There are no additional notes associated with this service or procedure.
PERIPHERAL VASCULAR DISORDERS WITH CC,300,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],20061.53,,"Fee schedule rate ($20,061.53). Adds an outlier to normal pricing equal to the per diem rate ($49,296.97) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.9), with a minimum of zero.",,,,0,other,9174.14,21005.20,There are no additional notes associated with this service or procedure.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],11418.14,,"Case rate ($11,194.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,549.37, add-ons for qualifying new technology services are included. If operating cost exceeds $45,420.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,436.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $8,572.81 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,604.42 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $676.48. The transfer capital threshold is the transfer adjustment factor * $676.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,11194.25,36094.03,Inpatient DRG
Dstr Nrolytc Agnt Parverteb Fct Sngl Crvcl/Thora|LEFT SIDE,CASE-64633,APC,64633,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1919.19,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1827.80,1919.19,OPPS APC
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],23835.16,,"Fee schedule rate ($23,835.16). Adds an outlier to normal pricing equal to the per diem rate ($63,133.20) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10533.95,24956.34,There are no additional notes associated with this service or procedure.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],36628.13,,"Case rate ($35,389.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $33,057.71, add-ons for qualifying new technology services are included. If operating cost exceeds $67,928.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,206.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.3. The base transfer operating payment is the transfer adjustment factor * $30,998.46 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $31,112.76 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,446.08. The transfer capital threshold is the transfer adjustment factor * $2,446.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,35389.50,101083.00,Inpatient DRG
"Suture Digital Nerve Hand/Foot 1 Nerve|RIGHT HAND, THUMB",CASE-64831,APC,64831,CPT,0360,RC,,,F5,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1919.19,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1827.80,1919.19,OPPS APC
Esophagogastroduodenoscopy Transoral Diagnostic,CASE-43235,APC,43235,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],891.41,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,848.96,891.41,OPPS APC
NONTRAUMATIC STUPOR AND COMA WITH MCC,080,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],14202.39,,"Case rate ($14,202.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,347.79, add-ons for qualifying new technology services are included. If operating cost exceeds $48,218.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,656.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $11,360.96 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,402.84 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $896.49. The transfer capital threshold is the transfer adjustment factor * $896.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,14202.39,35615.37,Inpatient DRG
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],49717.39,,"Fee schedule rate ($49,717.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,14908.05,49717.39,There are no additional notes associated with this service or procedure.
PREMATURITY WITHOUT MAJOR PROBLEMS,792,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],11512.88,,"Fee schedule rate ($11,512.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,1956.00,19457.66,There are no additional notes associated with this service or procedure.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",063,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],6965.00,,,,,,0,other,6965.00,35701.87,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],37149.27,,"Fee schedule rate ($37,149.27). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,12455.21,37149.27,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],8787.35,,"Case rate ($8,368.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,932.99, add-ons for qualifying new technology services are included. If operating cost exceeds $42,804.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,218.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $5,965.43 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,988.04 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $458.52. The transfer capital threshold is the transfer adjustment factor * $458.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8563.30,31533.97,Inpatient DRG
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],75545.91,,,,,,0,other,27944.96,86252.84,There are no additional notes associated with this service or procedure.
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],27222.08,,"Fee schedule rate ($27,222.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7389.00,37134.43,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],6965.00,,,,,,0,other,6965.00,32293.66,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],60793.48,,"Fee schedule rate ($60,793.48). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15.7), with a minimum of zero.",,,,0,other,23851.92,63653.13,There are no additional notes associated with this service or procedure.
Total Thyroid Lobectomy Uni W/WO Isthmusectomy,CASE-60220,APC,60220,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5658.76,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5658.76,5941.70,OPPS APC
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],14699.43,,"Fee schedule rate ($14,699.43). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6683.37,14699.43,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],9595.54,,"Case rate ($9,138.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,650.48, add-ons for qualifying new technology services are included. If operating cost exceeds $43,521.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,273.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $6,680.20 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,705.53 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $513.46. The transfer capital threshold is the transfer adjustment factor * $513.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9356.31,25026.36,Inpatient DRG
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],31118.69,,"Case rate ($17,782.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,677.93, add-ons for qualifying new technology services are included. If operating cost exceeds $51,548.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,918.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $14,678.86 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,732.98 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,158.31. The transfer capital threshold is the transfer adjustment factor * $1,158.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,17782.11,46523.26,All Other Inpatient
"HC Repair Nail Bed|RIGHT HAND, FIFTH DIGIT",CASE-11760,APC,11760,CPT,0450,RC,,,F9,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
"Laminec/Facetect/Foramin,Lumbar|LEFT SIDE",CASE-63047,APC,63047,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7029.71,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6791.99,7131.59,OPPS APC
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],14206.79,,,,,,0,other,6834.39,21354.82,There are no additional notes associated with this service or procedure.
TRAUMATIC INJURY WITH MCC,913,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],13323.90,,"Case rate ($12,689.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,960.36, add-ons for qualifying new technology services are included. If operating cost exceeds $46,831.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,526.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $9,977.58 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,015.41 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $766.90. The transfer capital threshold is the transfer adjustment factor * $766.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13014.58,42838.46,Inpatient DRG
"DIGESTIVE MALIGNANCY,MAJOR",240,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],12892.40,,"The inlier payment is calculated as the lesser of the standard DRG payment $12,892.40 and the transfer payment, which is a per diem of $1,879.36. If cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,12892.40,13537.02,Estimated amount calculated based on 4 day length of stay.
SEIZURES WITH MCC,100,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],15409.62,,"Case rate ($14,675.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,811.97, add-ons for qualifying new technology services are included. If operating cost exceeds $48,682.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,668.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $11,822.20 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,867.02 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $908.68. The transfer capital threshold is the transfer adjustment factor * $908.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,15061.09,38110.41,Inpatient DRG
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],29837.65,,"Fee schedule rate ($29,837.65). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,12696.97,47123.82,There are no additional notes associated with this service or procedure.
Cysto W/Urtroscopy&/Pyeloscopy Dx|UNUSUAL NON-OVERLAPPING SERVICE|LEFT SIDE,CASE-52351,APC,52351,CPT,0360,RC,,,XU|LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3414.95,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3299.47,3464.44,OPPS APC
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],25026.36,,"Fee schedule rate ($25,026.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9356.31,25026.36,There are no additional notes associated with this service or procedure.
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],10136.44,,"Case rate ($10,136.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,565.33, add-ons for qualifying new technology services are included. If operating cost exceeds $44,436.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,359.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $7,592.38 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,620.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $599.11. The transfer capital threshold is the transfer adjustment factor * $599.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10136.44,24444.75,Inpatient DRG
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC,192,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],6607.26,,"Case rate ($6,292.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,989.50, add-ons for qualifying new technology services are included. If operating cost exceeds $40,860.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,077.96, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,029.69 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,044.54 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $317.98. The transfer capital threshold is the transfer adjustment factor * $317.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6292.63,12753.78,Inpatient DRG
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC",061,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],20616.23,,"Case rate ($20,616.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $19,314.45, add-ons for qualifying new technology services are included. If operating cost exceeds $54,185.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,125.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $17,305.68 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $17,369.49 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,365.59. The transfer capital threshold is the transfer adjustment factor * $1,365.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,20616.23,62315.82,Inpatient DRG
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC",514,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],19212.08,,"Fee schedule rate ($19,212.08). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,8868.04,22699.91,There are no additional notes associated with this service or procedure.
MAJOR CHEST TRAUMA WITHOUT CC/MCC,185,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],7416.61,,"Case rate ($7,271.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,899.84, add-ons for qualifying new technology services are included. If operating cost exceeds $41,770.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,149.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,936.68 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,954.88 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $389.55. The transfer capital threshold is the transfer adjustment factor * $389.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,7271.19,21771.61,Inpatient DRG
MINOR BLADDER PROCEDURES WITHOUT CC/MCC,664,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],9215.32,,"Case rate ($9,034.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,540.33, add-ons for qualifying new technology services are included. If operating cost exceeds $43,411.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,278.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $6,571.15 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,595.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $518.53. The transfer capital threshold is the transfer adjustment factor * $518.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,9034.63,31876.87,Inpatient DRG
HC Rt Bronchoscopy Alveolar Lavage,CASE-31624,APC,31624,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6605.95,,"APC Price ($6,605.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6605.95,6936.25,OPPS APC
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],34245.00,,"Fee schedule rate ($34,245.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,12725.42,34245.00,There are no additional notes associated with this service or procedure.
Rpr Recrt Ingun Hernia Any Age Incarcerated,CASE-49521,APC,49521,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6059.65,,"APC Price ($6,059.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6059.65,6362.63,OPPS APC
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6336.93,,"Case rate ($6,122.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,831.37, add-ons for qualifying new technology services are included. If operating cost exceeds $40,702.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,065.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $3,872.14 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,886.42 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $305.55. The transfer capital threshold is the transfer adjustment factor * $305.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,1188.00,12138.74,Inpatient DRG
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],56089.29,,,,,,0,other,21248.73,56089.29,There are no additional notes associated with this service or procedure.
Mastectomy Partial|LEFT SIDE,CASE-19301,APC,19301,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6526.12,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6215.36,6526.12,OPPS APC
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITH MCC OR ANTINEOPLASTIC IMPLANT OR EPILEPSY WITH NEUROSTIMULATOR,023,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],136379.44,,"Fee schedule rate ($136,379.44). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,15168.00,136379.44,There are no additional notes associated with this service or procedure.
Chemodenervation Internal Anal Sphincter,CASE-46505,APC,46505,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],2598.08,,"APC Price ($2,598.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2598.08,2727.99,OPPS APC
Sigmoidoscopy Flx W/Biopsy Single/Multiple|COLORECTAL CANCER SCREEN,CASE-45331,APC,45331,CPT,0360,RC,,,PT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],870.46,,"APC Price ($870.46). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,870.46,913.99,OPPS APC
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],16400.70,,"Fee schedule rate ($16,400.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,16400.70,There are no additional notes associated with this service or procedure.
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],7544.40,,"Case rate ($7,396.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,016.38, add-ons for qualifying new technology services are included. If operating cost exceeds $41,887.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,158.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,052.80 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,071.43 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $398.72. The transfer capital threshold is the transfer adjustment factor * $398.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,7396.47,16035.06,Inpatient DRG
TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC,084,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],8417.70,,"Case rate ($8,417.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,966.41, add-ons for qualifying new technology services are included. If operating cost exceeds $42,837.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,233.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $5,999.34 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,021.46 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $473.41. The transfer capital threshold is the transfer adjustment factor * $473.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,19445.16,Inpatient DRG
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC,807,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],10071.17,,"Fee schedule rate ($10,071.17). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5354.25,13266.23,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6841.83,,"Case rate ($6,841.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,500.42, add-ons for qualifying new technology services are included. If operating cost exceeds $41,371.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,118.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $4,538.73 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,555.47 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $358.15. The transfer capital threshold is the transfer adjustment factor * $358.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6841.83,21167.26,Inpatient DRG
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,064,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],15563.58,,"Case rate ($15,563.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,614.08, add-ons for qualifying new technology services are included. If operating cost exceeds $49,485.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,756.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $12,622.59 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,669.13 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $996.05. The transfer capital threshold is the transfer adjustment factor * $996.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,15563.58,41838.16,Inpatient DRG
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,373,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],7008.36,,"Case rate ($6,870.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,527.50, add-ons for qualifying new technology services are included. If operating cost exceeds $41,398.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,120.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $4,565.72 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,582.56 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $360.28. The transfer capital threshold is the transfer adjustment factor * $360.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6870.94,14313.05,Inpatient DRG
"Tendon Sheath Incision|RIGHT HAND, FIFTH DIGIT|UNUSUAL NON-OVERLAPPING SERVICE",CASE-26055,APC,26055,CPT,0360,RC,,,F9|XU,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
"Neuroplasty Other Arm/Leg Nerve,Open|LEFT SIDE",CASE-64708,APC,64708,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6791.99,7131.59,OPPS APC
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],27632.41,,,,,,0,other,11454.97,28394.78,There are no additional notes associated with this service or procedure.
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],7505.33,,"Case rate ($7,147.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,785.17, add-ons for qualifying new technology services are included. If operating cost exceeds $41,656.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,140.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $4,822.44 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,840.22 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $380.54. The transfer capital threshold is the transfer adjustment factor * $380.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,16400.70,Inpatient DRG
Ercp W/Sphincterotomy/Papillotomy,CASE-43262,APC,43262,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3608.81,,"APC Price ($3,608.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3608.81,3789.26,OPPS APC
"Inj Dx/Ther Agnt Paravert Facet Joint, Cerv/Thorac, Add Level",CASE-64492,APC,64492,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],827.89,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,827.89,869.28,OPPS APC
Inject Rx Other Periph Nerve|LEFT SIDE,CASE-64640,APC,64640,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],827.89,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,827.89,869.28,OPPS APC
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],11059.47,,"Case rate ($11,059.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,424, add-ons for qualifying new technology services are included. If operating cost exceeds $45,295.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,426.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $8,447.91 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,479.05 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $666.62. The transfer capital threshold is the transfer adjustment factor * $666.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,11059.47,28423.20,Inpatient DRG
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],17233.12,,,,,,0,other,7875.94,17233.12,There are no additional notes associated with this service or procedure.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],20559.34,,"Case rate ($20,559.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $19,261.52, add-ons for qualifying new technology services are included. If operating cost exceeds $54,132.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,121.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $17,252.96 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $17,316.57 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,361.43. The transfer capital threshold is the transfer adjustment factor * $1,361.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,20559.34,54086.17,Inpatient DRG
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],19604.30,,"Fee schedule rate ($19,604.30). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9446.38,21796.21,There are no additional notes associated with this service or procedure.
"Inj Dx/Ther Agnt Paravert Facet Joint, Cerv/Thorac, Add Level",CASE-64492,APC,64492,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],827.89,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,827.89,869.28,OPPS APC
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],20401.88,,"Fee schedule rate ($20,401.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,20401.88,There are no additional notes associated with this service or procedure.
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],6965.00,,,,,,0,other,6965.00,34422.94,There are no additional notes associated with this service or procedure.
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITHOUT MCC,430,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],41000.16,,"Case rate ($41,000.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $38,277.19, add-ons for qualifying new technology services are included. If operating cost exceeds $73,148.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,616.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $36,198.76 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $36,332.23 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,856.44. The transfer capital threshold is the transfer adjustment factor * $2,856.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,41000.16,133156.90,Inpatient DRG
Surgical Arthroscopy Sho W/Coracoacrm Ligm Rls|LEFT SIDE,CASE-29826,APC,29826,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7029.71,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6791.99,7131.59,OPPS APC
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC,520,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],39786.42,,"Fee schedule rate ($39,786.42). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12061.74,39786.42,There are no additional notes associated with this service or procedure.
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],35419.59,,"Fee schedule rate ($35,419.59). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,7086.00,57872.02,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],19230.33,,,,,,0,other,8563.30,31533.97,There are no additional notes associated with this service or procedure.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],37158.98,,"Case rate ($35,389.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $33,057.71, add-ons for qualifying new technology services are included. If operating cost exceeds $67,928.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,206.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.3. The base transfer operating payment is the transfer adjustment factor * $30,998.46 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $31,112.76 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,446.08. The transfer capital threshold is the transfer adjustment factor * $2,446.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,35389.50,101083.00,Inpatient DRG
COMPLICATIONS OF TREATMENT WITH CC,920,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],20731.52,,"Fee schedule rate ($20,731.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8732.59,20731.52,There are no additional notes associated with this service or procedure.
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],81306.30,,"Fee schedule rate ($81,306.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,20846.48,81306.30,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],8972.00,,"Per diem ($8,972). If length of stay < 6.1, first 1 days paid at a per diem of $17,944 instead. Capped at $54,730.85.",,,,0,other,8972.00,81524.17,Estimated amount calculated based on 4 day length of stay.
"Open Tx Distal Phalangeal Fracture Each|LEFT HAND, FIFTH DIGIT",CASE-26765,APC,26765,CPT,0360,RC,,,F4,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,073,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],13065.57,,"Case rate ($12,809.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,051.90, add-ons for qualifying new technology services are included. If operating cost exceeds $46,922.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,554.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $10,069.82 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,106.95 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $794.61. The transfer capital threshold is the transfer adjustment factor * $794.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,12809.38,43475.01,Inpatient DRG
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],40108.48,,"Fee schedule rate ($40,108.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,5569.00,40108.48,There are no additional notes associated with this service or procedure.
CHOLECYSTECTOMY WITH C.D.E. WITH MCC,411,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],62078.92,,"Fee schedule rate ($62,078.92). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15), with a minimum of zero.",,,,0,other,24315.13,88615.28,There are no additional notes associated with this service or procedure.
MAJOR BLADDER PROCEDURES WITH MCC,653,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],37878.05,,"Case rate ($37,135.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $34,681.82, add-ons for qualifying new technology services are included. If operating cost exceeds $69,552.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,333.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.5. The base transfer operating payment is the transfer adjustment factor * $32,616.61 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $32,736.87 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,573.77. The transfer capital threshold is the transfer adjustment factor * $2,573.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,10280.00,125343.98,Inpatient DRG
CHEST PAIN,313,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],6965.00,,,,,,0,other,6820.84,15377.66,There are no additional notes associated with this service or procedure.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],11875.90,,"Case rate ($11,310.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,674.88, add-ons for qualifying new technology services are included. If operating cost exceeds $45,545.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,428.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $8,696.96 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,729.93 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $668.47. The transfer capital threshold is the transfer adjustment factor * $668.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,11593.79,38248.08,Inpatient DRG
KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,689,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],22831.22,,,,,,0,other,9802.58,22831.22,There are no additional notes associated with this service or procedure.
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC,519,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],50780.20,,"Fee schedule rate ($50,780.20). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,15490.44,50780.20,There are no additional notes associated with this service or procedure.
MAJOR THUMB OR JOINT PROCEDURES,506,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],19761.54,,"Fee schedule rate ($19,761.54). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11081.83,26548.21,There are no additional notes associated with this service or procedure.
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC,964,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],34154.06,,"Fee schedule rate ($34,154.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12323.82,34154.06,There are no additional notes associated with this service or procedure.
Egd Transoral Biopsy Single/Multiple,CASE-43239,APC,43239,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],848.96,,"APC Price ($848.96). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,848.96,878.67,OPPS APC
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],18379.29,,"Fee schedule rate ($18,379.29). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,6965.00,36140.75,There are no additional notes associated with this service or procedure.
MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,708,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],27860.62,,"Fee schedule rate ($27,860.62). Adds an outlier to normal pricing equal to the per diem rate ($54,966.40) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10138.21,29171.15,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITH CC,386,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],19879.00,,"Fee schedule rate ($19,879.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8556.53,19879.00,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,394,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],20909.61,,"Fee schedule rate ($20,909.61). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8281.56,20909.61,There are no additional notes associated with this service or procedure.
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],22753.01,,"Case rate ($13,001.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,230.82, add-ons for qualifying new technology services are included. If operating cost exceeds $47,101.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,568.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $10,248.08 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,285.87 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $808.68. The transfer capital threshold is the transfer adjustment factor * $808.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,7868.00,32126.64,All Other Inpatient
"NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY",789,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],3054.00,,,,,,0,other,3054.00,14857.05,Estimated amount calculated based on 1 day length of stay.
VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC,033,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],31250.88,,"Fee schedule rate ($31,250.88). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7.9), with a minimum of zero.",,,,0,other,13206.23,42156.44,There are no additional notes associated with this service or procedure.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],11681.49,,"Fee schedule rate ($11,681.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5778.62,11681.49,There are no additional notes associated with this service or procedure.
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],33835.79,,"Fee schedule rate ($33,835.79). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,7000.00,33835.79,There are no additional notes associated with this service or procedure.
SALIVARY GLAND PROCEDURES,139,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],30690.92,,"Fee schedule rate ($30,690.92). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,10313.19,30690.92,There are no additional notes associated with this service or procedure.
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],29783.11,,,,,,0,other,12195.15,39424.57,There are no additional notes associated with this service or procedure.
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],14481.61,,"Case rate ($13,792.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,966.02, add-ons for qualifying new technology services are included. If operating cost exceeds $47,837.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,626.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $10,980.58 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,021.07 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $866.48. The transfer capital threshold is the transfer adjustment factor * $866.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,34422.94,Inpatient DRG
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],13110.79,,,,,,0,other,5139.72,13110.79,There are no additional notes associated with this service or procedure.
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITHOUT CC/MCC",630,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],27428.38,,"Fee schedule rate ($27,428.38). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,11828.78,42541.02,There are no additional notes associated with this service or procedure.
HC Lyr Clos Sc Tk Ext 2.6-7 Cm,CASE-12032,APC,12032,CPT,0450,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1623.23,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1545.93,1623.23,OPPS APC
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],14690.49,,"Fee schedule rate ($14,690.49). Adds an outlier to normal pricing equal to the per diem rate ($54,770.58) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.7), with a minimum of zero.",,,,0,other,7238.69,16804.22,There are no additional notes associated with this service or procedure.
Cysto W/Urtroscopy&/Pyeloscopy Dx|LEFT SIDE,CASE-52351,APC,52351,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3299.47,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3299.47,3464.44,OPPS APC
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,690,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],7798.29,,"Case rate ($7,426.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,044.73, add-ons for qualifying new technology services are included. If operating cost exceeds $41,915.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,160.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,081.05 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,099.78 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $400.94. The transfer capital threshold is the transfer adjustment factor * $400.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7426.94,15928.53,Inpatient DRG
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],43399.23,,"Fee schedule rate ($43,399.23). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9888.00,43399.23,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],59476.09,,"Fee schedule rate ($59,476.09). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15.9), with a minimum of zero.",,,,0,other,23377.19,96365.69,There are no additional notes associated with this service or procedure.
"NEONATE BIRTH WEIGHT 2000-2499 GRAMS WITH RESPIRATORY DISTRESS SYNDROME OR OTHER MAJOR RESPIRATORY CONDITION,MINOR",622,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],14454.53,,"Case rate ($13,766.22). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13766.22,14454.53,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,394,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],17584.61,,"Fee schedule rate ($17,584.61). Adds an outlier to normal pricing equal to the per diem rate ($53,248.69) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,8281.56,20909.61,There are no additional notes associated with this service or procedure.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],62041.12,,"Fee schedule rate ($62,041.12). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,18497.24,62041.12,There are no additional notes associated with this service or procedure.
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC",514,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],19212.08,,"Fee schedule rate ($19,212.08). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,8868.04,22699.91,There are no additional notes associated with this service or procedure.
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],30373.26,,"Case rate ($17,356.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,281.67, add-ons for qualifying new technology services are included. If operating cost exceeds $51,152.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,887.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $14,284.05 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,336.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,127.15. The transfer capital threshold is the transfer adjustment factor * $1,127.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,17356.15,44778.95,All Other Inpatient
Arthrs Kne Surg W/Meniscectomy Med/Lat W/Shvg|RIGHT SIDE,CASE-29881,APC,29881,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITH MCC OR ANTINEOPLASTIC IMPLANT OR EPILEPSY WITH NEUROSTIMULATOR,023,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],112755.11,,,,,,0,other,15168.00,136379.44,There are no additional notes associated with this service or procedure.
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],16763.25,,"Fee schedule rate ($16,763.25). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9151.11,30245.71,There are no additional notes associated with this service or procedure.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],42586.49,,"Fee schedule rate ($42,586.49). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,13341.67,42586.49,There are no additional notes associated with this service or procedure.
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC",514,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],20115.80,,,,,,0,other,8868.04,22699.91,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITHOUT STERILIZATION WITH CC,787,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],21975.27,,,,,,0,other,9508.01,23722.94,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,082,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],17816.99,,"Case rate ($16,968.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,949.12, add-ons for qualifying new technology services are included. If operating cost exceeds $50,820.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,832.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $13,951.27 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,004.17 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,072.33. The transfer capital threshold is the transfer adjustment factor * $1,072.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,17423.21,56223.11,Inpatient DRG
RADIOTHERAPY,849,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],20293.88,,"Case rate ($20,293.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $19,014.57, add-ons for qualifying new technology services are included. If operating cost exceeds $53,885.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,101.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $17,006.91 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $17,069.62 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,342.01. The transfer capital threshold is the transfer adjustment factor * $1,342.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,20293.88,81867.07,Inpatient DRG
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],23811.59,,"Case rate ($23,344.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $21,852.68, add-ons for qualifying new technology services are included. If operating cost exceeds $56,723.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,325.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $19,834.60 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $19,907.73 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,565.15. The transfer capital threshold is the transfer adjustment factor * $1,565.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,23344.70,62179.32,Inpatient DRG
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],11684.07,,"Case rate ($11,454.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,791.92, add-ons for qualifying new technology services are included. If operating cost exceeds $45,662.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,455.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $8,814.47 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,846.97 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $695.55. The transfer capital threshold is the transfer adjustment factor * $695.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,11454.97,28394.78,Inpatient DRG
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],41190.50,,"Fee schedule rate ($41,190.50). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,16787.98,62990.26,There are no additional notes associated with this service or procedure.
Chemodenervation Muscle Neck Unilat for Dystonia,CASE-64616,APC,64616,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],301.68,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,287.31,301.68,OPPS APC
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],42138.30,,,,,,0,other,7453.00,42138.30,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],18366.40,,"Fee schedule rate ($18,366.40). Adds an outlier to normal pricing equal to the per diem rate ($38,964.32) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.5), with a minimum of zero.",,,,0,other,8563.30,31533.97,There are no additional notes associated with this service or procedure.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],23520.23,,"Fee schedule rate ($23,520.23). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10517.71,24909.11,There are no additional notes associated with this service or procedure.
OTHER CEREBROVASCULAR DISORDERS WITH CC,071,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],9123.46,,"Case rate ($8,689.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,231.38, add-ons for qualifying new technology services are included. If operating cost exceeds $43,102.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,241.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,262.69 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,286.43 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $481.36. The transfer capital threshold is the transfer adjustment factor * $481.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5843.00,29215.10,Inpatient DRG
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],28253.40,,"Fee schedule rate ($28,253.40). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,12126.09,29582.40,There are no additional notes associated with this service or procedure.
PERIPHERAL VASCULAR DISORDERS WITH CC,300,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],20331.78,,"Fee schedule rate ($20,331.78). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,9174.14,21005.20,There are no additional notes associated with this service or procedure.
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],21576.11,,"Case rate ($20,846.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $19,528.64, add-ons for qualifying new technology services are included. If operating cost exceeds $54,399.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,142.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $17,519.09 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $17,583.69 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,382.43. The transfer capital threshold is the transfer adjustment factor * $1,382.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,20846.48,81306.30,Inpatient DRG
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],39361.94,,"Fee schedule rate ($39,361.94). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.8), with a minimum of zero.",,,,0,other,16129.04,59610.47,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC,084,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],19445.16,,"Fee schedule rate ($19,445.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,6965.00,19445.16,There are no additional notes associated with this service or procedure.
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC,939,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],97674.79,,"Fee schedule rate ($97,674.79). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,26517.40,97674.79,There are no additional notes associated with this service or procedure.
HC Joint Injection/Aspir Large WO US|DISTINCT PROCEDURAL SERVICE|RIGHT SIDE|PBB CHARGE,CASE-20610,APC,20610,CPT,0510,RC,,,59|RT|PBB,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],297.37,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,287.31,301.68,OPPS APC
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,093,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],6965.00,,,,,,0,other,6965.00,19011.32,There are no additional notes associated with this service or procedure.
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC,520,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],39786.42,,"Fee schedule rate ($39,786.42). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12061.74,39786.42,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],24328.96,,"Case rate ($23,851.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $22,324.54, add-ons for qualifying new technology services are included. If operating cost exceeds $57,195.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,362.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.8. The base transfer operating payment is the transfer adjustment factor * $20,304.73 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $20,379.59 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,602.24. The transfer capital threshold is the transfer adjustment factor * $1,602.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,23851.92,63653.13,Inpatient DRG
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],8225.64,,"Case rate ($7,833.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,423.35, add-ons for qualifying new technology services are included. If operating cost exceeds $42,294.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,190.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,458.28 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,478.41 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $430.71. The transfer capital threshold is the transfer adjustment factor * $430.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5883.03,17111.12,Inpatient DRG
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],40737.46,,"Fee schedule rate ($40,737.46). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,7665.00,40737.46,There are no additional notes associated with this service or procedure.
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],7775.55,,"Fee schedule rate ($7,775.55). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7438.45,15961.98,There are no additional notes associated with this service or procedure.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,074,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],9104.11,,"Case rate ($8,925.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,438.90, add-ons for qualifying new technology services are included. If operating cost exceeds $43,309.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,270.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,470.10 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,493.95 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $510.55. The transfer capital threshold is the transfer adjustment factor * $510.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,8925.60,20919.08,Inpatient DRG
"Rpr Coltrl Ligm Mtcarphlngl/Iphal Jt|LEFT HAND, THUMB",CASE-26540,APC,26540,CPT,0360,RC,,,FA,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],10098.51,,"Case rate ($10,098.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,530.04, add-ons for qualifying new technology services are included. If operating cost exceeds $44,401.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,356.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $7,557.23 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,585.10 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $596.34. The transfer capital threshold is the transfer adjustment factor * $596.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10098.51,24259.09,Inpatient DRG
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],14067.85,,"Case rate ($13,792.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,966.02, add-ons for qualifying new technology services are included. If operating cost exceeds $47,837.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,626.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $10,980.58 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,021.07 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $866.48. The transfer capital threshold is the transfer adjustment factor * $866.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6965.00,34422.94,Inpatient DRG
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],85466.62,,"Fee schedule rate ($85,466.62). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,21382.16,85466.62,There are no additional notes associated with this service or procedure.
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],33221.97,,"Fee schedule rate ($33,221.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (47), with a minimum of zero.",,,,0,other,15283.90,38757.79,There are no additional notes associated with this service or procedure.
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],9151.11,,"Case rate ($9,151.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,648.69, add-ons for qualifying new technology services are included. If operating cost exceeds $43,519.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,287.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,679.11 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,703.74 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $527.05. The transfer capital threshold is the transfer adjustment factor * $527.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9151.11,30245.71,Inpatient DRG
GI Tract Imaging Intraluminal Colon I&R,CASE-91113,APC,91113,CPT,0750,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],900.93,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,870.46,913.99,OPPS APC
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],19691.31,,"Fee schedule rate ($19,691.31). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,9040.72,26966.33,There are no additional notes associated with this service or procedure.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],8367.70,,"Case rate ($7,969.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,560.46, add-ons for qualifying new technology services are included. If operating cost exceeds $42,431.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,189.96, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,594.30 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,615.51 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $429.99. The transfer capital threshold is the transfer adjustment factor * $429.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8151.55,18033.97,Inpatient DRG
"Amp F/Th 1/2 Jt/Phalanx W/Neurect W/Dir Clsr|RIGHT HAND, SECOND DIGIT",CASE-26951,APC,26951,CPT,0360,RC,,,F6,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
GASTROINTESTINAL HEMORRHAGE WITH CC,378,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],20845.19,,"Fee schedule rate ($20,845.19). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8586.33,20845.19,There are no additional notes associated with this service or procedure.
"DIVERTICULITIS AND DIVERTICULOSIS,MAJOR",244,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],11621.42,,"Case rate ($11,068.02). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11068.02,11621.42,There are no additional notes associated with this service or procedure.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],28649.93,,"Fee schedule rate ($28,649.93). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,12268.97,41006.47,There are no additional notes associated with this service or procedure.
HEADACHES WITHOUT MCC,103,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],20883.08,,"Fee schedule rate ($20,883.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,20883.08,There are no additional notes associated with this service or procedure.
Neuroplasty &/Transpos Median Nrv Carpal Tunne|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64721,APC,64721,CPT,0360,RC,,,RT|XU,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1827.80,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1827.80,1919.19,OPPS APC
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],67794.72,,"Fee schedule rate ($67,794.72). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,10862.00,86437.13,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],21784.85,,"Fee schedule rate ($21,784.85). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.4), with a minimum of zero.",,,,0,other,9795.13,23899.13,There are no additional notes associated with this service or procedure.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC,099,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],22084.20,,"Fee schedule rate ($22,084.20). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11171.21,26807.94,There are no additional notes associated with this service or procedure.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],43444.85,,,,,,0,other,16897.01,43444.85,There are no additional notes associated with this service or procedure.
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],8004.45,,"Case rate ($7,847.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,435.96, add-ons for qualifying new technology services are included. If operating cost exceeds $42,306.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,191.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,470.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,491.01 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $431.70. The transfer capital threshold is the transfer adjustment factor * $431.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,7847.50,17755.26,Inpatient DRG
"Inj Dx/Ther Agnt Paravert Facet Joint, Cerv/Thorac, Add Level",CASE-64492,APC,64492,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],827.89,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,827.89,869.28,OPPS APC
"OTHER DISORDERS OF THE LIVER,MAJOR",283,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],2026.86,,"Case rate for a one day stay ($2,026.86). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,2026.86,2128.20,There are no additional notes associated with this service or procedure.
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC,497,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],10330.20,,"Case rate ($10,127.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,557.14, add-ons for qualifying new technology services are included. If operating cost exceeds $44,428.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,358.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 1.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $7,584.22 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,612.19 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $598.47. The transfer capital threshold is the transfer adjustment factor * $598.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,10127.65,37761.19,Inpatient DRG
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],12954.48,,"Case rate ($7,402.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,022.05, add-ons for qualifying new technology services are included. If operating cost exceeds $41,893.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,159.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,058.45 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,077.10 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $399.16. The transfer capital threshold is the transfer adjustment factor * $399.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,7402.56,16438.59,All Other Inpatient
DIABETES WITH CC,638,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],8014.07,,"Case rate ($8,014.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,590.93, add-ons for qualifying new technology services are included. If operating cost exceeds $42,461.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,203.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,625.24 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,645.98 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $443.89. The transfer capital threshold is the transfer adjustment factor * $443.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8014.07,17634.53,Inpatient DRG
"MAJOR BILIARY TRACT PROCEDURES,MODERATE",261,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],23498.40,,"Case rate ($22,379.43). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,22379.43,23498.40,There are no additional notes associated with this service or procedure.
CERVICAL SPINAL FUSION WITHOUT CC/MCC,473,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],62077.11,,"Fee schedule rate ($62,077.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,18477.61,62077.11,There are no additional notes associated with this service or procedure.
NORMAL NEWBORN,795,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],2074.00,,,,,,0,other,1369.79,5771.52,Estimated amount calculated based on 2 day length of stay.
"EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME, NEONATE",790,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],44304.49,,"Case rate ($42,194.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $39,388.49, add-ons for qualifying new technology services are included. If operating cost exceeds $74,259.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,703.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 17.9. The base transfer operating payment is the transfer adjustment factor * $37,305.99 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $37,443.54 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,943.81. The transfer capital threshold is the transfer adjustment factor * $2,943.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,3054.00,44304.49,Inpatient DRG
Redo Excis Lumbar Disk|LEFT SIDE,CASE-63042,APC,63042,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6791.99,7131.59,OPPS APC
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],17223.78,,"Fee schedule rate ($17,223.78). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,8151.55,18033.97,There are no additional notes associated with this service or procedure.
Cysto W/Ureteroscopy W/Lithotripsy|LEFT SIDE,CASE-52353,APC,52353,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5269.71,,"APC Price ($5,018.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5018.77,5269.71,OPPS APC
HC N Block Inj Intercost Sng,CASE-64420,APC,64420,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],660.72,,"APC Price ($660.72). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,660.72,693.76,OPPS APC
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],37899.49,,"Fee schedule rate ($37,899.49). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,14747.55,37899.49,There are no additional notes associated with this service or procedure.
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],6944.10,,"Case rate ($6,944.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,595.55, add-ons for qualifying new technology services are included. If operating cost exceeds $41,466.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,125.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,633.51 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,650.60 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $365.63. The transfer capital threshold is the transfer adjustment factor * $365.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,5068.21,14525.56,Inpatient DRG
Laparoscopic Appendectomy|UNUSUAL NON-OVERLAPPING SERVICE,CASE-44970,APC,44970,CPT,0360,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5658.76,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5658.76,5941.70,OPPS APC
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC,519,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],39357.94,,,,,,0,other,15490.44,50780.20,There are no additional notes associated with this service or procedure.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,477,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],62359.39,,"Fee schedule rate ($62,359.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,25339.74,67976.16,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,066,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],6579.76,,"Case rate ($6,579.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,256.61, add-ons for qualifying new technology services are included. If operating cost exceeds $41,127.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,098.96, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $4,295.82 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,311.66 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $338.98. The transfer capital threshold is the transfer adjustment factor * $338.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6579.76,20083.61,Inpatient DRG
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],9151.11,,"Case rate ($9,151.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,648.69, add-ons for qualifying new technology services are included. If operating cost exceeds $43,519.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,287.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,679.11 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,703.74 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $527.05. The transfer capital threshold is the transfer adjustment factor * $527.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9151.11,30245.71,Inpatient DRG
"PROCEDURES FOR OBESITY,MINOR",403,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],11100.91,,"Case rate ($11,100.91). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,11100.91,11655.96,There are no additional notes associated with this service or procedure.
VENTRICULAR SHUNT PROCEDURES WITH MCC,031,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],84202.04,,"Fee schedule rate ($84,202.04). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16.6), with a minimum of zero.",,,,0,other,32287.20,88162.80,There are no additional notes associated with this service or procedure.
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],17150.47,,,,,,0,other,7847.50,17755.26,There are no additional notes associated with this service or procedure.
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],28394.78,,"Fee schedule rate ($28,394.78). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11454.97,28394.78,There are no additional notes associated with this service or procedure.
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],10311.17,,"Case rate ($10,311.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,727.87, add-ons for qualifying new technology services are included. If operating cost exceeds $44,598.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,371.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $7,754.32 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,782.91 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $611.89. The transfer capital threshold is the transfer adjustment factor * $611.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10311.17,24308.97,Inpatient DRG
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],8767.31,,"Case rate ($8,349.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,915.22, add-ons for qualifying new technology services are included. If operating cost exceeds $42,786.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,217.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $5,947.72 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,970.27 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $457.16. The transfer capital threshold is the transfer adjustment factor * $457.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8543.64,23239.84,Inpatient DRG
Optx Dstl Radl I-Artic Fx/Epiphysl Sep 2 Frag|LEFT SIDE,CASE-25608,APC,25608,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7029.71,OPPS APC
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],15540.00,,"Fee schedule rate ($15,540). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12126.09,29582.40,There are no additional notes associated with this service or procedure.
Revise Ulnar Nerve at Wrist|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64719,APC,64719,CPT,0360,RC,,,LT|XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3309.51,,"APC Price ($3,197.60). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3309.51,3357.48,OPPS APC
Exc Tumor Soft Tissue Abdl Wall Subfascial 5cm/>,CASE-22901,APC,22901,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],2854.83,,"APC Price ($2,718.88). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2718.88,2854.83,OPPS APC
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],59494.91,,"Fee schedule rate ($59,494.91). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,18594.09,59494.91,There are no additional notes associated with this service or procedure.
NONTRAUMATIC STUPOR AND COMA WITH MCC,080,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],30179.40,,"Fee schedule rate ($30,179.40). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,14202.39,35615.37,There are no additional notes associated with this service or procedure.
"KIDNEY AND URINARY TRACT INFECTIONS,MODERATE",463,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],1870.92,,"Case rate for a one day stay ($1,870.92). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,1870.92,1964.47,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],11376.37,,"Case rate ($10,834.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,214.84, add-ons for qualifying new technology services are included. If operating cost exceeds $45,085.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,410.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $8,239.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,269.90 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $650.18. The transfer capital threshold is the transfer adjustment factor * $650.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10834.64,25830.00,Inpatient DRG
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],8643.20,,"Case rate ($8,643.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,176.19, add-ons for qualifying new technology services are included. If operating cost exceeds $43,047.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,249.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $6,208.35 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,231.24 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $489.90. The transfer capital threshold is the transfer adjustment factor * $489.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8643.20,19462.52,Inpatient DRG
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC,805,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],9253.36,,"Case rate ($9,253.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,743.82, add-ons for qualifying new technology services are included. If operating cost exceeds $43,614.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,294.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $6,773.89 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,798.87 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $534.53. The transfer capital threshold is the transfer adjustment factor * $534.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9253.36,21235.42,Inpatient DRG
Egd Transoral Biopsy Single/Multiple|UNUSUAL NON-OVERLAPPING SERVICE,CASE-43239,APC,43239,CPT,0360,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1796.14,,"APC Price ($1,796.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1796.14,1885.95,OPPS APC
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,988,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],42425.46,,"Fee schedule rate ($42,425.46). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,13075.52,42425.46,There are no additional notes associated with this service or procedure.
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],33221.97,,"Fee schedule rate ($33,221.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (47), with a minimum of zero.",,,,0,other,15283.90,38757.79,There are no additional notes associated with this service or procedure.
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC",758,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],18398.35,,"Fee schedule rate ($18,398.35). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8574.80,19263.78,There are no additional notes associated with this service or procedure.
HC Joint Injection/Aspir Large WO US|RIGHT SIDE,CASE-20610,APC,20610,CPT,0510,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],287.31,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
CESAREAN SECTION WITH STERILIZATION WITHOUT CC/MCC,785,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],8431.24,,"Case rate ($8,431.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,979, add-ons for qualifying new technology services are included. If operating cost exceeds $42,850.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,234.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,011.89 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,034.06 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $474.40. The transfer capital threshold is the transfer adjustment factor * $474.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8431.24,20142.33,Inpatient DRG
Esophagogastroduodenoscopy Transoral Diagnostic|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-43235,APC,43235,CPT,0360,RC,,,74,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],891.41,,"APC Price ($848.96). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,848.96,891.41,OPPS APC
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],38378.80,,"Fee schedule rate ($38,378.80). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,14370.36,38378.80,There are no additional notes associated with this service or procedure.
FRACTURES OF FEMUR WITH MCC,533,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],13189.61,,"Case rate ($12,561.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,821.33, add-ons for qualifying new technology services are included. If operating cost exceeds $46,692.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,536.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $9,840.09 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,876.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $776.48. The transfer capital threshold is the transfer adjustment factor * $776.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6852.00,49490.05,Inpatient DRG
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],10448.43,,"Case rate ($9,950.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,392.71, add-ons for qualifying new technology services are included. If operating cost exceeds $44,263.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,345.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $7,420.40 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,447.76 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $585.54. The transfer capital threshold is the transfer adjustment factor * $585.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7243.75,23262.15,Inpatient DRG
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],12509.83,,"Case rate ($11,914.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,219.06, add-ons for qualifying new technology services are included. If operating cost exceeds $46,090.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,489.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $9,240.03 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,274.10 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $729.13. The transfer capital threshold is the transfer adjustment factor * $729.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,11914.12,40426.76,Inpatient DRG
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],12027.72,,"Case rate ($11,454.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,791.92, add-ons for qualifying new technology services are included. If operating cost exceeds $45,662.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,455.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $8,814.47 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,846.97 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $695.55. The transfer capital threshold is the transfer adjustment factor * $695.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,11454.97,28394.78,Inpatient DRG
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC,817,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],17789.37,,"Case rate ($16,942.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,924.61, add-ons for qualifying new technology services are included. If operating cost exceeds $50,795.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,830.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $13,926.85 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,979.66 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,070.45. The transfer capital threshold is the transfer adjustment factor * $1,070.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,17396.11,44895.04,Inpatient DRG
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,093,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],7337.55,,"Case rate ($7,337.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,961.57, add-ons for qualifying new technology services are included. If operating cost exceeds $41,832.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,154.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,998.19 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,016.62 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $394.41. The transfer capital threshold is the transfer adjustment factor * $394.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,19011.32,Inpatient DRG
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],10284.89,,"Case rate ($9,795.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,247.81, add-ons for qualifying new technology services are included. If operating cost exceeds $44,118.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,334.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $7,276.03 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,302.86 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $574.15. The transfer capital threshold is the transfer adjustment factor * $574.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9795.13,23899.13,Inpatient DRG
Parathyroidectomy/Exploration Parathyroids|SEPARATE STRUCTURE|RIGHT SIDE,CASE-60500,APC,60500,CPT,0360,RC,,,XS|RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],9949.78,,"APC Price ($9,949.78). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,9949.78,10447.27,OPPS APC
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],13486.95,,"Fee schedule rate ($13,486.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6915.64,14442.92,There are no additional notes associated with this service or procedure.
Removal Implant Deep,CASE-20680,APC,20680,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1919.19,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1827.80,1919.19,OPPS APC
Submucous Rescj Inferior Turbinate Prtl/Compl,CASE-30140,APC,30140,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.52,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.35,3258.52,OPPS APC
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],10736.25,,"Fee schedule rate ($10,736.25). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8643.20,19462.52,There are no additional notes associated with this service or procedure.
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],5065.00,,"Per diem ($5,065). If length of stay < 2.1, first 1 days paid at a per diem of $10,130 instead. Capped at $10,636.84.",,,,0,other,5065.00,12558.65,Estimated amount calculated based on 2 day length of stay.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],21470.70,,"Case rate ($12,268.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,549.17, add-ons for qualifying new technology services are included. If operating cost exceeds $46,420.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,515.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,568.94 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,604.22 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $755.08. The transfer capital threshold is the transfer adjustment factor * $755.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,12268.97,41006.47,All Other Inpatient
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],59476.09,,"Fee schedule rate ($59,476.09). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15.9), with a minimum of zero.",,,,0,other,23377.19,96365.69,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],28619.77,,"Case rate ($27,256.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $25,492.14, add-ons for qualifying new technology services are included. If operating cost exceeds $60,363.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,611.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. The base transfer operating payment is the transfer adjustment factor * $23,460.69 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $23,547.19 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,851.28. The transfer capital threshold is the transfer adjustment factor * $1,851.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,27256.92,81353.66,Inpatient DRG
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],27433.71,,"Case rate ($26,127.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $24,441.31, add-ons for qualifying new technology services are included. If operating cost exceeds $59,312.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,528.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. The base transfer operating payment is the transfer adjustment factor * $22,413.72 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $22,496.36 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,768.66. The transfer capital threshold is the transfer adjustment factor * $1,768.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,26127.34,90333.60,Inpatient DRG
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],39424.57,,"Fee schedule rate ($39,424.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12195.15,39424.57,There are no additional notes associated with this service or procedure.
OSTEOMYELITIS WITH CC,540,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],11259.77,,"Case rate ($10,723.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,111.53, add-ons for qualifying new technology services are included. If operating cost exceeds $44,982.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,402.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $8,136.58 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,166.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $642.06. The transfer capital threshold is the transfer adjustment factor * $642.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9809.07,25507.30,Inpatient DRG
POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES,769,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],31756.41,,"Fee schedule rate ($31,756.41). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.7), with a minimum of zero.",,,,0,other,13388.39,33250.19,There are no additional notes associated with this service or procedure.
Brnchsc Incl Fluor Gdnce Dx W/Cell Washg Spx,CASE-31622,APC,31622,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1666.03,,"APC Price ($1,666.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1666.03,1749.33,OPPS APC
MAJOR BLADDER PROCEDURES WITH MCC,653,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],102249.56,,,,,,0,other,10280.00,125343.98,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITH MCC,385,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],12660.40,,"Case rate ($12,660.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,913.31, add-ons for qualifying new technology services are included. If operating cost exceeds $46,784.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,543.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $9,931.73 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,968.35 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $783.71. The transfer capital threshold is the transfer adjustment factor * $783.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,11480.01,31134.92,Inpatient DRG
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITH MCC,429,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],66106.51,,"Case rate ($62,958.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $58,704.65, add-ons for qualifying new technology services are included. If operating cost exceeds $93,575.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $6,222.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.6. The base transfer operating payment is the transfer adjustment factor * $56,551.19 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $56,759.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,462.45. The transfer capital threshold is the transfer adjustment factor * $4,462.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,62958.58,177294.98,Inpatient DRG
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],8891.90,,"Case rate ($8,468.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,013.65, add-ons for qualifying new technology services are included. If operating cost exceeds $42,884.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,237.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,046.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,068.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $477.12. The transfer capital threshold is the transfer adjustment factor * $477.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6963.00,18954.85,Inpatient DRG
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],14309.17,,"Fee schedule rate ($14,309.17). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,17467.27,There are no additional notes associated with this service or procedure.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],19501.98,,"Case rate ($19,119.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,922.16, add-ons for qualifying new technology services are included. If operating cost exceeds $52,793.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,016.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $15,918.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,977.21 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,256.13. The transfer capital threshold is the transfer adjustment factor * $1,256.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,11348.00,62454.12,Inpatient DRG
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],28334.16,,"Fee schedule rate ($28,334.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,7868.00,32126.64,There are no additional notes associated with this service or procedure.
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],10998.68,,"Case rate ($10,626.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,021.44, add-ons for qualifying new technology services are included. If operating cost exceeds $44,892.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,394.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $8,046.82 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,076.49 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $634.97. The transfer capital threshold is the transfer adjustment factor * $634.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,10626.74,25225.91,Inpatient DRG
Injection Aa&/Strd Intercostal Nrv Ea Addl Lvl,CASE-64421,APC,64421,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],856.86,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,827.89,869.28,OPPS APC
HC N Block Inj Intercost Sng|LEFT SIDE,CASE-64420,APC,64420,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],660.72,,"APC Price ($660.72). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,660.72,693.76,OPPS APC
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC,858,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],33794.11,,"Fee schedule rate ($33,794.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11377.76,33794.11,There are no additional notes associated with this service or procedure.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],7332.00,,"Per diem ($7,332). If length of stay < 4.6, first 1 days paid at a per diem of $14,664 instead. Capped at $33,727.80.",,,,0,other,7332.00,35314.31,Estimated amount calculated based on 3 day length of stay.
Cysto W/Insert Ureteral Stent|BILATERAL PROCEDURE,CASE-52332,APC,52332,CPT,0360,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3464.44,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3299.47,3464.44,OPPS APC
Egd Transoral Control Bleeding Any Method,CASE-43255,APC,43255,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1796.14,,"APC Price ($1,796.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1796.14,1885.95,OPPS APC
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],36988.38,,"Fee schedule rate ($36,988.38). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.7), with a minimum of zero.",,,,0,other,15273.74,39820.52,There are no additional notes associated with this service or procedure.
Colsc Flexible W/Transendoscopic Balloon Dilat,CASE-45386,APC,45386,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1120.09,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1120.09,1176.09,OPPS APC
"EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME, NEONATE",790,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],3054.00,,,,,,0,other,3054.00,44304.49,Estimated amount calculated based on 17 day length of stay.
"HC I&D Finger Abscess Simple|RIGHT HAND, THUMB",CASE-26010,APC,26010,CPT,0450,RC,,,F5,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],187.80,,"APC Price ($187.80). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,187.80,197.19,OPPS APC
HC Inj Tendon Sheath/Ligament|PBB CHARGE|RIGHT SIDE,CASE-20550,APC,20550,CPT,0510,RC,,,PBB|RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],297.37,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,287.31,301.68,OPPS APC
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],15318.94,,"Fee schedule rate ($15,318.94). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6214.05,15318.94,There are no additional notes associated with this service or procedure.
"Open Tx Metacarpal Fracture Single Ea Bone|RIGHT HAND, THIRD DIGIT",CASE-26615,APC,26615,CPT,0360,RC,,,F7,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
Nasal/Sinus Ndsc Surg W/Concha Bullosa Resection|RIGHT SIDE,CASE-31240,APC,31240,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.52,,"APC Price ($3,103.35). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.35,3258.52,OPPS APC
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],8571.21,,"Case rate ($8,163.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,729.53, add-ons for qualifying new technology services are included. If operating cost exceeds $42,600.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,214.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,763.33 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,784.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $454.78. The transfer capital threshold is the transfer adjustment factor * $454.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8163.06,18067.42,Inpatient DRG
HC N Block Inj Intercost Sng,CASE-64420,APC,64420,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],693.76,,"APC Price ($660.72). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,660.72,693.76,OPPS APC
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC,497,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],23775.72,,,,,,0,other,10127.65,37761.19,There are no additional notes associated with this service or procedure.
"Rpr/Advmnt Flxr Tdn Zone 2 W/O Fr Grft Ea Tendon|LEFT HAND, FOURTH DIGIT",CASE-26356,APC,26356,CPT,0360,RC,,,F3,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],8153.63,,"Case rate ($7,993.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,572.03, add-ons for qualifying new technology services are included. If operating cost exceeds $42,443.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,202.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $5,606.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,627.08 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $442.40. The transfer capital threshold is the transfer adjustment factor * $442.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,5415.00,17575.50,Inpatient DRG
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],20553.44,,"Fee schedule rate ($20,553.44). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8874.81,20553.44,There are no additional notes associated with this service or procedure.
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],33221.97,,"Fee schedule rate ($33,221.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (47), with a minimum of zero.",,,,0,other,15283.90,38757.79,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],7923.33,,"Case rate ($7,923.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,506.51, add-ons for qualifying new technology services are included. If operating cost exceeds $42,377.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,197.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $5,541.13 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,561.56 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $437.25. The transfer capital threshold is the transfer adjustment factor * $437.25. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,1188.00,17370.86,Inpatient DRG
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],31323.82,,,,,,0,other,12725.42,34245.00,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],14472.36,,"Case rate ($13,783.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,957.83, add-ons for qualifying new technology services are included. If operating cost exceeds $47,828.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,625.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $10,972.42 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,012.88 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $865.83. The transfer capital threshold is the transfer adjustment factor * $865.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13783.20,41580.51,Inpatient DRG
"ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",770,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],8735.30,,"Case rate ($8,735.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,261.87, add-ons for qualifying new technology services are included. If operating cost exceeds $43,132.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,256.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $6,293.72 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,316.92 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $496.64. The transfer capital threshold is the transfer adjustment factor * $496.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8735.30,19730.13,Inpatient DRG
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],36776.05,,"Fee schedule rate ($36,776.05). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11053.39,36776.05,There are no additional notes associated with this service or procedure.
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],13872.99,,"Fee schedule rate ($13,872.99). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.8), with a minimum of zero.",,,,0,other,5068.21,14525.56,There are no additional notes associated with this service or procedure.
Insj/Rplcmt Breast Implant Sep Day Mastectomy|BILATERAL PROCEDURE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-19342,APC,19342,CPT,0360,RC,,,50|XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],8033.01,,"APC Price ($7,650.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,7650.49,8033.01,OPPS APC
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6561.93,,"Case rate ($6,340.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,033.60, add-ons for qualifying new technology services are included. If operating cost exceeds $40,904.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,081.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $4,073.62 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,088.64 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $321.45. The transfer capital threshold is the transfer adjustment factor * $321.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6340.03,15076.44,Inpatient DRG
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],17249.81,,"Case rate ($16,428.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,418.58, add-ons for qualifying new technology services are included. If operating cost exceeds $50,289.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,819.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $13,424.13 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,473.63 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,059.30. The transfer capital threshold is the transfer adjustment factor * $1,059.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,16428.39,42083.20,Inpatient DRG
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],12126.09,,"Case rate ($12,126.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,416.25, add-ons for qualifying new technology services are included. If operating cost exceeds $46,287.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,504.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $9,436.50 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,471.29 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $744.63. The transfer capital threshold is the transfer adjustment factor * $744.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12126.09,29582.40,Inpatient DRG
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],19763.43,,"Fee schedule rate ($19,763.43). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,8318.14,19763.43,There are no additional notes associated with this service or procedure.
"ANTEPARTUM WITHOUT O.R. PROCEDURE,MINOR",566,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],2613.78,,"The inlier payment is calculated as the lesser of the standard DRG payment $2,613.78 and the transfer payment, which is a per diem of $1,281.27. If cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,2613.78,2744.47,Estimated amount calculated based on 1 day length of stay.
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,093,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],19011.32,,"Fee schedule rate ($19,011.32). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,19011.32,There are no additional notes associated with this service or procedure.
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],9667.64,,"Fee schedule rate ($9,667.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,5139.72,13110.79,There are no additional notes associated with this service or procedure.
"MAJOR RESPIRATORY INFECTIONS AND INFLAMMATIONS,MODERATE",137,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],7487.43,,"Case rate ($7,130.89). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7130.89,7487.43,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],32795.66,,"Fee schedule rate ($32,795.66). Adds an outlier to normal pricing equal to the per diem rate ($69,146.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,1188.00,34338.33,There are no additional notes associated with this service or procedure.
Cysto Calibration Dilat Urtl Strix/Stenosis,CASE-52281,APC,52281,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1956.65,,"APC Price ($1,956.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1956.65,2054.48,OPPS APC
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],29216.99,,"Fee schedule rate ($29,216.99). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9755.86,29216.99,There are no additional notes associated with this service or procedure.
TRAUMATIC INJURY WITH MCC,913,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],13014.58,,"Case rate ($13,014.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,242.79, add-ons for qualifying new technology services are included. If operating cost exceeds $47,113.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,569.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $10,260.01 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,297.84 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $809.62. The transfer capital threshold is the transfer adjustment factor * $809.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,13014.58,42838.46,Inpatient DRG
ALLERGIC REACTIONS WITH MCC,915,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],33088.84,,,,,,0,other,13332.86,33088.84,There are no additional notes associated with this service or procedure.
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|RIGHT HAND, SECOND DIGIT",CASE-26160,APC,26160,CPT,0360,RC,,,F6,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1505.12,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1505.12,1557.80,OPPS APC
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC,434,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],13390.01,,"Fee schedule rate ($13,390.01). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6770.05,14019.86,There are no additional notes associated with this service or procedure.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],61290.90,,"Fee schedule rate ($61,290.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,23799.09,63499.65,There are no additional notes associated with this service or procedure.
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],17123.74,,"Case rate ($16,787.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,753.10, add-ons for qualifying new technology services are included. If operating cost exceeds $50,624.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,845.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $13,757.43 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,808.15 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,085.60. The transfer capital threshold is the transfer adjustment factor * $1,085.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,16787.98,62990.26,Inpatient DRG
VENTRICULAR SHUNT PROCEDURES WITH CC,032,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],16749.95,,"Case rate ($15,952.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,001.86, add-ons for qualifying new technology services are included. If operating cost exceeds $49,872.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,759.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $13,007.59 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,056.91 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $999.79. The transfer capital threshold is the transfer adjustment factor * $999.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,16376.22,46275.08,Inpatient DRG
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],37914.65,,"Fee schedule rate ($37,914.65). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9865.56,37914.65,There are no additional notes associated with this service or procedure.
HC Joint Injection/Aspir Large WO US|DISTINCT PROCEDURAL SERVICE|RIGHT SIDE|PBB CHARGE,CASE-20610,APC,20610,CPT,0510,RC,,,59|RT|PBB,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],301.68,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,287.31,301.68,OPPS APC
Laps Tx Ectopic Preg W/Salping&/Oophorectomy|RIGHT SIDE,CASE-59151,APC,59151,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5856.81,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5658.76,5941.70,OPPS APC
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],36094.03,,"Fee schedule rate ($36,094.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11194.25,36094.03,There are no additional notes associated with this service or procedure.
Egd Endoscopic Stent Placement W/Wire& Dilation,CASE-43266,APC,43266,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5682.51,,"APC Price ($5,682.51). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5682.51,5966.63,OPPS APC
Inj for Sacroiliac Jt Anesth|LEFT SIDE,CASE-G0260,APC,G0260,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],660.72,,"APC Price ($660.72). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,660.72,693.76,OPPS APC
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],14586.15,,"Case rate ($13,891.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,058.63, add-ons for qualifying new technology services are included. If operating cost exceeds $47,929.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,633.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,072.85 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,113.68 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $873.76. The transfer capital threshold is the transfer adjustment factor * $873.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13891.57,34712.20,Inpatient DRG
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],18918.49,,"Fee schedule rate ($18,918.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9282.47,21320.03,There are no additional notes associated with this service or procedure.
"ANTEPARTUM WITHOUT O.R. PROCEDURE,MAJOR",566,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],7288.28,,"Case rate ($6,941.22). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6941.22,7288.28,There are no additional notes associated with this service or procedure.
OSTEOMYELITIS WITHOUT CC/MCC,541,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],12735.24,,"Case rate ($7,277.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,905.50, add-ons for qualifying new technology services are included. If operating cost exceeds $41,776.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,149.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $4,942.33 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,960.55 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $390.00. The transfer capital threshold is the transfer adjustment factor * $390.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,5103.00,15493.67,All Other Inpatient
"Prq Skel Fixj Phlngl Shft Fx Prox/Middle Px/F/T|RIGHT HAND, FIFTH DIGIT",CASE-26727,APC,26727,CPT,0360,RC,,,F9,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
HC Joint Injection/Aspir Large WO US|RIGHT SIDE,CASE-20610,APC,20610,CPT,0510,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],287.31,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],12272.58,,"Fee schedule rate ($12,272.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5628.97,12272.58,There are no additional notes associated with this service or procedure.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],38222.57,,,,,,0,other,7605.00,39153.65,There are no additional notes associated with this service or procedure.
NONTRAUMATIC STUPOR AND COMA WITH MCC,080,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],30179.40,,"Fee schedule rate ($30,179.40). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,14202.39,35615.37,There are no additional notes associated with this service or procedure.
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],8165.30,,"Fee schedule rate ($8,165.30). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4341.01,12882.53,There are no additional notes associated with this service or procedure.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],26028.48,,"Case rate ($26,028.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $24,349.34, add-ons for qualifying new technology services are included. If operating cost exceeds $59,220.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,521.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $22,322.08 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $22,404.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,761.43. The transfer capital threshold is the transfer adjustment factor * $1,761.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,26028.48,80635.65,Inpatient DRG
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],28038.61,,"Fee schedule rate ($28,038.61). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12126.09,29582.40,There are no additional notes associated with this service or procedure.
Colsc Flexible W/Control Bleeding Any Method,CASE-45382,APC,45382,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1120.09,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1120.09,1176.09,OPPS APC
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC",494,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],39945.55,,"Fee schedule rate ($39,945.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,15533.10,39945.55,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC,084,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],8638.95,,"Case rate ($8,227.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,801.26, add-ons for qualifying new technology services are included. If operating cost exceeds $42,672.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,208.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $5,834.19 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,856.31 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $448.43. The transfer capital threshold is the transfer adjustment factor * $448.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,19445.16,Inpatient DRG
Transection/Avulsion Oth Spinal Nrv Xdrl|RIGHT SIDE,CASE-64772,APC,64772,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
MAJOR CHEST TRAUMA WITHOUT CC/MCC,185,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],21771.61,,"Fee schedule rate ($21,771.61). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7271.19,21771.61,There are no additional notes associated with this service or procedure.
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],13478.34,,"Fee schedule rate ($13,478.34). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,6801.88,22557.82,There are no additional notes associated with this service or procedure.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC,192,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],6965.00,,,,,,0,other,6292.63,12753.78,There are no additional notes associated with this service or procedure.
Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE,CASE-62323,APC,62323,CPT,0360,RC,,,XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],693.76,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,660.72,693.76,OPPS APC
VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC,033,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],42156.44,,"Fee schedule rate ($42,156.44). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,13206.23,42156.44,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],10834.64,,"Case rate ($10,834.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,214.84, add-ons for qualifying new technology services are included. If operating cost exceeds $45,085.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,410.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $8,239.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,269.90 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $650.18. The transfer capital threshold is the transfer adjustment factor * $650.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10834.64,25830.00,Inpatient DRG
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],13568.55,,"Fee schedule rate ($13,568.55). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6834.39,21354.82,There are no additional notes associated with this service or procedure.
PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,337,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],12957.08,,"Case rate ($12,340.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,615.32, add-ons for qualifying new technology services are included. If operating cost exceeds $46,486.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,520.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $9,634.84 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,670.37 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $760.28. The transfer capital threshold is the transfer adjustment factor * $760.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12340.08,38926.31,Inpatient DRG
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],21089.59,,"Fee schedule rate ($21,089.59). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,6965.00,21089.59,There are no additional notes associated with this service or procedure.
DIABETES WITHOUT CC/MCC,639,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],11899.36,,"Fee schedule rate ($11,899.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6151.76,12223.35,There are no additional notes associated with this service or procedure.
HYPERTENSION WITHOUT MCC,305,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],9549.75,,"Fee schedule rate ($9,549.75). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7058.55,17230.49,There are no additional notes associated with this service or procedure.
"CHRONIC OBSTRUCTIVE PULMONARY DISEASE,MODERATE",140,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],2133.23,,"Case rate for a one day stay ($2,031.65). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,2031.65,2133.23,There are no additional notes associated with this service or procedure.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,073,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],43475.01,,"Fee schedule rate ($43,475.01). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,12809.38,43475.01,There are no additional notes associated with this service or procedure.
OTHER MENTAL DISORDER DIAGNOSES,887,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],9197.17,,"Case rate ($9,197.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,691.53, add-ons for qualifying new technology services are included. If operating cost exceeds $43,562.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,290.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,721.79 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,746.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $530.42. The transfer capital threshold is the transfer adjustment factor * $530.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,2070.00,21072.10,Inpatient DRG
Rpr Aa Hernia Recr 3-10 Cm Ncrc8/Strangulated,CASE-49616,APC,49616,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5856.81,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5658.76,5941.70,OPPS APC
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],18217.52,,"Fee schedule rate ($18,217.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7414.07,18217.52,There are no additional notes associated with this service or procedure.
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],15809.93,,"Case rate ($15,057.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,167.35, add-ons for qualifying new technology services are included. If operating cost exceeds $49,038.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,695.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $12,176.23 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,222.40 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $935.89. The transfer capital threshold is the transfer adjustment factor * $935.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,15453.88,39251.68,Inpatient DRG
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],22557.82,,"Fee schedule rate ($22,557.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6801.88,22557.82,There are no additional notes associated with this service or procedure.
"NEONATE BIRTH WEIGHT 2000-2499 GRAMS NORMAL NEWBORN OR NEONATE WITH OTHER PROBLEM,MINOR",626,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],1580.61,,"Case rate ($1,505.34). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,1505.34,1580.61,There are no additional notes associated with this service or procedure.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC,858,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],11655.72,,"Case rate ($11,100.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,479.43, add-ons for qualifying new technology services are included. If operating cost exceeds $45,350.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,413.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $8,502.24 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,534.48 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $653.50. The transfer capital threshold is the transfer adjustment factor * $653.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,11377.76,33794.11,Inpatient DRG
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],2070.00,,,,,,0,other,1188.00,12138.74,Estimated amount calculated based on 1 day length of stay.
Surgical Arthroscopy Shoulder Removal Loose/FB|SEPARATE STRUCTURE|RIGHT SIDE,CASE-29819,APC,29819,CPT,0360,RC,,,XS|RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7029.71,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6791.99,7029.71,OPPS APC
SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS,029,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],61889.56,,"Fee schedule rate ($61,889.56). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13641.00,67130.05,There are no additional notes associated with this service or procedure.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,098,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],18360.48,,"Case rate ($17,486.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,402.62, add-ons for qualifying new technology services are included. If operating cost exceeds $51,273.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,896.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $14,404.56 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,457.67 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,136.66. The transfer capital threshold is the transfer adjustment factor * $1,136.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,45156.75,Inpatient DRG
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC,817,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],43874.75,,"Fee schedule rate ($43,874.75). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,17396.11,44895.04,There are no additional notes associated with this service or procedure.
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],13760.97,,"Case rate ($13,295.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,504.24, add-ons for qualifying new technology services are included. If operating cost exceeds $47,375.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,590.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $10,520.50 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,559.29 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $830.17. The transfer capital threshold is the transfer adjustment factor * $830.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,7000.00,33835.79,Inpatient DRG
BRONCHITIS AND ASTHMA WITH CC/MCC,202,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],14307.27,,"Fee schedule rate ($14,307.27). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7606.34,19110.30,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],24703.21,,"Case rate ($23,526.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $22,022.15, add-ons for qualifying new technology services are included. If operating cost exceeds $56,893.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,338.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.7. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.7)) / 2. The base transfer operating payment is the transfer adjustment factor * $20,003.44 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $20,077.20 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,578.47. The transfer capital threshold is the transfer adjustment factor * $1,578.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,23526.87,94787.57,Inpatient DRG
DIABETES WITH MCC,637,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],27368.25,,"Fee schedule rate ($27,368.25). Adds an outlier to normal pricing equal to the per diem rate ($39,561.63) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,9959.03,28655.62,There are no additional notes associated with this service or procedure.
Arthrp Interpos Intercarpal/Metacarpal Joints|LEFT SIDE,CASE-25447,APC,25447,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
Excision Tumor Soft Tissue Foot/Toe Subq <1.5cm|LEFT SIDE,CASE-28043,APC,28043,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1545.93,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1545.93,1623.23,OPPS APC
Cysto Bladder W/Ureteral Catheterization,CASE-52005,APC,52005,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],2054.48,,"APC Price ($1,956.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1956.65,2054.48,OPPS APC
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,086,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],30728.81,,"Fee schedule rate ($30,728.81). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8442.00,30728.81,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],42569.49,,"Case rate ($40,542.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $37,851.31, add-ons for qualifying new technology services are included. If operating cost exceeds $72,722.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,582.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.6. The base transfer operating payment is the transfer adjustment factor * $35,774.45 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $35,906.36 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,822.96. The transfer capital threshold is the transfer adjustment factor * $2,822.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,40542.37,128358.13,Inpatient DRG
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],26966.33,,"Fee schedule rate ($26,966.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,9040.72,26966.33,There are no additional notes associated with this service or procedure.
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC,805,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],20281.41,,"Fee schedule rate ($20,281.41). Adds an outlier to normal pricing equal to the per diem rate ($31,438.44) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.5), with a minimum of zero.",,,,0,other,9253.36,21235.42,There are no additional notes associated with this service or procedure.
PREMATURITY WITH MAJOR PROBLEMS,791,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],3186.77,,,,,,0,other,3048.21,30904.42,Estimated amount calculated based on 5 day length of stay.
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],13077.97,,"Case rate ($12,455.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,722.41, add-ons for qualifying new technology services are included. If operating cost exceeds $46,593.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,528.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $9,741.55 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,777.47 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $768.70. The transfer capital threshold is the transfer adjustment factor * $768.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12455.21,37149.27,Inpatient DRG
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],24444.75,,"Fee schedule rate ($24,444.75). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10136.44,24444.75,There are no additional notes associated with this service or procedure.
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],16055.90,,"Fee schedule rate ($16,055.90). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8163.06,18067.42,There are no additional notes associated with this service or procedure.
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],36140.75,,,,,,0,other,6965.00,36140.75,There are no additional notes associated with this service or procedure.
"Corrj Hallux Valgus W/Sesmdc W/Dist Metar Osteot|RIGHT FOOT, GREAT TOE",CASE-28296,APC,28296,CPT,0360,RC,,,T5,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],17356.15,,"Case rate ($17,356.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,281.67, add-ons for qualifying new technology services are included. If operating cost exceeds $51,152.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,887.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $14,284.05 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,336.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,127.15. The transfer capital threshold is the transfer adjustment factor * $1,127.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,17356.15,44778.95,Inpatient DRG
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],5710.23,,"Case rate ($5,710.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,447.70, add-ons for qualifying new technology services are included. If operating cost exceeds $40,318.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,035.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $3,489.88 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,502.75 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $275.39. The transfer capital threshold is the transfer adjustment factor * $275.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,3079.00,10940.41,Inpatient DRG
CESAREAN SECTION WITH STERILIZATION WITH MCC,783,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],19499.60,,"Case rate ($18,571.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,411.86, add-ons for qualifying new technology services are included. If operating cost exceeds $52,282.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,975.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $15,410.10 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,466.92 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,216.01. The transfer capital threshold is the transfer adjustment factor * $1,216.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12612.10,23722.94,Inpatient DRG
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],22563.61,,"Case rate ($21,489.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,126.50, add-ons for qualifying new technology services are included. If operating cost exceeds $54,997.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,189.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.6. The base transfer operating payment is the transfer adjustment factor * $18,114.76 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,181.55 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,429.43. The transfer capital threshold is the transfer adjustment factor * $1,429.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,21489.15,68942.79,Inpatient DRG
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],85466.62,,"Fee schedule rate ($85,466.62). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,21382.16,85466.62,There are no additional notes associated with this service or procedure.
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],29594.00,,"Fee schedule rate ($29,594.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,13571.25,33781.47,There are no additional notes associated with this service or procedure.
NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,601,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],6344.15,,"Case rate ($6,042.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,756.39, add-ons for qualifying new technology services are included. If operating cost exceeds $40,627.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,059.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $3,797.45 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,811.45 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $299.66. The transfer capital threshold is the transfer adjustment factor * $299.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6042.05,12359.72,Inpatient DRG
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],12990.19,,"Case rate ($12,990.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,220.11, add-ons for qualifying new technology services are included. If operating cost exceeds $47,091.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,567.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $10,237.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,275.16 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $807.83. The transfer capital threshold is the transfer adjustment factor * $807.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9888.00,43399.23,Inpatient DRG
Arthrs Knee Abrasion Arthrp/Mlt Drlg/Microfx|LEFT SIDE,CASE-29879,APC,29879,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],21630.93,,,,,,0,other,9389.48,22358.90,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH CC,427,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],134742.59,,"Fee schedule rate ($134,742.59). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,50829.82,142040.39,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITHOUT CC/MCC,517,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],28052.31,,"Fee schedule rate ($28,052.31). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,10207.96,29371.86,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],46523.26,,"Fee schedule rate ($46,523.26). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,17782.11,46523.26,There are no additional notes associated with this service or procedure.
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC",605,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],8433.36,,"Case rate ($8,148.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,715.67, add-ons for qualifying new technology services are included. If operating cost exceeds $42,586.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,213.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,749.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,770.72 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $453.69. The transfer capital threshold is the transfer adjustment factor * $453.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,8148.17,18024.13,Inpatient DRG
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],39424.57,,"Fee schedule rate ($39,424.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12195.15,39424.57,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,448,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],79697.35,,"Fee schedule rate ($79,697.35). Adds an outlier to normal pricing equal to the per diem rate ($108,215.07) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,30663.95,94077.13,There are no additional notes associated with this service or procedure.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],8988.07,,"Case rate ($8,811.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,333.06, add-ons for qualifying new technology services are included. If operating cost exceeds $43,204.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,262.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,364.65 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,388.11 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $502.23. The transfer capital threshold is the transfer adjustment factor * $502.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6965.00,20401.88,Inpatient DRG
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],7665.00,,"Per diem ($7,665). If length of stay < 4, first 1 days paid at a per diem of $15,330 instead. Capped at $30,658.90.",,,,0,other,7665.00,40737.46,Estimated amount calculated based on 5 day length of stay.
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],16035.06,,"Fee schedule rate ($16,035.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,7396.47,16035.06,There are no additional notes associated with this service or procedure.
"OTHER DIGESTIVE SYSTEM DIAGNOSES,MINOR",254,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],5798.63,,"Case rate ($5,522.50). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5522.50,5798.63,There are no additional notes associated with this service or procedure.
Cysto/Uretero W/Lithotripsy &Indwell Stent Insrt|LEFT SIDE,CASE-52356,APC,52356,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5018.77,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5018.77,5269.71,OPPS APC
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],24444.75,,"Fee schedule rate ($24,444.75). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10136.44,24444.75,There are no additional notes associated with this service or procedure.
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],7000.00,,"Per diem ($7,000). If length of stay < 4.5, first 1 days paid at a per diem of $14,000 instead. Capped at $31,498.95.",,,,0,other,7000.00,33835.79,Estimated amount calculated based on 2 day length of stay.
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],11168.08,,"Fee schedule rate ($11,168.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5937.41,12366.99,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,447,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],156646.82,,"Fee schedule rate ($156,646.82). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,47193.21,156646.82,There are no additional notes associated with this service or procedure.
CERVICAL SPINAL FUSION WITH CC,472,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],70198.84,,"Fee schedule rate ($70,198.84). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,21896.13,70198.84,There are no additional notes associated with this service or procedure.
Rpr/Advmnt Flxr Tdn Zone 2 W/O Fr Grft Ea Tendon,CASE-26356,APC,26356,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC,807,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],6510.67,,"Case rate ($6,510.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,192.35, add-ons for qualifying new technology services are included. If operating cost exceeds $41,063.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,093.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $4,231.80 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,247.40 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $333.93. The transfer capital threshold is the transfer adjustment factor * $333.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,5354.25,13266.23,Inpatient DRG
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITHOUT MCC,430,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],133156.90,,"Fee schedule rate ($133,156.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,41000.16,133156.90,There are no additional notes associated with this service or procedure.
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR,518,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],49516.95,,"Fee schedule rate ($49,516.95). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,13252.00,89342.77,There are no additional notes associated with this service or procedure.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],30112.02,,"Fee schedule rate ($30,112.02). Adds an outlier to normal pricing equal to the per diem rate ($53,484.01) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.5), with a minimum of zero.",,,,0,other,12795.84,41944.25,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC",281,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],23859.35,,"Fee schedule rate ($23,859.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8169.15,23859.35,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC,817,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],18265.92,,"Case rate ($17,396.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,318.84, add-ons for qualifying new technology services are included. If operating cost exceeds $51,189.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,890.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $14,321.08 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,373.88 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,130.07. The transfer capital threshold is the transfer adjustment factor * $1,130.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,17396.11,44895.04,Inpatient DRG
Injection Aa&/Strd Ilioinguinal Ih Nerves|LEFT SIDE,CASE-64425,APC,64425,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],693.76,,"APC Price ($660.72). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,660.72,693.76,OPPS APC
Bronchoscopy W/Plmt Fiducial Markers Single/Mult,CASE-31626,APC,31626,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6936.25,,"APC Price ($6,605.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6605.95,6936.25,OPPS APC
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],85466.62,,"Fee schedule rate ($85,466.62). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,21382.16,85466.62,There are no additional notes associated with this service or procedure.
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],8877.69,,"Case rate ($8,454.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,001.06, add-ons for qualifying new technology services are included. If operating cost exceeds $42,872.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,236.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,033.86 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,056.11 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $476.13. The transfer capital threshold is the transfer adjustment factor * $476.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6230.00,22762.43,Inpatient DRG
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],97015.50,,"Fee schedule rate ($97,015.50). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,26809.29,97015.50,There are no additional notes associated with this service or procedure.
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],81454.07,,"Fee schedule rate ($81,454.07). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,10078.00,81454.07,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],28423.20,,"Fee schedule rate ($28,423.20). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11059.47,28423.20,There are no additional notes associated with this service or procedure.
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],6937.19,,"Case rate ($6,606.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,281.82, add-ons for qualifying new technology services are included. If operating cost exceeds $41,152.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,100.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,320.93 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,336.86 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $340.96. The transfer capital threshold is the transfer adjustment factor * $340.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5919.29,13545.65,Inpatient DRG
VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC,033,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],31250.88,,"Fee schedule rate ($31,250.88). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7.9), with a minimum of zero.",,,,0,other,13206.23,42156.44,There are no additional notes associated with this service or procedure.
VENTRICULAR SHUNT PROCEDURES WITH MCC,031,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],33901.56,,"Case rate ($32,287.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $30,171.71, add-ons for qualifying new technology services are included. If operating cost exceeds $65,042.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,979.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7. The base transfer operating payment is the transfer adjustment factor * $28,123.07 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $28,226.76 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,219.19. The transfer capital threshold is the transfer adjustment factor * $2,219.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,32287.20,88162.80,Inpatient DRG
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,098,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],38799.38,,"Fee schedule rate ($38,799.38). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,6965.00,45156.75,There are no additional notes associated with this service or procedure.
Dstr Nrolytc Agnt Parverteb Fct Sngl Lmbr/Sacral|BILATERAL PROCEDURE,CASE-64635,APC,64635,CPT,0360,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1891.77,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1827.80,1919.19,OPPS APC
Sling Operation Stress Incontinence,CASE-57288,APC,57288,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],4846.30,,"APC Price ($4,682.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,4682.41,4916.53,OPPS APC
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],10347.06,,"Case rate ($10,347.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,761.25, add-ons for qualifying new technology services are included. If operating cost exceeds $44,632.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,374.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $7,787.59 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,816.30 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $614.52. The transfer capital threshold is the transfer adjustment factor * $614.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10347.06,28821.04,Inpatient DRG
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",004,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],97641.94,,"Case rate ($92,992.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $86,814.26, add-ons for qualifying new technology services are included. If operating cost exceeds $121,685.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $8,258.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 22.4. The base transfer operating payment is the transfer adjustment factor * $84,548.75 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $84,869.31 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $6,498.62. The transfer capital threshold is the transfer adjustment factor * $6,498.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10249.47,272554.00,Inpatient DRG
RESPIRATORY NEOPLASMS WITHOUT CC/MCC,182,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],7049.74,,"Case rate ($7,049.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,693.83, add-ons for qualifying new technology services are included. If operating cost exceeds $41,564.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,133.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,731.43 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,748.88 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $373.36. The transfer capital threshold is the transfer adjustment factor * $373.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,23037.13,Inpatient DRG
MAJOR BLADDER PROCEDURES WITH MCC,653,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],125343.98,,"Fee schedule rate ($125,343.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,10280.00,125343.98,There are no additional notes associated with this service or procedure.
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],27222.08,,"Fee schedule rate ($27,222.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7389.00,37134.43,There are no additional notes associated with this service or procedure.
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],8643.20,,"Case rate ($8,643.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,176.19, add-ons for qualifying new technology services are included. If operating cost exceeds $43,047.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,249.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $6,208.35 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,231.24 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $489.90. The transfer capital threshold is the transfer adjustment factor * $489.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8643.20,19462.52,Inpatient DRG
"Tendon Sheath Incision|UNUSUAL NON-OVERLAPPING SERVICE|LEFT HAND, THUMB",CASE-26055,APC,26055,CPT,0360,RC,,,XU|FA,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC,806,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],6640.88,,"Case rate ($6,510.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,192.35, add-ons for qualifying new technology services are included. If operating cost exceeds $41,063.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,093.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $4,231.80 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,247.40 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $333.93. The transfer capital threshold is the transfer adjustment factor * $333.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,5354.25,13416.00,Inpatient DRG
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|RIGHT HAND, THIRD DIGIT",CASE-26160,APC,26160,CPT,0360,RC,,,F7,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1557.80,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1505.12,1580.37,OPPS APC
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],11812.10,,,,,,0,other,6010.23,12246.05,There are no additional notes associated with this service or procedure.
Neuroplasty &/Transposition Ulnar Nerve Elbow|RIGHT SIDE,CASE-64718,APC,64718,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1891.77,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1827.80,1919.19,OPPS APC
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],46016.63,,,,,,0,other,17782.11,46523.26,There are no additional notes associated with this service or procedure.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",062,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],14537.08,,"Case rate ($13,844.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,015.16, add-ons for qualifying new technology services are included. If operating cost exceeds $47,886.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,630.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $11,029.54 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,070.21 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $870.34. The transfer capital threshold is the transfer adjustment factor * $870.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13844.84,44304.80,Inpatient DRG
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],62041.12,,"Fee schedule rate ($62,041.12). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,18497.24,62041.12,There are no additional notes associated with this service or procedure.
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],43128.05,,,,,,0,other,16787.98,62990.26,There are no additional notes associated with this service or procedure.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],10517.71,,"Case rate ($10,517.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,920.01, add-ons for qualifying new technology services are included. If operating cost exceeds $44,791.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,386.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $7,945.76 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,975.06 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $627.00. The transfer capital threshold is the transfer adjustment factor * $627.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10517.71,24909.11,Inpatient DRG
COAGULATION DISORDERS,813,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],28664.96,,"Fee schedule rate ($28,664.96). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.7), with a minimum of zero.",,,,0,other,12274.39,30013.33,There are no additional notes associated with this service or procedure.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],32370.17,,"Case rate ($18,497.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,343.20, add-ons for qualifying new technology services are included. If operating cost exceeds $52,214.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,970.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $15,341.68 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,398.25 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,210.61. The transfer capital threshold is the transfer adjustment factor * $1,210.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,18497.24,62041.12,All Other Inpatient
OSTEOMYELITIS WITH CC,540,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],11098.92,,"Case rate ($10,723.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,111.53, add-ons for qualifying new technology services are included. If operating cost exceeds $44,982.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,402.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $8,136.58 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,166.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $642.06. The transfer capital threshold is the transfer adjustment factor * $642.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,9809.07,25507.30,Inpatient DRG
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],28756.63,,"Fee schedule rate ($28,756.63). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,13148.66,32553.63,There are no additional notes associated with this service or procedure.
HC Drain/Inj Joint/Bursa W/US Large|LEFT SIDE,CASE-20611,APC,20611,CPT,0510,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],301.68,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,287.31,301.68,OPPS APC
Optx Dstl Radl I-Artic Fx/Epiphysl Sep 3 Frag|RIGHT SIDE,CASE-25609,APC,25609,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH CC",457,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],42327.47,,"Case rate ($42,327.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $39,511.96, add-ons for qualifying new technology services are included. If operating cost exceeds $74,382.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,713.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $37,429.01 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $37,567.02 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,953.52. The transfer capital threshold is the transfer adjustment factor * $2,953.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,42327.47,160549.49,Inpatient DRG
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],20362.22,,"Fee schedule rate ($20,362.22). Adds an outlier to normal pricing equal to the per diem rate ($66,744.74) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.8), with a minimum of zero.",,,,0,other,9282.47,21320.03,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],16066.07,,"Case rate ($16,066.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,081.53, add-ons for qualifying new technology services are included. If operating cost exceeds $49,952.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,792.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $13,088.32 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,136.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,032.80. The transfer capital threshold is the transfer adjustment factor * $1,032.80. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,41030.48,Inpatient DRG
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],24675.88,,"Fee schedule rate ($24,675.88). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10834.64,25830.00,There are no additional notes associated with this service or procedure.
"NEONATE BIRTH WEIGHT > 2499 GRAMS NORMAL NEWBORN OR NEONATE WITH OTHER PROBLEM,MINOR",640,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],1130.37,,"Case rate ($1,130.37). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,1130.37,1186.89,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,167,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],14865.60,,"Case rate ($14,157.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,306.21, add-ons for qualifying new technology services are included. If operating cost exceeds $48,177.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,653.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $11,319.53 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,361.26 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $893.22. The transfer capital threshold is the transfer adjustment factor * $893.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,14157.71,43522.37,Inpatient DRG
Submucous Rescj Inferior Turbinate Prtl/Compl,CASE-30140,APC,30140,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3211.97,,"APC Price ($3,103.35). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.35,3258.52,OPPS APC
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],59891.41,,"Fee schedule rate ($59,891.41). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15), with a minimum of zero.",,,,0,other,23526.87,94787.57,There are no additional notes associated with this service or procedure.
HC Injection Small Joint/Bursa|PBB CHARGE,CASE-20600,APC,20600,CPT,0361,RC,,,PBB,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],297.37,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,287.31,301.68,OPPS APC
CHEST PAIN,313,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],6820.84,,"Case rate ($6,820.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,480.89, add-ons for qualifying new technology services are included. If operating cost exceeds $41,351.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,116.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $4,519.27 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,535.94 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $356.62. The transfer capital threshold is the transfer adjustment factor * $356.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6820.84,15377.66,Inpatient DRG
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],23344.70,,"Case rate ($23,344.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $21,852.68, add-ons for qualifying new technology services are included. If operating cost exceeds $56,723.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,325.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $19,834.60 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $19,907.73 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,565.15. The transfer capital threshold is the transfer adjustment factor * $1,565.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,23344.70,62179.32,Inpatient DRG
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],37768.77,,"Fee schedule rate ($37,768.77). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7453.00,42138.30,There are no additional notes associated with this service or procedure.
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC",605,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],17214.39,,"Fee schedule rate ($17,214.39). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8148.17,18024.13,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,086,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],10766.92,,"Case rate ($10,766.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,151.85, add-ons for qualifying new technology services are included. If operating cost exceeds $45,022.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,405.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $8,176.75 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,206.90 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $645.23. The transfer capital threshold is the transfer adjustment factor * $645.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8442.00,30728.81,Inpatient DRG
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],12184.87,,"Case rate ($11,945.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,248.66, add-ons for qualifying new technology services are included. If operating cost exceeds $46,119.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,491.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $9,269.54 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,303.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $731.46. The transfer capital threshold is the transfer adjustment factor * $731.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6167.00,29058.99,Inpatient DRG
Mastectomy Simple Complete|RIGHT SIDE,CASE-19303,APC,19303,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6432.89,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6215.36,6432.89,OPPS APC
OTHER DISORDERS OF NERVOUS SYSTEM WITH CC,092,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],19225.24,,"Fee schedule rate ($19,225.24). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8872.78,26765.51,There are no additional notes associated with this service or procedure.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],21278.92,,"Case rate ($20,559.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $19,261.52, add-ons for qualifying new technology services are included. If operating cost exceeds $54,132.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,121.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $17,252.96 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $17,316.57 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,361.43. The transfer capital threshold is the transfer adjustment factor * $1,361.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,20559.34,54086.17,Inpatient DRG
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],6965.00,,,,,,0,other,6965.00,32293.66,There are no additional notes associated with this service or procedure.
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],29474.94,,"Fee schedule rate ($29,474.94). Adds an outlier to normal pricing equal to the per diem rate ($65,448.99) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.4), with a minimum of zero.",,,,0,other,12566.28,30861.41,There are no additional notes associated with this service or procedure.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],54764.34,,"Fee schedule rate ($54,764.34). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,18178.96,54764.34,There are no additional notes associated with this service or procedure.
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],13386.36,,"Case rate ($13,386.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,588.65, add-ons for qualifying new technology services are included. If operating cost exceeds $47,459.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,596.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $10,604.60 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,643.70 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $836.81. The transfer capital threshold is the transfer adjustment factor * $836.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,13386.36,33244.29,Inpatient DRG
"ALCOHOLIC LIVER DISEASE,MODERATE",280,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],1969.25,,"Case rate for a one day stay ($1,969.25). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,1969.25,2067.71,There are no additional notes associated with this service or procedure.
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],27222.08,,"Fee schedule rate ($27,222.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7389.00,37134.43,There are no additional notes associated with this service or procedure.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,057,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],39884.93,,"Fee schedule rate ($39,884.93). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,10718.84,39884.93,There are no additional notes associated with this service or procedure.
"LIMB REATTACHMENT, HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA",956,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],148259.86,,"Fee schedule rate ($148,259.86). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,27428.25,148259.86,There are no additional notes associated with this service or procedure.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],13435.63,,"Case rate ($12,795.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,039.30, add-ons for qualifying new technology services are included. If operating cost exceeds $46,910.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,553.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $10,057.27 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,094.35 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $793.62. The transfer capital threshold is the transfer adjustment factor * $793.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12795.84,41944.25,Inpatient DRG
ALLERGIC REACTIONS WITH MCC,915,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],27385.01,,"Fee schedule rate ($27,385.01). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,13332.86,33088.84,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,086,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],10766.92,,"Case rate ($10,766.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,151.85, add-ons for qualifying new technology services are included. If operating cost exceeds $45,022.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,405.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $8,176.75 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,206.90 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $645.23. The transfer capital threshold is the transfer adjustment factor * $645.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8442.00,30728.81,Inpatient DRG
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],17111.12,,,,,,0,other,5883.03,17111.12,There are no additional notes associated with this service or procedure.
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],37899.49,,"Fee schedule rate ($37,899.49). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,14747.55,37899.49,There are no additional notes associated with this service or procedure.
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],53275.26,,"Fee schedule rate ($53,275.26). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,15940.79,53275.26,There are no additional notes associated with this service or procedure.
HC Drain/Inj Joint/Bursa W/US Large|LEFT SIDE,CASE-20611,APC,20611,CPT,0510,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],297.37,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,287.31,301.68,OPPS APC
Excision Ganglion Wrist Dorsal/Volar Primary|LEFT SIDE,CASE-25111,APC,25111,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1580.37,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1505.12,1580.37,OPPS APC
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC,519,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],37589.76,,"Fee schedule rate ($37,589.76). Adds an outlier to normal pricing equal to the per diem rate ($123,674.40) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,15490.44,50780.20,There are no additional notes associated with this service or procedure.
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],16438.59,,"Fee schedule rate ($16,438.59). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7402.56,16438.59,There are no additional notes associated with this service or procedure.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],19528.77,,"Case rate ($18,598.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,437.70, add-ons for qualifying new technology services are included. If operating cost exceeds $52,308.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,978.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 5.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $15,435.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,492.75 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,218.04. The transfer capital threshold is the transfer adjustment factor * $1,218.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,18598.83,48389.68,Inpatient DRG
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],11381.83,,"Case rate ($6,503.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,186.05, add-ons for qualifying new technology services are included. If operating cost exceeds $41,057.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,093.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $4,225.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,241.10 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $333.44. The transfer capital threshold is the transfer adjustment factor * $333.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,6503.90,14492.93,All Other Inpatient
"Amp F/Th 1/2 Jt/Phalanx W/Neurect W/Dir Clsr|LEFT HAND, SECOND DIGIT",CASE-26951,APC,26951,CPT,0360,RC,,,F1,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],21854.96,,"Fee schedule rate ($21,854.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10638.94,25261.33,There are no additional notes associated with this service or procedure.
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],6606.85,,"Case rate ($6,606.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,281.82, add-ons for qualifying new technology services are included. If operating cost exceeds $41,152.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,100.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,320.93 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,336.86 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $340.96. The transfer capital threshold is the transfer adjustment factor * $340.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,5919.29,13545.65,Inpatient DRG
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],16400.70,,"Fee schedule rate ($16,400.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,16400.70,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],14871.83,,"Fee schedule rate ($14,871.83). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6558.75,14871.83,There are no additional notes associated with this service or procedure.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,345,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12427.36,,"Case rate ($11,835.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,164.44, add-ons for qualifying new technology services are included. If operating cost exceeds $46,035.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,465.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $9,184.67 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,219.49 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $705.96. The transfer capital threshold is the transfer adjustment factor * $705.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12134.89,33616.03,Inpatient DRG
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],53152.12,,"Fee schedule rate ($53,152.12). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,19152.11,53152.12,There are no additional notes associated with this service or procedure.
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],5791.49,,"Fee schedule rate ($5,791.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,3079.00,10940.41,There are no additional notes associated with this service or procedure.
OTHER MENTAL DISORDER DIAGNOSES,887,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],9381.11,,"Case rate ($9,197.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,691.53, add-ons for qualifying new technology services are included. If operating cost exceeds $43,562.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,290.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,721.79 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,746.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $530.42. The transfer capital threshold is the transfer adjustment factor * $530.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,2070.00,21072.10,Inpatient DRG
Ercp Destruction/Lithotripsy Calculi Any Method,CASE-43265,APC,43265,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5682.51,,"APC Price ($5,682.51). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5682.51,5966.63,OPPS APC
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],128358.13,,"Fee schedule rate ($128,358.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,40542.37,128358.13,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],37495.79,,"Fee schedule rate ($37,495.79). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.8), with a minimum of zero.",,,,0,other,15456.59,41402.42,There are no additional notes associated with this service or procedure.
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],15095.84,,"Fee schedule rate ($15,095.84). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11454.97,28394.78,There are no additional notes associated with this service or procedure.
Colonoscopy W/Biopsy Single/Multiple|COLORECTAL CANCER SCREEN,CASE-45380,APC,45380,CPT,0360,RC,,,PT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1120.09,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1120.09,1176.09,OPPS APC
"NEONATE BIRTH WEIGHT 2000-2499 GRAMS NORMAL NEWBORN OR NEONATE WITH OTHER PROBLEM,MAJOR",626,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],7047.57,,"Case rate ($7,047.57). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,7047.57,7399.95,There are no additional notes associated with this service or procedure.
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],15333.48,,"Case rate ($14,603.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,720.75, add-ons for qualifying new technology services are included. If operating cost exceeds $48,591.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,685.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $11,732.54 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,775.80 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $925.81. The transfer capital threshold is the transfer adjustment factor * $925.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,14603.31,45017.13,Inpatient DRG
Egd Transoral Control Bleeding Any Method,CASE-43255,APC,43255,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1796.14,,"APC Price ($1,796.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1796.14,1885.95,OPPS APC
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],7847.50,,"Case rate ($7,847.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,435.96, add-ons for qualifying new technology services are included. If operating cost exceeds $42,306.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,191.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,470.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,491.01 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $431.70. The transfer capital threshold is the transfer adjustment factor * $431.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7847.50,17755.26,Inpatient DRG
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],14492.93,,"Fee schedule rate ($14,492.93). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6503.90,14492.93,There are no additional notes associated with this service or procedure.
FRACTURES OF FEMUR WITH MCC,533,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],12561.53,,"Case rate ($12,561.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,821.33, add-ons for qualifying new technology services are included. If operating cost exceeds $46,692.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,536.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $9,840.09 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,876.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $776.48. The transfer capital threshold is the transfer adjustment factor * $776.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6852.00,49490.05,Inpatient DRG
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],9577.27,,"Case rate ($9,389.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,870.44, add-ons for qualifying new technology services are included. If operating cost exceeds $43,741.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,304.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,900.05 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,925.50 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $544.48. The transfer capital threshold is the transfer adjustment factor * $544.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,9389.48,22358.90,Inpatient DRG
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],11561.99,,"Case rate ($6,606.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,281.82, add-ons for qualifying new technology services are included. If operating cost exceeds $41,152.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,100.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,320.93 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,336.86 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $340.96. The transfer capital threshold is the transfer adjustment factor * $340.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,5919.29,13545.65,All Other Inpatient
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],46453.28,,"Case rate ($44,241.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $41,371.19, add-ons for qualifying new technology services are included. If operating cost exceeds $76,242.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,778.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 12.5. The base transfer operating payment is the transfer adjustment factor * $39,277.32 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $39,426.24 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,018.95. The transfer capital threshold is the transfer adjustment factor * $3,018.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,45521.20,142438.06,Inpatient DRG
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],59521.43,,"Fee schedule rate ($59,521.43). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,16689.78,59521.43,There are no additional notes associated with this service or procedure.
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],20981.60,,"Fee schedule rate ($20,981.60). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,10003.71,23415.63,There are no additional notes associated with this service or procedure.
Cystourethroscopy Inj Chemodenervation Bladder|UNUSUAL NON-OVERLAPPING SERVICE,CASE-52287,APC,52287,CPT,0360,RC,,,XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3464.44,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3299.47,3464.44,OPPS APC
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],21382.16,,"Case rate ($21,382.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,026.97, add-ons for qualifying new technology services are included. If operating cost exceeds $54,897.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,181.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6)) / 2. The base transfer operating payment is the transfer adjustment factor * $18,015.59 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,082.01 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,421.61. The transfer capital threshold is the transfer adjustment factor * $1,421.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,21382.16,85466.62,Inpatient DRG
"Amp F/Th 1/2 Jt/Phalanx W/Neurect W/Dir Clsr|LEFT HAND, SECOND DIGIT",CASE-26951,APC,26951,CPT,0360,RC,,,F1,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],18045.04,,"Fee schedule rate ($18,045.04). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,1188.00,18893.86,There are no additional notes associated with this service or procedure.
SINGLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL,402,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],29755.49,,"Case rate ($29,172.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $27,273.75, add-ons for qualifying new technology services are included. If operating cost exceeds $62,144.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,751.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $25,235.76 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $25,328.80 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,991.35. The transfer capital threshold is the transfer adjustment factor * $1,991.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,29172.05,124455.45,Inpatient DRG
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",004,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],10715.36,,,,,,0,other,10249.47,272554.00,Estimated amount calculated based on 6 day length of stay.
Rmvl Spinal Nstim Eltrd Prq Array Incl Fluor,CASE-63661,APC,63661,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3436.06,,"APC Price ($3,272.44). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3272.44,3436.06,OPPS APC
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],8319.50,,"Case rate ($7,923.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,506.51, add-ons for qualifying new technology services are included. If operating cost exceeds $42,377.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,197.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $5,541.13 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,561.56 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $437.25. The transfer capital threshold is the transfer adjustment factor * $437.25. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,1188.00,17370.86,Inpatient DRG
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],52909.62,,"Fee schedule rate ($52,909.62). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,23344.70,62179.32,There are no additional notes associated with this service or procedure.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,097,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],26404.32,,"Case rate ($26,404.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $24,698.97, add-ons for qualifying new technology services are included. If operating cost exceeds $59,569.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,548.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.7. The base transfer operating payment is the transfer adjustment factor * $22,670.44 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $22,754.03 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,788.92. The transfer capital threshold is the transfer adjustment factor * $1,788.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,26404.32,79915.74,Inpatient DRG
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC,832,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7022.55,,"Case rate ($6,688.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,366.29, add-ons for qualifying new technology services are included. If operating cost exceeds $41,237.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,098.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $4,404.64 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,421.34 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $338.55. The transfer capital threshold is the transfer adjustment factor * $338.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,4803.31,14198.92,Inpatient DRG
Prq Skeletal Fixj Metacarpal Fx Each Bone|RIGHT SIDE,CASE-26608,APC,26608,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],24528.10,,"Fee schedule rate ($24,528.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10989.72,26280.60,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],18671.22,,"Case rate ($17,782.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,677.93, add-ons for qualifying new technology services are included. If operating cost exceeds $51,548.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,918.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $14,678.86 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,732.98 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,158.31. The transfer capital threshold is the transfer adjustment factor * $1,158.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,17782.11,46523.26,Inpatient DRG
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],97015.50,,"Fee schedule rate ($97,015.50). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,26809.29,97015.50,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],19458.27,,"Fee schedule rate ($19,458.27). Adds an outlier to normal pricing equal to the per diem rate ($75,355.48) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,8956.76,28983.97,There are no additional notes associated with this service or procedure.
Optx Dstl Radl I-Artic Fx/Epiphysl Sep 3 Frag|LEFT SIDE,CASE-25609,APC,25609,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
"HC ED Avulsion Nail Plate Single|RIGHT HAND, THUMB",CASE-11730,APC,11730,CPT,0450,RC,,,F5,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],187.80,,"APC Price ($187.80). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,187.80,197.19,OPPS APC
Trurl Electrosurg Rescj Prostate Bleed Complete,CASE-52601,APC,52601,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5269.71,,"APC Price ($5,018.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5018.77,5269.71,OPPS APC
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],45845.03,,"Fee schedule rate ($45,845.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,18598.83,48389.68,There are no additional notes associated with this service or procedure.
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],81306.30,,"Fee schedule rate ($81,306.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,20846.48,81306.30,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC,831,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],10088.35,,"Case rate ($10,088.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,520.59, add-ons for qualifying new technology services are included. If operating cost exceeds $44,391.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,355.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $7,547.82 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,575.65 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $595.60. The transfer capital threshold is the transfer adjustment factor * $595.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,4941.30,23661.59,Inpatient DRG
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],13354.32,,"Case rate ($13,092.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,315.24, add-ons for qualifying new technology services are included. If operating cost exceeds $47,186.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,575.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $10,332.19 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,370.29 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $815.31. The transfer capital threshold is the transfer adjustment factor * $815.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,13092.47,33159.45,Inpatient DRG
TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC,087,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],8139.36,,"Case rate ($8,139.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,707.48, add-ons for qualifying new technology services are included. If operating cost exceeds $42,578.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,213.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $5,741.36 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,762.53 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $453.05. The transfer capital threshold is the transfer adjustment factor * $453.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8139.36,22679.07,Inpatient DRG
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],10390.62,,"Case rate ($9,895.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,356.33, add-ons for qualifying new technology services are included. If operating cost exceeds $44,227.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,327.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $7,383.38 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,411.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $567.50. The transfer capital threshold is the transfer adjustment factor * $567.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10136.44,24444.75,Inpatient DRG
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],48961.48,,"Fee schedule rate ($48,961.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11575.50,48961.48,There are no additional notes associated with this service or procedure.
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],14810.25,,"Fee schedule rate ($14,810.25). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6965.00,34422.94,There are no additional notes associated with this service or procedure.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],25276.59,,"Fee schedule rate ($25,276.59). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,11053.39,36776.05,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],52803.53,,"Fee schedule rate ($52,803.53). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,14337.84,52803.53,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,448,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],94077.13,,"Fee schedule rate ($94,077.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,30663.95,94077.13,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC",281,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],8455.07,,"Case rate ($8,169.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,735.20, add-ons for qualifying new technology services are included. If operating cost exceeds $42,606.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,215.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $5,768.98 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,790.25 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $455.23. The transfer capital threshold is the transfer adjustment factor * $455.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,8169.15,23859.35,Inpatient DRG
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC,192,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],12753.78,,"Fee schedule rate ($12,753.78). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6292.63,12753.78,There are no additional notes associated with this service or procedure.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],67790.93,,"Fee schedule rate ($67,790.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,21597.50,67790.93,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,699,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],8818.60,,"Case rate ($8,818.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,339.37, add-ons for qualifying new technology services are included. If operating cost exceeds $43,210.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,262.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $6,370.92 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,394.41 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $502.73. The transfer capital threshold is the transfer adjustment factor * $502.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,5961.00,19972.16,Inpatient DRG
Tx Anal Fstl Trans/Supra/Xtrasphnctrc Incl Seton,CASE-46280,APC,46280,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],2727.99,,"APC Price ($2,598.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2598.08,2727.99,OPPS APC
"Open Tx Phalangeal Shaft Fracture Prox/Middle Ea|RIGHT HAND, FIFTH DIGIT",CASE-26735,APC,26735,CPT,0360,RC,,,F9,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7029.71,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6791.99,7131.59,OPPS APC
"Open Tx Distal Phalangeal Fracture Each|RIGHT HAND, SECOND DIGIT",CASE-26765,APC,26765,CPT,0360,RC,,,F6,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6185.36,,"Case rate ($5,890.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,623.07, add-ons for qualifying new technology services are included. If operating cost exceeds $40,494.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,041.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,664.22 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,678.12 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $281.64. The transfer capital threshold is the transfer adjustment factor * $281.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6010.23,12246.05,Inpatient DRG
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],20297.68,,"Fee schedule rate ($20,297.68). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6965.00,21404.64,There are no additional notes associated with this service or procedure.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],21809.80,,"Case rate ($21,382.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,026.97, add-ons for qualifying new technology services are included. If operating cost exceeds $54,897.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,181.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6)) / 2. The base transfer operating payment is the transfer adjustment factor * $18,015.59 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,082.01 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,421.61. The transfer capital threshold is the transfer adjustment factor * $1,421.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 102%.",,,,0,other,21382.16,85466.62,Inpatient DRG
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],18033.97,,,,,,0,other,8151.55,18033.97,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,448,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],83446.22,,,,,,0,other,30663.95,94077.13,There are no additional notes associated with this service or procedure.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],6683.37,,"Case rate ($6,683.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,353, add-ons for qualifying new technology services are included. If operating cost exceeds $41,224.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,106.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,391.86 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,408.05 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $346.56. The transfer capital threshold is the transfer adjustment factor * $346.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6683.37,14699.43,Inpatient DRG
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],52699.33,,"Fee schedule rate ($52,699.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,18105.81,52699.33,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],107110.70,,"Fee schedule rate ($107,110.70). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (21), with a minimum of zero.",,,,0,other,40542.37,128358.13,There are no additional notes associated with this service or procedure.
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],6230.00,,"Per diem ($6,230). If length of stay < 2.9, first 1 days paid at a per diem of $12,460 instead. Capped at $18,065.71.",,,,0,other,6230.00,22762.43,Estimated amount calculated based on 3 day length of stay.
INFLAMMATORY BOWEL DISEASE WITH MCC,385,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],29736.16,,"Fee schedule rate ($29,736.16). Adds an outlier to normal pricing equal to the per diem rate ($112,108.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.5), with a minimum of zero.",,,,0,other,11480.01,31134.92,There are no additional notes associated with this service or procedure.
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],13548.15,,"Fee schedule rate ($13,548.15). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10136.44,24444.75,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITH STERILIZATION WITH CC,784,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],9124.01,,"Case rate ($9,124.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,623.49, add-ons for qualifying new technology services are included. If operating cost exceeds $43,494.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,285.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,654.00 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,678.54 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $525.07. The transfer capital threshold is the transfer adjustment factor * $525.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9124.01,23722.94,Inpatient DRG
INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC,198,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],23505.07,,"Fee schedule rate ($23,505.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6795.12,23505.07,There are no additional notes associated with this service or procedure.
Colonoscopy Flx W/Endoscopic Mucosal Resection|UNUSUAL NON-OVERLAPPING SERVICE|COLORECTAL CANCER SCREEN,CASE-45390,APC,45390,CPT,0360,RC,,,XU|PT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],2598.08,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2598.08,2727.99,OPPS APC
NONTRAUMATIC STUPOR AND COMA WITH MCC,080,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],30179.40,,"Fee schedule rate ($30,179.40). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,14202.39,35615.37,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],28038.61,,"Fee schedule rate ($28,038.61). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12126.09,29582.40,There are no additional notes associated with this service or procedure.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,544,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],7196.25,,"Case rate ($7,055.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,698.86, add-ons for qualifying new technology services are included. If operating cost exceeds $41,569.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,133.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $4,736.45 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,753.92 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $373.75. The transfer capital threshold is the transfer adjustment factor * $373.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,7055.15,23207.64,Inpatient DRG
OTHER DISORDERS OF NERVOUS SYSTEM WITH CC,092,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],26765.51,,"Fee schedule rate ($26,765.51). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8872.78,26765.51,There are no additional notes associated with this service or procedure.
Tonsillectomy & Adenoidectomy Age 12/>,CASE-42821,APC,42821,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.52,,"APC Price ($3,103.35). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.35,3258.52,OPPS APC
Laryngoscopy Direct Operative W/Biopsy|UNUSUAL NON-OVERLAPPING SERVICE,CASE-31535,APC,31535,CPT,0360,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3489.82,,"APC Price ($3,489.82). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3489.82,3664.31,OPPS APC
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],14383.21,,"Case rate ($14,383.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,516, add-ons for qualifying new technology services are included. If operating cost exceeds $48,387.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,669.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,528.54 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,571.05 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $909.72. The transfer capital threshold is the transfer adjustment factor * $909.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,36140.75,Inpatient DRG
Laparoscopy Surg Rpr Initial Inguinal Hernia|LEFT SIDE,CASE-49650,APC,49650,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5658.76,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5658.76,5941.70,OPPS APC
Open Implantation Nea Sacral Nerve,CASE-64581,APC,64581,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],18794.54,,"APC Price ($18,158.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,18158.97,19066.92,OPPS APC
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],25026.36,,"Fee schedule rate ($25,026.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9356.31,25026.36,There are no additional notes associated with this service or procedure.
Tympanostomy General Anesthesia|BILATERAL PROCEDURE,CASE-69436,APC,69436,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1452.32,,"APC Price ($1,452.32). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1452.32,1524.94,OPPS APC
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],86235.79,,"Fee schedule rate ($86,235.79). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,32296.02,88188.38,There are no additional notes associated with this service or procedure.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],23790.06,,"Fee schedule rate ($23,790.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10517.71,24909.11,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],30398.48,,"Case rate ($30,398.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $28,414.67, add-ons for qualifying new technology services are included. If operating cost exceeds $63,285.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,841.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.2. The base transfer operating payment is the transfer adjustment factor * $26,372.48 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $26,469.72 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,081.05. The transfer capital threshold is the transfer adjustment factor * $2,081.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,30398.48,82674.88,Inpatient DRG
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC,817,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],44895.04,,,,,,0,other,17396.11,44895.04,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,091,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],33004.27,,"Fee schedule rate ($33,004.27). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13838.06,40030.81,There are no additional notes associated with this service or procedure.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",063,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],12024.16,,"Case rate ($11,451.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,788.77, add-ons for qualifying new technology services are included. If operating cost exceeds $45,659.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,455.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $8,811.33 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,843.82 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $695.30. The transfer capital threshold is the transfer adjustment factor * $695.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,35701.87,Inpatient DRG
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],25013.10,,"Fee schedule rate ($25,013.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10846.16,25863.45,There are no additional notes associated with this service or procedure.
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",759,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],11643.60,,"Fee schedule rate ($11,643.60). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6190.22,13057.66,There are no additional notes associated with this service or procedure.
CHOLECYSTECTOMY WITH C.D.E. WITH MCC,411,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],24315.13,,"Case rate ($24,315.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $22,755.46, add-ons for qualifying new technology services are included. If operating cost exceeds $57,626.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,396.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $20,734.06 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $20,810.51 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,636.12. The transfer capital threshold is the transfer adjustment factor * $1,636.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,24315.13,88615.28,Inpatient DRG
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC,519,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],15490.44,,"Case rate ($15,490.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,546.03, add-ons for qualifying new technology services are included. If operating cost exceeds $49,417.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,750.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $12,554.80 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,601.09 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $990.70. The transfer capital threshold is the transfer adjustment factor * $990.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,15490.44,50780.20,Inpatient DRG
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],67107.92,,"Fee schedule rate ($67,107.92). Adds an outlier to normal pricing equal to the per diem rate ($118,521.29) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16.7), with a minimum of zero.",,,,0,other,26127.34,90333.60,There are no additional notes associated with this service or procedure.
HC Biopsy/Exc Lymph Node Needle|RIGHT SIDE,CASE-38505,APC,38505,CPT,0361,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1623.23,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1545.93,1623.23,OPPS APC
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],36875.62,,"Fee schedule rate ($36,875.62). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.7), with a minimum of zero.",,,,0,other,15233.11,38610.21,There are no additional notes associated with this service or procedure.
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],45157.33,,"Fee schedule rate ($45,157.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,10733.06,45157.33,There are no additional notes associated with this service or procedure.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],41006.47,,"Fee schedule rate ($41,006.47). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12268.97,41006.47,There are no additional notes associated with this service or procedure.
PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,337,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],12771.98,,"Case rate ($12,340.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,615.32, add-ons for qualifying new technology services are included. If operating cost exceeds $46,486.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,520.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $9,634.84 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,670.37 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $760.28. The transfer capital threshold is the transfer adjustment factor * $760.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,12340.08,38926.31,Inpatient DRG
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],81454.07,,"Fee schedule rate ($81,454.07). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,10078.00,81454.07,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],26966.33,,"Fee schedule rate ($26,966.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,9040.72,26966.33,There are no additional notes associated with this service or procedure.
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],33488.23,,"Fee schedule rate ($33,488.23). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,16787.98,62990.26,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,065,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],8786.76,,"Case rate ($8,786.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,309.75, add-ons for qualifying new technology services are included. If operating cost exceeds $43,180.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,260.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,341.42 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,364.80 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $500.40. The transfer capital threshold is the transfer adjustment factor * $500.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8786.76,25681.86,Inpatient DRG
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],6965.00,,,,,,0,other,6965.00,19126.88,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],17651.07,,"Fee schedule rate ($17,651.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,6564.18,17651.07,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],32941.94,,"Case rate ($32,296.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $30,179.91, add-ons for qualifying new technology services are included. If operating cost exceeds $65,050.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,979.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $28,131.23 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $28,234.95 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,219.83. The transfer capital threshold is the transfer adjustment factor * $2,219.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,32296.02,88188.38,Inpatient DRG
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR,518,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],89342.77,,"Fee schedule rate ($89,342.77). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,13252.00,89342.77,There are no additional notes associated with this service or procedure.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],36094.03,,"Fee schedule rate ($36,094.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11194.25,36094.03,There are no additional notes associated with this service or procedure.
O.R. PROCEDURES FOR OBESITY WITH CC,620,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],23261.17,,"Fee schedule rate ($23,261.17). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12782.30,43753.50,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],94787.57,,"Fee schedule rate ($94,787.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,23526.87,94787.57,There are no additional notes associated with this service or procedure.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],17194.49,,"Fee schedule rate ($17,194.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8554.50,19204.75,There are no additional notes associated with this service or procedure.
"Correction Hammertoe|RIGHT FOOT, SECOND DIGIT",CASE-28285,APC,28285,CPT,0360,RC,,,T6,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
"OTHER NON-HYPOVOLEMIC ELECTROLYTE DISORDERS,MODERATE",425,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],6423.72,,"Case rate ($6,117.83). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6117.83,6423.72,There are no additional notes associated with this service or procedure.
Cysto/Pyeloscopy Bx&/Fulguration Pelivc Lesion|LEFT SIDE,CASE-52354,APC,52354,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5018.77,,"APC Price ($5,018.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5018.77,5269.71,OPPS APC
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,191,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],6965.00,,,,,,0,other,6965.00,16612.88,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],29166.74,,"Fee schedule rate ($29,166.74). Adds an outlier to normal pricing equal to the per diem rate ($36,758.78) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,12455.21,37149.27,There are no additional notes associated with this service or procedure.
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],9311.62,,"Case rate ($9,311.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,798, add-ons for qualifying new technology services are included. If operating cost exceeds $43,669.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,298.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $6,827.87 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,853.05 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $538.79. The transfer capital threshold is the transfer adjustment factor * $538.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,21404.64,Inpatient DRG
CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC,788,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],8438.02,,"Case rate ($8,438.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,985.31, add-ons for qualifying new technology services are included. If operating cost exceeds $42,856.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,234.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,018.17 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,040.36 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $474.89. The transfer capital threshold is the transfer adjustment factor * $474.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8438.02,20142.33,Inpatient DRG
"NEONATE BIRTH WEIGHT > 2499 GRAMS NORMAL NEWBORN OR NEONATE WITH OTHER PROBLEM,MINOR",640,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],1186.89,,"Case rate ($1,130.37). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,1130.37,1186.89,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC,832,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],14198.92,,,,,,0,other,4803.31,14198.92,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITH STERILIZATION WITH CC,784,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],23722.94,,"Fee schedule rate ($23,722.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9124.01,23722.94,There are no additional notes associated with this service or procedure.
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],37899.49,,"Fee schedule rate ($37,899.49). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,14747.55,37899.49,There are no additional notes associated with this service or procedure.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,761,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5808.41,,"Case rate ($5,808.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,539.05, add-ons for qualifying new technology services are included. If operating cost exceeds $40,410.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,042.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $3,580.90 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,594.10 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $282.57. The transfer capital threshold is the transfer adjustment factor * $282.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,5808.41,11946.72,Inpatient DRG
Rpr 1st Ingun Hrna Age 5 Yrs/> Reducible|LEFT SIDE,CASE-49505,APC,49505,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3518.91,,"APC Price ($3,351.34). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3351.34,3518.91,OPPS APC
SIGNS AND SYMPTOMS WITH MCC,947,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],30414.32,,"Fee schedule rate ($30,414.32). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,10541.41,30414.32,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],16206.75,,"Fee schedule rate ($16,206.75). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,12984.79,32077.45,There are no additional notes associated with this service or procedure.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],26949.28,,"Fee schedule rate ($26,949.28). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9977.99,26949.28,There are no additional notes associated with this service or procedure.
HC Lyr Clos Nk Hnd Ft 2.6-5 Cm,CASE-12042,APC,12042,CPT,0450,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1623.23,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1545.93,1623.23,OPPS APC
MAJOR BLADDER PROCEDURES WITH MCC,653,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],125343.98,,"Fee schedule rate ($125,343.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,10280.00,125343.98,There are no additional notes associated with this service or procedure.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,074,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],8925.60,,"Case rate ($8,925.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,438.90, add-ons for qualifying new technology services are included. If operating cost exceeds $43,309.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,270.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,470.10 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,493.95 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $510.55. The transfer capital threshold is the transfer adjustment factor * $510.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8925.60,20919.08,Inpatient DRG
Injection Aa&/Strd Ilioinguinal Ih Nerves|LEFT SIDE,CASE-64425,APC,64425,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],660.72,,"APC Price ($660.72). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,660.72,693.76,OPPS APC
OSTEOMYELITIS WITH CC,540,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],18450.55,,"Fee schedule rate ($18,450.55). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,9809.07,25507.30,There are no additional notes associated with this service or procedure.
COMPLICATIONS OF TREATMENT WITH CC,920,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],20731.52,,"Fee schedule rate ($20,731.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8732.59,20731.52,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],62708.63,,,,,,0,other,23526.87,94787.57,There are no additional notes associated with this service or procedure.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],24315.03,,"Case rate ($23,157.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $21,717.81, add-ons for qualifying new technology services are included. If operating cost exceeds $56,588.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,274.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.1. The base transfer operating payment is the transfer adjustment factor * $19,698.17 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $19,772.86 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,514.05. The transfer capital threshold is the transfer adjustment factor * $1,514.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,23799.09,63499.65,Inpatient DRG
FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,748,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],25601.70,,"Fee schedule rate ($25,601.70). Adds an outlier to normal pricing equal to the per diem rate ($21,136.29) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9316.20,26805.98,There are no additional notes associated with this service or procedure.
Submucous Rescj Inferior Turbinate Prtl/Compl|BILATERAL PROCEDURE,CASE-30140,APC,30140,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6605.95,,"APC Price ($6,605.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6605.95,6936.25,OPPS APC
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],9667.64,,"Fee schedule rate ($9,667.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,5139.72,13110.79,There are no additional notes associated with this service or procedure.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],25667.48,,"Fee schedule rate ($25,667.48). Adds an outlier to normal pricing equal to the per diem rate ($77,296.48) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,11194.25,36094.03,There are no additional notes associated with this service or procedure.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],18178.96,,"Case rate ($18,178.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,047.10, add-ons for qualifying new technology services are included. If operating cost exceeds $51,918.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,947.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $15,046.67 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,102.15 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,187.33. The transfer capital threshold is the transfer adjustment factor * $1,187.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,18178.96,54764.34,Inpatient DRG
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],26391.01,,"Fee schedule rate ($26,391.01). Adds an outlier to normal pricing equal to the per diem rate ($77,296.48) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,11454.97,28394.78,There are no additional notes associated with this service or procedure.
Colon Ca Scrn Not Hi Rsk Ind,CASE-G0121,APC,G0121,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],870.46,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,870.46,913.99,OPPS APC
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],26178.21,,"Fee schedule rate ($26,178.21). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,13917.42,34889.29,There are no additional notes associated with this service or procedure.
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC,805,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],20902.03,,"Fee schedule rate ($20,902.03). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9253.36,21235.42,There are no additional notes associated with this service or procedure.
"Tendon Sheath Incision|RIGHT HAND, THUMB",CASE-26055,APC,26055,CPT,0360,RC,,,F5,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1505.12,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1505.12,1580.37,OPPS APC
NONTRAUMATIC STUPOR AND COMA WITH MCC,080,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],30179.40,,"Fee schedule rate ($30,179.40). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,14202.39,35615.37,There are no additional notes associated with this service or procedure.
Exc Rct Tum Incl Muscularis Propria,CASE-45172,APC,45172,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],2598.08,,"APC Price ($2,598.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2598.08,2727.99,OPPS APC
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],34012.76,,"Case rate ($19,435.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $18,216.37, add-ons for qualifying new technology services are included. If operating cost exceeds $53,087.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,039.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.9. The base transfer operating payment is the transfer adjustment factor * $16,211.64 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $16,271.42 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,279.26. The transfer capital threshold is the transfer adjustment factor * $1,279.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,19435.86,50821.76,All Other Inpatient
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],73588.10,,"Fee schedule rate ($73,588.10). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,21585.31,73588.10,There are no additional notes associated with this service or procedure.
"VAGINAL DELIVERY WITH O.R. PROCEDURE EXCEPT STERILIZATION AND/OR D&C,MODERATE",542,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],5003.91,,"Case rate ($5,003.91). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,5003.91,5254.11,There are no additional notes associated with this service or procedure.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH CC,026,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],63202.45,,"Fee schedule rate ($63,202.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,23000.66,63202.45,There are no additional notes associated with this service or procedure.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],45706.73,,"Fee schedule rate ($45,706.73). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,7921.00,45706.73,There are no additional notes associated with this service or procedure.
"Inj Dx/Ther Agnt Paravert Facet Joint, Cerv/Thorac, Add Level|RIGHT SIDE",CASE-64492,APC,64492,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],827.89,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,827.89,869.28,OPPS APC
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],13361.69,,"Case rate ($12,725.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,973.79, add-ons for qualifying new technology services are included. If operating cost exceeds $46,844.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,548.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $9,991.99 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,028.83 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $788.47. The transfer capital threshold is the transfer adjustment factor * $788.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12725.42,34245.00,Inpatient DRG
"OTHER DISORDERS OF THE LIVER,MAJOR",283,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],2128.20,,"Case rate for a one day stay ($2,026.86). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,2026.86,2128.20,There are no additional notes associated with this service or procedure.
OTHER MENTAL DISORDER DIAGNOSES,887,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],2401.00,,,,,,0,other,2070.00,21072.10,Estimated amount calculated based on 1 day length of stay.
Egd Removal Tumor Polyp/Other Lesion Snare Tech,CASE-43251,APC,43251,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1796.14,,"APC Price ($1,796.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1796.14,1885.95,OPPS APC
OTHER DISORDERS OF NERVOUS SYSTEM WITH CC,092,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],19225.24,,"Fee schedule rate ($19,225.24). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8872.78,26765.51,There are no additional notes associated with this service or procedure.
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],15240.59,,"Case rate ($14,725.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,834.15, add-ons for qualifying new technology services are included. If operating cost exceeds $48,705.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,694.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,845.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,889.20 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $934.73. The transfer capital threshold is the transfer adjustment factor * $934.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,7389.00,37134.43,Inpatient DRG
"Amputation Toe Metatarsophalangeal Joint|LEFT FOOT, SECOND DIGIT",CASE-28820,APC,28820,CPT,0360,RC,,,T1,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3062.67,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
Excision Pilonidal Cyst/Sinus Extensive,CASE-11771,APC,11771,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],2814.04,,"APC Price ($2,718.88). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2814.04,2854.83,OPPS APC
Parathyroidectomy/Exploration Parathyroids|LEFT SIDE,CASE-60500,APC,60500,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5735.04,,"APC Price ($5,541.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5541.10,5818.16,OPPS APC
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],12333.36,,"Case rate ($12,091.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,384.11, add-ons for qualifying new technology services are included. If operating cost exceeds $46,255.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,502.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $9,404.49 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,439.16 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $742.11. The transfer capital threshold is the transfer adjustment factor * $742.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6965.00,29482.05,Inpatient DRG
Arthrs Knee Abrasion Arthrp/Mlt Drlg/Microfx|RIGHT SIDE,CASE-29879,APC,29879,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],9206.20,,"Case rate ($8,767.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,292.11, add-ons for qualifying new technology services are included. If operating cost exceeds $43,163.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,258.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,323.85 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,347.16 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $499.01. The transfer capital threshold is the transfer adjustment factor * $499.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8767.81,19824.58,Inpatient DRG
Exc Tumor Soft Tissue Abdl Wall Subfascial 5cm/>,CASE-22901,APC,22901,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],2854.83,,"APC Price ($2,718.88). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2718.88,2854.83,OPPS APC
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],6965.00,,,,,,0,other,5139.72,13110.79,There are no additional notes associated with this service or procedure.
"Amp F/Th 1/2 Jt/Phalanx W/Neurect W/Dir Clsr|LEFT HAND, THIRD DIGIT",CASE-26951,APC,26951,CPT,0360,RC,,,F2,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
OTHER DISORDERS OF NERVOUS SYSTEM WITH CC,092,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],9316.42,,"Case rate ($8,872.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,389.76, add-ons for qualifying new technology services are included. If operating cost exceeds $43,260.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,266.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $6,421.14 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,444.81 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $506.69. The transfer capital threshold is the transfer adjustment factor * $506.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8872.78,26765.51,Inpatient DRG
"Rpr Coltrl Ligm Mtcarphlngl/Iphal Jt|LEFT HAND, THUMB",CASE-26540,APC,26540,CPT,0360,RC,,,FA,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC,497,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],10127.65,,"Case rate ($10,127.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,557.14, add-ons for qualifying new technology services are included. If operating cost exceeds $44,428.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,358.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 1.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $7,584.22 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,612.19 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $598.47. The transfer capital threshold is the transfer adjustment factor * $598.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10127.65,37761.19,Inpatient DRG
APPENDIX PROCEDURES WITH MCC,397,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],45007.36,,"Fee schedule rate ($45,007.36). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.5), with a minimum of zero.",,,,0,other,18163.37,51558.84,There are no additional notes associated with this service or procedure.
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],11914.12,,"Case rate ($11,914.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,219.06, add-ons for qualifying new technology services are included. If operating cost exceeds $46,090.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,489.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $9,240.03 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,274.10 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $729.13. The transfer capital threshold is the transfer adjustment factor * $729.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,11914.12,40426.76,Inpatient DRG
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],20567.06,,"Fee schedule rate ($20,567.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,9356.31,25026.36,There are no additional notes associated with this service or procedure.
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|LEFT HAND, THUMB",CASE-26160,APC,26160,CPT,0360,RC,,,FA,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1580.37,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1505.12,1580.37,OPPS APC
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],90333.60,,"Fee schedule rate ($90,333.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,26127.34,90333.60,There are no additional notes associated with this service or procedure.
Prq Impltj Neurostimulator Eltrd Peripheral Nrv|LEFT SIDE,CASE-64555,APC,64555,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6174.06,,"APC Price ($5,965.28). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5965.28,6263.54,OPPS APC
VAGINAL DELIVERY WITH O.R. PROCEDURES EXCEPT STERILIZATION AND/OR D&C,768,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],13416.00,,,,,,0,other,6426.91,13416.00,There are no additional notes associated with this service or procedure.
"SEPTICEMIA AND DISSEMINATED INFECTIONS,MODERATE",720,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],1948.81,,"Case rate for a one day stay ($1,948.81). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,1948.81,2046.25,There are no additional notes associated with this service or procedure.
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",759,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],11643.60,,"Fee schedule rate ($11,643.60). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6190.22,13057.66,There are no additional notes associated with this service or procedure.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],18627.00,,"Fee schedule rate ($18,627). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,7332.00,35314.31,There are no additional notes associated with this service or procedure.
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],35419.59,,"Fee schedule rate ($35,419.59). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,7086.00,57872.02,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],29241.62,,"Fee schedule rate ($29,241.62). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,12984.79,32077.45,There are no additional notes associated with this service or procedure.
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],6325.21,,"Case rate ($6,201.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,904.45, add-ons for qualifying new technology services are included. If operating cost exceeds $40,775.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,071.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,944.95 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,959.50 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $311.30. The transfer capital threshold is the transfer adjustment factor * $311.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,5937.41,12366.99,Inpatient DRG
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],25253.70,,"Fee schedule rate ($25,253.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11974.38,29141.64,There are no additional notes associated with this service or procedure.
O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC,621,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],12767.94,,"Case rate ($12,159.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,447.74, add-ons for qualifying new technology services are included. If operating cost exceeds $46,318.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,507.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $9,467.88 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,502.79 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $747.11. The transfer capital threshold is the transfer adjustment factor * $747.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12159.94,36669.96,Inpatient DRG
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH CC,427,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],51863.61,,"Case rate ($49,393.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $46,174.24, add-ons for qualifying new technology services are included. If operating cost exceeds $81,045.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $5,146.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $44,062.23 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $44,229.29 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,386.73. The transfer capital threshold is the transfer adjustment factor * $3,386.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,50829.82,142040.39,Inpatient DRG
Unlisted Laparoscopy Procedure Oviduct Ovary,CASE-58679,APC,58679,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5941.70,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5658.76,5941.70,OPPS APC
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],62084.69,,"Fee schedule rate ($62,084.69). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (35), with a minimum of zero.",,,,0,other,30398.48,82674.88,There are no additional notes associated with this service or procedure.
PREMATURITY WITH MAJOR PROBLEMS,791,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],3354.00,,,,,,0,other,3048.21,30904.42,Estimated amount calculated based on 5 day length of stay.
OTHER MENTAL DISORDER DIAGNOSES,887,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],2070.00,,,,,,0,other,2070.00,21072.10,Estimated amount calculated based on 1 day length of stay.
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],21854.96,,"Fee schedule rate ($21,854.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10638.94,25261.33,There are no additional notes associated with this service or procedure.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],28210.44,,"Case rate ($16,120.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,131.93, add-ons for qualifying new technology services are included. If operating cost exceeds $50,002.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,796.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $13,138.54 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,186.98 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,036.76. The transfer capital threshold is the transfer adjustment factor * $1,036.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,16120.25,41187.90,All Other Inpatient
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC,964,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],34154.06,,"Fee schedule rate ($34,154.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12323.82,34154.06,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,167,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],33891.30,,"Fee schedule rate ($33,891.30). Adds an outlier to normal pricing equal to the per diem rate ($66,990.29) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.6), with a minimum of zero.",,,,0,other,14157.71,43522.37,There are no additional notes associated with this service or procedure.
Colonoscopy Flx Dx W/Collj Spec When Pfrmd|COLORECTAL CANCER SCREEN,CASE-45378,APC,45378,CPT,0360,RC,,,PT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],870.46,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,870.46,913.99,OPPS APC
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],15802.03,,"Fee schedule rate ($15,802.03). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7566.45,16333.88,There are no additional notes associated with this service or procedure.
Excision Excessive Skin & Subq Tissue Abdomen,CASE-15847,APC,15847,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6215.36,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6215.36,6526.12,OPPS APC
"MAJOR LARGE BOWEL PROCEDURES,EXTREME",231,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],45476.07,,"Case rate ($43,310.54). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,43310.54,45476.07,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,426,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],80410.35,,"Case rate ($76,581.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $71,377.56, add-ons for qualifying new technology services are included. If operating cost exceeds $106,248.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $7,218.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $69,177.55 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $69,432.61 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $5,458.79. The transfer capital threshold is the transfer adjustment factor * $5,458.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,76581.29,216864.15,Inpatient DRG
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC",629,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],24750.60,,"Fee schedule rate ($24,750.60). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,16699.94,44657.18,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],82674.88,,,,,,0,other,30398.48,82674.88,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],85305.59,,"Fee schedule rate ($85,305.59). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,21719.40,85305.59,There are no additional notes associated with this service or procedure.
Optx Patllr Fx W/Int Fixj/Patllc&Soft Tiss Rpr|LEFT SIDE,CASE-27524,APC,27524,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
CHEST PAIN,313,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],15377.66,,"Fee schedule rate ($15,377.66). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,6820.84,15377.66,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,690,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7686.88,,"Case rate ($7,426.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,044.73, add-ons for qualifying new technology services are included. If operating cost exceeds $41,915.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,160.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,081.05 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,099.78 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $400.94. The transfer capital threshold is the transfer adjustment factor * $400.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,7426.94,15928.53,Inpatient DRG
HC Inj Aa&/Strd Greater Occipital Nerve|LEFT SIDE,CASE-64405,APC,64405,CPT,0450,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],297.37,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,287.31,301.68,OPPS APC
"OTHER NON-HYPOVOLEMIC ELECTROLYTE DISORDERS,MODERATE",425,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],6117.83,,"Case rate ($6,117.83). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,6117.83,6423.72,There are no additional notes associated with this service or procedure.
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],15244.88,,"Fee schedule rate ($15,244.88). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,7438.45,15961.98,There are no additional notes associated with this service or procedure.
Litholapaxy Comp/Lg > 2.5 Cm,CASE-52318,APC,52318,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3464.44,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3299.47,3464.44,OPPS APC
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],24686.74,,"Case rate ($23,851.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $22,324.54, add-ons for qualifying new technology services are included. If operating cost exceeds $57,195.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,362.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.8. The base transfer operating payment is the transfer adjustment factor * $20,304.73 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $20,379.59 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,602.24. The transfer capital threshold is the transfer adjustment factor * $1,602.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,23851.92,63653.13,Inpatient DRG
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],43888.01,,"Fee schedule rate ($43,888.01). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11717.72,43888.01,There are no additional notes associated with this service or procedure.
PREMATURITY WITH MAJOR PROBLEMS,791,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],3186.77,,,,,,0,other,3048.21,30904.42,Estimated amount calculated based on 5 day length of stay.
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,448,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],94077.13,,"Fee schedule rate ($94,077.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,30663.95,94077.13,There are no additional notes associated with this service or procedure.
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],14046.24,,"Case rate ($13,571.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,760.65, add-ons for qualifying new technology services are included. If operating cost exceeds $47,631.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,610.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $10,775.96 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,815.69 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $850.33. The transfer capital threshold is the transfer adjustment factor * $850.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,13571.25,33781.47,Inpatient DRG
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],11594.35,,"Fee schedule rate ($11,594.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6164.03,14071.02,There are no additional notes associated with this service or procedure.
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC",011,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],150008.48,,"Fee schedule rate ($150,008.48). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (44), with a minimum of zero.",,,,0,other,38880.49,150008.48,There are no additional notes associated with this service or procedure.
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],33221.97,,"Fee schedule rate ($33,221.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (47), with a minimum of zero.",,,,0,other,15283.90,38757.79,There are no additional notes associated with this service or procedure.
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC,519,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],50780.20,,"Fee schedule rate ($50,780.20). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,15490.44,50780.20,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],40737.46,,"Fee schedule rate ($40,737.46). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,7665.00,40737.46,There are no additional notes associated with this service or procedure.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],20559.34,,"Case rate ($20,559.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $19,261.52, add-ons for qualifying new technology services are included. If operating cost exceeds $54,132.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,121.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $17,252.96 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $17,316.57 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,361.43. The transfer capital threshold is the transfer adjustment factor * $1,361.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,20559.34,54086.17,Inpatient DRG
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,544,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],23207.64,,"Fee schedule rate ($23,207.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,7055.15,23207.64,There are no additional notes associated with this service or procedure.
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",004,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],95747.60,,"Case rate ($95,747.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $89,207.57, add-ons for qualifying new technology services are included. If operating cost exceeds $124,078.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $8,620.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 22.4. The base transfer operating payment is the transfer adjustment factor * $86,942.06 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $87,262.63 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $6,860.59. The transfer capital threshold is the transfer adjustment factor * $6,860.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10249.47,272554.00,Inpatient DRG
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITHOUT MCC,430,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],43050.17,,"Case rate ($41,000.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $38,277.19, add-ons for qualifying new technology services are included. If operating cost exceeds $73,148.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,616.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $36,198.76 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $36,332.23 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,856.44. The transfer capital threshold is the transfer adjustment factor * $2,856.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,41000.16,133156.90,Inpatient DRG
HC Non Stress Test,CASE-59025,APC,59025,CPT,0920,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],195.86,,"APC Price ($189.24). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,189.24,198.70,OPPS APC
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],23344.70,,"Case rate ($23,344.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $21,852.68, add-ons for qualifying new technology services are included. If operating cost exceeds $56,723.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,325.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $19,834.60 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $19,907.73 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,565.15. The transfer capital threshold is the transfer adjustment factor * $1,565.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,23344.70,62179.32,Inpatient DRG
Arthrs Aided Ant Cruciate Ligm Rpr/Agmntj/Rcnstj|SEPARATE STRUCTURE|LEFT SIDE,CASE-29888,APC,29888,CPT,0360,RC,,,XS|LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7029.71,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6791.99,7131.59,OPPS APC
NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,601,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],12359.72,,"Fee schedule rate ($12,359.72). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6042.05,12359.72,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],35192.25,,"Fee schedule rate ($35,192.25). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,10895.60,35192.25,There are no additional notes associated with this service or procedure.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITHOUT CC/MCC,816,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],14733.53,,"Fee schedule rate ($14,733.53). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6224.90,14733.53,There are no additional notes associated with this service or procedure.
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],28334.16,,"Fee schedule rate ($28,334.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,7868.00,32126.64,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],1188.00,,,,,,0,other,1188.00,34338.33,Estimated amount calculated based on 6 day length of stay.
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],23377.19,,"Case rate ($23,377.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $21,882.92, add-ons for qualifying new technology services are included. If operating cost exceeds $56,753.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,327.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $19,864.72 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $19,937.97 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,567.52. The transfer capital threshold is the transfer adjustment factor * $1,567.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,23377.19,96365.69,Inpatient DRG
HC Inj Lympho for Sentinal Node,CASE-38792,APC,38792,CPT,0361,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6432.89,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6215.36,6526.12,OPPS APC
INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC,198,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],23505.07,,"Fee schedule rate ($23,505.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6795.12,23505.07,There are no additional notes associated with this service or procedure.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],16900.84,,"Fee schedule rate ($16,900.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8151.55,18033.97,There are no additional notes associated with this service or procedure.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],25704.37,,"Case rate ($24,480.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $22,951.20, add-ons for qualifying new technology services are included. If operating cost exceeds $57,822.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,368.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $20,926.90 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $21,006.25 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,608.49. The transfer capital threshold is the transfer adjustment factor * $1,608.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,25162.32,75579.22,Inpatient DRG
HC Drain/Inj Joint/Bursa W/US Large|RIGHT SIDE,CASE-20611,APC,20611,CPT,0510,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],301.68,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,287.31,301.68,OPPS APC
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],35528.17,,"Fee schedule rate ($35,528.17). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,14747.55,37899.49,There are no additional notes associated with this service or procedure.
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],12937.10,,"Fee schedule rate ($12,937.10). Adds an outlier to normal pricing equal to the per diem rate ($49,808.13) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.5), with a minimum of zero.",,,,0,other,5919.29,13545.65,There are no additional notes associated with this service or procedure.
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],24126.45,,"Fee schedule rate ($24,126.45). Adds an outlier to normal pricing equal to the per diem rate ($62,306.11) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10638.94,25261.33,There are no additional notes associated with this service or procedure.
Hysteroscopy Endometrial Ablation,CASE-58563,APC,58563,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],4846.30,,"APC Price ($4,682.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,4682.41,4916.53,OPPS APC
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,426,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],207121.41,,"Fee schedule rate ($207,121.41). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,76581.29,216864.15,There are no additional notes associated with this service or procedure.
Laps Gastric Restrictive Px Remove Device & Port,CASE-43774,APC,43774,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3789.26,,"APC Price ($3,608.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3608.81,3789.26,OPPS APC
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],7034.85,,"Case rate ($7,034.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,679.97, add-ons for qualifying new technology services are included. If operating cost exceeds $41,550.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,132.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $4,717.62 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,735.02 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $372.27. The transfer capital threshold is the transfer adjustment factor * $372.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,21089.59,Inpatient DRG
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],21675.85,,"Fee schedule rate ($21,675.85). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,9755.86,29216.99,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],24675.88,,"Fee schedule rate ($24,675.88). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10834.64,25830.00,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],6841.83,,"Case rate ($6,841.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,500.42, add-ons for qualifying new technology services are included. If operating cost exceeds $41,371.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,118.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $4,538.73 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,555.47 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $358.15. The transfer capital threshold is the transfer adjustment factor * $358.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6841.83,21167.26,Inpatient DRG
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],33938.10,,"Fee schedule rate ($33,938.10). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11165.00,61234.06,There are no additional notes associated with this service or procedure.
"SEIZURE,EXTREME",053,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],21938.52,,"Case rate ($20,893.83). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,20893.83,21938.52,There are no additional notes associated with this service or procedure.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],52699.33,,"Fee schedule rate ($52,699.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,18105.81,52699.33,There are no additional notes associated with this service or procedure.
CHEST PAIN,313,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7059.57,,"Case rate ($6,820.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,480.89, add-ons for qualifying new technology services are included. If operating cost exceeds $41,351.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,116.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $4,519.27 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,535.94 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $356.62. The transfer capital threshold is the transfer adjustment factor * $356.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6820.84,15377.66,Inpatient DRG
CHEST PAIN,313,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],6957.26,,"Case rate ($6,820.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,480.89, add-ons for qualifying new technology services are included. If operating cost exceeds $41,351.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,116.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $4,519.27 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,535.94 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $356.62. The transfer capital threshold is the transfer adjustment factor * $356.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6820.84,15377.66,Inpatient DRG
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],11162.57,,"Case rate ($6,378.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,069.50, add-ons for qualifying new technology services are included. If operating cost exceeds $40,940.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,084.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,109.40 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,124.55 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $324.27. The transfer capital threshold is the transfer adjustment factor * $324.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,4341.01,12882.53,All Other Inpatient
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITHOUT CC/MCC",630,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],11828.78,,"Case rate ($11,828.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,139.67, add-ons for qualifying new technology services are included. If operating cost exceeds $46,010.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,482.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $9,160.95 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,194.72 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $722.89. The transfer capital threshold is the transfer adjustment factor * $722.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,11828.78,42541.02,Inpatient DRG
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],11945.95,,"Case rate ($11,945.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,248.66, add-ons for qualifying new technology services are included. If operating cost exceeds $46,119.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,491.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $9,269.54 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,303.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $731.46. The transfer capital threshold is the transfer adjustment factor * $731.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6167.00,29058.99,Inpatient DRG
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,450,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],146009.19,,"Fee schedule rate ($146,009.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,38037.38,146009.19,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],28235.64,,"Fee schedule rate ($28,235.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,14344.60,36028.59,There are no additional notes associated with this service or procedure.
VENTRICULAR SHUNT PROCEDURES WITH MCC,031,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],32287.20,,"Case rate ($32,287.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $30,171.71, add-ons for qualifying new technology services are included. If operating cost exceeds $65,042.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,979.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7. The base transfer operating payment is the transfer adjustment factor * $28,123.07 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $28,226.76 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,219.19. The transfer capital threshold is the transfer adjustment factor * $2,219.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,32287.20,88162.80,Inpatient DRG
PREMATURITY WITHOUT MAJOR PROBLEMS,792,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],11512.88,,"Fee schedule rate ($11,512.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,1956.00,19457.66,There are no additional notes associated with this service or procedure.
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],50066.10,,"Fee schedule rate ($50,066.10). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,26127.34,90333.60,There are no additional notes associated with this service or procedure.
Parathyroidectomy/Exploration Parathyroids|SEPARATE STRUCTURE|RIGHT SIDE,CASE-60500,APC,60500,CPT,0360,RC,,,XS|RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],10298.02,,"APC Price ($9,949.78). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,9949.78,10447.27,OPPS APC
Laps Surg Prst8ect Rpbic Rad W/Nrv Sparing Robot,CASE-55866,APC,55866,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],10447.27,,"APC Price ($9,949.78). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,9949.78,10447.27,OPPS APC
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC,519,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],50780.20,,"Fee schedule rate ($50,780.20). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,15490.44,50780.20,There are no additional notes associated with this service or procedure.
Neuroplasty &/Transpos Median Nrv Carpal Tunne|RIGHT SIDE,CASE-64721,APC,64721,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1919.19,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1827.80,1919.19,OPPS APC
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],28751.41,,"Fee schedule rate ($28,751.41). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12305.53,30103.84,There are no additional notes associated with this service or procedure.
VAGINAL DELIVERY WITH O.R. PROCEDURES EXCEPT STERILIZATION AND/OR D&C,768,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],9201.90,,"Case rate ($9,201.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,695.94, add-ons for qualifying new technology services are included. If operating cost exceeds $43,566.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,290.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $6,726.19 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,750.99 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $530.76. The transfer capital threshold is the transfer adjustment factor * $530.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6426.91,13416.00,Inpatient DRG
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5949.32,,"Case rate ($5,666.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,413.52, add-ons for qualifying new technology services are included. If operating cost exceeds $40,284.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,025.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $3,455.47 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,468.57 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $265.60. The transfer capital threshold is the transfer adjustment factor * $265.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5778.62,11681.49,Inpatient DRG
Nasal/Sinus Ndsc Surg W/Dilation Frontal Sinus|BILATERAL PROCEDURE,CASE-31296,APC,31296,CPT,0360,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6936.25,,"APC Price ($6,605.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6605.95,6936.25,OPPS APC
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],36008.91,,,,,,0,other,14337.84,52803.53,There are no additional notes associated with this service or procedure.
"Open Tx Phalangeal Shaft Fracture Prox/Middle Ea|RIGHT HAND, FOURTH DIGIT",CASE-26735,APC,26735,CPT,0360,RC,,,F8,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,064,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],41838.16,,"Fee schedule rate ($41,838.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,15563.58,41838.16,There are no additional notes associated with this service or procedure.
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],15802.03,,"Fee schedule rate ($15,802.03). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7566.45,16333.88,There are no additional notes associated with this service or procedure.
PREMATURITY WITHOUT MAJOR PROBLEMS,792,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],11512.88,,"Fee schedule rate ($11,512.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,1956.00,19457.66,There are no additional notes associated with this service or procedure.
FRACTURES OF FEMUR WITH MCC,533,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],49490.05,,"Fee schedule rate ($49,490.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,6852.00,49490.05,There are no additional notes associated with this service or procedure.
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC,805,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],20902.03,,"Fee schedule rate ($20,902.03). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9253.36,21235.42,There are no additional notes associated with this service or procedure.
Cystourethroscopy W/Dest &/Rmvl Med Bladder Tum,CASE-52235,APC,52235,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3464.44,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3299.47,3464.44,OPPS APC
"Suture Digital Nerve Hand/Foot 1 Nerve|LEFT HAND, THUMB",CASE-64831,APC,64831,CPT,0360,RC,,,FA,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH MCC",510,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],89863.76,,"Fee schedule rate ($89,863.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10710.00,89863.76,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],28235.64,,"Fee schedule rate ($28,235.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,14344.60,36028.59,There are no additional notes associated with this service or procedure.
Inj for Sacroiliac Jt Anesth|LEFT SIDE,CASE-G0260,APC,G0260,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],693.76,,"APC Price ($660.72). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,660.72,693.76,OPPS APC
FRACTURES OF FEMUR WITH MCC,533,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],12812.76,,"Case rate ($12,561.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,821.33, add-ons for qualifying new technology services are included. If operating cost exceeds $46,692.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,536.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $9,840.09 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,876.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $776.48. The transfer capital threshold is the transfer adjustment factor * $776.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6852.00,49490.05,Inpatient DRG
Litholapaxy Smpl/Sm <2.5 Cm,CASE-52317,APC,52317,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3299.47,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3299.47,3464.44,OPPS APC
INFLAMMATORY BOWEL DISEASE WITH CC,386,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],19879.00,,"Fee schedule rate ($19,879.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8556.53,19879.00,There are no additional notes associated with this service or procedure.
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],11628.75,,"Fee schedule rate ($11,628.75). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,10003.71,23415.63,There are no additional notes associated with this service or procedure.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],45706.73,,"Fee schedule rate ($45,706.73). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,7921.00,45706.73,There are no additional notes associated with this service or procedure.
Dstr Nrolytc Agnt Parverteb Fct Sngl Crvcl/Thora|RIGHT SIDE,CASE-64633,APC,64633,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1827.80,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1827.80,1919.19,OPPS APC
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],19579.01,,"Case rate ($18,646.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,513.37, add-ons for qualifying new technology services are included. If operating cost exceeds $52,384.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,952.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $15,509.62 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,568.42 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,192.11. The transfer capital threshold is the transfer adjustment factor * $1,192.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,19152.11,53152.12,Inpatient DRG
Transection/Avulsion Oth Spinal Nrv Xdrl,CASE-64772,APC,64772,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],62990.26,,"Fee schedule rate ($62,990.26). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,16787.98,62990.26,There are no additional notes associated with this service or procedure.
OTHER CEREBROVASCULAR DISORDERS WITH CC,071,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],15562.93,,"Case rate ($8,893.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,408.66, add-ons for qualifying new technology services are included. If operating cost exceeds $43,279.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,268.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,439.97 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,463.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $508.18. The transfer capital threshold is the transfer adjustment factor * $508.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,5843.00,29215.10,All Other Inpatient
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],39820.52,,"Fee schedule rate ($39,820.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,15273.74,39820.52,There are no additional notes associated with this service or procedure.
HC Inj Anesth Celiac Plexus,CASE-64530,APC,64530,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],827.89,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,827.89,869.28,OPPS APC
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,988,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],13075.52,,"Case rate ($13,075.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,299.49, add-ons for qualifying new technology services are included. If operating cost exceeds $47,170.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,574.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $10,316.50 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,354.54 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $814.07. The transfer capital threshold is the transfer adjustment factor * $814.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,13075.52,42425.46,Inpatient DRG
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],39053.73,,"Fee schedule rate ($39,053.73). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,16017.99,51903.64,There are no additional notes associated with this service or procedure.
HC Peripheral Block - Femoral Single or Saphenous W/Img Gdn,CASE-64447,APC,64447,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7029.71,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6791.99,7131.59,OPPS APC
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],22353.41,,"Case rate ($21,597.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,227.30, add-ons for qualifying new technology services are included. If operating cost exceeds $55,098.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,197.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $18,215.19 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,282.35 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,437.36. The transfer capital threshold is the transfer adjustment factor * $1,437.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,21597.50,67790.93,Inpatient DRG
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC",458,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],31712.19,,"Case rate ($30,202.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $28,231.97, add-ons for qualifying new technology services are included. If operating cost exceeds $63,102.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,826.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $26,190.45 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $26,287.02 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,066.69. The transfer capital threshold is the transfer adjustment factor * $2,066.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,30202.09,132827.25,Inpatient DRG
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],52449.26,,"Fee schedule rate ($52,449.26). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,17693.40,52449.26,There are no additional notes associated with this service or procedure.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],13608.50,,"Case rate ($13,341.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,547.08, add-ons for qualifying new technology services are included. If operating cost exceeds $47,418.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,593.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $10,563.18 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,602.13 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $833.54. The transfer capital threshold is the transfer adjustment factor * $833.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,13341.67,42586.49,Inpatient DRG
Cysto Bladder W/Ureteral Catheterization|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-52005,APC,52005,CPT,0360,RC,,,LT|XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3414.95,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3299.47,3464.44,OPPS APC
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,450,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],146009.19,,"Fee schedule rate ($146,009.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,38037.38,146009.19,There are no additional notes associated with this service or procedure.
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],24950.10,,"Fee schedule rate ($24,950.10). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,14603.31,45017.13,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],37914.65,,"Fee schedule rate ($37,914.65). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9865.56,37914.65,There are no additional notes associated with this service or procedure.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITHOUT CC/MCC,816,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],6349.40,,"Case rate ($6,224.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,926.50, add-ons for qualifying new technology services are included. If operating cost exceeds $40,797.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,073.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $3,966.92 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,981.55 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $313.03. The transfer capital threshold is the transfer adjustment factor * $313.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6224.90,14733.53,Inpatient DRG
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],12770.37,,,,,,0,other,6340.03,15076.44,There are no additional notes associated with this service or procedure.
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],13482.55,,"Case rate ($12,840.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,080.88, add-ons for qualifying new technology services are included. If operating cost exceeds $46,951.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,556.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $10,098.70 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,135.93 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $796.89. The transfer capital threshold is the transfer adjustment factor * $796.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,1188.00,31658.33,Inpatient DRG
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],23870.71,,"Fee schedule rate ($23,870.71). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10626.74,25225.91,There are no additional notes associated with this service or procedure.
Removal Implant Deep|UNUSUAL NON-OVERLAPPING SERVICE,CASE-20680,APC,20680,CPT,0360,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,6791.99,OPPS APC
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],30055.64,,"Fee schedule rate ($30,055.64). Adds an outlier to normal pricing equal to the per diem rate ($74,094.67) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.9), with a minimum of zero.",,,,0,other,12775.53,31469.43,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC,087,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],22679.07,,"Fee schedule rate ($22,679.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,8139.36,22679.07,There are no additional notes associated with this service or procedure.
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],33159.45,,"Fee schedule rate ($33,159.45). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,13092.47,33159.45,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],35192.25,,"Fee schedule rate ($35,192.25). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,10895.60,35192.25,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITH STERILIZATION WITHOUT CC/MCC,785,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],20142.33,,"Fee schedule rate ($20,142.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8431.24,20142.33,There are no additional notes associated with this service or procedure.
Laps Tx Ectopic Preg W/Salping&/Oophorectomy|LEFT SIDE,CASE-59151,APC,59151,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5856.81,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5658.76,5941.70,OPPS APC
MAJOR CHEST PROCEDURES WITH CC,164,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],19462.37,,"Case rate ($18,535.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,409.82, add-ons for qualifying new technology services are included. If operating cost exceeds $52,280.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,944.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $15,406.46 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,464.87 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,184.18. The transfer capital threshold is the transfer adjustment factor * $1,184.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,19037.66,77058.83,Inpatient DRG
CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC,788,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],8606.78,,"Case rate ($8,438.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,985.31, add-ons for qualifying new technology services are included. If operating cost exceeds $42,856.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,234.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,018.17 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,040.36 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $474.89. The transfer capital threshold is the transfer adjustment factor * $474.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,8438.02,20142.33,Inpatient DRG
Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE,CASE-62323,APC,62323,CPT,0360,RC,,,XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],693.76,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,660.72,693.76,OPPS APC
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],37914.65,,"Fee schedule rate ($37,914.65). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9865.56,37914.65,There are no additional notes associated with this service or procedure.
SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS,029,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],61889.56,,"Fee schedule rate ($61,889.56). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13641.00,67130.05,There are no additional notes associated with this service or procedure.
NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,601,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],6162.89,,"Case rate ($6,042.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,756.39, add-ons for qualifying new technology services are included. If operating cost exceeds $40,627.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,059.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $3,797.45 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,811.45 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $299.66. The transfer capital threshold is the transfer adjustment factor * $299.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6042.05,12359.72,Inpatient DRG
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC,497,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],37761.19,,"Fee schedule rate ($37,761.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10127.65,37761.19,There are no additional notes associated with this service or procedure.
NORMAL NEWBORN,795,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],2576.52,,"Fee schedule rate ($2,576.52). Adds an outlier to normal pricing equal to the per diem rate ($414) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,1369.79,5771.52,There are no additional notes associated with this service or procedure.
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],33835.79,,"Fee schedule rate ($33,835.79). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,7000.00,33835.79,There are no additional notes associated with this service or procedure.
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],25829.63,,"Fee schedule rate ($25,829.63). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6965.00,29482.05,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],59021.28,,"Fee schedule rate ($59,021.28). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,23851.92,63653.13,There are no additional notes associated with this service or procedure.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],45706.73,,"Fee schedule rate ($45,706.73). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,7921.00,45706.73,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,690,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],14625.55,,"Fee schedule rate ($14,625.55). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7426.94,15928.53,There are no additional notes associated with this service or procedure.
Prq Skeletal Fixj Metacarpal Fx Each Bone|RIGHT SIDE,CASE-26608,APC,26608,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],10826.73,,"Case rate ($10,311.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,727.87, add-ons for qualifying new technology services are included. If operating cost exceeds $44,598.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,371.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $7,754.32 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,782.91 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $611.89. The transfer capital threshold is the transfer adjustment factor * $611.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10311.17,24308.97,Inpatient DRG
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],29166.74,,"Fee schedule rate ($29,166.74). Adds an outlier to normal pricing equal to the per diem rate ($36,758.78) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,12455.21,37149.27,There are no additional notes associated with this service or procedure.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],10112.59,,"Case rate ($5,778.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,511.33, add-ons for qualifying new technology services are included. If operating cost exceeds $40,382.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,040.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $3,553.28 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,566.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $280.39. The transfer capital threshold is the transfer adjustment factor * $280.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,5778.62,11681.49,All Other Inpatient
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],14492.93,,"Fee schedule rate ($14,492.93). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6503.90,14492.93,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITH MCC,385,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],11480.01,,"Fee schedule rate ($11,480.01). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11480.01,31134.92,There are no additional notes associated with this service or procedure.
"Open Tx Metacarpal Fracture Single Ea Bone|RIGHT HAND, THIRD DIGIT",CASE-26615,APC,26615,CPT,0360,RC,,,F7,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],94787.57,,"Fee schedule rate ($94,787.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,23526.87,94787.57,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,066,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],20083.61,,"Fee schedule rate ($20,083.61). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6579.76,20083.61,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],12732.39,,"Case rate ($12,126.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,416.25, add-ons for qualifying new technology services are included. If operating cost exceeds $46,287.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,504.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $9,436.50 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,471.29 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $744.63. The transfer capital threshold is the transfer adjustment factor * $744.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12126.09,29582.40,Inpatient DRG
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC,862,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],6855.00,,"Per diem ($6,855). If length of stay < 5, first 1 days paid at a per diem of $13,710 instead. Capped at $34,272.79.",,,,0,other,6855.00,35884.94,Estimated amount calculated based on 3 day length of stay.
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH CC",457,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],88982.25,,"Fee schedule rate ($88,982.25). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,42327.47,160549.49,There are no additional notes associated with this service or procedure.
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],7402.56,,"Case rate ($7,402.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,022.05, add-ons for qualifying new technology services are included. If operating cost exceeds $41,893.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,159.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,058.45 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,077.10 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $399.16. The transfer capital threshold is the transfer adjustment factor * $399.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7402.56,16438.59,Inpatient DRG
HC Joint Injection/Aspir Large WO US|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-20610,APC,20610,CPT,0510,RC,,,RT|XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],301.68,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,287.31,301.68,OPPS APC
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],19119.59,,"Case rate ($19,119.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,922.16, add-ons for qualifying new technology services are included. If operating cost exceeds $52,793.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,016.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $15,918.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,977.21 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,256.13. The transfer capital threshold is the transfer adjustment factor * $1,256.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,11348.00,62454.12,Inpatient DRG
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],67794.72,,"Fee schedule rate ($67,794.72). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,10862.00,86437.13,There are no additional notes associated with this service or procedure.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],13149.46,,"Fee schedule rate ($13,149.46). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.9), with a minimum of zero.",,,,0,other,6683.37,14699.43,There are no additional notes associated with this service or procedure.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,191,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],16612.88,,"Fee schedule rate ($16,612.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6965.00,16612.88,There are no additional notes associated with this service or procedure.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],14603.19,,"Case rate ($13,907.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,073.74, add-ons for qualifying new technology services are included. If operating cost exceeds $47,944.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,634.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $11,087.92 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,128.80 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $874.95. The transfer capital threshold is the transfer adjustment factor * $874.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13907.80,52794.06,Inpatient DRG
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH MCC",510,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],23519.99,,"Case rate ($22,399.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,973.84, add-ons for qualifying new technology services are included. If operating cost exceeds $55,844.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,256.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.3. The base transfer operating payment is the transfer adjustment factor * $18,958.99 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $19,028.89 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,496.05. The transfer capital threshold is the transfer adjustment factor * $1,496.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10710.00,89863.76,Inpatient DRG
NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,601,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],11369.77,,"Fee schedule rate ($11,369.77). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,6042.05,12359.72,There are no additional notes associated with this service or procedure.
Thyroidectomy Total/Subtotal Lmtd Neck Dissect,CASE-60252,APC,60252,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5541.10,,"APC Price ($5,541.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5541.10,5818.16,OPPS APC
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,083,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],28680.85,,"Fee schedule rate ($28,680.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,28680.85,There are no additional notes associated with this service or procedure.
HC Biopsy/Exc Lymph Node Needle|TECHNICAL COMPONENT|RIGHT SIDE,CASE-38505,APC,38505,CPT,0361,RC,,,TC|RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1623.23,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1545.93,1623.23,OPPS APC
PERITONEAL ADHESIOLYSIS WITH CC,336,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],41492.89,,,,,,0,other,16225.22,53705.31,There are no additional notes associated with this service or procedure.
OTHER MENTAL DISORDER DIAGNOSES,887,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],2070.00,,,,,,0,other,2070.00,21072.10,Estimated amount calculated based on 1 day length of stay.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],19422.10,,"Case rate ($18,497.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,343.20, add-ons for qualifying new technology services are included. If operating cost exceeds $52,214.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,970.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $15,341.68 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,398.25 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,210.61. The transfer capital threshold is the transfer adjustment factor * $1,210.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,18497.24,62041.12,Inpatient DRG
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],8468.48,,"Case rate ($8,468.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,013.65, add-ons for qualifying new technology services are included. If operating cost exceeds $42,884.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,237.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,046.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,068.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $477.12. The transfer capital threshold is the transfer adjustment factor * $477.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6963.00,18954.85,Inpatient DRG
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC,497,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],37761.19,,"Fee schedule rate ($37,761.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10127.65,37761.19,There are no additional notes associated with this service or procedure.
Egd Transoral Control Bleeding Any Method,CASE-43255,APC,43255,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1859.01,,"APC Price ($1,796.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1796.14,1885.95,OPPS APC
"NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY",789,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],14857.05,,"Case rate ($14,149.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,298.65, add-ons for qualifying new technology services are included. If operating cost exceeds $48,169.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,652.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $11,312.00 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,353.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $892.63. The transfer capital threshold is the transfer adjustment factor * $892.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,3054.00,14857.05,Inpatient DRG
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],19877.10,,"Fee schedule rate ($19,877.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8009.34,19877.10,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,555,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],42290.95,,"Fee schedule rate ($42,290.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10896.27,42290.95,There are no additional notes associated with this service or procedure.
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],11575.50,,"Case rate ($11,575.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,904.06, add-ons for qualifying new technology services are included. If operating cost exceeds $45,775.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,464.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $8,926.20 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,959.11 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $704.37. The transfer capital threshold is the transfer adjustment factor * $704.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,11575.50,48961.48,Inpatient DRG
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC,832,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],9034.88,,"Fee schedule rate ($9,034.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4803.31,14198.92,There are no additional notes associated with this service or procedure.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],16900.84,,"Fee schedule rate ($16,900.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8151.55,18033.97,There are no additional notes associated with this service or procedure.
Injection Aa&/Strd Intercostal Nrv Ea Addl Lvl|RIGHT SIDE,CASE-64421,APC,64421,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],856.86,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,827.89,869.28,OPPS APC
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],12606.23,,"Case rate ($12,606.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,862.91, add-ons for qualifying new technology services are included. If operating cost exceeds $46,733.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,539.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $9,881.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,917.95 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $779.75. The transfer capital threshold is the transfer adjustment factor * $779.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12606.23,36868.88,Inpatient DRG
VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC,033,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],42156.44,,"Fee schedule rate ($42,156.44). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,13206.23,42156.44,There are no additional notes associated with this service or procedure.
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],7053.95,,"Case rate ($6,915.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,569.08, add-ons for qualifying new technology services are included. If operating cost exceeds $41,440.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,123.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,607.15 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,624.14 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $363.55. The transfer capital threshold is the transfer adjustment factor * $363.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6915.64,14442.92,Inpatient DRG
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],14830.15,,"Fee schedule rate ($14,830.15). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,7884.32,17835.23,There are no additional notes associated with this service or procedure.
"NEONATE BIRTH WEIGHT > 2499 GRAMS WITH OTHER SIGNIFICANT CONDITION,MINOR",639,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],2680.66,,"Case rate ($2,680.66). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,2680.66,2814.69,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],30063.84,,"Fee schedule rate ($30,063.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13891.57,34712.20,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],21892.85,,"Fee schedule rate ($21,892.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7569.84,21892.85,There are no additional notes associated with this service or procedure.
CERVICAL SPINAL FUSION WITH MCC,471,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],90745.76,,"Fee schedule rate ($90,745.76). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,34645.26,111337.93,There are no additional notes associated with this service or procedure.
"MAJOR ESOPHAGEAL DISORDERS,EXTREME",242,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],23025.20,,"Case rate ($23,025.20). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,23025.20,24176.46,There are no additional notes associated with this service or procedure.
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],45157.33,,"Fee schedule rate ($45,157.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,10733.06,45157.33,There are no additional notes associated with this service or procedure.
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5980.17,,"Case rate ($5,777.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,510.70, add-ons for qualifying new technology services are included. If operating cost exceeds $40,381.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,040.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $3,552.65 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,565.75 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $280.34. The transfer capital threshold is the transfer adjustment factor * $280.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,5065.00,12558.65,Inpatient DRG
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],16458.91,,"Fee schedule rate ($16,458.91). Adds an outlier to normal pricing equal to the per diem rate ($62,521.14) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,7875.94,17233.12,There are no additional notes associated with this service or procedure.
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],16428.39,,"Case rate ($16,428.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,418.58, add-ons for qualifying new technology services are included. If operating cost exceeds $50,289.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,819.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $13,424.13 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,473.63 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,059.30. The transfer capital threshold is the transfer adjustment factor * $1,059.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,16428.39,42083.20,Inpatient DRG
"PROCEDURES FOR OBESITY,MODERATE",403,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],15014.02,,"Case rate ($14,299.07). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,14299.07,15014.02,There are no additional notes associated with this service or procedure.
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],8163.06,,"Case rate ($8,163.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,729.53, add-ons for qualifying new technology services are included. If operating cost exceeds $42,600.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,214.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,763.33 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,784.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $454.78. The transfer capital threshold is the transfer adjustment factor * $454.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8163.06,18067.42,Inpatient DRG
Nsl/Sinus Ndsc Max Antrost W/Rmvl Tiss Max Sinus|LEFT SIDE,CASE-31267,APC,31267,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6936.25,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6605.95,6936.25,OPPS APC
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC",514,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],19212.08,,"Fee schedule rate ($19,212.08). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,8868.04,22699.91,There are no additional notes associated with this service or procedure.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],45933.85,,"Fee schedule rate ($45,933.85). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,18497.24,62041.12,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],9169.30,,"Case rate ($8,859.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,377.16, add-ons for qualifying new technology services are included. If operating cost exceeds $43,248.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,265.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $6,408.58 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,432.21 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $505.70. The transfer capital threshold is the transfer adjustment factor * $505.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,8859.23,20090.22,Inpatient DRG
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],9334.13,,"Case rate ($9,151.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,648.69, add-ons for qualifying new technology services are included. If operating cost exceeds $43,519.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,287.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,679.11 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,703.74 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $527.05. The transfer capital threshold is the transfer adjustment factor * $527.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,9151.11,30245.71,Inpatient DRG
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],6511.25,,"Case rate ($6,201.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,904.45, add-ons for qualifying new technology services are included. If operating cost exceeds $40,775.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,071.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,944.95 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,959.50 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $311.30. The transfer capital threshold is the transfer adjustment factor * $311.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5937.41,12366.99,Inpatient DRG
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],24989.04,,"Case rate ($23,799.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $22,275.40, add-ons for qualifying new technology services are included. If operating cost exceeds $57,146.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,358.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.1. The base transfer operating payment is the transfer adjustment factor * $20,255.77 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $20,330.45 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,598.38. The transfer capital threshold is the transfer adjustment factor * $1,598.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,23799.09,63499.65,Inpatient DRG
CESAREAN SECTION WITHOUT STERILIZATION WITH MCC,786,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],23722.94,,"Fee schedule rate ($23,722.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12612.10,23722.94,There are no additional notes associated with this service or procedure.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],11999.57,,"Case rate ($11,593.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,921.06, add-ons for qualifying new technology services are included. If operating cost exceeds $45,792.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,465.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $8,943.14 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,976.12 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $705.70. The transfer capital threshold is the transfer adjustment factor * $705.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,11593.79,38248.08,Inpatient DRG
INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,352,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],26528.70,,"Fee schedule rate ($26,528.70). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,9853.37,26528.70,There are no additional notes associated with this service or procedure.
"ANTEPARTUM WITH O.R. PROCEDURE,MAJOR",547,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],15997.15,,"Case rate ($15,235.38). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,15235.38,15997.15,There are no additional notes associated with this service or procedure.
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC,806,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],10071.17,,"Fee schedule rate ($10,071.17). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5354.25,13416.00,There are no additional notes associated with this service or procedure.
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],34032.82,,"Fee schedule rate ($34,032.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,15233.11,38610.21,There are no additional notes associated with this service or procedure.
OTHER CEREBROVASCULAR DISORDERS WITH CC,071,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],29215.10,,"Fee schedule rate ($29,215.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5843.00,29215.10,There are no additional notes associated with this service or procedure.
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 2nd Level|BILATERAL PROCEDURE,CASE-64494,APC,64494,CPT,0360,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],856.86,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,827.89,869.28,OPPS APC
RADIOTHERAPY,849,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],81867.07,,"Fee schedule rate ($81,867.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,20293.88,81867.07,There are no additional notes associated with this service or procedure.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC",061,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],21028.55,,"Case rate ($20,616.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $19,314.45, add-ons for qualifying new technology services are included. If operating cost exceeds $54,185.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,125.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $17,305.68 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $17,369.49 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,365.59. The transfer capital threshold is the transfer adjustment factor * $1,365.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,20616.23,62315.82,Inpatient DRG
SALIVARY GLAND PROCEDURES,139,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],10828.85,,"Case rate ($10,313.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,729.75, add-ons for qualifying new technology services are included. If operating cost exceeds $44,600.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,372.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $7,756.21 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,784.80 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $612.04. The transfer capital threshold is the transfer adjustment factor * $612.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10313.19,30690.92,Inpatient DRG
NORMAL NEWBORN,795,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3421.18,,"Case rate ($3,258.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $3,169.15, add-ons for qualifying new technology services are included. If operating cost exceeds $38,040.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $1,853.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $1,219.58 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $1,224.20 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $93.74. The transfer capital threshold is the transfer adjustment factor * $93.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,1369.79,5771.52,Inpatient DRG
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],14674.80,,"Fee schedule rate ($14,674.80). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6711.00,16865.16,There are no additional notes associated with this service or procedure.
Perq Nl/Pl Lithotrp Complex >2 Cm Mlt Locations|RIGHT SIDE,CASE-50081,APC,50081,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],8860.83,,"APC Price ($8,860.83). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,8860.83,9303.88,OPPS APC
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],67794.72,,"Fee schedule rate ($67,794.72). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,10862.00,86437.13,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],43250.97,,"Fee schedule rate ($43,250.97). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,27256.92,81353.66,There are no additional notes associated with this service or procedure.
Anoscopy Dx W/HRA &Chem Agnts Enhancement W/Bx,CASE-46607,APC,46607,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1120.09,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1120.09,1176.09,OPPS APC
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],23749.69,,"Case rate ($13,571.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,760.65, add-ons for qualifying new technology services are included. If operating cost exceeds $47,631.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,610.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $10,775.96 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,815.69 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $850.33. The transfer capital threshold is the transfer adjustment factor * $850.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,13571.25,33781.47,All Other Inpatient
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],19230.88,,"Fee schedule rate ($19,230.88). Adds an outlier to normal pricing equal to the per diem rate ($71,679.63) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8874.81,20553.44,There are no additional notes associated with this service or procedure.
Blepharoplasty Upper Eyelid W/Excessive Skin,CASE-15823,APC,15823,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],2027.84,,"APC Price ($1,931.28). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1931.28,2027.84,OPPS APC
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,068,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],23184.90,,"Fee schedule rate ($23,184.90). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,23184.90,There are no additional notes associated with this service or procedure.
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],24528.10,,"Fee schedule rate ($24,528.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10989.72,26280.60,There are no additional notes associated with this service or procedure.
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH MCC",722,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],34009.69,,"Fee schedule rate ($34,009.69). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,14200.37,56869.13,There are no additional notes associated with this service or procedure.
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],27222.08,,"Fee schedule rate ($27,222.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7389.00,37134.43,There are no additional notes associated with this service or procedure.
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],21354.82,,"Fee schedule rate ($21,354.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6834.39,21354.82,There are no additional notes associated with this service or procedure.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],23618.74,,"Fee schedule rate ($23,618.74). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10533.95,24956.34,There are no additional notes associated with this service or procedure.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,329,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],86631.74,,"Fee schedule rate ($86,631.74). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (38), with a minimum of zero.",,,,0,other,33072.77,90445.33,There are no additional notes associated with this service or procedure.
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC,519,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],50780.20,,"Fee schedule rate ($50,780.20). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,15490.44,50780.20,There are no additional notes associated with this service or procedure.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],20227.96,,,,,,0,other,8906.63,28434.57,There are no additional notes associated with this service or procedure.
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],8136.74,,"Case rate ($7,749.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,344.60, add-ons for qualifying new technology services are included. If operating cost exceeds $42,215.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,184.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,379.82 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,399.66 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $424.52. The transfer capital threshold is the transfer adjustment factor * $424.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6711.00,16865.16,Inpatient DRG
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITH MCC OR ANTINEOPLASTIC IMPLANT OR EPILEPSY WITH NEUROSTIMULATOR,023,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],42177.23,,"Case rate ($40,750.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $38,045.35, add-ons for qualifying new technology services are included. If operating cost exceeds $72,916.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,598.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $35,967.78 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $36,100.40 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,838.21. The transfer capital threshold is the transfer adjustment factor * $2,838.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103.5%.",,,,0,other,15168.00,136379.44,Inpatient DRG
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],23954.07,,"Fee schedule rate ($23,954.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,6167.00,29058.99,There are no additional notes associated with this service or procedure.
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],9667.64,,"Fee schedule rate ($9,667.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,5139.72,13110.79,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITH CC,164,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],77058.83,,"Fee schedule rate ($77,058.83). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,19037.66,77058.83,There are no additional notes associated with this service or procedure.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],31685.17,,"Case rate ($18,105.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,979.06, add-ons for qualifying new technology services are included. If operating cost exceeds $51,850.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,941.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $14,978.89 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,034.11 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,181.98. The transfer capital threshold is the transfer adjustment factor * $1,181.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,18105.81,52699.33,All Other Inpatient
Excision Prepatellar Bursa|BILATERAL PROCEDURE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-27340,APC,27340,CPT,0360,RC,,,50|XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7029.71,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6791.99,7131.59,OPPS APC
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7661.65,,"Case rate ($7,402.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,022.05, add-ons for qualifying new technology services are included. If operating cost exceeds $41,893.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,159.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,058.45 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,077.10 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $399.16. The transfer capital threshold is the transfer adjustment factor * $399.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,7402.56,16438.59,Inpatient DRG
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC,862,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],14295.18,,"Case rate ($14,295.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,434.11, add-ons for qualifying new technology services are included. If operating cost exceeds $48,305.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,663.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $11,446.95 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,489.15 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $903.28. The transfer capital threshold is the transfer adjustment factor * $903.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6855.00,35884.94,Inpatient DRG
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],36875.62,,"Fee schedule rate ($36,875.62). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.7), with a minimum of zero.",,,,0,other,15233.11,38610.21,There are no additional notes associated with this service or procedure.
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],13724.81,,"Case rate ($7,842.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,431.55, add-ons for qualifying new technology services are included. If operating cost exceeds $42,302.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,191.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $5,466.44 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,486.60 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $431.36. The transfer capital threshold is the transfer adjustment factor * $431.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,5280.00,17136.70,All Other Inpatient
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],16226.57,,"Case rate ($15,453.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,512.02, add-ons for qualifying new technology services are included. If operating cost exceeds $49,383.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,747.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $12,520.90 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,567.07 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $988.02. The transfer capital threshold is the transfer adjustment factor * $988.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,15453.88,39251.68,Inpatient DRG
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],13863.15,,"Fee schedule rate ($13,863.15). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10846.16,25863.45,There are no additional notes associated with this service or procedure.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],23799.09,,"Case rate ($23,799.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $22,275.40, add-ons for qualifying new technology services are included. If operating cost exceeds $57,146.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,358.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.1. The base transfer operating payment is the transfer adjustment factor * $20,255.77 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $20,330.45 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,598.38. The transfer capital threshold is the transfer adjustment factor * $1,598.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,23799.09,63499.65,Inpatient DRG
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],18739.51,,"Case rate ($18,105.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,979.06, add-ons for qualifying new technology services are included. If operating cost exceeds $51,850.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,941.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $14,978.89 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,034.11 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,181.98. The transfer capital threshold is the transfer adjustment factor * $1,181.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,18105.81,52699.33,Inpatient DRG
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,761,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],6098.83,,"Case rate ($5,808.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,539.05, add-ons for qualifying new technology services are included. If operating cost exceeds $40,410.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,042.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $3,580.90 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,594.10 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $282.57. The transfer capital threshold is the transfer adjustment factor * $282.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5808.41,11946.72,Inpatient DRG
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC",494,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],39945.55,,"Fee schedule rate ($39,945.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,15533.10,39945.55,There are no additional notes associated with this service or procedure.
Edg US Exam Surgical Alter Stom Duodenum/Jejunum,CASE-43259,APC,43259,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1796.14,,"APC Price ($1,796.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1796.14,1885.95,OPPS APC
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],6965.00,,,,,,0,other,5139.72,13110.79,There are no additional notes associated with this service or procedure.
SINGLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL,402,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],124455.45,,"Fee schedule rate ($124,455.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,29172.05,124455.45,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],28821.04,,"Fee schedule rate ($28,821.04). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,10347.06,28821.04,There are no additional notes associated with this service or procedure.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC",156,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],12624.95,,"Fee schedule rate ($12,624.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6625.12,13598.77,There are no additional notes associated with this service or procedure.
APPENDIX PROCEDURES WITH MCC,397,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],51558.84,,"Fee schedule rate ($51,558.84). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,18163.37,51558.84,There are no additional notes associated with this service or procedure.
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],33221.97,,"Fee schedule rate ($33,221.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (47), with a minimum of zero.",,,,0,other,15283.90,38757.79,There are no additional notes associated with this service or procedure.
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],9592.53,,"Fee schedule rate ($9,592.53). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7733.72,18043.23,There are no additional notes associated with this service or procedure.
HC Inj Tendon Sheath/Ligament|RIGHT SIDE,CASE-20550,APC,20550,CPT,0510,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],301.68,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,287.31,301.68,OPPS APC
Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|RIGHT SIDE,CASE-26160,APC,26160,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1827.80,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1827.80,1919.19,OPPS APC
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],21089.59,,"Fee schedule rate ($21,089.59). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,6965.00,21089.59,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITH CC,164,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],19037.66,,"Case rate ($19,037.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,845.93, add-ons for qualifying new technology services are included. If operating cost exceeds $52,716.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,010.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $15,842.57 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,900.98 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,250.14. The transfer capital threshold is the transfer adjustment factor * $1,250.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,19037.66,77058.83,Inpatient DRG
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],33197.83,,"Fee schedule rate ($33,197.83). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.8), with a minimum of zero.",,,,0,other,13907.80,52794.06,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,555,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],42290.95,,"Fee schedule rate ($42,290.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10896.27,42290.95,There are no additional notes associated with this service or procedure.
PERIPHERAL VASCULAR DISORDERS WITH CC,300,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],9174.14,,"Case rate ($9,174.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,670.11, add-ons for qualifying new technology services are included. If operating cost exceeds $43,541.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,288.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,700.45 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,725.16 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $528.73. The transfer capital threshold is the transfer adjustment factor * $528.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9174.14,21005.20,Inpatient DRG
Cystourethroscopy With Biopsy,CASE-52204,APC,52204,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],2054.48,,"APC Price ($1,956.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1956.65,2054.48,OPPS APC
VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC,033,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],31250.88,,"Fee schedule rate ($31,250.88). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7.9), with a minimum of zero.",,,,0,other,13206.23,42156.44,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],29241.62,,"Fee schedule rate ($29,241.62). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,12984.79,32077.45,There are no additional notes associated with this service or procedure.
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],21089.59,,"Fee schedule rate ($21,089.59). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,6965.00,21089.59,There are no additional notes associated with this service or procedure.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],36988.38,,"Fee schedule rate ($36,988.38). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.7), with a minimum of zero.",,,,0,other,15273.74,39820.52,There are no additional notes associated with this service or procedure.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],142438.06,,"Fee schedule rate ($142,438.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (40), with a minimum of zero.",,,,0,other,45521.20,142438.06,There are no additional notes associated with this service or procedure.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],52794.06,,"Fee schedule rate ($52,794.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (37), with a minimum of zero.",,,,0,other,13907.80,52794.06,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],6965.00,,,,,,0,other,6164.03,14071.02,There are no additional notes associated with this service or procedure.
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITHOUT CC/MCC",630,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],12065.36,,"Case rate ($11,828.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,139.67, add-ons for qualifying new technology services are included. If operating cost exceeds $46,010.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,482.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $9,160.95 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,194.72 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $722.89. The transfer capital threshold is the transfer adjustment factor * $722.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,11828.78,42541.02,Inpatient DRG
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7616.10,,"Case rate ($7,253.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,893.22, add-ons for qualifying new technology services are included. If operating cost exceeds $41,764.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,138.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $4,929.58 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,948.27 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $378.90. The transfer capital threshold is the transfer adjustment factor * $378.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7414.07,18217.52,Inpatient DRG
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC,832,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],9034.88,,"Fee schedule rate ($9,034.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4803.31,14198.92,There are no additional notes associated with this service or procedure.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,057,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],25493.52,,,,,,0,other,10718.84,39884.93,There are no additional notes associated with this service or procedure.
PREMATURITY WITHOUT MAJOR PROBLEMS,792,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],11512.88,,"Fee schedule rate ($11,512.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,1956.00,19457.66,There are no additional notes associated with this service or procedure.
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],81454.07,,"Fee schedule rate ($81,454.07). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,10078.00,81454.07,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],19763.43,,"Fee schedule rate ($19,763.43). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,8318.14,19763.43,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],7547.49,,"Case rate ($7,547.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,156.87, add-ons for qualifying new technology services are included. If operating cost exceeds $42,027.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,169.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $5,192.77 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,211.92 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $409.76. The transfer capital threshold is the transfer adjustment factor * $409.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,19126.88,Inpatient DRG
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC",156,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],13598.77,,,,,,0,other,6625.12,13598.77,There are no additional notes associated with this service or procedure.
SPINAL PROCEDURES WITHOUT CC/MCC,030,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],44714.01,,"Fee schedule rate ($44,714.01). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,16810.99,44714.01,There are no additional notes associated with this service or procedure.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],21597.50,,"Case rate ($21,597.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,227.30, add-ons for qualifying new technology services are included. If operating cost exceeds $55,098.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,197.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $18,215.19 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,282.35 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,437.36. The transfer capital threshold is the transfer adjustment factor * $1,437.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,21597.50,67790.93,Inpatient DRG
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],62708.63,,,,,,0,other,23526.87,94787.57,There are no additional notes associated with this service or procedure.
NORMAL NEWBORN,795,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],2576.52,,"Fee schedule rate ($2,576.52). Adds an outlier to normal pricing equal to the per diem rate ($414) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,1369.79,5771.52,There are no additional notes associated with this service or procedure.
Arthrs Knee W/Meniscectomy Med&Lat W/Shaving|LEFT SIDE,CASE-29880,APC,29880,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],9549.99,,"Case rate ($9,095.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,610.04, add-ons for qualifying new technology services are included. If operating cost exceeds $43,481.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,270.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $6,639.92 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,665.09 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $510.36. The transfer capital threshold is the transfer adjustment factor * $510.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,21404.64,Inpatient DRG
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],19877.10,,"Fee schedule rate ($19,877.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8009.34,19877.10,There are no additional notes associated with this service or procedure.
Colonoscopy W/Biopsy Single/Multiple|COLORECTAL CANCER SCREEN|UNUSUAL NON-OVERLAPPING SERVICE,CASE-45380,APC,45380,CPT,0360,RC,,,PT|XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1159.29,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1120.09,1176.09,OPPS APC
"HC Aerosol, Hhn, Mdi, Ippb|ADJ",CASE-94640,APC,94640,CPT,0410,RC,,,ADJ,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7029.71,OPPS APC
Destruction Neurolytic Agt Genicular Nerve W/Img|RIGHT SIDE,CASE-64624,APC,64624,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1827.80,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1827.80,1891.77,OPPS APC
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],5791.49,,"Fee schedule rate ($5,791.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,3079.00,10940.41,There are no additional notes associated with this service or procedure.
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],12920.81,,"Case rate ($12,305.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,583.18, add-ons for qualifying new technology services are included. If operating cost exceeds $46,454.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,517.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $9,602.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,638.24 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $757.76. The transfer capital threshold is the transfer adjustment factor * $757.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12305.53,30103.84,Inpatient DRG
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],35474.53,,"Fee schedule rate ($35,474.53). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,16428.39,42083.20,There are no additional notes associated with this service or procedure.
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],31477.13,,"Fee schedule rate ($31,477.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9648.19,31477.13,There are no additional notes associated with this service or procedure.
"Inj Dx/Ther Agnt Paravert Facet Joint, Cerv/Thorac, 2nd Level",CASE-64491,APC,64491,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],827.89,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,827.89,869.28,OPPS APC
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],17651.07,,"Fee schedule rate ($17,651.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,6564.18,17651.07,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],17651.07,,"Fee schedule rate ($17,651.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,6564.18,17651.07,There are no additional notes associated with this service or procedure.
RESPIRATORY NEOPLASMS WITHOUT CC/MCC,182,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],23037.13,,"Fee schedule rate ($23,037.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6965.00,23037.13,There are no additional notes associated with this service or procedure.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],38248.08,,"Fee schedule rate ($38,248.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11593.79,38248.08,There are no additional notes associated with this service or procedure.
CELLULITIS WITH MCC,602,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],11801.50,,"Case rate ($11,570.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,899.02, add-ons for qualifying new technology services are included. If operating cost exceeds $45,770.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,463.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $8,921.17 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,954.07 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $703.97. The transfer capital threshold is the transfer adjustment factor * $703.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,11570.10,28349.31,Inpatient DRG
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],24444.75,,"Fee schedule rate ($24,444.75). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10136.44,24444.75,There are no additional notes associated with this service or procedure.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],56476.93,,,,,,0,other,21382.16,85466.62,There are no additional notes associated with this service or procedure.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],23835.16,,"Fee schedule rate ($23,835.16). Adds an outlier to normal pricing equal to the per diem rate ($63,133.20) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10533.95,24956.34,There are no additional notes associated with this service or procedure.
HC Gastric Procedure Unlisted,CASE-43999,APC,43999,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],848.96,,"APC Price ($848.96). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,848.96,891.41,OPPS APC
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],32263.82,,"Fee schedule rate ($32,263.82). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13571.25,33781.47,There are no additional notes associated with this service or procedure.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],26949.28,,"Fee schedule rate ($26,949.28). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9977.99,26949.28,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],16590.46,,"Fee schedule rate ($16,590.46). Adds an outlier to normal pricing equal to the per diem rate ($69,146.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,1188.00,17370.86,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],42768.36,,"Fee schedule rate ($42,768.36). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,14295.18,42768.36,There are no additional notes associated with this service or procedure.
SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS,029,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],61889.56,,"Fee schedule rate ($61,889.56). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13641.00,67130.05,There are no additional notes associated with this service or procedure.
Mastectomy Simple Complete|LEFT SIDE,CASE-19303,APC,19303,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6215.36,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6215.36,6526.12,OPPS APC
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC",629,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],16699.94,,"Case rate ($16,699.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,671.20, add-ons for qualifying new technology services are included. If operating cost exceeds $50,542.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,839.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $13,675.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,726.25 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,079.16. The transfer capital threshold is the transfer adjustment factor * $1,079.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,16699.94,44657.18,Inpatient DRG
FRACTURES OF FEMUR WITH MCC,533,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],6852.00,,"Per diem ($6,852). If length of stay < 4.3, first 1 days paid at a per diem of $13,704 instead. Capped at $29,461.79.",,,,0,other,6852.00,49490.05,Estimated amount calculated based on 2 day length of stay.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],19319.20,,"Fee schedule rate ($19,319.20). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8906.63,28434.57,There are no additional notes associated with this service or procedure.
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],13872.99,,"Fee schedule rate ($13,872.99). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.8), with a minimum of zero.",,,,0,other,5068.21,14525.56,There are no additional notes associated with this service or procedure.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC,434,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],13390.01,,"Fee schedule rate ($13,390.01). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6770.05,14019.86,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,083,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],27465.16,,,,,,0,other,6965.00,28680.85,There are no additional notes associated with this service or procedure.
"NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY",789,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],3354.00,,,,,,0,other,3054.00,14857.05,Estimated amount calculated based on 1 day length of stay.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],17223.78,,"Fee schedule rate ($17,223.78). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,8151.55,18033.97,There are no additional notes associated with this service or procedure.
OTHER MENTAL DISORDER DIAGNOSES,887,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],6965.00,,,,,,0,other,2070.00,21072.10,There are no additional notes associated with this service or procedure.
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC,520,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],12061.74,,"Case rate ($12,061.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,356.39, add-ons for qualifying new technology services are included. If operating cost exceeds $46,227.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,499.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $9,376.87 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,411.44 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $739.93. The transfer capital threshold is the transfer adjustment factor * $739.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12061.74,39786.42,Inpatient DRG
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,068,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],6965.00,,,,,,0,other,6965.00,23184.90,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITHOUT STERILIZATION WITH CC,787,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],20988.02,,"Fee schedule rate ($20,988.02). Adds an outlier to normal pricing equal to the per diem rate ($39,437.39) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,9508.01,23722.94,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,066,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6810.05,,"Case rate ($6,579.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,256.61, add-ons for qualifying new technology services are included. If operating cost exceeds $41,127.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,098.96, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $4,295.82 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,311.66 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $338.98. The transfer capital threshold is the transfer adjustment factor * $338.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6579.76,20083.61,Inpatient DRG
FRACTURES OF FEMUR WITH MCC,533,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],49490.05,,"Fee schedule rate ($49,490.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,6852.00,49490.05,There are no additional notes associated with this service or procedure.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,074,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],19371.82,,"Fee schedule rate ($19,371.82). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,8925.60,20919.08,There are no additional notes associated with this service or procedure.
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,450,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],104870.54,,,,,,0,other,38037.38,146009.19,There are no additional notes associated with this service or procedure.
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],13545.65,,,,,,0,other,5919.29,13545.65,There are no additional notes associated with this service or procedure.
"OTHER DIGESTIVE SYSTEM DIAGNOSES,MODERATE",254,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],7606.73,,"Case rate ($7,606.73). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,7606.73,7987.07,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC,833,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],3041.73,,"Fee schedule rate ($3,041.73). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,3041.73,10289.10,There are no additional notes associated with this service or procedure.
OSTEOMYELITIS WITH CC,540,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],18450.55,,"Fee schedule rate ($18,450.55). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,9809.07,25507.30,There are no additional notes associated with this service or procedure.
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],36024.65,,,,,,0,other,14343.25,36024.65,There are no additional notes associated with this service or procedure.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,329,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],86382.02,,"Fee schedule rate ($86,382.02). Adds an outlier to normal pricing equal to the per diem rate ($147,722.18) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,33072.77,90445.33,There are no additional notes associated with this service or procedure.
"HC Repair Nail Bed|RIGHT HAND, FIFTH DIGIT",CASE-11760,APC,11760,CPT,0450,RC,,,F9,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
HC Pbb Carpal Tunnel Inj Pmc|BILATERAL PROCEDURE,CASE-20526,APC,20526,CPT,0510,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],297.37,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,287.31,297.37,OPPS APC
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],20373.57,,,,,,0,other,8956.76,28983.97,There are no additional notes associated with this service or procedure.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,074,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],8925.60,,"Case rate ($8,925.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,438.90, add-ons for qualifying new technology services are included. If operating cost exceeds $43,309.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,270.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,470.10 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,493.95 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $510.55. The transfer capital threshold is the transfer adjustment factor * $510.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8925.60,20919.08,Inpatient DRG
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,544,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],23207.64,,"Fee schedule rate ($23,207.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,7055.15,23207.64,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],13639.70,,"Case rate ($12,990.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,220.11, add-ons for qualifying new technology services are included. If operating cost exceeds $47,091.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,567.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $10,237.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,275.16 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $807.83. The transfer capital threshold is the transfer adjustment factor * $807.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9888.00,43399.23,Inpatient DRG
Open Tx Clavicular Fracture Internal Fixation|RIGHT SIDE,CASE-23515,APC,23515,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC,862,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],28705.48,,"Fee schedule rate ($28,705.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (42), with a minimum of zero.",,,,0,other,6855.00,35884.94,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],13952.52,,"Case rate ($13,952.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,115.33, add-ons for qualifying new technology services are included. If operating cost exceeds $47,986.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,638.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $11,129.34 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,170.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $878.22. The transfer capital threshold is the transfer adjustment factor * $878.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,13917.42,34889.29,Inpatient DRG
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,761,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],5808.41,,"Case rate ($5,808.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,539.05, add-ons for qualifying new technology services are included. If operating cost exceeds $40,410.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,042.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $3,580.90 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,594.10 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $282.57. The transfer capital threshold is the transfer adjustment factor * $282.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,5808.41,11946.72,Inpatient DRG
"NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY",789,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],3054.00,,,,,,0,other,3054.00,14857.05,Estimated amount calculated based on 1 day length of stay.
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH MCC",722,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],14910.39,,"Case rate ($14,200.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,345.91, add-ons for qualifying new technology services are included. If operating cost exceeds $48,216.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,656.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $11,359.07 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,400.95 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $896.34. The transfer capital threshold is the transfer adjustment factor * $896.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,14200.37,56869.13,Inpatient DRG
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],35127.88,,"Fee schedule rate ($35,127.88). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.5), with a minimum of zero.",,,,0,other,14603.31,45017.13,There are no additional notes associated with this service or procedure.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],28035.79,,,,,,0,other,11593.79,38248.08,There are no additional notes associated with this service or procedure.
Mastectomy Partial|RIGHT SIDE,CASE-19301,APC,19301,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3793.21,,"APC Price ($3,664.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3664.94,3848.19,OPPS APC
NERVOUS SYSTEM NEOPLASMS WITH MCC,054,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],25589.03,,"Fee schedule rate ($25,589.03). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,6965.00,30044.81,There are no additional notes associated with this service or procedure.
"Amputation Toe Metatarsophalangeal Joint|LEFT FOOT, SECOND DIGIT",CASE-28820,APC,28820,CPT,0360,RC,,,T1,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3062.67,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],10096.80,,"Fee schedule rate ($10,096.80). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7414.07,18217.52,There are no additional notes associated with this service or procedure.
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],5791.49,,"Fee schedule rate ($5,791.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,3079.00,10940.41,There are no additional notes associated with this service or procedure.
Dstrj Lesion Anus Simple Surg Excision,CASE-46922,APC,46922,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],2689.02,,"APC Price ($2,598.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2598.08,2727.99,OPPS APC
UNGROUPABLE,999,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],48752.15,,"Case rate ($48,752.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $45,488.70, add-ons for qualifying new technology services are included. If operating cost exceeds $80,359.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $5,183.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 12.7. The base transfer operating payment is the transfer adjustment factor * $43,383.78 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $43,543.75 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,423.41. The transfer capital threshold is the transfer adjustment factor * $3,423.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10228.00,161307.29,Inpatient DRG
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],9992.90,,"Case rate ($5,710.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,447.70, add-ons for qualifying new technology services are included. If operating cost exceeds $40,318.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,035.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $3,489.88 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,502.75 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $275.39. The transfer capital threshold is the transfer adjustment factor * $275.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,3079.00,10940.41,All Other Inpatient
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7941.86,,"Case rate ($7,563.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,182.42, add-ons for qualifying new technology services are included. If operating cost exceeds $42,053.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,161.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,217.69 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,237.47 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $401.04. The transfer capital threshold is the transfer adjustment factor * $401.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7733.72,18043.23,Inpatient DRG
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],7453.00,,"Per diem ($7,453). If length of stay < 5.4, first 1 days paid at a per diem of $14,906 instead. Capped at $40,245.21.",,,,0,other,7453.00,42138.30,Estimated amount calculated based on 3 day length of stay.
Cysto Calibration Dilat Urtl Strix/Stenosis,CASE-52281,APC,52281,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1956.65,,"APC Price ($1,956.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1956.65,2054.48,OPPS APC
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],15802.03,,"Fee schedule rate ($15,802.03). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7566.45,16333.88,There are no additional notes associated with this service or procedure.
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITH MCC,429,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],177294.98,,"Fee schedule rate ($177,294.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,62958.58,177294.98,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITH CC,164,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],77058.83,,"Fee schedule rate ($77,058.83). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,19037.66,77058.83,There are no additional notes associated with this service or procedure.
POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES,769,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],29791.03,,"Fee schedule rate ($29,791.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,13388.39,33250.19,There are no additional notes associated with this service or procedure.
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC,964,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],34154.06,,"Fee schedule rate ($34,154.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12323.82,34154.06,There are no additional notes associated with this service or procedure.
Dstrj Lesion Penis Simple Laser,CASE-54057,APC,54057,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],652.69,,"APC Price ($652.69). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,652.69,685.32,OPPS APC
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC,862,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],35884.94,,,,,,0,other,6855.00,35884.94,There are no additional notes associated with this service or procedure.
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],8234.89,,"Case rate ($7,842.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,431.55, add-ons for qualifying new technology services are included. If operating cost exceeds $42,302.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,191.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $5,466.44 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,486.60 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $431.36. The transfer capital threshold is the transfer adjustment factor * $431.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5280.00,17136.70,Inpatient DRG
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],128358.13,,"Fee schedule rate ($128,358.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,40542.37,128358.13,There are no additional notes associated with this service or procedure.
VENTRICULAR SHUNT PROCEDURES WITH CC,032,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],40047.88,,"Fee schedule rate ($40,047.88). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,16376.22,46275.08,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,689,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],10292.71,,"Case rate ($9,802.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,254.74, add-ons for qualifying new technology services are included. If operating cost exceeds $44,125.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,334.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $7,282.94 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,309.79 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $574.70. The transfer capital threshold is the transfer adjustment factor * $574.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9802.58,22831.22,Inpatient DRG
MAJOR CHEST TRAUMA WITHOUT CC/MCC,185,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7470.48,,"Case rate ($7,114.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,763.94, add-ons for qualifying new technology services are included. If operating cost exceeds $41,634.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,128.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,800.78 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,818.99 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $369.00. The transfer capital threshold is the transfer adjustment factor * $369.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7271.19,21771.61,Inpatient DRG
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],35528.17,,"Fee schedule rate ($35,528.17). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,14747.55,37899.49,There are no additional notes associated with this service or procedure.
HC Drain/Inj Joint/Bursa W/US Large|PBB CHARGE,CASE-20611,APC,20611,CPT,0510,RC,,,PBB,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],297.37,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,287.31,301.68,OPPS APC
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],14725.21,,"Case rate ($14,725.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,834.15, add-ons for qualifying new technology services are included. If operating cost exceeds $48,705.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,694.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,845.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,889.20 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $934.73. The transfer capital threshold is the transfer adjustment factor * $934.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7389.00,37134.43,Inpatient DRG
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],12152.18,,"Case rate ($6,944.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,595.55, add-ons for qualifying new technology services are included. If operating cost exceeds $41,466.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,125.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,633.51 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,650.60 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $365.63. The transfer capital threshold is the transfer adjustment factor * $365.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,5068.21,14525.56,All Other Inpatient
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],45706.73,,"Fee schedule rate ($45,706.73). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,7921.00,45706.73,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF NERVOUS SYSTEM WITH CC,092,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],26765.51,,"Fee schedule rate ($26,765.51). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8872.78,26765.51,There are no additional notes associated with this service or procedure.
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],30245.71,,"Fee schedule rate ($30,245.71). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9151.11,30245.71,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],59021.28,,"Fee schedule rate ($59,021.28). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,23851.92,63653.13,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],40737.46,,"Fee schedule rate ($40,737.46). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,7665.00,40737.46,There are no additional notes associated with this service or procedure.
Exc B9 Lesion Mrgn Xcp Sk Tg S/N/H/F/G 1.1-2.0cm,CASE-11422,APC,11422,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1600.04,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1600.04,1623.23,OPPS APC
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],28235.64,,"Fee schedule rate ($28,235.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,14344.60,36028.59,There are no additional notes associated with this service or procedure.
COAGULATION DISORDERS,813,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],29046.49,,"Fee schedule rate ($29,046.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12274.39,30013.33,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],53152.12,,"Fee schedule rate ($53,152.12). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,19152.11,53152.12,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],18518.02,,,,,,0,other,8318.14,19763.43,There are no additional notes associated with this service or procedure.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],19604.30,,"Fee schedule rate ($19,604.30). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9446.38,21796.21,There are no additional notes associated with this service or procedure.
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],45017.13,,"Fee schedule rate ($45,017.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,14603.31,45017.13,There are no additional notes associated with this service or procedure.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],27747.62,,"Case rate ($26,809.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $25,075.72, add-ons for qualifying new technology services are included. If operating cost exceeds $59,946.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,578.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $23,045.79 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $23,130.76 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,818.54. The transfer capital threshold is the transfer adjustment factor * $1,818.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,26809.29,97015.50,Inpatient DRG
"NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY",789,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],6663.33,,,,,,0,other,3054.00,14857.05,Estimated amount calculated based on 1 day length of stay.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],10347.06,,"Case rate ($10,347.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,761.25, add-ons for qualifying new technology services are included. If operating cost exceeds $44,632.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,374.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $7,787.59 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,816.30 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $614.52. The transfer capital threshold is the transfer adjustment factor * $614.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10347.06,28821.04,Inpatient DRG
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,064,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],37792.72,,"Fee schedule rate ($37,792.72). Adds an outlier to normal pricing equal to the per diem rate ($115,085.88) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,15563.58,41838.16,There are no additional notes associated with this service or procedure.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],69000.38,,"Fee schedule rate ($69,000.38). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15), with a minimum of zero.",,,,0,other,26809.29,97015.50,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC,832,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],9034.88,,"Fee schedule rate ($9,034.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4803.31,14198.92,There are no additional notes associated with this service or procedure.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],51630.84,,"Fee schedule rate ($51,630.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,20559.34,54086.17,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,699,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],9259.53,,"Case rate ($8,818.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,339.37, add-ons for qualifying new technology services are included. If operating cost exceeds $43,210.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,262.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $6,370.92 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,394.41 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $502.73. The transfer capital threshold is the transfer adjustment factor * $502.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5961.00,19972.16,Inpatient DRG
Bronchoscopy Bronchial/Endobrncl Bx 1+ Sites,CASE-31625,APC,31625,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3611.96,,"APC Price ($3,489.82). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3611.96,3611.96,OPPS APC
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC,497,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],23775.72,,,,,,0,other,10127.65,37761.19,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],85305.59,,"Fee schedule rate ($85,305.59). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,21719.40,85305.59,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],41580.51,,"Fee schedule rate ($41,580.51). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,13783.20,41580.51,There are no additional notes associated with this service or procedure.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],7453.00,,"Per diem ($7,453). If length of stay < 5.4, first 1 days paid at a per diem of $14,906 instead. Capped at $40,245.21.",,,,0,other,7453.00,42138.30,Estimated amount calculated based on 3 day length of stay.
Ercp Remove Foreign Body/Stent Biliary/Panc Duct,CASE-43275,APC,43275,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3608.81,,"APC Price ($3,608.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3608.81,3789.26,OPPS APC
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC,858,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],26176.77,,"Fee schedule rate ($26,176.77). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11377.76,33794.11,There are no additional notes associated with this service or procedure.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],7332.00,,"Per diem ($7,332). If length of stay < 4.6, first 1 days paid at a per diem of $14,664 instead. Capped at $33,727.80.",,,,0,other,7332.00,35314.31,Estimated amount calculated based on 3 day length of stay.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],80635.65,,"Fee schedule rate ($80,635.65). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,26028.48,80635.65,There are no additional notes associated with this service or procedure.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,057,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],10933.22,,"Case rate ($10,718.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,107.12, add-ons for qualifying new technology services are included. If operating cost exceeds $44,978.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,401.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,132.18 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,162.17 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $641.71. The transfer capital threshold is the transfer adjustment factor * $641.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,10718.84,39884.93,Inpatient DRG
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC",458,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],132827.25,,"Fee schedule rate ($132,827.25). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,30202.09,132827.25,There are no additional notes associated with this service or procedure.
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,450,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],146009.19,,"Fee schedule rate ($146,009.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,38037.38,146009.19,There are no additional notes associated with this service or procedure.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],19204.75,,,,,,0,other,8554.50,19204.75,There are no additional notes associated with this service or procedure.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],41944.25,,"Fee schedule rate ($41,944.25). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12795.84,41944.25,There are no additional notes associated with this service or procedure.
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],10136.44,,"Case rate ($10,136.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,565.33, add-ons for qualifying new technology services are included. If operating cost exceeds $44,436.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,359.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $7,592.38 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,620.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $599.11. The transfer capital threshold is the transfer adjustment factor * $599.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10136.44,24444.75,Inpatient DRG
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITHOUT CC/MCC,816,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],6965.00,,,,,,0,other,6224.90,14733.53,There are no additional notes associated with this service or procedure.
Nasal/Sinus Ndsc Surg W/Concha Bullosa Resection|RIGHT SIDE,CASE-31240,APC,31240,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3211.97,,"APC Price ($3,103.35). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.35,3258.52,OPPS APC
Nsl/Sinus Ndsc Max Antrost W/Rmvl Tiss Max Sinus,CASE-31267,APC,31267,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6605.95,,"APC Price ($6,605.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6605.95,6936.25,OPPS APC
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],10846.16,,"Case rate ($10,846.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,225.56, add-ons for qualifying new technology services are included. If operating cost exceeds $45,096.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,410.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $8,250.19 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,280.61 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $651.02. The transfer capital threshold is the transfer adjustment factor * $651.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10846.16,25863.45,Inpatient DRG
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],42021.93,,"Fee schedule rate ($42,021.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,21248.73,56089.29,There are no additional notes associated with this service or procedure.
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral Ea Addl,CASE-64484,APC,64484,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],827.89,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,827.89,869.28,OPPS APC
"Amp F/Th 1/2 Jt/Phalanx W/Neurect W/Dir Clsr|RIGHT HAND, SECOND DIGIT",CASE-26951,APC,26951,CPT,0360,RC,,,F6,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
HC Joint Injection/Aspir Large WO US|UNUSUAL NON-OVERLAPPING SERVICE|RIGHT SIDE,CASE-20610,APC,20610,CPT,0510,RC,,,XU|RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],16035.06,,"Fee schedule rate ($16,035.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,7396.47,16035.06,There are no additional notes associated with this service or procedure.
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC,964,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],34154.06,,"Fee schedule rate ($34,154.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12323.82,34154.06,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],34481.40,,"Fee schedule rate ($34,481.40). Adds an outlier to normal pricing equal to the per diem rate ($50,543.29) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,14370.36,38378.80,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],25091.22,,"Case rate ($14,337.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,473.80, add-ons for qualifying new technology services are included. If operating cost exceeds $48,344.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,666.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $11,486.49 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,528.84 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $906.40. The transfer capital threshold is the transfer adjustment factor * $906.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,14337.84,52803.53,All Other Inpatient
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,069,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],20333.68,,"Fee schedule rate ($20,333.68). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,20333.68,There are no additional notes associated with this service or procedure.
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],5415.00,,"Per diem ($5,415). If length of stay < 3.1, first 1 days paid at a per diem of $10,830 instead. Capped at $16,785.91.",,,,0,other,5415.00,17575.50,Estimated amount calculated based on 3 day length of stay.
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],5893.50,,"Case rate ($5,777.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,510.70, add-ons for qualifying new technology services are included. If operating cost exceeds $40,381.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,040.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $3,552.65 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,565.75 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $280.34. The transfer capital threshold is the transfer adjustment factor * $280.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,5065.00,12558.65,Inpatient DRG
OTHER CEREBROVASCULAR DISORDERS WITH MCC,070,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],37774.46,,"Fee schedule rate ($37,774.46). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,13219.09,37774.46,There are no additional notes associated with this service or procedure.
PREMATURITY WITHOUT MAJOR PROBLEMS,792,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],11512.88,,"Fee schedule rate ($11,512.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,1956.00,19457.66,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,167,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],43522.37,,"Fee schedule rate ($43,522.37). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,14157.71,43522.37,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],15061.83,,"Case rate ($14,344.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,480.09, add-ons for qualifying new technology services are included. If operating cost exceeds $48,351.10 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,666.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $11,492.77 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,535.14 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $906.89. The transfer capital threshold is the transfer adjustment factor * $906.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,14344.60,36028.59,Inpatient DRG
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],14455.04,,"Fee schedule rate ($14,455.04). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5280.00,17136.70,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],58394.20,,"Fee schedule rate ($58,394.20). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,9370.00,65732.99,There are no additional notes associated with this service or procedure.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],46215.75,,"Fee schedule rate ($46,215.75). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.7), with a minimum of zero.",,,,0,other,18598.83,48389.68,There are no additional notes associated with this service or procedure.
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC",458,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],31712.19,,"Case rate ($30,202.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $28,231.97, add-ons for qualifying new technology services are included. If operating cost exceeds $63,102.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,826.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $26,190.45 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $26,287.02 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,066.69. The transfer capital threshold is the transfer adjustment factor * $2,066.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,30202.09,132827.25,Inpatient DRG
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],28235.64,,"Fee schedule rate ($28,235.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,14344.60,36028.59,There are no additional notes associated with this service or procedure.
DIABETES WITHOUT CC/MCC,639,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],11899.36,,"Fee schedule rate ($11,899.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6151.76,12223.35,There are no additional notes associated with this service or procedure.
HC Repair Tun or Non Cath W/Port,CASE-36576,APC,36576,CPT,0361,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1525.02,,"APC Price ($1,473.45). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1473.45,1547.12,OPPS APC
Cervical Lymphadec Modified Radical Neck Dsj|RIGHT SIDE,CASE-38724,APC,38724,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],206.06,,"APC Price ($199.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,199.10,209.05,OPPS APC
Prq Impltj Neurostimulator Eltrd Peripheral Nrv,CASE-64555,APC,64555,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5965.28,,"APC Price ($5,965.28). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5965.28,6263.54,OPPS APC
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],38839.49,,"Fee schedule rate ($38,839.49). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.6), with a minimum of zero.",,,,0,other,15940.79,53275.26,There are no additional notes associated with this service or procedure.
Arthrd Ant Interbody Decompress Cervical Belw C2|SEPARATE STRUCTURE,CASE-22551,APC,22551,CPT,0360,RC,,,XS,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],12437.92,,"APC Price ($12,017.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,12437.92,12437.92,OPPS APC
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],6801.88,,"Case rate ($6,801.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,463.25, add-ons for qualifying new technology services are included. If operating cost exceeds $41,334.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,115.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,501.70 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,518.30 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $355.23. The transfer capital threshold is the transfer adjustment factor * $355.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6801.88,22557.82,Inpatient DRG
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,083,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],28680.85,,"Fee schedule rate ($28,680.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,28680.85,There are no additional notes associated with this service or procedure.
Exc Tumor Soft Tis Neck/Ant Thorax Subq 3 Cm/>,CASE-21552,APC,21552,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],2854.83,,"APC Price ($2,718.88). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2718.88,2854.83,OPPS APC
"EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME, NEONATE",790,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],3354.00,,,,,,0,other,3054.00,44304.49,Estimated amount calculated based on 17 day length of stay.
VAGINAL DELIVERY WITH O.R. PROCEDURES EXCEPT STERILIZATION AND/OR D&C,768,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],9201.90,,"Case rate ($9,201.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,695.94, add-ons for qualifying new technology services are included. If operating cost exceeds $43,566.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,290.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $6,726.19 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,750.99 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $530.76. The transfer capital threshold is the transfer adjustment factor * $530.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6426.91,13416.00,Inpatient DRG
HC Inj Trigger Pt 1-2 Musc Grps,CASE-20552,APC,20552,CPT,0510,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],297.37,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,287.31,301.68,OPPS APC
MINOR BLADDER PROCEDURES WITHOUT CC/MCC,664,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],20599.85,,,,,,0,other,9034.63,31876.87,There are no additional notes associated with this service or procedure.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,418,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],39884.93,,"Fee schedule rate ($39,884.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,13400.58,39884.93,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],7994.00,,"Per diem ($7,994). If length of stay < 1.7, first 1 days paid at a per diem of $15,988 instead. Capped at $13,589.22.",,,,0,other,6841.83,21167.26,Estimated amount calculated based on 1 day length of stay.
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],9311.62,,"Case rate ($9,311.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,798, add-ons for qualifying new technology services are included. If operating cost exceeds $43,669.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,298.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $6,827.87 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,853.05 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $538.79. The transfer capital threshold is the transfer adjustment factor * $538.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,21404.64,Inpatient DRG
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,191,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],8036.50,,"Case rate ($7,653.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,255.78, add-ons for qualifying new technology services are included. If operating cost exceeds $42,126.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,177.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,291.32 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,310.83 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $417.54. The transfer capital threshold is the transfer adjustment factor * $417.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,16612.88,Inpatient DRG
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],33835.79,,"Fee schedule rate ($33,835.79). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,7000.00,33835.79,There are no additional notes associated with this service or procedure.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,056,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],59328.19,,"Fee schedule rate ($59,328.19). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (44), with a minimum of zero.",,,,0,other,7659.00,59328.19,There are no additional notes associated with this service or procedure.
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC",923,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],6965.00,,,,,,0,other,6965.00,20068.57,There are no additional notes associated with this service or procedure.
Mastectomy Partial|RIGHT SIDE,CASE-19301,APC,19301,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3664.94,,"APC Price ($3,664.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3664.94,3848.19,OPPS APC
Excision Olecranon Bursa|RIGHT SIDE,CASE-24105,APC,24105,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],32878.30,,,,,,0,other,13260.40,32878.30,There are no additional notes associated with this service or procedure.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],24259.09,,"Fee schedule rate ($24,259.09). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10098.51,24259.09,There are no additional notes associated with this service or procedure.
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITH MCC OR ANTINEOPLASTIC IMPLANT OR EPILEPSY WITH NEUROSTIMULATOR,023,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],40750.95,,"Case rate ($40,750.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $38,045.35, add-ons for qualifying new technology services are included. If operating cost exceeds $72,916.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,598.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $35,967.78 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $36,100.40 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,838.21. The transfer capital threshold is the transfer adjustment factor * $2,838.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,15168.00,136379.44,Inpatient DRG
"Tendon Sheath Incision|LEFT HAND, THUMB",CASE-26055,APC,26055,CPT,0360,RC,,,FA,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1505.12,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1505.12,1580.37,OPPS APC
GASTROINTESTINAL HEMORRHAGE WITH MCC,377,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],31575.65,,"Fee schedule rate ($31,575.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,7634.00,35969.56,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],39053.73,,"Fee schedule rate ($39,053.73). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,16017.99,51903.64,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],12272.58,,"Fee schedule rate ($12,272.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5628.97,12272.58,There are no additional notes associated with this service or procedure.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],14327.35,,"Fee schedule rate ($14,327.35). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9977.99,26949.28,There are no additional notes associated with this service or procedure.
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level|BILATERAL PROCEDURE,CASE-64483,APC,64483,CPT,0360,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],856.86,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,827.89,869.28,OPPS APC
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,394,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],20909.61,,"Fee schedule rate ($20,909.61). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8281.56,20909.61,There are no additional notes associated with this service or procedure.
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC",758,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],16323.02,,"Fee schedule rate ($16,323.02). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8574.80,19263.78,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITH CC,164,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],77058.83,,"Fee schedule rate ($77,058.83). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,19037.66,77058.83,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],16129.04,,"Case rate ($16,129.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,140.12, add-ons for qualifying new technology services are included. If operating cost exceeds $50,011.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,797.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $13,146.70 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,195.17 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,037.40. The transfer capital threshold is the transfer adjustment factor * $1,037.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,16129.04,59610.47,Inpatient DRG
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,447,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],131473.84,,,,,,0,other,47193.21,156646.82,There are no additional notes associated with this service or procedure.
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITHOUT CC/MCC",630,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],42541.02,,"Fee schedule rate ($42,541.02). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11828.78,42541.02,There are no additional notes associated with this service or procedure.
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],29216.99,,"Fee schedule rate ($29,216.99). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9755.86,29216.99,There are no additional notes associated with this service or procedure.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",062,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],24555.30,,"Fee schedule rate ($24,555.30). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,13844.84,44304.80,There are no additional notes associated with this service or procedure.
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],37899.49,,"Fee schedule rate ($37,899.49). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,14747.55,37899.49,There are no additional notes associated with this service or procedure.
Arthrs Wrst Exc&/Rpr Triang Fibrocart&/Joint|LEFT SIDE,CASE-29846,APC,29846,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],21587.31,,"Case rate ($20,559.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $19,261.52, add-ons for qualifying new technology services are included. If operating cost exceeds $54,132.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,121.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $17,252.96 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $17,316.57 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,361.43. The transfer capital threshold is the transfer adjustment factor * $1,361.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,20559.34,54086.17,Inpatient DRG
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC,833,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5651.16,,"Case rate ($5,382.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,148.83, add-ons for qualifying new technology services are included. If operating cost exceeds $40,019.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,005.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $3,191.77 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,203.88 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $245.33. The transfer capital threshold is the transfer adjustment factor * $245.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,3041.73,10289.10,Inpatient DRG
"OTHER DISORDERS OF NERVOUS SYSTEM,MAJOR",058,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],1185.06,,"Case rate for a one day stay ($1,185.06). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,1185.06,1244.31,There are no additional notes associated with this service or procedure.
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH CC",457,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],160549.49,,"Fee schedule rate ($160,549.49). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,42327.47,160549.49,There are no additional notes associated with this service or procedure.
OTHER MENTAL DISORDER DIAGNOSES,887,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],9433.35,,"Case rate ($8,984.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,506.49, add-ons for qualifying new technology services are included. If operating cost exceeds $43,377.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,262.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,536.76 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,561.54 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $502.43. The transfer capital threshold is the transfer adjustment factor * $502.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,2070.00,21072.10,Inpatient DRG
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],12891.14,,"Case rate ($12,455.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,722.41, add-ons for qualifying new technology services are included. If operating cost exceeds $46,593.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,528.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $9,741.55 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,777.47 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $768.70. The transfer capital threshold is the transfer adjustment factor * $768.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,12455.21,37149.27,Inpatient DRG
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],8044.02,,"Case rate ($7,660.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,273.10, add-ons for qualifying new technology services are included. If operating cost exceeds $42,144.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,167.96, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,308.03 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,328.15 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $407.99. The transfer capital threshold is the transfer adjustment factor * $407.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5883.03,17111.12,Inpatient DRG
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITHOUT CC/MCC,816,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],14733.53,,"Fee schedule rate ($14,733.53). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6224.90,14733.53,There are no additional notes associated with this service or procedure.
Removal Implant Deep,CASE-20680,APC,20680,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1891.77,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1827.80,1919.19,OPPS APC
Laps Fulg/Exc Ovary Viscera/Peritoneal Surface|LEFT SIDE,CASE-58662,APC,58662,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5856.81,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5658.76,5941.70,OPPS APC
HEADACHES WITHOUT MCC,103,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7814.18,,"Case rate ($7,442.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,069.07, add-ons for qualifying new technology services are included. If operating cost exceeds $41,940.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,152.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $5,104.76 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,124.12 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $392.36. The transfer capital threshold is the transfer adjustment factor * $392.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,20883.08,Inpatient DRG
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],59610.47,,"Fee schedule rate ($59,610.47). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,16129.04,59610.47,There are no additional notes associated with this service or procedure.
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],17255.73,,"Fee schedule rate ($17,255.73). Adds an outlier to normal pricing equal to the per diem rate ($43,191.57) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,8163.06,18067.42,There are no additional notes associated with this service or procedure.
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],7086.00,,"Per diem ($7,086). If length of stay < 7.8, first 1 days paid at a per diem of $14,172 instead. Capped at $55,272.09.",,,,0,other,7086.00,57872.02,Estimated amount calculated based on 5 day length of stay.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],54764.34,,"Fee schedule rate ($54,764.34). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,18178.96,54764.34,There are no additional notes associated with this service or procedure.
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],23262.15,,,,,,0,other,7243.75,23262.15,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],24037.59,,"Case rate ($22,892.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $21,471.50, add-ons for qualifying new technology services are included. If operating cost exceeds $56,342.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,255.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.7. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.7)) / 2. The base transfer operating payment is the transfer adjustment factor * $19,452.79 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $19,526.55 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,495.19. The transfer capital threshold is the transfer adjustment factor * $1,495.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,23526.87,94787.57,Inpatient DRG
TRAUMATIC INJURY WITH MCC,913,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],42838.46,,"Fee schedule rate ($42,838.46). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13014.58,42838.46,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],59021.28,,"Fee schedule rate ($59,021.28). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,23851.92,63653.13,There are no additional notes associated with this service or procedure.
HC Drain/Inj Joint/Bursa W/US Large|LEFT SIDE,CASE-20611,APC,20611,CPT,0510,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],28540.32,,"Case rate ($27,181.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $25,468.84, add-ons for qualifying new technology services are included. If operating cost exceeds $60,339.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,561.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.8. The base transfer operating payment is the transfer adjustment factor * $23,435.03 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $23,523.89 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,801.27. The transfer capital threshold is the transfer adjustment factor * $1,801.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,27944.96,86252.84,Inpatient DRG
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],13486.95,,"Fee schedule rate ($13,486.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6915.64,14442.92,There are no additional notes associated with this service or procedure.
Laps Surg Rpr Recurrent Inguinal Hernia|BILATERAL PROCEDURE,CASE-49651,APC,49651,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5658.76,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5658.76,5941.70,OPPS APC
"KIDNEY AND URINARY TRACT INFECTIONS,MINOR",463,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],1739.43,,"Case rate for a one day stay ($1,739.43). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,1739.43,1826.40,There are no additional notes associated with this service or procedure.
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],24444.75,,"Fee schedule rate ($24,444.75). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10136.44,24444.75,There are no additional notes associated with this service or procedure.
Colonoscopy W/Biopsy Single/Multiple|COLORECTAL CANCER SCREEN,CASE-45380,APC,45380,CPT,0360,RC,,,PT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1176.09,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1120.09,1176.09,OPPS APC
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],29243.52,,"Fee schedule rate ($29,243.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,14343.25,36024.65,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,167,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],14865.60,,"Case rate ($14,157.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,306.21, add-ons for qualifying new technology services are included. If operating cost exceeds $48,177.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,653.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $11,319.53 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,361.26 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $893.22. The transfer capital threshold is the transfer adjustment factor * $893.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,14157.71,43522.37,Inpatient DRG
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],7868.00,,"Per diem ($7,868). If length of stay < 3.9, first 1 days paid at a per diem of $15,736 instead. Capped at $30,683.33.",,,,0,other,7868.00,32126.64,Estimated amount calculated based on 3 day length of stay.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,056,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],31541.32,,"Fee schedule rate ($31,541.32). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (44), with a minimum of zero.",,,,0,other,7659.00,59328.19,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITHOUT CC/MCC,428,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],40817.88,,"Case rate ($40,017.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $37,363.07, add-ons for qualifying new technology services are included. If operating cost exceeds $72,234.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,544.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $35,288.01 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $35,418.12 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,784.57. The transfer capital threshold is the transfer adjustment factor * $2,784.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,40017.53,118904.57,Inpatient DRG
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],13960.40,,"Case rate ($13,295.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,504.24, add-ons for qualifying new technology services are included. If operating cost exceeds $47,375.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,590.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $10,520.50 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,559.29 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $830.17. The transfer capital threshold is the transfer adjustment factor * $830.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7000.00,33835.79,Inpatient DRG
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],33781.47,,,,,,0,other,13571.25,33781.47,There are no additional notes associated with this service or procedure.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,988,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],32341.12,,,,,,0,other,13075.52,42425.46,There are no additional notes associated with this service or procedure.
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],7389.00,,"Per diem ($7,389). If length of stay < 4.8, first 1 days paid at a per diem of $14,778 instead. Capped at $35,466.15.",,,,0,other,7389.00,37134.43,Estimated amount calculated based on 6 day length of stay.
Esophagoscopy Intra/Transmural Needle Aspirat/Bx,CASE-43232,APC,43232,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1859.01,,"APC Price ($1,796.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1796.14,1885.95,OPPS APC
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],12667.71,,"Case rate ($7,238.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,869.60, add-ons for qualifying new technology services are included. If operating cost exceeds $41,740.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,147.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,906.55 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,924.64 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $387.18. The transfer capital threshold is the transfer adjustment factor * $387.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,7238.69,16804.22,All Other Inpatient
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],21630.93,,,,,,0,other,9389.48,22358.90,There are no additional notes associated with this service or procedure.
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],16438.59,,"Fee schedule rate ($16,438.59). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7402.56,16438.59,There are no additional notes associated with this service or procedure.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,479,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],15260.23,,"Case rate ($14,533.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,655.86, add-ons for qualifying new technology services are included. If operating cost exceeds $48,526.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,680.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $11,667.89 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,710.91 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $920.71. The transfer capital threshold is the transfer adjustment factor * $920.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10586.00,50518.76,Inpatient DRG
O.R. PROCEDURES FOR OBESITY WITH CC,620,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],13087.17,,"Case rate ($12,463.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,750.19, add-ons for qualifying new technology services are included. If operating cost exceeds $46,621.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,510.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $9,768.21 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,805.24 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $750.81. The transfer capital threshold is the transfer adjustment factor * $750.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12782.30,43753.50,Inpatient DRG
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITHOUT CC/MCC,816,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],6224.90,,"Case rate ($6,224.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,926.50, add-ons for qualifying new technology services are included. If operating cost exceeds $40,797.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,073.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $3,966.92 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,981.55 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $313.03. The transfer capital threshold is the transfer adjustment factor * $313.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6224.90,14733.53,Inpatient DRG
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],7353.00,,"Per diem ($7,353). If length of stay < 4.1, first 1 days paid at a per diem of $14,706 instead. Capped at $30,145.85.",,,,0,other,7353.00,33398.16,Estimated amount calculated based on 4 day length of stay.
Rmvl Spinal Nstim Eltrd Prq Array Incl Fluor,CASE-63661,APC,63661,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3272.44,,"APC Price ($3,272.44). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3272.44,3436.06,OPPS APC
TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC,084,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],8417.70,,"Case rate ($8,417.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,966.41, add-ons for qualifying new technology services are included. If operating cost exceeds $42,837.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,233.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $5,999.34 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,021.46 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $473.41. The transfer capital threshold is the transfer adjustment factor * $473.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,19445.16,Inpatient DRG
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,167,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],14157.71,,"Case rate ($14,157.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,306.21, add-ons for qualifying new technology services are included. If operating cost exceeds $48,177.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,653.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $11,319.53 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,361.26 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $893.22. The transfer capital threshold is the transfer adjustment factor * $893.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,14157.71,43522.37,Inpatient DRG
"Application Uniplane External Fixation System|RIGHT HAND, FIFTH DIGIT",CASE-20690,APC,20690,CPT,0360,RC,,,F9,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],31644.05,,"Fee schedule rate ($31,644.05). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,16689.78,59521.43,There are no additional notes associated with this service or procedure.
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC,058,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],33637.83,,,,,,0,other,13521.80,40853.02,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],11594.35,,"Fee schedule rate ($11,594.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6164.03,14071.02,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],23703.75,,"Fee schedule rate ($23,703.75). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,14295.18,42768.36,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],19371.27,,"Fee schedule rate ($19,371.27). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7641.61,19371.27,There are no additional notes associated with this service or procedure.
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],12725.42,,"Case rate ($12,725.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,973.79, add-ons for qualifying new technology services are included. If operating cost exceeds $46,844.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,548.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $9,991.99 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,028.83 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $788.47. The transfer capital threshold is the transfer adjustment factor * $788.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12725.42,34245.00,Inpatient DRG
UNGROUPABLE,999,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],161307.29,,"Fee schedule rate ($161,307.29). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (41), with a minimum of zero.",,,,0,other,10228.00,161307.29,There are no additional notes associated with this service or procedure.
MAJOR CHEST TRAUMA WITHOUT CC/MCC,185,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],12724.58,,"Case rate ($7,271.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,899.84, add-ons for qualifying new technology services are included. If operating cost exceeds $41,770.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,149.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,936.68 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,954.88 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $389.55. The transfer capital threshold is the transfer adjustment factor * $389.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,7271.19,21771.61,All Other Inpatient
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,085,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],44704.18,,,,,,0,other,9282.00,57443.16,There are no additional notes associated with this service or procedure.
Colonoscopy W/Biopsy Single/Multiple|COLORECTAL CANCER SCREEN,CASE-45380,APC,45380,CPT,0360,RC,,,PT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1120.09,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1120.09,1176.09,OPPS APC
OTHER CEREBROVASCULAR DISORDERS WITH MCC,070,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],20082.46,,"Fee schedule rate ($20,082.46). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,13219.09,37774.46,There are no additional notes associated with this service or procedure.
Colpocleisis Le Fort Type,CASE-57120,APC,57120,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],4916.53,,"APC Price ($4,682.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,4682.41,4916.53,OPPS APC
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC,520,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],39786.42,,"Fee schedule rate ($39,786.42). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12061.74,39786.42,There are no additional notes associated with this service or procedure.
"Suture Digital Nerve Hand/Foot 1 Nerve|LEFT HAND, THUMB",CASE-64831,APC,64831,CPT,0360,RC,,,FA,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC,806,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],10071.17,,"Fee schedule rate ($10,071.17). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5354.25,13416.00,There are no additional notes associated with this service or procedure.
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],45157.33,,"Fee schedule rate ($45,157.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,10733.06,45157.33,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,083,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],28680.85,,"Fee schedule rate ($28,680.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,28680.85,There are no additional notes associated with this service or procedure.
Hysteroscopy Bx Endometrium&/Polypc W/WO D&C,CASE-58558,APC,58558,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3030.03,,"APC Price ($3,030.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3030.03,3181.53,OPPS APC
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC,192,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6473.17,,"Case rate ($6,164.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,878.57, add-ons for qualifying new technology services are included. If operating cost exceeds $40,749.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,061.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $3,918.76 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,933.62 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $301.20. The transfer capital threshold is the transfer adjustment factor * $301.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6292.63,12753.78,Inpatient DRG
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC,807,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],6836.20,,"Case rate ($6,510.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,192.35, add-ons for qualifying new technology services are included. If operating cost exceeds $41,063.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,093.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $4,231.80 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,247.40 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $333.93. The transfer capital threshold is the transfer adjustment factor * $333.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5354.25,13266.23,Inpatient DRG
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],32168.63,,"Fee schedule rate ($32,168.63). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,13904.43,34749.58,There are no additional notes associated with this service or procedure.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],24259.09,,"Fee schedule rate ($24,259.09). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10098.51,24259.09,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],23239.84,,"Fee schedule rate ($23,239.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8543.64,23239.84,There are no additional notes associated with this service or procedure.
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],54920.47,,,,,,0,other,20846.48,81306.30,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],28503.86,,"Case rate ($27,944.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $26,132.21, add-ons for qualifying new technology services are included. If operating cost exceeds $61,003.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,661.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.8. The base transfer operating payment is the transfer adjustment factor * $24,098.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $24,187.26 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,901.60. The transfer capital threshold is the transfer adjustment factor * $1,901.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,27944.96,86252.84,Inpatient DRG
SPINAL PROCEDURES WITH MCC,028,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],120982.83,,"Fee schedule rate ($120,982.83). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,42633.57,120982.83,There are no additional notes associated with this service or procedure.
TRAUMATIC INJURY WITH MCC,913,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],42838.46,,"Fee schedule rate ($42,838.46). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13014.58,42838.46,There are no additional notes associated with this service or procedure.
"NEONATE BIRTH WEIGHT > 2499 GRAMS WITH OTHER SIGNIFICANT CONDITION,MINOR",639,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],2680.66,,"Case rate ($2,680.66). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,2680.66,2814.69,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],12808.03,,"Case rate ($12,808.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,050.64, add-ons for qualifying new technology services are included. If operating cost exceeds $46,921.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,554.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $10,068.57 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,105.69 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $794.51. The transfer capital threshold is the transfer adjustment factor * $794.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7353.00,33398.16,Inpatient DRG
OTHER MENTAL DISORDER DIAGNOSES,887,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],16095.05,,"Case rate ($9,197.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,691.53, add-ons for qualifying new technology services are included. If operating cost exceeds $43,562.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,290.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,721.79 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,746.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $530.42. The transfer capital threshold is the transfer adjustment factor * $530.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,2070.00,21072.10,All Other Inpatient
"Amp F/Th 1/2 Jt/Phalanx W/Neurect W/Dir Clsr|LEFT HAND, SECOND DIGIT",CASE-26951,APC,26951,CPT,0360,RC,,,F1,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
Removal Intrauterine Device Iud,CASE-58301,APC,58301,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],295.22,,"APC Price ($285.23). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,285.23,295.22,OPPS APC
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,091,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],33004.27,,"Fee schedule rate ($33,004.27). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13838.06,40030.81,There are no additional notes associated with this service or procedure.
Placement Seton,CASE-46020,APC,46020,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],2598.08,,"APC Price ($2,598.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2598.08,2727.99,OPPS APC
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],36875.62,,"Fee schedule rate ($36,875.62). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.7), with a minimum of zero.",,,,0,other,15233.11,38610.21,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],32293.66,,"Fee schedule rate ($32,293.66). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,32293.66,There are no additional notes associated with this service or procedure.
MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,708,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],27860.62,,"Fee schedule rate ($27,860.62). Adds an outlier to normal pricing equal to the per diem rate ($54,966.40) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10138.21,29171.15,There are no additional notes associated with this service or procedure.
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],27589.62,,"Fee schedule rate ($27,589.62). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12566.28,30861.41,There are no additional notes associated with this service or procedure.
Dstr Nrolytc Agnt Parverteb Fct Sngl Crvcl/Thora|LEFT SIDE,CASE-64633,APC,64633,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1827.80,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1827.80,1919.19,OPPS APC
"SEPTICEMIA AND DISSEMINATED INFECTIONS,MAJOR",720,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],13651.10,,"Case rate ($13,651.10). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,13651.10,14333.66,There are no additional notes associated with this service or procedure.
Tx Anal Fstl Trans/Supra/Xtrasphnctrc Incl Seton,CASE-46280,APC,46280,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],2727.99,,"APC Price ($2,598.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2598.08,2727.99,OPPS APC
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],29585.82,,"Fee schedule rate ($29,585.82). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12606.23,36868.88,There are no additional notes associated with this service or procedure.
Insj/Rplcmt Breast Implant Sep Day Mastectomy|LEFT SIDE,CASE-19342,APC,19342,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],7650.49,,"APC Price ($7,650.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,7650.49,8033.01,OPPS APC
BRONCHITIS AND ASTHMA WITHOUT CC/MCC,203,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5927.78,,"Case rate ($5,927.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $5,614.23, add-ons for qualifying new technology services are included. If operating cost exceeds $44,258.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $3,061.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,235.54 + an uncompensated DSH payment of $1,359.91. The transfer operating threshold is the transfer adjustment factor * $4,254.32 + an uncompensated DSH payment of $1,359.91. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $332.34. The transfer capital threshold is the transfer adjustment factor * $332.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,4763.76,13707.00,Inpatient DRG
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],12696.97,,"Case rate ($12,696.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,947.32, add-ons for qualifying new technology services are included. If operating cost exceeds $46,818.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,546.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,965.63 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,002.37 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $786.39. The transfer capital threshold is the transfer adjustment factor * $786.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12696.97,47123.82,Inpatient DRG
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],23954.07,,"Fee schedule rate ($23,954.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,6167.00,29058.99,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],40542.37,,"Case rate ($40,542.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $37,851.31, add-ons for qualifying new technology services are included. If operating cost exceeds $72,722.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,582.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.6. The base transfer operating payment is the transfer adjustment factor * $35,774.45 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $35,906.36 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,822.96. The transfer capital threshold is the transfer adjustment factor * $2,822.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,40542.37,128358.13,Inpatient DRG
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],97015.50,,"Fee schedule rate ($97,015.50). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,26809.29,97015.50,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,064,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],15563.58,,"Case rate ($15,563.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,614.08, add-ons for qualifying new technology services are included. If operating cost exceeds $49,485.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,756.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $12,622.59 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,669.13 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $996.05. The transfer capital threshold is the transfer adjustment factor * $996.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,15563.58,41838.16,Inpatient DRG
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],32126.64,,,,,,0,other,7868.00,32126.64,There are no additional notes associated with this service or procedure.
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],19170.43,,"Case rate ($18,257.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,150.65, add-ons for qualifying new technology services are included. If operating cost exceeds $52,021.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,924.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $15,148.26 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,205.70 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,164.33. The transfer capital threshold is the transfer adjustment factor * $1,164.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8480.00,59081.91,Inpatient DRG
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],6965.00,,,,,,0,other,4341.01,12882.53,There are no additional notes associated with this service or procedure.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,073,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],43475.01,,"Fee schedule rate ($43,475.01). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,12809.38,43475.01,There are no additional notes associated with this service or procedure.
HC Biopsy/Exc Lymph Node Needle|TECHNICAL COMPONENT,CASE-38505,APC,38505,CPT,0361,RC,,,TC,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1545.93,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1545.93,1623.23,OPPS APC
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC,862,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],25016.57,,"Case rate ($14,295.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,434.11, add-ons for qualifying new technology services are included. If operating cost exceeds $48,305.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,663.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $11,446.95 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,489.15 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $903.28. The transfer capital threshold is the transfer adjustment factor * $903.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,6855.00,35884.94,All Other Inpatient
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],27944.96,,"Case rate ($27,944.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $26,132.21, add-ons for qualifying new technology services are included. If operating cost exceeds $61,003.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,661.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.8. The base transfer operating payment is the transfer adjustment factor * $24,098.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $24,187.26 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,901.60. The transfer capital threshold is the transfer adjustment factor * $1,901.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,27944.96,86252.84,Inpatient DRG
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],105091.76,,"Fee schedule rate ($105,091.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,35719.96,105091.76,There are no additional notes associated with this service or procedure.
MAJOR THUMB OR JOINT PROCEDURES,506,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],11469.69,,"Case rate ($11,081.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,444.79, add-ons for qualifying new technology services are included. If operating cost exceeds $45,315.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,428.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $8,468.62 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,499.84 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $668.26. The transfer capital threshold is the transfer adjustment factor * $668.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,11081.83,26548.21,Inpatient DRG
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC,831,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],9294.42,,"Fee schedule rate ($9,294.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,4941.30,23661.59,There are no additional notes associated with this service or procedure.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,074,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],20919.08,,"Fee schedule rate ($20,919.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8925.60,20919.08,There are no additional notes associated with this service or procedure.
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6944.10,,"Case rate ($6,944.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,595.55, add-ons for qualifying new technology services are included. If operating cost exceeds $41,466.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,125.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,633.51 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,650.60 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $365.63. The transfer capital threshold is the transfer adjustment factor * $365.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,5068.21,14525.56,Inpatient DRG
VENTRICULAR SHUNT PROCEDURES WITH CC,032,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],24601.75,,"Fee schedule rate ($24,601.75). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,16376.22,46275.08,There are no additional notes associated with this service or procedure.
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],14455.04,,"Fee schedule rate ($14,455.04). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5280.00,17136.70,There are no additional notes associated with this service or procedure.
Laps Surg Cholecystectomy W/Cholangiography,CASE-47563,APC,47563,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5856.81,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5658.76,5941.70,OPPS APC
SEIZURES WITH MCC,100,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],15362.31,,"Case rate ($15,061.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,146.62, add-ons for qualifying new technology services are included. If operating cost exceeds $49,017.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,719.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $12,156.85 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,201.67 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $959.30. The transfer capital threshold is the transfer adjustment factor * $959.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,15061.09,38110.41,Inpatient DRG
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6153.12,,"Case rate ($6,153.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,859.72, add-ons for qualifying new technology services are included. If operating cost exceeds $40,730.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,067.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,900.39 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,914.77 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $307.78. The transfer capital threshold is the transfer adjustment factor * $307.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6153.12,13947.32,Inpatient DRG
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],13550.71,,"Case rate ($13,092.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,315.24, add-ons for qualifying new technology services are included. If operating cost exceeds $47,186.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,575.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $10,332.19 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,370.29 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $815.31. The transfer capital threshold is the transfer adjustment factor * $815.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,13092.47,33159.45,Inpatient DRG
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],33038.25,,"Fee schedule rate ($33,038.25). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,16129.04,59610.47,There are no additional notes associated with this service or procedure.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],51630.84,,"Fee schedule rate ($51,630.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,20559.34,54086.17,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC,087,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],8355.28,,"Case rate ($7,957.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,549.43, add-ons for qualifying new technology services are included. If operating cost exceeds $42,420.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,189.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $5,583.32 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,604.48 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $429.15. The transfer capital threshold is the transfer adjustment factor * $429.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8139.36,22679.07,Inpatient DRG
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,477,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],25339.74,,"Case rate ($25,339.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $23,708.63, add-ons for qualifying new technology services are included. If operating cost exceeds $58,579.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,471.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 8.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $21,683.73 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $21,763.68 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,711.06. The transfer capital threshold is the transfer adjustment factor * $1,711.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,25339.74,67976.16,Inpatient DRG
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6801.88,,"Case rate ($6,801.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,463.25, add-ons for qualifying new technology services are included. If operating cost exceeds $41,334.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,115.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,501.70 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,518.30 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $355.23. The transfer capital threshold is the transfer adjustment factor * $355.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6801.88,22557.82,Inpatient DRG
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],16756.96,,"Case rate ($16,428.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,418.58, add-ons for qualifying new technology services are included. If operating cost exceeds $50,289.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,819.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $13,424.13 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,473.63 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,059.30. The transfer capital threshold is the transfer adjustment factor * $1,059.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,16428.39,42083.20,Inpatient DRG
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],21892.85,,"Fee schedule rate ($21,892.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7569.84,21892.85,There are no additional notes associated with this service or procedure.
"Inj Dx/Ther Agnt Paravert Facet Joint, Cerv/Thorac, 2nd Level",CASE-64491,APC,64491,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],856.86,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,827.89,869.28,OPPS APC
Laryngoscopy Direct Operative W/Biopsy,CASE-31535,APC,31535,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3611.96,,"APC Price ($3,489.82). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3489.82,3664.31,OPPS APC
"Inj Dx/Ther Agnt Paravert Facet Joint, Cerv/Thorac, Add Level|RIGHT SIDE",CASE-64492,APC,64492,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],827.89,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,827.89,869.28,OPPS APC
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],15061.83,,"Case rate ($14,344.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,480.09, add-ons for qualifying new technology services are included. If operating cost exceeds $48,351.10 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,666.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $11,492.77 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,535.14 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $906.89. The transfer capital threshold is the transfer adjustment factor * $906.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,14344.60,36028.59,Inpatient DRG
"Amputation Metatarsal W/Toe Single|RIGHT FOOT, FIFTH DIGIT",CASE-28810,APC,28810,CPT,0360,RC,,,T9,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level|RIGHT SIDE,CASE-64483,APC,64483,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],827.89,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,827.89,869.28,OPPS APC
TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC,084,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],8586.05,,"Case rate ($8,417.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,966.41, add-ons for qualifying new technology services are included. If operating cost exceeds $42,837.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,233.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $5,999.34 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,021.46 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $473.41. The transfer capital threshold is the transfer adjustment factor * $473.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6965.00,19445.16,Inpatient DRG
POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES,769,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],13388.39,,"Case rate ($13,388.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,590.54, add-ons for qualifying new technology services are included. If operating cost exceeds $47,461.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,596.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $10,606.49 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,645.59 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $836.96. The transfer capital threshold is the transfer adjustment factor * $836.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,13388.39,33250.19,Inpatient DRG
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],21377.04,,"Fee schedule rate ($21,377.04). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,9648.19,31477.13,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],18585.05,,"Fee schedule rate ($18,585.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8859.23,20090.22,There are no additional notes associated with this service or procedure.
HC Inj Aa&/Strd Other Peripheral Nerve/Branch,CASE-64450,APC,64450,CPT,0450,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],660.72,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,660.72,693.76,OPPS APC
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],22750.61,,"Case rate ($21,667.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,292.19, add-ons for qualifying new technology services are included. If operating cost exceeds $55,163.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,202.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $18,279.84 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,347.24 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,442.46. The transfer capital threshold is the transfer adjustment factor * $1,442.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8972.00,81524.17,Inpatient DRG
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],33910.82,,"Case rate ($32,296.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $30,179.91, add-ons for qualifying new technology services are included. If operating cost exceeds $65,050.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,979.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $28,131.23 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $28,234.95 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,219.83. The transfer capital threshold is the transfer adjustment factor * $2,219.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,32296.02,88188.38,Inpatient DRG
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],35474.53,,"Fee schedule rate ($35,474.53). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,16428.39,42083.20,There are no additional notes associated with this service or procedure.
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],32263.82,,"Fee schedule rate ($32,263.82). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13571.25,33781.47,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,699,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],19570.20,,"Fee schedule rate ($19,570.20). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5961.00,19972.16,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],15808.67,,"Fee schedule rate ($15,808.67). Adds an outlier to normal pricing equal to the per diem rate ($67,650.85) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,7641.61,19371.27,There are no additional notes associated with this service or procedure.
OSTEOMYELITIS WITHOUT CC/MCC,541,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],11429.52,,"Fee schedule rate ($11,429.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5103.00,15493.67,There are no additional notes associated with this service or procedure.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,352,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],26528.70,,"Fee schedule rate ($26,528.70). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,9853.37,26528.70,There are no additional notes associated with this service or procedure.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],20401.88,,"Fee schedule rate ($20,401.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,20401.88,There are no additional notes associated with this service or procedure.
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],29474.94,,"Fee schedule rate ($29,474.94). Adds an outlier to normal pricing equal to the per diem rate ($65,448.99) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.4), with a minimum of zero.",,,,0,other,12566.28,30861.41,There are no additional notes associated with this service or procedure.
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],11168.08,,"Fee schedule rate ($11,168.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5937.41,12366.99,There are no additional notes associated with this service or procedure.
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],15636.71,,"Case rate ($14,892.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,013.56, add-ons for qualifying new technology services are included. If operating cost exceeds $48,884.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,684.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.2. The base transfer operating payment is the transfer adjustment factor * $12,023.02 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,068.61 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $924.12. The transfer capital threshold is the transfer adjustment factor * $924.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,15283.90,38757.79,Inpatient DRG
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],6697.54,,"Case rate ($6,378.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,069.50, add-ons for qualifying new technology services are included. If operating cost exceeds $40,940.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,084.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,109.40 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,124.55 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $324.27. The transfer capital threshold is the transfer adjustment factor * $324.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,4341.01,12882.53,Inpatient DRG
TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC,084,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],19445.16,,"Fee schedule rate ($19,445.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,6965.00,19445.16,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],32293.66,,"Fee schedule rate ($32,293.66). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,32293.66,There are no additional notes associated with this service or procedure.
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC,519,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],26996.85,,"Fee schedule rate ($26,996.85). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,15490.44,50780.20,There are no additional notes associated with this service or procedure.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,352,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],9853.37,,"Case rate ($9,853.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,301.99, add-ons for qualifying new technology services are included. If operating cost exceeds $44,173.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,338.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $7,330.01 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,357.04 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $578.41. The transfer capital threshold is the transfer adjustment factor * $578.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9853.37,26528.70,Inpatient DRG
SINGLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL,402,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],75557.26,,"Fee schedule rate ($75,557.26). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.9), with a minimum of zero.",,,,0,other,29172.05,124455.45,There are no additional notes associated with this service or procedure.
SPINAL PROCEDURES WITH MCC,028,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],118225.32,,,,,,0,other,42633.57,120982.83,There are no additional notes associated with this service or procedure.
NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,601,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6042.05,,"Case rate ($6,042.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,756.39, add-ons for qualifying new technology services are included. If operating cost exceeds $40,627.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,059.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $3,797.45 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,811.45 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $299.66. The transfer capital threshold is the transfer adjustment factor * $299.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6042.05,12359.72,Inpatient DRG
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],34032.82,,"Fee schedule rate ($34,032.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,15233.11,38610.21,There are no additional notes associated with this service or procedure.
Mastopexy|BILATERAL PROCEDURE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-19316,APC,19316,CPT,0360,RC,,,50|XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6432.89,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6215.36,6432.89,OPPS APC
COAGULATION DISORDERS,813,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],29046.49,,"Fee schedule rate ($29,046.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12274.39,30013.33,There are no additional notes associated with this service or procedure.
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],25829.63,,"Fee schedule rate ($25,829.63). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6965.00,29482.05,There are no additional notes associated with this service or procedure.
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],8401.01,,"Fee schedule rate ($8,401.01). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7566.45,16333.88,There are no additional notes associated with this service or procedure.
"MAJOR LARGE BOWEL PROCEDURES,EXTREME",231,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],43310.54,,"Case rate ($43,310.54). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,43310.54,45476.07,There are no additional notes associated with this service or procedure.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],7605.00,,"Per diem ($7,605). If length of stay < 4.8, first 1 days paid at a per diem of $15,210 instead. Capped at $36,505.40.",,,,0,other,7605.00,39153.65,Estimated amount calculated based on 3 day length of stay.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],22425.60,,"Case rate ($21,667.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,292.19, add-ons for qualifying new technology services are included. If operating cost exceeds $55,163.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,202.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $18,279.84 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,347.24 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,442.46. The transfer capital threshold is the transfer adjustment factor * $1,442.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,8972.00,81524.17,Inpatient DRG
FRACTURES OF FEMUR WITH MCC,533,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],12862.16,,"Case rate ($12,249.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,550.45, add-ons for qualifying new technology services are included. If operating cost exceeds $46,421.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,495.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $9,569.22 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,605.50 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $735.51. The transfer capital threshold is the transfer adjustment factor * $735.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6852.00,49490.05,Inpatient DRG
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],53939.67,,"Fee schedule rate ($53,939.67). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,21382.16,85466.62,There are no additional notes associated with this service or procedure.
Egd Intrmural Needle Aspir/Biop Altered Anatomy,CASE-43242,APC,43242,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3735.12,,"APC Price ($3,608.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3608.81,3789.26,OPPS APC
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,373,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],13780.60,,"Fee schedule rate ($13,780.60). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6870.94,14313.05,There are no additional notes associated with this service or procedure.
"CHOLECYSTECTOMY,MAJOR",263,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],20693.19,,"Case rate ($20,693.19). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,20693.19,21727.85,There are no additional notes associated with this service or procedure.
Arthrodesis Posterior/Pstlat Tq 1ntrspc Lumbar,CASE-22612,APC,22612,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],16986.50,,"APC Price ($16,412.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,16986.50,17232.68,OPPS APC
Arthroscopy Knee W/Meniscus Rpr Medial&Lateral|LEFT SIDE,CASE-29883,APC,29883,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],60793.48,,"Fee schedule rate ($60,793.48). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15.7), with a minimum of zero.",,,,0,other,23851.92,63653.13,There are no additional notes associated with this service or procedure.
Redo Excis Lumbar Disk|RIGHT SIDE,CASE-63042,APC,63042,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],16035.06,,"Fee schedule rate ($16,035.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,7396.47,16035.06,There are no additional notes associated with this service or procedure.
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",004,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],10715.36,,,,,,0,other,10249.47,272554.00,Estimated amount calculated based on 6 day length of stay.
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],6971.08,,"Case rate ($6,834.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,493.49, add-ons for qualifying new technology services are included. If operating cost exceeds $41,364.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,117.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $4,531.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,548.54 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $357.61. The transfer capital threshold is the transfer adjustment factor * $357.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6834.39,21354.82,Inpatient DRG
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],17233.12,,,,,,0,other,7875.94,17233.12,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],9880.58,,"Fee schedule rate ($9,880.58). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8859.23,20090.22,There are no additional notes associated with this service or procedure.
Removal Cerclage Suture Under Anesthesia,CASE-59871,APC,59871,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3030.03,,"APC Price ($3,030.03). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3030.03,3181.53,OPPS APC
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",759,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6664.26,,"Case rate ($6,438.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,125.57, add-ons for qualifying new technology services are included. If operating cost exceeds $40,996.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,088.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,165.27 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,180.62 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $328.68. The transfer capital threshold is the transfer adjustment factor * $328.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6190.22,13057.66,Inpatient DRG
HEADACHES WITHOUT MCC,103,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],6965.00,,,,,,0,other,6965.00,20883.08,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],30055.64,,"Fee schedule rate ($30,055.64). Adds an outlier to normal pricing equal to the per diem rate ($74,094.67) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.9), with a minimum of zero.",,,,0,other,12775.53,31469.43,There are no additional notes associated with this service or procedure.
"ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",770,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],9172.07,,"Case rate ($8,735.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,261.87, add-ons for qualifying new technology services are included. If operating cost exceeds $43,132.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,256.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $6,293.72 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,316.92 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $496.64. The transfer capital threshold is the transfer adjustment factor * $496.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8735.30,19730.13,Inpatient DRG
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],40426.76,,"Fee schedule rate ($40,426.76). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,11914.12,40426.76,There are no additional notes associated with this service or procedure.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],20401.88,,"Fee schedule rate ($20,401.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,20401.88,There are no additional notes associated with this service or procedure.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,098,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],6965.00,,,,,,0,other,6965.00,45156.75,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],15609.47,,"Fee schedule rate ($15,609.47). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7569.84,21892.85,There are no additional notes associated with this service or procedure.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],17524.27,,"Case rate ($16,689.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,661.75, add-ons for qualifying new technology services are included. If operating cost exceeds $50,532.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,838.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $13,666.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,716.80 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,078.42. The transfer capital threshold is the transfer adjustment factor * $1,078.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,16689.78,59521.43,Inpatient DRG
Neuroplasty &/Transpos Median Nrv Carpal Tunne|LEFT SIDE,CASE-64721,APC,64721,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1919.19,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1827.80,1919.19,OPPS APC
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],23426.13,,"Case rate ($13,386.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,588.65, add-ons for qualifying new technology services are included. If operating cost exceeds $47,459.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,596.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $10,604.60 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,643.70 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $836.81. The transfer capital threshold is the transfer adjustment factor * $836.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,13386.36,33244.29,All Other Inpatient
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],43888.01,,"Fee schedule rate ($43,888.01). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11717.72,43888.01,There are no additional notes associated with this service or procedure.
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],42021.93,,"Fee schedule rate ($42,021.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,21248.73,56089.29,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],2070.00,,,,,,0,other,1188.00,12138.74,Estimated amount calculated based on 1 day length of stay.
HEADACHES WITHOUT MCC,103,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],20883.08,,"Fee schedule rate ($20,883.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,20883.08,There are no additional notes associated with this service or procedure.
NERVOUS SYSTEM NEOPLASMS WITH MCC,054,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],25589.03,,"Fee schedule rate ($25,589.03). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,6965.00,30044.81,There are no additional notes associated with this service or procedure.
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],14674.80,,"Fee schedule rate ($14,674.80). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6711.00,16865.16,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,448,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],31277.23,,"Case rate ($30,663.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $28,661.63, add-ons for qualifying new technology services are included. If operating cost exceeds $63,532.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,860.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $26,618.53 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $26,716.68 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,100.47. The transfer capital threshold is the transfer adjustment factor * $2,100.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,30663.95,94077.13,Inpatient DRG
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],6965.00,,,,,,0,other,6965.00,23385.72,There are no additional notes associated with this service or procedure.
Fissurectomy Incl Sphincterotomy When Performed,CASE-46200,APC,46200,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],2689.02,,"APC Price ($2,598.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2598.08,2727.99,OPPS APC
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],6965.00,,,,,,0,other,6965.00,15340.19,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,064,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],39570.45,,,,,,0,other,15563.58,41838.16,There are no additional notes associated with this service or procedure.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],46916.26,,"Case rate ($26,809.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $25,075.72, add-ons for qualifying new technology services are included. If operating cost exceeds $59,946.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,578.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $23,045.79 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $23,130.76 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,818.54. The transfer capital threshold is the transfer adjustment factor * $1,818.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,26809.29,97015.50,All Other Inpatient
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],26178.21,,"Fee schedule rate ($26,178.21). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,13917.42,34889.29,There are no additional notes associated with this service or procedure.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],46215.75,,"Fee schedule rate ($46,215.75). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.7), with a minimum of zero.",,,,0,other,18598.83,48389.68,There are no additional notes associated with this service or procedure.
"Amputation Toe Interphalangeal Joint|LEFT FOOT, SECOND DIGIT",CASE-28825,APC,28825,CPT,0360,RC,,,T1,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],42021.93,,"Fee schedule rate ($42,021.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,21248.73,56089.29,There are no additional notes associated with this service or procedure.
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],35528.17,,"Fee schedule rate ($35,528.17). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,14747.55,37899.49,There are no additional notes associated with this service or procedure.
Rpr/Advmnt Flxr Tdn Zone 2 W/O Fr Grft Ea Tendon,CASE-26356,APC,26356,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
Arthroscopy Knee W/Meniscus Rpr Medial/Lateral|LEFT SIDE,CASE-29882,APC,29882,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
"Exc Tum/Vasc Mal Sft Tiss Hand/Fngr Subq <1.5cm|RIGHT HAND, THIRD DIGIT",CASE-26115,APC,26115,CPT,0360,RC,,,F7,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1545.93,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1545.93,1623.23,OPPS APC
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],13923.42,,"Case rate ($13,260.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,471.48, add-ons for qualifying new technology services are included. If operating cost exceeds $47,342.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,587.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $10,487.86 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,526.53 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $827.60. The transfer capital threshold is the transfer adjustment factor * $827.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13260.40,32878.30,Inpatient DRG
HC Peripheral Block - Femoral Single or Saphenous W/Img Gdn,CASE-64447,APC,64447,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6791.99,7131.59,OPPS APC
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],22392.72,,"Case rate ($12,795.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,039.30, add-ons for qualifying new technology services are included. If operating cost exceeds $46,910.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,553.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $10,057.27 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,094.35 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $793.62. The transfer capital threshold is the transfer adjustment factor * $793.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,12795.84,41944.25,All Other Inpatient
OTHER CEREBROVASCULAR DISORDERS WITH CC,071,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],29215.10,,"Fee schedule rate ($29,215.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5843.00,29215.10,There are no additional notes associated with this service or procedure.
MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,708,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],11081.24,,"Case rate ($11,081.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $10,413.93, add-ons for qualifying new technology services are included. If operating cost exceeds $49,058.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $3,436.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.3. The base transfer operating payment is the transfer adjustment factor * $9,014.04 + an uncompensated DSH payment of $1,359.91. The transfer operating threshold is the transfer adjustment factor * $9,054.03 + an uncompensated DSH payment of $1,359.91. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $707.29. The transfer capital threshold is the transfer adjustment factor * $707.29. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10138.21,29171.15,Inpatient DRG
GASTROINTESTINAL HEMORRHAGE WITH MCC,377,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],7634.00,,"Per diem ($7,634). If length of stay < 4.5, first 1 days paid at a per diem of $15,268 instead. Capped at $34,353.60.",,,,0,other,7634.00,35969.56,Estimated amount calculated based on 3 day length of stay.
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC,807,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],12670.24,,"Fee schedule rate ($12,670.24). Adds an outlier to normal pricing equal to the per diem rate ($29,637.88) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,5354.25,13266.23,There are no additional notes associated with this service or procedure.
Prq Impltj Neurostimulator Eltrd Peripheral Nrv|LEFT SIDE,CASE-64555,APC,64555,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6263.54,,"APC Price ($5,965.28). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5965.28,6263.54,OPPS APC
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],6965.00,,,,,,0,other,6965.00,20401.88,There are no additional notes associated with this service or procedure.
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,095,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],48575.01,,"Fee schedule rate ($48,575.01). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,19411.47,50750.92,There are no additional notes associated with this service or procedure.
Injection Aa&/Strd Ilioinguinal Ih Nerves|LEFT SIDE,CASE-64425,APC,64425,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],693.76,,"APC Price ($660.72). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,660.72,693.76,OPPS APC
"Open Tx Articular Fracture Mcp/IP Joint Ea|LEFT HAND, FIFTH DIGIT",CASE-26746,APC,26746,CPT,0360,RC,,,F4,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
Revision of Reconstructed Breast|BILATERAL PROCEDURE,CASE-19380,APC,19380,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6215.36,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6215.36,6215.36,OPPS APC
Egd Removal Tumor Polyp/Other Lesion Snare Tech,CASE-43251,APC,43251,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1885.95,,"APC Price ($1,796.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1796.14,1885.95,OPPS APC
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],17365.00,,"Fee schedule rate ($17,365.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5683.00,19635.68,There are no additional notes associated with this service or procedure.
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITH MCC OR ANTINEOPLASTIC IMPLANT OR EPILEPSY WITH NEUROSTIMULATOR,023,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],136379.44,,"Fee schedule rate ($136,379.44). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,15168.00,136379.44,There are no additional notes associated with this service or procedure.
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],15453.88,,"Case rate ($15,453.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,512.02, add-ons for qualifying new technology services are included. If operating cost exceeds $49,383.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,747.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $12,520.90 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,567.07 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $988.02. The transfer capital threshold is the transfer adjustment factor * $988.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,15453.88,39251.68,Inpatient DRG
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],22363.67,,"Fee schedule rate ($22,363.67). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10003.71,23415.63,There are no additional notes associated with this service or procedure.
Blepharoplasty Upper Eyelid W/Excessive Skin,CASE-15823,APC,15823,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1931.28,,"APC Price ($1,931.28). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1931.28,2027.84,OPPS APC
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],22727.25,,"Fee schedule rate ($22,727.25). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12268.97,41006.47,There are no additional notes associated with this service or procedure.
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],90333.60,,"Fee schedule rate ($90,333.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,26127.34,90333.60,There are no additional notes associated with this service or procedure.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,345,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],33616.03,,"Fee schedule rate ($33,616.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12134.89,33616.03,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],17693.40,,"Case rate ($17,693.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,595.40, add-ons for qualifying new technology services are included. If operating cost exceeds $51,466.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,911.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $14,596.63 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,650.45 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,151.82. The transfer capital threshold is the transfer adjustment factor * $1,151.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,17693.40,52449.26,Inpatient DRG
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],11168.08,,"Fee schedule rate ($11,168.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5937.41,12366.99,There are no additional notes associated with this service or procedure.
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],45017.13,,"Fee schedule rate ($45,017.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,14603.31,45017.13,There are no additional notes associated with this service or procedure.
Arthrp Intercarpal/Carp/Mtcrpl Jt Suspension|RIGHT SIDE,CASE-25448,APC,25448,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3169.86,3169.86,OPPS APC
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC",458,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],31712.19,,"Case rate ($30,202.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $28,231.97, add-ons for qualifying new technology services are included. If operating cost exceeds $63,102.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,826.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $26,190.45 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $26,287.02 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,066.69. The transfer capital threshold is the transfer adjustment factor * $2,066.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,30202.09,132827.25,Inpatient DRG
"RESPIRATORY MALIGNANCY,MAJOR",136,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],12417.67,,"Case rate ($12,417.67). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,12417.67,13038.55,There are no additional notes associated with this service or procedure.
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC,939,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],97674.79,,"Fee schedule rate ($97,674.79). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,26517.40,97674.79,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],31693.30,,"Case rate ($31,693.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $29,619.21, add-ons for qualifying new technology services are included. If operating cost exceeds $64,490.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,935.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. The base transfer operating payment is the transfer adjustment factor * $27,572.60 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $27,674.26 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,175.75. The transfer capital threshold is the transfer adjustment factor * $2,175.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10862.00,86437.13,Inpatient DRG
"PEPTIC ULCER AND GASTRITIS,MODERATE",241,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],8662.55,,"Case rate ($8,662.55). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,8662.55,9095.68,There are no additional notes associated with this service or procedure.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,345,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],12134.89,,"Case rate ($12,134.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,424.43, add-ons for qualifying new technology services are included. If operating cost exceeds $46,295.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,505.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $9,444.66 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,479.48 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $745.28. The transfer capital threshold is the transfer adjustment factor * $745.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12134.89,33616.03,Inpatient DRG
Colonoscopy W/Biopsy Single/Multiple|COLORECTAL CANCER SCREEN|UNUSUAL NON-OVERLAPPING SERVICE,CASE-45380,APC,45380,CPT,0360,RC,,,PT|XU,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1120.09,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1120.09,1176.09,OPPS APC
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],24126.45,,"Fee schedule rate ($24,126.45). Adds an outlier to normal pricing equal to the per diem rate ($62,306.11) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10638.94,25261.33,There are no additional notes associated with this service or procedure.
"LIMB REATTACHMENT, HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA",956,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],28013.71,,"Case rate ($26,679.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $25,001.34, add-ons for qualifying new technology services are included. If operating cost exceeds $59,872.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,525.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $22,969.30 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $23,056.39 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,765.47. The transfer capital threshold is the transfer adjustment factor * $1,765.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,27428.25,148259.86,Inpatient DRG
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],101083.00,,"Fee schedule rate ($101,083.00). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,35389.50,101083.00,There are no additional notes associated with this service or procedure.
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR,518,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],13252.00,,"Per diem ($13,252). If length of stay < 5.3, first 1 days paid at a per diem of $26,504 instead. Capped at $70,235.08.",,,,0,other,13252.00,89342.77,Estimated amount calculated based on 1 day length of stay.
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH MCC",722,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],14910.39,,"Case rate ($14,200.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,345.91, add-ons for qualifying new technology services are included. If operating cost exceeds $48,216.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,656.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $11,359.07 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,400.95 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $896.34. The transfer capital threshold is the transfer adjustment factor * $896.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,14200.37,56869.13,Inpatient DRG
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],11280.66,,"Case rate ($11,059.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,424, add-ons for qualifying new technology services are included. If operating cost exceeds $45,295.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,426.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $8,447.91 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,479.05 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $666.62. The transfer capital threshold is the transfer adjustment factor * $666.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,11059.47,28423.20,Inpatient DRG
CHOLECYSTECTOMY WITH C.D.E. WITH MCC,411,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],88615.28,,"Fee schedule rate ($88,615.28). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,24315.13,88615.28,There are no additional notes associated with this service or procedure.
COAGULATION DISORDERS,813,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],12274.39,,"Case rate ($12,274.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,554.21, add-ons for qualifying new technology services are included. If operating cost exceeds $46,425.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,515.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $9,573.96 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,609.26 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $755.48. The transfer capital threshold is the transfer adjustment factor * $755.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12274.39,30013.33,Inpatient DRG
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],11812.10,,,,,,0,other,6010.23,12246.05,There are no additional notes associated with this service or procedure.
VENTRICULAR SHUNT PROCEDURES WITH MCC,031,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],62406.76,,"Fee schedule rate ($62,406.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,32287.20,88162.80,There are no additional notes associated with this service or procedure.
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],27589.62,,"Fee schedule rate ($27,589.62). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12566.28,30861.41,There are no additional notes associated with this service or procedure.
"Inj Dx/Ther Agnt Paravert Facet Joint, Cerv/Thorac, 2nd Level|RIGHT SIDE",CASE-64491,APC,64491,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],869.28,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,827.89,869.28,OPPS APC
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,091,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],34556.75,,,,,,0,other,13838.06,40030.81,There are no additional notes associated with this service or procedure.
CERVICAL SPINAL FUSION WITH CC,472,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],22990.94,,"Case rate ($21,896.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,505.12, add-ons for qualifying new technology services are included. If operating cost exceeds $55,376.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,219.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $18,491.99 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,560.18 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,459.20. The transfer capital threshold is the transfer adjustment factor * $1,459.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,21896.13,70198.84,Inpatient DRG
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],19371.27,,"Fee schedule rate ($19,371.27). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8643.20,19462.52,There are no additional notes associated with this service or procedure.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH CC,026,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],58431.20,,"Fee schedule rate ($58,431.20). Adds an outlier to normal pricing equal to the per diem rate ($112,420.62) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,23000.66,63202.45,There are no additional notes associated with this service or procedure.
Optx Patllr Fx W/Int Fixj/Patllc&Soft Tiss Rpr,CASE-27524,APC,27524,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6791.99,7131.59,OPPS APC
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],47797.26,,"Case rate ($45,521.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $42,483.01, add-ons for qualifying new technology services are included. If operating cost exceeds $77,354.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,947.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 12.5. The base transfer operating payment is the transfer adjustment factor * $40,389.14 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $40,538.06 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,187.10. The transfer capital threshold is the transfer adjustment factor * $3,187.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,45521.20,142438.06,Inpatient DRG
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC,497,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],22707.58,,"Fee schedule rate ($22,707.58). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7.8), with a minimum of zero.",,,,0,other,10127.65,37761.19,There are no additional notes associated with this service or procedure.
MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,708,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],27860.62,,"Fee schedule rate ($27,860.62). Adds an outlier to normal pricing equal to the per diem rate ($54,966.40) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10138.21,29171.15,There are no additional notes associated with this service or procedure.
Peri-Implant Capsulectomy Breast Complete|LEFT SIDE,CASE-19371,APC,19371,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3664.94,,"APC Price ($3,664.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3664.94,3848.19,OPPS APC
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],12937.10,,"Fee schedule rate ($12,937.10). Adds an outlier to normal pricing equal to the per diem rate ($49,808.13) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.5), with a minimum of zero.",,,,0,other,5919.29,13545.65,There are no additional notes associated with this service or procedure.
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,451,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],60708.91,,"Fee schedule rate ($60,708.91). Adds an outlier to normal pricing equal to the per diem rate ($108,215.07) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,23821.44,94077.13,There are no additional notes associated with this service or procedure.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],48538.56,,"Fee schedule rate ($48,538.56). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,19435.86,50821.76,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],34481.40,,"Fee schedule rate ($34,481.40). Adds an outlier to normal pricing equal to the per diem rate ($50,543.29) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,14370.36,38378.80,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],19458.27,,"Fee schedule rate ($19,458.27). Adds an outlier to normal pricing equal to the per diem rate ($75,355.48) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,8956.76,28983.97,There are no additional notes associated with this service or procedure.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",062,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],34576.42,,,,,,0,other,13844.84,44304.80,There are no additional notes associated with this service or procedure.
CERVICAL SPINAL FUSION WITH CC,472,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],70198.84,,"Fee schedule rate ($70,198.84). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,21896.13,70198.84,There are no additional notes associated with this service or procedure.
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,450,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],100159.17,,"Fee schedule rate ($100,159.17). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15), with a minimum of zero.",,,,0,other,38037.38,146009.19,There are no additional notes associated with this service or procedure.
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],11734.41,,"Case rate ($11,175.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,549.28, add-ons for qualifying new technology services are included. If operating cost exceeds $45,420.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,418.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $8,571.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,604.33 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $658.85. The transfer capital threshold is the transfer adjustment factor * $658.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,11454.97,28394.78,Inpatient DRG
HC Inject Tendon Origin/Insert|BILATERAL PROCEDURE,CASE-20551,APC,20551,CPT,0361,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],301.68,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,287.31,301.68,OPPS APC
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],2070.00,,,,,,0,other,1188.00,31658.33,Estimated amount calculated based on 16 day length of stay.
"Amputation Toe Interphalangeal Joint|RIGHT FOOT, THIRD DIGIT",CASE-28825,APC,28825,CPT,0360,RC,,,T7,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3062.67,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,065,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],9015.09,,"Case rate ($8,585.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,135.19, add-ons for qualifying new technology services are included. If operating cost exceeds $43,006.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,233.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,166.86 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,190.24 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $474.00. The transfer capital threshold is the transfer adjustment factor * $474.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8786.76,25681.86,Inpatient DRG
VENTRICULAR SHUNT PROCEDURES WITH CC,032,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],40047.88,,"Fee schedule rate ($40,047.88). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,16376.22,46275.08,There are no additional notes associated with this service or procedure.
CELLULITIS WITH MCC,602,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],28349.31,,"Fee schedule rate ($28,349.31). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11570.10,28349.31,There are no additional notes associated with this service or procedure.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC,434,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],14019.86,,,,,,0,other,6770.05,14019.86,There are no additional notes associated with this service or procedure.
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],25253.70,,"Fee schedule rate ($25,253.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11974.38,29141.64,There are no additional notes associated with this service or procedure.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],54503.46,,"Fee schedule rate ($54,503.46). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.9), with a minimum of zero.",,,,0,other,21585.31,73588.10,There are no additional notes associated with this service or procedure.
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],16064.26,,"Fee schedule rate ($16,064.26). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7733.72,18043.23,There are no additional notes associated with this service or procedure.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC,192,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],6965.00,,,,,,0,other,6292.63,12753.78,There are no additional notes associated with this service or procedure.
Exc Tumor Soft Tissue Abdl Wall Subfascial 5cm/>,CASE-22901,APC,22901,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],2814.04,,"APC Price ($2,718.88). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2718.88,2854.83,OPPS APC
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],28923.03,,"Case rate ($27,944.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $26,132.21, add-ons for qualifying new technology services are included. If operating cost exceeds $61,003.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,661.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.8. The base transfer operating payment is the transfer adjustment factor * $24,098.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $24,187.26 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,901.60. The transfer capital threshold is the transfer adjustment factor * $1,901.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,27944.96,86252.84,Inpatient DRG
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 1 Level|LEFT SIDE,CASE-64493,APC,64493,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],827.89,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,827.89,869.28,OPPS APC
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC,833,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],5595.79,,"Case rate ($5,486.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,239.18, add-ons for qualifying new technology services are included. If operating cost exceeds $40,110.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,018.96, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $3,282.12 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,294.23 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $258.99. The transfer capital threshold is the transfer adjustment factor * $258.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,3041.73,10289.10,Inpatient DRG
Prq Impltj Neurostimulator Eltrd Peripheral Nrv|LEFT SIDE,CASE-64555,APC,64555,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5965.28,,"APC Price ($5,965.28). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5965.28,6263.54,OPPS APC
VAGINAL DELIVERY WITH O.R. PROCEDURES EXCEPT STERILIZATION AND/OR D&C,768,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],12088.81,,"Fee schedule rate ($12,088.81). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6426.91,13416.00,There are no additional notes associated with this service or procedure.
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],19432.35,,"Fee schedule rate ($19,432.35). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,9696.93,35061.53,There are no additional notes associated with this service or procedure.
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral Ea Addl,CASE-64484,APC,64484,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],869.28,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,827.89,869.28,OPPS APC
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITHOUT MCC,430,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],133156.90,,"Fee schedule rate ($133,156.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,41000.16,133156.90,There are no additional notes associated with this service or procedure.
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],27665.18,,"Fee schedule rate ($27,665.18). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,11914.12,40426.76,There are no additional notes associated with this service or procedure.
Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq|COLORECTAL CANCER SCREEN,CASE-45385,APC,45385,CPT,0360,RC,,,PT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1159.29,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1120.09,1176.09,OPPS APC
OSTEOMYELITIS WITH CC,540,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],24361.37,,"Fee schedule rate ($24,361.37). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.6), with a minimum of zero.",,,,0,other,9809.07,25507.30,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],11051.33,,"Case rate ($10,834.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,214.84, add-ons for qualifying new technology services are included. If operating cost exceeds $45,085.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,410.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $8,239.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,269.90 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $650.18. The transfer capital threshold is the transfer adjustment factor * $650.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,10834.64,25830.00,Inpatient DRG
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITH MCC,429,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],177294.98,,"Fee schedule rate ($177,294.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,62958.58,177294.98,There are no additional notes associated with this service or procedure.
VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC,033,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],42156.44,,"Fee schedule rate ($42,156.44). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,13206.23,42156.44,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],42768.36,,"Fee schedule rate ($42,768.36). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,14295.18,42768.36,There are no additional notes associated with this service or procedure.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],10476.89,,"Case rate ($9,977.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,417.91, add-ons for qualifying new technology services are included. If operating cost exceeds $44,288.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,347.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $7,445.51 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,472.96 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $587.52. The transfer capital threshold is the transfer adjustment factor * $587.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9977.99,26949.28,Inpatient DRG
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],12246.05,,"Fee schedule rate ($12,246.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6010.23,12246.05,There are no additional notes associated with this service or procedure.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC,434,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],13280.45,,"Fee schedule rate ($13,280.45). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6770.05,14019.86,There are no additional notes associated with this service or procedure.
Surgical Arthroscopy Shoulder Repair Slap Lesion|RIGHT SIDE,CASE-29807,APC,29807,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6791.99,7131.59,OPPS APC
CHOLECYSTECTOMY WITH C.D.E. WITH MCC,411,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],88615.28,,"Fee schedule rate ($88,615.28). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,24315.13,88615.28,There are no additional notes associated with this service or procedure.
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,068,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],23184.90,,"Fee schedule rate ($23,184.90). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,23184.90,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],19371.27,,"Fee schedule rate ($19,371.27). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7641.61,19371.27,There are no additional notes associated with this service or procedure.
PREMATURITY WITH MAJOR PROBLEMS,791,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],3186.77,,,,,,0,other,3048.21,30904.42,Estimated amount calculated based on 5 day length of stay.
RADIOTHERAPY,849,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],50919.63,,"Fee schedule rate ($50,919.63). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15.8), with a minimum of zero.",,,,0,other,20293.88,81867.07,There are no additional notes associated with this service or procedure.
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],10299.17,,"Case rate ($9,950.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,392.71, add-ons for qualifying new technology services are included. If operating cost exceeds $44,263.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,345.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $7,420.40 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,447.76 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $585.54. The transfer capital threshold is the transfer adjustment factor * $585.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,7243.75,23262.15,Inpatient DRG
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],23520.23,,"Fee schedule rate ($23,520.23). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10517.71,24909.11,There are no additional notes associated with this service or procedure.
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],8447.49,,"Case rate ($8,447.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,994.13, add-ons for qualifying new technology services are included. If operating cost exceeds $42,865.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,235.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,026.96 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,049.18 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $475.59. The transfer capital threshold is the transfer adjustment factor * $475.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,1188.00,18893.86,Inpatient DRG
SINGLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL,402,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],30630.65,,"Case rate ($29,172.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $27,273.75, add-ons for qualifying new technology services are included. If operating cost exceeds $62,144.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,751.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $25,235.76 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $25,328.80 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,991.35. The transfer capital threshold is the transfer adjustment factor * $1,991.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,29172.05,124455.45,Inpatient DRG
HC Inj Anes/Steroid C/D Facet Sg|LEFT SIDE,CASE-64490,APC,64490,CPT,0361,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],869.28,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,827.89,869.28,OPPS APC
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],62179.32,,,,,,0,other,23344.70,62179.32,There are no additional notes associated with this service or procedure.
Open Biopsy/Excision Inguinofemoral Nodes|RIGHT SIDE,CASE-38531,APC,38531,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6215.36,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6215.36,6526.12,OPPS APC
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],11565.93,,"Fee schedule rate ($11,565.93). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6148.93,15887.21,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITHOUT CC/MCC,428,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],105654.25,,"Fee schedule rate ($105,654.25). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,40017.53,118904.57,There are no additional notes associated with this service or procedure.
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC,964,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],12570.30,,"Case rate ($12,323.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,600.20, add-ons for qualifying new technology services are included. If operating cost exceeds $46,471.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,519.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $9,619.78 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,655.25 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $759.10. The transfer capital threshold is the transfer adjustment factor * $759.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,12323.82,34154.06,Inpatient DRG
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC",494,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],15533.10,,"Case rate ($15,533.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,585.72, add-ons for qualifying new technology services are included. If operating cost exceeds $49,456.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,753.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $12,594.34 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,640.78 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $993.82. The transfer capital threshold is the transfer adjustment factor * $993.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,15533.10,39945.55,Inpatient DRG
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITHOUT CC/MCC,428,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],40017.53,,"Case rate ($40,017.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $37,363.07, add-ons for qualifying new technology services are included. If operating cost exceeds $72,234.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,544.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $35,288.01 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $35,418.12 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,784.57. The transfer capital threshold is the transfer adjustment factor * $2,784.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,40017.53,118904.57,Inpatient DRG
"NEONATE BIRTH WEIGHT 1500-1999 GRAMS WITH RESPIRATORY DISTRESS SYNDROME OR OTHER MAJOR RESPIRATORY CONDITION,MODERATE",612,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],11512.05,,"Case rate ($10,963.86). Base payment rate plus any adjustments related to outliers.",,,,0,other,10963.86,11512.05,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,066,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],13466.94,,,,,,0,other,6579.76,20083.61,There are no additional notes associated with this service or procedure.
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level|BILATERAL PROCEDURE,CASE-64483,APC,64483,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],827.89,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,827.89,869.28,OPPS APC
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC,832,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],7173.26,,"Case rate ($6,831.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,490.97, add-ons for qualifying new technology services are included. If operating cost exceeds $41,361.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,117.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $4,529.32 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,546.02 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $357.41. The transfer capital threshold is the transfer adjustment factor * $357.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,4803.31,14198.92,Inpatient DRG
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],15076.44,,"Fee schedule rate ($15,076.44). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6340.03,15076.44,There are no additional notes associated with this service or procedure.
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC",011,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],102498.90,,"Fee schedule rate ($102,498.90). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,38880.49,150008.48,There are no additional notes associated with this service or procedure.
SPINAL PROCEDURES WITHOUT CC/MCC,030,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],41254.39,,"Fee schedule rate ($41,254.39). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,16810.99,44714.01,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],6963.00,,"Per diem ($6,963). If length of stay < 2.6, first 1 days paid at a per diem of $13,926 instead. Capped at $18,103.30.",,,,0,other,6963.00,18954.85,Estimated amount calculated based on 3 day length of stay.
OTHER CEREBROVASCULAR DISORDERS WITH CC,071,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],29215.10,,"Fee schedule rate ($29,215.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5843.00,29215.10,There are no additional notes associated with this service or procedure.
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],6965.00,,,,,,0,other,6965.00,36140.75,There are no additional notes associated with this service or procedure.
Unlisted Procedure Arthroscopy,CASE-29999,APC,29999,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
NORMAL NEWBORN,795,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],2576.52,,"Fee schedule rate ($2,576.52). Adds an outlier to normal pricing equal to the per diem rate ($414) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,1369.79,5771.52,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],34712.20,,,,,,0,other,13891.57,34712.20,There are no additional notes associated with this service or procedure.
Split Agrft F/S/N/H/F/G/M/D Gt 1st 100 Cm/</1 %,CASE-15120,APC,15120,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3317.01,,"APC Price ($3,317.01). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3317.01,3482.86,OPPS APC
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC,858,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],27408.09,,,,,,0,other,11377.76,33794.11,There are no additional notes associated with this service or procedure.
CERVICAL SPINAL FUSION WITH CC,472,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],70198.84,,"Fee schedule rate ($70,198.84). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,21896.13,70198.84,There are no additional notes associated with this service or procedure.
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],14455.04,,"Fee schedule rate ($14,455.04). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5280.00,17136.70,There are no additional notes associated with this service or procedure.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",062,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],33023.06,,"Fee schedule rate ($33,023.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,13844.84,44304.80,There are no additional notes associated with this service or procedure.
HC Lyr Clos Sc Tk Ext 2.6-7 Cm,CASE-12032,APC,12032,CPT,0450,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1600.04,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1545.93,1623.23,OPPS APC
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC",061,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],36078.40,,"Case rate ($20,616.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $19,314.45, add-ons for qualifying new technology services are included. If operating cost exceeds $54,185.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,125.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $17,305.68 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $17,369.49 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,365.59. The transfer capital threshold is the transfer adjustment factor * $1,365.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,20616.23,62315.82,All Other Inpatient
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],97015.50,,"Fee schedule rate ($97,015.50). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,26809.29,97015.50,There are no additional notes associated with this service or procedure.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],29997.59,,,,,,0,other,12268.97,41006.47,There are no additional notes associated with this service or procedure.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,057,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],39884.93,,"Fee schedule rate ($39,884.93). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,10718.84,39884.93,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL OBSTRUCTION WITH CC,389,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],8731.37,,"Fee schedule rate ($8,731.37). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5118.00,16423.43,There are no additional notes associated with this service or procedure.
Laparoscopic Appendectomy,CASE-44970,APC,44970,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5941.70,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5658.76,5941.70,OPPS APC
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],32126.64,,,,,,0,other,7868.00,32126.64,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC,833,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],5760.37,,"Case rate ($5,486.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,239.18, add-ons for qualifying new technology services are included. If operating cost exceeds $40,110.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,018.96, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $3,282.12 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,294.23 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $258.99. The transfer capital threshold is the transfer adjustment factor * $258.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,3041.73,10289.10,Inpatient DRG
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],27832.43,,"Fee schedule rate ($27,832.43). Adds an outlier to normal pricing equal to the per diem rate ($62,521.14) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.7), with a minimum of zero.",,,,0,other,11974.38,29141.64,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC,084,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],19445.16,,"Fee schedule rate ($19,445.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,6965.00,19445.16,There are no additional notes associated with this service or procedure.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],24259.09,,"Fee schedule rate ($24,259.09). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10098.51,24259.09,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],52449.26,,"Fee schedule rate ($52,449.26). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,17693.40,52449.26,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,373,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],7214.49,,"Case rate ($6,870.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,527.50, add-ons for qualifying new technology services are included. If operating cost exceeds $41,398.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,120.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $4,565.72 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,582.56 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $360.28. The transfer capital threshold is the transfer adjustment factor * $360.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6870.94,14313.05,Inpatient DRG
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,065,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],8786.76,,"Case rate ($8,786.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,309.75, add-ons for qualifying new technology services are included. If operating cost exceeds $43,180.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,260.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,341.42 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,364.80 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $500.40. The transfer capital threshold is the transfer adjustment factor * $500.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8786.76,25681.86,Inpatient DRG
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,479,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],10586.00,,"Per diem ($10,586). If length of stay < 3.3, first 1 days paid at a per diem of $21,172 instead. Capped at $34,934.31.",,,,0,other,10586.00,50518.76,Estimated amount calculated based on 2 day length of stay.
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],10299.17,,"Case rate ($9,950.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,392.71, add-ons for qualifying new technology services are included. If operating cost exceeds $44,263.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,345.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $7,420.40 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,447.76 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $585.54. The transfer capital threshold is the transfer adjustment factor * $585.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,7243.75,23262.15,Inpatient DRG
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],12818.71,,"Fee schedule rate ($12,818.71). Adds an outlier to normal pricing equal to the per diem rate ($42,942.49) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,6564.18,17651.07,There are no additional notes associated with this service or procedure.
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],7000.00,,"Per diem ($7,000). If length of stay < 4.5, first 1 days paid at a per diem of $14,000 instead. Capped at $31,498.95.",,,,0,other,7000.00,33835.79,Estimated amount calculated based on 2 day length of stay.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC,099,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],22084.20,,"Fee schedule rate ($22,084.20). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11171.21,26807.94,There are no additional notes associated with this service or procedure.
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|RIGHT HAND, THUMB",CASE-26160,APC,26160,CPT,0360,RC,,,F5,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1623.23,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1545.93,1623.23,OPPS APC
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],14699.43,,"Fee schedule rate ($14,699.43). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6683.37,14699.43,There are no additional notes associated with this service or procedure.
"Tendon Sheath Incision|LEFT HAND, FOURTH DIGIT",CASE-26055,APC,26055,CPT,0360,RC,,,F3,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1580.37,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1505.12,1580.37,OPPS APC
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,329,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],86382.02,,"Fee schedule rate ($86,382.02). Adds an outlier to normal pricing equal to the per diem rate ($147,722.18) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,33072.77,90445.33,There are no additional notes associated with this service or procedure.
HC Gastroesophag Reflx Test W/Tel Ph Eltrd,CASE-91035,APC,91035,CPT,0750,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],843.99,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,803.80,843.99,OPPS APC
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],12173.48,,"Case rate ($11,593.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,921.06, add-ons for qualifying new technology services are included. If operating cost exceeds $45,792.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,465.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $8,943.14 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,976.12 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $705.70. The transfer capital threshold is the transfer adjustment factor * $705.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,11593.79,38248.08,Inpatient DRG
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],20846.48,,"Case rate ($20,846.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $19,528.64, add-ons for qualifying new technology services are included. If operating cost exceeds $54,399.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,142.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $17,519.09 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $17,583.69 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,382.43. The transfer capital threshold is the transfer adjustment factor * $1,382.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,20846.48,81306.30,Inpatient DRG
Neuroplasty &/Transposition Ulnar Nerve Elbow,CASE-64718,APC,64718,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1827.80,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1827.80,1919.19,OPPS APC
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH CC,026,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],61179.73,,,,,,0,other,23000.66,63202.45,There are no additional notes associated with this service or procedure.
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],8339.44,,"Case rate ($8,057.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,631.26, add-ons for qualifying new technology services are included. If operating cost exceeds $42,502.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,207.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,665.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,686.30 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $447.06. The transfer capital threshold is the transfer adjustment factor * $447.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6524.00,17760.46,Inpatient DRG
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,345,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],33616.03,,"Fee schedule rate ($33,616.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12134.89,33616.03,There are no additional notes associated with this service or procedure.
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],20981.60,,"Fee schedule rate ($20,981.60). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,10003.71,23415.63,There are no additional notes associated with this service or procedure.
CHOLECYSTECTOMY WITH C.D.E. WITH MCC,411,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],64999.03,,,,,,0,other,24315.13,88615.28,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],85305.59,,"Fee schedule rate ($85,305.59). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,21719.40,85305.59,There are no additional notes associated with this service or procedure.
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],14492.93,,"Fee schedule rate ($14,492.93). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6503.90,14492.93,There are no additional notes associated with this service or procedure.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],19604.30,,"Fee schedule rate ($19,604.30). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9446.38,21796.21,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],7994.00,,"Per diem ($7,994). If length of stay < 1.7, first 1 days paid at a per diem of $15,988 instead. Capped at $13,589.22.",,,,0,other,6841.83,21167.26,Estimated amount calculated based on 1 day length of stay.
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],39251.68,,,,,,0,other,15453.88,39251.68,There are no additional notes associated with this service or procedure.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],24989.04,,"Case rate ($23,799.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $22,275.40, add-ons for qualifying new technology services are included. If operating cost exceeds $57,146.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,358.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.1. The base transfer operating payment is the transfer adjustment factor * $20,255.77 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $20,330.45 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,598.38. The transfer capital threshold is the transfer adjustment factor * $1,598.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,23799.09,63499.65,Inpatient DRG
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],29837.65,,"Fee schedule rate ($29,837.65). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,12696.97,47123.82,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],41353.22,,"Case rate ($40,542.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $37,851.31, add-ons for qualifying new technology services are included. If operating cost exceeds $72,722.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,582.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.6. The base transfer operating payment is the transfer adjustment factor * $35,774.45 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $35,906.36 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,822.96. The transfer capital threshold is the transfer adjustment factor * $2,822.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,40542.37,128358.13,Inpatient DRG
Removal Implant Deep|LEFT SIDE,CASE-20680,APC,20680,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],2814.04,,"APC Price ($2,718.88). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2718.88,2854.83,OPPS APC
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],22557.82,,"Fee schedule rate ($22,557.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6801.88,22557.82,There are no additional notes associated with this service or procedure.
Dstr Nrolytc Agnt Parverteb Fct Sngl Lmbr/Sacral|RIGHT SIDE,CASE-64635,APC,64635,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1891.77,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1827.80,1919.19,OPPS APC
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],21489.15,,"Case rate ($21,489.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,126.50, add-ons for qualifying new technology services are included. If operating cost exceeds $54,997.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,189.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.6. The base transfer operating payment is the transfer adjustment factor * $18,114.76 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,181.55 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,429.43. The transfer capital threshold is the transfer adjustment factor * $1,429.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,21489.15,68942.79,Inpatient DRG
TRAUMATIC INJURY WITH MCC,913,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],13665.31,,"Case rate ($13,014.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,242.79, add-ons for qualifying new technology services are included. If operating cost exceeds $47,113.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,569.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $10,260.01 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,297.84 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $809.62. The transfer capital threshold is the transfer adjustment factor * $809.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13014.58,42838.46,Inpatient DRG
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",063,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],6965.00,,,,,,0,other,6965.00,35701.87,There are no additional notes associated with this service or procedure.
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],27553.62,,"Fee schedule rate ($27,553.62). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12305.53,30103.84,There are no additional notes associated with this service or procedure.
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC",758,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],16323.02,,"Fee schedule rate ($16,323.02). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8574.80,19263.78,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],62084.69,,"Fee schedule rate ($62,084.69). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (35), with a minimum of zero.",,,,0,other,30398.48,82674.88,There are no additional notes associated with this service or procedure.
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],6586.33,,"Case rate ($6,457.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,142.59, add-ons for qualifying new technology services are included. If operating cost exceeds $41,013.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,089.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $4,182.21 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,197.63 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $330.02. The transfer capital threshold is the transfer adjustment factor * $330.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,5139.72,13110.79,Inpatient DRG
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],36094.03,,"Fee schedule rate ($36,094.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11194.25,36094.03,There are no additional notes associated with this service or procedure.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],17365.00,,"Fee schedule rate ($17,365.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5683.00,19635.68,There are no additional notes associated with this service or procedure.
NEONATE WITH OTHER SIGNIFICANT PROBLEMS,794,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],3383.58,,"Fee schedule rate ($3,383.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,1798.85,12536.83,There are no additional notes associated with this service or procedure.
CHOLECYSTECTOMY WITH C.D.E. WITH MCC,411,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],64999.03,,,,,,0,other,24315.13,88615.28,There are no additional notes associated with this service or procedure.
HC Joint Injection/Aspir Large WO US|PBB CHARGE|RIGHT SIDE,CASE-20610,APC,20610,CPT,0510,RC,,,PBB|RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],301.68,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,287.31,301.68,OPPS APC
Sigmoidoscopy Flx Dx W/Collj Spec Br/Wa if Pfrmd,CASE-45330,APC,45330,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],870.46,,"APC Price ($870.46). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,870.46,913.99,OPPS APC
CERVICAL SPINAL FUSION WITH CC,472,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],22662.49,,"Case rate ($21,896.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,505.12, add-ons for qualifying new technology services are included. If operating cost exceeds $55,376.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,219.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $18,491.99 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,560.18 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,459.20. The transfer capital threshold is the transfer adjustment factor * $1,459.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,21896.13,70198.84,Inpatient DRG
Biopsy Cervix Single/Mult/Excision of Lesion Spx,CASE-57500,APC,57500,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],862.13,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,862.13,905.23,OPPS APC
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],12138.74,,,,,,0,other,1188.00,12138.74,There are no additional notes associated with this service or procedure.
PERITONEAL ADHESIOLYSIS WITH CC,336,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],16225.22,,"Case rate ($16,225.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,229.58, add-ons for qualifying new technology services are included. If operating cost exceeds $50,100.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,804.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $13,235.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,284.63 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,044.44. The transfer capital threshold is the transfer adjustment factor * $1,044.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,16225.22,53705.31,Inpatient DRG
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],28394.78,,"Fee schedule rate ($28,394.78). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11454.97,28394.78,There are no additional notes associated with this service or procedure.
Laparoscopy Surg Rpr Initial Inguinal Hernia|LEFT SIDE,CASE-49650,APC,49650,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5658.76,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5658.76,5941.70,OPPS APC
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],13947.32,,"Fee schedule rate ($13,947.32). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6153.12,13947.32,There are no additional notes associated with this service or procedure.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,988,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],23513.70,,"Fee schedule rate ($23,513.70). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,13075.52,42425.46,There are no additional notes associated with this service or procedure.
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],37016.57,,"Fee schedule rate ($37,016.57). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15), with a minimum of zero.",,,,0,other,15283.90,38757.79,There are no additional notes associated with this service or procedure.
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],6965.00,,,,,,0,other,6965.00,17467.27,There are no additional notes associated with this service or procedure.
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITHOUT MCC,430,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],133156.90,,"Fee schedule rate ($133,156.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,41000.16,133156.90,There are no additional notes associated with this service or procedure.
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],15019.71,,"Case rate ($14,725.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,834.15, add-ons for qualifying new technology services are included. If operating cost exceeds $48,705.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,694.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,845.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,889.20 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $934.73. The transfer capital threshold is the transfer adjustment factor * $934.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,7389.00,37134.43,Inpatient DRG
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],53275.26,,"Fee schedule rate ($53,275.26). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,15940.79,53275.26,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,426,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],207121.41,,"Fee schedule rate ($207,121.41). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,76581.29,216864.15,There are no additional notes associated with this service or procedure.
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC",011,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],107320.33,,,,,,0,other,38880.49,150008.48,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],2070.00,,,,,,0,other,1188.00,17370.86,Estimated amount calculated based on 3 day length of stay.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],97015.50,,"Fee schedule rate ($97,015.50). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,26809.29,97015.50,There are no additional notes associated with this service or procedure.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],93728.21,,"Fee schedule rate ($93,728.21). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,35719.96,105091.76,There are no additional notes associated with this service or procedure.
Mastectomy Partial|LEFT SIDE,CASE-19301,APC,19301,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6215.36,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6215.36,6526.12,OPPS APC
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],17269.71,,"Case rate ($16,447.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,436.22, add-ons for qualifying new technology services are included. If operating cost exceeds $50,307.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,820.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $13,441.70 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,491.27 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,060.68. The transfer capital threshold is the transfer adjustment factor * $1,060.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7453.00,42138.30,Inpatient DRG
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],35127.88,,"Fee schedule rate ($35,127.88). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.5), with a minimum of zero.",,,,0,other,14603.31,45017.13,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC,833,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],3171.00,,"Fee schedule rate ($3,171). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,3041.73,10289.10,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,690,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],14625.55,,"Fee schedule rate ($14,625.55). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7426.94,15928.53,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],31469.43,,,,,,0,other,12775.53,31469.43,There are no additional notes associated with this service or procedure.
FRACTURES OF FEMUR WITH MCC,533,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],12561.53,,"Case rate ($12,561.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,821.33, add-ons for qualifying new technology services are included. If operating cost exceeds $46,692.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,536.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $9,840.09 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,876.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $776.48. The transfer capital threshold is the transfer adjustment factor * $776.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6852.00,49490.05,Inpatient DRG
Arthrs Kne Surg W/Meniscectomy Med/Lat W/Shvg|RIGHT SIDE,CASE-29881,APC,29881,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
"Tendon Sheath Incision|RIGHT HAND, THUMB",CASE-26055,APC,26055,CPT,0360,RC,,,F5,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1557.80,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1505.12,1580.37,OPPS APC
CHEST PAIN,313,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6820.84,,"Case rate ($6,820.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,480.89, add-ons for qualifying new technology services are included. If operating cost exceeds $41,351.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,116.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $4,519.27 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,535.94 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $356.62. The transfer capital threshold is the transfer adjustment factor * $356.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6820.84,15377.66,Inpatient DRG
HC Inj Trigger Pt 1-2 Musc Grps|PBB CHARGE,CASE-20552,APC,20552,CPT,0510,RC,,,PBB,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],301.68,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,287.31,301.68,OPPS APC
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],7453.00,,"Per diem ($7,453). If length of stay < 5.4, first 1 days paid at a per diem of $14,906 instead. Capped at $40,245.21.",,,,0,other,7453.00,42138.30,Estimated amount calculated based on 3 day length of stay.
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],11847.11,,"Fee schedule rate ($11,847.11). Adds an outlier to normal pricing equal to the per diem rate ($62,538.40) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,6214.05,15318.94,There are no additional notes associated with this service or procedure.
CELLULITIS WITH MCC,602,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],28349.31,,"Fee schedule rate ($28,349.31). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11570.10,28349.31,There are no additional notes associated with this service or procedure.
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC,806,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],6836.20,,"Case rate ($6,510.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,192.35, add-ons for qualifying new technology services are included. If operating cost exceeds $41,063.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,093.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $4,231.80 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,247.40 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $333.93. The transfer capital threshold is the transfer adjustment factor * $333.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5354.25,13416.00,Inpatient DRG
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],32327.17,,"Case rate ($31,693.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $29,619.21, add-ons for qualifying new technology services are included. If operating cost exceeds $64,490.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,935.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. The base transfer operating payment is the transfer adjustment factor * $27,572.60 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $27,674.26 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,175.75. The transfer capital threshold is the transfer adjustment factor * $2,175.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,10862.00,86437.13,Inpatient DRG
HC Joint Injection/Aspir Large WO US|BILATERAL PROCEDURE|PBB CHARGE,CASE-20610,APC,20610,CPT,0510,RC,,,50|PBB,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",063,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],11451.58,,"Case rate ($11,451.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,788.77, add-ons for qualifying new technology services are included. If operating cost exceeds $45,659.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,455.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $8,811.33 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,843.82 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $695.30. The transfer capital threshold is the transfer adjustment factor * $695.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,35701.87,Inpatient DRG
MAJOR BLADDER PROCEDURES WITH MCC,653,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],125343.98,,"Fee schedule rate ($125,343.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,10280.00,125343.98,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],16063.95,,"Fee schedule rate ($16,063.95). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8956.76,28983.97,There are no additional notes associated with this service or procedure.
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],16787.98,,"Case rate ($16,787.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,753.10, add-ons for qualifying new technology services are included. If operating cost exceeds $50,624.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,845.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $13,757.43 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,808.15 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,085.60. The transfer capital threshold is the transfer adjustment factor * $1,085.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,16787.98,62990.26,Inpatient DRG
Excision Malignant Lesion F/E/E/N/L 1.1-2.0 Cm,CASE-11642,APC,11642,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1545.93,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1545.93,1600.04,OPPS APC
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],15128.37,,"Fee schedule rate ($15,128.37). Adds an outlier to normal pricing equal to the per diem rate ($46,867.46) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7396.47,16035.06,There are no additional notes associated with this service or procedure.
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],23216.87,,"Fee schedule rate ($23,216.87). Adds an outlier to normal pricing equal to the per diem rate ($51,531) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.7), with a minimum of zero.",,,,0,other,10311.17,24308.97,There are no additional notes associated with this service or procedure.
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],32168.63,,"Fee schedule rate ($32,168.63). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,13904.43,34749.58,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,447,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],47193.21,,"Case rate ($47,193.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $44,038.45, add-ons for qualifying new technology services are included. If operating cost exceeds $78,909.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $5,069.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $41,938.87 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $42,093.51 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,309.39. The transfer capital threshold is the transfer adjustment factor * $3,309.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,47193.21,156646.82,Inpatient DRG
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,448,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],94077.13,,"Fee schedule rate ($94,077.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,30663.95,94077.13,There are no additional notes associated with this service or procedure.
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],7766.29,,"Case rate ($7,396.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,016.38, add-ons for qualifying new technology services are included. If operating cost exceeds $41,887.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,158.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,052.80 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,071.43 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $398.72. The transfer capital threshold is the transfer adjustment factor * $398.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7396.47,16035.06,Inpatient DRG
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],13625.25,,"Fee schedule rate ($13,625.25). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7243.75,23262.15,There are no additional notes associated with this service or procedure.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITHOUT CC/MCC,816,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],12435.86,,,,,,0,other,6224.90,14733.53,There are no additional notes associated with this service or procedure.
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,068,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],23184.90,,"Fee schedule rate ($23,184.90). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,23184.90,There are no additional notes associated with this service or procedure.
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],34032.82,,"Fee schedule rate ($34,032.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,15233.11,38610.21,There are no additional notes associated with this service or procedure.
BRONCHITIS AND ASTHMA WITH CC/MCC,202,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],14307.27,,"Fee schedule rate ($14,307.27). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7606.34,19110.30,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,065,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],19879.67,,,,,,0,other,8786.76,25681.86,There are no additional notes associated with this service or procedure.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],18178.96,,"Case rate ($18,178.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,047.10, add-ons for qualifying new technology services are included. If operating cost exceeds $51,918.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,947.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $15,046.67 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,102.15 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,187.33. The transfer capital threshold is the transfer adjustment factor * $1,187.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,18178.96,54764.34,Inpatient DRG
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],15117.84,,,,,,0,other,6965.00,16400.70,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITHOUT CC/MCC,428,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],118904.57,,"Fee schedule rate ($118,904.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,40017.53,118904.57,There are no additional notes associated with this service or procedure.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],23520.23,,"Fee schedule rate ($23,520.23). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10517.71,24909.11,There are no additional notes associated with this service or procedure.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,329,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],86631.74,,"Fee schedule rate ($86,631.74). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (38), with a minimum of zero.",,,,0,other,33072.77,90445.33,There are no additional notes associated with this service or procedure.
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],22487.70,,"Fee schedule rate ($22,487.70). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10048.39,23545.50,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITH MCC,385,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],21593.52,,"Fee schedule rate ($21,593.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11480.01,31134.92,There are no additional notes associated with this service or procedure.
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],21512.35,,"Fee schedule rate ($21,512.35). Adds an outlier to normal pricing equal to the per diem rate ($37,521.53) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,9696.93,35061.53,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],11276.95,,"Case rate ($10,895.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,271.55, add-ons for qualifying new technology services are included. If operating cost exceeds $45,142.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,414.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $8,296.01 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,326.60 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $654.64. The transfer capital threshold is the transfer adjustment factor * $654.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,10895.60,35192.25,Inpatient DRG
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],54180.83,,"Fee schedule rate ($54,180.83). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,15491.11,54180.83,There are no additional notes associated with this service or procedure.
Cysto W/Ureteroscopy W/Rmvl/Manj Stones|RIGHT SIDE,CASE-52352,APC,52352,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3414.95,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3299.47,3464.44,OPPS APC
Hysteroscopy Diagnostic Separate Procedure,CASE-58555,APC,58555,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3030.03,,"APC Price ($3,030.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3030.03,3181.53,OPPS APC
"VAGINAL DELIVERY WITH O.R. PROCEDURE EXCEPT STERILIZATION AND/OR D&C,MAJOR",542,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],8944.87,,"Case rate ($8,518.92). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8518.92,8944.87,There are no additional notes associated with this service or procedure.
"CESAREAN SECTION WITH STERILIZATION,MODERATE",539,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],8204.64,,"Case rate ($7,813.94). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7813.94,8204.64,There are no additional notes associated with this service or procedure.
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC,519,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],27108.27,,"Case rate ($15,490.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,546.03, add-ons for qualifying new technology services are included. If operating cost exceeds $49,417.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,750.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $12,554.80 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,601.09 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $990.70. The transfer capital threshold is the transfer adjustment factor * $990.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,15490.44,50780.20,All Other Inpatient
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],41493.06,,"Fee schedule rate ($41,493.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,16897.01,43444.85,There are no additional notes associated with this service or procedure.
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],53569.45,,"Fee schedule rate ($53,569.45). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14.8), with a minimum of zero.",,,,0,other,21248.73,56089.29,There are no additional notes associated with this service or procedure.
Dstr Nrolytc Agnt Parverteb Fct Addl Crvcl/Thora|LEFT SIDE,CASE-64634,APC,64634,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1919.19,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1827.80,1919.19,OPPS APC
Excision Hydrocele Unilateral|LEFT SIDE,CASE-55040,APC,55040,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3468.64,,"APC Price ($3,351.34). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3351.34,3518.91,OPPS APC
HC Joint Injection/Aspir Large WO US|PBB CHARGE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-20610,APC,20610,CPT,0510,RC,,,PBB|XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],301.68,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,287.31,301.68,OPPS APC
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],12526.44,,"Fee schedule rate ($12,526.44). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5415.00,17575.50,There are no additional notes associated with this service or procedure.
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],20362.22,,"Fee schedule rate ($20,362.22). Adds an outlier to normal pricing equal to the per diem rate ($66,744.74) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.8), with a minimum of zero.",,,,0,other,9282.47,21320.03,There are no additional notes associated with this service or procedure.
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,307,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],8898.75,,"Fee schedule rate ($8,898.75). Adds an outlier to normal pricing equal to the per diem rate ($3,770.33) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6335.27,18228.77,There are no additional notes associated with this service or procedure.
O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC,621,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],12403.14,,"Case rate ($12,159.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,447.74, add-ons for qualifying new technology services are included. If operating cost exceeds $46,318.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,507.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $9,467.88 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,502.79 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $747.11. The transfer capital threshold is the transfer adjustment factor * $747.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,12159.94,36669.96,Inpatient DRG
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],28423.20,,"Fee schedule rate ($28,423.20). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11059.47,28423.20,There are no additional notes associated with this service or procedure.
POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES,769,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],29791.03,,"Fee schedule rate ($29,791.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,13388.39,33250.19,There are no additional notes associated with this service or procedure.
HC >= 12 Lead Ekg|ADJ,CASE-93005,APC,93005,CPT,0730,RC,,,ADJ,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],130.85,,"APC Price ($124.62). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,124.62,130.85,OPPS APC
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],13724.51,,"Case rate ($13,260.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,471.48, add-ons for qualifying new technology services are included. If operating cost exceeds $47,342.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,587.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $10,487.86 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,526.53 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $827.60. The transfer capital threshold is the transfer adjustment factor * $827.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,13260.40,32878.30,Inpatient DRG
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],21195.68,,"Fee schedule rate ($21,195.68). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,6965.00,21195.68,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],15456.59,,"Case rate ($15,456.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,514.54, add-ons for qualifying new technology services are included. If operating cost exceeds $49,385.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,748.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $12,523.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,569.59 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $988.22. The transfer capital threshold is the transfer adjustment factor * $988.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,15456.59,41402.42,Inpatient DRG
Bx/Exc Lymph Node Open Deep Axillary Node|BILATERAL PROCEDURE,CASE-38525,APC,38525,CPT,0360,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6526.12,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6215.36,6526.12,OPPS APC
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,448,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],94077.13,,"Fee schedule rate ($94,077.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,30663.95,94077.13,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],28756.63,,"Fee schedule rate ($28,756.63). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,13148.66,32553.63,There are no additional notes associated with this service or procedure.
"CVA AND PRECEREBRAL OCCLUSION WITH INFARCTION,MAJOR",045,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],14380.85,,"Case rate ($13,696.05). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13696.05,14380.85,There are no additional notes associated with this service or procedure.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],26776.27,,"Fee schedule rate ($26,776.27). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,11593.79,38248.08,There are no additional notes associated with this service or procedure.
Laparoscopy Surg Rpr Initial Inguinal Hernia|RIGHT SIDE,CASE-49650,APC,49650,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5941.70,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5658.76,5941.70,OPPS APC
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,082,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],56223.11,,"Fee schedule rate ($56,223.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,17423.21,56223.11,There are no additional notes associated with this service or procedure.
"Tendon Sheath Incision|RIGHT HAND, FOURTH DIGIT",CASE-26055,APC,26055,CPT,0360,RC,,,F8,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1557.80,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1505.12,1580.37,OPPS APC
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],25026.36,,"Fee schedule rate ($25,026.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9356.31,25026.36,There are no additional notes associated with this service or procedure.
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITH MCC OR ANTINEOPLASTIC IMPLANT OR EPILEPSY WITH NEUROSTIMULATOR,023,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],15168.00,,"Per diem ($15,168). If length of stay < 7.1, first 1 days paid at a per diem of $30,336 instead. Capped at $107,689.53.",,,,0,other,15168.00,136379.44,Estimated amount calculated based on 6 day length of stay.
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],34245.00,,"Fee schedule rate ($34,245.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,12725.42,34245.00,There are no additional notes associated with this service or procedure.
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],30935.16,,"Fee schedule rate ($30,935.16). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13092.47,33159.45,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITHOUT CC/MCC,428,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],105654.25,,"Fee schedule rate ($105,654.25). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,40017.53,118904.57,There are no additional notes associated with this service or procedure.
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],37016.57,,"Fee schedule rate ($37,016.57). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15), with a minimum of zero.",,,,0,other,15283.90,38757.79,There are no additional notes associated with this service or procedure.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],14008.75,,"Case rate ($13,341.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,547.08, add-ons for qualifying new technology services are included. If operating cost exceeds $47,418.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,593.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $10,563.18 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,602.13 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $833.54. The transfer capital threshold is the transfer adjustment factor * $833.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13341.67,42586.49,Inpatient DRG
ENDOCRINE DISORDERS WITH CC,644,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7066.99,,"Case rate ($6,730.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $6,281.58, add-ons for qualifying new technology services are included. If operating cost exceeds $45,851.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $3,268.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $6,253.04. The transfer operating threshold is the transfer adjustment factor * $6,281.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $477.43. The transfer capital threshold is the transfer adjustment factor * $477.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7066.99,20334.21,Inpatient DRG
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],33835.79,,"Fee schedule rate ($33,835.79). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,7000.00,33835.79,There are no additional notes associated with this service or procedure.
FRACTURES OF FEMUR WITH MCC,533,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],6852.00,,"Per diem ($6,852). If length of stay < 4.3, first 1 days paid at a per diem of $13,704 instead. Capped at $29,461.79.",,,,0,other,6852.00,49490.05,Estimated amount calculated based on 2 day length of stay.
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],11065.78,,"Fee schedule rate ($11,065.78). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5883.03,17111.12,There are no additional notes associated with this service or procedure.
TRAUMATIC INJURY WITH MCC,913,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],42838.46,,"Fee schedule rate ($42,838.46). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13014.58,42838.46,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],41402.42,,"Fee schedule rate ($41,402.42). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,15456.59,41402.42,There are no additional notes associated with this service or procedure.
"Open Tx Distal Phalangeal Fracture Each|RIGHT HAND, FIFTH DIGIT",CASE-26765,APC,26765,CPT,0360,RC,,,F9,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
Optx Dstl Radl X-Artic Fx/Epiphysl Sep|RIGHT SIDE,CASE-25607,APC,25607,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7029.71,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6791.99,7131.59,OPPS APC
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],9888.00,,"Per diem ($9,888). If length of stay < 3.1, first 1 days paid at a per diem of $19,776 instead. Capped at $30,651.38.",,,,0,other,9888.00,43399.23,Estimated amount calculated based on 1 day length of stay.
HC Inj Lympho for Sentinal Node|RIGHT SIDE,CASE-38792,APC,38792,CPT,0361,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6432.89,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6215.36,6526.12,OPPS APC
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],19126.88,,"Fee schedule rate ($19,126.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,19126.88,There are no additional notes associated with this service or procedure.
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC",923,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],6965.00,,,,,,0,other,6965.00,20068.57,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],16662.45,,"Fee schedule rate ($16,662.45). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13891.57,34712.20,There are no additional notes associated with this service or procedure.
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],37016.57,,"Fee schedule rate ($37,016.57). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15), with a minimum of zero.",,,,0,other,15283.90,38757.79,There are no additional notes associated with this service or procedure.
Osteoplasty Radius/Ulna Shortening|RIGHT SIDE,CASE-25390,APC,25390,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7029.71,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,7029.71,7029.71,OPPS APC
CESAREAN SECTION WITH STERILIZATION WITHOUT CC/MCC,785,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],20142.33,,"Fee schedule rate ($20,142.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8431.24,20142.33,There are no additional notes associated with this service or procedure.
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],22557.82,,"Fee schedule rate ($22,557.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6801.88,22557.82,There are no additional notes associated with this service or procedure.
PREMATURITY WITH MAJOR PROBLEMS,791,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],3186.77,,,,,,0,other,3048.21,30904.42,Estimated amount calculated based on 5 day length of stay.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,699,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],5961.00,,"Per diem ($5,961). If length of stay < 3.2, first 1 days paid at a per diem of $11,922 instead. Capped at $19,074.90.",,,,0,other,5961.00,19972.16,Estimated amount calculated based on 3 day length of stay.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],25609.86,,"Fee schedule rate ($25,609.86). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,12775.53,31469.43,There are no additional notes associated with this service or procedure.
FULL TERM NEONATE WITH MAJOR PROBLEMS,793,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],30785.42,,"Case rate ($30,181.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $28,213.07, add-ons for qualifying new technology services are included. If operating cost exceeds $63,084.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,825.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $26,171.62 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $26,268.12 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,065.20. The transfer capital threshold is the transfer adjustment factor * $2,065.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,4302.90,82045.22,Inpatient DRG
HC Peripheral Block - Femoral Single or Saphenous W/Img Gdn|LEFT SIDE,CASE-64447,APC,64447,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],660.72,,"APC Price ($660.72). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,660.72,693.76,OPPS APC
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITHOUT MCC,430,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],133156.90,,"Fee schedule rate ($133,156.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,41000.16,133156.90,There are no additional notes associated with this service or procedure.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,056,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],7659.00,,"Per diem ($7,659). If length of stay < 5.7, first 1 days paid at a per diem of $15,318 instead. Capped at $43,658.02.",,,,0,other,7659.00,59328.19,Estimated amount calculated based on 3 day length of stay.
"Corrj Hallux Valgus W/Sesmdc W/Rescj Prox Phal|LEFT FOOT, GREAT TOE",CASE-28292,APC,28292,CPT,0360,RC,,,TA,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],11213.85,,"Case rate ($10,834.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,214.84, add-ons for qualifying new technology services are included. If operating cost exceeds $45,085.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,410.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $8,239.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,269.90 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $650.18. The transfer capital threshold is the transfer adjustment factor * $650.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,10834.64,25830.00,Inpatient DRG
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],21892.85,,"Fee schedule rate ($21,892.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7569.84,21892.85,There are no additional notes associated with this service or procedure.
SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS,029,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],25048.54,,"Case rate ($25,048.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $23,437.73, add-ons for qualifying new technology services are included. If operating cost exceeds $58,308.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,449.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.7)) / 2. The base transfer operating payment is the transfer adjustment factor * $21,413.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $21,492.79 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,689.76. The transfer capital threshold is the transfer adjustment factor * $1,689.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,13641.00,67130.05,Inpatient DRG
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],97015.50,,"Fee schedule rate ($97,015.50). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,26809.29,97015.50,There are no additional notes associated with this service or procedure.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],41006.47,,"Fee schedule rate ($41,006.47). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12268.97,41006.47,There are no additional notes associated with this service or procedure.
Prep Site F/S/N/H/F/G/M/D Gt 1st 100 Sq Cm/1pct,CASE-15004,APC,15004,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],380.51,,"APC Price ($380.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,380.51,399.53,OPPS APC
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH CC,354,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],12952.69,,"Case rate ($12,514.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $11,748.98, add-ons for qualifying new technology services are included. If operating cost exceeds $50,393.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $3,540.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $10,343.20 + an uncompensated DSH payment of $1,359.91. The transfer operating threshold is the transfer adjustment factor * $10,389.07 + an uncompensated DSH payment of $1,359.91. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $811.58. The transfer capital threshold is the transfer adjustment factor * $811.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,11633.13,33472.54,Inpatient DRG
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],20109.72,,"Case rate ($19,152.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,952.40, add-ons for qualifying new technology services are included. If operating cost exceeds $52,823.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,018.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $15,948.65 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $16,007.45 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,258.51. The transfer capital threshold is the transfer adjustment factor * $1,258.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,19152.11,53152.12,Inpatient DRG
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],85305.59,,"Fee schedule rate ($85,305.59). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,21719.40,85305.59,There are no additional notes associated with this service or procedure.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],9137.93,,"Case rate ($8,702.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,231.63, add-ons for qualifying new technology services are included. If operating cost exceeds $43,102.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,254.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,263.59 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,286.68 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $494.26. The transfer capital threshold is the transfer adjustment factor * $494.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5683.00,19635.68,Inpatient DRG
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],26949.28,,"Fee schedule rate ($26,949.28). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9977.99,26949.28,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC,833,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],6965.00,,,,,,0,other,3041.73,10289.10,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],21784.85,,"Fee schedule rate ($21,784.85). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.4), with a minimum of zero.",,,,0,other,9795.13,23899.13,There are no additional notes associated with this service or procedure.
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],52453.14,,"Fee schedule rate ($52,453.14). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14.9), with a minimum of zero.",,,,0,other,20846.48,81306.30,There are no additional notes associated with this service or procedure.
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],16379.98,,"Fee schedule rate ($16,379.98). Adds an outlier to normal pricing equal to the per diem rate ($46,377.87) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7847.50,17755.26,There are no additional notes associated with this service or procedure.
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],14249.81,,"Case rate ($13,571.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,760.65, add-ons for qualifying new technology services are included. If operating cost exceeds $47,631.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,610.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $10,775.96 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,815.69 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $850.33. The transfer capital threshold is the transfer adjustment factor * $850.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13571.25,33781.47,Inpatient DRG
SALIVARY GLAND PROCEDURES,139,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],10570.76,,"Case rate ($10,067.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,516.24, add-ons for qualifying new technology services are included. If operating cost exceeds $44,387.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,339.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $7,542.70 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,571.29 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $579.75. The transfer capital threshold is the transfer adjustment factor * $579.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10313.19,30690.92,Inpatient DRG
"NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY",789,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],14480.63,,"Case rate ($13,791.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,987.26, add-ons for qualifying new technology services are included. If operating cost exceeds $47,858.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,605.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $11,000.60 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,042.31 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $845.53. The transfer capital threshold is the transfer adjustment factor * $845.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,3054.00,14857.05,Inpatient DRG
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH CC,026,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],63202.45,,"Fee schedule rate ($63,202.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,23000.66,63202.45,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,086,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],11033.18,,"Case rate ($10,507.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,926.76, add-ons for qualifying new technology services are included. If operating cost exceeds $44,797.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,371.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,951.66 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,981.81 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $611.18. The transfer capital threshold is the transfer adjustment factor * $611.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8442.00,30728.81,Inpatient DRG
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],5065.00,,"Per diem ($5,065). If length of stay < 2.1, first 1 days paid at a per diem of $10,130 instead. Capped at $10,636.84.",,,,0,other,5065.00,12558.65,Estimated amount calculated based on 2 day length of stay.
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,690,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],14625.55,,"Fee schedule rate ($14,625.55). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7426.94,15928.53,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],88188.38,,,,,,0,other,32296.02,88188.38,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],8081.80,,"Case rate ($7,923.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,506.51, add-ons for qualifying new technology services are included. If operating cost exceeds $42,377.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,197.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $5,541.13 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,561.56 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $437.25. The transfer capital threshold is the transfer adjustment factor * $437.25. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,1188.00,17370.86,Inpatient DRG
"HEART FAILURE,MODERATE",194,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],7970.95,,"The inlier payment is calculated as the lesser of the standard DRG payment $7,591.38 and the transfer payment, which is a per diem of $1,820.47. If cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7591.38,7970.95,Estimated amount calculated based on 4 day length of stay.
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],12246.05,,"Fee schedule rate ($12,246.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6010.23,12246.05,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,394,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],8447.19,,"Case rate ($8,281.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,839.77, add-ons for qualifying new technology services are included. If operating cost exceeds $42,710.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,223.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,873.17 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,894.83 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $463.45. The transfer capital threshold is the transfer adjustment factor * $463.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,8281.56,20909.61,Inpatient DRG
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],15206.21,,"Case rate ($14,908.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,004.25, add-ons for qualifying new technology services are included. If operating cost exceeds $48,875.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,708.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $12,014.99 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,059.30 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $948.10. The transfer capital threshold is the transfer adjustment factor * $948.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,14908.05,49717.39,Inpatient DRG
Arthrs Aid Tibial Fx Prox Unicondylar Bicondylar,CASE-29856,APC,29856,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],12618.18,,"APC Price ($12,017.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,12618.18,12618.18,OPPS APC
Laps Abd Prtm&Omentum Dx W/WO Spec Br/Wa Spx,CASE-49320,APC,49320,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5658.76,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5658.76,5941.70,OPPS APC
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],12133.80,,"Fee schedule rate ($12,133.80). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7569.84,21892.85,There are no additional notes associated with this service or procedure.
"OTHER NON-HYPOVOLEMIC ELECTROLYTE DISORDERS,MODERATE",425,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],6117.83,,"Case rate ($6,117.83). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,6117.83,6423.72,There are no additional notes associated with this service or procedure.
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5879.61,,"Case rate ($5,599.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,351.63, add-ons for qualifying new technology services are included. If operating cost exceeds $40,222.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,020.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $3,393.82 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,406.68 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $260.86. The transfer capital threshold is the transfer adjustment factor * $260.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,3079.00,10940.41,Inpatient DRG
BRONCHITIS AND ASTHMA WITH CC/MCC,202,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],14307.27,,"Fee schedule rate ($14,307.27). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7606.34,19110.30,There are no additional notes associated with this service or procedure.
Anoscopy Dx W/HRA &Chem Agnts Enhancement W/Bx,CASE-46607,APC,46607,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1176.09,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1120.09,1176.09,OPPS APC
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],23932.97,,"Fee schedule rate ($23,932.97). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,14603.31,45017.13,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],25026.36,,"Fee schedule rate ($25,026.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9356.31,25026.36,There are no additional notes associated with this service or procedure.
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],28445.08,,"Fee schedule rate ($28,445.08). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.8), with a minimum of zero.",,,,0,other,12195.15,39424.57,There are no additional notes associated with this service or procedure.
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7673.56,,"Case rate ($7,414.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,032.76, add-ons for qualifying new technology services are included. If operating cost exceeds $41,903.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,159.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,069.12 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,087.81 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $400.00. The transfer capital threshold is the transfer adjustment factor * $400.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,7414.07,18217.52,Inpatient DRG
"Laminec/Facetect/Foramin,Lumbar|SEPARATE STRUCTURE",CASE-63047,APC,63047,CPT,0360,RC,,,XS,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],26287.03,,"APC Price ($25,398.09). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,25398.09,26668.00,OPPS APC
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC,027,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],56363.30,,"Fee schedule rate ($56,363.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,19030.20,56363.30,There are no additional notes associated with this service or procedure.
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],32168.63,,"Fee schedule rate ($32,168.63). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,13904.43,34749.58,There are no additional notes associated with this service or procedure.
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],18675.44,,,,,,0,other,6965.00,23385.72,There are no additional notes associated with this service or procedure.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],30112.02,,"Fee schedule rate ($30,112.02). Adds an outlier to normal pricing equal to the per diem rate ($53,484.01) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.5), with a minimum of zero.",,,,0,other,12795.84,41944.25,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,426,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],177294.98,,"Fee schedule rate ($177,294.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,76581.29,216864.15,There are no additional notes associated with this service or procedure.
HC Peripheral Block - Femoral Single or Saphenous W/Img Gdn,CASE-64447,APC,64447,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6791.99,7131.59,OPPS APC
"OTHER DIGESTIVE SYSTEM DIAGNOSES,MINOR",254,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],5522.50,,"Case rate ($5,522.50). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,5522.50,5798.63,There are no additional notes associated with this service or procedure.
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC",758,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],9003.54,,"Case rate ($8,574.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,112.57, add-ons for qualifying new technology services are included. If operating cost exceeds $42,983.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,244.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $6,144.96 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,167.62 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $484.90. The transfer capital threshold is the transfer adjustment factor * $484.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8574.80,19263.78,Inpatient DRG
Rpr Aa Hernia 1st < 3 Cm Reducible,CASE-49591,APC,49591,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3518.91,,"APC Price ($3,351.34). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3518.91,3518.91,OPPS APC
CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC,788,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],8438.02,,"Case rate ($8,438.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,985.31, add-ons for qualifying new technology services are included. If operating cost exceeds $42,856.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,234.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,018.17 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,040.36 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $474.89. The transfer capital threshold is the transfer adjustment factor * $474.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8438.02,20142.33,Inpatient DRG
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],53275.26,,"Fee schedule rate ($53,275.26). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,15940.79,53275.26,There are no additional notes associated with this service or procedure.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],20553.44,,"Fee schedule rate ($20,553.44). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8874.81,20553.44,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],8734.05,,"Case rate ($8,318.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,873.80, add-ons for qualifying new technology services are included. If operating cost exceeds $42,744.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,226.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,907.07 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,928.85 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $466.13. The transfer capital threshold is the transfer adjustment factor * $466.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8318.14,19763.43,Inpatient DRG
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC,434,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],13280.45,,"Fee schedule rate ($13,280.45). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6770.05,14019.86,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],32293.66,,"Fee schedule rate ($32,293.66). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,32293.66,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],33277.97,,"Case rate ($31,693.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $29,619.21, add-ons for qualifying new technology services are included. If operating cost exceeds $64,490.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,935.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. The base transfer operating payment is the transfer adjustment factor * $27,572.60 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $27,674.26 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,175.75. The transfer capital threshold is the transfer adjustment factor * $2,175.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10862.00,86437.13,Inpatient DRG
RESPIRATORY NEOPLASMS WITH CC,181,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],9434.04,,"Case rate ($8,984.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,507.11, add-ons for qualifying new technology services are included. If operating cost exceeds $43,378.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,262.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,537.37 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,562.16 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $502.48. The transfer capital threshold is the transfer adjustment factor * $502.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9197.84,21074.07,Inpatient DRG
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,450,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],104870.54,,,,,,0,other,38037.38,146009.19,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC,084,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],18807.28,,,,,,0,other,6965.00,19445.16,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],13260.40,,"Case rate ($13,260.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,471.48, add-ons for qualifying new technology services are included. If operating cost exceeds $47,342.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,587.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $10,487.86 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,526.53 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $827.60. The transfer capital threshold is the transfer adjustment factor * $827.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,13260.40,32878.30,Inpatient DRG
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],9762.40,,"Case rate ($9,570.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,039.28, add-ons for qualifying new technology services are included. If operating cost exceeds $43,910.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,317.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $7,068.27 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,094.33 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $557.76. The transfer capital threshold is the transfer adjustment factor * $557.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,5569.00,40108.48,Inpatient DRG
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],16226.57,,"Case rate ($15,453.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,512.02, add-ons for qualifying new technology services are included. If operating cost exceeds $49,383.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,747.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $12,520.90 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,567.07 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $988.02. The transfer capital threshold is the transfer adjustment factor * $988.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,15453.88,39251.68,Inpatient DRG
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],11406.48,,"Fee schedule rate ($11,406.48). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,9097.60,21455.22,There are no additional notes associated with this service or procedure.
Dstr Nrolytc Agnt Parverteb Fct Addl Crvcl/Thora,CASE-64634,APC,64634,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1919.19,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1827.80,1919.19,OPPS APC
CERVICAL SPINAL FUSION WITH CC,472,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],70198.84,,"Fee schedule rate ($70,198.84). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,21896.13,70198.84,There are no additional notes associated with this service or procedure.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,191,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7860.43,,"Case rate ($7,486.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,110.12, add-ons for qualifying new technology services are included. If operating cost exceeds $41,981.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,155.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,145.66 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,165.17 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $395.51. The transfer capital threshold is the transfer adjustment factor * $395.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,16612.88,Inpatient DRG
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],5791.49,,"Fee schedule rate ($5,791.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,3079.00,10940.41,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],14038.14,,"Case rate ($13,762.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,938.93, add-ons for qualifying new technology services are included. If operating cost exceeds $47,809.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,624.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $10,953.59 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,993.98 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $864.35. The transfer capital threshold is the transfer adjustment factor * $864.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,1188.00,34338.33,Inpatient DRG
HC Inj Tendon Sheath/Ligament|PBB CHARGE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-20550,APC,20550,CPT,0510,RC,,,PBB|XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],301.68,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,287.31,301.68,OPPS APC
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],34422.94,,,,,,0,other,6965.00,34422.94,There are no additional notes associated with this service or procedure.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],18933.95,,"Fee schedule rate ($18,933.95). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.8), with a minimum of zero.",,,,0,other,8767.81,19824.58,There are no additional notes associated with this service or procedure.
TRAUMATIC INJURY WITH MCC,913,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],42838.46,,"Fee schedule rate ($42,838.46). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13014.58,42838.46,There are no additional notes associated with this service or procedure.
MAJOR THUMB OR JOINT PROCEDURES,506,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],19761.54,,"Fee schedule rate ($19,761.54). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11081.83,26548.21,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH CC,427,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],51846.42,,"Case rate ($50,829.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $47,421.51, add-ons for qualifying new technology services are included. If operating cost exceeds $82,292.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $5,335.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $45,309.50 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $45,476.56 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,575.37. The transfer capital threshold is the transfer adjustment factor * $3,575.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,50829.82,142040.39,Inpatient DRG
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],13310.79,,"Case rate ($12,676.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,948.71, add-ons for qualifying new technology services are included. If operating cost exceeds $46,819.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,525.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $9,965.98 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,003.76 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $766.01. The transfer capital threshold is the transfer adjustment factor * $766.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7868.00,32126.64,Inpatient DRG
HC Inj Lympho for Sentinal Node|RIGHT SIDE,CASE-38792,APC,38792,CPT,0361,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6215.36,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6215.36,6526.12,OPPS APC
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],26949.28,,"Fee schedule rate ($26,949.28). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9977.99,26949.28,There are no additional notes associated with this service or procedure.
"HEART FAILURE,MAJOR",194,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],12284.52,,"Case rate ($11,699.54). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11699.54,12284.52,There are no additional notes associated with this service or procedure.
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],40714.72,,"Fee schedule rate ($40,714.72). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,17356.15,44778.95,There are no additional notes associated with this service or procedure.
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],9755.86,,"Case rate ($9,755.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,211.27, add-ons for qualifying new technology services are included. If operating cost exceeds $44,082.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,331.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $7,239.63 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,266.32 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $571.28. The transfer capital threshold is the transfer adjustment factor * $571.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9755.86,29216.99,Inpatient DRG
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],9040.72,,"Case rate ($9,040.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,546, add-ons for qualifying new technology services are included. If operating cost exceeds $43,417.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,278.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,576.80 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,601.05 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $518.97. The transfer capital threshold is the transfer adjustment factor * $518.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9040.72,26966.33,Inpatient DRG
"SINGLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL,MINOR",300,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],32618.25,,"Case rate ($31,065.00). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,31065.00,32618.25,There are no additional notes associated with this service or procedure.
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],62990.26,,"Fee schedule rate ($62,990.26). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,16787.98,62990.26,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],8991.47,,"Case rate ($8,563.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,101.85, add-ons for qualifying new technology services are included. If operating cost exceeds $42,972.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,244.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $6,134.29 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,156.91 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $484.06. The transfer capital threshold is the transfer adjustment factor * $484.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8563.30,31533.97,Inpatient DRG
CHEST PAIN,313,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],15377.66,,"Fee schedule rate ($15,377.66). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,6820.84,15377.66,There are no additional notes associated with this service or procedure.
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC",605,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],8311.13,,"Case rate ($8,148.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,715.67, add-ons for qualifying new technology services are included. If operating cost exceeds $42,586.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,213.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,749.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,770.72 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $453.69. The transfer capital threshold is the transfer adjustment factor * $453.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,8148.17,18024.13,Inpatient DRG
OTHER CEREBROVASCULAR DISORDERS WITH CC,071,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],8893.10,,"Case rate ($8,893.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,408.66, add-ons for qualifying new technology services are included. If operating cost exceeds $43,279.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,268.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,439.97 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,463.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $508.18. The transfer capital threshold is the transfer adjustment factor * $508.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,5843.00,29215.10,Inpatient DRG
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],33114.42,,,,,,0,other,13341.67,42586.49,There are no additional notes associated with this service or procedure.
DIABETES WITH CC,638,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],16842.29,,"Fee schedule rate ($16,842.29). Adds an outlier to normal pricing equal to the per diem rate ($39,561.63) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,8014.07,17634.53,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],30636.35,,"Fee schedule rate ($30,636.35). Adds an outlier to normal pricing equal to the per diem rate ($67,650.85) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12984.79,32077.45,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],81524.17,,"Fee schedule rate ($81,524.17). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,8972.00,81524.17,There are no additional notes associated with this service or procedure.
O.R. PROCEDURES FOR OBESITY WITH CC,620,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],30074.44,,"Fee schedule rate ($30,074.44). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7.8), with a minimum of zero.",,,,0,other,12782.30,43753.50,There are no additional notes associated with this service or procedure.
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],9667.64,,"Fee schedule rate ($9,667.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,5139.72,13110.79,There are no additional notes associated with this service or procedure.
Arthrs Wrst Exc&/Rpr Triang Fibrocart&/Joint,CASE-29846,APC,29846,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],23870.71,,"Fee schedule rate ($23,870.71). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10626.74,25225.91,There are no additional notes associated with this service or procedure.
Chemodenervation Muscle Neck Unilat for Dystonia,CASE-64616,APC,64616,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],297.37,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,287.31,301.68,OPPS APC
DIABETES WITHOUT CC/MCC,639,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],6965.00,,,,,,0,other,6151.76,12223.35,There are no additional notes associated with this service or procedure.
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],61234.06,,"Fee schedule rate ($61,234.06). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11165.00,61234.06,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],18585.05,,"Fee schedule rate ($18,585.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8859.23,20090.22,There are no additional notes associated with this service or procedure.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],14380.76,,"Case rate ($14,098.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,251.41, add-ons for qualifying new technology services are included. If operating cost exceeds $48,122.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,648.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $11,264.92 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,306.46 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $888.91. The transfer capital threshold is the transfer adjustment factor * $888.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,7332.00,35314.31,Inpatient DRG
SALIVARY GLAND PROCEDURES,139,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],10674.15,,"Case rate ($10,313.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,729.75, add-ons for qualifying new technology services are included. If operating cost exceeds $44,600.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,372.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $7,756.21 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,784.80 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $612.04. The transfer capital threshold is the transfer adjustment factor * $612.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,10313.19,30690.92,Inpatient DRG
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],30861.41,,,,,,0,other,12566.28,30861.41,There are no additional notes associated with this service or procedure.
SPINAL PROCEDURES WITHOUT CC/MCC,030,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],44714.01,,"Fee schedule rate ($44,714.01). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,16810.99,44714.01,There are no additional notes associated with this service or procedure.
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],12558.65,,"Fee schedule rate ($12,558.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5065.00,12558.65,There are no additional notes associated with this service or procedure.
SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS,029,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],26300.97,,"Case rate ($25,048.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $23,437.73, add-ons for qualifying new technology services are included. If operating cost exceeds $58,308.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,449.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.7)) / 2. The base transfer operating payment is the transfer adjustment factor * $21,413.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $21,492.79 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,689.76. The transfer capital threshold is the transfer adjustment factor * $1,689.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13641.00,67130.05,Inpatient DRG
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,345,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],33616.03,,"Fee schedule rate ($33,616.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12134.89,33616.03,There are no additional notes associated with this service or procedure.
"HC Repair Nail Bed|RIGHT HAND, FIFTH DIGIT",CASE-11760,APC,11760,CPT,0450,RC,,,F9,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],11212.09,,"Fee schedule rate ($11,212.09). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,6965.00,21089.59,There are no additional notes associated with this service or procedure.
"NEONATE BIRTH WEIGHT 2000-2499 GRAMS WITH RESPIRATORY DISTRESS SYNDROME OR OTHER MAJOR RESPIRATORY CONDITION,MODERATE",622,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],22037.53,,"Case rate ($20,988.12). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,20988.12,22037.53,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITH STERILIZATION WITH CC,784,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],19922.46,,"Fee schedule rate ($19,922.46). Adds an outlier to normal pricing equal to the per diem rate ($39,437.39) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,9124.01,23722.94,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,086,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],30728.81,,"Fee schedule rate ($30,728.81). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8442.00,30728.81,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],28423.20,,"Fee schedule rate ($28,423.20). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11059.47,28423.20,There are no additional notes associated with this service or procedure.
Laps Vaginal Hysterectomy Uterus 250 Gm/<,CASE-58550,APC,58550,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5658.76,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5658.76,5941.70,OPPS APC
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH MCC",510,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],89863.76,,"Fee schedule rate ($89,863.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10710.00,89863.76,There are no additional notes associated with this service or procedure.
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],25013.10,,"Fee schedule rate ($25,013.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10846.16,25863.45,There are no additional notes associated with this service or procedure.
CELLULITIS WITH MCC,602,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],26710.49,,"Fee schedule rate ($26,710.49). Adds an outlier to normal pricing equal to the per diem rate ($28,488.06) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.8), with a minimum of zero.",,,,0,other,11570.10,28349.31,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],17686.09,,"Fee schedule rate ($17,686.09). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8318.14,19763.43,There are no additional notes associated with this service or procedure.
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC,520,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],21108.05,,"Case rate ($12,061.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,356.39, add-ons for qualifying new technology services are included. If operating cost exceeds $46,227.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,499.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $9,376.87 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,411.44 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $739.93. The transfer capital threshold is the transfer adjustment factor * $739.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,12061.74,39786.42,All Other Inpatient
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],6937.92,,"Case rate ($6,801.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,463.25, add-ons for qualifying new technology services are included. If operating cost exceeds $41,334.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,115.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,501.70 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,518.30 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $355.23. The transfer capital threshold is the transfer adjustment factor * $355.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6801.88,22557.82,Inpatient DRG
CESAREAN SECTION WITH STERILIZATION WITH CC,784,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],9580.21,,"Case rate ($9,124.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,623.49, add-ons for qualifying new technology services are included. If operating cost exceeds $43,494.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,285.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,654.00 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,678.54 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $525.07. The transfer capital threshold is the transfer adjustment factor * $525.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9124.01,23722.94,Inpatient DRG
PREMATURITY WITHOUT MAJOR PROBLEMS,792,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],6380.85,,"Fee schedule rate ($6,380.85). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,1956.00,19457.66,There are no additional notes associated with this service or procedure.
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],16333.88,,,,,,0,other,7566.45,16333.88,There are no additional notes associated with this service or procedure.
SPINAL PROCEDURES WITH MCC,028,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],44765.25,,"Case rate ($42,633.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $39,796.72, add-ons for qualifying new technology services are included. If operating cost exceeds $74,667.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,735.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.5. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 9.5)) / 2. The base transfer operating payment is the transfer adjustment factor * $37,712.72 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $37,851.77 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,975.91. The transfer capital threshold is the transfer adjustment factor * $2,975.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,42633.57,120982.83,Inpatient DRG
NORMAL NEWBORN,795,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],2074.00,,,,,,0,other,1369.79,5771.52,Estimated amount calculated based on 2 day length of stay.
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],68942.79,,"Fee schedule rate ($68,942.79). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,21489.15,68942.79,There are no additional notes associated with this service or procedure.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],15530.92,,"Case rate ($8,874.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,391.65, add-ons for qualifying new technology services are included. If operating cost exceeds $43,262.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,266.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $6,423.02 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,446.70 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $506.84. The transfer capital threshold is the transfer adjustment factor * $506.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,8874.81,20553.44,All Other Inpatient
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],17223.78,,"Fee schedule rate ($17,223.78). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,8151.55,18033.97,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],46523.26,,"Fee schedule rate ($46,523.26). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,17782.11,46523.26,There are no additional notes associated with this service or procedure.
"NEONATE TRANSFERRED < 5 DAYS OLD BORN HERE,MODERATE",581,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],1604.01,,"The inlier payment is calculated as the lesser of the standard DRG payment $1,604.01 and the transfer payment, which is a per diem of $1,253.13. If cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,1604.01,1684.21,Estimated amount calculated based on 1 day length of stay.
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],28423.20,,"Fee schedule rate ($28,423.20). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11059.47,28423.20,There are no additional notes associated with this service or procedure.
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],26725.53,,"Fee schedule rate ($26,725.53). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.6), with a minimum of zero.",,,,0,other,11575.50,48961.48,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],10864.41,,"Case rate ($10,347.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,761.25, add-ons for qualifying new technology services are included. If operating cost exceeds $44,632.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,374.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $7,787.59 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,816.30 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $614.52. The transfer capital threshold is the transfer adjustment factor * $614.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10347.06,28821.04,Inpatient DRG
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],24546.05,,"Case rate ($23,377.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $21,882.92, add-ons for qualifying new technology services are included. If operating cost exceeds $56,753.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,327.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $19,864.72 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $19,937.97 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,567.52. The transfer capital threshold is the transfer adjustment factor * $1,567.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,23377.19,96365.69,Inpatient DRG
CESAREAN SECTION WITHOUT STERILIZATION WITH MCC,786,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],23722.94,,"Fee schedule rate ($23,722.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12612.10,23722.94,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,394,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],8695.64,,"Case rate ($8,281.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,839.77, add-ons for qualifying new technology services are included. If operating cost exceeds $42,710.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,223.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,873.17 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,894.83 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $463.45. The transfer capital threshold is the transfer adjustment factor * $463.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8281.56,20909.61,Inpatient DRG
VENTRICULAR SHUNT PROCEDURES WITH MCC,031,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],62406.76,,"Fee schedule rate ($62,406.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,32287.20,88162.80,There are no additional notes associated with this service or procedure.
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],12195.15,,"Case rate ($12,195.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,480.50, add-ons for qualifying new technology services are included. If operating cost exceeds $46,351.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,509.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,500.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,535.55 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $749.68. The transfer capital threshold is the transfer adjustment factor * $749.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12195.15,39424.57,Inpatient DRG
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],28334.16,,"Fee schedule rate ($28,334.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,7868.00,32126.64,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12234.80,,"Case rate ($11,652.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,993.49, add-ons for qualifying new technology services are included. If operating cost exceeds $45,864.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,452.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $9,014.37 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,048.54 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $692.87. The transfer capital threshold is the transfer adjustment factor * $692.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6167.00,29058.99,Inpatient DRG
PLEURAL EFFUSION WITH MCC,186,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],12306.63,,"Case rate ($11,720.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $11,009.40, add-ons for qualifying new technology services are included. If operating cost exceeds $49,654.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $3,482.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $9,606.87 + an uncompensated DSH payment of $1,359.91. The transfer operating threshold is the transfer adjustment factor * $9,649.48 + an uncompensated DSH payment of $1,359.91. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $753.81. The transfer capital threshold is the transfer adjustment factor * $753.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10804.96,31089.66,Inpatient DRG
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],5139.72,,"Fee schedule rate ($5,139.72). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,5139.72,13110.79,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],14871.83,,"Fee schedule rate ($14,871.83). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6558.75,14871.83,There are no additional notes associated with this service or procedure.
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],7956.52,,"Case rate ($7,956.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,537.38, add-ons for qualifying new technology services are included. If operating cost exceeds $42,408.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,199.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,571.89 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,592.43 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $439.68. The transfer capital threshold is the transfer adjustment factor * $439.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,17467.27,Inpatient DRG
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],18137.75,,"Case rate ($17,782.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,677.93, add-ons for qualifying new technology services are included. If operating cost exceeds $51,548.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,918.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $14,678.86 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,732.98 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,158.31. The transfer capital threshold is the transfer adjustment factor * $1,158.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,17782.11,46523.26,Inpatient DRG
Ligamentous Reconstruction Knee Extra-Articular|LEFT SIDE|SEPARATE STRUCTURE,CASE-27427,APC,27427,CPT,0360,RC,,,LT|XS,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6791.99,7131.59,OPPS APC
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],23899.13,,"Fee schedule rate ($23,899.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9795.13,23899.13,There are no additional notes associated with this service or procedure.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],36988.38,,"Fee schedule rate ($36,988.38). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.7), with a minimum of zero.",,,,0,other,15273.74,39820.52,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7811.65,,"Case rate ($7,547.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,156.87, add-ons for qualifying new technology services are included. If operating cost exceeds $42,027.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,169.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $5,192.77 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,211.92 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $409.76. The transfer capital threshold is the transfer adjustment factor * $409.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6965.00,19126.88,Inpatient DRG
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH MCC",722,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],14532.41,,"Case rate ($13,840.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,033.22, add-ons for qualifying new technology services are included. If operating cost exceeds $47,904.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,609.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $11,046.38 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,088.27 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $849.05. The transfer capital threshold is the transfer adjustment factor * $849.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,14200.37,56869.13,Inpatient DRG
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],20817.01,,"Fee schedule rate ($20,817.01). Adds an outlier to normal pricing equal to the per diem rate ($37,789.38) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,9446.38,21796.21,There are no additional notes associated with this service or procedure.
TRAUMATIC INJURY WITH MCC,913,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],42838.46,,"Fee schedule rate ($42,838.46). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13014.58,42838.46,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],15318.94,,"Fee schedule rate ($15,318.94). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6214.05,15318.94,There are no additional notes associated with this service or procedure.
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],10846.16,,"Case rate ($10,846.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,225.56, add-ons for qualifying new technology services are included. If operating cost exceeds $45,096.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,410.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $8,250.19 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,280.61 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $651.02. The transfer capital threshold is the transfer adjustment factor * $651.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10846.16,25863.45,Inpatient DRG
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITHOUT CC/MCC,517,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],11148.12,,"Case rate ($11,148.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $10,476.23, add-ons for qualifying new technology services are included. If operating cost exceeds $49,120.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $3,441.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $9,076.06 + an uncompensated DSH payment of $1,359.91. The transfer operating threshold is the transfer adjustment factor * $9,116.32 + an uncompensated DSH payment of $1,359.91. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $712.16. The transfer capital threshold is the transfer adjustment factor * $712.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10207.96,29371.86,Inpatient DRG
CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC,788,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],20142.33,,"Fee schedule rate ($20,142.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8438.02,20142.33,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,064,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],41838.16,,"Fee schedule rate ($41,838.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,15563.58,41838.16,There are no additional notes associated with this service or procedure.
Brnchsc Incl Fluor Gdnce Dx W/Cell Washg Spx,CASE-31622,APC,31622,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1666.03,,"APC Price ($1,666.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1666.03,1749.33,OPPS APC
HC Peripheral Block - Femoral Single or Saphenous W/Img Gdn|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64447,APC,64447,CPT,0360,RC,,,LT|XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,7029.71,7131.59,OPPS APC
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5796.79,,"Case rate ($5,520.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,278.11, add-ons for qualifying new technology services are included. If operating cost exceeds $40,149.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,015.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,320.57 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,333.16 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $255.23. The transfer capital threshold is the transfer adjustment factor * $255.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5628.97,12272.58,Inpatient DRG
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],29241.62,,"Fee schedule rate ($29,241.62). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,12984.79,32077.45,There are no additional notes associated with this service or procedure.
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],41190.50,,"Fee schedule rate ($41,190.50). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,16787.98,62990.26,There are no additional notes associated with this service or procedure.
"NEONATE BIRTH WEIGHT 2000-2499 GRAMS WITH OTHER SIGNIFICANT CONDITION,MAJOR",625,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],29788.58,,"Case rate ($28,370.08). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,28370.08,29788.58,There are no additional notes associated with this service or procedure.
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],17755.26,,"Fee schedule rate ($17,755.26). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7847.50,17755.26,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,448,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],50015.29,,"Fee schedule rate ($50,015.29). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,30663.95,94077.13,There are no additional notes associated with this service or procedure.
CERVICAL SPINAL FUSION WITH MCC,471,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],111337.93,,"Fee schedule rate ($111,337.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,34645.26,111337.93,There are no additional notes associated with this service or procedure.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],19877.10,,"Fee schedule rate ($19,877.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8009.34,19877.10,There are no additional notes associated with this service or procedure.
Laps Fulg/Exc Ovary Viscera/Peritoneal Surface|BILATERAL PROCEDURE,CASE-58662,APC,58662,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5658.76,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5658.76,5941.70,OPPS APC
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],16822.43,,"Case rate ($16,021.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,066.20, add-ons for qualifying new technology services are included. If operating cost exceeds $49,937.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,764.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $13,071.69 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,121.25 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,004.72. The transfer capital threshold is the transfer adjustment factor * $1,004.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7453.00,42138.30,Inpatient DRG
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],7224.45,,"Case rate ($7,224.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,856.36, add-ons for qualifying new technology services are included. If operating cost exceeds $41,727.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,146.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $4,893.37 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,911.41 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $386.14. The transfer capital threshold is the transfer adjustment factor * $386.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,15340.19,Inpatient DRG
Laryngoscopy Direct Operative W/Biopsy|UNUSUAL NON-OVERLAPPING SERVICE,CASE-31535,APC,31535,CPT,0360,RC,,,XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3664.31,,"APC Price ($3,489.82). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3489.82,3664.31,OPPS APC
CESAREAN SECTION WITHOUT STERILIZATION WITH CC,787,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],20988.02,,"Fee schedule rate ($20,988.02). Adds an outlier to normal pricing equal to the per diem rate ($39,437.39) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,9508.01,23722.94,There are no additional notes associated with this service or procedure.
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC,058,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],32126.63,,"Fee schedule rate ($32,126.63). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13521.80,40853.02,There are no additional notes associated with this service or procedure.
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],16283.24,,"Fee schedule rate ($16,283.24). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7875.94,17233.12,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],13256.31,,"Case rate ($12,808.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,050.64, add-ons for qualifying new technology services are included. If operating cost exceeds $46,921.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,554.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $10,068.57 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,105.69 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $794.51. The transfer capital threshold is the transfer adjustment factor * $794.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,7353.00,33398.16,Inpatient DRG
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],15733.39,,"Fee schedule rate ($15,733.39). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,13571.25,33781.47,There are no additional notes associated with this service or procedure.
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,069,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],6965.00,,,,,,0,other,6965.00,20333.68,There are no additional notes associated with this service or procedure.
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],40192.59,,"Fee schedule rate ($40,192.59). Adds an outlier to normal pricing equal to the per diem rate ($235,324.88) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.6), with a minimum of zero.",,,,0,other,16428.39,42083.20,There are no additional notes associated with this service or procedure.
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],34245.00,,"Fee schedule rate ($34,245.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,12725.42,34245.00,There are no additional notes associated with this service or procedure.
Egd Flexible Foreign Body Removal,CASE-43247,APC,43247,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1859.01,,"APC Price ($1,796.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1796.14,1885.95,OPPS APC
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],29141.64,,,,,,0,other,11974.38,29141.64,There are no additional notes associated with this service or procedure.
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],32168.63,,"Fee schedule rate ($32,168.63). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,13904.43,34749.58,There are no additional notes associated with this service or procedure.
Tenodesis Long Tendon Biceps|LEFT SIDE,CASE-23430,APC,23430,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7029.71,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6791.99,7131.59,OPPS APC
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],17651.07,,"Fee schedule rate ($17,651.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,6564.18,17651.07,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,167,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],14440.86,,"Case rate ($14,157.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,306.21, add-ons for qualifying new technology services are included. If operating cost exceeds $48,177.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,653.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $11,319.53 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,361.26 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $893.22. The transfer capital threshold is the transfer adjustment factor * $893.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,14157.71,43522.37,Inpatient DRG
BRONCHITIS AND ASTHMA WITHOUT CC/MCC,203,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],13707.00,,,,,,0,other,4763.76,13707.00,There are no additional notes associated with this service or procedure.
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],81454.07,,"Fee schedule rate ($81,454.07). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,10078.00,81454.07,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],30055.64,,"Fee schedule rate ($30,055.64). Adds an outlier to normal pricing equal to the per diem rate ($74,094.67) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.9), with a minimum of zero.",,,,0,other,12775.53,31469.43,There are no additional notes associated with this service or procedure.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,988,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],30888.17,,"Fee schedule rate ($30,888.17). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.5), with a minimum of zero.",,,,0,other,13075.52,42425.46,There are no additional notes associated with this service or procedure.
HC Inj Trigger Pt 1-2 Musc Grps|PBB CHARGE,CASE-20552,APC,20552,CPT,0510,RC,,,PBB,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],297.37,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,287.31,301.68,OPPS APC
"LIMB REATTACHMENT, HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA",956,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],148259.86,,"Fee schedule rate ($148,259.86). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,27428.25,148259.86,There are no additional notes associated with this service or procedure.
OTHER CEREBROVASCULAR DISORDERS WITH CC,071,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],15531.95,,"Fee schedule rate ($15,531.95). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5843.00,29215.10,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],59610.47,,"Fee schedule rate ($59,610.47). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,16129.04,59610.47,There are no additional notes associated with this service or procedure.
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH MCC",510,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],22399.99,,"Case rate ($22,399.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,973.84, add-ons for qualifying new technology services are included. If operating cost exceeds $55,844.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,256.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.3. The base transfer operating payment is the transfer adjustment factor * $18,958.99 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $19,028.89 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,496.05. The transfer capital threshold is the transfer adjustment factor * $1,496.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10710.00,89863.76,Inpatient DRG
"HC Repair Nail Bed|LEFT HAND, THIRD DIGIT",CASE-11760,APC,11760,CPT,0450,RC,,,F2,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],726.38,,"APC Price ($691.79). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,691.79,726.38,OPPS APC
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],36094.03,,"Fee schedule rate ($36,094.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11194.25,36094.03,There are no additional notes associated with this service or procedure.
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],29482.05,,,,,,0,other,6965.00,29482.05,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],52803.53,,"Fee schedule rate ($52,803.53). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,14337.84,52803.53,There are no additional notes associated with this service or procedure.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],12127.84,,"Case rate ($11,717.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,036.36, add-ons for qualifying new technology services are included. If operating cost exceeds $45,907.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,474.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $9,058.01 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,091.41 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $714.77. The transfer capital threshold is the transfer adjustment factor * $714.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,11717.72,43888.01,Inpatient DRG
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],31577.54,,"Fee schedule rate ($31,577.54). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,15453.88,39251.68,There are no additional notes associated with this service or procedure.
"Amputation Toe Metatarsophalangeal Joint|RIGHT HAND, FOURTH DIGIT",CASE-28820,APC,28820,CPT,0360,RC,,,F8,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC",629,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],23741.60,,"Fee schedule rate ($23,741.60). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,16699.94,44657.18,There are no additional notes associated with this service or procedure.
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],26721.94,,"Fee schedule rate ($26,721.94). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6965.00,34422.94,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],96365.69,,"Fee schedule rate ($96,365.69). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,23377.19,96365.69,There are no additional notes associated with this service or procedure.
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],34245.00,,"Fee schedule rate ($34,245.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,12725.42,34245.00,There are no additional notes associated with this service or procedure.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],61290.90,,"Fee schedule rate ($61,290.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,23799.09,63499.65,There are no additional notes associated with this service or procedure.
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,095,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],19411.47,,"Case rate ($19,411.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $18,193.69, add-ons for qualifying new technology services are included. If operating cost exceeds $53,064.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,037.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.6. The base transfer operating payment is the transfer adjustment factor * $16,189.05 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $16,248.74 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,277.48. The transfer capital threshold is the transfer adjustment factor * $1,277.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,19411.47,50750.92,Inpatient DRG
Bx/Exc Lymph Node Open Deep Axillary Node|LEFT SIDE,CASE-38525,APC,38525,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6526.12,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6215.36,6526.12,OPPS APC
HC Peripheral Block - Femoral Single or Saphenous W/Img Gdn,CASE-64447,APC,64447,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],67794.72,,"Fee schedule rate ($67,794.72). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,10862.00,86437.13,There are no additional notes associated with this service or procedure.
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],40714.72,,"Fee schedule rate ($40,714.72). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,17356.15,44778.95,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],8468.48,,"Case rate ($8,468.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,013.65, add-ons for qualifying new technology services are included. If operating cost exceeds $42,884.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,237.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,046.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,068.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $477.12. The transfer capital threshold is the transfer adjustment factor * $477.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6963.00,18954.85,Inpatient DRG
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],17686.09,,"Fee schedule rate ($17,686.09). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8318.14,19763.43,There are no additional notes associated with this service or procedure.
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",004,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],10715.36,,,,,,0,other,10249.47,272554.00,Estimated amount calculated based on 6 day length of stay.
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],14678.03,,"Case rate ($13,979.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,162.50, add-ons for qualifying new technology services are included. If operating cost exceeds $48,033.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,618.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $11,175.18 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,217.55 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $858.95. The transfer capital threshold is the transfer adjustment factor * $858.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,14343.25,36024.65,Inpatient DRG
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],30112.02,,"Fee schedule rate ($30,112.02). Adds an outlier to normal pricing equal to the per diem rate ($53,484.01) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.5), with a minimum of zero.",,,,0,other,12795.84,41944.25,There are no additional notes associated with this service or procedure.
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],37016.57,,"Fee schedule rate ($37,016.57). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15), with a minimum of zero.",,,,0,other,15283.90,38757.79,There are no additional notes associated with this service or procedure.
Blepharoplasty Upper Eyelid W/Excessive Skin,CASE-15823,APC,15823,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1998.87,,"APC Price ($1,931.28). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1931.28,2027.84,OPPS APC
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],16283.24,,"Fee schedule rate ($16,283.24). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7875.94,17233.12,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],2401.00,,,,,,0,other,1188.00,17370.86,Estimated amount calculated based on 3 day length of stay.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],26420.44,,"Case rate ($25,162.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $23,543.58, add-ons for qualifying new technology services are included. If operating cost exceeds $58,414.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,458.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $21,519.28 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $21,598.63 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,698.08. The transfer capital threshold is the transfer adjustment factor * $1,698.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,25162.32,75579.22,Inpatient DRG
DIABETES WITHOUT CC/MCC,639,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6367.07,,"Case rate ($6,151.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,858.45, add-ons for qualifying new technology services are included. If operating cost exceeds $40,729.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,067.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $3,899.13 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,913.51 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $307.68. The transfer capital threshold is the transfer adjustment factor * $307.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6151.76,12223.35,Inpatient DRG
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC,805,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],9253.36,,"Case rate ($9,253.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,743.82, add-ons for qualifying new technology services are included. If operating cost exceeds $43,614.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,294.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $6,773.89 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,798.87 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $534.53. The transfer capital threshold is the transfer adjustment factor * $534.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9253.36,21235.42,Inpatient DRG
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],46215.75,,"Fee schedule rate ($46,215.75). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.7), with a minimum of zero.",,,,0,other,18598.83,48389.68,There are no additional notes associated with this service or procedure.
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],29216.99,,"Fee schedule rate ($29,216.99). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9755.86,29216.99,There are no additional notes associated with this service or procedure.
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],14886.62,,"Case rate ($14,383.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,516, add-ons for qualifying new technology services are included. If operating cost exceeds $48,387.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,669.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,528.54 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,571.05 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $909.72. The transfer capital threshold is the transfer adjustment factor * $909.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6965.00,36140.75,Inpatient DRG
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],41213.48,,,,,,0,other,16129.04,59610.47,There are no additional notes associated with this service or procedure.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],26729.05,,"Case rate ($15,273.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,344.45, add-ons for qualifying new technology services are included. If operating cost exceeds $49,215.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,734.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $12,353.94 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,399.49 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $974.85. The transfer capital threshold is the transfer adjustment factor * $974.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,15273.74,39820.52,All Other Inpatient
"MAJOR RESPIRATORY INFECTIONS AND INFLAMMATIONS,MODERATE",137,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],7487.43,,"Case rate ($7,130.89). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7130.89,7487.43,There are no additional notes associated with this service or procedure.
Removal Intrauterine Device Iud,CASE-58301,APC,58301,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],285.23,,"APC Price ($285.23). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,285.23,295.22,OPPS APC
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],12558.65,,"Fee schedule rate ($12,558.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5065.00,12558.65,There are no additional notes associated with this service or procedure.
VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC,033,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],42156.44,,"Fee schedule rate ($42,156.44). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,13206.23,42156.44,There are no additional notes associated with this service or procedure.
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],28334.16,,"Fee schedule rate ($28,334.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,7868.00,32126.64,There are no additional notes associated with this service or procedure.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,479,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],50518.76,,"Fee schedule rate ($50,518.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,10586.00,50518.76,There are no additional notes associated with this service or procedure.
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],16064.26,,"Fee schedule rate ($16,064.26). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7733.72,18043.23,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],94787.57,,"Fee schedule rate ($94,787.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,23526.87,94787.57,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH CC,427,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],135659.15,,"Fee schedule rate ($135,659.15). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.8), with a minimum of zero.",,,,0,other,50829.82,142040.39,There are no additional notes associated with this service or procedure.
"NEONATE BIRTH WEIGHT 2000-2499 GRAMS NORMAL NEWBORN OR NEONATE WITH OTHER PROBLEM,MINOR",626,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],1505.34,,"Case rate ($1,505.34). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,1505.34,1580.61,There are no additional notes associated with this service or procedure.
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],34749.58,,,,,,0,other,13904.43,34749.58,There are no additional notes associated with this service or procedure.
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],17169.59,,"Case rate ($16,351.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,374.39, add-ons for qualifying new technology services are included. If operating cost exceeds $50,245.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,788.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $13,378.72 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,429.44 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,028.32. The transfer capital threshold is the transfer adjustment factor * $1,028.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,16787.98,62990.26,Inpatient DRG
Colpopexy Vaginal Intraperitoneal Approach|UNUSUAL NON-OVERLAPPING SERVICE,CASE-57283,APC,57283,CPT,0360,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6941.03,,"APC Price ($6,941.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6941.03,7288.08,OPPS APC
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],35061.53,,"Fee schedule rate ($35,061.53). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,9696.93,35061.53,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],24567.74,,"Case rate ($24,567.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $22,990.45, add-ons for qualifying new technology services are included. If operating cost exceeds $57,861.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,414.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.7. The base transfer operating payment is the transfer adjustment factor * $20,968.18 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $21,045.49 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,654.60. The transfer capital threshold is the transfer adjustment factor * $1,654.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9370.00,65732.99,Inpatient DRG
Hysteroscopy Endometrial Ablation,CASE-58563,APC,58563,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],4916.53,,"APC Price ($4,682.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,4682.41,4916.53,OPPS APC
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],10626.21,,"Case rate ($10,120.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,550.21, add-ons for qualifying new technology services are included. If operating cost exceeds $44,421.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,357.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $7,577.32 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,605.26 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $597.93. The transfer capital threshold is the transfer adjustment factor * $597.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10120.20,26204.74,Inpatient DRG
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC",442,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],18157.80,,"Fee schedule rate ($18,157.80). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6607.45,19011.92,There are no additional notes associated with this service or procedure.
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],18594.09,,"Case rate ($18,594.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,433.29, add-ons for qualifying new technology services are included. If operating cost exceeds $52,304.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,977.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $15,431.44 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,488.34 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,217.69. The transfer capital threshold is the transfer adjustment factor * $1,217.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,18594.09,59494.91,Inpatient DRG
"Neuroplasty Other Arm/Leg Nerve,Open|RIGHT SIDE",CASE-64708,APC,64708,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7029.71,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6791.99,7131.59,OPPS APC
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC,027,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],19410.80,,"Case rate ($19,030.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,839, add-ons for qualifying new technology services are included. If operating cost exceeds $52,710.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,009.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $15,835.66 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,894.05 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,249.59. The transfer capital threshold is the transfer adjustment factor * $1,249.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 102%.",,,,0,other,19030.20,56363.30,Inpatient DRG
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,097,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],26404.32,,"Case rate ($26,404.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $24,698.97, add-ons for qualifying new technology services are included. If operating cost exceeds $59,569.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,548.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.7. The base transfer operating payment is the transfer adjustment factor * $22,670.44 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $22,754.03 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,788.92. The transfer capital threshold is the transfer adjustment factor * $1,788.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,26404.32,79915.74,Inpatient DRG
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],31401.22,,"Fee schedule rate ($31,401.22). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.7), with a minimum of zero.",,,,0,other,13260.40,32878.30,There are no additional notes associated with this service or procedure.
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],7086.00,,"Per diem ($7,086). If length of stay < 7.8, first 1 days paid at a per diem of $14,172 instead. Capped at $55,272.09.",,,,0,other,7086.00,57872.02,Estimated amount calculated based on 5 day length of stay.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],22292.26,,"Fee schedule rate ($22,292.26). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9977.99,26949.28,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],59476.09,,"Fee schedule rate ($59,476.09). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15.9), with a minimum of zero.",,,,0,other,23377.19,96365.69,There are no additional notes associated with this service or procedure.
Laparoscopy W/Rmvl Adnexal Structures|RIGHT SIDE,CASE-58661,APC,58661,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5941.70,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5658.76,5941.70,OPPS APC
Exc Cyst/Aberrant Breast Tissue Open 1/> Lesion|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-19120,APC,19120,CPT,0360,RC,,,RT|XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6526.12,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6215.36,6526.12,OPPS APC
CHOLECYSTECTOMY WITH C.D.E. WITH MCC,411,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],88615.28,,"Fee schedule rate ($88,615.28). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,24315.13,88615.28,There are no additional notes associated with this service or procedure.
"CESAREAN SECTION WITH STERILIZATION,MODERATE",539,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],8204.64,,"Case rate ($7,813.94). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7813.94,8204.64,There are no additional notes associated with this service or procedure.
TRAUMATIC INJURY WITH MCC,913,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],30719.04,,"Fee schedule rate ($30,719.04). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.5), with a minimum of zero.",,,,0,other,13014.58,42838.46,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],28821.04,,"Fee schedule rate ($28,821.04). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,10347.06,28821.04,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],29058.99,,,,,,0,other,6167.00,29058.99,There are no additional notes associated with this service or procedure.
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC,805,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],20281.41,,"Fee schedule rate ($20,281.41). Adds an outlier to normal pricing equal to the per diem rate ($31,438.44) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.5), with a minimum of zero.",,,,0,other,9253.36,21235.42,There are no additional notes associated with this service or procedure.
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],14383.21,,"Case rate ($14,383.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,516, add-ons for qualifying new technology services are included. If operating cost exceeds $48,387.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,669.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,528.54 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,571.05 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $909.72. The transfer capital threshold is the transfer adjustment factor * $909.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,36140.75,Inpatient DRG
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITH MCC,429,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],177294.98,,"Fee schedule rate ($177,294.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,62958.58,177294.98,There are no additional notes associated with this service or procedure.
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],6201.19,,"Case rate ($6,201.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,904.45, add-ons for qualifying new technology services are included. If operating cost exceeds $40,775.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,071.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,944.95 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,959.50 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $311.30. The transfer capital threshold is the transfer adjustment factor * $311.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,5937.41,12366.99,Inpatient DRG
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],21382.16,,"Case rate ($21,382.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,026.97, add-ons for qualifying new technology services are included. If operating cost exceeds $54,897.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,181.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6)) / 2. The base transfer operating payment is the transfer adjustment factor * $18,015.59 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,082.01 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,421.61. The transfer capital threshold is the transfer adjustment factor * $1,421.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,21382.16,85466.62,Inpatient DRG
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7344.86,,"Case rate ($6,995.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,652.42, add-ons for qualifying new technology services are included. If operating cost exceeds $41,523.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,120.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $4,689.69 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,707.47 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $360.46. The transfer capital threshold is the transfer adjustment factor * $360.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,16400.70,Inpatient DRG
"CHOLECYSTECTOMY,MAJOR",263,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],21727.85,,"Case rate ($20,693.19). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,20693.19,21727.85,There are no additional notes associated with this service or procedure.
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],28394.78,,"Fee schedule rate ($28,394.78). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11454.97,28394.78,There are no additional notes associated with this service or procedure.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],10177.55,,"Case rate ($9,977.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,417.91, add-ons for qualifying new technology services are included. If operating cost exceeds $44,288.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,347.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $7,445.51 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,472.96 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $587.52. The transfer capital threshold is the transfer adjustment factor * $587.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,9977.99,26949.28,Inpatient DRG
"Corrj Hallux Valgus W/Sesmdc W/Rescj Prox Phal|LEFT FOOT, GREAT TOE",CASE-28292,APC,28292,CPT,0360,RC,,,TA,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC,939,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],68190.40,,"Fee schedule rate ($68,190.40). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16.5), with a minimum of zero.",,,,0,other,26517.40,97674.79,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7032.89,,"Case rate ($6,697.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,375.48, add-ons for qualifying new technology services are included. If operating cost exceeds $41,246.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,099.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $4,413.79 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,430.53 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $339.25. The transfer capital threshold is the transfer adjustment factor * $339.25. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6841.83,21167.26,Inpatient DRG
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],12272.58,,"Fee schedule rate ($12,272.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5628.97,12272.58,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC,817,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],17744.03,,"Case rate ($17,396.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,318.84, add-ons for qualifying new technology services are included. If operating cost exceeds $51,189.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,890.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $14,321.08 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,373.88 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,130.07. The transfer capital threshold is the transfer adjustment factor * $1,130.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,17396.11,44895.04,Inpatient DRG
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],27553.62,,"Fee schedule rate ($27,553.62). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12305.53,30103.84,There are no additional notes associated with this service or procedure.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],8929.50,,"Case rate ($8,504.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,059.21, add-ons for qualifying new technology services are included. If operating cost exceeds $42,930.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,228.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,091.17 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,114.26 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $468.18. The transfer capital threshold is the transfer adjustment factor * $468.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5683.00,19635.68,Inpatient DRG
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITHOUT CC/MCC,816,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],14733.53,,"Fee schedule rate ($14,733.53). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6224.90,14733.53,There are no additional notes associated with this service or procedure.
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",759,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],6760.85,,"Case rate ($6,438.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,125.57, add-ons for qualifying new technology services are included. If operating cost exceeds $40,996.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,088.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,165.27 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,180.62 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $328.68. The transfer capital threshold is the transfer adjustment factor * $328.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6190.22,13057.66,Inpatient DRG
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],15832.71,,"Case rate ($15,078.77). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,187.57, add-ons for qualifying new technology services are included. If operating cost exceeds $49,058.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,697.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $12,196.37 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,242.62 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $937.44. The transfer capital threshold is the transfer adjustment factor * $937.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,15476.23,42787.31,Inpatient DRG
Rpr 1st Fem Hernia Any Age Incarcerated|RIGHT SIDE,CASE-49553,APC,49553,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3518.91,,"APC Price ($3,351.34). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3351.34,3518.91,OPPS APC
CESAREAN SECTION WITH STERILIZATION WITH CC,784,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],23722.94,,"Fee schedule rate ($23,722.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9124.01,23722.94,There are no additional notes associated with this service or procedure.
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],25013.10,,"Fee schedule rate ($25,013.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10846.16,25863.45,There are no additional notes associated with this service or procedure.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],63499.65,,,,,,0,other,23799.09,63499.65,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],30372.64,,"Fee schedule rate ($30,372.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,13260.40,32878.30,There are no additional notes associated with this service or procedure.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],53739.90,,"Fee schedule rate ($53,739.90). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,35389.50,101083.00,There are no additional notes associated with this service or procedure.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],16900.84,,"Fee schedule rate ($16,900.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8151.55,18033.97,There are no additional notes associated with this service or procedure.
"NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY",789,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],6663.33,,,,,,0,other,3054.00,14857.05,Estimated amount calculated based on 1 day length of stay.
Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx,CASE-28270,APC,28270,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
NORMAL NEWBORN,795,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],3298.01,,"Case rate ($3,298.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $3,203.67, add-ons for qualifying new technology services are included. If operating cost exceeds $38,074.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $1,858.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $1,254.10 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $1,258.72 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $98.96. The transfer capital threshold is the transfer adjustment factor * $98.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,1369.79,5771.52,Inpatient DRG
NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,601,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],11369.77,,"Fee schedule rate ($11,369.77). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,6042.05,12359.72,There are no additional notes associated with this service or procedure.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC,434,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],7108.55,,"Case rate ($6,770.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,433.64, add-ons for qualifying new technology services are included. If operating cost exceeds $41,304.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,112.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,472.20 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,488.69 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $352.90. The transfer capital threshold is the transfer adjustment factor * $352.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6770.05,14019.86,Inpatient DRG
SIGNS AND SYMPTOMS WITH MCC,947,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],30414.32,,"Fee schedule rate ($30,414.32). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,10541.41,30414.32,There are no additional notes associated with this service or procedure.
"PERIPHERAL AND OTHER VASCULAR DISORDERS,MAJOR",197,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],11491.34,,"Case rate ($10,944.13). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10944.13,11491.34,There are no additional notes associated with this service or procedure.
Laparoscopy Radical Nephrectomy|RIGHT SIDE,CASE-50545,APC,50545,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],347.26,,"APC Price ($335.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,347.26,352.29,OPPS APC
CERVICAL SPINAL FUSION WITHOUT CC/MCC,473,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],18477.61,,"Case rate ($18,477.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,324.93, add-ons for qualifying new technology services are included. If operating cost exceeds $52,195.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,969.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.6. The base transfer operating payment is the transfer adjustment factor * $15,323.48 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,379.98 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,209.17. The transfer capital threshold is the transfer adjustment factor * $1,209.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,18477.61,62077.11,Inpatient DRG
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],20506.01,,"Case rate ($11,717.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,036.36, add-ons for qualifying new technology services are included. If operating cost exceeds $45,907.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,474.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $9,058.01 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,091.41 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $714.77. The transfer capital threshold is the transfer adjustment factor * $714.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,11717.72,43888.01,All Other Inpatient
COAGULATION DISORDERS,813,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],29046.49,,"Fee schedule rate ($29,046.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12274.39,30013.33,There are no additional notes associated with this service or procedure.
Neuroplasty &/Transpos Median Nrv Carpal Tunne|RIGHT SIDE,CASE-64721,APC,64721,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1891.77,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1827.80,1919.19,OPPS APC
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],31528.46,,,,,,0,other,12795.84,41944.25,There are no additional notes associated with this service or procedure.
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],15019.71,,"Case rate ($14,725.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,834.15, add-ons for qualifying new technology services are included. If operating cost exceeds $48,705.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,694.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,845.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,889.20 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $934.73. The transfer capital threshold is the transfer adjustment factor * $934.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,7389.00,37134.43,Inpatient DRG
OTHER CEREBROVASCULAR DISORDERS WITH MCC,070,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],13880.04,,"Case rate ($13,219.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,433.04, add-ons for qualifying new technology services are included. If operating cost exceeds $47,304.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,584.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $10,449.57 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,488.10 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $824.57. The transfer capital threshold is the transfer adjustment factor * $824.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13219.09,37774.46,Inpatient DRG
O.R. PROCEDURES FOR OBESITY WITH CC,620,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],22369.03,,"Case rate ($12,782.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,026.70, add-ons for qualifying new technology services are included. If operating cost exceeds $46,897.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,552.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $10,044.72 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,081.75 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $792.63. The transfer capital threshold is the transfer adjustment factor * $792.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,12782.30,43753.50,All Other Inpatient
Insj Biomchn Dev Intervertebral Dsc Spc W/Arthrd,CASE-22853,APC,22853,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],12618.18,,"APC Price ($12,017.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,12017.31,12618.18,OPPS APC
Lamnotmy Incl W/Dcmprsn Nrv Root 1 Intrspc Lumbr|RIGHT SIDE,CASE-63030,APC,63030,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7029.71,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6791.99,7131.59,OPPS APC
HC Non Stress Test|UNUSUAL NON-OVERLAPPING SERVICE,CASE-59025,APC,59025,CPT,0920,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],189.24,,"APC Price ($189.24). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,189.24,198.70,OPPS APC
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC,832,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],13561.03,,"Fee schedule rate ($13,561.03). Adds an outlier to normal pricing equal to the per diem rate ($18,253.69) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,4803.31,14198.92,There are no additional notes associated with this service or procedure.
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],12091.53,,"Case rate ($12,091.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,384.11, add-ons for qualifying new technology services are included. If operating cost exceeds $46,255.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,502.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $9,404.49 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,439.16 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $742.11. The transfer capital threshold is the transfer adjustment factor * $742.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,29482.05,Inpatient DRG
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],6965.00,,,,,,0,other,6965.00,19126.88,There are no additional notes associated with this service or procedure.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,098,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],18098.19,,"Case rate ($17,486.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,402.62, add-ons for qualifying new technology services are included. If operating cost exceeds $51,273.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,896.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $14,404.56 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,457.67 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,136.66. The transfer capital threshold is the transfer adjustment factor * $1,136.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6965.00,45156.75,Inpatient DRG
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC",494,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],16309.76,,"Case rate ($15,533.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,585.72, add-ons for qualifying new technology services are included. If operating cost exceeds $49,456.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,753.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $12,594.34 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,640.78 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $993.82. The transfer capital threshold is the transfer adjustment factor * $993.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,15533.10,39945.55,Inpatient DRG
SPINAL PROCEDURES WITHOUT CC/MCC,030,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],17651.54,,"Case rate ($16,810.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,774.52, add-ons for qualifying new technology services are included. If operating cost exceeds $50,645.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,847.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $13,778.77 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,829.57 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,087.28. The transfer capital threshold is the transfer adjustment factor * $1,087.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,16810.99,44714.01,Inpatient DRG
OSTEOMYELITIS WITHOUT CC/MCC,541,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],7641.14,,"Case rate ($7,277.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,905.50, add-ons for qualifying new technology services are included. If operating cost exceeds $41,776.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,149.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $4,942.33 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,960.55 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $390.00. The transfer capital threshold is the transfer adjustment factor * $390.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5103.00,15493.67,Inpatient DRG
Excision Distal Ulna Partial/Complete,CASE-25240,APC,25240,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3062.67,OPPS APC
Split Agrft F/S/N/H/F/G/M/D Gt 1st 100 Cm/</1 %,CASE-15120,APC,15120,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3433.11,,"APC Price ($3,317.01). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3317.01,3482.86,OPPS APC
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],10049.53,,"Case rate ($9,570.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,039.28, add-ons for qualifying new technology services are included. If operating cost exceeds $43,910.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,317.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $7,068.27 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,094.33 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $557.76. The transfer capital threshold is the transfer adjustment factor * $557.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5569.00,40108.48,Inpatient DRG
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],9888.00,,"Per diem ($9,888). If length of stay < 3.1, first 1 days paid at a per diem of $19,776 instead. Capped at $30,651.38.",,,,0,other,9888.00,43399.23,Estimated amount calculated based on 1 day length of stay.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC",061,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],51814.18,,"Fee schedule rate ($51,814.18). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,20616.23,62315.82,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],30063.84,,"Fee schedule rate ($30,063.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13891.57,34712.20,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],12818.71,,"Fee schedule rate ($12,818.71). Adds an outlier to normal pricing equal to the per diem rate ($42,942.49) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,6564.18,17651.07,There are no additional notes associated with this service or procedure.
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],18618.15,,"Case rate ($10,638.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,032.78, add-ons for qualifying new technology services are included. If operating cost exceeds $44,903.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,395.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,058.12 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,087.83 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $635.87. The transfer capital threshold is the transfer adjustment factor * $635.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,10638.94,25261.33,All Other Inpatient
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],7238.69,,"Case rate ($7,238.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,869.60, add-ons for qualifying new technology services are included. If operating cost exceeds $41,740.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,147.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,906.55 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,924.64 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $387.18. The transfer capital threshold is the transfer adjustment factor * $387.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7238.69,16804.22,Inpatient DRG
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],10049.53,,"Case rate ($9,570.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,039.28, add-ons for qualifying new technology services are included. If operating cost exceeds $43,910.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,317.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $7,068.27 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,094.33 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $557.76. The transfer capital threshold is the transfer adjustment factor * $557.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5569.00,40108.48,Inpatient DRG
"CVA AND PRECEREBRAL OCCLUSION WITH INFARCTION,EXTREME",045,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],21474.91,,"Case rate ($21,474.91). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $45,251, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,21474.91,22548.66,There are no additional notes associated with this service or procedure.
Prq Impltj Neurostim Eltrd Sacral Nrve W/Imaging,CASE-64561,APC,64561,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6263.54,,"APC Price ($5,965.28). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5965.28,6263.54,OPPS APC
"OTHER DIGESTIVE SYSTEM AND ABDOMINAL PROCEDURES,EXTREME",229,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],43070.04,,"Case rate ($41,019.09). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,41019.09,43070.04,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],37914.65,,"Fee schedule rate ($37,914.65). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9865.56,37914.65,There are no additional notes associated with this service or procedure.
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],7053.95,,"Case rate ($6,915.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,569.08, add-ons for qualifying new technology services are included. If operating cost exceeds $41,440.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,123.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,607.15 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,624.14 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $363.55. The transfer capital threshold is the transfer adjustment factor * $363.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6915.64,14442.92,Inpatient DRG
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],12651.45,,"Fee schedule rate ($12,651.45). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,6503.90,14492.93,There are no additional notes associated with this service or procedure.
Inj for Sacroiliac Jt Anesth|BILATERAL PROCEDURE,CASE-G0260,APC,G0260,CPT,0360,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],683.85,,"APC Price ($660.72). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,660.72,693.76,OPPS APC
Exc B9 Lesion Mrgn Xcp Sk Tg T/a/L >4.0 Cm,CASE-11406,APC,11406,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1545.93,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1545.93,1623.23,OPPS APC
Tendon Sheath Incision,CASE-26055,APC,26055,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1505.12,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1505.12,1580.37,OPPS APC
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],15453.88,,"Case rate ($15,453.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,512.02, add-ons for qualifying new technology services are included. If operating cost exceeds $49,383.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,747.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $12,520.90 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,567.07 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $988.02. The transfer capital threshold is the transfer adjustment factor * $988.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,15453.88,39251.68,Inpatient DRG
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],26949.28,,"Fee schedule rate ($26,949.28). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9977.99,26949.28,There are no additional notes associated with this service or procedure.
HC Inject Tendon Origin/Insert|BILATERAL PROCEDURE,CASE-20551,APC,20551,CPT,0361,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],297.37,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,287.31,301.68,OPPS APC
Amputation Metatarsal W/Toe Single,CASE-28810,APC,28810,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3062.67,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],22626.77,,"Fee schedule rate ($22,626.77). Adds an outlier to normal pricing equal to the per diem rate ($36,883.74) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.5), with a minimum of zero.",,,,0,other,10098.51,24259.09,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,373,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],13780.60,,"Fee schedule rate ($13,780.60). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6870.94,14313.05,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],22414.05,,"Case rate ($12,808.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,050.64, add-ons for qualifying new technology services are included. If operating cost exceeds $46,921.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,554.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $10,068.57 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,105.69 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $794.51. The transfer capital threshold is the transfer adjustment factor * $794.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,7353.00,33398.16,All Other Inpatient
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],19528.77,,"Case rate ($18,598.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,437.70, add-ons for qualifying new technology services are included. If operating cost exceeds $52,308.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,978.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 5.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $15,435.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,492.75 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,218.04. The transfer capital threshold is the transfer adjustment factor * $1,218.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,18598.83,48389.68,Inpatient DRG
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],52699.33,,"Fee schedule rate ($52,699.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,18105.81,52699.33,There are no additional notes associated with this service or procedure.
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],6010.23,,"Case rate ($6,010.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,726.79, add-ons for qualifying new technology services are included. If operating cost exceeds $40,597.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,057.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,767.95 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,781.84 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $297.33. The transfer capital threshold is the transfer adjustment factor * $297.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6010.23,12246.05,Inpatient DRG
"VAGINAL DELIVERY WITH O.R. PROCEDURE EXCEPT STERILIZATION AND/OR D&C,MODERATE",542,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],5254.11,,"Case rate ($5,003.91). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5003.91,5254.11,There are no additional notes associated with this service or procedure.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],38517.10,,"Fee schedule rate ($38,517.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,16897.01,43444.85,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],59610.47,,"Fee schedule rate ($59,610.47). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,16129.04,59610.47,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],70242.60,,"Fee schedule rate ($70,242.60). Adds an outlier to normal pricing equal to the per diem rate ($137,416) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16.5), with a minimum of zero.",,,,0,other,27256.92,81353.66,There are no additional notes associated with this service or procedure.
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],23870.71,,"Fee schedule rate ($23,870.71). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10626.74,25225.91,There are no additional notes associated with this service or procedure.
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],11133.98,,"Fee schedule rate ($11,133.98). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5919.29,13545.65,There are no additional notes associated with this service or procedure.
Destruction Neurolytic Agt Genicular Nerve W/Img,CASE-64624,APC,64624,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1919.19,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1827.80,1919.19,OPPS APC
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],7766.29,,"Case rate ($7,396.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,016.38, add-ons for qualifying new technology services are included. If operating cost exceeds $41,887.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,158.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,052.80 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,071.43 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $398.72. The transfer capital threshold is the transfer adjustment factor * $398.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7396.47,16035.06,Inpatient DRG
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],81454.07,,"Fee schedule rate ($81,454.07). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,10078.00,81454.07,There are no additional notes associated with this service or procedure.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],16120.25,,"Case rate ($16,120.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,131.93, add-ons for qualifying new technology services are included. If operating cost exceeds $50,002.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,796.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $13,138.54 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,186.98 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,036.76. The transfer capital threshold is the transfer adjustment factor * $1,036.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,16120.25,41187.90,Inpatient DRG
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,191,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],16587.71,,,,,,0,other,6965.00,16612.88,There are no additional notes associated with this service or procedure.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],18867.18,,"Case rate ($18,497.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,343.20, add-ons for qualifying new technology services are included. If operating cost exceeds $52,214.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,970.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $15,341.68 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,398.25 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,210.61. The transfer capital threshold is the transfer adjustment factor * $1,210.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,18497.24,62041.12,Inpatient DRG
Esophagoscopy Intra/Transmural Needle Aspirat/Bx,CASE-43232,APC,43232,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1796.14,,"APC Price ($1,796.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1796.14,1885.95,OPPS APC
Cystourethroscopy|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-52000,APC,52000,CPT,0360,RC,,,74,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],652.69,,"APC Price ($652.69). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,652.69,685.32,OPPS APC
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,451,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],23821.44,,"Case rate ($23,821.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $22,296.19, add-ons for qualifying new technology services are included. If operating cost exceeds $57,167.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,359.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $20,276.48 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $20,351.24 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,600.01. The transfer capital threshold is the transfer adjustment factor * $1,600.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,23821.44,94077.13,Inpatient DRG
NONTRAUMATIC STUPOR AND COMA WITH MCC,080,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],30179.40,,"Fee schedule rate ($30,179.40). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,14202.39,35615.37,There are no additional notes associated with this service or procedure.
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],6511.25,,"Case rate ($6,201.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,904.45, add-ons for qualifying new technology services are included. If operating cost exceeds $40,775.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,071.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,944.95 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,959.50 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $311.30. The transfer capital threshold is the transfer adjustment factor * $311.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5937.41,12366.99,Inpatient DRG
Excision Olecranon Bursa|LEFT SIDE,CASE-24105,APC,24105,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,085,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],17330.41,,"Case rate ($17,330.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,257.72, add-ons for qualifying new technology services are included. If operating cost exceeds $51,128.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,885.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $14,260.20 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,312.77 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,125.27. The transfer capital threshold is the transfer adjustment factor * $1,125.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9282.00,57443.16,Inpatient DRG
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],16900.84,,"Fee schedule rate ($16,900.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8151.55,18033.97,There are no additional notes associated with this service or procedure.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,418,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],14070.61,,"Case rate ($13,400.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,601.88, add-ons for qualifying new technology services are included. If operating cost exceeds $47,472.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,597.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $10,617.79 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,656.93 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $837.85. The transfer capital threshold is the transfer adjustment factor * $837.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13400.58,39884.93,Inpatient DRG
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],23790.06,,"Fee schedule rate ($23,790.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10517.71,24909.11,There are no additional notes associated with this service or procedure.
Laps Surg Rpr Recurrent Inguinal Hernia|RIGHT SIDE,CASE-49651,APC,49651,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5941.70,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5658.76,5941.70,OPPS APC
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR,518,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],89342.77,,"Fee schedule rate ($89,342.77). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,13252.00,89342.77,There are no additional notes associated with this service or procedure.
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,451,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],94077.13,,"Fee schedule rate ($94,077.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,23821.44,94077.13,There are no additional notes associated with this service or procedure.
COMPLICATIONS OF TREATMENT WITH CC,920,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],11490.15,,"Fee schedule rate ($11,490.15). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8732.59,20731.52,There are no additional notes associated with this service or procedure.
"Laminec/Facetect/Foramin,Lumbar|LEFT SIDE",CASE-63047,APC,63047,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6791.99,7131.59,OPPS APC
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],15076.44,,"Fee schedule rate ($15,076.44). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6340.03,15076.44,There are no additional notes associated with this service or procedure.
Exc Tumor Soft Tissue Thigh/Knee Subfasc <5cm|LEFT SIDE,CASE-27328,APC,27328,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],2854.83,,"APC Price ($2,718.88). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2718.88,2854.83,OPPS APC
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],37914.65,,"Fee schedule rate ($37,914.65). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9865.56,37914.65,There are no additional notes associated with this service or procedure.
"Tendon Sheath Incision|RIGHT HAND, THUMB",CASE-26055,APC,26055,CPT,0360,RC,,,F5,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1580.37,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1505.12,1580.37,OPPS APC
HC Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn,CASE-62321,APC,62321,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],693.76,,"APC Price ($660.72). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,660.72,693.76,OPPS APC
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC,058,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],40853.02,,"Fee schedule rate ($40,853.02). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,13521.80,40853.02,There are no additional notes associated with this service or procedure.
Arthrs Aided Ant Cruciate Ligm Rpr/Agmntj/Rcnstj|LEFT SIDE,CASE-29888,APC,29888,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],12017.31,,"APC Price ($12,017.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12017.31,12618.18,OPPS APC
NEONATE WITH OTHER SIGNIFICANT PROBLEMS,794,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],12536.83,,"Case rate ($11,939.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,242.99, add-ons for qualifying new technology services are included. If operating cost exceeds $46,114.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,490.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $9,263.89 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,298.04 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $731.01. The transfer capital threshold is the transfer adjustment factor * $731.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,1798.85,12536.83,Inpatient DRG
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],32168.63,,"Fee schedule rate ($32,168.63). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,13904.43,34749.58,There are no additional notes associated with this service or procedure.
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],54180.83,,"Fee schedule rate ($54,180.83). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,15491.11,54180.83,There are no additional notes associated with this service or procedure.
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,306,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],31007.02,,,,,,0,other,12616.37,31007.02,There are no additional notes associated with this service or procedure.
FULL TERM NEONATE WITH MAJOR PROBLEMS,793,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],31690.87,,"Case rate ($30,181.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $28,213.07, add-ons for qualifying new technology services are included. If operating cost exceeds $63,084.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,825.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $26,171.62 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $26,268.12 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,065.20. The transfer capital threshold is the transfer adjustment factor * $2,065.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,4302.90,82045.22,Inpatient DRG
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],16669.71,,"Fee schedule rate ($16,669.71). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8767.81,19824.58,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,086,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],16336.70,,"Fee schedule rate ($16,336.70). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8442.00,30728.81,There are no additional notes associated with this service or procedure.
PREMATURITY WITH MAJOR PROBLEMS,791,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],3048.21,,,,,,0,other,3048.21,30904.42,Estimated amount calculated based on 5 day length of stay.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],12527.66,,"Case rate ($12,527.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,789.82, add-ons for qualifying new technology services are included. If operating cost exceeds $46,660.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,533.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $9,808.71 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,844.88 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $774.00. The transfer capital threshold is the transfer adjustment factor * $774.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12527.66,29917.96,Inpatient DRG
HC Inject Tendon Origin/Insert|RIGHT SIDE,CASE-20551,APC,20551,CPT,0361,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],297.37,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,287.31,301.68,OPPS APC
PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,337,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],38926.31,,"Fee schedule rate ($38,926.31). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,12340.08,38926.31,There are no additional notes associated with this service or procedure.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC,858,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],17966.34,,"Fee schedule rate ($17,966.34). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11377.76,33794.11,There are no additional notes associated with this service or procedure.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],19868.19,,"Case rate ($18,922.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,770.10, add-ons for qualifying new technology services are included. If operating cost exceeds $52,641.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,971.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.9. The base transfer operating payment is the transfer adjustment factor * $15,765.37 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,825.15 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,211.76. The transfer capital threshold is the transfer adjustment factor * $1,211.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,19435.86,50821.76,Inpatient DRG
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],7402.56,,"Case rate ($7,402.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,022.05, add-ons for qualifying new technology services are included. If operating cost exceeds $41,893.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,159.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,058.45 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,077.10 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $399.16. The transfer capital threshold is the transfer adjustment factor * $399.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7402.56,16438.59,Inpatient DRG
CERVICAL SPINAL FUSION WITH MCC,471,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],111337.93,,"Fee schedule rate ($111,337.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,34645.26,111337.93,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITH CC,164,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],47433.53,,"Fee schedule rate ($47,433.53). Adds an outlier to normal pricing equal to the per diem rate ($158,028.38) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,19037.66,77058.83,There are no additional notes associated with this service or procedure.
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],29243.52,,"Fee schedule rate ($29,243.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,14343.25,36024.65,There are no additional notes associated with this service or procedure.
Hysteroscopy Bx Endometrium&/Polypc W/WO D&C,CASE-58558,APC,58558,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3181.53,,"APC Price ($3,030.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3030.03,3181.53,OPPS APC
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],10568.70,,"Case rate ($10,065.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,514.41, add-ons for qualifying new technology services are included. If operating cost exceeds $44,385.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,339.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $7,540.86 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,569.46 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $579.61. The transfer capital threshold is the transfer adjustment factor * $579.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10311.17,24308.97,Inpatient DRG
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],58394.20,,"Fee schedule rate ($58,394.20). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,9370.00,65732.99,There are no additional notes associated with this service or procedure.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],19877.10,,"Fee schedule rate ($19,877.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8009.34,19877.10,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],107110.70,,"Fee schedule rate ($107,110.70). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (21), with a minimum of zero.",,,,0,other,40542.37,128358.13,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],43703.12,,"Fee schedule rate ($43,703.12). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.7), with a minimum of zero.",,,,0,other,17693.40,52449.26,There are no additional notes associated with this service or procedure.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],11468.70,,"Case rate ($10,922.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,313.38, add-ons for qualifying new technology services are included. If operating cost exceeds $45,184.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,400.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $8,336.82 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,368.43 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $640.79. The transfer capital threshold is the transfer adjustment factor * $640.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,11194.25,36094.03,Inpatient DRG
Prtl Exc Pst Vrt Intrnsc B1y Les 1 Vrt Sgm Thrc,CASE-22101,APC,22101,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,7131.59,7131.59,OPPS APC
Cysto W/Urtroscopy&/Pyeloscopy Dx|UNUSUAL NON-OVERLAPPING SERVICE|LEFT SIDE,CASE-52351,APC,52351,CPT,0360,RC,,,XU|LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3464.44,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3299.47,3464.44,OPPS APC
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7673.56,,"Case rate ($7,414.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,032.76, add-ons for qualifying new technology services are included. If operating cost exceeds $41,903.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,159.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,069.12 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,087.81 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $400.00. The transfer capital threshold is the transfer adjustment factor * $400.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,7414.07,18217.52,Inpatient DRG
"CARDIAC ARREST, UNEXPLAINED WITH MCC",296,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],36459.67,,"Fee schedule rate ($36,459.67). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12522.25,36459.67,There are no additional notes associated with this service or procedure.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,270,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],35415.32,,"Case rate ($34,720.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $32,431.98, add-ons for qualifying new technology services are included. If operating cost exceeds $71,076.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $5,156.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.4. The base transfer operating payment is the transfer adjustment factor * $30,933.64 + an uncompensated DSH payment of $1,359.91. The transfer operating threshold is the transfer adjustment factor * $31,072.08 + an uncompensated DSH payment of $1,359.91. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,427.36. The transfer capital threshold is the transfer adjustment factor * $2,427.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 102%.",,,,0,other,34720.90,101002.04,Inpatient DRG
"Open Tx Articular Fracture Mcp/IP Joint Ea|LEFT HAND, FOURTH DIGIT",CASE-26746,APC,26746,CPT,0360,RC,,,F3,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3169.86,OPPS APC
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,451,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],25012.51,,"Case rate ($23,821.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $22,296.19, add-ons for qualifying new technology services are included. If operating cost exceeds $57,167.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,359.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $20,276.48 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $20,351.24 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,600.01. The transfer capital threshold is the transfer adjustment factor * $1,600.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,23821.44,94077.13,Inpatient DRG
Insj/Rplcmt Spinal Npg/Rcvr Pocket Crtj&Connj,CASE-63685,APC,63685,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],29894.47,,"APC Price ($28,883.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,28883.55,30327.72,OPPS APC
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],15940.79,,"Case rate ($15,940.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,964.98, add-ons for qualifying new technology services are included. If operating cost exceeds $49,835.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,783.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $12,972.20 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,020.03 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,023.63. The transfer capital threshold is the transfer adjustment factor * $1,023.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,15940.79,53275.26,Inpatient DRG
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],14492.93,,"Fee schedule rate ($14,492.93). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6503.90,14492.93,There are no additional notes associated with this service or procedure.
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],23385.72,,"Fee schedule rate ($23,385.72). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,23385.72,There are no additional notes associated with this service or procedure.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,479,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],25433.71,,"Case rate ($14,533.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,655.86, add-ons for qualifying new technology services are included. If operating cost exceeds $48,526.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,680.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $11,667.89 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,710.91 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $920.71. The transfer capital threshold is the transfer adjustment factor * $920.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,10586.00,50518.76,All Other Inpatient
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,097,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],44292.15,,"Fee schedule rate ($44,292.15). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,26404.32,79915.74,There are no additional notes associated with this service or procedure.
CERVICAL SPINAL FUSION WITH CC,472,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],21896.13,,"Case rate ($21,896.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,505.12, add-ons for qualifying new technology services are included. If operating cost exceeds $55,376.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,219.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $18,491.99 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,560.18 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,459.20. The transfer capital threshold is the transfer adjustment factor * $1,459.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,21896.13,70198.84,Inpatient DRG
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],23799.09,,"Case rate ($23,799.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $22,275.40, add-ons for qualifying new technology services are included. If operating cost exceeds $57,146.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,358.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.1. The base transfer operating payment is the transfer adjustment factor * $20,255.77 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $20,330.45 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,598.38. The transfer capital threshold is the transfer adjustment factor * $1,598.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,23799.09,63499.65,Inpatient DRG
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],25808.21,,"Case rate ($14,747.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,854.94, add-ons for qualifying new technology services are included. If operating cost exceeds $48,725.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,696.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $11,866.24 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,909.99 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $936.36. The transfer capital threshold is the transfer adjustment factor * $936.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,14747.55,37899.49,All Other Inpatient
CESAREAN SECTION WITHOUT STERILIZATION WITH MCC,786,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],13115.49,,"Case rate ($13,115.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,336.66, add-ons for qualifying new technology services are included. If operating cost exceeds $47,207.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,576.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $10,353.53 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,391.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $817.00. The transfer capital threshold is the transfer adjustment factor * $817.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12612.10,23722.94,Inpatient DRG
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR,518,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],73538.85,,,,,,0,other,13252.00,89342.77,There are no additional notes associated with this service or procedure.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],16829.13,,"Fee schedule rate ($16,829.13). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,8009.34,19877.10,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],38378.80,,"Fee schedule rate ($38,378.80). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,14370.36,38378.80,There are no additional notes associated with this service or procedure.
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],14610.75,,"Case rate ($14,610.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,727.68, add-ons for qualifying new technology services are included. If operating cost exceeds $48,598.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,686.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.6. The base transfer operating payment is the transfer adjustment factor * $11,739.44 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,782.73 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $926.36. The transfer capital threshold is the transfer adjustment factor * $926.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6277.00,36801.89,Inpatient DRG
"DIABETES,MINOR",420,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],5403.76,,"Case rate ($5,146.44). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5146.44,5403.76,There are no additional notes associated with this service or procedure.
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],7261.42,,"Case rate ($6,915.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,569.08, add-ons for qualifying new technology services are included. If operating cost exceeds $41,440.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,123.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,607.15 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,624.14 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $363.55. The transfer capital threshold is the transfer adjustment factor * $363.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6915.64,14442.92,Inpatient DRG
"OTHER DIGESTIVE SYSTEM DIAGNOSES,MODERATE",254,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],7606.73,,"Case rate ($7,606.73). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,7606.73,7987.07,There are no additional notes associated with this service or procedure.
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],68942.79,,"Fee schedule rate ($68,942.79). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,21489.15,68942.79,There are no additional notes associated with this service or procedure.
Neuroplasty &/Transposition Ulnar Nerve Elbow|LEFT SIDE|SEPARATE STRUCTURE,CASE-64718,APC,64718,CPT,0360,RC,,,LT|XS,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],29342.21,,"Case rate ($27,944.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $26,132.21, add-ons for qualifying new technology services are included. If operating cost exceeds $61,003.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,661.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.8. The base transfer operating payment is the transfer adjustment factor * $24,098.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $24,187.26 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,901.60. The transfer capital threshold is the transfer adjustment factor * $1,901.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,27944.96,86252.84,Inpatient DRG
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",062,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],13844.84,,"Case rate ($13,844.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,015.16, add-ons for qualifying new technology services are included. If operating cost exceeds $47,886.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,630.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $11,029.54 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,070.21 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $870.34. The transfer capital threshold is the transfer adjustment factor * $870.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,13844.84,44304.80,Inpatient DRG
Laps Fulg/Exc Ovary Viscera/Peritoneal Surface|LEFT SIDE,CASE-58662,APC,58662,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5658.76,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5658.76,5941.70,OPPS APC
"Tendon Sheath Incision|LEFT HAND, THIRD DIGIT",CASE-26055,APC,26055,CPT,0360,RC,,,F2,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1919.19,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1827.80,1919.19,OPPS APC
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],45437.59,,"Fee schedule rate ($45,437.59). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,21382.16,85466.62,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,689,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],22417.63,,"Fee schedule rate ($22,417.63). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,9802.58,22831.22,There are no additional notes associated with this service or procedure.
FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,748,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],25601.70,,"Fee schedule rate ($25,601.70). Adds an outlier to normal pricing equal to the per diem rate ($21,136.29) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9316.20,26805.98,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITH STERILIZATION WITH CC,784,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],23722.94,,"Fee schedule rate ($23,722.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9124.01,23722.94,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITH STERILIZATION WITHOUT CC/MCC,785,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],20142.33,,"Fee schedule rate ($20,142.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8431.24,20142.33,There are no additional notes associated with this service or procedure.
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],6511.25,,"Case rate ($6,201.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,904.45, add-ons for qualifying new technology services are included. If operating cost exceeds $40,775.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,071.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,944.95 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,959.50 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $311.30. The transfer capital threshold is the transfer adjustment factor * $311.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5937.41,12366.99,Inpatient DRG
OTHER CEREBROVASCULAR DISORDERS WITH CC,071,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],20188.60,,,,,,0,other,5843.00,29215.10,There are no additional notes associated with this service or procedure.
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],6965.00,,,,,,0,other,6148.93,15887.21,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,091,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],40030.81,,"Fee schedule rate ($40,030.81). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,13838.06,40030.81,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,447,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],48157.33,,"Case rate ($45,864.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $42,883.97, add-ons for qualifying new technology services are included. If operating cost exceeds $77,754.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,894.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $40,784.39 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $40,939.02 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,134.78. The transfer capital threshold is the transfer adjustment factor * $3,134.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,47193.21,156646.82,Inpatient DRG
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,073,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],43475.01,,"Fee schedule rate ($43,475.01). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,12809.38,43475.01,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],12808.03,,"Case rate ($12,808.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,050.64, add-ons for qualifying new technology services are included. If operating cost exceeds $46,921.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,554.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $10,068.57 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,105.69 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $794.51. The transfer capital threshold is the transfer adjustment factor * $794.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7353.00,33398.16,Inpatient DRG
CERVICAL SPINAL FUSION WITHOUT CC/MCC,473,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],18847.16,,"Case rate ($18,477.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,324.93, add-ons for qualifying new technology services are included. If operating cost exceeds $52,195.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,969.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.6. The base transfer operating payment is the transfer adjustment factor * $15,323.48 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,379.98 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,209.17. The transfer capital threshold is the transfer adjustment factor * $1,209.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,18477.61,62077.11,Inpatient DRG
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC,519,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],50780.20,,"Fee schedule rate ($50,780.20). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,15490.44,50780.20,There are no additional notes associated with this service or procedure.
Cysto/Uretero W/Lithotripsy &Indwell Stent Insrt|BILATERAL PROCEDURE,CASE-52356,APC,52356,CPT,0360,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5269.71,,"APC Price ($5,018.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5018.77,5269.71,OPPS APC
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],8136.74,,"Case rate ($7,749.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,344.60, add-ons for qualifying new technology services are included. If operating cost exceeds $42,215.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,184.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,379.82 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,399.66 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $424.52. The transfer capital threshold is the transfer adjustment factor * $424.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6711.00,16865.16,Inpatient DRG
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],21719.40,,"Case rate ($21,719.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,340.70, add-ons for qualifying new technology services are included. If operating cost exceeds $55,211.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,206.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.2. The base transfer operating payment is the transfer adjustment factor * $18,328.17 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,395.75 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,446.27. The transfer capital threshold is the transfer adjustment factor * $1,446.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,21719.40,85305.59,Inpatient DRG
Exc Tumor Soft Tissue Thigh/Knee Subfasc <5cm|LEFT SIDE,CASE-27328,APC,27328,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],2814.04,,"APC Price ($2,718.88). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2718.88,2854.83,OPPS APC
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],133270.57,,"Fee schedule rate ($133,270.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,33623.33,133270.57,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,093,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],6965.00,,,,,,0,other,6965.00,19011.32,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,091,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],40030.81,,"Fee schedule rate ($40,030.81). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,13838.06,40030.81,There are no additional notes associated with this service or procedure.
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],14610.75,,"Case rate ($14,610.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,727.68, add-ons for qualifying new technology services are included. If operating cost exceeds $48,598.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,686.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.6. The base transfer operating payment is the transfer adjustment factor * $11,739.44 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,782.73 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $926.36. The transfer capital threshold is the transfer adjustment factor * $926.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6277.00,36801.89,Inpatient DRG
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],46431.62,,"Case rate ($45,521.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $42,483.01, add-ons for qualifying new technology services are included. If operating cost exceeds $77,354.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,947.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 12.5. The base transfer operating payment is the transfer adjustment factor * $40,389.14 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $40,538.06 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,187.10. The transfer capital threshold is the transfer adjustment factor * $3,187.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,45521.20,142438.06,Inpatient DRG
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC,939,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],68190.40,,"Fee schedule rate ($68,190.40). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16.5), with a minimum of zero.",,,,0,other,26517.40,97674.79,There are no additional notes associated with this service or procedure.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,025,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],34372.30,,"Case rate ($32,735.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $30,588.77, add-ons for qualifying new technology services are included. If operating cost exceeds $65,459.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,011.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.4. The base transfer operating payment is the transfer adjustment factor * $28,538.59 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $28,643.82 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,251.98. The transfer capital threshold is the transfer adjustment factor * $2,251.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,13351.00,91631.33,Inpatient DRG
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITHOUT CC/MCC,428,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],40017.53,,"Case rate ($40,017.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $37,363.07, add-ons for qualifying new technology services are included. If operating cost exceeds $72,234.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,544.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $35,288.01 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $35,418.12 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,784.57. The transfer capital threshold is the transfer adjustment factor * $2,784.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,40017.53,118904.57,Inpatient DRG
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,479,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],50518.76,,"Fee schedule rate ($50,518.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,10586.00,50518.76,There are no additional notes associated with this service or procedure.
HC >= 12 Lead Ekg|UNUSUAL NON-OVERLAPPING SERVICE,CASE-93005,APC,93005,CPT,0730,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3489.82,,"APC Price ($3,489.82). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3489.82,3611.96,OPPS APC
Laps W/Vag Hysterect 250 Gm/&Rmvl Tube&/Ovaries,CASE-58552,APC,58552,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],9949.78,,"APC Price ($9,949.78). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,9949.78,10298.02,OPPS APC
PREMATURITY WITHOUT MAJOR PROBLEMS,792,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],11512.88,,"Fee schedule rate ($11,512.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,1956.00,19457.66,There are no additional notes associated with this service or procedure.
Egd US Guided Transmural Injxn/Fiducial Marker,CASE-43253,APC,43253,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1885.95,,"APC Price ($1,796.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1796.14,1885.95,OPPS APC
Redo Excis Lumbar Disk|SEPARATE STRUCTURE,CASE-63042,APC,63042,CPT,0360,RC,,,XS,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],25398.09,,"APC Price ($25,398.09). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,25398.09,26668.00,OPPS APC
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],8790.94,,"Case rate ($8,372.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,924.20, add-ons for qualifying new technology services are included. If operating cost exceeds $42,795.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,230.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,957.28 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,979.25 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $470.09. The transfer capital threshold is the transfer adjustment factor * $470.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,23385.72,Inpatient DRG
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,426,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],216864.15,,,,,,0,other,76581.29,216864.15,There are no additional notes associated with this service or procedure.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,191,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],16612.88,,"Fee schedule rate ($16,612.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6965.00,16612.88,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],33398.16,,"Fee schedule rate ($33,398.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,7353.00,33398.16,There are no additional notes associated with this service or procedure.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],24259.09,,"Fee schedule rate ($24,259.09). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10098.51,24259.09,There are no additional notes associated with this service or procedure.
Dilation Esoph Unguided Sound/Bougie 1/Mult Pass,CASE-43450,APC,43450,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],848.96,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,848.96,891.41,OPPS APC
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral Ea Addl|LEFT SIDE,CASE-64484,APC,64484,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],869.28,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,827.89,869.28,OPPS APC
Colonoscopy W/Biopsy Single/Multiple|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-45380,APC,45380,CPT,0360,RC,,,74,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1176.09,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1120.09,1176.09,OPPS APC
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,988,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],42425.46,,"Fee schedule rate ($42,425.46). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,13075.52,42425.46,There are no additional notes associated with this service or procedure.
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],12526.44,,"Fee schedule rate ($12,526.44). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5415.00,17575.50,There are no additional notes associated with this service or procedure.
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],14230.80,,"Case rate ($13,553.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,765.46, add-ons for qualifying new technology services are included. If operating cost exceeds $47,636.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,588.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $10,779.64 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,820.51 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $828.55. The transfer capital threshold is the transfer adjustment factor * $828.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13904.43,34749.58,Inpatient DRG
POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES,769,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],31756.41,,"Fee schedule rate ($31,756.41). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.7), with a minimum of zero.",,,,0,other,13388.39,33250.19,There are no additional notes associated with this service or procedure.
Laps Surg Bilateral Total Pelvic Lmphadectomy,CASE-38571,APC,38571,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],10298.02,,"APC Price ($9,949.78). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,9949.78,10447.27,OPPS APC
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],23520.23,,"Fee schedule rate ($23,520.23). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10517.71,24909.11,There are no additional notes associated with this service or procedure.
Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq|COLORECTAL CANCER SCREEN,CASE-45385,APC,45385,CPT,0360,RC,,,PT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1159.29,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1120.09,1176.09,OPPS APC
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],16035.06,,"Fee schedule rate ($16,035.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,7396.47,16035.06,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],28038.61,,"Fee schedule rate ($28,038.61). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12126.09,29582.40,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,699,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],19570.20,,"Fee schedule rate ($19,570.20). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5961.00,19972.16,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],19152.11,,"Case rate ($19,152.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,952.40, add-ons for qualifying new technology services are included. If operating cost exceeds $52,823.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,018.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $15,948.65 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $16,007.45 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,258.51. The transfer capital threshold is the transfer adjustment factor * $1,258.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,19152.11,53152.12,Inpatient DRG
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,345,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],28277.83,,"Fee schedule rate ($28,277.83). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12134.89,33616.03,There are no additional notes associated with this service or procedure.
Breast Augmentation With Implant|RIGHT SIDE,CASE-19325,APC,19325,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],8033.01,,"APC Price ($7,650.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,7918.25,8033.01,OPPS APC
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],31477.13,,"Fee schedule rate ($31,477.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9648.19,31477.13,There are no additional notes associated with this service or procedure.
OSTEOMYELITIS WITH CC,540,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],24361.37,,"Fee schedule rate ($24,361.37). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.6), with a minimum of zero.",,,,0,other,9809.07,25507.30,There are no additional notes associated with this service or procedure.
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],6965.00,,,,,,0,other,6965.00,29482.05,There are no additional notes associated with this service or procedure.
HC Joint Injection/Aspir Large WO US|BILATERAL PROCEDURE,CASE-20610,APC,20610,CPT,0510,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
Hysteroscopy Endometrial Ablation,CASE-58563,APC,58563,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],4682.41,,"APC Price ($4,682.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,4682.41,4916.53,OPPS APC
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],2070.00,,,,,,0,other,1188.00,18893.86,Estimated amount calculated based on 3 day length of stay.
Rpr Recrt Ingun Hernia Any Age Incarcerated,CASE-49521,APC,49521,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6362.63,,"APC Price ($6,059.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6059.65,6362.63,OPPS APC
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6606.85,,"Case rate ($6,606.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,281.82, add-ons for qualifying new technology services are included. If operating cost exceeds $41,152.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,100.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,320.93 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,336.86 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $340.96. The transfer capital threshold is the transfer adjustment factor * $340.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,5919.29,13545.65,Inpatient DRG
Anterior Instrumentation 2-3 Vertebral Segments|UNUSUAL NON-OVERLAPPING SERVICE,CASE-22845,APC,22845,CPT,0360,RC,,,XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12618.18,,"APC Price ($12,017.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,12437.92,12618.18,OPPS APC
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],24675.88,,"Fee schedule rate ($24,675.88). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10834.64,25830.00,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],8023.69,,"Case rate ($7,641.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,244.44, add-ons for qualifying new technology services are included. If operating cost exceeds $42,115.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,176.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,280.02 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,299.49 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $416.65. The transfer capital threshold is the transfer adjustment factor * $416.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7641.61,19371.27,Inpatient DRG
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],2070.00,,,,,,0,other,1188.00,34338.33,Estimated amount calculated based on 6 day length of stay.
PREMATURITY WITH MAJOR PROBLEMS,791,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],3186.77,,,,,,0,other,3048.21,30904.42,Estimated amount calculated based on 5 day length of stay.
SALIVARY GLAND PROCEDURES,139,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],30690.92,,"Fee schedule rate ($30,690.92). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,10313.19,30690.92,There are no additional notes associated with this service or procedure.
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],37899.49,,"Fee schedule rate ($37,899.49). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,14747.55,37899.49,There are no additional notes associated with this service or procedure.
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],35419.59,,"Fee schedule rate ($35,419.59). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,7086.00,57872.02,There are no additional notes associated with this service or procedure.
Colonoscopy W/Biopsy Single/Multiple|COLORECTAL CANCER SCREEN|UNUSUAL NON-OVERLAPPING SERVICE,CASE-45380,APC,45380,CPT,0360,RC,,,PT|XU,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1120.09,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1120.09,1176.09,OPPS APC
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",063,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],35701.87,,"Fee schedule rate ($35,701.87). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,35701.87,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],16278.78,,,,,,0,other,6965.00,19126.88,There are no additional notes associated with this service or procedure.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],58320.32,,"Fee schedule rate ($58,320.32). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,16286.16,58320.32,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],14657.77,,"Case rate ($14,370.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,504.04, add-ons for qualifying new technology services are included. If operating cost exceeds $48,375.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,668.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $11,516.62 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,559.08 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $908.78. The transfer capital threshold is the transfer adjustment factor * $908.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,14370.36,38378.80,Inpatient DRG
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC,806,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6510.67,,"Case rate ($6,510.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,192.35, add-ons for qualifying new technology services are included. If operating cost exceeds $41,063.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,093.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $4,231.80 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,247.40 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $333.93. The transfer capital threshold is the transfer adjustment factor * $333.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,5354.25,13416.00,Inpatient DRG
COMPLICATIONS OF TREATMENT WITH CC,920,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],18836.22,,"Fee schedule rate ($18,836.22). Adds an outlier to normal pricing equal to the per diem rate ($49,808.13) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,8732.59,20731.52,There are no additional notes associated with this service or procedure.
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|RIGHT HAND, FIFTH DIGIT",CASE-26160,APC,26160,CPT,0360,RC,,,F9,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1557.80,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1505.12,1580.37,OPPS APC
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],8314.58,,"Case rate ($8,151.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,718.82, add-ons for qualifying new technology services are included. If operating cost exceeds $42,589.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,213.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,752.66 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,773.87 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $453.94. The transfer capital threshold is the transfer adjustment factor * $453.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,8151.55,18033.97,Inpatient DRG
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],35419.59,,"Fee schedule rate ($35,419.59). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,7086.00,57872.02,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC,831,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],23661.59,,,,,,0,other,4941.30,23661.59,There are no additional notes associated with this service or procedure.
Insj Penile Prosthesos Inflatable Self-Contained,CASE-54401,APC,54401,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],19400.15,,"APC Price ($19,400.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,19400.15,20370.16,OPPS APC
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC,434,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],13390.01,,"Fee schedule rate ($13,390.01). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6770.05,14019.86,There are no additional notes associated with this service or procedure.
Arthrd Ant Interbody Min Dsc Lumbar,CASE-22558,APC,22558,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],26668.00,,"APC Price ($25,398.09). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,26668.00,26668.00,OPPS APC
BRONCHITIS AND ASTHMA WITHOUT CC/MCC,203,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],13707.00,,,,,,0,other,4763.76,13707.00,There are no additional notes associated with this service or procedure.
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC,964,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],28802.15,,"Fee schedule rate ($28,802.15). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,12323.82,34154.06,There are no additional notes associated with this service or procedure.
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],7833.94,,"Case rate ($7,833.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,423.35, add-ons for qualifying new technology services are included. If operating cost exceeds $42,294.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,190.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,458.28 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,478.41 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $430.71. The transfer capital threshold is the transfer adjustment factor * $430.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,5883.03,17111.12,Inpatient DRG
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],40192.59,,"Fee schedule rate ($40,192.59). Adds an outlier to normal pricing equal to the per diem rate ($235,324.88) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.6), with a minimum of zero.",,,,0,other,16428.39,42083.20,There are no additional notes associated with this service or procedure.
SEIZURES WITH MCC,100,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],32323.98,,"Fee schedule rate ($32,323.98). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,15061.09,38110.41,There are no additional notes associated with this service or procedure.
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],16235.87,,"Fee schedule rate ($16,235.87). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6524.00,17760.46,There are no additional notes associated with this service or procedure.
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],56787.82,,,,,,0,other,21489.15,68942.79,There are no additional notes associated with this service or procedure.
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],20170.75,,"Fee schedule rate ($20,170.75). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10048.39,23545.50,There are no additional notes associated with this service or procedure.
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC,964,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],28802.15,,"Fee schedule rate ($28,802.15). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,12323.82,34154.06,There are no additional notes associated with this service or procedure.
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,307,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],7434.68,,"Case rate ($7,434.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $7,017.68, add-ons for qualifying new technology services are included. If operating cost exceeds $45,662.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $3,170.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $5,632.79 + an uncompensated DSH payment of $1,359.91. The transfer operating threshold is the transfer adjustment factor * $5,657.77 + an uncompensated DSH payment of $1,359.91. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $441.98. The transfer capital threshold is the transfer adjustment factor * $441.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6335.27,18228.77,Inpatient DRG
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,544,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],7055.15,,"Case rate ($7,055.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,698.86, add-ons for qualifying new technology services are included. If operating cost exceeds $41,569.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,133.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $4,736.45 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,753.92 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $373.75. The transfer capital threshold is the transfer adjustment factor * $373.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7055.15,23207.64,Inpatient DRG
"Capsulectomy/Capsulotomy Iphal Joint Each|LEFT HAND, SECOND DIGIT",CASE-26525,APC,26525,CPT,0360,RC,,,F1,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3169.86,OPPS APC
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],22732.01,,"Fee schedule rate ($22,732.01). Adds an outlier to normal pricing equal to the per diem rate ($114,196.66) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.5), with a minimum of zero.",,,,0,other,10136.44,24444.75,There are no additional notes associated with this service or procedure.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],18911.60,,"Case rate ($18,011.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,920.88, add-ons for qualifying new technology services are included. If operating cost exceeds $51,791.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,906.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $14,919.36 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,975.93 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,146.74. The transfer capital threshold is the transfer adjustment factor * $1,146.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,18497.24,62041.12,Inpatient DRG
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITHOUT CC/MCC,428,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],42018.41,,"Case rate ($40,017.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $37,363.07, add-ons for qualifying new technology services are included. If operating cost exceeds $72,234.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,544.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $35,288.01 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $35,418.12 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,784.57. The transfer capital threshold is the transfer adjustment factor * $2,784.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,40017.53,118904.57,Inpatient DRG
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],16669.71,,"Fee schedule rate ($16,669.71). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8767.81,19824.58,There are no additional notes associated with this service or procedure.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC,099,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],11729.77,,"Case rate ($11,171.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,527.95, add-ons for qualifying new technology services are included. If operating cost exceeds $45,398.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,434.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,551.47 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,583.00 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $674.80. The transfer capital threshold is the transfer adjustment factor * $674.80. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,11171.21,26807.94,Inpatient DRG
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],37149.27,,"Fee schedule rate ($37,149.27). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,12455.21,37149.27,There are no additional notes associated with this service or procedure.
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC,519,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],39357.94,,,,,,0,other,15490.44,50780.20,There are no additional notes associated with this service or procedure.
BRONCHITIS AND ASTHMA WITH CC/MCC,202,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],8521.98,,"Case rate ($8,521.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,063.43, add-ons for qualifying new technology services are included. If operating cost exceeds $42,934.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,241.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,096.00 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,118.48 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $481.03. The transfer capital threshold is the transfer adjustment factor * $481.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7606.34,19110.30,Inpatient DRG
CERVICAL SPINAL FUSION WITH MCC,471,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],34645.26,,"Case rate ($34,645.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $32,365.35, add-ons for qualifying new technology services are included. If operating cost exceeds $67,236.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,151.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $30,308.64 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $30,420.39 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,391.65. The transfer capital threshold is the transfer adjustment factor * $2,391.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,34645.26,111337.93,Inpatient DRG
Prq Skel Fixj Dstl Phlngl Fx Fngr/Thmb Ea,CASE-26756,APC,26756,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],26127.34,,"Case rate ($26,127.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $24,441.31, add-ons for qualifying new technology services are included. If operating cost exceeds $59,312.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,528.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. The base transfer operating payment is the transfer adjustment factor * $22,413.72 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $22,496.36 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,768.66. The transfer capital threshold is the transfer adjustment factor * $1,768.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,26127.34,90333.60,Inpatient DRG
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC,833,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5486.07,,"Case rate ($5,486.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,239.18, add-ons for qualifying new technology services are included. If operating cost exceeds $40,110.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,018.96, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $3,282.12 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,294.23 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $258.99. The transfer capital threshold is the transfer adjustment factor * $258.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,3041.73,10289.10,Inpatient DRG
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],9282.47,,"Case rate ($9,282.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,770.90, add-ons for qualifying new technology services are included. If operating cost exceeds $43,641.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,296.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,800.88 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,825.96 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $536.66. The transfer capital threshold is the transfer adjustment factor * $536.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9282.47,21320.03,Inpatient DRG
Sigmoidoscopy Flx Ndsc US Xm,CASE-45341,APC,45341,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],913.99,,"APC Price ($870.46). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,870.46,913.99,OPPS APC
"Suture Digital Nerve Hand/Foot 1 Nerve|LEFT HAND, THUMB",CASE-64831,APC,64831,CPT,0360,RC,,,FA,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,345,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],12741.63,,"Case rate ($12,134.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,424.43, add-ons for qualifying new technology services are included. If operating cost exceeds $46,295.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,505.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $9,444.66 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,479.48 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $745.28. The transfer capital threshold is the transfer adjustment factor * $745.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12134.89,33616.03,Inpatient DRG
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],12966.13,,"Case rate ($12,527.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,789.82, add-ons for qualifying new technology services are included. If operating cost exceeds $46,660.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,533.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $9,808.71 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,844.88 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $774.00. The transfer capital threshold is the transfer adjustment factor * $774.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,12527.66,29917.96,Inpatient DRG
Ercp W/Sphincterotomy/Papillotomy,CASE-43262,APC,43262,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3608.81,,"APC Price ($3,608.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3608.81,3789.26,OPPS APC
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,056,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],18561.00,,"Case rate ($17,677.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,580.28, add-ons for qualifying new technology services are included. If operating cost exceeds $51,451.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,910.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $14,581.57 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,635.33 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,150.63. The transfer capital threshold is the transfer adjustment factor * $1,150.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7659.00,59328.19,Inpatient DRG
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],10114.56,,"Case rate ($9,632.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,111.24, add-ons for qualifying new technology services are included. If operating cost exceeds $43,982.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,308.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $7,139.22 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,166.29 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $548.74. The transfer capital threshold is the transfer adjustment factor * $548.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9865.56,37914.65,Inpatient DRG
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,447,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],125567.31,,"Fee schedule rate ($125,567.31). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15.7), with a minimum of zero.",,,,0,other,47193.21,156646.82,There are no additional notes associated with this service or procedure.
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],37488.28,,"Fee schedule rate ($37,488.28). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.5), with a minimum of zero.",,,,0,other,15453.88,39251.68,There are no additional notes associated with this service or procedure.
Mastectomy Partial,CASE-19301,APC,19301,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3793.21,,"APC Price ($3,664.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3793.21,3793.21,OPPS APC
Mast Modf Rad W/Ax Lymph Nod W/WO Pect/Alis Min|RIGHT SIDE,CASE-19307,APC,19307,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6526.12,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6215.36,6526.12,OPPS APC
VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC,033,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],42156.44,,"Fee schedule rate ($42,156.44). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,13206.23,42156.44,There are no additional notes associated with this service or procedure.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],37768.77,,"Fee schedule rate ($37,768.77). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7453.00,42138.30,There are no additional notes associated with this service or procedure.
Ndsc Dcmprn Spinal Cord 1 W/Lamot Ntrspc Lumbar,CASE-62380,APC,62380,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],18918.49,,"Fee schedule rate ($18,918.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9282.47,21320.03,There are no additional notes associated with this service or procedure.
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],26721.94,,"Fee schedule rate ($26,721.94). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6965.00,34422.94,There are no additional notes associated with this service or procedure.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],29207.85,,"Fee schedule rate ($29,207.85). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,18105.81,52699.33,There are no additional notes associated with this service or procedure.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],9446.38,,"Case rate ($9,446.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,923.36, add-ons for qualifying new technology services are included. If operating cost exceeds $43,794.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,308.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,952.78 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,978.41 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $548.64. The transfer capital threshold is the transfer adjustment factor * $548.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9446.38,21796.21,Inpatient DRG
Laps Gstrc Rstrictiv Px Longitudinal Gastrectomy,CASE-43775,APC,43775,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],46.02,,"APC Price ($43.83). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,43.83,46.02,OPPS APC
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],13372.82,,"Case rate ($7,641.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,244.44, add-ons for qualifying new technology services are included. If operating cost exceeds $42,115.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,176.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,280.02 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,299.49 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $416.65. The transfer capital threshold is the transfer adjustment factor * $416.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,7641.61,19371.27,All Other Inpatient
DIABETES WITHOUT CC/MCC,639,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],6965.00,,,,,,0,other,6151.76,12223.35,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],21784.85,,"Fee schedule rate ($21,784.85). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.4), with a minimum of zero.",,,,0,other,9795.13,23899.13,There are no additional notes associated with this service or procedure.
"Tendon Sheath Incision|RIGHT HAND, FIFTH DIGIT",CASE-26055,APC,26055,CPT,0360,RC,,,F9,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1505.12,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1505.12,1580.37,OPPS APC
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],15854.69,,"Case rate ($15,099.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,182.53, add-ons for qualifying new technology services are included. If operating cost exceeds $49,053.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,722.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $12,192.63 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,237.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $962.12. The transfer capital threshold is the transfer adjustment factor * $962.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7605.00,39153.65,Inpatient DRG
"ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",770,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],17800.73,,"Fee schedule rate ($17,800.73). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,8735.30,19730.13,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,083,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],28680.85,,"Fee schedule rate ($28,680.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,28680.85,There are no additional notes associated with this service or procedure.
HC Drain/Inj Joint/Bursa W/US Large|PBB CHARGE,CASE-20611,APC,20611,CPT,0510,RC,,,PBB,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],301.68,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,287.31,301.68,OPPS APC
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],16384.85,,"Case rate ($15,604.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,677.74, add-ons for qualifying new technology services are included. If operating cost exceeds $49,548.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,734.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $12,684.69 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,732.79 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $974.98. The transfer capital threshold is the transfer adjustment factor * $974.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,16017.99,51903.64,Inpatient DRG
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],16969.63,,"Case rate ($9,696.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,156.46, add-ons for qualifying new technology services are included. If operating cost exceeds $44,027.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,326.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $7,185.02 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,211.51 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $566.97. The transfer capital threshold is the transfer adjustment factor * $566.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,9696.93,35061.53,All Other Inpatient
Laps Gstr Rstcv Px W/Byp Roux-en-Y Limb <150 Cm,CASE-43644,APC,43644,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],297.37,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,287.31,301.68,OPPS APC
Surgical Arthroscopy Shoulder W/Rotator Cuff Rpr|LEFT SIDE,CASE-29827,APC,29827,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6791.99,7131.59,OPPS APC
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],13386.36,,"Case rate ($13,386.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,588.65, add-ons for qualifying new technology services are included. If operating cost exceeds $47,459.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,596.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $10,604.60 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,643.70 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $836.81. The transfer capital threshold is the transfer adjustment factor * $836.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,13386.36,33244.29,Inpatient DRG
Arthrs Knee W/Meniscectomy Med&Lat W/Shaving|LEFT SIDE,CASE-29880,APC,29880,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],52699.33,,"Fee schedule rate ($52,699.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,18105.81,52699.33,There are no additional notes associated with this service or procedure.
RADIOTHERAPY,849,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],21004.17,,"Case rate ($20,293.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $19,014.57, add-ons for qualifying new technology services are included. If operating cost exceeds $53,885.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,101.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $17,006.91 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $17,069.62 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,342.01. The transfer capital threshold is the transfer adjustment factor * $1,342.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,20293.88,81867.07,Inpatient DRG
RADIOTHERAPY,849,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],81867.07,,"Fee schedule rate ($81,867.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,20293.88,81867.07,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,373,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],14313.05,,,,,,0,other,6870.94,14313.05,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],25609.86,,"Fee schedule rate ($25,609.86). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,12775.53,31469.43,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],15609.47,,"Fee schedule rate ($15,609.47). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7569.84,21892.85,There are no additional notes associated with this service or procedure.
OTHER CEREBROVASCULAR DISORDERS WITH MCC,070,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],37774.46,,"Fee schedule rate ($37,774.46). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,13219.09,37774.46,There are no additional notes associated with this service or procedure.
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],6738.99,,"Case rate ($6,606.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,281.82, add-ons for qualifying new technology services are included. If operating cost exceeds $41,152.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,100.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,320.93 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,336.86 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $340.96. The transfer capital threshold is the transfer adjustment factor * $340.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,5919.29,13545.65,Inpatient DRG
RADIOTHERAPY,849,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],81867.07,,"Fee schedule rate ($81,867.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,20293.88,81867.07,There are no additional notes associated with this service or procedure.
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],25555.79,,"Case rate ($14,603.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,720.75, add-ons for qualifying new technology services are included. If operating cost exceeds $48,591.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,685.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $11,732.54 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,775.80 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $925.81. The transfer capital threshold is the transfer adjustment factor * $925.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,14603.31,45017.13,All Other Inpatient
Nasal/Sinus Ndsc W/Partial Ethmoidectomy|LEFT SIDE,CASE-31254,APC,31254,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6936.25,,"APC Price ($6,605.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6837.16,6936.25,OPPS APC
HEART FAILURE AND SHOCK WITH CC,292,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],15550.06,,"Fee schedule rate ($15,550.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5502.00,16705.77,There are no additional notes associated with this service or procedure.
TRAUMATIC INJURY WITH MCC,913,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],13665.31,,"Case rate ($13,014.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,242.79, add-ons for qualifying new technology services are included. If operating cost exceeds $47,113.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,569.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $10,260.01 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,297.84 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $809.62. The transfer capital threshold is the transfer adjustment factor * $809.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13014.58,42838.46,Inpatient DRG
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],6277.00,,"Per diem ($6,277). If length of stay < 5.6, first 1 days paid at a per diem of $12,554 instead. Capped at $35,148.55.",,,,0,other,6277.00,36801.89,Estimated amount calculated based on 4 day length of stay.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],10709.21,,"Case rate ($10,347.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,761.25, add-ons for qualifying new technology services are included. If operating cost exceeds $44,632.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,374.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $7,787.59 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,816.30 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $614.52. The transfer capital threshold is the transfer adjustment factor * $614.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,10347.06,28821.04,Inpatient DRG
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],59891.41,,"Fee schedule rate ($59,891.41). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15), with a minimum of zero.",,,,0,other,23526.87,94787.57,There are no additional notes associated with this service or procedure.
"PEPTIC ULCER AND GASTRITIS,MODERATE",241,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],9095.68,,"Case rate ($8,662.55). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8662.55,9095.68,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITHOUT STERILIZATION WITH MCC,786,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],13574.53,,"Case rate ($13,115.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,336.66, add-ons for qualifying new technology services are included. If operating cost exceeds $47,207.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,576.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $10,353.53 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,391.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $817.00. The transfer capital threshold is the transfer adjustment factor * $817.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,12612.10,23722.94,Inpatient DRG
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],15600.07,,"Fee schedule rate ($15,600.07). Adds an outlier to normal pricing equal to the per diem rate ($180,117.98) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,7566.45,16333.88,There are no additional notes associated with this service or procedure.
"ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",770,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],19730.13,,,,,,0,other,8735.30,19730.13,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,447,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],131473.84,,,,,,0,other,47193.21,156646.82,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],7924.86,,"Case rate ($7,547.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,156.87, add-ons for qualifying new technology services are included. If operating cost exceeds $42,027.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,169.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $5,192.77 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,211.92 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $409.76. The transfer capital threshold is the transfer adjustment factor * $409.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,19126.88,Inpatient DRG
"EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME, NEONATE",790,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],42194.75,,"Case rate ($42,194.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $39,388.49, add-ons for qualifying new technology services are included. If operating cost exceeds $74,259.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,703.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 17.9. The base transfer operating payment is the transfer adjustment factor * $37,305.99 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $37,443.54 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,943.81. The transfer capital threshold is the transfer adjustment factor * $2,943.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,3054.00,44304.49,Inpatient DRG
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,555,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],24840.59,,"Fee schedule rate ($24,840.59). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10896.27,42290.95,There are no additional notes associated with this service or procedure.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],20553.44,,"Fee schedule rate ($20,553.44). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8874.81,20553.44,There are no additional notes associated with this service or procedure.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,025,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],91631.33,,"Fee schedule rate ($91,631.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,13351.00,91631.33,There are no additional notes associated with this service or procedure.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,025,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],33881.26,,"Case rate ($32,735.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $30,588.77, add-ons for qualifying new technology services are included. If operating cost exceeds $65,459.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,011.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.4. The base transfer operating payment is the transfer adjustment factor * $28,538.59 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $28,643.82 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,251.98. The transfer capital threshold is the transfer adjustment factor * $2,251.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103.5%.",,,,0,other,13351.00,91631.33,Inpatient DRG
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC,497,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],22707.58,,"Fee schedule rate ($22,707.58). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7.8), with a minimum of zero.",,,,0,other,10127.65,37761.19,There are no additional notes associated with this service or procedure.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC",156,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],12987.84,,"Fee schedule rate ($12,987.84). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,6625.12,13598.77,There are no additional notes associated with this service or procedure.
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],12195.15,,"Case rate ($12,195.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,480.50, add-ons for qualifying new technology services are included. If operating cost exceeds $46,351.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,509.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,500.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,535.55 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $749.68. The transfer capital threshold is the transfer adjustment factor * $749.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12195.15,39424.57,Inpatient DRG
"Correction Hammertoe|LEFT FOOT, SECOND DIGIT",CASE-28285,APC,28285,CPT,0360,RC,,,T1,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],37914.65,,"Fee schedule rate ($37,914.65). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9865.56,37914.65,There are no additional notes associated with this service or procedure.
Ercp Destruction/Lithotripsy Calculi Any Method,CASE-43265,APC,43265,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5682.51,,"APC Price ($5,682.51). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5682.51,5966.63,OPPS APC
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],8115.65,,"Case rate ($7,956.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,537.38, add-ons for qualifying new technology services are included. If operating cost exceeds $42,408.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,199.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,571.89 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,592.43 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $439.68. The transfer capital threshold is the transfer adjustment factor * $439.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6965.00,17467.27,Inpatient DRG
Revision Peri-Implant Capsule Breast,CASE-19370,APC,19370,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],8033.01,,"APC Price ($7,650.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,7918.25,8033.01,OPPS APC
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],17628.93,,"Fee schedule rate ($17,628.93). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,13092.47,33159.45,There are no additional notes associated with this service or procedure.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],87909.90,,"Fee schedule rate ($87,909.90). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,33623.33,133270.57,There are no additional notes associated with this service or procedure.
HC Peripheral Block - Femoral Single or Saphenous W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE|RIGHT SIDE,CASE-64447,APC,64447,CPT,0360,RC,,,XU|RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1580.37,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1505.12,1580.37,OPPS APC
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],31691.39,,"Fee schedule rate ($31,691.39). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,16129.04,59610.47,There are no additional notes associated with this service or procedure.
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],28751.41,,"Fee schedule rate ($28,751.41). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12305.53,30103.84,There are no additional notes associated with this service or procedure.
OSTEOMYELITIS WITHOUT CC/MCC,541,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],11429.52,,"Fee schedule rate ($11,429.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5103.00,15493.67,There are no additional notes associated with this service or procedure.
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],22732.01,,"Fee schedule rate ($22,732.01). Adds an outlier to normal pricing equal to the per diem rate ($114,196.66) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.5), with a minimum of zero.",,,,0,other,10136.44,24444.75,There are no additional notes associated with this service or procedure.
HC Inj Trigger Pt 1-2 Musc Grps|PBB CHARGE,CASE-20552,APC,20552,CPT,0510,RC,,,PBB,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
Excision Interdigital Morton Neuroma Single Each|RIGHT SIDE,CASE-28080,APC,28080,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1580.37,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1505.12,1580.37,OPPS APC
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],43949.31,,"Fee schedule rate ($43,949.31). Adds an outlier to normal pricing equal to the per diem rate ($149,567.78) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,17782.11,46523.26,There are no additional notes associated with this service or procedure.
PERITONEAL ADHESIOLYSIS WITH CC,336,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],53705.31,,"Fee schedule rate ($53,705.31). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,16225.22,53705.31,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,085,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],17936.97,,"Case rate ($17,330.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,257.72, add-ons for qualifying new technology services are included. If operating cost exceeds $51,128.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,885.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $14,260.20 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,312.77 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,125.27. The transfer capital threshold is the transfer adjustment factor * $1,125.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,9282.00,57443.16,Inpatient DRG
Surgical Arthroscopy Sho W/Coracoacrm Ligm Rls|LEFT SIDE,CASE-29826,APC,29826,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6791.99,7131.59,OPPS APC
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],8271.77,,"Case rate ($7,877.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,475.30, add-ons for qualifying new technology services are included. If operating cost exceeds $42,346.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,183.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,509.46 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,530.35 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $423.47. The transfer capital threshold is the transfer adjustment factor * $423.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6524.00,17760.46,Inpatient DRG
"HIV WITH MULTIPLE MAJOR HIV RELATED CONDITIONS,EXTREME",890,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],32873.82,,"Case rate ($31,308.40). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,31308.40,32873.82,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC,831,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],10592.77,,"Case rate ($10,088.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,520.59, add-ons for qualifying new technology services are included. If operating cost exceeds $44,391.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,355.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $7,547.82 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,575.65 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $595.60. The transfer capital threshold is the transfer adjustment factor * $595.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,4941.30,23661.59,Inpatient DRG
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],28821.04,,"Fee schedule rate ($28,821.04). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,10347.06,28821.04,There are no additional notes associated with this service or procedure.
Arthrs Kne Surg W/Meniscectomy Med/Lat W/Shvg|RIGHT SIDE,CASE-29881,APC,29881,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],16776.29,,"Case rate ($16,447.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,436.22, add-ons for qualifying new technology services are included. If operating cost exceeds $50,307.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,820.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $13,441.70 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,491.27 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,060.68. The transfer capital threshold is the transfer adjustment factor * $1,060.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,7453.00,42138.30,Inpatient DRG
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,270,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],36456.95,,"Case rate ($34,720.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $32,431.98, add-ons for qualifying new technology services are included. If operating cost exceeds $71,076.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $5,156.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.4. The base transfer operating payment is the transfer adjustment factor * $30,933.64 + an uncompensated DSH payment of $1,359.91. The transfer operating threshold is the transfer adjustment factor * $31,072.08 + an uncompensated DSH payment of $1,359.91. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,427.36. The transfer capital threshold is the transfer adjustment factor * $2,427.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,34720.90,101002.04,Inpatient DRG
"ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",770,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],17800.73,,"Fee schedule rate ($17,800.73). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,8735.30,19730.13,There are no additional notes associated with this service or procedure.
"Arthrodesis Great Toe Metatarsophalangeal Joint|LEFT FOOT, GREAT TOE",CASE-28750,APC,28750,CPT,0360,RC,,,TA,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6791.99,7131.59,OPPS APC
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],26725.53,,"Fee schedule rate ($26,725.53). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.6), with a minimum of zero.",,,,0,other,11575.50,48961.48,There are no additional notes associated with this service or procedure.
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC,806,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],6836.20,,"Case rate ($6,510.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,192.35, add-ons for qualifying new technology services are included. If operating cost exceeds $41,063.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,093.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $4,231.80 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,247.40 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $333.93. The transfer capital threshold is the transfer adjustment factor * $333.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5354.25,13416.00,Inpatient DRG
Chromotubation Oviduct W/Materials,CASE-58350,APC,58350,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],4846.30,,"APC Price ($4,682.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,4682.41,4916.53,OPPS APC
SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS,029,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],13641.00,,"Per diem ($13,641). If length of stay < 4.7, first 1 days paid at a per diem of $27,282 instead. Capped at $64,114.20.",,,,0,other,13641.00,67130.05,Estimated amount calculated based on 5 day length of stay.
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],7734.30,,"Case rate ($7,366). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,988.03, add-ons for qualifying new technology services are included. If operating cost exceeds $41,859.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,156.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,024.55 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,043.08 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $396.49. The transfer capital threshold is the transfer adjustment factor * $396.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,21195.68,Inpatient DRG
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],90333.60,,"Fee schedule rate ($90,333.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,26127.34,90333.60,There are no additional notes associated with this service or procedure.
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],7562.35,,"Case rate ($7,414.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,032.76, add-ons for qualifying new technology services are included. If operating cost exceeds $41,903.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,159.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,069.12 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,087.81 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $400.00. The transfer capital threshold is the transfer adjustment factor * $400.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,7414.07,18217.52,Inpatient DRG
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],8326.32,,"Case rate ($8,163.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,729.53, add-ons for qualifying new technology services are included. If operating cost exceeds $42,600.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,214.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,763.33 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,784.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $454.78. The transfer capital threshold is the transfer adjustment factor * $454.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,8163.06,18067.42,Inpatient DRG
CELLULITIS WITH MCC,602,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],11851.75,,"Case rate ($11,287.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,653.44, add-ons for qualifying new technology services are included. If operating cost exceeds $45,524.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,426.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $8,675.59 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,708.49 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $666.83. The transfer capital threshold is the transfer adjustment factor * $666.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,11570.10,28349.31,Inpatient DRG
Hemorrhoid Ntrnl & Xtrnl 1 Column W/Fissurecto,CASE-46257,APC,46257,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],2727.99,,"APC Price ($2,598.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2598.08,2727.99,OPPS APC
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],41493.06,,"Fee schedule rate ($41,493.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,16897.01,43444.85,There are no additional notes associated with this service or procedure.
OTHER CEREBROVASCULAR DISORDERS WITH MCC,070,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],31286.59,,"Fee schedule rate ($31,286.59). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13219.09,37774.46,There are no additional notes associated with this service or procedure.
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7831.28,,"Case rate ($7,566.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,174.51, add-ons for qualifying new technology services are included. If operating cost exceeds $42,045.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,171.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,210.35 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,229.56 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $411.15. The transfer capital threshold is the transfer adjustment factor * $411.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,7566.45,16333.88,Inpatient DRG
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],16265.67,,"Case rate ($15,491.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,546.67, add-ons for qualifying new technology services are included. If operating cost exceeds $49,417.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,750.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $12,555.42 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,601.72 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $990.75. The transfer capital threshold is the transfer adjustment factor * $990.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,15491.11,54180.83,Inpatient DRG
ALLERGIC REACTIONS WITH MCC,915,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],27385.01,,"Fee schedule rate ($27,385.01). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,13332.86,33088.84,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,082,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],18294.37,,"Case rate ($17,423.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,344.04, add-ons for qualifying new technology services are included. If operating cost exceeds $51,215.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,892.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $14,346.19 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,399.08 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,132.06. The transfer capital threshold is the transfer adjustment factor * $1,132.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,17423.21,56223.11,Inpatient DRG
OTHER DISORDERS OF THE EYE WITHOUT MCC,125,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],15108.00,,,,,,0,other,7144.54,17952.29,There are no additional notes associated with this service or procedure.
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],18217.52,,"Fee schedule rate ($18,217.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7414.07,18217.52,There are no additional notes associated with this service or procedure.
Brnchsc Ebus Guided Sampl 3/> Node Station/Strux,CASE-31653,APC,31653,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6605.95,,"APC Price ($6,605.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6605.95,6936.25,OPPS APC
"DISORDERS OF GALLBLADDER AND BILIARY TRACT,MODERATE",284,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],9371.91,,"The inlier payment is calculated as the lesser of the standard DRG payment $9,371.91 and the transfer payment, which is a per diem of $2,617.85. If cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,9371.91,9840.51,Estimated amount calculated based on 1 day length of stay.
Biopsy Vaginal Mucosa Simple|UNUSUAL NON-OVERLAPPING SERVICE,CASE-57100,APC,57100,CPT,0360,RC,,,XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5856.81,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5658.76,5941.70,OPPS APC
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC,806,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],10071.17,,"Fee schedule rate ($10,071.17). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5354.25,13416.00,There are no additional notes associated with this service or procedure.
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],12432.82,,"Fee schedule rate ($12,432.82). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,23385.72,There are no additional notes associated with this service or procedure.
SPINAL PROCEDURES WITH MCC,028,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],44765.25,,"Case rate ($42,633.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $39,796.72, add-ons for qualifying new technology services are included. If operating cost exceeds $74,667.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,735.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.5. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 9.5)) / 2. The base transfer operating payment is the transfer adjustment factor * $37,712.72 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $37,851.77 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,975.91. The transfer capital threshold is the transfer adjustment factor * $2,975.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,42633.57,120982.83,Inpatient DRG
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],52794.06,,"Fee schedule rate ($52,794.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (37), with a minimum of zero.",,,,0,other,13907.80,52794.06,There are no additional notes associated with this service or procedure.
Prq Skeletal Fixj Metacarpal Fx Each Bone|RIGHT SIDE,CASE-26608,APC,26608,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],101083.00,,"Fee schedule rate ($101,083.00). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,35389.50,101083.00,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],15821.26,,"Case rate ($9,040.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,546, add-ons for qualifying new technology services are included. If operating cost exceeds $43,417.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,278.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,576.80 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,601.05 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $518.97. The transfer capital threshold is the transfer adjustment factor * $518.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,9040.72,26966.33,All Other Inpatient
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],71140.65,,"Fee schedule rate ($71,140.65). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,40542.37,128358.13,There are no additional notes associated with this service or procedure.
Colsc Flx With Directed Submucosal Njx Any Sbst|COLORECTAL CANCER SCREEN,CASE-45381,APC,45381,CPT,0360,RC,,,PT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1120.09,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1120.09,1176.09,OPPS APC
"EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME, NEONATE",790,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],3054.00,,,,,,0,other,3054.00,44304.49,Estimated amount calculated based on 17 day length of stay.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],11681.49,,"Fee schedule rate ($11,681.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5778.62,11681.49,There are no additional notes associated with this service or procedure.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],9252.42,,"Case rate ($8,811.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,333.06, add-ons for qualifying new technology services are included. If operating cost exceeds $43,204.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,262.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,364.65 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,388.11 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $502.23. The transfer capital threshold is the transfer adjustment factor * $502.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,20401.88,Inpatient DRG
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],45845.03,,"Fee schedule rate ($45,845.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,18598.83,48389.68,There are no additional notes associated with this service or procedure.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITHOUT CC/MCC,816,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],6536.15,,"Case rate ($6,224.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,926.50, add-ons for qualifying new technology services are included. If operating cost exceeds $40,797.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,073.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $3,966.92 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,981.55 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $313.03. The transfer capital threshold is the transfer adjustment factor * $313.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6224.90,14733.53,Inpatient DRG
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],15076.44,,"Fee schedule rate ($15,076.44). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6340.03,15076.44,There are no additional notes associated with this service or procedure.
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral Ea Addl|LEFT SIDE,CASE-64484,APC,64484,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],827.89,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,827.89,869.28,OPPS APC
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],22479.58,,"Case rate ($21,719.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,340.70, add-ons for qualifying new technology services are included. If operating cost exceeds $55,211.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,206.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.2. The base transfer operating payment is the transfer adjustment factor * $18,328.17 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,395.75 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,446.27. The transfer capital threshold is the transfer adjustment factor * $1,446.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,21719.40,85305.59,Inpatient DRG
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],11168.08,,"Fee schedule rate ($11,168.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5937.41,12366.99,There are no additional notes associated with this service or procedure.
PERITONEAL ADHESIOLYSIS WITH CC,336,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],16793.10,,"Case rate ($16,225.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,229.58, add-ons for qualifying new technology services are included. If operating cost exceeds $50,100.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,804.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $13,235.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,284.63 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,044.44. The transfer capital threshold is the transfer adjustment factor * $1,044.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,16225.22,53705.31,Inpatient DRG
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],5415.00,,"Per diem ($5,415). If length of stay < 3.1, first 1 days paid at a per diem of $10,830 instead. Capped at $16,785.91.",,,,0,other,5415.00,17575.50,Estimated amount calculated based on 3 day length of stay.
HC Inj Anes/Steroid C/D Facet Sg,CASE-64490,APC,64490,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],827.89,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,827.89,869.28,OPPS APC
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],7665.00,,"Per diem ($7,665). If length of stay < 4, first 1 days paid at a per diem of $15,330 instead. Capped at $30,658.90.",,,,0,other,7665.00,40737.46,Estimated amount calculated based on 5 day length of stay.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",062,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],24228.47,,"Case rate ($13,844.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,015.16, add-ons for qualifying new technology services are included. If operating cost exceeds $47,886.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,630.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $11,029.54 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,070.21 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $870.34. The transfer capital threshold is the transfer adjustment factor * $870.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,13844.84,44304.80,All Other Inpatient
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],28434.57,,"Fee schedule rate ($28,434.57). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,8906.63,28434.57,There are no additional notes associated with this service or procedure.
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],28655.14,,"Case rate ($28,093.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $26,270.18, add-ons for qualifying new technology services are included. If operating cost exceeds $61,141.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,672.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $24,235.87 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $24,325.23 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,912.45. The transfer capital threshold is the transfer adjustment factor * $1,912.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 102%.",,,,0,other,10078.00,81454.07,Inpatient DRG
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],8120.41,,"Case rate ($7,733.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,330.12, add-ons for qualifying new technology services are included. If operating cost exceeds $42,201.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,183.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,365.38 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,385.17 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $423.38. The transfer capital threshold is the transfer adjustment factor * $423.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7733.72,18043.23,Inpatient DRG
"SPINAL PROCEDURES,MINOR",023,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],4703.06,,"Case rate for a one day stay ($4,703.06). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,4703.06,4938.21,There are no additional notes associated with this service or procedure.
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC",629,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],44657.18,,"Fee schedule rate ($44,657.18). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,16699.94,44657.18,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],16017.99,,"Case rate ($16,017.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,036.80, add-ons for qualifying new technology services are included. If operating cost exceeds $49,907.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,789.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $13,043.76 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,091.85 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,029.28. The transfer capital threshold is the transfer adjustment factor * $1,029.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,16017.99,51903.64,Inpatient DRG
"OTHER DIGESTIVE SYSTEM DIAGNOSES,MODERATE",254,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],7987.07,,"Case rate ($7,606.73). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7606.73,7987.07,There are no additional notes associated with this service or procedure.
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],59081.91,,"Fee schedule rate ($59,081.91). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,8480.00,59081.91,There are no additional notes associated with this service or procedure.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],59521.43,,"Fee schedule rate ($59,521.43). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,16689.78,59521.43,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],28235.64,,"Fee schedule rate ($28,235.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,14344.60,36028.59,There are no additional notes associated with this service or procedure.
PREMATURITY WITHOUT MAJOR PROBLEMS,792,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],18531.10,,"Case rate ($18,531.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,374.70, add-ons for qualifying new technology services are included. If operating cost exceeds $52,245.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,973.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. The base transfer operating payment is the transfer adjustment factor * $15,373.07 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,429.75 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,213.09. The transfer capital threshold is the transfer adjustment factor * $1,213.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,1956.00,19457.66,Inpatient DRG
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],12601.27,,"Case rate ($12,001.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,318.84, add-ons for qualifying new technology services are included. If operating cost exceeds $46,189.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,477.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $9,338.49 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,373.89 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $717.78. The transfer capital threshold is the transfer adjustment factor * $717.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12305.53,30103.84,Inpatient DRG
Cysto/Uretero W/Lithotripsy &Indwell Stent Insrt|LEFT SIDE,CASE-52356,APC,52356,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5018.77,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5018.77,5269.71,OPPS APC
INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC,198,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],7134.88,,"Case rate ($6,795.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,456.95, add-ons for qualifying new technology services are included. If operating cost exceeds $41,327.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,114.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,495.42 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,512.00 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $354.73. The transfer capital threshold is the transfer adjustment factor * $354.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6795.12,23505.07,Inpatient DRG
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],16828.14,,"Case rate ($16,026.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,044.99, add-ons for qualifying new technology services are included. If operating cost exceeds $49,916.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,789.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $13,051.92 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,100.04 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,029.93. The transfer capital threshold is the transfer adjustment factor * $1,029.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,11165.00,61234.06,Inpatient DRG
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],15343.67,,"Case rate ($8,767.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,292.11, add-ons for qualifying new technology services are included. If operating cost exceeds $43,163.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,258.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,323.85 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,347.16 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $499.01. The transfer capital threshold is the transfer adjustment factor * $499.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,8767.81,19824.58,All Other Inpatient
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],15244.88,,"Fee schedule rate ($15,244.88). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,7438.45,15961.98,There are no additional notes associated with this service or procedure.
Bronchoscopy W/Transbroncl Ndl Aspir Bx Ea Lobe,CASE-31633,APC,31633,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6936.25,,"APC Price ($6,605.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6605.95,6936.25,OPPS APC
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],6965.00,,,,,,0,other,6965.00,23385.72,There are no additional notes associated with this service or procedure.
O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC,621,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],12159.94,,"Case rate ($12,159.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,447.74, add-ons for qualifying new technology services are included. If operating cost exceeds $46,318.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,507.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $9,467.88 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,502.79 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $747.11. The transfer capital threshold is the transfer adjustment factor * $747.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12159.94,36669.96,Inpatient DRG
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],26721.94,,"Fee schedule rate ($26,721.94). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6965.00,34422.94,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,065,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],14233.80,,"Fee schedule rate ($14,233.80). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,8786.76,25681.86,There are no additional notes associated with this service or procedure.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC,434,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7007.00,,"Case rate ($6,770.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,433.64, add-ons for qualifying new technology services are included. If operating cost exceeds $41,304.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,112.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,472.20 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,488.69 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $352.90. The transfer capital threshold is the transfer adjustment factor * $352.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6770.05,14019.86,Inpatient DRG
INFLAMMATORY BOWEL DISEASE WITH MCC,385,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],29736.16,,"Fee schedule rate ($29,736.16). Adds an outlier to normal pricing equal to the per diem rate ($112,108.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.5), with a minimum of zero.",,,,0,other,11480.01,31134.92,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],18366.40,,"Fee schedule rate ($18,366.40). Adds an outlier to normal pricing equal to the per diem rate ($38,964.32) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.5), with a minimum of zero.",,,,0,other,8563.30,31533.97,There are no additional notes associated with this service or procedure.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH CC,026,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],24150.69,,"Case rate ($23,000.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $21,532.64, add-ons for qualifying new technology services are included. If operating cost exceeds $56,403.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,299.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $19,515.74 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $19,587.69 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,539.98. The transfer capital threshold is the transfer adjustment factor * $1,539.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,23000.66,63202.45,Inpatient DRG
Cystoscopy prostatic imp 1-3,CASE-C9739,APC,C9739,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5018.77,,"APC Price ($5,018.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5018.77,5269.71,OPPS APC
Cysto/Uretero W/Lithotripsy &Indwell Stent Insrt|RIGHT SIDE,CASE-52356,APC,52356,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5018.77,,"APC Price ($5,018.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5018.77,5269.71,OPPS APC
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],14699.43,,"Fee schedule rate ($14,699.43). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6683.37,14699.43,There are no additional notes associated with this service or procedure.
VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC,033,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],13206.23,,"Case rate ($13,206.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,421.07, add-ons for qualifying new technology services are included. If operating cost exceeds $47,292.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,583.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $10,437.64 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,476.13 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $823.63. The transfer capital threshold is the transfer adjustment factor * $823.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,13206.23,42156.44,Inpatient DRG
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],8144.18,,"Fee schedule rate ($8,144.18). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6214.05,15318.94,There are no additional notes associated with this service or procedure.
RESPIRATORY NEOPLASMS WITHOUT CC/MCC,182,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],6965.00,,,,,,0,other,6965.00,23037.13,There are no additional notes associated with this service or procedure.
OTHER MENTAL DISORDER DIAGNOSES,887,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],9657.03,,"Case rate ($9,197.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,691.53, add-ons for qualifying new technology services are included. If operating cost exceeds $43,562.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,290.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,721.79 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,746.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $530.42. The transfer capital threshold is the transfer adjustment factor * $530.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,2070.00,21072.10,Inpatient DRG
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],30538.70,,,,,,0,other,12455.21,37149.27,There are no additional notes associated with this service or procedure.
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC,807,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],6836.20,,"Case rate ($6,510.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,192.35, add-ons for qualifying new technology services are included. If operating cost exceeds $41,063.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,093.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $4,231.80 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,247.40 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $333.93. The transfer capital threshold is the transfer adjustment factor * $333.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5354.25,13266.23,Inpatient DRG
CERVICAL SPINAL FUSION WITHOUT CC/MCC,473,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],19401.49,,"Case rate ($18,477.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,324.93, add-ons for qualifying new technology services are included. If operating cost exceeds $52,195.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,969.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.6. The base transfer operating payment is the transfer adjustment factor * $15,323.48 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,379.98 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,209.17. The transfer capital threshold is the transfer adjustment factor * $1,209.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,18477.61,62077.11,Inpatient DRG
CERVICAL SPINAL FUSION WITH CC,472,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],70198.84,,"Fee schedule rate ($70,198.84). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,21896.13,70198.84,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],25026.36,,"Fee schedule rate ($25,026.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9356.31,25026.36,There are no additional notes associated with this service or procedure.
"OTHER BACK AND NECK DISORDERS FRACTURES AND INJURIES,MODERATE",347,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],1995.58,,"Case rate for a one day stay ($1,995.58). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,1995.58,2095.36,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC,831,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],10592.77,,"Case rate ($10,088.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,520.59, add-ons for qualifying new technology services are included. If operating cost exceeds $44,391.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,355.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $7,547.82 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,575.65 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $595.60. The transfer capital threshold is the transfer adjustment factor * $595.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,4941.30,23661.59,Inpatient DRG
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],60646.89,,"Fee schedule rate ($60,646.89). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15.6), with a minimum of zero.",,,,0,other,23799.09,63499.65,There are no additional notes associated with this service or procedure.
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],7684.90,,"Fee schedule rate ($7,684.90). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5280.00,17136.70,There are no additional notes associated with this service or procedure.
"Laminec/Facetect/Foramin,Lumbar",CASE-63047,APC,63047,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],14193.90,,"Fee schedule rate ($14,193.90). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,12775.53,31469.43,There are no additional notes associated with this service or procedure.
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],19593.97,,"Fee schedule rate ($19,593.97). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,15821.59,40320.14,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITHOUT STERILIZATION WITH CC,787,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],9508.01,,"Case rate ($9,508.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,980.70, add-ons for qualifying new technology services are included. If operating cost exceeds $43,851.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,313.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $7,009.90 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,035.74 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $553.15. The transfer capital threshold is the transfer adjustment factor * $553.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9508.01,23722.94,Inpatient DRG
Colonoscopy W/Biopsy Single/Multiple,CASE-45380,APC,45380,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1120.09,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1120.09,1176.09,OPPS APC
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],10643.26,,"Case rate ($10,136.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,565.33, add-ons for qualifying new technology services are included. If operating cost exceeds $44,436.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,359.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $7,592.38 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,620.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $599.11. The transfer capital threshold is the transfer adjustment factor * $599.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10136.44,24444.75,Inpatient DRG
HEADACHES WITHOUT MCC,103,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],7988.85,,"Case rate ($7,608.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,213.57, add-ons for qualifying new technology services are included. If operating cost exceeds $42,084.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,174.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $5,249.26 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,268.62 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $414.22. The transfer capital threshold is the transfer adjustment factor * $414.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,20883.08,Inpatient DRG
OTHER DISORDERS OF THE EYE WITHOUT MCC,125,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],14429.27,,"Fee schedule rate ($14,429.27). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.9), with a minimum of zero.",,,,0,other,7144.54,17952.29,There are no additional notes associated with this service or procedure.
Revision of Reconstructed Breast|BILATERAL PROCEDURE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-19380,APC,19380,CPT,0360,RC,,,50|XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7918.25,,"APC Price ($7,650.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,7918.25,7918.25,OPPS APC
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],85466.62,,"Fee schedule rate ($85,466.62). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,21382.16,85466.62,There are no additional notes associated with this service or procedure.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],142438.06,,"Fee schedule rate ($142,438.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (40), with a minimum of zero.",,,,0,other,45521.20,142438.06,There are no additional notes associated with this service or procedure.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],9007.39,,"Case rate ($8,702.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,231.63, add-ons for qualifying new technology services are included. If operating cost exceeds $43,102.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,254.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,263.59 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,286.68 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $494.26. The transfer capital threshold is the transfer adjustment factor * $494.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,5683.00,19635.68,Inpatient DRG
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],18518.02,,,,,,0,other,8318.14,19763.43,There are no additional notes associated with this service or procedure.
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],6277.00,,"Per diem ($6,277). If length of stay < 5.6, first 1 days paid at a per diem of $12,554 instead. Capped at $35,148.55.",,,,0,other,6277.00,36801.89,Estimated amount calculated based on 4 day length of stay.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],19849.17,,"Fee schedule rate ($19,849.17). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,9097.60,21455.22,There are no additional notes associated with this service or procedure.
Surgical Arthroscopy Sho W/Coracoacrm Ligm Rls|RIGHT SIDE,CASE-29826,APC,29826,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC,099,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],22084.20,,"Fee schedule rate ($22,084.20). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11171.21,26807.94,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],15378.02,,"Case rate ($8,787.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,310.38, add-ons for qualifying new technology services are included. If operating cost exceeds $43,181.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,260.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,342.05 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,365.43 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $500.45. The transfer capital threshold is the transfer adjustment factor * $500.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,6965.00,32293.66,All Other Inpatient
Bx/Exc Lymph Node Open Deep Axillary Node|LEFT SIDE,CASE-38525,APC,38525,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6215.36,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6215.36,6526.12,OPPS APC
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],33221.97,,"Fee schedule rate ($33,221.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (47), with a minimum of zero.",,,,0,other,15283.90,38757.79,There are no additional notes associated with this service or procedure.
"Tendon Sheath Incision|RIGHT HAND, FIFTH DIGIT|UNUSUAL NON-OVERLAPPING SERVICE",CASE-26055,APC,26055,CPT,0360,RC,,,F9|XU,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|RIGHT HAND, FOURTH DIGIT",CASE-26160,APC,26160,CPT,0360,RC,,,F8,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1505.12,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1505.12,1580.37,OPPS APC
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,095,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],25824.48,,"Fee schedule rate ($25,824.48). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,19411.47,50750.92,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC",281,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],8169.15,,"Case rate ($8,169.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,735.20, add-ons for qualifying new technology services are included. If operating cost exceeds $42,606.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,215.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $5,768.98 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,790.25 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $455.23. The transfer capital threshold is the transfer adjustment factor * $455.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8169.15,23859.35,Inpatient DRG
"LIMB REATTACHMENT, HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA",956,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],148259.86,,"Fee schedule rate ($148,259.86). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,27428.25,148259.86,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL OBSTRUCTION WITH CC,389,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],16423.43,,"Fee schedule rate ($16,423.43). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5118.00,16423.43,There are no additional notes associated with this service or procedure.
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",759,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6438.90,,"Case rate ($6,438.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,125.57, add-ons for qualifying new technology services are included. If operating cost exceeds $40,996.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,088.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,165.27 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,180.62 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $328.68. The transfer capital threshold is the transfer adjustment factor * $328.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6190.22,13057.66,Inpatient DRG
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],78944.25,,"Fee schedule rate ($78,944.25). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (40), with a minimum of zero.",,,,0,other,45521.20,142438.06,There are no additional notes associated with this service or procedure.
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],13625.25,,"Fee schedule rate ($13,625.25). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7243.75,23262.15,There are no additional notes associated with this service or procedure.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],31007.30,,"Fee schedule rate ($31,007.30). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,16120.25,41187.90,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC,831,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],10341.62,,"Case rate ($9,849.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,312.82, add-ons for qualifying new technology services are included. If operating cost exceeds $44,183.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,324.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $7,340.04 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,367.87 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $564.17. The transfer capital threshold is the transfer adjustment factor * $564.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,4941.30,23661.59,Inpatient DRG
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],6965.00,,,,,,0,other,6965.00,16400.70,There are no additional notes associated with this service or procedure.
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],29482.05,,,,,,0,other,6965.00,29482.05,There are no additional notes associated with this service or procedure.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC,027,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],19981.71,,"Case rate ($19,030.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,839, add-ons for qualifying new technology services are included. If operating cost exceeds $52,710.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,009.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $15,835.66 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,894.05 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,249.59. The transfer capital threshold is the transfer adjustment factor * $1,249.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,19030.20,56363.30,Inpatient DRG
Ercp W/Biopsy Single/Multiple,CASE-43261,APC,43261,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3608.81,,"APC Price ($3,608.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3608.81,3789.26,OPPS APC
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],33608.45,,"Fee schedule rate ($33,608.45). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,7332.00,35314.31,There are no additional notes associated with this service or procedure.
"PEPTIC ULCER AND GASTRITIS,MODERATE",241,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],8662.55,,"Case rate ($8,662.55). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,8662.55,9095.68,There are no additional notes associated with this service or procedure.
HC Pbb Carpal Tunnel Inj Pmc|PBB CHARGE,CASE-20526,APC,20526,CPT,0510,RC,,,PBB,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],301.68,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,287.31,301.68,OPPS APC
MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,708,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],10138.21,,"Case rate ($9,655.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $9,011.46, add-ons for qualifying new technology services are included. If operating cost exceeds $48,581.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $3,476.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.3. The base transfer operating payment is the transfer adjustment factor * $8,970.52. The transfer operating threshold is the transfer adjustment factor * $9,011.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $684.92. The transfer capital threshold is the transfer adjustment factor * $684.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10138.21,29171.15,Inpatient DRG
"FEMALE REPRODUCTIVE SYSTEM INFECTIONS,MODERATE",531,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],6876.53,,"Case rate ($6,876.53). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,6876.53,7220.36,There are no additional notes associated with this service or procedure.
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],90333.60,,"Fee schedule rate ($90,333.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,26127.34,90333.60,There are no additional notes associated with this service or procedure.
CERVICAL SPINAL FUSION WITHOUT CC/MCC,473,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],62077.11,,"Fee schedule rate ($62,077.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,18477.61,62077.11,There are no additional notes associated with this service or procedure.
"Laminec/Facetect/Foramin,Thoracic",CASE-63046,APC,63046,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],16986.50,,"APC Price ($16,412.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,16412.07,17232.68,OPPS APC
POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES,769,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],29791.03,,"Fee schedule rate ($29,791.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,13388.39,33250.19,There are no additional notes associated with this service or procedure.
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],81306.30,,"Fee schedule rate ($81,306.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,20846.48,81306.30,There are no additional notes associated with this service or procedure.
"NEONATE BIRTH WEIGHT 2000-2499 GRAMS WITH OTHER SIGNIFICANT CONDITION,MODERATE",625,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],14038.13,,"Case rate ($14,038.13). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,14038.13,14740.04,There are no additional notes associated with this service or procedure.
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],13960.40,,"Case rate ($13,295.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,504.24, add-ons for qualifying new technology services are included. If operating cost exceeds $47,375.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,590.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $10,520.50 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,559.29 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $830.17. The transfer capital threshold is the transfer adjustment factor * $830.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7000.00,33835.79,Inpatient DRG
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],34032.82,,"Fee schedule rate ($34,032.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,15233.11,38610.21,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC,084,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],19445.16,,"Fee schedule rate ($19,445.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,6965.00,19445.16,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],27884.19,,"Fee schedule rate ($27,884.19). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,17693.40,52449.26,There are no additional notes associated with this service or procedure.
"HYPERTENSION,MODERATE",199,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],7075.31,,"The inlier payment is calculated as the lesser of the standard DRG payment $6,738.39 and the transfer payment, which is a per diem of $2,315.60. If cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6738.39,7075.31,Estimated amount calculated based on 2 day length of stay.
Hallux Rigidus W/Cheilectomy 1st Mp Jt W/O Implt|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-28289,APC,28289,CPT,0360,RC,,,LT|XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6791.99,7131.59,OPPS APC
GASTROINTESTINAL HEMORRHAGE WITH MCC,377,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],15040.50,,"Case rate ($14,324.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,461.19, add-ons for qualifying new technology services are included. If operating cost exceeds $48,332.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,665.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $11,473.94 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,516.24 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $905.41. The transfer capital threshold is the transfer adjustment factor * $905.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7634.00,35969.56,Inpatient DRG
BRONCHITIS AND ASTHMA WITH CC/MCC,202,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],8820.25,,"Case rate ($8,521.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,063.43, add-ons for qualifying new technology services are included. If operating cost exceeds $42,934.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,241.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,096.00 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,118.48 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $481.03. The transfer capital threshold is the transfer adjustment factor * $481.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,7606.34,19110.30,Inpatient DRG
"Amputation Toe Interphalangeal Joint|RIGHT FOOT, FOURTH DIGIT",CASE-28825,APC,28825,CPT,0360,RC,,,T8,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,761,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],6621.30,,"Fee schedule rate ($6,621.30). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,5808.41,11946.72,There are no additional notes associated with this service or procedure.
Ercp W/Biopsy Single/Multiple|UNUSUAL NON-OVERLAPPING SERVICE,CASE-43261,APC,43261,CPT,0360,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5682.51,,"APC Price ($5,682.51). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5682.51,5966.63,OPPS APC
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",062,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],33023.06,,"Fee schedule rate ($33,023.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,13844.84,44304.80,There are no additional notes associated with this service or procedure.
Excision Interdigital Morton Neuroma Single Each|RIGHT SIDE,CASE-28080,APC,28080,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1505.12,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1505.12,1580.37,OPPS APC
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],54875.56,,"Fee schedule rate ($54,875.56). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,21719.40,85305.59,There are no additional notes associated with this service or procedure.
MAJOR ESOPHAGEAL DISORDERS WITH CC,369,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],9804.90,,"Fee schedule rate ($9,804.90). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6965.00,19680.94,There are no additional notes associated with this service or procedure.
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],29216.99,,"Fee schedule rate ($29,216.99). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9755.86,29216.99,There are no additional notes associated with this service or procedure.
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],19462.52,,,,,,0,other,8643.20,19462.52,There are no additional notes associated with this service or procedure.
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],28093.27,,"Case rate ($28,093.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $26,270.18, add-ons for qualifying new technology services are included. If operating cost exceeds $61,141.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,672.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $24,235.87 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $24,325.23 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,912.45. The transfer capital threshold is the transfer adjustment factor * $1,912.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,10078.00,81454.07,Inpatient DRG
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],23882.41,,"Case rate ($13,647.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,831.20, add-ons for qualifying new technology services are included. If operating cost exceeds $47,702.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,615.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $10,846.26 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,886.25 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $855.88. The transfer capital threshold is the transfer adjustment factor * $855.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,7921.00,45706.73,All Other Inpatient
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],22955.40,,"Case rate ($21,862.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,473.63, add-ons for qualifying new technology services are included. If operating cost exceeds $55,344.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,216.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. The base transfer operating payment is the transfer adjustment factor * $18,460.61 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,528.68 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,456.72. The transfer capital threshold is the transfer adjustment factor * $1,456.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7086.00,57872.02,Inpatient DRG
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,097,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],71069.39,,,,,,0,other,26404.32,79915.74,There are no additional notes associated with this service or procedure.
OTHER MENTAL DISORDER DIAGNOSES,887,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],2070.00,,,,,,0,other,2070.00,21072.10,Estimated amount calculated based on 1 day length of stay.
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],14830.15,,"Fee schedule rate ($14,830.15). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,7884.32,17835.23,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],21167.26,,"Fee schedule rate ($21,167.26). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,6841.83,21167.26,There are no additional notes associated with this service or procedure.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITHOUT CC/MCC,816,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],8165.85,,"Fee schedule rate ($8,165.85). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6224.90,14733.53,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],8859.23,,"Case rate ($8,859.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,377.16, add-ons for qualifying new technology services are included. If operating cost exceeds $43,248.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,265.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $6,408.58 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,432.21 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $505.70. The transfer capital threshold is the transfer adjustment factor * $505.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8859.23,20090.22,Inpatient DRG
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],12526.44,,"Fee schedule rate ($12,526.44). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5415.00,17575.50,There are no additional notes associated with this service or procedure.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],18405.99,,"Case rate ($10,517.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,920.01, add-ons for qualifying new technology services are included. If operating cost exceeds $44,791.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,386.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $7,945.76 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,975.06 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $627.00. The transfer capital threshold is the transfer adjustment factor * $627.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,10517.71,24909.11,All Other Inpatient
Lithotripsy Xtrcorp Shock Wave|RIGHT SIDE,CASE-50590,APC,50590,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3464.44,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3299.47,3464.44,OPPS APC
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,085,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],57443.16,,"Fee schedule rate ($57,443.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,9282.00,57443.16,There are no additional notes associated with this service or procedure.
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],59494.91,,"Fee schedule rate ($59,494.91). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,18594.09,59494.91,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,086,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],30728.81,,"Fee schedule rate ($30,728.81). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8442.00,30728.81,There are no additional notes associated with this service or procedure.
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC,519,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],16032.61,,"Case rate ($15,490.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,546.03, add-ons for qualifying new technology services are included. If operating cost exceeds $49,417.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,750.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $12,554.80 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,601.09 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $990.70. The transfer capital threshold is the transfer adjustment factor * $990.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,15490.44,50780.20,Inpatient DRG
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],37149.27,,"Fee schedule rate ($37,149.27). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,12455.21,37149.27,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],13891.57,,"Case rate ($13,891.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,058.63, add-ons for qualifying new technology services are included. If operating cost exceeds $47,929.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,633.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,072.85 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,113.68 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $873.76. The transfer capital threshold is the transfer adjustment factor * $873.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,13891.57,34712.20,Inpatient DRG
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,345,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],33616.03,,"Fee schedule rate ($33,616.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12134.89,33616.03,There are no additional notes associated with this service or procedure.
"LYMPHOMA MYELOMA AND NON-ACUTE LEUKEMIA,MAJOR",691,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],20026.37,,"Case rate ($19,072.73). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,19072.73,20026.37,There are no additional notes associated with this service or procedure.
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],5791.49,,"Fee schedule rate ($5,791.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,3079.00,10940.41,There are no additional notes associated with this service or procedure.
FULL TERM NEONATE WITH MAJOR PROBLEMS,793,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],31690.87,,"Case rate ($30,181.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $28,213.07, add-ons for qualifying new technology services are included. If operating cost exceeds $63,084.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,825.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $26,171.62 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $26,268.12 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,065.20. The transfer capital threshold is the transfer adjustment factor * $2,065.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,4302.90,82045.22,Inpatient DRG
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],25534.84,,,,,,0,other,10733.06,45157.33,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],13444.85,,"Case rate ($12,990.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,220.11, add-ons for qualifying new technology services are included. If operating cost exceeds $47,091.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,567.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $10,237.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,275.16 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $807.83. The transfer capital threshold is the transfer adjustment factor * $807.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,9888.00,43399.23,Inpatient DRG
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],54764.34,,"Fee schedule rate ($54,764.34). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,18178.96,54764.34,There are no additional notes associated with this service or procedure.
Anrct Xm Surg Req Anes General Spi/Edrl Dx|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-45990,APC,45990,CPT,0360,RC,,,74,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],2727.99,,"APC Price ($2,598.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2598.08,2727.99,OPPS APC
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],58394.20,,"Fee schedule rate ($58,394.20). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,9370.00,65732.99,There are no additional notes associated with this service or procedure.
RADIOTHERAPY,849,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],45373.65,,"Fee schedule rate ($45,373.65). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,20293.88,81867.07,There are no additional notes associated with this service or procedure.
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],9667.64,,"Fee schedule rate ($9,667.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,5139.72,13110.79,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC,084,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],6965.00,,,,,,0,other,6965.00,19445.16,There are no additional notes associated with this service or procedure.
VAGINAL DELIVERY WITH O.R. PROCEDURES EXCEPT STERILIZATION AND/OR D&C,768,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],9385.94,,"Case rate ($9,201.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,695.94, add-ons for qualifying new technology services are included. If operating cost exceeds $43,566.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,290.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $6,726.19 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,750.99 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $530.76. The transfer capital threshold is the transfer adjustment factor * $530.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6426.91,13416.00,Inpatient DRG
TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC,084,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],8838.59,,"Case rate ($8,417.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,966.41, add-ons for qualifying new technology services are included. If operating cost exceeds $42,837.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,233.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $5,999.34 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,021.46 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $473.41. The transfer capital threshold is the transfer adjustment factor * $473.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,19445.16,Inpatient DRG
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],36875.62,,"Fee schedule rate ($36,875.62). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.7), with a minimum of zero.",,,,0,other,15233.11,38610.21,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],62084.69,,"Fee schedule rate ($62,084.69). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (35), with a minimum of zero.",,,,0,other,30398.48,82674.88,There are no additional notes associated with this service or procedure.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",063,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],11730.96,,"Case rate ($11,172.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,546.21, add-ons for qualifying new technology services are included. If operating cost exceeds $45,417.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,418.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $8,568.78 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,601.26 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $658.62. The transfer capital threshold is the transfer adjustment factor * $658.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,35701.87,Inpatient DRG
FRACTURES OF FEMUR WITH MCC,533,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],49490.05,,"Fee schedule rate ($49,490.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,6852.00,49490.05,There are no additional notes associated with this service or procedure.
Rpr 1st Ingun Hrna Age 5 Yrs/> Reducible|LEFT SIDE,CASE-49505,APC,49505,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3351.34,,"APC Price ($3,351.34). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3351.34,3518.91,OPPS APC
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],29243.52,,"Fee schedule rate ($29,243.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,14343.25,36024.65,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],31533.97,,"Fee schedule rate ($31,533.97). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8563.30,31533.97,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,448,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],79697.35,,"Fee schedule rate ($79,697.35). Adds an outlier to normal pricing equal to the per diem rate ($108,215.07) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,30663.95,94077.13,There are no additional notes associated with this service or procedure.
CELLULITIS WITH MCC,602,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],28349.31,,"Fee schedule rate ($28,349.31). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11570.10,28349.31,There are no additional notes associated with this service or procedure.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,098,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],38799.38,,"Fee schedule rate ($38,799.38). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,6965.00,45156.75,There are no additional notes associated with this service or procedure.
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],7086.00,,"Per diem ($7,086). If length of stay < 7.8, first 1 days paid at a per diem of $14,172 instead. Capped at $55,272.09.",,,,0,other,7086.00,57872.02,Estimated amount calculated based on 5 day length of stay.
GASTROINTESTINAL HEMORRHAGE WITH CC,378,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],8586.33,,"Case rate ($8,586.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,123.28, add-ons for qualifying new technology services are included. If operating cost exceeds $42,994.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,245.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,155.63 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,178.33 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $485.74. The transfer capital threshold is the transfer adjustment factor * $485.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8586.33,20845.19,Inpatient DRG
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,690,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],7798.29,,"Case rate ($7,426.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,044.73, add-ons for qualifying new technology services are included. If operating cost exceeds $41,915.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,160.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,081.05 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,099.78 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $400.94. The transfer capital threshold is the transfer adjustment factor * $400.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7426.94,15928.53,Inpatient DRG
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC,520,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],28074.86,,"Fee schedule rate ($28,074.86). Adds an outlier to normal pricing equal to the per diem rate ($68,872.56) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,12061.74,39786.42,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],20659.14,,"Fee schedule rate ($20,659.14). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.9), with a minimum of zero.",,,,0,other,9389.48,22358.90,There are no additional notes associated with this service or procedure.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],7585.67,,"Case rate ($7,224.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,856.36, add-ons for qualifying new technology services are included. If operating cost exceeds $41,727.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,146.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $4,893.37 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,911.41 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $386.14. The transfer capital threshold is the transfer adjustment factor * $386.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,15340.19,Inpatient DRG
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC,862,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],28705.48,,"Fee schedule rate ($28,705.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (42), with a minimum of zero.",,,,0,other,6855.00,35884.94,There are no additional notes associated with this service or procedure.
HC Blood Occult Peroxidase Actv Qual Feces 1-3 Spec,CASE-82272,APC,82272,CPT,0301,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],4.44,,,,,,0,other,4.23,4.44,There are no additional notes associated with this service or procedure.
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],11903.29,,"Case rate ($6,801.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,463.25, add-ons for qualifying new technology services are included. If operating cost exceeds $41,334.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,115.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,501.70 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,518.30 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $355.23. The transfer capital threshold is the transfer adjustment factor * $355.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,6801.88,22557.82,All Other Inpatient
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],17003.38,,"Case rate ($16,428.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,418.58, add-ons for qualifying new technology services are included. If operating cost exceeds $50,289.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,819.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $13,424.13 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,473.63 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,059.30. The transfer capital threshold is the transfer adjustment factor * $1,059.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,16428.39,42083.20,Inpatient DRG
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],11539.21,,"Case rate ($10,989.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,359.11, add-ons for qualifying new technology services are included. If operating cost exceeds $45,230.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,421.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $8,383.26 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,414.17 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $661.52. The transfer capital threshold is the transfer adjustment factor * $661.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10989.72,26280.60,Inpatient DRG
"POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT PROCEDURE,MAJOR",561,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],2074.03,,"Case rate for a one day stay ($1,975.27). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,1975.27,2074.03,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],30372.64,,"Fee schedule rate ($30,372.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,13260.40,32878.30,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC,087,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],22679.07,,"Fee schedule rate ($22,679.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,8139.36,22679.07,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],19691.31,,"Fee schedule rate ($19,691.31). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,9040.72,26966.33,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC,788,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],10708.50,,"Fee schedule rate ($10,708.50). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8438.02,20142.33,There are no additional notes associated with this service or procedure.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],28434.57,,"Fee schedule rate ($28,434.57). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,8906.63,28434.57,There are no additional notes associated with this service or procedure.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",062,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],14121.74,,"Case rate ($13,844.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,015.16, add-ons for qualifying new technology services are included. If operating cost exceeds $47,886.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,630.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $11,029.54 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,070.21 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $870.34. The transfer capital threshold is the transfer adjustment factor * $870.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,13844.84,44304.80,Inpatient DRG
CESAREAN SECTION WITH STERILIZATION WITH MCC,783,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],19499.60,,"Case rate ($18,571.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,411.86, add-ons for qualifying new technology services are included. If operating cost exceeds $52,282.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,975.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $15,410.10 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,466.92 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,216.01. The transfer capital threshold is the transfer adjustment factor * $1,216.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12612.10,23722.94,Inpatient DRG
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],12696.11,,"Case rate ($12,091.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,384.11, add-ons for qualifying new technology services are included. If operating cost exceeds $46,255.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,502.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $9,404.49 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,439.16 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $742.11. The transfer capital threshold is the transfer adjustment factor * $742.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,29482.05,Inpatient DRG
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],26966.33,,"Fee schedule rate ($26,966.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,9040.72,26966.33,There are no additional notes associated with this service or procedure.
Cysto W/Removal of Tumors Small,CASE-52234,APC,52234,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3464.44,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3299.47,3464.44,OPPS APC
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],13534.01,,"Case rate ($7,733.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,330.12, add-ons for qualifying new technology services are included. If operating cost exceeds $42,201.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,183.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,365.38 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,385.17 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $423.38. The transfer capital threshold is the transfer adjustment factor * $423.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,7733.72,18043.23,All Other Inpatient
NONTRAUMATIC STUPOR AND COMA WITH MCC,080,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],14912.51,,"Case rate ($14,202.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,347.79, add-ons for qualifying new technology services are included. If operating cost exceeds $48,218.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,656.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $11,360.96 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,402.84 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $896.49. The transfer capital threshold is the transfer adjustment factor * $896.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,14202.39,35615.37,Inpatient DRG
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],8811.83,,"Case rate ($8,811.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,333.06, add-ons for qualifying new technology services are included. If operating cost exceeds $43,204.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,262.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,364.65 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,388.11 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $502.23. The transfer capital threshold is the transfer adjustment factor * $502.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,20401.88,Inpatient DRG
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],14206.79,,,,,,0,other,6834.39,21354.82,There are no additional notes associated with this service or procedure.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],8009.34,,"Case rate ($8,009.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,586.52, add-ons for qualifying new technology services are included. If operating cost exceeds $42,457.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,203.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $5,620.85 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,641.57 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $443.54. The transfer capital threshold is the transfer adjustment factor * $443.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8009.34,19877.10,Inpatient DRG
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],85466.62,,"Fee schedule rate ($85,466.62). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,21382.16,85466.62,There are no additional notes associated with this service or procedure.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITHOUT CC/MCC,816,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],14733.53,,"Fee schedule rate ($14,733.53). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6224.90,14733.53,There are no additional notes associated with this service or procedure.
Egd Transoral Control Bleeding Any Method,CASE-43255,APC,43255,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1885.95,,"APC Price ($1,796.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1796.14,1885.95,OPPS APC
HEADACHES WITHOUT MCC,103,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],20883.08,,"Fee schedule rate ($20,883.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,20883.08,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],21892.85,,"Fee schedule rate ($21,892.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7569.84,21892.85,There are no additional notes associated with this service or procedure.
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],6965.00,,,,,,0,other,6965.00,23385.72,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITH STERILIZATION WITH MCC,783,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],23722.94,,"Fee schedule rate ($23,722.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12612.10,23722.94,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],13222.67,,"Case rate ($12,775.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,020.41, add-ons for qualifying new technology services are included. If operating cost exceeds $46,891.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,552.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $10,038.44 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,075.45 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $792.13. The transfer capital threshold is the transfer adjustment factor * $792.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,12775.53,31469.43,Inpatient DRG
BRONCHITIS AND ASTHMA WITH CC/MCC,202,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],14307.27,,"Fee schedule rate ($14,307.27). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7606.34,19110.30,There are no additional notes associated with this service or procedure.
MINOR BLADDER PROCEDURES WITHOUT CC/MCC,664,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],9267.70,,"Case rate ($8,826.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,359.44, add-ons for qualifying new technology services are included. If operating cost exceeds $43,230.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,251.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $6,390.26 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,414.49 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $491.17. The transfer capital threshold is the transfer adjustment factor * $491.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9034.63,31876.87,Inpatient DRG
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],8468.48,,"Case rate ($8,468.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,013.65, add-ons for qualifying new technology services are included. If operating cost exceeds $42,884.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,237.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,046.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,068.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $477.12. The transfer capital threshold is the transfer adjustment factor * $477.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6963.00,18954.85,Inpatient DRG
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],93728.21,,"Fee schedule rate ($93,728.21). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,35719.96,105091.76,There are no additional notes associated with this service or procedure.
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],34570.85,,"Fee schedule rate ($34,570.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,6965.00,36140.75,There are no additional notes associated with this service or procedure.
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],28445.08,,"Fee schedule rate ($28,445.08). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.8), with a minimum of zero.",,,,0,other,12195.15,39424.57,There are no additional notes associated with this service or procedure.
Brnschsc Tndsc Ebus Dx/Tx Intervention Perph Les,CASE-31654,APC,31654,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6936.25,,"APC Price ($6,605.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6605.95,6936.25,OPPS APC
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],10947.72,,"Case rate ($10,733.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,120.35, add-ons for qualifying new technology services are included. If operating cost exceeds $44,991.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,402.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $8,145.37 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,175.40 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $642.75. The transfer capital threshold is the transfer adjustment factor * $642.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,10733.06,45157.33,Inpatient DRG
Rinsj Rptd Biceps/Triceps Tdn Dstl W/WO Tdn Grf|LEFT SIDE,CASE-24342,APC,24342,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
Conization Cervix W/WO D&C Rpr Eltrd Exc,CASE-57522,APC,57522,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3030.03,,"APC Price ($3,030.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3030.03,3181.53,OPPS APC
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],18217.52,,"Fee schedule rate ($18,217.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7414.07,18217.52,There are no additional notes associated with this service or procedure.
"HIV WITH MULTIPLE MAJOR HIV RELATED CONDITIONS,EXTREME",890,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],32873.82,,"Case rate ($31,308.40). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,31308.40,32873.82,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],6965.00,,,,,,0,other,6965.00,21195.68,There are no additional notes associated with this service or procedure.
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],27553.62,,"Fee schedule rate ($27,553.62). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12305.53,30103.84,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],28235.64,,"Fee schedule rate ($28,235.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,14344.60,36028.59,There are no additional notes associated with this service or procedure.
"SPINAL FUSION AND OTHER BACK AND NECK PROCEDURES EXCEPT FOR DISC PROCEDURES,MINOR",321,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],5302.83,,"Case rate for a one day stay ($5,302.83). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,5302.83,5567.97,There are no additional notes associated with this service or procedure.
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],21854.96,,"Fee schedule rate ($21,854.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10638.94,25261.33,There are no additional notes associated with this service or procedure.
SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS,029,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],61889.56,,"Fee schedule rate ($61,889.56). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13641.00,67130.05,There are no additional notes associated with this service or procedure.
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],9667.64,,"Fee schedule rate ($9,667.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,5139.72,13110.79,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,167,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],14440.86,,"Case rate ($14,157.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,306.21, add-ons for qualifying new technology services are included. If operating cost exceeds $48,177.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,653.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $11,319.53 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,361.26 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $893.22. The transfer capital threshold is the transfer adjustment factor * $893.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,14157.71,43522.37,Inpatient DRG
Sigmoidoscopy Flx Ndsc US Xm,CASE-45341,APC,45341,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],913.99,,"APC Price ($870.46). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,870.46,913.99,OPPS APC
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],15653.45,,"Case rate ($14,908.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,004.25, add-ons for qualifying new technology services are included. If operating cost exceeds $48,875.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,708.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $12,014.99 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,059.30 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $948.10. The transfer capital threshold is the transfer adjustment factor * $948.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,14908.05,49717.39,Inpatient DRG
CESAREAN SECTION WITH STERILIZATION WITHOUT CC/MCC,785,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],20142.33,,"Fee schedule rate ($20,142.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8431.24,20142.33,There are no additional notes associated with this service or procedure.
Hysteroscopy Removal Leiomyomata,CASE-58561,APC,58561,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],4682.41,,"APC Price ($4,682.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,4682.41,4916.53,OPPS APC
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],35978.85,,"Case rate ($20,559.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $19,261.52, add-ons for qualifying new technology services are included. If operating cost exceeds $54,132.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,121.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $17,252.96 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $17,316.57 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,361.43. The transfer capital threshold is the transfer adjustment factor * $1,361.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,20559.34,54086.17,All Other Inpatient
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],8690.71,,"Case rate ($8,276.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,847.21, add-ons for qualifying new technology services are included. If operating cost exceeds $42,718.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,211.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,879.97 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,902.26 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $451.95. The transfer capital threshold is the transfer adjustment factor * $451.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6963.00,18954.85,Inpatient DRG
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],19763.43,,"Fee schedule rate ($19,763.43). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,8318.14,19763.43,There are no additional notes associated with this service or procedure.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],58245.60,,"Fee schedule rate ($58,245.60). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,35719.96,105091.76,There are no additional notes associated with this service or procedure.
Cysto Bladder W/Ureteral Catheterization|BILATERAL PROCEDURE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-52005,APC,52005,CPT,0360,RC,,,50|XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3464.44,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3299.47,3464.44,OPPS APC
Vulvectomy Simple Partial,CASE-56620,APC,56620,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3030.03,,"APC Price ($3,030.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3030.03,3181.53,OPPS APC
Amputation Metatarsal W/Toe Single,CASE-28810,APC,28810,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],13100.98,,"Case rate ($12,477.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,762.45, add-ons for qualifying new technology services are included. If operating cost exceeds $46,633.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,511.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $9,780.42 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,817.50 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $751.75. The transfer capital threshold is the transfer adjustment factor * $751.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12795.84,41944.25,Inpatient DRG
"Inj Dx/Ther Agnt Paravert Facet Joint, Cerv/Thorac, 2nd Level|RIGHT SIDE",CASE-64491,APC,64491,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],856.86,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,827.89,869.28,OPPS APC
GASTROINTESTINAL OBSTRUCTION WITH CC,389,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],16423.43,,"Fee schedule rate ($16,423.43). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5118.00,16423.43,There are no additional notes associated with this service or procedure.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,761,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],6965.00,,,,,,0,other,5808.41,11946.72,There are no additional notes associated with this service or procedure.
O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC,621,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],12159.94,,"Case rate ($12,159.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,447.74, add-ons for qualifying new technology services are included. If operating cost exceeds $46,318.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,507.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $9,467.88 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,502.79 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $747.11. The transfer capital threshold is the transfer adjustment factor * $747.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12159.94,36669.96,Inpatient DRG
Ndsc Njx Implt Matrl Urt&/Bldr Nck,CASE-51715,APC,51715,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3299.47,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3299.47,3464.44,OPPS APC
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],28619.77,,"Case rate ($27,256.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $25,492.14, add-ons for qualifying new technology services are included. If operating cost exceeds $60,363.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,611.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. The base transfer operating payment is the transfer adjustment factor * $23,460.69 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $23,547.19 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,851.28. The transfer capital threshold is the transfer adjustment factor * $1,851.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,27256.92,81353.66,Inpatient DRG
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],10826.73,,"Case rate ($10,311.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,727.87, add-ons for qualifying new technology services are included. If operating cost exceeds $44,598.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,371.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $7,754.32 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,782.91 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $611.89. The transfer capital threshold is the transfer adjustment factor * $611.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10311.17,24308.97,Inpatient DRG
OTHER CEREBROVASCULAR DISORDERS WITH MCC,070,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],37774.46,,"Fee schedule rate ($37,774.46). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,13219.09,37774.46,There are no additional notes associated with this service or procedure.
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],12508.88,,"Case rate ($7,147.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,785.17, add-ons for qualifying new technology services are included. If operating cost exceeds $41,656.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,140.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $4,822.44 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,840.22 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $380.54. The transfer capital threshold is the transfer adjustment factor * $380.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,6965.00,16400.70,All Other Inpatient
NORMAL NEWBORN,795,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3298.01,,"Case rate ($3,298.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $3,203.67, add-ons for qualifying new technology services are included. If operating cost exceeds $38,074.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $1,858.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $1,254.10 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $1,258.72 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $98.96. The transfer capital threshold is the transfer adjustment factor * $98.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,1369.79,5771.52,Inpatient DRG
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,479,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],10586.00,,"Per diem ($10,586). If length of stay < 3.3, first 1 days paid at a per diem of $21,172 instead. Capped at $34,934.31.",,,,0,other,10586.00,50518.76,Estimated amount calculated based on 2 day length of stay.
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],32168.63,,"Fee schedule rate ($32,168.63). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,13904.43,34749.58,There are no additional notes associated with this service or procedure.
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],37199.37,,,,,,0,other,14747.55,37899.49,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH CC,427,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],53371.31,,"Case rate ($50,829.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $47,421.51, add-ons for qualifying new technology services are included. If operating cost exceeds $82,292.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $5,335.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $45,309.50 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $45,476.56 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,575.37. The transfer capital threshold is the transfer adjustment factor * $3,575.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,50829.82,142040.39,Inpatient DRG
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],39337.51,,"Fee schedule rate ($39,337.51). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,16120.25,41187.90,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,690,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],14625.55,,"Fee schedule rate ($14,625.55). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7426.94,15928.53,There are no additional notes associated with this service or procedure.
Egd US Guided Transmural Injxn/Fiducial Marker,CASE-43253,APC,43253,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1859.01,,"APC Price ($1,796.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1796.14,1885.95,OPPS APC
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],16869.37,,"Case rate ($16,066.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,081.53, add-ons for qualifying new technology services are included. If operating cost exceeds $49,952.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,792.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $13,088.32 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,136.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,032.80. The transfer capital threshold is the transfer adjustment factor * $1,032.80. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,41030.48,Inpatient DRG
POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES,769,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],13704.87,,"Case rate ($13,052.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,298.57, add-ons for qualifying new technology services are included. If operating cost exceeds $47,169.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,552.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $10,314.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,353.62 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $792.80. The transfer capital threshold is the transfer adjustment factor * $792.80. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13388.39,33250.19,Inpatient DRG
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],26420.44,,"Case rate ($25,162.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $23,543.58, add-ons for qualifying new technology services are included. If operating cost exceeds $58,414.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,458.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $21,519.28 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $21,598.63 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,698.08. The transfer capital threshold is the transfer adjustment factor * $1,698.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,25162.32,75579.22,Inpatient DRG
SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS,029,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],13641.00,,"Per diem ($13,641). If length of stay < 4.7, first 1 days paid at a per diem of $27,282 instead. Capped at $64,114.20.",,,,0,other,13641.00,67130.05,Estimated amount calculated based on 5 day length of stay.
Esophageal Motility Study W/Interp&Rpt,CASE-91010,APC,91010,CPT,0750,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],366.75,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,349.28,366.75,OPPS APC
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,450,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],100159.17,,"Fee schedule rate ($100,159.17). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15), with a minimum of zero.",,,,0,other,38037.38,146009.19,There are no additional notes associated with this service or procedure.
VAGINAL DELIVERY WITH O.R. PROCEDURES EXCEPT STERILIZATION AND/OR D&C,768,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],9438.18,,"Case rate ($8,988.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,510.78, add-ons for qualifying new technology services are included. If operating cost exceeds $43,381.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,262.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $6,541.03 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,565.83 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $502.76. The transfer capital threshold is the transfer adjustment factor * $502.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6426.91,13416.00,Inpatient DRG
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],7868.00,,"Per diem ($7,868). If length of stay < 3.9, first 1 days paid at a per diem of $15,736 instead. Capped at $30,683.33.",,,,0,other,7868.00,32126.64,Estimated amount calculated based on 3 day length of stay.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],27382.89,,"Case rate ($26,078.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $24,441.32, add-ons for qualifying new technology services are included. If operating cost exceeds $59,312.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,482.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $22,411.39 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $22,496.37 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,722.59. The transfer capital threshold is the transfer adjustment factor * $1,722.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,26809.29,97015.50,Inpatient DRG
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],7290.89,,"Case rate ($7,147.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,785.17, add-ons for qualifying new technology services are included. If operating cost exceeds $41,656.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,140.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $4,822.44 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,840.22 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $380.54. The transfer capital threshold is the transfer adjustment factor * $380.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6965.00,16400.70,Inpatient DRG
Esophagogastroduodenoscopy Submucosal Injection|SEPARATE STRUCTURE,CASE-43236,APC,43236,CPT,0360,RC,,,XS,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1885.95,,"APC Price ($1,796.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1796.14,1885.95,OPPS APC
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],13246.56,,,,,,0,other,6503.90,14492.93,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],43949.31,,"Fee schedule rate ($43,949.31). Adds an outlier to normal pricing equal to the per diem rate ($149,567.78) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,17782.11,46523.26,There are no additional notes associated with this service or procedure.
Nasal/Sinus Endoscopy W/Sphenoidotomy|BILATERAL PROCEDURE,CASE-31287,APC,31287,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6605.95,,"APC Price ($6,605.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6605.95,6936.25,OPPS APC
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],40108.48,,"Fee schedule rate ($40,108.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,5569.00,40108.48,There are no additional notes associated with this service or procedure.
Chemodenervation Internal Anal Sphincter,CASE-46505,APC,46505,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],2727.99,,"APC Price ($2,598.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2598.08,2727.99,OPPS APC
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,426,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],177294.98,,"Fee schedule rate ($177,294.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,76581.29,216864.15,There are no additional notes associated with this service or procedure.
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],7544.40,,"Case rate ($7,396.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,016.38, add-ons for qualifying new technology services are included. If operating cost exceeds $41,887.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,158.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,052.80 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,071.43 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $398.72. The transfer capital threshold is the transfer adjustment factor * $398.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,7396.47,16035.06,Inpatient DRG
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],13305.05,,"Fee schedule rate ($13,305.05). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9356.31,25026.36,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,093,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],19011.32,,"Fee schedule rate ($19,011.32). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,19011.32,There are no additional notes associated with this service or procedure.
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC",758,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],18398.35,,"Fee schedule rate ($18,398.35). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8574.80,19263.78,There are no additional notes associated with this service or procedure.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],17194.49,,"Fee schedule rate ($17,194.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8554.50,19204.75,There are no additional notes associated with this service or procedure.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,074,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],8925.60,,"Case rate ($8,925.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,438.90, add-ons for qualifying new technology services are included. If operating cost exceeds $43,309.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,270.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,470.10 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,493.95 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $510.55. The transfer capital threshold is the transfer adjustment factor * $510.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8925.60,20919.08,Inpatient DRG
"ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",770,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],17800.73,,"Fee schedule rate ($17,800.73). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,8735.30,19730.13,There are no additional notes associated with this service or procedure.
Hemorrhoidectomy Ntrnl & Xtrnl 1 Column/Group,CASE-46255,APC,46255,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],2598.08,,"APC Price ($2,598.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2598.08,2727.99,OPPS APC
Hemorrhoidectomy Ntrnl & Xtrnl 1 Column/Group,CASE-46255,APC,46255,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],2727.99,,"APC Price ($2,598.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2598.08,2727.99,OPPS APC
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],41402.42,,"Fee schedule rate ($41,402.42). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,15456.59,41402.42,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],6965.00,,,,,,0,other,6965.00,21195.68,There are no additional notes associated with this service or procedure.
HC Joint Injection/Aspir Large WO US|BILATERAL PROCEDURE|PBB CHARGE,CASE-20610,APC,20610,CPT,0510,RC,,,50|PBB,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],301.68,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,287.31,301.68,OPPS APC
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC",281,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],18085.13,,,,,,0,other,8169.15,23859.35,There are no additional notes associated with this service or procedure.
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],24701.52,,"Fee schedule rate ($24,701.52). Adds an outlier to normal pricing equal to the per diem rate ($51,462.28) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,10846.16,25863.45,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],34391.19,,"Fee schedule rate ($34,391.19). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,14337.84,52803.53,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],9858.95,,"Case rate ($9,389.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,870.44, add-ons for qualifying new technology services are included. If operating cost exceeds $43,741.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,304.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,900.05 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,925.50 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $544.48. The transfer capital threshold is the transfer adjustment factor * $544.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9389.48,22358.90,Inpatient DRG
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],37899.49,,"Fee schedule rate ($37,899.49). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,14747.55,37899.49,There are no additional notes associated with this service or procedure.
Exc Breast Les Preop Plmt Rad Marker Open 1 Les|RIGHT SIDE|SEPARATE PRACTITIONER,CASE-19125,APC,19125,CPT,0360,RC,,,RT|XP,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6432.89,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6432.89,6432.89,OPPS APC
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH MCC",510,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],89863.76,,"Fee schedule rate ($89,863.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10710.00,89863.76,There are no additional notes associated with this service or procedure.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],52794.06,,"Fee schedule rate ($52,794.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (37), with a minimum of zero.",,,,0,other,13907.80,52794.06,There are no additional notes associated with this service or procedure.
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC",758,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],8799.06,,"Case rate ($8,380.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,943.41, add-ons for qualifying new technology services are included. If operating cost exceeds $42,814.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,219.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $5,975.80 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,998.46 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $459.31. The transfer capital threshold is the transfer adjustment factor * $459.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8574.80,19263.78,Inpatient DRG
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],37591.64,,"Fee schedule rate ($37,591.64). Adds an outlier to normal pricing equal to the per diem rate ($51,531) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.1), with a minimum of zero.",,,,0,other,15491.11,54180.83,There are no additional notes associated with this service or procedure.
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],35419.59,,"Fee schedule rate ($35,419.59). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,7086.00,57872.02,There are no additional notes associated with this service or procedure.
Laps Surg Cholecystectomy W/Cholangiography,CASE-47563,APC,47563,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5941.70,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5658.76,5941.70,OPPS APC
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,086,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],30728.81,,"Fee schedule rate ($30,728.81). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8442.00,30728.81,There are no additional notes associated with this service or procedure.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,191,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],16612.88,,"Fee schedule rate ($16,612.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6965.00,16612.88,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],7183.92,,"Case rate ($6,841.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,500.42, add-ons for qualifying new technology services are included. If operating cost exceeds $41,371.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,118.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $4,538.73 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,555.47 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $358.15. The transfer capital threshold is the transfer adjustment factor * $358.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6841.83,21167.26,Inpatient DRG
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,373,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],13780.60,,"Fee schedule rate ($13,780.60). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6870.94,14313.05,There are no additional notes associated with this service or procedure.
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],32168.63,,"Fee schedule rate ($32,168.63). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,13904.43,34749.58,There are no additional notes associated with this service or procedure.
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC,805,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],20281.41,,"Fee schedule rate ($20,281.41). Adds an outlier to normal pricing equal to the per diem rate ($31,438.44) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.5), with a minimum of zero.",,,,0,other,9253.36,21235.42,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],40737.46,,"Fee schedule rate ($40,737.46). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,7665.00,40737.46,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],18311.90,,"Fee schedule rate ($18,311.90). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8543.64,23239.84,There are no additional notes associated with this service or procedure.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],42586.49,,"Fee schedule rate ($42,586.49). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,13341.67,42586.49,There are no additional notes associated with this service or procedure.
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],14492.93,,"Fee schedule rate ($14,492.93). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6503.90,14492.93,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF THE EYE WITHOUT MCC,125,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],17952.29,,"Fee schedule rate ($17,952.29). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (6), with a minimum of zero.",,,,0,other,7144.54,17952.29,There are no additional notes associated with this service or procedure.
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],15263.71,,"Case rate ($14,747.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,854.94, add-ons for qualifying new technology services are included. If operating cost exceeds $48,725.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,696.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $11,866.24 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,909.99 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $936.36. The transfer capital threshold is the transfer adjustment factor * $936.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,14747.55,37899.49,Inpatient DRG
"DISORDERS OF GALLBLADDER AND BILIARY TRACT,MODERATE",284,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],9840.51,,"The inlier payment is calculated as the lesser of the standard DRG payment $9,371.91 and the transfer payment, which is a per diem of $2,617.85. If cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9371.91,9840.51,Estimated amount calculated based on 1 day length of stay.
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],11281.44,,"Fee schedule rate ($11,281.44). Adds an outlier to normal pricing equal to the per diem rate ($62,521.14) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,6010.23,12246.05,There are no additional notes associated with this service or procedure.
"Amputation Toe Interphalangeal Joint|RIGHT FOOT, THIRD DIGIT",CASE-28825,APC,28825,CPT,0360,RC,,,T7,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
Exc Rct Tum Incl Muscularis Propria,CASE-45172,APC,45172,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],2689.02,,"APC Price ($2,598.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2598.08,2727.99,OPPS APC
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],17069.51,,"Case rate ($16,256.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,285.55, add-ons for qualifying new technology services are included. If operating cost exceeds $50,156.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,781.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $13,290.21 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,340.60 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,021.52. The transfer capital threshold is the transfer adjustment factor * $1,021.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,16689.78,59521.43,Inpatient DRG
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,477,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],64922.30,,"Fee schedule rate ($64,922.30). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16.6), with a minimum of zero.",,,,0,other,25339.74,67976.16,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,699,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],19570.20,,"Fee schedule rate ($19,570.20). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5961.00,19972.16,There are no additional notes associated with this service or procedure.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],36094.03,,"Fee schedule rate ($36,094.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11194.25,36094.03,There are no additional notes associated with this service or procedure.
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],23078.81,,"Fee schedule rate ($23,078.81). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10311.17,24308.97,There are no additional notes associated with this service or procedure.
NON-MALIGNANT BREAST DISORDERS WITH CC/MCC,600,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],15046.13,,"Fee schedule rate ($15,046.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7999.14,20495.56,There are no additional notes associated with this service or procedure.
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],15060.41,,"Case rate ($14,343.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,478.83, add-ons for qualifying new technology services are included. If operating cost exceeds $48,349.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,666.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $11,491.51 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,533.88 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $906.79. The transfer capital threshold is the transfer adjustment factor * $906.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,14343.25,36024.65,Inpatient DRG
OSTEOMYELITIS WITHOUT CC/MCC,541,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],7641.14,,"Case rate ($7,277.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,905.50, add-ons for qualifying new technology services are included. If operating cost exceeds $41,776.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,149.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $4,942.33 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,960.55 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $390.00. The transfer capital threshold is the transfer adjustment factor * $390.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5103.00,15493.67,Inpatient DRG
Laparoscopic Appendectomy|UNUSUAL NON-OVERLAPPING SERVICE,CASE-44970,APC,44970,CPT,0360,RC,,,XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5856.81,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5658.76,5941.70,OPPS APC
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],68942.79,,"Fee schedule rate ($68,942.79). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,21489.15,68942.79,There are no additional notes associated with this service or procedure.
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC",629,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],17534.94,,"Case rate ($16,699.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,671.20, add-ons for qualifying new technology services are included. If operating cost exceeds $50,542.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,839.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $13,675.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,726.25 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,079.16. The transfer capital threshold is the transfer adjustment factor * $1,079.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,16699.94,44657.18,Inpatient DRG
SPINAL PROCEDURES WITHOUT CC/MCC,030,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],17193.04,,"Case rate ($16,374.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,395.22, add-ons for qualifying new technology services are included. If operating cost exceeds $50,266.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,789.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $13,399.47 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,450.27 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,029.91. The transfer capital threshold is the transfer adjustment factor * $1,029.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,16810.99,44714.01,Inpatient DRG
Open Treatment Ulnar Fracture Proximal End|LEFT SIDE,CASE-24685,APC,24685,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7029.71,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6791.99,7131.59,OPPS APC
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],27665.18,,"Fee schedule rate ($27,665.18). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,11914.12,40426.76,There are no additional notes associated with this service or procedure.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],16286.16,,"Case rate ($16,286.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,286.28, add-ons for qualifying new technology services are included. If operating cost exceeds $50,157.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,808.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $13,292.32 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,341.33 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,048.90. The transfer capital threshold is the transfer adjustment factor * $1,048.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,16286.16,58320.32,Inpatient DRG
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC,807,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6695.39,,"Case rate ($6,376.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,075.86, add-ons for qualifying new technology services are included. If operating cost exceeds $40,946.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,076.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $4,115.31 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,130.91 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $316.31. The transfer capital threshold is the transfer adjustment factor * $316.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5354.25,13266.23,Inpatient DRG
HC >= 12 Lead Ekg,CASE-93005,APC,93005,CPT,0730,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],55.22,,"APC Price ($55.22). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,55.22,57.98,OPPS APC
ALLERGIC REACTIONS WITH MCC,915,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],13799.51,,"Case rate ($13,332.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,538.89, add-ons for qualifying new technology services are included. If operating cost exceeds $47,409.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,592.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $10,555.02 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,593.94 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $832.90. The transfer capital threshold is the transfer adjustment factor * $832.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,13332.86,33088.84,Inpatient DRG
NEONATE WITH OTHER SIGNIFICANT PROBLEMS,794,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],3383.58,,"Fee schedule rate ($3,383.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,1798.85,12536.83,There are no additional notes associated with this service or procedure.
HC Joint Injection/Aspir Large WO US|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-20610,APC,20610,CPT,0510,RC,,,LT|XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],301.68,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,287.31,301.68,OPPS APC
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],20227.96,,,,,,0,other,8906.63,28434.57,There are no additional notes associated with this service or procedure.
Fissurectomy Incl Sphincterotomy When Performed,CASE-46200,APC,46200,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],2598.08,,"APC Price ($2,598.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2598.08,2727.99,OPPS APC
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level|RIGHT SIDE,CASE-64483,APC,64483,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],827.89,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,827.89,869.28,OPPS APC
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],2070.00,,,,,,0,other,1188.00,17370.86,Estimated amount calculated based on 3 day length of stay.
OTHER DISORDERS OF NERVOUS SYSTEM WITH CC,092,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],26765.51,,"Fee schedule rate ($26,765.51). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8872.78,26765.51,There are no additional notes associated with this service or procedure.
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],6325.21,,"Case rate ($6,201.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,904.45, add-ons for qualifying new technology services are included. If operating cost exceeds $40,775.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,071.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,944.95 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,959.50 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $311.30. The transfer capital threshold is the transfer adjustment factor * $311.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,5937.41,12366.99,Inpatient DRG
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],14492.93,,"Fee schedule rate ($14,492.93). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6503.90,14492.93,There are no additional notes associated with this service or procedure.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],58840.83,,"Case rate ($33,623.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $31,414.68, add-ons for qualifying new technology services are included. If operating cost exceeds $66,285.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,076.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.4. The base transfer operating payment is the transfer adjustment factor * $29,361.48 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $29,469.74 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,316.91. The transfer capital threshold is the transfer adjustment factor * $2,316.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,33623.33,133270.57,All Other Inpatient
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITHOUT CC/MCC",630,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],12420.22,,"Case rate ($11,828.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,139.67, add-ons for qualifying new technology services are included. If operating cost exceeds $46,010.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,482.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $9,160.95 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,194.72 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $722.89. The transfer capital threshold is the transfer adjustment factor * $722.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,11828.78,42541.02,Inpatient DRG
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],6965.00,,,,,,0,other,6164.03,14071.02,There are no additional notes associated with this service or procedure.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,097,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],79915.74,,"Fee schedule rate ($79,915.74). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,26404.32,79915.74,There are no additional notes associated with this service or procedure.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC,862,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],15261.02,,"Fee schedule rate ($15,261.02). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (42), with a minimum of zero.",,,,0,other,6855.00,35884.94,There are no additional notes associated with this service or procedure.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6683.37,,"Case rate ($6,683.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,353, add-ons for qualifying new technology services are included. If operating cost exceeds $41,224.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,106.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,391.86 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,408.05 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $346.56. The transfer capital threshold is the transfer adjustment factor * $346.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6683.37,14699.43,Inpatient DRG
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC",156,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],12987.84,,"Fee schedule rate ($12,987.84). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,6625.12,13598.77,There are no additional notes associated with this service or procedure.
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,451,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],63564.58,,,,,,0,other,23821.44,94077.13,There are no additional notes associated with this service or procedure.
Insertion Breast Implant Same Day of Mastectomy,CASE-19340,APC,19340,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],7650.49,,"APC Price ($7,650.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,7650.49,8033.01,OPPS APC
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC,832,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],13561.03,,"Fee schedule rate ($13,561.03). Adds an outlier to normal pricing equal to the per diem rate ($18,253.69) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,4803.31,14198.92,There are no additional notes associated with this service or procedure.
OSTEOMYELITIS WITHOUT CC/MCC,541,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7476.68,,"Case rate ($7,120.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,769.45, add-ons for qualifying new technology services are included. If operating cost exceeds $41,640.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,129.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $4,806.28 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,824.50 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $369.42. The transfer capital threshold is the transfer adjustment factor * $369.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5103.00,15493.67,Inpatient DRG
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],17651.07,,"Fee schedule rate ($17,651.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,6564.18,17651.07,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,555,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],24840.59,,"Fee schedule rate ($24,840.59). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10896.27,42290.95,There are no additional notes associated with this service or procedure.
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],45157.33,,"Fee schedule rate ($45,157.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,10733.06,45157.33,There are no additional notes associated with this service or procedure.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,418,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],39884.93,,"Fee schedule rate ($39,884.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,13400.58,39884.93,There are no additional notes associated with this service or procedure.
Rhytidectomy Smas Flap,CASE-15829,APC,15829,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],2336.65,,"APC Price ($2,225.38). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2225.38,2336.65,OPPS APC
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral Ea Addl|RIGHT SIDE,CASE-64484,APC,64484,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],856.86,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,827.89,869.28,OPPS APC
Cysto W/Ureteroscopy W/Lithotripsy|RIGHT SIDE,CASE-52353,APC,52353,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5269.71,,"APC Price ($5,018.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5269.71,5269.71,OPPS APC
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],18783.45,,"Fee schedule rate ($18,783.45). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6277.00,36801.89,There are no additional notes associated with this service or procedure.
"NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY",789,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],6663.33,,,,,,0,other,3054.00,14857.05,Estimated amount calculated based on 1 day length of stay.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],59521.43,,"Fee schedule rate ($59,521.43). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,16689.78,59521.43,There are no additional notes associated with this service or procedure.
INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC,198,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],13459.55,,"Fee schedule rate ($13,459.55). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.7), with a minimum of zero.",,,,0,other,6795.12,23505.07,There are no additional notes associated with this service or procedure.
SEIZURES WITH MCC,100,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],32323.98,,"Fee schedule rate ($32,323.98). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,15061.09,38110.41,There are no additional notes associated with this service or procedure.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],19319.20,,"Fee schedule rate ($19,319.20). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8906.63,28434.57,There are no additional notes associated with this service or procedure.
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],6230.00,,"Per diem ($6,230). If length of stay < 2.9, first 1 days paid at a per diem of $12,460 instead. Capped at $18,065.71.",,,,0,other,6230.00,22762.43,Estimated amount calculated based on 3 day length of stay.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,418,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],39884.93,,"Fee schedule rate ($39,884.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,13400.58,39884.93,There are no additional notes associated with this service or procedure.
PERIPHERAL VASCULAR DISORDERS WITH CC,300,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],20331.78,,"Fee schedule rate ($20,331.78). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,9174.14,21005.20,There are no additional notes associated with this service or procedure.
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 1 Level|LEFT SIDE,CASE-64493,APC,64493,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],827.89,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,827.89,869.28,OPPS APC
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],73588.10,,"Fee schedule rate ($73,588.10). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,21585.31,73588.10,There are no additional notes associated with this service or procedure.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC,858,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],27408.09,,,,,,0,other,11377.76,33794.11,There are no additional notes associated with this service or procedure.
Lamnotmy Incl W/Dcmprsn Nrv Root 1 Intrspc Lumbr,CASE-63030,APC,63030,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],10358.84,,"Case rate ($9,865.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,313.33, add-ons for qualifying new technology services are included. If operating cost exceeds $44,184.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,339.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $7,341.31 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,368.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $579.30. The transfer capital threshold is the transfer adjustment factor * $579.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9865.56,37914.65,Inpatient DRG
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],8714.51,,"Case rate ($8,543.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,083.58, add-ons for qualifying new technology services are included. If operating cost exceeds $42,954.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,242.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,116.09 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,138.64 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $482.62. The transfer capital threshold is the transfer adjustment factor * $482.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,8543.64,23239.84,Inpatient DRG
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC",629,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],17284.44,,"Case rate ($16,699.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,671.20, add-ons for qualifying new technology services are included. If operating cost exceeds $50,542.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,839.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $13,675.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,726.25 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,079.16. The transfer capital threshold is the transfer adjustment factor * $1,079.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,16699.94,44657.18,Inpatient DRG
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC,434,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],6770.05,,"Case rate ($6,770.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,433.64, add-ons for qualifying new technology services are included. If operating cost exceeds $41,304.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,112.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,472.20 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,488.69 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $352.90. The transfer capital threshold is the transfer adjustment factor * $352.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6770.05,14019.86,Inpatient DRG
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],62990.26,,"Fee schedule rate ($62,990.26). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,16787.98,62990.26,There are no additional notes associated with this service or procedure.
RESPIRATORY NEOPLASMS WITHOUT CC/MCC,182,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],6965.00,,,,,,0,other,6965.00,23037.13,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],13064.19,,"Case rate ($12,808.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,050.64, add-ons for qualifying new technology services are included. If operating cost exceeds $46,921.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,554.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $10,068.57 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,105.69 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $794.51. The transfer capital threshold is the transfer adjustment factor * $794.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,7353.00,33398.16,Inpatient DRG
Arthrp Intercarpal/Carp/Mtcrpl Jt Suspension,CASE-25448,APC,25448,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,065,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],25681.86,,"Fee schedule rate ($25,681.86). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,8786.76,25681.86,There are no additional notes associated with this service or procedure.
Neuroplasty &/Transposition Ulnar Nerve Elbow|UNUSUAL NON-OVERLAPPING SERVICE|LEFT SIDE,CASE-64718,APC,64718,CPT,0360,RC,,,XU|LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
"DIABETES,MAJOR",420,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],10364.30,,"Case rate ($9,870.76). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9870.76,10364.30,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,085,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],57443.16,,"Fee schedule rate ($57,443.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,9282.00,57443.16,There are no additional notes associated with this service or procedure.
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],16055.90,,"Fee schedule rate ($16,055.90). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8163.06,18067.42,There are no additional notes associated with this service or procedure.
HC Joint Injection/Aspir Large WO US|LEFT SIDE|PBB CHARGE,CASE-20610,APC,20610,CPT,0510,RC,,,LT|PBB,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
"Tendon Sheath Incision|RIGHT HAND, THUMB",CASE-26055,APC,26055,CPT,0360,RC,,,F5,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1505.12,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1505.12,1580.37,OPPS APC
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],33188.44,,"Fee schedule rate ($33,188.44). Adds an outlier to normal pricing equal to the per diem rate ($84,167.29) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.5), with a minimum of zero.",,,,0,other,13904.43,34749.58,There are no additional notes associated with this service or procedure.
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC",629,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],44657.18,,"Fee schedule rate ($44,657.18). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,16699.94,44657.18,There are no additional notes associated with this service or procedure.
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],25829.63,,"Fee schedule rate ($25,829.63). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6965.00,29482.05,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,167,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],43522.37,,"Fee schedule rate ($43,522.37). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,14157.71,43522.37,There are no additional notes associated with this service or procedure.
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],25829.63,,"Fee schedule rate ($25,829.63). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6965.00,29482.05,There are no additional notes associated with this service or procedure.
NON-MALIGNANT BREAST DISORDERS WITH CC/MCC,600,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],15046.13,,"Fee schedule rate ($15,046.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7999.14,20495.56,There are no additional notes associated with this service or procedure.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],11681.49,,"Fee schedule rate ($11,681.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5778.62,11681.49,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,093,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],7704.43,,"Case rate ($7,337.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,961.57, add-ons for qualifying new technology services are included. If operating cost exceeds $41,832.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,154.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,998.19 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,016.62 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $394.41. The transfer capital threshold is the transfer adjustment factor * $394.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,19011.32,Inpatient DRG
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],17264.73,,"Case rate ($9,865.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,313.33, add-ons for qualifying new technology services are included. If operating cost exceeds $44,184.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,339.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $7,341.31 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,368.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $579.30. The transfer capital threshold is the transfer adjustment factor * $579.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,9865.56,37914.65,All Other Inpatient
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],11043.60,,"Case rate ($10,517.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,920.01, add-ons for qualifying new technology services are included. If operating cost exceeds $44,791.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,386.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $7,945.76 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,975.06 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $627.00. The transfer capital threshold is the transfer adjustment factor * $627.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10517.71,24909.11,Inpatient DRG
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,068,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],13647.78,,"Case rate ($7,798.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,390.60, add-ons for qualifying new technology services are included. If operating cost exceeds $42,261.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,188.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $5,425.64 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,445.65 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $428.14. The transfer capital threshold is the transfer adjustment factor * $428.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,6965.00,23184.90,All Other Inpatient
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],28434.57,,"Fee schedule rate ($28,434.57). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,8906.63,28434.57,There are no additional notes associated with this service or procedure.
SPINAL PROCEDURES WITH MCC,028,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],74608.75,,"Case rate ($42,633.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $39,796.72, add-ons for qualifying new technology services are included. If operating cost exceeds $74,667.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,735.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.5. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 9.5)) / 2. The base transfer operating payment is the transfer adjustment factor * $37,712.72 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $37,851.77 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,975.91. The transfer capital threshold is the transfer adjustment factor * $2,975.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,42633.57,120982.83,All Other Inpatient
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],21354.82,,"Fee schedule rate ($21,354.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6834.39,21354.82,There are no additional notes associated with this service or procedure.
"PROCEDURES FOR OBESITY,MINOR",403,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],11100.91,,"Case rate ($11,100.91). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,11100.91,11655.96,There are no additional notes associated with this service or procedure.
HEART FAILURE AND SHOCK WITH CC,292,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],5502.00,,"Per diem ($5,502). If length of stay < 2.9, first 1 days paid at a per diem of $11,004 instead. Capped at $15,955.26.",,,,0,other,5502.00,16705.77,Estimated amount calculated based on 2 day length of stay.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],59021.28,,"Fee schedule rate ($59,021.28). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,23851.92,63653.13,There are no additional notes associated with this service or procedure.
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],14667.78,,"Fee schedule rate ($14,667.78). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12566.28,30861.41,There are no additional notes associated with this service or procedure.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],38517.10,,"Fee schedule rate ($38,517.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,16897.01,43444.85,There are no additional notes associated with this service or procedure.
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],13904.43,,"Case rate ($13,904.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,070.60, add-ons for qualifying new technology services are included. If operating cost exceeds $47,941.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,634.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,084.78 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,125.65 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $874.70. The transfer capital threshold is the transfer adjustment factor * $874.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,13904.43,34749.58,Inpatient DRG
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],9777.20,,"Case rate ($9,311.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,798, add-ons for qualifying new technology services are included. If operating cost exceeds $43,669.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,298.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $6,827.87 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,853.05 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $538.79. The transfer capital threshold is the transfer adjustment factor * $538.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,21404.64,Inpatient DRG
Neuroplasty &/Transposition Ulnar Nerve Elbow|LEFT SIDE|SEPARATE STRUCTURE,CASE-64718,APC,64718,CPT,0360,RC,,,LT|XS,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7029.71,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6791.99,7131.59,OPPS APC
"Tendon Sheath Incision|UNUSUAL NON-OVERLAPPING SERVICE|LEFT HAND, THUMB",CASE-26055,APC,26055,CPT,0360,RC,,,XU|FA,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH CC",457,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],160549.49,,"Fee schedule rate ($160,549.49). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,42327.47,160549.49,There are no additional notes associated with this service or procedure.
HEART FAILURE AND SHOCK WITH CC,292,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],15550.06,,"Fee schedule rate ($15,550.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5502.00,16705.77,There are no additional notes associated with this service or procedure.
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],6965.00,,,,,,0,other,5883.03,17111.12,There are no additional notes associated with this service or procedure.
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],11065.78,,"Fee schedule rate ($11,065.78). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5883.03,17111.12,There are no additional notes associated with this service or procedure.
"Prq Skel Fixj Phlngl Shft Fx Prox/Middle Px/F/T|LEFT HAND, FOURTH DIGIT",CASE-26727,APC,26727,CPT,0360,RC,,,F3,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],10448.43,,"Case rate ($9,950.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,392.71, add-ons for qualifying new technology services are included. If operating cost exceeds $44,263.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,345.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $7,420.40 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,447.76 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $585.54. The transfer capital threshold is the transfer adjustment factor * $585.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7243.75,23262.15,Inpatient DRG
Laps Rpr Paraesphgl Hrna Incl Fundplsty W/Mesh,CASE-43282,APC,43282,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],9949.78,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,9949.78,10447.27,OPPS APC
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],11269.71,,"Case rate ($10,733.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,120.35, add-ons for qualifying new technology services are included. If operating cost exceeds $44,991.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,402.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $8,145.37 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,175.40 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $642.75. The transfer capital threshold is the transfer adjustment factor * $642.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10733.06,45157.33,Inpatient DRG
"EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME, NEONATE",790,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],3054.00,,,,,,0,other,3054.00,44304.49,Estimated amount calculated based on 17 day length of stay.
GASTROINTESTINAL HEMORRHAGE WITH MCC,377,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],14324.29,,"Case rate ($14,324.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,461.19, add-ons for qualifying new technology services are included. If operating cost exceeds $48,332.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,665.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $11,473.94 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,516.24 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $905.41. The transfer capital threshold is the transfer adjustment factor * $905.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7634.00,35969.56,Inpatient DRG
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,761,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],11946.72,,"Fee schedule rate ($11,946.72). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,5808.41,11946.72,There are no additional notes associated with this service or procedure.
SEIZURES WITH MCC,100,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],32323.98,,"Fee schedule rate ($32,323.98). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,15061.09,38110.41,There are no additional notes associated with this service or procedure.
HC Injection Small Joint/Bursa|PBB CHARGE,CASE-20600,APC,20600,CPT,0361,RC,,,PBB,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],287.31,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC",758,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],16323.02,,"Fee schedule rate ($16,323.02). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8574.80,19263.78,There are no additional notes associated with this service or procedure.
O.R. PROCEDURES FOR OBESITY WITH CC,620,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],43753.50,,"Fee schedule rate ($43,753.50). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12782.30,43753.50,There are no additional notes associated with this service or procedure.
RADIOTHERAPY,849,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],81867.07,,"Fee schedule rate ($81,867.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,20293.88,81867.07,There are no additional notes associated with this service or procedure.
"Laminec/Facetect/Foramin,Lumbar",CASE-63047,APC,63047,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
PREMATURITY WITHOUT MAJOR PROBLEMS,792,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],19457.66,,"Case rate ($18,531.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,374.70, add-ons for qualifying new technology services are included. If operating cost exceeds $52,245.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,973.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. The base transfer operating payment is the transfer adjustment factor * $15,373.07 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,429.75 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,213.09. The transfer capital threshold is the transfer adjustment factor * $1,213.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,1956.00,19457.66,Inpatient DRG
"NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY",789,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],6663.33,,,,,,0,other,3054.00,14857.05,Estimated amount calculated based on 1 day length of stay.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],57067.24,,,,,,0,other,21585.31,73588.10,There are no additional notes associated with this service or procedure.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],6965.00,,,,,,0,other,5778.62,11681.49,There are no additional notes associated with this service or procedure.
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],12091.53,,"Case rate ($12,091.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,384.11, add-ons for qualifying new technology services are included. If operating cost exceeds $46,255.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,502.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $9,404.49 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,439.16 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $742.11. The transfer capital threshold is the transfer adjustment factor * $742.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,29482.05,Inpatient DRG
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],33321.87,,"Fee schedule rate ($33,321.87). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.9), with a minimum of zero.",,,,0,other,13917.42,34889.29,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],6965.00,,,,,,0,other,6340.03,15076.44,There are no additional notes associated with this service or procedure.
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6457.19,,"Case rate ($6,457.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,142.59, add-ons for qualifying new technology services are included. If operating cost exceeds $41,013.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,089.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $4,182.21 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,197.63 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $330.02. The transfer capital threshold is the transfer adjustment factor * $330.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,5139.72,13110.79,Inpatient DRG
Marsupialization Bartholins Gland Cyst|LEFT SIDE,CASE-56440,APC,56440,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3136.08,,"APC Price ($3,030.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3030.03,3181.53,OPPS APC
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],9533.13,,"Fee schedule rate ($9,533.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5068.21,14525.56,There are no additional notes associated with this service or procedure.
Enteroscopy > 2nd Prtn Abltj Lesion,CASE-44369,APC,44369,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1859.01,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1796.14,1885.95,OPPS APC
"NEONATE BIRTH WEIGHT 1500-1999 GRAMS WITH OR WITHOUT OTHER SIGNIFICANT CONDITION,MINOR",614,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],11512.05,,"Case rate ($10,963.86). Base payment rate plus any adjustments related to outliers.",,,,0,other,10963.86,11512.05,There are no additional notes associated with this service or procedure.
Transection/Avulsion Oth Spinal Nrv Xdrl|RIGHT SIDE,CASE-64772,APC,64772,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
Revision of Reconstructed Breast,CASE-19380,APC,19380,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6526.12,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6215.36,6526.12,OPPS APC
HC Inj Tendon Sheath/Ligament|RIGHT SIDE,CASE-20550,APC,20550,CPT,0510,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
CERVICAL SPINAL FUSION WITH MCC,471,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],61707.45,,"Fee schedule rate ($61,707.45). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,34645.26,111337.93,There are no additional notes associated with this service or procedure.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],26949.28,,"Fee schedule rate ($26,949.28). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9977.99,26949.28,There are no additional notes associated with this service or procedure.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],62041.12,,"Fee schedule rate ($62,041.12). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,18497.24,62041.12,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],13077.97,,"Case rate ($12,455.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,722.41, add-ons for qualifying new technology services are included. If operating cost exceeds $46,593.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,528.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $9,741.55 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,777.47 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $768.70. The transfer capital threshold is the transfer adjustment factor * $768.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12455.21,37149.27,Inpatient DRG
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],18905.23,,"Fee schedule rate ($18,905.23). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6963.00,18954.85,There are no additional notes associated with this service or procedure.
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7137.12,,"Case rate ($6,797.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,468, add-ons for qualifying new technology services are included. If operating cost exceeds $41,339.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,106.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,505.96 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,523.05 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $346.34. The transfer capital threshold is the transfer adjustment factor * $346.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5068.21,14525.56,Inpatient DRG
Bronchoscopy W/Plmt Fiducial Markers Single/Mult,CASE-31626,APC,31626,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6605.95,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6605.95,6936.25,OPPS APC
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC,099,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],11394.63,,"Case rate ($11,171.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,527.95, add-ons for qualifying new technology services are included. If operating cost exceeds $45,398.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,434.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,551.47 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,583.00 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $674.80. The transfer capital threshold is the transfer adjustment factor * $674.80. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,11171.21,26807.94,Inpatient DRG
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],37149.27,,"Fee schedule rate ($37,149.27). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,12455.21,37149.27,There are no additional notes associated with this service or procedure.
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC,807,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],10071.17,,"Fee schedule rate ($10,071.17). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5354.25,13266.23,There are no additional notes associated with this service or procedure.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],22299.30,,"Fee schedule rate ($22,299.30). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12795.84,41944.25,There are no additional notes associated with this service or procedure.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,309,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],6965.00,,,,,,0,other,5055.77,14547.21,There are no additional notes associated with this service or procedure.
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC,519,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],37589.76,,"Fee schedule rate ($37,589.76). Adds an outlier to normal pricing equal to the per diem rate ($123,674.40) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,15490.44,50780.20,There are no additional notes associated with this service or procedure.
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|LEFT HAND, SECOND DIGIT",CASE-26160,APC,26160,CPT,0360,RC,,,F1,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1580.37,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1505.12,1580.37,OPPS APC
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],15808.32,,"Case rate ($15,273.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,344.45, add-ons for qualifying new technology services are included. If operating cost exceeds $49,215.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,734.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $12,353.94 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,399.49 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $974.85. The transfer capital threshold is the transfer adjustment factor * $974.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,15273.74,39820.52,Inpatient DRG
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],31918.40,,"Case rate ($30,398.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $28,414.67, add-ons for qualifying new technology services are included. If operating cost exceeds $63,285.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,841.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.2. The base transfer operating payment is the transfer adjustment factor * $26,372.48 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $26,469.72 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,081.05. The transfer capital threshold is the transfer adjustment factor * $2,081.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,30398.48,82674.88,Inpatient DRG
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],11847.11,,"Fee schedule rate ($11,847.11). Adds an outlier to normal pricing equal to the per diem rate ($62,538.40) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,6214.05,15318.94,There are no additional notes associated with this service or procedure.
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],45017.13,,"Fee schedule rate ($45,017.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,14603.31,45017.13,There are no additional notes associated with this service or procedure.
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC,964,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],12755.15,,"Case rate ($12,323.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,600.20, add-ons for qualifying new technology services are included. If operating cost exceeds $46,471.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,519.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $9,619.78 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,655.25 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $759.10. The transfer capital threshold is the transfer adjustment factor * $759.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,12323.82,34154.06,Inpatient DRG
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],12890.50,,"Case rate ($7,366). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,988.03, add-ons for qualifying new technology services are included. If operating cost exceeds $41,859.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,156.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,024.55 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,043.08 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $396.49. The transfer capital threshold is the transfer adjustment factor * $396.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,6965.00,21195.68,All Other Inpatient
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6503.90,,"Case rate ($6,503.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,186.05, add-ons for qualifying new technology services are included. If operating cost exceeds $41,057.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,093.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $4,225.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,241.10 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $333.44. The transfer capital threshold is the transfer adjustment factor * $333.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6503.90,14492.93,Inpatient DRG
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],43128.05,,,,,,0,other,16787.98,62990.26,There are no additional notes associated with this service or procedure.
"LIMB REATTACHMENT, HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA",956,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],28799.66,,"Case rate ($27,428.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $25,651.53, add-ons for qualifying new technology services are included. If operating cost exceeds $60,522.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,623.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $23,619.49 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $23,706.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,863.81. The transfer capital threshold is the transfer adjustment factor * $1,863.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,27428.25,148259.86,Inpatient DRG
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],6965.00,,,,,,0,other,5778.62,11681.49,There are no additional notes associated with this service or procedure.
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6793.41,,"Case rate ($6,469.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,162.87, add-ons for qualifying new technology services are included. If operating cost exceeds $41,033.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,082.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,201.98 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,217.92 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $322.97. The transfer capital threshold is the transfer adjustment factor * $322.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5919.29,13545.65,Inpatient DRG
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],19604.30,,"Fee schedule rate ($19,604.30). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9446.38,21796.21,There are no additional notes associated with this service or procedure.
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],48961.48,,"Fee schedule rate ($48,961.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11575.50,48961.48,There are no additional notes associated with this service or procedure.
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],7147.93,,"Case rate ($7,147.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,785.17, add-ons for qualifying new technology services are included. If operating cost exceeds $41,656.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,140.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $4,822.44 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,840.22 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $380.54. The transfer capital threshold is the transfer adjustment factor * $380.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,16400.70,Inpatient DRG
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],12526.44,,"Fee schedule rate ($12,526.44). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5415.00,17575.50,There are no additional notes associated with this service or procedure.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC,099,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],25603.58,,"Fee schedule rate ($25,603.58). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.7), with a minimum of zero.",,,,0,other,11171.21,26807.94,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITH CC,386,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],18347.61,,"Fee schedule rate ($18,347.61). Adds an outlier to normal pricing equal to the per diem rate ($111,650.51) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8556.53,19879.00,There are no additional notes associated with this service or procedure.
HC Inj Lympho for Sentinal Node|RIGHT SIDE,CASE-38792,APC,38792,CPT,0361,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6215.36,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6215.36,6526.12,OPPS APC
GASTROINTESTINAL HEMORRHAGE WITH MCC,377,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],31575.65,,"Fee schedule rate ($31,575.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,7634.00,35969.56,There are no additional notes associated with this service or procedure.
Open Implantation Nea Sacral Nerve,CASE-64581,APC,64581,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],18158.97,,"APC Price ($18,158.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,18158.97,19066.92,OPPS APC
NON-MALIGNANT BREAST DISORDERS WITH CC/MCC,600,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],8998.74,,"Case rate ($8,998.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,506.94, add-ons for qualifying new technology services are included. If operating cost exceeds $43,377.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,275.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $6,537.88 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,561.99 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $515.90. The transfer capital threshold is the transfer adjustment factor * $515.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7999.14,20495.56,Inpatient DRG
"Exc Lesion Eyelid W/O Clsr/W/Simple Dir Closure|UPPER RIGHT, EYELID",CASE-67840,APC,67840,CPT,0360,RC,,,E3,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],979.76,,"APC Price ($933.10). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,965.76,979.76,OPPS APC
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITHOUT CC/MCC",630,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],12420.22,,"Case rate ($11,828.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,139.67, add-ons for qualifying new technology services are included. If operating cost exceeds $46,010.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,482.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $9,160.95 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,194.72 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $722.89. The transfer capital threshold is the transfer adjustment factor * $722.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,11828.78,42541.02,Inpatient DRG
HEADACHES WITHOUT MCC,103,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],6965.00,,,,,,0,other,6965.00,20883.08,There are no additional notes associated with this service or procedure.
Hemorrhoidectomy Ntrnl & Xtrnl 1 Column/Group,CASE-46255,APC,46255,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],2689.02,,"APC Price ($2,598.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2598.08,2727.99,OPPS APC
Sigmoidoscopy Flx Dx W/Collj Spec Br/Wa if Pfrmd|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-45330,APC,45330,CPT,0360,RC,,,74,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],900.93,,"APC Price ($870.46). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,870.46,913.99,OPPS APC
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC,833,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],6965.00,,,,,,0,other,3041.73,10289.10,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],6965.00,,,,,,0,other,6965.00,41030.48,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],23954.07,,"Fee schedule rate ($23,954.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,6167.00,29058.99,There are no additional notes associated with this service or procedure.
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],21354.82,,"Fee schedule rate ($21,354.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6834.39,21354.82,There are no additional notes associated with this service or procedure.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",062,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],44304.80,,"Fee schedule rate ($44,304.80). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,13844.84,44304.80,There are no additional notes associated with this service or procedure.
"DIVERTICULITIS AND DIVERTICULOSIS,MINOR",244,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],1960.55,,"Case rate for a one day stay ($1,867.19). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,1867.19,1960.55,There are no additional notes associated with this service or procedure.
Reconstruction Nail Bed W/Graft,CASE-11762,APC,11762,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],2027.84,,"APC Price ($1,931.28). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1931.28,2027.84,OPPS APC
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],26301.36,,"Fee schedule rate ($26,301.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11247.07,27028.33,There are no additional notes associated with this service or procedure.
PERIPHERAL VASCULAR DISORDERS WITH CC,300,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],9632.85,,"Case rate ($9,174.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,670.11, add-ons for qualifying new technology services are included. If operating cost exceeds $43,541.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,288.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,700.45 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,725.16 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $528.73. The transfer capital threshold is the transfer adjustment factor * $528.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9174.14,21005.20,Inpatient DRG
"ASTHMA,MAJOR",141,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],8881.55,,"Case rate ($8,458.62). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8458.62,8881.55,There are no additional notes associated with this service or procedure.
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6915.64,,"Case rate ($6,915.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,569.08, add-ons for qualifying new technology services are included. If operating cost exceeds $41,440.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,123.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,607.15 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,624.14 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $363.55. The transfer capital threshold is the transfer adjustment factor * $363.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6915.64,14442.92,Inpatient DRG
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,555,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],24840.59,,"Fee schedule rate ($24,840.59). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10896.27,42290.95,There are no additional notes associated with this service or procedure.
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],8052.99,,"Case rate ($7,669.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,281.07, add-ons for qualifying new technology services are included. If operating cost exceeds $42,152.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,168.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $5,315.96 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,336.12 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $408.60. The transfer capital threshold is the transfer adjustment factor * $408.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5280.00,17136.70,Inpatient DRG
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC",923,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],8047.79,,"Case rate ($8,047.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $7,588.71, add-ons for qualifying new technology services are included. If operating cost exceeds $46,233.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $3,215.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,201.30 + an uncompensated DSH payment of $1,359.91. The transfer operating threshold is the transfer adjustment factor * $6,228.80 + an uncompensated DSH payment of $1,359.91. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $486.59. The transfer capital threshold is the transfer adjustment factor * $486.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,20068.57,Inpatient DRG
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,097,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],79915.74,,"Fee schedule rate ($79,915.74). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,26404.32,79915.74,There are no additional notes associated with this service or procedure.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,097,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],79915.74,,"Fee schedule rate ($79,915.74). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,26404.32,79915.74,There are no additional notes associated with this service or procedure.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],67790.93,,"Fee schedule rate ($67,790.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,21597.50,67790.93,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,065,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],9226.10,,"Case rate ($8,786.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,309.75, add-ons for qualifying new technology services are included. If operating cost exceeds $43,180.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,260.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,341.42 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,364.80 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $500.40. The transfer capital threshold is the transfer adjustment factor * $500.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8786.76,25681.86,Inpatient DRG
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],7176.11,,"Case rate ($6,834.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,493.49, add-ons for qualifying new technology services are included. If operating cost exceeds $41,364.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,117.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $4,531.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,548.54 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $357.61. The transfer capital threshold is the transfer adjustment factor * $357.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6834.39,21354.82,Inpatient DRG
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],29243.52,,"Fee schedule rate ($29,243.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,14343.25,36024.65,There are no additional notes associated with this service or procedure.
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],7833.94,,"Case rate ($7,833.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,423.35, add-ons for qualifying new technology services are included. If operating cost exceeds $42,294.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,190.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,458.28 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,478.41 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $430.71. The transfer capital threshold is the transfer adjustment factor * $430.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,5883.03,17111.12,Inpatient DRG
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC,831,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],9294.42,,"Fee schedule rate ($9,294.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,4941.30,23661.59,There are no additional notes associated with this service or procedure.
CERVICAL SPINAL FUSION WITH MCC,471,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],111337.93,,"Fee schedule rate ($111,337.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,34645.26,111337.93,There are no additional notes associated with this service or procedure.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],47368.65,,"Fee schedule rate ($47,368.65). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,21382.16,85466.62,There are no additional notes associated with this service or procedure.
"Correction Hammertoe|RIGHT FOOT, FIFTH DIGIT",CASE-28285,APC,28285,CPT,0360,RC,,,T9,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC,806,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],5354.25,,"Fee schedule rate ($5,354.25). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5354.25,13416.00,There are no additional notes associated with this service or procedure.
Bx/Exc Lymph Node Open Deep Cervical Node|LEFT SIDE,CASE-38510,APC,38510,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5735.04,,"APC Price ($5,541.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5541.10,5818.16,OPPS APC
INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC,198,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],23505.07,,"Fee schedule rate ($23,505.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6795.12,23505.07,There are no additional notes associated with this service or procedure.
Exc B9 Lesion Mrgn Xcp Sk Tg S/N/H/F/G 0.5 Cm/<,CASE-11420,APC,11420,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1545.93,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1545.93,1623.23,OPPS APC
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],31626.74,,"Fee schedule rate ($31,626.74). Adds an outlier to normal pricing equal to the per diem rate ($86,383.13) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,13341.67,42586.49,There are no additional notes associated with this service or procedure.
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],12551.64,,"Case rate ($12,305.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,583.18, add-ons for qualifying new technology services are included. If operating cost exceeds $46,454.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,517.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $9,602.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,638.24 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $757.76. The transfer capital threshold is the transfer adjustment factor * $757.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,12305.53,30103.84,Inpatient DRG
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",063,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],11680.61,,"Case rate ($11,451.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,788.77, add-ons for qualifying new technology services are included. If operating cost exceeds $45,659.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,455.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $8,811.33 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,843.82 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $695.30. The transfer capital threshold is the transfer adjustment factor * $695.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6965.00,35701.87,Inpatient DRG
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],15244.88,,"Fee schedule rate ($15,244.88). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,7438.45,15961.98,There are no additional notes associated with this service or procedure.
OTHER CEREBROVASCULAR DISORDERS WITH CC,071,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],8893.10,,"Case rate ($8,893.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,408.66, add-ons for qualifying new technology services are included. If operating cost exceeds $43,279.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,268.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,439.97 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,463.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $508.18. The transfer capital threshold is the transfer adjustment factor * $508.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,5843.00,29215.10,Inpatient DRG
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],15600.07,,"Fee schedule rate ($15,600.07). Adds an outlier to normal pricing equal to the per diem rate ($180,117.98) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,7566.45,16333.88,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,448,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],30663.95,,"Case rate ($30,663.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $28,661.63, add-ons for qualifying new technology services are included. If operating cost exceeds $63,532.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,860.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $26,618.53 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $26,716.68 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,100.47. The transfer capital threshold is the transfer adjustment factor * $2,100.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,30663.95,94077.13,Inpatient DRG
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,479,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],10586.00,,"Per diem ($10,586). If length of stay < 3.3, first 1 days paid at a per diem of $21,172 instead. Capped at $34,934.31.",,,,0,other,10586.00,50518.76,Estimated amount calculated based on 2 day length of stay.
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],2070.00,,,,,,0,other,1188.00,18893.86,Estimated amount calculated based on 3 day length of stay.
Exc Breast Les Preop Plmt Rad Marker Open 1 Les|RIGHT SIDE,CASE-19125,APC,19125,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3848.19,,"APC Price ($3,664.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3664.94,3848.19,OPPS APC
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC",061,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],54251.46,,,,,,0,other,20616.23,62315.82,There are no additional notes associated with this service or procedure.
"LIMB REATTACHMENT, HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA",956,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],148259.86,,"Fee schedule rate ($148,259.86). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,27428.25,148259.86,There are no additional notes associated with this service or procedure.
DIABETES WITHOUT CC/MCC,639,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],6326.19,,"Fee schedule rate ($6,326.19). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6151.76,12223.35,There are no additional notes associated with this service or procedure.
Cysto W/Insert Ureteral Stent|RIGHT SIDE,CASE-52332,APC,52332,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3299.47,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3299.47,3464.44,OPPS APC
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,555,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],42290.95,,"Fee schedule rate ($42,290.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10896.27,42290.95,There are no additional notes associated with this service or procedure.
"EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME, NEONATE",790,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],43038.65,,"Case rate ($42,194.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $39,388.49, add-ons for qualifying new technology services are included. If operating cost exceeds $74,259.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,703.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 17.9. The base transfer operating payment is the transfer adjustment factor * $37,305.99 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $37,443.54 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,943.81. The transfer capital threshold is the transfer adjustment factor * $2,943.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,3054.00,44304.49,Inpatient DRG
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],25609.86,,"Fee schedule rate ($25,609.86). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,12775.53,31469.43,There are no additional notes associated with this service or procedure.
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],19997.63,,"Fee schedule rate ($19,997.63). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,9151.11,30245.71,There are no additional notes associated with this service or procedure.
Egd Balloon Dilation Esophagus <30 Mm Diam,CASE-43249,APC,43249,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1796.14,,"APC Price ($1,796.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1796.14,1885.95,OPPS APC
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 2nd Level,CASE-64494,APC,64494,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],869.28,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,827.89,869.28,OPPS APC
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],43399.23,,"Fee schedule rate ($43,399.23). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9888.00,43399.23,There are no additional notes associated with this service or procedure.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],16286.16,,"Case rate ($16,286.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,286.28, add-ons for qualifying new technology services are included. If operating cost exceeds $50,157.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,808.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $13,292.32 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,341.33 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,048.90. The transfer capital threshold is the transfer adjustment factor * $1,048.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,16286.16,58320.32,Inpatient DRG
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],7389.00,,"Per diem ($7,389). If length of stay < 4.8, first 1 days paid at a per diem of $14,778 instead. Capped at $35,466.15.",,,,0,other,7389.00,37134.43,Estimated amount calculated based on 6 day length of stay.
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],18366.40,,"Fee schedule rate ($18,366.40). Adds an outlier to normal pricing equal to the per diem rate ($38,964.32) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.5), with a minimum of zero.",,,,0,other,8563.30,31533.97,There are no additional notes associated with this service or procedure.
DIABETES WITH CC,638,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],16842.29,,"Fee schedule rate ($16,842.29). Adds an outlier to normal pricing equal to the per diem rate ($39,561.63) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,8014.07,17634.53,There are no additional notes associated with this service or procedure.
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC,939,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],54134.85,,"Fee schedule rate ($54,134.85). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,26517.40,97674.79,There are no additional notes associated with this service or procedure.
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],18751.20,,"Case rate ($18,751.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,579.45, add-ons for qualifying new technology services are included. If operating cost exceeds $52,450.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,989.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $15,577.06 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,634.50 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,229.18. The transfer capital threshold is the transfer adjustment factor * $1,229.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8480.00,59081.91,Inpatient DRG
Dstr Nrolytc Agnt Parverteb Fct Addl Crvcl/Thora|RIGHT SIDE,CASE-64634,APC,64634,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1919.19,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1891.77,1919.19,OPPS APC
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],24701.52,,"Fee schedule rate ($24,701.52). Adds an outlier to normal pricing equal to the per diem rate ($51,462.28) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,10846.16,25863.45,There are no additional notes associated with this service or procedure.
Injection Aa&/Strd Ilioinguinal Ih Nerves|LEFT SIDE,CASE-64425,APC,64425,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],660.72,,"APC Price ($660.72). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,660.72,693.76,OPPS APC
Surgical Arthroscopy Shoulder Biceps Tenodesis|LEFT SIDE,CASE-29828,APC,29828,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],58320.32,,"Fee schedule rate ($58,320.32). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,16286.16,58320.32,There are no additional notes associated with this service or procedure.
OTHER MENTAL DISORDER DIAGNOSES,887,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],9519.07,,"Case rate ($9,197.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,691.53, add-ons for qualifying new technology services are included. If operating cost exceeds $43,562.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,290.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,721.79 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,746.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $530.42. The transfer capital threshold is the transfer adjustment factor * $530.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,2070.00,21072.10,Inpatient DRG
Nasal/Sinus Ndsc W/Rmvl Tiss From Frontal Sinus|BILATERAL PROCEDURE,CASE-31276,APC,31276,CPT,0360,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6936.25,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6837.16,6936.25,OPPS APC
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],33890.73,,"Fee schedule rate ($33,890.73). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6277.00,36801.89,There are no additional notes associated with this service or procedure.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,544,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],7196.25,,"Case rate ($7,055.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,698.86, add-ons for qualifying new technology services are included. If operating cost exceeds $41,569.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,133.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $4,736.45 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,753.92 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $373.75. The transfer capital threshold is the transfer adjustment factor * $373.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,7055.15,23207.64,Inpatient DRG
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC,099,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],22084.20,,"Fee schedule rate ($22,084.20). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11171.21,26807.94,There are no additional notes associated with this service or procedure.
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],12817.61,,"Case rate ($12,566.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,825.74, add-ons for qualifying new technology services are included. If operating cost exceeds $46,696.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,536.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $9,844.49 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,880.79 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $776.83. The transfer capital threshold is the transfer adjustment factor * $776.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,12566.28,30861.41,Inpatient DRG
Excision Distal Ulna Partial/Complete|RIGHT SIDE,CASE-25240,APC,25240,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7477.31,,"Case rate ($7,224.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,856.36, add-ons for qualifying new technology services are included. If operating cost exceeds $41,727.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,146.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $4,893.37 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,911.41 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $386.14. The transfer capital threshold is the transfer adjustment factor * $386.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6965.00,15340.19,Inpatient DRG
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],17741.86,,"Case rate ($16,897.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,854.53, add-ons for qualifying new technology services are included. If operating cost exceeds $50,725.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,853.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $13,858.48 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,909.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,093.57. The transfer capital threshold is the transfer adjustment factor * $1,093.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,16897.01,43444.85,Inpatient DRG
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],11960.18,,"Case rate ($6,834.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,493.49, add-ons for qualifying new technology services are included. If operating cost exceeds $41,364.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,117.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $4,531.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,548.54 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $357.61. The transfer capital threshold is the transfer adjustment factor * $357.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,6834.39,21354.82,All Other Inpatient
Inj for Sacroiliac Jt Anesth|BILATERAL PROCEDURE,CASE-G0260,APC,G0260,CPT,0360,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],693.76,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,660.72,693.76,OPPS APC
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],29324.40,,"Fee schedule rate ($29,324.40). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,23344.70,62179.32,There are no additional notes associated with this service or procedure.
HC Joint Injection/Aspir Medium WO US|PBB CHARGE,CASE-20605,APC,20605,CPT,0510,RC,,,PBB,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],287.31,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],24444.75,,"Fee schedule rate ($24,444.75). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10136.44,24444.75,There are no additional notes associated with this service or procedure.
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],8165.30,,"Fee schedule rate ($8,165.30). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4341.01,12882.53,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,699,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],19570.20,,"Fee schedule rate ($19,570.20). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5961.00,19972.16,There are no additional notes associated with this service or procedure.
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITHOUT MCC,430,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],73800.30,,"Fee schedule rate ($73,800.30). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,41000.16,133156.90,There are no additional notes associated with this service or procedure.
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],14674.80,,"Fee schedule rate ($14,674.80). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6711.00,16865.16,There are no additional notes associated with this service or procedure.
TRAUMATIC INJURY WITH MCC,913,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],13014.58,,"Case rate ($13,014.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,242.79, add-ons for qualifying new technology services are included. If operating cost exceeds $47,113.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,569.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $10,260.01 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,297.84 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $809.62. The transfer capital threshold is the transfer adjustment factor * $809.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,13014.58,42838.46,Inpatient DRG
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],6277.00,,"Per diem ($6,277). If length of stay < 5.6, first 1 days paid at a per diem of $12,554 instead. Capped at $35,148.55.",,,,0,other,6277.00,36801.89,Estimated amount calculated based on 4 day length of stay.
FRACTURES OF FEMUR WITH MCC,533,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],6852.00,,"Per diem ($6,852). If length of stay < 4.3, first 1 days paid at a per diem of $13,704 instead. Capped at $29,461.79.",,,,0,other,6852.00,49490.05,Estimated amount calculated based on 2 day length of stay.
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],14071.02,,,,,,0,other,6164.03,14071.02,There are no additional notes associated with this service or procedure.
"ASTHMA,MINOR",141,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],4318.17,,"Case rate ($4,112.54). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4318.17,4318.17,There are no additional notes associated with this service or procedure.
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],10390.62,,"Case rate ($9,895.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,356.33, add-ons for qualifying new technology services are included. If operating cost exceeds $44,227.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,327.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $7,383.38 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,411.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $567.50. The transfer capital threshold is the transfer adjustment factor * $567.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10136.44,24444.75,Inpatient DRG
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH CC",457,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],43808.93,,"Case rate ($42,327.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $39,511.96, add-ons for qualifying new technology services are included. If operating cost exceeds $74,382.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,713.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $37,429.01 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $37,567.02 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,953.52. The transfer capital threshold is the transfer adjustment factor * $2,953.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,42327.47,160549.49,Inpatient DRG
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],133270.57,,"Fee schedule rate ($133,270.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,33623.33,133270.57,There are no additional notes associated with this service or procedure.
Injection Aa&/Strd Intercostal Nrv Ea Addl Lvl|RIGHT SIDE,CASE-64421,APC,64421,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],827.89,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,827.89,869.28,OPPS APC
HC Injection Small Joint/Bursa|LEFT SIDE,CASE-20600,APC,20600,CPT,0361,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],47751.13,,"Fee schedule rate ($47,751.13). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.7), with a minimum of zero.",,,,0,other,19152.11,53152.12,There are no additional notes associated with this service or procedure.
"Inj Dx/Ther Agnt Paravert Facet Joint, Cerv/Thorac, 2nd Level|RIGHT SIDE",CASE-64491,APC,64491,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],856.86,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,827.89,869.28,OPPS APC
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],96365.69,,"Fee schedule rate ($96,365.69). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,23377.19,96365.69,There are no additional notes associated with this service or procedure.
Strtctc Cptr Asstd Px Extradural Cranial,CASE-61782,APC,61782,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5541.10,,"APC Price ($5,541.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5541.10,5818.16,OPPS APC
BRONCHITIS AND ASTHMA WITH CC/MCC,202,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],8521.98,,"Case rate ($8,521.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,063.43, add-ons for qualifying new technology services are included. If operating cost exceeds $42,934.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,241.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,096.00 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,118.48 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $481.03. The transfer capital threshold is the transfer adjustment factor * $481.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7606.34,19110.30,Inpatient DRG
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],43949.31,,"Fee schedule rate ($43,949.31). Adds an outlier to normal pricing equal to the per diem rate ($149,567.78) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,17782.11,46523.26,There are no additional notes associated with this service or procedure.
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],15762.96,,"Case rate ($15,453.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,512.02, add-ons for qualifying new technology services are included. If operating cost exceeds $49,383.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,747.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $12,520.90 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,567.07 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $988.02. The transfer capital threshold is the transfer adjustment factor * $988.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,15453.88,39251.68,Inpatient DRG
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],9226.81,,"Case rate ($8,787.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,310.38, add-ons for qualifying new technology services are included. If operating cost exceeds $43,181.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,260.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,342.05 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,365.43 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $500.45. The transfer capital threshold is the transfer adjustment factor * $500.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,32293.66,Inpatient DRG
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],67790.93,,"Fee schedule rate ($67,790.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,21597.50,67790.93,There are no additional notes associated with this service or procedure.
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC,939,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],68190.40,,"Fee schedule rate ($68,190.40). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16.5), with a minimum of zero.",,,,0,other,26517.40,97674.79,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF NERVOUS SYSTEM WITH CC,092,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],9102.75,,"Case rate ($8,669.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,213, add-ons for qualifying new technology services are included. If operating cost exceeds $43,084.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,239.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $6,244.38 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,268.05 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $479.96. The transfer capital threshold is the transfer adjustment factor * $479.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8872.78,26765.51,Inpatient DRG
"Inj Dx/Ther Agnt Paravert Facet Joint, Cerv/Thorac, 2nd Level",CASE-64491,APC,64491,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],869.28,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,827.89,869.28,OPPS APC
OSTEOMYELITIS WITH CC,540,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],24361.37,,"Fee schedule rate ($24,361.37). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.6), with a minimum of zero.",,,,0,other,9809.07,25507.30,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITH STERILIZATION WITH MCC,783,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],12612.10,,"Fee schedule rate ($12,612.10). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12612.10,23722.94,There are no additional notes associated with this service or procedure.
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],7290.89,,"Case rate ($7,147.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,785.17, add-ons for qualifying new technology services are included. If operating cost exceeds $41,656.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,140.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $4,822.44 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,840.22 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $380.54. The transfer capital threshold is the transfer adjustment factor * $380.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6965.00,16400.70,Inpatient DRG
HYPERTENSION WITHOUT MCC,305,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],17230.49,,"Fee schedule rate ($17,230.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7058.55,17230.49,There are no additional notes associated with this service or procedure.
Sigmoidoscopy Flx W/Biopsy Single/Multiple|COLORECTAL CANCER SCREEN,CASE-45331,APC,45331,CPT,0360,RC,,,PT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],900.93,,"APC Price ($870.46). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,870.46,913.99,OPPS APC
INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,352,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],26528.70,,"Fee schedule rate ($26,528.70). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,9853.37,26528.70,There are no additional notes associated with this service or procedure.
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],14455.04,,"Fee schedule rate ($14,455.04). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5280.00,17136.70,There are no additional notes associated with this service or procedure.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITHOUT CC/MCC,816,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],14733.53,,"Fee schedule rate ($14,733.53). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6224.90,14733.53,There are no additional notes associated with this service or procedure.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],19849.17,,"Fee schedule rate ($19,849.17). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,9097.60,21455.22,There are no additional notes associated with this service or procedure.
CHEST PAIN,313,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],15377.66,,"Fee schedule rate ($15,377.66). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,6820.84,15377.66,There are no additional notes associated with this service or procedure.
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],6965.00,,,,,,0,other,5883.03,17111.12,There are no additional notes associated with this service or procedure.
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7281.07,,"Case rate ($7,034.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,679.97, add-ons for qualifying new technology services are included. If operating cost exceeds $41,550.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,132.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $4,717.62 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,735.02 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $372.27. The transfer capital threshold is the transfer adjustment factor * $372.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6965.00,21089.59,Inpatient DRG
HEADACHES WITHOUT MCC,103,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],7608.43,,"Case rate ($7,608.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,213.57, add-ons for qualifying new technology services are included. If operating cost exceeds $42,084.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,174.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $5,249.26 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,268.62 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $414.22. The transfer capital threshold is the transfer adjustment factor * $414.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,20883.08,Inpatient DRG
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],25704.37,,"Case rate ($24,480.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $22,951.20, add-ons for qualifying new technology services are included. If operating cost exceeds $57,822.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,368.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $20,926.90 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $21,006.25 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,608.49. The transfer capital threshold is the transfer adjustment factor * $1,608.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,25162.32,75579.22,Inpatient DRG
"Amputation Toe Interphalangeal Joint|LEFT FOOT, THIRD DIGIT",CASE-28825,APC,28825,CPT,0360,RC,,,T2,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],14309.17,,"Fee schedule rate ($14,309.17). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,17467.27,There are no additional notes associated with this service or procedure.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],14098.78,,"Case rate ($14,098.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,251.41, add-ons for qualifying new technology services are included. If operating cost exceeds $48,122.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,648.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $11,264.92 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,306.46 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $888.91. The transfer capital threshold is the transfer adjustment factor * $888.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7332.00,35314.31,Inpatient DRG
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],21195.68,,"Fee schedule rate ($21,195.68). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,6965.00,21195.68,There are no additional notes associated with this service or procedure.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],133270.57,,"Fee schedule rate ($133,270.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,33623.33,133270.57,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],14344.60,,"Case rate ($14,344.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,480.09, add-ons for qualifying new technology services are included. If operating cost exceeds $48,351.10 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,666.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $11,492.77 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,535.14 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $906.89. The transfer capital threshold is the transfer adjustment factor * $906.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,14344.60,36028.59,Inpatient DRG
"ANTEPARTUM WITHOUT O.R. PROCEDURE,MODERATE",566,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],3744.16,,"Case rate ($3,744.16). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,3744.16,3931.37,There are no additional notes associated with this service or procedure.
Surgical Arthroscopy Shoulder Xtnsv Dbrdmt 3+|RIGHT SIDE,CASE-29823,APC,29823,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7029.71,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6791.99,7131.59,OPPS APC
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],9492.76,,"Case rate ($9,040.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,546, add-ons for qualifying new technology services are included. If operating cost exceeds $43,417.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,278.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,576.80 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,601.05 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $518.97. The transfer capital threshold is the transfer adjustment factor * $518.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9040.72,26966.33,Inpatient DRG
"ALCOHOLIC LIVER DISEASE,MODERATE",280,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],2067.71,,"Case rate for a one day stay ($1,969.25). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,1969.25,2067.71,There are no additional notes associated with this service or procedure.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],53939.67,,"Fee schedule rate ($53,939.67). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,21382.16,85466.62,There are no additional notes associated with this service or procedure.
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],18893.86,,,,,,0,other,1188.00,18893.86,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,448,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],94077.13,,"Fee schedule rate ($94,077.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,30663.95,94077.13,There are no additional notes associated with this service or procedure.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,345,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],33616.03,,"Fee schedule rate ($33,616.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12134.89,33616.03,There are no additional notes associated with this service or procedure.
HC Inj Trigger Pt 1-2 Musc Grps|ADJ,CASE-20552,APC,20552,CPT,0510,RC,,,ADJ,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],297.37,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,287.31,301.68,OPPS APC
Excision Hydrocele Unilateral|LEFT SIDE,CASE-55040,APC,55040,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3518.91,,"APC Price ($3,351.34). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3351.34,3518.91,OPPS APC
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7834.78,,"Case rate ($7,569.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,177.66, add-ons for qualifying new technology services are included. If operating cost exceeds $42,048.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,171.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,213.49 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,232.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $411.40. The transfer capital threshold is the transfer adjustment factor * $411.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,7569.84,21892.85,Inpatient DRG
Exc B9 Lesion Mrgn Xcp Sk Tg S/N/H/F/G 0.6-1.0cm,CASE-11421,APC,11421,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],662.83,,"APC Price ($662.83). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,662.83,695.97,OPPS APC
PERIPHERAL VASCULAR DISORDERS WITH CC,300,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],20061.53,,"Fee schedule rate ($20,061.53). Adds an outlier to normal pricing equal to the per diem rate ($49,296.97) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.9), with a minimum of zero.",,,,0,other,9174.14,21005.20,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],12984.79,,"Case rate ($12,984.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,215.07, add-ons for qualifying new technology services are included. If operating cost exceeds $47,086.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,567.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $10,232.39 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,270.12 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $807.44. The transfer capital threshold is the transfer adjustment factor * $807.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12984.79,32077.45,Inpatient DRG
OTHER CEREBROVASCULAR DISORDERS WITH MCC,070,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],31286.59,,"Fee schedule rate ($31,286.59). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13219.09,37774.46,There are no additional notes associated with this service or procedure.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH CC,026,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],63202.45,,"Fee schedule rate ($63,202.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,23000.66,63202.45,There are no additional notes associated with this service or procedure.
Cystourethroscopy,CASE-52000,APC,52000,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],652.69,,"APC Price ($652.69). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,652.69,685.32,OPPS APC
Parathyroidectomy/Exploration Parathyroids,CASE-60500,APC,60500,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5541.10,,"APC Price ($5,541.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5541.10,5818.16,OPPS APC
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],9104.82,,"Case rate ($8,671.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,214.84, add-ons for qualifying new technology services are included. If operating cost exceeds $43,085.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,240.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $6,246.21 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,269.89 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $480.10. The transfer capital threshold is the transfer adjustment factor * $480.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8874.81,20553.44,Inpatient DRG
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],25814.06,,"Fee schedule rate ($25,814.06). Adds an outlier to normal pricing equal to the per diem rate ($46,867.46) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,11247.07,27028.33,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],54875.56,,"Fee schedule rate ($54,875.56). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,21719.40,85305.59,There are no additional notes associated with this service or procedure.
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],7551.60,,"Fee schedule rate ($7,551.60). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7243.75,23262.15,There are no additional notes associated with this service or procedure.
Rpr Aa Hernia Recr > 10 Cm Reducible,CASE-49617,APC,49617,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],199.10,,"APC Price ($199.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,199.10,209.05,OPPS APC
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],20297.68,,"Fee schedule rate ($20,297.68). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6965.00,21404.64,There are no additional notes associated with this service or procedure.
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],20297.68,,"Fee schedule rate ($20,297.68). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6965.00,21404.64,There are no additional notes associated with this service or procedure.
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],19462.52,,,,,,0,other,8643.20,19462.52,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],28038.61,,"Fee schedule rate ($28,038.61). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12126.09,29582.40,There are no additional notes associated with this service or procedure.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],20553.44,,"Fee schedule rate ($20,553.44). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8874.81,20553.44,There are no additional notes associated with this service or procedure.
MAJOR CHEST TRAUMA WITHOUT CC/MCC,185,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],21771.61,,"Fee schedule rate ($21,771.61). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7271.19,21771.61,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,699,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],19972.16,,,,,,0,other,5961.00,19972.16,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],31091.14,,"Fee schedule rate ($31,091.14). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13148.66,32553.63,There are no additional notes associated with this service or procedure.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",063,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],27622.57,,,,,,0,other,6965.00,35701.87,There are no additional notes associated with this service or procedure.
"NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY",789,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],6663.33,,,,,,0,other,3054.00,14857.05,Estimated amount calculated based on 1 day length of stay.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],13341.67,,"Case rate ($13,341.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,547.08, add-ons for qualifying new technology services are included. If operating cost exceeds $47,418.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,593.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $10,563.18 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,602.13 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $833.54. The transfer capital threshold is the transfer adjustment factor * $833.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,13341.67,42586.49,Inpatient DRG
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],30063.84,,"Fee schedule rate ($30,063.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13891.57,34712.20,There are no additional notes associated with this service or procedure.
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITHOUT MCC,430,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],133156.90,,"Fee schedule rate ($133,156.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,41000.16,133156.90,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],32852.04,,"Fee schedule rate ($32,852.04). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,13783.20,41580.51,There are no additional notes associated with this service or procedure.
VENTRICULAR SHUNT PROCEDURES WITH CC,032,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],40047.88,,"Fee schedule rate ($40,047.88). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,16376.22,46275.08,There are no additional notes associated with this service or procedure.
Cysto W/Rescj/Fulg Orthopic Ureterocele Uni/Bi,CASE-52300,APC,52300,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3414.95,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3299.47,3464.44,OPPS APC
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],81353.66,,"Fee schedule rate ($81,353.66). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,27256.92,81353.66,There are no additional notes associated with this service or procedure.
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 1 Level,CASE-64493,APC,64493,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],856.86,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,827.89,869.28,OPPS APC
CESAREAN SECTION WITHOUT STERILIZATION WITH MCC,786,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],23722.94,,"Fee schedule rate ($23,722.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12612.10,23722.94,There are no additional notes associated with this service or procedure.
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],25261.33,,,,,,0,other,10638.94,25261.33,There are no additional notes associated with this service or procedure.
MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,708,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],10138.21,,"Case rate ($9,655.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $9,011.46, add-ons for qualifying new technology services are included. If operating cost exceeds $48,581.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $3,476.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.3. The base transfer operating payment is the transfer adjustment factor * $8,970.52. The transfer operating threshold is the transfer adjustment factor * $9,011.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $684.92. The transfer capital threshold is the transfer adjustment factor * $684.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10138.21,29171.15,Inpatient DRG
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC,497,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],37761.19,,"Fee schedule rate ($37,761.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10127.65,37761.19,There are no additional notes associated with this service or procedure.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],7332.00,,"Per diem ($7,332). If length of stay < 4.6, first 1 days paid at a per diem of $14,664 instead. Capped at $33,727.80.",,,,0,other,7332.00,35314.31,Estimated amount calculated based on 3 day length of stay.
Rpr Ingun Hernia Sliding Any Age|RIGHT SIDE,CASE-49525,APC,49525,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3518.91,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3351.34,3518.91,OPPS APC
TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC,084,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],6965.00,,,,,,0,other,6965.00,19445.16,There are no additional notes associated with this service or procedure.
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],8120.41,,"Case rate ($7,733.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,330.12, add-ons for qualifying new technology services are included. If operating cost exceeds $42,201.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,183.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,365.38 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,385.17 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $423.38. The transfer capital threshold is the transfer adjustment factor * $423.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7733.72,18043.23,Inpatient DRG
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,066,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],6579.76,,"Case rate ($6,579.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,256.61, add-ons for qualifying new technology services are included. If operating cost exceeds $41,127.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,098.96, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $4,295.82 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,311.66 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $338.98. The transfer capital threshold is the transfer adjustment factor * $338.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6579.76,20083.61,Inpatient DRG
CESAREAN SECTION WITHOUT STERILIZATION WITH MCC,786,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],23722.94,,"Fee schedule rate ($23,722.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12612.10,23722.94,There are no additional notes associated with this service or procedure.
SPINAL PROCEDURES WITH MCC,028,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],64319.47,,"Fee schedule rate ($64,319.47). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,42633.57,120982.83,There are no additional notes associated with this service or procedure.
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],18043.23,,"Fee schedule rate ($18,043.23). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7733.72,18043.23,There are no additional notes associated with this service or procedure.
Arthrs Knee Debridement/Shaving Artclr Crtlg|RIGHT SIDE,CASE-29877,APC,29877,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],30245.71,,"Fee schedule rate ($30,245.71). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9151.11,30245.71,There are no additional notes associated with this service or procedure.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],45933.85,,"Fee schedule rate ($45,933.85). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,18497.24,62041.12,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],23316.48,,"Fee schedule rate ($23,316.48). Adds an outlier to normal pricing equal to the per diem rate ($44,995.76) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7.7), with a minimum of zero.",,,,0,other,10347.06,28821.04,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL HEMORRHAGE WITH MCC,377,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],31575.65,,"Fee schedule rate ($31,575.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,7634.00,35969.56,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],23899.13,,"Fee schedule rate ($23,899.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9795.13,23899.13,There are no additional notes associated with this service or procedure.
Open Implantation Nea Sacral Nerve,CASE-64581,APC,64581,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],18158.97,,"APC Price ($18,158.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,18158.97,19066.92,OPPS APC
Exc Breast Les Preop Plmt Rad Marker Open 1 Les|LEFT SIDE,CASE-19125,APC,19125,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3664.94,,"APC Price ($3,664.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3664.94,3848.19,OPPS APC
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],18671.22,,"Case rate ($17,782.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,677.93, add-ons for qualifying new technology services are included. If operating cost exceeds $51,548.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,918.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $14,678.86 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,732.98 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,158.31. The transfer capital threshold is the transfer adjustment factor * $1,158.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,17782.11,46523.26,Inpatient DRG
OTHER DISORDERS OF THE EYE WITHOUT MCC,125,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],7501.77,,"Case rate ($7,144.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,782.02, add-ons for qualifying new technology services are included. If operating cost exceeds $41,653.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,140.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,819.30 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,837.07 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $380.29. The transfer capital threshold is the transfer adjustment factor * $380.29. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7144.54,17952.29,Inpatient DRG
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],7749.28,,"Case rate ($7,749.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,344.60, add-ons for qualifying new technology services are included. If operating cost exceeds $42,215.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,184.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,379.82 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,399.66 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $424.52. The transfer capital threshold is the transfer adjustment factor * $424.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6711.00,16865.16,Inpatient DRG
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral Ea Addl,CASE-64484,APC,64484,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],827.89,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,827.89,869.28,OPPS APC
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],24299.59,,"Fee schedule rate ($24,299.59). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,7921.00,45706.73,There are no additional notes associated with this service or procedure.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],142438.06,,"Fee schedule rate ($142,438.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (40), with a minimum of zero.",,,,0,other,45521.20,142438.06,There are no additional notes associated with this service or procedure.
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],48025.07,,"Fee schedule rate ($48,025.07). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,26127.34,90333.60,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],13947.32,,"Fee schedule rate ($13,947.32). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6153.12,13947.32,There are no additional notes associated with this service or procedure.
Surgical Arthroscopy Shoulder Repair Slap Lesion,CASE-29807,APC,29807,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],36094.03,,"Fee schedule rate ($36,094.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11194.25,36094.03,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],19173.27,,,,,,0,other,8543.64,23239.84,There are no additional notes associated with this service or procedure.
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],8339.44,,"Case rate ($8,057.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,631.26, add-ons for qualifying new technology services are included. If operating cost exceeds $42,502.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,207.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,665.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,686.30 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $447.06. The transfer capital threshold is the transfer adjustment factor * $447.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6524.00,17760.46,Inpatient DRG
"OTHER SKIN SUBCUTANEOUS TISSUE AND BREAST DISORDERS,MINOR",385,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],4735.29,,"Case rate ($4,735.29). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,4735.29,4972.05,There are no additional notes associated with this service or procedure.
PREMATURITY WITH MAJOR PROBLEMS,791,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],3232.95,,,,,,0,other,3048.21,30904.42,Estimated amount calculated based on 5 day length of stay.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,073,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],30149.61,,"Fee schedule rate ($30,149.61). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12809.38,43475.01,There are no additional notes associated with this service or procedure.
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,094,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],67889.44,,"Fee schedule rate ($67,889.44). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,25778.58,67889.44,There are no additional notes associated with this service or procedure.
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],8106.18,,"Case rate ($8,106.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,676.61, add-ons for qualifying new technology services are included. If operating cost exceeds $42,547.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,210.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,710.61 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,731.66 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $450.62. The transfer capital threshold is the transfer adjustment factor * $450.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8106.18,18245.94,Inpatient DRG
NON-MALIGNANT BREAST DISORDERS WITH CC/MCC,600,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],8998.74,,"Case rate ($8,998.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,506.94, add-ons for qualifying new technology services are included. If operating cost exceeds $43,377.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,275.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $6,537.88 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,561.99 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $515.90. The transfer capital threshold is the transfer adjustment factor * $515.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7999.14,20495.56,Inpatient DRG
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],30861.41,,,,,,0,other,12566.28,30861.41,There are no additional notes associated with this service or procedure.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],6474.30,,"Fee schedule rate ($6,474.30). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5778.62,11681.49,There are no additional notes associated with this service or procedure.
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],26721.94,,"Fee schedule rate ($26,721.94). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6965.00,34422.94,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],57456.84,,,,,,0,other,21719.40,85305.59,There are no additional notes associated with this service or procedure.
COAGULATION DISORDERS,813,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],12888.11,,"Case rate ($12,274.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,554.21, add-ons for qualifying new technology services are included. If operating cost exceeds $46,425.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,515.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $9,573.96 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,609.26 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $755.48. The transfer capital threshold is the transfer adjustment factor * $755.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12274.39,30013.33,Inpatient DRG
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],9533.13,,"Fee schedule rate ($9,533.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5068.21,14525.56,There are no additional notes associated with this service or procedure.
"Amp F/Th 1/2 Jt/Phalanx W/Neurect W/Dir Clsr|RIGHT HAND, SECOND DIGIT",CASE-26951,APC,26951,CPT,0360,RC,,,F6,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,451,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],25012.51,,"Case rate ($23,821.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $22,296.19, add-ons for qualifying new technology services are included. If operating cost exceeds $57,167.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,359.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $20,276.48 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $20,351.24 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,600.01. The transfer capital threshold is the transfer adjustment factor * $1,600.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,23821.44,94077.13,Inpatient DRG
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],18341.97,,"Fee schedule rate ($18,341.97). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.9), with a minimum of zero.",,,,0,other,8554.50,19204.75,There are no additional notes associated with this service or procedure.
Cysto Bladder W/Ureteral Catheterization|UNUSUAL NON-OVERLAPPING SERVICE,CASE-52005,APC,52005,CPT,0360,RC,,,XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3414.95,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3299.47,3464.44,OPPS APC
Neuroplasty &/Transpos Median Nrv Carpal Tunne|RIGHT SIDE|SEPARATE STRUCTURE,CASE-64721,APC,64721,CPT,0360,RC,,,RT|XS,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6791.99,7131.59,OPPS APC
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC,833,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],5721.39,,"Fee schedule rate ($5,721.39). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,3041.73,10289.10,There are no additional notes associated with this service or procedure.
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],9755.86,,"Case rate ($9,755.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,211.27, add-ons for qualifying new technology services are included. If operating cost exceeds $44,082.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,331.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $7,239.63 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,266.32 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $571.28. The transfer capital threshold is the transfer adjustment factor * $571.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9755.86,29216.99,Inpatient DRG
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],14472.36,,"Case rate ($13,783.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,957.83, add-ons for qualifying new technology services are included. If operating cost exceeds $47,828.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,625.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $10,972.42 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,012.88 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $865.83. The transfer capital threshold is the transfer adjustment factor * $865.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13783.20,41580.51,Inpatient DRG
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC,434,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],11847.59,,"Case rate ($6,770.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,433.64, add-ons for qualifying new technology services are included. If operating cost exceeds $41,304.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,112.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,472.20 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,488.69 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $352.90. The transfer capital threshold is the transfer adjustment factor * $352.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,6770.05,14019.86,All Other Inpatient
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC",494,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],16076.76,,"Case rate ($15,533.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,585.72, add-ons for qualifying new technology services are included. If operating cost exceeds $49,456.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,753.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $12,594.34 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,640.78 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $993.82. The transfer capital threshold is the transfer adjustment factor * $993.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,15533.10,39945.55,Inpatient DRG
"ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",770,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],17800.73,,"Fee schedule rate ($17,800.73). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,8735.30,19730.13,There are no additional notes associated with this service or procedure.
OTHER CEREBROVASCULAR DISORDERS WITH MCC,070,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],37774.46,,"Fee schedule rate ($37,774.46). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,13219.09,37774.46,There are no additional notes associated with this service or procedure.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],58320.32,,"Fee schedule rate ($58,320.32). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,16286.16,58320.32,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],28756.63,,"Fee schedule rate ($28,756.63). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,13148.66,32553.63,There are no additional notes associated with this service or procedure.
Bx/Exc Lymph Node Open Deep Axillary Node|RIGHT SIDE,CASE-38525,APC,38525,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6215.36,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6215.36,6526.12,OPPS APC
Arthrs Kne Surg W/Meniscectomy Med/Lat W/Shvg|RIGHT SIDE|SEPARATE STRUCTURE,CASE-29881,APC,29881,CPT,0360,RC,,,RT|XS,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],23870.71,,"Fee schedule rate ($23,870.71). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10626.74,25225.91,There are no additional notes associated with this service or procedure.
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITH MCC OR ANTINEOPLASTIC IMPLANT OR EPILEPSY WITH NEUROSTIMULATOR,023,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],41591.64,,"Case rate ($39,611.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $37,055.24, add-ons for qualifying new technology services are included. If operating cost exceeds $71,926.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,448.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $34,977.67 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $35,110.29 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,688.47. The transfer capital threshold is the transfer adjustment factor * $2,688.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,15168.00,136379.44,Inpatient DRG
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],19230.88,,"Fee schedule rate ($19,230.88). Adds an outlier to normal pricing equal to the per diem rate ($71,679.63) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8874.81,20553.44,There are no additional notes associated with this service or procedure.
"HC Unlisted Procedure, Nervous System",CASE-64999,APC,64999,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,7029.71,7131.59,OPPS APC
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 2nd Level|BILATERAL PROCEDURE,CASE-64494,APC,64494,CPT,0360,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],869.28,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,827.89,869.28,OPPS APC
VAGINAL DELIVERY WITH O.R. PROCEDURES EXCEPT STERILIZATION AND/OR D&C,768,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],12088.81,,"Fee schedule rate ($12,088.81). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6426.91,13416.00,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITH CC,386,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],8856.01,,"Case rate ($8,556.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,095.56, add-ons for qualifying new technology services are included. If operating cost exceeds $42,966.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,243.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,128.01 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,150.61 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $483.56. The transfer capital threshold is the transfer adjustment factor * $483.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,8556.53,19879.00,Inpatient DRG
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],52794.06,,"Fee schedule rate ($52,794.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (37), with a minimum of zero.",,,,0,other,13907.80,52794.06,There are no additional notes associated with this service or procedure.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],28434.57,,"Fee schedule rate ($28,434.57). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,8906.63,28434.57,There are no additional notes associated with this service or procedure.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],46957.19,,,,,,0,other,18105.81,52699.33,There are no additional notes associated with this service or procedure.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],36776.05,,"Fee schedule rate ($36,776.05). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11053.39,36776.05,There are no additional notes associated with this service or procedure.
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],15060.41,,"Case rate ($14,343.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,478.83, add-ons for qualifying new technology services are included. If operating cost exceeds $48,349.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,666.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $11,491.51 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,533.88 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $906.79. The transfer capital threshold is the transfer adjustment factor * $906.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,14343.25,36024.65,Inpatient DRG
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC",442,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],9668.40,,"Fee schedule rate ($9,668.40). Adds an outlier to normal pricing equal to the per diem rate ($3,770.33) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6607.45,19011.92,There are no additional notes associated with this service or procedure.
NERVOUS SYSTEM NEOPLASMS WITH MCC,054,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],6965.00,,,,,,0,other,6965.00,30044.81,There are no additional notes associated with this service or procedure.
Dstr Nrolytc Agnt Parverteb Fct Sngl Lmbr/Sacral|BILATERAL PROCEDURE,CASE-64635,APC,64635,CPT,0360,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1919.19,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1827.80,1919.19,OPPS APC
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,093,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],15668.80,,,,,,0,other,6965.00,19011.32,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],8970.82,,"Case rate ($8,543.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,083.58, add-ons for qualifying new technology services are included. If operating cost exceeds $42,954.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,242.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,116.09 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,138.64 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $482.62. The transfer capital threshold is the transfer adjustment factor * $482.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8543.64,23239.84,Inpatient DRG
NON-MALIGNANT BREAST DISORDERS WITH CC/MCC,600,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],15046.13,,"Fee schedule rate ($15,046.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7999.14,20495.56,There are no additional notes associated with this service or procedure.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],23618.74,,"Fee schedule rate ($23,618.74). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10533.95,24956.34,There are no additional notes associated with this service or procedure.
UNGROUPABLE,999,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],48752.15,,"Case rate ($48,752.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $45,488.70, add-ons for qualifying new technology services are included. If operating cost exceeds $80,359.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $5,183.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 12.7. The base transfer operating payment is the transfer adjustment factor * $43,383.78 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $43,543.75 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,423.41. The transfer capital threshold is the transfer adjustment factor * $3,423.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10228.00,161307.29,Inpatient DRG
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],16379.98,,"Fee schedule rate ($16,379.98). Adds an outlier to normal pricing equal to the per diem rate ($46,377.87) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7847.50,17755.26,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITH STERILIZATION WITHOUT CC/MCC,785,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],20142.33,,"Fee schedule rate ($20,142.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8431.24,20142.33,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],5741.55,,"Case rate ($5,628.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,372.11, add-ons for qualifying new technology services are included. If operating cost exceeds $40,243.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,029.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,414.56 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,427.15 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $269.44. The transfer capital threshold is the transfer adjustment factor * $269.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,5628.97,12272.58,Inpatient DRG
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],7833.94,,"Case rate ($7,833.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,423.35, add-ons for qualifying new technology services are included. If operating cost exceeds $42,294.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,190.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,458.28 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,478.41 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $430.71. The transfer capital threshold is the transfer adjustment factor * $430.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,5883.03,17111.12,Inpatient DRG
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],23520.23,,"Fee schedule rate ($23,520.23). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10517.71,24909.11,There are no additional notes associated with this service or procedure.
BRONCHITIS AND ASTHMA WITHOUT CC/MCC,203,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],13707.00,,,,,,0,other,4763.76,13707.00,There are no additional notes associated with this service or procedure.
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],27222.08,,"Fee schedule rate ($27,222.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7389.00,37134.43,There are no additional notes associated with this service or procedure.
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],37016.57,,"Fee schedule rate ($37,016.57). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15), with a minimum of zero.",,,,0,other,15283.90,38757.79,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,066,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],20083.61,,"Fee schedule rate ($20,083.61). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6579.76,20083.61,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],18312.67,,"Case rate ($17,693.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,595.40, add-ons for qualifying new technology services are included. If operating cost exceeds $51,466.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,911.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $14,596.63 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,650.45 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,151.82. The transfer capital threshold is the transfer adjustment factor * $1,151.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,17693.40,52449.26,Inpatient DRG
Ostectomy Complete Other Metatarsal Head 2/3/4|RIGHT SIDE,CASE-28112,APC,28112,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],23216.87,,"Fee schedule rate ($23,216.87). Adds an outlier to normal pricing equal to the per diem rate ($51,531) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.7), with a minimum of zero.",,,,0,other,10311.17,24308.97,There are no additional notes associated with this service or procedure.
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],18043.23,,"Fee schedule rate ($18,043.23). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7733.72,18043.23,There are no additional notes associated with this service or procedure.
Exc Tumor Soft Tiss Back/Flank Subfascial 5 Cm/>,CASE-21933,APC,21933,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],2814.04,,"APC Price ($2,718.88). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2718.88,2854.83,OPPS APC
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],22627.47,,"Case rate ($21,862.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,473.63, add-ons for qualifying new technology services are included. If operating cost exceeds $55,344.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,216.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. The base transfer operating payment is the transfer adjustment factor * $18,460.61 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,528.68 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,456.72. The transfer capital threshold is the transfer adjustment factor * $1,456.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,7086.00,57872.02,Inpatient DRG
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],18918.49,,"Fee schedule rate ($18,918.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9282.47,21320.03,There are no additional notes associated with this service or procedure.
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC,807,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],10071.17,,"Fee schedule rate ($10,071.17). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5354.25,13266.23,There are no additional notes associated with this service or procedure.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC",156,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],6711.95,,"Fee schedule rate ($6,711.95). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6625.12,13598.77,There are no additional notes associated with this service or procedure.
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],22311.17,,"Case rate ($21,248.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $19,902.85, add-ons for qualifying new technology services are included. If operating cost exceeds $54,773.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,171.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.3. The base transfer operating payment is the transfer adjustment factor * $17,891.94 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $17,957.90 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,411.85. The transfer capital threshold is the transfer adjustment factor * $1,411.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,21248.73,56089.29,Inpatient DRG
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],35884.94,,,,,,0,other,14295.18,42768.36,There are no additional notes associated with this service or procedure.
PREMATURITY WITHOUT MAJOR PROBLEMS,792,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],11512.88,,"Fee schedule rate ($11,512.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,1956.00,19457.66,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC",281,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],8385.64,,"Case rate ($7,986.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,576.39, add-ons for qualifying new technology services are included. If operating cost exceeds $42,447.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,191.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $5,610.17 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,631.44 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $431.21. The transfer capital threshold is the transfer adjustment factor * $431.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8169.15,23859.35,Inpatient DRG
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,373,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7111.42,,"Case rate ($6,870.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,527.50, add-ons for qualifying new technology services are included. If operating cost exceeds $41,398.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,120.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $4,565.72 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,582.56 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $360.28. The transfer capital threshold is the transfer adjustment factor * $360.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6870.94,14313.05,Inpatient DRG
Cysto W/Removal of Lesions Small,CASE-52224,APC,52224,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3464.44,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3299.47,3464.44,OPPS APC
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC",514,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],22699.91,,"Fee schedule rate ($22,699.91). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8868.04,22699.91,There are no additional notes associated with this service or procedure.
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],9151.11,,"Case rate ($9,151.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,648.69, add-ons for qualifying new technology services are included. If operating cost exceeds $43,519.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,287.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,679.11 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,703.74 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $527.05. The transfer capital threshold is the transfer adjustment factor * $527.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9151.11,30245.71,Inpatient DRG
"OTHER DISORDERS OF THE LIVER,MAJOR",283,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],2128.20,,"Case rate for a one day stay ($2,026.86). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,2026.86,2128.20,There are no additional notes associated with this service or procedure.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],61290.90,,"Fee schedule rate ($61,290.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,23799.09,63499.65,There are no additional notes associated with this service or procedure.
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],31323.82,,,,,,0,other,12725.42,34245.00,There are no additional notes associated with this service or procedure.
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],20170.75,,"Fee schedule rate ($20,170.75). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10048.39,23545.50,There are no additional notes associated with this service or procedure.
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITHOUT CC/MCC",630,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],27428.38,,"Fee schedule rate ($27,428.38). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,11828.78,42541.02,There are no additional notes associated with this service or procedure.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],10779.20,,"Case rate ($10,265.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,701.28, add-ons for qualifying new technology services are included. If operating cost exceeds $44,572.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,353.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $7,727.04 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,756.33 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $593.92. The transfer capital threshold is the transfer adjustment factor * $593.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10517.71,24909.11,Inpatient DRG
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC",458,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],132827.25,,"Fee schedule rate ($132,827.25). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,30202.09,132827.25,There are no additional notes associated with this service or procedure.
Laps Gastric Restrictive Px Remove Device & Port,CASE-43774,APC,43774,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3735.12,,"APC Price ($3,608.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3608.81,3789.26,OPPS APC
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],24368.86,,"Case rate ($23,208.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $21,765.60, add-ons for qualifying new technology services are included. If operating cost exceeds $56,636.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,277.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.8. The base transfer operating payment is the transfer adjustment factor * $19,745.78 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $19,820.65 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,517.71. The transfer capital threshold is the transfer adjustment factor * $1,517.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,23851.92,63653.13,Inpatient DRG
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],11374.36,,"Case rate ($10,989.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,359.11, add-ons for qualifying new technology services are included. If operating cost exceeds $45,230.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,421.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $8,383.26 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,414.17 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $661.52. The transfer capital threshold is the transfer adjustment factor * $661.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,10989.72,26280.60,Inpatient DRG
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC,099,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],11171.21,,"Case rate ($11,171.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,527.95, add-ons for qualifying new technology services are included. If operating cost exceeds $45,398.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,434.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,551.47 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,583.00 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $674.80. The transfer capital threshold is the transfer adjustment factor * $674.80. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,11171.21,26807.94,Inpatient DRG
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC,806,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],10071.17,,"Fee schedule rate ($10,071.17). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5354.25,13416.00,There are no additional notes associated with this service or procedure.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC,027,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],19981.71,,"Case rate ($19,030.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,839, add-ons for qualifying new technology services are included. If operating cost exceeds $52,710.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,009.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $15,835.66 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,894.05 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,249.59. The transfer capital threshold is the transfer adjustment factor * $1,249.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,19030.20,56363.30,Inpatient DRG
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],49997.29,,,,,,0,other,19152.11,53152.12,There are no additional notes associated with this service or procedure.
PREMATURITY WITHOUT MAJOR PROBLEMS,792,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],19457.66,,"Case rate ($18,531.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,374.70, add-ons for qualifying new technology services are included. If operating cost exceeds $52,245.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,973.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. The base transfer operating payment is the transfer adjustment factor * $15,373.07 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,429.75 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,213.09. The transfer capital threshold is the transfer adjustment factor * $1,213.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,1956.00,19457.66,Inpatient DRG
INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC,198,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7032.95,,"Case rate ($6,795.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,456.95, add-ons for qualifying new technology services are included. If operating cost exceeds $41,327.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,114.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,495.42 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,512.00 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $354.73. The transfer capital threshold is the transfer adjustment factor * $354.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6795.12,23505.07,Inpatient DRG
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC,434,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],6770.05,,"Case rate ($6,770.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,433.64, add-ons for qualifying new technology services are included. If operating cost exceeds $41,304.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,112.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,472.20 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,488.69 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $352.90. The transfer capital threshold is the transfer adjustment factor * $352.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6770.05,14019.86,Inpatient DRG
HC Inject Tendon Origin/Insert|LEFT SIDE,CASE-20551,APC,20551,CPT,0361,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC,099,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],11729.77,,"Case rate ($11,171.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,527.95, add-ons for qualifying new technology services are included. If operating cost exceeds $45,398.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,434.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,551.47 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,583.00 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $674.80. The transfer capital threshold is the transfer adjustment factor * $674.80. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,11171.21,26807.94,Inpatient DRG
HC Pbb Carpal Tunnel Inj Pmc|PBB CHARGE,CASE-20526,APC,20526,CPT,0510,RC,,,PBB,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],297.37,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,287.31,301.68,OPPS APC
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],21854.96,,"Fee schedule rate ($21,854.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10638.94,25261.33,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH CC,427,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],50829.82,,"Case rate ($50,829.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $47,421.51, add-ons for qualifying new technology services are included. If operating cost exceeds $82,292.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $5,335.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $45,309.50 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $45,476.56 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,575.37. The transfer capital threshold is the transfer adjustment factor * $3,575.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,50829.82,142040.39,Inpatient DRG
Osteot W/WO Lngth Shrt/Corrj Metar Xcp 1st Ea|LEFT SIDE,CASE-28308,APC,28308,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],133270.57,,"Fee schedule rate ($133,270.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,33623.33,133270.57,There are no additional notes associated with this service or procedure.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],37768.77,,"Fee schedule rate ($37,768.77). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7453.00,42138.30,There are no additional notes associated with this service or procedure.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],47797.26,,"Case rate ($45,521.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $42,483.01, add-ons for qualifying new technology services are included. If operating cost exceeds $77,354.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,947.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 12.5. The base transfer operating payment is the transfer adjustment factor * $40,389.14 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $40,538.06 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,187.10. The transfer capital threshold is the transfer adjustment factor * $3,187.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,45521.20,142438.06,Inpatient DRG
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],17902.13,,,,,,0,other,8106.18,18245.94,There are no additional notes associated with this service or procedure.
CERVICAL SPINAL FUSION WITH MCC,471,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],36377.52,,"Case rate ($34,645.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $32,365.35, add-ons for qualifying new technology services are included. If operating cost exceeds $67,236.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,151.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $30,308.64 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $30,420.39 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,391.65. The transfer capital threshold is the transfer adjustment factor * $2,391.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,34645.26,111337.93,Inpatient DRG
HC N Block Inj Suprascapular Nerv|RIGHT SIDE,CASE-64418,APC,64418,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],660.72,,"APC Price ($660.72). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,660.72,693.76,OPPS APC
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],25099.93,,"Fee schedule rate ($25,099.93). Adds an outlier to normal pricing equal to the per diem rate ($40,783.87) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10989.72,26280.60,There are no additional notes associated with this service or procedure.
Tonsillectomy Primary/Secondary Age 12/>,CASE-42826,APC,42826,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.35,,"APC Price ($3,103.35). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.35,3258.52,OPPS APC
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,329,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],34230.32,,"Case rate ($33,072.77). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $30,902.51, add-ons for qualifying new technology services are included. If operating cost exceeds $65,773.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,036.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.4. The base transfer operating payment is the transfer adjustment factor * $28,851.18 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $28,957.55 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,276.64. The transfer capital threshold is the transfer adjustment factor * $2,276.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,33072.77,90445.33,Inpatient DRG
Excision Olecranon Bursa|RIGHT SIDE,CASE-24105,APC,24105,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3169.86,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],81524.17,,"Fee schedule rate ($81,524.17). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,8972.00,81524.17,There are no additional notes associated with this service or procedure.
VAGINAL DELIVERY WITH O.R. PROCEDURES EXCEPT STERILIZATION AND/OR D&C,768,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],12088.81,,"Fee schedule rate ($12,088.81). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6426.91,13416.00,There are no additional notes associated with this service or procedure.
UNGROUPABLE,999,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],161307.29,,"Fee schedule rate ($161,307.29). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (41), with a minimum of zero.",,,,0,other,10228.00,161307.29,There are no additional notes associated with this service or procedure.
HC Inj Aa&/Strd Greater Occipital Nerve|LEFT SIDE,CASE-64405,APC,64405,CPT,0450,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],297.37,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,287.31,301.68,OPPS APC
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],10223.39,,"Fee schedule rate ($10,223.39). Adds an outlier to normal pricing equal to the per diem rate ($48,095.58) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,5628.97,12272.58,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITH CC,164,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],47433.53,,"Fee schedule rate ($47,433.53). Adds an outlier to normal pricing equal to the per diem rate ($158,028.38) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,19037.66,77058.83,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],9543.44,,"Case rate ($9,356.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,839.58, add-ons for qualifying new technology services are included. If operating cost exceeds $43,710.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,302.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $6,869.30 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,894.63 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $542.06. The transfer capital threshold is the transfer adjustment factor * $542.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,9356.31,25026.36,Inpatient DRG
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],8057.43,,"Case rate ($8,057.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,631.26, add-ons for qualifying new technology services are included. If operating cost exceeds $42,502.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,207.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,665.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,686.30 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $447.06. The transfer capital threshold is the transfer adjustment factor * $447.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6524.00,17760.46,Inpatient DRG
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],52909.62,,"Fee schedule rate ($52,909.62). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,23344.70,62179.32,There are no additional notes associated with this service or procedure.
SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS,029,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],25048.54,,"Case rate ($25,048.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $23,437.73, add-ons for qualifying new technology services are included. If operating cost exceeds $58,308.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,449.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.7)) / 2. The base transfer operating payment is the transfer adjustment factor * $21,413.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $21,492.79 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,689.76. The transfer capital threshold is the transfer adjustment factor * $1,689.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,13641.00,67130.05,Inpatient DRG
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],48538.56,,"Fee schedule rate ($48,538.56). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,19435.86,50821.76,There are no additional notes associated with this service or procedure.
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],16055.90,,"Fee schedule rate ($16,055.90). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8163.06,18067.42,There are no additional notes associated with this service or procedure.
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITH MCC OR ANTINEOPLASTIC IMPLANT OR EPILEPSY WITH NEUROSTIMULATOR,023,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],136379.44,,"Fee schedule rate ($136,379.44). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,15168.00,136379.44,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],52449.26,,"Fee schedule rate ($52,449.26). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,17693.40,52449.26,There are no additional notes associated with this service or procedure.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITHOUT CC/MCC,816,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6224.90,,"Case rate ($6,224.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,926.50, add-ons for qualifying new technology services are included. If operating cost exceeds $40,797.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,073.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $3,966.92 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,981.55 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $313.03. The transfer capital threshold is the transfer adjustment factor * $313.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6224.90,14733.53,Inpatient DRG
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],9088.95,,"Case rate ($8,656.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,200.75, add-ons for qualifying new technology services are included. If operating cost exceeds $43,071.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,238.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $6,232.17 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,255.80 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $479.02. The transfer capital threshold is the transfer adjustment factor * $479.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8859.23,20090.22,Inpatient DRG
"ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",770,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],8735.30,,"Case rate ($8,735.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,261.87, add-ons for qualifying new technology services are included. If operating cost exceeds $43,132.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,256.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $6,293.72 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,316.92 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $496.64. The transfer capital threshold is the transfer adjustment factor * $496.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8735.30,19730.13,Inpatient DRG
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],42787.31,,"Fee schedule rate ($42,787.31). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,15476.23,42787.31,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],22358.90,,"Fee schedule rate ($22,358.90). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9389.48,22358.90,There are no additional notes associated with this service or procedure.
NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,601,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],12359.72,,"Fee schedule rate ($12,359.72). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6042.05,12359.72,There are no additional notes associated with this service or procedure.
HC Bx Breast 1st Lesion US Img|RIGHT SIDE,CASE-19083,APC,19083,CPT,0361,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1623.23,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1545.93,1623.23,OPPS APC
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],23340.86,,,,,,0,other,9977.99,26949.28,There are no additional notes associated with this service or procedure.
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],10643.26,,"Case rate ($10,136.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,565.33, add-ons for qualifying new technology services are included. If operating cost exceeds $44,436.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,359.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $7,592.38 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,620.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $599.11. The transfer capital threshold is the transfer adjustment factor * $599.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10136.44,24444.75,Inpatient DRG
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],9097.60,,"Case rate ($9,097.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,598.92, add-ons for qualifying new technology services are included. If operating cost exceeds $43,469.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,283.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,629.53 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,653.97 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $523.14. The transfer capital threshold is the transfer adjustment factor * $523.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9097.60,21455.22,Inpatient DRG
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],17488.41,,"Case rate ($16,897.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,854.53, add-ons for qualifying new technology services are included. If operating cost exceeds $50,725.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,853.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $13,858.48 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,909.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,093.57. The transfer capital threshold is the transfer adjustment factor * $1,093.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,16897.01,43444.85,Inpatient DRG
CESAREAN SECTION WITHOUT STERILIZATION WITH CC,787,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],21975.27,,,,,,0,other,9508.01,23722.94,There are no additional notes associated with this service or procedure.
OTHER CEREBROVASCULAR DISORDERS WITH MCC,070,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],37774.46,,"Fee schedule rate ($37,774.46). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,13219.09,37774.46,There are no additional notes associated with this service or procedure.
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7640.94,,"Case rate ($7,277.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,915.28, add-ons for qualifying new technology services are included. If operating cost exceeds $41,786.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,140.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $4,951.55 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,970.33 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $380.59. The transfer capital threshold is the transfer adjustment factor * $380.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7438.45,15961.98,Inpatient DRG
"NEONATE BIRTH WEIGHT > 2499 GRAMS WITH RESPIRATORY DISTRESS SYNDROME OR OTHER MAJOR RESPIRATORY CONDITION,MODERATE",634,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],9427.82,,"Case rate ($9,427.82). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,9427.82,9899.21,There are no additional notes associated with this service or procedure.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,329,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],86631.74,,"Fee schedule rate ($86,631.74). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (38), with a minimum of zero.",,,,0,other,33072.77,90445.33,There are no additional notes associated with this service or procedure.
Insj/Rplcmt Perq Eltrd Ra Pn W/Int Nstim 1st Ra,CASE-64596,APC,64596,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],10429.83,,"APC Price ($10,429.83). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,10429.83,10951.32,OPPS APC
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,085,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],57443.16,,"Fee schedule rate ($57,443.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,9282.00,57443.16,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],31091.14,,"Fee schedule rate ($31,091.14). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13148.66,32553.63,There are no additional notes associated with this service or procedure.
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6606.85,,"Case rate ($6,606.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,281.82, add-ons for qualifying new technology services are included. If operating cost exceeds $41,152.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,100.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,320.93 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,336.86 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $340.96. The transfer capital threshold is the transfer adjustment factor * $340.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,5919.29,13545.65,Inpatient DRG
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",623,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],33712.76,,"Fee schedule rate ($33,712.76). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,14093.37,33712.76,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL HEMORRHAGE WITH CC,378,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],8810.81,,"Case rate ($8,391.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,953.83, add-ons for qualifying new technology services are included. If operating cost exceeds $42,824.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,220.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,986.18 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,008.88 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $460.11. The transfer capital threshold is the transfer adjustment factor * $460.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8586.33,20845.19,Inpatient DRG
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],14699.43,,"Fee schedule rate ($14,699.43). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6683.37,14699.43,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],33321.87,,"Fee schedule rate ($33,321.87). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.9), with a minimum of zero.",,,,0,other,13917.42,34889.29,There are no additional notes associated with this service or procedure.
Nasal/Sinus Ndsc W/Rmvl Tiss From Frontal Sinus|LEFT SIDE,CASE-31276,APC,31276,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6936.25,,"APC Price ($6,605.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6605.95,6936.25,OPPS APC
ENDOCRINE DISORDERS WITH CC,644,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],19420.69,,"Fee schedule rate ($19,420.69). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7066.99,20334.21,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],59610.47,,"Fee schedule rate ($59,610.47). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,16129.04,59610.47,There are no additional notes associated with this service or procedure.
OTHER CEREBROVASCULAR DISORDERS WITH MCC,070,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],37774.46,,"Fee schedule rate ($37,774.46). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,13219.09,37774.46,There are no additional notes associated with this service or procedure.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],42787.31,,"Fee schedule rate ($42,787.31). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,15476.23,42787.31,There are no additional notes associated with this service or procedure.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,056,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],59328.19,,"Fee schedule rate ($59,328.19). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (44), with a minimum of zero.",,,,0,other,7659.00,59328.19,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITH CC,164,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],19037.66,,"Case rate ($19,037.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,845.93, add-ons for qualifying new technology services are included. If operating cost exceeds $52,716.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,010.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $15,842.57 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,900.98 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,250.14. The transfer capital threshold is the transfer adjustment factor * $1,250.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,19037.66,77058.83,Inpatient DRG
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,555,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],10896.27,,"Case rate ($10,896.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,272.18, add-ons for qualifying new technology services are included. If operating cost exceeds $45,143.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,414.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,296.64 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,327.23 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $654.69. The transfer capital threshold is the transfer adjustment factor * $654.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10896.27,42290.95,Inpatient DRG
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC",629,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],44657.18,,"Fee schedule rate ($44,657.18). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,16699.94,44657.18,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],16693.56,,"Case rate ($16,129.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,140.12, add-ons for qualifying new technology services are included. If operating cost exceeds $50,011.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,797.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $13,146.70 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,195.17 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,037.40. The transfer capital threshold is the transfer adjustment factor * $1,037.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,16129.04,59610.47,Inpatient DRG
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,083,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],6965.00,,,,,,0,other,6965.00,28680.85,There are no additional notes associated with this service or procedure.
"Partical Excision Bone Phalanx Toe|RIGHT FOOT, FIFTH DIGIT",CASE-28124,APC,28124,CPT,0360,RC,,,T9,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],25099.93,,"Fee schedule rate ($25,099.93). Adds an outlier to normal pricing equal to the per diem rate ($40,783.87) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10989.72,26280.60,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],23899.13,,"Fee schedule rate ($23,899.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9795.13,23899.13,There are no additional notes associated with this service or procedure.
CHEST PAIN,313,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],14167.44,,,,,,0,other,6820.84,15377.66,There are no additional notes associated with this service or procedure.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,097,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],27724.54,,"Case rate ($26,404.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $24,698.97, add-ons for qualifying new technology services are included. If operating cost exceeds $59,569.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,548.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.7. The base transfer operating payment is the transfer adjustment factor * $22,670.44 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $22,754.03 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,788.92. The transfer capital threshold is the transfer adjustment factor * $1,788.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,26404.32,79915.74,Inpatient DRG
UNGROUPABLE,999,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],161307.29,,"Fee schedule rate ($161,307.29). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (41), with a minimum of zero.",,,,0,other,10228.00,161307.29,There are no additional notes associated with this service or procedure.
"Laminec/Facetect/Foramin,Thoracic",CASE-63046,APC,63046,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],16412.07,,"APC Price ($16,412.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,16412.07,17232.68,OPPS APC
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],16379.98,,"Fee schedule rate ($16,379.98). Adds an outlier to normal pricing equal to the per diem rate ($46,377.87) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7847.50,17755.26,There are no additional notes associated with this service or procedure.
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],16035.06,,"Fee schedule rate ($16,035.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,7396.47,16035.06,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],67794.72,,"Fee schedule rate ($67,794.72). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,10862.00,86437.13,There are no additional notes associated with this service or procedure.
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],14830.15,,"Fee schedule rate ($14,830.15). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,7884.32,17835.23,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],20567.06,,"Fee schedule rate ($20,567.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,9356.31,25026.36,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],62273.77,,,,,,0,other,23377.19,96365.69,There are no additional notes associated with this service or procedure.
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],14492.93,,"Fee schedule rate ($14,492.93). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6503.90,14492.93,There are no additional notes associated with this service or procedure.
Brnchsc Incl Fluor Gdnce Dx W/Cell Washg Spx,CASE-31622,APC,31622,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1749.33,,"APC Price ($1,666.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1666.03,1749.33,OPPS APC
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,091,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],13838.06,,"Case rate ($13,838.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,008.86, add-ons for qualifying new technology services are included. If operating cost exceeds $47,879.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,629.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $11,023.26 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,063.91 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $869.84. The transfer capital threshold is the transfer adjustment factor * $869.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,13838.06,40030.81,Inpatient DRG
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH CC",457,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],117335.92,,,,,,0,other,42327.47,160549.49,There are no additional notes associated with this service or procedure.
Hallux Rigidus W/Cheilectomy 1st Mp Jt W/O Implt,CASE-28289,APC,28289,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
CESAREAN SECTION WITH STERILIZATION WITH MCC,783,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],23722.94,,"Fee schedule rate ($23,722.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12612.10,23722.94,There are no additional notes associated with this service or procedure.
HEART FAILURE AND SHOCK WITH CC,292,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],15550.06,,"Fee schedule rate ($15,550.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5502.00,16705.77,There are no additional notes associated with this service or procedure.
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],12882.53,,,,,,0,other,4341.01,12882.53,There are no additional notes associated with this service or procedure.
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,095,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],19411.47,,"Case rate ($19,411.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $18,193.69, add-ons for qualifying new technology services are included. If operating cost exceeds $53,064.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,037.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.6. The base transfer operating payment is the transfer adjustment factor * $16,189.05 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $16,248.74 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,277.48. The transfer capital threshold is the transfer adjustment factor * $1,277.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,19411.47,50750.92,Inpatient DRG
Prq Skel Fixj Dstl Phlngl Fx Fngr/Thmb Ea,CASE-26756,APC,26756,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
HC Biopsy/Exc Lymph Node Needle,CASE-38505,APC,38505,CPT,0361,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1600.04,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1545.93,1623.23,OPPS APC
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],15891.15,,,,,,0,other,7414.07,18217.52,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,447,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],49552.87,,"Case rate ($47,193.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $44,038.45, add-ons for qualifying new technology services are included. If operating cost exceeds $78,909.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $5,069.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $41,938.87 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $42,093.51 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,309.39. The transfer capital threshold is the transfer adjustment factor * $3,309.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,47193.21,156646.82,Inpatient DRG
MINOR BLADDER PROCEDURES WITHOUT CC/MCC,664,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],31876.87,,"Fee schedule rate ($31,876.87). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9034.63,31876.87,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],14586.15,,"Case rate ($13,891.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,058.63, add-ons for qualifying new technology services are included. If operating cost exceeds $47,929.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,633.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,072.85 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,113.68 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $873.76. The transfer capital threshold is the transfer adjustment factor * $873.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13891.57,34712.20,Inpatient DRG
HC Remove Tun Cath Vad W/Port,CASE-36590,APC,36590,CPT,0361,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1547.12,,"APC Price ($1,473.45). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1473.45,1547.12,OPPS APC
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],94787.57,,"Fee schedule rate ($94,787.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,23526.87,94787.57,There are no additional notes associated with this service or procedure.
Removal Intrauterine Device Iud,CASE-58301,APC,58301,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],285.23,,"APC Price ($285.23). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,285.23,295.22,OPPS APC
Open Tx Metacarpal Fracture Single Ea Bone|RIGHT SIDE,CASE-26615,APC,26615,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],15333.48,,"Case rate ($14,603.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,720.75, add-ons for qualifying new technology services are included. If operating cost exceeds $48,591.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,685.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $11,732.54 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,775.80 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $925.81. The transfer capital threshold is the transfer adjustment factor * $925.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,14603.31,45017.13,Inpatient DRG
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],18918.49,,"Fee schedule rate ($18,918.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9282.47,21320.03,There are no additional notes associated with this service or procedure.
Optx Dstl Radl X-Artic Fx/Epiphysl Sep|LEFT SIDE,CASE-25607,APC,25607,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
Injection Aa&/Strd Genicular Nrv Branches W/Img|BILATERAL PROCEDURE,CASE-64454,APC,64454,CPT,0360,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],683.85,,"APC Price ($660.72). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,660.72,693.76,OPPS APC
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],23078.81,,"Fee schedule rate ($23,078.81). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10311.17,24308.97,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC,833,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],5721.39,,"Fee schedule rate ($5,721.39). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,3041.73,10289.10,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,066,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],6908.75,,"Case rate ($6,579.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,256.61, add-ons for qualifying new technology services are included. If operating cost exceeds $41,127.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,098.96, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $4,295.82 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,311.66 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $338.98. The transfer capital threshold is the transfer adjustment factor * $338.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6579.76,20083.61,Inpatient DRG
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],49163.22,,"Case rate ($28,093.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $26,270.18, add-ons for qualifying new technology services are included. If operating cost exceeds $61,141.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,672.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $24,235.87 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $24,325.23 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,912.45. The transfer capital threshold is the transfer adjustment factor * $1,912.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 175%.",,,,0,other,10078.00,81454.07,All Other Inpatient
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,086,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],8442.00,,"Per diem ($8,442). If length of stay < 2.9, first 1 days paid at a per diem of $16,884 instead. Capped at $24,481.64.",,,,0,other,8442.00,30728.81,Estimated amount calculated based on 2 day length of stay.
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],7875.94,,"Case rate ($7,875.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,462.42, add-ons for qualifying new technology services are included. If operating cost exceeds $42,333.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,193.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $5,497.20 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,517.46 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $433.78. The transfer capital threshold is the transfer adjustment factor * $433.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7875.94,17233.12,Inpatient DRG
VENTRICULAR SHUNT PROCEDURES WITH MCC,031,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],62406.76,,"Fee schedule rate ($62,406.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,32287.20,88162.80,There are no additional notes associated with this service or procedure.
Laparoscopy Surg Rpr Initial Inguinal Hernia|LEFT SIDE,CASE-49650,APC,49650,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5941.70,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5658.76,5941.70,OPPS APC
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,544,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],7055.15,,"Case rate ($7,055.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,698.86, add-ons for qualifying new technology services are included. If operating cost exceeds $41,569.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,133.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $4,736.45 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,753.92 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $373.75. The transfer capital threshold is the transfer adjustment factor * $373.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7055.15,23207.64,Inpatient DRG
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,093,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],7704.43,,"Case rate ($7,337.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,961.57, add-ons for qualifying new technology services are included. If operating cost exceeds $41,832.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,154.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,998.19 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,016.62 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $394.41. The transfer capital threshold is the transfer adjustment factor * $394.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,19011.32,Inpatient DRG
Cysto/Pyeloscopy Bx&/Fulguration Pelivc Lesion|LEFT SIDE,CASE-52354,APC,52354,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5018.77,,"APC Price ($5,018.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5018.77,5269.71,OPPS APC
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],11440.26,,"Case rate ($11,053.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,418.34, add-ons for qualifying new technology services are included. If operating cost exceeds $45,289.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,426.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $8,442.26 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,473.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $666.18. The transfer capital threshold is the transfer adjustment factor * $666.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,11053.39,36776.05,Inpatient DRG
Ostectomy Complete Other Metatarsal Head 2/3/4|RIGHT SIDE,CASE-28112,APC,28112,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,098,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],38799.38,,"Fee schedule rate ($38,799.38). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,6965.00,45156.75,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],14370.36,,"Case rate ($14,370.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,504.04, add-ons for qualifying new technology services are included. If operating cost exceeds $48,375.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,668.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $11,516.62 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,559.08 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $908.78. The transfer capital threshold is the transfer adjustment factor * $908.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,14370.36,38378.80,Inpatient DRG
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],43949.31,,"Fee schedule rate ($43,949.31). Adds an outlier to normal pricing equal to the per diem rate ($149,567.78) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,17782.11,46523.26,There are no additional notes associated with this service or procedure.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],8409.81,,"Case rate ($8,009.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,586.52, add-ons for qualifying new technology services are included. If operating cost exceeds $42,457.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,203.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $5,620.85 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,641.57 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $443.54. The transfer capital threshold is the transfer adjustment factor * $443.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8009.34,19877.10,Inpatient DRG
FRACTURES OF FEMUR WITH MCC,533,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],6852.00,,"Per diem ($6,852). If length of stay < 4.3, first 1 days paid at a per diem of $13,704 instead. Capped at $29,461.79.",,,,0,other,6852.00,49490.05,Estimated amount calculated based on 2 day length of stay.
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC,519,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],50780.20,,"Fee schedule rate ($50,780.20). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,15490.44,50780.20,There are no additional notes associated with this service or procedure.
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],7034.85,,"Case rate ($7,034.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,679.97, add-ons for qualifying new technology services are included. If operating cost exceeds $41,550.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,132.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $4,717.62 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,735.02 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $372.27. The transfer capital threshold is the transfer adjustment factor * $372.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,21089.59,Inpatient DRG
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],15309.46,,"Fee schedule rate ($15,309.46). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6965.00,15340.19,There are no additional notes associated with this service or procedure.
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],9746.59,,"Case rate ($9,282.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,770.90, add-ons for qualifying new technology services are included. If operating cost exceeds $43,641.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,296.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,800.88 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,825.96 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $536.66. The transfer capital threshold is the transfer adjustment factor * $536.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9282.47,21320.03,Inpatient DRG
COMPLICATIONS OF TREATMENT WITH CC,920,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],20731.52,,"Fee schedule rate ($20,731.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8732.59,20731.52,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],28821.04,,"Fee schedule rate ($28,821.04). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,10347.06,28821.04,There are no additional notes associated with this service or procedure.
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH MCC",510,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],22847.99,,"Case rate ($22,399.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,973.84, add-ons for qualifying new technology services are included. If operating cost exceeds $55,844.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,256.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.3. The base transfer operating payment is the transfer adjustment factor * $18,958.99 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $19,028.89 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,496.05. The transfer capital threshold is the transfer adjustment factor * $1,496.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,10710.00,89863.76,Inpatient DRG
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],21195.68,,"Fee schedule rate ($21,195.68). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,6965.00,21195.68,There are no additional notes associated with this service or procedure.
DIABETES WITH CC,638,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],16842.29,,"Fee schedule rate ($16,842.29). Adds an outlier to normal pricing equal to the per diem rate ($39,561.63) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,8014.07,17634.53,There are no additional notes associated with this service or procedure.
Cystourethroscopy With Biopsy,CASE-52204,APC,52204,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],2054.48,,"APC Price ($1,956.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1956.65,2054.48,OPPS APC
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC,964,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],12323.82,,"Case rate ($12,323.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,600.20, add-ons for qualifying new technology services are included. If operating cost exceeds $46,471.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,519.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $9,619.78 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,655.25 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $759.10. The transfer capital threshold is the transfer adjustment factor * $759.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12323.82,34154.06,Inpatient DRG
Intraop Sentinel Lymph Node ID W/Dye Injection,CASE-38900,APC,38900,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6526.12,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6215.36,6526.12,OPPS APC
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,097,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],26970.16,,"Case rate ($25,685.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $24,074.91, add-ons for qualifying new technology services are included. If operating cost exceeds $58,945.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,454.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.7. The base transfer operating payment is the transfer adjustment factor * $22,046.38 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $22,129.96 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,694.54. The transfer capital threshold is the transfer adjustment factor * $1,694.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,26404.32,79915.74,Inpatient DRG
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,083,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],6965.00,,,,,,0,other,6965.00,28680.85,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],15088.88,,"Case rate ($14,370.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,504.04, add-ons for qualifying new technology services are included. If operating cost exceeds $48,375.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,668.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $11,516.62 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,559.08 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $908.78. The transfer capital threshold is the transfer adjustment factor * $908.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,14370.36,38378.80,Inpatient DRG
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC,497,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],37761.19,,"Fee schedule rate ($37,761.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10127.65,37761.19,There are no additional notes associated with this service or procedure.
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],23870.71,,"Fee schedule rate ($23,870.71). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10626.74,25225.91,There are no additional notes associated with this service or procedure.
Vulvectomy Simple Partial|BILATERAL PROCEDURE,CASE-56620,APC,56620,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3030.03,,"APC Price ($3,030.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3030.03,3181.53,OPPS APC
CHOLECYSTECTOMY WITH C.D.E. WITH MCC,411,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],24840.95,,"Case rate ($23,658.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $22,184.70, add-ons for qualifying new technology services are included. If operating cost exceeds $57,055.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,309.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $20,163.30 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $20,239.75 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,549.80. The transfer capital threshold is the transfer adjustment factor * $1,549.80. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,24315.13,88615.28,Inpatient DRG
CESAREAN SECTION WITHOUT STERILIZATION WITH MCC,786,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],13426.74,,"Case rate ($12,787.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,051.65, add-ons for qualifying new technology services are included. If operating cost exceeds $46,922.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,533.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $10,068.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,106.70 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $773.89. The transfer capital threshold is the transfer adjustment factor * $773.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12612.10,23722.94,Inpatient DRG
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],85305.59,,"Fee schedule rate ($85,305.59). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,21719.40,85305.59,There are no additional notes associated with this service or procedure.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",062,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],44304.80,,"Fee schedule rate ($44,304.80). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,13844.84,44304.80,There are no additional notes associated with this service or procedure.
Myomectomy 5/> Myomas &/>250 Gm Abdomina,CASE-58146,APC,58146,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],206.06,,"APC Price ($199.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,206.06,209.05,OPPS APC
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],17686.09,,"Fee schedule rate ($17,686.09). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8318.14,19763.43,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],8319.50,,"Case rate ($7,923.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,506.51, add-ons for qualifying new technology services are included. If operating cost exceeds $42,377.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,197.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $5,541.13 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,561.56 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $437.25. The transfer capital threshold is the transfer adjustment factor * $437.25. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,1188.00,17370.86,Inpatient DRG
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],29058.99,,,,,,0,other,6167.00,29058.99,There are no additional notes associated with this service or procedure.
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],29243.52,,"Fee schedule rate ($29,243.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,14343.25,36024.65,There are no additional notes associated with this service or procedure.
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],26204.74,,"Fee schedule rate ($26,204.74). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10120.20,26204.74,There are no additional notes associated with this service or procedure.
Bx/Exc Lymph Node Open Deep Cervical Node|LEFT SIDE,CASE-38510,APC,38510,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5541.10,,"APC Price ($5,541.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5541.10,5818.16,OPPS APC
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],34245.00,,"Fee schedule rate ($34,245.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,12725.42,34245.00,There are no additional notes associated with this service or procedure.
Breast Augmentation With Implant|RIGHT SIDE,CASE-19325,APC,19325,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7918.25,,"APC Price ($7,650.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,7918.25,8033.01,OPPS APC
SIGNS AND SYMPTOMS WITH MCC,947,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],30414.32,,"Fee schedule rate ($30,414.32). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,10541.41,30414.32,There are no additional notes associated with this service or procedure.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",062,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],14121.74,,"Case rate ($13,844.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,015.16, add-ons for qualifying new technology services are included. If operating cost exceeds $47,886.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,630.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $11,029.54 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,070.21 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $870.34. The transfer capital threshold is the transfer adjustment factor * $870.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,13844.84,44304.80,Inpatient DRG
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC",758,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],16323.02,,"Fee schedule rate ($16,323.02). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8574.80,19263.78,There are no additional notes associated with this service or procedure.
PERIPHERAL VASCULAR DISORDERS WITH CC,300,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],20331.78,,"Fee schedule rate ($20,331.78). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,9174.14,21005.20,There are no additional notes associated with this service or procedure.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC,192,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],12753.78,,"Fee schedule rate ($12,753.78). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6292.63,12753.78,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],17651.07,,"Fee schedule rate ($17,651.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,6564.18,17651.07,There are no additional notes associated with this service or procedure.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",062,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],33023.06,,"Fee schedule rate ($33,023.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,13844.84,44304.80,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],10137.96,,"Case rate ($9,795.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,247.81, add-ons for qualifying new technology services are included. If operating cost exceeds $44,118.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,334.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $7,276.03 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,302.86 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $574.15. The transfer capital threshold is the transfer adjustment factor * $574.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,9795.13,23899.13,Inpatient DRG
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH CC,026,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],63202.45,,"Fee schedule rate ($63,202.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,23000.66,63202.45,There are no additional notes associated with this service or procedure.
Arthrs Kne Surg W/Meniscectomy Med/Lat W/Shvg|LEFT SIDE,CASE-29881,APC,29881,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,167,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],43522.37,,"Fee schedule rate ($43,522.37). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,14157.71,43522.37,There are no additional notes associated with this service or procedure.
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],6510.51,,"Fee schedule rate ($6,510.51). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6010.23,12246.05,There are no additional notes associated with this service or procedure.
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],10353.84,,"Case rate ($10,003.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,441.84, add-ons for qualifying new technology services are included. If operating cost exceeds $44,312.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,349.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $7,469.36 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,496.90 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $589.41. The transfer capital threshold is the transfer adjustment factor * $589.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,10003.71,23415.63,Inpatient DRG
NEONATE WITH OTHER SIGNIFICANT PROBLEMS,794,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],12178.64,,"Case rate ($11,939.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,242.99, add-ons for qualifying new technology services are included. If operating cost exceeds $46,114.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,490.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $9,263.89 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,298.04 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $731.01. The transfer capital threshold is the transfer adjustment factor * $731.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,1798.85,12536.83,Inpatient DRG
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],14472.36,,"Case rate ($13,783.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,957.83, add-ons for qualifying new technology services are included. If operating cost exceeds $47,828.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,625.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $10,972.42 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,012.88 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $865.83. The transfer capital threshold is the transfer adjustment factor * $865.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13783.20,41580.51,Inpatient DRG
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],58394.20,,"Fee schedule rate ($58,394.20). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,9370.00,65732.99,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],6965.00,,,,,,0,other,6164.03,14071.02,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],2070.00,,,,,,0,other,1188.00,34338.33,Estimated amount calculated based on 6 day length of stay.
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH CC,427,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],134742.59,,"Fee schedule rate ($134,742.59). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,50829.82,142040.39,There are no additional notes associated with this service or procedure.
Rcnstj Midface Lefort I 1 Piece W/Bone Grafts,CASE-21145,APC,21145,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5818.16,,"APC Price ($5,541.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5818.16,5818.16,OPPS APC
Thyroidectomy Total/Complete|BILATERAL PROCEDURE,CASE-60240,APC,60240,CPT,0360,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],10298.02,,"APC Price ($9,949.78). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,9949.78,10447.27,OPPS APC
OSTEOMYELITIS WITHOUT CC/MCC,541,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],11429.52,,"Fee schedule rate ($11,429.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5103.00,15493.67,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7774.84,,"Case rate ($7,404.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,034.14, add-ons for qualifying new technology services are included. If operating cost exceeds $41,905.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,149.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,069.97 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,089.19 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $389.69. The transfer capital threshold is the transfer adjustment factor * $389.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7569.84,21892.85,Inpatient DRG
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],13460.55,,"Case rate ($12,819.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,081.67, add-ons for qualifying new technology services are included. If operating cost exceeds $46,952.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,536.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $10,098.43 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,136.72 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $776.19. The transfer capital threshold is the transfer adjustment factor * $776.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13148.66,32553.63,Inpatient DRG
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC,939,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],27047.75,,"Case rate ($26,517.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $24,804.19, add-ons for qualifying new technology services are included. If operating cost exceeds $59,675.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,557.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $22,775.26 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $22,859.24 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,797.19. The transfer capital threshold is the transfer adjustment factor * $1,797.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,26517.40,97674.79,Inpatient DRG
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],10864.41,,"Case rate ($10,347.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,761.25, add-ons for qualifying new technology services are included. If operating cost exceeds $44,632.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,374.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $7,787.59 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,816.30 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $614.52. The transfer capital threshold is the transfer adjustment factor * $614.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10347.06,28821.04,Inpatient DRG
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],43888.01,,"Fee schedule rate ($43,888.01). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11717.72,43888.01,There are no additional notes associated with this service or procedure.
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],14455.04,,"Fee schedule rate ($14,455.04). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5280.00,17136.70,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],107110.70,,"Fee schedule rate ($107,110.70). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (21), with a minimum of zero.",,,,0,other,40542.37,128358.13,There are no additional notes associated with this service or procedure.
Endoscopic Papilla Cannulation Bile/Pancreatic,CASE-43273,APC,43273,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3789.26,,"APC Price ($3,608.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3608.81,3789.26,OPPS APC
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],67790.93,,"Fee schedule rate ($67,790.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,21597.50,67790.93,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],28983.97,,"Fee schedule rate ($28,983.97). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8956.76,28983.97,There are no additional notes associated with this service or procedure.
NON-MALIGNANT BREAST DISORDERS WITH CC/MCC,600,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],15046.13,,"Fee schedule rate ($15,046.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7999.14,20495.56,There are no additional notes associated with this service or procedure.
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],10298.57,,"Fee schedule rate ($10,298.57). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8643.20,19462.52,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],23526.87,,"Case rate ($23,526.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $22,022.15, add-ons for qualifying new technology services are included. If operating cost exceeds $56,893.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,338.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.7. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.7)) / 2. The base transfer operating payment is the transfer adjustment factor * $20,003.44 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $20,077.20 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,578.47. The transfer capital threshold is the transfer adjustment factor * $1,578.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,23526.87,94787.57,Inpatient DRG
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],11454.97,,"Case rate ($11,454.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,791.92, add-ons for qualifying new technology services are included. If operating cost exceeds $45,662.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,455.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $8,814.47 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,846.97 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $695.55. The transfer capital threshold is the transfer adjustment factor * $695.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,11454.97,28394.78,Inpatient DRG
HC Inj Tendon Sheath/Ligament,CASE-20550,APC,20550,CPT,0510,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],297.37,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,287.31,301.68,OPPS APC
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC",156,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],13598.77,,,,,,0,other,6625.12,13598.77,There are no additional notes associated with this service or procedure.
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],21854.96,,"Fee schedule rate ($21,854.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10638.94,25261.33,There are no additional notes associated with this service or procedure.
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],21854.96,,"Fee schedule rate ($21,854.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10638.94,25261.33,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6788.31,,"Case rate ($6,558.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,237.08, add-ons for qualifying new technology services are included. If operating cost exceeds $41,108.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,097.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $4,276.36 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,292.13 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $337.45. The transfer capital threshold is the transfer adjustment factor * $337.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6558.75,14871.83,Inpatient DRG
"VAGINAL DELIVERY,MAJOR",560,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],6092.62,,"Case rate ($6,092.62). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,6092.62,6397.25,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],19126.88,,"Fee schedule rate ($19,126.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,19126.88,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],9040.72,,"Case rate ($9,040.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,546, add-ons for qualifying new technology services are included. If operating cost exceeds $43,417.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,278.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,576.80 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,601.05 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $518.97. The transfer capital threshold is the transfer adjustment factor * $518.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9040.72,26966.33,Inpatient DRG
NERVOUS SYSTEM NEOPLASMS WITH MCC,054,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],12899.48,,"Case rate ($12,285.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,564.29, add-ons for qualifying new technology services are included. If operating cost exceeds $46,435.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,516.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $9,584.00 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,619.34 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $756.27. The transfer capital threshold is the transfer adjustment factor * $756.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,30044.81,Inpatient DRG
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],24387.68,,"Fee schedule rate ($24,387.68). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10733.06,45157.33,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITH MCC,385,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],12913.61,,"Case rate ($12,660.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,913.31, add-ons for qualifying new technology services are included. If operating cost exceeds $46,784.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,543.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $9,931.73 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,968.35 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $783.71. The transfer capital threshold is the transfer adjustment factor * $783.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,11480.01,31134.92,Inpatient DRG
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],6965.00,,,,,,0,other,6148.93,15887.21,There are no additional notes associated with this service or procedure.
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],11281.44,,"Fee schedule rate ($11,281.44). Adds an outlier to normal pricing equal to the per diem rate ($62,521.14) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,6010.23,12246.05,There are no additional notes associated with this service or procedure.
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],11209.51,,"Case rate ($10,989.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,359.11, add-ons for qualifying new technology services are included. If operating cost exceeds $45,230.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,421.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $8,383.26 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,414.17 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $661.52. The transfer capital threshold is the transfer adjustment factor * $661.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,10989.72,26280.60,Inpatient DRG
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC,817,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],43874.75,,"Fee schedule rate ($43,874.75). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,17396.11,44895.04,There are no additional notes associated with this service or procedure.
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],10733.06,,"Case rate ($10,733.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,120.35, add-ons for qualifying new technology services are included. If operating cost exceeds $44,991.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,402.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $8,145.37 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,175.40 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $642.75. The transfer capital threshold is the transfer adjustment factor * $642.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10733.06,45157.33,Inpatient DRG
Mastectomy Partial W/Axillary Lymphadenectomy|LEFT SIDE,CASE-19302,APC,19302,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6215.36,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6215.36,6432.89,OPPS APC
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,091,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],40030.81,,"Fee schedule rate ($40,030.81). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,13838.06,40030.81,There are no additional notes associated with this service or procedure.
PREMATURITY WITHOUT MAJOR PROBLEMS,792,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],2074.00,,,,,,0,other,1956.00,19457.66,Estimated amount calculated based on 3 day length of stay.
DIABETES WITH MCC,637,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],10909.44,,"Case rate ($10,909.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $10,253.93, add-ons for qualifying new technology services are included. If operating cost exceeds $48,898.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $3,423.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $8,854.74 + an uncompensated DSH payment of $1,359.91. The transfer operating threshold is the transfer adjustment factor * $8,894.02 + an uncompensated DSH payment of $1,359.91. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $694.79. The transfer capital threshold is the transfer adjustment factor * $694.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9959.03,28655.62,Inpatient DRG
"DORSAL AND LUMBAR FUSION PROCEDURE EXCEPT FOR CURVATURE OF BACK,MODERATE",304,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],7627.61,,"Case rate for a one day stay ($7,627.61). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,7627.61,8008.99,There are no additional notes associated with this service or procedure.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],36094.03,,"Fee schedule rate ($36,094.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11194.25,36094.03,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],62273.77,,,,,,0,other,23377.19,96365.69,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],15318.94,,"Fee schedule rate ($15,318.94). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6214.05,15318.94,There are no additional notes associated with this service or procedure.
PERIPHERAL VASCULAR DISORDERS WITH CC,300,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],9357.62,,"Case rate ($9,174.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,670.11, add-ons for qualifying new technology services are included. If operating cost exceeds $43,541.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,288.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,700.45 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,725.16 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $528.73. The transfer capital threshold is the transfer adjustment factor * $528.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,9174.14,21005.20,Inpatient DRG
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],45017.13,,"Fee schedule rate ($45,017.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,14603.31,45017.13,There are no additional notes associated with this service or procedure.
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],10311.17,,"Case rate ($10,311.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,727.87, add-ons for qualifying new technology services are included. If operating cost exceeds $44,598.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,371.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $7,754.32 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,782.91 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $611.89. The transfer capital threshold is the transfer adjustment factor * $611.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10311.17,24308.97,Inpatient DRG
"NEONATE BIRTH WEIGHT 1500-1999 GRAMS WITH RESPIRATORY DISTRESS SYNDROME OR OTHER MAJOR RESPIRATORY CONDITION,MODERATE",612,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],11512.05,,"Case rate ($10,963.86). Base payment rate plus any adjustments related to outliers.",,,,0,other,10963.86,11512.05,There are no additional notes associated with this service or procedure.
BRONCHITIS AND ASTHMA WITH CC/MCC,202,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],18251.76,,"Fee schedule rate ($18,251.76). Adds an outlier to normal pricing equal to the per diem rate ($45,948.49) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,7606.34,19110.30,There are no additional notes associated with this service or procedure.
VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC,033,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],13668.45,,"Case rate ($13,206.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,421.07, add-ons for qualifying new technology services are included. If operating cost exceeds $47,292.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,583.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $10,437.64 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,476.13 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $823.63. The transfer capital threshold is the transfer adjustment factor * $823.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,13206.23,42156.44,Inpatient DRG
Laparoscopy Surg Partial Nephrectomy|LEFT SIDE,CASE-50543,APC,50543,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],10298.02,,"APC Price ($9,949.78). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,9949.78,10447.27,OPPS APC
HEADACHES WITHOUT MCC,103,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],20883.08,,"Fee schedule rate ($20,883.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,20883.08,There are no additional notes associated with this service or procedure.
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC,805,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],9253.36,,"Case rate ($9,253.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,743.82, add-ons for qualifying new technology services are included. If operating cost exceeds $43,614.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,294.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $6,773.89 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,798.87 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $534.53. The transfer capital threshold is the transfer adjustment factor * $534.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9253.36,21235.42,Inpatient DRG
Cysto Bladder W/Ureteral Catheterization|UNUSUAL NON-OVERLAPPING SERVICE,CASE-52005,APC,52005,CPT,0360,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3299.47,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3299.47,3464.44,OPPS APC
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],11522.52,,"Case rate ($10,973.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,361.17, add-ons for qualifying new technology services are included. If operating cost exceeds $45,232.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,404.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,384.43 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,416.22 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $644.45. The transfer capital threshold is the transfer adjustment factor * $644.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,11247.07,27028.33,Inpatient DRG
SALIVARY GLAND PROCEDURES,139,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],10519.45,,"Case rate ($10,313.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,729.75, add-ons for qualifying new technology services are included. If operating cost exceeds $44,600.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,372.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $7,756.21 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,784.80 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $612.04. The transfer capital threshold is the transfer adjustment factor * $612.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,10313.19,30690.92,Inpatient DRG
CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC,788,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],20142.33,,"Fee schedule rate ($20,142.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8438.02,20142.33,There are no additional notes associated with this service or procedure.
PSYCHOSES,885,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],11632.25,,"Case rate ($11,404.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,744.67, add-ons for qualifying new technology services are included. If operating cost exceeds $45,615.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,451.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.5. The base transfer operating payment is the transfer adjustment factor * $8,767.39 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,799.72 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $691.83. The transfer capital threshold is the transfer adjustment factor * $691.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,2070.00,27484.83,Inpatient DRG
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],12696.11,,"Case rate ($12,091.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,384.11, add-ons for qualifying new technology services are included. If operating cost exceeds $46,255.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,502.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $9,404.49 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,439.16 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $742.11. The transfer capital threshold is the transfer adjustment factor * $742.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,29482.05,Inpatient DRG
"NEONATE TRANSFERRED < 5 DAYS OLD BORN HERE,MODERATE",581,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],1684.21,,"The inlier payment is calculated as the lesser of the standard DRG payment $1,604.01 and the transfer payment, which is a per diem of $1,253.13. If cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,1604.01,1684.21,Estimated amount calculated based on 1 day length of stay.
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",623,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],14375.24,,"Case rate ($14,093.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,246.37, add-ons for qualifying new technology services are included. If operating cost exceeds $48,117.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,648.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $11,259.90 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,301.42 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $888.52. The transfer capital threshold is the transfer adjustment factor * $888.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,14093.37,33712.76,Inpatient DRG
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],18366.40,,"Fee schedule rate ($18,366.40). Adds an outlier to normal pricing equal to the per diem rate ($38,964.32) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.5), with a minimum of zero.",,,,0,other,8563.30,31533.97,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,083,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],11397.40,,"Case rate ($11,397.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,738.37, add-ons for qualifying new technology services are included. If operating cost exceeds $45,609.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,451.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $8,761.12 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,793.42 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $691.34. The transfer capital threshold is the transfer adjustment factor * $691.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,28680.85,Inpatient DRG
Esophageal Motility Study W/Interp&Rpt,CASE-91010,APC,91010,CPT,0750,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],349.28,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,349.28,366.75,OPPS APC
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 2nd Level|RIGHT SIDE,CASE-64494,APC,64494,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],856.86,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,827.89,869.28,OPPS APC
Thoracoscopy With Biopsyies of Pleura,CASE-32609,APC,32609,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5658.76,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5658.76,5941.70,OPPS APC
SPINAL PROCEDURES WITHOUT CC/MCC,030,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],44714.01,,"Fee schedule rate ($44,714.01). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,16810.99,44714.01,There are no additional notes associated with this service or procedure.
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7604.36,,"Case rate ($7,242.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,882.80, add-ons for qualifying new technology services are included. If operating cost exceeds $41,753.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,138.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $4,919.20 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,937.85 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $378.10. The transfer capital threshold is the transfer adjustment factor * $378.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7402.56,16438.59,Inpatient DRG
Laryngoscopy Exc Tum&/Stripping Cords/Epiglott,CASE-31540,APC,31540,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3489.82,,"APC Price ($3,489.82). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3489.82,3664.31,OPPS APC
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,450,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],100159.17,,"Fee schedule rate ($100,159.17). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15), with a minimum of zero.",,,,0,other,38037.38,146009.19,There are no additional notes associated with this service or procedure.
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH CC",457,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],112064.54,,"Fee schedule rate ($112,064.54). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.9), with a minimum of zero.",,,,0,other,42327.47,160549.49,There are no additional notes associated with this service or procedure.
DIABETES WITH CC,638,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],15195.79,,"Fee schedule rate ($15,195.79). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8014.07,17634.53,There are no additional notes associated with this service or procedure.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],40108.48,,"Fee schedule rate ($40,108.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,5569.00,40108.48,There are no additional notes associated with this service or procedure.
Vulvectomy Simple Partial|BILATERAL PROCEDURE,CASE-56620,APC,56620,CPT,0360,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3181.53,,"APC Price ($3,030.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3030.03,3181.53,OPPS APC
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],12246.05,,"Fee schedule rate ($12,246.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6010.23,12246.05,There are no additional notes associated with this service or procedure.
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",004,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],10249.47,,,,,,0,other,10249.47,272554.00,Estimated amount calculated based on 6 day length of stay.
Insj Biomchn Dev Intervertebral Dsc Spc W/Arthrd,CASE-22853,APC,22853,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12618.18,,"APC Price ($12,017.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,12017.31,12618.18,OPPS APC
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],39424.57,,"Fee schedule rate ($39,424.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12195.15,39424.57,There are no additional notes associated with this service or procedure.
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|RIGHT HAND, THUMB",CASE-26160,APC,26160,CPT,0360,RC,,,F5,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1623.23,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1545.93,1623.23,OPPS APC
Cysto W/Ureteroscopy W/Lithotripsy|LEFT SIDE,CASE-52353,APC,52353,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5018.77,,"APC Price ($5,018.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5018.77,5269.71,OPPS APC
"POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT PROCEDURE,MINOR",561,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],1416.46,,"Case rate for a one day stay ($1,349.01). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,1349.01,1416.46,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],37665.71,,,,,,0,other,14908.05,49717.39,There are no additional notes associated with this service or procedure.
Arthrd Ant Interbody Decompress Cervical Belw C2,CASE-22551,APC,22551,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],12437.92,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,12017.31,12618.18,OPPS APC
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],5995.74,,"Case rate ($5,710.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,447.70, add-ons for qualifying new technology services are included. If operating cost exceeds $40,318.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,035.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $3,489.88 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,502.75 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $275.39. The transfer capital threshold is the transfer adjustment factor * $275.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,3079.00,10940.41,Inpatient DRG
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],20373.57,,,,,,0,other,8956.76,28983.97,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],7547.49,,"Case rate ($7,547.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,156.87, add-ons for qualifying new technology services are included. If operating cost exceeds $42,027.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,169.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $5,192.77 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,211.92 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $409.76. The transfer capital threshold is the transfer adjustment factor * $409.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,19126.88,Inpatient DRG
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],6965.00,,,,,,0,other,1188.00,12138.74,There are no additional notes associated with this service or procedure.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],59385.88,,"Fee schedule rate ($59,385.88). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,23344.70,62179.32,There are no additional notes associated with this service or procedure.
COAGULATION DISORDERS,813,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],12519.88,,"Case rate ($12,274.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,554.21, add-ons for qualifying new technology services are included. If operating cost exceeds $46,425.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,515.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $9,573.96 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,609.26 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $755.48. The transfer capital threshold is the transfer adjustment factor * $755.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,12274.39,30013.33,Inpatient DRG
Rmvl/Revj Sling Stress Incontinence,CASE-57287,APC,57287,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3136.08,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3030.03,3136.08,OPPS APC
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],10533.95,,"Case rate ($10,533.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,935.13, add-ons for qualifying new technology services are included. If operating cost exceeds $44,806.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,388.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $7,960.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,990.18 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $628.19. The transfer capital threshold is the transfer adjustment factor * $628.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10533.95,24956.34,Inpatient DRG
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],24675.88,,"Fee schedule rate ($24,675.88). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10834.64,25830.00,There are no additional notes associated with this service or procedure.
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC",514,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],22699.91,,"Fee schedule rate ($22,699.91). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8868.04,22699.91,There are no additional notes associated with this service or procedure.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC,027,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],49643.10,,,,,,0,other,19030.20,56363.30,There are no additional notes associated with this service or procedure.
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],16428.39,,"Case rate ($16,428.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,418.58, add-ons for qualifying new technology services are included. If operating cost exceeds $50,289.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,819.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $13,424.13 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,473.63 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,059.30. The transfer capital threshold is the transfer adjustment factor * $1,059.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,16428.39,42083.20,Inpatient DRG
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],9858.95,,"Case rate ($9,389.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,870.44, add-ons for qualifying new technology services are included. If operating cost exceeds $43,741.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,304.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,900.05 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,925.50 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $544.48. The transfer capital threshold is the transfer adjustment factor * $544.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9389.48,22358.90,Inpatient DRG
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,450,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],38826.08,,"Case rate ($36,977.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $34,600.10, add-ons for qualifying new technology services are included. If operating cost exceeds $69,471.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,260.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $32,531.80 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $32,655.15 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,500.47. The transfer capital threshold is the transfer adjustment factor * $2,500.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,38037.38,146009.19,Inpatient DRG
MAJOR THUMB OR JOINT PROCEDURES,506,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],25355.52,,"Fee schedule rate ($25,355.52). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.5), with a minimum of zero.",,,,0,other,11081.83,26548.21,There are no additional notes associated with this service or procedure.
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC",458,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],132827.25,,"Fee schedule rate ($132,827.25). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,30202.09,132827.25,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],21892.85,,"Fee schedule rate ($21,892.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7569.84,21892.85,There are no additional notes associated with this service or procedure.
MINOR BLADDER PROCEDURES WITHOUT CC/MCC,664,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],31876.87,,"Fee schedule rate ($31,876.87). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9034.63,31876.87,There are no additional notes associated with this service or procedure.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],20553.44,,"Fee schedule rate ($20,553.44). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8874.81,20553.44,There are no additional notes associated with this service or procedure.
Induced Abortion Dilation & Evacuation,CASE-59841,APC,59841,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3136.08,,"APC Price ($3,030.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3030.03,3181.53,OPPS APC
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],8811.83,,"Case rate ($8,811.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,333.06, add-ons for qualifying new technology services are included. If operating cost exceeds $43,204.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,262.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,364.65 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,388.11 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $502.23. The transfer capital threshold is the transfer adjustment factor * $502.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,20401.88,Inpatient DRG
"Inj Dx/Ther Agnt Paravert Facet Joint, Cerv/Thorac, 2nd Level|LEFT SIDE|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA",CASE-64491,APC,64491,CPT,0360,RC,,,LT|74,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],856.86,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,827.89,869.28,OPPS APC
CHEST PAIN,313,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],7161.88,,"Case rate ($6,820.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,480.89, add-ons for qualifying new technology services are included. If operating cost exceeds $41,351.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,116.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $4,519.27 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,535.94 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $356.62. The transfer capital threshold is the transfer adjustment factor * $356.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6820.84,15377.66,Inpatient DRG
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],29260.35,,"Fee schedule rate ($29,260.35). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (37), with a minimum of zero.",,,,0,other,13907.80,52794.06,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],59891.41,,"Fee schedule rate ($59,891.41). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15), with a minimum of zero.",,,,0,other,23526.87,94787.57,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],34409.98,,"Fee schedule rate ($34,409.98). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,14344.60,36028.59,There are no additional notes associated with this service or procedure.
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],13792.01,,"Case rate ($13,792.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,966.02, add-ons for qualifying new technology services are included. If operating cost exceeds $47,837.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,626.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $10,980.58 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,021.07 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $866.48. The transfer capital threshold is the transfer adjustment factor * $866.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,34422.94,Inpatient DRG
Prq Impltj Neurostimulator Eltrd Peripheral Nrv|LEFT SIDE,CASE-64555,APC,64555,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6263.54,,"APC Price ($5,965.28). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5965.28,6263.54,OPPS APC
HC Inj Trigger Pt 1-2 Musc Grps|PBB CHARGE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-20552,APC,20552,CPT,0510,RC,,,PBB|XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],297.37,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,287.31,301.68,OPPS APC
Neuroplasty &/Transpos Median Nrv Carpal Tunne|LEFT SIDE,CASE-64721,APC,64721,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1919.19,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1827.80,1919.19,OPPS APC
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],20297.68,,"Fee schedule rate ($20,297.68). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6965.00,21404.64,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],23526.87,,"Case rate ($23,526.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $22,022.15, add-ons for qualifying new technology services are included. If operating cost exceeds $56,893.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,338.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.7. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.7)) / 2. The base transfer operating payment is the transfer adjustment factor * $20,003.44 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $20,077.20 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,578.47. The transfer capital threshold is the transfer adjustment factor * $1,578.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,23526.87,94787.57,Inpatient DRG
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],12858.35,,"Case rate ($12,606.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,862.91, add-ons for qualifying new technology services are included. If operating cost exceeds $46,733.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,539.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $9,881.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,917.95 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $779.75. The transfer capital threshold is the transfer adjustment factor * $779.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,12606.23,36868.88,Inpatient DRG
MAJOR THUMB OR JOINT PROCEDURES,506,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],19761.54,,"Fee schedule rate ($19,761.54). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11081.83,26548.21,There are no additional notes associated with this service or procedure.
Removal Cerclage Suture Under Anesthesia,CASE-59871,APC,59871,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3181.53,,"APC Price ($3,030.03). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3030.03,3181.53,OPPS APC
Rpr Nonunion Scaphoid Carpal Bne W/WO Rdl Stylec|RIGHT SIDE,CASE-25440,APC,25440,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7029.71,OPPS APC
"Prq Skel Fixj Phlngl Shft Fx Prox/Middle Px/F/T|RIGHT HAND, THUMB",CASE-26727,APC,26727,CPT,0360,RC,,,F5,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,555,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],42290.95,,"Fee schedule rate ($42,290.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10896.27,42290.95,There are no additional notes associated with this service or procedure.
"NEONATE TRANSFERRED < 5 DAYS OLD BORN HERE,EXTREME",581,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],4772.57,,"The inlier payment is calculated as the lesser of the standard DRG payment $4,772.57 and the transfer payment, which is a per diem of $3,615.58. If cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,4772.57,5011.20,Estimated amount calculated based on 1 day length of stay.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,085,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],57443.16,,"Fee schedule rate ($57,443.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,9282.00,57443.16,There are no additional notes associated with this service or procedure.
Surgical Arthroscopy Shoulder Repair Slap Lesion|RIGHT SIDE,CASE-29807,APC,29807,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],94787.57,,"Fee schedule rate ($94,787.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,23526.87,94787.57,There are no additional notes associated with this service or procedure.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC,434,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],13280.45,,"Fee schedule rate ($13,280.45). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6770.05,14019.86,There are no additional notes associated with this service or procedure.
NEONATE WITH OTHER SIGNIFICANT PROBLEMS,794,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],3383.58,,"Fee schedule rate ($3,383.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,1798.85,12536.83,There are no additional notes associated with this service or procedure.
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC,807,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],12670.24,,"Fee schedule rate ($12,670.24). Adds an outlier to normal pricing equal to the per diem rate ($29,637.88) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,5354.25,13266.23,There are no additional notes associated with this service or procedure.
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],26391.01,,"Fee schedule rate ($26,391.01). Adds an outlier to normal pricing equal to the per diem rate ($77,296.48) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,11454.97,28394.78,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],22357.18,,"Case rate ($12,775.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,020.41, add-ons for qualifying new technology services are included. If operating cost exceeds $46,891.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,552.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $10,038.44 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,075.45 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $792.13. The transfer capital threshold is the transfer adjustment factor * $792.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,12775.53,31469.43,All Other Inpatient
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],15589.58,,"Case rate ($15,283.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,353.89, add-ons for qualifying new technology services are included. If operating cost exceeds $49,224.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,735.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.2. The base transfer operating payment is the transfer adjustment factor * $12,363.36 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,408.94 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $975.59. The transfer capital threshold is the transfer adjustment factor * $975.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,15283.90,38757.79,Inpatient DRG
PREMATURITY WITH MAJOR PROBLEMS,791,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],30021.44,,"Case rate ($29,432.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $27,516.30, add-ons for qualifying new technology services are included. If operating cost exceeds $62,387.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,770.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 13.3. The base transfer operating payment is the transfer adjustment factor * $25,477.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $25,571.35 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,010.42. The transfer capital threshold is the transfer adjustment factor * $2,010.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,3048.21,30904.42,Inpatient DRG
"CARDIAC ARREST, UNEXPLAINED WITH MCC",296,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],21913.94,,"Case rate ($12,522.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,784.78, add-ons for qualifying new technology services are included. If operating cost exceeds $46,655.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,533.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $9,803.69 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,839.84 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $773.61. The transfer capital threshold is the transfer adjustment factor * $773.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,12522.25,36459.67,All Other Inpatient
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],20148.94,,"Fee schedule rate ($20,148.94). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,14747.55,37899.49,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH CC,427,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],50829.82,,"Case rate ($50,829.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $47,421.51, add-ons for qualifying new technology services are included. If operating cost exceeds $82,292.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $5,335.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $45,309.50 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $45,476.56 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,575.37. The transfer capital threshold is the transfer adjustment factor * $3,575.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,50829.82,142040.39,Inpatient DRG
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],20401.88,,"Fee schedule rate ($20,401.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,20401.88,There are no additional notes associated with this service or procedure.
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],10057.85,,"Fee schedule rate ($10,057.85). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9282.47,21320.03,There are no additional notes associated with this service or procedure.
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,069,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],6965.00,,,,,,0,other,6965.00,20333.68,There are no additional notes associated with this service or procedure.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,025,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],91631.33,,"Fee schedule rate ($91,631.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,13351.00,91631.33,There are no additional notes associated with this service or procedure.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],9040.64,,"Case rate ($8,610.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,157.86, add-ons for qualifying new technology services are included. If operating cost exceeds $43,028.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,235.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,189.44 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,212.91 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $475.73. The transfer capital threshold is the transfer adjustment factor * $475.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,20401.88,Inpatient DRG
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],21089.59,,"Fee schedule rate ($21,089.59). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,6965.00,21089.59,There are no additional notes associated with this service or procedure.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],22229.55,,"Fee schedule rate ($22,229.55). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,5569.00,40108.48,There are no additional notes associated with this service or procedure.
Repair Complex Trunk 2.6-7.5 Cm|UNUSUAL NON-OVERLAPPING SERVICE,CASE-13101,APC,13101,CPT,0360,RC,,,XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],2854.83,,"APC Price ($2,718.88). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2718.88,2854.83,OPPS APC
DIABETES WITHOUT CC/MCC,639,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],12223.35,,,,,,0,other,6151.76,12223.35,There are no additional notes associated with this service or procedure.
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],59081.91,,"Fee schedule rate ($59,081.91). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,8480.00,59081.91,There are no additional notes associated with this service or procedure.
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],26280.60,,,,,,0,other,10989.72,26280.60,There are no additional notes associated with this service or procedure.
Hysteroscopy Diagnostic Separate Procedure,CASE-58555,APC,58555,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3136.08,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3030.03,3181.53,OPPS APC
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,082,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],17423.21,,"Case rate ($17,423.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,344.04, add-ons for qualifying new technology services are included. If operating cost exceeds $51,215.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,892.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $14,346.19 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,399.08 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,132.06. The transfer capital threshold is the transfer adjustment factor * $1,132.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,17423.21,56223.11,Inpatient DRG
Open Implantation Nea Sacral Nerve,CASE-64581,APC,64581,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],19066.92,,"APC Price ($18,158.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,18158.97,19066.92,OPPS APC
CERVICAL SPINAL FUSION WITHOUT CC/MCC,473,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],18891.59,,"Case rate ($17,991.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,903.11, add-ons for qualifying new technology services are included. If operating cost exceeds $51,774.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,905.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.6. The base transfer operating payment is the transfer adjustment factor * $14,901.66 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,958.16 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,145.38. The transfer capital threshold is the transfer adjustment factor * $1,145.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,18477.61,62077.11,Inpatient DRG
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC,817,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],17744.03,,"Case rate ($17,396.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,318.84, add-ons for qualifying new technology services are included. If operating cost exceeds $51,189.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,890.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $14,321.08 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,373.88 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,130.07. The transfer capital threshold is the transfer adjustment factor * $1,130.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,17396.11,44895.04,Inpatient DRG
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],30245.71,,"Fee schedule rate ($30,245.71). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9151.11,30245.71,There are no additional notes associated with this service or procedure.
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],8057.43,,"Case rate ($8,057.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,631.26, add-ons for qualifying new technology services are included. If operating cost exceeds $42,502.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,207.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,665.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,686.30 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $447.06. The transfer capital threshold is the transfer adjustment factor * $447.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6524.00,17760.46,Inpatient DRG
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],18585.05,,"Fee schedule rate ($18,585.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8859.23,20090.22,There are no additional notes associated with this service or procedure.
"NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY",789,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],3054.00,,,,,,0,other,3054.00,14857.05,Estimated amount calculated based on 1 day length of stay.
Open Tx Clavicular Fracture Internal Fixation|LEFT SIDE,CASE-23515,APC,23515,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7131.59,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6791.99,7131.59,OPPS APC
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,447,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],156646.82,,"Fee schedule rate ($156,646.82). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,47193.21,156646.82,There are no additional notes associated with this service or procedure.
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,068,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],8188.67,,"Case rate ($7,798.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,390.60, add-ons for qualifying new technology services are included. If operating cost exceeds $42,261.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,188.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $5,425.64 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,445.65 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $428.14. The transfer capital threshold is the transfer adjustment factor * $428.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,23184.90,Inpatient DRG
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],29917.96,,"Fee schedule rate ($29,917.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,12527.66,29917.96,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITH MCC,385,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],21593.52,,"Fee schedule rate ($21,593.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11480.01,31134.92,There are no additional notes associated with this service or procedure.
"MAJOR BILIARY TRACT PROCEDURES,MODERATE",261,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],23498.40,,"Case rate ($22,379.43). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,22379.43,23498.40,There are no additional notes associated with this service or procedure.
Egd Flexible Foreign Body Removal,CASE-43247,APC,43247,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1885.95,,"APC Price ($1,796.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1796.14,1885.95,OPPS APC
Redo Excis Lumbar Disk|RIGHT SIDE,CASE-63042,APC,63042,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],24528.10,,"Fee schedule rate ($24,528.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10989.72,26280.60,There are no additional notes associated with this service or procedure.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],41493.06,,"Fee schedule rate ($41,493.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,16897.01,43444.85,There are no additional notes associated with this service or procedure.
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",759,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],12471.03,,"Fee schedule rate ($12,471.03). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.9), with a minimum of zero.",,,,0,other,6190.22,13057.66,There are no additional notes associated with this service or procedure.
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],24701.52,,"Fee schedule rate ($24,701.52). Adds an outlier to normal pricing equal to the per diem rate ($51,462.28) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,10846.16,25863.45,There are no additional notes associated with this service or procedure.
Dstr Nrolytc Agnt Parverteb Fct Sngl Crvcl/Thora|BILATERAL PROCEDURE,CASE-64633,APC,64633,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1827.80,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1827.80,1891.77,OPPS APC
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],86252.84,,"Fee schedule rate ($86,252.84). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,27944.96,86252.84,There are no additional notes associated with this service or procedure.
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC,964,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],34154.06,,"Fee schedule rate ($34,154.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12323.82,34154.06,There are no additional notes associated with this service or procedure.
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],13794.06,,"Fee schedule rate ($13,794.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,6915.64,14442.92,There are no additional notes associated with this service or procedure.
HC Joint Injection/Aspir Large WO US|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-20610,APC,20610,CPT,0510,RC,,,RT|XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],301.68,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,287.31,301.68,OPPS APC
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],29166.74,,"Fee schedule rate ($29,166.74). Adds an outlier to normal pricing equal to the per diem rate ($36,758.78) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,12455.21,37149.27,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],19763.43,,"Fee schedule rate ($19,763.43). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,8318.14,19763.43,There are no additional notes associated with this service or procedure.
"DISORDERS OF GALLBLADDER AND BILIARY TRACT,MODERATE",284,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],9840.51,,"The inlier payment is calculated as the lesser of the standard DRG payment $9,371.91 and the transfer payment, which is a per diem of $2,617.85. If cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9371.91,9840.51,Estimated amount calculated based on 1 day length of stay.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],39153.65,,"Fee schedule rate ($39,153.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,7605.00,39153.65,There are no additional notes associated with this service or procedure.
"Tx Open Tendon Flexor Toe 1 Tendon Spx|RIGHT FOOT, SECOND DIGIT",CASE-28232,APC,28232,CPT,0360,RC,,,T6,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1580.37,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1505.12,1580.37,OPPS APC
HC Inj Aa&/Strd Other Peripheral Nerve/Branch|LEFT SIDE,CASE-64450,APC,64450,CPT,0450,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],693.76,,"APC Price ($660.72). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,660.72,693.76,OPPS APC
CESAREAN SECTION WITH STERILIZATION WITH MCC,783,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],23722.94,,"Fee schedule rate ($23,722.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12612.10,23722.94,There are no additional notes associated with this service or procedure.
Arthrd Ant Interdy Cervcl Belw C2 Ea Addl Ntrspc,CASE-22552,APC,22552,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],12437.92,,"APC Price ($12,017.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,12017.31,12618.18,OPPS APC
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],18905.23,,"Fee schedule rate ($18,905.23). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6963.00,18954.85,There are no additional notes associated with this service or procedure.
SPINAL PROCEDURES WITHOUT CC/MCC,030,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],43194.95,,,,,,0,other,16810.99,44714.01,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6214.05,,"Case rate ($6,214.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,916.41, add-ons for qualifying new technology services are included. If operating cost exceeds $40,787.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,072.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $3,956.88 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,971.47 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $312.24. The transfer capital threshold is the transfer adjustment factor * $312.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6214.05,15318.94,Inpatient DRG
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],21455.22,,"Fee schedule rate ($21,455.22). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,9097.60,21455.22,There are no additional notes associated with this service or procedure.
TRAUMATIC INJURY WITH MCC,913,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],42838.46,,"Fee schedule rate ($42,838.46). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13014.58,42838.46,There are no additional notes associated with this service or procedure.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],39337.51,,"Fee schedule rate ($39,337.51). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,16120.25,41187.90,There are no additional notes associated with this service or procedure.
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC",011,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],39658.10,,"Case rate ($38,880.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $36,305.31, add-ons for qualifying new technology services are included. If operating cost exceeds $71,176.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,461.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 11.4. The base transfer operating payment is the transfer adjustment factor * $34,234.14 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $34,360.36 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,701.41. The transfer capital threshold is the transfer adjustment factor * $2,701.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,38880.49,150008.48,Inpatient DRG
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],15088.88,,"Case rate ($14,370.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,504.04, add-ons for qualifying new technology services are included. If operating cost exceeds $48,375.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,668.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $11,516.62 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,559.08 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $908.78. The transfer capital threshold is the transfer adjustment factor * $908.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,14370.36,38378.80,Inpatient DRG
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,394,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],8447.19,,"Case rate ($8,281.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,839.77, add-ons for qualifying new technology services are included. If operating cost exceeds $42,710.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,223.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,873.17 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,894.83 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $463.45. The transfer capital threshold is the transfer adjustment factor * $463.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,8281.56,20909.61,Inpatient DRG
Cysto W/Ureteroscopy W/Rmvl/Manj Stones|LEFT SIDE,CASE-52352,APC,52352,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3299.47,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3299.47,3464.44,OPPS APC
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],14603.31,,"Case rate ($14,603.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,720.75, add-ons for qualifying new technology services are included. If operating cost exceeds $48,591.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,685.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $11,732.54 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,775.80 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $925.81. The transfer capital threshold is the transfer adjustment factor * $925.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,14603.31,45017.13,Inpatient DRG
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC,805,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],20902.03,,"Fee schedule rate ($20,902.03). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9253.36,21235.42,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITH STERILIZATION WITH CC,784,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],19922.46,,"Fee schedule rate ($19,922.46). Adds an outlier to normal pricing equal to the per diem rate ($39,437.39) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,9124.01,23722.94,There are no additional notes associated with this service or procedure.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],37768.77,,"Fee schedule rate ($37,768.77). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7453.00,42138.30,There are no additional notes associated with this service or procedure.
Vulvectomy Simple Partial|BILATERAL PROCEDURE,CASE-56620,APC,56620,CPT,0360,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3181.53,,"APC Price ($3,030.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3030.03,3181.53,OPPS APC
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],29243.52,,"Fee schedule rate ($29,243.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,14343.25,36024.65,There are no additional notes associated with this service or procedure.
"Partical Excision Bone Phalanx Toe|RIGHT FOOT, FIFTH DIGIT",CASE-28124,APC,28124,CPT,0360,RC,,,T9,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,083,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],15247.93,,"Fee schedule rate ($15,247.93). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,28680.85,There are no additional notes associated with this service or procedure.
PSYCHOSES,885,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],11974.38,,"Case rate ($11,404.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,744.67, add-ons for qualifying new technology services are included. If operating cost exceeds $45,615.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,451.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.5. The base transfer operating payment is the transfer adjustment factor * $8,767.39 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,799.72 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $691.83. The transfer capital threshold is the transfer adjustment factor * $691.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,2070.00,27484.83,Inpatient DRG
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH CC",457,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],42327.47,,"Case rate ($42,327.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $39,511.96, add-ons for qualifying new technology services are included. If operating cost exceeds $74,382.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,713.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $37,429.01 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $37,567.02 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,953.52. The transfer capital threshold is the transfer adjustment factor * $2,953.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,42327.47,160549.49,Inpatient DRG
O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC,621,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],28347.36,,"Fee schedule rate ($28,347.36). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12159.94,36669.96,There are no additional notes associated with this service or procedure.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],19319.20,,"Fee schedule rate ($19,319.20). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8906.63,28434.57,There are no additional notes associated with this service or procedure.
HC Joint Injection/Aspir Large WO US|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-20610,APC,20610,CPT,0510,RC,,,LT|XU,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
Laparoscopy Surg W/Bx Single/Multiple,CASE-49321,APC,49321,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5856.81,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5658.76,5941.70,OPPS APC
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],22557.82,,"Fee schedule rate ($22,557.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6801.88,22557.82,There are no additional notes associated with this service or procedure.
"Correction Hammertoe|RIGHT FOOT, FIFTH DIGIT",CASE-28285,APC,28285,CPT,0360,RC,,,T9,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
"ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",770,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],9172.07,,"Case rate ($8,735.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,261.87, add-ons for qualifying new technology services are included. If operating cost exceeds $43,132.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,256.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $6,293.72 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,316.92 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $496.64. The transfer capital threshold is the transfer adjustment factor * $496.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8735.30,19730.13,Inpatient DRG
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,306,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],31007.02,,,,,,0,other,12616.37,31007.02,There are no additional notes associated with this service or procedure.
Arthrp Intercarpal/Carp/Mtcrpl Jt Suspension|LEFT SIDE,CASE-25448,APC,25448,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,093,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],19011.32,,"Fee schedule rate ($19,011.32). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,19011.32,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],28423.20,,"Fee schedule rate ($28,423.20). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11059.47,28423.20,There are no additional notes associated with this service or procedure.
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,451,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],94077.13,,"Fee schedule rate ($94,077.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,23821.44,94077.13,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,555,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],11114.20,,"Case rate ($10,896.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,272.18, add-ons for qualifying new technology services are included. If operating cost exceeds $45,143.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,414.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,296.64 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,327.23 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $654.69. The transfer capital threshold is the transfer adjustment factor * $654.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,10896.27,42290.95,Inpatient DRG
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],25026.36,,"Fee schedule rate ($25,026.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9356.31,25026.36,There are no additional notes associated with this service or procedure.
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],54180.83,,"Fee schedule rate ($54,180.83). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,15491.11,54180.83,There are no additional notes associated with this service or procedure.
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],53275.26,,"Fee schedule rate ($53,275.26). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,15940.79,53275.26,There are no additional notes associated with this service or procedure.
Cysto W/Ureteroscopy W/Rmvl/Manj Stones|RIGHT SIDE,CASE-52352,APC,52352,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3414.95,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3299.47,3464.44,OPPS APC
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],24161.76,,"Case rate ($23,344.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $21,852.68, add-ons for qualifying new technology services are included. If operating cost exceeds $56,723.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,325.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $19,834.60 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $19,907.73 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,565.15. The transfer capital threshold is the transfer adjustment factor * $1,565.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,23344.70,62179.32,Inpatient DRG
CERVICAL SPINAL FUSION WITH CC,472,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],55366.06,,"Fee schedule rate ($55,366.06). Adds an outlier to normal pricing equal to the per diem rate ($66,990.29) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,21896.13,70198.84,There are no additional notes associated with this service or procedure.
SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS,029,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],26300.97,,"Case rate ($25,048.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $23,437.73, add-ons for qualifying new technology services are included. If operating cost exceeds $58,308.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,449.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.7)) / 2. The base transfer operating payment is the transfer adjustment factor * $21,413.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $21,492.79 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,689.76. The transfer capital threshold is the transfer adjustment factor * $1,689.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13641.00,67130.05,Inpatient DRG
HEART FAILURE AND SHOCK WITH CC,292,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],16705.77,,,,,,0,other,5502.00,16705.77,There are no additional notes associated with this service or procedure.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],67790.93,,"Fee schedule rate ($67,790.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,21597.50,67790.93,There are no additional notes associated with this service or procedure.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC,192,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],6965.00,,,,,,0,other,6292.63,12753.78,There are no additional notes associated with this service or procedure.
Neuroplasty &/Transpos Median Nrv Carpal Tunne|BILATERAL PROCEDURE,CASE-64721,APC,64721,CPT,0360,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1919.19,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1827.80,1919.19,OPPS APC
Insj Multi-Component Inflatable Penile Prosth,CASE-54405,APC,54405,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],20370.16,,"APC Price ($19,400.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,19400.15,20370.16,OPPS APC
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITHOUT CC/MCC,816,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],14733.53,,"Fee schedule rate ($14,733.53). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6224.90,14733.53,There are no additional notes associated with this service or procedure.
Chemodenervation Internal Anal Sphincter,CASE-46505,APC,46505,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],2598.08,,"APC Price ($2,598.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2598.08,2727.99,OPPS APC
ENDOCRINE DISORDERS WITH CC,644,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],8480.10,,"Case rate ($8,076.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $7,615.48, add-ons for qualifying new technology services are included. If operating cost exceeds $46,260.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $3,217.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $6,227.71 + an uncompensated DSH payment of $1,359.91. The transfer operating threshold is the transfer adjustment factor * $6,255.58 + an uncompensated DSH payment of $1,359.91. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $488.69. The transfer capital threshold is the transfer adjustment factor * $488.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7066.99,20334.21,Inpatient DRG
COAGULATION DISORDERS,813,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],29046.49,,"Fee schedule rate ($29,046.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12274.39,30013.33,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,373,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],13670.03,,"Fee schedule rate ($13,670.03). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6870.94,14313.05,There are no additional notes associated with this service or procedure.
SPINAL PROCEDURES WITH MCC,028,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],67053.00,,"Fee schedule rate ($67,053). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,42633.57,120982.83,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],16066.07,,"Case rate ($16,066.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,081.53, add-ons for qualifying new technology services are included. If operating cost exceeds $49,952.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,792.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $13,088.32 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,136.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,032.80. The transfer capital threshold is the transfer adjustment factor * $1,032.80. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,41030.48,Inpatient DRG
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,073,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],30149.61,,"Fee schedule rate ($30,149.61). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12809.38,43475.01,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],41402.42,,"Fee schedule rate ($41,402.42). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,15456.59,41402.42,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,447,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],125567.31,,"Fee schedule rate ($125,567.31). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15.7), with a minimum of zero.",,,,0,other,47193.21,156646.82,There are no additional notes associated with this service or procedure.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],13920.03,,"Case rate ($13,647.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,831.20, add-ons for qualifying new technology services are included. If operating cost exceeds $47,702.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,615.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $10,846.26 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,886.25 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $855.88. The transfer capital threshold is the transfer adjustment factor * $855.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,7921.00,45706.73,Inpatient DRG
"Tx Open Tendon Flexor Toe 1 Tendon Spx|RIGHT FOOT, SECOND DIGIT",CASE-28232,APC,28232,CPT,0360,RC,,,T6,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1505.12,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1505.12,1580.37,OPPS APC
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],7772.69,,"Case rate ($7,402.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,022.05, add-ons for qualifying new technology services are included. If operating cost exceeds $41,893.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,159.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,058.45 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,077.10 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $399.16. The transfer capital threshold is the transfer adjustment factor * $399.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7402.56,16438.59,Inpatient DRG
NON-MALIGNANT BREAST DISORDERS WITH CC/MCC,600,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],15747.80,,"Case rate ($8,998.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,506.94, add-ons for qualifying new technology services are included. If operating cost exceeds $43,377.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,275.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $6,537.88 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,561.99 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $515.90. The transfer capital threshold is the transfer adjustment factor * $515.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,7999.14,20495.56,All Other Inpatient
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7437.35,,"Case rate ($7,083.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,734.53, add-ons for qualifying new technology services are included. If operating cost exceeds $41,605.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,126.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,771.49 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,789.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $366.75. The transfer capital threshold is the transfer adjustment factor * $366.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7238.69,16804.22,Inpatient DRG
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],22311.17,,"Case rate ($21,248.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $19,902.85, add-ons for qualifying new technology services are included. If operating cost exceeds $54,773.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,171.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.3. The base transfer operating payment is the transfer adjustment factor * $17,891.94 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $17,957.90 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,411.85. The transfer capital threshold is the transfer adjustment factor * $1,411.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,21248.73,56089.29,Inpatient DRG
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],14581.08,,"Case rate ($14,295.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,434.11, add-ons for qualifying new technology services are included. If operating cost exceeds $48,305.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,663.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $11,446.95 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,489.15 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $903.28. The transfer capital threshold is the transfer adjustment factor * $903.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,14295.18,42768.36,Inpatient DRG
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],6965.00,,,,,,0,other,5883.03,17111.12,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],24669.57,,"Fee schedule rate ($24,669.57). Adds an outlier to normal pricing equal to the per diem rate ($34,856.52) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.7), with a minimum of zero.",,,,0,other,10834.64,25830.00,There are no additional notes associated with this service or procedure.
Prep Site F/S/N/H/F/G/M/D Gt 1st 100 Sq Cm/1pct,CASE-15004,APC,15004,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],380.51,,"APC Price ($380.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,380.51,399.53,OPPS APC
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,086,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],30728.81,,"Fee schedule rate ($30,728.81). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8442.00,30728.81,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITH MCC,385,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],21593.52,,"Fee schedule rate ($21,593.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11480.01,31134.92,There are no additional notes associated with this service or procedure.
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],12558.65,,"Fee schedule rate ($12,558.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5065.00,12558.65,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],47751.13,,"Fee schedule rate ($47,751.13). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.7), with a minimum of zero.",,,,0,other,19152.11,53152.12,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],24413.25,,,,,,0,other,10347.06,28821.04,There are no additional notes associated with this service or procedure.
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],13842.68,,"Case rate ($13,571.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,760.65, add-ons for qualifying new technology services are included. If operating cost exceeds $47,631.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,610.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $10,775.96 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,815.69 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $850.33. The transfer capital threshold is the transfer adjustment factor * $850.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,13571.25,33781.47,Inpatient DRG
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,082,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],44973.75,,,,,,0,other,17423.21,56223.11,There are no additional notes associated with this service or procedure.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC",156,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],13598.77,,,,,,0,other,6625.12,13598.77,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,086,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],30728.81,,"Fee schedule rate ($30,728.81). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8442.00,30728.81,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],21195.68,,"Fee schedule rate ($21,195.68). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,6965.00,21195.68,There are no additional notes associated with this service or procedure.
HC Blood Occult Peroxidase Actv Qual Feces 1-3 Spec,CASE-82272,APC,82272,CPT,0301,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],4.23,,,,,,0,other,4.23,4.44,There are no additional notes associated with this service or procedure.
"NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY",789,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],14149.57,,"Case rate ($14,149.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,298.65, add-ons for qualifying new technology services are included. If operating cost exceeds $48,169.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,652.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $11,312.00 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,353.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $892.63. The transfer capital threshold is the transfer adjustment factor * $892.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,3054.00,14857.05,Inpatient DRG
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,068,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],23184.90,,"Fee schedule rate ($23,184.90). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,23184.90,There are no additional notes associated with this service or procedure.
RESPIRATORY NEOPLASMS WITHOUT CC/MCC,182,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],23037.13,,"Fee schedule rate ($23,037.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6965.00,23037.13,There are no additional notes associated with this service or procedure.
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],20981.60,,"Fee schedule rate ($20,981.60). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,10003.71,23415.63,There are no additional notes associated with this service or procedure.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,477,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],62359.39,,"Fee schedule rate ($62,359.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,25339.74,67976.16,There are no additional notes associated with this service or procedure.
INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC,198,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],13027.35,,"Fee schedule rate ($13,027.35). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6795.12,23505.07,There are no additional notes associated with this service or procedure.
Esophagogastroduodenoscopy US Scope W/Adj Strxrs,CASE-43237,APC,43237,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1796.14,,"APC Price ($1,796.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1796.14,1885.95,OPPS APC
HC Repair Tun or Non Cath W/Port,CASE-36576,APC,36576,CPT,0361,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1547.12,,"APC Price ($1,473.45). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1473.45,1547.12,OPPS APC
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,025,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],32735.52,,"Case rate ($32,735.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $30,588.77, add-ons for qualifying new technology services are included. If operating cost exceeds $65,459.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,011.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.4. The base transfer operating payment is the transfer adjustment factor * $28,538.59 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $28,643.82 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,251.98. The transfer capital threshold is the transfer adjustment factor * $2,251.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,13351.00,91631.33,Inpatient DRG
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],6965.00,,,,,,0,other,5883.03,17111.12,There are no additional notes associated with this service or procedure.
Revj/Rmvl Perph Neurostimulator Electrode Array,CASE-64585,APC,64585,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],18794.54,,"APC Price ($18,158.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,18158.97,19066.92,OPPS APC
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],20109.72,,"Case rate ($19,152.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,952.40, add-ons for qualifying new technology services are included. If operating cost exceeds $52,823.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,018.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $15,948.65 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $16,007.45 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,258.51. The transfer capital threshold is the transfer adjustment factor * $1,258.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,19152.11,53152.12,Inpatient DRG
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",063,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],19787.25,,"Fee schedule rate ($19,787.25). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,35701.87,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],35973.56,,"Fee schedule rate ($35,973.56). Adds an outlier to normal pricing equal to the per diem rate ($68,707.98) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,14908.05,49717.39,There are no additional notes associated with this service or procedure.
MINOR BLADDER PROCEDURES WITHOUT CC/MCC,664,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],9215.32,,"Case rate ($9,034.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,540.33, add-ons for qualifying new technology services are included. If operating cost exceeds $43,411.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,278.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $6,571.15 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,595.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $518.53. The transfer capital threshold is the transfer adjustment factor * $518.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,9034.63,31876.87,Inpatient DRG
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC,939,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],97674.79,,"Fee schedule rate ($97,674.79). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,26517.40,97674.79,There are no additional notes associated with this service or procedure.
POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES,769,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],31756.41,,"Fee schedule rate ($31,756.41). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.7), with a minimum of zero.",,,,0,other,13388.39,33250.19,There are no additional notes associated with this service or procedure.
Colsc Flexible W/Transendoscopic Balloon Dilat,CASE-45386,APC,45386,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1120.09,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1120.09,1176.09,OPPS APC
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],26301.36,,"Fee schedule rate ($26,301.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11247.07,27028.33,There are no additional notes associated with this service or procedure.
Peri-Implant Capsulectomy Breast Complete|RIGHT SIDE,CASE-19371,APC,19371,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6432.89,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6215.36,6432.89,OPPS APC
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,761,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],11225.73,,,,,,0,other,5808.41,11946.72,There are no additional notes associated with this service or procedure.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],93728.21,,"Fee schedule rate ($93,728.21). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,35719.96,105091.76,There are no additional notes associated with this service or procedure.
HC Inj Aa&/Strd Greater Occipital Nerve|LEFT SIDE,CASE-64405,APC,64405,CPT,0450,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
HC Remove Lung Catheter,CASE-32552,APC,32552,CPT,0361,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],891.41,,"APC Price ($848.96). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,848.96,891.41,OPPS APC
CESAREAN SECTION WITH STERILIZATION WITHOUT CC/MCC,785,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],20142.33,,"Fee schedule rate ($20,142.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8431.24,20142.33,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],8319.50,,"Case rate ($7,923.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,506.51, add-ons for qualifying new technology services are included. If operating cost exceeds $42,377.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,197.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $5,541.13 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,561.56 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $437.25. The transfer capital threshold is the transfer adjustment factor * $437.25. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,1188.00,17370.86,Inpatient DRG
"NEONATE BIRTH WEIGHT 2000-2499 GRAMS WITH OTHER SIGNIFICANT CONDITION,MINOR",625,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],9296.26,,"Case rate ($9,296.26). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,9296.26,9761.07,There are no additional notes associated with this service or procedure.
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],27553.62,,"Fee schedule rate ($27,553.62). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12305.53,30103.84,There are no additional notes associated with this service or procedure.
"Tendon Sheath Incision|RIGHT HAND, THIRD DIGIT",CASE-26055,APC,26055,CPT,0360,RC,,,F7,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1505.12,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1505.12,1580.37,OPPS APC
HC Inj Tendon Sheath/Ligament|RIGHT SIDE,CASE-20550,APC,20550,CPT,0510,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],301.68,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,287.31,301.68,OPPS APC
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],35061.53,,"Fee schedule rate ($35,061.53). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,9696.93,35061.53,There are no additional notes associated with this service or procedure.
VAGINAL DELIVERY WITH O.R. PROCEDURES EXCEPT STERILIZATION AND/OR D&C,768,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],9523.97,,"Case rate ($9,201.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,695.94, add-ons for qualifying new technology services are included. If operating cost exceeds $43,566.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,290.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $6,726.19 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,750.99 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $530.76. The transfer capital threshold is the transfer adjustment factor * $530.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6426.91,13416.00,Inpatient DRG
CHOLECYSTECTOMY WITH C.D.E. WITH MCC,411,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],24801.43,,"Case rate ($24,315.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $22,755.46, add-ons for qualifying new technology services are included. If operating cost exceeds $57,626.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,396.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $20,734.06 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $20,810.51 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,636.12. The transfer capital threshold is the transfer adjustment factor * $1,636.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,24315.13,88615.28,Inpatient DRG
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],2070.00,,,,,,0,other,1188.00,34338.33,Estimated amount calculated based on 6 day length of stay.
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],12509.83,,"Case rate ($11,914.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,219.06, add-ons for qualifying new technology services are included. If operating cost exceeds $46,090.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,489.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $9,240.03 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,274.10 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $729.13. The transfer capital threshold is the transfer adjustment factor * $729.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,11914.12,40426.76,Inpatient DRG
FULL TERM NEONATE WITH MAJOR PROBLEMS,793,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],78359.29,,"Fee schedule rate ($78,359.29). Adds an outlier to normal pricing equal to the per diem rate ($27,082.03) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.7), with a minimum of zero.",,,,0,other,4302.90,82045.22,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC",281,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],8169.15,,"Case rate ($8,169.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,735.20, add-ons for qualifying new technology services are included. If operating cost exceeds $42,606.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,215.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $5,768.98 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,790.25 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $455.23. The transfer capital threshold is the transfer adjustment factor * $455.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8169.15,23859.35,Inpatient DRG
Laps Fulg/Exc Ovary Viscera/Peritoneal Surface,CASE-58662,APC,58662,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5658.76,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5658.76,5941.70,OPPS APC
HC Joint Injection/Aspir Large WO US|BILATERAL PROCEDURE,CASE-20610,APC,20610,CPT,0510,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,450,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],77624.52,,"Fee schedule rate ($77,624.52). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,38037.38,146009.19,There are no additional notes associated with this service or procedure.
FULL TERM NEONATE WITH MAJOR PROBLEMS,793,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],31238.14,,"Case rate ($30,181.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $28,213.07, add-ons for qualifying new technology services are included. If operating cost exceeds $63,084.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,825.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $26,171.62 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $26,268.12 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,065.20. The transfer capital threshold is the transfer adjustment factor * $2,065.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,4302.90,82045.22,Inpatient DRG
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],9824.13,,"Case rate ($9,356.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,839.58, add-ons for qualifying new technology services are included. If operating cost exceeds $43,710.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,302.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $6,869.30 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,894.63 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $542.06. The transfer capital threshold is the transfer adjustment factor * $542.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9356.31,25026.36,Inpatient DRG
OTHER DISORDERS OF NERVOUS SYSTEM WITH CC,092,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],26765.51,,"Fee schedule rate ($26,765.51). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8872.78,26765.51,There are no additional notes associated with this service or procedure.
Surgical Arthroscopy Shoulder Dstl Claviculc|RIGHT SIDE,CASE-29824,APC,29824,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7029.71,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6791.99,7131.59,OPPS APC
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],21354.82,,"Fee schedule rate ($21,354.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6834.39,21354.82,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],38378.80,,"Fee schedule rate ($38,378.80). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,14370.36,38378.80,There are no additional notes associated with this service or procedure.
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],8665.35,,"Case rate ($8,372.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,924.20, add-ons for qualifying new technology services are included. If operating cost exceeds $42,795.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,230.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,957.28 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,979.25 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $470.09. The transfer capital threshold is the transfer adjustment factor * $470.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6965.00,23385.72,Inpatient DRG
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],14586.15,,"Case rate ($13,891.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,058.63, add-ons for qualifying new technology services are included. If operating cost exceeds $47,929.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,633.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,072.85 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,113.68 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $873.76. The transfer capital threshold is the transfer adjustment factor * $873.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13891.57,34712.20,Inpatient DRG
HC Biopsy/Exc Lymph Node Needle,CASE-38505,APC,38505,CPT,0361,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1623.23,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1545.93,1623.23,OPPS APC
Surgical Arthroscopy Shoulder Removal Loose/FB,CASE-29819,APC,29819,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7029.71,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6791.99,7029.71,OPPS APC
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,068,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],8071.69,,"Case rate ($7,798.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,390.60, add-ons for qualifying new technology services are included. If operating cost exceeds $42,261.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,188.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $5,425.64 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,445.65 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $428.14. The transfer capital threshold is the transfer adjustment factor * $428.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6965.00,23184.90,Inpatient DRG
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],11731.65,,"Fee schedule rate ($11,731.65). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,6841.83,21167.26,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],14295.18,,"Case rate ($14,295.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,434.11, add-ons for qualifying new technology services are included. If operating cost exceeds $48,305.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,663.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $11,446.95 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,489.15 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $903.28. The transfer capital threshold is the transfer adjustment factor * $903.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,14295.18,42768.36,Inpatient DRG
GASTROINTESTINAL OBSTRUCTION WITH CC,389,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],15540.89,,,,,,0,other,5118.00,16423.43,There are no additional notes associated with this service or procedure.
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],38839.49,,"Fee schedule rate ($38,839.49). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.6), with a minimum of zero.",,,,0,other,15940.79,53275.26,There are no additional notes associated with this service or procedure.
"Remove Spinal Neurostim Electrode Plate/Paddle, Incl Fluoro",CASE-63662,APC,63662,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3272.44,,"APC Price ($3,272.44). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3272.44,3436.06,OPPS APC
OTHER DISORDERS OF NERVOUS SYSTEM WITH CC,092,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],26765.51,,"Fee schedule rate ($26,765.51). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8872.78,26765.51,There are no additional notes associated with this service or procedure.
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],8106.00,,"Fee schedule rate ($8,106). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7438.45,15961.98,There are no additional notes associated with this service or procedure.
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,306,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],29614.01,,"Fee schedule rate ($29,614.01). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12616.37,31007.02,There are no additional notes associated with this service or procedure.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],17269.71,,"Case rate ($16,447.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,436.22, add-ons for qualifying new technology services are included. If operating cost exceeds $50,307.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,820.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $13,441.70 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,491.27 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,060.68. The transfer capital threshold is the transfer adjustment factor * $1,060.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7453.00,42138.30,Inpatient DRG
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],10517.39,,"Case rate ($10,311.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,727.87, add-ons for qualifying new technology services are included. If operating cost exceeds $44,598.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,371.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $7,754.32 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,782.91 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $611.89. The transfer capital threshold is the transfer adjustment factor * $611.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,10311.17,24308.97,Inpatient DRG
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],49717.39,,"Fee schedule rate ($49,717.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,14908.05,49717.39,There are no additional notes associated with this service or procedure.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],17461.48,,"Case rate ($9,977.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,417.91, add-ons for qualifying new technology services are included. If operating cost exceeds $44,288.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,347.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $7,445.51 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,472.96 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $587.52. The transfer capital threshold is the transfer adjustment factor * $587.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,9977.99,26949.28,All Other Inpatient
Cysto/Uretero W/Lithotripsy &Indwell Stent Insrt|SEPARATE STRUCTURE|RIGHT SIDE,CASE-52356,APC,52356,CPT,0360,RC,,,XS|RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5269.71,,"APC Price ($5,018.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5018.77,5269.71,OPPS APC
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH CC,427,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],134742.59,,"Fee schedule rate ($134,742.59). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,50829.82,142040.39,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,065,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],19879.67,,,,,,0,other,8786.76,25681.86,There are no additional notes associated with this service or procedure.
"EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME, NEONATE",790,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],3354.00,,,,,,0,other,3054.00,44304.49,Estimated amount calculated based on 17 day length of stay.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,761,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],11946.72,,"Fee schedule rate ($11,946.72). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,5808.41,11946.72,There are no additional notes associated with this service or procedure.
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],22363.67,,"Fee schedule rate ($22,363.67). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10003.71,23415.63,There are no additional notes associated with this service or procedure.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],42787.31,,"Fee schedule rate ($42,787.31). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,15476.23,42787.31,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITH CC,386,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],19879.00,,"Fee schedule rate ($19,879.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8556.53,19879.00,There are no additional notes associated with this service or procedure.
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],8165.30,,"Fee schedule rate ($8,165.30). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4341.01,12882.53,There are no additional notes associated with this service or procedure.
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,095,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],19799.70,,"Case rate ($19,411.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $18,193.69, add-ons for qualifying new technology services are included. If operating cost exceeds $53,064.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,037.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.6. The base transfer operating payment is the transfer adjustment factor * $16,189.05 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $16,248.74 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,277.48. The transfer capital threshold is the transfer adjustment factor * $1,277.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,19411.47,50750.92,Inpatient DRG
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],14100.50,,"Case rate ($8,057.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,631.26, add-ons for qualifying new technology services are included. If operating cost exceeds $42,502.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,207.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,665.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,686.30 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $447.06. The transfer capital threshold is the transfer adjustment factor * $447.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,6524.00,17760.46,All Other Inpatient
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC,497,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],37761.19,,"Fee schedule rate ($37,761.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10127.65,37761.19,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],22358.90,,"Fee schedule rate ($22,358.90). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9389.48,22358.90,There are no additional notes associated with this service or procedure.
Submucous Rescj Inferior Turbinate Prtl/Compl|BILATERAL PROCEDURE,CASE-30140,APC,30140,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6605.95,,"APC Price ($6,605.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6605.95,6936.25,OPPS APC
Excision Tumor Soft Tissue Foot/Toe Subq <1.5cm|LEFT SIDE,CASE-28043,APC,28043,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1600.04,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1545.93,1623.23,OPPS APC
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,082,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],31160.85,,"Fee schedule rate ($31,160.85). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,17423.21,56223.11,There are no additional notes associated with this service or procedure.
"NEONATE TRANSFERRED < 5 DAYS OLD BORN HERE,EXTREME",581,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],4772.57,,"The inlier payment is calculated as the lesser of the standard DRG payment $4,772.57 and the transfer payment, which is a per diem of $3,615.58. If cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,4772.57,5011.20,Estimated amount calculated based on 1 day length of stay.
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",004,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],10715.36,,,,,,0,other,10249.47,272554.00,Estimated amount calculated based on 6 day length of stay.
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],19126.88,,"Fee schedule rate ($19,126.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,19126.88,There are no additional notes associated with this service or procedure.
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],27553.62,,"Fee schedule rate ($27,553.62). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12305.53,30103.84,There are no additional notes associated with this service or procedure.
CHEST PAIN,313,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],14167.44,,,,,,0,other,6820.84,15377.66,There are no additional notes associated with this service or procedure.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC,027,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],19696.26,,"Case rate ($19,030.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,839, add-ons for qualifying new technology services are included. If operating cost exceeds $52,710.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,009.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $15,835.66 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,894.05 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,249.59. The transfer capital threshold is the transfer adjustment factor * $1,249.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103.5%.",,,,0,other,19030.20,56363.30,Inpatient DRG
NEONATE WITH OTHER SIGNIFICANT PROBLEMS,794,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],12536.83,,"Case rate ($11,939.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,242.99, add-ons for qualifying new technology services are included. If operating cost exceeds $46,114.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,490.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $9,263.89 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,298.04 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $731.01. The transfer capital threshold is the transfer adjustment factor * $731.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,1798.85,12536.83,Inpatient DRG
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],12305.53,,"Case rate ($12,305.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,583.18, add-ons for qualifying new technology services are included. If operating cost exceeds $46,454.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,517.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $9,602.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,638.24 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $757.76. The transfer capital threshold is the transfer adjustment factor * $757.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12305.53,30103.84,Inpatient DRG
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],9865.56,,"Case rate ($9,865.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,313.33, add-ons for qualifying new technology services are included. If operating cost exceeds $44,184.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,339.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $7,341.31 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,368.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $579.30. The transfer capital threshold is the transfer adjustment factor * $579.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9865.56,37914.65,Inpatient DRG
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,373,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],13780.60,,"Fee schedule rate ($13,780.60). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6870.94,14313.05,There are no additional notes associated with this service or procedure.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],20932.80,,"Fee schedule rate ($20,932.80). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7453.00,42138.30,There are no additional notes associated with this service or procedure.
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],11855.89,,"Case rate ($11,454.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,791.92, add-ons for qualifying new technology services are included. If operating cost exceeds $45,662.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,455.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $8,814.47 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,846.97 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $695.55. The transfer capital threshold is the transfer adjustment factor * $695.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,11454.97,28394.78,Inpatient DRG
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],13092.47,,"Case rate ($13,092.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,315.24, add-ons for qualifying new technology services are included. If operating cost exceeds $47,186.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,575.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $10,332.19 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,370.29 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $815.31. The transfer capital threshold is the transfer adjustment factor * $815.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,13092.47,33159.45,Inpatient DRG
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],16055.90,,"Fee schedule rate ($16,055.90). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8163.06,18067.42,There are no additional notes associated with this service or procedure.
Arthrs Aided Ant Cruciate Ligm Rpr/Agmntj/Rcnstj|RIGHT SIDE,CASE-29888,APC,29888,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7029.71,OPPS APC
SPINAL PROCEDURES WITHOUT CC/MCC,030,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],41254.39,,"Fee schedule rate ($41,254.39). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,16810.99,44714.01,There are no additional notes associated with this service or procedure.
"SEPTICEMIA AND DISSEMINATED INFECTIONS,EXTREME",720,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],24856.17,,"The inlier payment is calculated as the lesser of the standard DRG payment $24,856.17 and the transfer payment, which is a per diem of $2,401.56. If cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,24856.17,26098.98,Estimated amount calculated based on 2 day length of stay.
PREMATURITY WITHOUT MAJOR PROBLEMS,792,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],11512.88,,"Fee schedule rate ($11,512.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,1956.00,19457.66,There are no additional notes associated with this service or procedure.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],17234.95,,"Case rate ($16,897.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,854.53, add-ons for qualifying new technology services are included. If operating cost exceeds $50,725.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,853.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $13,858.48 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,909.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,093.57. The transfer capital threshold is the transfer adjustment factor * $1,093.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,16897.01,43444.85,Inpatient DRG
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],11060.65,,"Case rate ($10,533.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,935.13, add-ons for qualifying new technology services are included. If operating cost exceeds $44,806.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,388.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $7,960.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,990.18 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $628.19. The transfer capital threshold is the transfer adjustment factor * $628.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10533.95,24956.34,Inpatient DRG
HEADACHES WITHOUT MCC,103,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],7988.85,,"Case rate ($7,608.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,213.57, add-ons for qualifying new technology services are included. If operating cost exceeds $42,084.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,174.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $5,249.26 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,268.62 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $414.22. The transfer capital threshold is the transfer adjustment factor * $414.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,20883.08,Inpatient DRG
O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC,621,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],36669.96,,"Fee schedule rate ($36,669.96). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,12159.94,36669.96,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],37914.65,,"Fee schedule rate ($37,914.65). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9865.56,37914.65,There are no additional notes associated with this service or procedure.
NONTRAUMATIC STUPOR AND COMA WITH MCC,080,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],14486.44,,"Case rate ($14,202.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,347.79, add-ons for qualifying new technology services are included. If operating cost exceeds $48,218.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,656.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $11,360.96 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,402.84 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $896.49. The transfer capital threshold is the transfer adjustment factor * $896.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,14202.39,35615.37,Inpatient DRG
HC Injection Small Joint/Bursa|PBB CHARGE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-20600,APC,20600,CPT,0361,RC,,,PBB|XU,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,287.31,OPPS APC
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],66833.55,,"Fee schedule rate ($66,833.55). Adds an outlier to normal pricing equal to the per diem rate ($141,521.30) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,26028.48,80635.65,There are no additional notes associated with this service or procedure.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],8289.67,,"Case rate ($8,009.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,586.52, add-ons for qualifying new technology services are included. If operating cost exceeds $42,457.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,203.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $5,620.85 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,641.57 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $443.54. The transfer capital threshold is the transfer adjustment factor * $443.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,8009.34,19877.10,Inpatient DRG
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],12651.45,,"Fee schedule rate ($12,651.45). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,6503.90,14492.93,There are no additional notes associated with this service or procedure.
Implnt Bio Implnt for Soft Tissue Reinforcement|LEFT SIDE,CASE-15777,APC,15777,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6215.36,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6215.36,6215.36,OPPS APC
"Open Tx Distal Phalangeal Fracture Each|RIGHT HAND, SECOND DIGIT",CASE-26765,APC,26765,CPT,0360,RC,,,F6,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],26465.57,,,,,,0,other,11053.39,36776.05,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],12234.80,,"Case rate ($11,652.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,993.49, add-ons for qualifying new technology services are included. If operating cost exceeds $45,864.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,452.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $9,014.37 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,048.54 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $692.87. The transfer capital threshold is the transfer adjustment factor * $692.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6167.00,29058.99,Inpatient DRG
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],14871.83,,"Fee schedule rate ($14,871.83). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6558.75,14871.83,There are no additional notes associated with this service or procedure.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],7585.67,,"Case rate ($7,224.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,856.36, add-ons for qualifying new technology services are included. If operating cost exceeds $41,727.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,146.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $4,893.37 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,911.41 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $386.14. The transfer capital threshold is the transfer adjustment factor * $386.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,15340.19,Inpatient DRG
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],31973.49,,"Fee schedule rate ($31,973.49). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,13386.36,33244.29,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITHOUT CC/MCC,517,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],28052.31,,"Fee schedule rate ($28,052.31). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,10207.96,29371.86,There are no additional notes associated with this service or procedure.
UNGROUPABLE,999,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],161307.29,,"Fee schedule rate ($161,307.29). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (41), with a minimum of zero.",,,,0,other,10228.00,161307.29,There are no additional notes associated with this service or procedure.
Dstr Nrolytc Agnt Parverteb Fct Sngl Lmbr/Sacral|LEFT SIDE,CASE-64635,APC,64635,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1891.77,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1827.80,1919.19,OPPS APC
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC",156,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],12987.84,,"Fee schedule rate ($12,987.84). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,6625.12,13598.77,There are no additional notes associated with this service or procedure.
FRACTURES OF FEMUR WITH MCC,533,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],49490.05,,"Fee schedule rate ($49,490.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,6852.00,49490.05,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITHOUT CC/MCC,517,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],19509.21,,"Case rate ($11,148.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $10,476.23, add-ons for qualifying new technology services are included. If operating cost exceeds $49,120.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $3,441.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $9,076.06 + an uncompensated DSH payment of $1,359.91. The transfer operating threshold is the transfer adjustment factor * $9,116.32 + an uncompensated DSH payment of $1,359.91. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $712.16. The transfer capital threshold is the transfer adjustment factor * $712.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,10207.96,29371.86,All Other Inpatient
Tonsillectomy Primary/Secondary Age 12/>,CASE-42826,APC,42826,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.52,,"APC Price ($3,103.35). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.35,3258.52,OPPS APC
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],15766.27,,"Case rate ($15,233.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,306.64, add-ons for qualifying new technology services are included. If operating cost exceeds $49,177.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,731.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $12,316.28 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,361.69 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $971.88. The transfer capital threshold is the transfer adjustment factor * $971.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,15233.11,38610.21,Inpatient DRG
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],23520.23,,"Fee schedule rate ($23,520.23). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10517.71,24909.11,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITH MCC,385,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],21593.52,,"Fee schedule rate ($21,593.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11480.01,31134.92,There are no additional notes associated with this service or procedure.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],26949.28,,"Fee schedule rate ($26,949.28). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9977.99,26949.28,There are no additional notes associated with this service or procedure.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH CC,026,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],61179.73,,,,,,0,other,23000.66,63202.45,There are no additional notes associated with this service or procedure.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],38246.19,,"Fee schedule rate ($38,246.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,19435.86,50821.76,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],7366.00,,"Case rate ($7,366). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,988.03, add-ons for qualifying new technology services are included. If operating cost exceeds $41,859.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,156.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,024.55 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,043.08 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $396.49. The transfer capital threshold is the transfer adjustment factor * $396.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,21195.68,Inpatient DRG
GASTROINTESTINAL HEMORRHAGE WITH CC,378,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],20845.19,,"Fee schedule rate ($20,845.19). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8586.33,20845.19,There are no additional notes associated with this service or procedure.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],13243.69,,"Case rate ($12,795.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,039.30, add-ons for qualifying new technology services are included. If operating cost exceeds $46,910.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,553.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $10,057.27 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,094.35 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $793.62. The transfer capital threshold is the transfer adjustment factor * $793.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,12795.84,41944.25,Inpatient DRG
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],9370.00,,"Per diem ($9,370). If length of stay < 6.7, first 1 days paid at a per diem of $18,740 instead. Capped at $62,779.90.",,,,0,other,9370.00,65732.99,Estimated amount calculated based on 3 day length of stay.
Brnchsc Ebus Guided Sampl 1/2 Node Station/Strux,CASE-31652,APC,31652,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6837.16,,"APC Price ($6,605.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6605.95,6837.16,OPPS APC
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],57102.65,,,,,,0,other,21597.50,67790.93,There are no additional notes associated with this service or procedure.
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC",641,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],14928.67,,"Fee schedule rate ($14,928.67). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7214.98,15312.64,There are no additional notes associated with this service or procedure.
HC Non Stress Test,CASE-59025,APC,59025,CPT,0920,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],198.70,,"APC Price ($189.24). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,189.24,198.70,OPPS APC
"Laminec/Facetect/Foramin,Thoracic",CASE-63046,APC,63046,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],17232.68,,"APC Price ($16,412.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,16412.07,17232.68,OPPS APC
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],7513.32,,"Case rate ($7,366). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,988.03, add-ons for qualifying new technology services are included. If operating cost exceeds $41,859.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,156.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,024.55 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,043.08 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $396.49. The transfer capital threshold is the transfer adjustment factor * $396.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6965.00,21195.68,Inpatient DRG
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],27553.62,,"Fee schedule rate ($27,553.62). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12305.53,30103.84,There are no additional notes associated with this service or procedure.
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,451,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],94077.13,,"Fee schedule rate ($94,077.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,23821.44,94077.13,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],14244.58,,"Case rate ($13,762.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,938.93, add-ons for qualifying new technology services are included. If operating cost exceeds $47,809.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,624.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $10,953.59 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,993.98 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $864.35. The transfer capital threshold is the transfer adjustment factor * $864.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,1188.00,34338.33,Inpatient DRG
Cystourethroscopy With Biopsy,CASE-52204,APC,52204,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1956.65,,"APC Price ($1,956.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1956.65,2054.48,OPPS APC
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],52794.06,,"Fee schedule rate ($52,794.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (37), with a minimum of zero.",,,,0,other,13907.80,52794.06,There are no additional notes associated with this service or procedure.
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],53275.26,,"Fee schedule rate ($53,275.26). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,15940.79,53275.26,There are no additional notes associated with this service or procedure.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC",156,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6812.03,,"Case rate ($6,487.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,179.41, add-ons for qualifying new technology services are included. If operating cost exceeds $41,050.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,084.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $4,218.46 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,234.46 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $324.24. The transfer capital threshold is the transfer adjustment factor * $324.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6625.12,13598.77,Inpatient DRG
"SEIZURE,MINOR",053,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],2225.17,,"Case rate for a one day stay ($2,119.21). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,2119.21,2225.17,There are no additional notes associated with this service or procedure.
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],8057.83,,"Case rate ($7,674.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,285.36, add-ons for qualifying new technology services are included. If operating cost exceeds $42,156.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,168.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,320.23 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,340.41 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $408.93. The transfer capital threshold is the transfer adjustment factor * $408.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7847.50,17755.26,Inpatient DRG
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],22762.43,,"Fee schedule rate ($22,762.43). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6230.00,22762.43,There are no additional notes associated with this service or procedure.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],7224.45,,"Case rate ($7,224.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,856.36, add-ons for qualifying new technology services are included. If operating cost exceeds $41,727.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,146.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $4,893.37 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,911.41 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $386.14. The transfer capital threshold is the transfer adjustment factor * $386.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,15340.19,Inpatient DRG
Rpr Ingun Hernia Sliding Any Age|RIGHT SIDE,CASE-49525,APC,49525,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3468.64,,"APC Price ($3,351.34). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3351.34,3518.91,OPPS APC
HC Trigger Point 3 or More|PBB CHARGE,CASE-20553,APC,20553,CPT,0510,RC,,,PBB,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],297.37,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,287.31,301.68,OPPS APC
Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq|COLORECTAL CANCER SCREEN,CASE-45385,APC,45385,CPT,0360,RC,,,PT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1176.09,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1120.09,1176.09,OPPS APC
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC,817,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],17789.37,,"Case rate ($16,942.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,924.61, add-ons for qualifying new technology services are included. If operating cost exceeds $50,795.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,830.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $13,926.85 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,979.66 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,070.45. The transfer capital threshold is the transfer adjustment factor * $1,070.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,17396.11,44895.04,Inpatient DRG
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,167,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],14157.71,,"Case rate ($14,157.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,306.21, add-ons for qualifying new technology services are included. If operating cost exceeds $48,177.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,653.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $11,319.53 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,361.26 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $893.22. The transfer capital threshold is the transfer adjustment factor * $893.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,14157.71,43522.37,Inpatient DRG
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],61234.06,,"Fee schedule rate ($61,234.06). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11165.00,61234.06,There are no additional notes associated with this service or procedure.
PREMATURITY WITH MAJOR PROBLEMS,791,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],3354.00,,,,,,0,other,3048.21,30904.42,Estimated amount calculated based on 5 day length of stay.
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],13550.71,,"Case rate ($13,092.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,315.24, add-ons for qualifying new technology services are included. If operating cost exceeds $47,186.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,575.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $10,332.19 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,370.29 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $815.31. The transfer capital threshold is the transfer adjustment factor * $815.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,13092.47,33159.45,Inpatient DRG
OTHER CEREBROVASCULAR DISORDERS WITH MCC,070,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],37774.46,,"Fee schedule rate ($37,774.46). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,13219.09,37774.46,There are no additional notes associated with this service or procedure.
Cerclage Cervix Pregnancy Vaginal,CASE-59320,APC,59320,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3181.53,,"APC Price ($3,030.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3030.03,3181.53,OPPS APC
VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC,033,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],13470.35,,"Case rate ($13,206.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,421.07, add-ons for qualifying new technology services are included. If operating cost exceeds $47,292.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,583.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $10,437.64 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,476.13 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $823.63. The transfer capital threshold is the transfer adjustment factor * $823.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,13206.23,42156.44,Inpatient DRG
BRONCHITIS AND ASTHMA WITH CC/MCC,202,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],8745.23,,"Case rate ($8,328.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,895.62, add-ons for qualifying new technology services are included. If operating cost exceeds $42,766.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,215.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,928.19 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,950.67 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $455.65. The transfer capital threshold is the transfer adjustment factor * $455.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7606.34,19110.30,Inpatient DRG
Mastectomy Partial|BILATERAL PROCEDURE,CASE-19301,APC,19301,CPT,0360,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6526.12,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6215.36,6526.12,OPPS APC
"Amputation Metatarsal W/Toe Single|RIGHT FOOT, FIFTH DIGIT",CASE-28810,APC,28810,CPT,0360,RC,,,T9,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],33608.45,,"Fee schedule rate ($33,608.45). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,7332.00,35314.31,There are no additional notes associated with this service or procedure.
OTHER MENTAL DISORDER DIAGNOSES,887,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],21072.10,,,,,,0,other,2070.00,21072.10,There are no additional notes associated with this service or procedure.
HEADACHES WITHOUT MCC,103,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],20883.08,,"Fee schedule rate ($20,883.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,20883.08,There are no additional notes associated with this service or procedure.
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],8447.49,,"Case rate ($8,447.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,994.13, add-ons for qualifying new technology services are included. If operating cost exceeds $42,865.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,235.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,026.96 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,049.18 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $475.59. The transfer capital threshold is the transfer adjustment factor * $475.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,1188.00,18893.86,Inpatient DRG
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],10989.72,,"Case rate ($10,989.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,359.11, add-ons for qualifying new technology services are included. If operating cost exceeds $45,230.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,421.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $8,383.26 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,414.17 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $661.52. The transfer capital threshold is the transfer adjustment factor * $661.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10989.72,26280.60,Inpatient DRG
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],52449.26,,"Fee schedule rate ($52,449.26). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,17693.40,52449.26,There are no additional notes associated with this service or procedure.
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],6524.00,,"Per diem ($6,524). If length of stay < 2.6, first 1 days paid at a per diem of $13,048 instead. Capped at $16,962.56.",,,,0,other,6524.00,17760.46,Estimated amount calculated based on 2 day length of stay.
HC N Block Inj Suprascapular Nerv|RIGHT SIDE,CASE-64418,APC,64418,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],693.76,,"APC Price ($660.72). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,660.72,693.76,OPPS APC
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],28031.48,,"Case rate ($16,017.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,036.80, add-ons for qualifying new technology services are included. If operating cost exceeds $49,907.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,789.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $13,043.76 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,091.85 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,029.28. The transfer capital threshold is the transfer adjustment factor * $1,029.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,16017.99,51903.64,All Other Inpatient
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],34397.36,,,,,,0,other,13783.20,41580.51,There are no additional notes associated with this service or procedure.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],39337.51,,"Fee schedule rate ($39,337.51). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,16120.25,41187.90,There are no additional notes associated with this service or procedure.
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],15636.71,,"Case rate ($14,892.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,013.56, add-ons for qualifying new technology services are included. If operating cost exceeds $48,884.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,684.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.2. The base transfer operating payment is the transfer adjustment factor * $12,023.02 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,068.61 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $924.12. The transfer capital threshold is the transfer adjustment factor * $924.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,15283.90,38757.79,Inpatient DRG
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],31007.30,,"Fee schedule rate ($31,007.30). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,16120.25,41187.90,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],14086.54,,"Case rate ($13,415.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,637.40, add-ons for qualifying new technology services are included. If operating cost exceeds $47,508.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,578.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $10,652.07 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,692.45 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $818.74. The transfer capital threshold is the transfer adjustment factor * $818.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,1188.00,34338.33,Inpatient DRG
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],38222.57,,,,,,0,other,7605.00,39153.65,There are no additional notes associated with this service or procedure.
Largsc Exc Tum&/Strpg Cords/Epigl Mcrscp/Tlscp,CASE-31541,APC,31541,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3664.31,,"APC Price ($3,489.82). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3489.82,3664.31,OPPS APC
MAJOR THUMB OR JOINT PROCEDURES,506,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],11635.92,,"Case rate ($11,081.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,444.79, add-ons for qualifying new technology services are included. If operating cost exceeds $45,315.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,428.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $8,468.62 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,499.84 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $668.26. The transfer capital threshold is the transfer adjustment factor * $668.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,11081.83,26548.21,Inpatient DRG
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],43128.05,,,,,,0,other,16787.98,62990.26,There are no additional notes associated with this service or procedure.
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],5065.00,,"Per diem ($5,065). If length of stay < 2.1, first 1 days paid at a per diem of $10,130 instead. Capped at $10,636.84.",,,,0,other,5065.00,12558.65,Estimated amount calculated based on 2 day length of stay.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",063,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],20040.27,,"Case rate ($11,451.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,788.77, add-ons for qualifying new technology services are included. If operating cost exceeds $45,659.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,455.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $8,811.33 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,843.82 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $695.30. The transfer capital threshold is the transfer adjustment factor * $695.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,6965.00,35701.87,All Other Inpatient
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],14690.49,,"Fee schedule rate ($14,690.49). Adds an outlier to normal pricing equal to the per diem rate ($54,770.58) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.7), with a minimum of zero.",,,,0,other,7238.69,16804.22,There are no additional notes associated with this service or procedure.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],59521.43,,"Fee schedule rate ($59,521.43). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,16689.78,59521.43,There are no additional notes associated with this service or procedure.
HC Biopsy/Exc Lymph Node Needle|TECHNICAL COMPONENT,CASE-38505,APC,38505,CPT,0361,RC,,,TC,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1545.93,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1545.93,1623.23,OPPS APC
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],9533.13,,"Fee schedule rate ($9,533.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5068.21,14525.56,There are no additional notes associated with this service or procedure.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],59385.88,,"Fee schedule rate ($59,385.88). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,23344.70,62179.32,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC,833,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],5721.39,,"Fee schedule rate ($5,721.39). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,3041.73,10289.10,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],19763.43,,"Fee schedule rate ($19,763.43). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,8318.14,19763.43,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],57305.33,,,,,,0,other,8972.00,81524.17,There are no additional notes associated with this service or procedure.
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6378.61,,"Case rate ($6,378.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,069.50, add-ons for qualifying new technology services are included. If operating cost exceeds $40,940.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,084.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,109.40 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,124.55 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $324.27. The transfer capital threshold is the transfer adjustment factor * $324.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,4341.01,12882.53,Inpatient DRG
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],24373.11,,"Fee schedule rate ($24,373.11). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,18598.83,48389.68,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],51903.64,,"Fee schedule rate ($51,903.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,16017.99,51903.64,There are no additional notes associated with this service or procedure.
O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC,621,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],12159.94,,"Case rate ($12,159.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,447.74, add-ons for qualifying new technology services are included. If operating cost exceeds $46,318.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,507.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $9,467.88 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,502.79 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $747.11. The transfer capital threshold is the transfer adjustment factor * $747.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12159.94,36669.96,Inpatient DRG
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],26549.05,,"Case rate ($26,028.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $24,349.34, add-ons for qualifying new technology services are included. If operating cost exceeds $59,220.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,521.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $22,322.08 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $22,404.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,761.43. The transfer capital threshold is the transfer adjustment factor * $1,761.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 102%.",,,,0,other,26028.48,80635.65,Inpatient DRG
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],12268.97,,"Case rate ($12,268.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,549.17, add-ons for qualifying new technology services are included. If operating cost exceeds $46,420.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,515.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,568.94 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,604.22 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $755.08. The transfer capital threshold is the transfer adjustment factor * $755.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12268.97,41006.47,Inpatient DRG
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],45157.33,,"Fee schedule rate ($45,157.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,10733.06,45157.33,There are no additional notes associated with this service or procedure.
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],11133.98,,"Fee schedule rate ($11,133.98). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5919.29,13545.65,There are no additional notes associated with this service or procedure.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],52909.62,,"Fee schedule rate ($52,909.62). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,23344.70,62179.32,There are no additional notes associated with this service or procedure.
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],9648.19,,"Case rate ($9,648.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,111.10, add-ons for qualifying new technology services are included. If operating cost exceeds $43,982.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,323.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $7,139.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,166.15 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $563.40. The transfer capital threshold is the transfer adjustment factor * $563.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9648.19,31477.13,Inpatient DRG
Cysto W/Simple Removal Stone & Stent|RIGHT SIDE,CASE-52310,APC,52310,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],2054.48,,"APC Price ($1,956.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1956.65,2054.48,OPPS APC
O.R. PROCEDURES FOR OBESITY WITH CC,620,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],43753.50,,"Fee schedule rate ($43,753.50). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12782.30,43753.50,There are no additional notes associated with this service or procedure.
DIABETES WITHOUT CC/MCC,639,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],11899.36,,"Fee schedule rate ($11,899.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6151.76,12223.35,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],30636.35,,"Fee schedule rate ($30,636.35). Adds an outlier to normal pricing equal to the per diem rate ($67,650.85) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12984.79,32077.45,There are no additional notes associated with this service or procedure.
Exc B9 Lesion Mrgn Xcp Sk Tg T/a/L 2.1-3.0 Cm,CASE-11403,APC,11403,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],2814.04,,"APC Price ($2,718.88). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2718.88,2854.83,OPPS APC
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],35419.59,,"Fee schedule rate ($35,419.59). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,7086.00,57872.02,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC",281,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],18085.13,,,,,,0,other,8169.15,23859.35,There are no additional notes associated with this service or procedure.
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],34245.00,,"Fee schedule rate ($34,245.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,12725.42,34245.00,There are no additional notes associated with this service or procedure.
Arthrs Knee W/Meniscectomy Med&Lat W/Shaving|LEFT SIDE,CASE-29880,APC,29880,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
GASTROINTESTINAL HEMORRHAGE WITH MCC,377,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],31575.65,,"Fee schedule rate ($31,575.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,7634.00,35969.56,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITHOUT CC/MCC,428,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],118904.57,,"Fee schedule rate ($118,904.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,40017.53,118904.57,There are no additional notes associated with this service or procedure.
Bronchoscopy Needle Bx Trachea Main Stem&/Bron,CASE-31629,APC,31629,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6936.25,,"APC Price ($6,605.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6605.95,6936.25,OPPS APC
VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC,033,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],42156.44,,"Fee schedule rate ($42,156.44). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,13206.23,42156.44,There are no additional notes associated with this service or procedure.
Ostc Prtl Exostc/Condylc Metar Head|RIGHT SIDE|SEPARATE STRUCTURE,CASE-28288,APC,28288,CPT,0360,RC,,,RT|XS,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3062.67,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC",641,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],14624.71,,"Fee schedule rate ($14,624.71). Adds an outlier to normal pricing equal to the per diem rate ($38,755.52) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7214.98,15312.64,There are no additional notes associated with this service or procedure.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],9918.70,,"Case rate ($9,446.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,923.36, add-ons for qualifying new technology services are included. If operating cost exceeds $43,794.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,308.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,952.78 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,978.41 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $548.64. The transfer capital threshold is the transfer adjustment factor * $548.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9446.38,21796.21,Inpatient DRG
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],11594.35,,"Fee schedule rate ($11,594.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6164.03,14071.02,There are no additional notes associated with this service or procedure.
NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,601,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],6344.15,,"Case rate ($6,042.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,756.39, add-ons for qualifying new technology services are included. If operating cost exceeds $40,627.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,059.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $3,797.45 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,811.45 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $299.66. The transfer capital threshold is the transfer adjustment factor * $299.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6042.05,12359.72,Inpatient DRG
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC",011,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],150008.48,,"Fee schedule rate ($150,008.48). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (44), with a minimum of zero.",,,,0,other,38880.49,150008.48,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],58394.20,,"Fee schedule rate ($58,394.20). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,9370.00,65732.99,There are no additional notes associated with this service or procedure.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,191,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],16612.88,,"Fee schedule rate ($16,612.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6965.00,16612.88,There are no additional notes associated with this service or procedure.
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 1 Level|BILATERAL PROCEDURE,CASE-64493,APC,64493,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],827.89,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,827.89,869.28,OPPS APC
"INFECTIOUS AND PARASITIC DISEASES INCLUDING HIV WITH O.R. PROCEDURE,EXTREME",710,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],49120.77,,"Case rate ($46,781.69). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $48,300, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,46781.69,49120.77,There are no additional notes associated with this service or procedure.
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],10503.90,,"Case rate ($10,003.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,441.84, add-ons for qualifying new technology services are included. If operating cost exceeds $44,312.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,349.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $7,469.36 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,496.90 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $589.41. The transfer capital threshold is the transfer adjustment factor * $589.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10003.71,23415.63,Inpatient DRG
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],54180.83,,"Fee schedule rate ($54,180.83). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,15491.11,54180.83,There are no additional notes associated with this service or procedure.
"FEVER AND INFLAMMATORY CONDITIONS,MODERATE",722,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],2047.71,,"Case rate for a one day stay ($2,047.71). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,2047.71,2150.10,There are no additional notes associated with this service or procedure.
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],11108.72,,"Case rate ($10,733.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,120.35, add-ons for qualifying new technology services are included. If operating cost exceeds $44,991.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,402.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $8,145.37 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,175.40 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $642.75. The transfer capital threshold is the transfer adjustment factor * $642.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,10733.06,45157.33,Inpatient DRG
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],20846.48,,"Case rate ($20,846.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $19,528.64, add-ons for qualifying new technology services are included. If operating cost exceeds $54,399.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,142.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $17,519.09 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $17,583.69 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,382.43. The transfer capital threshold is the transfer adjustment factor * $1,382.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,20846.48,81306.30,Inpatient DRG
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC,058,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],40853.02,,"Fee schedule rate ($40,853.02). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,13521.80,40853.02,There are no additional notes associated with this service or procedure.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,479,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],14824.22,,"Case rate ($14,533.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,655.86, add-ons for qualifying new technology services are included. If operating cost exceeds $48,526.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,680.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $11,667.89 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,710.91 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $920.71. The transfer capital threshold is the transfer adjustment factor * $920.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,10586.00,50518.76,Inpatient DRG
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],18588.16,,"Fee schedule rate ($18,588.16). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.8), with a minimum of zero.",,,,0,other,8643.20,19462.52,There are no additional notes associated with this service or procedure.
Chemodenervation Muscle Neck Unilat for Dystonia|BILATERAL PROCEDURE,CASE-64616,APC,64616,CPT,0360,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],297.37,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,287.31,301.68,OPPS APC
SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS,029,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],25048.54,,"Case rate ($25,048.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $23,437.73, add-ons for qualifying new technology services are included. If operating cost exceeds $58,308.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,449.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.7)) / 2. The base transfer operating payment is the transfer adjustment factor * $21,413.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $21,492.79 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,689.76. The transfer capital threshold is the transfer adjustment factor * $1,689.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,13641.00,67130.05,Inpatient DRG
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],12558.65,,"Fee schedule rate ($12,558.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5065.00,12558.65,There are no additional notes associated with this service or procedure.
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC",514,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],12068.21,,"Fee schedule rate ($12,068.21). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8868.04,22699.91,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],16338.35,,"Case rate ($16,017.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,036.80, add-ons for qualifying new technology services are included. If operating cost exceeds $49,907.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,789.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $13,043.76 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,091.85 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,029.28. The transfer capital threshold is the transfer adjustment factor * $1,029.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,16017.99,51903.64,Inpatient DRG
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],17097.87,,"Fee schedule rate ($17,097.87). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,8106.18,18245.94,There are no additional notes associated with this service or procedure.
HC Repair Tun or Non Cath W/Port,CASE-36576,APC,36576,CPT,0361,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1547.12,,"APC Price ($1,473.45). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1473.45,1547.12,OPPS APC
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,086,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],30728.81,,"Fee schedule rate ($30,728.81). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8442.00,30728.81,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITH STERILIZATION WITH CC,784,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],23722.94,,"Fee schedule rate ($23,722.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9124.01,23722.94,There are no additional notes associated with this service or procedure.
HC Inject Tendon Origin/Insert|LEFT SIDE,CASE-20551,APC,20551,CPT,0361,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],297.37,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,287.31,301.68,OPPS APC
HC Inj Aa&/Strd Other Peripheral Nerve/Branch|RIGHT SIDE,CASE-64450,APC,64450,CPT,0450,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],660.72,,"APC Price ($660.72). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,660.72,683.85,OPPS APC
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],9608.67,,"Case rate ($9,151.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,648.69, add-ons for qualifying new technology services are included. If operating cost exceeds $43,519.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,287.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,679.11 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,703.74 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $527.05. The transfer capital threshold is the transfer adjustment factor * $527.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9151.11,30245.71,Inpatient DRG
"NEONATE BIRTH WEIGHT 1500-1999 GRAMS WITH MAJOR ANOMALY,MINOR",611,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],10963.86,,"Case rate ($10,963.86). Base payment rate plus any adjustments related to outliers.",,,,0,other,10963.86,11512.05,There are no additional notes associated with this service or procedure.
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],6937.19,,"Case rate ($6,606.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,281.82, add-ons for qualifying new technology services are included. If operating cost exceeds $41,152.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,100.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,320.93 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,336.86 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $340.96. The transfer capital threshold is the transfer adjustment factor * $340.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5919.29,13545.65,Inpatient DRG
HEADACHES WITHOUT MCC,103,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7814.18,,"Case rate ($7,442.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,069.07, add-ons for qualifying new technology services are included. If operating cost exceeds $41,940.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,152.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $5,104.76 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,124.12 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $392.36. The transfer capital threshold is the transfer adjustment factor * $392.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,20883.08,Inpatient DRG
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],6426.00,,"Fee schedule rate ($6,426). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6164.03,14071.02,There are no additional notes associated with this service or procedure.
POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES,769,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],16511.25,,"Fee schedule rate ($16,511.25). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,13388.39,33250.19,There are no additional notes associated with this service or procedure.
CERVICAL SPINAL FUSION WITHOUT CC/MCC,473,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],18477.61,,"Case rate ($18,477.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,324.93, add-ons for qualifying new technology services are included. If operating cost exceeds $52,195.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,969.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.6. The base transfer operating payment is the transfer adjustment factor * $15,323.48 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,379.98 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,209.17. The transfer capital threshold is the transfer adjustment factor * $1,209.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,18477.61,62077.11,Inpatient DRG
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],25814.06,,"Fee schedule rate ($25,814.06). Adds an outlier to normal pricing equal to the per diem rate ($46,867.46) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,11247.07,27028.33,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],22805.37,,"Case rate ($21,719.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,340.70, add-ons for qualifying new technology services are included. If operating cost exceeds $55,211.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,206.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.2. The base transfer operating payment is the transfer adjustment factor * $18,328.17 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,395.75 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,446.27. The transfer capital threshold is the transfer adjustment factor * $1,446.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,21719.40,85305.59,Inpatient DRG
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],6886.69,,"Case rate ($6,558.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,237.08, add-ons for qualifying new technology services are included. If operating cost exceeds $41,108.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,097.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $4,276.36 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,292.13 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $337.45. The transfer capital threshold is the transfer adjustment factor * $337.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6558.75,14871.83,Inpatient DRG
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",063,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],35701.87,,"Fee schedule rate ($35,701.87). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,35701.87,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,699,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],15432.55,,"Case rate ($8,818.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,339.37, add-ons for qualifying new technology services are included. If operating cost exceeds $43,210.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,262.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $6,370.92 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,394.41 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $502.73. The transfer capital threshold is the transfer adjustment factor * $502.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,5961.00,19972.16,All Other Inpatient
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],7414.07,,"Case rate ($7,414.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,032.76, add-ons for qualifying new technology services are included. If operating cost exceeds $41,903.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,159.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,069.12 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,087.81 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $400.00. The transfer capital threshold is the transfer adjustment factor * $400.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7414.07,18217.52,Inpatient DRG
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],22241.27,,"Case rate ($21,489.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,126.50, add-ons for qualifying new technology services are included. If operating cost exceeds $54,997.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,189.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.6. The base transfer operating payment is the transfer adjustment factor * $18,114.76 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,181.55 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,429.43. The transfer capital threshold is the transfer adjustment factor * $1,429.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,21489.15,68942.79,Inpatient DRG
Colsc Flexible W/Transendoscopic Balloon Dilat|COLORECTAL CANCER SCREEN,CASE-45386,APC,45386,CPT,0360,RC,,,PT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1120.09,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1120.09,1176.09,OPPS APC
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],8200.65,,"Case rate ($7,923.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,506.51, add-ons for qualifying new technology services are included. If operating cost exceeds $42,377.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,197.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $5,541.13 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,561.56 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $437.25. The transfer capital threshold is the transfer adjustment factor * $437.25. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,1188.00,17370.86,Inpatient DRG
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],86252.84,,"Fee schedule rate ($86,252.84). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,27944.96,86252.84,There are no additional notes associated with this service or procedure.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],64429.92,,"Fee schedule rate ($64,429.92). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,25162.32,75579.22,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC,833,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],5721.39,,"Fee schedule rate ($5,721.39). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,3041.73,10289.10,There are no additional notes associated with this service or procedure.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],11139.15,,,,,,0,other,5778.62,11681.49,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],112149.06,,,,,,0,other,40542.37,128358.13,There are no additional notes associated with this service or procedure.
Esophageal Motility Study W/Interp&Rpt,CASE-91010,APC,91010,CPT,0750,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],361.51,,"APC Price ($349.28). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,349.28,366.75,OPPS APC
VENTRICULAR SHUNT PROCEDURES WITH CC,032,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],46275.08,,"Fee schedule rate ($46,275.08). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,16376.22,46275.08,There are no additional notes associated with this service or procedure.
RESPIRATORY NEOPLASMS WITHOUT CC/MCC,182,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],6965.00,,,,,,0,other,6965.00,23037.13,There are no additional notes associated with this service or procedure.
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,450,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],100159.17,,"Fee schedule rate ($100,159.17). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15), with a minimum of zero.",,,,0,other,38037.38,146009.19,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],86235.79,,"Fee schedule rate ($86,235.79). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,32296.02,88188.38,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,093,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],19011.32,,"Fee schedule rate ($19,011.32). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,19011.32,There are no additional notes associated with this service or procedure.
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],67107.92,,"Fee schedule rate ($67,107.92). Adds an outlier to normal pricing equal to the per diem rate ($118,521.29) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16.7), with a minimum of zero.",,,,0,other,26127.34,90333.60,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,066,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],20083.61,,"Fee schedule rate ($20,083.61). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6579.76,20083.61,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],72151.96,,"Fee schedule rate ($72,151.96). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,27944.96,86252.84,There are no additional notes associated with this service or procedure.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],21198.45,,"Fee schedule rate ($21,198.45). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11593.79,38248.08,There are no additional notes associated with this service or procedure.
"Open Tx Distal Phalangeal Fracture Each|RIGHT HAND, SECOND DIGIT",CASE-26765,APC,26765,CPT,0360,RC,,,F6,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,074,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],9238.00,,"Case rate ($8,925.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,438.90, add-ons for qualifying new technology services are included. If operating cost exceeds $43,309.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,270.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,470.10 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,493.95 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $510.55. The transfer capital threshold is the transfer adjustment factor * $510.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,8925.60,20919.08,Inpatient DRG
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],14295.18,,"Case rate ($14,295.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,434.11, add-ons for qualifying new technology services are included. If operating cost exceeds $48,305.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,663.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $11,446.95 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,489.15 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $903.28. The transfer capital threshold is the transfer adjustment factor * $903.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,14295.18,42768.36,Inpatient DRG
Peri-Implant Capsulectomy Breast Complete|LEFT SIDE,CASE-19371,APC,19371,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3793.21,,"APC Price ($3,664.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3664.94,3848.19,OPPS APC
OTHER MENTAL DISORDER DIAGNOSES,887,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],6965.00,,,,,,0,other,2070.00,21072.10,There are no additional notes associated with this service or procedure.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],29367.82,,"Fee schedule rate ($29,367.82). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.7), with a minimum of zero.",,,,0,other,12527.66,29917.96,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],72151.96,,"Fee schedule rate ($72,151.96). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,27944.96,86252.84,There are no additional notes associated with this service or procedure.
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC",514,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],8868.04,,"Case rate ($8,868.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,385.35, add-ons for qualifying new technology services are included. If operating cost exceeds $43,256.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,266.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $6,416.74 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,440.40 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $506.34. The transfer capital threshold is the transfer adjustment factor * $506.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8868.04,22699.91,Inpatient DRG
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],6524.75,,"Case rate ($6,214.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,916.41, add-ons for qualifying new technology services are included. If operating cost exceeds $40,787.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,072.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $3,956.88 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,971.47 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $312.24. The transfer capital threshold is the transfer adjustment factor * $312.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6214.05,15318.94,Inpatient DRG
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],8487.31,,"Case rate ($8,083.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,655.19, add-ons for qualifying new technology services are included. If operating cost exceeds $42,526.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,208.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,689.27 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,710.24 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $448.94. The transfer capital threshold is the transfer adjustment factor * $448.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7884.32,17835.23,Inpatient DRG
"OTHER SKIN SUBCUTANEOUS TISSUE AND BREAST DISORDERS,MINOR",385,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],4735.29,,"Case rate ($4,735.29). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,4735.29,4972.05,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],6965.00,,,,,,0,other,6965.00,21195.68,There are no additional notes associated with this service or procedure.
Dstr Nrolytc Agnt Parverteb Fct Addl Lmbr/Sacral|RIGHT SIDE,CASE-64636,APC,64636,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1827.80,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1827.80,1919.19,OPPS APC
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6521.48,,"Case rate ($6,210.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,921.46, add-ons for qualifying new technology services are included. If operating cost exceeds $40,792.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,064.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $3,961.49 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,976.51 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $304.49. The transfer capital threshold is the transfer adjustment factor * $304.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6340.03,15076.44,Inpatient DRG
CESAREAN SECTION WITHOUT STERILIZATION WITH MCC,786,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],13377.80,,"Case rate ($13,115.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,336.66, add-ons for qualifying new technology services are included. If operating cost exceeds $47,207.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,576.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $10,353.53 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,391.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $817.00. The transfer capital threshold is the transfer adjustment factor * $817.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,12612.10,23722.94,Inpatient DRG
HC Inject Tendon Origin/Insert|LEFT SIDE,CASE-20551,APC,20551,CPT,0361,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],301.68,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,287.31,301.68,OPPS APC
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],28235.64,,"Fee schedule rate ($28,235.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,14344.60,36028.59,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITHOUT CC/MCC,428,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],40817.88,,"Case rate ($40,017.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $37,363.07, add-ons for qualifying new technology services are included. If operating cost exceeds $72,234.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,544.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $35,288.01 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $35,418.12 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,784.57. The transfer capital threshold is the transfer adjustment factor * $2,784.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,40017.53,118904.57,Inpatient DRG
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],13634.03,,"Case rate ($12,984.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,215.07, add-ons for qualifying new technology services are included. If operating cost exceeds $47,086.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,567.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $10,232.39 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,270.12 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $807.44. The transfer capital threshold is the transfer adjustment factor * $807.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12984.79,32077.45,Inpatient DRG
"MAJOR BLADDER PROCEDURES,MAJOR",441,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],35284.99,,"Case rate ($35,284.99). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,35284.99,37049.24,There are no additional notes associated with this service or procedure.
HC Inj Anes/Steroid C/D Facet Sg|BILATERAL PROCEDURE,CASE-64490,APC,64490,CPT,0361,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],869.28,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,827.89,869.28,OPPS APC
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,066,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],20083.61,,"Fee schedule rate ($20,083.61). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6579.76,20083.61,There are no additional notes associated with this service or procedure.
PLEURAL EFFUSION WITH MCC,186,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],11720.60,,"Case rate ($11,720.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $11,009.40, add-ons for qualifying new technology services are included. If operating cost exceeds $49,654.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $3,482.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $9,606.87 + an uncompensated DSH payment of $1,359.91. The transfer operating threshold is the transfer adjustment factor * $9,649.48 + an uncompensated DSH payment of $1,359.91. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $753.81. The transfer capital threshold is the transfer adjustment factor * $753.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10804.96,31089.66,Inpatient DRG
CERVICAL SPINAL FUSION WITH MCC,471,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],35338.17,,"Case rate ($34,645.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $32,365.35, add-ons for qualifying new technology services are included. If operating cost exceeds $67,236.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,151.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $30,308.64 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $30,420.39 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,391.65. The transfer capital threshold is the transfer adjustment factor * $2,391.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,34645.26,111337.93,Inpatient DRG
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITH MCC OR ANTINEOPLASTIC IMPLANT OR EPILEPSY WITH NEUROSTIMULATOR,023,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],72504.95,,"Fee schedule rate ($72,504.95). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,15168.00,136379.44,There are no additional notes associated with this service or procedure.
HC Inj Tendon Sheath/Ligament|PBB CHARGE,CASE-20550,APC,20550,CPT,0510,RC,,,PBB,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],301.68,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,287.31,301.68,OPPS APC
"CARDIAC ARREST, UNEXPLAINED WITH MCC",296,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],36459.67,,"Fee schedule rate ($36,459.67). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12522.25,36459.67,There are no additional notes associated with this service or procedure.
Open Biopsy/Excision Inguinofemoral Nodes|RIGHT SIDE,CASE-38531,APC,38531,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6526.12,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6215.36,6526.12,OPPS APC
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],11809.42,,"Case rate ($11,247.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,598.51, add-ons for qualifying new technology services are included. If operating cost exceeds $45,469.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,440.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,621.77 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,653.56 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $680.34. The transfer capital threshold is the transfer adjustment factor * $680.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,11247.07,27028.33,Inpatient DRG
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],23870.71,,"Fee schedule rate ($23,870.71). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10626.74,25225.91,There are no additional notes associated with this service or procedure.
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],27832.43,,"Fee schedule rate ($27,832.43). Adds an outlier to normal pricing equal to the per diem rate ($62,521.14) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.7), with a minimum of zero.",,,,0,other,11974.38,29141.64,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],11446.55,,"Case rate ($11,059.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,424, add-ons for qualifying new technology services are included. If operating cost exceeds $45,295.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,426.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $8,447.91 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,479.05 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $666.62. The transfer capital threshold is the transfer adjustment factor * $666.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,11059.47,28423.20,Inpatient DRG
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],36127.48,,"Case rate ($34,407.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $32,204.39, add-ons for qualifying new technology services are included. If operating cost exceeds $67,075.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,077.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.3. The base transfer operating payment is the transfer adjustment factor * $30,145.14 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $30,259.44 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,317.03. The transfer capital threshold is the transfer adjustment factor * $2,317.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,35389.50,101083.00,Inpatient DRG
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],48961.48,,"Fee schedule rate ($48,961.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11575.50,48961.48,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,448,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],31311.40,,"Case rate ($29,820.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $27,928.88, add-ons for qualifying new technology services are included. If operating cost exceeds $62,799.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,749.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $25,885.78 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $25,983.93 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,989.64. The transfer capital threshold is the transfer adjustment factor * $1,989.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,30663.95,94077.13,Inpatient DRG
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],8982.23,,"Case rate ($8,554.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,093.67, add-ons for qualifying new technology services are included. If operating cost exceeds $42,964.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,243.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,126.13 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,148.72 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $483.41. The transfer capital threshold is the transfer adjustment factor * $483.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8554.50,19204.75,Inpatient DRG
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],5065.00,,"Per diem ($5,065). If length of stay < 2.1, first 1 days paid at a per diem of $10,130 instead. Capped at $10,636.84.",,,,0,other,5065.00,12558.65,Estimated amount calculated based on 2 day length of stay.
Low cost skin substitute app,CASE-C5275,APC,C5275,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],693.76,,"APC Price ($660.72). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,660.72,693.76,OPPS APC
Dbrdmt Fx&/Dislc Subq T/M/F Bone,CASE-11012,APC,11012,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7131.59,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,7029.71,7131.59,OPPS APC
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],41944.25,,"Fee schedule rate ($41,944.25). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12795.84,41944.25,There are no additional notes associated with this service or procedure.
Dstrj Lesion Anus Extensive,CASE-46924,APC,46924,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],2689.02,,"APC Price ($2,598.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2598.08,2727.99,OPPS APC
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC,831,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],9294.42,,"Fee schedule rate ($9,294.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,4941.30,23661.59,There are no additional notes associated with this service or procedure.
Unlisted Laparoscopic Procedure Liver,CASE-47379,APC,47379,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5658.76,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5658.76,5941.70,OPPS APC
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],8389.90,,"Case rate ($8,106.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,676.61, add-ons for qualifying new technology services are included. If operating cost exceeds $42,547.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,210.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,710.61 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,731.66 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $450.62. The transfer capital threshold is the transfer adjustment factor * $450.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,8106.18,18245.94,Inpatient DRG
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],13792.01,,"Case rate ($13,792.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,966.02, add-ons for qualifying new technology services are included. If operating cost exceeds $47,837.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,626.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $10,980.58 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,021.07 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $866.48. The transfer capital threshold is the transfer adjustment factor * $866.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,34422.94,Inpatient DRG
PERIPHERAL VASCULAR DISORDERS WITH CC,300,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],20061.53,,"Fee schedule rate ($20,061.53). Adds an outlier to normal pricing equal to the per diem rate ($49,296.97) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.9), with a minimum of zero.",,,,0,other,9174.14,21005.20,There are no additional notes associated with this service or procedure.
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],20426.70,,"Fee schedule rate ($20,426.70). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,15821.59,40320.14,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL OBSTRUCTION WITH CC,389,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],16423.43,,"Fee schedule rate ($16,423.43). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5118.00,16423.43,There are no additional notes associated with this service or procedure.
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12488.77,,"Case rate ($11,894.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,218.97, add-ons for qualifying new technology services are included. If operating cost exceeds $46,089.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,470.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,238.99 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,274.02 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $710.13. The transfer capital threshold is the transfer adjustment factor * $710.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12195.15,39424.57,Inpatient DRG
NERVOUS SYSTEM NEOPLASMS WITH MCC,054,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],25589.03,,"Fee schedule rate ($25,589.03). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,6965.00,30044.81,There are no additional notes associated with this service or procedure.
"LIMB REATTACHMENT, HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA",956,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],27428.25,,"Case rate ($27,428.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $25,651.53, add-ons for qualifying new technology services are included. If operating cost exceeds $60,522.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,623.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $23,619.49 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $23,706.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,863.81. The transfer capital threshold is the transfer adjustment factor * $1,863.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,27428.25,148259.86,Inpatient DRG
CESAREAN SECTION WITH STERILIZATION WITHOUT CC/MCC,785,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],20142.33,,"Fee schedule rate ($20,142.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8431.24,20142.33,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,447,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],156646.82,,"Fee schedule rate ($156,646.82). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,47193.21,156646.82,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC,087,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],8546.33,,"Case rate ($8,139.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,707.48, add-ons for qualifying new technology services are included. If operating cost exceeds $42,578.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,213.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $5,741.36 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,762.53 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $453.05. The transfer capital threshold is the transfer adjustment factor * $453.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8139.36,22679.07,Inpatient DRG
PERIPHERAL VASCULAR DISORDERS WITH CC,300,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],9632.85,,"Case rate ($9,174.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,670.11, add-ons for qualifying new technology services are included. If operating cost exceeds $43,541.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,288.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,700.45 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,725.16 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $528.73. The transfer capital threshold is the transfer adjustment factor * $528.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9174.14,21005.20,Inpatient DRG
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],38378.80,,"Fee schedule rate ($38,378.80). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,14370.36,38378.80,There are no additional notes associated with this service or procedure.
HC Non Stress Test,CASE-59025,APC,59025,CPT,0920,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],189.24,,"APC Price ($189.24). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,189.24,198.70,OPPS APC
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,091,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],40030.81,,"Fee schedule rate ($40,030.81). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,13838.06,40030.81,There are no additional notes associated with this service or procedure.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,025,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],13351.00,,"Per diem ($13,351). If length of stay < 6.4, first 1 days paid at a per diem of $26,702 instead. Capped at $85,446.13.",,,,0,other,13351.00,91631.33,Estimated amount calculated based on 4 day length of stay.
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level|RIGHT SIDE,CASE-64483,APC,64483,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],856.86,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,827.89,869.28,OPPS APC
NERVOUS SYSTEM NEOPLASMS WITH MCC,054,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],14182.35,,"Fee schedule rate ($14,182.35). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,6965.00,30044.81,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],96365.69,,"Fee schedule rate ($96,365.69). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,23377.19,96365.69,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],23899.13,,"Fee schedule rate ($23,899.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9795.13,23899.13,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],12808.03,,"Case rate ($12,808.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,050.64, add-ons for qualifying new technology services are included. If operating cost exceeds $46,921.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,554.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $10,068.57 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,105.69 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $794.51. The transfer capital threshold is the transfer adjustment factor * $794.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7353.00,33398.16,Inpatient DRG
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC,832,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],4803.31,,"Fee schedule rate ($4,803.31). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4803.31,14198.92,There are no additional notes associated with this service or procedure.
"HERNIA PROCEDURES EXCEPT INGUINAL FEMORAL AND UMBILICAL,MODERATE",227,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],3765.73,,"Case rate for a one day stay ($3,586.41). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,3586.41,3765.73,There are no additional notes associated with this service or procedure.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],11440.26,,"Case rate ($11,053.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,418.34, add-ons for qualifying new technology services are included. If operating cost exceeds $45,289.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,426.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $8,442.26 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,473.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $666.18. The transfer capital threshold is the transfer adjustment factor * $666.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,11053.39,36776.05,Inpatient DRG
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6330.99,,"Case rate ($6,029.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,752.35, add-ons for qualifying new technology services are included. If operating cost exceeds $40,623.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,051.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,793.02 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,807.40 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $291.54. The transfer capital threshold is the transfer adjustment factor * $291.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6153.12,13947.32,Inpatient DRG
BRONCHITIS AND ASTHMA WITHOUT CC/MCC,203,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],6965.00,,,,,,0,other,4763.76,13707.00,There are no additional notes associated with this service or procedure.
HC Breath Hydrogen/Met Test,CASE-91065,APC,91065,CPT,0920,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],202.11,,"APC Price ($202.11). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,202.11,212.21,OPPS APC
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,394,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],20909.61,,"Fee schedule rate ($20,909.61). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8281.56,20909.61,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],46523.26,,"Fee schedule rate ($46,523.26). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,17782.11,46523.26,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],16628.38,,"Case rate ($16,066.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,081.53, add-ons for qualifying new technology services are included. If operating cost exceeds $49,952.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,792.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $13,088.32 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,136.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,032.80. The transfer capital threshold is the transfer adjustment factor * $1,032.80. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6965.00,41030.48,Inpatient DRG
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],11734.41,,"Case rate ($11,175.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,549.28, add-ons for qualifying new technology services are included. If operating cost exceeds $45,420.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,418.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $8,571.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,604.33 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $658.85. The transfer capital threshold is the transfer adjustment factor * $658.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,11454.97,28394.78,Inpatient DRG
Arthrd Ant Interdy Cervcl Belw C2 Ea Addl Ntrspc,CASE-22552,APC,22552,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],12017.31,,"APC Price ($12,017.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12017.31,12618.18,OPPS APC
GASTROINTESTINAL OBSTRUCTION WITH CC,389,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],16423.43,,"Fee schedule rate ($16,423.43). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5118.00,16423.43,There are no additional notes associated with this service or procedure.
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC,797,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],20928.55,,"Fee schedule rate ($20,928.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8719.72,20928.55,There are no additional notes associated with this service or procedure.
Cysto W/Urtroscopy&/Pyeloscopy Dx|UNUSUAL NON-OVERLAPPING SERVICE,CASE-52351,APC,52351,CPT,0360,RC,,,XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3464.44,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3299.47,3464.44,OPPS APC
Sigmoidoscopy Flx Control Bleeding,CASE-45334,APC,45334,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1176.09,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1120.09,1176.09,OPPS APC
VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC,033,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],42156.44,,"Fee schedule rate ($42,156.44). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,13206.23,42156.44,There are no additional notes associated with this service or procedure.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],20553.44,,"Fee schedule rate ($20,553.44). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8874.81,20553.44,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],59610.47,,"Fee schedule rate ($59,610.47). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,16129.04,59610.47,There are no additional notes associated with this service or procedure.
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],35474.53,,"Fee schedule rate ($35,474.53). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,16428.39,42083.20,There are no additional notes associated with this service or procedure.
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],11539.21,,"Case rate ($10,989.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,359.11, add-ons for qualifying new technology services are included. If operating cost exceeds $45,230.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,421.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $8,383.26 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,414.17 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $661.52. The transfer capital threshold is the transfer adjustment factor * $661.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10989.72,26280.60,Inpatient DRG
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],52699.33,,"Fee schedule rate ($52,699.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,18105.81,52699.33,There are no additional notes associated with this service or procedure.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],58320.32,,"Fee schedule rate ($58,320.32). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,16286.16,58320.32,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],13642.55,,"Case rate ($12,992.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,222.63, add-ons for qualifying new technology services are included. If operating cost exceeds $47,093.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,568.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $10,239.92 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,277.68 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $808.03. The transfer capital threshold is the transfer adjustment factor * $808.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7665.00,40737.46,Inpatient DRG
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],8480.00,,"Per diem ($8,480). If length of stay < 5.5, first 1 days paid at a per diem of $16,960 instead. Capped at $46,638.59.",,,,0,other,8480.00,59081.91,Estimated amount calculated based on 3 day length of stay.
SPINAL PROCEDURES WITHOUT CC/MCC,030,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],41254.39,,"Fee schedule rate ($41,254.39). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,16810.99,44714.01,There are no additional notes associated with this service or procedure.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,191,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],8036.50,,"Case rate ($7,653.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,255.78, add-ons for qualifying new technology services are included. If operating cost exceeds $42,126.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,177.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,291.32 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,310.83 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $417.54. The transfer capital threshold is the transfer adjustment factor * $417.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,16612.88,Inpatient DRG
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],32168.63,,"Fee schedule rate ($32,168.63). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,13904.43,34749.58,There are no additional notes associated with this service or procedure.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC,862,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],28705.48,,"Fee schedule rate ($28,705.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (42), with a minimum of zero.",,,,0,other,6855.00,35884.94,There are no additional notes associated with this service or procedure.
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],13478.34,,"Fee schedule rate ($13,478.34). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,6801.88,22557.82,There are no additional notes associated with this service or procedure.
Esophagoscopy Intra/Transmural Needle Aspirat/Bx,CASE-43232,APC,43232,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1796.14,,"APC Price ($1,796.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1796.14,1885.95,OPPS APC
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC",281,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],8577.61,,"Case rate ($8,169.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,735.20, add-ons for qualifying new technology services are included. If operating cost exceeds $42,606.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,215.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $5,768.98 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,790.25 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $455.23. The transfer capital threshold is the transfer adjustment factor * $455.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8169.15,23859.35,Inpatient DRG
"Fasct Prtl Palmr Addl Dgt Prox Iphal Jt W/WO Rpr|RIGHT HAND, FOURTH DIGIT",CASE-26125,APC,26125,CPT,0360,RC,,,F8,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],86252.84,,"Fee schedule rate ($86,252.84). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,27944.96,86252.84,There are no additional notes associated with this service or procedure.
SINGLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL,402,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],29790.92,,"Case rate ($28,372.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $26,579.07, add-ons for qualifying new technology services are included. If operating cost exceeds $61,450.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,646.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $24,541.07 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $24,634.12 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,886.28. The transfer capital threshold is the transfer adjustment factor * $1,886.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,29172.05,124455.45,Inpatient DRG
Prq Impltj Neurostimulator Eltrd Peripheral Nrv,CASE-64555,APC,64555,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5965.28,,"APC Price ($5,965.28). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5965.28,6263.54,OPPS APC
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],8218.58,,"Case rate ($8,057.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,631.26, add-ons for qualifying new technology services are included. If operating cost exceeds $42,502.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,207.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,665.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,686.30 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $447.06. The transfer capital threshold is the transfer adjustment factor * $447.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6524.00,17760.46,Inpatient DRG
"OPEN CRANIOTOMY EXCEPT TRAUMA,EXTREME",021,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],66079.19,,"Case rate ($62,932.56). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $56,008, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,62932.56,66079.19,There are no additional notes associated with this service or procedure.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],38517.10,,"Fee schedule rate ($38,517.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,16897.01,43444.85,There are no additional notes associated with this service or procedure.
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],11170.89,,"Case rate ($10,638.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,032.78, add-ons for qualifying new technology services are included. If operating cost exceeds $44,903.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,395.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,058.12 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,087.83 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $635.87. The transfer capital threshold is the transfer adjustment factor * $635.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10638.94,25261.33,Inpatient DRG
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],24444.75,,"Fee schedule rate ($24,444.75). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10136.44,24444.75,There are no additional notes associated with this service or procedure.
"VAGINAL DELIVERY,MINOR",560,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],3906.04,,"Case rate ($3,720.04). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,3720.04,3906.04,There are no additional notes associated with this service or procedure.
SALIVARY GLAND PROCEDURES,139,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],23222.51,,"Fee schedule rate ($23,222.51). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.9), with a minimum of zero.",,,,0,other,10313.19,30690.92,There are no additional notes associated with this service or procedure.
SPINAL PROCEDURES WITHOUT CC/MCC,030,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],44714.01,,"Fee schedule rate ($44,714.01). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,16810.99,44714.01,There are no additional notes associated with this service or procedure.
SEIZURES WITH MCC,100,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],17184.76,,"Fee schedule rate ($17,184.76). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,15061.09,38110.41,There are no additional notes associated with this service or procedure.
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],6965.00,,,,,,0,other,6965.00,21089.59,There are no additional notes associated with this service or procedure.
HC Joint Injection/Aspir Large WO US|PBB CHARGE|RIGHT SIDE,CASE-20610,APC,20610,CPT,0510,RC,,,PBB|RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],301.68,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,287.31,301.68,OPPS APC
"OPEN CRANIOTOMY EXCEPT TRAUMA,EXTREME",021,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],62932.56,,"Case rate ($62,932.56). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $56,008, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,62932.56,66079.19,There are no additional notes associated with this service or procedure.
ALLERGIC REACTIONS WITH MCC,915,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],31602.31,,"Fee schedule rate ($31,602.31). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.8), with a minimum of zero.",,,,0,other,13332.86,33088.84,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITH MCC,385,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],29736.16,,"Fee schedule rate ($29,736.16). Adds an outlier to normal pricing equal to the per diem rate ($112,108.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.5), with a minimum of zero.",,,,0,other,11480.01,31134.92,There are no additional notes associated with this service or procedure.
HEART FAILURE AND SHOCK WITH CC,292,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],13465.25,,"Case rate ($7,694.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,293.57, add-ons for qualifying new technology services are included. If operating cost exceeds $42,164.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,180.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,328.98 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,348.63 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $420.51. The transfer capital threshold is the transfer adjustment factor * $420.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,5502.00,16705.77,All Other Inpatient
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],39424.57,,"Fee schedule rate ($39,424.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12195.15,39424.57,There are no additional notes associated with this service or procedure.
SEIZURES WITH MCC,100,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],32323.98,,"Fee schedule rate ($32,323.98). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,15061.09,38110.41,There are no additional notes associated with this service or procedure.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,056,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],45711.64,,,,,,0,other,7659.00,59328.19,There are no additional notes associated with this service or procedure.
Anrct Xm Surg Req Anes General Spi/Edrl Dx|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-45990,APC,45990,CPT,0360,RC,,,74,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],2598.08,,"APC Price ($2,598.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2598.08,2727.99,OPPS APC
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],14394.57,,"Case rate ($13,907.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,073.74, add-ons for qualifying new technology services are included. If operating cost exceeds $47,944.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,634.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $11,087.92 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,128.80 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $874.95. The transfer capital threshold is the transfer adjustment factor * $874.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,13907.80,52794.06,Inpatient DRG
"Open Tx Articular Fracture Mcp/IP Joint Ea|LEFT HAND, FIFTH DIGIT",CASE-26746,APC,26746,CPT,0360,RC,,,F4,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,270,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],34720.90,,"Case rate ($34,720.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $32,431.98, add-ons for qualifying new technology services are included. If operating cost exceeds $71,076.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $5,156.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.4. The base transfer operating payment is the transfer adjustment factor * $30,933.64 + an uncompensated DSH payment of $1,359.91. The transfer operating threshold is the transfer adjustment factor * $31,072.08 + an uncompensated DSH payment of $1,359.91. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,427.36. The transfer capital threshold is the transfer adjustment factor * $2,427.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,34720.90,101002.04,Inpatient DRG
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],20170.75,,"Fee schedule rate ($20,170.75). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10048.39,23545.50,There are no additional notes associated with this service or procedure.
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],15177.23,,"Fee schedule rate ($15,177.23). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,7414.07,18217.52,There are no additional notes associated with this service or procedure.
Exc Breast Les Preop Plmt Rad Marker Open 1 Les|BILATERAL PROCEDURE,CASE-19125,APC,19125,CPT,0360,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3793.21,,"APC Price ($3,664.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3793.21,3848.19,OPPS APC
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],43399.23,,"Fee schedule rate ($43,399.23). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9888.00,43399.23,There are no additional notes associated with this service or procedure.
Egd Intrmural US Needle Aspirate/Biopsy Esophags,CASE-43238,APC,43238,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1796.14,,"APC Price ($1,796.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1796.14,1885.95,OPPS APC
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,056,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],59328.19,,"Fee schedule rate ($59,328.19). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (44), with a minimum of zero.",,,,0,other,7659.00,59328.19,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],30055.64,,"Fee schedule rate ($30,055.64). Adds an outlier to normal pricing equal to the per diem rate ($74,094.67) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.9), with a minimum of zero.",,,,0,other,12775.53,31469.43,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6214.05,,"Case rate ($6,214.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,916.41, add-ons for qualifying new technology services are included. If operating cost exceeds $40,787.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,072.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $3,956.88 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,971.47 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $312.24. The transfer capital threshold is the transfer adjustment factor * $312.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6214.05,15318.94,Inpatient DRG
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],19545.88,,"Case rate ($18,615.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,483.96, add-ons for qualifying new technology services are included. If operating cost exceeds $52,354.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,949.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $15,480.32 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,539.01 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,189.85. The transfer capital threshold is the transfer adjustment factor * $1,189.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,11348.00,62454.12,Inpatient DRG
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],6130.43,,"Case rate ($6,010.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,726.79, add-ons for qualifying new technology services are included. If operating cost exceeds $40,597.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,057.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,767.95 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,781.84 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $297.33. The transfer capital threshold is the transfer adjustment factor * $297.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6010.23,12246.05,Inpatient DRG
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],23377.19,,"Case rate ($23,377.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $21,882.92, add-ons for qualifying new technology services are included. If operating cost exceeds $56,753.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,327.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $19,864.72 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $19,937.97 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,567.52. The transfer capital threshold is the transfer adjustment factor * $1,567.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,23377.19,96365.69,Inpatient DRG
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],5628.97,,"Case rate ($5,628.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,372.11, add-ons for qualifying new technology services are included. If operating cost exceeds $40,243.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,029.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,414.56 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,427.15 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $269.44. The transfer capital threshold is the transfer adjustment factor * $269.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,5628.97,12272.58,Inpatient DRG
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],81306.30,,"Fee schedule rate ($81,306.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,20846.48,81306.30,There are no additional notes associated with this service or procedure.
"NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY",789,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],3354.00,,,,,,0,other,3054.00,14857.05,Estimated amount calculated based on 1 day length of stay.
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC,833,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5486.07,,"Case rate ($5,486.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,239.18, add-ons for qualifying new technology services are included. If operating cost exceeds $40,110.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,018.96, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $3,282.12 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,294.23 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $258.99. The transfer capital threshold is the transfer adjustment factor * $258.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,3041.73,10289.10,Inpatient DRG
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],12305.53,,"Case rate ($12,305.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,583.18, add-ons for qualifying new technology services are included. If operating cost exceeds $46,454.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,517.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $9,602.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,638.24 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $757.76. The transfer capital threshold is the transfer adjustment factor * $757.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12305.53,30103.84,Inpatient DRG
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],8874.81,,"Case rate ($8,874.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,391.65, add-ons for qualifying new technology services are included. If operating cost exceeds $43,262.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,266.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $6,423.02 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,446.70 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $506.84. The transfer capital threshold is the transfer adjustment factor * $506.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8874.81,20553.44,Inpatient DRG
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],21377.04,,"Fee schedule rate ($21,377.04). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,9648.19,31477.13,There are no additional notes associated with this service or procedure.
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],22557.82,,"Fee schedule rate ($22,557.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6801.88,22557.82,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],2070.00,,,,,,0,other,1188.00,34338.33,Estimated amount calculated based on 6 day length of stay.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],18341.97,,"Fee schedule rate ($18,341.97). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.9), with a minimum of zero.",,,,0,other,8554.50,19204.75,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],34889.29,,,,,,0,other,13917.42,34889.29,There are no additional notes associated with this service or procedure.
Prep Site Trunk/Arm/Leg 1st 100 Sq Cm/1pct,CASE-15002,APC,15002,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],716.00,,"APC Price ($691.79). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,691.79,726.38,OPPS APC
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],22563.61,,"Case rate ($21,489.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,126.50, add-ons for qualifying new technology services are included. If operating cost exceeds $54,997.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,189.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.6. The base transfer operating payment is the transfer adjustment factor * $18,114.76 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,181.55 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,429.43. The transfer capital threshold is the transfer adjustment factor * $1,429.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,21489.15,68942.79,Inpatient DRG
Arthrs Wrst Exc&/Rpr Triang Fibrocart&/Joint|RIGHT SIDE,CASE-29846,APC,29846,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,699,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],9259.53,,"Case rate ($8,818.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,339.37, add-ons for qualifying new technology services are included. If operating cost exceeds $43,210.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,262.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $6,370.92 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,394.41 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $502.73. The transfer capital threshold is the transfer adjustment factor * $502.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5961.00,19972.16,Inpatient DRG
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,098,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],38799.38,,"Fee schedule rate ($38,799.38). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,6965.00,45156.75,There are no additional notes associated with this service or procedure.
HEART FAILURE AND SHOCK WITH CC,292,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],15550.06,,"Fee schedule rate ($15,550.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5502.00,16705.77,There are no additional notes associated with this service or procedure.
HC Joint Injection/Aspir Large WO US|BILATERAL PROCEDURE|PBB CHARGE,CASE-20610,APC,20610,CPT,0510,RC,,,50|PBB,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],301.68,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,287.31,301.68,OPPS APC
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],8163.06,,"Case rate ($8,163.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,729.53, add-ons for qualifying new technology services are included. If operating cost exceeds $42,600.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,214.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,763.33 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,784.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $454.78. The transfer capital threshold is the transfer adjustment factor * $454.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8163.06,18067.42,Inpatient DRG
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],6711.00,,"Per diem ($6,711). If length of stay < 2.4, first 1 days paid at a per diem of $13,422 instead. Capped at $16,107.48.",,,,0,other,6711.00,16865.16,Estimated amount calculated based on 2 day length of stay.
Colonoscopy W/Biopsy Single/Multiple|SEPARATE STRUCTURE,CASE-45380,APC,45380,CPT,0360,RC,,,XS,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1120.09,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1120.09,1176.09,OPPS APC
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,699,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],5961.00,,"Per diem ($5,961). If length of stay < 3.2, first 1 days paid at a per diem of $11,922 instead. Capped at $19,074.90.",,,,0,other,5961.00,19972.16,Estimated amount calculated based on 3 day length of stay.
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC",629,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],44657.18,,"Fee schedule rate ($44,657.18). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,16699.94,44657.18,There are no additional notes associated with this service or procedure.
HEART FAILURE AND SHOCK WITH CC,292,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],15550.06,,"Fee schedule rate ($15,550.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5502.00,16705.77,There are no additional notes associated with this service or procedure.
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],13651.81,,"Case rate ($13,001.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,230.82, add-ons for qualifying new technology services are included. If operating cost exceeds $47,101.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,568.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $10,248.08 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,285.87 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $808.68. The transfer capital threshold is the transfer adjustment factor * $808.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7868.00,32126.64,Inpatient DRG
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],17097.87,,"Fee schedule rate ($17,097.87). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,8106.18,18245.94,There are no additional notes associated with this service or procedure.
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],15145.28,,"Fee schedule rate ($15,145.28). Adds an outlier to normal pricing equal to the per diem rate ($54,966.40) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7402.56,16438.59,There are no additional notes associated with this service or procedure.
Egd Percutaneous Placement Gastrostomy Tube,CASE-43246,APC,43246,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1885.95,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1796.14,1885.95,OPPS APC
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],28983.97,,"Fee schedule rate ($28,983.97). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8956.76,28983.97,There are no additional notes associated with this service or procedure.
Laparoscopic Appendectomy|UNUSUAL NON-OVERLAPPING SERVICE,CASE-44970,APC,44970,CPT,0360,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5658.76,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5658.76,5941.70,OPPS APC
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],23790.06,,"Fee schedule rate ($23,790.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10517.71,24909.11,There are no additional notes associated with this service or procedure.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,074,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],20919.08,,"Fee schedule rate ($20,919.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8925.60,20919.08,There are no additional notes associated with this service or procedure.
Excision Olecranon Bursa|RIGHT SIDE,CASE-24105,APC,24105,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],10998.68,,"Case rate ($10,474.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,896.13, add-ons for qualifying new technology services are included. If operating cost exceeds $44,767.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,368.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $7,921.14 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,951.18 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $608.84. The transfer capital threshold is the transfer adjustment factor * $608.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10733.06,45157.33,Inpatient DRG
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],24368.86,,"Case rate ($23,208.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $21,765.60, add-ons for qualifying new technology services are included. If operating cost exceeds $56,636.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,277.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.8. The base transfer operating payment is the transfer adjustment factor * $19,745.78 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $19,820.65 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,517.71. The transfer capital threshold is the transfer adjustment factor * $1,517.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,23851.92,63653.13,Inpatient DRG
RADIOTHERAPY,849,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],81867.07,,"Fee schedule rate ($81,867.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,20293.88,81867.07,There are no additional notes associated with this service or procedure.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],67460.63,,,,,,0,other,25162.32,75579.22,There are no additional notes associated with this service or procedure.
Laps Tx Ectopic Preg W/Salping&/Oophorectomy,CASE-59151,APC,59151,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5658.76,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5658.76,5941.70,OPPS APC
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC,058,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],32126.63,,"Fee schedule rate ($32,126.63). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13521.80,40853.02,There are no additional notes associated with this service or procedure.
Intraop Sentinel Lymph Node ID W/Dye Injection|LEFT SIDE,CASE-38900,APC,38900,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6432.89,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6215.36,6526.12,OPPS APC
Colonoscopy W/Biopsy Single/Multiple|UNUSUAL NON-OVERLAPPING SERVICE,CASE-45380,APC,45380,CPT,0360,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1120.09,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1120.09,1176.09,OPPS APC
"LIMB REATTACHMENT, HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA",956,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],28799.66,,"Case rate ($27,428.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $25,651.53, add-ons for qualifying new technology services are included. If operating cost exceeds $60,522.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,623.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $23,619.49 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $23,706.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,863.81. The transfer capital threshold is the transfer adjustment factor * $1,863.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,27428.25,148259.86,Inpatient DRG
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],10201.52,,"Case rate ($9,715.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,188.44, add-ons for qualifying new technology services are included. If operating cost exceeds $44,059.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,314.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $7,216.13 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,243.49 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $554.65. The transfer capital threshold is the transfer adjustment factor * $554.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7243.75,23262.15,Inpatient DRG
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],11274.46,,"Case rate ($11,053.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,418.34, add-ons for qualifying new technology services are included. If operating cost exceeds $45,289.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,426.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $8,442.26 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,473.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $666.18. The transfer capital threshold is the transfer adjustment factor * $666.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,11053.39,36776.05,Inpatient DRG
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],7956.52,,"Case rate ($7,956.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,537.38, add-ons for qualifying new technology services are included. If operating cost exceeds $42,408.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,199.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,571.89 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,592.43 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $439.68. The transfer capital threshold is the transfer adjustment factor * $439.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,17467.27,Inpatient DRG
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],7921.00,,"Per diem ($7,921). If length of stay < 4.1, first 1 days paid at a per diem of $15,842 instead. Capped at $32,474.30.",,,,0,other,7921.00,45706.73,Estimated amount calculated based on 2 day length of stay.
MAJOR BLADDER PROCEDURES WITH MCC,653,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],10280.00,,"Per diem ($10,280). If length of stay < 9.5, first 1 days paid at a per diem of $20,560 instead. Capped at $97,655.95.",,,,0,other,10280.00,125343.98,Estimated amount calculated based on 10 day length of stay.
APPENDIX PROCEDURES WITH MCC,397,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],45007.36,,"Fee schedule rate ($45,007.36). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.5), with a minimum of zero.",,,,0,other,18163.37,51558.84,There are no additional notes associated with this service or procedure.
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],12101.45,,"Fee schedule rate ($12,101.45). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6230.00,22762.43,There are no additional notes associated with this service or procedure.
Colonoscopy Flx Dx W/Collj Spec When Pfrmd,CASE-45378,APC,45378,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],870.46,,"APC Price ($870.46). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,870.46,913.99,OPPS APC
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],15920.80,,"Case rate ($9,097.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,598.92, add-ons for qualifying new technology services are included. If operating cost exceeds $43,469.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,283.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,629.53 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,653.97 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $523.14. The transfer capital threshold is the transfer adjustment factor * $523.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,9097.60,21455.22,All Other Inpatient
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],33608.45,,"Fee schedule rate ($33,608.45). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,7332.00,35314.31,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],19371.27,,"Fee schedule rate ($19,371.27). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7641.61,19371.27,There are no additional notes associated with this service or procedure.
Cysto W/Urtroscopy&/Pyeloscopy Dx|LEFT SIDE,CASE-52351,APC,52351,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3464.44,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3299.47,3464.44,OPPS APC
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],23954.07,,"Fee schedule rate ($23,954.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,6167.00,29058.99,There are no additional notes associated with this service or procedure.
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],13482.55,,"Case rate ($12,840.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,080.88, add-ons for qualifying new technology services are included. If operating cost exceeds $46,951.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,556.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $10,098.70 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,135.93 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $796.89. The transfer capital threshold is the transfer adjustment factor * $796.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,1188.00,31658.33,Inpatient DRG
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],35389.50,,"Case rate ($35,389.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $33,057.71, add-ons for qualifying new technology services are included. If operating cost exceeds $67,928.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,206.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.3. The base transfer operating payment is the transfer adjustment factor * $30,998.46 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $31,112.76 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,446.08. The transfer capital threshold is the transfer adjustment factor * $2,446.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,35389.50,101083.00,Inpatient DRG
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITH MCC,429,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],66106.51,,"Case rate ($62,958.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $58,704.65, add-ons for qualifying new technology services are included. If operating cost exceeds $93,575.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $6,222.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.6. The base transfer operating payment is the transfer adjustment factor * $56,551.19 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $56,759.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,462.45. The transfer capital threshold is the transfer adjustment factor * $4,462.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,62958.58,177294.98,Inpatient DRG
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],14718.75,,"Case rate ($14,017.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,198.65, add-ons for qualifying new technology services are included. If operating cost exceeds $48,069.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,621.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,211.19 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,253.70 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $861.72. The transfer capital threshold is the transfer adjustment factor * $861.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,36140.75,Inpatient DRG
Submucous Rescj Inferior Turbinate Prtl/Compl|RIGHT SIDE,CASE-30140,APC,30140,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6605.95,,"APC Price ($6,605.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6605.95,6936.25,OPPS APC
"Laminec/Facetect/Foramin,Cervical",CASE-63045,APC,63045,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
HC Joint Injection/Aspir Large WO US|SEPARATE STRUCTURE|LEFT SIDE,CASE-20610,APC,20610,CPT,0510,RC,,,XS|LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],297.37,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,287.31,301.68,OPPS APC
VENTRICULAR SHUNT PROCEDURES WITH MCC,031,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],32932.94,,"Case rate ($32,287.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $30,171.71, add-ons for qualifying new technology services are included. If operating cost exceeds $65,042.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,979.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7. The base transfer operating payment is the transfer adjustment factor * $28,123.07 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $28,226.76 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,219.19. The transfer capital threshold is the transfer adjustment factor * $2,219.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,32287.20,88162.80,Inpatient DRG
Laps Fulg/Exc Ovary Viscera/Peritoneal Surface|BILATERAL PROCEDURE,CASE-58662,APC,58662,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5658.76,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5658.76,5941.70,OPPS APC
SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS,029,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],13641.00,,"Per diem ($13,641). If length of stay < 4.7, first 1 days paid at a per diem of $27,282 instead. Capped at $64,114.20.",,,,0,other,13641.00,67130.05,Estimated amount calculated based on 5 day length of stay.
HC Cv Cath Plac W/Port Tun >5,CASE-36561,APC,36561,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],2955.48,,"APC Price ($2,955.48). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2955.48,3103.25,OPPS APC
NON-MALIGNANT BREAST DISORDERS WITH CC/MCC,600,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],9231.13,,"Case rate ($8,791.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,326.97, add-ons for qualifying new technology services are included. If operating cost exceeds $43,197.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,248.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $6,357.91 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,382.02 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $488.68. The transfer capital threshold is the transfer adjustment factor * $488.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7999.14,20495.56,Inpatient DRG
SPINAL PROCEDURES WITH MCC,028,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],120982.83,,"Fee schedule rate ($120,982.83). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,42633.57,120982.83,There are no additional notes associated with this service or procedure.
DIABETES WITH CC,638,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],16842.29,,"Fee schedule rate ($16,842.29). Adds an outlier to normal pricing equal to the per diem rate ($39,561.63) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,8014.07,17634.53,There are no additional notes associated with this service or procedure.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],5569.00,,"Per diem ($5,569). If length of stay < 3.8, first 1 days paid at a per diem of $11,138 instead. Capped at $21,162.80.",,,,0,other,5569.00,40108.48,Estimated amount calculated based on 2 day length of stay.
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],32168.63,,"Fee schedule rate ($32,168.63). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,13904.43,34749.58,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],41580.51,,"Fee schedule rate ($41,580.51). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,13783.20,41580.51,There are no additional notes associated with this service or procedure.
"CARDIAC ARREST, UNEXPLAINED WITH MCC",296,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],20207.25,,"Fee schedule rate ($20,207.25). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12522.25,36459.67,There are no additional notes associated with this service or procedure.
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC,797,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],13416.00,,,,,,0,other,8719.72,20928.55,There are no additional notes associated with this service or procedure.
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],33835.79,,"Fee schedule rate ($33,835.79). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,7000.00,33835.79,There are no additional notes associated with this service or procedure.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],38248.08,,"Fee schedule rate ($38,248.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11593.79,38248.08,There are no additional notes associated with this service or procedure.
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],5937.41,,"Fee schedule rate ($5,937.41). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5937.41,12366.99,There are no additional notes associated with this service or procedure.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,073,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],12809.38,,"Case rate ($12,809.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,051.90, add-ons for qualifying new technology services are included. If operating cost exceeds $46,922.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,554.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $10,069.82 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,106.95 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $794.61. The transfer capital threshold is the transfer adjustment factor * $794.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12809.38,43475.01,Inpatient DRG
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,394,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],17584.61,,"Fee schedule rate ($17,584.61). Adds an outlier to normal pricing equal to the per diem rate ($53,248.69) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,8281.56,20909.61,There are no additional notes associated with this service or procedure.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],31626.74,,"Fee schedule rate ($31,626.74). Adds an outlier to normal pricing equal to the per diem rate ($86,383.13) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,13341.67,42586.49,There are no additional notes associated with this service or procedure.
VENTRICULAR SHUNT PROCEDURES WITH MCC,031,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],62406.76,,"Fee schedule rate ($62,406.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,32287.20,88162.80,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6793.93,,"Case rate ($6,564.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,242.12, add-ons for qualifying new technology services are included. If operating cost exceeds $41,113.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,097.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $4,281.39 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,297.17 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $337.84. The transfer capital threshold is the transfer adjustment factor * $337.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6564.18,17651.07,Inpatient DRG
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],7389.00,,"Per diem ($7,389). If length of stay < 4.8, first 1 days paid at a per diem of $14,778 instead. Capped at $35,466.15.",,,,0,other,7389.00,37134.43,Estimated amount calculated based on 6 day length of stay.
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],6965.00,,,,,,0,other,6965.00,16400.70,There are no additional notes associated with this service or procedure.
Nasal/Sinus Ndsc W/Rmvl Tiss From Frontal Sinus,CASE-31276,APC,31276,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6936.25,,"APC Price ($6,605.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6605.95,6936.25,OPPS APC
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,191,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],7653.81,,"Case rate ($7,653.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,255.78, add-ons for qualifying new technology services are included. If operating cost exceeds $42,126.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,177.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,291.32 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,310.83 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $417.54. The transfer capital threshold is the transfer adjustment factor * $417.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,16612.88,Inpatient DRG
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],11065.78,,"Fee schedule rate ($11,065.78). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5883.03,17111.12,There are no additional notes associated with this service or procedure.
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH MCC",510,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],59434.38,,,,,,0,other,10710.00,89863.76,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,555,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],24840.59,,"Fee schedule rate ($24,840.59). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10896.27,42290.95,There are no additional notes associated with this service or procedure.
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],40426.76,,"Fee schedule rate ($40,426.76). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,11914.12,40426.76,There are no additional notes associated with this service or procedure.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC",494,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],15843.76,,"Case rate ($15,533.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,585.72, add-ons for qualifying new technology services are included. If operating cost exceeds $49,456.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,753.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $12,594.34 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,640.78 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $993.82. The transfer capital threshold is the transfer adjustment factor * $993.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,15533.10,39945.55,Inpatient DRG
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],61234.06,,"Fee schedule rate ($61,234.06). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11165.00,61234.06,There are no additional notes associated with this service or procedure.
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC",458,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],132827.25,,"Fee schedule rate ($132,827.25). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,30202.09,132827.25,There are no additional notes associated with this service or procedure.
"Suture Digital Nerve Hand/Foot 1 Nerve|LEFT HAND, THUMB",CASE-64831,APC,64831,CPT,0360,RC,,,FA,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],13194.59,,"Case rate ($12,566.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,825.74, add-ons for qualifying new technology services are included. If operating cost exceeds $46,696.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,536.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $9,844.49 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,880.79 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $776.83. The transfer capital threshold is the transfer adjustment factor * $776.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12566.28,30861.41,Inpatient DRG
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],16055.90,,"Fee schedule rate ($16,055.90). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8163.06,18067.42,There are no additional notes associated with this service or procedure.
Thyroidectomy Total/Complete,CASE-60240,APC,60240,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5658.76,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5658.76,5941.70,OPPS APC
NONTRAUMATIC STUPOR AND COMA WITH MCC,080,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],14534.47,,"Case rate ($13,842.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,035.05, add-ons for qualifying new technology services are included. If operating cost exceeds $47,906.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,609.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $11,048.21 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,090.10 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $849.19. The transfer capital threshold is the transfer adjustment factor * $849.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,14202.39,35615.37,Inpatient DRG
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],43399.23,,"Fee schedule rate ($43,399.23). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9888.00,43399.23,There are no additional notes associated with this service or procedure.
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],16235.87,,"Fee schedule rate ($16,235.87). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6524.00,17760.46,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITH CC,164,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],77058.83,,"Fee schedule rate ($77,058.83). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,19037.66,77058.83,There are no additional notes associated with this service or procedure.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],29917.96,,"Fee schedule rate ($29,917.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,12527.66,29917.96,There are no additional notes associated with this service or procedure.
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],7147.93,,"Case rate ($7,147.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,785.17, add-ons for qualifying new technology services are included. If operating cost exceeds $41,656.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,140.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $4,822.44 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,840.22 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $380.54. The transfer capital threshold is the transfer adjustment factor * $380.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,16400.70,Inpatient DRG
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC",011,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],150008.48,,"Fee schedule rate ($150,008.48). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (44), with a minimum of zero.",,,,0,other,38880.49,150008.48,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],33398.16,,"Fee schedule rate ($33,398.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,7353.00,33398.16,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],6963.00,,"Per diem ($6,963). If length of stay < 2.6, first 1 days paid at a per diem of $13,926 instead. Capped at $18,103.30.",,,,0,other,6963.00,18954.85,Estimated amount calculated based on 3 day length of stay.
"HC Excis Nail Matrix Perm Rmvl|LEFT FOOT, GREAT TOE|UNUSUAL NON-OVERLAPPING SERVICE",CASE-11750,APC,11750,CPT,0450,RC,,,TA|XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3169.86,OPPS APC
CESAREAN SECTION WITHOUT STERILIZATION WITH MCC,786,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],23722.94,,"Fee schedule rate ($23,722.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12612.10,23722.94,There are no additional notes associated with this service or procedure.
Laps Surg Rpr Recurrent Inguinal Hernia|BILATERAL PROCEDURE,CASE-49651,APC,49651,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5658.76,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5658.76,5941.70,OPPS APC
HC Non Stress Test,CASE-59025,APC,59025,CPT,0920,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],195.86,,"APC Price ($189.24). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,189.24,198.70,OPPS APC
Mastectomy Simple Complete|LEFT SIDE,CASE-19303,APC,19303,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6526.12,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6215.36,6526.12,OPPS APC
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],59021.28,,"Fee schedule rate ($59,021.28). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,23851.92,63653.13,There are no additional notes associated with this service or procedure.
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],41190.50,,"Fee schedule rate ($41,190.50). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,16787.98,62990.26,There are no additional notes associated with this service or procedure.
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,068,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],6965.00,,,,,,0,other,6965.00,23184.90,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,064,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],41838.16,,"Fee schedule rate ($41,838.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,15563.58,41838.16,There are no additional notes associated with this service or procedure.
PREMATURITY WITHOUT MAJOR PROBLEMS,792,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],11512.88,,"Fee schedule rate ($11,512.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,1956.00,19457.66,There are no additional notes associated with this service or procedure.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,479,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],50518.76,,"Fee schedule rate ($50,518.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,10586.00,50518.76,There are no additional notes associated with this service or procedure.
HYPERTENSION WITHOUT MCC,305,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],7199.72,,"Case rate ($7,058.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,702.02, add-ons for qualifying new technology services are included. If operating cost exceeds $41,573.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,133.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,739.59 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,757.07 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $374.00. The transfer capital threshold is the transfer adjustment factor * $374.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,7058.55,17230.49,Inpatient DRG
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],8868.77,,"Case rate ($8,446.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,005.29, add-ons for qualifying new technology services are included. If operating cost exceeds $42,876.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,224.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $6,037.45 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,060.34 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $464.05. The transfer capital threshold is the transfer adjustment factor * $464.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8643.20,19462.52,Inpatient DRG
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC,964,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],28802.15,,"Fee schedule rate ($28,802.15). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,12323.82,34154.06,There are no additional notes associated with this service or procedure.
HC Inj Trigger Pt 1-2 Musc Grps,CASE-20552,APC,20552,CPT,0510,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],38517.10,,"Fee schedule rate ($38,517.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,16897.01,43444.85,There are no additional notes associated with this service or procedure.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],15401.69,,"Case rate ($15,099.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,182.53, add-ons for qualifying new technology services are included. If operating cost exceeds $49,053.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,722.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $12,192.63 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,237.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $962.12. The transfer capital threshold is the transfer adjustment factor * $962.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,7605.00,39153.65,Inpatient DRG
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,066,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],6711.36,,"Case rate ($6,579.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,256.61, add-ons for qualifying new technology services are included. If operating cost exceeds $41,127.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,098.96, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $4,295.82 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,311.66 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $338.98. The transfer capital threshold is the transfer adjustment factor * $338.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6579.76,20083.61,Inpatient DRG
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,448,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],94077.13,,"Fee schedule rate ($94,077.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,30663.95,94077.13,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],21167.26,,"Fee schedule rate ($21,167.26). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,6841.83,21167.26,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,065,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],25681.86,,"Fee schedule rate ($25,681.86). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,8786.76,25681.86,There are no additional notes associated with this service or procedure.
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],5280.00,,"Per diem ($5,280). If length of stay < 3.1, first 1 days paid at a per diem of $10,560 instead. Capped at $16,366.82.",,,,0,other,5280.00,17136.70,Estimated amount calculated based on 3 day length of stay.
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC,805,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],21235.42,,,,,,0,other,9253.36,21235.42,There are no additional notes associated with this service or procedure.
VENTRICULAR SHUNT PROCEDURES WITH CC,032,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],25647.30,,"Fee schedule rate ($25,647.30). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,16376.22,46275.08,There are no additional notes associated with this service or procedure.
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],36868.88,,"Fee schedule rate ($36,868.88). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12606.23,36868.88,There are no additional notes associated with this service or procedure.
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],12091.53,,"Case rate ($12,091.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,384.11, add-ons for qualifying new technology services are included. If operating cost exceeds $46,255.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,502.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $9,404.49 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,439.16 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $742.11. The transfer capital threshold is the transfer adjustment factor * $742.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,29482.05,Inpatient DRG
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],105091.76,,"Fee schedule rate ($105,091.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,35719.96,105091.76,There are no additional notes associated with this service or procedure.
Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq|COLORECTAL CANCER SCREEN|UNUSUAL NON-OVERLAPPING SERVICE,CASE-45385,APC,45385,CPT,0360,RC,,,PT|XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1159.29,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1120.09,1176.09,OPPS APC
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],33159.45,,"Fee schedule rate ($33,159.45). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,13092.47,33159.45,There are no additional notes associated with this service or procedure.
HC Gastroesophag Reflx Test W/Tel Ph Eltrd|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-91035,APC,91035,CPT,0750,RC,,,74,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],843.99,,"APC Price ($803.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,843.99,843.99,OPPS APC
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],10120.20,,"Case rate ($10,120.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,550.21, add-ons for qualifying new technology services are included. If operating cost exceeds $44,421.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,357.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $7,577.32 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,605.26 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $597.93. The transfer capital threshold is the transfer adjustment factor * $597.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10120.20,26204.74,Inpatient DRG
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,450,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],80923.50,,"Fee schedule rate ($80,923.50). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,38037.38,146009.19,There are no additional notes associated with this service or procedure.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],126615.59,,,,,,0,other,45521.20,142438.06,There are no additional notes associated with this service or procedure.
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],53275.26,,"Fee schedule rate ($53,275.26). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,15940.79,53275.26,There are no additional notes associated with this service or procedure.
Rpr 1st Fem Hernia Any Age Incarcerated|RIGHT SIDE,CASE-49553,APC,49553,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3518.91,,"APC Price ($3,351.34). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3351.34,3518.91,OPPS APC
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],15076.44,,"Fee schedule rate ($15,076.44). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6340.03,15076.44,There are no additional notes associated with this service or procedure.
SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS,029,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],25925.24,,"Case rate ($25,048.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $23,437.73, add-ons for qualifying new technology services are included. If operating cost exceeds $58,308.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,449.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.7)) / 2. The base transfer operating payment is the transfer adjustment factor * $21,413.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $21,492.79 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,689.76. The transfer capital threshold is the transfer adjustment factor * $1,689.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,13641.00,67130.05,Inpatient DRG
"ANTEPARTUM WITHOUT O.R. PROCEDURE,MAJOR",566,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],7288.28,,"Case rate ($6,941.22). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6941.22,7288.28,There are no additional notes associated with this service or procedure.
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],26204.74,,"Fee schedule rate ($26,204.74). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10120.20,26204.74,There are no additional notes associated with this service or procedure.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,074,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],20919.08,,"Fee schedule rate ($20,919.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8925.60,20919.08,There are no additional notes associated with this service or procedure.
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],6965.00,,,,,,0,other,6965.00,21089.59,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],47751.13,,"Fee schedule rate ($47,751.13). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.7), with a minimum of zero.",,,,0,other,19152.11,53152.12,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],24350.31,,"Case rate ($23,526.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $22,022.15, add-ons for qualifying new technology services are included. If operating cost exceeds $56,893.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,338.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.7. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.7)) / 2. The base transfer operating payment is the transfer adjustment factor * $20,003.44 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $20,077.20 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,578.47. The transfer capital threshold is the transfer adjustment factor * $1,578.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,23526.87,94787.57,Inpatient DRG
CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC,788,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],20142.33,,"Fee schedule rate ($20,142.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8438.02,20142.33,There are no additional notes associated with this service or procedure.
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],16035.06,,"Fee schedule rate ($16,035.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,7396.47,16035.06,There are no additional notes associated with this service or procedure.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,309,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6207.80,,"Case rate ($6,207.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $5,875.02, add-ons for qualifying new technology services are included. If operating cost exceeds $44,519.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $3,081.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,495.17 + an uncompensated DSH payment of $1,359.91. The transfer operating threshold is the transfer adjustment factor * $4,515.10 + an uncompensated DSH payment of $1,359.91. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $352.72. The transfer capital threshold is the transfer adjustment factor * $352.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,5055.77,14547.21,Inpatient DRG
HC N Block Inj Intercost Sng|RIGHT SIDE,CASE-64420,APC,64420,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],683.85,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,660.72,693.76,OPPS APC
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],16259.61,,"Case rate ($15,940.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,964.98, add-ons for qualifying new technology services are included. If operating cost exceeds $49,835.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,783.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $12,972.20 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,020.03 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,023.63. The transfer capital threshold is the transfer adjustment factor * $1,023.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,15940.79,53275.26,Inpatient DRG
"Correction Hammertoe|RIGHT FOOT, FIFTH DIGIT",CASE-28285,APC,28285,CPT,0360,RC,,,T9,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
Cysto impl 4 or more,CASE-C9740,APC,C9740,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],8860.83,,"APC Price ($8,860.83). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,8860.83,9303.88,OPPS APC
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],7291.31,,"Case rate ($6,944.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,595.55, add-ons for qualifying new technology services are included. If operating cost exceeds $41,466.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,125.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,633.51 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,650.60 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $365.63. The transfer capital threshold is the transfer adjustment factor * $365.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5068.21,14525.56,Inpatient DRG
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],42767.23,,"Fee schedule rate ($42,767.23). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,17356.15,44778.95,There are no additional notes associated with this service or procedure.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],5569.00,,"Per diem ($5,569). If length of stay < 3.8, first 1 days paid at a per diem of $11,138 instead. Capped at $21,162.80.",,,,0,other,5569.00,40108.48,Estimated amount calculated based on 2 day length of stay.
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],10120.20,,"Case rate ($10,120.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,550.21, add-ons for qualifying new technology services are included. If operating cost exceeds $44,421.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,357.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $7,577.32 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,605.26 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $597.93. The transfer capital threshold is the transfer adjustment factor * $597.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10120.20,26204.74,Inpatient DRG
Cysto/Uretero W/Lithotripsy &Indwell Stent Insrt|BILATERAL PROCEDURE,CASE-52356,APC,52356,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5018.77,,"APC Price ($5,018.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5018.77,5269.71,OPPS APC
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],6524.00,,"Per diem ($6,524). If length of stay < 2.6, first 1 days paid at a per diem of $13,048 instead. Capped at $16,962.56.",,,,0,other,6524.00,17760.46,Estimated amount calculated based on 2 day length of stay.
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],17467.27,,,,,,0,other,6965.00,17467.27,There are no additional notes associated with this service or procedure.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],47169.70,,,,,,0,other,18178.96,54764.34,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],9795.13,,"Case rate ($9,795.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,247.81, add-ons for qualifying new technology services are included. If operating cost exceeds $44,118.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,334.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $7,276.03 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,302.86 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $574.15. The transfer capital threshold is the transfer adjustment factor * $574.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9795.13,23899.13,Inpatient DRG
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],19435.86,,"Case rate ($19,435.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $18,216.37, add-ons for qualifying new technology services are included. If operating cost exceeds $53,087.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,039.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.9. The base transfer operating payment is the transfer adjustment factor * $16,211.64 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $16,271.42 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,279.26. The transfer capital threshold is the transfer adjustment factor * $1,279.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,19435.86,50821.76,Inpatient DRG
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],36780.25,,,,,,0,other,14603.31,45017.13,There are no additional notes associated with this service or procedure.
BRONCHITIS AND ASTHMA WITH CC/MCC,202,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],8948.08,,"Case rate ($8,521.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,063.43, add-ons for qualifying new technology services are included. If operating cost exceeds $42,934.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,241.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,096.00 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,118.48 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $481.03. The transfer capital threshold is the transfer adjustment factor * $481.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7606.34,19110.30,Inpatient DRG
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],12526.44,,"Fee schedule rate ($12,526.44). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5415.00,17575.50,There are no additional notes associated with this service or procedure.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],62041.12,,"Fee schedule rate ($62,041.12). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,18497.24,62041.12,There are no additional notes associated with this service or procedure.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,329,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],34230.32,,"Case rate ($33,072.77). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $30,902.51, add-ons for qualifying new technology services are included. If operating cost exceeds $65,773.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,036.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.4. The base transfer operating payment is the transfer adjustment factor * $28,851.18 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $28,957.55 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,276.64. The transfer capital threshold is the transfer adjustment factor * $2,276.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,33072.77,90445.33,Inpatient DRG
"SPINAL PROCEDURES,MINOR",023,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],4938.21,,"Case rate for a one day stay ($4,703.06). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4703.06,4938.21,There are no additional notes associated with this service or procedure.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],9570.98,,"Case rate ($9,570.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,039.28, add-ons for qualifying new technology services are included. If operating cost exceeds $43,910.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,317.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $7,068.27 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,094.33 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $557.76. The transfer capital threshold is the transfer adjustment factor * $557.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,5569.00,40108.48,Inpatient DRG
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,544,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],12862.50,,"Fee schedule rate ($12,862.50). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,7055.15,23207.64,There are no additional notes associated with this service or procedure.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],52794.06,,"Fee schedule rate ($52,794.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (37), with a minimum of zero.",,,,0,other,13907.80,52794.06,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],16578.62,,"Case rate ($16,017.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,036.80, add-ons for qualifying new technology services are included. If operating cost exceeds $49,907.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,789.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $13,043.76 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,091.85 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,029.28. The transfer capital threshold is the transfer adjustment factor * $1,029.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,16017.99,51903.64,Inpatient DRG
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITHOUT MCC,430,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],133156.90,,"Fee schedule rate ($133,156.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,41000.16,133156.90,There are no additional notes associated with this service or procedure.
FRACTURES OF FEMUR WITH MCC,533,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],12561.53,,"Case rate ($12,561.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,821.33, add-ons for qualifying new technology services are included. If operating cost exceeds $46,692.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,536.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $9,840.09 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,876.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $776.48. The transfer capital threshold is the transfer adjustment factor * $776.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6852.00,49490.05,Inpatient DRG
MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,708,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],27860.62,,"Fee schedule rate ($27,860.62). Adds an outlier to normal pricing equal to the per diem rate ($54,966.40) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10138.21,29171.15,There are no additional notes associated with this service or procedure.
Rpr/Advmnt Flxr Tdn Zone 2 W/O Fr Grft Ea Tendon,CASE-26356,APC,26356,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
"Open Tx Articular Fracture Mcp/IP Joint Ea|LEFT HAND, FOURTH DIGIT",CASE-26746,APC,26746,CPT,0360,RC,,,F3,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3169.86,OPPS APC
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,073,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],13449.85,,"Case rate ($12,809.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,051.90, add-ons for qualifying new technology services are included. If operating cost exceeds $46,922.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,554.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $10,069.82 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,106.95 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $794.61. The transfer capital threshold is the transfer adjustment factor * $794.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12809.38,43475.01,Inpatient DRG
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITH MCC OR ANTINEOPLASTIC IMPLANT OR EPILEPSY WITH NEUROSTIMULATOR,023,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],136379.44,,"Fee schedule rate ($136,379.44). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,15168.00,136379.44,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC,833,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5678.08,,"Case rate ($5,486.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,239.18, add-ons for qualifying new technology services are included. If operating cost exceeds $40,110.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,018.96, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $3,282.12 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,294.23 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $258.99. The transfer capital threshold is the transfer adjustment factor * $258.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,3041.73,10289.10,Inpatient DRG
HC Peripheral Block - Femoral Single or Saphenous W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64447,APC,64447,CPT,0360,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
HC Joint Injection/Aspir Large WO US|RIGHT SIDE|PBB CHARGE,CASE-20610,APC,20610,CPT,0510,RC,,,RT|PBB,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6871.40,,"Case rate ($6,544.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,232.10, add-ons for qualifying new technology services are included. If operating cost exceeds $41,103.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,088.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,270.96 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,287.15 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $328.28. The transfer capital threshold is the transfer adjustment factor * $328.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6683.37,14699.43,Inpatient DRG
Colsc Flexible W/Transendoscopic Balloon Dilat|COLORECTAL CANCER SCREEN,CASE-45386,APC,45386,CPT,0360,RC,,,PT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1159.29,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1120.09,1176.09,OPPS APC
VENTRICULAR SHUNT PROCEDURES WITH MCC,031,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],32932.94,,"Case rate ($32,287.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $30,171.71, add-ons for qualifying new technology services are included. If operating cost exceeds $65,042.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,979.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7. The base transfer operating payment is the transfer adjustment factor * $28,123.07 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $28,226.76 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,219.19. The transfer capital threshold is the transfer adjustment factor * $2,219.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,32287.20,88162.80,Inpatient DRG
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],18867.18,,"Case rate ($18,497.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,343.20, add-ons for qualifying new technology services are included. If operating cost exceeds $52,214.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,970.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $15,341.68 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,398.25 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,210.61. The transfer capital threshold is the transfer adjustment factor * $1,210.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,18497.24,62041.12,Inpatient DRG
"CVA AND PRECEREBRAL OCCLUSION WITH INFARCTION,MODERATE",045,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],10746.50,,"Case rate ($10,234.76). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10234.76,10746.50,There are no additional notes associated with this service or procedure.
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],6965.00,,,,,,0,other,6965.00,36140.75,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF THE EYE WITHOUT MCC,125,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],17952.29,,"Fee schedule rate ($17,952.29). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (6), with a minimum of zero.",,,,0,other,7144.54,17952.29,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],28821.04,,"Fee schedule rate ($28,821.04). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,10347.06,28821.04,There are no additional notes associated with this service or procedure.
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],10733.06,,"Case rate ($10,733.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,120.35, add-ons for qualifying new technology services are included. If operating cost exceeds $44,991.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,402.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $8,145.37 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,175.40 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $642.75. The transfer capital threshold is the transfer adjustment factor * $642.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10733.06,45157.33,Inpatient DRG
Colorectal Scrn; Hi Risk Ind,CASE-G0105,APC,G0105,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],870.46,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,870.46,913.99,OPPS APC
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],29216.99,,"Fee schedule rate ($29,216.99). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9755.86,29216.99,There are no additional notes associated with this service or procedure.
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],20846.48,,"Case rate ($20,846.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $19,528.64, add-ons for qualifying new technology services are included. If operating cost exceeds $54,399.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,142.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $17,519.09 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $17,583.69 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,382.43. The transfer capital threshold is the transfer adjustment factor * $1,382.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,20846.48,81306.30,Inpatient DRG
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],40320.14,,,,,,0,other,15821.59,40320.14,There are no additional notes associated with this service or procedure.
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],10400.08,,"Case rate ($10,048.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,483.42, add-ons for qualifying new technology services are included. If operating cost exceeds $44,354.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,352.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,510.78 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,538.48 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $592.68. The transfer capital threshold is the transfer adjustment factor * $592.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,10048.39,23545.50,Inpatient DRG
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,025,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],48715.00,,"Fee schedule rate ($48,715.00). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,13351.00,91631.33,There are no additional notes associated with this service or procedure.
UNGROUPABLE,999,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],10228.00,,"Per diem ($10,228). If length of stay < 12.7, first 1 days paid at a per diem of $20,456 instead. Capped at $129,893.46.",,,,0,other,10228.00,161307.29,Estimated amount calculated based on 9 day length of stay.
UNGROUPABLE,999,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],161307.29,,"Fee schedule rate ($161,307.29). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (41), with a minimum of zero.",,,,0,other,10228.00,161307.29,There are no additional notes associated with this service or procedure.
Laps Surg Rpr Recurrent Inguinal Hernia|LEFT SIDE,CASE-49651,APC,49651,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5941.70,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5658.76,5941.70,OPPS APC
Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq|COLORECTAL CANCER SCREEN|UNUSUAL NON-OVERLAPPING SERVICE,CASE-45385,APC,45385,CPT,0360,RC,,,PT|XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1176.09,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1120.09,1176.09,OPPS APC
"ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",770,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],17800.73,,"Fee schedule rate ($17,800.73). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,8735.30,19730.13,There are no additional notes associated with this service or procedure.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],39316.61,,,,,,0,other,15476.23,42787.31,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],14440.86,,"Case rate ($13,952.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,115.33, add-ons for qualifying new technology services are included. If operating cost exceeds $47,986.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,638.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $11,129.34 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,170.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $878.22. The transfer capital threshold is the transfer adjustment factor * $878.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,13917.42,34889.29,Inpatient DRG
"NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY",789,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],3354.00,,,,,,0,other,3054.00,14857.05,Estimated amount calculated based on 1 day length of stay.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC,192,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],12753.78,,"Fee schedule rate ($12,753.78). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6292.63,12753.78,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITHOUT STERILIZATION WITH MCC,786,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],13115.49,,"Case rate ($13,115.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,336.66, add-ons for qualifying new technology services are included. If operating cost exceeds $47,207.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,576.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $10,353.53 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,391.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $817.00. The transfer capital threshold is the transfer adjustment factor * $817.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12612.10,23722.94,Inpatient DRG
INFLAMMATORY BOWEL DISEASE WITH MCC,385,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],29736.16,,"Fee schedule rate ($29,736.16). Adds an outlier to normal pricing equal to the per diem rate ($112,108.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.5), with a minimum of zero.",,,,0,other,11480.01,31134.92,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],18954.85,,,,,,0,other,6963.00,18954.85,There are no additional notes associated with this service or procedure.
RESPIRATORY NEOPLASMS WITH CC,181,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],17609.39,,"Fee schedule rate ($17,609.39). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9197.84,21074.07,There are no additional notes associated with this service or procedure.
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH CC",457,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],112064.54,,"Fee schedule rate ($112,064.54). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.9), with a minimum of zero.",,,,0,other,42327.47,160549.49,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],19822.43,,"Case rate ($19,152.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,952.40, add-ons for qualifying new technology services are included. If operating cost exceeds $52,823.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,018.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $15,948.65 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $16,007.45 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,258.51. The transfer capital threshold is the transfer adjustment factor * $1,258.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,19152.11,53152.12,Inpatient DRG
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],39820.52,,"Fee schedule rate ($39,820.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,15273.74,39820.52,There are no additional notes associated with this service or procedure.
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|RIGHT HAND, THIRD DIGIT",CASE-26160,APC,26160,CPT,0360,RC,,,F7,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1580.37,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1505.12,1580.37,OPPS APC
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",759,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],11643.60,,"Fee schedule rate ($11,643.60). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6190.22,13057.66,There are no additional notes associated with this service or procedure.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,025,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],89465.42,,,,,,0,other,13351.00,91631.33,There are no additional notes associated with this service or procedure.
Enteroscopy > 2nd Prtn W/Control Bleeding,CASE-44366,APC,44366,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1859.01,,"APC Price ($1,796.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1796.14,1885.95,OPPS APC
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],12272.58,,"Fee schedule rate ($12,272.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5628.97,12272.58,There are no additional notes associated with this service or procedure.
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],15128.37,,"Fee schedule rate ($15,128.37). Adds an outlier to normal pricing equal to the per diem rate ($46,867.46) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7396.47,16035.06,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],34397.36,,,,,,0,other,13783.20,41580.51,There are no additional notes associated with this service or procedure.
"Tendon Sheath Incision|RIGHT HAND, THIRD DIGIT|UNUSUAL NON-OVERLAPPING SERVICE",CASE-26055,APC,26055,CPT,0360,RC,,,F7|XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1580.37,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1505.12,1580.37,OPPS APC
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],46523.26,,"Fee schedule rate ($46,523.26). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,17782.11,46523.26,There are no additional notes associated with this service or procedure.
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC,807,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],6640.88,,"Case rate ($6,510.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,192.35, add-ons for qualifying new technology services are included. If operating cost exceeds $41,063.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,093.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $4,231.80 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,247.40 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $333.93. The transfer capital threshold is the transfer adjustment factor * $333.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,5354.25,13266.23,Inpatient DRG
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,098,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],17881.16,,"Case rate ($17,029.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,006.10, add-ons for qualifying new technology services are included. If operating cost exceeds $50,877.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,836.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $14,008.04 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,061.15 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,076.69. The transfer capital threshold is the transfer adjustment factor * $1,076.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,45156.75,Inpatient DRG
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],15090.08,,"Case rate ($14,371.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,528.29, add-ons for qualifying new technology services are included. If operating cost exceeds $48,399.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,646.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $11,539.59 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,583.34 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $886.96. The transfer capital threshold is the transfer adjustment factor * $886.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,14747.55,37899.49,Inpatient DRG
"NEONATE BIRTH WEIGHT 2000-2499 GRAMS NORMAL NEWBORN OR NEONATE WITH OTHER PROBLEM,MODERATE",626,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],2614.38,,"Case rate ($2,489.89). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,2489.89,2614.38,There are no additional notes associated with this service or procedure.
OTHER CEREBROVASCULAR DISORDERS WITH CC,071,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],29215.10,,"Fee schedule rate ($29,215.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5843.00,29215.10,There are no additional notes associated with this service or procedure.
Placement Seton,CASE-46020,APC,46020,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],2689.02,,"APC Price ($2,598.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2598.08,2727.99,OPPS APC
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|LEFT HAND, FIFTH DIGIT",CASE-26160,APC,26160,CPT,0360,RC,,,F4,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1505.12,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1505.12,1580.37,OPPS APC
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC",641,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],14928.67,,"Fee schedule rate ($14,928.67). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7214.98,15312.64,There are no additional notes associated with this service or procedure.
Egd Transoral Biopsy Single/Multiple|SEPARATE STRUCTURE,CASE-43239,APC,43239,CPT,0360,RC,,,XS,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1859.01,,"APC Price ($1,796.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1796.14,1885.95,OPPS APC
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,069,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],20333.68,,"Fee schedule rate ($20,333.68). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,20333.68,There are no additional notes associated with this service or procedure.
HC Inj Aa&/Strd Other Peripheral Nerve/Branch|LEFT SIDE,CASE-64450,APC,64450,CPT,0450,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],660.72,,"APC Price ($660.72). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,660.72,693.76,OPPS APC
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],35304.50,,"Case rate ($33,623.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $31,414.68, add-ons for qualifying new technology services are included. If operating cost exceeds $66,285.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,076.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.4. The base transfer operating payment is the transfer adjustment factor * $29,361.48 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $29,469.74 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,316.91. The transfer capital threshold is the transfer adjustment factor * $2,316.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,33623.33,133270.57,Inpatient DRG
Colorectal Scrn; Hi Risk Ind|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-G0105,APC,G0105,CPT,0360,RC,,,74,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],870.46,,"APC Price ($870.46). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,870.46,913.99,OPPS APC
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],38610.21,,,,,,0,other,15233.11,38610.21,There are no additional notes associated with this service or procedure.
Tnot Elbow Lateral/Medial Debride Open Tdn Rpr|RIGHT SIDE,CASE-24359,APC,24359,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],13331.82,,"Case rate ($12,696.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,947.32, add-ons for qualifying new technology services are included. If operating cost exceeds $46,818.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,546.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,965.63 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,002.37 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $786.39. The transfer capital threshold is the transfer adjustment factor * $786.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12696.97,47123.82,Inpatient DRG
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],11973.20,,"Case rate ($6,841.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,500.42, add-ons for qualifying new technology services are included. If operating cost exceeds $41,371.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,118.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $4,538.73 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,555.47 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $358.15. The transfer capital threshold is the transfer adjustment factor * $358.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,6841.83,21167.26,All Other Inpatient
"Amp F/Th 1/2 Jt/Phalanx W/Neurect W/Dir Clsr|LEFT HAND, SECOND DIGIT",CASE-26951,APC,26951,CPT,0360,RC,,,F1,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
CHEST PAIN,313,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],15377.66,,"Fee schedule rate ($15,377.66). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,6820.84,15377.66,There are no additional notes associated with this service or procedure.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH CC,026,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],23460.67,,"Case rate ($23,000.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $21,532.64, add-ons for qualifying new technology services are included. If operating cost exceeds $56,403.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,299.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $19,515.74 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $19,587.69 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,539.98. The transfer capital threshold is the transfer adjustment factor * $1,539.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 102%.",,,,0,other,23000.66,63202.45,Inpatient DRG
Dstr Nrolytc Agnt Parverteb Fct Addl Crvcl/Thora|LEFT SIDE,CASE-64634,APC,64634,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1891.77,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1827.80,1919.19,OPPS APC
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC",458,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],132827.25,,"Fee schedule rate ($132,827.25). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,30202.09,132827.25,There are no additional notes associated with this service or procedure.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,345,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],12427.36,,"Case rate ($11,835.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,164.44, add-ons for qualifying new technology services are included. If operating cost exceeds $46,035.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,465.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $9,184.67 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,219.49 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $705.96. The transfer capital threshold is the transfer adjustment factor * $705.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12134.89,33616.03,Inpatient DRG
MINOR BLADDER PROCEDURES WITHOUT CC/MCC,664,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],31876.87,,"Fee schedule rate ($31,876.87). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9034.63,31876.87,There are no additional notes associated with this service or procedure.
BRONCHITIS AND ASTHMA WITH CC/MCC,202,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],14307.27,,"Fee schedule rate ($14,307.27). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7606.34,19110.30,There are no additional notes associated with this service or procedure.
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITH MCC,429,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],62958.58,,"Case rate ($62,958.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $58,704.65, add-ons for qualifying new technology services are included. If operating cost exceeds $93,575.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $6,222.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.6. The base transfer operating payment is the transfer adjustment factor * $56,551.19 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $56,759.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,462.45. The transfer capital threshold is the transfer adjustment factor * $4,462.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,62958.58,177294.98,Inpatient DRG
"Arthrodesis Interphalangeal Jt W/WO Int Fixj|RIGHT HAND, FIFTH DIGIT",CASE-26860,APC,26860,CPT,0360,RC,,,F9,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,098,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],38799.38,,"Fee schedule rate ($38,799.38). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,6965.00,45156.75,There are no additional notes associated with this service or procedure.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,097,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],67876.56,,"Fee schedule rate ($67,876.56). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17.7), with a minimum of zero.",,,,0,other,26404.32,79915.74,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],35192.25,,"Fee schedule rate ($35,192.25). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,10895.60,35192.25,There are no additional notes associated with this service or procedure.
HEART FAILURE AND SHOCK WITH CC,292,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],15550.06,,"Fee schedule rate ($15,550.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5502.00,16705.77,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS WITH MCC,947,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],24977.98,,,,,,0,other,10541.41,30414.32,There are no additional notes associated with this service or procedure.
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],25829.63,,"Fee schedule rate ($25,829.63). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6965.00,29482.05,There are no additional notes associated with this service or procedure.
Arthrs Kne Surg W/Meniscectomy Med/Lat W/Shvg|RIGHT SIDE|SEPARATE STRUCTURE,CASE-29881,APC,29881,CPT,0360,RC,,,RT|XS,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7029.71,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6791.99,7131.59,OPPS APC
Excision Excessive Skin & Subq Tissue Abdomen,CASE-15847,APC,15847,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6526.12,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6215.36,6526.12,OPPS APC
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],47797.26,,"Case rate ($45,521.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $42,483.01, add-ons for qualifying new technology services are included. If operating cost exceeds $77,354.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,947.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 12.5. The base transfer operating payment is the transfer adjustment factor * $40,389.14 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $40,538.06 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,187.10. The transfer capital threshold is the transfer adjustment factor * $3,187.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,45521.20,142438.06,Inpatient DRG
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,426,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],78108.43,,"Case rate ($74,388.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $69,473.26, add-ons for qualifying new technology services are included. If operating cost exceeds $104,344.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $6,930.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $67,273.25 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $67,528.31 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $5,170.78. The transfer capital threshold is the transfer adjustment factor * $5,170.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,76581.29,216864.15,Inpatient DRG
INFLAMMATORY BOWEL DISEASE WITH CC,386,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],19879.00,,"Fee schedule rate ($19,879.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8556.53,19879.00,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],20567.06,,"Fee schedule rate ($20,567.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,9356.31,25026.36,There are no additional notes associated with this service or procedure.
"NEONATE BIRTH WEIGHT 2000-2499 GRAMS WITH OTHER SIGNIFICANT CONDITION,MAJOR",625,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],28370.08,,"Case rate ($28,370.08). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,28370.08,29788.58,There are no additional notes associated with this service or procedure.
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],67107.92,,"Fee schedule rate ($67,107.92). Adds an outlier to normal pricing equal to the per diem rate ($118,521.29) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16.7), with a minimum of zero.",,,,0,other,26127.34,90333.60,There are no additional notes associated with this service or procedure.
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC,805,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],9438.43,,"Case rate ($9,253.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,743.82, add-ons for qualifying new technology services are included. If operating cost exceeds $43,614.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,294.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $6,773.89 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,798.87 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $534.53. The transfer capital threshold is the transfer adjustment factor * $534.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,9253.36,21235.42,Inpatient DRG
Amputation Metatarsal W/Toe Single,CASE-28810,APC,28810,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
HYPERTENSION WITHOUT MCC,305,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],17230.49,,"Fee schedule rate ($17,230.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7058.55,17230.49,There are no additional notes associated with this service or procedure.
Mast Modf Rad W/Ax Lymph Nod W/WO Pect/Alis Min|RIGHT SIDE,CASE-19307,APC,19307,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6215.36,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6215.36,6526.12,OPPS APC
CESAREAN SECTION WITHOUT STERILIZATION WITH MCC,786,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],23722.94,,"Fee schedule rate ($23,722.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12612.10,23722.94,There are no additional notes associated with this service or procedure.
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],12651.45,,"Fee schedule rate ($12,651.45). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,6503.90,14492.93,There are no additional notes associated with this service or procedure.
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],21305.84,,"Case rate ($20,291.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $19,046.38, add-ons for qualifying new technology services are included. If operating cost exceeds $53,917.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,069.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $17,036.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $17,101.43 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,309.49. The transfer capital threshold is the transfer adjustment factor * $1,309.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,20846.48,81306.30,Inpatient DRG
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],6130.43,,"Case rate ($6,010.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,726.79, add-ons for qualifying new technology services are included. If operating cost exceeds $40,597.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,057.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,767.95 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,781.84 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $297.33. The transfer capital threshold is the transfer adjustment factor * $297.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6010.23,12246.05,Inpatient DRG
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],8816.06,,"Case rate ($8,643.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,176.19, add-ons for qualifying new technology services are included. If operating cost exceeds $43,047.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,249.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $6,208.35 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,231.24 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $489.90. The transfer capital threshold is the transfer adjustment factor * $489.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,8643.20,19462.52,Inpatient DRG
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],13414.31,,"Case rate ($12,775.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,020.41, add-ons for qualifying new technology services are included. If operating cost exceeds $46,891.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,552.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $10,038.44 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,075.45 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $792.13. The transfer capital threshold is the transfer adjustment factor * $792.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12775.53,31469.43,Inpatient DRG
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],26949.28,,"Fee schedule rate ($26,949.28). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9977.99,26949.28,There are no additional notes associated with this service or procedure.
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC",641,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],14624.71,,"Fee schedule rate ($14,624.71). Adds an outlier to normal pricing equal to the per diem rate ($38,755.52) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7214.98,15312.64,There are no additional notes associated with this service or procedure.
"Open Tx Phalangeal Shaft Fracture Prox/Middle Ea|LEFT HAND, FIFTH DIGIT",CASE-26735,APC,26735,CPT,0360,RC,,,F4,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],19952.48,,,,,,0,other,6965.00,20401.88,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],35192.25,,"Fee schedule rate ($35,192.25). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,10895.60,35192.25,There are no additional notes associated with this service or procedure.
"Tendon Sheath Incision|RIGHT HAND, THIRD DIGIT",CASE-26055,APC,26055,CPT,0360,RC,,,F7,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1557.80,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1505.12,1580.37,OPPS APC
"Inj Dx/Ther Agnt Paravert Facet Joint, Cerv/Thorac, 2nd Level|LEFT SIDE|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA",CASE-64491,APC,64491,CPT,0360,RC,,,LT|74,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],827.89,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,827.89,869.28,OPPS APC
Rinsj Rptd Biceps/Triceps Tdn Dstl W/WO Tdn Grf|RIGHT SIDE,CASE-24342,APC,24342,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7029.71,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6791.99,7131.59,OPPS APC
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],6965.00,,,,,,0,other,6965.00,15340.19,There are no additional notes associated with this service or procedure.
HEART FAILURE AND SHOCK WITH CC,292,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],15550.06,,"Fee schedule rate ($15,550.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5502.00,16705.77,There are no additional notes associated with this service or procedure.
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],36868.88,,"Fee schedule rate ($36,868.88). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12606.23,36868.88,There are no additional notes associated with this service or procedure.
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],35127.88,,"Fee schedule rate ($35,127.88). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.5), with a minimum of zero.",,,,0,other,14603.31,45017.13,There are no additional notes associated with this service or procedure.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],33608.45,,"Fee schedule rate ($33,608.45). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,7332.00,35314.31,There are no additional notes associated with this service or procedure.
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],37899.49,,"Fee schedule rate ($37,899.49). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,14747.55,37899.49,There are no additional notes associated with this service or procedure.
Colonoscopy Flx Dx W/Collj Spec When Pfrmd,CASE-45378,APC,45378,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],913.99,,"APC Price ($870.46). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,870.46,913.99,OPPS APC
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC,027,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],19030.20,,"Case rate ($19,030.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,839, add-ons for qualifying new technology services are included. If operating cost exceeds $52,710.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,009.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $15,835.66 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,894.05 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,249.59. The transfer capital threshold is the transfer adjustment factor * $1,249.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,19030.20,56363.30,Inpatient DRG
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],34892.92,,"Fee schedule rate ($34,892.92). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,6965.00,41030.48,There are no additional notes associated with this service or procedure.
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],21960.82,,"Case rate ($20,915.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $19,627.84, add-ons for qualifying new technology services are included. If operating cost exceeds $54,498.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,113.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.6. The base transfer operating payment is the transfer adjustment factor * $17,616.10 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $17,682.89 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,354.01. The transfer capital threshold is the transfer adjustment factor * $1,354.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,21489.15,68942.79,Inpatient DRG
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],10626.74,,"Case rate ($10,626.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,021.44, add-ons for qualifying new technology services are included. If operating cost exceeds $44,892.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,394.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $8,046.82 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,076.49 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $634.97. The transfer capital threshold is the transfer adjustment factor * $634.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10626.74,25225.91,Inpatient DRG
HC >= 12 Lead Ekg,CASE-93005,APC,93005,CPT,0730,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],55.22,,"APC Price ($55.22). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,55.22,57.98,OPPS APC
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],12558.65,,"Fee schedule rate ($12,558.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5065.00,12558.65,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],43399.23,,"Fee schedule rate ($43,399.23). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9888.00,43399.23,There are no additional notes associated with this service or procedure.
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],4525.50,,"Fee schedule rate ($4,525.50). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4341.01,12882.53,There are no additional notes associated with this service or procedure.
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],14599.65,,"Case rate ($13,904.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,070.60, add-ons for qualifying new technology services are included. If operating cost exceeds $47,941.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,634.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,084.78 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,125.65 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $874.70. The transfer capital threshold is the transfer adjustment factor * $874.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13904.43,34749.58,Inpatient DRG
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],24567.74,,"Case rate ($24,567.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $22,990.45, add-ons for qualifying new technology services are included. If operating cost exceeds $57,861.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,414.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.7. The base transfer operating payment is the transfer adjustment factor * $20,968.18 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $21,045.49 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,654.60. The transfer capital threshold is the transfer adjustment factor * $1,654.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9370.00,65732.99,Inpatient DRG
SPINAL PROCEDURES WITH MCC,028,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],120982.83,,"Fee schedule rate ($120,982.83). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,42633.57,120982.83,There are no additional notes associated with this service or procedure.
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],13478.34,,"Fee schedule rate ($13,478.34). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,6801.88,22557.82,There are no additional notes associated with this service or procedure.
Aspiration Bladder Insert Suprapubic Catheter,CASE-51102,APC,51102,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],2025.13,,"APC Price ($1,956.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1956.65,2054.48,OPPS APC
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC,520,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],12061.74,,"Case rate ($12,061.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,356.39, add-ons for qualifying new technology services are included. If operating cost exceeds $46,227.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,499.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $9,376.87 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,411.44 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $739.93. The transfer capital threshold is the transfer adjustment factor * $739.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12061.74,39786.42,Inpatient DRG
"Corrj Hallux Valgus W/Sesmdc W/Dist Metar Osteot|LEFT FOOT, GREAT TOE",CASE-28296,APC,28296,CPT,0360,RC,,,TA,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7029.71,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6791.99,7131.59,OPPS APC
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6185.36,,"Case rate ($5,890.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,623.07, add-ons for qualifying new technology services are included. If operating cost exceeds $40,494.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,041.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,664.22 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,678.12 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $281.64. The transfer capital threshold is the transfer adjustment factor * $281.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6010.23,12246.05,Inpatient DRG
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,555,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],42290.95,,"Fee schedule rate ($42,290.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10896.27,42290.95,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],32293.66,,"Fee schedule rate ($32,293.66). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,32293.66,There are no additional notes associated with this service or procedure.
CHOLECYSTECTOMY WITH C.D.E. WITH MCC,411,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],88615.28,,"Fee schedule rate ($88,615.28). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,24315.13,88615.28,There are no additional notes associated with this service or procedure.
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],33188.44,,"Fee schedule rate ($33,188.44). Adds an outlier to normal pricing equal to the per diem rate ($84,167.29) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.5), with a minimum of zero.",,,,0,other,13904.43,34749.58,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],2070.00,,,,,,0,other,1188.00,34338.33,Estimated amount calculated based on 6 day length of stay.
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],14455.04,,"Fee schedule rate ($14,455.04). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5280.00,17136.70,There are no additional notes associated with this service or procedure.
Colonoscopy Flx Dx W/Collj Spec When Pfrmd|COLORECTAL CANCER SCREEN,CASE-45378,APC,45378,CPT,0360,RC,,,PT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],870.46,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,870.46,913.99,OPPS APC
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],39797.94,,"Fee schedule rate ($39,797.94). Adds an outlier to normal pricing equal to the per diem rate ($75,578.79) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.5), with a minimum of zero.",,,,0,other,16286.16,58320.32,There are no additional notes associated with this service or procedure.
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],42021.93,,"Fee schedule rate ($42,021.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,21248.73,56089.29,There are no additional notes associated with this service or procedure.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,418,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],33285.61,,,,,,0,other,13400.58,39884.93,There are no additional notes associated with this service or procedure.
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],19371.27,,"Fee schedule rate ($19,371.27). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8643.20,19462.52,There are no additional notes associated with this service or procedure.
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],28394.78,,"Fee schedule rate ($28,394.78). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11454.97,28394.78,There are no additional notes associated with this service or procedure.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],5894.19,,"Case rate ($5,778.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,511.33, add-ons for qualifying new technology services are included. If operating cost exceeds $40,382.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,040.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $3,553.28 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,566.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $280.39. The transfer capital threshold is the transfer adjustment factor * $280.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,5778.62,11681.49,Inpatient DRG
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITHOUT MCC,430,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],41845.63,,"Case rate ($39,852.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $37,280.72, add-ons for qualifying new technology services are included. If operating cost exceeds $72,151.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,465.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $35,202.30 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $35,335.77 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,705.73. The transfer capital threshold is the transfer adjustment factor * $2,705.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,41000.16,133156.90,Inpatient DRG
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],53939.67,,"Fee schedule rate ($53,939.67). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,21382.16,85466.62,There are no additional notes associated with this service or procedure.
CERVICAL SPINAL FUSION WITHOUT CC/MCC,473,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],45879.35,,"Fee schedule rate ($45,879.35). Adds an outlier to normal pricing equal to the per diem rate ($58,401.78) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,18477.61,62077.11,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],22358.90,,"Fee schedule rate ($22,358.90). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9389.48,22358.90,There are no additional notes associated with this service or procedure.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],45521.20,,"Case rate ($45,521.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $42,483.01, add-ons for qualifying new technology services are included. If operating cost exceeds $77,354.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,947.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 12.5. The base transfer operating payment is the transfer adjustment factor * $40,389.14 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $40,538.06 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,187.10. The transfer capital threshold is the transfer adjustment factor * $3,187.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,45521.20,142438.06,Inpatient DRG
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],20981.60,,"Fee schedule rate ($20,981.60). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,10003.71,23415.63,There are no additional notes associated with this service or procedure.
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 2nd Level|RIGHT SIDE,CASE-64494,APC,64494,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],827.89,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,827.89,869.28,OPPS APC
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],9074.68,,"Case rate ($8,767.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,292.11, add-ons for qualifying new technology services are included. If operating cost exceeds $43,163.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,258.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,323.85 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,347.16 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $499.01. The transfer capital threshold is the transfer adjustment factor * $499.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,8767.81,19824.58,Inpatient DRG
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],14370.36,,"Case rate ($14,370.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,504.04, add-ons for qualifying new technology services are included. If operating cost exceeds $48,375.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,668.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $11,516.62 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,559.08 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $908.78. The transfer capital threshold is the transfer adjustment factor * $908.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,14370.36,38378.80,Inpatient DRG
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],11974.38,,"Case rate ($11,974.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,275.12, add-ons for qualifying new technology services are included. If operating cost exceeds $46,146.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,493.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $9,295.90 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,330.17 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $733.54. The transfer capital threshold is the transfer adjustment factor * $733.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,11974.38,29141.64,Inpatient DRG
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],14112.34,,,,,,0,other,6801.88,22557.82,There are no additional notes associated with this service or procedure.
Nasal/Sinus Ndsc W/Rmvl Tiss From Frontal Sinus|BILATERAL PROCEDURE,CASE-31276,APC,31276,CPT,0360,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6837.16,,"APC Price ($6,605.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6837.16,6936.25,OPPS APC
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC,806,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6510.67,,"Case rate ($6,510.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,192.35, add-ons for qualifying new technology services are included. If operating cost exceeds $41,063.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,093.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $4,231.80 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,247.40 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $333.93. The transfer capital threshold is the transfer adjustment factor * $333.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,5354.25,13416.00,Inpatient DRG
Laps Surg Rpr Recurrent Inguinal Hernia|LEFT SIDE,CASE-49651,APC,49651,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5658.76,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5658.76,5941.70,OPPS APC
"Amputation Toe Interphalangeal Joint|RIGHT FOOT, THIRD DIGIT",CASE-28825,APC,28825,CPT,0360,RC,,,T7,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3062.67,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC,939,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],27843.27,,"Case rate ($26,517.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $24,804.19, add-ons for qualifying new technology services are included. If operating cost exceeds $59,675.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,557.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $22,775.26 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $22,859.24 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,797.19. The transfer capital threshold is the transfer adjustment factor * $1,797.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,26517.40,97674.79,Inpatient DRG
"INFECTIOUS AND PARASITIC DISEASES INCLUDING HIV WITH O.R. PROCEDURE,MINOR",710,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],13387.36,,"Case rate ($12,749.87). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12749.87,13387.36,There are no additional notes associated with this service or procedure.
"CHOLECYSTECTOMY,MINOR",263,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],11805.88,,"Case rate ($11,805.88). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,11805.88,12396.17,There are no additional notes associated with this service or procedure.
TRAUMATIC INJURY WITH MCC,913,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],42838.46,,"Fee schedule rate ($42,838.46). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13014.58,42838.46,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],35973.56,,"Fee schedule rate ($35,973.56). Adds an outlier to normal pricing equal to the per diem rate ($68,707.98) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,14908.05,49717.39,There are no additional notes associated with this service or procedure.
Bx/Exc Lymph Node Open Deep Axillary Node|RIGHT SIDE,CASE-38525,APC,38525,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6432.89,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6215.36,6526.12,OPPS APC
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],18178.96,,"Case rate ($18,178.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,047.10, add-ons for qualifying new technology services are included. If operating cost exceeds $51,918.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,947.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $15,046.67 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,102.15 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,187.33. The transfer capital threshold is the transfer adjustment factor * $1,187.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,18178.96,54764.34,Inpatient DRG
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH CC,427,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],134742.59,,"Fee schedule rate ($134,742.59). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,50829.82,142040.39,There are no additional notes associated with this service or procedure.
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],9533.13,,"Fee schedule rate ($9,533.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5068.21,14525.56,There are no additional notes associated with this service or procedure.
"Rpr/Advmnt Flxr Tdn Zone 2 W/O Fr Grft Ea Tendon|LEFT HAND, FOURTH DIGIT",CASE-26356,APC,26356,CPT,0360,RC,,,F3,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
HC Gastric Procedure Unlisted,CASE-43999,APC,43999,CPT,0361,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],878.67,,"APC Price ($848.96). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,848.96,891.41,OPPS APC
Inj for Sacroiliac Jt Anesth|RIGHT SIDE,CASE-G0260,APC,G0260,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],660.72,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,660.72,693.76,OPPS APC
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],20004.60,,"Fee schedule rate ($20,004.60). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11194.25,36094.03,There are no additional notes associated with this service or procedure.
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],16400.70,,"Fee schedule rate ($16,400.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,16400.70,There are no additional notes associated with this service or procedure.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,073,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],13114.77,,"Case rate ($12,490.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,774.70, add-ons for qualifying new technology services are included. If operating cost exceeds $46,645.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,512.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $9,792.62 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,829.75 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $752.68. The transfer capital threshold is the transfer adjustment factor * $752.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12809.38,43475.01,Inpatient DRG
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],54236.60,,"Fee schedule rate ($54,236.60). Adds an outlier to normal pricing equal to the per diem rate ($122,612.56) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,21489.15,68942.79,There are no additional notes associated with this service or procedure.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],5683.00,,"Per diem ($5,683). If length of stay < 3.3, first 1 days paid at a per diem of $11,366 instead. Capped at $18,753.53.",,,,0,other,5683.00,19635.68,Estimated amount calculated based on 3 day length of stay.
HC Inj Anes/Steroid C/D Facet Sg|LEFT SIDE,CASE-64490,APC,64490,CPT,0361,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],827.89,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,827.89,869.28,OPPS APC
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],6780.05,,"Case rate ($6,457.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,142.59, add-ons for qualifying new technology services are included. If operating cost exceeds $41,013.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,089.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $4,182.21 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,197.63 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $330.02. The transfer capital threshold is the transfer adjustment factor * $330.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5139.72,13110.79,Inpatient DRG
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,167,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],43522.37,,"Fee schedule rate ($43,522.37). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,14157.71,43522.37,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],28983.97,,"Fee schedule rate ($28,983.97). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8956.76,28983.97,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC,831,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],9294.42,,"Fee schedule rate ($9,294.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,4941.30,23661.59,There are no additional notes associated with this service or procedure.
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC,497,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],37761.19,,"Fee schedule rate ($37,761.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10127.65,37761.19,There are no additional notes associated with this service or procedure.
Adjnt Tis Trnsfr/Reargmt Any Area 30.1-60 Sq Cm,CASE-14301,APC,14301,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3317.01,,"APC Price ($3,317.01). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3317.01,3317.01,OPPS APC
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],73588.10,,"Fee schedule rate ($73,588.10). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,21585.31,73588.10,There are no additional notes associated with this service or procedure.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC,099,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],25603.58,,"Fee schedule rate ($25,603.58). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.7), with a minimum of zero.",,,,0,other,11171.21,26807.94,There are no additional notes associated with this service or procedure.
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],14455.04,,"Fee schedule rate ($14,455.04). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5280.00,17136.70,There are no additional notes associated with this service or procedure.
"Amputation Toe Metatarsophalangeal Joint|RIGHT FOOT, SECOND DIGIT",CASE-28820,APC,28820,CPT,0360,RC,,,T6,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],22340.80,,"Case rate ($21,585.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,215.96, add-ons for qualifying new technology services are included. If operating cost exceeds $55,086.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,196.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $18,203.89 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,271.01 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,436.47. The transfer capital threshold is the transfer adjustment factor * $1,436.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,21585.31,73588.10,Inpatient DRG
"INFECTIOUS AND PARASITIC DISEASES INCLUDING HIV WITH O.R. PROCEDURE,MODERATE",710,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],19723.98,,"Case rate ($19,723.98). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,19723.98,20710.18,There are no additional notes associated with this service or procedure.
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],34245.00,,"Fee schedule rate ($34,245.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,12725.42,34245.00,There are no additional notes associated with this service or procedure.
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC,797,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],20928.55,,"Fee schedule rate ($20,928.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8719.72,20928.55,There are no additional notes associated with this service or procedure.
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],8136.74,,"Case rate ($7,749.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,344.60, add-ons for qualifying new technology services are included. If operating cost exceeds $42,215.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,184.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,379.82 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,399.66 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $424.52. The transfer capital threshold is the transfer adjustment factor * $424.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6711.00,16865.16,Inpatient DRG
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,083,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],11625.35,,"Case rate ($11,397.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,738.37, add-ons for qualifying new technology services are included. If operating cost exceeds $45,609.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,451.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $8,761.12 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,793.42 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $691.34. The transfer capital threshold is the transfer adjustment factor * $691.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6965.00,28680.85,Inpatient DRG
Laps Rpr Paraesphgl Hrna Incl Fundplsty W/Mesh,CASE-43282,APC,43282,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],10447.27,,"APC Price ($9,949.78). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,9949.78,10447.27,OPPS APC
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],10517.71,,"Case rate ($10,517.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,920.01, add-ons for qualifying new technology services are included. If operating cost exceeds $44,791.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,386.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $7,945.76 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,975.06 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $627.00. The transfer capital threshold is the transfer adjustment factor * $627.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10517.71,24909.11,Inpatient DRG
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],24136.02,,"Case rate ($13,792.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,966.02, add-ons for qualifying new technology services are included. If operating cost exceeds $47,837.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,626.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $10,980.58 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,021.07 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $866.48. The transfer capital threshold is the transfer adjustment factor * $866.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,6965.00,34422.94,All Other Inpatient
"NEONATE BIRTH WEIGHT > 2499 GRAMS NORMAL NEWBORN OR NEONATE WITH OTHER PROBLEM,MAJOR",640,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],2898.84,,"Case rate ($2,898.84). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,2898.84,3043.78,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],30372.64,,"Fee schedule rate ($30,372.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,13260.40,32878.30,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],53152.12,,"Fee schedule rate ($53,152.12). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,19152.11,53152.12,There are no additional notes associated with this service or procedure.
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],7956.52,,"Case rate ($7,956.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,537.38, add-ons for qualifying new technology services are included. If operating cost exceeds $42,408.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,199.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,571.89 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,592.43 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $439.68. The transfer capital threshold is the transfer adjustment factor * $439.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,17467.27,Inpatient DRG
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],37488.28,,"Fee schedule rate ($37,488.28). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.5), with a minimum of zero.",,,,0,other,15453.88,39251.68,There are no additional notes associated with this service or procedure.
Hallux Rigidus W/Cheilectomy 1st Mp Jt W/O Implt|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-28289,APC,28289,CPT,0360,RC,,,LT|XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7029.71,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6791.99,7131.59,OPPS APC
HC App Skin Sub Other Tot <100 1st 25,CASE-15275,APC,15275,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1505.12,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1505.12,1557.80,OPPS APC
VENTRICULAR SHUNT PROCEDURES WITH MCC,031,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],33178.01,,"Fee schedule rate ($33,178.01). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,32287.20,88162.80,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,064,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],41838.16,,"Fee schedule rate ($41,838.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,15563.58,41838.16,There are no additional notes associated with this service or procedure.
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],6965.00,,,,,,0,other,6965.00,17467.27,There are no additional notes associated with this service or procedure.
Optx Dstl Radl I-Artic Fx/Epiphysl Sep 3 Frag|LEFT SIDE,CASE-25609,APC,25609,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7029.71,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6791.99,7131.59,OPPS APC
"INFECTIOUS AND PARASITIC DISEASES INCLUDING HIV WITH O.R. PROCEDURE,MAJOR",710,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],29457.70,,"Case rate ($29,457.70). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,29457.70,30930.59,There are no additional notes associated with this service or procedure.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,191,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],16587.71,,,,,,0,other,6965.00,16612.88,There are no additional notes associated with this service or procedure.
Cysto W/Ureteroscopy W/Rmvl/Manj Stones,CASE-52352,APC,52352,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3299.47,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3299.47,3464.44,OPPS APC
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],7414.07,,"Case rate ($7,414.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,032.76, add-ons for qualifying new technology services are included. If operating cost exceeds $41,903.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,159.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,069.12 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,087.81 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $400.00. The transfer capital threshold is the transfer adjustment factor * $400.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7414.07,18217.52,Inpatient DRG
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],86252.84,,"Fee schedule rate ($86,252.84). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,27944.96,86252.84,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],41353.22,,"Case rate ($40,542.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $37,851.31, add-ons for qualifying new technology services are included. If operating cost exceeds $72,722.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,582.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.6. The base transfer operating payment is the transfer adjustment factor * $35,774.45 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $35,906.36 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,822.96. The transfer capital threshold is the transfer adjustment factor * $2,822.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,40542.37,128358.13,Inpatient DRG
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC,497,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],37761.19,,"Fee schedule rate ($37,761.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10127.65,37761.19,There are no additional notes associated with this service or procedure.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,345,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],33616.03,,"Fee schedule rate ($33,616.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12134.89,33616.03,There are no additional notes associated with this service or procedure.
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],11154.68,,"Fee schedule rate ($11,154.68). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,10003.71,23415.63,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],7513.32,,"Case rate ($7,366). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,988.03, add-ons for qualifying new technology services are included. If operating cost exceeds $41,859.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,156.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,024.55 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,043.08 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $396.49. The transfer capital threshold is the transfer adjustment factor * $396.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6965.00,21195.68,Inpatient DRG
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],7396.47,,"Case rate ($7,396.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,016.38, add-ons for qualifying new technology services are included. If operating cost exceeds $41,887.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,158.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,052.80 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,071.43 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $398.72. The transfer capital threshold is the transfer adjustment factor * $398.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7396.47,16035.06,Inpatient DRG
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],105091.76,,"Fee schedule rate ($105,091.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,35719.96,105091.76,There are no additional notes associated with this service or procedure.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],12303.61,,"Case rate ($11,717.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,036.36, add-ons for qualifying new technology services are included. If operating cost exceeds $45,907.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,474.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $9,058.01 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,091.41 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $714.77. The transfer capital threshold is the transfer adjustment factor * $714.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,11717.72,43888.01,Inpatient DRG
SALIVARY GLAND PROCEDURES,139,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],23222.51,,"Fee schedule rate ($23,222.51). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.9), with a minimum of zero.",,,,0,other,10313.19,30690.92,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF THE EYE WITHOUT MCC,125,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],17952.29,,"Fee schedule rate ($17,952.29). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (6), with a minimum of zero.",,,,0,other,7144.54,17952.29,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],7994.00,,"Per diem ($7,994). If length of stay < 1.7, first 1 days paid at a per diem of $15,988 instead. Capped at $13,589.22.",,,,0,other,6841.83,21167.26,Estimated amount calculated based on 1 day length of stay.
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],44778.95,,,,,,0,other,17356.15,44778.95,There are no additional notes associated with this service or procedure.
PREMATURITY WITH MAJOR PROBLEMS,791,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],30904.42,,"Case rate ($29,432.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $27,516.30, add-ons for qualifying new technology services are included. If operating cost exceeds $62,387.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,770.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 13.3. The base transfer operating payment is the transfer adjustment factor * $25,477.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $25,571.35 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,010.42. The transfer capital threshold is the transfer adjustment factor * $2,010.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,3048.21,30904.42,Inpatient DRG
Egd Percutaneous Placement Gastrostomy Tube,CASE-43246,APC,43246,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1859.01,,"APC Price ($1,796.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1796.14,1885.95,OPPS APC
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],10895.60,,"Case rate ($10,895.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,271.55, add-ons for qualifying new technology services are included. If operating cost exceeds $45,142.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,414.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $8,296.01 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,326.60 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $654.64. The transfer capital threshold is the transfer adjustment factor * $654.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10895.60,35192.25,Inpatient DRG
"DIABETES,MINOR",420,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],5146.44,,"Case rate ($5,146.44). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,5146.44,5403.76,There are no additional notes associated with this service or procedure.
"DISORDERS OF PANCREAS EXCEPT MALIGNANCY,MODERATE",282,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],1920.06,,"Case rate for a one day stay ($1,920.06). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,1920.06,2016.06,There are no additional notes associated with this service or procedure.
CELLULITIS WITH MCC,602,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],11975.05,,"Case rate ($11,570.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,899.02, add-ons for qualifying new technology services are included. If operating cost exceeds $45,770.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,463.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $8,921.17 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,954.07 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $703.97. The transfer capital threshold is the transfer adjustment factor * $703.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,11570.10,28349.31,Inpatient DRG
"CHRONIC OBSTRUCTIVE PULMONARY DISEASE,MODERATE",140,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],2031.65,,"Case rate for a one day stay ($2,031.65). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,2031.65,2133.23,There are no additional notes associated with this service or procedure.
Hysteroscopy Removal Leiomyomata,CASE-58561,APC,58561,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],4846.30,,"APC Price ($4,682.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,4682.41,4916.53,OPPS APC
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],13090.35,,"Fee schedule rate ($13,090.35). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10533.95,24956.34,There are no additional notes associated with this service or procedure.
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],17584.68,,"Case rate ($10,048.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,483.42, add-ons for qualifying new technology services are included. If operating cost exceeds $44,354.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,352.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,510.78 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,538.48 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $592.68. The transfer capital threshold is the transfer adjustment factor * $592.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,10048.39,23545.50,All Other Inpatient
"HC Aerosol, Hhn, Mdi, Ippb|ADJ",CASE-94640,APC,94640,CPT,0410,RC,,,ADJ,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7029.71,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6791.99,7029.71,OPPS APC
Egd Transoral Biopsy Single/Multiple|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-43239,APC,43239,CPT,0360,RC,,,74,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],848.96,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,848.96,891.41,OPPS APC
COMPLICATIONS OF TREATMENT WITH CC,920,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],20731.52,,"Fee schedule rate ($20,731.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8732.59,20731.52,There are no additional notes associated with this service or procedure.
Laparoscopy Supracervical Hysterectomy 250 Gm/<,CASE-58541,APC,58541,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],10298.02,,"APC Price ($9,949.78). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,9949.78,10447.27,OPPS APC
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],28434.57,,"Fee schedule rate ($28,434.57). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,8906.63,28434.57,There are no additional notes associated with this service or procedure.
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],18223.96,,"Case rate ($17,356.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,281.67, add-ons for qualifying new technology services are included. If operating cost exceeds $51,152.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,887.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $14,284.05 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,336.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,127.15. The transfer capital threshold is the transfer adjustment factor * $1,127.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,17356.15,44778.95,Inpatient DRG
Brnchsc Brushing/Protected Brushings,CASE-31623,APC,31623,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6936.25,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6837.16,6936.25,OPPS APC
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],9273.92,,"Case rate ($8,832.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,364.96, add-ons for qualifying new technology services are included. If operating cost exceeds $43,235.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,251.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,395.76 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,420.01 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $491.59. The transfer capital threshold is the transfer adjustment factor * $491.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9040.72,26966.33,Inpatient DRG
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],36776.05,,"Fee schedule rate ($36,776.05). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11053.39,36776.05,There are no additional notes associated with this service or procedure.
SKIN ULCERS WITH MCC,592,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],15116.17,,"Case rate ($15,116.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $14,168.54, add-ons for qualifying new technology services are included. If operating cost exceeds $53,556.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $3,795.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.8. The base transfer operating payment is the transfer adjustment factor * $12,752.10 + an uncompensated DSH payment of $1,359.91. The transfer operating threshold is the transfer adjustment factor * $12,808.63 + an uncompensated DSH payment of $1,359.91. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,004.16. The transfer capital threshold is the transfer adjustment factor * $1,004.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,15116.17,38644.05,Inpatient DRG
VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC,033,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],42156.44,,"Fee schedule rate ($42,156.44). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,13206.23,42156.44,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],28423.20,,"Fee schedule rate ($28,423.20). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11059.47,28423.20,There are no additional notes associated with this service or procedure.
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC,807,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],6836.20,,"Case rate ($6,510.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,192.35, add-ons for qualifying new technology services are included. If operating cost exceeds $41,063.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,093.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $4,231.80 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,247.40 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $333.93. The transfer capital threshold is the transfer adjustment factor * $333.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5354.25,13266.23,Inpatient DRG
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,093,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],6965.00,,,,,,0,other,6965.00,19011.32,There are no additional notes associated with this service or procedure.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,056,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],59328.19,,"Fee schedule rate ($59,328.19). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (44), with a minimum of zero.",,,,0,other,7659.00,59328.19,There are no additional notes associated with this service or procedure.
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],11065.78,,"Fee schedule rate ($11,065.78). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5883.03,17111.12,There are no additional notes associated with this service or procedure.
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],17033.98,,"Fee schedule rate ($17,033.98). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.8), with a minimum of zero.",,,,0,other,7884.32,17835.23,There are no additional notes associated with this service or procedure.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],8146.95,,"Fee schedule rate ($8,146.95). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6683.37,14699.43,There are no additional notes associated with this service or procedure.
RESPIRATORY NEOPLASMS WITH CC,181,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],9381.80,,"Case rate ($9,197.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,692.16, add-ons for qualifying new technology services are included. If operating cost exceeds $43,563.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,290.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,722.42 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,747.21 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $530.47. The transfer capital threshold is the transfer adjustment factor * $530.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,9197.84,21074.07,Inpatient DRG
Exc Rct Procidentia W/Anast Perineal Approach,CASE-45130,APC,45130,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],50.48,,"APC Price ($48.78). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,48.78,51.22,OPPS APC
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],14455.04,,"Fee schedule rate ($14,455.04). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5280.00,17136.70,There are no additional notes associated with this service or procedure.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],17620.75,,,,,,0,other,8009.34,19877.10,There are no additional notes associated with this service or procedure.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",062,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],13844.84,,"Case rate ($13,844.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,015.16, add-ons for qualifying new technology services are included. If operating cost exceeds $47,886.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,630.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $11,029.54 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,070.21 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $870.34. The transfer capital threshold is the transfer adjustment factor * $870.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,13844.84,44304.80,Inpatient DRG
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC,939,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],97674.79,,"Fee schedule rate ($97,674.79). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,26517.40,97674.79,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC",281,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],17272.65,,"Fee schedule rate ($17,272.65). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.9), with a minimum of zero.",,,,0,other,8169.15,23859.35,There are no additional notes associated with this service or procedure.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],120927.32,,"Fee schedule rate ($120,927.32). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,45521.20,142438.06,There are no additional notes associated with this service or procedure.
Exc Rct Tum Not Incl Muscularis Propria,CASE-45171,APC,45171,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],2727.99,,"APC Price ($2,598.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2598.08,2727.99,OPPS APC
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],10130.60,,"Case rate ($9,648.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,111.10, add-ons for qualifying new technology services are included. If operating cost exceeds $43,982.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,323.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $7,139.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,166.15 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $563.40. The transfer capital threshold is the transfer adjustment factor * $563.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9648.19,31477.13,Inpatient DRG
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],2070.00,,,,,,0,other,1188.00,17370.86,Estimated amount calculated based on 3 day length of stay.
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,091,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],14529.96,,"Case rate ($13,838.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,008.86, add-ons for qualifying new technology services are included. If operating cost exceeds $47,879.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,629.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $11,023.26 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,063.91 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $869.84. The transfer capital threshold is the transfer adjustment factor * $869.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13838.06,40030.81,Inpatient DRG
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],13486.95,,"Fee schedule rate ($13,486.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6915.64,14442.92,There are no additional notes associated with this service or procedure.
HC Inj Anes/Steroid C/D Facet Sg|RIGHT SIDE,CASE-64490,APC,64490,CPT,0361,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],827.89,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,827.89,869.28,OPPS APC
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC",442,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],7849.58,,"Case rate ($7,695.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $7,260.76, add-ons for qualifying new technology services are included. If operating cost exceeds $45,905.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $3,189.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $5,874.79 + an uncompensated DSH payment of $1,359.91. The transfer operating threshold is the transfer adjustment factor * $5,900.84 + an uncompensated DSH payment of $1,359.91. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $460.97. The transfer capital threshold is the transfer adjustment factor * $460.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6607.45,19011.92,Inpatient DRG
HC Peripheral Block - Femoral Single or Saphenous W/Img Gdn|LEFT SIDE,CASE-64447,APC,64447,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],693.76,,"APC Price ($660.72). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,660.72,693.76,OPPS APC
"HC Injection Small Joint/Bursa|RIGHT HAND, FOURTH DIGIT",CASE-20600,APC,20600,CPT,0361,RC,,,F8,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1580.37,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1505.12,1580.37,OPPS APC
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],39153.65,,"Fee schedule rate ($39,153.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,7605.00,39153.65,There are no additional notes associated with this service or procedure.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC",061,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],62315.82,,"Fee schedule rate ($62,315.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,20616.23,62315.82,There are no additional notes associated with this service or procedure.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],105091.76,,"Fee schedule rate ($105,091.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,35719.96,105091.76,There are no additional notes associated with this service or procedure.
SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS,029,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],61889.56,,"Fee schedule rate ($61,889.56). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13641.00,67130.05,There are no additional notes associated with this service or procedure.
OSTEOMYELITIS WITH CC,540,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],10938.06,,"Case rate ($10,723.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,111.53, add-ons for qualifying new technology services are included. If operating cost exceeds $44,982.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,402.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $8,136.58 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,166.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $642.06. The transfer capital threshold is the transfer adjustment factor * $642.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,9809.07,25507.30,Inpatient DRG
"HYPOVOLEMIA AND RELATED ELECTROLYTE DISORDERS,MODERATE",422,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],2019.98,,"Case rate for a one day stay ($1,923.79). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,1923.79,2019.98,There are no additional notes associated with this service or procedure.
VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC,033,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],13206.23,,"Case rate ($13,206.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,421.07, add-ons for qualifying new technology services are included. If operating cost exceeds $47,292.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,583.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $10,437.64 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,476.13 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $823.63. The transfer capital threshold is the transfer adjustment factor * $823.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,13206.23,42156.44,Inpatient DRG
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],18739.51,,"Case rate ($18,105.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,979.06, add-ons for qualifying new technology services are included. If operating cost exceeds $51,850.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,941.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $14,978.89 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,034.11 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,181.98. The transfer capital threshold is the transfer adjustment factor * $1,181.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,18105.81,52699.33,Inpatient DRG
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],8206.88,,"Case rate ($7,816.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,417.70, add-ons for qualifying new technology services are included. If operating cost exceeds $42,288.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,179.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $5,452.08 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,472.75 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $419.06. The transfer capital threshold is the transfer adjustment factor * $419.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5415.00,17575.50,Inpatient DRG
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],85305.59,,"Fee schedule rate ($85,305.59). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,21719.40,85305.59,There are no additional notes associated with this service or procedure.
Amputation Metatarsal W/Toe Single,CASE-28810,APC,28810,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],6965.00,,,,,,0,other,6965.00,29482.05,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],21167.26,,"Fee schedule rate ($21,167.26). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,6841.83,21167.26,There are no additional notes associated with this service or procedure.
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],21320.03,,,,,,0,other,9282.47,21320.03,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],11594.35,,"Fee schedule rate ($11,594.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6164.03,14071.02,There are no additional notes associated with this service or procedure.
Surgical Arthroscopy Shoulder Biceps Tenodesis|LEFT SIDE,CASE-29828,APC,29828,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6791.99,7131.59,OPPS APC
Insj Biomchn Dev Vrt Corpectomy Defect W/Arthrd,CASE-22854,APC,22854,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],12017.31,,"APC Price ($12,017.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12017.31,12618.18,OPPS APC
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],13709.40,,"Case rate ($7,833.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,423.35, add-ons for qualifying new technology services are included. If operating cost exceeds $42,294.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,190.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,458.28 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,478.41 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $430.71. The transfer capital threshold is the transfer adjustment factor * $430.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,5883.03,17111.12,All Other Inpatient
Cystourethroscopy Inj Chemodenervation Bladder,CASE-52287,APC,52287,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1956.65,,"APC Price ($1,956.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1956.65,2054.48,OPPS APC
"SKIN ULCERS,MAJOR",380,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],10791.73,,"Case rate ($10,791.73). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,10791.73,11331.32,There are no additional notes associated with this service or procedure.
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],29216.99,,"Fee schedule rate ($29,216.99). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9755.86,29216.99,There are no additional notes associated with this service or procedure.
SEIZURES WITH MCC,100,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],32323.98,,"Fee schedule rate ($32,323.98). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,15061.09,38110.41,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],26966.33,,"Fee schedule rate ($26,966.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,9040.72,26966.33,There are no additional notes associated with this service or procedure.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],18341.97,,"Fee schedule rate ($18,341.97). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.9), with a minimum of zero.",,,,0,other,8554.50,19204.75,There are no additional notes associated with this service or procedure.
HYPERTENSION WITHOUT MCC,305,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],7411.48,,"Case rate ($7,058.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,702.02, add-ons for qualifying new technology services are included. If operating cost exceeds $41,573.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,133.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,739.59 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,757.07 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $374.00. The transfer capital threshold is the transfer adjustment factor * $374.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7058.55,17230.49,Inpatient DRG
HC Joint Injection/Aspir Large WO US|BILATERAL PROCEDURE,CASE-20610,APC,20610,CPT,0510,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],297.37,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,287.31,301.68,OPPS APC
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],11053.39,,"Case rate ($11,053.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,418.34, add-ons for qualifying new technology services are included. If operating cost exceeds $45,289.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,426.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $8,442.26 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,473.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $666.18. The transfer capital threshold is the transfer adjustment factor * $666.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,11053.39,36776.05,Inpatient DRG
NORMAL NEWBORN,795,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],3462.91,,"Case rate ($3,298.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $3,203.67, add-ons for qualifying new technology services are included. If operating cost exceeds $38,074.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $1,858.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $1,254.10 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $1,258.72 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $98.96. The transfer capital threshold is the transfer adjustment factor * $98.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,1369.79,5771.52,Inpatient DRG
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,191,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],6965.00,,,,,,0,other,6965.00,16612.88,There are no additional notes associated with this service or procedure.
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],9667.64,,"Fee schedule rate ($9,667.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,5139.72,13110.79,There are no additional notes associated with this service or procedure.
Dstr Nrolytc Agnt Parverteb Fct Sngl Crvcl/Thora|LEFT SIDE,CASE-64633,APC,64633,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1919.19,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1827.80,1919.19,OPPS APC
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],37505.96,,"Case rate ($35,719.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $33,365.14, add-ons for qualifying new technology services are included. If operating cost exceeds $68,236.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,230.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.9. The base transfer operating payment is the transfer adjustment factor * $31,304.77 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $31,420.19 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,470.26. The transfer capital threshold is the transfer adjustment factor * $2,470.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,35719.96,105091.76,Inpatient DRG
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],21892.85,,"Fee schedule rate ($21,892.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7569.84,21892.85,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITHOUT CC/MCC,428,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],63214.58,,"Fee schedule rate ($63,214.58). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,40017.53,118904.57,There are no additional notes associated with this service or procedure.
"Neuroplasty Sciatic Nerve,Open|LEFT SIDE",CASE-64712,APC,64712,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6791.99,7131.59,OPPS APC
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],27222.08,,"Fee schedule rate ($27,222.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7389.00,37134.43,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF THE EYE WITHOUT MCC,125,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],7144.54,,"Case rate ($7,144.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,782.02, add-ons for qualifying new technology services are included. If operating cost exceeds $41,653.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,140.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,819.30 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,837.07 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $380.29. The transfer capital threshold is the transfer adjustment factor * $380.29. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7144.54,17952.29,Inpatient DRG
INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC,198,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],14092.67,,,,,,0,other,6795.12,23505.07,There are no additional notes associated with this service or procedure.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],15905.62,,"Fee schedule rate ($15,905.62). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,12527.66,29917.96,There are no additional notes associated with this service or procedure.
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],59494.91,,"Fee schedule rate ($59,494.91). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,18594.09,59494.91,There are no additional notes associated with this service or procedure.
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 2nd Level|RIGHT SIDE,CASE-64494,APC,64494,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],827.89,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,827.89,869.28,OPPS APC
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,057,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],18757.97,,"Case rate ($10,718.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,107.12, add-ons for qualifying new technology services are included. If operating cost exceeds $44,978.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,401.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,132.18 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,162.17 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $641.71. The transfer capital threshold is the transfer adjustment factor * $641.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,10718.84,39884.93,All Other Inpatient
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7831.28,,"Case rate ($7,566.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,174.51, add-ons for qualifying new technology services are included. If operating cost exceeds $42,045.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,171.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,210.35 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,229.56 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $411.15. The transfer capital threshold is the transfer adjustment factor * $411.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,7566.45,16333.88,Inpatient DRG
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|RIGHT HAND, FIFTH DIGIT",CASE-26160,APC,26160,CPT,0360,RC,,,F9,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1580.37,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1505.12,1580.37,OPPS APC
FULL TERM NEONATE WITH MAJOR PROBLEMS,793,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],82045.22,,,,,,0,other,4302.90,82045.22,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],52803.53,,"Fee schedule rate ($52,803.53). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,14337.84,52803.53,There are no additional notes associated with this service or procedure.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],15099.70,,"Case rate ($15,099.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,182.53, add-ons for qualifying new technology services are included. If operating cost exceeds $49,053.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,722.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $12,192.63 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,237.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $962.12. The transfer capital threshold is the transfer adjustment factor * $962.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7605.00,39153.65,Inpatient DRG
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],27944.96,,"Case rate ($27,944.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $26,132.21, add-ons for qualifying new technology services are included. If operating cost exceeds $61,003.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,661.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.8. The base transfer operating payment is the transfer adjustment factor * $24,098.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $24,187.26 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,901.60. The transfer capital threshold is the transfer adjustment factor * $1,901.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,27944.96,86252.84,Inpatient DRG
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],23340.86,,,,,,0,other,9977.99,26949.28,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],22737.43,,"Fee schedule rate ($22,737.43). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,14295.18,42768.36,There are no additional notes associated with this service or procedure.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],54764.34,,"Fee schedule rate ($54,764.34). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,18178.96,54764.34,There are no additional notes associated with this service or procedure.
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",759,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],11643.60,,"Fee schedule rate ($11,643.60). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6190.22,13057.66,There are no additional notes associated with this service or procedure.
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],12558.65,,"Fee schedule rate ($12,558.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5065.00,12558.65,There are no additional notes associated with this service or procedure.
"NEONATE BIRTH WEIGHT > 2499 GRAMS WITH OTHER SIGNIFICANT CONDITION,MINOR",639,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],2814.69,,"Case rate ($2,680.66). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,2680.66,2814.69,There are no additional notes associated with this service or procedure.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],66833.55,,"Fee schedule rate ($66,833.55). Adds an outlier to normal pricing equal to the per diem rate ($141,521.30) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,26028.48,80635.65,There are no additional notes associated with this service or procedure.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],58320.32,,"Fee schedule rate ($58,320.32). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,16286.16,58320.32,There are no additional notes associated with this service or procedure.
Esophagogastroduodenoscopy Submucosal Injection|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-43236,APC,43236,CPT,0360,RC,,,74,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],848.96,,"APC Price ($848.96). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,848.96,891.41,OPPS APC
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",004,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],260309.36,,"Fee schedule rate ($260,309.36). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (35), with a minimum of zero.",,,,0,other,10249.47,272554.00,There are no additional notes associated with this service or procedure.
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],25013.10,,"Fee schedule rate ($25,013.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10846.16,25863.45,There are no additional notes associated with this service or procedure.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC,858,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],11377.76,,"Case rate ($11,377.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,720.10, add-ons for qualifying new technology services are included. If operating cost exceeds $45,591.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,449.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $8,742.91 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,775.15 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $689.90. The transfer capital threshold is the transfer adjustment factor * $689.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,11377.76,33794.11,Inpatient DRG
CERVICAL SPINAL FUSION WITH MCC,471,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],90745.76,,"Fee schedule rate ($90,745.76). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,34645.26,111337.93,There are no additional notes associated with this service or procedure.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,761,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],11946.72,,"Fee schedule rate ($11,946.72). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,5808.41,11946.72,There are no additional notes associated with this service or procedure.
CELLULITIS WITH MCC,602,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],28349.31,,"Fee schedule rate ($28,349.31). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11570.10,28349.31,There are no additional notes associated with this service or procedure.
"CARDIAC ARREST, UNEXPLAINED WITH MCC",296,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],36459.67,,"Fee schedule rate ($36,459.67). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12522.25,36459.67,There are no additional notes associated with this service or procedure.
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,450,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],38826.08,,"Case rate ($36,977.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $34,600.10, add-ons for qualifying new technology services are included. If operating cost exceeds $69,471.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,260.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $32,531.80 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $32,655.15 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,500.47. The transfer capital threshold is the transfer adjustment factor * $2,500.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,38037.38,146009.19,Inpatient DRG
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,069,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],20333.68,,"Fee schedule rate ($20,333.68). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,20333.68,There are no additional notes associated with this service or procedure.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],22626.77,,"Fee schedule rate ($22,626.77). Adds an outlier to normal pricing equal to the per diem rate ($36,883.74) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.5), with a minimum of zero.",,,,0,other,10098.51,24259.09,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],18954.85,,,,,,0,other,6963.00,18954.85,There are no additional notes associated with this service or procedure.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC,862,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],14295.18,,"Case rate ($14,295.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,434.11, add-ons for qualifying new technology services are included. If operating cost exceeds $48,305.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,663.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $11,446.95 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,489.15 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $903.28. The transfer capital threshold is the transfer adjustment factor * $903.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6855.00,35884.94,Inpatient DRG
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],18178.96,,"Case rate ($18,178.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,047.10, add-ons for qualifying new technology services are included. If operating cost exceeds $51,918.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,947.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $15,046.67 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,102.15 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,187.33. The transfer capital threshold is the transfer adjustment factor * $1,187.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,18178.96,54764.34,Inpatient DRG
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],14481.61,,"Case rate ($13,792.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,966.02, add-ons for qualifying new technology services are included. If operating cost exceeds $47,837.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,626.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $10,980.58 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,021.07 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $866.48. The transfer capital threshold is the transfer adjustment factor * $866.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,34422.94,Inpatient DRG
SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS,029,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],25549.51,,"Case rate ($25,048.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $23,437.73, add-ons for qualifying new technology services are included. If operating cost exceeds $58,308.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,449.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.7)) / 2. The base transfer operating payment is the transfer adjustment factor * $21,413.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $21,492.79 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,689.76. The transfer capital threshold is the transfer adjustment factor * $1,689.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,13641.00,67130.05,Inpatient DRG
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],8083.15,,"Case rate ($8,083.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,655.19, add-ons for qualifying new technology services are included. If operating cost exceeds $42,526.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,208.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,689.27 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,710.24 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $448.94. The transfer capital threshold is the transfer adjustment factor * $448.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7884.32,17835.23,Inpatient DRG
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],40918.00,,"Fee schedule rate ($40,918.00). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,16689.78,59521.43,There are no additional notes associated with this service or procedure.
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],14674.80,,"Fee schedule rate ($14,674.80). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6711.00,16865.16,There are no additional notes associated with this service or procedure.
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC,805,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],20281.41,,"Fee schedule rate ($20,281.41). Adds an outlier to normal pricing equal to the per diem rate ($31,438.44) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.5), with a minimum of zero.",,,,0,other,9253.36,21235.42,There are no additional notes associated with this service or procedure.
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],10203.78,,"Case rate ($10,003.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,441.84, add-ons for qualifying new technology services are included. If operating cost exceeds $44,312.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,349.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $7,469.36 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,496.90 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $589.41. The transfer capital threshold is the transfer adjustment factor * $589.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,10003.71,23415.63,Inpatient DRG
HC Inj Tendon Sheath/Ligament|RIGHT SIDE,CASE-20550,APC,20550,CPT,0510,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
GASTROINTESTINAL HEMORRHAGE WITH CC,378,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],20845.19,,"Fee schedule rate ($20,845.19). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8586.33,20845.19,There are no additional notes associated with this service or procedure.
RESPIRATORY NEOPLASMS WITHOUT CC/MCC,182,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],6965.00,,,,,,0,other,6965.00,23037.13,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],52449.26,,"Fee schedule rate ($52,449.26). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,17693.40,52449.26,There are no additional notes associated with this service or procedure.
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],25261.33,,,,,,0,other,10638.94,25261.33,There are no additional notes associated with this service or procedure.
DIABETES WITH MCC,637,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],9959.03,,"Case rate ($9,484.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $8,852.20, add-ons for qualifying new technology services are included. If operating cost exceeds $48,421.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $3,463.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $8,811.98. The transfer operating threshold is the transfer adjustment factor * $8,852.20 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $672.81. The transfer capital threshold is the transfer adjustment factor * $672.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9959.03,28655.62,Inpatient DRG
CESAREAN SECTION WITH STERILIZATION WITH CC,784,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],9358.80,,"Case rate ($8,913.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,440.32, add-ons for qualifying new technology services are included. If operating cost exceeds $43,311.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,257.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,470.84 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,495.37 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $497.36. The transfer capital threshold is the transfer adjustment factor * $497.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9124.01,23722.94,Inpatient DRG
"Tendon Sheath Incision|UNUSUAL NON-OVERLAPPING SERVICE|LEFT HAND, THIRD DIGIT",CASE-26055,APC,26055,CPT,0360,RC,,,XU|F2,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1505.12,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1505.12,1557.80,OPPS APC
MINOR BLADDER PROCEDURES WITHOUT CC/MCC,664,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],31876.87,,"Fee schedule rate ($31,876.87). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9034.63,31876.87,There are no additional notes associated with this service or procedure.
Preparation Skin Cell Ssp Agrft 1st 25 Sq Cm/<,CASE-15013,APC,15013,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6875.26,,"APC Price ($6,642.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6875.26,6875.26,OPPS APC
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],6697.54,,"Case rate ($6,378.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,069.50, add-ons for qualifying new technology services are included. If operating cost exceeds $40,940.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,084.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,109.40 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,124.55 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $324.27. The transfer capital threshold is the transfer adjustment factor * $324.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,4341.01,12882.53,Inpatient DRG
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],35192.25,,"Fee schedule rate ($35,192.25). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,10895.60,35192.25,There are no additional notes associated with this service or procedure.
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],12246.05,,"Fee schedule rate ($12,246.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6010.23,12246.05,There are no additional notes associated with this service or procedure.
Lithotripsy Xtrcorp Shock Wave|BILATERAL PROCEDURE,CASE-50590,APC,50590,CPT,0360,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3464.44,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3299.47,3464.44,OPPS APC
Trachelectomy Cervicectomy Amp Cervix Spx,CASE-57530,APC,57530,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],4682.41,,"APC Price ($4,682.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,4682.41,4916.53,OPPS APC
CHOLECYSTECTOMY WITH C.D.E. WITH MCC,411,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],88615.28,,"Fee schedule rate ($88,615.28). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,24315.13,88615.28,There are no additional notes associated with this service or procedure.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],60646.89,,"Fee schedule rate ($60,646.89). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15.6), with a minimum of zero.",,,,0,other,23799.09,63499.65,There are no additional notes associated with this service or procedure.
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],13486.95,,"Fee schedule rate ($13,486.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6915.64,14442.92,There are no additional notes associated with this service or procedure.
"Tendon Sheath Incision|RIGHT HAND, SECOND DIGIT",CASE-26055,APC,26055,CPT,0360,RC,,,F6,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1580.37,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1505.12,1580.37,OPPS APC
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC",641,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],8274.00,,"Fee schedule rate ($8,274). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7214.98,15312.64,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF THE EYE WITHOUT MCC,125,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],17952.29,,"Fee schedule rate ($17,952.29). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (6), with a minimum of zero.",,,,0,other,7144.54,17952.29,There are no additional notes associated with this service or procedure.
HC Inj Aa&/Strd Greater Occipital Nerve|BILATERAL PROCEDURE,CASE-64405,APC,64405,CPT,0450,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
DIABETES WITHOUT CC/MCC,639,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],6965.00,,,,,,0,other,6151.76,12223.35,There are no additional notes associated with this service or procedure.
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",004,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],10715.36,,,,,,0,other,10249.47,272554.00,Estimated amount calculated based on 6 day length of stay.
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],37495.79,,"Fee schedule rate ($37,495.79). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.8), with a minimum of zero.",,,,0,other,15456.59,41402.42,There are no additional notes associated with this service or procedure.
Laser Vaporization of Prostate for Urine Flow,CASE-52648,APC,52648,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5018.77,,"APC Price ($5,018.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5018.77,5269.71,OPPS APC
SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS,029,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],67130.05,,,,,,0,other,13641.00,67130.05,There are no additional notes associated with this service or procedure.
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],17575.50,,,,,,0,other,5415.00,17575.50,There are no additional notes associated with this service or procedure.
"FOOT AND TOE PROCEDURES,MINOR",314,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],10777.59,,"Case rate ($10,264.37). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10264.37,10777.59,There are no additional notes associated with this service or procedure.
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],38839.49,,"Fee schedule rate ($38,839.49). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.6), with a minimum of zero.",,,,0,other,15940.79,53275.26,There are no additional notes associated with this service or procedure.
Egd US Guided Transmural Injxn/Fiducial Marker,CASE-43253,APC,43253,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1796.14,,"APC Price ($1,796.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1796.14,1885.95,OPPS APC
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],7414.07,,"Case rate ($7,414.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,032.76, add-ons for qualifying new technology services are included. If operating cost exceeds $41,903.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,159.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,069.12 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,087.81 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $400.00. The transfer capital threshold is the transfer adjustment factor * $400.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7414.07,18217.52,Inpatient DRG
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],5883.03,,"Fee schedule rate ($5,883.03). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5883.03,17111.12,There are no additional notes associated with this service or procedure.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],38246.19,,"Fee schedule rate ($38,246.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,19435.86,50821.76,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,447,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],156646.82,,"Fee schedule rate ($156,646.82). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,47193.21,156646.82,There are no additional notes associated with this service or procedure.
Laparoscopy Supracervical Hysterectomy 250 Gm/<,CASE-58541,APC,58541,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],10447.27,,"APC Price ($9,949.78). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,9949.78,10447.27,OPPS APC
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],23801.30,,,,,,0,other,10136.44,24444.75,There are no additional notes associated with this service or procedure.
Tnot Elbow Lateral/Medial Debride Open Tdn Rpr|LEFT SIDE,CASE-24359,APC,24359,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],28038.61,,"Fee schedule rate ($28,038.61). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12126.09,29582.40,There are no additional notes associated with this service or procedure.
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],14830.15,,"Fee schedule rate ($14,830.15). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,7884.32,17835.23,There are no additional notes associated with this service or procedure.
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],21354.82,,"Fee schedule rate ($21,354.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6834.39,21354.82,There are no additional notes associated with this service or procedure.
Lithotripsy Xtrcorp Shock Wave|LEFT SIDE,CASE-50590,APC,50590,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3299.47,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3299.47,3414.95,OPPS APC
SIGNS AND SYMPTOMS WITH MCC,947,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],23855.83,,"Fee schedule rate ($23,855.83). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10541.41,30414.32,There are no additional notes associated with this service or procedure.
Brnschsc Tndsc Ebus Dx/Tx Intervention Perph Les,CASE-31654,APC,31654,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6605.95,,"APC Price ($6,605.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6605.95,6936.25,OPPS APC
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],14871.83,,"Fee schedule rate ($14,871.83). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6558.75,14871.83,There are no additional notes associated with this service or procedure.
"Prq Skel Fixj Phlngl Shft Fx Prox/Middle Px/F/T|RIGHT HAND, THUMB",CASE-26727,APC,26727,CPT,0360,RC,,,F5,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC,831,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],4941.30,,"Fee schedule rate ($4,941.30). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,4941.30,23661.59,There are no additional notes associated with this service or procedure.
Cystourethroscopy W/Dest &/Rmvl Med Bladder Tum,CASE-52235,APC,52235,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3414.95,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3299.47,3464.44,OPPS APC
"NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY",789,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],6663.33,,,,,,0,other,3054.00,14857.05,Estimated amount calculated based on 1 day length of stay.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],52449.26,,"Fee schedule rate ($52,449.26). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,17693.40,52449.26,There are no additional notes associated with this service or procedure.
Injection Aa&/Strd Genicular Nrv Branches W/Img|LEFT SIDE,CASE-64454,APC,64454,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],683.85,,"APC Price ($660.72). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,660.72,693.76,OPPS APC
"Amputation Toe Metatarsophalangeal Joint|RIGHT FOOT, SECOND DIGIT",CASE-28820,APC,28820,CPT,0360,RC,,,T6,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],9137.93,,"Case rate ($8,702.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,231.63, add-ons for qualifying new technology services are included. If operating cost exceeds $43,102.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,254.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,263.59 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,286.68 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $494.26. The transfer capital threshold is the transfer adjustment factor * $494.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5683.00,19635.68,Inpatient DRG
GASTROINTESTINAL HEMORRHAGE WITH MCC,377,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],31575.65,,"Fee schedule rate ($31,575.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,7634.00,35969.56,There are no additional notes associated with this service or procedure.
Unlisted Px Female Genital System Nonobstetrical,CASE-58999,APC,58999,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],198.70,,"APC Price ($189.24). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,189.24,198.70,OPPS APC
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",623,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],32096.64,,"Fee schedule rate ($32,096.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,14093.37,33712.76,There are no additional notes associated with this service or procedure.
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],11225.78,,"Case rate ($10,846.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,225.56, add-ons for qualifying new technology services are included. If operating cost exceeds $45,096.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,410.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $8,250.19 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,280.61 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $651.02. The transfer capital threshold is the transfer adjustment factor * $651.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,10846.16,25863.45,Inpatient DRG
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],33152.73,,"Fee schedule rate ($33,152.73). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13891.57,34712.20,There are no additional notes associated with this service or procedure.
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],24444.75,,"Fee schedule rate ($24,444.75). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10136.44,24444.75,There are no additional notes associated with this service or procedure.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],13768.00,,,,,,0,other,6683.37,14699.43,There are no additional notes associated with this service or procedure.
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],17255.73,,"Fee schedule rate ($17,255.73). Adds an outlier to normal pricing equal to the per diem rate ($43,191.57) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,8163.06,18067.42,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7081.29,,"Case rate ($6,841.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,500.42, add-ons for qualifying new technology services are included. If operating cost exceeds $41,371.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,118.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $4,538.73 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,555.47 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $358.15. The transfer capital threshold is the transfer adjustment factor * $358.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6841.83,21167.26,Inpatient DRG
Removal Implant Deep,CASE-20680,APC,20680,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1827.80,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1827.80,1919.19,OPPS APC
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],8725.59,,"Case rate ($8,554.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,093.67, add-ons for qualifying new technology services are included. If operating cost exceeds $42,964.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,243.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,126.13 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,148.72 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $483.41. The transfer capital threshold is the transfer adjustment factor * $483.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,8554.50,19204.75,Inpatient DRG
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],16387.39,,"Case rate ($16,066.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,081.53, add-ons for qualifying new technology services are included. If operating cost exceeds $49,952.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,792.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $13,088.32 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,136.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,032.80. The transfer capital threshold is the transfer adjustment factor * $1,032.80. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6965.00,41030.48,Inpatient DRG
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],9865.56,,"Case rate ($9,865.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,313.33, add-ons for qualifying new technology services are included. If operating cost exceeds $44,184.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,339.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $7,341.31 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,368.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $579.30. The transfer capital threshold is the transfer adjustment factor * $579.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9865.56,37914.65,Inpatient DRG
Surgical Arthroscopy Shoulder Repair Slap Lesion|RIGHT SIDE,CASE-29807,APC,29807,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7029.71,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6791.99,7131.59,OPPS APC
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC,058,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],32126.63,,"Fee schedule rate ($32,126.63). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13521.80,40853.02,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,373,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],7214.49,,"Case rate ($6,870.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,527.50, add-ons for qualifying new technology services are included. If operating cost exceeds $41,398.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,120.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $4,565.72 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,582.56 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $360.28. The transfer capital threshold is the transfer adjustment factor * $360.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6870.94,14313.05,Inpatient DRG
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH MCC",510,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],89863.76,,"Fee schedule rate ($89,863.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10710.00,89863.76,There are no additional notes associated with this service or procedure.
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],33221.97,,"Fee schedule rate ($33,221.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (47), with a minimum of zero.",,,,0,other,15283.90,38757.79,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],22809.58,,,,,,0,other,9795.13,23899.13,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL OBSTRUCTION WITH CC,389,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],16423.43,,"Fee schedule rate ($16,423.43). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5118.00,16423.43,There are no additional notes associated with this service or procedure.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],14603.19,,"Case rate ($13,907.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,073.74, add-ons for qualifying new technology services are included. If operating cost exceeds $47,944.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,634.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $11,087.92 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,128.80 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $874.95. The transfer capital threshold is the transfer adjustment factor * $874.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13907.80,52794.06,Inpatient DRG
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],13639.70,,"Case rate ($12,990.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,220.11, add-ons for qualifying new technology services are included. If operating cost exceeds $47,091.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,567.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $10,237.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,275.16 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $807.83. The transfer capital threshold is the transfer adjustment factor * $807.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9888.00,43399.23,Inpatient DRG
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],47123.82,,"Fee schedule rate ($47,123.82). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,12696.97,47123.82,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],12984.79,,"Case rate ($12,984.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,215.07, add-ons for qualifying new technology services are included. If operating cost exceeds $47,086.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,567.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $10,232.39 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,270.12 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $807.44. The transfer capital threshold is the transfer adjustment factor * $807.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12984.79,32077.45,Inpatient DRG
Arthrs Wrst Exc&/Rpr Triang Fibrocart&/Joint|LEFT SIDE,CASE-29846,APC,29846,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
Cysto W/Urtroscopy&/Pyeloscopy Dx,CASE-52351,APC,52351,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3464.44,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3299.47,3464.44,OPPS APC
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],38378.80,,"Fee schedule rate ($38,378.80). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,14370.36,38378.80,There are no additional notes associated with this service or procedure.
HC Joint Injection/Aspir Large WO US|RIGHT SIDE,CASE-20610,APC,20610,CPT,0510,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],297.37,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,287.31,301.68,OPPS APC
Laps Surg Prst8ect Rpbic Rad W/Nrv Sparing Robot,CASE-55866,APC,55866,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],9949.78,,"APC Price ($9,949.78). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,9949.78,10447.27,OPPS APC
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],16900.84,,"Fee schedule rate ($16,900.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8151.55,18033.97,There are no additional notes associated with this service or procedure.
DIABETES WITHOUT CC/MCC,639,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],6459.35,,"Case rate ($6,151.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,858.45, add-ons for qualifying new technology services are included. If operating cost exceeds $40,729.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,067.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $3,899.13 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,913.51 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $307.68. The transfer capital threshold is the transfer adjustment factor * $307.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6151.76,12223.35,Inpatient DRG
O.R. PROCEDURES FOR OBESITY WITH CC,620,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],30074.44,,"Fee schedule rate ($30,074.44). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7.8), with a minimum of zero.",,,,0,other,12782.30,43753.50,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],8859.23,,"Case rate ($8,859.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,377.16, add-ons for qualifying new technology services are included. If operating cost exceeds $43,248.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,265.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $6,408.58 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,432.21 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $505.70. The transfer capital threshold is the transfer adjustment factor * $505.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8859.23,20090.22,Inpatient DRG
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],58394.20,,"Fee schedule rate ($58,394.20). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,9370.00,65732.99,There are no additional notes associated with this service or procedure.
HEART FAILURE AND SHOCK WITH CC,292,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],15550.06,,"Fee schedule rate ($15,550.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5502.00,16705.77,There are no additional notes associated with this service or procedure.
"OTHER DIGESTIVE SYSTEM AND ABDOMINAL PROCEDURES,EXTREME",229,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],41019.09,,"Case rate ($41,019.09). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,41019.09,43070.04,There are no additional notes associated with this service or procedure.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,057,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],39884.93,,"Fee schedule rate ($39,884.93). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,10718.84,39884.93,There are no additional notes associated with this service or procedure.
SEIZURES WITH MCC,100,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],32323.98,,"Fee schedule rate ($32,323.98). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,15061.09,38110.41,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITH MCC,385,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],31134.92,,,,,,0,other,11480.01,31134.92,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF NERVOUS SYSTEM WITH CC,092,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],9102.75,,"Case rate ($8,669.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,213, add-ons for qualifying new technology services are included. If operating cost exceeds $43,084.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,239.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $6,244.38 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,268.05 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $479.96. The transfer capital threshold is the transfer adjustment factor * $479.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8872.78,26765.51,Inpatient DRG
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],16035.06,,"Fee schedule rate ($16,035.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,7396.47,16035.06,There are no additional notes associated with this service or procedure.
HC Inj Tendon Sheath/Ligament|PBB CHARGE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-20550,APC,20550,CPT,0510,RC,,,PBB|XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],297.37,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,287.31,301.68,OPPS APC
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],14008.75,,"Case rate ($13,341.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,547.08, add-ons for qualifying new technology services are included. If operating cost exceeds $47,418.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,593.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $10,563.18 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,602.13 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $833.54. The transfer capital threshold is the transfer adjustment factor * $833.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13341.67,42586.49,Inpatient DRG
"MAJOR GASTROINTESTINAL AND PERITONEAL INFECTIONS,MAJOR",248,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],11830.94,,"Case rate ($11,267.56). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11267.56,11830.94,There are no additional notes associated with this service or procedure.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],9231.95,,"Fee schedule rate ($9,231.95). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5683.00,19635.68,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,699,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],8994.97,,"Case rate ($8,818.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,339.37, add-ons for qualifying new technology services are included. If operating cost exceeds $43,210.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,262.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $6,370.92 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,394.41 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $502.73. The transfer capital threshold is the transfer adjustment factor * $502.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,5961.00,19972.16,Inpatient DRG
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],13762.88,,"Case rate ($13,762.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,938.93, add-ons for qualifying new technology services are included. If operating cost exceeds $47,809.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,624.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $10,953.59 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,993.98 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $864.35. The transfer capital threshold is the transfer adjustment factor * $864.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,1188.00,34338.33,Inpatient DRG
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],31410.38,,"Fee schedule rate ($31,410.38). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,8480.00,59081.91,There are no additional notes associated with this service or procedure.
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],10078.00,,"Per diem ($10,078). If length of stay < 7.2, first 1 days paid at a per diem of $20,156 instead. Capped at $72,563.53.",,,,0,other,10078.00,81454.07,Estimated amount calculated based on 15 day length of stay.
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC,058,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],14197.89,,"Case rate ($13,521.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,714.66, add-ons for qualifying new technology services are included. If operating cost exceeds $47,585.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,606.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $10,730.14 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,769.70 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $846.71. The transfer capital threshold is the transfer adjustment factor * $846.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13521.80,40853.02,Inpatient DRG
"Amputation Toe Interphalangeal Joint|RIGHT FOOT, THIRD DIGIT",CASE-28825,APC,28825,CPT,0360,RC,,,T7,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
"Exc Tum/Vasc Mal Sft Tiss Hand/Fngr Subq <1.5cm|RIGHT HAND, SECOND DIGIT",CASE-26115,APC,26115,CPT,0360,RC,,,F6,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1545.93,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1545.93,1623.23,OPPS APC
Colpopexy Vaginal Intraperitoneal Approach|UNUSUAL NON-OVERLAPPING SERVICE,CASE-57283,APC,57283,CPT,0360,RC,,,XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7288.08,,"APC Price ($6,941.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6941.03,7288.08,OPPS APC
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],8083.15,,"Case rate ($8,083.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,655.19, add-ons for qualifying new technology services are included. If operating cost exceeds $42,526.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,208.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,689.27 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,710.24 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $448.94. The transfer capital threshold is the transfer adjustment factor * $448.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7884.32,17835.23,Inpatient DRG
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],15586.60,,"Case rate ($8,906.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,421.26, add-ons for qualifying new technology services are included. If operating cost exceeds $43,292.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,269.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $6,452.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,476.31 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $509.17. The transfer capital threshold is the transfer adjustment factor * $509.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,8906.63,28434.57,All Other Inpatient
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],20981.60,,"Fee schedule rate ($20,981.60). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,10003.71,23415.63,There are no additional notes associated with this service or procedure.
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITH MCC,429,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],169317.41,,"Fee schedule rate ($169,317.41). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,62958.58,177294.98,There are no additional notes associated with this service or procedure.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],8169.53,,"Case rate ($8,009.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,586.52, add-ons for qualifying new technology services are included. If operating cost exceeds $42,457.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,203.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $5,620.85 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,641.57 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $443.54. The transfer capital threshold is the transfer adjustment factor * $443.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,8009.34,19877.10,Inpatient DRG
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],56787.82,,,,,,0,other,21489.15,68942.79,There are no additional notes associated with this service or procedure.
Colonoscopy W/Biopsy Single/Multiple|SEPARATE STRUCTURE,CASE-45380,APC,45380,CPT,0360,RC,,,XS,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1176.09,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1120.09,1176.09,OPPS APC
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC,797,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],9155.71,,"Case rate ($8,719.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,247.38, add-ons for qualifying new technology services are included. If operating cost exceeds $43,118.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,255.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $6,279.28 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,302.43 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $495.50. The transfer capital threshold is the transfer adjustment factor * $495.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8719.72,20928.55,Inpatient DRG
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,086,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],11305.27,,"Case rate ($10,766.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,151.85, add-ons for qualifying new technology services are included. If operating cost exceeds $45,022.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,405.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $8,176.75 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,206.90 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $645.23. The transfer capital threshold is the transfer adjustment factor * $645.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8442.00,30728.81,Inpatient DRG
Rpr 1st Ingun Hrna Age 5 Yrs/> Reducible|LEFT SIDE,CASE-49505,APC,49505,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3518.91,,"APC Price ($3,351.34). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3351.34,3518.91,OPPS APC
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],62454.12,,"Fee schedule rate ($62,454.12). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11348.00,62454.12,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS WITH MCC,947,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],30414.32,,"Fee schedule rate ($30,414.32). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,10541.41,30414.32,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL OBSTRUCTION WITH CC,389,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],7293.54,,"Case rate ($7,293.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,920.63, add-ons for qualifying new technology services are included. If operating cost exceeds $41,791.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,151.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $4,957.39 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,975.67 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $391.19. The transfer capital threshold is the transfer adjustment factor * $391.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,5118.00,16423.43,Inpatient DRG
INFLAMMATORY BOWEL DISEASE WITH CC,386,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],8556.53,,"Case rate ($8,556.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,095.56, add-ons for qualifying new technology services are included. If operating cost exceeds $42,966.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,243.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,128.01 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,150.61 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $483.56. The transfer capital threshold is the transfer adjustment factor * $483.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8556.53,19879.00,Inpatient DRG
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],39251.68,,,,,,0,other,15453.88,39251.68,There are no additional notes associated with this service or procedure.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,073,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],30149.61,,"Fee schedule rate ($30,149.61). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12809.38,43475.01,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],36103.36,,,,,,0,other,14370.36,38378.80,There are no additional notes associated with this service or procedure.
Removal Implant Deep,CASE-20680,APC,20680,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1919.19,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1827.80,1919.19,OPPS APC
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],51630.84,,"Fee schedule rate ($51,630.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,20559.34,54086.17,There are no additional notes associated with this service or procedure.
"LIMB REATTACHMENT, HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA",956,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],148259.86,,"Fee schedule rate ($148,259.86). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,27428.25,148259.86,There are no additional notes associated with this service or procedure.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],20559.34,,"Case rate ($20,559.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $19,261.52, add-ons for qualifying new technology services are included. If operating cost exceeds $54,132.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,121.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $17,252.96 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $17,316.57 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,361.43. The transfer capital threshold is the transfer adjustment factor * $1,361.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,20559.34,54086.17,Inpatient DRG
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],8943.17,,"Case rate ($8,767.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,292.11, add-ons for qualifying new technology services are included. If operating cost exceeds $43,163.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,258.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,323.85 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,347.16 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $499.01. The transfer capital threshold is the transfer adjustment factor * $499.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,8767.81,19824.58,Inpatient DRG
"Open Tx Phalangeal Shaft Fracture Prox/Middle Ea|RIGHT HAND, FOURTH DIGIT",CASE-26735,APC,26735,CPT,0360,RC,,,F8,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
Surgical Arthroscopy Shoulder Xtnsv Dbrdmt 3+|LEFT SIDE,CASE-29823,APC,29823,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6791.99,7131.59,OPPS APC
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],78960.67,,"Fee schedule rate ($78,960.67). Adds an outlier to normal pricing equal to the per diem rate ($149,567.78) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19.1), with a minimum of zero.",,,,0,other,30398.48,82674.88,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],13947.32,,"Fee schedule rate ($13,947.32). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6153.12,13947.32,There are no additional notes associated with this service or procedure.
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 1 Level,CASE-64493,APC,64493,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],869.28,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,827.89,869.28,OPPS APC
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],16400.70,,"Fee schedule rate ($16,400.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,16400.70,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],13252.76,,"Case rate ($12,992.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,222.63, add-ons for qualifying new technology services are included. If operating cost exceeds $47,093.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,568.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $10,239.92 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,277.68 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $808.03. The transfer capital threshold is the transfer adjustment factor * $808.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,7665.00,40737.46,Inpatient DRG
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],23790.06,,"Fee schedule rate ($23,790.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10517.71,24909.11,There are no additional notes associated with this service or procedure.
HC Joint Injection/Aspir Large WO US|LEFT SIDE|PBB CHARGE,CASE-20610,APC,20610,CPT,0510,RC,,,LT|PBB,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],297.37,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,287.31,301.68,OPPS APC
SPINAL PROCEDURES WITH MCC,028,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],120982.83,,"Fee schedule rate ($120,982.83). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,42633.57,120982.83,There are no additional notes associated with this service or procedure.
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],16283.24,,"Fee schedule rate ($16,283.24). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7875.94,17233.12,There are no additional notes associated with this service or procedure.
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],28334.16,,"Fee schedule rate ($28,334.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,7868.00,32126.64,There are no additional notes associated with this service or procedure.
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC,519,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],16264.96,,"Case rate ($15,490.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,546.03, add-ons for qualifying new technology services are included. If operating cost exceeds $49,417.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,750.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $12,554.80 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,601.09 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $990.70. The transfer capital threshold is the transfer adjustment factor * $990.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,15490.44,50780.20,Inpatient DRG
DIABETES WITHOUT CC/MCC,639,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],12223.35,,,,,,0,other,6151.76,12223.35,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC,831,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],6965.00,,,,,,0,other,4941.30,23661.59,There are no additional notes associated with this service or procedure.
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|RIGHT HAND, THIRD DIGIT",CASE-26160,APC,26160,CPT,0360,RC,,,F7,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1505.12,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1505.12,1580.37,OPPS APC
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],21404.64,,,,,,0,other,6965.00,21404.64,There are no additional notes associated with this service or procedure.
Bronchoscopy W/Plmt Fiducial Markers Single/Mult,CASE-31626,APC,31626,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6837.16,,"APC Price ($6,605.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6605.95,6936.25,OPPS APC
COAGULATION DISORDERS,813,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],29046.49,,"Fee schedule rate ($29,046.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12274.39,30013.33,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],7665.00,,"Per diem ($7,665). If length of stay < 4, first 1 days paid at a per diem of $15,330 instead. Capped at $30,658.90.",,,,0,other,7665.00,40737.46,Estimated amount calculated based on 5 day length of stay.
Reconstruction Nail Bed W/Graft,CASE-11762,APC,11762,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1931.28,,"APC Price ($1,931.28). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1931.28,2027.84,OPPS APC
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],5710.23,,"Case rate ($5,710.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,447.70, add-ons for qualifying new technology services are included. If operating cost exceeds $40,318.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,035.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $3,489.88 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,502.75 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $275.39. The transfer capital threshold is the transfer adjustment factor * $275.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,3079.00,10940.41,Inpatient DRG
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],14672.51,,"Case rate ($13,973.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,157.60, add-ons for qualifying new technology services are included. If operating cost exceeds $48,028.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,618.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $11,170.29 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,212.65 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $858.57. The transfer capital threshold is the transfer adjustment factor * $858.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,14337.84,52803.53,Inpatient DRG
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],22563.61,,"Case rate ($21,489.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,126.50, add-ons for qualifying new technology services are included. If operating cost exceeds $54,997.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,189.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.6. The base transfer operating payment is the transfer adjustment factor * $18,114.76 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,181.55 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,429.43. The transfer capital threshold is the transfer adjustment factor * $1,429.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,21489.15,68942.79,Inpatient DRG
Peri-Implant Capsulectomy Breast Complete|LEFT SIDE,CASE-19371,APC,19371,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3664.94,,"APC Price ($3,664.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3664.94,3848.19,OPPS APC
PREMATURITY WITHOUT MAJOR PROBLEMS,792,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],18901.72,,"Case rate ($18,531.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,374.70, add-ons for qualifying new technology services are included. If operating cost exceeds $52,245.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,973.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. The base transfer operating payment is the transfer adjustment factor * $15,373.07 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,429.75 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,213.09. The transfer capital threshold is the transfer adjustment factor * $1,213.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,1956.00,19457.66,Inpatient DRG
Dstr Nrolytc Agnt Parverteb Fct Sngl Crvcl/Thora|BILATERAL PROCEDURE,CASE-64633,APC,64633,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1827.80,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1827.80,1891.77,OPPS APC
SALIVARY GLAND PROCEDURES,139,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],17010.00,,"Fee schedule rate ($17,010). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,10313.19,30690.92,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],47804.40,,"Fee schedule rate ($47,804.40). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,27944.96,86252.84,There are no additional notes associated with this service or procedure.
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],16438.59,,"Fee schedule rate ($16,438.59). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7402.56,16438.59,There are no additional notes associated with this service or procedure.
OTHER CEREBROVASCULAR DISORDERS WITH CC,071,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],5843.00,,"Per diem ($5,843). If length of stay < 3.3, first 1 days paid at a per diem of $11,686 instead. Capped at $19,281.62.",,,,0,other,5843.00,29215.10,Estimated amount calculated based on 3 day length of stay.
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH MCC",510,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],59434.38,,,,,,0,other,10710.00,89863.76,There are no additional notes associated with this service or procedure.
HC Inj Aa&/Strd Greater Occipital Nerve|BILATERAL PROCEDURE,CASE-64405,APC,64405,CPT,0450,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],301.68,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,287.31,301.68,OPPS APC
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],16819.90,,,,,,0,other,7733.72,18043.23,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,086,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],30728.81,,"Fee schedule rate ($30,728.81). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8442.00,30728.81,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC,833,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],10289.10,,,,,,0,other,3041.73,10289.10,There are no additional notes associated with this service or procedure.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC,862,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],28705.48,,"Fee schedule rate ($28,705.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (42), with a minimum of zero.",,,,0,other,6855.00,35884.94,There are no additional notes associated with this service or procedure.
Ostc Prtl Exostc/Condylc Metar Head|RIGHT SIDE|SEPARATE STRUCTURE,CASE-28288,APC,28288,CPT,0360,RC,,,RT|XS,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],29594.00,,"Fee schedule rate ($29,594.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,13571.25,33781.47,There are no additional notes associated with this service or procedure.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],10927.06,,"Fee schedule rate ($10,927.06). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8874.81,20553.44,There are no additional notes associated with this service or procedure.
"NEONATE BIRTH WEIGHT > 2499 GRAMS WITH RESPIRATORY DISTRESS SYNDROME OR OTHER MAJOR RESPIRATORY CONDITION,MAJOR",634,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],22128.47,,"Case rate ($21,074.73). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,21074.73,22128.47,There are no additional notes associated with this service or procedure.
NON-MALIGNANT BREAST DISORDERS WITH CC/MCC,600,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],15046.13,,"Fee schedule rate ($15,046.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7999.14,20495.56,There are no additional notes associated with this service or procedure.
"Open Tx Phalangeal Shaft Fracture Prox/Middle Ea|LEFT HAND, FOURTH DIGIT",CASE-26735,APC,26735,CPT,0360,RC,,,F3,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7157.69,,"Case rate ($6,915.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,569.08, add-ons for qualifying new technology services are included. If operating cost exceeds $41,440.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,123.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,607.15 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,624.14 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $363.55. The transfer capital threshold is the transfer adjustment factor * $363.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6915.64,14442.92,Inpatient DRG
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC",629,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],44657.18,,"Fee schedule rate ($44,657.18). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,16699.94,44657.18,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC,832,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],7173.26,,"Case rate ($6,831.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,490.97, add-ons for qualifying new technology services are included. If operating cost exceeds $41,361.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,117.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $4,529.32 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,546.02 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $357.41. The transfer capital threshold is the transfer adjustment factor * $357.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,4803.31,14198.92,Inpatient DRG
PREMATURITY WITH MAJOR PROBLEMS,791,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],30021.44,,"Case rate ($29,432.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $27,516.30, add-ons for qualifying new technology services are included. If operating cost exceeds $62,387.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,770.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 13.3. The base transfer operating payment is the transfer adjustment factor * $25,477.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $25,571.35 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,010.42. The transfer capital threshold is the transfer adjustment factor * $2,010.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,3048.21,30904.42,Inpatient DRG
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,309,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],14547.21,,,,,,0,other,5055.77,14547.21,There are no additional notes associated with this service or procedure.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],11717.72,,"Case rate ($11,717.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,036.36, add-ons for qualifying new technology services are included. If operating cost exceeds $45,907.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,474.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $9,058.01 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,091.41 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $714.77. The transfer capital threshold is the transfer adjustment factor * $714.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,11717.72,43888.01,Inpatient DRG
VENTRICULAR SHUNT PROCEDURES WITH MCC,031,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],84202.04,,"Fee schedule rate ($84,202.04). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16.6), with a minimum of zero.",,,,0,other,32287.20,88162.80,There are no additional notes associated with this service or procedure.
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],54236.60,,"Fee schedule rate ($54,236.60). Adds an outlier to normal pricing equal to the per diem rate ($122,612.56) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,21489.15,68942.79,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,394,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],20909.61,,"Fee schedule rate ($20,909.61). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8281.56,20909.61,There are no additional notes associated with this service or procedure.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],8767.81,,"Case rate ($8,767.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,292.11, add-ons for qualifying new technology services are included. If operating cost exceeds $43,163.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,258.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,323.85 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,347.16 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $499.01. The transfer capital threshold is the transfer adjustment factor * $499.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8767.81,19824.58,Inpatient DRG
"POST-OPERATIVE POST-TRAUMA OTHER DEVICE INFECTIONS WITH O.R. PROCEDURE,MODERATE",711,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],16727.01,,"Case rate ($15,930.49). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,15930.49,16727.01,There are no additional notes associated with this service or procedure.
HC Trigger Point 3 or More|PBB CHARGE,CASE-20553,APC,20553,CPT,0510,RC,,,PBB,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],301.68,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,287.31,301.68,OPPS APC
"Tendon Sheath Incision|RIGHT HAND, FOURTH DIGIT",CASE-26055,APC,26055,CPT,0360,RC,,,F8,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1505.12,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1505.12,1580.37,OPPS APC
Prq Impltj Neurostimulator Eltrd Peripheral Nrv,CASE-64555,APC,64555,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6174.06,,"APC Price ($5,965.28). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5965.28,6263.54,OPPS APC
"DISORDERS OF PANCREAS EXCEPT MALIGNANCY,MODERATE",282,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],2016.06,,"Case rate for a one day stay ($1,920.06). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,1920.06,2016.06,There are no additional notes associated with this service or procedure.
NORMAL NEWBORN,795,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3421.18,,"Case rate ($3,258.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $3,169.15, add-ons for qualifying new technology services are included. If operating cost exceeds $38,040.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $1,853.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $1,219.58 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $1,224.20 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $93.74. The transfer capital threshold is the transfer adjustment factor * $93.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,1369.79,5771.52,Inpatient DRG
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],15785.75,,"Case rate ($15,476.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,532.81, add-ons for qualifying new technology services are included. If operating cost exceeds $49,403.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,749.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $12,541.62 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,587.86 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $989.66. The transfer capital threshold is the transfer adjustment factor * $989.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,15476.23,42787.31,Inpatient DRG
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],37591.64,,"Fee schedule rate ($37,591.64). Adds an outlier to normal pricing equal to the per diem rate ($51,531) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.1), with a minimum of zero.",,,,0,other,15491.11,54180.83,There are no additional notes associated with this service or procedure.
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],12383.18,,"Case rate ($11,793.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,125.23, add-ons for qualifying new technology services are included. If operating cost exceeds $45,996.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,462.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $9,145.60 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,180.28 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $702.95. The transfer capital threshold is the transfer adjustment factor * $702.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,29482.05,Inpatient DRG
Dbrdmt Fx&/Dislc Subq T/M/F Bone,CASE-11012,APC,11012,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7131.59,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,7029.71,7131.59,OPPS APC
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],42021.93,,"Fee schedule rate ($42,021.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,21248.73,56089.29,There are no additional notes associated with this service or procedure.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC,434,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],13280.45,,"Fee schedule rate ($13,280.45). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6770.05,14019.86,There are no additional notes associated with this service or procedure.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC,858,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],33794.11,,"Fee schedule rate ($33,794.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11377.76,33794.11,There are no additional notes associated with this service or procedure.
MINOR BLADDER PROCEDURES WITHOUT CC/MCC,664,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],9034.63,,"Case rate ($9,034.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,540.33, add-ons for qualifying new technology services are included. If operating cost exceeds $43,411.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,278.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $6,571.15 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,595.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $518.53. The transfer capital threshold is the transfer adjustment factor * $518.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9034.63,31876.87,Inpatient DRG
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],31091.14,,"Fee schedule rate ($31,091.14). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13148.66,32553.63,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],14908.05,,"Case rate ($14,908.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,004.25, add-ons for qualifying new technology services are included. If operating cost exceeds $48,875.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,708.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $12,014.99 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,059.30 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $948.10. The transfer capital threshold is the transfer adjustment factor * $948.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,14908.05,49717.39,Inpatient DRG
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH CC,026,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],63202.45,,"Fee schedule rate ($63,202.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,23000.66,63202.45,There are no additional notes associated with this service or procedure.
OTHER CEREBROVASCULAR DISORDERS WITH CC,071,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],29215.10,,"Fee schedule rate ($29,215.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5843.00,29215.10,There are no additional notes associated with this service or procedure.
Bronchoscopy W/Transbronchial Lung Bx 1 Lobe,CASE-31628,APC,31628,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6605.95,,"APC Price ($6,605.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6605.95,6936.25,OPPS APC
"NERVOUS SYSTEM MALIGNANCY,MODERATE",041,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],9704.66,,"Case rate ($9,242.53). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9242.53,9704.66,There are no additional notes associated with this service or procedure.
Destruction Neurolytic Agt Genicular Nerve W/Img,CASE-64624,APC,64624,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1827.80,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1827.80,1919.19,OPPS APC
TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC,084,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],19445.16,,"Fee schedule rate ($19,445.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,6965.00,19445.16,There are no additional notes associated with this service or procedure.
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],20297.68,,"Fee schedule rate ($20,297.68). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6965.00,21404.64,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],11594.35,,"Fee schedule rate ($11,594.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6164.03,14071.02,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],34712.20,,,,,,0,other,13891.57,34712.20,There are no additional notes associated with this service or procedure.
BRONCHITIS AND ASTHMA WITHOUT CC/MCC,203,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],6965.00,,,,,,0,other,4763.76,13707.00,There are no additional notes associated with this service or procedure.
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],8447.49,,"Case rate ($8,447.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,994.13, add-ons for qualifying new technology services are included. If operating cost exceeds $42,865.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,235.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,026.96 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,049.18 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $475.59. The transfer capital threshold is the transfer adjustment factor * $475.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,1188.00,18893.86,Inpatient DRG
O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC,621,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],28347.36,,"Fee schedule rate ($28,347.36). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12159.94,36669.96,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],19187.65,,"Fee schedule rate ($19,187.65). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8859.23,20090.22,There are no additional notes associated with this service or procedure.
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],21854.96,,"Fee schedule rate ($21,854.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10638.94,25261.33,There are no additional notes associated with this service or procedure.
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC",011,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],150008.48,,"Fee schedule rate ($150,008.48). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (44), with a minimum of zero.",,,,0,other,38880.49,150008.48,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,065,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],25681.86,,"Fee schedule rate ($25,681.86). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,8786.76,25681.86,There are no additional notes associated with this service or procedure.
"LYMPHATIC AND OTHER MALIGNANCIES AND NEOPLASMS OF UNCERTAIN BEHAVIOR,MODERATE",694,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],2179.51,,"Case rate for a one day stay ($2,075.72). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,2075.72,2179.51,There are no additional notes associated with this service or procedure.
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],24528.10,,"Fee schedule rate ($24,528.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10989.72,26280.60,There are no additional notes associated with this service or procedure.
CERVICAL SPINAL FUSION WITH CC,472,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],57970.41,,,,,,0,other,21896.13,70198.84,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],86252.84,,"Fee schedule rate ($86,252.84). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,27944.96,86252.84,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,065,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],8786.76,,"Case rate ($8,786.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,309.75, add-ons for qualifying new technology services are included. If operating cost exceeds $43,180.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,260.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,341.42 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,364.80 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $500.40. The transfer capital threshold is the transfer adjustment factor * $500.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8786.76,25681.86,Inpatient DRG
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],2070.00,,,,,,0,other,1188.00,12138.74,Estimated amount calculated based on 1 day length of stay.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,699,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],19972.16,,,,,,0,other,5961.00,19972.16,There are no additional notes associated with this service or procedure.
OSTEOMYELITIS WITHOUT CC/MCC,541,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],7422.83,,"Case rate ($7,277.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,905.50, add-ons for qualifying new technology services are included. If operating cost exceeds $41,776.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,149.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $4,942.33 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,960.55 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $390.00. The transfer capital threshold is the transfer adjustment factor * $390.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,5103.00,15493.67,Inpatient DRG
HC Joint Injection/Aspir Large WO US|BILATERAL PROCEDURE|PBB CHARGE,CASE-20610,APC,20610,CPT,0510,RC,,,50|PBB,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7941.86,,"Case rate ($7,563.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,182.42, add-ons for qualifying new technology services are included. If operating cost exceeds $42,053.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,161.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,217.69 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,237.47 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $401.04. The transfer capital threshold is the transfer adjustment factor * $401.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7733.72,18043.23,Inpatient DRG
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],34800.15,,"Case rate ($33,623.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $31,414.68, add-ons for qualifying new technology services are included. If operating cost exceeds $66,285.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,076.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.4. The base transfer operating payment is the transfer adjustment factor * $29,361.48 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $29,469.74 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,316.91. The transfer capital threshold is the transfer adjustment factor * $2,316.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,33623.33,133270.57,Inpatient DRG
GASTROINTESTINAL HEMORRHAGE WITH CC,378,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],18430.30,,"Fee schedule rate ($18,430.30). Adds an outlier to normal pricing equal to the per diem rate ($75,427.18) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,8586.33,20845.19,There are no additional notes associated with this service or procedure.
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],13794.06,,"Fee schedule rate ($13,794.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,6915.64,14442.92,There are no additional notes associated with this service or procedure.
Arthrt Expl Drg/Rmvl Loose/FB Iphal Jt Ea,CASE-26080,APC,26080,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1557.80,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1505.12,1557.80,OPPS APC
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],16055.90,,"Fee schedule rate ($16,055.90). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8163.06,18067.42,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],47751.13,,"Fee schedule rate ($47,751.13). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.7), with a minimum of zero.",,,,0,other,19152.11,53152.12,There are no additional notes associated with this service or procedure.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],67790.93,,"Fee schedule rate ($67,790.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,21597.50,67790.93,There are no additional notes associated with this service or procedure.
ALLERGIC REACTIONS WITH MCC,915,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],27385.01,,"Fee schedule rate ($27,385.01). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,13332.86,33088.84,There are no additional notes associated with this service or procedure.
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],13794.06,,"Fee schedule rate ($13,794.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,6915.64,14442.92,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],23899.13,,"Fee schedule rate ($23,899.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9795.13,23899.13,There are no additional notes associated with this service or procedure.
"VAGINAL DELIVERY,MODERATE",560,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],4534.59,,"Case rate ($4,318.66). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4318.66,4534.59,There are no additional notes associated with this service or procedure.
Realignment Extensor Tendon Hand Each Tendon,CASE-26437,APC,26437,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC,198,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],23505.07,,"Fee schedule rate ($23,505.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6795.12,23505.07,There are no additional notes associated with this service or procedure.
RESPIRATORY NEOPLASMS WITHOUT CC/MCC,182,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],23037.13,,"Fee schedule rate ($23,037.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6965.00,23037.13,There are no additional notes associated with this service or procedure.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],51630.84,,"Fee schedule rate ($51,630.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,20559.34,54086.17,There are no additional notes associated with this service or procedure.
"HC Repair Nail Bed|RIGHT HAND, FIFTH DIGIT",CASE-11760,APC,11760,CPT,0450,RC,,,F9,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,057,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],39884.93,,"Fee schedule rate ($39,884.93). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,10718.84,39884.93,There are no additional notes associated with this service or procedure.
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],40714.72,,"Fee schedule rate ($40,714.72). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,17356.15,44778.95,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6793.93,,"Case rate ($6,564.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,242.12, add-ons for qualifying new technology services are included. If operating cost exceeds $41,113.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,097.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $4,281.39 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,297.17 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $337.84. The transfer capital threshold is the transfer adjustment factor * $337.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6564.18,17651.07,Inpatient DRG
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],40426.76,,"Fee schedule rate ($40,426.76). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,11914.12,40426.76,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL HEMORRHAGE WITH MCC,377,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],17500.35,,"Fee schedule rate ($17,500.35). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,7634.00,35969.56,There are no additional notes associated with this service or procedure.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,479,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],50518.76,,"Fee schedule rate ($50,518.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,10586.00,50518.76,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],33152.73,,"Fee schedule rate ($33,152.73). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13891.57,34712.20,There are no additional notes associated with this service or procedure.
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC,058,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],13792.24,,"Case rate ($13,521.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,714.66, add-ons for qualifying new technology services are included. If operating cost exceeds $47,585.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,606.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $10,730.14 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,769.70 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $846.71. The transfer capital threshold is the transfer adjustment factor * $846.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,13521.80,40853.02,Inpatient DRG
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],18366.40,,"Fee schedule rate ($18,366.40). Adds an outlier to normal pricing equal to the per diem rate ($38,964.32) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.5), with a minimum of zero.",,,,0,other,8563.30,31533.97,There are no additional notes associated with this service or procedure.
Cysto W/Urtroscopy&/Pyeloscopy Dx,CASE-52351,APC,52351,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3299.47,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3299.47,3464.44,OPPS APC
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,373,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],13780.60,,"Fee schedule rate ($13,780.60). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6870.94,14313.05,There are no additional notes associated with this service or procedure.
CHEST PAIN,313,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],14167.44,,,,,,0,other,6820.84,15377.66,There are no additional notes associated with this service or procedure.
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],33159.45,,"Fee schedule rate ($33,159.45). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,13092.47,33159.45,There are no additional notes associated with this service or procedure.
Surg Nasopharyngoscopy Dilat Eustachian Tube Bi,CASE-69706,APC,69706,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5541.10,,"APC Price ($5,541.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5541.10,5818.16,OPPS APC
CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC,788,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],8438.02,,"Case rate ($8,438.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,985.31, add-ons for qualifying new technology services are included. If operating cost exceeds $42,856.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,234.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,018.17 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,040.36 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $474.89. The transfer capital threshold is the transfer adjustment factor * $474.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8438.02,20142.33,Inpatient DRG
FRACTURES OF FEMUR WITH MCC,533,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],6852.00,,"Per diem ($6,852). If length of stay < 4.3, first 1 days paid at a per diem of $13,704 instead. Capped at $29,461.79.",,,,0,other,6852.00,49490.05,Estimated amount calculated based on 2 day length of stay.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC,027,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],31238.55,,"Fee schedule rate ($31,238.55). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,19030.20,56363.30,There are no additional notes associated with this service or procedure.
Mastectomy Simple Complete|LEFT SIDE,CASE-19303,APC,19303,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6215.36,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6215.36,6526.12,OPPS APC
"Neuroplasty Other Arm/Leg Nerve,Open|LEFT SIDE",CASE-64708,APC,64708,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7029.71,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6791.99,7131.59,OPPS APC
OTHER CEREBROVASCULAR DISORDERS WITH MCC,070,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],37774.46,,"Fee schedule rate ($37,774.46). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,13219.09,37774.46,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],49717.39,,"Fee schedule rate ($49,717.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,14908.05,49717.39,There are no additional notes associated with this service or procedure.
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5777.94,,"Case rate ($5,777.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,510.70, add-ons for qualifying new technology services are included. If operating cost exceeds $40,381.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,040.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $3,552.65 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,565.75 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $280.34. The transfer capital threshold is the transfer adjustment factor * $280.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,5065.00,12558.65,Inpatient DRG
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],16578.62,,"Case rate ($16,017.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,036.80, add-ons for qualifying new technology services are included. If operating cost exceeds $49,907.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,789.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $13,043.76 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,091.85 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,029.28. The transfer capital threshold is the transfer adjustment factor * $1,029.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,16017.99,51903.64,Inpatient DRG
Egd Dilation Gastric/Duodenal Stricture,CASE-43245,APC,43245,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1796.14,,"APC Price ($1,796.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1796.14,1885.95,OPPS APC
HC Drain/Inj Joint/Bursa W/US Large|LEFT SIDE,CASE-20611,APC,20611,CPT,0510,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],297.37,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,287.31,301.68,OPPS APC
"Arthrodesis Great Toe Metatarsophalangeal Joint|RIGHT FOOT, GREAT TOE",CASE-28750,APC,28750,CPT,0360,RC,,,T5,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6791.99,7131.59,OPPS APC
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,065,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],18986.57,,"Fee schedule rate ($18,986.57). Adds an outlier to normal pricing equal to the per diem rate ($85,884.96) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,8786.76,25681.86,There are no additional notes associated with this service or procedure.
PERIPHERAL VASCULAR DISORDERS WITH CC,300,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],20331.78,,"Fee schedule rate ($20,331.78). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,9174.14,21005.20,There are no additional notes associated with this service or procedure.
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],15341.29,,"Case rate ($14,610.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,727.68, add-ons for qualifying new technology services are included. If operating cost exceeds $48,598.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,686.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.6. The base transfer operating payment is the transfer adjustment factor * $11,739.44 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,782.73 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $926.36. The transfer capital threshold is the transfer adjustment factor * $926.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6277.00,36801.89,Inpatient DRG
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],47123.82,,"Fee schedule rate ($47,123.82). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,12696.97,47123.82,There are no additional notes associated with this service or procedure.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],42586.49,,"Fee schedule rate ($42,586.49). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,13341.67,42586.49,There are no additional notes associated with this service or procedure.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],47123.82,,"Fee schedule rate ($47,123.82). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,12696.97,47123.82,There are no additional notes associated with this service or procedure.
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],54180.83,,"Fee schedule rate ($54,180.83). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,15491.11,54180.83,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],34397.36,,,,,,0,other,13783.20,41580.51,There are no additional notes associated with this service or procedure.
SALIVARY GLAND PROCEDURES,139,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],10828.85,,"Case rate ($10,313.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,729.75, add-ons for qualifying new technology services are included. If operating cost exceeds $44,600.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,372.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $7,756.21 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,784.80 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $612.04. The transfer capital threshold is the transfer adjustment factor * $612.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10313.19,30690.92,Inpatient DRG
NORMAL NEWBORN,795,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],2576.52,,"Fee schedule rate ($2,576.52). Adds an outlier to normal pricing equal to the per diem rate ($414) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,1369.79,5771.52,There are no additional notes associated with this service or procedure.
FRACTURES OF FEMUR WITH MCC,533,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],21982.68,,"Case rate ($12,561.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,821.33, add-ons for qualifying new technology services are included. If operating cost exceeds $46,692.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,536.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $9,840.09 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,876.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $776.48. The transfer capital threshold is the transfer adjustment factor * $776.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,6852.00,49490.05,All Other Inpatient
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],7665.00,,"Per diem ($7,665). If length of stay < 4, first 1 days paid at a per diem of $15,330 instead. Capped at $30,658.90.",,,,0,other,7665.00,40737.46,Estimated amount calculated based on 5 day length of stay.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],17365.00,,"Fee schedule rate ($17,365.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5683.00,19635.68,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],8484.50,,"Case rate ($8,318.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,873.80, add-ons for qualifying new technology services are included. If operating cost exceeds $42,744.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,226.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,907.07 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,928.85 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $466.13. The transfer capital threshold is the transfer adjustment factor * $466.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,8318.14,19763.43,Inpatient DRG
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],17365.00,,"Fee schedule rate ($17,365.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5683.00,19635.68,There are no additional notes associated with this service or procedure.
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH MCC",722,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],14910.39,,"Case rate ($14,200.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,345.91, add-ons for qualifying new technology services are included. If operating cost exceeds $48,216.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,656.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $11,359.07 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,400.95 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $896.34. The transfer capital threshold is the transfer adjustment factor * $896.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,14200.37,56869.13,Inpatient DRG
CESAREAN SECTION WITHOUT STERILIZATION WITH CC,787,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],23722.94,,"Fee schedule rate ($23,722.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9508.01,23722.94,There are no additional notes associated with this service or procedure.
CERVICAL SPINAL FUSION WITHOUT CC/MCC,473,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],48037.46,,,,,,0,other,18477.61,62077.11,There are no additional notes associated with this service or procedure.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],41006.47,,"Fee schedule rate ($41,006.47). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12268.97,41006.47,There are no additional notes associated with this service or procedure.
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],45722.85,,"Case rate ($26,127.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $24,441.31, add-ons for qualifying new technology services are included. If operating cost exceeds $59,312.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,528.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. The base transfer operating payment is the transfer adjustment factor * $22,413.72 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $22,496.36 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,768.66. The transfer capital threshold is the transfer adjustment factor * $1,768.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,26127.34,90333.60,All Other Inpatient
TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC,087,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],22679.07,,"Fee schedule rate ($22,679.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,8139.36,22679.07,There are no additional notes associated with this service or procedure.
O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC,621,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],28347.36,,"Fee schedule rate ($28,347.36). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12159.94,36669.96,There are no additional notes associated with this service or procedure.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,097,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],67876.56,,"Fee schedule rate ($67,876.56). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17.7), with a minimum of zero.",,,,0,other,26404.32,79915.74,There are no additional notes associated with this service or procedure.
VENTRICULAR SHUNT PROCEDURES WITH MCC,031,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],33417.25,,"Case rate ($32,287.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $30,171.71, add-ons for qualifying new technology services are included. If operating cost exceeds $65,042.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,979.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7. The base transfer operating payment is the transfer adjustment factor * $28,123.07 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $28,226.76 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,219.19. The transfer capital threshold is the transfer adjustment factor * $2,219.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,32287.20,88162.80,Inpatient DRG
HC Drain/Inj Joint/Bursa W/US Large|RIGHT SIDE,CASE-20611,APC,20611,CPT,0510,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],301.68,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,287.31,301.68,OPPS APC
HC Drain/Inj Joint/Bursa W/US Large,CASE-20611,APC,20611,CPT,0510,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],11158.08,,"Case rate ($10,626.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,021.44, add-ons for qualifying new technology services are included. If operating cost exceeds $44,892.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,394.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $8,046.82 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,076.49 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $634.97. The transfer capital threshold is the transfer adjustment factor * $634.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10626.74,25225.91,Inpatient DRG
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,074,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],9156.58,,"Case rate ($8,720.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,260.79, add-ons for qualifying new technology services are included. If operating cost exceeds $43,131.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,243.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,291.99 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,315.84 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $483.62. The transfer capital threshold is the transfer adjustment factor * $483.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8925.60,20919.08,Inpatient DRG
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC,497,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],10381.65,,"Case rate ($9,887.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,348.36, add-ons for qualifying new technology services are included. If operating cost exceeds $44,219.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,326.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 1.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $7,375.45 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,403.41 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $566.89. The transfer capital threshold is the transfer adjustment factor * $566.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10127.65,37761.19,Inpatient DRG
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],34570.85,,"Fee schedule rate ($34,570.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,6965.00,36140.75,There are no additional notes associated with this service or procedure.
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,069,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],7354.47,,"Case rate ($7,354.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,977.32, add-ons for qualifying new technology services are included. If operating cost exceeds $41,848.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,155.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $5,013.88 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,032.37 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $395.65. The transfer capital threshold is the transfer adjustment factor * $395.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,20333.68,Inpatient DRG
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],13293.55,,"Case rate ($12,660.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,933.40, add-ons for qualifying new technology services are included. If operating cost exceeds $46,804.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,524.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $9,950.72 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,988.45 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $764.84. The transfer capital threshold is the transfer adjustment factor * $764.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12984.79,32077.45,Inpatient DRG
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],31577.54,,"Fee schedule rate ($31,577.54). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,15453.88,39251.68,There are no additional notes associated with this service or procedure.
Laryngoscopy Direct Operative W/Biopsy|UNUSUAL NON-OVERLAPPING SERVICE,CASE-31535,APC,31535,CPT,0360,RC,,,XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3611.96,,"APC Price ($3,489.82). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3489.82,3664.31,OPPS APC
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],10568.70,,"Case rate ($10,065.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,514.41, add-ons for qualifying new technology services are included. If operating cost exceeds $44,385.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,339.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $7,540.86 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,569.46 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $579.61. The transfer capital threshold is the transfer adjustment factor * $579.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10311.17,24308.97,Inpatient DRG
VAGINAL DELIVERY WITH O.R. PROCEDURES EXCEPT STERILIZATION AND/OR D&C,768,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],12088.81,,"Fee schedule rate ($12,088.81). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6426.91,13416.00,There are no additional notes associated with this service or procedure.
Esophagoscopy Intra/Transmural Needle Aspirat/Bx,CASE-43232,APC,43232,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1885.95,,"APC Price ($1,796.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1796.14,1885.95,OPPS APC
RESPIRATORY NEOPLASMS WITHOUT CC/MCC,182,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],23037.13,,"Fee schedule rate ($23,037.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6965.00,23037.13,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC,832,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],9034.88,,"Fee schedule rate ($9,034.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4803.31,14198.92,There are no additional notes associated with this service or procedure.
NORMAL NEWBORN,795,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],2576.52,,"Fee schedule rate ($2,576.52). Adds an outlier to normal pricing equal to the per diem rate ($414) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,1369.79,5771.52,There are no additional notes associated with this service or procedure.
Repair Intermediate S/a/T/E >30.0 Cm,CASE-12037,APC,12037,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1545.93,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1545.93,1623.23,OPPS APC
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],15273.74,,"Case rate ($15,273.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,344.45, add-ons for qualifying new technology services are included. If operating cost exceeds $49,215.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,734.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $12,353.94 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,399.49 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $974.85. The transfer capital threshold is the transfer adjustment factor * $974.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,15273.74,39820.52,Inpatient DRG
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],97015.50,,"Fee schedule rate ($97,015.50). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,26809.29,97015.50,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],46523.26,,"Fee schedule rate ($46,523.26). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,17782.11,46523.26,There are no additional notes associated with this service or procedure.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],23520.23,,"Fee schedule rate ($23,520.23). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10517.71,24909.11,There are no additional notes associated with this service or procedure.
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],17097.87,,"Fee schedule rate ($17,097.87). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,8106.18,18245.94,There are no additional notes associated with this service or procedure.
Unlisted Laparoscopy Procedure Stomach,CASE-43659,APC,43659,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5658.76,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5658.76,5941.70,OPPS APC
Prq Impltj Neurostimulator Eltrd Peripheral Nrv,CASE-64555,APC,64555,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6263.54,,"APC Price ($5,965.28). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5965.28,6263.54,OPPS APC
Ligamentous Reconstruction Knee Extra-Articular|LEFT SIDE|SEPARATE STRUCTURE,CASE-27427,APC,27427,CPT,0360,RC,,,LT|XS,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7029.71,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6791.99,7131.59,OPPS APC
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],40426.76,,"Fee schedule rate ($40,426.76). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,11914.12,40426.76,There are no additional notes associated with this service or procedure.
ALLERGIC REACTIONS WITH MCC,915,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],27385.01,,"Fee schedule rate ($27,385.01). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,13332.86,33088.84,There are no additional notes associated with this service or procedure.
SPINAL PROCEDURES WITHOUT CC/MCC,030,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],17399.37,,"Case rate ($16,810.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,774.52, add-ons for qualifying new technology services are included. If operating cost exceeds $50,645.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,847.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $13,778.77 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,829.57 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,087.28. The transfer capital threshold is the transfer adjustment factor * $1,087.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,16810.99,44714.01,Inpatient DRG
CERVICAL SPINAL FUSION WITH MCC,471,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],95014.33,,,,,,0,other,34645.26,111337.93,There are no additional notes associated with this service or procedure.
"MAJOR GASTROINTESTINAL AND PERITONEAL INFECTIONS,MAJOR",248,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],11267.56,,"Case rate ($11,267.56). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,11267.56,11830.94,There are no additional notes associated with this service or procedure.
Colsc Flexible W/Control Bleeding Any Method|UNUSUAL NON-OVERLAPPING SERVICE,CASE-45382,APC,45382,CPT,0360,RC,,,XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1159.29,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1120.09,1176.09,OPPS APC
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],31973.49,,"Fee schedule rate ($31,973.49). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,13386.36,33244.29,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],10507.06,,"Fee schedule rate ($10,507.06). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,8318.14,19763.43,There are no additional notes associated with this service or procedure.
Revise Ulnar Nerve at Wrist|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64719,APC,64719,CPT,0360,RC,,,LT|XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3309.51,,"APC Price ($3,197.60). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3309.51,3357.48,OPPS APC
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],41006.47,,"Fee schedule rate ($41,006.47). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12268.97,41006.47,There are no additional notes associated with this service or procedure.
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC,805,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],9716.03,,"Case rate ($9,253.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,743.82, add-ons for qualifying new technology services are included. If operating cost exceeds $43,614.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,294.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $6,773.89 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,798.87 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $534.53. The transfer capital threshold is the transfer adjustment factor * $534.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9253.36,21235.42,Inpatient DRG
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],23885.04,,"Case rate ($22,747.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $21,336.09, add-ons for qualifying new technology services are included. If operating cost exceeds $56,207.10 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,244.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $19,317.89 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $19,391.14 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,484.82. The transfer capital threshold is the transfer adjustment factor * $1,484.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,23377.19,96365.69,Inpatient DRG
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],59521.43,,"Fee schedule rate ($59,521.43). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,16689.78,59521.43,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,555,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],42290.95,,"Fee schedule rate ($42,290.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10896.27,42290.95,There are no additional notes associated with this service or procedure.
"VAGINAL DELIVERY WITH O.R. PROCEDURE EXCEPT STERILIZATION AND/OR D&C,MAJOR",542,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],8518.92,,"Case rate ($8,518.92). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,8518.92,8944.87,There are no additional notes associated with this service or procedure.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC,027,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],47412.86,,"Fee schedule rate ($47,412.86). Adds an outlier to normal pricing equal to the per diem rate ($103,062) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,19030.20,56363.30,There are no additional notes associated with this service or procedure.
PREMATURITY WITH MAJOR PROBLEMS,791,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],3186.77,,,,,,0,other,3048.21,30904.42,Estimated amount calculated based on 5 day length of stay.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC,434,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],13280.45,,"Fee schedule rate ($13,280.45). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6770.05,14019.86,There are no additional notes associated with this service or procedure.
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR,518,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],28616.93,,"Case rate ($27,254.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $25,489.62, add-ons for qualifying new technology services are included. If operating cost exceeds $60,360.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,611.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 5.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $23,458.18 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $23,544.67 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,851.08. The transfer capital threshold is the transfer adjustment factor * $1,851.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13252.00,89342.77,Inpatient DRG
GASTROINTESTINAL HEMORRHAGE WITH MCC,377,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],14658.70,,"Case rate ($13,960.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,145.34, add-ons for qualifying new technology services are included. If operating cost exceeds $48,016.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,617.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $11,158.09 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,200.39 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $857.64. The transfer capital threshold is the transfer adjustment factor * $857.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7634.00,35969.56,Inpatient DRG
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],6428.77,,"Case rate ($6,122.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,831.37, add-ons for qualifying new technology services are included. If operating cost exceeds $40,702.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,065.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $3,872.14 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,886.42 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $305.55. The transfer capital threshold is the transfer adjustment factor * $305.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,1188.00,12138.74,Inpatient DRG
MAJOR THUMB OR JOINT PROCEDURES,506,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],19761.54,,"Fee schedule rate ($19,761.54). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11081.83,26548.21,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],7641.61,,"Case rate ($7,641.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,244.44, add-ons for qualifying new technology services are included. If operating cost exceeds $42,115.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,176.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,280.02 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,299.49 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $416.65. The transfer capital threshold is the transfer adjustment factor * $416.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7641.61,19371.27,Inpatient DRG
MAJOR THUMB OR JOINT PROCEDURES,506,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],11303.47,,"Case rate ($11,081.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,444.79, add-ons for qualifying new technology services are included. If operating cost exceeds $45,315.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,428.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $8,468.62 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,499.84 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $668.26. The transfer capital threshold is the transfer adjustment factor * $668.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,11081.83,26548.21,Inpatient DRG
Open Tx Clavicular Fracture Internal Fixation|RIGHT SIDE,CASE-23515,APC,23515,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6791.99,7131.59,OPPS APC
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],36970.16,,"Case rate ($35,719.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $33,365.14, add-ons for qualifying new technology services are included. If operating cost exceeds $68,236.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,230.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.9. The base transfer operating payment is the transfer adjustment factor * $31,304.77 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $31,420.19 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,470.26. The transfer capital threshold is the transfer adjustment factor * $2,470.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,35719.96,105091.76,Inpatient DRG
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,098,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],6965.00,,,,,,0,other,6965.00,45156.75,There are no additional notes associated with this service or procedure.
Peri-Implant Capsulectomy Breast Complete|BILATERAL PROCEDURE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-19371,APC,19371,CPT,0360,RC,,,50|XU,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],7650.49,,"APC Price ($7,650.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,7650.49,8033.01,OPPS APC
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,098,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],18360.48,,"Case rate ($17,486.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,402.62, add-ons for qualifying new technology services are included. If operating cost exceeds $51,273.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,896.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $14,404.56 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,457.67 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,136.66. The transfer capital threshold is the transfer adjustment factor * $1,136.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,45156.75,Inpatient DRG
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,093,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],6965.00,,,,,,0,other,6965.00,19011.32,There are no additional notes associated with this service or procedure.
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],22557.82,,"Fee schedule rate ($22,557.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6801.88,22557.82,There are no additional notes associated with this service or procedure.
Laps Fulg/Exc Ovary Viscera/Peritoneal Surface|RIGHT SIDE,CASE-58662,APC,58662,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5856.81,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5658.76,5941.70,OPPS APC
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],9746.59,,"Case rate ($9,282.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,770.90, add-ons for qualifying new technology services are included. If operating cost exceeds $43,641.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,296.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,800.88 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,825.96 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $536.66. The transfer capital threshold is the transfer adjustment factor * $536.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9282.47,21320.03,Inpatient DRG
"SPINAL FUSION AND OTHER BACK AND NECK PROCEDURES EXCEPT FOR DISC PROCEDURES,MINOR",321,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],5567.97,,"Case rate for a one day stay ($5,302.83). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5302.83,5567.97,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],7948.33,,"Case rate ($7,569.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,177.66, add-ons for qualifying new technology services are included. If operating cost exceeds $42,048.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,171.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,213.49 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,232.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $411.40. The transfer capital threshold is the transfer adjustment factor * $411.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7569.84,21892.85,Inpatient DRG
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],20170.75,,"Fee schedule rate ($20,170.75). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10048.39,23545.50,There are no additional notes associated with this service or procedure.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],26809.29,,"Case rate ($26,809.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $25,075.72, add-ons for qualifying new technology services are included. If operating cost exceeds $59,946.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,578.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $23,045.79 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $23,130.76 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,818.54. The transfer capital threshold is the transfer adjustment factor * $1,818.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,26809.29,97015.50,Inpatient DRG
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],59610.47,,"Fee schedule rate ($59,610.47). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,16129.04,59610.47,There are no additional notes associated with this service or procedure.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,352,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],26528.70,,"Fee schedule rate ($26,528.70). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,9853.37,26528.70,There are no additional notes associated with this service or procedure.
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC",629,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],29224.90,,"Case rate ($16,699.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,671.20, add-ons for qualifying new technology services are included. If operating cost exceeds $50,542.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,839.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $13,675.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,726.25 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,079.16. The transfer capital threshold is the transfer adjustment factor * $1,079.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,16699.94,44657.18,All Other Inpatient
Bx/Exc Lymph Node Open Deep Axillary Node,CASE-38525,APC,38525,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3848.19,,"APC Price ($3,664.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3664.94,3848.19,OPPS APC
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,167,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],35485.50,,,,,,0,other,14157.71,43522.37,There are no additional notes associated with this service or procedure.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],5683.00,,"Per diem ($5,683). If length of stay < 3.3, first 1 days paid at a per diem of $11,366 instead. Capped at $18,753.53.",,,,0,other,5683.00,19635.68,Estimated amount calculated based on 3 day length of stay.
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],15491.11,,"Case rate ($15,491.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,546.67, add-ons for qualifying new technology services are included. If operating cost exceeds $49,417.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,750.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $12,555.42 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,601.72 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $990.75. The transfer capital threshold is the transfer adjustment factor * $990.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,15491.11,54180.83,Inpatient DRG
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],58320.32,,"Fee schedule rate ($58,320.32). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,16286.16,58320.32,There are no additional notes associated with this service or procedure.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],12882.42,,"Case rate ($12,268.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,549.17, add-ons for qualifying new technology services are included. If operating cost exceeds $46,420.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,515.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,568.94 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,604.22 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $755.08. The transfer capital threshold is the transfer adjustment factor * $755.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12268.97,41006.47,Inpatient DRG
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],13486.95,,"Fee schedule rate ($13,486.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6915.64,14442.92,There are no additional notes associated with this service or procedure.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],45706.73,,"Fee schedule rate ($45,706.73). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,7921.00,45706.73,There are no additional notes associated with this service or procedure.
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],9311.62,,"Case rate ($9,311.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,798, add-ons for qualifying new technology services are included. If operating cost exceeds $43,669.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,298.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $6,827.87 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,853.05 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $538.79. The transfer capital threshold is the transfer adjustment factor * $538.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,21404.64,Inpatient DRG
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,690,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],14625.55,,"Fee schedule rate ($14,625.55). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7426.94,15928.53,There are no additional notes associated with this service or procedure.
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC,805,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],9577.23,,"Case rate ($9,253.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,743.82, add-ons for qualifying new technology services are included. If operating cost exceeds $43,614.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,294.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $6,773.89 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,798.87 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $534.53. The transfer capital threshold is the transfer adjustment factor * $534.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,9253.36,21235.42,Inpatient DRG
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],22217.08,,"Fee schedule rate ($22,217.08). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.4), with a minimum of zero.",,,,0,other,7243.75,23262.15,There are no additional notes associated with this service or procedure.
"Open Tx Articular Fracture Mcp/IP Joint Ea|LEFT HAND, FIFTH DIGIT",CASE-26746,APC,26746,CPT,0360,RC,,,F4,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
CERVICAL SPINAL FUSION WITHOUT CC/MCC,473,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],19124.33,,"Case rate ($18,477.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,324.93, add-ons for qualifying new technology services are included. If operating cost exceeds $52,195.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,969.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.6. The base transfer operating payment is the transfer adjustment factor * $15,323.48 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,379.98 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,209.17. The transfer capital threshold is the transfer adjustment factor * $1,209.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,18477.61,62077.11,Inpatient DRG
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],37899.49,,"Fee schedule rate ($37,899.49). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,14747.55,37899.49,There are no additional notes associated with this service or procedure.
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,307,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],6965.00,,,,,,0,other,6335.27,18228.77,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],13947.32,,"Fee schedule rate ($13,947.32). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6153.12,13947.32,There are no additional notes associated with this service or procedure.
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC,520,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],39786.42,,"Fee schedule rate ($39,786.42). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12061.74,39786.42,There are no additional notes associated with this service or procedure.
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|RIGHT HAND, THUMB",CASE-26160,APC,26160,CPT,0360,RC,,,F5,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1545.93,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1545.93,1623.23,OPPS APC
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC",629,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],17033.94,,"Case rate ($16,699.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,671.20, add-ons for qualifying new technology services are included. If operating cost exceeds $50,542.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,839.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $13,675.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,726.25 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,079.16. The transfer capital threshold is the transfer adjustment factor * $1,079.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,16699.94,44657.18,Inpatient DRG
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],15609.47,,"Fee schedule rate ($15,609.47). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7569.84,21892.85,There are no additional notes associated with this service or procedure.
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7771.40,,"Case rate ($7,401.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,031.08, add-ons for qualifying new technology services are included. If operating cost exceeds $41,902.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,149.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,066.92 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,086.13 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $389.46. The transfer capital threshold is the transfer adjustment factor * $389.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7566.45,16333.88,Inpatient DRG
Laps Fulg/Exc Ovary Viscera/Peritoneal Surface|RIGHT SIDE,CASE-58662,APC,58662,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5658.76,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5658.76,5941.70,OPPS APC
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],8559.13,,"Case rate ($8,151.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,718.82, add-ons for qualifying new technology services are included. If operating cost exceeds $42,589.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,213.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,752.66 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,773.87 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $453.94. The transfer capital threshold is the transfer adjustment factor * $453.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8151.55,18033.97,Inpatient DRG
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],13414.31,,"Case rate ($12,775.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,020.41, add-ons for qualifying new technology services are included. If operating cost exceeds $46,891.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,552.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $10,038.44 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,075.45 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $792.13. The transfer capital threshold is the transfer adjustment factor * $792.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12775.53,31469.43,Inpatient DRG
"Open Tx Phalangeal Shaft Fracture Prox/Middle Ea|LEFT HAND, FIFTH DIGIT",CASE-26735,APC,26735,CPT,0360,RC,,,F4,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,426,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],76581.29,,"Case rate ($76,581.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $71,377.56, add-ons for qualifying new technology services are included. If operating cost exceeds $106,248.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $7,218.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $69,177.55 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $69,432.61 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $5,458.79. The transfer capital threshold is the transfer adjustment factor * $5,458.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,76581.29,216864.15,Inpatient DRG
GASTROINTESTINAL HEMORRHAGE WITH MCC,377,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],31575.65,,"Fee schedule rate ($31,575.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,7634.00,35969.56,There are no additional notes associated with this service or procedure.
RADIOTHERAPY,849,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],21308.57,,"Case rate ($20,293.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $19,014.57, add-ons for qualifying new technology services are included. If operating cost exceeds $53,885.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,101.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $17,006.91 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $17,069.62 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,342.01. The transfer capital threshold is the transfer adjustment factor * $1,342.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,20293.88,81867.07,Inpatient DRG
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],6524.00,,"Per diem ($6,524). If length of stay < 2.6, first 1 days paid at a per diem of $13,048 instead. Capped at $16,962.56.",,,,0,other,6524.00,17760.46,Estimated amount calculated based on 2 day length of stay.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],16856.18,,"Case rate ($16,286.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,286.28, add-ons for qualifying new technology services are included. If operating cost exceeds $50,157.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,808.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $13,292.32 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,341.33 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,048.90. The transfer capital threshold is the transfer adjustment factor * $1,048.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103.5%.",,,,0,other,16286.16,58320.32,Inpatient DRG
SPINAL PROCEDURES WITHOUT CC/MCC,030,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],44714.01,,"Fee schedule rate ($44,714.01). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,16810.99,44714.01,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],7794.44,,"Case rate ($7,641.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,244.44, add-ons for qualifying new technology services are included. If operating cost exceeds $42,115.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,176.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,280.02 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,299.49 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $416.65. The transfer capital threshold is the transfer adjustment factor * $416.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,7641.61,19371.27,Inpatient DRG
Mastectomy Simple Complete,CASE-19303,APC,19303,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6432.89,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6432.89,6432.89,OPPS APC
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],18830.52,,"Fee schedule rate ($18,830.52). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,7086.00,57872.02,There are no additional notes associated with this service or procedure.
HC I&D Ischio Perirectal Abs,CASE-46040,APC,46040,CPT,0450,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1120.09,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1120.09,1176.09,OPPS APC
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],54503.46,,"Fee schedule rate ($54,503.46). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.9), with a minimum of zero.",,,,0,other,21585.31,73588.10,There are no additional notes associated with this service or procedure.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],39820.52,,"Fee schedule rate ($39,820.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,15273.74,39820.52,There are no additional notes associated with this service or procedure.
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITH MCC,429,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],177294.98,,"Fee schedule rate ($177,294.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,62958.58,177294.98,There are no additional notes associated with this service or procedure.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],19087.91,,"Case rate ($18,178.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,047.10, add-ons for qualifying new technology services are included. If operating cost exceeds $51,918.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,947.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $15,046.67 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,102.15 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,187.33. The transfer capital threshold is the transfer adjustment factor * $1,187.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,18178.96,54764.34,Inpatient DRG
"CESAREAN SECTION WITHOUT STERILIZATION,MODERATE",540,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],7838.06,,"Case rate ($7,838.06). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,7838.06,8229.96,There are no additional notes associated with this service or procedure.
Laparoscopy W/Rmvl Adnexal Structures|BILATERAL PROCEDURE,CASE-58661,APC,58661,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5658.76,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5658.76,5856.81,OPPS APC
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,082,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],56223.11,,"Fee schedule rate ($56,223.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,17423.21,56223.11,There are no additional notes associated with this service or procedure.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,074,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],20919.08,,"Fee schedule rate ($20,919.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8925.60,20919.08,There are no additional notes associated with this service or procedure.
HC Inj Trigger Pt 1-2 Musc Grps|ADJ,CASE-20552,APC,20552,CPT,0510,RC,,,ADJ,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],287.31,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,082,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],18294.37,,"Case rate ($17,423.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,344.04, add-ons for qualifying new technology services are included. If operating cost exceeds $51,215.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,892.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $14,346.19 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,399.08 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,132.06. The transfer capital threshold is the transfer adjustment factor * $1,132.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,17423.21,56223.11,Inpatient DRG
NON-MALIGNANT BREAST DISORDERS WITH CC/MCC,600,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],7999.14,,"Fee schedule rate ($7,999.14). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7999.14,20495.56,There are no additional notes associated with this service or procedure.
Arthrs Aided Ant Cruciate Ligm Rpr/Agmntj/Rcnstj|RIGHT SIDE,CASE-29888,APC,29888,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7029.71,OPPS APC
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH MCC",722,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],34009.69,,"Fee schedule rate ($34,009.69). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,14200.37,56869.13,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],32296.02,,"Case rate ($32,296.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $30,179.91, add-ons for qualifying new technology services are included. If operating cost exceeds $65,050.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,979.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $28,131.23 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $28,234.95 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,219.83. The transfer capital threshold is the transfer adjustment factor * $2,219.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,32296.02,88188.38,Inpatient DRG
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],14830.15,,"Fee schedule rate ($14,830.15). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,7884.32,17835.23,There are no additional notes associated with this service or procedure.
Neuroplasty &/Transposition Ulnar Nerve Elbow|LEFT SIDE|SEPARATE STRUCTURE,CASE-64718,APC,64718,CPT,0360,RC,,,LT|XS,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],20403.76,,"Fee schedule rate ($20,403.76). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,14370.36,38378.80,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,086,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],11033.18,,"Case rate ($10,507.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,926.76, add-ons for qualifying new technology services are included. If operating cost exceeds $44,797.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,371.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,951.66 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,981.81 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $611.18. The transfer capital threshold is the transfer adjustment factor * $611.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8442.00,30728.81,Inpatient DRG
GASTROINTESTINAL OBSTRUCTION WITH CC,389,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7493.25,,"Case rate ($7,136.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,784.16, add-ons for qualifying new technology services are included. If operating cost exceeds $41,655.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,130.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $4,820.93 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,839.21 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $370.55. The transfer capital threshold is the transfer adjustment factor * $370.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5118.00,16423.43,Inpatient DRG
CESAREAN SECTION WITH STERILIZATION WITH CC,784,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],19922.46,,"Fee schedule rate ($19,922.46). Adds an outlier to normal pricing equal to the per diem rate ($39,437.39) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,9124.01,23722.94,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITHOUT STERILIZATION WITH CC,787,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],9508.01,,"Case rate ($9,508.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,980.70, add-ons for qualifying new technology services are included. If operating cost exceeds $43,851.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,313.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $7,009.90 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,035.74 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $553.15. The transfer capital threshold is the transfer adjustment factor * $553.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9508.01,23722.94,Inpatient DRG
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],51656.32,,"Fee schedule rate ($51,656.32). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,20559.34,54086.17,There are no additional notes associated with this service or procedure.
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],29216.99,,"Fee schedule rate ($29,216.99). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9755.86,29216.99,There are no additional notes associated with this service or procedure.
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],13001.72,,"Case rate ($13,001.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,230.82, add-ons for qualifying new technology services are included. If operating cost exceeds $47,101.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,568.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $10,248.08 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,285.87 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $808.68. The transfer capital threshold is the transfer adjustment factor * $808.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7868.00,32126.64,Inpatient DRG
CERVICAL SPINAL FUSION WITH MCC,471,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],36377.52,,"Case rate ($34,645.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $32,365.35, add-ons for qualifying new technology services are included. If operating cost exceeds $67,236.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,151.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $30,308.64 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $30,420.39 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,391.65. The transfer capital threshold is the transfer adjustment factor * $2,391.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,34645.26,111337.93,Inpatient DRG
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],31477.13,,"Fee schedule rate ($31,477.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9648.19,31477.13,There are no additional notes associated with this service or procedure.
OTHER CEREBROVASCULAR DISORDERS WITH MCC,070,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],31286.59,,"Fee schedule rate ($31,286.59). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13219.09,37774.46,There are no additional notes associated with this service or procedure.
HEADACHES WITHOUT MCC,103,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],7988.85,,"Case rate ($7,608.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,213.57, add-ons for qualifying new technology services are included. If operating cost exceeds $42,084.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,174.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $5,249.26 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,268.62 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $414.22. The transfer capital threshold is the transfer adjustment factor * $414.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,20883.08,Inpatient DRG
"HIV WITH MULTIPLE MAJOR HIV RELATED CONDITIONS,EXTREME",890,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],31308.40,,"Case rate ($31,308.40). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,31308.40,32873.82,There are no additional notes associated with this service or procedure.
Ercp Biliary/Panc Duct Stent Exchange W/Dil&Wire,CASE-43276,APC,43276,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5682.51,,"APC Price ($5,682.51). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5682.51,5966.63,OPPS APC
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],27589.62,,"Fee schedule rate ($27,589.62). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12566.28,30861.41,There are no additional notes associated with this service or procedure.
Exc Lesion Eyelid W/O Clsr/W/Simple Dir Closure,CASE-67840,APC,67840,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],933.10,,"APC Price ($933.10). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,933.10,979.76,OPPS APC
"OPIOID ABUSE AND DEPENDENCE,MODERATE",773,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],4907.58,,"Case rate ($4,673.89). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4673.89,4907.58,There are no additional notes associated with this service or procedure.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],26587.11,,"Case rate ($25,321.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $23,734.86, add-ons for qualifying new technology services are included. If operating cost exceeds $58,605.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,428.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $21,707.60 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $21,789.91 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,668.50. The transfer capital threshold is the transfer adjustment factor * $1,668.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,26028.48,80635.65,Inpatient DRG
Realignment Extensor Tendon Hand Each Tendon,CASE-26437,APC,26437,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITHOUT CC/MCC",630,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],28718.58,,,,,,0,other,11828.78,42541.02,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],41402.42,,"Fee schedule rate ($41,402.42). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,15456.59,41402.42,There are no additional notes associated with this service or procedure.
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",759,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],11643.60,,"Fee schedule rate ($11,643.60). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6190.22,13057.66,There are no additional notes associated with this service or procedure.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],16776.29,,"Case rate ($16,447.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,436.22, add-ons for qualifying new technology services are included. If operating cost exceeds $50,307.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,820.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $13,441.70 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,491.27 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,060.68. The transfer capital threshold is the transfer adjustment factor * $1,060.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,7453.00,42138.30,Inpatient DRG
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],8289.67,,"Case rate ($8,009.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,586.52, add-ons for qualifying new technology services are included. If operating cost exceeds $42,457.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,203.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $5,620.85 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,641.57 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $443.54. The transfer capital threshold is the transfer adjustment factor * $443.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,8009.34,19877.10,Inpatient DRG
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],7183.92,,"Case rate ($6,841.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,500.42, add-ons for qualifying new technology services are included. If operating cost exceeds $41,371.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,118.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $4,538.73 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,555.47 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $358.15. The transfer capital threshold is the transfer adjustment factor * $358.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6841.83,21167.26,Inpatient DRG
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],12227.29,,,,,,0,other,6153.12,13947.32,There are no additional notes associated with this service or procedure.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],23618.74,,"Fee schedule rate ($23,618.74). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10533.95,24956.34,There are no additional notes associated with this service or procedure.
FULL TERM NEONATE WITH MAJOR PROBLEMS,793,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],78359.29,,"Fee schedule rate ($78,359.29). Adds an outlier to normal pricing equal to the per diem rate ($27,082.03) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.7), with a minimum of zero.",,,,0,other,4302.90,82045.22,There are no additional notes associated with this service or procedure.
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH MCC",722,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],56869.13,,"Fee schedule rate ($56,869.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,14200.37,56869.13,There are no additional notes associated with this service or procedure.
"Arthrodesis Interphalangeal Jt W/WO Int Fixj|LEFT HAND, FOURTH DIGIT",CASE-26860,APC,26860,CPT,0360,RC,,,F3,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5825.98,,"Case rate ($5,628.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,372.11, add-ons for qualifying new technology services are included. If operating cost exceeds $40,243.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,029.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,414.56 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,427.15 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $269.44. The transfer capital threshold is the transfer adjustment factor * $269.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,5628.97,12272.58,Inpatient DRG
HC I&D Ischio Perirectal Abs,CASE-46040,APC,46040,CPT,0450,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1120.09,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1120.09,1176.09,OPPS APC
OSTEOMYELITIS WITHOUT CC/MCC,541,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],11429.52,,"Fee schedule rate ($11,429.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5103.00,15493.67,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],2070.00,,,,,,0,other,1188.00,17370.86,Estimated amount calculated based on 3 day length of stay.
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],13482.55,,"Case rate ($12,840.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,080.88, add-ons for qualifying new technology services are included. If operating cost exceeds $46,951.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,556.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $10,098.70 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,135.93 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $796.89. The transfer capital threshold is the transfer adjustment factor * $796.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,1188.00,31658.33,Inpatient DRG
"NEONATE BIRTH WEIGHT > 2499 GRAMS NORMAL NEWBORN OR NEONATE WITH OTHER PROBLEM,MODERATE",640,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],1628.96,,"Case rate ($1,551.39). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,1551.39,1628.96,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,373,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],13670.03,,"Fee schedule rate ($13,670.03). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6870.94,14313.05,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],41580.51,,"Fee schedule rate ($41,580.51). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,13783.20,41580.51,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],58394.20,,"Fee schedule rate ($58,394.20). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,9370.00,65732.99,There are no additional notes associated with this service or procedure.
Destruction Neurolytic Agt Genicular Nerve W/Img|BILATERAL PROCEDURE,CASE-64624,APC,64624,CPT,0360,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1919.19,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1827.80,1919.19,OPPS APC
Anesthesia Upper GI Endoscopic Px Ercp,CASE-00732,APC,00732,CPT,0370,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3789.26,,"APC Price ($3,608.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3789.26,3789.26,OPPS APC
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,394,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],20909.61,,"Fee schedule rate ($20,909.61). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8281.56,20909.61,There are no additional notes associated with this service or procedure.
UNGROUPABLE,999,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],10228.00,,"Per diem ($10,228). If length of stay < 12.7, first 1 days paid at a per diem of $20,456 instead. Capped at $129,893.46.",,,,0,other,10228.00,161307.29,Estimated amount calculated based on 9 day length of stay.
OSTEOMYELITIS WITH CC,540,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],18450.55,,"Fee schedule rate ($18,450.55). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,9809.07,25507.30,There are no additional notes associated with this service or procedure.
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],15128.37,,"Fee schedule rate ($15,128.37). Adds an outlier to normal pricing equal to the per diem rate ($46,867.46) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7396.47,16035.06,There are no additional notes associated with this service or procedure.
Laps Rpr Paraesphgl Hrna Incl Fundplsty W/O Mesh,CASE-43281,APC,43281,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],10298.02,,"APC Price ($9,949.78). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,9949.78,10447.27,OPPS APC
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],90333.60,,"Fee schedule rate ($90,333.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,26127.34,90333.60,There are no additional notes associated with this service or procedure.
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],20170.75,,"Fee schedule rate ($20,170.75). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10048.39,23545.50,There are no additional notes associated with this service or procedure.
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],21888.80,,"Case rate ($20,846.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $19,528.64, add-ons for qualifying new technology services are included. If operating cost exceeds $54,399.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,142.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $17,519.09 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $17,583.69 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,382.43. The transfer capital threshold is the transfer adjustment factor * $1,382.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,20846.48,81306.30,Inpatient DRG
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],72151.96,,"Fee schedule rate ($72,151.96). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,27944.96,86252.84,There are no additional notes associated with this service or procedure.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],13100.98,,"Case rate ($12,477.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,762.45, add-ons for qualifying new technology services are included. If operating cost exceeds $46,633.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,511.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $9,780.42 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,817.50 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $751.75. The transfer capital threshold is the transfer adjustment factor * $751.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12795.84,41944.25,Inpatient DRG
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],12696.97,,"Case rate ($12,696.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,947.32, add-ons for qualifying new technology services are included. If operating cost exceeds $46,818.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,546.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,965.63 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,002.37 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $786.39. The transfer capital threshold is the transfer adjustment factor * $786.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12696.97,47123.82,Inpatient DRG
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",062,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],33023.06,,"Fee schedule rate ($33,023.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,13844.84,44304.80,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],15456.59,,"Case rate ($15,456.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,514.54, add-ons for qualifying new technology services are included. If operating cost exceeds $49,385.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,748.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $12,523.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,569.59 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $988.22. The transfer capital threshold is the transfer adjustment factor * $988.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,15456.59,41402.42,Inpatient DRG
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],85305.59,,"Fee schedule rate ($85,305.59). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,21719.40,85305.59,There are no additional notes associated with this service or procedure.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],41944.25,,"Fee schedule rate ($41,944.25). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12795.84,41944.25,There are no additional notes associated with this service or procedure.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],38248.08,,"Fee schedule rate ($38,248.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11593.79,38248.08,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,083,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],11397.40,,"Case rate ($11,397.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,738.37, add-ons for qualifying new technology services are included. If operating cost exceeds $45,609.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,451.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $8,761.12 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,793.42 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $691.34. The transfer capital threshold is the transfer adjustment factor * $691.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,28680.85,Inpatient DRG
OSTEOMYELITIS WITH CC,540,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],18450.55,,"Fee schedule rate ($18,450.55). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,9809.07,25507.30,There are no additional notes associated with this service or procedure.
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],26029.95,,"Fee schedule rate ($26,029.95). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11575.50,48961.48,There are no additional notes associated with this service or procedure.
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC,805,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],20902.03,,"Fee schedule rate ($20,902.03). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9253.36,21235.42,There are no additional notes associated with this service or procedure.
Rhytidectomy Smas Flap,CASE-15829,APC,15829,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],2225.38,,"APC Price ($2,225.38). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2225.38,2336.65,OPPS APC
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],15491.11,,"Case rate ($15,491.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,546.67, add-ons for qualifying new technology services are included. If operating cost exceeds $49,417.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,750.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $12,555.42 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,601.72 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $990.75. The transfer capital threshold is the transfer adjustment factor * $990.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,15491.11,54180.83,Inpatient DRG
VENTRICULAR SHUNT PROCEDURES WITH MCC,031,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],32965.75,,"Case rate ($31,395.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $29,397.55, add-ons for qualifying new technology services are included. If operating cost exceeds $64,268.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,862.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7. The base transfer operating payment is the transfer adjustment factor * $27,348.91 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $27,452.60 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,102.10. The transfer capital threshold is the transfer adjustment factor * $2,102.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,32287.20,88162.80,Inpatient DRG
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],25013.10,,"Fee schedule rate ($25,013.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10846.16,25863.45,There are no additional notes associated with this service or procedure.
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC,807,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],10071.17,,"Fee schedule rate ($10,071.17). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5354.25,13266.23,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],28253.40,,"Fee schedule rate ($28,253.40). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,12126.09,29582.40,There are no additional notes associated with this service or procedure.
HC Cv Cath Plac W/Port Tun >5,CASE-36561,APC,36561,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],2955.48,,"APC Price ($2,955.48). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2955.48,3103.25,OPPS APC
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],14231.57,,"Case rate ($13,952.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,115.33, add-ons for qualifying new technology services are included. If operating cost exceeds $47,986.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,638.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $11,129.34 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,170.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $878.22. The transfer capital threshold is the transfer adjustment factor * $878.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,13917.42,34889.29,Inpatient DRG
HEADACHES WITHOUT MCC,103,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7874.73,,"Case rate ($7,608.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,213.57, add-ons for qualifying new technology services are included. If operating cost exceeds $42,084.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,174.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $5,249.26 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,268.62 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $414.22. The transfer capital threshold is the transfer adjustment factor * $414.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6965.00,20883.08,Inpatient DRG
CESAREAN SECTION WITH STERILIZATION WITH CC,784,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],19922.46,,"Fee schedule rate ($19,922.46). Adds an outlier to normal pricing equal to the per diem rate ($39,437.39) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,9124.01,23722.94,There are no additional notes associated with this service or procedure.
"SEPTICEMIA AND DISSEMINATED INFECTIONS,MAJOR",720,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],14333.66,,"Case rate ($13,651.10). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13651.10,14333.66,There are no additional notes associated with this service or procedure.
NONTRAUMATIC STUPOR AND COMA WITH MCC,080,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],14202.39,,"Case rate ($14,202.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,347.79, add-ons for qualifying new technology services are included. If operating cost exceeds $48,218.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,656.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $11,360.96 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,402.84 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $896.49. The transfer capital threshold is the transfer adjustment factor * $896.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,14202.39,35615.37,Inpatient DRG
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,066,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],6908.75,,"Case rate ($6,579.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,256.61, add-ons for qualifying new technology services are included. If operating cost exceeds $41,127.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,098.96, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $4,295.82 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,311.66 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $338.98. The transfer capital threshold is the transfer adjustment factor * $338.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6579.76,20083.61,Inpatient DRG
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],14625.55,,"Fee schedule rate ($14,625.55). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7438.45,15961.98,There are no additional notes associated with this service or procedure.
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],24444.75,,"Fee schedule rate ($24,444.75). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10136.44,24444.75,There are no additional notes associated with this service or procedure.
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],8379.44,,"Case rate ($7,980.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,570.88, add-ons for qualifying new technology services are included. If operating cost exceeds $42,441.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,190.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,604.68 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,625.93 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $430.79. The transfer capital threshold is the transfer adjustment factor * $430.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8163.06,18067.42,Inpatient DRG
OTHER CEREBROVASCULAR DISORDERS WITH CC,071,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],29215.10,,"Fee schedule rate ($29,215.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5843.00,29215.10,There are no additional notes associated with this service or procedure.
VENTRICULAR SHUNT PROCEDURES WITH MCC,031,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],33901.56,,"Case rate ($32,287.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $30,171.71, add-ons for qualifying new technology services are included. If operating cost exceeds $65,042.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,979.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7. The base transfer operating payment is the transfer adjustment factor * $28,123.07 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $28,226.76 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,219.19. The transfer capital threshold is the transfer adjustment factor * $2,219.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,32287.20,88162.80,Inpatient DRG
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],35419.59,,"Fee schedule rate ($35,419.59). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,7086.00,57872.02,There are no additional notes associated with this service or procedure.
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],15537.77,,"Case rate ($15,233.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,306.64, add-ons for qualifying new technology services are included. If operating cost exceeds $49,177.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,731.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $12,316.28 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,361.69 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $971.88. The transfer capital threshold is the transfer adjustment factor * $971.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,15233.11,38610.21,Inpatient DRG
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],15177.23,,"Fee schedule rate ($15,177.23). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,7414.07,18217.52,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITH MCC,385,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],13293.42,,"Case rate ($12,660.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,913.31, add-ons for qualifying new technology services are included. If operating cost exceeds $46,784.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,543.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $9,931.73 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,968.35 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $783.71. The transfer capital threshold is the transfer adjustment factor * $783.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,11480.01,31134.92,Inpatient DRG
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],28655.14,,"Case rate ($28,093.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $26,270.18, add-ons for qualifying new technology services are included. If operating cost exceeds $61,141.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,672.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $24,235.87 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $24,325.23 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,912.45. The transfer capital threshold is the transfer adjustment factor * $1,912.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 102%.",,,,0,other,10078.00,81454.07,Inpatient DRG
NONTRAUMATIC STUPOR AND COMA WITH MCC,080,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],30179.40,,"Fee schedule rate ($30,179.40). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,14202.39,35615.37,There are no additional notes associated with this service or procedure.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],15832.71,,"Case rate ($15,078.77). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,187.57, add-ons for qualifying new technology services are included. If operating cost exceeds $49,058.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,697.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $12,196.37 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,242.62 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $937.44. The transfer capital threshold is the transfer adjustment factor * $937.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,15476.23,42787.31,Inpatient DRG
Ercp Remove Calculi/Debris Biliary/Pancreas Duct,CASE-43264,APC,43264,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5881.39,,"APC Price ($5,682.51). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5682.51,5966.63,OPPS APC
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],13762.88,,"Case rate ($13,762.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,938.93, add-ons for qualifying new technology services are included. If operating cost exceeds $47,809.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,624.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $10,953.59 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,993.98 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $864.35. The transfer capital threshold is the transfer adjustment factor * $864.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,1188.00,34338.33,Inpatient DRG
CHEST PAIN,313,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],11936.47,,"Case rate ($6,820.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,480.89, add-ons for qualifying new technology services are included. If operating cost exceeds $41,351.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,116.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $4,519.27 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,535.94 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $356.62. The transfer capital threshold is the transfer adjustment factor * $356.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,6820.84,15377.66,All Other Inpatient
Optx Dstl Radl X-Artic Fx/Epiphysl Sep|RIGHT SIDE,CASE-25607,APC,25607,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6791.99,7131.59,OPPS APC
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],9151.11,,"Case rate ($9,151.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,648.69, add-ons for qualifying new technology services are included. If operating cost exceeds $43,519.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,287.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,679.11 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,703.74 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $527.05. The transfer capital threshold is the transfer adjustment factor * $527.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9151.11,30245.71,Inpatient DRG
COMPLICATIONS OF TREATMENT WITH CC,920,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],8732.59,,"Case rate ($8,732.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,259.35, add-ons for qualifying new technology services are included. If operating cost exceeds $43,130.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,256.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,291.21 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,314.40 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $496.44. The transfer capital threshold is the transfer adjustment factor * $496.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8732.59,20731.52,Inpatient DRG
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],11565.93,,"Fee schedule rate ($11,565.93). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6148.93,15887.21,There are no additional notes associated with this service or procedure.
SPINAL PROCEDURES WITH MCC,028,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],44125.74,,"Case rate ($42,633.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $39,796.72, add-ons for qualifying new technology services are included. If operating cost exceeds $74,667.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,735.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.5. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 9.5)) / 2. The base transfer operating payment is the transfer adjustment factor * $37,712.72 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $37,851.77 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,975.91. The transfer capital threshold is the transfer adjustment factor * $2,975.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,42633.57,120982.83,Inpatient DRG
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],42869.24,,"Fee schedule rate ($42,869.24). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,26028.48,80635.65,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],16552.29,,,,,,0,other,7641.61,19371.27,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH CC,427,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],51863.61,,"Case rate ($49,393.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $46,174.24, add-ons for qualifying new technology services are included. If operating cost exceeds $81,045.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $5,146.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $44,062.23 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $44,229.29 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,386.73. The transfer capital threshold is the transfer adjustment factor * $3,386.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,50829.82,142040.39,Inpatient DRG
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],30236.06,,"Fee schedule rate ($30,236.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.8), with a minimum of zero.",,,,0,other,1188.00,31658.33,There are no additional notes associated with this service or procedure.
Cysto Bladder W/Ureteral Catheterization|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-52005,APC,52005,CPT,0360,RC,,,LT|XU,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3299.47,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3299.47,3464.44,OPPS APC
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],17627.38,,"Case rate ($16,787.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,753.10, add-ons for qualifying new technology services are included. If operating cost exceeds $50,624.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,845.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $13,757.43 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,808.15 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,085.60. The transfer capital threshold is the transfer adjustment factor * $1,085.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,16787.98,62990.26,Inpatient DRG
PLEURAL EFFUSION WITH MCC,186,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],12306.63,,"Case rate ($11,720.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $11,009.40, add-ons for qualifying new technology services are included. If operating cost exceeds $49,654.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $3,482.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $9,606.87 + an uncompensated DSH payment of $1,359.91. The transfer operating threshold is the transfer adjustment factor * $9,649.48 + an uncompensated DSH payment of $1,359.91. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $753.81. The transfer capital threshold is the transfer adjustment factor * $753.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10804.96,31089.66,Inpatient DRG
Arthrp Interpos Intercarpal/Metacarpal Joints|RIGHT SIDE,CASE-25447,APC,25447,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3169.86,OPPS APC
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],81306.30,,"Fee schedule rate ($81,306.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,20846.48,81306.30,There are no additional notes associated with this service or procedure.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],120927.32,,"Fee schedule rate ($120,927.32). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,45521.20,142438.06,There are no additional notes associated with this service or procedure.
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],7243.75,,"Fee schedule rate ($7,243.75). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7243.75,23262.15,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],28423.20,,"Fee schedule rate ($28,423.20). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11059.47,28423.20,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITHOUT CC/MCC,428,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],42018.41,,"Case rate ($40,017.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $37,363.07, add-ons for qualifying new technology services are included. If operating cost exceeds $72,234.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,544.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $35,288.01 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $35,418.12 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,784.57. The transfer capital threshold is the transfer adjustment factor * $2,784.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,40017.53,118904.57,Inpatient DRG
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],46215.75,,"Fee schedule rate ($46,215.75). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.7), with a minimum of zero.",,,,0,other,18598.83,48389.68,There are no additional notes associated with this service or procedure.
CELLULITIS WITH MCC,602,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],15712.20,,"Fee schedule rate ($15,712.20). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11570.10,28349.31,There are no additional notes associated with this service or procedure.
Bx/Exc Lymph Node Open Deep Axillary Node,CASE-38525,APC,38525,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3664.94,,"APC Price ($3,664.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3664.94,3848.19,OPPS APC
HC Peripheral Block - Femoral Single or Saphenous W/Img Gdn|LEFT SIDE,CASE-64447,APC,64447,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],660.72,,"APC Price ($660.72). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,660.72,693.76,OPPS APC
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],18905.23,,"Fee schedule rate ($18,905.23). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6963.00,18954.85,There are no additional notes associated with this service or procedure.
COMPLICATIONS OF TREATMENT WITH CC,920,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],20731.52,,"Fee schedule rate ($20,731.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8732.59,20731.52,There are no additional notes associated with this service or procedure.
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],67107.92,,"Fee schedule rate ($67,107.92). Adds an outlier to normal pricing equal to the per diem rate ($118,521.29) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16.7), with a minimum of zero.",,,,0,other,26127.34,90333.60,There are no additional notes associated with this service or procedure.
NON-MALIGNANT BREAST DISORDERS WITH CC/MCC,600,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],20495.56,,,,,,0,other,7999.14,20495.56,There are no additional notes associated with this service or procedure.
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],8151.60,,"Case rate ($7,875.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,462.42, add-ons for qualifying new technology services are included. If operating cost exceeds $42,333.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,193.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $5,497.20 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,517.46 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $433.78. The transfer capital threshold is the transfer adjustment factor * $433.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,7875.94,17233.12,Inpatient DRG
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],16265.67,,"Case rate ($15,491.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,546.67, add-ons for qualifying new technology services are included. If operating cost exceeds $49,417.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,750.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $12,555.42 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,601.72 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $990.75. The transfer capital threshold is the transfer adjustment factor * $990.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,15491.11,54180.83,Inpatient DRG
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],10517.90,,"Case rate ($6,010.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,726.79, add-ons for qualifying new technology services are included. If operating cost exceeds $40,597.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,057.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,767.95 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,781.84 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $297.33. The transfer capital threshold is the transfer adjustment factor * $297.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,6010.23,12246.05,All Other Inpatient
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],10791.09,,"Fee schedule rate ($10,791.09). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6965.00,21404.64,There are no additional notes associated with this service or procedure.
Laps Fulg/Exc Ovary Viscera/Peritoneal Surface,CASE-58662,APC,58662,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5941.70,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5658.76,5941.70,OPPS APC
"Amputation Toe Interphalangeal Joint|LEFT FOOT, THIRD DIGIT",CASE-28825,APC,28825,CPT,0360,RC,,,T2,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],48094.52,,,,,,0,other,18497.24,62041.12,There are no additional notes associated with this service or procedure.
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC",011,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],40824.51,,"Case rate ($38,880.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $36,305.31, add-ons for qualifying new technology services are included. If operating cost exceeds $71,176.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,461.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 11.4. The base transfer operating payment is the transfer adjustment factor * $34,234.14 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $34,360.36 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,701.41. The transfer capital threshold is the transfer adjustment factor * $2,701.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,38880.49,150008.48,Inpatient DRG
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],24092.63,,"Fee schedule rate ($24,092.63). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10626.74,25225.91,There are no additional notes associated with this service or procedure.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],39797.94,,"Fee schedule rate ($39,797.94). Adds an outlier to normal pricing equal to the per diem rate ($75,578.79) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.5), with a minimum of zero.",,,,0,other,16286.16,58320.32,There are no additional notes associated with this service or procedure.
INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC,198,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],13459.55,,"Fee schedule rate ($13,459.55). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.7), with a minimum of zero.",,,,0,other,6795.12,23505.07,There are no additional notes associated with this service or procedure.
Laps Surg W/Aspir Cavity/Cyst Single/Multiple,CASE-49322,APC,49322,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5658.76,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5658.76,5941.70,OPPS APC
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],41006.47,,"Fee schedule rate ($41,006.47). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12268.97,41006.47,There are no additional notes associated with this service or procedure.
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],6230.00,,"Per diem ($6,230). If length of stay < 2.9, first 1 days paid at a per diem of $12,460 instead. Capped at $18,065.71.",,,,0,other,6230.00,22762.43,Estimated amount calculated based on 3 day length of stay.
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],33835.79,,"Fee schedule rate ($33,835.79). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,7000.00,33835.79,There are no additional notes associated with this service or procedure.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],45845.03,,"Fee schedule rate ($45,845.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,18598.83,48389.68,There are no additional notes associated with this service or procedure.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],19635.68,,,,,,0,other,5683.00,19635.68,There are no additional notes associated with this service or procedure.
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],15891.15,,,,,,0,other,7414.07,18217.52,There are no additional notes associated with this service or procedure.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],19604.30,,"Fee schedule rate ($19,604.30). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9446.38,21796.21,There are no additional notes associated with this service or procedure.
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],27589.62,,"Fee schedule rate ($27,589.62). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12566.28,30861.41,There are no additional notes associated with this service or procedure.
HC Joint Injection/Aspir Large WO US|DISTINCT PROCEDURAL SERVICE|RIGHT SIDE|PBB CHARGE,CASE-20610,APC,20610,CPT,0510,RC,,,59|RT|PBB,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
"ASTHMA,MAJOR",141,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],8458.62,,"Case rate ($8,458.62). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,8458.62,8881.55,There are no additional notes associated with this service or procedure.
Inject Rx Other Periph Nerve|LEFT SIDE,CASE-64640,APC,64640,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],869.28,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,827.89,869.28,OPPS APC
CESAREAN SECTION WITHOUT STERILIZATION WITH CC,787,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],21975.27,,,,,,0,other,9508.01,23722.94,There are no additional notes associated with this service or procedure.
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],12202.35,,"Case rate ($11,621.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,964.70, add-ons for qualifying new technology services are included. If operating cost exceeds $45,835.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,450.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $8,985.68 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,019.75 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $690.66. The transfer capital threshold is the transfer adjustment factor * $690.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,11914.12,40426.76,Inpatient DRG
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],15765.72,,"Case rate ($15,456.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,514.54, add-ons for qualifying new technology services are included. If operating cost exceeds $49,385.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,748.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $12,523.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,569.59 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $988.22. The transfer capital threshold is the transfer adjustment factor * $988.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,15456.59,41402.42,Inpatient DRG
HEADACHES WITHOUT MCC,103,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],20883.08,,"Fee schedule rate ($20,883.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,20883.08,There are no additional notes associated with this service or procedure.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,025,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],13351.00,,"Per diem ($13,351). If length of stay < 6.4, first 1 days paid at a per diem of $26,702 instead. Capped at $85,446.13.",,,,0,other,13351.00,91631.33,Estimated amount calculated based on 4 day length of stay.
Lamnotmy Incl W/Dcmprsn Nrv Root 1 Intrspc Lumbr|BILATERAL PROCEDURE,CASE-63030,APC,63030,CPT,0360,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7029.71,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6791.99,7131.59,OPPS APC
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],23851.93,,"Case rate ($22,716.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $21,306.68, add-ons for qualifying new technology services are included. If operating cost exceeds $56,177.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,242.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $19,288.59 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $19,361.73 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,482.57. The transfer capital threshold is the transfer adjustment factor * $1,482.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,23344.70,62179.32,Inpatient DRG
"ALCOHOLIC LIVER DISEASE,EXTREME",280,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],24390.20,,"Case rate ($24,390.20). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,24390.20,25609.71,There are no additional notes associated with this service or procedure.
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],12725.42,,"Case rate ($12,725.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,973.79, add-ons for qualifying new technology services are included. If operating cost exceeds $46,844.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,548.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $9,991.99 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,028.83 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $788.47. The transfer capital threshold is the transfer adjustment factor * $788.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12725.42,34245.00,Inpatient DRG
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC",514,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],19212.08,,"Fee schedule rate ($19,212.08). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,8868.04,22699.91,There are no additional notes associated with this service or procedure.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,345,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],29607.98,,,,,,0,other,12134.89,33616.03,There are no additional notes associated with this service or procedure.
MAJOR ESOPHAGEAL DISORDERS WITH CC,369,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],8718.38,,"Case rate ($8,718.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,246.12, add-ons for qualifying new technology services are included. If operating cost exceeds $43,117.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,255.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,278.03 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,301.17 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $495.40. The transfer capital threshold is the transfer adjustment factor * $495.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,19680.94,Inpatient DRG
CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC,788,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],11163.60,,"Fee schedule rate ($11,163.60). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8438.02,20142.33,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],14908.05,,"Case rate ($14,908.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,004.25, add-ons for qualifying new technology services are included. If operating cost exceeds $48,875.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,708.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $12,014.99 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,059.30 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $948.10. The transfer capital threshold is the transfer adjustment factor * $948.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,14908.05,49717.39,Inpatient DRG
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],20362.22,,"Fee schedule rate ($20,362.22). Adds an outlier to normal pricing equal to the per diem rate ($66,744.74) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.8), with a minimum of zero.",,,,0,other,9282.47,21320.03,There are no additional notes associated with this service or procedure.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],23520.23,,"Fee schedule rate ($23,520.23). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10517.71,24909.11,There are no additional notes associated with this service or procedure.
Excision Tumor Soft Tissue Shoulder Subq 3 Cm/>,CASE-23071,APC,23071,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5941.70,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5658.76,5941.70,OPPS APC
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC,831,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],9294.42,,"Fee schedule rate ($9,294.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,4941.30,23661.59,There are no additional notes associated with this service or procedure.
"ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",770,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],17800.73,,"Fee schedule rate ($17,800.73). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,8735.30,19730.13,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],19458.27,,"Fee schedule rate ($19,458.27). Adds an outlier to normal pricing equal to the per diem rate ($75,355.48) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,8956.76,28983.97,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,689,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],22417.63,,"Fee schedule rate ($22,417.63). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,9802.58,22831.22,There are no additional notes associated with this service or procedure.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,988,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],13337.03,,"Case rate ($13,075.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,299.49, add-ons for qualifying new technology services are included. If operating cost exceeds $47,170.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,574.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $10,316.50 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,354.54 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $814.07. The transfer capital threshold is the transfer adjustment factor * $814.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,13075.52,42425.46,Inpatient DRG
Destruction Neurolytic Agt Genicular Nerve W/Img|BILATERAL PROCEDURE,CASE-64624,APC,64624,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1827.80,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1827.80,1919.19,OPPS APC
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7655.35,,"Case rate ($7,396.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,016.38, add-ons for qualifying new technology services are included. If operating cost exceeds $41,887.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,158.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,052.80 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,071.43 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $398.72. The transfer capital threshold is the transfer adjustment factor * $398.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,7396.47,16035.06,Inpatient DRG
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITHOUT CC/MCC,428,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],41418.14,,"Case rate ($40,017.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $37,363.07, add-ons for qualifying new technology services are included. If operating cost exceeds $72,234.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,544.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $35,288.01 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $35,418.12 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,784.57. The transfer capital threshold is the transfer adjustment factor * $2,784.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,40017.53,118904.57,Inpatient DRG
VENTRICULAR SHUNT PROCEDURES WITH CC,032,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],46275.08,,"Fee schedule rate ($46,275.08). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,16376.22,46275.08,There are no additional notes associated with this service or procedure.
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITH MCC OR ANTINEOPLASTIC IMPLANT OR EPILEPSY WITH NEUROSTIMULATOR,023,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],42788.50,,"Case rate ($40,750.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $38,045.35, add-ons for qualifying new technology services are included. If operating cost exceeds $72,916.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,598.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $35,967.78 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $36,100.40 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,838.21. The transfer capital threshold is the transfer adjustment factor * $2,838.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,15168.00,136379.44,Inpatient DRG
Excision Ganglion Wrist Dorsal/Volar Primary|RIGHT SIDE,CASE-25111,APC,25111,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],21892.85,,"Fee schedule rate ($21,892.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7569.84,21892.85,There are no additional notes associated with this service or procedure.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],18033.97,,,,,,0,other,8151.55,18033.97,There are no additional notes associated with this service or procedure.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,098,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],30600.80,,"Case rate ($17,486.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,402.62, add-ons for qualifying new technology services are included. If operating cost exceeds $51,273.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,896.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $14,404.56 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,457.67 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,136.66. The transfer capital threshold is the transfer adjustment factor * $1,136.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,6965.00,45156.75,All Other Inpatient
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],16438.59,,"Fee schedule rate ($16,438.59). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7402.56,16438.59,There are no additional notes associated with this service or procedure.
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],15802.03,,"Fee schedule rate ($15,802.03). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7566.45,16333.88,There are no additional notes associated with this service or procedure.
Egd Intrmural US Needle Aspirate/Biopsy Esophags,CASE-43238,APC,43238,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1885.95,,"APC Price ($1,796.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1796.14,1885.95,OPPS APC
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],39820.52,,"Fee schedule rate ($39,820.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,15273.74,39820.52,There are no additional notes associated with this service or procedure.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],36094.03,,"Fee schedule rate ($36,094.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11194.25,36094.03,There are no additional notes associated with this service or procedure.
COAGULATION DISORDERS,813,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],12274.39,,"Case rate ($12,274.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,554.21, add-ons for qualifying new technology services are included. If operating cost exceeds $46,425.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,515.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $9,573.96 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,609.26 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $755.48. The transfer capital threshold is the transfer adjustment factor * $755.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12274.39,30013.33,Inpatient DRG
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],19523.79,,"Case rate ($18,594.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,433.29, add-ons for qualifying new technology services are included. If operating cost exceeds $52,304.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,977.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $15,431.44 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,488.34 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,217.69. The transfer capital threshold is the transfer adjustment factor * $1,217.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,18594.09,59494.91,Inpatient DRG
Neuroplasty &/Transpos Median Nrv Carpal Tunne|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64721,APC,64721,CPT,0360,RC,,,LT|XU,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],21719.40,,"Case rate ($21,719.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,340.70, add-ons for qualifying new technology services are included. If operating cost exceeds $55,211.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,206.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.2. The base transfer operating payment is the transfer adjustment factor * $18,328.17 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,395.75 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,446.27. The transfer capital threshold is the transfer adjustment factor * $1,446.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,21719.40,85305.59,Inpatient DRG
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],36970.16,,"Case rate ($35,719.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $33,365.14, add-ons for qualifying new technology services are included. If operating cost exceeds $68,236.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,230.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.9. The base transfer operating payment is the transfer adjustment factor * $31,304.77 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $31,420.19 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,470.26. The transfer capital threshold is the transfer adjustment factor * $2,470.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,35719.96,105091.76,Inpatient DRG
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],22557.82,,"Fee schedule rate ($22,557.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6801.88,22557.82,There are no additional notes associated with this service or procedure.
OSTEOMYELITIS WITHOUT CC/MCC,541,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],5103.00,,"Per diem ($5,103). If length of stay < 2.9, first 1 days paid at a per diem of $10,206 instead. Capped at $14,797.61.",,,,0,other,5103.00,15493.67,Estimated amount calculated based on 1 day length of stay.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],51630.84,,"Fee schedule rate ($51,630.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,20559.34,54086.17,There are no additional notes associated with this service or procedure.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC",061,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],20616.23,,"Case rate ($20,616.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $19,314.45, add-ons for qualifying new technology services are included. If operating cost exceeds $54,185.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,125.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $17,305.68 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $17,369.49 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,365.59. The transfer capital threshold is the transfer adjustment factor * $1,365.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,20616.23,62315.82,Inpatient DRG
CESAREAN SECTION WITH STERILIZATION WITHOUT CC/MCC,785,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],20142.33,,"Fee schedule rate ($20,142.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8431.24,20142.33,There are no additional notes associated with this service or procedure.
Thyroidectomy Total/Complete,CASE-60240,APC,60240,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5941.70,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5658.76,5941.70,OPPS APC
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],61234.06,,"Fee schedule rate ($61,234.06). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11165.00,61234.06,There are no additional notes associated with this service or procedure.
Unlisted Procedure Hemic or Lymphatic System,CASE-38999,APC,38999,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],13350.78,,"APC Price ($12,899.30). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,12899.30,13544.27,OPPS APC
CESAREAN SECTION WITHOUT STERILIZATION WITH MCC,786,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],13148.10,,"Fee schedule rate ($13,148.10). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12612.10,23722.94,There are no additional notes associated with this service or procedure.
Excision Distal Ulna Partial/Complete,CASE-25240,APC,25240,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3062.67,OPPS APC
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],12840.52,,"Case rate ($12,840.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,080.88, add-ons for qualifying new technology services are included. If operating cost exceeds $46,951.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,556.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $10,098.70 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,135.93 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $796.89. The transfer capital threshold is the transfer adjustment factor * $796.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,1188.00,31658.33,Inpatient DRG
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],7784.77,,"Case rate ($7,414.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,032.76, add-ons for qualifying new technology services are included. If operating cost exceeds $41,903.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,159.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,069.12 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,087.81 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $400.00. The transfer capital threshold is the transfer adjustment factor * $400.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7414.07,18217.52,Inpatient DRG
DIABETES WITHOUT CC/MCC,639,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],11899.36,,"Fee schedule rate ($11,899.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6151.76,12223.35,There are no additional notes associated with this service or procedure.
"Neuroplasty Other Arm/Leg Nerve,Open|LEFT SIDE",CASE-64708,APC,64708,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7029.71,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6791.99,7131.59,OPPS APC
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],24444.75,,"Fee schedule rate ($24,444.75). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10136.44,24444.75,There are no additional notes associated with this service or procedure.
Inj for Sacroiliac Jt Anesth|LEFT SIDE,CASE-G0260,APC,G0260,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],683.85,,"APC Price ($660.72). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,660.72,693.76,OPPS APC
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],6676.70,,"Fee schedule rate ($6,676.70). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5065.00,12558.65,There are no additional notes associated with this service or procedure.
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],20362.22,,"Fee schedule rate ($20,362.22). Adds an outlier to normal pricing equal to the per diem rate ($66,744.74) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.8), with a minimum of zero.",,,,0,other,9282.47,21320.03,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],21784.85,,"Fee schedule rate ($21,784.85). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.4), with a minimum of zero.",,,,0,other,9795.13,23899.13,There are no additional notes associated with this service or procedure.
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],12558.65,,"Fee schedule rate ($12,558.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5065.00,12558.65,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],26431.82,,"Fee schedule rate ($26,431.82). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,14908.05,49717.39,There are no additional notes associated with this service or procedure.
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],15453.88,,"Case rate ($15,453.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,512.02, add-ons for qualifying new technology services are included. If operating cost exceeds $49,383.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,747.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $12,520.90 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,567.07 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $988.02. The transfer capital threshold is the transfer adjustment factor * $988.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,15453.88,39251.68,Inpatient DRG
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],43949.31,,"Fee schedule rate ($43,949.31). Adds an outlier to normal pricing equal to the per diem rate ($149,567.78) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,17782.11,46523.26,There are no additional notes associated with this service or procedure.
Sigmoidoscopy Flx W/Biopsy Single/Multiple|COLORECTAL CANCER SCREEN,CASE-45331,APC,45331,CPT,0360,RC,,,PT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],870.46,,"APC Price ($870.46). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,870.46,913.99,OPPS APC
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC",442,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],8080.45,,"Case rate ($7,695.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $7,260.76, add-ons for qualifying new technology services are included. If operating cost exceeds $45,905.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $3,189.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $5,874.79 + an uncompensated DSH payment of $1,359.91. The transfer operating threshold is the transfer adjustment factor * $5,900.84 + an uncompensated DSH payment of $1,359.91. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $460.97. The transfer capital threshold is the transfer adjustment factor * $460.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6607.45,19011.92,Inpatient DRG
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],10048.39,,"Case rate ($10,048.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,483.42, add-ons for qualifying new technology services are included. If operating cost exceeds $44,354.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,352.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,510.78 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,538.48 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $592.68. The transfer capital threshold is the transfer adjustment factor * $592.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10048.39,23545.50,Inpatient DRG
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],30112.02,,"Fee schedule rate ($30,112.02). Adds an outlier to normal pricing equal to the per diem rate ($53,484.01) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.5), with a minimum of zero.",,,,0,other,12795.84,41944.25,There are no additional notes associated with this service or procedure.
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],12526.44,,"Fee schedule rate ($12,526.44). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5415.00,17575.50,There are no additional notes associated with this service or procedure.
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],23545.50,,,,,,0,other,10048.39,23545.50,There are no additional notes associated with this service or procedure.
HC Lyr Clos Nk Hnd Ft <2.6cm,CASE-12041,APC,12041,CPT,0450,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1545.93,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1545.93,1623.23,OPPS APC
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],12937.10,,"Fee schedule rate ($12,937.10). Adds an outlier to normal pricing equal to the per diem rate ($49,808.13) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.5), with a minimum of zero.",,,,0,other,5919.29,13545.65,There are no additional notes associated with this service or procedure.
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],11811.40,,"Fee schedule rate ($11,811.40). Adds an outlier to normal pricing equal to the per diem rate ($53,248.69) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.7), with a minimum of zero.",,,,0,other,5937.41,12366.99,There are no additional notes associated with this service or procedure.
HC Joint Injection/Aspir Large WO US|DISTINCT PROCEDURAL SERVICE|RIGHT SIDE|PBB CHARGE,CASE-20610,APC,20610,CPT,0510,RC,,,59|RT|PBB,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],26301.36,,"Fee schedule rate ($26,301.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11247.07,27028.33,There are no additional notes associated with this service or procedure.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],15401.69,,"Case rate ($15,099.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,182.53, add-ons for qualifying new technology services are included. If operating cost exceeds $49,053.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,722.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $12,192.63 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,237.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $962.12. The transfer capital threshold is the transfer adjustment factor * $962.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,7605.00,39153.65,Inpatient DRG
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],31091.14,,"Fee schedule rate ($31,091.14). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13148.66,32553.63,There are no additional notes associated with this service or procedure.
Neuroplasty &/Transposition Ulnar Nerve Elbow|LEFT SIDE|SEPARATE STRUCTURE,CASE-64718,APC,64718,CPT,0360,RC,,,LT|XS,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7029.71,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6791.99,7131.59,OPPS APC
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],41944.25,,"Fee schedule rate ($41,944.25). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12795.84,41944.25,There are no additional notes associated with this service or procedure.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],37550.29,,"Fee schedule rate ($37,550.29). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,15476.23,42787.31,There are no additional notes associated with this service or procedure.
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],16438.59,,"Fee schedule rate ($16,438.59). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7402.56,16438.59,There are no additional notes associated with this service or procedure.
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC,497,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],10127.65,,"Case rate ($10,127.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,557.14, add-ons for qualifying new technology services are included. If operating cost exceeds $44,428.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,358.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 1.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $7,584.22 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,612.19 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $598.47. The transfer capital threshold is the transfer adjustment factor * $598.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10127.65,37761.19,Inpatient DRG
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,065,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],25681.86,,"Fee schedule rate ($25,681.86). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,8786.76,25681.86,There are no additional notes associated with this service or procedure.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],24956.34,,,,,,0,other,10533.95,24956.34,There are no additional notes associated with this service or procedure.
"HC Unlisted Procedure, Nervous System",CASE-64999,APC,64999,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,7029.71,7131.59,OPPS APC
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],17651.07,,"Fee schedule rate ($17,651.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,6564.18,17651.07,There are no additional notes associated with this service or procedure.
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],17963.62,,"Case rate ($17,356.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,281.67, add-ons for qualifying new technology services are included. If operating cost exceeds $51,152.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,887.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $14,284.05 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,336.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,127.15. The transfer capital threshold is the transfer adjustment factor * $1,127.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,17356.15,44778.95,Inpatient DRG
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,086,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],8442.00,,"Per diem ($8,442). If length of stay < 2.9, first 1 days paid at a per diem of $16,884 instead. Capped at $24,481.64.",,,,0,other,8442.00,30728.81,Estimated amount calculated based on 2 day length of stay.
Dstr Nrolytc Agnt Parverteb Fct Sngl Crvcl/Thora|LEFT SIDE,CASE-64633,APC,64633,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1827.80,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1827.80,1919.19,OPPS APC
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],23344.70,,"Case rate ($23,344.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $21,852.68, add-ons for qualifying new technology services are included. If operating cost exceeds $56,723.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,325.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $19,834.60 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $19,907.73 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,565.15. The transfer capital threshold is the transfer adjustment factor * $1,565.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,23344.70,62179.32,Inpatient DRG
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],8389.90,,"Case rate ($8,106.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,676.61, add-ons for qualifying new technology services are included. If operating cost exceeds $42,547.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,210.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,710.61 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,731.66 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $450.62. The transfer capital threshold is the transfer adjustment factor * $450.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,8106.18,18245.94,Inpatient DRG
BRONCHITIS AND ASTHMA WITH CC/MCC,202,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],18251.76,,"Fee schedule rate ($18,251.76). Adds an outlier to normal pricing equal to the per diem rate ($45,948.49) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,7606.34,19110.30,There are no additional notes associated with this service or procedure.
Cysto Bladder W/Ureteral Catheterization|RIGHT SIDE,CASE-52005,APC,52005,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],2025.13,,"APC Price ($1,956.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1956.65,2054.48,OPPS APC
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],9416.02,,"Case rate ($9,097.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,598.92, add-ons for qualifying new technology services are included. If operating cost exceeds $43,469.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,283.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,629.53 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,653.97 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $523.14. The transfer capital threshold is the transfer adjustment factor * $523.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,9097.60,21455.22,Inpatient DRG
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],17255.73,,"Fee schedule rate ($17,255.73). Adds an outlier to normal pricing equal to the per diem rate ($43,191.57) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,8163.06,18067.42,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],6965.00,,,,,,0,other,6558.75,14871.83,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],33426.38,,"Case rate ($32,296.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $30,179.91, add-ons for qualifying new technology services are included. If operating cost exceeds $65,050.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,979.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $28,131.23 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $28,234.95 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,219.83. The transfer capital threshold is the transfer adjustment factor * $2,219.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,32296.02,88188.38,Inpatient DRG
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],14690.49,,"Fee schedule rate ($14,690.49). Adds an outlier to normal pricing equal to the per diem rate ($54,770.58) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.7), with a minimum of zero.",,,,0,other,7238.69,16804.22,There are no additional notes associated with this service or procedure.
Prq Impltj Neurostim Eltrd Sacral Nrve W/Imaging,CASE-64561,APC,64561,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6174.06,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5965.28,6263.54,OPPS APC
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH MCC",510,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],23519.99,,"Case rate ($22,399.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,973.84, add-ons for qualifying new technology services are included. If operating cost exceeds $55,844.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,256.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.3. The base transfer operating payment is the transfer adjustment factor * $18,958.99 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $19,028.89 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,496.05. The transfer capital threshold is the transfer adjustment factor * $1,496.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10710.00,89863.76,Inpatient DRG
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],73588.10,,"Fee schedule rate ($73,588.10). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,21585.31,73588.10,There are no additional notes associated with this service or procedure.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC",061,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],54251.46,,,,,,0,other,20616.23,62315.82,There are no additional notes associated with this service or procedure.
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],8366.06,,"Case rate ($8,083.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,655.19, add-ons for qualifying new technology services are included. If operating cost exceeds $42,526.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,208.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,689.27 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,710.24 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $448.94. The transfer capital threshold is the transfer adjustment factor * $448.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,7884.32,17835.23,Inpatient DRG
ALLERGIC REACTIONS WITH MCC,915,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],23332.51,,"Case rate ($13,332.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,538.89, add-ons for qualifying new technology services are included. If operating cost exceeds $47,409.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,592.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $10,555.02 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,593.94 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $832.90. The transfer capital threshold is the transfer adjustment factor * $832.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,13332.86,33088.84,All Other Inpatient
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],28983.97,,"Fee schedule rate ($28,983.97). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8956.76,28983.97,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],78960.67,,"Fee schedule rate ($78,960.67). Adds an outlier to normal pricing equal to the per diem rate ($149,567.78) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19.1), with a minimum of zero.",,,,0,other,30398.48,82674.88,There are no additional notes associated with this service or procedure.
CERVICAL SPINAL FUSION WITH CC,472,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],70198.84,,"Fee schedule rate ($70,198.84). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,21896.13,70198.84,There are no additional notes associated with this service or procedure.
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],6937.19,,"Case rate ($6,606.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,281.82, add-ons for qualifying new technology services are included. If operating cost exceeds $41,152.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,100.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,320.93 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,336.86 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $340.96. The transfer capital threshold is the transfer adjustment factor * $340.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5919.29,13545.65,Inpatient DRG
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,426,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],177294.98,,"Fee schedule rate ($177,294.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,76581.29,216864.15,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC,788,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],20142.33,,"Fee schedule rate ($20,142.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8438.02,20142.33,There are no additional notes associated with this service or procedure.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],11325.13,,"Case rate ($10,785.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,185.94, add-ons for qualifying new technology services are included. If operating cost exceeds $45,056.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,391.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $8,209.86 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,240.99 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $631.03. The transfer capital threshold is the transfer adjustment factor * $631.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,11053.39,36776.05,Inpatient DRG
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC,520,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],39786.42,,"Fee schedule rate ($39,786.42). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12061.74,39786.42,There are no additional notes associated with this service or procedure.
RESPIRATORY NEOPLASMS WITHOUT CC/MCC,182,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],14832.52,,,,,,0,other,6965.00,23037.13,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],6167.00,,"Per diem ($6,167). If length of stay < 4.5, first 1 days paid at a per diem of $12,334 instead. Capped at $27,753.50.",,,,0,other,6167.00,29058.99,Estimated amount calculated based on 3 day length of stay.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],59521.43,,"Fee schedule rate ($59,521.43). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,16689.78,59521.43,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],17651.07,,"Fee schedule rate ($17,651.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,6564.18,17651.07,There are no additional notes associated with this service or procedure.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],11717.72,,"Case rate ($11,717.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,036.36, add-ons for qualifying new technology services are included. If operating cost exceeds $45,907.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,474.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $9,058.01 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,091.41 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $714.77. The transfer capital threshold is the transfer adjustment factor * $714.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,11717.72,43888.01,Inpatient DRG
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],22626.77,,"Fee schedule rate ($22,626.77). Adds an outlier to normal pricing equal to the per diem rate ($36,883.74) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.5), with a minimum of zero.",,,,0,other,10098.51,24259.09,There are no additional notes associated with this service or procedure.
NORMAL NEWBORN,795,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],2074.00,,,,,,0,other,1369.79,5771.52,Estimated amount calculated based on 2 day length of stay.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],9137.26,,"Case rate ($8,702.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,243.64, add-ons for qualifying new technology services are included. If operating cost exceeds $43,114.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,242.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $6,274.90 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,298.69 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $482.30. The transfer capital threshold is the transfer adjustment factor * $482.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8906.63,28434.57,Inpatient DRG
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],18045.04,,"Fee schedule rate ($18,045.04). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,1188.00,18893.86,There are no additional notes associated with this service or procedure.
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC",758,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],8874.92,,"Case rate ($8,574.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,112.57, add-ons for qualifying new technology services are included. If operating cost exceeds $42,983.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,244.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $6,144.96 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,167.62 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $484.90. The transfer capital threshold is the transfer adjustment factor * $484.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,8574.80,19263.78,Inpatient DRG
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],7600.62,,"Case rate ($7,238.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,869.60, add-ons for qualifying new technology services are included. If operating cost exceeds $41,740.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,147.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,906.55 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,924.64 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $387.18. The transfer capital threshold is the transfer adjustment factor * $387.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7238.69,16804.22,Inpatient DRG
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],54537.29,,"Fee schedule rate ($54,537.29). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.7), with a minimum of zero.",,,,0,other,21597.50,67790.93,There are no additional notes associated with this service or procedure.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC,858,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],11377.76,,"Case rate ($11,377.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,720.10, add-ons for qualifying new technology services are included. If operating cost exceeds $45,591.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,449.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $8,742.91 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,775.15 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $689.90. The transfer capital threshold is the transfer adjustment factor * $689.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,11377.76,33794.11,Inpatient DRG
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],128358.13,,"Fee schedule rate ($128,358.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,40542.37,128358.13,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],59021.28,,"Fee schedule rate ($59,021.28). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,23851.92,63653.13,There are no additional notes associated with this service or procedure.
Arthrd Ant Interbody Decompress Cervical Belw C2,CASE-22551,APC,22551,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],12017.31,,"APC Price ($12,017.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12017.31,12618.18,OPPS APC
FRACTURES OF FEMUR WITH MCC,533,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],30847.63,,,,,,0,other,6852.00,49490.05,There are no additional notes associated with this service or procedure.
"SEPTICEMIA AND DISSEMINATED INFECTIONS,MAJOR",720,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],13651.10,,"Case rate ($13,651.10). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,13651.10,14333.66,There are no additional notes associated with this service or procedure.
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],16804.22,,"Fee schedule rate ($16,804.22). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7238.69,16804.22,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],34391.19,,"Fee schedule rate ($34,391.19). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,14337.84,52803.53,There are no additional notes associated with this service or procedure.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],14380.76,,"Case rate ($14,098.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,251.41, add-ons for qualifying new technology services are included. If operating cost exceeds $48,122.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,648.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $11,264.92 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,306.46 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $888.91. The transfer capital threshold is the transfer adjustment factor * $888.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,7332.00,35314.31,Inpatient DRG
Arthrs Kne Surg W/Meniscectomy Med/Lat W/Shvg|RIGHT SIDE,CASE-29881,APC,29881,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],18578.07,,"Case rate ($17,693.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,595.40, add-ons for qualifying new technology services are included. If operating cost exceeds $51,466.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,911.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $14,596.63 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,650.45 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,151.82. The transfer capital threshold is the transfer adjustment factor * $1,151.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,17693.40,52449.26,Inpatient DRG
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],24546.05,,"Case rate ($23,377.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $21,882.92, add-ons for qualifying new technology services are included. If operating cost exceeds $56,753.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,327.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $19,864.72 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $19,937.97 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,567.52. The transfer capital threshold is the transfer adjustment factor * $1,567.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,23377.19,96365.69,Inpatient DRG
CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC,788,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],8659.65,,"Case rate ($8,247.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,819.64, add-ons for qualifying new technology services are included. If operating cost exceeds $42,690.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,209.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,852.50 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,874.69 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $449.84. The transfer capital threshold is the transfer adjustment factor * $449.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8438.02,20142.33,Inpatient DRG
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC,964,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],12940.01,,"Case rate ($12,323.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,600.20, add-ons for qualifying new technology services are included. If operating cost exceeds $46,471.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,519.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $9,619.78 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,655.25 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $759.10. The transfer capital threshold is the transfer adjustment factor * $759.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12323.82,34154.06,Inpatient DRG
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],18312.67,,"Case rate ($17,693.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,595.40, add-ons for qualifying new technology services are included. If operating cost exceeds $51,466.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,911.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $14,596.63 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,650.45 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,151.82. The transfer capital threshold is the transfer adjustment factor * $1,151.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,17693.40,52449.26,Inpatient DRG
INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC,198,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],23505.07,,"Fee schedule rate ($23,505.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6795.12,23505.07,There are no additional notes associated with this service or procedure.
RESPIRATORY NEOPLASMS WITHOUT CC/MCC,182,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],7402.23,,"Case rate ($7,049.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,693.83, add-ons for qualifying new technology services are included. If operating cost exceeds $41,564.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,133.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,731.43 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,748.88 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $373.36. The transfer capital threshold is the transfer adjustment factor * $373.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,23037.13,Inpatient DRG
Rinsj Rptd Biceps/Triceps Tdn Dstl W/WO Tdn Grf|RIGHT SIDE,CASE-24342,APC,24342,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6791.99,7131.59,OPPS APC
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],62454.12,,"Fee schedule rate ($62,454.12). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11348.00,62454.12,There are no additional notes associated with this service or procedure.
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,068,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],8188.67,,"Case rate ($7,798.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,390.60, add-ons for qualifying new technology services are included. If operating cost exceeds $42,261.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,188.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $5,425.64 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,445.65 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $428.14. The transfer capital threshold is the transfer adjustment factor * $428.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,23184.90,Inpatient DRG
PREMATURITY WITHOUT MAJOR PROBLEMS,792,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],2074.00,,,,,,0,other,1956.00,19457.66,Estimated amount calculated based on 3 day length of stay.
"Capsulectomy/Capsulotomy Iphal Joint Each|RIGHT HAND, FOURTH DIGIT",CASE-26525,APC,26525,CPT,0360,RC,,,F8,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],13148.66,,"Case rate ($13,148.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,367.53, add-ons for qualifying new technology services are included. If operating cost exceeds $47,238.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,579.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $10,384.29 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,422.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $819.42. The transfer capital threshold is the transfer adjustment factor * $819.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,13148.66,32553.63,Inpatient DRG
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],19371.27,,"Fee schedule rate ($19,371.27). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8643.20,19462.52,There are no additional notes associated with this service or procedure.
Exc Cyst/Aberrant Breast Tissue Open 1/> Lesion|BILATERAL PROCEDURE,CASE-19120,APC,19120,CPT,0360,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3793.21,,"APC Price ($3,664.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3793.21,3848.19,OPPS APC
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,329,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],86382.02,,"Fee schedule rate ($86,382.02). Adds an outlier to normal pricing equal to the per diem rate ($147,722.18) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,33072.77,90445.33,There are no additional notes associated with this service or procedure.
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],30245.71,,"Fee schedule rate ($30,245.71). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9151.11,30245.71,There are no additional notes associated with this service or procedure.
Insj/Rplcmt Breast Implant Sep Day Mastectomy|RIGHT SIDE,CASE-19342,APC,19342,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7918.25,,"APC Price ($7,650.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,7650.49,7918.25,OPPS APC
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],23954.07,,"Fee schedule rate ($23,954.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,6167.00,29058.99,There are no additional notes associated with this service or procedure.
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC",605,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],17131.97,,"Fee schedule rate ($17,131.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8148.17,18024.13,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITH STERILIZATION WITHOUT CC/MCC,785,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],19006.00,,,,,,0,other,8431.24,20142.33,There are no additional notes associated with this service or procedure.
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],68942.79,,"Fee schedule rate ($68,942.79). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,21489.15,68942.79,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],32795.66,,"Fee schedule rate ($32,795.66). Adds an outlier to normal pricing equal to the per diem rate ($69,146.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,1188.00,34338.33,There are no additional notes associated with this service or procedure.
Secondary Closure Surg Wound/Dehsn Extsv/Complic,CASE-13160,APC,13160,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3433.11,,"APC Price ($3,317.01). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3317.01,3433.11,OPPS APC
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],40714.72,,"Fee schedule rate ($40,714.72). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,17356.15,44778.95,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],37149.27,,"Fee schedule rate ($37,149.27). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,12455.21,37149.27,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,086,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],25633.23,,,,,,0,other,8442.00,30728.81,There are no additional notes associated with this service or procedure.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],75579.22,,"Fee schedule rate ($75,579.22). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,25162.32,75579.22,There are no additional notes associated with this service or procedure.
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],6524.00,,"Per diem ($6,524). If length of stay < 2.6, first 1 days paid at a per diem of $13,048 instead. Capped at $16,962.56.",,,,0,other,6524.00,17760.46,Estimated amount calculated based on 2 day length of stay.
RADIOTHERAPY,849,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],20293.88,,"Case rate ($20,293.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $19,014.57, add-ons for qualifying new technology services are included. If operating cost exceeds $53,885.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,101.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $17,006.91 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $17,069.62 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,342.01. The transfer capital threshold is the transfer adjustment factor * $1,342.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,20293.88,81867.07,Inpatient DRG
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],6829.10,,"Case rate ($6,503.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,186.05, add-ons for qualifying new technology services are included. If operating cost exceeds $41,057.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,093.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $4,225.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,241.10 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $333.44. The transfer capital threshold is the transfer adjustment factor * $333.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6503.90,14492.93,Inpatient DRG
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,329,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],86631.74,,"Fee schedule rate ($86,631.74). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (38), with a minimum of zero.",,,,0,other,33072.77,90445.33,There are no additional notes associated with this service or procedure.
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],27553.62,,"Fee schedule rate ($27,553.62). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12305.53,30103.84,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],62084.69,,"Fee schedule rate ($62,084.69). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (35), with a minimum of zero.",,,,0,other,30398.48,82674.88,There are no additional notes associated with this service or procedure.
Fasct Palm W/WO Z-Plasty Tissue Reargmt/Skn Grft|LEFT SIDE,CASE-26121,APC,26121,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3169.86,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC,099,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],22084.20,,"Fee schedule rate ($22,084.20). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11171.21,26807.94,There are no additional notes associated with this service or procedure.
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],13872.99,,"Fee schedule rate ($13,872.99). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.8), with a minimum of zero.",,,,0,other,5068.21,14525.56,There are no additional notes associated with this service or procedure.
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],7783.37,,"Case rate ($7,412.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,031.50, add-ons for qualifying new technology services are included. If operating cost exceeds $41,902.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,159.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $5,067.86 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,086.55 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $399.90. The transfer capital threshold is the transfer adjustment factor * $399.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6148.93,15887.21,Inpatient DRG
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],52909.62,,"Fee schedule rate ($52,909.62). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,23344.70,62179.32,There are no additional notes associated with this service or procedure.
Correction Hammertoe|LEFT SIDE,CASE-28285,APC,28285,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7029.71,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6791.99,7131.59,OPPS APC
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],21278.92,,"Case rate ($20,559.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $19,261.52, add-ons for qualifying new technology services are included. If operating cost exceeds $54,132.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,121.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $17,252.96 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $17,316.57 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,361.43. The transfer capital threshold is the transfer adjustment factor * $1,361.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,20559.34,54086.17,Inpatient DRG
"UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY EXCEPT LEIOMYOMA,MINOR",513,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],5430.47,,"Case rate for a one day stay ($5,430.47). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,5430.47,5701.99,There are no additional notes associated with this service or procedure.
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],18043.23,,"Fee schedule rate ($18,043.23). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7733.72,18043.23,There are no additional notes associated with this service or procedure.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],40785.15,,"Fee schedule rate ($40,785.15). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,21585.31,73588.10,There are no additional notes associated with this service or procedure.
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],21862.29,,"Case rate ($21,862.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,473.63, add-ons for qualifying new technology services are included. If operating cost exceeds $55,344.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,216.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. The base transfer operating payment is the transfer adjustment factor * $18,460.61 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,528.68 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,456.72. The transfer capital threshold is the transfer adjustment factor * $1,456.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7086.00,57872.02,Inpatient DRG
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],27136.20,,"Fee schedule rate ($27,136.20). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11575.50,48961.48,There are no additional notes associated with this service or procedure.
HC Incis/Drain Scrotum/Testis Epididym,CASE-54700,APC,54700,CPT,0450,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1956.65,,"APC Price ($1,956.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1956.65,2054.48,OPPS APC
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],17755.26,,"Fee schedule rate ($17,755.26). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7847.50,17755.26,There are no additional notes associated with this service or procedure.
"Amputation Toe Interphalangeal Joint|RIGHT FOOT, FOURTH DIGIT",CASE-28825,APC,28825,CPT,0360,RC,,,T8,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
HC Drain/Inj Joint/Bursa W/US Large|PBB CHARGE|RIGHT SIDE,CASE-20611,APC,20611,CPT,0510,RC,,,PBB|RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],297.37,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,287.31,301.68,OPPS APC
Rinsj Rptd Biceps/Triceps Tdn Dstl W/WO Tdn Grf|RIGHT SIDE,CASE-24342,APC,24342,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],14098.78,,"Case rate ($14,098.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,251.41, add-ons for qualifying new technology services are included. If operating cost exceeds $48,122.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,648.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $11,264.92 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,306.46 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $888.91. The transfer capital threshold is the transfer adjustment factor * $888.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7332.00,35314.31,Inpatient DRG
Exc Tumor Soft Tissue Thigh/Knee Subfasc <5cm|LEFT SIDE,CASE-27328,APC,27328,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],2718.88,,"APC Price ($2,718.88). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2718.88,2854.83,OPPS APC
HC Drain/Inj Joint/Bursa W/US Large|LEFT SIDE,CASE-20611,APC,20611,CPT,0510,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],17102.17,,"Fee schedule rate ($17,102.17). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,13904.43,34749.58,There are no additional notes associated with this service or procedure.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC",494,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],37708.15,,"Fee schedule rate ($37,708.15). Adds an outlier to normal pricing equal to the per diem rate ($63,554.89) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,15533.10,39945.55,There are no additional notes associated with this service or procedure.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6871.40,,"Case rate ($6,544.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,232.10, add-ons for qualifying new technology services are included. If operating cost exceeds $41,103.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,088.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,270.96 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,287.15 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $328.28. The transfer capital threshold is the transfer adjustment factor * $328.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6683.37,14699.43,Inpatient DRG
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],18467.93,,"Case rate ($18,105.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,979.06, add-ons for qualifying new technology services are included. If operating cost exceeds $51,850.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,941.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $14,978.89 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,034.11 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,181.98. The transfer capital threshold is the transfer adjustment factor * $1,181.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,18105.81,52699.33,Inpatient DRG
Laps Abd Prtm&Omentum Dx W/WO Spec Br/Wa Spx,CASE-49320,APC,49320,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5658.76,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5658.76,5941.70,OPPS APC
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],12937.10,,"Fee schedule rate ($12,937.10). Adds an outlier to normal pricing equal to the per diem rate ($49,808.13) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.5), with a minimum of zero.",,,,0,other,5919.29,13545.65,There are no additional notes associated with this service or procedure.
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC",514,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],9097.91,,"Case rate ($8,664.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,208.71, add-ons for qualifying new technology services are included. If operating cost exceeds $43,079.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,239.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $6,240.10 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,263.76 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $479.63. The transfer capital threshold is the transfer adjustment factor * $479.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8868.04,22699.91,Inpatient DRG
UNGROUPABLE,999,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],51189.76,,"Case rate ($48,752.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $45,488.70, add-ons for qualifying new technology services are included. If operating cost exceeds $80,359.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $5,183.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 12.7. The base transfer operating payment is the transfer adjustment factor * $43,383.78 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $43,543.75 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,423.41. The transfer capital threshold is the transfer adjustment factor * $3,423.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10228.00,161307.29,Inpatient DRG
Esophagogastroduodenoscopy Submucosal Injection|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-43236,APC,43236,CPT,0360,RC,,,74,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],891.41,,"APC Price ($848.96). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,848.96,891.41,OPPS APC
"Inj Dx/Ther Agnt Paravert Facet Joint, Cerv/Thorac, 2nd Level|RIGHT SIDE",CASE-64491,APC,64491,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],827.89,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,827.89,869.28,OPPS APC
CHOLECYSTECTOMY WITH C.D.E. WITH MCC,411,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],24801.43,,"Case rate ($24,315.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $22,755.46, add-ons for qualifying new technology services are included. If operating cost exceeds $57,626.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,396.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $20,734.06 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $20,810.51 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,636.12. The transfer capital threshold is the transfer adjustment factor * $1,636.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,24315.13,88615.28,Inpatient DRG
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],51630.84,,"Fee schedule rate ($51,630.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,20559.34,54086.17,There are no additional notes associated with this service or procedure.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],16689.78,,"Case rate ($16,689.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,661.75, add-ons for qualifying new technology services are included. If operating cost exceeds $50,532.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,838.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $13,666.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,716.80 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,078.42. The transfer capital threshold is the transfer adjustment factor * $1,078.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,16689.78,59521.43,Inpatient DRG
TRAUMATIC INJURY WITH MCC,913,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],30719.04,,"Fee schedule rate ($30,719.04). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.5), with a minimum of zero.",,,,0,other,13014.58,42838.46,There are no additional notes associated with this service or procedure.
"OTHER DIGESTIVE SYSTEM AND ABDOMINAL PROCEDURES,MODERATE",229,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],3362.84,,"Case rate for a one day stay ($3,362.84). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,3362.84,3530.98,There are no additional notes associated with this service or procedure.
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],12305.53,,"Case rate ($12,305.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,583.18, add-ons for qualifying new technology services are included. If operating cost exceeds $46,454.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,517.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $9,602.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,638.24 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $757.76. The transfer capital threshold is the transfer adjustment factor * $757.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12305.53,30103.84,Inpatient DRG
"VAGINAL DELIVERY WITH O.R. PROCEDURE EXCEPT STERILIZATION AND/OR D&C,MODERATE",542,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],5003.91,,"Case rate ($5,003.91). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,5003.91,5254.11,There are no additional notes associated with this service or procedure.
NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,601,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],12359.72,,"Fee schedule rate ($12,359.72). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6042.05,12359.72,There are no additional notes associated with this service or procedure.
"Arthrodesis Interphalangeal Jt W/WO Int Fixj|LEFT HAND, FIFTH DIGIT",CASE-26860,APC,26860,CPT,0360,RC,,,F4,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7029.71,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6791.99,7131.59,OPPS APC
Dstrj Lesion Penis Simple Laser,CASE-54057,APC,54057,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],675.53,,"APC Price ($652.69). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,652.69,685.32,OPPS APC
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],36776.05,,"Fee schedule rate ($36,776.05). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11053.39,36776.05,There are no additional notes associated with this service or procedure.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],26809.29,,"Case rate ($26,809.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $25,075.72, add-ons for qualifying new technology services are included. If operating cost exceeds $59,946.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,578.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $23,045.79 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $23,130.76 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,818.54. The transfer capital threshold is the transfer adjustment factor * $1,818.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,26809.29,97015.50,Inpatient DRG
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC,817,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],42878.11,,"Fee schedule rate ($42,878.11). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.5), with a minimum of zero.",,,,0,other,17396.11,44895.04,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],53152.12,,"Fee schedule rate ($53,152.12). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,19152.11,53152.12,There are no additional notes associated with this service or procedure.
MAJOR CHEST TRAUMA WITHOUT CC/MCC,185,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],7634.75,,"Case rate ($7,271.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,899.84, add-ons for qualifying new technology services are included. If operating cost exceeds $41,770.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,149.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,936.68 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,954.88 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $389.55. The transfer capital threshold is the transfer adjustment factor * $389.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7271.19,21771.61,Inpatient DRG
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],20981.60,,"Fee schedule rate ($20,981.60). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,10003.71,23415.63,There are no additional notes associated with this service or procedure.
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],15042.50,,"Case rate ($14,747.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,854.94, add-ons for qualifying new technology services are included. If operating cost exceeds $48,725.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,696.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $11,866.24 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,909.99 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $936.36. The transfer capital threshold is the transfer adjustment factor * $936.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,14747.55,37899.49,Inpatient DRG
Arthrs Aided Ant Cruciate Ligm Rpr/Agmntj/Rcnstj|LEFT SIDE,CASE-29888,APC,29888,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12618.18,,"APC Price ($12,017.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,12017.31,12618.18,OPPS APC
Cysto Calibration Dilat Urtl Strix/Stenosis,CASE-52281,APC,52281,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],2054.48,,"APC Price ($1,956.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1956.65,2054.48,OPPS APC
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],16787.98,,"Case rate ($16,787.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,753.10, add-ons for qualifying new technology services are included. If operating cost exceeds $50,624.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,845.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $13,757.43 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,808.15 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,085.60. The transfer capital threshold is the transfer adjustment factor * $1,085.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,16787.98,62990.26,Inpatient DRG
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,066,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],20083.61,,"Fee schedule rate ($20,083.61). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6579.76,20083.61,There are no additional notes associated with this service or procedure.
"Tendon Sheath Incision|UNUSUAL NON-OVERLAPPING SERVICE|LEFT HAND, THUMB",CASE-26055,APC,26055,CPT,0360,RC,,,XU|FA,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC",011,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],150008.48,,"Fee schedule rate ($150,008.48). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (44), with a minimum of zero.",,,,0,other,38880.49,150008.48,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],16764.76,,"Fee schedule rate ($16,764.76). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8563.30,31533.97,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC,831,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],6965.00,,,,,,0,other,4941.30,23661.59,There are no additional notes associated with this service or procedure.
Nasal/Sinus Endoscopy W/Sphenoidotomy|BILATERAL PROCEDURE,CASE-31287,APC,31287,CPT,0360,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6936.25,,"APC Price ($6,605.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6605.95,6936.25,OPPS APC
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,074,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],20919.08,,"Fee schedule rate ($20,919.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8925.60,20919.08,There are no additional notes associated with this service or procedure.
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],21248.73,,"Case rate ($21,248.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $19,902.85, add-ons for qualifying new technology services are included. If operating cost exceeds $54,773.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,171.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.3. The base transfer operating payment is the transfer adjustment factor * $17,891.94 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $17,957.90 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,411.85. The transfer capital threshold is the transfer adjustment factor * $1,411.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,21248.73,56089.29,Inpatient DRG
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],37550.29,,"Fee schedule rate ($37,550.29). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,15476.23,42787.31,There are no additional notes associated with this service or procedure.
Ercp Biliary/Panc Duct Stent Exchange W/Dil&Wire,CASE-43276,APC,43276,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5881.39,,"APC Price ($5,682.51). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5682.51,5966.63,OPPS APC
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],8972.00,,"Per diem ($8,972). If length of stay < 6.1, first 1 days paid at a per diem of $17,944 instead. Capped at $54,730.85.",,,,0,other,8972.00,81524.17,Estimated amount calculated based on 4 day length of stay.
Redo Excis Lumbar Disk|SEPARATE STRUCTURE,CASE-63042,APC,63042,CPT,0360,RC,,,XS,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],26287.03,,"APC Price ($25,398.09). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,25398.09,26668.00,OPPS APC
Thyroidectomy Total/Complete,CASE-60240,APC,60240,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5658.76,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5658.76,5941.70,OPPS APC
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5949.32,,"Case rate ($5,666.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,413.52, add-ons for qualifying new technology services are included. If operating cost exceeds $40,284.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,025.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $3,455.47 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,468.57 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $265.60. The transfer capital threshold is the transfer adjustment factor * $265.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5778.62,11681.49,Inpatient DRG
Cysto W/Removal of Lesions Small,CASE-52224,APC,52224,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3299.47,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3299.47,3464.44,OPPS APC
PERIPHERAL VASCULAR DISORDERS WITH CC,300,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],9632.85,,"Case rate ($9,174.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,670.11, add-ons for qualifying new technology services are included. If operating cost exceeds $43,541.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,288.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,700.45 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,725.16 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $528.73. The transfer capital threshold is the transfer adjustment factor * $528.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9174.14,21005.20,Inpatient DRG
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],34570.85,,"Fee schedule rate ($34,570.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,6965.00,36140.75,There are no additional notes associated with this service or procedure.
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],36855.62,,"Fee schedule rate ($36,855.62). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,15821.59,40320.14,There are no additional notes associated with this service or procedure.
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],10036.32,,"Case rate ($9,696.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,156.46, add-ons for qualifying new technology services are included. If operating cost exceeds $44,027.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,326.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $7,185.02 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,211.51 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $566.97. The transfer capital threshold is the transfer adjustment factor * $566.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,9696.93,35061.53,Inpatient DRG
"OTHER DISORDERS OF NERVOUS SYSTEM,MAJOR",058,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],1244.31,,"Case rate for a one day stay ($1,185.06). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,1185.06,1244.31,There are no additional notes associated with this service or procedure.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],39820.52,,"Fee schedule rate ($39,820.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,15273.74,39820.52,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC,832,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],9034.88,,"Fee schedule rate ($9,034.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4803.31,14198.92,There are no additional notes associated with this service or procedure.
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],14285.36,,"Case rate ($8,163.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,729.53, add-ons for qualifying new technology services are included. If operating cost exceeds $42,600.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,214.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,763.33 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,784.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $454.78. The transfer capital threshold is the transfer adjustment factor * $454.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,8163.06,18067.42,All Other Inpatient
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],6965.00,,,,,,0,other,6965.00,21195.68,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITHOUT STERILIZATION WITH CC,787,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],23722.94,,"Fee schedule rate ($23,722.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9508.01,23722.94,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],34391.19,,"Fee schedule rate ($34,391.19). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,14337.84,52803.53,There are no additional notes associated with this service or procedure.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],59521.43,,"Fee schedule rate ($59,521.43). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,16689.78,59521.43,There are no additional notes associated with this service or procedure.
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|LEFT HAND, THIRD DIGIT",CASE-26160,APC,26160,CPT,0360,RC,,,F2,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1557.80,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1505.12,1580.37,OPPS APC
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC,939,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],68190.40,,"Fee schedule rate ($68,190.40). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16.5), with a minimum of zero.",,,,0,other,26517.40,97674.79,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITHOUT STERILIZATION WITH CC,787,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],23722.94,,"Fee schedule rate ($23,722.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9508.01,23722.94,There are no additional notes associated with this service or procedure.
HC Drain/Inj Joint/Bursa W/US Large|RIGHT SIDE,CASE-20611,APC,20611,CPT,0510,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6214.05,,"Case rate ($6,214.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,916.41, add-ons for qualifying new technology services are included. If operating cost exceeds $40,787.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,072.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $3,956.88 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,971.47 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $312.24. The transfer capital threshold is the transfer adjustment factor * $312.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6214.05,15318.94,Inpatient DRG
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],32263.82,,"Fee schedule rate ($32,263.82). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13571.25,33781.47,There are no additional notes associated with this service or procedure.
SKIN ULCERS WITH MCC,592,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],15645.24,,"Case rate ($15,116.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $14,168.54, add-ons for qualifying new technology services are included. If operating cost exceeds $53,556.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $3,795.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.8. The base transfer operating payment is the transfer adjustment factor * $12,752.10 + an uncompensated DSH payment of $1,359.91. The transfer operating threshold is the transfer adjustment factor * $12,808.63 + an uncompensated DSH payment of $1,359.91. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,004.16. The transfer capital threshold is the transfer adjustment factor * $1,004.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,15116.17,38644.05,Inpatient DRG
GASTROINTESTINAL HEMORRHAGE WITH CC,378,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],18430.30,,"Fee schedule rate ($18,430.30). Adds an outlier to normal pricing equal to the per diem rate ($75,427.18) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,8586.33,20845.19,There are no additional notes associated with this service or procedure.
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,068,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],17008.80,,,,,,0,other,6965.00,23184.90,There are no additional notes associated with this service or procedure.
CERVICAL SPINAL FUSION WITHOUT CC/MCC,473,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],62077.11,,"Fee schedule rate ($62,077.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,18477.61,62077.11,There are no additional notes associated with this service or procedure.
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],28093.27,,"Case rate ($28,093.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $26,270.18, add-ons for qualifying new technology services are included. If operating cost exceeds $61,141.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,672.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $24,235.87 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $24,325.23 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,912.45. The transfer capital threshold is the transfer adjustment factor * $1,912.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,10078.00,81454.07,Inpatient DRG
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,095,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],19411.47,,"Case rate ($19,411.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $18,193.69, add-ons for qualifying new technology services are included. If operating cost exceeds $53,064.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,037.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.6. The base transfer operating payment is the transfer adjustment factor * $16,189.05 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $16,248.74 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,277.48. The transfer capital threshold is the transfer adjustment factor * $1,277.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,19411.47,50750.92,Inpatient DRG
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],7366.00,,"Case rate ($7,366). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,988.03, add-ons for qualifying new technology services are included. If operating cost exceeds $41,859.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,156.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,024.55 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,043.08 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $396.49. The transfer capital threshold is the transfer adjustment factor * $396.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,21195.68,Inpatient DRG
Surgical Arthroscopy Shoulder Repair Slap Lesion,CASE-29807,APC,29807,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7029.71,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6791.99,7131.59,OPPS APC
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC,434,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6770.05,,"Case rate ($6,770.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,433.64, add-ons for qualifying new technology services are included. If operating cost exceeds $41,304.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,112.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,472.20 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,488.69 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $352.90. The transfer capital threshold is the transfer adjustment factor * $352.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6770.05,14019.86,Inpatient DRG
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],86437.13,,,,,,0,other,10862.00,86437.13,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],6787.66,,"Case rate ($6,787.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,450.02, add-ons for qualifying new technology services are included. If operating cost exceeds $41,321.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,114.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,488.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,505.07 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $354.19. The transfer capital threshold is the transfer adjustment factor * $354.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6164.03,14071.02,Inpatient DRG
"NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY",789,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],14857.05,,"Case rate ($14,149.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,298.65, add-ons for qualifying new technology services are included. If operating cost exceeds $48,169.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,652.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $11,312.00 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,353.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $892.63. The transfer capital threshold is the transfer adjustment factor * $892.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,3054.00,14857.05,Inpatient DRG
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC,058,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],33637.83,,,,,,0,other,13521.80,40853.02,There are no additional notes associated with this service or procedure.
"Tendon Sheath Incision|RIGHT HAND, THIRD DIGIT",CASE-26055,APC,26055,CPT,0360,RC,,,F7,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1580.37,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1505.12,1580.37,OPPS APC
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],54764.34,,"Fee schedule rate ($54,764.34). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,18178.96,54764.34,There are no additional notes associated with this service or procedure.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,352,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],21946.47,,"Fee schedule rate ($21,946.47). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,9853.37,26528.70,There are no additional notes associated with this service or procedure.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],24259.09,,"Fee schedule rate ($24,259.09). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10098.51,24259.09,There are no additional notes associated with this service or procedure.
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC,964,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],12570.30,,"Case rate ($12,323.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,600.20, add-ons for qualifying new technology services are included. If operating cost exceeds $46,471.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,519.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $9,619.78 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,655.25 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $759.10. The transfer capital threshold is the transfer adjustment factor * $759.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,12323.82,34154.06,Inpatient DRG
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],97015.50,,"Fee schedule rate ($97,015.50). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,26809.29,97015.50,There are no additional notes associated with this service or procedure.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC,192,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],12753.78,,"Fee schedule rate ($12,753.78). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6292.63,12753.78,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],18585.05,,"Fee schedule rate ($18,585.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8859.23,20090.22,There are no additional notes associated with this service or procedure.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],21587.31,,"Case rate ($20,559.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $19,261.52, add-ons for qualifying new technology services are included. If operating cost exceeds $54,132.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,121.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $17,252.96 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $17,316.57 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,361.43. The transfer capital threshold is the transfer adjustment factor * $1,361.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,20559.34,54086.17,Inpatient DRG
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC,099,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],22084.20,,"Fee schedule rate ($22,084.20). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11171.21,26807.94,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,373,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],13780.60,,"Fee schedule rate ($13,780.60). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6870.94,14313.05,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],13891.57,,"Case rate ($13,891.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,058.63, add-ons for qualifying new technology services are included. If operating cost exceeds $47,929.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,633.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,072.85 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,113.68 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $873.76. The transfer capital threshold is the transfer adjustment factor * $873.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,13891.57,34712.20,Inpatient DRG
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],48538.56,,"Fee schedule rate ($48,538.56). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,19435.86,50821.76,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],49717.39,,"Fee schedule rate ($49,717.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,14908.05,49717.39,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,085,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],57443.16,,"Fee schedule rate ($57,443.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,9282.00,57443.16,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC,831,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],9294.42,,"Fee schedule rate ($9,294.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,4941.30,23661.59,There are no additional notes associated with this service or procedure.
"LIMB REATTACHMENT, HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA",956,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],148259.86,,"Fee schedule rate ($148,259.86). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,27428.25,148259.86,There are no additional notes associated with this service or procedure.
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],21854.96,,"Fee schedule rate ($21,854.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10638.94,25261.33,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],42768.36,,"Fee schedule rate ($42,768.36). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,14295.18,42768.36,There are no additional notes associated with this service or procedure.
BRONCHITIS AND ASTHMA WITH CC/MCC,202,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],18251.76,,"Fee schedule rate ($18,251.76). Adds an outlier to normal pricing equal to the per diem rate ($45,948.49) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,7606.34,19110.30,There are no additional notes associated with this service or procedure.
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],11065.78,,"Fee schedule rate ($11,065.78). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5883.03,17111.12,There are no additional notes associated with this service or procedure.
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],6937.92,,"Case rate ($6,801.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,463.25, add-ons for qualifying new technology services are included. If operating cost exceeds $41,334.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,115.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,501.70 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,518.30 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $355.23. The transfer capital threshold is the transfer adjustment factor * $355.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6801.88,22557.82,Inpatient DRG
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],84226.47,,"Fee schedule rate ($84,226.47). Adds an outlier to normal pricing equal to the per diem rate ($75,906.87) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14.7), with a minimum of zero.",,,,0,other,32296.02,88188.38,There are no additional notes associated with this service or procedure.
Laparoscopy Surg W/Bx Single/Multiple,CASE-49321,APC,49321,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5658.76,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5658.76,5941.70,OPPS APC
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],19087.91,,"Case rate ($18,178.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,047.10, add-ons for qualifying new technology services are included. If operating cost exceeds $51,918.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,947.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $15,046.67 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,102.15 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,187.33. The transfer capital threshold is the transfer adjustment factor * $1,187.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,18178.96,54764.34,Inpatient DRG
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],21354.82,,"Fee schedule rate ($21,354.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6834.39,21354.82,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,167,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],43522.37,,"Fee schedule rate ($43,522.37). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,14157.71,43522.37,There are no additional notes associated with this service or procedure.
NORMAL NEWBORN,795,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],2074.00,,,,,,0,other,1369.79,5771.52,Estimated amount calculated based on 2 day length of stay.
Conization Cervix W/WO D&C Rpr Eltrd Exc,CASE-57522,APC,57522,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3030.03,,"APC Price ($3,030.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3030.03,3181.53,OPPS APC
HC Biopsy/Exc Lymph Node Needle|LEFT SIDE,CASE-38505,APC,38505,CPT,0361,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1545.93,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1545.93,1600.04,OPPS APC
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6010.23,,"Case rate ($6,010.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,726.79, add-ons for qualifying new technology services are included. If operating cost exceeds $40,597.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,057.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,767.95 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,781.84 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $297.33. The transfer capital threshold is the transfer adjustment factor * $297.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6010.23,12246.05,Inpatient DRG
Arthrs Aided Ant Cruciate Ligm Rpr/Agmntj/Rcnstj|SEPARATE STRUCTURE|LEFT SIDE,CASE-29888,APC,29888,CPT,0360,RC,,,XS|LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
Biopsy Floor Mouth,CASE-41108,APC,41108,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1545.93,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1545.93,1623.23,OPPS APC
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],19877.10,,"Fee schedule rate ($19,877.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8009.34,19877.10,There are no additional notes associated with this service or procedure.
NERVOUS SYSTEM NEOPLASMS WITH MCC,054,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],12285.22,,"Case rate ($12,285.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,564.29, add-ons for qualifying new technology services are included. If operating cost exceeds $46,435.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,516.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $9,584.00 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,619.34 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $756.27. The transfer capital threshold is the transfer adjustment factor * $756.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,30044.81,Inpatient DRG
"Open Tx Distal Phalangeal Fracture Each|RIGHT HAND, SECOND DIGIT",CASE-26765,APC,26765,CPT,0360,RC,,,F6,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC,099,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],11729.77,,"Case rate ($11,171.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,527.95, add-ons for qualifying new technology services are included. If operating cost exceeds $45,398.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,434.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,551.47 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,583.00 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $674.80. The transfer capital threshold is the transfer adjustment factor * $674.80. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,11171.21,26807.94,Inpatient DRG
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],7993.75,,"Case rate ($7,993.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,572.03, add-ons for qualifying new technology services are included. If operating cost exceeds $42,443.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,202.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $5,606.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,627.08 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $442.40. The transfer capital threshold is the transfer adjustment factor * $442.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,5415.00,17575.50,Inpatient DRG
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,098,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],6965.00,,,,,,0,other,6965.00,45156.75,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],96365.69,,"Fee schedule rate ($96,365.69). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,23377.19,96365.69,There are no additional notes associated with this service or procedure.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],9351.96,,"Case rate ($8,906.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,421.26, add-ons for qualifying new technology services are included. If operating cost exceeds $43,292.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,269.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $6,452.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,476.31 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $509.17. The transfer capital threshold is the transfer adjustment factor * $509.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8906.63,28434.57,Inpatient DRG
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC,858,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],26176.77,,"Fee schedule rate ($26,176.77). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11377.76,33794.11,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,447,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],125567.31,,"Fee schedule rate ($125,567.31). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15.7), with a minimum of zero.",,,,0,other,47193.21,156646.82,There are no additional notes associated with this service or procedure.
Cysto Bladder W/Ureteral Catheterization,CASE-52005,APC,52005,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],2025.13,,"APC Price ($1,956.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1956.65,2054.48,OPPS APC
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],6965.00,,,,,,0,other,6965.00,21089.59,There are no additional notes associated with this service or procedure.
"MAJOR BLADDER PROCEDURES,MAJOR",441,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],35284.99,,"Case rate ($35,284.99). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,35284.99,37049.24,There are no additional notes associated with this service or procedure.
Unlisted Px Female Genital System Nonobstetrical,CASE-58999,APC,58999,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],195.86,,"APC Price ($189.24). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,189.24,198.70,OPPS APC
PSYCHOSES,885,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],2070.00,,,,,,0,other,2070.00,27484.83,Estimated amount calculated based on 3 day length of stay.
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],20567.06,,"Fee schedule rate ($20,567.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,9356.31,25026.36,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],38378.80,,"Fee schedule rate ($38,378.80). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,14370.36,38378.80,There are no additional notes associated with this service or procedure.
BRONCHITIS AND ASTHMA WITH CC/MCC,202,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],18251.76,,"Fee schedule rate ($18,251.76). Adds an outlier to normal pricing equal to the per diem rate ($45,948.49) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,7606.34,19110.30,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],19371.27,,"Fee schedule rate ($19,371.27). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7641.61,19371.27,There are no additional notes associated with this service or procedure.
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],28751.41,,"Fee schedule rate ($28,751.41). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12305.53,30103.84,There are no additional notes associated with this service or procedure.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],16669.71,,"Fee schedule rate ($16,669.71). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8767.81,19824.58,There are no additional notes associated with this service or procedure.
Cysto W/Ureteroscopy W/Rmvl/Manj Stones,CASE-52352,APC,52352,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3414.95,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3299.47,3464.44,OPPS APC
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],9088.95,,"Case rate ($8,656.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,200.75, add-ons for qualifying new technology services are included. If operating cost exceeds $43,071.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,238.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $6,232.17 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,255.80 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $479.02. The transfer capital threshold is the transfer adjustment factor * $479.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8859.23,20090.22,Inpatient DRG
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],10517.39,,"Case rate ($10,311.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,727.87, add-ons for qualifying new technology services are included. If operating cost exceeds $44,598.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,371.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $7,754.32 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,782.91 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $611.89. The transfer capital threshold is the transfer adjustment factor * $611.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,10311.17,24308.97,Inpatient DRG
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],17365.00,,"Fee schedule rate ($17,365.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5683.00,19635.68,There are no additional notes associated with this service or procedure.
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],16787.93,,"Fee schedule rate ($16,787.93). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,15453.88,39251.68,There are no additional notes associated with this service or procedure.
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],15809.93,,"Case rate ($15,057.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,167.35, add-ons for qualifying new technology services are included. If operating cost exceeds $49,038.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,695.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $12,176.23 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,222.40 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $935.89. The transfer capital threshold is the transfer adjustment factor * $935.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,15453.88,39251.68,Inpatient DRG
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC,027,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],47412.86,,"Fee schedule rate ($47,412.86). Adds an outlier to normal pricing equal to the per diem rate ($103,062) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,19030.20,56363.30,There are no additional notes associated with this service or procedure.
Arthrp Intercarpal/Carp/Mtcrpl Jt Suspension|LEFT SIDE,CASE-25448,APC,25448,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC,805,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],20902.03,,"Fee schedule rate ($20,902.03). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9253.36,21235.42,There are no additional notes associated with this service or procedure.
SINGLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL,402,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],124455.45,,"Fee schedule rate ($124,455.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,29172.05,124455.45,There are no additional notes associated with this service or procedure.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],46957.19,,,,,,0,other,18105.81,52699.33,There are no additional notes associated with this service or procedure.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],38248.08,,"Fee schedule rate ($38,248.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11593.79,38248.08,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL HEMORRHAGE WITH MCC,377,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],15040.50,,"Case rate ($14,324.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,461.19, add-ons for qualifying new technology services are included. If operating cost exceeds $48,332.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,665.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $11,473.94 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,516.24 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $905.41. The transfer capital threshold is the transfer adjustment factor * $905.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7634.00,35969.56,Inpatient DRG
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],33188.44,,"Fee schedule rate ($33,188.44). Adds an outlier to normal pricing equal to the per diem rate ($84,167.29) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.5), with a minimum of zero.",,,,0,other,13904.43,34749.58,There are no additional notes associated with this service or procedure.
Nsl/Sinus Ndsc Max Antrost W/Rmvl Tiss Max Sinus|LEFT SIDE,CASE-31267,APC,31267,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6936.25,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6605.95,6936.25,OPPS APC
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],25013.10,,"Fee schedule rate ($25,013.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10846.16,25863.45,There are no additional notes associated with this service or procedure.
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],26204.74,,"Fee schedule rate ($26,204.74). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10120.20,26204.74,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],81353.66,,"Fee schedule rate ($81,353.66). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,27256.92,81353.66,There are no additional notes associated with this service or procedure.
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],44778.95,,,,,,0,other,17356.15,44778.95,There are no additional notes associated with this service or procedure.
MAJOR BLADDER PROCEDURES WITH MCC,653,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],125343.98,,"Fee schedule rate ($125,343.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,10280.00,125343.98,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],28821.04,,"Fee schedule rate ($28,821.04). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,10347.06,28821.04,There are no additional notes associated with this service or procedure.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,479,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],50518.76,,"Fee schedule rate ($50,518.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,10586.00,50518.76,There are no additional notes associated with this service or procedure.
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],7086.00,,"Per diem ($7,086). If length of stay < 7.8, first 1 days paid at a per diem of $14,172 instead. Capped at $55,272.09.",,,,0,other,7086.00,57872.02,Estimated amount calculated based on 5 day length of stay.
SEIZURES WITH MCC,100,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],15588.23,,"Case rate ($15,061.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,146.62, add-ons for qualifying new technology services are included. If operating cost exceeds $49,017.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,719.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $12,156.85 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,201.67 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $959.30. The transfer capital threshold is the transfer adjustment factor * $959.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,15061.09,38110.41,Inpatient DRG
VENTRICULAR SHUNT PROCEDURES WITH MCC,031,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],62406.76,,"Fee schedule rate ($62,406.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,32287.20,88162.80,There are no additional notes associated with this service or procedure.
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],18217.52,,"Fee schedule rate ($18,217.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7414.07,18217.52,There are no additional notes associated with this service or procedure.
CHOLECYSTECTOMY WITH C.D.E. WITH MCC,411,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],62078.92,,"Fee schedule rate ($62,078.92). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15), with a minimum of zero.",,,,0,other,24315.13,88615.28,There are no additional notes associated with this service or procedure.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITHOUT CC/MCC,816,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6442.77,,"Case rate ($6,224.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,926.50, add-ons for qualifying new technology services are included. If operating cost exceeds $40,797.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,073.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $3,966.92 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,981.55 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $313.03. The transfer capital threshold is the transfer adjustment factor * $313.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6224.90,14733.53,Inpatient DRG
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],42586.49,,"Fee schedule rate ($42,586.49). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,13341.67,42586.49,There are no additional notes associated with this service or procedure.
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC,807,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],10071.17,,"Fee schedule rate ($10,071.17). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5354.25,13266.23,There are no additional notes associated with this service or procedure.
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],35474.53,,"Fee schedule rate ($35,474.53). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,16428.39,42083.20,There are no additional notes associated with this service or procedure.
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],18245.94,,"Fee schedule rate ($18,245.94). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8106.18,18245.94,There are no additional notes associated with this service or procedure.
Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE,CASE-62323,APC,62323,CPT,0360,RC,,,XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],683.85,,"APC Price ($660.72). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,660.72,693.76,OPPS APC
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],19371.27,,"Fee schedule rate ($19,371.27). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7641.61,19371.27,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],7641.61,,"Case rate ($7,641.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,244.44, add-ons for qualifying new technology services are included. If operating cost exceeds $42,115.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,176.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,280.02 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,299.49 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $416.65. The transfer capital threshold is the transfer adjustment factor * $416.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7641.61,19371.27,Inpatient DRG
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC,939,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],97674.79,,"Fee schedule rate ($97,674.79). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,26517.40,97674.79,There are no additional notes associated with this service or procedure.
Lithotripsy Xtrcorp Shock Wave|BILATERAL PROCEDURE,CASE-50590,APC,50590,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3299.47,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3299.47,3464.44,OPPS APC
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITHOUT MCC,430,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],133156.90,,"Fee schedule rate ($133,156.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,41000.16,133156.90,There are no additional notes associated with this service or procedure.
RESPIRATORY NEOPLASMS WITH CC,181,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],17609.39,,"Fee schedule rate ($17,609.39). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9197.84,21074.07,There are no additional notes associated with this service or procedure.
UNGROUPABLE,999,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],10228.00,,"Per diem ($10,228). If length of stay < 12.7, first 1 days paid at a per diem of $20,456 instead. Capped at $129,893.46.",,,,0,other,10228.00,161307.29,Estimated amount calculated based on 9 day length of stay.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],17365.00,,"Fee schedule rate ($17,365.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5683.00,19635.68,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],22195.49,,"Case rate ($21,138.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $19,836.17, add-ons for qualifying new technology services are included. If operating cost exceeds $54,707.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,129.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.2. The base transfer operating payment is the transfer adjustment factor * $17,823.64 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $17,891.22 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,369.97. The transfer capital threshold is the transfer adjustment factor * $1,369.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,21719.40,85305.59,Inpatient DRG
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC,833,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],10289.10,,,,,,0,other,3041.73,10289.10,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],32293.66,,"Fee schedule rate ($32,293.66). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,32293.66,There are no additional notes associated with this service or procedure.
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],13047.45,,"Case rate ($12,606.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,862.91, add-ons for qualifying new technology services are included. If operating cost exceeds $46,733.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,539.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $9,881.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,917.95 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $779.75. The transfer capital threshold is the transfer adjustment factor * $779.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,12606.23,36868.88,Inpatient DRG
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],7734.30,,"Case rate ($7,366). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,988.03, add-ons for qualifying new technology services are included. If operating cost exceeds $41,859.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,156.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,024.55 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,043.08 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $396.49. The transfer capital threshold is the transfer adjustment factor * $396.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,21195.68,Inpatient DRG
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],11194.25,,"Case rate ($11,194.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,549.37, add-ons for qualifying new technology services are included. If operating cost exceeds $45,420.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,436.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $8,572.81 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,604.42 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $676.48. The transfer capital threshold is the transfer adjustment factor * $676.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,11194.25,36094.03,Inpatient DRG
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],39820.52,,"Fee schedule rate ($39,820.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,15273.74,39820.52,There are no additional notes associated with this service or procedure.
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],16265.67,,"Case rate ($15,491.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,546.67, add-ons for qualifying new technology services are included. If operating cost exceeds $49,417.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,750.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $12,555.42 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,601.72 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $990.75. The transfer capital threshold is the transfer adjustment factor * $990.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,15491.11,54180.83,Inpatient DRG
Hrv Skin for Skin Cell Ssp Agrft 1st 25 Sq Cm/<,CASE-15011,APC,15011,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1931.28,,"APC Price ($1,931.28). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1931.28,1998.87,OPPS APC
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],47114.44,,"Case rate ($45,521.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $42,483.01, add-ons for qualifying new technology services are included. If operating cost exceeds $77,354.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,947.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 12.5. The base transfer operating payment is the transfer adjustment factor * $40,389.14 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $40,538.06 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,187.10. The transfer capital threshold is the transfer adjustment factor * $3,187.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,45521.20,142438.06,Inpatient DRG
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,988,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],32341.12,,,,,,0,other,13075.52,42425.46,There are no additional notes associated with this service or procedure.
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC,797,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],20928.55,,"Fee schedule rate ($20,928.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8719.72,20928.55,There are no additional notes associated with this service or procedure.
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],22311.17,,"Case rate ($21,248.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $19,902.85, add-ons for qualifying new technology services are included. If operating cost exceeds $54,773.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,171.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.3. The base transfer operating payment is the transfer adjustment factor * $17,891.94 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $17,957.90 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,411.85. The transfer capital threshold is the transfer adjustment factor * $1,411.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,21248.73,56089.29,Inpatient DRG
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],9888.00,,"Per diem ($9,888). If length of stay < 3.1, first 1 days paid at a per diem of $19,776 instead. Capped at $30,651.38.",,,,0,other,9888.00,43399.23,Estimated amount calculated based on 1 day length of stay.
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],8354.35,,"Case rate ($7,956.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,537.38, add-ons for qualifying new technology services are included. If operating cost exceeds $42,408.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,199.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,571.89 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,592.43 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $439.68. The transfer capital threshold is the transfer adjustment factor * $439.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,17467.27,Inpatient DRG
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],34406.22,,"Fee schedule rate ($34,406.22). Adds an outlier to normal pricing equal to the per diem rate ($49,808.13) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,14343.25,36024.65,There are no additional notes associated with this service or procedure.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC",061,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],62315.82,,"Fee schedule rate ($62,315.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,20616.23,62315.82,There are no additional notes associated with this service or procedure.
Autograft Spine Surgery Local From Same Incision,CASE-20936,APC,20936,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],16986.50,,"APC Price ($16,412.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,16412.07,17232.68,OPPS APC
INFLAMMATORY BOWEL DISEASE WITH CC,386,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],19879.00,,"Fee schedule rate ($19,879.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8556.53,19879.00,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL HEMORRHAGE WITH MCC,377,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],14825.64,,"Case rate ($14,324.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,461.19, add-ons for qualifying new technology services are included. If operating cost exceeds $48,332.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,665.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $11,473.94 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,516.24 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $905.41. The transfer capital threshold is the transfer adjustment factor * $905.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,7634.00,35969.56,Inpatient DRG
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,447,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],47193.21,,"Case rate ($47,193.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $44,038.45, add-ons for qualifying new technology services are included. If operating cost exceeds $78,909.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $5,069.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $41,938.87 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $42,093.51 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,309.39. The transfer capital threshold is the transfer adjustment factor * $3,309.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,47193.21,156646.82,Inpatient DRG
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],17703.27,,"Case rate ($17,356.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,281.67, add-ons for qualifying new technology services are included. If operating cost exceeds $51,152.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,887.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $14,284.05 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,336.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,127.15. The transfer capital threshold is the transfer adjustment factor * $1,127.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,17356.15,44778.95,Inpatient DRG
HC Inj Trigger Pt 1-2 Musc Grps|PBB CHARGE,CASE-20552,APC,20552,CPT,0510,RC,,,PBB,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
NERVOUS SYSTEM NEOPLASMS WITH MCC,054,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],30044.81,,,,,,0,other,6965.00,30044.81,There are no additional notes associated with this service or procedure.
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,450,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],100159.17,,"Fee schedule rate ($100,159.17). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15), with a minimum of zero.",,,,0,other,38037.38,146009.19,There are no additional notes associated with this service or procedure.
Excision Olecranon Bursa|LEFT SIDE,CASE-24105,APC,24105,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6791.99,7131.59,OPPS APC
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],9942.69,,"Case rate ($9,469.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,958.67, add-ons for qualifying new technology services are included. If operating cost exceeds $43,829.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,297.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $6,987.23 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,013.72 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $537.06. The transfer capital threshold is the transfer adjustment factor * $537.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9696.93,35061.53,Inpatient DRG
VAGINAL DELIVERY WITH O.R. PROCEDURES EXCEPT STERILIZATION AND/OR D&C,768,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],12088.81,,"Fee schedule rate ($12,088.81). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6426.91,13416.00,There are no additional notes associated with this service or procedure.
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],11165.00,,"Per diem ($11,165). If length of stay < 3.5, first 1 days paid at a per diem of $22,330 instead. Capped at $39,078.16.",,,,0,other,11165.00,61234.06,Estimated amount calculated based on 3 day length of stay.
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITHOUT CC/MCC",630,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],11828.78,,"Case rate ($11,828.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,139.67, add-ons for qualifying new technology services are included. If operating cost exceeds $46,010.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,482.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $9,160.95 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,194.72 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $722.89. The transfer capital threshold is the transfer adjustment factor * $722.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,11828.78,42541.02,Inpatient DRG
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",062,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],44304.80,,"Fee schedule rate ($44,304.80). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,13844.84,44304.80,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITHOUT CC/MCC,428,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],105654.25,,"Fee schedule rate ($105,654.25). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,40017.53,118904.57,There are no additional notes associated with this service or procedure.
Esophagogastroduodenoscopy US Scope W/Adj Strxrs,CASE-43237,APC,43237,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1796.14,,"APC Price ($1,796.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1796.14,1885.95,OPPS APC
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],43399.23,,"Fee schedule rate ($43,399.23). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9888.00,43399.23,There are no additional notes associated with this service or procedure.
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],24126.45,,"Fee schedule rate ($24,126.45). Adds an outlier to normal pricing equal to the per diem rate ($62,306.11) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10638.94,25261.33,There are no additional notes associated with this service or procedure.
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7073.59,,"Case rate ($6,834.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,493.49, add-ons for qualifying new technology services are included. If operating cost exceeds $41,364.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,117.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $4,531.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,548.54 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $357.61. The transfer capital threshold is the transfer adjustment factor * $357.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6834.39,21354.82,Inpatient DRG
Strtctc Cptr Asstd Px Extradural Cranial,CASE-61782,APC,61782,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5735.04,,"APC Price ($5,541.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5541.10,5818.16,OPPS APC
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],18217.52,,"Fee schedule rate ($18,217.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7414.07,18217.52,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],47279.40,,"Fee schedule rate ($47,279.40). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,21719.40,85305.59,There are no additional notes associated with this service or procedure.
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC,519,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],50780.20,,"Fee schedule rate ($50,780.20). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,15490.44,50780.20,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],6965.00,,,,,,0,other,6965.00,41030.48,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC,817,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],42878.11,,"Fee schedule rate ($42,878.11). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.5), with a minimum of zero.",,,,0,other,17396.11,44895.04,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],29241.62,,"Fee schedule rate ($29,241.62). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,12984.79,32077.45,There are no additional notes associated with this service or procedure.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],38246.19,,"Fee schedule rate ($38,246.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,19435.86,50821.76,There are no additional notes associated with this service or procedure.
Unlisted Procedure Arthroscopy,CASE-29999,APC,29999,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
FRACTURES OF FEMUR WITH MCC,533,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],49490.05,,"Fee schedule rate ($49,490.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,6852.00,49490.05,There are no additional notes associated with this service or procedure.
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],15994.77,,"Case rate ($15,453.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,512.02, add-ons for qualifying new technology services are included. If operating cost exceeds $49,383.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,747.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $12,520.90 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,567.07 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $988.02. The transfer capital threshold is the transfer adjustment factor * $988.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,15453.88,39251.68,Inpatient DRG
HC Inj Lympho for Sentinal Node|RIGHT SIDE,CASE-38792,APC,38792,CPT,0361,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6215.36,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6215.36,6526.12,OPPS APC
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,064,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],15563.58,,"Case rate ($15,563.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,614.08, add-ons for qualifying new technology services are included. If operating cost exceeds $49,485.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,756.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $12,622.59 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,669.13 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $996.05. The transfer capital threshold is the transfer adjustment factor * $996.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,15563.58,41838.16,Inpatient DRG
Esophagoscopy Flexible Transoral With Biopsy,CASE-43202,APC,43202,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1859.01,,"APC Price ($1,796.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1796.14,1885.95,OPPS APC
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,699,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],9259.53,,"Case rate ($8,818.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,339.37, add-ons for qualifying new technology services are included. If operating cost exceeds $43,210.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,262.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $6,370.92 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,394.41 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $502.73. The transfer capital threshold is the transfer adjustment factor * $502.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5961.00,19972.16,Inpatient DRG
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],9977.99,,"Case rate ($9,977.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,417.91, add-ons for qualifying new technology services are included. If operating cost exceeds $44,288.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,347.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $7,445.51 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,472.96 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $587.52. The transfer capital threshold is the transfer adjustment factor * $587.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9977.99,26949.28,Inpatient DRG
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],20401.88,,"Fee schedule rate ($20,401.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,20401.88,There are no additional notes associated with this service or procedure.
"SEPTICEMIA AND DISSEMINATED INFECTIONS,EXTREME",720,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],26098.98,,"The inlier payment is calculated as the lesser of the standard DRG payment $24,856.17 and the transfer payment, which is a per diem of $2,401.56. If cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,24856.17,26098.98,Estimated amount calculated based on 2 day length of stay.
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC",514,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],22699.91,,"Fee schedule rate ($22,699.91). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8868.04,22699.91,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],33152.73,,"Fee schedule rate ($33,152.73). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13891.57,34712.20,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],20617.56,,,,,,0,other,9040.72,26966.33,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],11677.97,,"Fee schedule rate ($11,677.97). Adds an outlier to normal pricing equal to the per diem rate ($67,650.85) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.7), with a minimum of zero.",,,,0,other,6153.12,13947.32,There are no additional notes associated with this service or procedure.
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],23385.72,,"Fee schedule rate ($23,385.72). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,23385.72,There are no additional notes associated with this service or procedure.
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],17902.13,,,,,,0,other,8106.18,18245.94,There are no additional notes associated with this service or procedure.
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITH MCC,429,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],65162.13,,"Case rate ($62,958.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $58,704.65, add-ons for qualifying new technology services are included. If operating cost exceeds $93,575.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $6,222.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.6. The base transfer operating payment is the transfer adjustment factor * $56,551.19 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $56,759.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,462.45. The transfer capital threshold is the transfer adjustment factor * $4,462.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,62958.58,177294.98,Inpatient DRG
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],12558.65,,"Fee schedule rate ($12,558.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5065.00,12558.65,There are no additional notes associated with this service or procedure.
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC",758,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],8574.80,,"Case rate ($8,574.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,112.57, add-ons for qualifying new technology services are included. If operating cost exceeds $42,983.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,244.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $6,144.96 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,167.62 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $484.90. The transfer capital threshold is the transfer adjustment factor * $484.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8574.80,19263.78,Inpatient DRG
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC,805,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],20902.03,,"Fee schedule rate ($20,902.03). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9253.36,21235.42,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,447,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],156646.82,,"Fee schedule rate ($156,646.82). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,47193.21,156646.82,There are no additional notes associated with this service or procedure.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],93728.21,,"Fee schedule rate ($93,728.21). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,35719.96,105091.76,There are no additional notes associated with this service or procedure.
SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS,029,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],61889.56,,"Fee schedule rate ($61,889.56). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13641.00,67130.05,There are no additional notes associated with this service or procedure.
COAGULATION DISORDERS,813,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],12274.39,,"Case rate ($12,274.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,554.21, add-ons for qualifying new technology services are included. If operating cost exceeds $46,425.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,515.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $9,573.96 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,609.26 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $755.48. The transfer capital threshold is the transfer adjustment factor * $755.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12274.39,30013.33,Inpatient DRG
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],21377.04,,"Fee schedule rate ($21,377.04). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,9648.19,31477.13,There are no additional notes associated with this service or procedure.
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC,520,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],39786.42,,"Fee schedule rate ($39,786.42). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12061.74,39786.42,There are no additional notes associated with this service or procedure.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,191,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],7653.81,,"Case rate ($7,653.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,255.78, add-ons for qualifying new technology services are included. If operating cost exceeds $42,126.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,177.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,291.32 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,310.83 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $417.54. The transfer capital threshold is the transfer adjustment factor * $417.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,16612.88,Inpatient DRG
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],81306.30,,"Fee schedule rate ($81,306.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,20846.48,81306.30,There are no additional notes associated with this service or procedure.
CERVICAL SPINAL FUSION WITH CC,472,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],70198.84,,"Fee schedule rate ($70,198.84). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,21896.13,70198.84,There are no additional notes associated with this service or procedure.
Cysto W/Removal of Lesions Small,CASE-52224,APC,52224,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3299.47,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3299.47,3464.44,OPPS APC
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],14725.21,,"Case rate ($14,725.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,834.15, add-ons for qualifying new technology services are included. If operating cost exceeds $48,705.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,694.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,845.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,889.20 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $934.73. The transfer capital threshold is the transfer adjustment factor * $934.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7389.00,37134.43,Inpatient DRG
Colorectal Scrn; Hi Risk Ind,CASE-G0105,APC,G0105,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],900.93,,"APC Price ($870.46). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,870.46,913.99,OPPS APC
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],42586.49,,"Fee schedule rate ($42,586.49). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,13341.67,42586.49,There are no additional notes associated with this service or procedure.
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],16819.90,,,,,,0,other,7733.72,18043.23,There are no additional notes associated with this service or procedure.
O.R. PROCEDURES FOR OBESITY WITH CC,620,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],43753.50,,"Fee schedule rate ($43,753.50). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12782.30,43753.50,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,064,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],16341.76,,"Case rate ($15,563.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,614.08, add-ons for qualifying new technology services are included. If operating cost exceeds $49,485.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,756.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $12,622.59 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,669.13 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $996.05. The transfer capital threshold is the transfer adjustment factor * $996.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,15563.58,41838.16,Inpatient DRG
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,069,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7555.36,,"Case rate ($7,195.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,839.30, add-ons for qualifying new technology services are included. If operating cost exceeds $41,710.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,134.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $4,875.86 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,894.35 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $374.77. The transfer capital threshold is the transfer adjustment factor * $374.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,20333.68,Inpatient DRG
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],9696.93,,"Case rate ($9,696.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,156.46, add-ons for qualifying new technology services are included. If operating cost exceeds $44,027.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,326.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $7,185.02 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,211.51 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $566.97. The transfer capital threshold is the transfer adjustment factor * $566.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9696.93,35061.53,Inpatient DRG
BRONCHITIS AND ASTHMA WITH CC/MCC,202,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],14307.27,,"Fee schedule rate ($14,307.27). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7606.34,19110.30,There are no additional notes associated with this service or procedure.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",063,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],6965.00,,,,,,0,other,6965.00,35701.87,There are no additional notes associated with this service or procedure.
Largsc Exc Tum&/Strpg Cords/Epigl Mcrscp/Tlscp,CASE-31541,APC,31541,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3611.96,,"APC Price ($3,489.82). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3489.82,3664.31,OPPS APC
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH MCC",510,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],22889.12,,"Case rate ($21,799.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,451.94, add-ons for qualifying new technology services are included. If operating cost exceeds $55,322.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,177.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.3. The base transfer operating payment is the transfer adjustment factor * $18,437.09 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,506.99 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,417.12. The transfer capital threshold is the transfer adjustment factor * $1,417.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10710.00,89863.76,Inpatient DRG
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],22563.61,,"Case rate ($21,489.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,126.50, add-ons for qualifying new technology services are included. If operating cost exceeds $54,997.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,189.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.6. The base transfer operating payment is the transfer adjustment factor * $18,114.76 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,181.55 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,429.43. The transfer capital threshold is the transfer adjustment factor * $1,429.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,21489.15,68942.79,Inpatient DRG
Surgical Arthroscopy Shoulder Biceps Tenodesis|LEFT SIDE,CASE-29828,APC,29828,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITH MCC OR ANTINEOPLASTIC IMPLANT OR EPILEPSY WITH NEUROSTIMULATOR,023,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],136379.44,,"Fee schedule rate ($136,379.44). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,15168.00,136379.44,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],10834.64,,"Case rate ($10,834.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,214.84, add-ons for qualifying new technology services are included. If operating cost exceeds $45,085.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,410.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $8,239.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,269.90 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $650.18. The transfer capital threshold is the transfer adjustment factor * $650.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10834.64,25830.00,Inpatient DRG
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],23290.05,,"Fee schedule rate ($23,290.05). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,21248.73,56089.29,There are no additional notes associated with this service or procedure.
Pelvic Examination W/Anesthesia Other Than Local,CASE-57410,APC,57410,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3181.53,,"APC Price ($3,030.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3030.03,3181.53,OPPS APC
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],25814.06,,"Fee schedule rate ($25,814.06). Adds an outlier to normal pricing equal to the per diem rate ($46,867.46) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,11247.07,27028.33,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],25059.09,,"Case rate ($24,567.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $22,990.45, add-ons for qualifying new technology services are included. If operating cost exceeds $57,861.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,414.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.7. The base transfer operating payment is the transfer adjustment factor * $20,968.18 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $21,045.49 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,654.60. The transfer capital threshold is the transfer adjustment factor * $1,654.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,9370.00,65732.99,Inpatient DRG
Insj/Rplcmt Breast Implant Sep Day Mastectomy|RIGHT SIDE,CASE-19342,APC,19342,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],7650.49,,"APC Price ($7,650.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,7650.49,7918.25,OPPS APC
Surgical Arthroscopy Sho W/Coracoacrm Ligm Rls|LEFT SIDE,CASE-29826,APC,29826,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
COMPLICATIONS OF TREATMENT WITH CC,920,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],18836.22,,"Fee schedule rate ($18,836.22). Adds an outlier to normal pricing equal to the per diem rate ($49,808.13) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,8732.59,20731.52,There are no additional notes associated with this service or procedure.
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC",629,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],42872.25,,,,,,0,other,16699.94,44657.18,There are no additional notes associated with this service or procedure.
SALIVARY GLAND PROCEDURES,139,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],24314.87,,,,,,0,other,10313.19,30690.92,There are no additional notes associated with this service or procedure.
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],33188.44,,"Fee schedule rate ($33,188.44). Adds an outlier to normal pricing equal to the per diem rate ($84,167.29) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.5), with a minimum of zero.",,,,0,other,13904.43,34749.58,There are no additional notes associated with this service or procedure.
CERVICAL SPINAL FUSION WITH CC,472,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],37320.60,,"Fee schedule rate ($37,320.60). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,21896.13,70198.84,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],29069.25,,"Fee schedule rate ($29,069.25). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,17693.40,52449.26,There are no additional notes associated with this service or procedure.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC,099,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],22084.20,,"Fee schedule rate ($22,084.20). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11171.21,26807.94,There are no additional notes associated with this service or procedure.
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],27589.62,,"Fee schedule rate ($27,589.62). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12566.28,30861.41,There are no additional notes associated with this service or procedure.
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,069,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7611.88,,"Case rate ($7,354.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,977.32, add-ons for qualifying new technology services are included. If operating cost exceeds $41,848.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,155.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $5,013.88 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,032.37 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $395.65. The transfer capital threshold is the transfer adjustment factor * $395.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6965.00,20333.68,Inpatient DRG
Cysto Bladder W/Ureteral Catheterization|RIGHT SIDE,CASE-52005,APC,52005,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1956.65,,"APC Price ($1,956.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1956.65,2054.48,OPPS APC
Nasal/Sinus Endoscopy W/Sphenoidotomy|BILATERAL PROCEDURE,CASE-31287,APC,31287,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6605.95,,"APC Price ($6,605.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6605.95,6936.25,OPPS APC
NEONATE WITH OTHER SIGNIFICANT PROBLEMS,794,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],3383.58,,"Fee schedule rate ($3,383.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,1798.85,12536.83,There are no additional notes associated with this service or procedure.
PREMATURITY WITH MAJOR PROBLEMS,791,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],30904.42,,"Case rate ($29,432.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $27,516.30, add-ons for qualifying new technology services are included. If operating cost exceeds $62,387.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,770.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 13.3. The base transfer operating payment is the transfer adjustment factor * $25,477.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $25,571.35 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,010.42. The transfer capital threshold is the transfer adjustment factor * $2,010.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,3048.21,30904.42,Inpatient DRG
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC,797,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],8719.72,,"Case rate ($8,719.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,247.38, add-ons for qualifying new technology services are included. If operating cost exceeds $43,118.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,255.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $6,279.28 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,302.43 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $495.50. The transfer capital threshold is the transfer adjustment factor * $495.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8719.72,20928.55,Inpatient DRG
Peri-Implant Capsulectomy Breast Complete|BILATERAL PROCEDURE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-19371,APC,19371,CPT,0360,RC,,,50|XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],8033.01,,"APC Price ($7,650.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,7650.49,8033.01,OPPS APC
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],21195.68,,"Fee schedule rate ($21,195.68). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,6965.00,21195.68,There are no additional notes associated with this service or procedure.
FRACTURES OF FEMUR WITH MCC,533,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],12561.53,,"Case rate ($12,561.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,821.33, add-ons for qualifying new technology services are included. If operating cost exceeds $46,692.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,536.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $9,840.09 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,876.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $776.48. The transfer capital threshold is the transfer adjustment factor * $776.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6852.00,49490.05,Inpatient DRG
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH MCC",510,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],10710.00,,"Per diem ($10,710). If length of stay < 5.3, first 1 days paid at a per diem of $21,420 instead. Capped at $56,764.26.",,,,0,other,10710.00,89863.76,Estimated amount calculated based on 6 day length of stay.
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],19371.27,,"Fee schedule rate ($19,371.27). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8643.20,19462.52,There are no additional notes associated with this service or procedure.
Esophagogastroduodenoscopy Submucosal Injection|UNUSUAL NON-OVERLAPPING SERVICE,CASE-43236,APC,43236,CPT,0360,RC,,,XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],891.41,,"APC Price ($848.96). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,848.96,891.41,OPPS APC
Exc B9 Lesion Mrgn Xcp Sk Tg T/a/L 2.1-3.0 Cm,CASE-11403,APC,11403,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],2718.88,,"APC Price ($2,718.88). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2718.88,2854.83,OPPS APC
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,082,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],56223.11,,"Fee schedule rate ($56,223.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,17423.21,56223.11,There are no additional notes associated with this service or procedure.
Colorectal Scrn; Hi Risk Ind|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-G0105,APC,G0105,CPT,0360,RC,,,74,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],913.99,,"APC Price ($870.46). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,870.46,913.99,OPPS APC
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],52803.53,,"Fee schedule rate ($52,803.53). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,14337.84,52803.53,There are no additional notes associated with this service or procedure.
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],10120.20,,"Case rate ($10,120.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,550.21, add-ons for qualifying new technology services are included. If operating cost exceeds $44,421.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,357.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $7,577.32 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,605.26 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $597.93. The transfer capital threshold is the transfer adjustment factor * $597.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10120.20,26204.74,Inpatient DRG
MAJOR THUMB OR JOINT PROCEDURES,506,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],26548.21,,,,,,0,other,11081.83,26548.21,There are no additional notes associated with this service or procedure.
"Inj Dx/Ther Agnt Paravert Facet Joint, Cerv/Thorac, Add Level|RIGHT SIDE",CASE-64492,APC,64492,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],869.28,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,827.89,869.28,OPPS APC
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITH MCC OR ANTINEOPLASTIC IMPLANT OR EPILEPSY WITH NEUROSTIMULATOR,023,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],136379.44,,"Fee schedule rate ($136,379.44). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,15168.00,136379.44,There are no additional notes associated with this service or procedure.
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,068,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],17008.80,,,,,,0,other,6965.00,23184.90,There are no additional notes associated with this service or procedure.
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,450,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],100159.17,,"Fee schedule rate ($100,159.17). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15), with a minimum of zero.",,,,0,other,38037.38,146009.19,There are no additional notes associated with this service or procedure.
HC Injection Small Joint/Bursa,CASE-20600,APC,20600,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],26204.74,,"Fee schedule rate ($26,204.74). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10120.20,26204.74,There are no additional notes associated with this service or procedure.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],20817.01,,"Fee schedule rate ($20,817.01). Adds an outlier to normal pricing equal to the per diem rate ($37,789.38) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,9446.38,21796.21,There are no additional notes associated with this service or procedure.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],23344.70,,"Case rate ($23,344.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $21,852.68, add-ons for qualifying new technology services are included. If operating cost exceeds $56,723.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,325.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $19,834.60 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $19,907.73 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,565.15. The transfer capital threshold is the transfer adjustment factor * $1,565.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,23344.70,62179.32,Inpatient DRG
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],53152.12,,"Fee schedule rate ($53,152.12). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,19152.11,53152.12,There are no additional notes associated with this service or procedure.
"CHOLECYSTECTOMY,MODERATE",263,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],15125.74,,"Case rate ($15,125.74). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,15125.74,15882.03,There are no additional notes associated with this service or procedure.
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,095,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],48470.91,,"Fee schedule rate ($48,470.91). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.8), with a minimum of zero.",,,,0,other,19411.47,50750.92,There are no additional notes associated with this service or procedure.
Cysto Calibration Dilat Urtl Strix/Stenosis,CASE-52281,APC,52281,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1956.65,,"APC Price ($1,956.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1956.65,2054.48,OPPS APC
CESAREAN SECTION WITH STERILIZATION WITH MCC,783,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],18942.47,,"Case rate ($18,571.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,411.86, add-ons for qualifying new technology services are included. If operating cost exceeds $52,282.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,975.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $15,410.10 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,466.92 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,216.01. The transfer capital threshold is the transfer adjustment factor * $1,216.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,12612.10,23722.94,Inpatient DRG
OSTEOMYELITIS WITH CC,540,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],24361.37,,"Fee schedule rate ($24,361.37). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.6), with a minimum of zero.",,,,0,other,9809.07,25507.30,There are no additional notes associated with this service or procedure.
Inject Rx Other Periph Nerve|LEFT SIDE,CASE-64640,APC,64640,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],869.28,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,827.89,869.28,OPPS APC
MAJOR BLADDER PROCEDURES WITH MCC,653,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],10280.00,,"Per diem ($10,280). If length of stay < 9.5, first 1 days paid at a per diem of $20,560 instead. Capped at $97,655.95.",,,,0,other,10280.00,125343.98,Estimated amount calculated based on 10 day length of stay.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,064,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],41838.16,,"Fee schedule rate ($41,838.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,15563.58,41838.16,There are no additional notes associated with this service or procedure.
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC",629,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],16699.94,,"Case rate ($16,699.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,671.20, add-ons for qualifying new technology services are included. If operating cost exceeds $50,542.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,839.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $13,675.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,726.25 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,079.16. The transfer capital threshold is the transfer adjustment factor * $1,079.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,16699.94,44657.18,Inpatient DRG
SINGLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL,402,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],29755.49,,"Case rate ($29,172.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $27,273.75, add-ons for qualifying new technology services are included. If operating cost exceeds $62,144.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,751.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $25,235.76 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $25,328.80 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,991.35. The transfer capital threshold is the transfer adjustment factor * $1,991.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,29172.05,124455.45,Inpatient DRG
HC Inj Tendon Sheath/Ligament|PBB CHARGE|RIGHT SIDE,CASE-20550,APC,20550,CPT,0510,RC,,,PBB|RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],11811.40,,"Fee schedule rate ($11,811.40). Adds an outlier to normal pricing equal to the per diem rate ($53,248.69) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.7), with a minimum of zero.",,,,0,other,5937.41,12366.99,There are no additional notes associated with this service or procedure.
"OTHER ESOPHAGEAL DISORDERS,EXTREME",243,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],21153.39,,"Case rate ($20,146.09). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,20146.09,21153.39,There are no additional notes associated with this service or procedure.
Repair Each Addnl Digit Nerve,CASE-64832,APC,64832,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],15099.70,,"Case rate ($15,099.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,182.53, add-ons for qualifying new technology services are included. If operating cost exceeds $49,053.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,722.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $12,192.63 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,237.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $962.12. The transfer capital threshold is the transfer adjustment factor * $962.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7605.00,39153.65,Inpatient DRG
"Tendon Sheath Incision|LEFT HAND, FOURTH DIGIT",CASE-26055,APC,26055,CPT,0360,RC,,,F3,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1505.12,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1505.12,1580.37,OPPS APC
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,085,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],57443.16,,"Fee schedule rate ($57,443.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,9282.00,57443.16,There are no additional notes associated with this service or procedure.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],24989.04,,"Case rate ($23,799.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $22,275.40, add-ons for qualifying new technology services are included. If operating cost exceeds $57,146.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,358.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.1. The base transfer operating payment is the transfer adjustment factor * $20,255.77 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $20,330.45 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,598.38. The transfer capital threshold is the transfer adjustment factor * $1,598.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,23799.09,63499.65,Inpatient DRG
"VAGINAL DELIVERY,MAJOR",560,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],6397.25,,"Case rate ($6,092.62). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6092.62,6397.25,There are no additional notes associated with this service or procedure.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],31007.30,,"Fee schedule rate ($31,007.30). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,16120.25,41187.90,There are no additional notes associated with this service or procedure.
FRACTURES OF FEMUR WITH MCC,533,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],13189.61,,"Case rate ($12,561.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,821.33, add-ons for qualifying new technology services are included. If operating cost exceeds $46,692.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,536.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $9,840.09 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,876.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $776.48. The transfer capital threshold is the transfer adjustment factor * $776.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6852.00,49490.05,Inpatient DRG
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC,831,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],6965.00,,,,,,0,other,4941.30,23661.59,There are no additional notes associated with this service or procedure.
"COCAINE ABUSE AND DEPENDENCE,EXTREME",774,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],20088.54,,"Case rate ($19,131.94). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,19131.94,20088.54,There are no additional notes associated with this service or procedure.
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],10448.91,,"Fee schedule rate ($10,448.91). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,3079.00,10940.41,There are no additional notes associated with this service or procedure.
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],29916.58,,"Fee schedule rate ($29,916.58). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12725.42,34245.00,There are no additional notes associated with this service or procedure.
O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC,621,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],36669.96,,"Fee schedule rate ($36,669.96). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,12159.94,36669.96,There are no additional notes associated with this service or procedure.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],38248.08,,"Fee schedule rate ($38,248.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11593.79,38248.08,There are no additional notes associated with this service or procedure.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],26776.27,,"Fee schedule rate ($26,776.27). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,11593.79,38248.08,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,091,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],14529.96,,"Case rate ($13,838.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,008.86, add-ons for qualifying new technology services are included. If operating cost exceeds $47,879.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,629.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $11,023.26 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,063.91 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $869.84. The transfer capital threshold is the transfer adjustment factor * $869.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13838.06,40030.81,Inpatient DRG
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],25044.52,,"Case rate ($23,851.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $22,324.54, add-ons for qualifying new technology services are included. If operating cost exceeds $57,195.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,362.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.8. The base transfer operating payment is the transfer adjustment factor * $20,304.73 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $20,379.59 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,602.24. The transfer capital threshold is the transfer adjustment factor * $1,602.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,23851.92,63653.13,Inpatient DRG
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],15340.19,,,,,,0,other,6965.00,15340.19,There are no additional notes associated with this service or procedure.
Colsc Flexible W/Transendoscopic Balloon Dilat,CASE-45386,APC,45386,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1176.09,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1120.09,1176.09,OPPS APC
Vaginal Hysterectomy Uterus 250 Gm/<,CASE-58260,APC,58260,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],4682.41,,"APC Price ($4,682.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,4682.41,4916.53,OPPS APC
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],19688.76,,"Case rate ($18,751.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,579.45, add-ons for qualifying new technology services are included. If operating cost exceeds $52,450.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,989.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $15,577.06 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,634.50 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,229.18. The transfer capital threshold is the transfer adjustment factor * $1,229.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8480.00,59081.91,Inpatient DRG
Brnschsc Tndsc Ebus Dx/Tx Intervention Perph Les,CASE-31654,APC,31654,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6837.16,,"APC Price ($6,605.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6605.95,6936.25,OPPS APC
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],41213.48,,,,,,0,other,16129.04,59610.47,There are no additional notes associated with this service or procedure.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC,434,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],7360.50,,"Fee schedule rate ($7,360.50). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6770.05,14019.86,There are no additional notes associated with this service or procedure.
HC Inj Aa&/Strd Other Peripheral Nerve/Branch,CASE-64450,APC,64450,CPT,0450,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],693.76,,"APC Price ($660.72). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,660.72,693.76,OPPS APC
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,448,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],94077.13,,"Fee schedule rate ($94,077.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,30663.95,94077.13,There are no additional notes associated with this service or procedure.
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],12526.44,,"Fee schedule rate ($12,526.44). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5415.00,17575.50,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,555,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],23439.15,,"Fee schedule rate ($23,439.15). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10896.27,42290.95,There are no additional notes associated with this service or procedure.
"ANTEPARTUM WITHOUT O.R. PROCEDURE,MAJOR",566,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],6941.22,,"Case rate ($6,941.22). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,6941.22,7288.28,There are no additional notes associated with this service or procedure.
FULL TERM NEONATE WITH MAJOR PROBLEMS,793,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],30181.78,,"Case rate ($30,181.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $28,213.07, add-ons for qualifying new technology services are included. If operating cost exceeds $63,084.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,825.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $26,171.62 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $26,268.12 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,065.20. The transfer capital threshold is the transfer adjustment factor * $2,065.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,4302.90,82045.22,Inpatient DRG
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],26204.74,,"Fee schedule rate ($26,204.74). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10120.20,26204.74,There are no additional notes associated with this service or procedure.
HC Drain/Inj Joint/Bursa W/US Large|BILATERAL PROCEDURE,CASE-20611,APC,20611,CPT,0510,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],297.37,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,287.31,301.68,OPPS APC
BRONCHITIS AND ASTHMA WITH CC/MCC,202,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],7929.60,,"Fee schedule rate ($7,929.60). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7606.34,19110.30,There are no additional notes associated with this service or procedure.
"SPINAL FUSION AND OTHER BACK AND NECK PROCEDURES EXCEPT FOR DISC PROCEDURES,MINOR",321,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],5567.97,,"Case rate for a one day stay ($5,302.83). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5302.83,5567.97,There are no additional notes associated with this service or procedure.
FRACTURES OF FEMUR WITH MCC,533,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],13001.18,,"Case rate ($12,561.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,821.33, add-ons for qualifying new technology services are included. If operating cost exceeds $46,692.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,536.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $9,840.09 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,876.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $776.48. The transfer capital threshold is the transfer adjustment factor * $776.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6852.00,49490.05,Inpatient DRG
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,068,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],23184.90,,"Fee schedule rate ($23,184.90). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,23184.90,There are no additional notes associated with this service or procedure.
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],11133.98,,"Fee schedule rate ($11,133.98). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5919.29,13545.65,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],6965.00,,,,,,0,other,6965.00,32293.66,There are no additional notes associated with this service or procedure.
NERVOUS SYSTEM NEOPLASMS WITH MCC,054,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],12285.22,,"Case rate ($12,285.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,564.29, add-ons for qualifying new technology services are included. If operating cost exceeds $46,435.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,516.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $9,584.00 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,619.34 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $756.27. The transfer capital threshold is the transfer adjustment factor * $756.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,30044.81,Inpatient DRG
Nasal/Sinus Ndsc Total With Sphenoidotomy|BILATERAL PROCEDURE,CASE-31257,APC,31257,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6605.95,,"APC Price ($6,605.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6605.95,6936.25,OPPS APC
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC",156,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],12987.84,,"Fee schedule rate ($12,987.84). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,6625.12,13598.77,There are no additional notes associated with this service or procedure.
Cysto W/Insert Ureteral Stent,CASE-52332,APC,52332,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3299.47,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3299.47,3464.44,OPPS APC
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],16055.90,,"Fee schedule rate ($16,055.90). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8163.06,18067.42,There are no additional notes associated with this service or procedure.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,191,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],16612.88,,"Fee schedule rate ($16,612.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6965.00,16612.88,There are no additional notes associated with this service or procedure.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],11593.79,,"Case rate ($11,593.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,921.06, add-ons for qualifying new technology services are included. If operating cost exceeds $45,792.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,465.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $8,943.14 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,976.12 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $705.70. The transfer capital threshold is the transfer adjustment factor * $705.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,11593.79,38248.08,Inpatient DRG
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],22153.79,,"Case rate ($21,719.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,340.70, add-ons for qualifying new technology services are included. If operating cost exceeds $55,211.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,206.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.2. The base transfer operating payment is the transfer adjustment factor * $18,328.17 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,395.75 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,446.27. The transfer capital threshold is the transfer adjustment factor * $1,446.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,21719.40,85305.59,Inpatient DRG
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,191,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],6965.00,,,,,,0,other,6965.00,16612.88,There are no additional notes associated with this service or procedure.
Rpr Ingun Hernia Sliding Any Age,CASE-49525,APC,49525,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3468.64,,"APC Price ($3,351.34). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3351.34,3518.91,OPPS APC
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,082,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],17423.21,,"Case rate ($17,423.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,344.04, add-ons for qualifying new technology services are included. If operating cost exceeds $51,215.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,892.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $14,346.19 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,399.08 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,132.06. The transfer capital threshold is the transfer adjustment factor * $1,132.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,17423.21,56223.11,Inpatient DRG
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],31007.30,,"Fee schedule rate ($31,007.30). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,16120.25,41187.90,There are no additional notes associated with this service or procedure.
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],18751.20,,"Case rate ($18,751.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,579.45, add-ons for qualifying new technology services are included. If operating cost exceeds $52,450.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,989.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $15,577.06 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,634.50 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,229.18. The transfer capital threshold is the transfer adjustment factor * $1,229.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8480.00,59081.91,Inpatient DRG
CERVICAL SPINAL FUSION WITH CC,472,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],55366.06,,"Fee schedule rate ($55,366.06). Adds an outlier to normal pricing equal to the per diem rate ($66,990.29) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,21896.13,70198.84,There are no additional notes associated with this service or procedure.
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],18915.50,,,,,,0,other,6230.00,22762.43,There are no additional notes associated with this service or procedure.
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC,807,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],10071.17,,"Fee schedule rate ($10,071.17). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5354.25,13266.23,There are no additional notes associated with this service or procedure.
"Open Tx Distal Phalangeal Fracture Each|RIGHT HAND, FIFTH DIGIT",CASE-26765,APC,26765,CPT,0360,RC,,,F9,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
CERVICAL SPINAL FUSION WITHOUT CC/MCC,473,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],62077.11,,"Fee schedule rate ($62,077.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,18477.61,62077.11,There are no additional notes associated with this service or procedure.
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC",458,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],30202.09,,"Case rate ($30,202.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $28,231.97, add-ons for qualifying new technology services are included. If operating cost exceeds $63,102.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,826.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $26,190.45 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $26,287.02 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,066.69. The transfer capital threshold is the transfer adjustment factor * $2,066.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,30202.09,132827.25,Inpatient DRG
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,064,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],15874.85,,"Case rate ($15,563.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,614.08, add-ons for qualifying new technology services are included. If operating cost exceeds $49,485.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,756.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $12,622.59 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,669.13 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $996.05. The transfer capital threshold is the transfer adjustment factor * $996.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,15563.58,41838.16,Inpatient DRG
Exc Rct Procidentia W/Anast Perineal Approach,CASE-45130,APC,45130,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],50.48,,"APC Price ($48.78). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,48.78,51.22,OPPS APC
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],29917.96,,"Fee schedule rate ($29,917.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,12527.66,29917.96,There are no additional notes associated with this service or procedure.
SPINAL PROCEDURES WITHOUT CC/MCC,030,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],41254.39,,"Fee schedule rate ($41,254.39). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,16810.99,44714.01,There are no additional notes associated with this service or procedure.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,098,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],38799.38,,"Fee schedule rate ($38,799.38). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,6965.00,45156.75,There are no additional notes associated with this service or procedure.
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],12651.45,,"Fee schedule rate ($12,651.45). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,6503.90,14492.93,There are no additional notes associated with this service or procedure.
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral Ea Addl|LEFT SIDE,CASE-64484,APC,64484,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],856.86,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,827.89,869.28,OPPS APC
NEONATE WITH OTHER SIGNIFICANT PROBLEMS,794,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],1875.30,,"Fee schedule rate ($1,875.30). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,1798.85,12536.83,There are no additional notes associated with this service or procedure.
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],11811.40,,"Fee schedule rate ($11,811.40). Adds an outlier to normal pricing equal to the per diem rate ($53,248.69) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.7), with a minimum of zero.",,,,0,other,5937.41,12366.99,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,065,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],9226.10,,"Case rate ($8,786.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,309.75, add-ons for qualifying new technology services are included. If operating cost exceeds $43,180.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,260.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,341.42 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,364.80 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $500.40. The transfer capital threshold is the transfer adjustment factor * $500.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8786.76,25681.86,Inpatient DRG
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC,434,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],13280.45,,"Fee schedule rate ($13,280.45). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6770.05,14019.86,There are no additional notes associated with this service or procedure.
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR,518,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],28616.93,,"Case rate ($27,254.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $25,489.62, add-ons for qualifying new technology services are included. If operating cost exceeds $60,360.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,611.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 5.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $23,458.18 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $23,544.67 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,851.08. The transfer capital threshold is the transfer adjustment factor * $1,851.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13252.00,89342.77,Inpatient DRG
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,074,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],9371.88,,"Case rate ($8,925.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,438.90, add-ons for qualifying new technology services are included. If operating cost exceeds $43,309.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,270.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,470.10 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,493.95 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $510.55. The transfer capital threshold is the transfer adjustment factor * $510.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8925.60,20919.08,Inpatient DRG
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],6965.00,,,,,,0,other,6965.00,23385.72,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],8972.00,,"Per diem ($8,972). If length of stay < 6.1, first 1 days paid at a per diem of $17,944 instead. Capped at $54,730.85.",,,,0,other,8972.00,81524.17,Estimated amount calculated based on 4 day length of stay.
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,093,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],12840.71,,"Case rate ($7,337.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,961.57, add-ons for qualifying new technology services are included. If operating cost exceeds $41,832.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,154.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,998.19 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,016.62 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $394.41. The transfer capital threshold is the transfer adjustment factor * $394.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,6965.00,19011.32,All Other Inpatient
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],38248.08,,"Fee schedule rate ($38,248.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11593.79,38248.08,There are no additional notes associated with this service or procedure.
"Tendon Sheath Incision|UNUSUAL NON-OVERLAPPING SERVICE|LEFT HAND, THIRD DIGIT",CASE-26055,APC,26055,CPT,0360,RC,,,XU|F2,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1505.12,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1505.12,1557.80,OPPS APC
Arthrt Expl Drg/Rmvl Loose/FB Iphal Jt Ea,CASE-26080,APC,26080,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1505.12,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1505.12,1557.80,OPPS APC
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],17755.26,,"Fee schedule rate ($17,755.26). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7847.50,17755.26,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITH STERILIZATION WITH MCC,783,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],19006.00,,,,,,0,other,12612.10,23722.94,There are no additional notes associated with this service or procedure.
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],9950.89,,"Case rate ($9,950.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,392.71, add-ons for qualifying new technology services are included. If operating cost exceeds $44,263.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,345.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $7,420.40 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,447.76 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $585.54. The transfer capital threshold is the transfer adjustment factor * $585.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7243.75,23262.15,Inpatient DRG
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,426,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],94257.34,,"Fee schedule rate ($94,257.34). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,76581.29,216864.15,There are no additional notes associated with this service or procedure.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,329,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],34726.41,,"Case rate ($33,072.77). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $30,902.51, add-ons for qualifying new technology services are included. If operating cost exceeds $65,773.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,036.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.4. The base transfer operating payment is the transfer adjustment factor * $28,851.18 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $28,957.55 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,276.64. The transfer capital threshold is the transfer adjustment factor * $2,276.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,33072.77,90445.33,Inpatient DRG
Mastectomy Partial|RIGHT SIDE,CASE-19301,APC,19301,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3848.19,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3664.94,3848.19,OPPS APC
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,068,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],8188.67,,"Case rate ($7,798.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,390.60, add-ons for qualifying new technology services are included. If operating cost exceeds $42,261.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,188.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $5,425.64 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,445.65 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $428.14. The transfer capital threshold is the transfer adjustment factor * $428.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,23184.90,Inpatient DRG
Secondary Closure Surg Wound/Dehsn Extsv/Complic,CASE-13160,APC,13160,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3317.01,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3317.01,3433.11,OPPS APC
TRAUMATIC INJURY WITH MCC,913,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],22775.52,,"Case rate ($13,014.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,242.79, add-ons for qualifying new technology services are included. If operating cost exceeds $47,113.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,569.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $10,260.01 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,297.84 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $809.62. The transfer capital threshold is the transfer adjustment factor * $809.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,13014.58,42838.46,All Other Inpatient
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],22809.58,,,,,,0,other,9795.13,23899.13,There are no additional notes associated with this service or procedure.
Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq,CASE-45385,APC,45385,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1120.09,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1120.09,1176.09,OPPS APC
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],27382.89,,"Case rate ($26,078.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $24,441.32, add-ons for qualifying new technology services are included. If operating cost exceeds $59,312.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,482.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $22,411.39 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $22,496.37 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,722.59. The transfer capital threshold is the transfer adjustment factor * $1,722.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,26809.29,97015.50,Inpatient DRG
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],21354.82,,"Fee schedule rate ($21,354.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6834.39,21354.82,There are no additional notes associated with this service or procedure.
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITHOUT MCC,430,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],108381.11,,"Fee schedule rate ($108,381.11). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.6), with a minimum of zero.",,,,0,other,41000.16,133156.90,There are no additional notes associated with this service or procedure.
PERITONEAL ADHESIOLYSIS WITH CC,336,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],39628.80,,"Fee schedule rate ($39,628.80). Adds an outlier to normal pricing equal to the per diem rate ($54,966.40) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,16225.22,53705.31,There are no additional notes associated with this service or procedure.
DIABETES WITH CC,638,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],15195.79,,"Fee schedule rate ($15,195.79). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8014.07,17634.53,There are no additional notes associated with this service or procedure.
VAGINAL DELIVERY WITH O.R. PROCEDURES EXCEPT STERILIZATION AND/OR D&C,768,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],12088.81,,"Fee schedule rate ($12,088.81). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6426.91,13416.00,There are no additional notes associated with this service or procedure.
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 2nd Level,CASE-64494,APC,64494,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],856.86,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,827.89,869.28,OPPS APC
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],40108.48,,"Fee schedule rate ($40,108.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,5569.00,40108.48,There are no additional notes associated with this service or procedure.
OTHER CEREBROVASCULAR DISORDERS WITH MCC,070,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],13483.47,,"Case rate ($13,219.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,433.04, add-ons for qualifying new technology services are included. If operating cost exceeds $47,304.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,584.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $10,449.57 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,488.10 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $824.57. The transfer capital threshold is the transfer adjustment factor * $824.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,13219.09,37774.46,Inpatient DRG
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC,027,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],19030.20,,"Case rate ($19,030.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,839, add-ons for qualifying new technology services are included. If operating cost exceeds $52,710.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,009.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $15,835.66 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,894.05 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,249.59. The transfer capital threshold is the transfer adjustment factor * $1,249.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,19030.20,56363.30,Inpatient DRG
MAJOR THUMB OR JOINT PROCEDURES,506,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],11354.12,,"Case rate ($10,813.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,211.67, add-ons for qualifying new technology services are included. If operating cost exceeds $45,082.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,392.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $8,235.50 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,266.72 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $633.00. The transfer capital threshold is the transfer adjustment factor * $633.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,11081.83,26548.21,Inpatient DRG
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],15318.94,,"Fee schedule rate ($15,318.94). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6214.05,15318.94,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC,831,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],6965.00,,,,,,0,other,4941.30,23661.59,There are no additional notes associated with this service or procedure.
Open Tx Clavicular Fracture Internal Fixation,CASE-23515,APC,23515,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],15994.77,,"Case rate ($15,233.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,306.64, add-ons for qualifying new technology services are included. If operating cost exceeds $49,177.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,731.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $12,316.28 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,361.69 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $971.88. The transfer capital threshold is the transfer adjustment factor * $971.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,15233.11,38610.21,Inpatient DRG
Exc Lesion Spermatic Cord Separate Procedure|UNUSUAL NON-OVERLAPPING SERVICE,CASE-55520,APC,55520,CPT,0360,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3351.34,,"APC Price ($3,351.34). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3351.34,3518.91,OPPS APC
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,097,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],79915.74,,"Fee schedule rate ($79,915.74). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,26404.32,79915.74,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],86252.84,,"Fee schedule rate ($86,252.84). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,27944.96,86252.84,There are no additional notes associated with this service or procedure.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC",061,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],62315.82,,"Fee schedule rate ($62,315.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,20616.23,62315.82,There are no additional notes associated with this service or procedure.
HC Inj Lympho for Sentinal Node|SEPARATE PRACTITIONER,CASE-38792,APC,38792,CPT,0361,RC,,,XP,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6215.36,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6215.36,6526.12,OPPS APC
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],9270.25,,"Case rate ($8,956.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,467.88, add-ons for qualifying new technology services are included. If operating cost exceeds $43,338.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,272.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $6,498.97 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,522.93 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $512.83. The transfer capital threshold is the transfer adjustment factor * $512.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,8956.76,28983.97,Inpatient DRG
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],12920.81,,"Case rate ($12,305.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,583.18, add-ons for qualifying new technology services are included. If operating cost exceeds $46,454.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,517.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $9,602.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,638.24 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $757.76. The transfer capital threshold is the transfer adjustment factor * $757.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12305.53,30103.84,Inpatient DRG
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],19604.30,,"Fee schedule rate ($19,604.30). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9446.38,21796.21,There are no additional notes associated with this service or procedure.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],16286.16,,"Case rate ($16,286.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,286.28, add-ons for qualifying new technology services are included. If operating cost exceeds $50,157.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,808.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $13,292.32 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,341.33 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,048.90. The transfer capital threshold is the transfer adjustment factor * $1,048.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,16286.16,58320.32,Inpatient DRG
DIABETES WITH CC,638,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],8014.07,,"Case rate ($8,014.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,590.93, add-ons for qualifying new technology services are included. If operating cost exceeds $42,461.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,203.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,625.24 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,645.98 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $443.89. The transfer capital threshold is the transfer adjustment factor * $443.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8014.07,17634.53,Inpatient DRG
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC,434,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],13280.45,,"Fee schedule rate ($13,280.45). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6770.05,14019.86,There are no additional notes associated with this service or procedure.
NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,601,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],11369.77,,"Fee schedule rate ($11,369.77). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,6042.05,12359.72,There are no additional notes associated with this service or procedure.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,418,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],14070.61,,"Case rate ($13,400.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,601.88, add-ons for qualifying new technology services are included. If operating cost exceeds $47,472.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,597.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $10,617.79 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,656.93 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $837.85. The transfer capital threshold is the transfer adjustment factor * $837.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13400.58,39884.93,Inpatient DRG
CERVICAL SPINAL FUSION WITH CC,472,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],55366.06,,"Fee schedule rate ($55,366.06). Adds an outlier to normal pricing equal to the per diem rate ($66,990.29) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,21896.13,70198.84,There are no additional notes associated with this service or procedure.
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],10374.06,,"Case rate ($9,880.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,341.62, add-ons for qualifying new technology services are included. If operating cost exceeds $44,212.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,326.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $7,368.73 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,396.67 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $566.38. The transfer capital threshold is the transfer adjustment factor * $566.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10120.20,26204.74,Inpatient DRG
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITH MCC,429,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],177294.98,,"Fee schedule rate ($177,294.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,62958.58,177294.98,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6368.48,,"Case rate ($6,153.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,859.72, add-ons for qualifying new technology services are included. If operating cost exceeds $40,730.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,067.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,900.39 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,914.77 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $307.78. The transfer capital threshold is the transfer adjustment factor * $307.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6153.12,13947.32,Inpatient DRG
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],13996.50,,"Fee schedule rate ($13,996.50). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11974.38,29141.64,There are no additional notes associated with this service or procedure.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],26809.29,,"Case rate ($26,809.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $25,075.72, add-ons for qualifying new technology services are included. If operating cost exceeds $59,946.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,578.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $23,045.79 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $23,130.76 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,818.54. The transfer capital threshold is the transfer adjustment factor * $1,818.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,26809.29,97015.50,Inpatient DRG
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],34570.85,,"Fee schedule rate ($34,570.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,6965.00,36140.75,There are no additional notes associated with this service or procedure.
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",004,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],97641.94,,"Case rate ($92,992.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $86,814.26, add-ons for qualifying new technology services are included. If operating cost exceeds $121,685.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $8,258.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 22.4. The base transfer operating payment is the transfer adjustment factor * $84,548.75 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $84,869.31 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $6,498.62. The transfer capital threshold is the transfer adjustment factor * $6,498.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10249.47,272554.00,Inpatient DRG
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],7261.42,,"Case rate ($6,915.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,569.08, add-ons for qualifying new technology services are included. If operating cost exceeds $41,440.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,123.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,607.15 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,624.14 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $363.55. The transfer capital threshold is the transfer adjustment factor * $363.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6915.64,14442.92,Inpatient DRG
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],15503.65,,"Case rate ($8,859.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,377.16, add-ons for qualifying new technology services are included. If operating cost exceeds $43,248.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,265.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $6,408.58 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,432.21 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $505.70. The transfer capital threshold is the transfer adjustment factor * $505.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,8859.23,20090.22,All Other Inpatient
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],34406.22,,"Fee schedule rate ($34,406.22). Adds an outlier to normal pricing equal to the per diem rate ($49,808.13) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,14343.25,36024.65,There are no additional notes associated with this service or procedure.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],25665.57,,"Case rate ($25,162.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $23,543.58, add-ons for qualifying new technology services are included. If operating cost exceeds $58,414.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,458.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $21,519.28 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $21,598.63 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,698.08. The transfer capital threshold is the transfer adjustment factor * $1,698.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,25162.32,75579.22,Inpatient DRG
TRAUMATIC INJURY WITH MCC,913,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],30719.04,,"Fee schedule rate ($30,719.04). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.5), with a minimum of zero.",,,,0,other,13014.58,42838.46,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],45846.51,,"Fee schedule rate ($45,846.51). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,32296.02,88188.38,There are no additional notes associated with this service or procedure.
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],7717.78,,"Case rate ($7,566.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,174.51, add-ons for qualifying new technology services are included. If operating cost exceeds $42,045.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,171.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,210.35 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,229.56 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $411.15. The transfer capital threshold is the transfer adjustment factor * $411.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,7566.45,16333.88,Inpatient DRG
Rpr Aa Hernia 1st > 10 Cm Reducible,CASE-49595,APC,49595,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6059.65,,"APC Price ($6,059.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6059.65,6362.63,OPPS APC
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],40192.59,,"Fee schedule rate ($40,192.59). Adds an outlier to normal pricing equal to the per diem rate ($235,324.88) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.6), with a minimum of zero.",,,,0,other,16428.39,42083.20,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],11847.11,,"Fee schedule rate ($11,847.11). Adds an outlier to normal pricing equal to the per diem rate ($62,538.40) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,6214.05,15318.94,There are no additional notes associated with this service or procedure.
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],38839.49,,"Fee schedule rate ($38,839.49). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.6), with a minimum of zero.",,,,0,other,15940.79,53275.26,There are no additional notes associated with this service or procedure.
SALIVARY GLAND PROCEDURES,139,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],10570.76,,"Case rate ($10,067.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,516.24, add-ons for qualifying new technology services are included. If operating cost exceeds $44,387.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,339.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $7,542.70 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,571.29 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $579.75. The transfer capital threshold is the transfer adjustment factor * $579.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10313.19,30690.92,Inpatient DRG
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],16055.90,,"Fee schedule rate ($16,055.90). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8163.06,18067.42,There are no additional notes associated with this service or procedure.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],19604.30,,"Fee schedule rate ($19,604.30). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9446.38,21796.21,There are no additional notes associated with this service or procedure.
NORMAL NEWBORN,795,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],1428.00,,"Fee schedule rate ($1,428). Adds an outlier to normal pricing equal to the per diem rate ($449.65) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,1369.79,5771.52,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],6965.00,,,,,,0,other,6965.00,32293.66,There are no additional notes associated with this service or procedure.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],33608.45,,"Fee schedule rate ($33,608.45). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,7332.00,35314.31,There are no additional notes associated with this service or procedure.
O.R. PROCEDURES FOR OBESITY WITH CC,620,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],30074.44,,"Fee schedule rate ($30,074.44). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7.8), with a minimum of zero.",,,,0,other,12782.30,43753.50,There are no additional notes associated with this service or procedure.
SALIVARY GLAND PROCEDURES,139,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],30690.92,,"Fee schedule rate ($30,690.92). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,10313.19,30690.92,There are no additional notes associated with this service or procedure.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],28434.57,,"Fee schedule rate ($28,434.57). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,8906.63,28434.57,There are no additional notes associated with this service or procedure.
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],5791.49,,"Fee schedule rate ($5,791.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,3079.00,10940.41,There are no additional notes associated with this service or procedure.
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",623,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],33712.76,,"Fee schedule rate ($33,712.76). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,14093.37,33712.76,There are no additional notes associated with this service or procedure.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],36628.13,,"Case rate ($35,389.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $33,057.71, add-ons for qualifying new technology services are included. If operating cost exceeds $67,928.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,206.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.3. The base transfer operating payment is the transfer adjustment factor * $30,998.46 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $31,112.76 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,446.08. The transfer capital threshold is the transfer adjustment factor * $2,446.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,35389.50,101083.00,Inpatient DRG
COMPLICATIONS OF TREATMENT WITH CC,920,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],8907.24,,"Case rate ($8,732.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,259.35, add-ons for qualifying new technology services are included. If operating cost exceeds $43,130.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,256.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,291.21 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,314.40 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $496.44. The transfer capital threshold is the transfer adjustment factor * $496.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,8732.59,20731.52,Inpatient DRG
Arthrs Knee Debridement/Shaving Artclr Crtlg|RIGHT SIDE,CASE-29877,APC,29877,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
HC Gastroesophag Reflx Test W/Tel Ph Eltrd,CASE-91035,APC,91035,CPT,0750,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],803.80,,"APC Price ($803.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,803.80,843.99,OPPS APC
SEIZURES WITH MCC,100,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],36398.28,,"Fee schedule rate ($36,398.28). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,15061.09,38110.41,There are no additional notes associated with this service or procedure.
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],23385.72,,"Fee schedule rate ($23,385.72). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,23385.72,There are no additional notes associated with this service or procedure.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],42787.31,,"Fee schedule rate ($42,787.31). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,15476.23,42787.31,There are no additional notes associated with this service or procedure.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],64429.92,,"Fee schedule rate ($64,429.92). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,25162.32,75579.22,There are no additional notes associated with this service or procedure.
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],13236.54,,"Case rate ($12,606.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,862.91, add-ons for qualifying new technology services are included. If operating cost exceeds $46,733.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,539.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $9,881.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,917.95 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $779.75. The transfer capital threshold is the transfer adjustment factor * $779.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12606.23,36868.88,Inpatient DRG
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],21382.16,,"Case rate ($21,382.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,026.97, add-ons for qualifying new technology services are included. If operating cost exceeds $54,897.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,181.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6)) / 2. The base transfer operating payment is the transfer adjustment factor * $18,015.59 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,082.01 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,421.61. The transfer capital threshold is the transfer adjustment factor * $1,421.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,21382.16,85466.62,Inpatient DRG
SEIZURES WITH MCC,100,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],26356.91,,"Case rate ($15,061.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,146.62, add-ons for qualifying new technology services are included. If operating cost exceeds $49,017.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,719.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $12,156.85 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,201.67 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $959.30. The transfer capital threshold is the transfer adjustment factor * $959.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,15061.09,38110.41,All Other Inpatient
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],2070.00,,,,,,0,other,1188.00,34338.33,Estimated amount calculated based on 6 day length of stay.
Dbrdmt Fx&/Dislc Subq T/M/F Bone,CASE-11012,APC,11012,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7029.71,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,7029.71,7131.59,OPPS APC
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,373,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7062.56,,"Case rate ($6,726.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,401.82, add-ons for qualifying new technology services are included. If operating cost exceeds $41,272.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,101.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $4,440.04 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,456.87 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $341.27. The transfer capital threshold is the transfer adjustment factor * $341.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6870.94,14313.05,Inpatient DRG
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC,520,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],28074.86,,"Fee schedule rate ($28,074.86). Adds an outlier to normal pricing equal to the per diem rate ($68,872.56) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,12061.74,39786.42,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],81524.17,,"Fee schedule rate ($81,524.17). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,8972.00,81524.17,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],49717.39,,"Fee schedule rate ($49,717.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,14908.05,49717.39,There are no additional notes associated with this service or procedure.
CHEST PAIN,313,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7011.49,,"Case rate ($6,677.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,356.48, add-ons for qualifying new technology services are included. If operating cost exceeds $41,227.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,097.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $4,394.87 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,411.53 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $337.80. The transfer capital threshold is the transfer adjustment factor * $337.80. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6820.84,15377.66,Inpatient DRG
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],15009.94,,"Case rate ($14,295.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,434.11, add-ons for qualifying new technology services are included. If operating cost exceeds $48,305.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,663.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $11,446.95 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,489.15 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $903.28. The transfer capital threshold is the transfer adjustment factor * $903.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,14295.18,42768.36,Inpatient DRG
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],21923.41,,"Case rate ($12,527.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,789.82, add-ons for qualifying new technology services are included. If operating cost exceeds $46,660.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,533.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $9,808.71 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,844.88 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $774.00. The transfer capital threshold is the transfer adjustment factor * $774.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,12527.66,29917.96,All Other Inpatient
"Arthrodesis Interphalangeal Jt W/WO Int Fixj|LEFT HAND, THUMB",CASE-26860,APC,26860,CPT,0360,RC,,,FA,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3215.80,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],14873.32,,"Case rate ($14,370.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,504.04, add-ons for qualifying new technology services are included. If operating cost exceeds $48,375.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,668.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $11,516.62 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,559.08 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $908.78. The transfer capital threshold is the transfer adjustment factor * $908.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,14370.36,38378.80,Inpatient DRG
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC",605,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],17131.97,,"Fee schedule rate ($17,131.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8148.17,18024.13,There are no additional notes associated with this service or procedure.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],20553.44,,"Fee schedule rate ($20,553.44). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8874.81,20553.44,There are no additional notes associated with this service or procedure.
"Partical Excision Bone Phalanx Toe|RIGHT FOOT, FIFTH DIGIT",CASE-28124,APC,28124,CPT,0360,RC,,,T9,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC",629,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],44657.18,,"Fee schedule rate ($44,657.18). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,16699.94,44657.18,There are no additional notes associated with this service or procedure.
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,095,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],48575.01,,"Fee schedule rate ($48,575.01). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,19411.47,50750.92,There are no additional notes associated with this service or procedure.
RESPIRATORY NEOPLASMS WITHOUT CC/MCC,182,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],23037.13,,"Fee schedule rate ($23,037.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6965.00,23037.13,There are no additional notes associated with this service or procedure.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],105091.76,,"Fee schedule rate ($105,091.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,35719.96,105091.76,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,091,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],40030.81,,"Fee schedule rate ($40,030.81). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,13838.06,40030.81,There are no additional notes associated with this service or procedure.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],26949.28,,"Fee schedule rate ($26,949.28). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9977.99,26949.28,There are no additional notes associated with this service or procedure.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC",494,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],39945.55,,"Fee schedule rate ($39,945.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,15533.10,39945.55,There are no additional notes associated with this service or procedure.
MAJOR BLADDER PROCEDURES WITH MCC,653,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],102249.56,,,,,,0,other,10280.00,125343.98,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],15609.47,,"Fee schedule rate ($15,609.47). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7569.84,21892.85,There are no additional notes associated with this service or procedure.
MINOR BLADDER PROCEDURES WITHOUT CC/MCC,664,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],16947.06,,"Fee schedule rate ($16,947.06). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9034.63,31876.87,There are no additional notes associated with this service or procedure.
"OTHER COMPLICATIONS OF TREATMENT,MODERATE",813,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],7929.51,,"Case rate ($7,551.91). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7551.91,7929.51,There are no additional notes associated with this service or procedure.
Ercp Remove Foreign Body/Stent Biliary/Panc Duct,CASE-43275,APC,43275,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3735.12,,"APC Price ($3,608.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3608.81,3789.26,OPPS APC
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC",629,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],44657.18,,"Fee schedule rate ($44,657.18). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,16699.94,44657.18,There are no additional notes associated with this service or procedure.
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],53275.26,,"Fee schedule rate ($53,275.26). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,15940.79,53275.26,There are no additional notes associated with this service or procedure.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],7605.00,,"Per diem ($7,605). If length of stay < 4.8, first 1 days paid at a per diem of $15,210 instead. Capped at $36,505.40.",,,,0,other,7605.00,39153.65,Estimated amount calculated based on 3 day length of stay.
HC Drain/Inj Joint/Bursa W/US Large|PBB CHARGE|LEFT SIDE,CASE-20611,APC,20611,CPT,0510,RC,,,PBB|LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],12950.91,,"Case rate ($12,696.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,947.32, add-ons for qualifying new technology services are included. If operating cost exceeds $46,818.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,546.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,965.63 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,002.37 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $786.39. The transfer capital threshold is the transfer adjustment factor * $786.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,12696.97,47123.82,Inpatient DRG
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],25829.63,,"Fee schedule rate ($25,829.63). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6965.00,29482.05,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,426,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],80410.35,,"Case rate ($76,581.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $71,377.56, add-ons for qualifying new technology services are included. If operating cost exceeds $106,248.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $7,218.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $69,177.55 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $69,432.61 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $5,458.79. The transfer capital threshold is the transfer adjustment factor * $5,458.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,76581.29,216864.15,Inpatient DRG
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],6657.03,,"Case rate ($6,340.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,033.60, add-ons for qualifying new technology services are included. If operating cost exceeds $40,904.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,081.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $4,073.62 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,088.64 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $321.45. The transfer capital threshold is the transfer adjustment factor * $321.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6340.03,15076.44,Inpatient DRG
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC,833,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],5486.07,,"Case rate ($5,486.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,239.18, add-ons for qualifying new technology services are included. If operating cost exceeds $40,110.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,018.96, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $3,282.12 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,294.23 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $258.99. The transfer capital threshold is the transfer adjustment factor * $258.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,3041.73,10289.10,Inpatient DRG
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],8355.90,,"Fee schedule rate ($8,355.90). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6340.03,15076.44,There are no additional notes associated with this service or procedure.
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],16283.24,,"Fee schedule rate ($16,283.24). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7875.94,17233.12,There are no additional notes associated with this service or procedure.
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],14309.17,,"Fee schedule rate ($14,309.17). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,17467.27,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],6167.00,,"Per diem ($6,167). If length of stay < 4.5, first 1 days paid at a per diem of $12,334 instead. Capped at $27,753.50.",,,,0,other,6167.00,29058.99,Estimated amount calculated based on 3 day length of stay.
O.R. PROCEDURES FOR OBESITY WITH CC,620,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],43753.50,,"Fee schedule rate ($43,753.50). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12782.30,43753.50,There are no additional notes associated with this service or procedure.
FULL TERM NEONATE WITH MAJOR PROBLEMS,793,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],82045.22,,,,,,0,other,4302.90,82045.22,There are no additional notes associated with this service or procedure.
Cystoscopy prostatic imp 1-3,CASE-C9739,APC,C9739,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5018.77,,"APC Price ($5,018.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5018.77,5269.71,OPPS APC
MAJOR THUMB OR JOINT PROCEDURES,506,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],11635.92,,"Case rate ($11,081.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,444.79, add-ons for qualifying new technology services are included. If operating cost exceeds $45,315.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,428.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $8,468.62 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,499.84 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $668.26. The transfer capital threshold is the transfer adjustment factor * $668.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,11081.83,26548.21,Inpatient DRG
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],17072.76,,"Case rate ($9,755.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,211.27, add-ons for qualifying new technology services are included. If operating cost exceeds $44,082.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,331.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $7,239.63 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,266.32 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $571.28. The transfer capital threshold is the transfer adjustment factor * $571.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,9755.86,29216.99,All Other Inpatient
Inj for Sacroiliac Jt Anesth|RIGHT SIDE,CASE-G0260,APC,G0260,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],683.85,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,660.72,693.76,OPPS APC
INFLAMMATORY BOWEL DISEASE WITH CC,386,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],10568.50,,"Fee schedule rate ($10,568.50). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8556.53,19879.00,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],34409.98,,"Fee schedule rate ($34,409.98). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,14344.60,36028.59,There are no additional notes associated with this service or procedure.
HC Injection Small Joint/Bursa,CASE-20600,APC,20600,CPT,0361,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],297.37,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,287.31,301.68,OPPS APC
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],7842.75,,"Case rate ($7,842.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,431.55, add-ons for qualifying new technology services are included. If operating cost exceeds $42,302.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,191.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $5,466.44 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,486.60 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $431.36. The transfer capital threshold is the transfer adjustment factor * $431.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,5280.00,17136.70,Inpatient DRG
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],54537.29,,"Fee schedule rate ($54,537.29). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.7), with a minimum of zero.",,,,0,other,21597.50,67790.93,There are no additional notes associated with this service or procedure.
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],7261.42,,"Case rate ($6,915.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,569.08, add-ons for qualifying new technology services are included. If operating cost exceeds $41,440.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,123.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,607.15 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,624.14 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $363.55. The transfer capital threshold is the transfer adjustment factor * $363.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6915.64,14442.92,Inpatient DRG
KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,689,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],9998.63,,"Case rate ($9,802.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,254.74, add-ons for qualifying new technology services are included. If operating cost exceeds $44,125.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,334.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $7,282.94 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,309.79 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $574.70. The transfer capital threshold is the transfer adjustment factor * $574.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,9802.58,22831.22,Inpatient DRG
"LIMB REATTACHMENT, HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA",956,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],148259.86,,"Fee schedule rate ($148,259.86). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,27428.25,148259.86,There are no additional notes associated with this service or procedure.
"SINGLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL,MINOR",300,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],31065.00,,"Case rate ($31,065.00). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,31065.00,32618.25,There are no additional notes associated with this service or procedure.
CHOLECYSTECTOMY WITH C.D.E. WITH MCC,411,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],49113.75,,"Fee schedule rate ($49,113.75). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,24315.13,88615.28,There are no additional notes associated with this service or procedure.
PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,337,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],12771.98,,"Case rate ($12,340.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,615.32, add-ons for qualifying new technology services are included. If operating cost exceeds $46,486.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,520.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $9,634.84 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,670.37 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $760.28. The transfer capital threshold is the transfer adjustment factor * $760.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,12340.08,38926.31,Inpatient DRG
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],21992.44,,"Case rate ($21,248.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $19,902.85, add-ons for qualifying new technology services are included. If operating cost exceeds $54,773.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,171.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.3. The base transfer operating payment is the transfer adjustment factor * $17,891.94 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $17,957.90 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,411.85. The transfer capital threshold is the transfer adjustment factor * $1,411.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,21248.73,56089.29,Inpatient DRG
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],21585.31,,"Case rate ($21,585.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,215.96, add-ons for qualifying new technology services are included. If operating cost exceeds $55,086.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,196.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $18,203.89 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,271.01 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,436.47. The transfer capital threshold is the transfer adjustment factor * $1,436.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,21585.31,73588.10,Inpatient DRG
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],29585.82,,"Fee schedule rate ($29,585.82). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12606.23,36868.88,There are no additional notes associated with this service or procedure.
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,069,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],7501.56,,"Case rate ($7,354.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,977.32, add-ons for qualifying new technology services are included. If operating cost exceeds $41,848.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,155.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $5,013.88 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,032.37 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $395.65. The transfer capital threshold is the transfer adjustment factor * $395.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6965.00,20333.68,Inpatient DRG
Corrj Hallux Valgus W/Sesmdc W/Dist Metar Osteot|RIGHT SIDE,CASE-28296,APC,28296,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
"NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY",789,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],6663.33,,,,,,0,other,3054.00,14857.05,Estimated amount calculated based on 1 day length of stay.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC,862,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],15009.94,,"Case rate ($14,295.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,434.11, add-ons for qualifying new technology services are included. If operating cost exceeds $48,305.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,663.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $11,446.95 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,489.15 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $903.28. The transfer capital threshold is the transfer adjustment factor * $903.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6855.00,35884.94,Inpatient DRG
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,690,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],7775.55,,"Fee schedule rate ($7,775.55). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7426.94,15928.53,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITHOUT STERILIZATION WITH MCC,786,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],23722.94,,"Fee schedule rate ($23,722.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12612.10,23722.94,There are no additional notes associated with this service or procedure.
"Remv Vert Body,Cerv,One Sgmt",CASE-63081,APC,63081,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],12437.92,,"APC Price ($12,017.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,12017.31,12437.92,OPPS APC
"Excis Intrasp Lesn,Xdural,Lumbar",CASE-63267,APC,63267,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],9858.95,,"Case rate ($9,389.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,870.44, add-ons for qualifying new technology services are included. If operating cost exceeds $43,741.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,304.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,900.05 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,925.50 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $544.48. The transfer capital threshold is the transfer adjustment factor * $544.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9389.48,22358.90,Inpatient DRG
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,426,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],177294.98,,"Fee schedule rate ($177,294.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,76581.29,216864.15,There are no additional notes associated with this service or procedure.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],28649.93,,"Fee schedule rate ($28,649.93). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,12268.97,41006.47,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],12732.39,,"Case rate ($12,126.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,416.25, add-ons for qualifying new technology services are included. If operating cost exceeds $46,287.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,504.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $9,436.50 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,471.29 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $744.63. The transfer capital threshold is the transfer adjustment factor * $744.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12126.09,29582.40,Inpatient DRG
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],36868.88,,"Fee schedule rate ($36,868.88). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12606.23,36868.88,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC,087,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],22679.07,,"Fee schedule rate ($22,679.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,8139.36,22679.07,There are no additional notes associated with this service or procedure.
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],13625.25,,"Fee schedule rate ($13,625.25). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7243.75,23262.15,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],22358.90,,"Fee schedule rate ($22,358.90). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9389.48,22358.90,There are no additional notes associated with this service or procedure.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],75579.22,,"Fee schedule rate ($75,579.22). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,25162.32,75579.22,There are no additional notes associated with this service or procedure.
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],17738.77,,"Case rate ($10,136.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,565.33, add-ons for qualifying new technology services are included. If operating cost exceeds $44,436.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,359.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $7,592.38 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,620.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $599.11. The transfer capital threshold is the transfer adjustment factor * $599.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,10136.44,24444.75,All Other Inpatient
Exc B9 Lesion Mrgn Xcp Sk Tg T/a/L 3.1-4.0 Cm,CASE-11404,APC,11404,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1623.23,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1545.93,1623.23,OPPS APC
Exc Cyst/Aberrant Breast Tissue Open 1/> Lesion|LEFT SIDE,CASE-19120,APC,19120,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3664.94,,"APC Price ($3,664.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3664.94,3793.21,OPPS APC
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],2070.00,,,,,,0,other,1188.00,17370.86,Estimated amount calculated based on 3 day length of stay.
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],10839.27,,"Case rate ($10,626.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,021.44, add-ons for qualifying new technology services are included. If operating cost exceeds $44,892.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,394.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $8,046.82 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,076.49 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $634.97. The transfer capital threshold is the transfer adjustment factor * $634.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,10626.74,25225.91,Inpatient DRG
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],26391.01,,"Fee schedule rate ($26,391.01). Adds an outlier to normal pricing equal to the per diem rate ($77,296.48) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,11454.97,28394.78,There are no additional notes associated with this service or procedure.
NONTRAUMATIC STUPOR AND COMA WITH MCC,080,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],34015.33,,"Fee schedule rate ($34,015.33). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.5), with a minimum of zero.",,,,0,other,14202.39,35615.37,There are no additional notes associated with this service or procedure.
Colposcopy Cervix Bx Cervix & Endocrv Curretage,CASE-57454,APC,57454,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],299.50,,"APC Price ($285.23). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,285.23,299.50,OPPS APC
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],30245.71,,"Fee schedule rate ($30,245.71). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9151.11,30245.71,There are no additional notes associated with this service or procedure.
HC Joint Injection/Aspir Large WO US|RIGHT SIDE|PBB CHARGE,CASE-20610,APC,20610,CPT,0510,RC,,,RT|PBB,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],297.37,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,287.31,301.68,OPPS APC
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],18512.68,,"Case rate ($17,631.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,566.73, add-ons for qualifying new technology services are included. If operating cost exceeds $51,437.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,879.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $14,566.55 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,621.78 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,119.62. The transfer capital threshold is the transfer adjustment factor * $1,119.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,18105.81,52699.33,Inpatient DRG
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],68942.79,,"Fee schedule rate ($68,942.79). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,21489.15,68942.79,There are no additional notes associated with this service or procedure.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],19604.30,,"Fee schedule rate ($19,604.30). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9446.38,21796.21,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITH STERILIZATION WITH MCC,783,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],23722.94,,"Fee schedule rate ($23,722.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12612.10,23722.94,There are no additional notes associated with this service or procedure.
RADIOTHERAPY,849,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],81867.07,,"Fee schedule rate ($81,867.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,20293.88,81867.07,There are no additional notes associated with this service or procedure.
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],90333.60,,"Fee schedule rate ($90,333.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,26127.34,90333.60,There are no additional notes associated with this service or procedure.
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],21089.59,,"Fee schedule rate ($21,089.59). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,6965.00,21089.59,There are no additional notes associated with this service or procedure.
Cysto W/Ureteroscopy W/Rmvl/Manj Stones|BILATERAL PROCEDURE,CASE-52352,APC,52352,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3299.47,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3299.47,3464.44,OPPS APC
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],9075.36,,"Case rate ($8,643.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,176.19, add-ons for qualifying new technology services are included. If operating cost exceeds $43,047.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,249.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $6,208.35 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,231.24 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $489.90. The transfer capital threshold is the transfer adjustment factor * $489.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8643.20,19462.52,Inpatient DRG
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],26939.48,,"Case rate ($26,028.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $24,349.34, add-ons for qualifying new technology services are included. If operating cost exceeds $59,220.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,521.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $22,322.08 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $22,404.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,761.43. The transfer capital threshold is the transfer adjustment factor * $1,761.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103.5%.",,,,0,other,26028.48,80635.65,Inpatient DRG
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],13001.72,,"Case rate ($13,001.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,230.82, add-ons for qualifying new technology services are included. If operating cost exceeds $47,101.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,568.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $10,248.08 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,285.87 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $808.68. The transfer capital threshold is the transfer adjustment factor * $808.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7868.00,32126.64,Inpatient DRG
VAGINAL DELIVERY WITH O.R. PROCEDURES EXCEPT STERILIZATION AND/OR D&C,768,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],12088.81,,"Fee schedule rate ($12,088.81). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6426.91,13416.00,There are no additional notes associated with this service or procedure.
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],13654.09,,"Case rate ($13,386.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,588.65, add-ons for qualifying new technology services are included. If operating cost exceeds $47,459.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,596.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $10,604.60 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,643.70 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $836.81. The transfer capital threshold is the transfer adjustment factor * $836.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,13386.36,33244.29,Inpatient DRG
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,451,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],24655.19,,"Case rate ($23,821.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $22,296.19, add-ons for qualifying new technology services are included. If operating cost exceeds $57,167.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,359.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $20,276.48 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $20,351.24 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,600.01. The transfer capital threshold is the transfer adjustment factor * $1,600.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,23821.44,94077.13,Inpatient DRG
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],54537.29,,"Fee schedule rate ($54,537.29). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.7), with a minimum of zero.",,,,0,other,21597.50,67790.93,There are no additional notes associated with this service or procedure.
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],8877.69,,"Case rate ($8,454.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,001.06, add-ons for qualifying new technology services are included. If operating cost exceeds $42,872.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,236.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,033.86 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,056.11 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $476.13. The transfer capital threshold is the transfer adjustment factor * $476.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6230.00,22762.43,Inpatient DRG
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],31007.30,,"Fee schedule rate ($31,007.30). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,16120.25,41187.90,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],34892.92,,"Fee schedule rate ($34,892.92). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,6965.00,41030.48,There are no additional notes associated with this service or procedure.
Colsc Flexible W/Control Bleeding Any Method|UNUSUAL NON-OVERLAPPING SERVICE,CASE-45382,APC,45382,CPT,0360,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1120.09,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1120.09,1176.09,OPPS APC
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,073,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],43475.01,,"Fee schedule rate ($43,475.01). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,12809.38,43475.01,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],13299.05,,"Case rate ($12,665.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,938.30, add-ons for qualifying new technology services are included. If operating cost exceeds $46,809.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,525.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $9,955.60 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,993.35 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $765.21. The transfer capital threshold is the transfer adjustment factor * $765.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9888.00,43399.23,Inpatient DRG
"PROCEDURES FOR OBESITY,MODERATE",403,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],15014.02,,"Case rate ($14,299.07). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,14299.07,15014.02,There are no additional notes associated with this service or procedure.
"HC Excis Nail Matrix Perm Rmvl|LEFT FOOT, GREAT TOE|UNUSUAL NON-OVERLAPPING SERVICE",CASE-11750,APC,11750,CPT,0450,RC,,,TA|XU,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3169.86,OPPS APC
Egd Dilation Gastric/Duodenal Stricture,CASE-43245,APC,43245,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1885.95,,"APC Price ($1,796.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1796.14,1885.95,OPPS APC
"HIV WITH MULTIPLE MAJOR HIV RELATED CONDITIONS,EXTREME",890,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],31308.40,,"Case rate ($31,308.40). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,31308.40,32873.82,There are no additional notes associated with this service or procedure.
ALLERGIC REACTIONS WITH MCC,915,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],31602.31,,"Fee schedule rate ($31,602.31). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.8), with a minimum of zero.",,,,0,other,13332.86,33088.84,There are no additional notes associated with this service or procedure.
BRONCHITIS AND ASTHMA WITH CC/MCC,202,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],18251.76,,"Fee schedule rate ($18,251.76). Adds an outlier to normal pricing equal to the per diem rate ($45,948.49) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,7606.34,19110.30,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],13947.32,,"Fee schedule rate ($13,947.32). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6153.12,13947.32,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC,833,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],5721.39,,"Fee schedule rate ($5,721.39). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,3041.73,10289.10,There are no additional notes associated with this service or procedure.
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],18245.94,,"Fee schedule rate ($18,245.94). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8106.18,18245.94,There are no additional notes associated with this service or procedure.
Rpr Aa Hernia Recr 3-10 Cm Reducible,CASE-49615,APC,49615,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6059.65,,"APC Price ($6,059.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6059.65,6362.63,OPPS APC
HYPERTENSION WITHOUT MCC,305,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],17230.49,,"Fee schedule rate ($17,230.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7058.55,17230.49,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],10223.39,,"Fee schedule rate ($10,223.39). Adds an outlier to normal pricing equal to the per diem rate ($48,095.58) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,5628.97,12272.58,There are no additional notes associated with this service or procedure.
DIABETES WITHOUT CC/MCC,639,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],11899.36,,"Fee schedule rate ($11,899.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6151.76,12223.35,There are no additional notes associated with this service or procedure.
"NON-EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,EXTREME",952,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],38386.67,,"Case rate ($38,386.67). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,38386.67,40306.00,There are no additional notes associated with this service or procedure.
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],6942.60,,"Fee schedule rate ($6,942.60). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5415.00,17575.50,There are no additional notes associated with this service or procedure.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],18542.54,,"Case rate ($18,178.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,047.10, add-ons for qualifying new technology services are included. If operating cost exceeds $51,918.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,947.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $15,046.67 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,102.15 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,187.33. The transfer capital threshold is the transfer adjustment factor * $1,187.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,18178.96,54764.34,Inpatient DRG
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],43703.12,,"Fee schedule rate ($43,703.12). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.7), with a minimum of zero.",,,,0,other,17693.40,52449.26,There are no additional notes associated with this service or procedure.
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],21854.96,,"Fee schedule rate ($21,854.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10638.94,25261.33,There are no additional notes associated with this service or procedure.
"NEONATE BIRTH WEIGHT > 2499 GRAMS WITH OTHER MAJOR PROCEDURE,MINOR",631,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],4708.43,,"Case rate ($4,484.22). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4484.22,4708.43,There are no additional notes associated with this service or procedure.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],13141.36,,"Case rate ($12,696.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,947.32, add-ons for qualifying new technology services are included. If operating cost exceeds $46,818.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,546.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,965.63 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,002.37 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $786.39. The transfer capital threshold is the transfer adjustment factor * $786.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,12696.97,47123.82,Inpatient DRG
HC Inj Trigger Pt 1-2 Musc Grps|PBB CHARGE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-20552,APC,20552,CPT,0510,RC,,,PBB|XU,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
CHOLECYSTECTOMY WITH C.D.E. WITH MCC,411,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],88615.28,,"Fee schedule rate ($88,615.28). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,24315.13,88615.28,There are no additional notes associated with this service or procedure.
"CESAREAN SECTION WITHOUT STERILIZATION,MINOR",540,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],6211.03,,"Case rate ($6,211.03). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,6211.03,6521.58,There are no additional notes associated with this service or procedure.
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],7842.75,,"Case rate ($7,842.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,431.55, add-ons for qualifying new technology services are included. If operating cost exceeds $42,302.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,191.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $5,466.44 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,486.60 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $431.36. The transfer capital threshold is the transfer adjustment factor * $431.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,5280.00,17136.70,Inpatient DRG
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,555,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],10896.27,,"Case rate ($10,896.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,272.18, add-ons for qualifying new technology services are included. If operating cost exceeds $45,143.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,414.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,296.64 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,327.23 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $654.69. The transfer capital threshold is the transfer adjustment factor * $654.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10896.27,42290.95,Inpatient DRG
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],41961.35,,"Case rate ($40,542.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $37,851.31, add-ons for qualifying new technology services are included. If operating cost exceeds $72,722.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,582.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.6. The base transfer operating payment is the transfer adjustment factor * $35,774.45 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $35,906.36 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,822.96. The transfer capital threshold is the transfer adjustment factor * $2,822.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,40542.37,128358.13,Inpatient DRG
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],61234.06,,"Fee schedule rate ($61,234.06). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11165.00,61234.06,There are no additional notes associated with this service or procedure.
OSTEOMYELITIS WITH CC,540,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],10723.59,,"Case rate ($10,723.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,111.53, add-ons for qualifying new technology services are included. If operating cost exceeds $44,982.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,402.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $8,136.58 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,166.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $642.06. The transfer capital threshold is the transfer adjustment factor * $642.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9809.07,25507.30,Inpatient DRG
SKIN ULCERS WITH MCC,592,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],15116.17,,"Case rate ($15,116.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $14,168.54, add-ons for qualifying new technology services are included. If operating cost exceeds $53,556.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $3,795.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.8. The base transfer operating payment is the transfer adjustment factor * $12,752.10 + an uncompensated DSH payment of $1,359.91. The transfer operating threshold is the transfer adjustment factor * $12,808.63 + an uncompensated DSH payment of $1,359.91. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,004.16. The transfer capital threshold is the transfer adjustment factor * $1,004.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,15116.17,38644.05,Inpatient DRG
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],25253.70,,"Fee schedule rate ($25,253.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11974.38,29141.64,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],11594.35,,"Fee schedule rate ($11,594.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6164.03,14071.02,There are no additional notes associated with this service or procedure.
MAJOR CHEST TRAUMA WITHOUT CC/MCC,185,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],21771.61,,"Fee schedule rate ($21,771.61). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7271.19,21771.61,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],14951.37,,"Case rate ($8,543.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,083.58, add-ons for qualifying new technology services are included. If operating cost exceeds $42,954.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,242.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,116.09 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,138.64 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $482.62. The transfer capital threshold is the transfer adjustment factor * $482.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,8543.64,23239.84,All Other Inpatient
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",063,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],35701.87,,"Fee schedule rate ($35,701.87). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,35701.87,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],30063.84,,"Fee schedule rate ($30,063.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13891.57,34712.20,There are no additional notes associated with this service or procedure.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],13445.25,,"Fee schedule rate ($13,445.25). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10098.51,24259.09,There are no additional notes associated with this service or procedure.
"Tendon Sheath Incision|RIGHT HAND, THIRD DIGIT|UNUSUAL NON-OVERLAPPING SERVICE",CASE-26055,APC,26055,CPT,0360,RC,,,F7|XU,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1505.12,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1505.12,1580.37,OPPS APC
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],7734.30,,"Case rate ($7,366). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,988.03, add-ons for qualifying new technology services are included. If operating cost exceeds $41,859.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,156.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,024.55 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,043.08 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $396.49. The transfer capital threshold is the transfer adjustment factor * $396.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,21195.68,Inpatient DRG
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH MCC",510,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],22399.99,,"Case rate ($22,399.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,973.84, add-ons for qualifying new technology services are included. If operating cost exceeds $55,844.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,256.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.3. The base transfer operating payment is the transfer adjustment factor * $18,958.99 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $19,028.89 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,496.05. The transfer capital threshold is the transfer adjustment factor * $1,496.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10710.00,89863.76,Inpatient DRG
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],11681.49,,"Fee schedule rate ($11,681.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5778.62,11681.49,There are no additional notes associated with this service or procedure.
"ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",770,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],18843.74,,"Fee schedule rate ($18,843.74). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,8735.30,19730.13,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],18585.05,,"Fee schedule rate ($18,585.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8859.23,20090.22,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],14472.36,,"Case rate ($13,783.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,957.83, add-ons for qualifying new technology services are included. If operating cost exceeds $47,828.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,625.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $10,972.42 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,012.88 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $865.83. The transfer capital threshold is the transfer adjustment factor * $865.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13783.20,41580.51,Inpatient DRG
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],26966.33,,"Fee schedule rate ($26,966.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,9040.72,26966.33,There are no additional notes associated with this service or procedure.
Cysto W/Insert Ureteral Stent|LEFT SIDE,CASE-52332,APC,52332,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3299.47,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3299.47,3464.44,OPPS APC
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC,939,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],97674.79,,"Fee schedule rate ($97,674.79). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,26517.40,97674.79,There are no additional notes associated with this service or procedure.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],31626.74,,"Fee schedule rate ($31,626.74). Adds an outlier to normal pricing equal to the per diem rate ($86,383.13) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,13341.67,42586.49,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITHOUT STERILIZATION WITH CC,787,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],9983.41,,"Case rate ($9,508.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,980.70, add-ons for qualifying new technology services are included. If operating cost exceeds $43,851.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,313.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $7,009.90 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,035.74 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $553.15. The transfer capital threshold is the transfer adjustment factor * $553.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9508.01,23722.94,Inpatient DRG
"ANTEPARTUM WITH O.R. PROCEDURE,MAJOR",547,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],15997.15,,"Case rate ($15,235.38). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,15235.38,15997.15,There are no additional notes associated with this service or procedure.
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],14455.04,,"Fee schedule rate ($14,455.04). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5280.00,17136.70,There are no additional notes associated with this service or procedure.
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH MCC",510,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],23183.99,,"Case rate ($22,399.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,973.84, add-ons for qualifying new technology services are included. If operating cost exceeds $55,844.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,256.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.3. The base transfer operating payment is the transfer adjustment factor * $18,958.99 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $19,028.89 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,496.05. The transfer capital threshold is the transfer adjustment factor * $1,496.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,10710.00,89863.76,Inpatient DRG
MINOR BLADDER PROCEDURES WITHOUT CC/MCC,664,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],15810.60,,"Case rate ($9,034.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,540.33, add-ons for qualifying new technology services are included. If operating cost exceeds $43,411.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,278.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $6,571.15 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,595.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $518.53. The transfer capital threshold is the transfer adjustment factor * $518.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,9034.63,31876.87,All Other Inpatient
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],17033.98,,"Fee schedule rate ($17,033.98). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.8), with a minimum of zero.",,,,0,other,7884.32,17835.23,There are no additional notes associated with this service or procedure.
"Tendon Sheath Incision|LEFT HAND, FOURTH DIGIT",CASE-26055,APC,26055,CPT,0360,RC,,,F3,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1580.37,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1505.12,1580.37,OPPS APC
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC,862,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],15009.94,,"Case rate ($14,295.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,434.11, add-ons for qualifying new technology services are included. If operating cost exceeds $48,305.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,663.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $11,446.95 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,489.15 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $903.28. The transfer capital threshold is the transfer adjustment factor * $903.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6855.00,35884.94,Inpatient DRG
Perq Drainage Pleura Insert Cath W/O Imaging|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-32556,APC,32556,CPT,0360,RC,,,LT|XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5856.81,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5658.76,5856.81,OPPS APC
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],62041.12,,"Fee schedule rate ($62,041.12). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,18497.24,62041.12,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,447,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],156646.82,,"Fee schedule rate ($156,646.82). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,47193.21,156646.82,There are no additional notes associated with this service or procedure.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],101083.00,,"Fee schedule rate ($101,083.00). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,35389.50,101083.00,There are no additional notes associated with this service or procedure.
OSTEOMYELITIS WITHOUT CC/MCC,541,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],5103.00,,"Per diem ($5,103). If length of stay < 2.9, first 1 days paid at a per diem of $10,206 instead. Capped at $14,797.61.",,,,0,other,5103.00,15493.67,Estimated amount calculated based on 1 day length of stay.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],16900.84,,"Fee schedule rate ($16,900.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8151.55,18033.97,There are no additional notes associated with this service or procedure.
"Arthrodesis Interphalangeal Jt W/WO Int Fixj|RIGHT HAND, FIFTH DIGIT",CASE-26860,APC,26860,CPT,0360,RC,,,F9,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],37149.27,,"Fee schedule rate ($37,149.27). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,12455.21,37149.27,There are no additional notes associated with this service or procedure.
CERVICAL SPINAL FUSION WITH CC,472,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],70198.84,,"Fee schedule rate ($70,198.84). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,21896.13,70198.84,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],12984.79,,"Case rate ($12,984.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,215.07, add-ons for qualifying new technology services are included. If operating cost exceeds $47,086.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,567.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $10,232.39 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,270.12 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $807.44. The transfer capital threshold is the transfer adjustment factor * $807.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12984.79,32077.45,Inpatient DRG
DIABETES WITHOUT CC/MCC,639,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],6151.76,,"Case rate ($6,151.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,858.45, add-ons for qualifying new technology services are included. If operating cost exceeds $40,729.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,067.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $3,899.13 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,913.51 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $307.68. The transfer capital threshold is the transfer adjustment factor * $307.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6151.76,12223.35,Inpatient DRG
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5628.97,,"Case rate ($5,628.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,372.11, add-ons for qualifying new technology services are included. If operating cost exceeds $40,243.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,029.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,414.56 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,427.15 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $269.44. The transfer capital threshold is the transfer adjustment factor * $269.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,5628.97,12272.58,Inpatient DRG
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],8271.77,,"Case rate ($7,877.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,475.30, add-ons for qualifying new technology services are included. If operating cost exceeds $42,346.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,183.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,509.46 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,530.35 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $423.47. The transfer capital threshold is the transfer adjustment factor * $423.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6524.00,17760.46,Inpatient DRG
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],101083.00,,"Fee schedule rate ($101,083.00). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,35389.50,101083.00,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],37495.79,,"Fee schedule rate ($37,495.79). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.8), with a minimum of zero.",,,,0,other,15456.59,41402.42,There are no additional notes associated with this service or procedure.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,056,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],59328.19,,"Fee schedule rate ($59,328.19). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (44), with a minimum of zero.",,,,0,other,7659.00,59328.19,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL HEMORRHAGE WITH CC,378,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],8886.85,,"Case rate ($8,586.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,123.28, add-ons for qualifying new technology services are included. If operating cost exceeds $42,994.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,245.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,155.63 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,178.33 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $485.74. The transfer capital threshold is the transfer adjustment factor * $485.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,8586.33,20845.19,Inpatient DRG
"ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",770,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],9041.04,,"Case rate ($8,735.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,261.87, add-ons for qualifying new technology services are included. If operating cost exceeds $43,132.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,256.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $6,293.72 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,316.92 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $496.64. The transfer capital threshold is the transfer adjustment factor * $496.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,8735.30,19730.13,Inpatient DRG
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],7772.69,,"Case rate ($7,402.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,022.05, add-ons for qualifying new technology services are included. If operating cost exceeds $41,893.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,159.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,058.45 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,077.10 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $399.16. The transfer capital threshold is the transfer adjustment factor * $399.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7402.56,16438.59,Inpatient DRG
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],17755.26,,"Fee schedule rate ($17,755.26). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7847.50,17755.26,There are no additional notes associated with this service or procedure.
MAJOR THUMB OR JOINT PROCEDURES,506,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],11469.69,,"Case rate ($11,081.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,444.79, add-ons for qualifying new technology services are included. If operating cost exceeds $45,315.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,428.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $8,468.62 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,499.84 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $668.26. The transfer capital threshold is the transfer adjustment factor * $668.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,11081.83,26548.21,Inpatient DRG
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],45050.58,,"Fee schedule rate ($45,050.58). Adds an outlier to normal pricing equal to the per diem rate ($120,238.99) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,18178.96,54764.34,There are no additional notes associated with this service or procedure.
RESPIRATORY NEOPLASMS WITH CC,181,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],17609.39,,"Fee schedule rate ($17,609.39). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9197.84,21074.07,There are no additional notes associated with this service or procedure.
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],11165.00,,"Per diem ($11,165). If length of stay < 3.5, first 1 days paid at a per diem of $22,330 instead. Capped at $39,078.16.",,,,0,other,11165.00,61234.06,Estimated amount calculated based on 3 day length of stay.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],9206.20,,"Case rate ($8,767.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,292.11, add-ons for qualifying new technology services are included. If operating cost exceeds $43,163.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,258.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,323.85 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,347.16 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $499.01. The transfer capital threshold is the transfer adjustment factor * $499.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8767.81,19824.58,Inpatient DRG
Int Hrhc by Ligation 2+ Hroid W/O Img Gdn,CASE-46946,APC,46946,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],2598.08,,"APC Price ($2,598.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2598.08,2727.99,OPPS APC
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],19126.88,,"Fee schedule rate ($19,126.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,19126.88,There are no additional notes associated with this service or procedure.
SPINAL PROCEDURES WITHOUT CC/MCC,030,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],23771.82,,"Fee schedule rate ($23,771.82). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,16810.99,44714.01,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,085,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],30328.22,,"Case rate ($17,330.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,257.72, add-ons for qualifying new technology services are included. If operating cost exceeds $51,128.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,885.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $14,260.20 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,312.77 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,125.27. The transfer capital threshold is the transfer adjustment factor * $1,125.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,9282.00,57443.16,All Other Inpatient
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,451,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],24337.80,,"Case rate ($23,178.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $21,738.03, add-ons for qualifying new technology services are included. If operating cost exceeds $56,609.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,275.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $19,718.32 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $19,793.08 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,515.60. The transfer capital threshold is the transfer adjustment factor * $1,515.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,23821.44,94077.13,Inpatient DRG
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,091,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],33004.27,,"Fee schedule rate ($33,004.27). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13838.06,40030.81,There are no additional notes associated with this service or procedure.
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7598.16,,"Case rate ($7,236.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,877.29, add-ons for qualifying new technology services are included. If operating cost exceeds $41,748.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,137.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,913.71 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,932.34 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $377.68. The transfer capital threshold is the transfer adjustment factor * $377.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7396.47,16035.06,Inpatient DRG
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],26301.36,,"Fee schedule rate ($26,301.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11247.07,27028.33,There are no additional notes associated with this service or procedure.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],20401.88,,"Fee schedule rate ($20,401.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,20401.88,There are no additional notes associated with this service or procedure.
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5777.94,,"Case rate ($5,777.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,510.70, add-ons for qualifying new technology services are included. If operating cost exceeds $40,381.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,040.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $3,552.65 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,565.75 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $280.34. The transfer capital threshold is the transfer adjustment factor * $280.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,5065.00,12558.65,Inpatient DRG
Prtl Exc B1 Tarsal/Metar B1 Xcp Talus/Calcaneus|RIGHT SIDE,CASE-28122,APC,28122,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3169.86,OPPS APC
APPENDIX PROCEDURES WITH MCC,397,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],45007.36,,"Fee schedule rate ($45,007.36). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.5), with a minimum of zero.",,,,0,other,18163.37,51558.84,There are no additional notes associated with this service or procedure.
"Corrj Hallux Valgus W/Sesmdc W/Rescj Prox Phal|LEFT FOOT, GREAT TOE",CASE-28292,APC,28292,CPT,0360,RC,,,TA,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],2070.00,,,,,,0,other,1188.00,18893.86,Estimated amount calculated based on 3 day length of stay.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],27256.92,,"Case rate ($27,256.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $25,492.14, add-ons for qualifying new technology services are included. If operating cost exceeds $60,363.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,611.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. The base transfer operating payment is the transfer adjustment factor * $23,460.69 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $23,547.19 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,851.28. The transfer capital threshold is the transfer adjustment factor * $1,851.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,27256.92,81353.66,Inpatient DRG
INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC,198,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],12496.27,,"Fee schedule rate ($12,496.27). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6795.12,23505.07,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],24567.74,,"Case rate ($24,567.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $22,990.45, add-ons for qualifying new technology services are included. If operating cost exceeds $57,861.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,414.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.7. The base transfer operating payment is the transfer adjustment factor * $20,968.18 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $21,045.49 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,654.60. The transfer capital threshold is the transfer adjustment factor * $1,654.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9370.00,65732.99,Inpatient DRG
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],29594.00,,"Fee schedule rate ($29,594.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,13571.25,33781.47,There are no additional notes associated with this service or procedure.
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],14455.04,,"Fee schedule rate ($14,455.04). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5280.00,17136.70,There are no additional notes associated with this service or procedure.
Injection Aa&/Strd Intercostal Nrv Ea Addl Lvl,CASE-64421,APC,64421,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],827.89,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,827.89,869.28,OPPS APC
Rpr Xtnsr Tdn Cntrl Slip Tiss W/Lat Band Ea Fngr,CASE-26426,APC,26426,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC,621,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],29680.79,,,,,,0,other,12159.94,36669.96,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL OBSTRUCTION WITH CC,389,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],5118.00,,"Per diem ($5,118). If length of stay < 2.9, first 1 days paid at a per diem of $10,236 instead. Capped at $14,842.71.",,,,0,other,5118.00,16423.43,Estimated amount calculated based on 2 day length of stay.
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],9040.72,,"Case rate ($9,040.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,546, add-ons for qualifying new technology services are included. If operating cost exceeds $43,417.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,278.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,576.80 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,601.05 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $518.97. The transfer capital threshold is the transfer adjustment factor * $518.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9040.72,26966.33,Inpatient DRG
NORMAL NEWBORN,795,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],2576.52,,"Fee schedule rate ($2,576.52). Adds an outlier to normal pricing equal to the per diem rate ($414) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,1369.79,5771.52,There are no additional notes associated with this service or procedure.
"Corrj Hallux Valgus W/Sesmdc W/Rescj Prox Phal|LEFT FOOT, GREAT TOE",CASE-28292,APC,28292,CPT,0360,RC,,,TA,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3062.67,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],12173.48,,"Case rate ($11,593.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,921.06, add-ons for qualifying new technology services are included. If operating cost exceeds $45,792.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,465.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $8,943.14 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,976.12 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $705.70. The transfer capital threshold is the transfer adjustment factor * $705.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,11593.79,38248.08,Inpatient DRG
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],29585.82,,"Fee schedule rate ($29,585.82). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12606.23,36868.88,There are no additional notes associated with this service or procedure.
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],8044.02,,"Case rate ($7,660.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,273.10, add-ons for qualifying new technology services are included. If operating cost exceeds $42,144.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,167.96, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,308.03 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,328.15 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $407.99. The transfer capital threshold is the transfer adjustment factor * $407.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5883.03,17111.12,Inpatient DRG
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],27553.62,,"Fee schedule rate ($27,553.62). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12305.53,30103.84,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,064,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],16108.31,,"Case rate ($15,563.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,614.08, add-ons for qualifying new technology services are included. If operating cost exceeds $49,485.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,756.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $12,622.59 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,669.13 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $996.05. The transfer capital threshold is the transfer adjustment factor * $996.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,15563.58,41838.16,Inpatient DRG
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITHOUT CC/MCC",630,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],42541.02,,"Fee schedule rate ($42,541.02). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11828.78,42541.02,There are no additional notes associated with this service or procedure.
Exc Tumor Soft Tissue Abdl Wall Subfascial 5cm/>,CASE-22901,APC,22901,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],2718.88,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2718.88,2854.83,OPPS APC
Egd Band Ligation Esophgeal/Gastric Varices,CASE-43244,APC,43244,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1859.01,,"APC Price ($1,796.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1796.14,1885.95,OPPS APC
Secondary Closure Surg Wound/Dehsn Extsv/Complic,CASE-13160,APC,13160,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3317.01,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3317.01,3433.11,OPPS APC
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,426,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],207121.41,,"Fee schedule rate ($207,121.41). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,76581.29,216864.15,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,555,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],42290.95,,"Fee schedule rate ($42,290.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10896.27,42290.95,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],34481.40,,"Fee schedule rate ($34,481.40). Adds an outlier to normal pricing equal to the per diem rate ($50,543.29) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,14370.36,38378.80,There are no additional notes associated with this service or procedure.
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR,518,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],27799.30,,"Case rate ($27,254.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $25,489.62, add-ons for qualifying new technology services are included. If operating cost exceeds $60,360.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,611.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 5.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $23,458.18 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $23,544.67 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,851.08. The transfer capital threshold is the transfer adjustment factor * $1,851.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,13252.00,89342.77,Inpatient DRG
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],96365.69,,"Fee schedule rate ($96,365.69). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,23377.19,96365.69,There are no additional notes associated with this service or procedure.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],11348.00,,"Per diem ($11,348). If length of stay < 4.2, first 1 days paid at a per diem of $22,696 instead. Capped at $47,660.93.",,,,0,other,11348.00,62454.12,Estimated amount calculated based on 5 day length of stay.
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],54875.56,,"Fee schedule rate ($54,875.56). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,21719.40,85305.59,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,083,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],6965.00,,,,,,0,other,6965.00,28680.85,There are no additional notes associated with this service or procedure.
Revj/Rmvl Impl Spi Npg/Rcvr Dtch Connj Eltrd Ra,CASE-63688,APC,63688,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3436.06,,"APC Price ($3,272.44). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3272.44,3436.06,OPPS APC
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],31658.33,,,,,,0,other,1188.00,31658.33,There are no additional notes associated with this service or procedure.
NON-MALIGNANT BREAST DISORDERS WITH CC/MCC,600,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],15046.13,,"Fee schedule rate ($15,046.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7999.14,20495.56,There are no additional notes associated with this service or procedure.
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,068,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],23184.90,,"Fee schedule rate ($23,184.90). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,23184.90,There are no additional notes associated with this service or procedure.
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],33221.97,,"Fee schedule rate ($33,221.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (47), with a minimum of zero.",,,,0,other,15283.90,38757.79,There are no additional notes associated with this service or procedure.
Arthrs Kne Surg W/Meniscectomy Med/Lat W/Shvg|LEFT SIDE|SEPARATE STRUCTURE,CASE-29881,APC,29881,CPT,0360,RC,,,LT|XS,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6791.99,7131.59,OPPS APC
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,477,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],64922.30,,"Fee schedule rate ($64,922.30). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16.6), with a minimum of zero.",,,,0,other,25339.74,67976.16,There are no additional notes associated with this service or procedure.
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],6965.00,,,,,,0,other,4341.01,12882.53,There are no additional notes associated with this service or procedure.
Cysto W/Ureteroscopy W/Rmvl/Manj Stones,CASE-52352,APC,52352,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3464.44,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3299.47,3464.44,OPPS APC
Prq Impltj Neurostimulator Eltrd Peripheral Nrv,CASE-64555,APC,64555,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6263.54,,"APC Price ($5,965.28). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5965.28,6263.54,OPPS APC
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],64429.92,,"Fee schedule rate ($64,429.92). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,25162.32,75579.22,There are no additional notes associated with this service or procedure.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],12556.70,,"Fee schedule rate ($12,556.70). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10533.95,24956.34,There are no additional notes associated with this service or procedure.
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],9468.12,,"Case rate ($9,282.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,770.90, add-ons for qualifying new technology services are included. If operating cost exceeds $43,641.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,296.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,800.88 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,825.96 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $536.66. The transfer capital threshold is the transfer adjustment factor * $536.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,9282.47,21320.03,Inpatient DRG
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],8225.64,,"Case rate ($7,833.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,423.35, add-ons for qualifying new technology services are included. If operating cost exceeds $42,294.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,190.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,458.28 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,478.41 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $430.71. The transfer capital threshold is the transfer adjustment factor * $430.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5883.03,17111.12,Inpatient DRG
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],59385.88,,"Fee schedule rate ($59,385.88). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,23344.70,62179.32,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC,087,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],8546.33,,"Case rate ($8,139.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,707.48, add-ons for qualifying new technology services are included. If operating cost exceeds $42,578.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,213.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $5,741.36 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,762.53 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $453.05. The transfer capital threshold is the transfer adjustment factor * $453.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8139.36,22679.07,Inpatient DRG
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC,833,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],6965.00,,,,,,0,other,3041.73,10289.10,There are no additional notes associated with this service or procedure.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],16669.71,,"Fee schedule rate ($16,669.71). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8767.81,19824.58,There are no additional notes associated with this service or procedure.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],45845.03,,"Fee schedule rate ($45,845.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,18598.83,48389.68,There are no additional notes associated with this service or procedure.
UNGROUPABLE,999,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],10228.00,,"Per diem ($10,228). If length of stay < 12.7, first 1 days paid at a per diem of $20,456 instead. Capped at $129,893.46.",,,,0,other,10228.00,161307.29,Estimated amount calculated based on 9 day length of stay.
Incision & Removal Foreign Body Subq Tiss Compl,CASE-10121,APC,10121,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1545.93,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1545.93,1623.23,OPPS APC
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],42083.20,,,,,,0,other,16428.39,42083.20,There are no additional notes associated with this service or procedure.
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],10300.89,,"Case rate ($9,810.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,276.67, add-ons for qualifying new technology services are included. If operating cost exceeds $44,147.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,321.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,304.03 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,331.72 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $561.40. The transfer capital threshold is the transfer adjustment factor * $561.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10048.39,23545.50,Inpatient DRG
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC,964,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],12940.01,,"Case rate ($12,323.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,600.20, add-ons for qualifying new technology services are included. If operating cost exceeds $46,471.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,519.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $9,619.78 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,655.25 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $759.10. The transfer capital threshold is the transfer adjustment factor * $759.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12323.82,34154.06,Inpatient DRG
RESPIRATORY NEOPLASMS WITHOUT CC/MCC,182,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],23037.13,,"Fee schedule rate ($23,037.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6965.00,23037.13,There are no additional notes associated with this service or procedure.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],8151.55,,"Case rate ($8,151.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,718.82, add-ons for qualifying new technology services are included. If operating cost exceeds $42,589.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,213.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,752.66 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,773.87 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $453.94. The transfer capital threshold is the transfer adjustment factor * $453.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8151.55,18033.97,Inpatient DRG
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],33321.87,,"Fee schedule rate ($33,321.87). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.9), with a minimum of zero.",,,,0,other,13917.42,34889.29,There are no additional notes associated with this service or procedure.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],58320.32,,"Fee schedule rate ($58,320.32). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,16286.16,58320.32,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITHOUT CC/MCC,428,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],110624.09,,,,,,0,other,40017.53,118904.57,There are no additional notes associated with this service or procedure.
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],10733.06,,"Case rate ($10,733.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,120.35, add-ons for qualifying new technology services are included. If operating cost exceeds $44,991.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,402.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $8,145.37 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,175.40 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $642.75. The transfer capital threshold is the transfer adjustment factor * $642.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10733.06,45157.33,Inpatient DRG
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],5415.00,,"Per diem ($5,415). If length of stay < 3.1, first 1 days paid at a per diem of $10,830 instead. Capped at $16,785.91.",,,,0,other,5415.00,17575.50,Estimated amount calculated based on 3 day length of stay.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],45706.73,,"Fee schedule rate ($45,706.73). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,7921.00,45706.73,There are no additional notes associated with this service or procedure.
Cysto W/Urtroscopy&/Pyeloscopy Dx|LEFT SIDE,CASE-52351,APC,52351,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3299.47,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3299.47,3464.44,OPPS APC
Dstr Nrolytc Agnt Parverteb Fct Sngl Lmbr/Sacral|LEFT SIDE,CASE-64635,APC,64635,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1827.80,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1827.80,1919.19,OPPS APC
Exc Tum/Vasc Mal Sft Tiss Hand/Fngr Subq <1.5cm|RIGHT SIDE,CASE-26115,APC,26115,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1545.93,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1545.93,1623.23,OPPS APC
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],40890.77,,,,,,0,other,16017.99,51903.64,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],19126.88,,"Fee schedule rate ($19,126.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,19126.88,There are no additional notes associated with this service or procedure.
Ndsc Eval Intstinal Pouch Dx W/Collj Spec Spx,CASE-44385,APC,44385,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],870.46,,"APC Price ($870.46). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,870.46,913.99,OPPS APC
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,451,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],94077.13,,"Fee schedule rate ($94,077.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,23821.44,94077.13,There are no additional notes associated with this service or procedure.
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],26301.36,,"Fee schedule rate ($26,301.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11247.07,27028.33,There are no additional notes associated with this service or procedure.
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],29916.58,,"Fee schedule rate ($29,916.58). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12725.42,34245.00,There are no additional notes associated with this service or procedure.
HYPERTENSION WITHOUT MCC,305,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],17230.49,,"Fee schedule rate ($17,230.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7058.55,17230.49,There are no additional notes associated with this service or procedure.
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],10550.81,,"Case rate ($10,048.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,483.42, add-ons for qualifying new technology services are included. If operating cost exceeds $44,354.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,352.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,510.78 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,538.48 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $592.68. The transfer capital threshold is the transfer adjustment factor * $592.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10048.39,23545.50,Inpatient DRG
"Correction Hammertoe|LEFT FOOT, SECOND DIGIT",CASE-28285,APC,28285,CPT,0360,RC,,,T1,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7029.71,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6791.99,7131.59,OPPS APC
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,699,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],19570.20,,"Fee schedule rate ($19,570.20). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5961.00,19972.16,There are no additional notes associated with this service or procedure.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],67790.93,,"Fee schedule rate ($67,790.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,21597.50,67790.93,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],34481.40,,"Fee schedule rate ($34,481.40). Adds an outlier to normal pricing equal to the per diem rate ($50,543.29) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,14370.36,38378.80,There are no additional notes associated with this service or procedure.
NON-MALIGNANT BREAST DISORDERS WITH CC/MCC,600,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],15046.13,,"Fee schedule rate ($15,046.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7999.14,20495.56,There are no additional notes associated with this service or procedure.
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],26301.36,,"Fee schedule rate ($26,301.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11247.07,27028.33,There are no additional notes associated with this service or procedure.
"OTHER DIGESTIVE SYSTEM DIAGNOSES,MAJOR",254,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],11504.00,,"Case rate ($10,956.19). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10956.19,11504.00,There are no additional notes associated with this service or procedure.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],19849.17,,"Fee schedule rate ($19,849.17). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,9097.60,21455.22,There are no additional notes associated with this service or procedure.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],34295.80,,"Case rate ($33,623.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $31,414.68, add-ons for qualifying new technology services are included. If operating cost exceeds $66,285.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,076.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.4. The base transfer operating payment is the transfer adjustment factor * $29,361.48 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $29,469.74 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,316.91. The transfer capital threshold is the transfer adjustment factor * $2,316.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,33623.33,133270.57,Inpatient DRG
ALLERGIC REACTIONS WITH MCC,915,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],31602.31,,"Fee schedule rate ($31,602.31). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.8), with a minimum of zero.",,,,0,other,13332.86,33088.84,There are no additional notes associated with this service or procedure.
HC Peripheral Block - Femoral Single or Saphenous W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64447,APC,64447,CPT,0360,RC,,,XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7029.71,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6791.99,7131.59,OPPS APC
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC,027,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],19410.80,,"Case rate ($19,030.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,839, add-ons for qualifying new technology services are included. If operating cost exceeds $52,710.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,009.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $15,835.66 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,894.05 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,249.59. The transfer capital threshold is the transfer adjustment factor * $1,249.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 102%.",,,,0,other,19030.20,56363.30,Inpatient DRG
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],80635.65,,"Fee schedule rate ($80,635.65). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,26028.48,80635.65,There are no additional notes associated with this service or procedure.
Sgmdsc Flx Rmvl Tum Polyp/Oth Les Snare Tq|COLORECTAL CANCER SCREEN,CASE-45338,APC,45338,CPT,0360,RC,,,PT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1159.29,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1120.09,1176.09,OPPS APC
Secondary Closure Surg Wound/Dehsn Extsv/Complic,CASE-13160,APC,13160,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3317.01,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3317.01,3433.11,OPPS APC
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,761,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],6965.00,,,,,,0,other,5808.41,11946.72,There are no additional notes associated with this service or procedure.
Nerve Repair W/Nerve Allograft First Strand|LEFT SIDE,CASE-64912,APC,64912,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],8625.13,,"APC Price ($8,214.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,8214.41,8625.13,OPPS APC
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],16828.14,,"Case rate ($16,026.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,044.99, add-ons for qualifying new technology services are included. If operating cost exceeds $49,916.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,789.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $13,051.92 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,100.04 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,029.93. The transfer capital threshold is the transfer adjustment factor * $1,029.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,11165.00,61234.06,Inpatient DRG
PERIPHERAL VASCULAR DISORDERS WITH CC,300,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],9495.23,,"Case rate ($9,174.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,670.11, add-ons for qualifying new technology services are included. If operating cost exceeds $43,541.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,288.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,700.45 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,725.16 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $528.73. The transfer capital threshold is the transfer adjustment factor * $528.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,9174.14,21005.20,Inpatient DRG
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],84226.47,,"Fee schedule rate ($84,226.47). Adds an outlier to normal pricing equal to the per diem rate ($75,906.87) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14.7), with a minimum of zero.",,,,0,other,32296.02,88188.38,There are no additional notes associated with this service or procedure.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],28434.57,,"Fee schedule rate ($28,434.57). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,8906.63,28434.57,There are no additional notes associated with this service or procedure.
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],17755.26,,"Fee schedule rate ($17,755.26). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7847.50,17755.26,There are no additional notes associated with this service or procedure.
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],13651.81,,"Case rate ($13,001.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,230.82, add-ons for qualifying new technology services are included. If operating cost exceeds $47,101.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,568.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $10,248.08 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,285.87 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $808.68. The transfer capital threshold is the transfer adjustment factor * $808.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7868.00,32126.64,Inpatient DRG
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],24528.10,,"Fee schedule rate ($24,528.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10989.72,26280.60,There are no additional notes associated with this service or procedure.
HC Drain/Inj Joint/Bursa W/US Large|PBB CHARGE|RIGHT SIDE,CASE-20611,APC,20611,CPT,0510,RC,,,PBB|RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],287.31,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],20090.22,,,,,,0,other,8859.23,20090.22,There are no additional notes associated with this service or procedure.
Tnot Elbow Lateral/Medial Debride Open Tdn Rpr|LEFT SIDE,CASE-24359,APC,24359,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],5791.49,,"Fee schedule rate ($5,791.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,3079.00,10940.41,There are no additional notes associated with this service or procedure.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC,099,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],11740.87,,"Fee schedule rate ($11,740.87). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11171.21,26807.94,There are no additional notes associated with this service or procedure.
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],2070.00,,,,,,0,other,1188.00,18893.86,Estimated amount calculated based on 3 day length of stay.
COMPLICATIONS OF TREATMENT WITH CC,920,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],18836.22,,"Fee schedule rate ($18,836.22). Adds an outlier to normal pricing equal to the per diem rate ($49,808.13) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,8732.59,20731.52,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,447,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],47193.21,,"Case rate ($47,193.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $44,038.45, add-ons for qualifying new technology services are included. If operating cost exceeds $78,909.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $5,069.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $41,938.87 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $42,093.51 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,309.39. The transfer capital threshold is the transfer adjustment factor * $3,309.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,47193.21,156646.82,Inpatient DRG
"LYMPHATIC AND OTHER MALIGNANCIES AND NEOPLASMS OF UNCERTAIN BEHAVIOR,MODERATE",694,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],2075.72,,"Case rate for a one day stay ($2,075.72). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,2075.72,2179.51,There are no additional notes associated with this service or procedure.
Arthrs Wrst Exc&/Rpr Triang Fibrocart&/Joint|RIGHT SIDE,CASE-29846,APC,29846,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
Colonoscopy Flx Dx W/Collj Spec When Pfrmd|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-45378,APC,45378,CPT,0360,RC,,,74,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],900.93,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,870.46,913.99,OPPS APC
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],23415.63,,,,,,0,other,10003.71,23415.63,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITHOUT STERILIZATION WITH MCC,786,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],23722.94,,"Fee schedule rate ($23,722.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12612.10,23722.94,There are no additional notes associated with this service or procedure.
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7604.36,,"Case rate ($7,242.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,882.80, add-ons for qualifying new technology services are included. If operating cost exceeds $41,753.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,138.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $4,919.20 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,937.85 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $378.10. The transfer capital threshold is the transfer adjustment factor * $378.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7402.56,16438.59,Inpatient DRG
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC,192,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],6965.00,,,,,,0,other,6292.63,12753.78,There are no additional notes associated with this service or procedure.
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC",923,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],6965.00,,,,,,0,other,6965.00,20068.57,There are no additional notes associated with this service or procedure.
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],24528.10,,"Fee schedule rate ($24,528.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10989.72,26280.60,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],14344.60,,"Case rate ($14,344.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,480.09, add-ons for qualifying new technology services are included. If operating cost exceeds $48,351.10 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,666.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $11,492.77 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,535.14 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $906.89. The transfer capital threshold is the transfer adjustment factor * $906.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,14344.60,36028.59,Inpatient DRG
"DRUG AND ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE,MINOR",770,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],2732.19,,"Case rate ($2,732.19). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,2732.19,2868.80,There are no additional notes associated with this service or procedure.
NORMAL NEWBORN,795,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],2576.52,,"Fee schedule rate ($2,576.52). Adds an outlier to normal pricing equal to the per diem rate ($414) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,1369.79,5771.52,There are no additional notes associated with this service or procedure.
UNGROUPABLE,999,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],48752.15,,"Case rate ($48,752.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $45,488.70, add-ons for qualifying new technology services are included. If operating cost exceeds $80,359.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $5,183.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 12.7. The base transfer operating payment is the transfer adjustment factor * $43,383.78 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $43,543.75 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,423.41. The transfer capital threshold is the transfer adjustment factor * $3,423.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10228.00,161307.29,Inpatient DRG
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],16590.46,,"Fee schedule rate ($16,590.46). Adds an outlier to normal pricing equal to the per diem rate ($69,146.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,1188.00,17370.86,There are no additional notes associated with this service or procedure.
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],10048.39,,"Case rate ($10,048.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,483.42, add-ons for qualifying new technology services are included. If operating cost exceeds $44,354.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,352.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,510.78 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,538.48 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $592.68. The transfer capital threshold is the transfer adjustment factor * $592.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10048.39,23545.50,Inpatient DRG
ALLERGIC REACTIONS WITH MCC,915,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],15177.75,,"Fee schedule rate ($15,177.75). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,13332.86,33088.84,There are no additional notes associated with this service or procedure.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,761,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],10164.72,,"Case rate ($5,808.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,539.05, add-ons for qualifying new technology services are included. If operating cost exceeds $40,410.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,042.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $3,580.90 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,594.10 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $282.57. The transfer capital threshold is the transfer adjustment factor * $282.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,5808.41,11946.72,All Other Inpatient
Intraop Sentinel Lymph Node ID W/Dye Injection|LEFT SIDE,CASE-38900,APC,38900,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6432.89,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6215.36,6526.12,OPPS APC
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],13568.55,,"Fee schedule rate ($13,568.55). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6834.39,21354.82,There are no additional notes associated with this service or procedure.
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],21512.35,,"Fee schedule rate ($21,512.35). Adds an outlier to normal pricing equal to the per diem rate ($37,521.53) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,9696.93,35061.53,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],6164.03,,"Fee schedule rate ($6,164.03). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6164.03,14071.02,There are no additional notes associated with this service or procedure.
CERVICAL SPINAL FUSION WITHOUT CC/MCC,473,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],19401.49,,"Case rate ($18,477.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,324.93, add-ons for qualifying new technology services are included. If operating cost exceeds $52,195.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,969.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.6. The base transfer operating payment is the transfer adjustment factor * $15,323.48 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,379.98 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,209.17. The transfer capital threshold is the transfer adjustment factor * $1,209.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,18477.61,62077.11,Inpatient DRG
"FEMALE REPRODUCTIVE SYSTEM INFECTIONS,MODERATE",531,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],6876.53,,"Case rate ($6,876.53). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,6876.53,7220.36,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],32077.45,,,,,,0,other,12984.79,32077.45,There are no additional notes associated with this service or procedure.
Dstr Nrolytc Agnt Parverteb Fct Sngl Lmbr/Sacral|BILATERAL PROCEDURE,CASE-64635,APC,64635,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1827.80,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1827.80,1919.19,OPPS APC
HYPERTENSION WITHOUT MCC,305,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],7411.48,,"Case rate ($7,058.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,702.02, add-ons for qualifying new technology services are included. If operating cost exceeds $41,573.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,133.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,739.59 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,757.07 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $374.00. The transfer capital threshold is the transfer adjustment factor * $374.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7058.55,17230.49,Inpatient DRG
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],2070.00,,,,,,0,other,1188.00,12138.74,Estimated amount calculated based on 1 day length of stay.
"Repair Extensor Tendon Finger W/O Graft Each|LEFT HAND, THUMB",CASE-26418,APC,26418,CPT,0360,RC,,,FA,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1557.80,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1505.12,1580.37,OPPS APC
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,988,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],30888.17,,"Fee schedule rate ($30,888.17). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.5), with a minimum of zero.",,,,0,other,13075.52,42425.46,There are no additional notes associated with this service or procedure.
Mastectomy Partial W/Axillary Lymphadenectomy,CASE-19302,APC,19302,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6526.12,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6526.12,6526.12,OPPS APC
HYPERTENSION WITHOUT MCC,305,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],17230.49,,"Fee schedule rate ($17,230.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7058.55,17230.49,There are no additional notes associated with this service or procedure.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],18434.41,,"Case rate ($10,533.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,935.13, add-ons for qualifying new technology services are included. If operating cost exceeds $44,806.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,388.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $7,960.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,990.18 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $628.19. The transfer capital threshold is the transfer adjustment factor * $628.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,10533.95,24956.34,All Other Inpatient
RADIOTHERAPY,849,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],50919.63,,"Fee schedule rate ($50,919.63). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15.8), with a minimum of zero.",,,,0,other,20293.88,81867.07,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,086,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],30728.81,,"Fee schedule rate ($30,728.81). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8442.00,30728.81,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],37149.27,,"Fee schedule rate ($37,149.27). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,12455.21,37149.27,There are no additional notes associated with this service or procedure.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],11681.49,,"Fee schedule rate ($11,681.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5778.62,11681.49,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,555,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],42290.95,,"Fee schedule rate ($42,290.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10896.27,42290.95,There are no additional notes associated with this service or procedure.
SPINAL PROCEDURES WITH MCC,028,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],120982.83,,"Fee schedule rate ($120,982.83). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,42633.57,120982.83,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],13762.88,,"Case rate ($13,762.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,938.93, add-ons for qualifying new technology services are included. If operating cost exceeds $47,809.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,624.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $10,953.59 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,993.98 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $864.35. The transfer capital threshold is the transfer adjustment factor * $864.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,1188.00,34338.33,Inpatient DRG
Laparoscopy Supracervical Hysterectomy 250 Gm/<,CASE-58541,APC,58541,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],10298.02,,"APC Price ($9,949.78). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,9949.78,10447.27,OPPS APC
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],14309.17,,"Fee schedule rate ($14,309.17). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,17467.27,There are no additional notes associated with this service or procedure.
Tx Anal Fstl Trans/Supra/Xtrasphnctrc Incl Seton,CASE-46280,APC,46280,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],2689.02,,"APC Price ($2,598.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2598.08,2727.99,OPPS APC
Anoscopy Dx W/HRA &Chem Agnts Enhancement W/Bx,CASE-46607,APC,46607,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1159.29,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1120.09,1176.09,OPPS APC
VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC,033,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],42156.44,,"Fee schedule rate ($42,156.44). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,13206.23,42156.44,There are no additional notes associated with this service or procedure.
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],34570.85,,"Fee schedule rate ($34,570.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,6965.00,36140.75,There are no additional notes associated with this service or procedure.
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,451,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],94077.13,,"Fee schedule rate ($94,077.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,23821.44,94077.13,There are no additional notes associated with this service or procedure.
Esophagoscopy Flexible Transoral With Biopsy,CASE-43202,APC,43202,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1885.95,,"APC Price ($1,796.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1796.14,1885.95,OPPS APC
Dstr Nrolytc Agnt Parverteb Fct Sngl Lmbr/Sacral|LEFT SIDE,CASE-64635,APC,64635,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1827.80,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1827.80,1919.19,OPPS APC
Rmvl Spinal Nstim Eltrd Prq Array Incl Fluor,CASE-63661,APC,63661,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3386.97,,"APC Price ($3,272.44). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3272.44,3436.06,OPPS APC
"OTHER DIGESTIVE SYSTEM AND ABDOMINAL PROCEDURES,MODERATE",229,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],3530.98,,"Case rate for a one day stay ($3,362.84). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,3362.84,3530.98,There are no additional notes associated with this service or procedure.
"CARDIAC ARREST, UNEXPLAINED WITH MCC",296,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],36459.67,,"Fee schedule rate ($36,459.67). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12522.25,36459.67,There are no additional notes associated with this service or procedure.
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],5280.00,,"Per diem ($5,280). If length of stay < 3.1, first 1 days paid at a per diem of $10,560 instead. Capped at $16,366.82.",,,,0,other,5280.00,17136.70,Estimated amount calculated based on 3 day length of stay.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],33398.16,,"Fee schedule rate ($33,398.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,7353.00,33398.16,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],14071.02,,,,,,0,other,6164.03,14071.02,There are no additional notes associated with this service or procedure.
"NEONATE BIRTH WEIGHT > 2499 GRAMS NORMAL NEWBORN OR NEONATE WITH OTHER PROBLEM,MODERATE",640,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],1628.96,,"Case rate ($1,551.39). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,1551.39,1628.96,There are no additional notes associated with this service or procedure.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],6965.00,,,,,,0,other,6965.00,20401.88,There are no additional notes associated with this service or procedure.
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],7082.98,,"Case rate ($6,944.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,595.55, add-ons for qualifying new technology services are included. If operating cost exceeds $41,466.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,125.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,633.51 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,650.60 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $365.63. The transfer capital threshold is the transfer adjustment factor * $365.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,5068.21,14525.56,Inpatient DRG
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],34570.85,,"Fee schedule rate ($34,570.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,6965.00,36140.75,There are no additional notes associated with this service or procedure.
Insj/Rplcmt Perq Eltrd Ra Pn W/Int Nstim 1st Ra,CASE-64596,APC,64596,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],10429.83,,"APC Price ($10,429.83). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,10429.83,10951.32,OPPS APC
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],15839.99,,,,,,0,other,7396.47,16035.06,There are no additional notes associated with this service or procedure.
VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC,033,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],42156.44,,"Fee schedule rate ($42,156.44). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,13206.23,42156.44,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],22100.60,,"Case rate ($21,667.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,292.19, add-ons for qualifying new technology services are included. If operating cost exceeds $55,163.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,202.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $18,279.84 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,347.24 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,442.46. The transfer capital threshold is the transfer adjustment factor * $1,442.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,8972.00,81524.17,Inpatient DRG
Perq Nl/Pl Lithotrp Simple Up to 2 Cm 1 Location|RIGHT SIDE,CASE-50080,APC,50080,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],9170.96,,"APC Price ($8,860.83). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,8860.83,9303.88,OPPS APC
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],14481.61,,"Case rate ($13,792.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,966.02, add-ons for qualifying new technology services are included. If operating cost exceeds $47,837.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,626.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $10,980.58 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,021.07 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $866.48. The transfer capital threshold is the transfer adjustment factor * $866.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,34422.94,Inpatient DRG
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],38378.80,,"Fee schedule rate ($38,378.80). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,14370.36,38378.80,There are no additional notes associated with this service or procedure.
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],9282.47,,"Case rate ($9,282.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,770.90, add-ons for qualifying new technology services are included. If operating cost exceeds $43,641.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,296.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,800.88 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,825.96 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $536.66. The transfer capital threshold is the transfer adjustment factor * $536.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9282.47,21320.03,Inpatient DRG
Prq Skel Fixj Dstl Phlngl Fx Fngr/Thmb Ea,CASE-26756,APC,26756,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],15102.37,,"Case rate ($14,383.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,516, add-ons for qualifying new technology services are included. If operating cost exceeds $48,387.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,669.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,528.54 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,571.05 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $909.72. The transfer capital threshold is the transfer adjustment factor * $909.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,36140.75,Inpatient DRG
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],35192.25,,"Fee schedule rate ($35,192.25). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,10895.60,35192.25,There are no additional notes associated with this service or procedure.
PSYCHOSES,885,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],11404.17,,"Case rate ($11,404.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,744.67, add-ons for qualifying new technology services are included. If operating cost exceeds $45,615.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,451.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.5. The base transfer operating payment is the transfer adjustment factor * $8,767.39 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,799.72 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $691.83. The transfer capital threshold is the transfer adjustment factor * $691.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,2070.00,27484.83,Inpatient DRG
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],8767.81,,"Case rate ($8,767.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,292.11, add-ons for qualifying new technology services are included. If operating cost exceeds $43,163.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,258.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,323.85 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,347.16 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $499.01. The transfer capital threshold is the transfer adjustment factor * $499.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8767.81,19824.58,Inpatient DRG
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],13947.32,,"Fee schedule rate ($13,947.32). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6153.12,13947.32,There are no additional notes associated with this service or procedure.
Transurethral Resection Bladder Neck,CASE-52500,APC,52500,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3414.95,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3299.47,3464.44,OPPS APC
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],14672.51,,"Case rate ($13,973.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,157.60, add-ons for qualifying new technology services are included. If operating cost exceeds $48,028.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,618.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $11,170.29 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,212.65 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $858.57. The transfer capital threshold is the transfer adjustment factor * $858.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,14337.84,52803.53,Inpatient DRG
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],46523.26,,"Fee schedule rate ($46,523.26). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,17782.11,46523.26,There are no additional notes associated with this service or procedure.
Rpr Ingun Hernia Sliding Any Age|RIGHT SIDE,CASE-49525,APC,49525,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3518.91,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3351.34,3518.91,OPPS APC
Intraop Sentinel Lymph Node ID W/Dye Injection|RIGHT SIDE,CASE-38900,APC,38900,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6215.36,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6215.36,6526.12,OPPS APC
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC",011,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],150008.48,,"Fee schedule rate ($150,008.48). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (44), with a minimum of zero.",,,,0,other,38880.49,150008.48,There are no additional notes associated with this service or procedure.
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,068,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],7954.70,,"Case rate ($7,798.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,390.60, add-ons for qualifying new technology services are included. If operating cost exceeds $42,261.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,188.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $5,425.64 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,445.65 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $428.14. The transfer capital threshold is the transfer adjustment factor * $428.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6965.00,23184.90,Inpatient DRG
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],13762.88,,"Case rate ($13,762.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,938.93, add-ons for qualifying new technology services are included. If operating cost exceeds $47,809.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,624.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $10,953.59 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,993.98 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $864.35. The transfer capital threshold is the transfer adjustment factor * $864.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,1188.00,34338.33,Inpatient DRG
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],33197.83,,"Fee schedule rate ($33,197.83). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.8), with a minimum of zero.",,,,0,other,13907.80,52794.06,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],15609.47,,"Fee schedule rate ($15,609.47). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7569.84,21892.85,There are no additional notes associated with this service or procedure.
Surgical Arthroscopy Sho W/Coracoacrm Ligm Rls|RIGHT SIDE,CASE-29826,APC,29826,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,097,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],42486.51,,"Fee schedule rate ($42,486.51). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,26404.32,79915.74,There are no additional notes associated with this service or procedure.
DIABETES WITH MCC,637,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],11454.91,,"Case rate ($10,909.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $10,253.93, add-ons for qualifying new technology services are included. If operating cost exceeds $48,898.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $3,423.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $8,854.74 + an uncompensated DSH payment of $1,359.91. The transfer operating threshold is the transfer adjustment factor * $8,894.02 + an uncompensated DSH payment of $1,359.91. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $694.79. The transfer capital threshold is the transfer adjustment factor * $694.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9959.03,28655.62,Inpatient DRG
Esophagogastroduodenoscopy Submucosal Injection|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-43236,APC,43236,CPT,0360,RC,,,74,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],878.67,,"APC Price ($848.96). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,848.96,891.41,OPPS APC
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],39820.52,,"Fee schedule rate ($39,820.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,15273.74,39820.52,There are no additional notes associated with this service or procedure.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],53939.67,,"Fee schedule rate ($53,939.67). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,21382.16,85466.62,There are no additional notes associated with this service or procedure.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC,862,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],28705.48,,"Fee schedule rate ($28,705.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (42), with a minimum of zero.",,,,0,other,6855.00,35884.94,There are no additional notes associated with this service or procedure.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],43888.01,,"Fee schedule rate ($43,888.01). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11717.72,43888.01,There are no additional notes associated with this service or procedure.
Destruction Neurolytic Agt Genicular Nerve W/Img|RIGHT SIDE,CASE-64624,APC,64624,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1891.77,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1827.80,1891.77,OPPS APC
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],14309.17,,"Fee schedule rate ($14,309.17). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,17467.27,There are no additional notes associated with this service or procedure.
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC",011,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],38880.49,,"Case rate ($38,880.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $36,305.31, add-ons for qualifying new technology services are included. If operating cost exceeds $71,176.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,461.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 11.4. The base transfer operating payment is the transfer adjustment factor * $34,234.14 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $34,360.36 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,701.41. The transfer capital threshold is the transfer adjustment factor * $2,701.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,38880.49,150008.48,Inpatient DRG
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],17370.86,,,,,,0,other,1188.00,17370.86,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,426,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],79261.64,,"Case rate ($76,581.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $71,377.56, add-ons for qualifying new technology services are included. If operating cost exceeds $106,248.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $7,218.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $69,177.55 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $69,432.61 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $5,458.79. The transfer capital threshold is the transfer adjustment factor * $5,458.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,76581.29,216864.15,Inpatient DRG
Open Tx Clavicular Fracture Internal Fixation,CASE-23515,APC,23515,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7029.71,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6791.99,7131.59,OPPS APC
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],37016.57,,"Fee schedule rate ($37,016.57). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15), with a minimum of zero.",,,,0,other,15283.90,38757.79,There are no additional notes associated with this service or procedure.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],20401.88,,"Fee schedule rate ($20,401.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,20401.88,There are no additional notes associated with this service or procedure.
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],33221.97,,"Fee schedule rate ($33,221.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (47), with a minimum of zero.",,,,0,other,15283.90,38757.79,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],17782.11,,"Case rate ($17,782.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,677.93, add-ons for qualifying new technology services are included. If operating cost exceeds $51,548.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,918.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $14,678.86 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,732.98 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,158.31. The transfer capital threshold is the transfer adjustment factor * $1,158.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,17782.11,46523.26,Inpatient DRG
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],32852.04,,"Fee schedule rate ($32,852.04). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,13783.20,41580.51,There are no additional notes associated with this service or procedure.
Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|RIGHT SIDE,CASE-26160,APC,26160,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1891.77,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1827.80,1919.19,OPPS APC
OTHER DISORDERS OF NERVOUS SYSTEM WITH CC,092,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],26765.51,,"Fee schedule rate ($26,765.51). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8872.78,26765.51,There are no additional notes associated with this service or procedure.
VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC,033,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],22412.10,,"Fee schedule rate ($22,412.10). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,13206.23,42156.44,There are no additional notes associated with this service or procedure.
Rpr Aa Hernia Recr 3-10 Cm Reducible,CASE-49615,APC,49615,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6362.63,,"APC Price ($6,059.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6059.65,6362.63,OPPS APC
HC Inj Lympho for Sentinal Node|SEPARATE PRACTITIONER,CASE-38792,APC,38792,CPT,0361,RC,,,XP,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6526.12,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6215.36,6526.12,OPPS APC
PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,337,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],12957.08,,"Case rate ($12,340.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,615.32, add-ons for qualifying new technology services are included. If operating cost exceeds $46,486.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,520.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $9,634.84 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,670.37 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $760.28. The transfer capital threshold is the transfer adjustment factor * $760.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12340.08,38926.31,Inpatient DRG
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],72151.96,,"Fee schedule rate ($72,151.96). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,27944.96,86252.84,There are no additional notes associated with this service or procedure.
Cysto Bladder W/Ureteral Catheterization|BILATERAL PROCEDURE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-52005,APC,52005,CPT,0360,RC,,,50|XU,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3299.47,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3299.47,3464.44,OPPS APC
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],59081.91,,"Fee schedule rate ($59,081.91). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,8480.00,59081.91,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITH STERILIZATION WITHOUT CC/MCC,785,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],20142.33,,"Fee schedule rate ($20,142.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8431.24,20142.33,There are no additional notes associated with this service or procedure.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],8485.05,,"Fee schedule rate ($8,485.05). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6965.00,15340.19,There are no additional notes associated with this service or procedure.
"NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY",789,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],6663.33,,,,,,0,other,3054.00,14857.05,Estimated amount calculated based on 1 day length of stay.
"Laminec/Facetect/Foramin,Cervical",CASE-63045,APC,63045,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6791.99,7131.59,OPPS APC
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],26874.85,,,,,,0,other,11194.25,36094.03,There are no additional notes associated with this service or procedure.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],33608.45,,"Fee schedule rate ($33,608.45). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,7332.00,35314.31,There are no additional notes associated with this service or procedure.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],17194.49,,"Fee schedule rate ($17,194.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8554.50,19204.75,There are no additional notes associated with this service or procedure.
NON-MALIGNANT BREAST DISORDERS WITH CC/MCC,600,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],20495.56,,,,,,0,other,7999.14,20495.56,There are no additional notes associated with this service or procedure.
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],81306.30,,"Fee schedule rate ($81,306.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,20846.48,81306.30,There are no additional notes associated with this service or procedure.
Dstr Nrolytc Agnt Parverteb Fct Addl Lmbr/Sacral|RIGHT SIDE,CASE-64636,APC,64636,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1827.80,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1827.80,1919.19,OPPS APC
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],10327.22,,"Case rate ($9,977.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,417.91, add-ons for qualifying new technology services are included. If operating cost exceeds $44,288.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,347.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $7,445.51 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,472.96 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $587.52. The transfer capital threshold is the transfer adjustment factor * $587.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,9977.99,26949.28,Inpatient DRG
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],85305.59,,"Fee schedule rate ($85,305.59). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,21719.40,85305.59,There are no additional notes associated with this service or procedure.
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC,805,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],9716.03,,"Case rate ($9,253.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,743.82, add-ons for qualifying new technology services are included. If operating cost exceeds $43,614.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,294.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $6,773.89 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,798.87 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $534.53. The transfer capital threshold is the transfer adjustment factor * $534.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9253.36,21235.42,Inpatient DRG
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],54503.46,,"Fee schedule rate ($54,503.46). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.9), with a minimum of zero.",,,,0,other,21585.31,73588.10,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH CC,427,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],142040.39,,,,,,0,other,50829.82,142040.39,There are no additional notes associated with this service or procedure.
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITHOUT CC/MCC",630,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],11828.78,,"Case rate ($11,828.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,139.67, add-ons for qualifying new technology services are included. If operating cost exceeds $46,010.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,482.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $9,160.95 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,194.72 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $722.89. The transfer capital threshold is the transfer adjustment factor * $722.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,11828.78,42541.02,Inpatient DRG
RESPIRATORY NEOPLASMS WITHOUT CC/MCC,182,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],23037.13,,"Fee schedule rate ($23,037.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6965.00,23037.13,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],53152.12,,"Fee schedule rate ($53,152.12). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,19152.11,53152.12,There are no additional notes associated with this service or procedure.
PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,337,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],12636.48,,"Case rate ($12,034.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,350.09, add-ons for qualifying new technology services are included. If operating cost exceeds $46,221.10 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,480.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $9,369.62 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,405.14 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $720.17. The transfer capital threshold is the transfer adjustment factor * $720.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12340.08,38926.31,Inpatient DRG
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],24528.10,,"Fee schedule rate ($24,528.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10989.72,26280.60,There are no additional notes associated with this service or procedure.
HEART FAILURE AND SHOCK WITH CC,292,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],5502.00,,"Per diem ($5,502). If length of stay < 2.9, first 1 days paid at a per diem of $11,004 instead. Capped at $15,955.26.",,,,0,other,5502.00,16705.77,Estimated amount calculated based on 2 day length of stay.
MAJOR BLADDER PROCEDURES WITH MCC,653,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],37135.34,,"Case rate ($37,135.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $34,681.82, add-ons for qualifying new technology services are included. If operating cost exceeds $69,552.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,333.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.5. The base transfer operating payment is the transfer adjustment factor * $32,616.61 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $32,736.87 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,573.77. The transfer capital threshold is the transfer adjustment factor * $2,573.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10280.00,125343.98,Inpatient DRG
"POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT PROCEDURE,MINOR",561,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],1349.01,,"Case rate for a one day stay ($1,349.01). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,1349.01,1416.46,There are no additional notes associated with this service or procedure.
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC,497,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],22707.58,,"Fee schedule rate ($22,707.58). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7.8), with a minimum of zero.",,,,0,other,10127.65,37761.19,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],15649.20,,"Fee schedule rate ($15,649.20). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,14344.60,36028.59,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,082,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],42953.28,,"Fee schedule rate ($42,953.28). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.6), with a minimum of zero.",,,,0,other,17423.21,56223.11,There are no additional notes associated with this service or procedure.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,345,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],12559.61,,"Case rate ($12,134.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,424.43, add-ons for qualifying new technology services are included. If operating cost exceeds $46,295.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,505.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $9,444.66 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,479.48 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $745.28. The transfer capital threshold is the transfer adjustment factor * $745.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,12134.89,33616.03,Inpatient DRG
CERVICAL SPINAL FUSION WITH MCC,471,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],111337.93,,"Fee schedule rate ($111,337.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,34645.26,111337.93,There are no additional notes associated with this service or procedure.
Submucous Rescj Inferior Turbinate Prtl/Compl,CASE-30140,APC,30140,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.35,,"APC Price ($3,103.35). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.35,3258.52,OPPS APC
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],31533.97,,"Fee schedule rate ($31,533.97). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8563.30,31533.97,There are no additional notes associated with this service or procedure.
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],22060.90,,"Case rate ($12,606.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,862.91, add-ons for qualifying new technology services are included. If operating cost exceeds $46,733.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,539.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $9,881.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,917.95 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $779.75. The transfer capital threshold is the transfer adjustment factor * $779.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,12606.23,36868.88,All Other Inpatient
Insj Multi-Component Inflatable Penile Prosth,CASE-54405,APC,54405,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],20079.15,,"APC Price ($19,400.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,19400.15,20370.16,OPPS APC
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],41580.51,,"Fee schedule rate ($41,580.51). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,13783.20,41580.51,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC,788,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],8438.02,,"Case rate ($8,438.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,985.31, add-ons for qualifying new technology services are included. If operating cost exceeds $42,856.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,234.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,018.17 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,040.36 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $474.89. The transfer capital threshold is the transfer adjustment factor * $474.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8438.02,20142.33,Inpatient DRG
HC Inject Tendon Origin/Insert|BILATERAL PROCEDURE,CASE-20551,APC,20551,CPT,0361,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],297.37,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,287.31,301.68,OPPS APC
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],32093.19,,,,,,0,other,9888.00,43399.23,There are no additional notes associated with this service or procedure.
RADIOTHERAPY,849,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],53314.83,,,,,,0,other,20293.88,81867.07,There are no additional notes associated with this service or procedure.
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],6965.00,,,,,,0,other,6965.00,23385.72,There are no additional notes associated with this service or procedure.
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],13486.95,,"Fee schedule rate ($13,486.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6915.64,14442.92,There are no additional notes associated with this service or procedure.
O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC,621,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],12585.54,,"Case rate ($12,159.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,447.74, add-ons for qualifying new technology services are included. If operating cost exceeds $46,318.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,507.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $9,467.88 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,502.79 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $747.11. The transfer capital threshold is the transfer adjustment factor * $747.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,12159.94,36669.96,Inpatient DRG
Injection Aa&/Strd Ilioinguinal Ih Nerves,CASE-64425,APC,64425,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],693.76,,"APC Price ($660.72). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,660.72,693.76,OPPS APC
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITHOUT MCC,430,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],42435.17,,"Case rate ($41,000.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $38,277.19, add-ons for qualifying new technology services are included. If operating cost exceeds $73,148.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,616.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $36,198.76 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $36,332.23 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,856.44. The transfer capital threshold is the transfer adjustment factor * $2,856.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,41000.16,133156.90,Inpatient DRG
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],11809.42,,"Case rate ($11,247.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,598.51, add-ons for qualifying new technology services are included. If operating cost exceeds $45,469.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,440.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,621.77 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,653.56 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $680.34. The transfer capital threshold is the transfer adjustment factor * $680.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,11247.07,27028.33,Inpatient DRG
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],21512.35,,"Fee schedule rate ($21,512.35). Adds an outlier to normal pricing equal to the per diem rate ($37,521.53) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,9696.93,35061.53,There are no additional notes associated with this service or procedure.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,098,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],38799.38,,"Fee schedule rate ($38,799.38). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,6965.00,45156.75,There are no additional notes associated with this service or procedure.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH CC,354,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],13140.41,,"Case rate ($12,514.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $11,748.98, add-ons for qualifying new technology services are included. If operating cost exceeds $50,393.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $3,540.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $10,343.20 + an uncompensated DSH payment of $1,359.91. The transfer operating threshold is the transfer adjustment factor * $10,389.07 + an uncompensated DSH payment of $1,359.91. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $811.58. The transfer capital threshold is the transfer adjustment factor * $811.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,11633.13,33472.54,Inpatient DRG
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC,434,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],13280.45,,"Fee schedule rate ($13,280.45). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6770.05,14019.86,There are no additional notes associated with this service or procedure.
HC Rt Bronchoscopy Alveolar Lavage,CASE-31624,APC,31624,CPT,0361,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6936.25,,"APC Price ($6,605.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6605.95,6936.25,OPPS APC
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],69000.38,,"Fee schedule rate ($69,000.38). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15), with a minimum of zero.",,,,0,other,26809.29,97015.50,There are no additional notes associated with this service or procedure.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC,434,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],13280.45,,"Fee schedule rate ($13,280.45). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6770.05,14019.86,There are no additional notes associated with this service or procedure.
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],15802.03,,"Fee schedule rate ($15,802.03). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7566.45,16333.88,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,065,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],25681.86,,"Fee schedule rate ($25,681.86). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,8786.76,25681.86,There are no additional notes associated with this service or procedure.
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],8052.99,,"Case rate ($7,669.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,281.07, add-ons for qualifying new technology services are included. If operating cost exceeds $42,152.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,168.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $5,315.96 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,336.12 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $408.60. The transfer capital threshold is the transfer adjustment factor * $408.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5280.00,17136.70,Inpatient DRG
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],16055.90,,"Fee schedule rate ($16,055.90). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8163.06,18067.42,There are no additional notes associated with this service or procedure.
Laparoscopic Appendectomy,CASE-44970,APC,44970,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5658.76,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5658.76,5941.70,OPPS APC
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],52449.26,,"Fee schedule rate ($52,449.26). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,17693.40,52449.26,There are no additional notes associated with this service or procedure.
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],13760.97,,"Case rate ($13,295.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,504.24, add-ons for qualifying new technology services are included. If operating cost exceeds $47,375.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,590.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $10,520.50 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,559.29 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $830.17. The transfer capital threshold is the transfer adjustment factor * $830.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,7000.00,33835.79,Inpatient DRG
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],8367.70,,"Case rate ($7,969.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,560.46, add-ons for qualifying new technology services are included. If operating cost exceeds $42,431.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,189.96, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,594.30 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,615.51 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $429.99. The transfer capital threshold is the transfer adjustment factor * $429.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8151.55,18033.97,Inpatient DRG
Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx,CASE-28270,APC,28270,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6791.99,7131.59,OPPS APC
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],19881.64,,,,,,0,other,6965.00,32293.66,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],6965.00,,,,,,0,other,6164.03,14071.02,There are no additional notes associated with this service or procedure.
Rmvl & Rplcmt Inflatable Penile Prosth Same Sess,CASE-54410,APC,54410,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],19400.15,,"APC Price ($19,400.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,19400.15,20370.16,OPPS APC
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],8108.13,,"Case rate ($7,833.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,423.35, add-ons for qualifying new technology services are included. If operating cost exceeds $42,294.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,190.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,458.28 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,478.41 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $430.71. The transfer capital threshold is the transfer adjustment factor * $430.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,5883.03,17111.12,Inpatient DRG
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],22219.70,,"Case rate ($12,696.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,947.32, add-ons for qualifying new technology services are included. If operating cost exceeds $46,818.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,546.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,965.63 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,002.37 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $786.39. The transfer capital threshold is the transfer adjustment factor * $786.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,12696.97,47123.82,All Other Inpatient
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITHOUT CC/MCC,816,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6224.90,,"Case rate ($6,224.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,926.50, add-ons for qualifying new technology services are included. If operating cost exceeds $40,797.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,073.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $3,966.92 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,981.55 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $313.03. The transfer capital threshold is the transfer adjustment factor * $313.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6224.90,14733.53,Inpatient DRG
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],26721.94,,"Fee schedule rate ($26,721.94). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6965.00,34422.94,There are no additional notes associated with this service or procedure.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],12882.42,,"Case rate ($12,268.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,549.17, add-ons for qualifying new technology services are included. If operating cost exceeds $46,420.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,515.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,568.94 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,604.22 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $755.08. The transfer capital threshold is the transfer adjustment factor * $755.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12268.97,41006.47,Inpatient DRG
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],59610.47,,"Fee schedule rate ($59,610.47). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,16129.04,59610.47,There are no additional notes associated with this service or procedure.
Conization Cervix W/WO D&C Rpr Eltrd Exc,CASE-57522,APC,57522,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3181.53,,"APC Price ($3,030.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3030.03,3181.53,OPPS APC
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,066,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],20083.61,,"Fee schedule rate ($20,083.61). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6579.76,20083.61,There are no additional notes associated with this service or procedure.
RADIOTHERAPY,849,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],50919.63,,"Fee schedule rate ($50,919.63). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15.8), with a minimum of zero.",,,,0,other,20293.88,81867.07,There are no additional notes associated with this service or procedure.
Excision Skin Abd Infraumbilical Panniculectomy,CASE-15830,APC,15830,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6432.89,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6215.36,6526.12,OPPS APC
Blepharoplasty Upper Eyelid W/Excessive Skin,CASE-15823,APC,15823,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1998.87,,"APC Price ($1,931.28). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1931.28,2027.84,OPPS APC
HC Anterior Epitaxis Simple|RIGHT SIDE,CASE-30901,APC,30901,CPT,0450,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],124.54,,"APC Price ($124.54). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,124.54,130.76,OPPS APC
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],31973.49,,"Fee schedule rate ($31,973.49). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,13386.36,33244.29,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],9404.60,,"Case rate ($8,956.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,467.88, add-ons for qualifying new technology services are included. If operating cost exceeds $43,338.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,272.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $6,498.97 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,522.93 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $512.83. The transfer capital threshold is the transfer adjustment factor * $512.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8956.76,28983.97,Inpatient DRG
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,073,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],31567.81,,,,,,0,other,12809.38,43475.01,There are no additional notes associated with this service or procedure.
DIABETES WITHOUT CC/MCC,639,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],11899.36,,"Fee schedule rate ($11,899.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6151.76,12223.35,There are no additional notes associated with this service or procedure.
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],28394.78,,"Fee schedule rate ($28,394.78). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11454.97,28394.78,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,690,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],14625.55,,"Fee schedule rate ($14,625.55). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7426.94,15928.53,There are no additional notes associated with this service or procedure.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC,099,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],11171.21,,"Case rate ($11,171.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,527.95, add-ons for qualifying new technology services are included. If operating cost exceeds $45,398.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,434.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,551.47 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,583.00 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $674.80. The transfer capital threshold is the transfer adjustment factor * $674.80. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,11171.21,26807.94,Inpatient DRG
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],10130.60,,"Case rate ($9,648.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,111.10, add-ons for qualifying new technology services are included. If operating cost exceeds $43,982.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,323.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $7,139.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,166.15 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $563.40. The transfer capital threshold is the transfer adjustment factor * $563.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9648.19,31477.13,Inpatient DRG
TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC,084,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],19445.16,,"Fee schedule rate ($19,445.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,6965.00,19445.16,There are no additional notes associated with this service or procedure.
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],13029.20,,"Case rate ($12,408.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,698.73, add-ons for qualifying new technology services are included. If operating cost exceeds $46,569.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,506.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $9,716.93 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,753.78 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $746.87. The transfer capital threshold is the transfer adjustment factor * $746.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12725.42,34245.00,Inpatient DRG
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],62454.12,,"Fee schedule rate ($62,454.12). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11348.00,62454.12,There are no additional notes associated with this service or procedure.
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],5283.60,,"Fee schedule rate ($5,283.60). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5068.21,14525.56,There are no additional notes associated with this service or procedure.
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC,797,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],20928.55,,"Fee schedule rate ($20,928.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8719.72,20928.55,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],30636.35,,"Fee schedule rate ($30,636.35). Adds an outlier to normal pricing equal to the per diem rate ($67,650.85) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12984.79,32077.45,There are no additional notes associated with this service or procedure.
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",623,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],14586.64,,"Case rate ($14,093.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,246.37, add-ons for qualifying new technology services are included. If operating cost exceeds $48,117.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,648.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $11,259.90 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,301.42 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $888.52. The transfer capital threshold is the transfer adjustment factor * $888.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,14093.37,33712.76,Inpatient DRG
MINOR BLADDER PROCEDURES WITHOUT CC/MCC,664,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],31876.87,,"Fee schedule rate ($31,876.87). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9034.63,31876.87,There are no additional notes associated with this service or procedure.
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],18245.94,,"Fee schedule rate ($18,245.94). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8106.18,18245.94,There are no additional notes associated with this service or procedure.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],25162.32,,"Case rate ($25,162.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $23,543.58, add-ons for qualifying new technology services are included. If operating cost exceeds $58,414.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,458.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $21,519.28 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $21,598.63 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,698.08. The transfer capital threshold is the transfer adjustment factor * $1,698.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,25162.32,75579.22,Inpatient DRG
TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC,087,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],22679.07,,"Fee schedule rate ($22,679.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,8139.36,22679.07,There are no additional notes associated with this service or procedure.
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC",605,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],9495.15,,"Fee schedule rate ($9,495.15). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8148.17,18024.13,There are no additional notes associated with this service or procedure.
Marsupialization Bartholins Gland Cyst,CASE-56440,APC,56440,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3181.53,,"APC Price ($3,030.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3030.03,3181.53,OPPS APC
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],6965.00,,,,,,0,other,6965.00,19126.88,There are no additional notes associated with this service or procedure.
Removal Tissue Expander W/O Insertion Implant|BILATERAL PROCEDURE,CASE-11971,APC,11971,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],2718.88,,"APC Price ($2,718.88). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2718.88,2814.04,OPPS APC
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],17097.87,,"Fee schedule rate ($17,097.87). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,8106.18,18245.94,There are no additional notes associated with this service or procedure.
Rmvl Noninfct Mesh/Prosth Aa/Parastomal Hrna Rpr,CASE-49623,APC,49623,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],199.10,,"APC Price ($199.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,199.10,209.05,OPPS APC
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],12091.53,,"Case rate ($12,091.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,384.11, add-ons for qualifying new technology services are included. If operating cost exceeds $46,255.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,502.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $9,404.49 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,439.16 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $742.11. The transfer capital threshold is the transfer adjustment factor * $742.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,29482.05,Inpatient DRG
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC",758,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],16323.02,,"Fee schedule rate ($16,323.02). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8574.80,19263.78,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],85305.59,,"Fee schedule rate ($85,305.59). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,21719.40,85305.59,There are no additional notes associated with this service or procedure.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],17365.00,,"Fee schedule rate ($17,365.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5683.00,19635.68,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],6564.18,,"Case rate ($6,564.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,242.12, add-ons for qualifying new technology services are included. If operating cost exceeds $41,113.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,097.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $4,281.39 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,297.17 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $337.84. The transfer capital threshold is the transfer adjustment factor * $337.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6564.18,17651.07,Inpatient DRG
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],10895.60,,"Case rate ($10,895.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,271.55, add-ons for qualifying new technology services are included. If operating cost exceeds $45,142.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,414.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $8,296.01 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,326.60 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $654.64. The transfer capital threshold is the transfer adjustment factor * $654.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10895.60,35192.25,Inpatient DRG
CESAREAN SECTION WITH STERILIZATION WITH CC,784,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],20859.59,,,,,,0,other,9124.01,23722.94,There are no additional notes associated with this service or procedure.
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],35474.53,,"Fee schedule rate ($35,474.53). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,16428.39,42083.20,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC,817,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],17396.11,,"Case rate ($17,396.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,318.84, add-ons for qualifying new technology services are included. If operating cost exceeds $51,189.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,890.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $14,321.08 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,373.88 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,130.07. The transfer capital threshold is the transfer adjustment factor * $1,130.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,17396.11,44895.04,Inpatient DRG
NEONATE WITH OTHER SIGNIFICANT PROBLEMS,794,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],12178.64,,"Case rate ($11,939.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,242.99, add-ons for qualifying new technology services are included. If operating cost exceeds $46,114.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,490.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $9,263.89 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,298.04 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $731.01. The transfer capital threshold is the transfer adjustment factor * $731.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,1798.85,12536.83,Inpatient DRG
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],37149.27,,"Fee schedule rate ($37,149.27). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,12455.21,37149.27,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],96365.69,,"Fee schedule rate ($96,365.69). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,23377.19,96365.69,There are no additional notes associated with this service or procedure.
Prep Site Trunk/Arm/Leg 1st 100 Sq Cm/1pct,CASE-15002,APC,15002,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],726.38,,"APC Price ($691.79). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,691.79,726.38,OPPS APC
BRONCHITIS AND ASTHMA WITHOUT CC/MCC,203,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],6224.17,,"Case rate ($5,927.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $5,614.23, add-ons for qualifying new technology services are included. If operating cost exceeds $44,258.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $3,061.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,235.54 + an uncompensated DSH payment of $1,359.91. The transfer operating threshold is the transfer adjustment factor * $4,254.32 + an uncompensated DSH payment of $1,359.91. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $332.34. The transfer capital threshold is the transfer adjustment factor * $332.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,4763.76,13707.00,Inpatient DRG
"Fasct Prtl Palmar 1 Dgt Prox Iphal Jt W/WO Rpr|RIGHT HAND, THUMB",CASE-26123,APC,26123,CPT,0360,RC,,,F5,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3169.86,OPPS APC
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,418,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],39884.93,,"Fee schedule rate ($39,884.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,13400.58,39884.93,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,066,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6579.76,,"Case rate ($6,579.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,256.61, add-ons for qualifying new technology services are included. If operating cost exceeds $41,127.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,098.96, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $4,295.82 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,311.66 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $338.98. The transfer capital threshold is the transfer adjustment factor * $338.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6579.76,20083.61,Inpatient DRG
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],27632.41,,,,,,0,other,11454.97,28394.78,There are no additional notes associated with this service or procedure.
Sigmoidoscopy Flx Dx W/Collj Spec Br/Wa if Pfrmd|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-45330,APC,45330,CPT,0360,RC,,,74,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],900.93,,"APC Price ($870.46). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,870.46,913.99,OPPS APC
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],23239.84,,"Fee schedule rate ($23,239.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8543.64,23239.84,There are no additional notes associated with this service or procedure.
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],21089.59,,"Fee schedule rate ($21,089.59). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,6965.00,21089.59,There are no additional notes associated with this service or procedure.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],52699.33,,"Fee schedule rate ($52,699.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,18105.81,52699.33,There are no additional notes associated with this service or procedure.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],28649.93,,"Fee schedule rate ($28,649.93). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,12268.97,41006.47,There are no additional notes associated with this service or procedure.
Egd Intrmural Needle Aspir/Biop Altered Anatomy,CASE-43242,APC,43242,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3608.81,,"APC Price ($3,608.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3608.81,3789.26,OPPS APC
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],10940.41,,,,,,0,other,3079.00,10940.41,There are no additional notes associated with this service or procedure.
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC",011,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],40824.51,,"Case rate ($38,880.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $36,305.31, add-ons for qualifying new technology services are included. If operating cost exceeds $71,176.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,461.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 11.4. The base transfer operating payment is the transfer adjustment factor * $34,234.14 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $34,360.36 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,701.41. The transfer capital threshold is the transfer adjustment factor * $2,701.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,38880.49,150008.48,Inpatient DRG
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,394,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],8500.21,,"Case rate ($8,095.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,678.10, add-ons for qualifying new technology services are included. If operating cost exceeds $42,549.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,198.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,711.50 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,733.15 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $439.00. The transfer capital threshold is the transfer adjustment factor * $439.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8281.56,20909.61,Inpatient DRG
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],7396.47,,"Case rate ($7,396.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,016.38, add-ons for qualifying new technology services are included. If operating cost exceeds $41,887.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,158.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,052.80 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,071.43 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $398.72. The transfer capital threshold is the transfer adjustment factor * $398.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7396.47,16035.06,Inpatient DRG
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",004,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],260309.36,,"Fee schedule rate ($260,309.36). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (35), with a minimum of zero.",,,,0,other,10249.47,272554.00,There are no additional notes associated with this service or procedure.
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],6965.00,,,,,,0,other,6965.00,17467.27,There are no additional notes associated with this service or procedure.
Rpr 1st Fem Hernia Any Age Incarcerated|RIGHT SIDE,CASE-49553,APC,49553,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3351.34,,"APC Price ($3,351.34). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3351.34,3518.91,OPPS APC
Prq Skeletal Fixj Metacarpal Fx Each Bone|RIGHT SIDE,CASE-26608,APC,26608,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,069,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],20333.68,,"Fee schedule rate ($20,333.68). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,20333.68,There are no additional notes associated with this service or procedure.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,025,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],32735.52,,"Case rate ($32,735.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $30,588.77, add-ons for qualifying new technology services are included. If operating cost exceeds $65,459.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,011.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.4. The base transfer operating payment is the transfer adjustment factor * $28,538.59 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $28,643.82 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,251.98. The transfer capital threshold is the transfer adjustment factor * $2,251.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,13351.00,91631.33,Inpatient DRG
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC",061,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],62315.82,,"Fee schedule rate ($62,315.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,20616.23,62315.82,There are no additional notes associated with this service or procedure.
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],21320.03,,,,,,0,other,9282.47,21320.03,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC,817,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],43874.75,,"Fee schedule rate ($43,874.75). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,17396.11,44895.04,There are no additional notes associated with this service or procedure.
SKIN ULCERS WITH MCC,592,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],38644.05,,"Fee schedule rate ($38,644.05). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15), with a minimum of zero.",,,,0,other,15116.17,38644.05,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF NERVOUS SYSTEM WITH CC,092,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],26765.51,,"Fee schedule rate ($26,765.51). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8872.78,26765.51,There are no additional notes associated with this service or procedure.
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],17356.15,,"Case rate ($17,356.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,281.67, add-ons for qualifying new technology services are included. If operating cost exceeds $51,152.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,887.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $14,284.05 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,336.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,127.15. The transfer capital threshold is the transfer adjustment factor * $1,127.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,17356.15,44778.95,Inpatient DRG
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH MCC",510,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],22847.99,,"Case rate ($22,399.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,973.84, add-ons for qualifying new technology services are included. If operating cost exceeds $55,844.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,256.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.3. The base transfer operating payment is the transfer adjustment factor * $18,958.99 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $19,028.89 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,496.05. The transfer capital threshold is the transfer adjustment factor * $1,496.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,10710.00,89863.76,Inpatient DRG
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],36776.05,,"Fee schedule rate ($36,776.05). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11053.39,36776.05,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],23045.40,,"Fee schedule rate ($23,045.40). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,13783.20,41580.51,There are no additional notes associated with this service or procedure.
"INFECTIOUS AND PARASITIC DISEASES INCLUDING HIV WITH O.R. PROCEDURE,MODERATE",710,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],20710.18,,"Case rate ($19,723.98). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,19723.98,20710.18,There are no additional notes associated with this service or procedure.
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],16438.59,,"Fee schedule rate ($16,438.59). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7402.56,16438.59,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],9270.25,,"Case rate ($8,956.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,467.88, add-ons for qualifying new technology services are included. If operating cost exceeds $43,338.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,272.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $6,498.97 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,522.93 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $512.83. The transfer capital threshold is the transfer adjustment factor * $512.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,8956.76,28983.97,Inpatient DRG
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],14648.64,,"Fee schedule rate ($14,648.64). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12305.53,30103.84,There are no additional notes associated with this service or procedure.
"NEONATE BIRTH WEIGHT 1500-1999 GRAMS WITH OR WITHOUT OTHER SIGNIFICANT CONDITION,MINOR",614,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],10963.86,,"Case rate ($10,963.86). Base payment rate plus any adjustments related to outliers.",,,,0,other,10963.86,11512.05,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,093,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],15668.80,,,,,,0,other,6965.00,19011.32,There are no additional notes associated with this service or procedure.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC",494,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],37708.15,,"Fee schedule rate ($37,708.15). Adds an outlier to normal pricing equal to the per diem rate ($63,554.89) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,15533.10,39945.55,There are no additional notes associated with this service or procedure.
HC Joint Injection/Aspir Large WO US|DISTINCT PROCEDURAL SERVICE|RIGHT SIDE|PBB CHARGE,CASE-20610,APC,20610,CPT,0510,RC,,,59|RT|PBB,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],297.37,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,287.31,301.68,OPPS APC
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,025,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],91631.33,,"Fee schedule rate ($91,631.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,13351.00,91631.33,There are no additional notes associated with this service or procedure.
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],6965.00,,,,,,0,other,6965.00,34422.94,There are no additional notes associated with this service or procedure.
Insertion Breast Implant Same Day of Mastectomy|BILATERAL PROCEDURE,CASE-19340,APC,19340,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],12899.30,,"APC Price ($12,899.30). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12899.30,12899.30,OPPS APC
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC",494,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],39481.90,,,,,,0,other,15533.10,39945.55,There are no additional notes associated with this service or procedure.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],62454.12,,"Fee schedule rate ($62,454.12). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11348.00,62454.12,There are no additional notes associated with this service or procedure.
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],13891.24,,"Case rate ($13,229.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,464.01, add-ons for qualifying new technology services are included. If operating cost exceeds $47,335.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,565.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $10,479.32 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,519.06 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $805.47. The transfer capital threshold is the transfer adjustment factor * $805.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13571.25,33781.47,Inpatient DRG
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],24669.57,,"Fee schedule rate ($24,669.57). Adds an outlier to normal pricing equal to the per diem rate ($34,856.52) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.7), with a minimum of zero.",,,,0,other,10834.64,25830.00,There are no additional notes associated with this service or procedure.
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],10474.41,,"Case rate ($10,120.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,550.21, add-ons for qualifying new technology services are included. If operating cost exceeds $44,421.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,357.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $7,577.32 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,605.26 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $597.93. The transfer capital threshold is the transfer adjustment factor * $597.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,10120.20,26204.74,Inpatient DRG
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",759,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],12471.03,,"Fee schedule rate ($12,471.03). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.9), with a minimum of zero.",,,,0,other,6190.22,13057.66,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],34892.92,,"Fee schedule rate ($34,892.92). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,6965.00,41030.48,There are no additional notes associated with this service or procedure.
Implant Neurostim/Receiver,CASE-64590,APC,64590,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],19066.92,,"APC Price ($18,158.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,18158.97,19066.92,OPPS APC
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],40737.46,,"Fee schedule rate ($40,737.46). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,7665.00,40737.46,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF THE EYE WITHOUT MCC,125,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],7144.54,,"Case rate ($7,144.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,782.02, add-ons for qualifying new technology services are included. If operating cost exceeds $41,653.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,140.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,819.30 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,837.07 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $380.29. The transfer capital threshold is the transfer adjustment factor * $380.29. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7144.54,17952.29,Inpatient DRG
NORMAL NEWBORN,795,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],1956.00,,,,,,0,other,1369.79,5771.52,Estimated amount calculated based on 2 day length of stay.
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",759,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],13057.66,,,,,,0,other,6190.22,13057.66,There are no additional notes associated with this service or procedure.
"HEART FAILURE,MAJOR",194,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],11699.54,,"Case rate ($11,699.54). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,11699.54,12284.52,There are no additional notes associated with this service or procedure.
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],15063.61,,"Fee schedule rate ($15,063.61). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,7868.00,32126.64,There are no additional notes associated with this service or procedure.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,418,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],21204.48,,"Fee schedule rate ($21,204.48). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,13400.58,39884.93,There are no additional notes associated with this service or procedure.
DIABETES WITHOUT CC/MCC,639,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6151.76,,"Case rate ($6,151.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,858.45, add-ons for qualifying new technology services are included. If operating cost exceeds $40,729.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,067.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $3,899.13 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,913.51 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $307.68. The transfer capital threshold is the transfer adjustment factor * $307.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6151.76,12223.35,Inpatient DRG
Unlisted Procedure Hemic or Lymphatic System,CASE-38999,APC,38999,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],13544.27,,"APC Price ($12,899.30). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,12899.30,13544.27,OPPS APC
HC Inj Aa&/Strd Greater Occipital Nerve|LEFT SIDE,CASE-64405,APC,64405,CPT,0450,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,068,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],7798.73,,"Case rate ($7,798.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,390.60, add-ons for qualifying new technology services are included. If operating cost exceeds $42,261.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,188.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $5,425.64 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,445.65 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $428.14. The transfer capital threshold is the transfer adjustment factor * $428.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,23184.90,Inpatient DRG
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],13792.01,,"Case rate ($13,792.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,966.02, add-ons for qualifying new technology services are included. If operating cost exceeds $47,837.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,626.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $10,980.58 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,021.07 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $866.48. The transfer capital threshold is the transfer adjustment factor * $866.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,34422.94,Inpatient DRG
HC Joint Injection/Aspir Medium WO US|PBB CHARGE|RIGHT SIDE,CASE-20605,APC,20605,CPT,0510,RC,,,PBB|RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
Colonoscopy W/Biopsy Single/Multiple|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-45380,APC,45380,CPT,0360,RC,,,74,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1159.29,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1120.09,1176.09,OPPS APC
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],6214.05,,"Case rate ($6,214.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,916.41, add-ons for qualifying new technology services are included. If operating cost exceeds $40,787.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,072.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $3,956.88 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,971.47 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $312.24. The transfer capital threshold is the transfer adjustment factor * $312.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6214.05,15318.94,Inpatient DRG
CESAREAN SECTION WITHOUT STERILIZATION WITH CC,787,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],9750.15,,"Case rate ($9,285.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,787.73, add-ons for qualifying new technology services are included. If operating cost exceeds $43,658.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,283.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $6,816.93 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,842.78 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $523.97. The transfer capital threshold is the transfer adjustment factor * $523.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9508.01,23722.94,Inpatient DRG
Cystourethroscopy,CASE-52000,APC,52000,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],685.32,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,652.69,685.32,OPPS APC
SPINAL PROCEDURES WITHOUT CC/MCC,030,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],44714.01,,"Fee schedule rate ($44,714.01). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,16810.99,44714.01,There are no additional notes associated with this service or procedure.
"CARDIAC ARREST, UNEXPLAINED WITH MCC",296,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],12822.14,,"Case rate ($12,211.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,514.91, add-ons for qualifying new technology services are included. If operating cost exceeds $46,385.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,492.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $9,533.82 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,569.96 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $732.79. The transfer capital threshold is the transfer adjustment factor * $732.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12522.25,36459.67,Inpatient DRG
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],90333.60,,"Fee schedule rate ($90,333.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,26127.34,90333.60,There are no additional notes associated with this service or procedure.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,761,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],6965.00,,,,,,0,other,5808.41,11946.72,There are no additional notes associated with this service or procedure.
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],18217.52,,"Fee schedule rate ($18,217.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7414.07,18217.52,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITHOUT CC/MCC,428,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],40017.53,,"Case rate ($40,017.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $37,363.07, add-ons for qualifying new technology services are included. If operating cost exceeds $72,234.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,544.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $35,288.01 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $35,418.12 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,784.57. The transfer capital threshold is the transfer adjustment factor * $2,784.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,40017.53,118904.57,Inpatient DRG
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],15054.73,,"Case rate ($14,337.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,473.80, add-ons for qualifying new technology services are included. If operating cost exceeds $48,344.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,666.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $11,486.49 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,528.84 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $906.40. The transfer capital threshold is the transfer adjustment factor * $906.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,14337.84,52803.53,Inpatient DRG
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],29166.74,,"Fee schedule rate ($29,166.74). Adds an outlier to normal pricing equal to the per diem rate ($36,758.78) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,12455.21,37149.27,There are no additional notes associated with this service or procedure.
Colpocleisis Le Fort Type,CASE-57120,APC,57120,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],4682.41,,"APC Price ($4,682.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,4682.41,4916.53,OPPS APC
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITHOUT CC/MCC",630,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],42541.02,,"Fee schedule rate ($42,541.02). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11828.78,42541.02,There are no additional notes associated with this service or procedure.
"Open Tx Phalangeal Shaft Fracture Prox/Middle Ea|LEFT HAND, FIFTH DIGIT",CASE-26735,APC,26735,CPT,0360,RC,,,F4,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC",641,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],14928.67,,"Fee schedule rate ($14,928.67). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7214.98,15312.64,There are no additional notes associated with this service or procedure.
"Suture Digital Nerve Hand/Foot 1 Nerve|RIGHT HAND, SECOND DIGIT",CASE-64831,APC,64831,CPT,0360,RC,,,F6,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
"Amputation Toe Interphalangeal Joint|RIGHT FOOT, THIRD DIGIT",CASE-28825,APC,28825,CPT,0360,RC,,,T7,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],24669.57,,"Fee schedule rate ($24,669.57). Adds an outlier to normal pricing equal to the per diem rate ($34,856.52) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.7), with a minimum of zero.",,,,0,other,10834.64,25830.00,There are no additional notes associated with this service or procedure.
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITH MCC,429,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],177294.98,,"Fee schedule rate ($177,294.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,62958.58,177294.98,There are no additional notes associated with this service or procedure.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,544,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],7407.91,,"Case rate ($7,055.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,698.86, add-ons for qualifying new technology services are included. If operating cost exceeds $41,569.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,133.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $4,736.45 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,753.92 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $373.75. The transfer capital threshold is the transfer adjustment factor * $373.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7055.15,23207.64,Inpatient DRG
UNGROUPABLE,999,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],161307.29,,"Fee schedule rate ($161,307.29). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (41), with a minimum of zero.",,,,0,other,10228.00,161307.29,There are no additional notes associated with this service or procedure.
Colon Ca Scrn Not Hi Rsk Ind,CASE-G0121,APC,G0121,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],900.93,,"APC Price ($870.46). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,870.46,913.99,OPPS APC
Laps Surg Rpr Recurrent Inguinal Hernia|RIGHT SIDE,CASE-49651,APC,49651,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5856.81,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5658.76,5941.70,OPPS APC
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC,807,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6510.67,,"Case rate ($6,510.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,192.35, add-ons for qualifying new technology services are included. If operating cost exceeds $41,063.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,093.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $4,231.80 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,247.40 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $333.93. The transfer capital threshold is the transfer adjustment factor * $333.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,5354.25,13266.23,Inpatient DRG
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],126615.59,,,,,,0,other,45521.20,142438.06,There are no additional notes associated with this service or procedure.
CERVICAL SPINAL FUSION WITH MCC,471,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],90745.76,,"Fee schedule rate ($90,745.76). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,34645.26,111337.93,There are no additional notes associated with this service or procedure.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],50821.76,,,,,,0,other,19435.86,50821.76,There are no additional notes associated with this service or procedure.
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],11168.08,,"Fee schedule rate ($11,168.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5937.41,12366.99,There are no additional notes associated with this service or procedure.
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,307,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],7434.68,,"Case rate ($7,434.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $7,017.68, add-ons for qualifying new technology services are included. If operating cost exceeds $45,662.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $3,170.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $5,632.79 + an uncompensated DSH payment of $1,359.91. The transfer operating threshold is the transfer adjustment factor * $5,657.77 + an uncompensated DSH payment of $1,359.91. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $441.98. The transfer capital threshold is the transfer adjustment factor * $441.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6335.27,18228.77,Inpatient DRG
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH CC,026,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],58431.20,,"Fee schedule rate ($58,431.20). Adds an outlier to normal pricing equal to the per diem rate ($112,420.62) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,23000.66,63202.45,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],21784.85,,"Fee schedule rate ($21,784.85). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.4), with a minimum of zero.",,,,0,other,9795.13,23899.13,There are no additional notes associated with this service or procedure.
"Correction Hammertoe|RIGHT FOOT, SECOND DIGIT",CASE-28285,APC,28285,CPT,0360,RC,,,T6,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
O.R. PROCEDURES FOR OBESITY WITH CC,620,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],12782.30,,"Case rate ($12,782.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,026.70, add-ons for qualifying new technology services are included. If operating cost exceeds $46,897.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,552.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $10,044.72 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,081.75 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $792.63. The transfer capital threshold is the transfer adjustment factor * $792.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12782.30,43753.50,Inpatient DRG
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],14228.44,,,,,,0,other,6841.83,21167.26,There are no additional notes associated with this service or procedure.
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],32390.31,,,,,,0,other,13092.47,33159.45,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],10223.39,,"Fee schedule rate ($10,223.39). Adds an outlier to normal pricing equal to the per diem rate ($48,095.58) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,5628.97,12272.58,There are no additional notes associated with this service or procedure.
DIABETES WITH MCC,637,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],10909.44,,"Case rate ($10,909.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $10,253.93, add-ons for qualifying new technology services are included. If operating cost exceeds $48,898.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $3,423.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $8,854.74 + an uncompensated DSH payment of $1,359.91. The transfer operating threshold is the transfer adjustment factor * $8,894.02 + an uncompensated DSH payment of $1,359.91. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $694.79. The transfer capital threshold is the transfer adjustment factor * $694.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9959.03,28655.62,Inpatient DRG
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7811.65,,"Case rate ($7,547.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,156.87, add-ons for qualifying new technology services are included. If operating cost exceeds $42,027.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,169.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $5,192.77 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,211.92 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $409.76. The transfer capital threshold is the transfer adjustment factor * $409.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6965.00,19126.88,Inpatient DRG
NORMAL NEWBORN,795,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],3462.91,,"Case rate ($3,298.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $3,203.67, add-ons for qualifying new technology services are included. If operating cost exceeds $38,074.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $1,858.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $1,254.10 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $1,258.72 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $98.96. The transfer capital threshold is the transfer adjustment factor * $98.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,1369.79,5771.52,Inpatient DRG
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH MCC",722,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],34009.69,,"Fee schedule rate ($34,009.69). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,14200.37,56869.13,There are no additional notes associated with this service or procedure.
HC Joint Injection/Aspir Large WO US|UNUSUAL NON-OVERLAPPING SERVICE|RIGHT SIDE,CASE-20610,APC,20610,CPT,0510,RC,,,XU|RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],301.68,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,287.31,301.68,OPPS APC
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],20938.30,,,,,,0,other,9151.11,30245.71,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,555,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],11165.01,,"Case rate ($10,633.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,043.79, add-ons for qualifying new technology services are included. If operating cost exceeds $44,914.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,380.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,068.25 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,098.84 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $620.14. The transfer capital threshold is the transfer adjustment factor * $620.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10896.27,42290.95,Inpatient DRG
Egd Dilation Gastric/Duodenal Stricture,CASE-43245,APC,43245,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1859.01,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1796.14,1885.95,OPPS APC
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],15099.70,,"Case rate ($15,099.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,182.53, add-ons for qualifying new technology services are included. If operating cost exceeds $49,053.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,722.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $12,192.63 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,237.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $962.12. The transfer capital threshold is the transfer adjustment factor * $962.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7605.00,39153.65,Inpatient DRG
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],6153.12,,"Case rate ($6,153.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,859.72, add-ons for qualifying new technology services are included. If operating cost exceeds $40,730.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,067.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,900.39 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,914.77 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $307.78. The transfer capital threshold is the transfer adjustment factor * $307.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6153.12,13947.32,Inpatient DRG
SIGNS AND SYMPTOMS WITH MCC,947,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],30414.32,,"Fee schedule rate ($30,414.32). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,10541.41,30414.32,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,065,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],9015.09,,"Case rate ($8,585.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,135.19, add-ons for qualifying new technology services are included. If operating cost exceeds $43,006.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,233.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,166.86 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,190.24 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $474.00. The transfer capital threshold is the transfer adjustment factor * $474.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8786.76,25681.86,Inpatient DRG
"Repair Extensor Tendon Finger W/O Graft Each|LEFT HAND, FOURTH DIGIT",CASE-26418,APC,26418,CPT,0360,RC,,,F3,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],23899.13,,"Fee schedule rate ($23,899.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9795.13,23899.13,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],39361.94,,"Fee schedule rate ($39,361.94). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.8), with a minimum of zero.",,,,0,other,16129.04,59610.47,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITHOUT STERILIZATION WITH CC,787,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],13148.10,,"Fee schedule rate ($13,148.10). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9508.01,23722.94,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],10864.41,,"Case rate ($10,347.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,761.25, add-ons for qualifying new technology services are included. If operating cost exceeds $44,632.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,374.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $7,787.59 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,816.30 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $614.52. The transfer capital threshold is the transfer adjustment factor * $614.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10347.06,28821.04,Inpatient DRG
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],23851.93,,"Case rate ($22,716.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $21,306.68, add-ons for qualifying new technology services are included. If operating cost exceeds $56,177.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,242.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $19,288.59 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $19,361.73 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,482.57. The transfer capital threshold is the transfer adjustment factor * $1,482.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,23344.70,62179.32,Inpatient DRG
VENTRICULAR SHUNT PROCEDURES WITH CC,032,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],46275.08,,"Fee schedule rate ($46,275.08). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,16376.22,46275.08,There are no additional notes associated with this service or procedure.
OTHER MENTAL DISORDER DIAGNOSES,887,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],2070.00,,,,,,0,other,2070.00,21072.10,Estimated amount calculated based on 1 day length of stay.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,394,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],17584.61,,"Fee schedule rate ($17,584.61). Adds an outlier to normal pricing equal to the per diem rate ($53,248.69) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,8281.56,20909.61,There are no additional notes associated with this service or procedure.
Cysto W/Insert Ureteral Stent,CASE-52332,APC,52332,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3464.44,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3299.47,3464.44,OPPS APC
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],37134.43,,,,,,0,other,7389.00,37134.43,There are no additional notes associated with this service or procedure.
Exc Rct Tum Incl Muscularis Propria,CASE-45172,APC,45172,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],2689.02,,"APC Price ($2,598.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2598.08,2727.99,OPPS APC
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR,518,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],28208.12,,"Case rate ($27,254.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $25,489.62, add-ons for qualifying new technology services are included. If operating cost exceeds $60,360.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,611.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 5.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $23,458.18 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $23,544.67 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,851.08. The transfer capital threshold is the transfer adjustment factor * $1,851.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,13252.00,89342.77,Inpatient DRG
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],6965.00,,,,,,0,other,6965.00,36140.75,There are no additional notes associated with this service or procedure.
Dstr Nrolytc Agnt Parverteb Fct Addl Lmbr/Sacral|LEFT SIDE,CASE-64636,APC,64636,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1919.19,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1827.80,1919.19,OPPS APC
CESAREAN SECTION WITH STERILIZATION WITH CC,784,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],23722.94,,"Fee schedule rate ($23,722.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9124.01,23722.94,There are no additional notes associated with this service or procedure.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,479,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],10586.00,,"Per diem ($10,586). If length of stay < 3.3, first 1 days paid at a per diem of $21,172 instead. Capped at $34,934.31.",,,,0,other,10586.00,50518.76,Estimated amount calculated based on 2 day length of stay.
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],7291.31,,"Case rate ($6,944.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,595.55, add-ons for qualifying new technology services are included. If operating cost exceeds $41,466.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,125.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,633.51 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,650.60 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $365.63. The transfer capital threshold is the transfer adjustment factor * $365.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5068.21,14525.56,Inpatient DRG
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],21455.22,,"Fee schedule rate ($21,455.22). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,9097.60,21455.22,There are no additional notes associated with this service or procedure.
"Rpr Coltrl Ligm Mtcarphlngl/Iphal Jt|RIGHT HAND, THUMB",CASE-26540,APC,26540,CPT,0360,RC,,,F5,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],80635.65,,"Fee schedule rate ($80,635.65). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,26028.48,80635.65,There are no additional notes associated with this service or procedure.
DIABETES WITH CC,638,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],8227.59,,"Case rate ($7,835.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,436.08, add-ons for qualifying new technology services are included. If operating cost exceeds $42,307.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,180.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,470.39 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,491.13 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $420.47. The transfer capital threshold is the transfer adjustment factor * $420.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8014.07,17634.53,Inpatient DRG
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],38008.95,,"Case rate ($21,719.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,340.70, add-ons for qualifying new technology services are included. If operating cost exceeds $55,211.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,206.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.2. The base transfer operating payment is the transfer adjustment factor * $18,328.17 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,395.75 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,446.27. The transfer capital threshold is the transfer adjustment factor * $1,446.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,21719.40,85305.59,All Other Inpatient
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],15341.29,,"Case rate ($14,610.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,727.68, add-ons for qualifying new technology services are included. If operating cost exceeds $48,598.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,686.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.6. The base transfer operating payment is the transfer adjustment factor * $11,739.44 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,782.73 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $926.36. The transfer capital threshold is the transfer adjustment factor * $926.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6277.00,36801.89,Inpatient DRG
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],12246.05,,"Fee schedule rate ($12,246.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6010.23,12246.05,There are no additional notes associated with this service or procedure.
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC,807,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],10071.17,,"Fee schedule rate ($10,071.17). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5354.25,13266.23,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],33398.16,,"Fee schedule rate ($33,398.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,7353.00,33398.16,There are no additional notes associated with this service or procedure.
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],7868.00,,"Per diem ($7,868). If length of stay < 3.9, first 1 days paid at a per diem of $15,736 instead. Capped at $30,683.33.",,,,0,other,7868.00,32126.64,Estimated amount calculated based on 3 day length of stay.
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],19126.22,,"Case rate ($18,751.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,579.45, add-ons for qualifying new technology services are included. If operating cost exceeds $52,450.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,989.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $15,577.06 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,634.50 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,229.18. The transfer capital threshold is the transfer adjustment factor * $1,229.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,8480.00,59081.91,Inpatient DRG
HC Joint Injection/Aspir Medium WO US|PBB CHARGE,CASE-20605,APC,20605,CPT,0510,RC,,,PBB,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],297.37,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,287.31,301.68,OPPS APC
Dstr Nrolytc Agnt Parverteb Fct Sngl Crvcl/Thora|BILATERAL PROCEDURE,CASE-64633,APC,64633,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1827.80,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1827.80,1891.77,OPPS APC
"NEONATE BIRTH WEIGHT 1500-1999 GRAMS WITH MAJOR ANOMALY,MINOR",611,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],10963.86,,"Case rate ($10,963.86). Base payment rate plus any adjustments related to outliers.",,,,0,other,10963.86,11512.05,There are no additional notes associated with this service or procedure.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH CC,026,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],23000.66,,"Case rate ($23,000.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $21,532.64, add-ons for qualifying new technology services are included. If operating cost exceeds $56,403.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,299.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $19,515.74 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $19,587.69 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,539.98. The transfer capital threshold is the transfer adjustment factor * $1,539.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,23000.66,63202.45,Inpatient DRG
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC",494,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],37708.15,,"Fee schedule rate ($37,708.15). Adds an outlier to normal pricing equal to the per diem rate ($63,554.89) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,15533.10,39945.55,There are no additional notes associated with this service or procedure.
"Rpr Coltrl Ligm Mtcarphlngl/Iphal Jt|LEFT HAND, THUMB",CASE-26540,APC,26540,CPT,0360,RC,,,FA,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
HC N Block Inj Intercost Sng,CASE-64420,APC,64420,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],693.76,,"APC Price ($660.72). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,660.72,693.76,OPPS APC
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC,862,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],28705.48,,"Fee schedule rate ($28,705.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (42), with a minimum of zero.",,,,0,other,6855.00,35884.94,There are no additional notes associated with this service or procedure.
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],2070.00,,,,,,0,other,1188.00,31658.33,Estimated amount calculated based on 16 day length of stay.
Tympanostomy General Anesthesia|BILATERAL PROCEDURE,CASE-69436,APC,69436,CPT,0360,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1503.15,,"APC Price ($1,452.32). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1452.32,1524.94,OPPS APC
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],24259.09,,"Fee schedule rate ($24,259.09). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10098.51,24259.09,There are no additional notes associated with this service or procedure.
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,307,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6335.27,,"Case rate ($6,033.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $5,631.17, add-ons for qualifying new technology services are included. If operating cost exceeds $45,200.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $3,219.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $5,605.59. The transfer operating threshold is the transfer adjustment factor * $5,631.17 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $428.00. The transfer capital threshold is the transfer adjustment factor * $428.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6335.27,18228.77,Inpatient DRG
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],85466.62,,"Fee schedule rate ($85,466.62). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,21382.16,85466.62,There are no additional notes associated with this service or procedure.
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],6965.00,,,,,,0,other,6148.93,15887.21,There are no additional notes associated with this service or procedure.
Nasal/Sinus Ndsc W/Rmvl Tiss From Frontal Sinus|LEFT SIDE,CASE-31276,APC,31276,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6605.95,,"APC Price ($6,605.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6605.95,6936.25,OPPS APC
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],29474.94,,"Fee schedule rate ($29,474.94). Adds an outlier to normal pricing equal to the per diem rate ($65,448.99) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.4), with a minimum of zero.",,,,0,other,12566.28,30861.41,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,690,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7686.88,,"Case rate ($7,426.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,044.73, add-ons for qualifying new technology services are included. If operating cost exceeds $41,915.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,160.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,081.05 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,099.78 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $400.94. The transfer capital threshold is the transfer adjustment factor * $400.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,7426.94,15928.53,Inpatient DRG
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,690,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],15212.93,,"Fee schedule rate ($15,212.93). Adds an outlier to normal pricing equal to the per diem rate ($36,758.78) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,7426.94,15928.53,There are no additional notes associated with this service or procedure.
Rpr Aa Hernia 1st < 3 Cm Ncrc8/Strangulated,CASE-49592,APC,49592,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5856.81,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5856.81,5941.70,OPPS APC
HC Inj Trigger Pt 1-2 Musc Grps|PBB CHARGE|SEPARATE STRUCTURE,CASE-20552,APC,20552,CPT,0510,RC,,,PBB|XS,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],301.68,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,287.31,301.68,OPPS APC
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],12455.21,,"Case rate ($12,455.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,722.41, add-ons for qualifying new technology services are included. If operating cost exceeds $46,593.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,528.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $9,741.55 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,777.47 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $768.70. The transfer capital threshold is the transfer adjustment factor * $768.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12455.21,37149.27,Inpatient DRG
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,448,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],94077.13,,"Fee schedule rate ($94,077.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,30663.95,94077.13,There are no additional notes associated with this service or procedure.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],14699.43,,"Fee schedule rate ($14,699.43). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6683.37,14699.43,There are no additional notes associated with this service or procedure.
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",004,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],167558.30,,"Case rate ($95,747.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $89,207.57, add-ons for qualifying new technology services are included. If operating cost exceeds $124,078.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $8,620.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 22.4. The base transfer operating payment is the transfer adjustment factor * $86,942.06 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $87,262.63 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $6,860.59. The transfer capital threshold is the transfer adjustment factor * $6,860.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,10249.47,272554.00,All Other Inpatient
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],11593.79,,"Case rate ($11,593.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,921.06, add-ons for qualifying new technology services are included. If operating cost exceeds $45,792.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,465.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $8,943.14 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,976.12 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $705.70. The transfer capital threshold is the transfer adjustment factor * $705.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,11593.79,38248.08,Inpatient DRG
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],8106.18,,"Case rate ($8,106.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,676.61, add-ons for qualifying new technology services are included. If operating cost exceeds $42,547.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,210.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,710.61 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,731.66 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $450.62. The transfer capital threshold is the transfer adjustment factor * $450.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8106.18,18245.94,Inpatient DRG
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],15751.44,,,,,,0,other,6965.00,21195.68,There are no additional notes associated with this service or procedure.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],22029.45,,"Case rate ($21,597.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,227.30, add-ons for qualifying new technology services are included. If operating cost exceeds $55,098.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,197.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $18,215.19 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,282.35 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,437.36. The transfer capital threshold is the transfer adjustment factor * $1,437.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,21597.50,67790.93,Inpatient DRG
SINGLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL,402,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],124455.45,,"Fee schedule rate ($124,455.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,29172.05,124455.45,There are no additional notes associated with this service or procedure.
"Hallux Rigidus W/Cheilectomy 1st Mp Jt W/O Implt|RIGHT FOOT, GREAT TOE",CASE-28289,APC,28289,CPT,0360,RC,,,T5,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3215.80,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC,807,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],5354.25,,"Fee schedule rate ($5,354.25). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5354.25,13266.23,There are no additional notes associated with this service or procedure.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC",494,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],15533.10,,"Case rate ($15,533.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,585.72, add-ons for qualifying new technology services are included. If operating cost exceeds $49,456.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,753.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $12,594.34 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,640.78 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $993.82. The transfer capital threshold is the transfer adjustment factor * $993.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,15533.10,39945.55,Inpatient DRG
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],28394.78,,"Fee schedule rate ($28,394.78). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11454.97,28394.78,There are no additional notes associated with this service or procedure.
BRONCHITIS AND ASTHMA WITH CC/MCC,202,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],8521.98,,"Case rate ($8,521.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,063.43, add-ons for qualifying new technology services are included. If operating cost exceeds $42,934.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,241.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,096.00 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,118.48 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $481.03. The transfer capital threshold is the transfer adjustment factor * $481.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7606.34,19110.30,Inpatient DRG
OSTEOMYELITIS WITH CC,540,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],10723.59,,"Case rate ($10,723.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,111.53, add-ons for qualifying new technology services are included. If operating cost exceeds $44,982.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,402.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $8,136.58 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,166.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $642.06. The transfer capital threshold is the transfer adjustment factor * $642.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9809.07,25507.30,Inpatient DRG
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],52794.06,,"Fee schedule rate ($52,794.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (37), with a minimum of zero.",,,,0,other,13907.80,52794.06,There are no additional notes associated with this service or procedure.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,761,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],11946.72,,"Fee schedule rate ($11,946.72). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,5808.41,11946.72,There are no additional notes associated with this service or procedure.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,098,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],17835.89,,"Case rate ($17,486.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,402.62, add-ons for qualifying new technology services are included. If operating cost exceeds $51,273.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,896.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $14,404.56 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,457.67 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,136.66. The transfer capital threshold is the transfer adjustment factor * $1,136.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6965.00,45156.75,Inpatient DRG
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],8656.84,,"Fee schedule rate ($8,656.84). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7875.94,17233.12,There are no additional notes associated with this service or procedure.
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],14309.17,,"Fee schedule rate ($14,309.17). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,17467.27,There are no additional notes associated with this service or procedure.
FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,748,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],23959.95,,"Fee schedule rate ($23,959.95). Adds an outlier to normal pricing equal to the per diem rate ($6,436.73) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,9316.20,26805.98,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],43399.23,,"Fee schedule rate ($43,399.23). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9888.00,43399.23,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],23899.13,,"Fee schedule rate ($23,899.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9795.13,23899.13,There are no additional notes associated with this service or procedure.
Tonsillectomy & Adenoidectomy Age 12/>,CASE-42821,APC,42821,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.52,,"APC Price ($3,103.35). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.35,3258.52,OPPS APC
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],81454.07,,"Fee schedule rate ($81,454.07). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,10078.00,81454.07,There are no additional notes associated with this service or procedure.
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],27896.38,,"Case rate ($15,940.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,964.98, add-ons for qualifying new technology services are included. If operating cost exceeds $49,835.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,783.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $12,972.20 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,020.03 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,023.63. The transfer capital threshold is the transfer adjustment factor * $1,023.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,15940.79,53275.26,All Other Inpatient
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,069,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],7354.47,,"Case rate ($7,354.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,977.32, add-ons for qualifying new technology services are included. If operating cost exceeds $41,848.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,155.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $5,013.88 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,032.37 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $395.65. The transfer capital threshold is the transfer adjustment factor * $395.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,20333.68,Inpatient DRG
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],39361.94,,"Fee schedule rate ($39,361.94). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.8), with a minimum of zero.",,,,0,other,16129.04,59610.47,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],14871.83,,"Fee schedule rate ($14,871.83). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6558.75,14871.83,There are no additional notes associated with this service or procedure.
"NEONATE BIRTH WEIGHT > 2499 GRAMS WITH OTHER MAJOR PROCEDURE,MINOR",631,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],4708.43,,"Case rate ($4,484.22). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4484.22,4708.43,There are no additional notes associated with this service or procedure.
"PEPTIC ULCER AND GASTRITIS,MODERATE",241,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],9095.68,,"Case rate ($8,662.55). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8662.55,9095.68,There are no additional notes associated with this service or procedure.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],29917.96,,"Fee schedule rate ($29,917.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,12527.66,29917.96,There are no additional notes associated with this service or procedure.
Perq Nl/Pl Lithotrp Simple Up to 2 Cm 1 Location|LEFT SIDE,CASE-50080,APC,50080,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],8860.83,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,8860.83,9303.88,OPPS APC
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],31973.49,,"Fee schedule rate ($31,973.49). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,13386.36,33244.29,There are no additional notes associated with this service or procedure.
HEADACHES WITHOUT MCC,103,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],6965.00,,,,,,0,other,6965.00,20883.08,There are no additional notes associated with this service or procedure.
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC",641,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],7214.98,,"Case rate ($7,214.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,847.54, add-ons for qualifying new technology services are included. If operating cost exceeds $41,718.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,145.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $4,884.58 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,902.59 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $385.44. The transfer capital threshold is the transfer adjustment factor * $385.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7214.98,15312.64,Inpatient DRG
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],35474.53,,"Fee schedule rate ($35,474.53). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,16428.39,42083.20,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,093,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],6965.00,,,,,,0,other,6965.00,19011.32,There are no additional notes associated with this service or procedure.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC,027,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],19981.71,,"Case rate ($19,030.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,839, add-ons for qualifying new technology services are included. If operating cost exceeds $52,710.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,009.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $15,835.66 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,894.05 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,249.59. The transfer capital threshold is the transfer adjustment factor * $1,249.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,19030.20,56363.30,Inpatient DRG
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],15114.43,,"Case rate ($14,603.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,720.75, add-ons for qualifying new technology services are included. If operating cost exceeds $48,591.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,685.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $11,732.54 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,775.80 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $925.81. The transfer capital threshold is the transfer adjustment factor * $925.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,14603.31,45017.13,Inpatient DRG
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],14451.02,,"Case rate ($13,762.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,938.93, add-ons for qualifying new technology services are included. If operating cost exceeds $47,809.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,624.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $10,953.59 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,993.98 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $864.35. The transfer capital threshold is the transfer adjustment factor * $864.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,1188.00,34338.33,Inpatient DRG
"INFECTIOUS AND PARASITIC DISEASES INCLUDING HIV WITH O.R. PROCEDURE,MODERATE",710,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],19723.98,,"Case rate ($19,723.98). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,19723.98,20710.18,There are no additional notes associated with this service or procedure.
"CARDIAC ARREST, UNEXPLAINED WITH MCC",296,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],36459.67,,"Fee schedule rate ($36,459.67). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12522.25,36459.67,There are no additional notes associated with this service or procedure.
Laps Surg Cholecystectomy W/Cholangiography,CASE-47563,APC,47563,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5658.76,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5658.76,5941.70,OPPS APC
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC,099,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],22084.20,,"Fee schedule rate ($22,084.20). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11171.21,26807.94,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITH MCC,385,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],21593.52,,"Fee schedule rate ($21,593.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11480.01,31134.92,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF NERVOUS SYSTEM WITH CC,092,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],26765.51,,"Fee schedule rate ($26,765.51). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8872.78,26765.51,There are no additional notes associated with this service or procedure.
OTHER CEREBROVASCULAR DISORDERS WITH CC,071,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],5843.00,,"Per diem ($5,843). If length of stay < 3.3, first 1 days paid at a per diem of $11,686 instead. Capped at $19,281.62.",,,,0,other,5843.00,29215.10,Estimated amount calculated based on 3 day length of stay.
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,083,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],6965.00,,,,,,0,other,6965.00,28680.85,There are no additional notes associated with this service or procedure.
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC",458,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],132827.25,,"Fee schedule rate ($132,827.25). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,30202.09,132827.25,There are no additional notes associated with this service or procedure.
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],62990.26,,"Fee schedule rate ($62,990.26). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,16787.98,62990.26,There are no additional notes associated with this service or procedure.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],23520.23,,"Fee schedule rate ($23,520.23). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10517.71,24909.11,There are no additional notes associated with this service or procedure.
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],12514.73,,"Case rate ($12,091.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,384.11, add-ons for qualifying new technology services are included. If operating cost exceeds $46,255.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,502.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $9,404.49 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,439.16 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $742.11. The transfer capital threshold is the transfer adjustment factor * $742.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6965.00,29482.05,Inpatient DRG
Egd Band Ligation Esophgeal/Gastric Varices,CASE-43244,APC,43244,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1859.01,,"APC Price ($1,796.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1796.14,1885.95,OPPS APC
"Tenolysis Extensor Tendon Hand/Finger Each|LEFT HAND, SECOND DIGIT",CASE-26445,APC,26445,CPT,0360,RC,,,F1,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3169.86,OPPS APC
"Inj Dx/Ther Agnt Paravert Facet Joint, Cerv/Thorac, Add Level|RIGHT SIDE",CASE-64492,APC,64492,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],856.86,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,827.89,869.28,OPPS APC
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],22487.70,,"Fee schedule rate ($22,487.70). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10048.39,23545.50,There are no additional notes associated with this service or procedure.
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],7389.00,,"Per diem ($7,389). If length of stay < 4.8, first 1 days paid at a per diem of $14,778 instead. Capped at $35,466.15.",,,,0,other,7389.00,37134.43,Estimated amount calculated based on 6 day length of stay.
Chemodenervation Muscle Neck Unilat for Dystonia,CASE-64616,APC,64616,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],16235.87,,"Fee schedule rate ($16,235.87). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6524.00,17760.46,There are no additional notes associated with this service or procedure.
"HEART FAILURE,MAJOR",194,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],12284.52,,"Case rate ($11,699.54). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11699.54,12284.52,There are no additional notes associated with this service or procedure.
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],16283.24,,"Fee schedule rate ($16,283.24). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7875.94,17233.12,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,083,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],19945.45,,"Case rate ($11,397.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,738.37, add-ons for qualifying new technology services are included. If operating cost exceeds $45,609.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,451.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $8,761.12 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,793.42 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $691.34. The transfer capital threshold is the transfer adjustment factor * $691.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,6965.00,28680.85,All Other Inpatient
MAJOR ESOPHAGEAL DISORDERS WITH CC,369,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],19680.94,,,,,,0,other,6965.00,19680.94,There are no additional notes associated with this service or procedure.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,025,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],91631.33,,"Fee schedule rate ($91,631.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,13351.00,91631.33,There are no additional notes associated with this service or procedure.
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],9755.86,,"Case rate ($9,755.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,211.27, add-ons for qualifying new technology services are included. If operating cost exceeds $44,082.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,331.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $7,239.63 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,266.32 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $571.28. The transfer capital threshold is the transfer adjustment factor * $571.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9755.86,29216.99,Inpatient DRG
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],34892.92,,"Fee schedule rate ($34,892.92). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,6965.00,41030.48,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITH MCC,385,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],21593.52,,"Fee schedule rate ($21,593.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11480.01,31134.92,There are no additional notes associated with this service or procedure.
Int Hrhc by Ligation 2+ Hroid W/O Img Gdn,CASE-46946,APC,46946,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],2727.99,,"APC Price ($2,598.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2598.08,2727.99,OPPS APC
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],32390.31,,,,,,0,other,13092.47,33159.45,There are no additional notes associated with this service or procedure.
HC Anterior Epitaxis Simple|RIGHT SIDE,CASE-30901,APC,30901,CPT,0450,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],124.54,,"APC Price ($124.54). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,124.54,130.76,OPPS APC
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,690,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],14625.55,,"Fee schedule rate ($14,625.55). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7426.94,15928.53,There are no additional notes associated with this service or procedure.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],37572.15,,"Fee schedule rate ($37,572.15). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,21597.50,67790.93,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,085,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],17722.41,,"Case rate ($16,878.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,865.17, add-ons for qualifying new technology services are included. If operating cost exceeds $50,736.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,825.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $13,867.65 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,920.22 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,065.90. The transfer capital threshold is the transfer adjustment factor * $1,065.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9282.00,57443.16,Inpatient DRG
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6379.98,,"Case rate ($6,076.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,795.85, add-ons for qualifying new technology services are included. If operating cost exceeds $40,666.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,054.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,836.36 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,850.90 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $294.87. The transfer capital threshold is the transfer adjustment factor * $294.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5937.41,12366.99,Inpatient DRG
"ANTEPARTUM WITHOUT O.R. PROCEDURE,MODERATE",566,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],3744.16,,"Case rate ($3,744.16). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,3744.16,3931.37,There are no additional notes associated with this service or procedure.
HC Biopsy/Exc Lymph Node Needle|RIGHT SIDE,CASE-38505,APC,38505,CPT,0361,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1600.04,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1545.93,1623.23,OPPS APC
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],6965.00,,,,,,0,other,6965.00,36140.75,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,448,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],94077.13,,"Fee schedule rate ($94,077.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,30663.95,94077.13,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],19691.31,,"Fee schedule rate ($19,691.31). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,9040.72,26966.33,There are no additional notes associated with this service or procedure.
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],16400.70,,"Fee schedule rate ($16,400.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,16400.70,There are no additional notes associated with this service or procedure.
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],11065.78,,"Fee schedule rate ($11,065.78). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5883.03,17111.12,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],41402.42,,"Fee schedule rate ($41,402.42). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,15456.59,41402.42,There are no additional notes associated with this service or procedure.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITHOUT CC/MCC,816,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],7832.96,,"Fee schedule rate ($7,832.96). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6224.90,14733.53,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],28923.03,,"Case rate ($27,944.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $26,132.21, add-ons for qualifying new technology services are included. If operating cost exceeds $61,003.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,661.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.8. The base transfer operating payment is the transfer adjustment factor * $24,098.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $24,187.26 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,901.60. The transfer capital threshold is the transfer adjustment factor * $1,901.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,27944.96,86252.84,Inpatient DRG
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],21195.68,,"Fee schedule rate ($21,195.68). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,6965.00,21195.68,There are no additional notes associated with this service or procedure.
Hrv Skin for Skin Cell Ssp Agrft 1st 25 Sq Cm/<,CASE-15011,APC,15011,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1998.87,,"APC Price ($1,931.28). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1931.28,1998.87,OPPS APC
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7834.78,,"Case rate ($7,569.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,177.66, add-ons for qualifying new technology services are included. If operating cost exceeds $42,048.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,171.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,213.49 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,232.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $411.40. The transfer capital threshold is the transfer adjustment factor * $411.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,7569.84,21892.85,Inpatient DRG
Colonoscopy W/Biopsy Single/Multiple|COLORECTAL CANCER SCREEN|UNUSUAL NON-OVERLAPPING SERVICE,CASE-45380,APC,45380,CPT,0360,RC,,,PT|XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1176.09,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1120.09,1176.09,OPPS APC
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],81454.07,,"Fee schedule rate ($81,454.07). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,10078.00,81454.07,There are no additional notes associated with this service or procedure.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,073,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],30149.61,,"Fee schedule rate ($30,149.61). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12809.38,43475.01,There are no additional notes associated with this service or procedure.
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],2070.00,,,,,,0,other,1188.00,31658.33,Estimated amount calculated based on 16 day length of stay.
INFLAMMATORY BOWEL DISEASE WITH CC,386,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],18347.61,,"Fee schedule rate ($18,347.61). Adds an outlier to normal pricing equal to the per diem rate ($111,650.51) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8556.53,19879.00,There are no additional notes associated with this service or procedure.
Dstr Nrolytc Agnt Parverteb Fct Sngl Lmbr/Sacral|RIGHT SIDE,CASE-64635,APC,64635,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1891.77,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1827.80,1919.19,OPPS APC
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],8239.88,,"Case rate ($7,847.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,435.96, add-ons for qualifying new technology services are included. If operating cost exceeds $42,306.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,191.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,470.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,491.01 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $431.70. The transfer capital threshold is the transfer adjustment factor * $431.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7847.50,17755.26,Inpatient DRG
SPINAL PROCEDURES WITHOUT CC/MCC,030,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],41254.39,,"Fee schedule rate ($41,254.39). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,16810.99,44714.01,There are no additional notes associated with this service or procedure.
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],42021.93,,"Fee schedule rate ($42,021.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,21248.73,56089.29,There are no additional notes associated with this service or procedure.
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],16064.26,,"Fee schedule rate ($16,064.26). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7733.72,18043.23,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],18905.23,,"Fee schedule rate ($18,905.23). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6963.00,18954.85,There are no additional notes associated with this service or procedure.
DIABETES WITH CC,638,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],15195.79,,"Fee schedule rate ($15,195.79). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8014.07,17634.53,There are no additional notes associated with this service or procedure.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],21455.22,,"Fee schedule rate ($21,455.22). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,9097.60,21455.22,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],6965.00,,,,,,0,other,6164.03,14071.02,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],19371.27,,"Fee schedule rate ($19,371.27). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7641.61,19371.27,There are no additional notes associated with this service or procedure.
Cysto Bladder W/Ureteral Catheterization|RIGHT SIDE,CASE-52005,APC,52005,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],2054.48,,"APC Price ($1,956.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1956.65,2054.48,OPPS APC
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],17693.40,,"Case rate ($17,693.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,595.40, add-ons for qualifying new technology services are included. If operating cost exceeds $51,466.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,911.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $14,596.63 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,650.45 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,151.82. The transfer capital threshold is the transfer adjustment factor * $1,151.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,17693.40,52449.26,Inpatient DRG
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC,805,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],9253.36,,"Case rate ($9,253.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,743.82, add-ons for qualifying new technology services are included. If operating cost exceeds $43,614.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,294.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $6,773.89 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,798.87 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $534.53. The transfer capital threshold is the transfer adjustment factor * $534.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9253.36,21235.42,Inpatient DRG
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],62990.26,,"Fee schedule rate ($62,990.26). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,16787.98,62990.26,There are no additional notes associated with this service or procedure.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],34001.86,,,,,,0,other,7921.00,45706.73,There are no additional notes associated with this service or procedure.
FRACTURES OF FEMUR WITH MCC,533,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],30847.63,,,,,,0,other,6852.00,49490.05,There are no additional notes associated with this service or procedure.
Nasal/Sinus Ndsc Surg W/Concha Bullosa Resection|RIGHT SIDE,CASE-31240,APC,31240,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.35,,"APC Price ($3,103.35). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.35,3258.52,OPPS APC
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,373,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],13780.60,,"Fee schedule rate ($13,780.60). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6870.94,14313.05,There are no additional notes associated with this service or procedure.
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],14599.65,,"Case rate ($13,904.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,070.60, add-ons for qualifying new technology services are included. If operating cost exceeds $47,941.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,634.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,084.78 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,125.65 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $874.70. The transfer capital threshold is the transfer adjustment factor * $874.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13904.43,34749.58,Inpatient DRG
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],8982.23,,"Case rate ($8,554.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,093.67, add-ons for qualifying new technology services are included. If operating cost exceeds $42,964.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,243.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,126.13 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,148.72 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $483.41. The transfer capital threshold is the transfer adjustment factor * $483.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8554.50,19204.75,Inpatient DRG
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],35419.59,,"Fee schedule rate ($35,419.59). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,7086.00,57872.02,There are no additional notes associated with this service or procedure.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",062,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],33023.06,,"Fee schedule rate ($33,023.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,13844.84,44304.80,There are no additional notes associated with this service or procedure.
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],19462.52,,,,,,0,other,8643.20,19462.52,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,373,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7062.56,,"Case rate ($6,726.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,401.82, add-ons for qualifying new technology services are included. If operating cost exceeds $41,272.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,101.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $4,440.04 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,456.87 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $341.27. The transfer capital threshold is the transfer adjustment factor * $341.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6870.94,14313.05,Inpatient DRG
INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC,198,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],13459.55,,"Fee schedule rate ($13,459.55). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.7), with a minimum of zero.",,,,0,other,6795.12,23505.07,There are no additional notes associated with this service or procedure.
NON-MALIGNANT BREAST DISORDERS WITH CC/MCC,600,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],15046.13,,"Fee schedule rate ($15,046.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7999.14,20495.56,There are no additional notes associated with this service or procedure.
Surgical Arthroscopy Shoulder Dstl Claviculc|RIGHT SIDE,CASE-29824,APC,29824,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6791.99,7131.59,OPPS APC
HC Rt Bronchoscopy Alveolar Lavage,CASE-31624,APC,31624,CPT,0361,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6936.25,,"APC Price ($6,605.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6605.95,6936.25,OPPS APC
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],28035.79,,,,,,0,other,11593.79,38248.08,There are no additional notes associated with this service or procedure.
SPINAL PROCEDURES WITHOUT CC/MCC,030,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],44714.01,,"Fee schedule rate ($44,714.01). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,16810.99,44714.01,There are no additional notes associated with this service or procedure.
MAJOR THUMB OR JOINT PROCEDURES,506,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],11081.83,,"Case rate ($11,081.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,444.79, add-ons for qualifying new technology services are included. If operating cost exceeds $45,315.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,428.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $8,468.62 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,499.84 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $668.26. The transfer capital threshold is the transfer adjustment factor * $668.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,11081.83,26548.21,Inpatient DRG
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],9950.98,,"Case rate ($9,755.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,211.27, add-ons for qualifying new technology services are included. If operating cost exceeds $44,082.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,331.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $7,239.63 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,266.32 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $571.28. The transfer capital threshold is the transfer adjustment factor * $571.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,9755.86,29216.99,Inpatient DRG
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],23801.30,,,,,,0,other,10136.44,24444.75,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],34409.98,,"Fee schedule rate ($34,409.98). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,14344.60,36028.59,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],86252.84,,"Fee schedule rate ($86,252.84). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,27944.96,86252.84,There are no additional notes associated with this service or procedure.
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],13794.06,,"Fee schedule rate ($13,794.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,6915.64,14442.92,There are no additional notes associated with this service or procedure.
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],8234.89,,"Case rate ($7,842.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,431.55, add-ons for qualifying new technology services are included. If operating cost exceeds $42,302.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,191.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $5,466.44 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,486.60 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $431.36. The transfer capital threshold is the transfer adjustment factor * $431.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5280.00,17136.70,Inpatient DRG
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],12173.48,,"Case rate ($11,593.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,921.06, add-ons for qualifying new technology services are included. If operating cost exceeds $45,792.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,465.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $8,943.14 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,976.12 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $705.70. The transfer capital threshold is the transfer adjustment factor * $705.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,11593.79,38248.08,Inpatient DRG
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC",514,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],22699.91,,"Fee schedule rate ($22,699.91). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8868.04,22699.91,There are no additional notes associated with this service or procedure.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],54764.34,,"Fee schedule rate ($54,764.34). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,18178.96,54764.34,There are no additional notes associated with this service or procedure.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],120927.32,,"Fee schedule rate ($120,927.32). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,45521.20,142438.06,There are no additional notes associated with this service or procedure.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],24511.94,,"Case rate ($23,344.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $21,852.68, add-ons for qualifying new technology services are included. If operating cost exceeds $56,723.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,325.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $19,834.60 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $19,907.73 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,565.15. The transfer capital threshold is the transfer adjustment factor * $1,565.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,23344.70,62179.32,Inpatient DRG
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,085,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],18196.93,,"Case rate ($17,330.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,257.72, add-ons for qualifying new technology services are included. If operating cost exceeds $51,128.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,885.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $14,260.20 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,312.77 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,125.27. The transfer capital threshold is the transfer adjustment factor * $1,125.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9282.00,57443.16,Inpatient DRG
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],10862.00,,"Per diem ($10,862). If length of stay < 7.6, first 1 days paid at a per diem of $21,724 instead. Capped at $82,553.89.",,,,0,other,10862.00,86437.13,Estimated amount calculated based on 6 day length of stay.
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC,797,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],9155.71,,"Case rate ($8,719.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,247.38, add-ons for qualifying new technology services are included. If operating cost exceeds $43,118.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,255.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $6,279.28 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,302.43 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $495.50. The transfer capital threshold is the transfer adjustment factor * $495.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8719.72,20928.55,Inpatient DRG
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6606.85,,"Case rate ($6,606.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,281.82, add-ons for qualifying new technology services are included. If operating cost exceeds $41,152.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,100.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,320.93 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,336.86 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $340.96. The transfer capital threshold is the transfer adjustment factor * $340.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,5919.29,13545.65,Inpatient DRG
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],8409.81,,"Case rate ($8,009.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,586.52, add-ons for qualifying new technology services are included. If operating cost exceeds $42,457.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,203.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $5,620.85 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,641.57 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $443.54. The transfer capital threshold is the transfer adjustment factor * $443.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8009.34,19877.10,Inpatient DRG
Neuroplasty &/Transposition Ulnar Nerve Elbow|LEFT SIDE|SEPARATE STRUCTURE,CASE-64718,APC,64718,CPT,0360,RC,,,LT|XS,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6791.99,7131.59,OPPS APC
VENTRICULAR SHUNT PROCEDURES WITH CC,032,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],16376.22,,"Case rate ($16,376.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,370.06, add-ons for qualifying new technology services are included. If operating cost exceeds $50,241.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,815.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $13,375.80 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,425.12 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,055.48. The transfer capital threshold is the transfer adjustment factor * $1,055.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,16376.22,46275.08,Inpatient DRG
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],23899.13,,"Fee schedule rate ($23,899.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9795.13,23899.13,There are no additional notes associated with this service or procedure.
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],28334.16,,"Fee schedule rate ($28,334.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,7868.00,32126.64,There are no additional notes associated with this service or procedure.
Redo Excis Lumbar Disk|RIGHT SIDE,CASE-63042,APC,63042,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7029.71,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6791.99,7131.59,OPPS APC
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],18585.05,,"Fee schedule rate ($18,585.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8859.23,20090.22,There are no additional notes associated with this service or procedure.
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH MCC",510,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],47775.29,,"Fee schedule rate ($47,775.29). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10710.00,89863.76,There are no additional notes associated with this service or procedure.
PREMATURITY WITHOUT MAJOR PROBLEMS,792,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],2074.00,,,,,,0,other,1956.00,19457.66,Estimated amount calculated based on 3 day length of stay.
HC Biopsy/Exc Lymph Node Needle,CASE-38505,APC,38505,CPT,0361,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1623.23,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1545.93,1623.23,OPPS APC
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC,099,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],11562.20,,"Case rate ($11,171.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,527.95, add-ons for qualifying new technology services are included. If operating cost exceeds $45,398.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,434.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,551.47 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,583.00 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $674.80. The transfer capital threshold is the transfer adjustment factor * $674.80. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,11171.21,26807.94,Inpatient DRG
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,451,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],60708.91,,"Fee schedule rate ($60,708.91). Adds an outlier to normal pricing equal to the per diem rate ($108,215.07) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,23821.44,94077.13,There are no additional notes associated with this service or procedure.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],16829.13,,"Fee schedule rate ($16,829.13). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,8009.34,19877.10,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],2070.00,,,,,,0,other,1188.00,17370.86,Estimated amount calculated based on 3 day length of stay.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],22626.77,,"Fee schedule rate ($22,626.77). Adds an outlier to normal pricing equal to the per diem rate ($36,883.74) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.5), with a minimum of zero.",,,,0,other,10098.51,24259.09,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],15609.47,,"Fee schedule rate ($15,609.47). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7569.84,21892.85,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH CC,427,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],135659.15,,"Fee schedule rate ($135,659.15). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.8), with a minimum of zero.",,,,0,other,50829.82,142040.39,There are no additional notes associated with this service or procedure.
"CESAREAN SECTION WITHOUT STERILIZATION,MINOR",540,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],6521.58,,"Case rate ($6,211.03). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6211.03,6521.58,There are no additional notes associated with this service or procedure.
Perq Nl/Pl Lithotrp Complex >2 Cm Mlt Locations|RIGHT SIDE,CASE-50081,APC,50081,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],9303.88,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,8860.83,9303.88,OPPS APC
PREMATURITY WITH MAJOR PROBLEMS,791,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],3054.00,,,,,,0,other,3048.21,30904.42,Estimated amount calculated based on 5 day length of stay.
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],10448.91,,"Fee schedule rate ($10,448.91). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,3079.00,10940.41,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],10767.96,,"Case rate ($6,153.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,859.72, add-ons for qualifying new technology services are included. If operating cost exceeds $40,730.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,067.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,900.39 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,914.77 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $307.78. The transfer capital threshold is the transfer adjustment factor * $307.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,6153.12,13947.32,All Other Inpatient
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],15088.88,,"Case rate ($14,370.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,504.04, add-ons for qualifying new technology services are included. If operating cost exceeds $48,375.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,668.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $11,516.62 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,559.08 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $908.78. The transfer capital threshold is the transfer adjustment factor * $908.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,14370.36,38378.80,Inpatient DRG
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],9318.55,,"Case rate ($8,874.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,391.65, add-ons for qualifying new technology services are included. If operating cost exceeds $43,262.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,266.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $6,423.02 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,446.70 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $506.84. The transfer capital threshold is the transfer adjustment factor * $506.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8874.81,20553.44,Inpatient DRG
CERVICAL SPINAL FUSION WITH MCC,471,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],111337.93,,"Fee schedule rate ($111,337.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,34645.26,111337.93,There are no additional notes associated with this service or procedure.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC,099,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],25603.58,,"Fee schedule rate ($25,603.58). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.7), with a minimum of zero.",,,,0,other,11171.21,26807.94,There are no additional notes associated with this service or procedure.
CELLULITIS WITH MCC,602,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],28349.31,,"Fee schedule rate ($28,349.31). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11570.10,28349.31,There are no additional notes associated with this service or procedure.
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],16033.30,,"Case rate ($15,491.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,546.67, add-ons for qualifying new technology services are included. If operating cost exceeds $49,417.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,750.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $12,555.42 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,601.72 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $990.75. The transfer capital threshold is the transfer adjustment factor * $990.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,15491.11,54180.83,Inpatient DRG
"OTHER DIGESTIVE SYSTEM DIAGNOSES,MINOR",254,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],5798.63,,"Case rate ($5,522.50). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5522.50,5798.63,There are no additional notes associated with this service or procedure.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],26776.27,,"Fee schedule rate ($26,776.27). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,11593.79,38248.08,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],10736.25,,"Fee schedule rate ($10,736.25). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7641.61,19371.27,There are no additional notes associated with this service or procedure.
SALIVARY GLAND PROCEDURES,139,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],30690.92,,"Fee schedule rate ($30,690.92). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,10313.19,30690.92,There are no additional notes associated with this service or procedure.
"Tendon Sheath Incision|RIGHT HAND, SECOND DIGIT",CASE-26055,APC,26055,CPT,0360,RC,,,F6,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1557.80,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1505.12,1580.37,OPPS APC
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],12368.61,,"Case rate ($12,126.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,416.25, add-ons for qualifying new technology services are included. If operating cost exceeds $46,287.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,504.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $9,436.50 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,471.29 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $744.63. The transfer capital threshold is the transfer adjustment factor * $744.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,12126.09,29582.40,Inpatient DRG
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],6937.19,,"Case rate ($6,606.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,281.82, add-ons for qualifying new technology services are included. If operating cost exceeds $41,152.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,100.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,320.93 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,336.86 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $340.96. The transfer capital threshold is the transfer adjustment factor * $340.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5919.29,13545.65,Inpatient DRG
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],28434.57,,"Fee schedule rate ($28,434.57). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,8906.63,28434.57,There are no additional notes associated with this service or procedure.
"NEONATE BIRTH WEIGHT 1500-1999 GRAMS WITH OR WITHOUT OTHER SIGNIFICANT CONDITION,MODERATE",614,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],10963.86,,"Case rate ($10,963.86). Base payment rate plus any adjustments related to outliers.",,,,0,other,10963.86,11512.05,There are no additional notes associated with this service or procedure.
"BRONCHIOLITIS AND RSV PNEUMONIA,MODERATE",138,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],5100.99,,"Case rate ($4,858.09). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4858.09,5100.99,There are no additional notes associated with this service or procedure.
Esophagogastroduodenoscopy Submucosal Injection|UNUSUAL NON-OVERLAPPING SERVICE,CASE-43236,APC,43236,CPT,0360,RC,,,XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],878.67,,"APC Price ($848.96). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,848.96,891.41,OPPS APC
Hallux Rigidus W/Cheilectomy 1st Mp Jt W/O Implt,CASE-28289,APC,28289,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],28821.04,,"Fee schedule rate ($28,821.04). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,10347.06,28821.04,There are no additional notes associated with this service or procedure.
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC",011,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],150008.48,,"Fee schedule rate ($150,008.48). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (44), with a minimum of zero.",,,,0,other,38880.49,150008.48,There are no additional notes associated with this service or procedure.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],40181.04,,"Fee schedule rate ($40,181.04). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,25162.32,75579.22,There are no additional notes associated with this service or procedure.
"LIMB REATTACHMENT, HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA",956,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],27428.25,,"Case rate ($27,428.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $25,651.53, add-ons for qualifying new technology services are included. If operating cost exceeds $60,522.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,623.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $23,619.49 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $23,706.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,863.81. The transfer capital threshold is the transfer adjustment factor * $1,863.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,27428.25,148259.86,Inpatient DRG
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],14830.15,,"Fee schedule rate ($14,830.15). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,7884.32,17835.23,There are no additional notes associated with this service or procedure.
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 2nd Level|LEFT SIDE,CASE-64494,APC,64494,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],827.89,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,827.89,869.28,OPPS APC
GASTROINTESTINAL HEMORRHAGE WITH CC,378,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],8758.06,,"Case rate ($8,586.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,123.28, add-ons for qualifying new technology services are included. If operating cost exceeds $42,994.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,245.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,155.63 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,178.33 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $485.74. The transfer capital threshold is the transfer adjustment factor * $485.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,8586.33,20845.19,Inpatient DRG
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,095,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],48575.01,,"Fee schedule rate ($48,575.01). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,19411.47,50750.92,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC,832,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7022.55,,"Case rate ($6,688.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,366.29, add-ons for qualifying new technology services are included. If operating cost exceeds $41,237.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,098.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $4,404.64 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,421.34 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $338.55. The transfer capital threshold is the transfer adjustment factor * $338.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,4803.31,14198.92,Inpatient DRG
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],33221.97,,"Fee schedule rate ($33,221.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (47), with a minimum of zero.",,,,0,other,15283.90,38757.79,There are no additional notes associated with this service or procedure.
Arthrd Ant Ntrbd Min Dsc Ea Addl Interspace,CASE-22585,APC,22585,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],12618.18,,"APC Price ($12,017.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,12437.92,12618.18,OPPS APC
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,329,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],86631.74,,"Fee schedule rate ($86,631.74). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (38), with a minimum of zero.",,,,0,other,33072.77,90445.33,There are no additional notes associated with this service or procedure.
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],18918.49,,"Fee schedule rate ($18,918.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9282.47,21320.03,There are no additional notes associated with this service or procedure.
OTHER CEREBROVASCULAR DISORDERS WITH CC,071,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],29215.10,,"Fee schedule rate ($29,215.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5843.00,29215.10,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],18905.23,,"Fee schedule rate ($18,905.23). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6963.00,18954.85,There are no additional notes associated with this service or procedure.
Tonsillectomy & Adenoidectomy Age 12/>,CASE-42821,APC,42821,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.35,,"APC Price ($3,103.35). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.35,3258.52,OPPS APC
OTHER MENTAL DISORDER DIAGNOSES,887,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],2070.00,,,,,,0,other,2070.00,21072.10,Estimated amount calculated based on 1 day length of stay.
Prq Impltj Neurostimulator Eltrd Peripheral Nrv|LEFT SIDE,CASE-64555,APC,64555,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5965.28,,"APC Price ($5,965.28). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5965.28,6263.54,OPPS APC
O.R. PROCEDURES FOR OBESITY WITH CC,620,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],43753.50,,"Fee schedule rate ($43,753.50). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12782.30,43753.50,There are no additional notes associated with this service or procedure.
Thoracoscopy With Biopsyies of Pleura,CASE-32609,APC,32609,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5856.81,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5658.76,5941.70,OPPS APC
RESPIRATORY NEOPLASMS WITHOUT CC/MCC,182,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],23037.13,,"Fee schedule rate ($23,037.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6965.00,23037.13,There are no additional notes associated with this service or procedure.
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],12606.23,,"Case rate ($12,606.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,862.91, add-ons for qualifying new technology services are included. If operating cost exceeds $46,733.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,539.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $9,881.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,917.95 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $779.75. The transfer capital threshold is the transfer adjustment factor * $779.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12606.23,36868.88,Inpatient DRG
RADIOTHERAPY,849,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],81867.07,,"Fee schedule rate ($81,867.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,20293.88,81867.07,There are no additional notes associated with this service or procedure.
HYPERTENSION WITHOUT MCC,305,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],17230.49,,"Fee schedule rate ($17,230.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7058.55,17230.49,There are no additional notes associated with this service or procedure.
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],10643.26,,"Case rate ($10,136.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,565.33, add-ons for qualifying new technology services are included. If operating cost exceeds $44,436.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,359.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $7,592.38 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,620.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $599.11. The transfer capital threshold is the transfer adjustment factor * $599.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10136.44,24444.75,Inpatient DRG
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],9357.15,,"Case rate ($9,040.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,546, add-ons for qualifying new technology services are included. If operating cost exceeds $43,417.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,278.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,576.80 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,601.05 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $518.97. The transfer capital threshold is the transfer adjustment factor * $518.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,9040.72,26966.33,Inpatient DRG
"Amputation Toe Interphalangeal Joint|RIGHT FOOT, FOURTH DIGIT",CASE-28825,APC,28825,CPT,0360,RC,,,T8,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3062.67,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],16552.29,,,,,,0,other,7641.61,19371.27,There are no additional notes associated with this service or procedure.
PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,337,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12636.48,,"Case rate ($12,034.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,350.09, add-ons for qualifying new technology services are included. If operating cost exceeds $46,221.10 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,480.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $9,369.62 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,405.14 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $720.17. The transfer capital threshold is the transfer adjustment factor * $720.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12340.08,38926.31,Inpatient DRG
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],9370.00,,"Per diem ($9,370). If length of stay < 6.7, first 1 days paid at a per diem of $18,740 instead. Capped at $62,779.90.",,,,0,other,9370.00,65732.99,Estimated amount calculated based on 3 day length of stay.
"MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS,MINOR",532,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],2696.74,,"Case rate for a one day stay ($2,568.32). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,2568.32,2696.74,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],31563.88,,,,,,0,other,7353.00,33398.16,There are no additional notes associated with this service or procedure.
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],20046.20,,"Case rate ($11,454.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,791.92, add-ons for qualifying new technology services are included. If operating cost exceeds $45,662.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,455.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $8,814.47 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,846.97 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $695.55. The transfer capital threshold is the transfer adjustment factor * $695.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,11454.97,28394.78,All Other Inpatient
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,394,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],18411.77,,,,,,0,other,8281.56,20909.61,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],25609.86,,"Fee schedule rate ($25,609.86). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,12775.53,31469.43,There are no additional notes associated with this service or procedure.
Injection Aa&/Strd Intercostal Nrv Ea Addl Lvl|LEFT SIDE,CASE-64421,APC,64421,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],827.89,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,827.89,869.28,OPPS APC
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITHOUT MCC,430,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],108381.11,,"Fee schedule rate ($108,381.11). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.6), with a minimum of zero.",,,,0,other,41000.16,133156.90,There are no additional notes associated with this service or procedure.
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],7383.46,,"Case rate ($7,238.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,869.60, add-ons for qualifying new technology services are included. If operating cost exceeds $41,740.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,147.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,906.55 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,924.64 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $387.18. The transfer capital threshold is the transfer adjustment factor * $387.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,7238.69,16804.22,Inpatient DRG
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],2070.00,,,,,,0,other,1188.00,31658.33,Estimated amount calculated based on 16 day length of stay.
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],10834.64,,"Case rate ($10,834.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,214.84, add-ons for qualifying new technology services are included. If operating cost exceeds $45,085.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,410.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $8,239.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,269.90 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $650.18. The transfer capital threshold is the transfer adjustment factor * $650.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10834.64,25830.00,Inpatient DRG
HC Debride Subq First 20 Sq Cm,CASE-11042,APC,11042,CPT,0361,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],399.53,,"APC Price ($380.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,399.53,399.53,OPPS APC
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],29367.82,,"Fee schedule rate ($29,367.82). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.7), with a minimum of zero.",,,,0,other,12527.66,29917.96,There are no additional notes associated with this service or procedure.
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],14950.65,,"Case rate ($14,238.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,404.52, add-ons for qualifying new technology services are included. If operating cost exceeds $48,275.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,637.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.6. The base transfer operating payment is the transfer adjustment factor * $11,416.28 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,459.57 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $877.48. The transfer capital threshold is the transfer adjustment factor * $877.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6277.00,36801.89,Inpatient DRG
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],29342.21,,"Case rate ($27,944.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $26,132.21, add-ons for qualifying new technology services are included. If operating cost exceeds $61,003.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,661.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.8. The base transfer operating payment is the transfer adjustment factor * $24,098.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $24,187.26 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,901.60. The transfer capital threshold is the transfer adjustment factor * $1,901.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,27944.96,86252.84,Inpatient DRG
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],12943.82,,"Case rate ($7,396.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,016.38, add-ons for qualifying new technology services are included. If operating cost exceeds $41,887.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,158.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,052.80 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,071.43 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $398.72. The transfer capital threshold is the transfer adjustment factor * $398.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,7396.47,16035.06,All Other Inpatient
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC",641,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],14624.71,,"Fee schedule rate ($14,624.71). Adds an outlier to normal pricing equal to the per diem rate ($38,755.52) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7214.98,15312.64,There are no additional notes associated with this service or procedure.
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,451,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],63564.58,,,,,,0,other,23821.44,94077.13,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],19763.43,,"Fee schedule rate ($19,763.43). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,8318.14,19763.43,There are no additional notes associated with this service or procedure.
Open Tx Metacarpal Fracture Single Ea Bone|RIGHT SIDE,CASE-26615,APC,26615,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC,621,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],36669.96,,"Fee schedule rate ($36,669.96). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,12159.94,36669.96,There are no additional notes associated with this service or procedure.
PERIPHERAL VASCULAR DISORDERS WITH CC,300,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],20331.78,,"Fee schedule rate ($20,331.78). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,9174.14,21005.20,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,091,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],40030.81,,"Fee schedule rate ($40,030.81). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,13838.06,40030.81,There are no additional notes associated with this service or procedure.
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC,806,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],10071.17,,"Fee schedule rate ($10,071.17). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5354.25,13416.00,There are no additional notes associated with this service or procedure.
"ANTEPARTUM WITHOUT O.R. PROCEDURE,MINOR",566,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],2744.47,,"The inlier payment is calculated as the lesser of the standard DRG payment $2,613.78 and the transfer payment, which is a per diem of $1,281.27. If cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,2613.78,2744.47,Estimated amount calculated based on 1 day length of stay.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH CC,354,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],11633.13,,"Case rate ($11,079.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $10,340.23, add-ons for qualifying new technology services are included. If operating cost exceeds $49,909.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $3,577.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $10,293.25. The transfer operating threshold is the transfer adjustment factor * $10,340.23 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $785.91. The transfer capital threshold is the transfer adjustment factor * $785.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,11633.13,33472.54,Inpatient DRG
"DIABETES,MODERATE",420,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],2208.90,,"Case rate for a one day stay ($2,103.71). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,2103.71,2208.90,There are no additional notes associated with this service or procedure.
NORMAL NEWBORN,795,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],1956.00,,,,,,0,other,1369.79,5771.52,Estimated amount calculated based on 2 day length of stay.
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC,058,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],40853.02,,"Fee schedule rate ($40,853.02). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,13521.80,40853.02,There are no additional notes associated with this service or procedure.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],37768.77,,"Fee schedule rate ($37,768.77). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7453.00,42138.30,There are no additional notes associated with this service or procedure.
NEONATE WITH OTHER SIGNIFICANT PROBLEMS,794,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],3383.58,,"Fee schedule rate ($3,383.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,1798.85,12536.83,There are no additional notes associated with this service or procedure.
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH MCC",510,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],89863.76,,"Fee schedule rate ($89,863.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10710.00,89863.76,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,167,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],24775.99,,"Case rate ($14,157.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,306.21, add-ons for qualifying new technology services are included. If operating cost exceeds $48,177.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,653.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $11,319.53 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,361.26 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $893.22. The transfer capital threshold is the transfer adjustment factor * $893.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,14157.71,43522.37,All Other Inpatient
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],18751.20,,"Case rate ($18,751.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,579.45, add-ons for qualifying new technology services are included. If operating cost exceeds $52,450.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,989.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $15,577.06 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,634.50 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,229.18. The transfer capital threshold is the transfer adjustment factor * $1,229.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8480.00,59081.91,Inpatient DRG
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],30236.06,,"Fee schedule rate ($30,236.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.8), with a minimum of zero.",,,,0,other,1188.00,31658.33,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],12770.37,,,,,,0,other,6340.03,15076.44,There are no additional notes associated with this service or procedure.
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],29482.05,,,,,,0,other,6965.00,29482.05,There are no additional notes associated with this service or procedure.
Egd Percutaneous Placement Gastrostomy Tube,CASE-43246,APC,43246,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1859.01,,"APC Price ($1,796.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1796.14,1885.95,OPPS APC
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],9977.99,,"Case rate ($9,977.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,417.91, add-ons for qualifying new technology services are included. If operating cost exceeds $44,288.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,347.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $7,445.51 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,472.96 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $587.52. The transfer capital threshold is the transfer adjustment factor * $587.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9977.99,26949.28,Inpatient DRG
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],61234.06,,"Fee schedule rate ($61,234.06). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11165.00,61234.06,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC,788,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],20142.33,,"Fee schedule rate ($20,142.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8438.02,20142.33,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],19338.90,,"Fee schedule rate ($19,338.90). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,6965.00,41030.48,There are no additional notes associated with this service or procedure.
PERIPHERAL VASCULAR DISORDERS WITH CC,300,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],16054.75,,"Case rate ($9,174.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,670.11, add-ons for qualifying new technology services are included. If operating cost exceeds $43,541.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,288.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,700.45 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,725.16 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $528.73. The transfer capital threshold is the transfer adjustment factor * $528.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,9174.14,21005.20,All Other Inpatient
Sigmoidoscopy Flx Ndsc US Xm,CASE-45341,APC,45341,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],870.46,,"APC Price ($870.46). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,870.46,913.99,OPPS APC
SIGNS AND SYMPTOMS WITH MCC,947,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],30414.32,,"Fee schedule rate ($30,414.32). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,10541.41,30414.32,There are no additional notes associated with this service or procedure.
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],23385.72,,"Fee schedule rate ($23,385.72). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,23385.72,There are no additional notes associated with this service or procedure.
Excision Ganglion Wrist Dorsal/Volar Primary|RIGHT SIDE,CASE-25111,APC,25111,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],26127.34,,"Case rate ($26,127.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $24,441.31, add-ons for qualifying new technology services are included. If operating cost exceeds $59,312.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,528.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. The base transfer operating payment is the transfer adjustment factor * $22,413.72 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $22,496.36 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,768.66. The transfer capital threshold is the transfer adjustment factor * $1,768.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,26127.34,90333.60,Inpatient DRG
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],9608.67,,"Case rate ($9,151.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,648.69, add-ons for qualifying new technology services are included. If operating cost exceeds $43,519.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,287.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,679.11 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,703.74 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $527.05. The transfer capital threshold is the transfer adjustment factor * $527.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9151.11,30245.71,Inpatient DRG
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC,058,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],13995.06,,"Case rate ($13,521.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,714.66, add-ons for qualifying new technology services are included. If operating cost exceeds $47,585.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,606.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $10,730.14 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,769.70 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $846.71. The transfer capital threshold is the transfer adjustment factor * $846.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,13521.80,40853.02,Inpatient DRG
"NEONATE BIRTH WEIGHT > 2499 GRAMS WITH OTHER SIGNIFICANT CONDITION,MODERATE",639,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],5007.74,,"Case rate ($4,769.28). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4769.28,5007.74,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],21167.26,,"Fee schedule rate ($21,167.26). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,6841.83,21167.26,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],9389.48,,"Case rate ($9,389.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,870.44, add-ons for qualifying new technology services are included. If operating cost exceeds $43,741.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,304.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,900.05 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,925.50 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $544.48. The transfer capital threshold is the transfer adjustment factor * $544.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9389.48,22358.90,Inpatient DRG
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],23618.74,,"Fee schedule rate ($23,618.74). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10533.95,24956.34,There are no additional notes associated with this service or procedure.
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],27028.33,,,,,,0,other,11247.07,27028.33,There are no additional notes associated with this service or procedure.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],20553.44,,"Fee schedule rate ($20,553.44). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8874.81,20553.44,There are no additional notes associated with this service or procedure.
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],10947.72,,"Case rate ($10,733.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,120.35, add-ons for qualifying new technology services are included. If operating cost exceeds $44,991.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,402.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $8,145.37 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,175.40 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $642.75. The transfer capital threshold is the transfer adjustment factor * $642.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,10733.06,45157.33,Inpatient DRG
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],37914.65,,"Fee schedule rate ($37,914.65). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9865.56,37914.65,There are no additional notes associated with this service or procedure.
Ercp Stent Placement Biliary/Pancreatic Duct,CASE-43274,APC,43274,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5966.63,,"APC Price ($5,682.51). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5682.51,5966.63,OPPS APC
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],31577.54,,"Fee schedule rate ($31,577.54). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,15453.88,39251.68,There are no additional notes associated with this service or procedure.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],10567.49,,"Fee schedule rate ($10,567.49). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8009.34,19877.10,There are no additional notes associated with this service or procedure.
"CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS,MINOR",201,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],4813.13,,"Case rate ($4,813.13). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,4813.13,5053.79,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITH MCC,385,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],12660.40,,"Case rate ($12,660.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,913.31, add-ons for qualifying new technology services are included. If operating cost exceeds $46,784.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,543.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $9,931.73 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,968.35 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $783.71. The transfer capital threshold is the transfer adjustment factor * $783.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,11480.01,31134.92,Inpatient DRG
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],19187.65,,"Fee schedule rate ($19,187.65). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8859.23,20090.22,There are no additional notes associated with this service or procedure.
VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC,033,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],13519.22,,"Case rate ($12,875.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,133.75, add-ons for qualifying new technology services are included. If operating cost exceeds $47,004.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,540.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $10,150.32 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,188.80 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $780.18. The transfer capital threshold is the transfer adjustment factor * $780.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13206.23,42156.44,Inpatient DRG
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],16235.87,,"Fee schedule rate ($16,235.87). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6524.00,17760.46,There are no additional notes associated with this service or procedure.
DIABETES WITHOUT CC/MCC,639,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],10765.58,,"Case rate ($6,151.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,858.45, add-ons for qualifying new technology services are included. If operating cost exceeds $40,729.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,067.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $3,899.13 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,913.51 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $307.68. The transfer capital threshold is the transfer adjustment factor * $307.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,6151.76,12223.35,All Other Inpatient
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],9552.48,,"Case rate ($9,097.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,598.92, add-ons for qualifying new technology services are included. If operating cost exceeds $43,469.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,283.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,629.53 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,653.97 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $523.14. The transfer capital threshold is the transfer adjustment factor * $523.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9097.60,21455.22,Inpatient DRG
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],14630.12,,"Case rate ($14,343.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,478.83, add-ons for qualifying new technology services are included. If operating cost exceeds $48,349.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,666.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $11,491.51 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,533.88 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $906.79. The transfer capital threshold is the transfer adjustment factor * $906.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,14343.25,36024.65,Inpatient DRG
MAJOR BLADDER PROCEDURES WITH MCC,653,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],125343.98,,"Fee schedule rate ($125,343.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,10280.00,125343.98,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,082,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],56223.11,,"Fee schedule rate ($56,223.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,17423.21,56223.11,There are no additional notes associated with this service or procedure.
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],17136.70,,,,,,0,other,5280.00,17136.70,There are no additional notes associated with this service or procedure.
HC Inj Tendon Sheath/Ligament,CASE-20550,APC,20550,CPT,0510,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],9351.96,,"Case rate ($8,906.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,421.26, add-ons for qualifying new technology services are included. If operating cost exceeds $43,292.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,269.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $6,452.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,476.31 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $509.17. The transfer capital threshold is the transfer adjustment factor * $509.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8906.63,28434.57,Inpatient DRG
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],11179.35,,"Fee schedule rate ($11,179.35). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10048.39,23545.50,There are no additional notes associated with this service or procedure.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC",156,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],6956.38,,"Case rate ($6,625.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,298.82, add-ons for qualifying new technology services are included. If operating cost exceeds $41,169.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,102.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $4,337.88 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,353.87 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $342.30. The transfer capital threshold is the transfer adjustment factor * $342.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6625.12,13598.77,Inpatient DRG
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],35192.25,,"Fee schedule rate ($35,192.25). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,10895.60,35192.25,There are no additional notes associated with this service or procedure.
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],38259.01,,"Case rate ($21,862.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,473.63, add-ons for qualifying new technology services are included. If operating cost exceeds $55,344.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,216.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. The base transfer operating payment is the transfer adjustment factor * $18,460.61 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,528.68 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,456.72. The transfer capital threshold is the transfer adjustment factor * $1,456.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,7086.00,57872.02,All Other Inpatient
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],128358.13,,"Fee schedule rate ($128,358.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,40542.37,128358.13,There are no additional notes associated with this service or procedure.
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],8165.30,,"Fee schedule rate ($8,165.30). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4341.01,12882.53,There are no additional notes associated with this service or procedure.
SALIVARY GLAND PROCEDURES,139,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],23222.51,,"Fee schedule rate ($23,222.51). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.9), with a minimum of zero.",,,,0,other,10313.19,30690.92,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC,788,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],20142.33,,"Fee schedule rate ($20,142.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8438.02,20142.33,There are no additional notes associated with this service or procedure.
Cysto Bladder W/Ureteral Catheterization,CASE-52005,APC,52005,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1956.65,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1956.65,2054.48,OPPS APC
HC External Version,CASE-59412,APC,59412,CPT,0720,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3136.08,,"APC Price ($3,030.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3030.03,3181.53,OPPS APC
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,064,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],41838.16,,"Fee schedule rate ($41,838.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,15563.58,41838.16,There are no additional notes associated with this service or procedure.
"LIMB REATTACHMENT, HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA",956,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],28388.24,,"Case rate ($27,428.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $25,651.53, add-ons for qualifying new technology services are included. If operating cost exceeds $60,522.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,623.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $23,619.49 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $23,706.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,863.81. The transfer capital threshold is the transfer adjustment factor * $1,863.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,27428.25,148259.86,Inpatient DRG
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],12526.44,,"Fee schedule rate ($12,526.44). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5415.00,17575.50,There are no additional notes associated with this service or procedure.
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],38508.74,,"Fee schedule rate ($38,508.74). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.6), with a minimum of zero.",,,,0,other,15821.59,40320.14,There are no additional notes associated with this service or procedure.
Intraop Sentinel Lymph Node ID W/Dye Injection,CASE-38900,APC,38900,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6432.89,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6215.36,6526.12,OPPS APC
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],128358.13,,"Fee schedule rate ($128,358.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,40542.37,128358.13,There are no additional notes associated with this service or procedure.
Nsl/Sinus Ndsc Max Antrost W/Rmvl Tiss Max Sinus|BILATERAL PROCEDURE,CASE-31267,APC,31267,CPT,0360,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6936.25,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6605.95,6936.25,OPPS APC
Litholapaxy Smpl/Sm <2.5 Cm,CASE-52317,APC,52317,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3299.47,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3299.47,3464.44,OPPS APC
OTHER DISORDERS OF THE EYE WITHOUT MCC,125,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],15108.00,,,,,,0,other,7144.54,17952.29,There are no additional notes associated with this service or procedure.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],28434.57,,"Fee schedule rate ($28,434.57). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,8906.63,28434.57,There are no additional notes associated with this service or procedure.
HC Inj Tendon Sheath/Ligament|PBB CHARGE|SEPARATE STRUCTURE,CASE-20550,APC,20550,CPT,0510,RC,,,PBB|XS,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
"CARDIAC ARREST, UNEXPLAINED WITH MCC",296,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],30733.51,,,,,,0,other,12522.25,36459.67,There are no additional notes associated with this service or procedure.
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],16458.91,,"Fee schedule rate ($16,458.91). Adds an outlier to normal pricing equal to the per diem rate ($62,521.14) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,7875.94,17233.12,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],7127.04,,"Case rate ($6,787.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,450.02, add-ons for qualifying new technology services are included. If operating cost exceeds $41,321.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,114.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,488.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,505.07 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $354.19. The transfer capital threshold is the transfer adjustment factor * $354.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6164.03,14071.02,Inpatient DRG
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,082,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],56223.11,,"Fee schedule rate ($56,223.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,17423.21,56223.11,There are no additional notes associated with this service or procedure.
Laparoscopy Surg Cholecystectomy,CASE-47562,APC,47562,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5941.70,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5658.76,5941.70,OPPS APC
Neuroplasty &/Transposition Ulnar Nerve Elbow|UNUSUAL NON-OVERLAPPING SERVICE|LEFT SIDE,CASE-64718,APC,64718,CPT,0360,RC,,,XU|LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC,832,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],9034.88,,"Fee schedule rate ($9,034.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4803.31,14198.92,There are no additional notes associated with this service or procedure.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],42586.49,,"Fee schedule rate ($42,586.49). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,13341.67,42586.49,There are no additional notes associated with this service or procedure.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],10885.83,,"Case rate ($10,517.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,920.01, add-ons for qualifying new technology services are included. If operating cost exceeds $44,791.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,386.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $7,945.76 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,975.06 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $627.00. The transfer capital threshold is the transfer adjustment factor * $627.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,10517.71,24909.11,Inpatient DRG
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR,518,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],89342.77,,"Fee schedule rate ($89,342.77). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,13252.00,89342.77,There are no additional notes associated with this service or procedure.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],12795.84,,"Case rate ($12,795.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,039.30, add-ons for qualifying new technology services are included. If operating cost exceeds $46,910.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,553.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $10,057.27 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,094.35 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $793.62. The transfer capital threshold is the transfer adjustment factor * $793.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12795.84,41944.25,Inpatient DRG
Cystostomy Cystotomy W/Drainage,CASE-51040,APC,51040,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],2025.13,,"APC Price ($1,956.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1956.65,2054.48,OPPS APC
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],10795.75,,"Case rate ($10,281.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,715.99, add-ons for qualifying new technology services are included. If operating cost exceeds $44,587.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,355.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $7,741.69 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,771.04 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $595.04. The transfer capital threshold is the transfer adjustment factor * $595.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10533.95,24956.34,Inpatient DRG
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],7238.69,,"Case rate ($7,238.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,869.60, add-ons for qualifying new technology services are included. If operating cost exceeds $41,740.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,147.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,906.55 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,924.64 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $387.18. The transfer capital threshold is the transfer adjustment factor * $387.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7238.69,16804.22,Inpatient DRG
Exc B9 Lesion Mrgn Xcp Sk Tg T/a/L 2.1-3.0 Cm,CASE-11403,APC,11403,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],2854.83,,"APC Price ($2,718.88). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2718.88,2854.83,OPPS APC
SEIZURES WITH MCC,100,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],15814.14,,"Case rate ($15,061.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,146.62, add-ons for qualifying new technology services are included. If operating cost exceeds $49,017.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,719.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $12,156.85 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,201.67 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $959.30. The transfer capital threshold is the transfer adjustment factor * $959.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,15061.09,38110.41,Inpatient DRG
O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC,621,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],36669.96,,"Fee schedule rate ($36,669.96). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,12159.94,36669.96,There are no additional notes associated with this service or procedure.
Intraop Sentinel Lymph Node ID W/Dye Injection,CASE-38900,APC,38900,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6215.36,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6215.36,6526.12,OPPS APC
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],20401.88,,"Fee schedule rate ($20,401.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,20401.88,There are no additional notes associated with this service or procedure.
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],12690.66,,"Fee schedule rate ($12,690.66). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10626.74,25225.91,There are no additional notes associated with this service or procedure.
Neuroplasty &/Transposition Ulnar Nerve Elbow|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64718,APC,64718,CPT,0360,RC,,,LT|XU,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],12310.99,,"Case rate ($7,034.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,679.97, add-ons for qualifying new technology services are included. If operating cost exceeds $41,550.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,132.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $4,717.62 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,735.02 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $372.27. The transfer capital threshold is the transfer adjustment factor * $372.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,6965.00,21089.59,All Other Inpatient
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC,099,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],26807.94,,,,,,0,other,11171.21,26807.94,There are no additional notes associated with this service or procedure.
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],36868.88,,"Fee schedule rate ($36,868.88). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12606.23,36868.88,There are no additional notes associated with this service or procedure.
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC,058,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],32126.63,,"Fee schedule rate ($32,126.63). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13521.80,40853.02,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],10714.62,,"Case rate ($6,122.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,831.37, add-ons for qualifying new technology services are included. If operating cost exceeds $40,702.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,065.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $3,872.14 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,886.42 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $305.55. The transfer capital threshold is the transfer adjustment factor * $305.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,1188.00,12138.74,All Other Inpatient
PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,337,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],28847.26,,"Fee schedule rate ($28,847.26). Adds an outlier to normal pricing equal to the per diem rate ($89,320.38) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.8), with a minimum of zero.",,,,0,other,12340.08,38926.31,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],12818.71,,"Fee schedule rate ($12,818.71). Adds an outlier to normal pricing equal to the per diem rate ($42,942.49) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,6564.18,17651.07,There are no additional notes associated with this service or procedure.
CHEST PAIN,313,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],15377.66,,"Fee schedule rate ($15,377.66). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,6820.84,15377.66,There are no additional notes associated with this service or procedure.
"Prq Skel Fixj Phlngl Shft Fx Prox/Middle Px/F/T|LEFT HAND, FOURTH DIGIT",CASE-26727,APC,26727,CPT,0360,RC,,,F3,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],16235.87,,"Fee schedule rate ($16,235.87). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6524.00,17760.46,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC,087,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],8302.15,,"Case rate ($8,139.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,707.48, add-ons for qualifying new technology services are included. If operating cost exceeds $42,578.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,213.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $5,741.36 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,762.53 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $453.05. The transfer capital threshold is the transfer adjustment factor * $453.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,8139.36,22679.07,Inpatient DRG
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],11376.37,,"Case rate ($10,834.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,214.84, add-ons for qualifying new technology services are included. If operating cost exceeds $45,085.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,410.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $8,239.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,269.90 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $650.18. The transfer capital threshold is the transfer adjustment factor * $650.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10834.64,25830.00,Inpatient DRG
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],15076.44,,"Fee schedule rate ($15,076.44). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6340.03,15076.44,There are no additional notes associated with this service or procedure.
"Open Tx Articular Fracture Mcp/IP Joint Ea|LEFT HAND, FIFTH DIGIT",CASE-26746,APC,26746,CPT,0360,RC,,,F4,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
NON-MALIGNANT BREAST DISORDERS WITH CC/MCC,600,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],15046.13,,"Fee schedule rate ($15,046.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7999.14,20495.56,There are no additional notes associated with this service or procedure.
HC Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn,CASE-62321,APC,62321,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],683.85,,"APC Price ($660.72). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,660.72,693.76,OPPS APC
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",062,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],44304.80,,"Fee schedule rate ($44,304.80). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,13844.84,44304.80,There are no additional notes associated with this service or procedure.
"Neuroplasty Sciatic Nerve,Open|LEFT SIDE",CASE-64712,APC,64712,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
MAJOR CHEST TRAUMA WITHOUT CC/MCC,185,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],15475.96,,,,,,0,other,7271.19,21771.61,There are no additional notes associated with this service or procedure.
TRAUMATIC INJURY WITH MCC,913,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],13665.31,,"Case rate ($13,014.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,242.79, add-ons for qualifying new technology services are included. If operating cost exceeds $47,113.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,569.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $10,260.01 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,297.84 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $809.62. The transfer capital threshold is the transfer adjustment factor * $809.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13014.58,42838.46,Inpatient DRG
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],28334.16,,"Fee schedule rate ($28,334.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,7868.00,32126.64,There are no additional notes associated with this service or procedure.
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],7086.00,,"Per diem ($7,086). If length of stay < 7.8, first 1 days paid at a per diem of $14,172 instead. Capped at $55,272.09.",,,,0,other,7086.00,57872.02,Estimated amount calculated based on 5 day length of stay.
CESAREAN SECTION WITH STERILIZATION WITH CC,784,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],23722.94,,"Fee schedule rate ($23,722.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9124.01,23722.94,There are no additional notes associated with this service or procedure.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],28434.57,,"Fee schedule rate ($28,434.57). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,8906.63,28434.57,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],46523.26,,"Fee schedule rate ($46,523.26). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,17782.11,46523.26,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],28253.40,,"Fee schedule rate ($28,253.40). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,12126.09,29582.40,There are no additional notes associated with this service or procedure.
GI Tract Imaging Intraluminal Colon I&R,CASE-91113,APC,91113,CPT,0750,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],870.46,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,870.46,913.99,OPPS APC
SINGLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL,402,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],30630.65,,"Case rate ($29,172.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $27,273.75, add-ons for qualifying new technology services are included. If operating cost exceeds $62,144.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,751.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $25,235.76 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $25,328.80 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,991.35. The transfer capital threshold is the transfer adjustment factor * $1,991.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,29172.05,124455.45,Inpatient DRG
Arthrs Wrst Exc&/Rpr Triang Fibrocart&/Joint|LEFT SIDE,CASE-29846,APC,29846,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
O.R. PROCEDURES FOR OBESITY WITH CC,620,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],43753.50,,"Fee schedule rate ($43,753.50). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12782.30,43753.50,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,373,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7111.42,,"Case rate ($6,870.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,527.50, add-ons for qualifying new technology services are included. If operating cost exceeds $41,398.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,120.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $4,565.72 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,582.56 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $360.28. The transfer capital threshold is the transfer adjustment factor * $360.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6870.94,14313.05,Inpatient DRG
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],59081.91,,"Fee schedule rate ($59,081.91). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,8480.00,59081.91,There are no additional notes associated with this service or procedure.
MAJOR CHEST TRAUMA WITHOUT CC/MCC,185,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],7271.19,,"Case rate ($7,271.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,899.84, add-ons for qualifying new technology services are included. If operating cost exceeds $41,770.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,149.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,936.68 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,954.88 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $389.55. The transfer capital threshold is the transfer adjustment factor * $389.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7271.19,21771.61,Inpatient DRG
Excision Malignant Lesion Trunk/Arm/Leg > 4.0 Cm,CASE-11606,APC,11606,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6432.89,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6215.36,6526.12,OPPS APC
Thyroidectomy Total/Subtotal Lmtd Neck Dissect,CASE-60252,APC,60252,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5818.16,,"APC Price ($5,541.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5541.10,5818.16,OPPS APC
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],18206.06,,"Fee schedule rate ($18,206.06). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,12725.42,34245.00,There are no additional notes associated with this service or procedure.
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],11165.00,,"Per diem ($11,165). If length of stay < 3.5, first 1 days paid at a per diem of $22,330 instead. Capped at $39,078.16.",,,,0,other,11165.00,61234.06,Estimated amount calculated based on 3 day length of stay.
SALIVARY GLAND PROCEDURES,139,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],30690.92,,"Fee schedule rate ($30,690.92). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,10313.19,30690.92,There are no additional notes associated with this service or procedure.
"EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME, NEONATE",790,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],42194.75,,"Case rate ($42,194.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $39,388.49, add-ons for qualifying new technology services are included. If operating cost exceeds $74,259.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,703.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 17.9. The base transfer operating payment is the transfer adjustment factor * $37,305.99 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $37,443.54 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,943.81. The transfer capital threshold is the transfer adjustment factor * $2,943.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,3054.00,44304.49,Inpatient DRG
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],16804.22,,"Fee schedule rate ($16,804.22). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7238.69,16804.22,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,083,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],28680.85,,"Fee schedule rate ($28,680.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,28680.85,There are no additional notes associated with this service or procedure.
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITHOUT MCC,430,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],108381.11,,"Fee schedule rate ($108,381.11). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.6), with a minimum of zero.",,,,0,other,41000.16,133156.90,There are no additional notes associated with this service or procedure.
"LYMPHOMA MYELOMA AND NON-ACUTE LEUKEMIA,MAJOR",691,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],20026.37,,"Case rate ($19,072.73). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,19072.73,20026.37,There are no additional notes associated with this service or procedure.
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],13571.25,,"Case rate ($13,571.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,760.65, add-ons for qualifying new technology services are included. If operating cost exceeds $47,631.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,610.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $10,775.96 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,815.69 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $850.33. The transfer capital threshold is the transfer adjustment factor * $850.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,13571.25,33781.47,Inpatient DRG
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITHOUT MCC,430,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],41000.16,,"Case rate ($41,000.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $38,277.19, add-ons for qualifying new technology services are included. If operating cost exceeds $73,148.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,616.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $36,198.76 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $36,332.23 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,856.44. The transfer capital threshold is the transfer adjustment factor * $2,856.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,41000.16,133156.90,Inpatient DRG
"POST-OPERATIVE POST-TRAUMA OTHER DEVICE INFECTIONS WITH O.R. PROCEDURE,MODERATE",711,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],15930.49,,"Case rate ($15,930.49). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,15930.49,16727.01,There are no additional notes associated with this service or procedure.
HC Inj Trigger Pt 1-2 Musc Grps|PBB CHARGE|SEPARATE STRUCTURE,CASE-20552,APC,20552,CPT,0510,RC,,,PBB|XS,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],20079.44,,"Fee schedule rate ($20,079.44). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7453.00,42138.30,There are no additional notes associated with this service or procedure.
HC Inj Lympho for Sentinal Node,CASE-38792,APC,38792,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6215.36,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6215.36,6526.12,OPPS APC
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,451,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],24337.80,,"Case rate ($23,178.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $21,738.03, add-ons for qualifying new technology services are included. If operating cost exceeds $56,609.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,275.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $19,718.32 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $19,793.08 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,515.60. The transfer capital threshold is the transfer adjustment factor * $1,515.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,23821.44,94077.13,Inpatient DRG
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],49717.39,,"Fee schedule rate ($49,717.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,14908.05,49717.39,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],23899.13,,"Fee schedule rate ($23,899.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9795.13,23899.13,There are no additional notes associated with this service or procedure.
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],26391.01,,"Fee schedule rate ($26,391.01). Adds an outlier to normal pricing equal to the per diem rate ($77,296.48) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,11454.97,28394.78,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],9595.54,,"Case rate ($9,138.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,650.48, add-ons for qualifying new technology services are included. If operating cost exceeds $43,521.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,273.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $6,680.20 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,705.53 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $513.46. The transfer capital threshold is the transfer adjustment factor * $513.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9356.31,25026.36,Inpatient DRG
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],31528.46,,,,,,0,other,12795.84,41944.25,There are no additional notes associated with this service or procedure.
Episiotomy/Vag Rpr Oth/Thn Attending,CASE-59300,APC,59300,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3136.08,,"APC Price ($3,030.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3030.03,3181.53,OPPS APC
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],53152.12,,"Fee schedule rate ($53,152.12). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,19152.11,53152.12,There are no additional notes associated with this service or procedure.
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC,519,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],37589.76,,"Fee schedule rate ($37,589.76). Adds an outlier to normal pricing equal to the per diem rate ($123,674.40) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,15490.44,50780.20,There are no additional notes associated with this service or procedure.
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],10491.22,,"Case rate ($10,136.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,565.33, add-ons for qualifying new technology services are included. If operating cost exceeds $44,436.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,359.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $7,592.38 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,620.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $599.11. The transfer capital threshold is the transfer adjustment factor * $599.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,10136.44,24444.75,Inpatient DRG
NONTRAUMATIC STUPOR AND COMA WITH MCC,080,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],30179.40,,"Fee schedule rate ($30,179.40). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,14202.39,35615.37,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],34892.92,,"Fee schedule rate ($34,892.92). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,6965.00,41030.48,There are no additional notes associated with this service or procedure.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],37768.77,,"Fee schedule rate ($37,768.77). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7453.00,42138.30,There are no additional notes associated with this service or procedure.
"NEONATE BIRTH WEIGHT > 2499 GRAMS WITH OTHER SIGNIFICANT CONDITION,MAJOR",639,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],17657.19,,"Case rate ($16,816.37). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,16816.37,17657.19,There are no additional notes associated with this service or procedure.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],16581.60,,"Fee schedule rate ($16,581.60). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,12527.66,29917.96,There are no additional notes associated with this service or procedure.
"Partical Excision Bone Phalanx Toe|RIGHT FOOT, FIFTH DIGIT",CASE-28124,APC,28124,CPT,0360,RC,,,T9,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
"DIVERTICULITIS AND DIVERTICULOSIS,MINOR",244,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],1867.19,,"Case rate for a one day stay ($1,867.19). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,1867.19,1960.55,There are no additional notes associated with this service or procedure.
OSTEOMYELITIS WITH CC,540,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],25507.30,,,,,,0,other,9809.07,25507.30,There are no additional notes associated with this service or procedure.
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],54920.47,,,,,,0,other,20846.48,81306.30,There are no additional notes associated with this service or procedure.
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],12393.48,,"Case rate ($11,974.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,275.12, add-ons for qualifying new technology services are included. If operating cost exceeds $46,146.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,493.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $9,295.90 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,330.17 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $733.54. The transfer capital threshold is the transfer adjustment factor * $733.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,11974.38,29141.64,Inpatient DRG
RESPIRATORY NEOPLASMS WITH CC,181,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],21074.07,,,,,,0,other,9197.84,21074.07,There are no additional notes associated with this service or procedure.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",063,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],35701.87,,"Fee schedule rate ($35,701.87). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,35701.87,There are no additional notes associated with this service or procedure.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],31007.30,,"Fee schedule rate ($31,007.30). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,16120.25,41187.90,There are no additional notes associated with this service or procedure.
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC",011,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],107320.33,,,,,,0,other,38880.49,150008.48,There are no additional notes associated with this service or procedure.
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],25013.10,,"Fee schedule rate ($25,013.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10846.16,25863.45,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,064,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],37792.72,,"Fee schedule rate ($37,792.72). Adds an outlier to normal pricing equal to the per diem rate ($115,085.88) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,15563.58,41838.16,There are no additional notes associated with this service or procedure.
Enteroscopy > 2nd Prtn Abltj Lesion,CASE-44369,APC,44369,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1885.95,,"APC Price ($1,796.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1796.14,1885.95,OPPS APC
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,345,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],33616.03,,"Fee schedule rate ($33,616.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12134.89,33616.03,There are no additional notes associated with this service or procedure.
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],5777.94,,"Case rate ($5,777.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,510.70, add-ons for qualifying new technology services are included. If operating cost exceeds $40,381.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,040.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $3,552.65 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,565.75 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $280.34. The transfer capital threshold is the transfer adjustment factor * $280.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,5065.00,12558.65,Inpatient DRG
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],10862.00,,"Per diem ($10,862). If length of stay < 7.6, first 1 days paid at a per diem of $21,724 instead. Capped at $82,553.89.",,,,0,other,10862.00,86437.13,Estimated amount calculated based on 6 day length of stay.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],18182.77,,"Case rate ($17,316.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,273.85, add-ons for qualifying new technology services are included. If operating cost exceeds $51,144.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,857.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $14,274.78 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,328.90 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,097.19. The transfer capital threshold is the transfer adjustment factor * $1,097.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,17782.11,46523.26,Inpatient DRG
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,083,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],28680.85,,"Fee schedule rate ($28,680.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,28680.85,There are no additional notes associated with this service or procedure.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],26776.27,,"Fee schedule rate ($26,776.27). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,11593.79,38248.08,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6299.93,,"Case rate ($5,999.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,724.78, add-ons for qualifying new technology services are included. If operating cost exceeds $40,595.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,049.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $3,765.55 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,779.83 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $289.43. The transfer capital threshold is the transfer adjustment factor * $289.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,1188.00,12138.74,Inpatient DRG
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],86252.84,,"Fee schedule rate ($86,252.84). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,27944.96,86252.84,There are no additional notes associated with this service or procedure.
MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,708,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],29171.15,,,,,,0,other,10138.21,29171.15,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],52449.26,,"Fee schedule rate ($52,449.26). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,17693.40,52449.26,There are no additional notes associated with this service or procedure.
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],27589.62,,"Fee schedule rate ($27,589.62). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12566.28,30861.41,There are no additional notes associated with this service or procedure.
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],14309.17,,"Fee schedule rate ($14,309.17). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,17467.27,There are no additional notes associated with this service or procedure.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC",494,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],37708.15,,"Fee schedule rate ($37,708.15). Adds an outlier to normal pricing equal to the per diem rate ($63,554.89) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,15533.10,39945.55,There are no additional notes associated with this service or procedure.
"Amputation Metatarsal W/Toe Single|RIGHT FOOT, THIRD DIGIT",CASE-28810,APC,28810,CPT,0360,RC,,,T7,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3215.80,3215.80,OPPS APC
Tissue Expander Placement Breast Reconstruction|LEFT SIDE,CASE-19357,APC,19357,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],12899.30,,"APC Price ($12,899.30). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12899.30,13350.78,OPPS APC
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],14391.09,,"Case rate ($13,904.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,070.60, add-ons for qualifying new technology services are included. If operating cost exceeds $47,941.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,634.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,084.78 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,125.65 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $874.70. The transfer capital threshold is the transfer adjustment factor * $874.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,13904.43,34749.58,Inpatient DRG
PERIPHERAL VASCULAR DISORDERS WITH CC,300,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],20331.78,,"Fee schedule rate ($20,331.78). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,9174.14,21005.20,There are no additional notes associated with this service or procedure.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC,858,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],26176.77,,"Fee schedule rate ($26,176.77). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11377.76,33794.11,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],6965.00,,,,,,0,other,6558.75,14871.83,There are no additional notes associated with this service or procedure.
OTHER CEREBROVASCULAR DISORDERS WITH MCC,070,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],31286.59,,"Fee schedule rate ($31,286.59). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13219.09,37774.46,There are no additional notes associated with this service or procedure.
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],45017.13,,"Fee schedule rate ($45,017.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,14603.31,45017.13,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],53152.12,,"Fee schedule rate ($53,152.12). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,19152.11,53152.12,There are no additional notes associated with this service or procedure.
"Arthrodesis Interphalangeal Jt W/WO Int Fixj|LEFT HAND, FIFTH DIGIT",CASE-26860,APC,26860,CPT,0360,RC,,,F4,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6791.99,7131.59,OPPS APC
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],47699.61,,"Case rate ($27,256.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $25,492.14, add-ons for qualifying new technology services are included. If operating cost exceeds $60,363.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,611.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. The base transfer operating payment is the transfer adjustment factor * $23,460.69 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $23,547.19 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,851.28. The transfer capital threshold is the transfer adjustment factor * $1,851.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,27256.92,81353.66,All Other Inpatient
MAJOR BLADDER PROCEDURES WITH MCC,653,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],37135.34,,"Case rate ($37,135.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $34,681.82, add-ons for qualifying new technology services are included. If operating cost exceeds $69,552.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,333.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.5. The base transfer operating payment is the transfer adjustment factor * $32,616.61 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $32,736.87 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,573.77. The transfer capital threshold is the transfer adjustment factor * $2,573.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10280.00,125343.98,Inpatient DRG
Rhytidectomy Smas Flap,CASE-15829,APC,15829,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],2336.65,,"APC Price ($2,225.38). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2225.38,2336.65,OPPS APC
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],38248.08,,"Fee schedule rate ($38,248.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11593.79,38248.08,There are no additional notes associated with this service or procedure.
INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC,198,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],23505.07,,"Fee schedule rate ($23,505.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6795.12,23505.07,There are no additional notes associated with this service or procedure.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,988,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],42425.46,,"Fee schedule rate ($42,425.46). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,13075.52,42425.46,There are no additional notes associated with this service or procedure.
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC",514,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],19212.08,,"Fee schedule rate ($19,212.08). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,8868.04,22699.91,There are no additional notes associated with this service or procedure.
COAGULATION DISORDERS,813,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],29046.49,,"Fee schedule rate ($29,046.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12274.39,30013.33,There are no additional notes associated with this service or procedure.
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC",458,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],132827.25,,"Fee schedule rate ($132,827.25). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,30202.09,132827.25,There are no additional notes associated with this service or procedure.
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],23078.81,,"Fee schedule rate ($23,078.81). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10311.17,24308.97,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],21719.40,,"Case rate ($21,719.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,340.70, add-ons for qualifying new technology services are included. If operating cost exceeds $55,211.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,206.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.2. The base transfer operating payment is the transfer adjustment factor * $18,328.17 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,395.75 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,446.27. The transfer capital threshold is the transfer adjustment factor * $1,446.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,21719.40,85305.59,Inpatient DRG
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,025,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],91631.33,,"Fee schedule rate ($91,631.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,13351.00,91631.33,There are no additional notes associated with this service or procedure.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],35389.50,,"Case rate ($35,389.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $33,057.71, add-ons for qualifying new technology services are included. If operating cost exceeds $67,928.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,206.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.3. The base transfer operating payment is the transfer adjustment factor * $30,998.46 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $31,112.76 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,446.08. The transfer capital threshold is the transfer adjustment factor * $2,446.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,35389.50,101083.00,Inpatient DRG
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],21005.25,,"Fee schedule rate ($21,005.25). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,14747.55,37899.49,There are no additional notes associated with this service or procedure.
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],54236.60,,"Fee schedule rate ($54,236.60). Adds an outlier to normal pricing equal to the per diem rate ($122,612.56) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,21489.15,68942.79,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],11612.44,,"Case rate ($11,059.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,424, add-ons for qualifying new technology services are included. If operating cost exceeds $45,295.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,426.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $8,447.91 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,479.05 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $666.62. The transfer capital threshold is the transfer adjustment factor * $666.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,11059.47,28423.20,Inpatient DRG
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],37768.77,,"Fee schedule rate ($37,768.77). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7453.00,42138.30,There are no additional notes associated with this service or procedure.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],58320.32,,"Fee schedule rate ($58,320.32). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,16286.16,58320.32,There are no additional notes associated with this service or procedure.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],27345.48,,"Case rate ($26,809.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $25,075.72, add-ons for qualifying new technology services are included. If operating cost exceeds $59,946.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,578.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $23,045.79 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $23,130.76 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,818.54. The transfer capital threshold is the transfer adjustment factor * $1,818.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,26809.29,97015.50,Inpatient DRG
Exc B9 Lesion Mrgn Xcp Sk Tg S/N/H/F/G 1.1-2.0cm,CASE-11422,APC,11422,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1623.23,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1600.04,1623.23,OPPS APC
"POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT PROCEDURE,MODERATE",561,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],4075.27,,"Case rate ($4,075.27). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,4075.27,4279.03,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,426,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],216864.15,,,,,,0,other,76581.29,216864.15,There are no additional notes associated with this service or procedure.
HC Inj Anes/Steroid C/D Facet Sg|LEFT SIDE|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-64490,APC,64490,CPT,0361,RC,,,LT|74,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],827.89,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,827.89,869.28,OPPS APC
CHEST PAIN,313,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],15377.66,,"Fee schedule rate ($15,377.66). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,6820.84,15377.66,There are no additional notes associated with this service or procedure.
Total Thyroid Lobectomy Uni W/WO Isthmusectomy|LEFT SIDE,CASE-60220,APC,60220,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5658.76,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5658.76,5856.81,OPPS APC
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],45017.13,,"Fee schedule rate ($45,017.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,14603.31,45017.13,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITH MCC,385,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],12913.61,,"Case rate ($12,660.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,913.31, add-ons for qualifying new technology services are included. If operating cost exceeds $46,784.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,543.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $9,931.73 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,968.35 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $783.71. The transfer capital threshold is the transfer adjustment factor * $783.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,11480.01,31134.92,Inpatient DRG
Arthrs Knee Abrasion Arthrp/Mlt Drlg/Microfx|LEFT SIDE,CASE-29879,APC,29879,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],10733.06,,"Case rate ($10,733.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,120.35, add-ons for qualifying new technology services are included. If operating cost exceeds $44,991.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,402.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $8,145.37 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,175.40 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $642.75. The transfer capital threshold is the transfer adjustment factor * $642.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10733.06,45157.33,Inpatient DRG
Laparoscopy Colpopexy Suspension Vaginal Apex,CASE-57425,APC,57425,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],9949.78,,"APC Price ($9,949.78). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,9949.78,10447.27,OPPS APC
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC,027,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],56363.30,,"Fee schedule rate ($56,363.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,19030.20,56363.30,There are no additional notes associated with this service or procedure.
FRACTURES OF FEMUR WITH MCC,533,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],12561.53,,"Case rate ($12,561.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,821.33, add-ons for qualifying new technology services are included. If operating cost exceeds $46,692.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,536.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $9,840.09 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,876.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $776.48. The transfer capital threshold is the transfer adjustment factor * $776.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6852.00,49490.05,Inpatient DRG
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],22750.61,,"Case rate ($21,667.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,292.19, add-ons for qualifying new technology services are included. If operating cost exceeds $55,163.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,202.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $18,279.84 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,347.24 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,442.46. The transfer capital threshold is the transfer adjustment factor * $1,442.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8972.00,81524.17,Inpatient DRG
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,761,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],6965.00,,,,,,0,other,5808.41,11946.72,There are no additional notes associated with this service or procedure.
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],24528.10,,"Fee schedule rate ($24,528.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10989.72,26280.60,There are no additional notes associated with this service or procedure.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],59521.43,,"Fee schedule rate ($59,521.43). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,16689.78,59521.43,There are no additional notes associated with this service or procedure.
HC Inj Trigger Pt 1-2 Musc Grps|PBB CHARGE|SEPARATE STRUCTURE,CASE-20552,APC,20552,CPT,0510,RC,,,PBB|XS,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],297.37,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,287.31,301.68,OPPS APC
SPINAL PROCEDURES WITHOUT CC/MCC,030,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],17651.54,,"Case rate ($16,810.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,774.52, add-ons for qualifying new technology services are included. If operating cost exceeds $50,645.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,847.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $13,778.77 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,829.57 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,087.28. The transfer capital threshold is the transfer adjustment factor * $1,087.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,16810.99,44714.01,Inpatient DRG
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,073,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],43475.01,,"Fee schedule rate ($43,475.01). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,12809.38,43475.01,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC,833,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],5721.39,,"Fee schedule rate ($5,721.39). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,3041.73,10289.10,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC,832,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],13561.03,,"Fee schedule rate ($13,561.03). Adds an outlier to normal pricing equal to the per diem rate ($18,253.69) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,4803.31,14198.92,There are no additional notes associated with this service or procedure.
"ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",770,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],9041.04,,"Case rate ($8,735.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,261.87, add-ons for qualifying new technology services are included. If operating cost exceeds $43,132.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,256.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $6,293.72 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,316.92 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $496.64. The transfer capital threshold is the transfer adjustment factor * $496.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,8735.30,19730.13,Inpatient DRG
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],24259.09,,"Fee schedule rate ($24,259.09). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10098.51,24259.09,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],7569.84,,"Case rate ($7,569.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,177.66, add-ons for qualifying new technology services are included. If operating cost exceeds $42,048.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,171.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,213.49 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,232.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $411.40. The transfer capital threshold is the transfer adjustment factor * $411.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7569.84,21892.85,Inpatient DRG
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],18043.23,,"Fee schedule rate ($18,043.23). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7733.72,18043.23,There are no additional notes associated with this service or procedure.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],41006.47,,"Fee schedule rate ($41,006.47). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12268.97,41006.47,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITH STERILIZATION WITHOUT CC/MCC,785,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],8431.24,,"Case rate ($8,431.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,979, add-ons for qualifying new technology services are included. If operating cost exceeds $42,850.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,234.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,011.89 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,034.06 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $474.40. The transfer capital threshold is the transfer adjustment factor * $474.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8431.24,20142.33,Inpatient DRG
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],9824.13,,"Case rate ($9,356.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,839.58, add-ons for qualifying new technology services are included. If operating cost exceeds $43,710.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,302.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $6,869.30 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,894.63 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $542.06. The transfer capital threshold is the transfer adjustment factor * $542.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9356.31,25026.36,Inpatient DRG
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],52699.33,,"Fee schedule rate ($52,699.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,18105.81,52699.33,There are no additional notes associated with this service or procedure.
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,451,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],94077.13,,"Fee schedule rate ($94,077.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,23821.44,94077.13,There are no additional notes associated with this service or procedure.
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],6711.00,,"Per diem ($6,711). If length of stay < 2.4, first 1 days paid at a per diem of $13,422 instead. Capped at $16,107.48.",,,,0,other,6711.00,16865.16,Estimated amount calculated based on 2 day length of stay.
"UTERINE AND ADNEXA PROCEDURES FOR LEIOMYOMA,MODERATE",519,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],4868.92,,"Case rate for a one day stay ($4,637.07). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4637.07,4868.92,There are no additional notes associated with this service or procedure.
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],20434.05,,"Fee schedule rate ($20,434.05). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12606.23,36868.88,There are no additional notes associated with this service or procedure.
PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,337,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],38926.31,,"Fee schedule rate ($38,926.31). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,12340.08,38926.31,There are no additional notes associated with this service or procedure.
Litholapaxy Smpl/Sm <2.5 Cm,CASE-52317,APC,52317,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3464.44,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3299.47,3464.44,OPPS APC
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],8460.30,,"Case rate ($8,057.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,631.26, add-ons for qualifying new technology services are included. If operating cost exceeds $42,502.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,207.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,665.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,686.30 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $447.06. The transfer capital threshold is the transfer adjustment factor * $447.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6524.00,17760.46,Inpatient DRG
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],17249.81,,"Case rate ($16,428.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,418.58, add-ons for qualifying new technology services are included. If operating cost exceeds $50,289.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,819.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $13,424.13 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,473.63 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,059.30. The transfer capital threshold is the transfer adjustment factor * $1,059.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,16428.39,42083.20,Inpatient DRG
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],36140.75,,,,,,0,other,6965.00,36140.75,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],11594.35,,"Fee schedule rate ($11,594.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6164.03,14071.02,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],23954.07,,"Fee schedule rate ($23,954.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,6167.00,29058.99,There are no additional notes associated with this service or procedure.
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC,497,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],22707.58,,"Fee schedule rate ($22,707.58). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7.8), with a minimum of zero.",,,,0,other,10127.65,37761.19,There are no additional notes associated with this service or procedure.
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],16438.59,,"Fee schedule rate ($16,438.59). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7402.56,16438.59,There are no additional notes associated with this service or procedure.
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],11807.01,,"Case rate ($11,575.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,904.06, add-ons for qualifying new technology services are included. If operating cost exceeds $45,775.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,464.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $8,926.20 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,959.11 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $704.37. The transfer capital threshold is the transfer adjustment factor * $704.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,11575.50,48961.48,Inpatient DRG
OTHER CEREBROVASCULAR DISORDERS WITH MCC,070,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],13681.76,,"Case rate ($13,219.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,433.04, add-ons for qualifying new technology services are included. If operating cost exceeds $47,304.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,584.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $10,449.57 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,488.10 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $824.57. The transfer capital threshold is the transfer adjustment factor * $824.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,13219.09,37774.46,Inpatient DRG
FULL TERM NEONATE WITH MAJOR PROBLEMS,793,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],78359.29,,"Fee schedule rate ($78,359.29). Adds an outlier to normal pricing equal to the per diem rate ($27,082.03) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.7), with a minimum of zero.",,,,0,other,4302.90,82045.22,There are no additional notes associated with this service or procedure.
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",004,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],10715.36,,,,,,0,other,10249.47,272554.00,Estimated amount calculated based on 6 day length of stay.
Repair Intermediate S/a/T/E >30.0 Cm,CASE-12037,APC,12037,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1600.04,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1545.93,1623.23,OPPS APC
"MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS,MINOR",532,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],2568.32,,"Case rate for a one day stay ($2,568.32). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,2568.32,2696.74,There are no additional notes associated with this service or procedure.
NERVOUS SYSTEM NEOPLASMS WITH MCC,054,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],25589.03,,"Fee schedule rate ($25,589.03). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,6965.00,30044.81,There are no additional notes associated with this service or procedure.
"UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY EXCEPT LEIOMYOMA,MINOR",513,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],5701.99,,"Case rate for a one day stay ($5,430.47). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5430.47,5701.99,There are no additional notes associated with this service or procedure.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],8169.53,,"Case rate ($8,009.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,586.52, add-ons for qualifying new technology services are included. If operating cost exceeds $42,457.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,203.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $5,620.85 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,641.57 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $443.54. The transfer capital threshold is the transfer adjustment factor * $443.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,8009.34,19877.10,Inpatient DRG
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],9905.96,,"Case rate ($9,570.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,039.28, add-ons for qualifying new technology services are included. If operating cost exceeds $43,910.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,317.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $7,068.27 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,094.33 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $557.76. The transfer capital threshold is the transfer adjustment factor * $557.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,5569.00,40108.48,Inpatient DRG
Exc Breast Les Preop Plmt Rad Marker Open 1 Les|BILATERAL PROCEDURE,CASE-19125,APC,19125,CPT,0360,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3848.19,,"APC Price ($3,664.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3793.21,3848.19,OPPS APC
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],19763.43,,"Fee schedule rate ($19,763.43). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,8318.14,19763.43,There are no additional notes associated with this service or procedure.
FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,748,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],26805.98,,,,,,0,other,9316.20,26805.98,There are no additional notes associated with this service or procedure.
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",759,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],12471.03,,"Fee schedule rate ($12,471.03). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.9), with a minimum of zero.",,,,0,other,6190.22,13057.66,There are no additional notes associated with this service or procedure.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],19011.10,,"Case rate ($18,105.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,979.06, add-ons for qualifying new technology services are included. If operating cost exceeds $51,850.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,941.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $14,978.89 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,034.11 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,181.98. The transfer capital threshold is the transfer adjustment factor * $1,181.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,18105.81,52699.33,Inpatient DRG
"INFECTIOUS AND PARASITIC DISEASES INCLUDING HIV WITH O.R. PROCEDURE,MAJOR",710,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],30930.59,,"Case rate ($29,457.70). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,29457.70,30930.59,There are no additional notes associated with this service or procedure.
Sigmoidoscopy Flx Control Bleeding,CASE-45334,APC,45334,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1176.09,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1120.09,1176.09,OPPS APC
SPINAL PROCEDURES WITH MCC,028,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],44765.25,,"Case rate ($42,633.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $39,796.72, add-ons for qualifying new technology services are included. If operating cost exceeds $74,667.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,735.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.5. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 9.5)) / 2. The base transfer operating payment is the transfer adjustment factor * $37,712.72 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $37,851.77 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,975.91. The transfer capital threshold is the transfer adjustment factor * $2,975.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,42633.57,120982.83,Inpatient DRG
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],8543.64,,"Case rate ($8,543.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,083.58, add-ons for qualifying new technology services are included. If operating cost exceeds $42,954.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,242.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,116.09 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,138.64 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $482.62. The transfer capital threshold is the transfer adjustment factor * $482.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8543.64,23239.84,Inpatient DRG
"CARDIAC ARREST, UNEXPLAINED WITH MCC",296,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],13148.36,,"Case rate ($12,522.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,784.78, add-ons for qualifying new technology services are included. If operating cost exceeds $46,655.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,533.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $9,803.69 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,839.84 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $773.61. The transfer capital threshold is the transfer adjustment factor * $773.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12522.25,36459.67,Inpatient DRG
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],7772.69,,"Case rate ($7,402.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,022.05, add-ons for qualifying new technology services are included. If operating cost exceeds $41,893.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,159.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,058.45 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,077.10 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $399.16. The transfer capital threshold is the transfer adjustment factor * $399.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7402.56,16438.59,Inpatient DRG
Unlisted Laparoscopy Procedure Oviduct Ovary,CASE-58679,APC,58679,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5658.76,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5658.76,5941.70,OPPS APC
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7025.31,,"Case rate ($6,690.77). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,368.74, add-ons for qualifying new technology services are included. If operating cost exceeds $41,239.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,098.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $4,407.08 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,423.79 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $338.74. The transfer capital threshold is the transfer adjustment factor * $338.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6834.39,21354.82,Inpatient DRG
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,761,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],11946.72,,"Fee schedule rate ($11,946.72). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,5808.41,11946.72,There are no additional notes associated with this service or procedure.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,352,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],10346.04,,"Case rate ($9,853.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,301.99, add-ons for qualifying new technology services are included. If operating cost exceeds $44,173.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,338.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $7,330.01 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,357.04 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $578.41. The transfer capital threshold is the transfer adjustment factor * $578.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9853.37,26528.70,Inpatient DRG
"PERIPHERAL AND OTHER VASCULAR DISORDERS,MAJOR",197,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],11491.34,,"Case rate ($10,944.13). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10944.13,11491.34,There are no additional notes associated with this service or procedure.
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],13568.55,,"Fee schedule rate ($13,568.55). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6834.39,21354.82,There are no additional notes associated with this service or procedure.
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],13702.80,,"Case rate ($13,050.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,296.73, add-ons for qualifying new technology services are included. If operating cost exceeds $47,167.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,552.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $10,312.68 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,351.78 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $792.66. The transfer capital threshold is the transfer adjustment factor * $792.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13386.36,33244.29,Inpatient DRG
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],94787.57,,"Fee schedule rate ($94,787.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,23526.87,94787.57,There are no additional notes associated with this service or procedure.
DIABETES WITH CC,638,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],8414.77,,"Case rate ($8,014.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,590.93, add-ons for qualifying new technology services are included. If operating cost exceeds $42,461.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,203.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,625.24 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,645.98 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $443.89. The transfer capital threshold is the transfer adjustment factor * $443.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8014.07,17634.53,Inpatient DRG
CERVICAL SPINAL FUSION WITH MCC,471,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],111337.93,,"Fee schedule rate ($111,337.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,34645.26,111337.93,There are no additional notes associated with this service or procedure.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,352,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],26528.70,,"Fee schedule rate ($26,528.70). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,9853.37,26528.70,There are no additional notes associated with this service or procedure.
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],36780.25,,,,,,0,other,14603.31,45017.13,There are no additional notes associated with this service or procedure.
Cystourethroscopy Inj Chemodenervation Bladder|SEPARATE STRUCTURE,CASE-52287,APC,52287,CPT,0360,RC,,,XS,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3299.47,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3299.47,3464.44,OPPS APC
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],33197.83,,"Fee schedule rate ($33,197.83). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.8), with a minimum of zero.",,,,0,other,13907.80,52794.06,There are no additional notes associated with this service or procedure.
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],9637.53,,"Case rate ($9,311.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,798, add-ons for qualifying new technology services are included. If operating cost exceeds $43,669.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,298.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $6,827.87 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,853.05 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $538.79. The transfer capital threshold is the transfer adjustment factor * $538.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6965.00,21404.64,Inpatient DRG
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,095,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],48575.01,,"Fee schedule rate ($48,575.01). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,19411.47,50750.92,There are no additional notes associated with this service or procedure.
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC,964,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],34154.06,,"Fee schedule rate ($34,154.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12323.82,34154.06,There are no additional notes associated with this service or procedure.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,097,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],26404.32,,"Case rate ($26,404.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $24,698.97, add-ons for qualifying new technology services are included. If operating cost exceeds $59,569.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,548.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.7. The base transfer operating payment is the transfer adjustment factor * $22,670.44 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $22,754.03 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,788.92. The transfer capital threshold is the transfer adjustment factor * $1,788.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,26404.32,79915.74,Inpatient DRG
NONTRAUMATIC STUPOR AND COMA WITH MCC,080,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],30179.40,,"Fee schedule rate ($30,179.40). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,14202.39,35615.37,There are no additional notes associated with this service or procedure.
DIABETES WITH CC,638,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],8078.71,,"Fee schedule rate ($8,078.71). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8014.07,17634.53,There are no additional notes associated with this service or procedure.
Bronchoscopy W/Cptr-Asst Image-Guided Navigation,CASE-31627,APC,31627,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6837.16,,"APC Price ($6,605.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6605.95,6936.25,OPPS APC
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC",641,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],14928.67,,"Fee schedule rate ($14,928.67). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7214.98,15312.64,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL HEMORRHAGE WITH CC,378,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],18430.30,,"Fee schedule rate ($18,430.30). Adds an outlier to normal pricing equal to the per diem rate ($75,427.18) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,8586.33,20845.19,There are no additional notes associated with this service or procedure.
Tx Anal Fstl Trans/Supra/Xtrasphnctrc Incl Seton,CASE-46280,APC,46280,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],2598.08,,"APC Price ($2,598.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2598.08,2727.99,OPPS APC
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],6960.45,,"Fee schedule rate ($6,960.45). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5065.00,12558.65,There are no additional notes associated with this service or procedure.
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],5280.00,,"Per diem ($5,280). If length of stay < 3.1, first 1 days paid at a per diem of $10,560 instead. Capped at $16,366.82.",,,,0,other,5280.00,17136.70,Estimated amount calculated based on 3 day length of stay.
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITHOUT CC/MCC",630,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],42541.02,,"Fee schedule rate ($42,541.02). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11828.78,42541.02,There are no additional notes associated with this service or procedure.
HC Lyr Clos Sc Tk Ext 2.6-7 Cm|SEPARATE STRUCTURE,CASE-12032,APC,12032,CPT,0450,RC,,,XS,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],2854.83,,"APC Price ($2,718.88). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2718.88,2854.83,OPPS APC
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,083,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],15895.95,,"Fee schedule rate ($15,895.95). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,28680.85,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],10223.39,,"Fee schedule rate ($10,223.39). Adds an outlier to normal pricing equal to the per diem rate ($48,095.58) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,5628.97,12272.58,There are no additional notes associated with this service or procedure.
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],45017.13,,"Fee schedule rate ($45,017.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,14603.31,45017.13,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],13208.11,,"Case rate ($7,547.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,156.87, add-ons for qualifying new technology services are included. If operating cost exceeds $42,027.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,169.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $5,192.77 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,211.92 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $409.76. The transfer capital threshold is the transfer adjustment factor * $409.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,6965.00,19126.88,All Other Inpatient
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],6965.00,,,,,,0,other,6340.03,15076.44,There are no additional notes associated with this service or procedure.
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH CC",457,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],112064.54,,"Fee schedule rate ($112,064.54). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.9), with a minimum of zero.",,,,0,other,42327.47,160549.49,There are no additional notes associated with this service or procedure.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],85466.62,,"Fee schedule rate ($85,466.62). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,21382.16,85466.62,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],6965.00,,,,,,0,other,6965.00,32293.66,There are no additional notes associated with this service or procedure.
CERVICAL SPINAL FUSION WITH MCC,471,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],111337.93,,"Fee schedule rate ($111,337.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,34645.26,111337.93,There are no additional notes associated with this service or procedure.
Unlisted Px Female Genital System Nonobstetrical,CASE-58999,APC,58999,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],189.24,,"APC Price ($189.24). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,189.24,198.70,OPPS APC
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],15309.46,,"Fee schedule rate ($15,309.46). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6965.00,15340.19,There are no additional notes associated with this service or procedure.
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC,497,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],37761.19,,"Fee schedule rate ($37,761.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10127.65,37761.19,There are no additional notes associated with this service or procedure.
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],16458.91,,"Fee schedule rate ($16,458.91). Adds an outlier to normal pricing equal to the per diem rate ($62,521.14) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,7875.94,17233.12,There are no additional notes associated with this service or procedure.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC,858,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],11946.65,,"Case rate ($11,377.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,720.10, add-ons for qualifying new technology services are included. If operating cost exceeds $45,591.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,449.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $8,742.91 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,775.15 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $689.90. The transfer capital threshold is the transfer adjustment factor * $689.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,11377.76,33794.11,Inpatient DRG
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],48961.48,,"Fee schedule rate ($48,961.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11575.50,48961.48,There are no additional notes associated with this service or procedure.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],14098.78,,"Case rate ($14,098.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,251.41, add-ons for qualifying new technology services are included. If operating cost exceeds $48,122.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,648.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $11,264.92 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,306.46 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $888.91. The transfer capital threshold is the transfer adjustment factor * $888.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7332.00,35314.31,Inpatient DRG
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],90333.60,,"Fee schedule rate ($90,333.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,26127.34,90333.60,There are no additional notes associated with this service or procedure.
Trachelectomy Cervicectomy Amp Cervix Spx,CASE-57530,APC,57530,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],4846.30,,"APC Price ($4,682.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,4682.41,4916.53,OPPS APC
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,085,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],57443.16,,"Fee schedule rate ($57,443.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,9282.00,57443.16,There are no additional notes associated with this service or procedure.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],13968.53,,"Case rate ($13,303.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,532.63, add-ons for qualifying new technology services are included. If operating cost exceeds $47,403.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,570.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $10,547.69 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,587.68 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $810.72. The transfer capital threshold is the transfer adjustment factor * $810.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7921.00,45706.73,Inpatient DRG
Rpr Aa Hernia 1st 3-10 Cm Ncrc8/Strangulated,CASE-49594,APC,49594,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5658.76,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5658.76,5941.70,OPPS APC
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],13545.65,,,,,,0,other,5919.29,13545.65,There are no additional notes associated with this service or procedure.
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],23216.87,,"Fee schedule rate ($23,216.87). Adds an outlier to normal pricing equal to the per diem rate ($51,531) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.7), with a minimum of zero.",,,,0,other,10311.17,24308.97,There are no additional notes associated with this service or procedure.
Repair Brow Ptosis|BILATERAL PROCEDURE,CASE-67900,APC,67900,CPT,0360,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],2303.27,,"APC Price ($2,225.38). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2225.38,2336.65,OPPS APC
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC",629,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],17033.94,,"Case rate ($16,699.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,671.20, add-ons for qualifying new technology services are included. If operating cost exceeds $50,542.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,839.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $13,675.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,726.25 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,079.16. The transfer capital threshold is the transfer adjustment factor * $1,079.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,16699.94,44657.18,Inpatient DRG
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,418,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],31790.24,,"Fee schedule rate ($31,790.24). Adds an outlier to normal pricing equal to the per diem rate ($79,031.36) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.9), with a minimum of zero.",,,,0,other,13400.58,39884.93,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],15318.94,,"Fee schedule rate ($15,318.94). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6214.05,15318.94,There are no additional notes associated with this service or procedure.
Tnot Elbow Lateral/Medial Debride Open Tdn Rpr|LEFT SIDE,CASE-24359,APC,24359,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],29917.96,,"Fee schedule rate ($29,917.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,12527.66,29917.96,There are no additional notes associated with this service or procedure.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],31241.17,,,,,,0,other,12696.97,47123.82,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],15076.44,,"Fee schedule rate ($15,076.44). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6340.03,15076.44,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],28756.63,,"Fee schedule rate ($28,756.63). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,13148.66,32553.63,There are no additional notes associated with this service or procedure.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],11053.39,,"Case rate ($11,053.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,418.34, add-ons for qualifying new technology services are included. If operating cost exceeds $45,289.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,426.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $8,442.26 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,473.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $666.18. The transfer capital threshold is the transfer adjustment factor * $666.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,11053.39,36776.05,Inpatient DRG
Nasal/Sinus Ndsc Total With Sphenoidotomy|BILATERAL PROCEDURE,CASE-31257,APC,31257,CPT,0360,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6936.25,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6605.95,6936.25,OPPS APC
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC,964,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],34154.06,,"Fee schedule rate ($34,154.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12323.82,34154.06,There are no additional notes associated with this service or procedure.
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC,939,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],68190.40,,"Fee schedule rate ($68,190.40). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16.5), with a minimum of zero.",,,,0,other,26517.40,97674.79,There are no additional notes associated with this service or procedure.
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,450,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],39939.25,,"Case rate ($38,037.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $35,520.98, add-ons for qualifying new technology services are included. If operating cost exceeds $70,391.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,399.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $33,452.68 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $33,576.02 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,639.75. The transfer capital threshold is the transfer adjustment factor * $2,639.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,38037.38,146009.19,Inpatient DRG
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],10448.43,,"Case rate ($9,950.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,392.71, add-ons for qualifying new technology services are included. If operating cost exceeds $44,263.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,345.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $7,420.40 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,447.76 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $585.54. The transfer capital threshold is the transfer adjustment factor * $585.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7243.75,23262.15,Inpatient DRG
Rpr 1st Ingun Hrna Age 5 Yrs/> Reducible|RIGHT SIDE,CASE-49505,APC,49505,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3468.64,,"APC Price ($3,351.34). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3351.34,3518.91,OPPS APC
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",004,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],10715.36,,,,,,0,other,10249.47,272554.00,Estimated amount calculated based on 6 day length of stay.
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],21377.04,,"Fee schedule rate ($21,377.04). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,9648.19,31477.13,There are no additional notes associated with this service or procedure.
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],17255.73,,"Fee schedule rate ($17,255.73). Adds an outlier to normal pricing equal to the per diem rate ($43,191.57) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,8163.06,18067.42,There are no additional notes associated with this service or procedure.
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],15802.03,,"Fee schedule rate ($15,802.03). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7566.45,16333.88,There are no additional notes associated with this service or procedure.
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITH MCC OR ANTINEOPLASTIC IMPLANT OR EPILEPSY WITH NEUROSTIMULATOR,023,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],42177.23,,"Case rate ($40,750.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $38,045.35, add-ons for qualifying new technology services are included. If operating cost exceeds $72,916.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,598.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $35,967.78 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $36,100.40 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,838.21. The transfer capital threshold is the transfer adjustment factor * $2,838.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103.5%.",,,,0,other,15168.00,136379.44,Inpatient DRG
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC,964,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],30156.97,,,,,,0,other,12323.82,34154.06,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],51903.64,,"Fee schedule rate ($51,903.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,16017.99,51903.64,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC,084,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],8712.32,,"Case rate ($8,417.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,966.41, add-ons for qualifying new technology services are included. If operating cost exceeds $42,837.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,233.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $5,999.34 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,021.46 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $473.41. The transfer capital threshold is the transfer adjustment factor * $473.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6965.00,19445.16,Inpatient DRG
SKIN ULCERS WITH MCC,592,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],26453.30,,"Case rate ($15,116.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $14,168.54, add-ons for qualifying new technology services are included. If operating cost exceeds $53,556.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $3,795.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.8. The base transfer operating payment is the transfer adjustment factor * $12,752.10 + an uncompensated DSH payment of $1,359.91. The transfer operating threshold is the transfer adjustment factor * $12,808.63 + an uncompensated DSH payment of $1,359.91. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,004.16. The transfer capital threshold is the transfer adjustment factor * $1,004.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,15116.17,38644.05,All Other Inpatient
OSTEOMYELITIS WITHOUT CC/MCC,541,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],5103.00,,"Per diem ($5,103). If length of stay < 2.9, first 1 days paid at a per diem of $10,206 instead. Capped at $14,797.61.",,,,0,other,5103.00,15493.67,Estimated amount calculated based on 1 day length of stay.
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],8297.99,,"Case rate ($7,902.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,498.58, add-ons for qualifying new technology services are included. If operating cost exceeds $42,369.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,185.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,532.65 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,553.63 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $425.25. The transfer capital threshold is the transfer adjustment factor * $425.25. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7884.32,17835.23,Inpatient DRG
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],23899.13,,"Fee schedule rate ($23,899.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9795.13,23899.13,There are no additional notes associated with this service or procedure.
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],8643.20,,"Case rate ($8,643.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,176.19, add-ons for qualifying new technology services are included. If operating cost exceeds $43,047.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,249.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $6,208.35 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,231.24 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $489.90. The transfer capital threshold is the transfer adjustment factor * $489.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8643.20,19462.52,Inpatient DRG
CESAREAN SECTION WITHOUT STERILIZATION WITH CC,787,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],9698.17,,"Case rate ($9,508.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,980.70, add-ons for qualifying new technology services are included. If operating cost exceeds $43,851.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,313.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $7,009.90 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,035.74 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $553.15. The transfer capital threshold is the transfer adjustment factor * $553.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,9508.01,23722.94,Inpatient DRG
Unlisted Laparoscopy Px Abd Pertoneum & Omentum,CASE-49329,APC,49329,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5658.76,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5658.76,5856.81,OPPS APC
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],10672.06,,"Case rate ($10,311.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,727.87, add-ons for qualifying new technology services are included. If operating cost exceeds $44,598.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,371.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $7,754.32 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,782.91 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $611.89. The transfer capital threshold is the transfer adjustment factor * $611.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,10311.17,24308.97,Inpatient DRG
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],24909.11,,,,,,0,other,10517.71,24909.11,There are no additional notes associated with this service or procedure.
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],12696.11,,"Case rate ($12,091.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,384.11, add-ons for qualifying new technology services are included. If operating cost exceeds $46,255.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,502.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $9,404.49 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,439.16 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $742.11. The transfer capital threshold is the transfer adjustment factor * $742.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,29482.05,Inpatient DRG
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],70264.60,,,,,,0,other,26127.34,90333.60,There are no additional notes associated with this service or procedure.
OSTEOMYELITIS WITHOUT CC/MCC,541,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],5103.00,,"Per diem ($5,103). If length of stay < 2.9, first 1 days paid at a per diem of $10,206 instead. Capped at $14,797.61.",,,,0,other,5103.00,15493.67,Estimated amount calculated based on 1 day length of stay.
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,450,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],146009.19,,"Fee schedule rate ($146,009.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,38037.38,146009.19,There are no additional notes associated with this service or procedure.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],41944.25,,"Fee schedule rate ($41,944.25). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12795.84,41944.25,There are no additional notes associated with this service or procedure.
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],11133.98,,"Fee schedule rate ($11,133.98). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5919.29,13545.65,There are no additional notes associated with this service or procedure.
"HEART FAILURE,EXTREME",194,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],23379.83,,"Case rate ($22,266.50). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,22266.50,23379.83,There are no additional notes associated with this service or procedure.
"OTHER DIGESTIVE SYSTEM AND ABDOMINAL PROCEDURES,MODERATE",229,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],3362.84,,"Case rate for a one day stay ($3,362.84). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,3362.84,3530.98,There are no additional notes associated with this service or procedure.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],14394.57,,"Case rate ($13,907.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,073.74, add-ons for qualifying new technology services are included. If operating cost exceeds $47,944.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,634.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $11,087.92 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,128.80 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $874.95. The transfer capital threshold is the transfer adjustment factor * $874.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,13907.80,52794.06,Inpatient DRG
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],14803.72,,"Case rate ($14,098.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,251.41, add-ons for qualifying new technology services are included. If operating cost exceeds $48,122.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,648.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $11,264.92 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,306.46 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $888.91. The transfer capital threshold is the transfer adjustment factor * $888.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7332.00,35314.31,Inpatient DRG
"OTHER COMPLICATIONS OF TREATMENT,MODERATE",813,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],7551.91,,"Case rate ($7,551.91). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,7551.91,7929.51,There are no additional notes associated with this service or procedure.
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",623,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],14798.04,,"Case rate ($14,093.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,246.37, add-ons for qualifying new technology services are included. If operating cost exceeds $48,117.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,648.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $11,259.90 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,301.42 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $888.52. The transfer capital threshold is the transfer adjustment factor * $888.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,14093.37,33712.76,Inpatient DRG
VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC,033,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],42156.44,,"Fee schedule rate ($42,156.44). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,13206.23,42156.44,There are no additional notes associated with this service or procedure.
GI Tract Imaging Intraluminal Colon I&R,CASE-91113,APC,91113,CPT,0750,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],900.93,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,870.46,913.99,OPPS APC
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],21715.81,,"Case rate ($20,681.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $19,410.33, add-ons for qualifying new technology services are included. If operating cost exceeds $54,281.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,097.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.3. The base transfer operating payment is the transfer adjustment factor * $17,399.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $17,465.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,337.36. The transfer capital threshold is the transfer adjustment factor * $1,337.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,21248.73,56089.29,Inpatient DRG
HC Injection Small Joint/Bursa|LEFT SIDE,CASE-20600,APC,20600,CPT,0361,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,306,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],22078.65,,"Case rate ($12,616.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,872.35, add-ons for qualifying new technology services are included. If operating cost exceeds $46,743.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,540.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $9,890.94 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,927.40 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $780.49. The transfer capital threshold is the transfer adjustment factor * $780.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,12616.37,31007.02,All Other Inpatient
Arthrp Intercarpal/Carp/Mtcrpl Jt Suspension,CASE-25448,APC,25448,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],63499.65,,,,,,0,other,23799.09,63499.65,There are no additional notes associated with this service or procedure.
"Amputation Toe Interphalangeal Joint|LEFT FOOT, SECOND DIGIT",CASE-28825,APC,28825,CPT,0360,RC,,,T1,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],28821.04,,"Fee schedule rate ($28,821.04). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,10347.06,28821.04,There are no additional notes associated with this service or procedure.
PREMATURITY WITHOUT MAJOR PROBLEMS,792,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],11512.88,,"Fee schedule rate ($11,512.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,1956.00,19457.66,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],72151.96,,"Fee schedule rate ($72,151.96). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,27944.96,86252.84,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITHOUT STERILIZATION WITH CC,787,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],20988.02,,"Fee schedule rate ($20,988.02). Adds an outlier to normal pricing equal to the per diem rate ($39,437.39) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,9508.01,23722.94,There are no additional notes associated with this service or procedure.
CERVICAL SPINAL FUSION WITHOUT CC/MCC,473,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],45879.35,,"Fee schedule rate ($45,879.35). Adds an outlier to normal pricing equal to the per diem rate ($58,401.78) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,18477.61,62077.11,There are no additional notes associated with this service or procedure.
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",759,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],6567.68,,"Case rate ($6,438.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,125.57, add-ons for qualifying new technology services are included. If operating cost exceeds $40,996.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,088.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,165.27 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,180.62 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $328.68. The transfer capital threshold is the transfer adjustment factor * $328.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6190.22,13057.66,Inpatient DRG
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],24085.04,,"Case rate ($13,762.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,938.93, add-ons for qualifying new technology services are included. If operating cost exceeds $47,809.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,624.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $10,953.59 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,993.98 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $864.35. The transfer capital threshold is the transfer adjustment factor * $864.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,1188.00,34338.33,All Other Inpatient
Arthroplasty Patella W/O Prosthesis|BILATERAL PROCEDURE,CASE-27437,APC,27437,CPT,0360,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6791.99,7131.59,OPPS APC
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,066,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],6965.00,,,,,,0,other,6579.76,20083.61,There are no additional notes associated with this service or procedure.
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],14830.15,,"Fee schedule rate ($14,830.15). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,7884.32,17835.23,There are no additional notes associated with this service or procedure.
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],15491.11,,"Case rate ($15,491.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,546.67, add-ons for qualifying new technology services are included. If operating cost exceeds $49,417.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,750.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $12,555.42 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,601.72 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $990.75. The transfer capital threshold is the transfer adjustment factor * $990.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,15491.11,54180.83,Inpatient DRG
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],40192.59,,"Fee schedule rate ($40,192.59). Adds an outlier to normal pricing equal to the per diem rate ($235,324.88) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.6), with a minimum of zero.",,,,0,other,16428.39,42083.20,There are no additional notes associated with this service or procedure.
Preparation Skin Cell Ssp Agrft 1st 25 Sq Cm/<,CASE-15013,APC,15013,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6875.26,,"APC Price ($6,642.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6875.26,6875.26,OPPS APC
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],6965.00,,,,,,0,other,6965.00,21404.64,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,065,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],19879.67,,,,,,0,other,8786.76,25681.86,There are no additional notes associated with this service or procedure.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],5683.00,,"Per diem ($5,683). If length of stay < 3.3, first 1 days paid at a per diem of $11,366 instead. Capped at $18,753.53.",,,,0,other,5683.00,19635.68,Estimated amount calculated based on 3 day length of stay.
"CESAREAN SECTION WITHOUT STERILIZATION,MODERATE",540,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],7838.06,,"Case rate ($7,838.06). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,7838.06,8229.96,There are no additional notes associated with this service or procedure.
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",759,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6622.25,,"Case rate ($6,306.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,010.91, add-ons for qualifying new technology services are included. If operating cost exceeds $40,881.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,071.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,050.60 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,065.96 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $311.34. The transfer capital threshold is the transfer adjustment factor * $311.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6190.22,13057.66,Inpatient DRG
TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC,087,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],22679.07,,"Fee schedule rate ($22,679.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,8139.36,22679.07,There are no additional notes associated with this service or procedure.
Anrct Xm Surg Req Anes General Spi/Edrl Dx|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-45990,APC,45990,CPT,0360,RC,,,74,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],2598.08,,"APC Price ($2,598.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2598.08,2727.99,OPPS APC
OSTEOMYELITIS WITH CC,540,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],10938.06,,"Case rate ($10,723.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,111.53, add-ons for qualifying new technology services are included. If operating cost exceeds $44,982.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,402.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $8,136.58 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,166.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $642.06. The transfer capital threshold is the transfer adjustment factor * $642.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,9809.07,25507.30,Inpatient DRG
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,091,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],24216.61,,"Case rate ($13,838.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,008.86, add-ons for qualifying new technology services are included. If operating cost exceeds $47,879.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,629.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $11,023.26 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,063.91 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $869.84. The transfer capital threshold is the transfer adjustment factor * $869.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,13838.06,40030.81,All Other Inpatient
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],13947.32,,"Fee schedule rate ($13,947.32). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6153.12,13947.32,There are no additional notes associated with this service or procedure.
VENTRICULAR SHUNT PROCEDURES WITH MCC,031,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],62406.76,,"Fee schedule rate ($62,406.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,32287.20,88162.80,There are no additional notes associated with this service or procedure.
HC Biopsy Liver Percutan Needle,CASE-47000,APC,47000,CPT,0361,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1623.23,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1545.93,1623.23,OPPS APC
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],45706.73,,"Fee schedule rate ($45,706.73). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,7921.00,45706.73,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITHOUT STERILIZATION WITH CC,787,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],20988.02,,"Fee schedule rate ($20,988.02). Adds an outlier to normal pricing equal to the per diem rate ($39,437.39) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,9508.01,23722.94,There are no additional notes associated with this service or procedure.
"EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME, NEONATE",790,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],4160.10,,,,,,0,other,3054.00,44304.49,Estimated amount calculated based on 17 day length of stay.
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,690,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],14625.55,,"Fee schedule rate ($14,625.55). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7426.94,15928.53,There are no additional notes associated with this service or procedure.
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],31973.49,,"Fee schedule rate ($31,973.49). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,13386.36,33244.29,There are no additional notes associated with this service or procedure.
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],45157.33,,"Fee schedule rate ($45,157.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,10733.06,45157.33,There are no additional notes associated with this service or procedure.
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],11247.07,,"Case rate ($11,247.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,598.51, add-ons for qualifying new technology services are included. If operating cost exceeds $45,469.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,440.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,621.77 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,653.56 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $680.34. The transfer capital threshold is the transfer adjustment factor * $680.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,11247.07,27028.33,Inpatient DRG
HEADACHES WITHOUT MCC,103,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],7608.43,,"Case rate ($7,608.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,213.57, add-ons for qualifying new technology services are included. If operating cost exceeds $42,084.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,174.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $5,249.26 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,268.62 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $414.22. The transfer capital threshold is the transfer adjustment factor * $414.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,20883.08,Inpatient DRG
Open Biopsy/Excision Inguinofemoral Nodes|RIGHT SIDE,CASE-38531,APC,38531,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6215.36,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6215.36,6526.12,OPPS APC
HC Inj Aa&/Strd Greater Occipital Nerve|BILATERAL PROCEDURE,CASE-64405,APC,64405,CPT,0450,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],297.37,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,287.31,301.68,OPPS APC
VENTRICULAR SHUNT PROCEDURES WITH CC,032,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],28658.39,,"Case rate ($16,376.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,370.06, add-ons for qualifying new technology services are included. If operating cost exceeds $50,241.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,815.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $13,375.80 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,425.12 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,055.48. The transfer capital threshold is the transfer adjustment factor * $1,055.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,16376.22,46275.08,All Other Inpatient
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],26949.28,,"Fee schedule rate ($26,949.28). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9977.99,26949.28,There are no additional notes associated with this service or procedure.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],19952.48,,,,,,0,other,6965.00,20401.88,There are no additional notes associated with this service or procedure.
CHOLECYSTECTOMY WITH C.D.E. WITH MCC,411,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],88615.28,,"Fee schedule rate ($88,615.28). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,24315.13,88615.28,There are no additional notes associated with this service or procedure.
MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,708,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],11635.30,,"Case rate ($11,081.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $10,413.93, add-ons for qualifying new technology services are included. If operating cost exceeds $49,058.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $3,436.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.3. The base transfer operating payment is the transfer adjustment factor * $9,014.04 + an uncompensated DSH payment of $1,359.91. The transfer operating threshold is the transfer adjustment factor * $9,054.03 + an uncompensated DSH payment of $1,359.91. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $707.29. The transfer capital threshold is the transfer adjustment factor * $707.29. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10138.21,29171.15,Inpatient DRG
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,095,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],19411.47,,"Case rate ($19,411.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $18,193.69, add-ons for qualifying new technology services are included. If operating cost exceeds $53,064.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,037.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.6. The base transfer operating payment is the transfer adjustment factor * $16,189.05 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $16,248.74 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,277.48. The transfer capital threshold is the transfer adjustment factor * $1,277.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,19411.47,50750.92,Inpatient DRG
POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES,769,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],29791.03,,"Fee schedule rate ($29,791.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,13388.39,33250.19,There are no additional notes associated with this service or procedure.
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],15847.88,,"Case rate ($15,093.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,201.05, add-ons for qualifying new technology services are included. If operating cost exceeds $49,072.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,698.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $12,209.80 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,256.10 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $938.47. The transfer capital threshold is the transfer adjustment factor * $938.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,15491.11,54180.83,Inpatient DRG
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],23899.13,,"Fee schedule rate ($23,899.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9795.13,23899.13,There are no additional notes associated with this service or procedure.
Laparoscopic Appendectomy,CASE-44970,APC,44970,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5856.81,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5658.76,5941.70,OPPS APC
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],45933.85,,"Fee schedule rate ($45,933.85). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,18497.24,62041.12,There are no additional notes associated with this service or procedure.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],16689.78,,"Case rate ($16,689.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,661.75, add-ons for qualifying new technology services are included. If operating cost exceeds $50,532.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,838.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $13,666.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,716.80 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,078.42. The transfer capital threshold is the transfer adjustment factor * $1,078.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,16689.78,59521.43,Inpatient DRG
"Amputation Toe Metatarsophalangeal Joint|LEFT FOOT, SECOND DIGIT",CASE-28820,APC,28820,CPT,0360,RC,,,T1,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC",281,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],14296.01,,"Case rate ($8,169.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,735.20, add-ons for qualifying new technology services are included. If operating cost exceeds $42,606.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,215.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $5,768.98 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,790.25 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $455.23. The transfer capital threshold is the transfer adjustment factor * $455.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,8169.15,23859.35,All Other Inpatient
"Inj Dx/Ther Agnt Paravert Facet Joint, Cerv/Thorac, 2nd Level|LEFT SIDE|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA",CASE-64491,APC,64491,CPT,0360,RC,,,LT|74,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],869.28,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,827.89,869.28,OPPS APC
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH MCC",722,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],35609.47,,,,,,0,other,14200.37,56869.13,There are no additional notes associated with this service or procedure.
VENTRICULAR SHUNT PROCEDURES WITH MCC,031,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],62406.76,,"Fee schedule rate ($62,406.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,32287.20,88162.80,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],16693.56,,"Case rate ($16,129.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,140.12, add-ons for qualifying new technology services are included. If operating cost exceeds $50,011.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,797.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $13,146.70 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,195.17 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,037.40. The transfer capital threshold is the transfer adjustment factor * $1,037.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,16129.04,59610.47,Inpatient DRG
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],19371.27,,"Fee schedule rate ($19,371.27). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8643.20,19462.52,There are no additional notes associated with this service or procedure.
Insj/Rplcmt Spinal Npg/Rcvr Pocket Crtj&Connj,CASE-63685,APC,63685,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],30327.72,,"APC Price ($28,883.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,28883.55,30327.72,OPPS APC
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],7414.07,,"Case rate ($7,414.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,032.76, add-ons for qualifying new technology services are included. If operating cost exceeds $41,903.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,159.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,069.12 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,087.81 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $400.00. The transfer capital threshold is the transfer adjustment factor * $400.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7414.07,18217.52,Inpatient DRG
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],17194.49,,"Fee schedule rate ($17,194.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8554.50,19204.75,There are no additional notes associated with this service or procedure.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],23790.06,,"Fee schedule rate ($23,790.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10517.71,24909.11,There are no additional notes associated with this service or procedure.
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],35061.53,,"Fee schedule rate ($35,061.53). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,9696.93,35061.53,There are no additional notes associated with this service or procedure.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,073,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],13257.71,,"Case rate ($12,809.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,051.90, add-ons for qualifying new technology services are included. If operating cost exceeds $46,922.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,554.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $10,069.82 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,106.95 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $794.61. The transfer capital threshold is the transfer adjustment factor * $794.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,12809.38,43475.01,Inpatient DRG
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC",514,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],9311.44,,"Case rate ($8,868.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,385.35, add-ons for qualifying new technology services are included. If operating cost exceeds $43,256.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,266.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $6,416.74 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,440.40 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $506.34. The transfer capital threshold is the transfer adjustment factor * $506.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8868.04,22699.91,Inpatient DRG
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],16235.87,,"Fee schedule rate ($16,235.87). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6524.00,17760.46,There are no additional notes associated with this service or procedure.
RESPIRATORY NEOPLASMS WITHOUT CC/MCC,182,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],14832.52,,,,,,0,other,6965.00,23037.13,There are no additional notes associated with this service or procedure.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],48538.56,,"Fee schedule rate ($48,538.56). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,19435.86,50821.76,There are no additional notes associated with this service or procedure.
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],40916.35,,,,,,0,other,11165.00,61234.06,There are no additional notes associated with this service or procedure.
VENTRICULAR SHUNT PROCEDURES WITH MCC,031,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],88162.80,,,,,,0,other,32287.20,88162.80,There are no additional notes associated with this service or procedure.
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],39424.57,,"Fee schedule rate ($39,424.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12195.15,39424.57,There are no additional notes associated with this service or procedure.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],45706.73,,"Fee schedule rate ($45,706.73). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,7921.00,45706.73,There are no additional notes associated with this service or procedure.
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],23216.87,,"Fee schedule rate ($23,216.87). Adds an outlier to normal pricing equal to the per diem rate ($51,531) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.7), with a minimum of zero.",,,,0,other,10311.17,24308.97,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF NERVOUS SYSTEM WITH CC,092,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],20129.57,,,,,,0,other,8872.78,26765.51,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,064,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],16341.76,,"Case rate ($15,563.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,614.08, add-ons for qualifying new technology services are included. If operating cost exceeds $49,485.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,756.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $12,622.59 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,669.13 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $996.05. The transfer capital threshold is the transfer adjustment factor * $996.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,15563.58,41838.16,Inpatient DRG
"INFECTIOUS AND PARASITIC DISEASES INCLUDING HIV WITH O.R. PROCEDURE,MODERATE",710,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],20710.18,,"Case rate ($19,723.98). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,19723.98,20710.18,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],37914.65,,"Fee schedule rate ($37,914.65). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9865.56,37914.65,There are no additional notes associated with this service or procedure.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC,027,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],19454.77,,"Case rate ($18,528.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,403.08, add-ons for qualifying new technology services are included. If operating cost exceeds $52,274.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,943.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $15,399.75 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,458.13 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,183.66. The transfer capital threshold is the transfer adjustment factor * $1,183.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,19030.20,56363.30,Inpatient DRG
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC",605,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],17214.39,,"Fee schedule rate ($17,214.39). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8148.17,18024.13,There are no additional notes associated with this service or procedure.
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12907.72,,"Case rate ($12,293.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,590.89, add-ons for qualifying new technology services are included. If operating cost exceeds $46,461.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,498.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $9,609.50 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,645.94 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $738.61. The transfer capital threshold is the transfer adjustment factor * $738.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12606.23,36868.88,Inpatient DRG
"ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",770,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],17800.73,,"Fee schedule rate ($17,800.73). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,8735.30,19730.13,There are no additional notes associated with this service or procedure.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],38246.19,,"Fee schedule rate ($38,246.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,19435.86,50821.76,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],6965.00,,,,,,0,other,6965.00,21195.68,There are no additional notes associated with this service or procedure.
Tympanostomy General Anesthesia|RIGHT SIDE,CASE-69436,APC,69436,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5541.10,,"APC Price ($5,541.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5541.10,5735.04,OPPS APC
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],61234.06,,"Fee schedule rate ($61,234.06). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11165.00,61234.06,There are no additional notes associated with this service or procedure.
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],13486.95,,"Fee schedule rate ($13,486.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6915.64,14442.92,There are no additional notes associated with this service or procedure.
Egd Dilation Gastric/Duodenal Stricture,CASE-43245,APC,43245,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1796.14,,"APC Price ($1,796.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1796.14,1885.95,OPPS APC
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],22363.67,,"Fee schedule rate ($22,363.67). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10003.71,23415.63,There are no additional notes associated with this service or procedure.
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],23078.81,,"Fee schedule rate ($23,078.81). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10311.17,24308.97,There are no additional notes associated with this service or procedure.
Osteot W/WO Lngth Shrt/Corrj Metar Xcp 1st Ea|RIGHT SIDE,CASE-28308,APC,28308,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],31533.97,,"Fee schedule rate ($31,533.97). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8563.30,31533.97,There are no additional notes associated with this service or procedure.
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],17097.87,,"Fee schedule rate ($17,097.87). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,8106.18,18245.94,There are no additional notes associated with this service or procedure.
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],14830.15,,"Fee schedule rate ($14,830.15). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,7884.32,17835.23,There are no additional notes associated with this service or procedure.
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],40714.72,,"Fee schedule rate ($40,714.72). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,17356.15,44778.95,There are no additional notes associated with this service or procedure.
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],42021.93,,"Fee schedule rate ($42,021.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,21248.73,56089.29,There are no additional notes associated with this service or procedure.
COAGULATION DISORDERS,813,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],12703.99,,"Case rate ($12,274.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,554.21, add-ons for qualifying new technology services are included. If operating cost exceeds $46,425.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,515.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $9,573.96 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,609.26 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $755.48. The transfer capital threshold is the transfer adjustment factor * $755.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,12274.39,30013.33,Inpatient DRG
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,074,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],20919.08,,"Fee schedule rate ($20,919.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8925.60,20919.08,There are no additional notes associated with this service or procedure.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,056,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],59328.19,,"Fee schedule rate ($59,328.19). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (44), with a minimum of zero.",,,,0,other,7659.00,59328.19,There are no additional notes associated with this service or procedure.
MINOR BLADDER PROCEDURES WITHOUT CC/MCC,664,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],31876.87,,"Fee schedule rate ($31,876.87). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9034.63,31876.87,There are no additional notes associated with this service or procedure.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],66833.55,,"Fee schedule rate ($66,833.55). Adds an outlier to normal pricing equal to the per diem rate ($141,521.30) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,26028.48,80635.65,There are no additional notes associated with this service or procedure.
"CVA AND PRECEREBRAL OCCLUSION WITH INFARCTION,EXTREME",045,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],22548.66,,"Case rate ($21,474.91). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $45,251, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,21474.91,22548.66,There are no additional notes associated with this service or procedure.
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],10130.60,,"Case rate ($9,648.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,111.10, add-ons for qualifying new technology services are included. If operating cost exceeds $43,982.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,323.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $7,139.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,166.15 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $563.40. The transfer capital threshold is the transfer adjustment factor * $563.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9648.19,31477.13,Inpatient DRG
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],7766.29,,"Case rate ($7,396.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,016.38, add-ons for qualifying new technology services are included. If operating cost exceeds $41,887.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,158.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,052.80 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,071.43 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $398.72. The transfer capital threshold is the transfer adjustment factor * $398.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7396.47,16035.06,Inpatient DRG
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,068,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],6965.00,,,,,,0,other,6965.00,23184.90,There are no additional notes associated with this service or procedure.
"Repair Extensor Tendon Finger W/O Graft Each|LEFT HAND, FOURTH DIGIT",CASE-26418,APC,26418,CPT,0360,RC,,,F3,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
OTHER CEREBROVASCULAR DISORDERS WITH CC,071,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],20188.60,,,,,,0,other,5843.00,29215.10,There are no additional notes associated with this service or procedure.
Tenodesis Long Tendon Biceps|LEFT SIDE,CASE-23430,APC,23430,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],23520.23,,"Fee schedule rate ($23,520.23). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10517.71,24909.11,There are no additional notes associated with this service or procedure.
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC",514,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],8868.04,,"Case rate ($8,868.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,385.35, add-ons for qualifying new technology services are included. If operating cost exceeds $43,256.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,266.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $6,416.74 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,440.40 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $506.34. The transfer capital threshold is the transfer adjustment factor * $506.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8868.04,22699.91,Inpatient DRG
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],31401.22,,"Fee schedule rate ($31,401.22). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.7), with a minimum of zero.",,,,0,other,13260.40,32878.30,There are no additional notes associated with this service or procedure.
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],8165.30,,"Fee schedule rate ($8,165.30). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4341.01,12882.53,There are no additional notes associated with this service or procedure.
HC Joint Injection/Aspir Large WO US|PBB CHARGE,CASE-20610,APC,20610,CPT,0510,RC,,,PBB,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],297.37,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,287.31,301.68,OPPS APC
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral Ea Addl|RIGHT SIDE,CASE-64484,APC,64484,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],869.28,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,827.89,869.28,OPPS APC
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],10533.95,,"Case rate ($10,533.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,935.13, add-ons for qualifying new technology services are included. If operating cost exceeds $44,806.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,388.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $7,960.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,990.18 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $628.19. The transfer capital threshold is the transfer adjustment factor * $628.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10533.95,24956.34,Inpatient DRG
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],8543.64,,"Case rate ($8,543.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,083.58, add-ons for qualifying new technology services are included. If operating cost exceeds $42,954.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,242.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,116.09 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,138.64 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $482.62. The transfer capital threshold is the transfer adjustment factor * $482.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8543.64,23239.84,Inpatient DRG
INFLAMMATORY BOWEL DISEASE WITH CC,386,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],19879.00,,"Fee schedule rate ($19,879.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8556.53,19879.00,There are no additional notes associated with this service or procedure.
"CARDIAC ARREST, UNEXPLAINED WITH MCC",296,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],30733.51,,,,,,0,other,12522.25,36459.67,There are no additional notes associated with this service or procedure.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],29917.96,,"Fee schedule rate ($29,917.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,12527.66,29917.96,There are no additional notes associated with this service or procedure.
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],61234.06,,"Fee schedule rate ($61,234.06). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11165.00,61234.06,There are no additional notes associated with this service or procedure.
MAJOR BLADDER PROCEDURES WITH MCC,653,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],102249.56,,,,,,0,other,10280.00,125343.98,There are no additional notes associated with this service or procedure.
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],10181.78,,"Case rate ($9,696.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,156.46, add-ons for qualifying new technology services are included. If operating cost exceeds $44,027.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,326.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $7,185.02 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,211.51 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $566.97. The transfer capital threshold is the transfer adjustment factor * $566.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9696.93,35061.53,Inpatient DRG
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],61234.06,,"Fee schedule rate ($61,234.06). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11165.00,61234.06,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],32293.66,,"Fee schedule rate ($32,293.66). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,32293.66,There are no additional notes associated with this service or procedure.
HC Trigger Point 3 or More|PBB CHARGE,CASE-20553,APC,20553,CPT,0510,RC,,,PBB,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],301.68,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,287.31,301.68,OPPS APC
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],43888.01,,"Fee schedule rate ($43,888.01). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11717.72,43888.01,There are no additional notes associated with this service or procedure.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],42586.49,,"Fee schedule rate ($42,586.49). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,13341.67,42586.49,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],28756.63,,"Fee schedule rate ($28,756.63). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,13148.66,32553.63,There are no additional notes associated with this service or procedure.
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC,805,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],20902.03,,"Fee schedule rate ($20,902.03). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9253.36,21235.42,There are no additional notes associated with this service or procedure.
"Exc Tum/Vasc Mal Sft Tiss Hand/Fngr Subq <1.5cm|RIGHT HAND, SECOND DIGIT",CASE-26115,APC,26115,CPT,0360,RC,,,F6,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1545.93,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1545.93,1623.23,OPPS APC
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],11677.97,,"Fee schedule rate ($11,677.97). Adds an outlier to normal pricing equal to the per diem rate ($67,650.85) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.7), with a minimum of zero.",,,,0,other,6153.12,13947.32,There are no additional notes associated with this service or procedure.
CERVICAL SPINAL FUSION WITH CC,472,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],70198.84,,"Fee schedule rate ($70,198.84). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,21896.13,70198.84,There are no additional notes associated with this service or procedure.
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],13295.62,,"Case rate ($13,295.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,504.24, add-ons for qualifying new technology services are included. If operating cost exceeds $47,375.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,590.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $10,520.50 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,559.29 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $830.17. The transfer capital threshold is the transfer adjustment factor * $830.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7000.00,33835.79,Inpatient DRG
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],6210.36,,"Fee schedule rate ($6,210.36). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5778.62,11681.49,There are no additional notes associated with this service or procedure.
MAJOR BLADDER PROCEDURES WITH MCC,653,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],125343.98,,"Fee schedule rate ($125,343.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,10280.00,125343.98,There are no additional notes associated with this service or procedure.
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],37591.64,,"Fee schedule rate ($37,591.64). Adds an outlier to normal pricing equal to the per diem rate ($51,531) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.1), with a minimum of zero.",,,,0,other,15491.11,54180.83,There are no additional notes associated with this service or procedure.
PERITONEAL ADHESIOLYSIS WITH CC,336,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],39628.80,,"Fee schedule rate ($39,628.80). Adds an outlier to normal pricing equal to the per diem rate ($54,966.40) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,16225.22,53705.31,There are no additional notes associated with this service or procedure.
Colsc Flexible W/Control Bleeding Any Method,CASE-45382,APC,45382,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1159.29,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1120.09,1176.09,OPPS APC
Bronchoscopy W/Transbronchial Lung Bx 1 Lobe,CASE-31628,APC,31628,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6837.16,,"APC Price ($6,605.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6605.95,6936.25,OPPS APC
Litholapaxy Comp/Lg > 2.5 Cm,CASE-52318,APC,52318,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3299.47,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3299.47,3464.44,OPPS APC
Egd Endoscopic Stent Placement W/Wire& Dilation,CASE-43266,APC,43266,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5966.63,,"APC Price ($5,682.51). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5682.51,5966.63,OPPS APC
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],34570.85,,"Fee schedule rate ($34,570.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,6965.00,36140.75,There are no additional notes associated with this service or procedure.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],28649.93,,"Fee schedule rate ($28,649.93). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,12268.97,41006.47,There are no additional notes associated with this service or procedure.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC",156,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],12987.84,,"Fee schedule rate ($12,987.84). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,6625.12,13598.77,There are no additional notes associated with this service or procedure.
PREMATURITY WITH MAJOR PROBLEMS,791,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],29432.78,,"Case rate ($29,432.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $27,516.30, add-ons for qualifying new technology services are included. If operating cost exceeds $62,387.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,770.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 13.3. The base transfer operating payment is the transfer adjustment factor * $25,477.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $25,571.35 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,010.42. The transfer capital threshold is the transfer adjustment factor * $2,010.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,3048.21,30904.42,Inpatient DRG
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC,939,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],97674.79,,"Fee schedule rate ($97,674.79). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,26517.40,97674.79,There are no additional notes associated with this service or procedure.
NON-MALIGNANT BREAST DISORDERS WITH CC/MCC,600,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],19574.79,,"Fee schedule rate ($19,574.79). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7999.14,20495.56,There are no additional notes associated with this service or procedure.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],35719.96,,"Case rate ($35,719.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $33,365.14, add-ons for qualifying new technology services are included. If operating cost exceeds $68,236.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,230.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.9. The base transfer operating payment is the transfer adjustment factor * $31,304.77 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $31,420.19 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,470.26. The transfer capital threshold is the transfer adjustment factor * $2,470.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,35719.96,105091.76,Inpatient DRG
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,056,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],7659.00,,"Per diem ($7,659). If length of stay < 5.7, first 1 days paid at a per diem of $15,318 instead. Capped at $43,658.02.",,,,0,other,7659.00,59328.19,Estimated amount calculated based on 3 day length of stay.
"CARDIAC ARREST, UNEXPLAINED WITH MCC",296,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],29352.79,,"Fee schedule rate ($29,352.79). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.2), with a minimum of zero.",,,,0,other,12522.25,36459.67,There are no additional notes associated with this service or procedure.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],19144.64,,"Case rate ($18,497.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,343.20, add-ons for qualifying new technology services are included. If operating cost exceeds $52,214.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,970.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $15,341.68 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,398.25 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,210.61. The transfer capital threshold is the transfer adjustment factor * $1,210.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,18497.24,62041.12,Inpatient DRG
Surgical Arthroscopy Sho W/Coracoacrm Ligm Rls|LEFT SIDE,CASE-29826,APC,29826,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7029.71,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6791.99,7131.59,OPPS APC
CERVICAL SPINAL FUSION WITH MCC,471,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],36377.52,,"Case rate ($34,645.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $32,365.35, add-ons for qualifying new technology services are included. If operating cost exceeds $67,236.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,151.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $30,308.64 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $30,420.39 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,391.65. The transfer capital threshold is the transfer adjustment factor * $2,391.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,34645.26,111337.93,Inpatient DRG
COAGULATION DISORDERS,813,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],12703.99,,"Case rate ($12,274.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,554.21, add-ons for qualifying new technology services are included. If operating cost exceeds $46,425.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,515.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $9,573.96 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,609.26 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $755.48. The transfer capital threshold is the transfer adjustment factor * $755.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,12274.39,30013.33,Inpatient DRG
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],21675.85,,"Fee schedule rate ($21,675.85). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,9755.86,29216.99,There are no additional notes associated with this service or procedure.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],26949.28,,"Fee schedule rate ($26,949.28). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9977.99,26949.28,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],2070.00,,,,,,0,other,1188.00,34338.33,Estimated amount calculated based on 6 day length of stay.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],12990.19,,"Case rate ($12,990.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,220.11, add-ons for qualifying new technology services are included. If operating cost exceeds $47,091.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,567.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $10,237.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,275.16 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $807.83. The transfer capital threshold is the transfer adjustment factor * $807.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9888.00,43399.23,Inpatient DRG
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],12272.58,,"Fee schedule rate ($12,272.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5628.97,12272.58,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITH STERILIZATION WITHOUT CC/MCC,785,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],8852.80,,"Case rate ($8,431.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,979, add-ons for qualifying new technology services are included. If operating cost exceeds $42,850.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,234.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,011.89 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,034.06 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $474.40. The transfer capital threshold is the transfer adjustment factor * $474.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8431.24,20142.33,Inpatient DRG
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],62084.69,,"Fee schedule rate ($62,084.69). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (35), with a minimum of zero.",,,,0,other,30398.48,82674.88,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],23851.92,,"Case rate ($23,851.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $22,324.54, add-ons for qualifying new technology services are included. If operating cost exceeds $57,195.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,362.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.8. The base transfer operating payment is the transfer adjustment factor * $20,304.73 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $20,379.59 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,602.24. The transfer capital threshold is the transfer adjustment factor * $1,602.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,23851.92,63653.13,Inpatient DRG
OTHER DISORDERS OF NERVOUS SYSTEM WITH CC,092,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],20129.57,,,,,,0,other,8872.78,26765.51,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF NERVOUS SYSTEM WITH CC,092,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],8872.78,,"Case rate ($8,872.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,389.76, add-ons for qualifying new technology services are included. If operating cost exceeds $43,260.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,266.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $6,421.14 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,444.81 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $506.69. The transfer capital threshold is the transfer adjustment factor * $506.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8872.78,26765.51,Inpatient DRG
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],28966.51,,,,,,0,other,11914.12,40426.76,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],58394.20,,"Fee schedule rate ($58,394.20). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,9370.00,65732.99,There are no additional notes associated with this service or procedure.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],8151.55,,"Case rate ($8,151.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,718.82, add-ons for qualifying new technology services are included. If operating cost exceeds $42,589.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,213.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,752.66 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,773.87 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $453.94. The transfer capital threshold is the transfer adjustment factor * $453.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8151.55,18033.97,Inpatient DRG
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC,858,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],11655.72,,"Case rate ($11,100.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,479.43, add-ons for qualifying new technology services are included. If operating cost exceeds $45,350.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,413.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $8,502.24 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,534.48 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $653.50. The transfer capital threshold is the transfer adjustment factor * $653.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,11377.76,33794.11,Inpatient DRG
O.R. PROCEDURES FOR OBESITY WITH CC,620,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],43753.50,,"Fee schedule rate ($43,753.50). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12782.30,43753.50,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],6923.41,,"Case rate ($6,787.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,450.02, add-ons for qualifying new technology services are included. If operating cost exceeds $41,321.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,114.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,488.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,505.07 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $354.19. The transfer capital threshold is the transfer adjustment factor * $354.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6164.03,14071.02,Inpatient DRG
OSTEOMYELITIS WITHOUT CC/MCC,541,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],11429.52,,"Fee schedule rate ($11,429.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5103.00,15493.67,There are no additional notes associated with this service or procedure.
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC,806,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],6640.88,,"Case rate ($6,510.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,192.35, add-ons for qualifying new technology services are included. If operating cost exceeds $41,063.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,093.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $4,231.80 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,247.40 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $333.93. The transfer capital threshold is the transfer adjustment factor * $333.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,5354.25,13416.00,Inpatient DRG
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC,519,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],16264.96,,"Case rate ($15,490.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,546.03, add-ons for qualifying new technology services are included. If operating cost exceeds $49,417.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,750.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $12,554.80 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,601.09 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $990.70. The transfer capital threshold is the transfer adjustment factor * $990.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,15490.44,50780.20,Inpatient DRG
Dilation & Curettage Dx&/Ther Nonobstetric,CASE-58120,APC,58120,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3136.08,,"APC Price ($3,030.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3030.03,3181.53,OPPS APC
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],36875.62,,"Fee schedule rate ($36,875.62). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.7), with a minimum of zero.",,,,0,other,15233.11,38610.21,There are no additional notes associated with this service or procedure.
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],48961.48,,"Fee schedule rate ($48,961.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11575.50,48961.48,There are no additional notes associated with this service or procedure.
Breast Reduction|BILATERAL PROCEDURE,CASE-19318,APC,19318,CPT,0360,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6432.89,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6215.36,6526.12,OPPS APC
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],17356.15,,"Case rate ($17,356.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,281.67, add-ons for qualifying new technology services are included. If operating cost exceeds $51,152.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,887.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $14,284.05 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,336.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,127.15. The transfer capital threshold is the transfer adjustment factor * $1,127.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,17356.15,44778.95,Inpatient DRG
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,082,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],17423.21,,"Case rate ($17,423.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,344.04, add-ons for qualifying new technology services are included. If operating cost exceeds $51,215.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,892.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $14,346.19 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,399.08 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,132.06. The transfer capital threshold is the transfer adjustment factor * $1,132.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,17423.21,56223.11,Inpatient DRG
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],21455.22,,"Fee schedule rate ($21,455.22). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,9097.60,21455.22,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],23377.19,,"Case rate ($23,377.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $21,882.92, add-ons for qualifying new technology services are included. If operating cost exceeds $56,753.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,327.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $19,864.72 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $19,937.97 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,567.52. The transfer capital threshold is the transfer adjustment factor * $1,567.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,23377.19,96365.69,Inpatient DRG
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],34032.82,,"Fee schedule rate ($34,032.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,15233.11,38610.21,There are no additional notes associated with this service or procedure.
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 2nd Level,CASE-64494,APC,64494,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],856.86,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,827.89,869.28,OPPS APC
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],18217.52,,"Fee schedule rate ($18,217.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7414.07,18217.52,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],30063.84,,"Fee schedule rate ($30,063.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13891.57,34712.20,There are no additional notes associated with this service or procedure.
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],17902.13,,,,,,0,other,8106.18,18245.94,There are no additional notes associated with this service or procedure.
Cysto Bladder W/Ureteral Catheterization|BILATERAL PROCEDURE,CASE-52005,APC,52005,CPT,0360,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],2054.48,,"APC Price ($1,956.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1956.65,2054.48,OPPS APC
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],24195.39,,"Case rate ($23,377.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $21,882.92, add-ons for qualifying new technology services are included. If operating cost exceeds $56,753.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,327.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $19,864.72 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $19,937.97 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,567.52. The transfer capital threshold is the transfer adjustment factor * $1,567.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,23377.19,96365.69,Inpatient DRG
PREMATURITY WITH MAJOR PROBLEMS,791,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],30462.93,,"Case rate ($29,432.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $27,516.30, add-ons for qualifying new technology services are included. If operating cost exceeds $62,387.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,770.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 13.3. The base transfer operating payment is the transfer adjustment factor * $25,477.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $25,571.35 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,010.42. The transfer capital threshold is the transfer adjustment factor * $2,010.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,3048.21,30904.42,Inpatient DRG
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],27589.62,,"Fee schedule rate ($27,589.62). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12566.28,30861.41,There are no additional notes associated with this service or procedure.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC",156,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],6956.38,,"Case rate ($6,625.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,298.82, add-ons for qualifying new technology services are included. If operating cost exceeds $41,169.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,102.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $4,337.88 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,353.87 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $342.30. The transfer capital threshold is the transfer adjustment factor * $342.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6625.12,13598.77,Inpatient DRG
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],18412.80,,"Fee schedule rate ($18,412.80). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (47), with a minimum of zero.",,,,0,other,15283.90,38757.79,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],81524.17,,"Fee schedule rate ($81,524.17). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,8972.00,81524.17,There are no additional notes associated with this service or procedure.
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],20955.17,,"Case rate ($11,974.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,275.12, add-ons for qualifying new technology services are included. If operating cost exceeds $46,146.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,493.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $9,295.90 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,330.17 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $733.54. The transfer capital threshold is the transfer adjustment factor * $733.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,11974.38,29141.64,All Other Inpatient
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],10003.71,,"Case rate ($10,003.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,441.84, add-ons for qualifying new technology services are included. If operating cost exceeds $44,312.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,349.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $7,469.36 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,496.90 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $589.41. The transfer capital threshold is the transfer adjustment factor * $589.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10003.71,23415.63,Inpatient DRG
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],8487.31,,"Case rate ($8,083.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,655.19, add-ons for qualifying new technology services are included. If operating cost exceeds $42,526.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,208.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,689.27 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,710.24 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $448.94. The transfer capital threshold is the transfer adjustment factor * $448.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7884.32,17835.23,Inpatient DRG
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],44034.06,,"Case rate ($25,162.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $23,543.58, add-ons for qualifying new technology services are included. If operating cost exceeds $58,414.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,458.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $21,519.28 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $21,598.63 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,698.08. The transfer capital threshold is the transfer adjustment factor * $1,698.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,25162.32,75579.22,All Other Inpatient
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],42767.23,,"Fee schedule rate ($42,767.23). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,17356.15,44778.95,There are no additional notes associated with this service or procedure.
Perq Nl/Pl Lithotrp Simple Up to 2 Cm 1 Location|LEFT SIDE,CASE-50080,APC,50080,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],9170.96,,"APC Price ($8,860.83). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,8860.83,9303.88,OPPS APC
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],41944.25,,"Fee schedule rate ($41,944.25). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12795.84,41944.25,There are no additional notes associated with this service or procedure.
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],7868.00,,"Per diem ($7,868). If length of stay < 3.9, first 1 days paid at a per diem of $15,736 instead. Capped at $30,683.33.",,,,0,other,7868.00,32126.64,Estimated amount calculated based on 3 day length of stay.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],38378.80,,"Fee schedule rate ($38,378.80). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,14370.36,38378.80,There are no additional notes associated with this service or procedure.
HC Peripheral Block - Femoral Single or Saphenous W/Img Gdn|LEFT SIDE,CASE-64447,APC,64447,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],683.85,,"APC Price ($660.72). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,660.72,693.76,OPPS APC
NEONATE WITH OTHER SIGNIFICANT PROBLEMS,794,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],12357.73,,"Case rate ($11,939.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,242.99, add-ons for qualifying new technology services are included. If operating cost exceeds $46,114.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,490.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $9,263.89 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,298.04 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $731.01. The transfer capital threshold is the transfer adjustment factor * $731.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,1798.85,12536.83,Inpatient DRG
RESPIRATORY NEOPLASMS WITHOUT CC/MCC,182,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],6965.00,,,,,,0,other,6965.00,23037.13,There are no additional notes associated with this service or procedure.
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],18217.52,,"Fee schedule rate ($18,217.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7414.07,18217.52,There are no additional notes associated with this service or procedure.
HC Plcmt Tunnel Pleural Drain Cat,CASE-32550,APC,32550,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3351.34,,"APC Price ($3,351.34). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3351.34,3518.91,OPPS APC
Cysto W/Ureteroscopy W/Rmvl/Manj Stones,CASE-52352,APC,52352,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3299.47,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3299.47,3464.44,OPPS APC
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,477,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],26606.73,,"Case rate ($25,339.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $23,708.63, add-ons for qualifying new technology services are included. If operating cost exceeds $58,579.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,471.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 8.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $21,683.73 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $21,763.68 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,711.06. The transfer capital threshold is the transfer adjustment factor * $1,711.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,25339.74,67976.16,Inpatient DRG
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],42138.30,,,,,,0,other,7453.00,42138.30,There are no additional notes associated with this service or procedure.
Excision Excessive Skin & Subq Tissue Abdomen,CASE-15847,APC,15847,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6526.12,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6215.36,6526.12,OPPS APC
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITHOUT CC/MCC,816,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],10893.58,,"Case rate ($6,224.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,926.50, add-ons for qualifying new technology services are included. If operating cost exceeds $40,797.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,073.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $3,966.92 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,981.55 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $313.03. The transfer capital threshold is the transfer adjustment factor * $313.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,6224.90,14733.53,All Other Inpatient
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],34481.40,,"Fee schedule rate ($34,481.40). Adds an outlier to normal pricing equal to the per diem rate ($50,543.29) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,14370.36,38378.80,There are no additional notes associated with this service or procedure.
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],6965.00,,,,,,0,other,4341.01,12882.53,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],65732.99,,,,,,0,other,9370.00,65732.99,There are no additional notes associated with this service or procedure.
NEONATE WITH OTHER SIGNIFICANT PROBLEMS,794,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],3383.58,,"Fee schedule rate ($3,383.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,1798.85,12536.83,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],19152.11,,"Case rate ($19,152.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,952.40, add-ons for qualifying new technology services are included. If operating cost exceeds $52,823.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,018.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $15,948.65 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $16,007.45 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,258.51. The transfer capital threshold is the transfer adjustment factor * $1,258.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,19152.11,53152.12,Inpatient DRG
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],54180.83,,"Fee schedule rate ($54,180.83). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,15491.11,54180.83,There are no additional notes associated with this service or procedure.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],39153.65,,"Fee schedule rate ($39,153.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,7605.00,39153.65,There are no additional notes associated with this service or procedure.
Hallux Rigidus W/Cheilectomy 1st Mp Jt W/O Implt,CASE-28289,APC,28289,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
"Arthrodesis Great Toe Metatarsophalangeal Joint|RIGHT FOOT, GREAT TOE",CASE-28750,APC,28750,CPT,0360,RC,,,T5,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",004,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],99098.77,,"Case rate ($95,747.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $89,207.57, add-ons for qualifying new technology services are included. If operating cost exceeds $124,078.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $8,620.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 22.4. The base transfer operating payment is the transfer adjustment factor * $86,942.06 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $87,262.63 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $6,860.59. The transfer capital threshold is the transfer adjustment factor * $6,860.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,10249.47,272554.00,Inpatient DRG
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],21892.85,,"Fee schedule rate ($21,892.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7569.84,21892.85,There are no additional notes associated with this service or procedure.
HYPERTENSION WITHOUT MCC,305,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],7058.55,,"Case rate ($7,058.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,702.02, add-ons for qualifying new technology services are included. If operating cost exceeds $41,573.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,133.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,739.59 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,757.07 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $374.00. The transfer capital threshold is the transfer adjustment factor * $374.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7058.55,17230.49,Inpatient DRG
Hemorrhoid Ntrnl & Xtrnl 1 Column W/Fissurecto,CASE-46257,APC,46257,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],2689.02,,"APC Price ($2,598.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2598.08,2727.99,OPPS APC
HYPERTENSION WITHOUT MCC,305,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],12352.46,,"Case rate ($7,058.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,702.02, add-ons for qualifying new technology services are included. If operating cost exceeds $41,573.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,133.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,739.59 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,757.07 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $374.00. The transfer capital threshold is the transfer adjustment factor * $374.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,7058.55,17230.49,All Other Inpatient
HC Peripheral Block - Femoral Single or Saphenous W/Img Gdn|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64447,APC,64447,CPT,0360,RC,,,RT|XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
Neuroplasty &/Transposition Ulnar Nerve Elbow|UNUSUAL NON-OVERLAPPING SERVICE|LEFT SIDE,CASE-64718,APC,64718,CPT,0360,RC,,,XU|LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7752.07,,"Case rate ($7,382.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,013.92, add-ons for qualifying new technology services are included. If operating cost exceeds $41,884.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,148.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $5,049.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,068.97 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $388.14. The transfer capital threshold is the transfer adjustment factor * $388.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,19126.88,Inpatient DRG
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],42787.31,,"Fee schedule rate ($42,787.31). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,15476.23,42787.31,There are no additional notes associated with this service or procedure.
"MAJOR RESPIRATORY INFECTIONS AND INFLAMMATIONS,EXTREME",137,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],18845.78,,"Case rate ($18,845.78). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,18845.78,19788.07,There are no additional notes associated with this service or procedure.
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],12526.44,,"Fee schedule rate ($12,526.44). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5415.00,17575.50,There are no additional notes associated with this service or procedure.
NORMAL NEWBORN,795,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],2074.00,,,,,,0,other,1369.79,5771.52,Estimated amount calculated based on 2 day length of stay.
"MAJOR RESPIRATORY INFECTIONS AND INFLAMMATIONS,MODERATE",137,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],7130.89,,"Case rate ($7,130.89). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,7130.89,7487.43,There are no additional notes associated with this service or procedure.
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],13310.79,,"Case rate ($12,676.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,948.71, add-ons for qualifying new technology services are included. If operating cost exceeds $46,819.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,525.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $9,965.98 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,003.76 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $766.01. The transfer capital threshold is the transfer adjustment factor * $766.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7868.00,32126.64,Inpatient DRG
NON-MALIGNANT BREAST DISORDERS WITH CC/MCC,600,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],8998.74,,"Case rate ($8,998.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,506.94, add-ons for qualifying new technology services are included. If operating cost exceeds $43,377.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,275.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $6,537.88 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,561.99 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $515.90. The transfer capital threshold is the transfer adjustment factor * $515.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7999.14,20495.56,Inpatient DRG
Surgical Arthroscopy Shoulder Xtnsv Dbrdmt 3+|RIGHT SIDE,CASE-29823,APC,29823,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],20589.45,,"Fee schedule rate ($20,589.45). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,12455.21,37149.27,There are no additional notes associated with this service or procedure.
"SEIZURE,MINOR",053,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],2225.17,,"Case rate for a one day stay ($2,119.21). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,2119.21,2225.17,There are no additional notes associated with this service or procedure.
"LIMB REATTACHMENT, HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA",956,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],70718.06,,"Fee schedule rate ($70,718.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,27428.25,148259.86,There are no additional notes associated with this service or procedure.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],19422.10,,"Case rate ($18,497.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,343.20, add-ons for qualifying new technology services are included. If operating cost exceeds $52,214.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,970.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $15,341.68 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,398.25 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,210.61. The transfer capital threshold is the transfer adjustment factor * $1,210.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,18497.24,62041.12,Inpatient DRG
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],13146.51,,"Case rate ($12,520.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,802.89, add-ons for qualifying new technology services are included. If operating cost exceeds $46,673.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,514.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $9,820.70 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,857.94 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $754.84. The transfer capital threshold is the transfer adjustment factor * $754.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,1188.00,31658.33,Inpatient DRG
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],29594.00,,"Fee schedule rate ($29,594.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,13571.25,33781.47,There are no additional notes associated with this service or procedure.
CERVICAL SPINAL FUSION WITHOUT CC/MCC,473,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],19401.49,,"Case rate ($18,477.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,324.93, add-ons for qualifying new technology services are included. If operating cost exceeds $52,195.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,969.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.6. The base transfer operating payment is the transfer adjustment factor * $15,323.48 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,379.98 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,209.17. The transfer capital threshold is the transfer adjustment factor * $1,209.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,18477.61,62077.11,Inpatient DRG
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],16447.34,,"Case rate ($16,447.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,436.22, add-ons for qualifying new technology services are included. If operating cost exceeds $50,307.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,820.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $13,441.70 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,491.27 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,060.68. The transfer capital threshold is the transfer adjustment factor * $1,060.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7453.00,42138.30,Inpatient DRG
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,191,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],7653.81,,"Case rate ($7,653.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,255.78, add-ons for qualifying new technology services are included. If operating cost exceeds $42,126.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,177.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,291.32 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,310.83 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $417.54. The transfer capital threshold is the transfer adjustment factor * $417.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,16612.88,Inpatient DRG
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],30112.02,,"Fee schedule rate ($30,112.02). Adds an outlier to normal pricing equal to the per diem rate ($53,484.01) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.5), with a minimum of zero.",,,,0,other,12795.84,41944.25,There are no additional notes associated with this service or procedure.
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],6965.00,,,,,,0,other,6965.00,34422.94,There are no additional notes associated with this service or procedure.
Excision Distal Ulna Partial/Complete|RIGHT SIDE,CASE-25240,APC,25240,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,447,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],49552.87,,"Case rate ($47,193.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $44,038.45, add-ons for qualifying new technology services are included. If operating cost exceeds $78,909.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $5,069.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $41,938.87 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $42,093.51 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,309.39. The transfer capital threshold is the transfer adjustment factor * $3,309.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,47193.21,156646.82,Inpatient DRG
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],70264.60,,,,,,0,other,26127.34,90333.60,There are no additional notes associated with this service or procedure.
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],14249.81,,"Case rate ($13,571.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,760.65, add-ons for qualifying new technology services are included. If operating cost exceeds $47,631.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,610.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $10,775.96 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,815.69 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $850.33. The transfer capital threshold is the transfer adjustment factor * $850.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13571.25,33781.47,Inpatient DRG
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],24387.68,,"Fee schedule rate ($24,387.68). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10733.06,45157.33,There are no additional notes associated with this service or procedure.
OSTEOMYELITIS WITHOUT CC/MCC,541,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],15493.67,,,,,,0,other,5103.00,15493.67,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],28423.20,,"Fee schedule rate ($28,423.20). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11059.47,28423.20,There are no additional notes associated with this service or procedure.
"LIMB REATTACHMENT, HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA",956,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],74044.55,,,,,,0,other,27428.25,148259.86,There are no additional notes associated with this service or procedure.
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|RIGHT HAND, FIFTH DIGIT",CASE-26160,APC,26160,CPT,0360,RC,,,F9,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1505.12,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1505.12,1580.37,OPPS APC
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],12272.58,,"Fee schedule rate ($12,272.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5628.97,12272.58,There are no additional notes associated with this service or procedure.
"Correction Hammertoe|RIGHT FOOT, SECOND DIGIT",CASE-28285,APC,28285,CPT,0360,RC,,,T6,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITHOUT MCC,430,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],113479.23,,,,,,0,other,41000.16,133156.90,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],78960.67,,"Fee schedule rate ($78,960.67). Adds an outlier to normal pricing equal to the per diem rate ($149,567.78) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19.1), with a minimum of zero.",,,,0,other,30398.48,82674.88,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,066,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],6965.00,,,,,,0,other,6579.76,20083.61,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],21195.68,,"Fee schedule rate ($21,195.68). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,6965.00,21195.68,There are no additional notes associated with this service or procedure.
Dstr Nrolytc Agnt Parverteb Fct Sngl Lmbr/Sacral|BILATERAL PROCEDURE,CASE-64635,APC,64635,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1827.80,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1827.80,1919.19,OPPS APC
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],18905.23,,"Fee schedule rate ($18,905.23). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6963.00,18954.85,There are no additional notes associated with this service or procedure.
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],7000.00,,"Per diem ($7,000). If length of stay < 4.5, first 1 days paid at a per diem of $14,000 instead. Capped at $31,498.95.",,,,0,other,7000.00,33835.79,Estimated amount calculated based on 2 day length of stay.
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],29474.94,,"Fee schedule rate ($29,474.94). Adds an outlier to normal pricing equal to the per diem rate ($65,448.99) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.4), with a minimum of zero.",,,,0,other,12566.28,30861.41,There are no additional notes associated with this service or procedure.
Laps Surg Rpr Recurrent Inguinal Hernia|LEFT SIDE,CASE-49651,APC,49651,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5856.81,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5658.76,5941.70,OPPS APC
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],18918.49,,"Fee schedule rate ($18,918.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9282.47,21320.03,There are no additional notes associated with this service or procedure.
OSTEOMYELITIS WITHOUT CC/MCC,541,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],11429.52,,"Fee schedule rate ($11,429.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5103.00,15493.67,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,065,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],25681.86,,"Fee schedule rate ($25,681.86). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,8786.76,25681.86,There are no additional notes associated with this service or procedure.
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],15145.28,,"Fee schedule rate ($15,145.28). Adds an outlier to normal pricing equal to the per diem rate ($54,966.40) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7402.56,16438.59,There are no additional notes associated with this service or procedure.
"Laminec/Facetect/Foramin,Lumbar|LEFT SIDE",CASE-63047,APC,63047,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7029.71,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6791.99,7131.59,OPPS APC
"POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT PROCEDURE,MAJOR",561,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],1975.27,,"Case rate for a one day stay ($1,975.27). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,1975.27,2074.03,There are no additional notes associated with this service or procedure.
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],12154.28,,"Case rate ($11,575.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,904.06, add-ons for qualifying new technology services are included. If operating cost exceeds $45,775.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,464.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $8,926.20 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,959.11 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $704.37. The transfer capital threshold is the transfer adjustment factor * $704.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,11575.50,48961.48,Inpatient DRG
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC",605,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],17131.97,,"Fee schedule rate ($17,131.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8148.17,18024.13,There are no additional notes associated with this service or procedure.
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],13989.06,,"Case rate ($7,993.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,572.03, add-ons for qualifying new technology services are included. If operating cost exceeds $42,443.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,202.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $5,606.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,627.08 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $442.40. The transfer capital threshold is the transfer adjustment factor * $442.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,5415.00,17575.50,All Other Inpatient
Nasal/Sinus Ndsc Tot W/Frnt Sins Expl Tiss Rmvl|LEFT SIDE,CASE-31253,APC,31253,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6936.25,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6605.95,6936.25,OPPS APC
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],23385.72,,"Fee schedule rate ($23,385.72). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,23385.72,There are no additional notes associated with this service or procedure.
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],7147.93,,"Case rate ($7,147.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,785.17, add-ons for qualifying new technology services are included. If operating cost exceeds $41,656.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,140.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $4,822.44 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,840.22 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $380.54. The transfer capital threshold is the transfer adjustment factor * $380.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,16400.70,Inpatient DRG
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,345,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],28277.83,,"Fee schedule rate ($28,277.83). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12134.89,33616.03,There are no additional notes associated with this service or procedure.
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],6230.00,,"Per diem ($6,230). If length of stay < 2.9, first 1 days paid at a per diem of $12,460 instead. Capped at $18,065.71.",,,,0,other,6230.00,22762.43,Estimated amount calculated based on 3 day length of stay.
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],7875.94,,"Case rate ($7,875.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,462.42, add-ons for qualifying new technology services are included. If operating cost exceeds $42,333.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,193.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $5,497.20 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,517.46 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $433.78. The transfer capital threshold is the transfer adjustment factor * $433.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7875.94,17233.12,Inpatient DRG
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],18587.22,,"Case rate ($17,702.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,632.90, add-ons for qualifying new technology services are included. If operating cost exceeds $51,503.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,884.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $14,632.47 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,687.95 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,124.69. The transfer capital threshold is the transfer adjustment factor * $1,124.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,18178.96,54764.34,Inpatient DRG
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],12840.52,,"Case rate ($12,840.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,080.88, add-ons for qualifying new technology services are included. If operating cost exceeds $46,951.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,556.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $10,098.70 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,135.93 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $796.89. The transfer capital threshold is the transfer adjustment factor * $796.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,1188.00,31658.33,Inpatient DRG
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],38246.19,,"Fee schedule rate ($38,246.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,19435.86,50821.76,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],25609.86,,"Fee schedule rate ($25,609.86). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,12775.53,31469.43,There are no additional notes associated with this service or procedure.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],8725.59,,"Case rate ($8,554.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,093.67, add-ons for qualifying new technology services are included. If operating cost exceeds $42,964.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,243.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,126.13 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,148.72 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $483.41. The transfer capital threshold is the transfer adjustment factor * $483.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,8554.50,19204.75,Inpatient DRG
CESAREAN SECTION WITHOUT STERILIZATION WITH MCC,786,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],19006.00,,,,,,0,other,12612.10,23722.94,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC,833,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],5721.39,,"Fee schedule rate ($5,721.39). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,3041.73,10289.10,There are no additional notes associated with this service or procedure.
Unlisted Laparoscopy Procedure Stomach,CASE-43659,APC,43659,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5658.76,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5658.76,5941.70,OPPS APC
OTHER CEREBROVASCULAR DISORDERS WITH MCC,070,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],20935.95,,"Fee schedule rate ($20,935.95). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,13219.09,37774.46,There are no additional notes associated with this service or procedure.
NORMAL NEWBORN,795,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],2074.00,,,,,,0,other,1369.79,5771.52,Estimated amount calculated based on 2 day length of stay.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],28619.77,,"Case rate ($27,256.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $25,492.14, add-ons for qualifying new technology services are included. If operating cost exceeds $60,363.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,611.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. The base transfer operating payment is the transfer adjustment factor * $23,460.69 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $23,547.19 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,851.28. The transfer capital threshold is the transfer adjustment factor * $1,851.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,27256.92,81353.66,Inpatient DRG
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],94787.57,,"Fee schedule rate ($94,787.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,23526.87,94787.57,There are no additional notes associated with this service or procedure.
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC",011,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],150008.48,,"Fee schedule rate ($150,008.48). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (44), with a minimum of zero.",,,,0,other,38880.49,150008.48,There are no additional notes associated with this service or procedure.
Colsc Flx With Directed Submucosal Njx Any Sbst,CASE-45381,APC,45381,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1120.09,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1120.09,1176.09,OPPS APC
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],52453.14,,"Fee schedule rate ($52,453.14). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14.9), with a minimum of zero.",,,,0,other,20846.48,81306.30,There are no additional notes associated with this service or procedure.
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITHOUT CC/MCC",630,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],28718.58,,,,,,0,other,11828.78,42541.02,There are no additional notes associated with this service or procedure.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC",061,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],62315.82,,"Fee schedule rate ($62,315.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,20616.23,62315.82,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],31401.22,,"Fee schedule rate ($31,401.22). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.7), with a minimum of zero.",,,,0,other,13260.40,32878.30,There are no additional notes associated with this service or procedure.
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],11374.36,,"Case rate ($10,989.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,359.11, add-ons for qualifying new technology services are included. If operating cost exceeds $45,230.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,421.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $8,383.26 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,414.17 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $661.52. The transfer capital threshold is the transfer adjustment factor * $661.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,10989.72,26280.60,Inpatient DRG
OTHER CEREBROVASCULAR DISORDERS WITH MCC,070,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],32758.27,,,,,,0,other,13219.09,37774.46,There are no additional notes associated with this service or procedure.
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],26657.94,,"Case rate ($15,233.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,306.64, add-ons for qualifying new technology services are included. If operating cost exceeds $49,177.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,731.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $12,316.28 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,361.69 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $971.88. The transfer capital threshold is the transfer adjustment factor * $971.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,15233.11,38610.21,All Other Inpatient
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],10149.91,,"Case rate ($9,950.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,392.71, add-ons for qualifying new technology services are included. If operating cost exceeds $44,263.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,345.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $7,420.40 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,447.76 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $585.54. The transfer capital threshold is the transfer adjustment factor * $585.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,7243.75,23262.15,Inpatient DRG
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC,833,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],6965.00,,,,,,0,other,3041.73,10289.10,There are no additional notes associated with this service or procedure.
Exc Breast Les Preop Plmt Rad Marker Open 1 Les|LEFT SIDE,CASE-19125,APC,19125,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3848.19,,"APC Price ($3,664.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3664.94,3848.19,OPPS APC
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],14699.43,,"Fee schedule rate ($14,699.43). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6683.37,14699.43,There are no additional notes associated with this service or procedure.
"Tx Open Tendon Flexor Toe 1 Tendon Spx|RIGHT FOOT, SECOND DIGIT",CASE-28232,APC,28232,CPT,0360,RC,,,T6,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1557.80,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1505.12,1580.37,OPPS APC
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],26280.60,,,,,,0,other,10989.72,26280.60,There are no additional notes associated with this service or procedure.
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],8106.18,,"Case rate ($8,106.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,676.61, add-ons for qualifying new technology services are included. If operating cost exceeds $42,547.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,210.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,710.61 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,731.66 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $450.62. The transfer capital threshold is the transfer adjustment factor * $450.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8106.18,18245.94,Inpatient DRG
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],11681.49,,"Fee schedule rate ($11,681.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5778.62,11681.49,There are no additional notes associated with this service or procedure.
Arthrs Knee Abrasion Arthrp/Mlt Drlg/Microfx|RIGHT SIDE,CASE-29879,APC,29879,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,345,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],33616.03,,"Fee schedule rate ($33,616.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12134.89,33616.03,There are no additional notes associated with this service or procedure.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],36040.46,,"Fee schedule rate ($36,040.46). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,21597.50,67790.93,There are no additional notes associated with this service or procedure.
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],68942.79,,"Fee schedule rate ($68,942.79). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,21489.15,68942.79,There are no additional notes associated with this service or procedure.
Suction Assisted Lipectomy Lower Extremity|BILATERAL PROCEDURE,CASE-15879,APC,15879,CPT,0360,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6526.12,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6215.36,6526.12,OPPS APC
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],9533.13,,"Fee schedule rate ($9,533.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5068.21,14525.56,There are no additional notes associated with this service or procedure.
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],90333.60,,"Fee schedule rate ($90,333.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,26127.34,90333.60,There are no additional notes associated with this service or procedure.
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],17033.98,,"Fee schedule rate ($17,033.98). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.8), with a minimum of zero.",,,,0,other,7884.32,17835.23,There are no additional notes associated with this service or procedure.
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],15177.23,,"Fee schedule rate ($15,177.23). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,7414.07,18217.52,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],33398.16,,"Fee schedule rate ($33,398.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,7353.00,33398.16,There are no additional notes associated with this service or procedure.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,544,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],12338.14,,"Fee schedule rate ($12,338.14). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,7055.15,23207.64,There are no additional notes associated with this service or procedure.
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|LEFT HAND, FIFTH DIGIT",CASE-26160,APC,26160,CPT,0360,RC,,,F4,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1580.37,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1505.12,1580.37,OPPS APC
Pelvic Examination W/Anesthesia Other Than Local,CASE-57410,APC,57410,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3030.03,,"APC Price ($3,030.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3030.03,3181.53,OPPS APC
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],23526.87,,"Case rate ($23,526.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $22,022.15, add-ons for qualifying new technology services are included. If operating cost exceeds $56,893.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,338.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.7. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.7)) / 2. The base transfer operating payment is the transfer adjustment factor * $20,003.44 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $20,077.20 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,578.47. The transfer capital threshold is the transfer adjustment factor * $1,578.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,23526.87,94787.57,Inpatient DRG
RESPIRATORY NEOPLASMS WITH CC,181,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],9197.84,,"Case rate ($9,197.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,692.16, add-ons for qualifying new technology services are included. If operating cost exceeds $43,563.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,290.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,722.42 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,747.21 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $530.47. The transfer capital threshold is the transfer adjustment factor * $530.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9197.84,21074.07,Inpatient DRG
CERVICAL SPINAL FUSION WITHOUT CC/MCC,473,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],62077.11,,"Fee schedule rate ($62,077.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,18477.61,62077.11,There are no additional notes associated with this service or procedure.
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],12566.28,,"Case rate ($12,566.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,825.74, add-ons for qualifying new technology services are included. If operating cost exceeds $46,696.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,536.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $9,844.49 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,880.79 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $776.83. The transfer capital threshold is the transfer adjustment factor * $776.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12566.28,30861.41,Inpatient DRG
SPINAL PROCEDURES WITH MCC,028,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],43510.34,,"Case rate ($41,438.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $38,758.58, add-ons for qualifying new technology services are included. If operating cost exceeds $73,629.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,578.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.5. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 9.5)) / 2. The base transfer operating payment is the transfer adjustment factor * $36,674.58 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $36,813.63 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,818.89. The transfer capital threshold is the transfer adjustment factor * $2,818.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,42633.57,120982.83,Inpatient DRG
SINGLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL,402,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],124455.45,,"Fee schedule rate ($124,455.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,29172.05,124455.45,There are no additional notes associated with this service or procedure.
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],33159.45,,"Fee schedule rate ($33,159.45). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,13092.47,33159.45,There are no additional notes associated with this service or procedure.
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],23078.81,,"Fee schedule rate ($23,078.81). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10311.17,24308.97,There are no additional notes associated with this service or procedure.
HC Gastroesophag Reflx Test W/Tel Ph Eltrd|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-91035,APC,91035,CPT,0750,RC,,,74,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],843.99,,"APC Price ($803.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,843.99,843.99,OPPS APC
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],11681.49,,"Fee schedule rate ($11,681.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5778.62,11681.49,There are no additional notes associated with this service or procedure.
"DIGESTIVE MALIGNANCY,MAJOR",240,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],13537.02,,"The inlier payment is calculated as the lesser of the standard DRG payment $12,892.40 and the transfer payment, which is a per diem of $1,879.36. If cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12892.40,13537.02,Estimated amount calculated based on 4 day length of stay.
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,690,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],7426.94,,"Case rate ($7,426.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,044.73, add-ons for qualifying new technology services are included. If operating cost exceeds $41,915.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,160.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,081.05 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,099.78 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $400.94. The transfer capital threshold is the transfer adjustment factor * $400.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7426.94,15928.53,Inpatient DRG
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],16250.04,,"Case rate ($15,476.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,532.81, add-ons for qualifying new technology services are included. If operating cost exceeds $49,403.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,749.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $12,541.62 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,587.86 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $989.66. The transfer capital threshold is the transfer adjustment factor * $989.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,15476.23,42787.31,Inpatient DRG
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,477,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],25846.53,,"Case rate ($25,339.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $23,708.63, add-ons for qualifying new technology services are included. If operating cost exceeds $58,579.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,471.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 8.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $21,683.73 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $21,763.68 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,711.06. The transfer capital threshold is the transfer adjustment factor * $1,711.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,25339.74,67976.16,Inpatient DRG
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],10626.21,,"Case rate ($10,120.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,550.21, add-ons for qualifying new technology services are included. If operating cost exceeds $44,421.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,357.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $7,577.32 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,605.26 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $597.93. The transfer capital threshold is the transfer adjustment factor * $597.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10120.20,26204.74,Inpatient DRG
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],13982.89,,"Fee schedule rate ($13,982.89). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11247.07,27028.33,There are no additional notes associated with this service or procedure.
Esophagogastroduodenoscopy Transoral Diagnostic,CASE-43235,APC,43235,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],848.96,,"APC Price ($848.96). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,848.96,891.41,OPPS APC
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],94787.57,,"Fee schedule rate ($94,787.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,23526.87,94787.57,There are no additional notes associated with this service or procedure.
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],11065.78,,"Fee schedule rate ($11,065.78). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5883.03,17111.12,There are no additional notes associated with this service or procedure.
HC Inj Tendon Sheath/Ligament|PBB CHARGE,CASE-20550,APC,20550,CPT,0510,RC,,,PBB,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],297.37,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,287.31,301.68,OPPS APC
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],11133.98,,"Fee schedule rate ($11,133.98). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5919.29,13545.65,There are no additional notes associated with this service or procedure.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],9097.60,,"Case rate ($9,097.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,598.92, add-ons for qualifying new technology services are included. If operating cost exceeds $43,469.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,283.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,629.53 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,653.97 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $523.14. The transfer capital threshold is the transfer adjustment factor * $523.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9097.60,21455.22,Inpatient DRG
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,309,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],10863.65,,"Case rate ($6,207.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $5,875.02, add-ons for qualifying new technology services are included. If operating cost exceeds $44,519.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $3,081.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,495.17 + an uncompensated DSH payment of $1,359.91. The transfer operating threshold is the transfer adjustment factor * $4,515.10 + an uncompensated DSH payment of $1,359.91. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $352.72. The transfer capital threshold is the transfer adjustment factor * $352.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,5055.77,14547.21,All Other Inpatient
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,082,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],56223.11,,"Fee schedule rate ($56,223.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,17423.21,56223.11,There are no additional notes associated with this service or procedure.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],48094.52,,,,,,0,other,18497.24,62041.12,There are no additional notes associated with this service or procedure.
"LIMB REATTACHMENT, HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA",956,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],70718.06,,"Fee schedule rate ($70,718.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,27428.25,148259.86,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],59610.47,,"Fee schedule rate ($59,610.47). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,16129.04,59610.47,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],6886.69,,"Case rate ($6,558.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,237.08, add-ons for qualifying new technology services are included. If operating cost exceeds $41,108.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,097.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $4,276.36 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,292.13 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $337.45. The transfer capital threshold is the transfer adjustment factor * $337.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6558.75,14871.83,Inpatient DRG
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],19160.40,,"Fee schedule rate ($19,160.40). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,6965.00,36140.75,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],10862.00,,"Per diem ($10,862). If length of stay < 7.6, first 1 days paid at a per diem of $21,724 instead. Capped at $82,553.89.",,,,0,other,10862.00,86437.13,Estimated amount calculated based on 6 day length of stay.
COMPLICATIONS OF TREATMENT WITH CC,920,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],20731.52,,"Fee schedule rate ($20,731.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8732.59,20731.52,There are no additional notes associated with this service or procedure.
Exc Lesion Spermatic Cord Separate Procedure|UNUSUAL NON-OVERLAPPING SERVICE,CASE-55520,APC,55520,CPT,0360,RC,,,XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3518.91,,"APC Price ($3,351.34). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3351.34,3518.91,OPPS APC
Egd Flexible Foreign Body Removal,CASE-43247,APC,43247,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1796.14,,"APC Price ($1,796.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1796.14,1885.95,OPPS APC
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC,939,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],26517.40,,"Case rate ($26,517.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $24,804.19, add-ons for qualifying new technology services are included. If operating cost exceeds $59,675.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,557.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $22,775.26 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $22,859.24 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,797.19. The transfer capital threshold is the transfer adjustment factor * $1,797.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,26517.40,97674.79,Inpatient DRG
"MODERATELY EXTENSIVE O.R. PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,MODERATE",793,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],14578.64,,"Case rate ($14,578.64). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,14578.64,15307.57,There are no additional notes associated with this service or procedure.
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],90333.60,,"Fee schedule rate ($90,333.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,26127.34,90333.60,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,064,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],39570.45,,,,,,0,other,15563.58,41838.16,There are no additional notes associated with this service or procedure.
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],18245.94,,"Fee schedule rate ($18,245.94). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8106.18,18245.94,There are no additional notes associated with this service or procedure.
Exc Lesion Spermatic Cord Separate Procedure|UNUSUAL NON-OVERLAPPING SERVICE,CASE-55520,APC,55520,CPT,0360,RC,,,XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3468.64,,"APC Price ($3,351.34). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3351.34,3518.91,OPPS APC
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],8115.65,,"Case rate ($7,956.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,537.38, add-ons for qualifying new technology services are included. If operating cost exceeds $42,408.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,199.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,571.89 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,592.43 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $439.68. The transfer capital threshold is the transfer adjustment factor * $439.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6965.00,17467.27,Inpatient DRG
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],2070.00,,,,,,0,other,1188.00,12138.74,Estimated amount calculated based on 1 day length of stay.
SPINAL PROCEDURES WITH MCC,028,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],120982.83,,"Fee schedule rate ($120,982.83). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,42633.57,120982.83,There are no additional notes associated with this service or procedure.
Cysto W/Urtroscopy&/Pyeloscopy Dx,CASE-52351,APC,52351,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3414.95,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3299.47,3464.44,OPPS APC
"Capsulectomy/Capsulotomy Iphal Joint Each|RIGHT HAND, FOURTH DIGIT",CASE-26525,APC,26525,CPT,0360,RC,,,F8,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],80635.65,,"Fee schedule rate ($80,635.65). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,26028.48,80635.65,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,065,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],25681.86,,"Fee schedule rate ($25,681.86). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,8786.76,25681.86,There are no additional notes associated with this service or procedure.
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],6503.90,,"Case rate ($6,503.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,186.05, add-ons for qualifying new technology services are included. If operating cost exceeds $41,057.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,093.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $4,225.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,241.10 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $333.44. The transfer capital threshold is the transfer adjustment factor * $333.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6503.90,14492.93,Inpatient DRG
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 1 Level|LEFT SIDE,CASE-64493,APC,64493,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],869.28,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,827.89,869.28,OPPS APC
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],13000.21,,"Case rate ($12,381.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,672.99, add-ons for qualifying new technology services are included. If operating cost exceeds $46,544.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,504.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,691.30 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,728.04 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $744.90. The transfer capital threshold is the transfer adjustment factor * $744.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12696.97,47123.82,Inpatient DRG
Colonoscopy W/Biopsy Single/Multiple|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-45380,APC,45380,CPT,0360,RC,,,74,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1120.09,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1120.09,1176.09,OPPS APC
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,098,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],38799.38,,"Fee schedule rate ($38,799.38). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,6965.00,45156.75,There are no additional notes associated with this service or procedure.
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral Ea Addl|RIGHT SIDE,CASE-64484,APC,64484,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],869.28,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,827.89,869.28,OPPS APC
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITHOUT CC/MCC",630,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],11828.78,,"Case rate ($11,828.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,139.67, add-ons for qualifying new technology services are included. If operating cost exceeds $46,010.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,482.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $9,160.95 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,194.72 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $722.89. The transfer capital threshold is the transfer adjustment factor * $722.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,11828.78,42541.02,Inpatient DRG
HYPERTENSION WITHOUT MCC,305,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7305.60,,"Case rate ($7,058.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,702.02, add-ons for qualifying new technology services are included. If operating cost exceeds $41,573.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,133.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,739.59 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,757.07 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $374.00. The transfer capital threshold is the transfer adjustment factor * $374.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,7058.55,17230.49,Inpatient DRG
NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,601,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],12359.72,,"Fee schedule rate ($12,359.72). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6042.05,12359.72,There are no additional notes associated with this service or procedure.
"Open Tx Distal Phalangeal Fracture Each|LEFT HAND, FIFTH DIGIT",CASE-26765,APC,26765,CPT,0360,RC,,,F4,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
COMPLICATIONS OF TREATMENT WITH CC,920,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],9038.23,,"Case rate ($8,732.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,259.35, add-ons for qualifying new technology services are included. If operating cost exceeds $43,130.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,256.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,291.21 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,314.40 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $496.44. The transfer capital threshold is the transfer adjustment factor * $496.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,8732.59,20731.52,Inpatient DRG
"VAGINAL DELIVERY WITH O.R. PROCEDURE EXCEPT STERILIZATION AND/OR D&C,MINOR",542,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],4518.49,,"Case rate ($4,303.32). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4303.32,4518.49,There are no additional notes associated with this service or procedure.
COAGULATION DISORDERS,813,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],30013.33,,,,,,0,other,12274.39,30013.33,There are no additional notes associated with this service or procedure.
Removal Implant Deep|LEFT SIDE,CASE-20680,APC,20680,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],2854.83,,"APC Price ($2,718.88). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2718.88,2854.83,OPPS APC
VENTRICULAR SHUNT PROCEDURES WITH MCC,031,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],62406.76,,"Fee schedule rate ($62,406.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,32287.20,88162.80,There are no additional notes associated with this service or procedure.
Esophagogastroduodenoscopy Transoral Diagnostic|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-43235,APC,43235,CPT,0360,RC,,,74,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],878.67,,"APC Price ($848.96). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,848.96,891.41,OPPS APC
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],22292.26,,"Fee schedule rate ($22,292.26). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9977.99,26949.28,There are no additional notes associated with this service or procedure.
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC,805,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],20902.03,,"Fee schedule rate ($20,902.03). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9253.36,21235.42,There are no additional notes associated with this service or procedure.
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],28093.27,,"Case rate ($28,093.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $26,270.18, add-ons for qualifying new technology services are included. If operating cost exceeds $61,141.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,672.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $24,235.87 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $24,325.23 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,912.45. The transfer capital threshold is the transfer adjustment factor * $1,912.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,10078.00,81454.07,Inpatient DRG
Neuroplasty &/Transpos Median Nrv Carpal Tunne|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64721,APC,64721,CPT,0360,RC,,,RT|XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1891.77,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1827.80,1919.19,OPPS APC
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC",011,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],79750.71,,"Fee schedule rate ($79,750.71). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (44), with a minimum of zero.",,,,0,other,38880.49,150008.48,There are no additional notes associated with this service or procedure.
Rpr Xtnsr Tdn Cntrl Slip Tiss W/Lat Band Ea Fngr,CASE-26426,APC,26426,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
Open Biopsy/Excision Inguinofemoral Nodes|RIGHT SIDE,CASE-38531,APC,38531,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6215.36,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6215.36,6526.12,OPPS APC
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],6428.77,,"Case rate ($6,122.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,831.37, add-ons for qualifying new technology services are included. If operating cost exceeds $40,702.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,065.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $3,872.14 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,886.42 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $305.55. The transfer capital threshold is the transfer adjustment factor * $305.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,1188.00,12138.74,Inpatient DRG
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],52803.53,,"Fee schedule rate ($52,803.53). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,14337.84,52803.53,There are no additional notes associated with this service or procedure.
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC",458,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],78415.67,,"Fee schedule rate ($78,415.67). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.8), with a minimum of zero.",,,,0,other,30202.09,132827.25,There are no additional notes associated with this service or procedure.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,544,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],23207.64,,"Fee schedule rate ($23,207.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,7055.15,23207.64,There are no additional notes associated with this service or procedure.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,418,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],13869.60,,"Case rate ($13,400.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,601.88, add-ons for qualifying new technology services are included. If operating cost exceeds $47,472.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,597.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $10,617.79 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,656.93 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $837.85. The transfer capital threshold is the transfer adjustment factor * $837.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,13400.58,39884.93,Inpatient DRG
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],29582.40,,,,,,0,other,12126.09,29582.40,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],30538.70,,,,,,0,other,12455.21,37149.27,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],37149.27,,"Fee schedule rate ($37,149.27). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,12455.21,37149.27,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],52803.53,,"Fee schedule rate ($52,803.53). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,14337.84,52803.53,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],9795.13,,"Case rate ($9,795.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,247.81, add-ons for qualifying new technology services are included. If operating cost exceeds $44,118.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,334.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $7,276.03 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,302.86 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $574.15. The transfer capital threshold is the transfer adjustment factor * $574.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9795.13,23899.13,Inpatient DRG
Arthrodesis Cmbn Tq 1ntrspc Each Additional,CASE-22634,APC,22634,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],25398.09,,"APC Price ($25,398.09). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,25398.09,26668.00,OPPS APC
OTHER DISORDERS OF NERVOUS SYSTEM WITH CC,092,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],9316.42,,"Case rate ($8,872.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,389.76, add-ons for qualifying new technology services are included. If operating cost exceeds $43,260.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,266.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $6,421.14 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,444.81 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $506.69. The transfer capital threshold is the transfer adjustment factor * $506.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8872.78,26765.51,Inpatient DRG
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC",923,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],8208.75,,"Case rate ($8,047.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $7,588.71, add-ons for qualifying new technology services are included. If operating cost exceeds $46,233.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $3,215.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,201.30 + an uncompensated DSH payment of $1,359.91. The transfer operating threshold is the transfer adjustment factor * $6,228.80 + an uncompensated DSH payment of $1,359.91. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $486.59. The transfer capital threshold is the transfer adjustment factor * $486.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6965.00,20068.57,Inpatient DRG
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,082,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],44973.75,,,,,,0,other,17423.21,56223.11,There are no additional notes associated with this service or procedure.
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],15821.59,,"Case rate ($15,821.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,854.10, add-ons for qualifying new technology services are included. If operating cost exceeds $49,725.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,774.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $12,861.73 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,909.15 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,014.92. The transfer capital threshold is the transfer adjustment factor * $1,014.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,15821.59,40320.14,Inpatient DRG
INFLAMMATORY BOWEL DISEASE WITH CC,386,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],8780.45,,"Case rate ($8,362.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,926.87, add-ons for qualifying new technology services are included. If operating cost exceeds $42,797.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,218.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $5,959.32 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,981.92 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $458.05. The transfer capital threshold is the transfer adjustment factor * $458.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8556.53,19879.00,Inpatient DRG
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],54236.60,,"Fee schedule rate ($54,236.60). Adds an outlier to normal pricing equal to the per diem rate ($122,612.56) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,21489.15,68942.79,There are no additional notes associated with this service or procedure.
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC,807,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],12670.24,,"Fee schedule rate ($12,670.24). Adds an outlier to normal pricing equal to the per diem rate ($29,637.88) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,5354.25,13266.23,There are no additional notes associated with this service or procedure.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,073,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],31567.81,,,,,,0,other,12809.38,43475.01,There are no additional notes associated with this service or procedure.
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],7566.45,,"Case rate ($7,566.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,174.51, add-ons for qualifying new technology services are included. If operating cost exceeds $42,045.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,171.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,210.35 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,229.56 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $411.15. The transfer capital threshold is the transfer adjustment factor * $411.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7566.45,16333.88,Inpatient DRG
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],24669.57,,"Fee schedule rate ($24,669.57). Adds an outlier to normal pricing equal to the per diem rate ($34,856.52) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.7), with a minimum of zero.",,,,0,other,10834.64,25830.00,There are no additional notes associated with this service or procedure.
Laps Fulg/Exc Ovary Viscera/Peritoneal Surface|RIGHT SIDE,CASE-58662,APC,58662,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5941.70,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5658.76,5941.70,OPPS APC
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],12418.38,,"Case rate ($11,827.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,156.48, add-ons for qualifying new technology services are included. If operating cost exceeds $46,027.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,465.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $9,176.73 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,211.53 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $705.35. The transfer capital threshold is the transfer adjustment factor * $705.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12126.09,29582.40,Inpatient DRG
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],45157.33,,"Fee schedule rate ($45,157.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,10733.06,45157.33,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],28756.63,,"Fee schedule rate ($28,756.63). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,13148.66,32553.63,There are no additional notes associated with this service or procedure.
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],25863.45,,,,,,0,other,10846.16,25863.45,There are no additional notes associated with this service or procedure.
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,069,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],20333.68,,"Fee schedule rate ($20,333.68). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,20333.68,There are no additional notes associated with this service or procedure.
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],45017.13,,"Fee schedule rate ($45,017.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,14603.31,45017.13,There are no additional notes associated with this service or procedure.
BRONCHITIS AND ASTHMA WITH CC/MCC,202,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],8820.25,,"Case rate ($8,521.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,063.43, add-ons for qualifying new technology services are included. If operating cost exceeds $42,934.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,241.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,096.00 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,118.48 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $481.03. The transfer capital threshold is the transfer adjustment factor * $481.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,7606.34,19110.30,Inpatient DRG
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],12696.97,,"Case rate ($12,696.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,947.32, add-ons for qualifying new technology services are included. If operating cost exceeds $46,818.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,546.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,965.63 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,002.37 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $786.39. The transfer capital threshold is the transfer adjustment factor * $786.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12696.97,47123.82,Inpatient DRG
Lamnotmy Incl W/Dcmprsn Nrv Root 1 Intrspc Lumbr|LEFT SIDE,CASE-63030,APC,63030,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6791.99,7131.59,OPPS APC
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],33221.97,,"Fee schedule rate ($33,221.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (47), with a minimum of zero.",,,,0,other,15283.90,38757.79,There are no additional notes associated with this service or procedure.
"Inj Dx/Ther Agnt Paravert Facet Joint, Lumbar/Sac, Add Level",CASE-64495,APC,64495,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],827.89,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,827.89,869.28,OPPS APC
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],13947.32,,"Fee schedule rate ($13,947.32). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6153.12,13947.32,There are no additional notes associated with this service or procedure.
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],27665.18,,"Fee schedule rate ($27,665.18). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,11914.12,40426.76,There are no additional notes associated with this service or procedure.
Laps Abd Prtm&Omentum Dx W/WO Spec Br/Wa Spx,CASE-49320,APC,49320,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5941.70,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5658.76,5941.70,OPPS APC
Colpocleisis Le Fort Type,CASE-57120,APC,57120,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],4916.53,,"APC Price ($4,682.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,4682.41,4916.53,OPPS APC
"POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT PROCEDURE,MAJOR",561,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],1975.27,,"Case rate for a one day stay ($1,975.27). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,1975.27,2074.03,There are no additional notes associated with this service or procedure.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,056,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],7659.00,,"Per diem ($7,659). If length of stay < 5.7, first 1 days paid at a per diem of $15,318 instead. Capped at $43,658.02.",,,,0,other,7659.00,59328.19,Estimated amount calculated based on 3 day length of stay.
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],13077.97,,"Case rate ($12,455.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,722.41, add-ons for qualifying new technology services are included. If operating cost exceeds $46,593.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,528.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $9,741.55 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,777.47 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $768.70. The transfer capital threshold is the transfer adjustment factor * $768.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12455.21,37149.27,Inpatient DRG
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],53152.12,,"Fee schedule rate ($53,152.12). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,19152.11,53152.12,There are no additional notes associated with this service or procedure.
Optx Patllr Fx W/Int Fixj/Patllc&Soft Tiss Rpr|LEFT SIDE,CASE-27524,APC,27524,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6791.99,7131.59,OPPS APC
Arthrs Wrst Exc&/Rpr Triang Fibrocart&/Joint,CASE-29846,APC,29846,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
Carpectomy All Bones Proximal Row|RIGHT SIDE,CASE-25215,APC,25215,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3062.67,OPPS APC
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,699,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],9047.54,,"Case rate ($8,616.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,163.99, add-ons for qualifying new technology services are included. If operating cost exceeds $43,035.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,236.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $6,195.55 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,219.04 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $476.20. The transfer capital threshold is the transfer adjustment factor * $476.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5961.00,19972.16,Inpatient DRG
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],42586.49,,"Fee schedule rate ($42,586.49). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,13341.67,42586.49,There are no additional notes associated with this service or procedure.
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],17835.23,,,,,,0,other,7884.32,17835.23,There are no additional notes associated with this service or procedure.
HC Inject Tendon Origin/Insert|LEFT SIDE,CASE-20551,APC,20551,CPT,0361,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],297.37,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,287.31,301.68,OPPS APC
"Repair Extensor Tendon Finger W/O Graft Each|LEFT HAND, THIRD DIGIT",CASE-26418,APC,26418,CPT,0360,RC,,,F2,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1580.37,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1505.12,1580.37,OPPS APC
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],13486.95,,"Fee schedule rate ($13,486.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6915.64,14442.92,There are no additional notes associated with this service or procedure.
PSYCHOSES,885,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],19957.30,,"Case rate ($11,404.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,744.67, add-ons for qualifying new technology services are included. If operating cost exceeds $45,615.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,451.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.5. The base transfer operating payment is the transfer adjustment factor * $8,767.39 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,799.72 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $691.83. The transfer capital threshold is the transfer adjustment factor * $691.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,2070.00,27484.83,All Other Inpatient
Laps Abd Prtm&Omentum Dx W/WO Spec Br/Wa Spx,CASE-49320,APC,49320,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5658.76,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5658.76,5941.70,OPPS APC
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],14279.80,,"Case rate ($13,599.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,808.96, add-ons for qualifying new technology services are included. If operating cost exceeds $47,679.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,591.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $10,822.98 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,864.01 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $831.88. The transfer capital threshold is the transfer adjustment factor * $831.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13917.42,34889.29,Inpatient DRG
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],1188.00,,,,,,0,other,1188.00,12138.74,Estimated amount calculated based on 1 day length of stay.
"CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS,MINOR",201,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],5053.79,,"Case rate ($4,813.13). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4813.13,5053.79,There are no additional notes associated with this service or procedure.
DIABETES WITHOUT CC/MCC,639,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],12223.35,,,,,,0,other,6151.76,12223.35,There are no additional notes associated with this service or procedure.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,191,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],16612.88,,"Fee schedule rate ($16,612.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6965.00,16612.88,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,091,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],33004.27,,"Fee schedule rate ($33,004.27). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13838.06,40030.81,There are no additional notes associated with this service or procedure.
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],21715.81,,"Case rate ($20,681.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $19,410.33, add-ons for qualifying new technology services are included. If operating cost exceeds $54,281.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,097.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.3. The base transfer operating payment is the transfer adjustment factor * $17,399.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $17,465.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,337.36. The transfer capital threshold is the transfer adjustment factor * $1,337.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,21248.73,56089.29,Inpatient DRG
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],17097.87,,"Fee schedule rate ($17,097.87). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,8106.18,18245.94,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],34892.92,,"Fee schedule rate ($34,892.92). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,6965.00,41030.48,There are no additional notes associated with this service or procedure.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],20817.01,,"Fee schedule rate ($20,817.01). Adds an outlier to normal pricing equal to the per diem rate ($37,789.38) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,9446.38,21796.21,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],63653.13,,,,,,0,other,23851.92,63653.13,There are no additional notes associated with this service or procedure.
SPINAL PROCEDURES WITH MCC,028,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],112913.98,,"Fee schedule rate ($112,913.98). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,42633.57,120982.83,There are no additional notes associated with this service or procedure.
"Arthrodesis Interphalangeal Jt W/WO Int Fixj|RIGHT HAND, FIFTH DIGIT",CASE-26860,APC,26860,CPT,0360,RC,,,F9,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
Optx Dstl Radl I-Artic Fx/Epiphysl Sep 2 Frag|RIGHT SIDE,CASE-25608,APC,25608,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7029.71,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6791.99,7029.71,OPPS APC
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],45706.73,,"Fee schedule rate ($45,706.73). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,7921.00,45706.73,There are no additional notes associated with this service or procedure.
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],15102.37,,"Case rate ($14,383.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,516, add-ons for qualifying new technology services are included. If operating cost exceeds $48,387.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,669.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,528.54 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,571.05 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $909.72. The transfer capital threshold is the transfer adjustment factor * $909.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,36140.75,Inpatient DRG
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC,833,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],5595.79,,"Case rate ($5,486.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,239.18, add-ons for qualifying new technology services are included. If operating cost exceeds $40,110.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,018.96, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $3,282.12 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,294.23 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $258.99. The transfer capital threshold is the transfer adjustment factor * $258.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,3041.73,10289.10,Inpatient DRG
HC Drain/Inj Joint/Bursa W/US Large,CASE-20611,APC,20611,CPT,0510,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],297.37,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,287.31,301.68,OPPS APC
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],16055.90,,"Fee schedule rate ($16,055.90). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8163.06,18067.42,There are no additional notes associated with this service or procedure.
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],34245.00,,"Fee schedule rate ($34,245.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,12725.42,34245.00,There are no additional notes associated with this service or procedure.
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],8163.06,,"Case rate ($8,163.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,729.53, add-ons for qualifying new technology services are included. If operating cost exceeds $42,600.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,214.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,763.33 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,784.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $454.78. The transfer capital threshold is the transfer adjustment factor * $454.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8163.06,18067.42,Inpatient DRG
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC,520,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],21152.10,,"Fee schedule rate ($21,152.10). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12061.74,39786.42,There are no additional notes associated with this service or procedure.
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,095,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],48575.01,,"Fee schedule rate ($48,575.01). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,19411.47,50750.92,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,082,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],29890.53,,"Fee schedule rate ($29,890.53). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,17423.21,56223.11,There are no additional notes associated with this service or procedure.
Excision Inferior Turbinate Partial/Complete|LEFT SIDE,CASE-30130,APC,30130,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6605.95,,"APC Price ($6,605.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6605.95,6936.25,OPPS APC
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,167,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],14865.60,,"Case rate ($14,157.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,306.21, add-ons for qualifying new technology services are included. If operating cost exceeds $48,177.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,653.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $11,319.53 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,361.26 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $893.22. The transfer capital threshold is the transfer adjustment factor * $893.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,14157.71,43522.37,Inpatient DRG
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],62041.12,,"Fee schedule rate ($62,041.12). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,18497.24,62041.12,There are no additional notes associated with this service or procedure.
HC Inj Aa&/Strd Greater Occipital Nerve|RIGHT SIDE,CASE-64405,APC,64405,CPT,0450,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC,087,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],22679.07,,"Fee schedule rate ($22,679.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,8139.36,22679.07,There are no additional notes associated with this service or procedure.
HC Inj Aa&/Strd Greater Occipital Nerve|RIGHT SIDE,CASE-64405,APC,64405,CPT,0450,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],301.68,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,287.31,301.68,OPPS APC
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],19371.27,,"Fee schedule rate ($19,371.27). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8643.20,19462.52,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],15054.73,,"Case rate ($14,337.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,473.80, add-ons for qualifying new technology services are included. If operating cost exceeds $48,344.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,666.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $11,486.49 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,528.84 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $906.40. The transfer capital threshold is the transfer adjustment factor * $906.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,14337.84,52803.53,Inpatient DRG
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],29594.00,,"Fee schedule rate ($29,594.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,13571.25,33781.47,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITHOUT CC/MCC,517,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],29371.86,,,,,,0,other,10207.96,29371.86,There are no additional notes associated with this service or procedure.
SPINAL PROCEDURES WITH MCC,028,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],120982.83,,"Fee schedule rate ($120,982.83). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,42633.57,120982.83,There are no additional notes associated with this service or procedure.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],37768.77,,"Fee schedule rate ($37,768.77). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7453.00,42138.30,There are no additional notes associated with this service or procedure.
HC Peripheral Block - Femoral Single or Saphenous W/Img Gdn|LEFT SIDE,CASE-64447,APC,64447,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],693.76,,"APC Price ($660.72). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,660.72,693.76,OPPS APC
Cysto W/Ureteroscopy W/Rmvl/Manj Stones|BILATERAL PROCEDURE,CASE-52352,APC,52352,CPT,0360,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3464.44,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3299.47,3464.44,OPPS APC
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],12455.21,,"Case rate ($12,455.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,722.41, add-ons for qualifying new technology services are included. If operating cost exceeds $46,593.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,528.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $9,741.55 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,777.47 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $768.70. The transfer capital threshold is the transfer adjustment factor * $768.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12455.21,37149.27,Inpatient DRG
"Open Tx Phalangeal Shaft Fracture Prox/Middle Ea|LEFT HAND, THIRD DIGIT",CASE-26735,APC,26735,CPT,0360,RC,,,F2,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],26204.74,,"Fee schedule rate ($26,204.74). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10120.20,26204.74,There are no additional notes associated with this service or procedure.
MAJOR CHEST TRAUMA WITHOUT CC/MCC,185,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],14780.69,,"Fee schedule rate ($14,780.69). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.7), with a minimum of zero.",,,,0,other,7271.19,21771.61,There are no additional notes associated with this service or procedure.
Ostc Prtl Exostc/Condylc Metar Head|RIGHT SIDE|SEPARATE STRUCTURE,CASE-28288,APC,28288,CPT,0360,RC,,,RT|XS,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3062.67,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,448,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],79697.35,,"Fee schedule rate ($79,697.35). Adds an outlier to normal pricing equal to the per diem rate ($108,215.07) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,30663.95,94077.13,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],14871.83,,"Fee schedule rate ($14,871.83). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6558.75,14871.83,There are no additional notes associated with this service or procedure.
Laps Surg W/Aspir Cavity/Cyst Single/Multiple,CASE-49322,APC,49322,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5941.70,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5658.76,5941.70,OPPS APC
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],33608.45,,"Fee schedule rate ($33,608.45). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,7332.00,35314.31,There are no additional notes associated with this service or procedure.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],13341.67,,"Case rate ($13,341.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,547.08, add-ons for qualifying new technology services are included. If operating cost exceeds $47,418.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,593.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $10,563.18 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,602.13 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $833.54. The transfer capital threshold is the transfer adjustment factor * $833.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,13341.67,42586.49,Inpatient DRG
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],17223.78,,"Fee schedule rate ($17,223.78). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,8151.55,18033.97,There are no additional notes associated with this service or procedure.
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],12995.84,,"Fee schedule rate ($12,995.84). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10136.44,24444.75,There are no additional notes associated with this service or procedure.
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],14492.93,,"Fee schedule rate ($14,492.93). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6503.90,14492.93,There are no additional notes associated with this service or procedure.
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],16379.98,,"Fee schedule rate ($16,379.98). Adds an outlier to normal pricing equal to the per diem rate ($46,377.87) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7847.50,17755.26,There are no additional notes associated with this service or procedure.
HC Drain/Inj Joint/Bursa W/US Large|BILATERAL PROCEDURE,CASE-20611,APC,20611,CPT,0510,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],301.68,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,287.31,301.68,OPPS APC
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],30372.64,,"Fee schedule rate ($30,372.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,13260.40,32878.30,There are no additional notes associated with this service or procedure.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,057,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],24348.21,,"Fee schedule rate ($24,348.21). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.9), with a minimum of zero.",,,,0,other,10718.84,39884.93,There are no additional notes associated with this service or procedure.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC,027,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],47412.86,,"Fee schedule rate ($47,412.86). Adds an outlier to normal pricing equal to the per diem rate ($103,062) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,19030.20,56363.30,There are no additional notes associated with this service or procedure.
"CESAREAN SECTION WITHOUT STERILIZATION,MODERATE",540,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],8229.96,,"Case rate ($7,838.06). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7838.06,8229.96,There are no additional notes associated with this service or procedure.
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC",011,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],40241.31,,"Case rate ($38,880.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $36,305.31, add-ons for qualifying new technology services are included. If operating cost exceeds $71,176.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,461.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 11.4. The base transfer operating payment is the transfer adjustment factor * $34,234.14 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $34,360.36 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,701.41. The transfer capital threshold is the transfer adjustment factor * $2,701.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,38880.49,150008.48,Inpatient DRG
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],10826.73,,"Case rate ($10,311.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,727.87, add-ons for qualifying new technology services are included. If operating cost exceeds $44,598.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,371.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $7,754.32 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,782.91 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $611.89. The transfer capital threshold is the transfer adjustment factor * $611.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10311.17,24308.97,Inpatient DRG
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],133270.57,,"Fee schedule rate ($133,270.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,33623.33,133270.57,There are no additional notes associated with this service or procedure.
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC,964,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12619.91,,"Case rate ($12,018.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,335.39, add-ons for qualifying new technology services are included. If operating cost exceeds $46,206.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,479.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $9,354.97 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,390.44 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $719.04. The transfer capital threshold is the transfer adjustment factor * $719.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12323.82,34154.06,Inpatient DRG
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,074,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],9104.11,,"Case rate ($8,925.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,438.90, add-ons for qualifying new technology services are included. If operating cost exceeds $43,309.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,270.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,470.10 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,493.95 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $510.55. The transfer capital threshold is the transfer adjustment factor * $510.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,8925.60,20919.08,Inpatient DRG
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],11980.64,,"Case rate ($11,575.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,904.06, add-ons for qualifying new technology services are included. If operating cost exceeds $45,775.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,464.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $8,926.20 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,959.11 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $704.37. The transfer capital threshold is the transfer adjustment factor * $704.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,11575.50,48961.48,Inpatient DRG
Osteot W/WO Lngth Shrt/Corrj Metar Xcp 1st Ea|RIGHT SIDE,CASE-28308,APC,28308,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
Surgical Arthroscopy Shoulder Dstl Claviculc|RIGHT SIDE,CASE-29824,APC,29824,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],25026.36,,"Fee schedule rate ($25,026.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9356.31,25026.36,There are no additional notes associated with this service or procedure.
SPINAL PROCEDURES WITH MCC,028,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],120982.83,,"Fee schedule rate ($120,982.83). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,42633.57,120982.83,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],28821.04,,"Fee schedule rate ($28,821.04). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,10347.06,28821.04,There are no additional notes associated with this service or procedure.
"CHOLECYSTECTOMY,MODERATE",263,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],15125.74,,"Case rate ($15,125.74). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,15125.74,15882.03,There are no additional notes associated with this service or procedure.
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],23078.81,,"Fee schedule rate ($23,078.81). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10311.17,24308.97,There are no additional notes associated with this service or procedure.
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",004,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],260309.36,,"Fee schedule rate ($260,309.36). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (35), with a minimum of zero.",,,,0,other,10249.47,272554.00,There are no additional notes associated with this service or procedure.
"PERIPHERAL AND OTHER VASCULAR DISORDERS,MAJOR",197,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],10944.13,,"Case rate ($10,944.13). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,10944.13,11491.34,There are no additional notes associated with this service or procedure.
Laparoscopy Urethral Suspension Stress Incont,CASE-51990,APC,51990,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],9949.78,,"APC Price ($9,949.78). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,9949.78,10447.27,OPPS APC
INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC,198,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],7134.88,,"Case rate ($6,795.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,456.95, add-ons for qualifying new technology services are included. If operating cost exceeds $41,327.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,114.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,495.42 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,512.00 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $354.73. The transfer capital threshold is the transfer adjustment factor * $354.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6795.12,23505.07,Inpatient DRG
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC",061,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],62315.82,,"Fee schedule rate ($62,315.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,20616.23,62315.82,There are no additional notes associated with this service or procedure.
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC",758,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],8746.30,,"Case rate ($8,574.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,112.57, add-ons for qualifying new technology services are included. If operating cost exceeds $42,983.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,244.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $6,144.96 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,167.62 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $484.90. The transfer capital threshold is the transfer adjustment factor * $484.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,8574.80,19263.78,Inpatient DRG
POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES,769,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],15838.14,,"Fee schedule rate ($15,838.14). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,13388.39,33250.19,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC,833,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],5721.39,,"Fee schedule rate ($5,721.39). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,3041.73,10289.10,There are no additional notes associated with this service or procedure.
Brnchsc Brushing/Protected Brushings,CASE-31623,APC,31623,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6936.25,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6837.16,6936.25,OPPS APC
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],20090.22,,,,,,0,other,8859.23,20090.22,There are no additional notes associated with this service or procedure.
VENTRICULAR SHUNT PROCEDURES WITH CC,032,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],40047.88,,"Fee schedule rate ($40,047.88). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,16376.22,46275.08,There are no additional notes associated with this service or procedure.
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],16235.87,,"Fee schedule rate ($16,235.87). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6524.00,17760.46,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],37665.71,,,,,,0,other,14908.05,49717.39,There are no additional notes associated with this service or procedure.
PSYCHOSES,885,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],2070.00,,,,,,0,other,2070.00,27484.83,Estimated amount calculated based on 3 day length of stay.
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,307,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],18228.77,,,,,,0,other,6335.27,18228.77,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITHOUT CC/MCC,428,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],118904.57,,"Fee schedule rate ($118,904.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,40017.53,118904.57,There are no additional notes associated with this service or procedure.
MAJOR CHEST TRAUMA WITHOUT CC/MCC,185,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],14780.69,,"Fee schedule rate ($14,780.69). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.7), with a minimum of zero.",,,,0,other,7271.19,21771.61,There are no additional notes associated with this service or procedure.
Laparoscopy Surg Rpr Initial Inguinal Hernia|BILATERAL PROCEDURE,CASE-49650,APC,49650,CPT,0360,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5941.70,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5658.76,5941.70,OPPS APC
"Hallux Rigidus W/Cheilectomy 1st Mp Jt W/O Implt|RIGHT FOOT, GREAT TOE",CASE-28289,APC,28289,CPT,0360,RC,,,T5,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
OTHER CEREBROVASCULAR DISORDERS WITH CC,071,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],8893.10,,"Case rate ($8,893.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,408.66, add-ons for qualifying new technology services are included. If operating cost exceeds $43,279.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,268.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,439.97 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,463.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $508.18. The transfer capital threshold is the transfer adjustment factor * $508.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,5843.00,29215.10,Inpatient DRG
Colorectal Scrn; Hi Risk Ind,CASE-G0105,APC,G0105,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],870.46,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,870.46,913.99,OPPS APC
Optx Dstl Radl X-Artic Fx/Epiphysl Sep|RIGHT SIDE,CASE-25607,APC,25607,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
Egd Band Ligation Esophgeal/Gastric Varices,CASE-43244,APC,43244,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1885.95,,"APC Price ($1,796.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1796.14,1885.95,OPPS APC
Int Hrhc by Ligation Single Hroid W/O Img Gdn,CASE-46945,APC,46945,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],2727.99,,"APC Price ($2,598.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2598.08,2727.99,OPPS APC
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],18965.97,,"Case rate ($18,594.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,433.29, add-ons for qualifying new technology services are included. If operating cost exceeds $52,304.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,977.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $15,431.44 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,488.34 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,217.69. The transfer capital threshold is the transfer adjustment factor * $1,217.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,18594.09,59494.91,Inpatient DRG
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITH MCC,429,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],169317.41,,"Fee schedule rate ($169,317.41). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,62958.58,177294.98,There are no additional notes associated with this service or procedure.
"Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx|SEPARATE STRUCTURE|LEFT FOOT, SECOND DIGIT",CASE-28270,APC,28270,CPT,0360,RC,,,XS|T1,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7029.71,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,7029.71,7029.71,OPPS APC
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],41580.51,,"Fee schedule rate ($41,580.51). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,13783.20,41580.51,There are no additional notes associated with this service or procedure.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],36094.03,,"Fee schedule rate ($36,094.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11194.25,36094.03,There are no additional notes associated with this service or procedure.
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],18588.16,,"Fee schedule rate ($18,588.16). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.8), with a minimum of zero.",,,,0,other,8643.20,19462.52,There are no additional notes associated with this service or procedure.
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],10852.08,,"Case rate ($6,201.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,904.45, add-ons for qualifying new technology services are included. If operating cost exceeds $40,775.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,071.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,944.95 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,959.50 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $311.30. The transfer capital threshold is the transfer adjustment factor * $311.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,5937.41,12366.99,All Other Inpatient
"CARDIAC ARREST, UNEXPLAINED WITH MCC",296,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],29352.79,,"Fee schedule rate ($29,352.79). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.2), with a minimum of zero.",,,,0,other,12522.25,36459.67,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],30372.64,,"Fee schedule rate ($30,372.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,13260.40,32878.30,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],24546.05,,"Case rate ($23,377.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $21,882.92, add-ons for qualifying new technology services are included. If operating cost exceeds $56,753.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,327.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $19,864.72 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $19,937.97 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,567.52. The transfer capital threshold is the transfer adjustment factor * $1,567.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,23377.19,96365.69,Inpatient DRG
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7614.73,,"Case rate ($7,252.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,891.99, add-ons for qualifying new technology services are included. If operating cost exceeds $41,763.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,138.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,928.36 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,947.04 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $378.81. The transfer capital threshold is the transfer adjustment factor * $378.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6148.93,15887.21,Inpatient DRG
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",062,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],44304.80,,"Fee schedule rate ($44,304.80). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,13844.84,44304.80,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],2070.00,,,,,,0,other,1188.00,17370.86,Estimated amount calculated based on 3 day length of stay.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],19204.75,,,,,,0,other,8554.50,19204.75,There are no additional notes associated with this service or procedure.
DIABETES WITH CC,638,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],16842.29,,"Fee schedule rate ($16,842.29). Adds an outlier to normal pricing equal to the per diem rate ($39,561.63) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,8014.07,17634.53,There are no additional notes associated with this service or procedure.
MAJOR CHEST TRAUMA WITHOUT CC/MCC,185,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],7271.19,,"Case rate ($7,271.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,899.84, add-ons for qualifying new technology services are included. If operating cost exceeds $41,770.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,149.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,936.68 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,954.88 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $389.55. The transfer capital threshold is the transfer adjustment factor * $389.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7271.19,21771.61,Inpatient DRG
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],13634.03,,"Case rate ($12,984.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,215.07, add-ons for qualifying new technology services are included. If operating cost exceeds $47,086.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,567.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $10,232.39 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,270.12 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $807.44. The transfer capital threshold is the transfer adjustment factor * $807.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12984.79,32077.45,Inpatient DRG
"ALCOHOL ABUSE AND DEPENDENCE,EXTREME",775,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],24471.34,,"Case rate ($24,471.34). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,24471.34,25694.91,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],24053.40,,"Fee schedule rate ($24,053.40). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9888.00,43399.23,There are no additional notes associated with this service or procedure.
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITHOUT MCC,430,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],113479.23,,,,,,0,other,41000.16,133156.90,There are no additional notes associated with this service or procedure.
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],33890.73,,"Fee schedule rate ($33,890.73). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6277.00,36801.89,There are no additional notes associated with this service or procedure.
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC",758,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],18398.35,,"Fee schedule rate ($18,398.35). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8574.80,19263.78,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],26966.33,,"Fee schedule rate ($26,966.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,9040.72,26966.33,There are no additional notes associated with this service or procedure.
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],20297.68,,"Fee schedule rate ($20,297.68). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6965.00,21404.64,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],21195.68,,"Fee schedule rate ($21,195.68). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,6965.00,21195.68,There are no additional notes associated with this service or procedure.
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],8535.98,,"Fee schedule rate ($8,535.98). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8163.06,18067.42,There are no additional notes associated with this service or procedure.
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],15145.28,,"Fee schedule rate ($15,145.28). Adds an outlier to normal pricing equal to the per diem rate ($54,966.40) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7402.56,16438.59,There are no additional notes associated with this service or procedure.
Corrj Hallux Valgus W/Sesmdc W/Dist Metar Osteot|RIGHT SIDE,CASE-28296,APC,28296,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
Realignment Extensor Tendon Hand Each Tendon|RIGHT SIDE,CASE-26437,APC,26437,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3215.80,3215.80,OPPS APC
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],8409.81,,"Case rate ($8,009.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,586.52, add-ons for qualifying new technology services are included. If operating cost exceeds $42,457.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,203.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $5,620.85 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,641.57 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $443.54. The transfer capital threshold is the transfer adjustment factor * $443.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8009.34,19877.10,Inpatient DRG
CESAREAN SECTION WITHOUT STERILIZATION WITH CC,787,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],9983.41,,"Case rate ($9,508.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,980.70, add-ons for qualifying new technology services are included. If operating cost exceeds $43,851.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,313.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $7,009.90 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,035.74 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $553.15. The transfer capital threshold is the transfer adjustment factor * $553.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9508.01,23722.94,Inpatient DRG
HC Pbb Carpal Tunnel Inj Pmc|PBB CHARGE,CASE-20526,APC,20526,CPT,0510,RC,,,PBB,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
Laparoscopy Surg Rpr Initial Inguinal Hernia|RIGHT SIDE,CASE-49650,APC,49650,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5941.70,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5658.76,5941.70,OPPS APC
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,056,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],17677.14,,"Case rate ($17,677.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,580.28, add-ons for qualifying new technology services are included. If operating cost exceeds $51,451.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,910.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $14,581.57 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,635.33 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,150.63. The transfer capital threshold is the transfer adjustment factor * $1,150.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7659.00,59328.19,Inpatient DRG
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],23954.07,,"Fee schedule rate ($23,954.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,6167.00,29058.99,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],24838.71,,"Fee schedule rate ($24,838.71). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,10895.60,35192.25,There are no additional notes associated with this service or procedure.
"NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY",789,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],14149.57,,"Case rate ($14,149.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,298.65, add-ons for qualifying new technology services are included. If operating cost exceeds $48,169.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,652.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $11,312.00 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,353.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $892.63. The transfer capital threshold is the transfer adjustment factor * $892.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,3054.00,14857.05,Inpatient DRG
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],21013.21,,"Case rate ($20,012.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $18,786.59, add-ons for qualifying new technology services are included. If operating cost exceeds $53,657.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,049.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $16,778.03 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $16,841.64 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,289.60. The transfer capital threshold is the transfer adjustment factor * $1,289.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,20559.34,54086.17,Inpatient DRG
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],67107.92,,"Fee schedule rate ($67,107.92). Adds an outlier to normal pricing equal to the per diem rate ($118,521.29) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16.7), with a minimum of zero.",,,,0,other,26127.34,90333.60,There are no additional notes associated with this service or procedure.
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC",641,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7467.50,,"Case rate ($7,214.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,847.54, add-ons for qualifying new technology services are included. If operating cost exceeds $41,718.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,145.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $4,884.58 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,902.59 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $385.44. The transfer capital threshold is the transfer adjustment factor * $385.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,7214.98,15312.64,Inpatient DRG
"Open Tx Phalangeal Shaft Fracture Prox/Middle Ea|LEFT HAND, FIFTH DIGIT",CASE-26735,APC,26735,CPT,0360,RC,,,F4,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
NEONATE WITH OTHER SIGNIFICANT PROBLEMS,794,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],3383.58,,"Fee schedule rate ($3,383.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,1798.85,12536.83,There are no additional notes associated with this service or procedure.
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],15994.77,,"Case rate ($15,233.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,306.64, add-ons for qualifying new technology services are included. If operating cost exceeds $49,177.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,731.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $12,316.28 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,361.69 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $971.88. The transfer capital threshold is the transfer adjustment factor * $971.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,15233.11,38610.21,Inpatient DRG
Laryngoscopy Exc Tum&/Stripping Cords/Epiglott,CASE-31540,APC,31540,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3611.96,,"APC Price ($3,489.82). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3489.82,3664.31,OPPS APC
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],59081.91,,"Fee schedule rate ($59,081.91). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,8480.00,59081.91,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],30398.48,,"Case rate ($30,398.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $28,414.67, add-ons for qualifying new technology services are included. If operating cost exceeds $63,285.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,841.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.2. The base transfer operating payment is the transfer adjustment factor * $26,372.48 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $26,469.72 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,081.05. The transfer capital threshold is the transfer adjustment factor * $2,081.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,30398.48,82674.88,Inpatient DRG
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC",061,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],62315.82,,"Fee schedule rate ($62,315.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,20616.23,62315.82,There are no additional notes associated with this service or procedure.
NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,601,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6042.05,,"Case rate ($6,042.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,756.39, add-ons for qualifying new technology services are included. If operating cost exceeds $40,627.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,059.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $3,797.45 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,811.45 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $299.66. The transfer capital threshold is the transfer adjustment factor * $299.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6042.05,12359.72,Inpatient DRG
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITHOUT CC/MCC,816,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],6536.15,,"Case rate ($6,224.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,926.50, add-ons for qualifying new technology services are included. If operating cost exceeds $40,797.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,073.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $3,966.92 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,981.55 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $313.03. The transfer capital threshold is the transfer adjustment factor * $313.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6224.90,14733.53,Inpatient DRG
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],13806.09,,"Case rate ($13,148.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,367.53, add-ons for qualifying new technology services are included. If operating cost exceeds $47,238.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,579.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $10,384.29 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,422.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $819.42. The transfer capital threshold is the transfer adjustment factor * $819.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13148.66,32553.63,Inpatient DRG
PSYCHOSES,885,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],2070.00,,,,,,0,other,2070.00,27484.83,Estimated amount calculated based on 3 day length of stay.
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],33159.45,,"Fee schedule rate ($33,159.45). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,13092.47,33159.45,There are no additional notes associated with this service or procedure.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],45706.73,,"Fee schedule rate ($45,706.73). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,7921.00,45706.73,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITHOUT STERILIZATION WITH CC,787,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],20988.02,,"Fee schedule rate ($20,988.02). Adds an outlier to normal pricing equal to the per diem rate ($39,437.39) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,9508.01,23722.94,There are no additional notes associated with this service or procedure.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],85466.62,,"Fee schedule rate ($85,466.62). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,21382.16,85466.62,There are no additional notes associated with this service or procedure.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,098,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],6965.00,,,,,,0,other,6965.00,45156.75,There are no additional notes associated with this service or procedure.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITHOUT CC/MCC,816,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],6965.00,,,,,,0,other,6224.90,14733.53,There are no additional notes associated with this service or procedure.
O.R. PROCEDURES FOR OBESITY WITH CC,620,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],13421.42,,"Case rate ($12,782.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,026.70, add-ons for qualifying new technology services are included. If operating cost exceeds $46,897.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,552.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $10,044.72 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,081.75 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $792.63. The transfer capital threshold is the transfer adjustment factor * $792.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12782.30,43753.50,Inpatient DRG
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC",494,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],16309.76,,"Case rate ($15,533.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,585.72, add-ons for qualifying new technology services are included. If operating cost exceeds $49,456.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,753.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $12,594.34 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,640.78 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $993.82. The transfer capital threshold is the transfer adjustment factor * $993.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,15533.10,39945.55,Inpatient DRG
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,064,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],15563.58,,"Case rate ($15,563.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,614.08, add-ons for qualifying new technology services are included. If operating cost exceeds $49,485.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,756.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $12,622.59 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,669.13 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $996.05. The transfer capital threshold is the transfer adjustment factor * $996.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,15563.58,41838.16,Inpatient DRG
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,025,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],57287.16,,"Case rate ($32,735.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $30,588.77, add-ons for qualifying new technology services are included. If operating cost exceeds $65,459.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,011.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.4. The base transfer operating payment is the transfer adjustment factor * $28,538.59 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $28,643.82 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,251.98. The transfer capital threshold is the transfer adjustment factor * $2,251.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 175%.",,,,0,other,13351.00,91631.33,All Other Inpatient
Cysto W/Rescj/Fulg Orthopic Ureterocele Uni/Bi,CASE-52300,APC,52300,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3299.47,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3299.47,3464.44,OPPS APC
INFLAMMATORY BOWEL DISEASE WITH CC,386,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],19879.00,,"Fee schedule rate ($19,879.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8556.53,19879.00,There are no additional notes associated with this service or procedure.
OTHER CEREBROVASCULAR DISORDERS WITH CC,071,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],29215.10,,"Fee schedule rate ($29,215.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5843.00,29215.10,There are no additional notes associated with this service or procedure.
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],23385.72,,"Fee schedule rate ($23,385.72). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,23385.72,There are no additional notes associated with this service or procedure.
"POISONING OF MEDICINAL AGENTS,MODERATE",812,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],5905.13,,"Case rate ($5,905.13). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,5905.13,6200.39,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],73546.72,,,,,,0,other,27256.92,81353.66,There are no additional notes associated with this service or procedure.
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],15994.77,,"Case rate ($15,453.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,512.02, add-ons for qualifying new technology services are included. If operating cost exceeds $49,383.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,747.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $12,520.90 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,567.07 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $988.02. The transfer capital threshold is the transfer adjustment factor * $988.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,15453.88,39251.68,Inpatient DRG
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],7585.67,,"Case rate ($7,224.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,856.36, add-ons for qualifying new technology services are included. If operating cost exceeds $41,727.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,146.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $4,893.37 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,911.41 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $386.14. The transfer capital threshold is the transfer adjustment factor * $386.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,15340.19,Inpatient DRG
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC,939,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],97674.79,,"Fee schedule rate ($97,674.79). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,26517.40,97674.79,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,447,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],156646.82,,"Fee schedule rate ($156,646.82). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,47193.21,156646.82,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],81353.66,,"Fee schedule rate ($81,353.66). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,27256.92,81353.66,There are no additional notes associated with this service or procedure.
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],16400.70,,"Fee schedule rate ($16,400.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,16400.70,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],14337.84,,"Case rate ($14,337.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,473.80, add-ons for qualifying new technology services are included. If operating cost exceeds $48,344.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,666.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $11,486.49 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,528.84 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $906.40. The transfer capital threshold is the transfer adjustment factor * $906.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,14337.84,52803.53,Inpatient DRG
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITHOUT CC/MCC,428,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],118904.57,,"Fee schedule rate ($118,904.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,40017.53,118904.57,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,093,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7538.11,,"Case rate ($7,179.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,823.98, add-ons for qualifying new technology services are included. If operating cost exceeds $41,694.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,133.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,860.60 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,879.03 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $373.60. The transfer capital threshold is the transfer adjustment factor * $373.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,19011.32,Inpatient DRG
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],6801.88,,"Case rate ($6,801.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,463.25, add-ons for qualifying new technology services are included. If operating cost exceeds $41,334.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,115.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,501.70 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,518.30 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $355.23. The transfer capital threshold is the transfer adjustment factor * $355.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6801.88,22557.82,Inpatient DRG
Osteot W/WO Lngth Shrt/Corrj Metar Xcp 1st Ea|RIGHT SIDE,CASE-28308,APC,28308,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],16048.10,,"Case rate ($15,283.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,353.89, add-ons for qualifying new technology services are included. If operating cost exceeds $49,224.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,735.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.2. The base transfer operating payment is the transfer adjustment factor * $12,363.36 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,408.94 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $975.59. The transfer capital threshold is the transfer adjustment factor * $975.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,15283.90,38757.79,Inpatient DRG
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,073,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],30149.61,,"Fee schedule rate ($30,149.61). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12809.38,43475.01,There are no additional notes associated with this service or procedure.
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC",629,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],40946.19,,"Fee schedule rate ($40,946.19). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,16699.94,44657.18,There are no additional notes associated with this service or procedure.
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],21512.35,,"Fee schedule rate ($21,512.35). Adds an outlier to normal pricing equal to the per diem rate ($37,521.53) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,9696.93,35061.53,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],15253.64,,"Case rate ($14,527.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,673.50, add-ons for qualifying new technology services are included. If operating cost exceeds $48,544.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,658.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $11,684.25 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,728.55 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $898.08. The transfer capital threshold is the transfer adjustment factor * $898.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,14908.05,49717.39,Inpatient DRG
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],11011.30,,"Case rate ($10,638.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,032.78, add-ons for qualifying new technology services are included. If operating cost exceeds $44,903.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,395.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,058.12 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,087.83 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $635.87. The transfer capital threshold is the transfer adjustment factor * $635.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,10638.94,25261.33,Inpatient DRG
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],26725.53,,"Fee schedule rate ($26,725.53). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.6), with a minimum of zero.",,,,0,other,11575.50,48961.48,There are no additional notes associated with this service or procedure.
Dstr Nrolytc Agnt Parverteb Fct Sngl Crvcl/Thora,CASE-64633,APC,64633,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1891.77,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1827.80,1919.19,OPPS APC
SPINAL PROCEDURES WITH MCC,028,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],42633.57,,"Case rate ($42,633.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $39,796.72, add-ons for qualifying new technology services are included. If operating cost exceeds $74,667.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,735.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.5. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 9.5)) / 2. The base transfer operating payment is the transfer adjustment factor * $37,712.72 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $37,851.77 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,975.91. The transfer capital threshold is the transfer adjustment factor * $2,975.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,42633.57,120982.83,Inpatient DRG
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],81306.30,,"Fee schedule rate ($81,306.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,20846.48,81306.30,There are no additional notes associated with this service or procedure.
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],6965.00,,,,,,0,other,6965.00,21404.64,There are no additional notes associated with this service or procedure.
VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC,033,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],13866.54,,"Case rate ($13,206.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,421.07, add-ons for qualifying new technology services are included. If operating cost exceeds $47,292.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,583.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $10,437.64 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,476.13 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $823.63. The transfer capital threshold is the transfer adjustment factor * $823.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13206.23,42156.44,Inpatient DRG
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],38517.10,,"Fee schedule rate ($38,517.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,16897.01,43444.85,There are no additional notes associated with this service or procedure.
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],14625.55,,"Fee schedule rate ($14,625.55). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7438.45,15961.98,There are no additional notes associated with this service or procedure.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],9624.30,,"Fee schedule rate ($9,624.30). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5683.00,19635.68,There are no additional notes associated with this service or procedure.
NERVOUS SYSTEM NEOPLASMS WITH MCC,054,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],25589.03,,"Fee schedule rate ($25,589.03). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,6965.00,30044.81,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],16066.07,,"Case rate ($16,066.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,081.53, add-ons for qualifying new technology services are included. If operating cost exceeds $49,952.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,792.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $13,088.32 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,136.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,032.80. The transfer capital threshold is the transfer adjustment factor * $1,032.80. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,41030.48,Inpatient DRG
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],15076.44,,"Fee schedule rate ($15,076.44). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6340.03,15076.44,There are no additional notes associated with this service or procedure.
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],45157.33,,"Fee schedule rate ($45,157.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,10733.06,45157.33,There are no additional notes associated with this service or procedure.
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],7783.37,,"Case rate ($7,412.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,031.50, add-ons for qualifying new technology services are included. If operating cost exceeds $41,902.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,159.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $5,067.86 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,086.55 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $399.90. The transfer capital threshold is the transfer adjustment factor * $399.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6148.93,15887.21,Inpatient DRG
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],52794.06,,"Fee schedule rate ($52,794.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (37), with a minimum of zero.",,,,0,other,13907.80,52794.06,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,167,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],43522.37,,"Fee schedule rate ($43,522.37). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,14157.71,43522.37,There are no additional notes associated with this service or procedure.
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7229.61,,"Case rate ($6,885.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,550.10, add-ons for qualifying new technology services are included. If operating cost exceeds $41,421.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,112.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $4,587.76 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,605.15 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $352.63. The transfer capital threshold is the transfer adjustment factor * $352.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,21089.59,Inpatient DRG
Brnchsc Brushing/Protected Brushings,CASE-31623,APC,31623,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6837.16,,"APC Price ($6,605.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6837.16,6936.25,OPPS APC
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],14699.43,,"Fee schedule rate ($14,699.43). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6683.37,14699.43,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],128358.13,,"Fee schedule rate ($128,358.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,40542.37,128358.13,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],40542.37,,"Case rate ($40,542.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $37,851.31, add-ons for qualifying new technology services are included. If operating cost exceeds $72,722.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,582.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.6. The base transfer operating payment is the transfer adjustment factor * $35,774.45 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $35,906.36 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,822.96. The transfer capital threshold is the transfer adjustment factor * $2,822.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,40542.37,128358.13,Inpatient DRG
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],47123.82,,"Fee schedule rate ($47,123.82). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,12696.97,47123.82,There are no additional notes associated with this service or procedure.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC,862,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],14581.08,,"Case rate ($14,295.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,434.11, add-ons for qualifying new technology services are included. If operating cost exceeds $48,305.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,663.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $11,446.95 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,489.15 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $903.28. The transfer capital threshold is the transfer adjustment factor * $903.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6855.00,35884.94,Inpatient DRG
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],20075.57,,"Case rate ($19,119.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,922.16, add-ons for qualifying new technology services are included. If operating cost exceeds $52,793.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,016.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $15,918.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,977.21 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,256.13. The transfer capital threshold is the transfer adjustment factor * $1,256.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,11348.00,62454.12,Inpatient DRG
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],25253.70,,"Fee schedule rate ($25,253.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11974.38,29141.64,There are no additional notes associated with this service or procedure.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],29917.96,,"Fee schedule rate ($29,917.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,12527.66,29917.96,There are no additional notes associated with this service or procedure.
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],35061.53,,"Fee schedule rate ($35,061.53). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,9696.93,35061.53,There are no additional notes associated with this service or procedure.
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,069,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],20333.68,,"Fee schedule rate ($20,333.68). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,20333.68,There are no additional notes associated with this service or procedure.
Cysto Bladder W/Ureteral Catheterization|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-52005,APC,52005,CPT,0360,RC,,,LT|XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3464.44,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3299.47,3464.44,OPPS APC
Arthrs Knee W/Meniscectomy Med&Lat W/Shaving|LEFT SIDE,CASE-29880,APC,29880,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],12696.97,,"Case rate ($12,696.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,947.32, add-ons for qualifying new technology services are included. If operating cost exceeds $46,818.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,546.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,965.63 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,002.37 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $786.39. The transfer capital threshold is the transfer adjustment factor * $786.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12696.97,47123.82,Inpatient DRG
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],43888.01,,"Fee schedule rate ($43,888.01). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11717.72,43888.01,There are no additional notes associated with this service or procedure.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],19877.10,,"Fee schedule rate ($19,877.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8009.34,19877.10,There are no additional notes associated with this service or procedure.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,479,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],50518.76,,"Fee schedule rate ($50,518.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,10586.00,50518.76,There are no additional notes associated with this service or procedure.
NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,601,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],11369.77,,"Fee schedule rate ($11,369.77). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,6042.05,12359.72,There are no additional notes associated with this service or procedure.
Cystourethroscopy|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-52000,APC,52000,CPT,0360,RC,,,74,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],685.32,,"APC Price ($652.69). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,652.69,685.32,OPPS APC
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],14107.24,,"Case rate ($13,435.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,655.78, add-ons for qualifying new technology services are included. If operating cost exceeds $47,526.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,580.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $10,670.38 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,710.83 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $820.15. The transfer capital threshold is the transfer adjustment factor * $820.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13783.20,41580.51,Inpatient DRG
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],41580.51,,"Fee schedule rate ($41,580.51). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,13783.20,41580.51,There are no additional notes associated with this service or procedure.
"NEONATE BIRTH WEIGHT 2000-2499 GRAMS WITH OTHER SIGNIFICANT CONDITION,MODERATE",625,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],14740.04,,"Case rate ($14,038.13). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,14038.13,14740.04,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],9824.13,,"Case rate ($9,356.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,839.58, add-ons for qualifying new technology services are included. If operating cost exceeds $43,710.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,302.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $6,869.30 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,894.63 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $542.06. The transfer capital threshold is the transfer adjustment factor * $542.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9356.31,25026.36,Inpatient DRG
INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC,198,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6985.28,,"Case rate ($6,652.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,333.20, add-ons for qualifying new technology services are included. If operating cost exceeds $41,204.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,095.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,371.67 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,388.25 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $336.02. The transfer capital threshold is the transfer adjustment factor * $336.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6795.12,23505.07,Inpatient DRG
CESAREAN SECTION WITH STERILIZATION WITHOUT CC/MCC,785,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],8852.80,,"Case rate ($8,431.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,979, add-ons for qualifying new technology services are included. If operating cost exceeds $42,850.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,234.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,011.89 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,034.06 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $474.40. The transfer capital threshold is the transfer adjustment factor * $474.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8431.24,20142.33,Inpatient DRG
HEADACHES WITHOUT MCC,103,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],20883.08,,"Fee schedule rate ($20,883.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,20883.08,There are no additional notes associated with this service or procedure.
PERIPHERAL VASCULAR DISORDERS WITH CC,300,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],10809.22,,"Fee schedule rate ($10,809.22). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,9174.14,21005.20,There are no additional notes associated with this service or procedure.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],12268.97,,"Case rate ($12,268.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,549.17, add-ons for qualifying new technology services are included. If operating cost exceeds $46,420.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,515.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,568.94 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,604.22 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $755.08. The transfer capital threshold is the transfer adjustment factor * $755.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12268.97,41006.47,Inpatient DRG
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC,805,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],20902.03,,"Fee schedule rate ($20,902.03). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9253.36,21235.42,There are no additional notes associated with this service or procedure.
OSTEOMYELITIS WITH CC,540,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],24361.37,,"Fee schedule rate ($24,361.37). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.6), with a minimum of zero.",,,,0,other,9809.07,25507.30,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],41580.51,,"Fee schedule rate ($41,580.51). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,13783.20,41580.51,There are no additional notes associated with this service or procedure.
Surgical Arthroscopy Shoulder W/Rotator Cuff Rpr|RIGHT SIDE,CASE-29827,APC,29827,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
GASTROINTESTINAL HEMORRHAGE WITH MCC,377,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],7634.00,,"Per diem ($7,634). If length of stay < 4.5, first 1 days paid at a per diem of $15,268 instead. Capped at $34,353.60.",,,,0,other,7634.00,35969.56,Estimated amount calculated based on 3 day length of stay.
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],13478.34,,"Fee schedule rate ($13,478.34). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,6801.88,22557.82,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,064,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],41838.16,,"Fee schedule rate ($41,838.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,15563.58,41838.16,There are no additional notes associated with this service or procedure.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC,858,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],11946.65,,"Case rate ($11,377.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,720.10, add-ons for qualifying new technology services are included. If operating cost exceeds $45,591.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,449.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $8,742.91 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,775.15 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $689.90. The transfer capital threshold is the transfer adjustment factor * $689.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,11377.76,33794.11,Inpatient DRG
CERVICAL SPINAL FUSION WITHOUT CC/MCC,473,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],18847.16,,"Case rate ($18,477.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,324.93, add-ons for qualifying new technology services are included. If operating cost exceeds $52,195.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,969.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.6. The base transfer operating payment is the transfer adjustment factor * $15,323.48 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,379.98 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,209.17. The transfer capital threshold is the transfer adjustment factor * $1,209.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,18477.61,62077.11,Inpatient DRG
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,479,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],50518.76,,"Fee schedule rate ($50,518.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,10586.00,50518.76,There are no additional notes associated with this service or procedure.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],16669.71,,"Fee schedule rate ($16,669.71). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8767.81,19824.58,There are no additional notes associated with this service or procedure.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,988,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],42425.46,,"Fee schedule rate ($42,425.46). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,13075.52,42425.46,There are no additional notes associated with this service or procedure.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],22640.74,,"Fee schedule rate ($22,640.74). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,13341.67,42586.49,There are no additional notes associated with this service or procedure.
MAJOR BLADDER PROCEDURES WITH MCC,653,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],125343.98,,"Fee schedule rate ($125,343.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,10280.00,125343.98,There are no additional notes associated with this service or procedure.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],43888.01,,"Fee schedule rate ($43,888.01). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11717.72,43888.01,There are no additional notes associated with this service or procedure.
Injection Aa&/Strd Genicular Nrv Branches W/Img|RIGHT SIDE,CASE-64454,APC,64454,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],693.76,,"APC Price ($660.72). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,660.72,693.76,OPPS APC
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],34338.33,,,,,,0,other,1188.00,34338.33,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,555,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],22483.61,,"Fee schedule rate ($22,483.61). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10896.27,42290.95,There are no additional notes associated with this service or procedure.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],52794.06,,"Fee schedule rate ($52,794.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (37), with a minimum of zero.",,,,0,other,13907.80,52794.06,There are no additional notes associated with this service or procedure.
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],38508.74,,"Fee schedule rate ($38,508.74). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.6), with a minimum of zero.",,,,0,other,15821.59,40320.14,There are no additional notes associated with this service or procedure.
APPENDIX PROCEDURES WITH MCC,397,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],19071.54,,"Case rate ($18,163.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,032.61, add-ons for qualifying new technology services are included. If operating cost exceeds $51,903.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,946.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $15,032.24 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,087.66 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,186.19. The transfer capital threshold is the transfer adjustment factor * $1,186.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,18163.37,51558.84,Inpatient DRG
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],11043.60,,"Case rate ($10,517.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,920.01, add-ons for qualifying new technology services are included. If operating cost exceeds $44,791.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,386.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $7,945.76 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,975.06 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $627.00. The transfer capital threshold is the transfer adjustment factor * $627.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10517.71,24909.11,Inpatient DRG
CESAREAN SECTION WITH STERILIZATION WITH CC,784,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],9124.01,,"Case rate ($9,124.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,623.49, add-ons for qualifying new technology services are included. If operating cost exceeds $43,494.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,285.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,654.00 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,678.54 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $525.07. The transfer capital threshold is the transfer adjustment factor * $525.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9124.01,23722.94,Inpatient DRG
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],28751.41,,"Fee schedule rate ($28,751.41). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12305.53,30103.84,There are no additional notes associated with this service or procedure.
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH MCC",510,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],10710.00,,"Per diem ($10,710). If length of stay < 5.3, first 1 days paid at a per diem of $21,420 instead. Capped at $56,764.26.",,,,0,other,10710.00,89863.76,Estimated amount calculated based on 6 day length of stay.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC,099,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],11445.22,,"Case rate ($10,900.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,292.55, add-ons for qualifying new technology services are included. If operating cost exceeds $45,163.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,399.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,316.07 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,347.60 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $639.19. The transfer capital threshold is the transfer adjustment factor * $639.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,11171.21,26807.94,Inpatient DRG
Arthrp Interpos Intercarpal/Metacarpal Joints|LEFT SIDE,CASE-25447,APC,25447,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
"Tendon Sheath Incision|RIGHT HAND, SECOND DIGIT",CASE-26055,APC,26055,CPT,0360,RC,,,F6,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1505.12,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1505.12,1580.37,OPPS APC
"DIABETES,MODERATE",420,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],2103.71,,"Case rate for a one day stay ($2,103.71). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,2103.71,2208.90,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],6965.00,,,,,,0,other,1188.00,12138.74,There are no additional notes associated with this service or procedure.
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],10374.06,,"Case rate ($9,880.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,341.62, add-ons for qualifying new technology services are included. If operating cost exceeds $44,212.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,326.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $7,368.73 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,396.67 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $566.38. The transfer capital threshold is the transfer adjustment factor * $566.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10120.20,26204.74,Inpatient DRG
"Arthrodesis Great Toe Metatarsophalangeal Joint|LEFT FOOT, GREAT TOE",CASE-28750,APC,28750,CPT,0360,RC,,,TA,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],18585.05,,"Fee schedule rate ($18,585.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8859.23,20090.22,There are no additional notes associated with this service or procedure.
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],11158.08,,"Case rate ($10,626.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,021.44, add-ons for qualifying new technology services are included. If operating cost exceeds $44,892.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,394.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $8,046.82 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,076.49 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $634.97. The transfer capital threshold is the transfer adjustment factor * $634.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10626.74,25225.91,Inpatient DRG
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",063,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],6965.00,,,,,,0,other,6965.00,35701.87,There are no additional notes associated with this service or procedure.
COMPLICATIONS OF TREATMENT WITH CC,920,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],9169.22,,"Case rate ($8,732.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,259.35, add-ons for qualifying new technology services are included. If operating cost exceeds $43,130.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,256.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,291.21 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,314.40 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $496.44. The transfer capital threshold is the transfer adjustment factor * $496.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8732.59,20731.52,Inpatient DRG
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],24675.88,,"Fee schedule rate ($24,675.88). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10834.64,25830.00,There are no additional notes associated with this service or procedure.
INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC,198,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],13459.55,,"Fee schedule rate ($13,459.55). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.7), with a minimum of zero.",,,,0,other,6795.12,23505.07,There are no additional notes associated with this service or procedure.
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],32168.63,,"Fee schedule rate ($32,168.63). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,13904.43,34749.58,There are no additional notes associated with this service or procedure.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],10779.20,,"Case rate ($10,265.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,701.28, add-ons for qualifying new technology services are included. If operating cost exceeds $44,572.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,353.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $7,727.04 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,756.33 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $593.92. The transfer capital threshold is the transfer adjustment factor * $593.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10517.71,24909.11,Inpatient DRG
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,057,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],39884.93,,"Fee schedule rate ($39,884.93). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,10718.84,39884.93,There are no additional notes associated with this service or procedure.
FULL TERM NEONATE WITH MAJOR PROBLEMS,793,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],31690.87,,"Case rate ($30,181.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $28,213.07, add-ons for qualifying new technology services are included. If operating cost exceeds $63,084.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,825.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $26,171.62 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $26,268.12 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,065.20. The transfer capital threshold is the transfer adjustment factor * $2,065.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,4302.90,82045.22,Inpatient DRG
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],38248.08,,"Fee schedule rate ($38,248.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11593.79,38248.08,There are no additional notes associated with this service or procedure.
"VERTIGO AND OTHER LABYRINTH DISORDERS,MODERATE",111,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],2611.05,,"Case rate for a one day stay ($2,611.05). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,2611.05,2741.60,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS WITH MCC,947,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],30414.32,,"Fee schedule rate ($30,414.32). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,10541.41,30414.32,There are no additional notes associated with this service or procedure.
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],7086.00,,"Per diem ($7,086). If length of stay < 7.8, first 1 days paid at a per diem of $14,172 instead. Capped at $55,272.09.",,,,0,other,7086.00,57872.02,Estimated amount calculated based on 5 day length of stay.
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],7550.61,,"Case rate ($7,402.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,022.05, add-ons for qualifying new technology services are included. If operating cost exceeds $41,893.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,159.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,058.45 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,077.10 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $399.16. The transfer capital threshold is the transfer adjustment factor * $399.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,7402.56,16438.59,Inpatient DRG
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,056,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],7659.00,,"Per diem ($7,659). If length of stay < 5.7, first 1 days paid at a per diem of $15,318 instead. Capped at $43,658.02.",,,,0,other,7659.00,59328.19,Estimated amount calculated based on 3 day length of stay.
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC,807,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6738.54,,"Case rate ($6,510.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,192.35, add-ons for qualifying new technology services are included. If operating cost exceeds $41,063.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,093.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $4,231.80 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,247.40 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $333.93. The transfer capital threshold is the transfer adjustment factor * $333.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,5354.25,13266.23,Inpatient DRG
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],42586.49,,"Fee schedule rate ($42,586.49). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,13341.67,42586.49,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],16590.46,,"Fee schedule rate ($16,590.46). Adds an outlier to normal pricing equal to the per diem rate ($69,146.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,1188.00,17370.86,There are no additional notes associated with this service or procedure.
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,451,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],94077.13,,"Fee schedule rate ($94,077.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,23821.44,94077.13,There are no additional notes associated with this service or procedure.
HC Bx Breast 1st Lesion US Img|LEFT SIDE,CASE-19083,APC,19083,CPT,0361,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1623.23,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1545.93,1623.23,OPPS APC
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],18105.81,,"Case rate ($18,105.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,979.06, add-ons for qualifying new technology services are included. If operating cost exceeds $51,850.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,941.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $14,978.89 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,034.11 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,181.98. The transfer capital threshold is the transfer adjustment factor * $1,181.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,18105.81,52699.33,Inpatient DRG
Cysto W/Ureteroscopy W/Lithotripsy,CASE-52353,APC,52353,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5018.77,,"APC Price ($5,018.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5018.77,5269.71,OPPS APC
HC Inj Lympho for Sentinal Node|UNUSUAL NON-OVERLAPPING SERVICE,CASE-38792,APC,38792,CPT,0361,RC,,,XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6526.12,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6215.36,6526.12,OPPS APC
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],16428.39,,"Case rate ($16,428.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,418.58, add-ons for qualifying new technology services are included. If operating cost exceeds $50,289.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,819.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $13,424.13 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,473.63 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,059.30. The transfer capital threshold is the transfer adjustment factor * $1,059.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,16428.39,42083.20,Inpatient DRG
TRAUMATIC INJURY WITH MCC,913,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],30719.04,,"Fee schedule rate ($30,719.04). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.5), with a minimum of zero.",,,,0,other,13014.58,42838.46,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7025.23,,"Case rate ($6,787.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,450.02, add-ons for qualifying new technology services are included. If operating cost exceeds $41,321.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,114.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,488.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,505.07 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $354.19. The transfer capital threshold is the transfer adjustment factor * $354.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6164.03,14071.02,Inpatient DRG
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,544,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],23207.64,,"Fee schedule rate ($23,207.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,7055.15,23207.64,There are no additional notes associated with this service or procedure.
HYPERTENSION WITHOUT MCC,305,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],17230.49,,"Fee schedule rate ($17,230.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7058.55,17230.49,There are no additional notes associated with this service or procedure.
HC Anterior Epitaxis Simple|RIGHT SIDE,CASE-30901,APC,30901,CPT,0450,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],128.90,,"APC Price ($124.54). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,124.54,130.76,OPPS APC
"NEONATE TRANSFERRED < 5 DAYS OLD BORN HERE,MODERATE",581,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],1684.21,,"The inlier payment is calculated as the lesser of the standard DRG payment $1,604.01 and the transfer payment, which is a per diem of $1,253.13. If cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,1604.01,1684.21,Estimated amount calculated based on 1 day length of stay.
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC,939,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],68190.40,,"Fee schedule rate ($68,190.40). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16.5), with a minimum of zero.",,,,0,other,26517.40,97674.79,There are no additional notes associated with this service or procedure.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],10846.48,,"Fee schedule rate ($10,846.48). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,20401.88,There are no additional notes associated with this service or procedure.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],59385.88,,"Fee schedule rate ($59,385.88). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,23344.70,62179.32,There are no additional notes associated with this service or procedure.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],10603.44,,"Case rate ($10,098.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,530.04, add-ons for qualifying new technology services are included. If operating cost exceeds $44,401.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,356.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $7,557.23 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,585.10 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $596.34. The transfer capital threshold is the transfer adjustment factor * $596.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10098.51,24259.09,Inpatient DRG
"LIMB REATTACHMENT, HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA",956,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],148259.86,,"Fee schedule rate ($148,259.86). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,27428.25,148259.86,There are no additional notes associated with this service or procedure.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC,099,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],26807.94,,,,,,0,other,11171.21,26807.94,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],9389.48,,"Case rate ($9,389.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,870.44, add-ons for qualifying new technology services are included. If operating cost exceeds $43,741.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,304.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,900.05 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,925.50 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $544.48. The transfer capital threshold is the transfer adjustment factor * $544.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9389.48,22358.90,Inpatient DRG
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,066,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],6965.00,,,,,,0,other,6579.76,20083.61,There are no additional notes associated with this service or procedure.
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],7141.97,,"Case rate ($6,801.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,463.25, add-ons for qualifying new technology services are included. If operating cost exceeds $41,334.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,115.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,501.70 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,518.30 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $355.23. The transfer capital threshold is the transfer adjustment factor * $355.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6801.88,22557.82,Inpatient DRG
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],35973.56,,"Fee schedule rate ($35,973.56). Adds an outlier to normal pricing equal to the per diem rate ($68,707.98) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,14908.05,49717.39,There are no additional notes associated with this service or procedure.
CERVICAL SPINAL FUSION WITHOUT CC/MCC,473,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],62077.11,,"Fee schedule rate ($62,077.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,18477.61,62077.11,There are no additional notes associated with this service or procedure.
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,069,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],7501.56,,"Case rate ($7,354.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,977.32, add-ons for qualifying new technology services are included. If operating cost exceeds $41,848.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,155.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $5,013.88 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,032.37 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $395.65. The transfer capital threshold is the transfer adjustment factor * $395.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6965.00,20333.68,Inpatient DRG
Revision of Reconstructed Breast|BILATERAL PROCEDURE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-19380,APC,19380,CPT,0360,RC,,,50|XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7918.25,,"APC Price ($7,650.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,7918.25,7918.25,OPPS APC
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],16900.84,,"Fee schedule rate ($16,900.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8151.55,18033.97,There are no additional notes associated with this service or procedure.
Rpr 1st Ingun Hrna Age 5 Yrs/> Incarcerated|RIGHT SIDE,CASE-49507,APC,49507,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3351.34,,"APC Price ($3,351.34). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3351.34,3518.91,OPPS APC
"Open Tx Distal Phalangeal Fracture Each|RIGHT HAND, FIFTH DIGIT",CASE-26765,APC,26765,CPT,0360,RC,,,F9,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],8122.16,,"Case rate ($7,847.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,435.96, add-ons for qualifying new technology services are included. If operating cost exceeds $42,306.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,191.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,470.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,491.01 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $431.70. The transfer capital threshold is the transfer adjustment factor * $431.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,7847.50,17755.26,Inpatient DRG
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],36008.91,,,,,,0,other,14337.84,52803.53,There are no additional notes associated with this service or procedure.
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],81454.07,,"Fee schedule rate ($81,454.07). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,10078.00,81454.07,There are no additional notes associated with this service or procedure.
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC",923,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],6965.00,,,,,,0,other,6965.00,20068.57,There are no additional notes associated with this service or procedure.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],72246.07,,,,,,0,other,26809.29,97015.50,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],32296.02,,"Case rate ($32,296.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $30,179.91, add-ons for qualifying new technology services are included. If operating cost exceeds $65,050.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,979.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $28,131.23 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $28,234.95 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,219.83. The transfer capital threshold is the transfer adjustment factor * $2,219.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,32296.02,88188.38,Inpatient DRG
Parathyroidectomy/Exploration Parathyroids|LEFT SIDE,CASE-60500,APC,60500,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5541.10,,"APC Price ($5,541.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5541.10,5818.16,OPPS APC
Laps Abd Prtm&Omentum Dx W/WO Spec Br/Wa Spx,CASE-49320,APC,49320,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5856.81,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5658.76,5941.70,OPPS APC
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],59021.28,,"Fee schedule rate ($59,021.28). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,23851.92,63653.13,There are no additional notes associated with this service or procedure.
Dstr Nrolytc Agnt Parverteb Fct Addl Lmbr/Sacral|RIGHT SIDE,CASE-64636,APC,64636,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1891.77,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1827.80,1919.19,OPPS APC
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC",758,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],9003.54,,"Case rate ($8,574.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,112.57, add-ons for qualifying new technology services are included. If operating cost exceeds $42,983.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,244.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $6,144.96 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,167.62 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $484.90. The transfer capital threshold is the transfer adjustment factor * $484.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8574.80,19263.78,Inpatient DRG
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC,058,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],13995.06,,"Case rate ($13,521.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,714.66, add-ons for qualifying new technology services are included. If operating cost exceeds $47,585.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,606.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $10,730.14 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,769.70 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $846.71. The transfer capital threshold is the transfer adjustment factor * $846.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,13521.80,40853.02,Inpatient DRG
SINGLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL,402,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],124455.45,,"Fee schedule rate ($124,455.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,29172.05,124455.45,There are no additional notes associated with this service or procedure.
Gastroenterology Procedure,CASE-91299,APC,91299,CPT,0750,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],120.44,,"APC Price ($120.44). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,120.44,126.46,OPPS APC
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],39797.94,,"Fee schedule rate ($39,797.94). Adds an outlier to normal pricing equal to the per diem rate ($75,578.79) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.5), with a minimum of zero.",,,,0,other,16286.16,58320.32,There are no additional notes associated with this service or procedure.
Rpr Recrt Ingun Hernia Any Age Incarcerated|LEFT SIDE,CASE-49521,APC,49521,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6271.74,,"APC Price ($6,059.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6059.65,6362.63,OPPS APC
BRONCHITIS AND ASTHMA WITH CC/MCC,202,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],8692.42,,"Case rate ($8,521.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,063.43, add-ons for qualifying new technology services are included. If operating cost exceeds $42,934.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,241.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,096.00 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,118.48 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $481.03. The transfer capital threshold is the transfer adjustment factor * $481.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,7606.34,19110.30,Inpatient DRG
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],59081.91,,"Fee schedule rate ($59,081.91). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,8480.00,59081.91,There are no additional notes associated with this service or procedure.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],8876.85,,"Case rate ($8,702.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,231.63, add-ons for qualifying new technology services are included. If operating cost exceeds $43,102.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,254.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,263.59 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,286.68 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $494.26. The transfer capital threshold is the transfer adjustment factor * $494.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,5683.00,19635.68,Inpatient DRG
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],20817.01,,"Fee schedule rate ($20,817.01). Adds an outlier to normal pricing equal to the per diem rate ($37,789.38) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,9446.38,21796.21,There are no additional notes associated with this service or procedure.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],59521.43,,"Fee schedule rate ($59,521.43). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,16689.78,59521.43,There are no additional notes associated with this service or procedure.
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],10203.78,,"Case rate ($10,003.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,441.84, add-ons for qualifying new technology services are included. If operating cost exceeds $44,312.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,349.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $7,469.36 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,496.90 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $589.41. The transfer capital threshold is the transfer adjustment factor * $589.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,10003.71,23415.63,Inpatient DRG
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],11225.78,,"Case rate ($10,846.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,225.56, add-ons for qualifying new technology services are included. If operating cost exceeds $45,096.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,410.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $8,250.19 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,280.61 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $651.02. The transfer capital threshold is the transfer adjustment factor * $651.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,10846.16,25863.45,Inpatient DRG
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],7924.86,,"Case rate ($7,547.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,156.87, add-ons for qualifying new technology services are included. If operating cost exceeds $42,027.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,169.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $5,192.77 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,211.92 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $409.76. The transfer capital threshold is the transfer adjustment factor * $409.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,19126.88,Inpatient DRG
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],32168.63,,"Fee schedule rate ($32,168.63). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,13904.43,34749.58,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC,788,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],8859.92,,"Case rate ($8,438.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,985.31, add-ons for qualifying new technology services are included. If operating cost exceeds $42,856.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,234.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,018.17 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,040.36 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $474.89. The transfer capital threshold is the transfer adjustment factor * $474.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8438.02,20142.33,Inpatient DRG
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],15626.34,,"Case rate ($14,882.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,004.37, add-ons for qualifying new technology services are included. If operating cost exceeds $48,875.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,683.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $12,013.86 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,059.42 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $923.41. The transfer capital threshold is the transfer adjustment factor * $923.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,15273.74,39820.52,Inpatient DRG
Injection Aa&/Strd Genicular Nrv Branches W/Img|BILATERAL PROCEDURE,CASE-64454,APC,64454,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],660.72,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,660.72,693.76,OPPS APC
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,069,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],15717.99,,,,,,0,other,6965.00,20333.68,There are no additional notes associated with this service or procedure.
MAJOR BLADDER PROCEDURES WITH MCC,653,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],125343.98,,"Fee schedule rate ($125,343.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,10280.00,125343.98,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITH STERILIZATION WITH MCC,783,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],19221.04,,"Case rate ($18,571.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,411.86, add-ons for qualifying new technology services are included. If operating cost exceeds $52,282.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,975.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $15,410.10 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,466.92 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,216.01. The transfer capital threshold is the transfer adjustment factor * $1,216.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,12612.10,23722.94,Inpatient DRG
Endoscopic Papilla Cannulation Bile/Pancreatic,CASE-43273,APC,43273,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3789.26,,"APC Price ($3,608.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3608.81,3789.26,OPPS APC
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],68942.79,,"Fee schedule rate ($68,942.79). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,21489.15,68942.79,There are no additional notes associated with this service or procedure.
SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS,029,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],61889.56,,"Fee schedule rate ($61,889.56). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13641.00,67130.05,There are no additional notes associated with this service or procedure.
Tnot Elbow Lateral/Medial Debride Open Tdn Rpr|RIGHT SIDE,CASE-24359,APC,24359,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],13654.09,,"Case rate ($13,386.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,588.65, add-ons for qualifying new technology services are included. If operating cost exceeds $47,459.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,596.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $10,604.60 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,643.70 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $836.81. The transfer capital threshold is the transfer adjustment factor * $836.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,13386.36,33244.29,Inpatient DRG
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],15448.98,,"Case rate ($14,713.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,846.90, add-ons for qualifying new technology services are included. If operating cost exceeds $48,717.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,671.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,856.99 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,901.95 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $911.36. The transfer capital threshold is the transfer adjustment factor * $911.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7605.00,39153.65,Inpatient DRG
CESAREAN SECTION WITH STERILIZATION WITH MCC,783,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],19006.00,,,,,,0,other,12612.10,23722.94,There are no additional notes associated with this service or procedure.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],11016.60,,"Fee schedule rate ($11,016.60). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8009.34,19877.10,There are no additional notes associated with this service or procedure.
HYPERTENSION WITHOUT MCC,305,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],14190.59,,"Fee schedule rate ($14,190.59). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,7058.55,17230.49,There are no additional notes associated with this service or procedure.
Colonoscopy W/Biopsy Single/Multiple|UNUSUAL NON-OVERLAPPING SERVICE|COLORECTAL CANCER SCREEN,CASE-45380,APC,45380,CPT,0360,RC,,,XU|PT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1120.09,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1120.09,1176.09,OPPS APC
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],94787.57,,"Fee schedule rate ($94,787.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,23526.87,94787.57,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],15318.94,,"Fee schedule rate ($15,318.94). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6214.05,15318.94,There are no additional notes associated with this service or procedure.
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],6965.00,,,,,,0,other,5139.72,13110.79,There are no additional notes associated with this service or procedure.
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],53275.26,,"Fee schedule rate ($53,275.26). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,15940.79,53275.26,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],19763.43,,"Fee schedule rate ($19,763.43). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,8318.14,19763.43,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS WITH MCC,947,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],10910.36,,"Case rate ($10,541.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,942.06, add-ons for qualifying new technology services are included. If operating cost exceeds $44,813.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,388.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $7,967.73 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,997.11 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $628.73. The transfer capital threshold is the transfer adjustment factor * $628.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,10541.41,30414.32,Inpatient DRG
MINOR BLADDER PROCEDURES WITHOUT CC/MCC,664,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],9034.63,,"Case rate ($9,034.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,540.33, add-ons for qualifying new technology services are included. If operating cost exceeds $43,411.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,278.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $6,571.15 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,595.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $518.53. The transfer capital threshold is the transfer adjustment factor * $518.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9034.63,31876.87,Inpatient DRG
Removal Implant Deep|LEFT SIDE,CASE-20680,APC,20680,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],2718.88,,"APC Price ($2,718.88). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2718.88,2854.83,OPPS APC
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC,520,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],28074.86,,"Fee schedule rate ($28,074.86). Adds an outlier to normal pricing equal to the per diem rate ($68,872.56) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,12061.74,39786.42,There are no additional notes associated with this service or procedure.
PERIPHERAL VASCULAR DISORDERS WITH CC,300,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],9174.14,,"Case rate ($9,174.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,670.11, add-ons for qualifying new technology services are included. If operating cost exceeds $43,541.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,288.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,700.45 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,725.16 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $528.73. The transfer capital threshold is the transfer adjustment factor * $528.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9174.14,21005.20,Inpatient DRG
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],29241.62,,"Fee schedule rate ($29,241.62). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,12984.79,32077.45,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],28423.20,,"Fee schedule rate ($28,423.20). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11059.47,28423.20,There are no additional notes associated with this service or procedure.
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],13571.25,,"Case rate ($13,571.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,760.65, add-ons for qualifying new technology services are included. If operating cost exceeds $47,631.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,610.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $10,775.96 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,815.69 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $850.33. The transfer capital threshold is the transfer adjustment factor * $850.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,13571.25,33781.47,Inpatient DRG
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],24528.10,,"Fee schedule rate ($24,528.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10989.72,26280.60,There are no additional notes associated with this service or procedure.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],17194.49,,"Fee schedule rate ($17,194.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8554.50,19204.75,There are no additional notes associated with this service or procedure.
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],36801.89,,,,,,0,other,6277.00,36801.89,There are no additional notes associated with this service or procedure.
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC",923,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],8329.46,,"Case rate ($8,047.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $7,588.71, add-ons for qualifying new technology services are included. If operating cost exceeds $46,233.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $3,215.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,201.30 + an uncompensated DSH payment of $1,359.91. The transfer operating threshold is the transfer adjustment factor * $6,228.80 + an uncompensated DSH payment of $1,359.91. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $486.59. The transfer capital threshold is the transfer adjustment factor * $486.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6965.00,20068.57,Inpatient DRG
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,074,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],9371.88,,"Case rate ($8,925.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,438.90, add-ons for qualifying new technology services are included. If operating cost exceeds $43,309.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,270.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,470.10 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,493.95 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $510.55. The transfer capital threshold is the transfer adjustment factor * $510.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8925.60,20919.08,Inpatient DRG
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],9893.02,,"Case rate ($9,421.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,914.56, add-ons for qualifying new technology services are included. If operating cost exceeds $43,785.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,293.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $6,943.28 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,969.61 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $533.68. The transfer capital threshold is the transfer adjustment factor * $533.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9648.19,31477.13,Inpatient DRG
"NEONATE BIRTH WEIGHT > 2499 GRAMS WITH RESPIRATORY DISTRESS SYNDROME OR OTHER MAJOR RESPIRATORY CONDITION,MAJOR",634,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],21074.73,,"Case rate ($21,074.73). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,21074.73,22128.47,There are no additional notes associated with this service or procedure.
MAJOR BLADDER PROCEDURES WITH MCC,653,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],125343.98,,"Fee schedule rate ($125,343.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,10280.00,125343.98,There are no additional notes associated with this service or procedure.
MAJOR BLADDER PROCEDURES WITH MCC,653,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],38992.11,,"Case rate ($37,135.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $34,681.82, add-ons for qualifying new technology services are included. If operating cost exceeds $69,552.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,333.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.5. The base transfer operating payment is the transfer adjustment factor * $32,616.61 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $32,736.87 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,573.77. The transfer capital threshold is the transfer adjustment factor * $2,573.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10280.00,125343.98,Inpatient DRG
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,345,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],33616.03,,"Fee schedule rate ($33,616.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12134.89,33616.03,There are no additional notes associated with this service or procedure.
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],23415.63,,,,,,0,other,10003.71,23415.63,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],37914.65,,"Fee schedule rate ($37,914.65). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9865.56,37914.65,There are no additional notes associated with this service or procedure.
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITHOUT MCC,430,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],133156.90,,"Fee schedule rate ($133,156.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,41000.16,133156.90,There are no additional notes associated with this service or procedure.
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],13625.25,,"Fee schedule rate ($13,625.25). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7243.75,23262.15,There are no additional notes associated with this service or procedure.
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],13246.56,,,,,,0,other,6503.90,14492.93,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],58394.20,,"Fee schedule rate ($58,394.20). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,9370.00,65732.99,There are no additional notes associated with this service or procedure.
"HERNIA PROCEDURES EXCEPT INGUINAL FEMORAL AND UMBILICAL,MODERATE",227,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],3765.73,,"Case rate for a one day stay ($3,586.41). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,3586.41,3765.73,There are no additional notes associated with this service or procedure.
HC Inj Tendon Sheath/Ligament|PBB CHARGE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-20550,APC,20550,CPT,0510,RC,,,PBB|XU,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],287.31,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
COMPLICATIONS OF TREATMENT WITH CC,920,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],19722.26,,,,,,0,other,8732.59,20731.52,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],43341.62,,"Fee schedule rate ($43,341.62). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,8972.00,81524.17,There are no additional notes associated with this service or procedure.
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],34245.00,,"Fee schedule rate ($34,245.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,12725.42,34245.00,There are no additional notes associated with this service or procedure.
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],25013.10,,"Fee schedule rate ($25,013.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10846.16,25863.45,There are no additional notes associated with this service or procedure.
OTHER CEREBROVASCULAR DISORDERS WITH CC,071,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],9337.76,,"Case rate ($8,893.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,408.66, add-ons for qualifying new technology services are included. If operating cost exceeds $43,279.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,268.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,439.97 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,463.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $508.18. The transfer capital threshold is the transfer adjustment factor * $508.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5843.00,29215.10,Inpatient DRG
INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC,198,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6985.28,,"Case rate ($6,652.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,333.20, add-ons for qualifying new technology services are included. If operating cost exceeds $41,204.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,095.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,371.67 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,388.25 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $336.02. The transfer capital threshold is the transfer adjustment factor * $336.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6795.12,23505.07,Inpatient DRG
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITH MCC,429,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],169317.41,,"Fee schedule rate ($169,317.41). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,62958.58,177294.98,There are no additional notes associated with this service or procedure.
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITHOUT CC/MCC",630,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],42541.02,,"Fee schedule rate ($42,541.02). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11828.78,42541.02,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],16129.04,,"Case rate ($16,129.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,140.12, add-ons for qualifying new technology services are included. If operating cost exceeds $50,011.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,797.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $13,146.70 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,195.17 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,037.40. The transfer capital threshold is the transfer adjustment factor * $1,037.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,16129.04,59610.47,Inpatient DRG
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],22487.70,,"Fee schedule rate ($22,487.70). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10048.39,23545.50,There are no additional notes associated with this service or procedure.
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC,519,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],50780.20,,"Fee schedule rate ($50,780.20). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,15490.44,50780.20,There are no additional notes associated with this service or procedure.
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],25253.70,,"Fee schedule rate ($25,253.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11974.38,29141.64,There are no additional notes associated with this service or procedure.
"SEIZURE,EXTREME",053,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],21938.52,,"Case rate ($20,893.83). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,20893.83,21938.52,There are no additional notes associated with this service or procedure.
NONTRAUMATIC STUPOR AND COMA WITH MCC,080,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],30179.40,,"Fee schedule rate ($30,179.40). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,14202.39,35615.37,There are no additional notes associated with this service or procedure.
HC Non Stress Test|UNUSUAL NON-OVERLAPPING SERVICE,CASE-59025,APC,59025,CPT,0920,RC,,,XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],195.86,,"APC Price ($189.24). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,189.24,198.70,OPPS APC
Marsupialization Bartholins Gland Cyst|LEFT SIDE,CASE-56440,APC,56440,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3181.53,,"APC Price ($3,030.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3030.03,3181.53,OPPS APC
VENTRICULAR SHUNT PROCEDURES WITH MCC,031,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],32965.75,,"Case rate ($31,395.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $29,397.55, add-ons for qualifying new technology services are included. If operating cost exceeds $64,268.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,862.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7. The base transfer operating payment is the transfer adjustment factor * $27,348.91 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $27,452.60 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,102.10. The transfer capital threshold is the transfer adjustment factor * $2,102.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,32287.20,88162.80,Inpatient DRG
SEIZURES WITH MCC,100,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],15814.14,,"Case rate ($15,061.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,146.62, add-ons for qualifying new technology services are included. If operating cost exceeds $49,017.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,719.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $12,156.85 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,201.67 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $959.30. The transfer capital threshold is the transfer adjustment factor * $959.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,15061.09,38110.41,Inpatient DRG
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],31533.97,,"Fee schedule rate ($31,533.97). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8563.30,31533.97,There are no additional notes associated with this service or procedure.
Destruction Neurolytic Agt Genicular Nerve W/Img,CASE-64624,APC,64624,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1891.77,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1827.80,1919.19,OPPS APC
POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES,769,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],31756.41,,"Fee schedule rate ($31,756.41). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.7), with a minimum of zero.",,,,0,other,13388.39,33250.19,There are no additional notes associated with this service or procedure.
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",759,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],12471.03,,"Fee schedule rate ($12,471.03). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.9), with a minimum of zero.",,,,0,other,6190.22,13057.66,There are no additional notes associated with this service or procedure.
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],32168.63,,"Fee schedule rate ($32,168.63). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,13904.43,34749.58,There are no additional notes associated with this service or procedure.
SINGLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL,402,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],124455.45,,"Fee schedule rate ($124,455.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,29172.05,124455.45,There are no additional notes associated with this service or procedure.
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,069,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],7354.47,,"Case rate ($7,354.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,977.32, add-ons for qualifying new technology services are included. If operating cost exceeds $41,848.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,155.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $5,013.88 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,032.37 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $395.65. The transfer capital threshold is the transfer adjustment factor * $395.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,20333.68,Inpatient DRG
HC Joint Injection/Aspir Large WO US|LEFT SIDE,CASE-20610,APC,20610,CPT,0510,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],297.37,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,287.31,301.68,OPPS APC
Fasct Prtl Palmr Addl Dgt Prox Iphal Jt W/WO Rpr,CASE-26125,APC,26125,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3215.80,3215.80,OPPS APC
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],8480.00,,"Per diem ($8,480). If length of stay < 5.5, first 1 days paid at a per diem of $16,960 instead. Capped at $46,638.59.",,,,0,other,8480.00,59081.91,Estimated amount calculated based on 3 day length of stay.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],29241.62,,"Fee schedule rate ($29,241.62). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,12984.79,32077.45,There are no additional notes associated with this service or procedure.
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],11974.38,,"Case rate ($11,974.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,275.12, add-ons for qualifying new technology services are included. If operating cost exceeds $46,146.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,493.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $9,295.90 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,330.17 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $733.54. The transfer capital threshold is the transfer adjustment factor * $733.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,11974.38,29141.64,Inpatient DRG
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],16787.98,,"Case rate ($16,787.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,753.10, add-ons for qualifying new technology services are included. If operating cost exceeds $50,624.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,845.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $13,757.43 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,808.15 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,085.60. The transfer capital threshold is the transfer adjustment factor * $1,085.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,16787.98,62990.26,Inpatient DRG
"Capsulectomy/Capsulotomy Iphal Joint Each|RIGHT HAND, FOURTH DIGIT",CASE-26525,APC,26525,CPT,0360,RC,,,F8,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],52803.53,,"Fee schedule rate ($52,803.53). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,14337.84,52803.53,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],14279.80,,"Case rate ($13,599.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,808.96, add-ons for qualifying new technology services are included. If operating cost exceeds $47,679.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,591.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $10,822.98 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,864.01 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $831.88. The transfer capital threshold is the transfer adjustment factor * $831.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13917.42,34889.29,Inpatient DRG
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],16787.98,,"Case rate ($16,787.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,753.10, add-ons for qualifying new technology services are included. If operating cost exceeds $50,624.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,845.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $13,757.43 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,808.15 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,085.60. The transfer capital threshold is the transfer adjustment factor * $1,085.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,16787.98,62990.26,Inpatient DRG
Open Treatment Ulnar Fracture Proximal End|LEFT SIDE,CASE-24685,APC,24685,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6791.99,7131.59,OPPS APC
DIABETES WITH MCC,637,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],12869.85,,"Fee schedule rate ($12,869.85). Adds an outlier to normal pricing equal to the per diem rate ($3,770.33) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,9959.03,28655.62,There are no additional notes associated with this service or procedure.
HC Peripheral Block - Femoral Single or Saphenous W/Img Gdn|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64447,APC,64447,CPT,0360,RC,,,RT|XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],15802.03,,"Fee schedule rate ($15,802.03). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7566.45,16333.88,There are no additional notes associated with this service or procedure.
OSTEOMYELITIS WITHOUT CC/MCC,541,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],7277.28,,"Case rate ($7,277.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,905.50, add-ons for qualifying new technology services are included. If operating cost exceeds $41,776.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,149.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $4,942.33 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,960.55 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $390.00. The transfer capital threshold is the transfer adjustment factor * $390.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,5103.00,15493.67,Inpatient DRG
Colonoscopy Flx Dx W/Collj Spec When Pfrmd|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-45378,APC,45378,CPT,0360,RC,,,74,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],913.99,,"APC Price ($870.46). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,870.46,913.99,OPPS APC
Cysto W/Urtroscopy&/Pyeloscopy Dx|LEFT SIDE,CASE-52351,APC,52351,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3464.44,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3299.47,3464.44,OPPS APC
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC,806,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6695.39,,"Case rate ($6,376.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,075.86, add-ons for qualifying new technology services are included. If operating cost exceeds $40,946.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,076.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $4,115.31 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,130.91 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $316.31. The transfer capital threshold is the transfer adjustment factor * $316.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5354.25,13416.00,Inpatient DRG
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC,807,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],12670.24,,"Fee schedule rate ($12,670.24). Adds an outlier to normal pricing equal to the per diem rate ($29,637.88) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,5354.25,13266.23,There are no additional notes associated with this service or procedure.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC,192,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],12753.78,,"Fee schedule rate ($12,753.78). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6292.63,12753.78,There are no additional notes associated with this service or procedure.
PLEURAL EFFUSION WITH MCC,186,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],11720.60,,"Case rate ($11,720.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $11,009.40, add-ons for qualifying new technology services are included. If operating cost exceeds $49,654.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $3,482.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $9,606.87 + an uncompensated DSH payment of $1,359.91. The transfer operating threshold is the transfer adjustment factor * $9,649.48 + an uncompensated DSH payment of $1,359.91. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $753.81. The transfer capital threshold is the transfer adjustment factor * $753.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10804.96,31089.66,Inpatient DRG
TRAUMATIC INJURY WITH MCC,913,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],13014.58,,"Case rate ($13,014.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,242.79, add-ons for qualifying new technology services are included. If operating cost exceeds $47,113.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,569.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $10,260.01 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,297.84 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $809.62. The transfer capital threshold is the transfer adjustment factor * $809.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,13014.58,42838.46,Inpatient DRG
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],23899.13,,"Fee schedule rate ($23,899.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9795.13,23899.13,There are no additional notes associated with this service or procedure.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],41006.47,,"Fee schedule rate ($41,006.47). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12268.97,41006.47,There are no additional notes associated with this service or procedure.
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC",641,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],14928.67,,"Fee schedule rate ($14,928.67). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7214.98,15312.64,There are no additional notes associated with this service or procedure.
Egd Insert Guide Wire Dilator Passage Esophagus,CASE-43248,APC,43248,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],878.67,,"APC Price ($848.96). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,848.96,891.41,OPPS APC
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],28756.63,,"Fee schedule rate ($28,756.63). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,13148.66,32553.63,There are no additional notes associated with this service or procedure.
Tonsillectomy Primary/Secondary Age 12/>,CASE-42826,APC,42826,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.35,,"APC Price ($3,103.35). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.35,3258.52,OPPS APC
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC",629,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],44657.18,,"Fee schedule rate ($44,657.18). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,16699.94,44657.18,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],13525.61,,"Case rate ($13,260.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,471.48, add-ons for qualifying new technology services are included. If operating cost exceeds $47,342.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,587.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $10,487.86 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,526.53 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $827.60. The transfer capital threshold is the transfer adjustment factor * $827.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,13260.40,32878.30,Inpatient DRG
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],28983.97,,"Fee schedule rate ($28,983.97). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8956.76,28983.97,There are no additional notes associated with this service or procedure.
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],7412.73,,"Case rate ($7,412.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,031.50, add-ons for qualifying new technology services are included. If operating cost exceeds $41,902.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,159.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $5,067.86 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,086.55 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $399.90. The transfer capital threshold is the transfer adjustment factor * $399.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6148.93,15887.21,Inpatient DRG
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],14008.75,,"Case rate ($13,341.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,547.08, add-ons for qualifying new technology services are included. If operating cost exceeds $47,418.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,593.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $10,563.18 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,602.13 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $833.54. The transfer capital threshold is the transfer adjustment factor * $833.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13341.67,42586.49,Inpatient DRG
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6915.64,,"Case rate ($6,915.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,569.08, add-ons for qualifying new technology services are included. If operating cost exceeds $41,440.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,123.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,607.15 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,624.14 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $363.55. The transfer capital threshold is the transfer adjustment factor * $363.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6915.64,14442.92,Inpatient DRG
Colon Ca Scrn Not Hi Rsk Ind,CASE-G0121,APC,G0121,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],870.46,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,870.46,913.99,OPPS APC
"Exc Tum/Vasc Mal Sft Tiss Hand/Fngr Subq <1.5cm|RIGHT HAND, SECOND DIGIT",CASE-26115,APC,26115,CPT,0360,RC,,,F6,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1623.23,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1545.93,1623.23,OPPS APC
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],6711.00,,"Per diem ($6,711). If length of stay < 2.4, first 1 days paid at a per diem of $13,422 instead. Capped at $16,107.48.",,,,0,other,6711.00,16865.16,Estimated amount calculated based on 2 day length of stay.
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],16193.10,,"Fee schedule rate ($16,193.10). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9755.86,29216.99,There are no additional notes associated with this service or procedure.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],14592.24,,"Case rate ($14,098.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,251.41, add-ons for qualifying new technology services are included. If operating cost exceeds $48,122.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,648.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $11,264.92 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,306.46 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $888.91. The transfer capital threshold is the transfer adjustment factor * $888.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,7332.00,35314.31,Inpatient DRG
Int Hrhc by Ligation 2+ Hroid W/O Img Gdn,CASE-46946,APC,46946,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],2689.02,,"APC Price ($2,598.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2598.08,2727.99,OPPS APC
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,699,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],19570.20,,"Fee schedule rate ($19,570.20). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5961.00,19972.16,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC,832,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],13561.03,,"Fee schedule rate ($13,561.03). Adds an outlier to normal pricing equal to the per diem rate ($18,253.69) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,4803.31,14198.92,There are no additional notes associated with this service or procedure.
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],37134.43,,,,,,0,other,7389.00,37134.43,There are no additional notes associated with this service or procedure.
"COCAINE ABUSE AND DEPENDENCE,MAJOR",774,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],7555.20,,"Case rate ($7,555.20). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,7555.20,7932.96,There are no additional notes associated with this service or procedure.
HC Plcmt Tunnel Pleural Drain Cat,CASE-32550,APC,32550,CPT,0361,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3468.64,,"APC Price ($3,351.34). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3351.34,3518.91,OPPS APC
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,097,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],79915.74,,"Fee schedule rate ($79,915.74). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,26404.32,79915.74,There are no additional notes associated with this service or procedure.
FULL TERM NEONATE WITH MAJOR PROBLEMS,793,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],30181.78,,"Case rate ($30,181.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $28,213.07, add-ons for qualifying new technology services are included. If operating cost exceeds $63,084.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,825.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $26,171.62 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $26,268.12 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,065.20. The transfer capital threshold is the transfer adjustment factor * $2,065.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,4302.90,82045.22,Inpatient DRG
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],52449.26,,"Fee schedule rate ($52,449.26). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,17693.40,52449.26,There are no additional notes associated with this service or procedure.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,098,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],38799.38,,"Fee schedule rate ($38,799.38). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,6965.00,45156.75,There are no additional notes associated with this service or procedure.
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],25829.63,,"Fee schedule rate ($25,829.63). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6965.00,29482.05,There are no additional notes associated with this service or procedure.
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],26204.74,,"Fee schedule rate ($26,204.74). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10120.20,26204.74,There are no additional notes associated with this service or procedure.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],35314.31,,,,,,0,other,7332.00,35314.31,There are no additional notes associated with this service or procedure.
Mastectomy Partial|LEFT SIDE,CASE-19301,APC,19301,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6215.36,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6215.36,6526.12,OPPS APC
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC,519,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],50780.20,,"Fee schedule rate ($50,780.20). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,15490.44,50780.20,There are no additional notes associated with this service or procedure.
HC Inj Anesth Celiac Plexus|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64530,APC,64530,CPT,0361,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],827.89,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,827.89,869.28,OPPS APC
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],9850.70,,"Case rate ($5,628.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,372.11, add-ons for qualifying new technology services are included. If operating cost exceeds $40,243.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,029.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,414.56 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,427.15 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $269.44. The transfer capital threshold is the transfer adjustment factor * $269.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,5628.97,12272.58,All Other Inpatient
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],15802.03,,"Fee schedule rate ($15,802.03). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7566.45,16333.88,There are no additional notes associated with this service or procedure.
Colorectal Scrn; Hi Risk Ind|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-G0105,APC,G0105,CPT,0360,RC,,,74,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],900.93,,"APC Price ($870.46). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,870.46,913.99,OPPS APC
CESAREAN SECTION WITHOUT STERILIZATION WITH CC,787,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],23722.94,,"Fee schedule rate ($23,722.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9508.01,23722.94,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],6167.00,,"Per diem ($6,167). If length of stay < 4.5, first 1 days paid at a per diem of $12,334 instead. Capped at $27,753.50.",,,,0,other,6167.00,29058.99,Estimated amount calculated based on 3 day length of stay.
Tr/Trnspl Tdn Carp/Mtcrpl Hand W/O Fr Grf Ea Tdn,CASE-26480,APC,26480,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
Insj/Rplcmt Breast Implant Sep Day Mastectomy|LEFT SIDE,CASE-19342,APC,19342,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],7650.49,,"APC Price ($7,650.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,7650.49,8033.01,OPPS APC
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],25829.63,,"Fee schedule rate ($25,829.63). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6965.00,29482.05,There are no additional notes associated with this service or procedure.
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],14625.55,,"Fee schedule rate ($14,625.55). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7438.45,15961.98,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC,087,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],22679.07,,"Fee schedule rate ($22,679.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,8139.36,22679.07,There are no additional notes associated with this service or procedure.
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,451,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],25012.51,,"Case rate ($23,821.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $22,296.19, add-ons for qualifying new technology services are included. If operating cost exceeds $57,167.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,359.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $20,276.48 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $20,351.24 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,600.01. The transfer capital threshold is the transfer adjustment factor * $1,600.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,23821.44,94077.13,Inpatient DRG
Repair Complex Trunk 2.6-7.5 Cm|UNUSUAL NON-OVERLAPPING SERVICE,CASE-13101,APC,13101,CPT,0360,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],2718.88,,"APC Price ($2,718.88). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2718.88,2854.83,OPPS APC
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],6829.10,,"Case rate ($6,503.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,186.05, add-ons for qualifying new technology services are included. If operating cost exceeds $41,057.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,093.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $4,225.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,241.10 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $333.44. The transfer capital threshold is the transfer adjustment factor * $333.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6503.90,14492.93,Inpatient DRG
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],32101.06,,,,,,0,other,7665.00,40737.46,There are no additional notes associated with this service or procedure.
Episiotomy/Vag Rpr Oth/Thn Attending,CASE-59300,APC,59300,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3136.08,,"APC Price ($3,030.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3030.03,3181.53,OPPS APC
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],19763.43,,"Fee schedule rate ($19,763.43). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,8318.14,19763.43,There are no additional notes associated with this service or procedure.
Ercp Destruction/Lithotripsy Calculi Any Method,CASE-43265,APC,43265,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5966.63,,"APC Price ($5,682.51). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5682.51,5966.63,OPPS APC
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH CC",457,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],43198.38,,"Case rate ($41,141.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $38,481.63, add-ons for qualifying new technology services are included. If operating cost exceeds $73,352.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,557.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $36,398.68 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $36,536.68 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,797.69. The transfer capital threshold is the transfer adjustment factor * $2,797.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,42327.47,160549.49,Inpatient DRG
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],6965.00,,,,,,0,other,6965.00,21195.68,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITH STERILIZATION WITHOUT CC/MCC,785,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],8852.80,,"Case rate ($8,431.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,979, add-ons for qualifying new technology services are included. If operating cost exceeds $42,850.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,234.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,011.89 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,034.06 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $474.40. The transfer capital threshold is the transfer adjustment factor * $474.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8431.24,20142.33,Inpatient DRG
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6201.19,,"Case rate ($6,201.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,904.45, add-ons for qualifying new technology services are included. If operating cost exceeds $40,775.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,071.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,944.95 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,959.50 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $311.30. The transfer capital threshold is the transfer adjustment factor * $311.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,5937.41,12366.99,Inpatient DRG
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],23954.07,,"Fee schedule rate ($23,954.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,6167.00,29058.99,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],31040.85,,"Case rate ($29,562.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $27,688.70, add-ons for qualifying new technology services are included. If operating cost exceeds $62,559.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,731.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.2. The base transfer operating payment is the transfer adjustment factor * $25,646.51 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $25,743.75 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,971.25. The transfer capital threshold is the transfer adjustment factor * $1,971.25. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,30398.48,82674.88,Inpatient DRG
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],37505.96,,"Case rate ($35,719.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $33,365.14, add-ons for qualifying new technology services are included. If operating cost exceeds $68,236.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,230.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.9. The base transfer operating payment is the transfer adjustment factor * $31,304.77 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $31,420.19 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,470.26. The transfer capital threshold is the transfer adjustment factor * $2,470.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,35719.96,105091.76,Inpatient DRG
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],17365.00,,"Fee schedule rate ($17,365.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5683.00,19635.68,There are no additional notes associated with this service or procedure.
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",759,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],13057.66,,,,,,0,other,6190.22,13057.66,There are no additional notes associated with this service or procedure.
Hemorrhoid Ntrnl & Xtrnl 1 Column W/Fissurecto,CASE-46257,APC,46257,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],2598.08,,"APC Price ($2,598.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2598.08,2727.99,OPPS APC
GASTROINTESTINAL OBSTRUCTION WITH CC,389,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],12763.70,,"Case rate ($7,293.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,920.63, add-ons for qualifying new technology services are included. If operating cost exceeds $41,791.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,151.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $4,957.39 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,975.67 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $391.19. The transfer capital threshold is the transfer adjustment factor * $391.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,5118.00,16423.43,All Other Inpatient
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],23010.16,,"Case rate ($13,148.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,367.53, add-ons for qualifying new technology services are included. If operating cost exceeds $47,238.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,579.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $10,384.29 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,422.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $819.42. The transfer capital threshold is the transfer adjustment factor * $819.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,13148.66,32553.63,All Other Inpatient
SIGNS AND SYMPTOMS WITH MCC,947,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],11068.48,,"Case rate ($10,541.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,942.06, add-ons for qualifying new technology services are included. If operating cost exceeds $44,813.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,388.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $7,967.73 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,997.11 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $628.73. The transfer capital threshold is the transfer adjustment factor * $628.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10541.41,30414.32,Inpatient DRG
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],21195.68,,"Fee schedule rate ($21,195.68). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,6965.00,21195.68,There are no additional notes associated with this service or procedure.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],27120.18,,"Fee schedule rate ($27,120.18). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,11717.72,43888.01,There are no additional notes associated with this service or procedure.
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITHOUT CC/MCC",630,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],42541.02,,"Fee schedule rate ($42,541.02). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11828.78,42541.02,There are no additional notes associated with this service or procedure.
RESPIRATORY NEOPLASMS WITH CC,181,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],9657.73,,"Case rate ($9,197.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,692.16, add-ons for qualifying new technology services are included. If operating cost exceeds $43,563.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,290.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,722.42 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,747.21 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $530.47. The transfer capital threshold is the transfer adjustment factor * $530.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9197.84,21074.07,Inpatient DRG
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],28503.86,,"Case rate ($27,944.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $26,132.21, add-ons for qualifying new technology services are included. If operating cost exceeds $61,003.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,661.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.8. The base transfer operating payment is the transfer adjustment factor * $24,098.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $24,187.26 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,901.60. The transfer capital threshold is the transfer adjustment factor * $1,901.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,27944.96,86252.84,Inpatient DRG
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],38248.08,,"Fee schedule rate ($38,248.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11593.79,38248.08,There are no additional notes associated with this service or procedure.
BRONCHITIS AND ASTHMA WITH CC/MCC,202,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],14307.27,,"Fee schedule rate ($14,307.27). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7606.34,19110.30,There are no additional notes associated with this service or procedure.
BRONCHITIS AND ASTHMA WITHOUT CC/MCC,203,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5927.78,,"Case rate ($5,927.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $5,614.23, add-ons for qualifying new technology services are included. If operating cost exceeds $44,258.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $3,061.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,235.54 + an uncompensated DSH payment of $1,359.91. The transfer operating threshold is the transfer adjustment factor * $4,254.32 + an uncompensated DSH payment of $1,359.91. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $332.34. The transfer capital threshold is the transfer adjustment factor * $332.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,4763.76,13707.00,Inpatient DRG
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC,806,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],10071.17,,"Fee schedule rate ($10,071.17). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5354.25,13416.00,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],31091.14,,"Fee schedule rate ($31,091.14). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13148.66,32553.63,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],19763.43,,"Fee schedule rate ($19,763.43). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,8318.14,19763.43,There are no additional notes associated with this service or procedure.
"NEONATE BIRTH WEIGHT > 2499 GRAMS NORMAL NEWBORN OR NEONATE WITH OTHER PROBLEM,MINOR",640,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],1130.37,,"Case rate ($1,130.37). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,1130.37,1186.89,There are no additional notes associated with this service or procedure.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],33623.33,,"Case rate ($33,623.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $31,414.68, add-ons for qualifying new technology services are included. If operating cost exceeds $66,285.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,076.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.4. The base transfer operating payment is the transfer adjustment factor * $29,361.48 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $29,469.74 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,316.91. The transfer capital threshold is the transfer adjustment factor * $2,316.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,33623.33,133270.57,Inpatient DRG
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],67790.93,,"Fee schedule rate ($67,790.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,21597.50,67790.93,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC,832,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],9034.88,,"Fee schedule rate ($9,034.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4803.31,14198.92,There are no additional notes associated with this service or procedure.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],54537.29,,"Fee schedule rate ($54,537.29). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.7), with a minimum of zero.",,,,0,other,21597.50,67790.93,There are no additional notes associated with this service or procedure.
SPINAL PROCEDURES WITHOUT CC/MCC,030,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],44714.01,,"Fee schedule rate ($44,714.01). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,16810.99,44714.01,There are no additional notes associated with this service or procedure.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",063,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],12024.16,,"Case rate ($11,451.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,788.77, add-ons for qualifying new technology services are included. If operating cost exceeds $45,659.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,455.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $8,811.33 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,843.82 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $695.30. The transfer capital threshold is the transfer adjustment factor * $695.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,35701.87,Inpatient DRG
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],14950.65,,"Case rate ($14,238.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,404.52, add-ons for qualifying new technology services are included. If operating cost exceeds $48,275.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,637.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.6. The base transfer operating payment is the transfer adjustment factor * $11,416.28 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,459.57 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $877.48. The transfer capital threshold is the transfer adjustment factor * $877.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6277.00,36801.89,Inpatient DRG
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],15177.23,,"Fee schedule rate ($15,177.23). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,7414.07,18217.52,There are no additional notes associated with this service or procedure.
HC Joint Injection/Aspir Large WO US|LEFT SIDE|PBB CHARGE,CASE-20610,APC,20610,CPT,0510,RC,,,LT|PBB,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],14674.80,,"Fee schedule rate ($14,674.80). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6711.00,16865.16,There are no additional notes associated with this service or procedure.
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,451,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],94077.13,,"Fee schedule rate ($94,077.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,23821.44,94077.13,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC,833,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],5721.39,,"Fee schedule rate ($5,721.39). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,3041.73,10289.10,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],23851.92,,"Case rate ($23,851.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $22,324.54, add-ons for qualifying new technology services are included. If operating cost exceeds $57,195.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,362.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.8. The base transfer operating payment is the transfer adjustment factor * $20,304.73 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $20,379.59 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,602.24. The transfer capital threshold is the transfer adjustment factor * $1,602.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,23851.92,63653.13,Inpatient DRG
Rpr Ingun Hernia Sliding Any Age,CASE-49525,APC,49525,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3351.34,,"APC Price ($3,351.34). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3351.34,3518.91,OPPS APC
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],28821.04,,"Fee schedule rate ($28,821.04). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,10347.06,28821.04,There are no additional notes associated with this service or procedure.
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],40426.76,,"Fee schedule rate ($40,426.76). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,11914.12,40426.76,There are no additional notes associated with this service or procedure.
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC",605,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],8311.13,,"Case rate ($8,148.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,715.67, add-ons for qualifying new technology services are included. If operating cost exceeds $42,586.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,213.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,749.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,770.72 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $453.69. The transfer capital threshold is the transfer adjustment factor * $453.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,8148.17,18024.13,Inpatient DRG
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],9985.88,,"Case rate ($9,648.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,111.10, add-ons for qualifying new technology services are included. If operating cost exceeds $43,982.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,323.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $7,139.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,166.15 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $563.40. The transfer capital threshold is the transfer adjustment factor * $563.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,9648.19,31477.13,Inpatient DRG
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],52534.65,,"Fee schedule rate ($52,534.65). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,23526.87,94787.57,There are no additional notes associated with this service or procedure.
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC,058,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],40853.02,,"Fee schedule rate ($40,853.02). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,13521.80,40853.02,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],35973.56,,"Fee schedule rate ($35,973.56). Adds an outlier to normal pricing equal to the per diem rate ($68,707.98) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,14908.05,49717.39,There are no additional notes associated with this service or procedure.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],8985.19,,"Fee schedule rate ($8,985.19). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8151.55,18033.97,There are no additional notes associated with this service or procedure.
Anterior Colporraphy Rpr Cystocele W/Cysto,CASE-57240,APC,57240,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5194.43,,"APC Price ($5,018.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5018.77,5269.71,OPPS APC
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],14244.58,,"Case rate ($13,762.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,938.93, add-ons for qualifying new technology services are included. If operating cost exceeds $47,809.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,624.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $10,953.59 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,993.98 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $864.35. The transfer capital threshold is the transfer adjustment factor * $864.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,1188.00,34338.33,Inpatient DRG
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],35192.25,,"Fee schedule rate ($35,192.25). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,10895.60,35192.25,There are no additional notes associated with this service or procedure.
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],7607.34,,"Fee schedule rate ($7,607.34). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,17467.27,There are no additional notes associated with this service or procedure.
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],14830.15,,"Fee schedule rate ($14,830.15). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,7884.32,17835.23,There are no additional notes associated with this service or procedure.
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],18918.49,,"Fee schedule rate ($18,918.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9282.47,21320.03,There are no additional notes associated with this service or procedure.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],24259.09,,"Fee schedule rate ($24,259.09). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10098.51,24259.09,There are no additional notes associated with this service or procedure.
HEART FAILURE AND SHOCK WITH CC,292,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],15550.06,,"Fee schedule rate ($15,550.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5502.00,16705.77,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],23899.13,,"Fee schedule rate ($23,899.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9795.13,23899.13,There are no additional notes associated with this service or procedure.
Arthroscopy Knee W/Meniscus Rpr Medial/Lateral|RIGHT SIDE,CASE-29882,APC,29882,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7029.71,OPPS APC
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],18815.22,,"Case rate ($18,178.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,047.10, add-ons for qualifying new technology services are included. If operating cost exceeds $51,918.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,947.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $15,046.67 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,102.15 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,187.33. The transfer capital threshold is the transfer adjustment factor * $1,187.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,18178.96,54764.34,Inpatient DRG
FRACTURES OF FEMUR WITH MCC,533,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],49490.05,,"Fee schedule rate ($49,490.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,6852.00,49490.05,There are no additional notes associated with this service or procedure.
"NEONATE BIRTH WEIGHT > 2499 GRAMS WITH MAJOR ANOMALY,MAJOR",633,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],23435.09,,"Case rate ($22,319.13). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,22319.13,23435.09,There are no additional notes associated with this service or procedure.
Cysto/Uretero W/Lithotripsy &Indwell Stent Insrt|BILATERAL PROCEDURE,CASE-52356,APC,52356,CPT,0360,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5194.43,,"APC Price ($5,018.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5018.77,5269.71,OPPS APC
COAGULATION DISORDERS,813,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],29046.49,,"Fee schedule rate ($29,046.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12274.39,30013.33,There are no additional notes associated with this service or procedure.
Excision Skin Abd Infraumbilical Panniculectomy,CASE-15830,APC,15830,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6215.36,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6215.36,6526.12,OPPS APC
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],12272.58,,"Fee schedule rate ($12,272.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5628.97,12272.58,There are no additional notes associated with this service or procedure.
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR,518,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],27254.22,,"Case rate ($27,254.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $25,489.62, add-ons for qualifying new technology services are included. If operating cost exceeds $60,360.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,611.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 5.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $23,458.18 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $23,544.67 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,851.08. The transfer capital threshold is the transfer adjustment factor * $1,851.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,13252.00,89342.77,Inpatient DRG
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],12558.65,,"Fee schedule rate ($12,558.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5065.00,12558.65,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,065,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],18986.57,,"Fee schedule rate ($18,986.57). Adds an outlier to normal pricing equal to the per diem rate ($85,884.96) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,8786.76,25681.86,There are no additional notes associated with this service or procedure.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],38517.10,,"Fee schedule rate ($38,517.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,16897.01,43444.85,There are no additional notes associated with this service or procedure.
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],13904.43,,"Case rate ($13,904.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,070.60, add-ons for qualifying new technology services are included. If operating cost exceeds $47,941.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,634.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,084.78 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,125.65 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $874.70. The transfer capital threshold is the transfer adjustment factor * $874.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,13904.43,34749.58,Inpatient DRG
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],8554.50,,"Case rate ($8,554.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,093.67, add-ons for qualifying new technology services are included. If operating cost exceeds $42,964.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,243.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,126.13 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,148.72 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $483.41. The transfer capital threshold is the transfer adjustment factor * $483.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8554.50,19204.75,Inpatient DRG
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,345,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],12134.89,,"Case rate ($12,134.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,424.43, add-ons for qualifying new technology services are included. If operating cost exceeds $46,295.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,505.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $9,444.66 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,479.48 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $745.28. The transfer capital threshold is the transfer adjustment factor * $745.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12134.89,33616.03,Inpatient DRG
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],21667.25,,"Case rate ($21,667.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,292.19, add-ons for qualifying new technology services are included. If operating cost exceeds $55,163.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,202.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $18,279.84 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,347.24 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,442.46. The transfer capital threshold is the transfer adjustment factor * $1,442.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8972.00,81524.17,Inpatient DRG
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],30935.16,,"Fee schedule rate ($30,935.16). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13092.47,33159.45,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC,084,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],8417.70,,"Case rate ($8,417.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,966.41, add-ons for qualifying new technology services are included. If operating cost exceeds $42,837.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,233.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $5,999.34 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,021.46 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $473.41. The transfer capital threshold is the transfer adjustment factor * $473.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,19445.16,Inpatient DRG
OSTEOMYELITIS WITHOUT CC/MCC,541,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],11429.52,,"Fee schedule rate ($11,429.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5103.00,15493.67,There are no additional notes associated with this service or procedure.
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],36481.34,,"Case rate ($20,846.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $19,528.64, add-ons for qualifying new technology services are included. If operating cost exceeds $54,399.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,142.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $17,519.09 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $17,583.69 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,382.43. The transfer capital threshold is the transfer adjustment factor * $1,382.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,20846.48,81306.30,All Other Inpatient
NORMAL NEWBORN,795,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],3462.91,,"Case rate ($3,298.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $3,203.67, add-ons for qualifying new technology services are included. If operating cost exceeds $38,074.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $1,858.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $1,254.10 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $1,258.72 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $98.96. The transfer capital threshold is the transfer adjustment factor * $98.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,1369.79,5771.52,Inpatient DRG
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC,058,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],32126.63,,"Fee schedule rate ($32,126.63). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13521.80,40853.02,There are no additional notes associated with this service or procedure.
Egd Percutaneous Placement Gastrostomy Tube,CASE-43246,APC,43246,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1796.14,,"APC Price ($1,796.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1796.14,1885.95,OPPS APC
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],47123.82,,"Fee schedule rate ($47,123.82). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,12696.97,47123.82,There are no additional notes associated with this service or procedure.
VENTRICULAR SHUNT PROCEDURES WITH MCC,031,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],32287.20,,"Case rate ($32,287.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $30,171.71, add-ons for qualifying new technology services are included. If operating cost exceeds $65,042.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,979.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7. The base transfer operating payment is the transfer adjustment factor * $28,123.07 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $28,226.76 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,219.19. The transfer capital threshold is the transfer adjustment factor * $2,219.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,32287.20,88162.80,Inpatient DRG
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],29916.58,,"Fee schedule rate ($29,916.58). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12725.42,34245.00,There are no additional notes associated with this service or procedure.
Dstr Nrolytc Agnt Parverteb Fct Addl Lmbr/Sacral|LEFT SIDE,CASE-64636,APC,64636,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1919.19,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1827.80,1919.19,OPPS APC
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],81454.07,,"Fee schedule rate ($81,454.07). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,10078.00,81454.07,There are no additional notes associated with this service or procedure.
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],16283.24,,"Fee schedule rate ($16,283.24). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7875.94,17233.12,There are no additional notes associated with this service or procedure.
Post Colporrhaphy Rectocele W/WO Perineorrhaphy,CASE-57250,APC,57250,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],10298.02,,"APC Price ($9,949.78). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,9949.78,10447.27,OPPS APC
Laps Rpr Paraesphgl Hrna Incl Fundplsty W/Mesh,CASE-43282,APC,43282,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],9949.78,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,9949.78,10447.27,OPPS APC
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC,858,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],33794.11,,"Fee schedule rate ($33,794.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11377.76,33794.11,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITH STERILIZATION WITHOUT CC/MCC,785,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],8431.24,,"Case rate ($8,431.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,979, add-ons for qualifying new technology services are included. If operating cost exceeds $42,850.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,234.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,011.89 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,034.06 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $474.40. The transfer capital threshold is the transfer adjustment factor * $474.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8431.24,20142.33,Inpatient DRG
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],20981.60,,"Fee schedule rate ($20,981.60). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,10003.71,23415.63,There are no additional notes associated with this service or procedure.
CHEST PAIN,313,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],6965.00,,,,,,0,other,6820.84,15377.66,There are no additional notes associated with this service or procedure.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],25665.57,,"Case rate ($25,162.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $23,543.58, add-ons for qualifying new technology services are included. If operating cost exceeds $58,414.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,458.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $21,519.28 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $21,598.63 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,698.08. The transfer capital threshold is the transfer adjustment factor * $1,698.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,25162.32,75579.22,Inpatient DRG
PREMATURITY WITH MAJOR PROBLEMS,791,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],3186.77,,,,,,0,other,3048.21,30904.42,Estimated amount calculated based on 5 day length of stay.
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC,806,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],6510.67,,"Case rate ($6,510.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,192.35, add-ons for qualifying new technology services are included. If operating cost exceeds $41,063.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,093.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $4,231.80 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,247.40 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $333.93. The transfer capital threshold is the transfer adjustment factor * $333.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,5354.25,13416.00,Inpatient DRG
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],15076.44,,"Fee schedule rate ($15,076.44). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6340.03,15076.44,There are no additional notes associated with this service or procedure.
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],15341.29,,"Case rate ($14,610.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,727.68, add-ons for qualifying new technology services are included. If operating cost exceeds $48,598.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,686.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.6. The base transfer operating payment is the transfer adjustment factor * $11,739.44 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,782.73 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $926.36. The transfer capital threshold is the transfer adjustment factor * $926.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6277.00,36801.89,Inpatient DRG
Revj/Rmvl Perph Neurostimulator Electrode Array,CASE-64585,APC,64585,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],18158.97,,"APC Price ($18,158.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,18158.97,19066.92,OPPS APC
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],69000.38,,"Fee schedule rate ($69,000.38). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15), with a minimum of zero.",,,,0,other,26809.29,97015.50,There are no additional notes associated with this service or procedure.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],10603.44,,"Case rate ($10,098.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,530.04, add-ons for qualifying new technology services are included. If operating cost exceeds $44,401.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,356.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $7,557.23 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,585.10 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $596.34. The transfer capital threshold is the transfer adjustment factor * $596.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10098.51,24259.09,Inpatient DRG
MAJOR BLADDER PROCEDURES WITH MCC,653,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],38435.08,,"Case rate ($37,135.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $34,681.82, add-ons for qualifying new technology services are included. If operating cost exceeds $69,552.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,333.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.5. The base transfer operating payment is the transfer adjustment factor * $32,616.61 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $32,736.87 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,573.77. The transfer capital threshold is the transfer adjustment factor * $2,573.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,10280.00,125343.98,Inpatient DRG
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],67107.92,,"Fee schedule rate ($67,107.92). Adds an outlier to normal pricing equal to the per diem rate ($118,521.29) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16.7), with a minimum of zero.",,,,0,other,26127.34,90333.60,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],14370.36,,"Case rate ($14,370.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,504.04, add-ons for qualifying new technology services are included. If operating cost exceeds $48,375.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,668.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $11,516.62 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,559.08 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $908.78. The transfer capital threshold is the transfer adjustment factor * $908.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,14370.36,38378.80,Inpatient DRG
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],33398.16,,"Fee schedule rate ($33,398.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,7353.00,33398.16,There are no additional notes associated with this service or procedure.
Laparoscopy Supracervical Hysterectomy 250 Gm/<,CASE-58541,APC,58541,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],9949.78,,"APC Price ($9,949.78). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,9949.78,10447.27,OPPS APC
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],29917.96,,"Fee schedule rate ($29,917.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,12527.66,29917.96,There are no additional notes associated with this service or procedure.
HC Non Stress Test|UNUSUAL NON-OVERLAPPING SERVICE,CASE-59025,APC,59025,CPT,0920,RC,,,XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],198.70,,"APC Price ($189.24). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,189.24,198.70,OPPS APC
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],18223.96,,"Case rate ($17,356.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,281.67, add-ons for qualifying new technology services are included. If operating cost exceeds $51,152.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,887.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $14,284.05 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,336.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,127.15. The transfer capital threshold is the transfer adjustment factor * $1,127.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,17356.15,44778.95,Inpatient DRG
OTHER CEREBROVASCULAR DISORDERS WITH CC,071,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],20188.60,,,,,,0,other,5843.00,29215.10,There are no additional notes associated with this service or procedure.
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],13295.62,,"Case rate ($13,295.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,504.24, add-ons for qualifying new technology services are included. If operating cost exceeds $47,375.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,590.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $10,520.50 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,559.29 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $830.17. The transfer capital threshold is the transfer adjustment factor * $830.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7000.00,33835.79,Inpatient DRG
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],16283.24,,"Fee schedule rate ($16,283.24). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7875.94,17233.12,There are no additional notes associated with this service or procedure.
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],40916.35,,,,,,0,other,11165.00,61234.06,There are no additional notes associated with this service or procedure.
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],13904.43,,"Case rate ($13,904.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,070.60, add-ons for qualifying new technology services are included. If operating cost exceeds $47,941.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,634.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,084.78 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,125.65 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $874.70. The transfer capital threshold is the transfer adjustment factor * $874.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,13904.43,34749.58,Inpatient DRG
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC",758,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],15005.90,,"Case rate ($8,574.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,112.57, add-ons for qualifying new technology services are included. If operating cost exceeds $42,983.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,244.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $6,144.96 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,167.62 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $484.90. The transfer capital threshold is the transfer adjustment factor * $484.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,8574.80,19263.78,All Other Inpatient
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],25667.48,,"Fee schedule rate ($25,667.48). Adds an outlier to normal pricing equal to the per diem rate ($77,296.48) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,11194.25,36094.03,There are no additional notes associated with this service or procedure.
OTHER MENTAL DISORDER DIAGNOSES,887,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],2070.00,,,,,,0,other,2070.00,21072.10,Estimated amount calculated based on 1 day length of stay.
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC,497,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],37761.19,,"Fee schedule rate ($37,761.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10127.65,37761.19,There are no additional notes associated with this service or procedure.
HC Injection Small Joint/Bursa|PBB CHARGE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-20600,APC,20600,CPT,0361,RC,,,PBB|XU,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,287.31,OPPS APC
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,167,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],43522.37,,"Fee schedule rate ($43,522.37). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,14157.71,43522.37,There are no additional notes associated with this service or procedure.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,056,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],18030.68,,"Case rate ($17,677.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,580.28, add-ons for qualifying new technology services are included. If operating cost exceeds $51,451.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,910.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $14,581.57 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,635.33 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,150.63. The transfer capital threshold is the transfer adjustment factor * $1,150.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,7659.00,59328.19,Inpatient DRG
INFLAMMATORY BOWEL DISEASE WITH CC,386,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],8556.53,,"Case rate ($8,556.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,095.56, add-ons for qualifying new technology services are included. If operating cost exceeds $42,966.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,243.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,128.01 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,150.61 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $483.56. The transfer capital threshold is the transfer adjustment factor * $483.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8556.53,19879.00,Inpatient DRG
Genioplasty Augmentation,CASE-21120,APC,21120,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5541.10,,"APC Price ($5,541.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5541.10,5818.16,OPPS APC
PSYCHOSES,885,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],2070.00,,,,,,0,other,2070.00,27484.83,Estimated amount calculated based on 3 day length of stay.
MAJOR BLADDER PROCEDURES WITH MCC,653,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],125343.98,,"Fee schedule rate ($125,343.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,10280.00,125343.98,There are no additional notes associated with this service or procedure.
"Amp F/Th 1/2 Jt/Phalanx W/Neurect W/Dir Clsr|LEFT HAND, THIRD DIGIT",CASE-26951,APC,26951,CPT,0360,RC,,,F2,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
"Arthrodesis Interphalangeal Jt W/WO Int Fixj|LEFT HAND, FOURTH DIGIT",CASE-26860,APC,26860,CPT,0360,RC,,,F3,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3062.67,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
HC Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn,CASE-62321,APC,62321,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],693.76,,"APC Price ($660.72). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,660.72,693.76,OPPS APC
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITH MCC OR ANTINEOPLASTIC IMPLANT OR EPILEPSY WITH NEUROSTIMULATOR,023,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],136379.44,,"Fee schedule rate ($136,379.44). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,15168.00,136379.44,There are no additional notes associated with this service or procedure.
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],7888.39,,"Case rate ($7,733.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,330.12, add-ons for qualifying new technology services are included. If operating cost exceeds $42,201.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,183.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,365.38 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,385.17 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $423.38. The transfer capital threshold is the transfer adjustment factor * $423.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,7733.72,18043.23,Inpatient DRG
Tendon Sheath Incision,CASE-26055,APC,26055,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1557.80,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1505.12,1580.37,OPPS APC
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],18933.95,,"Fee schedule rate ($18,933.95). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.8), with a minimum of zero.",,,,0,other,8767.81,19824.58,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],21784.85,,"Fee schedule rate ($21,784.85). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.4), with a minimum of zero.",,,,0,other,9795.13,23899.13,There are no additional notes associated with this service or procedure.
HC Inj Tendon Sheath/Ligament,CASE-20550,APC,20550,CPT,0510,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],301.68,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,287.31,301.68,OPPS APC
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],13904.43,,"Case rate ($13,904.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,070.60, add-ons for qualifying new technology services are included. If operating cost exceeds $47,941.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,634.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,084.78 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,125.65 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $874.70. The transfer capital threshold is the transfer adjustment factor * $874.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,13904.43,34749.58,Inpatient DRG
HC Injection Small Joint/Bursa|PBB CHARGE,CASE-20600,APC,20600,CPT,0361,RC,,,PBB,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],301.68,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,287.31,301.68,OPPS APC
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],18588.16,,"Fee schedule rate ($18,588.16). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.8), with a minimum of zero.",,,,0,other,8643.20,19462.52,There are no additional notes associated with this service or procedure.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],21323.33,,"Fee schedule rate ($21,323.33). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,5569.00,40108.48,There are no additional notes associated with this service or procedure.
SEIZURES WITH MCC,100,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],36398.28,,"Fee schedule rate ($36,398.28). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,15061.09,38110.41,There are no additional notes associated with this service or procedure.
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH MCC",510,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],59434.38,,,,,,0,other,10710.00,89863.76,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],46523.26,,"Fee schedule rate ($46,523.26). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,17782.11,46523.26,There are no additional notes associated with this service or procedure.
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],24387.68,,"Fee schedule rate ($24,387.68). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10733.06,45157.33,There are no additional notes associated with this service or procedure.
Anoscopy Dx W/HRA &Chem Agnts Enhancement W/Bx|SEPARATE STRUCTURE,CASE-46607,APC,46607,CPT,0360,RC,,,XS,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],2689.02,,"APC Price ($2,598.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2598.08,2727.99,OPPS APC
HC Joint Injection/Aspir Large WO US|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-20610,APC,20610,CPT,0510,RC,,,RT|XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],297.37,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,287.31,301.68,OPPS APC
Excision Choledochal Cyst,CASE-47715,APC,47715,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],301.68,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,287.31,301.68,OPPS APC
HC Biopsy/Exc Lymph Node Needle|LEFT SIDE,CASE-38505,APC,38505,CPT,0361,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1600.04,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1545.93,1600.04,OPPS APC
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],27222.08,,"Fee schedule rate ($27,222.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7389.00,37134.43,There are no additional notes associated with this service or procedure.
HEADACHES WITHOUT MCC,103,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],16455.88,,,,,,0,other,6965.00,20883.08,There are no additional notes associated with this service or procedure.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],17194.49,,"Fee schedule rate ($17,194.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8554.50,19204.75,There are no additional notes associated with this service or procedure.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],9814.33,,"Case rate ($9,346.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,844.71, add-ons for qualifying new technology services are included. If operating cost exceeds $43,715.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,288.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $6,873.70 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,899.76 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $528.33. The transfer capital threshold is the transfer adjustment factor * $528.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5569.00,40108.48,Inpatient DRG
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],35061.53,,"Fee schedule rate ($35,061.53). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,9696.93,35061.53,There are no additional notes associated with this service or procedure.
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR,518,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],73538.85,,,,,,0,other,13252.00,89342.77,There are no additional notes associated with this service or procedure.
Hysteroscopy Bx Endometrium&/Polypc W/WO D&C,CASE-58558,APC,58558,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3030.03,,"APC Price ($3,030.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3030.03,3181.53,OPPS APC
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITHOUT CC/MCC,816,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],14733.53,,"Fee schedule rate ($14,733.53). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6224.90,14733.53,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],70242.60,,"Fee schedule rate ($70,242.60). Adds an outlier to normal pricing equal to the per diem rate ($137,416) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16.5), with a minimum of zero.",,,,0,other,27256.92,81353.66,There are no additional notes associated with this service or procedure.
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],16064.26,,"Fee schedule rate ($16,064.26). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7733.72,18043.23,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],24675.88,,"Fee schedule rate ($24,675.88). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10834.64,25830.00,There are no additional notes associated with this service or procedure.
HC Injection Small Joint/Bursa,CASE-20600,APC,20600,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,167,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],23138.29,,"Fee schedule rate ($23,138.29). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,14157.71,43522.37,There are no additional notes associated with this service or procedure.
Exc Tumor Soft Tiss Back/Flank Subfascial 5 Cm/>,CASE-21933,APC,21933,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],2718.88,,"APC Price ($2,718.88). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2718.88,2854.83,OPPS APC
COAGULATION DISORDERS,813,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],29046.49,,"Fee schedule rate ($29,046.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12274.39,30013.33,There are no additional notes associated with this service or procedure.
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],14690.49,,"Fee schedule rate ($14,690.49). Adds an outlier to normal pricing equal to the per diem rate ($54,770.58) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.7), with a minimum of zero.",,,,0,other,7238.69,16804.22,There are no additional notes associated with this service or procedure.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],49902.84,,,,,,0,other,11348.00,62454.12,There are no additional notes associated with this service or procedure.
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH MCC",722,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],56869.13,,"Fee schedule rate ($56,869.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,14200.37,56869.13,There are no additional notes associated with this service or procedure.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],16900.84,,"Fee schedule rate ($16,900.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8151.55,18033.97,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],20090.22,,,,,,0,other,8859.23,20090.22,There are no additional notes associated with this service or procedure.
Cysto/Uretero W/Lithotripsy &Indwell Stent Insrt|RIGHT SIDE,CASE-52356,APC,52356,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5018.77,,"APC Price ($5,018.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5018.77,5269.71,OPPS APC
Sphincterotomy Anal Division Sphincter Spx,CASE-46080,APC,46080,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],2598.08,,"APC Price ($2,598.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2598.08,2727.99,OPPS APC
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC,858,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],33794.11,,"Fee schedule rate ($33,794.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11377.76,33794.11,There are no additional notes associated with this service or procedure.
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],14309.17,,"Fee schedule rate ($14,309.17). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,17467.27,There are no additional notes associated with this service or procedure.
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],36855.62,,"Fee schedule rate ($36,855.62). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,15821.59,40320.14,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC,817,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],43874.75,,"Fee schedule rate ($43,874.75). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,17396.11,44895.04,There are no additional notes associated with this service or procedure.
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],29243.52,,"Fee schedule rate ($29,243.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,14343.25,36024.65,There are no additional notes associated with this service or procedure.
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],2401.00,,,,,,0,other,1188.00,31658.33,Estimated amount calculated based on 16 day length of stay.
Rpr Ingun Hernia Sliding Any Age|RIGHT SIDE,CASE-49525,APC,49525,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3351.34,,"APC Price ($3,351.34). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3351.34,3518.91,OPPS APC
Transection/Avulsion Oth Spinal Nrv Xdrl,CASE-64772,APC,64772,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,083,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],11675.74,,"Case rate ($11,119.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,497.20, add-ons for qualifying new technology services are included. If operating cost exceeds $45,368.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,414.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $8,519.94 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,552.25 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $654.86. The transfer capital threshold is the transfer adjustment factor * $654.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,28680.85,Inpatient DRG
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],61234.06,,"Fee schedule rate ($61,234.06). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11165.00,61234.06,There are no additional notes associated with this service or procedure.
OSTEOMYELITIS WITHOUT CC/MCC,541,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],6076.41,,"Fee schedule rate ($6,076.41). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5103.00,15493.67,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH CC,427,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],134742.59,,"Fee schedule rate ($134,742.59). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,50829.82,142040.39,There are no additional notes associated with this service or procedure.
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],7505.33,,"Case rate ($7,147.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,785.17, add-ons for qualifying new technology services are included. If operating cost exceeds $41,656.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,140.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $4,822.44 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,840.22 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $380.54. The transfer capital threshold is the transfer adjustment factor * $380.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,16400.70,Inpatient DRG
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,074,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],20919.08,,"Fee schedule rate ($20,919.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8925.60,20919.08,There are no additional notes associated with this service or procedure.
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC",629,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],42872.25,,,,,,0,other,16699.94,44657.18,There are no additional notes associated with this service or procedure.
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",004,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],97662.55,,"Case rate ($95,747.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $89,207.57, add-ons for qualifying new technology services are included. If operating cost exceeds $124,078.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $8,620.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 22.4. The base transfer operating payment is the transfer adjustment factor * $86,942.06 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $87,262.63 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $6,860.59. The transfer capital threshold is the transfer adjustment factor * $6,860.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,10249.47,272554.00,Inpatient DRG
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],8004.40,,"Case rate ($7,733.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,330.12, add-ons for qualifying new technology services are included. If operating cost exceeds $42,201.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,183.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,365.38 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,385.17 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $423.38. The transfer capital threshold is the transfer adjustment factor * $423.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,7733.72,18043.23,Inpatient DRG
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH CC,026,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],63202.45,,"Fee schedule rate ($63,202.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,23000.66,63202.45,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC,831,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],9294.42,,"Fee schedule rate ($9,294.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,4941.30,23661.59,There are no additional notes associated with this service or procedure.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],36094.03,,"Fee schedule rate ($36,094.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11194.25,36094.03,There are no additional notes associated with this service or procedure.
HC Inj Anes/Steroid C/D Facet Sg|LEFT SIDE,CASE-64490,APC,64490,CPT,0361,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],856.86,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,827.89,869.28,OPPS APC
O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC,621,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],36669.96,,"Fee schedule rate ($36,669.96). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,12159.94,36669.96,There are no additional notes associated with this service or procedure.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],11593.79,,"Case rate ($11,593.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,921.06, add-ons for qualifying new technology services are included. If operating cost exceeds $45,792.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,465.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $8,943.14 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,976.12 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $705.70. The transfer capital threshold is the transfer adjustment factor * $705.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,11593.79,38248.08,Inpatient DRG
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],9282.47,,"Case rate ($9,282.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,770.90, add-ons for qualifying new technology services are included. If operating cost exceeds $43,641.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,296.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,800.88 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,825.96 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $536.66. The transfer capital threshold is the transfer adjustment factor * $536.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9282.47,21320.03,Inpatient DRG
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH CC,354,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],31968.77,,"Fee schedule rate ($31,968.77). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11633.13,33472.54,There are no additional notes associated with this service or procedure.
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITH MCC OR ANTINEOPLASTIC IMPLANT OR EPILEPSY WITH NEUROSTIMULATOR,023,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],15168.00,,"Per diem ($15,168). If length of stay < 7.1, first 1 days paid at a per diem of $30,336 instead. Capped at $107,689.53.",,,,0,other,15168.00,136379.44,Estimated amount calculated based on 6 day length of stay.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,025,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],91631.33,,"Fee schedule rate ($91,631.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,13351.00,91631.33,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],2070.00,,,,,,0,other,1188.00,12138.74,Estimated amount calculated based on 1 day length of stay.
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],24444.75,,"Fee schedule rate ($24,444.75). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10136.44,24444.75,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],52803.53,,"Fee schedule rate ($52,803.53). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,14337.84,52803.53,There are no additional notes associated with this service or procedure.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],19589.94,,"Case rate ($11,194.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,549.37, add-ons for qualifying new technology services are included. If operating cost exceeds $45,420.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,436.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $8,572.81 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,604.42 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $676.48. The transfer capital threshold is the transfer adjustment factor * $676.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,11194.25,36094.03,All Other Inpatient
RESPIRATORY NEOPLASMS WITH CC,181,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],20127.30,,"Fee schedule rate ($20,127.30). Adds an outlier to normal pricing equal to the per diem rate ($54,966.40) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,9197.84,21074.07,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],6965.00,,,,,,0,other,6340.03,15076.44,There are no additional notes associated with this service or procedure.
CERVICAL SPINAL FUSION WITHOUT CC/MCC,473,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],48037.46,,,,,,0,other,18477.61,62077.11,There are no additional notes associated with this service or procedure.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],62454.12,,"Fee schedule rate ($62,454.12). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11348.00,62454.12,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,082,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],42953.28,,"Fee schedule rate ($42,953.28). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.6), with a minimum of zero.",,,,0,other,17423.21,56223.11,There are no additional notes associated with this service or procedure.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],62454.12,,"Fee schedule rate ($62,454.12). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11348.00,62454.12,There are no additional notes associated with this service or procedure.
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,095,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],19843.34,,"Case rate ($18,898.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,748.04, add-ons for qualifying new technology services are included. If operating cost exceeds $52,619.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,970.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.6. The base transfer operating payment is the transfer adjustment factor * $15,743.40 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,803.09 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,210.07. The transfer capital threshold is the transfer adjustment factor * $1,210.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,19411.47,50750.92,Inpatient DRG
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],45845.03,,"Fee schedule rate ($45,845.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,18598.83,48389.68,There are no additional notes associated with this service or procedure.
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],9533.13,,"Fee schedule rate ($9,533.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5068.21,14525.56,There are no additional notes associated with this service or procedure.
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],9075.36,,"Case rate ($8,643.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,176.19, add-ons for qualifying new technology services are included. If operating cost exceeds $43,047.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,249.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $6,208.35 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,231.24 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $489.90. The transfer capital threshold is the transfer adjustment factor * $489.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8643.20,19462.52,Inpatient DRG
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,426,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],98263.20,,"Fee schedule rate ($98,263.20). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,76581.29,216864.15,There are no additional notes associated with this service or procedure.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],48538.56,,"Fee schedule rate ($48,538.56). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,19435.86,50821.76,There are no additional notes associated with this service or procedure.
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],9471.40,,"Case rate ($9,151.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,648.69, add-ons for qualifying new technology services are included. If operating cost exceeds $43,519.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,287.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,679.11 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,703.74 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $527.05. The transfer capital threshold is the transfer adjustment factor * $527.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,9151.11,30245.71,Inpatient DRG
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],18043.23,,"Fee schedule rate ($18,043.23). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7733.72,18043.23,There are no additional notes associated with this service or procedure.
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC,805,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],20902.03,,"Fee schedule rate ($20,902.03). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9253.36,21235.42,There are no additional notes associated with this service or procedure.
Anterior Colporraphy Rpr Cystocele W/Cysto,CASE-57240,APC,57240,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5269.71,,"APC Price ($5,018.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5018.77,5269.71,OPPS APC
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],38517.10,,"Fee schedule rate ($38,517.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,16897.01,43444.85,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,448,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],94077.13,,"Fee schedule rate ($94,077.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,30663.95,94077.13,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],38378.80,,"Fee schedule rate ($38,378.80). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,14370.36,38378.80,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],7353.00,,"Per diem ($7,353). If length of stay < 4.1, first 1 days paid at a per diem of $14,706 instead. Capped at $30,145.85.",,,,0,other,7353.00,33398.16,Estimated amount calculated based on 4 day length of stay.
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC,964,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],28802.15,,"Fee schedule rate ($28,802.15). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,12323.82,34154.06,There are no additional notes associated with this service or procedure.
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC,805,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],21235.42,,,,,,0,other,9253.36,21235.42,There are no additional notes associated with this service or procedure.
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6683.19,,"Case rate ($6,457.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,142.59, add-ons for qualifying new technology services are included. If operating cost exceeds $41,013.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,089.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $4,182.21 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,197.63 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $330.02. The transfer capital threshold is the transfer adjustment factor * $330.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,5139.72,13110.79,Inpatient DRG
RADIOTHERAPY,849,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],35514.29,,"Case rate ($20,293.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $19,014.57, add-ons for qualifying new technology services are included. If operating cost exceeds $53,885.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,101.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $17,006.91 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $17,069.62 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,342.01. The transfer capital threshold is the transfer adjustment factor * $1,342.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,20293.88,81867.07,All Other Inpatient
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],11168.08,,"Fee schedule rate ($11,168.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5937.41,12366.99,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,086,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],30728.81,,"Fee schedule rate ($30,728.81). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8442.00,30728.81,There are no additional notes associated with this service or procedure.
HC Biopsy Liver Percutan Needle,CASE-47000,APC,47000,CPT,0361,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1600.04,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1545.93,1623.23,OPPS APC
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],40108.48,,"Fee schedule rate ($40,108.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,5569.00,40108.48,There are no additional notes associated with this service or procedure.
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",759,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],6760.85,,"Case rate ($6,438.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,125.57, add-ons for qualifying new technology services are included. If operating cost exceeds $40,996.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,088.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,165.27 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,180.62 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $328.68. The transfer capital threshold is the transfer adjustment factor * $328.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6190.22,13057.66,Inpatient DRG
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],8592.71,,"Case rate ($8,183.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,760.21, add-ons for qualifying new technology services are included. If operating cost exceeds $42,631.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,205.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,793.29 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,815.26 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $445.29. The transfer capital threshold is the transfer adjustment factor * $445.29. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,23385.72,Inpatient DRG
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,373,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],7008.36,,"Case rate ($6,870.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,527.50, add-ons for qualifying new technology services are included. If operating cost exceeds $41,398.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,120.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $4,565.72 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,582.56 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $360.28. The transfer capital threshold is the transfer adjustment factor * $360.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6870.94,14313.05,Inpatient DRG
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",063,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],35701.87,,"Fee schedule rate ($35,701.87). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,35701.87,There are no additional notes associated with this service or procedure.
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],36868.88,,"Fee schedule rate ($36,868.88). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12606.23,36868.88,There are no additional notes associated with this service or procedure.
CHOLECYSTECTOMY WITH C.D.E. WITH MCC,411,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],88615.28,,"Fee schedule rate ($88,615.28). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,24315.13,88615.28,There are no additional notes associated with this service or procedure.
RADIOTHERAPY,849,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],81867.07,,"Fee schedule rate ($81,867.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,20293.88,81867.07,There are no additional notes associated with this service or procedure.
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],19126.22,,"Case rate ($18,751.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,579.45, add-ons for qualifying new technology services are included. If operating cost exceeds $52,450.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,989.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $15,577.06 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,634.50 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,229.18. The transfer capital threshold is the transfer adjustment factor * $1,229.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,8480.00,59081.91,Inpatient DRG
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH MCC",510,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],89863.76,,"Fee schedule rate ($89,863.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10710.00,89863.76,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],51903.64,,"Fee schedule rate ($51,903.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,16017.99,51903.64,There are no additional notes associated with this service or procedure.
HC Peripheral Block - Femoral Single or Saphenous W/Img Gdn|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64447,APC,64447,CPT,0360,RC,,,LT|XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,7029.71,7131.59,OPPS APC
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC",011,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],40824.51,,"Case rate ($38,880.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $36,305.31, add-ons for qualifying new technology services are included. If operating cost exceeds $71,176.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,461.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 11.4. The base transfer operating payment is the transfer adjustment factor * $34,234.14 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $34,360.36 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,701.41. The transfer capital threshold is the transfer adjustment factor * $2,701.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,38880.49,150008.48,Inpatient DRG
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],22762.43,,"Fee schedule rate ($22,762.43). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6230.00,22762.43,There are no additional notes associated with this service or procedure.
VAGINAL DELIVERY WITH O.R. PROCEDURES EXCEPT STERILIZATION AND/OR D&C,768,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],9201.90,,"Case rate ($9,201.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,695.94, add-ons for qualifying new technology services are included. If operating cost exceeds $43,566.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,290.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $6,726.19 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,750.99 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $530.76. The transfer capital threshold is the transfer adjustment factor * $530.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6426.91,13416.00,Inpatient DRG
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],68942.79,,"Fee schedule rate ($68,942.79). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,21489.15,68942.79,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITHOUT CC/MCC,428,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],105654.25,,"Fee schedule rate ($105,654.25). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,40017.53,118904.57,There are no additional notes associated with this service or procedure.
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],21354.82,,"Fee schedule rate ($21,354.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6834.39,21354.82,There are no additional notes associated with this service or procedure.
RADIOTHERAPY,849,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],50919.63,,"Fee schedule rate ($50,919.63). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15.8), with a minimum of zero.",,,,0,other,20293.88,81867.07,There are no additional notes associated with this service or procedure.
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],29527.05,,"Fee schedule rate ($29,527.05). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,15940.79,53275.26,There are no additional notes associated with this service or procedure.
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],36868.88,,"Fee schedule rate ($36,868.88). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12606.23,36868.88,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],34892.92,,"Fee schedule rate ($34,892.92). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,6965.00,41030.48,There are no additional notes associated with this service or procedure.
Open Tx Clavicular Fracture Internal Fixation,CASE-23515,APC,23515,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6791.99,7131.59,OPPS APC
PREMATURITY WITHOUT MAJOR PROBLEMS,792,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],1956.00,,,,,,0,other,1956.00,19457.66,Estimated amount calculated based on 3 day length of stay.
Arthrs Kne Surg W/Meniscectomy Med/Lat W/Shvg|RIGHT SIDE,CASE-29881,APC,29881,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
Rpr Ingun Hernia Sliding Any Age,CASE-49525,APC,49525,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3518.91,,"APC Price ($3,351.34). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3351.34,3518.91,OPPS APC
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],13230.00,,"Fee schedule rate ($13,230). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10626.74,25225.91,There are no additional notes associated with this service or procedure.
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC",758,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],16323.02,,"Fee schedule rate ($16,323.02). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8574.80,19263.78,There are no additional notes associated with this service or procedure.
Exc Bartholins Gland/Cyst|LEFT SIDE,CASE-56740,APC,56740,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3136.08,,"APC Price ($3,030.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3030.03,3136.08,OPPS APC
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],14871.83,,"Fee schedule rate ($14,871.83). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6558.75,14871.83,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],28756.63,,"Fee schedule rate ($28,756.63). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,13148.66,32553.63,There are no additional notes associated with this service or procedure.
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],2070.00,,,,,,0,other,1188.00,18893.86,Estimated amount calculated based on 3 day length of stay.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],13149.46,,"Fee schedule rate ($13,149.46). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.9), with a minimum of zero.",,,,0,other,6683.37,14699.43,There are no additional notes associated with this service or procedure.
Prq Skel Fixj Dstl Phlngl Fx Fngr/Thmb Ea,CASE-26756,APC,26756,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],7600.62,,"Case rate ($7,238.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,869.60, add-ons for qualifying new technology services are included. If operating cost exceeds $41,740.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,147.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,906.55 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,924.64 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $387.18. The transfer capital threshold is the transfer adjustment factor * $387.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7238.69,16804.22,Inpatient DRG
Egd Transoral Control Bleeding Any Method|UNUSUAL NON-OVERLAPPING SERVICE,CASE-43255,APC,43255,CPT,0360,RC,,,XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1885.95,,"APC Price ($1,796.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1796.14,1885.95,OPPS APC
GASTROINTESTINAL HEMORRHAGE WITH CC,378,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],19297.23,,,,,,0,other,8586.33,20845.19,There are no additional notes associated with this service or procedure.
NERVOUS SYSTEM NEOPLASMS WITH MCC,054,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],6965.00,,,,,,0,other,6965.00,30044.81,There are no additional notes associated with this service or procedure.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],6965.00,,,,,,0,other,6965.00,20401.88,There are no additional notes associated with this service or procedure.
HC Inj Anes/Steroid C/D Facet Sg|LEFT SIDE,CASE-64490,APC,64490,CPT,0361,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],856.86,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,827.89,869.28,OPPS APC
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,098,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],18360.48,,"Case rate ($17,486.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,402.62, add-ons for qualifying new technology services are included. If operating cost exceeds $51,273.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,896.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $14,404.56 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,457.67 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,136.66. The transfer capital threshold is the transfer adjustment factor * $1,136.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,45156.75,Inpatient DRG
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],20075.57,,"Case rate ($19,119.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,922.16, add-ons for qualifying new technology services are included. If operating cost exceeds $52,793.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,016.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $15,918.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,977.21 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,256.13. The transfer capital threshold is the transfer adjustment factor * $1,256.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,11348.00,62454.12,Inpatient DRG
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],36868.88,,"Fee schedule rate ($36,868.88). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12606.23,36868.88,There are no additional notes associated with this service or procedure.
CHEST PAIN,313,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],15377.66,,"Fee schedule rate ($15,377.66). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,6820.84,15377.66,There are no additional notes associated with this service or procedure.
POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES,769,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],29791.03,,"Fee schedule rate ($29,791.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,13388.39,33250.19,There are no additional notes associated with this service or procedure.
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC,939,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],97674.79,,"Fee schedule rate ($97,674.79). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,26517.40,97674.79,There are no additional notes associated with this service or procedure.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],97015.50,,"Fee schedule rate ($97,015.50). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,26809.29,97015.50,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],6965.00,,,,,,0,other,6965.00,41030.48,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],16343.72,,,,,,0,other,7569.84,21892.85,There are no additional notes associated with this service or procedure.
Colsc Flexible W/Control Bleeding Any Method,CASE-45382,APC,45382,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1159.29,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1120.09,1176.09,OPPS APC
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC,797,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],20928.55,,"Fee schedule rate ($20,928.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8719.72,20928.55,There are no additional notes associated with this service or procedure.
"Tendon Sheath Incision|LEFT HAND, THIRD DIGIT",CASE-26055,APC,26055,CPT,0360,RC,,,F2,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1891.77,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1827.80,1919.19,OPPS APC
VENTRICULAR SHUNT PROCEDURES WITH CC,032,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],16376.22,,"Case rate ($16,376.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,370.06, add-ons for qualifying new technology services are included. If operating cost exceeds $50,241.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,815.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $13,375.80 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,425.12 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,055.48. The transfer capital threshold is the transfer adjustment factor * $1,055.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,16376.22,46275.08,Inpatient DRG
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],24669.57,,"Fee schedule rate ($24,669.57). Adds an outlier to normal pricing equal to the per diem rate ($34,856.52) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.7), with a minimum of zero.",,,,0,other,10834.64,25830.00,There are no additional notes associated with this service or procedure.
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],34032.82,,"Fee schedule rate ($34,032.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,15233.11,38610.21,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],14370.36,,"Case rate ($14,370.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,504.04, add-ons for qualifying new technology services are included. If operating cost exceeds $48,375.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,668.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $11,516.62 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,559.08 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $908.78. The transfer capital threshold is the transfer adjustment factor * $908.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,14370.36,38378.80,Inpatient DRG
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],31401.22,,"Fee schedule rate ($31,401.22). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.7), with a minimum of zero.",,,,0,other,13260.40,32878.30,There are no additional notes associated with this service or procedure.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],9040.64,,"Case rate ($8,610.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,157.86, add-ons for qualifying new technology services are included. If operating cost exceeds $43,028.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,235.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,189.44 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,212.91 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $475.73. The transfer capital threshold is the transfer adjustment factor * $475.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,20401.88,Inpatient DRG
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,448,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],94077.13,,"Fee schedule rate ($94,077.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,30663.95,94077.13,There are no additional notes associated with this service or procedure.
Esophagogastroduodenoscopy Transoral Diagnostic|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-43235,APC,43235,CPT,0360,RC,,,74,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],848.96,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,848.96,891.41,OPPS APC
Egd Removal Tumor Polyp/Other Lesion Snare Tech,CASE-43251,APC,43251,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1796.14,,"APC Price ($1,796.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1796.14,1885.95,OPPS APC
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],6277.00,,"Per diem ($6,277). If length of stay < 5.6, first 1 days paid at a per diem of $12,554 instead. Capped at $35,148.55.",,,,0,other,6277.00,36801.89,Estimated amount calculated based on 4 day length of stay.
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],29497.93,,"Case rate ($28,093.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $26,270.18, add-ons for qualifying new technology services are included. If operating cost exceeds $61,141.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,672.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $24,235.87 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $24,325.23 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,912.45. The transfer capital threshold is the transfer adjustment factor * $1,912.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,10078.00,81454.07,Inpatient DRG
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],8372.32,,"Case rate ($8,372.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,924.20, add-ons for qualifying new technology services are included. If operating cost exceeds $42,795.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,230.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,957.28 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,979.25 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $470.09. The transfer capital threshold is the transfer adjustment factor * $470.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,23385.72,Inpatient DRG
Arthroscopy Knee W/Meniscus Rpr Medial&Lateral|LEFT SIDE,CASE-29883,APC,29883,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,601,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6253.52,,"Case rate ($6,042.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,756.39, add-ons for qualifying new technology services are included. If operating cost exceeds $40,627.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,059.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $3,797.45 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,811.45 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $299.66. The transfer capital threshold is the transfer adjustment factor * $299.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6042.05,12359.72,Inpatient DRG
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],17365.00,,"Fee schedule rate ($17,365.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5683.00,19635.68,There are no additional notes associated with this service or procedure.
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],16498.72,,"Case rate ($15,940.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,964.98, add-ons for qualifying new technology services are included. If operating cost exceeds $49,835.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,783.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $12,972.20 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,020.03 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,023.63. The transfer capital threshold is the transfer adjustment factor * $1,023.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,15940.79,53275.26,Inpatient DRG
Cystourethroscopy W/Dest &/Rmvl Med Bladder Tum,CASE-52235,APC,52235,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3464.44,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3299.47,3464.44,OPPS APC
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],26301.36,,"Fee schedule rate ($26,301.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11247.07,27028.33,There are no additional notes associated with this service or procedure.
Orchiectomy Radical Tumor Inguinal Approach|LEFT SIDE,CASE-54530,APC,54530,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3518.91,,"APC Price ($3,351.34). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3351.34,3518.91,OPPS APC
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,069,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],7722.19,,"Case rate ($7,354.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,977.32, add-ons for qualifying new technology services are included. If operating cost exceeds $41,848.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,155.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $5,013.88 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,032.37 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $395.65. The transfer capital threshold is the transfer adjustment factor * $395.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,20333.68,Inpatient DRG
Rpr Aa Hernia 1st > 10 Cm Reducible,CASE-49595,APC,49595,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6362.63,,"APC Price ($6,059.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6059.65,6362.63,OPPS APC
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],16451.62,,"Case rate ($16,129.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,140.12, add-ons for qualifying new technology services are included. If operating cost exceeds $50,011.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,797.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $13,146.70 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,195.17 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,037.40. The transfer capital threshold is the transfer adjustment factor * $1,037.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,16129.04,59610.47,Inpatient DRG
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],12558.65,,"Fee schedule rate ($12,558.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5065.00,12558.65,There are no additional notes associated with this service or procedure.
NORMAL NEWBORN,795,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],2576.52,,"Fee schedule rate ($2,576.52). Adds an outlier to normal pricing equal to the per diem rate ($414) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,1369.79,5771.52,There are no additional notes associated with this service or procedure.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],54764.34,,"Fee schedule rate ($54,764.34). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,18178.96,54764.34,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC,084,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],18807.28,,,,,,0,other,6965.00,19445.16,There are no additional notes associated with this service or procedure.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],28434.57,,"Fee schedule rate ($28,434.57). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,8906.63,28434.57,There are no additional notes associated with this service or procedure.
"Amputation Toe Metatarsophalangeal Joint|LEFT FOOT, SECOND DIGIT",CASE-28820,APC,28820,CPT,0360,RC,,,T1,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES,769,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],29791.03,,"Fee schedule rate ($29,791.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,13388.39,33250.19,There are no additional notes associated with this service or procedure.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,329,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],48014.40,,"Fee schedule rate ($48,014.40). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (38), with a minimum of zero.",,,,0,other,33072.77,90445.33,There are no additional notes associated with this service or procedure.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],40108.48,,"Fee schedule rate ($40,108.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,5569.00,40108.48,There are no additional notes associated with this service or procedure.
FULL TERM NEONATE WITH MAJOR PROBLEMS,793,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],30181.78,,"Case rate ($30,181.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $28,213.07, add-ons for qualifying new technology services are included. If operating cost exceeds $63,084.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,825.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $26,171.62 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $26,268.12 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,065.20. The transfer capital threshold is the transfer adjustment factor * $2,065.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,4302.90,82045.22,Inpatient DRG
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],72246.07,,,,,,0,other,26809.29,97015.50,There are no additional notes associated with this service or procedure.
BRONCHITIS AND ASTHMA WITHOUT CC/MCC,203,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],6965.00,,,,,,0,other,4763.76,13707.00,There are no additional notes associated with this service or procedure.
OTHER CEREBROVASCULAR DISORDERS WITH CC,071,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],5843.00,,"Per diem ($5,843). If length of stay < 3.3, first 1 days paid at a per diem of $11,686 instead. Capped at $19,281.62.",,,,0,other,5843.00,29215.10,Estimated amount calculated based on 3 day length of stay.
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],35474.53,,"Fee schedule rate ($35,474.53). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,16428.39,42083.20,There are no additional notes associated with this service or procedure.
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],29916.58,,"Fee schedule rate ($29,916.58). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12725.42,34245.00,There are no additional notes associated with this service or procedure.
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC,939,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],27843.27,,"Case rate ($26,517.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $24,804.19, add-ons for qualifying new technology services are included. If operating cost exceeds $59,675.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,557.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $22,775.26 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $22,859.24 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,797.19. The transfer capital threshold is the transfer adjustment factor * $1,797.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,26517.40,97674.79,Inpatient DRG
Carpectomy All Bones Proximal Row,CASE-25215,APC,25215,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3215.80,3215.80,OPPS APC
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],18709.65,,"Fee schedule rate ($18,709.65). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,10895.60,35192.25,There are no additional notes associated with this service or procedure.
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],8032.50,,"Fee schedule rate ($8,032.50). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6503.90,14492.93,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC,817,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],42878.11,,"Fee schedule rate ($42,878.11). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.5), with a minimum of zero.",,,,0,other,17396.11,44895.04,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],23239.84,,"Fee schedule rate ($23,239.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8543.64,23239.84,There are no additional notes associated with this service or procedure.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH CC,026,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],63202.45,,"Fee schedule rate ($63,202.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,23000.66,63202.45,There are no additional notes associated with this service or procedure.
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],21854.96,,"Fee schedule rate ($21,854.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10638.94,25261.33,There are no additional notes associated with this service or procedure.
Inj for Sacroiliac Jt Anesth|RIGHT SIDE,CASE-G0260,APC,G0260,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],683.85,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,660.72,693.76,OPPS APC
Egd Intrmural US Needle Aspirate/Biopsy Esophags|REDUCED SERVICES,CASE-43238,APC,43238,CPT,0360,RC,,,52,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1885.95,,"APC Price ($1,796.14). Discounted by 50%. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1796.14,1885.95,OPPS APC
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH CC,026,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],63202.45,,"Fee schedule rate ($63,202.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,23000.66,63202.45,There are no additional notes associated with this service or procedure.
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],27665.18,,"Fee schedule rate ($27,665.18). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,11914.12,40426.76,There are no additional notes associated with this service or procedure.
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC,497,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],10634.03,,"Case rate ($10,127.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,557.14, add-ons for qualifying new technology services are included. If operating cost exceeds $44,428.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,358.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 1.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $7,584.22 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,612.19 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $598.47. The transfer capital threshold is the transfer adjustment factor * $598.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10127.65,37761.19,Inpatient DRG
TRAUMATIC INJURY WITH MCC,913,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],32164.02,,,,,,0,other,13014.58,42838.46,There are no additional notes associated with this service or procedure.
Rpr Aa Hernia 1st > 10 Cm Ncrc8/Strangulated|UNUSUAL NON-OVERLAPPING SERVICE,CASE-49596,APC,49596,CPT,0360,RC,,,XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5941.70,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5658.76,5941.70,OPPS APC
Excision Tumor Soft Tissue Foot/Toe Subq <1.5cm|LEFT SIDE,CASE-28043,APC,28043,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1600.04,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1545.93,1623.23,OPPS APC
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,073,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],13449.85,,"Case rate ($12,809.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,051.90, add-ons for qualifying new technology services are included. If operating cost exceeds $46,922.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,554.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $10,069.82 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,106.95 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $794.61. The transfer capital threshold is the transfer adjustment factor * $794.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12809.38,43475.01,Inpatient DRG
GASTROINTESTINAL HEMORRHAGE WITH MCC,377,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],31575.65,,"Fee schedule rate ($31,575.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,7634.00,35969.56,There are no additional notes associated with this service or procedure.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC",156,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6625.12,,"Case rate ($6,625.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,298.82, add-ons for qualifying new technology services are included. If operating cost exceeds $41,169.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,102.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $4,337.88 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,353.87 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $342.30. The transfer capital threshold is the transfer adjustment factor * $342.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6625.12,13598.77,Inpatient DRG
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC,939,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],71397.99,,,,,,0,other,26517.40,97674.79,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],14344.60,,"Case rate ($14,344.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,480.09, add-ons for qualifying new technology services are included. If operating cost exceeds $48,351.10 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,666.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $11,492.77 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,535.14 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $906.89. The transfer capital threshold is the transfer adjustment factor * $906.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,14344.60,36028.59,Inpatient DRG
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC",061,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],20616.23,,"Case rate ($20,616.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $19,314.45, add-ons for qualifying new technology services are included. If operating cost exceeds $54,185.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,125.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $17,305.68 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $17,369.49 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,365.59. The transfer capital threshold is the transfer adjustment factor * $1,365.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,20616.23,62315.82,Inpatient DRG
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC,964,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],12619.91,,"Case rate ($12,018.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,335.39, add-ons for qualifying new technology services are included. If operating cost exceeds $46,206.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,479.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $9,354.97 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,390.44 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $719.04. The transfer capital threshold is the transfer adjustment factor * $719.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12323.82,34154.06,Inpatient DRG
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC,858,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],33794.11,,"Fee schedule rate ($33,794.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11377.76,33794.11,There are no additional notes associated with this service or procedure.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],12897.13,,"Fee schedule rate ($12,897.13). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10098.51,24259.09,There are no additional notes associated with this service or procedure.
HC Trigger Point 3 or More|PBB CHARGE,CASE-20553,APC,20553,CPT,0510,RC,,,PBB,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],297.37,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,287.31,301.68,OPPS APC
Laps Gstr Rstcv Px W/Byp Roux-en-Y Limb <150 Cm,CASE-43644,APC,43644,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],8321.46,,"Case rate ($7,925.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,519.41, add-ons for qualifying new technology services are included. If operating cost exceeds $42,390.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,186.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,553.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,574.46 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $426.85. The transfer capital threshold is the transfer adjustment factor * $426.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8106.18,18245.94,Inpatient DRG
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],2070.00,,,,,,0,other,1188.00,31658.33,Estimated amount calculated based on 16 day length of stay.
Rmvl/Revj Sling Stress Incontinence,CASE-57287,APC,57287,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3136.08,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3030.03,3136.08,OPPS APC
HC Inj Aa&/Strd Greater Occipital Nerve|LEFT SIDE,CASE-64405,APC,64405,CPT,0450,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],301.68,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,287.31,301.68,OPPS APC
Open Tx Clavicular Fracture Internal Fixation|LEFT SIDE,CASE-23515,APC,23515,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7131.59,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6791.99,7131.59,OPPS APC
Incisional Biopsy Skin Single Lesion,CASE-11106,APC,11106,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],726.38,,"APC Price ($691.79). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,726.38,726.38,OPPS APC
SPINAL PROCEDURES WITH MCC,028,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],112913.98,,"Fee schedule rate ($112,913.98). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,42633.57,120982.83,There are no additional notes associated with this service or procedure.
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],25253.70,,"Fee schedule rate ($25,253.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11974.38,29141.64,There are no additional notes associated with this service or procedure.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],25162.32,,"Case rate ($25,162.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $23,543.58, add-ons for qualifying new technology services are included. If operating cost exceeds $58,414.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,458.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $21,519.28 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $21,598.63 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,698.08. The transfer capital threshold is the transfer adjustment factor * $1,698.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,25162.32,75579.22,Inpatient DRG
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],18585.05,,"Fee schedule rate ($18,585.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8859.23,20090.22,There are no additional notes associated with this service or procedure.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],8554.50,,"Case rate ($8,554.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,093.67, add-ons for qualifying new technology services are included. If operating cost exceeds $42,964.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,243.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,126.13 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,148.72 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $483.41. The transfer capital threshold is the transfer adjustment factor * $483.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8554.50,19204.75,Inpatient DRG
OTHER CEREBROVASCULAR DISORDERS WITH MCC,070,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],13483.47,,"Case rate ($13,219.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,433.04, add-ons for qualifying new technology services are included. If operating cost exceeds $47,304.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,584.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $10,449.57 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,488.10 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $824.57. The transfer capital threshold is the transfer adjustment factor * $824.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,13219.09,37774.46,Inpatient DRG
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],19435.86,,"Case rate ($19,435.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $18,216.37, add-ons for qualifying new technology services are included. If operating cost exceeds $53,087.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,039.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.9. The base transfer operating payment is the transfer adjustment factor * $16,211.64 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $16,271.42 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,279.26. The transfer capital threshold is the transfer adjustment factor * $1,279.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,19435.86,50821.76,Inpatient DRG
Hrv Skin for Skin Cell Ssp Agrft 1st 25 Sq Cm/<,CASE-15011,APC,15011,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1931.28,,"APC Price ($1,931.28). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1931.28,1998.87,OPPS APC
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],38517.10,,"Fee schedule rate ($38,517.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,16897.01,43444.85,There are no additional notes associated with this service or procedure.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],23618.74,,"Fee schedule rate ($23,618.74). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10533.95,24956.34,There are no additional notes associated with this service or procedure.
Destruction Neurolytic Agt Genicular Nerve W/Img,CASE-64624,APC,64624,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1827.80,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1827.80,1919.19,OPPS APC
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],36780.25,,,,,,0,other,14603.31,45017.13,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],16229.42,,"Case rate ($15,456.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,514.54, add-ons for qualifying new technology services are included. If operating cost exceeds $49,385.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,748.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $12,523.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,569.59 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $988.22. The transfer capital threshold is the transfer adjustment factor * $988.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,15456.59,41402.42,Inpatient DRG
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],29243.52,,"Fee schedule rate ($29,243.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,14343.25,36024.65,There are no additional notes associated with this service or procedure.
Thyroidectomy Total/Complete|BILATERAL PROCEDURE,CASE-60240,APC,60240,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],9949.78,,"APC Price ($9,949.78). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,9949.78,10447.27,OPPS APC
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,098,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],6965.00,,,,,,0,other,6965.00,45156.75,There are no additional notes associated with this service or procedure.
HC Gastroesophag Reflx Test W/Tel Ph Eltrd|REDUCED SERVICES,CASE-91035,APC,91035,CPT,0750,RC,,,52,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],843.99,,"APC Price ($803.80). Discounted by 50%. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,803.80,843.99,OPPS APC
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],35474.53,,"Fee schedule rate ($35,474.53). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,16428.39,42083.20,There are no additional notes associated with this service or procedure.
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],35127.88,,"Fee schedule rate ($35,127.88). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.5), with a minimum of zero.",,,,0,other,14603.31,45017.13,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],23851.92,,"Case rate ($23,851.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $22,324.54, add-ons for qualifying new technology services are included. If operating cost exceeds $57,195.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,362.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.8. The base transfer operating payment is the transfer adjustment factor * $20,304.73 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $20,379.59 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,602.24. The transfer capital threshold is the transfer adjustment factor * $1,602.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,23851.92,63653.13,Inpatient DRG
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],29166.74,,"Fee schedule rate ($29,166.74). Adds an outlier to normal pricing equal to the per diem rate ($36,758.78) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,12455.21,37149.27,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],37495.79,,"Fee schedule rate ($37,495.79). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.8), with a minimum of zero.",,,,0,other,15456.59,41402.42,There are no additional notes associated with this service or procedure.
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITHOUT CC/MCC",630,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],27428.38,,"Fee schedule rate ($27,428.38). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,11828.78,42541.02,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],31006.45,,"Case rate ($30,398.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $28,414.67, add-ons for qualifying new technology services are included. If operating cost exceeds $63,285.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,841.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.2. The base transfer operating payment is the transfer adjustment factor * $26,372.48 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $26,469.72 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,081.05. The transfer capital threshold is the transfer adjustment factor * $2,081.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,30398.48,82674.88,Inpatient DRG
Hysteroscopy Bx Endometrium&/Polypc W/WO D&C,CASE-58558,APC,58558,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3181.53,,"APC Price ($3,030.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3030.03,3181.53,OPPS APC
NORMAL NEWBORN,795,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],2576.52,,"Fee schedule rate ($2,576.52). Adds an outlier to normal pricing equal to the per diem rate ($414) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,1369.79,5771.52,There are no additional notes associated with this service or procedure.
"CESAREAN SECTION WITHOUT STERILIZATION,MINOR",540,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],6521.58,,"Case rate ($6,211.03). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6211.03,6521.58,There are no additional notes associated with this service or procedure.
BRONCHITIS AND ASTHMA WITH CC/MCC,202,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],7606.34,,"Fee schedule rate ($7,606.34). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7606.34,19110.30,There are no additional notes associated with this service or procedure.
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC",629,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],44657.18,,"Fee schedule rate ($44,657.18). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,16699.94,44657.18,There are no additional notes associated with this service or procedure.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],24511.94,,"Case rate ($23,344.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $21,852.68, add-ons for qualifying new technology services are included. If operating cost exceeds $56,723.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,325.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $19,834.60 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $19,907.73 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,565.15. The transfer capital threshold is the transfer adjustment factor * $1,565.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,23344.70,62179.32,Inpatient DRG
"MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS,MINOR",532,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],2568.32,,"Case rate for a one day stay ($2,568.32). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,2568.32,2696.74,There are no additional notes associated with this service or procedure.
Dstr Nrolytc Agnt Parverteb Fct Sngl Lmbr/Sacral|RIGHT SIDE,CASE-64635,APC,64635,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1827.80,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1827.80,1919.19,OPPS APC
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC,832,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],9034.88,,"Fee schedule rate ($9,034.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4803.31,14198.92,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],22153.79,,"Case rate ($21,719.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,340.70, add-ons for qualifying new technology services are included. If operating cost exceeds $55,211.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,206.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.2. The base transfer operating payment is the transfer adjustment factor * $18,328.17 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,395.75 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,446.27. The transfer capital threshold is the transfer adjustment factor * $1,446.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,21719.40,85305.59,Inpatient DRG
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],14819.84,,"Case rate ($8,468.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,013.65, add-ons for qualifying new technology services are included. If operating cost exceeds $42,884.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,237.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,046.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,068.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $477.12. The transfer capital threshold is the transfer adjustment factor * $477.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,6963.00,18954.85,All Other Inpatient
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],1188.00,,,,,,0,other,1188.00,17370.86,Estimated amount calculated based on 3 day length of stay.
"Decompress Spinal Cord,1 Seg|LEFT SIDE",CASE-63056,APC,63056,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7029.71,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6791.99,7131.59,OPPS APC
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],38839.49,,"Fee schedule rate ($38,839.49). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.6), with a minimum of zero.",,,,0,other,15940.79,53275.26,There are no additional notes associated with this service or procedure.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],40108.48,,"Fee schedule rate ($40,108.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,5569.00,40108.48,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],43399.23,,"Fee schedule rate ($43,399.23). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9888.00,43399.23,There are no additional notes associated with this service or procedure.
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],10130.60,,"Case rate ($9,648.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,111.10, add-ons for qualifying new technology services are included. If operating cost exceeds $43,982.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,323.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $7,139.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,166.15 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $563.40. The transfer capital threshold is the transfer adjustment factor * $563.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9648.19,31477.13,Inpatient DRG
CESAREAN SECTION WITH STERILIZATION WITH MCC,783,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],23722.94,,"Fee schedule rate ($23,722.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12612.10,23722.94,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],22358.90,,"Fee schedule rate ($22,358.90). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9389.48,22358.90,There are no additional notes associated with this service or procedure.
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC",011,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],102498.90,,"Fee schedule rate ($102,498.90). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,38880.49,150008.48,There are no additional notes associated with this service or procedure.
Cysto W/Simple Removal Stone & Stent|RIGHT SIDE,CASE-52310,APC,52310,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],2025.13,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1956.65,2054.48,OPPS APC
Lamnotmy Incl W/Dcmprsn Nrv Root 1 Intrspc Lumbr|BILATERAL PROCEDURE,CASE-63030,APC,63030,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],11139.15,,,,,,0,other,5778.62,11681.49,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],18905.23,,"Fee schedule rate ($18,905.23). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6963.00,18954.85,There are no additional notes associated with this service or procedure.
"NERVOUS SYSTEM MALIGNANCY,MAJOR",041,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],12460.43,,"Case rate ($12,460.43). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,12460.43,13083.45,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],6965.00,,,,,,0,other,1188.00,12138.74,There are no additional notes associated with this service or procedure.
Ercp Remove Calculi/Debris Biliary/Pancreas Duct,CASE-43264,APC,43264,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5682.51,,"APC Price ($5,682.51). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5682.51,5966.63,OPPS APC
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",062,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],44304.80,,"Fee schedule rate ($44,304.80). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,13844.84,44304.80,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],31469.43,,,,,,0,other,12775.53,31469.43,There are no additional notes associated with this service or procedure.
Hysteroscopy Diagnostic Separate Procedure,CASE-58555,APC,58555,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3030.03,,"APC Price ($3,030.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3030.03,3181.53,OPPS APC
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],9185.43,,"Case rate ($8,874.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,391.65, add-ons for qualifying new technology services are included. If operating cost exceeds $43,262.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,266.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $6,423.02 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,446.70 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $506.84. The transfer capital threshold is the transfer adjustment factor * $506.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,8874.81,20553.44,Inpatient DRG
VENTRICULAR SHUNT PROCEDURES WITH CC,032,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],46275.08,,"Fee schedule rate ($46,275.08). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,16376.22,46275.08,There are no additional notes associated with this service or procedure.
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],21354.82,,"Fee schedule rate ($21,354.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6834.39,21354.82,There are no additional notes associated with this service or procedure.
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],24092.63,,"Fee schedule rate ($24,092.63). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10626.74,25225.91,There are no additional notes associated with this service or procedure.
POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES,769,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],14057.81,,"Case rate ($13,388.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,590.54, add-ons for qualifying new technology services are included. If operating cost exceeds $47,461.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,596.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $10,606.49 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,645.59 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $836.96. The transfer capital threshold is the transfer adjustment factor * $836.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13388.39,33250.19,Inpatient DRG
COAGULATION DISORDERS,813,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],28664.96,,"Fee schedule rate ($28,664.96). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.7), with a minimum of zero.",,,,0,other,12274.39,30013.33,There are no additional notes associated with this service or procedure.
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|RIGHT HAND, THUMB",CASE-26160,APC,26160,CPT,0360,RC,,,F5,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1600.04,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1545.93,1623.23,OPPS APC
Dstr Nrolytc Agnt Parverteb Fct Sngl Lmbr/Sacral|BILATERAL PROCEDURE,CASE-64635,APC,64635,CPT,0360,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1919.19,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1827.80,1919.19,OPPS APC
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],11113.51,,"Case rate ($10,895.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,271.55, add-ons for qualifying new technology services are included. If operating cost exceeds $45,142.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,414.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $8,296.01 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,326.60 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $654.64. The transfer capital threshold is the transfer adjustment factor * $654.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,10895.60,35192.25,Inpatient DRG
DIABETES WITH CC,638,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],17634.53,,,,,,0,other,8014.07,17634.53,There are no additional notes associated with this service or procedure.
"HEAD TRAUMA WITH COMA > 1 HOUR OR HEMORRHAGE,MODERATE",055,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],9649.41,,"Case rate ($9,189.91). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9649.41,9649.41,There are no additional notes associated with this service or procedure.
HYPERTENSION WITHOUT MCC,305,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],14858.10,,,,,,0,other,7058.55,17230.49,There are no additional notes associated with this service or procedure.
RESPIRATORY NEOPLASMS WITHOUT CC/MCC,182,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],14832.52,,,,,,0,other,6965.00,23037.13,There are no additional notes associated with this service or procedure.
VENTRICULAR SHUNT PROCEDURES WITH MCC,031,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],33901.56,,"Case rate ($32,287.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $30,171.71, add-ons for qualifying new technology services are included. If operating cost exceeds $65,042.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,979.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7. The base transfer operating payment is the transfer adjustment factor * $28,123.07 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $28,226.76 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,219.19. The transfer capital threshold is the transfer adjustment factor * $2,219.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,32287.20,88162.80,Inpatient DRG
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC",629,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],40946.19,,"Fee schedule rate ($40,946.19). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,16699.94,44657.18,There are no additional notes associated with this service or procedure.
"OPEN CRANIOTOMY EXCEPT TRAUMA,MODERATE",021,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],30857.78,,"Case rate ($30,857.78). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,30857.78,32400.67,There are no additional notes associated with this service or procedure.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],62041.12,,"Fee schedule rate ($62,041.12). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,18497.24,62041.12,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,167,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],33891.30,,"Fee schedule rate ($33,891.30). Adds an outlier to normal pricing equal to the per diem rate ($66,990.29) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.6), with a minimum of zero.",,,,0,other,14157.71,43522.37,There are no additional notes associated with this service or procedure.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,352,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],26528.70,,"Fee schedule rate ($26,528.70). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,9853.37,26528.70,There are no additional notes associated with this service or procedure.
Colsc Flexible W/Control Bleeding Any Method,CASE-45382,APC,45382,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1120.09,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1120.09,1176.09,OPPS APC
"NEONATE BIRTH WEIGHT 2000-2499 GRAMS WITH OTHER SIGNIFICANT CONDITION,MAJOR",625,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],29788.58,,"Case rate ($28,370.08). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,28370.08,29788.58,There are no additional notes associated with this service or procedure.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],39820.52,,"Fee schedule rate ($39,820.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,15273.74,39820.52,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,066,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6579.76,,"Case rate ($6,579.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,256.61, add-ons for qualifying new technology services are included. If operating cost exceeds $41,127.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,098.96, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $4,295.82 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,311.66 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $338.98. The transfer capital threshold is the transfer adjustment factor * $338.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6579.76,20083.61,Inpatient DRG
Cysto Bladder W/Ureteral Catheterization,CASE-52005,APC,52005,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1956.65,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1956.65,2054.48,OPPS APC
HC Joint Injection/Aspir Large WO US|RIGHT SIDE,CASE-20610,APC,20610,CPT,0510,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],301.68,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,287.31,301.68,OPPS APC
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],15456.59,,"Case rate ($15,456.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,514.54, add-ons for qualifying new technology services are included. If operating cost exceeds $49,385.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,748.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $12,523.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,569.59 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $988.22. The transfer capital threshold is the transfer adjustment factor * $988.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,15456.59,41402.42,Inpatient DRG
CELLULITIS WITH MCC,602,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],28349.31,,"Fee schedule rate ($28,349.31). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11570.10,28349.31,There are no additional notes associated with this service or procedure.
FULL TERM NEONATE WITH MAJOR PROBLEMS,793,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],78359.29,,"Fee schedule rate ($78,359.29). Adds an outlier to normal pricing equal to the per diem rate ($27,082.03) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.7), with a minimum of zero.",,,,0,other,4302.90,82045.22,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],6965.00,,,,,,0,other,6965.00,19126.88,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],58394.20,,"Fee schedule rate ($58,394.20). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,9370.00,65732.99,There are no additional notes associated with this service or procedure.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,073,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],12809.38,,"Case rate ($12,809.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,051.90, add-ons for qualifying new technology services are included. If operating cost exceeds $46,922.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,554.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $10,069.82 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,106.95 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $794.61. The transfer capital threshold is the transfer adjustment factor * $794.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12809.38,43475.01,Inpatient DRG
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],21248.73,,"Case rate ($21,248.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $19,902.85, add-ons for qualifying new technology services are included. If operating cost exceeds $54,773.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,171.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.3. The base transfer operating payment is the transfer adjustment factor * $17,891.94 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $17,957.90 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,411.85. The transfer capital threshold is the transfer adjustment factor * $1,411.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,21248.73,56089.29,Inpatient DRG
Injection Aa&/Strd Genicular Nrv Branches W/Img|BILATERAL PROCEDURE,CASE-64454,APC,64454,CPT,0360,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],693.76,,"APC Price ($660.72). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,660.72,693.76,OPPS APC
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],19371.27,,"Fee schedule rate ($19,371.27). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8643.20,19462.52,There are no additional notes associated with this service or procedure.
ALLERGIC REACTIONS WITH MCC,915,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],13648.28,,"Case rate ($12,998.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,248.33, add-ons for qualifying new technology services are included. If operating cost exceeds $47,119.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,548.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $10,264.46 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,303.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $788.95. The transfer capital threshold is the transfer adjustment factor * $788.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13332.86,33088.84,Inpatient DRG
MINOR BLADDER PROCEDURES WITHOUT CC/MCC,664,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],31876.87,,"Fee schedule rate ($31,876.87). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9034.63,31876.87,There are no additional notes associated with this service or procedure.
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],13872.99,,"Fee schedule rate ($13,872.99). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.8), with a minimum of zero.",,,,0,other,5068.21,14525.56,There are no additional notes associated with this service or procedure.
Arthrs Kne Surg W/Meniscectomy Med/Lat W/Shvg|LEFT SIDE|SEPARATE STRUCTURE,CASE-29881,APC,29881,CPT,0360,RC,,,LT|XS,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6791.99,7131.59,OPPS APC
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC",061,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],62315.82,,"Fee schedule rate ($62,315.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,20616.23,62315.82,There are no additional notes associated with this service or procedure.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC,099,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],22084.20,,"Fee schedule rate ($22,084.20). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11171.21,26807.94,There are no additional notes associated with this service or procedure.
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],16064.26,,"Fee schedule rate ($16,064.26). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7733.72,18043.23,There are no additional notes associated with this service or procedure.
PERITONEAL ADHESIOLYSIS WITH CC,336,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],53705.31,,"Fee schedule rate ($53,705.31). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,16225.22,53705.31,There are no additional notes associated with this service or procedure.
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],10448.91,,"Fee schedule rate ($10,448.91). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,3079.00,10940.41,There are no additional notes associated with this service or procedure.
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,451,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],60708.91,,"Fee schedule rate ($60,708.91). Adds an outlier to normal pricing equal to the per diem rate ($108,215.07) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,23821.44,94077.13,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],14228.44,,,,,,0,other,6841.83,21167.26,There are no additional notes associated with this service or procedure.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],10229.13,,"Case rate ($9,742.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,212.95, add-ons for qualifying new technology services are included. If operating cost exceeds $44,083.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,316.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $7,240.55 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,268.00 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $556.53. The transfer capital threshold is the transfer adjustment factor * $556.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9977.99,26949.28,Inpatient DRG
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],13170.81,,"Case rate ($12,725.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,973.79, add-ons for qualifying new technology services are included. If operating cost exceeds $46,844.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,548.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $9,991.99 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,028.83 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $788.47. The transfer capital threshold is the transfer adjustment factor * $788.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,12725.42,34245.00,Inpatient DRG
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],20659.14,,"Fee schedule rate ($20,659.14). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.9), with a minimum of zero.",,,,0,other,9389.48,22358.90,There are no additional notes associated with this service or procedure.
Colonoscopy W/Biopsy Single/Multiple,CASE-45380,APC,45380,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1120.09,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1120.09,1176.09,OPPS APC
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC",629,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],44657.18,,"Fee schedule rate ($44,657.18). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,16699.94,44657.18,There are no additional notes associated with this service or procedure.
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],33890.73,,"Fee schedule rate ($33,890.73). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6277.00,36801.89,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC,832,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],9034.88,,"Fee schedule rate ($9,034.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4803.31,14198.92,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],59891.41,,"Fee schedule rate ($59,891.41). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15), with a minimum of zero.",,,,0,other,23526.87,94787.57,There are no additional notes associated with this service or procedure.
VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC,033,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],13206.23,,"Case rate ($13,206.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,421.07, add-ons for qualifying new technology services are included. If operating cost exceeds $47,292.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,583.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $10,437.64 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,476.13 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $823.63. The transfer capital threshold is the transfer adjustment factor * $823.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,13206.23,42156.44,Inpatient DRG
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,083,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],11625.35,,"Case rate ($11,397.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,738.37, add-ons for qualifying new technology services are included. If operating cost exceeds $45,609.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,451.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $8,761.12 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,793.42 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $691.34. The transfer capital threshold is the transfer adjustment factor * $691.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6965.00,28680.85,Inpatient DRG
Excision Malignant Lesion Trunk/Arm/Leg > 4.0 Cm,CASE-11606,APC,11606,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6215.36,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6215.36,6526.12,OPPS APC
HC Biopsy/Exc Lymph Node Needle|TECHNICAL COMPONENT|RIGHT SIDE,CASE-38505,APC,38505,CPT,0361,RC,,,TC|RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1600.04,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1545.93,1623.23,OPPS APC
Excision Choledochal Cyst,CASE-47715,APC,47715,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
"RESPIRATORY MALIGNANCY,MAJOR",136,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],12417.67,,"Case rate ($12,417.67). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,12417.67,13038.55,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],33152.73,,"Fee schedule rate ($33,152.73). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13891.57,34712.20,There are no additional notes associated with this service or procedure.
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC,807,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],10071.17,,"Fee schedule rate ($10,071.17). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5354.25,13266.23,There are no additional notes associated with this service or procedure.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],39122.48,,"Fee schedule rate ($39,122.48). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,21585.31,73588.10,There are no additional notes associated with this service or procedure.
Colonoscopy W/Biopsy Single/Multiple|UNUSUAL NON-OVERLAPPING SERVICE|COLORECTAL CANCER SCREEN,CASE-45380,APC,45380,CPT,0360,RC,,,XU|PT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1159.29,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1120.09,1176.09,OPPS APC
Cysto W/Insert Ureteral Stent,CASE-52332,APC,52332,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3464.44,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3299.47,3464.44,OPPS APC
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],9533.13,,"Fee schedule rate ($9,533.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5068.21,14525.56,There are no additional notes associated with this service or procedure.
Sling Operation Stress Incontinence,CASE-57288,APC,57288,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],4682.41,,"APC Price ($4,682.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,4682.41,4916.53,OPPS APC
Insertion Breast Implant Same Day of Mastectomy|RIGHT SIDE,CASE-19340,APC,19340,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],7650.49,,"APC Price ($7,650.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,7650.49,7650.49,OPPS APC
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],15309.46,,"Fee schedule rate ($15,309.46). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6965.00,15340.19,There are no additional notes associated with this service or procedure.
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],8571.21,,"Case rate ($8,163.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,729.53, add-ons for qualifying new technology services are included. If operating cost exceeds $42,600.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,214.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,763.33 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,784.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $454.78. The transfer capital threshold is the transfer adjustment factor * $454.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8163.06,18067.42,Inpatient DRG
"NEONATE BIRTH WEIGHT > 2499 GRAMS WITH RESPIRATORY DISTRESS SYNDROME OR OTHER MAJOR RESPIRATORY CONDITION,MINOR",634,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],5919.50,,"Case rate ($5,637.62). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5637.62,5919.50,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITH CC,164,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],77058.83,,"Fee schedule rate ($77,058.83). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,19037.66,77058.83,There are no additional notes associated with this service or procedure.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],15099.70,,"Case rate ($15,099.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,182.53, add-ons for qualifying new technology services are included. If operating cost exceeds $49,053.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,722.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $12,192.63 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,237.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $962.12. The transfer capital threshold is the transfer adjustment factor * $962.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7605.00,39153.65,Inpatient DRG
Laps Surg Cholecystectomy W/Cholangiography|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-47563,APC,47563,CPT,0360,RC,,,74,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5941.70,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5658.76,5941.70,OPPS APC
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],62990.26,,"Fee schedule rate ($62,990.26). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,16787.98,62990.26,There are no additional notes associated with this service or procedure.
"Tendon Sheath Incision|LEFT FOOT, GREAT TOE",CASE-26055,APC,26055,CPT,0360,RC,,,TA,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1827.80,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1827.80,1919.19,OPPS APC
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],35973.56,,"Fee schedule rate ($35,973.56). Adds an outlier to normal pricing equal to the per diem rate ($68,707.98) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,14908.05,49717.39,There are no additional notes associated with this service or procedure.
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],40320.14,,,,,,0,other,15821.59,40320.14,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],38378.80,,"Fee schedule rate ($38,378.80). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,14370.36,38378.80,There are no additional notes associated with this service or procedure.
Prq Impltj Neurostim Eltrd Sacral Nrve W/Imaging,CASE-64561,APC,64561,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5965.28,,"APC Price ($5,965.28). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5965.28,6263.54,OPPS APC
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],27632.41,,,,,,0,other,11454.97,28394.78,There are no additional notes associated with this service or procedure.
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],24444.75,,"Fee schedule rate ($24,444.75). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10136.44,24444.75,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],17686.09,,"Fee schedule rate ($17,686.09). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8318.14,19763.43,There are no additional notes associated with this service or procedure.
"Inj Dx/Ther Agnt Paravert Facet Joint, Cerv/Thorac, 2nd Level|RIGHT SIDE",CASE-64491,APC,64491,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],869.28,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,827.89,869.28,OPPS APC
Revision of Reconstructed Breast,CASE-19380,APC,19380,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6215.36,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6215.36,6526.12,OPPS APC
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC,058,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],13840.84,,"Case rate ($13,181.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,419.28, add-ons for qualifying new technology services are included. If operating cost exceeds $47,290.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,562.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $10,434.76 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,474.33 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $802.04. The transfer capital threshold is the transfer adjustment factor * $802.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13521.80,40853.02,Inpatient DRG
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC",011,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],150008.48,,"Fee schedule rate ($150,008.48). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (44), with a minimum of zero.",,,,0,other,38880.49,150008.48,There are no additional notes associated with this service or procedure.
Rpr Aa Hernia Recr 3-10 Cm Ncrc8/Strangulated,CASE-49616,APC,49616,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5941.70,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5658.76,5941.70,OPPS APC
NORMAL NEWBORN,795,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],2576.52,,"Fee schedule rate ($2,576.52). Adds an outlier to normal pricing equal to the per diem rate ($414) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,1369.79,5771.52,There are no additional notes associated with this service or procedure.
Cysto W/Urtroscopy&/Pyeloscopy Dx|UNUSUAL NON-OVERLAPPING SERVICE|LEFT SIDE,CASE-52351,APC,52351,CPT,0360,RC,,,XU|LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3299.47,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3299.47,3464.44,OPPS APC
OTHER MENTAL DISORDER DIAGNOSES,887,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],2070.00,,,,,,0,other,2070.00,21072.10,Estimated amount calculated based on 1 day length of stay.
SPINAL PROCEDURES WITHOUT CC/MCC,030,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],44714.01,,"Fee schedule rate ($44,714.01). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,16810.99,44714.01,There are no additional notes associated with this service or procedure.
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],68942.79,,"Fee schedule rate ($68,942.79). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,21489.15,68942.79,There are no additional notes associated with this service or procedure.
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],11565.93,,"Fee schedule rate ($11,565.93). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6148.93,15887.21,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC,832,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],9034.88,,"Fee schedule rate ($9,034.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4803.31,14198.92,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],10062.87,,"Case rate ($9,865.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,313.33, add-ons for qualifying new technology services are included. If operating cost exceeds $44,184.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,339.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $7,341.31 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,368.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $579.30. The transfer capital threshold is the transfer adjustment factor * $579.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,9865.56,37914.65,Inpatient DRG
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],52794.06,,"Fee schedule rate ($52,794.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (37), with a minimum of zero.",,,,0,other,13907.80,52794.06,There are no additional notes associated with this service or procedure.
"NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY",789,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],6663.33,,,,,,0,other,3054.00,14857.05,Estimated amount calculated based on 1 day length of stay.
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,069,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],6965.00,,,,,,0,other,6965.00,20333.68,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],6466.83,,"Case rate ($6,340.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,033.60, add-ons for qualifying new technology services are included. If operating cost exceeds $40,904.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,081.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $4,073.62 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,088.64 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $321.45. The transfer capital threshold is the transfer adjustment factor * $321.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6340.03,15076.44,Inpatient DRG
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],53939.67,,"Fee schedule rate ($53,939.67). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,21382.16,85466.62,There are no additional notes associated with this service or procedure.
HC Injection Small Joint/Bursa|PBB CHARGE,CASE-20600,APC,20600,CPT,0361,RC,,,PBB,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],301.68,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,287.31,301.68,OPPS APC
CESAREAN SECTION WITH STERILIZATION WITHOUT CC/MCC,785,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],8726.33,,"Case rate ($8,431.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,979, add-ons for qualifying new technology services are included. If operating cost exceeds $42,850.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,234.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,011.89 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,034.06 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $474.40. The transfer capital threshold is the transfer adjustment factor * $474.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,8431.24,20142.33,Inpatient DRG
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level|BILATERAL PROCEDURE,CASE-64483,APC,64483,CPT,0360,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],869.28,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,827.89,869.28,OPPS APC
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],25796.13,,"Case rate ($24,567.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $22,990.45, add-ons for qualifying new technology services are included. If operating cost exceeds $57,861.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,414.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.7. The base transfer operating payment is the transfer adjustment factor * $20,968.18 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $21,045.49 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,654.60. The transfer capital threshold is the transfer adjustment factor * $1,654.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9370.00,65732.99,Inpatient DRG
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],13261.75,,"Case rate ($13,001.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,230.82, add-ons for qualifying new technology services are included. If operating cost exceeds $47,101.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,568.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $10,248.08 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,285.87 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $808.68. The transfer capital threshold is the transfer adjustment factor * $808.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,7868.00,32126.64,Inpatient DRG
HC N Block Inj Suprascapular Nerv|LEFT SIDE,CASE-64418,APC,64418,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],693.76,,"APC Price ($660.72). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,660.72,693.76,OPPS APC
Laparoscopy Colpopexy Suspension Vaginal Apex,CASE-57425,APC,57425,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],10298.02,,"APC Price ($9,949.78). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,9949.78,10447.27,OPPS APC
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],24675.88,,"Fee schedule rate ($24,675.88). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10834.64,25830.00,There are no additional notes associated with this service or procedure.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],73588.10,,"Fee schedule rate ($73,588.10). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,21585.31,73588.10,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],2070.00,,,,,,0,other,1188.00,34338.33,Estimated amount calculated based on 6 day length of stay.
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],37914.65,,"Fee schedule rate ($37,914.65). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9865.56,37914.65,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,085,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],57443.16,,"Fee schedule rate ($57,443.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,9282.00,57443.16,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,082,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],42953.28,,"Fee schedule rate ($42,953.28). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.6), with a minimum of zero.",,,,0,other,17423.21,56223.11,There are no additional notes associated with this service or procedure.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,098,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],38799.38,,"Fee schedule rate ($38,799.38). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,6965.00,45156.75,There are no additional notes associated with this service or procedure.
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],42767.23,,"Fee schedule rate ($42,767.23). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,17356.15,44778.95,There are no additional notes associated with this service or procedure.
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],45017.13,,"Fee schedule rate ($45,017.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,14603.31,45017.13,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],41580.51,,"Fee schedule rate ($41,580.51). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,13783.20,41580.51,There are no additional notes associated with this service or procedure.
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],7847.50,,"Case rate ($7,847.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,435.96, add-ons for qualifying new technology services are included. If operating cost exceeds $42,306.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,191.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,470.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,491.01 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $431.70. The transfer capital threshold is the transfer adjustment factor * $431.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7847.50,17755.26,Inpatient DRG
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],8787.44,,"Case rate ($8,787.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,310.38, add-ons for qualifying new technology services are included. If operating cost exceeds $43,181.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,260.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,342.05 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,365.43 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $500.45. The transfer capital threshold is the transfer adjustment factor * $500.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,32293.66,Inpatient DRG
Largsc Exc Tum&/Strpg Cords/Epigl Mcrscp/Tlscp|LEFT SIDE,CASE-31541,APC,31541,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3489.82,,"APC Price ($3,489.82). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3489.82,3611.96,OPPS APC
"NEONATE BIRTH WEIGHT > 2499 GRAMS WITH MAJOR ANOMALY,MINOR",633,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],2014.61,,"Case rate ($1,918.68). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,1918.68,2014.61,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],25044.52,,"Case rate ($23,851.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $22,324.54, add-ons for qualifying new technology services are included. If operating cost exceeds $57,195.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,362.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.8. The base transfer operating payment is the transfer adjustment factor * $20,304.73 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $20,379.59 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,602.24. The transfer capital threshold is the transfer adjustment factor * $1,602.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,23851.92,63653.13,Inpatient DRG
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITH MCC OR ANTINEOPLASTIC IMPLANT OR EPILEPSY WITH NEUROSTIMULATOR,023,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],136379.44,,"Fee schedule rate ($136,379.44). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,15168.00,136379.44,There are no additional notes associated with this service or procedure.
"Decompress Spinal Cord,1 Seg|LEFT SIDE",CASE-63056,APC,63056,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],33608.45,,"Fee schedule rate ($33,608.45). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,7332.00,35314.31,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,699,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],5961.00,,"Per diem ($5,961). If length of stay < 3.2, first 1 days paid at a per diem of $11,922 instead. Capped at $19,074.90.",,,,0,other,5961.00,19972.16,Estimated amount calculated based on 3 day length of stay.
"VERTIGO AND OTHER LABYRINTH DISORDERS,MODERATE",111,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],2741.60,,"Case rate for a one day stay ($2,611.05). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,2611.05,2741.60,There are no additional notes associated with this service or procedure.
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],2070.00,,,,,,0,other,1188.00,31658.33,Estimated amount calculated based on 16 day length of stay.
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],11133.98,,"Fee schedule rate ($11,133.98). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5919.29,13545.65,There are no additional notes associated with this service or procedure.
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],27553.62,,"Fee schedule rate ($27,553.62). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12305.53,30103.84,There are no additional notes associated with this service or procedure.
SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS,029,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],61889.56,,"Fee schedule rate ($61,889.56). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13641.00,67130.05,There are no additional notes associated with this service or procedure.
PERIPHERAL VASCULAR DISORDERS WITH CC,300,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],9632.85,,"Case rate ($9,174.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,670.11, add-ons for qualifying new technology services are included. If operating cost exceeds $43,541.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,288.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,700.45 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,725.16 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $528.73. The transfer capital threshold is the transfer adjustment factor * $528.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9174.14,21005.20,Inpatient DRG
RADIOTHERAPY,849,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],21308.57,,"Case rate ($20,293.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $19,014.57, add-ons for qualifying new technology services are included. If operating cost exceeds $53,885.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,101.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $17,006.91 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $17,069.62 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,342.01. The transfer capital threshold is the transfer adjustment factor * $1,342.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,20293.88,81867.07,Inpatient DRG
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],18045.04,,"Fee schedule rate ($18,045.04). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,1188.00,18893.86,There are no additional notes associated with this service or procedure.
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],18918.49,,"Fee schedule rate ($18,918.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9282.47,21320.03,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],30063.84,,"Fee schedule rate ($30,063.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13891.57,34712.20,There are no additional notes associated with this service or procedure.
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],27589.62,,"Fee schedule rate ($27,589.62). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12566.28,30861.41,There are no additional notes associated with this service or procedure.
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITHOUT CC/MCC",630,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],12242.79,,"Case rate ($11,828.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,139.67, add-ons for qualifying new technology services are included. If operating cost exceeds $46,010.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,482.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $9,160.95 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,194.72 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $722.89. The transfer capital threshold is the transfer adjustment factor * $722.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,11828.78,42541.02,Inpatient DRG
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,477,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],62359.39,,"Fee schedule rate ($62,359.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,25339.74,67976.16,There are no additional notes associated with this service or procedure.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],18341.97,,"Fee schedule rate ($18,341.97). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.9), with a minimum of zero.",,,,0,other,8554.50,19204.75,There are no additional notes associated with this service or procedure.
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],9667.64,,"Fee schedule rate ($9,667.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,5139.72,13110.79,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,082,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],42953.28,,"Fee schedule rate ($42,953.28). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.6), with a minimum of zero.",,,,0,other,17423.21,56223.11,There are no additional notes associated with this service or procedure.
Cerclage Cervix Pregnancy Vaginal,CASE-59320,APC,59320,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3181.53,,"APC Price ($3,030.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3030.03,3181.53,OPPS APC
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],59494.91,,"Fee schedule rate ($59,494.91). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,18594.09,59494.91,There are no additional notes associated with this service or procedure.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],10517.71,,"Case rate ($10,517.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,920.01, add-ons for qualifying new technology services are included. If operating cost exceeds $44,791.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,386.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $7,945.76 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,975.06 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $627.00. The transfer capital threshold is the transfer adjustment factor * $627.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10517.71,24909.11,Inpatient DRG
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],15887.21,,,,,,0,other,6148.93,15887.21,There are no additional notes associated with this service or procedure.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],27120.18,,"Fee schedule rate ($27,120.18). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,11717.72,43888.01,There are no additional notes associated with this service or procedure.
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC",514,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],22699.91,,"Fee schedule rate ($22,699.91). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8868.04,22699.91,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],17651.07,,"Fee schedule rate ($17,651.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,6564.18,17651.07,There are no additional notes associated with this service or procedure.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],61290.90,,"Fee schedule rate ($61,290.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,23799.09,63499.65,There are no additional notes associated with this service or procedure.
Ercp Destruction/Lithotripsy Calculi Any Method,CASE-43265,APC,43265,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5682.51,,"APC Price ($5,682.51). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5682.51,5966.63,OPPS APC
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",759,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],11643.60,,"Fee schedule rate ($11,643.60). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6190.22,13057.66,There are no additional notes associated with this service or procedure.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],80635.65,,"Fee schedule rate ($80,635.65). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,26028.48,80635.65,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],8891.90,,"Case rate ($8,468.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,013.65, add-ons for qualifying new technology services are included. If operating cost exceeds $42,884.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,237.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,046.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,068.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $477.12. The transfer capital threshold is the transfer adjustment factor * $477.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6963.00,18954.85,Inpatient DRG
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],96365.69,,"Fee schedule rate ($96,365.69). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,23377.19,96365.69,There are no additional notes associated with this service or procedure.
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],10989.72,,"Case rate ($10,989.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,359.11, add-ons for qualifying new technology services are included. If operating cost exceeds $45,230.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,421.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $8,383.26 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,414.17 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $661.52. The transfer capital threshold is the transfer adjustment factor * $661.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10989.72,26280.60,Inpatient DRG
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH CC",457,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],160549.49,,"Fee schedule rate ($160,549.49). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,42327.47,160549.49,There are no additional notes associated with this service or procedure.
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],36855.62,,"Fee schedule rate ($36,855.62). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,15821.59,40320.14,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,167,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],43522.37,,"Fee schedule rate ($43,522.37). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,14157.71,43522.37,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH CC,427,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],134742.59,,"Fee schedule rate ($134,742.59). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,50829.82,142040.39,There are no additional notes associated with this service or procedure.
"MODERATELY EXTENSIVE O.R. PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,MODERATE",793,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],15307.57,,"Case rate ($14,578.64). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,14578.64,15307.57,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],10895.60,,"Case rate ($10,895.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,271.55, add-ons for qualifying new technology services are included. If operating cost exceeds $45,142.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,414.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $8,296.01 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,326.60 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $654.64. The transfer capital threshold is the transfer adjustment factor * $654.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10895.60,35192.25,Inpatient DRG
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],9683.78,,"Case rate ($9,356.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,839.58, add-ons for qualifying new technology services are included. If operating cost exceeds $43,710.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,302.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $6,869.30 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,894.63 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $542.06. The transfer capital threshold is the transfer adjustment factor * $542.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,9356.31,25026.36,Inpatient DRG
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,066,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],20083.61,,"Fee schedule rate ($20,083.61). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6579.76,20083.61,There are no additional notes associated with this service or procedure.
"OTHER EAR NOSE MOUTH THROAT AND CRANIAL OR FACIAL DIAGNOSES,MINOR",115,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],4810.94,,"Case rate ($4,810.94). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,4810.94,5051.49,There are no additional notes associated with this service or procedure.
"KIDNEY AND URINARY TRACT INFECTIONS,MODERATE",463,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],1870.92,,"Case rate for a one day stay ($1,870.92). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,1870.92,1964.47,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],25609.86,,"Fee schedule rate ($25,609.86). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,12775.53,31469.43,There are no additional notes associated with this service or procedure.
Cysto W/Insert Ureteral Stent,CASE-52332,APC,52332,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3299.47,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3299.47,3464.44,OPPS APC
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],15609.47,,"Fee schedule rate ($15,609.47). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7569.84,21892.85,There are no additional notes associated with this service or procedure.
Intraop Sentinel Lymph Node ID W/Dye Injection|LEFT SIDE,CASE-38900,APC,38900,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6215.36,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6215.36,6526.12,OPPS APC
"NON-EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,EXTREME",952,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],38386.67,,"Case rate ($38,386.67). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,38386.67,40306.00,There are no additional notes associated with this service or procedure.
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],18245.94,,"Fee schedule rate ($18,245.94). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8106.18,18245.94,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],19173.27,,,,,,0,other,8543.64,23239.84,There are no additional notes associated with this service or procedure.
HC Inj Trigger Pt 1-2 Musc Grps|PBB CHARGE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-20552,APC,20552,CPT,0510,RC,,,PBB|XU,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],17249.81,,"Case rate ($16,428.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,418.58, add-ons for qualifying new technology services are included. If operating cost exceeds $50,289.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,819.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $13,424.13 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,473.63 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,059.30. The transfer capital threshold is the transfer adjustment factor * $1,059.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,16428.39,42083.20,Inpatient DRG
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],14455.04,,"Fee schedule rate ($14,455.04). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5280.00,17136.70,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],11440.38,,"Case rate ($10,895.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,271.55, add-ons for qualifying new technology services are included. If operating cost exceeds $45,142.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,414.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $8,296.01 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,326.60 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $654.64. The transfer capital threshold is the transfer adjustment factor * $654.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10895.60,35192.25,Inpatient DRG
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],8767.81,,"Case rate ($8,767.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,292.11, add-ons for qualifying new technology services are included. If operating cost exceeds $43,163.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,258.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,323.85 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,347.16 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $499.01. The transfer capital threshold is the transfer adjustment factor * $499.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8767.81,19824.58,Inpatient DRG
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],33608.45,,"Fee schedule rate ($33,608.45). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,7332.00,35314.31,There are no additional notes associated with this service or procedure.
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],45157.33,,"Fee schedule rate ($45,157.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,10733.06,45157.33,There are no additional notes associated with this service or procedure.
VENTRICULAR SHUNT PROCEDURES WITH MCC,031,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],33417.25,,"Case rate ($32,287.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $30,171.71, add-ons for qualifying new technology services are included. If operating cost exceeds $65,042.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,979.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7. The base transfer operating payment is the transfer adjustment factor * $28,123.07 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $28,226.76 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,219.19. The transfer capital threshold is the transfer adjustment factor * $2,219.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,32287.20,88162.80,Inpatient DRG
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],62454.12,,"Fee schedule rate ($62,454.12). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11348.00,62454.12,There are no additional notes associated with this service or procedure.
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC",923,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],8450.18,,"Case rate ($8,047.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $7,588.71, add-ons for qualifying new technology services are included. If operating cost exceeds $46,233.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $3,215.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,201.30 + an uncompensated DSH payment of $1,359.91. The transfer operating threshold is the transfer adjustment factor * $6,228.80 + an uncompensated DSH payment of $1,359.91. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $486.59. The transfer capital threshold is the transfer adjustment factor * $486.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,20068.57,Inpatient DRG
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],25013.10,,"Fee schedule rate ($25,013.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10846.16,25863.45,There are no additional notes associated with this service or procedure.
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],12558.65,,"Fee schedule rate ($12,558.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5065.00,12558.65,There are no additional notes associated with this service or procedure.
Excision Distal Ulna Partial/Complete|RIGHT SIDE,CASE-25240,APC,25240,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],59610.47,,"Fee schedule rate ($59,610.47). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,16129.04,59610.47,There are no additional notes associated with this service or procedure.
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],6965.00,,,,,,0,other,6965.00,21089.59,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,447,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],131473.84,,,,,,0,other,47193.21,156646.82,There are no additional notes associated with this service or procedure.
DIABETES WITH CC,638,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],15195.79,,"Fee schedule rate ($15,195.79). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8014.07,17634.53,There are no additional notes associated with this service or procedure.
HC N Block Inj Intercost Sng|LEFT SIDE,CASE-64420,APC,64420,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],693.76,,"APC Price ($660.72). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,660.72,693.76,OPPS APC
"Laminec/Facetect/Foramin,Lumbar",CASE-63047,APC,63047,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6791.99,7131.59,OPPS APC
"NEONATE BIRTH WEIGHT > 2499 GRAMS WITH MAJOR ANOMALY,MINOR",633,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],1918.68,,"Case rate ($1,918.68). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,1918.68,2014.61,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC",281,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],8577.61,,"Case rate ($8,169.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,735.20, add-ons for qualifying new technology services are included. If operating cost exceeds $42,606.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,215.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $5,768.98 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,790.25 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $455.23. The transfer capital threshold is the transfer adjustment factor * $455.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8169.15,23859.35,Inpatient DRG
VENTRICULAR SHUNT PROCEDURES WITH CC,032,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],17195.03,,"Case rate ($16,376.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,370.06, add-ons for qualifying new technology services are included. If operating cost exceeds $50,241.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,815.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $13,375.80 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,425.12 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,055.48. The transfer capital threshold is the transfer adjustment factor * $1,055.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,16376.22,46275.08,Inpatient DRG
VAGINAL DELIVERY WITH O.R. PROCEDURES EXCEPT STERILIZATION AND/OR D&C,768,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],12088.81,,"Fee schedule rate ($12,088.81). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6426.91,13416.00,There are no additional notes associated with this service or procedure.
Sphincterotomy Anal Division Sphincter Spx,CASE-46080,APC,46080,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],2689.02,,"APC Price ($2,598.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2598.08,2727.99,OPPS APC
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7157.69,,"Case rate ($6,915.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,569.08, add-ons for qualifying new technology services are included. If operating cost exceeds $41,440.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,123.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,607.15 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,624.14 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $363.55. The transfer capital threshold is the transfer adjustment factor * $363.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6915.64,14442.92,Inpatient DRG
INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,352,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],21946.47,,"Fee schedule rate ($21,946.47). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,9853.37,26528.70,There are no additional notes associated with this service or procedure.
MAJOR THUMB OR JOINT PROCEDURES,506,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],11635.92,,"Case rate ($11,081.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,444.79, add-ons for qualifying new technology services are included. If operating cost exceeds $45,315.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,428.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $8,468.62 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,499.84 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $668.26. The transfer capital threshold is the transfer adjustment factor * $668.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,11081.83,26548.21,Inpatient DRG
OTHER CEREBROVASCULAR DISORDERS WITH MCC,070,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],37774.46,,"Fee schedule rate ($37,774.46). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,13219.09,37774.46,There are no additional notes associated with this service or procedure.
Laps Gstr Rstcv Px W/Byp Roux-en-Y Limb <150 Cm,CASE-43644,APC,43644,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],301.68,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,287.31,301.68,OPPS APC
HEADACHES WITHOUT MCC,103,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],11102.31,,"Fee schedule rate ($11,102.31). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,20883.08,There are no additional notes associated with this service or procedure.
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],18980.78,,"Case rate ($10,846.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,225.56, add-ons for qualifying new technology services are included. If operating cost exceeds $45,096.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,410.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $8,250.19 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,280.61 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $651.02. The transfer capital threshold is the transfer adjustment factor * $651.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,10846.16,25863.45,All Other Inpatient
"Inj Dx/Ther Agnt Paravert Facet Joint, Cerv/Thorac, 2nd Level",CASE-64491,APC,64491,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],856.86,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,827.89,869.28,OPPS APC
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,345,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],18631.20,,"Fee schedule rate ($18,631.20). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12134.89,33616.03,There are no additional notes associated with this service or procedure.
VAGINAL DELIVERY WITH O.R. PROCEDURES EXCEPT STERILIZATION AND/OR D&C,768,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],12088.81,,"Fee schedule rate ($12,088.81). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6426.91,13416.00,There are no additional notes associated with this service or procedure.
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],90333.60,,"Fee schedule rate ($90,333.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,26127.34,90333.60,There are no additional notes associated with this service or procedure.
Inj for Sacroiliac Jt Anesth|RIGHT SIDE,CASE-G0260,APC,G0260,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],660.72,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,660.72,693.76,OPPS APC
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,094,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],66140.08,,"Fee schedule rate ($66,140.08). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16.5), with a minimum of zero.",,,,0,other,25778.58,67889.44,There are no additional notes associated with this service or procedure.
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],23078.81,,"Fee schedule rate ($23,078.81). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10311.17,24308.97,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],11376.37,,"Case rate ($10,834.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,214.84, add-ons for qualifying new technology services are included. If operating cost exceeds $45,085.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,410.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $8,239.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,269.90 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $650.18. The transfer capital threshold is the transfer adjustment factor * $650.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10834.64,25830.00,Inpatient DRG
Suction Assisted Lipectomy Trunk,CASE-15877,APC,15877,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1623.23,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1600.04,1623.23,OPPS APC
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],59521.43,,"Fee schedule rate ($59,521.43). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,16689.78,59521.43,There are no additional notes associated with this service or procedure.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],64429.92,,"Fee schedule rate ($64,429.92). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,25162.32,75579.22,There are no additional notes associated with this service or procedure.
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],22762.43,,"Fee schedule rate ($22,762.43). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6230.00,22762.43,There are no additional notes associated with this service or procedure.
OTHER CEREBROVASCULAR DISORDERS WITH CC,071,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],29215.10,,"Fee schedule rate ($29,215.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5843.00,29215.10,There are no additional notes associated with this service or procedure.
Cystostomy Cystotomy W/Drainage,CASE-51040,APC,51040,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],2054.48,,"APC Price ($1,956.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1956.65,2054.48,OPPS APC
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],18497.24,,"Case rate ($18,497.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,343.20, add-ons for qualifying new technology services are included. If operating cost exceeds $52,214.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,970.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $15,341.68 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,398.25 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,210.61. The transfer capital threshold is the transfer adjustment factor * $1,210.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,18497.24,62041.12,Inpatient DRG
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],12526.44,,"Fee schedule rate ($12,526.44). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5415.00,17575.50,There are no additional notes associated with this service or procedure.
UNGROUPABLE,999,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],10228.00,,"Per diem ($10,228). If length of stay < 12.7, first 1 days paid at a per diem of $20,456 instead. Capped at $129,893.46.",,,,0,other,10228.00,161307.29,Estimated amount calculated based on 9 day length of stay.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],28756.63,,"Fee schedule rate ($28,756.63). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,13148.66,32553.63,There are no additional notes associated with this service or procedure.
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],36875.62,,"Fee schedule rate ($36,875.62). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.7), with a minimum of zero.",,,,0,other,15233.11,38610.21,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],26966.33,,"Fee schedule rate ($26,966.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,9040.72,26966.33,There are no additional notes associated with this service or procedure.
MAJOR THUMB OR JOINT PROCEDURES,506,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],25355.52,,"Fee schedule rate ($25,355.52). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.5), with a minimum of zero.",,,,0,other,11081.83,26548.21,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],16818.89,,"Case rate ($16,017.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,036.80, add-ons for qualifying new technology services are included. If operating cost exceeds $49,907.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,789.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $13,043.76 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,091.85 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,029.28. The transfer capital threshold is the transfer adjustment factor * $1,029.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,16017.99,51903.64,Inpatient DRG
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],15318.94,,"Fee schedule rate ($15,318.94). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6214.05,15318.94,There are no additional notes associated with this service or procedure.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],29997.59,,,,,,0,other,12268.97,41006.47,There are no additional notes associated with this service or procedure.
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],5791.49,,"Fee schedule rate ($5,791.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,3079.00,10940.41,There are no additional notes associated with this service or procedure.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],8702.79,,"Case rate ($8,702.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,231.63, add-ons for qualifying new technology services are included. If operating cost exceeds $43,102.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,254.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,263.59 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,286.68 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $494.26. The transfer capital threshold is the transfer adjustment factor * $494.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,5683.00,19635.68,Inpatient DRG
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],40666.46,,,,,,0,other,15940.79,53275.26,There are no additional notes associated with this service or procedure.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITHOUT CC/MCC,816,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],6536.15,,"Case rate ($6,224.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,926.50, add-ons for qualifying new technology services are included. If operating cost exceeds $40,797.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,073.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $3,966.92 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,981.55 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $313.03. The transfer capital threshold is the transfer adjustment factor * $313.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6224.90,14733.53,Inpatient DRG
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],12564.01,,"Case rate ($11,965.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,285.76, add-ons for qualifying new technology services are included. If operating cost exceeds $46,156.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,475.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,305.53 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,340.81 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $715.24. The transfer capital threshold is the transfer adjustment factor * $715.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12268.97,41006.47,Inpatient DRG
PREMATURITY WITH MAJOR PROBLEMS,791,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],3186.77,,,,,,0,other,3048.21,30904.42,Estimated amount calculated based on 5 day length of stay.
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],12979.93,,"Case rate ($12,725.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,973.79, add-ons for qualifying new technology services are included. If operating cost exceeds $46,844.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,548.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $9,991.99 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,028.83 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $788.47. The transfer capital threshold is the transfer adjustment factor * $788.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,12725.42,34245.00,Inpatient DRG
Dstrj Lesion Anus Extensive,CASE-46924,APC,46924,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],2727.99,,"APC Price ($2,598.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2598.08,2727.99,OPPS APC
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],13113.40,,"Case rate ($12,488.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,773.48, add-ons for qualifying new technology services are included. If operating cost exceeds $46,644.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,512.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $9,791.40 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,828.53 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $752.59. The transfer capital threshold is the transfer adjustment factor * $752.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7353.00,33398.16,Inpatient DRG
TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC,087,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],22679.07,,"Fee schedule rate ($22,679.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,8139.36,22679.07,There are no additional notes associated with this service or procedure.
Laps Rpr Paraesphgl Hrna Incl Fundplsty W/O Mesh,CASE-43281,APC,43281,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],9949.78,,"APC Price ($9,949.78). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,9949.78,10447.27,OPPS APC
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,069,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],20333.68,,"Fee schedule rate ($20,333.68). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,20333.68,There are no additional notes associated with this service or procedure.
ALLERGIC REACTIONS WITH MCC,915,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],27385.01,,"Fee schedule rate ($27,385.01). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,13332.86,33088.84,There are no additional notes associated with this service or procedure.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,418,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],14070.61,,"Case rate ($13,400.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,601.88, add-ons for qualifying new technology services are included. If operating cost exceeds $47,472.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,597.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $10,617.79 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,656.93 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $837.85. The transfer capital threshold is the transfer adjustment factor * $837.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13400.58,39884.93,Inpatient DRG
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],10533.95,,"Case rate ($10,533.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,935.13, add-ons for qualifying new technology services are included. If operating cost exceeds $44,806.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,388.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $7,960.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,990.18 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $628.19. The transfer capital threshold is the transfer adjustment factor * $628.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10533.95,24956.34,Inpatient DRG
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],10111.40,,"Case rate ($5,777.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,510.70, add-ons for qualifying new technology services are included. If operating cost exceeds $40,381.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,040.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $3,552.65 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,565.75 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $280.34. The transfer capital threshold is the transfer adjustment factor * $280.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,5065.00,12558.65,All Other Inpatient
Colonoscopy Flx Dx W/Collj Spec When Pfrmd|COLORECTAL CANCER SCREEN,CASE-45378,APC,45378,CPT,0360,RC,,,PT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],870.46,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,870.46,913.99,OPPS APC
NON-MALIGNANT BREAST DISORDERS WITH CC/MCC,600,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],15046.13,,"Fee schedule rate ($15,046.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7999.14,20495.56,There are no additional notes associated with this service or procedure.
SEIZURES WITH MCC,100,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],32323.98,,"Fee schedule rate ($32,323.98). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,15061.09,38110.41,There are no additional notes associated with this service or procedure.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,097,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],79915.74,,"Fee schedule rate ($79,915.74). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,26404.32,79915.74,There are no additional notes associated with this service or procedure.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC,192,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6292.63,,"Case rate ($6,292.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,989.50, add-ons for qualifying new technology services are included. If operating cost exceeds $40,860.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,077.96, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,029.69 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,044.54 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $317.98. The transfer capital threshold is the transfer adjustment factor * $317.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6292.63,12753.78,Inpatient DRG
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],23316.48,,"Fee schedule rate ($23,316.48). Adds an outlier to normal pricing equal to the per diem rate ($44,995.76) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7.7), with a minimum of zero.",,,,0,other,10347.06,28821.04,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],21719.40,,"Case rate ($21,719.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,340.70, add-ons for qualifying new technology services are included. If operating cost exceeds $55,211.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,206.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.2. The base transfer operating payment is the transfer adjustment factor * $18,328.17 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,395.75 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,446.27. The transfer capital threshold is the transfer adjustment factor * $1,446.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,21719.40,85305.59,Inpatient DRG
Rpr Aa Hernia 1st 3-10 Cm Ncrc8/Strangulated,CASE-49594,APC,49594,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5856.81,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5658.76,5941.70,OPPS APC
"NEONATE BIRTH WEIGHT 2000-2499 GRAMS WITH RESPIRATORY DISTRESS SYNDROME OR OTHER MAJOR RESPIRATORY CONDITION,MODERATE",622,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],20988.12,,"Case rate ($20,988.12). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,20988.12,22037.53,There are no additional notes associated with this service or procedure.
OTHER CEREBROVASCULAR DISORDERS WITH CC,071,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],8893.10,,"Case rate ($8,893.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,408.66, add-ons for qualifying new technology services are included. If operating cost exceeds $43,279.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,268.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,439.97 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,463.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $508.18. The transfer capital threshold is the transfer adjustment factor * $508.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,5843.00,29215.10,Inpatient DRG
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],16229.42,,"Case rate ($15,456.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,514.54, add-ons for qualifying new technology services are included. If operating cost exceeds $49,385.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,748.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $12,523.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,569.59 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $988.22. The transfer capital threshold is the transfer adjustment factor * $988.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,15456.59,41402.42,Inpatient DRG
Dstrj Lesion Anus Extensive,CASE-46924,APC,46924,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],2727.99,,"APC Price ($2,598.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2598.08,2727.99,OPPS APC
Exc B9 Lesion Mrgn Xcp Sk Tg S/N/H/F/G 3.1-4.0cm,CASE-11424,APC,11424,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1827.80,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1827.80,1919.19,OPPS APC
"Partical Excision Bone Phalanx Toe|RIGHT FOOT, FIFTH DIGIT",CASE-28124,APC,28124,CPT,0360,RC,,,T9,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],15887.21,,,,,,0,other,6148.93,15887.21,There are no additional notes associated with this service or procedure.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],36776.05,,"Fee schedule rate ($36,776.05). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11053.39,36776.05,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],19691.31,,"Fee schedule rate ($19,691.31). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,9040.72,26966.33,There are no additional notes associated with this service or procedure.
"NEONATE BIRTH WEIGHT 2000-2499 GRAMS WITH OTHER SIGNIFICANT CONDITION,MINOR",625,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],9761.07,,"Case rate ($9,296.26). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9296.26,9761.07,There are no additional notes associated with this service or procedure.
"Open Tx Distal Phalangeal Fracture Each|LEFT HAND, FIFTH DIGIT",CASE-26765,APC,26765,CPT,0360,RC,,,F4,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],52803.53,,"Fee schedule rate ($52,803.53). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,14337.84,52803.53,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],8859.23,,"Case rate ($8,859.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,377.16, add-ons for qualifying new technology services are included. If operating cost exceeds $43,248.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,265.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $6,408.58 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,432.21 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $505.70. The transfer capital threshold is the transfer adjustment factor * $505.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8859.23,20090.22,Inpatient DRG
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],11565.93,,"Fee schedule rate ($11,565.93). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6148.93,15887.21,There are no additional notes associated with this service or procedure.
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],8165.30,,"Fee schedule rate ($8,165.30). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4341.01,12882.53,There are no additional notes associated with this service or procedure.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],7453.00,,"Per diem ($7,453). If length of stay < 5.4, first 1 days paid at a per diem of $14,906 instead. Capped at $40,245.21.",,,,0,other,7453.00,42138.30,Estimated amount calculated based on 3 day length of stay.
"COCAINE ABUSE AND DEPENDENCE,EXTREME",774,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],20088.54,,"Case rate ($19,131.94). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,19131.94,20088.54,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITH MCC,385,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],21593.52,,"Fee schedule rate ($21,593.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11480.01,31134.92,There are no additional notes associated with this service or procedure.
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],12937.10,,"Fee schedule rate ($12,937.10). Adds an outlier to normal pricing equal to the per diem rate ($49,808.13) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.5), with a minimum of zero.",,,,0,other,5919.29,13545.65,There are no additional notes associated with this service or procedure.
Optx Dstl Radl X-Artic Fx/Epiphysl Sep|LEFT SIDE,CASE-25607,APC,25607,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6791.99,7131.59,OPPS APC
"HC Injection Small Joint/Bursa|RIGHT HAND, FOURTH DIGIT",CASE-20600,APC,20600,CPT,0361,RC,,,F8,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1580.37,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1505.12,1580.37,OPPS APC
Nasal/Sinus Ndsc W/Rmvl Tiss From Frontal Sinus|LEFT SIDE,CASE-31276,APC,31276,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6837.16,,"APC Price ($6,605.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6605.95,6936.25,OPPS APC
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH CC",457,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],112064.54,,"Fee schedule rate ($112,064.54). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.9), with a minimum of zero.",,,,0,other,42327.47,160549.49,There are no additional notes associated with this service or procedure.
HC Gastric Procedure Unlisted,CASE-43999,APC,43999,CPT,0361,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],878.67,,"APC Price ($848.96). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,848.96,891.41,OPPS APC
Surgical Arthroscopy Sho W/Coracoacrm Ligm Rls|LEFT SIDE,CASE-29826,APC,29826,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC,833,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],5721.39,,"Fee schedule rate ($5,721.39). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,3041.73,10289.10,There are no additional notes associated with this service or procedure.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],17741.86,,"Case rate ($16,897.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,854.53, add-ons for qualifying new technology services are included. If operating cost exceeds $50,725.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,853.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $13,858.48 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,909.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,093.57. The transfer capital threshold is the transfer adjustment factor * $1,093.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,16897.01,43444.85,Inpatient DRG
Excision Malignant Lesion Trunk/Arm/Leg > 4.0 Cm,CASE-11606,APC,11606,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6526.12,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6215.36,6526.12,OPPS APC
"DORSAL AND LUMBAR FUSION PROCEDURE EXCEPT FOR CURVATURE OF BACK,MODERATE",304,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],7627.61,,"Case rate for a one day stay ($7,627.61). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,7627.61,8008.99,There are no additional notes associated with this service or procedure.
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,450,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],146009.19,,"Fee schedule rate ($146,009.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,38037.38,146009.19,There are no additional notes associated with this service or procedure.
POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES,769,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],29791.03,,"Fee schedule rate ($29,791.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,13388.39,33250.19,There are no additional notes associated with this service or procedure.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,098,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],17486.17,,"Case rate ($17,486.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,402.62, add-ons for qualifying new technology services are included. If operating cost exceeds $51,273.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,896.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $14,404.56 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,457.67 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,136.66. The transfer capital threshold is the transfer adjustment factor * $1,136.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,45156.75,Inpatient DRG
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,073,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],30149.61,,"Fee schedule rate ($30,149.61). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12809.38,43475.01,There are no additional notes associated with this service or procedure.
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],25829.63,,"Fee schedule rate ($25,829.63). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6965.00,29482.05,There are no additional notes associated with this service or procedure.
PERITONEAL ADHESIOLYSIS WITH CC,336,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],39628.80,,"Fee schedule rate ($39,628.80). Adds an outlier to normal pricing equal to the per diem rate ($54,966.40) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,16225.22,53705.31,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,690,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],7426.94,,"Case rate ($7,426.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,044.73, add-ons for qualifying new technology services are included. If operating cost exceeds $41,915.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,160.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,081.05 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,099.78 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $400.94. The transfer capital threshold is the transfer adjustment factor * $400.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7426.94,15928.53,Inpatient DRG
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],13625.25,,"Fee schedule rate ($13,625.25). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7243.75,23262.15,There are no additional notes associated with this service or procedure.
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],45017.13,,"Fee schedule rate ($45,017.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,14603.31,45017.13,There are no additional notes associated with this service or procedure.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC",061,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],20616.23,,"Case rate ($20,616.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $19,314.45, add-ons for qualifying new technology services are included. If operating cost exceeds $54,185.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,125.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $17,305.68 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $17,369.49 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,365.59. The transfer capital threshold is the transfer adjustment factor * $1,365.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,20616.23,62315.82,Inpatient DRG
"HEART FAILURE,EXTREME",194,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],23379.83,,"Case rate ($22,266.50). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,22266.50,23379.83,There are no additional notes associated with this service or procedure.
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],6965.00,,,,,,0,other,5139.72,13110.79,There are no additional notes associated with this service or procedure.
Excision Olecranon Bursa|LEFT SIDE,CASE-24105,APC,24105,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7029.71,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6791.99,7131.59,OPPS APC
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],34570.85,,"Fee schedule rate ($34,570.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,6965.00,36140.75,There are no additional notes associated with this service or procedure.
Esophagoscopy Intra/Transmural Needle Aspirat/Bx,CASE-43232,APC,43232,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1796.14,,"APC Price ($1,796.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1796.14,1885.95,OPPS APC
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,093,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],19011.32,,"Fee schedule rate ($19,011.32). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,19011.32,There are no additional notes associated with this service or procedure.
"Hallux Rigidus W/Cheilectomy 1st Mp Jt W/O Implt|LEFT FOOT, GREAT TOE",CASE-28289,APC,28289,CPT,0360,RC,,,TA,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
TRAUMATIC INJURY WITH MCC,913,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],42838.46,,"Fee schedule rate ($42,838.46). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13014.58,42838.46,There are no additional notes associated with this service or procedure.
Colonoscopy W/Biopsy Single/Multiple|UNUSUAL NON-OVERLAPPING SERVICE,CASE-45380,APC,45380,CPT,0360,RC,,,XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1176.09,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1120.09,1176.09,OPPS APC
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],7749.28,,"Case rate ($7,749.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,344.60, add-ons for qualifying new technology services are included. If operating cost exceeds $42,215.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,184.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,379.82 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,399.66 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $424.52. The transfer capital threshold is the transfer adjustment factor * $424.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6711.00,16865.16,Inpatient DRG
Egd Transoral Biopsy Single/Multiple|UNUSUAL NON-OVERLAPPING SERVICE,CASE-43239,APC,43239,CPT,0360,RC,,,XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1859.01,,"APC Price ($1,796.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1796.14,1885.95,OPPS APC
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC,831,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],9294.42,,"Fee schedule rate ($9,294.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,4941.30,23661.59,There are no additional notes associated with this service or procedure.
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC",514,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],22699.91,,"Fee schedule rate ($22,699.91). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8868.04,22699.91,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,086,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],10766.92,,"Case rate ($10,766.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,151.85, add-ons for qualifying new technology services are included. If operating cost exceeds $45,022.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,405.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $8,176.75 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,206.90 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $645.23. The transfer capital threshold is the transfer adjustment factor * $645.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8442.00,30728.81,Inpatient DRG
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],43703.12,,"Fee schedule rate ($43,703.12). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.7), with a minimum of zero.",,,,0,other,17693.40,52449.26,There are no additional notes associated with this service or procedure.
OSTEOMYELITIS WITH CC,540,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],18450.55,,"Fee schedule rate ($18,450.55). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,9809.07,25507.30,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC,832,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],6831.68,,"Case rate ($6,831.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,490.97, add-ons for qualifying new technology services are included. If operating cost exceeds $41,361.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,117.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $4,529.32 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,546.02 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $357.41. The transfer capital threshold is the transfer adjustment factor * $357.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,4803.31,14198.92,Inpatient DRG
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],13241.29,,"Case rate ($7,566.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,174.51, add-ons for qualifying new technology services are included. If operating cost exceeds $42,045.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,171.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,210.35 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,229.56 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $411.15. The transfer capital threshold is the transfer adjustment factor * $411.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,7566.45,16333.88,All Other Inpatient
SPINAL PROCEDURES WITHOUT CC/MCC,030,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],41254.39,,"Fee schedule rate ($41,254.39). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,16810.99,44714.01,There are no additional notes associated with this service or procedure.
"Partical Excision Bone Phalanx Toe|LEFT FOOT, THIRD DIGIT",CASE-28124,APC,28124,CPT,0360,RC,,,T2,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7029.71,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6791.99,7131.59,OPPS APC
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],11565.93,,"Fee schedule rate ($11,565.93). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6148.93,15887.21,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],12272.58,,"Fee schedule rate ($12,272.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5628.97,12272.58,There are no additional notes associated with this service or procedure.
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC",629,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],17284.44,,"Case rate ($16,699.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,671.20, add-ons for qualifying new technology services are included. If operating cost exceeds $50,542.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,839.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $13,675.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,726.25 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,079.16. The transfer capital threshold is the transfer adjustment factor * $1,079.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,16699.94,44657.18,Inpatient DRG
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],11353.10,,"Fee schedule rate ($11,353.10). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6834.39,21354.82,There are no additional notes associated with this service or procedure.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],62454.12,,"Fee schedule rate ($62,454.12). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11348.00,62454.12,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,083,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],28680.85,,"Fee schedule rate ($28,680.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,28680.85,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],9389.48,,"Case rate ($9,389.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,870.44, add-ons for qualifying new technology services are included. If operating cost exceeds $43,741.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,304.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,900.05 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,925.50 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $544.48. The transfer capital threshold is the transfer adjustment factor * $544.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9389.48,22358.90,Inpatient DRG
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],13907.80,,"Case rate ($13,907.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,073.74, add-ons for qualifying new technology services are included. If operating cost exceeds $47,944.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,634.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $11,087.92 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,128.80 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $874.95. The transfer capital threshold is the transfer adjustment factor * $874.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,13907.80,52794.06,Inpatient DRG
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],26949.28,,"Fee schedule rate ($26,949.28). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9977.99,26949.28,There are no additional notes associated with this service or procedure.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],8151.55,,"Case rate ($8,151.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,718.82, add-ons for qualifying new technology services are included. If operating cost exceeds $42,589.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,213.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,752.66 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,773.87 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $453.94. The transfer capital threshold is the transfer adjustment factor * $453.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8151.55,18033.97,Inpatient DRG
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC,858,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],11775.98,,"Case rate ($11,377.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,720.10, add-ons for qualifying new technology services are included. If operating cost exceeds $45,591.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,449.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $8,742.91 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,775.15 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $689.90. The transfer capital threshold is the transfer adjustment factor * $689.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,11377.76,33794.11,Inpatient DRG
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],8933.82,,"Fee schedule rate ($8,933.82). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7238.69,16804.22,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],11446.55,,"Case rate ($11,059.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,424, add-ons for qualifying new technology services are included. If operating cost exceeds $45,295.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,426.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $8,447.91 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,479.05 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $666.62. The transfer capital threshold is the transfer adjustment factor * $666.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,11059.47,28423.20,Inpatient DRG
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],11168.08,,"Fee schedule rate ($11,168.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5937.41,12366.99,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITH STERILIZATION WITHOUT CC/MCC,785,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],8726.33,,"Case rate ($8,431.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,979, add-ons for qualifying new technology services are included. If operating cost exceeds $42,850.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,234.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,011.89 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,034.06 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $474.40. The transfer capital threshold is the transfer adjustment factor * $474.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,8431.24,20142.33,Inpatient DRG
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],14249.81,,"Case rate ($13,571.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,760.65, add-ons for qualifying new technology services are included. If operating cost exceeds $47,631.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,610.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $10,775.96 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,815.69 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $850.33. The transfer capital threshold is the transfer adjustment factor * $850.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13571.25,33781.47,Inpatient DRG
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],105091.76,,"Fee schedule rate ($105,091.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,35719.96,105091.76,There are no additional notes associated with this service or procedure.
OSTEOMYELITIS WITHOUT CC/MCC,541,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],15493.67,,,,,,0,other,5103.00,15493.67,There are no additional notes associated with this service or procedure.
Osteot W/WO Lngth Shrt/Corrj Metar Xcp 1st Ea|RIGHT SIDE,CASE-28308,APC,28308,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
Dstr Nrolytc Agnt Parverteb Fct Addl Lmbr/Sacral,CASE-64636,APC,64636,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1827.80,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1827.80,1919.19,OPPS APC
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],49717.39,,"Fee schedule rate ($49,717.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,14908.05,49717.39,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL HEMORRHAGE WITH MCC,377,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],7634.00,,"Per diem ($7,634). If length of stay < 4.5, first 1 days paid at a per diem of $15,268 instead. Capped at $34,353.60.",,,,0,other,7634.00,35969.56,Estimated amount calculated based on 3 day length of stay.
Chromotubation Oviduct W/Materials|UNUSUAL NON-OVERLAPPING SERVICE,CASE-58350,APC,58350,CPT,0360,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5658.76,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5658.76,5941.70,OPPS APC
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],97015.50,,"Fee schedule rate ($97,015.50). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,26809.29,97015.50,There are no additional notes associated with this service or procedure.
OSTEOMYELITIS WITH CC,540,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],24361.37,,"Fee schedule rate ($24,361.37). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.6), with a minimum of zero.",,,,0,other,9809.07,25507.30,There are no additional notes associated with this service or procedure.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH CC,026,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],61179.73,,,,,,0,other,23000.66,63202.45,There are no additional notes associated with this service or procedure.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],15309.46,,"Fee schedule rate ($15,309.46). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6965.00,15340.19,There are no additional notes associated with this service or procedure.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],10098.51,,"Case rate ($10,098.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,530.04, add-ons for qualifying new technology services are included. If operating cost exceeds $44,401.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,356.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $7,557.23 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,585.10 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $596.34. The transfer capital threshold is the transfer adjustment factor * $596.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10098.51,24259.09,Inpatient DRG
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],28334.16,,"Fee schedule rate ($28,334.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,7868.00,32126.64,There are no additional notes associated with this service or procedure.
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],25863.45,,,,,,0,other,10846.16,25863.45,There are no additional notes associated with this service or procedure.
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],12102.37,,"Case rate ($6,915.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,569.08, add-ons for qualifying new technology services are included. If operating cost exceeds $41,440.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,123.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,607.15 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,624.14 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $363.55. The transfer capital threshold is the transfer adjustment factor * $363.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,6915.64,14442.92,All Other Inpatient
"Corrj Hallux Valgus W/Sesmdc W/Dist Metar Osteot|RIGHT FOOT, GREAT TOE",CASE-28296,APC,28296,CPT,0360,RC,,,T5,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
Ndsc Njx Implt Matrl Urt&/Bldr Nck,CASE-51715,APC,51715,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3414.95,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3299.47,3464.44,OPPS APC
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,025,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],91631.33,,"Fee schedule rate ($91,631.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,13351.00,91631.33,There are no additional notes associated with this service or procedure.
HC Inj Aa&/Strd Other Peripheral Nerve/Branch|LEFT SIDE,CASE-64450,APC,64450,CPT,0450,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],683.85,,"APC Price ($660.72). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,660.72,693.76,OPPS APC
GASTROINTESTINAL HEMORRHAGE WITH MCC,377,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],15040.50,,"Case rate ($14,324.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,461.19, add-ons for qualifying new technology services are included. If operating cost exceeds $48,332.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,665.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $11,473.94 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,516.24 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $905.41. The transfer capital threshold is the transfer adjustment factor * $905.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7634.00,35969.56,Inpatient DRG
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],15128.37,,"Fee schedule rate ($15,128.37). Adds an outlier to normal pricing equal to the per diem rate ($46,867.46) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7396.47,16035.06,There are no additional notes associated with this service or procedure.
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],7993.75,,"Case rate ($7,993.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,572.03, add-ons for qualifying new technology services are included. If operating cost exceeds $42,443.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,202.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $5,606.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,627.08 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $442.40. The transfer capital threshold is the transfer adjustment factor * $442.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,5415.00,17575.50,Inpatient DRG
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],42842.73,,,,,,0,other,16689.78,59521.43,There are no additional notes associated with this service or procedure.
Egd Transoral Biopsy Single/Multiple|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-43239,APC,43239,CPT,0360,RC,,,74,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],891.41,,"APC Price ($848.96). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,848.96,891.41,OPPS APC
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],42586.49,,"Fee schedule rate ($42,586.49). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,13341.67,42586.49,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,086,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],11305.27,,"Case rate ($10,766.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,151.85, add-ons for qualifying new technology services are included. If operating cost exceeds $45,022.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,405.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $8,176.75 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,206.90 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $645.23. The transfer capital threshold is the transfer adjustment factor * $645.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8442.00,30728.81,Inpatient DRG
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],19407.49,,"Case rate ($18,751.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,579.45, add-ons for qualifying new technology services are included. If operating cost exceeds $52,450.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,989.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $15,577.06 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,634.50 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,229.18. The transfer capital threshold is the transfer adjustment factor * $1,229.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,8480.00,59081.91,Inpatient DRG
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC,519,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],28144.20,,"Fee schedule rate ($28,144.20). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,15490.44,50780.20,There are no additional notes associated with this service or procedure.
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],5791.49,,"Fee schedule rate ($5,791.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,3079.00,10940.41,There are no additional notes associated with this service or procedure.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],38248.08,,"Fee schedule rate ($38,248.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11593.79,38248.08,There are no additional notes associated with this service or procedure.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],19528.77,,"Case rate ($18,598.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,437.70, add-ons for qualifying new technology services are included. If operating cost exceeds $52,308.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,978.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 5.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $15,435.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,492.75 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,218.04. The transfer capital threshold is the transfer adjustment factor * $1,218.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,18598.83,48389.68,Inpatient DRG
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],12268.97,,"Case rate ($12,268.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,549.17, add-ons for qualifying new technology services are included. If operating cost exceeds $46,420.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,515.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,568.94 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,604.22 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $755.08. The transfer capital threshold is the transfer adjustment factor * $755.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12268.97,41006.47,Inpatient DRG
MAJOR BLADDER PROCEDURES WITH MCC,653,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],125343.98,,"Fee schedule rate ($125,343.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,10280.00,125343.98,There are no additional notes associated with this service or procedure.
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],31577.54,,"Fee schedule rate ($31,577.54). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,15453.88,39251.68,There are no additional notes associated with this service or procedure.
HEART FAILURE AND SHOCK WITH CC,292,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],5502.00,,"Per diem ($5,502). If length of stay < 2.9, first 1 days paid at a per diem of $11,004 instead. Capped at $15,955.26.",,,,0,other,5502.00,16705.77,Estimated amount calculated based on 2 day length of stay.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],28821.04,,"Fee schedule rate ($28,821.04). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,10347.06,28821.04,There are no additional notes associated with this service or procedure.
RESPIRATORY NEOPLASMS WITHOUT CC/MCC,182,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],23037.13,,"Fee schedule rate ($23,037.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6965.00,23037.13,There are no additional notes associated with this service or procedure.
"NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY",789,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],14644.80,,"Case rate ($14,149.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,298.65, add-ons for qualifying new technology services are included. If operating cost exceeds $48,169.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,652.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $11,312.00 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,353.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $892.63. The transfer capital threshold is the transfer adjustment factor * $892.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,3054.00,14857.05,Inpatient DRG
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,761,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],11946.72,,"Fee schedule rate ($11,946.72). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,5808.41,11946.72,There are no additional notes associated with this service or procedure.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,074,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],19371.82,,"Fee schedule rate ($19,371.82). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,8925.60,20919.08,There are no additional notes associated with this service or procedure.
Ndsc Eval Intstinal Pouch Dx W/Collj Spec Spx,CASE-44385,APC,44385,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],870.46,,"APC Price ($870.46). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,870.46,913.99,OPPS APC
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC",605,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],17214.39,,"Fee schedule rate ($17,214.39). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8148.17,18024.13,There are no additional notes associated with this service or procedure.
Ercp Remove Calculi/Debris Biliary/Pancreas Duct,CASE-43264,APC,43264,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5881.39,,"APC Price ($5,682.51). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5682.51,5966.63,OPPS APC
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],58394.20,,"Fee schedule rate ($58,394.20). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,9370.00,65732.99,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC,084,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],6965.00,,,,,,0,other,6965.00,19445.16,There are no additional notes associated with this service or procedure.
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],27982.66,,,,,,0,other,11575.50,48961.48,There are no additional notes associated with this service or procedure.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],28434.57,,"Fee schedule rate ($28,434.57). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,8906.63,28434.57,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL HEMORRHAGE WITH MCC,377,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],31575.65,,"Fee schedule rate ($31,575.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,7634.00,35969.56,There are no additional notes associated with this service or procedure.
Marsupialization Bartholins Gland Cyst|LEFT SIDE,CASE-56440,APC,56440,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3030.03,,"APC Price ($3,030.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3030.03,3181.53,OPPS APC
Cysto W/Ureteroscopy W/Lithotripsy|LEFT SIDE,CASE-52353,APC,52353,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5194.43,,"APC Price ($5,018.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5018.77,5269.71,OPPS APC
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC",061,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],51814.18,,"Fee schedule rate ($51,814.18). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,20616.23,62315.82,There are no additional notes associated with this service or procedure.
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral Ea Addl|RIGHT SIDE,CASE-64484,APC,64484,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],827.89,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,827.89,869.28,OPPS APC
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,345,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],12741.63,,"Case rate ($12,134.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,424.43, add-ons for qualifying new technology services are included. If operating cost exceeds $46,295.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,505.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $9,444.66 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,479.48 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $745.28. The transfer capital threshold is the transfer adjustment factor * $745.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12134.89,33616.03,Inpatient DRG
Cysto W/Ureteroscopy W/Rmvl/Manj Stones|RIGHT SIDE,CASE-52352,APC,52352,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3299.47,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3299.47,3464.44,OPPS APC
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],20407.65,,"Case rate ($19,435.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $18,216.37, add-ons for qualifying new technology services are included. If operating cost exceeds $53,087.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,039.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.9. The base transfer operating payment is the transfer adjustment factor * $16,211.64 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $16,271.42 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,279.26. The transfer capital threshold is the transfer adjustment factor * $1,279.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,19435.86,50821.76,Inpatient DRG
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],15309.46,,"Fee schedule rate ($15,309.46). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6965.00,15340.19,There are no additional notes associated with this service or procedure.
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],11992.67,,"Fee schedule rate ($11,992.67). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6801.88,22557.82,There are no additional notes associated with this service or procedure.
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],16804.22,,"Fee schedule rate ($16,804.22). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7238.69,16804.22,There are no additional notes associated with this service or procedure.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],67790.93,,"Fee schedule rate ($67,790.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,21597.50,67790.93,There are no additional notes associated with this service or procedure.
"NEONATE BIRTH WEIGHT 1250-1499 GRAMS WITH RESPIRATORY DISTRESS SYNDROME OR OTHER MAJOR RESPIRATORY CONDITION OR MAJOR ANOMALY,MAJOR",607,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],87869.86,,"Case rate ($87,869.86). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $58,117, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,87869.86,92263.35,There are no additional notes associated with this service or procedure.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",062,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],44304.80,,"Fee schedule rate ($44,304.80). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,13844.84,44304.80,There are no additional notes associated with this service or procedure.
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",759,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],11643.60,,"Fee schedule rate ($11,643.60). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6190.22,13057.66,There are no additional notes associated with this service or procedure.
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],15821.59,,"Case rate ($15,821.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,854.10, add-ons for qualifying new technology services are included. If operating cost exceeds $49,725.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,774.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $12,861.73 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,909.15 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,014.92. The transfer capital threshold is the transfer adjustment factor * $1,014.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,15821.59,40320.14,Inpatient DRG
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],12246.05,,"Fee schedule rate ($12,246.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6010.23,12246.05,There are no additional notes associated with this service or procedure.
RESPIRATORY NEOPLASMS WITH CC,181,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],20127.30,,"Fee schedule rate ($20,127.30). Adds an outlier to normal pricing equal to the per diem rate ($54,966.40) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,9197.84,21074.07,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],67794.72,,"Fee schedule rate ($67,794.72). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,10862.00,86437.13,There are no additional notes associated with this service or procedure.
Exc Breast Les Preop Plmt Rad Marker Open 1 Les|RIGHT SIDE,CASE-19125,APC,19125,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3848.19,,"APC Price ($3,664.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3664.94,3848.19,OPPS APC
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],11260.25,,"Case rate ($10,724.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,128.34, add-ons for qualifying new technology services are included. If operating cost exceeds $44,999.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,386.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $8,152.48 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,183.39 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $626.62. The transfer capital threshold is the transfer adjustment factor * $626.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10989.72,26280.60,Inpatient DRG
NEONATE WITH OTHER SIGNIFICANT PROBLEMS,794,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],1956.00,,,,,,0,other,1798.85,12536.83,Estimated amount calculated based on 2 day length of stay.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],10050.80,,"Fee schedule rate ($10,050.80). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6963.00,18954.85,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,167,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],33891.30,,"Fee schedule rate ($33,891.30). Adds an outlier to normal pricing equal to the per diem rate ($66,990.29) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.6), with a minimum of zero.",,,,0,other,14157.71,43522.37,There are no additional notes associated with this service or procedure.
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 1 Level,CASE-64493,APC,64493,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],827.89,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,827.89,869.28,OPPS APC
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],27589.62,,"Fee schedule rate ($27,589.62). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12566.28,30861.41,There are no additional notes associated with this service or procedure.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,056,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],45711.64,,,,,,0,other,7659.00,59328.19,There are no additional notes associated with this service or procedure.
SEIZURES WITH MCC,100,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],15814.14,,"Case rate ($15,061.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,146.62, add-ons for qualifying new technology services are included. If operating cost exceeds $49,017.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,719.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $12,156.85 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,201.67 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $959.30. The transfer capital threshold is the transfer adjustment factor * $959.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,15061.09,38110.41,Inpatient DRG
ALLERGIC REACTIONS WITH MCC,915,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],13332.86,,"Case rate ($13,332.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,538.89, add-ons for qualifying new technology services are included. If operating cost exceeds $47,409.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,592.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $10,555.02 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,593.94 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $832.90. The transfer capital threshold is the transfer adjustment factor * $832.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,13332.86,33088.84,Inpatient DRG
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],29585.82,,"Fee schedule rate ($29,585.82). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12606.23,36868.88,There are no additional notes associated with this service or procedure.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],67790.93,,"Fee schedule rate ($67,790.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,21597.50,67790.93,There are no additional notes associated with this service or procedure.
NORMAL NEWBORN,795,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],2074.00,,,,,,0,other,1369.79,5771.52,Estimated amount calculated based on 2 day length of stay.
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,068,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],6965.00,,,,,,0,other,6965.00,23184.90,There are no additional notes associated with this service or procedure.
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],16138.02,,"Case rate ($15,821.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,854.10, add-ons for qualifying new technology services are included. If operating cost exceeds $49,725.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,774.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $12,861.73 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,909.15 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,014.92. The transfer capital threshold is the transfer adjustment factor * $1,014.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,15821.59,40320.14,Inpatient DRG
Osteoplasty Radius/Ulna Shortening,CASE-25390,APC,25390,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
Arthroscopy Knee W/Meniscus Rpr Medial/Lateral|RIGHT SIDE,CASE-29882,APC,29882,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7029.71,OPPS APC
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],12246.05,,"Fee schedule rate ($12,246.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6010.23,12246.05,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],30063.84,,"Fee schedule rate ($30,063.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13891.57,34712.20,There are no additional notes associated with this service or procedure.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],8222.77,,"Case rate ($7,831.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,431.79, add-ons for qualifying new technology services are included. If operating cost exceeds $42,302.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,180.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $5,466.12 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,486.84 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $420.14. The transfer capital threshold is the transfer adjustment factor * $420.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8009.34,19877.10,Inpatient DRG
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],58394.20,,"Fee schedule rate ($58,394.20). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,9370.00,65732.99,There are no additional notes associated with this service or procedure.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],54764.34,,"Fee schedule rate ($54,764.34). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,18178.96,54764.34,There are no additional notes associated with this service or procedure.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],11418.14,,"Case rate ($11,194.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,549.37, add-ons for qualifying new technology services are included. If operating cost exceeds $45,420.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,436.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $8,572.81 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,604.42 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $676.48. The transfer capital threshold is the transfer adjustment factor * $676.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,11194.25,36094.03,Inpatient DRG
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],90333.60,,"Fee schedule rate ($90,333.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,26127.34,90333.60,There are no additional notes associated with this service or procedure.
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],14455.04,,"Fee schedule rate ($14,455.04). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5280.00,17136.70,There are no additional notes associated with this service or procedure.
Cysto W/Ureteroscopy W/Rmvl/Manj Stones|RIGHT SIDE,CASE-52352,APC,52352,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3464.44,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3299.47,3464.44,OPPS APC
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],22358.90,,"Fee schedule rate ($22,358.90). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9389.48,22358.90,There are no additional notes associated with this service or procedure.
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],6506.18,,"Case rate ($6,378.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,069.50, add-ons for qualifying new technology services are included. If operating cost exceeds $40,940.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,084.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,109.40 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,124.55 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $324.27. The transfer capital threshold is the transfer adjustment factor * $324.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,4341.01,12882.53,Inpatient DRG
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],24259.09,,"Fee schedule rate ($24,259.09). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10098.51,24259.09,There are no additional notes associated with this service or procedure.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,025,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],33390.23,,"Case rate ($32,735.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $30,588.77, add-ons for qualifying new technology services are included. If operating cost exceeds $65,459.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,011.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.4. The base transfer operating payment is the transfer adjustment factor * $28,538.59 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $28,643.82 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,251.98. The transfer capital threshold is the transfer adjustment factor * $2,251.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 102%.",,,,0,other,13351.00,91631.33,Inpatient DRG
Arthrs Kne Surg W/Meniscectomy Med/Lat W/Shvg|RIGHT SIDE|SEPARATE STRUCTURE,CASE-29881,APC,29881,CPT,0360,RC,,,RT|XS,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6791.99,7131.59,OPPS APC
Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq,CASE-45385,APC,45385,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1120.09,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1120.09,1176.09,OPPS APC
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],11388.47,,"Case rate ($10,846.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,225.56, add-ons for qualifying new technology services are included. If operating cost exceeds $45,096.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,410.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $8,250.19 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,280.61 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $651.02. The transfer capital threshold is the transfer adjustment factor * $651.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10846.16,25863.45,Inpatient DRG
Tnot Elbow Lateral/Medial Debride Open Tdn Rpr|LEFT SIDE,CASE-24359,APC,24359,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",759,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],11643.60,,"Fee schedule rate ($11,643.60). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6190.22,13057.66,There are no additional notes associated with this service or procedure.
Exc Prtd Tum/Prtd Glnd Lat Dsj&Prsrv Facial Nr|RIGHT SIDE,CASE-42415,APC,42415,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5735.04,,"APC Price ($5,541.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5541.10,5818.16,OPPS APC
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],25667.48,,"Fee schedule rate ($25,667.48). Adds an outlier to normal pricing equal to the per diem rate ($77,296.48) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,11194.25,36094.03,There are no additional notes associated with this service or procedure.
HC Inj Anes/Steroid C/D Facet Sg,CASE-64490,APC,64490,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],827.89,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,827.89,869.28,OPPS APC
TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC,084,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],8838.59,,"Case rate ($8,417.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,966.41, add-ons for qualifying new technology services are included. If operating cost exceeds $42,837.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,233.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $5,999.34 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,021.46 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $473.41. The transfer capital threshold is the transfer adjustment factor * $473.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,19445.16,Inpatient DRG
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,544,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],23207.64,,"Fee schedule rate ($23,207.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,7055.15,23207.64,There are no additional notes associated with this service or procedure.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],13149.46,,"Fee schedule rate ($13,149.46). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.9), with a minimum of zero.",,,,0,other,6683.37,14699.43,There are no additional notes associated with this service or procedure.
Cysto W/Ureteroscopy W/Rmvl/Manj Stones|LEFT SIDE,CASE-52352,APC,52352,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3464.44,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3299.47,3464.44,OPPS APC
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC",514,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],22699.91,,"Fee schedule rate ($22,699.91). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8868.04,22699.91,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],24567.74,,"Case rate ($24,567.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $22,990.45, add-ons for qualifying new technology services are included. If operating cost exceeds $57,861.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,414.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.7. The base transfer operating payment is the transfer adjustment factor * $20,968.18 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $21,045.49 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,654.60. The transfer capital threshold is the transfer adjustment factor * $1,654.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9370.00,65732.99,Inpatient DRG
"ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",770,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],8962.64,,"Case rate ($8,535.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,088.62, add-ons for qualifying new technology services are included. If operating cost exceeds $42,959.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,230.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $6,120.47 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,143.67 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $470.43. The transfer capital threshold is the transfer adjustment factor * $470.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8735.30,19730.13,Inpatient DRG
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,057,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],39884.93,,"Fee schedule rate ($39,884.93). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,10718.84,39884.93,There are no additional notes associated with this service or procedure.
Laps Rpr Paraesphgl Hrna Incl Fundplsty W/O Mesh,CASE-43281,APC,43281,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],10447.27,,"APC Price ($9,949.78). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,9949.78,10447.27,OPPS APC
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],22269.49,,"Case rate ($12,725.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,973.79, add-ons for qualifying new technology services are included. If operating cost exceeds $46,844.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,548.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $9,991.99 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,028.83 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $788.47. The transfer capital threshold is the transfer adjustment factor * $788.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,12725.42,34245.00,All Other Inpatient
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],8956.76,,"Case rate ($8,956.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,467.88, add-ons for qualifying new technology services are included. If operating cost exceeds $43,338.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,272.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $6,498.97 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,522.93 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $512.83. The transfer capital threshold is the transfer adjustment factor * $512.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8956.76,28983.97,Inpatient DRG
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],28394.78,,"Fee schedule rate ($28,394.78). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11454.97,28394.78,There are no additional notes associated with this service or procedure.
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],29076.53,,"Case rate ($28,093.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $26,270.18, add-ons for qualifying new technology services are included. If operating cost exceeds $61,141.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,672.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $24,235.87 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $24,325.23 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,912.45. The transfer capital threshold is the transfer adjustment factor * $1,912.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103.5%.",,,,0,other,10078.00,81454.07,Inpatient DRG
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],26178.21,,"Fee schedule rate ($26,178.21). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,13917.42,34889.29,There are no additional notes associated with this service or procedure.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],22071.25,,"Case rate ($21,020.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $19,725.88, add-ons for qualifying new technology services are included. If operating cost exceeds $54,596.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,121.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $17,713.77 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $17,780.93 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,361.52. The transfer capital threshold is the transfer adjustment factor * $1,361.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,21597.50,67790.93,Inpatient DRG
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,085,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],57443.16,,"Fee schedule rate ($57,443.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,9282.00,57443.16,There are no additional notes associated with this service or procedure.
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|RIGHT HAND, FIFTH DIGIT",CASE-26160,APC,26160,CPT,0360,RC,,,F9,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1505.12,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1505.12,1580.37,OPPS APC
DIABETES WITHOUT CC/MCC,639,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],11899.36,,"Fee schedule rate ($11,899.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6151.76,12223.35,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],8468.48,,"Case rate ($8,468.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,013.65, add-ons for qualifying new technology services are included. If operating cost exceeds $42,884.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,237.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,046.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,068.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $477.12. The transfer capital threshold is the transfer adjustment factor * $477.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6963.00,18954.85,Inpatient DRG
Cystourethroscopy,CASE-52000,APC,52000,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],685.32,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,652.69,685.32,OPPS APC
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],37158.98,,"Case rate ($35,389.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $33,057.71, add-ons for qualifying new technology services are included. If operating cost exceeds $67,928.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,206.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.3. The base transfer operating payment is the transfer adjustment factor * $30,998.46 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $31,112.76 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,446.08. The transfer capital threshold is the transfer adjustment factor * $2,446.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,35389.50,101083.00,Inpatient DRG
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],16055.90,,"Fee schedule rate ($16,055.90). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8163.06,18067.42,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],17370.86,,,,,,0,other,1188.00,17370.86,There are no additional notes associated with this service or procedure.
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],18223.96,,"Case rate ($17,356.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,281.67, add-ons for qualifying new technology services are included. If operating cost exceeds $51,152.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,887.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $14,284.05 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,336.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,127.15. The transfer capital threshold is the transfer adjustment factor * $1,127.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,17356.15,44778.95,Inpatient DRG
Cmbnd Anterpost Colporraphy W/Cysto,CASE-57260,APC,57260,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],4682.41,,"APC Price ($4,682.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,4682.41,4916.53,OPPS APC
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],16400.70,,"Fee schedule rate ($16,400.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,16400.70,There are no additional notes associated with this service or procedure.
"Dbrdmt Fx&/Dislc Subq T/M/F Bone|RIGHT HAND, FIFTH DIGIT",CASE-11012,APC,11012,CPT,0360,RC,,,F9,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3062.67,OPPS APC
CHEST PAIN,313,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],15377.66,,"Fee schedule rate ($15,377.66). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,6820.84,15377.66,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],15429.83,,"Case rate ($14,908.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,004.25, add-ons for qualifying new technology services are included. If operating cost exceeds $48,875.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,708.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $12,014.99 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,059.30 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $948.10. The transfer capital threshold is the transfer adjustment factor * $948.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,14908.05,49717.39,Inpatient DRG
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],10626.74,,"Case rate ($10,626.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,021.44, add-ons for qualifying new technology services are included. If operating cost exceeds $44,892.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,394.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $8,046.82 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,076.49 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $634.97. The transfer capital threshold is the transfer adjustment factor * $634.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10626.74,25225.91,Inpatient DRG
"MAJOR RESPIRATORY INFECTIONS AND INFLAMMATIONS,EXTREME",137,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],19788.07,,"Case rate ($18,845.78). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,18845.78,19788.07,There are no additional notes associated with this service or procedure.
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,306,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],13247.19,,"Case rate ($12,616.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,872.35, add-ons for qualifying new technology services are included. If operating cost exceeds $46,743.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,540.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $9,890.94 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,927.40 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $780.49. The transfer capital threshold is the transfer adjustment factor * $780.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12616.37,31007.02,Inpatient DRG
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],15765.72,,"Case rate ($15,456.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,514.54, add-ons for qualifying new technology services are included. If operating cost exceeds $49,385.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,748.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $12,523.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,569.59 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $988.22. The transfer capital threshold is the transfer adjustment factor * $988.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,15456.59,41402.42,Inpatient DRG
Dstr Nrolytc Agnt Parverteb Fct Sngl Lmbr/Sacral|LEFT SIDE,CASE-64635,APC,64635,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1919.19,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1827.80,1919.19,OPPS APC
PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,337,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],12340.08,,"Case rate ($12,340.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,615.32, add-ons for qualifying new technology services are included. If operating cost exceeds $46,486.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,520.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $9,634.84 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,670.37 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $760.28. The transfer capital threshold is the transfer adjustment factor * $760.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12340.08,38926.31,Inpatient DRG
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],10097.32,,"Case rate ($9,755.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,211.27, add-ons for qualifying new technology services are included. If operating cost exceeds $44,082.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,331.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $7,239.63 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,266.32 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $571.28. The transfer capital threshold is the transfer adjustment factor * $571.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,9755.86,29216.99,Inpatient DRG
"NEONATE BIRTH WEIGHT > 2499 GRAMS WITH MAJOR ANOMALY,MAJOR",633,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],22319.13,,"Case rate ($22,319.13). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,22319.13,23435.09,There are no additional notes associated with this service or procedure.
"COAGULATION AND PLATELET DISORDERS,MODERATE",661,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],10268.75,,"Case rate ($9,779.76). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9779.76,10268.75,There are no additional notes associated with this service or procedure.
HC Debride Subq First 20 Sq Cm,CASE-11042,APC,11042,CPT,0361,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],399.53,,"APC Price ($380.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,399.53,399.53,OPPS APC
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],31477.13,,"Fee schedule rate ($31,477.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9648.19,31477.13,There are no additional notes associated with this service or procedure.
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6834.39,,"Case rate ($6,834.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,493.49, add-ons for qualifying new technology services are included. If operating cost exceeds $41,364.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,117.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $4,531.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,548.54 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $357.61. The transfer capital threshold is the transfer adjustment factor * $357.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6834.39,21354.82,Inpatient DRG
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],40714.72,,"Fee schedule rate ($40,714.72). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,17356.15,44778.95,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],11594.35,,"Fee schedule rate ($11,594.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6164.03,14071.02,There are no additional notes associated with this service or procedure.
DIABETES WITH CC,638,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],8014.07,,"Case rate ($8,014.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,590.93, add-ons for qualifying new technology services are included. If operating cost exceeds $42,461.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,203.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,625.24 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,645.98 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $443.89. The transfer capital threshold is the transfer adjustment factor * $443.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8014.07,17634.53,Inpatient DRG
FRACTURES OF FEMUR WITH MCC,533,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],49490.05,,"Fee schedule rate ($49,490.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,6852.00,49490.05,There are no additional notes associated with this service or procedure.
Nasal/Sinus Ndsc Surg W/Concha Bullosa Resection|RIGHT SIDE,CASE-31240,APC,31240,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3211.97,,"APC Price ($3,103.35). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.35,3258.52,OPPS APC
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],15812.70,,"Case rate ($15,059.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,169.80, add-ons for qualifying new technology services are included. If operating cost exceeds $49,040.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,696.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $12,178.67 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,224.85 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $936.08. The transfer capital threshold is the transfer adjustment factor * $936.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,15456.59,41402.42,Inpatient DRG
Reconstruction Nail Bed W/Graft,CASE-11762,APC,11762,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1931.28,,"APC Price ($1,931.28). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1931.28,2027.84,OPPS APC
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],30372.64,,"Fee schedule rate ($30,372.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,13260.40,32878.30,There are no additional notes associated with this service or procedure.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],10603.44,,"Case rate ($10,098.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,530.04, add-ons for qualifying new technology services are included. If operating cost exceeds $44,401.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,356.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $7,557.23 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,585.10 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $596.34. The transfer capital threshold is the transfer adjustment factor * $596.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10098.51,24259.09,Inpatient DRG
Colsc Flx With Directed Submucosal Njx Any Sbst,CASE-45381,APC,45381,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1159.29,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1120.09,1176.09,OPPS APC
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],31007.30,,"Fee schedule rate ($31,007.30). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,16120.25,41187.90,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],12126.09,,"Case rate ($12,126.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,416.25, add-ons for qualifying new technology services are included. If operating cost exceeds $46,287.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,504.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $9,436.50 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,471.29 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $744.63. The transfer capital threshold is the transfer adjustment factor * $744.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12126.09,29582.40,Inpatient DRG
Rmvl & Rplcmt Inflatable Penile Prosth Same Sess,CASE-54410,APC,54410,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],19400.15,,"APC Price ($19,400.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,19400.15,20370.16,OPPS APC
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],17365.00,,"Fee schedule rate ($17,365.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5683.00,19635.68,There are no additional notes associated with this service or procedure.
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],31973.49,,"Fee schedule rate ($31,973.49). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,13386.36,33244.29,There are no additional notes associated with this service or procedure.
COMPLICATIONS OF TREATMENT WITH CC,920,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],19722.26,,,,,,0,other,8732.59,20731.52,There are no additional notes associated with this service or procedure.
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],27832.43,,"Fee schedule rate ($27,832.43). Adds an outlier to normal pricing equal to the per diem rate ($62,521.14) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.7), with a minimum of zero.",,,,0,other,11974.38,29141.64,There are no additional notes associated with this service or procedure.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],37795.63,,"Case rate ($21,597.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,227.30, add-ons for qualifying new technology services are included. If operating cost exceeds $55,098.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,197.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $18,215.19 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,282.35 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,437.36. The transfer capital threshold is the transfer adjustment factor * $1,437.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,21597.50,67790.93,All Other Inpatient
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],2070.00,,,,,,0,other,1188.00,18893.86,Estimated amount calculated based on 3 day length of stay.
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],8511.49,,"Case rate ($8,106.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,676.61, add-ons for qualifying new technology services are included. If operating cost exceeds $42,547.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,210.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,710.61 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,731.66 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $450.62. The transfer capital threshold is the transfer adjustment factor * $450.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8106.18,18245.94,Inpatient DRG
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC",514,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],22699.91,,"Fee schedule rate ($22,699.91). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8868.04,22699.91,There are no additional notes associated with this service or procedure.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,074,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],9371.88,,"Case rate ($8,925.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,438.90, add-ons for qualifying new technology services are included. If operating cost exceeds $43,309.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,270.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,470.10 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,493.95 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $510.55. The transfer capital threshold is the transfer adjustment factor * $510.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8925.60,20919.08,Inpatient DRG
OSTEOMYELITIS WITHOUT CC/MCC,541,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],11429.52,,"Fee schedule rate ($11,429.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5103.00,15493.67,There are no additional notes associated with this service or procedure.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],44847.62,,"Fee schedule rate ($44,847.62). Adds an outlier to normal pricing equal to the per diem rate ($79,031.36) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,18105.81,52699.33,There are no additional notes associated with this service or procedure.
OSTEOMYELITIS WITHOUT CC/MCC,541,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],15493.67,,,,,,0,other,5103.00,15493.67,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITH CC,386,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],18347.61,,"Fee schedule rate ($18,347.61). Adds an outlier to normal pricing equal to the per diem rate ($111,650.51) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8556.53,19879.00,There are no additional notes associated with this service or procedure.
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],53569.45,,"Fee schedule rate ($53,569.45). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14.8), with a minimum of zero.",,,,0,other,21248.73,56089.29,There are no additional notes associated with this service or procedure.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],142438.06,,"Fee schedule rate ($142,438.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (40), with a minimum of zero.",,,,0,other,45521.20,142438.06,There are no additional notes associated with this service or procedure.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],5778.62,,"Case rate ($5,778.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,511.33, add-ons for qualifying new technology services are included. If operating cost exceeds $40,382.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,040.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $3,553.28 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,566.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $280.39. The transfer capital threshold is the transfer adjustment factor * $280.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,5778.62,11681.49,Inpatient DRG
MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,708,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],11302.86,,"Case rate ($11,081.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $10,413.93, add-ons for qualifying new technology services are included. If operating cost exceeds $49,058.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $3,436.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.3. The base transfer operating payment is the transfer adjustment factor * $9,014.04 + an uncompensated DSH payment of $1,359.91. The transfer operating threshold is the transfer adjustment factor * $9,054.03 + an uncompensated DSH payment of $1,359.91. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $707.29. The transfer capital threshold is the transfer adjustment factor * $707.29. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,10138.21,29171.15,Inpatient DRG
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],8235.00,,"Case rate ($7,956.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,537.38, add-ons for qualifying new technology services are included. If operating cost exceeds $42,408.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,199.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,571.89 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,592.43 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $439.68. The transfer capital threshold is the transfer adjustment factor * $439.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6965.00,17467.27,Inpatient DRG
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,091,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],21282.03,,"Fee schedule rate ($21,282.03). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,13838.06,40030.81,There are no additional notes associated with this service or procedure.
COAGULATION DISORDERS,813,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],29046.49,,"Fee schedule rate ($29,046.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12274.39,30013.33,There are no additional notes associated with this service or procedure.
CELLULITIS WITH MCC,602,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],15071.67,,"Fee schedule rate ($15,071.67). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11570.10,28349.31,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],2070.00,,,,,,0,other,1188.00,17370.86,Estimated amount calculated based on 3 day length of stay.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],35192.25,,"Fee schedule rate ($35,192.25). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,10895.60,35192.25,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],37495.79,,"Fee schedule rate ($37,495.79). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.8), with a minimum of zero.",,,,0,other,15456.59,41402.42,There are no additional notes associated with this service or procedure.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],64429.92,,"Fee schedule rate ($64,429.92). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,25162.32,75579.22,There are no additional notes associated with this service or procedure.
OTHER CEREBROVASCULAR DISORDERS WITH MCC,070,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],32758.27,,,,,,0,other,13219.09,37774.46,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,093,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],15668.80,,,,,,0,other,6965.00,19011.32,There are no additional notes associated with this service or procedure.
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],31577.54,,"Fee schedule rate ($31,577.54). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,15453.88,39251.68,There are no additional notes associated with this service or procedure.
FRACTURES OF FEMUR WITH MCC,533,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],27429.15,,"Fee schedule rate ($27,429.15). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,6852.00,49490.05,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,083,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],28680.85,,"Fee schedule rate ($28,680.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,28680.85,There are no additional notes associated with this service or procedure.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],67790.93,,"Fee schedule rate ($67,790.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,21597.50,67790.93,There are no additional notes associated with this service or procedure.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,479,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],50518.76,,"Fee schedule rate ($50,518.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,10586.00,50518.76,There are no additional notes associated with this service or procedure.
NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,601,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6253.52,,"Case rate ($6,042.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,756.39, add-ons for qualifying new technology services are included. If operating cost exceeds $40,627.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,059.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $3,797.45 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,811.45 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $299.66. The transfer capital threshold is the transfer adjustment factor * $299.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6042.05,12359.72,Inpatient DRG
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,097,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],26970.16,,"Case rate ($25,685.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $24,074.91, add-ons for qualifying new technology services are included. If operating cost exceeds $58,945.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,454.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.7. The base transfer operating payment is the transfer adjustment factor * $22,046.38 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $22,129.96 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,694.54. The transfer capital threshold is the transfer adjustment factor * $1,694.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,26404.32,79915.74,Inpatient DRG
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],85466.62,,"Fee schedule rate ($85,466.62). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,21382.16,85466.62,There are no additional notes associated with this service or procedure.
Open Tx Carpal Scaphoid Navicular Fracture|LEFT SIDE,CASE-25628,APC,25628,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
"Surg Implnt Neuroelect,Epidural",CASE-63655,APC,63655,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],29894.47,,"APC Price ($28,883.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,28883.55,30327.72,OPPS APC
"HC Injection Small Joint/Bursa|RIGHT HAND, FOURTH DIGIT",CASE-20600,APC,20600,CPT,0361,RC,,,F8,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1505.12,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1505.12,1580.37,OPPS APC
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",063,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],35701.87,,"Fee schedule rate ($35,701.87). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,35701.87,There are no additional notes associated with this service or procedure.
CHOLECYSTECTOMY WITH C.D.E. WITH MCC,411,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],62078.92,,"Fee schedule rate ($62,078.92). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15), with a minimum of zero.",,,,0,other,24315.13,88615.28,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],6965.00,,,,,,0,other,1188.00,12138.74,There are no additional notes associated with this service or procedure.
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC,805,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],9253.36,,"Case rate ($9,253.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,743.82, add-ons for qualifying new technology services are included. If operating cost exceeds $43,614.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,294.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $6,773.89 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,798.87 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $534.53. The transfer capital threshold is the transfer adjustment factor * $534.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9253.36,21235.42,Inpatient DRG
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],19604.30,,"Fee schedule rate ($19,604.30). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9446.38,21796.21,There are no additional notes associated with this service or procedure.
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH MCC",722,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],14200.37,,"Case rate ($14,200.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,345.91, add-ons for qualifying new technology services are included. If operating cost exceeds $48,216.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,656.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $11,359.07 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,400.95 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $896.34. The transfer capital threshold is the transfer adjustment factor * $896.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,14200.37,56869.13,Inpatient DRG
"SEPTICEMIA AND DISSEMINATED INFECTIONS,MODERATE",720,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],2046.25,,"Case rate for a one day stay ($1,948.81). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,1948.81,2046.25,There are no additional notes associated with this service or procedure.
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],13702.80,,"Case rate ($13,050.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,296.73, add-ons for qualifying new technology services are included. If operating cost exceeds $47,167.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,552.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $10,312.68 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,351.78 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $792.66. The transfer capital threshold is the transfer adjustment factor * $792.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13386.36,33244.29,Inpatient DRG
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],24701.52,,"Fee schedule rate ($24,701.52). Adds an outlier to normal pricing equal to the per diem rate ($51,462.28) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,10846.16,25863.45,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,373,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],13780.60,,"Fee schedule rate ($13,780.60). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6870.94,14313.05,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],22358.90,,"Fee schedule rate ($22,358.90). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9389.48,22358.90,There are no additional notes associated with this service or procedure.
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],13571.25,,"Case rate ($13,571.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,760.65, add-ons for qualifying new technology services are included. If operating cost exceeds $47,631.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,610.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $10,775.96 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,815.69 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $850.33. The transfer capital threshold is the transfer adjustment factor * $850.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,13571.25,33781.47,Inpatient DRG
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],26301.36,,"Fee schedule rate ($26,301.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11247.07,27028.33,There are no additional notes associated with this service or procedure.
Egd Balloon Dilation Esophagus <30 Mm Diam,CASE-43249,APC,43249,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1885.95,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1796.14,1885.95,OPPS APC
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],13762.88,,"Case rate ($13,762.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,938.93, add-ons for qualifying new technology services are included. If operating cost exceeds $47,809.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,624.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $10,953.59 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,993.98 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $864.35. The transfer capital threshold is the transfer adjustment factor * $864.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,1188.00,34338.33,Inpatient DRG
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,091,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],40030.81,,"Fee schedule rate ($40,030.81). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,13838.06,40030.81,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6368.48,,"Case rate ($6,153.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,859.72, add-ons for qualifying new technology services are included. If operating cost exceeds $40,730.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,067.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,900.39 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,914.77 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $307.78. The transfer capital threshold is the transfer adjustment factor * $307.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6153.12,13947.32,Inpatient DRG
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],62084.69,,"Fee schedule rate ($62,084.69). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (35), with a minimum of zero.",,,,0,other,30398.48,82674.88,There are no additional notes associated with this service or procedure.
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],5065.00,,"Per diem ($5,065). If length of stay < 2.1, first 1 days paid at a per diem of $10,130 instead. Capped at $10,636.84.",,,,0,other,5065.00,12558.65,Estimated amount calculated based on 2 day length of stay.
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC,805,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],20902.03,,"Fee schedule rate ($20,902.03). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9253.36,21235.42,There are no additional notes associated with this service or procedure.
Biopsy Vaginal Mucosa Simple|UNUSUAL NON-OVERLAPPING SERVICE,CASE-57100,APC,57100,CPT,0360,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5658.76,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5658.76,5941.70,OPPS APC
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],40714.72,,"Fee schedule rate ($40,714.72). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,17356.15,44778.95,There are no additional notes associated with this service or procedure.
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],14725.21,,"Case rate ($14,725.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,834.15, add-ons for qualifying new technology services are included. If operating cost exceeds $48,705.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,694.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,845.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,889.20 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $934.73. The transfer capital threshold is the transfer adjustment factor * $934.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7389.00,37134.43,Inpatient DRG
Arthrodesis Combined Tq 1ntrspc Lumbar,CASE-22633,APC,22633,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],26668.00,,"APC Price ($25,398.09). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,25398.09,26668.00,OPPS APC
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],18905.23,,"Fee schedule rate ($18,905.23). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6963.00,18954.85,There are no additional notes associated with this service or procedure.
TRAUMATIC INJURY WITH MCC,913,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],32164.02,,,,,,0,other,13014.58,42838.46,There are no additional notes associated with this service or procedure.
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],29585.82,,"Fee schedule rate ($29,585.82). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12606.23,36868.88,There are no additional notes associated with this service or procedure.
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],12195.15,,"Case rate ($12,195.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,480.50, add-ons for qualifying new technology services are included. If operating cost exceeds $46,351.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,509.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,500.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,535.55 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $749.68. The transfer capital threshold is the transfer adjustment factor * $749.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12195.15,39424.57,Inpatient DRG
HC Drain/Inj Joint/Bursa W/US Large|PBB CHARGE|RIGHT SIDE,CASE-20611,APC,20611,CPT,0510,RC,,,PBB|RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],297.37,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,287.31,301.68,OPPS APC
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC",494,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],37708.15,,"Fee schedule rate ($37,708.15). Adds an outlier to normal pricing equal to the per diem rate ($63,554.89) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,15533.10,39945.55,There are no additional notes associated with this service or procedure.
"OTHER PNEUMONIA,MAJOR",139,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],10665.92,,"Case rate ($10,158.02). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10158.02,10665.92,There are no additional notes associated with this service or procedure.
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],53275.26,,"Fee schedule rate ($53,275.26). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,15940.79,53275.26,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITH CC,386,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],18347.61,,"Fee schedule rate ($18,347.61). Adds an outlier to normal pricing equal to the per diem rate ($111,650.51) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8556.53,19879.00,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],28756.63,,"Fee schedule rate ($28,756.63). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,13148.66,32553.63,There are no additional notes associated with this service or procedure.
HEADACHES WITHOUT MCC,103,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],20883.08,,"Fee schedule rate ($20,883.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,20883.08,There are no additional notes associated with this service or procedure.
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],20170.75,,"Fee schedule rate ($20,170.75). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10048.39,23545.50,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],24675.88,,"Fee schedule rate ($24,675.88). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10834.64,25830.00,There are no additional notes associated with this service or procedure.
HC Joint Injection/Aspir Large WO US|RIGHT SIDE|PBB CHARGE,CASE-20610,APC,20610,CPT,0510,RC,,,RT|PBB,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
COAGULATION DISORDERS,813,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],30013.33,,,,,,0,other,12274.39,30013.33,There are no additional notes associated with this service or procedure.
HC Inj Lympho for Sentinal Node|UNUSUAL NON-OVERLAPPING SERVICE,CASE-38792,APC,38792,CPT,0361,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6215.36,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6215.36,6526.12,OPPS APC
"INFECTIOUS AND PARASITIC DISEASES INCLUDING HIV WITH O.R. PROCEDURE,MAJOR",710,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],29457.70,,"Case rate ($29,457.70). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,29457.70,30930.59,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,394,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],20909.61,,"Fee schedule rate ($20,909.61). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8281.56,20909.61,There are no additional notes associated with this service or procedure.
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],33781.47,,,,,,0,other,13571.25,33781.47,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITH MCC,385,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],31134.92,,,,,,0,other,11480.01,31134.92,There are no additional notes associated with this service or procedure.
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH CC",457,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],112064.54,,"Fee schedule rate ($112,064.54). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.9), with a minimum of zero.",,,,0,other,42327.47,160549.49,There are no additional notes associated with this service or procedure.
SPINAL PROCEDURES WITHOUT CC/MCC,030,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],16810.99,,"Case rate ($16,810.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,774.52, add-ons for qualifying new technology services are included. If operating cost exceeds $50,645.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,847.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $13,778.77 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,829.57 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,087.28. The transfer capital threshold is the transfer adjustment factor * $1,087.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,16810.99,44714.01,Inpatient DRG
"HC Aerosol, Hhn, Mdi, Ippb",CASE-94640,APC,94640,CPT,0410,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3414.95,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3299.47,3464.44,OPPS APC
Injection Aa&/Strd Genicular Nrv Branches W/Img|BILATERAL PROCEDURE,CASE-64454,APC,64454,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],660.72,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,660.72,693.76,OPPS APC
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,091,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],40030.81,,"Fee schedule rate ($40,030.81). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,13838.06,40030.81,There are no additional notes associated with this service or procedure.
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC,058,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],13840.84,,"Case rate ($13,181.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,419.28, add-ons for qualifying new technology services are included. If operating cost exceeds $47,290.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,562.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $10,434.76 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,474.33 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $802.04. The transfer capital threshold is the transfer adjustment factor * $802.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13521.80,40853.02,Inpatient DRG
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC,058,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],32126.63,,"Fee schedule rate ($32,126.63). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13521.80,40853.02,There are no additional notes associated with this service or procedure.
"CARDIAC ARREST, UNEXPLAINED WITH MCC",296,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],36459.67,,"Fee schedule rate ($36,459.67). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12522.25,36459.67,There are no additional notes associated with this service or procedure.
RESPIRATORY NEOPLASMS WITHOUT CC/MCC,182,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],7190.73,,"Case rate ($7,049.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,693.83, add-ons for qualifying new technology services are included. If operating cost exceeds $41,564.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,133.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,731.43 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,748.88 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $373.36. The transfer capital threshold is the transfer adjustment factor * $373.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6965.00,23037.13,Inpatient DRG
OTHER MENTAL DISORDER DIAGNOSES,887,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],9519.07,,"Case rate ($9,197.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,691.53, add-ons for qualifying new technology services are included. If operating cost exceeds $43,562.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,290.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,721.79 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,746.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $530.42. The transfer capital threshold is the transfer adjustment factor * $530.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,2070.00,21072.10,Inpatient DRG
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC,805,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],20902.03,,"Fee schedule rate ($20,902.03). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9253.36,21235.42,There are no additional notes associated with this service or procedure.
VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC,033,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],42156.44,,"Fee schedule rate ($42,156.44). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,13206.23,42156.44,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],12550.50,,"Case rate ($12,126.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,416.25, add-ons for qualifying new technology services are included. If operating cost exceeds $46,287.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,504.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $9,436.50 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,471.29 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $744.63. The transfer capital threshold is the transfer adjustment factor * $744.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,12126.09,29582.40,Inpatient DRG
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],6230.00,,"Per diem ($6,230). If length of stay < 2.9, first 1 days paid at a per diem of $12,460 instead. Capped at $18,065.71.",,,,0,other,6230.00,22762.43,Estimated amount calculated based on 3 day length of stay.
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITHOUT CC/MCC",630,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],42541.02,,"Fee schedule rate ($42,541.02). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11828.78,42541.02,There are no additional notes associated with this service or procedure.
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],8571.21,,"Case rate ($8,163.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,729.53, add-ons for qualifying new technology services are included. If operating cost exceeds $42,600.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,214.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,763.33 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,784.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $454.78. The transfer capital threshold is the transfer adjustment factor * $454.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8163.06,18067.42,Inpatient DRG
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,448,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],32197.15,,"Case rate ($30,663.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $28,661.63, add-ons for qualifying new technology services are included. If operating cost exceeds $63,532.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,860.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $26,618.53 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $26,716.68 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,100.47. The transfer capital threshold is the transfer adjustment factor * $2,100.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,30663.95,94077.13,Inpatient DRG
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,057,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],24348.21,,"Fee schedule rate ($24,348.21). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.9), with a minimum of zero.",,,,0,other,10718.84,39884.93,There are no additional notes associated with this service or procedure.
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],81306.30,,"Fee schedule rate ($81,306.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,20846.48,81306.30,There are no additional notes associated with this service or procedure.
"CHRONIC OBSTRUCTIVE PULMONARY DISEASE,MODERATE",140,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],2133.23,,"Case rate for a one day stay ($2,031.65). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,2031.65,2133.23,There are no additional notes associated with this service or procedure.
Cystourethroscopy Inj Chemodenervation Bladder|UNUSUAL NON-OVERLAPPING SERVICE,CASE-52287,APC,52287,CPT,0360,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3299.47,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3299.47,3464.44,OPPS APC
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],13642.55,,"Case rate ($12,992.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,222.63, add-ons for qualifying new technology services are included. If operating cost exceeds $47,093.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,568.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $10,239.92 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,277.68 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $808.03. The transfer capital threshold is the transfer adjustment factor * $808.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7665.00,40737.46,Inpatient DRG
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],40192.59,,"Fee schedule rate ($40,192.59). Adds an outlier to normal pricing equal to the per diem rate ($235,324.88) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.6), with a minimum of zero.",,,,0,other,16428.39,42083.20,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC,833,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],5721.39,,"Fee schedule rate ($5,721.39). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,3041.73,10289.10,There are no additional notes associated with this service or procedure.
NORMAL NEWBORN,795,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],3363.97,,"Case rate ($3,298.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $3,203.67, add-ons for qualifying new technology services are included. If operating cost exceeds $38,074.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $1,858.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $1,254.10 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $1,258.72 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $98.96. The transfer capital threshold is the transfer adjustment factor * $98.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,1369.79,5771.52,Inpatient DRG
Laps Tx Ectopic Preg W/Salping&/Oophorectomy|LEFT SIDE,CASE-59151,APC,59151,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5658.76,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5658.76,5941.70,OPPS APC
Cysto/Pyeloscopy Bx&/Fulguration Pelivc Lesion|LEFT SIDE,CASE-52354,APC,52354,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5269.71,,"APC Price ($5,018.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5018.77,5269.71,OPPS APC
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],8165.30,,"Fee schedule rate ($8,165.30). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4341.01,12882.53,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL HEMORRHAGE WITH MCC,377,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],14324.29,,"Case rate ($14,324.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,461.19, add-ons for qualifying new technology services are included. If operating cost exceeds $48,332.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,665.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $11,473.94 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,516.24 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $905.41. The transfer capital threshold is the transfer adjustment factor * $905.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7634.00,35969.56,Inpatient DRG
HC I&D Ischio Perirectal Abs,CASE-46040,APC,46040,CPT,0450,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1159.29,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1120.09,1176.09,OPPS APC
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,056,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],59328.19,,"Fee schedule rate ($59,328.19). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (44), with a minimum of zero.",,,,0,other,7659.00,59328.19,There are no additional notes associated with this service or procedure.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],17365.00,,"Fee schedule rate ($17,365.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5683.00,19635.68,There are no additional notes associated with this service or procedure.
COAGULATION DISORDERS,813,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],28664.96,,"Fee schedule rate ($28,664.96). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.7), with a minimum of zero.",,,,0,other,12274.39,30013.33,There are no additional notes associated with this service or procedure.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],39153.65,,"Fee schedule rate ($39,153.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,7605.00,39153.65,There are no additional notes associated with this service or procedure.
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],30103.84,,,,,,0,other,12305.53,30103.84,There are no additional notes associated with this service or procedure.
Cysto W/Ureteroscopy W/Lithotripsy,CASE-52353,APC,52353,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5269.71,,"APC Price ($5,018.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5018.77,5269.71,OPPS APC
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],33890.73,,"Fee schedule rate ($33,890.73). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6277.00,36801.89,There are no additional notes associated with this service or procedure.
CHOLECYSTECTOMY WITH C.D.E. WITH MCC,411,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],88615.28,,"Fee schedule rate ($88,615.28). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,24315.13,88615.28,There are no additional notes associated with this service or procedure.
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],2070.00,,,,,,0,other,1188.00,31658.33,Estimated amount calculated based on 16 day length of stay.
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],38757.79,,,,,,0,other,15283.90,38757.79,There are no additional notes associated with this service or procedure.
Mastectomy Partial|BILATERAL PROCEDURE,CASE-19301,APC,19301,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6215.36,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6215.36,6526.12,OPPS APC
"CHOLECYSTECTOMY,MAJOR",263,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],20693.19,,"Case rate ($20,693.19). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,20693.19,21727.85,There are no additional notes associated with this service or procedure.
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],8165.30,,"Fee schedule rate ($8,165.30). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4341.01,12882.53,There are no additional notes associated with this service or procedure.
CERVICAL SPINAL FUSION WITH CC,472,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],21896.13,,"Case rate ($21,896.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,505.12, add-ons for qualifying new technology services are included. If operating cost exceeds $55,376.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,219.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $18,491.99 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,560.18 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,459.20. The transfer capital threshold is the transfer adjustment factor * $1,459.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,21896.13,70198.84,Inpatient DRG
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC",629,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],44657.18,,"Fee schedule rate ($44,657.18). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,16699.94,44657.18,There are no additional notes associated with this service or procedure.
Excision Malignant Lesion Trunk/Arm/Leg > 4.0 Cm,CASE-11606,APC,11606,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6526.12,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6215.36,6526.12,OPPS APC
Arthroscopy Knee W/Meniscus Rpr Medial/Lateral,CASE-29882,APC,29882,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],12618.18,,"APC Price ($12,017.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,12017.31,12618.18,OPPS APC
Laps Surg Prst8ect Rpbic Rad W/Nrv Sparing Robot,CASE-55866,APC,55866,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],10298.02,,"APC Price ($9,949.78). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,9949.78,10447.27,OPPS APC
HC Biopsy/Exc Lymph Node Needle,CASE-38505,APC,38505,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1545.93,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1545.93,1623.23,OPPS APC
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],37914.65,,"Fee schedule rate ($37,914.65). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9865.56,37914.65,There are no additional notes associated with this service or procedure.
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],30028.95,,"Fee schedule rate ($30,028.95). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,15491.11,54180.83,There are no additional notes associated with this service or procedure.
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],14309.17,,"Fee schedule rate ($14,309.17). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,17467.27,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH CC,427,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],50829.82,,"Case rate ($50,829.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $47,421.51, add-ons for qualifying new technology services are included. If operating cost exceeds $82,292.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $5,335.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $45,309.50 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $45,476.56 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,575.37. The transfer capital threshold is the transfer adjustment factor * $3,575.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,50829.82,142040.39,Inpatient DRG
Prq Impltj Neurostimulator Eltrd Peripheral Nrv|LEFT SIDE,CASE-64555,APC,64555,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5965.28,,"APC Price ($5,965.28). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5965.28,6263.54,OPPS APC
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],61234.06,,"Fee schedule rate ($61,234.06). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11165.00,61234.06,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,555,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],42290.95,,"Fee schedule rate ($42,290.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10896.27,42290.95,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,373,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],14313.05,,,,,,0,other,6870.94,14313.05,There are no additional notes associated with this service or procedure.
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],11168.08,,"Fee schedule rate ($11,168.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5937.41,12366.99,There are no additional notes associated with this service or procedure.
Colonoscopy Flx Dx W/Collj Spec When Pfrmd|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-45378,APC,45378,CPT,0360,RC,,,74,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],913.99,,"APC Price ($870.46). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,870.46,913.99,OPPS APC
"Inj Dx/Ther Agnt Paravert Facet Joint, Cerv/Thorac, Add Level|RIGHT SIDE",CASE-64492,APC,64492,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],869.28,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,827.89,869.28,OPPS APC
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,095,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],50750.92,,,,,,0,other,19411.47,50750.92,There are no additional notes associated with this service or procedure.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],101083.00,,"Fee schedule rate ($101,083.00). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,35389.50,101083.00,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL HEMORRHAGE WITH MCC,377,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],31575.65,,"Fee schedule rate ($31,575.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,7634.00,35969.56,There are no additional notes associated with this service or procedure.
Dstr Nrolytc Agnt Parverteb Fct Sngl Crvcl/Thora,CASE-64633,APC,64633,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1827.80,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1827.80,1919.19,OPPS APC
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],51630.84,,"Fee schedule rate ($51,630.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,20559.34,54086.17,There are no additional notes associated with this service or procedure.
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],30245.71,,"Fee schedule rate ($30,245.71). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9151.11,30245.71,There are no additional notes associated with this service or procedure.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],19087.91,,"Case rate ($18,178.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,047.10, add-ons for qualifying new technology services are included. If operating cost exceeds $51,918.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,947.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $15,046.67 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,102.15 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,187.33. The transfer capital threshold is the transfer adjustment factor * $1,187.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,18178.96,54764.34,Inpatient DRG
"BRONCHIOLITIS AND RSV PNEUMONIA,MODERATE",138,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],5100.99,,"Case rate ($4,858.09). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4858.09,5100.99,There are no additional notes associated with this service or procedure.
Cysto/Uretero W/Lithotripsy &Indwell Stent Insrt|SEPARATE STRUCTURE|RIGHT SIDE,CASE-52356,APC,52356,CPT,0360,RC,,,XS|RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5194.43,,"APC Price ($5,018.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5018.77,5269.71,OPPS APC
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",004,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],99098.77,,"Case rate ($95,747.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $89,207.57, add-ons for qualifying new technology services are included. If operating cost exceeds $124,078.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $8,620.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 22.4. The base transfer operating payment is the transfer adjustment factor * $86,942.06 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $87,262.63 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $6,860.59. The transfer capital threshold is the transfer adjustment factor * $6,860.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,10249.47,272554.00,Inpatient DRG
Anterior Colporraphy Rpr Cystocele W/Cysto,CASE-57240,APC,57240,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5018.77,,"APC Price ($5,018.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5018.77,5269.71,OPPS APC
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,447,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],48844.97,,"Case rate ($47,193.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $44,038.45, add-ons for qualifying new technology services are included. If operating cost exceeds $78,909.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $5,069.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $41,938.87 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $42,093.51 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,309.39. The transfer capital threshold is the transfer adjustment factor * $3,309.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,47193.21,156646.82,Inpatient DRG
"Tendon Sheath Incision|LEFT HAND, FOURTH DIGIT",CASE-26055,APC,26055,CPT,0360,RC,,,F3,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1505.12,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1505.12,1580.37,OPPS APC
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],9888.00,,"Per diem ($9,888). If length of stay < 3.1, first 1 days paid at a per diem of $19,776 instead. Capped at $30,651.38.",,,,0,other,9888.00,43399.23,Estimated amount calculated based on 1 day length of stay.
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],9492.76,,"Case rate ($9,040.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,546, add-ons for qualifying new technology services are included. If operating cost exceeds $43,417.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,278.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,576.80 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,601.05 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $518.97. The transfer capital threshold is the transfer adjustment factor * $518.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9040.72,26966.33,Inpatient DRG
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,555,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],42290.95,,"Fee schedule rate ($42,290.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10896.27,42290.95,There are no additional notes associated with this service or procedure.
Dstr Nrolytc Agnt Parverteb Fct Addl Lmbr/Sacral,CASE-64636,APC,64636,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1891.77,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1827.80,1919.19,OPPS APC
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],84226.47,,"Fee schedule rate ($84,226.47). Adds an outlier to normal pricing equal to the per diem rate ($75,906.87) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14.7), with a minimum of zero.",,,,0,other,32296.02,88188.38,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],15061.83,,"Case rate ($14,344.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,480.09, add-ons for qualifying new technology services are included. If operating cost exceeds $48,351.10 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,666.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $11,492.77 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,535.14 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $906.89. The transfer capital threshold is the transfer adjustment factor * $906.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,14344.60,36028.59,Inpatient DRG
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],33152.73,,"Fee schedule rate ($33,152.73). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13891.57,34712.20,There are no additional notes associated with this service or procedure.
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],13386.36,,"Case rate ($13,386.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,588.65, add-ons for qualifying new technology services are included. If operating cost exceeds $47,459.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,596.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $10,604.60 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,643.70 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $836.81. The transfer capital threshold is the transfer adjustment factor * $836.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,13386.36,33244.29,Inpatient DRG
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],59385.88,,"Fee schedule rate ($59,385.88). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,23344.70,62179.32,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC,831,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],23661.59,,,,,,0,other,4941.30,23661.59,There are no additional notes associated with this service or procedure.
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC,807,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],12670.24,,"Fee schedule rate ($12,670.24). Adds an outlier to normal pricing equal to the per diem rate ($29,637.88) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,5354.25,13266.23,There are no additional notes associated with this service or procedure.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],43444.85,,,,,,0,other,16897.01,43444.85,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],6965.00,,,,,,0,other,6340.03,15076.44,There are no additional notes associated with this service or procedure.
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],8480.00,,"Per diem ($8,480). If length of stay < 5.5, first 1 days paid at a per diem of $16,960 instead. Capped at $46,638.59.",,,,0,other,8480.00,59081.91,Estimated amount calculated based on 3 day length of stay.
Hallux Rigidus W/Cheilectomy 1st Mp Jt W/O Implt|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-28289,APC,28289,CPT,0360,RC,,,LT|XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7029.71,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6791.99,7131.59,OPPS APC
Total Thyroid Lobectomy Uni W/WO Isthmusectomy,CASE-60220,APC,60220,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5856.81,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5658.76,5941.70,OPPS APC
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],45062.85,,"Fee schedule rate ($45,062.85). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,20846.48,81306.30,There are no additional notes associated with this service or procedure.
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],11454.97,,"Case rate ($11,454.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,791.92, add-ons for qualifying new technology services are included. If operating cost exceeds $45,662.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,455.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $8,814.47 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,846.97 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $695.55. The transfer capital threshold is the transfer adjustment factor * $695.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,11454.97,28394.78,Inpatient DRG
CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC,788,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],20142.33,,"Fee schedule rate ($20,142.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8438.02,20142.33,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],9226.81,,"Case rate ($8,787.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,310.38, add-ons for qualifying new technology services are included. If operating cost exceeds $43,181.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,260.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,342.05 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,365.43 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $500.45. The transfer capital threshold is the transfer adjustment factor * $500.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,32293.66,Inpatient DRG
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],15177.23,,"Fee schedule rate ($15,177.23). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,7414.07,18217.52,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,083,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],11796.31,,"Case rate ($11,397.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,738.37, add-ons for qualifying new technology services are included. If operating cost exceeds $45,609.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,451.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $8,761.12 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,793.42 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $691.34. The transfer capital threshold is the transfer adjustment factor * $691.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6965.00,28680.85,Inpatient DRG
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],52794.06,,"Fee schedule rate ($52,794.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (37), with a minimum of zero.",,,,0,other,13907.80,52794.06,There are no additional notes associated with this service or procedure.
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],7801.73,,"Fee schedule rate ($7,801.73). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6711.00,16865.16,There are no additional notes associated with this service or procedure.
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],11575.50,,"Case rate ($11,575.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,904.06, add-ons for qualifying new technology services are included. If operating cost exceeds $45,775.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,464.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $8,926.20 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,959.11 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $704.37. The transfer capital threshold is the transfer adjustment factor * $704.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,11575.50,48961.48,Inpatient DRG
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC",011,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],38880.49,,"Case rate ($38,880.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $36,305.31, add-ons for qualifying new technology services are included. If operating cost exceeds $71,176.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,461.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 11.4. The base transfer operating payment is the transfer adjustment factor * $34,234.14 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $34,360.36 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,701.41. The transfer capital threshold is the transfer adjustment factor * $2,701.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,38880.49,150008.48,Inpatient DRG
NORMAL NEWBORN,795,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],3298.01,,"Case rate ($3,298.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $3,203.67, add-ons for qualifying new technology services are included. If operating cost exceeds $38,074.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $1,858.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $1,254.10 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $1,258.72 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $98.96. The transfer capital threshold is the transfer adjustment factor * $98.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,1369.79,5771.52,Inpatient DRG
"Remv Vert Body,Cerv,One Sgmt",CASE-63081,APC,63081,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],12017.31,,"APC Price ($12,017.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12017.31,12437.92,OPPS APC
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],18970.81,,"Case rate ($18,598.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,437.70, add-ons for qualifying new technology services are included. If operating cost exceeds $52,308.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,978.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 5.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $15,435.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,492.75 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,218.04. The transfer capital threshold is the transfer adjustment factor * $1,218.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,18598.83,48389.68,Inpatient DRG
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],10902.75,,"Case rate ($10,383.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,810.96, add-ons for qualifying new technology services are included. If operating cost exceeds $44,681.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,362.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $7,836.30 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,866.01 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $602.32. The transfer capital threshold is the transfer adjustment factor * $602.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10638.94,25261.33,Inpatient DRG
"Excis Intrasp Lesn,Xdural,Lumbar",CASE-63267,APC,63267,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
Cystourethroscopy Inj Chemodenervation Bladder,CASE-52287,APC,52287,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],2025.13,,"APC Price ($1,956.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1956.65,2054.48,OPPS APC
HYPERTENSION WITHOUT MCC,305,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],17230.49,,"Fee schedule rate ($17,230.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7058.55,17230.49,There are no additional notes associated with this service or procedure.
"CHRONIC OBSTRUCTIVE PULMONARY DISEASE,MAJOR",140,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],9860.08,,"Case rate ($9,390.55). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9390.55,9860.08,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,555,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],42290.95,,"Fee schedule rate ($42,290.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10896.27,42290.95,There are no additional notes associated with this service or procedure.
Nasal/Sinus Ndsc W/Rmvl Tiss From Frontal Sinus|BILATERAL PROCEDURE,CASE-31276,APC,31276,CPT,0360,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6936.25,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6837.16,6936.25,OPPS APC
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,191,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],6965.00,,,,,,0,other,6965.00,16612.88,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC,817,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],17396.11,,"Case rate ($17,396.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,318.84, add-ons for qualifying new technology services are included. If operating cost exceeds $51,189.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,890.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $14,321.08 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,373.88 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,130.07. The transfer capital threshold is the transfer adjustment factor * $1,130.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,17396.11,44895.04,Inpatient DRG
RESPIRATORY NEOPLASMS WITH CC,181,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],9197.84,,"Case rate ($9,197.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,692.16, add-ons for qualifying new technology services are included. If operating cost exceeds $43,563.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,290.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,722.42 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,747.21 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $530.47. The transfer capital threshold is the transfer adjustment factor * $530.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9197.84,21074.07,Inpatient DRG
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],62990.26,,"Fee schedule rate ($62,990.26). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,16787.98,62990.26,There are no additional notes associated with this service or procedure.
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],5065.00,,"Per diem ($5,065). If length of stay < 2.1, first 1 days paid at a per diem of $10,130 instead. Capped at $10,636.84.",,,,0,other,5065.00,12558.65,Estimated amount calculated based on 2 day length of stay.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],81353.66,,"Fee schedule rate ($81,353.66). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,27256.92,81353.66,There are no additional notes associated with this service or procedure.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],16900.84,,"Fee schedule rate ($16,900.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8151.55,18033.97,There are no additional notes associated with this service or procedure.
"Tendon Sheath Incision|LEFT HAND, THUMB|UNUSUAL NON-OVERLAPPING SERVICE",CASE-26055,APC,26055,CPT,0360,RC,,,FA|XU,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
O.R. PROCEDURES FOR OBESITY WITH CC,620,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],31489.10,,,,,,0,other,12782.30,43753.50,There are no additional notes associated with this service or procedure.
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC,939,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],68190.40,,"Fee schedule rate ($68,190.40). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16.5), with a minimum of zero.",,,,0,other,26517.40,97674.79,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],24413.25,,,,,,0,other,10347.06,28821.04,There are no additional notes associated with this service or procedure.
DIABETES WITH CC,638,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],8422.05,,"Fee schedule rate ($8,422.05). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8014.07,17634.53,There are no additional notes associated with this service or procedure.
HC N Block Inj Intercost Sng|RIGHT SIDE,CASE-64420,APC,64420,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],693.76,,"APC Price ($660.72). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,660.72,693.76,OPPS APC
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITHOUT CC/MCC,517,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],10207.96,,"Case rate ($9,721.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $9,073.46, add-ons for qualifying new technology services are included. If operating cost exceeds $48,643.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $3,480.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $9,032.24. The transfer operating threshold is the transfer adjustment factor * $9,073.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $689.63. The transfer capital threshold is the transfer adjustment factor * $689.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10207.96,29371.86,Inpatient DRG
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,451,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],60708.91,,"Fee schedule rate ($60,708.91). Adds an outlier to normal pricing equal to the per diem rate ($108,215.07) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,23821.44,94077.13,There are no additional notes associated with this service or procedure.
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7039.95,,"Case rate ($6,801.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,463.25, add-ons for qualifying new technology services are included. If operating cost exceeds $41,334.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,115.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,501.70 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,518.30 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $355.23. The transfer capital threshold is the transfer adjustment factor * $355.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6801.88,22557.82,Inpatient DRG
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],7875.94,,"Case rate ($7,875.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,462.42, add-ons for qualifying new technology services are included. If operating cost exceeds $42,333.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,193.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $5,497.20 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,517.46 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $433.78. The transfer capital threshold is the transfer adjustment factor * $433.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7875.94,17233.12,Inpatient DRG
CERVICAL SPINAL FUSION WITH CC,472,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],70198.84,,"Fee schedule rate ($70,198.84). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,21896.13,70198.84,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],9795.13,,"Case rate ($9,795.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,247.81, add-ons for qualifying new technology services are included. If operating cost exceeds $44,118.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,334.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $7,276.03 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,302.86 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $574.15. The transfer capital threshold is the transfer adjustment factor * $574.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9795.13,23899.13,Inpatient DRG
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],18341.97,,"Fee schedule rate ($18,341.97). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.9), with a minimum of zero.",,,,0,other,8554.50,19204.75,There are no additional notes associated with this service or procedure.
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC,497,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],10482.12,,"Case rate ($10,127.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,557.14, add-ons for qualifying new technology services are included. If operating cost exceeds $44,428.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,358.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 1.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $7,584.22 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,612.19 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $598.47. The transfer capital threshold is the transfer adjustment factor * $598.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,10127.65,37761.19,Inpatient DRG
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],10353.84,,"Case rate ($10,003.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,441.84, add-ons for qualifying new technology services are included. If operating cost exceeds $44,312.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,349.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $7,469.36 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,496.90 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $589.41. The transfer capital threshold is the transfer adjustment factor * $589.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,10003.71,23415.63,Inpatient DRG
HC Joint Injection/Aspir Large WO US,CASE-20610,APC,20610,CPT,0510,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
SINGLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL,402,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],124455.45,,"Fee schedule rate ($124,455.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,29172.05,124455.45,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],26178.21,,"Fee schedule rate ($26,178.21). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,13917.42,34889.29,There are no additional notes associated with this service or procedure.
DIABETES WITHOUT CC/MCC,639,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],6965.00,,,,,,0,other,6151.76,12223.35,There are no additional notes associated with this service or procedure.
Ligamentous Reconstruction Knee Extra-Articular,CASE-27427,APC,27427,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
SALIVARY GLAND PROCEDURES,139,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],10313.19,,"Case rate ($10,313.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,729.75, add-ons for qualifying new technology services are included. If operating cost exceeds $44,600.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,372.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $7,756.21 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,784.80 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $612.04. The transfer capital threshold is the transfer adjustment factor * $612.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10313.19,30690.92,Inpatient DRG
Edg US Exam Surgical Alter Stom Duodenum/Jejunum,CASE-43259,APC,43259,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1796.14,,"APC Price ($1,796.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1796.14,1885.95,OPPS APC
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],35419.59,,"Fee schedule rate ($35,419.59). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,7086.00,57872.02,There are no additional notes associated with this service or procedure.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],23618.74,,"Fee schedule rate ($23,618.74). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10533.95,24956.34,There are no additional notes associated with this service or procedure.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC,434,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6770.05,,"Case rate ($6,770.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,433.64, add-ons for qualifying new technology services are included. If operating cost exceeds $41,304.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,112.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,472.20 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,488.69 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $352.90. The transfer capital threshold is the transfer adjustment factor * $352.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6770.05,14019.86,Inpatient DRG
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],13222.67,,"Case rate ($12,775.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,020.41, add-ons for qualifying new technology services are included. If operating cost exceeds $46,891.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,552.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $10,038.44 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,075.45 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $792.13. The transfer capital threshold is the transfer adjustment factor * $792.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,12775.53,31469.43,Inpatient DRG
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH CC,026,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],23460.67,,"Case rate ($23,000.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $21,532.64, add-ons for qualifying new technology services are included. If operating cost exceeds $56,403.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,299.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $19,515.74 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $19,587.69 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,539.98. The transfer capital threshold is the transfer adjustment factor * $1,539.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 102%.",,,,0,other,23000.66,63202.45,Inpatient DRG
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],31577.54,,"Fee schedule rate ($31,577.54). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,15453.88,39251.68,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITHOUT STERILIZATION WITH CC,787,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],23722.94,,"Fee schedule rate ($23,722.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9508.01,23722.94,There are no additional notes associated with this service or procedure.
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC",458,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],132827.25,,"Fee schedule rate ($132,827.25). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,30202.09,132827.25,There are no additional notes associated with this service or procedure.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,352,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],17243.40,,"Case rate ($9,853.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,301.99, add-ons for qualifying new technology services are included. If operating cost exceeds $44,173.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,338.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $7,330.01 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,357.04 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $578.41. The transfer capital threshold is the transfer adjustment factor * $578.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,9853.37,26528.70,All Other Inpatient
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],24444.75,,"Fee schedule rate ($24,444.75). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10136.44,24444.75,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],17651.07,,"Fee schedule rate ($17,651.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,6564.18,17651.07,There are no additional notes associated with this service or procedure.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,073,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],13257.71,,"Case rate ($12,809.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,051.90, add-ons for qualifying new technology services are included. If operating cost exceeds $46,922.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,554.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $10,069.82 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,106.95 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $794.61. The transfer capital threshold is the transfer adjustment factor * $794.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,12809.38,43475.01,Inpatient DRG
VENTRICULAR SHUNT PROCEDURES WITH MCC,031,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],62406.76,,"Fee schedule rate ($62,406.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,32287.20,88162.80,There are no additional notes associated with this service or procedure.
Laryngoscopy Direct Operative W/Biopsy,CASE-31535,APC,31535,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3664.31,,"APC Price ($3,489.82). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3489.82,3664.31,OPPS APC
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],7396.47,,"Case rate ($7,396.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,016.38, add-ons for qualifying new technology services are included. If operating cost exceeds $41,887.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,158.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,052.80 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,071.43 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $398.72. The transfer capital threshold is the transfer adjustment factor * $398.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7396.47,16035.06,Inpatient DRG
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,065,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],9094.30,,"Case rate ($8,786.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,309.75, add-ons for qualifying new technology services are included. If operating cost exceeds $43,180.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,260.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,341.42 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,364.80 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $500.40. The transfer capital threshold is the transfer adjustment factor * $500.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,8786.76,25681.86,Inpatient DRG
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],15653.45,,"Case rate ($14,908.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,004.25, add-ons for qualifying new technology services are included. If operating cost exceeds $48,875.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,708.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $12,014.99 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,059.30 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $948.10. The transfer capital threshold is the transfer adjustment factor * $948.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,14908.05,49717.39,Inpatient DRG
PERIPHERAL VASCULAR DISORDERS WITH CC,300,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],9357.62,,"Case rate ($9,174.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,670.11, add-ons for qualifying new technology services are included. If operating cost exceeds $43,541.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,288.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,700.45 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,725.16 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $528.73. The transfer capital threshold is the transfer adjustment factor * $528.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,9174.14,21005.20,Inpatient DRG
Exc Tumor Soft Tissue Abdl Wall Subfascial 5cm/>,CASE-22901,APC,22901,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],2718.88,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2718.88,2854.83,OPPS APC
Dstr Nrolytc Agnt Parverteb Fct Sngl Crvcl/Thora|RIGHT SIDE,CASE-64633,APC,64633,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1891.77,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1827.80,1919.19,OPPS APC
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],13260.40,,"Case rate ($13,260.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,471.48, add-ons for qualifying new technology services are included. If operating cost exceeds $47,342.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,587.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $10,487.86 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,526.53 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $827.60. The transfer capital threshold is the transfer adjustment factor * $827.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,13260.40,32878.30,Inpatient DRG
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],26649.89,,"Case rate ($26,127.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $24,441.31, add-ons for qualifying new technology services are included. If operating cost exceeds $59,312.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,528.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. The base transfer operating payment is the transfer adjustment factor * $22,413.72 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $22,496.36 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,768.66. The transfer capital threshold is the transfer adjustment factor * $1,768.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,26127.34,90333.60,Inpatient DRG
Bronchoscopy W/Transbronchial Lung Bx 1 Lobe,CASE-31628,APC,31628,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6837.16,,"APC Price ($6,605.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6605.95,6936.25,OPPS APC
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],18497.24,,"Case rate ($18,497.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,343.20, add-ons for qualifying new technology services are included. If operating cost exceeds $52,214.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,970.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $15,341.68 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,398.25 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,210.61. The transfer capital threshold is the transfer adjustment factor * $1,210.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,18497.24,62041.12,Inpatient DRG
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC,858,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],11946.65,,"Case rate ($11,377.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,720.10, add-ons for qualifying new technology services are included. If operating cost exceeds $45,591.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,449.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $8,742.91 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,775.15 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $689.90. The transfer capital threshold is the transfer adjustment factor * $689.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,11377.76,33794.11,Inpatient DRG
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC,099,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],22084.20,,"Fee schedule rate ($22,084.20). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11171.21,26807.94,There are no additional notes associated with this service or procedure.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],13808.63,,"Case rate ($13,341.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,547.08, add-ons for qualifying new technology services are included. If operating cost exceeds $47,418.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,593.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $10,563.18 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,602.13 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $833.54. The transfer capital threshold is the transfer adjustment factor * $833.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,13341.67,42586.49,Inpatient DRG
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],40192.59,,"Fee schedule rate ($40,192.59). Adds an outlier to normal pricing equal to the per diem rate ($235,324.88) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.6), with a minimum of zero.",,,,0,other,16428.39,42083.20,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITH STERILIZATION WITH CC,784,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],9580.21,,"Case rate ($9,124.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,623.49, add-ons for qualifying new technology services are included. If operating cost exceeds $43,494.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,285.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,654.00 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,678.54 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $525.07. The transfer capital threshold is the transfer adjustment factor * $525.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9124.01,23722.94,Inpatient DRG
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],23239.84,,"Fee schedule rate ($23,239.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8543.64,23239.84,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],33152.73,,"Fee schedule rate ($33,152.73). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13891.57,34712.20,There are no additional notes associated with this service or procedure.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],28017.14,,"Fee schedule rate ($28,017.14). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,18105.81,52699.33,There are no additional notes associated with this service or procedure.
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],9468.12,,"Case rate ($9,282.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,770.90, add-ons for qualifying new technology services are included. If operating cost exceeds $43,641.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,296.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,800.88 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,825.96 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $536.66. The transfer capital threshold is the transfer adjustment factor * $536.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,9282.47,21320.03,Inpatient DRG
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 2nd Level|BILATERAL PROCEDURE,CASE-64494,APC,64494,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],827.89,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,827.89,869.28,OPPS APC
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],22363.67,,"Fee schedule rate ($22,363.67). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10003.71,23415.63,There are no additional notes associated with this service or procedure.
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],15177.23,,"Fee schedule rate ($15,177.23). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,7414.07,18217.52,There are no additional notes associated with this service or procedure.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],10885.83,,"Case rate ($10,517.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,920.01, add-ons for qualifying new technology services are included. If operating cost exceeds $44,791.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,386.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $7,945.76 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,975.06 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $627.00. The transfer capital threshold is the transfer adjustment factor * $627.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,10517.71,24909.11,Inpatient DRG
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],9893.02,,"Case rate ($9,421.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,914.56, add-ons for qualifying new technology services are included. If operating cost exceeds $43,785.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,293.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $6,943.28 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,969.61 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $533.68. The transfer capital threshold is the transfer adjustment factor * $533.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9648.19,31477.13,Inpatient DRG
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],8767.81,,"Case rate ($8,767.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,292.11, add-ons for qualifying new technology services are included. If operating cost exceeds $43,163.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,258.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,323.85 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,347.16 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $499.01. The transfer capital threshold is the transfer adjustment factor * $499.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8767.81,19824.58,Inpatient DRG
"CARDIAC ARREST, UNEXPLAINED WITH MCC",296,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],13148.36,,"Case rate ($12,522.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,784.78, add-ons for qualifying new technology services are included. If operating cost exceeds $46,655.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,533.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $9,803.69 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,839.84 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $773.61. The transfer capital threshold is the transfer adjustment factor * $773.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12522.25,36459.67,Inpatient DRG
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,073,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],43475.01,,"Fee schedule rate ($43,475.01). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,12809.38,43475.01,There are no additional notes associated with this service or procedure.
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],15145.28,,"Fee schedule rate ($15,145.28). Adds an outlier to normal pricing equal to the per diem rate ($54,966.40) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7402.56,16438.59,There are no additional notes associated with this service or procedure.
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC,797,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],13416.00,,,,,,0,other,8719.72,20928.55,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],20617.56,,,,,,0,other,9040.72,26966.33,There are no additional notes associated with this service or procedure.
Endoscopic Papilla Cannulation Bile/Pancreatic,CASE-43273,APC,43273,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3735.12,,"APC Price ($3,608.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3608.81,3789.26,OPPS APC
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],94787.57,,"Fee schedule rate ($94,787.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,23526.87,94787.57,There are no additional notes associated with this service or procedure.
Inj for Sacroiliac Jt Anesth|LEFT SIDE,CASE-G0260,APC,G0260,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],660.72,,"APC Price ($660.72). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,660.72,693.76,OPPS APC
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],12808.03,,"Case rate ($12,808.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,050.64, add-ons for qualifying new technology services are included. If operating cost exceeds $46,921.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,554.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $10,068.57 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,105.69 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $794.51. The transfer capital threshold is the transfer adjustment factor * $794.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7353.00,33398.16,Inpatient DRG
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],60793.48,,"Fee schedule rate ($60,793.48). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15.7), with a minimum of zero.",,,,0,other,23851.92,63653.13,There are no additional notes associated with this service or procedure.
Repair Intermediate S/a/T/E >30.0 Cm|SEPARATE STRUCTURE,CASE-12037,APC,12037,CPT,0360,RC,,,XS,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1545.93,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1545.93,1623.23,OPPS APC
NONTRAUMATIC STUPOR AND COMA WITH MCC,080,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],34015.33,,"Fee schedule rate ($34,015.33). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.5), with a minimum of zero.",,,,0,other,14202.39,35615.37,There are no additional notes associated with this service or procedure.
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],14830.15,,"Fee schedule rate ($14,830.15). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,7884.32,17835.23,There are no additional notes associated with this service or procedure.
Laryngoscopy Direct Operative W/Biopsy,CASE-31535,APC,31535,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3489.82,,"APC Price ($3,489.82). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3489.82,3664.31,OPPS APC
HC Inj Aa&/Strd Other Peripheral Nerve/Branch,CASE-64450,APC,64450,CPT,0450,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],693.76,,"APC Price ($660.72). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,660.72,693.76,OPPS APC
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level|BILATERAL PROCEDURE,CASE-64483,APC,64483,CPT,0360,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],869.28,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,827.89,869.28,OPPS APC
Pelvic Examination W/Anesthesia Other Than Local,CASE-57410,APC,57410,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3030.03,,"APC Price ($3,030.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3030.03,3181.53,OPPS APC
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],9279.55,,"Case rate ($9,097.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,598.92, add-ons for qualifying new technology services are included. If operating cost exceeds $43,469.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,283.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,629.53 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,653.97 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $523.14. The transfer capital threshold is the transfer adjustment factor * $523.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,9097.60,21455.22,Inpatient DRG
"Open Tx Phalangeal Shaft Fracture Prox/Middle Ea|LEFT HAND, THIRD DIGIT",CASE-26735,APC,26735,CPT,0360,RC,,,F2,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
VENTRICULAR SHUNT PROCEDURES WITH CC,032,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],17195.03,,"Case rate ($16,376.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,370.06, add-ons for qualifying new technology services are included. If operating cost exceeds $50,241.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,815.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $13,375.80 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,425.12 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,055.48. The transfer capital threshold is the transfer adjustment factor * $1,055.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,16376.22,46275.08,Inpatient DRG
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",623,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],24663.40,,"Case rate ($14,093.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,246.37, add-ons for qualifying new technology services are included. If operating cost exceeds $48,117.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,648.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $11,259.90 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,301.42 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $888.52. The transfer capital threshold is the transfer adjustment factor * $888.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,14093.37,33712.76,All Other Inpatient
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],7921.00,,"Per diem ($7,921). If length of stay < 4.1, first 1 days paid at a per diem of $15,842 instead. Capped at $32,474.30.",,,,0,other,7921.00,45706.73,Estimated amount calculated based on 2 day length of stay.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],17273.92,,"Case rate ($16,689.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,661.75, add-ons for qualifying new technology services are included. If operating cost exceeds $50,532.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,838.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $13,666.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,716.80 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,078.42. The transfer capital threshold is the transfer adjustment factor * $1,078.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,16689.78,59521.43,Inpatient DRG
ALLERGIC REACTIONS WITH MCC,915,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],31602.31,,"Fee schedule rate ($31,602.31). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.8), with a minimum of zero.",,,,0,other,13332.86,33088.84,There are no additional notes associated with this service or procedure.
Dstrj Lesion Anus Extensive,CASE-46924,APC,46924,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],2598.08,,"APC Price ($2,598.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2598.08,2727.99,OPPS APC
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],16064.26,,"Fee schedule rate ($16,064.26). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7733.72,18043.23,There are no additional notes associated with this service or procedure.
HEADACHES WITHOUT MCC,103,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],20883.08,,"Fee schedule rate ($20,883.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,20883.08,There are no additional notes associated with this service or procedure.
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],14455.04,,"Fee schedule rate ($14,455.04). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5280.00,17136.70,There are no additional notes associated with this service or procedure.
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],32554.56,,"Fee schedule rate ($32,554.56). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11165.00,61234.06,There are no additional notes associated with this service or procedure.
"Excis Intrasp Lesn,Xdural,Lumbar",CASE-63267,APC,63267,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6791.99,7131.59,OPPS APC
VENTRICULAR SHUNT PROCEDURES WITH CC,032,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],40047.88,,"Fee schedule rate ($40,047.88). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,16376.22,46275.08,There are no additional notes associated with this service or procedure.
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC,964,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],12755.15,,"Case rate ($12,323.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,600.20, add-ons for qualifying new technology services are included. If operating cost exceeds $46,471.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,519.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $9,619.78 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,655.25 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $759.10. The transfer capital threshold is the transfer adjustment factor * $759.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,12323.82,34154.06,Inpatient DRG
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],22686.91,,"Fee schedule rate ($22,686.91). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,10120.20,26204.74,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,085,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],9282.00,,"Per diem ($9,282). If length of stay < 4.6, first 1 days paid at a per diem of $18,564 instead. Capped at $42,695.82.",,,,0,other,9282.00,57443.16,Estimated amount calculated based on 2 day length of stay.
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITH MCC,429,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],177294.98,,"Fee schedule rate ($177,294.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,62958.58,177294.98,There are no additional notes associated with this service or procedure.
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],13625.25,,"Fee schedule rate ($13,625.25). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7243.75,23262.15,There are no additional notes associated with this service or procedure.
HC Biopsy of Vulva/Perineum,CASE-56605,APC,56605,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],862.13,,"APC Price ($862.13). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,862.13,905.23,OPPS APC
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],25027.80,,"Fee schedule rate ($25,027.80). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,10733.06,45157.33,There are no additional notes associated with this service or procedure.
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],2070.00,,,,,,0,other,1188.00,31658.33,Estimated amount calculated based on 16 day length of stay.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],20817.01,,"Fee schedule rate ($20,817.01). Adds an outlier to normal pricing equal to the per diem rate ($37,789.38) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,9446.38,21796.21,There are no additional notes associated with this service or procedure.
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],18245.94,,"Fee schedule rate ($18,245.94). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8106.18,18245.94,There are no additional notes associated with this service or procedure.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],36988.38,,"Fee schedule rate ($36,988.38). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.7), with a minimum of zero.",,,,0,other,15273.74,39820.52,There are no additional notes associated with this service or procedure.
Arthrs Kne Surg W/Meniscectomy Med/Lat W/Shvg|LEFT SIDE,CASE-29881,APC,29881,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
CESAREAN SECTION WITHOUT STERILIZATION WITH CC,787,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],23722.94,,"Fee schedule rate ($23,722.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9508.01,23722.94,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,167,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],33891.30,,"Fee schedule rate ($33,891.30). Adds an outlier to normal pricing equal to the per diem rate ($66,990.29) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.6), with a minimum of zero.",,,,0,other,14157.71,43522.37,There are no additional notes associated with this service or procedure.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],101083.00,,"Fee schedule rate ($101,083.00). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,35389.50,101083.00,There are no additional notes associated with this service or procedure.
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],17033.98,,"Fee schedule rate ($17,033.98). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.8), with a minimum of zero.",,,,0,other,7884.32,17835.23,There are no additional notes associated with this service or procedure.
"EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME, NEONATE",790,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],43063.10,,"Case rate ($41,012.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $38,361.54, add-ons for qualifying new technology services are included. If operating cost exceeds $73,232.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,548.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 17.9. The base transfer operating payment is the transfer adjustment factor * $36,279.04 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $36,416.59 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,788.49. The transfer capital threshold is the transfer adjustment factor * $2,788.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,3054.00,44304.49,Inpatient DRG
HC Joint Injection/Aspir Large WO US|SEPARATE STRUCTURE|LEFT SIDE,CASE-20610,APC,20610,CPT,0510,RC,,,XS|LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],297.37,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,287.31,301.68,OPPS APC
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],8877.69,,"Case rate ($8,454.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,001.06, add-ons for qualifying new technology services are included. If operating cost exceeds $42,872.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,236.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,033.86 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,056.11 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $476.13. The transfer capital threshold is the transfer adjustment factor * $476.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6230.00,22762.43,Inpatient DRG
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH CC,026,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],63202.45,,"Fee schedule rate ($63,202.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,23000.66,63202.45,There are no additional notes associated with this service or procedure.
OSTEOMYELITIS WITH CC,540,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],18450.55,,"Fee schedule rate ($18,450.55). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,9809.07,25507.30,There are no additional notes associated with this service or procedure.
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],13047.45,,"Case rate ($12,606.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,862.91, add-ons for qualifying new technology services are included. If operating cost exceeds $46,733.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,539.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $9,881.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,917.95 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $779.75. The transfer capital threshold is the transfer adjustment factor * $779.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,12606.23,36868.88,Inpatient DRG
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],46202.59,,"Fee schedule rate ($46,202.59). Adds an outlier to normal pricing equal to the per diem rate ($126,777.34) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,18594.09,59494.91,There are no additional notes associated with this service or procedure.
Tnot Elbow Lateral/Medial Debride Open Tdn Rpr|RIGHT SIDE,CASE-24359,APC,24359,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],12704.31,,"Case rate ($12,455.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,722.41, add-ons for qualifying new technology services are included. If operating cost exceeds $46,593.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,528.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $9,741.55 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,777.47 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $768.70. The transfer capital threshold is the transfer adjustment factor * $768.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,12455.21,37149.27,Inpatient DRG
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],15628.19,,"Case rate ($15,099.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,182.53, add-ons for qualifying new technology services are included. If operating cost exceeds $49,053.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,722.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $12,192.63 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,237.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $962.12. The transfer capital threshold is the transfer adjustment factor * $962.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,7605.00,39153.65,Inpatient DRG
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],51903.64,,"Fee schedule rate ($51,903.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,16017.99,51903.64,There are no additional notes associated with this service or procedure.
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],53275.26,,"Fee schedule rate ($53,275.26). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,15940.79,53275.26,There are no additional notes associated with this service or procedure.
"Amp F/Th 1/2 Jt/Phalanx W/Neurect W/Dir Clsr|LEFT HAND, THIRD DIGIT",CASE-26951,APC,26951,CPT,0360,RC,,,F2,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,748,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],26805.98,,,,,,0,other,9316.20,26805.98,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],11253.39,,"Fee schedule rate ($11,253.39). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,6841.83,21167.26,There are no additional notes associated with this service or procedure.
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],26721.94,,"Fee schedule rate ($26,721.94). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6965.00,34422.94,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7909.07,,"Case rate ($7,641.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,244.44, add-ons for qualifying new technology services are included. If operating cost exceeds $42,115.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,176.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,280.02 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,299.49 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $416.65. The transfer capital threshold is the transfer adjustment factor * $416.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,7641.61,19371.27,Inpatient DRG
Open Tx Carpal Scaphoid Navicular Fracture|LEFT SIDE,CASE-25628,APC,25628,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7029.71,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6791.99,7131.59,OPPS APC
Exc Tumor Soft Tissue Thigh/Knee Subfasc <5cm|LEFT SIDE,CASE-27328,APC,27328,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],2718.88,,"APC Price ($2,718.88). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2718.88,2854.83,OPPS APC
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",759,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],12471.03,,"Fee schedule rate ($12,471.03). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.9), with a minimum of zero.",,,,0,other,6190.22,13057.66,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],24703.21,,"Case rate ($23,526.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $22,022.15, add-ons for qualifying new technology services are included. If operating cost exceeds $56,893.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,338.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.7. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.7)) / 2. The base transfer operating payment is the transfer adjustment factor * $20,003.44 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $20,077.20 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,578.47. The transfer capital threshold is the transfer adjustment factor * $1,578.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,23526.87,94787.57,Inpatient DRG
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],26007.09,,,,,,0,other,10895.60,35192.25,There are no additional notes associated with this service or procedure.
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],12305.53,,"Case rate ($12,305.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,583.18, add-ons for qualifying new technology services are included. If operating cost exceeds $46,454.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,517.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $9,602.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,638.24 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $757.76. The transfer capital threshold is the transfer adjustment factor * $757.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12305.53,30103.84,Inpatient DRG
POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES,769,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],13388.39,,"Case rate ($13,388.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,590.54, add-ons for qualifying new technology services are included. If operating cost exceeds $47,461.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,596.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $10,606.49 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,645.59 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $836.96. The transfer capital threshold is the transfer adjustment factor * $836.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,13388.39,33250.19,Inpatient DRG
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],11170.89,,"Case rate ($10,638.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,032.78, add-ons for qualifying new technology services are included. If operating cost exceeds $44,903.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,395.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,058.12 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,087.83 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $635.87. The transfer capital threshold is the transfer adjustment factor * $635.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10638.94,25261.33,Inpatient DRG
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,307,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],6965.00,,,,,,0,other,6335.27,18228.77,There are no additional notes associated with this service or procedure.
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],30935.16,,"Fee schedule rate ($30,935.16). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13092.47,33159.45,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],28235.64,,"Fee schedule rate ($28,235.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,14344.60,36028.59,There are no additional notes associated with this service or procedure.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],22017.02,,"Case rate ($21,585.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,215.96, add-ons for qualifying new technology services are included. If operating cost exceeds $55,086.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,196.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $18,203.89 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,271.01 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,436.47. The transfer capital threshold is the transfer adjustment factor * $1,436.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,21585.31,73588.10,Inpatient DRG
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],7141.97,,"Case rate ($6,801.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,463.25, add-ons for qualifying new technology services are included. If operating cost exceeds $41,334.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,115.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,501.70 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,518.30 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $355.23. The transfer capital threshold is the transfer adjustment factor * $355.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6801.88,22557.82,Inpatient DRG
CESAREAN SECTION WITH STERILIZATION WITH MCC,783,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],23722.94,,"Fee schedule rate ($23,722.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12612.10,23722.94,There are no additional notes associated with this service or procedure.
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITHOUT MCC,430,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],41000.16,,"Case rate ($41,000.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $38,277.19, add-ons for qualifying new technology services are included. If operating cost exceeds $73,148.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,616.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $36,198.76 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $36,332.23 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,856.44. The transfer capital threshold is the transfer adjustment factor * $2,856.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,41000.16,133156.90,Inpatient DRG
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],6511.25,,"Case rate ($6,201.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,904.45, add-ons for qualifying new technology services are included. If operating cost exceeds $40,775.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,071.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,944.95 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,959.50 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $311.30. The transfer capital threshold is the transfer adjustment factor * $311.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5937.41,12366.99,Inpatient DRG
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC,434,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],13280.45,,"Fee schedule rate ($13,280.45). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6770.05,14019.86,There are no additional notes associated with this service or procedure.
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],25253.70,,"Fee schedule rate ($25,253.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11974.38,29141.64,There are no additional notes associated with this service or procedure.
"HC Injection Small Joint/Bursa|RIGHT HAND, FOURTH DIGIT",CASE-20600,APC,20600,CPT,0361,RC,,,F8,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1557.80,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1505.12,1580.37,OPPS APC
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],52453.14,,"Fee schedule rate ($52,453.14). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14.9), with a minimum of zero.",,,,0,other,20846.48,81306.30,There are no additional notes associated with this service or procedure.
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC",458,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],52853.66,,"Case rate ($30,202.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $28,231.97, add-ons for qualifying new technology services are included. If operating cost exceeds $63,102.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,826.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $26,190.45 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $26,287.02 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,066.69. The transfer capital threshold is the transfer adjustment factor * $2,066.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,30202.09,132827.25,All Other Inpatient
CESAREAN SECTION WITHOUT STERILIZATION WITH MCC,786,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],13115.49,,"Case rate ($13,115.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,336.66, add-ons for qualifying new technology services are included. If operating cost exceeds $47,207.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,576.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $10,353.53 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,391.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $817.00. The transfer capital threshold is the transfer adjustment factor * $817.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12612.10,23722.94,Inpatient DRG
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],12246.05,,"Fee schedule rate ($12,246.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6010.23,12246.05,There are no additional notes associated with this service or procedure.
NONTRAUMATIC STUPOR AND COMA WITH MCC,080,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],14486.44,,"Case rate ($14,202.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,347.79, add-ons for qualifying new technology services are included. If operating cost exceeds $48,218.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,656.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $11,360.96 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,402.84 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $896.49. The transfer capital threshold is the transfer adjustment factor * $896.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,14202.39,35615.37,Inpatient DRG
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],8853.91,,"Case rate ($8,554.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,093.67, add-ons for qualifying new technology services are included. If operating cost exceeds $42,964.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,243.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,126.13 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,148.72 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $483.41. The transfer capital threshold is the transfer adjustment factor * $483.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,8554.50,19204.75,Inpatient DRG
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,329,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],34726.41,,"Case rate ($33,072.77). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $30,902.51, add-ons for qualifying new technology services are included. If operating cost exceeds $65,773.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,036.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.4. The base transfer operating payment is the transfer adjustment factor * $28,851.18 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $28,957.55 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,276.64. The transfer capital threshold is the transfer adjustment factor * $2,276.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,33072.77,90445.33,Inpatient DRG
RADIOTHERAPY,849,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],21308.57,,"Case rate ($20,293.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $19,014.57, add-ons for qualifying new technology services are included. If operating cost exceeds $53,885.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,101.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $17,006.91 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $17,069.62 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,342.01. The transfer capital threshold is the transfer adjustment factor * $1,342.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,20293.88,81867.07,Inpatient DRG
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],14169.40,,"Case rate ($13,891.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,058.63, add-ons for qualifying new technology services are included. If operating cost exceeds $47,929.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,633.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,072.85 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,113.68 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $873.76. The transfer capital threshold is the transfer adjustment factor * $873.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,13891.57,34712.20,Inpatient DRG
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],39424.57,,"Fee schedule rate ($39,424.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12195.15,39424.57,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC,831,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],10592.77,,"Case rate ($10,088.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,520.59, add-ons for qualifying new technology services are included. If operating cost exceeds $44,391.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,355.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $7,547.82 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,575.65 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $595.60. The transfer capital threshold is the transfer adjustment factor * $595.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,4941.30,23661.59,Inpatient DRG
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],32296.02,,"Case rate ($32,296.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $30,179.91, add-ons for qualifying new technology services are included. If operating cost exceeds $65,050.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,979.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $28,131.23 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $28,234.95 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,219.83. The transfer capital threshold is the transfer adjustment factor * $2,219.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,32296.02,88188.38,Inpatient DRG
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,345,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],28277.83,,"Fee schedule rate ($28,277.83). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12134.89,33616.03,There are no additional notes associated with this service or procedure.
"Arthrodesis Great Toe Metatarsophalangeal Joint|RIGHT FOOT, GREAT TOE",CASE-28750,APC,28750,CPT,0360,RC,,,T5,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
Split Agrft F/S/N/H/F/G/M/D Gt 1st 100 Cm/</1 %,CASE-15120,APC,15120,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3482.86,,"APC Price ($3,317.01). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3317.01,3482.86,OPPS APC
CESAREAN SECTION WITHOUT STERILIZATION WITH MCC,786,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],13771.26,,"Case rate ($13,115.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,336.66, add-ons for qualifying new technology services are included. If operating cost exceeds $47,207.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,576.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $10,353.53 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,391.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $817.00. The transfer capital threshold is the transfer adjustment factor * $817.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12612.10,23722.94,Inpatient DRG
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,761,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],6098.83,,"Case rate ($5,808.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,539.05, add-ons for qualifying new technology services are included. If operating cost exceeds $40,410.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,042.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $3,580.90 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,594.10 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $282.57. The transfer capital threshold is the transfer adjustment factor * $282.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5808.41,11946.72,Inpatient DRG
Esophagoscopy Flexible Transoral With Biopsy,CASE-43202,APC,43202,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1796.14,,"APC Price ($1,796.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1796.14,1885.95,OPPS APC
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],19371.27,,"Fee schedule rate ($19,371.27). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8643.20,19462.52,There are no additional notes associated with this service or procedure.
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],7956.52,,"Case rate ($7,956.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,537.38, add-ons for qualifying new technology services are included. If operating cost exceeds $42,408.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,199.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,571.89 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,592.43 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $439.68. The transfer capital threshold is the transfer adjustment factor * $439.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,17467.27,Inpatient DRG
MAJOR CHEST TRAUMA WITHOUT CC/MCC,185,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],21771.61,,"Fee schedule rate ($21,771.61). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7271.19,21771.61,There are no additional notes associated with this service or procedure.
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],18043.23,,"Fee schedule rate ($18,043.23). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7733.72,18043.23,There are no additional notes associated with this service or procedure.
Nasal/Sinus Ndsc Surg W/Concha Bullosa Resection|LEFT SIDE,CASE-31240,APC,31240,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3211.97,,"APC Price ($3,103.35). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.35,3211.97,OPPS APC
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,988,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],42425.46,,"Fee schedule rate ($42,425.46). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,13075.52,42425.46,There are no additional notes associated with this service or procedure.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],39153.65,,"Fee schedule rate ($39,153.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,7605.00,39153.65,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITH CC,386,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],8984.36,,"Case rate ($8,556.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,095.56, add-ons for qualifying new technology services are included. If operating cost exceeds $42,966.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,243.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,128.01 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,150.61 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $483.56. The transfer capital threshold is the transfer adjustment factor * $483.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8556.53,19879.00,Inpatient DRG
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],9036.41,,"Case rate ($8,859.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,377.16, add-ons for qualifying new technology services are included. If operating cost exceeds $43,248.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,265.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $6,408.58 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,432.21 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $505.70. The transfer capital threshold is the transfer adjustment factor * $505.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,8859.23,20090.22,Inpatient DRG
O.R. PROCEDURES FOR OBESITY WITH CC,620,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],13037.95,,"Case rate ($12,782.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,026.70, add-ons for qualifying new technology services are included. If operating cost exceeds $46,897.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,552.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $10,044.72 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,081.75 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $792.63. The transfer capital threshold is the transfer adjustment factor * $792.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,12782.30,43753.50,Inpatient DRG
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],34295.80,,"Case rate ($33,623.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $31,414.68, add-ons for qualifying new technology services are included. If operating cost exceeds $66,285.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,076.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.4. The base transfer operating payment is the transfer adjustment factor * $29,361.48 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $29,469.74 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,316.91. The transfer capital threshold is the transfer adjustment factor * $2,316.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,33623.33,133270.57,Inpatient DRG
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,555,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],11277.64,,"Case rate ($10,896.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,272.18, add-ons for qualifying new technology services are included. If operating cost exceeds $45,143.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,414.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,296.64 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,327.23 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $654.69. The transfer capital threshold is the transfer adjustment factor * $654.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,10896.27,42290.95,Inpatient DRG
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC,817,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],23325.63,,"Fee schedule rate ($23,325.63). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,17396.11,44895.04,There are no additional notes associated with this service or procedure.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],126615.59,,,,,,0,other,45521.20,142438.06,There are no additional notes associated with this service or procedure.
Parathyroidectomy/Exploration Parathyroids,CASE-60500,APC,60500,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5818.16,,"APC Price ($5,541.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5541.10,5818.16,OPPS APC
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],9357.15,,"Case rate ($9,040.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,546, add-ons for qualifying new technology services are included. If operating cost exceeds $43,417.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,278.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,576.80 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,601.05 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $518.97. The transfer capital threshold is the transfer adjustment factor * $518.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,9040.72,26966.33,Inpatient DRG
HC Biopsy/Exc Lymph Node Needle|RIGHT SIDE,CASE-38505,APC,38505,CPT,0361,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1545.93,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1545.93,1623.23,OPPS APC
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],17755.26,,"Fee schedule rate ($17,755.26). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7847.50,17755.26,There are no additional notes associated with this service or procedure.
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],23078.81,,"Fee schedule rate ($23,078.81). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10311.17,24308.97,There are no additional notes associated with this service or procedure.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,352,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],22978.80,,,,,,0,other,9853.37,26528.70,There are no additional notes associated with this service or procedure.
Open Tx Carpal Scaphoid Navicular Fracture|LEFT SIDE,CASE-25628,APC,25628,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7029.71,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6791.99,7131.59,OPPS APC
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],12775.53,,"Case rate ($12,775.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,020.41, add-ons for qualifying new technology services are included. If operating cost exceeds $46,891.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,552.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $10,038.44 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,075.45 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $792.13. The transfer capital threshold is the transfer adjustment factor * $792.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12775.53,31469.43,Inpatient DRG
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],69000.38,,"Fee schedule rate ($69,000.38). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15), with a minimum of zero.",,,,0,other,26809.29,97015.50,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],19691.31,,"Fee schedule rate ($19,691.31). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,9040.72,26966.33,There are no additional notes associated with this service or procedure.
VENTRICULAR SHUNT PROCEDURES WITH CC,032,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],46275.08,,"Fee schedule rate ($46,275.08). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,16376.22,46275.08,There are no additional notes associated with this service or procedure.
Excision Olecranon Bursa|LEFT SIDE,CASE-24105,APC,24105,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],28691.47,,"Case rate ($27,325.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $25,603.02, add-ons for qualifying new technology services are included. If operating cost exceeds $60,474.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,571.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $23,568.71 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $23,658.07 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,811.55. The transfer capital threshold is the transfer adjustment factor * $1,811.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,10078.00,81454.07,Inpatient DRG
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC,833,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],5760.37,,"Case rate ($5,486.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,239.18, add-ons for qualifying new technology services are included. If operating cost exceeds $40,110.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,018.96, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $3,282.12 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,294.23 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $258.99. The transfer capital threshold is the transfer adjustment factor * $258.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,3041.73,10289.10,Inpatient DRG
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,057,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],39884.93,,"Fee schedule rate ($39,884.93). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,10718.84,39884.93,There are no additional notes associated with this service or procedure.
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],22217.08,,"Fee schedule rate ($22,217.08). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.4), with a minimum of zero.",,,,0,other,7243.75,23262.15,There are no additional notes associated with this service or procedure.
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],22732.01,,"Fee schedule rate ($22,732.01). Adds an outlier to normal pricing equal to the per diem rate ($114,196.66) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.5), with a minimum of zero.",,,,0,other,10136.44,24444.75,There are no additional notes associated with this service or procedure.
"Tendon Sheath Incision|RIGHT HAND, FIFTH DIGIT|UNUSUAL NON-OVERLAPPING SERVICE",CASE-26055,APC,26055,CPT,0360,RC,,,F9|XU,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC,939,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],26517.40,,"Case rate ($26,517.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $24,804.19, add-ons for qualifying new technology services are included. If operating cost exceeds $59,675.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,557.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $22,775.26 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $22,859.24 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,797.19. The transfer capital threshold is the transfer adjustment factor * $1,797.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,26517.40,97674.79,Inpatient DRG
Excision Inferior Turbinate Partial/Complete|LEFT SIDE,CASE-30130,APC,30130,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6936.25,,"APC Price ($6,605.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6605.95,6936.25,OPPS APC
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],13421.68,,,,,,0,other,6564.18,17651.07,There are no additional notes associated with this service or procedure.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],7017.54,,"Case rate ($6,683.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,353, add-ons for qualifying new technology services are included. If operating cost exceeds $41,224.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,106.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,391.86 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,408.05 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $346.56. The transfer capital threshold is the transfer adjustment factor * $346.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6683.37,14699.43,Inpatient DRG
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITHOUT CC/MCC,816,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],6965.00,,,,,,0,other,6224.90,14733.53,There are no additional notes associated with this service or procedure.
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],14116.22,,"Case rate ($13,444.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,663.75, add-ons for qualifying new technology services are included. If operating cost exceeds $47,534.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,580.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $10,678.31 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,718.80 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $820.76. The transfer capital threshold is the transfer adjustment factor * $820.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,34422.94,Inpatient DRG
Exc Bartholins Gland/Cyst|LEFT SIDE,CASE-56740,APC,56740,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3030.03,,"APC Price ($3,030.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3030.03,3136.08,OPPS APC
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],8354.35,,"Case rate ($7,956.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,537.38, add-ons for qualifying new technology services are included. If operating cost exceeds $42,408.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,199.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,571.89 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,592.43 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $439.68. The transfer capital threshold is the transfer adjustment factor * $439.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,17467.27,Inpatient DRG
Colonoscopy W/Biopsy Single/Multiple|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-45380,APC,45380,CPT,0360,RC,,,74,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1176.09,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1120.09,1176.09,OPPS APC
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,091,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],40030.81,,"Fee schedule rate ($40,030.81). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,13838.06,40030.81,There are no additional notes associated with this service or procedure.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],45845.03,,"Fee schedule rate ($45,845.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,18598.83,48389.68,There are no additional notes associated with this service or procedure.
Laps Surg Rpr Recurrent Inguinal Hernia|BILATERAL PROCEDURE,CASE-49651,APC,49651,CPT,0360,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5856.81,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5658.76,5941.70,OPPS APC
GASTROINTESTINAL OBSTRUCTION WITH CC,389,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],5118.00,,"Per diem ($5,118). If length of stay < 2.9, first 1 days paid at a per diem of $10,236 instead. Capped at $14,842.71.",,,,0,other,5118.00,16423.43,Estimated amount calculated based on 2 day length of stay.
SIGNS AND SYMPTOMS WITH MCC,947,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],23855.83,,"Fee schedule rate ($23,855.83). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10541.41,30414.32,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],30372.64,,"Fee schedule rate ($30,372.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,13260.40,32878.30,There are no additional notes associated with this service or procedure.
PSYCHOSES,885,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],2070.00,,,,,,0,other,2070.00,27484.83,Estimated amount calculated based on 3 day length of stay.
Lithotripsy Xtrcorp Shock Wave|RIGHT SIDE,CASE-50590,APC,50590,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3299.47,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3299.47,3464.44,OPPS APC
Biopsy Cervix Single/Mult/Excision of Lesion Spx,CASE-57500,APC,57500,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],905.23,,"APC Price ($862.13). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,862.13,905.23,OPPS APC
TRAUMATIC INJURY WITH MCC,913,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],42838.46,,"Fee schedule rate ($42,838.46). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13014.58,42838.46,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC,084,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],6965.00,,,,,,0,other,6965.00,19445.16,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITHOUT STERILIZATION WITH MCC,786,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],23722.94,,"Fee schedule rate ($23,722.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12612.10,23722.94,There are no additional notes associated with this service or procedure.
Brnchsc Ebus Guided Sampl 1/2 Node Station/Strux,CASE-31652,APC,31652,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6605.95,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6605.95,6837.16,OPPS APC
MAJOR THUMB OR JOINT PROCEDURES,506,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],19761.54,,"Fee schedule rate ($19,761.54). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11081.83,26548.21,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],15409.08,,"Fee schedule rate ($15,409.08). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8956.76,28983.97,There are no additional notes associated with this service or procedure.
SINGLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL,402,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],124455.45,,"Fee schedule rate ($124,455.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,29172.05,124455.45,There are no additional notes associated with this service or procedure.
HC Joint Injection/Aspir Large WO US|BILATERAL PROCEDURE,CASE-20610,APC,20610,CPT,0510,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
"NEONATE BIRTH WEIGHT 1500-1999 GRAMS WITH OR WITHOUT OTHER SIGNIFICANT CONDITION,MINOR",614,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],11512.05,,"Case rate ($10,963.86). Base payment rate plus any adjustments related to outliers.",,,,0,other,10963.86,11512.05,There are no additional notes associated with this service or procedure.
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],22762.43,,"Fee schedule rate ($22,762.43). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6230.00,22762.43,There are no additional notes associated with this service or procedure.
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],11575.50,,"Case rate ($11,575.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,904.06, add-ons for qualifying new technology services are included. If operating cost exceeds $45,775.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,464.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $8,926.20 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,959.11 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $704.37. The transfer capital threshold is the transfer adjustment factor * $704.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,11575.50,48961.48,Inpatient DRG
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],9404.60,,"Case rate ($8,956.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,467.88, add-ons for qualifying new technology services are included. If operating cost exceeds $43,338.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,272.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $6,498.97 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,522.93 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $512.83. The transfer capital threshold is the transfer adjustment factor * $512.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8956.76,28983.97,Inpatient DRG
DIABETES WITHOUT CC/MCC,639,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],6459.35,,"Case rate ($6,151.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,858.45, add-ons for qualifying new technology services are included. If operating cost exceeds $40,729.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,067.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $3,899.13 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,913.51 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $307.68. The transfer capital threshold is the transfer adjustment factor * $307.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6151.76,12223.35,Inpatient DRG
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],54180.83,,"Fee schedule rate ($54,180.83). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,15491.11,54180.83,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,689,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],22417.63,,"Fee schedule rate ($22,417.63). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,9802.58,22831.22,There are no additional notes associated with this service or procedure.
TRAUMATIC INJURY WITH MCC,913,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],30719.04,,"Fee schedule rate ($30,719.04). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.5), with a minimum of zero.",,,,0,other,13014.58,42838.46,There are no additional notes associated with this service or procedure.
Neuroplasty &/Transpos Median Nrv Carpal Tunne|BILATERAL PROCEDURE,CASE-64721,APC,64721,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1827.80,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1827.80,1919.19,OPPS APC
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],15145.28,,"Fee schedule rate ($15,145.28). Adds an outlier to normal pricing equal to the per diem rate ($54,966.40) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7402.56,16438.59,There are no additional notes associated with this service or procedure.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],75579.22,,"Fee schedule rate ($75,579.22). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,25162.32,75579.22,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,426,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],207121.41,,"Fee schedule rate ($207,121.41). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,76581.29,216864.15,There are no additional notes associated with this service or procedure.
CERVICAL SPINAL FUSION WITHOUT CC/MCC,473,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],62077.11,,"Fee schedule rate ($62,077.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,18477.61,62077.11,There are no additional notes associated with this service or procedure.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],15854.69,,"Case rate ($15,099.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,182.53, add-ons for qualifying new technology services are included. If operating cost exceeds $49,053.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,722.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $12,192.63 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,237.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $962.12. The transfer capital threshold is the transfer adjustment factor * $962.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7605.00,39153.65,Inpatient DRG
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],17097.87,,"Fee schedule rate ($17,097.87). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,8106.18,18245.94,There are no additional notes associated with this service or procedure.
Colonoscopy Flx W/Endoscopic Mucosal Resection|UNUSUAL NON-OVERLAPPING SERVICE|COLORECTAL CANCER SCREEN,CASE-45390,APC,45390,CPT,0360,RC,,,XU|PT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],2598.08,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2598.08,2727.99,OPPS APC
DIABETES WITHOUT CC/MCC,639,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],6965.00,,,,,,0,other,6151.76,12223.35,There are no additional notes associated with this service or procedure.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],92045.07,,,,,,0,other,33623.33,133270.57,There are no additional notes associated with this service or procedure.
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC,807,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],6836.20,,"Case rate ($6,510.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,192.35, add-ons for qualifying new technology services are included. If operating cost exceeds $41,063.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,093.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $4,231.80 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,247.40 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $333.93. The transfer capital threshold is the transfer adjustment factor * $333.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5354.25,13266.23,Inpatient DRG
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],45050.58,,"Fee schedule rate ($45,050.58). Adds an outlier to normal pricing equal to the per diem rate ($120,238.99) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,18178.96,54764.34,There are no additional notes associated with this service or procedure.
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,450,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],146009.19,,"Fee schedule rate ($146,009.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,38037.38,146009.19,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],40737.46,,"Fee schedule rate ($40,737.46). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,7665.00,40737.46,There are no additional notes associated with this service or procedure.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],15309.46,,"Fee schedule rate ($15,309.46). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6965.00,15340.19,There are no additional notes associated with this service or procedure.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],40918.00,,"Fee schedule rate ($40,918.00). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,16689.78,59521.43,There are no additional notes associated with this service or procedure.
DIABETES WITH CC,638,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],8414.77,,"Case rate ($8,014.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,590.93, add-ons for qualifying new technology services are included. If operating cost exceeds $42,461.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,203.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,625.24 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,645.98 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $443.89. The transfer capital threshold is the transfer adjustment factor * $443.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8014.07,17634.53,Inpatient DRG
"Repair Extensor Tendon Finger W/O Graft Each|LEFT HAND, THIRD DIGIT",CASE-26418,APC,26418,CPT,0360,RC,,,F2,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1505.12,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1505.12,1580.37,OPPS APC
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITHOUT CC/MCC,816,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],14733.53,,"Fee schedule rate ($14,733.53). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6224.90,14733.53,There are no additional notes associated with this service or procedure.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],19604.30,,"Fee schedule rate ($19,604.30). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9446.38,21796.21,There are no additional notes associated with this service or procedure.
"ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",770,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],18843.74,,"Fee schedule rate ($18,843.74). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,8735.30,19730.13,There are no additional notes associated with this service or procedure.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC,027,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],47412.86,,"Fee schedule rate ($47,412.86). Adds an outlier to normal pricing equal to the per diem rate ($103,062) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,19030.20,56363.30,There are no additional notes associated with this service or procedure.
"NEONATE BIRTH WEIGHT 2000-2499 GRAMS NORMAL NEWBORN OR NEONATE WITH OTHER PROBLEM,MINOR",626,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],1505.34,,"Case rate ($1,505.34). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,1505.34,1580.61,There are no additional notes associated with this service or procedure.
O.R. PROCEDURES FOR OBESITY WITH CC,620,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],43753.50,,"Fee schedule rate ($43,753.50). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12782.30,43753.50,There are no additional notes associated with this service or procedure.
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH MCC",722,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],56869.13,,"Fee schedule rate ($56,869.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,14200.37,56869.13,There are no additional notes associated with this service or procedure.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],8995.77,,"Case rate ($8,567.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,118.03, add-ons for qualifying new technology services are included. If operating cost exceeds $42,989.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,232.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,149.77 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,173.08 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $472.69. The transfer capital threshold is the transfer adjustment factor * $472.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8767.81,19824.58,Inpatient DRG
Breast Reduction|BILATERAL PROCEDURE,CASE-19318,APC,19318,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6215.36,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6215.36,6526.12,OPPS APC
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],21888.80,,"Case rate ($20,846.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $19,528.64, add-ons for qualifying new technology services are included. If operating cost exceeds $54,399.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,142.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $17,519.09 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $17,583.69 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,382.43. The transfer capital threshold is the transfer adjustment factor * $1,382.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,20846.48,81306.30,Inpatient DRG
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],14699.43,,"Fee schedule rate ($14,699.43). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6683.37,14699.43,There are no additional notes associated with this service or procedure.
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],14725.21,,"Case rate ($14,725.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,834.15, add-ons for qualifying new technology services are included. If operating cost exceeds $48,705.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,694.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,845.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,889.20 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $934.73. The transfer capital threshold is the transfer adjustment factor * $934.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7389.00,37134.43,Inpatient DRG
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],28253.40,,"Fee schedule rate ($28,253.40). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,12126.09,29582.40,There are no additional notes associated with this service or procedure.
NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,601,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],12359.72,,"Fee schedule rate ($12,359.72). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6042.05,12359.72,There are no additional notes associated with this service or procedure.
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH MCC",510,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],10710.00,,"Per diem ($10,710). If length of stay < 5.3, first 1 days paid at a per diem of $21,420 instead. Capped at $56,764.26.",,,,0,other,10710.00,89863.76,Estimated amount calculated based on 6 day length of stay.
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],86252.84,,"Fee schedule rate ($86,252.84). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,27944.96,86252.84,There are no additional notes associated with this service or procedure.
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],13747.09,,"Case rate ($13,092.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,315.24, add-ons for qualifying new technology services are included. If operating cost exceeds $47,186.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,575.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $10,332.19 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,370.29 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $815.31. The transfer capital threshold is the transfer adjustment factor * $815.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13092.47,33159.45,Inpatient DRG
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],41006.47,,"Fee schedule rate ($41,006.47). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12268.97,41006.47,There are no additional notes associated with this service or procedure.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],51630.84,,"Fee schedule rate ($51,630.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,20559.34,54086.17,There are no additional notes associated with this service or procedure.
"ASTHMA,MODERATE",141,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],2206.34,,"Case rate for a one day stay ($2,101.28). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,2101.28,2206.34,There are no additional notes associated with this service or procedure.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,098,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],17486.17,,"Case rate ($17,486.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,402.62, add-ons for qualifying new technology services are included. If operating cost exceeds $51,273.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,896.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $14,404.56 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,457.67 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,136.66. The transfer capital threshold is the transfer adjustment factor * $1,136.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,45156.75,Inpatient DRG
"NEONATE BIRTH WEIGHT 1250-1499 GRAMS WITH RESPIRATORY DISTRESS SYNDROME OR OTHER MAJOR RESPIRATORY CONDITION OR MAJOR ANOMALY,MAJOR",607,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],92263.35,,"Case rate ($87,869.86). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $58,117, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,87869.86,92263.35,There are no additional notes associated with this service or procedure.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],12514.35,,"Case rate ($12,268.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,549.17, add-ons for qualifying new technology services are included. If operating cost exceeds $46,420.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,515.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,568.94 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,604.22 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $755.08. The transfer capital threshold is the transfer adjustment factor * $755.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,12268.97,41006.47,Inpatient DRG
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],86235.79,,"Fee schedule rate ($86,235.79). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,32296.02,88188.38,There are no additional notes associated with this service or procedure.
Insj/Rplcmt Breast Implant Sep Day Mastectomy|BILATERAL PROCEDURE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-19342,APC,19342,CPT,0360,RC,,,50|XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7918.25,,"APC Price ($7,650.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,7650.49,8033.01,OPPS APC
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH CC",457,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],160549.49,,"Fee schedule rate ($160,549.49). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,42327.47,160549.49,There are no additional notes associated with this service or procedure.
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH MCC",722,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],14532.41,,"Case rate ($13,840.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,033.22, add-ons for qualifying new technology services are included. If operating cost exceeds $47,904.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,609.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $11,046.38 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,088.27 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $849.05. The transfer capital threshold is the transfer adjustment factor * $849.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,14200.37,56869.13,Inpatient DRG
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],59476.09,,"Fee schedule rate ($59,476.09). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15.9), with a minimum of zero.",,,,0,other,23377.19,96365.69,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],24733.69,,"Fee schedule rate ($24,733.69). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,17782.11,46523.26,There are no additional notes associated with this service or procedure.
HEADACHES WITHOUT MCC,103,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],7988.85,,"Case rate ($7,608.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,213.57, add-ons for qualifying new technology services are included. If operating cost exceeds $42,084.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,174.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $5,249.26 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,268.62 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $414.22. The transfer capital threshold is the transfer adjustment factor * $414.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,20883.08,Inpatient DRG
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],15309.46,,"Fee schedule rate ($15,309.46). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6965.00,15340.19,There are no additional notes associated with this service or procedure.
PSYCHOSES,885,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],26250.06,,"Fee schedule rate ($26,250.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15.8), with a minimum of zero.",,,,0,other,2070.00,27484.83,There are no additional notes associated with this service or procedure.
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],20981.60,,"Fee schedule rate ($20,981.60). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,10003.71,23415.63,There are no additional notes associated with this service or procedure.
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC",641,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],14624.71,,"Fee schedule rate ($14,624.71). Adds an outlier to normal pricing equal to the per diem rate ($38,755.52) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7214.98,15312.64,There are no additional notes associated with this service or procedure.
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],8487.31,,"Case rate ($8,083.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,655.19, add-ons for qualifying new technology services are included. If operating cost exceeds $42,526.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,208.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,689.27 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,710.24 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $448.94. The transfer capital threshold is the transfer adjustment factor * $448.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7884.32,17835.23,Inpatient DRG
CESAREAN SECTION WITH STERILIZATION WITHOUT CC/MCC,785,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],20142.33,,"Fee schedule rate ($20,142.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8431.24,20142.33,There are no additional notes associated with this service or procedure.
Dstr Nrolytc Agnt Parverteb Fct Sngl Crvcl/Thora|RIGHT SIDE,CASE-64633,APC,64633,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1919.19,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1827.80,1919.19,OPPS APC
"ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",770,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],17800.73,,"Fee schedule rate ($17,800.73). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,8735.30,19730.13,There are no additional notes associated with this service or procedure.
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],19523.79,,"Case rate ($18,594.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,433.29, add-ons for qualifying new technology services are included. If operating cost exceeds $52,304.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,977.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $15,431.44 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,488.34 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,217.69. The transfer capital threshold is the transfer adjustment factor * $1,217.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,18594.09,59494.91,Inpatient DRG
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,074,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],20919.08,,"Fee schedule rate ($20,919.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8925.60,20919.08,There are no additional notes associated with this service or procedure.
"HC I&D Finger Abscess Simple|RIGHT HAND, THUMB",CASE-26010,APC,26010,CPT,0450,RC,,,F5,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],197.19,,"APC Price ($187.80). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,187.80,197.19,OPPS APC
TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC,087,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],17189.96,,"Fee schedule rate ($17,189.96). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,8139.36,22679.07,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,082,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],17816.99,,"Case rate ($16,968.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,949.12, add-ons for qualifying new technology services are included. If operating cost exceeds $50,820.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,832.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $13,951.27 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,004.17 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,072.33. The transfer capital threshold is the transfer adjustment factor * $1,072.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,17423.21,56223.11,Inpatient DRG
Ercp W/Biopsy Single/Multiple,CASE-43261,APC,43261,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3608.81,,"APC Price ($3,608.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3608.81,3789.26,OPPS APC
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC",923,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],8047.79,,"Case rate ($8,047.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $7,588.71, add-ons for qualifying new technology services are included. If operating cost exceeds $46,233.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $3,215.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,201.30 + an uncompensated DSH payment of $1,359.91. The transfer operating threshold is the transfer adjustment factor * $6,228.80 + an uncompensated DSH payment of $1,359.91. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $486.59. The transfer capital threshold is the transfer adjustment factor * $486.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,20068.57,Inpatient DRG
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],12791.10,,"Fee schedule rate ($12,791.10). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10311.17,24308.97,There are no additional notes associated with this service or procedure.
"Tendon Sheath Incision|RIGHT HAND, THUMB",CASE-26055,APC,26055,CPT,0360,RC,,,F5,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1505.12,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1505.12,1580.37,OPPS APC
HC Joint Injection/Aspir Large WO US|PBB CHARGE|RIGHT SIDE,CASE-20610,APC,20610,CPT,0510,RC,,,PBB|RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],297.37,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,287.31,301.68,OPPS APC
NON-MALIGNANT BREAST DISORDERS WITH CC/MCC,600,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],9448.68,,"Case rate ($8,998.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,506.94, add-ons for qualifying new technology services are included. If operating cost exceeds $43,377.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,275.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $6,537.88 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,561.99 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $515.90. The transfer capital threshold is the transfer adjustment factor * $515.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7999.14,20495.56,Inpatient DRG
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],45706.73,,"Fee schedule rate ($45,706.73). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,7921.00,45706.73,There are no additional notes associated with this service or procedure.
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC",629,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],44657.18,,"Fee schedule rate ($44,657.18). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,16699.94,44657.18,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],34391.19,,"Fee schedule rate ($34,391.19). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,14337.84,52803.53,There are no additional notes associated with this service or procedure.
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],15800.93,,"Case rate ($15,491.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,546.67, add-ons for qualifying new technology services are included. If operating cost exceeds $49,417.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,750.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $12,555.42 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,601.72 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $990.75. The transfer capital threshold is the transfer adjustment factor * $990.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,15491.11,54180.83,Inpatient DRG
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],38517.10,,"Fee schedule rate ($38,517.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,16897.01,43444.85,There are no additional notes associated with this service or procedure.
Colsc Flexible W/Transendoscopic Balloon Dilat,CASE-45386,APC,45386,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1120.09,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1120.09,1176.09,OPPS APC
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],12704.31,,"Case rate ($12,455.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,722.41, add-ons for qualifying new technology services are included. If operating cost exceeds $46,593.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,528.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $9,741.55 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,777.47 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $768.70. The transfer capital threshold is the transfer adjustment factor * $768.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,12455.21,37149.27,Inpatient DRG
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],13872.99,,"Fee schedule rate ($13,872.99). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.8), with a minimum of zero.",,,,0,other,5068.21,14525.56,There are no additional notes associated with this service or procedure.
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC,806,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6510.67,,"Case rate ($6,510.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,192.35, add-ons for qualifying new technology services are included. If operating cost exceeds $41,063.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,093.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $4,231.80 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,247.40 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $333.93. The transfer capital threshold is the transfer adjustment factor * $333.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,5354.25,13416.00,Inpatient DRG
MINOR BLADDER PROCEDURES WITHOUT CC/MCC,664,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],9486.36,,"Case rate ($9,034.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,540.33, add-ons for qualifying new technology services are included. If operating cost exceeds $43,411.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,278.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $6,571.15 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,595.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $518.53. The transfer capital threshold is the transfer adjustment factor * $518.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9034.63,31876.87,Inpatient DRG
Dstr Nrolytc Agnt Parverteb Fct Addl Lmbr/Sacral|RIGHT SIDE,CASE-64636,APC,64636,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1891.77,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1827.80,1919.19,OPPS APC
Laps Surg Rpr Recurrent Inguinal Hernia|RIGHT SIDE,CASE-49651,APC,49651,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5658.76,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5658.76,5941.70,OPPS APC
RESPIRATORY NEOPLASMS WITH CC,181,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],20127.30,,"Fee schedule rate ($20,127.30). Adds an outlier to normal pricing equal to the per diem rate ($54,966.40) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,9197.84,21074.07,There are no additional notes associated with this service or procedure.
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],22299.54,,"Case rate ($21,862.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,473.63, add-ons for qualifying new technology services are included. If operating cost exceeds $55,344.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,216.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. The base transfer operating payment is the transfer adjustment factor * $18,460.61 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,528.68 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,456.72. The transfer capital threshold is the transfer adjustment factor * $1,456.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,7086.00,57872.02,Inpatient DRG
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,307,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],18228.77,,,,,,0,other,6335.27,18228.77,There are no additional notes associated with this service or procedure.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],47169.70,,,,,,0,other,18178.96,54764.34,There are no additional notes associated with this service or procedure.
POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES,769,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],29791.03,,"Fee schedule rate ($29,791.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,13388.39,33250.19,There are no additional notes associated with this service or procedure.
SALIVARY GLAND PROCEDURES,139,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],10313.19,,"Case rate ($10,313.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,729.75, add-ons for qualifying new technology services are included. If operating cost exceeds $44,600.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,372.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $7,756.21 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,784.80 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $612.04. The transfer capital threshold is the transfer adjustment factor * $612.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10313.19,30690.92,Inpatient DRG
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,555,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],24840.59,,"Fee schedule rate ($24,840.59). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10896.27,42290.95,There are no additional notes associated with this service or procedure.
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],10078.00,,"Per diem ($10,078). If length of stay < 7.2, first 1 days paid at a per diem of $20,156 instead. Capped at $72,563.53.",,,,0,other,10078.00,81454.07,Estimated amount calculated based on 15 day length of stay.
ALLERGIC REACTIONS WITH MCC,915,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],13999.50,,"Case rate ($13,332.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,538.89, add-ons for qualifying new technology services are included. If operating cost exceeds $47,409.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,592.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $10,555.02 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,593.94 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $832.90. The transfer capital threshold is the transfer adjustment factor * $832.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13332.86,33088.84,Inpatient DRG
Intraop Sentinel Lymph Node ID W/Dye Injection|RIGHT SIDE,CASE-38900,APC,38900,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6526.12,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6215.36,6526.12,OPPS APC
Surgical Arthroscopy Shoulder W/Rotator Cuff Rpr|LEFT SIDE,CASE-29827,APC,29827,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
DIABETES WITH CC,638,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],8294.56,,"Case rate ($8,014.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,590.93, add-ons for qualifying new technology services are included. If operating cost exceeds $42,461.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,203.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,625.24 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,645.98 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $443.89. The transfer capital threshold is the transfer adjustment factor * $443.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,8014.07,17634.53,Inpatient DRG
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,426,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],78108.43,,"Case rate ($74,388.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $69,473.26, add-ons for qualifying new technology services are included. If operating cost exceeds $104,344.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $6,930.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $67,273.25 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $67,528.31 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $5,170.78. The transfer capital threshold is the transfer adjustment factor * $5,170.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,76581.29,216864.15,Inpatient DRG
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],14625.55,,"Fee schedule rate ($14,625.55). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7438.45,15961.98,There are no additional notes associated with this service or procedure.
Laryngoscopy Direct Operative W/Biopsy,CASE-31535,APC,31535,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3489.82,,"APC Price ($3,489.82). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3489.82,3664.31,OPPS APC
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],13571.25,,"Case rate ($13,571.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,760.65, add-ons for qualifying new technology services are included. If operating cost exceeds $47,631.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,610.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $10,775.96 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,815.69 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $850.33. The transfer capital threshold is the transfer adjustment factor * $850.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,13571.25,33781.47,Inpatient DRG
"Tendon Sheath Incision|UNUSUAL NON-OVERLAPPING SERVICE|LEFT HAND, THIRD DIGIT",CASE-26055,APC,26055,CPT,0360,RC,,,XU|F2,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1557.80,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1505.12,1557.80,OPPS APC
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],59081.91,,"Fee schedule rate ($59,081.91). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,8480.00,59081.91,There are no additional notes associated with this service or procedure.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],44847.62,,"Fee schedule rate ($44,847.62). Adds an outlier to normal pricing equal to the per diem rate ($79,031.36) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,18105.81,52699.33,There are no additional notes associated with this service or procedure.
Wmhc Perc Implant Stim Lead Ea,CASE-63650,APC,63650,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6174.06,,"APC Price ($5,965.28). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5965.28,6263.54,OPPS APC
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],12272.58,,"Fee schedule rate ($12,272.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5628.97,12272.58,There are no additional notes associated with this service or procedure.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],23691.11,,,,,,0,other,10098.51,24259.09,There are no additional notes associated with this service or procedure.
Laser Vaporization of Prostate for Urine Flow,CASE-52648,APC,52648,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5194.43,,"APC Price ($5,018.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5018.77,5269.71,OPPS APC
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITHOUT CC/MCC,816,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],14733.53,,"Fee schedule rate ($14,733.53). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6224.90,14733.53,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],9356.31,,"Case rate ($9,356.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,839.58, add-ons for qualifying new technology services are included. If operating cost exceeds $43,710.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,302.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $6,869.30 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,894.63 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $542.06. The transfer capital threshold is the transfer adjustment factor * $542.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9356.31,25026.36,Inpatient DRG
"CARDIAC ARREST, UNEXPLAINED WITH MCC",296,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],12960.53,,"Case rate ($12,522.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,784.78, add-ons for qualifying new technology services are included. If operating cost exceeds $46,655.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,533.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $9,803.69 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,839.84 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $773.61. The transfer capital threshold is the transfer adjustment factor * $773.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,12522.25,36459.67,Inpatient DRG
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],16804.22,,"Fee schedule rate ($16,804.22). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7238.69,16804.22,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS WITH MCC,947,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],10910.36,,"Case rate ($10,541.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,942.06, add-ons for qualifying new technology services are included. If operating cost exceeds $44,813.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,388.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $7,967.73 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,997.11 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $628.73. The transfer capital threshold is the transfer adjustment factor * $628.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,10541.41,30414.32,Inpatient DRG
"Exc Tum/Vasc Mal Sft Tiss Hand/Fngr Subq <1.5cm|RIGHT HAND, SECOND DIGIT",CASE-26115,APC,26115,CPT,0360,RC,,,F6,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1623.23,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1545.93,1623.23,OPPS APC
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],26949.28,,"Fee schedule rate ($26,949.28). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9977.99,26949.28,There are no additional notes associated with this service or procedure.
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|LEFT HAND, THUMB",CASE-26160,APC,26160,CPT,0360,RC,,,FA,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1505.12,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1505.12,1580.37,OPPS APC
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],16658.16,,"Case rate ($15,864.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,920.37, add-ons for qualifying new technology services are included. If operating cost exceeds $49,791.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,753.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $12,926.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,975.42 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $993.55. The transfer capital threshold is the transfer adjustment factor * $993.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,16286.16,58320.32,Inpatient DRG
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],28038.61,,"Fee schedule rate ($28,038.61). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12126.09,29582.40,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],59476.09,,"Fee schedule rate ($59,476.09). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15.9), with a minimum of zero.",,,,0,other,23377.19,96365.69,There are no additional notes associated with this service or procedure.
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],35061.53,,"Fee schedule rate ($35,061.53). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,9696.93,35061.53,There are no additional notes associated with this service or procedure.
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],6965.00,,,,,,0,other,6965.00,34422.94,There are no additional notes associated with this service or procedure.
HC Drain/Inj Joint/Bursa W/US Large,CASE-20611,APC,20611,CPT,0510,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],301.68,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,287.31,301.68,OPPS APC
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR,518,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],89342.77,,"Fee schedule rate ($89,342.77). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,13252.00,89342.77,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],49717.39,,"Fee schedule rate ($49,717.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,14908.05,49717.39,There are no additional notes associated with this service or procedure.
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,451,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],63564.58,,,,,,0,other,23821.44,94077.13,There are no additional notes associated with this service or procedure.
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7108.12,,"Case rate ($6,769.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,442.26, add-ons for qualifying new technology services are included. If operating cost exceeds $41,313.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,104.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,480.33 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,497.31 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $344.37. The transfer capital threshold is the transfer adjustment factor * $344.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6915.64,14442.92,Inpatient DRG
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],11565.93,,"Fee schedule rate ($11,565.93). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6148.93,15887.21,There are no additional notes associated with this service or procedure.
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,451,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],94077.13,,"Fee schedule rate ($94,077.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,23821.44,94077.13,There are no additional notes associated with this service or procedure.
POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES,769,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],29791.03,,"Fee schedule rate ($29,791.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,13388.39,33250.19,There are no additional notes associated with this service or procedure.
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],16235.87,,"Fee schedule rate ($16,235.87). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6524.00,17760.46,There are no additional notes associated with this service or procedure.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],29837.65,,"Fee schedule rate ($29,837.65). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,12696.97,47123.82,There are no additional notes associated with this service or procedure.
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],26204.74,,"Fee schedule rate ($26,204.74). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10120.20,26204.74,There are no additional notes associated with this service or procedure.
MAJOR BLADDER PROCEDURES WITH MCC,653,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],38992.11,,"Case rate ($37,135.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $34,681.82, add-ons for qualifying new technology services are included. If operating cost exceeds $69,552.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,333.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.5. The base transfer operating payment is the transfer adjustment factor * $32,616.61 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $32,736.87 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,573.77. The transfer capital threshold is the transfer adjustment factor * $2,573.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10280.00,125343.98,Inpatient DRG
HEADACHES WITHOUT MCC,103,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7874.73,,"Case rate ($7,608.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,213.57, add-ons for qualifying new technology services are included. If operating cost exceeds $42,084.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,174.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $5,249.26 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,268.62 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $414.22. The transfer capital threshold is the transfer adjustment factor * $414.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6965.00,20883.08,Inpatient DRG
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],15076.44,,"Fee schedule rate ($15,076.44). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6340.03,15076.44,There are no additional notes associated with this service or procedure.
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],14886.62,,"Case rate ($14,383.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,516, add-ons for qualifying new technology services are included. If operating cost exceeds $48,387.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,669.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,528.54 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,571.05 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $909.72. The transfer capital threshold is the transfer adjustment factor * $909.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6965.00,36140.75,Inpatient DRG
Episiotomy/Vag Rpr Oth/Thn Attending,CASE-59300,APC,59300,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3181.53,,"APC Price ($3,030.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3030.03,3181.53,OPPS APC
"CHRONIC OBSTRUCTIVE PULMONARY DISEASE,MAJOR",140,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],9860.08,,"Case rate ($9,390.55). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9390.55,9860.08,There are no additional notes associated with this service or procedure.
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],37899.49,,"Fee schedule rate ($37,899.49). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,14747.55,37899.49,There are no additional notes associated with this service or procedure.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],80635.65,,"Fee schedule rate ($80,635.65). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,26028.48,80635.65,There are no additional notes associated with this service or procedure.
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH MCC",722,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],56869.13,,"Fee schedule rate ($56,869.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,14200.37,56869.13,There are no additional notes associated with this service or procedure.
HC Trigger Point 3 or More|PBB CHARGE,CASE-20553,APC,20553,CPT,0510,RC,,,PBB,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
Excision H/P/P/U Simple/Intermediate Repair,CASE-11470,APC,11470,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],2854.83,,"APC Price ($2,718.88). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2718.88,2854.83,OPPS APC
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],53275.26,,"Fee schedule rate ($53,275.26). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,15940.79,53275.26,There are no additional notes associated with this service or procedure.
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],14230.80,,"Case rate ($13,553.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,765.46, add-ons for qualifying new technology services are included. If operating cost exceeds $47,636.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,588.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $10,779.64 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,820.51 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $828.55. The transfer capital threshold is the transfer adjustment factor * $828.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13904.43,34749.58,Inpatient DRG
"Open Tx Phalangeal Shaft Fracture Prox/Middle Ea|RIGHT HAND, FIFTH DIGIT",CASE-26735,APC,26735,CPT,0360,RC,,,F9,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6791.99,7131.59,OPPS APC
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",623,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],32096.64,,"Fee schedule rate ($32,096.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,14093.37,33712.76,There are no additional notes associated with this service or procedure.
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],7402.56,,"Case rate ($7,402.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,022.05, add-ons for qualifying new technology services are included. If operating cost exceeds $41,893.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,159.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,058.45 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,077.10 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $399.16. The transfer capital threshold is the transfer adjustment factor * $399.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7402.56,16438.59,Inpatient DRG
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],20401.88,,"Fee schedule rate ($20,401.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,20401.88,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],43399.23,,"Fee schedule rate ($43,399.23). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9888.00,43399.23,There are no additional notes associated with this service or procedure.
Optx Dstl Radl I-Artic Fx/Epiphysl Sep 2 Frag|LEFT SIDE,CASE-25608,APC,25608,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7029.71,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6791.99,7029.71,OPPS APC
PERIPHERAL VASCULAR DISORDERS WITH CC,300,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],20331.78,,"Fee schedule rate ($20,331.78). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,9174.14,21005.20,There are no additional notes associated with this service or procedure.
Laparoscopy Surg Partial Nephrectomy|LEFT SIDE,CASE-50543,APC,50543,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],10298.02,,"APC Price ($9,949.78). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,9949.78,10447.27,OPPS APC
PREMATURITY WITH MAJOR PROBLEMS,791,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],3054.00,,,,,,0,other,3048.21,30904.42,Estimated amount calculated based on 5 day length of stay.
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],11575.50,,"Case rate ($11,575.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,904.06, add-ons for qualifying new technology services are included. If operating cost exceeds $45,775.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,464.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $8,926.20 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,959.11 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $704.37. The transfer capital threshold is the transfer adjustment factor * $704.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,11575.50,48961.48,Inpatient DRG
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],28434.57,,"Fee schedule rate ($28,434.57). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,8906.63,28434.57,There are no additional notes associated with this service or procedure.
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],8460.30,,"Case rate ($8,057.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,631.26, add-ons for qualifying new technology services are included. If operating cost exceeds $42,502.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,207.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,665.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,686.30 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $447.06. The transfer capital threshold is the transfer adjustment factor * $447.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6524.00,17760.46,Inpatient DRG
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITH MCC,429,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],177294.98,,"Fee schedule rate ($177,294.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,62958.58,177294.98,There are no additional notes associated with this service or procedure.
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],14690.49,,"Fee schedule rate ($14,690.49). Adds an outlier to normal pricing equal to the per diem rate ($54,770.58) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.7), with a minimum of zero.",,,,0,other,7238.69,16804.22,There are no additional notes associated with this service or procedure.
Sigmoidoscopy Flx Dx W/Collj Spec Br/Wa if Pfrmd,CASE-45330,APC,45330,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],870.46,,"APC Price ($870.46). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,870.46,913.99,OPPS APC
"SEIZURE,EXTREME",053,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],20893.83,,"Case rate ($20,893.83). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,20893.83,21938.52,There are no additional notes associated with this service or procedure.
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],18043.23,,"Fee schedule rate ($18,043.23). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7733.72,18043.23,There are no additional notes associated with this service or procedure.
NON-MALIGNANT BREAST DISORDERS WITH CC/MCC,600,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],15046.13,,"Fee schedule rate ($15,046.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7999.14,20495.56,There are no additional notes associated with this service or procedure.
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],14206.49,,"Fee schedule rate ($14,206.49). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6965.00,34422.94,There are no additional notes associated with this service or procedure.
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],5791.49,,"Fee schedule rate ($5,791.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,3079.00,10940.41,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],34409.55,,"Fee schedule rate ($34,409.55). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (35), with a minimum of zero.",,,,0,other,30398.48,82674.88,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],10554.00,,"Case rate ($10,347.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,761.25, add-ons for qualifying new technology services are included. If operating cost exceeds $44,632.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,374.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $7,787.59 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,816.30 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $614.52. The transfer capital threshold is the transfer adjustment factor * $614.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,10347.06,28821.04,Inpatient DRG
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],26949.28,,"Fee schedule rate ($26,949.28). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9977.99,26949.28,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITH MCC,385,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],13103.51,,"Case rate ($12,660.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,913.31, add-ons for qualifying new technology services are included. If operating cost exceeds $46,784.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,543.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $9,931.73 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,968.35 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $783.71. The transfer capital threshold is the transfer adjustment factor * $783.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,11480.01,31134.92,Inpatient DRG
Excision Skin Abd Infraumbilical Panniculectomy,CASE-15830,APC,15830,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6526.12,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6215.36,6526.12,OPPS APC
Laps Tx Ectopic Preg W/Salping&/Oophorectomy,CASE-59151,APC,59151,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5941.70,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5658.76,5941.70,OPPS APC
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],7332.00,,"Per diem ($7,332). If length of stay < 4.6, first 1 days paid at a per diem of $14,664 instead. Capped at $33,727.80.",,,,0,other,7332.00,35314.31,Estimated amount calculated based on 3 day length of stay.
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC",011,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],102498.90,,"Fee schedule rate ($102,498.90). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,38880.49,150008.48,There are no additional notes associated with this service or procedure.
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITHOUT MCC,430,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],43050.17,,"Case rate ($41,000.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $38,277.19, add-ons for qualifying new technology services are included. If operating cost exceeds $73,148.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,616.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $36,198.76 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $36,332.23 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,856.44. The transfer capital threshold is the transfer adjustment factor * $2,856.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,41000.16,133156.90,Inpatient DRG
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 2nd Level|BILATERAL PROCEDURE,CASE-64494,APC,64494,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],827.89,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,827.89,869.28,OPPS APC
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC",629,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],42872.25,,,,,,0,other,16699.94,44657.18,There are no additional notes associated with this service or procedure.
NERVOUS SYSTEM NEOPLASMS WITH MCC,054,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],12715.20,,"Case rate ($12,285.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,564.29, add-ons for qualifying new technology services are included. If operating cost exceeds $46,435.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,516.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $9,584.00 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,619.34 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $756.27. The transfer capital threshold is the transfer adjustment factor * $756.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6965.00,30044.81,Inpatient DRG
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],28423.20,,"Fee schedule rate ($28,423.20). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11059.47,28423.20,There are no additional notes associated with this service or procedure.
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],35474.53,,"Fee schedule rate ($35,474.53). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,16428.39,42083.20,There are no additional notes associated with this service or procedure.
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],29594.00,,"Fee schedule rate ($29,594.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,13571.25,33781.47,There are no additional notes associated with this service or procedure.
DIABETES WITH MCC,637,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],11454.91,,"Case rate ($10,909.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $10,253.93, add-ons for qualifying new technology services are included. If operating cost exceeds $48,898.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $3,423.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $8,854.74 + an uncompensated DSH payment of $1,359.91. The transfer operating threshold is the transfer adjustment factor * $8,894.02 + an uncompensated DSH payment of $1,359.91. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $694.79. The transfer capital threshold is the transfer adjustment factor * $694.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9959.03,28655.62,Inpatient DRG
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC",758,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],16323.02,,"Fee schedule rate ($16,323.02). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8574.80,19263.78,There are no additional notes associated with this service or procedure.
"HC ED Avulsion Nail Plate Single|RIGHT HAND, THUMB",CASE-11730,APC,11730,CPT,0450,RC,,,F5,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],197.19,,"APC Price ($187.80). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,187.80,197.19,OPPS APC
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],6657.03,,"Case rate ($6,340.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,033.60, add-ons for qualifying new technology services are included. If operating cost exceeds $40,904.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,081.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $4,073.62 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,088.64 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $321.45. The transfer capital threshold is the transfer adjustment factor * $321.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6340.03,15076.44,Inpatient DRG
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITHOUT CC/MCC,816,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6404.14,,"Case rate ($6,099.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,817.30, add-ons for qualifying new technology services are included. If operating cost exceeds $40,688.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,056.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $3,857.72 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,872.35 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $296.51. The transfer capital threshold is the transfer adjustment factor * $296.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6224.90,14733.53,Inpatient DRG
Dstrj Lesion Anus Simple Surg Excision,CASE-46922,APC,46922,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],2598.08,,"APC Price ($2,598.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2598.08,2727.99,OPPS APC
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH CC,427,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],52608.86,,"Case rate ($50,829.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $47,421.51, add-ons for qualifying new technology services are included. If operating cost exceeds $82,292.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $5,335.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $45,309.50 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $45,476.56 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,575.37. The transfer capital threshold is the transfer adjustment factor * $3,575.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,50829.82,142040.39,Inpatient DRG
HC Inj Tendon Sheath/Ligament,CASE-20550,APC,20550,CPT,0510,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],297.37,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,287.31,301.68,OPPS APC
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],21892.85,,"Fee schedule rate ($21,892.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7569.84,21892.85,There are no additional notes associated with this service or procedure.
Laps Surg Cholecystectomy W/Cholangiography|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-47563,APC,47563,CPT,0360,RC,,,74,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5856.81,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5658.76,5941.70,OPPS APC
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],2070.00,,,,,,0,other,1188.00,34338.33,Estimated amount calculated based on 6 day length of stay.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,479,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],50518.76,,"Fee schedule rate ($50,518.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,10586.00,50518.76,There are no additional notes associated with this service or procedure.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],26949.28,,"Fee schedule rate ($26,949.28). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9977.99,26949.28,There are no additional notes associated with this service or procedure.
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],21489.15,,"Case rate ($21,489.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,126.50, add-ons for qualifying new technology services are included. If operating cost exceeds $54,997.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,189.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.6. The base transfer operating payment is the transfer adjustment factor * $18,114.76 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,181.55 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,429.43. The transfer capital threshold is the transfer adjustment factor * $1,429.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,21489.15,68942.79,Inpatient DRG
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC,497,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],10127.65,,"Case rate ($10,127.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,557.14, add-ons for qualifying new technology services are included. If operating cost exceeds $44,428.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,358.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 1.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $7,584.22 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,612.19 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $598.47. The transfer capital threshold is the transfer adjustment factor * $598.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10127.65,37761.19,Inpatient DRG
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],13625.25,,"Fee schedule rate ($13,625.25). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7243.75,23262.15,There are no additional notes associated with this service or procedure.
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC",514,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],8868.04,,"Case rate ($8,868.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,385.35, add-ons for qualifying new technology services are included. If operating cost exceeds $43,256.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,266.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $6,416.74 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,440.40 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $506.34. The transfer capital threshold is the transfer adjustment factor * $506.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8868.04,22699.91,Inpatient DRG
Grafting of Autologous Fat by Lipo Ea Addl 50 Cc,CASE-15772,APC,15772,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3664.94,,"APC Price ($3,664.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3664.94,3664.94,OPPS APC
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],2070.00,,,,,,0,other,1188.00,18893.86,Estimated amount calculated based on 3 day length of stay.
DIABETES WITHOUT CC/MCC,639,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],11899.36,,"Fee schedule rate ($11,899.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6151.76,12223.35,There are no additional notes associated with this service or procedure.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,057,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],39884.93,,"Fee schedule rate ($39,884.93). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,10718.84,39884.93,There are no additional notes associated with this service or procedure.
Unlisted Laparoscopy Px Abd Pertoneum & Omentum,CASE-49329,APC,49329,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5856.81,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5658.76,5856.81,OPPS APC
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],16343.72,,,,,,0,other,7569.84,21892.85,There are no additional notes associated with this service or procedure.
SALIVARY GLAND PROCEDURES,139,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],30690.92,,"Fee schedule rate ($30,690.92). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,10313.19,30690.92,There are no additional notes associated with this service or procedure.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC,027,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],56363.30,,"Fee schedule rate ($56,363.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,19030.20,56363.30,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],20659.14,,"Fee schedule rate ($20,659.14). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.9), with a minimum of zero.",,,,0,other,9389.48,22358.90,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],86437.13,,,,,,0,other,10862.00,86437.13,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,689,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],22417.63,,"Fee schedule rate ($22,417.63). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,9802.58,22831.22,There are no additional notes associated with this service or procedure.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],75579.22,,"Fee schedule rate ($75,579.22). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,25162.32,75579.22,There are no additional notes associated with this service or procedure.
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],15461.47,,"Case rate ($14,725.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,834.15, add-ons for qualifying new technology services are included. If operating cost exceeds $48,705.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,694.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,845.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,889.20 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $934.73. The transfer capital threshold is the transfer adjustment factor * $934.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7389.00,37134.43,Inpatient DRG
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,448,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],94077.13,,"Fee schedule rate ($94,077.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,30663.95,94077.13,There are no additional notes associated with this service or procedure.
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],31750.77,,"Fee schedule rate ($31,750.77). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13386.36,33244.29,There are no additional notes associated with this service or procedure.
COMPLICATIONS OF TREATMENT WITH CC,920,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],20731.52,,"Fee schedule rate ($20,731.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8732.59,20731.52,There are no additional notes associated with this service or procedure.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,056,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],18075.78,,"Case rate ($17,215.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,178.88, add-ons for qualifying new technology services are included. If operating cost exceeds $51,049.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,849.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $14,180.17 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,233.93 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,089.92. The transfer capital threshold is the transfer adjustment factor * $1,089.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7659.00,59328.19,Inpatient DRG
Laps Fulg/Exc Ovary Viscera/Peritoneal Surface,CASE-58662,APC,58662,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5941.70,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5658.76,5941.70,OPPS APC
RESPIRATORY NEOPLASMS WITH CC,181,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],17609.39,,"Fee schedule rate ($17,609.39). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9197.84,21074.07,There are no additional notes associated with this service or procedure.
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC",514,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],15519.07,,"Case rate ($8,868.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,385.35, add-ons for qualifying new technology services are included. If operating cost exceeds $43,256.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,266.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $6,416.74 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,440.40 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $506.34. The transfer capital threshold is the transfer adjustment factor * $506.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,8868.04,22699.91,All Other Inpatient
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],2070.00,,,,,,0,other,1188.00,17370.86,Estimated amount calculated based on 3 day length of stay.
"DORSAL AND LUMBAR FUSION PROCEDURE EXCEPT FOR CURVATURE OF BACK,MODERATE",304,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],8008.99,,"Case rate for a one day stay ($7,627.61). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7627.61,8008.99,There are no additional notes associated with this service or procedure.
Nsl/Sinus Ndsc Max Antrost W/Rmvl Tiss Max Sinus,CASE-31267,APC,31267,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6936.25,,"APC Price ($6,605.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6605.95,6936.25,OPPS APC
OTHER DISORDERS OF NERVOUS SYSTEM WITH CC,092,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],19225.24,,"Fee schedule rate ($19,225.24). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8872.78,26765.51,There are no additional notes associated with this service or procedure.
Open Tx Clavicular Fracture Internal Fixation|LEFT SIDE,CASE-23515,APC,23515,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],42021.93,,"Fee schedule rate ($42,021.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,21248.73,56089.29,There are no additional notes associated with this service or procedure.
Submucous Rescj Inferior Turbinate Prtl/Compl,CASE-30140,APC,30140,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3211.97,,"APC Price ($3,103.35). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.35,3258.52,OPPS APC
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],18043.23,,"Fee schedule rate ($18,043.23). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7733.72,18043.23,There are no additional notes associated with this service or procedure.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],33608.45,,"Fee schedule rate ($33,608.45). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,7332.00,35314.31,There are no additional notes associated with this service or procedure.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],54503.46,,"Fee schedule rate ($54,503.46). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.9), with a minimum of zero.",,,,0,other,21585.31,73588.10,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],40737.46,,"Fee schedule rate ($40,737.46). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,7665.00,40737.46,There are no additional notes associated with this service or procedure.
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC,807,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],10071.17,,"Fee schedule rate ($10,071.17). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5354.25,13266.23,There are no additional notes associated with this service or procedure.
O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC,621,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],36669.96,,"Fee schedule rate ($36,669.96). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,12159.94,36669.96,There are no additional notes associated with this service or procedure.
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],59081.91,,"Fee schedule rate ($59,081.91). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,8480.00,59081.91,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],8972.00,,"Per diem ($8,972). If length of stay < 6.1, first 1 days paid at a per diem of $17,944 instead. Capped at $54,730.85.",,,,0,other,8972.00,81524.17,Estimated amount calculated based on 4 day length of stay.
Septoplasty/Submucous Resecj W/WO Cartilage Grf,CASE-30520,APC,30520,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3211.97,,"APC Price ($3,103.35). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.35,3258.52,OPPS APC
Unlisted Laparoscopy Procedure Oviduct Ovary,CASE-58679,APC,58679,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5658.76,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5658.76,5941.70,OPPS APC
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,345,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],12741.63,,"Case rate ($12,134.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,424.43, add-ons for qualifying new technology services are included. If operating cost exceeds $46,295.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,505.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $9,444.66 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,479.48 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $745.28. The transfer capital threshold is the transfer adjustment factor * $745.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12134.89,33616.03,Inpatient DRG
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],34032.82,,"Fee schedule rate ($34,032.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,15233.11,38610.21,There are no additional notes associated with this service or procedure.
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],16259.61,,"Case rate ($15,940.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,964.98, add-ons for qualifying new technology services are included. If operating cost exceeds $49,835.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,783.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $12,972.20 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,020.03 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,023.63. The transfer capital threshold is the transfer adjustment factor * $1,023.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,15940.79,53275.26,Inpatient DRG
Optx Dstl Radl I-Artic Fx/Epiphysl Sep 2 Frag|RIGHT SIDE,CASE-25608,APC,25608,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7029.71,OPPS APC
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],29367.82,,"Fee schedule rate ($29,367.82). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.7), with a minimum of zero.",,,,0,other,12527.66,29917.96,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],13247.22,,"Case rate ($7,569.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,177.66, add-ons for qualifying new technology services are included. If operating cost exceeds $42,048.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,171.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,213.49 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,232.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $411.40. The transfer capital threshold is the transfer adjustment factor * $411.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,7569.84,21892.85,All Other Inpatient
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],16819.90,,,,,,0,other,7733.72,18043.23,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],10895.60,,"Case rate ($10,895.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,271.55, add-ons for qualifying new technology services are included. If operating cost exceeds $45,142.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,414.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $8,296.01 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,326.60 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $654.64. The transfer capital threshold is the transfer adjustment factor * $654.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10895.60,35192.25,Inpatient DRG
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],31626.74,,"Fee schedule rate ($31,626.74). Adds an outlier to normal pricing equal to the per diem rate ($86,383.13) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,13341.67,42586.49,There are no additional notes associated with this service or procedure.
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITH MCC OR ANTINEOPLASTIC IMPLANT OR EPILEPSY WITH NEUROSTIMULATOR,023,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],15168.00,,"Per diem ($15,168). If length of stay < 7.1, first 1 days paid at a per diem of $30,336 instead. Capped at $107,689.53.",,,,0,other,15168.00,136379.44,Estimated amount calculated based on 6 day length of stay.
SINGLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL,402,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],29790.92,,"Case rate ($28,372.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $26,579.07, add-ons for qualifying new technology services are included. If operating cost exceeds $61,450.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,646.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $24,541.07 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $24,634.12 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,886.28. The transfer capital threshold is the transfer adjustment factor * $1,886.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,29172.05,124455.45,Inpatient DRG
MAJOR THUMB OR JOINT PROCEDURES,506,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],26548.21,,,,,,0,other,11081.83,26548.21,There are no additional notes associated with this service or procedure.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],105091.76,,"Fee schedule rate ($105,091.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,35719.96,105091.76,There are no additional notes associated with this service or procedure.
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],29378.97,,"Case rate ($16,787.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,753.10, add-ons for qualifying new technology services are included. If operating cost exceeds $50,624.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,845.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $13,757.43 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,808.15 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,085.60. The transfer capital threshold is the transfer adjustment factor * $1,085.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,16787.98,62990.26,All Other Inpatient
"ANTEPARTUM WITHOUT O.R. PROCEDURE,MAJOR",566,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],6941.22,,"Case rate ($6,941.22). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,6941.22,7288.28,There are no additional notes associated with this service or procedure.
Insj/Rplcmt Breast Implant Sep Day Mastectomy|BILATERAL PROCEDURE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-19342,APC,19342,CPT,0360,RC,,,50|XU,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],7650.49,,"APC Price ($7,650.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,7650.49,8033.01,OPPS APC
VENTRICULAR SHUNT PROCEDURES WITH MCC,031,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],84202.04,,"Fee schedule rate ($84,202.04). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16.6), with a minimum of zero.",,,,0,other,32287.20,88162.80,There are no additional notes associated with this service or procedure.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],21455.22,,"Fee schedule rate ($21,455.22). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,9097.60,21455.22,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,690,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],14625.55,,"Fee schedule rate ($14,625.55). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7426.94,15928.53,There are no additional notes associated with this service or procedure.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC,027,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],47412.86,,"Fee schedule rate ($47,412.86). Adds an outlier to normal pricing equal to the per diem rate ($103,062) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,19030.20,56363.30,There are no additional notes associated with this service or procedure.
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7957.73,,"Case rate ($7,578.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,196.51, add-ons for qualifying new technology services are included. If operating cost exceeds $42,067.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,162.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,231.73 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,251.56 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $402.12. The transfer capital threshold is the transfer adjustment factor * $402.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6711.00,16865.16,Inpatient DRG
FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,748,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],10498.90,,"Case rate ($10,293.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $9,679.84, add-ons for qualifying new technology services are included. If operating cost exceeds $48,324.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $3,378.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.4. The base transfer operating payment is the transfer adjustment factor * $8,283.19 + an uncompensated DSH payment of $1,359.91. The transfer operating threshold is the transfer adjustment factor * $8,319.93 + an uncompensated DSH payment of $1,359.91. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $649.94. The transfer capital threshold is the transfer adjustment factor * $649.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,9316.20,26805.98,Inpatient DRG
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],16833.60,,"Fee schedule rate ($16,833.60). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,13260.40,32878.30,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITH STERILIZATION WITH MCC,783,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],19221.04,,"Case rate ($18,571.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,411.86, add-ons for qualifying new technology services are included. If operating cost exceeds $52,282.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,975.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $15,410.10 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,466.92 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,216.01. The transfer capital threshold is the transfer adjustment factor * $1,216.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,12612.10,23722.94,Inpatient DRG
SALIVARY GLAND PROCEDURES,139,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],30690.92,,"Fee schedule rate ($30,690.92). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,10313.19,30690.92,There are no additional notes associated with this service or procedure.
"Open Tx Phalangeal Shaft Fracture Prox/Middle Ea|RIGHT HAND, SECOND DIGIT",CASE-26735,APC,26735,CPT,0360,RC,,,F6,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3062.67,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],29367.82,,"Fee schedule rate ($29,367.82). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.7), with a minimum of zero.",,,,0,other,12527.66,29917.96,There are no additional notes associated with this service or procedure.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],5683.00,,"Per diem ($5,683). If length of stay < 3.3, first 1 days paid at a per diem of $11,366 instead. Capped at $18,753.53.",,,,0,other,5683.00,19635.68,Estimated amount calculated based on 3 day length of stay.
Tonsillectomy Primary/Secondary Age 12/>,CASE-42826,APC,42826,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3258.52,,"APC Price ($3,103.35). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.35,3258.52,OPPS APC
HC Drain/Inj Joint/Bursa W/US Large|LEFT SIDE,CASE-20611,APC,20611,CPT,0510,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],301.68,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,287.31,301.68,OPPS APC
Biopsy Vaginal Mucosa Simple|UNUSUAL NON-OVERLAPPING SERVICE,CASE-57100,APC,57100,CPT,0360,RC,,,XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5941.70,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5658.76,5941.70,OPPS APC
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],10704.29,,,,,,0,other,5628.97,12272.58,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],12184.87,,"Case rate ($11,945.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,248.66, add-ons for qualifying new technology services are included. If operating cost exceeds $46,119.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,491.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $9,269.54 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,303.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $731.46. The transfer capital threshold is the transfer adjustment factor * $731.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6167.00,29058.99,Inpatient DRG
HC Inj Trigger Pt 1-2 Musc Grps|ADJ,CASE-20552,APC,20552,CPT,0510,RC,,,ADJ,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],287.31,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],51630.84,,"Fee schedule rate ($51,630.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,20559.34,54086.17,There are no additional notes associated with this service or procedure.
VENTRICULAR SHUNT PROCEDURES WITH CC,032,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],40047.88,,"Fee schedule rate ($40,047.88). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,16376.22,46275.08,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],43399.23,,"Fee schedule rate ($43,399.23). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9888.00,43399.23,There are no additional notes associated with this service or procedure.
CERVICAL SPINAL FUSION WITH CC,472,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],21896.13,,"Case rate ($21,896.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,505.12, add-ons for qualifying new technology services are included. If operating cost exceeds $55,376.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,219.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $18,491.99 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,560.18 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,459.20. The transfer capital threshold is the transfer adjustment factor * $1,459.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,21896.13,70198.84,Inpatient DRG
"CESAREAN SECTION WITH STERILIZATION,MODERATE",539,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],7813.94,,"Case rate ($7,813.94). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,7813.94,8204.64,There are no additional notes associated with this service or procedure.
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],9746.59,,"Case rate ($9,282.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,770.90, add-ons for qualifying new technology services are included. If operating cost exceeds $43,641.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,296.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,800.88 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,825.96 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $536.66. The transfer capital threshold is the transfer adjustment factor * $536.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9282.47,21320.03,Inpatient DRG
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],62084.69,,"Fee schedule rate ($62,084.69). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (35), with a minimum of zero.",,,,0,other,30398.48,82674.88,There are no additional notes associated with this service or procedure.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],16829.13,,"Fee schedule rate ($16,829.13). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,8009.34,19877.10,There are no additional notes associated with this service or procedure.
Cysto W/Urtroscopy&/Pyeloscopy Dx|UNUSUAL NON-OVERLAPPING SERVICE|LEFT SIDE,CASE-52351,APC,52351,CPT,0360,RC,,,XU|LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3299.47,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3299.47,3464.44,OPPS APC
POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES,769,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],29791.03,,"Fee schedule rate ($29,791.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,13388.39,33250.19,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,689,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],11918.14,,"Fee schedule rate ($11,918.14). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,9802.58,22831.22,There are no additional notes associated with this service or procedure.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],105091.76,,"Fee schedule rate ($105,091.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,35719.96,105091.76,There are no additional notes associated with this service or procedure.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],29837.65,,"Fee schedule rate ($29,837.65). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,12696.97,47123.82,There are no additional notes associated with this service or procedure.
RADIOTHERAPY,849,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],50919.63,,"Fee schedule rate ($50,919.63). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15.8), with a minimum of zero.",,,,0,other,20293.88,81867.07,There are no additional notes associated with this service or procedure.
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],61234.06,,"Fee schedule rate ($61,234.06). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11165.00,61234.06,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,093,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],7704.43,,"Case rate ($7,337.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,961.57, add-ons for qualifying new technology services are included. If operating cost exceeds $41,832.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,154.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,998.19 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,016.62 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $394.41. The transfer capital threshold is the transfer adjustment factor * $394.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,19011.32,Inpatient DRG
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],53409.30,,"Fee schedule rate ($53,409.30). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,23377.19,96365.69,There are no additional notes associated with this service or procedure.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],28128.94,,"Fee schedule rate ($28,128.94). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,23344.70,62179.32,There are no additional notes associated with this service or procedure.
HC Gastroesophag Reflx Test W/Tel Ph Eltrd,CASE-91035,APC,91035,CPT,0750,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],803.80,,"APC Price ($803.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,803.80,843.99,OPPS APC
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC,964,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],34154.06,,"Fee schedule rate ($34,154.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12323.82,34154.06,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],13783.20,,"Case rate ($13,783.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,957.83, add-ons for qualifying new technology services are included. If operating cost exceeds $47,828.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,625.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $10,972.42 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,012.88 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $865.83. The transfer capital threshold is the transfer adjustment factor * $865.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,13783.20,41580.51,Inpatient DRG
Dstr Nrolytc Agnt Parverteb Fct Sngl Lmbr/Sacral|RIGHT SIDE,CASE-64635,APC,64635,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1827.80,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1827.80,1919.19,OPPS APC
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],21892.85,,"Fee schedule rate ($21,892.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7569.84,21892.85,There are no additional notes associated with this service or procedure.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],28782.85,,"Case rate ($16,447.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,436.22, add-ons for qualifying new technology services are included. If operating cost exceeds $50,307.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,820.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $13,441.70 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,491.27 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,060.68. The transfer capital threshold is the transfer adjustment factor * $1,060.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,7453.00,42138.30,All Other Inpatient
Dstr Nrolytc Agnt Parverteb Fct Addl Crvcl/Thora|LEFT SIDE,CASE-64634,APC,64634,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1827.80,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1827.80,1919.19,OPPS APC
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],24675.88,,"Fee schedule rate ($24,675.88). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10834.64,25830.00,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITH CC,386,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],8727.66,,"Case rate ($8,556.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,095.56, add-ons for qualifying new technology services are included. If operating cost exceeds $42,966.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,243.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,128.01 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,150.61 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $483.56. The transfer capital threshold is the transfer adjustment factor * $483.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,8556.53,19879.00,Inpatient DRG
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],26746.83,,"Case rate ($15,283.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,353.89, add-ons for qualifying new technology services are included. If operating cost exceeds $49,224.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,735.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.2. The base transfer operating payment is the transfer adjustment factor * $12,363.36 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,408.94 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $975.59. The transfer capital threshold is the transfer adjustment factor * $975.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,15283.90,38757.79,All Other Inpatient
Cysto/Pyeloscopy Bx&/Fulguration Pelivc Lesion|LEFT SIDE,CASE-52354,APC,52354,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5269.71,,"APC Price ($5,018.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5018.77,5269.71,OPPS APC
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],9755.86,,"Case rate ($9,755.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,211.27, add-ons for qualifying new technology services are included. If operating cost exceeds $44,082.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,331.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $7,239.63 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,266.32 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $571.28. The transfer capital threshold is the transfer adjustment factor * $571.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9755.86,29216.99,Inpatient DRG
APPENDIX PROCEDURES WITH MCC,397,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],18163.37,,"Case rate ($18,163.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,032.61, add-ons for qualifying new technology services are included. If operating cost exceeds $51,903.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,946.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $15,032.24 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,087.66 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,186.19. The transfer capital threshold is the transfer adjustment factor * $1,186.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,18163.37,51558.84,Inpatient DRG
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],25667.48,,"Fee schedule rate ($25,667.48). Adds an outlier to normal pricing equal to the per diem rate ($77,296.48) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,11194.25,36094.03,There are no additional notes associated with this service or procedure.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],45521.20,,"Case rate ($45,521.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $42,483.01, add-ons for qualifying new technology services are included. If operating cost exceeds $77,354.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,947.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 12.5. The base transfer operating payment is the transfer adjustment factor * $40,389.14 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $40,538.06 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,187.10. The transfer capital threshold is the transfer adjustment factor * $3,187.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,45521.20,142438.06,Inpatient DRG
Inject Rx Other Periph Nerve|LEFT SIDE,CASE-64640,APC,64640,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],856.86,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,827.89,869.28,OPPS APC
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],8135.12,,"Case rate ($7,747.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,353.98, add-ons for qualifying new technology services are included. If operating cost exceeds $42,224.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,174.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $5,388.60 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,409.03 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $414.18. The transfer capital threshold is the transfer adjustment factor * $414.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,1188.00,17370.86,Inpatient DRG
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],10300.89,,"Case rate ($9,810.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,276.67, add-ons for qualifying new technology services are included. If operating cost exceeds $44,147.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,321.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,304.03 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,331.72 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $561.40. The transfer capital threshold is the transfer adjustment factor * $561.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10048.39,23545.50,Inpatient DRG
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],7923.33,,"Case rate ($7,923.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,506.51, add-ons for qualifying new technology services are included. If operating cost exceeds $42,377.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,197.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $5,541.13 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,561.56 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $437.25. The transfer capital threshold is the transfer adjustment factor * $437.25. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,1188.00,17370.86,Inpatient DRG
CHEST PAIN,313,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],15377.66,,"Fee schedule rate ($15,377.66). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,6820.84,15377.66,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITHOUT CC/MCC,517,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],28052.31,,"Fee schedule rate ($28,052.31). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,10207.96,29371.86,There are no additional notes associated with this service or procedure.
Repair Intermediate S/a/T/E >30.0 Cm|SEPARATE STRUCTURE,CASE-12037,APC,12037,CPT,0360,RC,,,XS,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1623.23,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1545.93,1623.23,OPPS APC
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],86437.13,,,,,,0,other,10862.00,86437.13,There are no additional notes associated with this service or procedure.
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC,058,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],13521.80,,"Case rate ($13,521.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,714.66, add-ons for qualifying new technology services are included. If operating cost exceeds $47,585.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,606.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $10,730.14 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,769.70 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $846.71. The transfer capital threshold is the transfer adjustment factor * $846.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,13521.80,40853.02,Inpatient DRG
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],23239.84,,"Fee schedule rate ($23,239.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8543.64,23239.84,There are no additional notes associated with this service or procedure.
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],8165.30,,"Fee schedule rate ($8,165.30). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4341.01,12882.53,There are no additional notes associated with this service or procedure.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,477,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],62359.39,,"Fee schedule rate ($62,359.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,25339.74,67976.16,There are no additional notes associated with this service or procedure.
CERVICAL SPINAL FUSION WITH CC,472,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],70198.84,,"Fee schedule rate ($70,198.84). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,21896.13,70198.84,There are no additional notes associated with this service or procedure.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],34327.48,,"Case rate ($32,692.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $30,606.43, add-ons for qualifying new technology services are included. If operating cost exceeds $65,477.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,954.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.4. The base transfer operating payment is the transfer adjustment factor * $28,553.22 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $28,661.48 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,194.67. The transfer capital threshold is the transfer adjustment factor * $2,194.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,33623.33,133270.57,Inpatient DRG
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],44847.62,,"Fee schedule rate ($44,847.62). Adds an outlier to normal pricing equal to the per diem rate ($79,031.36) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,18105.81,52699.33,There are no additional notes associated with this service or procedure.
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7039.95,,"Case rate ($6,801.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,463.25, add-ons for qualifying new technology services are included. If operating cost exceeds $41,334.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,115.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,501.70 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,518.30 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $355.23. The transfer capital threshold is the transfer adjustment factor * $355.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6801.88,22557.82,Inpatient DRG
SALIVARY GLAND PROCEDURES,139,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],10828.85,,"Case rate ($10,313.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,729.75, add-ons for qualifying new technology services are included. If operating cost exceeds $44,600.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,372.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $7,756.21 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,784.80 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $612.04. The transfer capital threshold is the transfer adjustment factor * $612.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10313.19,30690.92,Inpatient DRG
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],21667.25,,"Case rate ($21,667.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,292.19, add-ons for qualifying new technology services are included. If operating cost exceeds $55,163.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,202.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $18,279.84 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,347.24 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,442.46. The transfer capital threshold is the transfer adjustment factor * $1,442.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8972.00,81524.17,Inpatient DRG
Dstr Nrolytc Agnt Parverteb Fct Sngl Crvcl/Thora,CASE-64633,APC,64633,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1919.19,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1827.80,1919.19,OPPS APC
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],27041.80,,"Case rate ($26,127.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $24,441.31, add-ons for qualifying new technology services are included. If operating cost exceeds $59,312.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,528.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. The base transfer operating payment is the transfer adjustment factor * $22,413.72 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $22,496.36 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,768.66. The transfer capital threshold is the transfer adjustment factor * $1,768.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,26127.34,90333.60,Inpatient DRG
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH CC,026,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],63202.45,,"Fee schedule rate ($63,202.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,23000.66,63202.45,There are no additional notes associated with this service or procedure.
SEIZURES WITH MCC,100,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],32323.98,,"Fee schedule rate ($32,323.98). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,15061.09,38110.41,There are no additional notes associated with this service or procedure.
APPENDIX PROCEDURES WITH MCC,397,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],45007.36,,"Fee schedule rate ($45,007.36). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.5), with a minimum of zero.",,,,0,other,18163.37,51558.84,There are no additional notes associated with this service or procedure.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH CC,026,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],58431.20,,"Fee schedule rate ($58,431.20). Adds an outlier to normal pricing equal to the per diem rate ($112,420.62) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,23000.66,63202.45,There are no additional notes associated with this service or procedure.
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],21089.59,,"Fee schedule rate ($21,089.59). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,6965.00,21089.59,There are no additional notes associated with this service or procedure.
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],18067.42,,,,,,0,other,8163.06,18067.42,There are no additional notes associated with this service or procedure.
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],20362.22,,"Fee schedule rate ($20,362.22). Adds an outlier to normal pricing equal to the per diem rate ($66,744.74) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.8), with a minimum of zero.",,,,0,other,9282.47,21320.03,There are no additional notes associated with this service or procedure.
Esophagogastroduodenoscopy Submucosal Injection|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-43236,APC,43236,CPT,0360,RC,,,74,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],848.96,,"APC Price ($848.96). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,848.96,891.41,OPPS APC
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],19371.27,,"Fee schedule rate ($19,371.27). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7641.61,19371.27,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITH CC,386,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],19879.00,,"Fee schedule rate ($19,879.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8556.53,19879.00,There are no additional notes associated with this service or procedure.
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],22217.08,,"Fee schedule rate ($22,217.08). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.4), with a minimum of zero.",,,,0,other,7243.75,23262.15,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],18905.23,,"Fee schedule rate ($18,905.23). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6963.00,18954.85,There are no additional notes associated with this service or procedure.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,191,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],16612.88,,"Fee schedule rate ($16,612.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6965.00,16612.88,There are no additional notes associated with this service or procedure.
CERVICAL SPINAL FUSION WITH CC,472,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],21896.13,,"Case rate ($21,896.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,505.12, add-ons for qualifying new technology services are included. If operating cost exceeds $55,376.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,219.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $18,491.99 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,560.18 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,459.20. The transfer capital threshold is the transfer adjustment factor * $1,459.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,21896.13,70198.84,Inpatient DRG
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],18918.49,,"Fee schedule rate ($18,918.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9282.47,21320.03,There are no additional notes associated with this service or procedure.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],45933.85,,"Fee schedule rate ($45,933.85). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,18497.24,62041.12,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],59021.28,,"Fee schedule rate ($59,021.28). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,23851.92,63653.13,There are no additional notes associated with this service or procedure.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,761,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],6098.83,,"Case rate ($5,808.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,539.05, add-ons for qualifying new technology services are included. If operating cost exceeds $40,410.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,042.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $3,580.90 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,594.10 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $282.57. The transfer capital threshold is the transfer adjustment factor * $282.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5808.41,11946.72,Inpatient DRG
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],16265.67,,"Case rate ($15,491.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,546.67, add-ons for qualifying new technology services are included. If operating cost exceeds $49,417.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,750.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $12,555.42 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,601.72 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $990.75. The transfer capital threshold is the transfer adjustment factor * $990.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,15491.11,54180.83,Inpatient DRG
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITHOUT CC/MCC,428,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],40017.53,,"Case rate ($40,017.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $37,363.07, add-ons for qualifying new technology services are included. If operating cost exceeds $72,234.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,544.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $35,288.01 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $35,418.12 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,784.57. The transfer capital threshold is the transfer adjustment factor * $2,784.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,40017.53,118904.57,Inpatient DRG
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],7183.92,,"Case rate ($6,841.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,500.42, add-ons for qualifying new technology services are included. If operating cost exceeds $41,371.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,118.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $4,538.73 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,555.47 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $358.15. The transfer capital threshold is the transfer adjustment factor * $358.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6841.83,21167.26,Inpatient DRG
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],9840.60,,"Fee schedule rate ($9,840.60). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7847.50,17755.26,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC,087,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],22679.07,,"Fee schedule rate ($22,679.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,8139.36,22679.07,There are no additional notes associated with this service or procedure.
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],17150.47,,,,,,0,other,7847.50,17755.26,There are no additional notes associated with this service or procedure.
"FOOT AND TOE PROCEDURES,MINOR",314,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],10264.37,,"Case rate ($10,264.37). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,10264.37,10777.59,There are no additional notes associated with this service or procedure.
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],48961.48,,"Fee schedule rate ($48,961.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11575.50,48961.48,There are no additional notes associated with this service or procedure.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],40108.48,,"Fee schedule rate ($40,108.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,5569.00,40108.48,There are no additional notes associated with this service or procedure.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],28649.93,,"Fee schedule rate ($28,649.93). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,12268.97,41006.47,There are no additional notes associated with this service or procedure.
Optx Dstl Radl I-Artic Fx/Epiphysl Sep 2 Frag|LEFT SIDE,CASE-25608,APC,25608,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7029.71,OPPS APC
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],14679.40,,"Case rate ($13,980.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,163.72, add-ons for qualifying new technology services are included. If operating cost exceeds $48,034.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,619.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $11,176.40 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,218.77 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $859.04. The transfer capital threshold is the transfer adjustment factor * $859.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,14344.60,36028.59,Inpatient DRG
Colorectal Scrn; Hi Risk Ind|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-G0105,APC,G0105,CPT,0360,RC,,,74,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],913.99,,"APC Price ($870.46). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,870.46,913.99,OPPS APC
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,095,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],48470.91,,"Fee schedule rate ($48,470.91). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.8), with a minimum of zero.",,,,0,other,19411.47,50750.92,There are no additional notes associated with this service or procedure.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],15099.70,,"Case rate ($15,099.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,182.53, add-ons for qualifying new technology services are included. If operating cost exceeds $49,053.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,722.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $12,192.63 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,237.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $962.12. The transfer capital threshold is the transfer adjustment factor * $962.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7605.00,39153.65,Inpatient DRG
"HEAD TRAUMA WITH COMA > 1 HOUR OR HEMORRHAGE,MODERATE",055,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],9649.41,,"Case rate ($9,189.91). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9649.41,9649.41,There are no additional notes associated with this service or procedure.
"SPINAL FUSION AND OTHER BACK AND NECK PROCEDURES EXCEPT FOR DISC PROCEDURES,MODERATE",321,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],23286.14,,"Case rate ($23,286.14). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,23286.14,24450.45,There are no additional notes associated with this service or procedure.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],14329.44,,"Case rate ($13,647.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,831.20, add-ons for qualifying new technology services are included. If operating cost exceeds $47,702.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,615.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $10,846.26 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,886.25 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $855.88. The transfer capital threshold is the transfer adjustment factor * $855.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7921.00,45706.73,Inpatient DRG
Thyroidectomy Total/Subtotal Lmtd Neck Dissect,CASE-60252,APC,60252,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5735.04,,"APC Price ($5,541.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5541.10,5818.16,OPPS APC
HC Inj Trigger Pt 1-2 Musc Grps|PBB CHARGE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-20552,APC,20552,CPT,0510,RC,,,PBB|XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],301.68,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,287.31,301.68,OPPS APC
Neuroplasty &/Transpos Median Nrv Carpal Tunne|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64721,APC,64721,CPT,0360,RC,,,RT|XU,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1827.80,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1827.80,1919.19,OPPS APC
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],90333.60,,"Fee schedule rate ($90,333.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,26127.34,90333.60,There are no additional notes associated with this service or procedure.
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level|LEFT SIDE,CASE-64483,APC,64483,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],856.86,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,827.89,869.28,OPPS APC
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7398.11,,"Case rate ($7,147.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,785.17, add-ons for qualifying new technology services are included. If operating cost exceeds $41,656.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,140.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $4,822.44 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,840.22 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $380.54. The transfer capital threshold is the transfer adjustment factor * $380.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6965.00,16400.70,Inpatient DRG
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC,797,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],8946.77,,"Case rate ($8,520.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,074.53, add-ons for qualifying new technology services are included. If operating cost exceeds $42,945.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,229.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $6,106.43 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,129.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $469.35. The transfer capital threshold is the transfer adjustment factor * $469.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8719.72,20928.55,Inpatient DRG
RADIOTHERAPY,849,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],50919.63,,"Fee schedule rate ($50,919.63). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15.8), with a minimum of zero.",,,,0,other,20293.88,81867.07,There are no additional notes associated with this service or procedure.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],39820.52,,"Fee schedule rate ($39,820.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,15273.74,39820.52,There are no additional notes associated with this service or procedure.
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITH MCC,429,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],98263.20,,"Fee schedule rate ($98,263.20). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,62958.58,177294.98,There are no additional notes associated with this service or procedure.
Arthroplasty Patella W/O Prosthesis|BILATERAL PROCEDURE,CASE-27437,APC,27437,CPT,0360,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7029.71,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6791.99,7131.59,OPPS APC
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],26420.44,,"Case rate ($25,162.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $23,543.58, add-ons for qualifying new technology services are included. If operating cost exceeds $58,414.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,458.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $21,519.28 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $21,598.63 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,698.08. The transfer capital threshold is the transfer adjustment factor * $1,698.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,25162.32,75579.22,Inpatient DRG
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],45050.58,,"Fee schedule rate ($45,050.58). Adds an outlier to normal pricing equal to the per diem rate ($120,238.99) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,18178.96,54764.34,There are no additional notes associated with this service or procedure.
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,095,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],48470.91,,"Fee schedule rate ($48,470.91). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.8), with a minimum of zero.",,,,0,other,19411.47,50750.92,There are no additional notes associated with this service or procedure.
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",759,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],6760.85,,"Case rate ($6,438.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,125.57, add-ons for qualifying new technology services are included. If operating cost exceeds $40,996.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,088.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,165.27 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,180.62 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $328.68. The transfer capital threshold is the transfer adjustment factor * $328.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6190.22,13057.66,Inpatient DRG
COMPLICATIONS OF TREATMENT WITH CC,920,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],20731.52,,"Fee schedule rate ($20,731.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8732.59,20731.52,There are no additional notes associated with this service or procedure.
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,451,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],24297.87,,"Case rate ($23,821.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $22,296.19, add-ons for qualifying new technology services are included. If operating cost exceeds $57,167.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,359.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $20,276.48 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $20,351.24 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,600.01. The transfer capital threshold is the transfer adjustment factor * $1,600.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,23821.44,94077.13,Inpatient DRG
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],45050.58,,"Fee schedule rate ($45,050.58). Adds an outlier to normal pricing equal to the per diem rate ($120,238.99) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,18178.96,54764.34,There are no additional notes associated with this service or procedure.
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],40666.46,,,,,,0,other,15940.79,53275.26,There are no additional notes associated with this service or procedure.
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC,964,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],34154.06,,"Fee schedule rate ($34,154.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12323.82,34154.06,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],33321.87,,"Fee schedule rate ($33,321.87). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.9), with a minimum of zero.",,,,0,other,13917.42,34889.29,There are no additional notes associated with this service or procedure.
COAGULATION DISORDERS,813,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],29046.49,,"Fee schedule rate ($29,046.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12274.39,30013.33,There are no additional notes associated with this service or procedure.
Egd Transoral Control Bleeding Any Method|UNUSUAL NON-OVERLAPPING SERVICE,CASE-43255,APC,43255,CPT,0360,RC,,,XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1885.95,,"APC Price ($1,796.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1796.14,1885.95,OPPS APC
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],20553.44,,"Fee schedule rate ($20,553.44). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8874.81,20553.44,There are no additional notes associated with this service or procedure.
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],14674.80,,"Fee schedule rate ($14,674.80). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6711.00,16865.16,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],17686.09,,"Fee schedule rate ($17,686.09). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8318.14,19763.43,There are no additional notes associated with this service or procedure.
COMPLICATIONS OF TREATMENT WITH CC,920,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],20731.52,,"Fee schedule rate ($20,731.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8732.59,20731.52,There are no additional notes associated with this service or procedure.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],12514.35,,"Case rate ($12,268.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,549.17, add-ons for qualifying new technology services are included. If operating cost exceeds $46,420.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,515.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,568.94 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,604.22 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $755.08. The transfer capital threshold is the transfer adjustment factor * $755.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,12268.97,41006.47,Inpatient DRG
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],81524.17,,"Fee schedule rate ($81,524.17). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,8972.00,81524.17,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,093,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],6965.00,,,,,,0,other,6965.00,19011.32,There are no additional notes associated with this service or procedure.
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,450,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],38798.13,,"Case rate ($38,037.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $35,520.98, add-ons for qualifying new technology services are included. If operating cost exceeds $70,391.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,399.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $33,452.68 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $33,576.02 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,639.75. The transfer capital threshold is the transfer adjustment factor * $2,639.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,38037.38,146009.19,Inpatient DRG
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],101083.00,,"Fee schedule rate ($101,083.00). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,35389.50,101083.00,There are no additional notes associated with this service or procedure.
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],11247.07,,"Case rate ($11,247.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,598.51, add-ons for qualifying new technology services are included. If operating cost exceeds $45,469.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,440.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,621.77 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,653.56 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $680.34. The transfer capital threshold is the transfer adjustment factor * $680.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,11247.07,27028.33,Inpatient DRG
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],41493.06,,"Fee schedule rate ($41,493.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,16897.01,43444.85,There are no additional notes associated with this service or procedure.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,057,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],10718.84,,"Case rate ($10,718.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,107.12, add-ons for qualifying new technology services are included. If operating cost exceeds $44,978.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,401.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,132.18 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,162.17 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $641.71. The transfer capital threshold is the transfer adjustment factor * $641.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10718.84,39884.93,Inpatient DRG
DIABETES WITHOUT CC/MCC,639,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],11899.36,,"Fee schedule rate ($11,899.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6151.76,12223.35,There are no additional notes associated with this service or procedure.
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],28394.78,,"Fee schedule rate ($28,394.78). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11454.97,28394.78,There are no additional notes associated with this service or procedure.
"Tendon Sheath Incision|RIGHT HAND, FIFTH DIGIT",CASE-26055,APC,26055,CPT,0360,RC,,,F9,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1557.80,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1505.12,1580.37,OPPS APC
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],8764.88,,"Case rate ($8,468.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,013.65, add-ons for qualifying new technology services are included. If operating cost exceeds $42,884.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,237.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,046.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,068.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $477.12. The transfer capital threshold is the transfer adjustment factor * $477.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6963.00,18954.85,Inpatient DRG
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],45845.03,,"Fee schedule rate ($45,845.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,18598.83,48389.68,There are no additional notes associated with this service or procedure.
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],22363.67,,"Fee schedule rate ($22,363.67). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10003.71,23415.63,There are no additional notes associated with this service or procedure.
HC External Version,CASE-59412,APC,59412,CPT,0720,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3030.03,,"APC Price ($3,030.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3030.03,3181.53,OPPS APC
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],23899.13,,"Fee schedule rate ($23,899.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9795.13,23899.13,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC,817,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],18265.92,,"Case rate ($17,396.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,318.84, add-ons for qualifying new technology services are included. If operating cost exceeds $51,189.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,890.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $14,321.08 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,373.88 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,130.07. The transfer capital threshold is the transfer adjustment factor * $1,130.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,17396.11,44895.04,Inpatient DRG
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH CC,427,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],134742.59,,"Fee schedule rate ($134,742.59). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,50829.82,142040.39,There are no additional notes associated with this service or procedure.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],38517.10,,"Fee schedule rate ($38,517.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,16897.01,43444.85,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],6965.00,,,,,,0,other,6340.03,15076.44,There are no additional notes associated with this service or procedure.
Grafting of Autologous Fat by Lipo 50 Cc or Less,CASE-15771,APC,15771,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3664.94,,"APC Price ($3,664.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3664.94,3664.94,OPPS APC
MINOR BLADDER PROCEDURES WITHOUT CC/MCC,664,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],31876.87,,"Fee schedule rate ($31,876.87). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9034.63,31876.87,There are no additional notes associated with this service or procedure.
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral Ea Addl|RIGHT SIDE,CASE-64484,APC,64484,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],827.89,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,827.89,869.28,OPPS APC
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,690,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],15928.53,,,,,,0,other,7426.94,15928.53,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],31533.97,,"Fee schedule rate ($31,533.97). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8563.30,31533.97,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC,087,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],8139.36,,"Case rate ($8,139.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,707.48, add-ons for qualifying new technology services are included. If operating cost exceeds $42,578.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,213.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $5,741.36 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,762.53 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $453.05. The transfer capital threshold is the transfer adjustment factor * $453.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8139.36,22679.07,Inpatient DRG
Insj/Rplcmt Spinal Npg/Rcvr Pocket Crtj&Connj,CASE-63685,APC,63685,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],29894.47,,"APC Price ($28,883.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,28883.55,30327.72,OPPS APC
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],42083.20,,,,,,0,other,16428.39,42083.20,There are no additional notes associated with this service or procedure.
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC,805,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],21235.42,,,,,,0,other,9253.36,21235.42,There are no additional notes associated with this service or procedure.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],10603.44,,"Case rate ($10,098.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,530.04, add-ons for qualifying new technology services are included. If operating cost exceeds $44,401.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,356.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $7,557.23 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,585.10 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $596.34. The transfer capital threshold is the transfer adjustment factor * $596.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10098.51,24259.09,Inpatient DRG
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],21248.73,,"Case rate ($21,248.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $19,902.85, add-ons for qualifying new technology services are included. If operating cost exceeds $54,773.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,171.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.3. The base transfer operating payment is the transfer adjustment factor * $17,891.94 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $17,957.90 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,411.85. The transfer capital threshold is the transfer adjustment factor * $1,411.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,21248.73,56089.29,Inpatient DRG
HC Incis/Drain Scrotum/Testis Epididym,CASE-54700,APC,54700,CPT,0450,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1956.65,,"APC Price ($1,956.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1956.65,2054.48,OPPS APC
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],10476.89,,"Case rate ($9,977.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,417.91, add-ons for qualifying new technology services are included. If operating cost exceeds $44,288.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,347.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $7,445.51 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,472.96 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $587.52. The transfer capital threshold is the transfer adjustment factor * $587.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9977.99,26949.28,Inpatient DRG
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],29114.99,,"Fee schedule rate ($29,114.99). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,18178.96,54764.34,There are no additional notes associated with this service or procedure.
SINGLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL,402,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],79111.38,,,,,,0,other,29172.05,124455.45,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,394,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],14492.73,,"Case rate ($8,281.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,839.77, add-ons for qualifying new technology services are included. If operating cost exceeds $42,710.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,223.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,873.17 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,894.83 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $463.45. The transfer capital threshold is the transfer adjustment factor * $463.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,8281.56,20909.61,All Other Inpatient
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],18223.96,,"Case rate ($17,356.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,281.67, add-ons for qualifying new technology services are included. If operating cost exceeds $51,152.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,887.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $14,284.05 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,336.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,127.15. The transfer capital threshold is the transfer adjustment factor * $1,127.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,17356.15,44778.95,Inpatient DRG
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC,833,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5651.16,,"Case rate ($5,382.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,148.83, add-ons for qualifying new technology services are included. If operating cost exceeds $40,019.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,005.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $3,191.77 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,203.88 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $245.33. The transfer capital threshold is the transfer adjustment factor * $245.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,3041.73,10289.10,Inpatient DRG
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC,497,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],17723.39,,"Case rate ($10,127.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,557.14, add-ons for qualifying new technology services are included. If operating cost exceeds $44,428.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,358.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 1.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $7,584.22 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,612.19 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $598.47. The transfer capital threshold is the transfer adjustment factor * $598.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,10127.65,37761.19,All Other Inpatient
MAJOR CHEST TRAUMA WITHOUT CC/MCC,185,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],21771.61,,"Fee schedule rate ($21,771.61). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7271.19,21771.61,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],52449.26,,"Fee schedule rate ($52,449.26). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,17693.40,52449.26,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITH STERILIZATION WITH CC,784,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],9124.01,,"Case rate ($9,124.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,623.49, add-ons for qualifying new technology services are included. If operating cost exceeds $43,494.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,285.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,654.00 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,678.54 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $525.07. The transfer capital threshold is the transfer adjustment factor * $525.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9124.01,23722.94,Inpatient DRG
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],11811.40,,"Fee schedule rate ($11,811.40). Adds an outlier to normal pricing equal to the per diem rate ($53,248.69) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.7), with a minimum of zero.",,,,0,other,5937.41,12366.99,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITH STERILIZATION WITH MCC,783,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],23722.94,,"Fee schedule rate ($23,722.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12612.10,23722.94,There are no additional notes associated with this service or procedure.
Cysto Calibration Dilat Urtl Strix/Stenosis,CASE-52281,APC,52281,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],2025.13,,"APC Price ($1,956.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1956.65,2054.48,OPPS APC
VENTRICULAR SHUNT PROCEDURES WITH CC,032,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],46275.08,,"Fee schedule rate ($46,275.08). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,16376.22,46275.08,There are no additional notes associated with this service or procedure.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITHOUT CC/MCC,816,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],14733.53,,"Fee schedule rate ($14,733.53). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6224.90,14733.53,There are no additional notes associated with this service or procedure.
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],10400.08,,"Case rate ($10,048.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,483.42, add-ons for qualifying new technology services are included. If operating cost exceeds $44,354.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,352.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,510.78 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,538.48 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $592.68. The transfer capital threshold is the transfer adjustment factor * $592.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,10048.39,23545.50,Inpatient DRG
RADIOTHERAPY,849,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],21308.57,,"Case rate ($20,293.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $19,014.57, add-ons for qualifying new technology services are included. If operating cost exceeds $53,885.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,101.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $17,006.91 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $17,069.62 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,342.01. The transfer capital threshold is the transfer adjustment factor * $1,342.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,20293.88,81867.07,Inpatient DRG
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,056,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],7659.00,,"Per diem ($7,659). If length of stay < 5.7, first 1 days paid at a per diem of $15,318 instead. Capped at $43,658.02.",,,,0,other,7659.00,59328.19,Estimated amount calculated based on 3 day length of stay.
CHEST PAIN,313,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],6965.00,,,,,,0,other,6820.84,15377.66,There are no additional notes associated with this service or procedure.
OTHER CEREBROVASCULAR DISORDERS WITH MCC,070,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],31286.59,,"Fee schedule rate ($31,286.59). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13219.09,37774.46,There are no additional notes associated with this service or procedure.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],36094.03,,"Fee schedule rate ($36,094.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11194.25,36094.03,There are no additional notes associated with this service or procedure.
NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,601,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],11369.77,,"Fee schedule rate ($11,369.77). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,6042.05,12359.72,There are no additional notes associated with this service or procedure.
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],21918.93,,"Case rate ($21,489.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,126.50, add-ons for qualifying new technology services are included. If operating cost exceeds $54,997.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,189.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.6. The base transfer operating payment is the transfer adjustment factor * $18,114.76 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,181.55 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,429.43. The transfer capital threshold is the transfer adjustment factor * $1,429.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,21489.15,68942.79,Inpatient DRG
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],13608.86,,"Case rate ($13,148.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,367.53, add-ons for qualifying new technology services are included. If operating cost exceeds $47,238.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,579.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $10,384.29 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,422.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $819.42. The transfer capital threshold is the transfer adjustment factor * $819.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,13148.66,32553.63,Inpatient DRG
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],29216.99,,"Fee schedule rate ($29,216.99). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9755.86,29216.99,There are no additional notes associated with this service or procedure.
Insertion Intrauterine Device Iud,CASE-58300,APC,58300,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3030.03,,"APC Price ($3,030.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3030.03,3136.08,OPPS APC
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],15626.34,,"Case rate ($14,882.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,004.37, add-ons for qualifying new technology services are included. If operating cost exceeds $48,875.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,683.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $12,013.86 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,059.42 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $923.41. The transfer capital threshold is the transfer adjustment factor * $923.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,15273.74,39820.52,Inpatient DRG
HC Inj Lympho for Sentinal Node|SEPARATE PRACTITIONER,CASE-38792,APC,38792,CPT,0361,RC,,,XP,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6215.36,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6215.36,6526.12,OPPS APC
VENTRICULAR SHUNT PROCEDURES WITH MCC,031,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],84202.04,,"Fee schedule rate ($84,202.04). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16.6), with a minimum of zero.",,,,0,other,32287.20,88162.80,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,091,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],33004.27,,"Fee schedule rate ($33,004.27). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13838.06,40030.81,There are no additional notes associated with this service or procedure.
Ercp W/Sphincterotomy/Papillotomy,CASE-43262,APC,43262,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3789.26,,"APC Price ($3,608.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3608.81,3789.26,OPPS APC
"VAGINAL DELIVERY,MINOR",560,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],3720.04,,"Case rate ($3,720.04). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,3720.04,3906.04,There are no additional notes associated with this service or procedure.
OSTEOMYELITIS WITH CC,540,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],18450.55,,"Fee schedule rate ($18,450.55). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,9809.07,25507.30,There are no additional notes associated with this service or procedure.
Dstr Nrolytc Agnt Parverteb Fct Addl Lmbr/Sacral|RIGHT SIDE,CASE-64636,APC,64636,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1919.19,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1827.80,1919.19,OPPS APC
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],25013.10,,"Fee schedule rate ($25,013.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10846.16,25863.45,There are no additional notes associated with this service or procedure.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],92811.11,,"Fee schedule rate ($92,811.11). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,35389.50,101083.00,There are no additional notes associated with this service or procedure.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,191,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7921.69,,"Case rate ($7,653.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,255.78, add-ons for qualifying new technology services are included. If operating cost exceeds $42,126.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,177.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,291.32 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,310.83 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $417.54. The transfer capital threshold is the transfer adjustment factor * $417.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6965.00,16612.88,Inpatient DRG
CESAREAN SECTION WITH STERILIZATION WITHOUT CC/MCC,785,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],19006.00,,,,,,0,other,8431.24,20142.33,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITH STERILIZATION WITH CC,784,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],9306.49,,"Case rate ($9,124.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,623.49, add-ons for qualifying new technology services are included. If operating cost exceeds $43,494.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,285.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,654.00 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,678.54 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $525.07. The transfer capital threshold is the transfer adjustment factor * $525.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,9124.01,23722.94,Inpatient DRG
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],56023.80,,"Fee schedule rate ($56,023.80). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,35389.50,101083.00,There are no additional notes associated with this service or procedure.
Hemorrhoid Ntrnl & Xtrnl 1 Column W/Fissurecto,CASE-46257,APC,46257,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],2727.99,,"APC Price ($2,598.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2598.08,2727.99,OPPS APC
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],8559.13,,"Case rate ($8,151.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,718.82, add-ons for qualifying new technology services are included. If operating cost exceeds $42,589.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,213.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,752.66 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,773.87 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $453.94. The transfer capital threshold is the transfer adjustment factor * $453.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8151.55,18033.97,Inpatient DRG
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],16498.03,,"Case rate ($15,712.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,778.22, add-ons for qualifying new technology services are included. If operating cost exceeds $49,649.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,742.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $12,784.80 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,833.27 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $982.67. The transfer capital threshold is the transfer adjustment factor * $982.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,16129.04,59610.47,Inpatient DRG
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,988,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],13729.30,,"Case rate ($13,075.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,299.49, add-ons for qualifying new technology services are included. If operating cost exceeds $47,170.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,574.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $10,316.50 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,354.54 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $814.07. The transfer capital threshold is the transfer adjustment factor * $814.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13075.52,42425.46,Inpatient DRG
HC Peripheral Block - Femoral Single or Saphenous W/Img Gdn|LEFT SIDE,CASE-64447,APC,64447,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],683.85,,"APC Price ($660.72). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,660.72,693.76,OPPS APC
Hrhc Ntrnl & Xtrnl 2/> Column/Group W/Fissu,CASE-46261,APC,46261,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],2727.99,,"APC Price ($2,598.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2598.08,2727.99,OPPS APC
Neuroplasty &/Transpos Median Nrv Carpal Tunne|RIGHT SIDE,CASE-64721,APC,64721,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1919.19,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1827.80,1919.19,OPPS APC
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],36776.05,,"Fee schedule rate ($36,776.05). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11053.39,36776.05,There are no additional notes associated with this service or procedure.
Post Colporrhaphy Rectocele W/WO Perineorrhaphy,CASE-57250,APC,57250,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],10447.27,,"APC Price ($9,949.78). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,9949.78,10447.27,OPPS APC
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],8874.81,,"Case rate ($8,874.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,391.65, add-ons for qualifying new technology services are included. If operating cost exceeds $43,262.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,266.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $6,423.02 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,446.70 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $506.84. The transfer capital threshold is the transfer adjustment factor * $506.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8874.81,20553.44,Inpatient DRG
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],35304.50,,"Case rate ($33,623.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $31,414.68, add-ons for qualifying new technology services are included. If operating cost exceeds $66,285.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,076.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.4. The base transfer operating payment is the transfer adjustment factor * $29,361.48 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $29,469.74 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,316.91. The transfer capital threshold is the transfer adjustment factor * $2,316.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,33623.33,133270.57,Inpatient DRG
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITH MCC,429,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],177294.98,,"Fee schedule rate ($177,294.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,62958.58,177294.98,There are no additional notes associated with this service or procedure.
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],21089.59,,"Fee schedule rate ($21,089.59). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,6965.00,21089.59,There are no additional notes associated with this service or procedure.
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],18594.09,,"Case rate ($18,594.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,433.29, add-ons for qualifying new technology services are included. If operating cost exceeds $52,304.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,977.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $15,431.44 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,488.34 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,217.69. The transfer capital threshold is the transfer adjustment factor * $1,217.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,18594.09,59494.91,Inpatient DRG
CERVICAL SPINAL FUSION WITH MCC,471,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],90745.76,,"Fee schedule rate ($90,745.76). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,34645.26,111337.93,There are no additional notes associated with this service or procedure.
Cystourethroscopy,CASE-52000,APC,52000,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],675.53,,"APC Price ($652.69). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,652.69,685.32,OPPS APC
Brnchsc Ebus Guided Sampl 3/> Node Station/Strux,CASE-31653,APC,31653,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6605.95,,"APC Price ($6,605.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6605.95,6936.25,OPPS APC
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],31040.85,,"Case rate ($29,562.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $27,688.70, add-ons for qualifying new technology services are included. If operating cost exceeds $62,559.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,731.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.2. The base transfer operating payment is the transfer adjustment factor * $25,646.51 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $25,743.75 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,971.25. The transfer capital threshold is the transfer adjustment factor * $1,971.25. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,30398.48,82674.88,Inpatient DRG
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],31528.46,,,,,,0,other,12795.84,41944.25,There are no additional notes associated with this service or procedure.
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC,520,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],39786.42,,"Fee schedule rate ($39,786.42). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12061.74,39786.42,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],32293.66,,"Fee schedule rate ($32,293.66). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,32293.66,There are no additional notes associated with this service or procedure.
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],62990.26,,"Fee schedule rate ($62,990.26). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,16787.98,62990.26,There are no additional notes associated with this service or procedure.
HC Inj Anes/Steroid C/D Facet Sg|BILATERAL PROCEDURE,CASE-64490,APC,64490,CPT,0361,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],856.86,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,827.89,869.28,OPPS APC
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],9075.36,,"Case rate ($8,643.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,176.19, add-ons for qualifying new technology services are included. If operating cost exceeds $43,047.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,249.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $6,208.35 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,231.24 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $489.90. The transfer capital threshold is the transfer adjustment factor * $489.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8643.20,19462.52,Inpatient DRG
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",062,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],13844.84,,"Case rate ($13,844.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,015.16, add-ons for qualifying new technology services are included. If operating cost exceeds $47,886.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,630.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $11,029.54 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,070.21 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $870.34. The transfer capital threshold is the transfer adjustment factor * $870.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,13844.84,44304.80,Inpatient DRG
Ercp W/Biopsy Single/Multiple,CASE-43261,APC,43261,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3608.81,,"APC Price ($3,608.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3608.81,3789.26,OPPS APC
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],41493.06,,"Fee schedule rate ($41,493.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,16897.01,43444.85,There are no additional notes associated with this service or procedure.
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,451,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],60708.91,,"Fee schedule rate ($60,708.91). Adds an outlier to normal pricing equal to the per diem rate ($108,215.07) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,23821.44,94077.13,There are no additional notes associated with this service or procedure.
PREMATURITY WITH MAJOR PROBLEMS,791,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],30904.42,,"Case rate ($29,432.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $27,516.30, add-ons for qualifying new technology services are included. If operating cost exceeds $62,387.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,770.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 13.3. The base transfer operating payment is the transfer adjustment factor * $25,477.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $25,571.35 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,010.42. The transfer capital threshold is the transfer adjustment factor * $2,010.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,3048.21,30904.42,Inpatient DRG
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],42787.31,,"Fee schedule rate ($42,787.31). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,15476.23,42787.31,There are no additional notes associated with this service or procedure.
"Open Tx Phalangeal Shaft Fracture Prox/Middle Ea|RIGHT HAND, FIFTH DIGIT",CASE-26735,APC,26735,CPT,0360,RC,,,F9,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
CESAREAN SECTION WITHOUT STERILIZATION WITH MCC,786,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],23722.94,,"Fee schedule rate ($23,722.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12612.10,23722.94,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],16017.99,,"Case rate ($16,017.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,036.80, add-ons for qualifying new technology services are included. If operating cost exceeds $49,907.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,789.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $13,043.76 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,091.85 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,029.28. The transfer capital threshold is the transfer adjustment factor * $1,029.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,16017.99,51903.64,Inpatient DRG
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],30063.84,,"Fee schedule rate ($30,063.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13891.57,34712.20,There are no additional notes associated with this service or procedure.
HC Remove Tun Cath Vad W/Port,CASE-36590,APC,36590,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1473.45,,"APC Price ($1,473.45). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1473.45,1547.12,OPPS APC
Laparoscopy Radical Nephrectomy,CASE-50545,APC,50545,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],352.29,,"APC Price ($335.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,352.29,352.29,OPPS APC
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],8734.05,,"Case rate ($8,318.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,873.80, add-ons for qualifying new technology services are included. If operating cost exceeds $42,744.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,226.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,907.07 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,928.85 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $466.13. The transfer capital threshold is the transfer adjustment factor * $466.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8318.14,19763.43,Inpatient DRG
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],68240.48,,"Fee schedule rate ($68,240.48). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,40542.37,128358.13,There are no additional notes associated with this service or procedure.
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],24126.45,,"Fee schedule rate ($24,126.45). Adds an outlier to normal pricing equal to the per diem rate ($62,306.11) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10638.94,25261.33,There are no additional notes associated with this service or procedure.
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],14674.80,,"Fee schedule rate ($14,674.80). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6711.00,16865.16,There are no additional notes associated with this service or procedure.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],16829.13,,"Fee schedule rate ($16,829.13). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,8009.34,19877.10,There are no additional notes associated with this service or procedure.
Colonoscopy W/Biopsy Single/Multiple|UNUSUAL NON-OVERLAPPING SERVICE,CASE-45380,APC,45380,CPT,0360,RC,,,XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1159.29,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1120.09,1176.09,OPPS APC
CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC,788,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],20142.33,,"Fee schedule rate ($20,142.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8438.02,20142.33,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,426,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],177294.98,,"Fee schedule rate ($177,294.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,76581.29,216864.15,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],94787.57,,"Fee schedule rate ($94,787.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,23526.87,94787.57,There are no additional notes associated with this service or procedure.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],31007.30,,"Fee schedule rate ($31,007.30). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,16120.25,41187.90,There are no additional notes associated with this service or procedure.
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],18217.52,,"Fee schedule rate ($18,217.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7414.07,18217.52,There are no additional notes associated with this service or procedure.
PREMATURITY WITH MAJOR PROBLEMS,791,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],30056.65,,"Case rate ($28,625.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $26,814.97, add-ons for qualifying new technology services are included. If operating cost exceeds $61,685.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,664.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 13.3. The base transfer operating payment is the transfer adjustment factor * $24,776.08 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $24,870.02 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,904.35. The transfer capital threshold is the transfer adjustment factor * $1,904.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,3048.21,30904.42,Inpatient DRG
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6944.10,,"Case rate ($6,944.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,595.55, add-ons for qualifying new technology services are included. If operating cost exceeds $41,466.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,125.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,633.51 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,650.60 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $365.63. The transfer capital threshold is the transfer adjustment factor * $365.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,5068.21,14525.56,Inpatient DRG
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,069,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],20333.68,,"Fee schedule rate ($20,333.68). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,20333.68,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],70242.60,,"Fee schedule rate ($70,242.60). Adds an outlier to normal pricing equal to the per diem rate ($137,416) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16.5), with a minimum of zero.",,,,0,other,27256.92,81353.66,There are no additional notes associated with this service or procedure.
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],8877.69,,"Case rate ($8,454.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,001.06, add-ons for qualifying new technology services are included. If operating cost exceeds $42,872.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,236.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,033.86 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,056.11 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $476.13. The transfer capital threshold is the transfer adjustment factor * $476.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6230.00,22762.43,Inpatient DRG
Cysto W/Removal of Tumors Small,CASE-52234,APC,52234,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3414.95,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3299.47,3464.44,OPPS APC
CESAREAN SECTION WITH STERILIZATION WITH MCC,783,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],23722.94,,"Fee schedule rate ($23,722.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12612.10,23722.94,There are no additional notes associated with this service or procedure.
"MAJOR STOMACH ESOPHAGEAL AND DUODENAL PROCEDURES,MINOR",220,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],15220.03,,"Case rate ($15,220.03). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,15220.03,15981.03,There are no additional notes associated with this service or procedure.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],6965.00,,,,,,0,other,5778.62,11681.49,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],6892.39,,"Case rate ($6,564.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,242.12, add-ons for qualifying new technology services are included. If operating cost exceeds $41,113.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,097.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $4,281.39 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,297.17 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $337.84. The transfer capital threshold is the transfer adjustment factor * $337.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6564.18,17651.07,Inpatient DRG
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],6965.00,,,,,,0,other,4341.01,12882.53,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],8734.05,,"Case rate ($8,318.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,873.80, add-ons for qualifying new technology services are included. If operating cost exceeds $42,744.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,226.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,907.07 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,928.85 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $466.13. The transfer capital threshold is the transfer adjustment factor * $466.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8318.14,19763.43,Inpatient DRG
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],12615.75,,"Fee schedule rate ($12,615.75). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6230.00,22762.43,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],28038.61,,"Fee schedule rate ($28,038.61). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12126.09,29582.40,There are no additional notes associated with this service or procedure.
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],22524.26,,,,,,0,other,9696.93,35061.53,There are no additional notes associated with this service or procedure.
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],15491.11,,"Case rate ($15,491.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,546.67, add-ons for qualifying new technology services are included. If operating cost exceeds $49,417.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,750.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $12,555.42 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,601.72 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $990.75. The transfer capital threshold is the transfer adjustment factor * $990.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,15491.11,54180.83,Inpatient DRG
Ercp Destruction/Lithotripsy Calculi Any Method,CASE-43265,APC,43265,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5881.39,,"APC Price ($5,682.51). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5682.51,5966.63,OPPS APC
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,025,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],33422.66,,"Case rate ($31,831.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $29,803.17, add-ons for qualifying new technology services are included. If operating cost exceeds $64,674.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,893.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.4. The base transfer operating payment is the transfer adjustment factor * $27,752.99 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $27,858.22 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,133.16. The transfer capital threshold is the transfer adjustment factor * $2,133.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,13351.00,91631.33,Inpatient DRG
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],37914.65,,"Fee schedule rate ($37,914.65). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9865.56,37914.65,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],21667.25,,"Case rate ($21,667.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,292.19, add-ons for qualifying new technology services are included. If operating cost exceeds $55,163.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,202.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $18,279.84 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,347.24 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,442.46. The transfer capital threshold is the transfer adjustment factor * $1,442.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8972.00,81524.17,Inpatient DRG
Colonoscopy W/Biopsy Single/Multiple|COLORECTAL CANCER SCREEN|UNUSUAL NON-OVERLAPPING SERVICE,CASE-45380,APC,45380,CPT,0360,RC,,,PT|XU,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1120.09,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1120.09,1176.09,OPPS APC
Colsc Flexible W/Control Bleeding Any Method,CASE-45382,APC,45382,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1176.09,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1120.09,1176.09,OPPS APC
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],13403.28,,"Case rate ($12,765.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,030.82, add-ons for qualifying new technology services are included. If operating cost exceeds $46,901.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,532.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $10,047.77 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,085.87 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $772.30. The transfer capital threshold is the transfer adjustment factor * $772.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13092.47,33159.45,Inpatient DRG
O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC,621,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],36669.96,,"Fee schedule rate ($36,669.96). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,12159.94,36669.96,There are no additional notes associated with this service or procedure.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,073,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],43475.01,,"Fee schedule rate ($43,475.01). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,12809.38,43475.01,There are no additional notes associated with this service or procedure.
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],12263.78,,"Case rate ($11,679.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,019.23, add-ons for qualifying new technology services are included. If operating cost exceeds $45,890.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,454.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $9,040.00 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,074.28 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $694.84. The transfer capital threshold is the transfer adjustment factor * $694.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,11974.38,29141.64,Inpatient DRG
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],32795.66,,"Fee schedule rate ($32,795.66). Adds an outlier to normal pricing equal to the per diem rate ($69,146.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,1188.00,34338.33,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,426,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],177294.98,,"Fee schedule rate ($177,294.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,76581.29,216864.15,There are no additional notes associated with this service or procedure.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,761,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],6351.37,,"Fee schedule rate ($6,351.37). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,5808.41,11946.72,There are no additional notes associated with this service or procedure.
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7661.65,,"Case rate ($7,402.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,022.05, add-ons for qualifying new technology services are included. If operating cost exceeds $41,893.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,159.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,058.45 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,077.10 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $399.16. The transfer capital threshold is the transfer adjustment factor * $399.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,7402.56,16438.59,Inpatient DRG
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,066,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6765.80,,"Case rate ($6,443.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,138.36, add-ons for qualifying new technology services are included. If operating cost exceeds $41,009.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,081.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $4,177.57 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,193.41 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $321.10. The transfer capital threshold is the transfer adjustment factor * $321.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6579.76,20083.61,Inpatient DRG
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],37550.29,,"Fee schedule rate ($37,550.29). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,15476.23,42787.31,There are no additional notes associated with this service or procedure.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",062,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],34576.42,,,,,,0,other,13844.84,44304.80,There are no additional notes associated with this service or procedure.
VENTRICULAR SHUNT PROCEDURES WITH CC,032,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],46275.08,,"Fee schedule rate ($46,275.08). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,16376.22,46275.08,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC,831,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],9294.42,,"Fee schedule rate ($9,294.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,4941.30,23661.59,There are no additional notes associated with this service or procedure.
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC,805,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],20281.41,,"Fee schedule rate ($20,281.41). Adds an outlier to normal pricing equal to the per diem rate ($31,438.44) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.5), with a minimum of zero.",,,,0,other,9253.36,21235.42,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],85305.59,,"Fee schedule rate ($85,305.59). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,21719.40,85305.59,There are no additional notes associated with this service or procedure.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,057,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],22105.65,,"Fee schedule rate ($22,105.65). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,10718.84,39884.93,There are no additional notes associated with this service or procedure.
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],18918.49,,"Fee schedule rate ($18,918.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9282.47,21320.03,There are no additional notes associated with this service or procedure.
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC",923,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],8329.46,,"Case rate ($8,047.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $7,588.71, add-ons for qualifying new technology services are included. If operating cost exceeds $46,233.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $3,215.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,201.30 + an uncompensated DSH payment of $1,359.91. The transfer operating threshold is the transfer adjustment factor * $6,228.80 + an uncompensated DSH payment of $1,359.91. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $486.59. The transfer capital threshold is the transfer adjustment factor * $486.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6965.00,20068.57,Inpatient DRG
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],16079.87,,"Fee schedule rate ($16,079.87). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9151.11,30245.71,There are no additional notes associated with this service or procedure.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,056,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],17677.14,,"Case rate ($17,677.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,580.28, add-ons for qualifying new technology services are included. If operating cost exceeds $51,451.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,910.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $14,581.57 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,635.33 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,150.63. The transfer capital threshold is the transfer adjustment factor * $1,150.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7659.00,59328.19,Inpatient DRG
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],16400.70,,"Fee schedule rate ($16,400.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,16400.70,There are no additional notes associated with this service or procedure.
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],13872.99,,"Fee schedule rate ($13,872.99). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.8), with a minimum of zero.",,,,0,other,5068.21,14525.56,There are no additional notes associated with this service or procedure.
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],54180.83,,"Fee schedule rate ($54,180.83). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,15491.11,54180.83,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,066,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],20083.61,,"Fee schedule rate ($20,083.61). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6579.76,20083.61,There are no additional notes associated with this service or procedure.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],13331.82,,"Case rate ($12,696.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,947.32, add-ons for qualifying new technology services are included. If operating cost exceeds $46,818.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,546.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,965.63 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,002.37 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $786.39. The transfer capital threshold is the transfer adjustment factor * $786.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12696.97,47123.82,Inpatient DRG
"Inj Dx/Ther Agnt Paravert Facet Joint, Cerv/Thorac, 2nd Level|RIGHT SIDE",CASE-64491,APC,64491,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],827.89,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,827.89,869.28,OPPS APC
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],21675.85,,"Fee schedule rate ($21,675.85). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,9755.86,29216.99,There are no additional notes associated with this service or procedure.
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],37185.28,,"Case rate ($21,248.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $19,902.85, add-ons for qualifying new technology services are included. If operating cost exceeds $54,773.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,171.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.3. The base transfer operating payment is the transfer adjustment factor * $17,891.94 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $17,957.90 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,411.85. The transfer capital threshold is the transfer adjustment factor * $1,411.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,21248.73,56089.29,All Other Inpatient
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],34245.00,,"Fee schedule rate ($34,245.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,12725.42,34245.00,There are no additional notes associated with this service or procedure.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",062,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],44304.80,,"Fee schedule rate ($44,304.80). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,13844.84,44304.80,There are no additional notes associated with this service or procedure.
MAJOR BLADDER PROCEDURES WITH MCC,653,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],37906.76,,"Case rate ($36,101.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $33,783.96, add-ons for qualifying new technology services are included. If operating cost exceeds $68,654.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,197.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.5. The base transfer operating payment is the transfer adjustment factor * $31,718.75 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $31,839.01 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,437.98. The transfer capital threshold is the transfer adjustment factor * $2,437.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10280.00,125343.98,Inpatient DRG
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],39424.57,,"Fee schedule rate ($39,424.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12195.15,39424.57,There are no additional notes associated with this service or procedure.
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],33159.45,,"Fee schedule rate ($33,159.45). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,13092.47,33159.45,There are no additional notes associated with this service or procedure.
HC Inject Tendon Origin/Insert|BILATERAL PROCEDURE,CASE-20551,APC,20551,CPT,0361,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
HC External Version,CASE-59412,APC,59412,CPT,0720,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3136.08,,"APC Price ($3,030.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3030.03,3181.53,OPPS APC
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],61290.90,,"Fee schedule rate ($61,290.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,23799.09,63499.65,There are no additional notes associated with this service or procedure.
SPINAL PROCEDURES WITHOUT CC/MCC,030,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],43194.95,,,,,,0,other,16810.99,44714.01,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,448,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],94077.13,,"Fee schedule rate ($94,077.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,30663.95,94077.13,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITH STERILIZATION WITH MCC,783,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],19499.60,,"Case rate ($18,571.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,411.86, add-ons for qualifying new technology services are included. If operating cost exceeds $52,282.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,975.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $15,410.10 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,466.92 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,216.01. The transfer capital threshold is the transfer adjustment factor * $1,216.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12612.10,23722.94,Inpatient DRG
HC Peripheral Block - Femoral Single or Saphenous W/Img Gdn|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64447,APC,64447,CPT,0360,RC,,,RT|XU,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],12364.06,,"Case rate ($11,945.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,248.66, add-ons for qualifying new technology services are included. If operating cost exceeds $46,119.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,491.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $9,269.54 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,303.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $731.46. The transfer capital threshold is the transfer adjustment factor * $731.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6167.00,29058.99,Inpatient DRG
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],23618.74,,"Fee schedule rate ($23,618.74). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10533.95,24956.34,There are no additional notes associated with this service or procedure.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,025,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],91631.33,,"Fee schedule rate ($91,631.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,13351.00,91631.33,There are no additional notes associated with this service or procedure.
HC Drain/Inj Joint/Bursa W/US Large|PBB CHARGE,CASE-20611,APC,20611,CPT,0510,RC,,,PBB,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],287.31,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],15067.30,,"Case rate ($14,349.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,508.07, add-ons for qualifying new technology services are included. If operating cost exceeds $48,379.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,645.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,519.44 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,563.12 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $885.41. The transfer capital threshold is the transfer adjustment factor * $885.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7389.00,37134.43,Inpatient DRG
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",062,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],44304.80,,"Fee schedule rate ($44,304.80). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,13844.84,44304.80,There are no additional notes associated with this service or procedure.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],21597.50,,"Case rate ($21,597.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,227.30, add-ons for qualifying new technology services are included. If operating cost exceeds $55,098.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,197.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $18,215.19 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,282.35 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,437.36. The transfer capital threshold is the transfer adjustment factor * $1,437.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,21597.50,67790.93,Inpatient DRG
Unlisted Laparoscopy Procedure Uterus,CASE-58578,APC,58578,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],10298.02,,"APC Price ($9,949.78). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,9949.78,10298.02,OPPS APC
NON-MALIGNANT BREAST DISORDERS WITH CC/MCC,600,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],20495.56,,,,,,0,other,7999.14,20495.56,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,373,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],13670.03,,"Fee schedule rate ($13,670.03). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6870.94,14313.05,There are no additional notes associated with this service or procedure.
Ercp Stent Placement Biliary/Pancreatic Duct,CASE-43274,APC,43274,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5966.63,,"APC Price ($5,682.51). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5682.51,5966.63,OPPS APC
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC",629,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],17534.94,,"Case rate ($16,699.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,671.20, add-ons for qualifying new technology services are included. If operating cost exceeds $50,542.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,839.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $13,675.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,726.25 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,079.16. The transfer capital threshold is the transfer adjustment factor * $1,079.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,16699.94,44657.18,Inpatient DRG
POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES,769,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],14057.81,,"Case rate ($13,388.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,590.54, add-ons for qualifying new technology services are included. If operating cost exceeds $47,461.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,596.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $10,606.49 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,645.59 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $836.96. The transfer capital threshold is the transfer adjustment factor * $836.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13388.39,33250.19,Inpatient DRG
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,091,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],40030.81,,"Fee schedule rate ($40,030.81). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,13838.06,40030.81,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],28423.20,,"Fee schedule rate ($28,423.20). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11059.47,28423.20,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],19504.80,,"Fee schedule rate ($19,504.80). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,10895.60,35192.25,There are no additional notes associated with this service or procedure.
HC Joint Injection/Aspir Large WO US|RIGHT SIDE|PBB CHARGE,CASE-20610,APC,20610,CPT,0510,RC,,,RT|PBB,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],301.68,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,287.31,301.68,OPPS APC
PREMATURITY WITH MAJOR PROBLEMS,791,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],3054.00,,,,,,0,other,3048.21,30904.42,Estimated amount calculated based on 5 day length of stay.
VAGINAL DELIVERY WITH O.R. PROCEDURES EXCEPT STERILIZATION AND/OR D&C,768,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],6700.05,,"Fee schedule rate ($6,700.05). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6426.91,13416.00,There are no additional notes associated with this service or procedure.
BRONCHITIS AND ASTHMA WITHOUT CC/MCC,203,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],5927.78,,"Case rate ($5,927.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $5,614.23, add-ons for qualifying new technology services are included. If operating cost exceeds $44,258.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $3,061.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,235.54 + an uncompensated DSH payment of $1,359.91. The transfer operating threshold is the transfer adjustment factor * $4,254.32 + an uncompensated DSH payment of $1,359.91. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $332.34. The transfer capital threshold is the transfer adjustment factor * $332.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,4763.76,13707.00,Inpatient DRG
RESPIRATORY NEOPLASMS WITH CC,181,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],9197.84,,"Case rate ($9,197.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,692.16, add-ons for qualifying new technology services are included. If operating cost exceeds $43,563.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,290.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,722.42 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,747.21 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $530.47. The transfer capital threshold is the transfer adjustment factor * $530.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9197.84,21074.07,Inpatient DRG
VENTRICULAR SHUNT PROCEDURES WITH MCC,031,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],62406.76,,"Fee schedule rate ($62,406.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,32287.20,88162.80,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],28756.63,,"Fee schedule rate ($28,756.63). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,13148.66,32553.63,There are no additional notes associated with this service or procedure.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,191,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],16612.88,,"Fee schedule rate ($16,612.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6965.00,16612.88,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,065,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],25681.86,,"Fee schedule rate ($25,681.86). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,8786.76,25681.86,There are no additional notes associated with this service or procedure.
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],6965.00,,,,,,0,other,6965.00,17467.27,There are no additional notes associated with this service or procedure.
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],12736.22,,"Case rate ($12,305.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,583.18, add-ons for qualifying new technology services are included. If operating cost exceeds $46,454.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,517.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $9,602.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,638.24 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $757.76. The transfer capital threshold is the transfer adjustment factor * $757.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,12305.53,30103.84,Inpatient DRG
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|LEFT HAND, SECOND DIGIT",CASE-26160,APC,26160,CPT,0360,RC,,,F1,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1557.80,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1505.12,1580.37,OPPS APC
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],28394.78,,"Fee schedule rate ($28,394.78). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11454.97,28394.78,There are no additional notes associated with this service or procedure.
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC",458,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],82104.25,,,,,,0,other,30202.09,132827.25,There are no additional notes associated with this service or procedure.
Bx/Exc Lymph Node Open Deep Axillary Node|RIGHT SIDE,CASE-38525,APC,38525,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6526.12,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6215.36,6526.12,OPPS APC
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],18933.95,,"Fee schedule rate ($18,933.95). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.8), with a minimum of zero.",,,,0,other,8767.81,19824.58,There are no additional notes associated with this service or procedure.
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],13625.25,,"Fee schedule rate ($13,625.25). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7243.75,23262.15,There are no additional notes associated with this service or procedure.
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],6780.05,,"Case rate ($6,457.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,142.59, add-ons for qualifying new technology services are included. If operating cost exceeds $41,013.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,089.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $4,182.21 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,197.63 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $330.02. The transfer capital threshold is the transfer adjustment factor * $330.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5139.72,13110.79,Inpatient DRG
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC,831,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],9294.42,,"Fee schedule rate ($9,294.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,4941.30,23661.59,There are no additional notes associated with this service or procedure.
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC,058,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],40853.02,,"Fee schedule rate ($40,853.02). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,13521.80,40853.02,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],32802.57,,"Case rate ($31,693.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $29,619.21, add-ons for qualifying new technology services are included. If operating cost exceeds $64,490.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,935.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. The base transfer operating payment is the transfer adjustment factor * $27,572.60 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $27,674.26 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,175.75. The transfer capital threshold is the transfer adjustment factor * $2,175.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,10862.00,86437.13,Inpatient DRG
NEONATE WITH OTHER SIGNIFICANT PROBLEMS,794,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],3383.58,,"Fee schedule rate ($3,383.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,1798.85,12536.83,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],32711.70,,"Fee schedule rate ($32,711.70). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,23851.92,63653.13,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],14508.90,,"Fee schedule rate ($14,508.90). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,13917.42,34889.29,There are no additional notes associated with this service or procedure.
DIABETES WITH CC,638,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],8014.07,,"Case rate ($8,014.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,590.93, add-ons for qualifying new technology services are included. If operating cost exceeds $42,461.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,203.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,625.24 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,645.98 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $443.89. The transfer capital threshold is the transfer adjustment factor * $443.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8014.07,17634.53,Inpatient DRG
ALLERGIC REACTIONS WITH MCC,915,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],13332.86,,"Case rate ($13,332.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,538.89, add-ons for qualifying new technology services are included. If operating cost exceeds $47,409.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,592.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $10,555.02 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,593.94 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $832.90. The transfer capital threshold is the transfer adjustment factor * $832.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,13332.86,33088.84,Inpatient DRG
Laps Vaginal Hysterectomy Uterus 250 Gm/<,CASE-58550,APC,58550,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5941.70,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5658.76,5941.70,OPPS APC
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,086,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],25633.23,,,,,,0,other,8442.00,30728.81,There are no additional notes associated with this service or procedure.
NEONATE WITH OTHER SIGNIFICANT PROBLEMS,794,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],2074.00,,,,,,0,other,1798.85,12536.83,Estimated amount calculated based on 2 day length of stay.
TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC,087,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],22679.07,,"Fee schedule rate ($22,679.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,8139.36,22679.07,There are no additional notes associated with this service or procedure.
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC,806,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],10071.17,,"Fee schedule rate ($10,071.17). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5354.25,13416.00,There are no additional notes associated with this service or procedure.
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],33221.97,,"Fee schedule rate ($33,221.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (47), with a minimum of zero.",,,,0,other,15283.90,38757.79,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],43703.12,,"Fee schedule rate ($43,703.12). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.7), with a minimum of zero.",,,,0,other,17693.40,52449.26,There are no additional notes associated with this service or procedure.
PERIPHERAL VASCULAR DISORDERS WITH CC,300,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],20331.78,,"Fee schedule rate ($20,331.78). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,9174.14,21005.20,There are no additional notes associated with this service or procedure.
"Amputation Toe Metatarsophalangeal Joint|RIGHT HAND, FOURTH DIGIT",CASE-28820,APC,28820,CPT,0360,RC,,,F8,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
HEART FAILURE AND SHOCK WITH CC,292,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],15550.06,,"Fee schedule rate ($15,550.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5502.00,16705.77,There are no additional notes associated with this service or procedure.
NERVOUS SYSTEM NEOPLASMS WITH MCC,054,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],12899.48,,"Case rate ($12,285.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,564.29, add-ons for qualifying new technology services are included. If operating cost exceeds $46,435.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,516.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $9,584.00 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,619.34 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $756.27. The transfer capital threshold is the transfer adjustment factor * $756.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,30044.81,Inpatient DRG
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],18918.49,,"Fee schedule rate ($18,918.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9282.47,21320.03,There are no additional notes associated with this service or procedure.
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],25253.70,,"Fee schedule rate ($25,253.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11974.38,29141.64,There are no additional notes associated with this service or procedure.
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],23078.81,,"Fee schedule rate ($23,078.81). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10311.17,24308.97,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],7948.33,,"Case rate ($7,569.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,177.66, add-ons for qualifying new technology services are included. If operating cost exceeds $42,048.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,171.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,213.49 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,232.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $411.40. The transfer capital threshold is the transfer adjustment factor * $411.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7569.84,21892.85,Inpatient DRG
OTHER DISORDERS OF THE EYE WITHOUT MCC,125,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7341.41,,"Case rate ($6,991.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,649.36, add-ons for qualifying new technology services are included. If operating cost exceeds $41,520.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,120.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,686.64 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,704.41 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $360.23. The transfer capital threshold is the transfer adjustment factor * $360.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7144.54,17952.29,Inpatient DRG
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],37591.64,,"Fee schedule rate ($37,591.64). Adds an outlier to normal pricing equal to the per diem rate ($51,531) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.1), with a minimum of zero.",,,,0,other,15491.11,54180.83,There are no additional notes associated with this service or procedure.
MAJOR THUMB OR JOINT PROCEDURES,506,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],25355.52,,"Fee schedule rate ($25,355.52). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.5), with a minimum of zero.",,,,0,other,11081.83,26548.21,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],25026.36,,"Fee schedule rate ($25,026.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9356.31,25026.36,There are no additional notes associated with this service or procedure.
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC,806,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],10071.17,,"Fee schedule rate ($10,071.17). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5354.25,13416.00,There are no additional notes associated with this service or procedure.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],16531.17,,"Case rate ($9,446.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,923.36, add-ons for qualifying new technology services are included. If operating cost exceeds $43,794.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,308.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,952.78 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,978.41 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $548.64. The transfer capital threshold is the transfer adjustment factor * $548.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,9446.38,21796.21,All Other Inpatient
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],13561.24,,"Case rate ($7,749.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,344.60, add-ons for qualifying new technology services are included. If operating cost exceeds $42,215.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,184.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,379.82 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,399.66 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $424.52. The transfer capital threshold is the transfer adjustment factor * $424.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,6711.00,16865.16,All Other Inpatient
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],42787.31,,"Fee schedule rate ($42,787.31). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,15476.23,42787.31,There are no additional notes associated with this service or procedure.
Perq Nl/Pl Lithotrp Simple Up to 2 Cm 1 Location|LEFT SIDE,CASE-50080,APC,50080,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],8860.83,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,8860.83,9303.88,OPPS APC
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],31626.74,,"Fee schedule rate ($31,626.74). Adds an outlier to normal pricing equal to the per diem rate ($86,383.13) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,13341.67,42586.49,There are no additional notes associated with this service or procedure.
RESPIRATORY NEOPLASMS WITHOUT CC/MCC,182,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],7049.74,,"Case rate ($7,049.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,693.83, add-ons for qualifying new technology services are included. If operating cost exceeds $41,564.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,133.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,731.43 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,748.88 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $373.36. The transfer capital threshold is the transfer adjustment factor * $373.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,23037.13,Inpatient DRG
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],48375.90,,,,,,0,other,18594.09,59494.91,There are no additional notes associated with this service or procedure.
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],10940.41,,,,,,0,other,3079.00,10940.41,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7847.99,,"Case rate ($7,474.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,099.09, add-ons for qualifying new technology services are included. If operating cost exceeds $41,970.10 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,154.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,134.67 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,154.14 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $394.66. The transfer capital threshold is the transfer adjustment factor * $394.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7641.61,19371.27,Inpatient DRG
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 1 Level|LEFT SIDE,CASE-64493,APC,64493,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],856.86,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,827.89,869.28,OPPS APC
TRAUMATIC INJURY WITH MCC,913,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],42838.46,,"Fee schedule rate ($42,838.46). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13014.58,42838.46,There are no additional notes associated with this service or procedure.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH CC,354,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],12514.68,,"Case rate ($12,514.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $11,748.98, add-ons for qualifying new technology services are included. If operating cost exceeds $50,393.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $3,540.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $10,343.20 + an uncompensated DSH payment of $1,359.91. The transfer operating threshold is the transfer adjustment factor * $10,389.07 + an uncompensated DSH payment of $1,359.91. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $811.58. The transfer capital threshold is the transfer adjustment factor * $811.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,11633.13,33472.54,Inpatient DRG
CHEST PAIN,313,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7011.49,,"Case rate ($6,677.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,356.48, add-ons for qualifying new technology services are included. If operating cost exceeds $41,227.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,097.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $4,394.87 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,411.53 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $337.80. The transfer capital threshold is the transfer adjustment factor * $337.80. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6820.84,15377.66,Inpatient DRG
HC Inj Tendon Sheath/Ligament|PBB CHARGE|SEPARATE STRUCTURE,CASE-20550,APC,20550,CPT,0510,RC,,,PBB|XS,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],297.37,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,287.31,301.68,OPPS APC
Ostectomy Calcaneus Spur W/WO Plntar Fascial Rls|LEFT SIDE,CASE-28119,APC,28119,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3169.86,3215.80,OPPS APC
PERITONEAL ADHESIOLYSIS WITH CC,336,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],53705.31,,"Fee schedule rate ($53,705.31). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,16225.22,53705.31,There are no additional notes associated with this service or procedure.
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",759,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6664.26,,"Case rate ($6,438.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,125.57, add-ons for qualifying new technology services are included. If operating cost exceeds $40,996.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,088.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,165.27 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,180.62 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $328.68. The transfer capital threshold is the transfer adjustment factor * $328.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6190.22,13057.66,Inpatient DRG
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],84226.47,,"Fee schedule rate ($84,226.47). Adds an outlier to normal pricing equal to the per diem rate ($75,906.87) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14.7), with a minimum of zero.",,,,0,other,32296.02,88188.38,There are no additional notes associated with this service or procedure.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],31626.74,,"Fee schedule rate ($31,626.74). Adds an outlier to normal pricing equal to the per diem rate ($86,383.13) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,13341.67,42586.49,There are no additional notes associated with this service or procedure.
HC Lyr Clos Sc Tk Ext 2.6-7 Cm,CASE-12032,APC,12032,CPT,0450,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1545.93,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1545.93,1623.23,OPPS APC
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],37914.65,,"Fee schedule rate ($37,914.65). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9865.56,37914.65,There are no additional notes associated with this service or procedure.
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC,520,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],39786.42,,"Fee schedule rate ($39,786.42). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12061.74,39786.42,There are no additional notes associated with this service or procedure.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],16120.25,,"Case rate ($16,120.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,131.93, add-ons for qualifying new technology services are included. If operating cost exceeds $50,002.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,796.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $13,138.54 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,186.98 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,036.76. The transfer capital threshold is the transfer adjustment factor * $1,036.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,16120.25,41187.90,Inpatient DRG
O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC,621,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],12403.14,,"Case rate ($12,159.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,447.74, add-ons for qualifying new technology services are included. If operating cost exceeds $46,318.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,507.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $9,467.88 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,502.79 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $747.11. The transfer capital threshold is the transfer adjustment factor * $747.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,12159.94,36669.96,Inpatient DRG
Laps Tx Ectopic Preg W/Salping&/Oophorectomy|LEFT SIDE,CASE-59151,APC,59151,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5856.81,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5658.76,5941.70,OPPS APC
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],12246.05,,"Fee schedule rate ($12,246.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6010.23,12246.05,There are no additional notes associated with this service or procedure.
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],7170.22,,"Fee schedule rate ($7,170.22). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6915.64,14442.92,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,065,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],18986.57,,"Fee schedule rate ($18,986.57). Adds an outlier to normal pricing equal to the per diem rate ($85,884.96) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,8786.76,25681.86,There are no additional notes associated with this service or procedure.
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],16803.11,,"Case rate ($16,002.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,049.04, add-ons for qualifying new technology services are included. If operating cost exceeds $49,920.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,763.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $13,054.59 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,104.09 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,003.41. The transfer capital threshold is the transfer adjustment factor * $1,003.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,16428.39,42083.20,Inpatient DRG
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],12880.35,,"Fee schedule rate ($12,880.35). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8543.64,23239.84,There are no additional notes associated with this service or procedure.
PLEURAL EFFUSION WITH MCC,186,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],12306.63,,"Case rate ($11,720.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $11,009.40, add-ons for qualifying new technology services are included. If operating cost exceeds $49,654.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $3,482.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $9,606.87 + an uncompensated DSH payment of $1,359.91. The transfer operating threshold is the transfer adjustment factor * $9,649.48 + an uncompensated DSH payment of $1,359.91. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $753.81. The transfer capital threshold is the transfer adjustment factor * $753.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10804.96,31089.66,Inpatient DRG
CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC,788,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],20142.33,,"Fee schedule rate ($20,142.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8438.02,20142.33,There are no additional notes associated with this service or procedure.
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC,797,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],8894.11,,"Case rate ($8,719.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,247.38, add-ons for qualifying new technology services are included. If operating cost exceeds $43,118.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,255.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $6,279.28 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,302.43 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $495.50. The transfer capital threshold is the transfer adjustment factor * $495.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,8719.72,20928.55,Inpatient DRG
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],33835.79,,"Fee schedule rate ($33,835.79). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,7000.00,33835.79,There are no additional notes associated with this service or procedure.
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],6711.00,,"Per diem ($6,711). If length of stay < 2.4, first 1 days paid at a per diem of $13,422 instead. Capped at $16,107.48.",,,,0,other,6711.00,16865.16,Estimated amount calculated based on 2 day length of stay.
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITHOUT CC/MCC,428,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],42018.41,,"Case rate ($40,017.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $37,363.07, add-ons for qualifying new technology services are included. If operating cost exceeds $72,234.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,544.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $35,288.01 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $35,418.12 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,784.57. The transfer capital threshold is the transfer adjustment factor * $2,784.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,40017.53,118904.57,Inpatient DRG
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC,817,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],43874.75,,"Fee schedule rate ($43,874.75). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,17396.11,44895.04,There are no additional notes associated with this service or procedure.
Fissurectomy Incl Sphincterotomy When Performed,CASE-46200,APC,46200,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],2598.08,,"APC Price ($2,598.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2598.08,2727.99,OPPS APC
HC Bx Breast 1st Lesion US Img|BILATERAL PROCEDURE,CASE-19083,APC,19083,CPT,0361,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],2814.04,,"APC Price ($2,718.88). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2718.88,2854.83,OPPS APC
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH CC",457,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],44443.84,,"Case rate ($42,327.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $39,511.96, add-ons for qualifying new technology services are included. If operating cost exceeds $74,382.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,713.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $37,429.01 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $37,567.02 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,953.52. The transfer capital threshold is the transfer adjustment factor * $2,953.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,42327.47,160549.49,Inpatient DRG
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC,858,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],33794.11,,"Fee schedule rate ($33,794.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11377.76,33794.11,There are no additional notes associated with this service or procedure.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC",494,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],39945.55,,"Fee schedule rate ($39,945.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,15533.10,39945.55,There are no additional notes associated with this service or procedure.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",063,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],6965.00,,,,,,0,other,6965.00,35701.87,There are no additional notes associated with this service or procedure.
"Inj Dx/Ther Agnt Paravert Facet Joint, Lumbar/Sac, Add Level",CASE-64495,APC,64495,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],827.89,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,827.89,869.28,OPPS APC
Egd Intrmural US Needle Aspirate/Biopsy Esophags|REDUCED SERVICES,CASE-43238,APC,43238,CPT,0360,RC,,,52,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1796.14,,"APC Price ($1,796.14). Discounted by 50%. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1796.14,1885.95,OPPS APC
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITHOUT CC/MCC",630,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],27428.38,,"Fee schedule rate ($27,428.38). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,11828.78,42541.02,There are no additional notes associated with this service or procedure.
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],30935.16,,"Fee schedule rate ($30,935.16). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13092.47,33159.45,There are no additional notes associated with this service or procedure.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,191,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],7653.81,,"Case rate ($7,653.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,255.78, add-ons for qualifying new technology services are included. If operating cost exceeds $42,126.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,177.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,291.32 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,310.83 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $417.54. The transfer capital threshold is the transfer adjustment factor * $417.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,16612.88,Inpatient DRG
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],15128.37,,"Fee schedule rate ($15,128.37). Adds an outlier to normal pricing equal to the per diem rate ($46,867.46) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7396.47,16035.06,There are no additional notes associated with this service or procedure.
Repair Complex Trunk 2.6-7.5 Cm|UNUSUAL NON-OVERLAPPING SERVICE,CASE-13101,APC,13101,CPT,0360,RC,,,XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],2854.83,,"APC Price ($2,718.88). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2718.88,2854.83,OPPS APC
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],19435.86,,"Case rate ($19,435.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $18,216.37, add-ons for qualifying new technology services are included. If operating cost exceeds $53,087.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,039.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.9. The base transfer operating payment is the transfer adjustment factor * $16,211.64 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $16,271.42 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,279.26. The transfer capital threshold is the transfer adjustment factor * $1,279.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,19435.86,50821.76,Inpatient DRG
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],10728.06,,"Case rate ($10,517.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,920.01, add-ons for qualifying new technology services are included. If operating cost exceeds $44,791.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,386.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $7,945.76 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,975.06 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $627.00. The transfer capital threshold is the transfer adjustment factor * $627.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,10517.71,24909.11,Inpatient DRG
Vulvectomy Simple Partial|BILATERAL PROCEDURE,CASE-56620,APC,56620,CPT,0360,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3136.08,,"APC Price ($3,030.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3030.03,3181.53,OPPS APC
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],35061.53,,"Fee schedule rate ($35,061.53). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,9696.93,35061.53,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC,788,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],20142.33,,"Fee schedule rate ($20,142.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8438.02,20142.33,There are no additional notes associated with this service or procedure.
Sling Operation Stress Incontinence,CASE-57288,APC,57288,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],4916.53,,"APC Price ($4,682.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,4682.41,4916.53,OPPS APC
Open Treatment Ulnar Fracture Proximal End|LEFT SIDE,CASE-24685,APC,24685,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC",629,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],40946.19,,"Fee schedule rate ($40,946.19). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,16699.94,44657.18,There are no additional notes associated with this service or procedure.
Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq|SEPARATE STRUCTURE|COLORECTAL CANCER SCREEN,CASE-45385,APC,45385,CPT,0360,RC,,,XS|PT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1159.29,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1120.09,1176.09,OPPS APC
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],8454.94,,"Case rate ($8,454.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,001.06, add-ons for qualifying new technology services are included. If operating cost exceeds $42,872.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,236.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,033.86 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,056.11 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $476.13. The transfer capital threshold is the transfer adjustment factor * $476.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6230.00,22762.43,Inpatient DRG
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,091,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],40030.81,,"Fee schedule rate ($40,030.81). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,13838.06,40030.81,There are no additional notes associated with this service or procedure.
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],3079.00,,"Fee schedule rate ($3,079.00). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,3079.00,10940.41,There are no additional notes associated with this service or procedure.
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,451,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],94077.13,,"Fee schedule rate ($94,077.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,23821.44,94077.13,There are no additional notes associated with this service or procedure.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,191,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],6965.00,,,,,,0,other,6965.00,16612.88,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,689,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],17154.52,,"Case rate ($9,802.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,254.74, add-ons for qualifying new technology services are included. If operating cost exceeds $44,125.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,334.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $7,282.94 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,309.79 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $574.70. The transfer capital threshold is the transfer adjustment factor * $574.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,9802.58,22831.22,All Other Inpatient
HC Joint Injection/Aspir Large WO US|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-20610,APC,20610,CPT,0510,RC,,,RT|XU,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
"HC Aerosol, Hhn, Mdi, Ippb|ADJ",CASE-94640,APC,94640,CPT,0410,RC,,,ADJ,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7029.71,OPPS APC
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],28983.97,,"Fee schedule rate ($28,983.97). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8956.76,28983.97,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],52449.26,,"Fee schedule rate ($52,449.26). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,17693.40,52449.26,There are no additional notes associated with this service or procedure.
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],28445.08,,"Fee schedule rate ($28,445.08). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.8), with a minimum of zero.",,,,0,other,12195.15,39424.57,There are no additional notes associated with this service or procedure.
HC Bx Breast 1st Lesion US Img|RIGHT SIDE,CASE-19083,APC,19083,CPT,0361,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1600.04,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1545.93,1623.23,OPPS APC
Laparoscopy Surg Cholecystectomy,CASE-47562,APC,47562,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5941.70,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5658.76,5941.70,OPPS APC
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],22686.91,,"Fee schedule rate ($22,686.91). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,10120.20,26204.74,There are no additional notes associated with this service or procedure.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,479,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],14824.22,,"Case rate ($14,533.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,655.86, add-ons for qualifying new technology services are included. If operating cost exceeds $48,526.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,680.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $11,667.89 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,710.91 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $920.71. The transfer capital threshold is the transfer adjustment factor * $920.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,10586.00,50518.76,Inpatient DRG
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],18017.71,,"Fee schedule rate ($18,017.71). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6277.00,36801.89,There are no additional notes associated with this service or procedure.
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],27832.43,,"Fee schedule rate ($27,832.43). Adds an outlier to normal pricing equal to the per diem rate ($62,521.14) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.7), with a minimum of zero.",,,,0,other,11974.38,29141.64,There are no additional notes associated with this service or procedure.
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC,805,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],20902.03,,"Fee schedule rate ($20,902.03). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9253.36,21235.42,There are no additional notes associated with this service or procedure.
NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,601,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],12359.72,,"Fee schedule rate ($12,359.72). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6042.05,12359.72,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],13405.94,,,,,,0,other,6558.75,14871.83,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC,833,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],6965.00,,,,,,0,other,3041.73,10289.10,There are no additional notes associated with this service or procedure.
NEONATE WITH OTHER SIGNIFICANT PROBLEMS,794,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],2074.00,,,,,,0,other,1798.85,12536.83,Estimated amount calculated based on 2 day length of stay.
VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC,033,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],31250.88,,"Fee schedule rate ($31,250.88). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7.9), with a minimum of zero.",,,,0,other,13206.23,42156.44,There are no additional notes associated with this service or procedure.
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],28093.27,,"Case rate ($28,093.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $26,270.18, add-ons for qualifying new technology services are included. If operating cost exceeds $61,141.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,672.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $24,235.87 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $24,325.23 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,912.45. The transfer capital threshold is the transfer adjustment factor * $1,912.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,10078.00,81454.07,Inpatient DRG
OSTEOMYELITIS WITHOUT CC/MCC,541,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],11429.52,,"Fee schedule rate ($11,429.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5103.00,15493.67,There are no additional notes associated with this service or procedure.
Arthrs Knee W/Meniscectomy Med&Lat W/Shaving|RIGHT SIDE,CASE-29880,APC,29880,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,394,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],17584.61,,"Fee schedule rate ($17,584.61). Adds an outlier to normal pricing equal to the per diem rate ($53,248.69) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,8281.56,20909.61,There are no additional notes associated with this service or procedure.
Ercp Remove Calculi/Debris Biliary/Pancreas Duct,CASE-43264,APC,43264,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5682.51,,"APC Price ($5,682.51). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5682.51,5966.63,OPPS APC
SKIN ULCERS WITH MCC,592,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],15116.17,,"Case rate ($15,116.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $14,168.54, add-ons for qualifying new technology services are included. If operating cost exceeds $53,556.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $3,795.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.8. The base transfer operating payment is the transfer adjustment factor * $12,752.10 + an uncompensated DSH payment of $1,359.91. The transfer operating threshold is the transfer adjustment factor * $12,808.63 + an uncompensated DSH payment of $1,359.91. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,004.16. The transfer capital threshold is the transfer adjustment factor * $1,004.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,15116.17,38644.05,Inpatient DRG
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],10300.48,,"Case rate ($10,098.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,530.04, add-ons for qualifying new technology services are included. If operating cost exceeds $44,401.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,356.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $7,557.23 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,585.10 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $596.34. The transfer capital threshold is the transfer adjustment factor * $596.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,10098.51,24259.09,Inpatient DRG
DIABETES WITH CC,638,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],15195.79,,"Fee schedule rate ($15,195.79). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8014.07,17634.53,There are no additional notes associated with this service or procedure.
"Amputation Toe Interphalangeal Joint|RIGHT FOOT, FOURTH DIGIT",CASE-28825,APC,28825,CPT,0360,RC,,,T8,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3062.67,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],128358.13,,"Fee schedule rate ($128,358.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,40542.37,128358.13,There are no additional notes associated with this service or procedure.
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],23385.72,,"Fee schedule rate ($23,385.72). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,23385.72,There are no additional notes associated with this service or procedure.
NERVOUS SYSTEM NEOPLASMS WITH MCC,054,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],12285.22,,"Case rate ($12,285.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,564.29, add-ons for qualifying new technology services are included. If operating cost exceeds $46,435.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,516.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $9,584.00 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,619.34 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $756.27. The transfer capital threshold is the transfer adjustment factor * $756.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,30044.81,Inpatient DRG
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],42787.31,,"Fee schedule rate ($42,787.31). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,15476.23,42787.31,There are no additional notes associated with this service or procedure.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],7605.00,,"Per diem ($7,605). If length of stay < 4.8, first 1 days paid at a per diem of $15,210 instead. Capped at $36,505.40.",,,,0,other,7605.00,39153.65,Estimated amount calculated based on 3 day length of stay.
CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC,788,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],8438.02,,"Case rate ($8,438.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,985.31, add-ons for qualifying new technology services are included. If operating cost exceeds $42,856.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,234.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,018.17 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,040.36 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $474.89. The transfer capital threshold is the transfer adjustment factor * $474.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8438.02,20142.33,Inpatient DRG
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],12558.65,,"Fee schedule rate ($12,558.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5065.00,12558.65,There are no additional notes associated with this service or procedure.
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],12920.81,,"Case rate ($12,305.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,583.18, add-ons for qualifying new technology services are included. If operating cost exceeds $46,454.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,517.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $9,602.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,638.24 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $757.76. The transfer capital threshold is the transfer adjustment factor * $757.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12305.53,30103.84,Inpatient DRG
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],59385.88,,"Fee schedule rate ($59,385.88). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,23344.70,62179.32,There are no additional notes associated with this service or procedure.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],16829.13,,"Fee schedule rate ($16,829.13). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,8009.34,19877.10,There are no additional notes associated with this service or procedure.
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],15233.11,,"Case rate ($15,233.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,306.64, add-ons for qualifying new technology services are included. If operating cost exceeds $49,177.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,731.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $12,316.28 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,361.69 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $971.88. The transfer capital threshold is the transfer adjustment factor * $971.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,15233.11,38610.21,Inpatient DRG
HC Joint Injection/Aspir Large WO US|DISTINCT PROCEDURAL SERVICE|RIGHT SIDE|PBB CHARGE,CASE-20610,APC,20610,CPT,0510,RC,,,59|RT|PBB,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],12651.45,,"Fee schedule rate ($12,651.45). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,6503.90,14492.93,There are no additional notes associated with this service or procedure.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],8139.14,,"Fee schedule rate ($8,139.14). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6965.00,15340.19,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],94787.57,,"Fee schedule rate ($94,787.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,23526.87,94787.57,There are no additional notes associated with this service or procedure.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],16037.43,,"Case rate ($15,273.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,344.45, add-ons for qualifying new technology services are included. If operating cost exceeds $49,215.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,734.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $12,353.94 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,399.49 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $974.85. The transfer capital threshold is the transfer adjustment factor * $974.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,15273.74,39820.52,Inpatient DRG
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],16669.71,,"Fee schedule rate ($16,669.71). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8767.81,19824.58,There are no additional notes associated with this service or procedure.
"HYPERTENSION,MODERATE",199,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],7075.31,,"The inlier payment is calculated as the lesser of the standard DRG payment $6,738.39 and the transfer payment, which is a per diem of $2,315.60. If cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6738.39,7075.31,Estimated amount calculated based on 2 day length of stay.
Open Tx Metacarpal Fracture Single Ea Bone|RIGHT SIDE,CASE-26615,APC,26615,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
HC Cv Cath Plac W/Port Tun >5,CASE-36561,APC,36561,CPT,0361,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3103.25,,"APC Price ($2,955.48). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2955.48,3103.25,OPPS APC
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],9950.89,,"Case rate ($9,950.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,392.71, add-ons for qualifying new technology services are included. If operating cost exceeds $44,263.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,345.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $7,420.40 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,447.76 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $585.54. The transfer capital threshold is the transfer adjustment factor * $585.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7243.75,23262.15,Inpatient DRG
RADIOTHERAPY,849,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],53314.83,,,,,,0,other,20293.88,81867.07,There are no additional notes associated with this service or procedure.
HYPERTENSION WITHOUT MCC,305,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],17230.49,,"Fee schedule rate ($17,230.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7058.55,17230.49,There are no additional notes associated with this service or procedure.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],31007.30,,"Fee schedule rate ($31,007.30). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,16120.25,41187.90,There are no additional notes associated with this service or procedure.
Colon Ca Scrn Not Hi Rsk Ind,CASE-G0121,APC,G0121,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],913.99,,"APC Price ($870.46). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,870.46,913.99,OPPS APC
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],32988.90,,"Fee schedule rate ($32,988.90). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,16689.78,59521.43,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITHOUT STERILIZATION WITH CC,787,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],9983.41,,"Case rate ($9,508.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,980.70, add-ons for qualifying new technology services are included. If operating cost exceeds $43,851.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,313.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $7,009.90 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,035.74 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $553.15. The transfer capital threshold is the transfer adjustment factor * $553.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9508.01,23722.94,Inpatient DRG
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],2070.00,,,,,,0,other,1188.00,34338.33,Estimated amount calculated based on 6 day length of stay.
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],6965.00,,,,,,0,other,4341.01,12882.53,There are no additional notes associated with this service or procedure.
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],13625.25,,"Fee schedule rate ($13,625.25). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7243.75,23262.15,There are no additional notes associated with this service or procedure.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],21809.80,,"Case rate ($21,382.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,026.97, add-ons for qualifying new technology services are included. If operating cost exceeds $54,897.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,181.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6)) / 2. The base transfer operating payment is the transfer adjustment factor * $18,015.59 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,082.01 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,421.61. The transfer capital threshold is the transfer adjustment factor * $1,421.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 102%.",,,,0,other,21382.16,85466.62,Inpatient DRG
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],73588.10,,"Fee schedule rate ($73,588.10). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,21585.31,73588.10,There are no additional notes associated with this service or procedure.
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,451,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],60708.91,,"Fee schedule rate ($60,708.91). Adds an outlier to normal pricing equal to the per diem rate ($108,215.07) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,23821.44,94077.13,There are no additional notes associated with this service or procedure.
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],22686.91,,"Fee schedule rate ($22,686.91). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,10120.20,26204.74,There are no additional notes associated with this service or procedure.
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],13001.72,,"Case rate ($13,001.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,230.82, add-ons for qualifying new technology services are included. If operating cost exceeds $47,101.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,568.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $10,248.08 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,285.87 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $808.68. The transfer capital threshold is the transfer adjustment factor * $808.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7868.00,32126.64,Inpatient DRG
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC",514,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],22699.91,,"Fee schedule rate ($22,699.91). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8868.04,22699.91,There are no additional notes associated with this service or procedure.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,056,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],17677.14,,"Case rate ($17,677.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,580.28, add-ons for qualifying new technology services are included. If operating cost exceeds $51,451.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,910.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $14,581.57 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,635.33 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,150.63. The transfer capital threshold is the transfer adjustment factor * $1,150.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7659.00,59328.19,Inpatient DRG
"NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY",789,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],14480.63,,"Case rate ($13,791.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,987.26, add-ons for qualifying new technology services are included. If operating cost exceeds $47,858.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,605.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $11,000.60 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,042.31 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $845.53. The transfer capital threshold is the transfer adjustment factor * $845.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,3054.00,14857.05,Inpatient DRG
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],6965.00,,,,,,0,other,6965.00,21404.64,There are no additional notes associated with this service or procedure.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,761,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],11946.72,,"Fee schedule rate ($11,946.72). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,5808.41,11946.72,There are no additional notes associated with this service or procedure.
"Open Tx Distal Phalangeal Fracture Each|RIGHT HAND, FIFTH DIGIT",CASE-26765,APC,26765,CPT,0360,RC,,,F9,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
Hallux Rigidus W/Cheilectomy 1st Mp Jt W/O Implt,CASE-28289,APC,28289,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],6524.75,,"Case rate ($6,214.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,916.41, add-ons for qualifying new technology services are included. If operating cost exceeds $40,787.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,072.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $3,956.88 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,971.47 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $312.24. The transfer capital threshold is the transfer adjustment factor * $312.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6214.05,15318.94,Inpatient DRG
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],120927.32,,"Fee schedule rate ($120,927.32). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,45521.20,142438.06,There are no additional notes associated with this service or procedure.
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC,058,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],40853.02,,"Fee schedule rate ($40,853.02). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,13521.80,40853.02,There are no additional notes associated with this service or procedure.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,479,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],14871.97,,"Case rate ($14,163.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,334.67, add-ons for qualifying new technology services are included. If operating cost exceeds $48,205.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,632.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $11,346.70 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,389.72 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $872.13. The transfer capital threshold is the transfer adjustment factor * $872.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10586.00,50518.76,Inpatient DRG
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC",494,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],39945.55,,"Fee schedule rate ($39,945.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,15533.10,39945.55,There are no additional notes associated with this service or procedure.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],87909.90,,"Fee schedule rate ($87,909.90). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,33623.33,133270.57,There are no additional notes associated with this service or procedure.
COMPLICATIONS OF TREATMENT WITH CC,920,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],8732.59,,"Case rate ($8,732.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,259.35, add-ons for qualifying new technology services are included. If operating cost exceeds $43,130.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,256.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,291.21 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,314.40 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $496.44. The transfer capital threshold is the transfer adjustment factor * $496.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8732.59,20731.52,Inpatient DRG
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITHOUT CC/MCC,517,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],11705.53,,"Case rate ($11,148.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $10,476.23, add-ons for qualifying new technology services are included. If operating cost exceeds $49,120.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $3,441.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $9,076.06 + an uncompensated DSH payment of $1,359.91. The transfer operating threshold is the transfer adjustment factor * $9,116.32 + an uncompensated DSH payment of $1,359.91. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $712.16. The transfer capital threshold is the transfer adjustment factor * $712.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10207.96,29371.86,Inpatient DRG
Cysto W/Ureteroscopy W/Rmvl/Manj Stones|RIGHT SIDE,CASE-52352,APC,52352,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3299.47,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3299.47,3464.44,OPPS APC
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],26391.01,,"Fee schedule rate ($26,391.01). Adds an outlier to normal pricing equal to the per diem rate ($77,296.48) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,11454.97,28394.78,There are no additional notes associated with this service or procedure.
COAGULATION DISORDERS,813,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],12519.88,,"Case rate ($12,274.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,554.21, add-ons for qualifying new technology services are included. If operating cost exceeds $46,425.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,515.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $9,573.96 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,609.26 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $755.48. The transfer capital threshold is the transfer adjustment factor * $755.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,12274.39,30013.33,Inpatient DRG
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],9549.99,,"Case rate ($9,095.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,610.04, add-ons for qualifying new technology services are included. If operating cost exceeds $43,481.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,270.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $6,639.92 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,665.09 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $510.36. The transfer capital threshold is the transfer adjustment factor * $510.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,21404.64,Inpatient DRG
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],14674.80,,"Fee schedule rate ($14,674.80). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6711.00,16865.16,There are no additional notes associated with this service or procedure.
Implnt Bio Implnt for Soft Tissue Reinforcement|RIGHT SIDE,CASE-15777,APC,15777,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6215.36,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6215.36,6432.89,OPPS APC
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC,832,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],9034.88,,"Fee schedule rate ($9,034.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4803.31,14198.92,There are no additional notes associated with this service or procedure.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],13968.53,,"Case rate ($13,303.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,532.63, add-ons for qualifying new technology services are included. If operating cost exceeds $47,403.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,570.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $10,547.69 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,587.68 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $810.72. The transfer capital threshold is the transfer adjustment factor * $810.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7921.00,45706.73,Inpatient DRG
"OTHER DIGESTIVE SYSTEM DIAGNOSES,MAJOR",254,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],10956.19,,"Case rate ($10,956.19). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,10956.19,11504.00,There are no additional notes associated with this service or procedure.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],20401.88,,"Fee schedule rate ($20,401.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,20401.88,There are no additional notes associated with this service or procedure.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],54503.46,,"Fee schedule rate ($54,503.46). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.9), with a minimum of zero.",,,,0,other,21585.31,73588.10,There are no additional notes associated with this service or procedure.
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],21404.64,,,,,,0,other,6965.00,21404.64,There are no additional notes associated with this service or procedure.
Cysto Bladder W/Ureteral Catheterization|UNUSUAL NON-OVERLAPPING SERVICE,CASE-52005,APC,52005,CPT,0360,RC,,,XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3464.44,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3299.47,3464.44,OPPS APC
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],19230.88,,"Fee schedule rate ($19,230.88). Adds an outlier to normal pricing equal to the per diem rate ($71,679.63) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8874.81,20553.44,There are no additional notes associated with this service or procedure.
"Prq Skel Fixj Phlngl Shft Fx Prox/Middle Px/F/T|LEFT HAND, FOURTH DIGIT",CASE-26727,APC,26727,CPT,0360,RC,,,F3,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],38378.80,,"Fee schedule rate ($38,378.80). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,14370.36,38378.80,There are no additional notes associated with this service or procedure.
Total Thyroid Lobectomy Uni W/WO Isthmusectomy|RIGHT SIDE,CASE-60220,APC,60220,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5658.76,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5658.76,5941.70,OPPS APC
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],41669.98,,,,,,0,other,16286.16,58320.32,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],30372.64,,"Fee schedule rate ($30,372.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,13260.40,32878.30,There are no additional notes associated with this service or procedure.
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],25013.10,,"Fee schedule rate ($25,013.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10846.16,25863.45,There are no additional notes associated with this service or procedure.
Neuroplasty &/Transposition Ulnar Nerve Elbow,CASE-64718,APC,64718,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1919.19,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1827.80,1919.19,OPPS APC
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],6122.64,,"Case rate ($6,122.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,831.37, add-ons for qualifying new technology services are included. If operating cost exceeds $40,702.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,065.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $3,872.14 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,886.42 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $305.55. The transfer capital threshold is the transfer adjustment factor * $305.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,1188.00,12138.74,Inpatient DRG
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],59610.47,,"Fee schedule rate ($59,610.47). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,16129.04,59610.47,There are no additional notes associated with this service or procedure.
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],25013.10,,"Fee schedule rate ($25,013.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10846.16,25863.45,There are no additional notes associated with this service or procedure.
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],15233.11,,"Case rate ($15,233.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,306.64, add-ons for qualifying new technology services are included. If operating cost exceeds $49,177.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,731.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $12,316.28 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,361.69 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $971.88. The transfer capital threshold is the transfer adjustment factor * $971.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,15233.11,38610.21,Inpatient DRG
HC Anterior Epitaxis Simple|RIGHT SIDE,CASE-30901,APC,30901,CPT,0450,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],130.76,,"APC Price ($124.54). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,124.54,130.76,OPPS APC
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],18979.80,,"Fee schedule rate ($18,979.80). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,12725.42,34245.00,There are no additional notes associated with this service or procedure.
"Tendon Sheath Incision|RIGHT HAND, FOURTH DIGIT",CASE-26055,APC,26055,CPT,0360,RC,,,F8,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1580.37,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1505.12,1580.37,OPPS APC
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC",514,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],22699.91,,"Fee schedule rate ($22,699.91). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8868.04,22699.91,There are no additional notes associated with this service or procedure.
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],25829.63,,"Fee schedule rate ($25,829.63). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6965.00,29482.05,There are no additional notes associated with this service or procedure.
"SPINAL FUSION AND OTHER BACK AND NECK PROCEDURES EXCEPT FOR DISC PROCEDURES,MODERATE",321,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],23286.14,,"Case rate ($23,286.14). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,23286.14,24450.45,There are no additional notes associated with this service or procedure.
Excision Choledochal Cyst,CASE-47715,APC,47715,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],8239.88,,"Case rate ($7,847.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,435.96, add-ons for qualifying new technology services are included. If operating cost exceeds $42,306.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,191.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,470.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,491.01 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $431.70. The transfer capital threshold is the transfer adjustment factor * $431.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7847.50,17755.26,Inpatient DRG
Tendon Sheath Incision,CASE-26055,APC,26055,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1580.37,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1505.12,1580.37,OPPS APC
Submucous Rescj Inferior Turbinate Prtl/Compl|BILATERAL PROCEDURE,CASE-30140,APC,30140,CPT,0360,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6837.16,,"APC Price ($6,605.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6605.95,6936.25,OPPS APC
INFLAMMATORY BOWEL DISEASE WITH CC,386,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],8984.36,,"Case rate ($8,556.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,095.56, add-ons for qualifying new technology services are included. If operating cost exceeds $42,966.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,243.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,128.01 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,150.61 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $483.56. The transfer capital threshold is the transfer adjustment factor * $483.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8556.53,19879.00,Inpatient DRG
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,068,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],23184.90,,"Fee schedule rate ($23,184.90). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,23184.90,There are no additional notes associated with this service or procedure.
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],22762.43,,"Fee schedule rate ($22,762.43). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6230.00,22762.43,There are no additional notes associated with this service or procedure.
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],16235.87,,"Fee schedule rate ($16,235.87). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6524.00,17760.46,There are no additional notes associated with this service or procedure.
OTHER CEREBROVASCULAR DISORDERS WITH MCC,070,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],13219.09,,"Case rate ($13,219.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,433.04, add-ons for qualifying new technology services are included. If operating cost exceeds $47,304.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,584.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $10,449.57 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,488.10 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $824.57. The transfer capital threshold is the transfer adjustment factor * $824.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,13219.09,37774.46,Inpatient DRG
CHOLECYSTECTOMY WITH C.D.E. WITH MCC,411,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],88615.28,,"Fee schedule rate ($88,615.28). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,24315.13,88615.28,There are no additional notes associated with this service or procedure.
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC,058,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],32126.63,,"Fee schedule rate ($32,126.63). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13521.80,40853.02,There are no additional notes associated with this service or procedure.
OSTEOMYELITIS WITHOUT CC/MCC,541,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],11429.52,,"Fee schedule rate ($11,429.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5103.00,15493.67,There are no additional notes associated with this service or procedure.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],6067.55,,"Case rate ($5,778.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,511.33, add-ons for qualifying new technology services are included. If operating cost exceeds $40,382.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,040.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $3,553.28 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,566.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $280.39. The transfer capital threshold is the transfer adjustment factor * $280.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5778.62,11681.49,Inpatient DRG
Cysto Bladder W/Ureteral Catheterization|RIGHT SIDE,CASE-52005,APC,52005,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1956.65,,"APC Price ($1,956.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1956.65,2054.48,OPPS APC
OTHER DISORDERS OF THE EYE WITHOUT MCC,125,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7341.41,,"Case rate ($6,991.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,649.36, add-ons for qualifying new technology services are included. If operating cost exceeds $41,520.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,120.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,686.64 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,704.41 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $360.23. The transfer capital threshold is the transfer adjustment factor * $360.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7144.54,17952.29,Inpatient DRG
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],19015.13,,"Case rate ($18,109.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,012.79, add-ons for qualifying new technology services are included. If operating cost exceeds $51,883.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,913.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 5.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $15,010.92 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,067.84 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,153.77. The transfer capital threshold is the transfer adjustment factor * $1,153.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,18598.83,48389.68,Inpatient DRG
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,306,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],29614.01,,"Fee schedule rate ($29,614.01). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12616.37,31007.02,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITH STERILIZATION WITH MCC,783,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],23722.94,,"Fee schedule rate ($23,722.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12612.10,23722.94,There are no additional notes associated with this service or procedure.
HC Inj Aa&/Strd Other Peripheral Nerve/Branch,CASE-64450,APC,64450,CPT,0450,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],660.72,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,660.72,693.76,OPPS APC
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],8165.30,,"Fee schedule rate ($8,165.30). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4341.01,12882.53,There are no additional notes associated with this service or procedure.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],8811.83,,"Case rate ($8,811.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,333.06, add-ons for qualifying new technology services are included. If operating cost exceeds $43,204.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,262.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,364.65 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,388.11 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $502.23. The transfer capital threshold is the transfer adjustment factor * $502.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,20401.88,Inpatient DRG
Intraop Sentinel Lymph Node ID W/Dye Injection|LEFT SIDE,CASE-38900,APC,38900,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6526.12,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6215.36,6526.12,OPPS APC
"MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS,MODERATE",532,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],2432.97,,"Case rate for a one day stay ($2,317.11). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,2432.97,2432.97,There are no additional notes associated with this service or procedure.
"Amputation Toe Metatarsophalangeal Joint|RIGHT HAND, FOURTH DIGIT",CASE-28820,APC,28820,CPT,0360,RC,,,F8,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
MAJOR CHEST TRAUMA WITHOUT CC/MCC,185,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],21771.61,,"Fee schedule rate ($21,771.61). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7271.19,21771.61,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC,084,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],19445.16,,"Fee schedule rate ($19,445.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,6965.00,19445.16,There are no additional notes associated with this service or procedure.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],19877.10,,"Fee schedule rate ($19,877.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8009.34,19877.10,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,091,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],40030.81,,"Fee schedule rate ($40,030.81). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,13838.06,40030.81,There are no additional notes associated with this service or procedure.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],21796.21,,,,,,0,other,9446.38,21796.21,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],9888.00,,"Per diem ($9,888). If length of stay < 3.1, first 1 days paid at a per diem of $19,776 instead. Capped at $30,651.38.",,,,0,other,9888.00,43399.23,Estimated amount calculated based on 1 day length of stay.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],24632.06,,"Case rate ($23,799.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $22,275.40, add-ons for qualifying new technology services are included. If operating cost exceeds $57,146.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,358.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.1. The base transfer operating payment is the transfer adjustment factor * $20,255.77 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $20,330.45 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,598.38. The transfer capital threshold is the transfer adjustment factor * $1,598.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,23799.09,63499.65,Inpatient DRG
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],28394.78,,"Fee schedule rate ($28,394.78). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11454.97,28394.78,There are no additional notes associated with this service or procedure.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,345,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],33616.03,,"Fee schedule rate ($33,616.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12134.89,33616.03,There are no additional notes associated with this service or procedure.
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC,805,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],20902.03,,"Fee schedule rate ($20,902.03). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9253.36,21235.42,There are no additional notes associated with this service or procedure.
Cysto/Uretero W/Lithotripsy &Indwell Stent Insrt|RIGHT SIDE,CASE-52356,APC,52356,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5269.71,,"APC Price ($5,018.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5018.77,5269.71,OPPS APC
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],29216.99,,"Fee schedule rate ($29,216.99). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9755.86,29216.99,There are no additional notes associated with this service or procedure.
COAGULATION DISORDERS,813,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],29046.49,,"Fee schedule rate ($29,046.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12274.39,30013.33,There are no additional notes associated with this service or procedure.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],20116.12,,"Case rate ($19,435.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $18,216.37, add-ons for qualifying new technology services are included. If operating cost exceeds $53,087.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,039.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.9. The base transfer operating payment is the transfer adjustment factor * $16,211.64 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $16,271.42 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,279.26. The transfer capital threshold is the transfer adjustment factor * $1,279.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,19435.86,50821.76,Inpatient DRG
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],10672.06,,"Case rate ($10,311.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,727.87, add-ons for qualifying new technology services are included. If operating cost exceeds $44,598.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,371.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $7,754.32 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,782.91 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $611.89. The transfer capital threshold is the transfer adjustment factor * $611.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,10311.17,24308.97,Inpatient DRG
FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,748,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],10807.69,,"Case rate ($10,293.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $9,679.84, add-ons for qualifying new technology services are included. If operating cost exceeds $48,324.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $3,378.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.4. The base transfer operating payment is the transfer adjustment factor * $8,283.19 + an uncompensated DSH payment of $1,359.91. The transfer operating threshold is the transfer adjustment factor * $8,319.93 + an uncompensated DSH payment of $1,359.91. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $649.94. The transfer capital threshold is the transfer adjustment factor * $649.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9316.20,26805.98,Inpatient DRG
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],31750.77,,"Fee schedule rate ($31,750.77). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13386.36,33244.29,There are no additional notes associated with this service or procedure.
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],35474.53,,"Fee schedule rate ($35,474.53). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,16428.39,42083.20,There are no additional notes associated with this service or procedure.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12827.65,,"Case rate ($12,216.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,519.81, add-ons for qualifying new technology services are included. If operating cost exceeds $46,390.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,493.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $9,538.70 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,574.86 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $733.17. The transfer capital threshold is the transfer adjustment factor * $733.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12527.66,29917.96,Inpatient DRG
Insj/Rplcmt Spinal Npg/Rcvr Pocket Crtj&Connj,CASE-63685,APC,63685,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],28883.55,,"APC Price ($28,883.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,28883.55,30327.72,OPPS APC
HC Peripheral Block - Femoral Single or Saphenous W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE|RIGHT SIDE,CASE-64447,APC,64447,CPT,0360,RC,,,XU|RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1557.80,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1505.12,1580.37,OPPS APC
NONTRAUMATIC STUPOR AND COMA WITH MCC,080,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],14534.47,,"Case rate ($13,842.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,035.05, add-ons for qualifying new technology services are included. If operating cost exceeds $47,906.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,609.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $11,048.21 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,090.10 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $849.19. The transfer capital threshold is the transfer adjustment factor * $849.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,14202.39,35615.37,Inpatient DRG
HC Drain/Inj Joint/Bursa W/US Large|PBB CHARGE|RIGHT SIDE,CASE-20611,APC,20611,CPT,0510,RC,,,PBB|RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],287.31,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
Suture Infrapatellar Tendon Primary|BILATERAL PROCEDURE,CASE-27380,APC,27380,CPT,0360,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6791.99,7131.59,OPPS APC
KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,689,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],21805.52,,"Fee schedule rate ($21,805.52). Adds an outlier to normal pricing equal to the per diem rate ($36,758.78) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,9802.58,22831.22,There are no additional notes associated with this service or procedure.
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],21089.59,,"Fee schedule rate ($21,089.59). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,6965.00,21089.59,There are no additional notes associated with this service or procedure.
HC Peripheral Block - Femoral Single or Saphenous W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64447,APC,64447,CPT,0360,RC,,,XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6791.99,7131.59,OPPS APC
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],36464.27,,"Case rate ($34,727.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $32,503.39, add-ons for qualifying new technology services are included. If operating cost exceeds $67,374.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,099.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.9. The base transfer operating payment is the transfer adjustment factor * $30,443.02 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $30,558.44 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,339.92. The transfer capital threshold is the transfer adjustment factor * $2,339.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,35719.96,105091.76,Inpatient DRG
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],41402.42,,"Fee schedule rate ($41,402.42). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,15456.59,41402.42,There are no additional notes associated with this service or procedure.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],23835.16,,"Fee schedule rate ($23,835.16). Adds an outlier to normal pricing equal to the per diem rate ($63,133.20) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10533.95,24956.34,There are no additional notes associated with this service or procedure.
HC Biopsy/Exc Lymph Node Needle|LEFT SIDE,CASE-38505,APC,38505,CPT,0361,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1545.93,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1545.93,1600.04,OPPS APC
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],47751.13,,"Fee schedule rate ($47,751.13). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.7), with a minimum of zero.",,,,0,other,19152.11,53152.12,There are no additional notes associated with this service or procedure.
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],46202.59,,"Fee schedule rate ($46,202.59). Adds an outlier to normal pricing equal to the per diem rate ($126,777.34) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,18594.09,59494.91,There are no additional notes associated with this service or procedure.
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC,058,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],13521.80,,"Case rate ($13,521.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,714.66, add-ons for qualifying new technology services are included. If operating cost exceeds $47,585.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,606.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $10,730.14 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,769.70 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $846.71. The transfer capital threshold is the transfer adjustment factor * $846.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,13521.80,40853.02,Inpatient DRG
PLEURAL EFFUSION WITH MCC,186,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],20511.05,,"Case rate ($11,720.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $11,009.40, add-ons for qualifying new technology services are included. If operating cost exceeds $49,654.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $3,482.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $9,606.87 + an uncompensated DSH payment of $1,359.91. The transfer operating threshold is the transfer adjustment factor * $9,649.48 + an uncompensated DSH payment of $1,359.91. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $753.81. The transfer capital threshold is the transfer adjustment factor * $753.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,10804.96,31089.66,All Other Inpatient
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],10902.64,,"Case rate ($10,533.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,935.13, add-ons for qualifying new technology services are included. If operating cost exceeds $44,806.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,388.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $7,960.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,990.18 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $628.19. The transfer capital threshold is the transfer adjustment factor * $628.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,10533.95,24956.34,Inpatient DRG
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],19230.88,,"Fee schedule rate ($19,230.88). Adds an outlier to normal pricing equal to the per diem rate ($71,679.63) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8874.81,20553.44,There are no additional notes associated with this service or procedure.
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],7875.94,,"Case rate ($7,875.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,462.42, add-ons for qualifying new technology services are included. If operating cost exceeds $42,333.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,193.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $5,497.20 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,517.46 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $433.78. The transfer capital threshold is the transfer adjustment factor * $433.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7875.94,17233.12,Inpatient DRG
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],61290.90,,"Fee schedule rate ($61,290.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,23799.09,63499.65,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],8637.85,,"Case rate ($8,468.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,013.65, add-ons for qualifying new technology services are included. If operating cost exceeds $42,884.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,237.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,046.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,068.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $477.12. The transfer capital threshold is the transfer adjustment factor * $477.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6963.00,18954.85,Inpatient DRG
RADIOTHERAPY,849,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],81867.07,,"Fee schedule rate ($81,867.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,20293.88,81867.07,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],2070.00,,,,,,0,other,1188.00,17370.86,Estimated amount calculated based on 3 day length of stay.
Open Implantation Nea Sacral Nerve,CASE-64581,APC,64581,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],18794.54,,"APC Price ($18,158.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,18158.97,19066.92,OPPS APC
SPINAL PROCEDURES WITH MCC,028,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],120982.83,,"Fee schedule rate ($120,982.83). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,42633.57,120982.83,There are no additional notes associated with this service or procedure.
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,069,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],6965.00,,,,,,0,other,6965.00,20333.68,There are no additional notes associated with this service or procedure.
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],37016.57,,"Fee schedule rate ($37,016.57). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15), with a minimum of zero.",,,,0,other,15283.90,38757.79,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],59476.09,,"Fee schedule rate ($59,476.09). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15.9), with a minimum of zero.",,,,0,other,23377.19,96365.69,There are no additional notes associated with this service or procedure.
Laps Surg W/Aspir Cavity/Cyst Single/Multiple,CASE-49322,APC,49322,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5856.81,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5658.76,5941.70,OPPS APC
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,025,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],13351.00,,"Per diem ($13,351). If length of stay < 6.4, first 1 days paid at a per diem of $26,702 instead. Capped at $85,446.13.",,,,0,other,13351.00,91631.33,Estimated amount calculated based on 4 day length of stay.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],6245.09,,"Case rate ($6,122.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,831.37, add-ons for qualifying new technology services are included. If operating cost exceeds $40,702.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,065.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $3,872.14 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,886.42 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $305.55. The transfer capital threshold is the transfer adjustment factor * $305.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,1188.00,12138.74,Inpatient DRG
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,699,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],8818.60,,"Case rate ($8,818.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,339.37, add-ons for qualifying new technology services are included. If operating cost exceeds $43,210.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,262.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $6,370.92 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,394.41 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $502.73. The transfer capital threshold is the transfer adjustment factor * $502.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,5961.00,19972.16,Inpatient DRG
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],51630.84,,"Fee schedule rate ($51,630.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,20559.34,54086.17,There are no additional notes associated with this service or procedure.
"FOOT AND TOE PROCEDURES,MINOR",314,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],10264.37,,"Case rate ($10,264.37). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,10264.37,10777.59,There are no additional notes associated with this service or procedure.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,074,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],11594.10,,"Fee schedule rate ($11,594.10). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8925.60,20919.08,There are no additional notes associated with this service or procedure.
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],2070.00,,,,,,0,other,1188.00,18893.86,Estimated amount calculated based on 3 day length of stay.
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level|LEFT SIDE,CASE-64483,APC,64483,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],869.28,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,827.89,869.28,OPPS APC
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],7412.73,,"Case rate ($7,412.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,031.50, add-ons for qualifying new technology services are included. If operating cost exceeds $41,902.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,159.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $5,067.86 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,086.55 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $399.90. The transfer capital threshold is the transfer adjustment factor * $399.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6148.93,15887.21,Inpatient DRG
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],20170.75,,"Fee schedule rate ($20,170.75). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10048.39,23545.50,There are no additional notes associated with this service or procedure.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],19788.78,,"Case rate ($19,119.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,922.16, add-ons for qualifying new technology services are included. If operating cost exceeds $52,793.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,016.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $15,918.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,977.21 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,256.13. The transfer capital threshold is the transfer adjustment factor * $1,256.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,11348.00,62454.12,Inpatient DRG
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],13435.63,,"Case rate ($12,795.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,039.30, add-ons for qualifying new technology services are included. If operating cost exceeds $46,910.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,553.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $10,057.27 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,094.35 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $793.62. The transfer capital threshold is the transfer adjustment factor * $793.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12795.84,41944.25,Inpatient DRG
MAJOR CHEST TRAUMA WITHOUT CC/MCC,185,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7470.48,,"Case rate ($7,114.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,763.94, add-ons for qualifying new technology services are included. If operating cost exceeds $41,634.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,128.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,800.78 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,818.99 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $369.00. The transfer capital threshold is the transfer adjustment factor * $369.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7271.19,21771.61,Inpatient DRG
"Amputation Toe Metatarsophalangeal Joint|RIGHT HAND, FOURTH DIGIT",CASE-28820,APC,28820,CPT,0360,RC,,,F8,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
VENTRICULAR SHUNT PROCEDURES WITH CC,032,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],16376.22,,"Case rate ($16,376.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,370.06, add-ons for qualifying new technology services are included. If operating cost exceeds $50,241.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,815.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $13,375.80 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,425.12 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,055.48. The transfer capital threshold is the transfer adjustment factor * $1,055.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,16376.22,46275.08,Inpatient DRG
"Open Tx Metacarpal Fracture Single Ea Bone|LEFT HAND, FOURTH DIGIT",CASE-26615,APC,26615,CPT,0360,RC,,,F3,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],7733.72,,"Case rate ($7,733.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,330.12, add-ons for qualifying new technology services are included. If operating cost exceeds $42,201.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,183.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,365.38 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,385.17 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $423.38. The transfer capital threshold is the transfer adjustment factor * $423.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7733.72,18043.23,Inpatient DRG
Removal Implant Deep|LEFT SIDE,CASE-20680,APC,20680,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],2814.04,,"APC Price ($2,718.88). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2718.88,2854.83,OPPS APC
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],8436.85,,"Case rate ($8,151.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,718.82, add-ons for qualifying new technology services are included. If operating cost exceeds $42,589.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,213.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,752.66 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,773.87 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $453.94. The transfer capital threshold is the transfer adjustment factor * $453.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,8151.55,18033.97,Inpatient DRG
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],12566.28,,"Case rate ($12,566.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,825.74, add-ons for qualifying new technology services are included. If operating cost exceeds $46,696.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,536.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $9,844.49 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,880.79 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $776.83. The transfer capital threshold is the transfer adjustment factor * $776.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12566.28,30861.41,Inpatient DRG
Cystourethroscopy|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-52000,APC,52000,CPT,0360,RC,,,74,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],652.69,,"APC Price ($652.69). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,652.69,685.32,OPPS APC
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],101083.00,,"Fee schedule rate ($101,083.00). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,35389.50,101083.00,There are no additional notes associated with this service or procedure.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],23520.23,,"Fee schedule rate ($23,520.23). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10517.71,24909.11,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],25293.50,,"Fee schedule rate ($25,293.50). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11059.47,28423.20,There are no additional notes associated with this service or procedure.
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],48961.48,,"Fee schedule rate ($48,961.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11575.50,48961.48,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,394,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],20909.61,,"Fee schedule rate ($20,909.61). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8281.56,20909.61,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],2070.00,,,,,,0,other,1188.00,17370.86,Estimated amount calculated based on 3 day length of stay.
MINOR BLADDER PROCEDURES WITHOUT CC/MCC,664,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],31876.87,,"Fee schedule rate ($31,876.87). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9034.63,31876.87,There are no additional notes associated with this service or procedure.
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],9533.13,,"Fee schedule rate ($9,533.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5068.21,14525.56,There are no additional notes associated with this service or procedure.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],22677.38,,"Case rate ($21,597.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,227.30, add-ons for qualifying new technology services are included. If operating cost exceeds $55,098.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,197.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $18,215.19 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,282.35 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,437.36. The transfer capital threshold is the transfer adjustment factor * $1,437.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,21597.50,67790.93,Inpatient DRG
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,329,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],90445.33,,,,,,0,other,33072.77,90445.33,There are no additional notes associated with this service or procedure.
OTHER CEREBROVASCULAR DISORDERS WITH CC,071,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],8893.10,,"Case rate ($8,893.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,408.66, add-ons for qualifying new technology services are included. If operating cost exceeds $43,279.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,268.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,439.97 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,463.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $508.18. The transfer capital threshold is the transfer adjustment factor * $508.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,5843.00,29215.10,Inpatient DRG
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],45521.20,,"Case rate ($45,521.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $42,483.01, add-ons for qualifying new technology services are included. If operating cost exceeds $77,354.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,947.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 12.5. The base transfer operating payment is the transfer adjustment factor * $40,389.14 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $40,538.06 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,187.10. The transfer capital threshold is the transfer adjustment factor * $3,187.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,45521.20,142438.06,Inpatient DRG
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],19545.88,,"Case rate ($18,615.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,483.96, add-ons for qualifying new technology services are included. If operating cost exceeds $52,354.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,949.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $15,480.32 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,539.01 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,189.85. The transfer capital threshold is the transfer adjustment factor * $1,189.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,11348.00,62454.12,Inpatient DRG
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],22686.91,,"Fee schedule rate ($22,686.91). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,10120.20,26204.74,There are no additional notes associated with this service or procedure.
CHEST PAIN,313,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],15377.66,,"Fee schedule rate ($15,377.66). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,6820.84,15377.66,There are no additional notes associated with this service or procedure.
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],18217.52,,"Fee schedule rate ($18,217.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7414.07,18217.52,There are no additional notes associated with this service or procedure.
PLEURAL EFFUSION WITH MCC,186,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],10804.96,,"Case rate ($10,290.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $9,604.11, add-ons for qualifying new technology services are included. If operating cost exceeds $49,173.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $3,521.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $9,560.48. The transfer operating threshold is the transfer adjustment factor * $9,604.11 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $729.96. The transfer capital threshold is the transfer adjustment factor * $729.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10804.96,31089.66,Inpatient DRG
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],8165.30,,"Fee schedule rate ($8,165.30). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4341.01,12882.53,There are no additional notes associated with this service or procedure.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC,858,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],33794.11,,"Fee schedule rate ($33,794.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11377.76,33794.11,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],25293.50,,"Fee schedule rate ($25,293.50). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11059.47,28423.20,There are no additional notes associated with this service or procedure.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],24259.09,,"Fee schedule rate ($24,259.09). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10098.51,24259.09,There are no additional notes associated with this service or procedure.
PSYCHOSES,885,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],11682.64,,"Case rate ($11,126.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,503.32, add-ons for qualifying new technology services are included. If operating cost exceeds $45,374.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,415.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.5. The base transfer operating payment is the transfer adjustment factor * $8,526.05 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,558.37 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $655.33. The transfer capital threshold is the transfer adjustment factor * $655.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,2070.00,27484.83,Inpatient DRG
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],11639.15,,"Fee schedule rate ($11,639.15). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7569.84,21892.85,There are no additional notes associated with this service or procedure.
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITHOUT MCC,430,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],41845.63,,"Case rate ($39,852.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $37,280.72, add-ons for qualifying new technology services are included. If operating cost exceeds $72,151.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,465.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $35,202.30 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $35,335.77 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,705.73. The transfer capital threshold is the transfer adjustment factor * $2,705.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,41000.16,133156.90,Inpatient DRG
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],101083.00,,"Fee schedule rate ($101,083.00). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,35389.50,101083.00,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],16935.49,,"Case rate ($16,129.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,140.12, add-ons for qualifying new technology services are included. If operating cost exceeds $50,011.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,797.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $13,146.70 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,195.17 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,037.40. The transfer capital threshold is the transfer adjustment factor * $1,037.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,16129.04,59610.47,Inpatient DRG
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC,099,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],22084.20,,"Fee schedule rate ($22,084.20). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11171.21,26807.94,There are no additional notes associated with this service or procedure.
BRONCHITIS AND ASTHMA WITH CC/MCC,202,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],14913.47,,"Case rate ($8,521.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,063.43, add-ons for qualifying new technology services are included. If operating cost exceeds $42,934.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,241.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,096.00 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,118.48 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $481.03. The transfer capital threshold is the transfer adjustment factor * $481.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,7606.34,19110.30,All Other Inpatient
CESAREAN SECTION WITHOUT STERILIZATION WITH CC,787,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],23722.94,,"Fee schedule rate ($23,722.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9508.01,23722.94,There are no additional notes associated with this service or procedure.
Laps Surg Bilateral Total Pelvic Lmphadectomy,CASE-38571,APC,38571,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],10447.27,,"APC Price ($9,949.78). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,9949.78,10447.27,OPPS APC
SPINAL PROCEDURES WITHOUT CC/MCC,030,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],17399.37,,"Case rate ($16,810.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,774.52, add-ons for qualifying new technology services are included. If operating cost exceeds $50,645.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,847.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $13,778.77 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,829.57 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,087.28. The transfer capital threshold is the transfer adjustment factor * $1,087.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,16810.99,44714.01,Inpatient DRG
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],26007.09,,,,,,0,other,10895.60,35192.25,There are no additional notes associated with this service or procedure.
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",004,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],10715.36,,,,,,0,other,10249.47,272554.00,Estimated amount calculated based on 6 day length of stay.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],59021.28,,"Fee schedule rate ($59,021.28). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,23851.92,63653.13,There are no additional notes associated with this service or procedure.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],15309.46,,"Fee schedule rate ($15,309.46). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6965.00,15340.19,There are no additional notes associated with this service or procedure.
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],11565.93,,"Fee schedule rate ($11,565.93). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6148.93,15887.21,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,086,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],11305.27,,"Case rate ($10,766.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,151.85, add-ons for qualifying new technology services are included. If operating cost exceeds $45,022.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,405.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $8,176.75 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,206.90 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $645.23. The transfer capital threshold is the transfer adjustment factor * $645.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8442.00,30728.81,Inpatient DRG
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],6965.00,,,,,,0,other,5778.62,11681.49,There are no additional notes associated with this service or procedure.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],97176.83,,,,,,0,other,35389.50,101083.00,There are no additional notes associated with this service or procedure.
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,095,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],48470.91,,"Fee schedule rate ($48,470.91). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.8), with a minimum of zero.",,,,0,other,19411.47,50750.92,There are no additional notes associated with this service or procedure.
MAJOR CHEST TRAUMA WITHOUT CC/MCC,185,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],21771.61,,"Fee schedule rate ($21,771.61). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7271.19,21771.61,There are no additional notes associated with this service or procedure.
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],31750.77,,"Fee schedule rate ($31,750.77). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13386.36,33244.29,There are no additional notes associated with this service or procedure.
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC",758,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],18398.35,,"Fee schedule rate ($18,398.35). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8574.80,19263.78,There are no additional notes associated with this service or procedure.
Removal Cerclage Suture Under Anesthesia,CASE-59871,APC,59871,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3136.08,,"APC Price ($3,030.03). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3030.03,3181.53,OPPS APC
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,095,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],48575.01,,"Fee schedule rate ($48,575.01). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,19411.47,50750.92,There are no additional notes associated with this service or procedure.
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],36855.62,,"Fee schedule rate ($36,855.62). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,15821.59,40320.14,There are no additional notes associated with this service or procedure.
"Rpr Coltrl Ligm Mtcarphlngl/Iphal Jt|RIGHT HAND, THUMB",CASE-26540,APC,26540,CPT,0360,RC,,,F5,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],21489.15,,"Case rate ($21,489.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,126.50, add-ons for qualifying new technology services are included. If operating cost exceeds $54,997.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,189.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.6. The base transfer operating payment is the transfer adjustment factor * $18,114.76 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,181.55 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,429.43. The transfer capital threshold is the transfer adjustment factor * $1,429.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,21489.15,68942.79,Inpatient DRG
"KNEE AND LOWER LEG PROCEDURES EXCEPT FOOT,MODERATE",313,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],20171.42,,"Case rate ($19,210.88). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,19210.88,20171.42,There are no additional notes associated with this service or procedure.
Cystourethroscopy W/Dest &/Rmvl Med Bladder Tum,CASE-52235,APC,52235,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3299.47,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3299.47,3464.44,OPPS APC
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],29141.64,,,,,,0,other,11974.38,29141.64,There are no additional notes associated with this service or procedure.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,761,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],11946.72,,"Fee schedule rate ($11,946.72). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,5808.41,11946.72,There are no additional notes associated with this service or procedure.
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC,058,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],13521.80,,"Case rate ($13,521.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,714.66, add-ons for qualifying new technology services are included. If operating cost exceeds $47,585.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,606.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $10,730.14 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,769.70 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $846.71. The transfer capital threshold is the transfer adjustment factor * $846.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,13521.80,40853.02,Inpatient DRG
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,373,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],13670.03,,"Fee schedule rate ($13,670.03). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6870.94,14313.05,There are no additional notes associated with this service or procedure.
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC",458,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],78415.67,,"Fee schedule rate ($78,415.67). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.8), with a minimum of zero.",,,,0,other,30202.09,132827.25,There are no additional notes associated with this service or procedure.
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],29243.52,,"Fee schedule rate ($29,243.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,14343.25,36024.65,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],2070.00,,,,,,0,other,1188.00,12138.74,Estimated amount calculated based on 1 day length of stay.
MAJOR CHEST TRAUMA WITHOUT CC/MCC,185,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],21771.61,,"Fee schedule rate ($21,771.61). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7271.19,21771.61,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],22142.34,,"Case rate ($21,087.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $19,788.99, add-ons for qualifying new technology services are included. If operating cost exceeds $54,660.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,126.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $17,776.64 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $17,844.04 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,366.35. The transfer capital threshold is the transfer adjustment factor * $1,366.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8972.00,81524.17,Inpatient DRG
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],7000.00,,"Per diem ($7,000). If length of stay < 4.5, first 1 days paid at a per diem of $14,000 instead. Capped at $31,498.95.",,,,0,other,7000.00,33835.79,Estimated amount calculated based on 2 day length of stay.
COAGULATION DISORDERS,813,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],12888.11,,"Case rate ($12,274.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,554.21, add-ons for qualifying new technology services are included. If operating cost exceeds $46,425.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,515.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $9,573.96 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,609.26 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $755.48. The transfer capital threshold is the transfer adjustment factor * $755.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12274.39,30013.33,Inpatient DRG
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH CC,427,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],142040.39,,,,,,0,other,50829.82,142040.39,There are no additional notes associated with this service or procedure.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,025,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],91631.33,,"Fee schedule rate ($91,631.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,13351.00,91631.33,There are no additional notes associated with this service or procedure.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],42586.49,,"Fee schedule rate ($42,586.49). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,13341.67,42586.49,There are no additional notes associated with this service or procedure.
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],7389.00,,"Per diem ($7,389). If length of stay < 4.8, first 1 days paid at a per diem of $14,778 instead. Capped at $35,466.15.",,,,0,other,7389.00,37134.43,Estimated amount calculated based on 6 day length of stay.
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],33890.73,,"Fee schedule rate ($33,890.73). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6277.00,36801.89,There are no additional notes associated with this service or procedure.
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],14610.75,,"Case rate ($14,610.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,727.68, add-ons for qualifying new technology services are included. If operating cost exceeds $48,598.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,686.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.6. The base transfer operating payment is the transfer adjustment factor * $11,739.44 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,782.73 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $926.36. The transfer capital threshold is the transfer adjustment factor * $926.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6277.00,36801.89,Inpatient DRG
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC,099,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],19549.62,,"Case rate ($11,171.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,527.95, add-ons for qualifying new technology services are included. If operating cost exceeds $45,398.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,434.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,551.47 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,583.00 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $674.80. The transfer capital threshold is the transfer adjustment factor * $674.80. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,11171.21,26807.94,All Other Inpatient
"POST-OPERATIVE POST-TRAUMA OTHER DEVICE INFECTIONS WITH O.R. PROCEDURE,MODERATE",711,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],15930.49,,"Case rate ($15,930.49). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,15930.49,16727.01,There are no additional notes associated with this service or procedure.
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],11454.97,,"Case rate ($11,454.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,791.92, add-ons for qualifying new technology services are included. If operating cost exceeds $45,662.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,455.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $8,814.47 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,846.97 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $695.55. The transfer capital threshold is the transfer adjustment factor * $695.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,11454.97,28394.78,Inpatient DRG
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITHOUT CC/MCC,816,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],12435.86,,,,,,0,other,6224.90,14733.53,There are no additional notes associated with this service or procedure.
Colonoscopy W/Biopsy Single/Multiple|COLORECTAL CANCER SCREEN|UNUSUAL NON-OVERLAPPING SERVICE,CASE-45380,APC,45380,CPT,0360,RC,,,PT|XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1159.29,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1120.09,1176.09,OPPS APC
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],6506.18,,"Case rate ($6,378.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,069.50, add-ons for qualifying new technology services are included. If operating cost exceeds $40,940.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,084.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,109.40 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,124.55 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $324.27. The transfer capital threshold is the transfer adjustment factor * $324.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,4341.01,12882.53,Inpatient DRG
Aspiration Bladder Insert Suprapubic Catheter,CASE-51102,APC,51102,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1956.65,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1956.65,2054.48,OPPS APC
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],17194.49,,"Fee schedule rate ($17,194.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8554.50,19204.75,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],40737.46,,"Fee schedule rate ($40,737.46). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,7665.00,40737.46,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],22805.37,,"Case rate ($21,719.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,340.70, add-ons for qualifying new technology services are included. If operating cost exceeds $55,211.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,206.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.2. The base transfer operating payment is the transfer adjustment factor * $18,328.17 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,395.75 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,446.27. The transfer capital threshold is the transfer adjustment factor * $1,446.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,21719.40,85305.59,Inpatient DRG
O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC,621,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],36669.96,,"Fee schedule rate ($36,669.96). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,12159.94,36669.96,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],19763.43,,"Fee schedule rate ($19,763.43). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,8318.14,19763.43,There are no additional notes associated with this service or procedure.
CELLULITIS WITH MCC,602,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],28349.31,,"Fee schedule rate ($28,349.31). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11570.10,28349.31,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],81524.17,,"Fee schedule rate ($81,524.17). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,8972.00,81524.17,There are no additional notes associated with this service or procedure.
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],8998.50,,"Fee schedule rate ($8,998.50). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6524.00,17760.46,There are no additional notes associated with this service or procedure.
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],14830.15,,"Fee schedule rate ($14,830.15). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,7884.32,17835.23,There are no additional notes associated with this service or procedure.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],9137.26,,"Case rate ($8,702.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,243.64, add-ons for qualifying new technology services are included. If operating cost exceeds $43,114.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,242.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $6,274.90 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,298.69 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $482.30. The transfer capital threshold is the transfer adjustment factor * $482.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8906.63,28434.57,Inpatient DRG
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],19688.76,,"Case rate ($18,751.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,579.45, add-ons for qualifying new technology services are included. If operating cost exceeds $52,450.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,989.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $15,577.06 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,634.50 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,229.18. The transfer capital threshold is the transfer adjustment factor * $1,229.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8480.00,59081.91,Inpatient DRG
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],22762.43,,"Fee schedule rate ($22,762.43). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6230.00,22762.43,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],14451.02,,"Case rate ($13,762.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,938.93, add-ons for qualifying new technology services are included. If operating cost exceeds $47,809.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,624.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $10,953.59 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,993.98 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $864.35. The transfer capital threshold is the transfer adjustment factor * $864.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,1188.00,34338.33,Inpatient DRG
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],11168.08,,"Fee schedule rate ($11,168.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5937.41,12366.99,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],73546.72,,,,,,0,other,27256.92,81353.66,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITHOUT CC/MCC,428,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],118904.57,,"Fee schedule rate ($118,904.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,40017.53,118904.57,There are no additional notes associated with this service or procedure.
Laps Gstr Rstcv Px W/Byp Roux-en-Y Limb <150 Cm,CASE-43644,APC,43644,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
Bronchoscopy Bronchial/Endobrncl Bx 1+ Sites|UNUSUAL NON-OVERLAPPING SERVICE,CASE-31625,APC,31625,CPT,0360,RC,,,XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6837.16,,"APC Price ($6,605.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6837.16,6936.25,OPPS APC
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,091,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],14163.16,,"Case rate ($13,488.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,705.41, add-ons for qualifying new technology services are included. If operating cost exceeds $47,576.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,583.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $10,719.82 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,760.46 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $823.95. The transfer capital threshold is the transfer adjustment factor * $823.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13838.06,40030.81,Inpatient DRG
"Fasct Prtl Palmr Addl Dgt Prox Iphal Jt W/WO Rpr|RIGHT HAND, FOURTH DIGIT",CASE-26125,APC,26125,CPT,0360,RC,,,F8,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],14055.68,,"Case rate ($13,386.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,588.65, add-ons for qualifying new technology services are included. If operating cost exceeds $47,459.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,596.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $10,604.60 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,643.70 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $836.81. The transfer capital threshold is the transfer adjustment factor * $836.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13386.36,33244.29,Inpatient DRG
"Amputation Toe Metatarsophalangeal Joint|LEFT FOOT, SECOND DIGIT",CASE-28820,APC,28820,CPT,0360,RC,,,T1,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3062.67,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,056,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],59328.19,,"Fee schedule rate ($59,328.19). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (44), with a minimum of zero.",,,,0,other,7659.00,59328.19,There are no additional notes associated with this service or procedure.
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH MCC",510,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],10710.00,,"Per diem ($10,710). If length of stay < 5.3, first 1 days paid at a per diem of $21,420 instead. Capped at $56,764.26.",,,,0,other,10710.00,89863.76,Estimated amount calculated based on 6 day length of stay.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],17365.00,,"Fee schedule rate ($17,365.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5683.00,19635.68,There are no additional notes associated with this service or procedure.
"Suture Digital Nerve Hand/Foot 1 Nerve|LEFT HAND, FOURTH DIGIT",CASE-64831,APC,64831,CPT,0360,RC,,,F3,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3169.86,3215.80,OPPS APC
TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC,087,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],8546.33,,"Case rate ($8,139.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,707.48, add-ons for qualifying new technology services are included. If operating cost exceeds $42,578.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,213.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $5,741.36 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,762.53 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $453.05. The transfer capital threshold is the transfer adjustment factor * $453.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8139.36,22679.07,Inpatient DRG
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],32126.64,,,,,,0,other,7868.00,32126.64,There are no additional notes associated with this service or procedure.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",062,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],44304.80,,"Fee schedule rate ($44,304.80). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,13844.84,44304.80,There are no additional notes associated with this service or procedure.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC,192,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],11012.10,,"Case rate ($6,292.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,989.50, add-ons for qualifying new technology services are included. If operating cost exceeds $40,860.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,077.96, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,029.69 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,044.54 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $317.98. The transfer capital threshold is the transfer adjustment factor * $317.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,6292.63,12753.78,All Other Inpatient
Laps Gstr Rstcv Px W/Byp Roux-en-Y Limb <150 Cm,CASE-43644,APC,43644,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
"Tendon Sheath Incision|LEFT FOOT, GREAT TOE",CASE-26055,APC,26055,CPT,0360,RC,,,TA,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1891.77,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1827.80,1919.19,OPPS APC
Peri-Implant Capsulectomy Breast Complete|BILATERAL PROCEDURE,CASE-19371,APC,19371,CPT,0360,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7918.25,,"APC Price ($7,650.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,7918.25,8033.01,OPPS APC
CESAREAN SECTION WITH STERILIZATION WITH MCC,783,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],18986.82,,"Case rate ($18,082.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,987.66, add-ons for qualifying new technology services are included. If operating cost exceeds $51,858.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,911.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $14,985.90 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,042.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,151.85. The transfer capital threshold is the transfer adjustment factor * $1,151.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12612.10,23722.94,Inpatient DRG
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],7086.00,,"Per diem ($7,086). If length of stay < 7.8, first 1 days paid at a per diem of $14,172 instead. Capped at $55,272.09.",,,,0,other,7086.00,57872.02,Estimated amount calculated based on 5 day length of stay.
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],12882.53,,,,,,0,other,4341.01,12882.53,There are no additional notes associated with this service or procedure.
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC,797,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],20928.55,,"Fee schedule rate ($20,928.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8719.72,20928.55,There are no additional notes associated with this service or procedure.
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITH MCC OR ANTINEOPLASTIC IMPLANT OR EPILEPSY WITH NEUROSTIMULATOR,023,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],15168.00,,"Per diem ($15,168). If length of stay < 7.1, first 1 days paid at a per diem of $30,336 instead. Capped at $107,689.53.",,,,0,other,15168.00,136379.44,Estimated amount calculated based on 6 day length of stay.
Thoracoscopy With Biopsyies of Pleura,CASE-32609,APC,32609,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5658.76,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5658.76,5941.70,OPPS APC
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],18245.94,,"Fee schedule rate ($18,245.94). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8106.18,18245.94,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],13574.43,,"Case rate ($12,928.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,182.77, add-ons for qualifying new technology services are included. If operating cost exceeds $47,053.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,543.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $10,199.15 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,237.82 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $783.93. The transfer capital threshold is the transfer adjustment factor * $783.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13260.40,32878.30,Inpatient DRG
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],21167.26,,"Fee schedule rate ($21,167.26). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,6841.83,21167.26,There are no additional notes associated with this service or procedure.
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],19371.27,,"Fee schedule rate ($19,371.27). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8643.20,19462.52,There are no additional notes associated with this service or procedure.
PREMATURITY WITHOUT MAJOR PROBLEMS,792,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],11512.88,,"Fee schedule rate ($11,512.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,1956.00,19457.66,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],22358.90,,"Fee schedule rate ($22,358.90). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9389.48,22358.90,There are no additional notes associated with this service or procedure.
Trurl Electrosurg Rescj Prostate Bleed Complete,CASE-52601,APC,52601,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5018.77,,"APC Price ($5,018.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5018.77,5269.71,OPPS APC
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],6067.55,,"Case rate ($5,778.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,511.33, add-ons for qualifying new technology services are included. If operating cost exceeds $40,382.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,040.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $3,553.28 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,566.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $280.39. The transfer capital threshold is the transfer adjustment factor * $280.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5778.62,11681.49,Inpatient DRG
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],18043.23,,"Fee schedule rate ($18,043.23). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7733.72,18043.23,There are no additional notes associated with this service or procedure.
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],14383.21,,"Case rate ($14,383.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,516, add-ons for qualifying new technology services are included. If operating cost exceeds $48,387.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,669.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,528.54 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,571.05 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $909.72. The transfer capital threshold is the transfer adjustment factor * $909.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,36140.75,Inpatient DRG
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],15983.18,,"Fee schedule rate ($15,983.18). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13891.57,34712.20,There are no additional notes associated with this service or procedure.
Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE,CASE-62323,APC,62323,CPT,0360,RC,,,XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],683.85,,"APC Price ($660.72). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,660.72,693.76,OPPS APC
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,418,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],13400.58,,"Case rate ($13,400.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,601.88, add-ons for qualifying new technology services are included. If operating cost exceeds $47,472.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,597.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $10,617.79 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,656.93 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $837.85. The transfer capital threshold is the transfer adjustment factor * $837.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,13400.58,39884.93,Inpatient DRG
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],81306.30,,"Fee schedule rate ($81,306.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,20846.48,81306.30,There are no additional notes associated with this service or procedure.
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],18594.09,,"Case rate ($18,594.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,433.29, add-ons for qualifying new technology services are included. If operating cost exceeds $52,304.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,977.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $15,431.44 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,488.34 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,217.69. The transfer capital threshold is the transfer adjustment factor * $1,217.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,18594.09,59494.91,Inpatient DRG
Excision Tumor Soft Tis Back/Flank Subq 3 Cm/>,CASE-21931,APC,21931,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1545.93,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1545.93,1600.04,OPPS APC
Hysteroscopy Removal Leiomyomata,CASE-58561,APC,58561,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],4682.41,,"APC Price ($4,682.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,4682.41,4916.53,OPPS APC
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],18578.07,,"Case rate ($17,693.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,595.40, add-ons for qualifying new technology services are included. If operating cost exceeds $51,466.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,911.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $14,596.63 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,650.45 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,151.82. The transfer capital threshold is the transfer adjustment factor * $1,151.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,17693.40,52449.26,Inpatient DRG
"ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",770,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],8910.01,,"Case rate ($8,735.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,261.87, add-ons for qualifying new technology services are included. If operating cost exceeds $43,132.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,256.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $6,293.72 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,316.92 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $496.64. The transfer capital threshold is the transfer adjustment factor * $496.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,8735.30,19730.13,Inpatient DRG
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],12246.05,,"Fee schedule rate ($12,246.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6010.23,12246.05,There are no additional notes associated with this service or procedure.
Revise Ulnar Nerve at Wrist|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64719,APC,64719,CPT,0360,RC,,,LT|XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3357.48,,"APC Price ($3,197.60). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3309.51,3357.48,OPPS APC
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],30352.35,,"Fee schedule rate ($30,352.35). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,18178.96,54764.34,There are no additional notes associated with this service or procedure.
COAGULATION DISORDERS,813,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],16098.60,,"Fee schedule rate ($16,098.60). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12274.39,30013.33,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],14377.77,,"Case rate ($13,891.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,058.63, add-ons for qualifying new technology services are included. If operating cost exceeds $47,929.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,633.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,072.85 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,113.68 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $873.76. The transfer capital threshold is the transfer adjustment factor * $873.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,13891.57,34712.20,Inpatient DRG
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,699,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],19972.16,,,,,,0,other,5961.00,19972.16,There are no additional notes associated with this service or procedure.
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],35474.53,,"Fee schedule rate ($35,474.53). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,16428.39,42083.20,There are no additional notes associated with this service or procedure.
Rpr Nonunion/Malunion Radius/Ulna W/O Autograft,CASE-25400,APC,25400,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7029.71,OPPS APC
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],96365.69,,"Fee schedule rate ($96,365.69). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,23377.19,96365.69,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6340.03,,"Case rate ($6,340.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,033.60, add-ons for qualifying new technology services are included. If operating cost exceeds $40,904.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,081.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $4,073.62 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,088.64 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $321.45. The transfer capital threshold is the transfer adjustment factor * $321.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6340.03,15076.44,Inpatient DRG
Laps W/Vag Hysterect 250 Gm/&Rmvl Tube&/Ovaries,CASE-58552,APC,58552,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],10298.02,,"APC Price ($9,949.78). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,9949.78,10298.02,OPPS APC
VENTRICULAR SHUNT PROCEDURES WITH CC,032,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],46275.08,,"Fee schedule rate ($46,275.08). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,16376.22,46275.08,There are no additional notes associated with this service or procedure.
SPINAL PROCEDURES WITHOUT CC/MCC,030,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],44714.01,,"Fee schedule rate ($44,714.01). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,16810.99,44714.01,There are no additional notes associated with this service or procedure.
NERVOUS SYSTEM NEOPLASMS WITH MCC,054,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],6965.00,,,,,,0,other,6965.00,30044.81,There are no additional notes associated with this service or procedure.
"Suture Digital Nerve Hand/Foot 1 Nerve|RIGHT HAND, THUMB",CASE-64831,APC,64831,CPT,0360,RC,,,F5,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1919.19,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1827.80,1919.19,OPPS APC
NON-MALIGNANT BREAST DISORDERS WITH CC/MCC,600,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],9448.68,,"Case rate ($8,998.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,506.94, add-ons for qualifying new technology services are included. If operating cost exceeds $43,377.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,275.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $6,537.88 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,561.99 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $515.90. The transfer capital threshold is the transfer adjustment factor * $515.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7999.14,20495.56,Inpatient DRG
SINGLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL,402,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],30193.07,,"Case rate ($29,172.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $27,273.75, add-ons for qualifying new technology services are included. If operating cost exceeds $62,144.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,751.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $25,235.76 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $25,328.80 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,991.35. The transfer capital threshold is the transfer adjustment factor * $1,991.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,29172.05,124455.45,Inpatient DRG
Dstr Nrolytc Agnt Parverteb Fct Addl Crvcl/Thora,CASE-64634,APC,64634,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1891.77,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1827.80,1919.19,OPPS APC
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],16669.71,,"Fee schedule rate ($16,669.71). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8767.81,19824.58,There are no additional notes associated with this service or procedure.
HC Joint Injection/Aspir Large WO US|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-20610,APC,20610,CPT,0510,RC,,,LT|XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],297.37,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,287.31,301.68,OPPS APC
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6793.41,,"Case rate ($6,469.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,162.87, add-ons for qualifying new technology services are included. If operating cost exceeds $41,033.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,082.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,201.98 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,217.92 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $322.97. The transfer capital threshold is the transfer adjustment factor * $322.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5919.29,13545.65,Inpatient DRG
Cystourethroscopy,CASE-52000,APC,52000,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],675.53,,"APC Price ($652.69). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,652.69,685.32,OPPS APC
Rmvl/Revj Sling Stress Incontinence,CASE-57287,APC,57287,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3030.03,,"APC Price ($3,030.03). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3030.03,3136.08,OPPS APC
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],13891.57,,"Case rate ($13,891.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,058.63, add-ons for qualifying new technology services are included. If operating cost exceeds $47,929.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,633.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,072.85 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,113.68 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $873.76. The transfer capital threshold is the transfer adjustment factor * $873.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,13891.57,34712.20,Inpatient DRG
HC Joint Injection/Aspir Medium WO US|PBB CHARGE|RIGHT SIDE,CASE-20605,APC,20605,CPT,0510,RC,,,PBB|RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],297.37,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,287.31,301.68,OPPS APC
COMPLICATIONS OF TREATMENT WITH CC,920,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],8732.59,,"Case rate ($8,732.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,259.35, add-ons for qualifying new technology services are included. If operating cost exceeds $43,130.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,256.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,291.21 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,314.40 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $496.44. The transfer capital threshold is the transfer adjustment factor * $496.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8732.59,20731.52,Inpatient DRG
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],19691.31,,"Fee schedule rate ($19,691.31). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,9040.72,26966.33,There are no additional notes associated with this service or procedure.
HC Inj Anes/Steroid C/D Facet Sg|RIGHT SIDE,CASE-64490,APC,64490,CPT,0361,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],856.86,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,827.89,869.28,OPPS APC
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC,806,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6695.39,,"Case rate ($6,376.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,075.86, add-ons for qualifying new technology services are included. If operating cost exceeds $40,946.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,076.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $4,115.31 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,130.91 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $316.31. The transfer capital threshold is the transfer adjustment factor * $316.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5354.25,13416.00,Inpatient DRG
RADIOTHERAPY,849,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],50919.63,,"Fee schedule rate ($50,919.63). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15.8), with a minimum of zero.",,,,0,other,20293.88,81867.07,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],35973.56,,"Fee schedule rate ($35,973.56). Adds an outlier to normal pricing equal to the per diem rate ($68,707.98) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,14908.05,49717.39,There are no additional notes associated with this service or procedure.
CHEST PAIN,313,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],15377.66,,"Fee schedule rate ($15,377.66). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,6820.84,15377.66,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],9095.00,,"Case rate ($8,787.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,310.38, add-ons for qualifying new technology services are included. If operating cost exceeds $43,181.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,260.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,342.05 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,365.43 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $500.45. The transfer capital threshold is the transfer adjustment factor * $500.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6965.00,32293.66,Inpatient DRG
HC Inject Tendon Origin/Insert|RIGHT SIDE,CASE-20551,APC,20551,CPT,0361,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],297.37,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,287.31,301.68,OPPS APC
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],6697.54,,"Case rate ($6,378.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,069.50, add-ons for qualifying new technology services are included. If operating cost exceeds $40,940.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,084.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,109.40 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,124.55 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $324.27. The transfer capital threshold is the transfer adjustment factor * $324.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,4341.01,12882.53,Inpatient DRG
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,025,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],32735.52,,"Case rate ($32,735.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $30,588.77, add-ons for qualifying new technology services are included. If operating cost exceeds $65,459.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,011.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.4. The base transfer operating payment is the transfer adjustment factor * $28,538.59 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $28,643.82 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,251.98. The transfer capital threshold is the transfer adjustment factor * $2,251.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,13351.00,91631.33,Inpatient DRG
INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC,198,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],23505.07,,"Fee schedule rate ($23,505.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6795.12,23505.07,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],6689.93,,"Case rate ($6,558.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,237.08, add-ons for qualifying new technology services are included. If operating cost exceeds $41,108.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,097.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $4,276.36 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,292.13 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $337.45. The transfer capital threshold is the transfer adjustment factor * $337.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6558.75,14871.83,Inpatient DRG
Ostectomy Calcaneus Spur W/WO Plntar Fascial Rls|LEFT SIDE,CASE-28119,APC,28119,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3169.86,3215.80,OPPS APC
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC",758,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],16323.02,,"Fee schedule rate ($16,323.02). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8574.80,19263.78,There are no additional notes associated with this service or procedure.
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],7733.72,,"Case rate ($7,733.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,330.12, add-ons for qualifying new technology services are included. If operating cost exceeds $42,201.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,183.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,365.38 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,385.17 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $423.38. The transfer capital threshold is the transfer adjustment factor * $423.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7733.72,18043.23,Inpatient DRG
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,191,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],8036.50,,"Case rate ($7,653.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,255.78, add-ons for qualifying new technology services are included. If operating cost exceeds $42,126.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,177.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,291.32 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,310.83 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $417.54. The transfer capital threshold is the transfer adjustment factor * $417.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,16612.88,Inpatient DRG
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],43399.23,,"Fee schedule rate ($43,399.23). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9888.00,43399.23,There are no additional notes associated with this service or procedure.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],40108.48,,"Fee schedule rate ($40,108.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,5569.00,40108.48,There are no additional notes associated with this service or procedure.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],8995.77,,"Case rate ($8,567.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,118.03, add-ons for qualifying new technology services are included. If operating cost exceeds $42,989.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,232.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,149.77 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,173.08 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $472.69. The transfer capital threshold is the transfer adjustment factor * $472.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8767.81,19824.58,Inpatient DRG
Anoscopy Dx W/HRA &Chem Agnts Enhancement W/Bx|SEPARATE STRUCTURE,CASE-46607,APC,46607,CPT,0360,RC,,,XS,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],2689.02,,"APC Price ($2,598.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2598.08,2727.99,OPPS APC
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],14871.83,,"Fee schedule rate ($14,871.83). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6558.75,14871.83,There are no additional notes associated with this service or procedure.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],51656.32,,"Fee schedule rate ($51,656.32). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,20559.34,54086.17,There are no additional notes associated with this service or procedure.
MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,708,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],29171.15,,,,,,0,other,10138.21,29171.15,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],28983.97,,"Fee schedule rate ($28,983.97). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8956.76,28983.97,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],18960.62,,"Case rate ($10,834.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,214.84, add-ons for qualifying new technology services are included. If operating cost exceeds $45,085.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,410.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $8,239.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,269.90 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $650.18. The transfer capital threshold is the transfer adjustment factor * $650.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,10834.64,25830.00,All Other Inpatient
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC,817,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],42878.11,,"Fee schedule rate ($42,878.11). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.5), with a minimum of zero.",,,,0,other,17396.11,44895.04,There are no additional notes associated with this service or procedure.
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH CC",457,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],112064.54,,"Fee schedule rate ($112,064.54). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.9), with a minimum of zero.",,,,0,other,42327.47,160549.49,There are no additional notes associated with this service or procedure.
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],22557.82,,"Fee schedule rate ($22,557.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6801.88,22557.82,There are no additional notes associated with this service or procedure.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],10865.40,,"Fee schedule rate ($10,865.40). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9446.38,21796.21,There are no additional notes associated with this service or procedure.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],28649.93,,"Fee schedule rate ($28,649.93). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,12268.97,41006.47,There are no additional notes associated with this service or procedure.
"Rpr Coltrl Ligm Mtcarphlngl/Iphal Jt|LEFT HAND, SECOND DIGIT",CASE-26540,APC,26540,CPT,0360,RC,,,F1,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3169.86,OPPS APC
"Application Uniplane External Fixation System|RIGHT HAND, FIFTH DIGIT",CASE-20690,APC,20690,CPT,0360,RC,,,F9,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6791.99,7131.59,OPPS APC
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC",494,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],16309.76,,"Case rate ($15,533.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,585.72, add-ons for qualifying new technology services are included. If operating cost exceeds $49,456.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,753.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $12,594.34 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,640.78 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $993.82. The transfer capital threshold is the transfer adjustment factor * $993.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,15533.10,39945.55,Inpatient DRG
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,555,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],42290.95,,"Fee schedule rate ($42,290.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10896.27,42290.95,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],21892.85,,"Fee schedule rate ($21,892.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7569.84,21892.85,There are no additional notes associated with this service or procedure.
Prq Impltj Neurostim Eltrd Sacral Nrve W/Imaging,CASE-64561,APC,64561,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6174.06,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5965.28,6263.54,OPPS APC
Vulvectomy Simple Partial|BILATERAL PROCEDURE,CASE-56620,APC,56620,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3030.03,,"APC Price ($3,030.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3030.03,3181.53,OPPS APC
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],5628.97,,"Case rate ($5,628.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,372.11, add-ons for qualifying new technology services are included. If operating cost exceeds $40,243.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,029.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,414.56 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,427.15 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $269.44. The transfer capital threshold is the transfer adjustment factor * $269.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,5628.97,12272.58,Inpatient DRG
Suture Infrapatellar Tendon Primary|BILATERAL PROCEDURE,CASE-27380,APC,27380,CPT,0360,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7029.71,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6791.99,7131.59,OPPS APC
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],9577.27,,"Case rate ($9,389.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,870.44, add-ons for qualifying new technology services are included. If operating cost exceeds $43,741.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,304.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,900.05 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,925.50 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $544.48. The transfer capital threshold is the transfer adjustment factor * $544.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,9389.48,22358.90,Inpatient DRG
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],11565.93,,"Fee schedule rate ($11,565.93). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6148.93,15887.21,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],54875.56,,"Fee schedule rate ($54,875.56). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,21719.40,85305.59,There are no additional notes associated with this service or procedure.
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],32168.63,,"Fee schedule rate ($32,168.63). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,13904.43,34749.58,There are no additional notes associated with this service or procedure.
NONTRAUMATIC STUPOR AND COMA WITH MCC,080,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],14699.47,,"Case rate ($14,202.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,347.79, add-ons for qualifying new technology services are included. If operating cost exceeds $48,218.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,656.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $11,360.96 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,402.84 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $896.49. The transfer capital threshold is the transfer adjustment factor * $896.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,14202.39,35615.37,Inpatient DRG
"NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY",789,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],6663.33,,,,,,0,other,3054.00,14857.05,Estimated amount calculated based on 1 day length of stay.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,477,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],62359.39,,"Fee schedule rate ($62,359.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,25339.74,67976.16,There are no additional notes associated with this service or procedure.
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],35419.59,,"Fee schedule rate ($35,419.59). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,7086.00,57872.02,There are no additional notes associated with this service or procedure.
PSYCHOSES,885,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],11974.38,,"Case rate ($11,404.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,744.67, add-ons for qualifying new technology services are included. If operating cost exceeds $45,615.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,451.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.5. The base transfer operating payment is the transfer adjustment factor * $8,767.39 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,799.72 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $691.83. The transfer capital threshold is the transfer adjustment factor * $691.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,2070.00,27484.83,Inpatient DRG
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],54236.60,,"Fee schedule rate ($54,236.60). Adds an outlier to normal pricing equal to the per diem rate ($122,612.56) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,21489.15,68942.79,There are no additional notes associated with this service or procedure.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],22017.02,,"Case rate ($21,585.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,215.96, add-ons for qualifying new technology services are included. If operating cost exceeds $55,086.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,196.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $18,203.89 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,271.01 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,436.47. The transfer capital threshold is the transfer adjustment factor * $1,436.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,21585.31,73588.10,Inpatient DRG
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],6829.10,,"Case rate ($6,503.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,186.05, add-ons for qualifying new technology services are included. If operating cost exceeds $41,057.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,093.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $4,225.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,241.10 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $333.44. The transfer capital threshold is the transfer adjustment factor * $333.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6503.90,14492.93,Inpatient DRG
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],28394.78,,"Fee schedule rate ($28,394.78). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11454.97,28394.78,There are no additional notes associated with this service or procedure.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],133270.57,,"Fee schedule rate ($133,270.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,33623.33,133270.57,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],35192.25,,"Fee schedule rate ($35,192.25). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,10895.60,35192.25,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],29342.21,,"Case rate ($27,944.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $26,132.21, add-ons for qualifying new technology services are included. If operating cost exceeds $61,003.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,661.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.8. The base transfer operating payment is the transfer adjustment factor * $24,098.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $24,187.26 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,901.60. The transfer capital threshold is the transfer adjustment factor * $1,901.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,27944.96,86252.84,Inpatient DRG
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,082,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],30490.62,,"Case rate ($17,423.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,344.04, add-ons for qualifying new technology services are included. If operating cost exceeds $51,215.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,892.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $14,346.19 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,399.08 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,132.06. The transfer capital threshold is the transfer adjustment factor * $1,132.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,17423.21,56223.11,All Other Inpatient
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],75579.22,,"Fee schedule rate ($75,579.22). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,25162.32,75579.22,There are no additional notes associated with this service or procedure.
Colonoscopy W/Biopsy Single/Multiple,CASE-45380,APC,45380,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1176.09,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1120.09,1176.09,OPPS APC
Cystourethroscopy Inj Chemodenervation Bladder,CASE-52287,APC,52287,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1956.65,,"APC Price ($1,956.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1956.65,2054.48,OPPS APC
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],9533.13,,"Fee schedule rate ($9,533.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5068.21,14525.56,There are no additional notes associated with this service or procedure.
"BRONCHIOLITIS AND RSV PNEUMONIA,MODERATE",138,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],4858.09,,"Case rate ($4,858.09). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,4858.09,5100.99,There are no additional notes associated with this service or procedure.
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],8511.49,,"Case rate ($8,106.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,676.61, add-ons for qualifying new technology services are included. If operating cost exceeds $42,547.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,210.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,710.61 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,731.66 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $450.62. The transfer capital threshold is the transfer adjustment factor * $450.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8106.18,18245.94,Inpatient DRG
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],29497.93,,"Case rate ($28,093.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $26,270.18, add-ons for qualifying new technology services are included. If operating cost exceeds $61,141.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,672.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $24,235.87 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $24,325.23 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,912.45. The transfer capital threshold is the transfer adjustment factor * $1,912.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,10078.00,81454.07,Inpatient DRG
NON-MALIGNANT BREAST DISORDERS WITH CC/MCC,600,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],19574.79,,"Fee schedule rate ($19,574.79). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7999.14,20495.56,There are no additional notes associated with this service or procedure.
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],28334.16,,"Fee schedule rate ($28,334.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,7868.00,32126.64,There are no additional notes associated with this service or procedure.
O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC,621,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],28347.36,,"Fee schedule rate ($28,347.36). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12159.94,36669.96,There are no additional notes associated with this service or procedure.
CERVICAL SPINAL FUSION WITHOUT CC/MCC,473,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],62077.11,,"Fee schedule rate ($62,077.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,18477.61,62077.11,There are no additional notes associated with this service or procedure.
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH MCC",510,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],89863.76,,"Fee schedule rate ($89,863.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10710.00,89863.76,There are no additional notes associated with this service or procedure.
OSTEOMYELITIS WITHOUT CC/MCC,541,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],7277.28,,"Case rate ($7,277.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,905.50, add-ons for qualifying new technology services are included. If operating cost exceeds $41,776.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,149.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $4,942.33 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,960.55 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $390.00. The transfer capital threshold is the transfer adjustment factor * $390.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,5103.00,15493.67,Inpatient DRG
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],12573.10,,"Case rate ($11,974.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,275.12, add-ons for qualifying new technology services are included. If operating cost exceeds $46,146.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,493.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $9,295.90 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,330.17 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $733.54. The transfer capital threshold is the transfer adjustment factor * $733.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,11974.38,29141.64,Inpatient DRG
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],15448.98,,"Case rate ($14,713.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,846.90, add-ons for qualifying new technology services are included. If operating cost exceeds $48,717.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,671.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,856.99 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,901.95 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $911.36. The transfer capital threshold is the transfer adjustment factor * $911.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7605.00,39153.65,Inpatient DRG
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],8372.32,,"Case rate ($8,372.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,924.20, add-ons for qualifying new technology services are included. If operating cost exceeds $42,795.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,230.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,957.28 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,979.25 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $470.09. The transfer capital threshold is the transfer adjustment factor * $470.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,23385.72,Inpatient DRG
PREMATURITY WITH MAJOR PROBLEMS,791,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],3186.77,,,,,,0,other,3048.21,30904.42,Estimated amount calculated based on 5 day length of stay.
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,082,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],56223.11,,"Fee schedule rate ($56,223.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,17423.21,56223.11,There are no additional notes associated with this service or procedure.
Colorectal Scrn; Hi Risk Ind|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-G0105,APC,G0105,CPT,0360,RC,,,74,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],900.93,,"APC Price ($870.46). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,870.46,913.99,OPPS APC
BRONCHITIS AND ASTHMA WITHOUT CC/MCC,203,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],6965.00,,,,,,0,other,4763.76,13707.00,There are no additional notes associated with this service or procedure.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],26420.44,,"Case rate ($25,162.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $23,543.58, add-ons for qualifying new technology services are included. If operating cost exceeds $58,414.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,458.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $21,519.28 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $21,598.63 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,698.08. The transfer capital threshold is the transfer adjustment factor * $1,698.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,25162.32,75579.22,Inpatient DRG
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],11612.44,,"Case rate ($11,059.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,424, add-ons for qualifying new technology services are included. If operating cost exceeds $45,295.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,426.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $8,447.91 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,479.05 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $666.62. The transfer capital threshold is the transfer adjustment factor * $666.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,11059.47,28423.20,Inpatient DRG
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],16438.59,,"Fee schedule rate ($16,438.59). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7402.56,16438.59,There are no additional notes associated with this service or procedure.
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],12526.44,,"Fee schedule rate ($12,526.44). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5415.00,17575.50,There are no additional notes associated with this service or procedure.
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],15589.58,,"Case rate ($15,283.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,353.89, add-ons for qualifying new technology services are included. If operating cost exceeds $49,224.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,735.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.2. The base transfer operating payment is the transfer adjustment factor * $12,363.36 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,408.94 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $975.59. The transfer capital threshold is the transfer adjustment factor * $975.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,15283.90,38757.79,Inpatient DRG
Cysto W/Ureteroscopy W/Rmvl/Manj Stones|LEFT SIDE,CASE-52352,APC,52352,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3414.95,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3299.47,3464.44,OPPS APC
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC",758,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],16323.02,,"Fee schedule rate ($16,323.02). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8574.80,19263.78,There are no additional notes associated with this service or procedure.
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],42021.93,,"Fee schedule rate ($42,021.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,21248.73,56089.29,There are no additional notes associated with this service or procedure.
"HERNIA PROCEDURES EXCEPT INGUINAL FEMORAL AND UMBILICAL,MODERATE",227,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],3586.41,,"Case rate for a one day stay ($3,586.41). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,3586.41,3765.73,There are no additional notes associated with this service or procedure.
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],7749.28,,"Case rate ($7,749.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,344.60, add-ons for qualifying new technology services are included. If operating cost exceeds $42,215.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,184.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,379.82 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,399.66 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $424.52. The transfer capital threshold is the transfer adjustment factor * $424.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6711.00,16865.16,Inpatient DRG
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],26966.33,,"Fee schedule rate ($26,966.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,9040.72,26966.33,There are no additional notes associated with this service or procedure.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],23799.09,,"Case rate ($23,799.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $22,275.40, add-ons for qualifying new technology services are included. If operating cost exceeds $57,146.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,358.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.1. The base transfer operating payment is the transfer adjustment factor * $20,255.77 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $20,330.45 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,598.38. The transfer capital threshold is the transfer adjustment factor * $1,598.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,23799.09,63499.65,Inpatient DRG
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],16498.03,,"Case rate ($15,712.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,778.22, add-ons for qualifying new technology services are included. If operating cost exceeds $49,649.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,742.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $12,784.80 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,833.27 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $982.67. The transfer capital threshold is the transfer adjustment factor * $982.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,16129.04,59610.47,Inpatient DRG
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],19011.10,,"Case rate ($18,105.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,979.06, add-ons for qualifying new technology services are included. If operating cost exceeds $51,850.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,941.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $14,978.89 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,034.11 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,181.98. The transfer capital threshold is the transfer adjustment factor * $1,181.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,18105.81,52699.33,Inpatient DRG
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],25769.12,,"Case rate ($14,725.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,834.15, add-ons for qualifying new technology services are included. If operating cost exceeds $48,705.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,694.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,845.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,889.20 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $934.73. The transfer capital threshold is the transfer adjustment factor * $934.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,7389.00,37134.43,All Other Inpatient
HC Inj Trigger Pt 1-2 Musc Grps|ADJ,CASE-20552,APC,20552,CPT,0510,RC,,,ADJ,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],301.68,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,287.31,301.68,OPPS APC
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],35314.31,,,,,,0,other,7332.00,35314.31,There are no additional notes associated with this service or procedure.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,544,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],14181.20,,"Fee schedule rate ($14,181.20). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7055.15,23207.64,There are no additional notes associated with this service or procedure.
Vulvectomy Simple Partial,CASE-56620,APC,56620,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3181.53,,"APC Price ($3,030.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3030.03,3181.53,OPPS APC
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITHOUT CC/MCC",630,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],42541.02,,"Fee schedule rate ($42,541.02). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11828.78,42541.02,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,448,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],83446.22,,,,,,0,other,30663.95,94077.13,There are no additional notes associated with this service or procedure.
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],18245.94,,"Fee schedule rate ($18,245.94). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8106.18,18245.94,There are no additional notes associated with this service or procedure.
Tx Incomplete Abortion Any Trimester Surgical,CASE-59812,APC,59812,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3030.03,,"APC Price ($3,030.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3030.03,3181.53,OPPS APC
FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,748,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],10807.69,,"Case rate ($10,293.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $9,679.84, add-ons for qualifying new technology services are included. If operating cost exceeds $48,324.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $3,378.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.4. The base transfer operating payment is the transfer adjustment factor * $8,283.19 + an uncompensated DSH payment of $1,359.91. The transfer operating threshold is the transfer adjustment factor * $8,319.93 + an uncompensated DSH payment of $1,359.91. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $649.94. The transfer capital threshold is the transfer adjustment factor * $649.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9316.20,26805.98,Inpatient DRG
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],10998.68,,"Case rate ($10,474.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,896.13, add-ons for qualifying new technology services are included. If operating cost exceeds $44,767.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,368.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $7,921.14 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,951.18 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $608.84. The transfer capital threshold is the transfer adjustment factor * $608.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10733.06,45157.33,Inpatient DRG
"Arthrodesis Interphalangeal Jt W/WO Int Fixj|LEFT HAND, THUMB",CASE-26860,APC,26860,CPT,0360,RC,,,FA,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3215.80,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
SALIVARY GLAND PROCEDURES,139,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],23222.51,,"Fee schedule rate ($23,222.51). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.9), with a minimum of zero.",,,,0,other,10313.19,30690.92,There are no additional notes associated with this service or procedure.
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],21675.85,,"Fee schedule rate ($21,675.85). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,9755.86,29216.99,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6153.12,,"Case rate ($6,153.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,859.72, add-ons for qualifying new technology services are included. If operating cost exceeds $40,730.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,067.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,900.39 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,914.77 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $307.78. The transfer capital threshold is the transfer adjustment factor * $307.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6153.12,13947.32,Inpatient DRG
NON-MALIGNANT BREAST DISORDERS WITH CC/MCC,600,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],19574.79,,"Fee schedule rate ($19,574.79). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7999.14,20495.56,There are no additional notes associated with this service or procedure.
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC,964,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],21566.69,,"Case rate ($12,323.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,600.20, add-ons for qualifying new technology services are included. If operating cost exceeds $46,471.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,519.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $9,619.78 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,655.25 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $759.10. The transfer capital threshold is the transfer adjustment factor * $759.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,12323.82,34154.06,All Other Inpatient
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC,806,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],10071.17,,"Fee schedule rate ($10,071.17). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5354.25,13416.00,There are no additional notes associated with this service or procedure.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,191,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],7806.89,,"Case rate ($7,653.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,255.78, add-ons for qualifying new technology services are included. If operating cost exceeds $42,126.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,177.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,291.32 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,310.83 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $417.54. The transfer capital threshold is the transfer adjustment factor * $417.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6965.00,16612.88,Inpatient DRG
Neuroplasty &/Transpos Median Nrv Carpal Tunne|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64721,APC,64721,CPT,0360,RC,,,RT|XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1919.19,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1827.80,1919.19,OPPS APC
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC,434,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],13280.45,,"Fee schedule rate ($13,280.45). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6770.05,14019.86,There are no additional notes associated with this service or procedure.
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC",514,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],9045.40,,"Case rate ($8,868.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,385.35, add-ons for qualifying new technology services are included. If operating cost exceeds $43,256.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,266.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $6,416.74 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,440.40 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $506.34. The transfer capital threshold is the transfer adjustment factor * $506.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,8868.04,22699.91,Inpatient DRG
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level|BILATERAL PROCEDURE,CASE-64483,APC,64483,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],827.89,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,827.89,869.28,OPPS APC
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],8778.37,,"Case rate ($8,360.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,925.03, add-ons for qualifying new technology services are included. If operating cost exceeds $42,796.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,217.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $5,957.49 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,980.08 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $457.91. The transfer capital threshold is the transfer adjustment factor * $457.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8554.50,19204.75,Inpatient DRG
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,555,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],24840.59,,"Fee schedule rate ($24,840.59). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10896.27,42290.95,There are no additional notes associated with this service or procedure.
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],36140.75,,,,,,0,other,6965.00,36140.75,There are no additional notes associated with this service or procedure.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],8702.79,,"Case rate ($8,702.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,231.63, add-ons for qualifying new technology services are included. If operating cost exceeds $43,102.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,254.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,263.59 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,286.68 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $494.26. The transfer capital threshold is the transfer adjustment factor * $494.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,5683.00,19635.68,Inpatient DRG
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],2070.00,,,,,,0,other,1188.00,17370.86,Estimated amount calculated based on 3 day length of stay.
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],27553.62,,"Fee schedule rate ($27,553.62). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12305.53,30103.84,There are no additional notes associated with this service or procedure.
"VAGINAL DELIVERY WITH O.R. PROCEDURE EXCEPT STERILIZATION AND/OR D&C,MODERATE",542,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],5254.11,,"Case rate ($5,003.91). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5003.91,5254.11,There are no additional notes associated with this service or procedure.
Colonoscopy W/Biopsy Single/Multiple|UNUSUAL NON-OVERLAPPING SERVICE|COLORECTAL CANCER SCREEN,CASE-45380,APC,45380,CPT,0360,RC,,,XU|PT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1176.09,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1120.09,1176.09,OPPS APC
Transurethral Resection Bladder Neck,CASE-52500,APC,52500,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3464.44,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3299.47,3464.44,OPPS APC
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],45845.03,,"Fee schedule rate ($45,845.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,18598.83,48389.68,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],33398.16,,"Fee schedule rate ($33,398.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,7353.00,33398.16,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITHOUT CC/MCC,428,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],118904.57,,"Fee schedule rate ($118,904.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,40017.53,118904.57,There are no additional notes associated with this service or procedure.
SPINAL PROCEDURES WITH MCC,028,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],43486.24,,"Case rate ($42,633.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $39,796.72, add-ons for qualifying new technology services are included. If operating cost exceeds $74,667.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,735.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.5. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 9.5)) / 2. The base transfer operating payment is the transfer adjustment factor * $37,712.72 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $37,851.77 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,975.91. The transfer capital threshold is the transfer adjustment factor * $2,975.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,42633.57,120982.83,Inpatient DRG
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],15318.94,,"Fee schedule rate ($15,318.94). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6214.05,15318.94,There are no additional notes associated with this service or procedure.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],9185.43,,"Case rate ($8,874.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,391.65, add-ons for qualifying new technology services are included. If operating cost exceeds $43,262.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,266.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $6,423.02 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,446.70 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $506.84. The transfer capital threshold is the transfer adjustment factor * $506.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,8874.81,20553.44,Inpatient DRG
HEADACHES WITHOUT MCC,103,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],20883.08,,"Fee schedule rate ($20,883.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,20883.08,There are no additional notes associated with this service or procedure.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],31813.18,,"Case rate ($18,178.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,047.10, add-ons for qualifying new technology services are included. If operating cost exceeds $51,918.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,947.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $15,046.67 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,102.15 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,187.33. The transfer capital threshold is the transfer adjustment factor * $1,187.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,18178.96,54764.34,All Other Inpatient
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],22805.37,,"Case rate ($21,719.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,340.70, add-ons for qualifying new technology services are included. If operating cost exceeds $55,211.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,206.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.2. The base transfer operating payment is the transfer adjustment factor * $18,328.17 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,395.75 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,446.27. The transfer capital threshold is the transfer adjustment factor * $1,446.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,21719.40,85305.59,Inpatient DRG
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],21862.29,,"Case rate ($21,862.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,473.63, add-ons for qualifying new technology services are included. If operating cost exceeds $55,344.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,216.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. The base transfer operating payment is the transfer adjustment factor * $18,460.61 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,528.68 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,456.72. The transfer capital threshold is the transfer adjustment factor * $1,456.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7086.00,57872.02,Inpatient DRG
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],28751.41,,"Fee schedule rate ($28,751.41). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12305.53,30103.84,There are no additional notes associated with this service or procedure.
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],14492.93,,"Fee schedule rate ($14,492.93). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6503.90,14492.93,There are no additional notes associated with this service or procedure.
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",759,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],11268.08,,"Case rate ($6,438.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,125.57, add-ons for qualifying new technology services are included. If operating cost exceeds $40,996.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,088.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,165.27 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,180.62 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $328.68. The transfer capital threshold is the transfer adjustment factor * $328.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,6190.22,13057.66,All Other Inpatient
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],22565.55,,"Fee schedule rate ($22,565.55). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,17356.15,44778.95,There are no additional notes associated with this service or procedure.
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],9667.64,,"Fee schedule rate ($9,667.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,5139.72,13110.79,There are no additional notes associated with this service or procedure.
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],81306.30,,"Fee schedule rate ($81,306.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,20846.48,81306.30,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],46016.63,,,,,,0,other,17782.11,46523.26,There are no additional notes associated with this service or procedure.
Colon Ca Scrn Not Hi Rsk Ind|DOCUMENTATION ON FILE,CASE-G0121,APC,G0121,CPT,0360,RC,,,KX,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],900.93,,"APC Price ($870.46). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,870.46,913.99,OPPS APC
PREMATURITY WITH MAJOR PROBLEMS,791,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],29432.78,,"Case rate ($29,432.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $27,516.30, add-ons for qualifying new technology services are included. If operating cost exceeds $62,387.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,770.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 13.3. The base transfer operating payment is the transfer adjustment factor * $25,477.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $25,571.35 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,010.42. The transfer capital threshold is the transfer adjustment factor * $2,010.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,3048.21,30904.42,Inpatient DRG
Neuroplasty &/Transposition Ulnar Nerve Elbow,CASE-64718,APC,64718,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1891.77,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1827.80,1919.19,OPPS APC
SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS,870,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],161307.29,,"Fee schedule rate ($161,307.29). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (41), with a minimum of zero.",,,,0,other,161307.29,161307.29,There are no additional notes associated with this service or procedure.
OTHER MENTAL DISORDER DIAGNOSES,887,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],6965.00,,,,,,0,other,2070.00,21072.10,There are no additional notes associated with this service or procedure.
Endoscopic Papilla Cannulation Bile/Pancreatic,CASE-43273,APC,43273,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3608.81,,"APC Price ($3,608.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3608.81,3789.26,OPPS APC
Surgical Arthroscopy Shoulder Repair Slap Lesion|LEFT SIDE,CASE-29807,APC,29807,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,988,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],30888.17,,"Fee schedule rate ($30,888.17). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.5), with a minimum of zero.",,,,0,other,13075.52,42425.46,There are no additional notes associated with this service or procedure.
Perq Nl/Pl Lithotrp Simple Up to 2 Cm 1 Location|LEFT SIDE,CASE-50080,APC,50080,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],9303.88,,"APC Price ($8,860.83). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,8860.83,9303.88,OPPS APC
SINGLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL,402,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],29172.05,,"Case rate ($29,172.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $27,273.75, add-ons for qualifying new technology services are included. If operating cost exceeds $62,144.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,751.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $25,235.76 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $25,328.80 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,991.35. The transfer capital threshold is the transfer adjustment factor * $1,991.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,29172.05,124455.45,Inpatient DRG
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],13608.50,,"Case rate ($13,341.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,547.08, add-ons for qualifying new technology services are included. If operating cost exceeds $47,418.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,593.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $10,563.18 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,602.13 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $833.54. The transfer capital threshold is the transfer adjustment factor * $833.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,13341.67,42586.49,Inpatient DRG
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],13947.32,,"Fee schedule rate ($13,947.32). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6153.12,13947.32,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH CC,427,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],135659.15,,"Fee schedule rate ($135,659.15). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.8), with a minimum of zero.",,,,0,other,50829.82,142040.39,There are no additional notes associated with this service or procedure.
PREMATURITY WITH MAJOR PROBLEMS,791,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],3186.77,,,,,,0,other,3048.21,30904.42,Estimated amount calculated based on 5 day length of stay.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],52803.53,,"Fee schedule rate ($52,803.53). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,14337.84,52803.53,There are no additional notes associated with this service or procedure.
Open Biopsy/Excision Inguinofemoral Nodes|RIGHT SIDE,CASE-38531,APC,38531,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6432.89,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6215.36,6526.12,OPPS APC
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITHOUT CC/MCC",630,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],42541.02,,"Fee schedule rate ($42,541.02). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11828.78,42541.02,There are no additional notes associated with this service or procedure.
CHEST PAIN,313,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],15377.66,,"Fee schedule rate ($15,377.66). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,6820.84,15377.66,There are no additional notes associated with this service or procedure.
Arthrp Interpos Intercarpal/Metacarpal Joints|RIGHT SIDE,CASE-25447,APC,25447,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3169.86,OPPS APC
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH CC,026,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],58431.20,,"Fee schedule rate ($58,431.20). Adds an outlier to normal pricing equal to the per diem rate ($112,420.62) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,23000.66,63202.45,There are no additional notes associated with this service or procedure.
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC",514,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],9311.44,,"Case rate ($8,868.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,385.35, add-ons for qualifying new technology services are included. If operating cost exceeds $43,256.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,266.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $6,416.74 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,440.40 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $506.34. The transfer capital threshold is the transfer adjustment factor * $506.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8868.04,22699.91,Inpatient DRG
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],25253.70,,"Fee schedule rate ($25,253.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11974.38,29141.64,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],33277.97,,"Case rate ($31,693.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $29,619.21, add-ons for qualifying new technology services are included. If operating cost exceeds $64,490.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,935.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. The base transfer operating payment is the transfer adjustment factor * $27,572.60 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $27,674.26 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,175.75. The transfer capital threshold is the transfer adjustment factor * $2,175.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10862.00,86437.13,Inpatient DRG
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],13486.95,,"Fee schedule rate ($13,486.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6915.64,14442.92,There are no additional notes associated with this service or procedure.
Colsc Flx With Directed Submucosal Njx Any Sbst|COLORECTAL CANCER SCREEN,CASE-45381,APC,45381,CPT,0360,RC,,,PT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1120.09,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1120.09,1176.09,OPPS APC
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],32980.62,,,,,,0,other,7000.00,33835.79,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],59021.28,,"Fee schedule rate ($59,021.28). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,23851.92,63653.13,There are no additional notes associated with this service or procedure.
PREMATURITY WITHOUT MAJOR PROBLEMS,792,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],18946.11,,"Case rate ($18,043.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,951.51, add-ons for qualifying new technology services are included. If operating cost exceeds $51,822.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,909.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. The base transfer operating payment is the transfer adjustment factor * $14,949.88 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,006.56 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,149.08. The transfer capital threshold is the transfer adjustment factor * $1,149.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,1956.00,19457.66,Inpatient DRG
Esophagogastroduodenoscopy Submucosal Injection|UNUSUAL NON-OVERLAPPING SERVICE,CASE-43236,APC,43236,CPT,0360,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],848.96,,"APC Price ($848.96). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,848.96,891.41,OPPS APC
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],59494.91,,"Fee schedule rate ($59,494.91). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,18594.09,59494.91,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITH STERILIZATION WITH CC,784,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],12612.10,,"Fee schedule rate ($12,612.10). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9124.01,23722.94,There are no additional notes associated with this service or procedure.
PREMATURITY WITHOUT MAJOR PROBLEMS,792,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],18946.11,,"Case rate ($18,043.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,951.51, add-ons for qualifying new technology services are included. If operating cost exceeds $51,822.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,909.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. The base transfer operating payment is the transfer adjustment factor * $14,949.88 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,006.56 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,149.08. The transfer capital threshold is the transfer adjustment factor * $1,149.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,1956.00,19457.66,Inpatient DRG
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],24528.10,,"Fee schedule rate ($24,528.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10989.72,26280.60,There are no additional notes associated with this service or procedure.
Laps Surg Rpr Recurrent Inguinal Hernia|BILATERAL PROCEDURE,CASE-49651,APC,49651,CPT,0360,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5941.70,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5658.76,5941.70,OPPS APC
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],16035.06,,"Fee schedule rate ($16,035.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,7396.47,16035.06,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],6965.00,,,,,,0,other,6558.75,14871.83,There are no additional notes associated with this service or procedure.
SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS,029,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],32903.05,,"Fee schedule rate ($32,903.05). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13641.00,67130.05,There are no additional notes associated with this service or procedure.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],41187.90,,,,,,0,other,16120.25,41187.90,There are no additional notes associated with this service or procedure.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],6965.00,,,,,,0,other,6965.00,20401.88,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,426,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],177294.98,,"Fee schedule rate ($177,294.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,76581.29,216864.15,There are no additional notes associated with this service or procedure.
Insj/Rplcmt Perq Eltrd Ra Pn W/Int Nstim 1st Ra,CASE-64596,APC,64596,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],10951.32,,"APC Price ($10,429.83). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,10429.83,10951.32,OPPS APC
Cystourethroscopy W/Dest &/Rmvl Tumor Large,CASE-52240,APC,52240,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5269.71,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5018.77,5269.71,OPPS APC
COMPLICATIONS OF TREATMENT WITH CC,920,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],9169.22,,"Case rate ($8,732.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,259.35, add-ons for qualifying new technology services are included. If operating cost exceeds $43,130.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,256.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,291.21 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,314.40 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $496.44. The transfer capital threshold is the transfer adjustment factor * $496.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8732.59,20731.52,Inpatient DRG
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],59081.91,,"Fee schedule rate ($59,081.91). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,8480.00,59081.91,There are no additional notes associated with this service or procedure.
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],12937.10,,"Fee schedule rate ($12,937.10). Adds an outlier to normal pricing equal to the per diem rate ($49,808.13) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.5), with a minimum of zero.",,,,0,other,5919.29,13545.65,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],28235.64,,"Fee schedule rate ($28,235.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,14344.60,36028.59,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],16066.07,,"Case rate ($16,066.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,081.53, add-ons for qualifying new technology services are included. If operating cost exceeds $49,952.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,792.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $13,088.32 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,136.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,032.80. The transfer capital threshold is the transfer adjustment factor * $1,032.80. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,41030.48,Inpatient DRG
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,082,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],18033.02,,"Case rate ($17,423.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,344.04, add-ons for qualifying new technology services are included. If operating cost exceeds $51,215.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,892.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $14,346.19 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,399.08 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,132.06. The transfer capital threshold is the transfer adjustment factor * $1,132.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,17423.21,56223.11,Inpatient DRG
Excision Pilonidal Cyst/Sinus Complicated,CASE-11772,APC,11772,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],2854.83,,"APC Price ($2,718.88). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2718.88,2854.83,OPPS APC
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],8326.32,,"Case rate ($8,163.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,729.53, add-ons for qualifying new technology services are included. If operating cost exceeds $42,600.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,214.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,763.33 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,784.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $454.78. The transfer capital threshold is the transfer adjustment factor * $454.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,8163.06,18067.42,Inpatient DRG
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",062,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],14329.41,,"Case rate ($13,844.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,015.16, add-ons for qualifying new technology services are included. If operating cost exceeds $47,886.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,630.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $11,029.54 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,070.21 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $870.34. The transfer capital threshold is the transfer adjustment factor * $870.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,13844.84,44304.80,Inpatient DRG
HC Rep Cpx Sc Arm Lg 2.6-7.5cm,CASE-13121,APC,13121,CPT,0450,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1545.93,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1545.93,1623.23,OPPS APC
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],8537.49,,"Case rate ($8,130.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,711.19, add-ons for qualifying new technology services are included. If operating cost exceeds $42,582.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,201.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,744.46 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,766.24 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $441.53. The transfer capital threshold is the transfer adjustment factor * $441.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8318.14,19763.43,Inpatient DRG
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITHOUT CC/MCC,816,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6404.14,,"Case rate ($6,099.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,817.30, add-ons for qualifying new technology services are included. If operating cost exceeds $40,688.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,056.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $3,857.72 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,872.35 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $296.51. The transfer capital threshold is the transfer adjustment factor * $296.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6224.90,14733.53,Inpatient DRG
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],19763.43,,"Fee schedule rate ($19,763.43). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,8318.14,19763.43,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITHOUT CC/MCC,428,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],110624.09,,,,,,0,other,40017.53,118904.57,There are no additional notes associated with this service or procedure.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH CC,354,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],31968.77,,"Fee schedule rate ($31,968.77). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11633.13,33472.54,There are no additional notes associated with this service or procedure.
Arthrodesis Cmbn Tq 1ntrspc Each Additional,CASE-22634,APC,22634,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],26668.00,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,25398.09,26668.00,OPPS APC
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],28210.91,,"Case rate ($27,256.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $25,492.14, add-ons for qualifying new technology services are included. If operating cost exceeds $60,363.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,611.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. The base transfer operating payment is the transfer adjustment factor * $23,460.69 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $23,547.19 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,851.28. The transfer capital threshold is the transfer adjustment factor * $1,851.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,27256.92,81353.66,Inpatient DRG
NORMAL NEWBORN,795,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],2576.52,,"Fee schedule rate ($2,576.52). Adds an outlier to normal pricing equal to the per diem rate ($414) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,1369.79,5771.52,There are no additional notes associated with this service or procedure.
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6457.19,,"Case rate ($6,457.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,142.59, add-ons for qualifying new technology services are included. If operating cost exceeds $41,013.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,089.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $4,182.21 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,197.63 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $330.02. The transfer capital threshold is the transfer adjustment factor * $330.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,5139.72,13110.79,Inpatient DRG
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],11594.35,,"Fee schedule rate ($11,594.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6164.03,14071.02,There are no additional notes associated with this service or procedure.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,098,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],6965.00,,,,,,0,other,6965.00,45156.75,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL HEMORRHAGE WITH CC,378,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],8758.06,,"Case rate ($8,586.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,123.28, add-ons for qualifying new technology services are included. If operating cost exceeds $42,994.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,245.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,155.63 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,178.33 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $485.74. The transfer capital threshold is the transfer adjustment factor * $485.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,8586.33,20845.19,Inpatient DRG
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC",923,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],20068.57,,,,,,0,other,6965.00,20068.57,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC,832,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],9034.88,,"Fee schedule rate ($9,034.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4803.31,14198.92,There are no additional notes associated with this service or procedure.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],39153.65,,"Fee schedule rate ($39,153.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,7605.00,39153.65,There are no additional notes associated with this service or procedure.
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],13747.09,,"Case rate ($13,092.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,315.24, add-ons for qualifying new technology services are included. If operating cost exceeds $47,186.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,575.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $10,332.19 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,370.29 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $815.31. The transfer capital threshold is the transfer adjustment factor * $815.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13092.47,33159.45,Inpatient DRG
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,309,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],6965.00,,,,,,0,other,5055.77,14547.21,There are no additional notes associated with this service or procedure.
NONTRAUMATIC STUPOR AND COMA WITH MCC,080,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],30179.40,,"Fee schedule rate ($30,179.40). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,14202.39,35615.37,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],42768.36,,"Fee schedule rate ($42,768.36). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,14295.18,42768.36,There are no additional notes associated with this service or procedure.
Esophagogastroduodenoscopy Submucosal Injection|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-43236,APC,43236,CPT,0360,RC,,,74,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],891.41,,"APC Price ($848.96). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,848.96,891.41,OPPS APC
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],32852.04,,"Fee schedule rate ($32,852.04). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,13783.20,41580.51,There are no additional notes associated with this service or procedure.
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],22762.43,,"Fee schedule rate ($22,762.43). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6230.00,22762.43,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,699,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],19570.20,,"Fee schedule rate ($19,570.20). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5961.00,19972.16,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,066,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],6965.00,,,,,,0,other,6579.76,20083.61,There are no additional notes associated with this service or procedure.
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],5415.00,,"Per diem ($5,415). If length of stay < 3.1, first 1 days paid at a per diem of $10,830 instead. Capped at $16,785.91.",,,,0,other,5415.00,17575.50,Estimated amount calculated based on 3 day length of stay.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],31007.30,,"Fee schedule rate ($31,007.30). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,16120.25,41187.90,There are no additional notes associated with this service or procedure.
Arthrs Kne Surg W/Meniscectomy Med/Lat W/Shvg|RIGHT SIDE|SEPARATE STRUCTURE,CASE-29881,APC,29881,CPT,0360,RC,,,RT|XS,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],19249.79,,"Case rate ($18,598.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,437.70, add-ons for qualifying new technology services are included. If operating cost exceeds $52,308.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,978.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 5.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $15,435.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,492.75 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,218.04. The transfer capital threshold is the transfer adjustment factor * $1,218.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,18598.83,48389.68,Inpatient DRG
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],33835.79,,"Fee schedule rate ($33,835.79). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,7000.00,33835.79,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],19763.43,,"Fee schedule rate ($19,763.43). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,8318.14,19763.43,There are no additional notes associated with this service or procedure.
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12383.18,,"Case rate ($11,793.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,125.23, add-ons for qualifying new technology services are included. If operating cost exceeds $45,996.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,462.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $9,145.60 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,180.28 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $702.95. The transfer capital threshold is the transfer adjustment factor * $702.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,29482.05,Inpatient DRG
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],35474.53,,"Fee schedule rate ($35,474.53). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,16428.39,42083.20,There are no additional notes associated with this service or procedure.
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],8163.06,,"Case rate ($8,163.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,729.53, add-ons for qualifying new technology services are included. If operating cost exceeds $42,600.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,214.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,763.33 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,784.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $454.78. The transfer capital threshold is the transfer adjustment factor * $454.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8163.06,18067.42,Inpatient DRG
HC Biopsy of Vulva/Perineum,CASE-56605,APC,56605,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],862.13,,"APC Price ($862.13). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,862.13,905.23,OPPS APC
COAGULATION DISORDERS,813,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],12569.53,,"Case rate ($11,970.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,290.66, add-ons for qualifying new technology services are included. If operating cost exceeds $46,161.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,475.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $9,310.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,345.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $715.62. The transfer capital threshold is the transfer adjustment factor * $715.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12274.39,30013.33,Inpatient DRG
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],14309.17,,"Fee schedule rate ($14,309.17). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,17467.27,There are no additional notes associated with this service or procedure.
"EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME, NEONATE",790,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],43671.57,,"Case rate ($42,194.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $39,388.49, add-ons for qualifying new technology services are included. If operating cost exceeds $74,259.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,703.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 17.9. The base transfer operating payment is the transfer adjustment factor * $37,305.99 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $37,443.54 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,943.81. The transfer capital threshold is the transfer adjustment factor * $2,943.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,3054.00,44304.49,Inpatient DRG
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],39153.65,,"Fee schedule rate ($39,153.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,7605.00,39153.65,There are no additional notes associated with this service or procedure.
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],5415.00,,"Per diem ($5,415). If length of stay < 3.1, first 1 days paid at a per diem of $10,830 instead. Capped at $16,785.91.",,,,0,other,5415.00,17575.50,Estimated amount calculated based on 3 day length of stay.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,329,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],90445.33,,,,,,0,other,33072.77,90445.33,There are no additional notes associated with this service or procedure.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITHOUT CC/MCC,816,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],6965.00,,,,,,0,other,6224.90,14733.53,There are no additional notes associated with this service or procedure.
"NEONATE BIRTH WEIGHT > 2499 GRAMS WITH RESPIRATORY DISTRESS SYNDROME OR OTHER MAJOR RESPIRATORY CONDITION,MODERATE",634,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],9427.82,,"Case rate ($9,427.82). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,9427.82,9899.21,There are no additional notes associated with this service or procedure.
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],15263.71,,"Case rate ($14,747.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,854.94, add-ons for qualifying new technology services are included. If operating cost exceeds $48,725.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,696.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $11,866.24 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,909.99 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $936.36. The transfer capital threshold is the transfer adjustment factor * $936.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,14747.55,37899.49,Inpatient DRG
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],6965.00,,,,,,0,other,4341.01,12882.53,There are no additional notes associated with this service or procedure.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],9446.38,,"Case rate ($9,446.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,923.36, add-ons for qualifying new technology services are included. If operating cost exceeds $43,794.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,308.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,952.78 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,978.41 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $548.64. The transfer capital threshold is the transfer adjustment factor * $548.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9446.38,21796.21,Inpatient DRG
HC Joint Injection/Aspir Large WO US|PBB CHARGE|LEFT SIDE,CASE-20610,APC,20610,CPT,0510,RC,,,PBB|LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],297.37,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,287.31,301.68,OPPS APC
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,097,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],79915.74,,"Fee schedule rate ($79,915.74). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,26404.32,79915.74,There are no additional notes associated with this service or procedure.
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],22363.67,,"Fee schedule rate ($22,363.67). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10003.71,23415.63,There are no additional notes associated with this service or procedure.
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],16400.70,,"Fee schedule rate ($16,400.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,16400.70,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],21167.26,,"Fee schedule rate ($21,167.26). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,6841.83,21167.26,There are no additional notes associated with this service or procedure.
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC,058,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],40853.02,,"Fee schedule rate ($40,853.02). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,13521.80,40853.02,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],6965.00,,,,,,0,other,6965.00,21195.68,There are no additional notes associated with this service or procedure.
"SPINAL FUSION AND OTHER BACK AND NECK PROCEDURES EXCEPT FOR DISC PROCEDURES,MODERATE",321,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],24450.45,,"Case rate ($23,286.14). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,23286.14,24450.45,There are no additional notes associated with this service or procedure.
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,069,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],20333.68,,"Fee schedule rate ($20,333.68). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,20333.68,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],2070.00,,,,,,0,other,1188.00,34338.33,Estimated amount calculated based on 6 day length of stay.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],57067.24,,,,,,0,other,21585.31,73588.10,There are no additional notes associated with this service or procedure.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],11681.49,,"Fee schedule rate ($11,681.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5778.62,11681.49,There are no additional notes associated with this service or procedure.
CERVICAL SPINAL FUSION WITH CC,472,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],38906.70,,"Fee schedule rate ($38,906.70). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,21896.13,70198.84,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,065,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],15376.83,,"Case rate ($8,786.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,309.75, add-ons for qualifying new technology services are included. If operating cost exceeds $43,180.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,260.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,341.42 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,364.80 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $500.40. The transfer capital threshold is the transfer adjustment factor * $500.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,8786.76,25681.86,All Other Inpatient
Vaginal Hysterectomy Uterus 250 Gm/<,CASE-58260,APC,58260,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],4846.30,,"APC Price ($4,682.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,4682.41,4916.53,OPPS APC
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,073,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],43475.01,,"Fee schedule rate ($43,475.01). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,12809.38,43475.01,There are no additional notes associated with this service or procedure.
Gastroenterology Procedure,CASE-91299,APC,91299,CPT,0750,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],124.66,,"APC Price ($120.44). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,120.44,126.46,OPPS APC
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],37550.29,,"Fee schedule rate ($37,550.29). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,15476.23,42787.31,There are no additional notes associated with this service or procedure.
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],34032.82,,"Fee schedule rate ($34,032.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,15233.11,38610.21,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],45351.98,,"Fee schedule rate ($45,351.98). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,21719.40,85305.59,There are no additional notes associated with this service or procedure.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",062,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],14170.07,,"Case rate ($13,495.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,711.54, add-ons for qualifying new technology services are included. If operating cost exceeds $47,582.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,584.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $10,725.92 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,766.59 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $824.42. The transfer capital threshold is the transfer adjustment factor * $824.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13844.84,44304.80,Inpatient DRG
Thyroidectomy Total/Complete,CASE-60240,APC,60240,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5856.81,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5658.76,5941.70,OPPS APC
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],37606.01,,"Case rate ($21,489.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,126.50, add-ons for qualifying new technology services are included. If operating cost exceeds $54,997.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,189.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.6. The base transfer operating payment is the transfer adjustment factor * $18,114.76 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,181.55 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,429.43. The transfer capital threshold is the transfer adjustment factor * $1,429.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,21489.15,68942.79,All Other Inpatient
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],12775.53,,"Case rate ($12,775.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,020.41, add-ons for qualifying new technology services are included. If operating cost exceeds $46,891.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,552.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $10,038.44 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,075.45 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $792.13. The transfer capital threshold is the transfer adjustment factor * $792.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12775.53,31469.43,Inpatient DRG
SPINAL PROCEDURES WITH MCC,028,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],112913.98,,"Fee schedule rate ($112,913.98). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,42633.57,120982.83,There are no additional notes associated with this service or procedure.
"ANTEPARTUM WITH O.R. PROCEDURE,MAJOR",547,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],15235.38,,"Case rate ($15,235.38). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,15235.38,15997.15,There are no additional notes associated with this service or procedure.
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],21854.96,,"Fee schedule rate ($21,854.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10638.94,25261.33,There are no additional notes associated with this service or procedure.
Colsc Flexible W/Transendoscopic Balloon Dilat|COLORECTAL CANCER SCREEN,CASE-45386,APC,45386,CPT,0360,RC,,,PT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1176.09,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1120.09,1176.09,OPPS APC
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],26204.74,,"Fee schedule rate ($26,204.74). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10120.20,26204.74,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],52449.26,,"Fee schedule rate ($52,449.26). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,17693.40,52449.26,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],7353.00,,"Per diem ($7,353). If length of stay < 4.1, first 1 days paid at a per diem of $14,706 instead. Capped at $30,145.85.",,,,0,other,7353.00,33398.16,Estimated amount calculated based on 4 day length of stay.
Placement Seton,CASE-46020,APC,46020,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],2727.99,,"APC Price ($2,598.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2598.08,2727.99,OPPS APC
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,073,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],43475.01,,"Fee schedule rate ($43,475.01). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,12809.38,43475.01,There are no additional notes associated with this service or procedure.
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|LEFT HAND, THIRD DIGIT",CASE-26160,APC,26160,CPT,0360,RC,,,F2,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1580.37,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1505.12,1580.37,OPPS APC
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH CC,026,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],63202.45,,"Fee schedule rate ($63,202.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,23000.66,63202.45,There are no additional notes associated with this service or procedure.
"ALCOHOL ABUSE AND DEPENDENCE,EXTREME",775,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],24471.34,,"Case rate ($24,471.34). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,24471.34,25694.91,There are no additional notes associated with this service or procedure.
Ligamentous Reconstruction Knee Extra-Articular|RIGHT SIDE,CASE-27427,APC,27427,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12618.18,,"APC Price ($12,017.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,12017.31,12618.18,OPPS APC
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],15854.69,,"Case rate ($15,099.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,182.53, add-ons for qualifying new technology services are included. If operating cost exceeds $49,053.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,722.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $12,192.63 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,237.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $962.12. The transfer capital threshold is the transfer adjustment factor * $962.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7605.00,39153.65,Inpatient DRG
"NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY",789,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],14857.05,,"Case rate ($14,149.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,298.65, add-ons for qualifying new technology services are included. If operating cost exceeds $48,169.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,652.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $11,312.00 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,353.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $892.63. The transfer capital threshold is the transfer adjustment factor * $892.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,3054.00,14857.05,Inpatient DRG
"Excis Intrasp Lesn,Xdural,Lumbar",CASE-63267,APC,63267,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6791.99,7131.59,OPPS APC
VENTRICULAR SHUNT PROCEDURES WITH CC,032,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],17195.03,,"Case rate ($16,376.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,370.06, add-ons for qualifying new technology services are included. If operating cost exceeds $50,241.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,815.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $13,375.80 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,425.12 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,055.48. The transfer capital threshold is the transfer adjustment factor * $1,055.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,16376.22,46275.08,Inpatient DRG
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],13000.21,,"Case rate ($12,381.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,672.99, add-ons for qualifying new technology services are included. If operating cost exceeds $46,544.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,504.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,691.30 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,728.04 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $744.90. The transfer capital threshold is the transfer adjustment factor * $744.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12696.97,47123.82,Inpatient DRG
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],18594.09,,"Case rate ($18,594.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,433.29, add-ons for qualifying new technology services are included. If operating cost exceeds $52,304.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,977.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $15,431.44 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,488.34 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,217.69. The transfer capital threshold is the transfer adjustment factor * $1,217.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,18594.09,59494.91,Inpatient DRG
NERVOUS SYSTEM NEOPLASMS WITH MCC,054,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],25589.03,,"Fee schedule rate ($25,589.03). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,6965.00,30044.81,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,690,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],14625.55,,"Fee schedule rate ($14,625.55). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7426.94,15928.53,There are no additional notes associated with this service or procedure.
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],8219.40,,"Fee schedule rate ($8,219.40). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,7884.32,17835.23,There are no additional notes associated with this service or procedure.
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],12526.44,,"Fee schedule rate ($12,526.44). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5415.00,17575.50,There are no additional notes associated with this service or procedure.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],59521.43,,"Fee schedule rate ($59,521.43). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,16689.78,59521.43,There are no additional notes associated with this service or procedure.
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH MCC",510,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],89863.76,,"Fee schedule rate ($89,863.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10710.00,89863.76,There are no additional notes associated with this service or procedure.
HC Biopsy of Vulva/Perineum,CASE-56605,APC,56605,CPT,0361,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],892.30,,"APC Price ($862.13). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,862.13,905.23,OPPS APC
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,057,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],39884.93,,"Fee schedule rate ($39,884.93). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,10718.84,39884.93,There are no additional notes associated with this service or procedure.
UNGROUPABLE,999,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],85757.62,,"Fee schedule rate ($85,757.62). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (41), with a minimum of zero.",,,,0,other,10228.00,161307.29,There are no additional notes associated with this service or procedure.
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],15491.11,,"Case rate ($15,491.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,546.67, add-ons for qualifying new technology services are included. If operating cost exceeds $49,417.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,750.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $12,555.42 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,601.72 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $990.75. The transfer capital threshold is the transfer adjustment factor * $990.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,15491.11,54180.83,Inpatient DRG
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,068,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],23184.90,,"Fee schedule rate ($23,184.90). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,23184.90,There are no additional notes associated with this service or procedure.
HYPERTENSION WITHOUT MCC,305,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],7058.55,,"Case rate ($7,058.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,702.02, add-ons for qualifying new technology services are included. If operating cost exceeds $41,573.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,133.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,739.59 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,757.07 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $374.00. The transfer capital threshold is the transfer adjustment factor * $374.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7058.55,17230.49,Inpatient DRG
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],27553.62,,"Fee schedule rate ($27,553.62). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12305.53,30103.84,There are no additional notes associated with this service or procedure.
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],18588.16,,"Fee schedule rate ($18,588.16). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.8), with a minimum of zero.",,,,0,other,8643.20,19462.52,There are no additional notes associated with this service or procedure.
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],62990.26,,"Fee schedule rate ($62,990.26). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,16787.98,62990.26,There are no additional notes associated with this service or procedure.
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC",011,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],150008.48,,"Fee schedule rate ($150,008.48). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (44), with a minimum of zero.",,,,0,other,38880.49,150008.48,There are no additional notes associated with this service or procedure.
"Open Tx Distal Phalangeal Fracture Each|LEFT HAND, FIFTH DIGIT",CASE-26765,APC,26765,CPT,0360,RC,,,F4,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],58320.32,,"Fee schedule rate ($58,320.32). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,16286.16,58320.32,There are no additional notes associated with this service or procedure.
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],29594.00,,"Fee schedule rate ($29,594.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,13571.25,33781.47,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF NERVOUS SYSTEM WITH CC,092,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],9050.24,,"Case rate ($8,872.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,389.76, add-ons for qualifying new technology services are included. If operating cost exceeds $43,260.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,266.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $6,421.14 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,444.81 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $506.69. The transfer capital threshold is the transfer adjustment factor * $506.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,8872.78,26765.51,Inpatient DRG
"Arthrodesis Interphalangeal Jt W/WO Int Fixj|LEFT HAND, FIFTH DIGIT",CASE-26860,APC,26860,CPT,0360,RC,,,F4,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],52699.33,,"Fee schedule rate ($52,699.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,18105.81,52699.33,There are no additional notes associated with this service or procedure.
Edg US Exam Surgical Alter Stom Duodenum/Jejunum,CASE-43259,APC,43259,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1796.14,,"APC Price ($1,796.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1796.14,1885.95,OPPS APC
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],62084.69,,"Fee schedule rate ($62,084.69). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (35), with a minimum of zero.",,,,0,other,30398.48,82674.88,There are no additional notes associated with this service or procedure.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,761,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],5924.58,,"Case rate ($5,808.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,539.05, add-ons for qualifying new technology services are included. If operating cost exceeds $40,410.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,042.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $3,580.90 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,594.10 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $282.57. The transfer capital threshold is the transfer adjustment factor * $282.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,5808.41,11946.72,Inpatient DRG
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],16612.67,,"Case rate ($15,821.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,854.10, add-ons for qualifying new technology services are included. If operating cost exceeds $49,725.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,774.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $12,861.73 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,909.15 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,014.92. The transfer capital threshold is the transfer adjustment factor * $1,014.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,15821.59,40320.14,Inpatient DRG
Bx/Exc Lymph Node Open Deep Axillary Node,CASE-38525,APC,38525,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3664.94,,"APC Price ($3,664.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3664.94,3848.19,OPPS APC
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],13249.99,,"Case rate ($12,990.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,220.11, add-ons for qualifying new technology services are included. If operating cost exceeds $47,091.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,567.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $10,237.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,275.16 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $807.83. The transfer capital threshold is the transfer adjustment factor * $807.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,9888.00,43399.23,Inpatient DRG
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],16400.70,,"Fee schedule rate ($16,400.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,16400.70,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL HEMORRHAGE WITH MCC,377,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],35969.56,,,,,,0,other,7634.00,35969.56,There are no additional notes associated with this service or procedure.
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,451,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],94077.13,,"Fee schedule rate ($94,077.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,23821.44,94077.13,There are no additional notes associated with this service or procedure.
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC",605,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],18024.13,,,,,,0,other,8148.17,18024.13,There are no additional notes associated with this service or procedure.
"HC ED Avulsion Nail Plate Single|RIGHT HAND, THUMB",CASE-11730,APC,11730,CPT,0450,RC,,,F5,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],187.80,,"APC Price ($187.80). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,187.80,197.19,OPPS APC
"CVA AND PRECEREBRAL OCCLUSION WITH INFARCTION,EXTREME",045,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],22548.66,,"Case rate ($21,474.91). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $45,251, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,21474.91,22548.66,There are no additional notes associated with this service or procedure.
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC",514,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],22699.91,,"Fee schedule rate ($22,699.91). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8868.04,22699.91,There are no additional notes associated with this service or procedure.
BRONCHITIS AND ASTHMA WITH CC/MCC,202,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],8745.23,,"Case rate ($8,328.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,895.62, add-ons for qualifying new technology services are included. If operating cost exceeds $42,766.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,215.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,928.19 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,950.67 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $455.65. The transfer capital threshold is the transfer adjustment factor * $455.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7606.34,19110.30,Inpatient DRG
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,477,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],62359.39,,"Fee schedule rate ($62,359.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,25339.74,67976.16,There are no additional notes associated with this service or procedure.
OSTEOMYELITIS WITH CC,540,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],10989.02,,"Case rate ($10,465.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,887.55, add-ons for qualifying new technology services are included. If operating cost exceeds $44,758.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,368.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $7,912.60 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,942.60 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $608.18. The transfer capital threshold is the transfer adjustment factor * $608.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9809.07,25507.30,Inpatient DRG
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,082,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],56223.11,,"Fee schedule rate ($56,223.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,17423.21,56223.11,There are no additional notes associated with this service or procedure.
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],68942.79,,"Fee schedule rate ($68,942.79). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,21489.15,68942.79,There are no additional notes associated with this service or procedure.
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",623,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],33712.76,,"Fee schedule rate ($33,712.76). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,14093.37,33712.76,There are no additional notes associated with this service or procedure.
RESPIRATORY NEOPLASMS WITH CC,181,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],9381.80,,"Case rate ($9,197.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,692.16, add-ons for qualifying new technology services are included. If operating cost exceeds $43,563.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,290.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,722.42 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,747.21 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $530.47. The transfer capital threshold is the transfer adjustment factor * $530.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,9197.84,21074.07,Inpatient DRG
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],61290.90,,"Fee schedule rate ($61,290.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,23799.09,63499.65,There are no additional notes associated with this service or procedure.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],25667.48,,"Fee schedule rate ($25,667.48). Adds an outlier to normal pricing equal to the per diem rate ($77,296.48) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,11194.25,36094.03,There are no additional notes associated with this service or procedure.
SINGLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL,402,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],124455.45,,"Fee schedule rate ($124,455.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,29172.05,124455.45,There are no additional notes associated with this service or procedure.
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],7600.62,,"Case rate ($7,238.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,869.60, add-ons for qualifying new technology services are included. If operating cost exceeds $41,740.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,147.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,906.55 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,924.64 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $387.18. The transfer capital threshold is the transfer adjustment factor * $387.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7238.69,16804.22,Inpatient DRG
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC,192,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],12753.78,,"Fee schedule rate ($12,753.78). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6292.63,12753.78,There are no additional notes associated with this service or procedure.
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],16235.87,,"Fee schedule rate ($16,235.87). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6524.00,17760.46,There are no additional notes associated with this service or procedure.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],26028.48,,"Case rate ($26,028.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $24,349.34, add-ons for qualifying new technology services are included. If operating cost exceeds $59,220.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,521.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $22,322.08 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $22,404.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,761.43. The transfer capital threshold is the transfer adjustment factor * $1,761.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,26028.48,80635.65,Inpatient DRG
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],24413.25,,,,,,0,other,10347.06,28821.04,There are no additional notes associated with this service or procedure.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],45845.03,,"Fee schedule rate ($45,845.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,18598.83,48389.68,There are no additional notes associated with this service or procedure.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",062,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],44304.80,,"Fee schedule rate ($44,304.80). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,13844.84,44304.80,There are no additional notes associated with this service or procedure.
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],11619.00,,"Fee schedule rate ($11,619.00). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10638.94,25261.33,There are no additional notes associated with this service or procedure.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],15476.23,,"Case rate ($15,476.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,532.81, add-ons for qualifying new technology services are included. If operating cost exceeds $49,403.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,749.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $12,541.62 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,587.86 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $989.66. The transfer capital threshold is the transfer adjustment factor * $989.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,15476.23,42787.31,Inpatient DRG
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC,806,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],10071.17,,"Fee schedule rate ($10,071.17). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5354.25,13416.00,There are no additional notes associated with this service or procedure.
OSTEOMYELITIS WITH CC,540,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],18450.55,,"Fee schedule rate ($18,450.55). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,9809.07,25507.30,There are no additional notes associated with this service or procedure.
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],25829.63,,"Fee schedule rate ($25,829.63). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6965.00,29482.05,There are no additional notes associated with this service or procedure.
"DRUG AND ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE,MINOR",770,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],2868.80,,"Case rate ($2,732.19). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,2732.19,2868.80,There are no additional notes associated with this service or procedure.
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC,939,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],27085.41,,"Case rate ($25,795.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $24,177.24, add-ons for qualifying new technology services are included. If operating cost exceeds $59,048.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,462.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $22,148.31 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $22,232.29 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,702.37. The transfer capital threshold is the transfer adjustment factor * $1,702.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,26517.40,97674.79,Inpatient DRG
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],8554.50,,"Case rate ($8,554.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,093.67, add-ons for qualifying new technology services are included. If operating cost exceeds $42,964.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,243.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,126.13 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,148.72 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $483.41. The transfer capital threshold is the transfer adjustment factor * $483.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8554.50,19204.75,Inpatient DRG
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],1188.00,,,,,,0,other,1188.00,31658.33,Estimated amount calculated based on 16 day length of stay.
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],13097.33,,"Case rate ($12,840.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,080.88, add-ons for qualifying new technology services are included. If operating cost exceeds $46,951.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,556.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $10,098.70 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,135.93 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $796.89. The transfer capital threshold is the transfer adjustment factor * $796.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,1188.00,31658.33,Inpatient DRG
CHOLECYSTECTOMY WITH C.D.E. WITH MCC,411,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],88615.28,,"Fee schedule rate ($88,615.28). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,24315.13,88615.28,There are no additional notes associated with this service or procedure.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,479,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],50518.76,,"Fee schedule rate ($50,518.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,10586.00,50518.76,There are no additional notes associated with this service or procedure.
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,069,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],20333.68,,"Fee schedule rate ($20,333.68). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,20333.68,There are no additional notes associated with this service or procedure.
Incisional Biopsy Skin Single Lesion,CASE-11106,APC,11106,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],726.38,,"APC Price ($691.79). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,726.38,726.38,OPPS APC
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],36776.05,,"Fee schedule rate ($36,776.05). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11053.39,36776.05,There are no additional notes associated with this service or procedure.
HC Non Stress Test,CASE-59025,APC,59025,CPT,0920,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],198.70,,"APC Price ($189.24). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,189.24,198.70,OPPS APC
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC",281,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],8169.15,,"Case rate ($8,169.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,735.20, add-ons for qualifying new technology services are included. If operating cost exceeds $42,606.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,215.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $5,768.98 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,790.25 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $455.23. The transfer capital threshold is the transfer adjustment factor * $455.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8169.15,23859.35,Inpatient DRG
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],23754.07,,,,,,0,other,10120.20,26204.74,There are no additional notes associated with this service or procedure.
Rpr Aa Hernia 1st > 10 Cm Ncrc8/Strangulated|UNUSUAL NON-OVERLAPPING SERVICE,CASE-49596,APC,49596,CPT,0360,RC,,,XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5856.81,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5658.76,5941.70,OPPS APC
Repair Intermediate S/a/T/E 20.1-30.0 Cm,CASE-12036,APC,12036,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1545.93,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1545.93,1623.23,OPPS APC
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,074,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],19371.82,,"Fee schedule rate ($19,371.82). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,8925.60,20919.08,There are no additional notes associated with this service or procedure.
Parathyroidectomy/Exploration Parathyroids|RIGHT SIDE,CASE-60500,APC,60500,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5658.76,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5658.76,5941.70,OPPS APC
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],10448.43,,"Case rate ($9,950.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,392.71, add-ons for qualifying new technology services are included. If operating cost exceeds $44,263.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,345.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $7,420.40 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,447.76 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $585.54. The transfer capital threshold is the transfer adjustment factor * $585.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7243.75,23262.15,Inpatient DRG
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],8273.53,,"Case rate ($7,993.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,572.03, add-ons for qualifying new technology services are included. If operating cost exceeds $42,443.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,202.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $5,606.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,627.08 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $442.40. The transfer capital threshold is the transfer adjustment factor * $442.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,5415.00,17575.50,Inpatient DRG
Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn,CASE-62323,APC,62323,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],660.72,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,660.72,693.76,OPPS APC
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC",156,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],12624.95,,"Fee schedule rate ($12,624.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6625.12,13598.77,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITHOUT CC/MCC,517,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],28052.31,,"Fee schedule rate ($28,052.31). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,10207.96,29371.86,There are no additional notes associated with this service or procedure.
Laps Surg Bilateral Total Pelvic Lmphadectomy,CASE-38571,APC,38571,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],9949.78,,"APC Price ($9,949.78). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,9949.78,10447.27,OPPS APC
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],10626.21,,"Case rate ($10,120.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,550.21, add-ons for qualifying new technology services are included. If operating cost exceeds $44,421.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,357.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $7,577.32 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,605.26 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $597.93. The transfer capital threshold is the transfer adjustment factor * $597.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10120.20,26204.74,Inpatient DRG
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 2nd Level|RIGHT SIDE,CASE-64494,APC,64494,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],869.28,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,827.89,869.28,OPPS APC
O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC,621,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],29680.79,,,,,,0,other,12159.94,36669.96,There are no additional notes associated with this service or procedure.
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITHOUT MCC,430,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],43050.17,,"Case rate ($41,000.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $38,277.19, add-ons for qualifying new technology services are included. If operating cost exceeds $73,148.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,616.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $36,198.76 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $36,332.23 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,856.44. The transfer capital threshold is the transfer adjustment factor * $2,856.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,41000.16,133156.90,Inpatient DRG
DIABETES WITHOUT CC/MCC,639,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],11899.36,,"Fee schedule rate ($11,899.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6151.76,12223.35,There are no additional notes associated with this service or procedure.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],69000.38,,"Fee schedule rate ($69,000.38). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15), with a minimum of zero.",,,,0,other,26809.29,97015.50,There are no additional notes associated with this service or procedure.
SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS,029,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],61889.56,,"Fee schedule rate ($61,889.56). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13641.00,67130.05,There are no additional notes associated with this service or procedure.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],8559.13,,"Case rate ($8,151.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,718.82, add-ons for qualifying new technology services are included. If operating cost exceeds $42,589.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,213.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,752.66 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,773.87 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $453.94. The transfer capital threshold is the transfer adjustment factor * $453.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8151.55,18033.97,Inpatient DRG
OTHER CEREBROVASCULAR DISORDERS WITH MCC,070,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],13219.09,,"Case rate ($13,219.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,433.04, add-ons for qualifying new technology services are included. If operating cost exceeds $47,304.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,584.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $10,449.57 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,488.10 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $824.57. The transfer capital threshold is the transfer adjustment factor * $824.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,13219.09,37774.46,Inpatient DRG
SINGLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL,402,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],124455.45,,"Fee schedule rate ($124,455.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,29172.05,124455.45,There are no additional notes associated with this service or procedure.
Insj Penile Prosthesos Inflatable Self-Contained,CASE-54401,APC,54401,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],20079.15,,"APC Price ($19,400.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,19400.15,20370.16,OPPS APC
Optx Dstl Radl X-Artic Fx/Epiphysl Sep|LEFT SIDE,CASE-25607,APC,25607,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],60793.48,,"Fee schedule rate ($60,793.48). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15.7), with a minimum of zero.",,,,0,other,23851.92,63653.13,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],28756.63,,"Fee schedule rate ($28,756.63). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,13148.66,32553.63,There are no additional notes associated with this service or procedure.
Cysto W/Insert Ureteral Stent|LEFT SIDE,CASE-52332,APC,52332,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3299.47,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3299.47,3464.44,OPPS APC
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],8970.82,,"Case rate ($8,543.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,083.58, add-ons for qualifying new technology services are included. If operating cost exceeds $42,954.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,242.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,116.09 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,138.64 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $482.62. The transfer capital threshold is the transfer adjustment factor * $482.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8543.64,23239.84,Inpatient DRG
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],31973.49,,"Fee schedule rate ($31,973.49). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,13386.36,33244.29,There are no additional notes associated with this service or procedure.
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC",629,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],40946.19,,"Fee schedule rate ($40,946.19). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,16699.94,44657.18,There are no additional notes associated with this service or procedure.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],29917.96,,"Fee schedule rate ($29,917.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,12527.66,29917.96,There are no additional notes associated with this service or procedure.
SKIN ULCERS WITH MCC,592,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],15871.98,,"Case rate ($15,116.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $14,168.54, add-ons for qualifying new technology services are included. If operating cost exceeds $53,556.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $3,795.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.8. The base transfer operating payment is the transfer adjustment factor * $12,752.10 + an uncompensated DSH payment of $1,359.91. The transfer operating threshold is the transfer adjustment factor * $12,808.63 + an uncompensated DSH payment of $1,359.91. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,004.16. The transfer capital threshold is the transfer adjustment factor * $1,004.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,15116.17,38644.05,Inpatient DRG
Rmvl Noninfct Mesh/Prosth Aa/Parastomal Hrna Rpr,CASE-49623,APC,49623,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],199.10,,"APC Price ($199.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,199.10,209.05,OPPS APC
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",062,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],13844.84,,"Case rate ($13,844.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,015.16, add-ons for qualifying new technology services are included. If operating cost exceeds $47,886.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,630.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $11,029.54 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,070.21 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $870.34. The transfer capital threshold is the transfer adjustment factor * $870.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,13844.84,44304.80,Inpatient DRG
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],8956.76,,"Case rate ($8,956.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,467.88, add-ons for qualifying new technology services are included. If operating cost exceeds $43,338.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,272.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $6,498.97 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,522.93 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $512.83. The transfer capital threshold is the transfer adjustment factor * $512.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8956.76,28983.97,Inpatient DRG
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC,519,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],37589.76,,"Fee schedule rate ($37,589.76). Adds an outlier to normal pricing equal to the per diem rate ($123,674.40) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,15490.44,50780.20,There are no additional notes associated with this service or procedure.
Rinsj Rptd Biceps/Triceps Tdn Dstl W/WO Tdn Grf|RIGHT SIDE,CASE-24342,APC,24342,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7029.71,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6791.99,7131.59,OPPS APC
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],133270.57,,"Fee schedule rate ($133,270.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,33623.33,133270.57,There are no additional notes associated with this service or procedure.
MINOR BLADDER PROCEDURES WITHOUT CC/MCC,664,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],20599.85,,,,,,0,other,9034.63,31876.87,There are no additional notes associated with this service or procedure.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",062,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],44304.80,,"Fee schedule rate ($44,304.80). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,13844.84,44304.80,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],51903.64,,"Fee schedule rate ($51,903.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,16017.99,51903.64,There are no additional notes associated with this service or procedure.
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,451,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],23821.44,,"Case rate ($23,821.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $22,296.19, add-ons for qualifying new technology services are included. If operating cost exceeds $57,167.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,359.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $20,276.48 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $20,351.24 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,600.01. The transfer capital threshold is the transfer adjustment factor * $1,600.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,23821.44,94077.13,Inpatient DRG
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],20553.44,,"Fee schedule rate ($20,553.44). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8874.81,20553.44,There are no additional notes associated with this service or procedure.
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],20257.13,,"Case rate ($11,575.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,904.06, add-ons for qualifying new technology services are included. If operating cost exceeds $45,775.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,464.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $8,926.20 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,959.11 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $704.37. The transfer capital threshold is the transfer adjustment factor * $704.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,11575.50,48961.48,All Other Inpatient
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],11133.98,,"Fee schedule rate ($11,133.98). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5919.29,13545.65,There are no additional notes associated with this service or procedure.
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],17835.23,,,,,,0,other,7884.32,17835.23,There are no additional notes associated with this service or procedure.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,479,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],15260.23,,"Case rate ($14,533.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,655.86, add-ons for qualifying new technology services are included. If operating cost exceeds $48,526.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,680.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $11,667.89 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,710.91 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $920.71. The transfer capital threshold is the transfer adjustment factor * $920.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10586.00,50518.76,Inpatient DRG
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITHOUT MCC,430,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],41820.16,,"Case rate ($41,000.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $38,277.19, add-ons for qualifying new technology services are included. If operating cost exceeds $73,148.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,616.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $36,198.76 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $36,332.23 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,856.44. The transfer capital threshold is the transfer adjustment factor * $2,856.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,41000.16,133156.90,Inpatient DRG
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],8554.50,,"Case rate ($8,554.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,093.67, add-ons for qualifying new technology services are included. If operating cost exceeds $42,964.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,243.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,126.13 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,148.72 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $483.41. The transfer capital threshold is the transfer adjustment factor * $483.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8554.50,19204.75,Inpatient DRG
GASTROINTESTINAL HEMORRHAGE WITH MCC,377,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],35969.56,,,,,,0,other,7634.00,35969.56,There are no additional notes associated with this service or procedure.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC",442,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],8080.45,,"Case rate ($7,695.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $7,260.76, add-ons for qualifying new technology services are included. If operating cost exceeds $45,905.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $3,189.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $5,874.79 + an uncompensated DSH payment of $1,359.91. The transfer operating threshold is the transfer adjustment factor * $5,900.84 + an uncompensated DSH payment of $1,359.91. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $460.97. The transfer capital threshold is the transfer adjustment factor * $460.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6607.45,19011.92,Inpatient DRG
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],14599.65,,"Case rate ($13,904.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,070.60, add-ons for qualifying new technology services are included. If operating cost exceeds $47,941.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,634.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,084.78 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,125.65 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $874.70. The transfer capital threshold is the transfer adjustment factor * $874.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13904.43,34749.58,Inpatient DRG
"LIMB REATTACHMENT, HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA",956,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],148259.86,,"Fee schedule rate ($148,259.86). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,27428.25,148259.86,There are no additional notes associated with this service or procedure.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],54503.46,,"Fee schedule rate ($54,503.46). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.9), with a minimum of zero.",,,,0,other,21585.31,73588.10,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,555,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],42290.95,,"Fee schedule rate ($42,290.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10896.27,42290.95,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],81353.66,,"Fee schedule rate ($81,353.66). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,27256.92,81353.66,There are no additional notes associated with this service or procedure.
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,069,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],20333.68,,"Fee schedule rate ($20,333.68). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,20333.68,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],34481.40,,"Fee schedule rate ($34,481.40). Adds an outlier to normal pricing equal to the per diem rate ($50,543.29) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,14370.36,38378.80,There are no additional notes associated with this service or procedure.
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],19688.76,,"Case rate ($18,751.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,579.45, add-ons for qualifying new technology services are included. If operating cost exceeds $52,450.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,989.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $15,577.06 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,634.50 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,229.18. The transfer capital threshold is the transfer adjustment factor * $1,229.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8480.00,59081.91,Inpatient DRG
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],24528.10,,"Fee schedule rate ($24,528.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10989.72,26280.60,There are no additional notes associated with this service or procedure.
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],35127.88,,"Fee schedule rate ($35,127.88). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.5), with a minimum of zero.",,,,0,other,14603.31,45017.13,There are no additional notes associated with this service or procedure.
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],16804.22,,"Fee schedule rate ($16,804.22). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7238.69,16804.22,There are no additional notes associated with this service or procedure.
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC,964,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],12323.82,,"Case rate ($12,323.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,600.20, add-ons for qualifying new technology services are included. If operating cost exceeds $46,471.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,519.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $9,619.78 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,655.25 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $759.10. The transfer capital threshold is the transfer adjustment factor * $759.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12323.82,34154.06,Inpatient DRG
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],17097.87,,"Fee schedule rate ($17,097.87). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,8106.18,18245.94,There are no additional notes associated with this service or procedure.
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],27589.62,,"Fee schedule rate ($27,589.62). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12566.28,30861.41,There are no additional notes associated with this service or procedure.
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],6965.00,,,,,,0,other,6965.00,16400.70,There are no additional notes associated with this service or procedure.
CERVICAL SPINAL FUSION WITH MCC,471,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],111337.93,,"Fee schedule rate ($111,337.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,34645.26,111337.93,There are no additional notes associated with this service or procedure.
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],54180.83,,"Fee schedule rate ($54,180.83). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,15491.11,54180.83,There are no additional notes associated with this service or procedure.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],97176.83,,,,,,0,other,35389.50,101083.00,There are no additional notes associated with this service or procedure.
"ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",770,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],8735.30,,"Case rate ($8,735.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,261.87, add-ons for qualifying new technology services are included. If operating cost exceeds $43,132.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,256.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $6,293.72 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,316.92 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $496.64. The transfer capital threshold is the transfer adjustment factor * $496.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8735.30,19730.13,Inpatient DRG
Cysto/Uretero W/Lithotripsy &Indwell Stent Insrt|LEFT SIDE,CASE-52356,APC,52356,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5269.71,,"APC Price ($5,018.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5018.77,5269.71,OPPS APC
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],8676.91,,"Case rate ($8,263.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,834.96, add-ons for qualifying new technology services are included. If operating cost exceeds $42,705.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,210.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,867.76 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,890.01 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $451.01. The transfer capital threshold is the transfer adjustment factor * $451.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6230.00,22762.43,Inpatient DRG
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],14747.55,,"Case rate ($14,747.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,854.94, add-ons for qualifying new technology services are included. If operating cost exceeds $48,725.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,696.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $11,866.24 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,909.99 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $936.36. The transfer capital threshold is the transfer adjustment factor * $936.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,14747.55,37899.49,Inpatient DRG
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,479,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],36577.58,,,,,,0,other,10586.00,50518.76,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],32974.74,,"Case rate ($31,404.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $29,405.52, add-ons for qualifying new technology services are included. If operating cost exceeds $64,276.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,862.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $27,356.84 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $27,460.57 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,102.71. The transfer capital threshold is the transfer adjustment factor * $2,102.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,32296.02,88188.38,Inpatient DRG
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],7176.11,,"Case rate ($6,834.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,493.49, add-ons for qualifying new technology services are included. If operating cost exceeds $41,364.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,117.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $4,531.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,548.54 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $357.61. The transfer capital threshold is the transfer adjustment factor * $357.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6834.39,21354.82,Inpatient DRG
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],5824.43,,"Case rate ($5,710.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,447.70, add-ons for qualifying new technology services are included. If operating cost exceeds $40,318.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,035.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $3,489.88 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,502.75 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $275.39. The transfer capital threshold is the transfer adjustment factor * $275.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,3079.00,10940.41,Inpatient DRG
Prtl Exc B1 Tarsal/Metar B1 Xcp Talus/Calcaneus|LEFT SIDE,CASE-28122,APC,28122,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],23618.74,,"Fee schedule rate ($23,618.74). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10533.95,24956.34,There are no additional notes associated with this service or procedure.
HC Biopsy/Exc Lymph Node Needle|RIGHT SIDE,CASE-38505,APC,38505,CPT,0361,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1623.23,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1545.93,1623.23,OPPS APC
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC",281,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],17272.65,,"Fee schedule rate ($17,272.65). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.9), with a minimum of zero.",,,,0,other,8169.15,23859.35,There are no additional notes associated with this service or procedure.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],17524.27,,"Case rate ($16,689.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,661.75, add-ons for qualifying new technology services are included. If operating cost exceeds $50,532.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,838.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $13,666.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,716.80 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,078.42. The transfer capital threshold is the transfer adjustment factor * $1,078.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,16689.78,59521.43,Inpatient DRG
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6788.31,,"Case rate ($6,558.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,237.08, add-ons for qualifying new technology services are included. If operating cost exceeds $41,108.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,097.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $4,276.36 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,292.13 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $337.45. The transfer capital threshold is the transfer adjustment factor * $337.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6558.75,14871.83,Inpatient DRG
Hallux Rigidus W/Cheilectomy 1st Mp Jt W/O Implt,CASE-28289,APC,28289,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC,831,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],10441.44,,"Case rate ($10,088.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,520.59, add-ons for qualifying new technology services are included. If operating cost exceeds $44,391.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,355.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $7,547.82 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,575.65 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $595.60. The transfer capital threshold is the transfer adjustment factor * $595.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,4941.30,23661.59,Inpatient DRG
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],8480.00,,"Per diem ($8,480). If length of stay < 5.5, first 1 days paid at a per diem of $16,960 instead. Capped at $46,638.59.",,,,0,other,8480.00,59081.91,Estimated amount calculated based on 3 day length of stay.
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC",605,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],8148.17,,"Case rate ($8,148.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,715.67, add-ons for qualifying new technology services are included. If operating cost exceeds $42,586.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,213.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,749.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,770.72 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $453.69. The transfer capital threshold is the transfer adjustment factor * $453.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8148.17,18024.13,Inpatient DRG
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],7386.59,,"Case rate ($7,034.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,679.97, add-ons for qualifying new technology services are included. If operating cost exceeds $41,550.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,132.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $4,717.62 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,735.02 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $372.27. The transfer capital threshold is the transfer adjustment factor * $372.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,21089.59,Inpatient DRG
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],14309.17,,"Fee schedule rate ($14,309.17). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,17467.27,There are no additional notes associated with this service or procedure.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",062,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],14537.08,,"Case rate ($13,844.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,015.16, add-ons for qualifying new technology services are included. If operating cost exceeds $47,886.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,630.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $11,029.54 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,070.21 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $870.34. The transfer capital threshold is the transfer adjustment factor * $870.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13844.84,44304.80,Inpatient DRG
Egd Transoral Biopsy Single/Multiple,CASE-43239,APC,43239,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],878.67,,"APC Price ($848.96). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,848.96,878.67,OPPS APC
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,345,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],33616.03,,"Fee schedule rate ($33,616.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12134.89,33616.03,There are no additional notes associated with this service or procedure.
"Laminec/Facetect/Foramin,Lumbar|LEFT SIDE",CASE-63047,APC,63047,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
CESAREAN SECTION WITHOUT STERILIZATION WITH CC,787,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],12612.10,,"Fee schedule rate ($12,612.10). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9508.01,23722.94,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITH STERILIZATION WITH MCC,783,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],23722.94,,"Fee schedule rate ($23,722.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12612.10,23722.94,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,448,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],31737.19,,"Case rate ($30,663.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $28,661.63, add-ons for qualifying new technology services are included. If operating cost exceeds $63,532.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,860.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $26,618.53 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $26,716.68 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,100.47. The transfer capital threshold is the transfer adjustment factor * $2,100.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,30663.95,94077.13,Inpatient DRG
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],26483.27,,,,,,0,other,11059.47,28423.20,There are no additional notes associated with this service or procedure.
INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC,198,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6795.12,,"Case rate ($6,795.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,456.95, add-ons for qualifying new technology services are included. If operating cost exceeds $41,327.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,114.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,495.42 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,512.00 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $354.73. The transfer capital threshold is the transfer adjustment factor * $354.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6795.12,23505.07,Inpatient DRG
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],18918.49,,"Fee schedule rate ($18,918.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9282.47,21320.03,There are no additional notes associated with this service or procedure.
HC Inj Trigger Pt 1-2 Musc Grps|PBB CHARGE|SEPARATE STRUCTURE,CASE-20552,APC,20552,CPT,0510,RC,,,PBB|XS,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],297.37,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,287.31,301.68,OPPS APC
Rpr Coltrl Ligm Mtcarphlngl/Iphal Jt,CASE-26540,APC,26540,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],33159.45,,"Fee schedule rate ($33,159.45). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,13092.47,33159.45,There are no additional notes associated with this service or procedure.
HC Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn,CASE-62321,APC,62321,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],683.85,,"APC Price ($660.72). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,660.72,693.76,OPPS APC
Neuroplasty &/Transpos Median Nrv Carpal Tunne|RIGHT SIDE,CASE-64721,APC,64721,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1827.80,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1827.80,1919.19,OPPS APC
Implant Neurostim/Receiver,CASE-64590,APC,64590,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],18158.97,,"APC Price ($18,158.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,18158.97,19066.92,OPPS APC
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],6310.74,,"Case rate ($6,010.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,726.79, add-ons for qualifying new technology services are included. If operating cost exceeds $40,597.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,057.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,767.95 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,781.84 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $297.33. The transfer capital threshold is the transfer adjustment factor * $297.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6010.23,12246.05,Inpatient DRG
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,097,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],46207.56,,"Case rate ($26,404.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $24,698.97, add-ons for qualifying new technology services are included. If operating cost exceeds $59,569.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,548.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.7. The base transfer operating payment is the transfer adjustment factor * $22,670.44 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $22,754.03 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,788.92. The transfer capital threshold is the transfer adjustment factor * $1,788.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,26404.32,79915.74,All Other Inpatient
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC,832,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6831.68,,"Case rate ($6,831.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,490.97, add-ons for qualifying new technology services are included. If operating cost exceeds $41,361.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,117.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $4,529.32 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,546.02 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $357.41. The transfer capital threshold is the transfer adjustment factor * $357.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,4803.31,14198.92,Inpatient DRG
RESPIRATORY NEOPLASMS WITH CC,181,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],20127.30,,"Fee schedule rate ($20,127.30). Adds an outlier to normal pricing equal to the per diem rate ($54,966.40) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,9197.84,21074.07,There are no additional notes associated with this service or procedure.
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],24387.68,,"Fee schedule rate ($24,387.68). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10733.06,45157.33,There are no additional notes associated with this service or procedure.
Hemorrhoidectomy Int & Xtrnl 2/> Column/Gro,CASE-46260,APC,46260,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],2689.02,,"APC Price ($2,598.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2598.08,2727.99,OPPS APC
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,065,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],25681.86,,"Fee schedule rate ($25,681.86). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,8786.76,25681.86,There are no additional notes associated with this service or procedure.
VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC,033,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],13866.54,,"Case rate ($13,206.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,421.07, add-ons for qualifying new technology services are included. If operating cost exceeds $47,292.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,583.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $10,437.64 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,476.13 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $823.63. The transfer capital threshold is the transfer adjustment factor * $823.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13206.23,42156.44,Inpatient DRG
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITHOUT MCC,430,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],133156.90,,"Fee schedule rate ($133,156.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,41000.16,133156.90,There are no additional notes associated with this service or procedure.
Removal Tissue Expander W/O Insertion Implant|BILATERAL PROCEDURE,CASE-11971,APC,11971,CPT,0360,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],2814.04,,"APC Price ($2,718.88). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2718.88,2814.04,OPPS APC
TRAUMATIC INJURY WITH MCC,913,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],13274.87,,"Case rate ($13,014.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,242.79, add-ons for qualifying new technology services are included. If operating cost exceeds $47,113.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,569.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $10,260.01 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,297.84 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $809.62. The transfer capital threshold is the transfer adjustment factor * $809.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,13014.58,42838.46,Inpatient DRG
TRAUMATIC INJURY WITH MCC,913,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],13014.58,,"Case rate ($13,014.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,242.79, add-ons for qualifying new technology services are included. If operating cost exceeds $47,113.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,569.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $10,260.01 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,297.84 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $809.62. The transfer capital threshold is the transfer adjustment factor * $809.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,13014.58,42838.46,Inpatient DRG
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],26966.33,,"Fee schedule rate ($26,966.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,9040.72,26966.33,There are no additional notes associated with this service or procedure.
"EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME, NEONATE",790,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],44304.49,,"Case rate ($42,194.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $39,388.49, add-ons for qualifying new technology services are included. If operating cost exceeds $74,259.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,703.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 17.9. The base transfer operating payment is the transfer adjustment factor * $37,305.99 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $37,443.54 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,943.81. The transfer capital threshold is the transfer adjustment factor * $2,943.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,3054.00,44304.49,Inpatient DRG
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],10003.71,,"Case rate ($10,003.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,441.84, add-ons for qualifying new technology services are included. If operating cost exceeds $44,312.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,349.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $7,469.36 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,496.90 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $589.41. The transfer capital threshold is the transfer adjustment factor * $589.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10003.71,23415.63,Inpatient DRG
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],6965.00,,,,,,0,other,6965.00,41030.48,There are no additional notes associated with this service or procedure.
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC,520,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],39786.42,,"Fee schedule rate ($39,786.42). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12061.74,39786.42,There are no additional notes associated with this service or procedure.
VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC,033,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],42156.44,,"Fee schedule rate ($42,156.44). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,13206.23,42156.44,There are no additional notes associated with this service or procedure.
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],34032.82,,"Fee schedule rate ($34,032.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,15233.11,38610.21,There are no additional notes associated with this service or procedure.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],142438.06,,"Fee schedule rate ($142,438.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (40), with a minimum of zero.",,,,0,other,45521.20,142438.06,There are no additional notes associated with this service or procedure.
Cysto W/Urtroscopy&/Pyeloscopy Dx,CASE-52351,APC,52351,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3299.47,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3299.47,3464.44,OPPS APC
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],40426.76,,"Fee schedule rate ($40,426.76). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,11914.12,40426.76,There are no additional notes associated with this service or procedure.
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],23545.50,,,,,,0,other,10048.39,23545.50,There are no additional notes associated with this service or procedure.
"Amputation Toe Metatarsophalangeal Joint|LEFT FOOT, GREAT TOE",CASE-28820,APC,28820,CPT,0360,RC,,,TA,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3169.86,OPPS APC
"DORSAL AND LUMBAR FUSION PROCEDURE EXCEPT FOR CURVATURE OF BACK,MINOR",304,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],9305.53,,"Case rate for a one day stay ($9,305.53). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,9305.53,9770.81,There are no additional notes associated with this service or procedure.
Esophagoscopy Flexible Transoral Ultrasound Exam,CASE-43231,APC,43231,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1885.95,,"APC Price ($1,796.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1796.14,1885.95,OPPS APC
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,074,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],20283.05,,,,,,0,other,8925.60,20919.08,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,699,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],9127.25,,"Case rate ($8,818.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,339.37, add-ons for qualifying new technology services are included. If operating cost exceeds $43,210.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,262.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $6,370.92 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,394.41 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $502.73. The transfer capital threshold is the transfer adjustment factor * $502.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,5961.00,19972.16,Inpatient DRG
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],13891.57,,"Case rate ($13,891.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,058.63, add-ons for qualifying new technology services are included. If operating cost exceeds $47,929.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,633.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,072.85 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,113.68 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $873.76. The transfer capital threshold is the transfer adjustment factor * $873.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,13891.57,34712.20,Inpatient DRG
NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,601,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],6042.05,,"Case rate ($6,042.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,756.39, add-ons for qualifying new technology services are included. If operating cost exceeds $40,627.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,059.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $3,797.45 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,811.45 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $299.66. The transfer capital threshold is the transfer adjustment factor * $299.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6042.05,12359.72,Inpatient DRG
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],28235.64,,"Fee schedule rate ($28,235.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,14344.60,36028.59,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],34391.19,,"Fee schedule rate ($34,391.19). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,14337.84,52803.53,There are no additional notes associated with this service or procedure.
"CARDIAC ARREST, UNEXPLAINED WITH MCC",296,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],36459.67,,"Fee schedule rate ($36,459.67). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12522.25,36459.67,There are no additional notes associated with this service or procedure.
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,069,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],20333.68,,"Fee schedule rate ($20,333.68). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,20333.68,There are no additional notes associated with this service or procedure.
BRONCHITIS AND ASTHMA WITH CC/MCC,202,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],14307.27,,"Fee schedule rate ($14,307.27). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7606.34,19110.30,There are no additional notes associated with this service or procedure.
RESPIRATORY NEOPLASMS WITHOUT CC/MCC,182,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],23037.13,,"Fee schedule rate ($23,037.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6965.00,23037.13,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],26178.21,,"Fee schedule rate ($26,178.21). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,13917.42,34889.29,There are no additional notes associated with this service or procedure.
"NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY",789,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],6663.33,,,,,,0,other,3054.00,14857.05,Estimated amount calculated based on 1 day length of stay.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],48538.56,,"Fee schedule rate ($48,538.56). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,19435.86,50821.76,There are no additional notes associated with this service or procedure.
Peri-Implant Capsulectomy Breast Complete|LEFT SIDE,CASE-19371,APC,19371,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3664.94,,"APC Price ($3,664.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3664.94,3848.19,OPPS APC
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7073.59,,"Case rate ($6,834.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,493.49, add-ons for qualifying new technology services are included. If operating cost exceeds $41,364.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,117.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $4,531.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,548.54 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $357.61. The transfer capital threshold is the transfer adjustment factor * $357.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6834.39,21354.82,Inpatient DRG
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,086,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],10982.26,,"Case rate ($10,766.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,151.85, add-ons for qualifying new technology services are included. If operating cost exceeds $45,022.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,405.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $8,176.75 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,206.90 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $645.23. The transfer capital threshold is the transfer adjustment factor * $645.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,8442.00,30728.81,Inpatient DRG
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],128358.13,,"Fee schedule rate ($128,358.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,40542.37,128358.13,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],7924.86,,"Case rate ($7,547.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,156.87, add-ons for qualifying new technology services are included. If operating cost exceeds $42,027.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,169.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $5,192.77 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,211.92 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $409.76. The transfer capital threshold is the transfer adjustment factor * $409.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,19126.88,Inpatient DRG
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],9814.33,,"Case rate ($9,346.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,844.71, add-ons for qualifying new technology services are included. If operating cost exceeds $43,715.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,288.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $6,873.70 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,899.76 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $528.33. The transfer capital threshold is the transfer adjustment factor * $528.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5569.00,40108.48,Inpatient DRG
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],44847.62,,"Fee schedule rate ($44,847.62). Adds an outlier to normal pricing equal to the per diem rate ($79,031.36) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,18105.81,52699.33,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],6965.00,,,,,,0,other,6340.03,15076.44,There are no additional notes associated with this service or procedure.
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 2nd Level|LEFT SIDE,CASE-64494,APC,64494,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],856.86,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,827.89,869.28,OPPS APC
Osteot W/WO Lngth Shrt/Corrj Metar Xcp 1st Ea|LEFT SIDE,CASE-28308,APC,28308,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],21854.96,,"Fee schedule rate ($21,854.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10638.94,25261.33,There are no additional notes associated with this service or procedure.
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,069,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],20333.68,,"Fee schedule rate ($20,333.68). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,20333.68,There are no additional notes associated with this service or procedure.
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],12331.11,,"Case rate ($11,914.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,219.06, add-ons for qualifying new technology services are included. If operating cost exceeds $46,090.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,489.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $9,240.03 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,274.10 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $729.13. The transfer capital threshold is the transfer adjustment factor * $729.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,11914.12,40426.76,Inpatient DRG
PREMATURITY WITH MAJOR PROBLEMS,791,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],30056.65,,"Case rate ($28,625.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $26,814.97, add-ons for qualifying new technology services are included. If operating cost exceeds $61,685.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,664.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 13.3. The base transfer operating payment is the transfer adjustment factor * $24,776.08 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $24,870.02 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,904.35. The transfer capital threshold is the transfer adjustment factor * $1,904.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,3048.21,30904.42,Inpatient DRG
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],17488.41,,"Case rate ($16,897.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,854.53, add-ons for qualifying new technology services are included. If operating cost exceeds $50,725.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,853.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $13,858.48 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,909.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,093.57. The transfer capital threshold is the transfer adjustment factor * $1,093.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,16897.01,43444.85,Inpatient DRG
Insj/Rplcmt Perq Eltrd Ra Pn W/Int Nstim 1st Ra,CASE-64596,APC,64596,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],10794.87,,"APC Price ($10,429.83). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,10429.83,10951.32,OPPS APC
OTHER DISORDERS OF NERVOUS SYSTEM WITH CC,092,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],26765.51,,"Fee schedule rate ($26,765.51). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8872.78,26765.51,There are no additional notes associated with this service or procedure.
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],68942.79,,"Fee schedule rate ($68,942.79). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,21489.15,68942.79,There are no additional notes associated with this service or procedure.
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],16400.70,,"Fee schedule rate ($16,400.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,16400.70,There are no additional notes associated with this service or procedure.
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],6965.00,,,,,,0,other,6965.00,23385.72,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],23954.07,,"Fee schedule rate ($23,954.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,6167.00,29058.99,There are no additional notes associated with this service or procedure.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],15273.74,,"Case rate ($15,273.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,344.45, add-ons for qualifying new technology services are included. If operating cost exceeds $49,215.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,734.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $12,353.94 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,399.49 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $974.85. The transfer capital threshold is the transfer adjustment factor * $974.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,15273.74,39820.52,Inpatient DRG
Tnot Elbow Lateral/Medial Debride Open Tdn Rpr|RIGHT SIDE,CASE-24359,APC,24359,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
MAJOR CHEST TRAUMA WITHOUT CC/MCC,185,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],21771.61,,"Fee schedule rate ($21,771.61). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7271.19,21771.61,There are no additional notes associated with this service or procedure.
Suction Assisted Lipectomy Trunk,CASE-15877,APC,15877,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1600.04,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1600.04,1623.23,OPPS APC
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],25253.70,,"Fee schedule rate ($25,253.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11974.38,29141.64,There are no additional notes associated with this service or procedure.
PREMATURITY WITH MAJOR PROBLEMS,791,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],29432.78,,"Case rate ($29,432.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $27,516.30, add-ons for qualifying new technology services are included. If operating cost exceeds $62,387.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,770.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 13.3. The base transfer operating payment is the transfer adjustment factor * $25,477.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $25,571.35 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,010.42. The transfer capital threshold is the transfer adjustment factor * $2,010.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,3048.21,30904.42,Inpatient DRG
HC Drain/Inj Joint/Bursa W/US Large|RIGHT SIDE,CASE-20611,APC,20611,CPT,0510,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],297.37,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,287.31,301.68,OPPS APC
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],10223.39,,"Fee schedule rate ($10,223.39). Adds an outlier to normal pricing equal to the per diem rate ($48,095.58) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,5628.97,12272.58,There are no additional notes associated with this service or procedure.
"LIMB REATTACHMENT, HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA",956,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],27976.82,,"Case rate ($27,428.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $25,651.53, add-ons for qualifying new technology services are included. If operating cost exceeds $60,522.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,623.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $23,619.49 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $23,706.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,863.81. The transfer capital threshold is the transfer adjustment factor * $1,863.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,27428.25,148259.86,Inpatient DRG
"Open Tx Metacarpal Fracture Single Ea Bone|RIGHT HAND, THIRD DIGIT",CASE-26615,APC,26615,CPT,0360,RC,,,F7,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
MAJOR CHEST TRAUMA WITHOUT CC/MCC,185,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],14780.69,,"Fee schedule rate ($14,780.69). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.7), with a minimum of zero.",,,,0,other,7271.19,21771.61,There are no additional notes associated with this service or procedure.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,345,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],33616.03,,"Fee schedule rate ($33,616.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12134.89,33616.03,There are no additional notes associated with this service or procedure.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],24259.09,,"Fee schedule rate ($24,259.09). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10098.51,24259.09,There are no additional notes associated with this service or procedure.
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],16064.26,,"Fee schedule rate ($16,064.26). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7733.72,18043.23,There are no additional notes associated with this service or procedure.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],19849.17,,"Fee schedule rate ($19,849.17). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,9097.60,21455.22,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7025.23,,"Case rate ($6,787.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,450.02, add-ons for qualifying new technology services are included. If operating cost exceeds $41,321.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,114.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,488.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,505.07 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $354.19. The transfer capital threshold is the transfer adjustment factor * $354.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6164.03,14071.02,Inpatient DRG
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,074,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],20283.05,,,,,,0,other,8925.60,20919.08,There are no additional notes associated with this service or procedure.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],22664.58,,"Case rate ($21,585.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,215.96, add-ons for qualifying new technology services are included. If operating cost exceeds $55,086.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,196.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $18,203.89 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,271.01 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,436.47. The transfer capital threshold is the transfer adjustment factor * $1,436.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,21585.31,73588.10,Inpatient DRG
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],28149.75,,"Case rate ($26,809.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $25,075.72, add-ons for qualifying new technology services are included. If operating cost exceeds $59,946.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,578.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $23,045.79 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $23,130.76 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,818.54. The transfer capital threshold is the transfer adjustment factor * $1,818.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,26809.29,97015.50,Inpatient DRG
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],30112.02,,"Fee schedule rate ($30,112.02). Adds an outlier to normal pricing equal to the per diem rate ($53,484.01) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.5), with a minimum of zero.",,,,0,other,12795.84,41944.25,There are no additional notes associated with this service or procedure.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],7224.45,,"Case rate ($7,224.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,856.36, add-ons for qualifying new technology services are included. If operating cost exceeds $41,727.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,146.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $4,893.37 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,911.41 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $386.14. The transfer capital threshold is the transfer adjustment factor * $386.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,15340.19,Inpatient DRG
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,167,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],43522.37,,"Fee schedule rate ($43,522.37). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,14157.71,43522.37,There are no additional notes associated with this service or procedure.
NERVOUS SYSTEM NEOPLASMS WITH MCC,054,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],25589.03,,"Fee schedule rate ($25,589.03). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,6965.00,30044.81,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH CC,427,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],134742.59,,"Fee schedule rate ($134,742.59). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,50829.82,142040.39,There are no additional notes associated with this service or procedure.
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],29585.82,,"Fee schedule rate ($29,585.82). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12606.23,36868.88,There are no additional notes associated with this service or procedure.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],66833.55,,"Fee schedule rate ($66,833.55). Adds an outlier to normal pricing equal to the per diem rate ($141,521.30) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,26028.48,80635.65,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],11594.35,,"Fee schedule rate ($11,594.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6164.03,14071.02,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],21892.85,,"Fee schedule rate ($21,892.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7569.84,21892.85,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,426,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],76581.29,,"Case rate ($76,581.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $71,377.56, add-ons for qualifying new technology services are included. If operating cost exceeds $106,248.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $7,218.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $69,177.55 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $69,432.61 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $5,458.79. The transfer capital threshold is the transfer adjustment factor * $5,458.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,76581.29,216864.15,Inpatient DRG
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,699,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],19570.20,,"Fee schedule rate ($19,570.20). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5961.00,19972.16,There are no additional notes associated with this service or procedure.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,329,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],86631.74,,"Fee schedule rate ($86,631.74). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (38), with a minimum of zero.",,,,0,other,33072.77,90445.33,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],10137.96,,"Case rate ($9,795.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,247.81, add-ons for qualifying new technology services are included. If operating cost exceeds $44,118.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,334.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $7,276.03 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,302.86 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $574.15. The transfer capital threshold is the transfer adjustment factor * $574.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,9795.13,23899.13,Inpatient DRG
HC Drain/Inj Joint/Bursa W/US Large|PBB CHARGE|RIGHT SIDE,CASE-20611,APC,20611,CPT,0510,RC,,,PBB|RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],287.31,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
Ostc Prtl Exostc/Condylc Metar Head|RIGHT SIDE,CASE-28288,APC,28288,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],13806.09,,"Case rate ($13,148.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,367.53, add-ons for qualifying new technology services are included. If operating cost exceeds $47,238.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,579.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $10,384.29 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,422.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $819.42. The transfer capital threshold is the transfer adjustment factor * $819.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13148.66,32553.63,Inpatient DRG
Nasal/Sinus Ndsc W/Partial Ethmoidectomy,CASE-31254,APC,31254,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6936.25,,"APC Price ($6,605.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6605.95,6936.25,OPPS APC
PREMATURITY WITH MAJOR PROBLEMS,791,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],29432.78,,"Case rate ($29,432.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $27,516.30, add-ons for qualifying new technology services are included. If operating cost exceeds $62,387.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,770.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 13.3. The base transfer operating payment is the transfer adjustment factor * $25,477.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $25,571.35 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,010.42. The transfer capital threshold is the transfer adjustment factor * $2,010.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,3048.21,30904.42,Inpatient DRG
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],14016.35,,"Case rate ($8,009.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,586.52, add-ons for qualifying new technology services are included. If operating cost exceeds $42,457.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,203.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $5,620.85 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,641.57 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $443.54. The transfer capital threshold is the transfer adjustment factor * $443.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,8009.34,19877.10,All Other Inpatient
TRAUMATIC INJURY WITH MCC,913,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],30719.04,,"Fee schedule rate ($30,719.04). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.5), with a minimum of zero.",,,,0,other,13014.58,42838.46,There are no additional notes associated with this service or procedure.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,056,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],18295.84,,"Case rate ($17,677.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,580.28, add-ons for qualifying new technology services are included. If operating cost exceeds $51,451.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,910.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $14,581.57 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,635.33 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,150.63. The transfer capital threshold is the transfer adjustment factor * $1,150.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,7659.00,59328.19,Inpatient DRG
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC,806,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],10071.17,,"Fee schedule rate ($10,071.17). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5354.25,13416.00,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],6965.00,,,,,,0,other,6558.75,14871.83,There are no additional notes associated with this service or procedure.
DIABETES WITH CC,638,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],15195.79,,"Fee schedule rate ($15,195.79). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8014.07,17634.53,There are no additional notes associated with this service or procedure.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC",442,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],18157.80,,"Fee schedule rate ($18,157.80). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6607.45,19011.92,There are no additional notes associated with this service or procedure.
OSTEOMYELITIS WITH CC,540,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],11259.77,,"Case rate ($10,723.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,111.53, add-ons for qualifying new technology services are included. If operating cost exceeds $44,982.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,402.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $8,136.58 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,166.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $642.06. The transfer capital threshold is the transfer adjustment factor * $642.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9809.07,25507.30,Inpatient DRG
"PULMONARY EMBOLISM,MODERATE",134,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],7846.83,,"Case rate ($7,846.83). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,7846.83,8239.17,There are no additional notes associated with this service or procedure.
HC Gastroesophag Reflx Test W/Tel Ph Eltrd|REDUCED SERVICES,CASE-91035,APC,91035,CPT,0750,RC,,,52,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],803.80,,"APC Price ($803.80). Discounted by 50%. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,803.80,843.99,OPPS APC
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],9667.64,,"Fee schedule rate ($9,667.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,5139.72,13110.79,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],67794.72,,"Fee schedule rate ($67,794.72). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,10862.00,86437.13,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],14839.66,,"Case rate ($14,337.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,473.80, add-ons for qualifying new technology services are included. If operating cost exceeds $48,344.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,666.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $11,486.49 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,528.84 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $906.40. The transfer capital threshold is the transfer adjustment factor * $906.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,14337.84,52803.53,Inpatient DRG
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],15271.20,,"Fee schedule rate ($15,271.20). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12305.53,30103.84,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,083,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],11675.74,,"Case rate ($11,119.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,497.20, add-ons for qualifying new technology services are included. If operating cost exceeds $45,368.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,414.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $8,519.94 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,552.25 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $654.86. The transfer capital threshold is the transfer adjustment factor * $654.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,28680.85,Inpatient DRG
HC Inj Tendon Sheath/Ligament|PBB CHARGE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-20550,APC,20550,CPT,0510,RC,,,PBB|XU,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],287.31,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],52699.33,,"Fee schedule rate ($52,699.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,18105.81,52699.33,There are no additional notes associated with this service or procedure.
HC >= 12 Lead Ekg|PBB CHARGE,CASE-93005,APC,93005,CPT,0730,RC,,,PBB,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],57.98,,"APC Price ($55.22). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,55.22,57.98,OPPS APC
NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,601,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],12359.72,,"Fee schedule rate ($12,359.72). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6042.05,12359.72,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,093,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],19011.32,,"Fee schedule rate ($19,011.32). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,19011.32,There are no additional notes associated with this service or procedure.
NON-MALIGNANT BREAST DISORDERS WITH CC/MCC,600,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],19574.79,,"Fee schedule rate ($19,574.79). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7999.14,20495.56,There are no additional notes associated with this service or procedure.
Cysto Bladder W/Ureteral Catheterization,CASE-52005,APC,52005,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1956.65,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1956.65,2054.48,OPPS APC
HC Inj Aa&/Strd Greater Occipital Nerve|LEFT SIDE,CASE-64405,APC,64405,CPT,0450,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],301.68,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,287.31,301.68,OPPS APC
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],55871.12,,"Fee schedule rate ($55,871.12). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,35719.96,105091.76,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITH STERILIZATION WITHOUT CC/MCC,785,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],8652.76,,"Case rate ($8,240.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,813.51, add-ons for qualifying new technology services are included. If operating cost exceeds $42,684.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,209.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,846.40 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,868.56 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $449.37. The transfer capital threshold is the transfer adjustment factor * $449.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8431.24,20142.33,Inpatient DRG
PREMATURITY WITH MAJOR PROBLEMS,791,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],29432.78,,"Case rate ($29,432.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $27,516.30, add-ons for qualifying new technology services are included. If operating cost exceeds $62,387.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,770.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 13.3. The base transfer operating payment is the transfer adjustment factor * $25,477.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $25,571.35 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,010.42. The transfer capital threshold is the transfer adjustment factor * $2,010.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,3048.21,30904.42,Inpatient DRG
TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC,087,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],8546.33,,"Case rate ($8,139.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,707.48, add-ons for qualifying new technology services are included. If operating cost exceeds $42,578.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,213.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $5,741.36 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,762.53 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $453.05. The transfer capital threshold is the transfer adjustment factor * $453.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8139.36,22679.07,Inpatient DRG
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC,520,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],12061.74,,"Case rate ($12,061.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,356.39, add-ons for qualifying new technology services are included. If operating cost exceeds $46,227.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,499.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $9,376.87 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,411.44 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $739.93. The transfer capital threshold is the transfer adjustment factor * $739.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12061.74,39786.42,Inpatient DRG
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6601.86,,"Case rate ($6,378.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,069.50, add-ons for qualifying new technology services are included. If operating cost exceeds $40,940.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,084.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,109.40 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,124.55 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $324.27. The transfer capital threshold is the transfer adjustment factor * $324.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,4341.01,12882.53,Inpatient DRG
"OSTEOMYELITIS SEPTIC ARTHRITIS AND OTHER MUSCULOSKELETAL INFECTIONS,MODERATE",344,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],9448.65,,"Case rate ($9,448.65). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,9448.65,9921.08,There are no additional notes associated with this service or procedure.
NONTRAUMATIC STUPOR AND COMA WITH MCC,080,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],35615.37,,,,,,0,other,14202.39,35615.37,There are no additional notes associated with this service or procedure.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC,027,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],56363.30,,"Fee schedule rate ($56,363.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,19030.20,56363.30,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITH MCC,385,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],21593.52,,"Fee schedule rate ($21,593.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11480.01,31134.92,There are no additional notes associated with this service or procedure.
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],14185.82,,"Case rate ($8,106.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,676.61, add-ons for qualifying new technology services are included. If operating cost exceeds $42,547.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,210.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,710.61 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,731.66 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $450.62. The transfer capital threshold is the transfer adjustment factor * $450.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,8106.18,18245.94,All Other Inpatient
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC,520,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],22051.05,,"Fee schedule rate ($22,051.05). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12061.74,39786.42,There are no additional notes associated with this service or procedure.
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],81306.30,,"Fee schedule rate ($81,306.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,20846.48,81306.30,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],19187.65,,"Fee schedule rate ($19,187.65). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8859.23,20090.22,There are no additional notes associated with this service or procedure.
Implnt Bio Implnt for Soft Tissue Reinforcement|RIGHT SIDE,CASE-15777,APC,15777,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6432.89,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6215.36,6432.89,OPPS APC
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,065,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],25681.86,,"Fee schedule rate ($25,681.86). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,8786.76,25681.86,There are no additional notes associated with this service or procedure.
"Laminec/Facetect/Foramin,Lumbar|SEPARATE STRUCTURE",CASE-63047,APC,63047,CPT,0360,RC,,,XS,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],26668.00,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,25398.09,26668.00,OPPS APC
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],18585.05,,"Fee schedule rate ($18,585.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8859.23,20090.22,There are no additional notes associated with this service or procedure.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],33623.33,,"Case rate ($33,623.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $31,414.68, add-ons for qualifying new technology services are included. If operating cost exceeds $66,285.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,076.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.4. The base transfer operating payment is the transfer adjustment factor * $29,361.48 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $29,469.74 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,316.91. The transfer capital threshold is the transfer adjustment factor * $2,316.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,33623.33,133270.57,Inpatient DRG
CHEST PAIN,313,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6820.84,,"Case rate ($6,820.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,480.89, add-ons for qualifying new technology services are included. If operating cost exceeds $41,351.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,116.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $4,519.27 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,535.94 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $356.62. The transfer capital threshold is the transfer adjustment factor * $356.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6820.84,15377.66,Inpatient DRG
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],30112.02,,"Fee schedule rate ($30,112.02). Adds an outlier to normal pricing equal to the per diem rate ($53,484.01) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.5), with a minimum of zero.",,,,0,other,12795.84,41944.25,There are no additional notes associated with this service or procedure.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC",156,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],12624.95,,"Fee schedule rate ($12,624.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6625.12,13598.77,There are no additional notes associated with this service or procedure.
MINOR BLADDER PROCEDURES WITHOUT CC/MCC,664,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],31876.87,,"Fee schedule rate ($31,876.87). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9034.63,31876.87,There are no additional notes associated with this service or procedure.
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],16055.90,,"Fee schedule rate ($16,055.90). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8163.06,18067.42,There are no additional notes associated with this service or procedure.
Surgical Arthroscopy Shoulder Biceps Tenodesis,CASE-29828,APC,29828,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6791.99,7131.59,OPPS APC
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6688.49,,"Case rate ($6,369.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,069.73, add-ons for qualifying new technology services are included. If operating cost exceeds $40,940.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,075.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $4,109.20 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,124.78 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $315.84. The transfer capital threshold is the transfer adjustment factor * $315.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6503.90,14492.93,Inpatient DRG
TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC,087,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],12057.13,,"Fee schedule rate ($12,057.13). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,8139.36,22679.07,There are no additional notes associated with this service or procedure.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],20401.88,,"Fee schedule rate ($20,401.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,20401.88,There are no additional notes associated with this service or procedure.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],42787.31,,"Fee schedule rate ($42,787.31). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,15476.23,42787.31,There are no additional notes associated with this service or procedure.
"DISORDERS OF PANCREAS EXCEPT MALIGNANCY,MODERATE",282,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],1920.06,,"Case rate for a one day stay ($1,920.06). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,1920.06,2016.06,There are no additional notes associated with this service or procedure.
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 2nd Level|BILATERAL PROCEDURE,CASE-64494,APC,64494,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],827.89,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,827.89,869.28,OPPS APC
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7672.18,,"Case rate ($7,412.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,031.50, add-ons for qualifying new technology services are included. If operating cost exceeds $41,902.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,159.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $5,067.86 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,086.55 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $399.90. The transfer capital threshold is the transfer adjustment factor * $399.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6148.93,15887.21,Inpatient DRG
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH CC,354,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],31968.77,,"Fee schedule rate ($31,968.77). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11633.13,33472.54,There are no additional notes associated with this service or procedure.
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],6965.00,,,,,,0,other,6965.00,21404.64,There are no additional notes associated with this service or procedure.
Injection Aa&/Strd Genicular Nrv Branches W/Img|RIGHT SIDE,CASE-64454,APC,64454,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],660.72,,"APC Price ($660.72). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,660.72,693.76,OPPS APC
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],19119.59,,"Case rate ($19,119.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,922.16, add-ons for qualifying new technology services are included. If operating cost exceeds $52,793.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,016.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $15,918.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,977.21 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,256.13. The transfer capital threshold is the transfer adjustment factor * $1,256.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,11348.00,62454.12,Inpatient DRG
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,074,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],20919.08,,"Fee schedule rate ($20,919.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8925.60,20919.08,There are no additional notes associated with this service or procedure.
"CARDIAC ARREST, UNEXPLAINED WITH MCC",296,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12822.14,,"Case rate ($12,211.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,514.91, add-ons for qualifying new technology services are included. If operating cost exceeds $46,385.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,492.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $9,533.82 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,569.96 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $732.79. The transfer capital threshold is the transfer adjustment factor * $732.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12522.25,36459.67,Inpatient DRG
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],20334.26,,"Fee schedule rate ($20,334.26). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11593.79,38248.08,There are no additional notes associated with this service or procedure.
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC",641,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],15312.64,,,,,,0,other,7214.98,15312.64,There are no additional notes associated with this service or procedure.
Colonoscopy Flx Dx W/Collj Spec When Pfrmd|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-45378,APC,45378,CPT,0360,RC,,,74,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],870.46,,"APC Price ($870.46). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,870.46,913.99,OPPS APC
"Neuroplasty Other Arm/Leg Nerve,Open|RIGHT SIDE",CASE-64708,APC,64708,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],12527.66,,"Case rate ($12,527.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,789.82, add-ons for qualifying new technology services are included. If operating cost exceeds $46,660.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,533.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $9,808.71 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,844.88 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $774.00. The transfer capital threshold is the transfer adjustment factor * $774.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12527.66,29917.96,Inpatient DRG
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],61931.63,,"Case rate ($35,389.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $33,057.71, add-ons for qualifying new technology services are included. If operating cost exceeds $67,928.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,206.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.3. The base transfer operating payment is the transfer adjustment factor * $30,998.46 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $31,112.76 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,446.08. The transfer capital threshold is the transfer adjustment factor * $2,446.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,35389.50,101083.00,All Other Inpatient
HC Joint Injection/Aspir Large WO US,CASE-20610,APC,20610,CPT,0510,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],297.37,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,287.31,301.68,OPPS APC
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],21862.29,,"Case rate ($21,862.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,473.63, add-ons for qualifying new technology services are included. If operating cost exceeds $55,344.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,216.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. The base transfer operating payment is the transfer adjustment factor * $18,460.61 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,528.68 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,456.72. The transfer capital threshold is the transfer adjustment factor * $1,456.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7086.00,57872.02,Inpatient DRG
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,093,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],19011.32,,"Fee schedule rate ($19,011.32). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,19011.32,There are no additional notes associated with this service or procedure.
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC,806,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],6836.20,,"Case rate ($6,510.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,192.35, add-ons for qualifying new technology services are included. If operating cost exceeds $41,063.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,093.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $4,231.80 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,247.40 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $333.93. The transfer capital threshold is the transfer adjustment factor * $333.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5354.25,13416.00,Inpatient DRG
HC Blood Occult Peroxidase Actv Qual Feces 1-3 Spec,CASE-82272,APC,82272,CPT,0301,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],4.38,,,,,,0,other,4.23,4.44,There are no additional notes associated with this service or procedure.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],36988.38,,"Fee schedule rate ($36,988.38). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.7), with a minimum of zero.",,,,0,other,15273.74,39820.52,There are no additional notes associated with this service or procedure.
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],11575.50,,"Case rate ($11,575.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,904.06, add-ons for qualifying new technology services are included. If operating cost exceeds $45,775.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,464.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $8,926.20 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,959.11 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $704.37. The transfer capital threshold is the transfer adjustment factor * $704.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,11575.50,48961.48,Inpatient DRG
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,167,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],33891.30,,"Fee schedule rate ($33,891.30). Adds an outlier to normal pricing equal to the per diem rate ($66,990.29) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.6), with a minimum of zero.",,,,0,other,14157.71,43522.37,There are no additional notes associated with this service or procedure.
Esophagogastroduodenoscopy Submucosal Injection|UNUSUAL NON-OVERLAPPING SERVICE,CASE-43236,APC,43236,CPT,0360,RC,,,XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],891.41,,"APC Price ($848.96). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,848.96,891.41,OPPS APC
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,097,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],71069.39,,,,,,0,other,26404.32,79915.74,There are no additional notes associated with this service or procedure.
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],14625.55,,"Fee schedule rate ($14,625.55). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7438.45,15961.98,There are no additional notes associated with this service or procedure.
HC Joint Injection/Aspir Large WO US|LEFT SIDE|PBB CHARGE,CASE-20610,APC,20610,CPT,0510,RC,,,LT|PBB,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],301.68,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,287.31,301.68,OPPS APC
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],16804.22,,"Fee schedule rate ($16,804.22). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7238.69,16804.22,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,086,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],30728.81,,"Fee schedule rate ($30,728.81). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8442.00,30728.81,There are no additional notes associated with this service or procedure.
SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS,029,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],25588.42,,"Case rate ($24,369.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $22,848.26, add-ons for qualifying new technology services are included. If operating cost exceeds $57,719.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,360.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.7)) / 2. The base transfer operating payment is the transfer adjustment factor * $20,824.36 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $20,903.31 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,600.61. The transfer capital threshold is the transfer adjustment factor * $1,600.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13641.00,67130.05,Inpatient DRG
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],21354.82,,"Fee schedule rate ($21,354.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6834.39,21354.82,There are no additional notes associated with this service or procedure.
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],6965.00,,,,,,0,other,5139.72,13110.79,There are no additional notes associated with this service or procedure.
HC Gastric Procedure Unlisted,CASE-43999,APC,43999,CPT,0361,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],891.41,,"APC Price ($848.96). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,848.96,891.41,OPPS APC
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],20227.96,,,,,,0,other,8906.63,28434.57,There are no additional notes associated with this service or procedure.
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],30245.71,,"Fee schedule rate ($30,245.71). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9151.11,30245.71,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,082,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],17423.21,,"Case rate ($17,423.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,344.04, add-ons for qualifying new technology services are included. If operating cost exceeds $51,215.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,892.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $14,346.19 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,399.08 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,132.06. The transfer capital threshold is the transfer adjustment factor * $1,132.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,17423.21,56223.11,Inpatient DRG
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],45017.13,,"Fee schedule rate ($45,017.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,14603.31,45017.13,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,689,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],22417.63,,"Fee schedule rate ($22,417.63). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,9802.58,22831.22,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],85305.59,,"Fee schedule rate ($85,305.59). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,21719.40,85305.59,There are no additional notes associated with this service or procedure.
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],14902.97,,"Case rate ($14,610.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,727.68, add-ons for qualifying new technology services are included. If operating cost exceeds $48,598.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,686.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.6. The base transfer operating payment is the transfer adjustment factor * $11,739.44 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,782.73 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $926.36. The transfer capital threshold is the transfer adjustment factor * $926.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6277.00,36801.89,Inpatient DRG
HC Gastroesophag Reflx Test W/Tel Ph Eltrd,CASE-91035,APC,91035,CPT,0750,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],803.80,,"APC Price ($803.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,803.80,843.99,OPPS APC
"CARDIAC ARREST, UNEXPLAINED WITH MCC",296,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],36459.67,,"Fee schedule rate ($36,459.67). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12522.25,36459.67,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,167,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],14488.93,,"Case rate ($13,798.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,994.61, add-ons for qualifying new technology services are included. If operating cost exceeds $47,865.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,606.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $11,007.93 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,049.66 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $846.10. The transfer capital threshold is the transfer adjustment factor * $846.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,14157.71,43522.37,Inpatient DRG
NORMAL NEWBORN,795,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],3363.97,,"Case rate ($3,298.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $3,203.67, add-ons for qualifying new technology services are included. If operating cost exceeds $38,074.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $1,858.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $1,254.10 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $1,258.72 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $98.96. The transfer capital threshold is the transfer adjustment factor * $98.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,1369.79,5771.52,Inpatient DRG
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITH MCC,429,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],62958.58,,"Case rate ($62,958.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $58,704.65, add-ons for qualifying new technology services are included. If operating cost exceeds $93,575.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $6,222.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.6. The base transfer operating payment is the transfer adjustment factor * $56,551.19 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $56,759.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,462.45. The transfer capital threshold is the transfer adjustment factor * $4,462.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,62958.58,177294.98,Inpatient DRG
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,082,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],18033.02,,"Case rate ($17,423.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,344.04, add-ons for qualifying new technology services are included. If operating cost exceeds $51,215.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,892.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $14,346.19 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,399.08 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,132.06. The transfer capital threshold is the transfer adjustment factor * $1,132.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,17423.21,56223.11,Inpatient DRG
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],27120.18,,"Fee schedule rate ($27,120.18). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,11717.72,43888.01,There are no additional notes associated with this service or procedure.
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],22217.08,,"Fee schedule rate ($22,217.08). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.4), with a minimum of zero.",,,,0,other,7243.75,23262.15,There are no additional notes associated with this service or procedure.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],21796.21,,,,,,0,other,9446.38,21796.21,There are no additional notes associated with this service or procedure.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],61290.90,,"Fee schedule rate ($61,290.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,23799.09,63499.65,There are no additional notes associated with this service or procedure.
SALIVARY GLAND PROCEDURES,139,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],10313.19,,"Case rate ($10,313.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,729.75, add-ons for qualifying new technology services are included. If operating cost exceeds $44,600.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,372.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $7,756.21 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,784.80 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $612.04. The transfer capital threshold is the transfer adjustment factor * $612.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10313.19,30690.92,Inpatient DRG
Cysto W/Insert Ureteral Stent|LEFT SIDE,CASE-52332,APC,52332,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3464.44,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3299.47,3464.44,OPPS APC
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],7402.56,,"Case rate ($7,402.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,022.05, add-ons for qualifying new technology services are included. If operating cost exceeds $41,893.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,159.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,058.45 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,077.10 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $399.16. The transfer capital threshold is the transfer adjustment factor * $399.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7402.56,16438.59,Inpatient DRG
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],25276.59,,"Fee schedule rate ($25,276.59). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,11053.39,36776.05,There are no additional notes associated with this service or procedure.
Brnchsc Removal Bronchial Valve Initial,CASE-31648,APC,31648,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3664.31,,"APC Price ($3,489.82). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3489.82,3664.31,OPPS APC
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,448,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],94077.13,,"Fee schedule rate ($94,077.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,30663.95,94077.13,There are no additional notes associated with this service or procedure.
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],22557.82,,"Fee schedule rate ($22,557.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6801.88,22557.82,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],6965.00,,,,,,0,other,6965.00,41030.48,There are no additional notes associated with this service or procedure.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],22626.77,,"Fee schedule rate ($22,626.77). Adds an outlier to normal pricing equal to the per diem rate ($36,883.74) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.5), with a minimum of zero.",,,,0,other,10098.51,24259.09,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],14624.60,,"Case rate ($14,337.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,473.80, add-ons for qualifying new technology services are included. If operating cost exceeds $48,344.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,666.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $11,486.49 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,528.84 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $906.40. The transfer capital threshold is the transfer adjustment factor * $906.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,14337.84,52803.53,Inpatient DRG
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],85466.62,,"Fee schedule rate ($85,466.62). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,21382.16,85466.62,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS WITH MCC,947,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],24977.98,,,,,,0,other,10541.41,30414.32,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC,832,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],9034.88,,"Fee schedule rate ($9,034.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4803.31,14198.92,There are no additional notes associated with this service or procedure.
Neuroplasty &/Transpos Median Nrv Carpal Tunne|RIGHT SIDE|SEPARATE STRUCTURE,CASE-64721,APC,64721,CPT,0360,RC,,,RT|XS,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],31577.54,,"Fee schedule rate ($31,577.54). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,15453.88,39251.68,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],15076.44,,"Fee schedule rate ($15,076.44). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6340.03,15076.44,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],8468.48,,"Case rate ($8,468.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,013.65, add-ons for qualifying new technology services are included. If operating cost exceeds $42,884.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,237.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,046.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,068.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $477.12. The transfer capital threshold is the transfer adjustment factor * $477.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6963.00,18954.85,Inpatient DRG
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",004,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],100534.98,,"Case rate ($95,747.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $89,207.57, add-ons for qualifying new technology services are included. If operating cost exceeds $124,078.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $8,620.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 22.4. The base transfer operating payment is the transfer adjustment factor * $86,942.06 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $87,262.63 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $6,860.59. The transfer capital threshold is the transfer adjustment factor * $6,860.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10249.47,272554.00,Inpatient DRG
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],15128.37,,"Fee schedule rate ($15,128.37). Adds an outlier to normal pricing equal to the per diem rate ($46,867.46) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7396.47,16035.06,There are no additional notes associated with this service or procedure.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],27083.40,,"Case rate ($15,476.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,532.81, add-ons for qualifying new technology services are included. If operating cost exceeds $49,403.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,749.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $12,541.62 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,587.86 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $989.66. The transfer capital threshold is the transfer adjustment factor * $989.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,15476.23,42787.31,All Other Inpatient
OTHER CEREBROVASCULAR DISORDERS WITH MCC,070,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],13880.04,,"Case rate ($13,219.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,433.04, add-ons for qualifying new technology services are included. If operating cost exceeds $47,304.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,584.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $10,449.57 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,488.10 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $824.57. The transfer capital threshold is the transfer adjustment factor * $824.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13219.09,37774.46,Inpatient DRG
Inj for Sacroiliac Jt Anesth|RIGHT SIDE,CASE-G0260,APC,G0260,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],660.72,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,660.72,693.76,OPPS APC
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],51630.84,,"Fee schedule rate ($51,630.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,20559.34,54086.17,There are no additional notes associated with this service or procedure.
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],53275.26,,"Fee schedule rate ($53,275.26). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,15940.79,53275.26,There are no additional notes associated with this service or procedure.
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],27222.08,,"Fee schedule rate ($27,222.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7389.00,37134.43,There are no additional notes associated with this service or procedure.
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],27553.62,,"Fee schedule rate ($27,553.62). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12305.53,30103.84,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITH CC,386,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],19879.00,,"Fee schedule rate ($19,879.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8556.53,19879.00,There are no additional notes associated with this service or procedure.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],21455.22,,"Fee schedule rate ($21,455.22). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,9097.60,21455.22,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],2070.00,,,,,,0,other,1188.00,17370.86,Estimated amount calculated based on 3 day length of stay.
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH MCC",722,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],56869.13,,"Fee schedule rate ($56,869.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,14200.37,56869.13,There are no additional notes associated with this service or procedure.
Colsc Flx With Directed Submucosal Njx Any Sbst|COLORECTAL CANCER SCREEN,CASE-45381,APC,45381,CPT,0360,RC,,,PT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1120.09,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1120.09,1176.09,OPPS APC
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],23997.41,,"Case rate ($23,526.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $22,022.15, add-ons for qualifying new technology services are included. If operating cost exceeds $56,893.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,338.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.7. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.7)) / 2. The base transfer operating payment is the transfer adjustment factor * $20,003.44 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $20,077.20 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,578.47. The transfer capital threshold is the transfer adjustment factor * $1,578.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,23526.87,94787.57,Inpatient DRG
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,450,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],146009.19,,"Fee schedule rate ($146,009.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,38037.38,146009.19,There are no additional notes associated with this service or procedure.
"Tendon Sheath Incision|RIGHT HAND, FIFTH DIGIT",CASE-26055,APC,26055,CPT,0360,RC,,,F9,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1580.37,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1505.12,1580.37,OPPS APC
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC",494,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],15890.67,,"Case rate ($15,133.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,239.03, add-ons for qualifying new technology services are included. If operating cost exceeds $49,110.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,701.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $12,247.65 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,294.08 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $941.38. The transfer capital threshold is the transfer adjustment factor * $941.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,15533.10,39945.55,Inpatient DRG
OTHER CEREBROVASCULAR DISORDERS WITH MCC,070,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],37774.46,,"Fee schedule rate ($37,774.46). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,13219.09,37774.46,There are no additional notes associated with this service or procedure.
Bx/Exc Lymph Node Open Deep Cervical Node|LEFT SIDE,CASE-38510,APC,38510,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5818.16,,"APC Price ($5,541.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5541.10,5818.16,OPPS APC
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],36776.05,,"Fee schedule rate ($36,776.05). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11053.39,36776.05,There are no additional notes associated with this service or procedure.
CERVICAL SPINAL FUSION WITH CC,472,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],22662.49,,"Case rate ($21,896.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,505.12, add-ons for qualifying new technology services are included. If operating cost exceeds $55,376.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,219.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $18,491.99 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,560.18 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,459.20. The transfer capital threshold is the transfer adjustment factor * $1,459.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,21896.13,70198.84,Inpatient DRG
OTHER DISORDERS OF THE EYE WITHOUT MCC,125,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],17952.29,,"Fee schedule rate ($17,952.29). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (6), with a minimum of zero.",,,,0,other,7144.54,17952.29,There are no additional notes associated with this service or procedure.
Submucous Rescj Inferior Turbinate Prtl/Compl|BILATERAL PROCEDURE,CASE-30140,APC,30140,CPT,0360,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6936.25,,"APC Price ($6,605.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6605.95,6936.25,OPPS APC
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],18366.40,,"Fee schedule rate ($18,366.40). Adds an outlier to normal pricing equal to the per diem rate ($38,964.32) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.5), with a minimum of zero.",,,,0,other,8563.30,31533.97,There are no additional notes associated with this service or procedure.
PERITONEAL ADHESIOLYSIS WITH CC,336,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],16225.22,,"Case rate ($16,225.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,229.58, add-ons for qualifying new technology services are included. If operating cost exceeds $50,100.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,804.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $13,235.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,284.63 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,044.44. The transfer capital threshold is the transfer adjustment factor * $1,044.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,16225.22,53705.31,Inpatient DRG
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],6965.00,,,,,,0,other,6965.00,23385.72,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC,788,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],19006.00,,,,,,0,other,8438.02,20142.33,There are no additional notes associated with this service or procedure.
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],45157.33,,"Fee schedule rate ($45,157.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,10733.06,45157.33,There are no additional notes associated with this service or procedure.
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],10120.20,,"Case rate ($10,120.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,550.21, add-ons for qualifying new technology services are included. If operating cost exceeds $44,421.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,357.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $7,577.32 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,605.26 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $597.93. The transfer capital threshold is the transfer adjustment factor * $597.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10120.20,26204.74,Inpatient DRG
NONTRAUMATIC STUPOR AND COMA WITH MCC,080,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],14202.39,,"Case rate ($14,202.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,347.79, add-ons for qualifying new technology services are included. If operating cost exceeds $48,218.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,656.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $11,360.96 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,402.84 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $896.49. The transfer capital threshold is the transfer adjustment factor * $896.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,14202.39,35615.37,Inpatient DRG
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],9386.41,,"Case rate ($8,939.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,464.83, add-ons for qualifying new technology services are included. If operating cost exceeds $43,335.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,259.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,495.25 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,519.88 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $499.24. The transfer capital threshold is the transfer adjustment factor * $499.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9151.11,30245.71,Inpatient DRG
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],34911.45,,"Fee schedule rate ($34,911.45). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,16787.98,62990.26,There are no additional notes associated with this service or procedure.
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],30245.71,,"Fee schedule rate ($30,245.71). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9151.11,30245.71,There are no additional notes associated with this service or procedure.
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],20981.60,,"Fee schedule rate ($20,981.60). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,10003.71,23415.63,There are no additional notes associated with this service or procedure.
SPINAL PROCEDURES WITH MCC,028,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],120982.83,,"Fee schedule rate ($120,982.83). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,42633.57,120982.83,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],41213.48,,,,,,0,other,16129.04,59610.47,There are no additional notes associated with this service or procedure.
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],29076.53,,"Case rate ($28,093.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $26,270.18, add-ons for qualifying new technology services are included. If operating cost exceeds $61,141.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,672.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $24,235.87 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $24,325.23 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,912.45. The transfer capital threshold is the transfer adjustment factor * $1,912.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103.5%.",,,,0,other,10078.00,81454.07,Inpatient DRG
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],29917.96,,"Fee schedule rate ($29,917.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,12527.66,29917.96,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITH MCC,385,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],13293.42,,"Case rate ($12,660.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,913.31, add-ons for qualifying new technology services are included. If operating cost exceeds $46,784.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,543.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $9,931.73 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,968.35 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $783.71. The transfer capital threshold is the transfer adjustment factor * $783.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,11480.01,31134.92,Inpatient DRG
PERIPHERAL VASCULAR DISORDERS WITH CC,300,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],20331.78,,"Fee schedule rate ($20,331.78). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,9174.14,21005.20,There are no additional notes associated with this service or procedure.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",063,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],35701.87,,"Fee schedule rate ($35,701.87). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,35701.87,There are no additional notes associated with this service or procedure.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC,858,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],11377.76,,"Case rate ($11,377.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,720.10, add-ons for qualifying new technology services are included. If operating cost exceeds $45,591.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,449.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $8,742.91 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,775.15 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $689.90. The transfer capital threshold is the transfer adjustment factor * $689.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,11377.76,33794.11,Inpatient DRG
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],23239.84,,"Fee schedule rate ($23,239.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8543.64,23239.84,There are no additional notes associated with this service or procedure.
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],6457.19,,"Case rate ($6,457.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,142.59, add-ons for qualifying new technology services are included. If operating cost exceeds $41,013.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,089.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $4,182.21 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,197.63 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $330.02. The transfer capital threshold is the transfer adjustment factor * $330.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,5139.72,13110.79,Inpatient DRG
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],7665.00,,"Per diem ($7,665). If length of stay < 4, first 1 days paid at a per diem of $15,330 instead. Capped at $30,658.90.",,,,0,other,7665.00,40737.46,Estimated amount calculated based on 5 day length of stay.
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],9533.13,,"Fee schedule rate ($9,533.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5068.21,14525.56,There are no additional notes associated with this service or procedure.
BRONCHITIS AND ASTHMA WITH CC/MCC,202,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],14307.27,,"Fee schedule rate ($14,307.27). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7606.34,19110.30,There are no additional notes associated with this service or procedure.
Dstr Nrolytc Agnt Parverteb Fct Sngl Crvcl/Thora|LEFT SIDE,CASE-64633,APC,64633,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1891.77,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1827.80,1919.19,OPPS APC
"LYMPHOMA MYELOMA AND NON-ACUTE LEUKEMIA,MAJOR",691,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],19072.73,,"Case rate ($19,072.73). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,19072.73,20026.37,There are no additional notes associated with this service or procedure.
Rinsj Rptd Biceps/Triceps Tdn Dstl W/WO Tdn Grf|RIGHT SIDE,CASE-24342,APC,24342,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6791.99,7131.59,OPPS APC
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],14625.55,,"Fee schedule rate ($14,625.55). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7438.45,15961.98,There are no additional notes associated with this service or procedure.
UNGROUPABLE,999,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],161307.29,,"Fee schedule rate ($161,307.29). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (41), with a minimum of zero.",,,,0,other,10228.00,161307.29,There are no additional notes associated with this service or procedure.
"Tendon Sheath Incision|RIGHT HAND, FOURTH DIGIT",CASE-26055,APC,26055,CPT,0360,RC,,,F8,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1557.80,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1505.12,1580.37,OPPS APC
VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC,033,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],31250.88,,"Fee schedule rate ($31,250.88). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7.9), with a minimum of zero.",,,,0,other,13206.23,42156.44,There are no additional notes associated with this service or procedure.
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6915.64,,"Case rate ($6,915.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,569.08, add-ons for qualifying new technology services are included. If operating cost exceeds $41,440.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,123.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,607.15 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,624.14 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $363.55. The transfer capital threshold is the transfer adjustment factor * $363.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6915.64,14442.92,Inpatient DRG
NEONATE WITH OTHER SIGNIFICANT PROBLEMS,794,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],2074.00,,,,,,0,other,1798.85,12536.83,Estimated amount calculated based on 2 day length of stay.
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,307,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],7583.37,,"Case rate ($7,434.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $7,017.68, add-ons for qualifying new technology services are included. If operating cost exceeds $45,662.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $3,170.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $5,632.79 + an uncompensated DSH payment of $1,359.91. The transfer operating threshold is the transfer adjustment factor * $5,657.77 + an uncompensated DSH payment of $1,359.91. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $441.98. The transfer capital threshold is the transfer adjustment factor * $441.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6335.27,18228.77,Inpatient DRG
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],23618.74,,"Fee schedule rate ($23,618.74). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10533.95,24956.34,There are no additional notes associated with this service or procedure.
OSTEOMYELITIS WITHOUT CC/MCC,541,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],11429.52,,"Fee schedule rate ($11,429.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5103.00,15493.67,There are no additional notes associated with this service or procedure.
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 1 Level,CASE-64493,APC,64493,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],827.89,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,827.89,869.28,OPPS APC
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],13870.50,,"Fee schedule rate ($13,870.50). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9356.31,25026.36,There are no additional notes associated with this service or procedure.
"Open Tx Distal Phalangeal Fracture Each|RIGHT HAND, FIFTH DIGIT",CASE-26765,APC,26765,CPT,0360,RC,,,F9,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],7875.94,,"Case rate ($7,875.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,462.42, add-ons for qualifying new technology services are included. If operating cost exceeds $42,333.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,193.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $5,497.20 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,517.46 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $433.78. The transfer capital threshold is the transfer adjustment factor * $433.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7875.94,17233.12,Inpatient DRG
MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,708,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],29171.15,,,,,,0,other,10138.21,29171.15,There are no additional notes associated with this service or procedure.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],40108.48,,"Fee schedule rate ($40,108.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,5569.00,40108.48,There are no additional notes associated with this service or procedure.
HC Inj Anes/Steroid C/D Facet Sg|LEFT SIDE,CASE-64490,APC,64490,CPT,0361,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],827.89,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,827.89,869.28,OPPS APC
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],16384.85,,"Case rate ($15,604.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,677.74, add-ons for qualifying new technology services are included. If operating cost exceeds $49,548.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,734.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $12,684.69 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,732.79 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $974.98. The transfer capital threshold is the transfer adjustment factor * $974.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,16017.99,51903.64,Inpatient DRG
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC,434,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],13280.45,,"Fee schedule rate ($13,280.45). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6770.05,14019.86,There are no additional notes associated with this service or procedure.
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],26301.36,,"Fee schedule rate ($26,301.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11247.07,27028.33,There are no additional notes associated with this service or procedure.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,761,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],11946.72,,"Fee schedule rate ($11,946.72). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,5808.41,11946.72,There are no additional notes associated with this service or procedure.
"OTHER DISORDERS OF THE LIVER,MAJOR",283,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],2026.86,,"Case rate for a one day stay ($2,026.86). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,2026.86,2128.20,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITHOUT CC/MCC,428,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],42018.41,,"Case rate ($40,017.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $37,363.07, add-ons for qualifying new technology services are included. If operating cost exceeds $72,234.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,544.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $35,288.01 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $35,418.12 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,784.57. The transfer capital threshold is the transfer adjustment factor * $2,784.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,40017.53,118904.57,Inpatient DRG
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],16737.83,,"Case rate ($15,940.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,964.98, add-ons for qualifying new technology services are included. If operating cost exceeds $49,835.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,783.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $12,972.20 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,020.03 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,023.63. The transfer capital threshold is the transfer adjustment factor * $1,023.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,15940.79,53275.26,Inpatient DRG
OTHER CEREBROVASCULAR DISORDERS WITH MCC,070,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],13219.09,,"Case rate ($13,219.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,433.04, add-ons for qualifying new technology services are included. If operating cost exceeds $47,304.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,584.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $10,449.57 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,488.10 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $824.57. The transfer capital threshold is the transfer adjustment factor * $824.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,13219.09,37774.46,Inpatient DRG
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],17963.62,,"Case rate ($17,356.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,281.67, add-ons for qualifying new technology services are included. If operating cost exceeds $51,152.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,887.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $14,284.05 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,336.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,127.15. The transfer capital threshold is the transfer adjustment factor * $1,127.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,17356.15,44778.95,Inpatient DRG
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],7665.00,,"Per diem ($7,665). If length of stay < 4, first 1 days paid at a per diem of $15,330 instead. Capped at $30,658.90.",,,,0,other,7665.00,40737.46,Estimated amount calculated based on 5 day length of stay.
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC,964,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],34154.06,,"Fee schedule rate ($34,154.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12323.82,34154.06,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,394,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],20909.61,,"Fee schedule rate ($20,909.61). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8281.56,20909.61,There are no additional notes associated with this service or procedure.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH CC,026,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],58431.20,,"Fee schedule rate ($58,431.20). Adds an outlier to normal pricing equal to the per diem rate ($112,420.62) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,23000.66,63202.45,There are no additional notes associated with this service or procedure.
Bronchoscopy Bronchial/Endobrncl Bx 1+ Sites|UNUSUAL NON-OVERLAPPING SERVICE,CASE-31625,APC,31625,CPT,0360,RC,,,XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6936.25,,"APC Price ($6,605.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6837.16,6936.25,OPPS APC
"NEONATE BIRTH WEIGHT > 2499 GRAMS WITH RESPIRATORY DISTRESS SYNDROME OR OTHER MAJOR RESPIRATORY CONDITION,MINOR",634,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],5637.62,,"Case rate ($5,637.62). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,5637.62,5919.50,There are no additional notes associated with this service or procedure.
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],45157.33,,"Fee schedule rate ($45,157.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,10733.06,45157.33,There are no additional notes associated with this service or procedure.
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",623,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],32096.64,,"Fee schedule rate ($32,096.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,14093.37,33712.76,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,373,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],13780.60,,"Fee schedule rate ($13,780.60). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6870.94,14313.05,There are no additional notes associated with this service or procedure.
Cystourethroscopy W/Dest &/Rmvl Tumor Large,CASE-52240,APC,52240,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5018.77,,"APC Price ($5,018.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5018.77,5269.71,OPPS APC
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],7783.37,,"Case rate ($7,412.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,031.50, add-ons for qualifying new technology services are included. If operating cost exceeds $41,902.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,159.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $5,067.86 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,086.55 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $399.90. The transfer capital threshold is the transfer adjustment factor * $399.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6148.93,15887.21,Inpatient DRG
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],20297.68,,"Fee schedule rate ($20,297.68). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6965.00,21404.64,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC,833,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],5721.39,,"Fee schedule rate ($5,721.39). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,3041.73,10289.10,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITHOUT STERILIZATION WITH CC,787,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],23722.94,,"Fee schedule rate ($23,722.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9508.01,23722.94,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],28235.64,,"Fee schedule rate ($28,235.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,14344.60,36028.59,There are no additional notes associated with this service or procedure.
Arthrodesis Posterior/Pstlat Tq 1ntrspc Lumbar,CASE-22612,APC,22612,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],17232.68,,"APC Price ($16,412.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,16986.50,17232.68,OPPS APC
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],10114.56,,"Case rate ($9,632.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,111.24, add-ons for qualifying new technology services are included. If operating cost exceeds $43,982.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,308.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $7,139.22 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,166.29 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $548.74. The transfer capital threshold is the transfer adjustment factor * $548.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9865.56,37914.65,Inpatient DRG
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],17365.00,,"Fee schedule rate ($17,365.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5683.00,19635.68,There are no additional notes associated with this service or procedure.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],40108.48,,"Fee schedule rate ($40,108.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,5569.00,40108.48,There are no additional notes associated with this service or procedure.
NONTRAUMATIC STUPOR AND COMA WITH MCC,080,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],34015.33,,"Fee schedule rate ($34,015.33). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.5), with a minimum of zero.",,,,0,other,14202.39,35615.37,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],86235.79,,"Fee schedule rate ($86,235.79). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,32296.02,88188.38,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC,817,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],44895.04,,,,,,0,other,17396.11,44895.04,There are no additional notes associated with this service or procedure.
Cysto Bladder W/Ureteral Catheterization|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-52005,APC,52005,CPT,0360,RC,,,LT|XU,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3299.47,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3299.47,3464.44,OPPS APC
Tx Missed Abortion First Trimester Surgical,CASE-59820,APC,59820,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3181.53,,"APC Price ($3,030.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3030.03,3181.53,OPPS APC
Esophagogastroduodenoscopy Transoral Diagnostic|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-43235,APC,43235,CPT,0360,RC,,,74,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],848.96,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,848.96,891.41,OPPS APC
Arthrodesis Pst/Pstlat Tq 1ntrspc Ea Addl Ntrspc,CASE-22614,APC,22614,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],17232.68,,"APC Price ($16,412.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,16412.07,17232.68,OPPS APC
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,448,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],31737.19,,"Case rate ($30,663.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $28,661.63, add-ons for qualifying new technology services are included. If operating cost exceeds $63,532.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,860.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $26,618.53 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $26,716.68 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,100.47. The transfer capital threshold is the transfer adjustment factor * $2,100.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,30663.95,94077.13,Inpatient DRG
Lithotripsy Xtrcorp Shock Wave|BILATERAL PROCEDURE,CASE-50590,APC,50590,CPT,0360,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3464.44,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3299.47,3464.44,OPPS APC
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],57102.65,,,,,,0,other,21597.50,67790.93,There are no additional notes associated with this service or procedure.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],19501.98,,"Case rate ($19,119.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,922.16, add-ons for qualifying new technology services are included. If operating cost exceeds $52,793.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,016.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $15,918.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,977.21 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,256.13. The transfer capital threshold is the transfer adjustment factor * $1,256.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,11348.00,62454.12,Inpatient DRG
Nasal/Sinus Ndsc Tot W/Frnt Sins Expl Tiss Rmvl|LEFT SIDE,CASE-31253,APC,31253,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6837.16,,"APC Price ($6,605.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6605.95,6936.25,OPPS APC
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],86235.79,,"Fee schedule rate ($86,235.79). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,32296.02,88188.38,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,699,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],19570.20,,"Fee schedule rate ($19,570.20). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5961.00,19972.16,There are no additional notes associated with this service or procedure.
HC Gastroesophag Reflx Test W/Tel Ph Eltrd,CASE-91035,APC,91035,CPT,0750,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],831.93,,"APC Price ($803.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,803.80,843.99,OPPS APC
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],15937.95,,"Fee schedule rate ($15,937.95). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,13148.66,32553.63,There are no additional notes associated with this service or procedure.
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],30935.16,,"Fee schedule rate ($30,935.16). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13092.47,33159.45,There are no additional notes associated with this service or procedure.
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],53275.26,,"Fee schedule rate ($53,275.26). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,15940.79,53275.26,There are no additional notes associated with this service or procedure.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,544,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],23207.64,,"Fee schedule rate ($23,207.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,7055.15,23207.64,There are no additional notes associated with this service or procedure.
CHEST PAIN,313,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],6957.26,,"Case rate ($6,820.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,480.89, add-ons for qualifying new technology services are included. If operating cost exceeds $41,351.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,116.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $4,519.27 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,535.94 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $356.62. The transfer capital threshold is the transfer adjustment factor * $356.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6820.84,15377.66,Inpatient DRG
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],53152.12,,"Fee schedule rate ($53,152.12). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,19152.11,53152.12,There are no additional notes associated with this service or procedure.
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],81454.07,,"Fee schedule rate ($81,454.07). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,10078.00,81454.07,There are no additional notes associated with this service or procedure.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],6965.00,,,,,,0,other,5778.62,11681.49,There are no additional notes associated with this service or procedure.
CERVICAL SPINAL FUSION WITH MCC,471,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],111337.93,,"Fee schedule rate ($111,337.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,34645.26,111337.93,There are no additional notes associated with this service or procedure.
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],16438.59,,"Fee schedule rate ($16,438.59). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7402.56,16438.59,There are no additional notes associated with this service or procedure.
"HC Unlisted Procedure, Nervous System",CASE-64999,APC,64999,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7029.71,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,7029.71,7131.59,OPPS APC
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],12804.91,,"Case rate ($12,195.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,480.50, add-ons for qualifying new technology services are included. If operating cost exceeds $46,351.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,509.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,500.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,535.55 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $749.68. The transfer capital threshold is the transfer adjustment factor * $749.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12195.15,39424.57,Inpatient DRG
HEADACHES WITHOUT MCC,103,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],7608.43,,"Case rate ($7,608.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,213.57, add-ons for qualifying new technology services are included. If operating cost exceeds $42,084.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,174.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $5,249.26 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,268.62 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $414.22. The transfer capital threshold is the transfer adjustment factor * $414.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,20883.08,Inpatient DRG
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],6965.00,,,,,,0,other,6965.00,29482.05,There are no additional notes associated with this service or procedure.
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],20981.60,,"Fee schedule rate ($20,981.60). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,10003.71,23415.63,There are no additional notes associated with this service or procedure.
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],34422.94,,,,,,0,other,6965.00,34422.94,There are no additional notes associated with this service or procedure.
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7137.12,,"Case rate ($6,797.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,468, add-ons for qualifying new technology services are included. If operating cost exceeds $41,339.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,106.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,505.96 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,523.05 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $346.34. The transfer capital threshold is the transfer adjustment factor * $346.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5068.21,14525.56,Inpatient DRG
HEADACHES WITHOUT MCC,103,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],6965.00,,,,,,0,other,6965.00,20883.08,There are no additional notes associated with this service or procedure.
HC Joint Injection/Aspir Large WO US|SEPARATE STRUCTURE|LEFT SIDE,CASE-20610,APC,20610,CPT,0510,RC,,,XS|LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],301.68,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,287.31,301.68,OPPS APC
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,057,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],25493.52,,,,,,0,other,10718.84,39884.93,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],6892.39,,"Case rate ($6,564.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,242.12, add-ons for qualifying new technology services are included. If operating cost exceeds $41,113.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,097.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $4,281.39 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,297.17 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $337.84. The transfer capital threshold is the transfer adjustment factor * $337.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6564.18,17651.07,Inpatient DRG
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",004,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],260309.36,,"Fee schedule rate ($260,309.36). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (35), with a minimum of zero.",,,,0,other,10249.47,272554.00,There are no additional notes associated with this service or procedure.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],33608.45,,"Fee schedule rate ($33,608.45). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,7332.00,35314.31,There are no additional notes associated with this service or procedure.
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],18043.23,,"Fee schedule rate ($18,043.23). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7733.72,18043.23,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],28423.20,,"Fee schedule rate ($28,423.20). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11059.47,28423.20,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITH CC,164,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],77058.83,,"Fee schedule rate ($77,058.83). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,19037.66,77058.83,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,066,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],10677.27,,"Fee schedule rate ($10,677.27). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6579.76,20083.61,There are no additional notes associated with this service or procedure.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC,434,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],6905.45,,"Case rate ($6,770.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,433.64, add-ons for qualifying new technology services are included. If operating cost exceeds $41,304.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,112.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,472.20 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,488.69 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $352.90. The transfer capital threshold is the transfer adjustment factor * $352.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6770.05,14019.86,Inpatient DRG
HC Drain/Inj Joint/Bursa W/US Large|PBB CHARGE|LEFT SIDE,CASE-20611,APC,20611,CPT,0510,RC,,,PBB|LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],8020.50,,"Case rate ($7,749.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,344.60, add-ons for qualifying new technology services are included. If operating cost exceeds $42,215.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,184.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,379.82 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,399.66 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $424.52. The transfer capital threshold is the transfer adjustment factor * $424.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6711.00,16865.16,Inpatient DRG
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],24310.25,,"Case rate ($13,891.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,058.63, add-ons for qualifying new technology services are included. If operating cost exceeds $47,929.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,633.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,072.85 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,113.68 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $873.76. The transfer capital threshold is the transfer adjustment factor * $873.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,13891.57,34712.20,All Other Inpatient
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC,807,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6695.39,,"Case rate ($6,376.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,075.86, add-ons for qualifying new technology services are included. If operating cost exceeds $40,946.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,076.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $4,115.31 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,130.91 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $316.31. The transfer capital threshold is the transfer adjustment factor * $316.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5354.25,13266.23,Inpatient DRG
NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,601,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],6850.20,,"Fee schedule rate ($6,850.20). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6042.05,12359.72,There are no additional notes associated with this service or procedure.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],21170.23,,"Fee schedule rate ($21,170.23). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,15273.74,39820.52,There are no additional notes associated with this service or procedure.
"RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT > 96 HOURS,MAJOR",130,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],47720.91,,"Case rate ($45,448.49). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,45448.49,47720.91,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL HEMORRHAGE WITH CC,378,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],8886.85,,"Case rate ($8,586.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,123.28, add-ons for qualifying new technology services are included. If operating cost exceeds $42,994.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,245.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,155.63 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,178.33 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $485.74. The transfer capital threshold is the transfer adjustment factor * $485.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,8586.33,20845.19,Inpatient DRG
Egd Dilation Gastric/Duodenal Stricture,CASE-43245,APC,43245,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1796.14,,"APC Price ($1,796.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1796.14,1885.95,OPPS APC
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|LEFT HAND, SECOND DIGIT",CASE-26160,APC,26160,CPT,0360,RC,,,F1,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1505.12,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1505.12,1580.37,OPPS APC
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],8480.00,,"Per diem ($8,480). If length of stay < 5.5, first 1 days paid at a per diem of $16,960 instead. Capped at $46,638.59.",,,,0,other,8480.00,59081.91,Estimated amount calculated based on 3 day length of stay.
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],8117.25,,"Case rate ($7,842.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,431.55, add-ons for qualifying new technology services are included. If operating cost exceeds $42,302.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,191.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $5,466.44 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,486.60 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $431.36. The transfer capital threshold is the transfer adjustment factor * $431.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,5280.00,17136.70,Inpatient DRG
Bx/Exc Lymph Node Open Deep Axillary Node,CASE-38525,APC,38525,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3848.19,,"APC Price ($3,664.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3664.94,3848.19,OPPS APC
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC,519,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],15847.20,,"Case rate ($15,092.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,200.43, add-ons for qualifying new technology services are included. If operating cost exceeds $49,071.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,698.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $12,209.19 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,255.48 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $938.43. The transfer capital threshold is the transfer adjustment factor * $938.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,15490.44,50780.20,Inpatient DRG
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],16897.01,,"Case rate ($16,897.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,854.53, add-ons for qualifying new technology services are included. If operating cost exceeds $50,725.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,853.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $13,858.48 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,909.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,093.57. The transfer capital threshold is the transfer adjustment factor * $1,093.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,16897.01,43444.85,Inpatient DRG
Submucous Rescj Inferior Turbinate Prtl/Compl|RIGHT SIDE,CASE-30140,APC,30140,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6936.25,,"APC Price ($6,605.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6605.95,6936.25,OPPS APC
CESAREAN SECTION WITH STERILIZATION WITH MCC,783,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],23722.94,,"Fee schedule rate ($23,722.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12612.10,23722.94,There are no additional notes associated with this service or procedure.
Hysteroscopy Endometrial Ablation,CASE-58563,APC,58563,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],4846.30,,"APC Price ($4,682.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,4682.41,4916.53,OPPS APC
MAJOR CHEST TRAUMA WITHOUT CC/MCC,185,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],7634.75,,"Case rate ($7,271.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,899.84, add-ons for qualifying new technology services are included. If operating cost exceeds $41,770.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,149.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,936.68 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,954.88 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $389.55. The transfer capital threshold is the transfer adjustment factor * $389.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7271.19,21771.61,Inpatient DRG
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],35419.59,,"Fee schedule rate ($35,419.59). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,7086.00,57872.02,There are no additional notes associated with this service or procedure.
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],32263.82,,"Fee schedule rate ($32,263.82). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13571.25,33781.47,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],53152.12,,"Fee schedule rate ($53,152.12). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,19152.11,53152.12,There are no additional notes associated with this service or procedure.
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],45017.13,,"Fee schedule rate ($45,017.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,14603.31,45017.13,There are no additional notes associated with this service or procedure.
RESPIRATORY NEOPLASMS WITHOUT CC/MCC,182,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7244.78,,"Case rate ($6,899.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,563.58, add-ons for qualifying new technology services are included. If operating cost exceeds $41,434.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,113.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,601.18 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,618.63 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $353.66. The transfer capital threshold is the transfer adjustment factor * $353.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,23037.13,Inpatient DRG
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],2070.00,,,,,,0,other,1188.00,34338.33,Estimated amount calculated based on 6 day length of stay.
FRACTURES OF FEMUR WITH MCC,533,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],30847.63,,,,,,0,other,6852.00,49490.05,There are no additional notes associated with this service or procedure.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],9074.68,,"Case rate ($8,767.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,292.11, add-ons for qualifying new technology services are included. If operating cost exceeds $43,163.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,258.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,323.85 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,347.16 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $499.01. The transfer capital threshold is the transfer adjustment factor * $499.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,8767.81,19824.58,Inpatient DRG
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],14625.55,,"Fee schedule rate ($14,625.55). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7438.45,15961.98,There are no additional notes associated with this service or procedure.
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC,964,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],34154.06,,"Fee schedule rate ($34,154.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12323.82,34154.06,There are no additional notes associated with this service or procedure.
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],6524.00,,"Per diem ($6,524). If length of stay < 2.6, first 1 days paid at a per diem of $13,048 instead. Capped at $16,962.56.",,,,0,other,6524.00,17760.46,Estimated amount calculated based on 2 day length of stay.
Laparoscopy Colpopexy Suspension Vaginal Apex,CASE-57425,APC,57425,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],9949.78,,"APC Price ($9,949.78). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,9949.78,10447.27,OPPS APC
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level|LEFT SIDE,CASE-64483,APC,64483,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],827.89,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,827.89,869.28,OPPS APC
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],81524.17,,"Fee schedule rate ($81,524.17). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,8972.00,81524.17,There are no additional notes associated with this service or procedure.
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],12246.05,,"Fee schedule rate ($12,246.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6010.23,12246.05,There are no additional notes associated with this service or procedure.
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],16035.06,,"Fee schedule rate ($16,035.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,7396.47,16035.06,There are no additional notes associated with this service or procedure.
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],37488.28,,"Fee schedule rate ($37,488.28). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.5), with a minimum of zero.",,,,0,other,15453.88,39251.68,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],14631.49,,"Case rate ($14,344.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,480.09, add-ons for qualifying new technology services are included. If operating cost exceeds $48,351.10 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,666.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $11,492.77 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,535.14 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $906.89. The transfer capital threshold is the transfer adjustment factor * $906.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,14344.60,36028.59,Inpatient DRG
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],26204.74,,"Fee schedule rate ($26,204.74). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10120.20,26204.74,There are no additional notes associated with this service or procedure.
Surgical Arthroscopy Shoulder Xtnsv Dbrdmt 3+|LEFT SIDE,CASE-29823,APC,29823,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],39053.73,,"Fee schedule rate ($39,053.73). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,16017.99,51903.64,There are no additional notes associated with this service or procedure.
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],11113.94,,"Case rate ($10,584.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,998.45, add-ons for qualifying new technology services are included. If operating cost exceeds $44,869.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,376.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $8,023.08 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,053.50 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $616.67. The transfer capital threshold is the transfer adjustment factor * $616.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10846.16,25863.45,Inpatient DRG
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],16244.32,,"Case rate ($9,282.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,770.90, add-ons for qualifying new technology services are included. If operating cost exceeds $43,641.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,296.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,800.88 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,825.96 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $536.66. The transfer capital threshold is the transfer adjustment factor * $536.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,9282.47,21320.03,All Other Inpatient
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,448,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],31277.23,,"Case rate ($30,663.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $28,661.63, add-ons for qualifying new technology services are included. If operating cost exceeds $63,532.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,860.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $26,618.53 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $26,716.68 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,100.47. The transfer capital threshold is the transfer adjustment factor * $2,100.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,30663.95,94077.13,Inpatient DRG
OSTEOMYELITIS WITH CC,540,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],18450.55,,"Fee schedule rate ($18,450.55). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,9809.07,25507.30,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],8991.47,,"Case rate ($8,563.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,101.85, add-ons for qualifying new technology services are included. If operating cost exceeds $42,972.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,244.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $6,134.29 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,156.91 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $484.06. The transfer capital threshold is the transfer adjustment factor * $484.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8563.30,31533.97,Inpatient DRG
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],80635.65,,"Fee schedule rate ($80,635.65). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,26028.48,80635.65,There are no additional notes associated with this service or procedure.
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],11209.51,,"Case rate ($10,989.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,359.11, add-ons for qualifying new technology services are included. If operating cost exceeds $45,230.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,421.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $8,383.26 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,414.17 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $661.52. The transfer capital threshold is the transfer adjustment factor * $661.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,10989.72,26280.60,Inpatient DRG
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],13482.55,,"Case rate ($12,840.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,080.88, add-ons for qualifying new technology services are included. If operating cost exceeds $46,951.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,556.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $10,098.70 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,135.93 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $796.89. The transfer capital threshold is the transfer adjustment factor * $796.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,1188.00,31658.33,Inpatient DRG
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],142438.06,,"Fee schedule rate ($142,438.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (40), with a minimum of zero.",,,,0,other,45521.20,142438.06,There are no additional notes associated with this service or procedure.
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC",605,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],8148.17,,"Case rate ($8,148.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,715.67, add-ons for qualifying new technology services are included. If operating cost exceeds $42,586.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,213.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,749.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,770.72 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $453.69. The transfer capital threshold is the transfer adjustment factor * $453.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8148.17,18024.13,Inpatient DRG
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],27589.62,,"Fee schedule rate ($27,589.62). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12566.28,30861.41,There are no additional notes associated with this service or procedure.
Tonsillectomy Primary/Secondary Age 12/>,CASE-42826,APC,42826,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3211.97,,"APC Price ($3,103.35). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3103.35,3258.52,OPPS APC
"NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY",789,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],6663.33,,,,,,0,other,3054.00,14857.05,Estimated amount calculated based on 1 day length of stay.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],9777.00,,"Case rate ($9,446.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,923.36, add-ons for qualifying new technology services are included. If operating cost exceeds $43,794.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,308.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,952.78 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,978.41 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $548.64. The transfer capital threshold is the transfer adjustment factor * $548.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,9446.38,21796.21,Inpatient DRG
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],28253.40,,"Fee schedule rate ($28,253.40). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,12126.09,29582.40,There are no additional notes associated with this service or procedure.
"EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME, NEONATE",790,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],44304.49,,"Case rate ($42,194.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $39,388.49, add-ons for qualifying new technology services are included. If operating cost exceeds $74,259.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,703.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 17.9. The base transfer operating payment is the transfer adjustment factor * $37,305.99 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $37,443.54 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,943.81. The transfer capital threshold is the transfer adjustment factor * $2,943.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,3054.00,44304.49,Inpatient DRG
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,083,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],27465.16,,,,,,0,other,6965.00,28680.85,There are no additional notes associated with this service or procedure.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],37774.29,,"Case rate ($21,585.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,215.96, add-ons for qualifying new technology services are included. If operating cost exceeds $55,086.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,196.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $18,203.89 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,271.01 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,436.47. The transfer capital threshold is the transfer adjustment factor * $1,436.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,21585.31,73588.10,All Other Inpatient
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],35474.53,,"Fee schedule rate ($35,474.53). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,16428.39,42083.20,There are no additional notes associated with this service or procedure.
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],12439.05,,"Case rate ($12,195.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,480.50, add-ons for qualifying new technology services are included. If operating cost exceeds $46,351.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,509.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,500.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,535.55 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $749.68. The transfer capital threshold is the transfer adjustment factor * $749.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,12195.15,39424.57,Inpatient DRG
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],6711.00,,"Per diem ($6,711). If length of stay < 2.4, first 1 days paid at a per diem of $13,422 instead. Capped at $16,107.48.",,,,0,other,6711.00,16865.16,Estimated amount calculated based on 2 day length of stay.
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],13842.68,,"Case rate ($13,571.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,760.65, add-ons for qualifying new technology services are included. If operating cost exceeds $47,631.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,610.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $10,775.96 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,815.69 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $850.33. The transfer capital threshold is the transfer adjustment factor * $850.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,13571.25,33781.47,Inpatient DRG
Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE,CASE-62323,APC,62323,CPT,0360,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],660.72,,"APC Price ($660.72). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,660.72,693.76,OPPS APC
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],16669.71,,"Fee schedule rate ($16,669.71). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8767.81,19824.58,There are no additional notes associated with this service or procedure.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],6683.37,,"Case rate ($6,683.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,353, add-ons for qualifying new technology services are included. If operating cost exceeds $41,224.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,106.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,391.86 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,408.05 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $346.56. The transfer capital threshold is the transfer adjustment factor * $346.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6683.37,14699.43,Inpatient DRG
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],14985.78,,"Case rate ($8,563.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,101.85, add-ons for qualifying new technology services are included. If operating cost exceeds $42,972.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,244.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $6,134.29 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,156.91 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $484.06. The transfer capital threshold is the transfer adjustment factor * $484.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,8563.30,31533.97,All Other Inpatient
"NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY",789,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],6663.33,,,,,,0,other,3054.00,14857.05,Estimated amount calculated based on 1 day length of stay.
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],37899.49,,"Fee schedule rate ($37,899.49). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,14747.55,37899.49,There are no additional notes associated with this service or procedure.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,056,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],18030.68,,"Case rate ($17,677.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,580.28, add-ons for qualifying new technology services are included. If operating cost exceeds $51,451.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,910.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $14,581.57 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,635.33 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,150.63. The transfer capital threshold is the transfer adjustment factor * $1,150.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,7659.00,59328.19,Inpatient DRG
Removal Cerclage Suture Under Anesthesia,CASE-59871,APC,59871,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3136.08,,"APC Price ($3,030.03). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3030.03,3181.53,OPPS APC
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],101083.00,,"Fee schedule rate ($101,083.00). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,35389.50,101083.00,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],10062.87,,"Case rate ($9,865.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,313.33, add-ons for qualifying new technology services are included. If operating cost exceeds $44,184.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,339.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $7,341.31 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,368.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $579.30. The transfer capital threshold is the transfer adjustment factor * $579.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,9865.56,37914.65,Inpatient DRG
MAJOR CHEST PROCEDURES WITH CC,164,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],19989.54,,"Case rate ($19,037.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,845.93, add-ons for qualifying new technology services are included. If operating cost exceeds $52,716.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,010.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $15,842.57 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,900.98 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,250.14. The transfer capital threshold is the transfer adjustment factor * $1,250.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,19037.66,77058.83,Inpatient DRG
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH MCC",722,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],14484.38,,"Case rate ($14,200.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,345.91, add-ons for qualifying new technology services are included. If operating cost exceeds $48,216.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,656.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $11,359.07 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,400.95 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $896.34. The transfer capital threshold is the transfer adjustment factor * $896.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,14200.37,56869.13,Inpatient DRG
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],30538.70,,,,,,0,other,12455.21,37149.27,There are no additional notes associated with this service or procedure.
PLEURAL EFFUSION WITH MCC,186,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],12130.82,,"Case rate ($11,720.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $11,009.40, add-ons for qualifying new technology services are included. If operating cost exceeds $49,654.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $3,482.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $9,606.87 + an uncompensated DSH payment of $1,359.91. The transfer operating threshold is the transfer adjustment factor * $9,649.48 + an uncompensated DSH payment of $1,359.91. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $753.81. The transfer capital threshold is the transfer adjustment factor * $753.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,10804.96,31089.66,Inpatient DRG
NEONATE WITH OTHER SIGNIFICANT PROBLEMS,794,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],11939.84,,"Case rate ($11,939.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,242.99, add-ons for qualifying new technology services are included. If operating cost exceeds $46,114.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,490.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $9,263.89 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,298.04 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $731.01. The transfer capital threshold is the transfer adjustment factor * $731.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,1798.85,12536.83,Inpatient DRG
MAJOR BLADDER PROCEDURES WITH MCC,653,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],69470.10,,"Fee schedule rate ($69,470.10). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,10280.00,125343.98,There are no additional notes associated with this service or procedure.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6683.37,,"Case rate ($6,683.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,353, add-ons for qualifying new technology services are included. If operating cost exceeds $41,224.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,106.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,391.86 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,408.05 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $346.56. The transfer capital threshold is the transfer adjustment factor * $346.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6683.37,14699.43,Inpatient DRG
ALLERGIC REACTIONS WITH MCC,915,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],27385.01,,"Fee schedule rate ($27,385.01). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,13332.86,33088.84,There are no additional notes associated with this service or procedure.
VENTRICULAR SHUNT PROCEDURES WITH CC,032,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],46275.08,,"Fee schedule rate ($46,275.08). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,16376.22,46275.08,There are no additional notes associated with this service or procedure.
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,094,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],67889.44,,"Fee schedule rate ($67,889.44). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,25778.58,67889.44,There are no additional notes associated with this service or procedure.
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],26721.94,,"Fee schedule rate ($26,721.94). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6965.00,34422.94,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],21167.26,,"Fee schedule rate ($21,167.26). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,6841.83,21167.26,There are no additional notes associated with this service or procedure.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,098,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],38799.38,,"Fee schedule rate ($38,799.38). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,6965.00,45156.75,There are no additional notes associated with this service or procedure.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],57067.24,,,,,,0,other,21585.31,73588.10,There are no additional notes associated with this service or procedure.
PREMATURITY WITH MAJOR PROBLEMS,791,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],3186.77,,,,,,0,other,3048.21,30904.42,Estimated amount calculated based on 5 day length of stay.
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],2401.00,,,,,,0,other,1188.00,18893.86,Estimated amount calculated based on 3 day length of stay.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,057,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],24348.21,,"Fee schedule rate ($24,348.21). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.9), with a minimum of zero.",,,,0,other,10718.84,39884.93,There are no additional notes associated with this service or procedure.
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC",011,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],40824.51,,"Case rate ($38,880.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $36,305.31, add-ons for qualifying new technology services are included. If operating cost exceeds $71,176.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,461.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 11.4. The base transfer operating payment is the transfer adjustment factor * $34,234.14 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $34,360.36 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,701.41. The transfer capital threshold is the transfer adjustment factor * $2,701.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,38880.49,150008.48,Inpatient DRG
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],23545.50,,,,,,0,other,10048.39,23545.50,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],9858.95,,"Case rate ($9,389.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,870.44, add-ons for qualifying new technology services are included. If operating cost exceeds $43,741.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,304.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,900.05 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,925.50 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $544.48. The transfer capital threshold is the transfer adjustment factor * $544.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9389.48,22358.90,Inpatient DRG
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],9533.13,,"Fee schedule rate ($9,533.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5068.21,14525.56,There are no additional notes associated with this service or procedure.
Perq Nl/Pl Lithotrp Simple Up to 2 Cm 1 Location|RIGHT SIDE,CASE-50080,APC,50080,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],8860.83,,"APC Price ($8,860.83). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,8860.83,9303.88,OPPS APC
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],20135.47,,,,,,0,other,8874.81,20553.44,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7752.07,,"Case rate ($7,382.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,013.92, add-ons for qualifying new technology services are included. If operating cost exceeds $41,884.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,148.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $5,049.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,068.97 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $388.14. The transfer capital threshold is the transfer adjustment factor * $388.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,19126.88,Inpatient DRG
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,447,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],48157.33,,"Case rate ($45,864.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $42,883.97, add-ons for qualifying new technology services are included. If operating cost exceeds $77,754.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,894.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $40,784.39 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $40,939.02 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,134.78. The transfer capital threshold is the transfer adjustment factor * $3,134.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,47193.21,156646.82,Inpatient DRG
OTHER MENTAL DISORDER DIAGNOSES,887,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],2070.00,,,,,,0,other,2070.00,21072.10,Estimated amount calculated based on 1 day length of stay.
Destruction Neurolytic Agt Genicular Nerve W/Img,CASE-64624,APC,64624,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1827.80,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1827.80,1919.19,OPPS APC
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],96365.69,,"Fee schedule rate ($96,365.69). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,23377.19,96365.69,There are no additional notes associated with this service or procedure.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],22292.26,,"Fee schedule rate ($22,292.26). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9977.99,26949.28,There are no additional notes associated with this service or procedure.
Cysto W/Ureteroscopy W/Rmvl/Manj Stones|LEFT SIDE,CASE-52352,APC,52352,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3464.44,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3299.47,3464.44,OPPS APC
TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC,087,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],17998.55,,,,,,0,other,8139.36,22679.07,There are no additional notes associated with this service or procedure.
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],34245.00,,"Fee schedule rate ($34,245.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,12725.42,34245.00,There are no additional notes associated with this service or procedure.
PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,337,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],12586.88,,"Case rate ($12,340.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,615.32, add-ons for qualifying new technology services are included. If operating cost exceeds $46,486.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,520.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $9,634.84 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,670.37 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $760.28. The transfer capital threshold is the transfer adjustment factor * $760.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,12340.08,38926.31,Inpatient DRG
"NEONATE BIRTH WEIGHT > 2499 GRAMS WITH RESPIRATORY DISTRESS SYNDROME OR OTHER MAJOR RESPIRATORY CONDITION,MAJOR",634,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],21074.73,,"Case rate ($21,074.73). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,21074.73,22128.47,There are no additional notes associated with this service or procedure.
NON-MALIGNANT BREAST DISORDERS WITH CC/MCC,600,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],15046.13,,"Fee schedule rate ($15,046.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7999.14,20495.56,There are no additional notes associated with this service or procedure.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],10098.51,,"Case rate ($10,098.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,530.04, add-ons for qualifying new technology services are included. If operating cost exceeds $44,401.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,356.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $7,557.23 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,585.10 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $596.34. The transfer capital threshold is the transfer adjustment factor * $596.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10098.51,24259.09,Inpatient DRG
"OTHER BACK AND NECK DISORDERS FRACTURES AND INJURIES,MODERATE",347,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],2095.36,,"Case rate for a one day stay ($1,995.58). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,1995.58,2095.36,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],5910.42,,"Case rate ($5,628.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,372.11, add-ons for qualifying new technology services are included. If operating cost exceeds $40,243.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,029.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,414.56 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,427.15 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $269.44. The transfer capital threshold is the transfer adjustment factor * $269.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5628.97,12272.58,Inpatient DRG
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],18675.44,,,,,,0,other,6965.00,23385.72,There are no additional notes associated with this service or procedure.
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC,797,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],8894.11,,"Case rate ($8,719.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,247.38, add-ons for qualifying new technology services are included. If operating cost exceeds $43,118.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,255.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $6,279.28 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,302.43 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $495.50. The transfer capital threshold is the transfer adjustment factor * $495.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,8719.72,20928.55,Inpatient DRG
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],7547.49,,"Case rate ($7,547.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,156.87, add-ons for qualifying new technology services are included. If operating cost exceeds $42,027.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,169.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $5,192.77 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,211.92 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $409.76. The transfer capital threshold is the transfer adjustment factor * $409.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,19126.88,Inpatient DRG
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],27449.09,,"Fee schedule rate ($27,449.09). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,20559.34,54086.17,There are no additional notes associated with this service or procedure.
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],13568.55,,"Fee schedule rate ($13,568.55). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6834.39,21354.82,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,083,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],28680.85,,"Fee schedule rate ($28,680.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,28680.85,There are no additional notes associated with this service or procedure.
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],11137.18,,,,,,0,other,5065.00,12558.65,There are no additional notes associated with this service or procedure.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],8702.79,,"Case rate ($8,702.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,231.63, add-ons for qualifying new technology services are included. If operating cost exceeds $43,102.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,254.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,263.59 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,286.68 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $494.26. The transfer capital threshold is the transfer adjustment factor * $494.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,5683.00,19635.68,Inpatient DRG
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH CC,354,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],13140.41,,"Case rate ($12,514.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $11,748.98, add-ons for qualifying new technology services are included. If operating cost exceeds $50,393.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $3,540.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $10,343.20 + an uncompensated DSH payment of $1,359.91. The transfer operating threshold is the transfer adjustment factor * $10,389.07 + an uncompensated DSH payment of $1,359.91. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $811.58. The transfer capital threshold is the transfer adjustment factor * $811.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,11633.13,33472.54,Inpatient DRG
Hysteroscopy Lysis Intrauterine Adhesions,CASE-58559,APC,58559,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],4846.30,,"APC Price ($4,682.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,4682.41,4916.53,OPPS APC
CESAREAN SECTION WITH STERILIZATION WITH MCC,783,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],19006.00,,,,,,0,other,12612.10,23722.94,There are no additional notes associated with this service or procedure.
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],9746.59,,"Case rate ($9,282.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,770.90, add-ons for qualifying new technology services are included. If operating cost exceeds $43,641.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,296.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,800.88 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,825.96 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $536.66. The transfer capital threshold is the transfer adjustment factor * $536.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9282.47,21320.03,Inpatient DRG
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,373,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],14313.05,,,,,,0,other,6870.94,14313.05,There are no additional notes associated with this service or procedure.
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC,497,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],10634.03,,"Case rate ($10,127.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,557.14, add-ons for qualifying new technology services are included. If operating cost exceeds $44,428.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,358.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 1.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $7,584.22 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,612.19 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $598.47. The transfer capital threshold is the transfer adjustment factor * $598.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10127.65,37761.19,Inpatient DRG
Cysto W/Removal of Tumors Small,CASE-52234,APC,52234,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3464.44,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3299.47,3464.44,OPPS APC
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],32293.66,,"Fee schedule rate ($32,293.66). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,32293.66,There are no additional notes associated with this service or procedure.
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],6189.75,,"Fee schedule rate ($6,189.75). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5937.41,12366.99,There are no additional notes associated with this service or procedure.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],80635.65,,"Fee schedule rate ($80,635.65). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,26028.48,80635.65,There are no additional notes associated with this service or procedure.
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],36855.62,,"Fee schedule rate ($36,855.62). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,15821.59,40320.14,There are no additional notes associated with this service or procedure.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],16669.71,,"Fee schedule rate ($16,669.71). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8767.81,19824.58,There are no additional notes associated with this service or procedure.
HC Inject Tendon Origin/Insert|RIGHT SIDE,CASE-20551,APC,20551,CPT,0361,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,086,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],30728.81,,"Fee schedule rate ($30,728.81). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8442.00,30728.81,There are no additional notes associated with this service or procedure.
Chemodenervation Muscle Neck Unilat for Dystonia,CASE-64616,APC,64616,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],41190.50,,"Fee schedule rate ($41,190.50). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,16787.98,62990.26,There are no additional notes associated with this service or procedure.
VAGINAL DELIVERY WITH O.R. PROCEDURES EXCEPT STERILIZATION AND/OR D&C,768,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],9523.97,,"Case rate ($9,201.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,695.94, add-ons for qualifying new technology services are included. If operating cost exceeds $43,566.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,290.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $6,726.19 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,750.99 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $530.76. The transfer capital threshold is the transfer adjustment factor * $530.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6426.91,13416.00,Inpatient DRG
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH CC,354,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],21900.69,,"Case rate ($12,514.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $11,748.98, add-ons for qualifying new technology services are included. If operating cost exceeds $50,393.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $3,540.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $10,343.20 + an uncompensated DSH payment of $1,359.91. The transfer operating threshold is the transfer adjustment factor * $10,389.07 + an uncompensated DSH payment of $1,359.91. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $811.58. The transfer capital threshold is the transfer adjustment factor * $811.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,11633.13,33472.54,All Other Inpatient
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6834.39,,"Case rate ($6,834.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,493.49, add-ons for qualifying new technology services are included. If operating cost exceeds $41,364.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,117.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $4,531.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,548.54 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $357.61. The transfer capital threshold is the transfer adjustment factor * $357.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6834.39,21354.82,Inpatient DRG
Hysteroscopy Lysis Intrauterine Adhesions,CASE-58559,APC,58559,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],4682.41,,"APC Price ($4,682.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,4682.41,4916.53,OPPS APC
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH CC",457,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],43808.93,,"Case rate ($42,327.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $39,511.96, add-ons for qualifying new technology services are included. If operating cost exceeds $74,382.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,713.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $37,429.01 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $37,567.02 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,953.52. The transfer capital threshold is the transfer adjustment factor * $2,953.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,42327.47,160549.49,Inpatient DRG
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC",758,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],8874.92,,"Case rate ($8,574.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,112.57, add-ons for qualifying new technology services are included. If operating cost exceeds $42,983.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,244.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $6,144.96 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,167.62 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $484.90. The transfer capital threshold is the transfer adjustment factor * $484.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,8574.80,19263.78,Inpatient DRG
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],8239.88,,"Case rate ($7,847.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,435.96, add-ons for qualifying new technology services are included. If operating cost exceeds $42,306.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,191.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,470.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,491.01 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $431.70. The transfer capital threshold is the transfer adjustment factor * $431.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7847.50,17755.26,Inpatient DRG
Exc B9 Lesion Mrgn Xcp Sk Tg S/N/H/F/G 0.6-1.0cm,CASE-11421,APC,11421,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],662.83,,"APC Price ($662.83). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,662.83,695.97,OPPS APC
OSTEOMYELITIS WITH CC,540,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],18450.55,,"Fee schedule rate ($18,450.55). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,9809.07,25507.30,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],21892.85,,"Fee schedule rate ($21,892.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7569.84,21892.85,There are no additional notes associated with this service or procedure.
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],35061.53,,"Fee schedule rate ($35,061.53). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,9696.93,35061.53,There are no additional notes associated with this service or procedure.
Egd Band Ligation Esophgeal/Gastric Varices,CASE-43244,APC,43244,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1796.14,,"APC Price ($1,796.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1796.14,1885.95,OPPS APC
OTHER CEREBROVASCULAR DISORDERS WITH MCC,070,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],31286.59,,"Fee schedule rate ($31,286.59). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13219.09,37774.46,There are no additional notes associated with this service or procedure.
HC Inj Anes/Steroid C/D Facet Sg,CASE-64490,APC,64490,CPT,0361,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],869.28,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,827.89,869.28,OPPS APC
RADIOTHERAPY,849,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],20742.66,,"Case rate ($19,754.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $18,546.41, add-ons for qualifying new technology services are included. If operating cost exceeds $53,417.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,031.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $16,538.75 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $16,601.46 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,271.21. The transfer capital threshold is the transfer adjustment factor * $1,271.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,20293.88,81867.07,Inpatient DRG
NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,601,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],12359.72,,"Fee schedule rate ($12,359.72). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6042.05,12359.72,There are no additional notes associated with this service or procedure.
VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC,033,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],42156.44,,"Fee schedule rate ($42,156.44). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,13206.23,42156.44,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,447,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],125567.31,,"Fee schedule rate ($125,567.31). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15.7), with a minimum of zero.",,,,0,other,47193.21,156646.82,There are no additional notes associated with this service or procedure.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],47123.82,,"Fee schedule rate ($47,123.82). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,12696.97,47123.82,There are no additional notes associated with this service or procedure.
Cysto Bladder W/Ureteral Catheterization|UNUSUAL NON-OVERLAPPING SERVICE,CASE-52005,APC,52005,CPT,0360,RC,,,XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3464.44,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3299.47,3464.44,OPPS APC
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],15766.27,,"Case rate ($15,233.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,306.64, add-ons for qualifying new technology services are included. If operating cost exceeds $49,177.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,731.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $12,316.28 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,361.69 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $971.88. The transfer capital threshold is the transfer adjustment factor * $971.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,15233.11,38610.21,Inpatient DRG
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC,831,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],10290.12,,"Case rate ($10,088.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,520.59, add-ons for qualifying new technology services are included. If operating cost exceeds $44,391.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,355.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $7,547.82 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,575.65 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $595.60. The transfer capital threshold is the transfer adjustment factor * $595.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,4941.30,23661.59,Inpatient DRG
Nsl/Sinus Ndsc Max Antrost W/Rmvl Tiss Max Sinus,CASE-31267,APC,31267,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6837.16,,"APC Price ($6,605.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6605.95,6936.25,OPPS APC
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],19189.08,,"Fee schedule rate ($19,189.08). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11194.25,36094.03,There are no additional notes associated with this service or procedure.
Laps Surg Rpr Recurrent Inguinal Hernia|LEFT SIDE,CASE-49651,APC,49651,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5658.76,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5658.76,5941.70,OPPS APC
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],59476.09,,"Fee schedule rate ($59,476.09). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15.9), with a minimum of zero.",,,,0,other,23377.19,96365.69,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,426,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],177294.98,,"Fee schedule rate ($177,294.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,76581.29,216864.15,There are no additional notes associated with this service or procedure.
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],16438.59,,"Fee schedule rate ($16,438.59). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7402.56,16438.59,There are no additional notes associated with this service or procedure.
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],26721.94,,"Fee schedule rate ($26,721.94). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6965.00,34422.94,There are no additional notes associated with this service or procedure.
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],11857.25,,"Case rate ($11,292.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,658.34, add-ons for qualifying new technology services are included. If operating cost exceeds $45,529.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,427.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $8,680.48 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,713.39 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $667.20. The transfer capital threshold is the transfer adjustment factor * $667.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,11575.50,48961.48,Inpatient DRG
INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC,198,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],11891.46,,"Case rate ($6,795.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,456.95, add-ons for qualifying new technology services are included. If operating cost exceeds $41,327.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,114.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,495.42 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,512.00 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $354.73. The transfer capital threshold is the transfer adjustment factor * $354.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,6795.12,23505.07,All Other Inpatient
CERVICAL SPINAL FUSION WITH CC,472,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],70198.84,,"Fee schedule rate ($70,198.84). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,21896.13,70198.84,There are no additional notes associated with this service or procedure.
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],62990.26,,"Fee schedule rate ($62,990.26). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,16787.98,62990.26,There are no additional notes associated with this service or procedure.
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],19682.37,,"Case rate ($11,247.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,598.51, add-ons for qualifying new technology services are included. If operating cost exceeds $45,469.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,440.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,621.77 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,653.56 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $680.34. The transfer capital threshold is the transfer adjustment factor * $680.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,11247.07,27028.33,All Other Inpatient
HC Perq Vert Agmntj Cavity Crtj Uni/Bi Cannulation,CASE-22513,APC,22513,CPT,0361,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6791.99,7131.59,OPPS APC
SEIZURES WITH MCC,100,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],38110.41,,,,,,0,other,15061.09,38110.41,There are no additional notes associated with this service or procedure.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,025,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],89465.42,,,,,,0,other,13351.00,91631.33,There are no additional notes associated with this service or procedure.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC",156,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],6956.38,,"Case rate ($6,625.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,298.82, add-ons for qualifying new technology services are included. If operating cost exceeds $41,169.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,102.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $4,337.88 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,353.87 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $342.30. The transfer capital threshold is the transfer adjustment factor * $342.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6625.12,13598.77,Inpatient DRG
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],40918.00,,"Fee schedule rate ($40,918.00). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,16689.78,59521.43,There are no additional notes associated with this service or procedure.
SPINAL PROCEDURES WITHOUT CC/MCC,030,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],24782.10,,"Fee schedule rate ($24,782.10). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,16810.99,44714.01,There are no additional notes associated with this service or procedure.
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],13298.00,,"Fee schedule rate ($13,298.00). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10846.16,25863.45,There are no additional notes associated with this service or procedure.
Largsc Exc Tum&/Strpg Cords/Epigl Mcrscp/Tlscp,CASE-31541,APC,31541,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3664.31,,"APC Price ($3,489.82). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3489.82,3664.31,OPPS APC
OTHER MENTAL DISORDER DIAGNOSES,887,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],9657.03,,"Case rate ($9,197.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,691.53, add-ons for qualifying new technology services are included. If operating cost exceeds $43,562.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,290.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,721.79 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,746.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $530.42. The transfer capital threshold is the transfer adjustment factor * $530.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,2070.00,21072.10,Inpatient DRG
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,544,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],14181.20,,"Fee schedule rate ($14,181.20). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7055.15,23207.64,There are no additional notes associated with this service or procedure.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],6965.00,,,,,,0,other,6965.00,20401.88,There are no additional notes associated with this service or procedure.
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],7904.27,,"Case rate ($7,749.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,344.60, add-ons for qualifying new technology services are included. If operating cost exceeds $42,215.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,184.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,379.82 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,399.66 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $424.52. The transfer capital threshold is the transfer adjustment factor * $424.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6711.00,16865.16,Inpatient DRG
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],105091.76,,"Fee schedule rate ($105,091.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,35719.96,105091.76,There are no additional notes associated with this service or procedure.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,073,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],43475.01,,"Fee schedule rate ($43,475.01). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,12809.38,43475.01,There are no additional notes associated with this service or procedure.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC,099,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],22084.20,,"Fee schedule rate ($22,084.20). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11171.21,26807.94,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITHOUT CC/MCC,428,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],65901.15,,"Fee schedule rate ($65,901.15). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,40017.53,118904.57,There are no additional notes associated with this service or procedure.
"EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME, NEONATE",790,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],44304.49,,"Case rate ($42,194.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $39,388.49, add-ons for qualifying new technology services are included. If operating cost exceeds $74,259.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,703.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 17.9. The base transfer operating payment is the transfer adjustment factor * $37,305.99 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $37,443.54 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,943.81. The transfer capital threshold is the transfer adjustment factor * $2,943.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,3054.00,44304.49,Inpatient DRG
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],14344.60,,"Case rate ($14,344.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,480.09, add-ons for qualifying new technology services are included. If operating cost exceeds $48,351.10 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,666.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $11,492.77 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,535.14 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $906.89. The transfer capital threshold is the transfer adjustment factor * $906.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,14344.60,36028.59,Inpatient DRG
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITH MCC,429,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],169317.41,,"Fee schedule rate ($169,317.41). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,62958.58,177294.98,There are no additional notes associated with this service or procedure.
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],17233.12,,,,,,0,other,7875.94,17233.12,There are no additional notes associated with this service or procedure.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],73588.10,,"Fee schedule rate ($73,588.10). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,21585.31,73588.10,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],32852.04,,"Fee schedule rate ($32,852.04). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,13783.20,41580.51,There are no additional notes associated with this service or procedure.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],12504.33,,"Fee schedule rate ($12,504.33). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10517.71,24909.11,There are no additional notes associated with this service or procedure.
"Remv Vert Body,Cerv,One Sgmt",CASE-63081,APC,63081,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],12017.31,,"APC Price ($12,017.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12017.31,12437.92,OPPS APC
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],28445.08,,"Fee schedule rate ($28,445.08). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.8), with a minimum of zero.",,,,0,other,12195.15,39424.57,There are no additional notes associated with this service or procedure.
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],21089.59,,"Fee schedule rate ($21,089.59). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,6965.00,21089.59,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],57456.84,,,,,,0,other,21719.40,85305.59,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],2070.00,,,,,,0,other,1188.00,12138.74,Estimated amount calculated based on 1 day length of stay.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,329,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],33072.77,,"Case rate ($33,072.77). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $30,902.51, add-ons for qualifying new technology services are included. If operating cost exceeds $65,773.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,036.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.4. The base transfer operating payment is the transfer adjustment factor * $28,851.18 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $28,957.55 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,276.64. The transfer capital threshold is the transfer adjustment factor * $2,276.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,33072.77,90445.33,Inpatient DRG
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,095,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],20382.04,,"Case rate ($19,411.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $18,193.69, add-ons for qualifying new technology services are included. If operating cost exceeds $53,064.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,037.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.6. The base transfer operating payment is the transfer adjustment factor * $16,189.05 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $16,248.74 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,277.48. The transfer capital threshold is the transfer adjustment factor * $1,277.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,19411.47,50750.92,Inpatient DRG
Esophagoscopy Flexible Transoral Ultrasound Exam,CASE-43231,APC,43231,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1796.14,,"APC Price ($1,796.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1796.14,1885.95,OPPS APC
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,095,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],48575.01,,"Fee schedule rate ($48,575.01). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,19411.47,50750.92,There are no additional notes associated with this service or procedure.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC",061,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],62315.82,,"Fee schedule rate ($62,315.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,20616.23,62315.82,There are no additional notes associated with this service or procedure.
FRACTURES OF FEMUR WITH MCC,533,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],13189.61,,"Case rate ($12,561.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,821.33, add-ons for qualifying new technology services are included. If operating cost exceeds $46,692.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,536.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $9,840.09 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,876.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $776.48. The transfer capital threshold is the transfer adjustment factor * $776.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6852.00,49490.05,Inpatient DRG
Colon Ca Scrn Not Hi Rsk Ind,CASE-G0121,APC,G0121,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],900.93,,"APC Price ($870.46). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,870.46,913.99,OPPS APC
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],6787.66,,"Case rate ($6,787.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,450.02, add-ons for qualifying new technology services are included. If operating cost exceeds $41,321.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,114.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,488.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,505.07 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $354.19. The transfer capital threshold is the transfer adjustment factor * $354.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6164.03,14071.02,Inpatient DRG
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],33623.33,,"Case rate ($33,623.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $31,414.68, add-ons for qualifying new technology services are included. If operating cost exceeds $66,285.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,076.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.4. The base transfer operating payment is the transfer adjustment factor * $29,361.48 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $29,469.74 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,316.91. The transfer capital threshold is the transfer adjustment factor * $2,316.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,33623.33,133270.57,Inpatient DRG
Vag Hyst > 250 Gm Rmvl Tube&/Ovary,CASE-58291,APC,58291,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],4682.41,,"APC Price ($4,682.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,4682.41,4846.30,OPPS APC
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6378.61,,"Case rate ($6,378.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,069.50, add-ons for qualifying new technology services are included. If operating cost exceeds $40,940.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,084.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,109.40 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,124.55 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $324.27. The transfer capital threshold is the transfer adjustment factor * $324.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,4341.01,12882.53,Inpatient DRG
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,988,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],13533.16,,"Case rate ($13,075.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,299.49, add-ons for qualifying new technology services are included. If operating cost exceeds $47,170.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,574.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $10,316.50 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,354.54 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $814.07. The transfer capital threshold is the transfer adjustment factor * $814.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,13075.52,42425.46,Inpatient DRG
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],34892.92,,"Fee schedule rate ($34,892.92). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,6965.00,41030.48,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],23997.41,,"Case rate ($23,526.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $22,022.15, add-ons for qualifying new technology services are included. If operating cost exceeds $56,893.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,338.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.7. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.7)) / 2. The base transfer operating payment is the transfer adjustment factor * $20,003.44 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $20,077.20 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,578.47. The transfer capital threshold is the transfer adjustment factor * $1,578.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,23526.87,94787.57,Inpatient DRG
SEIZURES WITH MCC,100,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],32323.98,,"Fee schedule rate ($32,323.98). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,15061.09,38110.41,There are no additional notes associated with this service or procedure.
POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES,769,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],13856.98,,"Case rate ($13,388.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,590.54, add-ons for qualifying new technology services are included. If operating cost exceeds $47,461.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,596.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $10,606.49 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,645.59 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $836.96. The transfer capital threshold is the transfer adjustment factor * $836.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,13388.39,33250.19,Inpatient DRG
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],6133.05,,"Fee schedule rate ($6,133.05). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5883.03,17111.12,There are no additional notes associated with this service or procedure.
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],23754.07,,,,,,0,other,10120.20,26204.74,There are no additional notes associated with this service or procedure.
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],29497.93,,"Case rate ($28,093.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $26,270.18, add-ons for qualifying new technology services are included. If operating cost exceeds $61,141.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,672.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $24,235.87 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $24,325.23 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,912.45. The transfer capital threshold is the transfer adjustment factor * $1,912.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,10078.00,81454.07,Inpatient DRG
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],28046.90,,"Case rate ($16,026.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,044.99, add-ons for qualifying new technology services are included. If operating cost exceeds $49,916.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,789.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $13,051.92 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,100.04 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,029.93. The transfer capital threshold is the transfer adjustment factor * $1,029.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,11165.00,61234.06,All Other Inpatient
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],17169.59,,"Case rate ($16,351.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,374.39, add-ons for qualifying new technology services are included. If operating cost exceeds $50,245.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,788.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $13,378.72 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,429.44 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,028.32. The transfer capital threshold is the transfer adjustment factor * $1,028.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,16787.98,62990.26,Inpatient DRG
Submucous Rescj Inferior Turbinate Prtl/Compl,CASE-30140,APC,30140,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3103.35,,"APC Price ($3,103.35). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.35,3258.52,OPPS APC
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,426,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],177294.98,,"Fee schedule rate ($177,294.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,76581.29,216864.15,There are no additional notes associated with this service or procedure.
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC,497,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],37761.19,,"Fee schedule rate ($37,761.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10127.65,37761.19,There are no additional notes associated with this service or procedure.
Cysto/Uretero W/Lithotripsy &Indwell Stent Insrt|BILATERAL PROCEDURE,CASE-52356,APC,52356,CPT,0360,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5269.71,,"APC Price ($5,018.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5018.77,5269.71,OPPS APC
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],17370.86,,,,,,0,other,1188.00,17370.86,There are no additional notes associated with this service or procedure.
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],7842.75,,"Case rate ($7,842.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,431.55, add-ons for qualifying new technology services are included. If operating cost exceeds $42,302.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,191.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $5,466.44 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,486.60 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $431.36. The transfer capital threshold is the transfer adjustment factor * $431.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,5280.00,17136.70,Inpatient DRG
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5777.94,,"Case rate ($5,777.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,510.70, add-ons for qualifying new technology services are included. If operating cost exceeds $40,381.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,040.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $3,552.65 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,565.75 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $280.34. The transfer capital threshold is the transfer adjustment factor * $280.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,5065.00,12558.65,Inpatient DRG
OTHER CEREBROVASCULAR DISORDERS WITH CC,071,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],5843.00,,"Per diem ($5,843). If length of stay < 3.3, first 1 days paid at a per diem of $11,686 instead. Capped at $19,281.62.",,,,0,other,5843.00,29215.10,Estimated amount calculated based on 3 day length of stay.
INFLAMMATORY BOWEL DISEASE WITH MCC,385,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],22155.70,,"Case rate ($12,660.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,913.31, add-ons for qualifying new technology services are included. If operating cost exceeds $46,784.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,543.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $9,931.73 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,968.35 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $783.71. The transfer capital threshold is the transfer adjustment factor * $783.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,11480.01,31134.92,All Other Inpatient
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC,806,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],10071.17,,"Fee schedule rate ($10,071.17). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5354.25,13416.00,There are no additional notes associated with this service or procedure.
Nsl/Sinus Ndsc Max Antrost W/Rmvl Tiss Max Sinus,CASE-31267,APC,31267,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6605.95,,"APC Price ($6,605.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6605.95,6936.25,OPPS APC
NERVOUS SYSTEM NEOPLASMS WITH MCC,054,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],12899.48,,"Case rate ($12,285.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,564.29, add-ons for qualifying new technology services are included. If operating cost exceeds $46,435.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,516.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $9,584.00 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,619.34 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $756.27. The transfer capital threshold is the transfer adjustment factor * $756.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,30044.81,Inpatient DRG
Colon Ca Scrn Not Hi Rsk Ind|DOCUMENTATION ON FILE,CASE-G0121,APC,G0121,CPT,0360,RC,,,KX,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],913.99,,"APC Price ($870.46). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,870.46,913.99,OPPS APC
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],12404.38,,,,,,0,other,6214.05,15318.94,There are no additional notes associated with this service or procedure.
"LIMB REATTACHMENT, HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA",956,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],27428.25,,"Case rate ($27,428.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $25,651.53, add-ons for qualifying new technology services are included. If operating cost exceeds $60,522.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,623.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $23,619.49 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $23,706.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,863.81. The transfer capital threshold is the transfer adjustment factor * $1,863.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,27428.25,148259.86,Inpatient DRG
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,690,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],15212.93,,"Fee schedule rate ($15,212.93). Adds an outlier to normal pricing equal to the per diem rate ($36,758.78) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,7426.94,15928.53,There are no additional notes associated with this service or procedure.
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],9110.85,,"Fee schedule rate ($9,110.85). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7402.56,16438.59,There are no additional notes associated with this service or procedure.
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],38508.74,,"Fee schedule rate ($38,508.74). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.6), with a minimum of zero.",,,,0,other,15821.59,40320.14,There are no additional notes associated with this service or procedure.
Mastectomy Partial|LEFT SIDE|SEPARATE PRACTITIONER,CASE-19301,APC,19301,CPT,0360,RC,,,LT|XP,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6432.89,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6432.89,6526.12,OPPS APC
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],21851.78,,"Case rate ($20,811.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $19,531.04, add-ons for qualifying new technology services are included. If operating cost exceeds $54,402.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,106.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6)) / 2. The base transfer operating payment is the transfer adjustment factor * $17,519.66 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $17,586.09 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,346.60. The transfer capital threshold is the transfer adjustment factor * $1,346.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,21382.16,85466.62,Inpatient DRG
HC Non Stress Test|UNUSUAL NON-OVERLAPPING SERVICE,CASE-59025,APC,59025,CPT,0920,RC,,,XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],195.86,,"APC Price ($189.24). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,189.24,198.70,OPPS APC
RESPIRATORY NEOPLASMS WITHOUT CC/MCC,182,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7244.78,,"Case rate ($6,899.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,563.58, add-ons for qualifying new technology services are included. If operating cost exceeds $41,434.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,113.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,601.18 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,618.63 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $353.66. The transfer capital threshold is the transfer adjustment factor * $353.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,23037.13,Inpatient DRG
PREMATURITY WITH MAJOR PROBLEMS,791,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],3186.77,,,,,,0,other,3048.21,30904.42,Estimated amount calculated based on 5 day length of stay.
HC N Block Inj Intercost Sng|LEFT SIDE,CASE-64420,APC,64420,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],693.76,,"APC Price ($660.72). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,660.72,693.76,OPPS APC
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],37768.77,,"Fee schedule rate ($37,768.77). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7453.00,42138.30,There are no additional notes associated with this service or procedure.
COAGULATION DISORDERS,813,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],29046.49,,"Fee schedule rate ($29,046.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12274.39,30013.33,There are no additional notes associated with this service or procedure.
POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES,769,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],13388.39,,"Case rate ($13,388.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,590.54, add-ons for qualifying new technology services are included. If operating cost exceeds $47,461.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,596.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $10,606.49 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,645.59 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $836.96. The transfer capital threshold is the transfer adjustment factor * $836.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,13388.39,33250.19,Inpatient DRG
SINGLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL,402,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],29172.05,,"Case rate ($29,172.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $27,273.75, add-ons for qualifying new technology services are included. If operating cost exceeds $62,144.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,751.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $25,235.76 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $25,328.80 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,991.35. The transfer capital threshold is the transfer adjustment factor * $1,991.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,29172.05,124455.45,Inpatient DRG
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],37550.29,,"Fee schedule rate ($37,550.29). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,15476.23,42787.31,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL OBSTRUCTION WITH CC,389,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],16423.43,,"Fee schedule rate ($16,423.43). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5118.00,16423.43,There are no additional notes associated with this service or procedure.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5778.62,,"Case rate ($5,778.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,511.33, add-ons for qualifying new technology services are included. If operating cost exceeds $40,382.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,040.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $3,553.28 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,566.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $280.39. The transfer capital threshold is the transfer adjustment factor * $280.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,5778.62,11681.49,Inpatient DRG
INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,352,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],14103.75,,"Fee schedule rate ($14,103.75). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,9853.37,26528.70,There are no additional notes associated with this service or procedure.
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC,058,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],40853.02,,"Fee schedule rate ($40,853.02). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,13521.80,40853.02,There are no additional notes associated with this service or procedure.
RESPIRATORY NEOPLASMS WITHOUT CC/MCC,182,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],6965.00,,,,,,0,other,6965.00,23037.13,There are no additional notes associated with this service or procedure.
"Amputation Toe Interphalangeal Joint|LEFT FOOT, THIRD DIGIT",CASE-28825,APC,28825,CPT,0360,RC,,,T2,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],21455.22,,"Fee schedule rate ($21,455.22). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,9097.60,21455.22,There are no additional notes associated with this service or procedure.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],69000.38,,"Fee schedule rate ($69,000.38). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15), with a minimum of zero.",,,,0,other,26809.29,97015.50,There are no additional notes associated with this service or procedure.
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],14674.80,,"Fee schedule rate ($14,674.80). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6711.00,16865.16,There are no additional notes associated with this service or procedure.
Biopsy Vaginal Mucosa Simple|UNUSUAL NON-OVERLAPPING SERVICE,CASE-57100,APC,57100,CPT,0360,RC,,,XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5856.81,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5658.76,5941.70,OPPS APC
Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq|SEPARATE STRUCTURE|COLORECTAL CANCER SCREEN,CASE-45385,APC,45385,CPT,0360,RC,,,XS|PT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1159.29,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1120.09,1176.09,OPPS APC
Biopsy Cervix Single/Mult/Excision of Lesion Spx,CASE-57500,APC,57500,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],862.13,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,862.13,905.23,OPPS APC
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],26721.94,,"Fee schedule rate ($26,721.94). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6965.00,34422.94,There are no additional notes associated with this service or procedure.
"DIABETES,MINOR",420,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],5403.76,,"Case rate ($5,146.44). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5146.44,5403.76,There are no additional notes associated with this service or procedure.
"Laminec/Facetect/Foramin,Lumbar|SEPARATE STRUCTURE",CASE-63047,APC,63047,CPT,0360,RC,,,XS,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],26668.00,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,25398.09,26668.00,OPPS APC
MAJOR CHEST TRAUMA WITHOUT CC/MCC,185,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],7416.61,,"Case rate ($7,271.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,899.84, add-ons for qualifying new technology services are included. If operating cost exceeds $41,770.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,149.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,936.68 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,954.88 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $389.55. The transfer capital threshold is the transfer adjustment factor * $389.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,7271.19,21771.61,Inpatient DRG
Unlisted Laparoscopy Procedure Stomach,CASE-43659,APC,43659,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5658.76,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5658.76,5941.70,OPPS APC
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],52794.06,,"Fee schedule rate ($52,794.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (37), with a minimum of zero.",,,,0,other,13907.80,52794.06,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],37914.65,,"Fee schedule rate ($37,914.65). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9865.56,37914.65,There are no additional notes associated with this service or procedure.
HC Joint Injection/Aspir Large WO US|PBB CHARGE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-20610,APC,20610,CPT,0510,RC,,,PBB|XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],297.37,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,287.31,301.68,OPPS APC
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],8023.69,,"Case rate ($7,641.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,244.44, add-ons for qualifying new technology services are included. If operating cost exceeds $42,115.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,176.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,280.02 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,299.49 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $416.65. The transfer capital threshold is the transfer adjustment factor * $416.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7641.61,19371.27,Inpatient DRG
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],15333.48,,"Case rate ($14,603.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,720.75, add-ons for qualifying new technology services are included. If operating cost exceeds $48,591.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,685.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $11,732.54 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,775.80 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $925.81. The transfer capital threshold is the transfer adjustment factor * $925.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,14603.31,45017.13,Inpatient DRG
"NEONATE BIRTH WEIGHT 2000-2499 GRAMS WITH RESPIRATORY DISTRESS SYNDROME OR OTHER MAJOR RESPIRATORY CONDITION,MODERATE",622,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],22037.53,,"Case rate ($20,988.12). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,20988.12,22037.53,There are no additional notes associated with this service or procedure.
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],19688.76,,"Case rate ($18,751.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,579.45, add-ons for qualifying new technology services are included. If operating cost exceeds $52,450.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,989.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $15,577.06 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,634.50 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,229.18. The transfer capital threshold is the transfer adjustment factor * $1,229.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8480.00,59081.91,Inpatient DRG
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,093,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],19011.32,,"Fee schedule rate ($19,011.32). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,19011.32,There are no additional notes associated with this service or procedure.
SALIVARY GLAND PROCEDURES,139,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],30690.92,,"Fee schedule rate ($30,690.92). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,10313.19,30690.92,There are no additional notes associated with this service or procedure.
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,069,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],6965.00,,,,,,0,other,6965.00,20333.68,There are no additional notes associated with this service or procedure.
"LIMB REATTACHMENT, HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA",956,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],148259.86,,"Fee schedule rate ($148,259.86). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,27428.25,148259.86,There are no additional notes associated with this service or procedure.
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,306,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],25680.90,,"Fee schedule rate ($25,680.90). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,12616.37,31007.02,There are no additional notes associated with this service or procedure.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],13154.04,,"Case rate ($12,527.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,789.82, add-ons for qualifying new technology services are included. If operating cost exceeds $46,660.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,533.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $9,808.71 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,844.88 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $774.00. The transfer capital threshold is the transfer adjustment factor * $774.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12527.66,29917.96,Inpatient DRG
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],41580.51,,"Fee schedule rate ($41,580.51). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,13783.20,41580.51,There are no additional notes associated with this service or procedure.
Conization Cervix W/WO D&C Rpr Knife/Laser,CASE-57520,APC,57520,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3181.53,,"APC Price ($3,030.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3030.03,3181.53,OPPS APC
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],62041.12,,"Fee schedule rate ($62,041.12). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,18497.24,62041.12,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],8970.82,,"Case rate ($8,543.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,083.58, add-ons for qualifying new technology services are included. If operating cost exceeds $42,954.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,242.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,116.09 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,138.64 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $482.62. The transfer capital threshold is the transfer adjustment factor * $482.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8543.64,23239.84,Inpatient DRG
Vulvectomy Simple Partial,CASE-56620,APC,56620,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3030.03,,"APC Price ($3,030.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3030.03,3181.53,OPPS APC
Inject Rx Other Periph Nerve|LEFT SIDE,CASE-64640,APC,64640,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],827.89,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,827.89,869.28,OPPS APC
Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx,CASE-28270,APC,28270,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7029.71,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6791.99,7131.59,OPPS APC
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],14343.25,,"Case rate ($14,343.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,478.83, add-ons for qualifying new technology services are included. If operating cost exceeds $48,349.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,666.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $11,491.51 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,533.88 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $906.79. The transfer capital threshold is the transfer adjustment factor * $906.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,14343.25,36024.65,Inpatient DRG
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC,805,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],20281.41,,"Fee schedule rate ($20,281.41). Adds an outlier to normal pricing equal to the per diem rate ($31,438.44) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.5), with a minimum of zero.",,,,0,other,9253.36,21235.42,There are no additional notes associated with this service or procedure.
Colonoscopy W/Biopsy Single/Multiple|SEPARATE STRUCTURE,CASE-45380,APC,45380,CPT,0360,RC,,,XS,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1159.29,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1120.09,1176.09,OPPS APC
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],41006.47,,"Fee schedule rate ($41,006.47). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12268.97,41006.47,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],24669.57,,"Fee schedule rate ($24,669.57). Adds an outlier to normal pricing equal to the per diem rate ($34,856.52) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.7), with a minimum of zero.",,,,0,other,10834.64,25830.00,There are no additional notes associated with this service or procedure.
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],28334.16,,"Fee schedule rate ($28,334.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,7868.00,32126.64,There are no additional notes associated with this service or procedure.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],92811.11,,"Fee schedule rate ($92,811.11). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,35389.50,101083.00,There are no additional notes associated with this service or procedure.
Hysteroscopy Lysis Intrauterine Adhesions,CASE-58559,APC,58559,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],4682.41,,"APC Price ($4,682.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,4682.41,4916.53,OPPS APC
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC",011,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],102498.90,,"Fee schedule rate ($102,498.90). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,38880.49,150008.48,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],45855.57,,"Fee schedule rate ($45,855.57). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,27944.96,86252.84,There are no additional notes associated with this service or procedure.
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral Ea Addl|LEFT SIDE,CASE-64484,APC,64484,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],827.89,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,827.89,869.28,OPPS APC
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,329,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],33766.36,,"Case rate ($32,158.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $30,108.30, add-ons for qualifying new technology services are included. If operating cost exceeds $64,979.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,916.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.4. The base transfer operating payment is the transfer adjustment factor * $28,056.97 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $28,163.35 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,156.52. The transfer capital threshold is the transfer adjustment factor * $2,156.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,33072.77,90445.33,Inpatient DRG
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],43888.01,,"Fee schedule rate ($43,888.01). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11717.72,43888.01,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],8863.02,,"Case rate ($8,563.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,101.85, add-ons for qualifying new technology services are included. If operating cost exceeds $42,972.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,244.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $6,134.29 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,156.91 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $484.06. The transfer capital threshold is the transfer adjustment factor * $484.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,8563.30,31533.97,Inpatient DRG
CESAREAN SECTION WITH STERILIZATION WITH CC,784,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],9124.01,,"Case rate ($9,124.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,623.49, add-ons for qualifying new technology services are included. If operating cost exceeds $43,494.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,285.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,654.00 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,678.54 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $525.07. The transfer capital threshold is the transfer adjustment factor * $525.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9124.01,23722.94,Inpatient DRG
CELLULITIS WITH MCC,602,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],28349.31,,"Fee schedule rate ($28,349.31). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11570.10,28349.31,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],8859.23,,"Case rate ($8,859.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,377.16, add-ons for qualifying new technology services are included. If operating cost exceeds $43,248.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,265.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $6,408.58 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,432.21 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $505.70. The transfer capital threshold is the transfer adjustment factor * $505.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8859.23,20090.22,Inpatient DRG
Perq Nl/Pl Lithotrp Simple Up to 2 Cm 1 Location|LEFT SIDE,CASE-50080,APC,50080,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],9303.88,,"APC Price ($8,860.83). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,8860.83,9303.88,OPPS APC
PERIPHERAL VASCULAR DISORDERS WITH CC,300,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],21005.20,,,,,,0,other,9174.14,21005.20,There are no additional notes associated with this service or procedure.
"KIDNEY AND URINARY TRACT INFECTIONS,MAJOR",463,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],8976.11,,"Case rate ($8,976.11). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,8976.11,9424.92,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF NERVOUS SYSTEM WITH CC,092,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],26765.51,,"Fee schedule rate ($26,765.51). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8872.78,26765.51,There are no additional notes associated with this service or procedure.
"NEONATE BIRTH WEIGHT 1250-1499 GRAMS WITH RESPIRATORY DISTRESS SYNDROME OR OTHER MAJOR RESPIRATORY CONDITION OR MAJOR ANOMALY,MAJOR",607,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],87869.86,,"Case rate ($87,869.86). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $58,117, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,87869.86,92263.35,There are no additional notes associated with this service or procedure.
Thyroidectomy Total/Complete|BILATERAL PROCEDURE,CASE-60240,APC,60240,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],9949.78,,"APC Price ($9,949.78). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,9949.78,10447.27,OPPS APC
NONTRAUMATIC STUPOR AND COMA WITH MCC,080,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],34015.33,,"Fee schedule rate ($34,015.33). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.5), with a minimum of zero.",,,,0,other,14202.39,35615.37,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],32795.66,,"Fee schedule rate ($32,795.66). Adds an outlier to normal pricing equal to the per diem rate ($69,146.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,1188.00,34338.33,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],21534.51,,,,,,0,other,9356.31,25026.36,There are no additional notes associated with this service or procedure.
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],11974.38,,"Case rate ($11,974.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,275.12, add-ons for qualifying new technology services are included. If operating cost exceeds $46,146.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,493.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $9,295.90 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,330.17 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $733.54. The transfer capital threshold is the transfer adjustment factor * $733.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,11974.38,29141.64,Inpatient DRG
"Tx Open Tendon Flexor Toe 1 Tendon Spx|LEFT FOOT, SECOND DIGIT",CASE-28232,APC,28232,CPT,0360,RC,,,T1,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1580.37,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1505.12,1580.37,OPPS APC
Colon Ca Scrn Not Hi Rsk Ind|DOCUMENTATION ON FILE,CASE-G0121,APC,G0121,CPT,0360,RC,,,KX,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],900.93,,"APC Price ($870.46). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,870.46,913.99,OPPS APC
UNGROUPABLE,999,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],10228.00,,"Per diem ($10,228). If length of stay < 12.7, first 1 days paid at a per diem of $20,456 instead. Capped at $129,893.46.",,,,0,other,10228.00,161307.29,Estimated amount calculated based on 9 day length of stay.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],11139.15,,,,,,0,other,5778.62,11681.49,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],11102.21,,"Case rate ($10,573.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,988.03, add-ons for qualifying new technology services are included. If operating cost exceeds $44,859.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,375.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $8,012.70 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,043.08 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $615.88. The transfer capital threshold is the transfer adjustment factor * $615.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10834.64,25830.00,Inpatient DRG
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 2nd Level|LEFT SIDE,CASE-64494,APC,64494,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],856.86,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,827.89,869.28,OPPS APC
RADIOTHERAPY,849,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],21004.17,,"Case rate ($20,293.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $19,014.57, add-ons for qualifying new technology services are included. If operating cost exceeds $53,885.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,101.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $17,006.91 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $17,069.62 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,342.01. The transfer capital threshold is the transfer adjustment factor * $1,342.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,20293.88,81867.07,Inpatient DRG
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],13246.56,,,,,,0,other,6503.90,14492.93,There are no additional notes associated with this service or procedure.
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],48961.48,,"Fee schedule rate ($48,961.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11575.50,48961.48,There are no additional notes associated with this service or procedure.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC",156,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6625.12,,"Case rate ($6,625.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,298.82, add-ons for qualifying new technology services are included. If operating cost exceeds $41,169.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,102.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $4,337.88 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,353.87 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $342.30. The transfer capital threshold is the transfer adjustment factor * $342.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6625.12,13598.77,Inpatient DRG
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC",061,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],21647.04,,"Case rate ($20,616.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $19,314.45, add-ons for qualifying new technology services are included. If operating cost exceeds $54,185.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,125.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $17,305.68 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $17,369.49 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,365.59. The transfer capital threshold is the transfer adjustment factor * $1,365.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,20616.23,62315.82,Inpatient DRG
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],13331.82,,"Case rate ($12,696.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,947.32, add-ons for qualifying new technology services are included. If operating cost exceeds $46,818.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,546.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,965.63 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,002.37 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $786.39. The transfer capital threshold is the transfer adjustment factor * $786.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12696.97,47123.82,Inpatient DRG
Injection Aa&/Strd Genicular Nrv Branches W/Img|LEFT SIDE,CASE-64454,APC,64454,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],660.72,,"APC Price ($660.72). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,660.72,693.76,OPPS APC
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH MCC",722,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],24850.65,,"Case rate ($14,200.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,345.91, add-ons for qualifying new technology services are included. If operating cost exceeds $48,216.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,656.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $11,359.07 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,400.95 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $896.34. The transfer capital threshold is the transfer adjustment factor * $896.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,14200.37,56869.13,All Other Inpatient
HC Breath Hydrogen/Met Test,CASE-91065,APC,91065,CPT,0920,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],212.21,,"APC Price ($202.11). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,202.11,212.21,OPPS APC
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],13854.88,,"Case rate ($13,386.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,588.65, add-ons for qualifying new technology services are included. If operating cost exceeds $47,459.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,596.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $10,604.60 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,643.70 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $836.81. The transfer capital threshold is the transfer adjustment factor * $836.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,13386.36,33244.29,Inpatient DRG
NERVOUS SYSTEM NEOPLASMS WITH MCC,054,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],25589.03,,"Fee schedule rate ($25,589.03). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,6965.00,30044.81,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC,087,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],17189.96,,"Fee schedule rate ($17,189.96). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,8139.36,22679.07,There are no additional notes associated with this service or procedure.
Lamnotmy Incl W/Dcmprsn Nrv Root 1 Intrspc Lumbr|LEFT SIDE,CASE-63030,APC,63030,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6791.99,7131.59,OPPS APC
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],33197.83,,"Fee schedule rate ($33,197.83). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.8), with a minimum of zero.",,,,0,other,13907.80,52794.06,There are no additional notes associated with this service or procedure.
OTHER CEREBROVASCULAR DISORDERS WITH CC,071,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],9123.46,,"Case rate ($8,689.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,231.38, add-ons for qualifying new technology services are included. If operating cost exceeds $43,102.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,241.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,262.69 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,286.43 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $481.36. The transfer capital threshold is the transfer adjustment factor * $481.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5843.00,29215.10,Inpatient DRG
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],28038.61,,"Fee schedule rate ($28,038.61). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12126.09,29582.40,There are no additional notes associated with this service or procedure.
MAJOR CHEST TRAUMA WITHOUT CC/MCC,185,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],21771.61,,"Fee schedule rate ($21,771.61). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7271.19,21771.61,There are no additional notes associated with this service or procedure.
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,068,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],23184.90,,"Fee schedule rate ($23,184.90). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,23184.90,There are no additional notes associated with this service or procedure.
NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,601,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6217.80,,"Case rate ($5,921.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,651.86, add-ons for qualifying new technology services are included. If operating cost exceeds $40,522.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,043.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $3,692.91 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,706.91 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $283.85. The transfer capital threshold is the transfer adjustment factor * $283.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6042.05,12359.72,Inpatient DRG
"POISONING OF MEDICINAL AGENTS,MAJOR",812,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],9289.68,,"Case rate ($9,289.68). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,9289.68,9754.16,There are no additional notes associated with this service or procedure.
Laparoscopy W/Rmvl Adnexal Structures|RIGHT SIDE,CASE-58661,APC,58661,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5658.76,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5658.76,5941.70,OPPS APC
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,082,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],44973.75,,,,,,0,other,17423.21,56223.11,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],9188.34,,"Case rate ($8,750.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,288.98, add-ons for qualifying new technology services are included. If operating cost exceeds $43,159.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,245.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $6,320.07 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,344.03 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $485.78. The transfer capital threshold is the transfer adjustment factor * $485.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8956.76,28983.97,Inpatient DRG
OSTEOMYELITIS WITH CC,540,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],18450.55,,"Fee schedule rate ($18,450.55). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,9809.07,25507.30,There are no additional notes associated with this service or procedure.
"CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS,MINOR",201,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],5053.79,,"Case rate ($4,813.13). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4813.13,5053.79,There are no additional notes associated with this service or procedure.
Lamnotmy Incl W/Dcmprsn Nrv Root 1 Intrspc Lumbr,CASE-63030,APC,63030,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6791.99,7131.59,OPPS APC
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR,518,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],27254.22,,"Case rate ($27,254.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $25,489.62, add-ons for qualifying new technology services are included. If operating cost exceeds $60,360.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,611.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 5.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $23,458.18 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $23,544.67 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,851.08. The transfer capital threshold is the transfer adjustment factor * $1,851.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,13252.00,89342.77,Inpatient DRG
HC Inj Tendon Sheath/Ligament|PBB CHARGE,CASE-20550,APC,20550,CPT,0510,RC,,,PBB,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],287.31,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC",281,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],23859.35,,"Fee schedule rate ($23,859.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8169.15,23859.35,There are no additional notes associated with this service or procedure.
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],26204.74,,"Fee schedule rate ($26,204.74). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10120.20,26204.74,There are no additional notes associated with this service or procedure.
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],18918.49,,"Fee schedule rate ($18,918.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9282.47,21320.03,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],128358.13,,"Fee schedule rate ($128,358.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,40542.37,128358.13,There are no additional notes associated with this service or procedure.
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 1 Level|LEFT SIDE,CASE-64493,APC,64493,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],856.86,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,827.89,869.28,OPPS APC
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],32878.30,,,,,,0,other,13260.40,32878.30,There are no additional notes associated with this service or procedure.
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],26301.36,,"Fee schedule rate ($26,301.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11247.07,27028.33,There are no additional notes associated with this service or procedure.
GI Tract Imaging Intraluminal Colon I&R,CASE-91113,APC,91113,CPT,0750,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],870.46,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,870.46,913.99,OPPS APC
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC",758,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],9003.54,,"Case rate ($8,574.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,112.57, add-ons for qualifying new technology services are included. If operating cost exceeds $42,983.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,244.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $6,144.96 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,167.62 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $484.90. The transfer capital threshold is the transfer adjustment factor * $484.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8574.80,19263.78,Inpatient DRG
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],34759.42,,,,,,0,other,13907.80,52794.06,There are no additional notes associated with this service or procedure.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],20401.88,,"Fee schedule rate ($20,401.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,20401.88,There are no additional notes associated with this service or procedure.
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],45157.33,,"Fee schedule rate ($45,157.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,10733.06,45157.33,There are no additional notes associated with this service or procedure.
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],12725.42,,"Case rate ($12,725.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,973.79, add-ons for qualifying new technology services are included. If operating cost exceeds $46,844.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,548.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $9,991.99 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,028.83 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $788.47. The transfer capital threshold is the transfer adjustment factor * $788.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12725.42,34245.00,Inpatient DRG
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,074,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],20919.08,,"Fee schedule rate ($20,919.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8925.60,20919.08,There are no additional notes associated with this service or procedure.
VENTRICULAR SHUNT PROCEDURES WITH CC,032,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],46275.08,,"Fee schedule rate ($46,275.08). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,16376.22,46275.08,There are no additional notes associated with this service or procedure.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],37768.77,,"Fee schedule rate ($37,768.77). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7453.00,42138.30,There are no additional notes associated with this service or procedure.
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],8676.91,,"Case rate ($8,263.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,834.96, add-ons for qualifying new technology services are included. If operating cost exceeds $42,705.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,210.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,867.76 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,890.01 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $451.01. The transfer capital threshold is the transfer adjustment factor * $451.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6230.00,22762.43,Inpatient DRG
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC",514,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],22699.91,,"Fee schedule rate ($22,699.91). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8868.04,22699.91,There are no additional notes associated with this service or procedure.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,477,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],67976.16,,,,,,0,other,25339.74,67976.16,There are no additional notes associated with this service or procedure.
HC Biopsy Liver Percutan Needle,CASE-47000,APC,47000,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1545.93,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1545.93,1623.23,OPPS APC
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],61290.90,,"Fee schedule rate ($61,290.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,23799.09,63499.65,There are no additional notes associated with this service or procedure.
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],34245.00,,"Fee schedule rate ($34,245.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,12725.42,34245.00,There are no additional notes associated with this service or procedure.
Rpr Aa Hernia Recr > 10 Cm Reducible,CASE-49617,APC,49617,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],199.10,,"APC Price ($199.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,199.10,209.05,OPPS APC
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],90333.60,,"Fee schedule rate ($90,333.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,26127.34,90333.60,There are no additional notes associated with this service or procedure.
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],17755.26,,"Fee schedule rate ($17,755.26). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7847.50,17755.26,There are no additional notes associated with this service or procedure.
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],6201.19,,"Case rate ($6,201.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,904.45, add-ons for qualifying new technology services are included. If operating cost exceeds $40,775.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,071.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,944.95 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,959.50 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $311.30. The transfer capital threshold is the transfer adjustment factor * $311.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,5937.41,12366.99,Inpatient DRG
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],18043.23,,"Fee schedule rate ($18,043.23). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7733.72,18043.23,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],29241.62,,"Fee schedule rate ($29,241.62). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,12984.79,32077.45,There are no additional notes associated with this service or procedure.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,345,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],28277.83,,"Fee schedule rate ($28,277.83). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12134.89,33616.03,There are no additional notes associated with this service or procedure.
HC Rt Bronch Dx Clear Airway,CASE-31645,APC,31645,CPT,0361,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3664.31,,"APC Price ($3,489.82). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3489.82,3664.31,OPPS APC
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,074,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],9238.00,,"Case rate ($8,925.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,438.90, add-ons for qualifying new technology services are included. If operating cost exceeds $43,309.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,270.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,470.10 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,493.95 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $510.55. The transfer capital threshold is the transfer adjustment factor * $510.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,8925.60,20919.08,Inpatient DRG
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",004,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],260309.36,,"Fee schedule rate ($260,309.36). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (35), with a minimum of zero.",,,,0,other,10249.47,272554.00,There are no additional notes associated with this service or procedure.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],38517.10,,"Fee schedule rate ($38,517.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,16897.01,43444.85,There are no additional notes associated with this service or procedure.
Laparoscopic Appendectomy|UNUSUAL NON-OVERLAPPING SERVICE,CASE-44970,APC,44970,CPT,0360,RC,,,XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5941.70,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5658.76,5941.70,OPPS APC
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],10243.65,,"Case rate ($9,755.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,211.27, add-ons for qualifying new technology services are included. If operating cost exceeds $44,082.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,331.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $7,239.63 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,266.32 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $571.28. The transfer capital threshold is the transfer adjustment factor * $571.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9755.86,29216.99,Inpatient DRG
ALLERGIC REACTIONS WITH MCC,915,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],27385.01,,"Fee schedule rate ($27,385.01). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,13332.86,33088.84,There are no additional notes associated with this service or procedure.
PREMATURITY WITHOUT MAJOR PROBLEMS,792,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],18531.10,,"Case rate ($18,531.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,374.70, add-ons for qualifying new technology services are included. If operating cost exceeds $52,245.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,973.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. The base transfer operating payment is the transfer adjustment factor * $15,373.07 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,429.75 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,213.09. The transfer capital threshold is the transfer adjustment factor * $1,213.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,1956.00,19457.66,Inpatient DRG
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC,832,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],5007.45,,"Fee schedule rate ($5,007.45). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4803.31,14198.92,There are no additional notes associated with this service or procedure.
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],8033.46,,"Case rate ($7,875.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,462.42, add-ons for qualifying new technology services are included. If operating cost exceeds $42,333.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,193.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $5,497.20 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,517.46 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $433.78. The transfer capital threshold is the transfer adjustment factor * $433.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,7875.94,17233.12,Inpatient DRG
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],5683.00,,"Per diem ($5,683). If length of stay < 3.3, first 1 days paid at a per diem of $11,366 instead. Capped at $18,753.53.",,,,0,other,5683.00,19635.68,Estimated amount calculated based on 3 day length of stay.
Cysto/Uretero W/Lithotripsy &Indwell Stent Insrt|RIGHT SIDE,CASE-52356,APC,52356,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5269.71,,"APC Price ($5,018.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5018.77,5269.71,OPPS APC
TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC,087,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],8424.24,,"Case rate ($8,139.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,707.48, add-ons for qualifying new technology services are included. If operating cost exceeds $42,578.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,213.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $5,741.36 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,762.53 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $453.05. The transfer capital threshold is the transfer adjustment factor * $453.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,8139.36,22679.07,Inpatient DRG
HC Gastric Procedure Unlisted,CASE-43999,APC,43999,CPT,0361,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],891.41,,"APC Price ($848.96). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,848.96,891.41,OPPS APC
INFLAMMATORY BOWEL DISEASE WITH MCC,385,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],21593.52,,"Fee schedule rate ($21,593.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11480.01,31134.92,There are no additional notes associated with this service or procedure.
Colonoscopy W/Biopsy Single/Multiple,CASE-45380,APC,45380,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1176.09,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1120.09,1176.09,OPPS APC
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],8898.75,,"Fee schedule rate ($8,898.75). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8163.06,18067.42,There are no additional notes associated with this service or procedure.
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",759,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],6190.22,,"Fee schedule rate ($6,190.22). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6190.22,13057.66,There are no additional notes associated with this service or procedure.
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC,806,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],6510.67,,"Case rate ($6,510.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,192.35, add-ons for qualifying new technology services are included. If operating cost exceeds $41,063.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,093.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $4,231.80 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,247.40 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $333.93. The transfer capital threshold is the transfer adjustment factor * $333.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,5354.25,13416.00,Inpatient DRG
SIGNS AND SYMPTOMS WITH MCC,947,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],10803.36,,"Case rate ($10,288.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,722.73, add-ons for qualifying new technology services are included. If operating cost exceeds $44,593.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,355.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $7,748.40 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,777.78 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $595.56. The transfer capital threshold is the transfer adjustment factor * $595.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10541.41,30414.32,Inpatient DRG
HEART FAILURE AND SHOCK WITH CC,292,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],15550.06,,"Fee schedule rate ($15,550.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5502.00,16705.77,There are no additional notes associated with this service or procedure.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC",494,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],16309.76,,"Case rate ($15,533.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,585.72, add-ons for qualifying new technology services are included. If operating cost exceeds $49,456.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,753.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $12,594.34 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,640.78 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $993.82. The transfer capital threshold is the transfer adjustment factor * $993.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,15533.10,39945.55,Inpatient DRG
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],25026.36,,"Fee schedule rate ($25,026.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9356.31,25026.36,There are no additional notes associated with this service or procedure.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,761,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5808.41,,"Case rate ($5,808.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,539.05, add-ons for qualifying new technology services are included. If operating cost exceeds $40,410.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,042.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $3,580.90 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,594.10 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $282.57. The transfer capital threshold is the transfer adjustment factor * $282.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,5808.41,11946.72,Inpatient DRG
Rpr 1st Ingun Hrna Age 5 Yrs/> Incarcerated|RIGHT SIDE,CASE-49507,APC,49507,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3351.34,,"APC Price ($3,351.34). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3351.34,3518.91,OPPS APC
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],58320.32,,"Fee schedule rate ($58,320.32). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,16286.16,58320.32,There are no additional notes associated with this service or procedure.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],85466.62,,"Fee schedule rate ($85,466.62). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,21382.16,85466.62,There are no additional notes associated with this service or procedure.
INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC,198,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],23505.07,,"Fee schedule rate ($23,505.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6795.12,23505.07,There are no additional notes associated with this service or procedure.
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],8454.94,,"Case rate ($8,454.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,001.06, add-ons for qualifying new technology services are included. If operating cost exceeds $42,872.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,236.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,033.86 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,056.11 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $476.13. The transfer capital threshold is the transfer adjustment factor * $476.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6230.00,22762.43,Inpatient DRG
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],101083.00,,"Fee schedule rate ($101,083.00). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,35389.50,101083.00,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],21195.68,,"Fee schedule rate ($21,195.68). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,6965.00,21195.68,There are no additional notes associated with this service or procedure.
Cysto W/Ureteroscopy W/Rmvl/Manj Stones|BILATERAL PROCEDURE,CASE-52352,APC,52352,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3299.47,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3299.47,3464.44,OPPS APC
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,373,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],13780.60,,"Fee schedule rate ($13,780.60). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6870.94,14313.05,There are no additional notes associated with this service or procedure.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],26549.05,,"Case rate ($26,028.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $24,349.34, add-ons for qualifying new technology services are included. If operating cost exceeds $59,220.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,521.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $22,322.08 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $22,404.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,761.43. The transfer capital threshold is the transfer adjustment factor * $1,761.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 102%.",,,,0,other,26028.48,80635.65,Inpatient DRG
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],18497.24,,"Case rate ($18,497.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,343.20, add-ons for qualifying new technology services are included. If operating cost exceeds $52,214.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,970.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $15,341.68 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,398.25 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,210.61. The transfer capital threshold is the transfer adjustment factor * $1,210.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,18497.24,62041.12,Inpatient DRG
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITHOUT CC/MCC,428,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],105654.25,,"Fee schedule rate ($105,654.25). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,40017.53,118904.57,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],6978.67,,"Case rate ($6,841.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,500.42, add-ons for qualifying new technology services are included. If operating cost exceeds $41,371.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,118.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $4,538.73 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,555.47 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $358.15. The transfer capital threshold is the transfer adjustment factor * $358.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6841.83,21167.26,Inpatient DRG
Int Hrhc by Ligation Single Hroid W/O Img Gdn,CASE-46945,APC,46945,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],2598.08,,"APC Price ($2,598.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2598.08,2727.99,OPPS APC
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],11594.35,,"Fee schedule rate ($11,594.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6164.03,14071.02,There are no additional notes associated with this service or procedure.
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],15821.59,,"Case rate ($15,821.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,854.10, add-ons for qualifying new technology services are included. If operating cost exceeds $49,725.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,774.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $12,861.73 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,909.15 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,014.92. The transfer capital threshold is the transfer adjustment factor * $1,014.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,15821.59,40320.14,Inpatient DRG
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],17720.85,,"Fee schedule rate ($17,720.85). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,13386.36,33244.29,There are no additional notes associated with this service or procedure.
Chemodenervation Muscle Neck Unilat for Dystonia,CASE-64616,APC,64616,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC,520,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],12302.97,,"Case rate ($12,061.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,356.39, add-ons for qualifying new technology services are included. If operating cost exceeds $46,227.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,499.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $9,376.87 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,411.44 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $739.93. The transfer capital threshold is the transfer adjustment factor * $739.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,12061.74,39786.42,Inpatient DRG
VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC,033,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],23110.90,,"Case rate ($13,206.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,421.07, add-ons for qualifying new technology services are included. If operating cost exceeds $47,292.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,583.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $10,437.64 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,476.13 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $823.63. The transfer capital threshold is the transfer adjustment factor * $823.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,13206.23,42156.44,All Other Inpatient
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],11565.93,,"Fee schedule rate ($11,565.93). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6148.93,15887.21,There are no additional notes associated with this service or procedure.
Conization Cervix W/WO D&C Rpr Eltrd Exc,CASE-57522,APC,57522,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3030.03,,"APC Price ($3,030.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3030.03,3181.53,OPPS APC
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7774.84,,"Case rate ($7,404.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,034.14, add-ons for qualifying new technology services are included. If operating cost exceeds $41,905.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,149.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,069.97 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,089.19 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $389.69. The transfer capital threshold is the transfer adjustment factor * $389.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7569.84,21892.85,Inpatient DRG
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],13872.99,,"Fee schedule rate ($13,872.99). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.8), with a minimum of zero.",,,,0,other,5068.21,14525.56,There are no additional notes associated with this service or procedure.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],62041.12,,"Fee schedule rate ($62,041.12). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,18497.24,62041.12,There are no additional notes associated with this service or procedure.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,074,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],20919.08,,"Fee schedule rate ($20,919.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8925.60,20919.08,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITHOUT STERILIZATION WITH MCC,786,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],13771.26,,"Case rate ($13,115.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,336.66, add-ons for qualifying new technology services are included. If operating cost exceeds $47,207.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,576.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $10,353.53 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,391.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $817.00. The transfer capital threshold is the transfer adjustment factor * $817.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12612.10,23722.94,Inpatient DRG
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],8869.86,,"Case rate ($8,447.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,994.13, add-ons for qualifying new technology services are included. If operating cost exceeds $42,865.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,235.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,026.96 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,049.18 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $475.59. The transfer capital threshold is the transfer adjustment factor * $475.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,1188.00,18893.86,Inpatient DRG
BRONCHITIS AND ASTHMA WITHOUT CC/MCC,203,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5927.78,,"Case rate ($5,927.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $5,614.23, add-ons for qualifying new technology services are included. If operating cost exceeds $44,258.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $3,061.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,235.54 + an uncompensated DSH payment of $1,359.91. The transfer operating threshold is the transfer adjustment factor * $4,254.32 + an uncompensated DSH payment of $1,359.91. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $332.34. The transfer capital threshold is the transfer adjustment factor * $332.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,4763.76,13707.00,Inpatient DRG
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,069,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],6965.00,,,,,,0,other,6965.00,20333.68,There are no additional notes associated with this service or procedure.
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],24092.63,,"Fee schedule rate ($24,092.63). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10626.74,25225.91,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL HEMORRHAGE WITH MCC,377,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],16786.92,,"Fee schedule rate ($16,786.92). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,7634.00,35969.56,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],7794.44,,"Case rate ($7,641.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,244.44, add-ons for qualifying new technology services are included. If operating cost exceeds $42,115.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,176.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,280.02 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,299.49 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $416.65. The transfer capital threshold is the transfer adjustment factor * $416.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,7641.61,19371.27,Inpatient DRG
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],13080.27,,"Case rate ($12,457.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,744.07, add-ons for qualifying new technology services are included. If operating cost exceeds $46,615.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,510.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $9,762.10 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,799.12 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $750.34. The transfer capital threshold is the transfer adjustment factor * $750.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12775.53,31469.43,Inpatient DRG
"DRUG AND ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE,MINOR",770,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],2732.19,,"Case rate ($2,732.19). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,2732.19,2868.80,There are no additional notes associated with this service or procedure.
HC Inj Tendon Sheath/Ligament|PBB CHARGE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-20550,APC,20550,CPT,0510,RC,,,PBB|XU,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],287.31,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC",458,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],82104.25,,,,,,0,other,30202.09,132827.25,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL HEMORRHAGE WITH CC,378,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],9015.65,,"Case rate ($8,586.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,123.28, add-ons for qualifying new technology services are included. If operating cost exceeds $42,994.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,245.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,155.63 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,178.33 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $485.74. The transfer capital threshold is the transfer adjustment factor * $485.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8586.33,20845.19,Inpatient DRG
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],43399.23,,"Fee schedule rate ($43,399.23). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9888.00,43399.23,There are no additional notes associated with this service or procedure.
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],8244.81,,"Case rate ($8,083.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,655.19, add-ons for qualifying new technology services are included. If operating cost exceeds $42,526.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,208.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,689.27 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,710.24 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $448.94. The transfer capital threshold is the transfer adjustment factor * $448.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,7884.32,17835.23,Inpatient DRG
DIABETES WITHOUT CC/MCC,639,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6151.76,,"Case rate ($6,151.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,858.45, add-ons for qualifying new technology services are included. If operating cost exceeds $40,729.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,067.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $3,899.13 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,913.51 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $307.68. The transfer capital threshold is the transfer adjustment factor * $307.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6151.76,12223.35,Inpatient DRG
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7567.11,,"Case rate ($7,206.77). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,849.72, add-ons for qualifying new technology services are included. If operating cost exceeds $41,720.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,135.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $4,886.24 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,904.77 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $375.57. The transfer capital threshold is the transfer adjustment factor * $375.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,21195.68,Inpatient DRG
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC",494,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],37708.15,,"Fee schedule rate ($37,708.15). Adds an outlier to normal pricing equal to the per diem rate ($63,554.89) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,15533.10,39945.55,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],7127.04,,"Case rate ($6,787.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,450.02, add-ons for qualifying new technology services are included. If operating cost exceeds $41,321.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,114.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,488.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,505.07 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $354.19. The transfer capital threshold is the transfer adjustment factor * $354.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6164.03,14071.02,Inpatient DRG
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],15054.73,,"Case rate ($14,337.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,473.80, add-ons for qualifying new technology services are included. If operating cost exceeds $48,344.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,666.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $11,486.49 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,528.84 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $906.40. The transfer capital threshold is the transfer adjustment factor * $906.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,14337.84,52803.53,Inpatient DRG
Cysto W/Urtroscopy&/Pyeloscopy Dx,CASE-52351,APC,52351,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3464.44,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3299.47,3464.44,OPPS APC
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],36855.62,,"Fee schedule rate ($36,855.62). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,15821.59,40320.14,There are no additional notes associated with this service or procedure.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],7605.00,,"Per diem ($7,605). If length of stay < 4.8, first 1 days paid at a per diem of $15,210 instead. Capped at $36,505.40.",,,,0,other,7605.00,39153.65,Estimated amount calculated based on 3 day length of stay.
OSTEOMYELITIS WITH CC,540,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],10723.59,,"Case rate ($10,723.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,111.53, add-ons for qualifying new technology services are included. If operating cost exceeds $44,982.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,402.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $8,136.58 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,166.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $642.06. The transfer capital threshold is the transfer adjustment factor * $642.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9809.07,25507.30,Inpatient DRG
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,345,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],28277.83,,"Fee schedule rate ($28,277.83). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12134.89,33616.03,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],6167.00,,"Per diem ($6,167). If length of stay < 4.5, first 1 days paid at a per diem of $12,334 instead. Capped at $27,753.50.",,,,0,other,6167.00,29058.99,Estimated amount calculated based on 3 day length of stay.
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],12272.58,,"Fee schedule rate ($12,272.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5628.97,12272.58,There are no additional notes associated with this service or procedure.
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC",629,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],16699.94,,"Case rate ($16,699.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,671.20, add-ons for qualifying new technology services are included. If operating cost exceeds $50,542.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,839.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $13,675.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,726.25 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,079.16. The transfer capital threshold is the transfer adjustment factor * $1,079.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,16699.94,44657.18,Inpatient DRG
"Partical Excision Bone Phalanx Toe|LEFT FOOT, THIRD DIGIT",CASE-28124,APC,28124,CPT,0360,RC,,,T2,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6791.99,7131.59,OPPS APC
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,025,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],13351.00,,"Per diem ($13,351). If length of stay < 6.4, first 1 days paid at a per diem of $26,702 instead. Capped at $85,446.13.",,,,0,other,13351.00,91631.33,Estimated amount calculated based on 4 day length of stay.
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,555,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],42290.95,,"Fee schedule rate ($42,290.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10896.27,42290.95,There are no additional notes associated with this service or procedure.
Esophagogastroduodenoscopy Submucosal Injection|UNUSUAL NON-OVERLAPPING SERVICE,CASE-43236,APC,43236,CPT,0360,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],848.96,,"APC Price ($848.96). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,848.96,891.41,OPPS APC
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],11914.12,,"Case rate ($11,914.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,219.06, add-ons for qualifying new technology services are included. If operating cost exceeds $46,090.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,489.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $9,240.03 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,274.10 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $729.13. The transfer capital threshold is the transfer adjustment factor * $729.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,11914.12,40426.76,Inpatient DRG
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],16669.71,,"Fee schedule rate ($16,669.71). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8767.81,19824.58,There are no additional notes associated with this service or procedure.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],62041.12,,"Fee schedule rate ($62,041.12). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,18497.24,62041.12,There are no additional notes associated with this service or procedure.
Arthrs Knee W/Meniscectomy Med&Lat W/Shaving|RIGHT SIDE,CASE-29880,APC,29880,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
OSTEOMYELITIS WITHOUT CC/MCC,541,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],7422.83,,"Case rate ($7,277.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,905.50, add-ons for qualifying new technology services are included. If operating cost exceeds $41,776.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,149.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $4,942.33 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,960.55 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $390.00. The transfer capital threshold is the transfer adjustment factor * $390.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,5103.00,15493.67,Inpatient DRG
Arthrodesis Pst/Pstlat Tq 1ntrspc Ea Addl Ntrspc,CASE-22614,APC,22614,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],17232.68,,"APC Price ($16,412.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,16412.07,17232.68,OPPS APC
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],18178.96,,"Case rate ($18,178.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,047.10, add-ons for qualifying new technology services are included. If operating cost exceeds $51,918.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,947.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $15,046.67 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,102.15 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,187.33. The transfer capital threshold is the transfer adjustment factor * $1,187.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,18178.96,54764.34,Inpatient DRG
DIABETES WITH MCC,637,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],27368.25,,"Fee schedule rate ($27,368.25). Adds an outlier to normal pricing equal to the per diem rate ($39,561.63) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,9959.03,28655.62,There are no additional notes associated with this service or procedure.
Capsul Mttarphlngl Jt W/WO Tenorrhaphy Ea Jt Spx,CASE-28270,APC,28270,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],30372.64,,"Fee schedule rate ($30,372.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,13260.40,32878.30,There are no additional notes associated with this service or procedure.
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC,058,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],13521.80,,"Case rate ($13,521.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,714.66, add-ons for qualifying new technology services are included. If operating cost exceeds $47,585.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,606.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $10,730.14 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,769.70 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $846.71. The transfer capital threshold is the transfer adjustment factor * $846.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,13521.80,40853.02,Inpatient DRG
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],8563.30,,"Case rate ($8,563.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,101.85, add-ons for qualifying new technology services are included. If operating cost exceeds $42,972.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,244.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $6,134.29 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,156.91 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $484.06. The transfer capital threshold is the transfer adjustment factor * $484.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8563.30,31533.97,Inpatient DRG
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],18067.42,,,,,,0,other,8163.06,18067.42,There are no additional notes associated with this service or procedure.
MAJOR CHEST TRAUMA WITHOUT CC/MCC,185,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],11574.68,,"Fee schedule rate ($11,574.68). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7271.19,21771.61,There are no additional notes associated with this service or procedure.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,345,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],12134.89,,"Case rate ($12,134.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,424.43, add-ons for qualifying new technology services are included. If operating cost exceeds $46,295.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,505.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $9,444.66 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,479.48 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $745.28. The transfer capital threshold is the transfer adjustment factor * $745.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12134.89,33616.03,Inpatient DRG
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],85466.62,,"Fee schedule rate ($85,466.62). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,21382.16,85466.62,There are no additional notes associated with this service or procedure.
Rpr Aa Hernia Recr 3-10 Cm Ncrc8/Strangulated,CASE-49616,APC,49616,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5658.76,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5658.76,5941.70,OPPS APC
Colonoscopy W/Biopsy Single/Multiple|UNUSUAL NON-OVERLAPPING SERVICE|COLORECTAL CANCER SCREEN,CASE-45380,APC,45380,CPT,0360,RC,,,XU|PT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1176.09,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1120.09,1176.09,OPPS APC
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],10503.90,,"Case rate ($10,003.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,441.84, add-ons for qualifying new technology services are included. If operating cost exceeds $44,312.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,349.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $7,469.36 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,496.90 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $589.41. The transfer capital threshold is the transfer adjustment factor * $589.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10003.71,23415.63,Inpatient DRG
PREMATURITY WITH MAJOR PROBLEMS,791,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],3054.00,,,,,,0,other,3048.21,30904.42,Estimated amount calculated based on 5 day length of stay.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC,858,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],11946.65,,"Case rate ($11,377.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,720.10, add-ons for qualifying new technology services are included. If operating cost exceeds $45,591.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,449.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $8,742.91 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,775.15 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $689.90. The transfer capital threshold is the transfer adjustment factor * $689.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,11377.76,33794.11,Inpatient DRG
"ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",770,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],15286.78,,"Case rate ($8,735.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,261.87, add-ons for qualifying new technology services are included. If operating cost exceeds $43,132.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,256.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $6,293.72 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,316.92 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $496.64. The transfer capital threshold is the transfer adjustment factor * $496.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,8735.30,19730.13,All Other Inpatient
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],18578.07,,"Case rate ($17,693.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,595.40, add-ons for qualifying new technology services are included. If operating cost exceeds $51,466.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,911.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $14,596.63 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,650.45 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,151.82. The transfer capital threshold is the transfer adjustment factor * $1,151.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,17693.40,52449.26,Inpatient DRG
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],18217.52,,"Fee schedule rate ($18,217.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7414.07,18217.52,There are no additional notes associated with this service or procedure.
Open Tx Metacarpal Fracture Single Ea Bone|LEFT SIDE,CASE-26615,APC,26615,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3169.86,3215.80,OPPS APC
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],33426.38,,"Case rate ($32,296.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $30,179.91, add-ons for qualifying new technology services are included. If operating cost exceeds $65,050.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,979.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $28,131.23 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $28,234.95 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,219.83. The transfer capital threshold is the transfer adjustment factor * $2,219.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,32296.02,88188.38,Inpatient DRG
Total Thyroid Lobectomy Uni W/WO Isthmusectomy,CASE-60220,APC,60220,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5941.70,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5658.76,5941.70,OPPS APC
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC,831,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],9294.42,,"Fee schedule rate ($9,294.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,4941.30,23661.59,There are no additional notes associated with this service or procedure.
O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC,621,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],28347.36,,"Fee schedule rate ($28,347.36). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12159.94,36669.96,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],6965.00,,,,,,0,other,6340.03,15076.44,There are no additional notes associated with this service or procedure.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH CC,354,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],12514.68,,"Case rate ($12,514.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $11,748.98, add-ons for qualifying new technology services are included. If operating cost exceeds $50,393.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $3,540.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $10,343.20 + an uncompensated DSH payment of $1,359.91. The transfer operating threshold is the transfer adjustment factor * $10,389.07 + an uncompensated DSH payment of $1,359.91. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $811.58. The transfer capital threshold is the transfer adjustment factor * $811.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,11633.13,33472.54,Inpatient DRG
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],52803.53,,"Fee schedule rate ($52,803.53). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,14337.84,52803.53,There are no additional notes associated with this service or procedure.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC",156,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],12624.95,,"Fee schedule rate ($12,624.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6625.12,13598.77,There are no additional notes associated with this service or procedure.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],12966.13,,"Case rate ($12,527.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,789.82, add-ons for qualifying new technology services are included. If operating cost exceeds $46,660.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,533.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $9,808.71 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,844.88 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $774.00. The transfer capital threshold is the transfer adjustment factor * $774.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,12527.66,29917.96,Inpatient DRG
OTHER DISORDERS OF NERVOUS SYSTEM WITH CC,092,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],26765.51,,"Fee schedule rate ($26,765.51). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8872.78,26765.51,There are no additional notes associated with this service or procedure.
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],13651.81,,"Case rate ($13,001.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,230.82, add-ons for qualifying new technology services are included. If operating cost exceeds $47,101.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,568.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $10,248.08 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,285.87 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $808.68. The transfer capital threshold is the transfer adjustment factor * $808.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7868.00,32126.64,Inpatient DRG
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],36776.05,,"Fee schedule rate ($36,776.05). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11053.39,36776.05,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],37149.27,,"Fee schedule rate ($37,149.27). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,12455.21,37149.27,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITH STERILIZATION WITH MCC,783,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],23722.94,,"Fee schedule rate ($23,722.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12612.10,23722.94,There are no additional notes associated with this service or procedure.
OSTEOMYELITIS WITH CC,540,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],11259.77,,"Case rate ($10,723.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,111.53, add-ons for qualifying new technology services are included. If operating cost exceeds $44,982.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,402.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $8,136.58 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,166.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $642.06. The transfer capital threshold is the transfer adjustment factor * $642.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9809.07,25507.30,Inpatient DRG
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],10000.20,,"Fee schedule rate ($10,000.20). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7733.72,18043.23,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],17651.07,,"Fee schedule rate ($17,651.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,6564.18,17651.07,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],81353.66,,"Fee schedule rate ($81,353.66). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,27256.92,81353.66,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF THE EYE WITHOUT MCC,125,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],17952.29,,"Fee schedule rate ($17,952.29). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (6), with a minimum of zero.",,,,0,other,7144.54,17952.29,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],12272.58,,"Fee schedule rate ($12,272.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5628.97,12272.58,There are no additional notes associated with this service or procedure.
HC N Block Inj Intercost Sng|RIGHT SIDE,CASE-64420,APC,64420,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],660.72,,"APC Price ($660.72). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,660.72,693.76,OPPS APC
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],11472.01,,"Case rate ($11,247.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,598.51, add-ons for qualifying new technology services are included. If operating cost exceeds $45,469.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,440.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,621.77 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,653.56 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $680.34. The transfer capital threshold is the transfer adjustment factor * $680.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,11247.07,27028.33,Inpatient DRG
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],46523.26,,"Fee schedule rate ($46,523.26). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,17782.11,46523.26,There are no additional notes associated with this service or procedure.
"Inj Dx/Ther Agnt Paravert Facet Joint, Lumbar/Sac, Add Level",CASE-64495,APC,64495,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],856.86,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,827.89,869.28,OPPS APC
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],2070.00,,,,,,0,other,1188.00,12138.74,Estimated amount calculated based on 1 day length of stay.
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,690,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],15212.93,,"Fee schedule rate ($15,212.93). Adds an outlier to normal pricing equal to the per diem rate ($36,758.78) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,7426.94,15928.53,There are no additional notes associated with this service or procedure.
"SEIZURE,EXTREME",053,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],20893.83,,"Case rate ($20,893.83). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,20893.83,21938.52,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITH CC,164,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],40967.66,,"Fee schedule rate ($40,967.66). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,19037.66,77058.83,There are no additional notes associated with this service or procedure.
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],21862.29,,"Case rate ($21,862.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,473.63, add-ons for qualifying new technology services are included. If operating cost exceeds $55,344.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,216.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. The base transfer operating payment is the transfer adjustment factor * $18,460.61 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,528.68 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,456.72. The transfer capital threshold is the transfer adjustment factor * $1,456.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7086.00,57872.02,Inpatient DRG
Brnchsc Ebus Guided Sampl 1/2 Node Station/Strux,CASE-31652,APC,31652,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6605.95,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6605.95,6837.16,OPPS APC
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],39361.94,,"Fee schedule rate ($39,361.94). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.8), with a minimum of zero.",,,,0,other,16129.04,59610.47,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],84226.47,,"Fee schedule rate ($84,226.47). Adds an outlier to normal pricing equal to the per diem rate ($75,906.87) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14.7), with a minimum of zero.",,,,0,other,32296.02,88188.38,There are no additional notes associated with this service or procedure.
Episiotomy/Vag Rpr Oth/Thn Attending,CASE-59300,APC,59300,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3181.53,,"APC Price ($3,030.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3030.03,3181.53,OPPS APC
HC Biopsy/Exc Lymph Node Needle|RIGHT SIDE,CASE-38505,APC,38505,CPT,0361,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1545.93,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1545.93,1623.23,OPPS APC
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],25829.63,,"Fee schedule rate ($25,829.63). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6965.00,29482.05,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,064,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],41838.16,,"Fee schedule rate ($41,838.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,15563.58,41838.16,There are no additional notes associated with this service or procedure.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],17023.00,,"Case rate ($16,447.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,436.22, add-ons for qualifying new technology services are included. If operating cost exceeds $50,307.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,820.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $13,441.70 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,491.27 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,060.68. The transfer capital threshold is the transfer adjustment factor * $1,060.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,7453.00,42138.30,Inpatient DRG
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],26301.36,,"Fee schedule rate ($26,301.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11247.07,27028.33,There are no additional notes associated with this service or procedure.
Rmvl Noninfct Mesh/Prosth Aa/Parastomal Hrna Rpr,CASE-49623,APC,49623,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],209.05,,"APC Price ($199.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,199.10,209.05,OPPS APC
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],23835.16,,"Fee schedule rate ($23,835.16). Adds an outlier to normal pricing equal to the per diem rate ($63,133.20) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10533.95,24956.34,There are no additional notes associated with this service or procedure.
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],22363.67,,"Fee schedule rate ($22,363.67). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10003.71,23415.63,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],18311.90,,"Fee schedule rate ($18,311.90). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8543.64,23239.84,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,064,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],15563.58,,"Case rate ($15,563.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,614.08, add-ons for qualifying new technology services are included. If operating cost exceeds $49,485.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,756.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $12,622.59 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,669.13 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $996.05. The transfer capital threshold is the transfer adjustment factor * $996.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,15563.58,41838.16,Inpatient DRG
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],13051.76,,"Case rate ($12,795.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,039.30, add-ons for qualifying new technology services are included. If operating cost exceeds $46,910.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,553.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $10,057.27 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,094.35 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $793.62. The transfer capital threshold is the transfer adjustment factor * $793.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,12795.84,41944.25,Inpatient DRG
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,307,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],6965.00,,,,,,0,other,6335.27,18228.77,There are no additional notes associated with this service or procedure.
Cysto W/Ureteroscopy W/Rmvl/Manj Stones|LEFT SIDE,CASE-52352,APC,52352,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3414.95,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3299.47,3464.44,OPPS APC
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],8624.04,,"Case rate ($8,454.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,001.06, add-ons for qualifying new technology services are included. If operating cost exceeds $42,872.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,236.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,033.86 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,056.11 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $476.13. The transfer capital threshold is the transfer adjustment factor * $476.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6230.00,22762.43,Inpatient DRG
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],16669.71,,"Fee schedule rate ($16,669.71). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8767.81,19824.58,There are no additional notes associated with this service or procedure.
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],48375.90,,,,,,0,other,18594.09,59494.91,There are no additional notes associated with this service or procedure.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],15759.45,,"Fee schedule rate ($15,759.45). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,8906.63,28434.57,There are no additional notes associated with this service or procedure.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC,099,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],22084.20,,"Fee schedule rate ($22,084.20). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11171.21,26807.94,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],24120.60,,"Case rate ($13,783.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,957.83, add-ons for qualifying new technology services are included. If operating cost exceeds $47,828.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,625.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $10,972.42 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,012.88 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $865.83. The transfer capital threshold is the transfer adjustment factor * $865.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,13783.20,41580.51,All Other Inpatient
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],52794.06,,"Fee schedule rate ($52,794.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (37), with a minimum of zero.",,,,0,other,13907.80,52794.06,There are no additional notes associated with this service or procedure.
Laps Surg Cholecystectomy W/Cholangiography,CASE-47563,APC,47563,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5941.70,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5658.76,5941.70,OPPS APC
Revision of Spinal Shunt,CASE-63744,APC,63744,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3197.60,,"APC Price ($3,197.60). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3197.60,3357.48,OPPS APC
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],22130.54,,"Case rate ($21,382.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,026.97, add-ons for qualifying new technology services are included. If operating cost exceeds $54,897.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,181.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6)) / 2. The base transfer operating payment is the transfer adjustment factor * $18,015.59 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,082.01 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,421.61. The transfer capital threshold is the transfer adjustment factor * $1,421.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103.5%.",,,,0,other,21382.16,85466.62,Inpatient DRG
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],45521.20,,"Case rate ($45,521.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $42,483.01, add-ons for qualifying new technology services are included. If operating cost exceeds $77,354.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,947.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 12.5. The base transfer operating payment is the transfer adjustment factor * $40,389.14 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $40,538.06 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,187.10. The transfer capital threshold is the transfer adjustment factor * $3,187.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,45521.20,142438.06,Inpatient DRG
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],13486.95,,"Fee schedule rate ($13,486.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6915.64,14442.92,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],12227.29,,,,,,0,other,6153.12,13947.32,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],26178.21,,"Fee schedule rate ($26,178.21). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,13917.42,34889.29,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],53152.12,,"Fee schedule rate ($53,152.12). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,19152.11,53152.12,There are no additional notes associated with this service or procedure.
Tendon Sheath Incision,CASE-26055,APC,26055,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1557.80,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1505.12,1580.37,OPPS APC
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC,058,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],32126.63,,"Fee schedule rate ($32,126.63). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13521.80,40853.02,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS WITH MCC,947,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],10803.36,,"Case rate ($10,288.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,722.73, add-ons for qualifying new technology services are included. If operating cost exceeds $44,593.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,355.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $7,748.40 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,777.78 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $595.56. The transfer capital threshold is the transfer adjustment factor * $595.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10541.41,30414.32,Inpatient DRG
"ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",770,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],8735.30,,"Case rate ($8,735.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,261.87, add-ons for qualifying new technology services are included. If operating cost exceeds $43,132.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,256.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $6,293.72 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,316.92 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $496.64. The transfer capital threshold is the transfer adjustment factor * $496.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8735.30,19730.13,Inpatient DRG
Arthrs Aided Ant Cruciate Ligm Rpr/Agmntj/Rcnstj|RIGHT SIDE,CASE-29888,APC,29888,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7029.71,OPPS APC
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7398.11,,"Case rate ($7,147.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,785.17, add-ons for qualifying new technology services are included. If operating cost exceeds $41,656.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,140.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $4,822.44 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,840.22 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $380.54. The transfer capital threshold is the transfer adjustment factor * $380.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6965.00,16400.70,Inpatient DRG
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,373,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],13780.60,,"Fee schedule rate ($13,780.60). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6870.94,14313.05,There are no additional notes associated with this service or procedure.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],38248.08,,"Fee schedule rate ($38,248.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11593.79,38248.08,There are no additional notes associated with this service or procedure.
NORMAL NEWBORN,795,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],2576.52,,"Fee schedule rate ($2,576.52). Adds an outlier to normal pricing equal to the per diem rate ($414) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,1369.79,5771.52,There are no additional notes associated with this service or procedure.
HC Inj Anesth Celiac Plexus|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64530,APC,64530,CPT,0361,RC,,,XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],856.86,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,827.89,869.28,OPPS APC
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],34409.98,,"Fee schedule rate ($34,409.98). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,14344.60,36028.59,There are no additional notes associated with this service or procedure.
Revision of Reconstructed Breast|BILATERAL PROCEDURE,CASE-19380,APC,19380,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6215.36,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6215.36,6215.36,OPPS APC
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],6965.00,,,,,,0,other,6965.00,21089.59,There are no additional notes associated with this service or procedure.
Correction Hammertoe|LEFT SIDE,CASE-28285,APC,28285,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6791.99,7131.59,OPPS APC
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITHOUT MCC,430,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],133156.90,,"Fee schedule rate ($133,156.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,41000.16,133156.90,There are no additional notes associated with this service or procedure.
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],18751.20,,"Case rate ($18,751.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,579.45, add-ons for qualifying new technology services are included. If operating cost exceeds $52,450.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,989.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $15,577.06 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,634.50 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,229.18. The transfer capital threshold is the transfer adjustment factor * $1,229.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8480.00,59081.91,Inpatient DRG
Arthrs Kne Surg W/Meniscectomy Med/Lat W/Shvg|LEFT SIDE|SEPARATE STRUCTURE,CASE-29881,APC,29881,CPT,0360,RC,,,LT|XS,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7029.71,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6791.99,7131.59,OPPS APC
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,447,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],156646.82,,"Fee schedule rate ($156,646.82). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,47193.21,156646.82,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],65732.99,,,,,,0,other,9370.00,65732.99,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],14631.49,,"Case rate ($14,344.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,480.09, add-ons for qualifying new technology services are included. If operating cost exceeds $48,351.10 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,666.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $11,492.77 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,535.14 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $906.89. The transfer capital threshold is the transfer adjustment factor * $906.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,14344.60,36028.59,Inpatient DRG
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],16402.05,,"Fee schedule rate ($16,402.05). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,13571.25,33781.47,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],14871.83,,"Fee schedule rate ($14,871.83). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6558.75,14871.83,There are no additional notes associated with this service or procedure.
NON-MALIGNANT BREAST DISORDERS WITH CC/MCC,600,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],19574.79,,"Fee schedule rate ($19,574.79). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7999.14,20495.56,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITH CC,164,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],47433.53,,"Fee schedule rate ($47,433.53). Adds an outlier to normal pricing equal to the per diem rate ($158,028.38) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,19037.66,77058.83,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],15076.44,,"Fee schedule rate ($15,076.44). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6340.03,15076.44,There are no additional notes associated with this service or procedure.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],67790.93,,"Fee schedule rate ($67,790.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,21597.50,67790.93,There are no additional notes associated with this service or procedure.
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],6944.10,,"Case rate ($6,944.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,595.55, add-ons for qualifying new technology services are included. If operating cost exceeds $41,466.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,125.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,633.51 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,650.60 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $365.63. The transfer capital threshold is the transfer adjustment factor * $365.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,5068.21,14525.56,Inpatient DRG
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],8206.88,,"Case rate ($7,816.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,417.70, add-ons for qualifying new technology services are included. If operating cost exceeds $42,288.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,179.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $5,452.08 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,472.75 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $419.06. The transfer capital threshold is the transfer adjustment factor * $419.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5415.00,17575.50,Inpatient DRG
BRONCHITIS AND ASTHMA WITHOUT CC/MCC,203,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6135.25,,"Case rate ($5,927.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $5,614.23, add-ons for qualifying new technology services are included. If operating cost exceeds $44,258.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $3,061.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,235.54 + an uncompensated DSH payment of $1,359.91. The transfer operating threshold is the transfer adjustment factor * $4,254.32 + an uncompensated DSH payment of $1,359.91. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $332.34. The transfer capital threshold is the transfer adjustment factor * $332.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,4763.76,13707.00,Inpatient DRG
NONTRAUMATIC STUPOR AND COMA WITH MCC,080,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],14912.51,,"Case rate ($14,202.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,347.79, add-ons for qualifying new technology services are included. If operating cost exceeds $48,218.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,656.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $11,360.96 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,402.84 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $896.49. The transfer capital threshold is the transfer adjustment factor * $896.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,14202.39,35615.37,Inpatient DRG
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],13341.67,,"Case rate ($13,341.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,547.08, add-ons for qualifying new technology services are included. If operating cost exceeds $47,418.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,593.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $10,563.18 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,602.13 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $833.54. The transfer capital threshold is the transfer adjustment factor * $833.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,13341.67,42586.49,Inpatient DRG
TRAUMATIC INJURY WITH MCC,913,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],30719.04,,"Fee schedule rate ($30,719.04). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.5), with a minimum of zero.",,,,0,other,13014.58,42838.46,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC,084,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],10337.85,,"Fee schedule rate ($10,337.85). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,6965.00,19445.16,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],25609.86,,"Fee schedule rate ($25,609.86). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,12775.53,31469.43,There are no additional notes associated with this service or procedure.
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],31577.54,,"Fee schedule rate ($31,577.54). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,15453.88,39251.68,There are no additional notes associated with this service or procedure.
DIABETES WITH CC,638,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],15195.79,,"Fee schedule rate ($15,195.79). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8014.07,17634.53,There are no additional notes associated with this service or procedure.
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,069,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],7722.19,,"Case rate ($7,354.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,977.32, add-ons for qualifying new technology services are included. If operating cost exceeds $41,848.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,155.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $5,013.88 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,032.37 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $395.65. The transfer capital threshold is the transfer adjustment factor * $395.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,20333.68,Inpatient DRG
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],62454.12,,"Fee schedule rate ($62,454.12). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11348.00,62454.12,There are no additional notes associated with this service or procedure.
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],40714.72,,"Fee schedule rate ($40,714.72). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,17356.15,44778.95,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],14107.24,,"Case rate ($13,435.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,655.78, add-ons for qualifying new technology services are included. If operating cost exceeds $47,526.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,580.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $10,670.38 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,710.83 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $820.15. The transfer capital threshold is the transfer adjustment factor * $820.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13783.20,41580.51,Inpatient DRG
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,555,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],11441.08,,"Case rate ($10,896.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,272.18, add-ons for qualifying new technology services are included. If operating cost exceeds $45,143.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,414.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,296.64 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,327.23 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $654.69. The transfer capital threshold is the transfer adjustment factor * $654.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10896.27,42290.95,Inpatient DRG
Perq Nl/Pl Lithotrp Simple Up to 2 Cm 1 Location|LEFT SIDE,CASE-50080,APC,50080,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],9170.96,,"APC Price ($8,860.83). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,8860.83,9303.88,OPPS APC
Ostc Prtl Exostc/Condylc Metar Head|RIGHT SIDE,CASE-28288,APC,28288,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],11376.37,,"Case rate ($10,834.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,214.84, add-ons for qualifying new technology services are included. If operating cost exceeds $45,085.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,410.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $8,239.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,269.90 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $650.18. The transfer capital threshold is the transfer adjustment factor * $650.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10834.64,25830.00,Inpatient DRG
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC,858,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],33794.11,,"Fee schedule rate ($33,794.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11377.76,33794.11,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],41580.51,,"Fee schedule rate ($41,580.51). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,13783.20,41580.51,There are no additional notes associated with this service or procedure.
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],10048.39,,"Case rate ($10,048.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,483.42, add-ons for qualifying new technology services are included. If operating cost exceeds $44,354.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,352.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,510.78 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,538.48 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $592.68. The transfer capital threshold is the transfer adjustment factor * $592.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10048.39,23545.50,Inpatient DRG
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],13571.25,,"Case rate ($13,571.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,760.65, add-ons for qualifying new technology services are included. If operating cost exceeds $47,631.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,610.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $10,775.96 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,815.69 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $850.33. The transfer capital threshold is the transfer adjustment factor * $850.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,13571.25,33781.47,Inpatient DRG
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],24259.09,,"Fee schedule rate ($24,259.09). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10098.51,24259.09,There are no additional notes associated with this service or procedure.
BRONCHITIS AND ASTHMA WITH CC/MCC,202,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],14307.27,,"Fee schedule rate ($14,307.27). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7606.34,19110.30,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,394,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],8695.64,,"Case rate ($8,281.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,839.77, add-ons for qualifying new technology services are included. If operating cost exceeds $42,710.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,223.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,873.17 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,894.83 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $463.45. The transfer capital threshold is the transfer adjustment factor * $463.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8281.56,20909.61,Inpatient DRG
Correction Hammertoe|LEFT SIDE,CASE-28285,APC,28285,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
Perq Nl/Pl Lithotrp Complex >2 Cm Mlt Locations|RIGHT SIDE,CASE-50081,APC,50081,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],8860.83,,"APC Price ($8,860.83). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,8860.83,9303.88,OPPS APC
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,988,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],13729.30,,"Case rate ($13,075.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,299.49, add-ons for qualifying new technology services are included. If operating cost exceeds $47,170.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,574.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $10,316.50 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,354.54 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $814.07. The transfer capital threshold is the transfer adjustment factor * $814.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13075.52,42425.46,Inpatient DRG
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],17136.70,,,,,,0,other,5280.00,17136.70,There are no additional notes associated with this service or procedure.
Hysteroscopy Diagnostic Separate Procedure,CASE-58555,APC,58555,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3181.53,,"APC Price ($3,030.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3030.03,3181.53,OPPS APC
PREMATURITY WITH MAJOR PROBLEMS,791,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],3054.00,,,,,,0,other,3048.21,30904.42,Estimated amount calculated based on 5 day length of stay.
Rpr Aa Hernia 1st > 10 Cm Ncrc8/Strangulated|UNUSUAL NON-OVERLAPPING SERVICE,CASE-49596,APC,49596,CPT,0360,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5658.76,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5658.76,5941.70,OPPS APC
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],52803.53,,"Fee schedule rate ($52,803.53). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,14337.84,52803.53,There are no additional notes associated with this service or procedure.
"Arthrodesis Interphalangeal Jt W/WO Int Fixj|LEFT HAND, FOURTH DIGIT",CASE-26860,APC,26860,CPT,0360,RC,,,F3,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3062.67,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,057,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],39884.93,,"Fee schedule rate ($39,884.93). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,10718.84,39884.93,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,065,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],18986.57,,"Fee schedule rate ($18,986.57). Adds an outlier to normal pricing equal to the per diem rate ($85,884.96) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,8786.76,25681.86,There are no additional notes associated with this service or procedure.
"LIMB REATTACHMENT, HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA",956,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],82170.90,,"Fee schedule rate ($82,170.90). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,27428.25,148259.86,There are no additional notes associated with this service or procedure.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,418,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],39884.93,,"Fee schedule rate ($39,884.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,13400.58,39884.93,There are no additional notes associated with this service or procedure.
"SPINAL FUSION AND OTHER BACK AND NECK PROCEDURES EXCEPT FOR DISC PROCEDURES,MODERATE",321,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],24450.45,,"Case rate ($23,286.14). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,23286.14,24450.45,There are no additional notes associated with this service or procedure.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],75579.22,,"Fee schedule rate ($75,579.22). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,25162.32,75579.22,There are no additional notes associated with this service or procedure.
Esophageal Motility Study W/Interp&Rpt,CASE-91010,APC,91010,CPT,0750,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],366.75,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,349.28,366.75,OPPS APC
Submucous Rescj Inferior Turbinate Prtl/Compl|BILATERAL PROCEDURE,CASE-30140,APC,30140,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6605.95,,"APC Price ($6,605.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6605.95,6936.25,OPPS APC
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],15802.03,,"Fee schedule rate ($15,802.03). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7566.45,16333.88,There are no additional notes associated with this service or procedure.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],15854.69,,"Case rate ($15,099.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,182.53, add-ons for qualifying new technology services are included. If operating cost exceeds $49,053.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,722.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $12,192.63 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,237.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $962.12. The transfer capital threshold is the transfer adjustment factor * $962.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7605.00,39153.65,Inpatient DRG
Ercp Stent Placement Biliary/Pancreatic Duct,CASE-43274,APC,43274,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5682.51,,"APC Price ($5,682.51). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5682.51,5966.63,OPPS APC
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],9629.35,,"Case rate ($9,170.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,680.50, add-ons for qualifying new technology services are included. If operating cost exceeds $43,551.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,275.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,710.11 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,735.55 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $515.75. The transfer capital threshold is the transfer adjustment factor * $515.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9389.48,22358.90,Inpatient DRG
"CARDIAC ARREST, UNEXPLAINED WITH MCC",296,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],12522.25,,"Case rate ($12,522.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,784.78, add-ons for qualifying new technology services are included. If operating cost exceeds $46,655.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,533.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $9,803.69 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,839.84 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $773.61. The transfer capital threshold is the transfer adjustment factor * $773.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12522.25,36459.67,Inpatient DRG
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],61234.06,,"Fee schedule rate ($61,234.06). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11165.00,61234.06,There are no additional notes associated with this service or procedure.
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",623,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],32096.64,,"Fee schedule rate ($32,096.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,14093.37,33712.76,There are no additional notes associated with this service or procedure.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,345,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],12559.61,,"Case rate ($12,134.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,424.43, add-ons for qualifying new technology services are included. If operating cost exceeds $46,295.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,505.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $9,444.66 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,479.48 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $745.28. The transfer capital threshold is the transfer adjustment factor * $745.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,12134.89,33616.03,Inpatient DRG
OSTEOMYELITIS WITH CC,540,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],18450.55,,"Fee schedule rate ($18,450.55). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,9809.07,25507.30,There are no additional notes associated with this service or procedure.
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],14577.15,,"Fee schedule rate ($14,577.15). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11247.07,27028.33,There are no additional notes associated with this service or procedure.
"LIMB REATTACHMENT, HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA",956,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],70718.06,,"Fee schedule rate ($70,718.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,27428.25,148259.86,There are no additional notes associated with this service or procedure.
Int Hrhc by Ligation Single Hroid W/O Img Gdn,CASE-46945,APC,46945,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],2689.02,,"APC Price ($2,598.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2598.08,2727.99,OPPS APC
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],9667.64,,"Fee schedule rate ($9,667.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,5139.72,13110.79,There are no additional notes associated with this service or procedure.
FRACTURES OF FEMUR WITH MCC,533,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],6852.00,,"Per diem ($6,852). If length of stay < 4.3, first 1 days paid at a per diem of $13,704 instead. Capped at $29,461.79.",,,,0,other,6852.00,49490.05,Estimated amount calculated based on 2 day length of stay.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],13647.09,,"Case rate ($13,647.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,831.20, add-ons for qualifying new technology services are included. If operating cost exceeds $47,702.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,615.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $10,846.26 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,886.25 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $855.88. The transfer capital threshold is the transfer adjustment factor * $855.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7921.00,45706.73,Inpatient DRG
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],7389.00,,"Per diem ($7,389). If length of stay < 4.8, first 1 days paid at a per diem of $14,778 instead. Capped at $35,466.15.",,,,0,other,7389.00,37134.43,Estimated amount calculated based on 6 day length of stay.
COMPLICATIONS OF TREATMENT WITH CC,920,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],20731.52,,"Fee schedule rate ($20,731.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8732.59,20731.52,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITH STERILIZATION WITH CC,784,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],20859.59,,,,,,0,other,9124.01,23722.94,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],6892.39,,"Case rate ($6,564.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,242.12, add-ons for qualifying new technology services are included. If operating cost exceeds $41,113.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,097.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $4,281.39 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,297.17 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $337.84. The transfer capital threshold is the transfer adjustment factor * $337.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6564.18,17651.07,Inpatient DRG
Tx Anal Fstl Trans/Supra/Xtrasphnctrc Incl Seton,CASE-46280,APC,46280,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],2598.08,,"APC Price ($2,598.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2598.08,2727.99,OPPS APC
Cysto W/Removal of Lesions Small,CASE-52224,APC,52224,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3414.95,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3299.47,3464.44,OPPS APC
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],15802.03,,"Fee schedule rate ($15,802.03). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7566.45,16333.88,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],82674.88,,,,,,0,other,30398.48,82674.88,There are no additional notes associated with this service or procedure.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,477,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],44344.55,,"Case rate ($25,339.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $23,708.63, add-ons for qualifying new technology services are included. If operating cost exceeds $58,579.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,471.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 8.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $21,683.73 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $21,763.68 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,711.06. The transfer capital threshold is the transfer adjustment factor * $1,711.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,25339.74,67976.16,All Other Inpatient
Perq Drainage Pleura Insert Cath W/O Imaging|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-32556,APC,32556,CPT,0360,RC,,,LT|XU,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5658.76,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5658.76,5856.81,OPPS APC
Nasal/Sinus Ndsc Tot W/Frnt Sins Expl Tiss Rmvl|LEFT SIDE,CASE-31253,APC,31253,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6605.95,,"APC Price ($6,605.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6605.95,6936.25,OPPS APC
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],24387.68,,"Fee schedule rate ($24,387.68). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10733.06,45157.33,There are no additional notes associated with this service or procedure.
"Arthrodesis Great Toe Metatarsophalangeal Joint|RIGHT FOOT, GREAT TOE",CASE-28750,APC,28750,CPT,0360,RC,,,T5,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6791.99,7131.59,OPPS APC
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,098,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],6965.00,,,,,,0,other,6965.00,45156.75,There are no additional notes associated with this service or procedure.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],6965.00,,,,,,0,other,6965.00,15340.19,There are no additional notes associated with this service or procedure.
PERITONEAL ADHESIOLYSIS WITH CC,336,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],16225.22,,"Case rate ($16,225.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,229.58, add-ons for qualifying new technology services are included. If operating cost exceeds $50,100.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,804.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $13,235.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,284.63 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,044.44. The transfer capital threshold is the transfer adjustment factor * $1,044.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,16225.22,53705.31,Inpatient DRG
CHOLECYSTECTOMY WITH C.D.E. WITH MCC,411,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],88615.28,,"Fee schedule rate ($88,615.28). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,24315.13,88615.28,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],34409.98,,"Fee schedule rate ($34,409.98). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,14344.60,36028.59,There are no additional notes associated with this service or procedure.
Nsl/Sinus Ndsc Max Antrost W/Rmvl Tiss Max Sinus,CASE-31267,APC,31267,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6837.16,,"APC Price ($6,605.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6605.95,6936.25,OPPS APC
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6838.09,,"Case rate ($6,606.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,281.82, add-ons for qualifying new technology services are included. If operating cost exceeds $41,152.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,100.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,320.93 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,336.86 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $340.96. The transfer capital threshold is the transfer adjustment factor * $340.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,5919.29,13545.65,Inpatient DRG
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],75579.22,,"Fee schedule rate ($75,579.22). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,25162.32,75579.22,There are no additional notes associated with this service or procedure.
Peri-Implant Capsulectomy Breast Complete|LEFT SIDE,CASE-19371,APC,19371,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3848.19,,"APC Price ($3,664.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3664.94,3848.19,OPPS APC
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],6558.75,,"Case rate ($6,558.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,237.08, add-ons for qualifying new technology services are included. If operating cost exceeds $41,108.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,097.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $4,276.36 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,292.13 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $337.45. The transfer capital threshold is the transfer adjustment factor * $337.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6558.75,14871.83,Inpatient DRG
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],7017.54,,"Case rate ($6,683.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,353, add-ons for qualifying new technology services are included. If operating cost exceeds $41,224.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,106.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,391.86 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,408.05 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $346.56. The transfer capital threshold is the transfer adjustment factor * $346.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6683.37,14699.43,Inpatient DRG
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],27589.62,,"Fee schedule rate ($27,589.62). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12566.28,30861.41,There are no additional notes associated with this service or procedure.
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],8448.77,,"Case rate ($8,163.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,729.53, add-ons for qualifying new technology services are included. If operating cost exceeds $42,600.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,214.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,763.33 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,784.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $454.78. The transfer capital threshold is the transfer adjustment factor * $454.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,8163.06,18067.42,Inpatient DRG
Inj for Sacroiliac Jt Anesth|BILATERAL PROCEDURE,CASE-G0260,APC,G0260,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],660.72,,"APC Price ($660.72). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,660.72,693.76,OPPS APC
SPINAL PROCEDURES WITH MCC,028,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],112913.98,,"Fee schedule rate ($112,913.98). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,42633.57,120982.83,There are no additional notes associated with this service or procedure.
Arthrs Wrst Exc&/Rpr Triang Fibrocart&/Joint,CASE-29846,APC,29846,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],13947.32,,"Fee schedule rate ($13,947.32). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6153.12,13947.32,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],2070.00,,,,,,0,other,1188.00,17370.86,Estimated amount calculated based on 3 day length of stay.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],12882.42,,"Case rate ($12,268.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,549.17, add-ons for qualifying new technology services are included. If operating cost exceeds $46,420.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,515.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,568.94 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,604.22 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $755.08. The transfer capital threshold is the transfer adjustment factor * $755.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12268.97,41006.47,Inpatient DRG
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],81306.30,,"Fee schedule rate ($81,306.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,20846.48,81306.30,There are no additional notes associated with this service or procedure.
BRONCHITIS AND ASTHMA WITH CC/MCC,202,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],18251.76,,"Fee schedule rate ($18,251.76). Adds an outlier to normal pricing equal to the per diem rate ($45,948.49) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,7606.34,19110.30,There are no additional notes associated with this service or procedure.
HC Biopsy of Vulva/Perineum,CASE-56605,APC,56605,CPT,0361,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],905.23,,"APC Price ($862.13). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,862.13,905.23,OPPS APC
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC,027,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],19030.20,,"Case rate ($19,030.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,839, add-ons for qualifying new technology services are included. If operating cost exceeds $52,710.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,009.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $15,835.66 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,894.05 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,249.59. The transfer capital threshold is the transfer adjustment factor * $1,249.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,19030.20,56363.30,Inpatient DRG
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],42021.93,,"Fee schedule rate ($42,021.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,21248.73,56089.29,There are no additional notes associated with this service or procedure.
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],11688.60,,"Fee schedule rate ($11,688.60). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,6965.00,21089.59,There are no additional notes associated with this service or procedure.
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],20981.60,,"Fee schedule rate ($20,981.60). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,10003.71,23415.63,There are no additional notes associated with this service or procedure.
HC Inj Aa&/Strd Other Peripheral Nerve/Branch,CASE-64450,APC,64450,CPT,0450,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],683.85,,"APC Price ($660.72). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,660.72,693.76,OPPS APC
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],41944.25,,"Fee schedule rate ($41,944.25). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12795.84,41944.25,There are no additional notes associated with this service or procedure.
NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,601,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],12359.72,,"Fee schedule rate ($12,359.72). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6042.05,12359.72,There are no additional notes associated with this service or procedure.
HEART FAILURE AND SHOCK WITH CC,292,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],7848.32,,"Case rate ($7,694.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,293.57, add-ons for qualifying new technology services are included. If operating cost exceeds $42,164.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,180.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,328.98 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,348.63 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $420.51. The transfer capital threshold is the transfer adjustment factor * $420.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,5502.00,16705.77,Inpatient DRG
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],57102.65,,,,,,0,other,21597.50,67790.93,There are no additional notes associated with this service or procedure.
POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES,769,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],31756.41,,"Fee schedule rate ($31,756.41). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.7), with a minimum of zero.",,,,0,other,13388.39,33250.19,There are no additional notes associated with this service or procedure.
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],59081.91,,"Fee schedule rate ($59,081.91). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,8480.00,59081.91,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],22732.83,,"Case rate ($12,990.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,220.11, add-ons for qualifying new technology services are included. If operating cost exceeds $47,091.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,567.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $10,237.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,275.16 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $807.83. The transfer capital threshold is the transfer adjustment factor * $807.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,9888.00,43399.23,All Other Inpatient
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",062,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],14329.41,,"Case rate ($13,844.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,015.16, add-ons for qualifying new technology services are included. If operating cost exceeds $47,886.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,630.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $11,029.54 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,070.21 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $870.34. The transfer capital threshold is the transfer adjustment factor * $870.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,13844.84,44304.80,Inpatient DRG
Peri-Implant Capsulectomy Breast Complete|BILATERAL PROCEDURE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-19371,APC,19371,CPT,0360,RC,,,50|XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7918.25,,"APC Price ($7,650.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,7650.49,8033.01,OPPS APC
OTHER CEREBROVASCULAR DISORDERS WITH CC,071,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],29215.10,,"Fee schedule rate ($29,215.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5843.00,29215.10,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],86252.84,,"Fee schedule rate ($86,252.84). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,27944.96,86252.84,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],67794.72,,"Fee schedule rate ($67,794.72). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,10862.00,86437.13,There are no additional notes associated with this service or procedure.
HC Inj Tendon Sheath/Ligament|RIGHT SIDE,CASE-20550,APC,20550,CPT,0510,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],297.37,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,287.31,301.68,OPPS APC
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,057,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],39884.93,,"Fee schedule rate ($39,884.93). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,10718.84,39884.93,There are no additional notes associated with this service or procedure.
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],6965.00,,,,,,0,other,5139.72,13110.79,There are no additional notes associated with this service or procedure.
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],17033.98,,"Fee schedule rate ($17,033.98). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.8), with a minimum of zero.",,,,0,other,7884.32,17835.23,There are no additional notes associated with this service or procedure.
Open Tx Clavicular Fracture Internal Fixation|RIGHT SIDE,CASE-23515,APC,23515,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITHOUT CC/MCC,816,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],14733.53,,"Fee schedule rate ($14,733.53). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6224.90,14733.53,There are no additional notes associated with this service or procedure.
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],17445.75,,"Fee schedule rate ($17,445.75). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9648.19,31477.13,There are no additional notes associated with this service or procedure.
"Rpr/Advmnt Flxr Tdn Zone 2 W/O Fr Grft Ea Tendon|LEFT HAND, FOURTH DIGIT",CASE-26356,APC,26356,CPT,0360,RC,,,F3,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],46523.26,,"Fee schedule rate ($46,523.26). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,17782.11,46523.26,There are no additional notes associated with this service or procedure.
Inj for Sacroiliac Jt Anesth|LEFT SIDE,CASE-G0260,APC,G0260,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],660.72,,"APC Price ($660.72). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,660.72,693.76,OPPS APC
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],34892.92,,"Fee schedule rate ($34,892.92). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,6965.00,41030.48,There are no additional notes associated with this service or procedure.
MINOR BLADDER PROCEDURES WITHOUT CC/MCC,664,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],31876.87,,"Fee schedule rate ($31,876.87). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9034.63,31876.87,There are no additional notes associated with this service or procedure.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC",156,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],12624.95,,"Fee schedule rate ($12,624.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6625.12,13598.77,There are no additional notes associated with this service or procedure.
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],7505.33,,"Case rate ($7,147.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,785.17, add-ons for qualifying new technology services are included. If operating cost exceeds $41,656.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,140.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $4,822.44 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,840.22 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $380.54. The transfer capital threshold is the transfer adjustment factor * $380.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,16400.70,Inpatient DRG
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH MCC",722,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],56869.13,,"Fee schedule rate ($56,869.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,14200.37,56869.13,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5628.97,,"Case rate ($5,628.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,372.11, add-ons for qualifying new technology services are included. If operating cost exceeds $40,243.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,029.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,414.56 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,427.15 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $269.44. The transfer capital threshold is the transfer adjustment factor * $269.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,5628.97,12272.58,Inpatient DRG
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],18588.16,,"Fee schedule rate ($18,588.16). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.8), with a minimum of zero.",,,,0,other,8643.20,19462.52,There are no additional notes associated with this service or procedure.
Esophagogastroduodenoscopy Transoral Diagnostic,CASE-43235,APC,43235,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],891.41,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,848.96,891.41,OPPS APC
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITHOUT CC/MCC,428,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],40844.17,,"Case rate ($38,899.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $36,391.67, add-ons for qualifying new technology services are included. If operating cost exceeds $71,262.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,397.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $34,316.61 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $34,446.72 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,637.65. The transfer capital threshold is the transfer adjustment factor * $2,637.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,40017.53,118904.57,Inpatient DRG
Thyroidectomy Total/Subtotal Lmtd Neck Dissect,CASE-60252,APC,60252,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5541.10,,"APC Price ($5,541.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5541.10,5818.16,OPPS APC
CESAREAN SECTION WITH STERILIZATION WITH CC,784,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],23722.94,,"Fee schedule rate ($23,722.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9124.01,23722.94,There are no additional notes associated with this service or procedure.
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],6711.00,,"Per diem ($6,711). If length of stay < 2.4, first 1 days paid at a per diem of $13,422 instead. Capped at $16,107.48.",,,,0,other,6711.00,16865.16,Estimated amount calculated based on 2 day length of stay.
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],13261.75,,"Case rate ($13,001.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,230.82, add-ons for qualifying new technology services are included. If operating cost exceeds $47,101.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,568.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $10,248.08 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,285.87 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $808.68. The transfer capital threshold is the transfer adjustment factor * $808.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,7868.00,32126.64,Inpatient DRG
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],18915.50,,,,,,0,other,6230.00,22762.43,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],28756.63,,"Fee schedule rate ($28,756.63). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,13148.66,32553.63,There are no additional notes associated with this service or procedure.
DIABETES WITH CC,638,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],15195.79,,"Fee schedule rate ($15,195.79). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8014.07,17634.53,There are no additional notes associated with this service or procedure.
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],30245.71,,"Fee schedule rate ($30,245.71). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9151.11,30245.71,There are no additional notes associated with this service or procedure.
Excision Excessive Skin & Subq Tissue Abdomen,CASE-15847,APC,15847,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6215.36,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6215.36,6526.12,OPPS APC
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],21354.82,,"Fee schedule rate ($21,354.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6834.39,21354.82,There are no additional notes associated with this service or procedure.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],16897.01,,"Case rate ($16,897.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,854.53, add-ons for qualifying new technology services are included. If operating cost exceeds $50,725.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,853.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $13,858.48 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,909.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,093.57. The transfer capital threshold is the transfer adjustment factor * $1,093.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,16897.01,43444.85,Inpatient DRG
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],9221.53,,"Case rate ($9,040.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,546, add-ons for qualifying new technology services are included. If operating cost exceeds $43,417.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,278.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,576.80 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,601.05 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $518.97. The transfer capital threshold is the transfer adjustment factor * $518.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,9040.72,26966.33,Inpatient DRG
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],13295.62,,"Case rate ($13,295.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,504.24, add-ons for qualifying new technology services are included. If operating cost exceeds $47,375.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,590.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $10,520.50 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,559.29 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $830.17. The transfer capital threshold is the transfer adjustment factor * $830.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7000.00,33835.79,Inpatient DRG
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],6965.00,,,,,,0,other,6965.00,15340.19,There are no additional notes associated with this service or procedure.
Egd Transoral Biopsy Single/Multiple|SEPARATE STRUCTURE,CASE-43239,APC,43239,CPT,0360,RC,,,XS,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1885.95,,"APC Price ($1,796.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1796.14,1885.95,OPPS APC
O.R. PROCEDURES FOR OBESITY WITH CC,620,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],13229.68,,"Case rate ($12,782.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,026.70, add-ons for qualifying new technology services are included. If operating cost exceeds $46,897.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,552.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $10,044.72 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,081.75 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $792.63. The transfer capital threshold is the transfer adjustment factor * $792.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,12782.30,43753.50,Inpatient DRG
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],41006.47,,"Fee schedule rate ($41,006.47). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12268.97,41006.47,There are no additional notes associated with this service or procedure.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],54764.34,,"Fee schedule rate ($54,764.34). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,18178.96,54764.34,There are no additional notes associated with this service or procedure.
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],7414.07,,"Case rate ($7,414.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,032.76, add-ons for qualifying new technology services are included. If operating cost exceeds $41,903.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,159.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,069.12 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,087.81 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $400.00. The transfer capital threshold is the transfer adjustment factor * $400.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7414.07,18217.52,Inpatient DRG
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],38246.19,,"Fee schedule rate ($38,246.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,19435.86,50821.76,There are no additional notes associated with this service or procedure.
VAGINAL DELIVERY WITH O.R. PROCEDURES EXCEPT STERILIZATION AND/OR D&C,768,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],9662.00,,"Case rate ($9,201.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,695.94, add-ons for qualifying new technology services are included. If operating cost exceeds $43,566.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,290.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $6,726.19 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,750.99 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $530.76. The transfer capital threshold is the transfer adjustment factor * $530.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6426.91,13416.00,Inpatient DRG
VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC,033,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],13866.54,,"Case rate ($13,206.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,421.07, add-ons for qualifying new technology services are included. If operating cost exceeds $47,292.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,583.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $10,437.64 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,476.13 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $823.63. The transfer capital threshold is the transfer adjustment factor * $823.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13206.23,42156.44,Inpatient DRG
Hemorrhoidectomy Ntrnl & Xtrnl 1 Column/Group,CASE-46255,APC,46255,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],2598.08,,"APC Price ($2,598.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2598.08,2727.99,OPPS APC
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],19319.20,,"Fee schedule rate ($19,319.20). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8906.63,28434.57,There are no additional notes associated with this service or procedure.
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],6965.00,,,,,,0,other,4341.01,12882.53,There are no additional notes associated with this service or procedure.
"FEVER AND INFLAMMATORY CONDITIONS,MODERATE",722,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],2047.71,,"Case rate for a one day stay ($2,047.71). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,2047.71,2150.10,There are no additional notes associated with this service or procedure.
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],81454.07,,"Fee schedule rate ($81,454.07). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,10078.00,81454.07,There are no additional notes associated with this service or procedure.
HC Biopsy/Exc Lymph Node Needle,CASE-38505,APC,38505,CPT,0361,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1600.04,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1545.93,1623.23,OPPS APC
COAGULATION DISORDERS,813,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],15442.31,,"Fee schedule rate ($15,442.31). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12274.39,30013.33,There are no additional notes associated with this service or procedure.
Tr/Trnspl Tdn Carp/Mtcrpl Hand W/O Fr Grf Ea Tdn,CASE-26480,APC,26480,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],62454.12,,"Fee schedule rate ($62,454.12). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11348.00,62454.12,There are no additional notes associated with this service or procedure.
NORMAL NEWBORN,795,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],2074.00,,,,,,0,other,1369.79,5771.52,Estimated amount calculated based on 2 day length of stay.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,073,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],43475.01,,"Fee schedule rate ($43,475.01). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,12809.38,43475.01,There are no additional notes associated with this service or procedure.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC,862,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],28705.48,,"Fee schedule rate ($28,705.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (42), with a minimum of zero.",,,,0,other,6855.00,35884.94,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL HEMORRHAGE WITH MCC,377,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],7634.00,,"Per diem ($7,634). If length of stay < 4.5, first 1 days paid at a per diem of $15,268 instead. Capped at $34,353.60.",,,,0,other,7634.00,35969.56,Estimated amount calculated based on 3 day length of stay.
PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,337,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],38926.31,,"Fee schedule rate ($38,926.31). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,12340.08,38926.31,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],14871.83,,"Fee schedule rate ($14,871.83). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6558.75,14871.83,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],31533.97,,"Fee schedule rate ($31,533.97). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8563.30,31533.97,There are no additional notes associated with this service or procedure.
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],34570.85,,"Fee schedule rate ($34,570.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,6965.00,36140.75,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],94787.57,,"Fee schedule rate ($94,787.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,23526.87,94787.57,There are no additional notes associated with this service or procedure.
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],25253.70,,"Fee schedule rate ($25,253.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11974.38,29141.64,There are no additional notes associated with this service or procedure.
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITH MCC,429,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],177294.98,,"Fee schedule rate ($177,294.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,62958.58,177294.98,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],28756.63,,"Fee schedule rate ($28,756.63). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,13148.66,32553.63,There are no additional notes associated with this service or procedure.
CERVICAL SPINAL FUSION WITH CC,472,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],55366.06,,"Fee schedule rate ($55,366.06). Adds an outlier to normal pricing equal to the per diem rate ($66,990.29) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,21896.13,70198.84,There are no additional notes associated with this service or procedure.
HC Remove Lung Catheter,CASE-32552,APC,32552,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],848.96,,"APC Price ($848.96). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,848.96,891.41,OPPS APC
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7187.14,,"Case rate ($6,944.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,595.55, add-ons for qualifying new technology services are included. If operating cost exceeds $41,466.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,125.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,633.51 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,650.60 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $365.63. The transfer capital threshold is the transfer adjustment factor * $365.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,5068.21,14525.56,Inpatient DRG
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],27589.62,,"Fee schedule rate ($27,589.62). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12566.28,30861.41,There are no additional notes associated with this service or procedure.
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC,797,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],20928.55,,"Fee schedule rate ($20,928.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8719.72,20928.55,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],86235.79,,"Fee schedule rate ($86,235.79). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,32296.02,88188.38,There are no additional notes associated with this service or procedure.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,073,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],43475.01,,"Fee schedule rate ($43,475.01). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,12809.38,43475.01,There are no additional notes associated with this service or procedure.
HC Biopsy/Exc Lymph Node Needle|TECHNICAL COMPONENT,CASE-38505,APC,38505,CPT,0361,RC,,,TC,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1623.23,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1545.93,1623.23,OPPS APC
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,074,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],20919.08,,"Fee schedule rate ($20,919.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8925.60,20919.08,There are no additional notes associated with this service or procedure.
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],5791.49,,"Fee schedule rate ($5,791.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,3079.00,10940.41,There are no additional notes associated with this service or procedure.
VAGINAL DELIVERY WITH O.R. PROCEDURES EXCEPT STERILIZATION AND/OR D&C,768,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],13416.00,,,,,,0,other,6426.91,13416.00,There are no additional notes associated with this service or procedure.
HC >= 12 Lead Ekg|PBB CHARGE,CASE-93005,APC,93005,CPT,0730,RC,,,PBB,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],57.98,,"APC Price ($55.22). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,55.22,57.98,OPPS APC
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],39153.65,,"Fee schedule rate ($39,153.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,7605.00,39153.65,There are no additional notes associated with this service or procedure.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],35719.96,,"Case rate ($35,719.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $33,365.14, add-ons for qualifying new technology services are included. If operating cost exceeds $68,236.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,230.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.9. The base transfer operating payment is the transfer adjustment factor * $31,304.77 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $31,420.19 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,470.26. The transfer capital threshold is the transfer adjustment factor * $2,470.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,35719.96,105091.76,Inpatient DRG
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITH MCC,429,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],94257.34,,"Fee schedule rate ($94,257.34). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,62958.58,177294.98,There are no additional notes associated with this service or procedure.
Neuroplasty &/Transposition Ulnar Nerve Elbow|RIGHT SIDE,CASE-64718,APC,64718,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1827.80,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1827.80,1919.19,OPPS APC
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC,805,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],20902.03,,"Fee schedule rate ($20,902.03). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9253.36,21235.42,There are no additional notes associated with this service or procedure.
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",759,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],11643.60,,"Fee schedule rate ($11,643.60). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6190.22,13057.66,There are no additional notes associated with this service or procedure.
Lamnotmy Incl W/Dcmprsn Nrv Root 1 Intrspc Lumbr|RIGHT SIDE,CASE-63030,APC,63030,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6791.99,7131.59,OPPS APC
PREMATURITY WITH MAJOR PROBLEMS,791,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],3186.77,,,,,,0,other,3048.21,30904.42,Estimated amount calculated based on 5 day length of stay.
VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC,033,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],32720.88,,,,,,0,other,13206.23,42156.44,There are no additional notes associated with this service or procedure.
Dstrj Lesion Penis Simple Laser,CASE-54057,APC,54057,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],685.32,,"APC Price ($652.69). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,652.69,685.32,OPPS APC
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],52699.33,,"Fee schedule rate ($52,699.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,18105.81,52699.33,There are no additional notes associated with this service or procedure.
MAJOR BLADDER PROCEDURES WITH MCC,653,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],125343.98,,"Fee schedule rate ($125,343.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,10280.00,125343.98,There are no additional notes associated with this service or procedure.
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|LEFT HAND, SECOND DIGIT",CASE-26160,APC,26160,CPT,0360,RC,,,F1,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1557.80,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1505.12,1580.37,OPPS APC
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],32795.66,,"Fee schedule rate ($32,795.66). Adds an outlier to normal pricing equal to the per diem rate ($69,146.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,1188.00,34338.33,There are no additional notes associated with this service or procedure.
"CARDIAC ARREST, UNEXPLAINED WITH MCC",296,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],13148.36,,"Case rate ($12,522.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,784.78, add-ons for qualifying new technology services are included. If operating cost exceeds $46,655.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,533.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $9,803.69 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,839.84 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $773.61. The transfer capital threshold is the transfer adjustment factor * $773.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12522.25,36459.67,Inpatient DRG
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],13414.31,,"Case rate ($12,775.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,020.41, add-ons for qualifying new technology services are included. If operating cost exceeds $46,891.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,552.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $10,038.44 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,075.45 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $792.13. The transfer capital threshold is the transfer adjustment factor * $792.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12775.53,31469.43,Inpatient DRG
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],21248.73,,"Case rate ($21,248.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $19,902.85, add-ons for qualifying new technology services are included. If operating cost exceeds $54,773.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,171.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.3. The base transfer operating payment is the transfer adjustment factor * $17,891.94 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $17,957.90 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,411.85. The transfer capital threshold is the transfer adjustment factor * $1,411.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,21248.73,56089.29,Inpatient DRG
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC",458,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],31712.19,,"Case rate ($30,202.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $28,231.97, add-ons for qualifying new technology services are included. If operating cost exceeds $63,102.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,826.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $26,190.45 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $26,287.02 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,066.69. The transfer capital threshold is the transfer adjustment factor * $2,066.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,30202.09,132827.25,Inpatient DRG
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],96365.69,,"Fee schedule rate ($96,365.69). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,23377.19,96365.69,There are no additional notes associated with this service or procedure.
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7281.07,,"Case rate ($7,034.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,679.97, add-ons for qualifying new technology services are included. If operating cost exceeds $41,550.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,132.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $4,717.62 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,735.02 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $372.27. The transfer capital threshold is the transfer adjustment factor * $372.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6965.00,21089.59,Inpatient DRG
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],26127.34,,"Case rate ($26,127.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $24,441.31, add-ons for qualifying new technology services are included. If operating cost exceeds $59,312.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,528.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. The base transfer operating payment is the transfer adjustment factor * $22,413.72 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $22,496.36 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,768.66. The transfer capital threshold is the transfer adjustment factor * $1,768.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,26127.34,90333.60,Inpatient DRG
MAJOR BLADDER PROCEDURES WITH MCC,653,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],125343.98,,"Fee schedule rate ($125,343.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,10280.00,125343.98,There are no additional notes associated with this service or procedure.
"Tendon Sheath Incision|RIGHT HAND, SECOND DIGIT|UNUSUAL NON-OVERLAPPING SERVICE",CASE-26055,APC,26055,CPT,0360,RC,,,F6|XU,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1505.12,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1505.12,1580.37,OPPS APC
Laps Vaginal Hysterect > 250 Gm Rmvl Tube&/Ovar,CASE-58554,APC,58554,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],10298.02,,"APC Price ($9,949.78). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,9949.78,10447.27,OPPS APC
Prtl Exc B1 Tarsal/Metar B1 Xcp Talus/Calcaneus|RIGHT SIDE,CASE-28122,APC,28122,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3169.86,OPPS APC
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,025,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],91631.33,,"Fee schedule rate ($91,631.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,13351.00,91631.33,There are no additional notes associated with this service or procedure.
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],5280.00,,"Per diem ($5,280). If length of stay < 3.1, first 1 days paid at a per diem of $10,560 instead. Capped at $16,366.82.",,,,0,other,5280.00,17136.70,Estimated amount calculated based on 3 day length of stay.
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],90333.60,,"Fee schedule rate ($90,333.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,26127.34,90333.60,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],11594.35,,"Fee schedule rate ($11,594.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6164.03,14071.02,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,426,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],177294.98,,"Fee schedule rate ($177,294.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,76581.29,216864.15,There are no additional notes associated with this service or procedure.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],7453.00,,"Per diem ($7,453). If length of stay < 5.4, first 1 days paid at a per diem of $14,906 instead. Capped at $40,245.21.",,,,0,other,7453.00,42138.30,Estimated amount calculated based on 3 day length of stay.
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC,817,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],43874.75,,"Fee schedule rate ($43,874.75). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,17396.11,44895.04,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,689,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],9998.63,,"Case rate ($9,802.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,254.74, add-ons for qualifying new technology services are included. If operating cost exceeds $44,125.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,334.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $7,282.94 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,309.79 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $574.70. The transfer capital threshold is the transfer adjustment factor * $574.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,9802.58,22831.22,Inpatient DRG
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],18510.45,,"Fee schedule rate ($18,510.45). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,7353.00,33398.16,There are no additional notes associated with this service or procedure.
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],24444.75,,"Fee schedule rate ($24,444.75). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10136.44,24444.75,There are no additional notes associated with this service or procedure.
HC Joint Injection/Aspir Large WO US|PBB CHARGE|RIGHT SIDE,CASE-20610,APC,20610,CPT,0510,RC,,,PBB|RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],297.37,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,287.31,301.68,OPPS APC
TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC,084,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],8586.05,,"Case rate ($8,417.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,966.41, add-ons for qualifying new technology services are included. If operating cost exceeds $42,837.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,233.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $5,999.34 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,021.46 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $473.41. The transfer capital threshold is the transfer adjustment factor * $473.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6965.00,19445.16,Inpatient DRG
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],23954.07,,"Fee schedule rate ($23,954.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,6167.00,29058.99,There are no additional notes associated with this service or procedure.
Tissue Expander Placement Breast Reconstruction|BILATERAL PROCEDURE,CASE-19357,APC,19357,CPT,0360,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],13350.78,,"APC Price ($12,899.30). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,12899.30,13350.78,OPPS APC
"POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS,MAJOR",721,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],1864.88,,"Case rate for a one day stay ($1,864.88). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,1864.88,1958.12,There are no additional notes associated with this service or procedure.
HC >= 12 Lead Ekg,CASE-93005,APC,93005,CPT,0730,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],57.15,,"APC Price ($55.22). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,55.22,57.98,OPPS APC
HC N Block Inj Suprascapular Nerv|LEFT SIDE,CASE-64418,APC,64418,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],660.72,,"APC Price ($660.72). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,660.72,693.76,OPPS APC
"CARDIAC ARREST, UNEXPLAINED WITH MCC",296,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],36459.67,,"Fee schedule rate ($36,459.67). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12522.25,36459.67,There are no additional notes associated with this service or procedure.
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],11011.30,,"Case rate ($10,638.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,032.78, add-ons for qualifying new technology services are included. If operating cost exceeds $44,903.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,395.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,058.12 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,087.83 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $635.87. The transfer capital threshold is the transfer adjustment factor * $635.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,10638.94,25261.33,Inpatient DRG
Dstr Nrolytc Agnt Parverteb Fct Addl Lmbr/Sacral,CASE-64636,APC,64636,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1891.77,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1827.80,1919.19,OPPS APC
CESAREAN SECTION WITHOUT STERILIZATION WITH CC,787,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],9698.17,,"Case rate ($9,508.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,980.70, add-ons for qualifying new technology services are included. If operating cost exceeds $43,851.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,313.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $7,009.90 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,035.74 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $553.15. The transfer capital threshold is the transfer adjustment factor * $553.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,9508.01,23722.94,Inpatient DRG
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH MCC",510,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],89863.76,,"Fee schedule rate ($89,863.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10710.00,89863.76,There are no additional notes associated with this service or procedure.
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],14492.93,,"Fee schedule rate ($14,492.93). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6503.90,14492.93,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],24838.71,,"Fee schedule rate ($24,838.71). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,10895.60,35192.25,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],81524.17,,"Fee schedule rate ($81,524.17). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,8972.00,81524.17,There are no additional notes associated with this service or procedure.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,329,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],86631.74,,"Fee schedule rate ($86,631.74). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (38), with a minimum of zero.",,,,0,other,33072.77,90445.33,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],40737.46,,"Fee schedule rate ($40,737.46). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,7665.00,40737.46,There are no additional notes associated with this service or procedure.
CERVICAL SPINAL FUSION WITHOUT CC/MCC,473,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],62077.11,,"Fee schedule rate ($62,077.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,18477.61,62077.11,There are no additional notes associated with this service or procedure.
Colonoscopy W/Biopsy Single/Multiple|UNUSUAL NON-OVERLAPPING SERVICE,CASE-45380,APC,45380,CPT,0360,RC,,,XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1159.29,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1120.09,1176.09,OPPS APC
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],12882.42,,"Case rate ($12,268.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,549.17, add-ons for qualifying new technology services are included. If operating cost exceeds $46,420.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,515.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,568.94 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,604.22 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $755.08. The transfer capital threshold is the transfer adjustment factor * $755.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12268.97,41006.47,Inpatient DRG
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],15114.43,,"Case rate ($14,603.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,720.75, add-ons for qualifying new technology services are included. If operating cost exceeds $48,591.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,685.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $11,732.54 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,775.80 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $925.81. The transfer capital threshold is the transfer adjustment factor * $925.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,14603.31,45017.13,Inpatient DRG
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC,797,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],20928.55,,"Fee schedule rate ($20,928.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8719.72,20928.55,There are no additional notes associated with this service or procedure.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,479,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],15260.23,,"Case rate ($14,533.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,655.86, add-ons for qualifying new technology services are included. If operating cost exceeds $48,526.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,680.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $11,667.89 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,710.91 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $920.71. The transfer capital threshold is the transfer adjustment factor * $920.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10586.00,50518.76,Inpatient DRG
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],32168.63,,"Fee schedule rate ($32,168.63). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,13904.43,34749.58,There are no additional notes associated with this service or procedure.
SPINAL PROCEDURES WITH MCC,028,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],112913.98,,"Fee schedule rate ($112,913.98). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,42633.57,120982.83,There are no additional notes associated with this service or procedure.
PREMATURITY WITHOUT MAJOR PROBLEMS,792,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],1956.00,,,,,,0,other,1956.00,19457.66,Estimated amount calculated based on 3 day length of stay.
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],6066.84,,"Case rate ($5,777.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,510.70, add-ons for qualifying new technology services are included. If operating cost exceeds $40,381.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,040.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $3,552.65 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,565.75 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $280.34. The transfer capital threshold is the transfer adjustment factor * $280.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5065.00,12558.65,Inpatient DRG
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],9024.75,,"Fee schedule rate ($9,024.75). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7875.94,17233.12,There are no additional notes associated with this service or procedure.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC,858,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],11775.98,,"Case rate ($11,377.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,720.10, add-ons for qualifying new technology services are included. If operating cost exceeds $45,591.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,449.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $8,742.91 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,775.15 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $689.90. The transfer capital threshold is the transfer adjustment factor * $689.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,11377.76,33794.11,Inpatient DRG
PREMATURITY WITH MAJOR PROBLEMS,791,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],3186.77,,,,,,0,other,3048.21,30904.42,Estimated amount calculated based on 5 day length of stay.
Rpr Nonunion Scaphoid Carpal Bne W/WO Rdl Stylec|RIGHT SIDE,CASE-25440,APC,25440,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7029.71,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6791.99,7029.71,OPPS APC
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC",061,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],21647.04,,"Case rate ($20,616.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $19,314.45, add-ons for qualifying new technology services are included. If operating cost exceeds $54,185.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,125.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $17,305.68 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $17,369.49 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,365.59. The transfer capital threshold is the transfer adjustment factor * $1,365.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,20616.23,62315.82,Inpatient DRG
Ercp Stent Placement Biliary/Pancreatic Duct,CASE-43274,APC,43274,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5881.39,,"APC Price ($5,682.51). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5682.51,5966.63,OPPS APC
GASTROINTESTINAL HEMORRHAGE WITH MCC,377,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],14610.78,,"Case rate ($14,324.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,461.19, add-ons for qualifying new technology services are included. If operating cost exceeds $48,332.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,665.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $11,473.94 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,516.24 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $905.41. The transfer capital threshold is the transfer adjustment factor * $905.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,7634.00,35969.56,Inpatient DRG
Colon Ca Scrn Not Hi Rsk Ind|DOCUMENTATION ON FILE,CASE-G0121,APC,G0121,CPT,0360,RC,,,KX,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],913.99,,"APC Price ($870.46). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,870.46,913.99,OPPS APC
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],2070.00,,,,,,0,other,1188.00,34338.33,Estimated amount calculated based on 6 day length of stay.
Cysto W/Insert Ureteral Stent|RIGHT SIDE,CASE-52332,APC,52332,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3464.44,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3299.47,3464.44,OPPS APC
Laps Vaginal Hysterect > 250 Gm Rmvl Tube&/Ovar,CASE-58554,APC,58554,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],9949.78,,"APC Price ($9,949.78). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,9949.78,10447.27,OPPS APC
NERVOUS SYSTEM NEOPLASMS WITH MCC,054,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],30044.81,,,,,,0,other,6965.00,30044.81,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],85305.59,,"Fee schedule rate ($85,305.59). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,21719.40,85305.59,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,093,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],7484.30,,"Case rate ($7,337.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,961.57, add-ons for qualifying new technology services are included. If operating cost exceeds $41,832.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,154.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,998.19 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,016.62 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $394.41. The transfer capital threshold is the transfer adjustment factor * $394.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6965.00,19011.32,Inpatient DRG
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],142438.06,,"Fee schedule rate ($142,438.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (40), with a minimum of zero.",,,,0,other,45521.20,142438.06,There are no additional notes associated with this service or procedure.
CERVICAL SPINAL FUSION WITHOUT CC/MCC,473,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],45879.35,,"Fee schedule rate ($45,879.35). Adds an outlier to normal pricing equal to the per diem rate ($58,401.78) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,18477.61,62077.11,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],22479.58,,"Case rate ($21,719.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,340.70, add-ons for qualifying new technology services are included. If operating cost exceeds $55,211.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,206.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.2. The base transfer operating payment is the transfer adjustment factor * $18,328.17 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,395.75 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,446.27. The transfer capital threshold is the transfer adjustment factor * $1,446.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,21719.40,85305.59,Inpatient DRG
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],25016.57,,"Case rate ($14,295.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,434.11, add-ons for qualifying new technology services are included. If operating cost exceeds $48,305.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,663.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $11,446.95 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,489.15 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $903.28. The transfer capital threshold is the transfer adjustment factor * $903.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,14295.18,42768.36,All Other Inpatient
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],6965.00,,,,,,0,other,6965.00,29482.05,There are no additional notes associated with this service or procedure.
VENTRICULAR SHUNT PROCEDURES WITH CC,032,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],41931.69,,,,,,0,other,16376.22,46275.08,There are no additional notes associated with this service or procedure.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],17223.78,,"Fee schedule rate ($17,223.78). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,8151.55,18033.97,There are no additional notes associated with this service or procedure.
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITH MCC,429,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],169317.41,,"Fee schedule rate ($169,317.41). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,62958.58,177294.98,There are no additional notes associated with this service or procedure.
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],15940.79,,"Case rate ($15,940.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,964.98, add-ons for qualifying new technology services are included. If operating cost exceeds $49,835.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,783.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $12,972.20 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,020.03 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,023.63. The transfer capital threshold is the transfer adjustment factor * $1,023.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,15940.79,53275.26,Inpatient DRG
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],8314.58,,"Case rate ($8,151.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,718.82, add-ons for qualifying new technology services are included. If operating cost exceeds $42,589.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,213.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,752.66 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,773.87 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $453.94. The transfer capital threshold is the transfer adjustment factor * $453.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,8151.55,18033.97,Inpatient DRG
"CHOLECYSTECTOMY,MAJOR",263,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],21727.85,,"Case rate ($20,693.19). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,20693.19,21727.85,There are no additional notes associated with this service or procedure.
Unlisted Procedure Hemic or Lymphatic System,CASE-38999,APC,38999,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],13544.27,,"APC Price ($12,899.30). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,12899.30,13544.27,OPPS APC
OTHER CEREBROVASCULAR DISORDERS WITH MCC,070,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],13880.04,,"Case rate ($13,219.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,433.04, add-ons for qualifying new technology services are included. If operating cost exceeds $47,304.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,584.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $10,449.57 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,488.10 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $824.57. The transfer capital threshold is the transfer adjustment factor * $824.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13219.09,37774.46,Inpatient DRG
GASTROINTESTINAL HEMORRHAGE WITH CC,378,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],20845.19,,"Fee schedule rate ($20,845.19). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8586.33,20845.19,There are no additional notes associated with this service or procedure.
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],25099.93,,"Fee schedule rate ($25,099.93). Adds an outlier to normal pricing equal to the per diem rate ($40,783.87) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10989.72,26280.60,There are no additional notes associated with this service or procedure.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC",156,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],6956.38,,"Case rate ($6,625.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,298.82, add-ons for qualifying new technology services are included. If operating cost exceeds $41,169.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,102.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $4,337.88 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,353.87 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $342.30. The transfer capital threshold is the transfer adjustment factor * $342.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6625.12,13598.77,Inpatient DRG
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6688.49,,"Case rate ($6,369.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,069.73, add-ons for qualifying new technology services are included. If operating cost exceeds $40,940.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,075.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $4,109.20 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,124.78 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $315.84. The transfer capital threshold is the transfer adjustment factor * $315.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6503.90,14492.93,Inpatient DRG
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],10300.50,,"Fee schedule rate ($10,300.50). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8859.23,20090.22,There are no additional notes associated with this service or procedure.
HC Inj Anes/Steroid C/D Facet Sg|RIGHT SIDE,CASE-64490,APC,64490,CPT,0361,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],856.86,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,827.89,869.28,OPPS APC
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],12527.66,,"Case rate ($12,527.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,789.82, add-ons for qualifying new technology services are included. If operating cost exceeds $46,660.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,533.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $9,808.71 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,844.88 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $774.00. The transfer capital threshold is the transfer adjustment factor * $774.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12527.66,29917.96,Inpatient DRG
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,025,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],50785.35,,"Fee schedule rate ($50,785.35). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,13351.00,91631.33,There are no additional notes associated with this service or procedure.
"Tendon Sheath Incision|LEFT HAND, THIRD DIGIT",CASE-26055,APC,26055,CPT,0360,RC,,,F2,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1827.80,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1827.80,1919.19,OPPS APC
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],6524.61,,"Fee schedule rate ($6,524.61). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5628.97,12272.58,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,448,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],32197.15,,"Case rate ($30,663.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $28,661.63, add-ons for qualifying new technology services are included. If operating cost exceeds $63,532.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,860.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $26,618.53 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $26,716.68 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,100.47. The transfer capital threshold is the transfer adjustment factor * $2,100.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,30663.95,94077.13,Inpatient DRG
NEONATE WITH OTHER SIGNIFICANT PROBLEMS,794,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],2074.00,,,,,,0,other,1798.85,12536.83,Estimated amount calculated based on 2 day length of stay.
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC,832,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],7173.26,,"Case rate ($6,831.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,490.97, add-ons for qualifying new technology services are included. If operating cost exceeds $41,361.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,117.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $4,529.32 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,546.02 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $357.41. The transfer capital threshold is the transfer adjustment factor * $357.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,4803.31,14198.92,Inpatient DRG
"NEONATE BIRTH WEIGHT 2000-2499 GRAMS NORMAL NEWBORN OR NEONATE WITH OTHER PROBLEM,MODERATE",626,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],2489.89,,"Case rate ($2,489.89). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,2489.89,2614.38,There are no additional notes associated with this service or procedure.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC",494,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],15533.10,,"Case rate ($15,533.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,585.72, add-ons for qualifying new technology services are included. If operating cost exceeds $49,456.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,753.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $12,594.34 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,640.78 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $993.82. The transfer capital threshold is the transfer adjustment factor * $993.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,15533.10,39945.55,Inpatient DRG
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7187.14,,"Case rate ($6,944.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,595.55, add-ons for qualifying new technology services are included. If operating cost exceeds $41,466.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,125.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,633.51 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,650.60 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $365.63. The transfer capital threshold is the transfer adjustment factor * $365.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,5068.21,14525.56,Inpatient DRG
VENTRICULAR SHUNT PROCEDURES WITH CC,032,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],46275.08,,"Fee schedule rate ($46,275.08). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,16376.22,46275.08,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITHOUT STERILIZATION WITH CC,787,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],23722.94,,"Fee schedule rate ($23,722.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9508.01,23722.94,There are no additional notes associated with this service or procedure.
Excision Choledochal Cyst,CASE-47715,APC,47715,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],301.68,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,287.31,301.68,OPPS APC
Anrct Xm Surg Req Anes General Spi/Edrl Dx|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-45990,APC,45990,CPT,0360,RC,,,74,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],2689.02,,"APC Price ($2,598.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2598.08,2727.99,OPPS APC
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],30236.06,,"Fee schedule rate ($30,236.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.8), with a minimum of zero.",,,,0,other,1188.00,31658.33,There are no additional notes associated with this service or procedure.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],29837.65,,"Fee schedule rate ($29,837.65). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,12696.97,47123.82,There are no additional notes associated with this service or procedure.
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 1 Level,CASE-64493,APC,64493,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],856.86,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,827.89,869.28,OPPS APC
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],26776.27,,"Fee schedule rate ($26,776.27). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,11593.79,38248.08,There are no additional notes associated with this service or procedure.
Intraop Sentinel Lymph Node ID W/Dye Injection|RIGHT SIDE,CASE-38900,APC,38900,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6432.89,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6215.36,6526.12,OPPS APC
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5825.98,,"Case rate ($5,628.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,372.11, add-ons for qualifying new technology services are included. If operating cost exceeds $40,243.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,029.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,414.56 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,427.15 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $269.44. The transfer capital threshold is the transfer adjustment factor * $269.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,5628.97,12272.58,Inpatient DRG
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],36776.05,,"Fee schedule rate ($36,776.05). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11053.39,36776.05,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,065,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],25681.86,,"Fee schedule rate ($25,681.86). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,8786.76,25681.86,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,085,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],17330.41,,"Case rate ($17,330.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,257.72, add-ons for qualifying new technology services are included. If operating cost exceeds $51,128.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,885.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $14,260.20 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,312.77 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,125.27. The transfer capital threshold is the transfer adjustment factor * $1,125.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9282.00,57443.16,Inpatient DRG
Dstr Nrolytc Agnt Parverteb Fct Sngl Lmbr/Sacral|RIGHT SIDE,CASE-64635,APC,64635,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1919.19,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1827.80,1919.19,OPPS APC
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,097,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],79915.74,,"Fee schedule rate ($79,915.74). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,26404.32,79915.74,There are no additional notes associated with this service or procedure.
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],9533.13,,"Fee schedule rate ($9,533.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5068.21,14525.56,There are no additional notes associated with this service or procedure.
MAJOR BLADDER PROCEDURES WITH MCC,653,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],125343.98,,"Fee schedule rate ($125,343.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,10280.00,125343.98,There are no additional notes associated with this service or procedure.
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],5791.49,,"Fee schedule rate ($5,791.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,3079.00,10940.41,There are no additional notes associated with this service or procedure.
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],8480.00,,"Per diem ($8,480). If length of stay < 5.5, first 1 days paid at a per diem of $16,960 instead. Capped at $46,638.59.",,,,0,other,8480.00,59081.91,Estimated amount calculated based on 3 day length of stay.
"Arthrodesis Interphalangeal Jt W/WO Int Fixj|RIGHT HAND, FIFTH DIGIT",CASE-26860,APC,26860,CPT,0360,RC,,,F9,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3062.67,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
DIABETES WITHOUT CC/MCC,639,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],11899.36,,"Fee schedule rate ($11,899.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6151.76,12223.35,There are no additional notes associated with this service or procedure.
MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,708,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],11081.24,,"Case rate ($11,081.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $10,413.93, add-ons for qualifying new technology services are included. If operating cost exceeds $49,058.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $3,436.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.3. The base transfer operating payment is the transfer adjustment factor * $9,014.04 + an uncompensated DSH payment of $1,359.91. The transfer operating threshold is the transfer adjustment factor * $9,054.03 + an uncompensated DSH payment of $1,359.91. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $707.29. The transfer capital threshold is the transfer adjustment factor * $707.29. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10138.21,29171.15,Inpatient DRG
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],25026.36,,"Fee schedule rate ($25,026.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9356.31,25026.36,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],17651.07,,"Fee schedule rate ($17,651.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,6564.18,17651.07,There are no additional notes associated with this service or procedure.
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,068,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],7798.73,,"Case rate ($7,798.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,390.60, add-ons for qualifying new technology services are included. If operating cost exceeds $42,261.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,188.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $5,425.64 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,445.65 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $428.14. The transfer capital threshold is the transfer adjustment factor * $428.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,23184.90,Inpatient DRG
HC Perq Vert Agmntj Cavity Crtj Uni/Bi Cannulation,CASE-22513,APC,22513,CPT,0361,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7029.71,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6791.99,7131.59,OPPS APC
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,479,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],15042.22,,"Case rate ($14,533.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,655.86, add-ons for qualifying new technology services are included. If operating cost exceeds $48,526.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,680.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $11,667.89 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,710.91 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $920.71. The transfer capital threshold is the transfer adjustment factor * $920.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,10586.00,50518.76,Inpatient DRG
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],21851.78,,"Case rate ($20,811.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $19,531.04, add-ons for qualifying new technology services are included. If operating cost exceeds $54,402.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,106.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6)) / 2. The base transfer operating payment is the transfer adjustment factor * $17,519.66 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $17,586.09 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,346.60. The transfer capital threshold is the transfer adjustment factor * $1,346.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,21382.16,85466.62,Inpatient DRG
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,065,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],25681.86,,"Fee schedule rate ($25,681.86). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,8786.76,25681.86,There are no additional notes associated with this service or procedure.
Total Thyroid Lobectomy Uni W/WO Isthmusectomy|RIGHT SIDE,CASE-60220,APC,60220,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5856.81,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5658.76,5941.70,OPPS APC
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC,434,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],14019.86,,,,,,0,other,6770.05,14019.86,There are no additional notes associated with this service or procedure.
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],15244.88,,"Fee schedule rate ($15,244.88). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,7438.45,15961.98,There are no additional notes associated with this service or procedure.
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral Ea Addl|LEFT SIDE,CASE-64484,APC,64484,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],856.86,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,827.89,869.28,OPPS APC
HC Joint Injection/Aspir Large WO US|SEPARATE STRUCTURE|LEFT SIDE,CASE-20610,APC,20610,CPT,0510,RC,,,XS|LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
"Arthrodesis Great Toe Metatarsophalangeal Joint|RIGHT FOOT, GREAT TOE",CASE-28750,APC,28750,CPT,0360,RC,,,T5,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],16035.06,,"Fee schedule rate ($16,035.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,7396.47,16035.06,There are no additional notes associated with this service or procedure.
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],13110.79,,,,,,0,other,5139.72,13110.79,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],40542.37,,"Case rate ($40,542.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $37,851.31, add-ons for qualifying new technology services are included. If operating cost exceeds $72,722.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,582.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.6. The base transfer operating payment is the transfer adjustment factor * $35,774.45 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $35,906.36 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,822.96. The transfer capital threshold is the transfer adjustment factor * $2,822.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,40542.37,128358.13,Inpatient DRG
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],29243.52,,"Fee schedule rate ($29,243.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,14343.25,36024.65,There are no additional notes associated with this service or procedure.
Cystourethroscopy With Biopsy,CASE-52204,APC,52204,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1956.65,,"APC Price ($1,956.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1956.65,2054.48,OPPS APC
TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC,087,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],22679.07,,"Fee schedule rate ($22,679.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,8139.36,22679.07,There are no additional notes associated with this service or procedure.
RADIOTHERAPY,849,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],81867.07,,"Fee schedule rate ($81,867.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,20293.88,81867.07,There are no additional notes associated with this service or procedure.
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC,939,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],97674.79,,"Fee schedule rate ($97,674.79). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,26517.40,97674.79,There are no additional notes associated with this service or procedure.
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],22686.91,,"Fee schedule rate ($22,686.91). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,10120.20,26204.74,There are no additional notes associated with this service or procedure.
PERITONEAL ADHESIOLYSIS WITH CC,336,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],53705.31,,"Fee schedule rate ($53,705.31). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,16225.22,53705.31,There are no additional notes associated with this service or procedure.
Rpr Ingun Hernia Sliding Any Age|RIGHT SIDE,CASE-49525,APC,49525,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3351.34,,"APC Price ($3,351.34). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3351.34,3518.91,OPPS APC
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",759,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],12471.03,,"Fee schedule rate ($12,471.03). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.9), with a minimum of zero.",,,,0,other,6190.22,13057.66,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],70242.60,,"Fee schedule rate ($70,242.60). Adds an outlier to normal pricing equal to the per diem rate ($137,416) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16.5), with a minimum of zero.",,,,0,other,27256.92,81353.66,There are no additional notes associated with this service or procedure.
"POISONING OF MEDICINAL AGENTS,MAJOR",812,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],9289.68,,"Case rate ($9,289.68). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,9289.68,9754.16,There are no additional notes associated with this service or procedure.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],19144.64,,"Case rate ($18,497.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,343.20, add-ons for qualifying new technology services are included. If operating cost exceeds $52,214.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,970.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $15,341.68 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,398.25 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,210.61. The transfer capital threshold is the transfer adjustment factor * $1,210.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,18497.24,62041.12,Inpatient DRG
GASTROINTESTINAL OBSTRUCTION WITH CC,389,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],5118.00,,"Per diem ($5,118). If length of stay < 2.9, first 1 days paid at a per diem of $10,236 instead. Capped at $14,842.71.",,,,0,other,5118.00,16423.43,Estimated amount calculated based on 2 day length of stay.
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC,831,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],6965.00,,,,,,0,other,4941.30,23661.59,There are no additional notes associated with this service or procedure.
Arthrs Knee Abrasion Arthrp/Mlt Drlg/Microfx|LEFT SIDE,CASE-29879,APC,29879,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],80635.65,,"Fee schedule rate ($80,635.65). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,26028.48,80635.65,There are no additional notes associated with this service or procedure.
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],8218.58,,"Case rate ($8,057.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,631.26, add-ons for qualifying new technology services are included. If operating cost exceeds $42,502.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,207.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,665.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,686.30 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $447.06. The transfer capital threshold is the transfer adjustment factor * $447.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6524.00,17760.46,Inpatient DRG
Unlisted Px Female Genital System Nonobstetrical,CASE-58999,APC,58999,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],189.24,,"APC Price ($189.24). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,189.24,198.70,OPPS APC
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],16804.22,,"Fee schedule rate ($16,804.22). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7238.69,16804.22,There are no additional notes associated with this service or procedure.
"EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME, NEONATE",790,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],42194.75,,"Case rate ($42,194.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $39,388.49, add-ons for qualifying new technology services are included. If operating cost exceeds $74,259.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,703.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 17.9. The base transfer operating payment is the transfer adjustment factor * $37,305.99 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $37,443.54 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,943.81. The transfer capital threshold is the transfer adjustment factor * $2,943.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,3054.00,44304.49,Inpatient DRG
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC",011,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],150008.48,,"Fee schedule rate ($150,008.48). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (44), with a minimum of zero.",,,,0,other,38880.49,150008.48,There are no additional notes associated with this service or procedure.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,057,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],25493.52,,,,,,0,other,10718.84,39884.93,There are no additional notes associated with this service or procedure.
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],10181.78,,"Case rate ($9,696.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,156.46, add-ons for qualifying new technology services are included. If operating cost exceeds $44,027.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,326.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $7,185.02 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,211.51 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $566.97. The transfer capital threshold is the transfer adjustment factor * $566.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9696.93,35061.53,Inpatient DRG
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],59021.28,,"Fee schedule rate ($59,021.28). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,23851.92,63653.13,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC,831,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],9294.42,,"Fee schedule rate ($9,294.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,4941.30,23661.59,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH CC,427,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],51846.42,,"Case rate ($50,829.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $47,421.51, add-ons for qualifying new technology services are included. If operating cost exceeds $82,292.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $5,335.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $45,309.50 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $45,476.56 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,575.37. The transfer capital threshold is the transfer adjustment factor * $3,575.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,50829.82,142040.39,Inpatient DRG
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],32293.66,,"Fee schedule rate ($32,293.66). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,32293.66,There are no additional notes associated with this service or procedure.
Optx Dstl Radl I-Artic Fx/Epiphysl Sep 3 Frag|RIGHT SIDE,CASE-25609,APC,25609,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],9529.80,,"Fee schedule rate ($9,529.80). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8554.50,19204.75,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL HEMORRHAGE WITH CC,378,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],20845.19,,"Fee schedule rate ($20,845.19). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8586.33,20845.19,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],18366.40,,"Fee schedule rate ($18,366.40). Adds an outlier to normal pricing equal to the per diem rate ($38,964.32) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.5), with a minimum of zero.",,,,0,other,8563.30,31533.97,There are no additional notes associated with this service or procedure.
Surgical Arthroscopy Shoulder Repair Slap Lesion|RIGHT SIDE,CASE-29807,APC,29807,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,394,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],20909.61,,"Fee schedule rate ($20,909.61). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8281.56,20909.61,There are no additional notes associated with this service or procedure.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],16447.34,,"Case rate ($16,447.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,436.22, add-ons for qualifying new technology services are included. If operating cost exceeds $50,307.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,820.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $13,441.70 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,491.27 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,060.68. The transfer capital threshold is the transfer adjustment factor * $1,060.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7453.00,42138.30,Inpatient DRG
"ASTHMA,MAJOR",141,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],8881.55,,"Case rate ($8,458.62). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8458.62,8881.55,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],38378.80,,"Fee schedule rate ($38,378.80). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,14370.36,38378.80,There are no additional notes associated with this service or procedure.
BRONCHITIS AND ASTHMA WITH CC/MCC,202,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],14307.27,,"Fee schedule rate ($14,307.27). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7606.34,19110.30,There are no additional notes associated with this service or procedure.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],11053.39,,"Case rate ($11,053.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,418.34, add-ons for qualifying new technology services are included. If operating cost exceeds $45,289.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,426.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $8,442.26 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,473.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $666.18. The transfer capital threshold is the transfer adjustment factor * $666.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,11053.39,36776.05,Inpatient DRG
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],81353.66,,"Fee schedule rate ($81,353.66). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,27256.92,81353.66,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITHOUT STERILIZATION WITH CC,787,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],9508.01,,"Case rate ($9,508.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,980.70, add-ons for qualifying new technology services are included. If operating cost exceeds $43,851.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,313.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $7,009.90 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,035.74 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $553.15. The transfer capital threshold is the transfer adjustment factor * $553.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9508.01,23722.94,Inpatient DRG
INFLAMMATORY BOWEL DISEASE WITH MCC,385,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],29736.16,,"Fee schedule rate ($29,736.16). Adds an outlier to normal pricing equal to the per diem rate ($112,108.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.5), with a minimum of zero.",,,,0,other,11480.01,31134.92,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,426,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],207121.41,,"Fee schedule rate ($207,121.41). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,76581.29,216864.15,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,699,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],19570.20,,"Fee schedule rate ($19,570.20). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5961.00,19972.16,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC,087,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],17998.55,,,,,,0,other,8139.36,22679.07,There are no additional notes associated with this service or procedure.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC,099,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],25603.58,,"Fee schedule rate ($25,603.58). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.7), with a minimum of zero.",,,,0,other,11171.21,26807.94,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],23899.13,,"Fee schedule rate ($23,899.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9795.13,23899.13,There are no additional notes associated with this service or procedure.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],28035.79,,,,,,0,other,11593.79,38248.08,There are no additional notes associated with this service or procedure.
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],18045.04,,"Fee schedule rate ($18,045.04). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,1188.00,18893.86,There are no additional notes associated with this service or procedure.
SPINAL PROCEDURES WITH MCC,028,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],120982.83,,"Fee schedule rate ($120,982.83). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,42633.57,120982.83,There are no additional notes associated with this service or procedure.
"NEONATE BIRTH WEIGHT > 2499 GRAMS WITH OTHER SIGNIFICANT CONDITION,MAJOR",639,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],16816.37,,"Case rate ($16,816.37). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,16816.37,17657.19,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],19371.27,,"Fee schedule rate ($19,371.27). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7641.61,19371.27,There are no additional notes associated with this service or procedure.
"KIDNEY AND URINARY TRACT INFECTIONS,MINOR",463,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],1826.40,,"Case rate for a one day stay ($1,739.43). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,1739.43,1826.40,There are no additional notes associated with this service or procedure.
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],10078.00,,"Per diem ($10,078). If length of stay < 7.2, first 1 days paid at a per diem of $20,156 instead. Capped at $72,563.53.",,,,0,other,10078.00,81454.07,Estimated amount calculated based on 15 day length of stay.
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],16431.59,,"Case rate ($9,389.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,870.44, add-ons for qualifying new technology services are included. If operating cost exceeds $43,741.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,304.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,900.05 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,925.50 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $544.48. The transfer capital threshold is the transfer adjustment factor * $544.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,9389.48,22358.90,All Other Inpatient
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],23267.34,,"Case rate ($13,295.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,504.24, add-ons for qualifying new technology services are included. If operating cost exceeds $47,375.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,590.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $10,520.50 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,559.29 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $830.17. The transfer capital threshold is the transfer adjustment factor * $830.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,7000.00,33835.79,All Other Inpatient
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],23216.87,,"Fee schedule rate ($23,216.87). Adds an outlier to normal pricing equal to the per diem rate ($51,531) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.7), with a minimum of zero.",,,,0,other,10311.17,24308.97,There are no additional notes associated with this service or procedure.
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],7888.39,,"Case rate ($7,733.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,330.12, add-ons for qualifying new technology services are included. If operating cost exceeds $42,201.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,183.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,365.38 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,385.17 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $423.38. The transfer capital threshold is the transfer adjustment factor * $423.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,7733.72,18043.23,Inpatient DRG
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],7868.00,,"Per diem ($7,868). If length of stay < 3.9, first 1 days paid at a per diem of $15,736 instead. Capped at $30,683.33.",,,,0,other,7868.00,32126.64,Estimated amount calculated based on 3 day length of stay.
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],17575.50,,,,,,0,other,5415.00,17575.50,There are no additional notes associated with this service or procedure.
SEIZURES WITH MCC,100,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],32323.98,,"Fee schedule rate ($32,323.98). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,15061.09,38110.41,There are no additional notes associated with this service or procedure.
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITHOUT MCC,430,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],133156.90,,"Fee schedule rate ($133,156.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,41000.16,133156.90,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],21220.66,,"Case rate ($12,126.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,416.25, add-ons for qualifying new technology services are included. If operating cost exceeds $46,287.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,504.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $9,436.50 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,471.29 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $744.63. The transfer capital threshold is the transfer adjustment factor * $744.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,12126.09,29582.40,All Other Inpatient
Esophageal Motility Study W/Interp&Rpt,CASE-91010,APC,91010,CPT,0750,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],349.28,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,349.28,366.75,OPPS APC
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],11194.25,,"Case rate ($11,194.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,549.37, add-ons for qualifying new technology services are included. If operating cost exceeds $45,420.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,436.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $8,572.81 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,604.42 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $676.48. The transfer capital threshold is the transfer adjustment factor * $676.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,11194.25,36094.03,Inpatient DRG
ALLERGIC REACTIONS WITH MCC,915,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],27385.01,,"Fee schedule rate ($27,385.01). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,13332.86,33088.84,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC,084,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],8417.70,,"Case rate ($8,417.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,966.41, add-ons for qualifying new technology services are included. If operating cost exceeds $42,837.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,233.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $5,999.34 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,021.46 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $473.41. The transfer capital threshold is the transfer adjustment factor * $473.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,19445.16,Inpatient DRG
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],58320.32,,"Fee schedule rate ($58,320.32). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,16286.16,58320.32,There are no additional notes associated with this service or procedure.
NERVOUS SYSTEM NEOPLASMS WITH MCC,054,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],25589.03,,"Fee schedule rate ($25,589.03). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,6965.00,30044.81,There are no additional notes associated with this service or procedure.
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],16055.90,,"Fee schedule rate ($16,055.90). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8163.06,18067.42,There are no additional notes associated with this service or procedure.
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],6965.00,,,,,,0,other,5139.72,13110.79,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC,833,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],5721.39,,"Fee schedule rate ($5,721.39). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,3041.73,10289.10,There are no additional notes associated with this service or procedure.
Vag Hyst 250 Gm/< W/Rmvl Tube&/Ovary,CASE-58262,APC,58262,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],4846.30,,"APC Price ($4,682.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,4846.30,4846.30,OPPS APC
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],23216.87,,"Fee schedule rate ($23,216.87). Adds an outlier to normal pricing equal to the per diem rate ($51,531) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.7), with a minimum of zero.",,,,0,other,10311.17,24308.97,There are no additional notes associated with this service or procedure.
CHOLECYSTECTOMY WITH C.D.E. WITH MCC,411,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],25530.89,,"Case rate ($24,315.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $22,755.46, add-ons for qualifying new technology services are included. If operating cost exceeds $57,626.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,396.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $20,734.06 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $20,810.51 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,636.12. The transfer capital threshold is the transfer adjustment factor * $1,636.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,24315.13,88615.28,Inpatient DRG
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],10078.00,,"Per diem ($10,078). If length of stay < 7.2, first 1 days paid at a per diem of $20,156 instead. Capped at $72,563.53.",,,,0,other,10078.00,81454.07,Estimated amount calculated based on 15 day length of stay.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC,858,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],26176.77,,"Fee schedule rate ($26,176.77). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11377.76,33794.11,There are no additional notes associated with this service or procedure.
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],16393.83,,"Case rate ($15,613.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,685.70, add-ons for qualifying new technology services are included. If operating cost exceeds $49,556.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,735.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $12,692.63 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,740.75 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $975.59. The transfer capital threshold is the transfer adjustment factor * $975.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,11165.00,61234.06,Inpatient DRG
RADIOTHERAPY,849,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],50919.63,,"Fee schedule rate ($50,919.63). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15.8), with a minimum of zero.",,,,0,other,20293.88,81867.07,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],14337.84,,"Case rate ($14,337.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,473.80, add-ons for qualifying new technology services are included. If operating cost exceeds $48,344.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,666.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $11,486.49 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,528.84 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $906.40. The transfer capital threshold is the transfer adjustment factor * $906.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,14337.84,52803.53,Inpatient DRG
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC,434,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],7108.55,,"Case rate ($6,770.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,433.64, add-ons for qualifying new technology services are included. If operating cost exceeds $41,304.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,112.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,472.20 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,488.69 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $352.90. The transfer capital threshold is the transfer adjustment factor * $352.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6770.05,14019.86,Inpatient DRG
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,097,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],79915.74,,"Fee schedule rate ($79,915.74). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,26404.32,79915.74,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],13148.66,,"Case rate ($13,148.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,367.53, add-ons for qualifying new technology services are included. If operating cost exceeds $47,238.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,579.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $10,384.29 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,422.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $819.42. The transfer capital threshold is the transfer adjustment factor * $819.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,13148.66,32553.63,Inpatient DRG
Cysto W/Urtroscopy&/Pyeloscopy Dx|RIGHT SIDE,CASE-52351,APC,52351,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3299.47,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3299.47,3464.44,OPPS APC
FULL TERM NEONATE WITH MAJOR PROBLEMS,793,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],30181.78,,"Case rate ($30,181.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $28,213.07, add-ons for qualifying new technology services are included. If operating cost exceeds $63,084.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,825.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $26,171.62 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $26,268.12 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,065.20. The transfer capital threshold is the transfer adjustment factor * $2,065.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,4302.90,82045.22,Inpatient DRG
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],15839.99,,,,,,0,other,7396.47,16035.06,There are no additional notes associated with this service or procedure.
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC,797,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],9024.91,,"Case rate ($8,719.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,247.38, add-ons for qualifying new technology services are included. If operating cost exceeds $43,118.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,255.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $6,279.28 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,302.43 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $495.50. The transfer capital threshold is the transfer adjustment factor * $495.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,8719.72,20928.55,Inpatient DRG
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],14098.78,,"Case rate ($14,098.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,251.41, add-ons for qualifying new technology services are included. If operating cost exceeds $48,122.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,648.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $11,264.92 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,306.46 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $888.91. The transfer capital threshold is the transfer adjustment factor * $888.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7332.00,35314.31,Inpatient DRG
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],32553.63,,,,,,0,other,13148.66,32553.63,There are no additional notes associated with this service or procedure.
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC",758,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],16323.02,,"Fee schedule rate ($16,323.02). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8574.80,19263.78,There are no additional notes associated with this service or procedure.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],34385.40,,"Fee schedule rate ($34,385.40). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,18497.24,62041.12,There are no additional notes associated with this service or procedure.
Surgical Arthroscopy Shoulder Dstl Claviculc|LEFT SIDE,CASE-29824,APC,29824,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7029.71,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6791.99,7131.59,OPPS APC
PERIPHERAL VASCULAR DISORDERS WITH CC,300,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],20061.53,,"Fee schedule rate ($20,061.53). Adds an outlier to normal pricing equal to the per diem rate ($49,296.97) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.9), with a minimum of zero.",,,,0,other,9174.14,21005.20,There are no additional notes associated with this service or procedure.
HEADACHES WITHOUT MCC,103,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],20883.08,,"Fee schedule rate ($20,883.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,20883.08,There are no additional notes associated with this service or procedure.
Neuroplasty &/Transposition Ulnar Nerve Elbow|UNUSUAL NON-OVERLAPPING SERVICE|LEFT SIDE,CASE-64718,APC,64718,CPT,0360,RC,,,XU|LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|RIGHT HAND, SECOND DIGIT",CASE-26160,APC,26160,CPT,0360,RC,,,F6,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1505.12,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1505.12,1557.80,OPPS APC
PSYCHOSES,885,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],2070.00,,,,,,0,other,2070.00,27484.83,Estimated amount calculated based on 3 day length of stay.
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],13486.95,,"Fee schedule rate ($13,486.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6915.64,14442.92,There are no additional notes associated with this service or procedure.
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],22341.11,,"Case rate ($21,277.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $19,965.45, add-ons for qualifying new technology services are included. If operating cost exceeds $54,836.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,139.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. The base transfer operating payment is the transfer adjustment factor * $17,952.43 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,020.50 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,379.87. The transfer capital threshold is the transfer adjustment factor * $1,379.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7086.00,57872.02,Inpatient DRG
Colsc Flx With Directed Submucosal Njx Any Sbst|COLORECTAL CANCER SCREEN,CASE-45381,APC,45381,CPT,0360,RC,,,PT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1159.29,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1120.09,1176.09,OPPS APC
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],12366.99,,,,,,0,other,5937.41,12366.99,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],25609.86,,"Fee schedule rate ($25,609.86). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,12775.53,31469.43,There are no additional notes associated with this service or procedure.
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC,797,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],20928.55,,"Fee schedule rate ($20,928.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8719.72,20928.55,There are no additional notes associated with this service or procedure.
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],14472.38,,"Fee schedule rate ($14,472.38). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7389.00,37134.43,There are no additional notes associated with this service or procedure.
CHEST PAIN,313,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],6965.00,,,,,,0,other,6820.84,15377.66,There are no additional notes associated with this service or procedure.
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC,520,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],28074.86,,"Fee schedule rate ($28,074.86). Adds an outlier to normal pricing equal to the per diem rate ($68,872.56) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,12061.74,39786.42,There are no additional notes associated with this service or procedure.
UNGROUPABLE,999,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],49746.13,,"Case rate ($47,377.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $44,294.44, add-ons for qualifying new technology services are included. If operating cost exceeds $79,165.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $5,002.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 12.7. The base transfer operating payment is the transfer adjustment factor * $42,189.53 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $42,349.49 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,242.79. The transfer capital threshold is the transfer adjustment factor * $3,242.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10228.00,161307.29,Inpatient DRG
Open Tx Carpal Scaphoid Navicular Fracture|LEFT SIDE,CASE-25628,APC,25628,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6791.99,7131.59,OPPS APC
Insj Penile Prosthesos Inflatable Self-Contained,CASE-54401,APC,54401,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],19400.15,,"APC Price ($19,400.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,19400.15,20370.16,OPPS APC
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,094,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],66140.08,,"Fee schedule rate ($66,140.08). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16.5), with a minimum of zero.",,,,0,other,25778.58,67889.44,There are no additional notes associated with this service or procedure.
Open Tx Metacarpal Fracture Single Ea Bone|LEFT SIDE,CASE-26615,APC,26615,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3169.86,3215.80,OPPS APC
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],18918.49,,"Fee schedule rate ($18,918.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9282.47,21320.03,There are no additional notes associated with this service or procedure.
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],16026.80,,"Case rate ($16,026.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,044.99, add-ons for qualifying new technology services are included. If operating cost exceeds $49,916.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,789.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $13,051.92 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,100.04 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,029.93. The transfer capital threshold is the transfer adjustment factor * $1,029.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,11165.00,61234.06,Inpatient DRG
SEIZURES WITH MCC,100,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],36398.28,,"Fee schedule rate ($36,398.28). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,15061.09,38110.41,There are no additional notes associated with this service or procedure.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],14699.43,,"Fee schedule rate ($14,699.43). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6683.37,14699.43,There are no additional notes associated with this service or procedure.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,329,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],86631.74,,"Fee schedule rate ($86,631.74). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (38), with a minimum of zero.",,,,0,other,33072.77,90445.33,There are no additional notes associated with this service or procedure.
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],16458.91,,"Fee schedule rate ($16,458.91). Adds an outlier to normal pricing equal to the per diem rate ($62,521.14) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,7875.94,17233.12,There are no additional notes associated with this service or procedure.
"SICKLE CELL ANEMIA CRISIS,MODERATE",662,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],7675.80,,"Case rate ($7,675.80). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,7675.80,8059.59,There are no additional notes associated with this service or procedure.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],5569.00,,"Per diem ($5,569). If length of stay < 3.8, first 1 days paid at a per diem of $11,138 instead. Capped at $21,162.80.",,,,0,other,5569.00,40108.48,Estimated amount calculated based on 2 day length of stay.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],36776.05,,"Fee schedule rate ($36,776.05). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11053.39,36776.05,There are no additional notes associated with this service or procedure.
HEART FAILURE AND SHOCK WITH CC,292,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],15550.06,,"Fee schedule rate ($15,550.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5502.00,16705.77,There are no additional notes associated with this service or procedure.
Arthroscopy Knee W/Meniscus Rpr Medial/Lateral|RIGHT SIDE,CASE-29882,APC,29882,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7029.71,OPPS APC
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],13141.36,,"Case rate ($12,696.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,947.32, add-ons for qualifying new technology services are included. If operating cost exceeds $46,818.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,546.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,965.63 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,002.37 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $786.39. The transfer capital threshold is the transfer adjustment factor * $786.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,12696.97,47123.82,Inpatient DRG
"NERVOUS SYSTEM MALIGNANCY,MODERATE",041,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],9242.53,,"Case rate ($9,242.53). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,9242.53,9704.66,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],9040.72,,"Case rate ($9,040.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,546, add-ons for qualifying new technology services are included. If operating cost exceeds $43,417.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,278.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,576.80 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,601.05 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $518.97. The transfer capital threshold is the transfer adjustment factor * $518.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9040.72,26966.33,Inpatient DRG
Breast Reduction|RIGHT SIDE,CASE-19318,APC,19318,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6215.36,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6215.36,6526.12,OPPS APC
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],92811.11,,"Fee schedule rate ($92,811.11). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,35389.50,101083.00,There are no additional notes associated with this service or procedure.
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],30236.06,,"Fee schedule rate ($30,236.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.8), with a minimum of zero.",,,,0,other,1188.00,31658.33,There are no additional notes associated with this service or procedure.
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITHOUT CC/MCC",630,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],12420.22,,"Case rate ($11,828.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,139.67, add-ons for qualifying new technology services are included. If operating cost exceeds $46,010.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,482.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $9,160.95 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,194.72 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $722.89. The transfer capital threshold is the transfer adjustment factor * $722.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,11828.78,42541.02,Inpatient DRG
Cystourethroscopy Inj Chemodenervation Bladder|UNUSUAL NON-OVERLAPPING SERVICE,CASE-52287,APC,52287,CPT,0360,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3299.47,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3299.47,3464.44,OPPS APC
UNGROUPABLE,999,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],51189.76,,"Case rate ($48,752.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $45,488.70, add-ons for qualifying new technology services are included. If operating cost exceeds $80,359.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $5,183.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 12.7. The base transfer operating payment is the transfer adjustment factor * $43,383.78 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $43,543.75 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,423.41. The transfer capital threshold is the transfer adjustment factor * $3,423.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10228.00,161307.29,Inpatient DRG
"Amp F/Th 1/2 Jt/Phalanx W/Neurect W/Dir Clsr|LEFT HAND, SECOND DIGIT",CASE-26951,APC,26951,CPT,0360,RC,,,F1,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
GASTROINTESTINAL HEMORRHAGE WITH MCC,377,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],31575.65,,"Fee schedule rate ($31,575.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,7634.00,35969.56,There are no additional notes associated with this service or procedure.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],39820.52,,"Fee schedule rate ($39,820.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,15273.74,39820.52,There are no additional notes associated with this service or procedure.
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],2070.00,,,,,,0,other,1188.00,31658.33,Estimated amount calculated based on 16 day length of stay.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],10953.60,,"Fee schedule rate ($10,953.60). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,8318.14,19763.43,There are no additional notes associated with this service or procedure.
"MAJOR GASTROINTESTINAL AND PERITONEAL INFECTIONS,MAJOR",248,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],11830.94,,"Case rate ($11,267.56). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11267.56,11830.94,There are no additional notes associated with this service or procedure.
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC",758,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],8574.80,,"Case rate ($8,574.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,112.57, add-ons for qualifying new technology services are included. If operating cost exceeds $42,983.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,244.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $6,144.96 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,167.62 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $484.90. The transfer capital threshold is the transfer adjustment factor * $484.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8574.80,19263.78,Inpatient DRG
Brnschsc Tndsc Ebus Dx/Tx Intervention Perph Les,CASE-31654,APC,31654,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6936.25,,"APC Price ($6,605.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6605.95,6936.25,OPPS APC
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH CC,026,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],23000.66,,"Case rate ($23,000.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $21,532.64, add-ons for qualifying new technology services are included. If operating cost exceeds $56,403.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,299.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $19,515.74 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $19,587.69 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,539.98. The transfer capital threshold is the transfer adjustment factor * $1,539.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,23000.66,63202.45,Inpatient DRG
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],22686.91,,"Fee schedule rate ($22,686.91). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,10120.20,26204.74,There are no additional notes associated with this service or procedure.
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],10112.55,,"Fee schedule rate ($10,112.55). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8106.18,18245.94,There are no additional notes associated with this service or procedure.
HYPERTENSION WITHOUT MCC,305,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],17230.49,,"Fee schedule rate ($17,230.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7058.55,17230.49,There are no additional notes associated with this service or procedure.
"Tendon Sheath Incision|LEFT HAND, FIFTH DIGIT",CASE-26055,APC,26055,CPT,0360,RC,,,F4,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1580.37,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1505.12,1580.37,OPPS APC
Rpr Ingun Hernia Sliding Any Age,CASE-49525,APC,49525,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3518.91,,"APC Price ($3,351.34). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3351.34,3518.91,OPPS APC
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],73588.10,,"Fee schedule rate ($73,588.10). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,21585.31,73588.10,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL HEMORRHAGE WITH MCC,377,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],7634.00,,"Per diem ($7,634). If length of stay < 4.5, first 1 days paid at a per diem of $15,268 instead. Capped at $34,353.60.",,,,0,other,7634.00,35969.56,Estimated amount calculated based on 3 day length of stay.
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],14674.80,,"Fee schedule rate ($14,674.80). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6711.00,16865.16,There are no additional notes associated with this service or procedure.
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],11857.25,,"Case rate ($11,292.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,658.34, add-ons for qualifying new technology services are included. If operating cost exceeds $45,529.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,427.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $8,680.48 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,713.39 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $667.20. The transfer capital threshold is the transfer adjustment factor * $667.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,11575.50,48961.48,Inpatient DRG
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC",281,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],23859.35,,"Fee schedule rate ($23,859.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8169.15,23859.35,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],13634.03,,"Case rate ($12,984.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,215.07, add-ons for qualifying new technology services are included. If operating cost exceeds $47,086.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,567.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $10,232.39 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,270.12 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $807.44. The transfer capital threshold is the transfer adjustment factor * $807.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12984.79,32077.45,Inpatient DRG
Cysto W/Urtroscopy&/Pyeloscopy Dx|UNUSUAL NON-OVERLAPPING SERVICE,CASE-52351,APC,52351,CPT,0360,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3299.47,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3299.47,3464.44,OPPS APC
VENTRICULAR SHUNT PROCEDURES WITH CC,032,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],46275.08,,"Fee schedule rate ($46,275.08). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,16376.22,46275.08,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],14871.83,,"Fee schedule rate ($14,871.83). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6558.75,14871.83,There are no additional notes associated with this service or procedure.
"Exc Lesion Eyelid W/O Clsr/W/Simple Dir Closure|UPPER RIGHT, EYELID",CASE-67840,APC,67840,CPT,0360,RC,,,E3,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],965.76,,"APC Price ($933.10). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,965.76,979.76,OPPS APC
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,544,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],23207.64,,"Fee schedule rate ($23,207.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,7055.15,23207.64,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],11268.50,,"Fee schedule rate ($11,268.50). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,6965.00,21195.68,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITHOUT CC/MCC,517,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],28052.31,,"Fee schedule rate ($28,052.31). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,10207.96,29371.86,There are no additional notes associated with this service or procedure.
Anoscopy Dx W/HRA &Chem Agnts Enhancement W/Bx|SEPARATE STRUCTURE,CASE-46607,APC,46607,CPT,0360,RC,,,XS,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],2598.08,,"APC Price ($2,598.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2598.08,2727.99,OPPS APC
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,761,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6011.70,,"Case rate ($5,808.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,539.05, add-ons for qualifying new technology services are included. If operating cost exceeds $40,410.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,042.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $3,580.90 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,594.10 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $282.57. The transfer capital threshold is the transfer adjustment factor * $282.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,5808.41,11946.72,Inpatient DRG
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],6834.39,,"Case rate ($6,834.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,493.49, add-ons for qualifying new technology services are included. If operating cost exceeds $41,364.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,117.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $4,531.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,548.54 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $357.61. The transfer capital threshold is the transfer adjustment factor * $357.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6834.39,21354.82,Inpatient DRG
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],54180.83,,"Fee schedule rate ($54,180.83). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,15491.11,54180.83,There are no additional notes associated with this service or procedure.
"EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME, NEONATE",790,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],43671.57,,"Case rate ($42,194.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $39,388.49, add-ons for qualifying new technology services are included. If operating cost exceeds $74,259.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,703.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 17.9. The base transfer operating payment is the transfer adjustment factor * $37,305.99 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $37,443.54 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,943.81. The transfer capital threshold is the transfer adjustment factor * $2,943.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,3054.00,44304.49,Inpatient DRG
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],61290.90,,"Fee schedule rate ($61,290.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,23799.09,63499.65,There are no additional notes associated with this service or procedure.
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 1 Level|BILATERAL PROCEDURE,CASE-64493,APC,64493,CPT,0360,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],856.86,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,827.89,869.28,OPPS APC
"NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY",789,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],6373.62,,,,,,0,other,3054.00,14857.05,Estimated amount calculated based on 1 day length of stay.
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],22358.90,,"Fee schedule rate ($22,358.90). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9389.48,22358.90,There are no additional notes associated with this service or procedure.
TRAUMATIC INJURY WITH MCC,913,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],32164.02,,,,,,0,other,13014.58,42838.46,There are no additional notes associated with this service or procedure.
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],27222.08,,"Fee schedule rate ($27,222.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7389.00,37134.43,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,086,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],30728.81,,"Fee schedule rate ($30,728.81). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8442.00,30728.81,There are no additional notes associated with this service or procedure.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,056,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],17677.14,,"Case rate ($17,677.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,580.28, add-ons for qualifying new technology services are included. If operating cost exceeds $51,451.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,910.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $14,581.57 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,635.33 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,150.63. The transfer capital threshold is the transfer adjustment factor * $1,150.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7659.00,59328.19,Inpatient DRG
"Prq Skel Fixj Phlngl Shft Fx Prox/Middle Px/F/T|RIGHT HAND, THUMB",CASE-26727,APC,26727,CPT,0360,RC,,,F5,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
Egd Transoral Biopsy Single/Multiple|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-43239,APC,43239,CPT,0360,RC,,,74,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],878.67,,"APC Price ($848.96). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,848.96,891.41,OPPS APC
DIABETES WITHOUT CC/MCC,639,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],11899.36,,"Fee schedule rate ($11,899.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6151.76,12223.35,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],10862.00,,"Per diem ($10,862). If length of stay < 7.6, first 1 days paid at a per diem of $21,724 instead. Capped at $82,553.89.",,,,0,other,10862.00,86437.13,Estimated amount calculated based on 6 day length of stay.
ALLERGIC REACTIONS WITH MCC,915,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],27385.01,,"Fee schedule rate ($27,385.01). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,13332.86,33088.84,There are no additional notes associated with this service or procedure.
VAGINAL DELIVERY WITH O.R. PROCEDURES EXCEPT STERILIZATION AND/OR D&C,768,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],12088.81,,"Fee schedule rate ($12,088.81). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6426.91,13416.00,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],30063.84,,"Fee schedule rate ($30,063.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13891.57,34712.20,There are no additional notes associated with this service or procedure.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],10533.95,,"Case rate ($10,533.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,935.13, add-ons for qualifying new technology services are included. If operating cost exceeds $44,806.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,388.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $7,960.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,990.18 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $628.19. The transfer capital threshold is the transfer adjustment factor * $628.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10533.95,24956.34,Inpatient DRG
Laps Surg Rpr Recurrent Inguinal Hernia|LEFT SIDE,CASE-49651,APC,49651,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5941.70,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5658.76,5941.70,OPPS APC
VENTRICULAR SHUNT PROCEDURES WITH MCC,031,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],62406.76,,"Fee schedule rate ($62,406.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,32287.20,88162.80,There are no additional notes associated with this service or procedure.
"PULMONARY EMBOLISM,MODERATE",134,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],8239.17,,"Case rate ($7,846.83). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7846.83,8239.17,There are no additional notes associated with this service or procedure.
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC,939,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],46405.45,,"Case rate ($26,517.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $24,804.19, add-ons for qualifying new technology services are included. If operating cost exceeds $59,675.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,557.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $22,775.26 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $22,859.24 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,797.19. The transfer capital threshold is the transfer adjustment factor * $1,797.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,26517.40,97674.79,All Other Inpatient
Septoplasty/Submucous Resecj W/WO Cartilage Grf,CASE-30520,APC,30520,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.35,,"APC Price ($3,103.35). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.35,3258.52,OPPS APC
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],28751.41,,"Fee schedule rate ($28,751.41). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12305.53,30103.84,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],107110.70,,"Fee schedule rate ($107,110.70). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (21), with a minimum of zero.",,,,0,other,40542.37,128358.13,There are no additional notes associated with this service or procedure.
Bronchoscopy W/Plmt Fiducial Markers Single/Mult,CASE-31626,APC,31626,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6605.95,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6605.95,6936.25,OPPS APC
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12202.35,,"Case rate ($11,621.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,964.70, add-ons for qualifying new technology services are included. If operating cost exceeds $45,835.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,450.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $8,985.68 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,019.75 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $690.66. The transfer capital threshold is the transfer adjustment factor * $690.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,11914.12,40426.76,Inpatient DRG
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],15128.37,,"Fee schedule rate ($15,128.37). Adds an outlier to normal pricing equal to the per diem rate ($46,867.46) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7396.47,16035.06,There are no additional notes associated with this service or procedure.
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 2nd Level|LEFT SIDE,CASE-64494,APC,64494,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],869.28,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,827.89,869.28,OPPS APC
VENTRICULAR SHUNT PROCEDURES WITH CC,032,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],16376.22,,"Case rate ($16,376.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,370.06, add-ons for qualifying new technology services are included. If operating cost exceeds $50,241.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,815.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $13,375.80 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,425.12 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,055.48. The transfer capital threshold is the transfer adjustment factor * $1,055.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,16376.22,46275.08,Inpatient DRG
TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC,084,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],18807.28,,,,,,0,other,6965.00,19445.16,There are no additional notes associated with this service or procedure.
"OTHER EAR NOSE MOUTH THROAT AND CRANIAL OR FACIAL DIAGNOSES,MINOR",115,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],5051.49,,"Case rate ($4,810.94). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4810.94,5051.49,There are no additional notes associated with this service or procedure.
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7672.18,,"Case rate ($7,412.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,031.50, add-ons for qualifying new technology services are included. If operating cost exceeds $41,902.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,159.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $5,067.86 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,086.55 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $399.90. The transfer capital threshold is the transfer adjustment factor * $399.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6148.93,15887.21,Inpatient DRG
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],19551.67,,"Fee schedule rate ($19,551.67). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11053.39,36776.05,There are no additional notes associated with this service or procedure.
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],10078.00,,"Per diem ($10,078). If length of stay < 7.2, first 1 days paid at a per diem of $20,156 instead. Capped at $72,563.53.",,,,0,other,10078.00,81454.07,Estimated amount calculated based on 15 day length of stay.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],29367.82,,"Fee schedule rate ($29,367.82). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.7), with a minimum of zero.",,,,0,other,12527.66,29917.96,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],28235.64,,"Fee schedule rate ($28,235.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,14344.60,36028.59,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],10284.89,,"Case rate ($9,795.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,247.81, add-ons for qualifying new technology services are included. If operating cost exceeds $44,118.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,334.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $7,276.03 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,302.86 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $574.15. The transfer capital threshold is the transfer adjustment factor * $574.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9795.13,23899.13,Inpatient DRG
INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC,198,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],6931.02,,"Case rate ($6,795.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,456.95, add-ons for qualifying new technology services are included. If operating cost exceeds $41,327.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,114.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,495.42 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,512.00 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $354.73. The transfer capital threshold is the transfer adjustment factor * $354.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6795.12,23505.07,Inpatient DRG
HC Inj Anesth Celiac Plexus|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64530,APC,64530,CPT,0361,RC,,,XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],869.28,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,827.89,869.28,OPPS APC
FRACTURES OF FEMUR WITH MCC,533,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],26310.95,,"Fee schedule rate ($26,310.95). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,6852.00,49490.05,There are no additional notes associated with this service or procedure.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],14936.25,,"Fee schedule rate ($14,936.25). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9977.99,26949.28,There are no additional notes associated with this service or procedure.
Brnchsc Removal Bronchial Valve Initial,CASE-31648,APC,31648,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3489.82,,"APC Price ($3,489.82). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3489.82,3664.31,OPPS APC
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],8225.64,,"Case rate ($7,833.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,423.35, add-ons for qualifying new technology services are included. If operating cost exceeds $42,294.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,190.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,458.28 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,478.41 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $430.71. The transfer capital threshold is the transfer adjustment factor * $430.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5883.03,17111.12,Inpatient DRG
Cystourethroscopy,CASE-52000,APC,52000,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],652.69,,"APC Price ($652.69). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,652.69,685.32,OPPS APC
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],39424.57,,"Fee schedule rate ($39,424.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12195.15,39424.57,There are no additional notes associated with this service or procedure.
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],33159.45,,"Fee schedule rate ($33,159.45). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,13092.47,33159.45,There are no additional notes associated with this service or procedure.
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC,519,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],50780.20,,"Fee schedule rate ($50,780.20). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,15490.44,50780.20,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC",281,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],23859.35,,"Fee schedule rate ($23,859.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8169.15,23859.35,There are no additional notes associated with this service or procedure.
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],17375.56,,"Case rate ($16,787.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,753.10, add-ons for qualifying new technology services are included. If operating cost exceeds $50,624.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,845.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $13,757.43 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,808.15 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,085.60. The transfer capital threshold is the transfer adjustment factor * $1,085.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,16787.98,62990.26,Inpatient DRG
Nasal/Sinus Ndsc Tot W/Frnt Sins Expl Tiss Rmvl|LEFT SIDE,CASE-31253,APC,31253,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6837.16,,"APC Price ($6,605.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6605.95,6936.25,OPPS APC
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],16737.83,,"Case rate ($15,940.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,964.98, add-ons for qualifying new technology services are included. If operating cost exceeds $49,835.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,783.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $12,972.20 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,020.03 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,023.63. The transfer capital threshold is the transfer adjustment factor * $1,023.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,15940.79,53275.26,Inpatient DRG
SPINAL PROCEDURES WITHOUT CC/MCC,030,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],16810.99,,"Case rate ($16,810.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,774.52, add-ons for qualifying new technology services are included. If operating cost exceeds $50,645.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,847.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $13,778.77 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,829.57 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,087.28. The transfer capital threshold is the transfer adjustment factor * $1,087.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,16810.99,44714.01,Inpatient DRG
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],19750.09,,"Fee schedule rate ($19,750.09). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,12455.21,37149.27,There are no additional notes associated with this service or procedure.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],8009.34,,"Case rate ($8,009.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,586.52, add-ons for qualifying new technology services are included. If operating cost exceeds $42,457.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,203.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $5,620.85 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,641.57 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $443.54. The transfer capital threshold is the transfer adjustment factor * $443.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8009.34,19877.10,Inpatient DRG
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],26966.33,,"Fee schedule rate ($26,966.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,9040.72,26966.33,There are no additional notes associated with this service or procedure.
PERITONEAL ADHESIOLYSIS WITH CC,336,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],53705.31,,"Fee schedule rate ($53,705.31). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,16225.22,53705.31,There are no additional notes associated with this service or procedure.
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],22217.08,,"Fee schedule rate ($22,217.08). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.4), with a minimum of zero.",,,,0,other,7243.75,23262.15,There are no additional notes associated with this service or procedure.
CHEST PAIN,313,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],6965.00,,,,,,0,other,6820.84,15377.66,There are no additional notes associated with this service or procedure.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,097,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],67876.56,,"Fee schedule rate ($67,876.56). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17.7), with a minimum of zero.",,,,0,other,26404.32,79915.74,There are no additional notes associated with this service or procedure.
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],7562.35,,"Case rate ($7,414.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,032.76, add-ons for qualifying new technology services are included. If operating cost exceeds $41,903.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,159.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,069.12 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,087.81 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $400.00. The transfer capital threshold is the transfer adjustment factor * $400.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,7414.07,18217.52,Inpatient DRG
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC",156,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],12624.95,,"Fee schedule rate ($12,624.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6625.12,13598.77,There are no additional notes associated with this service or procedure.
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],24092.63,,"Fee schedule rate ($24,092.63). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10626.74,25225.91,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],39053.73,,"Fee schedule rate ($39,053.73). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,16017.99,51903.64,There are no additional notes associated with this service or procedure.
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],15600.07,,"Fee schedule rate ($15,600.07). Adds an outlier to normal pricing equal to the per diem rate ($180,117.98) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,7566.45,16333.88,There are no additional notes associated with this service or procedure.
Dstr Nrolytc Agnt Parverteb Fct Addl Lmbr/Sacral|LEFT SIDE,CASE-64636,APC,64636,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1891.77,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1827.80,1919.19,OPPS APC
Wmhc Perc Implant Stim Lead Ea,CASE-63650,APC,63650,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5965.28,,"APC Price ($5,965.28). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5965.28,6263.54,OPPS APC
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC,099,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],11445.22,,"Case rate ($10,900.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,292.55, add-ons for qualifying new technology services are included. If operating cost exceeds $45,163.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,399.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,316.07 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,347.60 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $639.19. The transfer capital threshold is the transfer adjustment factor * $639.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,11171.21,26807.94,Inpatient DRG
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,690,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],14625.55,,"Fee schedule rate ($14,625.55). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7426.94,15928.53,There are no additional notes associated with this service or procedure.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],61290.90,,"Fee schedule rate ($61,290.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,23799.09,63499.65,There are no additional notes associated with this service or procedure.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],46215.75,,"Fee schedule rate ($46,215.75). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.7), with a minimum of zero.",,,,0,other,18598.83,48389.68,There are no additional notes associated with this service or procedure.
Esophagogastroduodenoscopy Submucosal Injection|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-43236,APC,43236,CPT,0360,RC,,,74,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],878.67,,"APC Price ($848.96). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,848.96,891.41,OPPS APC
Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq,CASE-45385,APC,45385,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1176.09,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1120.09,1176.09,OPPS APC
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],112149.06,,,,,,0,other,40542.37,128358.13,There are no additional notes associated with this service or procedure.
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],14145.51,,"Case rate ($8,083.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,655.19, add-ons for qualifying new technology services are included. If operating cost exceeds $42,526.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,208.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,689.27 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,710.24 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $448.94. The transfer capital threshold is the transfer adjustment factor * $448.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,7884.32,17835.23,All Other Inpatient
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],21675.85,,"Fee schedule rate ($21,675.85). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,9755.86,29216.99,There are no additional notes associated with this service or procedure.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],19011.10,,"Case rate ($18,105.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,979.06, add-ons for qualifying new technology services are included. If operating cost exceeds $51,850.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,941.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $14,978.89 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,034.11 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,181.98. The transfer capital threshold is the transfer adjustment factor * $1,181.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,18105.81,52699.33,Inpatient DRG
"ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",770,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],9463.60,,"Fee schedule rate ($9,463.60). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,8735.30,19730.13,There are no additional notes associated with this service or procedure.
"NEONATE BIRTH WEIGHT 2000-2499 GRAMS WITH RESPIRATORY DISTRESS SYNDROME OR OTHER MAJOR RESPIRATORY CONDITION,MINOR",622,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],13766.22,,"Case rate ($13,766.22). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,13766.22,14454.53,There are no additional notes associated with this service or procedure.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC,858,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],33794.11,,"Fee schedule rate ($33,794.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11377.76,33794.11,There are no additional notes associated with this service or procedure.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],15579.21,,"Case rate ($15,273.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,344.45, add-ons for qualifying new technology services are included. If operating cost exceeds $49,215.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,734.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $12,353.94 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,399.49 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $974.85. The transfer capital threshold is the transfer adjustment factor * $974.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,15273.74,39820.52,Inpatient DRG
CESAREAN SECTION WITH STERILIZATION WITHOUT CC/MCC,785,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],20142.33,,"Fee schedule rate ($20,142.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8431.24,20142.33,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],16590.46,,"Fee schedule rate ($16,590.46). Adds an outlier to normal pricing equal to the per diem rate ($69,146.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,1188.00,17370.86,There are no additional notes associated with this service or procedure.
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],33221.97,,"Fee schedule rate ($33,221.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (47), with a minimum of zero.",,,,0,other,15283.90,38757.79,There are no additional notes associated with this service or procedure.
CELLULITIS WITH MCC,602,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],12148.61,,"Case rate ($11,570.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,899.02, add-ons for qualifying new technology services are included. If operating cost exceeds $45,770.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,463.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $8,921.17 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,954.07 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $703.97. The transfer capital threshold is the transfer adjustment factor * $703.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,11570.10,28349.31,Inpatient DRG
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],7547.49,,"Case rate ($7,547.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,156.87, add-ons for qualifying new technology services are included. If operating cost exceeds $42,027.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,169.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $5,192.77 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,211.92 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $409.76. The transfer capital threshold is the transfer adjustment factor * $409.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,19126.88,Inpatient DRG
"Tendon Sheath Incision|RIGHT HAND, THIRD DIGIT|UNUSUAL NON-OVERLAPPING SERVICE",CASE-26055,APC,26055,CPT,0360,RC,,,F7|XU,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1505.12,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1505.12,1580.37,OPPS APC
"OTHER DISORDERS OF NERVOUS SYSTEM,MINOR",058,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],1709.18,,"Case rate for a one day stay ($1,709.18). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,1709.18,1709.18,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC,831,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],9294.42,,"Fee schedule rate ($9,294.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,4941.30,23661.59,There are no additional notes associated with this service or procedure.
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],2070.00,,,,,,0,other,1188.00,18893.86,Estimated amount calculated based on 3 day length of stay.
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC,939,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],26517.40,,"Case rate ($26,517.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $24,804.19, add-ons for qualifying new technology services are included. If operating cost exceeds $59,675.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,557.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $22,775.26 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $22,859.24 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,797.19. The transfer capital threshold is the transfer adjustment factor * $1,797.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,26517.40,97674.79,Inpatient DRG
SALIVARY GLAND PROCEDURES,139,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],30690.92,,"Fee schedule rate ($30,690.92). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,10313.19,30690.92,There are no additional notes associated with this service or procedure.
Hysteroscopy Endometrial Ablation,CASE-58563,APC,58563,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],4682.41,,"APC Price ($4,682.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,4682.41,4916.53,OPPS APC
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],20970.53,,"Case rate ($20,559.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $19,261.52, add-ons for qualifying new technology services are included. If operating cost exceeds $54,132.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,121.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $17,252.96 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $17,316.57 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,361.43. The transfer capital threshold is the transfer adjustment factor * $1,361.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,20559.34,54086.17,Inpatient DRG
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],21320.03,,,,,,0,other,9282.47,21320.03,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,093,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],6965.00,,,,,,0,other,6965.00,19011.32,There are no additional notes associated with this service or procedure.
Cystourethroscopy W/Dest &/Rmvl Tumor Large,CASE-52240,APC,52240,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5018.77,,"APC Price ($5,018.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5018.77,5269.71,OPPS APC
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],16120.25,,"Case rate ($16,120.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,131.93, add-ons for qualifying new technology services are included. If operating cost exceeds $50,002.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,796.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $13,138.54 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,186.98 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,036.76. The transfer capital threshold is the transfer adjustment factor * $1,036.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,16120.25,41187.90,Inpatient DRG
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],5569.00,,"Per diem ($5,569). If length of stay < 3.8, first 1 days paid at a per diem of $11,138 instead. Capped at $21,162.80.",,,,0,other,5569.00,40108.48,Estimated amount calculated based on 2 day length of stay.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],18905.23,,"Fee schedule rate ($18,905.23). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6963.00,18954.85,There are no additional notes associated with this service or procedure.
HYPERTENSION WITHOUT MCC,305,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],17230.49,,"Fee schedule rate ($17,230.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7058.55,17230.49,There are no additional notes associated with this service or procedure.
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],14492.93,,"Fee schedule rate ($14,492.93). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6503.90,14492.93,There are no additional notes associated with this service or procedure.
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],23385.72,,"Fee schedule rate ($23,385.72). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,23385.72,There are no additional notes associated with this service or procedure.
MAJOR BLADDER PROCEDURES WITH MCC,653,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],37135.34,,"Case rate ($37,135.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $34,681.82, add-ons for qualifying new technology services are included. If operating cost exceeds $69,552.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,333.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.5. The base transfer operating payment is the transfer adjustment factor * $32,616.61 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $32,736.87 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,573.77. The transfer capital threshold is the transfer adjustment factor * $2,573.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10280.00,125343.98,Inpatient DRG
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],45933.85,,"Fee schedule rate ($45,933.85). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,18497.24,62041.12,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,690,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],14625.55,,"Fee schedule rate ($14,625.55). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7426.94,15928.53,There are no additional notes associated with this service or procedure.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],11307.45,,"Fee schedule rate ($11,307.45). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,20401.88,There are no additional notes associated with this service or procedure.
CERVICAL SPINAL FUSION WITHOUT CC/MCC,473,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],18477.61,,"Case rate ($18,477.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,324.93, add-ons for qualifying new technology services are included. If operating cost exceeds $52,195.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,969.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.6. The base transfer operating payment is the transfer adjustment factor * $15,323.48 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,379.98 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,209.17. The transfer capital threshold is the transfer adjustment factor * $1,209.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,18477.61,62077.11,Inpatient DRG
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],14309.17,,"Fee schedule rate ($14,309.17). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,17467.27,There are no additional notes associated with this service or procedure.
HC Injection Small Joint/Bursa,CASE-20600,APC,20600,CPT,0361,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],301.68,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,287.31,301.68,OPPS APC
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],14315.70,,"Fee schedule rate ($14,315.70). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6965.00,29482.05,There are no additional notes associated with this service or procedure.
Vag Hyst > 250 Gm Rmvl Tube&/Ovary,CASE-58291,APC,58291,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],4682.41,,"APC Price ($4,682.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,4682.41,4846.30,OPPS APC
HYPERTENSION WITHOUT MCC,305,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],17230.49,,"Fee schedule rate ($17,230.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7058.55,17230.49,There are no additional notes associated with this service or procedure.
O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC,621,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],12585.54,,"Case rate ($12,159.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,447.74, add-ons for qualifying new technology services are included. If operating cost exceeds $46,318.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,507.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $9,467.88 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,502.79 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $747.11. The transfer capital threshold is the transfer adjustment factor * $747.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,12159.94,36669.96,Inpatient DRG
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],18245.94,,"Fee schedule rate ($18,245.94). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8106.18,18245.94,There are no additional notes associated with this service or procedure.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],17194.49,,"Fee schedule rate ($17,194.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8554.50,19204.75,There are no additional notes associated with this service or procedure.
CELLULITIS WITH MCC,602,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],26710.49,,"Fee schedule rate ($26,710.49). Adds an outlier to normal pricing equal to the per diem rate ($28,488.06) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.8), with a minimum of zero.",,,,0,other,11570.10,28349.31,There are no additional notes associated with this service or procedure.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],15309.46,,"Fee schedule rate ($15,309.46). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6965.00,15340.19,There are no additional notes associated with this service or procedure.
"PULMONARY EMBOLISM,MAJOR",134,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],2442.79,,"Case rate for a one day stay ($2,326.47). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,2326.47,2442.79,There are no additional notes associated with this service or procedure.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH CC,026,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],63202.45,,"Fee schedule rate ($63,202.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,23000.66,63202.45,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],31563.88,,,,,,0,other,7353.00,33398.16,There are no additional notes associated with this service or procedure.
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],10078.00,,"Per diem ($10,078). If length of stay < 7.2, first 1 days paid at a per diem of $20,156 instead. Capped at $72,563.53.",,,,0,other,10078.00,81454.07,Estimated amount calculated based on 15 day length of stay.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],19187.65,,"Fee schedule rate ($19,187.65). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8859.23,20090.22,There are no additional notes associated with this service or procedure.
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],5280.00,,"Per diem ($5,280). If length of stay < 3.1, first 1 days paid at a per diem of $10,560 instead. Capped at $16,366.82.",,,,0,other,5280.00,17136.70,Estimated amount calculated based on 3 day length of stay.
UNGROUPABLE,999,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],50458.48,,"Case rate ($48,752.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $45,488.70, add-ons for qualifying new technology services are included. If operating cost exceeds $80,359.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $5,183.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 12.7. The base transfer operating payment is the transfer adjustment factor * $43,383.78 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $43,543.75 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,423.41. The transfer capital threshold is the transfer adjustment factor * $3,423.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,10228.00,161307.29,Inpatient DRG
PREMATURITY WITHOUT MAJOR PROBLEMS,792,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],1956.00,,,,,,0,other,1956.00,19457.66,Estimated amount calculated based on 3 day length of stay.
FULL TERM NEONATE WITH MAJOR PROBLEMS,793,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],52818.12,,"Case rate ($30,181.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $28,213.07, add-ons for qualifying new technology services are included. If operating cost exceeds $63,084.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,825.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $26,171.62 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $26,268.12 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,065.20. The transfer capital threshold is the transfer adjustment factor * $2,065.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,4302.90,82045.22,All Other Inpatient
CESAREAN SECTION WITH STERILIZATION WITHOUT CC/MCC,785,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],8599.86,,"Case rate ($8,431.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,979, add-ons for qualifying new technology services are included. If operating cost exceeds $42,850.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,234.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,011.89 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,034.06 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $474.40. The transfer capital threshold is the transfer adjustment factor * $474.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,8431.24,20142.33,Inpatient DRG
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],7569.84,,"Case rate ($7,569.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,177.66, add-ons for qualifying new technology services are included. If operating cost exceeds $42,048.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,171.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,213.49 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,232.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $411.40. The transfer capital threshold is the transfer adjustment factor * $411.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7569.84,21892.85,Inpatient DRG
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],15076.44,,"Fee schedule rate ($15,076.44). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6340.03,15076.44,There are no additional notes associated with this service or procedure.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,329,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],34726.41,,"Case rate ($33,072.77). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $30,902.51, add-ons for qualifying new technology services are included. If operating cost exceeds $65,773.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,036.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.4. The base transfer operating payment is the transfer adjustment factor * $28,851.18 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $28,957.55 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,276.64. The transfer capital threshold is the transfer adjustment factor * $2,276.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,33072.77,90445.33,Inpatient DRG
"ALCOHOLIC LIVER DISEASE,EXTREME",280,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],25609.71,,"Case rate ($24,390.20). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,24390.20,25609.71,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],7547.49,,"Case rate ($7,547.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,156.87, add-ons for qualifying new technology services are included. If operating cost exceeds $42,027.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,169.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $5,192.77 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,211.92 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $409.76. The transfer capital threshold is the transfer adjustment factor * $409.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,19126.88,Inpatient DRG
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],24259.09,,"Fee schedule rate ($24,259.09). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10098.51,24259.09,There are no additional notes associated with this service or procedure.
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],28445.08,,"Fee schedule rate ($28,445.08). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.8), with a minimum of zero.",,,,0,other,12195.15,39424.57,There are no additional notes associated with this service or procedure.
Laparoscopy Surg Cholecystectomy,CASE-47562,APC,47562,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5658.76,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5658.76,5941.70,OPPS APC
MINOR BLADDER PROCEDURES WITHOUT CC/MCC,664,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],19674.39,,"Fee schedule rate ($19,674.39). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,9034.63,31876.87,There are no additional notes associated with this service or procedure.
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],14830.15,,"Fee schedule rate ($14,830.15). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,7884.32,17835.23,There are no additional notes associated with this service or procedure.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],19119.59,,"Case rate ($19,119.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,922.16, add-ons for qualifying new technology services are included. If operating cost exceeds $52,793.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,016.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $15,918.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,977.21 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,256.13. The transfer capital threshold is the transfer adjustment factor * $1,256.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,11348.00,62454.12,Inpatient DRG
INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,352,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],22978.80,,,,,,0,other,9853.37,26528.70,There are no additional notes associated with this service or procedure.
HC Inj Lympho for Sentinal Node|RIGHT SIDE,CASE-38792,APC,38792,CPT,0361,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6432.89,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6215.36,6526.12,OPPS APC
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],24387.68,,"Fee schedule rate ($24,387.68). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10733.06,45157.33,There are no additional notes associated with this service or procedure.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,057,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],24348.21,,"Fee schedule rate ($24,348.21). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.9), with a minimum of zero.",,,,0,other,10718.84,39884.93,There are no additional notes associated with this service or procedure.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],18933.95,,"Fee schedule rate ($18,933.95). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.8), with a minimum of zero.",,,,0,other,8767.81,19824.58,There are no additional notes associated with this service or procedure.
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],27665.18,,"Fee schedule rate ($27,665.18). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,11914.12,40426.76,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC,831,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],6965.00,,,,,,0,other,4941.30,23661.59,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITH STERILIZATION WITH CC,784,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],23722.94,,"Fee schedule rate ($23,722.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9124.01,23722.94,There are no additional notes associated with this service or procedure.
"PROCEDURES FOR OBESITY,MODERATE",403,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],14299.07,,"Case rate ($14,299.07). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,14299.07,15014.02,There are no additional notes associated with this service or procedure.
HC Drain/Inj Joint/Bursa W/US Large|BILATERAL PROCEDURE,CASE-20611,APC,20611,CPT,0510,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],96365.69,,"Fee schedule rate ($96,365.69). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,23377.19,96365.69,There are no additional notes associated with this service or procedure.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],31007.30,,"Fee schedule rate ($31,007.30). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,16120.25,41187.90,There are no additional notes associated with this service or procedure.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],92811.11,,"Fee schedule rate ($92,811.11). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,35389.50,101083.00,There are no additional notes associated with this service or procedure.
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7437.35,,"Case rate ($7,083.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,734.53, add-ons for qualifying new technology services are included. If operating cost exceeds $41,605.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,126.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,771.49 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,789.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $366.75. The transfer capital threshold is the transfer adjustment factor * $366.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7238.69,16804.22,Inpatient DRG
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],51630.84,,"Fee schedule rate ($51,630.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,20559.34,54086.17,There are no additional notes associated with this service or procedure.
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],6965.00,,,,,,0,other,6965.00,29482.05,There are no additional notes associated with this service or procedure.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC,027,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],56363.30,,"Fee schedule rate ($56,363.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,19030.20,56363.30,There are no additional notes associated with this service or procedure.
"Tendon Sheath Incision|LEFT HAND, FOURTH DIGIT",CASE-26055,APC,26055,CPT,0360,RC,,,F3,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1505.12,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1505.12,1580.37,OPPS APC
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],13657.26,,"Case rate ($13,006.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,256.30, add-ons for qualifying new technology services are included. If operating cost exceeds $47,127.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,549.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $10,272.40 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,311.35 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $789.56. The transfer capital threshold is the transfer adjustment factor * $789.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13341.67,42586.49,Inpatient DRG
Excision Excessive Skin & Subq Tissue Abdomen,CASE-15847,APC,15847,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6432.89,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6215.36,6526.12,OPPS APC
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],18404.48,,"Case rate ($17,782.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,677.93, add-ons for qualifying new technology services are included. If operating cost exceeds $51,548.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,918.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $14,678.86 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,732.98 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,158.31. The transfer capital threshold is the transfer adjustment factor * $1,158.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,17782.11,46523.26,Inpatient DRG
Revision Peri-Implant Capsule Breast|RIGHT SIDE,CASE-19370,APC,19370,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],7650.49,,"APC Price ($7,650.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,7650.49,7650.49,OPPS APC
UNGROUPABLE,999,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],161307.29,,"Fee schedule rate ($161,307.29). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (41), with a minimum of zero.",,,,0,other,10228.00,161307.29,There are no additional notes associated with this service or procedure.
Laparoscopy Urethral Suspension Stress Incont,CASE-51990,APC,51990,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],10447.27,,"APC Price ($9,949.78). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,9949.78,10447.27,OPPS APC
Injection Aa&/Strd Intercostal Nrv Ea Addl Lvl,CASE-64421,APC,64421,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],869.28,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,827.89,869.28,OPPS APC
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],36855.62,,"Fee schedule rate ($36,855.62). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,15821.59,40320.14,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH CC,427,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],134742.59,,"Fee schedule rate ($134,742.59). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,50829.82,142040.39,There are no additional notes associated with this service or procedure.
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITH MCC,429,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],64224.74,,"Case rate ($61,166.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $57,147.93, add-ons for qualifying new technology services are included. If operating cost exceeds $92,018.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $5,986.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.6. The base transfer operating payment is the transfer adjustment factor * $54,994.47 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $55,202.98 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,227.00. The transfer capital threshold is the transfer adjustment factor * $4,227.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,62958.58,177294.98,Inpatient DRG
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],9334.13,,"Case rate ($9,151.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,648.69, add-ons for qualifying new technology services are included. If operating cost exceeds $43,519.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,287.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,679.11 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,703.74 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $527.05. The transfer capital threshold is the transfer adjustment factor * $527.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,9151.11,30245.71,Inpatient DRG
OSTEOMYELITIS WITHOUT CC/MCC,541,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],5103.00,,"Per diem ($5,103). If length of stay < 2.9, first 1 days paid at a per diem of $10,206 instead. Capped at $14,797.61.",,,,0,other,5103.00,15493.67,Estimated amount calculated based on 1 day length of stay.
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],31750.77,,"Fee schedule rate ($31,750.77). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13386.36,33244.29,There are no additional notes associated with this service or procedure.
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],16400.70,,"Fee schedule rate ($16,400.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,16400.70,There are no additional notes associated with this service or procedure.
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],14182.52,,"Case rate ($13,904.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,070.60, add-ons for qualifying new technology services are included. If operating cost exceeds $47,941.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,634.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,084.78 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,125.65 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $874.70. The transfer capital threshold is the transfer adjustment factor * $874.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,13904.43,34749.58,Inpatient DRG
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,477,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],62359.39,,"Fee schedule rate ($62,359.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,25339.74,67976.16,There are no additional notes associated with this service or procedure.
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],10846.16,,"Case rate ($10,846.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,225.56, add-ons for qualifying new technology services are included. If operating cost exceeds $45,096.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,410.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $8,250.19 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,280.61 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $651.02. The transfer capital threshold is the transfer adjustment factor * $651.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10846.16,25863.45,Inpatient DRG
"NEONATE BIRTH WEIGHT > 2499 GRAMS WITH OTHER SIGNIFICANT CONDITION,MINOR",639,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],2814.69,,"Case rate ($2,680.66). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,2680.66,2814.69,There are no additional notes associated with this service or procedure.
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC",011,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],150008.48,,"Fee schedule rate ($150,008.48). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (44), with a minimum of zero.",,,,0,other,38880.49,150008.48,There are no additional notes associated with this service or procedure.
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],10550.81,,"Case rate ($10,048.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,483.42, add-ons for qualifying new technology services are included. If operating cost exceeds $44,354.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,352.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,510.78 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,538.48 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $592.68. The transfer capital threshold is the transfer adjustment factor * $592.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10048.39,23545.50,Inpatient DRG
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,477,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],64922.30,,"Fee schedule rate ($64,922.30). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16.6), with a minimum of zero.",,,,0,other,25339.74,67976.16,There are no additional notes associated with this service or procedure.
"Exc Tum/Vasc Mal Sft Tiss Hand/Fngr Subq <1.5cm|RIGHT HAND, THIRD DIGIT",CASE-26115,APC,26115,CPT,0360,RC,,,F7,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1623.23,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1545.93,1623.23,OPPS APC
Wmhc Perc Implant Stim Lead Ea,CASE-63650,APC,63650,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6263.54,,"APC Price ($5,965.28). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5965.28,6263.54,OPPS APC
SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS,870,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],161307.29,,"Fee schedule rate ($161,307.29). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (41), with a minimum of zero.",,,,0,other,161307.29,161307.29,There are no additional notes associated with this service or procedure.
Rpr Recrt Ingun Hernia Any Age Incarcerated|LEFT SIDE,CASE-49521,APC,49521,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6362.63,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6059.65,6362.63,OPPS APC
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],48389.68,,,,,,0,other,18598.83,48389.68,There are no additional notes associated with this service or procedure.
Cysto W/Removal of Lesions Small,CASE-52224,APC,52224,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3299.47,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3299.47,3464.44,OPPS APC
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],10229.13,,"Case rate ($9,742.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,212.95, add-ons for qualifying new technology services are included. If operating cost exceeds $44,083.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,316.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $7,240.55 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,268.00 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $556.53. The transfer capital threshold is the transfer adjustment factor * $556.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9977.99,26949.28,Inpatient DRG
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,373,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],6870.94,,"Case rate ($6,870.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,527.50, add-ons for qualifying new technology services are included. If operating cost exceeds $41,398.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,120.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $4,565.72 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,582.56 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $360.28. The transfer capital threshold is the transfer adjustment factor * $360.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6870.94,14313.05,Inpatient DRG
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],13092.47,,"Case rate ($13,092.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,315.24, add-ons for qualifying new technology services are included. If operating cost exceeds $47,186.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,575.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $10,332.19 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,370.29 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $815.31. The transfer capital threshold is the transfer adjustment factor * $815.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,13092.47,33159.45,Inpatient DRG
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,479,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],14533.55,,"Case rate ($14,533.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,655.86, add-ons for qualifying new technology services are included. If operating cost exceeds $48,526.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,680.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $11,667.89 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,710.91 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $920.71. The transfer capital threshold is the transfer adjustment factor * $920.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10586.00,50518.76,Inpatient DRG
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],16897.01,,"Case rate ($16,897.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,854.53, add-ons for qualifying new technology services are included. If operating cost exceeds $50,725.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,853.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $13,858.48 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,909.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,093.57. The transfer capital threshold is the transfer adjustment factor * $1,093.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,16897.01,43444.85,Inpatient DRG
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,426,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],177294.98,,"Fee schedule rate ($177,294.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,76581.29,216864.15,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITH STERILIZATION WITHOUT CC/MCC,785,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],8652.76,,"Case rate ($8,240.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,813.51, add-ons for qualifying new technology services are included. If operating cost exceeds $42,684.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,209.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,846.40 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,868.56 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $449.37. The transfer capital threshold is the transfer adjustment factor * $449.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8431.24,20142.33,Inpatient DRG
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],45017.13,,"Fee schedule rate ($45,017.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,14603.31,45017.13,There are no additional notes associated with this service or procedure.
"NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY",789,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],3054.00,,,,,,0,other,3054.00,14857.05,Estimated amount calculated based on 1 day length of stay.
Laps Tx Ectopic Preg W/Salping&/Oophorectomy|RIGHT SIDE,CASE-59151,APC,59151,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5941.70,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5658.76,5941.70,OPPS APC
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],41580.51,,"Fee schedule rate ($41,580.51). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,13783.20,41580.51,There are no additional notes associated with this service or procedure.
CERVICAL SPINAL FUSION WITHOUT CC/MCC,473,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],62077.11,,"Fee schedule rate ($62,077.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,18477.61,62077.11,There are no additional notes associated with this service or procedure.
Cysto W/Removal of Lesions Small,CASE-52224,APC,52224,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3464.44,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3299.47,3464.44,OPPS APC
HC Inj Anes/Steroid C/D Facet Sg,CASE-64490,APC,64490,CPT,0361,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],856.86,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,827.89,869.28,OPPS APC
HC >= 12 Lead Ekg|UNUSUAL NON-OVERLAPPING SERVICE,CASE-93005,APC,93005,CPT,0730,RC,,,XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3611.96,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3489.82,3611.96,OPPS APC
"MAJOR BLADDER PROCEDURES,MAJOR",441,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],37049.24,,"Case rate ($35,284.99). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,35284.99,37049.24,There are no additional notes associated with this service or procedure.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,329,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],86631.74,,"Fee schedule rate ($86,631.74). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (38), with a minimum of zero.",,,,0,other,33072.77,90445.33,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],30372.64,,"Fee schedule rate ($30,372.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,13260.40,32878.30,There are no additional notes associated with this service or procedure.
Laryngoscopy Direct Operative W/Biopsy|UNUSUAL NON-OVERLAPPING SERVICE,CASE-31535,APC,31535,CPT,0360,RC,,,XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3611.96,,"APC Price ($3,489.82). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3489.82,3664.31,OPPS APC
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],52803.53,,"Fee schedule rate ($52,803.53). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,14337.84,52803.53,There are no additional notes associated with this service or procedure.
ENDOCRINE DISORDERS WITH CC,644,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],20334.21,,,,,,0,other,7066.99,20334.21,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,426,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],79261.64,,"Case rate ($76,581.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $71,377.56, add-ons for qualifying new technology services are included. If operating cost exceeds $106,248.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $7,218.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $69,177.55 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $69,432.61 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $5,458.79. The transfer capital threshold is the transfer adjustment factor * $5,458.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,76581.29,216864.15,Inpatient DRG
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],8244.81,,"Case rate ($8,083.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,655.19, add-ons for qualifying new technology services are included. If operating cost exceeds $42,526.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,208.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,689.27 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,710.24 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $448.94. The transfer capital threshold is the transfer adjustment factor * $448.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,7884.32,17835.23,Inpatient DRG
Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq|COLORECTAL CANCER SCREEN,CASE-45385,APC,45385,CPT,0360,RC,,,PT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1120.09,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1120.09,1176.09,OPPS APC
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],14945.70,,"Fee schedule rate ($14,945.70). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,9040.72,26966.33,There are no additional notes associated with this service or procedure.
"Tendon Sheath Incision|RIGHT HAND, FIFTH DIGIT|UNUSUAL NON-OVERLAPPING SERVICE",CASE-26055,APC,26055,CPT,0360,RC,,,F9|XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC",629,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],17534.94,,"Case rate ($16,699.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,671.20, add-ons for qualifying new technology services are included. If operating cost exceeds $50,542.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,839.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $13,675.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,726.25 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,079.16. The transfer capital threshold is the transfer adjustment factor * $1,079.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,16699.94,44657.18,Inpatient DRG
NEONATE WITH OTHER SIGNIFICANT PROBLEMS,794,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],3383.58,,"Fee schedule rate ($3,383.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,1798.85,12536.83,There are no additional notes associated with this service or procedure.
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],11065.78,,"Fee schedule rate ($11,065.78). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5883.03,17111.12,There are no additional notes associated with this service or procedure.
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,450,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],146009.19,,"Fee schedule rate ($146,009.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,38037.38,146009.19,There are no additional notes associated with this service or procedure.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,097,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],79915.74,,"Fee schedule rate ($79,915.74). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,26404.32,79915.74,There are no additional notes associated with this service or procedure.
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],12526.44,,"Fee schedule rate ($12,526.44). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5415.00,17575.50,There are no additional notes associated with this service or procedure.
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],23385.72,,"Fee schedule rate ($23,385.72). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,23385.72,There are no additional notes associated with this service or procedure.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],8559.13,,"Case rate ($8,151.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,718.82, add-ons for qualifying new technology services are included. If operating cost exceeds $42,589.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,213.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,752.66 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,773.87 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $453.94. The transfer capital threshold is the transfer adjustment factor * $453.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8151.55,18033.97,Inpatient DRG
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],29243.52,,"Fee schedule rate ($29,243.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,14343.25,36024.65,There are no additional notes associated with this service or procedure.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],39820.52,,"Fee schedule rate ($39,820.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,15273.74,39820.52,There are no additional notes associated with this service or procedure.
COAGULATION DISORDERS,813,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],28664.96,,"Fee schedule rate ($28,664.96). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.7), with a minimum of zero.",,,,0,other,12274.39,30013.33,There are no additional notes associated with this service or procedure.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,074,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],11121.45,,"Fee schedule rate ($11,121.45). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8925.60,20919.08,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,082,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],56223.11,,"Fee schedule rate ($56,223.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,17423.21,56223.11,There are no additional notes associated with this service or procedure.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,329,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],34726.41,,"Case rate ($33,072.77). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $30,902.51, add-ons for qualifying new technology services are included. If operating cost exceeds $65,773.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,036.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.4. The base transfer operating payment is the transfer adjustment factor * $28,851.18 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $28,957.55 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,276.64. The transfer capital threshold is the transfer adjustment factor * $2,276.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,33072.77,90445.33,Inpatient DRG
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC",061,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],21337.80,,"Case rate ($20,616.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $19,314.45, add-ons for qualifying new technology services are included. If operating cost exceeds $54,185.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,125.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $17,305.68 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $17,369.49 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,365.59. The transfer capital threshold is the transfer adjustment factor * $1,365.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,20616.23,62315.82,Inpatient DRG
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],6965.00,,,,,,0,other,6965.00,20401.88,There are no additional notes associated with this service or procedure.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,345,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],28277.83,,"Fee schedule rate ($28,277.83). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12134.89,33616.03,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC,833,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],5721.39,,"Fee schedule rate ($5,721.39). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,3041.73,10289.10,There are no additional notes associated with this service or procedure.
O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC,621,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],36669.96,,"Fee schedule rate ($36,669.96). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,12159.94,36669.96,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],128358.13,,"Fee schedule rate ($128,358.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,40542.37,128358.13,There are no additional notes associated with this service or procedure.
Prep Site F/S/N/H/F/G/M/D Gt 1st 100 Sq Cm/1pct,CASE-15004,APC,15004,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],399.53,,"APC Price ($380.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,380.51,399.53,OPPS APC
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],16283.24,,"Fee schedule rate ($16,283.24). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7875.94,17233.12,There are no additional notes associated with this service or procedure.
HYPERTENSION WITHOUT MCC,305,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],14190.59,,"Fee schedule rate ($14,190.59). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,7058.55,17230.49,There are no additional notes associated with this service or procedure.
Mastectomy Simple Complete|BILATERAL PROCEDURE,CASE-19303,APC,19303,CPT,0360,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6526.12,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6526.12,6526.12,OPPS APC
Rpr Recrt Ingun Hernia Any Age Incarcerated,CASE-49521,APC,49521,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6059.65,,"APC Price ($6,059.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6059.65,6362.63,OPPS APC
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],16375.35,,"Case rate ($15,821.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,854.10, add-ons for qualifying new technology services are included. If operating cost exceeds $49,725.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,774.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $12,861.73 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,909.15 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,014.92. The transfer capital threshold is the transfer adjustment factor * $1,014.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,15821.59,40320.14,Inpatient DRG
HC Joint Injection/Aspir Large WO US|RIGHT SIDE,CASE-20610,APC,20610,CPT,0510,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],287.31,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,091,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],14529.96,,"Case rate ($13,838.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,008.86, add-ons for qualifying new technology services are included. If operating cost exceeds $47,879.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,629.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $11,023.26 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,063.91 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $869.84. The transfer capital threshold is the transfer adjustment factor * $869.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13838.06,40030.81,Inpatient DRG
Transection/Avulsion Oth Spinal Nrv Xdrl|RIGHT SIDE,CASE-64772,APC,64772,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
Laparoscopy W/Rmvl Adnexal Structures|RIGHT SIDE,CASE-58661,APC,58661,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5856.81,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5658.76,5941.70,OPPS APC
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],21892.85,,"Fee schedule rate ($21,892.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7569.84,21892.85,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],18585.05,,"Fee schedule rate ($18,585.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8859.23,20090.22,There are no additional notes associated with this service or procedure.
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],14674.80,,"Fee schedule rate ($14,674.80). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6711.00,16865.16,There are no additional notes associated with this service or procedure.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],7368.94,,"Case rate ($7,224.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,856.36, add-ons for qualifying new technology services are included. If operating cost exceeds $41,727.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,146.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $4,893.37 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,911.41 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $386.14. The transfer capital threshold is the transfer adjustment factor * $386.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6965.00,15340.19,Inpatient DRG
HEADACHES WITHOUT MCC,103,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],20883.08,,"Fee schedule rate ($20,883.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,20883.08,There are no additional notes associated with this service or procedure.
Cysto W/Simple Removal Stone & Stent|RIGHT SIDE,CASE-52310,APC,52310,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1956.65,,"APC Price ($1,956.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1956.65,2054.48,OPPS APC
COMPLICATIONS OF TREATMENT WITH CC,920,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],20731.52,,"Fee schedule rate ($20,731.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8732.59,20731.52,There are no additional notes associated with this service or procedure.
SPINAL PROCEDURES WITH MCC,028,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],120982.83,,"Fee schedule rate ($120,982.83). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,42633.57,120982.83,There are no additional notes associated with this service or procedure.
Surgical Arthroscopy Shoulder Biceps Tenodesis|LEFT SIDE,CASE-29828,APC,29828,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
Laps Vaginal Hysterectomy Uterus 250 Gm/<,CASE-58550,APC,58550,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5856.81,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5658.76,5941.70,OPPS APC
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,068,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],12326.05,,"Fee schedule rate ($12,326.05). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,23184.90,There are no additional notes associated with this service or procedure.
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITH MCC OR ANTINEOPLASTIC IMPLANT OR EPILEPSY WITH NEUROSTIMULATOR,023,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],136379.44,,"Fee schedule rate ($136,379.44). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,15168.00,136379.44,There are no additional notes associated with this service or procedure.
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC,807,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],10071.17,,"Fee schedule rate ($10,071.17). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5354.25,13266.23,There are no additional notes associated with this service or procedure.
"HC I&D Finger Abscess Simple|RIGHT HAND, THUMB",CASE-26010,APC,26010,CPT,0450,RC,,,F5,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],187.80,,"APC Price ($187.80). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,187.80,197.19,OPPS APC
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],35304.50,,"Case rate ($33,623.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $31,414.68, add-ons for qualifying new technology services are included. If operating cost exceeds $66,285.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,076.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.4. The base transfer operating payment is the transfer adjustment factor * $29,361.48 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $29,469.74 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,316.91. The transfer capital threshold is the transfer adjustment factor * $2,316.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,33623.33,133270.57,Inpatient DRG
HC Lyr Clos Sc Tk Ext 2.6-7 Cm|SEPARATE STRUCTURE,CASE-12032,APC,12032,CPT,0450,RC,,,XS,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],2854.83,,"APC Price ($2,718.88). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2718.88,2854.83,OPPS APC
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC,805,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],9716.03,,"Case rate ($9,253.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,743.82, add-ons for qualifying new technology services are included. If operating cost exceeds $43,614.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,294.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $6,773.89 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,798.87 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $534.53. The transfer capital threshold is the transfer adjustment factor * $534.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9253.36,21235.42,Inpatient DRG
Laps Surg Rpr Recurrent Inguinal Hernia|RIGHT SIDE,CASE-49651,APC,49651,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5856.81,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5658.76,5941.70,OPPS APC
Vag Hyst > 250 Gm Rmvl Tube&/Ovary,CASE-58291,APC,58291,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],4846.30,,"APC Price ($4,682.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,4682.41,4846.30,OPPS APC
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC,099,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],26807.94,,,,,,0,other,11171.21,26807.94,There are no additional notes associated with this service or procedure.
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],14625.55,,"Fee schedule rate ($14,625.55). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7438.45,15961.98,There are no additional notes associated with this service or procedure.
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],4341.01,,"Fee schedule rate ($4,341.01). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4341.01,12882.53,There are no additional notes associated with this service or procedure.
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC,806,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],6836.20,,"Case rate ($6,510.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,192.35, add-ons for qualifying new technology services are included. If operating cost exceeds $41,063.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,093.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $4,231.80 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,247.40 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $333.93. The transfer capital threshold is the transfer adjustment factor * $333.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5354.25,13416.00,Inpatient DRG
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],11594.35,,"Fee schedule rate ($11,594.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6164.03,14071.02,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,086,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],18842.11,,"Case rate ($10,766.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,151.85, add-ons for qualifying new technology services are included. If operating cost exceeds $45,022.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,405.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $8,176.75 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,206.90 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $645.23. The transfer capital threshold is the transfer adjustment factor * $645.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,8442.00,30728.81,All Other Inpatient
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],28235.64,,"Fee schedule rate ($28,235.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,14344.60,36028.59,There are no additional notes associated with this service or procedure.
Nsl/Sinus Ndsc Max Antrost W/Rmvl Tiss Max Sinus|LEFT SIDE,CASE-31267,APC,31267,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6605.95,,"APC Price ($6,605.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6605.95,6936.25,OPPS APC
INFLAMMATORY BOWEL DISEASE WITH MCC,385,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],29736.16,,"Fee schedule rate ($29,736.16). Adds an outlier to normal pricing equal to the per diem rate ($112,108.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.5), with a minimum of zero.",,,,0,other,11480.01,31134.92,There are no additional notes associated with this service or procedure.
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH MCC",510,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],22889.12,,"Case rate ($21,799.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,451.94, add-ons for qualifying new technology services are included. If operating cost exceeds $55,322.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,177.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.3. The base transfer operating payment is the transfer adjustment factor * $18,437.09 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,506.99 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,417.12. The transfer capital threshold is the transfer adjustment factor * $1,417.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10710.00,89863.76,Inpatient DRG
HC Non Stress Test,CASE-59025,APC,59025,CPT,0920,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],189.24,,"APC Price ($189.24). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,189.24,198.70,OPPS APC
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC,520,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],39786.42,,"Fee schedule rate ($39,786.42). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12061.74,39786.42,There are no additional notes associated with this service or procedure.
HC Inj Anes/Steroid C/D Facet Sg|LEFT SIDE|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-64490,APC,64490,CPT,0361,RC,,,LT|74,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],869.28,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,827.89,869.28,OPPS APC
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],25026.36,,"Fee schedule rate ($25,026.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9356.31,25026.36,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF NERVOUS SYSTEM WITH CC,092,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],8872.78,,"Case rate ($8,872.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,389.76, add-ons for qualifying new technology services are included. If operating cost exceeds $43,260.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,266.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $6,421.14 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,444.81 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $506.69. The transfer capital threshold is the transfer adjustment factor * $506.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8872.78,26765.51,Inpatient DRG
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC,858,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],26176.77,,"Fee schedule rate ($26,176.77). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11377.76,33794.11,There are no additional notes associated with this service or procedure.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],16669.71,,"Fee schedule rate ($16,669.71). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8767.81,19824.58,There are no additional notes associated with this service or procedure.
TRAUMATIC INJURY WITH MCC,913,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],42838.46,,"Fee schedule rate ($42,838.46). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13014.58,42838.46,There are no additional notes associated with this service or procedure.
Chemodenervation Muscle Neck Unilat for Dystonia,CASE-64616,APC,64616,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],301.68,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,287.31,301.68,OPPS APC
"VAGINAL DELIVERY,MINOR",560,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],3906.04,,"Case rate ($3,720.04). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,3720.04,3906.04,There are no additional notes associated with this service or procedure.
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC,520,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],12664.83,,"Case rate ($12,061.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,356.39, add-ons for qualifying new technology services are included. If operating cost exceeds $46,227.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,499.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $9,376.87 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,411.44 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $739.93. The transfer capital threshold is the transfer adjustment factor * $739.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12061.74,39786.42,Inpatient DRG
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],24338.65,,"Case rate ($13,907.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,073.74, add-ons for qualifying new technology services are included. If operating cost exceeds $47,944.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,634.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $11,087.92 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,128.80 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $874.95. The transfer capital threshold is the transfer adjustment factor * $874.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,13907.80,52794.06,All Other Inpatient
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITH MCC,429,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],169317.41,,"Fee schedule rate ($169,317.41). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,62958.58,177294.98,There are no additional notes associated with this service or procedure.
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],18753.00,,"Fee schedule rate ($18,753). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,7000.00,33835.79,There are no additional notes associated with this service or procedure.
HC Plcmt Tunnel Pleural Drain Cat,CASE-32550,APC,32550,CPT,0361,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3518.91,,"APC Price ($3,351.34). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3351.34,3518.91,OPPS APC
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],6963.00,,"Per diem ($6,963). If length of stay < 2.6, first 1 days paid at a per diem of $13,926 instead. Capped at $18,103.30.",,,,0,other,6963.00,18954.85,Estimated amount calculated based on 3 day length of stay.
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH MCC",722,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],56869.13,,"Fee schedule rate ($56,869.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,14200.37,56869.13,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],22723.38,,"Case rate ($12,984.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,215.07, add-ons for qualifying new technology services are included. If operating cost exceeds $47,086.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,567.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $10,232.39 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,270.12 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $807.44. The transfer capital threshold is the transfer adjustment factor * $807.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,12984.79,32077.45,All Other Inpatient
Prep Site Trunk/Arm/Leg 1st 100 Sq Cm/1pct,CASE-15002,APC,15002,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],691.79,,"APC Price ($691.79). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,691.79,726.38,OPPS APC
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],10890.32,,"Case rate ($10,371.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,799.93, add-ons for qualifying new technology services are included. If operating cost exceeds $44,670.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,361.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $7,825.31 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,854.98 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $601.47. The transfer capital threshold is the transfer adjustment factor * $601.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10626.74,25225.91,Inpatient DRG
Sigmoidoscopy Flx W/Biopsy Single/Multiple,CASE-45331,APC,45331,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],870.46,,"APC Price ($870.46). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,870.46,913.99,OPPS APC
VAGINAL DELIVERY WITH O.R. PROCEDURES EXCEPT STERILIZATION AND/OR D&C,768,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],12088.81,,"Fee schedule rate ($12,088.81). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6426.91,13416.00,There are no additional notes associated with this service or procedure.
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],15537.77,,"Case rate ($15,233.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,306.64, add-ons for qualifying new technology services are included. If operating cost exceeds $49,177.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,731.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $12,316.28 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,361.69 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $971.88. The transfer capital threshold is the transfer adjustment factor * $971.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,15233.11,38610.21,Inpatient DRG
"CELLULITIS AND OTHER SKIN INFECTIONS,MODERATE",383,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],6487.32,,"Case rate ($6,487.32). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,6487.32,6811.69,There are no additional notes associated with this service or procedure.
POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES,769,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],33250.19,,,,,,0,other,13388.39,33250.19,There are no additional notes associated with this service or procedure.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,479,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],50518.76,,"Fee schedule rate ($50,518.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,10586.00,50518.76,There are no additional notes associated with this service or procedure.
Largsc Exc Tum&/Strpg Cords/Epigl Mcrscp/Tlscp|LEFT SIDE,CASE-31541,APC,31541,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3611.96,,"APC Price ($3,489.82). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3489.82,3611.96,OPPS APC
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],17136.70,,,,,,0,other,5280.00,17136.70,There are no additional notes associated with this service or procedure.
Cysto W/Simple Removal Stone & Stent|RIGHT SIDE,CASE-52310,APC,52310,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1956.65,,"APC Price ($1,956.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1956.65,2054.48,OPPS APC
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],7389.00,,"Per diem ($7,389). If length of stay < 4.8, first 1 days paid at a per diem of $14,778 instead. Capped at $35,466.15.",,,,0,other,7389.00,37134.43,Estimated amount calculated based on 6 day length of stay.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],23618.74,,"Fee schedule rate ($23,618.74). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10533.95,24956.34,There are no additional notes associated with this service or procedure.
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],34245.00,,"Fee schedule rate ($34,245.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,12725.42,34245.00,There are no additional notes associated with this service or procedure.
Cervical Lymphadec Modified Radical Neck Dsj|RIGHT SIDE,CASE-38724,APC,38724,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],209.05,,"APC Price ($199.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,199.10,209.05,OPPS APC
Sigmoidoscopy Flx Control Bleeding,CASE-45334,APC,45334,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1120.09,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1120.09,1176.09,OPPS APC
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],9888.00,,"Per diem ($9,888). If length of stay < 3.1, first 1 days paid at a per diem of $19,776 instead. Capped at $30,651.38.",,,,0,other,9888.00,43399.23,Estimated amount calculated based on 1 day length of stay.
HC Joint Injection/Aspir Large WO US|PBB CHARGE,CASE-20610,APC,20610,CPT,0510,RC,,,PBB,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],287.31,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],35419.59,,"Fee schedule rate ($35,419.59). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,7086.00,57872.02,There are no additional notes associated with this service or procedure.
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],11281.44,,"Fee schedule rate ($11,281.44). Adds an outlier to normal pricing equal to the per diem rate ($62,521.14) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,6010.23,12246.05,There are no additional notes associated with this service or procedure.
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|LEFT HAND, THUMB",CASE-26160,APC,26160,CPT,0360,RC,,,FA,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1505.12,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1505.12,1580.37,OPPS APC
"DIABETES,MODERATE",420,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],2208.90,,"Case rate for a one day stay ($2,103.71). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,2103.71,2208.90,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF NERVOUS SYSTEM WITH CC,092,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],9050.24,,"Case rate ($8,872.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,389.76, add-ons for qualifying new technology services are included. If operating cost exceeds $43,260.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,266.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $6,421.14 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,444.81 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $506.69. The transfer capital threshold is the transfer adjustment factor * $506.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,8872.78,26765.51,Inpatient DRG
Wmhc Perc Implant Stim Lead Ea,CASE-63650,APC,63650,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5965.28,,"APC Price ($5,965.28). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5965.28,6263.54,OPPS APC
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],11137.18,,,,,,0,other,5065.00,12558.65,There are no additional notes associated with this service or procedure.
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],17375.56,,"Case rate ($16,787.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,753.10, add-ons for qualifying new technology services are included. If operating cost exceeds $50,624.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,845.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $13,757.43 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,808.15 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,085.60. The transfer capital threshold is the transfer adjustment factor * $1,085.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,16787.98,62990.26,Inpatient DRG
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],21854.96,,"Fee schedule rate ($21,854.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10638.94,25261.33,There are no additional notes associated with this service or procedure.
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH CC",457,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],85354.74,,"Fee schedule rate ($85,354.74). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,42327.47,160549.49,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],9795.13,,"Case rate ($9,795.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,247.81, add-ons for qualifying new technology services are included. If operating cost exceeds $44,118.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,334.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $7,276.03 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,302.86 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $574.15. The transfer capital threshold is the transfer adjustment factor * $574.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9795.13,23899.13,Inpatient DRG
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],33321.87,,"Fee schedule rate ($33,321.87). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.9), with a minimum of zero.",,,,0,other,13917.42,34889.29,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,091,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],33004.27,,"Fee schedule rate ($33,004.27). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13838.06,40030.81,There are no additional notes associated with this service or procedure.
Arthrodesis Pst/Pstlat Tq 1ntrspc Ea Addl Ntrspc,CASE-22614,APC,22614,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],16412.07,,"APC Price ($16,412.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,16412.07,17232.68,OPPS APC
COAGULATION DISORDERS,813,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],29046.49,,"Fee schedule rate ($29,046.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12274.39,30013.33,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,064,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],41838.16,,"Fee schedule rate ($41,838.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,15563.58,41838.16,There are no additional notes associated with this service or procedure.
SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS,029,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],43834.95,,"Case rate ($25,048.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $23,437.73, add-ons for qualifying new technology services are included. If operating cost exceeds $58,308.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,449.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.7)) / 2. The base transfer operating payment is the transfer adjustment factor * $21,413.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $21,492.79 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,689.76. The transfer capital threshold is the transfer adjustment factor * $1,689.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,13641.00,67130.05,All Other Inpatient
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6521.48,,"Case rate ($6,210.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,921.46, add-ons for qualifying new technology services are included. If operating cost exceeds $40,792.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,064.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $3,961.49 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,976.51 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $304.49. The transfer capital threshold is the transfer adjustment factor * $304.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6340.03,15076.44,Inpatient DRG
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH CC",457,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],160549.49,,"Fee schedule rate ($160,549.49). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,42327.47,160549.49,There are no additional notes associated with this service or procedure.
"MODERATELY EXTENSIVE O.R. PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,MODERATE",793,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],14578.64,,"Case rate ($14,578.64). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,14578.64,15307.57,There are no additional notes associated with this service or procedure.
HC Joint Injection/Aspir Large WO US|PBB CHARGE|LEFT SIDE,CASE-20610,APC,20610,CPT,0510,RC,,,PBB|LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],287.31,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
Removal Implant Deep,CASE-20680,APC,20680,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1827.80,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1827.80,1919.19,OPPS APC
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,699,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],19570.20,,"Fee schedule rate ($19,570.20). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5961.00,19972.16,There are no additional notes associated with this service or procedure.
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC,807,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],10071.17,,"Fee schedule rate ($10,071.17). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5354.25,13266.23,There are no additional notes associated with this service or procedure.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],21455.22,,"Fee schedule rate ($21,455.22). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,9097.60,21455.22,There are no additional notes associated with this service or procedure.
"ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",770,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],17800.73,,"Fee schedule rate ($17,800.73). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,8735.30,19730.13,There are no additional notes associated with this service or procedure.
Esophagogastroduodenoscopy Submucosal Injection|SEPARATE STRUCTURE,CASE-43236,APC,43236,CPT,0360,RC,,,XS,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1859.01,,"APC Price ($1,796.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1796.14,1885.95,OPPS APC
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],45157.33,,"Fee schedule rate ($45,157.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,10733.06,45157.33,There are no additional notes associated with this service or procedure.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],36097.29,,"Case rate ($35,389.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $33,057.71, add-ons for qualifying new technology services are included. If operating cost exceeds $67,928.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,206.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.3. The base transfer operating payment is the transfer adjustment factor * $30,998.46 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $31,112.76 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,446.08. The transfer capital threshold is the transfer adjustment factor * $2,446.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,35389.50,101083.00,Inpatient DRG
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],6633.98,,"Case rate ($6,503.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,186.05, add-ons for qualifying new technology services are included. If operating cost exceeds $41,057.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,093.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $4,225.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,241.10 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $333.44. The transfer capital threshold is the transfer adjustment factor * $333.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6503.90,14492.93,Inpatient DRG
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],45050.58,,"Fee schedule rate ($45,050.58). Adds an outlier to normal pricing equal to the per diem rate ($120,238.99) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,18178.96,54764.34,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],14337.84,,"Case rate ($14,337.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,473.80, add-ons for qualifying new technology services are included. If operating cost exceeds $48,344.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,666.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $11,486.49 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,528.84 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $906.40. The transfer capital threshold is the transfer adjustment factor * $906.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,14337.84,52803.53,Inpatient DRG
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],39424.57,,"Fee schedule rate ($39,424.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12195.15,39424.57,There are no additional notes associated with this service or procedure.
Egd Transoral Biopsy Single/Multiple|SEPARATE STRUCTURE,CASE-43239,APC,43239,CPT,0360,RC,,,XS,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1796.14,,"APC Price ($1,796.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1796.14,1885.95,OPPS APC
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC,964,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],18929.40,,"Fee schedule rate ($18,929.40). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12323.82,34154.06,There are no additional notes associated with this service or procedure.
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC",758,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],9046.80,,"Fee schedule rate ($9,046.80). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8574.80,19263.78,There are no additional notes associated with this service or procedure.
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],35061.53,,"Fee schedule rate ($35,061.53). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,9696.93,35061.53,There are no additional notes associated with this service or procedure.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],52909.62,,"Fee schedule rate ($52,909.62). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,23344.70,62179.32,There are no additional notes associated with this service or procedure.
Neuroplasty &/Transpos Median Nrv Carpal Tunne|BILATERAL PROCEDURE,CASE-64721,APC,64721,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1827.80,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1827.80,1919.19,OPPS APC
Arthrs Aided Ant Cruciate Ligm Rpr/Agmntj/Rcnstj|SEPARATE STRUCTURE|LEFT SIDE,CASE-29888,APC,29888,CPT,0360,RC,,,XS|LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6791.99,7131.59,OPPS APC
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],28038.61,,"Fee schedule rate ($28,038.61). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12126.09,29582.40,There are no additional notes associated with this service or procedure.
"Exc Tum/Vasc Mal Sft Tiss Hand/Fngr Subq <1.5cm|RIGHT HAND, THIRD DIGIT",CASE-26115,APC,26115,CPT,0360,RC,,,F7,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1545.93,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1545.93,1623.23,OPPS APC
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC",011,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],150008.48,,"Fee schedule rate ($150,008.48). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (44), with a minimum of zero.",,,,0,other,38880.49,150008.48,There are no additional notes associated with this service or procedure.
PLEURAL EFFUSION WITH MCC,186,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],29692.94,,"Fee schedule rate ($29,692.94). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10804.96,31089.66,There are no additional notes associated with this service or procedure.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,329,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],86382.02,,"Fee schedule rate ($86,382.02). Adds an outlier to normal pricing equal to the per diem rate ($147,722.18) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,33072.77,90445.33,There are no additional notes associated with this service or procedure.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],33459.28,,"Case rate ($19,119.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,922.16, add-ons for qualifying new technology services are included. If operating cost exceeds $52,793.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,016.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $15,918.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,977.21 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,256.13. The transfer capital threshold is the transfer adjustment factor * $1,256.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,11348.00,62454.12,All Other Inpatient
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],13733.13,,"Case rate ($7,847.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,435.96, add-ons for qualifying new technology services are included. If operating cost exceeds $42,306.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,191.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,470.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,491.01 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $431.70. The transfer capital threshold is the transfer adjustment factor * $431.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,7847.50,17755.26,All Other Inpatient
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],10177.55,,"Case rate ($9,977.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,417.91, add-ons for qualifying new technology services are included. If operating cost exceeds $44,288.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,347.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $7,445.51 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,472.96 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $587.52. The transfer capital threshold is the transfer adjustment factor * $587.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,9977.99,26949.28,Inpatient DRG
APPENDIX PROCEDURES WITH MCC,397,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],45007.36,,"Fee schedule rate ($45,007.36). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.5), with a minimum of zero.",,,,0,other,18163.37,51558.84,There are no additional notes associated with this service or procedure.
DIABETES WITH CC,638,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],15195.79,,"Fee schedule rate ($15,195.79). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8014.07,17634.53,There are no additional notes associated with this service or procedure.
Tendon Sheath Incision,CASE-26055,APC,26055,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1505.12,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1505.12,1580.37,OPPS APC
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],33321.87,,"Fee schedule rate ($33,321.87). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.9), with a minimum of zero.",,,,0,other,13917.42,34889.29,There are no additional notes associated with this service or procedure.
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],22241.27,,"Case rate ($21,489.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,126.50, add-ons for qualifying new technology services are included. If operating cost exceeds $54,997.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,189.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.6. The base transfer operating payment is the transfer adjustment factor * $18,114.76 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,181.55 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,429.43. The transfer capital threshold is the transfer adjustment factor * $1,429.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,21489.15,68942.79,Inpatient DRG
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],16900.84,,"Fee schedule rate ($16,900.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8151.55,18033.97,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],21167.26,,"Fee schedule rate ($21,167.26). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,6841.83,21167.26,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],15076.44,,"Fee schedule rate ($15,076.44). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6340.03,15076.44,There are no additional notes associated with this service or procedure.
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],14492.93,,"Fee schedule rate ($14,492.93). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6503.90,14492.93,There are no additional notes associated with this service or procedure.
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],14525.56,,,,,,0,other,5068.21,14525.56,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],9824.13,,"Case rate ($9,356.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,839.58, add-ons for qualifying new technology services are included. If operating cost exceeds $43,710.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,302.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $6,869.30 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,894.63 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $542.06. The transfer capital threshold is the transfer adjustment factor * $542.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9356.31,25026.36,Inpatient DRG
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],54086.17,,,,,,0,other,20559.34,54086.17,There are no additional notes associated with this service or procedure.
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC,520,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],28074.86,,"Fee schedule rate ($28,074.86). Adds an outlier to normal pricing equal to the per diem rate ($68,872.56) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,12061.74,39786.42,There are no additional notes associated with this service or procedure.
"Open Tx Distal Phalangeal Fracture Each|LEFT HAND, FIFTH DIGIT",CASE-26765,APC,26765,CPT,0360,RC,,,F4,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,555,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],42290.95,,"Fee schedule rate ($42,290.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10896.27,42290.95,There are no additional notes associated with this service or procedure.
HC Pbb Carpal Tunnel Inj Pmc|BILATERAL PROCEDURE,CASE-20526,APC,20526,CPT,0510,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,297.37,OPPS APC
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],9356.31,,"Case rate ($9,356.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,839.58, add-ons for qualifying new technology services are included. If operating cost exceeds $43,710.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,302.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $6,869.30 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,894.63 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $542.06. The transfer capital threshold is the transfer adjustment factor * $542.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9356.31,25026.36,Inpatient DRG
Brnchsc Ebus Guided Sampl 3/> Node Station/Strux,CASE-31653,APC,31653,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6605.95,,"APC Price ($6,605.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6605.95,6936.25,OPPS APC
FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,748,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],25601.70,,"Fee schedule rate ($25,601.70). Adds an outlier to normal pricing equal to the per diem rate ($21,136.29) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9316.20,26805.98,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],19881.64,,,,,,0,other,6965.00,32293.66,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITHOUT STERILIZATION WITH CC,787,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],23722.94,,"Fee schedule rate ($23,722.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9508.01,23722.94,There are no additional notes associated with this service or procedure.
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],35127.88,,"Fee schedule rate ($35,127.88). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.5), with a minimum of zero.",,,,0,other,14603.31,45017.13,There are no additional notes associated with this service or procedure.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC",061,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],20616.23,,"Case rate ($20,616.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $19,314.45, add-ons for qualifying new technology services are included. If operating cost exceeds $54,185.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,125.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $17,305.68 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $17,369.49 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,365.59. The transfer capital threshold is the transfer adjustment factor * $1,365.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,20616.23,62315.82,Inpatient DRG
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",623,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],32096.64,,"Fee schedule rate ($32,096.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,14093.37,33712.76,There are no additional notes associated with this service or procedure.
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],81454.07,,"Fee schedule rate ($81,454.07). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,10078.00,81454.07,There are no additional notes associated with this service or procedure.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],19230.88,,"Fee schedule rate ($19,230.88). Adds an outlier to normal pricing equal to the per diem rate ($71,679.63) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8874.81,20553.44,There are no additional notes associated with this service or procedure.
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],18043.23,,"Fee schedule rate ($18,043.23). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7733.72,18043.23,There are no additional notes associated with this service or procedure.
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],8083.15,,"Case rate ($8,083.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,655.19, add-ons for qualifying new technology services are included. If operating cost exceeds $42,526.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,208.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,689.27 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,710.24 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $448.94. The transfer capital threshold is the transfer adjustment factor * $448.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7884.32,17835.23,Inpatient DRG
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,082,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],17423.21,,"Case rate ($17,423.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,344.04, add-ons for qualifying new technology services are included. If operating cost exceeds $51,215.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,892.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $14,346.19 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,399.08 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,132.06. The transfer capital threshold is the transfer adjustment factor * $1,132.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,17423.21,56223.11,Inpatient DRG
Esophageal Motility Study W/Interp&Rpt,CASE-91010,APC,91010,CPT,0750,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],349.28,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,349.28,366.75,OPPS APC
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,069,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7555.36,,"Case rate ($7,195.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,839.30, add-ons for qualifying new technology services are included. If operating cost exceeds $41,710.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,134.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $4,875.86 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,894.35 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $374.77. The transfer capital threshold is the transfer adjustment factor * $374.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,20333.68,Inpatient DRG
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,074,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],20919.08,,"Fee schedule rate ($20,919.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8925.60,20919.08,There are no additional notes associated with this service or procedure.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],80635.65,,"Fee schedule rate ($80,635.65). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,26028.48,80635.65,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],33398.16,,"Fee schedule rate ($33,398.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,7353.00,33398.16,There are no additional notes associated with this service or procedure.
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITHOUT MCC,430,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],108381.11,,"Fee schedule rate ($108,381.11). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.6), with a minimum of zero.",,,,0,other,41000.16,133156.90,There are no additional notes associated with this service or procedure.
HC N Block Inj Intercost Sng|LEFT SIDE,CASE-64420,APC,64420,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],660.72,,"APC Price ($660.72). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,660.72,693.76,OPPS APC
INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,352,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],10346.04,,"Case rate ($9,853.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,301.99, add-ons for qualifying new technology services are included. If operating cost exceeds $44,173.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,338.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $7,330.01 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,357.04 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $578.41. The transfer capital threshold is the transfer adjustment factor * $578.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9853.37,26528.70,Inpatient DRG
Ligamentous Reconstruction Knee Extra-Articular|RIGHT SIDE,CASE-27427,APC,27427,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],12017.31,,"APC Price ($12,017.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12017.31,12618.18,OPPS APC
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],29594.00,,"Fee schedule rate ($29,594.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,13571.25,33781.47,There are no additional notes associated with this service or procedure.
"Open Tx Articular Fracture Mcp/IP Joint Ea|LEFT HAND, FOURTH DIGIT",CASE-26746,APC,26746,CPT,0360,RC,,,F3,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3169.86,OPPS APC
"CESAREAN SECTION WITHOUT STERILIZATION,MAJOR",540,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],10786.25,,"Case rate ($10,786.25). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,10786.25,11325.56,There are no additional notes associated with this service or procedure.
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],8454.94,,"Case rate ($8,454.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,001.06, add-ons for qualifying new technology services are included. If operating cost exceeds $42,872.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,236.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,033.86 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,056.11 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $476.13. The transfer capital threshold is the transfer adjustment factor * $476.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6230.00,22762.43,Inpatient DRG
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],34272.79,,"Fee schedule rate ($34,272.79). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,14295.18,42768.36,There are no additional notes associated with this service or procedure.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC,099,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],25603.58,,"Fee schedule rate ($25,603.58). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.7), with a minimum of zero.",,,,0,other,11171.21,26807.94,There are no additional notes associated with this service or procedure.
Total Thyroid Lobectomy Uni W/WO Isthmusectomy|RIGHT SIDE,CASE-60220,APC,60220,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5941.70,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5658.76,5941.70,OPPS APC
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],81454.07,,"Fee schedule rate ($81,454.07). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,10078.00,81454.07,There are no additional notes associated with this service or procedure.
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH CC",457,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],112064.54,,"Fee schedule rate ($112,064.54). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.9), with a minimum of zero.",,,,0,other,42327.47,160549.49,There are no additional notes associated with this service or procedure.
Laparoscopy Tot Hysterectomy >250 G W/Tube/Ovar,CASE-58573,APC,58573,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],10298.02,,"APC Price ($9,949.78). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,9949.78,10447.27,OPPS APC
HC Joint Injection/Aspir Large WO US|RIGHT SIDE|PBB CHARGE,CASE-20610,APC,20610,CPT,0510,RC,,,RT|PBB,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],301.68,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,287.31,301.68,OPPS APC
Nsl/Sinus Ndsc Max Antrost W/Rmvl Tiss Max Sinus|BILATERAL PROCEDURE,CASE-31267,APC,31267,CPT,0360,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6936.25,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6605.95,6936.25,OPPS APC
CERVICAL SPINAL FUSION WITH CC,472,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],21896.13,,"Case rate ($21,896.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,505.12, add-ons for qualifying new technology services are included. If operating cost exceeds $55,376.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,219.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $18,491.99 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,560.18 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,459.20. The transfer capital threshold is the transfer adjustment factor * $1,459.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,21896.13,70198.84,Inpatient DRG
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,057,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],39884.93,,"Fee schedule rate ($39,884.93). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,10718.84,39884.93,There are no additional notes associated with this service or procedure.
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH MCC",510,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],89863.76,,"Fee schedule rate ($89,863.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10710.00,89863.76,There are no additional notes associated with this service or procedure.
SPINAL PROCEDURES WITHOUT CC/MCC,030,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],44714.01,,"Fee schedule rate ($44,714.01). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,16810.99,44714.01,There are no additional notes associated with this service or procedure.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],23520.23,,"Fee schedule rate ($23,520.23). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10517.71,24909.11,There are no additional notes associated with this service or procedure.
OSTEOMYELITIS WITH CC,540,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],24361.37,,"Fee schedule rate ($24,361.37). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.6), with a minimum of zero.",,,,0,other,9809.07,25507.30,There are no additional notes associated with this service or procedure.
HC Biopsy of Vulva/Perineum,CASE-56605,APC,56605,CPT,0361,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],892.30,,"APC Price ($862.13). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,862.13,905.23,OPPS APC
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITHOUT CC/MCC,816,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],14733.53,,"Fee schedule rate ($14,733.53). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6224.90,14733.53,There are no additional notes associated with this service or procedure.
COAGULATION DISORDERS,813,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],29046.49,,"Fee schedule rate ($29,046.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12274.39,30013.33,There are no additional notes associated with this service or procedure.
UNGROUPABLE,999,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],161307.29,,"Fee schedule rate ($161,307.29). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (41), with a minimum of zero.",,,,0,other,10228.00,161307.29,There are no additional notes associated with this service or procedure.
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],32263.82,,"Fee schedule rate ($32,263.82). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13571.25,33781.47,There are no additional notes associated with this service or procedure.
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],33835.79,,"Fee schedule rate ($33,835.79). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,7000.00,33835.79,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH CC,427,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],134742.59,,"Fee schedule rate ($134,742.59). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,50829.82,142040.39,There are no additional notes associated with this service or procedure.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],24275.07,,"Case rate ($23,799.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $22,275.40, add-ons for qualifying new technology services are included. If operating cost exceeds $57,146.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,358.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.1. The base transfer operating payment is the transfer adjustment factor * $20,255.77 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $20,330.45 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,598.38. The transfer capital threshold is the transfer adjustment factor * $1,598.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,23799.09,63499.65,Inpatient DRG
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],22695.45,,,,,,0,other,9755.86,29216.99,There are no additional notes associated with this service or procedure.
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],11133.98,,"Fee schedule rate ($11,133.98). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5919.29,13545.65,There are no additional notes associated with this service or procedure.
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC,058,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],13792.24,,"Case rate ($13,521.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,714.66, add-ons for qualifying new technology services are included. If operating cost exceeds $47,585.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,606.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $10,730.14 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,769.70 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $846.71. The transfer capital threshold is the transfer adjustment factor * $846.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,13521.80,40853.02,Inpatient DRG
Nasal/Sinus Ndsc Tot W/Sphendt W/Sphen Tiss Rmvl|RIGHT SIDE,CASE-31259,APC,31259,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6605.95,,"APC Price ($6,605.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6605.95,6936.25,OPPS APC
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],12543.25,,"Case rate ($11,945.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,248.66, add-ons for qualifying new technology services are included. If operating cost exceeds $46,119.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,491.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $9,269.54 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,303.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $731.46. The transfer capital threshold is the transfer adjustment factor * $731.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6167.00,29058.99,Inpatient DRG
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7771.40,,"Case rate ($7,401.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,031.08, add-ons for qualifying new technology services are included. If operating cost exceeds $41,902.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,149.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,066.92 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,086.13 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $389.46. The transfer capital threshold is the transfer adjustment factor * $389.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7566.45,16333.88,Inpatient DRG
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],29594.00,,"Fee schedule rate ($29,594.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,13571.25,33781.47,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,690,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],15212.93,,"Fee schedule rate ($15,212.93). Adds an outlier to normal pricing equal to the per diem rate ($36,758.78) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,7426.94,15928.53,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],9865.56,,"Case rate ($9,865.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,313.33, add-ons for qualifying new technology services are included. If operating cost exceeds $44,184.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,339.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $7,341.31 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,368.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $579.30. The transfer capital threshold is the transfer adjustment factor * $579.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9865.56,37914.65,Inpatient DRG
HC Joint Injection/Aspir Large WO US|SEPARATE STRUCTURE|LEFT SIDE,CASE-20610,APC,20610,CPT,0510,RC,,,XS|LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],25293.50,,"Fee schedule rate ($25,293.50). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11059.47,28423.20,There are no additional notes associated with this service or procedure.
"DIGESTIVE MALIGNANCY,MAJOR",240,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],12892.40,,"The inlier payment is calculated as the lesser of the standard DRG payment $12,892.40 and the transfer payment, which is a per diem of $1,879.36. If cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,12892.40,13537.02,Estimated amount calculated based on 4 day length of stay.
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,306,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],29614.01,,"Fee schedule rate ($29,614.01). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12616.37,31007.02,There are no additional notes associated with this service or procedure.
"Rpr Coltrl Ligm Mtcarphlngl/Iphal Jt|LEFT HAND, THUMB",CASE-26540,APC,26540,CPT,0360,RC,,,FA,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",004,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],272554.00,,,,,,0,other,10249.47,272554.00,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],32293.66,,"Fee schedule rate ($32,293.66). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,32293.66,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,066,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],20083.61,,"Fee schedule rate ($20,083.61). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6579.76,20083.61,There are no additional notes associated with this service or procedure.
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],11249.70,,"Fee schedule rate ($11,249.70). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6965.00,21404.64,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],42768.36,,"Fee schedule rate ($42,768.36). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,14295.18,42768.36,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],22100.60,,"Case rate ($21,667.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,292.19, add-ons for qualifying new technology services are included. If operating cost exceeds $55,163.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,202.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $18,279.84 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,347.24 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,442.46. The transfer capital threshold is the transfer adjustment factor * $1,442.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,8972.00,81524.17,Inpatient DRG
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|RIGHT HAND, THUMB",CASE-26160,APC,26160,CPT,0360,RC,,,F5,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1600.04,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1545.93,1623.23,OPPS APC
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],14455.04,,"Fee schedule rate ($14,455.04). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5280.00,17136.70,There are no additional notes associated with this service or procedure.
"Amputation Metatarsal W/Toe Single|RIGHT FOOT, FIFTH DIGIT",CASE-28810,APC,28810,CPT,0360,RC,,,T9,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],18217.52,,"Fee schedule rate ($18,217.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7414.07,18217.52,There are no additional notes associated with this service or procedure.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH CC,026,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],24150.69,,"Case rate ($23,000.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $21,532.64, add-ons for qualifying new technology services are included. If operating cost exceeds $56,403.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,299.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $19,515.74 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $19,587.69 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,539.98. The transfer capital threshold is the transfer adjustment factor * $1,539.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,23000.66,63202.45,Inpatient DRG
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],21089.59,,"Fee schedule rate ($21,089.59). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,6965.00,21089.59,There are no additional notes associated with this service or procedure.
Excision Tumor Soft Tissue Foot/Toe Subq <1.5cm|LEFT SIDE,CASE-28043,APC,28043,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1623.23,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1545.93,1623.23,OPPS APC
"Open Tx Phalangeal Shaft Fracture Prox/Middle Ea|LEFT HAND, FOURTH DIGIT",CASE-26735,APC,26735,CPT,0360,RC,,,F3,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],35973.56,,"Fee schedule rate ($35,973.56). Adds an outlier to normal pricing equal to the per diem rate ($68,707.98) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,14908.05,49717.39,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC,084,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],19445.16,,"Fee schedule rate ($19,445.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,6965.00,19445.16,There are no additional notes associated with this service or procedure.
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],6457.19,,"Case rate ($6,457.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,142.59, add-ons for qualifying new technology services are included. If operating cost exceeds $41,013.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,089.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $4,182.21 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,197.63 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $330.02. The transfer capital threshold is the transfer adjustment factor * $330.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,5139.72,13110.79,Inpatient DRG
Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq,CASE-45385,APC,45385,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1159.29,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1120.09,1176.09,OPPS APC
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,479,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],36577.58,,,,,,0,other,10586.00,50518.76,There are no additional notes associated with this service or procedure.
Mastopexy|BILATERAL PROCEDURE,CASE-19316,APC,19316,CPT,0360,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6432.89,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6432.89,6526.12,OPPS APC
Myomectomy 5/> Myomas &/>250 Gm Abdomina,CASE-58146,APC,58146,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],209.05,,"APC Price ($199.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,206.06,209.05,OPPS APC
Unlisted Procedure Arthroscopy,CASE-29999,APC,29999,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
CESAREAN SECTION WITH STERILIZATION WITHOUT CC/MCC,785,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],8852.80,,"Case rate ($8,431.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,979, add-ons for qualifying new technology services are included. If operating cost exceeds $42,850.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,234.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,011.89 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,034.06 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $474.40. The transfer capital threshold is the transfer adjustment factor * $474.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8431.24,20142.33,Inpatient DRG
Colsc Flx With Directed Submucosal Njx Any Sbst,CASE-45381,APC,45381,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1159.29,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1120.09,1176.09,OPPS APC
MINOR BLADDER PROCEDURES WITHOUT CC/MCC,664,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],9034.63,,"Case rate ($9,034.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,540.33, add-ons for qualifying new technology services are included. If operating cost exceeds $43,411.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,278.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $6,571.15 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,595.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $518.53. The transfer capital threshold is the transfer adjustment factor * $518.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9034.63,31876.87,Inpatient DRG
Surg Nasopharyngoscopy Dilat Eustachian Tube Bi,CASE-69706,APC,69706,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5818.16,,"APC Price ($5,541.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5541.10,5818.16,OPPS APC
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC,027,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],47412.86,,"Fee schedule rate ($47,412.86). Adds an outlier to normal pricing equal to the per diem rate ($103,062) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,19030.20,56363.30,There are no additional notes associated with this service or procedure.
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],20846.48,,"Case rate ($20,846.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $19,528.64, add-ons for qualifying new technology services are included. If operating cost exceeds $54,399.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,142.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $17,519.09 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $17,583.69 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,382.43. The transfer capital threshold is the transfer adjustment factor * $1,382.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,20846.48,81306.30,Inpatient DRG
Cysto/Pyeloscopy Bx&/Fulguration Pelivc Lesion|LEFT SIDE,CASE-52354,APC,52354,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5018.77,,"APC Price ($5,018.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5018.77,5269.71,OPPS APC
Egd Intrmural US Needle Aspirate/Biopsy Esophags,CASE-43238,APC,43238,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1859.01,,"APC Price ($1,796.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1796.14,1885.95,OPPS APC
HC Joint Injection/Aspir Large WO US|PBB CHARGE|BILATERAL PROCEDURE,CASE-20610,APC,20610,CPT,0510,RC,,,PBB|50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],301.68,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,287.31,301.68,OPPS APC
SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS,029,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],61889.56,,"Fee schedule rate ($61,889.56). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13641.00,67130.05,There are no additional notes associated with this service or procedure.
HC Drain/Inj Joint/Bursa W/US Large|PBB CHARGE,CASE-20611,APC,20611,CPT,0510,RC,,,PBB,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],297.37,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,287.31,301.68,OPPS APC
HC N Block Inj Intercost Sng|RIGHT SIDE,CASE-64420,APC,64420,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],683.85,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,660.72,693.76,OPPS APC
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],30398.48,,"Case rate ($30,398.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $28,414.67, add-ons for qualifying new technology services are included. If operating cost exceeds $63,285.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,841.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.2. The base transfer operating payment is the transfer adjustment factor * $26,372.48 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $26,469.72 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,081.05. The transfer capital threshold is the transfer adjustment factor * $2,081.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,30398.48,82674.88,Inpatient DRG
Repair Brow Ptosis|BILATERAL PROCEDURE,CASE-67900,APC,67900,CPT,0360,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],2303.27,,"APC Price ($2,225.38). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2225.38,2336.65,OPPS APC
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],8057.43,,"Case rate ($8,057.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,631.26, add-ons for qualifying new technology services are included. If operating cost exceeds $42,502.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,207.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,665.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,686.30 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $447.06. The transfer capital threshold is the transfer adjustment factor * $447.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6524.00,17760.46,Inpatient DRG
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],10643.26,,"Case rate ($10,136.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,565.33, add-ons for qualifying new technology services are included. If operating cost exceeds $44,436.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,359.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $7,592.38 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,620.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $599.11. The transfer capital threshold is the transfer adjustment factor * $599.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10136.44,24444.75,Inpatient DRG
SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS,029,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],61889.56,,"Fee schedule rate ($61,889.56). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13641.00,67130.05,There are no additional notes associated with this service or procedure.
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,451,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],94077.13,,"Fee schedule rate ($94,077.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,23821.44,94077.13,There are no additional notes associated with this service or procedure.
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],54180.83,,"Fee schedule rate ($54,180.83). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,15491.11,54180.83,There are no additional notes associated with this service or procedure.
"NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY",789,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],14857.05,,"Case rate ($14,149.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,298.65, add-ons for qualifying new technology services are included. If operating cost exceeds $48,169.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,652.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $11,312.00 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,353.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $892.63. The transfer capital threshold is the transfer adjustment factor * $892.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,3054.00,14857.05,Inpatient DRG
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],16438.59,,"Fee schedule rate ($16,438.59). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7402.56,16438.59,There are no additional notes associated with this service or procedure.
Arthrs Kne Surg W/Meniscectomy Med/Lat W/Shvg|LEFT SIDE,CASE-29881,APC,29881,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",759,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],11643.60,,"Fee schedule rate ($11,643.60). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6190.22,13057.66,There are no additional notes associated with this service or procedure.
Exc B9 Lesion Mrgn Xcp Sk Tg S/N/H/F/G 0.5 Cm/<,CASE-11420,APC,11420,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1545.93,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1545.93,1623.23,OPPS APC
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],19011.10,,"Case rate ($18,105.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,979.06, add-ons for qualifying new technology services are included. If operating cost exceeds $51,850.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,941.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $14,978.89 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,034.11 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,181.98. The transfer capital threshold is the transfer adjustment factor * $1,181.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,18105.81,52699.33,Inpatient DRG
"Exc Tum/Vasc Mal Sft Tiss Hand/Fngr Subq <1.5cm|RIGHT HAND, THIRD DIGIT",CASE-26115,APC,26115,CPT,0360,RC,,,F7,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1545.93,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1545.93,1623.23,OPPS APC
HC Trigger Point 3 or More,CASE-20553,APC,20553,CPT,0510,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],287.31,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],13952.52,,"Case rate ($13,952.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,115.33, add-ons for qualifying new technology services are included. If operating cost exceeds $47,986.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,638.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $11,129.34 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,170.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $878.22. The transfer capital threshold is the transfer adjustment factor * $878.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,13917.42,34889.29,Inpatient DRG
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,451,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],24655.19,,"Case rate ($23,821.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $22,296.19, add-ons for qualifying new technology services are included. If operating cost exceeds $57,167.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,359.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $20,276.48 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $20,351.24 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,600.01. The transfer capital threshold is the transfer adjustment factor * $1,600.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,23821.44,94077.13,Inpatient DRG
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],40737.46,,"Fee schedule rate ($40,737.46). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,7665.00,40737.46,There are no additional notes associated with this service or procedure.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],45845.03,,"Fee schedule rate ($45,845.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,18598.83,48389.68,There are no additional notes associated with this service or procedure.
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,068,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],23184.90,,"Fee schedule rate ($23,184.90). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,23184.90,There are no additional notes associated with this service or procedure.
HC Cv Cath Plac W/Port Tun >5,CASE-36561,APC,36561,CPT,0361,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3058.92,,"APC Price ($2,955.48). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2955.48,3103.25,OPPS APC
Arthrs Aided Ant Cruciate Ligm Rpr/Agmntj/Rcnstj|LEFT SIDE,CASE-29888,APC,29888,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],12017.31,,"APC Price ($12,017.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12017.31,12618.18,OPPS APC
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],16379.98,,"Fee schedule rate ($16,379.98). Adds an outlier to normal pricing equal to the per diem rate ($46,377.87) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7847.50,17755.26,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],34481.40,,"Fee schedule rate ($34,481.40). Adds an outlier to normal pricing equal to the per diem rate ($50,543.29) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,14370.36,38378.80,There are no additional notes associated with this service or procedure.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],37550.29,,"Fee schedule rate ($37,550.29). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,15476.23,42787.31,There are no additional notes associated with this service or procedure.
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],21673.70,,"Case rate ($21,248.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $19,902.85, add-ons for qualifying new technology services are included. If operating cost exceeds $54,773.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,171.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.3. The base transfer operating payment is the transfer adjustment factor * $17,891.94 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $17,957.90 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,411.85. The transfer capital threshold is the transfer adjustment factor * $1,411.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,21248.73,56089.29,Inpatient DRG
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],27222.08,,"Fee schedule rate ($27,222.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7389.00,37134.43,There are no additional notes associated with this service or procedure.
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 2nd Level,CASE-64494,APC,64494,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],869.28,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,827.89,869.28,OPPS APC
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],18905.23,,"Fee schedule rate ($18,905.23). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6963.00,18954.85,There are no additional notes associated with this service or procedure.
Nasal/Sinus Endoscopy W/Sphenoidotomy|BILATERAL PROCEDURE,CASE-31287,APC,31287,CPT,0360,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6936.25,,"APC Price ($6,605.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6605.95,6936.25,OPPS APC
HC Joint Injection/Aspir Large WO US|UNUSUAL NON-OVERLAPPING SERVICE|RIGHT SIDE,CASE-20610,APC,20610,CPT,0510,RC,,,XU|RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],297.37,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,287.31,301.68,OPPS APC
TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC,084,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],19445.16,,"Fee schedule rate ($19,445.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,6965.00,19445.16,There are no additional notes associated with this service or procedure.
NON-MALIGNANT BREAST DISORDERS WITH CC/MCC,600,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],9231.13,,"Case rate ($8,791.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,326.97, add-ons for qualifying new technology services are included. If operating cost exceeds $43,197.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,248.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $6,357.91 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,382.02 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $488.68. The transfer capital threshold is the transfer adjustment factor * $488.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7999.14,20495.56,Inpatient DRG
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],32974.20,,"Fee schedule rate ($32,974.20). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,18594.09,59494.91,There are no additional notes associated with this service or procedure.
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],24387.68,,"Fee schedule rate ($24,387.68). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10733.06,45157.33,There are no additional notes associated with this service or procedure.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],36776.05,,"Fee schedule rate ($36,776.05). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11053.39,36776.05,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],18366.40,,"Fee schedule rate ($18,366.40). Adds an outlier to normal pricing equal to the per diem rate ($38,964.32) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.5), with a minimum of zero.",,,,0,other,8563.30,31533.97,There are no additional notes associated with this service or procedure.
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],56089.29,,,,,,0,other,21248.73,56089.29,There are no additional notes associated with this service or procedure.
FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,748,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],9316.20,,"Case rate ($8,872.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $8,280.81, add-ons for qualifying new technology services are included. If operating cost exceeds $47,850.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $3,420.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.4. The base transfer operating payment is the transfer adjustment factor * $8,243.19. The transfer operating threshold is the transfer adjustment factor * $8,280.81 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $629.38. The transfer capital threshold is the transfer adjustment factor * $629.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9316.20,26805.98,Inpatient DRG
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],14455.04,,"Fee schedule rate ($14,455.04). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5280.00,17136.70,There are no additional notes associated with this service or procedure.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],23618.74,,"Fee schedule rate ($23,618.74). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10533.95,24956.34,There are no additional notes associated with this service or procedure.
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH MCC",510,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],89863.76,,"Fee schedule rate ($89,863.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10710.00,89863.76,There are no additional notes associated with this service or procedure.
Laps Fulg/Exc Ovary Viscera/Peritoneal Surface|LEFT SIDE,CASE-58662,APC,58662,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5658.76,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5658.76,5941.70,OPPS APC
GASTROINTESTINAL HEMORRHAGE WITH MCC,377,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],31575.65,,"Fee schedule rate ($31,575.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,7634.00,35969.56,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,083,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],28680.85,,"Fee schedule rate ($28,680.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,28680.85,There are no additional notes associated with this service or procedure.
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],13568.55,,"Fee schedule rate ($13,568.55). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6834.39,21354.82,There are no additional notes associated with this service or procedure.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC,858,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],26176.77,,"Fee schedule rate ($26,176.77). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11377.76,33794.11,There are no additional notes associated with this service or procedure.
Dstr Nrolytc Agnt Parverteb Fct Addl Crvcl/Thora,CASE-64634,APC,64634,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1827.80,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1827.80,1919.19,OPPS APC
Cysto Bladder W/Ureteral Catheterization|BILATERAL PROCEDURE,CASE-52005,APC,52005,CPT,0360,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],2054.48,,"APC Price ($1,956.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1956.65,2054.48,OPPS APC
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],28423.20,,"Fee schedule rate ($28,423.20). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11059.47,28423.20,There are no additional notes associated with this service or procedure.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,057,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],39884.93,,"Fee schedule rate ($39,884.93). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,10718.84,39884.93,There are no additional notes associated with this service or procedure.
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],30977.50,,,,,,0,other,12606.23,36868.88,There are no additional notes associated with this service or procedure.
Egd Intrmural Needle Aspir/Biop Altered Anatomy,CASE-43242,APC,43242,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3608.81,,"APC Price ($3,608.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3608.81,3789.26,OPPS APC
CESAREAN SECTION WITH STERILIZATION WITHOUT CC/MCC,785,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],20142.33,,"Fee schedule rate ($20,142.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8431.24,20142.33,There are no additional notes associated with this service or procedure.
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],6965.00,,,,,,0,other,6965.00,16400.70,There are no additional notes associated with this service or procedure.
Insj/Rplcmt Breast Implant Sep Day Mastectomy|BILATERAL PROCEDURE,CASE-19342,APC,19342,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],7650.49,,"APC Price ($7,650.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,7650.49,7650.49,OPPS APC
Hallux Rigidus W/Cheilectomy 1st Mp Jt W/O Implt|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-28289,APC,28289,CPT,0360,RC,,,LT|XU,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],10243.65,,"Case rate ($9,755.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,211.27, add-ons for qualifying new technology services are included. If operating cost exceeds $44,082.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,331.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $7,239.63 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,266.32 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $571.28. The transfer capital threshold is the transfer adjustment factor * $571.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9755.86,29216.99,Inpatient DRG
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],22451.27,,"Case rate ($21,382.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,026.97, add-ons for qualifying new technology services are included. If operating cost exceeds $54,897.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,181.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6)) / 2. The base transfer operating payment is the transfer adjustment factor * $18,015.59 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,082.01 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,421.61. The transfer capital threshold is the transfer adjustment factor * $1,421.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,21382.16,85466.62,Inpatient DRG
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC",605,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],8148.17,,"Case rate ($8,148.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,715.67, add-ons for qualifying new technology services are included. If operating cost exceeds $42,586.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,213.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,749.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,770.72 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $453.69. The transfer capital threshold is the transfer adjustment factor * $453.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8148.17,18024.13,Inpatient DRG
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],50392.99,,"Fee schedule rate ($50,392.99). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,23526.87,94787.57,There are no additional notes associated with this service or procedure.
"Tendon Sheath Incision|UNUSUAL NON-OVERLAPPING SERVICE|LEFT HAND, THUMB",CASE-26055,APC,26055,CPT,0360,RC,,,XU|FA,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],16926.26,,"Case rate ($16,120.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,131.93, add-ons for qualifying new technology services are included. If operating cost exceeds $50,002.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,796.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $13,138.54 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,186.98 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,036.76. The transfer capital threshold is the transfer adjustment factor * $1,036.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,16120.25,41187.90,Inpatient DRG
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC,964,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],12940.01,,"Case rate ($12,323.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,600.20, add-ons for qualifying new technology services are included. If operating cost exceeds $46,471.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,519.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $9,619.78 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,655.25 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $759.10. The transfer capital threshold is the transfer adjustment factor * $759.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12323.82,34154.06,Inpatient DRG
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],14699.43,,"Fee schedule rate ($14,699.43). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6683.37,14699.43,There are no additional notes associated with this service or procedure.
"CARDIAC ARREST, UNEXPLAINED WITH MCC",296,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],36459.67,,"Fee schedule rate ($36,459.67). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12522.25,36459.67,There are no additional notes associated with this service or procedure.
HYPERTENSION WITHOUT MCC,305,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],17230.49,,"Fee schedule rate ($17,230.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7058.55,17230.49,There are no additional notes associated with this service or procedure.
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],39424.57,,"Fee schedule rate ($39,424.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12195.15,39424.57,There are no additional notes associated with this service or procedure.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,191,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],16612.88,,"Fee schedule rate ($16,612.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6965.00,16612.88,There are no additional notes associated with this service or procedure.
OTHER CEREBROVASCULAR DISORDERS WITH CC,071,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],29215.10,,"Fee schedule rate ($29,215.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5843.00,29215.10,There are no additional notes associated with this service or procedure.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],61290.90,,"Fee schedule rate ($61,290.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,23799.09,63499.65,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],22578.15,,"Fee schedule rate ($22,578.15). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,7665.00,40737.46,There are no additional notes associated with this service or procedure.
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],17255.73,,"Fee schedule rate ($17,255.73). Adds an outlier to normal pricing equal to the per diem rate ($43,191.57) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,8163.06,18067.42,There are no additional notes associated with this service or procedure.
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],16787.98,,"Case rate ($16,787.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,753.10, add-ons for qualifying new technology services are included. If operating cost exceeds $50,624.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,845.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $13,757.43 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,808.15 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,085.60. The transfer capital threshold is the transfer adjustment factor * $1,085.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,16787.98,62990.26,Inpatient DRG
"NEONATE BIRTH WEIGHT > 2499 GRAMS WITH OTHER SIGNIFICANT CONDITION,MAJOR",639,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],16816.37,,"Case rate ($16,816.37). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,16816.37,17657.19,There are no additional notes associated with this service or procedure.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],70852.14,,"Fee schedule rate ($70,852.14). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,33623.33,133270.57,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],6153.12,,"Case rate ($6,153.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,859.72, add-ons for qualifying new technology services are included. If operating cost exceeds $40,730.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,067.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,900.39 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,914.77 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $307.78. The transfer capital threshold is the transfer adjustment factor * $307.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6153.12,13947.32,Inpatient DRG
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,167,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],14488.93,,"Case rate ($13,798.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,994.61, add-ons for qualifying new technology services are included. If operating cost exceeds $47,865.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,606.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $11,007.93 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,049.66 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $846.10. The transfer capital threshold is the transfer adjustment factor * $846.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,14157.71,43522.37,Inpatient DRG
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC",514,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],19212.08,,"Fee schedule rate ($19,212.08). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,8868.04,22699.91,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],15076.44,,"Fee schedule rate ($15,076.44). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6340.03,15076.44,There are no additional notes associated with this service or procedure.
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],29594.00,,"Fee schedule rate ($29,594.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,13571.25,33781.47,There are no additional notes associated with this service or procedure.
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],62990.26,,"Fee schedule rate ($62,990.26). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,16787.98,62990.26,There are no additional notes associated with this service or procedure.
"Corrj Hallux Valgus W/Sesmdc W/Dist Metar Osteot|LEFT FOOT, GREAT TOE",CASE-28296,APC,28296,CPT,0360,RC,,,TA,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6791.99,7131.59,OPPS APC
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],19523.79,,"Case rate ($18,594.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,433.29, add-ons for qualifying new technology services are included. If operating cost exceeds $52,304.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,977.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $15,431.44 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,488.34 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,217.69. The transfer capital threshold is the transfer adjustment factor * $1,217.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,18594.09,59494.91,Inpatient DRG
NON-MALIGNANT BREAST DISORDERS WITH CC/MCC,600,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],9313.70,,"Case rate ($8,998.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,506.94, add-ons for qualifying new technology services are included. If operating cost exceeds $43,377.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,275.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $6,537.88 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,561.99 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $515.90. The transfer capital threshold is the transfer adjustment factor * $515.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,7999.14,20495.56,Inpatient DRG
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],7904.27,,"Case rate ($7,749.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,344.60, add-ons for qualifying new technology services are included. If operating cost exceeds $42,215.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,184.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,379.82 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,399.66 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $424.52. The transfer capital threshold is the transfer adjustment factor * $424.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6711.00,16865.16,Inpatient DRG
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,056,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],59328.19,,"Fee schedule rate ($59,328.19). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (44), with a minimum of zero.",,,,0,other,7659.00,59328.19,There are no additional notes associated with this service or procedure.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC,858,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],33794.11,,"Fee schedule rate ($33,794.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11377.76,33794.11,There are no additional notes associated with this service or procedure.
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],33188.44,,"Fee schedule rate ($33,188.44). Adds an outlier to normal pricing equal to the per diem rate ($84,167.29) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.5), with a minimum of zero.",,,,0,other,13904.43,34749.58,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],23316.48,,"Fee schedule rate ($23,316.48). Adds an outlier to normal pricing equal to the per diem rate ($44,995.76) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7.7), with a minimum of zero.",,,,0,other,10347.06,28821.04,There are no additional notes associated with this service or procedure.
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],12502.35,,"Fee schedule rate ($12,502.35). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6801.88,22557.82,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC,833,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],5721.39,,"Fee schedule rate ($5,721.39). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,3041.73,10289.10,There are no additional notes associated with this service or procedure.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,057,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],11254.78,,"Case rate ($10,718.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,107.12, add-ons for qualifying new technology services are included. If operating cost exceeds $44,978.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,401.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,132.18 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,162.17 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $641.71. The transfer capital threshold is the transfer adjustment factor * $641.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10718.84,39884.93,Inpatient DRG
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],15600.07,,"Fee schedule rate ($15,600.07). Adds an outlier to normal pricing equal to the per diem rate ($180,117.98) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,7566.45,16333.88,There are no additional notes associated with this service or procedure.
NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,601,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],11369.77,,"Fee schedule rate ($11,369.77). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,6042.05,12359.72,There are no additional notes associated with this service or procedure.
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],7868.00,,"Per diem ($7,868). If length of stay < 3.9, first 1 days paid at a per diem of $15,736 instead. Capped at $30,683.33.",,,,0,other,7868.00,32126.64,Estimated amount calculated based on 3 day length of stay.
HC Inj Lympho for Sentinal Node,CASE-38792,APC,38792,CPT,0361,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6526.12,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6215.36,6526.12,OPPS APC
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITHOUT CC/MCC,428,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],118904.57,,"Fee schedule rate ($118,904.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,40017.53,118904.57,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],88188.38,,,,,,0,other,32296.02,88188.38,There are no additional notes associated with this service or procedure.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],6965.00,,,,,,0,other,5778.62,11681.49,There are no additional notes associated with this service or procedure.
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,068,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],7798.73,,"Case rate ($7,798.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,390.60, add-ons for qualifying new technology services are included. If operating cost exceeds $42,261.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,188.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $5,425.64 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,445.65 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $428.14. The transfer capital threshold is the transfer adjustment factor * $428.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,23184.90,Inpatient DRG
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC,831,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],23661.59,,,,,,0,other,4941.30,23661.59,There are no additional notes associated with this service or procedure.
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITHOUT CC/MCC",630,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],27428.38,,"Fee schedule rate ($27,428.38). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,11828.78,42541.02,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],36028.59,,,,,,0,other,14344.60,36028.59,There are no additional notes associated with this service or procedure.
COMPLICATIONS OF TREATMENT WITH CC,920,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],20731.52,,"Fee schedule rate ($20,731.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8732.59,20731.52,There are no additional notes associated with this service or procedure.
NERVOUS SYSTEM NEOPLASMS WITH MCC,054,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12580.56,,"Case rate ($11,981.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,300.46, add-ons for qualifying new technology services are included. If operating cost exceeds $46,171.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,476.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $9,320.18 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,355.51 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $716.37. The transfer capital threshold is the transfer adjustment factor * $716.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,30044.81,Inpatient DRG
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],24675.88,,"Fee schedule rate ($24,675.88). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10834.64,25830.00,There are no additional notes associated with this service or procedure.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],16900.84,,"Fee schedule rate ($16,900.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8151.55,18033.97,There are no additional notes associated with this service or procedure.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],97015.50,,"Fee schedule rate ($97,015.50). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,26809.29,97015.50,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6340.03,,"Case rate ($6,340.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,033.60, add-ons for qualifying new technology services are included. If operating cost exceeds $40,904.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,081.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $4,073.62 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,088.64 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $321.45. The transfer capital threshold is the transfer adjustment factor * $321.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6340.03,15076.44,Inpatient DRG
Excision Olecranon Bursa|RIGHT SIDE,CASE-24105,APC,24105,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3169.86,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
"Arthrodesis Interphalangeal Jt W/WO Int Fixj|LEFT HAND, FOURTH DIGIT",CASE-26860,APC,26860,CPT,0360,RC,,,F3,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],30063.84,,"Fee schedule rate ($30,063.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13891.57,34712.20,There are no additional notes associated with this service or procedure.
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],16865.16,,,,,,0,other,6711.00,16865.16,There are no additional notes associated with this service or procedure.
Arthrp Interpos Intercarpal/Metacarpal Joints|LEFT SIDE,CASE-25447,APC,25447,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
OTHER CEREBROVASCULAR DISORDERS WITH MCC,070,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],31286.59,,"Fee schedule rate ($31,286.59). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13219.09,37774.46,There are no additional notes associated with this service or procedure.
HC Plcmt Tunnel Pleural Drain Cat,CASE-32550,APC,32550,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3351.34,,"APC Price ($3,351.34). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3351.34,3518.91,OPPS APC
NON-MALIGNANT BREAST DISORDERS WITH CC/MCC,600,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],9448.68,,"Case rate ($8,998.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,506.94, add-ons for qualifying new technology services are included. If operating cost exceeds $43,377.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,275.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $6,537.88 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,561.99 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $515.90. The transfer capital threshold is the transfer adjustment factor * $515.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7999.14,20495.56,Inpatient DRG
Hallux Rigidus W/Cheilectomy 1st Mp Jt W/O Implt,CASE-28289,APC,28289,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],14581.08,,"Case rate ($14,295.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,434.11, add-ons for qualifying new technology services are included. If operating cost exceeds $48,305.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,663.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $11,446.95 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,489.15 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $903.28. The transfer capital threshold is the transfer adjustment factor * $903.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,14295.18,42768.36,Inpatient DRG
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],12961.20,,"Fee schedule rate ($12,961.20). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,23385.72,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],27802.06,,"Case rate ($27,256.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $25,492.14, add-ons for qualifying new technology services are included. If operating cost exceeds $60,363.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,611.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. The base transfer operating payment is the transfer adjustment factor * $23,460.69 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $23,547.19 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,851.28. The transfer capital threshold is the transfer adjustment factor * $1,851.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,27256.92,81353.66,Inpatient DRG
HC Inj Aa&/Strd Greater Occipital Nerve|LEFT SIDE,CASE-64405,APC,64405,CPT,0450,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
INFLAMMATORY BOWEL DISEASE WITH MCC,385,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],21593.52,,"Fee schedule rate ($21,593.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11480.01,31134.92,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],19763.43,,"Fee schedule rate ($19,763.43). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,8318.14,19763.43,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],30372.64,,"Fee schedule rate ($30,372.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,13260.40,32878.30,There are no additional notes associated with this service or procedure.
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,094,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],26680.83,,"Case rate ($25,778.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $24,116.87, add-ons for qualifying new technology services are included. If operating cost exceeds $58,987.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,503.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.9. The base transfer operating payment is the transfer adjustment factor * $22,090.47 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $22,171.92 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,743.16. The transfer capital threshold is the transfer adjustment factor * $1,743.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,25778.58,67889.44,Inpatient DRG
PERIPHERAL VASCULAR DISORDERS WITH CC,300,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],20331.78,,"Fee schedule rate ($20,331.78). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,9174.14,21005.20,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],14337.84,,"Case rate ($14,337.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,473.80, add-ons for qualifying new technology services are included. If operating cost exceeds $48,344.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,666.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $11,486.49 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,528.84 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $906.40. The transfer capital threshold is the transfer adjustment factor * $906.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,14337.84,52803.53,Inpatient DRG
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,479,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],26857.86,,"Fee schedule rate ($26,857.86). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,10586.00,50518.76,There are no additional notes associated with this service or procedure.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,479,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],50518.76,,"Fee schedule rate ($50,518.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,10586.00,50518.76,There are no additional notes associated with this service or procedure.
"VAGINAL DELIVERY,MAJOR",560,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],6092.62,,"Case rate ($6,092.62). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,6092.62,6397.25,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC,832,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],9034.88,,"Fee schedule rate ($9,034.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4803.31,14198.92,There are no additional notes associated with this service or procedure.
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],7993.75,,"Case rate ($7,993.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,572.03, add-ons for qualifying new technology services are included. If operating cost exceeds $42,443.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,202.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $5,606.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,627.08 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $442.40. The transfer capital threshold is the transfer adjustment factor * $442.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,5415.00,17575.50,Inpatient DRG
Replacement Tissue Expander W/Permanent Implant,CASE-11970,APC,11970,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7029.71,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6791.99,7131.59,OPPS APC
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC,434,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],14019.86,,,,,,0,other,6770.05,14019.86,There are no additional notes associated with this service or procedure.
"Amp F/Th 1/2 Jt/Phalanx W/Neurect W/Dir Clsr|LEFT HAND, SECOND DIGIT",CASE-26951,APC,26951,CPT,0360,RC,,,F1,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,337,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],38926.31,,"Fee schedule rate ($38,926.31). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,12340.08,38926.31,There are no additional notes associated with this service or procedure.
Excision Interdigital Morton Neuroma Single Each|RIGHT SIDE,CASE-28080,APC,28080,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1557.80,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1505.12,1580.37,OPPS APC
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],10448.91,,"Fee schedule rate ($10,448.91). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,3079.00,10940.41,There are no additional notes associated with this service or procedure.
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC",514,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],19212.08,,"Fee schedule rate ($19,212.08). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,8868.04,22699.91,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,066,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],6908.75,,"Case rate ($6,579.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,256.61, add-ons for qualifying new technology services are included. If operating cost exceeds $41,127.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,098.96, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $4,295.82 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,311.66 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $338.98. The transfer capital threshold is the transfer adjustment factor * $338.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6579.76,20083.61,Inpatient DRG
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC,817,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],43874.75,,"Fee schedule rate ($43,874.75). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,17396.11,44895.04,There are no additional notes associated with this service or procedure.
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],62990.26,,"Fee schedule rate ($62,990.26). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,16787.98,62990.26,There are no additional notes associated with this service or procedure.
SPINAL PROCEDURES WITHOUT CC/MCC,030,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],44714.01,,"Fee schedule rate ($44,714.01). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,16810.99,44714.01,There are no additional notes associated with this service or procedure.
NERVOUS SYSTEM NEOPLASMS WITH MCC,054,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],12530.92,,"Case rate ($12,285.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,564.29, add-ons for qualifying new technology services are included. If operating cost exceeds $46,435.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,516.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $9,584.00 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,619.34 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $756.27. The transfer capital threshold is the transfer adjustment factor * $756.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6965.00,30044.81,Inpatient DRG
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],7386.59,,"Case rate ($7,034.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,679.97, add-ons for qualifying new technology services are included. If operating cost exceeds $41,550.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,132.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $4,717.62 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,735.02 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $372.27. The transfer capital threshold is the transfer adjustment factor * $372.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,21089.59,Inpatient DRG
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],42768.36,,"Fee schedule rate ($42,768.36). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,14295.18,42768.36,There are no additional notes associated with this service or procedure.
CERVICAL SPINAL FUSION WITH MCC,471,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],90745.76,,"Fee schedule rate ($90,745.76). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,34645.26,111337.93,There are no additional notes associated with this service or procedure.
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],15244.88,,"Fee schedule rate ($15,244.88). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,7438.45,15961.98,There are no additional notes associated with this service or procedure.
Nsl/Sinus Ndsc Max Antrost W/Rmvl Tiss Max Sinus,CASE-31267,APC,31267,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6605.95,,"APC Price ($6,605.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6605.95,6936.25,OPPS APC
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,066,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],20083.61,,"Fee schedule rate ($20,083.61). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6579.76,20083.61,There are no additional notes associated with this service or procedure.
Lamnotmy Incl W/Dcmprsn Nrv Root 1 Intrspc Lumbr|RIGHT SIDE,CASE-63030,APC,63030,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],41030.48,,,,,,0,other,6965.00,41030.48,There are no additional notes associated with this service or procedure.
HC Gastroesophag Reflx Test W/Tel Ph Eltrd|REDUCED SERVICES,CASE-91035,APC,91035,CPT,0750,RC,,,52,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],803.80,,"APC Price ($803.80). Discounted by 50%. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,803.80,843.99,OPPS APC
DIABETES WITH CC,638,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],15195.79,,"Fee schedule rate ($15,195.79). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8014.07,17634.53,There are no additional notes associated with this service or procedure.
Bx/Exc Lymph Node Open Deep Axillary Node|BILATERAL PROCEDURE,CASE-38525,APC,38525,CPT,0360,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6432.89,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6215.36,6526.12,OPPS APC
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],31577.54,,"Fee schedule rate ($31,577.54). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,15453.88,39251.68,There are no additional notes associated with this service or procedure.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],38517.10,,"Fee schedule rate ($38,517.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,16897.01,43444.85,There are no additional notes associated with this service or procedure.
Inj for Sacroiliac Jt Anesth|BILATERAL PROCEDURE,CASE-G0260,APC,G0260,CPT,0360,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],683.85,,"APC Price ($660.72). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,660.72,693.76,OPPS APC
INFLAMMATORY BOWEL DISEASE WITH MCC,385,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],21593.52,,"Fee schedule rate ($21,593.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11480.01,31134.92,There are no additional notes associated with this service or procedure.
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],20170.75,,"Fee schedule rate ($20,170.75). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10048.39,23545.50,There are no additional notes associated with this service or procedure.
APPENDIX PROCEDURES WITH MCC,397,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],19071.54,,"Case rate ($18,163.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,032.61, add-ons for qualifying new technology services are included. If operating cost exceeds $51,903.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,946.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $15,032.24 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,087.66 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,186.19. The transfer capital threshold is the transfer adjustment factor * $1,186.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,18163.37,51558.84,Inpatient DRG
VAGINAL DELIVERY WITH O.R. PROCEDURES EXCEPT STERILIZATION AND/OR D&C,768,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],9662.00,,"Case rate ($9,201.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,695.94, add-ons for qualifying new technology services are included. If operating cost exceeds $43,566.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,290.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $6,726.19 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,750.99 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $530.76. The transfer capital threshold is the transfer adjustment factor * $530.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6426.91,13416.00,Inpatient DRG
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC,817,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],43874.75,,"Fee schedule rate ($43,874.75). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,17396.11,44895.04,There are no additional notes associated with this service or procedure.
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",759,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],11643.60,,"Fee schedule rate ($11,643.60). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6190.22,13057.66,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],12992.90,,"Case rate ($12,992.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,222.63, add-ons for qualifying new technology services are included. If operating cost exceeds $47,093.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,568.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $10,239.92 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,277.68 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $808.03. The transfer capital threshold is the transfer adjustment factor * $808.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7665.00,40737.46,Inpatient DRG
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],33890.73,,"Fee schedule rate ($33,890.73). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6277.00,36801.89,There are no additional notes associated with this service or procedure.
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],11168.08,,"Fee schedule rate ($11,168.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5937.41,12366.99,There are no additional notes associated with this service or procedure.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],13647.09,,"Case rate ($13,647.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,831.20, add-ons for qualifying new technology services are included. If operating cost exceeds $47,702.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,615.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $10,846.26 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,886.25 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $855.88. The transfer capital threshold is the transfer adjustment factor * $855.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7921.00,45706.73,Inpatient DRG
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],42021.93,,"Fee schedule rate ($42,021.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,21248.73,56089.29,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],24546.05,,"Case rate ($23,377.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $21,882.92, add-ons for qualifying new technology services are included. If operating cost exceeds $56,753.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,327.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $19,864.72 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $19,937.97 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,567.52. The transfer capital threshold is the transfer adjustment factor * $1,567.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,23377.19,96365.69,Inpatient DRG
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC,964,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],34154.06,,"Fee schedule rate ($34,154.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12323.82,34154.06,There are no additional notes associated with this service or procedure.
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],35061.53,,"Fee schedule rate ($35,061.53). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,9696.93,35061.53,There are no additional notes associated with this service or procedure.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],13907.80,,"Case rate ($13,907.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,073.74, add-ons for qualifying new technology services are included. If operating cost exceeds $47,944.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,634.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $11,087.92 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,128.80 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $874.95. The transfer capital threshold is the transfer adjustment factor * $874.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,13907.80,52794.06,Inpatient DRG
Egd Transoral Control Bleeding Any Method|UNUSUAL NON-OVERLAPPING SERVICE,CASE-43255,APC,43255,CPT,0360,RC,,,XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1859.01,,"APC Price ($1,796.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1796.14,1885.95,OPPS APC
"NEONATE BIRTH WEIGHT 2000-2499 GRAMS NORMAL NEWBORN OR NEONATE WITH OTHER PROBLEM,MAJOR",626,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],7047.57,,"Case rate ($7,047.57). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,7047.57,7399.95,There are no additional notes associated with this service or procedure.
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],28394.78,,"Fee schedule rate ($28,394.78). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11454.97,28394.78,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],29241.62,,"Fee schedule rate ($29,241.62). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,12984.79,32077.45,There are no additional notes associated with this service or procedure.
COMPLICATIONS OF TREATMENT WITH CC,920,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],20731.52,,"Fee schedule rate ($20,731.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8732.59,20731.52,There are no additional notes associated with this service or procedure.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],14699.43,,"Fee schedule rate ($14,699.43). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6683.37,14699.43,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],11280.66,,"Case rate ($11,059.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,424, add-ons for qualifying new technology services are included. If operating cost exceeds $45,295.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,426.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $8,447.91 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,479.05 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $666.62. The transfer capital threshold is the transfer adjustment factor * $666.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,11059.47,28423.20,Inpatient DRG
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],41402.42,,"Fee schedule rate ($41,402.42). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,15456.59,41402.42,There are no additional notes associated with this service or procedure.
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],12269.65,,"Fee schedule rate ($12,269.65). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10311.17,24308.97,There are no additional notes associated with this service or procedure.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC",494,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],39945.55,,"Fee schedule rate ($39,945.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,15533.10,39945.55,There are no additional notes associated with this service or procedure.
"LIMB REATTACHMENT, HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA",956,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],28799.66,,"Case rate ($27,428.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $25,651.53, add-ons for qualifying new technology services are included. If operating cost exceeds $60,522.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,623.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $23,619.49 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $23,706.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,863.81. The transfer capital threshold is the transfer adjustment factor * $1,863.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,27428.25,148259.86,Inpatient DRG
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],13154.04,,"Case rate ($12,527.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,789.82, add-ons for qualifying new technology services are included. If operating cost exceeds $46,660.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,533.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $9,808.71 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,844.88 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $774.00. The transfer capital threshold is the transfer adjustment factor * $774.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12527.66,29917.96,Inpatient DRG
VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC,033,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],32720.88,,,,,,0,other,13206.23,42156.44,There are no additional notes associated with this service or procedure.
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITHOUT MCC,430,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],133156.90,,"Fee schedule rate ($133,156.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,41000.16,133156.90,There are no additional notes associated with this service or procedure.
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC",923,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],8450.18,,"Case rate ($8,047.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $7,588.71, add-ons for qualifying new technology services are included. If operating cost exceeds $46,233.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $3,215.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,201.30 + an uncompensated DSH payment of $1,359.91. The transfer operating threshold is the transfer adjustment factor * $6,228.80 + an uncompensated DSH payment of $1,359.91. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $486.59. The transfer capital threshold is the transfer adjustment factor * $486.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,20068.57,Inpatient DRG
MAJOR ESOPHAGEAL DISORDERS WITH CC,369,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],6965.00,,,,,,0,other,6965.00,19680.94,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],94787.57,,"Fee schedule rate ($94,787.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,23526.87,94787.57,There are no additional notes associated with this service or procedure.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],11053.39,,"Case rate ($11,053.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,418.34, add-ons for qualifying new technology services are included. If operating cost exceeds $45,289.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,426.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $8,442.26 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,473.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $666.18. The transfer capital threshold is the transfer adjustment factor * $666.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,11053.39,36776.05,Inpatient DRG
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7655.35,,"Case rate ($7,396.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,016.38, add-ons for qualifying new technology services are included. If operating cost exceeds $41,887.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,158.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,052.80 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,071.43 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $398.72. The transfer capital threshold is the transfer adjustment factor * $398.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,7396.47,16035.06,Inpatient DRG
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],40542.37,,"Case rate ($40,542.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $37,851.31, add-ons for qualifying new technology services are included. If operating cost exceeds $72,722.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,582.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.6. The base transfer operating payment is the transfer adjustment factor * $35,774.45 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $35,906.36 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,822.96. The transfer capital threshold is the transfer adjustment factor * $2,822.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,40542.37,128358.13,Inpatient DRG
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],16295.34,,"Case rate ($9,311.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,798, add-ons for qualifying new technology services are included. If operating cost exceeds $43,669.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,298.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $6,827.87 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,853.05 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $538.79. The transfer capital threshold is the transfer adjustment factor * $538.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,6965.00,21404.64,All Other Inpatient
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],16684.46,,"Case rate ($16,120.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,131.93, add-ons for qualifying new technology services are included. If operating cost exceeds $50,002.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,796.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $13,138.54 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,186.98 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,036.76. The transfer capital threshold is the transfer adjustment factor * $1,036.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,16120.25,41187.90,Inpatient DRG
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,095,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],48575.01,,"Fee schedule rate ($48,575.01). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,19411.47,50750.92,There are no additional notes associated with this service or procedure.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],31007.30,,"Fee schedule rate ($31,007.30). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,16120.25,41187.90,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,093,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],7484.30,,"Case rate ($7,337.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,961.57, add-ons for qualifying new technology services are included. If operating cost exceeds $41,832.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,154.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,998.19 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,016.62 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $394.41. The transfer capital threshold is the transfer adjustment factor * $394.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6965.00,19011.32,Inpatient DRG
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],48389.68,,,,,,0,other,18598.83,48389.68,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],37495.79,,"Fee schedule rate ($37,495.79). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.8), with a minimum of zero.",,,,0,other,15456.59,41402.42,There are no additional notes associated with this service or procedure.
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],40426.76,,"Fee schedule rate ($40,426.76). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,11914.12,40426.76,There are no additional notes associated with this service or procedure.
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],15737.40,,"Fee schedule rate ($15,737.40). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11454.97,28394.78,There are no additional notes associated with this service or procedure.
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],14249.81,,"Case rate ($13,571.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,760.65, add-ons for qualifying new technology services are included. If operating cost exceeds $47,631.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,610.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $10,775.96 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,815.69 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $850.33. The transfer capital threshold is the transfer adjustment factor * $850.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13571.25,33781.47,Inpatient DRG
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],16804.22,,"Fee schedule rate ($16,804.22). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7238.69,16804.22,There are no additional notes associated with this service or procedure.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],21382.16,,"Case rate ($21,382.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,026.97, add-ons for qualifying new technology services are included. If operating cost exceeds $54,897.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,181.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6)) / 2. The base transfer operating payment is the transfer adjustment factor * $18,015.59 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,082.01 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,421.61. The transfer capital threshold is the transfer adjustment factor * $1,421.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,21382.16,85466.62,Inpatient DRG
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],34570.85,,"Fee schedule rate ($34,570.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,6965.00,36140.75,There are no additional notes associated with this service or procedure.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC",494,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],39945.55,,"Fee schedule rate ($39,945.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,15533.10,39945.55,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,689,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],22417.63,,"Fee schedule rate ($22,417.63). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,9802.58,22831.22,There are no additional notes associated with this service or procedure.
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],8225.64,,"Case rate ($7,833.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,423.35, add-ons for qualifying new technology services are included. If operating cost exceeds $42,294.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,190.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,458.28 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,478.41 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $430.71. The transfer capital threshold is the transfer adjustment factor * $430.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5883.03,17111.12,Inpatient DRG
SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS,029,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],61889.56,,"Fee schedule rate ($61,889.56). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13641.00,67130.05,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,555,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],10896.27,,"Case rate ($10,896.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,272.18, add-ons for qualifying new technology services are included. If operating cost exceeds $45,143.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,414.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,296.64 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,327.23 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $654.69. The transfer capital threshold is the transfer adjustment factor * $654.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10896.27,42290.95,Inpatient DRG
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],62990.26,,"Fee schedule rate ($62,990.26). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,16787.98,62990.26,There are no additional notes associated with this service or procedure.
Low cost skin substitute app,CASE-C5275,APC,C5275,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],660.72,,"APC Price ($660.72). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,660.72,693.76,OPPS APC
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],6695.46,,"Case rate ($6,564.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,242.12, add-ons for qualifying new technology services are included. If operating cost exceeds $41,113.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,097.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $4,281.39 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,297.17 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $337.84. The transfer capital threshold is the transfer adjustment factor * $337.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6564.18,17651.07,Inpatient DRG
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC",758,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],8799.06,,"Case rate ($8,380.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,943.41, add-ons for qualifying new technology services are included. If operating cost exceeds $42,814.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,219.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $5,975.80 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,998.46 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $459.31. The transfer capital threshold is the transfer adjustment factor * $459.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8574.80,19263.78,Inpatient DRG
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],39797.94,,"Fee schedule rate ($39,797.94). Adds an outlier to normal pricing equal to the per diem rate ($75,578.79) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.5), with a minimum of zero.",,,,0,other,16286.16,58320.32,There are no additional notes associated with this service or procedure.
FRACTURES OF FEMUR WITH MCC,533,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],12812.76,,"Case rate ($12,561.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,821.33, add-ons for qualifying new technology services are included. If operating cost exceeds $46,692.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,536.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $9,840.09 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,876.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $776.48. The transfer capital threshold is the transfer adjustment factor * $776.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6852.00,49490.05,Inpatient DRG
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],35192.25,,"Fee schedule rate ($35,192.25). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,10895.60,35192.25,There are no additional notes associated with this service or procedure.
Rinsj Rptd Biceps/Triceps Tdn Dstl W/WO Tdn Grf|LEFT SIDE,CASE-24342,APC,24342,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7029.71,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6791.99,7131.59,OPPS APC
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],28540.32,,"Case rate ($27,181.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $25,468.84, add-ons for qualifying new technology services are included. If operating cost exceeds $60,339.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,561.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.8. The base transfer operating payment is the transfer adjustment factor * $23,435.03 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $23,523.89 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,801.27. The transfer capital threshold is the transfer adjustment factor * $1,801.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,27944.96,86252.84,Inpatient DRG
MAJOR THUMB OR JOINT PROCEDURES,506,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],19393.20,,"Case rate ($11,081.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,444.79, add-ons for qualifying new technology services are included. If operating cost exceeds $45,315.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,428.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $8,468.62 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,499.84 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $668.26. The transfer capital threshold is the transfer adjustment factor * $668.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,11081.83,26548.21,All Other Inpatient
MAJOR THUMB OR JOINT PROCEDURES,506,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],19761.54,,"Fee schedule rate ($19,761.54). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11081.83,26548.21,There are no additional notes associated with this service or procedure.
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],12246.05,,"Fee schedule rate ($12,246.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6010.23,12246.05,There are no additional notes associated with this service or procedure.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],29917.96,,"Fee schedule rate ($29,917.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,12527.66,29917.96,There are no additional notes associated with this service or procedure.
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],11165.00,,"Per diem ($11,165). If length of stay < 3.5, first 1 days paid at a per diem of $22,330 instead. Capped at $39,078.16.",,,,0,other,11165.00,61234.06,Estimated amount calculated based on 3 day length of stay.
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],20617.56,,,,,,0,other,9040.72,26966.33,There are no additional notes associated with this service or procedure.
NEONATE WITH OTHER SIGNIFICANT PROBLEMS,794,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],2074.00,,,,,,0,other,1798.85,12536.83,Estimated amount calculated based on 2 day length of stay.
Neuroplasty &/Transposition Ulnar Nerve Elbow,CASE-64718,APC,64718,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1827.80,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1827.80,1919.19,OPPS APC
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],19319.20,,"Fee schedule rate ($19,319.20). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8906.63,28434.57,There are no additional notes associated with this service or procedure.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC,027,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],29965.06,,"Fee schedule rate ($29,965.06). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,19030.20,56363.30,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],7924.86,,"Case rate ($7,547.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,156.87, add-ons for qualifying new technology services are included. If operating cost exceeds $42,027.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,169.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $5,192.77 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,211.92 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $409.76. The transfer capital threshold is the transfer adjustment factor * $409.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,19126.88,Inpatient DRG
"Tendon Sheath Incision|UNUSUAL NON-OVERLAPPING SERVICE|LEFT HAND, THUMB",CASE-26055,APC,26055,CPT,0360,RC,,,XU|FA,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],11847.11,,"Fee schedule rate ($11,847.11). Adds an outlier to normal pricing equal to the per diem rate ($62,538.40) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,6214.05,15318.94,There are no additional notes associated with this service or procedure.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],17023.00,,"Case rate ($16,447.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,436.22, add-ons for qualifying new technology services are included. If operating cost exceeds $50,307.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,820.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $13,441.70 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,491.27 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,060.68. The transfer capital threshold is the transfer adjustment factor * $1,060.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,7453.00,42138.30,Inpatient DRG
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],33188.44,,"Fee schedule rate ($33,188.44). Adds an outlier to normal pricing equal to the per diem rate ($84,167.29) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.5), with a minimum of zero.",,,,0,other,13904.43,34749.58,There are no additional notes associated with this service or procedure.
TRAUMATIC INJURY WITH MCC,913,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],13470.09,,"Case rate ($13,014.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,242.79, add-ons for qualifying new technology services are included. If operating cost exceeds $47,113.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,569.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $10,260.01 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,297.84 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $809.62. The transfer capital threshold is the transfer adjustment factor * $809.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,13014.58,42838.46,Inpatient DRG
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],27553.62,,"Fee schedule rate ($27,553.62). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12305.53,30103.84,There are no additional notes associated with this service or procedure.
RESPIRATORY NEOPLASMS WITHOUT CC/MCC,182,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],7402.23,,"Case rate ($7,049.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,693.83, add-ons for qualifying new technology services are included. If operating cost exceeds $41,564.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,133.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,731.43 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,748.88 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $373.36. The transfer capital threshold is the transfer adjustment factor * $373.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,23037.13,Inpatient DRG
Brnchsc Ebus Guided Sampl 3/> Node Station/Strux,CASE-31653,APC,31653,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6936.25,,"APC Price ($6,605.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6605.95,6936.25,OPPS APC
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],6965.00,,,,,,0,other,6965.00,15340.19,There are no additional notes associated with this service or procedure.
NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,601,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],10573.59,,"Case rate ($6,042.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,756.39, add-ons for qualifying new technology services are included. If operating cost exceeds $40,627.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,059.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $3,797.45 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,811.45 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $299.66. The transfer capital threshold is the transfer adjustment factor * $299.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,6042.05,12359.72,All Other Inpatient
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],8906.63,,"Case rate ($8,906.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,421.26, add-ons for qualifying new technology services are included. If operating cost exceeds $43,292.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,269.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $6,452.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,476.31 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $509.17. The transfer capital threshold is the transfer adjustment factor * $509.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8906.63,28434.57,Inpatient DRG
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],28423.20,,"Fee schedule rate ($28,423.20). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11059.47,28423.20,There are no additional notes associated with this service or procedure.
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],14603.31,,"Case rate ($14,603.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,720.75, add-ons for qualifying new technology services are included. If operating cost exceeds $48,591.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,685.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $11,732.54 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,775.80 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $925.81. The transfer capital threshold is the transfer adjustment factor * $925.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,14603.31,45017.13,Inpatient DRG
"NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY",789,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],6663.33,,,,,,0,other,3054.00,14857.05,Estimated amount calculated based on 1 day length of stay.
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],11565.93,,"Fee schedule rate ($11,565.93). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6148.93,15887.21,There are no additional notes associated with this service or procedure.
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],16035.06,,"Fee schedule rate ($16,035.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,7396.47,16035.06,There are no additional notes associated with this service or procedure.
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC",458,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],30840.69,,"Case rate ($29,372.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $27,511.01, add-ons for qualifying new technology services are included. If operating cost exceeds $62,382.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,717.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $25,469.49 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $25,566.06 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,957.64. The transfer capital threshold is the transfer adjustment factor * $1,957.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,30202.09,132827.25,Inpatient DRG
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,373,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],12024.15,,"Case rate ($6,870.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,527.50, add-ons for qualifying new technology services are included. If operating cost exceeds $41,398.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,120.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $4,565.72 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,582.56 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $360.28. The transfer capital threshold is the transfer adjustment factor * $360.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,6870.94,14313.05,All Other Inpatient
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],25225.91,,,,,,0,other,10626.74,25225.91,There are no additional notes associated with this service or procedure.
Laparoscopy Surg W/Bx Single/Multiple,CASE-49321,APC,49321,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5941.70,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5658.76,5941.70,OPPS APC
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],21854.96,,"Fee schedule rate ($21,854.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10638.94,25261.33,There are no additional notes associated with this service or procedure.
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],18245.94,,"Fee schedule rate ($18,245.94). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8106.18,18245.94,There are no additional notes associated with this service or procedure.
OTHER CEREBROVASCULAR DISORDERS WITH CC,071,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],9070.96,,"Case rate ($8,893.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,408.66, add-ons for qualifying new technology services are included. If operating cost exceeds $43,279.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,268.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,439.97 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,463.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $508.18. The transfer capital threshold is the transfer adjustment factor * $508.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,5843.00,29215.10,Inpatient DRG
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],20333.25,,"Fee schedule rate ($20,333.25). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,19435.86,50821.76,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],21892.85,,"Fee schedule rate ($21,892.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7569.84,21892.85,There are no additional notes associated with this service or procedure.
FRACTURES OF FEMUR WITH MCC,533,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],49490.05,,"Fee schedule rate ($49,490.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,6852.00,49490.05,There are no additional notes associated with this service or procedure.
NORMAL NEWBORN,795,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],2576.52,,"Fee schedule rate ($2,576.52). Adds an outlier to normal pricing equal to the per diem rate ($414) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,1369.79,5771.52,There are no additional notes associated with this service or procedure.
HEADACHES WITHOUT MCC,103,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],7760.60,,"Case rate ($7,608.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,213.57, add-ons for qualifying new technology services are included. If operating cost exceeds $42,084.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,174.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $5,249.26 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,268.62 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $414.22. The transfer capital threshold is the transfer adjustment factor * $414.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6965.00,20883.08,Inpatient DRG
Enteroscopy > 2nd Prtn Abltj Lesion,CASE-44369,APC,44369,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1885.95,,"APC Price ($1,796.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1796.14,1885.95,OPPS APC
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],11063.08,,"Case rate ($10,846.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,225.56, add-ons for qualifying new technology services are included. If operating cost exceeds $45,096.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,410.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $8,250.19 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,280.61 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $651.02. The transfer capital threshold is the transfer adjustment factor * $651.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,10846.16,25863.45,Inpatient DRG
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],40714.72,,"Fee schedule rate ($40,714.72). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,17356.15,44778.95,There are no additional notes associated with this service or procedure.
Unlisted Procedure Hemic or Lymphatic System,CASE-38999,APC,38999,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],13350.78,,"APC Price ($12,899.30). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,12899.30,13544.27,OPPS APC
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC,519,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],15490.44,,"Case rate ($15,490.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,546.03, add-ons for qualifying new technology services are included. If operating cost exceeds $49,417.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,750.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $12,554.80 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,601.09 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $990.70. The transfer capital threshold is the transfer adjustment factor * $990.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,15490.44,50780.20,Inpatient DRG
O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC,621,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],12767.94,,"Case rate ($12,159.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,447.74, add-ons for qualifying new technology services are included. If operating cost exceeds $46,318.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,507.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $9,467.88 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,502.79 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $747.11. The transfer capital threshold is the transfer adjustment factor * $747.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12159.94,36669.96,Inpatient DRG
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],54764.34,,"Fee schedule rate ($54,764.34). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,18178.96,54764.34,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],31533.97,,"Fee schedule rate ($31,533.97). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8563.30,31533.97,There are no additional notes associated with this service or procedure.
Arthrs Aided Ant Cruciate Ligm Rpr/Agmntj/Rcnstj|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-29888,APC,29888,CPT,0360,RC,,,RT|XU,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],12017.31,,"APC Price ($12,017.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12017.31,12437.92,OPPS APC
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],32168.63,,"Fee schedule rate ($32,168.63). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,13904.43,34749.58,There are no additional notes associated with this service or procedure.
"COCAINE ABUSE AND DEPENDENCE,EXTREME",774,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],19131.94,,"Case rate ($19,131.94). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,19131.94,20088.54,There are no additional notes associated with this service or procedure.
"CARDIAC ARREST, UNEXPLAINED WITH MCC",296,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],36459.67,,"Fee schedule rate ($36,459.67). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12522.25,36459.67,There are no additional notes associated with this service or procedure.
CHOLECYSTECTOMY WITH C.D.E. WITH MCC,411,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],88615.28,,"Fee schedule rate ($88,615.28). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,24315.13,88615.28,There are no additional notes associated with this service or procedure.
Cysto W/Ureteroscopy W/Rmvl/Manj Stones|LEFT SIDE,CASE-52352,APC,52352,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3299.47,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3299.47,3464.44,OPPS APC
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,988,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],42425.46,,"Fee schedule rate ($42,425.46). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,13075.52,42425.46,There are no additional notes associated with this service or procedure.
"Prq Skel Fixj Phlngl Shft Fx Prox/Middle Px/F/T|LEFT HAND, FIFTH DIGIT",CASE-26727,APC,26727,CPT,0360,RC,,,F4,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],2070.00,,,,,,0,other,1188.00,18893.86,Estimated amount calculated based on 3 day length of stay.
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],6558.75,,"Case rate ($6,558.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,237.08, add-ons for qualifying new technology services are included. If operating cost exceeds $41,108.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,097.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $4,276.36 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,292.13 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $337.45. The transfer capital threshold is the transfer adjustment factor * $337.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6558.75,14871.83,Inpatient DRG
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],9446.38,,"Case rate ($9,446.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,923.36, add-ons for qualifying new technology services are included. If operating cost exceeds $43,794.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,308.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,952.78 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,978.41 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $548.64. The transfer capital threshold is the transfer adjustment factor * $548.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9446.38,21796.21,Inpatient DRG
"Inj Dx/Ther Agnt Paravert Facet Joint, Cerv/Thorac, Add Level",CASE-64492,APC,64492,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],856.86,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,827.89,869.28,OPPS APC
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],94787.57,,"Fee schedule rate ($94,787.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,23526.87,94787.57,There are no additional notes associated with this service or procedure.
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,450,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],146009.19,,"Fee schedule rate ($146,009.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,38037.38,146009.19,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],28235.64,,"Fee schedule rate ($28,235.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,14344.60,36028.59,There are no additional notes associated with this service or procedure.
NORMAL NEWBORN,795,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],2576.52,,"Fee schedule rate ($2,576.52). Adds an outlier to normal pricing equal to the per diem rate ($414) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,1369.79,5771.52,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],32293.66,,"Fee schedule rate ($32,293.66). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,32293.66,There are no additional notes associated with this service or procedure.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],10533.95,,"Case rate ($10,533.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,935.13, add-ons for qualifying new technology services are included. If operating cost exceeds $44,806.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,388.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $7,960.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,990.18 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $628.19. The transfer capital threshold is the transfer adjustment factor * $628.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10533.95,24956.34,Inpatient DRG
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],10249.36,,"Case rate ($10,048.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,483.42, add-ons for qualifying new technology services are included. If operating cost exceeds $44,354.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,352.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,510.78 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,538.48 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $592.68. The transfer capital threshold is the transfer adjustment factor * $592.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,10048.39,23545.50,Inpatient DRG
NERVOUS SYSTEM NEOPLASMS WITH MCC,054,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],13604.18,,"Fee schedule rate ($13,604.18). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,6965.00,30044.81,There are no additional notes associated with this service or procedure.
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],7412.73,,"Case rate ($7,412.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,031.50, add-ons for qualifying new technology services are included. If operating cost exceeds $41,902.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,159.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $5,067.86 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,086.55 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $399.90. The transfer capital threshold is the transfer adjustment factor * $399.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6148.93,15887.21,Inpatient DRG
OSTEOMYELITIS WITH CC,540,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],10225.95,,"Fee schedule rate ($10,225.95). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,9809.07,25507.30,There are no additional notes associated with this service or procedure.
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],30236.06,,"Fee schedule rate ($30,236.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.8), with a minimum of zero.",,,,0,other,1188.00,31658.33,There are no additional notes associated with this service or procedure.
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",004,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],95747.60,,"Case rate ($95,747.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $89,207.57, add-ons for qualifying new technology services are included. If operating cost exceeds $124,078.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $8,620.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 22.4. The base transfer operating payment is the transfer adjustment factor * $86,942.06 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $87,262.63 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $6,860.59. The transfer capital threshold is the transfer adjustment factor * $6,860.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10249.47,272554.00,Inpatient DRG
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,066,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],11131.05,,"Fee schedule rate ($11,131.05). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6579.76,20083.61,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],63653.13,,,,,,0,other,23851.92,63653.13,There are no additional notes associated with this service or procedure.
OTHER MENTAL DISORDER DIAGNOSES,887,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],9433.35,,"Case rate ($8,984.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,506.49, add-ons for qualifying new technology services are included. If operating cost exceeds $43,377.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,262.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,536.76 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,561.54 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $502.43. The transfer capital threshold is the transfer adjustment factor * $502.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,2070.00,21072.10,Inpatient DRG
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],21980.29,,"Fee schedule rate ($21,980.29). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9865.56,37914.65,There are no additional notes associated with this service or procedure.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],79662.10,,"Case rate ($45,521.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $42,483.01, add-ons for qualifying new technology services are included. If operating cost exceeds $77,354.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,947.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 12.5. The base transfer operating payment is the transfer adjustment factor * $40,389.14 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $40,538.06 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,187.10. The transfer capital threshold is the transfer adjustment factor * $3,187.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,45521.20,142438.06,All Other Inpatient
SIGNS AND SYMPTOMS WITH MCC,947,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],10541.41,,"Case rate ($10,541.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,942.06, add-ons for qualifying new technology services are included. If operating cost exceeds $44,813.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,388.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $7,967.73 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,997.11 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $628.73. The transfer capital threshold is the transfer adjustment factor * $628.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10541.41,30414.32,Inpatient DRG
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],20553.44,,"Fee schedule rate ($20,553.44). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8874.81,20553.44,There are no additional notes associated with this service or procedure.
UNGROUPABLE,999,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],161307.29,,"Fee schedule rate ($161,307.29). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (41), with a minimum of zero.",,,,0,other,10228.00,161307.29,There are no additional notes associated with this service or procedure.
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH MCC",722,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],14910.39,,"Case rate ($14,200.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,345.91, add-ons for qualifying new technology services are included. If operating cost exceeds $48,216.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,656.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $11,359.07 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,400.95 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $896.34. The transfer capital threshold is the transfer adjustment factor * $896.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,14200.37,56869.13,Inpatient DRG
SKIN ULCERS WITH MCC,592,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],38644.05,,"Fee schedule rate ($38,644.05). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15), with a minimum of zero.",,,,0,other,15116.17,38644.05,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],30055.64,,"Fee schedule rate ($30,055.64). Adds an outlier to normal pricing equal to the per diem rate ($74,094.67) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.9), with a minimum of zero.",,,,0,other,12775.53,31469.43,There are no additional notes associated with this service or procedure.
VENTRICULAR SHUNT PROCEDURES WITH MCC,031,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],62406.76,,"Fee schedule rate ($62,406.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,32287.20,88162.80,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],86235.79,,"Fee schedule rate ($86,235.79). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,32296.02,88188.38,There are no additional notes associated with this service or procedure.
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],6711.00,,"Per diem ($6,711). If length of stay < 2.4, first 1 days paid at a per diem of $13,422 instead. Capped at $16,107.48.",,,,0,other,6711.00,16865.16,Estimated amount calculated based on 2 day length of stay.
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],37488.28,,"Fee schedule rate ($37,488.28). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.5), with a minimum of zero.",,,,0,other,15453.88,39251.68,There are no additional notes associated with this service or procedure.
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],6697.54,,"Case rate ($6,378.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,069.50, add-ons for qualifying new technology services are included. If operating cost exceeds $40,940.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,084.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,109.40 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,124.55 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $324.27. The transfer capital threshold is the transfer adjustment factor * $324.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,4341.01,12882.53,Inpatient DRG
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,450,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],38037.38,,"Case rate ($38,037.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $35,520.98, add-ons for qualifying new technology services are included. If operating cost exceeds $70,391.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,399.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $33,452.68 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $33,576.02 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,639.75. The transfer capital threshold is the transfer adjustment factor * $2,639.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,38037.38,146009.19,Inpatient DRG
Egd Ablate Tumor Polyp/Lesion W/Dilation& Wire,CASE-43270,APC,43270,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1796.14,,"APC Price ($1,796.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1796.14,1885.95,OPPS APC
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 1 Level,CASE-64493,APC,64493,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],827.89,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,827.89,869.28,OPPS APC
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],12366.99,,,,,,0,other,5937.41,12366.99,There are no additional notes associated with this service or procedure.
DIABETES WITHOUT CC/MCC,639,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],6459.35,,"Case rate ($6,151.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,858.45, add-ons for qualifying new technology services are included. If operating cost exceeds $40,729.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,067.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $3,899.13 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,913.51 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $307.68. The transfer capital threshold is the transfer adjustment factor * $307.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6151.76,12223.35,Inpatient DRG
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],80635.65,,"Fee schedule rate ($80,635.65). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,26028.48,80635.65,There are no additional notes associated with this service or procedure.
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,095,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],20090.87,,"Case rate ($19,411.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $18,193.69, add-ons for qualifying new technology services are included. If operating cost exceeds $53,064.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,037.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.6. The base transfer operating payment is the transfer adjustment factor * $16,189.05 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $16,248.74 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,277.48. The transfer capital threshold is the transfer adjustment factor * $1,277.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,19411.47,50750.92,Inpatient DRG
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],13806.09,,"Case rate ($13,148.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,367.53, add-ons for qualifying new technology services are included. If operating cost exceeds $47,238.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,579.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $10,384.29 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,422.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $819.42. The transfer capital threshold is the transfer adjustment factor * $819.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13148.66,32553.63,Inpatient DRG
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],52449.26,,"Fee schedule rate ($52,449.26). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,17693.40,52449.26,There are no additional notes associated with this service or procedure.
Arthrd Ant Interbody Min Dsc Crv Below C2|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-22554,APC,22554,CPT,0360,RC,,,74,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],12437.92,,"APC Price ($12,017.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,12437.92,12618.18,OPPS APC
Enteroscopy > 2nd Prtn Abltj Lesion,CASE-44369,APC,44369,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1796.14,,"APC Price ($1,796.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1796.14,1885.95,OPPS APC
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],33835.79,,"Fee schedule rate ($33,835.79). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,7000.00,33835.79,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],49717.39,,"Fee schedule rate ($49,717.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,14908.05,49717.39,There are no additional notes associated with this service or procedure.
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],11809.42,,"Case rate ($11,247.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,598.51, add-ons for qualifying new technology services are included. If operating cost exceeds $45,469.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,440.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,621.77 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,653.56 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $680.34. The transfer capital threshold is the transfer adjustment factor * $680.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,11247.07,27028.33,Inpatient DRG
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],5569.00,,"Per diem ($5,569). If length of stay < 3.8, first 1 days paid at a per diem of $11,138 instead. Capped at $21,162.80.",,,,0,other,5569.00,40108.48,Estimated amount calculated based on 2 day length of stay.
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC",758,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],16323.02,,"Fee schedule rate ($16,323.02). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8574.80,19263.78,There are no additional notes associated with this service or procedure.
Exc Cyst/Aberrant Breast Tissue Open 1/> Lesion|LEFT SIDE,CASE-19120,APC,19120,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3793.21,,"APC Price ($3,664.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3664.94,3793.21,OPPS APC
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],15476.23,,"Case rate ($15,476.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,532.81, add-ons for qualifying new technology services are included. If operating cost exceeds $49,403.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,749.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $12,541.62 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,587.86 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $989.66. The transfer capital threshold is the transfer adjustment factor * $989.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,15476.23,42787.31,Inpatient DRG
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],6965.00,,,,,,0,other,6965.00,16400.70,There are no additional notes associated with this service or procedure.
CERVICAL SPINAL FUSION WITH CC,472,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],22990.94,,"Case rate ($21,896.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,505.12, add-ons for qualifying new technology services are included. If operating cost exceeds $55,376.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,219.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $18,491.99 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,560.18 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,459.20. The transfer capital threshold is the transfer adjustment factor * $1,459.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,21896.13,70198.84,Inpatient DRG
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC,797,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],20928.55,,"Fee schedule rate ($20,928.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8719.72,20928.55,There are no additional notes associated with this service or procedure.
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],17467.27,,,,,,0,other,6965.00,17467.27,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],23239.84,,"Fee schedule rate ($23,239.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8543.64,23239.84,There are no additional notes associated with this service or procedure.
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,450,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],146009.19,,"Fee schedule rate ($146,009.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,38037.38,146009.19,There are no additional notes associated with this service or procedure.
OTHER CEREBROVASCULAR DISORDERS WITH CC,071,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],9204.36,,"Case rate ($8,893.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,408.66, add-ons for qualifying new technology services are included. If operating cost exceeds $43,279.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,268.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,439.97 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,463.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $508.18. The transfer capital threshold is the transfer adjustment factor * $508.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,5843.00,29215.10,Inpatient DRG
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH CC",457,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],160549.49,,"Fee schedule rate ($160,549.49). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,42327.47,160549.49,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,064,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],41838.16,,"Fee schedule rate ($41,838.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,15563.58,41838.16,There are no additional notes associated with this service or procedure.
Cysto Bladder W/Ureteral Catheterization|BILATERAL PROCEDURE,CASE-52005,APC,52005,CPT,0360,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],2025.13,,"APC Price ($1,956.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1956.65,2054.48,OPPS APC
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],8734.57,,"Case rate ($8,563.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,101.85, add-ons for qualifying new technology services are included. If operating cost exceeds $42,972.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,244.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $6,134.29 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,156.91 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $484.06. The transfer capital threshold is the transfer adjustment factor * $484.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,8563.30,31533.97,Inpatient DRG
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],11594.35,,"Fee schedule rate ($11,594.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6164.03,14071.02,There are no additional notes associated with this service or procedure.
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],11565.93,,"Fee schedule rate ($11,565.93). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6148.93,15887.21,There are no additional notes associated with this service or procedure.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,056,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],59328.19,,"Fee schedule rate ($59,328.19). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (44), with a minimum of zero.",,,,0,other,7659.00,59328.19,There are no additional notes associated with this service or procedure.
"Neuroplasty Sciatic Nerve,Open|LEFT SIDE",CASE-64712,APC,64712,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7029.71,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6791.99,7131.59,OPPS APC
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],133270.57,,"Fee schedule rate ($133,270.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,33623.33,133270.57,There are no additional notes associated with this service or procedure.
"CARDIAC ARREST, UNEXPLAINED WITH MCC",296,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],36459.67,,"Fee schedule rate ($36,459.67). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12522.25,36459.67,There are no additional notes associated with this service or procedure.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],12173.48,,"Case rate ($11,593.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,921.06, add-ons for qualifying new technology services are included. If operating cost exceeds $45,792.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,465.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $8,943.14 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,976.12 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $705.70. The transfer capital threshold is the transfer adjustment factor * $705.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,11593.79,38248.08,Inpatient DRG
VAGINAL DELIVERY WITH O.R. PROCEDURES EXCEPT STERILIZATION AND/OR D&C,768,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],12088.81,,"Fee schedule rate ($12,088.81). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6426.91,13416.00,There are no additional notes associated with this service or procedure.
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC,939,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],27085.41,,"Case rate ($25,795.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $24,177.24, add-ons for qualifying new technology services are included. If operating cost exceeds $59,048.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,462.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $22,148.31 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $22,232.29 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,702.37. The transfer capital threshold is the transfer adjustment factor * $1,702.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,26517.40,97674.79,Inpatient DRG
Ercp Remove Calculi/Debris Biliary/Pancreas Duct,CASE-43264,APC,43264,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5966.63,,"APC Price ($5,682.51). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5682.51,5966.63,OPPS APC
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,306,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],29614.01,,"Fee schedule rate ($29,614.01). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12616.37,31007.02,There are no additional notes associated with this service or procedure.
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],16804.22,,"Fee schedule rate ($16,804.22). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7238.69,16804.22,There are no additional notes associated with this service or procedure.
HEADACHES WITHOUT MCC,103,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],6965.00,,,,,,0,other,6965.00,20883.08,There are no additional notes associated with this service or procedure.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC,858,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],26176.77,,"Fee schedule rate ($26,176.77). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11377.76,33794.11,There are no additional notes associated with this service or procedure.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],29367.82,,"Fee schedule rate ($29,367.82). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.7), with a minimum of zero.",,,,0,other,12527.66,29917.96,There are no additional notes associated with this service or procedure.
HYPERTENSION WITHOUT MCC,305,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],7199.72,,"Case rate ($7,058.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,702.02, add-ons for qualifying new technology services are included. If operating cost exceeds $41,573.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,133.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,739.59 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,757.07 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $374.00. The transfer capital threshold is the transfer adjustment factor * $374.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,7058.55,17230.49,Inpatient DRG
HC Inj Trigger Pt 1-2 Musc Grps|PBB CHARGE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-20552,APC,20552,CPT,0510,RC,,,PBB|XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],297.37,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,287.31,301.68,OPPS APC
HC Pbb Carpal Tunnel Inj Pmc|PBB CHARGE,CASE-20526,APC,20526,CPT,0510,RC,,,PBB,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],15273.74,,"Case rate ($15,273.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,344.45, add-ons for qualifying new technology services are included. If operating cost exceeds $49,215.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,734.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $12,353.94 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,399.49 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $974.85. The transfer capital threshold is the transfer adjustment factor * $974.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,15273.74,39820.52,Inpatient DRG
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],20559.34,,"Case rate ($20,559.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $19,261.52, add-ons for qualifying new technology services are included. If operating cost exceeds $54,132.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,121.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $17,252.96 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $17,316.57 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,361.43. The transfer capital threshold is the transfer adjustment factor * $1,361.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,20559.34,54086.17,Inpatient DRG
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],32263.82,,"Fee schedule rate ($32,263.82). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13571.25,33781.47,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],25098.39,,"Case rate ($23,903.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $22,413.24, add-ons for qualifying new technology services are included. If operating cost exceeds $57,284.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,327.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.7. The base transfer operating payment is the transfer adjustment factor * $20,390.97 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $20,468.29 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,567.30. The transfer capital threshold is the transfer adjustment factor * $1,567.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9370.00,65732.99,Inpatient DRG
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],16120.25,,"Case rate ($16,120.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,131.93, add-ons for qualifying new technology services are included. If operating cost exceeds $50,002.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,796.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $13,138.54 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,186.98 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,036.76. The transfer capital threshold is the transfer adjustment factor * $1,036.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,16120.25,41187.90,Inpatient DRG
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC,817,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],42878.11,,"Fee schedule rate ($42,878.11). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.5), with a minimum of zero.",,,,0,other,17396.11,44895.04,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],34892.92,,"Fee schedule rate ($34,892.92). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,6965.00,41030.48,There are no additional notes associated with this service or procedure.
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],7082.98,,"Case rate ($6,944.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,595.55, add-ons for qualifying new technology services are included. If operating cost exceeds $41,466.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,125.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,633.51 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,650.60 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $365.63. The transfer capital threshold is the transfer adjustment factor * $365.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,5068.21,14525.56,Inpatient DRG
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],7847.50,,"Case rate ($7,847.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,435.96, add-ons for qualifying new technology services are included. If operating cost exceeds $42,306.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,191.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,470.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,491.01 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $431.70. The transfer capital threshold is the transfer adjustment factor * $431.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7847.50,17755.26,Inpatient DRG
NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,601,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],12359.72,,"Fee schedule rate ($12,359.72). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6042.05,12359.72,There are no additional notes associated with this service or procedure.
"NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY",789,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],14432.56,,"Case rate ($14,149.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,298.65, add-ons for qualifying new technology services are included. If operating cost exceeds $48,169.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,652.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $11,312.00 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,353.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $892.63. The transfer capital threshold is the transfer adjustment factor * $892.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,3054.00,14857.05,Inpatient DRG
Ercp W/Biopsy Single/Multiple|UNUSUAL NON-OVERLAPPING SERVICE,CASE-43261,APC,43261,CPT,0360,RC,,,XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5966.63,,"APC Price ($5,682.51). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5682.51,5966.63,OPPS APC
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],28983.97,,"Fee schedule rate ($28,983.97). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8956.76,28983.97,There are no additional notes associated with this service or procedure.
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",623,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],32096.64,,"Fee schedule rate ($32,096.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,14093.37,33712.76,There are no additional notes associated with this service or procedure.
CHOLECYSTECTOMY WITH C.D.E. WITH MCC,411,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],24315.13,,"Case rate ($24,315.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $22,755.46, add-ons for qualifying new technology services are included. If operating cost exceeds $57,626.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,396.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $20,734.06 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $20,810.51 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,636.12. The transfer capital threshold is the transfer adjustment factor * $1,636.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,24315.13,88615.28,Inpatient DRG
CERVICAL SPINAL FUSION WITH CC,472,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],70198.84,,"Fee schedule rate ($70,198.84). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,21896.13,70198.84,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],15808.67,,"Fee schedule rate ($15,808.67). Adds an outlier to normal pricing equal to the per diem rate ($67,650.85) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,7641.61,19371.27,There are no additional notes associated with this service or procedure.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],9918.70,,"Case rate ($9,446.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,923.36, add-ons for qualifying new technology services are included. If operating cost exceeds $43,794.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,308.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,952.78 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,978.41 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $548.64. The transfer capital threshold is the transfer adjustment factor * $548.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9446.38,21796.21,Inpatient DRG
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],41402.42,,"Fee schedule rate ($41,402.42). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,15456.59,41402.42,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],31533.97,,"Fee schedule rate ($31,533.97). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8563.30,31533.97,There are no additional notes associated with this service or procedure.
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],10448.91,,"Fee schedule rate ($10,448.91). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,3079.00,10940.41,There are no additional notes associated with this service or procedure.
HC Drain/Inj Joint/Bursa W/US Large|PBB CHARGE,CASE-20611,APC,20611,CPT,0510,RC,,,PBB,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],287.31,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],14610.75,,"Case rate ($14,610.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,727.68, add-ons for qualifying new technology services are included. If operating cost exceeds $48,598.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,686.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.6. The base transfer operating payment is the transfer adjustment factor * $11,739.44 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,782.73 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $926.36. The transfer capital threshold is the transfer adjustment factor * $926.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6277.00,36801.89,Inpatient DRG
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],22130.54,,"Case rate ($21,382.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,026.97, add-ons for qualifying new technology services are included. If operating cost exceeds $54,897.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,181.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6)) / 2. The base transfer operating payment is the transfer adjustment factor * $18,015.59 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,082.01 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,421.61. The transfer capital threshold is the transfer adjustment factor * $1,421.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103.5%.",,,,0,other,21382.16,85466.62,Inpatient DRG
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],75579.22,,"Fee schedule rate ($75,579.22). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,25162.32,75579.22,There are no additional notes associated with this service or procedure.
MINOR BLADDER PROCEDURES WITHOUT CC/MCC,664,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],9486.36,,"Case rate ($9,034.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,540.33, add-ons for qualifying new technology services are included. If operating cost exceeds $43,411.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,278.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $6,571.15 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,595.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $518.53. The transfer capital threshold is the transfer adjustment factor * $518.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9034.63,31876.87,Inpatient DRG
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],31477.13,,"Fee schedule rate ($31,477.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9648.19,31477.13,There are no additional notes associated with this service or procedure.
O.R. PROCEDURES FOR OBESITY WITH CC,620,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],43753.50,,"Fee schedule rate ($43,753.50). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12782.30,43753.50,There are no additional notes associated with this service or procedure.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],23618.74,,"Fee schedule rate ($23,618.74). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10533.95,24956.34,There are no additional notes associated with this service or procedure.
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],23870.71,,"Fee schedule rate ($23,870.71). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10626.74,25225.91,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],37914.65,,"Fee schedule rate ($37,914.65). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9865.56,37914.65,There are no additional notes associated with this service or procedure.
Int Hrhc by Ligation 2+ Hroid W/O Img Gdn,CASE-46946,APC,46946,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],2598.08,,"APC Price ($2,598.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2598.08,2727.99,OPPS APC
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],52803.53,,"Fee schedule rate ($52,803.53). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,14337.84,52803.53,There are no additional notes associated with this service or procedure.
Cysto W/Insert Ureteral Stent|LEFT SIDE,CASE-52332,APC,52332,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3414.95,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3299.47,3464.44,OPPS APC
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],13170.81,,"Case rate ($12,725.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,973.79, add-ons for qualifying new technology services are included. If operating cost exceeds $46,844.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,548.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $9,991.99 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,028.83 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $788.47. The transfer capital threshold is the transfer adjustment factor * $788.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,12725.42,34245.00,Inpatient DRG
Enteroscopy > 2nd Prtn W/Control Bleeding,CASE-44366,APC,44366,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1885.95,,"APC Price ($1,796.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1796.14,1885.95,OPPS APC
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],36855.62,,"Fee schedule rate ($36,855.62). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,15821.59,40320.14,There are no additional notes associated with this service or procedure.
SPINAL PROCEDURES WITH MCC,028,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],44765.25,,"Case rate ($42,633.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $39,796.72, add-ons for qualifying new technology services are included. If operating cost exceeds $74,667.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,735.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.5. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 9.5)) / 2. The base transfer operating payment is the transfer adjustment factor * $37,712.72 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $37,851.77 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,975.91. The transfer capital threshold is the transfer adjustment factor * $2,975.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,42633.57,120982.83,Inpatient DRG
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],13148.66,,"Case rate ($13,148.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,367.53, add-ons for qualifying new technology services are included. If operating cost exceeds $47,238.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,579.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $10,384.29 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,422.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $819.42. The transfer capital threshold is the transfer adjustment factor * $819.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,13148.66,32553.63,Inpatient DRG
CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC,788,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],20142.33,,"Fee schedule rate ($20,142.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8438.02,20142.33,There are no additional notes associated with this service or procedure.
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],16283.24,,"Fee schedule rate ($16,283.24). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7875.94,17233.12,There are no additional notes associated with this service or procedure.
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],9533.13,,"Fee schedule rate ($9,533.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5068.21,14525.56,There are no additional notes associated with this service or procedure.
Egd Flexible Foreign Body Removal,CASE-43247,APC,43247,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1859.01,,"APC Price ($1,796.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1796.14,1885.95,OPPS APC
Cysto/Uretero W/Lithotripsy &Indwell Stent Insrt|BILATERAL PROCEDURE,CASE-52356,APC,52356,CPT,0360,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5194.43,,"APC Price ($5,018.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5018.77,5269.71,OPPS APC
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],36855.62,,"Fee schedule rate ($36,855.62). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,15821.59,40320.14,There are no additional notes associated with this service or procedure.
Injection Aa&/Strd Intercostal Nrv Ea Addl Lvl|LEFT SIDE,CASE-64421,APC,64421,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],869.28,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,827.89,869.28,OPPS APC
RESPIRATORY NEOPLASMS WITHOUT CC/MCC,182,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],6965.00,,,,,,0,other,6965.00,23037.13,There are no additional notes associated with this service or procedure.
PREMATURITY WITHOUT MAJOR PROBLEMS,792,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],18901.72,,"Case rate ($18,531.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,374.70, add-ons for qualifying new technology services are included. If operating cost exceeds $52,245.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,973.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. The base transfer operating payment is the transfer adjustment factor * $15,373.07 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,429.75 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,213.09. The transfer capital threshold is the transfer adjustment factor * $1,213.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,1956.00,19457.66,Inpatient DRG
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,057,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],11094.00,,"Case rate ($10,718.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,107.12, add-ons for qualifying new technology services are included. If operating cost exceeds $44,978.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,401.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,132.18 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,162.17 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $641.71. The transfer capital threshold is the transfer adjustment factor * $641.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,10718.84,39884.93,Inpatient DRG
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,095,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],19843.34,,"Case rate ($18,898.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,748.04, add-ons for qualifying new technology services are included. If operating cost exceeds $52,619.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,970.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.6. The base transfer operating payment is the transfer adjustment factor * $15,743.40 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,803.09 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,210.07. The transfer capital threshold is the transfer adjustment factor * $1,210.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,19411.47,50750.92,Inpatient DRG
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],28149.75,,"Case rate ($26,809.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $25,075.72, add-ons for qualifying new technology services are included. If operating cost exceeds $59,946.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,578.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $23,045.79 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $23,130.76 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,818.54. The transfer capital threshold is the transfer adjustment factor * $1,818.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,26809.29,97015.50,Inpatient DRG
APPENDIX PROCEDURES WITH MCC,397,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],51558.84,,"Fee schedule rate ($51,558.84). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,18163.37,51558.84,There are no additional notes associated with this service or procedure.
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 1 Level|LEFT SIDE,CASE-64493,APC,64493,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],869.28,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,827.89,869.28,OPPS APC
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],42768.36,,"Fee schedule rate ($42,768.36). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,14295.18,42768.36,There are no additional notes associated with this service or procedure.
Injection Aa&/Strd Genicular Nrv Branches W/Img|LEFT SIDE,CASE-64454,APC,64454,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],693.76,,"APC Price ($660.72). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,660.72,693.76,OPPS APC
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6749.91,,"Case rate ($6,428.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,124.26, add-ons for qualifying new technology services are included. If operating cost exceeds $40,995.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,079.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $4,163.53 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,179.31 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $320.02. The transfer capital threshold is the transfer adjustment factor * $320.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6564.18,17651.07,Inpatient DRG
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],13625.25,,"Fee schedule rate ($13,625.25). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7243.75,23262.15,There are no additional notes associated with this service or procedure.
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH MCC",722,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],34009.69,,"Fee schedule rate ($34,009.69). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,14200.37,56869.13,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],14451.02,,"Case rate ($13,762.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,938.93, add-ons for qualifying new technology services are included. If operating cost exceeds $47,809.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,624.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $10,953.59 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,993.98 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $864.35. The transfer capital threshold is the transfer adjustment factor * $864.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,1188.00,34338.33,Inpatient DRG
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],11391.45,,"Fee schedule rate ($11,391.45). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8874.81,20553.44,There are no additional notes associated with this service or procedure.
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],29916.58,,"Fee schedule rate ($29,916.58). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12725.42,34245.00,There are no additional notes associated with this service or procedure.
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC",011,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],102498.90,,"Fee schedule rate ($102,498.90). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,38880.49,150008.48,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,085,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],57443.16,,"Fee schedule rate ($57,443.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,9282.00,57443.16,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],41402.42,,"Fee schedule rate ($41,402.42). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,15456.59,41402.42,There are no additional notes associated with this service or procedure.
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC,520,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12352.81,,"Case rate ($11,764.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,098.27, add-ons for qualifying new technology services are included. If operating cost exceeds $45,969.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,460.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $9,118.74 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,153.32 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $700.89. The transfer capital threshold is the transfer adjustment factor * $700.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12061.74,39786.42,Inpatient DRG
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,065,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],18986.57,,"Fee schedule rate ($18,986.57). Adds an outlier to normal pricing equal to the per diem rate ($85,884.96) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,8786.76,25681.86,There are no additional notes associated with this service or procedure.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],18933.95,,"Fee schedule rate ($18,933.95). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.8), with a minimum of zero.",,,,0,other,8767.81,19824.58,There are no additional notes associated with this service or procedure.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],38246.19,,"Fee schedule rate ($38,246.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,19435.86,50821.76,There are no additional notes associated with this service or procedure.
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],19997.63,,"Fee schedule rate ($19,997.63). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,9151.11,30245.71,There are no additional notes associated with this service or procedure.
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC,797,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],8946.77,,"Case rate ($8,520.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,074.53, add-ons for qualifying new technology services are included. If operating cost exceeds $42,945.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,229.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $6,106.43 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,129.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $469.35. The transfer capital threshold is the transfer adjustment factor * $469.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8719.72,20928.55,Inpatient DRG
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC",641,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],14624.71,,"Fee schedule rate ($14,624.71). Adds an outlier to normal pricing equal to the per diem rate ($38,755.52) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7214.98,15312.64,There are no additional notes associated with this service or procedure.
Realignment Extensor Tendon Hand Each Tendon,CASE-26437,APC,26437,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],11300.08,,"Case rate ($6,457.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,142.59, add-ons for qualifying new technology services are included. If operating cost exceeds $41,013.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,089.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $4,182.21 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,197.63 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $330.02. The transfer capital threshold is the transfer adjustment factor * $330.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,5139.72,13110.79,All Other Inpatient
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],19997.63,,"Fee schedule rate ($19,997.63). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,9151.11,30245.71,There are no additional notes associated with this service or procedure.
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],26725.53,,"Fee schedule rate ($26,725.53). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.6), with a minimum of zero.",,,,0,other,11575.50,48961.48,There are no additional notes associated with this service or procedure.
Ndsc Njx Implt Matrl Urt&/Bldr Nck,CASE-51715,APC,51715,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3299.47,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3299.47,3464.44,OPPS APC
CERVICAL SPINAL FUSION WITHOUT CC/MCC,473,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],62077.11,,"Fee schedule rate ($62,077.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,18477.61,62077.11,There are no additional notes associated with this service or procedure.
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],38508.74,,"Fee schedule rate ($38,508.74). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.6), with a minimum of zero.",,,,0,other,15821.59,40320.14,There are no additional notes associated with this service or procedure.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],22058.83,,"Case rate ($21,008.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $19,714.85, add-ons for qualifying new technology services are included. If operating cost exceeds $54,585.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,120.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $17,702.78 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $17,769.90 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,360.68. The transfer capital threshold is the transfer adjustment factor * $1,360.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,21585.31,73588.10,Inpatient DRG
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC,832,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7070.79,,"Case rate ($6,831.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,490.97, add-ons for qualifying new technology services are included. If operating cost exceeds $41,361.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,117.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $4,529.32 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,546.02 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $357.41. The transfer capital threshold is the transfer adjustment factor * $357.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,4803.31,14198.92,Inpatient DRG
ALLERGIC REACTIONS WITH MCC,915,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],13648.28,,"Case rate ($12,998.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,248.33, add-ons for qualifying new technology services are included. If operating cost exceeds $47,119.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,548.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $10,264.46 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,303.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $788.95. The transfer capital threshold is the transfer adjustment factor * $788.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13332.86,33088.84,Inpatient DRG
Mastopexy|BILATERAL PROCEDURE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-19316,APC,19316,CPT,0360,RC,,,50|XU,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6215.36,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6215.36,6432.89,OPPS APC
Replacement Tissue Expander W/Permanent Implant,CASE-11970,APC,11970,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6791.99,7131.59,OPPS APC
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],21270.90,,"Fee schedule rate ($21,270.90). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,14370.36,38378.80,There are no additional notes associated with this service or procedure.
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],28334.16,,"Fee schedule rate ($28,334.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,7868.00,32126.64,There are no additional notes associated with this service or procedure.
Dstr Nrolytc Agnt Parverteb Fct Sngl Lmbr/Sacral|LEFT SIDE,CASE-64635,APC,64635,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1827.80,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1827.80,1919.19,OPPS APC
Tissue Expander Placement Breast Reconstruction|LEFT SIDE,CASE-19357,APC,19357,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],13350.78,,"APC Price ($12,899.30). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,12899.30,13350.78,OPPS APC
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],2401.00,,,,,,0,other,1188.00,12138.74,Estimated amount calculated based on 1 day length of stay.
COMPLICATIONS OF TREATMENT WITH CC,920,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],20731.52,,"Fee schedule rate ($20,731.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8732.59,20731.52,There are no additional notes associated with this service or procedure.
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITH MCC,429,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],177294.98,,"Fee schedule rate ($177,294.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,62958.58,177294.98,There are no additional notes associated with this service or procedure.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],18341.97,,"Fee schedule rate ($18,341.97). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.9), with a minimum of zero.",,,,0,other,8554.50,19204.75,There are no additional notes associated with this service or procedure.
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,450,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],39939.25,,"Case rate ($38,037.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $35,520.98, add-ons for qualifying new technology services are included. If operating cost exceeds $70,391.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,399.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $33,452.68 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $33,576.02 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,639.75. The transfer capital threshold is the transfer adjustment factor * $2,639.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,38037.38,146009.19,Inpatient DRG
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],25609.86,,"Fee schedule rate ($25,609.86). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,12775.53,31469.43,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],9782.85,,"Fee schedule rate ($9,782.85). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,6564.18,17651.07,There are no additional notes associated with this service or procedure.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],26776.27,,"Fee schedule rate ($26,776.27). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,11593.79,38248.08,There are no additional notes associated with this service or procedure.
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],14455.04,,"Fee schedule rate ($14,455.04). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5280.00,17136.70,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC,788,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],20142.33,,"Fee schedule rate ($20,142.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8438.02,20142.33,There are no additional notes associated with this service or procedure.
Injection Aa&/Strd Intercostal Nrv Ea Addl Lvl,CASE-64421,APC,64421,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],856.86,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,827.89,869.28,OPPS APC
Injection Aa&/Strd Ilioinguinal Ih Nerves,CASE-64425,APC,64425,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],660.72,,"APC Price ($660.72). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,660.72,693.76,OPPS APC
"Tendon Sheath Incision|LEFT HAND, THUMB",CASE-26055,APC,26055,CPT,0360,RC,,,FA,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1505.12,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1505.12,1580.37,OPPS APC
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],10136.44,,"Case rate ($10,136.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,565.33, add-ons for qualifying new technology services are included. If operating cost exceeds $44,436.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,359.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $7,592.38 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,620.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $599.11. The transfer capital threshold is the transfer adjustment factor * $599.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10136.44,24444.75,Inpatient DRG
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC",156,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6625.12,,"Case rate ($6,625.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,298.82, add-ons for qualifying new technology services are included. If operating cost exceeds $41,169.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,102.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $4,337.88 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,353.87 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $342.30. The transfer capital threshold is the transfer adjustment factor * $342.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6625.12,13598.77,Inpatient DRG
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],21167.26,,"Fee schedule rate ($21,167.26). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,6841.83,21167.26,There are no additional notes associated with this service or procedure.
Esophagoscopy Flexible Transoral With Biopsy,CASE-43202,APC,43202,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1859.01,,"APC Price ($1,796.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1796.14,1885.95,OPPS APC
MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,708,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],11081.24,,"Case rate ($11,081.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $10,413.93, add-ons for qualifying new technology services are included. If operating cost exceeds $49,058.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $3,436.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.3. The base transfer operating payment is the transfer adjustment factor * $9,014.04 + an uncompensated DSH payment of $1,359.91. The transfer operating threshold is the transfer adjustment factor * $9,054.03 + an uncompensated DSH payment of $1,359.91. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $707.29. The transfer capital threshold is the transfer adjustment factor * $707.29. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10138.21,29171.15,Inpatient DRG
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],25162.32,,"Case rate ($25,162.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $23,543.58, add-ons for qualifying new technology services are included. If operating cost exceeds $58,414.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,458.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $21,519.28 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $21,598.63 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,698.08. The transfer capital threshold is the transfer adjustment factor * $1,698.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,25162.32,75579.22,Inpatient DRG
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],53569.45,,"Fee schedule rate ($53,569.45). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14.8), with a minimum of zero.",,,,0,other,21248.73,56089.29,There are no additional notes associated with this service or procedure.
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",759,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6438.90,,"Case rate ($6,438.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,125.57, add-ons for qualifying new technology services are included. If operating cost exceeds $40,996.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,088.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,165.27 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,180.62 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $328.68. The transfer capital threshold is the transfer adjustment factor * $328.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6190.22,13057.66,Inpatient DRG
Replacement Tissue Expander W/Permanent Implant|LEFT SIDE,CASE-11970,APC,11970,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6791.99,7131.59,OPPS APC
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],41006.47,,"Fee schedule rate ($41,006.47). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12268.97,41006.47,There are no additional notes associated with this service or procedure.
Cystourethroscopy With Biopsy,CASE-52204,APC,52204,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1956.65,,"APC Price ($1,956.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1956.65,2054.48,OPPS APC
HC Plcmt Tunnel Pleural Drain Cat,CASE-32550,APC,32550,CPT,0361,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3518.91,,"APC Price ($3,351.34). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3351.34,3518.91,OPPS APC
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],33006.79,,"Fee schedule rate ($33,006.79). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (35), with a minimum of zero.",,,,0,other,30398.48,82674.88,There are no additional notes associated with this service or procedure.
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,450,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],146009.19,,"Fee schedule rate ($146,009.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,38037.38,146009.19,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],28038.61,,"Fee schedule rate ($28,038.61). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12126.09,29582.40,There are no additional notes associated with this service or procedure.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,025,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],33881.26,,"Case rate ($32,735.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $30,588.77, add-ons for qualifying new technology services are included. If operating cost exceeds $65,459.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,011.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.4. The base transfer operating payment is the transfer adjustment factor * $28,538.59 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $28,643.82 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,251.98. The transfer capital threshold is the transfer adjustment factor * $2,251.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103.5%.",,,,0,other,13351.00,91631.33,Inpatient DRG
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],15309.46,,"Fee schedule rate ($15,309.46). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6965.00,15340.19,There are no additional notes associated with this service or procedure.
PERIPHERAL VASCULAR DISORDERS WITH CC,300,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],20061.53,,"Fee schedule rate ($20,061.53). Adds an outlier to normal pricing equal to the per diem rate ($49,296.97) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.9), with a minimum of zero.",,,,0,other,9174.14,21005.20,There are no additional notes associated with this service or procedure.
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC,805,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],20902.03,,"Fee schedule rate ($20,902.03). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9253.36,21235.42,There are no additional notes associated with this service or procedure.
NEONATE WITH OTHER SIGNIFICANT PROBLEMS,794,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],3383.58,,"Fee schedule rate ($3,383.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,1798.85,12536.83,There are no additional notes associated with this service or procedure.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC,858,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],11605.32,,"Case rate ($11,377.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,720.10, add-ons for qualifying new technology services are included. If operating cost exceeds $45,591.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,449.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $8,742.91 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,775.15 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $689.90. The transfer capital threshold is the transfer adjustment factor * $689.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,11377.76,33794.11,Inpatient DRG
HC Inj Aa&/Strd Other Peripheral Nerve/Branch|RIGHT SIDE,CASE-64450,APC,64450,CPT,0450,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],683.85,,"APC Price ($660.72). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,660.72,683.85,OPPS APC
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],21800.74,,"Fee schedule rate ($21,800.74). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12268.97,41006.47,There are no additional notes associated with this service or procedure.
NERVOUS SYSTEM NEOPLASMS WITH MCC,054,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],25589.03,,"Fee schedule rate ($25,589.03). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,6965.00,30044.81,There are no additional notes associated with this service or procedure.
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],25814.06,,"Fee schedule rate ($25,814.06). Adds an outlier to normal pricing equal to the per diem rate ($46,867.46) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,11247.07,27028.33,There are no additional notes associated with this service or procedure.
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],18918.49,,"Fee schedule rate ($18,918.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9282.47,21320.03,There are no additional notes associated with this service or procedure.
PERITONEAL ADHESIOLYSIS WITH CC,336,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],16596.05,,"Case rate ($15,805.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,865.23, add-ons for qualifying new technology services are included. If operating cost exceeds $49,736.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,749.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $12,871.47 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,920.28 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $989.33. The transfer capital threshold is the transfer adjustment factor * $989.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,16225.22,53705.31,Inpatient DRG
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,066,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],6965.00,,,,,,0,other,6579.76,20083.61,There are no additional notes associated with this service or procedure.
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],22382.59,,,,,,0,other,9648.19,31477.13,There are no additional notes associated with this service or procedure.
Nsl/Sinus Ndsc Max Antrost W/Rmvl Tiss Max Sinus|RIGHT SIDE,CASE-31267,APC,31267,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6936.25,,"APC Price ($6,605.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6605.95,6936.25,OPPS APC
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],31973.49,,"Fee schedule rate ($31,973.49). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,13386.36,33244.29,There are no additional notes associated with this service or procedure.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],17194.49,,"Fee schedule rate ($17,194.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8554.50,19204.75,There are no additional notes associated with this service or procedure.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],11681.49,,"Fee schedule rate ($11,681.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5778.62,11681.49,There are no additional notes associated with this service or procedure.
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],16207.80,,"Fee schedule rate ($16,207.80). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,14343.25,36024.65,There are no additional notes associated with this service or procedure.
Open Tx Distal Fibular Fracture Lat Malleolus|RIGHT SIDE,CASE-27792,APC,27792,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITHOUT MCC,430,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],70791.71,,"Fee schedule rate ($70,791.71). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,41000.16,133156.90,There are no additional notes associated with this service or procedure.
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC,519,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],37589.76,,"Fee schedule rate ($37,589.76). Adds an outlier to normal pricing equal to the per diem rate ($123,674.40) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,15490.44,50780.20,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],25293.50,,"Fee schedule rate ($25,293.50). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11059.47,28423.20,There are no additional notes associated with this service or procedure.
Osteot W/WO Lngth Shrt/Corrj Metar Xcp 1st Ea|RIGHT SIDE,CASE-28308,APC,28308,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,025,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],33422.66,,"Case rate ($31,831.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $29,803.17, add-ons for qualifying new technology services are included. If operating cost exceeds $64,674.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,893.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.4. The base transfer operating payment is the transfer adjustment factor * $27,752.99 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $27,858.22 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,133.16. The transfer capital threshold is the transfer adjustment factor * $2,133.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,13351.00,91631.33,Inpatient DRG
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],14116.22,,"Case rate ($13,444.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,663.75, add-ons for qualifying new technology services are included. If operating cost exceeds $47,534.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,580.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $10,678.31 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,718.80 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $820.76. The transfer capital threshold is the transfer adjustment factor * $820.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,34422.94,Inpatient DRG
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],85466.62,,"Fee schedule rate ($85,466.62). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,21382.16,85466.62,There are no additional notes associated with this service or procedure.
MAJOR BLADDER PROCEDURES WITH MCC,653,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],125343.98,,"Fee schedule rate ($125,343.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,10280.00,125343.98,There are no additional notes associated with this service or procedure.
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC,797,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],20928.55,,"Fee schedule rate ($20,928.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8719.72,20928.55,There are no additional notes associated with this service or procedure.
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],5893.50,,"Case rate ($5,777.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,510.70, add-ons for qualifying new technology services are included. If operating cost exceeds $40,381.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,040.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $3,552.65 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,565.75 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $280.34. The transfer capital threshold is the transfer adjustment factor * $280.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,5065.00,12558.65,Inpatient DRG
COMPLICATIONS OF TREATMENT WITH CC,920,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],18836.22,,"Fee schedule rate ($18,836.22). Adds an outlier to normal pricing equal to the per diem rate ($49,808.13) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,8732.59,20731.52,There are no additional notes associated with this service or procedure.
Dstr Nrolytc Agnt Parverteb Fct Addl Lmbr/Sacral,CASE-64636,APC,64636,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1827.80,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1827.80,1919.19,OPPS APC
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,098,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],38799.38,,"Fee schedule rate ($38,799.38). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,6965.00,45156.75,There are no additional notes associated with this service or procedure.
"Amp F/Th 1/2 Jt/Phalanx W/Neurect W/Dir Clsr|RIGHT HAND, SECOND DIGIT",CASE-26951,APC,26951,CPT,0360,RC,,,F6,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],75545.91,,,,,,0,other,27944.96,86252.84,There are no additional notes associated with this service or procedure.
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC,519,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],50780.20,,"Fee schedule rate ($50,780.20). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,15490.44,50780.20,There are no additional notes associated with this service or procedure.
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],14674.80,,"Fee schedule rate ($14,674.80). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6711.00,16865.16,There are no additional notes associated with this service or procedure.
CERVICAL SPINAL FUSION WITHOUT CC/MCC,473,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],62077.11,,"Fee schedule rate ($62,077.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,18477.61,62077.11,There are no additional notes associated with this service or procedure.
HC Inject Tendon Origin/Insert|RIGHT SIDE,CASE-20551,APC,20551,CPT,0361,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],301.68,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,287.31,301.68,OPPS APC
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6393.09,,"Case rate ($6,088.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,807.49, add-ons for qualifying new technology services are included. If operating cost exceeds $40,678.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,055.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $3,847.95 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,862.54 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $295.76. The transfer capital threshold is the transfer adjustment factor * $295.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6214.05,15318.94,Inpatient DRG
"Amputation Toe Interphalangeal Joint|RIGHT FOOT, FOURTH DIGIT",CASE-28825,APC,28825,CPT,0360,RC,,,T8,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3062.67,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],8235.00,,"Case rate ($7,956.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,537.38, add-ons for qualifying new technology services are included. If operating cost exceeds $42,408.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,199.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,571.89 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,592.43 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $439.68. The transfer capital threshold is the transfer adjustment factor * $439.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6965.00,17467.27,Inpatient DRG
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],85305.59,,"Fee schedule rate ($85,305.59). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,21719.40,85305.59,There are no additional notes associated with this service or procedure.
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],5415.00,,"Per diem ($5,415). If length of stay < 3.1, first 1 days paid at a per diem of $10,830 instead. Capped at $16,785.91.",,,,0,other,5415.00,17575.50,Estimated amount calculated based on 3 day length of stay.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],45521.20,,"Case rate ($45,521.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $42,483.01, add-ons for qualifying new technology services are included. If operating cost exceeds $77,354.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,947.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 12.5. The base transfer operating payment is the transfer adjustment factor * $40,389.14 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $40,538.06 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,187.10. The transfer capital threshold is the transfer adjustment factor * $3,187.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,45521.20,142438.06,Inpatient DRG
"Open Tx Phalangeal Shaft Fracture Prox/Middle Ea|RIGHT HAND, SECOND DIGIT",CASE-26735,APC,26735,CPT,0360,RC,,,F6,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3062.67,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5796.79,,"Case rate ($5,520.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,278.11, add-ons for qualifying new technology services are included. If operating cost exceeds $40,149.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,015.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,320.57 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,333.16 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $255.23. The transfer capital threshold is the transfer adjustment factor * $255.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5628.97,12272.58,Inpatient DRG
Hysteroscopy Lysis Intrauterine Adhesions,CASE-58559,APC,58559,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],4846.30,,"APC Price ($4,682.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,4682.41,4916.53,OPPS APC
Egd Band Ligation Esophgeal/Gastric Varices,CASE-43244,APC,43244,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1796.14,,"APC Price ($1,796.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1796.14,1885.95,OPPS APC
Inj for Sacroiliac Jt Anesth|BILATERAL PROCEDURE,CASE-G0260,APC,G0260,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],660.72,,"APC Price ($660.72). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,660.72,693.76,OPPS APC
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],59610.47,,"Fee schedule rate ($59,610.47). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,16129.04,59610.47,There are no additional notes associated with this service or procedure.
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],10048.39,,"Case rate ($10,048.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,483.42, add-ons for qualifying new technology services are included. If operating cost exceeds $44,354.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,352.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,510.78 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,538.48 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $592.68. The transfer capital threshold is the transfer adjustment factor * $592.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10048.39,23545.50,Inpatient DRG
NERVOUS SYSTEM NEOPLASMS WITH MCC,054,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],25589.03,,"Fee schedule rate ($25,589.03). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,6965.00,30044.81,There are no additional notes associated with this service or procedure.
O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC,621,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],12767.94,,"Case rate ($12,159.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,447.74, add-ons for qualifying new technology services are included. If operating cost exceeds $46,318.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,507.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $9,467.88 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,502.79 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $747.11. The transfer capital threshold is the transfer adjustment factor * $747.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12159.94,36669.96,Inpatient DRG
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,093,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],19011.32,,"Fee schedule rate ($19,011.32). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,19011.32,There are no additional notes associated with this service or procedure.
BRONCHITIS AND ASTHMA WITHOUT CC/MCC,203,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],6965.00,,,,,,0,other,4763.76,13707.00,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,086,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],30728.81,,"Fee schedule rate ($30,728.81). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8442.00,30728.81,There are no additional notes associated with this service or procedure.
Arthrodesis Pst/Pstlat Tq 1ntrspc Ea Addl Ntrspc,CASE-22614,APC,22614,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],16412.07,,"APC Price ($16,412.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,16412.07,17232.68,OPPS APC
INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,352,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],26528.70,,"Fee schedule rate ($26,528.70). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,9853.37,26528.70,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],14624.60,,"Case rate ($14,337.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,473.80, add-ons for qualifying new technology services are included. If operating cost exceeds $48,344.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,666.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $11,486.49 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,528.84 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $906.40. The transfer capital threshold is the transfer adjustment factor * $906.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,14337.84,52803.53,Inpatient DRG
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],7414.97,,"Fee schedule rate ($7,414.97). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6153.12,13947.32,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC,817,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],42878.11,,"Fee schedule rate ($42,878.11). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.5), with a minimum of zero.",,,,0,other,17396.11,44895.04,There are no additional notes associated with this service or procedure.
HC Breath Hydrogen/Met Test,CASE-91065,APC,91065,CPT,0920,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],212.21,,"APC Price ($202.11). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,202.11,212.21,OPPS APC
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],53197.34,,"Case rate ($30,398.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $28,414.67, add-ons for qualifying new technology services are included. If operating cost exceeds $63,285.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,841.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.2. The base transfer operating payment is the transfer adjustment factor * $26,372.48 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $26,469.72 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,081.05. The transfer capital threshold is the transfer adjustment factor * $2,081.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,30398.48,82674.88,All Other Inpatient
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5710.23,,"Case rate ($5,710.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,447.70, add-ons for qualifying new technology services are included. If operating cost exceeds $40,318.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,035.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $3,489.88 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,502.75 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $275.39. The transfer capital threshold is the transfer adjustment factor * $275.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,3079.00,10940.41,Inpatient DRG
Hemorrhoid Ntrnl & Xtrnl 1 Column W/Fissurecto,CASE-46257,APC,46257,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],2598.08,,"APC Price ($2,598.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2598.08,2727.99,OPPS APC
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],14718.75,,"Case rate ($14,017.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,198.65, add-ons for qualifying new technology services are included. If operating cost exceeds $48,069.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,621.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,211.19 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,253.70 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $861.72. The transfer capital threshold is the transfer adjustment factor * $861.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,36140.75,Inpatient DRG
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,479,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],14533.55,,"Case rate ($14,533.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,655.86, add-ons for qualifying new technology services are included. If operating cost exceeds $48,526.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,680.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $11,667.89 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,710.91 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $920.71. The transfer capital threshold is the transfer adjustment factor * $920.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10586.00,50518.76,Inpatient DRG
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],6829.10,,"Case rate ($6,503.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,186.05, add-ons for qualifying new technology services are included. If operating cost exceeds $41,057.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,093.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $4,225.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,241.10 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $333.44. The transfer capital threshold is the transfer adjustment factor * $333.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6503.90,14492.93,Inpatient DRG
Parathyroidectomy/Exploration Parathyroids|LEFT SIDE,CASE-60500,APC,60500,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5735.04,,"APC Price ($5,541.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5541.10,5818.16,OPPS APC
Anoscopy Dx W/HRA &Chem Agnts Enhancement W/Bx,CASE-46607,APC,46607,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1176.09,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1120.09,1176.09,OPPS APC
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],17524.27,,"Case rate ($16,689.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,661.75, add-ons for qualifying new technology services are included. If operating cost exceeds $50,532.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,838.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $13,666.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,716.80 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,078.42. The transfer capital threshold is the transfer adjustment factor * $1,078.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,16689.78,59521.43,Inpatient DRG
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,373,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],13780.60,,"Fee schedule rate ($13,780.60). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6870.94,14313.05,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],12126.09,,"Case rate ($12,126.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,416.25, add-ons for qualifying new technology services are included. If operating cost exceeds $46,287.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,504.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $9,436.50 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,471.29 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $744.63. The transfer capital threshold is the transfer adjustment factor * $744.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12126.09,29582.40,Inpatient DRG
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],16590.46,,"Fee schedule rate ($16,590.46). Adds an outlier to normal pricing equal to the per diem rate ($69,146.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,1188.00,17370.86,There are no additional notes associated with this service or procedure.
HC Inj Tendon Sheath/Ligament|PBB CHARGE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-20550,APC,20550,CPT,0510,RC,,,PBB|XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],297.37,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,287.31,301.68,OPPS APC
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],59081.91,,"Fee schedule rate ($59,081.91). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,8480.00,59081.91,There are no additional notes associated with this service or procedure.
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,451,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],41687.52,,"Case rate ($23,821.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $22,296.19, add-ons for qualifying new technology services are included. If operating cost exceeds $57,167.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,359.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $20,276.48 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $20,351.24 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,600.01. The transfer capital threshold is the transfer adjustment factor * $1,600.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,23821.44,94077.13,All Other Inpatient
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITHOUT CC/MCC",630,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],27428.38,,"Fee schedule rate ($27,428.38). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,11828.78,42541.02,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,086,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],11305.27,,"Case rate ($10,766.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,151.85, add-ons for qualifying new technology services are included. If operating cost exceeds $45,022.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,405.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $8,176.75 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,206.90 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $645.23. The transfer capital threshold is the transfer adjustment factor * $645.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8442.00,30728.81,Inpatient DRG
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,074,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],15619.80,,"Case rate ($8,925.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,438.90, add-ons for qualifying new technology services are included. If operating cost exceeds $43,309.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,270.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,470.10 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,493.95 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $510.55. The transfer capital threshold is the transfer adjustment factor * $510.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,8925.60,20919.08,All Other Inpatient
COMPLICATIONS OF TREATMENT WITH CC,920,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],8907.24,,"Case rate ($8,732.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,259.35, add-ons for qualifying new technology services are included. If operating cost exceeds $43,130.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,256.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,291.21 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,314.40 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $496.44. The transfer capital threshold is the transfer adjustment factor * $496.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,8732.59,20731.52,Inpatient DRG
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],26301.36,,"Fee schedule rate ($26,301.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11247.07,27028.33,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITHOUT STERILIZATION WITH MCC,786,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],13574.53,,"Case rate ($13,115.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,336.66, add-ons for qualifying new technology services are included. If operating cost exceeds $47,207.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,576.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $10,353.53 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,391.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $817.00. The transfer capital threshold is the transfer adjustment factor * $817.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,12612.10,23722.94,Inpatient DRG
"NEONATE BIRTH WEIGHT 2000-2499 GRAMS WITH RESPIRATORY DISTRESS SYNDROME OR OTHER MAJOR RESPIRATORY CONDITION,MINOR",622,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],14454.53,,"Case rate ($13,766.22). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13766.22,14454.53,There are no additional notes associated with this service or procedure.
"OTHER DIGESTIVE SYSTEM AND ABDOMINAL PROCEDURES,EXTREME",229,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],41019.09,,"Case rate ($41,019.09). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,41019.09,43070.04,There are no additional notes associated with this service or procedure.
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],14830.15,,"Fee schedule rate ($14,830.15). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,7884.32,17835.23,There are no additional notes associated with this service or procedure.
Neuroplasty &/Transposition Ulnar Nerve Elbow|LEFT SIDE,CASE-64718,APC,64718,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1827.80,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1827.80,1919.19,OPPS APC
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH MCC",722,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],31518.90,,"Fee schedule rate ($31,518.90). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,14200.37,56869.13,There are no additional notes associated with this service or procedure.
Septoplasty/Submucous Resecj W/WO Cartilage Grf,CASE-30520,APC,30520,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.35,,"APC Price ($3,103.35). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.35,3258.52,OPPS APC
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,309,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],6207.80,,"Case rate ($6,207.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $5,875.02, add-ons for qualifying new technology services are included. If operating cost exceeds $44,519.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $3,081.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,495.17 + an uncompensated DSH payment of $1,359.91. The transfer operating threshold is the transfer adjustment factor * $4,515.10 + an uncompensated DSH payment of $1,359.91. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $352.72. The transfer capital threshold is the transfer adjustment factor * $352.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,5055.77,14547.21,Inpatient DRG
"NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY",789,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],6663.33,,,,,,0,other,3054.00,14857.05,Estimated amount calculated based on 1 day length of stay.
"LIMB REATTACHMENT, HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA",956,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],70718.06,,"Fee schedule rate ($70,718.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,27428.25,148259.86,There are no additional notes associated with this service or procedure.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],40918.00,,"Fee schedule rate ($40,918.00). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,16689.78,59521.43,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,689,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],22417.63,,"Fee schedule rate ($22,417.63). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,9802.58,22831.22,There are no additional notes associated with this service or procedure.
Exc B9 Lesion Mrgn Xcp Sk Tg T/a/L 0.6-1.0 Cm,CASE-11401,APC,11401,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],380.51,,"APC Price ($380.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,380.51,399.53,OPPS APC
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],133270.57,,"Fee schedule rate ($133,270.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,33623.33,133270.57,There are no additional notes associated with this service or procedure.
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],16283.24,,"Fee schedule rate ($16,283.24). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7875.94,17233.12,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],17477.25,,"Fee schedule rate ($17,477.25). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8563.30,31533.97,There are no additional notes associated with this service or procedure.
Open Tx Carpal Scaphoid Navicular Fracture|LEFT SIDE,CASE-25628,APC,25628,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6791.99,7131.59,OPPS APC
"Open Tx Articular Fracture Mcp/IP Joint Ea|LEFT HAND, FIFTH DIGIT",CASE-26746,APC,26746,CPT,0360,RC,,,F4,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,057,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],10933.22,,"Case rate ($10,718.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,107.12, add-ons for qualifying new technology services are included. If operating cost exceeds $44,978.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,401.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,132.18 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,162.17 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $641.71. The transfer capital threshold is the transfer adjustment factor * $641.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,10718.84,39884.93,Inpatient DRG
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],26043.00,,"Case rate ($25,162.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $23,543.58, add-ons for qualifying new technology services are included. If operating cost exceeds $58,414.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,458.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $21,519.28 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $21,598.63 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,698.08. The transfer capital threshold is the transfer adjustment factor * $1,698.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,25162.32,75579.22,Inpatient DRG
SEIZURES WITH MCC,100,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],15061.09,,"Case rate ($15,061.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,146.62, add-ons for qualifying new technology services are included. If operating cost exceeds $49,017.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,719.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $12,156.85 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,201.67 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $959.30. The transfer capital threshold is the transfer adjustment factor * $959.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,15061.09,38110.41,Inpatient DRG
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],34749.58,,,,,,0,other,13904.43,34749.58,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS WITH MCC,947,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],30414.32,,"Fee schedule rate ($30,414.32). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,10541.41,30414.32,There are no additional notes associated with this service or procedure.
MAJOR BLADDER PROCEDURES WITH MCC,653,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],10280.00,,"Per diem ($10,280). If length of stay < 9.5, first 1 days paid at a per diem of $20,560 instead. Capped at $97,655.95.",,,,0,other,10280.00,125343.98,Estimated amount calculated based on 10 day length of stay.
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],7000.00,,"Per diem ($7,000). If length of stay < 4.5, first 1 days paid at a per diem of $14,000 instead. Capped at $31,498.95.",,,,0,other,7000.00,33835.79,Estimated amount calculated based on 2 day length of stay.
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",759,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],6453.30,,"Fee schedule rate ($6,453.30). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6190.22,13057.66,There are no additional notes associated with this service or procedure.
Cysto W/Insert Ureteral Stent|RIGHT SIDE,CASE-52332,APC,52332,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3299.47,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3299.47,3464.44,OPPS APC
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH CC,427,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],134742.59,,"Fee schedule rate ($134,742.59). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,50829.82,142040.39,There are no additional notes associated with this service or procedure.
MAJOR CHEST TRAUMA WITHOUT CC/MCC,185,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],14780.69,,"Fee schedule rate ($14,780.69). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.7), with a minimum of zero.",,,,0,other,7271.19,21771.61,There are no additional notes associated with this service or procedure.
Unlisted Laparoscopic Procedure Liver,CASE-47379,APC,47379,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5658.76,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5658.76,5941.70,OPPS APC
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH CC,427,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],134742.59,,"Fee schedule rate ($134,742.59). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,50829.82,142040.39,There are no additional notes associated with this service or procedure.
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC,805,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],9577.23,,"Case rate ($9,253.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,743.82, add-ons for qualifying new technology services are included. If operating cost exceeds $43,614.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,294.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $6,773.89 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,798.87 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $534.53. The transfer capital threshold is the transfer adjustment factor * $534.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,9253.36,21235.42,Inpatient DRG
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITH MCC OR ANTINEOPLASTIC IMPLANT OR EPILEPSY WITH NEUROSTIMULATOR,023,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],136379.44,,"Fee schedule rate ($136,379.44). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,15168.00,136379.44,There are no additional notes associated with this service or procedure.
"Open Tx Phalangeal Shaft Fracture Prox/Middle Ea|RIGHT HAND, FOURTH DIGIT",CASE-26735,APC,26735,CPT,0360,RC,,,F8,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],40426.76,,"Fee schedule rate ($40,426.76). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,11914.12,40426.76,There are no additional notes associated with this service or procedure.
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],14603.31,,"Case rate ($14,603.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,720.75, add-ons for qualifying new technology services are included. If operating cost exceeds $48,591.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,685.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $11,732.54 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,775.80 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $925.81. The transfer capital threshold is the transfer adjustment factor * $925.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,14603.31,45017.13,Inpatient DRG
NERVOUS SYSTEM NEOPLASMS WITH MCC,054,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],25589.03,,"Fee schedule rate ($25,589.03). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,6965.00,30044.81,There are no additional notes associated with this service or procedure.
Parathyroidectomy/Exploration Parathyroids|RIGHT SIDE,CASE-60500,APC,60500,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5856.81,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5658.76,5941.70,OPPS APC
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|LEFT HAND, THUMB",CASE-26160,APC,26160,CPT,0360,RC,,,FA,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1557.80,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1505.12,1580.37,OPPS APC
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],59385.88,,"Fee schedule rate ($59,385.88). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,23344.70,62179.32,There are no additional notes associated with this service or procedure.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],52699.33,,"Fee schedule rate ($52,699.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,18105.81,52699.33,There are no additional notes associated with this service or procedure.
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],33890.73,,"Fee schedule rate ($33,890.73). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6277.00,36801.89,There are no additional notes associated with this service or procedure.
"UTERINE AND ADNEXA PROCEDURES FOR LEIOMYOMA,MODERATE",519,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],4637.07,,"Case rate for a one day stay ($4,637.07). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,4637.07,4868.92,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],26178.21,,"Fee schedule rate ($26,178.21). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,13917.42,34889.29,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],49717.39,,"Fee schedule rate ($49,717.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,14908.05,49717.39,There are no additional notes associated with this service or procedure.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC",156,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],12624.95,,"Fee schedule rate ($12,624.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6625.12,13598.77,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,082,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],42953.28,,"Fee schedule rate ($42,953.28). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.6), with a minimum of zero.",,,,0,other,17423.21,56223.11,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],24416.91,,"Case rate ($13,952.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,115.33, add-ons for qualifying new technology services are included. If operating cost exceeds $47,986.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,638.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $11,129.34 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,170.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $878.22. The transfer capital threshold is the transfer adjustment factor * $878.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,13917.42,34889.29,All Other Inpatient
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC,027,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],56363.30,,"Fee schedule rate ($56,363.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,19030.20,56363.30,There are no additional notes associated with this service or procedure.
NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,601,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],6344.15,,"Case rate ($6,042.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,756.39, add-ons for qualifying new technology services are included. If operating cost exceeds $40,627.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,059.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $3,797.45 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,811.45 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $299.66. The transfer capital threshold is the transfer adjustment factor * $299.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6042.05,12359.72,Inpatient DRG
HC Biopsy/Exc Lymph Node Needle|TECHNICAL COMPONENT|RIGHT SIDE,CASE-38505,APC,38505,CPT,0361,RC,,,TC|RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1545.93,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1545.93,1623.23,OPPS APC
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],53569.45,,"Fee schedule rate ($53,569.45). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14.8), with a minimum of zero.",,,,0,other,21248.73,56089.29,There are no additional notes associated with this service or procedure.
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],33159.45,,"Fee schedule rate ($33,159.45). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,13092.47,33159.45,There are no additional notes associated with this service or procedure.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],80635.65,,"Fee schedule rate ($80,635.65). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,26028.48,80635.65,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITH CC,386,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],19879.00,,"Fee schedule rate ($19,879.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8556.53,19879.00,There are no additional notes associated with this service or procedure.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],31007.30,,"Fee schedule rate ($31,007.30). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,16120.25,41187.90,There are no additional notes associated with this service or procedure.
"UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY EXCEPT LEIOMYOMA,MINOR",513,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],5430.47,,"Case rate for a one day stay ($5,430.47). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,5430.47,5701.99,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],7127.04,,"Case rate ($6,787.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,450.02, add-ons for qualifying new technology services are included. If operating cost exceeds $41,321.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,114.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,488.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,505.07 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $354.19. The transfer capital threshold is the transfer adjustment factor * $354.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6164.03,14071.02,Inpatient DRG
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,093,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],19011.32,,"Fee schedule rate ($19,011.32). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,19011.32,There are no additional notes associated with this service or procedure.
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC,497,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],10482.12,,"Case rate ($10,127.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,557.14, add-ons for qualifying new technology services are included. If operating cost exceeds $44,428.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,358.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 1.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $7,584.22 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,612.19 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $598.47. The transfer capital threshold is the transfer adjustment factor * $598.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,10127.65,37761.19,Inpatient DRG
"TRANSIENT ISCHEMIA,MODERATE",047,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],3484.29,,"Case rate for a one day stay ($3,318.37). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,3318.37,3484.29,There are no additional notes associated with this service or procedure.
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],11133.98,,"Fee schedule rate ($11,133.98). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5919.29,13545.65,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],31918.40,,"Case rate ($30,398.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $28,414.67, add-ons for qualifying new technology services are included. If operating cost exceeds $63,285.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,841.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.2. The base transfer operating payment is the transfer adjustment factor * $26,372.48 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $26,469.72 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,081.05. The transfer capital threshold is the transfer adjustment factor * $2,081.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,30398.48,82674.88,Inpatient DRG
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],10989.72,,"Case rate ($10,989.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,359.11, add-ons for qualifying new technology services are included. If operating cost exceeds $45,230.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,421.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $8,383.26 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,414.17 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $661.52. The transfer capital threshold is the transfer adjustment factor * $661.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10989.72,26280.60,Inpatient DRG
"INFECTIOUS AND PARASITIC DISEASES INCLUDING HIV WITH O.R. PROCEDURE,EXTREME",710,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],49120.77,,"Case rate ($46,781.69). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $48,300, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,46781.69,49120.77,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],12272.58,,"Fee schedule rate ($12,272.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5628.97,12272.58,There are no additional notes associated with this service or procedure.
RESPIRATORY NEOPLASMS WITHOUT CC/MCC,182,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],7402.23,,"Case rate ($7,049.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,693.83, add-ons for qualifying new technology services are included. If operating cost exceeds $41,564.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,133.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,731.43 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,748.88 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $373.36. The transfer capital threshold is the transfer adjustment factor * $373.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,23037.13,Inpatient DRG
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,345,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],17871.67,,"Fee schedule rate ($17,871.67). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12134.89,33616.03,There are no additional notes associated with this service or procedure.
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],15802.03,,"Fee schedule rate ($15,802.03). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7566.45,16333.88,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],40737.46,,"Fee schedule rate ($40,737.46). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,7665.00,40737.46,There are no additional notes associated with this service or procedure.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,345,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],33616.03,,"Fee schedule rate ($33,616.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12134.89,33616.03,There are no additional notes associated with this service or procedure.
SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS,029,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],13641.00,,"Per diem ($13,641). If length of stay < 4.7, first 1 days paid at a per diem of $27,282 instead. Capped at $64,114.20.",,,,0,other,13641.00,67130.05,Estimated amount calculated based on 5 day length of stay.
NON-MALIGNANT BREAST DISORDERS WITH CC/MCC,600,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],15046.13,,"Fee schedule rate ($15,046.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7999.14,20495.56,There are no additional notes associated with this service or procedure.
RESPIRATORY NEOPLASMS WITHOUT CC/MCC,182,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],12768.00,,"Fee schedule rate ($12,768). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6965.00,23037.13,There are no additional notes associated with this service or procedure.
O.R. PROCEDURES FOR OBESITY WITH CC,620,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],43753.50,,"Fee schedule rate ($43,753.50). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12782.30,43753.50,There are no additional notes associated with this service or procedure.
OSTEOMYELITIS WITH CC,540,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],18450.55,,"Fee schedule rate ($18,450.55). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,9809.07,25507.30,There are no additional notes associated with this service or procedure.
Revj/Rmvl Impl Spi Npg/Rcvr Dtch Connj Eltrd Ra,CASE-63688,APC,63688,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3386.97,,"APC Price ($3,272.44). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3272.44,3436.06,OPPS APC
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],39359.90,,,,,,0,other,15491.11,54180.83,There are no additional notes associated with this service or procedure.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",062,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],14537.08,,"Case rate ($13,844.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,015.16, add-ons for qualifying new technology services are included. If operating cost exceeds $47,886.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,630.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $11,029.54 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,070.21 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $870.34. The transfer capital threshold is the transfer adjustment factor * $870.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13844.84,44304.80,Inpatient DRG
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],51656.32,,"Fee schedule rate ($51,656.32). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,20559.34,54086.17,There are no additional notes associated with this service or procedure.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],21585.31,,"Case rate ($21,585.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,215.96, add-ons for qualifying new technology services are included. If operating cost exceeds $55,086.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,196.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $18,203.89 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,271.01 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,436.47. The transfer capital threshold is the transfer adjustment factor * $1,436.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,21585.31,73588.10,Inpatient DRG
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],9137.93,,"Case rate ($8,702.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,231.63, add-ons for qualifying new technology services are included. If operating cost exceeds $43,102.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,254.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,263.59 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,286.68 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $494.26. The transfer capital threshold is the transfer adjustment factor * $494.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5683.00,19635.68,Inpatient DRG
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,056,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],59328.19,,"Fee schedule rate ($59,328.19). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (44), with a minimum of zero.",,,,0,other,7659.00,59328.19,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,699,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],19570.20,,"Fee schedule rate ($19,570.20). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5961.00,19972.16,There are no additional notes associated with this service or procedure.
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],36868.88,,"Fee schedule rate ($36,868.88). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12606.23,36868.88,There are no additional notes associated with this service or procedure.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],52794.06,,"Fee schedule rate ($52,794.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (37), with a minimum of zero.",,,,0,other,13907.80,52794.06,There are no additional notes associated with this service or procedure.
PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,337,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],12957.08,,"Case rate ($12,340.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,615.32, add-ons for qualifying new technology services are included. If operating cost exceeds $46,486.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,520.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $9,634.84 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,670.37 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $760.28. The transfer capital threshold is the transfer adjustment factor * $760.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12340.08,38926.31,Inpatient DRG
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],13625.25,,"Fee schedule rate ($13,625.25). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7243.75,23262.15,There are no additional notes associated with this service or procedure.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,761,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],11946.72,,"Fee schedule rate ($11,946.72). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,5808.41,11946.72,There are no additional notes associated with this service or procedure.
HC Trigger Point 3 or More,CASE-20553,APC,20553,CPT,0510,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],297.37,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,287.31,301.68,OPPS APC
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],67790.93,,"Fee schedule rate ($67,790.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,21597.50,67790.93,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITH STERILIZATION WITH CC,784,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],19922.46,,"Fee schedule rate ($19,922.46). Adds an outlier to normal pricing equal to the per diem rate ($39,437.39) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,9124.01,23722.94,There are no additional notes associated with this service or procedure.
VENTRICULAR SHUNT PROCEDURES WITH CC,032,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],46275.08,,"Fee schedule rate ($46,275.08). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,16376.22,46275.08,There are no additional notes associated with this service or procedure.
CHEST PAIN,313,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],7161.88,,"Case rate ($6,820.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,480.89, add-ons for qualifying new technology services are included. If operating cost exceeds $41,351.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,116.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $4,519.27 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,535.94 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $356.62. The transfer capital threshold is the transfer adjustment factor * $356.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6820.84,15377.66,Inpatient DRG
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],17741.86,,"Case rate ($16,897.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,854.53, add-ons for qualifying new technology services are included. If operating cost exceeds $50,725.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,853.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $13,858.48 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,909.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,093.57. The transfer capital threshold is the transfer adjustment factor * $1,093.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,16897.01,43444.85,Inpatient DRG
Excision Prepatellar Bursa|BILATERAL PROCEDURE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-27340,APC,27340,CPT,0360,RC,,,50|XU,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],13478.34,,"Fee schedule rate ($13,478.34). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,6801.88,22557.82,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC,817,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],42878.11,,"Fee schedule rate ($42,878.11). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.5), with a minimum of zero.",,,,0,other,17396.11,44895.04,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],14377.77,,"Case rate ($13,891.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,058.63, add-ons for qualifying new technology services are included. If operating cost exceeds $47,929.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,633.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,072.85 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,113.68 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $873.76. The transfer capital threshold is the transfer adjustment factor * $873.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,13891.57,34712.20,Inpatient DRG
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],20553.44,,"Fee schedule rate ($20,553.44). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8874.81,20553.44,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],51903.64,,"Fee schedule rate ($51,903.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,16017.99,51903.64,There are no additional notes associated with this service or procedure.
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC,520,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],29395.47,,,,,,0,other,12061.74,39786.42,There are no additional notes associated with this service or procedure.
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],41190.50,,"Fee schedule rate ($41,190.50). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,16787.98,62990.26,There are no additional notes associated with this service or procedure.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],35719.96,,"Case rate ($35,719.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $33,365.14, add-ons for qualifying new technology services are included. If operating cost exceeds $68,236.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,230.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.9. The base transfer operating payment is the transfer adjustment factor * $31,304.77 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $31,420.19 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,470.26. The transfer capital threshold is the transfer adjustment factor * $2,470.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,35719.96,105091.76,Inpatient DRG
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC",011,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],40241.31,,"Case rate ($38,880.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $36,305.31, add-ons for qualifying new technology services are included. If operating cost exceeds $71,176.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,461.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 11.4. The base transfer operating payment is the transfer adjustment factor * $34,234.14 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $34,360.36 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,701.41. The transfer capital threshold is the transfer adjustment factor * $2,701.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,38880.49,150008.48,Inpatient DRG
"Tx Open Tendon Flexor Toe 1 Tendon Spx|RIGHT FOOT, SECOND DIGIT",CASE-28232,APC,28232,CPT,0360,RC,,,T6,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1580.37,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1505.12,1580.37,OPPS APC
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,373,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],13780.60,,"Fee schedule rate ($13,780.60). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6870.94,14313.05,There are no additional notes associated with this service or procedure.
NERVOUS SYSTEM NEOPLASMS WITH MCC,054,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],12715.20,,"Case rate ($12,285.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,564.29, add-ons for qualifying new technology services are included. If operating cost exceeds $46,435.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,516.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $9,584.00 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,619.34 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $756.27. The transfer capital threshold is the transfer adjustment factor * $756.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6965.00,30044.81,Inpatient DRG
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6992.18,,"Case rate ($6,659.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,339.33, add-ons for qualifying new technology services are included. If operating cost exceeds $41,210.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,096.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,377.78 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,394.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $336.49. The transfer capital threshold is the transfer adjustment factor * $336.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6801.88,22557.82,Inpatient DRG
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],14055.68,,"Case rate ($13,386.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,588.65, add-ons for qualifying new technology services are included. If operating cost exceeds $47,459.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,596.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $10,604.60 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,643.70 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $836.81. The transfer capital threshold is the transfer adjustment factor * $836.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13386.36,33244.29,Inpatient DRG
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],11060.65,,"Case rate ($10,533.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,935.13, add-ons for qualifying new technology services are included. If operating cost exceeds $44,806.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,388.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $7,960.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,990.18 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $628.19. The transfer capital threshold is the transfer adjustment factor * $628.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10533.95,24956.34,Inpatient DRG
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],10347.06,,"Case rate ($10,347.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,761.25, add-ons for qualifying new technology services are included. If operating cost exceeds $44,632.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,374.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $7,787.59 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,816.30 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $614.52. The transfer capital threshold is the transfer adjustment factor * $614.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10347.06,28821.04,Inpatient DRG
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],21347.55,,"Fee schedule rate ($21,347.55). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,16897.01,43444.85,There are no additional notes associated with this service or procedure.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,477,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],33152.83,,"Fee schedule rate ($33,152.83). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,25339.74,67976.16,There are no additional notes associated with this service or procedure.
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],8004.45,,"Case rate ($7,847.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,435.96, add-ons for qualifying new technology services are included. If operating cost exceeds $42,306.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,191.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,470.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,491.01 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $431.70. The transfer capital threshold is the transfer adjustment factor * $431.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,7847.50,17755.26,Inpatient DRG
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],39820.52,,"Fee schedule rate ($39,820.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,15273.74,39820.52,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITH STERILIZATION WITH CC,784,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],15967.02,,"Case rate ($9,124.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,623.49, add-ons for qualifying new technology services are included. If operating cost exceeds $43,494.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,285.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,654.00 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,678.54 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $525.07. The transfer capital threshold is the transfer adjustment factor * $525.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,9124.01,23722.94,All Other Inpatient
Ostc Prtl Exostc/Condylc Metar Head|RIGHT SIDE|SEPARATE STRUCTURE,CASE-28288,APC,28288,CPT,0360,RC,,,RT|XS,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
Colposcopy Cervix Bx Cervix & Endocrv Curretage,CASE-57454,APC,57454,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],295.22,,"APC Price ($285.23). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,285.23,299.50,OPPS APC
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],15309.46,,"Fee schedule rate ($15,309.46). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6965.00,15340.19,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,065,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],25681.86,,"Fee schedule rate ($25,681.86). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,8786.76,25681.86,There are no additional notes associated with this service or procedure.
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],10322.60,,"Case rate ($10,120.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,550.21, add-ons for qualifying new technology services are included. If operating cost exceeds $44,421.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,357.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $7,577.32 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,605.26 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $597.93. The transfer capital threshold is the transfer adjustment factor * $597.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,10120.20,26204.74,Inpatient DRG
Removal Implant Deep|LEFT SIDE,CASE-20680,APC,20680,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],2718.88,,"APC Price ($2,718.88). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2718.88,2854.83,OPPS APC
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],27329.90,,"Case rate ($26,028.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $24,349.34, add-ons for qualifying new technology services are included. If operating cost exceeds $59,220.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,521.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $22,322.08 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $22,404.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,761.43. The transfer capital threshold is the transfer adjustment factor * $1,761.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,26028.48,80635.65,Inpatient DRG
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|LEFT HAND, THUMB",CASE-26160,APC,26160,CPT,0360,RC,,,FA,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1580.37,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1505.12,1580.37,OPPS APC
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],14309.17,,"Fee schedule rate ($14,309.17). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,17467.27,There are no additional notes associated with this service or procedure.
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],8234.89,,"Case rate ($7,842.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,431.55, add-ons for qualifying new technology services are included. If operating cost exceeds $42,302.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,191.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $5,466.44 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,486.60 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $431.36. The transfer capital threshold is the transfer adjustment factor * $431.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5280.00,17136.70,Inpatient DRG
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],8009.34,,"Case rate ($8,009.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,586.52, add-ons for qualifying new technology services are included. If operating cost exceeds $42,457.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,203.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $5,620.85 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,641.57 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $443.54. The transfer capital threshold is the transfer adjustment factor * $443.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8009.34,19877.10,Inpatient DRG
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC,797,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],20928.55,,"Fee schedule rate ($20,928.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8719.72,20928.55,There are no additional notes associated with this service or procedure.
Mastectomy Partial|LEFT SIDE|SEPARATE PRACTITIONER,CASE-19301,APC,19301,CPT,0360,RC,,,LT|XP,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6526.12,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6432.89,6526.12,OPPS APC
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],33114.42,,,,,,0,other,13341.67,42586.49,There are no additional notes associated with this service or procedure.
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],27433.71,,"Case rate ($26,127.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $24,441.31, add-ons for qualifying new technology services are included. If operating cost exceeds $59,312.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,528.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. The base transfer operating payment is the transfer adjustment factor * $22,413.72 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $22,496.36 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,768.66. The transfer capital threshold is the transfer adjustment factor * $1,768.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,26127.34,90333.60,Inpatient DRG
Arthrs Knee Abrasion Arthrp/Mlt Drlg/Microfx|LEFT SIDE,CASE-29879,APC,29879,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",062,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],14537.08,,"Case rate ($13,844.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,015.16, add-ons for qualifying new technology services are included. If operating cost exceeds $47,886.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,630.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $11,029.54 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,070.21 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $870.34. The transfer capital threshold is the transfer adjustment factor * $870.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13844.84,44304.80,Inpatient DRG
Repair Complex Trunk 2.6-7.5 Cm|UNUSUAL NON-OVERLAPPING SERVICE,CASE-13101,APC,13101,CPT,0360,RC,,,XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],2814.04,,"APC Price ($2,718.88). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2718.88,2854.83,OPPS APC
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC,497,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],10330.20,,"Case rate ($10,127.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,557.14, add-ons for qualifying new technology services are included. If operating cost exceeds $44,428.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,358.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 1.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $7,584.22 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,612.19 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $598.47. The transfer capital threshold is the transfer adjustment factor * $598.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,10127.65,37761.19,Inpatient DRG
Int Hrhc by Ligation 2+ Hroid W/O Img Gdn,CASE-46946,APC,46946,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],2598.08,,"APC Price ($2,598.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2598.08,2727.99,OPPS APC
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],52449.26,,"Fee schedule rate ($52,449.26). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,17693.40,52449.26,There are no additional notes associated with this service or procedure.
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],16014.44,,"Case rate ($9,151.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,648.69, add-ons for qualifying new technology services are included. If operating cost exceeds $43,519.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,287.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,679.11 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,703.74 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $527.05. The transfer capital threshold is the transfer adjustment factor * $527.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,9151.11,30245.71,All Other Inpatient
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],16026.80,,"Case rate ($16,026.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,044.99, add-ons for qualifying new technology services are included. If operating cost exceeds $49,916.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,789.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $13,051.92 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,100.04 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,029.93. The transfer capital threshold is the transfer adjustment factor * $1,029.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,11165.00,61234.06,Inpatient DRG
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC,520,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],12664.83,,"Case rate ($12,061.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,356.39, add-ons for qualifying new technology services are included. If operating cost exceeds $46,227.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,499.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $9,376.87 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,411.44 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $739.93. The transfer capital threshold is the transfer adjustment factor * $739.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12061.74,39786.42,Inpatient DRG
Cystourethroscopy W/Dest &/Rmvl Med Bladder Tum,CASE-52235,APC,52235,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3299.47,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3299.47,3464.44,OPPS APC
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],75976.83,,,,,,0,other,10078.00,81454.07,There are no additional notes associated with this service or procedure.
Laps Gstrc Rstrictiv Px Longitudinal Gastrectomy,CASE-43775,APC,43775,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],46.02,,"APC Price ($43.83). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,43.83,46.02,OPPS APC
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],7733.72,,"Case rate ($7,733.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,330.12, add-ons for qualifying new technology services are included. If operating cost exceeds $42,201.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,183.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,365.38 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,385.17 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $423.38. The transfer capital threshold is the transfer adjustment factor * $423.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7733.72,18043.23,Inpatient DRG
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],35528.17,,"Fee schedule rate ($35,528.17). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,14747.55,37899.49,There are no additional notes associated with this service or procedure.
HC Inject Tendon Origin/Insert|BILATERAL PROCEDURE,CASE-20551,APC,20551,CPT,0361,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
Neuroplasty &/Transpos Median Nrv Carpal Tunne|RIGHT SIDE,CASE-64721,APC,64721,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1827.80,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1827.80,1919.19,OPPS APC
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC,797,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],9024.91,,"Case rate ($8,719.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,247.38, add-ons for qualifying new technology services are included. If operating cost exceeds $43,118.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,255.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $6,279.28 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,302.43 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $495.50. The transfer capital threshold is the transfer adjustment factor * $495.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,8719.72,20928.55,Inpatient DRG
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,074,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],20919.08,,"Fee schedule rate ($20,919.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8925.60,20919.08,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],28072.54,,"Fee schedule rate ($28,072.54). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,14337.84,52803.53,There are no additional notes associated with this service or procedure.
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],11133.98,,"Fee schedule rate ($11,133.98). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5919.29,13545.65,There are no additional notes associated with this service or procedure.
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITH MCC,429,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],62958.58,,"Case rate ($62,958.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $58,704.65, add-ons for qualifying new technology services are included. If operating cost exceeds $93,575.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $6,222.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.6. The base transfer operating payment is the transfer adjustment factor * $56,551.19 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $56,759.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,462.45. The transfer capital threshold is the transfer adjustment factor * $4,462.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,62958.58,177294.98,Inpatient DRG
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,025,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],91631.33,,"Fee schedule rate ($91,631.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,13351.00,91631.33,There are no additional notes associated with this service or procedure.
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],6965.00,,,,,,0,other,5883.03,17111.12,There are no additional notes associated with this service or procedure.
MINOR BLADDER PROCEDURES WITHOUT CC/MCC,664,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],20599.85,,,,,,0,other,9034.63,31876.87,There are no additional notes associated with this service or procedure.
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],10243.65,,"Case rate ($9,755.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,211.27, add-ons for qualifying new technology services are included. If operating cost exceeds $44,082.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,331.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $7,239.63 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,266.32 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $571.28. The transfer capital threshold is the transfer adjustment factor * $571.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9755.86,29216.99,Inpatient DRG
HYPERTENSION WITHOUT MCC,305,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7253.77,,"Case rate ($6,908.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,571.55, add-ons for qualifying new technology services are included. If operating cost exceeds $41,442.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,114.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,609.12 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,626.60 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $354.27. The transfer capital threshold is the transfer adjustment factor * $354.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7058.55,17230.49,Inpatient DRG
Arthrs Knee Abrasion Arthrp/Mlt Drlg/Microfx|RIGHT SIDE,CASE-29879,APC,29879,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],19371.27,,"Fee schedule rate ($19,371.27). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8643.20,19462.52,There are no additional notes associated with this service or procedure.
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH CC",457,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],117335.92,,,,,,0,other,42327.47,160549.49,There are no additional notes associated with this service or procedure.
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],21675.85,,"Fee schedule rate ($21,675.85). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,9755.86,29216.99,There are no additional notes associated with this service or procedure.
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],14625.55,,"Fee schedule rate ($14,625.55). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7438.45,15961.98,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],15318.94,,"Fee schedule rate ($15,318.94). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6214.05,15318.94,There are no additional notes associated with this service or procedure.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],16442.66,,"Case rate ($16,120.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,131.93, add-ons for qualifying new technology services are included. If operating cost exceeds $50,002.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,796.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $13,138.54 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,186.98 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,036.76. The transfer capital threshold is the transfer adjustment factor * $1,036.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,16120.25,41187.90,Inpatient DRG
PERIPHERAL VASCULAR DISORDERS WITH CC,300,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],20331.78,,"Fee schedule rate ($20,331.78). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,9174.14,21005.20,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,091,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],40030.81,,"Fee schedule rate ($40,030.81). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,13838.06,40030.81,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],59610.47,,"Fee schedule rate ($59,610.47). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,16129.04,59610.47,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],78960.67,,"Fee schedule rate ($78,960.67). Adds an outlier to normal pricing equal to the per diem rate ($149,567.78) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19.1), with a minimum of zero.",,,,0,other,30398.48,82674.88,There are no additional notes associated with this service or procedure.
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],33159.45,,"Fee schedule rate ($33,159.45). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,13092.47,33159.45,There are no additional notes associated with this service or procedure.
HC Peripheral Block - Femoral Single or Saphenous W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64447,APC,64447,CPT,0360,RC,,,XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7029.71,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6791.99,7131.59,OPPS APC
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],12992.90,,"Case rate ($12,992.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,222.63, add-ons for qualifying new technology services are included. If operating cost exceeds $47,093.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,568.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $10,239.92 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,277.68 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $808.03. The transfer capital threshold is the transfer adjustment factor * $808.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7665.00,40737.46,Inpatient DRG
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],2401.00,,,,,,0,other,1188.00,34338.33,Estimated amount calculated based on 6 day length of stay.
"NERVOUS SYSTEM MALIGNANCY,MAJOR",041,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],13083.45,,"Case rate ($12,460.43). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12460.43,13083.45,There are no additional notes associated with this service or procedure.
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],16865.16,,,,,,0,other,6711.00,16865.16,There are no additional notes associated with this service or procedure.
Enteroscopy > 2nd Prtn Abltj Lesion,CASE-44369,APC,44369,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1859.01,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1796.14,1885.95,OPPS APC
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],17111.12,,,,,,0,other,5883.03,17111.12,There are no additional notes associated with this service or procedure.
DIABETES WITH MCC,637,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],11291.27,,"Case rate ($10,909.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $10,253.93, add-ons for qualifying new technology services are included. If operating cost exceeds $48,898.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $3,423.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $8,854.74 + an uncompensated DSH payment of $1,359.91. The transfer operating threshold is the transfer adjustment factor * $8,894.02 + an uncompensated DSH payment of $1,359.91. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $694.79. The transfer capital threshold is the transfer adjustment factor * $694.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,9959.03,28655.62,Inpatient DRG
VENTRICULAR SHUNT PROCEDURES WITH CC,032,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],16376.22,,"Case rate ($16,376.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,370.06, add-ons for qualifying new technology services are included. If operating cost exceeds $50,241.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,815.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $13,375.80 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,425.12 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,055.48. The transfer capital threshold is the transfer adjustment factor * $1,055.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,16376.22,46275.08,Inpatient DRG
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],13154.04,,"Case rate ($12,527.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,789.82, add-ons for qualifying new technology services are included. If operating cost exceeds $46,660.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,533.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $9,808.71 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,844.88 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $774.00. The transfer capital threshold is the transfer adjustment factor * $774.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12527.66,29917.96,Inpatient DRG
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],35061.53,,"Fee schedule rate ($35,061.53). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,9696.93,35061.53,There are no additional notes associated with this service or procedure.
Dstr Nrolytc Agnt Parverteb Fct Sngl Crvcl/Thora|RIGHT SIDE,CASE-64633,APC,64633,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1827.80,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1827.80,1919.19,OPPS APC
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,418,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],13717.29,,"Case rate ($13,064.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,309.60, add-ons for qualifying new technology services are included. If operating cost exceeds $47,180.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,553.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $10,325.50 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,364.65 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $793.64. The transfer capital threshold is the transfer adjustment factor * $793.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13400.58,39884.93,Inpatient DRG
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],18182.77,,"Case rate ($17,316.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,273.85, add-ons for qualifying new technology services are included. If operating cost exceeds $51,144.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,857.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $14,274.78 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,328.90 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,097.19. The transfer capital threshold is the transfer adjustment factor * $1,097.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,17782.11,46523.26,Inpatient DRG
Prtl Exc Pst Vrt Intrnsc B1y Les 1 Vrt Sgm Thrc,CASE-22101,APC,22101,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,7131.59,7131.59,OPPS APC
FULL TERM NEONATE WITH MAJOR PROBLEMS,793,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],4302.90,,,,,,0,other,4302.90,82045.22,Estimated amount calculated based on 2 day length of stay.
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],9533.13,,"Fee schedule rate ($9,533.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5068.21,14525.56,There are no additional notes associated with this service or procedure.
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",623,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],33712.76,,"Fee schedule rate ($33,712.76). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,14093.37,33712.76,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],31469.43,,,,,,0,other,12775.53,31469.43,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],17782.11,,"Case rate ($17,782.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,677.93, add-ons for qualifying new technology services are included. If operating cost exceeds $51,548.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,918.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $14,678.86 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,732.98 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,158.31. The transfer capital threshold is the transfer adjustment factor * $1,158.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,17782.11,46523.26,Inpatient DRG
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],28821.04,,"Fee schedule rate ($28,821.04). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,10347.06,28821.04,There are no additional notes associated with this service or procedure.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],16926.26,,"Case rate ($16,120.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,131.93, add-ons for qualifying new technology services are included. If operating cost exceeds $50,002.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,796.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $13,138.54 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,186.98 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,036.76. The transfer capital threshold is the transfer adjustment factor * $1,036.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,16120.25,41187.90,Inpatient DRG
Egd Transoral Biopsy Single/Multiple|UNUSUAL NON-OVERLAPPING SERVICE,CASE-43239,APC,43239,CPT,0360,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1796.14,,"APC Price ($1,796.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1796.14,1885.95,OPPS APC
Cystourethroscopy Inj Chemodenervation Bladder,CASE-52287,APC,52287,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],2054.48,,"APC Price ($1,956.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1956.65,2054.48,OPPS APC
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],73588.10,,"Fee schedule rate ($73,588.10). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,21585.31,73588.10,There are no additional notes associated with this service or procedure.
NEONATE WITH OTHER SIGNIFICANT PROBLEMS,794,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],2074.00,,,,,,0,other,1798.85,12536.83,Estimated amount calculated based on 2 day length of stay.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,085,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],17677.02,,"Case rate ($17,330.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,257.72, add-ons for qualifying new technology services are included. If operating cost exceeds $51,128.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,885.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $14,260.20 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,312.77 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,125.27. The transfer capital threshold is the transfer adjustment factor * $1,125.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,9282.00,57443.16,Inpatient DRG
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],86252.84,,"Fee schedule rate ($86,252.84). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,27944.96,86252.84,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],12404.38,,,,,,0,other,6214.05,15318.94,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7567.11,,"Case rate ($7,206.77). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,849.72, add-ons for qualifying new technology services are included. If operating cost exceeds $41,720.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,135.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $4,886.24 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,904.77 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $375.57. The transfer capital threshold is the transfer adjustment factor * $375.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,21195.68,Inpatient DRG
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH MCC",722,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],14484.38,,"Case rate ($14,200.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,345.91, add-ons for qualifying new technology services are included. If operating cost exceeds $48,216.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,656.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $11,359.07 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,400.95 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $896.34. The transfer capital threshold is the transfer adjustment factor * $896.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,14200.37,56869.13,Inpatient DRG
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],15318.94,,"Fee schedule rate ($15,318.94). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6214.05,15318.94,There are no additional notes associated with this service or procedure.
Laps Fulg/Exc Ovary Viscera/Peritoneal Surface|BILATERAL PROCEDURE,CASE-58662,APC,58662,CPT,0360,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5856.81,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5658.76,5941.70,OPPS APC
Bronchoscopy Bronchial/Endobrncl Bx 1+ Sites|UNUSUAL NON-OVERLAPPING SERVICE,CASE-31625,APC,31625,CPT,0360,RC,,,XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6837.16,,"APC Price ($6,605.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6837.16,6936.25,OPPS APC
HEADACHES WITHOUT MCC,103,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],20883.08,,"Fee schedule rate ($20,883.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,20883.08,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL HEMORRHAGE WITH MCC,377,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],31575.65,,"Fee schedule rate ($31,575.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,7634.00,35969.56,There are no additional notes associated with this service or procedure.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],9097.60,,"Case rate ($9,097.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,598.92, add-ons for qualifying new technology services are included. If operating cost exceeds $43,469.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,283.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,629.53 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,653.97 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $523.14. The transfer capital threshold is the transfer adjustment factor * $523.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9097.60,21455.22,Inpatient DRG
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],6695.46,,"Case rate ($6,564.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,242.12, add-ons for qualifying new technology services are included. If operating cost exceeds $41,113.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,097.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $4,281.39 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,297.17 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $337.84. The transfer capital threshold is the transfer adjustment factor * $337.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6564.18,17651.07,Inpatient DRG
Laryngoscopy Exc Tum&/Stripping Cords/Epiglott,CASE-31540,APC,31540,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3611.96,,"APC Price ($3,489.82). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3489.82,3664.31,OPPS APC
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITH MCC OR ANTINEOPLASTIC IMPLANT OR EPILEPSY WITH NEUROSTIMULATOR,023,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],15168.00,,"Per diem ($15,168). If length of stay < 7.1, first 1 days paid at a per diem of $30,336 instead. Capped at $107,689.53.",,,,0,other,15168.00,136379.44,Estimated amount calculated based on 6 day length of stay.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],52803.53,,"Fee schedule rate ($52,803.53). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,14337.84,52803.53,There are no additional notes associated with this service or procedure.
"Tendon Sheath Incision|LEFT HAND, FIFTH DIGIT",CASE-26055,APC,26055,CPT,0360,RC,,,F4,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1557.80,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1505.12,1580.37,OPPS APC
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],40714.72,,"Fee schedule rate ($40,714.72). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,17356.15,44778.95,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],15609.47,,"Fee schedule rate ($15,609.47). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7569.84,21892.85,There are no additional notes associated with this service or procedure.
"NEONATE BIRTH WEIGHT 1250-1499 GRAMS WITH RESPIRATORY DISTRESS SYNDROME OR OTHER MAJOR RESPIRATORY CONDITION OR MAJOR ANOMALY,MAJOR",607,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],92263.35,,"Case rate ($87,869.86). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $58,117, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,87869.86,92263.35,There are no additional notes associated with this service or procedure.
"CARDIAC ARREST, UNEXPLAINED WITH MCC",296,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],29352.79,,"Fee schedule rate ($29,352.79). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.2), with a minimum of zero.",,,,0,other,12522.25,36459.67,There are no additional notes associated with this service or procedure.
Neuroplasty &/Transpos Median Nrv Carpal Tunne|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64721,APC,64721,CPT,0360,RC,,,RT|XU,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1827.80,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1827.80,1919.19,OPPS APC
OTHER CEREBROVASCULAR DISORDERS WITH CC,071,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],29215.10,,"Fee schedule rate ($29,215.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5843.00,29215.10,There are no additional notes associated with this service or procedure.
NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,601,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],12359.72,,"Fee schedule rate ($12,359.72). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6042.05,12359.72,There are no additional notes associated with this service or procedure.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],8874.81,,"Case rate ($8,874.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,391.65, add-ons for qualifying new technology services are included. If operating cost exceeds $43,262.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,266.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $6,423.02 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,446.70 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $506.84. The transfer capital threshold is the transfer adjustment factor * $506.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8874.81,20553.44,Inpatient DRG
ALLERGIC REACTIONS WITH MCC,915,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],27385.01,,"Fee schedule rate ($27,385.01). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,13332.86,33088.84,There are no additional notes associated with this service or procedure.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],11606.06,,"Case rate ($11,053.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,418.34, add-ons for qualifying new technology services are included. If operating cost exceeds $45,289.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,426.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $8,442.26 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,473.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $666.18. The transfer capital threshold is the transfer adjustment factor * $666.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,11053.39,36776.05,Inpatient DRG
Dilation & Curettage Dx&/Ther Nonobstetric,CASE-58120,APC,58120,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3030.03,,"APC Price ($3,030.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3030.03,3181.53,OPPS APC
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],37550.29,,"Fee schedule rate ($37,550.29). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,15476.23,42787.31,There are no additional notes associated with this service or procedure.
Surgical Arthroscopy Shoulder W/Rotator Cuff Rpr|LEFT SIDE,CASE-29827,APC,29827,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],5415.00,,"Per diem ($5,415). If length of stay < 3.1, first 1 days paid at a per diem of $10,830 instead. Capped at $16,785.91.",,,,0,other,5415.00,17575.50,Estimated amount calculated based on 3 day length of stay.
Hemorrhoidectomy Int & Xtrnl 2/> Column/Gro,CASE-46260,APC,46260,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],2598.08,,"APC Price ($2,598.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2598.08,2727.99,OPPS APC
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],16442.66,,"Case rate ($16,120.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,131.93, add-ons for qualifying new technology services are included. If operating cost exceeds $50,002.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,796.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $13,138.54 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,186.98 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,036.76. The transfer capital threshold is the transfer adjustment factor * $1,036.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,16120.25,41187.90,Inpatient DRG
Esophagogastroduodenoscopy US Scope W/Adj Strxrs,CASE-43237,APC,43237,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1885.95,,"APC Price ($1,796.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1796.14,1885.95,OPPS APC
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],25099.93,,"Fee schedule rate ($25,099.93). Adds an outlier to normal pricing equal to the per diem rate ($40,783.87) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10989.72,26280.60,There are no additional notes associated with this service or procedure.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],20553.44,,"Fee schedule rate ($20,553.44). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8874.81,20553.44,There are no additional notes associated with this service or procedure.
OTHER CEREBROVASCULAR DISORDERS WITH CC,071,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],9337.76,,"Case rate ($8,893.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,408.66, add-ons for qualifying new technology services are included. If operating cost exceeds $43,279.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,268.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,439.97 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,463.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $508.18. The transfer capital threshold is the transfer adjustment factor * $508.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5843.00,29215.10,Inpatient DRG
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH MCC",722,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],56869.13,,"Fee schedule rate ($56,869.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,14200.37,56869.13,There are no additional notes associated with this service or procedure.
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],13794.06,,"Fee schedule rate ($13,794.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,6915.64,14442.92,There are no additional notes associated with this service or procedure.
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],10491.22,,"Case rate ($10,136.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,565.33, add-ons for qualifying new technology services are included. If operating cost exceeds $44,436.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,359.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $7,592.38 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,620.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $599.11. The transfer capital threshold is the transfer adjustment factor * $599.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,10136.44,24444.75,Inpatient DRG
Cysto W/Insert Ureteral Stent|LEFT SIDE,CASE-52332,APC,52332,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3299.47,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3299.47,3464.44,OPPS APC
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,329,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],86631.74,,"Fee schedule rate ($86,631.74). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (38), with a minimum of zero.",,,,0,other,33072.77,90445.33,There are no additional notes associated with this service or procedure.
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH MCC",510,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],89863.76,,"Fee schedule rate ($89,863.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10710.00,89863.76,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],8609.27,,"Case rate ($8,318.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,873.80, add-ons for qualifying new technology services are included. If operating cost exceeds $42,744.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,226.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,907.07 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,928.85 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $466.13. The transfer capital threshold is the transfer adjustment factor * $466.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,8318.14,19763.43,Inpatient DRG
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,329,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],86631.74,,"Fee schedule rate ($86,631.74). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (38), with a minimum of zero.",,,,0,other,33072.77,90445.33,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],86252.84,,"Fee schedule rate ($86,252.84). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,27944.96,86252.84,There are no additional notes associated with this service or procedure.
HC Lyr Clos Nk Hnd Ft <2.6cm,CASE-12041,APC,12041,CPT,0450,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1545.93,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1545.93,1623.23,OPPS APC
Hrhc Ntrnl & Xtrnl 2/> Column/Group W/Fissu,CASE-46261,APC,46261,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],2689.02,,"APC Price ($2,598.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2598.08,2727.99,OPPS APC
ALLERGIC REACTIONS WITH MCC,915,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],27385.01,,"Fee schedule rate ($27,385.01). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,13332.86,33088.84,There are no additional notes associated with this service or procedure.
Enteroscopy > 2nd Prtn W/Control Bleeding,CASE-44366,APC,44366,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1796.14,,"APC Price ($1,796.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1796.14,1885.95,OPPS APC
CERVICAL SPINAL FUSION WITH MCC,471,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],111337.93,,"Fee schedule rate ($111,337.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,34645.26,111337.93,There are no additional notes associated with this service or procedure.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,057,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],39884.93,,"Fee schedule rate ($39,884.93). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,10718.84,39884.93,There are no additional notes associated with this service or procedure.
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],37899.49,,"Fee schedule rate ($37,899.49). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,14747.55,37899.49,There are no additional notes associated with this service or procedure.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,073,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],43475.01,,"Fee schedule rate ($43,475.01). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,12809.38,43475.01,There are no additional notes associated with this service or procedure.
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],13194.59,,"Case rate ($12,566.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,825.74, add-ons for qualifying new technology services are included. If operating cost exceeds $46,696.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,536.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $9,844.49 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,880.79 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $776.83. The transfer capital threshold is the transfer adjustment factor * $776.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12566.28,30861.41,Inpatient DRG
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],37914.65,,"Fee schedule rate ($37,914.65). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9865.56,37914.65,There are no additional notes associated with this service or procedure.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],51656.32,,"Fee schedule rate ($51,656.32). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,20559.34,54086.17,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],35192.25,,"Fee schedule rate ($35,192.25). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,10895.60,35192.25,There are no additional notes associated with this service or procedure.
Egd US Guided Transmural Injxn/Fiducial Marker,CASE-43253,APC,43253,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1885.95,,"APC Price ($1,796.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1796.14,1885.95,OPPS APC
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],5919.29,,"Fee schedule rate ($5,919.29). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5919.29,13545.65,There are no additional notes associated with this service or procedure.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],7224.45,,"Case rate ($7,224.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,856.36, add-ons for qualifying new technology services are included. If operating cost exceeds $41,727.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,146.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $4,893.37 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,911.41 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $386.14. The transfer capital threshold is the transfer adjustment factor * $386.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,15340.19,Inpatient DRG
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],38378.80,,"Fee schedule rate ($38,378.80). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,14370.36,38378.80,There are no additional notes associated with this service or procedure.
CERVICAL SPINAL FUSION WITH CC,472,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],22990.94,,"Case rate ($21,896.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,505.12, add-ons for qualifying new technology services are included. If operating cost exceeds $55,376.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,219.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $18,491.99 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,560.18 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,459.20. The transfer capital threshold is the transfer adjustment factor * $1,459.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,21896.13,70198.84,Inpatient DRG
Breast Reduction|LEFT SIDE,CASE-19318,APC,19318,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6215.36,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6215.36,6215.36,OPPS APC
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,451,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],94077.13,,"Fee schedule rate ($94,077.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,23821.44,94077.13,There are no additional notes associated with this service or procedure.
"NEONATE BIRTH WEIGHT > 2499 GRAMS WITH OTHER MAJOR PROCEDURE,MINOR",631,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],4484.22,,"Case rate ($4,484.22). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,4484.22,4708.43,There are no additional notes associated with this service or procedure.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],51630.84,,"Fee schedule rate ($51,630.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,20559.34,54086.17,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITHOUT STERILIZATION WITH MCC,786,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],19006.00,,,,,,0,other,12612.10,23722.94,There are no additional notes associated with this service or procedure.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC",061,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],51814.18,,"Fee schedule rate ($51,814.18). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,20616.23,62315.82,There are no additional notes associated with this service or procedure.
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],30245.71,,"Fee schedule rate ($30,245.71). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9151.11,30245.71,There are no additional notes associated with this service or procedure.
CHOLECYSTECTOMY WITH C.D.E. WITH MCC,411,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],25530.89,,"Case rate ($24,315.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $22,755.46, add-ons for qualifying new technology services are included. If operating cost exceeds $57,626.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,396.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $20,734.06 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $20,810.51 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,636.12. The transfer capital threshold is the transfer adjustment factor * $1,636.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,24315.13,88615.28,Inpatient DRG
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",004,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],272554.00,,,,,,0,other,10249.47,272554.00,There are no additional notes associated with this service or procedure.
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],14112.34,,,,,,0,other,6801.88,22557.82,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],11487.32,,"Case rate ($6,564.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,242.12, add-ons for qualifying new technology services are included. If operating cost exceeds $41,113.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,097.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $4,281.39 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,297.17 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $337.84. The transfer capital threshold is the transfer adjustment factor * $337.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,6564.18,17651.07,All Other Inpatient
SIGNS AND SYMPTOMS WITH MCC,947,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],30414.32,,"Fee schedule rate ($30,414.32). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,10541.41,30414.32,There are no additional notes associated with this service or procedure.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],29917.96,,"Fee schedule rate ($29,917.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,12527.66,29917.96,There are no additional notes associated with this service or procedure.
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6601.86,,"Case rate ($6,378.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,069.50, add-ons for qualifying new technology services are included. If operating cost exceeds $40,940.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,084.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,109.40 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,124.55 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $324.27. The transfer capital threshold is the transfer adjustment factor * $324.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,4341.01,12882.53,Inpatient DRG
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,699,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],5961.00,,"Per diem ($5,961). If length of stay < 3.2, first 1 days paid at a per diem of $11,922 instead. Capped at $19,074.90.",,,,0,other,5961.00,19972.16,Estimated amount calculated based on 3 day length of stay.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],81524.17,,"Fee schedule rate ($81,524.17). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,8972.00,81524.17,There are no additional notes associated with this service or procedure.
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],46202.59,,"Fee schedule rate ($46,202.59). Adds an outlier to normal pricing equal to the per diem rate ($126,777.34) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,18594.09,59494.91,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],16451.62,,"Case rate ($16,129.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,140.12, add-ons for qualifying new technology services are included. If operating cost exceeds $50,011.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,797.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $13,146.70 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,195.17 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,037.40. The transfer capital threshold is the transfer adjustment factor * $1,037.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,16129.04,59610.47,Inpatient DRG
HC Gastroesophag Reflx Test W/Tel Ph Eltrd|REDUCED SERVICES,CASE-91035,APC,91035,CPT,0750,RC,,,52,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],831.93,,"APC Price ($803.80). Discounted by 50%. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,803.80,843.99,OPPS APC
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],21630.93,,,,,,0,other,9389.48,22358.90,There are no additional notes associated with this service or procedure.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,352,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],26528.70,,"Fee schedule rate ($26,528.70). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,9853.37,26528.70,There are no additional notes associated with this service or procedure.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],10300.48,,"Case rate ($10,098.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,530.04, add-ons for qualifying new technology services are included. If operating cost exceeds $44,401.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,356.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $7,557.23 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,585.10 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $596.34. The transfer capital threshold is the transfer adjustment factor * $596.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,10098.51,24259.09,Inpatient DRG
Tissue Expander Placement Breast Reconstruction|LEFT SIDE,CASE-19357,APC,19357,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],13350.78,,"APC Price ($12,899.30). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,12899.30,13350.78,OPPS APC
"CARDIAC ARREST, UNEXPLAINED WITH MCC",296,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],19383.47,,"Fee schedule rate ($19,383.47). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12522.25,36459.67,There are no additional notes associated with this service or procedure.
Injection Aa&/Strd Ilioinguinal Ih Nerves|LEFT SIDE,CASE-64425,APC,64425,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],660.72,,"APC Price ($660.72). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,660.72,693.76,OPPS APC
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],16590.46,,"Fee schedule rate ($16,590.46). Adds an outlier to normal pricing equal to the per diem rate ($69,146.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,1188.00,17370.86,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],45758.86,,,,,,0,other,17693.40,52449.26,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],29166.74,,"Fee schedule rate ($29,166.74). Adds an outlier to normal pricing equal to the per diem rate ($36,758.78) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,12455.21,37149.27,There are no additional notes associated with this service or procedure.
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],2070.00,,,,,,0,other,1188.00,31658.33,Estimated amount calculated based on 16 day length of stay.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,761,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],6965.00,,,,,,0,other,5808.41,11946.72,There are no additional notes associated with this service or procedure.
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],8153.63,,"Case rate ($7,993.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,572.03, add-ons for qualifying new technology services are included. If operating cost exceeds $42,443.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,202.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $5,606.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,627.08 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $442.40. The transfer capital threshold is the transfer adjustment factor * $442.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,5415.00,17575.50,Inpatient DRG
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],14058.86,,"Case rate ($13,783.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,957.83, add-ons for qualifying new technology services are included. If operating cost exceeds $47,828.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,625.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $10,972.42 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,012.88 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $865.83. The transfer capital threshold is the transfer adjustment factor * $865.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,13783.20,41580.51,Inpatient DRG
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],18047.27,,"Case rate ($17,693.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,595.40, add-ons for qualifying new technology services are included. If operating cost exceeds $51,466.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,911.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $14,596.63 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,650.45 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,151.82. The transfer capital threshold is the transfer adjustment factor * $1,151.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,17693.40,52449.26,Inpatient DRG
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],9667.64,,"Fee schedule rate ($9,667.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,5139.72,13110.79,There are no additional notes associated with this service or procedure.
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,068,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],17008.80,,,,,,0,other,6965.00,23184.90,There are no additional notes associated with this service or procedure.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],62454.12,,"Fee schedule rate ($62,454.12). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11348.00,62454.12,There are no additional notes associated with this service or procedure.
INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC,198,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],23505.07,,"Fee schedule rate ($23,505.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6795.12,23505.07,There are no additional notes associated with this service or procedure.
"PULMONARY EMBOLISM,MAJOR",134,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],2326.47,,"Case rate for a one day stay ($2,326.47). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,2326.47,2442.79,There are no additional notes associated with this service or procedure.
Exc B9 Lesion Mrgn Xcp Sk Tg T/a/L 2.1-3.0 Cm,CASE-11403,APC,11403,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],2814.04,,"APC Price ($2,718.88). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2718.88,2854.83,OPPS APC
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,477,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],64922.30,,"Fee schedule rate ($64,922.30). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16.6), with a minimum of zero.",,,,0,other,25339.74,67976.16,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],43399.23,,"Fee schedule rate ($43,399.23). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9888.00,43399.23,There are no additional notes associated with this service or procedure.
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC,964,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],28802.15,,"Fee schedule rate ($28,802.15). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,12323.82,34154.06,There are no additional notes associated with this service or procedure.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],16447.34,,"Case rate ($16,447.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,436.22, add-ons for qualifying new technology services are included. If operating cost exceeds $50,307.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,820.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $13,441.70 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,491.27 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,060.68. The transfer capital threshold is the transfer adjustment factor * $1,060.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7453.00,42138.30,Inpatient DRG
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],11681.49,,"Fee schedule rate ($11,681.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5778.62,11681.49,There are no additional notes associated with this service or procedure.
APPENDIX PROCEDURES WITH MCC,397,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],51558.84,,"Fee schedule rate ($51,558.84). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,18163.37,51558.84,There are no additional notes associated with this service or procedure.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],42586.49,,"Fee schedule rate ($42,586.49). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,13341.67,42586.49,There are no additional notes associated with this service or procedure.
CELLULITIS WITH MCC,602,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],27966.92,,,,,,0,other,11570.10,28349.31,There are no additional notes associated with this service or procedure.
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],17748.64,,"Case rate ($16,903.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,888.46, add-ons for qualifying new technology services are included. If operating cost exceeds $50,759.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,827.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $13,890.84 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,943.51 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,067.68. The transfer capital threshold is the transfer adjustment factor * $1,067.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,17356.15,44778.95,Inpatient DRG
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],21455.22,,"Fee schedule rate ($21,455.22). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,9097.60,21455.22,There are no additional notes associated with this service or procedure.
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC,519,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],15490.44,,"Case rate ($15,490.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,546.03, add-ons for qualifying new technology services are included. If operating cost exceeds $49,417.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,750.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $12,554.80 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,601.09 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $990.70. The transfer capital threshold is the transfer adjustment factor * $990.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,15490.44,50780.20,Inpatient DRG
CESAREAN SECTION WITHOUT STERILIZATION WITH CC,787,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],23722.94,,"Fee schedule rate ($23,722.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9508.01,23722.94,There are no additional notes associated with this service or procedure.
Injection Aa&/Strd Intercostal Nrv Ea Addl Lvl|LEFT SIDE,CASE-64421,APC,64421,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],869.28,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,827.89,869.28,OPPS APC
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],13110.79,,,,,,0,other,5139.72,13110.79,There are no additional notes associated with this service or procedure.
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],5777.94,,"Case rate ($5,777.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,510.70, add-ons for qualifying new technology services are included. If operating cost exceeds $40,381.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,040.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $3,552.65 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,565.75 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $280.34. The transfer capital threshold is the transfer adjustment factor * $280.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,5065.00,12558.65,Inpatient DRG
SALIVARY GLAND PROCEDURES,139,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],30690.92,,"Fee schedule rate ($30,690.92). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,10313.19,30690.92,There are no additional notes associated with this service or procedure.
CERVICAL SPINAL FUSION WITH MCC,471,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],90745.76,,"Fee schedule rate ($90,745.76). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,34645.26,111337.93,There are no additional notes associated with this service or procedure.
HC Inj Aa&/Strd Greater Occipital Nerve|RIGHT SIDE,CASE-64405,APC,64405,CPT,0450,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],297.37,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,287.31,301.68,OPPS APC
Parathyroidectomy/Exploration Parathyroids|LEFT SIDE,CASE-60500,APC,60500,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5818.16,,"APC Price ($5,541.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5541.10,5818.16,OPPS APC
RADIOTHERAPY,849,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],81867.07,,"Fee schedule rate ($81,867.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,20293.88,81867.07,There are no additional notes associated with this service or procedure.
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],8366.06,,"Case rate ($8,083.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,655.19, add-ons for qualifying new technology services are included. If operating cost exceeds $42,526.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,208.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,689.27 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,710.24 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $448.94. The transfer capital threshold is the transfer adjustment factor * $448.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,7884.32,17835.23,Inpatient DRG
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],6965.00,,,,,,0,other,6965.00,36140.75,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITH CC,386,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],19879.00,,"Fee schedule rate ($19,879.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8556.53,19879.00,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC,084,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],6965.00,,,,,,0,other,6965.00,19445.16,There are no additional notes associated with this service or procedure.
Laps Vaginal Hysterect > 250 Gm Rmvl Tube&/Ovar,CASE-58554,APC,58554,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],10298.02,,"APC Price ($9,949.78). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,9949.78,10447.27,OPPS APC
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],36868.88,,"Fee schedule rate ($36,868.88). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12606.23,36868.88,There are no additional notes associated with this service or procedure.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,270,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],35415.32,,"Case rate ($34,720.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $32,431.98, add-ons for qualifying new technology services are included. If operating cost exceeds $71,076.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $5,156.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.4. The base transfer operating payment is the transfer adjustment factor * $30,933.64 + an uncompensated DSH payment of $1,359.91. The transfer operating threshold is the transfer adjustment factor * $31,072.08 + an uncompensated DSH payment of $1,359.91. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,427.36. The transfer capital threshold is the transfer adjustment factor * $2,427.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 102%.",,,,0,other,34720.90,101002.04,Inpatient DRG
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],87909.90,,"Fee schedule rate ($87,909.90). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,33623.33,133270.57,There are no additional notes associated with this service or procedure.
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC,058,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],40853.02,,"Fee schedule rate ($40,853.02). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,13521.80,40853.02,There are no additional notes associated with this service or procedure.
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],8669.31,,"Case rate ($8,256.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,828.22, add-ons for qualifying new technology services are included. If operating cost exceeds $42,699.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,210.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,861.05 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,883.27 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $450.49. The transfer capital threshold is the transfer adjustment factor * $450.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,1188.00,18893.86,Inpatient DRG
O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC,621,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],20323.80,,"Fee schedule rate ($20,323.80). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,12159.94,36669.96,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,064,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],23188.20,,"Fee schedule rate ($23,188.20). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,15563.58,41838.16,There are no additional notes associated with this service or procedure.
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC,497,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],37761.19,,"Fee schedule rate ($37,761.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10127.65,37761.19,There are no additional notes associated with this service or procedure.
"SPINAL FUSION AND OTHER BACK AND NECK PROCEDURES EXCEPT FOR DISC PROCEDURES,MINOR",321,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],5302.83,,"Case rate for a one day stay ($5,302.83). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,5302.83,5567.97,There are no additional notes associated with this service or procedure.
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],15233.11,,"Case rate ($15,233.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,306.64, add-ons for qualifying new technology services are included. If operating cost exceeds $49,177.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,731.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $12,316.28 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,361.69 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $971.88. The transfer capital threshold is the transfer adjustment factor * $971.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,15233.11,38610.21,Inpatient DRG
Dstr Nrolytc Agnt Parverteb Fct Addl Crvcl/Thora|RIGHT SIDE,CASE-64634,APC,64634,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1891.77,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1891.77,1919.19,OPPS APC
RESPIRATORY NEOPLASMS WITHOUT CC/MCC,182,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],23037.13,,"Fee schedule rate ($23,037.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6965.00,23037.13,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC,833,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],5721.39,,"Fee schedule rate ($5,721.39). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,3041.73,10289.10,There are no additional notes associated with this service or procedure.
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],7000.00,,"Per diem ($7,000). If length of stay < 4.5, first 1 days paid at a per diem of $14,000 instead. Capped at $31,498.95.",,,,0,other,7000.00,33835.79,Estimated amount calculated based on 2 day length of stay.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],38517.10,,"Fee schedule rate ($38,517.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,16897.01,43444.85,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC,831,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],9294.42,,"Fee schedule rate ($9,294.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,4941.30,23661.59,There are no additional notes associated with this service or procedure.
Rpr Recrt Ingun Hernia Any Age Incarcerated,CASE-49521,APC,49521,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6271.74,,"APC Price ($6,059.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6059.65,6362.63,OPPS APC
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],6965.00,,,,,,0,other,6965.00,36140.75,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF THE EYE WITHOUT MCC,125,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],14429.27,,"Fee schedule rate ($14,429.27). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.9), with a minimum of zero.",,,,0,other,7144.54,17952.29,There are no additional notes associated with this service or procedure.
Excision Inferior Turbinate Partial/Complete|LEFT SIDE,CASE-30130,APC,30130,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6605.95,,"APC Price ($6,605.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6605.95,6936.25,OPPS APC
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITH MCC,429,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],177294.98,,"Fee schedule rate ($177,294.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,62958.58,177294.98,There are no additional notes associated with this service or procedure.
Lamnotmy Incl W/Dcmprsn Nrv Root 1 Intrspc Lumbr|LEFT SIDE,CASE-63030,APC,63030,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
HEADACHES WITHOUT MCC,103,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],16455.88,,,,,,0,other,6965.00,20883.08,There are no additional notes associated with this service or procedure.
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC,497,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],20075.41,,"Fee schedule rate ($20,075.41). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10127.65,37761.19,There are no additional notes associated with this service or procedure.
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],41190.50,,"Fee schedule rate ($41,190.50). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,16787.98,62990.26,There are no additional notes associated with this service or procedure.
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],23870.71,,"Fee schedule rate ($23,870.71). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10626.74,25225.91,There are no additional notes associated with this service or procedure.
CERVICAL SPINAL FUSION WITHOUT CC/MCC,473,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],19401.49,,"Case rate ($18,477.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,324.93, add-ons for qualifying new technology services are included. If operating cost exceeds $52,195.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,969.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.6. The base transfer operating payment is the transfer adjustment factor * $15,323.48 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,379.98 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,209.17. The transfer capital threshold is the transfer adjustment factor * $1,209.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,18477.61,62077.11,Inpatient DRG
Hysteroscopy Endometrial Ablation,CASE-58563,APC,58563,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],4916.53,,"APC Price ($4,682.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,4682.41,4916.53,OPPS APC
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],20981.60,,"Fee schedule rate ($20,981.60). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,10003.71,23415.63,There are no additional notes associated with this service or procedure.
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|LEFT HAND, THIRD DIGIT",CASE-26160,APC,26160,CPT,0360,RC,,,F2,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1505.12,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1505.12,1580.37,OPPS APC
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],25293.50,,"Fee schedule rate ($25,293.50). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11059.47,28423.20,There are no additional notes associated with this service or procedure.
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],21263.41,,"Case rate ($20,846.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $19,528.64, add-ons for qualifying new technology services are included. If operating cost exceeds $54,399.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,142.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $17,519.09 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $17,583.69 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,382.43. The transfer capital threshold is the transfer adjustment factor * $1,382.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,20846.48,81306.30,Inpatient DRG
OTHER CEREBROVASCULAR DISORDERS WITH MCC,070,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],23133.41,,"Case rate ($13,219.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,433.04, add-ons for qualifying new technology services are included. If operating cost exceeds $47,304.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,584.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $10,449.57 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,488.10 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $824.57. The transfer capital threshold is the transfer adjustment factor * $824.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,13219.09,37774.46,All Other Inpatient
Laparoscopy W/Rmvl Adnexal Structures|RIGHT SIDE,CASE-58661,APC,58661,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5658.76,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5658.76,5941.70,OPPS APC
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],17755.26,,"Fee schedule rate ($17,755.26). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7847.50,17755.26,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],32802.57,,"Case rate ($31,693.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $29,619.21, add-ons for qualifying new technology services are included. If operating cost exceeds $64,490.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,935.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. The base transfer operating payment is the transfer adjustment factor * $27,572.60 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $27,674.26 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,175.75. The transfer capital threshold is the transfer adjustment factor * $2,175.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,10862.00,86437.13,Inpatient DRG
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",004,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],10715.36,,,,,,0,other,10249.47,272554.00,Estimated amount calculated based on 6 day length of stay.
Egd Ablate Tumor Polyp/Lesion W/Dilation& Wire,CASE-43270,APC,43270,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1859.01,,"APC Price ($1,796.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1796.14,1885.95,OPPS APC
Unlisted Laparoscopic Procedure Liver,CASE-47379,APC,47379,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5856.81,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5658.76,5941.70,OPPS APC
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],31918.40,,"Case rate ($30,398.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $28,414.67, add-ons for qualifying new technology services are included. If operating cost exceeds $63,285.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,841.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.2. The base transfer operating payment is the transfer adjustment factor * $26,372.48 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $26,469.72 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,081.05. The transfer capital threshold is the transfer adjustment factor * $2,081.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,30398.48,82674.88,Inpatient DRG
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],31477.13,,"Fee schedule rate ($31,477.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9648.19,31477.13,There are no additional notes associated with this service or procedure.
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],17356.15,,"Case rate ($17,356.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,281.67, add-ons for qualifying new technology services are included. If operating cost exceeds $51,152.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,887.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $14,284.05 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,336.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,127.15. The transfer capital threshold is the transfer adjustment factor * $1,127.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,17356.15,44778.95,Inpatient DRG
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],29243.52,,"Fee schedule rate ($29,243.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,14343.25,36024.65,There are no additional notes associated with this service or procedure.
Xpedicul Decompress Throacic Cord,CASE-63055,APC,63055,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6791.99,7131.59,OPPS APC
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5710.23,,"Case rate ($5,710.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,447.70, add-ons for qualifying new technology services are included. If operating cost exceeds $40,318.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,035.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $3,489.88 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,502.75 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $275.39. The transfer capital threshold is the transfer adjustment factor * $275.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,3079.00,10940.41,Inpatient DRG
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],16438.59,,"Fee schedule rate ($16,438.59). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7402.56,16438.59,There are no additional notes associated with this service or procedure.
VENTRICULAR SHUNT PROCEDURES WITH MCC,031,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],88162.80,,,,,,0,other,32287.20,88162.80,There are no additional notes associated with this service or procedure.
Cystourethroscopy Inj Chemodenervation Bladder|UNUSUAL NON-OVERLAPPING SERVICE,CASE-52287,APC,52287,CPT,0360,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3299.47,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3299.47,3464.44,OPPS APC
Dstrj Lesion Anus Simple Surg Excision,CASE-46922,APC,46922,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],2598.08,,"APC Price ($2,598.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2598.08,2727.99,OPPS APC
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITH MCC OR ANTINEOPLASTIC IMPLANT OR EPILEPSY WITH NEUROSTIMULATOR,023,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],41591.64,,"Case rate ($39,611.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $37,055.24, add-ons for qualifying new technology services are included. If operating cost exceeds $71,926.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,448.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $34,977.67 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $35,110.29 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,688.47. The transfer capital threshold is the transfer adjustment factor * $2,688.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,15168.00,136379.44,Inpatient DRG
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,448,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],32197.15,,"Case rate ($30,663.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $28,661.63, add-ons for qualifying new technology services are included. If operating cost exceeds $63,532.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,860.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $26,618.53 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $26,716.68 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,100.47. The transfer capital threshold is the transfer adjustment factor * $2,100.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,30663.95,94077.13,Inpatient DRG
Dstr Nrolytc Agnt Parverteb Fct Addl Lmbr/Sacral|RIGHT SIDE,CASE-64636,APC,64636,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1827.80,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1827.80,1919.19,OPPS APC
Colsc Flexible W/Control Bleeding Any Method|UNUSUAL NON-OVERLAPPING SERVICE,CASE-45382,APC,45382,CPT,0360,RC,,,XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1176.09,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1120.09,1176.09,OPPS APC
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],22158.27,,,,,,0,other,5569.00,40108.48,There are no additional notes associated with this service or procedure.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],31007.30,,"Fee schedule rate ($31,007.30). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,16120.25,41187.90,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],12818.71,,"Fee schedule rate ($12,818.71). Adds an outlier to normal pricing equal to the per diem rate ($42,942.49) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,6564.18,17651.07,There are no additional notes associated with this service or procedure.
Incision & Removal Foreign Body Subq Tiss Compl,CASE-10121,APC,10121,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1545.93,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1545.93,1623.23,OPPS APC
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC,520,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],39786.42,,"Fee schedule rate ($39,786.42). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12061.74,39786.42,There are no additional notes associated with this service or procedure.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],36127.48,,"Case rate ($34,407.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $32,204.39, add-ons for qualifying new technology services are included. If operating cost exceeds $67,075.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,077.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.3. The base transfer operating payment is the transfer adjustment factor * $30,145.14 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $30,259.44 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,317.03. The transfer capital threshold is the transfer adjustment factor * $2,317.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,35389.50,101083.00,Inpatient DRG
"LIMB REATTACHMENT, HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA",956,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],148259.86,,"Fee schedule rate ($148,259.86). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,27428.25,148259.86,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],41961.35,,"Case rate ($40,542.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $37,851.31, add-ons for qualifying new technology services are included. If operating cost exceeds $72,722.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,582.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.6. The base transfer operating payment is the transfer adjustment factor * $35,774.45 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $35,906.36 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,822.96. The transfer capital threshold is the transfer adjustment factor * $2,822.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,40542.37,128358.13,Inpatient DRG
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],25667.48,,"Fee schedule rate ($25,667.48). Adds an outlier to normal pricing equal to the per diem rate ($77,296.48) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,11194.25,36094.03,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],112149.06,,,,,,0,other,40542.37,128358.13,There are no additional notes associated with this service or procedure.
MAJOR BLADDER PROCEDURES WITH MCC,653,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],38992.11,,"Case rate ($37,135.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $34,681.82, add-ons for qualifying new technology services are included. If operating cost exceeds $69,552.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,333.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.5. The base transfer operating payment is the transfer adjustment factor * $32,616.61 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $32,736.87 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,573.77. The transfer capital threshold is the transfer adjustment factor * $2,573.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10280.00,125343.98,Inpatient DRG
Intraop Sentinel Lymph Node ID W/Dye Injection|LEFT SIDE,CASE-38900,APC,38900,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6215.36,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6215.36,6526.12,OPPS APC
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],36855.62,,"Fee schedule rate ($36,855.62). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,15821.59,40320.14,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL HEMORRHAGE WITH CC,378,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],11553.15,,"Fee schedule rate ($11,553.15). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8586.33,20845.19,There are no additional notes associated with this service or procedure.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],66833.55,,"Fee schedule rate ($66,833.55). Adds an outlier to normal pricing equal to the per diem rate ($141,521.30) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,26028.48,80635.65,There are no additional notes associated with this service or procedure.
Parathyroidectomy/Exploration Parathyroids|SEPARATE STRUCTURE|RIGHT SIDE,CASE-60500,APC,60500,CPT,0360,RC,,,XS|RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],9949.78,,"APC Price ($9,949.78). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,9949.78,10447.27,OPPS APC
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",062,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],33023.06,,"Fee schedule rate ($33,023.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,13844.84,44304.80,There are no additional notes associated with this service or procedure.
INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC,198,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],14092.67,,,,,,0,other,6795.12,23505.07,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],25044.52,,"Case rate ($23,851.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $22,324.54, add-ons for qualifying new technology services are included. If operating cost exceeds $57,195.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,362.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.8. The base transfer operating payment is the transfer adjustment factor * $20,304.73 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $20,379.59 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,602.24. The transfer capital threshold is the transfer adjustment factor * $1,602.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,23851.92,63653.13,Inpatient DRG
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],27222.08,,"Fee schedule rate ($27,222.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7389.00,37134.43,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6564.18,,"Case rate ($6,564.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,242.12, add-ons for qualifying new technology services are included. If operating cost exceeds $41,113.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,097.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $4,281.39 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,297.17 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $337.84. The transfer capital threshold is the transfer adjustment factor * $337.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6564.18,17651.07,Inpatient DRG
Insj Biomchn Dev Vrt Corpectomy Defect W/Arthrd,CASE-22854,APC,22854,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],12017.31,,"APC Price ($12,017.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12017.31,12618.18,OPPS APC
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],19371.27,,"Fee schedule rate ($19,371.27). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7641.61,19371.27,There are no additional notes associated with this service or procedure.
HC Inject Tendon Origin/Insert|LEFT SIDE,CASE-20551,APC,20551,CPT,0361,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],301.68,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,287.31,301.68,OPPS APC
UNGROUPABLE,999,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],136003.49,,,,,,0,other,10228.00,161307.29,There are no additional notes associated with this service or procedure.
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],20170.75,,"Fee schedule rate ($20,170.75). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10048.39,23545.50,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC,833,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],5721.39,,"Fee schedule rate ($5,721.39). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,3041.73,10289.10,There are no additional notes associated with this service or procedure.
OTHER CEREBROVASCULAR DISORDERS WITH CC,071,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],29215.10,,"Fee schedule rate ($29,215.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5843.00,29215.10,There are no additional notes associated with this service or procedure.
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],26725.53,,"Fee schedule rate ($26,725.53). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.6), with a minimum of zero.",,,,0,other,11575.50,48961.48,There are no additional notes associated with this service or procedure.
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],15145.28,,"Fee schedule rate ($15,145.28). Adds an outlier to normal pricing equal to the per diem rate ($54,966.40) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7402.56,16438.59,There are no additional notes associated with this service or procedure.
HC Inj Anes/Steroid C/D Facet Sg|LEFT SIDE,CASE-64490,APC,64490,CPT,0361,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],827.89,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,827.89,869.28,OPPS APC
"HYPERTENSION,MODERATE",199,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],6738.39,,"The inlier payment is calculated as the lesser of the standard DRG payment $6,738.39 and the transfer payment, which is a per diem of $2,315.60. If cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,6738.39,7075.31,Estimated amount calculated based on 2 day length of stay.
Cerclage Cervix Pregnancy Vaginal,CASE-59320,APC,59320,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3136.08,,"APC Price ($3,030.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3030.03,3181.53,OPPS APC
"Amputation Toe Metatarsophalangeal Joint|RIGHT HAND, FOURTH DIGIT",CASE-28820,APC,28820,CPT,0360,RC,,,F8,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
"Tx Open Tendon Flexor Toe 1 Tendon Spx|RIGHT FOOT, SECOND DIGIT",CASE-28232,APC,28232,CPT,0360,RC,,,T6,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1505.12,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1505.12,1580.37,OPPS APC
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],15839.99,,,,,,0,other,7396.47,16035.06,There are no additional notes associated with this service or procedure.
HC External Version,CASE-59412,APC,59412,CPT,0720,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3181.53,,"APC Price ($3,030.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3030.03,3181.53,OPPS APC
Esophagogastroduodenoscopy Transoral Diagnostic,CASE-43235,APC,43235,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],878.67,,"APC Price ($848.96). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,848.96,891.41,OPPS APC
"Tx Open Tendon Flexor Toe 1 Tendon Spx|RIGHT FOOT, SECOND DIGIT",CASE-28232,APC,28232,CPT,0360,RC,,,T6,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1557.80,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1505.12,1580.37,OPPS APC
NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,601,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],12359.72,,"Fee schedule rate ($12,359.72). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6042.05,12359.72,There are no additional notes associated with this service or procedure.
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC,797,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],20928.55,,"Fee schedule rate ($20,928.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8719.72,20928.55,There are no additional notes associated with this service or procedure.
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],33835.79,,"Fee schedule rate ($33,835.79). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,7000.00,33835.79,There are no additional notes associated with this service or procedure.
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",623,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],32096.64,,"Fee schedule rate ($32,096.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,14093.37,33712.76,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],11847.11,,"Fee schedule rate ($11,847.11). Adds an outlier to normal pricing equal to the per diem rate ($62,538.40) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,6214.05,15318.94,There are no additional notes associated with this service or procedure.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],45050.58,,"Fee schedule rate ($45,050.58). Adds an outlier to normal pricing equal to the per diem rate ($120,238.99) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,18178.96,54764.34,There are no additional notes associated with this service or procedure.
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITH MCC OR ANTINEOPLASTIC IMPLANT OR EPILEPSY WITH NEUROSTIMULATOR,023,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],136379.44,,"Fee schedule rate ($136,379.44). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,15168.00,136379.44,There are no additional notes associated with this service or procedure.
"Hallux Rigidus W/Cheilectomy 1st Mp Jt W/O Implt|LEFT FOOT, GREAT TOE",CASE-28289,APC,28289,CPT,0360,RC,,,TA,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
Lamnotmy Incl W/Dcmprsn Nrv Root 1 Intrspc Lumbr|BILATERAL PROCEDURE,CASE-63030,APC,63030,CPT,0360,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7029.71,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6791.99,7131.59,OPPS APC
SINGLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL,402,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],124455.45,,"Fee schedule rate ($124,455.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,29172.05,124455.45,There are no additional notes associated with this service or procedure.
Neuroplasty &/Transposition Ulnar Nerve Elbow|RIGHT SIDE,CASE-64718,APC,64718,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1919.19,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1827.80,1919.19,OPPS APC
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC",758,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],8574.80,,"Case rate ($8,574.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,112.57, add-ons for qualifying new technology services are included. If operating cost exceeds $42,983.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,244.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $6,144.96 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,167.62 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $484.90. The transfer capital threshold is the transfer adjustment factor * $484.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8574.80,19263.78,Inpatient DRG
PSYCHOSES,885,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],2070.00,,,,,,0,other,2070.00,27484.83,Estimated amount calculated based on 3 day length of stay.
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,095,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],48470.91,,"Fee schedule rate ($48,470.91). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.8), with a minimum of zero.",,,,0,other,19411.47,50750.92,There are no additional notes associated with this service or procedure.
Laps Supracrv Hysterect 250 Gm/< Rmvl Tube/Ovar,CASE-58542,APC,58542,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],9949.78,,"APC Price ($9,949.78). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,9949.78,10298.02,OPPS APC
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],8719.29,,"Fee schedule rate ($8,719.29). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,16400.70,There are no additional notes associated with this service or procedure.
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],11472.01,,"Case rate ($11,247.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,598.51, add-ons for qualifying new technology services are included. If operating cost exceeds $45,469.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,440.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,621.77 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,653.56 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $680.34. The transfer capital threshold is the transfer adjustment factor * $680.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,11247.07,27028.33,Inpatient DRG
"NEONATE BIRTH WEIGHT > 2499 GRAMS WITH MAJOR ANOMALY,MINOR",633,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],1918.68,,"Case rate ($1,918.68). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,1918.68,2014.61,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],8318.14,,"Case rate ($8,318.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,873.80, add-ons for qualifying new technology services are included. If operating cost exceeds $42,744.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,226.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,907.07 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,928.85 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $466.13. The transfer capital threshold is the transfer adjustment factor * $466.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8318.14,19763.43,Inpatient DRG
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],47123.82,,"Fee schedule rate ($47,123.82). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,12696.97,47123.82,There are no additional notes associated with this service or procedure.
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],14674.80,,"Fee schedule rate ($14,674.80). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6711.00,16865.16,There are no additional notes associated with this service or procedure.
Arthrp Interpos Intercarpal/Metacarpal Joints|LEFT SIDE,CASE-25447,APC,25447,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],25534.84,,,,,,0,other,10733.06,45157.33,There are no additional notes associated with this service or procedure.
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],14830.15,,"Fee schedule rate ($14,830.15). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,7884.32,17835.23,There are no additional notes associated with this service or procedure.
Egd Transoral Biopsy Single/Multiple|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-43239,APC,43239,CPT,0360,RC,,,74,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],848.96,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,848.96,891.41,OPPS APC
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],12770.37,,,,,,0,other,6340.03,15076.44,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],11331.34,,"Case rate ($10,791.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,191.45, add-ons for qualifying new technology services are included. If operating cost exceeds $45,062.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,391.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $8,215.35 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,246.50 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $631.45. The transfer capital threshold is the transfer adjustment factor * $631.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,11059.47,28423.20,Inpatient DRG
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],7438.45,,"Case rate ($7,438.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,055.44, add-ons for qualifying new technology services are included. If operating cost exceeds $41,926.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,161.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,091.72 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,110.49 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $401.79. The transfer capital threshold is the transfer adjustment factor * $401.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7438.45,15961.98,Inpatient DRG
Destruction Neurolytic Agt Genicular Nerve W/Img|RIGHT SIDE,CASE-64624,APC,64624,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1827.80,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1827.80,1891.77,OPPS APC
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],19877.10,,"Fee schedule rate ($19,877.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8009.34,19877.10,There are no additional notes associated with this service or procedure.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],52699.33,,"Fee schedule rate ($52,699.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,18105.81,52699.33,There are no additional notes associated with this service or procedure.
MINOR BLADDER PROCEDURES WITHOUT CC/MCC,664,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],9486.36,,"Case rate ($9,034.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,540.33, add-ons for qualifying new technology services are included. If operating cost exceeds $43,411.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,278.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $6,571.15 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,595.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $518.53. The transfer capital threshold is the transfer adjustment factor * $518.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9034.63,31876.87,Inpatient DRG
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,069,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],20333.68,,"Fee schedule rate ($20,333.68). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,20333.68,There are no additional notes associated with this service or procedure.
HC Inj Trigger Pt 1-2 Musc Grps|ADJ,CASE-20552,APC,20552,CPT,0510,RC,,,ADJ,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],297.37,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,287.31,301.68,OPPS APC
Cysto W/Urtroscopy&/Pyeloscopy Dx|RIGHT SIDE,CASE-52351,APC,52351,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3299.47,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3299.47,3464.44,OPPS APC
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],39259.55,,,,,,0,other,15456.59,41402.42,There are no additional notes associated with this service or procedure.
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],6965.00,,,,,,0,other,6965.00,16400.70,There are no additional notes associated with this service or procedure.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC,027,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],19981.71,,"Case rate ($19,030.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,839, add-ons for qualifying new technology services are included. If operating cost exceeds $52,710.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,009.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $15,835.66 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,894.05 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,249.59. The transfer capital threshold is the transfer adjustment factor * $1,249.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,19030.20,56363.30,Inpatient DRG
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,690,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],7426.94,,"Case rate ($7,426.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,044.73, add-ons for qualifying new technology services are included. If operating cost exceeds $41,915.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,160.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,081.05 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,099.78 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $400.94. The transfer capital threshold is the transfer adjustment factor * $400.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7426.94,15928.53,Inpatient DRG
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],15802.03,,"Fee schedule rate ($15,802.03). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7566.45,16333.88,There are no additional notes associated with this service or procedure.
HC Joint Injection/Aspir Medium WO US|PBB CHARGE|RIGHT SIDE,CASE-20605,APC,20605,CPT,0510,RC,,,PBB|RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
Laps Total Hysterect 250 Gm/< W/Rmvl Tube/Ovary,CASE-58571,APC,58571,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],9949.78,,"APC Price ($9,949.78). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,9949.78,9949.78,OPPS APC
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],87909.90,,"Fee schedule rate ($87,909.90). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,33623.33,133270.57,There are no additional notes associated with this service or procedure.
DIABETES WITHOUT CC/MCC,639,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],11899.36,,"Fee schedule rate ($11,899.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6151.76,12223.35,There are no additional notes associated with this service or procedure.
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],10989.72,,"Case rate ($10,989.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,359.11, add-ons for qualifying new technology services are included. If operating cost exceeds $45,230.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,421.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $8,383.26 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,414.17 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $661.52. The transfer capital threshold is the transfer adjustment factor * $661.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10989.72,26280.60,Inpatient DRG
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],14492.93,,"Fee schedule rate ($14,492.93). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6503.90,14492.93,There are no additional notes associated with this service or procedure.
Suction Assisted Lipectomy Upper Extremity|BILATERAL PROCEDURE,CASE-15878,APC,15878,CPT,0360,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],2027.84,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1998.87,2027.84,OPPS APC
Hemorrhoidectomy Int & Xtrnl 2/> Column/Gro,CASE-46260,APC,46260,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],2689.02,,"APC Price ($2,598.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2598.08,2727.99,OPPS APC
Unlisted Laparoscopy Procedure Uterus,CASE-58578,APC,58578,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],9949.78,,"APC Price ($9,949.78). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,9949.78,10298.02,OPPS APC
HC Lyr Clos Nk Hnd Ft 2.6-5 Cm,CASE-12042,APC,12042,CPT,0450,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1545.93,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1545.93,1623.23,OPPS APC
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],45845.03,,"Fee schedule rate ($45,845.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,18598.83,48389.68,There are no additional notes associated with this service or procedure.
MAJOR CHEST TRAUMA WITHOUT CC/MCC,185,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],21771.61,,"Fee schedule rate ($21,771.61). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7271.19,21771.61,There are no additional notes associated with this service or procedure.
"KIDNEY AND URINARY TRACT INFECTIONS,MAJOR",463,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],8976.11,,"Case rate ($8,976.11). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,8976.11,9424.92,There are no additional notes associated with this service or procedure.
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],3209.85,,"Fee schedule rate ($3,209.85). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,3079.00,10940.41,There are no additional notes associated with this service or procedure.
HC Injection Small Joint/Bursa|PBB CHARGE,CASE-20600,APC,20600,CPT,0361,RC,,,PBB,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],287.31,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
MINOR BLADDER PROCEDURES WITHOUT CC/MCC,664,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],9486.36,,"Case rate ($9,034.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,540.33, add-ons for qualifying new technology services are included. If operating cost exceeds $43,411.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,278.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $6,571.15 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,595.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $518.53. The transfer capital threshold is the transfer adjustment factor * $518.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9034.63,31876.87,Inpatient DRG
Dilation & Curettage Dx&/Ther Nonobstetric,CASE-58120,APC,58120,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3181.53,,"APC Price ($3,030.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3030.03,3181.53,OPPS APC
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],54236.60,,"Fee schedule rate ($54,236.60). Adds an outlier to normal pricing equal to the per diem rate ($122,612.56) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,21489.15,68942.79,There are no additional notes associated with this service or procedure.
"Tendon Sheath Incision|RIGHT HAND, SECOND DIGIT|UNUSUAL NON-OVERLAPPING SERVICE",CASE-26055,APC,26055,CPT,0360,RC,,,F6|XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1580.37,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1505.12,1580.37,OPPS APC
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],17651.07,,"Fee schedule rate ($17,651.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,6564.18,17651.07,There are no additional notes associated with this service or procedure.
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC,519,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],15490.44,,"Case rate ($15,490.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,546.03, add-ons for qualifying new technology services are included. If operating cost exceeds $49,417.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,750.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $12,554.80 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,601.09 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $990.70. The transfer capital threshold is the transfer adjustment factor * $990.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,15490.44,50780.20,Inpatient DRG
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],36776.05,,"Fee schedule rate ($36,776.05). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11053.39,36776.05,There are no additional notes associated with this service or procedure.
NEONATE WITH OTHER SIGNIFICANT PROBLEMS,794,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],4500.00,,,,,,0,other,1798.85,12536.83,There are no additional notes associated with this service or procedure.
Prq Impltj Neurostim Eltrd Sacral Nrve W/Imaging,CASE-64561,APC,64561,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5965.28,,"APC Price ($5,965.28). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5965.28,6263.54,OPPS APC
"Arthrodesis Interphalangeal Jt W/WO Int Fixj|LEFT HAND, FIFTH DIGIT",CASE-26860,APC,26860,CPT,0360,RC,,,F4,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6791.99,7131.59,OPPS APC
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,057,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],10718.84,,"Case rate ($10,718.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,107.12, add-ons for qualifying new technology services are included. If operating cost exceeds $44,978.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,401.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,132.18 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,162.17 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $641.71. The transfer capital threshold is the transfer adjustment factor * $641.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10718.84,39884.93,Inpatient DRG
GASTROINTESTINAL OBSTRUCTION WITH CC,389,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7548.81,,"Case rate ($7,293.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,920.63, add-ons for qualifying new technology services are included. If operating cost exceeds $41,791.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,151.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $4,957.39 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,975.67 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $391.19. The transfer capital threshold is the transfer adjustment factor * $391.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,5118.00,16423.43,Inpatient DRG
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],16035.06,,"Fee schedule rate ($16,035.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,7396.47,16035.06,There are no additional notes associated with this service or procedure.
Arthroplasty Patella W/O Prosthesis,CASE-27437,APC,27437,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,6791.99,OPPS APC
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],9389.48,,"Case rate ($9,389.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,870.44, add-ons for qualifying new technology services are included. If operating cost exceeds $43,741.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,304.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,900.05 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,925.50 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $544.48. The transfer capital threshold is the transfer adjustment factor * $544.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9389.48,22358.90,Inpatient DRG
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],36801.89,,,,,,0,other,6277.00,36801.89,There are no additional notes associated with this service or procedure.
RADIOTHERAPY,849,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],81867.07,,"Fee schedule rate ($81,867.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,20293.88,81867.07,There are no additional notes associated with this service or procedure.
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],30245.71,,"Fee schedule rate ($30,245.71). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9151.11,30245.71,There are no additional notes associated with this service or procedure.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,761,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5979.68,,"Case rate ($5,694.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,440.48, add-ons for qualifying new technology services are included. If operating cost exceeds $40,311.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,027.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $3,482.32 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,495.53 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $267.66. The transfer capital threshold is the transfer adjustment factor * $267.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5808.41,11946.72,Inpatient DRG
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],11974.38,,"Case rate ($11,974.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,275.12, add-ons for qualifying new technology services are included. If operating cost exceeds $46,146.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,493.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $9,295.90 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,330.17 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $733.54. The transfer capital threshold is the transfer adjustment factor * $733.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,11974.38,29141.64,Inpatient DRG
HC Biopsy/Exc Lymph Node Needle|TECHNICAL COMPONENT,CASE-38505,APC,38505,CPT,0361,RC,,,TC,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1600.04,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1545.93,1623.23,OPPS APC
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,394,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],20909.61,,"Fee schedule rate ($20,909.61). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8281.56,20909.61,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],8787.44,,"Case rate ($8,787.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,310.38, add-ons for qualifying new technology services are included. If operating cost exceeds $43,181.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,260.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,342.05 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,365.43 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $500.45. The transfer capital threshold is the transfer adjustment factor * $500.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,32293.66,Inpatient DRG
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],10049.53,,"Case rate ($9,570.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,039.28, add-ons for qualifying new technology services are included. If operating cost exceeds $43,910.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,317.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $7,068.27 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,094.33 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $557.76. The transfer capital threshold is the transfer adjustment factor * $557.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5569.00,40108.48,Inpatient DRG
VENTRICULAR SHUNT PROCEDURES WITH MCC,031,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],62406.76,,"Fee schedule rate ($62,406.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,32287.20,88162.80,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,699,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],9127.25,,"Case rate ($8,818.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,339.37, add-ons for qualifying new technology services are included. If operating cost exceeds $43,210.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,262.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $6,370.92 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,394.41 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $502.73. The transfer capital threshold is the transfer adjustment factor * $502.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,5961.00,19972.16,Inpatient DRG
OTHER MENTAL DISORDER DIAGNOSES,887,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],2070.00,,,,,,0,other,2070.00,21072.10,Estimated amount calculated based on 1 day length of stay.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,373,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],13780.60,,"Fee schedule rate ($13,780.60). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6870.94,14313.05,There are no additional notes associated with this service or procedure.
NERVOUS SYSTEM NEOPLASMS WITH MCC,054,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],25589.03,,"Fee schedule rate ($25,589.03). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,6965.00,30044.81,There are no additional notes associated with this service or procedure.
APPENDIX PROCEDURES WITH MCC,397,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],18163.37,,"Case rate ($18,163.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,032.61, add-ons for qualifying new technology services are included. If operating cost exceeds $51,903.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,946.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $15,032.24 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,087.66 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,186.19. The transfer capital threshold is the transfer adjustment factor * $1,186.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,18163.37,51558.84,Inpatient DRG
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,083,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],28680.85,,"Fee schedule rate ($28,680.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,28680.85,There are no additional notes associated with this service or procedure.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],97015.50,,"Fee schedule rate ($97,015.50). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,26809.29,97015.50,There are no additional notes associated with this service or procedure.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,191,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],16612.88,,"Fee schedule rate ($16,612.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6965.00,16612.88,There are no additional notes associated with this service or procedure.
"SICKLE CELL ANEMIA CRISIS,MODERATE",662,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],7675.80,,"Case rate ($7,675.80). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,7675.80,8059.59,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],23844.73,,"Case rate ($23,377.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $21,882.92, add-ons for qualifying new technology services are included. If operating cost exceeds $56,753.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,327.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $19,864.72 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $19,937.97 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,567.52. The transfer capital threshold is the transfer adjustment factor * $1,567.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,23377.19,96365.69,Inpatient DRG
Chromotubation Oviduct W/Materials,CASE-58350,APC,58350,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],4916.53,,"APC Price ($4,682.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,4682.41,4916.53,OPPS APC
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],22358.90,,"Fee schedule rate ($22,358.90). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9389.48,22358.90,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,086,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],10982.26,,"Case rate ($10,766.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,151.85, add-ons for qualifying new technology services are included. If operating cost exceeds $45,022.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,405.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $8,176.75 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,206.90 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $645.23. The transfer capital threshold is the transfer adjustment factor * $645.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,8442.00,30728.81,Inpatient DRG
NONTRAUMATIC STUPOR AND COMA WITH MCC,080,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],30179.40,,"Fee schedule rate ($30,179.40). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,14202.39,35615.37,There are no additional notes associated with this service or procedure.
OSTEOMYELITIS WITHOUT CC/MCC,541,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],7277.28,,"Case rate ($7,277.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,905.50, add-ons for qualifying new technology services are included. If operating cost exceeds $41,776.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,149.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $4,942.33 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,960.55 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $390.00. The transfer capital threshold is the transfer adjustment factor * $390.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,5103.00,15493.67,Inpatient DRG
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC,497,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],22707.58,,"Fee schedule rate ($22,707.58). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7.8), with a minimum of zero.",,,,0,other,10127.65,37761.19,There are no additional notes associated with this service or procedure.
NEONATE WITH OTHER SIGNIFICANT PROBLEMS,794,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],3383.58,,"Fee schedule rate ($3,383.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,1798.85,12536.83,There are no additional notes associated with this service or procedure.
Injection Aa&/Strd Intercostal Nrv Ea Addl Lvl|RIGHT SIDE,CASE-64421,APC,64421,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],869.28,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,827.89,869.28,OPPS APC
RESPIRATORY NEOPLASMS WITHOUT CC/MCC,182,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],12337.05,,"Case rate ($7,049.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,693.83, add-ons for qualifying new technology services are included. If operating cost exceeds $41,564.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,133.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,731.43 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,748.88 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $373.36. The transfer capital threshold is the transfer adjustment factor * $373.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,6965.00,23037.13,All Other Inpatient
DIABETES WITH MCC,637,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],27368.25,,"Fee schedule rate ($27,368.25). Adds an outlier to normal pricing equal to the per diem rate ($39,561.63) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,9959.03,28655.62,There are no additional notes associated with this service or procedure.
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH CC",457,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],160549.49,,"Fee schedule rate ($160,549.49). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,42327.47,160549.49,There are no additional notes associated with this service or procedure.
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],13794.06,,"Fee schedule rate ($13,794.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,6915.64,14442.92,There are no additional notes associated with this service or procedure.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],14428.87,,"Case rate ($13,741.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,941.31, add-ons for qualifying new technology services are included. If operating cost exceeds $47,812.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,601.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $10,954.82 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,996.36 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $842.01. The transfer capital threshold is the transfer adjustment factor * $842.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7332.00,35314.31,Inpatient DRG
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],13676.25,,"Fee schedule rate ($13,676.25). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10834.64,25830.00,There are no additional notes associated with this service or procedure.
"Tendon Sheath Incision|LEFT HAND, THUMB",CASE-26055,APC,26055,CPT,0360,RC,,,FA,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1505.12,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1505.12,1580.37,OPPS APC
"OSTEOMYELITIS SEPTIC ARTHRITIS AND OTHER MUSCULOSKELETAL INFECTIONS,MODERATE",344,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],9921.08,,"Case rate ($9,448.65). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9448.65,9921.08,There are no additional notes associated with this service or procedure.
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],68942.79,,"Fee schedule rate ($68,942.79). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,21489.15,68942.79,There are no additional notes associated with this service or procedure.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,352,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],26528.70,,"Fee schedule rate ($26,528.70). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,9853.37,26528.70,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC,087,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],22679.07,,"Fee schedule rate ($22,679.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,8139.36,22679.07,There are no additional notes associated with this service or procedure.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],29837.65,,"Fee schedule rate ($29,837.65). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,12696.97,47123.82,There are no additional notes associated with this service or procedure.
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],30935.16,,"Fee schedule rate ($30,935.16). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13092.47,33159.45,There are no additional notes associated with this service or procedure.
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC,806,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6738.54,,"Case rate ($6,510.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,192.35, add-ons for qualifying new technology services are included. If operating cost exceeds $41,063.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,093.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $4,231.80 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,247.40 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $333.93. The transfer capital threshold is the transfer adjustment factor * $333.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,5354.25,13416.00,Inpatient DRG
SIGNS AND SYMPTOMS WITH MCC,947,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],23855.83,,"Fee schedule rate ($23,855.83). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10541.41,30414.32,There are no additional notes associated with this service or procedure.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,761,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],11225.73,,,,,,0,other,5808.41,11946.72,There are no additional notes associated with this service or procedure.
DIABETES WITH CC,638,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],15195.79,,"Fee schedule rate ($15,195.79). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8014.07,17634.53,There are no additional notes associated with this service or procedure.
"CVA AND PRECEREBRAL OCCLUSION WITH INFARCTION,MODERATE",045,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],10234.76,,"Case rate ($10,234.76). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,10234.76,10746.50,There are no additional notes associated with this service or procedure.
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],8273.53,,"Case rate ($7,993.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,572.03, add-ons for qualifying new technology services are included. If operating cost exceeds $42,443.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,202.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $5,606.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,627.08 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $442.40. The transfer capital threshold is the transfer adjustment factor * $442.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,5415.00,17575.50,Inpatient DRG
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],6245.09,,"Case rate ($6,122.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,831.37, add-ons for qualifying new technology services are included. If operating cost exceeds $40,702.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,065.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $3,872.14 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,886.42 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $305.55. The transfer capital threshold is the transfer adjustment factor * $305.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,1188.00,12138.74,Inpatient DRG
HC Joint Injection/Aspir Large WO US|PBB CHARGE|LEFT SIDE,CASE-20610,APC,20610,CPT,0510,RC,,,PBB|LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],287.31,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],13768.00,,,,,,0,other,6683.37,14699.43,There are no additional notes associated with this service or procedure.
HEADACHES WITHOUT MCC,103,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],7608.43,,"Case rate ($7,608.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,213.57, add-ons for qualifying new technology services are included. If operating cost exceeds $42,084.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,174.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $5,249.26 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,268.62 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $414.22. The transfer capital threshold is the transfer adjustment factor * $414.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,20883.08,Inpatient DRG
SPINAL PROCEDURES WITH MCC,028,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],42633.57,,"Case rate ($42,633.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $39,796.72, add-ons for qualifying new technology services are included. If operating cost exceeds $74,667.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,735.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.5. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 9.5)) / 2. The base transfer operating payment is the transfer adjustment factor * $37,712.72 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $37,851.77 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,975.91. The transfer capital threshold is the transfer adjustment factor * $2,975.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,42633.57,120982.83,Inpatient DRG
Rpr Aa Hernia 1st 3-10 Cm Reducible,CASE-49593,APC,49593,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6362.63,,"APC Price ($6,059.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6059.65,6362.63,OPPS APC
Replacement Tissue Expander W/Permanent Implant|LEFT SIDE,CASE-11970,APC,11970,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6791.99,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
Placement Seton,CASE-46020,APC,46020,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],2689.02,,"APC Price ($2,598.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2598.08,2727.99,OPPS APC
PREMATURITY WITH MAJOR PROBLEMS,791,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],3186.77,,,,,,0,other,3048.21,30904.42,Estimated amount calculated based on 5 day length of stay.
Insj Inflatable Urethral/Bladder Neck Sphincter,CASE-53445,APC,53445,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],19400.15,,"APC Price ($19,400.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,19400.15,20370.16,OPPS APC
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],10517.71,,"Case rate ($10,517.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,920.01, add-ons for qualifying new technology services are included. If operating cost exceeds $44,791.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,386.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $7,945.76 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,975.06 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $627.00. The transfer capital threshold is the transfer adjustment factor * $627.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10517.71,24909.11,Inpatient DRG
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,479,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],50518.76,,"Fee schedule rate ($50,518.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,10586.00,50518.76,There are no additional notes associated with this service or procedure.
DIABETES WITH CC,638,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],15195.79,,"Fee schedule rate ($15,195.79). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8014.07,17634.53,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,448,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],83446.22,,,,,,0,other,30663.95,94077.13,There are no additional notes associated with this service or procedure.
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],11809.42,,"Case rate ($11,247.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,598.51, add-ons for qualifying new technology services are included. If operating cost exceeds $45,469.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,440.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,621.77 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,653.56 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $680.34. The transfer capital threshold is the transfer adjustment factor * $680.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,11247.07,27028.33,Inpatient DRG
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH CC",457,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],160549.49,,"Fee schedule rate ($160,549.49). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,42327.47,160549.49,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],6886.69,,"Case rate ($6,558.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,237.08, add-ons for qualifying new technology services are included. If operating cost exceeds $41,108.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,097.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $4,276.36 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,292.13 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $337.45. The transfer capital threshold is the transfer adjustment factor * $337.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6558.75,14871.83,Inpatient DRG
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],17755.26,,"Fee schedule rate ($17,755.26). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7847.50,17755.26,There are no additional notes associated with this service or procedure.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],33608.45,,"Fee schedule rate ($33,608.45). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,7332.00,35314.31,There are no additional notes associated with this service or procedure.
"SINGLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL,MINOR",300,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],32618.25,,"Case rate ($31,065.00). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,31065.00,32618.25,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,065,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],18986.57,,"Fee schedule rate ($18,986.57). Adds an outlier to normal pricing equal to the per diem rate ($85,884.96) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,8786.76,25681.86,There are no additional notes associated with this service or procedure.
Arthrt Expl Drg/Rmvl Loose/FB Iphal Jt Ea,CASE-26080,APC,26080,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1557.80,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1505.12,1557.80,OPPS APC
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],16590.46,,"Fee schedule rate ($16,590.46). Adds an outlier to normal pricing equal to the per diem rate ($69,146.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,1188.00,17370.86,There are no additional notes associated with this service or procedure.
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],8086.81,,"Case rate ($7,701.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,311.09, add-ons for qualifying new technology services are included. If operating cost exceeds $42,182.10 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,170.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $5,345.87 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,366.14 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $410.90. The transfer capital threshold is the transfer adjustment factor * $410.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7875.94,17233.12,Inpatient DRG
CHEST PAIN,313,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],15377.66,,"Fee schedule rate ($15,377.66). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,6820.84,15377.66,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC,788,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],20142.33,,"Fee schedule rate ($20,142.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8438.02,20142.33,There are no additional notes associated with this service or procedure.
DIABETES WITHOUT CC/MCC,639,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],11899.36,,"Fee schedule rate ($11,899.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6151.76,12223.35,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],26178.21,,"Fee schedule rate ($26,178.21). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,13917.42,34889.29,There are no additional notes associated with this service or procedure.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC,099,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],11729.77,,"Case rate ($11,171.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,527.95, add-ons for qualifying new technology services are included. If operating cost exceeds $45,398.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,434.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,551.47 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,583.00 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $674.80. The transfer capital threshold is the transfer adjustment factor * $674.80. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,11171.21,26807.94,Inpatient DRG
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC",494,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],27182.93,,"Case rate ($15,533.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,585.72, add-ons for qualifying new technology services are included. If operating cost exceeds $49,456.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,753.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $12,594.34 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,640.78 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $993.82. The transfer capital threshold is the transfer adjustment factor * $993.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,15533.10,39945.55,All Other Inpatient
PERIPHERAL VASCULAR DISORDERS WITH CC,300,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],20061.53,,"Fee schedule rate ($20,061.53). Adds an outlier to normal pricing equal to the per diem rate ($49,296.97) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.9), with a minimum of zero.",,,,0,other,9174.14,21005.20,There are no additional notes associated with this service or procedure.
Revision Peri-Implant Capsule Breast,CASE-19370,APC,19370,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],8033.01,,"APC Price ($7,650.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,7918.25,8033.01,OPPS APC
Laparoscopy W/Rmvl Adnexal Structures,CASE-58661,APC,58661,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5658.76,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5658.76,5941.70,OPPS APC
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],10744.63,,"Case rate ($10,533.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,935.13, add-ons for qualifying new technology services are included. If operating cost exceeds $44,806.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,388.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $7,960.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,990.18 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $628.19. The transfer capital threshold is the transfer adjustment factor * $628.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,10533.95,24956.34,Inpatient DRG
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],11065.78,,"Fee schedule rate ($11,065.78). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5883.03,17111.12,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,064,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],41838.16,,"Fee schedule rate ($41,838.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,15563.58,41838.16,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITHOUT CC/MCC,428,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],118904.57,,"Fee schedule rate ($118,904.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,40017.53,118904.57,There are no additional notes associated with this service or procedure.
RADIOTHERAPY,849,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],81867.07,,"Fee schedule rate ($81,867.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,20293.88,81867.07,There are no additional notes associated with this service or procedure.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],15309.46,,"Fee schedule rate ($15,309.46). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6965.00,15340.19,There are no additional notes associated with this service or procedure.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],26465.57,,,,,,0,other,11053.39,36776.05,There are no additional notes associated with this service or procedure.
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],40714.72,,"Fee schedule rate ($40,714.72). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,17356.15,44778.95,There are no additional notes associated with this service or procedure.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],85466.62,,"Fee schedule rate ($85,466.62). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,21382.16,85466.62,There are no additional notes associated with this service or procedure.
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],28323.33,,"Fee schedule rate ($28,323.33). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,15940.79,53275.26,There are no additional notes associated with this service or procedure.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],41944.25,,"Fee schedule rate ($41,944.25). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12795.84,41944.25,There are no additional notes associated with this service or procedure.
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],32390.31,,,,,,0,other,13092.47,33159.45,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],26178.21,,"Fee schedule rate ($26,178.21). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,13917.42,34889.29,There are no additional notes associated with this service or procedure.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITHOUT CC/MCC,816,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],12435.86,,,,,,0,other,6224.90,14733.53,There are no additional notes associated with this service or procedure.
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral Ea Addl|RIGHT SIDE,CASE-64484,APC,64484,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],856.86,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,827.89,869.28,OPPS APC
Xpedicul Decompress Throacic Cord|RIGHT SIDE,CASE-63055,APC,63055,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
"ASTHMA,MODERATE",141,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],2101.28,,"Case rate for a one day stay ($2,101.28). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,2101.28,2206.34,There are no additional notes associated with this service or procedure.
Repair Complex Trunk 2.6-7.5 Cm|UNUSUAL NON-OVERLAPPING SERVICE,CASE-13101,APC,13101,CPT,0360,RC,,,XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],2814.04,,"APC Price ($2,718.88). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2718.88,2854.83,OPPS APC
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,329,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],86382.02,,"Fee schedule rate ($86,382.02). Adds an outlier to normal pricing equal to the per diem rate ($147,722.18) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,33072.77,90445.33,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF NERVOUS SYSTEM WITH CC,092,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],8872.78,,"Case rate ($8,872.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,389.76, add-ons for qualifying new technology services are included. If operating cost exceeds $43,260.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,266.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $6,421.14 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,444.81 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $506.69. The transfer capital threshold is the transfer adjustment factor * $506.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8872.78,26765.51,Inpatient DRG
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITHOUT CC/MCC,428,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],118904.57,,"Fee schedule rate ($118,904.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,40017.53,118904.57,There are no additional notes associated with this service or procedure.
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],11640.72,,"Case rate ($11,247.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,598.51, add-ons for qualifying new technology services are included. If operating cost exceeds $45,469.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,440.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,621.77 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,653.56 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $680.34. The transfer capital threshold is the transfer adjustment factor * $680.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,11247.07,27028.33,Inpatient DRG
VAGINAL DELIVERY WITH O.R. PROCEDURES EXCEPT STERILIZATION AND/OR D&C,768,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],12088.81,,"Fee schedule rate ($12,088.81). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6426.91,13416.00,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],23316.48,,"Fee schedule rate ($23,316.48). Adds an outlier to normal pricing equal to the per diem rate ($44,995.76) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7.7), with a minimum of zero.",,,,0,other,10347.06,28821.04,There are no additional notes associated with this service or procedure.
Cysto W/Simple Removal Stone & Stent|RIGHT SIDE,CASE-52310,APC,52310,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1956.65,,"APC Price ($1,956.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1956.65,2054.48,OPPS APC
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,329,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],46057.01,,"Fee schedule rate ($46,057.01). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (38), with a minimum of zero.",,,,0,other,33072.77,90445.33,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC,087,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],17189.96,,"Fee schedule rate ($17,189.96). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,8139.36,22679.07,There are no additional notes associated with this service or procedure.
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 2nd Level,CASE-64494,APC,64494,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],827.89,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,827.89,869.28,OPPS APC
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],33608.45,,"Fee schedule rate ($33,608.45). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,7332.00,35314.31,There are no additional notes associated with this service or procedure.
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6560.80,,"Case rate ($6,248.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,956.38, add-ons for qualifying new technology services are included. If operating cost exceeds $40,827.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,067.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $3,996.28 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,011.43 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $307.16. The transfer capital threshold is the transfer adjustment factor * $307.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,4341.01,12882.53,Inpatient DRG
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,270,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],96464.47,,"Fee schedule rate ($96,464.47). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,34720.90,101002.04,There are no additional notes associated with this service or procedure.
PREMATURITY WITHOUT MAJOR PROBLEMS,792,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],11512.88,,"Fee schedule rate ($11,512.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,1956.00,19457.66,There are no additional notes associated with this service or procedure.
Biopsy Cervix Single/Mult/Excision of Lesion Spx,CASE-57500,APC,57500,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],862.13,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,862.13,905.23,OPPS APC
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],17365.00,,"Fee schedule rate ($17,365.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5683.00,19635.68,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],39259.55,,,,,,0,other,15456.59,41402.42,There are no additional notes associated with this service or procedure.
"NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY",789,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],6663.33,,,,,,0,other,3054.00,14857.05,Estimated amount calculated based on 1 day length of stay.
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],21675.85,,"Fee schedule rate ($21,675.85). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,9755.86,29216.99,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],28983.97,,"Fee schedule rate ($28,983.97). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8956.76,28983.97,There are no additional notes associated with this service or procedure.
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],8057.43,,"Case rate ($8,057.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,631.26, add-ons for qualifying new technology services are included. If operating cost exceeds $42,502.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,207.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,665.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,686.30 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $447.06. The transfer capital threshold is the transfer adjustment factor * $447.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6524.00,17760.46,Inpatient DRG
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],11606.06,,"Case rate ($11,053.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,418.34, add-ons for qualifying new technology services are included. If operating cost exceeds $45,289.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,426.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $8,442.26 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,473.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $666.18. The transfer capital threshold is the transfer adjustment factor * $666.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,11053.39,36776.05,Inpatient DRG
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,056,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],59328.19,,"Fee schedule rate ($59,328.19). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (44), with a minimum of zero.",,,,0,other,7659.00,59328.19,There are no additional notes associated with this service or procedure.
MINOR BLADDER PROCEDURES WITHOUT CC/MCC,664,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],19674.39,,"Fee schedule rate ($19,674.39). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,9034.63,31876.87,There are no additional notes associated with this service or procedure.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC",061,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],33129.67,,"Fee schedule rate ($33,129.67). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,20616.23,62315.82,There are no additional notes associated with this service or procedure.
Surg Nasopharyngoscopy Dilat Eustachian Tube Bi,CASE-69706,APC,69706,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5818.16,,"APC Price ($5,541.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5541.10,5818.16,OPPS APC
MINOR BLADDER PROCEDURES WITHOUT CC/MCC,664,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],19674.39,,"Fee schedule rate ($19,674.39). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,9034.63,31876.87,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],14846.66,,"Case rate ($14,344.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,480.09, add-ons for qualifying new technology services are included. If operating cost exceeds $48,351.10 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,666.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $11,492.77 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,535.14 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $906.89. The transfer capital threshold is the transfer adjustment factor * $906.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,14344.60,36028.59,Inpatient DRG
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC,805,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],11112.38,,"Fee schedule rate ($11,112.38). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9253.36,21235.42,There are no additional notes associated with this service or procedure.
DIABETES WITHOUT CC/MCC,639,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],6965.00,,,,,,0,other,6151.76,12223.35,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITH CC,386,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],8984.36,,"Case rate ($8,556.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,095.56, add-ons for qualifying new technology services are included. If operating cost exceeds $42,966.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,243.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,128.01 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,150.61 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $483.56. The transfer capital threshold is the transfer adjustment factor * $483.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8556.53,19879.00,Inpatient DRG
Cysto/Uretero W/Lithotripsy &Indwell Stent Insrt|RIGHT SIDE,CASE-52356,APC,52356,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5194.43,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5018.77,5269.71,OPPS APC
PSYCHOSES,885,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],2070.00,,,,,,0,other,2070.00,27484.83,Estimated amount calculated based on 3 day length of stay.
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],20362.22,,"Fee schedule rate ($20,362.22). Adds an outlier to normal pricing equal to the per diem rate ($66,744.74) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.8), with a minimum of zero.",,,,0,other,9282.47,21320.03,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],16818.89,,"Case rate ($16,017.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,036.80, add-ons for qualifying new technology services are included. If operating cost exceeds $49,907.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,789.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $13,043.76 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,091.85 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,029.28. The transfer capital threshold is the transfer adjustment factor * $1,029.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,16017.99,51903.64,Inpatient DRG
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],7772.69,,"Case rate ($7,402.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,022.05, add-ons for qualifying new technology services are included. If operating cost exceeds $41,893.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,159.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,058.45 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,077.10 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $399.16. The transfer capital threshold is the transfer adjustment factor * $399.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7402.56,16438.59,Inpatient DRG
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,064,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],41838.16,,"Fee schedule rate ($41,838.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,15563.58,41838.16,There are no additional notes associated with this service or procedure.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],7605.00,,"Per diem ($7,605). If length of stay < 4.8, first 1 days paid at a per diem of $15,210 instead. Capped at $36,505.40.",,,,0,other,7605.00,39153.65,Estimated amount calculated based on 3 day length of stay.
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],16184.69,,"Case rate ($15,413.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,500.05, add-ons for qualifying new technology services are included. If operating cost exceeds $49,371.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,721.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $12,507.68 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,555.10 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $961.37. The transfer capital threshold is the transfer adjustment factor * $961.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,15821.59,40320.14,Inpatient DRG
HC Inj Aa&/Strd Greater Occipital Nerve|RIGHT SIDE,CASE-64405,APC,64405,CPT,0450,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],301.68,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,287.31,301.68,OPPS APC
TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC,084,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],8712.32,,"Case rate ($8,417.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,966.41, add-ons for qualifying new technology services are included. If operating cost exceeds $42,837.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,233.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $5,999.34 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,021.46 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $473.41. The transfer capital threshold is the transfer adjustment factor * $473.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6965.00,19445.16,Inpatient DRG
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],15061.83,,"Case rate ($14,344.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,480.09, add-ons for qualifying new technology services are included. If operating cost exceeds $48,351.10 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,666.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $11,492.77 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,535.14 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $906.89. The transfer capital threshold is the transfer adjustment factor * $906.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,14344.60,36028.59,Inpatient DRG
HC Joint Injection/Aspir Medium WO US|PBB CHARGE,CASE-20605,APC,20605,CPT,0510,RC,,,PBB,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],297.37,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,287.31,301.68,OPPS APC
Arthrd Ant Interdy Cervcl Belw C2 Ea Addl Ntrspc,CASE-22552,APC,22552,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12618.18,,"APC Price ($12,017.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,12017.31,12618.18,OPPS APC
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],58320.32,,"Fee schedule rate ($58,320.32). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,16286.16,58320.32,There are no additional notes associated with this service or procedure.
"Excis Intrasp Lesn,Xdural,Lumbar",CASE-63267,APC,63267,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7029.71,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6791.99,7131.59,OPPS APC
Laparoscopy Surg Rpr Initial Inguinal Hernia|RIGHT SIDE,CASE-49650,APC,49650,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5856.81,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5658.76,5941.70,OPPS APC
Laryngoscopy Exc Tum&/Stripping Cords/Epiglott,CASE-31540,APC,31540,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3489.82,,"APC Price ($3,489.82). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3489.82,3664.31,OPPS APC
CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC,788,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],20142.33,,"Fee schedule rate ($20,142.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8438.02,20142.33,There are no additional notes associated with this service or procedure.
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],6965.00,,,,,,0,other,6965.00,17467.27,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,091,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],13838.06,,"Case rate ($13,838.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,008.86, add-ons for qualifying new technology services are included. If operating cost exceeds $47,879.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,629.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $11,023.26 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,063.91 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $869.84. The transfer capital threshold is the transfer adjustment factor * $869.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,13838.06,40030.81,Inpatient DRG
Insj/Rplcmt Breast Implant Sep Day Mastectomy|LEFT SIDE,CASE-19342,APC,19342,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7918.25,,"APC Price ($7,650.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,7650.49,8033.01,OPPS APC
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],8764.88,,"Case rate ($8,468.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,013.65, add-ons for qualifying new technology services are included. If operating cost exceeds $42,884.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,237.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,046.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,068.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $477.12. The transfer capital threshold is the transfer adjustment factor * $477.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6963.00,18954.85,Inpatient DRG
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],9683.78,,"Case rate ($9,356.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,839.58, add-ons for qualifying new technology services are included. If operating cost exceeds $43,710.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,302.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $6,869.30 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,894.63 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $542.06. The transfer capital threshold is the transfer adjustment factor * $542.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,9356.31,25026.36,Inpatient DRG
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],21854.96,,"Fee schedule rate ($21,854.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10638.94,25261.33,There are no additional notes associated with this service or procedure.
HC Rt Bronch Dx Clear Airway,CASE-31645,APC,31645,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3489.82,,"APC Price ($3,489.82). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3489.82,3664.31,OPPS APC
RESPIRATORY NEOPLASMS WITH CC,181,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],9759.75,,"Fee schedule rate ($9,759.75). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9197.84,21074.07,There are no additional notes associated with this service or procedure.
HC Joint Injection/Aspir Large WO US|PBB CHARGE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-20610,APC,20610,CPT,0510,RC,,,PBB|XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],301.68,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,287.31,301.68,OPPS APC
"KIDNEY AND URINARY TRACT INFECTIONS,MAJOR",463,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],9424.92,,"Case rate ($8,976.11). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8976.11,9424.92,There are no additional notes associated with this service or procedure.
"Open Tx Phalangeal Shaft Fracture Prox/Middle Ea|RIGHT HAND, FOURTH DIGIT",CASE-26735,APC,26735,CPT,0360,RC,,,F8,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
PREMATURITY WITHOUT MAJOR PROBLEMS,792,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],19457.66,,"Case rate ($18,531.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,374.70, add-ons for qualifying new technology services are included. If operating cost exceeds $52,245.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,973.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. The base transfer operating payment is the transfer adjustment factor * $15,373.07 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,429.75 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,213.09. The transfer capital threshold is the transfer adjustment factor * $1,213.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,1956.00,19457.66,Inpatient DRG
Egd Transoral Biopsy Single/Multiple|UNUSUAL NON-OVERLAPPING SERVICE,CASE-43239,APC,43239,CPT,0360,RC,,,XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1885.95,,"APC Price ($1,796.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1796.14,1885.95,OPPS APC
Lithotripsy Xtrcorp Shock Wave|RIGHT SIDE,CASE-50590,APC,50590,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3299.47,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3299.47,3464.44,OPPS APC
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],44847.62,,"Fee schedule rate ($44,847.62). Adds an outlier to normal pricing equal to the per diem rate ($79,031.36) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,18105.81,52699.33,There are no additional notes associated with this service or procedure.
COMPLICATIONS OF TREATMENT WITH CC,920,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],9169.22,,"Case rate ($8,732.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,259.35, add-ons for qualifying new technology services are included. If operating cost exceeds $43,130.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,256.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,291.21 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,314.40 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $496.44. The transfer capital threshold is the transfer adjustment factor * $496.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8732.59,20731.52,Inpatient DRG
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],12272.58,,"Fee schedule rate ($12,272.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5628.97,12272.58,There are no additional notes associated with this service or procedure.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,761,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],11946.72,,"Fee schedule rate ($11,946.72). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,5808.41,11946.72,There are no additional notes associated with this service or procedure.
"Open Tx Distal Phalangeal Fracture Each|RIGHT HAND, FIFTH DIGIT",CASE-26765,APC,26765,CPT,0360,RC,,,F9,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],7921.00,,"Per diem ($7,921). If length of stay < 4.1, first 1 days paid at a per diem of $15,842 instead. Capped at $32,474.30.",,,,0,other,7921.00,45706.73,Estimated amount calculated based on 2 day length of stay.
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,091,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],14529.96,,"Case rate ($13,838.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,008.86, add-ons for qualifying new technology services are included. If operating cost exceeds $47,879.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,629.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $11,023.26 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,063.91 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $869.84. The transfer capital threshold is the transfer adjustment factor * $869.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13838.06,40030.81,Inpatient DRG
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],26301.36,,"Fee schedule rate ($26,301.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11247.07,27028.33,There are no additional notes associated with this service or procedure.
COAGULATION DISORDERS,813,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],28664.96,,"Fee schedule rate ($28,664.96). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.7), with a minimum of zero.",,,,0,other,12274.39,30013.33,There are no additional notes associated with this service or procedure.
Dilation Esoph Unguided Sound/Bougie 1/Mult Pass,CASE-43450,APC,43450,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],891.41,,"APC Price ($848.96). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,848.96,891.41,OPPS APC
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],9218.36,,"Case rate ($8,906.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,421.26, add-ons for qualifying new technology services are included. If operating cost exceeds $43,292.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,269.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $6,452.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,476.31 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $509.17. The transfer capital threshold is the transfer adjustment factor * $509.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,8906.63,28434.57,Inpatient DRG
Laparoscopy Surg W/Bx Single/Multiple,CASE-49321,APC,49321,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5941.70,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5658.76,5941.70,OPPS APC
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],59610.47,,"Fee schedule rate ($59,610.47). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,16129.04,59610.47,There are no additional notes associated with this service or procedure.
O.R. PROCEDURES FOR OBESITY WITH CC,620,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],24249.75,,"Fee schedule rate ($24,249.75). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12782.30,43753.50,There are no additional notes associated with this service or procedure.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],34001.86,,,,,,0,other,7921.00,45706.73,There are no additional notes associated with this service or procedure.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],16669.71,,"Fee schedule rate ($16,669.71). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8767.81,19824.58,There are no additional notes associated with this service or procedure.
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC,797,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],11126.48,,"Fee schedule rate ($11,126.48). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8719.72,20928.55,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],67794.72,,"Fee schedule rate ($67,794.72). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,10862.00,86437.13,There are no additional notes associated with this service or procedure.
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],26301.36,,"Fee schedule rate ($26,301.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11247.07,27028.33,There are no additional notes associated with this service or procedure.
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],15802.03,,"Fee schedule rate ($15,802.03). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7566.45,16333.88,There are no additional notes associated with this service or procedure.
HC Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn,CASE-62321,APC,62321,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],660.72,,"APC Price ($660.72). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,660.72,693.76,OPPS APC
MAJOR ESOPHAGEAL DISORDERS WITH CC,369,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],6965.00,,,,,,0,other,6965.00,19680.94,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],12891.14,,"Case rate ($12,455.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,722.41, add-ons for qualifying new technology services are included. If operating cost exceeds $46,593.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,528.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $9,741.55 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,777.47 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $768.70. The transfer capital threshold is the transfer adjustment factor * $768.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,12455.21,37149.27,Inpatient DRG
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],25253.70,,"Fee schedule rate ($25,253.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11974.38,29141.64,There are no additional notes associated with this service or procedure.
Colsc Flexible W/Control Bleeding Any Method|UNUSUAL NON-OVERLAPPING SERVICE,CASE-45382,APC,45382,CPT,0360,RC,,,XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1159.29,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1120.09,1176.09,OPPS APC
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],19187.65,,"Fee schedule rate ($19,187.65). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8859.23,20090.22,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],42569.49,,"Case rate ($40,542.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $37,851.31, add-ons for qualifying new technology services are included. If operating cost exceeds $72,722.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,582.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.6. The base transfer operating payment is the transfer adjustment factor * $35,774.45 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $35,906.36 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,822.96. The transfer capital threshold is the transfer adjustment factor * $2,822.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,40542.37,128358.13,Inpatient DRG
Colsc Flx With Directed Submucosal Njx Any Sbst|COLORECTAL CANCER SCREEN,CASE-45381,APC,45381,CPT,0360,RC,,,PT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1159.29,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1120.09,1176.09,OPPS APC
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],36103.36,,,,,,0,other,14370.36,38378.80,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITHOUT STERILIZATION WITH MCC,786,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],23722.94,,"Fee schedule rate ($23,722.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12612.10,23722.94,There are no additional notes associated with this service or procedure.
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],46202.59,,"Fee schedule rate ($46,202.59). Adds an outlier to normal pricing equal to the per diem rate ($126,777.34) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,18594.09,59494.91,There are no additional notes associated with this service or procedure.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC,862,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],6855.00,,"Per diem ($6,855). If length of stay < 5, first 1 days paid at a per diem of $13,710 instead. Capped at $34,272.79.",,,,0,other,6855.00,35884.94,Estimated amount calculated based on 3 day length of stay.
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],6711.00,,"Per diem ($6,711). If length of stay < 2.4, first 1 days paid at a per diem of $13,422 instead. Capped at $16,107.48.",,,,0,other,6711.00,16865.16,Estimated amount calculated based on 2 day length of stay.
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],24701.52,,"Fee schedule rate ($24,701.52). Adds an outlier to normal pricing equal to the per diem rate ($51,462.28) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,10846.16,25863.45,There are no additional notes associated with this service or procedure.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC",061,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],62315.82,,"Fee schedule rate ($62,315.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,20616.23,62315.82,There are no additional notes associated with this service or procedure.
ALLERGIC REACTIONS WITH MCC,915,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],13332.86,,"Case rate ($13,332.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,538.89, add-ons for qualifying new technology services are included. If operating cost exceeds $47,409.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,592.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $10,555.02 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,593.94 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $832.90. The transfer capital threshold is the transfer adjustment factor * $832.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,13332.86,33088.84,Inpatient DRG
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],62084.69,,"Fee schedule rate ($62,084.69). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (35), with a minimum of zero.",,,,0,other,30398.48,82674.88,There are no additional notes associated with this service or procedure.
"Arthrodesis Interphalangeal Jt W/WO Int Fixj|RIGHT HAND, FIFTH DIGIT",CASE-26860,APC,26860,CPT,0360,RC,,,F9,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3062.67,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],36855.62,,"Fee schedule rate ($36,855.62). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,15821.59,40320.14,There are no additional notes associated with this service or procedure.
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7025.31,,"Case rate ($6,690.77). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,368.74, add-ons for qualifying new technology services are included. If operating cost exceeds $41,239.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,098.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $4,407.08 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,423.79 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $338.74. The transfer capital threshold is the transfer adjustment factor * $338.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6834.39,21354.82,Inpatient DRG
HC Joint Injection/Aspir Large WO US|PBB CHARGE,CASE-20610,APC,20610,CPT,0510,RC,,,PBB,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],287.31,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],27553.62,,"Fee schedule rate ($27,553.62). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12305.53,30103.84,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],49717.39,,"Fee schedule rate ($49,717.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,14908.05,49717.39,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],18311.90,,"Fee schedule rate ($18,311.90). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8543.64,23239.84,There are no additional notes associated with this service or procedure.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],19528.77,,"Case rate ($18,598.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,437.70, add-ons for qualifying new technology services are included. If operating cost exceeds $52,308.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,978.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 5.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $15,435.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,492.75 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,218.04. The transfer capital threshold is the transfer adjustment factor * $1,218.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,18598.83,48389.68,Inpatient DRG
HC Inj Anesth Celiac Plexus|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64530,APC,64530,CPT,0361,RC,,,XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],856.86,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,827.89,869.28,OPPS APC
PSYCHOSES,885,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],26250.06,,"Fee schedule rate ($26,250.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15.8), with a minimum of zero.",,,,0,other,2070.00,27484.83,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],13411.63,,"Case rate ($13,148.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,367.53, add-ons for qualifying new technology services are included. If operating cost exceeds $47,238.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,579.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $10,384.29 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,422.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $819.42. The transfer capital threshold is the transfer adjustment factor * $819.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,13148.66,32553.63,Inpatient DRG
CHOLECYSTECTOMY WITH C.D.E. WITH MCC,411,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],25166.16,,"Case rate ($24,315.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $22,755.46, add-ons for qualifying new technology services are included. If operating cost exceeds $57,626.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,396.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $20,734.06 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $20,810.51 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,636.12. The transfer capital threshold is the transfer adjustment factor * $1,636.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,24315.13,88615.28,Inpatient DRG
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],36868.88,,"Fee schedule rate ($36,868.88). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12606.23,36868.88,There are no additional notes associated with this service or procedure.
"Open Tx Metacarpal Fracture Single Ea Bone|LEFT HAND, FOURTH DIGIT",CASE-26615,APC,26615,CPT,0360,RC,,,F3,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,025,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],91631.33,,"Fee schedule rate ($91,631.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,13351.00,91631.33,There are no additional notes associated with this service or procedure.
TRAUMATIC INJURY WITH MCC,913,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],13014.58,,"Case rate ($13,014.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,242.79, add-ons for qualifying new technology services are included. If operating cost exceeds $47,113.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,569.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $10,260.01 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,297.84 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $809.62. The transfer capital threshold is the transfer adjustment factor * $809.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,13014.58,42838.46,Inpatient DRG
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],16035.06,,"Fee schedule rate ($16,035.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,7396.47,16035.06,There are no additional notes associated with this service or procedure.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,544,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],12346.51,,"Case rate ($7,055.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,698.86, add-ons for qualifying new technology services are included. If operating cost exceeds $41,569.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,133.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $4,736.45 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,753.92 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $373.75. The transfer capital threshold is the transfer adjustment factor * $373.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,7055.15,23207.64,All Other Inpatient
NORMAL NEWBORN,795,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],2576.52,,"Fee schedule rate ($2,576.52). Adds an outlier to normal pricing equal to the per diem rate ($414) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,1369.79,5771.52,There are no additional notes associated with this service or procedure.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC,099,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],25603.58,,"Fee schedule rate ($25,603.58). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.7), with a minimum of zero.",,,,0,other,11171.21,26807.94,There are no additional notes associated with this service or procedure.
MAJOR BLADDER PROCEDURES WITH MCC,653,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],10280.00,,"Per diem ($10,280). If length of stay < 9.5, first 1 days paid at a per diem of $20,560 instead. Capped at $97,655.95.",,,,0,other,10280.00,125343.98,Estimated amount calculated based on 10 day length of stay.
"Prq Skel Fixj Phlngl Shft Fx Prox/Middle Px/F/T|LEFT HAND, FOURTH DIGIT",CASE-26727,APC,26727,CPT,0360,RC,,,F3,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],13386.36,,"Case rate ($13,386.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,588.65, add-ons for qualifying new technology services are included. If operating cost exceeds $47,459.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,596.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $10,604.60 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,643.70 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $836.81. The transfer capital threshold is the transfer adjustment factor * $836.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,13386.36,33244.29,Inpatient DRG
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],33835.79,,"Fee schedule rate ($33,835.79). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,7000.00,33835.79,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],18137.75,,"Case rate ($17,782.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,677.93, add-ons for qualifying new technology services are included. If operating cost exceeds $51,548.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,918.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $14,678.86 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,732.98 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,158.31. The transfer capital threshold is the transfer adjustment factor * $1,158.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,17782.11,46523.26,Inpatient DRG
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,690,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],15212.93,,"Fee schedule rate ($15,212.93). Adds an outlier to normal pricing equal to the per diem rate ($36,758.78) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,7426.94,15928.53,There are no additional notes associated with this service or procedure.
MAJOR CHEST TRAUMA WITHOUT CC/MCC,185,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],7634.75,,"Case rate ($7,271.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,899.84, add-ons for qualifying new technology services are included. If operating cost exceeds $41,770.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,149.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,936.68 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,954.88 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $389.55. The transfer capital threshold is the transfer adjustment factor * $389.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7271.19,21771.61,Inpatient DRG
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],38508.74,,"Fee schedule rate ($38,508.74). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.6), with a minimum of zero.",,,,0,other,15821.59,40320.14,There are no additional notes associated with this service or procedure.
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],6965.00,,,,,,0,other,6965.00,36140.75,There are no additional notes associated with this service or procedure.
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],20297.68,,"Fee schedule rate ($20,297.68). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6965.00,21404.64,There are no additional notes associated with this service or procedure.
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],11133.98,,"Fee schedule rate ($11,133.98). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5919.29,13545.65,There are no additional notes associated with this service or procedure.
Arthrs Knee Abrasion Arthrp/Mlt Drlg/Microfx|RIGHT SIDE,CASE-29879,APC,29879,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],14586.15,,"Case rate ($13,891.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,058.63, add-ons for qualifying new technology services are included. If operating cost exceeds $47,929.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,633.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,072.85 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,113.68 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $873.76. The transfer capital threshold is the transfer adjustment factor * $873.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13891.57,34712.20,Inpatient DRG
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],26966.33,,"Fee schedule rate ($26,966.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,9040.72,26966.33,There are no additional notes associated with this service or procedure.
HC Joint Injection/Aspir Large WO US|PBB CHARGE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-20610,APC,20610,CPT,0510,RC,,,PBB|XU,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],29917.96,,"Fee schedule rate ($29,917.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,12527.66,29917.96,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC,817,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],17396.11,,"Case rate ($17,396.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,318.84, add-ons for qualifying new technology services are included. If operating cost exceeds $51,189.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,890.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $14,321.08 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,373.88 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,130.07. The transfer capital threshold is the transfer adjustment factor * $1,130.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,17396.11,44895.04,Inpatient DRG
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC",514,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],22699.91,,"Fee schedule rate ($22,699.91). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8868.04,22699.91,There are no additional notes associated with this service or procedure.
Esophagogastroduodenoscopy Submucosal Injection,CASE-43236,APC,43236,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],848.96,,"APC Price ($848.96). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,848.96,891.41,OPPS APC
CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC,788,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],8606.78,,"Case rate ($8,438.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,985.31, add-ons for qualifying new technology services are included. If operating cost exceeds $42,856.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,234.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,018.17 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,040.36 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $474.89. The transfer capital threshold is the transfer adjustment factor * $474.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,8438.02,20142.33,Inpatient DRG
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],14803.72,,"Case rate ($14,098.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,251.41, add-ons for qualifying new technology services are included. If operating cost exceeds $48,122.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,648.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $11,264.92 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,306.46 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $888.91. The transfer capital threshold is the transfer adjustment factor * $888.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7332.00,35314.31,Inpatient DRG
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],22358.90,,"Fee schedule rate ($22,358.90). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9389.48,22358.90,There are no additional notes associated with this service or procedure.
CERVICAL SPINAL FUSION WITH CC,472,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],57970.41,,,,,,0,other,21896.13,70198.84,There are no additional notes associated with this service or procedure.
SINGLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL,402,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],29172.05,,"Case rate ($29,172.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $27,273.75, add-ons for qualifying new technology services are included. If operating cost exceeds $62,144.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,751.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $25,235.76 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $25,328.80 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,991.35. The transfer capital threshold is the transfer adjustment factor * $1,991.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,29172.05,124455.45,Inpatient DRG
Laparoscopic Appendectomy|UNUSUAL NON-OVERLAPPING SERVICE,CASE-44970,APC,44970,CPT,0360,RC,,,XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5856.81,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5658.76,5941.70,OPPS APC
Injection Aa&/Strd Ilioinguinal Ih Nerves,CASE-64425,APC,64425,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],683.85,,"APC Price ($660.72). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,660.72,693.76,OPPS APC
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],19244.88,,"Case rate ($18,594.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,433.29, add-ons for qualifying new technology services are included. If operating cost exceeds $52,304.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,977.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $15,431.44 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,488.34 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,217.69. The transfer capital threshold is the transfer adjustment factor * $1,217.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,18594.09,59494.91,Inpatient DRG
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],9135.90,,"Case rate ($8,956.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,467.88, add-ons for qualifying new technology services are included. If operating cost exceeds $43,338.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,272.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $6,498.97 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,522.93 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $512.83. The transfer capital threshold is the transfer adjustment factor * $512.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,8956.76,28983.97,Inpatient DRG
Neuroplasty &/Transpos Median Nrv Carpal Tunne|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64721,APC,64721,CPT,0360,RC,,,LT|XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6791.99,7131.59,OPPS APC
Laparoscopy Tot Hysterectomy >250 G W/Tube/Ovar,CASE-58573,APC,58573,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],9949.78,,"APC Price ($9,949.78). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,9949.78,10447.27,OPPS APC
Hrhc Ntrnl & Xtrnl 2/> Column/Group W/Fissu,CASE-46261,APC,46261,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],2598.08,,"APC Price ($2,598.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2598.08,2727.99,OPPS APC
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,418,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],39884.93,,"Fee schedule rate ($39,884.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,13400.58,39884.93,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,064,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],39570.45,,,,,,0,other,15563.58,41838.16,There are no additional notes associated with this service or procedure.
HC Biopsy of Vulva/Perineum,CASE-56605,APC,56605,CPT,0361,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],905.23,,"APC Price ($862.13). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,862.13,905.23,OPPS APC
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],20938.30,,,,,,0,other,9151.11,30245.71,There are no additional notes associated with this service or procedure.
CERVICAL SPINAL FUSION WITHOUT CC/MCC,473,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],45879.35,,"Fee schedule rate ($45,879.35). Adds an outlier to normal pricing equal to the per diem rate ($58,401.78) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,18477.61,62077.11,There are no additional notes associated with this service or procedure.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",063,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],27622.57,,,,,,0,other,6965.00,35701.87,There are no additional notes associated with this service or procedure.
Cystourethroscopy|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-52000,APC,52000,CPT,0360,RC,,,74,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],675.53,,"APC Price ($652.69). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,652.69,685.32,OPPS APC
NEONATE WITH OTHER SIGNIFICANT PROBLEMS,794,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],3383.58,,"Fee schedule rate ($3,383.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,1798.85,12536.83,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],75545.91,,,,,,0,other,27944.96,86252.84,There are no additional notes associated with this service or procedure.
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],38210.55,,"Fee schedule rate ($38,210.55). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,21489.15,68942.79,There are no additional notes associated with this service or procedure.
BRONCHITIS AND ASTHMA WITH CC/MCC,202,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],14307.27,,"Fee schedule rate ($14,307.27). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7606.34,19110.30,There are no additional notes associated with this service or procedure.
PSYCHOSES,885,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],26250.06,,"Fee schedule rate ($26,250.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15.8), with a minimum of zero.",,,,0,other,2070.00,27484.83,There are no additional notes associated with this service or procedure.
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],18217.52,,"Fee schedule rate ($18,217.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7414.07,18217.52,There are no additional notes associated with this service or procedure.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],9367.05,,"Fee schedule rate ($9,367.05). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8151.55,18033.97,There are no additional notes associated with this service or procedure.
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,450,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],146009.19,,"Fee schedule rate ($146,009.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,38037.38,146009.19,There are no additional notes associated with this service or procedure.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC,434,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6959.74,,"Case rate ($6,628.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,310.53, add-ons for qualifying new technology services are included. If operating cost exceeds $41,181.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,094.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,349.09 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,365.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $334.28. The transfer capital threshold is the transfer adjustment factor * $334.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6770.05,14019.86,Inpatient DRG
Neuroplasty &/Transposition Ulnar Nerve Elbow|UNUSUAL NON-OVERLAPPING SERVICE|LEFT SIDE,CASE-64718,APC,64718,CPT,0360,RC,,,XU|LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],9331.88,,"Case rate ($8,887.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,416.42, add-ons for qualifying new technology services are included. If operating cost exceeds $43,287.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,255.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,447.03 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,471.47 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $495.53. The transfer capital threshold is the transfer adjustment factor * $495.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9097.60,21455.22,Inpatient DRG
FRACTURES OF FEMUR WITH MCC,533,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],49490.05,,"Fee schedule rate ($49,490.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,6852.00,49490.05,There are no additional notes associated with this service or procedure.
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],16438.59,,"Fee schedule rate ($16,438.59). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7402.56,16438.59,There are no additional notes associated with this service or procedure.
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],11811.40,,"Fee schedule rate ($11,811.40). Adds an outlier to normal pricing equal to the per diem rate ($53,248.69) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.7), with a minimum of zero.",,,,0,other,5937.41,12366.99,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],14871.83,,"Fee schedule rate ($14,871.83). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6558.75,14871.83,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,447,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],156646.82,,"Fee schedule rate ($156,646.82). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,47193.21,156646.82,There are no additional notes associated with this service or procedure.
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],22955.40,,"Case rate ($21,862.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,473.63, add-ons for qualifying new technology services are included. If operating cost exceeds $55,344.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,216.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. The base transfer operating payment is the transfer adjustment factor * $18,460.61 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,528.68 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,456.72. The transfer capital threshold is the transfer adjustment factor * $1,456.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7086.00,57872.02,Inpatient DRG
"LIMB REATTACHMENT, HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA",956,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],70718.06,,"Fee schedule rate ($70,718.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,27428.25,148259.86,There are no additional notes associated with this service or procedure.
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],29497.93,,"Case rate ($28,093.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $26,270.18, add-ons for qualifying new technology services are included. If operating cost exceeds $61,141.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,672.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $24,235.87 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $24,325.23 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,912.45. The transfer capital threshold is the transfer adjustment factor * $1,912.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,10078.00,81454.07,Inpatient DRG
Septoplasty/Submucous Resecj W/WO Cartilage Grf|BILATERAL PROCEDURE,CASE-30520,APC,30520,CPT,0360,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6936.25,,"APC Price ($6,605.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6605.95,6936.25,OPPS APC
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH CC,427,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],50829.82,,"Case rate ($50,829.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $47,421.51, add-ons for qualifying new technology services are included. If operating cost exceeds $82,292.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $5,335.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $45,309.50 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $45,476.56 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,575.37. The transfer capital threshold is the transfer adjustment factor * $3,575.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,50829.82,142040.39,Inpatient DRG
O.R. PROCEDURES FOR OBESITY WITH CC,620,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],43753.50,,"Fee schedule rate ($43,753.50). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12782.30,43753.50,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],8318.14,,"Case rate ($8,318.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,873.80, add-ons for qualifying new technology services are included. If operating cost exceeds $42,744.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,226.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,907.07 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,928.85 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $466.13. The transfer capital threshold is the transfer adjustment factor * $466.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8318.14,19763.43,Inpatient DRG
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],12795.84,,"Case rate ($12,795.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,039.30, add-ons for qualifying new technology services are included. If operating cost exceeds $46,910.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,553.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $10,057.27 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,094.35 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $793.62. The transfer capital threshold is the transfer adjustment factor * $793.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12795.84,41944.25,Inpatient DRG
Colonoscopy Flx Dx W/Collj Spec When Pfrmd,CASE-45378,APC,45378,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],900.93,,"APC Price ($870.46). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,870.46,913.99,OPPS APC
Egd Intrmural US Needle Aspirate/Biopsy Esophags|REDUCED SERVICES,CASE-43238,APC,43238,CPT,0360,RC,,,52,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1796.14,,"APC Price ($1,796.14). Discounted by 50%. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1796.14,1885.95,OPPS APC
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,345,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],28277.83,,"Fee schedule rate ($28,277.83). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12134.89,33616.03,There are no additional notes associated with this service or procedure.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC",494,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],21236.71,,"Fee schedule rate ($21,236.71). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,15533.10,39945.55,There are no additional notes associated with this service or procedure.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],13647.09,,"Case rate ($13,647.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,831.20, add-ons for qualifying new technology services are included. If operating cost exceeds $47,702.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,615.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $10,846.26 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,886.25 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $855.88. The transfer capital threshold is the transfer adjustment factor * $855.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7921.00,45706.73,Inpatient DRG
Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn,CASE-62323,APC,62323,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],660.72,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,660.72,693.76,OPPS APC
SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS,029,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],61889.56,,"Fee schedule rate ($61,889.56). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13641.00,67130.05,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],28756.63,,"Fee schedule rate ($28,756.63). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,13148.66,32553.63,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],59891.41,,"Fee schedule rate ($59,891.41). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15), with a minimum of zero.",,,,0,other,23526.87,94787.57,There are no additional notes associated with this service or procedure.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],19877.10,,"Fee schedule rate ($19,877.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8009.34,19877.10,There are no additional notes associated with this service or procedure.
"OPEN CRANIOTOMY EXCEPT TRAUMA,MODERATE",021,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],32400.67,,"Case rate ($30,857.78). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,30857.78,32400.67,There are no additional notes associated with this service or procedure.
Rpr 1st Ingun Hrna Age 5 Yrs/> Incarcerated|RIGHT SIDE,CASE-49507,APC,49507,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3351.34,,"APC Price ($3,351.34). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3351.34,3518.91,OPPS APC
MINOR BLADDER PROCEDURES WITHOUT CC/MCC,664,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],31876.87,,"Fee schedule rate ($31,876.87). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9034.63,31876.87,There are no additional notes associated with this service or procedure.
Trachelectomy Cervicectomy Amp Cervix Spx,CASE-57530,APC,57530,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],4916.53,,"APC Price ($4,682.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,4682.41,4916.53,OPPS APC
"EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME, NEONATE",790,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],3054.00,,,,,,0,other,3054.00,44304.49,Estimated amount calculated based on 17 day length of stay.
OTHER MENTAL DISORDER DIAGNOSES,887,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],6965.00,,,,,,0,other,2070.00,21072.10,There are no additional notes associated with this service or procedure.
Sphincterotomy Anal Division Sphincter Spx,CASE-46080,APC,46080,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],2689.02,,"APC Price ($2,598.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2598.08,2727.99,OPPS APC
Nerve Repair W/Nerve Allograft First Strand|LEFT SIDE,CASE-64912,APC,64912,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],8214.41,,"APC Price ($8,214.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,8214.41,8625.13,OPPS APC
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC,519,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],50780.20,,"Fee schedule rate ($50,780.20). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,15490.44,50780.20,There are no additional notes associated with this service or procedure.
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],13478.34,,"Fee schedule rate ($13,478.34). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,6801.88,22557.82,There are no additional notes associated with this service or procedure.
"Inj Dx/Ther Agnt Paravert Facet Joint, Cerv/Thorac, Add Level",CASE-64492,APC,64492,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],869.28,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,827.89,869.28,OPPS APC
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,074,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],20919.08,,"Fee schedule rate ($20,919.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8925.60,20919.08,There are no additional notes associated with this service or procedure.
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],15821.59,,"Case rate ($15,821.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,854.10, add-ons for qualifying new technology services are included. If operating cost exceeds $49,725.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,774.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $12,861.73 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,909.15 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,014.92. The transfer capital threshold is the transfer adjustment factor * $1,014.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,15821.59,40320.14,Inpatient DRG
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],29243.52,,"Fee schedule rate ($29,243.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,14343.25,36024.65,There are no additional notes associated with this service or procedure.
HC Joint Injection/Aspir Medium WO US|PBB CHARGE|RIGHT SIDE,CASE-20605,APC,20605,CPT,0510,RC,,,PBB|RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],301.68,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,287.31,301.68,OPPS APC
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC,519,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],39357.94,,,,,,0,other,15490.44,50780.20,There are no additional notes associated with this service or procedure.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,418,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],23451.02,,"Case rate ($13,400.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,601.88, add-ons for qualifying new technology services are included. If operating cost exceeds $47,472.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,597.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $10,617.79 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,656.93 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $837.85. The transfer capital threshold is the transfer adjustment factor * $837.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,13400.58,39884.93,All Other Inpatient
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],14523.60,,"Fee schedule rate ($14,523.60). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10120.20,26204.74,There are no additional notes associated with this service or procedure.
HC >= 12 Lead Ekg|ADJ,CASE-93005,APC,93005,CPT,0730,RC,,,ADJ,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],128.98,,"APC Price ($124.62). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,124.62,130.85,OPPS APC
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC",629,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],44657.18,,"Fee schedule rate ($44,657.18). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,16699.94,44657.18,There are no additional notes associated with this service or procedure.
DIABETES WITH MCC,637,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],28655.62,,,,,,0,other,9959.03,28655.62,There are no additional notes associated with this service or procedure.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,761,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],11946.72,,"Fee schedule rate ($11,946.72). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,5808.41,11946.72,There are no additional notes associated with this service or procedure.
"OTHER DIGESTIVE SYSTEM AND ABDOMINAL PROCEDURES,MODERATE",229,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],3530.98,,"Case rate for a one day stay ($3,362.84). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,3362.84,3530.98,There are no additional notes associated with this service or procedure.
Int Hrhc by Ligation Single Hroid W/O Img Gdn,CASE-46945,APC,46945,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],2598.08,,"APC Price ($2,598.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2598.08,2727.99,OPPS APC
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],13625.25,,"Fee schedule rate ($13,625.25). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7243.75,23262.15,There are no additional notes associated with this service or procedure.
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],5995.74,,"Case rate ($5,710.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,447.70, add-ons for qualifying new technology services are included. If operating cost exceeds $40,318.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,035.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $3,489.88 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,502.75 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $275.39. The transfer capital threshold is the transfer adjustment factor * $275.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,3079.00,10940.41,Inpatient DRG
Injection Aa&/Strd Genicular Nrv Branches W/Img|RIGHT SIDE,CASE-64454,APC,64454,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],683.85,,"APC Price ($660.72). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,660.72,693.76,OPPS APC
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],7944.77,,"Case rate ($7,566.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,174.51, add-ons for qualifying new technology services are included. If operating cost exceeds $42,045.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,171.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,210.35 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,229.56 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $411.15. The transfer capital threshold is the transfer adjustment factor * $411.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7566.45,16333.88,Inpatient DRG
"Decompress Spinal Cord,1 Seg|LEFT SIDE",CASE-63056,APC,63056,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6791.99,7131.59,OPPS APC
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],39053.73,,"Fee schedule rate ($39,053.73). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,16017.99,51903.64,There are no additional notes associated with this service or procedure.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],45933.85,,"Fee schedule rate ($45,933.85). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,18497.24,62041.12,There are no additional notes associated with this service or procedure.
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,068,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],7954.70,,"Case rate ($7,798.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,390.60, add-ons for qualifying new technology services are included. If operating cost exceeds $42,261.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,188.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $5,425.64 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,445.65 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $428.14. The transfer capital threshold is the transfer adjustment factor * $428.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6965.00,23184.90,Inpatient DRG
"Corrj Hallux Valgus W/Sesmdc W/Dist Metar Osteot|RIGHT FOOT, GREAT TOE",CASE-28296,APC,28296,CPT,0360,RC,,,T5,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],54086.17,,,,,,0,other,20559.34,54086.17,There are no additional notes associated with this service or procedure.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],11060.65,,"Case rate ($10,533.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,935.13, add-ons for qualifying new technology services are included. If operating cost exceeds $44,806.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,388.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $7,960.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,990.18 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $628.19. The transfer capital threshold is the transfer adjustment factor * $628.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10533.95,24956.34,Inpatient DRG
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],59610.47,,"Fee schedule rate ($59,610.47). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,16129.04,59610.47,There are no additional notes associated with this service or procedure.
HC Inj Aa&/Strd Greater Occipital Nerve|RIGHT SIDE,CASE-64405,APC,64405,CPT,0450,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],50821.76,,,,,,0,other,19435.86,50821.76,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,167,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],35485.50,,,,,,0,other,14157.71,43522.37,There are no additional notes associated with this service or procedure.
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],9696.93,,"Case rate ($9,696.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,156.46, add-ons for qualifying new technology services are included. If operating cost exceeds $44,027.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,326.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $7,185.02 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,211.51 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $566.97. The transfer capital threshold is the transfer adjustment factor * $566.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9696.93,35061.53,Inpatient DRG
Arthrd Ant Ntrbd Min Dsc Ea Addl Interspace,CASE-22585,APC,22585,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],12437.92,,"APC Price ($12,017.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,12437.92,12618.18,OPPS APC
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,690,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],15212.93,,"Fee schedule rate ($15,212.93). Adds an outlier to normal pricing equal to the per diem rate ($36,758.78) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,7426.94,15928.53,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],7353.00,,"Per diem ($7,353). If length of stay < 4.1, first 1 days paid at a per diem of $14,706 instead. Capped at $30,145.85.",,,,0,other,7353.00,33398.16,Estimated amount calculated based on 4 day length of stay.
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC,520,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],39786.42,,"Fee schedule rate ($39,786.42). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12061.74,39786.42,There are no additional notes associated with this service or procedure.
Breast Reduction|LEFT SIDE,CASE-19318,APC,19318,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6215.36,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6215.36,6215.36,OPPS APC
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],17280.71,,"Case rate ($16,457.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,473.04, add-ons for qualifying new technology services are included. If operating cost exceeds $50,344.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,795.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $13,476.99 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,528.09 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,035.87. The transfer capital threshold is the transfer adjustment factor * $1,035.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,16897.01,43444.85,Inpatient DRG
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],24444.75,,"Fee schedule rate ($24,444.75). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10136.44,24444.75,There are no additional notes associated with this service or procedure.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],105091.76,,"Fee schedule rate ($105,091.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,35719.96,105091.76,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],15110.95,,"Fee schedule rate ($15,110.95). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11059.47,28423.20,There are no additional notes associated with this service or procedure.
Unlisted Laparoscopy Procedure Oviduct Ovary,CASE-58679,APC,58679,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5658.76,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5658.76,5941.70,OPPS APC
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],11276.95,,"Case rate ($10,895.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,271.55, add-ons for qualifying new technology services are included. If operating cost exceeds $45,142.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,414.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $8,296.01 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,326.60 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $654.64. The transfer capital threshold is the transfer adjustment factor * $654.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,10895.60,35192.25,Inpatient DRG
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],17365.00,,"Fee schedule rate ($17,365.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5683.00,19635.68,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],15808.67,,"Fee schedule rate ($15,808.67). Adds an outlier to normal pricing equal to the per diem rate ($67,650.85) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,7641.61,19371.27,There are no additional notes associated with this service or procedure.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC,434,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],13280.45,,"Fee schedule rate ($13,280.45). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6770.05,14019.86,There are no additional notes associated with this service or procedure.
MINOR BLADDER PROCEDURES WITHOUT CC/MCC,664,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],31876.87,,"Fee schedule rate ($31,876.87). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9034.63,31876.87,There are no additional notes associated with this service or procedure.
Colon Ca Scrn Not Hi Rsk Ind,CASE-G0121,APC,G0121,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],870.46,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,870.46,913.99,OPPS APC
TRAUMATIC INJURY WITH MCC,913,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],13470.09,,"Case rate ($13,014.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,242.79, add-ons for qualifying new technology services are included. If operating cost exceeds $47,113.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,569.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $10,260.01 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,297.84 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $809.62. The transfer capital threshold is the transfer adjustment factor * $809.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,13014.58,42838.46,Inpatient DRG
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC,519,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],37589.76,,"Fee schedule rate ($37,589.76). Adds an outlier to normal pricing equal to the per diem rate ($123,674.40) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,15490.44,50780.20,There are no additional notes associated with this service or procedure.
Excision Hydrocele Unilateral|RIGHT SIDE,CASE-55040,APC,55040,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3351.34,,"APC Price ($3,351.34). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3351.34,3518.91,OPPS APC
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],23899.13,,"Fee schedule rate ($23,899.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9795.13,23899.13,There are no additional notes associated with this service or procedure.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,988,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],13386.01,,"Case rate ($12,748.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,015.50, add-ons for qualifying new technology services are included. If operating cost exceeds $46,886.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,531.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $10,032.51 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,070.55 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $771.12. The transfer capital threshold is the transfer adjustment factor * $771.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13075.52,42425.46,Inpatient DRG
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC,797,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],20928.55,,"Fee schedule rate ($20,928.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8719.72,20928.55,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],30372.64,,"Fee schedule rate ($30,372.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,13260.40,32878.30,There are no additional notes associated with this service or procedure.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],44847.62,,"Fee schedule rate ($44,847.62). Adds an outlier to normal pricing equal to the per diem rate ($79,031.36) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,18105.81,52699.33,There are no additional notes associated with this service or procedure.
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],22557.82,,"Fee schedule rate ($22,557.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6801.88,22557.82,There are no additional notes associated with this service or procedure.
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],8460.30,,"Case rate ($8,057.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,631.26, add-ons for qualifying new technology services are included. If operating cost exceeds $42,502.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,207.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,665.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,686.30 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $447.06. The transfer capital threshold is the transfer adjustment factor * $447.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6524.00,17760.46,Inpatient DRG
Bx/Exc Lymph Node Open Deep Cervical Node|LEFT SIDE,CASE-38510,APC,38510,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5541.10,,"APC Price ($5,541.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5541.10,5818.16,OPPS APC
HC Biopsy of Vulva/Perineum,CASE-56605,APC,56605,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],862.13,,"APC Price ($862.13). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,862.13,905.23,OPPS APC
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",004,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],10715.36,,,,,,0,other,10249.47,272554.00,Estimated amount calculated based on 6 day length of stay.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],12990.19,,"Case rate ($12,990.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,220.11, add-ons for qualifying new technology services are included. If operating cost exceeds $47,091.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,567.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $10,237.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,275.16 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $807.83. The transfer capital threshold is the transfer adjustment factor * $807.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9888.00,43399.23,Inpatient DRG
"ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",770,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],9865.80,,"Fee schedule rate ($9,865.80). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,8735.30,19730.13,There are no additional notes associated with this service or procedure.
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],27982.66,,,,,,0,other,11575.50,48961.48,There are no additional notes associated with this service or procedure.
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],22557.82,,"Fee schedule rate ($22,557.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6801.88,22557.82,There are no additional notes associated with this service or procedure.
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6010.23,,"Case rate ($6,010.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,726.79, add-ons for qualifying new technology services are included. If operating cost exceeds $40,597.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,057.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,767.95 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,781.84 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $297.33. The transfer capital threshold is the transfer adjustment factor * $297.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6010.23,12246.05,Inpatient DRG
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],33221.97,,"Fee schedule rate ($33,221.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (47), with a minimum of zero.",,,,0,other,15283.90,38757.79,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC,084,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],19445.16,,"Fee schedule rate ($19,445.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,6965.00,19445.16,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],12818.71,,"Fee schedule rate ($12,818.71). Adds an outlier to normal pricing equal to the per diem rate ($42,942.49) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,6564.18,17651.07,There are no additional notes associated with this service or procedure.
Arthrodesis Cmbn Tq 1ntrspc Each Additional,CASE-22634,APC,22634,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],26668.00,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,25398.09,26668.00,OPPS APC
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],9755.86,,"Case rate ($9,755.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,211.27, add-ons for qualifying new technology services are included. If operating cost exceeds $44,082.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,331.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $7,239.63 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,266.32 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $571.28. The transfer capital threshold is the transfer adjustment factor * $571.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9755.86,29216.99,Inpatient DRG
OTHER DISORDERS OF THE EYE WITHOUT MCC,125,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],7501.77,,"Case rate ($7,144.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,782.02, add-ons for qualifying new technology services are included. If operating cost exceeds $41,653.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,140.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,819.30 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,837.07 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $380.29. The transfer capital threshold is the transfer adjustment factor * $380.29. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7144.54,17952.29,Inpatient DRG
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12418.38,,"Case rate ($11,827.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,156.48, add-ons for qualifying new technology services are included. If operating cost exceeds $46,027.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,465.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $9,176.73 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,211.53 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $705.35. The transfer capital threshold is the transfer adjustment factor * $705.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12126.09,29582.40,Inpatient DRG
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],14344.60,,"Case rate ($14,344.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,480.09, add-ons for qualifying new technology services are included. If operating cost exceeds $48,351.10 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,666.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $11,492.77 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,535.14 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $906.89. The transfer capital threshold is the transfer adjustment factor * $906.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,14344.60,36028.59,Inpatient DRG
FULL TERM NEONATE WITH MAJOR PROBLEMS,793,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],82045.22,,,,,,0,other,4302.90,82045.22,There are no additional notes associated with this service or procedure.
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],6965.00,,,,,,0,other,6965.00,21404.64,There are no additional notes associated with this service or procedure.
HC Remove Lung Catheter,CASE-32552,APC,32552,CPT,0361,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],891.41,,"APC Price ($848.96). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,848.96,891.41,OPPS APC
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],21354.82,,"Fee schedule rate ($21,354.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6834.39,21354.82,There are no additional notes associated with this service or procedure.
Gastroenterology Procedure,CASE-91299,APC,91299,CPT,0750,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],120.44,,"APC Price ($120.44). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,120.44,126.46,OPPS APC
SALIVARY GLAND PROCEDURES,139,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],30690.92,,"Fee schedule rate ($30,690.92). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,10313.19,30690.92,There are no additional notes associated with this service or procedure.
Cysto W/Ureteroscopy W/Rmvl/Manj Stones,CASE-52352,APC,52352,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3299.47,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3299.47,3464.44,OPPS APC
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,477,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],26606.73,,"Case rate ($25,339.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $23,708.63, add-ons for qualifying new technology services are included. If operating cost exceeds $58,579.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,471.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 8.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $21,683.73 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $21,763.68 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,711.06. The transfer capital threshold is the transfer adjustment factor * $1,711.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,25339.74,67976.16,Inpatient DRG
Prq Impltj Neurostim Eltrd Sacral Nrve W/Imaging,CASE-64561,APC,64561,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5965.28,,"APC Price ($5,965.28). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5965.28,6263.54,OPPS APC
Laparoscopic Appendectomy,CASE-44970,APC,44970,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5658.76,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5658.76,5941.70,OPPS APC
"Open Tx Phalangeal Shaft Fracture Prox/Middle Ea|RIGHT HAND, FIFTH DIGIT",CASE-26735,APC,26735,CPT,0360,RC,,,F9,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6791.99,7131.59,OPPS APC
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],14309.17,,"Fee schedule rate ($14,309.17). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,17467.27,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],30398.48,,"Case rate ($30,398.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $28,414.67, add-ons for qualifying new technology services are included. If operating cost exceeds $63,285.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,841.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.2. The base transfer operating payment is the transfer adjustment factor * $26,372.48 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $26,469.72 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,081.05. The transfer capital threshold is the transfer adjustment factor * $2,081.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,30398.48,82674.88,Inpatient DRG
"CESAREAN SECTION WITHOUT STERILIZATION,MINOR",540,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],6211.03,,"Case rate ($6,211.03). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,6211.03,6521.58,There are no additional notes associated with this service or procedure.
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],2070.00,,,,,,0,other,1188.00,31658.33,Estimated amount calculated based on 16 day length of stay.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,988,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],22882.16,,"Case rate ($13,075.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,299.49, add-ons for qualifying new technology services are included. If operating cost exceeds $47,170.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,574.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $10,316.50 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,354.54 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $814.07. The transfer capital threshold is the transfer adjustment factor * $814.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,13075.52,42425.46,All Other Inpatient
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],16235.87,,"Fee schedule rate ($16,235.87). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6524.00,17760.46,There are no additional notes associated with this service or procedure.
"Inj Dx/Ther Agnt Paravert Facet Joint, Lumbar/Sac, Add Level",CASE-64495,APC,64495,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],869.28,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,827.89,869.28,OPPS APC
Laps Fulg/Exc Ovary Viscera/Peritoneal Surface,CASE-58662,APC,58662,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5856.81,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5658.76,5941.70,OPPS APC
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],11325.13,,"Case rate ($10,785.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,185.94, add-ons for qualifying new technology services are included. If operating cost exceeds $45,056.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,391.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $8,209.86 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,240.99 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $631.03. The transfer capital threshold is the transfer adjustment factor * $631.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,11053.39,36776.05,Inpatient DRG
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,447,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],125567.31,,"Fee schedule rate ($125,567.31). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15.7), with a minimum of zero.",,,,0,other,47193.21,156646.82,There are no additional notes associated with this service or procedure.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],32547.95,,"Case rate ($18,598.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,437.70, add-ons for qualifying new technology services are included. If operating cost exceeds $52,308.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,978.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 5.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $15,435.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,492.75 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,218.04. The transfer capital threshold is the transfer adjustment factor * $1,218.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,18598.83,48389.68,All Other Inpatient
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],51630.84,,"Fee schedule rate ($51,630.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,20559.34,54086.17,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC,084,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],19445.16,,"Fee schedule rate ($19,445.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,6965.00,19445.16,There are no additional notes associated with this service or procedure.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],18105.81,,"Case rate ($18,105.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,979.06, add-ons for qualifying new technology services are included. If operating cost exceeds $51,850.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,941.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $14,978.89 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,034.11 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,181.98. The transfer capital threshold is the transfer adjustment factor * $1,181.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,18105.81,52699.33,Inpatient DRG
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],29585.82,,"Fee schedule rate ($29,585.82). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12606.23,36868.88,There are no additional notes associated with this service or procedure.
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],33781.47,,,,,,0,other,13571.25,33781.47,There are no additional notes associated with this service or procedure.
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],16737.83,,"Case rate ($15,940.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,964.98, add-ons for qualifying new technology services are included. If operating cost exceeds $49,835.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,783.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $12,972.20 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,020.03 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,023.63. The transfer capital threshold is the transfer adjustment factor * $1,023.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,15940.79,53275.26,Inpatient DRG
VENTRICULAR SHUNT PROCEDURES WITH MCC,031,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],62406.76,,"Fee schedule rate ($62,406.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,32287.20,88162.80,There are no additional notes associated with this service or procedure.
Egd Dilation Gastric/Duodenal Stricture,CASE-43245,APC,43245,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1859.01,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1796.14,1885.95,OPPS APC
"Amputation Toe Interphalangeal Joint|RIGHT FOOT, SECOND DIGIT",CASE-28825,APC,28825,CPT,0360,RC,,,T6,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
Injection Aa&/Strd Genicular Nrv Branches W/Img|LEFT SIDE,CASE-64454,APC,64454,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],683.85,,"APC Price ($660.72). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,660.72,693.76,OPPS APC
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],13001.72,,"Case rate ($13,001.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,230.82, add-ons for qualifying new technology services are included. If operating cost exceeds $47,101.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,568.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $10,248.08 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,285.87 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $808.68. The transfer capital threshold is the transfer adjustment factor * $808.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7868.00,32126.64,Inpatient DRG
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],38517.10,,"Fee schedule rate ($38,517.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,16897.01,43444.85,There are no additional notes associated with this service or procedure.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],7921.00,,"Per diem ($7,921). If length of stay < 4.1, first 1 days paid at a per diem of $15,842 instead. Capped at $32,474.30.",,,,0,other,7921.00,45706.73,Estimated amount calculated based on 2 day length of stay.
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],14055.68,,"Case rate ($13,386.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,588.65, add-ons for qualifying new technology services are included. If operating cost exceeds $47,459.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,596.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $10,604.60 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,643.70 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $836.81. The transfer capital threshold is the transfer adjustment factor * $836.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13386.36,33244.29,Inpatient DRG
PREMATURITY WITHOUT MAJOR PROBLEMS,792,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],5900.00,,,,,,0,other,1956.00,19457.66,There are no additional notes associated with this service or procedure.
MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,708,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],27860.62,,"Fee schedule rate ($27,860.62). Adds an outlier to normal pricing equal to the per diem rate ($54,966.40) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10138.21,29171.15,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6744.39,,"Case rate ($6,423.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,119.36, add-ons for qualifying new technology services are included. If operating cost exceeds $40,990.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,079.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $4,158.65 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,174.41 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $319.64. The transfer capital threshold is the transfer adjustment factor * $319.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6558.75,14871.83,Inpatient DRG
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],15122.13,,"Case rate ($14,610.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,727.68, add-ons for qualifying new technology services are included. If operating cost exceeds $48,598.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,686.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.6. The base transfer operating payment is the transfer adjustment factor * $11,739.44 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,782.73 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $926.36. The transfer capital threshold is the transfer adjustment factor * $926.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6277.00,36801.89,Inpatient DRG
NON-MALIGNANT BREAST DISORDERS WITH CC/MCC,600,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],15046.13,,"Fee schedule rate ($15,046.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7999.14,20495.56,There are no additional notes associated with this service or procedure.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC",061,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],21647.04,,"Case rate ($20,616.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $19,314.45, add-ons for qualifying new technology services are included. If operating cost exceeds $54,185.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,125.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $17,305.68 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $17,369.49 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,365.59. The transfer capital threshold is the transfer adjustment factor * $1,365.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,20616.23,62315.82,Inpatient DRG
FULL TERM NEONATE WITH MAJOR PROBLEMS,793,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],30820.00,,"Case rate ($29,352.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $27,492.63, add-ons for qualifying new technology services are included. If operating cost exceeds $62,363.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,716.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $25,451.18 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $25,547.68 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,956.24. The transfer capital threshold is the transfer adjustment factor * $1,956.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,4302.90,82045.22,Inpatient DRG
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],81353.66,,"Fee schedule rate ($81,353.66). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,27256.92,81353.66,There are no additional notes associated with this service or procedure.
Parathyroidectomy/Exploration Parathyroids|SEPARATE STRUCTURE|RIGHT SIDE,CASE-60500,APC,60500,CPT,0360,RC,,,XS|RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],10447.27,,"APC Price ($9,949.78). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,9949.78,10447.27,OPPS APC
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],78960.67,,"Fee schedule rate ($78,960.67). Adds an outlier to normal pricing equal to the per diem rate ($149,567.78) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19.1), with a minimum of zero.",,,,0,other,30398.48,82674.88,There are no additional notes associated with this service or procedure.
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITHOUT CC/MCC",630,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],42541.02,,"Fee schedule rate ($42,541.02). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11828.78,42541.02,There are no additional notes associated with this service or procedure.
SALIVARY GLAND PROCEDURES,139,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],24314.87,,,,,,0,other,10313.19,30690.92,There are no additional notes associated with this service or procedure.
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],24332.75,,"Case rate ($13,904.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,070.60, add-ons for qualifying new technology services are included. If operating cost exceeds $47,941.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,634.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,084.78 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,125.65 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $874.70. The transfer capital threshold is the transfer adjustment factor * $874.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,13904.43,34749.58,All Other Inpatient
HC Biopsy/Exc Lymph Node Needle|RIGHT SIDE,CASE-38505,APC,38505,CPT,0361,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1600.04,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1545.93,1623.23,OPPS APC
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,085,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],17677.02,,"Case rate ($17,330.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,257.72, add-ons for qualifying new technology services are included. If operating cost exceeds $51,128.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,885.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $14,260.20 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,312.77 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,125.27. The transfer capital threshold is the transfer adjustment factor * $1,125.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,9282.00,57443.16,Inpatient DRG
Laps Surg Rpr Recurrent Inguinal Hernia|RIGHT SIDE,CASE-49651,APC,49651,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5658.76,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5658.76,5941.70,OPPS APC
Unlisted Laparoscopy Px Abd Pertoneum & Omentum,CASE-49329,APC,49329,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5856.81,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5658.76,5856.81,OPPS APC
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],31005.49,,"Fee schedule rate ($31,005.49). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,16286.16,58320.32,There are no additional notes associated with this service or procedure.
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],11812.10,,,,,,0,other,6010.23,12246.05,There are no additional notes associated with this service or procedure.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],51630.84,,"Fee schedule rate ($51,630.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,20559.34,54086.17,There are no additional notes associated with this service or procedure.
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC",923,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],20068.57,,,,,,0,other,6965.00,20068.57,There are no additional notes associated with this service or procedure.
"Tendon Sheath Incision|LEFT FOOT, GREAT TOE",CASE-26055,APC,26055,CPT,0360,RC,,,TA,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1827.80,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1827.80,1919.19,OPPS APC
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],75579.22,,"Fee schedule rate ($75,579.22). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,25162.32,75579.22,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,167,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],43522.37,,"Fee schedule rate ($43,522.37). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,14157.71,43522.37,There are no additional notes associated with this service or procedure.
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC",605,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],17131.97,,"Fee schedule rate ($17,131.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8148.17,18024.13,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH CC,427,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],71634.73,,"Fee schedule rate ($71,634.73). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,50829.82,142040.39,There are no additional notes associated with this service or procedure.
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],35127.88,,"Fee schedule rate ($35,127.88). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.5), with a minimum of zero.",,,,0,other,14603.31,45017.13,There are no additional notes associated with this service or procedure.
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],8011.50,,"Fee schedule rate ($8,011.50). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5280.00,17136.70,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],81524.17,,"Fee schedule rate ($81,524.17). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,8972.00,81524.17,There are no additional notes associated with this service or procedure.
"Arthrodesis Great Toe Metatarsophalangeal Joint|RIGHT FOOT, GREAT TOE",CASE-28750,APC,28750,CPT,0360,RC,,,T5,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7029.71,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6791.99,7131.59,OPPS APC
Exc Bartholins Gland/Cyst|LEFT SIDE,CASE-56740,APC,56740,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3030.03,,"APC Price ($3,030.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3030.03,3136.08,OPPS APC
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",004,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],10715.36,,,,,,0,other,10249.47,272554.00,Estimated amount calculated based on 6 day length of stay.
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC,058,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],13521.80,,"Case rate ($13,521.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,714.66, add-ons for qualifying new technology services are included. If operating cost exceeds $47,585.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,606.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $10,730.14 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,769.70 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $846.71. The transfer capital threshold is the transfer adjustment factor * $846.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,13521.80,40853.02,Inpatient DRG
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],26949.28,,"Fee schedule rate ($26,949.28). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9977.99,26949.28,There are no additional notes associated with this service or procedure.
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITHOUT MCC,430,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],41000.16,,"Case rate ($41,000.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $38,277.19, add-ons for qualifying new technology services are included. If operating cost exceeds $73,148.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,616.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $36,198.76 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $36,332.23 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,856.44. The transfer capital threshold is the transfer adjustment factor * $2,856.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,41000.16,133156.90,Inpatient DRG
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],23870.71,,"Fee schedule rate ($23,870.71). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10626.74,25225.91,There are no additional notes associated with this service or procedure.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC",156,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],6625.12,,"Case rate ($6,625.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,298.82, add-ons for qualifying new technology services are included. If operating cost exceeds $41,169.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,102.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $4,337.88 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,353.87 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $342.30. The transfer capital threshold is the transfer adjustment factor * $342.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6625.12,13598.77,Inpatient DRG
"DORSAL AND LUMBAR FUSION PROCEDURE EXCEPT FOR CURVATURE OF BACK,MINOR",304,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],9770.81,,"Case rate for a one day stay ($9,305.53). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9305.53,9770.81,There are no additional notes associated with this service or procedure.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],62041.12,,"Fee schedule rate ($62,041.12). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,18497.24,62041.12,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],15753.15,,"Fee schedule rate ($15,753.15). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11059.47,28423.20,There are no additional notes associated with this service or procedure.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],17365.00,,"Fee schedule rate ($17,365.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5683.00,19635.68,There are no additional notes associated with this service or procedure.
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],7999.61,,"Case rate ($7,842.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,431.55, add-ons for qualifying new technology services are included. If operating cost exceeds $42,302.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,191.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $5,466.44 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,486.60 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $431.36. The transfer capital threshold is the transfer adjustment factor * $431.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,5280.00,17136.70,Inpatient DRG
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],15546.05,,"Fee schedule rate ($15,546.05). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,12984.79,32077.45,There are no additional notes associated with this service or procedure.
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],16035.06,,"Fee schedule rate ($16,035.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,7396.47,16035.06,There are no additional notes associated with this service or procedure.
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],14455.04,,"Fee schedule rate ($14,455.04). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5280.00,17136.70,There are no additional notes associated with this service or procedure.
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],24701.52,,"Fee schedule rate ($24,701.52). Adds an outlier to normal pricing equal to the per diem rate ($51,462.28) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,10846.16,25863.45,There are no additional notes associated with this service or procedure.
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],13456.78,,"Case rate ($13,001.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,230.82, add-ons for qualifying new technology services are included. If operating cost exceeds $47,101.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,568.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $10,248.08 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,285.87 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $808.68. The transfer capital threshold is the transfer adjustment factor * $808.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,7868.00,32126.64,Inpatient DRG
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],14895.38,,"Case rate ($14,603.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,720.75, add-ons for qualifying new technology services are included. If operating cost exceeds $48,591.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,685.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $11,732.54 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,775.80 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $925.81. The transfer capital threshold is the transfer adjustment factor * $925.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,14603.31,45017.13,Inpatient DRG
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,098,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],20627.35,,"Fee schedule rate ($20,627.35). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,6965.00,45156.75,There are no additional notes associated with this service or procedure.
O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC,621,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],36669.96,,"Fee schedule rate ($36,669.96). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,12159.94,36669.96,There are no additional notes associated with this service or procedure.
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],7868.00,,"Per diem ($7,868). If length of stay < 3.9, first 1 days paid at a per diem of $15,736 instead. Capped at $30,683.33.",,,,0,other,7868.00,32126.64,Estimated amount calculated based on 3 day length of stay.
SPINAL PROCEDURES WITHOUT CC/MCC,030,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],44714.01,,"Fee schedule rate ($44,714.01). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,16810.99,44714.01,There are no additional notes associated with this service or procedure.
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|RIGHT HAND, SECOND DIGIT",CASE-26160,APC,26160,CPT,0360,RC,,,F6,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1557.80,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1505.12,1557.80,OPPS APC
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],33398.16,,"Fee schedule rate ($33,398.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,7353.00,33398.16,There are no additional notes associated with this service or procedure.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],60646.89,,"Fee schedule rate ($60,646.89). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15.6), with a minimum of zero.",,,,0,other,23799.09,63499.65,There are no additional notes associated with this service or procedure.
PERIPHERAL VASCULAR DISORDERS WITH CC,300,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],9174.14,,"Case rate ($9,174.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,670.11, add-ons for qualifying new technology services are included. If operating cost exceeds $43,541.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,288.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,700.45 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,725.16 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $528.73. The transfer capital threshold is the transfer adjustment factor * $528.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9174.14,21005.20,Inpatient DRG
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,085,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],17936.97,,"Case rate ($17,330.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,257.72, add-ons for qualifying new technology services are included. If operating cost exceeds $51,128.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,885.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $14,260.20 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,312.77 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,125.27. The transfer capital threshold is the transfer adjustment factor * $1,125.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,9282.00,57443.16,Inpatient DRG
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH CC",457,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],160549.49,,"Fee schedule rate ($160,549.49). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,42327.47,160549.49,There are no additional notes associated with this service or procedure.
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],11158.08,,"Case rate ($10,626.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,021.44, add-ons for qualifying new technology services are included. If operating cost exceeds $44,892.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,394.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $8,046.82 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,076.49 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $634.97. The transfer capital threshold is the transfer adjustment factor * $634.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10626.74,25225.91,Inpatient DRG
Cysto W/Urtroscopy&/Pyeloscopy Dx|LEFT SIDE,CASE-52351,APC,52351,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3299.47,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3299.47,3464.44,OPPS APC
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],28821.04,,"Fee schedule rate ($28,821.04). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,10347.06,28821.04,There are no additional notes associated with this service or procedure.
Laparoscopy Urethral Suspension Stress Incont,CASE-51990,APC,51990,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],10298.02,,"APC Price ($9,949.78). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,9949.78,10447.27,OPPS APC
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],10002.75,,"Case rate ($9,526.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,011.98, add-ons for qualifying new technology services are included. If operating cost exceeds $43,882.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,301.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $7,040.34 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,067.03 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $541.14. The transfer capital threshold is the transfer adjustment factor * $541.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9755.86,29216.99,Inpatient DRG
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],11945.95,,"Case rate ($11,945.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,248.66, add-ons for qualifying new technology services are included. If operating cost exceeds $46,119.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,491.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $9,269.54 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,303.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $731.46. The transfer capital threshold is the transfer adjustment factor * $731.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6167.00,29058.99,Inpatient DRG
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],31533.97,,"Fee schedule rate ($31,533.97). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8563.30,31533.97,There are no additional notes associated with this service or procedure.
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH MCC",510,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],23519.99,,"Case rate ($22,399.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,973.84, add-ons for qualifying new technology services are included. If operating cost exceeds $55,844.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,256.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.3. The base transfer operating payment is the transfer adjustment factor * $18,958.99 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $19,028.89 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,496.05. The transfer capital threshold is the transfer adjustment factor * $1,496.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10710.00,89863.76,Inpatient DRG
"Rpr Coltrl Ligm Mtcarphlngl/Iphal Jt|RIGHT HAND, THUMB",CASE-26540,APC,26540,CPT,0360,RC,,,F5,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],23247.00,,"Fee schedule rate ($23,247). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12795.84,41944.25,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],38378.80,,"Fee schedule rate ($38,378.80). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,14370.36,38378.80,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,066,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],6908.75,,"Case rate ($6,579.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,256.61, add-ons for qualifying new technology services are included. If operating cost exceeds $41,127.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,098.96, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $4,295.82 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,311.66 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $338.98. The transfer capital threshold is the transfer adjustment factor * $338.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6579.76,20083.61,Inpatient DRG
HC Inj Trigger Pt 1-2 Musc Grps,CASE-20552,APC,20552,CPT,0510,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],301.68,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,287.31,301.68,OPPS APC
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC,817,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],43874.75,,"Fee schedule rate ($43,874.75). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,17396.11,44895.04,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITHOUT CC/MCC,517,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],11705.53,,"Case rate ($11,148.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $10,476.23, add-ons for qualifying new technology services are included. If operating cost exceeds $49,120.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $3,441.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $9,076.06 + an uncompensated DSH payment of $1,359.91. The transfer operating threshold is the transfer adjustment factor * $9,116.32 + an uncompensated DSH payment of $1,359.91. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $712.16. The transfer capital threshold is the transfer adjustment factor * $712.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10207.96,29371.86,Inpatient DRG
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],14830.15,,"Fee schedule rate ($14,830.15). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,7884.32,17835.23,There are no additional notes associated with this service or procedure.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],12303.61,,"Case rate ($11,717.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,036.36, add-ons for qualifying new technology services are included. If operating cost exceeds $45,907.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,474.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $9,058.01 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,091.41 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $714.77. The transfer capital threshold is the transfer adjustment factor * $714.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,11717.72,43888.01,Inpatient DRG
Lam Facetectomy&Foramot 1 Vrt Sgm Ea Addl Sgm,CASE-63048,APC,63048,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,7029.71,7131.59,OPPS APC
Low cost skin substitute app,CASE-C5275,APC,C5275,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],660.72,,"APC Price ($660.72). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,660.72,693.76,OPPS APC
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],21195.68,,"Fee schedule rate ($21,195.68). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,6965.00,21195.68,There are no additional notes associated with this service or procedure.
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],13478.34,,"Fee schedule rate ($13,478.34). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,6801.88,22557.82,There are no additional notes associated with this service or procedure.
Breast Augmentation With Implant|RIGHT SIDE,CASE-19325,APC,19325,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7918.25,,"APC Price ($7,650.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,7918.25,8033.01,OPPS APC
Arthrs Kne Surg W/Meniscectomy Med/Lat W/Shvg|LEFT SIDE|SEPARATE STRUCTURE,CASE-29881,APC,29881,CPT,0360,RC,,,LT|XS,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,025,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],32735.52,,"Case rate ($32,735.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $30,588.77, add-ons for qualifying new technology services are included. If operating cost exceeds $65,459.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,011.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.4. The base transfer operating payment is the transfer adjustment factor * $28,538.59 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $28,643.82 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,251.98. The transfer capital threshold is the transfer adjustment factor * $2,251.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,13351.00,91631.33,Inpatient DRG
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],37149.27,,"Fee schedule rate ($37,149.27). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,12455.21,37149.27,There are no additional notes associated with this service or procedure.
Excision Malignant Lesion Trunk/Arm/Leg > 4.0 Cm,CASE-11606,APC,11606,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6215.36,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6215.36,6526.12,OPPS APC
"Laminec/Facetect/Foramin,Cervical",CASE-63045,APC,63045,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6791.99,7131.59,OPPS APC
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],11753.96,,"Case rate ($11,194.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,549.37, add-ons for qualifying new technology services are included. If operating cost exceeds $45,420.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,436.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $8,572.81 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,604.42 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $676.48. The transfer capital threshold is the transfer adjustment factor * $676.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,11194.25,36094.03,Inpatient DRG
Exc Tumor Soft Tissue Abdl Wall Subfascial 5cm/>,CASE-22901,APC,22901,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],2814.04,,"APC Price ($2,718.88). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2718.88,2854.83,OPPS APC
Prq Impltj Neurostimulator Eltrd Peripheral Nrv,CASE-64555,APC,64555,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6174.06,,"APC Price ($5,965.28). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5965.28,6263.54,OPPS APC
Mastopexy|BILATERAL PROCEDURE,CASE-19316,APC,19316,CPT,0360,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6526.12,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6432.89,6526.12,OPPS APC
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH CC",457,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],112064.54,,"Fee schedule rate ($112,064.54). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.9), with a minimum of zero.",,,,0,other,42327.47,160549.49,There are no additional notes associated with this service or procedure.
"OTHER DISORDERS OF NERVOUS SYSTEM,MINOR",058,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],1709.18,,"Case rate for a one day stay ($1,709.18). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,1709.18,1709.18,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],17686.09,,"Fee schedule rate ($17,686.09). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8318.14,19763.43,There are no additional notes associated with this service or procedure.
PERIPHERAL VASCULAR DISORDERS WITH CC,300,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],21005.20,,,,,,0,other,9174.14,21005.20,There are no additional notes associated with this service or procedure.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,479,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],14533.55,,"Case rate ($14,533.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,655.86, add-ons for qualifying new technology services are included. If operating cost exceeds $48,526.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,680.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $11,667.89 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,710.91 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $920.71. The transfer capital threshold is the transfer adjustment factor * $920.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10586.00,50518.76,Inpatient DRG
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,025,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],91631.33,,"Fee schedule rate ($91,631.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,13351.00,91631.33,There are no additional notes associated with this service or procedure.
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],28394.78,,"Fee schedule rate ($28,394.78). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11454.97,28394.78,There are no additional notes associated with this service or procedure.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],29207.12,,"Case rate ($16,689.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,661.75, add-ons for qualifying new technology services are included. If operating cost exceeds $50,532.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,838.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $13,666.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,716.80 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,078.42. The transfer capital threshold is the transfer adjustment factor * $1,078.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,16689.78,59521.43,All Other Inpatient
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,450,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],39368.69,,"Case rate ($38,037.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $35,520.98, add-ons for qualifying new technology services are included. If operating cost exceeds $70,391.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,399.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $33,452.68 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $33,576.02 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,639.75. The transfer capital threshold is the transfer adjustment factor * $2,639.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,38037.38,146009.19,Inpatient DRG
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITHOUT CC/MCC",630,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],27428.38,,"Fee schedule rate ($27,428.38). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,11828.78,42541.02,There are no additional notes associated with this service or procedure.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],92811.11,,"Fee schedule rate ($92,811.11). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,35389.50,101083.00,There are no additional notes associated with this service or procedure.
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],29783.11,,,,,,0,other,12195.15,39424.57,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],15088.88,,"Case rate ($14,370.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,504.04, add-ons for qualifying new technology services are included. If operating cost exceeds $48,375.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,668.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $11,516.62 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,559.08 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $908.78. The transfer capital threshold is the transfer adjustment factor * $908.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,14370.36,38378.80,Inpatient DRG
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC",156,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],6757.62,,"Case rate ($6,625.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,298.82, add-ons for qualifying new technology services are included. If operating cost exceeds $41,169.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,102.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $4,337.88 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,353.87 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $342.30. The transfer capital threshold is the transfer adjustment factor * $342.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6625.12,13598.77,Inpatient DRG
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],7833.94,,"Case rate ($7,833.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,423.35, add-ons for qualifying new technology services are included. If operating cost exceeds $42,294.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,190.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,458.28 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,478.41 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $430.71. The transfer capital threshold is the transfer adjustment factor * $430.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,5883.03,17111.12,Inpatient DRG
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],67794.72,,"Fee schedule rate ($67,794.72). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,10862.00,86437.13,There are no additional notes associated with this service or procedure.
Biopsy Floor Mouth,CASE-41108,APC,41108,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1623.23,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1545.93,1623.23,OPPS APC
HC Trigger Point 3 or More,CASE-20553,APC,20553,CPT,0510,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],301.68,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,287.31,301.68,OPPS APC
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],47794.95,,"Fee schedule rate ($47,794.95). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,32296.02,88188.38,There are no additional notes associated with this service or procedure.
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],11914.12,,"Case rate ($11,914.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,219.06, add-ons for qualifying new technology services are included. If operating cost exceeds $46,090.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,489.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $9,240.03 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,274.10 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $729.13. The transfer capital threshold is the transfer adjustment factor * $729.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,11914.12,40426.76,Inpatient DRG
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC,434,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],13280.45,,"Fee schedule rate ($13,280.45). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6770.05,14019.86,There are no additional notes associated with this service or procedure.
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC",758,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],19263.78,,,,,,0,other,8574.80,19263.78,There are no additional notes associated with this service or procedure.
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],22762.43,,"Fee schedule rate ($22,762.43). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6230.00,22762.43,There are no additional notes associated with this service or procedure.
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],7717.78,,"Case rate ($7,566.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,174.51, add-ons for qualifying new technology services are included. If operating cost exceeds $42,045.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,171.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,210.35 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,229.56 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $411.15. The transfer capital threshold is the transfer adjustment factor * $411.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,7566.45,16333.88,Inpatient DRG
"ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",770,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],19730.13,,,,,,0,other,8735.30,19730.13,There are no additional notes associated with this service or procedure.
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",623,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],17063.90,,"Fee schedule rate ($17,063.90). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,14093.37,33712.76,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],94787.57,,"Fee schedule rate ($94,787.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,23526.87,94787.57,There are no additional notes associated with this service or procedure.
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,069,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],20333.68,,"Fee schedule rate ($20,333.68). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,20333.68,There are no additional notes associated with this service or procedure.
"CARDIAC ARREST, UNEXPLAINED WITH MCC",296,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],30733.51,,,,,,0,other,12522.25,36459.67,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],21195.68,,"Fee schedule rate ($21,195.68). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,6965.00,21195.68,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC,087,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],17189.96,,"Fee schedule rate ($17,189.96). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,8139.36,22679.07,There are no additional notes associated with this service or procedure.
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],40714.72,,"Fee schedule rate ($40,714.72). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,17356.15,44778.95,There are no additional notes associated with this service or procedure.
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],15117.84,,,,,,0,other,6965.00,16400.70,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],12364.06,,"Case rate ($11,945.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,248.66, add-ons for qualifying new technology services are included. If operating cost exceeds $46,119.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,491.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $9,269.54 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,303.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $731.46. The transfer capital threshold is the transfer adjustment factor * $731.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6167.00,29058.99,Inpatient DRG
"OTHER ESOPHAGEAL DISORDERS,EXTREME",243,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],21153.39,,"Case rate ($20,146.09). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,20146.09,21153.39,There are no additional notes associated with this service or procedure.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],26424.48,,"Case rate ($15,099.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,182.53, add-ons for qualifying new technology services are included. If operating cost exceeds $49,053.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,722.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $12,192.63 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,237.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $962.12. The transfer capital threshold is the transfer adjustment factor * $962.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,7605.00,39153.65,All Other Inpatient
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,025,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],13351.00,,"Per diem ($13,351). If length of stay < 6.4, first 1 days paid at a per diem of $26,702 instead. Capped at $85,446.13.",,,,0,other,13351.00,91631.33,Estimated amount calculated based on 4 day length of stay.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],62084.69,,"Fee schedule rate ($62,084.69). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (35), with a minimum of zero.",,,,0,other,30398.48,82674.88,There are no additional notes associated with this service or procedure.
Perq Drainage Pleura Insert Cath W/O Imaging|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-32556,APC,32556,CPT,0360,RC,,,LT|XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5856.81,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5658.76,5856.81,OPPS APC
Laps Fulg/Exc Ovary Viscera/Peritoneal Surface|LEFT SIDE,CASE-58662,APC,58662,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5941.70,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5658.76,5941.70,OPPS APC
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],10517.71,,"Case rate ($10,517.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,920.01, add-ons for qualifying new technology services are included. If operating cost exceeds $44,791.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,386.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $7,945.76 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,975.06 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $627.00. The transfer capital threshold is the transfer adjustment factor * $627.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10517.71,24909.11,Inpatient DRG
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITHOUT CC/MCC,816,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],14733.53,,"Fee schedule rate ($14,733.53). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6224.90,14733.53,There are no additional notes associated with this service or procedure.
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 2nd Level|BILATERAL PROCEDURE,CASE-64494,APC,64494,CPT,0360,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],856.86,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,827.89,869.28,OPPS APC
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC,939,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],27843.27,,"Case rate ($26,517.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $24,804.19, add-ons for qualifying new technology services are included. If operating cost exceeds $59,675.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,557.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $22,775.26 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $22,859.24 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,797.19. The transfer capital threshold is the transfer adjustment factor * $1,797.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,26517.40,97674.79,Inpatient DRG
HEADACHES WITHOUT MCC,103,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],20883.08,,"Fee schedule rate ($20,883.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,20883.08,There are no additional notes associated with this service or procedure.
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],17748.64,,"Case rate ($16,903.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,888.46, add-ons for qualifying new technology services are included. If operating cost exceeds $50,759.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,827.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $13,890.84 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,943.51 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,067.68. The transfer capital threshold is the transfer adjustment factor * $1,067.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,17356.15,44778.95,Inpatient DRG
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],21980.29,,"Fee schedule rate ($21,980.29). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9865.56,37914.65,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,064,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],37792.72,,"Fee schedule rate ($37,792.72). Adds an outlier to normal pricing equal to the per diem rate ($115,085.88) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,15563.58,41838.16,There are no additional notes associated with this service or procedure.
HC Joint Injection/Aspir Large WO US|PBB CHARGE,CASE-20610,APC,20610,CPT,0510,RC,,,PBB,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],287.31,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
CESAREAN SECTION WITH STERILIZATION WITHOUT CC/MCC,785,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],8599.86,,"Case rate ($8,431.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,979, add-ons for qualifying new technology services are included. If operating cost exceeds $42,850.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,234.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,011.89 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,034.06 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $474.40. The transfer capital threshold is the transfer adjustment factor * $474.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,8431.24,20142.33,Inpatient DRG
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC,027,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],49643.10,,,,,,0,other,19030.20,56363.30,There are no additional notes associated with this service or procedure.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],21197.40,,"Fee schedule rate ($21,197.40). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,19435.86,50821.76,There are no additional notes associated with this service or procedure.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,074,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],20919.08,,"Fee schedule rate ($20,919.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8925.60,20919.08,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],6965.00,,,,,,0,other,6164.03,14071.02,There are no additional notes associated with this service or procedure.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],17023.58,,"Case rate ($16,689.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,661.75, add-ons for qualifying new technology services are included. If operating cost exceeds $50,532.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,838.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $13,666.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,716.80 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,078.42. The transfer capital threshold is the transfer adjustment factor * $1,078.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,16689.78,59521.43,Inpatient DRG
Cystoscopy prostatic imp 1-3,CASE-C9739,APC,C9739,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5269.71,,"APC Price ($5,018.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5018.77,5269.71,OPPS APC
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],31007.30,,"Fee schedule rate ($31,007.30). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,16120.25,41187.90,There are no additional notes associated with this service or procedure.
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],16055.90,,"Fee schedule rate ($16,055.90). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8163.06,18067.42,There are no additional notes associated with this service or procedure.
"COCAINE ABUSE AND DEPENDENCE,EXTREME",774,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],19131.94,,"Case rate ($19,131.94). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,19131.94,20088.54,There are no additional notes associated with this service or procedure.
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],26127.34,,"Case rate ($26,127.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $24,441.31, add-ons for qualifying new technology services are included. If operating cost exceeds $59,312.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,528.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. The base transfer operating payment is the transfer adjustment factor * $22,413.72 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $22,496.36 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,768.66. The transfer capital threshold is the transfer adjustment factor * $1,768.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,26127.34,90333.60,Inpatient DRG
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],11194.25,,"Case rate ($11,194.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,549.37, add-ons for qualifying new technology services are included. If operating cost exceeds $45,420.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,436.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $8,572.81 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,604.42 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $676.48. The transfer capital threshold is the transfer adjustment factor * $676.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,11194.25,36094.03,Inpatient DRG
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC",458,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],78415.67,,"Fee schedule rate ($78,415.67). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.8), with a minimum of zero.",,,,0,other,30202.09,132827.25,There are no additional notes associated with this service or procedure.
Excision Tumor Soft Tissue Foot/Toe Subq <1.5cm|LEFT SIDE,CASE-28043,APC,28043,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1545.93,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1545.93,1623.23,OPPS APC
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,093,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],19011.32,,"Fee schedule rate ($19,011.32). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,19011.32,There are no additional notes associated with this service or procedure.
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],20297.68,,"Fee schedule rate ($20,297.68). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6965.00,21404.64,There are no additional notes associated with this service or procedure.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],54764.34,,"Fee schedule rate ($54,764.34). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,18178.96,54764.34,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],19187.65,,"Fee schedule rate ($19,187.65). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8859.23,20090.22,There are no additional notes associated with this service or procedure.
FULL TERM NEONATE WITH MAJOR PROBLEMS,793,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],30820.00,,"Case rate ($29,352.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $27,492.63, add-ons for qualifying new technology services are included. If operating cost exceeds $62,363.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,716.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $25,451.18 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $25,547.68 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,956.24. The transfer capital threshold is the transfer adjustment factor * $1,956.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,4302.90,82045.22,Inpatient DRG
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],73588.10,,"Fee schedule rate ($73,588.10). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,21585.31,73588.10,There are no additional notes associated with this service or procedure.
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC",514,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],19212.08,,"Fee schedule rate ($19,212.08). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,8868.04,22699.91,There are no additional notes associated with this service or procedure.
FRACTURES OF FEMUR WITH MCC,533,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],49490.05,,"Fee schedule rate ($49,490.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,6852.00,49490.05,There are no additional notes associated with this service or procedure.
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],70264.60,,,,,,0,other,26127.34,90333.60,There are no additional notes associated with this service or procedure.
Osteot W/WO Lngth Shrt/Corrj Metar Xcp 1st Ea|LEFT SIDE,CASE-28308,APC,28308,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC",514,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],22699.91,,"Fee schedule rate ($22,699.91). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8868.04,22699.91,There are no additional notes associated with this service or procedure.
HYPERTENSION WITHOUT MCC,305,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],17230.49,,"Fee schedule rate ($17,230.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7058.55,17230.49,There are no additional notes associated with this service or procedure.
Arthrs Aided Ant Cruciate Ligm Rpr/Agmntj/Rcnstj|LEFT SIDE,CASE-29888,APC,29888,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],12618.18,,"APC Price ($12,017.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,12017.31,12618.18,OPPS APC
"HERNIA PROCEDURES EXCEPT INGUINAL FEMORAL AND UMBILICAL,EXTREME",227,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],40206.67,,"Case rate ($40,206.67). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,40206.67,42217.00,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],14650.15,,"Case rate ($13,952.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,115.33, add-ons for qualifying new technology services are included. If operating cost exceeds $47,986.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,638.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $11,129.34 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,170.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $878.22. The transfer capital threshold is the transfer adjustment factor * $878.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13917.42,34889.29,Inpatient DRG
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],17627.38,,"Case rate ($16,787.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,753.10, add-ons for qualifying new technology services are included. If operating cost exceeds $50,624.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,845.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $13,757.43 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,808.15 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,085.60. The transfer capital threshold is the transfer adjustment factor * $1,085.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,16787.98,62990.26,Inpatient DRG
SEIZURES WITH MCC,100,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],32323.98,,"Fee schedule rate ($32,323.98). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,15061.09,38110.41,There are no additional notes associated with this service or procedure.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],12950.91,,"Case rate ($12,696.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,947.32, add-ons for qualifying new technology services are included. If operating cost exceeds $46,818.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,546.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,965.63 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,002.37 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $786.39. The transfer capital threshold is the transfer adjustment factor * $786.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,12696.97,47123.82,Inpatient DRG
Rmvl Spinal Nstim Eltrd Prq Array Incl Fluor,CASE-63661,APC,63661,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3272.44,,"APC Price ($3,272.44). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3272.44,3436.06,OPPS APC
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],24528.10,,"Fee schedule rate ($24,528.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10989.72,26280.60,There are no additional notes associated with this service or procedure.
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC,805,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],20281.41,,"Fee schedule rate ($20,281.41). Adds an outlier to normal pricing equal to the per diem rate ($31,438.44) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.5), with a minimum of zero.",,,,0,other,9253.36,21235.42,There are no additional notes associated with this service or procedure.
Unlisted Laparoscopy Px Intestine Xcp Rectum,CASE-44238,APC,44238,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5856.81,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5658.76,5856.81,OPPS APC
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],2070.00,,,,,,0,other,1188.00,34338.33,Estimated amount calculated based on 6 day length of stay.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,373,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],6870.94,,"Case rate ($6,870.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,527.50, add-ons for qualifying new technology services are included. If operating cost exceeds $41,398.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,120.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $4,565.72 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,582.56 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $360.28. The transfer capital threshold is the transfer adjustment factor * $360.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6870.94,14313.05,Inpatient DRG
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],26649.89,,"Case rate ($26,127.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $24,441.31, add-ons for qualifying new technology services are included. If operating cost exceeds $59,312.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,528.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. The base transfer operating payment is the transfer adjustment factor * $22,413.72 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $22,496.36 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,768.66. The transfer capital threshold is the transfer adjustment factor * $1,768.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,26127.34,90333.60,Inpatient DRG
DIABETES WITHOUT CC/MCC,639,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],11899.36,,"Fee schedule rate ($11,899.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6151.76,12223.35,There are no additional notes associated with this service or procedure.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,025,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],13351.00,,"Per diem ($13,351). If length of stay < 6.4, first 1 days paid at a per diem of $26,702 instead. Capped at $85,446.13.",,,,0,other,13351.00,91631.33,Estimated amount calculated based on 4 day length of stay.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],7921.00,,"Per diem ($7,921). If length of stay < 4.1, first 1 days paid at a per diem of $15,842 instead. Capped at $32,474.30.",,,,0,other,7921.00,45706.73,Estimated amount calculated based on 2 day length of stay.
"ASTHMA,MAJOR",141,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],8458.62,,"Case rate ($8,458.62). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,8458.62,8881.55,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],6428.77,,"Case rate ($6,122.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,831.37, add-ons for qualifying new technology services are included. If operating cost exceeds $40,702.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,065.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $3,872.14 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,886.42 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $305.55. The transfer capital threshold is the transfer adjustment factor * $305.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,1188.00,12138.74,Inpatient DRG
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],12213.87,,"Case rate ($11,974.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,275.12, add-ons for qualifying new technology services are included. If operating cost exceeds $46,146.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,493.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $9,295.90 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,330.17 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $733.54. The transfer capital threshold is the transfer adjustment factor * $733.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,11974.38,29141.64,Inpatient DRG
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],22358.90,,"Fee schedule rate ($22,358.90). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9389.48,22358.90,There are no additional notes associated with this service or procedure.
CERVICAL SPINAL FUSION WITHOUT CC/MCC,473,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],62077.11,,"Fee schedule rate ($62,077.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,18477.61,62077.11,There are no additional notes associated with this service or procedure.
Revj/Rmvl Impl Spi Npg/Rcvr Dtch Connj Eltrd Ra,CASE-63688,APC,63688,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3436.06,,"APC Price ($3,272.44). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3272.44,3436.06,OPPS APC
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],8767.31,,"Case rate ($8,349.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,915.22, add-ons for qualifying new technology services are included. If operating cost exceeds $42,786.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,217.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $5,947.72 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,970.27 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $457.16. The transfer capital threshold is the transfer adjustment factor * $457.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8543.64,23239.84,Inpatient DRG
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],6965.00,,,,,,0,other,6965.00,29482.05,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,447,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],48137.07,,"Case rate ($47,193.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $44,038.45, add-ons for qualifying new technology services are included. If operating cost exceeds $78,909.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $5,069.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $41,938.87 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $42,093.51 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,309.39. The transfer capital threshold is the transfer adjustment factor * $3,309.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,47193.21,156646.82,Inpatient DRG
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],39424.57,,"Fee schedule rate ($39,424.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12195.15,39424.57,There are no additional notes associated with this service or procedure.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],11875.90,,"Case rate ($11,310.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,674.88, add-ons for qualifying new technology services are included. If operating cost exceeds $45,545.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,428.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $8,696.96 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,729.93 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $668.47. The transfer capital threshold is the transfer adjustment factor * $668.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,11593.79,38248.08,Inpatient DRG
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC,520,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],12352.81,,"Case rate ($11,764.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,098.27, add-ons for qualifying new technology services are included. If operating cost exceeds $45,969.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,460.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $9,118.74 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,153.32 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $700.89. The transfer capital threshold is the transfer adjustment factor * $700.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12061.74,39786.42,Inpatient DRG
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],10120.20,,"Case rate ($10,120.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,550.21, add-ons for qualifying new technology services are included. If operating cost exceeds $44,421.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,357.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $7,577.32 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,605.26 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $597.93. The transfer capital threshold is the transfer adjustment factor * $597.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10120.20,26204.74,Inpatient DRG
Laparoscopy Surg W/Bx Single/Multiple,CASE-49321,APC,49321,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5658.76,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5658.76,5941.70,OPPS APC
Dstrj Lesion Penis Simple Laser,CASE-54057,APC,54057,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],652.69,,"APC Price ($652.69). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,652.69,685.32,OPPS APC
"Prq Skel Fixj Phlngl Shft Fx Prox/Middle Px/F/T|RIGHT HAND, FIFTH DIGIT",CASE-26727,APC,26727,CPT,0360,RC,,,F9,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
MAJOR CHEST TRAUMA WITHOUT CC/MCC,185,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],21771.61,,"Fee schedule rate ($21,771.61). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7271.19,21771.61,There are no additional notes associated with this service or procedure.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],66833.55,,"Fee schedule rate ($66,833.55). Adds an outlier to normal pricing equal to the per diem rate ($141,521.30) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,26028.48,80635.65,There are no additional notes associated with this service or procedure.
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],13403.28,,"Case rate ($12,765.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,030.82, add-ons for qualifying new technology services are included. If operating cost exceeds $46,901.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,532.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $10,047.77 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,085.87 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $772.30. The transfer capital threshold is the transfer adjustment factor * $772.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13092.47,33159.45,Inpatient DRG
PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,337,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],38926.31,,"Fee schedule rate ($38,926.31). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,12340.08,38926.31,There are no additional notes associated with this service or procedure.
"Partical Excision Bone Phalanx Toe|LEFT FOOT, THIRD DIGIT",CASE-28124,APC,28124,CPT,0360,RC,,,T2,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6791.99,7131.59,OPPS APC
FULL TERM NEONATE WITH MAJOR PROBLEMS,793,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],31238.14,,"Case rate ($30,181.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $28,213.07, add-ons for qualifying new technology services are included. If operating cost exceeds $63,084.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,825.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $26,171.62 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $26,268.12 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,065.20. The transfer capital threshold is the transfer adjustment factor * $2,065.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,4302.90,82045.22,Inpatient DRG
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],15973.65,,"Fee schedule rate ($15,973.65). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,10347.06,28821.04,There are no additional notes associated with this service or procedure.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],9318.55,,"Case rate ($8,874.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,391.65, add-ons for qualifying new technology services are included. If operating cost exceeds $43,262.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,266.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $6,423.02 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,446.70 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $506.84. The transfer capital threshold is the transfer adjustment factor * $506.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8874.81,20553.44,Inpatient DRG
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,095,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],48575.01,,"Fee schedule rate ($48,575.01). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,19411.47,50750.92,There are no additional notes associated with this service or procedure.
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITH MCC OR ANTINEOPLASTIC IMPLANT OR EPILEPSY WITH NEUROSTIMULATOR,023,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],136379.44,,"Fee schedule rate ($136,379.44). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,15168.00,136379.44,There are no additional notes associated with this service or procedure.
Neuroplasty &/Transpos Median Nrv Carpal Tunne|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64721,APC,64721,CPT,0360,RC,,,RT|XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1919.19,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1827.80,1919.19,OPPS APC
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],16347.34,,"Case rate ($16,026.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,044.99, add-ons for qualifying new technology services are included. If operating cost exceeds $49,916.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,789.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $13,051.92 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,100.04 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,029.93. The transfer capital threshold is the transfer adjustment factor * $1,029.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,11165.00,61234.06,Inpatient DRG
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],32296.02,,"Case rate ($32,296.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $30,179.91, add-ons for qualifying new technology services are included. If operating cost exceeds $65,050.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,979.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $28,131.23 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $28,234.95 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,219.83. The transfer capital threshold is the transfer adjustment factor * $2,219.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,32296.02,88188.38,Inpatient DRG
HC Inj Trigger Pt 1-2 Musc Grps|ADJ,CASE-20552,APC,20552,CPT,0510,RC,,,ADJ,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],287.31,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],23078.81,,"Fee schedule rate ($23,078.81). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10311.17,24308.97,There are no additional notes associated with this service or procedure.
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],29216.99,,"Fee schedule rate ($29,216.99). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9755.86,29216.99,There are no additional notes associated with this service or procedure.
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],30103.84,,,,,,0,other,12305.53,30103.84,There are no additional notes associated with this service or procedure.
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",759,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6622.25,,"Case rate ($6,306.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,010.91, add-ons for qualifying new technology services are included. If operating cost exceeds $40,881.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,071.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,050.60 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,065.96 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $311.34. The transfer capital threshold is the transfer adjustment factor * $311.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6190.22,13057.66,Inpatient DRG
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],7766.29,,"Case rate ($7,396.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,016.38, add-ons for qualifying new technology services are included. If operating cost exceeds $41,887.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,158.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,052.80 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,071.43 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $398.72. The transfer capital threshold is the transfer adjustment factor * $398.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7396.47,16035.06,Inpatient DRG
BRONCHITIS AND ASTHMA WITHOUT CC/MCC,203,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],4832.10,,"Fee schedule rate ($4,832.10). Adds an outlier to normal pricing equal to the per diem rate ($3,770.33) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4763.76,13707.00,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],28756.63,,"Fee schedule rate ($28,756.63). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,13148.66,32553.63,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,083,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],11967.27,,"Case rate ($11,397.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,738.37, add-ons for qualifying new technology services are included. If operating cost exceeds $45,609.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,451.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $8,761.12 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,793.42 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $691.34. The transfer capital threshold is the transfer adjustment factor * $691.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,28680.85,Inpatient DRG
Revision of Reconstructed Breast,CASE-19380,APC,19380,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6526.12,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6215.36,6526.12,OPPS APC
Laps Rpr Paraesphgl Hrna Incl Fundplsty W/Mesh,CASE-43282,APC,43282,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],9949.78,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,9949.78,10447.27,OPPS APC
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],17693.40,,"Case rate ($17,693.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,595.40, add-ons for qualifying new technology services are included. If operating cost exceeds $51,466.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,911.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $14,596.63 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,650.45 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,151.82. The transfer capital threshold is the transfer adjustment factor * $1,151.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,17693.40,52449.26,Inpatient DRG
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],18518.02,,,,,,0,other,8318.14,19763.43,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL HEMORRHAGE WITH MCC,377,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],25067.51,,"Case rate ($14,324.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,461.19, add-ons for qualifying new technology services are included. If operating cost exceeds $48,332.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,665.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $11,473.94 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,516.24 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $905.41. The transfer capital threshold is the transfer adjustment factor * $905.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,7634.00,35969.56,All Other Inpatient
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],64429.92,,"Fee schedule rate ($64,429.92). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,25162.32,75579.22,There are no additional notes associated with this service or procedure.
Excision Malignant Lesion F/E/E/N/L 1.1-2.0 Cm,CASE-11642,APC,11642,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1600.04,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1545.93,1600.04,OPPS APC
SALIVARY GLAND PROCEDURES,139,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],10519.45,,"Case rate ($10,313.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,729.75, add-ons for qualifying new technology services are included. If operating cost exceeds $44,600.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,372.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $7,756.21 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,784.80 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $612.04. The transfer capital threshold is the transfer adjustment factor * $612.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,10313.19,30690.92,Inpatient DRG
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],12333.36,,"Case rate ($12,091.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,384.11, add-ons for qualifying new technology services are included. If operating cost exceeds $46,255.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,502.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $9,404.49 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,439.16 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $742.11. The transfer capital threshold is the transfer adjustment factor * $742.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6965.00,29482.05,Inpatient DRG
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],8120.41,,"Case rate ($7,733.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,330.12, add-ons for qualifying new technology services are included. If operating cost exceeds $42,201.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,183.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,365.38 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,385.17 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $423.38. The transfer capital threshold is the transfer adjustment factor * $423.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7733.72,18043.23,Inpatient DRG
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],9226.81,,"Case rate ($8,787.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,310.38, add-ons for qualifying new technology services are included. If operating cost exceeds $43,181.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,260.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,342.05 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,365.43 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $500.45. The transfer capital threshold is the transfer adjustment factor * $500.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,32293.66,Inpatient DRG
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],34570.85,,"Fee schedule rate ($34,570.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,6965.00,36140.75,There are no additional notes associated with this service or procedure.
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],15060.41,,"Case rate ($14,343.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,478.83, add-ons for qualifying new technology services are included. If operating cost exceeds $48,349.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,666.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $11,491.51 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,533.88 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $906.79. The transfer capital threshold is the transfer adjustment factor * $906.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,14343.25,36024.65,Inpatient DRG
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],52449.26,,"Fee schedule rate ($52,449.26). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,17693.40,52449.26,There are no additional notes associated with this service or procedure.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,418,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],39884.93,,"Fee schedule rate ($39,884.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,13400.58,39884.93,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,699,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],5961.00,,"Per diem ($5,961). If length of stay < 3.2, first 1 days paid at a per diem of $11,922 instead. Capped at $19,074.90.",,,,0,other,5961.00,19972.16,Estimated amount calculated based on 3 day length of stay.
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],30063.84,,"Fee schedule rate ($30,063.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13891.57,34712.20,There are no additional notes associated with this service or procedure.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],11753.96,,"Case rate ($11,194.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,549.37, add-ons for qualifying new technology services are included. If operating cost exceeds $45,420.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,436.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $8,572.81 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,604.42 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $676.48. The transfer capital threshold is the transfer adjustment factor * $676.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,11194.25,36094.03,Inpatient DRG
Exc B9 Lesion Mrgn Xcp Sk Tg S/N/H/F/G 1.1-2.0cm,CASE-11422,APC,11422,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1623.23,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1600.04,1623.23,OPPS APC
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],11594.35,,"Fee schedule rate ($11,594.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6164.03,14071.02,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],86252.84,,"Fee schedule rate ($86,252.84). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,27944.96,86252.84,There are no additional notes associated with this service or procedure.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],8874.81,,"Case rate ($8,874.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,391.65, add-ons for qualifying new technology services are included. If operating cost exceeds $43,262.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,266.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $6,423.02 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,446.70 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $506.84. The transfer capital threshold is the transfer adjustment factor * $506.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8874.81,20553.44,Inpatient DRG
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",759,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],11643.60,,"Fee schedule rate ($11,643.60). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6190.22,13057.66,There are no additional notes associated with this service or procedure.
CERVICAL SPINAL FUSION WITH CC,472,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],55366.06,,"Fee schedule rate ($55,366.06). Adds an outlier to normal pricing equal to the per diem rate ($66,990.29) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,21896.13,70198.84,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],81353.66,,"Fee schedule rate ($81,353.66). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,27256.92,81353.66,There are no additional notes associated with this service or procedure.
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|RIGHT HAND, SECOND DIGIT",CASE-26160,APC,26160,CPT,0360,RC,,,F6,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1557.80,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1505.12,1557.80,OPPS APC
Dstrj Lesion Penis Simple Laser,CASE-54057,APC,54057,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],652.69,,"APC Price ($652.69). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,652.69,685.32,OPPS APC
CESAREAN SECTION WITHOUT STERILIZATION WITH MCC,786,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],23722.94,,"Fee schedule rate ($23,722.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12612.10,23722.94,There are no additional notes associated with this service or procedure.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],18911.60,,"Case rate ($18,011.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,920.88, add-ons for qualifying new technology services are included. If operating cost exceeds $51,791.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,906.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $14,919.36 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,975.93 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,146.74. The transfer capital threshold is the transfer adjustment factor * $1,146.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,18497.24,62041.12,Inpatient DRG
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],8787.44,,"Case rate ($8,787.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,310.38, add-ons for qualifying new technology services are included. If operating cost exceeds $43,181.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,260.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,342.05 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,365.43 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $500.45. The transfer capital threshold is the transfer adjustment factor * $500.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,32293.66,Inpatient DRG
Correction Hammertoe|LEFT SIDE,CASE-28285,APC,28285,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7029.71,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6791.99,7131.59,OPPS APC
TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC,084,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],19445.16,,"Fee schedule rate ($19,445.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,6965.00,19445.16,There are no additional notes associated with this service or procedure.
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,450,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],66565.42,,"Case rate ($38,037.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $35,520.98, add-ons for qualifying new technology services are included. If operating cost exceeds $70,391.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,399.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $33,452.68 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $33,576.02 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,639.75. The transfer capital threshold is the transfer adjustment factor * $2,639.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,38037.38,146009.19,All Other Inpatient
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],34391.19,,"Fee schedule rate ($34,391.19). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,14337.84,52803.53,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,085,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],57443.16,,"Fee schedule rate ($57,443.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,9282.00,57443.16,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,065,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],8962.50,,"Case rate ($8,786.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,309.75, add-ons for qualifying new technology services are included. If operating cost exceeds $43,180.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,260.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,341.42 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,364.80 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $500.40. The transfer capital threshold is the transfer adjustment factor * $500.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,8786.76,25681.86,Inpatient DRG
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],20135.47,,,,,,0,other,8874.81,20553.44,There are no additional notes associated with this service or procedure.
HC Inj Anes/Steroid C/D Facet Sg|RIGHT SIDE,CASE-64490,APC,64490,CPT,0361,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],869.28,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,827.89,869.28,OPPS APC
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],23014.22,,,,,,0,other,9865.56,37914.65,There are no additional notes associated with this service or procedure.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],54537.29,,"Fee schedule rate ($54,537.29). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.7), with a minimum of zero.",,,,0,other,21597.50,67790.93,There are no additional notes associated with this service or procedure.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,025,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],34372.30,,"Case rate ($32,735.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $30,588.77, add-ons for qualifying new technology services are included. If operating cost exceeds $65,459.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,011.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.4. The base transfer operating payment is the transfer adjustment factor * $28,538.59 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $28,643.82 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,251.98. The transfer capital threshold is the transfer adjustment factor * $2,251.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,13351.00,91631.33,Inpatient DRG
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITHOUT CC/MCC",630,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],42541.02,,"Fee schedule rate ($42,541.02). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11828.78,42541.02,There are no additional notes associated with this service or procedure.
"Tendon Sheath Incision|RIGHT HAND, SECOND DIGIT|UNUSUAL NON-OVERLAPPING SERVICE",CASE-26055,APC,26055,CPT,0360,RC,,,F6|XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1557.80,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1505.12,1580.37,OPPS APC
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC,519,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],16032.61,,"Case rate ($15,490.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,546.03, add-ons for qualifying new technology services are included. If operating cost exceeds $49,417.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,750.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $12,554.80 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,601.09 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $990.70. The transfer capital threshold is the transfer adjustment factor * $990.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,15490.44,50780.20,Inpatient DRG
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],9648.19,,"Case rate ($9,648.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,111.10, add-ons for qualifying new technology services are included. If operating cost exceeds $43,982.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,323.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $7,139.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,166.15 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $563.40. The transfer capital threshold is the transfer adjustment factor * $563.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9648.19,31477.13,Inpatient DRG
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],6965.00,,,,,,0,other,6148.93,15887.21,There are no additional notes associated with this service or procedure.
Colonoscopy W/Biopsy Single/Multiple|UNUSUAL NON-OVERLAPPING SERVICE,CASE-45380,APC,45380,CPT,0360,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1120.09,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1120.09,1176.09,OPPS APC
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",623,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],32096.64,,"Fee schedule rate ($32,096.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,14093.37,33712.76,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITH CC,386,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],19879.00,,"Fee schedule rate ($19,879.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8556.53,19879.00,There are no additional notes associated with this service or procedure.
Egd Transoral Control Bleeding Any Method,CASE-43255,APC,43255,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1885.95,,"APC Price ($1,796.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1796.14,1885.95,OPPS APC
"Tendon Sheath Incision|RIGHT HAND, THIRD DIGIT",CASE-26055,APC,26055,CPT,0360,RC,,,F7,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1580.37,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1505.12,1580.37,OPPS APC
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],10704.29,,,,,,0,other,5628.97,12272.58,There are no additional notes associated with this service or procedure.
Arthrs Wrst Exc&/Rpr Triang Fibrocart&/Joint|LEFT SIDE,CASE-29846,APC,29846,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],33221.97,,"Fee schedule rate ($33,221.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (47), with a minimum of zero.",,,,0,other,15283.90,38757.79,There are no additional notes associated with this service or procedure.
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],20849.71,,"Case rate ($11,914.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,219.06, add-ons for qualifying new technology services are included. If operating cost exceeds $46,090.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,489.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $9,240.03 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,274.10 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $729.13. The transfer capital threshold is the transfer adjustment factor * $729.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,11914.12,40426.76,All Other Inpatient
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],26966.33,,"Fee schedule rate ($26,966.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,9040.72,26966.33,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITH CC,386,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],8556.53,,"Case rate ($8,556.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,095.56, add-ons for qualifying new technology services are included. If operating cost exceeds $42,966.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,243.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,128.01 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,150.61 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $483.56. The transfer capital threshold is the transfer adjustment factor * $483.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8556.53,19879.00,Inpatient DRG
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],17194.49,,"Fee schedule rate ($17,194.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8554.50,19204.75,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC,817,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],43874.75,,"Fee schedule rate ($43,874.75). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,17396.11,44895.04,There are no additional notes associated with this service or procedure.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,073,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],43475.01,,"Fee schedule rate ($43,475.01). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,12809.38,43475.01,There are no additional notes associated with this service or procedure.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],101083.00,,"Fee schedule rate ($101,083.00). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,35389.50,101083.00,There are no additional notes associated with this service or procedure.
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],16035.06,,"Fee schedule rate ($16,035.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,7396.47,16035.06,There are no additional notes associated with this service or procedure.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH CC,026,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],24150.69,,"Case rate ($23,000.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $21,532.64, add-ons for qualifying new technology services are included. If operating cost exceeds $56,403.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,299.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $19,515.74 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $19,587.69 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,539.98. The transfer capital threshold is the transfer adjustment factor * $1,539.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,23000.66,63202.45,Inpatient DRG
RADIOTHERAPY,849,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],20293.88,,"Case rate ($20,293.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $19,014.57, add-ons for qualifying new technology services are included. If operating cost exceeds $53,885.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,101.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $17,006.91 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $17,069.62 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,342.01. The transfer capital threshold is the transfer adjustment factor * $1,342.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,20293.88,81867.07,Inpatient DRG
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],73546.72,,,,,,0,other,27256.92,81353.66,There are no additional notes associated with this service or procedure.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],22451.27,,"Case rate ($21,382.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,026.97, add-ons for qualifying new technology services are included. If operating cost exceeds $54,897.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,181.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6)) / 2. The base transfer operating payment is the transfer adjustment factor * $18,015.59 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,082.01 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,421.61. The transfer capital threshold is the transfer adjustment factor * $1,421.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,21382.16,85466.62,Inpatient DRG
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],29243.52,,"Fee schedule rate ($29,243.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,14343.25,36024.65,There are no additional notes associated with this service or procedure.
"CESAREAN SECTION WITHOUT STERILIZATION,MAJOR",540,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],11325.56,,"Case rate ($10,786.25). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10786.25,11325.56,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],2070.00,,,,,,0,other,1188.00,12138.74,Estimated amount calculated based on 1 day length of stay.
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC,817,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],43874.75,,"Fee schedule rate ($43,874.75). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,17396.11,44895.04,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],28253.40,,"Fee schedule rate ($28,253.40). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,12126.09,29582.40,There are no additional notes associated with this service or procedure.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],14329.44,,"Case rate ($13,647.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,831.20, add-ons for qualifying new technology services are included. If operating cost exceeds $47,702.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,615.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $10,846.26 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,886.25 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $855.88. The transfer capital threshold is the transfer adjustment factor * $855.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7921.00,45706.73,Inpatient DRG
MAJOR CHEST PROCEDURES WITH CC,164,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],77058.83,,"Fee schedule rate ($77,058.83). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,19037.66,77058.83,There are no additional notes associated with this service or procedure.
Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn,CASE-62323,APC,62323,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],660.72,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,660.72,693.76,OPPS APC
CESAREAN SECTION WITHOUT STERILIZATION WITH CC,787,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],23722.94,,"Fee schedule rate ($23,722.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9508.01,23722.94,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,085,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],18196.93,,"Case rate ($17,330.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,257.72, add-ons for qualifying new technology services are included. If operating cost exceeds $51,128.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,885.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $14,260.20 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,312.77 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,125.27. The transfer capital threshold is the transfer adjustment factor * $1,125.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9282.00,57443.16,Inpatient DRG
HC Remove Lung Catheter,CASE-32552,APC,32552,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],848.96,,"APC Price ($848.96). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,848.96,891.41,OPPS APC
Arthrs Knee W/Meniscectomy Med&Lat W/Shaving|RIGHT SIDE,CASE-29880,APC,29880,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],14803.72,,"Case rate ($14,098.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,251.41, add-ons for qualifying new technology services are included. If operating cost exceeds $48,122.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,648.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $11,264.92 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,306.46 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $888.91. The transfer capital threshold is the transfer adjustment factor * $888.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7332.00,35314.31,Inpatient DRG
OTHER DISORDERS OF NERVOUS SYSTEM WITH CC,092,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],8872.78,,"Case rate ($8,872.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,389.76, add-ons for qualifying new technology services are included. If operating cost exceeds $43,260.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,266.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $6,421.14 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,444.81 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $506.69. The transfer capital threshold is the transfer adjustment factor * $506.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8872.78,26765.51,Inpatient DRG
"OTHER DIGESTIVE SYSTEM DIAGNOSES,MAJOR",254,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],11504.00,,"Case rate ($10,956.19). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10956.19,11504.00,There are no additional notes associated with this service or procedure.
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],31973.49,,"Fee schedule rate ($31,973.49). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,13386.36,33244.29,There are no additional notes associated with this service or procedure.
Brnchsc Ebus Guided Sampl 1/2 Node Station/Strux,CASE-31652,APC,31652,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6605.95,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6605.95,6837.16,OPPS APC
RESPIRATORY NEOPLASMS WITHOUT CC/MCC,182,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],7190.73,,"Case rate ($7,049.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,693.83, add-ons for qualifying new technology services are included. If operating cost exceeds $41,564.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,133.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,731.43 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,748.88 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $373.36. The transfer capital threshold is the transfer adjustment factor * $373.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6965.00,23037.13,Inpatient DRG
Egd Band Ligation Esophgeal/Gastric Varices,CASE-43244,APC,43244,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1885.95,,"APC Price ($1,796.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1796.14,1885.95,OPPS APC
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC,027,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],56363.30,,"Fee schedule rate ($56,363.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,19030.20,56363.30,There are no additional notes associated with this service or procedure.
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],11247.07,,"Case rate ($11,247.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,598.51, add-ons for qualifying new technology services are included. If operating cost exceeds $45,469.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,440.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,621.77 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,653.56 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $680.34. The transfer capital threshold is the transfer adjustment factor * $680.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,11247.07,27028.33,Inpatient DRG
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],53275.26,,"Fee schedule rate ($53,275.26). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,15940.79,53275.26,There are no additional notes associated with this service or procedure.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],52699.33,,"Fee schedule rate ($52,699.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,18105.81,52699.33,There are no additional notes associated with this service or procedure.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],7605.00,,"Per diem ($7,605). If length of stay < 4.8, first 1 days paid at a per diem of $15,210 instead. Capped at $36,505.40.",,,,0,other,7605.00,39153.65,Estimated amount calculated based on 3 day length of stay.
Cysto/Uretero W/Lithotripsy &Indwell Stent Insrt|BILATERAL PROCEDURE,CASE-52356,APC,52356,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5018.77,,"APC Price ($5,018.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5018.77,5269.71,OPPS APC
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],6170.85,,"Fee schedule rate ($6,170.85). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5919.29,13545.65,There are no additional notes associated with this service or procedure.
Colonoscopy W/Biopsy Single/Multiple|SEPARATE STRUCTURE,CASE-45380,APC,45380,CPT,0360,RC,,,XS,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1120.09,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1120.09,1176.09,OPPS APC
SEIZURES WITH MCC,100,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],32323.98,,"Fee schedule rate ($32,323.98). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,15061.09,38110.41,There are no additional notes associated with this service or procedure.
Xpedicul Decompress Throacic Cord|RIGHT SIDE,CASE-63055,APC,63055,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],16689.78,,"Case rate ($16,689.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,661.75, add-ons for qualifying new technology services are included. If operating cost exceeds $50,532.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,838.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $13,666.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,716.80 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,078.42. The transfer capital threshold is the transfer adjustment factor * $1,078.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,16689.78,59521.43,Inpatient DRG
SIGNS AND SYMPTOMS WITH MCC,947,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],30414.32,,"Fee schedule rate ($30,414.32). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,10541.41,30414.32,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITH STERILIZATION WITH MCC,783,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],19499.60,,"Case rate ($18,571.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,411.86, add-ons for qualifying new technology services are included. If operating cost exceeds $52,282.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,975.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $15,410.10 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,466.92 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,216.01. The transfer capital threshold is the transfer adjustment factor * $1,216.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12612.10,23722.94,Inpatient DRG
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,448,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],79697.35,,"Fee schedule rate ($79,697.35). Adds an outlier to normal pricing equal to the per diem rate ($108,215.07) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,30663.95,94077.13,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],10895.60,,"Case rate ($10,895.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,271.55, add-ons for qualifying new technology services are included. If operating cost exceeds $45,142.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,414.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $8,296.01 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,326.60 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $654.64. The transfer capital threshold is the transfer adjustment factor * $654.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10895.60,35192.25,Inpatient DRG
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],15847.88,,"Case rate ($15,093.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,201.05, add-ons for qualifying new technology services are included. If operating cost exceeds $49,072.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,698.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $12,209.80 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,256.10 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $938.47. The transfer capital threshold is the transfer adjustment factor * $938.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,15491.11,54180.83,Inpatient DRG
APPENDIX PROCEDURES WITH MCC,397,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],19071.54,,"Case rate ($18,163.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,032.61, add-ons for qualifying new technology services are included. If operating cost exceeds $51,903.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,946.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $15,032.24 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,087.66 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,186.19. The transfer capital threshold is the transfer adjustment factor * $1,186.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,18163.37,51558.84,Inpatient DRG
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],69000.38,,"Fee schedule rate ($69,000.38). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15), with a minimum of zero.",,,,0,other,26809.29,97015.50,There are no additional notes associated with this service or procedure.
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC,497,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],10127.65,,"Case rate ($10,127.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,557.14, add-ons for qualifying new technology services are included. If operating cost exceeds $44,428.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,358.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 1.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $7,584.22 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,612.19 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $598.47. The transfer capital threshold is the transfer adjustment factor * $598.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10127.65,37761.19,Inpatient DRG
Inj for Sacroiliac Jt Anesth|LEFT SIDE,CASE-G0260,APC,G0260,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],683.85,,"APC Price ($660.72). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,660.72,693.76,OPPS APC
Trurl Electrosurg Rescj Prostate Bleed Complete,CASE-52601,APC,52601,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5018.77,,"APC Price ($5,018.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5018.77,5269.71,OPPS APC
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],13783.20,,"Case rate ($13,783.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,957.83, add-ons for qualifying new technology services are included. If operating cost exceeds $47,828.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,625.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $10,972.42 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,012.88 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $865.83. The transfer capital threshold is the transfer adjustment factor * $865.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,13783.20,41580.51,Inpatient DRG
MAJOR ESOPHAGEAL DISORDERS WITH CC,369,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],9154.30,,"Case rate ($8,718.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,246.12, add-ons for qualifying new technology services are included. If operating cost exceeds $43,117.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,255.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,278.03 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,301.17 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $495.40. The transfer capital threshold is the transfer adjustment factor * $495.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,19680.94,Inpatient DRG
CESAREAN SECTION WITH STERILIZATION WITHOUT CC/MCC,785,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],8431.24,,"Case rate ($8,431.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,979, add-ons for qualifying new technology services are included. If operating cost exceeds $42,850.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,234.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,011.89 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,034.06 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $474.40. The transfer capital threshold is the transfer adjustment factor * $474.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8431.24,20142.33,Inpatient DRG
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],42768.36,,"Fee schedule rate ($42,768.36). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,14295.18,42768.36,There are no additional notes associated with this service or procedure.
Sigmoidoscopy Flx Ndsc US Xm,CASE-45341,APC,45341,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],870.46,,"APC Price ($870.46). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,870.46,913.99,OPPS APC
Colonoscopy Flx Dx W/Collj Spec When Pfrmd|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-45378,APC,45378,CPT,0360,RC,,,74,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],870.46,,"APC Price ($870.46). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,870.46,913.99,OPPS APC
Rpr Aa Hernia 1st 3-10 Cm Ncrc8/Strangulated,CASE-49594,APC,49594,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5941.70,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5658.76,5941.70,OPPS APC
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,095,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],20382.04,,"Case rate ($19,411.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $18,193.69, add-ons for qualifying new technology services are included. If operating cost exceeds $53,064.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,037.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.6. The base transfer operating payment is the transfer adjustment factor * $16,189.05 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $16,248.74 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,277.48. The transfer capital threshold is the transfer adjustment factor * $1,277.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,19411.47,50750.92,Inpatient DRG
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],11113.94,,"Case rate ($10,584.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,998.45, add-ons for qualifying new technology services are included. If operating cost exceeds $44,869.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,376.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $8,023.08 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,053.50 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $616.67. The transfer capital threshold is the transfer adjustment factor * $616.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10846.16,25863.45,Inpatient DRG
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],14796.15,,"Case rate ($8,454.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,001.06, add-ons for qualifying new technology services are included. If operating cost exceeds $42,872.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,236.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,033.86 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,056.11 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $476.13. The transfer capital threshold is the transfer adjustment factor * $476.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,6230.00,22762.43,All Other Inpatient
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC,027,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],56363.30,,"Fee schedule rate ($56,363.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,19030.20,56363.30,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],13952.52,,"Case rate ($13,952.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,115.33, add-ons for qualifying new technology services are included. If operating cost exceeds $47,986.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,638.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $11,129.34 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,170.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $878.22. The transfer capital threshold is the transfer adjustment factor * $878.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,13917.42,34889.29,Inpatient DRG
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],33321.87,,"Fee schedule rate ($33,321.87). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.9), with a minimum of zero.",,,,0,other,13917.42,34889.29,There are no additional notes associated with this service or procedure.
VAGINAL DELIVERY WITH O.R. PROCEDURES EXCEPT STERILIZATION AND/OR D&C,768,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],12088.81,,"Fee schedule rate ($12,088.81). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6426.91,13416.00,There are no additional notes associated with this service or procedure.
Esophagoscopy Flexible Transoral Ultrasound Exam,CASE-43231,APC,43231,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1796.14,,"APC Price ($1,796.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1796.14,1885.95,OPPS APC
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],15076.44,,"Fee schedule rate ($15,076.44). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6340.03,15076.44,There are no additional notes associated with this service or procedure.
VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC,033,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],42156.44,,"Fee schedule rate ($42,156.44). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,13206.23,42156.44,There are no additional notes associated with this service or procedure.
RESPIRATORY NEOPLASMS WITH CC,181,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],20127.30,,"Fee schedule rate ($20,127.30). Adds an outlier to normal pricing equal to the per diem rate ($54,966.40) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,9197.84,21074.07,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],12818.71,,"Fee schedule rate ($12,818.71). Adds an outlier to normal pricing equal to the per diem rate ($42,942.49) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,6564.18,17651.07,There are no additional notes associated with this service or procedure.
Unlisted Procedure Spine,CASE-22899,APC,22899,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],16412.07,,"APC Price ($16,412.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,16412.07,16412.07,OPPS APC
"ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",770,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],8962.64,,"Case rate ($8,535.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,088.62, add-ons for qualifying new technology services are included. If operating cost exceeds $42,959.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,230.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $6,120.47 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,143.67 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $470.43. The transfer capital threshold is the transfer adjustment factor * $470.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8735.30,19730.13,Inpatient DRG
"HC Aerosol, Hhn, Mdi, Ippb",CASE-94640,APC,94640,CPT,0410,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3299.47,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3299.47,3464.44,OPPS APC
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC",458,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],30202.09,,"Case rate ($30,202.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $28,231.97, add-ons for qualifying new technology services are included. If operating cost exceeds $63,102.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,826.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $26,190.45 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $26,287.02 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,066.69. The transfer capital threshold is the transfer adjustment factor * $2,066.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,30202.09,132827.25,Inpatient DRG
O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC,621,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],12159.94,,"Case rate ($12,159.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,447.74, add-ons for qualifying new technology services are included. If operating cost exceeds $46,318.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,507.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $9,467.88 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,502.79 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $747.11. The transfer capital threshold is the transfer adjustment factor * $747.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12159.94,36669.96,Inpatient DRG
Exc Prtd Tum/Prtd Glnd Lat Dsj&Prsrv Facial Nr|RIGHT SIDE,CASE-42415,APC,42415,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5735.04,,"APC Price ($5,541.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5541.10,5818.16,OPPS APC
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,167,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],43522.37,,"Fee schedule rate ($43,522.37). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,14157.71,43522.37,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],29582.40,,,,,,0,other,12126.09,29582.40,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],51903.64,,"Fee schedule rate ($51,903.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,16017.99,51903.64,There are no additional notes associated with this service or procedure.
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],45017.13,,"Fee schedule rate ($45,017.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,14603.31,45017.13,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7847.99,,"Case rate ($7,474.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,099.09, add-ons for qualifying new technology services are included. If operating cost exceeds $41,970.10 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,154.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,134.67 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,154.14 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $394.66. The transfer capital threshold is the transfer adjustment factor * $394.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7641.61,19371.27,Inpatient DRG
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],22762.43,,"Fee schedule rate ($22,762.43). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6230.00,22762.43,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],9492.76,,"Case rate ($9,040.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,546, add-ons for qualifying new technology services are included. If operating cost exceeds $43,417.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,278.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,576.80 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,601.05 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $518.97. The transfer capital threshold is the transfer adjustment factor * $518.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9040.72,26966.33,Inpatient DRG
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH CC",457,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],160549.49,,"Fee schedule rate ($160,549.49). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,42327.47,160549.49,There are no additional notes associated with this service or procedure.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],52909.62,,"Fee schedule rate ($52,909.62). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,23344.70,62179.32,There are no additional notes associated with this service or procedure.
"Inj Dx/Ther Agnt Paravert Facet Joint, Cerv/Thorac, 2nd Level|LEFT SIDE",CASE-64491,APC,64491,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],869.28,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,827.89,869.28,OPPS APC
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],12404.38,,,,,,0,other,6214.05,15318.94,There are no additional notes associated with this service or procedure.
NERVOUS SYSTEM NEOPLASMS WITH MCC,054,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],12530.92,,"Case rate ($12,285.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,564.29, add-ons for qualifying new technology services are included. If operating cost exceeds $46,435.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,516.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $9,584.00 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,619.34 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $756.27. The transfer capital threshold is the transfer adjustment factor * $756.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6965.00,30044.81,Inpatient DRG
"Remove Spinal Neurostim Electrode Plate/Paddle, Incl Fluoro",CASE-63662,APC,63662,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3436.06,,"APC Price ($3,272.44). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3272.44,3436.06,OPPS APC
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],13092.47,,"Case rate ($13,092.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,315.24, add-ons for qualifying new technology services are included. If operating cost exceeds $47,186.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,575.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $10,332.19 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,370.29 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $815.31. The transfer capital threshold is the transfer adjustment factor * $815.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,13092.47,33159.45,Inpatient DRG
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],36094.03,,"Fee schedule rate ($36,094.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11194.25,36094.03,There are no additional notes associated with this service or procedure.
Cysto W/Insert Ureteral Stent|RIGHT SIDE,CASE-52332,APC,52332,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3464.44,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3299.47,3464.44,OPPS APC
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],20170.75,,"Fee schedule rate ($20,170.75). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10048.39,23545.50,There are no additional notes associated with this service or procedure.
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],14690.49,,"Fee schedule rate ($14,690.49). Adds an outlier to normal pricing equal to the per diem rate ($54,770.58) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.7), with a minimum of zero.",,,,0,other,7238.69,16804.22,There are no additional notes associated with this service or procedure.
POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES,769,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],29791.03,,"Fee schedule rate ($29,791.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,13388.39,33250.19,There are no additional notes associated with this service or procedure.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],16017.90,,"Case rate ($15,476.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,532.81, add-ons for qualifying new technology services are included. If operating cost exceeds $49,403.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,749.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $12,541.62 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,587.86 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $989.66. The transfer capital threshold is the transfer adjustment factor * $989.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,15476.23,42787.31,Inpatient DRG
POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES,769,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],29791.03,,"Fee schedule rate ($29,791.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,13388.39,33250.19,There are no additional notes associated with this service or procedure.
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],21992.44,,"Case rate ($21,248.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $19,902.85, add-ons for qualifying new technology services are included. If operating cost exceeds $54,773.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,171.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.3. The base transfer operating payment is the transfer adjustment factor * $17,891.94 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $17,957.90 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,411.85. The transfer capital threshold is the transfer adjustment factor * $1,411.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,21248.73,56089.29,Inpatient DRG
KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,689,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],22417.63,,"Fee schedule rate ($22,417.63). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,9802.58,22831.22,There are no additional notes associated with this service or procedure.
Rpr Coltrl Ligm Mtcarphlngl/Iphal Jt,CASE-26540,APC,26540,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],42787.31,,"Fee schedule rate ($42,787.31). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,15476.23,42787.31,There are no additional notes associated with this service or procedure.
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],21248.73,,"Case rate ($21,248.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $19,902.85, add-ons for qualifying new technology services are included. If operating cost exceeds $54,773.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,171.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.3. The base transfer operating payment is the transfer adjustment factor * $17,891.94 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $17,957.90 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,411.85. The transfer capital threshold is the transfer adjustment factor * $1,411.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,21248.73,56089.29,Inpatient DRG
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC",923,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],8208.75,,"Case rate ($8,047.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $7,588.71, add-ons for qualifying new technology services are included. If operating cost exceeds $46,233.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $3,215.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,201.30 + an uncompensated DSH payment of $1,359.91. The transfer operating threshold is the transfer adjustment factor * $6,228.80 + an uncompensated DSH payment of $1,359.91. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $486.59. The transfer capital threshold is the transfer adjustment factor * $486.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6965.00,20068.57,Inpatient DRG
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],28394.78,,"Fee schedule rate ($28,394.78). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11454.97,28394.78,There are no additional notes associated with this service or procedure.
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],15484.93,,"Case rate ($14,747.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,854.94, add-ons for qualifying new technology services are included. If operating cost exceeds $48,725.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,696.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $11,866.24 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,909.99 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $936.36. The transfer capital threshold is the transfer adjustment factor * $936.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,14747.55,37899.49,Inpatient DRG
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC",156,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],12624.95,,"Fee schedule rate ($12,624.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6625.12,13598.77,There are no additional notes associated with this service or procedure.
CERVICAL SPINAL FUSION WITH CC,472,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],55366.06,,"Fee schedule rate ($55,366.06). Adds an outlier to normal pricing equal to the per diem rate ($66,990.29) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,21896.13,70198.84,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],37914.65,,"Fee schedule rate ($37,914.65). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9865.56,37914.65,There are no additional notes associated with this service or procedure.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC,862,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],15009.94,,"Case rate ($14,295.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,434.11, add-ons for qualifying new technology services are included. If operating cost exceeds $48,305.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,663.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $11,446.95 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,489.15 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $903.28. The transfer capital threshold is the transfer adjustment factor * $903.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6855.00,35884.94,Inpatient DRG
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC,058,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],40853.02,,"Fee schedule rate ($40,853.02). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,13521.80,40853.02,There are no additional notes associated with this service or procedure.
"MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS,MINOR",532,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],2696.74,,"Case rate for a one day stay ($2,568.32). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,2568.32,2696.74,There are no additional notes associated with this service or procedure.
HC Joint Injection/Aspir Large WO US,CASE-20610,APC,20610,CPT,0510,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],301.68,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,287.31,301.68,OPPS APC
PERIPHERAL VASCULAR DISORDERS WITH CC,300,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],20331.78,,"Fee schedule rate ($20,331.78). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,9174.14,21005.20,There are no additional notes associated with this service or procedure.
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC,806,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],10071.17,,"Fee schedule rate ($10,071.17). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5354.25,13416.00,There are no additional notes associated with this service or procedure.
TRAUMATIC INJURY WITH MCC,913,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],42838.46,,"Fee schedule rate ($42,838.46). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13014.58,42838.46,There are no additional notes associated with this service or procedure.
SPINAL PROCEDURES WITHOUT CC/MCC,030,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],16810.99,,"Case rate ($16,810.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,774.52, add-ons for qualifying new technology services are included. If operating cost exceeds $50,645.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,847.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $13,778.77 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,829.57 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,087.28. The transfer capital threshold is the transfer adjustment factor * $1,087.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,16810.99,44714.01,Inpatient DRG
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],19371.27,,"Fee schedule rate ($19,371.27). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8643.20,19462.52,There are no additional notes associated with this service or procedure.
"Amputation Toe Interphalangeal Joint|RIGHT FOOT, SECOND DIGIT",CASE-28825,APC,28825,CPT,0360,RC,,,T6,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
"NEONATE BIRTH WEIGHT 1500-1999 GRAMS WITH RESPIRATORY DISTRESS SYNDROME OR OTHER MAJOR RESPIRATORY CONDITION,MINOR",612,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],10963.86,,"Case rate ($10,963.86). Base payment rate plus any adjustments related to outliers.",,,,0,other,10963.86,11512.05,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],29058.99,,,,,,0,other,6167.00,29058.99,There are no additional notes associated with this service or procedure.
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],39424.57,,"Fee schedule rate ($39,424.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12195.15,39424.57,There are no additional notes associated with this service or procedure.
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC",514,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],9311.44,,"Case rate ($8,868.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,385.35, add-ons for qualifying new technology services are included. If operating cost exceeds $43,256.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,266.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $6,416.74 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,440.40 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $506.34. The transfer capital threshold is the transfer adjustment factor * $506.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8868.04,22699.91,Inpatient DRG
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],15456.59,,"Case rate ($15,456.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,514.54, add-ons for qualifying new technology services are included. If operating cost exceeds $49,385.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,748.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $12,523.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,569.59 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $988.22. The transfer capital threshold is the transfer adjustment factor * $988.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,15456.59,41402.42,Inpatient DRG
BRONCHITIS AND ASTHMA WITHOUT CC/MCC,203,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],5927.78,,"Case rate ($5,927.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $5,614.23, add-ons for qualifying new technology services are included. If operating cost exceeds $44,258.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $3,061.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,235.54 + an uncompensated DSH payment of $1,359.91. The transfer operating threshold is the transfer adjustment factor * $4,254.32 + an uncompensated DSH payment of $1,359.91. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $332.34. The transfer capital threshold is the transfer adjustment factor * $332.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,4763.76,13707.00,Inpatient DRG
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],87909.90,,"Fee schedule rate ($87,909.90). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,33623.33,133270.57,There are no additional notes associated with this service or procedure.
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITHOUT CC/MCC",630,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],11828.78,,"Case rate ($11,828.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,139.67, add-ons for qualifying new technology services are included. If operating cost exceeds $46,010.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,482.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $9,160.95 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,194.72 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $722.89. The transfer capital threshold is the transfer adjustment factor * $722.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,11828.78,42541.02,Inpatient DRG
Realignment Extensor Tendon Hand Each Tendon,CASE-26437,APC,26437,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],19824.58,,"Case rate ($19,435.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $18,216.37, add-ons for qualifying new technology services are included. If operating cost exceeds $53,087.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,039.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.9. The base transfer operating payment is the transfer adjustment factor * $16,211.64 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $16,271.42 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,279.26. The transfer capital threshold is the transfer adjustment factor * $1,279.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,19435.86,50821.76,Inpatient DRG
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC,964,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],34154.06,,"Fee schedule rate ($34,154.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12323.82,34154.06,There are no additional notes associated with this service or procedure.
Laps Surg Bilateral Total Pelvic Lmphadectomy,CASE-38571,APC,38571,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],9949.78,,"APC Price ($9,949.78). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,9949.78,10447.27,OPPS APC
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],27589.62,,"Fee schedule rate ($27,589.62). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12566.28,30861.41,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],16818.89,,"Case rate ($16,017.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,036.80, add-ons for qualifying new technology services are included. If operating cost exceeds $49,907.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,789.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $13,043.76 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,091.85 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,029.28. The transfer capital threshold is the transfer adjustment factor * $1,029.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,16017.99,51903.64,Inpatient DRG
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],14789.23,,,,,,0,other,6965.00,21089.59,There are no additional notes associated with this service or procedure.
O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC,621,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],29680.79,,,,,,0,other,12159.94,36669.96,There are no additional notes associated with this service or procedure.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6917.29,,"Case rate ($6,683.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,353, add-ons for qualifying new technology services are included. If operating cost exceeds $41,224.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,106.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,391.86 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,408.05 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $346.56. The transfer capital threshold is the transfer adjustment factor * $346.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6683.37,14699.43,Inpatient DRG
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],16804.22,,"Fee schedule rate ($16,804.22). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7238.69,16804.22,There are no additional notes associated with this service or procedure.
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],25568.81,,"Case rate ($14,610.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,727.68, add-ons for qualifying new technology services are included. If operating cost exceeds $48,598.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,686.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.6. The base transfer operating payment is the transfer adjustment factor * $11,739.44 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,782.73 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $926.36. The transfer capital threshold is the transfer adjustment factor * $926.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,6277.00,36801.89,All Other Inpatient
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,057,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],10984.18,,"Case rate ($10,461.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,883.26, add-ons for qualifying new technology services are included. If operating cost exceeds $44,754.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,367.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $7,908.32 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,938.31 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $607.85. The transfer capital threshold is the transfer adjustment factor * $607.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10718.84,39884.93,Inpatient DRG
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],43703.12,,"Fee schedule rate ($43,703.12). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.7), with a minimum of zero.",,,,0,other,17693.40,52449.26,There are no additional notes associated with this service or procedure.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],36776.05,,"Fee schedule rate ($36,776.05). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11053.39,36776.05,There are no additional notes associated with this service or procedure.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC,099,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],22084.20,,"Fee schedule rate ($22,084.20). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11171.21,26807.94,There are no additional notes associated with this service or procedure.
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],9685.19,,"Fee schedule rate ($9,685.19). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7414.07,18217.52,There are no additional notes associated with this service or procedure.
NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,601,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],6042.05,,"Case rate ($6,042.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,756.39, add-ons for qualifying new technology services are included. If operating cost exceeds $40,627.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,059.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $3,797.45 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,811.45 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $299.66. The transfer capital threshold is the transfer adjustment factor * $299.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6042.05,12359.72,Inpatient DRG
Laparoscopy Tot Hysterectomy >250 G W/Tube/Ovar,CASE-58573,APC,58573,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],10447.27,,"APC Price ($9,949.78). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,9949.78,10447.27,OPPS APC
Conization Cervix W/WO D&C Rpr Knife/Laser,CASE-57520,APC,57520,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3030.03,,"APC Price ($3,030.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3030.03,3181.53,OPPS APC
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],8734.05,,"Case rate ($8,318.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,873.80, add-ons for qualifying new technology services are included. If operating cost exceeds $42,744.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,226.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,907.07 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,928.85 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $466.13. The transfer capital threshold is the transfer adjustment factor * $466.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8318.14,19763.43,Inpatient DRG
Bronchoscopy W/Transbroncl Ndl Aspir Bx Ea Lobe,CASE-31633,APC,31633,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6837.16,,"APC Price ($6,605.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6605.95,6936.25,OPPS APC
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],11695.90,,"Case rate ($6,683.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,353, add-ons for qualifying new technology services are included. If operating cost exceeds $41,224.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,106.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,391.86 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,408.05 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $346.56. The transfer capital threshold is the transfer adjustment factor * $346.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,6683.37,14699.43,All Other Inpatient
"CARDIAC ARREST, UNEXPLAINED WITH MCC",296,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],36459.67,,"Fee schedule rate ($36,459.67). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12522.25,36459.67,There are no additional notes associated with this service or procedure.
PLEURAL EFFUSION WITH MCC,186,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],29692.94,,"Fee schedule rate ($29,692.94). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10804.96,31089.66,There are no additional notes associated with this service or procedure.
Colonoscopy W/Biopsy Single/Multiple|SEPARATE STRUCTURE,CASE-45380,APC,45380,CPT,0360,RC,,,XS,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1159.29,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1120.09,1176.09,OPPS APC
"SINGLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL,MINOR",300,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],31065.00,,"Case rate ($31,065.00). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,31065.00,32618.25,There are no additional notes associated with this service or procedure.
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],23385.72,,"Fee schedule rate ($23,385.72). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,23385.72,There are no additional notes associated with this service or procedure.
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],15818.84,,"Case rate ($15,283.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,353.89, add-ons for qualifying new technology services are included. If operating cost exceeds $49,224.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,735.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.2. The base transfer operating payment is the transfer adjustment factor * $12,363.36 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,408.94 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $975.59. The transfer capital threshold is the transfer adjustment factor * $975.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,15283.90,38757.79,Inpatient DRG
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],32293.66,,"Fee schedule rate ($32,293.66). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,32293.66,There are no additional notes associated with this service or procedure.
BRONCHITIS AND ASTHMA WITH CC/MCC,202,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],14307.27,,"Fee schedule rate ($14,307.27). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7606.34,19110.30,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],34391.19,,"Fee schedule rate ($34,391.19). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,14337.84,52803.53,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],23851.92,,"Case rate ($23,851.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $22,324.54, add-ons for qualifying new technology services are included. If operating cost exceeds $57,195.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,362.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.8. The base transfer operating payment is the transfer adjustment factor * $20,304.73 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $20,379.59 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,602.24. The transfer capital threshold is the transfer adjustment factor * $1,602.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,23851.92,63653.13,Inpatient DRG
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",063,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],11451.58,,"Case rate ($11,451.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,788.77, add-ons for qualifying new technology services are included. If operating cost exceeds $45,659.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,455.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $8,811.33 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,843.82 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $695.30. The transfer capital threshold is the transfer adjustment factor * $695.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,35701.87,Inpatient DRG
Replacement Tissue Expander W/Permanent Implant,CASE-11970,APC,11970,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6791.99,7131.59,OPPS APC
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,426,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],207121.41,,"Fee schedule rate ($207,121.41). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,76581.29,216864.15,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],10358.84,,"Case rate ($9,865.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,313.33, add-ons for qualifying new technology services are included. If operating cost exceeds $44,184.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,339.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $7,341.31 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,368.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $579.30. The transfer capital threshold is the transfer adjustment factor * $579.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9865.56,37914.65,Inpatient DRG
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],34892.92,,"Fee schedule rate ($34,892.92). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,6965.00,41030.48,There are no additional notes associated with this service or procedure.
"Partical Excision Bone Phalanx Toe|LEFT FOOT, THIRD DIGIT",CASE-28124,APC,28124,CPT,0360,RC,,,T2,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
Implant Neurostim/Receiver,CASE-64590,APC,64590,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],18158.97,,"APC Price ($18,158.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,18158.97,19066.92,OPPS APC
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],33890.73,,"Fee schedule rate ($33,890.73). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6277.00,36801.89,There are no additional notes associated with this service or procedure.
Colonoscopy Flx W/Endoscopic Mucosal Resection|UNUSUAL NON-OVERLAPPING SERVICE|COLORECTAL CANCER SCREEN,CASE-45390,APC,45390,CPT,0360,RC,,,XU|PT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],2689.02,,"APC Price ($2,598.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2598.08,2727.99,OPPS APC
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],16017.99,,"Case rate ($16,017.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,036.80, add-ons for qualifying new technology services are included. If operating cost exceeds $49,907.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,789.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $13,043.76 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,091.85 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,029.28. The transfer capital threshold is the transfer adjustment factor * $1,029.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,16017.99,51903.64,Inpatient DRG
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],38378.80,,"Fee schedule rate ($38,378.80). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,14370.36,38378.80,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,394,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],8571.41,,"Case rate ($8,281.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,839.77, add-ons for qualifying new technology services are included. If operating cost exceeds $42,710.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,223.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,873.17 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,894.83 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $463.45. The transfer capital threshold is the transfer adjustment factor * $463.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,8281.56,20909.61,Inpatient DRG
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],18751.20,,"Case rate ($18,751.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,579.45, add-ons for qualifying new technology services are included. If operating cost exceeds $52,450.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,989.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $15,577.06 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,634.50 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,229.18. The transfer capital threshold is the transfer adjustment factor * $1,229.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8480.00,59081.91,Inpatient DRG
HC Inj Anes/Steroid C/D Facet Sg,CASE-64490,APC,64490,CPT,0361,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],869.28,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,827.89,869.28,OPPS APC
Optx Dstl Radl I-Artic Fx/Epiphysl Sep 2 Frag|RIGHT SIDE,CASE-25608,APC,25608,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7029.71,OPPS APC
HC Bx Breast 1st Lesion US Img|BILATERAL PROCEDURE,CASE-19083,APC,19083,CPT,0361,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],2854.83,,"APC Price ($2,718.88). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2718.88,2854.83,OPPS APC
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],22058.83,,"Case rate ($21,008.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $19,714.85, add-ons for qualifying new technology services are included. If operating cost exceeds $54,585.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,120.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $17,702.78 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $17,769.90 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,360.68. The transfer capital threshold is the transfer adjustment factor * $1,360.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,21585.31,73588.10,Inpatient DRG
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],7332.00,,"Per diem ($7,332). If length of stay < 4.6, first 1 days paid at a per diem of $14,664 instead. Capped at $33,727.80.",,,,0,other,7332.00,35314.31,Estimated amount calculated based on 3 day length of stay.
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITH MCC,429,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],66106.51,,"Case rate ($62,958.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $58,704.65, add-ons for qualifying new technology services are included. If operating cost exceeds $93,575.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $6,222.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.6. The base transfer operating payment is the transfer adjustment factor * $56,551.19 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $56,759.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,462.45. The transfer capital threshold is the transfer adjustment factor * $4,462.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,62958.58,177294.98,Inpatient DRG
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],24989.04,,"Case rate ($23,799.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $22,275.40, add-ons for qualifying new technology services are included. If operating cost exceeds $57,146.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,358.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.1. The base transfer operating payment is the transfer adjustment factor * $20,255.77 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $20,330.45 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,598.38. The transfer capital threshold is the transfer adjustment factor * $1,598.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,23799.09,63499.65,Inpatient DRG
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],18105.81,,"Case rate ($18,105.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,979.06, add-ons for qualifying new technology services are included. If operating cost exceeds $51,850.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,941.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $14,978.89 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,034.11 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,181.98. The transfer capital threshold is the transfer adjustment factor * $1,181.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,18105.81,52699.33,Inpatient DRG
INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC,198,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],13459.55,,"Fee schedule rate ($13,459.55). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.7), with a minimum of zero.",,,,0,other,6795.12,23505.07,There are no additional notes associated with this service or procedure.
"NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY",789,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],14644.80,,"Case rate ($14,149.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,298.65, add-ons for qualifying new technology services are included. If operating cost exceeds $48,169.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,652.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $11,312.00 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,353.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $892.63. The transfer capital threshold is the transfer adjustment factor * $892.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,3054.00,14857.05,Inpatient DRG
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],8057.83,,"Case rate ($7,674.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,285.36, add-ons for qualifying new technology services are included. If operating cost exceeds $42,156.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,168.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,320.23 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,340.41 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $408.93. The transfer capital threshold is the transfer adjustment factor * $408.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7847.50,17755.26,Inpatient DRG
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],24672.87,,"Case rate ($14,098.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,251.41, add-ons for qualifying new technology services are included. If operating cost exceeds $48,122.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,648.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $11,264.92 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,306.46 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $888.91. The transfer capital threshold is the transfer adjustment factor * $888.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,7332.00,35314.31,All Other Inpatient
Repair Intermediate S/a/T/E >30.0 Cm|SEPARATE STRUCTURE,CASE-12037,APC,12037,CPT,0360,RC,,,XS,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1545.93,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1545.93,1623.23,OPPS APC
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH MCC",722,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],14200.37,,"Case rate ($14,200.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,345.91, add-ons for qualifying new technology services are included. If operating cost exceeds $48,216.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,656.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $11,359.07 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,400.95 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $896.34. The transfer capital threshold is the transfer adjustment factor * $896.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,14200.37,56869.13,Inpatient DRG
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],8524.90,,"Fee schedule rate ($8,524.90). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,7396.47,16035.06,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],13421.68,,,,,,0,other,6564.18,17651.07,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC,832,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],9034.88,,"Fee schedule rate ($9,034.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4803.31,14198.92,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC,087,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],8139.36,,"Case rate ($8,139.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,707.48, add-ons for qualifying new technology services are included. If operating cost exceeds $42,578.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,213.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $5,741.36 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,762.53 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $453.05. The transfer capital threshold is the transfer adjustment factor * $453.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8139.36,22679.07,Inpatient DRG
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],133270.57,,"Fee schedule rate ($133,270.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,33623.33,133270.57,There are no additional notes associated with this service or procedure.
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],29216.99,,"Fee schedule rate ($29,216.99). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9755.86,29216.99,There are no additional notes associated with this service or procedure.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],24161.76,,"Case rate ($23,344.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $21,852.68, add-ons for qualifying new technology services are included. If operating cost exceeds $56,723.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,325.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $19,834.60 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $19,907.73 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,565.15. The transfer capital threshold is the transfer adjustment factor * $1,565.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,23344.70,62179.32,Inpatient DRG
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,068,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],23184.90,,"Fee schedule rate ($23,184.90). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,23184.90,There are no additional notes associated with this service or procedure.
Esophagoscopy Intra/Transmural Needle Aspirat/Bx,CASE-43232,APC,43232,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1859.01,,"APC Price ($1,796.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1796.14,1885.95,OPPS APC
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],19371.27,,"Fee schedule rate ($19,371.27). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7641.61,19371.27,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],13947.32,,"Fee schedule rate ($13,947.32). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6153.12,13947.32,There are no additional notes associated with this service or procedure.
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],17255.73,,"Fee schedule rate ($17,255.73). Adds an outlier to normal pricing equal to the per diem rate ($43,191.57) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,8163.06,18067.42,There are no additional notes associated with this service or procedure.
Surg Nasopharyngoscopy Dilat Eustachian Tube Bi,CASE-69706,APC,69706,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5541.10,,"APC Price ($5,541.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5541.10,5818.16,OPPS APC
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],30636.35,,"Fee schedule rate ($30,636.35). Adds an outlier to normal pricing equal to the per diem rate ($67,650.85) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12984.79,32077.45,There are no additional notes associated with this service or procedure.
Repair Each Addnl Digit Nerve,CASE-64832,APC,64832,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
Inj for Sacroiliac Jt Anesth|LEFT SIDE,CASE-G0260,APC,G0260,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],693.76,,"APC Price ($660.72). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,660.72,693.76,OPPS APC
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC",061,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],51814.18,,"Fee schedule rate ($51,814.18). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,20616.23,62315.82,There are no additional notes associated with this service or procedure.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],15628.19,,"Case rate ($15,099.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,182.53, add-ons for qualifying new technology services are included. If operating cost exceeds $49,053.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,722.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $12,192.63 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,237.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $962.12. The transfer capital threshold is the transfer adjustment factor * $962.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,7605.00,39153.65,Inpatient DRG
"CESAREAN SECTION WITHOUT STERILIZATION,MAJOR",540,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],10786.25,,"Case rate ($10,786.25). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,10786.25,11325.56,There are no additional notes associated with this service or procedure.
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],9777.20,,"Case rate ($9,311.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,798, add-ons for qualifying new technology services are included. If operating cost exceeds $43,669.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,298.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $6,827.87 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,853.05 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $538.79. The transfer capital threshold is the transfer adjustment factor * $538.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,21404.64,Inpatient DRG
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],133270.57,,"Fee schedule rate ($133,270.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,33623.33,133270.57,There are no additional notes associated with this service or procedure.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],23618.74,,"Fee schedule rate ($23,618.74). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10533.95,24956.34,There are no additional notes associated with this service or procedure.
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],9520.30,,"Case rate ($9,066.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,583.69, add-ons for qualifying new technology services are included. If operating cost exceeds $43,454.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,268.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,613.67 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,638.74 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $508.34. The transfer capital threshold is the transfer adjustment factor * $508.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9282.47,21320.03,Inpatient DRG
UNGROUPABLE,999,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],161307.29,,"Fee schedule rate ($161,307.29). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (41), with a minimum of zero.",,,,0,other,10228.00,161307.29,There are no additional notes associated with this service or procedure.
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],21888.80,,"Case rate ($20,846.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $19,528.64, add-ons for qualifying new technology services are included. If operating cost exceeds $54,399.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,142.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $17,519.09 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $17,583.69 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,382.43. The transfer capital threshold is the transfer adjustment factor * $1,382.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,20846.48,81306.30,Inpatient DRG
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC,058,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],40853.02,,"Fee schedule rate ($40,853.02). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,13521.80,40853.02,There are no additional notes associated with this service or procedure.
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],37488.28,,"Fee schedule rate ($37,488.28). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.5), with a minimum of zero.",,,,0,other,15453.88,39251.68,There are no additional notes associated with this service or procedure.
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7616.10,,"Case rate ($7,253.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,893.22, add-ons for qualifying new technology services are included. If operating cost exceeds $41,764.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,138.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $4,929.58 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,948.27 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $378.90. The transfer capital threshold is the transfer adjustment factor * $378.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7414.07,18217.52,Inpatient DRG
COAGULATION DISORDERS,813,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],21480.18,,"Case rate ($12,274.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,554.21, add-ons for qualifying new technology services are included. If operating cost exceeds $46,425.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,515.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $9,573.96 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,609.26 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $755.48. The transfer capital threshold is the transfer adjustment factor * $755.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,12274.39,30013.33,All Other Inpatient
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],78960.67,,"Fee schedule rate ($78,960.67). Adds an outlier to normal pricing equal to the per diem rate ($149,567.78) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19.1), with a minimum of zero.",,,,0,other,30398.48,82674.88,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],19152.11,,"Case rate ($19,152.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,952.40, add-ons for qualifying new technology services are included. If operating cost exceeds $52,823.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,018.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $15,948.65 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $16,007.45 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,258.51. The transfer capital threshold is the transfer adjustment factor * $1,258.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,19152.11,53152.12,Inpatient DRG
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],7560.98,,"Case rate ($7,412.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,031.50, add-ons for qualifying new technology services are included. If operating cost exceeds $41,902.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,159.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $5,067.86 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,086.55 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $399.90. The transfer capital threshold is the transfer adjustment factor * $399.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6148.93,15887.21,Inpatient DRG
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],37917.69,,"Case rate ($21,667.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,292.19, add-ons for qualifying new technology services are included. If operating cost exceeds $55,163.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,202.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $18,279.84 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,347.24 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,442.46. The transfer capital threshold is the transfer adjustment factor * $1,442.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,8972.00,81524.17,All Other Inpatient
HC Inj Anes/Steroid C/D Facet Sg|RIGHT SIDE,CASE-64490,APC,64490,CPT,0361,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],827.89,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,827.89,869.28,OPPS APC
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC,817,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],43874.75,,"Fee schedule rate ($43,874.75). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,17396.11,44895.04,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,066,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6579.76,,"Case rate ($6,579.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,256.61, add-ons for qualifying new technology services are included. If operating cost exceeds $41,127.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,098.96, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $4,295.82 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,311.66 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $338.98. The transfer capital threshold is the transfer adjustment factor * $338.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6579.76,20083.61,Inpatient DRG
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],20401.88,,"Fee schedule rate ($20,401.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,20401.88,There are no additional notes associated with this service or procedure.
Excision Choledochal Cyst,CASE-47715,APC,47715,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],6067.55,,"Case rate ($5,778.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,511.33, add-ons for qualifying new technology services are included. If operating cost exceeds $40,382.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,040.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $3,553.28 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,566.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $280.39. The transfer capital threshold is the transfer adjustment factor * $280.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5778.62,11681.49,Inpatient DRG
"Open Tx Metacarpal Fracture Single Ea Bone|LEFT HAND, FOURTH DIGIT",CASE-26615,APC,26615,CPT,0360,RC,,,F3,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
Neuroplasty &/Transposition Ulnar Nerve Elbow|RIGHT SIDE,CASE-64718,APC,64718,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1827.80,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1827.80,1919.19,OPPS APC
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],28038.61,,"Fee schedule rate ($28,038.61). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12126.09,29582.40,There are no additional notes associated with this service or procedure.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],33197.83,,"Fee schedule rate ($33,197.83). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.8), with a minimum of zero.",,,,0,other,13907.80,52794.06,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITHOUT STERILIZATION WITH CC,787,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],9840.79,,"Case rate ($9,508.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,980.70, add-ons for qualifying new technology services are included. If operating cost exceeds $43,851.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,313.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $7,009.90 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,035.74 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $553.15. The transfer capital threshold is the transfer adjustment factor * $553.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,9508.01,23722.94,Inpatient DRG
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC",629,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],17534.94,,"Case rate ($16,699.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,671.20, add-ons for qualifying new technology services are included. If operating cost exceeds $50,542.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,839.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $13,675.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,726.25 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,079.16. The transfer capital threshold is the transfer adjustment factor * $1,079.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,16699.94,44657.18,Inpatient DRG
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],14845.26,,"Case rate ($14,343.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,478.83, add-ons for qualifying new technology services are included. If operating cost exceeds $48,349.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,666.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $11,491.51 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,533.88 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $906.79. The transfer capital threshold is the transfer adjustment factor * $906.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,14343.25,36024.65,Inpatient DRG
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],17524.27,,"Case rate ($16,689.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,661.75, add-ons for qualifying new technology services are included. If operating cost exceeds $50,532.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,838.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $13,666.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,716.80 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,078.42. The transfer capital threshold is the transfer adjustment factor * $1,078.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,16689.78,59521.43,Inpatient DRG
"CVA AND PRECEREBRAL OCCLUSION WITH INFARCTION,MAJOR",045,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],14380.85,,"Case rate ($13,696.05). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,13696.05,14380.85,There are no additional notes associated with this service or procedure.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],23691.11,,,,,,0,other,10098.51,24259.09,There are no additional notes associated with this service or procedure.
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],34032.82,,"Fee schedule rate ($34,032.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,15233.11,38610.21,There are no additional notes associated with this service or procedure.
Laparoscopy W/Rmvl Adnexal Structures,CASE-58661,APC,58661,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5941.70,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5658.76,5941.70,OPPS APC
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],7842.75,,"Case rate ($7,842.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,431.55, add-ons for qualifying new technology services are included. If operating cost exceeds $42,302.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,191.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $5,466.44 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,486.60 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $431.36. The transfer capital threshold is the transfer adjustment factor * $431.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,5280.00,17136.70,Inpatient DRG
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,699,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],19570.20,,"Fee schedule rate ($19,570.20). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5961.00,19972.16,There are no additional notes associated with this service or procedure.
PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,337,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],28847.26,,"Fee schedule rate ($28,847.26). Adds an outlier to normal pricing equal to the per diem rate ($89,320.38) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.8), with a minimum of zero.",,,,0,other,12340.08,38926.31,There are no additional notes associated with this service or procedure.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],26776.27,,"Fee schedule rate ($26,776.27). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,11593.79,38248.08,There are no additional notes associated with this service or procedure.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],36776.05,,"Fee schedule rate ($36,776.05). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11053.39,36776.05,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],6801.90,,"Fee schedule rate ($6,801.90). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5628.97,12272.58,There are no additional notes associated with this service or procedure.
"Amputation Toe Interphalangeal Joint|RIGHT FOOT, SECOND DIGIT",CASE-28825,APC,28825,CPT,0360,RC,,,T6,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],19126.88,,"Fee schedule rate ($19,126.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,19126.88,There are no additional notes associated with this service or procedure.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],5569.00,,"Per diem ($5,569). If length of stay < 3.8, first 1 days paid at a per diem of $11,138 instead. Capped at $21,162.80.",,,,0,other,5569.00,40108.48,Estimated amount calculated based on 2 day length of stay.
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],26966.33,,"Fee schedule rate ($26,966.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,9040.72,26966.33,There are no additional notes associated with this service or procedure.
Lam Facetectomy&Foramot 1 Vrt Sgm Ea Addl Sgm,CASE-63048,APC,63048,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7029.71,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,7029.71,7131.59,OPPS APC
PREMATURITY WITH MAJOR PROBLEMS,791,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],3054.00,,,,,,0,other,3048.21,30904.42,Estimated amount calculated based on 5 day length of stay.
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],23870.71,,"Fee schedule rate ($23,870.71). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10626.74,25225.91,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITH STERILIZATION WITH MCC,783,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],23722.94,,"Fee schedule rate ($23,722.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12612.10,23722.94,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],84226.47,,"Fee schedule rate ($84,226.47). Adds an outlier to normal pricing equal to the per diem rate ($75,906.87) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14.7), with a minimum of zero.",,,,0,other,32296.02,88188.38,There are no additional notes associated with this service or procedure.
APPENDIX PROCEDURES WITH MCC,397,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],45007.36,,"Fee schedule rate ($45,007.36). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.5), with a minimum of zero.",,,,0,other,18163.37,51558.84,There are no additional notes associated with this service or procedure.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],21382.16,,"Case rate ($21,382.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,026.97, add-ons for qualifying new technology services are included. If operating cost exceeds $54,897.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,181.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6)) / 2. The base transfer operating payment is the transfer adjustment factor * $18,015.59 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,082.01 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,421.61. The transfer capital threshold is the transfer adjustment factor * $1,421.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,21382.16,85466.62,Inpatient DRG
"NEONATE BIRTH WEIGHT 1500-1999 GRAMS WITH OR WITHOUT OTHER SIGNIFICANT CONDITION,MODERATE",614,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],11512.05,,"Case rate ($10,963.86). Base payment rate plus any adjustments related to outliers.",,,,0,other,10963.86,11512.05,There are no additional notes associated with this service or procedure.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],9446.38,,"Case rate ($9,446.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,923.36, add-ons for qualifying new technology services are included. If operating cost exceeds $43,794.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,308.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,952.78 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,978.41 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $548.64. The transfer capital threshold is the transfer adjustment factor * $548.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9446.38,21796.21,Inpatient DRG
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],29916.58,,"Fee schedule rate ($29,916.58). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12725.42,34245.00,There are no additional notes associated with this service or procedure.
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],21960.82,,"Case rate ($20,915.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $19,627.84, add-ons for qualifying new technology services are included. If operating cost exceeds $54,498.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,113.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.6. The base transfer operating payment is the transfer adjustment factor * $17,616.10 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $17,682.89 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,354.01. The transfer capital threshold is the transfer adjustment factor * $1,354.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,21489.15,68942.79,Inpatient DRG
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,426,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],207121.41,,"Fee schedule rate ($207,121.41). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,76581.29,216864.15,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],28821.04,,"Fee schedule rate ($28,821.04). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,10347.06,28821.04,There are no additional notes associated with this service or procedure.
Colonoscopy W/Biopsy Single/Multiple|COLORECTAL CANCER SCREEN,CASE-45380,APC,45380,CPT,0360,RC,,,PT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1159.29,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1120.09,1176.09,OPPS APC
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],105091.76,,"Fee schedule rate ($105,091.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,35719.96,105091.76,There are no additional notes associated with this service or procedure.
HC Peripheral Block - Femoral Single or Saphenous W/Img Gdn|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64447,APC,64447,CPT,0360,RC,,,RT|XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
NERVOUS SYSTEM NEOPLASMS WITH MCC,054,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],12285.22,,"Case rate ($12,285.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,564.29, add-ons for qualifying new technology services are included. If operating cost exceeds $46,435.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,516.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $9,584.00 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,619.34 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $756.27. The transfer capital threshold is the transfer adjustment factor * $756.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,30044.81,Inpatient DRG
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],13783.20,,"Case rate ($13,783.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,957.83, add-ons for qualifying new technology services are included. If operating cost exceeds $47,828.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,625.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $10,972.42 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,012.88 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $865.83. The transfer capital threshold is the transfer adjustment factor * $865.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,13783.20,41580.51,Inpatient DRG
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],14492.93,,"Fee schedule rate ($14,492.93). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6503.90,14492.93,There are no additional notes associated with this service or procedure.
"Amputation Toe Interphalangeal Joint|RIGHT FOOT, THIRD DIGIT",CASE-28825,APC,28825,CPT,0360,RC,,,T7,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3062.67,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],14124.74,,"Case rate ($13,647.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,831.20, add-ons for qualifying new technology services are included. If operating cost exceeds $47,702.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,615.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $10,846.26 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,886.25 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $855.88. The transfer capital threshold is the transfer adjustment factor * $855.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,7921.00,45706.73,Inpatient DRG
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,094,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],66140.08,,"Fee schedule rate ($66,140.08). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16.5), with a minimum of zero.",,,,0,other,25778.58,67889.44,There are no additional notes associated with this service or procedure.
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITH MCC OR ANTINEOPLASTIC IMPLANT OR EPILEPSY WITH NEUROSTIMULATOR,023,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],136379.44,,"Fee schedule rate ($136,379.44). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,15168.00,136379.44,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],23954.07,,"Fee schedule rate ($23,954.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,6167.00,29058.99,There are no additional notes associated with this service or procedure.
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],7147.93,,"Case rate ($7,147.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,785.17, add-ons for qualifying new technology services are included. If operating cost exceeds $41,656.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,140.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $4,822.44 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,840.22 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $380.54. The transfer capital threshold is the transfer adjustment factor * $380.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,16400.70,Inpatient DRG
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],11269.71,,"Case rate ($10,733.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,120.35, add-ons for qualifying new technology services are included. If operating cost exceeds $44,991.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,402.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $8,145.37 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,175.40 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $642.75. The transfer capital threshold is the transfer adjustment factor * $642.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10733.06,45157.33,Inpatient DRG
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],51903.64,,"Fee schedule rate ($51,903.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,16017.99,51903.64,There are no additional notes associated with this service or procedure.
Reconstruction Nail Bed W/Graft,CASE-11762,APC,11762,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1931.28,,"APC Price ($1,931.28). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1931.28,2027.84,OPPS APC
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],52803.53,,"Fee schedule rate ($52,803.53). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,14337.84,52803.53,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],107110.70,,"Fee schedule rate ($107,110.70). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (21), with a minimum of zero.",,,,0,other,40542.37,128358.13,There are no additional notes associated with this service or procedure.
SINGLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL,402,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],30193.07,,"Case rate ($29,172.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $27,273.75, add-ons for qualifying new technology services are included. If operating cost exceeds $62,144.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,751.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $25,235.76 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $25,328.80 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,991.35. The transfer capital threshold is the transfer adjustment factor * $1,991.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,29172.05,124455.45,Inpatient DRG
INFLAMMATORY BOWEL DISEASE WITH CC,386,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],19879.00,,"Fee schedule rate ($19,879.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8556.53,19879.00,There are no additional notes associated with this service or procedure.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],42586.49,,"Fee schedule rate ($42,586.49). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,13341.67,42586.49,There are no additional notes associated with this service or procedure.
"POST-OPERATIVE POST-TRAUMA OTHER DEVICE INFECTIONS WITH O.R. PROCEDURE,MODERATE",711,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],16727.01,,"Case rate ($15,930.49). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,15930.49,16727.01,There are no additional notes associated with this service or procedure.
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],44778.95,,,,,,0,other,17356.15,44778.95,There are no additional notes associated with this service or procedure.
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],14747.55,,"Case rate ($14,747.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,854.94, add-ons for qualifying new technology services are included. If operating cost exceeds $48,725.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,696.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $11,866.24 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,909.99 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $936.36. The transfer capital threshold is the transfer adjustment factor * $936.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,14747.55,37899.49,Inpatient DRG
Cysto/Uretero W/Lithotripsy &Indwell Stent Insrt|RIGHT SIDE,CASE-52356,APC,52356,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5194.43,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5018.77,5269.71,OPPS APC
INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC,198,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],7134.88,,"Case rate ($6,795.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,456.95, add-ons for qualifying new technology services are included. If operating cost exceeds $41,327.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,114.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,495.42 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,512.00 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $354.73. The transfer capital threshold is the transfer adjustment factor * $354.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6795.12,23505.07,Inpatient DRG
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],10902.75,,"Case rate ($10,383.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,810.96, add-ons for qualifying new technology services are included. If operating cost exceeds $44,681.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,362.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $7,836.30 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,866.01 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $602.32. The transfer capital threshold is the transfer adjustment factor * $602.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10638.94,25261.33,Inpatient DRG
Cysto W/Insert Ureteral Stent,CASE-52332,APC,52332,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3414.95,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3299.47,3464.44,OPPS APC
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,095,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],19799.70,,"Case rate ($19,411.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $18,193.69, add-ons for qualifying new technology services are included. If operating cost exceeds $53,064.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,037.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.6. The base transfer operating payment is the transfer adjustment factor * $16,189.05 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $16,248.74 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,277.48. The transfer capital threshold is the transfer adjustment factor * $1,277.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,19411.47,50750.92,Inpatient DRG
VENTRICULAR SHUNT PROCEDURES WITH CC,032,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],41931.69,,,,,,0,other,16376.22,46275.08,There are no additional notes associated with this service or procedure.
HC Bx Breast 1st Lesion US Img|RIGHT SIDE,CASE-19083,APC,19083,CPT,0361,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1545.93,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1545.93,1623.23,OPPS APC
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],23954.07,,"Fee schedule rate ($23,954.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,6167.00,29058.99,There are no additional notes associated with this service or procedure.
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,307,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],13010.69,,"Case rate ($7,434.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $7,017.68, add-ons for qualifying new technology services are included. If operating cost exceeds $45,662.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $3,170.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $5,632.79 + an uncompensated DSH payment of $1,359.91. The transfer operating threshold is the transfer adjustment factor * $5,657.77 + an uncompensated DSH payment of $1,359.91. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $441.98. The transfer capital threshold is the transfer adjustment factor * $441.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,6335.27,18228.77,All Other Inpatient
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],22451.27,,"Case rate ($21,382.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,026.97, add-ons for qualifying new technology services are included. If operating cost exceeds $54,897.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,181.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6)) / 2. The base transfer operating payment is the transfer adjustment factor * $18,015.59 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,082.01 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,421.61. The transfer capital threshold is the transfer adjustment factor * $1,421.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,21382.16,85466.62,Inpatient DRG
Redo Excis Lumbar Disk|LEFT SIDE,CASE-63042,APC,63042,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6791.99,7131.59,OPPS APC
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],11065.78,,"Fee schedule rate ($11,065.78). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5883.03,17111.12,There are no additional notes associated with this service or procedure.
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITHOUT CC/MCC",630,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],42541.02,,"Fee schedule rate ($42,541.02). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11828.78,42541.02,There are no additional notes associated with this service or procedure.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],97015.50,,"Fee schedule rate ($97,015.50). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,26809.29,97015.50,There are no additional notes associated with this service or procedure.
NONTRAUMATIC STUPOR AND COMA WITH MCC,080,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],30179.40,,"Fee schedule rate ($30,179.40). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,14202.39,35615.37,There are no additional notes associated with this service or procedure.
Sigmoidoscopy Flx Dx W/Collj Spec Br/Wa if Pfrmd,CASE-45330,APC,45330,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],913.99,,"APC Price ($870.46). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,870.46,913.99,OPPS APC
Laps Tx Ectopic Preg W/Salping&/Oophorectomy,CASE-59151,APC,59151,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5856.81,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5658.76,5941.70,OPPS APC
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],38248.08,,"Fee schedule rate ($38,248.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11593.79,38248.08,There are no additional notes associated with this service or procedure.
"Tendon Sheath Incision|RIGHT HAND, SECOND DIGIT",CASE-26055,APC,26055,CPT,0360,RC,,,F6,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1557.80,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1505.12,1580.37,OPPS APC
"NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY",789,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],3054.00,,,,,,0,other,3054.00,14857.05,Estimated amount calculated based on 1 day length of stay.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],7332.00,,"Per diem ($7,332). If length of stay < 4.6, first 1 days paid at a per diem of $14,664 instead. Capped at $33,727.80.",,,,0,other,7332.00,35314.31,Estimated amount calculated based on 3 day length of stay.
HC Layer Closure Face <2.5 Cm,CASE-12051,APC,12051,CPT,0450,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1600.04,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1600.04,1600.04,OPPS APC
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],36868.88,,"Fee schedule rate ($36,868.88). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12606.23,36868.88,There are no additional notes associated with this service or procedure.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],23618.74,,"Fee schedule rate ($23,618.74). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10533.95,24956.34,There are no additional notes associated with this service or procedure.
RESPIRATORY NEOPLASMS WITH CC,181,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],16096.22,,"Case rate ($9,197.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,692.16, add-ons for qualifying new technology services are included. If operating cost exceeds $43,563.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,290.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,722.42 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,747.21 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $530.47. The transfer capital threshold is the transfer adjustment factor * $530.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,9197.84,21074.07,All Other Inpatient
Prtl Exc B1 Tarsal/Metar B1 Xcp Talus/Calcaneus|LEFT SIDE,CASE-28122,APC,28122,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
SALIVARY GLAND PROCEDURES,139,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],18048.08,,"Case rate ($10,313.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,729.75, add-ons for qualifying new technology services are included. If operating cost exceeds $44,600.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,372.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $7,756.21 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,784.80 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $612.04. The transfer capital threshold is the transfer adjustment factor * $612.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,10313.19,30690.92,All Other Inpatient
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],62084.69,,"Fee schedule rate ($62,084.69). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (35), with a minimum of zero.",,,,0,other,30398.48,82674.88,There are no additional notes associated with this service or procedure.
DIABETES WITH CC,638,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],16842.29,,"Fee schedule rate ($16,842.29). Adds an outlier to normal pricing equal to the per diem rate ($39,561.63) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,8014.07,17634.53,There are no additional notes associated with this service or procedure.
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],9890.87,,"Case rate ($9,696.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,156.46, add-ons for qualifying new technology services are included. If operating cost exceeds $44,027.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,326.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $7,185.02 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,211.51 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $566.97. The transfer capital threshold is the transfer adjustment factor * $566.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,9696.93,35061.53,Inpatient DRG
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],41580.51,,"Fee schedule rate ($41,580.51). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,13783.20,41580.51,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],49717.39,,"Fee schedule rate ($49,717.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,14908.05,49717.39,There are no additional notes associated with this service or procedure.
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],27589.62,,"Fee schedule rate ($27,589.62). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12566.28,30861.41,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC,817,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],43874.75,,"Fee schedule rate ($43,874.75). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,17396.11,44895.04,There are no additional notes associated with this service or procedure.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC,862,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],14295.18,,"Case rate ($14,295.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,434.11, add-ons for qualifying new technology services are included. If operating cost exceeds $48,305.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,663.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $11,446.95 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,489.15 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $903.28. The transfer capital threshold is the transfer adjustment factor * $903.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6855.00,35884.94,Inpatient DRG
PREMATURITY WITH MAJOR PROBLEMS,791,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],3186.77,,,,,,0,other,3048.21,30904.42,Estimated amount calculated based on 5 day length of stay.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],8222.77,,"Case rate ($7,831.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,431.79, add-ons for qualifying new technology services are included. If operating cost exceeds $42,302.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,180.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $5,466.12 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,486.84 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $420.14. The transfer capital threshold is the transfer adjustment factor * $420.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8009.34,19877.10,Inpatient DRG
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],62041.12,,"Fee schedule rate ($62,041.12). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,18497.24,62041.12,There are no additional notes associated with this service or procedure.
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],15940.79,,"Case rate ($15,940.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,964.98, add-ons for qualifying new technology services are included. If operating cost exceeds $49,835.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,783.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $12,972.20 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,020.03 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,023.63. The transfer capital threshold is the transfer adjustment factor * $1,023.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,15940.79,53275.26,Inpatient DRG
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,479,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],15042.22,,"Case rate ($14,533.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,655.86, add-ons for qualifying new technology services are included. If operating cost exceeds $48,526.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,680.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $11,667.89 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,710.91 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $920.71. The transfer capital threshold is the transfer adjustment factor * $920.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,10586.00,50518.76,Inpatient DRG
HC Inj Tendon Sheath/Ligament|RIGHT SIDE,CASE-20550,APC,20550,CPT,0510,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],16283.24,,"Fee schedule rate ($16,283.24). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7875.94,17233.12,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,689,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],22417.63,,"Fee schedule rate ($22,417.63). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,9802.58,22831.22,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],42768.36,,"Fee schedule rate ($42,768.36). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,14295.18,42768.36,There are no additional notes associated with this service or procedure.
Lamnotmy Incl W/Dcmprsn Nrv Root 1 Intrspc Lumbr|LEFT SIDE,CASE-63030,APC,63030,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],67794.72,,"Fee schedule rate ($67,794.72). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,10862.00,86437.13,There are no additional notes associated with this service or procedure.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],45706.73,,"Fee schedule rate ($45,706.73). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,7921.00,45706.73,There are no additional notes associated with this service or procedure.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],31241.17,,,,,,0,other,12696.97,47123.82,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],23239.84,,"Fee schedule rate ($23,239.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8543.64,23239.84,There are no additional notes associated with this service or procedure.
Anoscopy Dx W/HRA &Chem Agnts Enhancement W/Bx|SEPARATE STRUCTURE,CASE-46607,APC,46607,CPT,0360,RC,,,XS,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],2598.08,,"APC Price ($2,598.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2598.08,2727.99,OPPS APC
"MAJOR BILIARY TRACT PROCEDURES,MODERATE",261,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],22379.43,,"Case rate ($22,379.43). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,22379.43,23498.40,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],26178.21,,"Fee schedule rate ($26,178.21). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,13917.42,34889.29,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],31533.97,,"Fee schedule rate ($31,533.97). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8563.30,31533.97,There are no additional notes associated with this service or procedure.
"Capsulectomy/Capsulotomy Iphal Joint Each|LEFT HAND, SECOND DIGIT",CASE-26525,APC,26525,CPT,0360,RC,,,F1,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3169.86,OPPS APC
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC",641,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],14624.71,,"Fee schedule rate ($14,624.71). Adds an outlier to normal pricing equal to the per diem rate ($38,755.52) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7214.98,15312.64,There are no additional notes associated with this service or procedure.
INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC,198,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],6795.12,,"Case rate ($6,795.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,456.95, add-ons for qualifying new technology services are included. If operating cost exceeds $41,327.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,114.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,495.42 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,512.00 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $354.73. The transfer capital threshold is the transfer adjustment factor * $354.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6795.12,23505.07,Inpatient DRG
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,095,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],48575.01,,"Fee schedule rate ($48,575.01). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,19411.47,50750.92,There are no additional notes associated with this service or procedure.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],36094.03,,"Fee schedule rate ($36,094.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11194.25,36094.03,There are no additional notes associated with this service or procedure.
RESPIRATORY NEOPLASMS WITHOUT CC/MCC,182,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],23037.13,,"Fee schedule rate ($23,037.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6965.00,23037.13,There are no additional notes associated with this service or procedure.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],101083.00,,"Fee schedule rate ($101,083.00). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,35389.50,101083.00,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],28235.64,,"Fee schedule rate ($28,235.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,14344.60,36028.59,There are no additional notes associated with this service or procedure.
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,068,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],23184.90,,"Fee schedule rate ($23,184.90). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,23184.90,There are no additional notes associated with this service or procedure.
Removal Implant Deep|LEFT SIDE,CASE-20680,APC,20680,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],2854.83,,"APC Price ($2,718.88). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2718.88,2854.83,OPPS APC
Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq|COLORECTAL CANCER SCREEN|UNUSUAL NON-OVERLAPPING SERVICE,CASE-45385,APC,45385,CPT,0360,RC,,,PT|XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1176.09,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1120.09,1176.09,OPPS APC
CHOLECYSTECTOMY WITH C.D.E. WITH MCC,411,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],62078.92,,"Fee schedule rate ($62,078.92). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15), with a minimum of zero.",,,,0,other,24315.13,88615.28,There are no additional notes associated with this service or procedure.
"ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",770,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],9172.07,,"Case rate ($8,735.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,261.87, add-ons for qualifying new technology services are included. If operating cost exceeds $43,132.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,256.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $6,293.72 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,316.92 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $496.64. The transfer capital threshold is the transfer adjustment factor * $496.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8735.30,19730.13,Inpatient DRG
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],26301.36,,"Fee schedule rate ($26,301.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11247.07,27028.33,There are no additional notes associated with this service or procedure.
SINGLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL,402,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],124455.45,,"Fee schedule rate ($124,455.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,29172.05,124455.45,There are no additional notes associated with this service or procedure.
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],16026.80,,"Case rate ($16,026.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,044.99, add-ons for qualifying new technology services are included. If operating cost exceeds $49,916.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,789.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $13,051.92 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,100.04 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,029.93. The transfer capital threshold is the transfer adjustment factor * $1,029.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,11165.00,61234.06,Inpatient DRG
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],10626.74,,"Case rate ($10,626.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,021.44, add-ons for qualifying new technology services are included. If operating cost exceeds $44,892.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,394.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $8,046.82 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,076.49 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $634.97. The transfer capital threshold is the transfer adjustment factor * $634.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10626.74,25225.91,Inpatient DRG
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],21980.29,,"Fee schedule rate ($21,980.29). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9865.56,37914.65,There are no additional notes associated with this service or procedure.
Exc Cyst/Aberrant Breast Tissue Open 1/> Lesion|BILATERAL PROCEDURE,CASE-19120,APC,19120,CPT,0360,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3793.21,,"APC Price ($3,664.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3793.21,3848.19,OPPS APC
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],15128.37,,"Fee schedule rate ($15,128.37). Adds an outlier to normal pricing equal to the per diem rate ($46,867.46) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7396.47,16035.06,There are no additional notes associated with this service or procedure.
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC",758,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],18398.35,,"Fee schedule rate ($18,398.35). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8574.80,19263.78,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,167,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],33891.30,,"Fee schedule rate ($33,891.30). Adds an outlier to normal pricing equal to the per diem rate ($66,990.29) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.6), with a minimum of zero.",,,,0,other,14157.71,43522.37,There are no additional notes associated with this service or procedure.
HC Drain/Inj Joint/Bursa W/US Large,CASE-20611,APC,20611,CPT,0510,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
CESAREAN SECTION WITHOUT STERILIZATION WITH MCC,786,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],23722.94,,"Fee schedule rate ($23,722.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12612.10,23722.94,There are no additional notes associated with this service or procedure.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,057,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],24348.21,,"Fee schedule rate ($24,348.21). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.9), with a minimum of zero.",,,,0,other,10718.84,39884.93,There are no additional notes associated with this service or procedure.
ALLERGIC REACTIONS WITH MCC,915,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],13999.50,,"Case rate ($13,332.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,538.89, add-ons for qualifying new technology services are included. If operating cost exceeds $47,409.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,592.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $10,555.02 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,593.94 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $832.90. The transfer capital threshold is the transfer adjustment factor * $832.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13332.86,33088.84,Inpatient DRG
UNGROUPABLE,999,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],48752.15,,"Case rate ($48,752.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $45,488.70, add-ons for qualifying new technology services are included. If operating cost exceeds $80,359.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $5,183.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 12.7. The base transfer operating payment is the transfer adjustment factor * $43,383.78 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $43,543.75 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,423.41. The transfer capital threshold is the transfer adjustment factor * $3,423.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10228.00,161307.29,Inpatient DRG
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],11677.97,,"Fee schedule rate ($11,677.97). Adds an outlier to normal pricing equal to the per diem rate ($67,650.85) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.7), with a minimum of zero.",,,,0,other,6153.12,13947.32,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],32941.94,,"Case rate ($32,296.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $30,179.91, add-ons for qualifying new technology services are included. If operating cost exceeds $65,050.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,979.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $28,131.23 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $28,234.95 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,219.83. The transfer capital threshold is the transfer adjustment factor * $2,219.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,32296.02,88188.38,Inpatient DRG
Submucous Rescj Inferior Turbinate Prtl/Compl,CASE-30140,APC,30140,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3103.35,,"APC Price ($3,103.35). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.35,3258.52,OPPS APC
Rpr Nonunion Scaphoid Carpal Bne W/WO Rdl Stylec|RIGHT SIDE,CASE-25440,APC,25440,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7029.71,OPPS APC
"POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS,MAJOR",721,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],1864.88,,"Case rate for a one day stay ($1,864.88). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,1864.88,1958.12,There are no additional notes associated with this service or procedure.
Colonoscopy W/Biopsy Single/Multiple|COLORECTAL CANCER SCREEN|UNUSUAL NON-OVERLAPPING SERVICE,CASE-45380,APC,45380,CPT,0360,RC,,,PT|XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1176.09,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1120.09,1176.09,OPPS APC
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],67790.93,,"Fee schedule rate ($67,790.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,21597.50,67790.93,There are no additional notes associated with this service or procedure.
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],12246.05,,"Fee schedule rate ($12,246.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6010.23,12246.05,There are no additional notes associated with this service or procedure.
Cysto W/Removal of Tumors Small,CASE-52234,APC,52234,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3299.47,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3299.47,3464.44,OPPS APC
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,095,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],33970.07,,"Case rate ($19,411.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $18,193.69, add-ons for qualifying new technology services are included. If operating cost exceeds $53,064.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,037.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.6. The base transfer operating payment is the transfer adjustment factor * $16,189.05 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $16,248.74 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,277.48. The transfer capital threshold is the transfer adjustment factor * $1,277.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,19411.47,50750.92,All Other Inpatient
Mastopexy,CASE-19316,APC,19316,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],7650.49,,"APC Price ($7,650.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,7650.49,7918.25,OPPS APC
NEONATE WITH OTHER SIGNIFICANT PROBLEMS,794,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],12228.57,,"Case rate ($11,646.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,987.98, add-ons for qualifying new technology services are included. If operating cost exceeds $45,858.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,452.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $9,008.87 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,043.03 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $692.44. The transfer capital threshold is the transfer adjustment factor * $692.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,1798.85,12536.83,Inpatient DRG
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],11677.97,,"Fee schedule rate ($11,677.97). Adds an outlier to normal pricing equal to the per diem rate ($67,650.85) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.7), with a minimum of zero.",,,,0,other,6153.12,13947.32,There are no additional notes associated with this service or procedure.
Optx Dstl Radl X-Artic Fx/Epiphysl Sep|RIGHT SIDE,CASE-25607,APC,25607,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6791.99,7131.59,OPPS APC
Dstr Nrolytc Agnt Parverteb Fct Addl Lmbr/Sacral|LEFT SIDE,CASE-64636,APC,64636,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1827.80,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1827.80,1919.19,OPPS APC
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],62041.12,,"Fee schedule rate ($62,041.12). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,18497.24,62041.12,There are no additional notes associated with this service or procedure.
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],11065.78,,"Fee schedule rate ($11,065.78). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5883.03,17111.12,There are no additional notes associated with this service or procedure.
HC Rep Cpx Sc Arm Lg 2.6-7.5cm,CASE-13121,APC,13121,CPT,0450,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1600.04,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1545.93,1623.23,OPPS APC
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],20075.57,,"Case rate ($19,119.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,922.16, add-ons for qualifying new technology services are included. If operating cost exceeds $52,793.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,016.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $15,918.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,977.21 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,256.13. The transfer capital threshold is the transfer adjustment factor * $1,256.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,11348.00,62454.12,Inpatient DRG
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC,099,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],11171.21,,"Case rate ($11,171.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,527.95, add-ons for qualifying new technology services are included. If operating cost exceeds $45,398.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,434.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,551.47 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,583.00 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $674.80. The transfer capital threshold is the transfer adjustment factor * $674.80. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,11171.21,26807.94,Inpatient DRG
Laparoscopy Surg Rpr Initial Inguinal Hernia|BILATERAL PROCEDURE,CASE-49650,APC,49650,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5658.76,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5658.76,5941.70,OPPS APC
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],25427.61,,"Case rate ($24,567.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $22,990.45, add-ons for qualifying new technology services are included. If operating cost exceeds $57,861.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,414.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.7. The base transfer operating payment is the transfer adjustment factor * $20,968.18 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $21,045.49 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,654.60. The transfer capital threshold is the transfer adjustment factor * $1,654.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,9370.00,65732.99,Inpatient DRG
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC",629,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],16699.94,,"Case rate ($16,699.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,671.20, add-ons for qualifying new technology services are included. If operating cost exceeds $50,542.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,839.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $13,675.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,726.25 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,079.16. The transfer capital threshold is the transfer adjustment factor * $1,079.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,16699.94,44657.18,Inpatient DRG
"Neuroplasty Other Arm/Leg Nerve,Open|RIGHT SIDE",CASE-64708,APC,64708,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7029.71,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6791.99,7131.59,OPPS APC
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,066,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6765.80,,"Case rate ($6,443.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,138.36, add-ons for qualifying new technology services are included. If operating cost exceeds $41,009.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,081.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $4,177.57 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,193.41 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $321.10. The transfer capital threshold is the transfer adjustment factor * $321.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6579.76,20083.61,Inpatient DRG
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],61234.06,,"Fee schedule rate ($61,234.06). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11165.00,61234.06,There are no additional notes associated with this service or procedure.
NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,601,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],12359.72,,"Fee schedule rate ($12,359.72). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6042.05,12359.72,There are no additional notes associated with this service or procedure.
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITH MCC OR ANTINEOPLASTIC IMPLANT OR EPILEPSY WITH NEUROSTIMULATOR,023,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],40750.95,,"Case rate ($40,750.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $38,045.35, add-ons for qualifying new technology services are included. If operating cost exceeds $72,916.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,598.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $35,967.78 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $36,100.40 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,838.21. The transfer capital threshold is the transfer adjustment factor * $2,838.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,15168.00,136379.44,Inpatient DRG
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],29917.96,,"Fee schedule rate ($29,917.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,12527.66,29917.96,There are no additional notes associated with this service or procedure.
Insj/Rplcmt Perq Eltrd Ra Pn W/Int Nstim 1st Ra,CASE-64596,APC,64596,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],10794.87,,"APC Price ($10,429.83). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,10429.83,10951.32,OPPS APC
Repair Intermediate S/a/T/E 20.1-30.0 Cm,CASE-12036,APC,12036,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1545.93,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1545.93,1623.23,OPPS APC
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],73588.10,,"Fee schedule rate ($73,588.10). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,21585.31,73588.10,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],10284.89,,"Case rate ($9,795.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,247.81, add-ons for qualifying new technology services are included. If operating cost exceeds $44,118.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,334.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $7,276.03 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,302.86 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $574.15. The transfer capital threshold is the transfer adjustment factor * $574.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9795.13,23899.13,Inpatient DRG
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],26178.21,,"Fee schedule rate ($26,178.21). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,13917.42,34889.29,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],18311.90,,"Fee schedule rate ($18,311.90). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8543.64,23239.84,There are no additional notes associated with this service or procedure.
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],30245.71,,"Fee schedule rate ($30,245.71). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9151.11,30245.71,There are no additional notes associated with this service or procedure.
Rpr 1st Ingun Hrna Age 5 Yrs/> Reducible|RIGHT SIDE,CASE-49505,APC,49505,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3351.34,,"APC Price ($3,351.34). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3351.34,3518.91,OPPS APC
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],19997.63,,"Fee schedule rate ($19,997.63). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,9151.11,30245.71,There are no additional notes associated with this service or procedure.
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],12551.64,,"Case rate ($12,305.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,583.18, add-ons for qualifying new technology services are included. If operating cost exceeds $46,454.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,517.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $9,602.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,638.24 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $757.76. The transfer capital threshold is the transfer adjustment factor * $757.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,12305.53,30103.84,Inpatient DRG
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],13647.09,,"Case rate ($13,647.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,831.20, add-ons for qualifying new technology services are included. If operating cost exceeds $47,702.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,615.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $10,846.26 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,886.25 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $855.88. The transfer capital threshold is the transfer adjustment factor * $855.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7921.00,45706.73,Inpatient DRG
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,309,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],6965.00,,,,,,0,other,5055.77,14547.21,There are no additional notes associated with this service or procedure.
Intraop Sentinel Lymph Node ID W/Dye Injection,CASE-38900,APC,38900,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6215.36,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6215.36,6526.12,OPPS APC
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],13657.26,,"Case rate ($13,006.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,256.30, add-ons for qualifying new technology services are included. If operating cost exceeds $47,127.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,549.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $10,272.40 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,311.35 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $789.56. The transfer capital threshold is the transfer adjustment factor * $789.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13341.67,42586.49,Inpatient DRG
"Inj Dx/Ther Agnt Paravert Facet Joint, Cerv/Thorac, 2nd Level|LEFT SIDE",CASE-64491,APC,64491,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],827.89,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,827.89,869.28,OPPS APC
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC,858,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],27408.09,,,,,,0,other,11377.76,33794.11,There are no additional notes associated with this service or procedure.
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],20981.60,,"Fee schedule rate ($20,981.60). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,10003.71,23415.63,There are no additional notes associated with this service or procedure.
Exc B9 Lesion Mrgn Xcp Sk Tg S/N/H/F/G 0.6-1.0cm,CASE-11421,APC,11421,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],686.03,,"APC Price ($662.83). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,662.83,695.97,OPPS APC
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7623.81,,"Case rate ($7,366). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,988.03, add-ons for qualifying new technology services are included. If operating cost exceeds $41,859.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,156.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,024.55 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,043.08 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $396.49. The transfer capital threshold is the transfer adjustment factor * $396.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6965.00,21195.68,Inpatient DRG
HC Joint Injection/Aspir Large WO US|PBB CHARGE|LEFT SIDE,CASE-20610,APC,20610,CPT,0510,RC,,,PBB|LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],301.68,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,287.31,301.68,OPPS APC
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],13243.69,,"Case rate ($12,795.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,039.30, add-ons for qualifying new technology services are included. If operating cost exceeds $46,910.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,553.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $10,057.27 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,094.35 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $793.62. The transfer capital threshold is the transfer adjustment factor * $793.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,12795.84,41944.25,Inpatient DRG
"CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS,MINOR",201,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],4813.13,,"Case rate ($4,813.13). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,4813.13,5053.79,There are no additional notes associated with this service or procedure.
Adjnt Tis Trnsfr/Reargmt Any Area 30.1-60 Sq Cm,CASE-14301,APC,14301,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3317.01,,"APC Price ($3,317.01). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3317.01,3317.01,OPPS APC
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,073,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],43475.01,,"Fee schedule rate ($43,475.01). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,12809.38,43475.01,There are no additional notes associated with this service or procedure.
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH CC",457,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],160549.49,,"Fee schedule rate ($160,549.49). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,42327.47,160549.49,There are no additional notes associated with this service or procedure.
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],31477.13,,"Fee schedule rate ($31,477.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9648.19,31477.13,There are no additional notes associated with this service or procedure.
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],13295.62,,"Case rate ($13,295.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,504.24, add-ons for qualifying new technology services are included. If operating cost exceeds $47,375.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,590.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $10,520.50 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,559.29 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $830.17. The transfer capital threshold is the transfer adjustment factor * $830.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7000.00,33835.79,Inpatient DRG
"Tendon Sheath Incision|RIGHT HAND, THIRD DIGIT|UNUSUAL NON-OVERLAPPING SERVICE",CASE-26055,APC,26055,CPT,0360,RC,,,F7|XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1580.37,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1505.12,1580.37,OPPS APC
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,095,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],48575.01,,"Fee schedule rate ($48,575.01). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,19411.47,50750.92,There are no additional notes associated with this service or procedure.
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],7884.32,,"Fee schedule rate ($7,884.32). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,7884.32,17835.23,There are no additional notes associated with this service or procedure.
"Tendon Sheath Incision|LEFT HAND, THIRD DIGIT",CASE-26055,APC,26055,CPT,0360,RC,,,F2,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1827.80,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1827.80,1919.19,OPPS APC
DIABETES WITH CC,638,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],8174.35,,"Case rate ($8,014.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,590.93, add-ons for qualifying new technology services are included. If operating cost exceeds $42,461.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,203.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,625.24 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,645.98 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $443.89. The transfer capital threshold is the transfer adjustment factor * $443.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,8014.07,17634.53,Inpatient DRG
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],13486.95,,"Fee schedule rate ($13,486.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6915.64,14442.92,There are no additional notes associated with this service or procedure.
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],18043.23,,"Fee schedule rate ($18,043.23). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7733.72,18043.23,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],54875.56,,"Fee schedule rate ($54,875.56). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,21719.40,85305.59,There are no additional notes associated with this service or procedure.
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],16306.17,,"Case rate ($15,529.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,607.89, add-ons for qualifying new technology services are included. If operating cost exceeds $49,478.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,729.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $12,615.11 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,662.94 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $969.63. The transfer capital threshold is the transfer adjustment factor * $969.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,15940.79,53275.26,Inpatient DRG
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,426,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],80410.35,,"Case rate ($76,581.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $71,377.56, add-ons for qualifying new technology services are included. If operating cost exceeds $106,248.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $7,218.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $69,177.55 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $69,432.61 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $5,458.79. The transfer capital threshold is the transfer adjustment factor * $5,458.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,76581.29,216864.15,Inpatient DRG
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,068,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],23184.90,,"Fee schedule rate ($23,184.90). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,23184.90,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITHOUT STERILIZATION WITH CC,787,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],23722.94,,"Fee schedule rate ($23,722.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9508.01,23722.94,There are no additional notes associated with this service or procedure.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],142438.06,,"Fee schedule rate ($142,438.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (40), with a minimum of zero.",,,,0,other,45521.20,142438.06,There are no additional notes associated with this service or procedure.
"HC Debrid,Subq Ea Addt'l 20sqcm",CASE-11045,APC,11045,CPT,0361,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],393.83,,"APC Price ($380.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,380.51,399.53,OPPS APC
"LIMB REATTACHMENT, HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA",956,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],148259.86,,"Fee schedule rate ($148,259.86). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,27428.25,148259.86,There are no additional notes associated with this service or procedure.
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],14830.15,,"Fee schedule rate ($14,830.15). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,7884.32,17835.23,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,083,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],27465.16,,,,,,0,other,6965.00,28680.85,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],8734.57,,"Case rate ($8,563.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,101.85, add-ons for qualifying new technology services are included. If operating cost exceeds $42,972.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,244.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $6,134.29 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,156.91 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $484.06. The transfer capital threshold is the transfer adjustment factor * $484.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,8563.30,31533.97,Inpatient DRG
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],26043.00,,"Case rate ($25,162.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $23,543.58, add-ons for qualifying new technology services are included. If operating cost exceeds $58,414.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,458.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $21,519.28 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $21,598.63 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,698.08. The transfer capital threshold is the transfer adjustment factor * $1,698.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,25162.32,75579.22,Inpatient DRG
HC Inj Anes/Steroid C/D Facet Sg|BILATERAL PROCEDURE,CASE-64490,APC,64490,CPT,0361,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],856.86,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,827.89,869.28,OPPS APC
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,097,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],79915.74,,"Fee schedule rate ($79,915.74). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,26404.32,79915.74,There are no additional notes associated with this service or procedure.
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],23385.72,,"Fee schedule rate ($23,385.72). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,23385.72,There are no additional notes associated with this service or procedure.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],73863.30,,"Fee schedule rate ($73,863.30). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,33623.33,133270.57,There are no additional notes associated with this service or procedure.
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],32980.62,,,,,,0,other,7000.00,33835.79,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH CC,427,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],134742.59,,"Fee schedule rate ($134,742.59). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,50829.82,142040.39,There are no additional notes associated with this service or procedure.
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],36855.62,,"Fee schedule rate ($36,855.62). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,15821.59,40320.14,There are no additional notes associated with this service or procedure.
Cysto W/Ureteroscopy W/Lithotripsy,CASE-52353,APC,52353,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5194.43,,"APC Price ($5,018.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5018.77,5269.71,OPPS APC
Peri-Implant Capsulectomy Breast Complete,CASE-19371,APC,19371,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],8033.01,,"APC Price ($7,650.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,7918.25,8033.01,OPPS APC
"Open Tx Metacarpal Fracture Single Ea Bone|RIGHT HAND, THIRD DIGIT",CASE-26615,APC,26615,CPT,0360,RC,,,F7,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6418.23,,"Case rate ($6,201.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,904.45, add-ons for qualifying new technology services are included. If operating cost exceeds $40,775.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,071.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,944.95 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,959.50 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $311.30. The transfer capital threshold is the transfer adjustment factor * $311.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,5937.41,12366.99,Inpatient DRG
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],23844.73,,"Case rate ($23,377.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $21,882.92, add-ons for qualifying new technology services are included. If operating cost exceeds $56,753.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,327.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $19,864.72 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $19,937.97 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,567.52. The transfer capital threshold is the transfer adjustment factor * $1,567.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,23377.19,96365.69,Inpatient DRG
HC Drain/Inj Joint/Bursa W/US Large|PBB CHARGE|LEFT SIDE,CASE-20611,APC,20611,CPT,0510,RC,,,PBB|LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],301.68,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,287.31,301.68,OPPS APC
Revision of Reconstructed Breast,CASE-19380,APC,19380,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6432.89,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6215.36,6526.12,OPPS APC
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,345,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],12377.59,,"Case rate ($12,134.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,424.43, add-ons for qualifying new technology services are included. If operating cost exceeds $46,295.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,505.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $9,444.66 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,479.48 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $745.28. The transfer capital threshold is the transfer adjustment factor * $745.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,12134.89,33616.03,Inpatient DRG
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC",442,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],18157.80,,"Fee schedule rate ($18,157.80). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6607.45,19011.92,There are no additional notes associated with this service or procedure.
Colonoscopy W/Biopsy Single/Multiple|UNUSUAL NON-OVERLAPPING SERVICE|COLORECTAL CANCER SCREEN,CASE-45380,APC,45380,CPT,0360,RC,,,XU|PT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1159.29,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1120.09,1176.09,OPPS APC
SEIZURES WITH MCC,100,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],17915.10,,"Fee schedule rate ($17,915.10). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,15061.09,38110.41,There are no additional notes associated with this service or procedure.
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],21341.51,,"Case rate ($12,195.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,480.50, add-ons for qualifying new technology services are included. If operating cost exceeds $46,351.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,509.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,500.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,535.55 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $749.68. The transfer capital threshold is the transfer adjustment factor * $749.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,12195.15,39424.57,All Other Inpatient
Esophagogastroduodenoscopy US Scope W/Adj Strxrs,CASE-43237,APC,43237,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1859.01,,"APC Price ($1,796.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1796.14,1885.95,OPPS APC
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],14592.24,,"Case rate ($14,098.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,251.41, add-ons for qualifying new technology services are included. If operating cost exceeds $48,122.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,648.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $11,264.92 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,306.46 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $888.91. The transfer capital threshold is the transfer adjustment factor * $888.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,7332.00,35314.31,Inpatient DRG
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],8447.49,,"Case rate ($8,447.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,994.13, add-ons for qualifying new technology services are included. If operating cost exceeds $42,865.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,235.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,026.96 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,049.18 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $475.59. The transfer capital threshold is the transfer adjustment factor * $475.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,1188.00,18893.86,Inpatient DRG
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],15997.57,,"Case rate ($15,456.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,514.54, add-ons for qualifying new technology services are included. If operating cost exceeds $49,385.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,748.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $12,523.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,569.59 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $988.22. The transfer capital threshold is the transfer adjustment factor * $988.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,15456.59,41402.42,Inpatient DRG
CELLULITIS WITH MCC,602,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],28349.31,,"Fee schedule rate ($28,349.31). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11570.10,28349.31,There are no additional notes associated with this service or procedure.
Excision Interdigital Morton Neuroma Single Each|RIGHT SIDE,CASE-28080,APC,28080,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1505.12,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1505.12,1580.37,OPPS APC
"Decompress Spinal Cord,1 Seg|LEFT SIDE",CASE-63056,APC,63056,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH CC,026,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],63202.45,,"Fee schedule rate ($63,202.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,23000.66,63202.45,There are no additional notes associated with this service or procedure.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC",494,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],39945.55,,"Fee schedule rate ($39,945.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,15533.10,39945.55,There are no additional notes associated with this service or procedure.
Esophagoscopy Flexible Transoral Ultrasound Exam,CASE-43231,APC,43231,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1859.01,,"APC Price ($1,796.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1796.14,1885.95,OPPS APC
HC Inj Anes/Steroid C/D Facet Sg|BILATERAL PROCEDURE,CASE-64490,APC,64490,CPT,0361,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],827.89,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,827.89,869.28,OPPS APC
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,086,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],25633.23,,,,,,0,other,8442.00,30728.81,There are no additional notes associated with this service or procedure.
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],37488.28,,"Fee schedule rate ($37,488.28). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.5), with a minimum of zero.",,,,0,other,15453.88,39251.68,There are no additional notes associated with this service or procedure.
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],46202.59,,"Fee schedule rate ($46,202.59). Adds an outlier to normal pricing equal to the per diem rate ($126,777.34) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,18594.09,59494.91,There are no additional notes associated with this service or procedure.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],97015.50,,"Fee schedule rate ($97,015.50). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,26809.29,97015.50,There are no additional notes associated with this service or procedure.
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],15600.07,,"Fee schedule rate ($15,600.07). Adds an outlier to normal pricing equal to the per diem rate ($180,117.98) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,7566.45,16333.88,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],10210.85,,"Case rate ($9,865.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,313.33, add-ons for qualifying new technology services are included. If operating cost exceeds $44,184.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,339.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $7,341.31 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,368.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $579.30. The transfer capital threshold is the transfer adjustment factor * $579.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,9865.56,37914.65,Inpatient DRG
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],12138.74,,,,,,0,other,1188.00,12138.74,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],67794.72,,"Fee schedule rate ($67,794.72). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,10862.00,86437.13,There are no additional notes associated with this service or procedure.
Vulvectomy Simple Partial,CASE-56620,APC,56620,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3181.53,,"APC Price ($3,030.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3030.03,3181.53,OPPS APC
Ostectomy Calcaneus Spur W/WO Plntar Fascial Rls|LEFT SIDE,CASE-28119,APC,28119,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3169.86,3215.80,OPPS APC
PLEURAL EFFUSION WITH MCC,186,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],29692.94,,"Fee schedule rate ($29,692.94). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10804.96,31089.66,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],33277.97,,"Case rate ($31,693.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $29,619.21, add-ons for qualifying new technology services are included. If operating cost exceeds $64,490.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,935.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. The base transfer operating payment is the transfer adjustment factor * $27,572.60 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $27,674.26 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,175.75. The transfer capital threshold is the transfer adjustment factor * $2,175.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10862.00,86437.13,Inpatient DRG
Thyroidectomy Total/Complete|BILATERAL PROCEDURE,CASE-60240,APC,60240,CPT,0360,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],10298.02,,"APC Price ($9,949.78). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,9949.78,10447.27,OPPS APC
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],47123.82,,"Fee schedule rate ($47,123.82). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,12696.97,47123.82,There are no additional notes associated with this service or procedure.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC,858,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],33794.11,,"Fee schedule rate ($33,794.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11377.76,33794.11,There are no additional notes associated with this service or procedure.
Low cost skin substitute app,CASE-C5276,APC,C5276,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],660.72,,"APC Price ($660.72). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,660.72,660.72,OPPS APC
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],14234.24,,"Case rate ($13,556.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,768.52, add-ons for qualifying new technology services are included. If operating cost exceeds $47,639.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,588.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $10,782.69 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,823.57 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $828.78. The transfer capital threshold is the transfer adjustment factor * $828.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13907.80,52794.06,Inpatient DRG
CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC,788,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],20142.33,,"Fee schedule rate ($20,142.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8438.02,20142.33,There are no additional notes associated with this service or procedure.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],15476.23,,"Case rate ($15,476.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,532.81, add-ons for qualifying new technology services are included. If operating cost exceeds $49,403.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,749.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $12,541.62 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,587.86 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $989.66. The transfer capital threshold is the transfer adjustment factor * $989.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,15476.23,42787.31,Inpatient DRG
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],25261.33,,,,,,0,other,10638.94,25261.33,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],16552.29,,,,,,0,other,7641.61,19371.27,There are no additional notes associated with this service or procedure.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],52909.62,,"Fee schedule rate ($52,909.62). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,23344.70,62179.32,There are no additional notes associated with this service or procedure.
HC Inject Tendon Origin/Insert|LEFT SIDE,CASE-20551,APC,20551,CPT,0361,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
Open Tx Clavicular Fracture Internal Fixation|LEFT SIDE,CASE-23515,APC,23515,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7029.71,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6791.99,7131.59,OPPS APC
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],13917.42,,"Fee schedule rate ($13,917.42). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,13917.42,34889.29,There are no additional notes associated with this service or procedure.
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],11565.93,,"Fee schedule rate ($11,565.93). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6148.93,15887.21,There are no additional notes associated with this service or procedure.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],15309.46,,"Fee schedule rate ($15,309.46). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6965.00,15340.19,There are no additional notes associated with this service or procedure.
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH MCC",722,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],56869.13,,"Fee schedule rate ($56,869.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,14200.37,56869.13,There are no additional notes associated with this service or procedure.
POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES,769,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],13704.87,,"Case rate ($13,052.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,298.57, add-ons for qualifying new technology services are included. If operating cost exceeds $47,169.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,552.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $10,314.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,353.62 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $792.80. The transfer capital threshold is the transfer adjustment factor * $792.80. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13388.39,33250.19,Inpatient DRG
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 1 Level|BILATERAL PROCEDURE,CASE-64493,APC,64493,CPT,0360,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],856.86,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,827.89,869.28,OPPS APC
NONTRAUMATIC STUPOR AND COMA WITH MCC,080,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],30179.40,,"Fee schedule rate ($30,179.40). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,14202.39,35615.37,There are no additional notes associated with this service or procedure.
NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,601,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],12359.72,,"Fee schedule rate ($12,359.72). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6042.05,12359.72,There are no additional notes associated with this service or procedure.
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],18859.73,,"Fee schedule rate ($18,859.73). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,16428.39,42083.20,There are no additional notes associated with this service or procedure.
Tympanostomy General Anesthesia|RIGHT SIDE,CASE-69436,APC,69436,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5735.04,,"APC Price ($5,541.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5541.10,5735.04,OPPS APC
Laser Vaporization of Prostate for Urine Flow,CASE-52648,APC,52648,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5269.71,,"APC Price ($5,018.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5018.77,5269.71,OPPS APC
Induced Abortion Dilation & Evacuation,CASE-59841,APC,59841,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3181.53,,"APC Price ($3,030.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3030.03,3181.53,OPPS APC
NON-MALIGNANT BREAST DISORDERS WITH CC/MCC,600,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],9313.70,,"Case rate ($8,998.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,506.94, add-ons for qualifying new technology services are included. If operating cost exceeds $43,377.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,275.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $6,537.88 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,561.99 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $515.90. The transfer capital threshold is the transfer adjustment factor * $515.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,7999.14,20495.56,Inpatient DRG
MAJOR CHEST PROCEDURES WITH CC,164,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],77058.83,,"Fee schedule rate ($77,058.83). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,19037.66,77058.83,There are no additional notes associated with this service or procedure.
Laps Surg Rpr Recurrent Inguinal Hernia|BILATERAL PROCEDURE,CASE-49651,APC,49651,CPT,0360,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5856.81,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5658.76,5941.70,OPPS APC
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],12621.98,,"Case rate ($12,195.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,480.50, add-ons for qualifying new technology services are included. If operating cost exceeds $46,351.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,509.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,500.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,535.55 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $749.68. The transfer capital threshold is the transfer adjustment factor * $749.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,12195.15,39424.57,Inpatient DRG
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],54764.34,,"Fee schedule rate ($54,764.34). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,18178.96,54764.34,There are no additional notes associated with this service or procedure.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH CC,026,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],23000.66,,"Case rate ($23,000.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $21,532.64, add-ons for qualifying new technology services are included. If operating cost exceeds $56,403.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,299.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $19,515.74 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $19,587.69 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,539.98. The transfer capital threshold is the transfer adjustment factor * $1,539.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,23000.66,63202.45,Inpatient DRG
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],12526.44,,"Fee schedule rate ($12,526.44). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5415.00,17575.50,There are no additional notes associated with this service or procedure.
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITH MCC OR ANTINEOPLASTIC IMPLANT OR EPILEPSY WITH NEUROSTIMULATOR,023,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],75586.35,,"Fee schedule rate ($75,586.35). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,15168.00,136379.44,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],11440.38,,"Case rate ($10,895.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,271.55, add-ons for qualifying new technology services are included. If operating cost exceeds $45,142.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,414.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $8,296.01 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,326.60 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $654.64. The transfer capital threshold is the transfer adjustment factor * $654.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10895.60,35192.25,Inpatient DRG
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],9865.56,,"Case rate ($9,865.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,313.33, add-ons for qualifying new technology services are included. If operating cost exceeds $44,184.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,339.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $7,341.31 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,368.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $579.30. The transfer capital threshold is the transfer adjustment factor * $579.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9865.56,37914.65,Inpatient DRG
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],30861.41,,,,,,0,other,12566.28,30861.41,There are no additional notes associated with this service or procedure.
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC,797,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],20928.55,,"Fee schedule rate ($20,928.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8719.72,20928.55,There are no additional notes associated with this service or procedure.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITHOUT CC/MCC,816,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],6224.90,,"Case rate ($6,224.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,926.50, add-ons for qualifying new technology services are included. If operating cost exceeds $40,797.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,073.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $3,966.92 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,981.55 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $313.03. The transfer capital threshold is the transfer adjustment factor * $313.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6224.90,14733.53,Inpatient DRG
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],16250.04,,"Case rate ($15,476.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,532.81, add-ons for qualifying new technology services are included. If operating cost exceeds $49,403.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,749.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $12,541.62 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,587.86 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $989.66. The transfer capital threshold is the transfer adjustment factor * $989.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,15476.23,42787.31,Inpatient DRG
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],58394.20,,"Fee schedule rate ($58,394.20). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,9370.00,65732.99,There are no additional notes associated with this service or procedure.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],52699.33,,"Fee schedule rate ($52,699.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,18105.81,52699.33,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],12355.26,,"Fee schedule rate ($12,355.26). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8543.64,23239.84,There are no additional notes associated with this service or procedure.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,477,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],62359.39,,"Fee schedule rate ($62,359.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,25339.74,67976.16,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,394,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],20909.61,,"Fee schedule rate ($20,909.61). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8281.56,20909.61,There are no additional notes associated with this service or procedure.
"NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY",789,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],6663.33,,,,,,0,other,3054.00,14857.05,Estimated amount calculated based on 1 day length of stay.
"Rpr Coltrl Ligm Mtcarphlngl/Iphal Jt|LEFT HAND, SECOND DIGIT",CASE-26540,APC,26540,CPT,0360,RC,,,F1,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3169.86,OPPS APC
PSYCHOSES,885,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],2401.00,,,,,,0,other,2070.00,27484.83,Estimated amount calculated based on 3 day length of stay.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],16611.88,,"Case rate ($16,286.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,286.28, add-ons for qualifying new technology services are included. If operating cost exceeds $50,157.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,808.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $13,292.32 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,341.33 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,048.90. The transfer capital threshold is the transfer adjustment factor * $1,048.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 102%.",,,,0,other,16286.16,58320.32,Inpatient DRG
Arthrp Interpos Intercarpal/Metacarpal Joints|LEFT SIDE,CASE-25447,APC,25447,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],22158.27,,,,,,0,other,5569.00,40108.48,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],8963.19,,"Case rate ($8,787.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,310.38, add-ons for qualifying new technology services are included. If operating cost exceeds $43,181.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,260.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,342.05 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,365.43 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $500.45. The transfer capital threshold is the transfer adjustment factor * $500.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6965.00,32293.66,Inpatient DRG
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,699,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],9259.53,,"Case rate ($8,818.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,339.37, add-ons for qualifying new technology services are included. If operating cost exceeds $43,210.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,262.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $6,370.92 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,394.41 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $502.73. The transfer capital threshold is the transfer adjustment factor * $502.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5961.00,19972.16,Inpatient DRG
NONTRAUMATIC STUPOR AND COMA WITH MCC,080,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],35615.37,,,,,,0,other,14202.39,35615.37,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITHOUT STERILIZATION WITH MCC,786,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],19006.00,,,,,,0,other,12612.10,23722.94,There are no additional notes associated with this service or procedure.
DIABETES WITH MCC,637,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],28655.62,,,,,,0,other,9959.03,28655.62,There are no additional notes associated with this service or procedure.
Repair Intermediate S/a/T/E 20.1-30.0 Cm,CASE-12036,APC,12036,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1623.23,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1545.93,1623.23,OPPS APC
Cysto W/Ureteroscopy W/Rmvl/Manj Stones|BILATERAL PROCEDURE,CASE-52352,APC,52352,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3299.47,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3299.47,3464.44,OPPS APC
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],14699.43,,"Fee schedule rate ($14,699.43). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6683.37,14699.43,There are no additional notes associated with this service or procedure.
ENDOCRINE DISORDERS WITH CC,644,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],8076.29,,"Case rate ($8,076.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $7,615.48, add-ons for qualifying new technology services are included. If operating cost exceeds $46,260.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $3,217.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $6,227.71 + an uncompensated DSH payment of $1,359.91. The transfer operating threshold is the transfer adjustment factor * $6,255.58 + an uncompensated DSH payment of $1,359.91. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $488.69. The transfer capital threshold is the transfer adjustment factor * $488.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7066.99,20334.21,Inpatient DRG
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,555,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],42290.95,,"Fee schedule rate ($42,290.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10896.27,42290.95,There are no additional notes associated with this service or procedure.
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],62990.26,,"Fee schedule rate ($62,990.26). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,16787.98,62990.26,There are no additional notes associated with this service or procedure.
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,068,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],8071.69,,"Case rate ($7,798.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,390.60, add-ons for qualifying new technology services are included. If operating cost exceeds $42,261.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,188.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $5,425.64 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,445.65 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $428.14. The transfer capital threshold is the transfer adjustment factor * $428.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6965.00,23184.90,Inpatient DRG
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],42842.73,,,,,,0,other,16689.78,59521.43,There are no additional notes associated with this service or procedure.
PREMATURITY WITHOUT MAJOR PROBLEMS,792,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],19457.66,,"Case rate ($18,531.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,374.70, add-ons for qualifying new technology services are included. If operating cost exceeds $52,245.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,973.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. The base transfer operating payment is the transfer adjustment factor * $15,373.07 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,429.75 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,213.09. The transfer capital threshold is the transfer adjustment factor * $1,213.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,1956.00,19457.66,Inpatient DRG
"CVA AND PRECEREBRAL OCCLUSION WITH INFARCTION,MAJOR",045,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],13696.05,,"Case rate ($13,696.05). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,13696.05,14380.85,There are no additional notes associated with this service or procedure.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],20559.34,,"Case rate ($20,559.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $19,261.52, add-ons for qualifying new technology services are included. If operating cost exceeds $54,132.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,121.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $17,252.96 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $17,316.57 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,361.43. The transfer capital threshold is the transfer adjustment factor * $1,361.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,20559.34,54086.17,Inpatient DRG
HC Inject Tendon Origin/Insert|RIGHT SIDE,CASE-20551,APC,20551,CPT,0361,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC,817,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],43874.75,,"Fee schedule rate ($43,874.75). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,17396.11,44895.04,There are no additional notes associated with this service or procedure.
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],16283.24,,"Fee schedule rate ($16,283.24). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7875.94,17233.12,There are no additional notes associated with this service or procedure.
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,981,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],98981.99,,"Fee schedule rate ($98,981.99). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,98981.99,98981.99,There are no additional notes associated with this service or procedure.
"Corrj Hallux Valgus W/Sesmdc W/Dist Metar Osteot|RIGHT FOOT, GREAT TOE",CASE-28296,APC,28296,CPT,0360,RC,,,T5,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],17194.49,,"Fee schedule rate ($17,194.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8554.50,19204.75,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL HEMORRHAGE WITH MCC,377,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],31575.65,,"Fee schedule rate ($31,575.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,7634.00,35969.56,There are no additional notes associated with this service or procedure.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],73588.10,,"Fee schedule rate ($73,588.10). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,21585.31,73588.10,There are no additional notes associated with this service or procedure.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,761,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],6965.00,,,,,,0,other,5808.41,11946.72,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],11164.32,,"Case rate ($10,632.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,043.18, add-ons for qualifying new technology services are included. If operating cost exceeds $44,914.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,380.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $8,067.64 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,098.23 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $620.10. The transfer capital threshold is the transfer adjustment factor * $620.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10895.60,35192.25,Inpatient DRG
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],61290.90,,"Fee schedule rate ($61,290.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,23799.09,63499.65,There are no additional notes associated with this service or procedure.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,309,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],6207.80,,"Case rate ($6,207.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $5,875.02, add-ons for qualifying new technology services are included. If operating cost exceeds $44,519.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $3,081.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,495.17 + an uncompensated DSH payment of $1,359.91. The transfer operating threshold is the transfer adjustment factor * $4,515.10 + an uncompensated DSH payment of $1,359.91. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $352.72. The transfer capital threshold is the transfer adjustment factor * $352.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,5055.77,14547.21,Inpatient DRG
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],19230.33,,,,,,0,other,8563.30,31533.97,There are no additional notes associated with this service or procedure.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],62454.12,,"Fee schedule rate ($62,454.12). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11348.00,62454.12,There are no additional notes associated with this service or procedure.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,191,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],16612.88,,"Fee schedule rate ($16,612.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6965.00,16612.88,There are no additional notes associated with this service or procedure.
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITH MCC,429,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],177294.98,,"Fee schedule rate ($177,294.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,62958.58,177294.98,There are no additional notes associated with this service or procedure.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],19877.10,,"Fee schedule rate ($19,877.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8009.34,19877.10,There are no additional notes associated with this service or procedure.
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],28394.78,,"Fee schedule rate ($28,394.78). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11454.97,28394.78,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITH STERILIZATION WITHOUT CC/MCC,785,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],20142.33,,"Fee schedule rate ($20,142.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8431.24,20142.33,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],21892.85,,"Fee schedule rate ($21,892.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7569.84,21892.85,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],81353.66,,"Fee schedule rate ($81,353.66). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,27256.92,81353.66,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],21195.68,,"Fee schedule rate ($21,195.68). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,6965.00,21195.68,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,093,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],6965.00,,,,,,0,other,6965.00,19011.32,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,447,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],47193.21,,"Case rate ($47,193.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $44,038.45, add-ons for qualifying new technology services are included. If operating cost exceeds $78,909.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $5,069.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $41,938.87 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $42,093.51 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,309.39. The transfer capital threshold is the transfer adjustment factor * $3,309.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,47193.21,156646.82,Inpatient DRG
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],40108.48,,"Fee schedule rate ($40,108.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,5569.00,40108.48,There are no additional notes associated with this service or procedure.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],9977.99,,"Case rate ($9,977.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,417.91, add-ons for qualifying new technology services are included. If operating cost exceeds $44,288.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,347.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $7,445.51 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,472.96 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $587.52. The transfer capital threshold is the transfer adjustment factor * $587.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9977.99,26949.28,Inpatient DRG
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,074,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],20919.08,,"Fee schedule rate ($20,919.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8925.60,20919.08,There are no additional notes associated with this service or procedure.
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],40320.14,,,,,,0,other,15821.59,40320.14,There are no additional notes associated with this service or procedure.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],15229.88,,"Case rate ($8,702.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,231.63, add-ons for qualifying new technology services are included. If operating cost exceeds $43,102.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,254.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,263.59 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,286.68 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $494.26. The transfer capital threshold is the transfer adjustment factor * $494.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,5683.00,19635.68,All Other Inpatient
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],8023.69,,"Case rate ($7,641.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,244.44, add-ons for qualifying new technology services are included. If operating cost exceeds $42,115.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,176.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,280.02 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,299.49 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $416.65. The transfer capital threshold is the transfer adjustment factor * $416.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7641.61,19371.27,Inpatient DRG
TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC,087,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],17189.96,,"Fee schedule rate ($17,189.96). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,8139.36,22679.07,There are no additional notes associated with this service or procedure.
"DIVERTICULITIS AND DIVERTICULOSIS,MINOR",244,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],1960.55,,"Case rate for a one day stay ($1,867.19). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,1867.19,1960.55,There are no additional notes associated with this service or procedure.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],9777.00,,"Case rate ($9,446.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,923.36, add-ons for qualifying new technology services are included. If operating cost exceeds $43,794.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,308.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,952.78 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,978.41 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $548.64. The transfer capital threshold is the transfer adjustment factor * $548.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,9446.38,21796.21,Inpatient DRG
"ALCOHOLIC LIVER DISEASE,MODERATE",280,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],1969.25,,"Case rate for a one day stay ($1,969.25). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,1969.25,2067.71,There are no additional notes associated with this service or procedure.
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],68942.79,,"Fee schedule rate ($68,942.79). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,21489.15,68942.79,There are no additional notes associated with this service or procedure.
"CHOLECYSTECTOMY,MINOR",263,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],12396.17,,"Case rate ($11,805.88). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11805.88,12396.17,There are no additional notes associated with this service or procedure.
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],2070.00,,,,,,0,other,1188.00,31658.33,Estimated amount calculated based on 16 day length of stay.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,056,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],18561.00,,"Case rate ($17,677.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,580.28, add-ons for qualifying new technology services are included. If operating cost exceeds $51,451.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,910.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $14,581.57 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,635.33 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,150.63. The transfer capital threshold is the transfer adjustment factor * $1,150.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7659.00,59328.19,Inpatient DRG
GI Tract Imaging Intraluminal Colon I&R,CASE-91113,APC,91113,CPT,0750,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],913.99,,"APC Price ($870.46). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,870.46,913.99,OPPS APC
"HC ED Avulsion Nail Plate Single|RIGHT HAND, THUMB",CASE-11730,APC,11730,CPT,0450,RC,,,F5,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],187.80,,"APC Price ($187.80). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,187.80,197.19,OPPS APC
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,093,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],7337.55,,"Case rate ($7,337.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,961.57, add-ons for qualifying new technology services are included. If operating cost exceeds $41,832.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,154.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,998.19 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,016.62 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $394.41. The transfer capital threshold is the transfer adjustment factor * $394.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,19011.32,Inpatient DRG
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,073,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],30149.61,,"Fee schedule rate ($30,149.61). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12809.38,43475.01,There are no additional notes associated with this service or procedure.
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],31750.77,,"Fee schedule rate ($31,750.77). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13386.36,33244.29,There are no additional notes associated with this service or procedure.
Neuroplasty &/Transposition Ulnar Nerve Elbow|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64718,APC,64718,CPT,0360,RC,,,LT|XU,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
"Tendon Sheath Incision|RIGHT HAND, SECOND DIGIT|UNUSUAL NON-OVERLAPPING SERVICE",CASE-26055,APC,26055,CPT,0360,RC,,,F6|XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1580.37,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1505.12,1580.37,OPPS APC
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],15940.79,,"Case rate ($15,940.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,964.98, add-ons for qualifying new technology services are included. If operating cost exceeds $49,835.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,783.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $12,972.20 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,020.03 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,023.63. The transfer capital threshold is the transfer adjustment factor * $1,023.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,15940.79,53275.26,Inpatient DRG
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",759,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],12471.03,,"Fee schedule rate ($12,471.03). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.9), with a minimum of zero.",,,,0,other,6190.22,13057.66,There are no additional notes associated with this service or procedure.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],12795.84,,"Case rate ($12,795.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,039.30, add-ons for qualifying new technology services are included. If operating cost exceeds $46,910.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,553.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $10,057.27 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,094.35 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $793.62. The transfer capital threshold is the transfer adjustment factor * $793.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12795.84,41944.25,Inpatient DRG
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],54180.83,,"Fee schedule rate ($54,180.83). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,15491.11,54180.83,There are no additional notes associated with this service or procedure.
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],9497.85,,"Case rate ($9,311.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,798, add-ons for qualifying new technology services are included. If operating cost exceeds $43,669.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,298.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $6,827.87 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,853.05 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $538.79. The transfer capital threshold is the transfer adjustment factor * $538.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6965.00,21404.64,Inpatient DRG
"Neuroplasty Sciatic Nerve,Open",CASE-64712,APC,64712,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6791.99,7131.59,OPPS APC
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],86235.79,,"Fee schedule rate ($86,235.79). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,32296.02,88188.38,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL HEMORRHAGE WITH MCC,377,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],35969.56,,,,,,0,other,7634.00,35969.56,There are no additional notes associated with this service or procedure.
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],8165.30,,"Fee schedule rate ($8,165.30). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4341.01,12882.53,There are no additional notes associated with this service or procedure.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],25276.59,,"Fee schedule rate ($25,276.59). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,11053.39,36776.05,There are no additional notes associated with this service or procedure.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],28434.57,,"Fee schedule rate ($28,434.57). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,8906.63,28434.57,There are no additional notes associated with this service or procedure.
HC Inj Aa&/Strd Other Peripheral Nerve/Branch,CASE-64450,APC,64450,CPT,0450,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],660.72,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,660.72,693.76,OPPS APC
CHOLECYSTECTOMY WITH C.D.E. WITH MCC,411,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],88615.28,,"Fee schedule rate ($88,615.28). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,24315.13,88615.28,There are no additional notes associated with this service or procedure.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC,027,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],47412.86,,"Fee schedule rate ($47,412.86). Adds an outlier to normal pricing equal to the per diem rate ($103,062) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,19030.20,56363.30,There are no additional notes associated with this service or procedure.
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],67107.92,,"Fee schedule rate ($67,107.92). Adds an outlier to normal pricing equal to the per diem rate ($118,521.29) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16.7), with a minimum of zero.",,,,0,other,26127.34,90333.60,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],25830.00,,,,,,0,other,10834.64,25830.00,There are no additional notes associated with this service or procedure.
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],39424.57,,"Fee schedule rate ($39,424.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12195.15,39424.57,There are no additional notes associated with this service or procedure.
CHEST PAIN,313,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],6965.00,,,,,,0,other,6820.84,15377.66,There are no additional notes associated with this service or procedure.
RESPIRATORY NEOPLASMS WITHOUT CC/MCC,182,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],23037.13,,"Fee schedule rate ($23,037.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6965.00,23037.13,There are no additional notes associated with this service or procedure.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],26949.28,,"Fee schedule rate ($26,949.28). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9977.99,26949.28,There are no additional notes associated with this service or procedure.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],59521.43,,"Fee schedule rate ($59,521.43). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,16689.78,59521.43,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,065,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],25681.86,,"Fee schedule rate ($25,681.86). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,8786.76,25681.86,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],8543.64,,"Case rate ($8,543.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,083.58, add-ons for qualifying new technology services are included. If operating cost exceeds $42,954.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,242.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,116.09 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,138.64 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $482.62. The transfer capital threshold is the transfer adjustment factor * $482.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8543.64,23239.84,Inpatient DRG
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],19230.88,,"Fee schedule rate ($19,230.88). Adds an outlier to normal pricing equal to the per diem rate ($71,679.63) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8874.81,20553.44,There are no additional notes associated with this service or procedure.
Brnchsc Removal Bronchial Valve Initial,CASE-31648,APC,31648,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3489.82,,"APC Price ($3,489.82). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3489.82,3664.31,OPPS APC
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC,520,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],12664.83,,"Case rate ($12,061.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,356.39, add-ons for qualifying new technology services are included. If operating cost exceeds $46,227.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,499.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $9,376.87 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,411.44 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $739.93. The transfer capital threshold is the transfer adjustment factor * $739.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12061.74,39786.42,Inpatient DRG
Exc Bartholins Gland/Cyst|LEFT SIDE,CASE-56740,APC,56740,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3136.08,,"APC Price ($3,030.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3030.03,3136.08,OPPS APC
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],9356.31,,"Case rate ($9,356.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,839.58, add-ons for qualifying new technology services are included. If operating cost exceeds $43,710.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,302.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $6,869.30 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,894.63 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $542.06. The transfer capital threshold is the transfer adjustment factor * $542.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9356.31,25026.36,Inpatient DRG
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],11133.98,,"Fee schedule rate ($11,133.98). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5919.29,13545.65,There are no additional notes associated with this service or procedure.
OSTEOMYELITIS WITHOUT CC/MCC,541,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],7641.14,,"Case rate ($7,277.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,905.50, add-ons for qualifying new technology services are included. If operating cost exceeds $41,776.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,149.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $4,942.33 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,960.55 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $390.00. The transfer capital threshold is the transfer adjustment factor * $390.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5103.00,15493.67,Inpatient DRG
FRACTURES OF FEMUR WITH MCC,533,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],49490.05,,"Fee schedule rate ($49,490.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,6852.00,49490.05,There are no additional notes associated with this service or procedure.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],10795.75,,"Case rate ($10,281.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,715.99, add-ons for qualifying new technology services are included. If operating cost exceeds $44,587.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,355.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $7,741.69 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,771.04 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $595.04. The transfer capital threshold is the transfer adjustment factor * $595.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10533.95,24956.34,Inpatient DRG
OTHER DISORDERS OF NERVOUS SYSTEM WITH CC,092,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],19225.24,,"Fee schedule rate ($19,225.24). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8872.78,26765.51,There are no additional notes associated with this service or procedure.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],51630.84,,"Fee schedule rate ($51,630.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,20559.34,54086.17,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITHOUT STERILIZATION WITH MCC,786,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],13115.49,,"Case rate ($13,115.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,336.66, add-ons for qualifying new technology services are included. If operating cost exceeds $47,207.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,576.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $10,353.53 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,391.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $817.00. The transfer capital threshold is the transfer adjustment factor * $817.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12612.10,23722.94,Inpatient DRG
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],22487.70,,"Fee schedule rate ($22,487.70). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10048.39,23545.50,There are no additional notes associated with this service or procedure.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC",061,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],62315.82,,"Fee schedule rate ($62,315.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,20616.23,62315.82,There are no additional notes associated with this service or procedure.
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],14442.92,,,,,,0,other,6915.64,14442.92,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],30372.64,,"Fee schedule rate ($30,372.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,13260.40,32878.30,There are no additional notes associated with this service or procedure.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],17269.71,,"Case rate ($16,447.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,436.22, add-ons for qualifying new technology services are included. If operating cost exceeds $50,307.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,820.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $13,441.70 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,491.27 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,060.68. The transfer capital threshold is the transfer adjustment factor * $1,060.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7453.00,42138.30,Inpatient DRG
"NEONATE BIRTH WEIGHT > 2499 GRAMS WITH MAJOR ANOMALY,MODERATE",633,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],6626.56,,"Case rate ($6,626.56). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,6626.56,6957.89,There are no additional notes associated with this service or procedure.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],47114.44,,"Case rate ($45,521.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $42,483.01, add-ons for qualifying new technology services are included. If operating cost exceeds $77,354.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,947.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 12.5. The base transfer operating payment is the transfer adjustment factor * $40,389.14 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $40,538.06 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,187.10. The transfer capital threshold is the transfer adjustment factor * $3,187.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,45521.20,142438.06,Inpatient DRG
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH MCC",722,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],56869.13,,"Fee schedule rate ($56,869.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,14200.37,56869.13,There are no additional notes associated with this service or procedure.
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],11565.93,,"Fee schedule rate ($11,565.93). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6148.93,15887.21,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,555,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],11114.20,,"Case rate ($10,896.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,272.18, add-ons for qualifying new technology services are included. If operating cost exceeds $45,143.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,414.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,296.64 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,327.23 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $654.69. The transfer capital threshold is the transfer adjustment factor * $654.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,10896.27,42290.95,Inpatient DRG
"NEONATE BIRTH WEIGHT > 2499 GRAMS WITH RESPIRATORY DISTRESS SYNDROME OR OTHER MAJOR RESPIRATORY CONDITION,MODERATE",634,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],9899.21,,"Case rate ($9,427.82). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9427.82,9899.21,There are no additional notes associated with this service or procedure.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],20401.88,,"Fee schedule rate ($20,401.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,20401.88,There are no additional notes associated with this service or procedure.
UNGROUPABLE,999,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],10228.00,,"Per diem ($10,228). If length of stay < 12.7, first 1 days paid at a per diem of $20,456 instead. Capped at $129,893.46.",,,,0,other,10228.00,161307.29,Estimated amount calculated based on 9 day length of stay.
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],10638.94,,"Case rate ($10,638.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,032.78, add-ons for qualifying new technology services are included. If operating cost exceeds $44,903.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,395.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,058.12 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,087.83 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $635.87. The transfer capital threshold is the transfer adjustment factor * $635.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10638.94,25261.33,Inpatient DRG
Tenodesis Long Tendon Biceps|RIGHT SIDE,CASE-23430,APC,23430,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],13411.63,,"Case rate ($13,148.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,367.53, add-ons for qualifying new technology services are included. If operating cost exceeds $47,238.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,579.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $10,384.29 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,422.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $819.42. The transfer capital threshold is the transfer adjustment factor * $819.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,13148.66,32553.63,Inpatient DRG
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],8393.44,,"Case rate ($7,993.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,572.03, add-ons for qualifying new technology services are included. If operating cost exceeds $42,443.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,202.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $5,606.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,627.08 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $442.40. The transfer capital threshold is the transfer adjustment factor * $442.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5415.00,17575.50,Inpatient DRG
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],8168.94,,"Case rate ($7,779.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,384, add-ons for qualifying new technology services are included. If operating cost exceeds $42,255.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,176.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,418.51 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,439.05 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $416.48. The transfer capital threshold is the transfer adjustment factor * $416.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,17467.27,Inpatient DRG
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],19152.11,,"Case rate ($19,152.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,952.40, add-ons for qualifying new technology services are included. If operating cost exceeds $52,823.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,018.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $15,948.65 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $16,007.45 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,258.51. The transfer capital threshold is the transfer adjustment factor * $1,258.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,19152.11,53152.12,Inpatient DRG
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],13642.55,,"Case rate ($12,992.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,222.63, add-ons for qualifying new technology services are included. If operating cost exceeds $47,093.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,568.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $10,239.92 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,277.68 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $808.03. The transfer capital threshold is the transfer adjustment factor * $808.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7665.00,40737.46,Inpatient DRG
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],40737.46,,"Fee schedule rate ($40,737.46). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,7665.00,40737.46,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],43949.31,,"Fee schedule rate ($43,949.31). Adds an outlier to normal pricing equal to the per diem rate ($149,567.78) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,17782.11,46523.26,There are no additional notes associated with this service or procedure.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC",156,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],12624.95,,"Fee schedule rate ($12,624.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6625.12,13598.77,There are no additional notes associated with this service or procedure.
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],2070.00,,,,,,0,other,1188.00,31658.33,Estimated amount calculated based on 16 day length of stay.
Ndsc Eval Intstinal Pouch Dx W/Collj Spec Spx,CASE-44385,APC,44385,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],913.99,,"APC Price ($870.46). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,870.46,913.99,OPPS APC
NORMAL NEWBORN,795,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3413.44,,"Case rate ($3,298.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $3,203.67, add-ons for qualifying new technology services are included. If operating cost exceeds $38,074.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $1,858.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $1,254.10 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $1,258.72 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $98.96. The transfer capital threshold is the transfer adjustment factor * $98.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,1369.79,5771.52,Inpatient DRG
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",004,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],100534.98,,"Case rate ($95,747.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $89,207.57, add-ons for qualifying new technology services are included. If operating cost exceeds $124,078.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $8,620.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 22.4. The base transfer operating payment is the transfer adjustment factor * $86,942.06 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $87,262.63 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $6,860.59. The transfer capital threshold is the transfer adjustment factor * $6,860.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10249.47,272554.00,Inpatient DRG
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],23078.81,,"Fee schedule rate ($23,078.81). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10311.17,24308.97,There are no additional notes associated with this service or procedure.
Unlisted Procedure Arthroscopy,CASE-29999,APC,29999,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],12527.66,,"Case rate ($12,527.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,789.82, add-ons for qualifying new technology services are included. If operating cost exceeds $46,660.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,533.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $9,808.71 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,844.88 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $774.00. The transfer capital threshold is the transfer adjustment factor * $774.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12527.66,29917.96,Inpatient DRG
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC",458,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],31259.16,,"Case rate ($30,202.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $28,231.97, add-ons for qualifying new technology services are included. If operating cost exceeds $63,102.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,826.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $26,190.45 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $26,287.02 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,066.69. The transfer capital threshold is the transfer adjustment factor * $2,066.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,30202.09,132827.25,Inpatient DRG
"Tendon Sheath Incision|LEFT HAND, THUMB",CASE-26055,APC,26055,CPT,0360,RC,,,FA,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1557.80,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1505.12,1580.37,OPPS APC
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],51903.64,,"Fee schedule rate ($51,903.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,16017.99,51903.64,There are no additional notes associated with this service or procedure.
SINGLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL,402,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],124455.45,,"Fee schedule rate ($124,455.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,29172.05,124455.45,There are no additional notes associated with this service or procedure.
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,068,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],8008.12,,"Case rate ($7,626.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,241.24, add-ons for qualifying new technology services are included. If operating cost exceeds $42,112.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,165.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $5,276.29 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,296.29 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $405.55. The transfer capital threshold is the transfer adjustment factor * $405.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,23184.90,Inpatient DRG
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],53152.12,,"Fee schedule rate ($53,152.12). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,19152.11,53152.12,There are no additional notes associated with this service or procedure.
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],15762.96,,"Case rate ($15,453.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,512.02, add-ons for qualifying new technology services are included. If operating cost exceeds $49,383.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,747.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $12,520.90 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,567.07 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $988.02. The transfer capital threshold is the transfer adjustment factor * $988.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,15453.88,39251.68,Inpatient DRG
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITH MCC,429,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],177294.98,,"Fee schedule rate ($177,294.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,62958.58,177294.98,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],70242.60,,"Fee schedule rate ($70,242.60). Adds an outlier to normal pricing equal to the per diem rate ($137,416) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16.5), with a minimum of zero.",,,,0,other,27256.92,81353.66,There are no additional notes associated with this service or procedure.
Insertion Intrauterine Device Iud,CASE-58300,APC,58300,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3136.08,,"APC Price ($3,030.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3030.03,3136.08,OPPS APC
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,699,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],19570.20,,"Fee schedule rate ($19,570.20). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5961.00,19972.16,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,447,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],156646.82,,"Fee schedule rate ($156,646.82). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,47193.21,156646.82,There are no additional notes associated with this service or procedure.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH CC,026,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],23501.30,,"Case rate ($22,382.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,995.42, add-ons for qualifying new technology services are included. If operating cost exceeds $55,866.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,218.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $18,978.51 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $19,050.47 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,458.73. The transfer capital threshold is the transfer adjustment factor * $1,458.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,23000.66,63202.45,Inpatient DRG
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],7176.11,,"Case rate ($6,834.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,493.49, add-ons for qualifying new technology services are included. If operating cost exceeds $41,364.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,117.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $4,531.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,548.54 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $357.61. The transfer capital threshold is the transfer adjustment factor * $357.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6834.39,21354.82,Inpatient DRG
"ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",770,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],8735.30,,"Case rate ($8,735.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,261.87, add-ons for qualifying new technology services are included. If operating cost exceeds $43,132.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,256.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $6,293.72 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,316.92 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $496.64. The transfer capital threshold is the transfer adjustment factor * $496.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8735.30,19730.13,Inpatient DRG
Rpr Aa Hernia Recr 3-10 Cm Ncrc8/Strangulated,CASE-49616,APC,49616,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5941.70,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5658.76,5941.70,OPPS APC
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],10862.00,,"Per diem ($10,862). If length of stay < 7.6, first 1 days paid at a per diem of $21,724 instead. Capped at $82,553.89.",,,,0,other,10862.00,86437.13,Estimated amount calculated based on 6 day length of stay.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],27594.12,,"Fee schedule rate ($27,594.12). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,16017.99,51903.64,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],10223.39,,"Fee schedule rate ($10,223.39). Adds an outlier to normal pricing equal to the per diem rate ($48,095.58) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,5628.97,12272.58,There are no additional notes associated with this service or procedure.
HC Joint Injection/Aspir Large WO US|BILATERAL PROCEDURE,CASE-20610,APC,20610,CPT,0510,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],301.68,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,287.31,301.68,OPPS APC
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],19997.63,,"Fee schedule rate ($19,997.63). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,9151.11,30245.71,There are no additional notes associated with this service or procedure.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],18598.83,,"Case rate ($18,598.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,437.70, add-ons for qualifying new technology services are included. If operating cost exceeds $52,308.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,978.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 5.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $15,435.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,492.75 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,218.04. The transfer capital threshold is the transfer adjustment factor * $1,218.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,18598.83,48389.68,Inpatient DRG
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC,192,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],12753.78,,"Fee schedule rate ($12,753.78). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6292.63,12753.78,There are no additional notes associated with this service or procedure.
Surgical Arthroscopy Shoulder Removal Loose/FB,CASE-29819,APC,29819,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7029.71,OPPS APC
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],18311.90,,"Fee schedule rate ($18,311.90). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8543.64,23239.84,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITH STERILIZATION WITH CC,784,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],23722.94,,"Fee schedule rate ($23,722.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9124.01,23722.94,There are no additional notes associated with this service or procedure.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],8906.63,,"Case rate ($8,906.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,421.26, add-ons for qualifying new technology services are included. If operating cost exceeds $43,292.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,269.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $6,452.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,476.31 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $509.17. The transfer capital threshold is the transfer adjustment factor * $509.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8906.63,28434.57,Inpatient DRG
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,082,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],42953.28,,"Fee schedule rate ($42,953.28). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.6), with a minimum of zero.",,,,0,other,17423.21,56223.11,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITH STERILIZATION WITH CC,784,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],19922.46,,"Fee schedule rate ($19,922.46). Adds an outlier to normal pricing equal to the per diem rate ($39,437.39) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,9124.01,23722.94,There are no additional notes associated with this service or procedure.
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,068,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],23184.90,,"Fee schedule rate ($23,184.90). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,23184.90,There are no additional notes associated with this service or procedure.
Lamnotmy Incl W/Dcmprsn Nrv Root 1 Intrspc Lumbr|LEFT SIDE,CASE-63030,APC,63030,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7029.71,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6791.99,7131.59,OPPS APC
DIABETES WITH CC,638,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],8174.35,,"Case rate ($8,014.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,590.93, add-ons for qualifying new technology services are included. If operating cost exceeds $42,461.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,203.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,625.24 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,645.98 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $443.89. The transfer capital threshold is the transfer adjustment factor * $443.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,8014.07,17634.53,Inpatient DRG
OTHER MENTAL DISORDER DIAGNOSES,887,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],9381.11,,"Case rate ($9,197.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,691.53, add-ons for qualifying new technology services are included. If operating cost exceeds $43,562.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,290.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,721.79 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,746.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $530.42. The transfer capital threshold is the transfer adjustment factor * $530.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,2070.00,21072.10,Inpatient DRG
HC Inj Trigger Pt 1-2 Musc Grps|PBB CHARGE|SEPARATE STRUCTURE,CASE-20552,APC,20552,CPT,0510,RC,,,PBB|XS,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,477,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],67976.16,,,,,,0,other,25339.74,67976.16,There are no additional notes associated with this service or procedure.
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,094,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],27067.51,,"Case rate ($25,778.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $24,116.87, add-ons for qualifying new technology services are included. If operating cost exceeds $58,987.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,503.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.9. The base transfer operating payment is the transfer adjustment factor * $22,090.47 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $22,171.92 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,743.16. The transfer capital threshold is the transfer adjustment factor * $1,743.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,25778.58,67889.44,Inpatient DRG
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],8790.94,,"Case rate ($8,372.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,924.20, add-ons for qualifying new technology services are included. If operating cost exceeds $42,795.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,230.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,957.28 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,979.25 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $470.09. The transfer capital threshold is the transfer adjustment factor * $470.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,23385.72,Inpatient DRG
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],21089.59,,"Fee schedule rate ($21,089.59). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,6965.00,21089.59,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,689,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],22417.63,,"Fee schedule rate ($22,417.63). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,9802.58,22831.22,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],32293.66,,"Fee schedule rate ($32,293.66). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,32293.66,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],9888.00,,"Per diem ($9,888). If length of stay < 3.1, first 1 days paid at a per diem of $19,776 instead. Capped at $30,651.38.",,,,0,other,9888.00,43399.23,Estimated amount calculated based on 1 day length of stay.
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],12027.72,,"Case rate ($11,454.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,791.92, add-ons for qualifying new technology services are included. If operating cost exceeds $45,662.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,455.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $8,814.47 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,846.97 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $695.55. The transfer capital threshold is the transfer adjustment factor * $695.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,11454.97,28394.78,Inpatient DRG
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC,192,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],12753.78,,"Fee schedule rate ($12,753.78). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6292.63,12753.78,There are no additional notes associated with this service or procedure.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,761,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],11946.72,,"Fee schedule rate ($11,946.72). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,5808.41,11946.72,There are no additional notes associated with this service or procedure.
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],56787.82,,,,,,0,other,21489.15,68942.79,There are no additional notes associated with this service or procedure.
HC Gastroesophag Reflx Test W/Tel Ph Eltrd,CASE-91035,APC,91035,CPT,0750,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],843.99,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,803.80,843.99,OPPS APC
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,091,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],14322.39,,"Case rate ($13,838.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,008.86, add-ons for qualifying new technology services are included. If operating cost exceeds $47,879.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,629.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $11,023.26 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,063.91 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $869.84. The transfer capital threshold is the transfer adjustment factor * $869.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,13838.06,40030.81,Inpatient DRG
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,426,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],216864.15,,,,,,0,other,76581.29,216864.15,There are no additional notes associated with this service or procedure.
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],8393.44,,"Case rate ($7,993.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,572.03, add-ons for qualifying new technology services are included. If operating cost exceeds $42,443.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,202.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $5,606.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,627.08 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $442.40. The transfer capital threshold is the transfer adjustment factor * $442.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5415.00,17575.50,Inpatient DRG
"Laminec/Facetect/Foramin,Lumbar|SEPARATE STRUCTURE",CASE-63047,APC,63047,CPT,0360,RC,,,XS,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],25398.09,,"APC Price ($25,398.09). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,25398.09,26668.00,OPPS APC
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],10149.91,,"Case rate ($9,950.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,392.71, add-ons for qualifying new technology services are included. If operating cost exceeds $44,263.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,345.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $7,420.40 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,447.76 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $585.54. The transfer capital threshold is the transfer adjustment factor * $585.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,7243.75,23262.15,Inpatient DRG
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],16283.24,,"Fee schedule rate ($16,283.24). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7875.94,17233.12,There are no additional notes associated with this service or procedure.
Cysto W/Urtroscopy&/Pyeloscopy Dx|UNUSUAL NON-OVERLAPPING SERVICE,CASE-52351,APC,52351,CPT,0360,RC,,,XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3464.44,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3299.47,3464.44,OPPS APC
Realignment Extensor Tendon Hand Each Tendon,CASE-26437,APC,26437,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,066,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],20083.61,,"Fee schedule rate ($20,083.61). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6579.76,20083.61,There are no additional notes associated with this service or procedure.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],17194.49,,"Fee schedule rate ($17,194.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8554.50,19204.75,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC,084,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],8838.59,,"Case rate ($8,417.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,966.41, add-ons for qualifying new technology services are included. If operating cost exceeds $42,837.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,233.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $5,999.34 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,021.46 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $473.41. The transfer capital threshold is the transfer adjustment factor * $473.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,19445.16,Inpatient DRG
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC,831,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],9294.42,,"Fee schedule rate ($9,294.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,4941.30,23661.59,There are no additional notes associated with this service or procedure.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],36094.03,,"Fee schedule rate ($36,094.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11194.25,36094.03,There are no additional notes associated with this service or procedure.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],20407.65,,"Case rate ($19,435.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $18,216.37, add-ons for qualifying new technology services are included. If operating cost exceeds $53,087.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,039.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.9. The base transfer operating payment is the transfer adjustment factor * $16,211.64 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $16,271.42 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,279.26. The transfer capital threshold is the transfer adjustment factor * $1,279.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,19435.86,50821.76,Inpatient DRG
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],9667.64,,"Fee schedule rate ($9,667.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,5139.72,13110.79,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],41402.42,,"Fee schedule rate ($41,402.42). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,15456.59,41402.42,There are no additional notes associated with this service or procedure.
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],62990.26,,"Fee schedule rate ($62,990.26). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,16787.98,62990.26,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],30055.64,,"Fee schedule rate ($30,055.64). Adds an outlier to normal pricing equal to the per diem rate ($74,094.67) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.9), with a minimum of zero.",,,,0,other,12775.53,31469.43,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],6167.00,,"Per diem ($6,167). If length of stay < 4.5, first 1 days paid at a per diem of $12,334 instead. Capped at $27,753.50.",,,,0,other,6167.00,29058.99,Estimated amount calculated based on 3 day length of stay.
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,448,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],30663.95,,"Case rate ($30,663.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $28,661.63, add-ons for qualifying new technology services are included. If operating cost exceeds $63,532.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,860.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $26,618.53 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $26,716.68 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,100.47. The transfer capital threshold is the transfer adjustment factor * $2,100.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,30663.95,94077.13,Inpatient DRG
Arthroplasty Patella W/O Prosthesis|BILATERAL PROCEDURE,CASE-27437,APC,27437,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
"PROCEDURES FOR OBESITY,MODERATE",403,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],14299.07,,"Case rate ($14,299.07). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,14299.07,15014.02,There are no additional notes associated with this service or procedure.
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral Ea Addl,CASE-64484,APC,64484,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],869.28,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,827.89,869.28,OPPS APC
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,085,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],9282.00,,"Per diem ($9,282). If length of stay < 4.6, first 1 days paid at a per diem of $18,564 instead. Capped at $42,695.82.",,,,0,other,9282.00,57443.16,Estimated amount calculated based on 2 day length of stay.
Laps Tx Ectopic Preg W/Salping&/Oophorectomy|LEFT SIDE,CASE-59151,APC,59151,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5941.70,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5658.76,5941.70,OPPS APC
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],21089.59,,"Fee schedule rate ($21,089.59). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,6965.00,21089.59,There are no additional notes associated with this service or procedure.
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],16428.39,,"Case rate ($16,428.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,418.58, add-ons for qualifying new technology services are included. If operating cost exceeds $50,289.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,819.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $13,424.13 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,473.63 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,059.30. The transfer capital threshold is the transfer adjustment factor * $1,059.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,16428.39,42083.20,Inpatient DRG
Sigmoidoscopy Flx W/Biopsy Single/Multiple|COLORECTAL CANCER SCREEN,CASE-45331,APC,45331,CPT,0360,RC,,,PT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],900.93,,"APC Price ($870.46). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,870.46,913.99,OPPS APC
HC Inj Anes/Steroid C/D Facet Sg|LEFT SIDE|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-64490,APC,64490,CPT,0361,RC,,,LT|74,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],827.89,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,827.89,869.28,OPPS APC
O.R. PROCEDURES FOR OBESITY WITH CC,620,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],43753.50,,"Fee schedule rate ($43,753.50). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12782.30,43753.50,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],21796.62,,"Case rate ($12,455.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,722.41, add-ons for qualifying new technology services are included. If operating cost exceeds $46,593.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,528.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $9,741.55 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,777.47 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $768.70. The transfer capital threshold is the transfer adjustment factor * $768.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,12455.21,37149.27,All Other Inpatient
CHEST PAIN,313,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],6820.84,,"Case rate ($6,820.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,480.89, add-ons for qualifying new technology services are included. If operating cost exceeds $41,351.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,116.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $4,519.27 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,535.94 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $356.62. The transfer capital threshold is the transfer adjustment factor * $356.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6820.84,15377.66,Inpatient DRG
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],19371.27,,"Fee schedule rate ($19,371.27). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7641.61,19371.27,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,085,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],57443.16,,"Fee schedule rate ($57,443.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,9282.00,57443.16,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],86235.79,,"Fee schedule rate ($86,235.79). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,32296.02,88188.38,There are no additional notes associated with this service or procedure.
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],15291.15,,"Fee schedule rate ($15,291.15). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12566.28,30861.41,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],14871.83,,"Fee schedule rate ($14,871.83). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6558.75,14871.83,There are no additional notes associated with this service or procedure.
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],19371.27,,"Fee schedule rate ($19,371.27). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8643.20,19462.52,There are no additional notes associated with this service or procedure.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],38246.19,,"Fee schedule rate ($38,246.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,19435.86,50821.76,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],40737.46,,"Fee schedule rate ($40,737.46). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,7665.00,40737.46,There are no additional notes associated with this service or procedure.
Rmvl/Revj Sling Stress Incontinence,CASE-57287,APC,57287,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3030.03,,"APC Price ($3,030.03). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3030.03,3136.08,OPPS APC
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],29474.94,,"Fee schedule rate ($29,474.94). Adds an outlier to normal pricing equal to the per diem rate ($65,448.99) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.4), with a minimum of zero.",,,,0,other,12566.28,30861.41,There are no additional notes associated with this service or procedure.
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC,806,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],10071.17,,"Fee schedule rate ($10,071.17). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5354.25,13416.00,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],58394.20,,"Fee schedule rate ($58,394.20). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,9370.00,65732.99,There are no additional notes associated with this service or procedure.
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],6965.00,,,,,,0,other,5883.03,17111.12,There are no additional notes associated with this service or procedure.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,761,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],5924.58,,"Case rate ($5,808.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,539.05, add-ons for qualifying new technology services are included. If operating cost exceeds $40,410.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,042.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $3,580.90 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,594.10 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $282.57. The transfer capital threshold is the transfer adjustment factor * $282.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,5808.41,11946.72,Inpatient DRG
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,086,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],8442.00,,"Per diem ($8,442). If length of stay < 2.9, first 1 days paid at a per diem of $16,884 instead. Capped at $24,481.64.",,,,0,other,8442.00,30728.81,Estimated amount calculated based on 2 day length of stay.
Lamnotmy Incl W/Dcmprsn Nrv Root 1 Intrspc Lumbr|LEFT SIDE,CASE-63030,APC,63030,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7029.71,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6791.99,7131.59,OPPS APC
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],34032.82,,"Fee schedule rate ($34,032.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,15233.11,38610.21,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,086,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],30728.81,,"Fee schedule rate ($30,728.81). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8442.00,30728.81,There are no additional notes associated with this service or procedure.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,056,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],59328.19,,"Fee schedule rate ($59,328.19). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (44), with a minimum of zero.",,,,0,other,7659.00,59328.19,There are no additional notes associated with this service or procedure.
NERVOUS SYSTEM NEOPLASMS WITH MCC,054,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],12285.22,,"Case rate ($12,285.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,564.29, add-ons for qualifying new technology services are included. If operating cost exceeds $46,435.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,516.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $9,584.00 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,619.34 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $756.27. The transfer capital threshold is the transfer adjustment factor * $756.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,30044.81,Inpatient DRG
PERIPHERAL VASCULAR DISORDERS WITH CC,300,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],20331.78,,"Fee schedule rate ($20,331.78). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,9174.14,21005.20,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],22142.34,,"Case rate ($21,087.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $19,788.99, add-ons for qualifying new technology services are included. If operating cost exceeds $54,660.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,126.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $17,776.64 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $17,844.04 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,366.35. The transfer capital threshold is the transfer adjustment factor * $1,366.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8972.00,81524.17,Inpatient DRG
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6564.18,,"Case rate ($6,564.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,242.12, add-ons for qualifying new technology services are included. If operating cost exceeds $41,113.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,097.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $4,281.39 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,297.17 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $337.84. The transfer capital threshold is the transfer adjustment factor * $337.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6564.18,17651.07,Inpatient DRG
NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,601,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],11369.77,,"Fee schedule rate ($11,369.77). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,6042.05,12359.72,There are no additional notes associated with this service or procedure.
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],8120.41,,"Case rate ($7,733.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,330.12, add-ons for qualifying new technology services are included. If operating cost exceeds $42,201.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,183.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,365.38 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,385.17 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $423.38. The transfer capital threshold is the transfer adjustment factor * $423.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7733.72,18043.23,Inpatient DRG
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH CC,427,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],134742.59,,"Fee schedule rate ($134,742.59). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,50829.82,142040.39,There are no additional notes associated with this service or procedure.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC,192,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],12753.78,,"Fee schedule rate ($12,753.78). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6292.63,12753.78,There are no additional notes associated with this service or procedure.
Exc Rct Tum Incl Muscularis Propria,CASE-45172,APC,45172,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],2598.08,,"APC Price ($2,598.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2598.08,2727.99,OPPS APC
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,068,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],23184.90,,"Fee schedule rate ($23,184.90). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,23184.90,There are no additional notes associated with this service or procedure.
NON-MALIGNANT BREAST DISORDERS WITH CC/MCC,600,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],8998.74,,"Case rate ($8,998.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,506.94, add-ons for qualifying new technology services are included. If operating cost exceeds $43,377.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,275.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $6,537.88 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,561.99 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $515.90. The transfer capital threshold is the transfer adjustment factor * $515.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7999.14,20495.56,Inpatient DRG
PERIPHERAL VASCULAR DISORDERS WITH CC,300,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],11268.60,,"Fee schedule rate ($11,268.60). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,9174.14,21005.20,There are no additional notes associated with this service or procedure.
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],25253.70,,"Fee schedule rate ($25,253.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11974.38,29141.64,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],28821.04,,"Fee schedule rate ($28,821.04). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,10347.06,28821.04,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],15808.67,,"Fee schedule rate ($15,808.67). Adds an outlier to normal pricing equal to the per diem rate ($67,650.85) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,7641.61,19371.27,There are no additional notes associated with this service or procedure.
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],23385.72,,"Fee schedule rate ($23,385.72). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,23385.72,There are no additional notes associated with this service or procedure.
"INFECTIOUS AND PARASITIC DISEASES INCLUDING HIV WITH O.R. PROCEDURE,MINOR",710,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],13387.36,,"Case rate ($12,749.87). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12749.87,13387.36,There are no additional notes associated with this service or procedure.
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],12154.28,,"Case rate ($11,575.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,904.06, add-ons for qualifying new technology services are included. If operating cost exceeds $45,775.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,464.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $8,926.20 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,959.11 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $704.37. The transfer capital threshold is the transfer adjustment factor * $704.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,11575.50,48961.48,Inpatient DRG
Orchiectomy Radical Tumor Inguinal Approach|LEFT SIDE,CASE-54530,APC,54530,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3518.91,,"APC Price ($3,351.34). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3351.34,3518.91,OPPS APC
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],12558.65,,"Fee schedule rate ($12,558.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5065.00,12558.65,There are no additional notes associated with this service or procedure.
HYPERTENSION WITHOUT MCC,305,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],14190.59,,"Fee schedule rate ($14,190.59). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,7058.55,17230.49,There are no additional notes associated with this service or procedure.
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],14309.17,,"Fee schedule rate ($14,309.17). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,17467.27,There are no additional notes associated with this service or procedure.
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],14343.25,,"Case rate ($14,343.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,478.83, add-ons for qualifying new technology services are included. If operating cost exceeds $48,349.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,666.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $11,491.51 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,533.88 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $906.79. The transfer capital threshold is the transfer adjustment factor * $906.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,14343.25,36024.65,Inpatient DRG
"VAGINAL DELIVERY WITH O.R. PROCEDURE EXCEPT STERILIZATION AND/OR D&C,MINOR",542,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],4518.49,,"Case rate ($4,303.32). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4303.32,4518.49,There are no additional notes associated with this service or procedure.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],8554.50,,"Case rate ($8,554.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,093.67, add-ons for qualifying new technology services are included. If operating cost exceeds $42,964.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,243.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,126.13 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,148.72 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $483.41. The transfer capital threshold is the transfer adjustment factor * $483.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8554.50,19204.75,Inpatient DRG
PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,337,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],21574.35,,"Fee schedule rate ($21,574.35). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,12340.08,38926.31,There are no additional notes associated with this service or procedure.
"Corrj Hallux Valgus W/Sesmdc W/Dist Metar Osteot|RIGHT FOOT, GREAT TOE",CASE-28296,APC,28296,CPT,0360,RC,,,T5,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
MINOR BLADDER PROCEDURES WITHOUT CC/MCC,664,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],19674.39,,"Fee schedule rate ($19,674.39). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,9034.63,31876.87,There are no additional notes associated with this service or procedure.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,761,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5979.68,,"Case rate ($5,694.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,440.48, add-ons for qualifying new technology services are included. If operating cost exceeds $40,311.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,027.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $3,482.32 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,495.53 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $267.66. The transfer capital threshold is the transfer adjustment factor * $267.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5808.41,11946.72,Inpatient DRG
HC Drain/Inj Joint/Bursa W/US Large|LEFT SIDE,CASE-20611,APC,20611,CPT,0510,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
HC Cv Cath Plac W/Port Tun >5,CASE-36561,APC,36561,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],2955.48,,"APC Price ($2,955.48). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2955.48,3103.25,OPPS APC
CESAREAN SECTION WITH STERILIZATION WITH MCC,783,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],23722.94,,"Fee schedule rate ($23,722.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12612.10,23722.94,There are no additional notes associated with this service or procedure.
Laparoscopy Tot Hysterectomy >250 G W/Tube/Ovar,CASE-58573,APC,58573,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],9949.78,,"APC Price ($9,949.78). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,9949.78,10447.27,OPPS APC
Chemodenervation Muscle Neck Unilat for Dystonia|BILATERAL PROCEDURE,CASE-64616,APC,64616,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
PERIPHERAL VASCULAR DISORDERS WITH CC,300,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],9409.88,,"Case rate ($8,961.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,485.66, add-ons for qualifying new technology services are included. If operating cost exceeds $43,356.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,260.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,516.00 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,540.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $500.84. The transfer capital threshold is the transfer adjustment factor * $500.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9174.14,21005.20,Inpatient DRG
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC,858,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],11605.32,,"Case rate ($11,377.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,720.10, add-ons for qualifying new technology services are included. If operating cost exceeds $45,591.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,449.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $8,742.91 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,775.15 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $689.90. The transfer capital threshold is the transfer adjustment factor * $689.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,11377.76,33794.11,Inpatient DRG
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],11388.47,,"Case rate ($10,846.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,225.56, add-ons for qualifying new technology services are included. If operating cost exceeds $45,096.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,410.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $8,250.19 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,280.61 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $651.02. The transfer capital threshold is the transfer adjustment factor * $651.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10846.16,25863.45,Inpatient DRG
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,479,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],15260.23,,"Case rate ($14,533.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,655.86, add-ons for qualifying new technology services are included. If operating cost exceeds $48,526.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,680.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $11,667.89 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,710.91 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $920.71. The transfer capital threshold is the transfer adjustment factor * $920.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10586.00,50518.76,Inpatient DRG
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],17686.09,,"Fee schedule rate ($17,686.09). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8318.14,19763.43,There are no additional notes associated with this service or procedure.
PREMATURITY WITHOUT MAJOR PROBLEMS,792,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],2074.00,,,,,,0,other,1956.00,19457.66,Estimated amount calculated based on 3 day length of stay.
Prtl Exc B1 Tarsal/Metar B1 Xcp Talus/Calcaneus|LEFT SIDE,CASE-28122,APC,28122,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3169.86,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC,497,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],22707.58,,"Fee schedule rate ($22,707.58). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7.8), with a minimum of zero.",,,,0,other,10127.65,37761.19,There are no additional notes associated with this service or procedure.
Colonoscopy W/Biopsy Single/Multiple|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-45380,APC,45380,CPT,0360,RC,,,74,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1120.09,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1120.09,1176.09,OPPS APC
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC",458,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],132827.25,,"Fee schedule rate ($132,827.25). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,30202.09,132827.25,There are no additional notes associated with this service or procedure.
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITH MCC OR ANTINEOPLASTIC IMPLANT OR EPILEPSY WITH NEUROSTIMULATOR,023,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],112755.11,,,,,,0,other,15168.00,136379.44,There are no additional notes associated with this service or procedure.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],9552.48,,"Case rate ($9,097.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,598.92, add-ons for qualifying new technology services are included. If operating cost exceeds $43,469.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,283.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,629.53 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,653.97 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $523.14. The transfer capital threshold is the transfer adjustment factor * $523.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9097.60,21455.22,Inpatient DRG
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],21512.35,,"Fee schedule rate ($21,512.35). Adds an outlier to normal pricing equal to the per diem rate ($37,521.53) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,9696.93,35061.53,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],96365.69,,"Fee schedule rate ($96,365.69). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,23377.19,96365.69,There are no additional notes associated with this service or procedure.
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],11168.08,,"Fee schedule rate ($11,168.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5937.41,12366.99,There are no additional notes associated with this service or procedure.
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],13568.55,,"Fee schedule rate ($13,568.55). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6834.39,21354.82,There are no additional notes associated with this service or procedure.
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],17249.81,,"Case rate ($16,428.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,418.58, add-ons for qualifying new technology services are included. If operating cost exceeds $50,289.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,819.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $13,424.13 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,473.63 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,059.30. The transfer capital threshold is the transfer adjustment factor * $1,059.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,16428.39,42083.20,Inpatient DRG
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,345,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],33616.03,,"Fee schedule rate ($33,616.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12134.89,33616.03,There are no additional notes associated with this service or procedure.
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],22470.91,,"Case rate ($12,840.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,080.88, add-ons for qualifying new technology services are included. If operating cost exceeds $46,951.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,556.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $10,098.70 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,135.93 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $796.89. The transfer capital threshold is the transfer adjustment factor * $796.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,1188.00,31658.33,All Other Inpatient
Replacement Tissue Expander W/Permanent Implant|BILATERAL PROCEDURE,CASE-11970,APC,11970,CPT,0360,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7029.71,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,7029.71,7131.59,OPPS APC
NEONATE WITH OTHER SIGNIFICANT PROBLEMS,794,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],12536.83,,"Case rate ($11,939.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,242.99, add-ons for qualifying new technology services are included. If operating cost exceeds $46,114.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,490.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $9,263.89 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,298.04 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $731.01. The transfer capital threshold is the transfer adjustment factor * $731.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,1798.85,12536.83,Inpatient DRG
Sigmoidoscopy Flx Dx W/Collj Spec Br/Wa if Pfrmd,CASE-45330,APC,45330,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],900.93,,"APC Price ($870.46). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,870.46,913.99,OPPS APC
UNGROUPABLE,999,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],161307.29,,"Fee schedule rate ($161,307.29). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (41), with a minimum of zero.",,,,0,other,10228.00,161307.29,There are no additional notes associated with this service or procedure.
HC Injection Small Joint/Bursa,CASE-20600,APC,20600,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
Open Tx Metacarpal Fracture Single Ea Bone|RIGHT SIDE,CASE-26615,APC,26615,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
Induced Abortion Dilation & Evacuation,CASE-59841,APC,59841,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3030.03,,"APC Price ($3,030.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3030.03,3181.53,OPPS APC
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],39361.94,,"Fee schedule rate ($39,361.94). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.8), with a minimum of zero.",,,,0,other,16129.04,59610.47,There are no additional notes associated with this service or procedure.
NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,601,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6042.05,,"Case rate ($6,042.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,756.39, add-ons for qualifying new technology services are included. If operating cost exceeds $40,627.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,059.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $3,797.45 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,811.45 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $299.66. The transfer capital threshold is the transfer adjustment factor * $299.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6042.05,12359.72,Inpatient DRG
Prq Skeletal Fixj Metacarpal Fx Each Bone|RIGHT SIDE,CASE-26608,APC,26608,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR,518,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],89342.77,,"Fee schedule rate ($89,342.77). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,13252.00,89342.77,There are no additional notes associated with this service or procedure.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH CC,026,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],63202.45,,"Fee schedule rate ($63,202.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,23000.66,63202.45,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],21784.85,,"Fee schedule rate ($21,784.85). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.4), with a minimum of zero.",,,,0,other,9795.13,23899.13,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,093,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],19011.32,,"Fee schedule rate ($19,011.32). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,19011.32,There are no additional notes associated with this service or procedure.
SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS,029,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],25048.54,,"Case rate ($25,048.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $23,437.73, add-ons for qualifying new technology services are included. If operating cost exceeds $58,308.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,449.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.7)) / 2. The base transfer operating payment is the transfer adjustment factor * $21,413.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $21,492.79 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,689.76. The transfer capital threshold is the transfer adjustment factor * $1,689.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,13641.00,67130.05,Inpatient DRG
Egd Intrmural US Needle Aspirate/Biopsy Esophags|REDUCED SERVICES,CASE-43238,APC,43238,CPT,0360,RC,,,52,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1796.14,,"APC Price ($1,796.14). Discounted by 50%. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1796.14,1885.95,OPPS APC
SEIZURES WITH MCC,100,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],32323.98,,"Fee schedule rate ($32,323.98). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,15061.09,38110.41,There are no additional notes associated with this service or procedure.
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],61234.06,,"Fee schedule rate ($61,234.06). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11165.00,61234.06,There are no additional notes associated with this service or procedure.
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC",458,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],132827.25,,"Fee schedule rate ($132,827.25). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,30202.09,132827.25,There are no additional notes associated with this service or procedure.
"OTHER BACK AND NECK DISORDERS FRACTURES AND INJURIES,MODERATE",347,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],1995.58,,"Case rate for a one day stay ($1,995.58). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,1995.58,2095.36,There are no additional notes associated with this service or procedure.
"Tendon Sheath Incision|RIGHT HAND, THIRD DIGIT",CASE-26055,APC,26055,CPT,0360,RC,,,F7,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1505.12,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1505.12,1580.37,OPPS APC
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",759,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],11643.60,,"Fee schedule rate ($11,643.60). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6190.22,13057.66,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC,831,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],5151.30,,"Fee schedule rate ($5,151.30). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,4941.30,23661.59,There are no additional notes associated with this service or procedure.
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],7566.45,,"Case rate ($7,566.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,174.51, add-ons for qualifying new technology services are included. If operating cost exceeds $42,045.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,171.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,210.35 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,229.56 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $411.15. The transfer capital threshold is the transfer adjustment factor * $411.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7566.45,16333.88,Inpatient DRG
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],12246.05,,"Fee schedule rate ($12,246.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6010.23,12246.05,There are no additional notes associated with this service or procedure.
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],14274.73,,"Case rate ($13,792.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,966.02, add-ons for qualifying new technology services are included. If operating cost exceeds $47,837.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,626.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $10,980.58 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,021.07 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $866.48. The transfer capital threshold is the transfer adjustment factor * $866.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6965.00,34422.94,Inpatient DRG
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],8484.50,,"Case rate ($8,318.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,873.80, add-ons for qualifying new technology services are included. If operating cost exceeds $42,744.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,226.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,907.07 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,928.85 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $466.13. The transfer capital threshold is the transfer adjustment factor * $466.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,8318.14,19763.43,Inpatient DRG
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],9273.92,,"Case rate ($8,832.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,364.96, add-ons for qualifying new technology services are included. If operating cost exceeds $43,235.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,251.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,395.76 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,420.01 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $491.59. The transfer capital threshold is the transfer adjustment factor * $491.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9040.72,26966.33,Inpatient DRG
HC Joint Injection/Aspir Medium WO US|PBB CHARGE|RIGHT SIDE,CASE-20605,APC,20605,CPT,0510,RC,,,PBB|RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],297.37,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,287.31,301.68,OPPS APC
Nasal/Sinus Ndsc Tot W/Frnt Sins Expl Tiss Rmvl|LEFT SIDE,CASE-31253,APC,31253,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6605.95,,"APC Price ($6,605.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6605.95,6936.25,OPPS APC
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,191,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7921.69,,"Case rate ($7,653.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,255.78, add-ons for qualifying new technology services are included. If operating cost exceeds $42,126.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,177.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,291.32 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,310.83 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $417.54. The transfer capital threshold is the transfer adjustment factor * $417.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6965.00,16612.88,Inpatient DRG
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],38508.74,,"Fee schedule rate ($38,508.74). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.6), with a minimum of zero.",,,,0,other,15821.59,40320.14,There are no additional notes associated with this service or procedure.
Breast Reduction|BILATERAL PROCEDURE,CASE-19318,APC,19318,CPT,0360,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6432.89,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6215.36,6526.12,OPPS APC
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],33244.29,,,,,,0,other,13386.36,33244.29,There are no additional notes associated with this service or procedure.
HC Joint Injection/Aspir Medium WO US|PBB CHARGE|RIGHT SIDE,CASE-20605,APC,20605,CPT,0510,RC,,,PBB|RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],301.68,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,287.31,301.68,OPPS APC
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],20659.14,,"Fee schedule rate ($20,659.14). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.9), with a minimum of zero.",,,,0,other,9389.48,22358.90,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],13113.40,,"Case rate ($12,488.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,773.48, add-ons for qualifying new technology services are included. If operating cost exceeds $46,644.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,512.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $9,791.40 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,828.53 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $752.59. The transfer capital threshold is the transfer adjustment factor * $752.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7353.00,33398.16,Inpatient DRG
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],41580.51,,"Fee schedule rate ($41,580.51). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,13783.20,41580.51,There are no additional notes associated with this service or procedure.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],133270.57,,"Fee schedule rate ($133,270.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,33623.33,133270.57,There are no additional notes associated with this service or procedure.
Open Implantation Nea Sacral Nerve,CASE-64581,APC,64581,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],18158.97,,"APC Price ($18,158.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,18158.97,19066.92,OPPS APC
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC",758,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],18398.35,,"Fee schedule rate ($18,398.35). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8574.80,19263.78,There are no additional notes associated with this service or procedure.
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,451,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],52140.90,,"Fee schedule rate ($52,140.90). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,23821.44,94077.13,There are no additional notes associated with this service or procedure.
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],13651.81,,"Case rate ($13,001.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,230.82, add-ons for qualifying new technology services are included. If operating cost exceeds $47,101.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,568.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $10,248.08 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,285.87 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $808.68. The transfer capital threshold is the transfer adjustment factor * $808.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7868.00,32126.64,Inpatient DRG
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],11060.65,,"Case rate ($10,533.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,935.13, add-ons for qualifying new technology services are included. If operating cost exceeds $44,806.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,388.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $7,960.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,990.18 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $628.19. The transfer capital threshold is the transfer adjustment factor * $628.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10533.95,24956.34,Inpatient DRG
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,085,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],9282.00,,"Per diem ($9,282). If length of stay < 4.6, first 1 days paid at a per diem of $18,564 instead. Capped at $42,695.82.",,,,0,other,9282.00,57443.16,Estimated amount calculated based on 2 day length of stay.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],6657.03,,"Case rate ($6,340.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,033.60, add-ons for qualifying new technology services are included. If operating cost exceeds $40,904.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,081.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $4,073.62 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,088.64 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $321.45. The transfer capital threshold is the transfer adjustment factor * $321.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6340.03,15076.44,Inpatient DRG
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],7396.47,,"Case rate ($7,396.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,016.38, add-ons for qualifying new technology services are included. If operating cost exceeds $41,887.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,158.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,052.80 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,071.43 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $398.72. The transfer capital threshold is the transfer adjustment factor * $398.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7396.47,16035.06,Inpatient DRG
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],7353.00,,"Per diem ($7,353). If length of stay < 4.1, first 1 days paid at a per diem of $14,706 instead. Capped at $30,145.85.",,,,0,other,7353.00,33398.16,Estimated amount calculated based on 4 day length of stay.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],16669.71,,"Fee schedule rate ($16,669.71). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8767.81,19824.58,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITH STERILIZATION WITHOUT CC/MCC,785,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],8431.24,,"Case rate ($8,431.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,979, add-ons for qualifying new technology services are included. If operating cost exceeds $42,850.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,234.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,011.89 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,034.06 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $474.40. The transfer capital threshold is the transfer adjustment factor * $474.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8431.24,20142.33,Inpatient DRG
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],18542.54,,"Case rate ($18,178.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,047.10, add-ons for qualifying new technology services are included. If operating cost exceeds $51,918.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,947.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $15,046.67 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,102.15 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,187.33. The transfer capital threshold is the transfer adjustment factor * $1,187.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,18178.96,54764.34,Inpatient DRG
Cysto W/Urtroscopy&/Pyeloscopy Dx|UNUSUAL NON-OVERLAPPING SERVICE|LEFT SIDE,CASE-52351,APC,52351,CPT,0360,RC,,,XU|LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3299.47,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3299.47,3464.44,OPPS APC
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],25162.32,,"Case rate ($25,162.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $23,543.58, add-ons for qualifying new technology services are included. If operating cost exceeds $58,414.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,458.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $21,519.28 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $21,598.63 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,698.08. The transfer capital threshold is the transfer adjustment factor * $1,698.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,25162.32,75579.22,Inpatient DRG
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITHOUT CC/MCC",630,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],42541.02,,"Fee schedule rate ($42,541.02). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11828.78,42541.02,There are no additional notes associated with this service or procedure.
Neuroplasty &/Transposition Ulnar Nerve Elbow|LEFT SIDE,CASE-64718,APC,64718,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1919.19,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1827.80,1919.19,OPPS APC
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],14492.93,,"Fee schedule rate ($14,492.93). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6503.90,14492.93,There are no additional notes associated with this service or procedure.
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],11247.07,,"Case rate ($11,247.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,598.51, add-ons for qualifying new technology services are included. If operating cost exceeds $45,469.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,440.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,621.77 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,653.56 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $680.34. The transfer capital threshold is the transfer adjustment factor * $680.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,11247.07,27028.33,Inpatient DRG
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC,831,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],6965.00,,,,,,0,other,4941.30,23661.59,There are no additional notes associated with this service or procedure.
OTHER CEREBROVASCULAR DISORDERS WITH MCC,070,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],37774.46,,"Fee schedule rate ($37,774.46). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,13219.09,37774.46,There are no additional notes associated with this service or procedure.
RADIOTHERAPY,849,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],81867.07,,"Fee schedule rate ($81,867.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,20293.88,81867.07,There are no additional notes associated with this service or procedure.
Neuroplasty &/Transpos Median Nrv Carpal Tunne|RIGHT SIDE|SEPARATE STRUCTURE,CASE-64721,APC,64721,CPT,0360,RC,,,RT|XS,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6791.99,7131.59,OPPS APC
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],14556.75,,"Case rate ($8,318.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,873.80, add-ons for qualifying new technology services are included. If operating cost exceeds $42,744.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,226.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,907.07 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,928.85 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $466.13. The transfer capital threshold is the transfer adjustment factor * $466.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,8318.14,19763.43,All Other Inpatient
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,373,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],13670.03,,"Fee schedule rate ($13,670.03). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6870.94,14313.05,There are no additional notes associated with this service or procedure.
NERVOUS SYSTEM NEOPLASMS WITH MCC,054,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],30044.81,,,,,,0,other,6965.00,30044.81,There are no additional notes associated with this service or procedure.
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,451,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],23821.44,,"Case rate ($23,821.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $22,296.19, add-ons for qualifying new technology services are included. If operating cost exceeds $57,167.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,359.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $20,276.48 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $20,351.24 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,600.01. The transfer capital threshold is the transfer adjustment factor * $1,600.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,23821.44,94077.13,Inpatient DRG
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],15600.07,,"Fee schedule rate ($15,600.07). Adds an outlier to normal pricing equal to the per diem rate ($180,117.98) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,7566.45,16333.88,There are no additional notes associated with this service or procedure.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],54764.34,,"Fee schedule rate ($54,764.34). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,18178.96,54764.34,There are no additional notes associated with this service or procedure.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],16250.04,,"Case rate ($15,476.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,532.81, add-ons for qualifying new technology services are included. If operating cost exceeds $49,403.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,749.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $12,541.62 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,587.86 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $989.66. The transfer capital threshold is the transfer adjustment factor * $989.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,15476.23,42787.31,Inpatient DRG
"Decompress Spinal Cord,1 Seg|LEFT SIDE",CASE-63056,APC,63056,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6791.99,7131.59,OPPS APC
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,761,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],11946.72,,"Fee schedule rate ($11,946.72). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,5808.41,11946.72,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,373,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6870.94,,"Case rate ($6,870.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,527.50, add-ons for qualifying new technology services are included. If operating cost exceeds $41,398.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,120.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $4,565.72 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,582.56 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $360.28. The transfer capital threshold is the transfer adjustment factor * $360.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6870.94,14313.05,Inpatient DRG
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,307,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],7806.41,,"Case rate ($7,434.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $7,017.68, add-ons for qualifying new technology services are included. If operating cost exceeds $45,662.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $3,170.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $5,632.79 + an uncompensated DSH payment of $1,359.91. The transfer operating threshold is the transfer adjustment factor * $5,657.77 + an uncompensated DSH payment of $1,359.91. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $441.98. The transfer capital threshold is the transfer adjustment factor * $441.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6335.27,18228.77,Inpatient DRG
TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC,084,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],6965.00,,,,,,0,other,6965.00,19445.16,There are no additional notes associated with this service or procedure.
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],12566.28,,"Case rate ($12,566.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,825.74, add-ons for qualifying new technology services are included. If operating cost exceeds $46,696.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,536.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $9,844.49 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,880.79 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $776.83. The transfer capital threshold is the transfer adjustment factor * $776.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12566.28,30861.41,Inpatient DRG
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],8136.74,,"Case rate ($7,749.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,344.60, add-ons for qualifying new technology services are included. If operating cost exceeds $42,215.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,184.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,379.82 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,399.66 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $424.52. The transfer capital threshold is the transfer adjustment factor * $424.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6711.00,16865.16,Inpatient DRG
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],16055.90,,"Fee schedule rate ($16,055.90). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8163.06,18067.42,There are no additional notes associated with this service or procedure.
Sgmdsc Flx Rmvl Tum Polyp/Oth Les Snare Tq|COLORECTAL CANCER SCREEN,CASE-45338,APC,45338,CPT,0360,RC,,,PT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1176.09,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1120.09,1176.09,OPPS APC
INFLAMMATORY BOWEL DISEASE WITH MCC,385,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],21593.52,,"Fee schedule rate ($21,593.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11480.01,31134.92,There are no additional notes associated with this service or procedure.
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",759,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],11643.60,,"Fee schedule rate ($11,643.60). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6190.22,13057.66,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],14650.15,,"Case rate ($13,952.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,115.33, add-ons for qualifying new technology services are included. If operating cost exceeds $47,986.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,638.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $11,129.34 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,170.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $878.22. The transfer capital threshold is the transfer adjustment factor * $878.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13917.42,34889.29,Inpatient DRG
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],41402.42,,"Fee schedule rate ($41,402.42). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,15456.59,41402.42,There are no additional notes associated with this service or procedure.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,544,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],23207.64,,"Fee schedule rate ($23,207.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,7055.15,23207.64,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],16590.46,,"Fee schedule rate ($16,590.46). Adds an outlier to normal pricing equal to the per diem rate ($69,146.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,1188.00,17370.86,There are no additional notes associated with this service or procedure.
Ercp W/Biopsy Single/Multiple|UNUSUAL NON-OVERLAPPING SERVICE,CASE-43261,APC,43261,CPT,0360,RC,,,XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5881.39,,"APC Price ($5,682.51). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5682.51,5966.63,OPPS APC
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],20567.06,,"Fee schedule rate ($20,567.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,9356.31,25026.36,There are no additional notes associated with this service or procedure.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],23790.06,,"Fee schedule rate ($23,790.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10517.71,24909.11,There are no additional notes associated with this service or procedure.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC",442,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],18157.80,,"Fee schedule rate ($18,157.80). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6607.45,19011.92,There are no additional notes associated with this service or procedure.
Int Hrhc by Ligation Single Hroid W/O Img Gdn,CASE-46945,APC,46945,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],2727.99,,"APC Price ($2,598.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2598.08,2727.99,OPPS APC
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],27553.62,,"Fee schedule rate ($27,553.62). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12305.53,30103.84,There are no additional notes associated with this service or procedure.
POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES,769,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],13388.39,,"Case rate ($13,388.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,590.54, add-ons for qualifying new technology services are included. If operating cost exceeds $47,461.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,596.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $10,606.49 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,645.59 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $836.96. The transfer capital threshold is the transfer adjustment factor * $836.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,13388.39,33250.19,Inpatient DRG
Xpedicul Decompress Throacic Cord|RIGHT SIDE,CASE-63055,APC,63055,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6791.99,7131.59,OPPS APC
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITHOUT MCC,430,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],133156.90,,"Fee schedule rate ($133,156.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,41000.16,133156.90,There are no additional notes associated with this service or procedure.
Hallux Rigidus W/Cheilectomy 1st Mp Jt W/O Implt|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-28289,APC,28289,CPT,0360,RC,,,LT|XU,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
Sphincterotomy Anal Division Sphincter Spx,CASE-46080,APC,46080,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],2598.08,,"APC Price ($2,598.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2598.08,2727.99,OPPS APC
"Laminec/Facetect/Foramin,Cervical",CASE-63045,APC,63045,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7029.71,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6791.99,7131.59,OPPS APC
Insj Inflatable Urethral/Bladder Neck Sphincter,CASE-53445,APC,53445,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],19400.15,,"APC Price ($19,400.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,19400.15,20370.16,OPPS APC
HEART FAILURE AND SHOCK WITH CC,292,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],16705.77,,,,,,0,other,5502.00,16705.77,There are no additional notes associated with this service or procedure.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],27120.18,,"Fee schedule rate ($27,120.18). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,11717.72,43888.01,There are no additional notes associated with this service or procedure.
PREMATURITY WITH MAJOR PROBLEMS,791,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],3186.77,,,,,,0,other,3048.21,30904.42,Estimated amount calculated based on 5 day length of stay.
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],6310.74,,"Case rate ($6,010.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,726.79, add-ons for qualifying new technology services are included. If operating cost exceeds $40,597.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,057.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,767.95 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,781.84 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $297.33. The transfer capital threshold is the transfer adjustment factor * $297.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6010.23,12246.05,Inpatient DRG
Mastectomy Partial|LEFT SIDE,CASE-19301,APC,19301,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6432.89,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6215.36,6526.12,OPPS APC
SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS,029,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],67130.05,,,,,,0,other,13641.00,67130.05,There are no additional notes associated with this service or procedure.
SINGLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL,402,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],75557.26,,"Fee schedule rate ($75,557.26). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.9), with a minimum of zero.",,,,0,other,29172.05,124455.45,There are no additional notes associated with this service or procedure.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],28395.88,,,,,,0,other,11717.72,43888.01,There are no additional notes associated with this service or procedure.
Fasct Palm W/WO Z-Plasty Tissue Reargmt/Skn Grft|LEFT SIDE,CASE-26121,APC,26121,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],59021.28,,"Fee schedule rate ($59,021.28). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,23851.92,63653.13,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,082,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],17771.67,,"Case rate ($17,423.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,344.04, add-ons for qualifying new technology services are included. If operating cost exceeds $51,215.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,892.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $14,346.19 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,399.08 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,132.06. The transfer capital threshold is the transfer adjustment factor * $1,132.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,17423.21,56223.11,Inpatient DRG
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC,833,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],6965.00,,,,,,0,other,3041.73,10289.10,There are no additional notes associated with this service or procedure.
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC,058,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],14197.89,,"Case rate ($13,521.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,714.66, add-ons for qualifying new technology services are included. If operating cost exceeds $47,585.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,606.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $10,730.14 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,769.70 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $846.71. The transfer capital threshold is the transfer adjustment factor * $846.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13521.80,40853.02,Inpatient DRG
Rpr Aa Hernia 1st 3-10 Cm Ncrc8/Strangulated,CASE-49594,APC,49594,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5941.70,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5658.76,5941.70,OPPS APC
Cystoscopy prostatic imp 1-3,CASE-C9739,APC,C9739,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5194.43,,"APC Price ($5,018.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5018.77,5269.71,OPPS APC
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,082,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],56223.11,,"Fee schedule rate ($56,223.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,17423.21,56223.11,There are no additional notes associated with this service or procedure.
OTHER MENTAL DISORDER DIAGNOSES,887,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],6965.00,,,,,,0,other,2070.00,21072.10,There are no additional notes associated with this service or procedure.
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|RIGHT HAND, SECOND DIGIT",CASE-26160,APC,26160,CPT,0360,RC,,,F6,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1505.12,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1505.12,1557.80,OPPS APC
HC Perq Vert Agmntj Cavity Crtj Uni/Bi Cannulation,CASE-22513,APC,22513,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6791.99,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],59081.91,,"Fee schedule rate ($59,081.91). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,8480.00,59081.91,There are no additional notes associated with this service or procedure.
"ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",770,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],9172.07,,"Case rate ($8,735.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,261.87, add-ons for qualifying new technology services are included. If operating cost exceeds $43,132.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,256.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $6,293.72 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,316.92 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $496.64. The transfer capital threshold is the transfer adjustment factor * $496.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8735.30,19730.13,Inpatient DRG
UNGROUPABLE,999,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],161307.29,,"Fee schedule rate ($161,307.29). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (41), with a minimum of zero.",,,,0,other,10228.00,161307.29,There are no additional notes associated with this service or procedure.
MAJOR CHEST TRAUMA WITHOUT CC/MCC,185,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],21771.61,,"Fee schedule rate ($21,771.61). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7271.19,21771.61,There are no additional notes associated with this service or procedure.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],17280.71,,"Case rate ($16,457.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,473.04, add-ons for qualifying new technology services are included. If operating cost exceeds $50,344.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,795.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $13,476.99 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,528.09 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,035.87. The transfer capital threshold is the transfer adjustment factor * $1,035.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,16897.01,43444.85,Inpatient DRG
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],11388.47,,"Case rate ($10,846.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,225.56, add-ons for qualifying new technology services are included. If operating cost exceeds $45,096.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,410.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $8,250.19 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,280.61 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $651.02. The transfer capital threshold is the transfer adjustment factor * $651.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10846.16,25863.45,Inpatient DRG
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],48961.48,,"Fee schedule rate ($48,961.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11575.50,48961.48,There are no additional notes associated with this service or procedure.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],33197.83,,"Fee schedule rate ($33,197.83). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.8), with a minimum of zero.",,,,0,other,13907.80,52794.06,There are no additional notes associated with this service or procedure.
SPINAL PROCEDURES WITHOUT CC/MCC,030,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],16810.99,,"Case rate ($16,810.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,774.52, add-ons for qualifying new technology services are included. If operating cost exceeds $50,645.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,847.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $13,778.77 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,829.57 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,087.28. The transfer capital threshold is the transfer adjustment factor * $1,087.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,16810.99,44714.01,Inpatient DRG
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],9570.98,,"Case rate ($9,570.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,039.28, add-ons for qualifying new technology services are included. If operating cost exceeds $43,910.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,317.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $7,068.27 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,094.33 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $557.76. The transfer capital threshold is the transfer adjustment factor * $557.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,5569.00,40108.48,Inpatient DRG
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],11269.71,,"Case rate ($10,733.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,120.35, add-ons for qualifying new technology services are included. If operating cost exceeds $44,991.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,402.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $8,145.37 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,175.40 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $642.75. The transfer capital threshold is the transfer adjustment factor * $642.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10733.06,45157.33,Inpatient DRG
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],20659.14,,"Fee schedule rate ($20,659.14). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.9), with a minimum of zero.",,,,0,other,9389.48,22358.90,There are no additional notes associated with this service or procedure.
Ligamentous Reconstruction Knee Extra-Articular|LEFT SIDE|SEPARATE STRUCTURE,CASE-27427,APC,27427,CPT,0360,RC,,,LT|XS,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC",758,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],16323.02,,"Fee schedule rate ($16,323.02). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8574.80,19263.78,There are no additional notes associated with this service or procedure.
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7614.73,,"Case rate ($7,252.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,891.99, add-ons for qualifying new technology services are included. If operating cost exceeds $41,763.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,138.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,928.36 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,947.04 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $378.81. The transfer capital threshold is the transfer adjustment factor * $378.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6148.93,15887.21,Inpatient DRG
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],60793.48,,"Fee schedule rate ($60,793.48). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15.7), with a minimum of zero.",,,,0,other,23851.92,63653.13,There are no additional notes associated with this service or procedure.
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC,519,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],16264.96,,"Case rate ($15,490.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,546.03, add-ons for qualifying new technology services are included. If operating cost exceeds $49,417.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,750.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $12,554.80 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,601.09 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $990.70. The transfer capital threshold is the transfer adjustment factor * $990.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,15490.44,50780.20,Inpatient DRG
CESAREAN SECTION WITH STERILIZATION WITH CC,784,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],19922.46,,"Fee schedule rate ($19,922.46). Adds an outlier to normal pricing equal to the per diem rate ($39,437.39) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,9124.01,23722.94,There are no additional notes associated with this service or procedure.
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC",458,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],132827.25,,"Fee schedule rate ($132,827.25). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,30202.09,132827.25,There are no additional notes associated with this service or procedure.
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],11281.44,,"Fee schedule rate ($11,281.44). Adds an outlier to normal pricing equal to the per diem rate ($62,521.14) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,6010.23,12246.05,There are no additional notes associated with this service or procedure.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC,027,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],56363.30,,"Fee schedule rate ($56,363.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,19030.20,56363.30,There are no additional notes associated with this service or procedure.
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],7733.72,,"Case rate ($7,733.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,330.12, add-ons for qualifying new technology services are included. If operating cost exceeds $42,201.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,183.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,365.38 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,385.17 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $423.38. The transfer capital threshold is the transfer adjustment factor * $423.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7733.72,18043.23,Inpatient DRG
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],36776.05,,"Fee schedule rate ($36,776.05). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11053.39,36776.05,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITHOUT CC/MCC,428,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],118904.57,,"Fee schedule rate ($118,904.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,40017.53,118904.57,There are no additional notes associated with this service or procedure.
"CARDIAC ARREST, UNEXPLAINED WITH MCC",296,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],36459.67,,"Fee schedule rate ($36,459.67). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12522.25,36459.67,There are no additional notes associated with this service or procedure.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC,434,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6959.74,,"Case rate ($6,628.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,310.53, add-ons for qualifying new technology services are included. If operating cost exceeds $41,181.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,094.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,349.09 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,365.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $334.28. The transfer capital threshold is the transfer adjustment factor * $334.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6770.05,14019.86,Inpatient DRG
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH MCC",722,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],14200.37,,"Case rate ($14,200.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,345.91, add-ons for qualifying new technology services are included. If operating cost exceeds $48,216.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,656.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $11,359.07 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,400.95 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $896.34. The transfer capital threshold is the transfer adjustment factor * $896.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,14200.37,56869.13,Inpatient DRG
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,083,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],11397.40,,"Case rate ($11,397.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,738.37, add-ons for qualifying new technology services are included. If operating cost exceeds $45,609.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,451.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $8,761.12 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,793.42 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $691.34. The transfer capital threshold is the transfer adjustment factor * $691.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,28680.85,Inpatient DRG
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],7698.44,,"Case rate ($7,547.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,156.87, add-ons for qualifying new technology services are included. If operating cost exceeds $42,027.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,169.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $5,192.77 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,211.92 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $409.76. The transfer capital threshold is the transfer adjustment factor * $409.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6965.00,19126.88,Inpatient DRG
Bronchoscopy Needle Bx Trachea Main Stem&/Bron,CASE-31629,APC,31629,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6605.95,,"APC Price ($6,605.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6605.95,6936.25,OPPS APC
"MAJOR RESPIRATORY INFECTIONS AND INFLAMMATIONS,EXTREME",137,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],19788.07,,"Case rate ($18,845.78). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,18845.78,19788.07,There are no additional notes associated with this service or procedure.
"OPEN CRANIOTOMY EXCEPT TRAUMA,EXTREME",021,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],62932.56,,"Case rate ($62,932.56). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $56,008, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,62932.56,66079.19,There are no additional notes associated with this service or procedure.
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITHOUT CC/MCC",630,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],12065.36,,"Case rate ($11,828.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,139.67, add-ons for qualifying new technology services are included. If operating cost exceeds $46,010.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,482.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $9,160.95 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,194.72 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $722.89. The transfer capital threshold is the transfer adjustment factor * $722.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,11828.78,42541.02,Inpatient DRG
POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES,769,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],33250.19,,,,,,0,other,13388.39,33250.19,There are no additional notes associated with this service or procedure.
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],33890.73,,"Fee schedule rate ($33,890.73). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6277.00,36801.89,There are no additional notes associated with this service or procedure.
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],8163.06,,"Case rate ($8,163.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,729.53, add-ons for qualifying new technology services are included. If operating cost exceeds $42,600.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,214.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,763.33 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,784.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $454.78. The transfer capital threshold is the transfer adjustment factor * $454.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8163.06,18067.42,Inpatient DRG
HC Inj Aa&/Strd Greater Occipital Nerve|BILATERAL PROCEDURE,CASE-64405,APC,64405,CPT,0450,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],297.37,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,287.31,301.68,OPPS APC
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,057,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],11254.78,,"Case rate ($10,718.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,107.12, add-ons for qualifying new technology services are included. If operating cost exceeds $44,978.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,401.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,132.18 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,162.17 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $641.71. The transfer capital threshold is the transfer adjustment factor * $641.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10718.84,39884.93,Inpatient DRG
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC,833,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],5721.39,,"Fee schedule rate ($5,721.39). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,3041.73,10289.10,There are no additional notes associated with this service or procedure.
"Tendon Sheath Incision|LEFT HAND, THUMB|UNUSUAL NON-OVERLAPPING SERVICE",CASE-26055,APC,26055,CPT,0360,RC,,,FA|XU,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],28394.78,,"Fee schedule rate ($28,394.78). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11454.97,28394.78,There are no additional notes associated with this service or procedure.
POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES,769,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],29791.03,,"Fee schedule rate ($29,791.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,13388.39,33250.19,There are no additional notes associated with this service or procedure.
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],11065.78,,"Fee schedule rate ($11,065.78). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5883.03,17111.12,There are no additional notes associated with this service or procedure.
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITH MCC,429,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],169317.41,,"Fee schedule rate ($169,317.41). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,62958.58,177294.98,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,690,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],14625.55,,"Fee schedule rate ($14,625.55). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7426.94,15928.53,There are no additional notes associated with this service or procedure.
NONTRAUMATIC STUPOR AND COMA WITH MCC,080,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],14912.51,,"Case rate ($14,202.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,347.79, add-ons for qualifying new technology services are included. If operating cost exceeds $48,218.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,656.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $11,360.96 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,402.84 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $896.49. The transfer capital threshold is the transfer adjustment factor * $896.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,14202.39,35615.37,Inpatient DRG
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],11281.44,,"Fee schedule rate ($11,281.44). Adds an outlier to normal pricing equal to the per diem rate ($62,521.14) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,6010.23,12246.05,There are no additional notes associated with this service or procedure.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,074,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],9156.58,,"Case rate ($8,720.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,260.79, add-ons for qualifying new technology services are included. If operating cost exceeds $43,131.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,243.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,291.99 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,315.84 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $483.62. The transfer capital threshold is the transfer adjustment factor * $483.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8925.60,20919.08,Inpatient DRG
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR,518,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],13252.00,,"Per diem ($13,252). If length of stay < 5.3, first 1 days paid at a per diem of $26,504 instead. Capped at $70,235.08.",,,,0,other,13252.00,89342.77,Estimated amount calculated based on 1 day length of stay.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],17223.78,,"Fee schedule rate ($17,223.78). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,8151.55,18033.97,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],15076.44,,"Fee schedule rate ($15,076.44). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6340.03,15076.44,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,086,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],10766.92,,"Case rate ($10,766.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,151.85, add-ons for qualifying new technology services are included. If operating cost exceeds $45,022.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,405.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $8,176.75 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,206.90 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $645.23. The transfer capital threshold is the transfer adjustment factor * $645.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8442.00,30728.81,Inpatient DRG
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,451,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],94077.13,,"Fee schedule rate ($94,077.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,23821.44,94077.13,There are no additional notes associated with this service or procedure.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],40918.00,,"Fee schedule rate ($40,918.00). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,16689.78,59521.43,There are no additional notes associated with this service or procedure.
HC Drain/Inj Joint/Bursa W/US Large|BILATERAL PROCEDURE,CASE-20611,APC,20611,CPT,0510,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
HC Inject Tendon Origin/Insert|BILATERAL PROCEDURE,CASE-20551,APC,20551,CPT,0361,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],301.68,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,287.31,301.68,OPPS APC
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],24259.09,,"Fee schedule rate ($24,259.09). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10098.51,24259.09,There are no additional notes associated with this service or procedure.
HC Inj Anes/Steroid C/D Facet Sg|BILATERAL PROCEDURE,CASE-64490,APC,64490,CPT,0361,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],827.89,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,827.89,869.28,OPPS APC
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],22299.54,,"Case rate ($21,862.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,473.63, add-ons for qualifying new technology services are included. If operating cost exceeds $55,344.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,216.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. The base transfer operating payment is the transfer adjustment factor * $18,460.61 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,528.68 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,456.72. The transfer capital threshold is the transfer adjustment factor * $1,456.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,7086.00,57872.02,Inpatient DRG
Musc Myocutaneous/Fasciocutaneous Flap Trunk,CASE-15734,APC,15734,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5658.76,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5658.76,5941.70,OPPS APC
CESAREAN SECTION WITH STERILIZATION WITH MCC,783,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],13148.10,,"Fee schedule rate ($13,148.10). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12612.10,23722.94,There are no additional notes associated with this service or procedure.
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],52453.14,,"Fee schedule rate ($52,453.14). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14.9), with a minimum of zero.",,,,0,other,20846.48,81306.30,There are no additional notes associated with this service or procedure.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,057,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],39884.93,,"Fee schedule rate ($39,884.93). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,10718.84,39884.93,There are no additional notes associated with this service or procedure.
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],81454.07,,"Fee schedule rate ($81,454.07). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,10078.00,81454.07,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],32093.19,,,,,,0,other,9888.00,43399.23,There are no additional notes associated with this service or procedure.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],45706.73,,"Fee schedule rate ($45,706.73). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,7921.00,45706.73,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],96365.69,,"Fee schedule rate ($96,365.69). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,23377.19,96365.69,There are no additional notes associated with this service or procedure.
Injection Aa&/Strd Genicular Nrv Branches W/Img|BILATERAL PROCEDURE,CASE-64454,APC,64454,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],660.72,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,660.72,693.76,OPPS APC
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],10744.63,,"Case rate ($10,533.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,935.13, add-ons for qualifying new technology services are included. If operating cost exceeds $44,806.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,388.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $7,960.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,990.18 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $628.19. The transfer capital threshold is the transfer adjustment factor * $628.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,10533.95,24956.34,Inpatient DRG
DIABETES WITH MCC,637,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],9959.03,,"Case rate ($9,484.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $8,852.20, add-ons for qualifying new technology services are included. If operating cost exceeds $48,421.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $3,463.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $8,811.98. The transfer operating threshold is the transfer adjustment factor * $8,852.20 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $672.81. The transfer capital threshold is the transfer adjustment factor * $672.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9959.03,28655.62,Inpatient DRG
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],34570.85,,"Fee schedule rate ($34,570.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,6965.00,36140.75,There are no additional notes associated with this service or procedure.
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],8539.77,,"Case rate ($8,372.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,924.20, add-ons for qualifying new technology services are included. If operating cost exceeds $42,795.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,230.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,957.28 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,979.25 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $470.09. The transfer capital threshold is the transfer adjustment factor * $470.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6965.00,23385.72,Inpatient DRG
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH MCC",510,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],22399.99,,"Case rate ($22,399.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,973.84, add-ons for qualifying new technology services are included. If operating cost exceeds $55,844.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,256.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.3. The base transfer operating payment is the transfer adjustment factor * $18,958.99 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $19,028.89 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,496.05. The transfer capital threshold is the transfer adjustment factor * $1,496.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10710.00,89863.76,Inpatient DRG
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC",458,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],78415.67,,"Fee schedule rate ($78,415.67). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.8), with a minimum of zero.",,,,0,other,30202.09,132827.25,There are no additional notes associated with this service or procedure.
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,094,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],37626.75,,"Fee schedule rate ($37,626.75). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,25778.58,67889.44,There are no additional notes associated with this service or procedure.
Open Biopsy/Excision Inguinofemoral Nodes|RIGHT SIDE,CASE-38531,APC,38531,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6432.89,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6215.36,6526.12,OPPS APC
POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES,769,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],13656.16,,"Case rate ($13,388.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,590.54, add-ons for qualifying new technology services are included. If operating cost exceeds $47,461.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,596.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $10,606.49 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,645.59 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $836.96. The transfer capital threshold is the transfer adjustment factor * $836.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,13388.39,33250.19,Inpatient DRG
SPINAL PROCEDURES WITHOUT CC/MCC,030,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],44714.01,,"Fee schedule rate ($44,714.01). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,16810.99,44714.01,There are no additional notes associated with this service or procedure.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,097,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],67876.56,,"Fee schedule rate ($67,876.56). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17.7), with a minimum of zero.",,,,0,other,26404.32,79915.74,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],23239.84,,"Fee schedule rate ($23,239.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8543.64,23239.84,There are no additional notes associated with this service or procedure.
HC I&D Ischio Perirectal Abs,CASE-46040,APC,46040,CPT,0450,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1159.29,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1120.09,1176.09,OPPS APC
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],11065.78,,"Fee schedule rate ($11,065.78). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5883.03,17111.12,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],18578.07,,"Case rate ($17,693.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,595.40, add-ons for qualifying new technology services are included. If operating cost exceeds $51,466.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,911.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $14,596.63 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,650.45 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,151.82. The transfer capital threshold is the transfer adjustment factor * $1,151.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,17693.40,52449.26,Inpatient DRG
CERVICAL SPINAL FUSION WITH CC,472,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],57970.41,,,,,,0,other,21896.13,70198.84,There are no additional notes associated with this service or procedure.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],15340.19,,,,,,0,other,6965.00,15340.19,There are no additional notes associated with this service or procedure.
RESPIRATORY NEOPLASMS WITHOUT CC/MCC,182,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],6965.00,,,,,,0,other,6965.00,23037.13,There are no additional notes associated with this service or procedure.
DIABETES WITH MCC,637,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],11127.63,,"Case rate ($10,909.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $10,253.93, add-ons for qualifying new technology services are included. If operating cost exceeds $48,898.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $3,423.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $8,854.74 + an uncompensated DSH payment of $1,359.91. The transfer operating threshold is the transfer adjustment factor * $8,894.02 + an uncompensated DSH payment of $1,359.91. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $694.79. The transfer capital threshold is the transfer adjustment factor * $694.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,9959.03,28655.62,Inpatient DRG
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],78960.67,,"Fee schedule rate ($78,960.67). Adds an outlier to normal pricing equal to the per diem rate ($149,567.78) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19.1), with a minimum of zero.",,,,0,other,30398.48,82674.88,There are no additional notes associated with this service or procedure.
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC,939,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],27047.75,,"Case rate ($26,517.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $24,804.19, add-ons for qualifying new technology services are included. If operating cost exceeds $59,675.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,557.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $22,775.26 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $22,859.24 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,797.19. The transfer capital threshold is the transfer adjustment factor * $1,797.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,26517.40,97674.79,Inpatient DRG
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],12804.91,,"Case rate ($12,195.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,480.50, add-ons for qualifying new technology services are included. If operating cost exceeds $46,351.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,509.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,500.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,535.55 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $749.68. The transfer capital threshold is the transfer adjustment factor * $749.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12195.15,39424.57,Inpatient DRG
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],6564.18,,"Case rate ($6,564.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,242.12, add-ons for qualifying new technology services are included. If operating cost exceeds $41,113.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,097.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $4,281.39 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,297.17 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $337.84. The transfer capital threshold is the transfer adjustment factor * $337.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6564.18,17651.07,Inpatient DRG
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],14943.06,,"Case rate ($14,231.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,397.78, add-ons for qualifying new technology services are included. If operating cost exceeds $48,268.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,636.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $11,409.57 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,452.83 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $876.97. The transfer capital threshold is the transfer adjustment factor * $876.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,14603.31,45017.13,Inpatient DRG
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],14699.43,,"Fee schedule rate ($14,699.43). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6683.37,14699.43,There are no additional notes associated with this service or procedure.
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC",011,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],150008.48,,"Fee schedule rate ($150,008.48). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (44), with a minimum of zero.",,,,0,other,38880.49,150008.48,There are no additional notes associated with this service or procedure.
PREMATURITY WITHOUT MAJOR PROBLEMS,792,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],2074.00,,,,,,0,other,1956.00,19457.66,Estimated amount calculated based on 3 day length of stay.
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],23801.30,,,,,,0,other,10136.44,24444.75,There are no additional notes associated with this service or procedure.
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC,806,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],10071.17,,"Fee schedule rate ($10,071.17). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5354.25,13416.00,There are no additional notes associated with this service or procedure.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],19435.86,,"Case rate ($19,435.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $18,216.37, add-ons for qualifying new technology services are included. If operating cost exceeds $53,087.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,039.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.9. The base transfer operating payment is the transfer adjustment factor * $16,211.64 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $16,271.42 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,279.26. The transfer capital threshold is the transfer adjustment factor * $1,279.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,19435.86,50821.76,Inpatient DRG
COAGULATION DISORDERS,813,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],29046.49,,"Fee schedule rate ($29,046.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12274.39,30013.33,There are no additional notes associated with this service or procedure.
CHEST PAIN,313,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6820.84,,"Case rate ($6,820.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,480.89, add-ons for qualifying new technology services are included. If operating cost exceeds $41,351.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,116.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $4,519.27 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,535.94 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $356.62. The transfer capital threshold is the transfer adjustment factor * $356.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6820.84,15377.66,Inpatient DRG
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],35314.31,,,,,,0,other,7332.00,35314.31,There are no additional notes associated with this service or procedure.
Arthrp Intercarpal/Carp/Mtcrpl Jt Suspension,CASE-25448,APC,25448,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],26178.21,,"Fee schedule rate ($26,178.21). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,13917.42,34889.29,There are no additional notes associated with this service or procedure.
Hysteroscopy Diagnostic Separate Procedure,CASE-58555,APC,58555,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3181.53,,"APC Price ($3,030.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3030.03,3181.53,OPPS APC
OTHER CEREBROVASCULAR DISORDERS WITH MCC,070,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],13532.33,,"Case rate ($12,887.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,145.39, add-ons for qualifying new technology services are included. If operating cost exceeds $47,016.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,541.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $10,161.92 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,200.44 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $781.07. The transfer capital threshold is the transfer adjustment factor * $781.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13219.09,37774.46,Inpatient DRG
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],7505.33,,"Case rate ($7,147.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,785.17, add-ons for qualifying new technology services are included. If operating cost exceeds $41,656.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,140.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $4,822.44 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,840.22 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $380.54. The transfer capital threshold is the transfer adjustment factor * $380.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,16400.70,Inpatient DRG
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITHOUT CC/MCC",630,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],22616.56,,"Fee schedule rate ($22,616.56). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11828.78,42541.02,There are no additional notes associated with this service or procedure.
HC Drain/Inj Joint/Bursa W/US Large|RIGHT SIDE,CASE-20611,APC,20611,CPT,0510,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],297.37,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,287.31,301.68,OPPS APC
"LIMB REATTACHMENT, HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA",956,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],148259.86,,"Fee schedule rate ($148,259.86). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,27428.25,148259.86,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],23954.07,,"Fee schedule rate ($23,954.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,6167.00,29058.99,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC,788,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],19006.00,,,,,,0,other,8438.02,20142.33,There are no additional notes associated with this service or procedure.
"CARDIAC ARREST, UNEXPLAINED WITH MCC",296,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],12772.70,,"Case rate ($12,522.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,784.78, add-ons for qualifying new technology services are included. If operating cost exceeds $46,655.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,533.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $9,803.69 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,839.84 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $773.61. The transfer capital threshold is the transfer adjustment factor * $773.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,12522.25,36459.67,Inpatient DRG
Rpr Xtnsr Tdn Cntrl Slip Tiss W/Lat Band Ea Fngr,CASE-26426,APC,26426,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
"RESPIRATORY MALIGNANCY,MAJOR",136,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],13038.55,,"Case rate ($12,417.67). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12417.67,13038.55,There are no additional notes associated with this service or procedure.
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 2nd Level|LEFT SIDE,CASE-64494,APC,64494,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],827.89,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,827.89,869.28,OPPS APC
INFLAMMATORY BOWEL DISEASE WITH MCC,385,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],13103.51,,"Case rate ($12,660.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,913.31, add-ons for qualifying new technology services are included. If operating cost exceeds $46,784.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,543.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $9,931.73 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,968.35 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $783.71. The transfer capital threshold is the transfer adjustment factor * $783.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,11480.01,31134.92,Inpatient DRG
Ercp W/Biopsy Single/Multiple,CASE-43261,APC,43261,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3789.26,,"APC Price ($3,608.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3608.81,3789.26,OPPS APC
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],9667.64,,"Fee schedule rate ($9,667.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,5139.72,13110.79,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,093,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],19011.32,,"Fee schedule rate ($19,011.32). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,19011.32,There are no additional notes associated with this service or procedure.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,191,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],7653.81,,"Case rate ($7,653.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,255.78, add-ons for qualifying new technology services are included. If operating cost exceeds $42,126.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,177.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,291.32 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,310.83 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $417.54. The transfer capital threshold is the transfer adjustment factor * $417.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,16612.88,Inpatient DRG
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,447,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],156646.82,,"Fee schedule rate ($156,646.82). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,47193.21,156646.82,There are no additional notes associated with this service or procedure.
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level|LEFT SIDE,CASE-64483,APC,64483,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],827.89,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,827.89,869.28,OPPS APC
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],14370.36,,"Case rate ($14,370.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,504.04, add-ons for qualifying new technology services are included. If operating cost exceeds $48,375.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,668.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $11,516.62 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,559.08 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $908.78. The transfer capital threshold is the transfer adjustment factor * $908.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,14370.36,38378.80,Inpatient DRG
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITHOUT CC/MCC,428,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],105654.25,,"Fee schedule rate ($105,654.25). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,40017.53,118904.57,There are no additional notes associated with this service or procedure.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],17223.78,,"Fee schedule rate ($17,223.78). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,8151.55,18033.97,There are no additional notes associated with this service or procedure.
HC Biopsy/Exc Lymph Node Needle|TECHNICAL COMPONENT|RIGHT SIDE,CASE-38505,APC,38505,CPT,0361,RC,,,TC|RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1545.93,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1545.93,1623.23,OPPS APC
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],11168.08,,"Fee schedule rate ($11,168.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5937.41,12366.99,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],18585.05,,"Fee schedule rate ($18,585.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8859.23,20090.22,There are no additional notes associated with this service or procedure.
Transection/Avulsion Oth Spinal Nrv Xdrl|RIGHT SIDE,CASE-64772,APC,64772,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],46016.63,,,,,,0,other,17782.11,46523.26,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],81524.17,,"Fee schedule rate ($81,524.17). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,8972.00,81524.17,There are no additional notes associated with this service or procedure.
Optx Dstl Radl I-Artic Fx/Epiphysl Sep 3 Frag|LEFT SIDE,CASE-25609,APC,25609,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6791.99,7131.59,OPPS APC
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],18245.94,,"Fee schedule rate ($18,245.94). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8106.18,18245.94,There are no additional notes associated with this service or procedure.
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],11158.08,,"Case rate ($10,626.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,021.44, add-ons for qualifying new technology services are included. If operating cost exceeds $44,892.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,394.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $8,046.82 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,076.49 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $634.97. The transfer capital threshold is the transfer adjustment factor * $634.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10626.74,25225.91,Inpatient DRG
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|RIGHT HAND, FOURTH DIGIT",CASE-26160,APC,26160,CPT,0360,RC,,,F8,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1557.80,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1505.12,1580.37,OPPS APC
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],12138.74,,,,,,0,other,1188.00,12138.74,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],6460.78,,"Case rate ($6,153.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,859.72, add-ons for qualifying new technology services are included. If operating cost exceeds $40,730.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,067.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,900.39 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,914.77 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $307.78. The transfer capital threshold is the transfer adjustment factor * $307.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6153.12,13947.32,Inpatient DRG
CERVICAL SPINAL FUSION WITHOUT CC/MCC,473,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],62077.11,,"Fee schedule rate ($62,077.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,18477.61,62077.11,There are no additional notes associated with this service or procedure.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],92811.11,,"Fee schedule rate ($92,811.11). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,35389.50,101083.00,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,093,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],19011.32,,"Fee schedule rate ($19,011.32). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,19011.32,There are no additional notes associated with this service or procedure.
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITHOUT MCC,430,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],133156.90,,"Fee schedule rate ($133,156.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,41000.16,133156.90,There are no additional notes associated with this service or procedure.
Colposcopy Cervix Bx Cervix & Endocrv Curretage,CASE-57454,APC,57454,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],285.23,,"APC Price ($285.23). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,285.23,299.50,OPPS APC
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],10351.97,,"Case rate ($9,859.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,322.01, add-ons for qualifying new technology services are included. If operating cost exceeds $44,193.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,324.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $7,349.20 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,377.06 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $564.88. The transfer capital threshold is the transfer adjustment factor * $564.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10098.51,24259.09,Inpatient DRG
"Amp F/Th 1/2 Jt/Phalanx W/Neurect W/Dir Clsr|LEFT HAND, THIRD DIGIT",CASE-26951,APC,26951,CPT,0360,RC,,,F2,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],13456.78,,"Case rate ($13,001.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,230.82, add-ons for qualifying new technology services are included. If operating cost exceeds $47,101.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,568.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $10,248.08 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,285.87 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $808.68. The transfer capital threshold is the transfer adjustment factor * $808.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,7868.00,32126.64,Inpatient DRG
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],29243.52,,"Fee schedule rate ($29,243.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,14343.25,36024.65,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],96365.69,,"Fee schedule rate ($96,365.69). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,23377.19,96365.69,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],18585.05,,"Fee schedule rate ($18,585.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8859.23,20090.22,There are no additional notes associated with this service or procedure.
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],38610.21,,,,,,0,other,15233.11,38610.21,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,426,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],80410.35,,"Case rate ($76,581.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $71,377.56, add-ons for qualifying new technology services are included. If operating cost exceeds $106,248.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $7,218.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $69,177.55 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $69,432.61 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $5,458.79. The transfer capital threshold is the transfer adjustment factor * $5,458.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,76581.29,216864.15,Inpatient DRG
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],24308.97,,,,,,0,other,10311.17,24308.97,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],23205.70,,"Case rate ($13,260.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,471.48, add-ons for qualifying new technology services are included. If operating cost exceeds $47,342.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,587.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $10,487.86 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,526.53 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $827.60. The transfer capital threshold is the transfer adjustment factor * $827.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,13260.40,32878.30,All Other Inpatient
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],16689.78,,"Case rate ($16,689.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,661.75, add-ons for qualifying new technology services are included. If operating cost exceeds $50,532.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,838.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $13,666.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,716.80 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,078.42. The transfer capital threshold is the transfer adjustment factor * $1,078.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,16689.78,59521.43,Inpatient DRG
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],31693.30,,"Case rate ($31,693.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $29,619.21, add-ons for qualifying new technology services are included. If operating cost exceeds $64,490.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,935.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. The base transfer operating payment is the transfer adjustment factor * $27,572.60 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $27,674.26 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,175.75. The transfer capital threshold is the transfer adjustment factor * $2,175.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10862.00,86437.13,Inpatient DRG
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],36855.62,,"Fee schedule rate ($36,855.62). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,15821.59,40320.14,There are no additional notes associated with this service or procedure.
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],8168.94,,"Case rate ($7,779.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,384, add-ons for qualifying new technology services are included. If operating cost exceeds $42,255.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,176.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,418.51 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,439.05 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $416.48. The transfer capital threshold is the transfer adjustment factor * $416.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,17467.27,Inpatient DRG
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],33398.16,,"Fee schedule rate ($33,398.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,7353.00,33398.16,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],33277.97,,"Case rate ($31,693.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $29,619.21, add-ons for qualifying new technology services are included. If operating cost exceeds $64,490.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,935.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. The base transfer operating payment is the transfer adjustment factor * $27,572.60 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $27,674.26 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,175.75. The transfer capital threshold is the transfer adjustment factor * $2,175.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10862.00,86437.13,Inpatient DRG
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],10550.81,,"Case rate ($10,048.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,483.42, add-ons for qualifying new technology services are included. If operating cost exceeds $44,354.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,352.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,510.78 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,538.48 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $592.68. The transfer capital threshold is the transfer adjustment factor * $592.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10048.39,23545.50,Inpatient DRG
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],6689.93,,"Case rate ($6,558.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,237.08, add-ons for qualifying new technology services are included. If operating cost exceeds $41,108.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,097.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $4,276.36 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,292.13 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $337.45. The transfer capital threshold is the transfer adjustment factor * $337.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6558.75,14871.83,Inpatient DRG
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,345,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],29607.98,,,,,,0,other,12134.89,33616.03,There are no additional notes associated with this service or procedure.
Colsc Flx With Directed Submucosal Njx Any Sbst,CASE-45381,APC,45381,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1176.09,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1120.09,1176.09,OPPS APC
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],8811.83,,"Case rate ($8,811.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,333.06, add-ons for qualifying new technology services are included. If operating cost exceeds $43,204.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,262.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,364.65 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,388.11 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $502.23. The transfer capital threshold is the transfer adjustment factor * $502.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,20401.88,Inpatient DRG
FULL TERM NEONATE WITH MAJOR PROBLEMS,793,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],78359.29,,"Fee schedule rate ($78,359.29). Adds an outlier to normal pricing equal to the per diem rate ($27,082.03) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.7), with a minimum of zero.",,,,0,other,4302.90,82045.22,There are no additional notes associated with this service or procedure.
Open Tx Carpal Scaphoid Navicular Fracture|RIGHT SIDE,CASE-25628,APC,25628,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7029.71,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,7029.71,7131.59,OPPS APC
Corrj Hallux Valgus W/Sesmdc W/Dist Metar Osteot|RIGHT SIDE,CASE-28296,APC,28296,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],26178.21,,"Fee schedule rate ($26,178.21). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,13917.42,34889.29,There are no additional notes associated with this service or procedure.
DIABETES WITH CC,638,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],14024.62,,"Case rate ($8,014.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,590.93, add-ons for qualifying new technology services are included. If operating cost exceeds $42,461.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,203.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,625.24 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,645.98 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $443.89. The transfer capital threshold is the transfer adjustment factor * $443.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,8014.07,17634.53,All Other Inpatient
Colonoscopy Flx Dx W/Collj Spec When Pfrmd|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-45378,APC,45378,CPT,0360,RC,,,74,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],900.93,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,870.46,913.99,OPPS APC
HC Debride Subq First 20 Sq Cm|SEPARATE STRUCTURE,CASE-11042,APC,11042,CPT,0361,RC,,,XS,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3169.86,3215.80,OPPS APC
Esophagogastroduodenoscopy US Scope W/Adj Strxrs,CASE-43237,APC,43237,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1885.95,,"APC Price ($1,796.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1796.14,1885.95,OPPS APC
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",004,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],260309.36,,"Fee schedule rate ($260,309.36). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (35), with a minimum of zero.",,,,0,other,10249.47,272554.00,There are no additional notes associated with this service or procedure.
"Prq Skel Fixj Phlngl Shft Fx Prox/Middle Px/F/T|RIGHT HAND, FIFTH DIGIT",CASE-26727,APC,26727,CPT,0360,RC,,,F9,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,426,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],177294.98,,"Fee schedule rate ($177,294.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,76581.29,216864.15,There are no additional notes associated with this service or procedure.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],26776.27,,"Fee schedule rate ($26,776.27). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,11593.79,38248.08,There are no additional notes associated with this service or procedure.
"Correction Hammertoe|LEFT FOOT, SECOND DIGIT",CASE-28285,APC,28285,CPT,0360,RC,,,T1,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7029.71,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6791.99,7131.59,OPPS APC
"Hallux Rigidus W/Cheilectomy 1st Mp Jt W/O Implt|LEFT FOOT, GREAT TOE",CASE-28289,APC,28289,CPT,0360,RC,,,TA,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],16235.87,,"Fee schedule rate ($16,235.87). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6524.00,17760.46,There are no additional notes associated with this service or procedure.
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],11133.98,,"Fee schedule rate ($11,133.98). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5919.29,13545.65,There are no additional notes associated with this service or procedure.
Laryngoscopy Direct Operative W/Biopsy,CASE-31535,APC,31535,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3611.96,,"APC Price ($3,489.82). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3489.82,3664.31,OPPS APC
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],81524.17,,"Fee schedule rate ($81,524.17). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,8972.00,81524.17,There are no additional notes associated with this service or procedure.
"Fasct Prtl Palmr Addl Dgt Prox Iphal Jt W/WO Rpr|RIGHT HAND, FOURTH DIGIT",CASE-26125,APC,26125,CPT,0360,RC,,,F8,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],12152.40,,"Case rate ($11,914.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,219.06, add-ons for qualifying new technology services are included. If operating cost exceeds $46,090.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,489.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $9,240.03 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,274.10 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $729.13. The transfer capital threshold is the transfer adjustment factor * $729.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,11914.12,40426.76,Inpatient DRG
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],18311.90,,"Fee schedule rate ($18,311.90). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8543.64,23239.84,There are no additional notes associated with this service or procedure.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],92811.11,,"Fee schedule rate ($92,811.11). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,35389.50,101083.00,There are no additional notes associated with this service or procedure.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],11999.57,,"Case rate ($11,593.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,921.06, add-ons for qualifying new technology services are included. If operating cost exceeds $45,792.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,465.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $8,943.14 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,976.12 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $705.70. The transfer capital threshold is the transfer adjustment factor * $705.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,11593.79,38248.08,Inpatient DRG
VENTRICULAR SHUNT PROCEDURES WITH CC,032,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],16749.95,,"Case rate ($15,952.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,001.86, add-ons for qualifying new technology services are included. If operating cost exceeds $49,872.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,759.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $13,007.59 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,056.91 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $999.79. The transfer capital threshold is the transfer adjustment factor * $999.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,16376.22,46275.08,Inpatient DRG
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,073,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],43475.01,,"Fee schedule rate ($43,475.01). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,12809.38,43475.01,There are no additional notes associated with this service or procedure.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,418,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],22105.65,,"Fee schedule rate ($22,105.65). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,13400.58,39884.93,There are no additional notes associated with this service or procedure.
OSTEOMYELITIS WITH CC,540,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],11098.92,,"Case rate ($10,723.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,111.53, add-ons for qualifying new technology services are included. If operating cost exceeds $44,982.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,402.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $8,136.58 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,166.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $642.06. The transfer capital threshold is the transfer adjustment factor * $642.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,9809.07,25507.30,Inpatient DRG
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,699,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],10846.50,,"Fee schedule rate ($10,846.50). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5961.00,19972.16,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITH STERILIZATION WITH MCC,783,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],18571.05,,"Case rate ($18,571.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,411.86, add-ons for qualifying new technology services are included. If operating cost exceeds $52,282.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,975.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $15,410.10 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,466.92 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,216.01. The transfer capital threshold is the transfer adjustment factor * $1,216.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12612.10,23722.94,Inpatient DRG
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",004,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],272554.00,,,,,,0,other,10249.47,272554.00,There are no additional notes associated with this service or procedure.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,098,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],17486.17,,"Case rate ($17,486.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,402.62, add-ons for qualifying new technology services are included. If operating cost exceeds $51,273.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,896.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $14,404.56 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,457.67 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,136.66. The transfer capital threshold is the transfer adjustment factor * $1,136.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,45156.75,Inpatient DRG
HC Joint Injection/Aspir Large WO US,CASE-20610,APC,20610,CPT,0510,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],297.37,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,287.31,301.68,OPPS APC
Prq Skel Fixj Dstl Phlngl Fx Fngr/Thmb Ea,CASE-26756,APC,26756,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],42021.93,,"Fee schedule rate ($42,021.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,21248.73,56089.29,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,065,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],9226.10,,"Case rate ($8,786.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,309.75, add-ons for qualifying new technology services are included. If operating cost exceeds $43,180.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,260.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,341.42 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,364.80 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $500.40. The transfer capital threshold is the transfer adjustment factor * $500.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8786.76,25681.86,Inpatient DRG
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],11681.49,,"Fee schedule rate ($11,681.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5778.62,11681.49,There are no additional notes associated with this service or procedure.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],39153.65,,"Fee schedule rate ($39,153.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,7605.00,39153.65,There are no additional notes associated with this service or procedure.
VENTRICULAR SHUNT PROCEDURES WITH MCC,031,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],32287.20,,"Case rate ($32,287.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $30,171.71, add-ons for qualifying new technology services are included. If operating cost exceeds $65,042.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,979.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7. The base transfer operating payment is the transfer adjustment factor * $28,123.07 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $28,226.76 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,219.19. The transfer capital threshold is the transfer adjustment factor * $2,219.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,32287.20,88162.80,Inpatient DRG
HC Trigger Point 3 or More,CASE-20553,APC,20553,CPT,0510,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],287.31,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,073,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],30149.61,,"Fee schedule rate ($30,149.61). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12809.38,43475.01,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,091,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],40030.81,,"Fee schedule rate ($40,030.81). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,13838.06,40030.81,There are no additional notes associated with this service or procedure.
VENTRICULAR SHUNT PROCEDURES WITH MCC,031,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],32287.20,,"Case rate ($32,287.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $30,171.71, add-ons for qualifying new technology services are included. If operating cost exceeds $65,042.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,979.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7. The base transfer operating payment is the transfer adjustment factor * $28,123.07 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $28,226.76 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,219.19. The transfer capital threshold is the transfer adjustment factor * $2,219.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,32287.20,88162.80,Inpatient DRG
HC Rep Cpx Sc Arm Lg 2.6-7.5cm,CASE-13121,APC,13121,CPT,0450,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1545.93,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1545.93,1623.23,OPPS APC
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],47123.82,,"Fee schedule rate ($47,123.82). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,12696.97,47123.82,There are no additional notes associated with this service or procedure.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,477,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],64922.30,,"Fee schedule rate ($64,922.30). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16.6), with a minimum of zero.",,,,0,other,25339.74,67976.16,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],31091.14,,"Fee schedule rate ($31,091.14). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13148.66,32553.63,There are no additional notes associated with this service or procedure.
"NEONATE BIRTH WEIGHT 1500-1999 GRAMS WITH RESPIRATORY DISTRESS SYNDROME OR OTHER MAJOR RESPIRATORY CONDITION,MINOR",612,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],11512.05,,"Case rate ($10,963.86). Base payment rate plus any adjustments related to outliers.",,,,0,other,10963.86,11512.05,There are no additional notes associated with this service or procedure.
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITHOUT CC/MCC",630,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],42541.02,,"Fee schedule rate ($42,541.02). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11828.78,42541.02,There are no additional notes associated with this service or procedure.
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],31477.13,,"Fee schedule rate ($31,477.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9648.19,31477.13,There are no additional notes associated with this service or procedure.
"EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME, NEONATE",790,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],3054.00,,,,,,0,other,3054.00,44304.49,Estimated amount calculated based on 17 day length of stay.
"VAGINAL DELIVERY WITH O.R. PROCEDURE EXCEPT STERILIZATION AND/OR D&C,MINOR",542,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],4303.32,,"Case rate ($4,303.32). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,4303.32,4518.49,There are no additional notes associated with this service or procedure.
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],15102.37,,"Case rate ($14,383.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,516, add-ons for qualifying new technology services are included. If operating cost exceeds $48,387.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,669.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,528.54 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,571.05 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $909.72. The transfer capital threshold is the transfer adjustment factor * $909.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,36140.75,Inpatient DRG
"NEONATE BIRTH WEIGHT > 2499 GRAMS WITH MAJOR ANOMALY,MODERATE",633,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],6957.89,,"Case rate ($6,626.56). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6626.56,6957.89,There are no additional notes associated with this service or procedure.
Colon Ca Scrn Not Hi Rsk Ind|DOCUMENTATION ON FILE,CASE-G0121,APC,G0121,CPT,0360,RC,,,KX,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],870.46,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,870.46,913.99,OPPS APC
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC",061,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],62315.82,,"Fee schedule rate ($62,315.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,20616.23,62315.82,There are no additional notes associated with this service or procedure.
BRONCHITIS AND ASTHMA WITH CC/MCC,202,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],8692.42,,"Case rate ($8,521.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,063.43, add-ons for qualifying new technology services are included. If operating cost exceeds $42,934.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,241.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,096.00 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,118.48 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $481.03. The transfer capital threshold is the transfer adjustment factor * $481.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,7606.34,19110.30,Inpatient DRG
Osteoplasty Radius/Ulna Shortening,CASE-25390,APC,25390,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
CESAREAN SECTION WITHOUT STERILIZATION WITH MCC,786,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],23722.94,,"Fee schedule rate ($23,722.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12612.10,23722.94,There are no additional notes associated with this service or procedure.
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],5791.49,,"Fee schedule rate ($5,791.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,3079.00,10940.41,There are no additional notes associated with this service or procedure.
APPENDIX PROCEDURES WITH MCC,397,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],45007.36,,"Fee schedule rate ($45,007.36). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.5), with a minimum of zero.",,,,0,other,18163.37,51558.84,There are no additional notes associated with this service or procedure.
"Surg Implnt Neuroelect,Epidural",CASE-63655,APC,63655,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],28883.55,,"APC Price ($28,883.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,28883.55,30327.72,OPPS APC
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC,831,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],10088.35,,"Case rate ($10,088.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,520.59, add-ons for qualifying new technology services are included. If operating cost exceeds $44,391.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,355.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $7,547.82 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,575.65 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $595.60. The transfer capital threshold is the transfer adjustment factor * $595.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,4941.30,23661.59,Inpatient DRG
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC",514,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],8868.04,,"Case rate ($8,868.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,385.35, add-ons for qualifying new technology services are included. If operating cost exceeds $43,256.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,266.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $6,416.74 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,440.40 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $506.34. The transfer capital threshold is the transfer adjustment factor * $506.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8868.04,22699.91,Inpatient DRG
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],33910.82,,"Case rate ($32,296.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $30,179.91, add-ons for qualifying new technology services are included. If operating cost exceeds $65,050.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,979.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $28,131.23 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $28,234.95 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,219.83. The transfer capital threshold is the transfer adjustment factor * $2,219.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,32296.02,88188.38,Inpatient DRG
Cysto impl 4 or more,CASE-C9740,APC,C9740,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],9303.88,,"APC Price ($8,860.83). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,8860.83,9303.88,OPPS APC
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],21587.31,,"Case rate ($20,559.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $19,261.52, add-ons for qualifying new technology services are included. If operating cost exceeds $54,132.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,121.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $17,252.96 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $17,316.57 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,361.43. The transfer capital threshold is the transfer adjustment factor * $1,361.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,20559.34,54086.17,Inpatient DRG
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],26939.48,,"Case rate ($26,028.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $24,349.34, add-ons for qualifying new technology services are included. If operating cost exceeds $59,220.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,521.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $22,322.08 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $22,404.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,761.43. The transfer capital threshold is the transfer adjustment factor * $1,761.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103.5%.",,,,0,other,26028.48,80635.65,Inpatient DRG
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],28751.41,,"Fee schedule rate ($28,751.41). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12305.53,30103.84,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],23014.22,,,,,,0,other,9865.56,37914.65,There are no additional notes associated with this service or procedure.
RESPIRATORY NEOPLASMS WITHOUT CC/MCC,182,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],7049.74,,"Case rate ($7,049.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,693.83, add-ons for qualifying new technology services are included. If operating cost exceeds $41,564.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,133.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,731.43 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,748.88 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $373.36. The transfer capital threshold is the transfer adjustment factor * $373.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,23037.13,Inpatient DRG
"SPINAL PROCEDURES,MINOR",023,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],4938.21,,"Case rate for a one day stay ($4,703.06). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4703.06,4938.21,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],28756.63,,"Fee schedule rate ($28,756.63). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,13148.66,32553.63,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],48903.68,,"Case rate ($27,944.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $26,132.21, add-ons for qualifying new technology services are included. If operating cost exceeds $61,003.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,661.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.8. The base transfer operating payment is the transfer adjustment factor * $24,098.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $24,187.26 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,901.60. The transfer capital threshold is the transfer adjustment factor * $1,901.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,27944.96,86252.84,All Other Inpatient
TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC,084,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],19445.16,,"Fee schedule rate ($19,445.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,6965.00,19445.16,There are no additional notes associated with this service or procedure.
OTHER CEREBROVASCULAR DISORDERS WITH CC,071,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],29215.10,,"Fee schedule rate ($29,215.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5843.00,29215.10,There are no additional notes associated with this service or procedure.
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],25814.06,,"Fee schedule rate ($25,814.06). Adds an outlier to normal pricing equal to the per diem rate ($46,867.46) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,11247.07,27028.33,There are no additional notes associated with this service or procedure.
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],24444.75,,"Fee schedule rate ($24,444.75). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10136.44,24444.75,There are no additional notes associated with this service or procedure.
Nsl/Sinus Ndsc Max Antrost W/Rmvl Tiss Max Sinus|RIGHT SIDE,CASE-31267,APC,31267,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6936.25,,"APC Price ($6,605.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6605.95,6936.25,OPPS APC
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],14265.21,,"Case rate ($8,151.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,718.82, add-ons for qualifying new technology services are included. If operating cost exceeds $42,589.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,213.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,752.66 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,773.87 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $453.94. The transfer capital threshold is the transfer adjustment factor * $453.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,8151.55,18033.97,All Other Inpatient
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,306,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],13247.19,,"Case rate ($12,616.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,872.35, add-ons for qualifying new technology services are included. If operating cost exceeds $46,743.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,540.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $9,890.94 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,927.40 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $780.49. The transfer capital threshold is the transfer adjustment factor * $780.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12616.37,31007.02,Inpatient DRG
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],49717.39,,"Fee schedule rate ($49,717.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,14908.05,49717.39,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],41580.51,,"Fee schedule rate ($41,580.51). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,13783.20,41580.51,There are no additional notes associated with this service or procedure.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,191,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],16612.88,,"Fee schedule rate ($16,612.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6965.00,16612.88,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],20659.14,,"Fee schedule rate ($20,659.14). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.9), with a minimum of zero.",,,,0,other,9389.48,22358.90,There are no additional notes associated with this service or procedure.
"ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",770,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],18843.74,,"Fee schedule rate ($18,843.74). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,8735.30,19730.13,There are no additional notes associated with this service or procedure.
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],31973.49,,"Fee schedule rate ($31,973.49). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,13386.36,33244.29,There are no additional notes associated with this service or procedure.
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITH MCC OR ANTINEOPLASTIC IMPLANT OR EPILEPSY WITH NEUROSTIMULATOR,023,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],71314.16,,"Case rate ($40,750.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $38,045.35, add-ons for qualifying new technology services are included. If operating cost exceeds $72,916.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,598.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $35,967.78 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $36,100.40 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,838.21. The transfer capital threshold is the transfer adjustment factor * $2,838.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 175%.",,,,0,other,15168.00,136379.44,All Other Inpatient
"PULMONARY EMBOLISM,MODERATE",134,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],7846.83,,"Case rate ($7,846.83). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,7846.83,8239.17,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,447,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],156646.82,,"Fee schedule rate ($156,646.82). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,47193.21,156646.82,There are no additional notes associated with this service or procedure.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],21587.31,,"Case rate ($20,559.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $19,261.52, add-ons for qualifying new technology services are included. If operating cost exceeds $54,132.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,121.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $17,252.96 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $17,316.57 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,361.43. The transfer capital threshold is the transfer adjustment factor * $1,361.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,20559.34,54086.17,Inpatient DRG
SEIZURES WITH MCC,100,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],32323.98,,"Fee schedule rate ($32,323.98). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,15061.09,38110.41,There are no additional notes associated with this service or procedure.
Ndsc Njx Implt Matrl Urt&/Bldr Nck,CASE-51715,APC,51715,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3464.44,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3299.47,3464.44,OPPS APC
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],11113.51,,"Case rate ($10,895.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,271.55, add-ons for qualifying new technology services are included. If operating cost exceeds $45,142.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,414.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $8,296.01 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,326.60 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $654.64. The transfer capital threshold is the transfer adjustment factor * $654.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,10895.60,35192.25,Inpatient DRG
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],13923.42,,"Case rate ($13,260.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,471.48, add-ons for qualifying new technology services are included. If operating cost exceeds $47,342.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,587.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $10,487.86 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,526.53 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $827.60. The transfer capital threshold is the transfer adjustment factor * $827.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13260.40,32878.30,Inpatient DRG
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH MCC",722,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],56869.13,,"Fee schedule rate ($56,869.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,14200.37,56869.13,There are no additional notes associated with this service or procedure.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC",061,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],62315.82,,"Fee schedule rate ($62,315.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,20616.23,62315.82,There are no additional notes associated with this service or procedure.
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],40426.76,,"Fee schedule rate ($40,426.76). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,11914.12,40426.76,There are no additional notes associated with this service or procedure.
Exc Cyst/Aberrant Breast Tissue Open 1/> Lesion|RIGHT SIDE,CASE-19120,APC,19120,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3664.94,,"APC Price ($3,664.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3664.94,3848.19,OPPS APC
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],120927.32,,"Fee schedule rate ($120,927.32). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,45521.20,142438.06,There are no additional notes associated with this service or procedure.
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],24126.45,,"Fee schedule rate ($24,126.45). Adds an outlier to normal pricing equal to the per diem rate ($62,306.11) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10638.94,25261.33,There are no additional notes associated with this service or procedure.
Surgical Arthroscopy Shoulder Xtnsv Dbrdmt 3+|RIGHT SIDE,CASE-29823,APC,29823,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6791.99,7131.59,OPPS APC
Parathyroidectomy/Exploration Parathyroids|RIGHT SIDE,CASE-60500,APC,60500,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5856.81,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5658.76,5941.70,OPPS APC
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],12272.58,,"Fee schedule rate ($12,272.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5628.97,12272.58,There are no additional notes associated with this service or procedure.
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC",458,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],78415.67,,"Fee schedule rate ($78,415.67). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.8), with a minimum of zero.",,,,0,other,30202.09,132827.25,There are no additional notes associated with this service or procedure.
MINOR BLADDER PROCEDURES WITHOUT CC/MCC,664,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],19674.39,,"Fee schedule rate ($19,674.39). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,9034.63,31876.87,There are no additional notes associated with this service or procedure.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],41006.47,,"Fee schedule rate ($41,006.47). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12268.97,41006.47,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],17651.07,,"Fee schedule rate ($17,651.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,6564.18,17651.07,There are no additional notes associated with this service or procedure.
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],14343.25,,"Case rate ($14,343.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,478.83, add-ons for qualifying new technology services are included. If operating cost exceeds $48,349.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,666.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $11,491.51 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,533.88 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $906.79. The transfer capital threshold is the transfer adjustment factor * $906.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,14343.25,36024.65,Inpatient DRG
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,761,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],11946.72,,"Fee schedule rate ($11,946.72). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,5808.41,11946.72,There are no additional notes associated with this service or procedure.
TRAUMATIC INJURY WITH MCC,913,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],42838.46,,"Fee schedule rate ($42,838.46). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13014.58,42838.46,There are no additional notes associated with this service or procedure.
ALLERGIC REACTIONS WITH MCC,915,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],27385.01,,"Fee schedule rate ($27,385.01). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,13332.86,33088.84,There are no additional notes associated with this service or procedure.
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC,497,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],10127.65,,"Case rate ($10,127.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,557.14, add-ons for qualifying new technology services are included. If operating cost exceeds $44,428.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,358.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 1.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $7,584.22 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,612.19 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $598.47. The transfer capital threshold is the transfer adjustment factor * $598.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10127.65,37761.19,Inpatient DRG
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],11164.32,,"Case rate ($10,632.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,043.18, add-ons for qualifying new technology services are included. If operating cost exceeds $44,914.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,380.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $8,067.64 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,098.23 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $620.10. The transfer capital threshold is the transfer adjustment factor * $620.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10895.60,35192.25,Inpatient DRG
HC Rep Cpx Sc Arm Lg 2.6-7.5cm,CASE-13121,APC,13121,CPT,0450,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1623.23,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1545.93,1623.23,OPPS APC
"KIDNEY AND URINARY TRACT INFECTIONS,MODERATE",463,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],1964.47,,"Case rate for a one day stay ($1,870.92). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,1870.92,1964.47,There are no additional notes associated with this service or procedure.
Rpr Xtnsr Tdn Cntrl Slip Tiss W/Lat Band Ea Fngr,CASE-26426,APC,26426,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],20981.60,,"Fee schedule rate ($20,981.60). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,10003.71,23415.63,There are no additional notes associated with this service or procedure.
Replacement Tissue Expander W/Permanent Implant|LEFT SIDE,CASE-11970,APC,11970,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6791.99,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC,964,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],34154.06,,"Fee schedule rate ($34,154.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12323.82,34154.06,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITH CC,164,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],47433.53,,"Fee schedule rate ($47,433.53). Adds an outlier to normal pricing equal to the per diem rate ($158,028.38) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,19037.66,77058.83,There are no additional notes associated with this service or procedure.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC,858,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],33794.11,,"Fee schedule rate ($33,794.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11377.76,33794.11,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],18905.23,,"Fee schedule rate ($18,905.23). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6963.00,18954.85,There are no additional notes associated with this service or procedure.
Exc B9 Lesion Mrgn Xcp Sk Tg T/a/L 2.1-3.0 Cm,CASE-11403,APC,11403,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],2718.88,,"APC Price ($2,718.88). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2718.88,2854.83,OPPS APC
CERVICAL SPINAL FUSION WITHOUT CC/MCC,473,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],62077.11,,"Fee schedule rate ($62,077.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,18477.61,62077.11,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],11612.44,,"Case rate ($11,059.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,424, add-ons for qualifying new technology services are included. If operating cost exceeds $45,295.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,426.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $8,447.91 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,479.05 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $666.62. The transfer capital threshold is the transfer adjustment factor * $666.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,11059.47,28423.20,Inpatient DRG
"CHOLECYSTECTOMY,MINOR",263,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],11805.88,,"Case rate ($11,805.88). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,11805.88,12396.17,There are no additional notes associated with this service or procedure.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,988,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],42425.46,,"Fee schedule rate ($42,425.46). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,13075.52,42425.46,There are no additional notes associated with this service or procedure.
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6834.39,,"Case rate ($6,834.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,493.49, add-ons for qualifying new technology services are included. If operating cost exceeds $41,364.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,117.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $4,531.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,548.54 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $357.61. The transfer capital threshold is the transfer adjustment factor * $357.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6834.39,21354.82,Inpatient DRG
Revision of Spinal Shunt,CASE-63744,APC,63744,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3357.48,,"APC Price ($3,197.60). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3197.60,3357.48,OPPS APC
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],21585.31,,"Case rate ($21,585.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,215.96, add-ons for qualifying new technology services are included. If operating cost exceeds $55,086.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,196.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $18,203.89 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,271.01 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,436.47. The transfer capital threshold is the transfer adjustment factor * $1,436.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,21585.31,73588.10,Inpatient DRG
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],37134.43,,,,,,0,other,7389.00,37134.43,There are no additional notes associated with this service or procedure.
Transurethral Resection Bladder Neck,CASE-52500,APC,52500,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3299.47,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3299.47,3464.44,OPPS APC
HC Inj Anes/Steroid C/D Facet Sg|LEFT SIDE,CASE-64490,APC,64490,CPT,0361,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],869.28,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,827.89,869.28,OPPS APC
HEART FAILURE AND SHOCK WITH CC,292,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],5502.00,,"Per diem ($5,502). If length of stay < 2.9, first 1 days paid at a per diem of $11,004 instead. Capped at $15,955.26.",,,,0,other,5502.00,16705.77,Estimated amount calculated based on 2 day length of stay.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],16818.89,,"Case rate ($16,017.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,036.80, add-ons for qualifying new technology services are included. If operating cost exceeds $49,907.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,789.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $13,043.76 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,091.85 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,029.28. The transfer capital threshold is the transfer adjustment factor * $1,029.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,16017.99,51903.64,Inpatient DRG
Neuroplasty &/Transposition Ulnar Nerve Elbow|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64718,APC,64718,CPT,0360,RC,,,LT|XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6791.99,7131.59,OPPS APC
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],43399.23,,"Fee schedule rate ($43,399.23). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9888.00,43399.23,There are no additional notes associated with this service or procedure.
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],35061.53,,"Fee schedule rate ($35,061.53). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,9696.93,35061.53,There are no additional notes associated with this service or procedure.
"PROCEDURES FOR OBESITY,MINOR",403,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],11655.96,,"Case rate ($11,100.91). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11100.91,11655.96,There are no additional notes associated with this service or procedure.
Pelvic Examination W/Anesthesia Other Than Local,CASE-57410,APC,57410,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3136.08,,"APC Price ($3,030.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3030.03,3181.53,OPPS APC
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],21700.35,,"Fee schedule rate ($21,700.35). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,7605.00,39153.65,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],23239.84,,"Fee schedule rate ($23,239.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8543.64,23239.84,There are no additional notes associated with this service or procedure.
NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,601,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],6162.89,,"Case rate ($6,042.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,756.39, add-ons for qualifying new technology services are included. If operating cost exceeds $40,627.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,059.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $3,797.45 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,811.45 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $299.66. The transfer capital threshold is the transfer adjustment factor * $299.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6042.05,12359.72,Inpatient DRG
Laparoscopy Surg Cholecystectomy,CASE-47562,APC,47562,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5658.76,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5658.76,5941.70,OPPS APC
SPINAL PROCEDURES WITH MCC,028,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],118225.32,,,,,,0,other,42633.57,120982.83,There are no additional notes associated with this service or procedure.
COAGULATION DISORDERS,813,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12569.53,,"Case rate ($11,970.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,290.66, add-ons for qualifying new technology services are included. If operating cost exceeds $46,161.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,475.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $9,310.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,345.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $715.62. The transfer capital threshold is the transfer adjustment factor * $715.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12274.39,30013.33,Inpatient DRG
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC",494,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],37708.15,,"Fee schedule rate ($37,708.15). Adds an outlier to normal pricing equal to the per diem rate ($63,554.89) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,15533.10,39945.55,There are no additional notes associated with this service or procedure.
Colonoscopy W/Biopsy Single/Multiple,CASE-45380,APC,45380,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1159.29,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1120.09,1176.09,OPPS APC
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],7641.61,,"Case rate ($7,641.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,244.44, add-ons for qualifying new technology services are included. If operating cost exceeds $42,115.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,176.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,280.02 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,299.49 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $416.65. The transfer capital threshold is the transfer adjustment factor * $416.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7641.61,19371.27,Inpatient DRG
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],22195.49,,"Case rate ($21,138.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $19,836.17, add-ons for qualifying new technology services are included. If operating cost exceeds $54,707.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,129.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.2. The base transfer operating payment is the transfer adjustment factor * $17,823.64 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $17,891.22 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,369.97. The transfer capital threshold is the transfer adjustment factor * $1,369.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,21719.40,85305.59,Inpatient DRG
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],25829.63,,"Fee schedule rate ($25,829.63). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6965.00,29482.05,There are no additional notes associated with this service or procedure.
Total Thyroid Lobectomy Uni W/WO Isthmusectomy|LEFT SIDE,CASE-60220,APC,60220,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5658.76,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5658.76,5856.81,OPPS APC
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],13783.20,,"Case rate ($13,783.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,957.83, add-ons for qualifying new technology services are included. If operating cost exceeds $47,828.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,625.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $10,972.42 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,012.88 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $865.83. The transfer capital threshold is the transfer adjustment factor * $865.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,13783.20,41580.51,Inpatient DRG
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,345,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],12741.63,,"Case rate ($12,134.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,424.43, add-ons for qualifying new technology services are included. If operating cost exceeds $46,295.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,505.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $9,444.66 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,479.48 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $745.28. The transfer capital threshold is the transfer adjustment factor * $745.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12134.89,33616.03,Inpatient DRG
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH CC",457,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],160549.49,,"Fee schedule rate ($160,549.49). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,42327.47,160549.49,There are no additional notes associated with this service or procedure.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],60646.89,,"Fee schedule rate ($60,646.89). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15.6), with a minimum of zero.",,,,0,other,23799.09,63499.65,There are no additional notes associated with this service or procedure.
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],26687.87,,"Case rate ($25,417.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $23,824.31, add-ons for qualifying new technology services are included. If operating cost exceeds $58,695.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,435.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. The base transfer operating payment is the transfer adjustment factor * $21,796.72 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $21,879.36 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,675.35. The transfer capital threshold is the transfer adjustment factor * $1,675.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,26127.34,90333.60,Inpatient DRG
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],20981.60,,"Fee schedule rate ($20,981.60). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,10003.71,23415.63,There are no additional notes associated with this service or procedure.
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC",011,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],39658.10,,"Case rate ($38,880.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $36,305.31, add-ons for qualifying new technology services are included. If operating cost exceeds $71,176.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,461.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 11.4. The base transfer operating payment is the transfer adjustment factor * $34,234.14 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $34,360.36 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,701.41. The transfer capital threshold is the transfer adjustment factor * $2,701.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,38880.49,150008.48,Inpatient DRG
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],33398.16,,"Fee schedule rate ($33,398.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,7353.00,33398.16,There are no additional notes associated with this service or procedure.
MAJOR CHEST TRAUMA WITHOUT CC/MCC,185,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],15475.96,,,,,,0,other,7271.19,21771.61,There are no additional notes associated with this service or procedure.
HC Rep Cpx Sc Arm Lg 2.6-7.5cm,CASE-13121,APC,13121,CPT,0450,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1623.23,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1545.93,1623.23,OPPS APC
Intraop Sentinel Lymph Node ID W/Dye Injection|LEFT SIDE,CASE-38900,APC,38900,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6215.36,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6215.36,6526.12,OPPS APC
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],20553.44,,"Fee schedule rate ($20,553.44). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8874.81,20553.44,There are no additional notes associated with this service or procedure.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,329,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],33072.77,,"Case rate ($33,072.77). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $30,902.51, add-ons for qualifying new technology services are included. If operating cost exceeds $65,773.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,036.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.4. The base transfer operating payment is the transfer adjustment factor * $28,851.18 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $28,957.55 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,276.64. The transfer capital threshold is the transfer adjustment factor * $2,276.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,33072.77,90445.33,Inpatient DRG
PERIPHERAL VASCULAR DISORDERS WITH CC,300,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],9174.14,,"Case rate ($9,174.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,670.11, add-ons for qualifying new technology services are included. If operating cost exceeds $43,541.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,288.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,700.45 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,725.16 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $528.73. The transfer capital threshold is the transfer adjustment factor * $528.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9174.14,21005.20,Inpatient DRG
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC",458,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],70616.46,,"Fee schedule rate ($70,616.46). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,30202.09,132827.25,There are no additional notes associated with this service or procedure.
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],33244.29,,,,,,0,other,13386.36,33244.29,There are no additional notes associated with this service or procedure.
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,450,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],146009.19,,"Fee schedule rate ($146,009.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,38037.38,146009.19,There are no additional notes associated with this service or procedure.
MAJOR CHEST TRAUMA WITHOUT CC/MCC,185,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],21771.61,,"Fee schedule rate ($21,771.61). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7271.19,21771.61,There are no additional notes associated with this service or procedure.
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],28751.41,,"Fee schedule rate ($28,751.41). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12305.53,30103.84,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],26483.27,,,,,,0,other,11059.47,28423.20,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC",281,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],13223.70,,"Fee schedule rate ($13,223.70). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8169.15,23859.35,There are no additional notes associated with this service or procedure.
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],33159.45,,"Fee schedule rate ($33,159.45). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,13092.47,33159.45,There are no additional notes associated with this service or procedure.
SEIZURES WITH MCC,100,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],36398.28,,"Fee schedule rate ($36,398.28). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,15061.09,38110.41,There are no additional notes associated with this service or procedure.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],22069.95,,"Fee schedule rate ($22,069.95). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,15273.74,39820.52,There are no additional notes associated with this service or procedure.
Marsupialization Bartholins Gland Cyst,CASE-56440,APC,56440,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3136.08,,"APC Price ($3,030.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3030.03,3181.53,OPPS APC
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC,939,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],68190.40,,"Fee schedule rate ($68,190.40). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16.5), with a minimum of zero.",,,,0,other,26517.40,97674.79,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],27802.06,,"Case rate ($27,256.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $25,492.14, add-ons for qualifying new technology services are included. If operating cost exceeds $60,363.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,611.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. The base transfer operating payment is the transfer adjustment factor * $23,460.69 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $23,547.19 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,851.28. The transfer capital threshold is the transfer adjustment factor * $1,851.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,27256.92,81353.66,Inpatient DRG
HC Inj Trigger Pt 1-2 Musc Grps|PBB CHARGE,CASE-20552,APC,20552,CPT,0510,RC,,,PBB,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],297.37,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,287.31,301.68,OPPS APC
Tr/Trnspl Tdn Carp/Mtcrpl Hand W/O Fr Grf Ea Tdn,CASE-26480,APC,26480,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],6965.00,,,,,,0,other,6148.93,15887.21,There are no additional notes associated with this service or procedure.
Neuroplasty &/Transpos Median Nrv Carpal Tunne|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64721,APC,64721,CPT,0360,RC,,,LT|XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6791.99,7131.59,OPPS APC
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],18598.83,,"Case rate ($18,598.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,437.70, add-ons for qualifying new technology services are included. If operating cost exceeds $52,308.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,978.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 5.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $15,435.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,492.75 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,218.04. The transfer capital threshold is the transfer adjustment factor * $1,218.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,18598.83,48389.68,Inpatient DRG
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],28434.57,,"Fee schedule rate ($28,434.57). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,8906.63,28434.57,There are no additional notes associated with this service or procedure.
Excision Tumor Soft Tissue Foot/Toe Subq <1.5cm|LEFT SIDE,CASE-28043,APC,28043,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1623.23,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1545.93,1623.23,OPPS APC
"CHOLECYSTECTOMY,MODERATE",263,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],15882.03,,"Case rate ($15,125.74). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,15125.74,15882.03,There are no additional notes associated with this service or procedure.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],101083.00,,"Fee schedule rate ($101,083.00). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,35389.50,101083.00,There are no additional notes associated with this service or procedure.
"CARDIAC ARREST, UNEXPLAINED WITH MCC",296,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],12522.25,,"Case rate ($12,522.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,784.78, add-ons for qualifying new technology services are included. If operating cost exceeds $46,655.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,533.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $9,803.69 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,839.84 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $773.61. The transfer capital threshold is the transfer adjustment factor * $773.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12522.25,36459.67,Inpatient DRG
HC Inj Tendon Sheath/Ligament|PBB CHARGE,CASE-20550,APC,20550,CPT,0510,RC,,,PBB,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],301.68,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,287.31,301.68,OPPS APC
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],19371.27,,"Fee schedule rate ($19,371.27). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7641.61,19371.27,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],24675.88,,"Fee schedule rate ($24,675.88). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10834.64,25830.00,There are no additional notes associated with this service or procedure.
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],59494.91,,"Fee schedule rate ($59,494.91). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,18594.09,59494.91,There are no additional notes associated with this service or procedure.
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],8165.30,,"Fee schedule rate ($8,165.30). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4341.01,12882.53,There are no additional notes associated with this service or procedure.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH CC,026,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],23805.68,,"Case rate ($23,000.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $21,532.64, add-ons for qualifying new technology services are included. If operating cost exceeds $56,403.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,299.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $19,515.74 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $19,587.69 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,539.98. The transfer capital threshold is the transfer adjustment factor * $1,539.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103.5%.",,,,0,other,23000.66,63202.45,Inpatient DRG
HC Inj Tendon Sheath/Ligament|RIGHT SIDE,CASE-20550,APC,20550,CPT,0510,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],297.37,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,287.31,301.68,OPPS APC
SEIZURES WITH MCC,100,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],32323.98,,"Fee schedule rate ($32,323.98). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,15061.09,38110.41,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],9865.56,,"Case rate ($9,865.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,313.33, add-ons for qualifying new technology services are included. If operating cost exceeds $44,184.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,339.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $7,341.31 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,368.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $579.30. The transfer capital threshold is the transfer adjustment factor * $579.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9865.56,37914.65,Inpatient DRG
MAJOR ESOPHAGEAL DISORDERS WITH CC,369,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],15257.17,,"Case rate ($8,718.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,246.12, add-ons for qualifying new technology services are included. If operating cost exceeds $43,117.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,255.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,278.03 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,301.17 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $495.40. The transfer capital threshold is the transfer adjustment factor * $495.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,6965.00,19680.94,All Other Inpatient
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],32852.04,,"Fee schedule rate ($32,852.04). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,13783.20,41580.51,There are no additional notes associated with this service or procedure.
"HC I&D Finger Abscess Simple|RIGHT HAND, THUMB",CASE-26010,APC,26010,CPT,0450,RC,,,F5,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],197.19,,"APC Price ($187.80). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,187.80,197.19,OPPS APC
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],9718.11,,"Case rate ($9,389.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,870.44, add-ons for qualifying new technology services are included. If operating cost exceeds $43,741.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,304.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,900.05 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,925.50 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $544.48. The transfer capital threshold is the transfer adjustment factor * $544.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,9389.48,22358.90,Inpatient DRG
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,329,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],86631.74,,"Fee schedule rate ($86,631.74). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (38), with a minimum of zero.",,,,0,other,33072.77,90445.33,There are no additional notes associated with this service or procedure.
PSYCHOSES,885,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],2070.00,,,,,,0,other,2070.00,27484.83,Estimated amount calculated based on 3 day length of stay.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],8409.81,,"Case rate ($8,009.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,586.52, add-ons for qualifying new technology services are included. If operating cost exceeds $42,457.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,203.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $5,620.85 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,641.57 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $443.54. The transfer capital threshold is the transfer adjustment factor * $443.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8009.34,19877.10,Inpatient DRG
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],39153.65,,"Fee schedule rate ($39,153.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,7605.00,39153.65,There are no additional notes associated with this service or procedure.
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],6230.00,,"Per diem ($6,230). If length of stay < 2.9, first 1 days paid at a per diem of $12,460 instead. Capped at $18,065.71.",,,,0,other,6230.00,22762.43,Estimated amount calculated based on 3 day length of stay.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],33197.83,,"Fee schedule rate ($33,197.83). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.8), with a minimum of zero.",,,,0,other,13907.80,52794.06,There are no additional notes associated with this service or procedure.
HC Inj Tendon Sheath/Ligament,CASE-20550,APC,20550,CPT,0510,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
"TRANSIENT ISCHEMIA,MODERATE",047,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],3484.29,,"Case rate for a one day stay ($3,318.37). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,3318.37,3484.29,There are no additional notes associated with this service or procedure.
OTHER MENTAL DISORDER DIAGNOSES,887,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],9197.17,,"Case rate ($9,197.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,691.53, add-ons for qualifying new technology services are included. If operating cost exceeds $43,562.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,290.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,721.79 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,746.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $530.42. The transfer capital threshold is the transfer adjustment factor * $530.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,2070.00,21072.10,Inpatient DRG
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],42787.31,,"Fee schedule rate ($42,787.31). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,15476.23,42787.31,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],16229.42,,"Case rate ($15,456.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,514.54, add-ons for qualifying new technology services are included. If operating cost exceeds $49,385.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,748.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $12,523.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,569.59 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $988.22. The transfer capital threshold is the transfer adjustment factor * $988.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,15456.59,41402.42,Inpatient DRG
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],39153.65,,"Fee schedule rate ($39,153.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,7605.00,39153.65,There are no additional notes associated with this service or procedure.
Nasal/Sinus Ndsc W/Rmvl Tiss From Frontal Sinus|LEFT SIDE,CASE-31276,APC,31276,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6936.25,,"APC Price ($6,605.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6605.95,6936.25,OPPS APC
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],11108.72,,"Case rate ($10,733.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,120.35, add-ons for qualifying new technology services are included. If operating cost exceeds $44,991.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,402.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $8,145.37 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,175.40 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $642.75. The transfer capital threshold is the transfer adjustment factor * $642.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,10733.06,45157.33,Inpatient DRG
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,073,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],12809.38,,"Case rate ($12,809.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,051.90, add-ons for qualifying new technology services are included. If operating cost exceeds $46,922.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,554.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $10,069.82 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,106.95 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $794.61. The transfer capital threshold is the transfer adjustment factor * $794.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12809.38,43475.01,Inpatient DRG
Orchiectomy Radical Tumor Inguinal Approach|LEFT SIDE,CASE-54530,APC,54530,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3468.64,,"APC Price ($3,351.34). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3351.34,3518.91,OPPS APC
CESAREAN SECTION WITH STERILIZATION WITH CC,784,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],9580.21,,"Case rate ($9,124.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,623.49, add-ons for qualifying new technology services are included. If operating cost exceeds $43,494.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,285.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,654.00 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,678.54 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $525.07. The transfer capital threshold is the transfer adjustment factor * $525.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9124.01,23722.94,Inpatient DRG
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR,518,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],13252.00,,"Per diem ($13,252). If length of stay < 5.3, first 1 days paid at a per diem of $26,504 instead. Capped at $70,235.08.",,,,0,other,13252.00,89342.77,Estimated amount calculated based on 1 day length of stay.
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,447,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],156646.82,,"Fee schedule rate ($156,646.82). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,47193.21,156646.82,There are no additional notes associated with this service or procedure.
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,069,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],12870.32,,"Case rate ($7,354.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,977.32, add-ons for qualifying new technology services are included. If operating cost exceeds $41,848.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,155.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $5,013.88 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,032.37 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $395.65. The transfer capital threshold is the transfer adjustment factor * $395.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,6965.00,20333.68,All Other Inpatient
Bronchoscopy W/Cptr-Asst Image-Guided Navigation,CASE-31627,APC,31627,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6605.95,,"APC Price ($6,605.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6605.95,6936.25,OPPS APC
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITHOUT CC/MCC",630,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],23577.75,,"Fee schedule rate ($23,577.75). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11828.78,42541.02,There are no additional notes associated with this service or procedure.
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],20981.60,,"Fee schedule rate ($20,981.60). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,10003.71,23415.63,There are no additional notes associated with this service or procedure.
Egd Transoral Biopsy Single/Multiple|UNUSUAL NON-OVERLAPPING SERVICE,CASE-43239,APC,43239,CPT,0360,RC,,,XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1859.01,,"APC Price ($1,796.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1796.14,1885.95,OPPS APC
Cystourethroscopy W/Dest &/Rmvl Med Bladder Tum,CASE-52235,APC,52235,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3414.95,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3299.47,3464.44,OPPS APC
Optx Dstl Radl X-Artic Fx/Epiphysl Sep|LEFT SIDE,CASE-25607,APC,25607,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6791.99,7131.59,OPPS APC
HYPERTENSION WITHOUT MCC,305,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7253.77,,"Case rate ($6,908.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,571.55, add-ons for qualifying new technology services are included. If operating cost exceeds $41,442.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,114.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,609.12 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,626.60 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $354.27. The transfer capital threshold is the transfer adjustment factor * $354.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7058.55,17230.49,Inpatient DRG
O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC,621,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],36669.96,,"Fee schedule rate ($36,669.96). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,12159.94,36669.96,There are no additional notes associated with this service or procedure.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],9252.42,,"Case rate ($8,811.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,333.06, add-ons for qualifying new technology services are included. If operating cost exceeds $43,204.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,262.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,364.65 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,388.11 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $502.23. The transfer capital threshold is the transfer adjustment factor * $502.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,20401.88,Inpatient DRG
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],24838.71,,"Fee schedule rate ($24,838.71). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,10895.60,35192.25,There are no additional notes associated with this service or procedure.
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],14943.06,,"Case rate ($14,231.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,397.78, add-ons for qualifying new technology services are included. If operating cost exceeds $48,268.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,636.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $11,409.57 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,452.83 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $876.97. The transfer capital threshold is the transfer adjustment factor * $876.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,14603.31,45017.13,Inpatient DRG
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],22809.58,,,,,,0,other,9795.13,23899.13,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],128358.13,,"Fee schedule rate ($128,358.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,40542.37,128358.13,There are no additional notes associated with this service or procedure.
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],41190.50,,"Fee schedule rate ($41,190.50). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,16787.98,62990.26,There are no additional notes associated with this service or procedure.
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],40426.76,,"Fee schedule rate ($40,426.76). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,11914.12,40426.76,There are no additional notes associated with this service or procedure.
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],15857.69,,,,,,0,other,7402.56,16438.59,There are no additional notes associated with this service or procedure.
TRAUMATIC INJURY WITH MCC,913,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],42838.46,,"Fee schedule rate ($42,838.46). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13014.58,42838.46,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC,817,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],43874.75,,"Fee schedule rate ($43,874.75). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,17396.11,44895.04,There are no additional notes associated with this service or procedure.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],19877.10,,"Fee schedule rate ($19,877.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8009.34,19877.10,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],7641.61,,"Case rate ($7,641.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,244.44, add-ons for qualifying new technology services are included. If operating cost exceeds $42,115.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,176.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,280.02 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,299.49 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $416.65. The transfer capital threshold is the transfer adjustment factor * $416.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7641.61,19371.27,Inpatient DRG
RESPIRATORY NEOPLASMS WITH CC,181,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],17609.39,,"Fee schedule rate ($17,609.39). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9197.84,21074.07,There are no additional notes associated with this service or procedure.
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC",923,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],14083.63,,"Case rate ($8,047.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $7,588.71, add-ons for qualifying new technology services are included. If operating cost exceeds $46,233.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $3,215.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,201.30 + an uncompensated DSH payment of $1,359.91. The transfer operating threshold is the transfer adjustment factor * $6,228.80 + an uncompensated DSH payment of $1,359.91. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $486.59. The transfer capital threshold is the transfer adjustment factor * $486.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,6965.00,20068.57,All Other Inpatient
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],31973.49,,"Fee schedule rate ($31,973.49). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,13386.36,33244.29,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,699,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],10404.32,,"Fee schedule rate ($10,404.32). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5961.00,19972.16,There are no additional notes associated with this service or procedure.
Submucous Rescj Inferior Turbinate Prtl/Compl,CASE-30140,APC,30140,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.52,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.35,3258.52,OPPS APC
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],39337.51,,"Fee schedule rate ($39,337.51). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,16120.25,41187.90,There are no additional notes associated with this service or procedure.
Brnchsc Incl Fluor Gdnce Dx W/Cell Washg Spx,CASE-31622,APC,31622,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1724.34,,"APC Price ($1,666.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1666.03,1749.33,OPPS APC
Insj/Rplcmt Breast Implant Sep Day Mastectomy|BILATERAL PROCEDURE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-19342,APC,19342,CPT,0360,RC,,,50|XU,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],7650.49,,"APC Price ($7,650.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,7650.49,8033.01,OPPS APC
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],20297.68,,"Fee schedule rate ($20,297.68). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6965.00,21404.64,There are no additional notes associated with this service or procedure.
Surgical Arthroscopy Shoulder Dstl Claviculc|LEFT SIDE,CASE-29824,APC,29824,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6791.99,7131.59,OPPS APC
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],14603.19,,"Case rate ($13,907.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,073.74, add-ons for qualifying new technology services are included. If operating cost exceeds $47,944.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,634.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $11,087.92 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,128.80 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $874.95. The transfer capital threshold is the transfer adjustment factor * $874.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13907.80,52794.06,Inpatient DRG
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],19126.88,,"Fee schedule rate ($19,126.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,19126.88,There are no additional notes associated with this service or procedure.
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],8790.94,,"Case rate ($8,372.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,924.20, add-ons for qualifying new technology services are included. If operating cost exceeds $42,795.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,230.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,957.28 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,979.25 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $470.09. The transfer capital threshold is the transfer adjustment factor * $470.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,23385.72,Inpatient DRG
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],12558.65,,"Fee schedule rate ($12,558.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5065.00,12558.65,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],30372.64,,"Fee schedule rate ($30,372.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,13260.40,32878.30,There are no additional notes associated with this service or procedure.
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],62990.26,,"Fee schedule rate ($62,990.26). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,16787.98,62990.26,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],19126.88,,"Fee schedule rate ($19,126.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,19126.88,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,085,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],17722.41,,"Case rate ($16,878.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,865.17, add-ons for qualifying new technology services are included. If operating cost exceeds $50,736.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,825.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $13,867.65 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,920.22 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,065.90. The transfer capital threshold is the transfer adjustment factor * $1,065.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9282.00,57443.16,Inpatient DRG
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],8269.74,,"Case rate ($7,875.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,462.42, add-ons for qualifying new technology services are included. If operating cost exceeds $42,333.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,193.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $5,497.20 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,517.46 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $433.78. The transfer capital threshold is the transfer adjustment factor * $433.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7875.94,17233.12,Inpatient DRG
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],61234.06,,"Fee schedule rate ($61,234.06). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11165.00,61234.06,There are no additional notes associated with this service or procedure.
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],24528.10,,"Fee schedule rate ($24,528.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10989.72,26280.60,There are no additional notes associated with this service or procedure.
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],15233.11,,"Case rate ($15,233.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,306.64, add-ons for qualifying new technology services are included. If operating cost exceeds $49,177.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,731.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $12,316.28 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,361.69 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $971.88. The transfer capital threshold is the transfer adjustment factor * $971.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,15233.11,38610.21,Inpatient DRG
VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC,033,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],42156.44,,"Fee schedule rate ($42,156.44). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,13206.23,42156.44,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],16017.99,,"Case rate ($16,017.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,036.80, add-ons for qualifying new technology services are included. If operating cost exceeds $49,907.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,789.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $13,043.76 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,091.85 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,029.28. The transfer capital threshold is the transfer adjustment factor * $1,029.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,16017.99,51903.64,Inpatient DRG
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],142438.06,,"Fee schedule rate ($142,438.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (40), with a minimum of zero.",,,,0,other,45521.20,142438.06,There are no additional notes associated with this service or procedure.
Parathyroidectomy/Exploration Parathyroids,CASE-60500,APC,60500,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5735.04,,"APC Price ($5,541.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5541.10,5818.16,OPPS APC
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],33890.73,,"Fee schedule rate ($33,890.73). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6277.00,36801.89,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],21719.40,,"Case rate ($21,719.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,340.70, add-ons for qualifying new technology services are included. If operating cost exceeds $55,211.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,206.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.2. The base transfer operating payment is the transfer adjustment factor * $18,328.17 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,395.75 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,446.27. The transfer capital threshold is the transfer adjustment factor * $1,446.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,21719.40,85305.59,Inpatient DRG
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH MCC",722,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],35609.47,,,,,,0,other,14200.37,56869.13,There are no additional notes associated with this service or procedure.
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITHOUT MCC,430,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],108381.11,,"Fee schedule rate ($108,381.11). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.6), with a minimum of zero.",,,,0,other,41000.16,133156.90,There are no additional notes associated with this service or procedure.
Egd Dilation Gastric/Duodenal Stricture,CASE-43245,APC,43245,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1885.95,,"APC Price ($1,796.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1796.14,1885.95,OPPS APC
COMPLICATIONS OF TREATMENT WITH CC,920,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],20731.52,,"Fee schedule rate ($20,731.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8732.59,20731.52,There are no additional notes associated with this service or procedure.
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],13747.09,,"Case rate ($13,092.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,315.24, add-ons for qualifying new technology services are included. If operating cost exceeds $47,186.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,575.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $10,332.19 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,370.29 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $815.31. The transfer capital threshold is the transfer adjustment factor * $815.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13092.47,33159.45,Inpatient DRG
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],13149.46,,"Fee schedule rate ($13,149.46). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.9), with a minimum of zero.",,,,0,other,6683.37,14699.43,There are no additional notes associated with this service or procedure.
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],21673.70,,"Case rate ($21,248.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $19,902.85, add-ons for qualifying new technology services are included. If operating cost exceeds $54,773.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,171.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.3. The base transfer operating payment is the transfer adjustment factor * $17,891.94 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $17,957.90 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,411.85. The transfer capital threshold is the transfer adjustment factor * $1,411.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,21248.73,56089.29,Inpatient DRG
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],16447.34,,"Case rate ($16,447.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,436.22, add-ons for qualifying new technology services are included. If operating cost exceeds $50,307.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,820.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $13,441.70 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,491.27 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,060.68. The transfer capital threshold is the transfer adjustment factor * $1,060.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7453.00,42138.30,Inpatient DRG
Unlisted Laparoscopy Px Intestine Xcp Rectum,CASE-44238,APC,44238,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5658.76,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5658.76,5856.81,OPPS APC
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],40737.46,,"Fee schedule rate ($40,737.46). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,7665.00,40737.46,There are no additional notes associated with this service or procedure.
Egd Endoscopic Stent Placement W/Wire& Dilation,CASE-43266,APC,43266,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5881.39,,"APC Price ($5,682.51). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5682.51,5966.63,OPPS APC
Excision H/P/P/U Simple/Intermediate Repair,CASE-11470,APC,11470,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],2718.88,,"APC Price ($2,718.88). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2718.88,2854.83,OPPS APC
MAJOR THUMB OR JOINT PROCEDURES,506,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],19761.54,,"Fee schedule rate ($19,761.54). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11081.83,26548.21,There are no additional notes associated with this service or procedure.
HC Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn,CASE-62321,APC,62321,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],660.72,,"APC Price ($660.72). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,660.72,693.76,OPPS APC
VENTRICULAR SHUNT PROCEDURES WITH CC,032,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],46275.08,,"Fee schedule rate ($46,275.08). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,16376.22,46275.08,There are no additional notes associated with this service or procedure.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,477,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],62359.39,,"Fee schedule rate ($62,359.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,25339.74,67976.16,There are no additional notes associated with this service or procedure.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],34327.48,,"Case rate ($32,692.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $30,606.43, add-ons for qualifying new technology services are included. If operating cost exceeds $65,477.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,954.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.4. The base transfer operating payment is the transfer adjustment factor * $28,553.22 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $28,661.48 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,194.67. The transfer capital threshold is the transfer adjustment factor * $2,194.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,33623.33,133270.57,Inpatient DRG
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],13568.55,,"Fee schedule rate ($13,568.55). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6834.39,21354.82,There are no additional notes associated with this service or procedure.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC",156,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],6625.12,,"Case rate ($6,625.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,298.82, add-ons for qualifying new technology services are included. If operating cost exceeds $41,169.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,102.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $4,337.88 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,353.87 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $342.30. The transfer capital threshold is the transfer adjustment factor * $342.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6625.12,13598.77,Inpatient DRG
SPINAL PROCEDURES WITH MCC,028,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],120982.83,,"Fee schedule rate ($120,982.83). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,42633.57,120982.83,There are no additional notes associated with this service or procedure.
Tnot Elbow Lateral/Medial Debride Open Tdn Rpr|RIGHT SIDE,CASE-24359,APC,24359,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],8436.85,,"Case rate ($8,151.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,718.82, add-ons for qualifying new technology services are included. If operating cost exceeds $42,589.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,213.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,752.66 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,773.87 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $453.94. The transfer capital threshold is the transfer adjustment factor * $453.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,8151.55,18033.97,Inpatient DRG
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],8982.23,,"Case rate ($8,554.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,093.67, add-ons for qualifying new technology services are included. If operating cost exceeds $42,964.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,243.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,126.13 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,148.72 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $483.41. The transfer capital threshold is the transfer adjustment factor * $483.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8554.50,19204.75,Inpatient DRG
HC Inject Tendon Origin/Insert|BILATERAL PROCEDURE,CASE-20551,APC,20551,CPT,0361,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,329,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],33766.36,,"Case rate ($32,158.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $30,108.30, add-ons for qualifying new technology services are included. If operating cost exceeds $64,979.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,916.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.4. The base transfer operating payment is the transfer adjustment factor * $28,056.97 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $28,163.35 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,156.52. The transfer capital threshold is the transfer adjustment factor * $2,156.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,33072.77,90445.33,Inpatient DRG
GASTROINTESTINAL HEMORRHAGE WITH MCC,377,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],31575.65,,"Fee schedule rate ($31,575.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,7634.00,35969.56,There are no additional notes associated with this service or procedure.
Exc Cyst/Aberrant Breast Tissue Open 1/> Lesion|RIGHT SIDE,CASE-19120,APC,19120,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3848.19,,"APC Price ($3,664.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3664.94,3848.19,OPPS APC
CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC,788,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],8733.35,,"Case rate ($8,438.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,985.31, add-ons for qualifying new technology services are included. If operating cost exceeds $42,856.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,234.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,018.17 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,040.36 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $474.89. The transfer capital threshold is the transfer adjustment factor * $474.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,8438.02,20142.33,Inpatient DRG
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC,058,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],40853.02,,"Fee schedule rate ($40,853.02). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,13521.80,40853.02,There are no additional notes associated with this service or procedure.
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,068,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],23184.90,,"Fee schedule rate ($23,184.90). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,23184.90,There are no additional notes associated with this service or procedure.
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],12651.45,,"Fee schedule rate ($12,651.45). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,6503.90,14492.93,There are no additional notes associated with this service or procedure.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC,027,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],56363.30,,"Fee schedule rate ($56,363.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,19030.20,56363.30,There are no additional notes associated with this service or procedure.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,057,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],10718.84,,"Case rate ($10,718.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,107.12, add-ons for qualifying new technology services are included. If operating cost exceeds $44,978.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,401.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,132.18 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,162.17 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $641.71. The transfer capital threshold is the transfer adjustment factor * $641.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10718.84,39884.93,Inpatient DRG
"Exc Tum/Vasc Mal Sft Tiss Hand/Fngr Subq <1.5cm|RIGHT HAND, SECOND DIGIT",CASE-26115,APC,26115,CPT,0360,RC,,,F6,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1600.04,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1545.93,1623.23,OPPS APC
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC,807,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],10071.17,,"Fee schedule rate ($10,071.17). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5354.25,13266.23,There are no additional notes associated with this service or procedure.
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],34749.58,,,,,,0,other,13904.43,34749.58,There are no additional notes associated with this service or procedure.
"KIDNEY AND URINARY TRACT INFECTIONS,MAJOR",463,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],9424.92,,"Case rate ($8,976.11). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8976.11,9424.92,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS WITH MCC,947,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],30414.32,,"Fee schedule rate ($30,414.32). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,10541.41,30414.32,There are no additional notes associated with this service or procedure.
Sigmoidoscopy Flx W/Biopsy Single/Multiple|COLORECTAL CANCER SCREEN,CASE-45331,APC,45331,CPT,0360,RC,,,PT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],913.99,,"APC Price ($870.46). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,870.46,913.99,OPPS APC
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],28210.91,,"Case rate ($27,256.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $25,492.14, add-ons for qualifying new technology services are included. If operating cost exceeds $60,363.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,611.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. The base transfer operating payment is the transfer adjustment factor * $23,460.69 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $23,547.19 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,851.28. The transfer capital threshold is the transfer adjustment factor * $1,851.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,27256.92,81353.66,Inpatient DRG
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],7833.94,,"Case rate ($7,833.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,423.35, add-ons for qualifying new technology services are included. If operating cost exceeds $42,294.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,190.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,458.28 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,478.41 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $430.71. The transfer capital threshold is the transfer adjustment factor * $430.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,5883.03,17111.12,Inpatient DRG
NORMAL NEWBORN,795,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3298.01,,"Case rate ($3,298.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $3,203.67, add-ons for qualifying new technology services are included. If operating cost exceeds $38,074.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $1,858.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $1,254.10 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $1,258.72 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $98.96. The transfer capital threshold is the transfer adjustment factor * $98.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,1369.79,5771.52,Inpatient DRG
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH MCC",510,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],89863.76,,"Fee schedule rate ($89,863.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10710.00,89863.76,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],6965.00,,,,,,0,other,6965.00,41030.48,There are no additional notes associated with this service or procedure.
NORMAL NEWBORN,795,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],1369.79,,"Fee schedule rate ($1,369.79). Adds an outlier to normal pricing equal to the per diem rate ($321.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,1369.79,5771.52,There are no additional notes associated with this service or procedure.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],10098.51,,"Case rate ($10,098.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,530.04, add-ons for qualifying new technology services are included. If operating cost exceeds $44,401.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,356.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $7,557.23 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,585.10 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $596.34. The transfer capital threshold is the transfer adjustment factor * $596.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10098.51,24259.09,Inpatient DRG
"OTHER EAR NOSE MOUTH THROAT AND CRANIAL OR FACIAL DIAGNOSES,MINOR",115,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],5051.49,,"Case rate ($4,810.94). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4810.94,5051.49,There are no additional notes associated with this service or procedure.
Prtl Exc B1 Tarsal/Metar B1 Xcp Talus/Calcaneus|LEFT SIDE,CASE-28122,APC,28122,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],19763.43,,"Fee schedule rate ($19,763.43). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,8318.14,19763.43,There are no additional notes associated with this service or procedure.
UNGROUPABLE,999,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],161307.29,,"Fee schedule rate ($161,307.29). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (41), with a minimum of zero.",,,,0,other,10228.00,161307.29,There are no additional notes associated with this service or procedure.
CHEST PAIN,313,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7059.57,,"Case rate ($6,820.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,480.89, add-ons for qualifying new technology services are included. If operating cost exceeds $41,351.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,116.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $4,519.27 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,535.94 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $356.62. The transfer capital threshold is the transfer adjustment factor * $356.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6820.84,15377.66,Inpatient DRG
Tympanostomy General Anesthesia|RIGHT SIDE,CASE-69436,APC,69436,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5735.04,,"APC Price ($5,541.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5541.10,5735.04,OPPS APC
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC,831,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],10441.44,,"Case rate ($10,088.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,520.59, add-ons for qualifying new technology services are included. If operating cost exceeds $44,391.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,355.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $7,547.82 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,575.65 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $595.60. The transfer capital threshold is the transfer adjustment factor * $595.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,4941.30,23661.59,Inpatient DRG
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC,434,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],7108.55,,"Case rate ($6,770.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,433.64, add-ons for qualifying new technology services are included. If operating cost exceeds $41,304.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,112.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,472.20 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,488.69 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $352.90. The transfer capital threshold is the transfer adjustment factor * $352.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6770.05,14019.86,Inpatient DRG
Egd Intrmural Needle Aspir/Biop Altered Anatomy,CASE-43242,APC,43242,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3789.26,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3608.81,3789.26,OPPS APC
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],34570.85,,"Fee schedule rate ($34,570.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,6965.00,36140.75,There are no additional notes associated with this service or procedure.
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",004,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],10715.36,,,,,,0,other,10249.47,272554.00,Estimated amount calculated based on 6 day length of stay.
"OTHER DIGESTIVE SYSTEM DIAGNOSES,MODERATE",254,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],7987.07,,"Case rate ($7,606.73). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7606.73,7987.07,There are no additional notes associated with this service or procedure.
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],31477.13,,"Fee schedule rate ($31,477.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9648.19,31477.13,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],7353.00,,"Per diem ($7,353). If length of stay < 4.1, first 1 days paid at a per diem of $14,706 instead. Capped at $30,145.85.",,,,0,other,7353.00,33398.16,Estimated amount calculated based on 4 day length of stay.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,345,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],12377.59,,"Case rate ($12,134.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,424.43, add-ons for qualifying new technology services are included. If operating cost exceeds $46,295.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,505.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $9,444.66 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,479.48 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $745.28. The transfer capital threshold is the transfer adjustment factor * $745.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,12134.89,33616.03,Inpatient DRG
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,085,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],57443.16,,"Fee schedule rate ($57,443.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,9282.00,57443.16,There are no additional notes associated with this service or procedure.
Laryngoscopy Direct Operative W/Biopsy|UNUSUAL NON-OVERLAPPING SERVICE,CASE-31535,APC,31535,CPT,0360,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3489.82,,"APC Price ($3,489.82). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3489.82,3664.31,OPPS APC
Sigmoidoscopy Flx W/Biopsy Single/Multiple,CASE-45331,APC,45331,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],870.46,,"APC Price ($870.46). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,870.46,913.99,OPPS APC
Hemorrhoidectomy Ntrnl & Xtrnl 1 Column/Group,CASE-46255,APC,46255,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],2727.99,,"APC Price ($2,598.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2598.08,2727.99,OPPS APC
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],49717.39,,"Fee schedule rate ($49,717.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,14908.05,49717.39,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],14071.02,,,,,,0,other,6164.03,14071.02,There are no additional notes associated with this service or procedure.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],15273.74,,"Case rate ($15,273.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,344.45, add-ons for qualifying new technology services are included. If operating cost exceeds $49,215.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,734.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $12,353.94 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,399.49 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $974.85. The transfer capital threshold is the transfer adjustment factor * $974.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,15273.74,39820.52,Inpatient DRG
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],6965.00,,,,,,0,other,6965.00,15340.19,There are no additional notes associated with this service or procedure.
Unlisted Laparoscopy Procedure Stomach,CASE-43659,APC,43659,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5941.70,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5658.76,5941.70,OPPS APC
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],38248.08,,"Fee schedule rate ($38,248.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11593.79,38248.08,There are no additional notes associated with this service or procedure.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],16856.18,,"Case rate ($16,286.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,286.28, add-ons for qualifying new technology services are included. If operating cost exceeds $50,157.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,808.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $13,292.32 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,341.33 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,048.90. The transfer capital threshold is the transfer adjustment factor * $1,048.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103.5%.",,,,0,other,16286.16,58320.32,Inpatient DRG
SALIVARY GLAND PROCEDURES,139,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],30690.92,,"Fee schedule rate ($30,690.92). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,10313.19,30690.92,There are no additional notes associated with this service or procedure.
INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC,198,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7032.95,,"Case rate ($6,795.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,456.95, add-ons for qualifying new technology services are included. If operating cost exceeds $41,327.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,114.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,495.42 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,512.00 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $354.73. The transfer capital threshold is the transfer adjustment factor * $354.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6795.12,23505.07,Inpatient DRG
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],9570.98,,"Case rate ($9,570.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,039.28, add-ons for qualifying new technology services are included. If operating cost exceeds $43,910.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,317.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $7,068.27 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,094.33 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $557.76. The transfer capital threshold is the transfer adjustment factor * $557.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,5569.00,40108.48,Inpatient DRG
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],29783.11,,,,,,0,other,12195.15,39424.57,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],33398.16,,"Fee schedule rate ($33,398.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,7353.00,33398.16,There are no additional notes associated with this service or procedure.
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],13561.53,,"Case rate ($13,295.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,504.24, add-ons for qualifying new technology services are included. If operating cost exceeds $47,375.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,590.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $10,520.50 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,559.29 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $830.17. The transfer capital threshold is the transfer adjustment factor * $830.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,7000.00,33835.79,Inpatient DRG
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],28423.20,,"Fee schedule rate ($28,423.20). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11059.47,28423.20,There are no additional notes associated with this service or procedure.
Prtl Exc B1 Tarsal/Metar B1 Xcp Talus/Calcaneus|LEFT SIDE,CASE-28122,APC,28122,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],29916.58,,"Fee schedule rate ($29,916.58). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12725.42,34245.00,There are no additional notes associated with this service or procedure.
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],9282.47,,"Case rate ($9,282.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,770.90, add-ons for qualifying new technology services are included. If operating cost exceeds $43,641.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,296.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,800.88 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,825.96 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $536.66. The transfer capital threshold is the transfer adjustment factor * $536.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9282.47,21320.03,Inpatient DRG
"NEONATE BIRTH WEIGHT 2000-2499 GRAMS WITH RESPIRATORY DISTRESS SYNDROME OR OTHER MAJOR RESPIRATORY CONDITION,MINOR",622,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],13766.22,,"Case rate ($13,766.22). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,13766.22,14454.53,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],28983.97,,"Fee schedule rate ($28,983.97). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8956.76,28983.97,There are no additional notes associated with this service or procedure.
HC Bx Breast 1st Lesion US Img|LEFT SIDE,CASE-19083,APC,19083,CPT,0361,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1545.93,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1545.93,1623.23,OPPS APC
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],26966.33,,"Fee schedule rate ($26,966.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,9040.72,26966.33,There are no additional notes associated with this service or procedure.
SPINAL PROCEDURES WITHOUT CC/MCC,030,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],44714.01,,"Fee schedule rate ($44,714.01). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,16810.99,44714.01,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF NERVOUS SYSTEM WITH CC,092,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],26765.51,,"Fee schedule rate ($26,765.51). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8872.78,26765.51,There are no additional notes associated with this service or procedure.
DIABETES WITH CC,638,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],15195.79,,"Fee schedule rate ($15,195.79). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8014.07,17634.53,There are no additional notes associated with this service or procedure.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,329,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],86631.74,,"Fee schedule rate ($86,631.74). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (38), with a minimum of zero.",,,,0,other,33072.77,90445.33,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS WITH MCC,947,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],18447.47,,"Case rate ($10,541.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,942.06, add-ons for qualifying new technology services are included. If operating cost exceeds $44,813.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,388.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $7,967.73 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,997.11 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $628.73. The transfer capital threshold is the transfer adjustment factor * $628.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,10541.41,30414.32,All Other Inpatient
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],39153.65,,"Fee schedule rate ($39,153.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,7605.00,39153.65,There are no additional notes associated with this service or procedure.
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],16138.02,,"Case rate ($15,821.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,854.10, add-ons for qualifying new technology services are included. If operating cost exceeds $49,725.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,774.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $12,861.73 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,909.15 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,014.92. The transfer capital threshold is the transfer adjustment factor * $1,014.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,15821.59,40320.14,Inpatient DRG
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,098,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],38799.38,,"Fee schedule rate ($38,799.38). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,6965.00,45156.75,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],25026.36,,"Fee schedule rate ($25,026.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9356.31,25026.36,There are no additional notes associated with this service or procedure.
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],10311.17,,"Case rate ($10,311.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,727.87, add-ons for qualifying new technology services are included. If operating cost exceeds $44,598.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,371.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $7,754.32 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,782.91 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $611.89. The transfer capital threshold is the transfer adjustment factor * $611.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10311.17,24308.97,Inpatient DRG
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,167,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],33891.30,,"Fee schedule rate ($33,891.30). Adds an outlier to normal pricing equal to the per diem rate ($66,990.29) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.6), with a minimum of zero.",,,,0,other,14157.71,43522.37,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],62084.69,,"Fee schedule rate ($62,084.69). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (35), with a minimum of zero.",,,,0,other,30398.48,82674.88,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],19881.64,,,,,,0,other,6965.00,32293.66,There are no additional notes associated with this service or procedure.
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],16400.70,,"Fee schedule rate ($16,400.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,16400.70,There are no additional notes associated with this service or procedure.
SINGLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL,402,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],30630.65,,"Case rate ($29,172.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $27,273.75, add-ons for qualifying new technology services are included. If operating cost exceeds $62,144.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,751.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $25,235.76 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $25,328.80 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,991.35. The transfer capital threshold is the transfer adjustment factor * $1,991.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,29172.05,124455.45,Inpatient DRG
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,064,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],41838.16,,"Fee schedule rate ($41,838.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,15563.58,41838.16,There are no additional notes associated with this service or procedure.
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,095,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],26922.00,,"Fee schedule rate ($26,922). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,19411.47,50750.92,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],28821.04,,"Fee schedule rate ($28,821.04). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,10347.06,28821.04,There are no additional notes associated with this service or procedure.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],14185.96,,"Case rate ($13,907.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,073.74, add-ons for qualifying new technology services are included. If operating cost exceeds $47,944.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,634.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $11,087.92 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,128.80 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $874.95. The transfer capital threshold is the transfer adjustment factor * $874.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,13907.80,52794.06,Inpatient DRG
HC Inj Trigger Pt 1-2 Musc Grps,CASE-20552,APC,20552,CPT,0510,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
Colsc Flexible W/Control Bleeding Any Method|UNUSUAL NON-OVERLAPPING SERVICE,CASE-45382,APC,45382,CPT,0360,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1120.09,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1120.09,1176.09,OPPS APC
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],18933.95,,"Fee schedule rate ($18,933.95). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.8), with a minimum of zero.",,,,0,other,8767.81,19824.58,There are no additional notes associated with this service or procedure.
Dilation & Curettage Dx&/Ther Nonobstetric,CASE-58120,APC,58120,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3030.03,,"APC Price ($3,030.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3030.03,3181.53,OPPS APC
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],49997.29,,,,,,0,other,19152.11,53152.12,There are no additional notes associated with this service or procedure.
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],48832.41,,,,,,0,other,8480.00,59081.91,There are no additional notes associated with this service or procedure.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],22451.27,,"Case rate ($21,382.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,026.97, add-ons for qualifying new technology services are included. If operating cost exceeds $54,897.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,181.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6)) / 2. The base transfer operating payment is the transfer adjustment factor * $18,015.59 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,082.01 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,421.61. The transfer capital threshold is the transfer adjustment factor * $1,421.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,21382.16,85466.62,Inpatient DRG
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],19763.43,,"Fee schedule rate ($19,763.43). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,8318.14,19763.43,There are no additional notes associated with this service or procedure.
MAJOR THUMB OR JOINT PROCEDURES,506,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],11081.83,,"Case rate ($11,081.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,444.79, add-ons for qualifying new technology services are included. If operating cost exceeds $45,315.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,428.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $8,468.62 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,499.84 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $668.26. The transfer capital threshold is the transfer adjustment factor * $668.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,11081.83,26548.21,Inpatient DRG
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral Ea Addl,CASE-64484,APC,64484,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],827.89,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,827.89,869.28,OPPS APC
Cysto W/Rescj/Fulg Orthopic Ureterocele Uni/Bi,CASE-52300,APC,52300,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3464.44,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3299.47,3464.44,OPPS APC
SPINAL PROCEDURES WITH MCC,028,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],118225.32,,,,,,0,other,42633.57,120982.83,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,082,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],56223.11,,"Fee schedule rate ($56,223.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,17423.21,56223.11,There are no additional notes associated with this service or procedure.
OSTEOMYELITIS WITH CC,540,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],18450.55,,"Fee schedule rate ($18,450.55). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,9809.07,25507.30,There are no additional notes associated with this service or procedure.
Hallux Rigidus W/Cheilectomy 1st Mp Jt W/O Implt|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-28289,APC,28289,CPT,0360,RC,,,LT|XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6791.99,7131.59,OPPS APC
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],31533.97,,"Fee schedule rate ($31,533.97). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8563.30,31533.97,There are no additional notes associated with this service or procedure.
Low cost skin substitute app,CASE-C5276,APC,C5276,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],660.72,,"APC Price ($660.72). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,660.72,660.72,OPPS APC
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],14112.34,,,,,,0,other,6801.88,22557.82,There are no additional notes associated with this service or procedure.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],28434.57,,"Fee schedule rate ($28,434.57). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,8906.63,28434.57,There are no additional notes associated with this service or procedure.
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC",629,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],40946.19,,"Fee schedule rate ($40,946.19). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,16699.94,44657.18,There are no additional notes associated with this service or procedure.
O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC,621,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],19495.27,,"Fee schedule rate ($19,495.27). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,12159.94,36669.96,There are no additional notes associated with this service or procedure.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC,027,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],56363.30,,"Fee schedule rate ($56,363.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,19030.20,56363.30,There are no additional notes associated with this service or procedure.
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6503.90,,"Case rate ($6,503.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,186.05, add-ons for qualifying new technology services are included. If operating cost exceeds $41,057.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,093.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $4,225.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,241.10 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $333.44. The transfer capital threshold is the transfer adjustment factor * $333.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6503.90,14492.93,Inpatient DRG
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC",458,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],132827.25,,"Fee schedule rate ($132,827.25). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,30202.09,132827.25,There are no additional notes associated with this service or procedure.
COMPLICATIONS OF TREATMENT WITH CC,920,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],20731.52,,"Fee schedule rate ($20,731.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8732.59,20731.52,There are no additional notes associated with this service or procedure.
O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC,621,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],12159.94,,"Case rate ($12,159.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,447.74, add-ons for qualifying new technology services are included. If operating cost exceeds $46,318.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,507.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $9,467.88 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,502.79 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $747.11. The transfer capital threshold is the transfer adjustment factor * $747.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12159.94,36669.96,Inpatient DRG
ENDOCRINE DISORDERS WITH CC,644,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],19420.69,,"Fee schedule rate ($19,420.69). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7066.99,20334.21,There are no additional notes associated with this service or procedure.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],22029.45,,"Case rate ($21,597.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,227.30, add-ons for qualifying new technology services are included. If operating cost exceeds $55,098.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,197.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $18,215.19 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,282.35 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,437.36. The transfer capital threshold is the transfer adjustment factor * $1,437.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,21597.50,67790.93,Inpatient DRG
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],52909.62,,"Fee schedule rate ($52,909.62). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,23344.70,62179.32,There are no additional notes associated with this service or procedure.
Open Tx Clavicular Fracture Internal Fixation,CASE-23515,APC,23515,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],23072.82,,"Fee schedule rate ($23,072.82). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9888.00,43399.23,There are no additional notes associated with this service or procedure.
Tr/Trnspl Tdn Carp/Mtcrpl Hand W/O Fr Grf Ea Tdn,CASE-26480,APC,26480,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],61234.06,,"Fee schedule rate ($61,234.06). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11165.00,61234.06,There are no additional notes associated with this service or procedure.
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],8616.44,,"Case rate ($8,447.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,994.13, add-ons for qualifying new technology services are included. If operating cost exceeds $42,865.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,235.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,026.96 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,049.18 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $475.59. The transfer capital threshold is the transfer adjustment factor * $475.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,1188.00,18893.86,Inpatient DRG
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],33835.79,,"Fee schedule rate ($33,835.79). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,7000.00,33835.79,There are no additional notes associated with this service or procedure.
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],7749.28,,"Case rate ($7,749.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,344.60, add-ons for qualifying new technology services are included. If operating cost exceeds $42,215.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,184.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,379.82 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,399.66 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $424.52. The transfer capital threshold is the transfer adjustment factor * $424.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6711.00,16865.16,Inpatient DRG
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],10049.53,,"Case rate ($9,570.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,039.28, add-ons for qualifying new technology services are included. If operating cost exceeds $43,910.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,317.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $7,068.27 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,094.33 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $557.76. The transfer capital threshold is the transfer adjustment factor * $557.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5569.00,40108.48,Inpatient DRG
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,167,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],43522.37,,"Fee schedule rate ($43,522.37). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,14157.71,43522.37,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],13639.70,,"Case rate ($12,990.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,220.11, add-ons for qualifying new technology services are included. If operating cost exceeds $47,091.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,567.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $10,237.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,275.16 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $807.83. The transfer capital threshold is the transfer adjustment factor * $807.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9888.00,43399.23,Inpatient DRG
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],38378.80,,"Fee schedule rate ($38,378.80). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,14370.36,38378.80,There are no additional notes associated with this service or procedure.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,025,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],91631.33,,"Fee schedule rate ($91,631.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,13351.00,91631.33,There are no additional notes associated with this service or procedure.
HC Perq Vert Agmntj Cavity Crtj Uni/Bi Cannulation,CASE-22513,APC,22513,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6791.99,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],36855.62,,"Fee schedule rate ($36,855.62). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,15821.59,40320.14,There are no additional notes associated with this service or procedure.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],9141.30,,"Fee schedule rate ($9,141.30). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8554.50,19204.75,There are no additional notes associated with this service or procedure.
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],18640.16,,"Fee schedule rate ($18,640.16). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,9696.93,35061.53,There are no additional notes associated with this service or procedure.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],43888.01,,"Fee schedule rate ($43,888.01). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11717.72,43888.01,There are no additional notes associated with this service or procedure.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],62454.12,,"Fee schedule rate ($62,454.12). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11348.00,62454.12,There are no additional notes associated with this service or procedure.
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],14599.65,,"Case rate ($13,904.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,070.60, add-ons for qualifying new technology services are included. If operating cost exceeds $47,941.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,634.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,084.78 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,125.65 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $874.70. The transfer capital threshold is the transfer adjustment factor * $874.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13904.43,34749.58,Inpatient DRG
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],11348.00,,"Per diem ($11,348). If length of stay < 4.2, first 1 days paid at a per diem of $22,696 instead. Capped at $47,660.93.",,,,0,other,11348.00,62454.12,Estimated amount calculated based on 5 day length of stay.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],31007.30,,"Fee schedule rate ($31,007.30). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,16120.25,41187.90,There are no additional notes associated with this service or procedure.
HC Inj Anesth Celiac Plexus,CASE-64530,APC,64530,CPT,0361,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],869.28,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,827.89,869.28,OPPS APC
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC,807,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],10071.17,,"Fee schedule rate ($10,071.17). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5354.25,13266.23,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],12992.90,,"Case rate ($12,992.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,222.63, add-ons for qualifying new technology services are included. If operating cost exceeds $47,093.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,568.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $10,239.92 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,277.68 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $808.03. The transfer capital threshold is the transfer adjustment factor * $808.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7665.00,40737.46,Inpatient DRG
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],40714.72,,"Fee schedule rate ($40,714.72). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,17356.15,44778.95,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],15808.67,,"Fee schedule rate ($15,808.67). Adds an outlier to normal pricing equal to the per diem rate ($67,650.85) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,7641.61,19371.27,There are no additional notes associated with this service or procedure.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,097,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],27724.54,,"Case rate ($26,404.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $24,698.97, add-ons for qualifying new technology services are included. If operating cost exceeds $59,569.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,548.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.7. The base transfer operating payment is the transfer adjustment factor * $22,670.44 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $22,754.03 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,788.92. The transfer capital threshold is the transfer adjustment factor * $1,788.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,26404.32,79915.74,Inpatient DRG
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],12246.05,,"Fee schedule rate ($12,246.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6010.23,12246.05,There are no additional notes associated with this service or procedure.
HC Inj Tendon Sheath/Ligament|PBB CHARGE,CASE-20550,APC,20550,CPT,0510,RC,,,PBB,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],287.31,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,098,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],38799.38,,"Fee schedule rate ($38,799.38). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,6965.00,45156.75,There are no additional notes associated with this service or procedure.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH CC,026,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],35029.05,,"Fee schedule rate ($35,029.05). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,23000.66,63202.45,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],19126.88,,"Fee schedule rate ($19,126.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,19126.88,There are no additional notes associated with this service or procedure.
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],42767.23,,"Fee schedule rate ($42,767.23). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,17356.15,44778.95,There are no additional notes associated with this service or procedure.
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC,939,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],26517.40,,"Case rate ($26,517.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $24,804.19, add-ons for qualifying new technology services are included. If operating cost exceeds $59,675.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,557.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $22,775.26 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $22,859.24 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,797.19. The transfer capital threshold is the transfer adjustment factor * $1,797.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,26517.40,97674.79,Inpatient DRG
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],12272.58,,"Fee schedule rate ($12,272.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5628.97,12272.58,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,083,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],28680.85,,"Fee schedule rate ($28,680.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,28680.85,There are no additional notes associated with this service or procedure.
Breast Reduction|BILATERAL PROCEDURE,CASE-19318,APC,19318,CPT,0360,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6526.12,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6215.36,6526.12,OPPS APC
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],20297.68,,"Fee schedule rate ($20,297.68). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6965.00,21404.64,There are no additional notes associated with this service or procedure.
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],40666.46,,,,,,0,other,15940.79,53275.26,There are no additional notes associated with this service or procedure.
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],15244.88,,"Fee schedule rate ($15,244.88). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,7438.45,15961.98,There are no additional notes associated with this service or procedure.
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITH MCC,429,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],177294.98,,"Fee schedule rate ($177,294.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,62958.58,177294.98,There are no additional notes associated with this service or procedure.
Cystourethroscopy W/Dest &/Rmvl Tumor Large,CASE-52240,APC,52240,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5269.71,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5018.77,5269.71,OPPS APC
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],61234.06,,"Fee schedule rate ($61,234.06). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11165.00,61234.06,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],81353.66,,"Fee schedule rate ($81,353.66). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,27256.92,81353.66,There are no additional notes associated with this service or procedure.
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],5358.15,,"Fee schedule rate ($5,358.15). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,5139.72,13110.79,There are no additional notes associated with this service or procedure.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],29367.82,,"Fee schedule rate ($29,367.82). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.7), with a minimum of zero.",,,,0,other,12527.66,29917.96,There are no additional notes associated with this service or procedure.
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 1 Level|LEFT SIDE,CASE-64493,APC,64493,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],827.89,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,827.89,869.28,OPPS APC
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],42787.31,,"Fee schedule rate ($42,787.31). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,15476.23,42787.31,There are no additional notes associated with this service or procedure.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],38728.27,,,,,,0,other,15273.74,39820.52,There are no additional notes associated with this service or procedure.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH CC,026,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],24150.69,,"Case rate ($23,000.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $21,532.64, add-ons for qualifying new technology services are included. If operating cost exceeds $56,403.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,299.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $19,515.74 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $19,587.69 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,539.98. The transfer capital threshold is the transfer adjustment factor * $1,539.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,23000.66,63202.45,Inpatient DRG
PERIPHERAL VASCULAR DISORDERS WITH CC,300,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],20061.53,,"Fee schedule rate ($20,061.53). Adds an outlier to normal pricing equal to the per diem rate ($49,296.97) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.9), with a minimum of zero.",,,,0,other,9174.14,21005.20,There are no additional notes associated with this service or procedure.
Neuroplasty &/Transposition Ulnar Nerve Elbow|LEFT SIDE,CASE-64718,APC,64718,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1827.80,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1827.80,1919.19,OPPS APC
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],2070.00,,,,,,0,other,1188.00,12138.74,Estimated amount calculated based on 1 day length of stay.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],27256.92,,"Case rate ($27,256.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $25,492.14, add-ons for qualifying new technology services are included. If operating cost exceeds $60,363.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,611.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. The base transfer operating payment is the transfer adjustment factor * $23,460.69 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $23,547.19 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,851.28. The transfer capital threshold is the transfer adjustment factor * $1,851.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,27256.92,81353.66,Inpatient DRG
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,167,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],35485.50,,,,,,0,other,14157.71,43522.37,There are no additional notes associated with this service or procedure.
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],37591.64,,"Fee schedule rate ($37,591.64). Adds an outlier to normal pricing equal to the per diem rate ($51,531) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.1), with a minimum of zero.",,,,0,other,15491.11,54180.83,There are no additional notes associated with this service or procedure.
"NEONATE BIRTH WEIGHT > 2499 GRAMS NORMAL NEWBORN OR NEONATE WITH OTHER PROBLEM,MODERATE",640,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],1551.39,,"Case rate ($1,551.39). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,1551.39,1628.96,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],13947.32,,"Fee schedule rate ($13,947.32). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6153.12,13947.32,There are no additional notes associated with this service or procedure.
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC",641,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],14928.67,,"Fee schedule rate ($14,928.67). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7214.98,15312.64,There are no additional notes associated with this service or procedure.
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],7566.45,,"Case rate ($7,566.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,174.51, add-ons for qualifying new technology services are included. If operating cost exceeds $42,045.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,171.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,210.35 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,229.56 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $411.15. The transfer capital threshold is the transfer adjustment factor * $411.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7566.45,16333.88,Inpatient DRG
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],14650.15,,"Case rate ($13,952.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,115.33, add-ons for qualifying new technology services are included. If operating cost exceeds $47,986.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,638.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $11,129.34 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,170.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $878.22. The transfer capital threshold is the transfer adjustment factor * $878.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13917.42,34889.29,Inpatient DRG
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],13610.32,,"Case rate ($12,962.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,214.63, add-ons for qualifying new technology services are included. If operating cost exceeds $47,085.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,546.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $10,230.89 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,269.68 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $786.37. The transfer capital threshold is the transfer adjustment factor * $786.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7000.00,33835.79,Inpatient DRG
Posterior Non-Segmental Instrumentation,CASE-22840,APC,22840,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],26287.03,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,25398.09,26287.03,OPPS APC
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],37158.98,,"Case rate ($35,389.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $33,057.71, add-ons for qualifying new technology services are included. If operating cost exceeds $67,928.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,206.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.3. The base transfer operating payment is the transfer adjustment factor * $30,998.46 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $31,112.76 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,446.08. The transfer capital threshold is the transfer adjustment factor * $2,446.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,35389.50,101083.00,Inpatient DRG
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],19371.27,,"Fee schedule rate ($19,371.27). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8643.20,19462.52,There are no additional notes associated with this service or procedure.
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,094,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],25778.58,,"Case rate ($25,778.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $24,116.87, add-ons for qualifying new technology services are included. If operating cost exceeds $58,987.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,503.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.9. The base transfer operating payment is the transfer adjustment factor * $22,090.47 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $22,171.92 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,743.16. The transfer capital threshold is the transfer adjustment factor * $1,743.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,25778.58,67889.44,Inpatient DRG
Laparoscopy W/Rmvl Adnexal Structures,CASE-58661,APC,58661,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5856.81,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5658.76,5941.70,OPPS APC
Neuroplasty &/Transposition Ulnar Nerve Elbow|RIGHT SIDE,CASE-64718,APC,64718,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1919.19,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1827.80,1919.19,OPPS APC
PREMATURITY WITHOUT MAJOR PROBLEMS,792,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],11512.88,,"Fee schedule rate ($11,512.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,1956.00,19457.66,There are no additional notes associated with this service or procedure.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC",494,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],39945.55,,"Fee schedule rate ($39,945.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,15533.10,39945.55,There are no additional notes associated with this service or procedure.
OTHER CEREBROVASCULAR DISORDERS WITH CC,071,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],9070.96,,"Case rate ($8,893.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,408.66, add-ons for qualifying new technology services are included. If operating cost exceeds $43,279.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,268.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,439.97 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,463.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $508.18. The transfer capital threshold is the transfer adjustment factor * $508.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,5843.00,29215.10,Inpatient DRG
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC,520,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],39786.42,,"Fee schedule rate ($39,786.42). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12061.74,39786.42,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,447,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],125567.31,,"Fee schedule rate ($125,567.31). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15.7), with a minimum of zero.",,,,0,other,47193.21,156646.82,There are no additional notes associated with this service or procedure.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],18598.83,,"Case rate ($18,598.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,437.70, add-ons for qualifying new technology services are included. If operating cost exceeds $52,308.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,978.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 5.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $15,435.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,492.75 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,218.04. The transfer capital threshold is the transfer adjustment factor * $1,218.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,18598.83,48389.68,Inpatient DRG
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],28423.20,,"Fee schedule rate ($28,423.20). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11059.47,28423.20,There are no additional notes associated with this service or procedure.
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5980.17,,"Case rate ($5,777.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,510.70, add-ons for qualifying new technology services are included. If operating cost exceeds $40,381.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,040.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $3,552.65 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,565.75 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $280.34. The transfer capital threshold is the transfer adjustment factor * $280.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,5065.00,12558.65,Inpatient DRG
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],13448.43,,"Case rate ($12,808.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,050.64, add-ons for qualifying new technology services are included. If operating cost exceeds $46,921.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,554.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $10,068.57 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,105.69 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $794.51. The transfer capital threshold is the transfer adjustment factor * $794.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7353.00,33398.16,Inpatient DRG
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,450,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],38037.38,,"Case rate ($38,037.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $35,520.98, add-ons for qualifying new technology services are included. If operating cost exceeds $70,391.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,399.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $33,452.68 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $33,576.02 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,639.75. The transfer capital threshold is the transfer adjustment factor * $2,639.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,38037.38,146009.19,Inpatient DRG
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],46523.26,,"Fee schedule rate ($46,523.26). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,17782.11,46523.26,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],15076.44,,"Fee schedule rate ($15,076.44). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6340.03,15076.44,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],17693.40,,"Case rate ($17,693.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,595.40, add-ons for qualifying new technology services are included. If operating cost exceeds $51,466.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,911.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $14,596.63 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,650.45 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,151.82. The transfer capital threshold is the transfer adjustment factor * $1,151.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,17693.40,52449.26,Inpatient DRG
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC,497,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],37761.19,,"Fee schedule rate ($37,761.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10127.65,37761.19,There are no additional notes associated with this service or procedure.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,418,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],39884.93,,"Fee schedule rate ($39,884.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,13400.58,39884.93,There are no additional notes associated with this service or procedure.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],26874.85,,,,,,0,other,11194.25,36094.03,There are no additional notes associated with this service or procedure.
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],11539.21,,"Case rate ($10,989.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,359.11, add-ons for qualifying new technology services are included. If operating cost exceeds $45,230.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,421.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $8,383.26 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,414.17 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $661.52. The transfer capital threshold is the transfer adjustment factor * $661.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10989.72,26280.60,Inpatient DRG
Anterior Colporraphy Rpr Cystocele W/Cysto,CASE-57240,APC,57240,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5269.71,,"APC Price ($5,018.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5018.77,5269.71,OPPS APC
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],32553.63,,,,,,0,other,13148.66,32553.63,There are no additional notes associated with this service or procedure.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],23790.06,,"Fee schedule rate ($23,790.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10517.71,24909.11,There are no additional notes associated with this service or procedure.
"Hallux Rigidus W/Cheilectomy 1st Mp Jt W/O Implt|RIGHT FOOT, GREAT TOE",CASE-28289,APC,28289,CPT,0360,RC,,,T5,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3215.80,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],10339.17,,"Case rate ($10,136.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,565.33, add-ons for qualifying new technology services are included. If operating cost exceeds $44,436.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,359.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $7,592.38 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,620.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $599.11. The transfer capital threshold is the transfer adjustment factor * $599.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,10136.44,24444.75,Inpatient DRG
Ercp W/Sphincterotomy/Papillotomy,CASE-43262,APC,43262,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3735.12,,"APC Price ($3,608.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3608.81,3789.26,OPPS APC
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",759,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],12471.03,,"Fee schedule rate ($12,471.03). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.9), with a minimum of zero.",,,,0,other,6190.22,13057.66,There are no additional notes associated with this service or procedure.
HC Drain/Inj Joint/Bursa W/US Large|BILATERAL PROCEDURE,CASE-20611,APC,20611,CPT,0510,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],297.37,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,287.31,301.68,OPPS APC
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,690,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],14625.55,,"Fee schedule rate ($14,625.55). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7426.94,15928.53,There are no additional notes associated with this service or procedure.
Cysto Bladder W/Ureteral Catheterization|UNUSUAL NON-OVERLAPPING SERVICE,CASE-52005,APC,52005,CPT,0360,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3299.47,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3299.47,3464.44,OPPS APC
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC,833,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],5486.07,,"Case rate ($5,486.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,239.18, add-ons for qualifying new technology services are included. If operating cost exceeds $40,110.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,018.96, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $3,282.12 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,294.23 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $258.99. The transfer capital threshold is the transfer adjustment factor * $258.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,3041.73,10289.10,Inpatient DRG
VENTRICULAR SHUNT PROCEDURES WITH MCC,031,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],33901.56,,"Case rate ($32,287.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $30,171.71, add-ons for qualifying new technology services are included. If operating cost exceeds $65,042.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,979.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7. The base transfer operating payment is the transfer adjustment factor * $28,123.07 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $28,226.76 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,219.19. The transfer capital threshold is the transfer adjustment factor * $2,219.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,32287.20,88162.80,Inpatient DRG
Revision of Spinal Shunt,CASE-63744,APC,63744,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3197.60,,"APC Price ($3,197.60). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3197.60,3357.48,OPPS APC
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],142438.06,,"Fee schedule rate ($142,438.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (40), with a minimum of zero.",,,,0,other,45521.20,142438.06,There are no additional notes associated with this service or procedure.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],9252.42,,"Case rate ($8,811.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,333.06, add-ons for qualifying new technology services are included. If operating cost exceeds $43,204.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,262.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,364.65 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,388.11 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $502.23. The transfer capital threshold is the transfer adjustment factor * $502.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,20401.88,Inpatient DRG
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,091,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],33004.27,,"Fee schedule rate ($33,004.27). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13838.06,40030.81,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],18047.27,,"Case rate ($17,693.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,595.40, add-ons for qualifying new technology services are included. If operating cost exceeds $51,466.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,911.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $14,596.63 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,650.45 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,151.82. The transfer capital threshold is the transfer adjustment factor * $1,151.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,17693.40,52449.26,Inpatient DRG
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],12817.61,,"Case rate ($12,566.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,825.74, add-ons for qualifying new technology services are included. If operating cost exceeds $46,696.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,536.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $9,844.49 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,880.79 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $776.83. The transfer capital threshold is the transfer adjustment factor * $776.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,12566.28,30861.41,Inpatient DRG
Arthrd Ant Interbody Decompress Cervical Belw C2,CASE-22551,APC,22551,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],12437.92,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,12017.31,12618.18,OPPS APC
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH MCC",722,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],56869.13,,"Fee schedule rate ($56,869.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,14200.37,56869.13,There are no additional notes associated with this service or procedure.
Colonoscopy Flx Dx W/Collj Spec When Pfrmd|COLORECTAL CANCER SCREEN,CASE-45378,APC,45378,CPT,0360,RC,,,PT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],913.99,,"APC Price ($870.46). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,870.46,913.99,OPPS APC
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],53275.26,,"Fee schedule rate ($53,275.26). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,15940.79,53275.26,There are no additional notes associated with this service or procedure.
HC Inj Trigger Pt 1-2 Musc Grps|PBB CHARGE,CASE-20552,APC,20552,CPT,0510,RC,,,PBB,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],301.68,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,287.31,301.68,OPPS APC
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],1188.00,,,,,,0,other,1188.00,18893.86,Estimated amount calculated based on 3 day length of stay.
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC,939,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],27445.51,,"Case rate ($26,517.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $24,804.19, add-ons for qualifying new technology services are included. If operating cost exceeds $59,675.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,557.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $22,775.26 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $22,859.24 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,797.19. The transfer capital threshold is the transfer adjustment factor * $1,797.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,26517.40,97674.79,Inpatient DRG
INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,352,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],9853.37,,"Case rate ($9,853.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,301.99, add-ons for qualifying new technology services are included. If operating cost exceeds $44,173.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,338.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $7,330.01 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,357.04 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $578.41. The transfer capital threshold is the transfer adjustment factor * $578.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9853.37,26528.70,Inpatient DRG
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,394,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],20909.61,,"Fee schedule rate ($20,909.61). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8281.56,20909.61,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,426,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],177294.98,,"Fee schedule rate ($177,294.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,76581.29,216864.15,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],54875.56,,"Fee schedule rate ($54,875.56). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,21719.40,85305.59,There are no additional notes associated with this service or procedure.
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],11165.00,,"Per diem ($11,165). If length of stay < 3.5, first 1 days paid at a per diem of $22,330 instead. Capped at $39,078.16.",,,,0,other,11165.00,61234.06,Estimated amount calculated based on 3 day length of stay.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],24838.71,,"Fee schedule rate ($24,838.71). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,10895.60,35192.25,There are no additional notes associated with this service or procedure.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],40108.48,,"Fee schedule rate ($40,108.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,5569.00,40108.48,There are no additional notes associated with this service or procedure.
"NEONATE BIRTH WEIGHT 2000-2499 GRAMS WITH OTHER SIGNIFICANT CONDITION,MAJOR",625,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],28370.08,,"Case rate ($28,370.08). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,28370.08,29788.58,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],8135.12,,"Case rate ($7,747.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,353.98, add-ons for qualifying new technology services are included. If operating cost exceeds $42,224.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,174.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $5,388.60 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,409.03 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $414.18. The transfer capital threshold is the transfer adjustment factor * $414.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,1188.00,17370.86,Inpatient DRG
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],14846.66,,"Case rate ($14,344.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,480.09, add-ons for qualifying new technology services are included. If operating cost exceeds $48,351.10 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,666.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $11,492.77 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,535.14 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $906.89. The transfer capital threshold is the transfer adjustment factor * $906.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,14344.60,36028.59,Inpatient DRG
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",004,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],10715.36,,,,,,0,other,10249.47,272554.00,Estimated amount calculated based on 6 day length of stay.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],40108.48,,"Fee schedule rate ($40,108.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,5569.00,40108.48,There are no additional notes associated with this service or procedure.
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],42083.20,,,,,,0,other,16428.39,42083.20,There are no additional notes associated with this service or procedure.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],75579.22,,"Fee schedule rate ($75,579.22). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,25162.32,75579.22,There are no additional notes associated with this service or procedure.
Exc Rct Tum Not Incl Muscularis Propria,CASE-45171,APC,45171,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],2598.08,,"APC Price ($2,598.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2598.08,2727.99,OPPS APC
"CARDIAC ARREST, UNEXPLAINED WITH MCC",296,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],36459.67,,"Fee schedule rate ($36,459.67). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12522.25,36459.67,There are no additional notes associated with this service or procedure.
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],26391.01,,"Fee schedule rate ($26,391.01). Adds an outlier to normal pricing equal to the per diem rate ($77,296.48) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,11454.97,28394.78,There are no additional notes associated with this service or procedure.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],31007.30,,"Fee schedule rate ($31,007.30). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,16120.25,41187.90,There are no additional notes associated with this service or procedure.
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5910.09,,"Case rate ($5,710.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,447.70, add-ons for qualifying new technology services are included. If operating cost exceeds $40,318.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,035.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $3,489.88 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,502.75 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $275.39. The transfer capital threshold is the transfer adjustment factor * $275.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,3079.00,10940.41,Inpatient DRG
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],41379.07,,"Case rate ($39,408.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $36,866.52, add-ons for qualifying new technology services are included. If operating cost exceeds $71,737.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,433.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.6. The base transfer operating payment is the transfer adjustment factor * $34,789.67 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $34,921.57 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,674.02. The transfer capital threshold is the transfer adjustment factor * $2,674.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,40542.37,128358.13,Inpatient DRG
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],18585.05,,"Fee schedule rate ($18,585.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8859.23,20090.22,There are no additional notes associated with this service or procedure.
"NEONATE BIRTH WEIGHT > 2499 GRAMS NORMAL NEWBORN OR NEONATE WITH OTHER PROBLEM,MAJOR",640,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],3043.78,,"Case rate ($2,898.84). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,2898.84,3043.78,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITH STERILIZATION WITH CC,784,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],9306.49,,"Case rate ($9,124.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,623.49, add-ons for qualifying new technology services are included. If operating cost exceeds $43,494.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,285.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,654.00 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,678.54 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $525.07. The transfer capital threshold is the transfer adjustment factor * $525.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,9124.01,23722.94,Inpatient DRG
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],18404.48,,"Case rate ($17,782.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,677.93, add-ons for qualifying new technology services are included. If operating cost exceeds $51,548.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,918.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $14,678.86 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,732.98 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,158.31. The transfer capital threshold is the transfer adjustment factor * $1,158.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,17782.11,46523.26,Inpatient DRG
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,069,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],10810.22,,"Fee schedule rate ($10,810.22). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,20333.68,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC,832,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7070.79,,"Case rate ($6,831.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,490.97, add-ons for qualifying new technology services are included. If operating cost exceeds $41,361.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,117.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $4,529.32 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,546.02 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $357.41. The transfer capital threshold is the transfer adjustment factor * $357.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,4803.31,14198.92,Inpatient DRG
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],35061.53,,"Fee schedule rate ($35,061.53). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,9696.93,35061.53,There are no additional notes associated with this service or procedure.
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC,805,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],20902.03,,"Fee schedule rate ($20,902.03). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9253.36,21235.42,There are no additional notes associated with this service or procedure.
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC,520,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],12483.90,,"Case rate ($12,061.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,356.39, add-ons for qualifying new technology services are included. If operating cost exceeds $46,227.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,499.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $9,376.87 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,411.44 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $739.93. The transfer capital threshold is the transfer adjustment factor * $739.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,12061.74,39786.42,Inpatient DRG
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],7332.00,,"Per diem ($7,332). If length of stay < 4.6, first 1 days paid at a per diem of $14,664 instead. Capped at $33,727.80.",,,,0,other,7332.00,35314.31,Estimated amount calculated based on 3 day length of stay.
CHOLECYSTECTOMY WITH C.D.E. WITH MCC,411,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],62078.92,,"Fee schedule rate ($62,078.92). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15), with a minimum of zero.",,,,0,other,24315.13,88615.28,There are no additional notes associated with this service or procedure.
"POISONING OF MEDICINAL AGENTS,MAJOR",812,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],9754.16,,"Case rate ($9,289.68). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9289.68,9754.16,There are no additional notes associated with this service or procedure.
Cysto Bladder W/Ureteral Catheterization|BILATERAL PROCEDURE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-52005,APC,52005,CPT,0360,RC,,,50|XU,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3299.47,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3299.47,3464.44,OPPS APC
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH CC,427,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],53371.31,,"Case rate ($50,829.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $47,421.51, add-ons for qualifying new technology services are included. If operating cost exceeds $82,292.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $5,335.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $45,309.50 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $45,476.56 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,575.37. The transfer capital threshold is the transfer adjustment factor * $3,575.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,50829.82,142040.39,Inpatient DRG
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],61290.90,,"Fee schedule rate ($61,290.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,23799.09,63499.65,There are no additional notes associated with this service or procedure.
Laps W/Vag Hysterect 250 Gm/&Rmvl Tube&/Ovaries,CASE-58552,APC,58552,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],9949.78,,"APC Price ($9,949.78). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,9949.78,10298.02,OPPS APC
CHOLECYSTECTOMY WITH C.D.E. WITH MCC,411,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],64999.03,,,,,,0,other,24315.13,88615.28,There are no additional notes associated with this service or procedure.
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],35127.88,,"Fee schedule rate ($35,127.88). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.5), with a minimum of zero.",,,,0,other,14603.31,45017.13,There are no additional notes associated with this service or procedure.
Musc Myocutaneous/Fasciocutaneous Flap Trunk,CASE-15734,APC,15734,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5941.70,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5658.76,5941.70,OPPS APC
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,690,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],7426.94,,"Case rate ($7,426.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,044.73, add-ons for qualifying new technology services are included. If operating cost exceeds $41,915.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,160.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,081.05 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,099.78 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $400.94. The transfer capital threshold is the transfer adjustment factor * $400.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7426.94,15928.53,Inpatient DRG
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],37574.25,,"Fee schedule rate ($37,574.25). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,10862.00,86437.13,There are no additional notes associated with this service or procedure.
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],16804.22,,"Fee schedule rate ($16,804.22). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7238.69,16804.22,There are no additional notes associated with this service or procedure.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],17194.49,,"Fee schedule rate ($17,194.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8554.50,19204.75,There are no additional notes associated with this service or procedure.
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],35474.53,,"Fee schedule rate ($35,474.53). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,16428.39,42083.20,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC,084,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],8417.70,,"Case rate ($8,417.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,966.41, add-ons for qualifying new technology services are included. If operating cost exceeds $42,837.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,233.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $5,999.34 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,021.46 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $473.41. The transfer capital threshold is the transfer adjustment factor * $473.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,19445.16,Inpatient DRG
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC",494,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],39945.55,,"Fee schedule rate ($39,945.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,15533.10,39945.55,There are no additional notes associated with this service or procedure.
"NEONATE BIRTH WEIGHT 1500-1999 GRAMS WITH OR WITHOUT OTHER SIGNIFICANT CONDITION,MODERATE",614,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],10963.86,,"Case rate ($10,963.86). Base payment rate plus any adjustments related to outliers.",,,,0,other,10963.86,11512.05,There are no additional notes associated with this service or procedure.
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],13478.34,,"Fee schedule rate ($13,478.34). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,6801.88,22557.82,There are no additional notes associated with this service or procedure.
Laps Tx Ectopic Preg W/Salping&/Oophorectomy,CASE-59151,APC,59151,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5856.81,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5658.76,5941.70,OPPS APC
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],6965.00,,,,,,0,other,6965.00,17467.27,There are no additional notes associated with this service or procedure.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],11053.39,,"Case rate ($11,053.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,418.34, add-ons for qualifying new technology services are included. If operating cost exceeds $45,289.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,426.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $8,442.26 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,473.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $666.18. The transfer capital threshold is the transfer adjustment factor * $666.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,11053.39,36776.05,Inpatient DRG
Surg Tx Anal Fistula Intersphincteric,CASE-46275,APC,46275,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],2598.08,,"APC Price ($2,598.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2598.08,2727.99,OPPS APC
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC",923,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],20068.57,,,,,,0,other,6965.00,20068.57,There are no additional notes associated with this service or procedure.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],11753.96,,"Case rate ($11,194.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,549.37, add-ons for qualifying new technology services are included. If operating cost exceeds $45,420.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,436.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $8,572.81 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,604.42 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $676.48. The transfer capital threshold is the transfer adjustment factor * $676.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,11194.25,36094.03,Inpatient DRG
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],23078.81,,"Fee schedule rate ($23,078.81). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10311.17,24308.97,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],13525.61,,"Case rate ($13,260.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,471.48, add-ons for qualifying new technology services are included. If operating cost exceeds $47,342.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,587.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $10,487.86 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,526.53 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $827.60. The transfer capital threshold is the transfer adjustment factor * $827.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,13260.40,32878.30,Inpatient DRG
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],34889.29,,,,,,0,other,13917.42,34889.29,There are no additional notes associated with this service or procedure.
"Correction Hammertoe|RIGHT FOOT, FIFTH DIGIT",CASE-28285,APC,28285,CPT,0360,RC,,,T9,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],14674.80,,"Fee schedule rate ($14,674.80). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6711.00,16865.16,There are no additional notes associated with this service or procedure.
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],28445.08,,"Fee schedule rate ($28,445.08). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.8), with a minimum of zero.",,,,0,other,12195.15,39424.57,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITHOUT STERILIZATION WITH CC,787,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],23722.94,,"Fee schedule rate ($23,722.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9508.01,23722.94,There are no additional notes associated with this service or procedure.
MINOR BLADDER PROCEDURES WITHOUT CC/MCC,664,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],31876.87,,"Fee schedule rate ($31,876.87). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9034.63,31876.87,There are no additional notes associated with this service or procedure.
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],6965.00,,,,,,0,other,4341.01,12882.53,There are no additional notes associated with this service or procedure.
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],8631.66,,"Fee schedule rate ($8,631.66). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6524.00,17760.46,There are no additional notes associated with this service or procedure.
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",004,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],95747.60,,"Case rate ($95,747.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $89,207.57, add-ons for qualifying new technology services are included. If operating cost exceeds $124,078.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $8,620.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 22.4. The base transfer operating payment is the transfer adjustment factor * $86,942.06 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $87,262.63 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $6,860.59. The transfer capital threshold is the transfer adjustment factor * $6,860.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10249.47,272554.00,Inpatient DRG
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],13031.04,,"Case rate ($12,775.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,020.41, add-ons for qualifying new technology services are included. If operating cost exceeds $46,891.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,552.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $10,038.44 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,075.45 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $792.13. The transfer capital threshold is the transfer adjustment factor * $792.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,12775.53,31469.43,Inpatient DRG
Excision Inferior Turbinate Partial/Complete|BILATERAL PROCEDURE,CASE-30130,APC,30130,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.35,,"APC Price ($3,103.35). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.35,3103.35,OPPS APC
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],17760.46,,,,,,0,other,6524.00,17760.46,There are no additional notes associated with this service or procedure.
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,068,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],8188.67,,"Case rate ($7,798.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,390.60, add-ons for qualifying new technology services are included. If operating cost exceeds $42,261.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,188.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $5,425.64 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,445.65 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $428.14. The transfer capital threshold is the transfer adjustment factor * $428.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,23184.90,Inpatient DRG
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],8750.86,,"Case rate ($8,454.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,001.06, add-ons for qualifying new technology services are included. If operating cost exceeds $42,872.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,236.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,033.86 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,056.11 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $476.13. The transfer capital threshold is the transfer adjustment factor * $476.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6230.00,22762.43,Inpatient DRG
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],41006.47,,"Fee schedule rate ($41,006.47). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12268.97,41006.47,There are no additional notes associated with this service or procedure.
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],40426.76,,"Fee schedule rate ($40,426.76). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,11914.12,40426.76,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],6965.00,,,,,,0,other,6965.00,21195.68,There are no additional notes associated with this service or procedure.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC",494,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],15843.76,,"Case rate ($15,533.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,585.72, add-ons for qualifying new technology services are included. If operating cost exceeds $49,456.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,753.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $12,594.34 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,640.78 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $993.82. The transfer capital threshold is the transfer adjustment factor * $993.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,15533.10,39945.55,Inpatient DRG
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],45017.13,,"Fee schedule rate ($45,017.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,14603.31,45017.13,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],26178.21,,"Fee schedule rate ($26,178.21). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,13917.42,34889.29,There are no additional notes associated with this service or procedure.
Septoplasty/Submucous Resecj W/WO Cartilage Grf,CASE-30520,APC,30520,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3258.52,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3103.35,3258.52,OPPS APC
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],5910.42,,"Case rate ($5,628.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,372.11, add-ons for qualifying new technology services are included. If operating cost exceeds $40,243.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,029.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,414.56 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,427.15 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $269.44. The transfer capital threshold is the transfer adjustment factor * $269.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5628.97,12272.58,Inpatient DRG
Tonsillectomy Primary/Secondary Age 12/>,CASE-42826,APC,42826,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3103.35,,"APC Price ($3,103.35). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3103.35,3258.52,OPPS APC
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,450,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],100159.17,,"Fee schedule rate ($100,159.17). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15), with a minimum of zero.",,,,0,other,38037.38,146009.19,There are no additional notes associated with this service or procedure.
CELLULITIS WITH MCC,602,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],28349.31,,"Fee schedule rate ($28,349.31). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11570.10,28349.31,There are no additional notes associated with this service or procedure.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],8906.63,,"Case rate ($8,906.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,421.26, add-ons for qualifying new technology services are included. If operating cost exceeds $43,292.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,269.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $6,452.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,476.31 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $509.17. The transfer capital threshold is the transfer adjustment factor * $509.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8906.63,28434.57,Inpatient DRG
Esophagogastroduodenoscopy Submucosal Injection|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-43236,APC,43236,CPT,0360,RC,,,74,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],848.96,,"APC Price ($848.96). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,848.96,891.41,OPPS APC
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],7034.85,,"Case rate ($7,034.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,679.97, add-ons for qualifying new technology services are included. If operating cost exceeds $41,550.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,132.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $4,717.62 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,735.02 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $372.27. The transfer capital threshold is the transfer adjustment factor * $372.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,21089.59,Inpatient DRG
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,450,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],146009.19,,"Fee schedule rate ($146,009.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,38037.38,146009.19,There are no additional notes associated with this service or procedure.
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],13001.72,,"Case rate ($13,001.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,230.82, add-ons for qualifying new technology services are included. If operating cost exceeds $47,101.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,568.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $10,248.08 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,285.87 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $808.68. The transfer capital threshold is the transfer adjustment factor * $808.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7868.00,32126.64,Inpatient DRG
VENTRICULAR SHUNT PROCEDURES WITH CC,032,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],46275.08,,"Fee schedule rate ($46,275.08). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,16376.22,46275.08,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],33152.73,,"Fee schedule rate ($33,152.73). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13891.57,34712.20,There are no additional notes associated with this service or procedure.
Intraop Sentinel Lymph Node ID W/Dye Injection|RIGHT SIDE,CASE-38900,APC,38900,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6215.36,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6215.36,6526.12,OPPS APC
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,095,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],48470.91,,"Fee schedule rate ($48,470.91). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.8), with a minimum of zero.",,,,0,other,19411.47,50750.92,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],12818.71,,"Fee schedule rate ($12,818.71). Adds an outlier to normal pricing equal to the per diem rate ($42,942.49) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,6564.18,17651.07,There are no additional notes associated with this service or procedure.
Lamnotmy Incl W/Dcmprsn Nrv Root 1 Intrspc Lumbr,CASE-63030,APC,63030,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7029.71,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6791.99,7131.59,OPPS APC
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,066,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],20083.61,,"Fee schedule rate ($20,083.61). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6579.76,20083.61,There are no additional notes associated with this service or procedure.
HC Inj Anesth Celiac Plexus|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64530,APC,64530,CPT,0361,RC,,,XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],869.28,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,827.89,869.28,OPPS APC
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,690,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7629.22,,"Case rate ($7,265.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,904.86, add-ons for qualifying new technology services are included. If operating cost exceeds $41,775.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,139.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $4,941.18 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,959.91 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $379.79. The transfer capital threshold is the transfer adjustment factor * $379.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7426.94,15928.53,Inpatient DRG
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],40737.46,,"Fee schedule rate ($40,737.46). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,7665.00,40737.46,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],16869.37,,"Case rate ($16,066.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,081.53, add-ons for qualifying new technology services are included. If operating cost exceeds $49,952.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,792.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $13,088.32 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,136.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,032.80. The transfer capital threshold is the transfer adjustment factor * $1,032.80. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,41030.48,Inpatient DRG
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],33969.60,,"Fee schedule rate ($33,969.60). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,23799.09,63499.65,There are no additional notes associated with this service or procedure.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,479,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],50518.76,,"Fee schedule rate ($50,518.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,10586.00,50518.76,There are no additional notes associated with this service or procedure.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,988,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],42425.46,,"Fee schedule rate ($42,425.46). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,13075.52,42425.46,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],21195.68,,"Fee schedule rate ($21,195.68). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,6965.00,21195.68,There are no additional notes associated with this service or procedure.
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level|LEFT SIDE,CASE-64483,APC,64483,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],827.89,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,827.89,869.28,OPPS APC
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,450,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],39368.69,,"Case rate ($38,037.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $35,520.98, add-ons for qualifying new technology services are included. If operating cost exceeds $70,391.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,399.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $33,452.68 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $33,576.02 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,639.75. The transfer capital threshold is the transfer adjustment factor * $2,639.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,38037.38,146009.19,Inpatient DRG
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],19877.10,,"Fee schedule rate ($19,877.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8009.34,19877.10,There are no additional notes associated with this service or procedure.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,025,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],13351.00,,"Per diem ($13,351). If length of stay < 6.4, first 1 days paid at a per diem of $26,702 instead. Capped at $85,446.13.",,,,0,other,13351.00,91631.33,Estimated amount calculated based on 4 day length of stay.
"NEONATE BIRTH WEIGHT 1500-1999 GRAMS WITH OR WITHOUT OTHER SIGNIFICANT CONDITION,MINOR",614,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],10963.86,,"Case rate ($10,963.86). Base payment rate plus any adjustments related to outliers.",,,,0,other,10963.86,11512.05,There are no additional notes associated with this service or procedure.
HC N Block Inj Suprascapular Nerv|RIGHT SIDE,CASE-64418,APC,64418,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],660.72,,"APC Price ($660.72). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,660.72,693.76,OPPS APC
Esophagogastroduodenoscopy Transoral Diagnostic,CASE-43235,APC,43235,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],848.96,,"APC Price ($848.96). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,848.96,891.41,OPPS APC
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],13448.43,,"Case rate ($12,808.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,050.64, add-ons for qualifying new technology services are included. If operating cost exceeds $46,921.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,554.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $10,068.57 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,105.69 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $794.51. The transfer capital threshold is the transfer adjustment factor * $794.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7353.00,33398.16,Inpatient DRG
HEART FAILURE AND SHOCK WITH CC,292,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],15550.06,,"Fee schedule rate ($15,550.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5502.00,16705.77,There are no additional notes associated with this service or procedure.
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],18588.16,,"Fee schedule rate ($18,588.16). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.8), with a minimum of zero.",,,,0,other,8643.20,19462.52,There are no additional notes associated with this service or procedure.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],16900.84,,"Fee schedule rate ($16,900.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8151.55,18033.97,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,091,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],40030.81,,"Fee schedule rate ($40,030.81). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,13838.06,40030.81,There are no additional notes associated with this service or procedure.
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,451,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],94077.13,,"Fee schedule rate ($94,077.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,23821.44,94077.13,There are no additional notes associated with this service or procedure.
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6801.88,,"Case rate ($6,801.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,463.25, add-ons for qualifying new technology services are included. If operating cost exceeds $41,334.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,115.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,501.70 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,518.30 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $355.23. The transfer capital threshold is the transfer adjustment factor * $355.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6801.88,22557.82,Inpatient DRG
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],18594.09,,"Case rate ($18,594.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,433.29, add-ons for qualifying new technology services are included. If operating cost exceeds $52,304.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,977.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $15,431.44 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,488.34 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,217.69. The transfer capital threshold is the transfer adjustment factor * $1,217.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,18594.09,59494.91,Inpatient DRG
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],11565.93,,"Fee schedule rate ($11,565.93). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6148.93,15887.21,There are no additional notes associated with this service or procedure.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITHOUT CC/MCC,816,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],6965.00,,,,,,0,other,6224.90,14733.53,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],23316.48,,"Fee schedule rate ($23,316.48). Adds an outlier to normal pricing equal to the per diem rate ($44,995.76) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7.7), with a minimum of zero.",,,,0,other,10347.06,28821.04,There are no additional notes associated with this service or procedure.
Excision Choledochal Cyst,CASE-47715,APC,47715,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],297.37,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,287.31,301.68,OPPS APC
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],8454.94,,"Case rate ($8,454.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,001.06, add-ons for qualifying new technology services are included. If operating cost exceeds $42,872.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,236.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,033.86 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,056.11 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $476.13. The transfer capital threshold is the transfer adjustment factor * $476.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6230.00,22762.43,Inpatient DRG
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",004,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],100534.98,,"Case rate ($95,747.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $89,207.57, add-ons for qualifying new technology services are included. If operating cost exceeds $124,078.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $8,620.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 22.4. The base transfer operating payment is the transfer adjustment factor * $86,942.06 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $87,262.63 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $6,860.59. The transfer capital threshold is the transfer adjustment factor * $6,860.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10249.47,272554.00,Inpatient DRG
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],25253.70,,"Fee schedule rate ($25,253.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11974.38,29141.64,There are no additional notes associated with this service or procedure.
SEIZURES WITH MCC,100,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],32323.98,,"Fee schedule rate ($32,323.98). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,15061.09,38110.41,There are no additional notes associated with this service or procedure.
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH MCC",510,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],89863.76,,"Fee schedule rate ($89,863.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10710.00,89863.76,There are no additional notes associated with this service or procedure.
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],26204.74,,"Fee schedule rate ($26,204.74). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10120.20,26204.74,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,167,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],43522.37,,"Fee schedule rate ($43,522.37). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,14157.71,43522.37,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],31378.15,,"Fee schedule rate ($31,378.15). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,23851.92,63653.13,There are no additional notes associated with this service or procedure.
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,451,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],60708.91,,"Fee schedule rate ($60,708.91). Adds an outlier to normal pricing equal to the per diem rate ($108,215.07) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,23821.44,94077.13,There are no additional notes associated with this service or procedure.
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],17755.26,,"Fee schedule rate ($17,755.26). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7847.50,17755.26,There are no additional notes associated with this service or procedure.
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC,964,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],30156.97,,,,,,0,other,12323.82,34154.06,There are no additional notes associated with this service or procedure.
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],25099.93,,"Fee schedule rate ($25,099.93). Adds an outlier to normal pricing equal to the per diem rate ($40,783.87) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10989.72,26280.60,There are no additional notes associated with this service or procedure.
Laps Fulg/Exc Ovary Viscera/Peritoneal Surface,CASE-58662,APC,58662,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5658.76,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5658.76,5941.70,OPPS APC
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,451,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],60708.91,,"Fee schedule rate ($60,708.91). Adds an outlier to normal pricing equal to the per diem rate ($108,215.07) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,23821.44,94077.13,There are no additional notes associated with this service or procedure.
HC Remove Lung Catheter,CASE-32552,APC,32552,CPT,0361,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],878.67,,"APC Price ($848.96). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,848.96,891.41,OPPS APC
Chromotubation Oviduct W/Materials|UNUSUAL NON-OVERLAPPING SERVICE,CASE-58350,APC,58350,CPT,0360,RC,,,XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5856.81,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5658.76,5941.70,OPPS APC
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],13642.55,,"Case rate ($12,992.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,222.63, add-ons for qualifying new technology services are included. If operating cost exceeds $47,093.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,568.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $10,239.92 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,277.68 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $808.03. The transfer capital threshold is the transfer adjustment factor * $808.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7665.00,40737.46,Inpatient DRG
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],58394.20,,"Fee schedule rate ($58,394.20). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,9370.00,65732.99,There are no additional notes associated with this service or procedure.
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC",011,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],102498.90,,"Fee schedule rate ($102,498.90). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,38880.49,150008.48,There are no additional notes associated with this service or procedure.
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],8624.04,,"Case rate ($8,454.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,001.06, add-ons for qualifying new technology services are included. If operating cost exceeds $42,872.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,236.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,033.86 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,056.11 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $476.13. The transfer capital threshold is the transfer adjustment factor * $476.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6230.00,22762.43,Inpatient DRG
INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC,198,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],23505.07,,"Fee schedule rate ($23,505.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6795.12,23505.07,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],128358.13,,"Fee schedule rate ($128,358.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,40542.37,128358.13,There are no additional notes associated with this service or procedure.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],11952.07,,"Case rate ($11,717.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,036.36, add-ons for qualifying new technology services are included. If operating cost exceeds $45,907.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,474.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $9,058.01 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,091.41 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $714.77. The transfer capital threshold is the transfer adjustment factor * $714.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,11717.72,43888.01,Inpatient DRG
Ercp Remove Foreign Body/Stent Biliary/Panc Duct,CASE-43275,APC,43275,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3608.81,,"APC Price ($3,608.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3608.81,3789.26,OPPS APC
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],30063.84,,"Fee schedule rate ($30,063.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13891.57,34712.20,There are no additional notes associated with this service or procedure.
"Inj Dx/Ther Agnt Paravert Facet Joint, Cerv/Thorac, 2nd Level|LEFT SIDE",CASE-64491,APC,64491,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],856.86,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,827.89,869.28,OPPS APC
CERVICAL SPINAL FUSION WITHOUT CC/MCC,473,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],48037.46,,,,,,0,other,18477.61,62077.11,There are no additional notes associated with this service or procedure.
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],42021.93,,"Fee schedule rate ($42,021.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,21248.73,56089.29,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],18954.85,,,,,,0,other,6963.00,18954.85,There are no additional notes associated with this service or procedure.
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],12558.65,,"Fee schedule rate ($12,558.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5065.00,12558.65,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],35192.25,,"Fee schedule rate ($35,192.25). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,10895.60,35192.25,There are no additional notes associated with this service or procedure.
"CARDIAC ARREST, UNEXPLAINED WITH MCC",296,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],29352.79,,"Fee schedule rate ($29,352.79). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.2), with a minimum of zero.",,,,0,other,12522.25,36459.67,There are no additional notes associated with this service or procedure.
Revision of Spinal Shunt,CASE-63744,APC,63744,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3309.51,,"APC Price ($3,197.60). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3197.60,3357.48,OPPS APC
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC,797,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],8719.72,,"Case rate ($8,719.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,247.38, add-ons for qualifying new technology services are included. If operating cost exceeds $43,118.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,255.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $6,279.28 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,302.43 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $495.50. The transfer capital threshold is the transfer adjustment factor * $495.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8719.72,20928.55,Inpatient DRG
BRONCHITIS AND ASTHMA WITHOUT CC/MCC,203,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],6965.00,,,,,,0,other,4763.76,13707.00,There are no additional notes associated with this service or procedure.
Breast Reduction|RIGHT SIDE,CASE-19318,APC,19318,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6526.12,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6215.36,6526.12,OPPS APC
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,074,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],19371.82,,"Fee schedule rate ($19,371.82). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,8925.60,20919.08,There are no additional notes associated with this service or procedure.
Excision Interdigital Morton Neuroma Single Each|LEFT SIDE,CASE-28080,APC,28080,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1557.80,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1505.12,1557.80,OPPS APC
BRONCHITIS AND ASTHMA WITH CC/MCC,202,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],14307.27,,"Fee schedule rate ($14,307.27). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7606.34,19110.30,There are no additional notes associated with this service or procedure.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],43888.01,,"Fee schedule rate ($43,888.01). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11717.72,43888.01,There are no additional notes associated with this service or procedure.
RADIOTHERAPY,849,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],20699.76,,"Case rate ($20,293.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $19,014.57, add-ons for qualifying new technology services are included. If operating cost exceeds $53,885.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,101.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $17,006.91 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $17,069.62 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,342.01. The transfer capital threshold is the transfer adjustment factor * $1,342.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,20293.88,81867.07,Inpatient DRG
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],8165.30,,"Fee schedule rate ($8,165.30). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4341.01,12882.53,There are no additional notes associated with this service or procedure.
"Correction Hammertoe|RIGHT FOOT, SECOND DIGIT",CASE-28285,APC,28285,CPT,0360,RC,,,T6,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,098,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],21504.00,,"Fee schedule rate ($21,504). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,6965.00,45156.75,There are no additional notes associated with this service or procedure.
Lithotripsy Xtrcorp Shock Wave|RIGHT SIDE,CASE-50590,APC,50590,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3414.95,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3299.47,3464.44,OPPS APC
Egd US Guided Transmural Injxn/Fiducial Marker,CASE-43253,APC,43253,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1796.14,,"APC Price ($1,796.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1796.14,1885.95,OPPS APC
NORMAL NEWBORN,795,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],2576.52,,"Fee schedule rate ($2,576.52). Adds an outlier to normal pricing equal to the per diem rate ($414) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,1369.79,5771.52,There are no additional notes associated with this service or procedure.
HEADACHES WITHOUT MCC,103,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],11574.15,,"Fee schedule rate ($11,574.15). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,20883.08,There are no additional notes associated with this service or procedure.
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],40714.72,,"Fee schedule rate ($40,714.72). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,17356.15,44778.95,There are no additional notes associated with this service or procedure.
"LIMB REATTACHMENT, HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA",956,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],148259.86,,"Fee schedule rate ($148,259.86). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,27428.25,148259.86,There are no additional notes associated with this service or procedure.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],44847.62,,"Fee schedule rate ($44,847.62). Adds an outlier to normal pricing equal to the per diem rate ($79,031.36) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,18105.81,52699.33,There are no additional notes associated with this service or procedure.
Hysteroscopy Diagnostic Separate Procedure,CASE-58555,APC,58555,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3030.03,,"APC Price ($3,030.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3030.03,3181.53,OPPS APC
Arthrp Intercarpal/Carp/Mtcrpl Jt Suspension,CASE-25448,APC,25448,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
CESAREAN SECTION WITHOUT STERILIZATION WITH MCC,786,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],13377.80,,"Case rate ($13,115.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,336.66, add-ons for qualifying new technology services are included. If operating cost exceeds $47,207.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,576.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $10,353.53 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,391.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $817.00. The transfer capital threshold is the transfer adjustment factor * $817.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,12612.10,23722.94,Inpatient DRG
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],6122.64,,"Case rate ($6,122.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,831.37, add-ons for qualifying new technology services are included. If operating cost exceeds $40,702.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,065.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $3,872.14 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,886.42 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $305.55. The transfer capital threshold is the transfer adjustment factor * $305.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,1188.00,12138.74,Inpatient DRG
HC Inj Anesth Celiac Plexus|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64530,APC,64530,CPT,0361,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],827.89,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,827.89,869.28,OPPS APC
Open Tx Distal Fibular Fracture Lat Malleolus|RIGHT SIDE,CASE-27792,APC,27792,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],7034.85,,"Case rate ($7,034.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,679.97, add-ons for qualifying new technology services are included. If operating cost exceeds $41,550.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,132.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $4,717.62 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,735.02 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $372.27. The transfer capital threshold is the transfer adjustment factor * $372.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,21089.59,Inpatient DRG
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],16804.22,,"Fee schedule rate ($16,804.22). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7238.69,16804.22,There are no additional notes associated with this service or procedure.
HC Biopsy/Exc Lymph Node Needle|RIGHT SIDE,CASE-38505,APC,38505,CPT,0361,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1545.93,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1545.93,1623.23,OPPS APC
Dstr Nrolytc Agnt Parverteb Fct Sngl Lmbr/Sacral|BILATERAL PROCEDURE,CASE-64635,APC,64635,CPT,0360,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1891.77,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1827.80,1919.19,OPPS APC
Surgical Arthroscopy Shoulder Dstl Claviculc|LEFT SIDE,CASE-29824,APC,29824,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],5280.00,,"Per diem ($5,280). If length of stay < 3.1, first 1 days paid at a per diem of $10,560 instead. Capped at $16,366.82.",,,,0,other,5280.00,17136.70,Estimated amount calculated based on 3 day length of stay.
HC Joint Injection/Aspir Large WO US|BILATERAL PROCEDURE|PBB CHARGE,CASE-20610,APC,20610,CPT,0510,RC,,,50|PBB,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],297.37,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,287.31,301.68,OPPS APC
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],59081.91,,"Fee schedule rate ($59,081.91). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,8480.00,59081.91,There are no additional notes associated with this service or procedure.
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],15584.93,,"Case rate ($14,842.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,967.60, add-ons for qualifying new technology services are included. If operating cost exceeds $48,838.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,680.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $11,977.24 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,022.65 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $920.60. The transfer capital threshold is the transfer adjustment factor * $920.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,15233.11,38610.21,Inpatient DRG
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC,520,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],29395.47,,,,,,0,other,12061.74,39786.42,There are no additional notes associated with this service or procedure.
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],12195.15,,"Case rate ($12,195.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,480.50, add-ons for qualifying new technology services are included. If operating cost exceeds $46,351.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,509.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,500.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,535.55 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $749.68. The transfer capital threshold is the transfer adjustment factor * $749.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12195.15,39424.57,Inpatient DRG
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],25103.05,,"Case rate ($14,344.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,480.09, add-ons for qualifying new technology services are included. If operating cost exceeds $48,351.10 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,666.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $11,492.77 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,535.14 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $906.89. The transfer capital threshold is the transfer adjustment factor * $906.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,14344.60,36028.59,All Other Inpatient
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],13331.82,,"Case rate ($12,696.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,947.32, add-ons for qualifying new technology services are included. If operating cost exceeds $46,818.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,546.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,965.63 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,002.37 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $786.39. The transfer capital threshold is the transfer adjustment factor * $786.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12696.97,47123.82,Inpatient DRG
VENTRICULAR SHUNT PROCEDURES WITH CC,032,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],40047.88,,"Fee schedule rate ($40,047.88). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,16376.22,46275.08,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,091,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],34556.75,,,,,,0,other,13838.06,40030.81,There are no additional notes associated with this service or procedure.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],52909.62,,"Fee schedule rate ($52,909.62). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,23344.70,62179.32,There are no additional notes associated with this service or procedure.
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],22627.47,,"Case rate ($21,862.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,473.63, add-ons for qualifying new technology services are included. If operating cost exceeds $55,344.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,216.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. The base transfer operating payment is the transfer adjustment factor * $18,460.61 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,528.68 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,456.72. The transfer capital threshold is the transfer adjustment factor * $1,456.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,7086.00,57872.02,Inpatient DRG
CESAREAN SECTION WITHOUT STERILIZATION WITH CC,787,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],20988.02,,"Fee schedule rate ($20,988.02). Adds an outlier to normal pricing equal to the per diem rate ($39,437.39) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,9508.01,23722.94,There are no additional notes associated with this service or procedure.
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],25099.93,,"Fee schedule rate ($25,099.93). Adds an outlier to normal pricing equal to the per diem rate ($40,783.87) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10989.72,26280.60,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC,832,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],9034.88,,"Fee schedule rate ($9,034.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4803.31,14198.92,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC,817,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],18004.97,,"Case rate ($17,396.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,318.84, add-ons for qualifying new technology services are included. If operating cost exceeds $51,189.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,890.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $14,321.08 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,373.88 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,130.07. The transfer capital threshold is the transfer adjustment factor * $1,130.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,17396.11,44895.04,Inpatient DRG
"Open Tx Phalangeal Shaft Fracture Prox/Middle Ea|RIGHT HAND, SECOND DIGIT",CASE-26735,APC,26735,CPT,0360,RC,,,F6,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3062.67,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],34570.85,,"Fee schedule rate ($34,570.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,6965.00,36140.75,There are no additional notes associated with this service or procedure.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],36094.03,,"Fee schedule rate ($36,094.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11194.25,36094.03,There are no additional notes associated with this service or procedure.
Dstrj Lesion Anus Simple Surg Excision,CASE-46922,APC,46922,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],2727.99,,"APC Price ($2,598.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2598.08,2727.99,OPPS APC
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],8690.71,,"Case rate ($8,276.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,847.21, add-ons for qualifying new technology services are included. If operating cost exceeds $42,718.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,211.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,879.97 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,902.26 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $451.95. The transfer capital threshold is the transfer adjustment factor * $451.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6963.00,18954.85,Inpatient DRG
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],21980.29,,"Fee schedule rate ($21,980.29). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9865.56,37914.65,There are no additional notes associated with this service or procedure.
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],13794.06,,"Fee schedule rate ($13,794.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,6915.64,14442.92,There are no additional notes associated with this service or procedure.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],31007.30,,"Fee schedule rate ($31,007.30). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,16120.25,41187.90,There are no additional notes associated with this service or procedure.
Colonoscopy W/Biopsy Single/Multiple,CASE-45380,APC,45380,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1120.09,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1120.09,1176.09,OPPS APC
Hemorrhoidectomy Ntrnl & Xtrnl 1 Column/Group,CASE-46255,APC,46255,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],2598.08,,"APC Price ($2,598.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2598.08,2727.99,OPPS APC
PSYCHOSES,885,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],2070.00,,,,,,0,other,2070.00,27484.83,Estimated amount calculated based on 3 day length of stay.
Ercp W/Sphincterotomy/Papillotomy,CASE-43262,APC,43262,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3608.81,,"APC Price ($3,608.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3608.81,3789.26,OPPS APC
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC",458,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],82104.25,,,,,,0,other,30202.09,132827.25,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],22358.90,,"Fee schedule rate ($22,358.90). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9389.48,22358.90,There are no additional notes associated with this service or procedure.
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],9696.93,,"Case rate ($9,696.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,156.46, add-ons for qualifying new technology services are included. If operating cost exceeds $44,027.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,326.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $7,185.02 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,211.51 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $566.97. The transfer capital threshold is the transfer adjustment factor * $566.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9696.93,35061.53,Inpatient DRG
SPINAL PROCEDURES WITHOUT CC/MCC,030,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],44714.01,,"Fee schedule rate ($44,714.01). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,16810.99,44714.01,There are no additional notes associated with this service or procedure.
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],8165.30,,"Fee schedule rate ($8,165.30). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4341.01,12882.53,There are no additional notes associated with this service or procedure.
Destruction Neurolytic Agt Genicular Nerve W/Img,CASE-64624,APC,64624,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1891.77,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1827.80,1919.19,OPPS APC
HC Biopsy/Exc Lymph Node Needle,CASE-38505,APC,38505,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1545.93,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1545.93,1623.23,OPPS APC
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],86235.79,,"Fee schedule rate ($86,235.79). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,32296.02,88188.38,There are no additional notes associated with this service or procedure.
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],2070.00,,,,,,0,other,1188.00,18893.86,Estimated amount calculated based on 3 day length of stay.
CESAREAN SECTION WITH STERILIZATION WITH MCC,783,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],23722.94,,"Fee schedule rate ($23,722.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12612.10,23722.94,There are no additional notes associated with this service or procedure.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],61290.90,,"Fee schedule rate ($61,290.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,23799.09,63499.65,There are no additional notes associated with this service or procedure.
OTHER MENTAL DISORDER DIAGNOSES,887,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],9197.17,,"Case rate ($9,197.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,691.53, add-ons for qualifying new technology services are included. If operating cost exceeds $43,562.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,290.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,721.79 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,746.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $530.42. The transfer capital threshold is the transfer adjustment factor * $530.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,2070.00,21072.10,Inpatient DRG
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],13097.33,,"Case rate ($12,840.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,080.88, add-ons for qualifying new technology services are included. If operating cost exceeds $46,951.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,556.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $10,098.70 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,135.93 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $796.89. The transfer capital threshold is the transfer adjustment factor * $796.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,1188.00,31658.33,Inpatient DRG
PERITONEAL ADHESIOLYSIS WITH CC,336,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],53705.31,,"Fee schedule rate ($53,705.31). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,16225.22,53705.31,There are no additional notes associated with this service or procedure.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],73588.10,,"Fee schedule rate ($73,588.10). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,21585.31,73588.10,There are no additional notes associated with this service or procedure.
Ercp Biliary/Panc Duct Stent Exchange W/Dil&Wire,CASE-43276,APC,43276,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5966.63,,"APC Price ($5,682.51). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5682.51,5966.63,OPPS APC
OTHER DISORDERS OF THE EYE WITHOUT MCC,125,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],17952.29,,"Fee schedule rate ($17,952.29). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (6), with a minimum of zero.",,,,0,other,7144.54,17952.29,There are no additional notes associated with this service or procedure.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC,192,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],12753.78,,"Fee schedule rate ($12,753.78). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6292.63,12753.78,There are no additional notes associated with this service or procedure.
HC Rt Bronch Dx Clear Airway,CASE-31645,APC,31645,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3489.82,,"APC Price ($3,489.82). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3489.82,3664.31,OPPS APC
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC,520,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],29395.47,,,,,,0,other,12061.74,39786.42,There are no additional notes associated with this service or procedure.
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],48961.48,,"Fee schedule rate ($48,961.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11575.50,48961.48,There are no additional notes associated with this service or procedure.
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,068,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],6965.00,,,,,,0,other,6965.00,23184.90,There are no additional notes associated with this service or procedure.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],11825.67,,"Case rate ($11,593.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,921.06, add-ons for qualifying new technology services are included. If operating cost exceeds $45,792.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,465.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $8,943.14 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,976.12 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $705.70. The transfer capital threshold is the transfer adjustment factor * $705.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,11593.79,38248.08,Inpatient DRG
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC,817,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],18265.92,,"Case rate ($17,396.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,318.84, add-ons for qualifying new technology services are included. If operating cost exceeds $51,189.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,890.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $14,321.08 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,373.88 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,130.07. The transfer capital threshold is the transfer adjustment factor * $1,130.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,17396.11,44895.04,Inpatient DRG
Revision of Spinal Shunt,CASE-63744,APC,63744,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3309.51,,"APC Price ($3,197.60). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3197.60,3357.48,OPPS APC
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],25293.50,,"Fee schedule rate ($25,293.50). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11059.47,28423.20,There are no additional notes associated with this service or procedure.
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITH MCC OR ANTINEOPLASTIC IMPLANT OR EPILEPSY WITH NEUROSTIMULATOR,023,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],136379.44,,"Fee schedule rate ($136,379.44). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,15168.00,136379.44,There are no additional notes associated with this service or procedure.
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 1 Level|RIGHT SIDE,CASE-64493,APC,64493,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],869.28,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,827.89,869.28,OPPS APC
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],24350.31,,"Case rate ($23,526.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $22,022.15, add-ons for qualifying new technology services are included. If operating cost exceeds $56,893.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,338.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.7. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.7)) / 2. The base transfer operating payment is the transfer adjustment factor * $20,003.44 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $20,077.20 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,578.47. The transfer capital threshold is the transfer adjustment factor * $1,578.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,23526.87,94787.57,Inpatient DRG
HYPERTENSION WITHOUT MCC,305,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],17230.49,,"Fee schedule rate ($17,230.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7058.55,17230.49,There are no additional notes associated with this service or procedure.
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],6915.64,,"Case rate ($6,915.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,569.08, add-ons for qualifying new technology services are included. If operating cost exceeds $41,440.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,123.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,607.15 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,624.14 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $363.55. The transfer capital threshold is the transfer adjustment factor * $363.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6915.64,14442.92,Inpatient DRG
"Neuroplasty Other Arm/Leg Nerve,Open|RIGHT SIDE",CASE-64708,APC,64708,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
"Repair Extensor Tendon Finger W/O Graft Each|LEFT HAND, THIRD DIGIT",CASE-26418,APC,26418,CPT,0360,RC,,,F2,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1505.12,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1505.12,1580.37,OPPS APC
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],62179.32,,,,,,0,other,23344.70,62179.32,There are no additional notes associated with this service or procedure.
RESPIRATORY NEOPLASMS WITHOUT CC/MCC,182,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],23037.13,,"Fee schedule rate ($23,037.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6965.00,23037.13,There are no additional notes associated with this service or procedure.
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],15600.07,,"Fee schedule rate ($15,600.07). Adds an outlier to normal pricing equal to the per diem rate ($180,117.98) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,7566.45,16333.88,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,091,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],40030.81,,"Fee schedule rate ($40,030.81). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,13838.06,40030.81,There are no additional notes associated with this service or procedure.
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],24126.45,,"Fee schedule rate ($24,126.45). Adds an outlier to normal pricing equal to the per diem rate ($62,306.11) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10638.94,25261.33,There are no additional notes associated with this service or procedure.
"OTHER PNEUMONIA,MAJOR",139,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],10158.02,,"Case rate ($10,158.02). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,10158.02,10665.92,There are no additional notes associated with this service or procedure.
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],7784.77,,"Case rate ($7,414.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,032.76, add-ons for qualifying new technology services are included. If operating cost exceeds $41,903.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,159.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,069.12 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,087.81 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $400.00. The transfer capital threshold is the transfer adjustment factor * $400.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7414.07,18217.52,Inpatient DRG
Trurl Electrosurg Rescj Prostate Bleed Complete,CASE-52601,APC,52601,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5194.43,,"APC Price ($5,018.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5018.77,5269.71,OPPS APC
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],13236.54,,"Case rate ($12,606.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,862.91, add-ons for qualifying new technology services are included. If operating cost exceeds $46,733.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,539.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $9,881.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,917.95 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $779.75. The transfer capital threshold is the transfer adjustment factor * $779.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12606.23,36868.88,Inpatient DRG
Genioplasty Augmentation,CASE-21120,APC,21120,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5818.16,,"APC Price ($5,541.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5541.10,5818.16,OPPS APC
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,761,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],11225.73,,,,,,0,other,5808.41,11946.72,There are no additional notes associated with this service or procedure.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC,027,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],19030.20,,"Case rate ($19,030.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,839, add-ons for qualifying new technology services are included. If operating cost exceeds $52,710.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,009.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $15,835.66 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,894.05 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,249.59. The transfer capital threshold is the transfer adjustment factor * $1,249.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,19030.20,56363.30,Inpatient DRG
Litholapaxy Smpl/Sm <2.5 Cm,CASE-52317,APC,52317,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3414.95,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3299.47,3464.44,OPPS APC
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,056,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],59328.19,,"Fee schedule rate ($59,328.19). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (44), with a minimum of zero.",,,,0,other,7659.00,59328.19,There are no additional notes associated with this service or procedure.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",062,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],44304.80,,"Fee schedule rate ($44,304.80). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,13844.84,44304.80,There are no additional notes associated with this service or procedure.
"MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS,MODERATE",532,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],2432.97,,"Case rate for a one day stay ($2,317.11). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,2432.97,2432.97,There are no additional notes associated with this service or procedure.
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],2070.00,,,,,,0,other,1188.00,31658.33,Estimated amount calculated based on 16 day length of stay.
"LIMB REATTACHMENT, HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA",956,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],28013.71,,"Case rate ($26,679.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $25,001.34, add-ons for qualifying new technology services are included. If operating cost exceeds $59,872.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,525.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $22,969.30 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $23,056.39 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,765.47. The transfer capital threshold is the transfer adjustment factor * $1,765.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,27428.25,148259.86,Inpatient DRG
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],5065.00,,"Per diem ($5,065). If length of stay < 2.1, first 1 days paid at a per diem of $10,130 instead. Capped at $10,636.84.",,,,0,other,5065.00,12558.65,Estimated amount calculated based on 2 day length of stay.
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],22557.82,,"Fee schedule rate ($22,557.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6801.88,22557.82,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],37149.27,,"Fee schedule rate ($37,149.27). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,12455.21,37149.27,There are no additional notes associated with this service or procedure.
Egd Intrmural US Needle Aspirate/Biopsy Esophags,CASE-43238,APC,43238,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1859.01,,"APC Price ($1,796.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1796.14,1885.95,OPPS APC
Lamnotmy Incl W/Dcmprsn Nrv Root 1 Intrspc Lumbr|LEFT SIDE|SEPARATE STRUCTURE,CASE-63030,APC,63030,CPT,0360,RC,,,LT|XS,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6791.99,7131.59,OPPS APC
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC",494,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],39945.55,,"Fee schedule rate ($39,945.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,15533.10,39945.55,There are no additional notes associated with this service or procedure.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],56476.93,,,,,,0,other,21382.16,85466.62,There are no additional notes associated with this service or procedure.
NONTRAUMATIC STUPOR AND COMA WITH MCC,080,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],30179.40,,"Fee schedule rate ($30,179.40). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,14202.39,35615.37,There are no additional notes associated with this service or procedure.
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],35419.59,,"Fee schedule rate ($35,419.59). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,7086.00,57872.02,There are no additional notes associated with this service or procedure.
Tympanostomy General Anesthesia|BILATERAL PROCEDURE,CASE-69436,APC,69436,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1452.32,,"APC Price ($1,452.32). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1452.32,1524.94,OPPS APC
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,329,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],33072.77,,"Case rate ($33,072.77). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $30,902.51, add-ons for qualifying new technology services are included. If operating cost exceeds $65,773.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,036.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.4. The base transfer operating payment is the transfer adjustment factor * $28,851.18 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $28,957.55 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,276.64. The transfer capital threshold is the transfer adjustment factor * $2,276.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,33072.77,90445.33,Inpatient DRG
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],12558.65,,"Fee schedule rate ($12,558.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5065.00,12558.65,There are no additional notes associated with this service or procedure.
OSTEOMYELITIS WITHOUT CC/MCC,541,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],7277.28,,"Case rate ($7,277.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,905.50, add-ons for qualifying new technology services are included. If operating cost exceeds $41,776.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,149.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $4,942.33 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,960.55 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $390.00. The transfer capital threshold is the transfer adjustment factor * $390.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,5103.00,15493.67,Inpatient DRG
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],11825.67,,"Case rate ($11,593.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,921.06, add-ons for qualifying new technology services are included. If operating cost exceeds $45,792.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,465.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $8,943.14 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,976.12 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $705.70. The transfer capital threshold is the transfer adjustment factor * $705.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,11593.79,38248.08,Inpatient DRG
HC Inj Anesth Celiac Plexus,CASE-64530,APC,64530,CPT,0361,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],856.86,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,827.89,869.28,OPPS APC
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],25013.10,,"Fee schedule rate ($25,013.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10846.16,25863.45,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],16147.35,,"Fee schedule rate ($16,147.35). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,13260.40,32878.30,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],19371.27,,"Fee schedule rate ($19,371.27). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7641.61,19371.27,There are no additional notes associated with this service or procedure.
Repair Complex Trunk 2.6-7.5 Cm|UNUSUAL NON-OVERLAPPING SERVICE,CASE-13101,APC,13101,CPT,0360,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],2718.88,,"APC Price ($2,718.88). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2718.88,2854.83,OPPS APC
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH MCC",510,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],89863.76,,"Fee schedule rate ($89,863.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10710.00,89863.76,There are no additional notes associated with this service or procedure.
"VAGINAL DELIVERY WITH O.R. PROCEDURE EXCEPT STERILIZATION AND/OR D&C,MAJOR",542,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],8944.87,,"Case rate ($8,518.92). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,8518.92,8944.87,There are no additional notes associated with this service or procedure.
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],10078.00,,"Per diem ($10,078). If length of stay < 7.2, first 1 days paid at a per diem of $20,156 instead. Capped at $72,563.53.",,,,0,other,10078.00,81454.07,Estimated amount calculated based on 15 day length of stay.
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,083,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],28680.85,,"Fee schedule rate ($28,680.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,28680.85,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],23316.48,,"Fee schedule rate ($23,316.48). Adds an outlier to normal pricing equal to the per diem rate ($44,995.76) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7.7), with a minimum of zero.",,,,0,other,10347.06,28821.04,There are no additional notes associated with this service or procedure.
HC Joint Injection/Aspir Large WO US|LEFT SIDE,CASE-20610,APC,20610,CPT,0510,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],13608.86,,"Case rate ($13,148.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,367.53, add-ons for qualifying new technology services are included. If operating cost exceeds $47,238.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,579.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $10,384.29 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,422.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $819.42. The transfer capital threshold is the transfer adjustment factor * $819.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,13148.66,32553.63,Inpatient DRG
DIABETES WITHOUT CC/MCC,639,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],11899.36,,"Fee schedule rate ($11,899.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6151.76,12223.35,There are no additional notes associated with this service or procedure.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],62454.12,,"Fee schedule rate ($62,454.12). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11348.00,62454.12,There are no additional notes associated with this service or procedure.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],29997.59,,,,,,0,other,12268.97,41006.47,There are no additional notes associated with this service or procedure.
Fasct Palm W/WO Z-Plasty Tissue Reargmt/Skn Grft|LEFT SIDE,CASE-26121,APC,26121,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
Lamnotmy Incl W/Dcmprsn Nrv Root 1 Intrspc Lumbr|BILATERAL PROCEDURE,CASE-63030,APC,63030,CPT,0360,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6791.99,7131.59,OPPS APC
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],29594.00,,"Fee schedule rate ($29,594.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,13571.25,33781.47,There are no additional notes associated with this service or procedure.
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],10638.94,,"Case rate ($10,638.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,032.78, add-ons for qualifying new technology services are included. If operating cost exceeds $44,903.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,395.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,058.12 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,087.83 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $635.87. The transfer capital threshold is the transfer adjustment factor * $635.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10638.94,25261.33,Inpatient DRG
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],27944.96,,"Case rate ($27,944.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $26,132.21, add-ons for qualifying new technology services are included. If operating cost exceeds $61,003.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,661.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.8. The base transfer operating payment is the transfer adjustment factor * $24,098.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $24,187.26 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,901.60. The transfer capital threshold is the transfer adjustment factor * $1,901.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,27944.96,86252.84,Inpatient DRG
O.R. PROCEDURES FOR OBESITY WITH CC,620,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],30074.44,,"Fee schedule rate ($30,074.44). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7.8), with a minimum of zero.",,,,0,other,12782.30,43753.50,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],6965.00,,,,,,0,other,6558.75,14871.83,There are no additional notes associated with this service or procedure.
Neuroplasty &/Transpos Median Nrv Carpal Tunne|LEFT SIDE,CASE-64721,APC,64721,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1891.77,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1827.80,1919.19,OPPS APC
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],14058.86,,"Case rate ($13,783.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,957.83, add-ons for qualifying new technology services are included. If operating cost exceeds $47,828.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,625.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $10,972.42 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,012.88 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $865.83. The transfer capital threshold is the transfer adjustment factor * $865.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,13783.20,41580.51,Inpatient DRG
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],7948.33,,"Case rate ($7,569.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,177.66, add-ons for qualifying new technology services are included. If operating cost exceeds $42,048.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,171.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,213.49 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,232.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $411.40. The transfer capital threshold is the transfer adjustment factor * $411.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7569.84,21892.85,Inpatient DRG
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],47123.82,,"Fee schedule rate ($47,123.82). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,12696.97,47123.82,There are no additional notes associated with this service or procedure.
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],48961.48,,"Fee schedule rate ($48,961.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11575.50,48961.48,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],72151.96,,"Fee schedule rate ($72,151.96). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,27944.96,86252.84,There are no additional notes associated with this service or procedure.
Cystourethroscopy Inj Chemodenervation Bladder|UNUSUAL NON-OVERLAPPING SERVICE,CASE-52287,APC,52287,CPT,0360,RC,,,XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3414.95,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3299.47,3464.44,OPPS APC
HC Joint Injection/Aspir Large WO US|PBB CHARGE|BILATERAL PROCEDURE,CASE-20610,APC,20610,CPT,0510,RC,,,PBB|50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],297.37,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,287.31,301.68,OPPS APC
INFLAMMATORY BOWEL DISEASE WITH MCC,385,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],31134.92,,,,,,0,other,11480.01,31134.92,There are no additional notes associated with this service or procedure.
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],20297.68,,"Fee schedule rate ($20,297.68). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6965.00,21404.64,There are no additional notes associated with this service or procedure.
CERVICAL SPINAL FUSION WITH MCC,471,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],111337.93,,"Fee schedule rate ($111,337.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,34645.26,111337.93,There are no additional notes associated with this service or procedure.
MAJOR ESOPHAGEAL DISORDERS WITH CC,369,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],9154.30,,"Case rate ($8,718.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,246.12, add-ons for qualifying new technology services are included. If operating cost exceeds $43,117.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,255.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,278.03 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,301.17 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $495.40. The transfer capital threshold is the transfer adjustment factor * $495.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,19680.94,Inpatient DRG
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],34032.82,,"Fee schedule rate ($34,032.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,15233.11,38610.21,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,555,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],24840.59,,"Fee schedule rate ($24,840.59). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10896.27,42290.95,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,699,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],9047.54,,"Case rate ($8,616.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,163.99, add-ons for qualifying new technology services are included. If operating cost exceeds $43,035.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,236.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $6,195.55 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,219.04 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $476.20. The transfer capital threshold is the transfer adjustment factor * $476.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5961.00,19972.16,Inpatient DRG
OTHER MENTAL DISORDER DIAGNOSES,887,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],2070.00,,,,,,0,other,2070.00,21072.10,Estimated amount calculated based on 1 day length of stay.
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],34406.22,,"Fee schedule rate ($34,406.22). Adds an outlier to normal pricing equal to the per diem rate ($49,808.13) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,14343.25,36024.65,There are no additional notes associated with this service or procedure.
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,451,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],50015.29,,"Fee schedule rate ($50,015.29). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,23821.44,94077.13,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL OBSTRUCTION WITH CC,389,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],5118.00,,"Per diem ($5,118). If length of stay < 2.9, first 1 days paid at a per diem of $10,236 instead. Capped at $14,842.71.",,,,0,other,5118.00,16423.43,Estimated amount calculated based on 2 day length of stay.
Sigmoidoscopy Flx W/Biopsy Single/Multiple,CASE-45331,APC,45331,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],913.99,,"APC Price ($870.46). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,870.46,913.99,OPPS APC
CESAREAN SECTION WITHOUT STERILIZATION WITH MCC,786,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],23722.94,,"Fee schedule rate ($23,722.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12612.10,23722.94,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],17651.07,,"Fee schedule rate ($17,651.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,6564.18,17651.07,There are no additional notes associated with this service or procedure.
Revj/Rmvl Perph Neurostimulator Electrode Array,CASE-64585,APC,64585,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],19066.92,,"APC Price ($18,158.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,18158.97,19066.92,OPPS APC
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,083,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],6965.00,,,,,,0,other,6965.00,28680.85,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],31563.88,,,,,,0,other,7353.00,33398.16,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],37495.79,,"Fee schedule rate ($37,495.79). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.8), with a minimum of zero.",,,,0,other,15456.59,41402.42,There are no additional notes associated with this service or procedure.
"INFECTIOUS AND PARASITIC DISEASES INCLUDING HIV WITH O.R. PROCEDURE,EXTREME",710,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],46781.69,,"Case rate ($46,781.69). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $48,300, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,46781.69,49120.77,There are no additional notes associated with this service or procedure.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,191,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],16612.88,,"Fee schedule rate ($16,612.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6965.00,16612.88,There are no additional notes associated with this service or procedure.
Repair Brow Ptosis|BILATERAL PROCEDURE,CASE-67900,APC,67900,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],2225.38,,"APC Price ($2,225.38). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2225.38,2336.65,OPPS APC
KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,689,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],21805.52,,"Fee schedule rate ($21,805.52). Adds an outlier to normal pricing equal to the per diem rate ($36,758.78) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,9802.58,22831.22,There are no additional notes associated with this service or procedure.
O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC,621,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],36669.96,,"Fee schedule rate ($36,669.96). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,12159.94,36669.96,There are no additional notes associated with this service or procedure.
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,068,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],23184.90,,"Fee schedule rate ($23,184.90). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,23184.90,There are no additional notes associated with this service or procedure.
Colonoscopy Flx W/Endoscopic Mucosal Resection|UNUSUAL NON-OVERLAPPING SERVICE|COLORECTAL CANCER SCREEN,CASE-45390,APC,45390,CPT,0360,RC,,,XU|PT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],2727.99,,"APC Price ($2,598.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2598.08,2727.99,OPPS APC
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],21013.65,,"Fee schedule rate ($21,013.65). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9865.56,37914.65,There are no additional notes associated with this service or procedure.
FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,748,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],10293.04,,"Case rate ($10,293.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $9,679.84, add-ons for qualifying new technology services are included. If operating cost exceeds $48,324.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $3,378.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.4. The base transfer operating payment is the transfer adjustment factor * $8,283.19 + an uncompensated DSH payment of $1,359.91. The transfer operating threshold is the transfer adjustment factor * $8,319.93 + an uncompensated DSH payment of $1,359.91. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $649.94. The transfer capital threshold is the transfer adjustment factor * $649.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9316.20,26805.98,Inpatient DRG
"Neuroplasty Sciatic Nerve,Open",CASE-64712,APC,64712,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],52449.26,,"Fee schedule rate ($52,449.26). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,17693.40,52449.26,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,555,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],11277.64,,"Case rate ($10,896.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,272.18, add-ons for qualifying new technology services are included. If operating cost exceeds $45,143.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,414.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,296.64 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,327.23 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $654.69. The transfer capital threshold is the transfer adjustment factor * $654.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,10896.27,42290.95,Inpatient DRG
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,761,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],6965.00,,,,,,0,other,5808.41,11946.72,There are no additional notes associated with this service or procedure.
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,307,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],7806.41,,"Case rate ($7,434.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $7,017.68, add-ons for qualifying new technology services are included. If operating cost exceeds $45,662.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $3,170.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $5,632.79 + an uncompensated DSH payment of $1,359.91. The transfer operating threshold is the transfer adjustment factor * $5,657.77 + an uncompensated DSH payment of $1,359.91. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $441.98. The transfer capital threshold is the transfer adjustment factor * $441.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6335.27,18228.77,Inpatient DRG
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],11594.35,,"Fee schedule rate ($11,594.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6164.03,14071.02,There are no additional notes associated with this service or procedure.
Sigmoidoscopy Flx W/Biopsy Single/Multiple,CASE-45331,APC,45331,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],900.93,,"APC Price ($870.46). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,870.46,913.99,OPPS APC
"NERVOUS SYSTEM MALIGNANCY,MODERATE",041,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],9242.53,,"Case rate ($9,242.53). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,9242.53,9704.66,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],6965.00,,,,,,0,other,6965.00,41030.48,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],32293.66,,"Fee schedule rate ($32,293.66). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,32293.66,There are no additional notes associated with this service or procedure.
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6560.80,,"Case rate ($6,248.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,956.38, add-ons for qualifying new technology services are included. If operating cost exceeds $40,827.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,067.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $3,996.28 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,011.43 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $307.16. The transfer capital threshold is the transfer adjustment factor * $307.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,4341.01,12882.53,Inpatient DRG
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],47751.13,,"Fee schedule rate ($47,751.13). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.7), with a minimum of zero.",,,,0,other,19152.11,53152.12,There are no additional notes associated with this service or procedure.
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC",923,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],8450.18,,"Case rate ($8,047.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $7,588.71, add-ons for qualifying new technology services are included. If operating cost exceeds $46,233.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $3,215.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,201.30 + an uncompensated DSH payment of $1,359.91. The transfer operating threshold is the transfer adjustment factor * $6,228.80 + an uncompensated DSH payment of $1,359.91. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $486.59. The transfer capital threshold is the transfer adjustment factor * $486.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,20068.57,Inpatient DRG
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],13952.52,,"Case rate ($13,952.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,115.33, add-ons for qualifying new technology services are included. If operating cost exceeds $47,986.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,638.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $11,129.34 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,170.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $878.22. The transfer capital threshold is the transfer adjustment factor * $878.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,13917.42,34889.29,Inpatient DRG
PREMATURITY WITHOUT MAJOR PROBLEMS,792,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],6120.72,,"Fee schedule rate ($6,120.72). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,1956.00,19457.66,There are no additional notes associated with this service or procedure.
UNGROUPABLE,999,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],10228.00,,"Per diem ($10,228). If length of stay < 12.7, first 1 days paid at a per diem of $20,456 instead. Capped at $129,893.46.",,,,0,other,10228.00,161307.29,Estimated amount calculated based on 9 day length of stay.
FRACTURES OF FEMUR WITH MCC,533,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],49490.05,,"Fee schedule rate ($49,490.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,6852.00,49490.05,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,066,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],20083.61,,"Fee schedule rate ($20,083.61). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6579.76,20083.61,There are no additional notes associated with this service or procedure.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],38728.27,,,,,,0,other,15273.74,39820.52,There are no additional notes associated with this service or procedure.
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],14625.55,,"Fee schedule rate ($14,625.55). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7438.45,15961.98,There are no additional notes associated with this service or procedure.
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC,807,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],12670.24,,"Fee schedule rate ($12,670.24). Adds an outlier to normal pricing equal to the per diem rate ($29,637.88) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,5354.25,13266.23,There are no additional notes associated with this service or procedure.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC",494,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],39945.55,,"Fee schedule rate ($39,945.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,15533.10,39945.55,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],42569.49,,"Case rate ($40,542.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $37,851.31, add-ons for qualifying new technology services are included. If operating cost exceeds $72,722.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,582.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.6. The base transfer operating payment is the transfer adjustment factor * $35,774.45 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $35,906.36 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,822.96. The transfer capital threshold is the transfer adjustment factor * $2,822.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,40542.37,128358.13,Inpatient DRG
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC,027,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],56363.30,,"Fee schedule rate ($56,363.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,19030.20,56363.30,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],15322.46,,"Fee schedule rate ($15,322.46). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,10347.06,28821.04,There are no additional notes associated with this service or procedure.
Arthroscopy Knee W/Meniscus Rpr Medial/Lateral|RIGHT SIDE,CASE-29882,APC,29882,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7029.71,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6791.99,7029.71,OPPS APC
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],14625.55,,"Fee schedule rate ($14,625.55). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7438.45,15961.98,There are no additional notes associated with this service or procedure.
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],14674.80,,"Fee schedule rate ($14,674.80). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6711.00,16865.16,There are no additional notes associated with this service or procedure.
"Open Tx Phalangeal Shaft Fracture Prox/Middle Ea|RIGHT HAND, FIFTH DIGIT",CASE-26735,APC,26735,CPT,0360,RC,,,F9,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],28334.16,,"Fee schedule rate ($28,334.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,7868.00,32126.64,There are no additional notes associated with this service or procedure.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC,099,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],11394.63,,"Case rate ($11,171.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,527.95, add-ons for qualifying new technology services are included. If operating cost exceeds $45,398.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,434.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,551.47 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,583.00 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $674.80. The transfer capital threshold is the transfer adjustment factor * $674.80. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,11171.21,26807.94,Inpatient DRG
Neuroplasty &/Transpos Median Nrv Carpal Tunne|LEFT SIDE,CASE-64721,APC,64721,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1891.77,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1827.80,1919.19,OPPS APC
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],31693.30,,"Case rate ($31,693.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $29,619.21, add-ons for qualifying new technology services are included. If operating cost exceeds $64,490.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,935.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. The base transfer operating payment is the transfer adjustment factor * $27,572.60 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $27,674.26 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,175.75. The transfer capital threshold is the transfer adjustment factor * $2,175.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10862.00,86437.13,Inpatient DRG
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC,519,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],16264.96,,"Case rate ($15,490.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,546.03, add-ons for qualifying new technology services are included. If operating cost exceeds $49,417.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,750.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $12,554.80 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,601.09 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $990.70. The transfer capital threshold is the transfer adjustment factor * $990.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,15490.44,50780.20,Inpatient DRG
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC",494,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],22139.25,,"Fee schedule rate ($22,139.25). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,15533.10,39945.55,There are no additional notes associated with this service or procedure.
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],34570.85,,"Fee schedule rate ($34,570.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,6965.00,36140.75,There are no additional notes associated with this service or procedure.
Exc Tumor Soft Tis Neck/Ant Thorax Subq 3 Cm/>,CASE-21552,APC,21552,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],2718.88,,"APC Price ($2,718.88). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2718.88,2854.83,OPPS APC
Bx/Exc Lymph Node Open Deep Cervical Node|LEFT SIDE,CASE-38510,APC,38510,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5818.16,,"APC Price ($5,541.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5541.10,5818.16,OPPS APC
GASTROINTESTINAL HEMORRHAGE WITH MCC,377,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],14324.29,,"Case rate ($14,324.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,461.19, add-ons for qualifying new technology services are included. If operating cost exceeds $48,332.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,665.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $11,473.94 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,516.24 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $905.41. The transfer capital threshold is the transfer adjustment factor * $905.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7634.00,35969.56,Inpatient DRG
Rmvl Noninfct Mesh/Prosth Aa/Parastomal Hrna Rpr,CASE-49623,APC,49623,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],206.06,,"APC Price ($199.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,199.10,209.05,OPPS APC
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],8842.67,,"Case rate ($8,543.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,083.58, add-ons for qualifying new technology services are included. If operating cost exceeds $42,954.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,242.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,116.09 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,138.64 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $482.62. The transfer capital threshold is the transfer adjustment factor * $482.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,8543.64,23239.84,Inpatient DRG
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],69977.32,,,,,,0,other,26028.48,80635.65,There are no additional notes associated with this service or procedure.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],52909.62,,"Fee schedule rate ($52,909.62). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,23344.70,62179.32,There are no additional notes associated with this service or procedure.
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],8539.77,,"Case rate ($8,372.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,924.20, add-ons for qualifying new technology services are included. If operating cost exceeds $42,795.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,230.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,957.28 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,979.25 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $470.09. The transfer capital threshold is the transfer adjustment factor * $470.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6965.00,23385.72,Inpatient DRG
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],18045.04,,"Fee schedule rate ($18,045.04). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,1188.00,18893.86,There are no additional notes associated with this service or procedure.
DIABETES WITH CC,638,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],8294.56,,"Case rate ($8,014.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,590.93, add-ons for qualifying new technology services are included. If operating cost exceeds $42,461.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,203.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,625.24 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,645.98 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $443.89. The transfer capital threshold is the transfer adjustment factor * $443.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,8014.07,17634.53,Inpatient DRG
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],12303.61,,"Case rate ($11,717.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,036.36, add-ons for qualifying new technology services are included. If operating cost exceeds $45,907.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,474.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $9,058.01 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,091.41 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $714.77. The transfer capital threshold is the transfer adjustment factor * $714.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,11717.72,43888.01,Inpatient DRG
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC",494,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],39945.55,,"Fee schedule rate ($39,945.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,15533.10,39945.55,There are no additional notes associated with this service or procedure.
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],9890.87,,"Case rate ($9,696.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,156.46, add-ons for qualifying new technology services are included. If operating cost exceeds $44,027.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,326.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $7,185.02 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,211.51 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $566.97. The transfer capital threshold is the transfer adjustment factor * $566.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,9696.93,35061.53,Inpatient DRG
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",004,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],10715.36,,,,,,0,other,10249.47,272554.00,Estimated amount calculated based on 6 day length of stay.
HC Peripheral Block - Femoral Single or Saphenous W/Img Gdn|UNUSUAL NON-OVERLAPPING SERVICE|RIGHT SIDE,CASE-64447,APC,64447,CPT,0360,RC,,,XU|RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1580.37,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1505.12,1580.37,OPPS APC
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],32983.62,,"Fee schedule rate ($32,983.62). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,18497.24,62041.12,There are no additional notes associated with this service or procedure.
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],31577.54,,"Fee schedule rate ($31,577.54). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,15453.88,39251.68,There are no additional notes associated with this service or procedure.
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],31477.13,,"Fee schedule rate ($31,477.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9648.19,31477.13,There are no additional notes associated with this service or procedure.
MAJOR BLADDER PROCEDURES WITH MCC,653,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],10280.00,,"Per diem ($10,280). If length of stay < 9.5, first 1 days paid at a per diem of $20,560 instead. Capped at $97,655.95.",,,,0,other,10280.00,125343.98,Estimated amount calculated based on 10 day length of stay.
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],12543.25,,"Case rate ($11,945.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,248.66, add-ons for qualifying new technology services are included. If operating cost exceeds $46,119.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,491.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $9,269.54 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,303.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $731.46. The transfer capital threshold is the transfer adjustment factor * $731.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6167.00,29058.99,Inpatient DRG
Arthrt Expl Drg/Rmvl Loose/FB Iphal Jt Ea,CASE-26080,APC,26080,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1505.12,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1505.12,1557.80,OPPS APC
HYPERTENSION WITHOUT MCC,305,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],7411.48,,"Case rate ($7,058.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,702.02, add-ons for qualifying new technology services are included. If operating cost exceeds $41,573.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,133.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,739.59 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,757.07 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $374.00. The transfer capital threshold is the transfer adjustment factor * $374.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7058.55,17230.49,Inpatient DRG
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC,806,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],11163.60,,"Fee schedule rate ($11,163.60). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5354.25,13416.00,There are no additional notes associated with this service or procedure.
RESPIRATORY NEOPLASMS WITHOUT CC/MCC,182,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],7049.74,,"Case rate ($7,049.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,693.83, add-ons for qualifying new technology services are included. If operating cost exceeds $41,564.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,133.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,731.43 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,748.88 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $373.36. The transfer capital threshold is the transfer adjustment factor * $373.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,23037.13,Inpatient DRG
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,093,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],7337.55,,"Case rate ($7,337.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,961.57, add-ons for qualifying new technology services are included. If operating cost exceeds $41,832.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,154.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,998.19 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,016.62 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $394.41. The transfer capital threshold is the transfer adjustment factor * $394.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,19011.32,Inpatient DRG
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],15309.46,,"Fee schedule rate ($15,309.46). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6965.00,15340.19,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],12126.09,,"Case rate ($12,126.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,416.25, add-ons for qualifying new technology services are included. If operating cost exceeds $46,287.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,504.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $9,436.50 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,471.29 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $744.63. The transfer capital threshold is the transfer adjustment factor * $744.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12126.09,29582.40,Inpatient DRG
Mast Modf Rad W/Ax Lymph Nod W/WO Pect/Alis Min|RIGHT SIDE,CASE-19307,APC,19307,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6432.89,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6215.36,6526.12,OPPS APC
"MAJOR ESOPHAGEAL DISORDERS,EXTREME",242,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],24176.46,,"Case rate ($23,025.20). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,23025.20,24176.46,There are no additional notes associated with this service or procedure.
HC >= 12 Lead Ekg|ADJ,CASE-93005,APC,93005,CPT,0730,RC,,,ADJ,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],128.98,,"APC Price ($124.62). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,124.62,130.85,OPPS APC
"HEART FAILURE,MODERATE",194,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],7970.95,,"The inlier payment is calculated as the lesser of the standard DRG payment $7,591.38 and the transfer payment, which is a per diem of $1,820.47. If cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7591.38,7970.95,Estimated amount calculated based on 4 day length of stay.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],19635.68,,,,,,0,other,5683.00,19635.68,There are no additional notes associated with this service or procedure.
Laparoscopy W/Rmvl Adnexal Structures|BILATERAL PROCEDURE,CASE-58661,APC,58661,CPT,0360,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5856.81,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5658.76,5856.81,OPPS APC
Esophagoscopy Flexible Transoral With Biopsy,CASE-43202,APC,43202,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1796.14,,"APC Price ($1,796.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1796.14,1885.95,OPPS APC
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],68942.79,,"Fee schedule rate ($68,942.79). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,21489.15,68942.79,There are no additional notes associated with this service or procedure.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],11348.00,,"Per diem ($11,348). If length of stay < 4.2, first 1 days paid at a per diem of $22,696 instead. Capped at $47,660.93.",,,,0,other,11348.00,62454.12,Estimated amount calculated based on 5 day length of stay.
HEART FAILURE AND SHOCK WITH CC,292,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],8618.40,,"Fee schedule rate ($8,618.40). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5502.00,16705.77,There are no additional notes associated with this service or procedure.
PERIPHERAL VASCULAR DISORDERS WITH CC,300,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],20331.78,,"Fee schedule rate ($20,331.78). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,9174.14,21005.20,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC,084,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],19445.16,,"Fee schedule rate ($19,445.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,6965.00,19445.16,There are no additional notes associated with this service or procedure.
Arthrs Kne Surg W/Meniscectomy Med/Lat W/Shvg|RIGHT SIDE,CASE-29881,APC,29881,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],15703.80,,"Fee schedule rate ($15,703.80). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,7868.00,32126.64,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,065,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],9226.10,,"Case rate ($8,786.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,309.75, add-ons for qualifying new technology services are included. If operating cost exceeds $43,180.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,260.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,341.42 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,364.80 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $500.40. The transfer capital threshold is the transfer adjustment factor * $500.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8786.76,25681.86,Inpatient DRG
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],25609.86,,"Fee schedule rate ($25,609.86). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,12775.53,31469.43,There are no additional notes associated with this service or procedure.
"MAJOR BLADDER PROCEDURES,MAJOR",441,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],37049.24,,"Case rate ($35,284.99). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,35284.99,37049.24,There are no additional notes associated with this service or procedure.
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC,807,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],6640.88,,"Case rate ($6,510.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,192.35, add-ons for qualifying new technology services are included. If operating cost exceeds $41,063.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,093.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $4,231.80 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,247.40 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $333.93. The transfer capital threshold is the transfer adjustment factor * $333.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,5354.25,13266.23,Inpatient DRG
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],7810.37,,"Case rate ($7,438.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,055.44, add-ons for qualifying new technology services are included. If operating cost exceeds $41,926.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,161.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,091.72 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,110.49 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $401.79. The transfer capital threshold is the transfer adjustment factor * $401.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7438.45,15961.98,Inpatient DRG
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],93728.21,,"Fee schedule rate ($93,728.21). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,35719.96,105091.76,There are no additional notes associated with this service or procedure.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],14008.75,,"Case rate ($13,341.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,547.08, add-ons for qualifying new technology services are included. If operating cost exceeds $47,418.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,593.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $10,563.18 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,602.13 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $833.54. The transfer capital threshold is the transfer adjustment factor * $833.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13341.67,42586.49,Inpatient DRG
CESAREAN SECTION WITHOUT STERILIZATION WITH MCC,786,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],13771.26,,"Case rate ($13,115.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,336.66, add-ons for qualifying new technology services are included. If operating cost exceeds $47,207.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,576.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $10,353.53 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,391.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $817.00. The transfer capital threshold is the transfer adjustment factor * $817.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12612.10,23722.94,Inpatient DRG
Redo Excis Lumbar Disk|RIGHT SIDE,CASE-63042,APC,63042,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6791.99,7131.59,OPPS APC
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],7783.37,,"Case rate ($7,412.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,031.50, add-ons for qualifying new technology services are included. If operating cost exceeds $41,902.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,159.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $5,067.86 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,086.55 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $399.90. The transfer capital threshold is the transfer adjustment factor * $399.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6148.93,15887.21,Inpatient DRG
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,447,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],156646.82,,"Fee schedule rate ($156,646.82). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,47193.21,156646.82,There are no additional notes associated with this service or procedure.
"Prq Skel Fixj Phlngl Shft Fx Prox/Middle Px/F/T|LEFT HAND, FOURTH DIGIT",CASE-26727,APC,26727,CPT,0360,RC,,,F3,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
"Corrj Hallux Valgus W/Sesmdc W/Dist Metar Osteot|LEFT FOOT, GREAT TOE",CASE-28296,APC,28296,CPT,0360,RC,,,TA,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6791.99,7131.59,OPPS APC
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],31577.54,,"Fee schedule rate ($31,577.54). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,15453.88,39251.68,There are no additional notes associated with this service or procedure.
"Amp F/Th 1/2 Jt/Phalanx W/Neurect W/Dir Clsr|RIGHT HAND, SECOND DIGIT",CASE-26951,APC,26951,CPT,0360,RC,,,F6,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,098,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],45156.75,,,,,,0,other,6965.00,45156.75,There are no additional notes associated with this service or procedure.
SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS,029,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],61889.56,,"Fee schedule rate ($61,889.56). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13641.00,67130.05,There are no additional notes associated with this service or procedure.
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],42021.93,,"Fee schedule rate ($42,021.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,21248.73,56089.29,There are no additional notes associated with this service or procedure.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,479,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],10586.00,,"Per diem ($10,586). If length of stay < 3.3, first 1 days paid at a per diem of $21,172 instead. Capped at $34,934.31.",,,,0,other,10586.00,50518.76,Estimated amount calculated based on 2 day length of stay.
Laps Tx Ectopic Preg W/Salping&/Oophorectomy|LEFT SIDE,CASE-59151,APC,59151,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5941.70,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5658.76,5941.70,OPPS APC
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],11681.49,,"Fee schedule rate ($11,681.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5778.62,11681.49,There are no additional notes associated with this service or procedure.
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITHOUT MCC,430,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],42435.17,,"Case rate ($41,000.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $38,277.19, add-ons for qualifying new technology services are included. If operating cost exceeds $73,148.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,616.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $36,198.76 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $36,332.23 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,856.44. The transfer capital threshold is the transfer adjustment factor * $2,856.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,41000.16,133156.90,Inpatient DRG
"HC ED Avulsion Nail Plate Single|RIGHT HAND, THUMB",CASE-11730,APC,11730,CPT,0450,RC,,,F5,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],197.19,,"APC Price ($187.80). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,187.80,197.19,OPPS APC
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],16333.88,,,,,,0,other,7566.45,16333.88,There are no additional notes associated with this service or procedure.
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],5995.74,,"Case rate ($5,710.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,447.70, add-ons for qualifying new technology services are included. If operating cost exceeds $40,318.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,035.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $3,489.88 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,502.75 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $275.39. The transfer capital threshold is the transfer adjustment factor * $275.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,3079.00,10940.41,Inpatient DRG
Chromotubation Oviduct W/Materials|UNUSUAL NON-OVERLAPPING SERVICE,CASE-58350,APC,58350,CPT,0360,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5658.76,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5658.76,5941.70,OPPS APC
VENTRICULAR SHUNT PROCEDURES WITH CC,032,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],41931.69,,,,,,0,other,16376.22,46275.08,There are no additional notes associated with this service or procedure.
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,095,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],50750.92,,,,,,0,other,19411.47,50750.92,There are no additional notes associated with this service or procedure.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,073,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],12809.38,,"Case rate ($12,809.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,051.90, add-ons for qualifying new technology services are included. If operating cost exceeds $46,922.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,554.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $10,069.82 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,106.95 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $794.61. The transfer capital threshold is the transfer adjustment factor * $794.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12809.38,43475.01,Inpatient DRG
GASTROINTESTINAL OBSTRUCTION WITH CC,389,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7493.25,,"Case rate ($7,136.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,784.16, add-ons for qualifying new technology services are included. If operating cost exceeds $41,655.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,130.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $4,820.93 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,839.21 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $370.55. The transfer capital threshold is the transfer adjustment factor * $370.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5118.00,16423.43,Inpatient DRG
CESAREAN SECTION WITHOUT STERILIZATION WITH CC,787,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],23722.94,,"Fee schedule rate ($23,722.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9508.01,23722.94,There are no additional notes associated with this service or procedure.
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],16375.35,,"Case rate ($15,821.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,854.10, add-ons for qualifying new technology services are included. If operating cost exceeds $49,725.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,774.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $12,861.73 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,909.15 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,014.92. The transfer capital threshold is the transfer adjustment factor * $1,014.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,15821.59,40320.14,Inpatient DRG
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],15340.19,,,,,,0,other,6965.00,15340.19,There are no additional notes associated with this service or procedure.
"Prq Skel Fixj Phlngl Shft Fx Prox/Middle Px/F/T|LEFT HAND, FIFTH DIGIT",CASE-26727,APC,26727,CPT,0360,RC,,,F4,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],21455.22,,"Fee schedule rate ($21,455.22). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,9097.60,21455.22,There are no additional notes associated with this service or procedure.
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC,806,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],10071.17,,"Fee schedule rate ($10,071.17). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5354.25,13416.00,There are no additional notes associated with this service or procedure.
Brnchsc Removal Bronchial Valve Initial,CASE-31648,APC,31648,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3489.82,,"APC Price ($3,489.82). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3489.82,3664.31,OPPS APC
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],92811.11,,"Fee schedule rate ($92,811.11). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,35389.50,101083.00,There are no additional notes associated with this service or procedure.
DIABETES WITH MCC,637,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],11127.63,,"Case rate ($10,909.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $10,253.93, add-ons for qualifying new technology services are included. If operating cost exceeds $48,898.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $3,423.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $8,854.74 + an uncompensated DSH payment of $1,359.91. The transfer operating threshold is the transfer adjustment factor * $8,894.02 + an uncompensated DSH payment of $1,359.91. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $694.79. The transfer capital threshold is the transfer adjustment factor * $694.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,9959.03,28655.62,Inpatient DRG
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],31477.13,,"Fee schedule rate ($31,477.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9648.19,31477.13,There are no additional notes associated with this service or procedure.
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],6148.93,,"Fee schedule rate ($6,148.93). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6148.93,15887.21,There are no additional notes associated with this service or procedure.
Injection Aa&/Strd Genicular Nrv Branches W/Img|BILATERAL PROCEDURE,CASE-64454,APC,64454,CPT,0360,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],693.76,,"APC Price ($660.72). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,660.72,693.76,OPPS APC
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],45157.33,,"Fee schedule rate ($45,157.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,10733.06,45157.33,There are no additional notes associated with this service or procedure.
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],10448.91,,"Fee schedule rate ($10,448.91). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,3079.00,10940.41,There are no additional notes associated with this service or procedure.
Pelvic Examination W/Anesthesia Other Than Local,CASE-57410,APC,57410,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3030.03,,"APC Price ($3,030.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3030.03,3181.53,OPPS APC
"ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",770,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],17800.73,,"Fee schedule rate ($17,800.73). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,8735.30,19730.13,There are no additional notes associated with this service or procedure.
Transection/Avulsion Oth Spinal Nrv Xdrl,CASE-64772,APC,64772,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],12027.72,,"Case rate ($11,454.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,791.92, add-ons for qualifying new technology services are included. If operating cost exceeds $45,662.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,455.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $8,814.47 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,846.97 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $695.55. The transfer capital threshold is the transfer adjustment factor * $695.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,11454.97,28394.78,Inpatient DRG
CHOLECYSTECTOMY WITH C.D.E. WITH MCC,411,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],47111.55,,"Fee schedule rate ($47,111.55). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,24315.13,88615.28,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],11059.47,,"Case rate ($11,059.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,424, add-ons for qualifying new technology services are included. If operating cost exceeds $45,295.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,426.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $8,447.91 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,479.05 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $666.62. The transfer capital threshold is the transfer adjustment factor * $666.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,11059.47,28423.20,Inpatient DRG
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral Ea Addl|RIGHT SIDE,CASE-64484,APC,64484,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],827.89,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,827.89,869.28,OPPS APC
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],25253.70,,"Fee schedule rate ($25,253.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11974.38,29141.64,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],37149.27,,"Fee schedule rate ($37,149.27). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,12455.21,37149.27,There are no additional notes associated with this service or procedure.
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],9777.20,,"Case rate ($9,311.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,798, add-ons for qualifying new technology services are included. If operating cost exceeds $43,669.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,298.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $6,827.87 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,853.05 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $538.79. The transfer capital threshold is the transfer adjustment factor * $538.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,21404.64,Inpatient DRG
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],7847.50,,"Case rate ($7,847.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,435.96, add-ons for qualifying new technology services are included. If operating cost exceeds $42,306.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,191.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,470.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,491.01 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $431.70. The transfer capital threshold is the transfer adjustment factor * $431.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7847.50,17755.26,Inpatient DRG
SEIZURES WITH MCC,100,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],36398.28,,"Fee schedule rate ($36,398.28). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,15061.09,38110.41,There are no additional notes associated with this service or procedure.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],21597.50,,"Case rate ($21,597.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,227.30, add-ons for qualifying new technology services are included. If operating cost exceeds $55,098.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,197.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $18,215.19 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,282.35 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,437.36. The transfer capital threshold is the transfer adjustment factor * $1,437.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,21597.50,67790.93,Inpatient DRG
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,065,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],8962.50,,"Case rate ($8,786.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,309.75, add-ons for qualifying new technology services are included. If operating cost exceeds $43,180.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,260.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,341.42 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,364.80 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $500.40. The transfer capital threshold is the transfer adjustment factor * $500.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,8786.76,25681.86,Inpatient DRG
OSTEOMYELITIS WITHOUT CC/MCC,541,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],11429.52,,"Fee schedule rate ($11,429.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5103.00,15493.67,There are no additional notes associated with this service or procedure.
Egd Ablate Tumor Polyp/Lesion W/Dilation& Wire,CASE-43270,APC,43270,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1885.95,,"APC Price ($1,796.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1796.14,1885.95,OPPS APC
Arthrp Intercarpal/Carp/Mtcrpl Jt Suspension,CASE-25448,APC,25448,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
"Tendon Sheath Incision|RIGHT HAND, SECOND DIGIT",CASE-26055,APC,26055,CPT,0360,RC,,,F6,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1505.12,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1505.12,1580.37,OPPS APC
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],43304.35,,"Fee schedule rate ($43,304.35). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,10078.00,81454.07,There are no additional notes associated with this service or procedure.
OTHER CEREBROVASCULAR DISORDERS WITH CC,071,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],5843.00,,"Per diem ($5,843). If length of stay < 3.3, first 1 days paid at a per diem of $11,686 instead. Capped at $19,281.62.",,,,0,other,5843.00,29215.10,Estimated amount calculated based on 3 day length of stay.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,761,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],11946.72,,"Fee schedule rate ($11,946.72). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,5808.41,11946.72,There are no additional notes associated with this service or procedure.
Injection Aa&/Strd Intercostal Nrv Ea Addl Lvl,CASE-64421,APC,64421,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],869.28,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,827.89,869.28,OPPS APC
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],13891.24,,"Case rate ($13,229.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,464.01, add-ons for qualifying new technology services are included. If operating cost exceeds $47,335.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,565.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $10,479.32 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,519.06 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $805.47. The transfer capital threshold is the transfer adjustment factor * $805.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13571.25,33781.47,Inpatient DRG
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],9120.24,,"Case rate ($8,811.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,333.06, add-ons for qualifying new technology services are included. If operating cost exceeds $43,204.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,262.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,364.65 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,388.11 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $502.23. The transfer capital threshold is the transfer adjustment factor * $502.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6965.00,20401.88,Inpatient DRG
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],7402.56,,"Case rate ($7,402.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,022.05, add-ons for qualifying new technology services are included. If operating cost exceeds $41,893.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,159.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,058.45 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,077.10 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $399.16. The transfer capital threshold is the transfer adjustment factor * $399.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7402.56,16438.59,Inpatient DRG
"EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME, NEONATE",790,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],3054.00,,,,,,0,other,3054.00,44304.49,Estimated amount calculated based on 17 day length of stay.
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,426,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],76581.29,,"Case rate ($76,581.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $71,377.56, add-ons for qualifying new technology services are included. If operating cost exceeds $106,248.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $7,218.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $69,177.55 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $69,432.61 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $5,458.79. The transfer capital threshold is the transfer adjustment factor * $5,458.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,76581.29,216864.15,Inpatient DRG
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],27553.62,,"Fee schedule rate ($27,553.62). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12305.53,30103.84,There are no additional notes associated with this service or procedure.
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],5995.74,,"Case rate ($5,710.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,447.70, add-ons for qualifying new technology services are included. If operating cost exceeds $40,318.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,035.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $3,489.88 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,502.75 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $275.39. The transfer capital threshold is the transfer adjustment factor * $275.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,3079.00,10940.41,Inpatient DRG
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,056,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],18561.00,,"Case rate ($17,677.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,580.28, add-ons for qualifying new technology services are included. If operating cost exceeds $51,451.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,910.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $14,581.57 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,635.33 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,150.63. The transfer capital threshold is the transfer adjustment factor * $1,150.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7659.00,59328.19,Inpatient DRG
VENTRICULAR SHUNT PROCEDURES WITH MCC,031,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],56502.60,,"Case rate ($32,287.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $30,171.71, add-ons for qualifying new technology services are included. If operating cost exceeds $65,042.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,979.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7. The base transfer operating payment is the transfer adjustment factor * $28,123.07 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $28,226.76 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,219.19. The transfer capital threshold is the transfer adjustment factor * $2,219.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,32287.20,88162.80,All Other Inpatient
Cysto W/Ureteroscopy W/Rmvl/Manj Stones|BILATERAL PROCEDURE,CASE-52352,APC,52352,CPT,0360,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3464.44,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3299.47,3464.44,OPPS APC
PSYCHOSES,885,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],2070.00,,,,,,0,other,2070.00,27484.83,Estimated amount calculated based on 3 day length of stay.
Ligamentous Reconstruction Knee Extra-Articular|RIGHT SIDE,CASE-27427,APC,27427,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],12017.31,,"APC Price ($12,017.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12017.31,12618.18,OPPS APC
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC",458,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],132827.25,,"Fee schedule rate ($132,827.25). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,30202.09,132827.25,There are no additional notes associated with this service or procedure.
Dstr Nrolytc Agnt Parverteb Fct Addl Crvcl/Thora|LEFT SIDE,CASE-64634,APC,64634,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1919.19,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1827.80,1919.19,OPPS APC
"Tendon Sheath Incision|LEFT FOOT, GREAT TOE",CASE-26055,APC,26055,CPT,0360,RC,,,TA,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1891.77,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1827.80,1919.19,OPPS APC
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],16458.91,,"Fee schedule rate ($16,458.91). Adds an outlier to normal pricing equal to the per diem rate ($62,521.14) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,7875.94,17233.12,There are no additional notes associated with this service or procedure.
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],15283.90,,"Case rate ($15,283.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,353.89, add-ons for qualifying new technology services are included. If operating cost exceeds $49,224.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,735.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.2. The base transfer operating payment is the transfer adjustment factor * $12,363.36 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,408.94 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $975.59. The transfer capital threshold is the transfer adjustment factor * $975.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,15283.90,38757.79,Inpatient DRG
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],9356.31,,"Case rate ($9,356.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,839.58, add-ons for qualifying new technology services are included. If operating cost exceeds $43,710.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,302.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $6,869.30 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,894.63 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $542.06. The transfer capital threshold is the transfer adjustment factor * $542.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9356.31,25026.36,Inpatient DRG
Total Thyroid Lobectomy Uni W/WO Isthmusectomy|LEFT SIDE,CASE-60220,APC,60220,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5856.81,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5658.76,5856.81,OPPS APC
Egd Transoral Biopsy Single/Multiple|SEPARATE STRUCTURE,CASE-43239,APC,43239,CPT,0360,RC,,,XS,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1885.95,,"APC Price ($1,796.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1796.14,1885.95,OPPS APC
HC Joint Injection/Aspir Large WO US|UNUSUAL NON-OVERLAPPING SERVICE|RIGHT SIDE,CASE-20610,APC,20610,CPT,0510,RC,,,XU|RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],14295.18,,"Case rate ($14,295.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,434.11, add-ons for qualifying new technology services are included. If operating cost exceeds $48,305.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,663.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $11,446.95 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,489.15 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $903.28. The transfer capital threshold is the transfer adjustment factor * $903.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,14295.18,42768.36,Inpatient DRG
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,329,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],86382.02,,"Fee schedule rate ($86,382.02). Adds an outlier to normal pricing equal to the per diem rate ($147,722.18) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,33072.77,90445.33,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],7906.48,,"Fee schedule rate ($7,906.48). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6558.75,14871.83,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],19458.27,,"Fee schedule rate ($19,458.27). Adds an outlier to normal pricing equal to the per diem rate ($75,355.48) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,8956.76,28983.97,There are no additional notes associated with this service or procedure.
HC Inj Trigger Pt 1-2 Musc Grps|ADJ,CASE-20552,APC,20552,CPT,0510,RC,,,ADJ,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],301.68,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,287.31,301.68,OPPS APC
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],36103.36,,,,,,0,other,14370.36,38378.80,There are no additional notes associated with this service or procedure.
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6201.19,,"Case rate ($6,201.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,904.45, add-ons for qualifying new technology services are included. If operating cost exceeds $40,775.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,071.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,944.95 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,959.50 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $311.30. The transfer capital threshold is the transfer adjustment factor * $311.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,5937.41,12366.99,Inpatient DRG
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],87909.90,,"Fee schedule rate ($87,909.90). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,33623.33,133270.57,There are no additional notes associated with this service or procedure.
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC",514,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],22699.91,,"Fee schedule rate ($22,699.91). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8868.04,22699.91,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],15456.59,,"Case rate ($15,456.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,514.54, add-ons for qualifying new technology services are included. If operating cost exceeds $49,385.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,748.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $12,523.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,569.59 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $988.22. The transfer capital threshold is the transfer adjustment factor * $988.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,15456.59,41402.42,Inpatient DRG
ALLERGIC REACTIONS WITH MCC,915,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],13599.52,,"Case rate ($13,332.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,538.89, add-ons for qualifying new technology services are included. If operating cost exceeds $47,409.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,592.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $10,555.02 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,593.94 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $832.90. The transfer capital threshold is the transfer adjustment factor * $832.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,13332.86,33088.84,Inpatient DRG
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,447,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],48137.07,,"Case rate ($47,193.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $44,038.45, add-ons for qualifying new technology services are included. If operating cost exceeds $78,909.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $5,069.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $41,938.87 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $42,093.51 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,309.39. The transfer capital threshold is the transfer adjustment factor * $3,309.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,47193.21,156646.82,Inpatient DRG
Peri-Implant Capsulectomy Breast Complete|RIGHT SIDE,CASE-19371,APC,19371,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6215.36,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6215.36,6432.89,OPPS APC
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],37899.49,,"Fee schedule rate ($37,899.49). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,14747.55,37899.49,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],41580.51,,"Fee schedule rate ($41,580.51). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,13783.20,41580.51,There are no additional notes associated with this service or procedure.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],6817.04,,"Case rate ($6,683.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,353, add-ons for qualifying new technology services are included. If operating cost exceeds $41,224.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,106.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,391.86 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,408.05 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $346.56. The transfer capital threshold is the transfer adjustment factor * $346.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6683.37,14699.43,Inpatient DRG
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],19788.78,,"Case rate ($19,119.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,922.16, add-ons for qualifying new technology services are included. If operating cost exceeds $52,793.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,016.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $15,918.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,977.21 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,256.13. The transfer capital threshold is the transfer adjustment factor * $1,256.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,11348.00,62454.12,Inpatient DRG
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC,858,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],33794.11,,"Fee schedule rate ($33,794.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11377.76,33794.11,There are no additional notes associated with this service or procedure.
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],16803.11,,"Case rate ($16,002.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,049.04, add-ons for qualifying new technology services are included. If operating cost exceeds $49,920.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,763.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $13,054.59 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,104.09 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,003.41. The transfer capital threshold is the transfer adjustment factor * $1,003.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,16428.39,42083.20,Inpatient DRG
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],12112.80,,"Fee schedule rate ($12,112.80). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10638.94,25261.33,There are no additional notes associated with this service or procedure.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],31626.74,,"Fee schedule rate ($31,626.74). Adds an outlier to normal pricing equal to the per diem rate ($86,383.13) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,13341.67,42586.49,There are no additional notes associated with this service or procedure.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],133270.57,,"Fee schedule rate ($133,270.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,33623.33,133270.57,There are no additional notes associated with this service or procedure.
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],31323.82,,,,,,0,other,12725.42,34245.00,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITHOUT STERILIZATION WITH CC,787,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],9508.01,,"Case rate ($9,508.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,980.70, add-ons for qualifying new technology services are included. If operating cost exceeds $43,851.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,313.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $7,009.90 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,035.74 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $553.15. The transfer capital threshold is the transfer adjustment factor * $553.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9508.01,23722.94,Inpatient DRG
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,083,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],11397.40,,"Case rate ($11,397.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,738.37, add-ons for qualifying new technology services are included. If operating cost exceeds $45,609.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,451.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $8,761.12 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,793.42 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $691.34. The transfer capital threshold is the transfer adjustment factor * $691.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,28680.85,Inpatient DRG
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH CC,026,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],63202.45,,"Fee schedule rate ($63,202.45). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,23000.66,63202.45,There are no additional notes associated with this service or procedure.
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],7749.28,,"Case rate ($7,749.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,344.60, add-ons for qualifying new technology services are included. If operating cost exceeds $42,215.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,184.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,379.82 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,399.66 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $424.52. The transfer capital threshold is the transfer adjustment factor * $424.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6711.00,16865.16,Inpatient DRG
RADIOTHERAPY,849,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],81867.07,,"Fee schedule rate ($81,867.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,20293.88,81867.07,There are no additional notes associated with this service or procedure.
"Inj Dx/Ther Agnt Paravert Facet Joint, Lumbar/Sac, Add Level",CASE-64495,APC,64495,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],856.86,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,827.89,869.28,OPPS APC
Colonoscopy Flx Dx W/Collj Spec When Pfrmd|COLORECTAL CANCER SCREEN,CASE-45378,APC,45378,CPT,0360,RC,,,PT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],900.93,,"APC Price ($870.46). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,870.46,913.99,OPPS APC
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],25026.36,,"Fee schedule rate ($25,026.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9356.31,25026.36,There are no additional notes associated with this service or procedure.
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],6780.05,,"Case rate ($6,457.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,142.59, add-ons for qualifying new technology services are included. If operating cost exceeds $41,013.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,089.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $4,182.21 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,197.63 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $330.02. The transfer capital threshold is the transfer adjustment factor * $330.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5139.72,13110.79,Inpatient DRG
Cerclage Cervix Pregnancy Vaginal,CASE-59320,APC,59320,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3030.03,,"APC Price ($3,030.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3030.03,3181.53,OPPS APC
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],26721.94,,"Fee schedule rate ($26,721.94). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6965.00,34422.94,There are no additional notes associated with this service or procedure.
Neuroplasty &/Transposition Ulnar Nerve Elbow|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-64718,APC,64718,CPT,0360,RC,,,LT|XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7029.71,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6791.99,7131.59,OPPS APC
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],10989.72,,"Case rate ($10,989.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,359.11, add-ons for qualifying new technology services are included. If operating cost exceeds $45,230.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,421.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $8,383.26 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,414.17 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $661.52. The transfer capital threshold is the transfer adjustment factor * $661.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10989.72,26280.60,Inpatient DRG
Excision Prepatellar Bursa|BILATERAL PROCEDURE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-27340,APC,27340,CPT,0360,RC,,,50|XU,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],34391.19,,"Fee schedule rate ($34,391.19). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,14337.84,52803.53,There are no additional notes associated with this service or procedure.
HC Perq Vert Agmntj Cavity Crtj Uni/Bi Cannulj Lmbr,CASE-22514,APC,22514,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,6791.99,OPPS APC
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",623,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],14423.36,,"Case rate ($13,736.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,936.41, add-ons for qualifying new technology services are included. If operating cost exceeds $47,807.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,601.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $10,949.94 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,991.46 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $841.64. The transfer capital threshold is the transfer adjustment factor * $841.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,14093.37,33712.76,Inpatient DRG
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],36855.62,,"Fee schedule rate ($36,855.62). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,15821.59,40320.14,There are no additional notes associated with this service or procedure.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],45845.03,,"Fee schedule rate ($45,845.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,18598.83,48389.68,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],17782.11,,"Case rate ($17,782.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,677.93, add-ons for qualifying new technology services are included. If operating cost exceeds $51,548.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,918.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $14,678.86 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,732.98 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,158.31. The transfer capital threshold is the transfer adjustment factor * $1,158.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,17782.11,46523.26,Inpatient DRG
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,544,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],23207.64,,"Fee schedule rate ($23,207.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,7055.15,23207.64,There are no additional notes associated with this service or procedure.
Tx Incomplete Abortion Any Trimester Surgical,CASE-59812,APC,59812,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3136.08,,"APC Price ($3,030.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3030.03,3181.53,OPPS APC
Repair Brow Ptosis|BILATERAL PROCEDURE,CASE-67900,APC,67900,CPT,0360,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],2336.65,,"APC Price ($2,225.38). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2225.38,2336.65,OPPS APC
Dstr Nrolytc Agnt Parverteb Fct Sngl Crvcl/Thora|LEFT SIDE,CASE-64633,APC,64633,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1827.80,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1827.80,1919.19,OPPS APC
Colsc Flexible W/Transendoscopic Balloon Dilat|COLORECTAL CANCER SCREEN,CASE-45386,APC,45386,CPT,0360,RC,,,PT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1120.09,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1120.09,1176.09,OPPS APC
Neuroplasty &/Transposition Ulnar Nerve Elbow|LEFT SIDE,CASE-64718,APC,64718,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1891.77,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1827.80,1919.19,OPPS APC
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],9533.13,,"Fee schedule rate ($9,533.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5068.21,14525.56,There are no additional notes associated with this service or procedure.
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],12558.65,,"Fee schedule rate ($12,558.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5065.00,12558.65,There are no additional notes associated with this service or procedure.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],22340.80,,"Case rate ($21,585.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,215.96, add-ons for qualifying new technology services are included. If operating cost exceeds $55,086.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,196.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $18,203.89 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,271.01 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,436.47. The transfer capital threshold is the transfer adjustment factor * $1,436.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,21585.31,73588.10,Inpatient DRG
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],13891.57,,"Case rate ($13,891.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,058.63, add-ons for qualifying new technology services are included. If operating cost exceeds $47,929.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,633.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,072.85 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,113.68 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $873.76. The transfer capital threshold is the transfer adjustment factor * $873.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,13891.57,34712.20,Inpatient DRG
Cysto W/Insert Ureteral Stent|LEFT SIDE,CASE-52332,APC,52332,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3464.44,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3299.47,3464.44,OPPS APC
"Tendon Sheath Incision|RIGHT HAND, THIRD DIGIT",CASE-26055,APC,26055,CPT,0360,RC,,,F7,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1505.12,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1505.12,1580.37,OPPS APC
Strtctc Cptr Asstd Px Extradural Cranial,CASE-61782,APC,61782,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5818.16,,"APC Price ($5,541.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5541.10,5818.16,OPPS APC
"Open Tx Phalangeal Shaft Fracture Prox/Middle Ea|LEFT HAND, FOURTH DIGIT",CASE-26735,APC,26735,CPT,0360,RC,,,F3,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
GASTROINTESTINAL HEMORRHAGE WITH MCC,377,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],7634.00,,"Per diem ($7,634). If length of stay < 4.5, first 1 days paid at a per diem of $15,268 instead. Capped at $34,353.60.",,,,0,other,7634.00,35969.56,Estimated amount calculated based on 3 day length of stay.
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,426,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],177294.98,,"Fee schedule rate ($177,294.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,76581.29,216864.15,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC,087,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],22679.07,,"Fee schedule rate ($22,679.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,8139.36,22679.07,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],16935.49,,"Case rate ($16,129.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,140.12, add-ons for qualifying new technology services are included. If operating cost exceeds $50,011.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,797.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $13,146.70 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,195.17 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,037.40. The transfer capital threshold is the transfer adjustment factor * $1,037.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,16129.04,59610.47,Inpatient DRG
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],11811.40,,"Fee schedule rate ($11,811.40). Adds an outlier to normal pricing equal to the per diem rate ($53,248.69) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.7), with a minimum of zero.",,,,0,other,5937.41,12366.99,There are no additional notes associated with this service or procedure.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],5569.00,,"Per diem ($5,569). If length of stay < 3.8, first 1 days paid at a per diem of $11,138 instead. Capped at $21,162.80.",,,,0,other,5569.00,40108.48,Estimated amount calculated based on 2 day length of stay.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],13249.99,,"Case rate ($12,990.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,220.11, add-ons for qualifying new technology services are included. If operating cost exceeds $47,091.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,567.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $10,237.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,275.16 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $807.83. The transfer capital threshold is the transfer adjustment factor * $807.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,9888.00,43399.23,Inpatient DRG
DIABETES WITHOUT CC/MCC,639,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],11899.36,,"Fee schedule rate ($11,899.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6151.76,12223.35,There are no additional notes associated with this service or procedure.
Destruction Neurolytic Agt Genicular Nerve W/Img|RIGHT SIDE,CASE-64624,APC,64624,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1827.80,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1827.80,1891.77,OPPS APC
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],67794.72,,"Fee schedule rate ($67,794.72). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,10862.00,86437.13,There are no additional notes associated with this service or procedure.
SPINAL PROCEDURES WITHOUT CC/MCC,030,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],17651.54,,"Case rate ($16,810.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,774.52, add-ons for qualifying new technology services are included. If operating cost exceeds $50,645.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,847.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $13,778.77 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,829.57 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,087.28. The transfer capital threshold is the transfer adjustment factor * $1,087.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,16810.99,44714.01,Inpatient DRG
OSTEOMYELITIS WITH CC,540,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],18450.55,,"Fee schedule rate ($18,450.55). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,9809.07,25507.30,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITH STERILIZATION WITH MCC,783,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],23722.94,,"Fee schedule rate ($23,722.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12612.10,23722.94,There are no additional notes associated with this service or procedure.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,097,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],79915.74,,"Fee schedule rate ($79,915.74). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,26404.32,79915.74,There are no additional notes associated with this service or procedure.
Tx Anal Fstl Trans/Supra/Xtrasphnctrc Incl Seton,CASE-46280,APC,46280,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],2689.02,,"APC Price ($2,598.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2598.08,2727.99,OPPS APC
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],9533.13,,"Fee schedule rate ($9,533.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5068.21,14525.56,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],12227.29,,,,,,0,other,6153.12,13947.32,There are no additional notes associated with this service or procedure.
Arthrd Ant Interbody Min Dsc Crv Below C2,CASE-22554,APC,22554,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],12437.92,,"APC Price ($12,017.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,12437.92,12437.92,OPPS APC
HYPERTENSION WITHOUT MCC,305,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],7058.55,,"Case rate ($7,058.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,702.02, add-ons for qualifying new technology services are included. If operating cost exceeds $41,573.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,133.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,739.59 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,757.07 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $374.00. The transfer capital threshold is the transfer adjustment factor * $374.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7058.55,17230.49,Inpatient DRG
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],8372.32,,"Case rate ($8,372.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,924.20, add-ons for qualifying new technology services are included. If operating cost exceeds $42,795.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,230.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,957.28 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,979.25 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $470.09. The transfer capital threshold is the transfer adjustment factor * $470.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,23385.72,Inpatient DRG
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,699,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],8994.97,,"Case rate ($8,818.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,339.37, add-ons for qualifying new technology services are included. If operating cost exceeds $43,210.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,262.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $6,370.92 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,394.41 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $502.73. The transfer capital threshold is the transfer adjustment factor * $502.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,5961.00,19972.16,Inpatient DRG
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],26721.94,,"Fee schedule rate ($26,721.94). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6965.00,34422.94,There are no additional notes associated with this service or procedure.
OSTEOMYELITIS WITHOUT CC/MCC,541,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],11429.52,,"Fee schedule rate ($11,429.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5103.00,15493.67,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],65732.99,,,,,,0,other,9370.00,65732.99,There are no additional notes associated with this service or procedure.
SPINAL PROCEDURES WITH MCC,028,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],120982.83,,"Fee schedule rate ($120,982.83). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,42633.57,120982.83,There are no additional notes associated with this service or procedure.
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],8643.20,,"Case rate ($8,643.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,176.19, add-ons for qualifying new technology services are included. If operating cost exceeds $43,047.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,249.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $6,208.35 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,231.24 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $489.90. The transfer capital threshold is the transfer adjustment factor * $489.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8643.20,19462.52,Inpatient DRG
Laps Gstr Rstcv Px W/Byp Roux-en-Y Limb <150 Cm,CASE-43644,APC,43644,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],301.68,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,287.31,301.68,OPPS APC
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],7238.69,,"Case rate ($7,238.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,869.60, add-ons for qualifying new technology services are included. If operating cost exceeds $41,740.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,147.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,906.55 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,924.64 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $387.18. The transfer capital threshold is the transfer adjustment factor * $387.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7238.69,16804.22,Inpatient DRG
Rpr/Advmnt Flxr Tdn Zone 2 W/O Fr Grft Ea Tendon,CASE-26356,APC,26356,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC,788,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],8859.92,,"Case rate ($8,438.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,985.31, add-ons for qualifying new technology services are included. If operating cost exceeds $42,856.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,234.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,018.17 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,040.36 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $474.89. The transfer capital threshold is the transfer adjustment factor * $474.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8438.02,20142.33,Inpatient DRG
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],53769.45,,"Fee schedule rate ($53,769.45). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,26809.29,97015.50,There are no additional notes associated with this service or procedure.
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level|LEFT SIDE,CASE-64483,APC,64483,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],856.86,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,827.89,869.28,OPPS APC
Laparoscopic Appendectomy|UNUSUAL NON-OVERLAPPING SERVICE,CASE-44970,APC,44970,CPT,0360,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],5658.76,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5658.76,5941.70,OPPS APC
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],23835.16,,"Fee schedule rate ($23,835.16). Adds an outlier to normal pricing equal to the per diem rate ($63,133.20) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10533.95,24956.34,There are no additional notes associated with this service or procedure.
HC Joint Injection/Aspir Large WO US|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-20610,APC,20610,CPT,0510,RC,,,RT|XU,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
Arthrs Knee Debridement/Shaving Artclr Crtlg|RIGHT SIDE,CASE-29877,APC,29877,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,074,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],20283.05,,,,,,0,other,8925.60,20919.08,There are no additional notes associated with this service or procedure.
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],15102.37,,"Case rate ($14,383.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,516, add-ons for qualifying new technology services are included. If operating cost exceeds $48,387.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,669.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,528.54 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,571.05 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $909.72. The transfer capital threshold is the transfer adjustment factor * $909.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,36140.75,Inpatient DRG
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],31477.13,,"Fee schedule rate ($31,477.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9648.19,31477.13,There are no additional notes associated with this service or procedure.
"ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",770,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],18843.74,,"Fee schedule rate ($18,843.74). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,8735.30,19730.13,There are no additional notes associated with this service or procedure.
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],27687.78,,"Case rate ($15,821.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,854.10, add-ons for qualifying new technology services are included. If operating cost exceeds $49,725.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,774.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $12,861.73 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,909.15 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,014.92. The transfer capital threshold is the transfer adjustment factor * $1,014.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,15821.59,40320.14,All Other Inpatient
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],69000.38,,"Fee schedule rate ($69,000.38). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15), with a minimum of zero.",,,,0,other,26809.29,97015.50,There are no additional notes associated with this service or procedure.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],97015.50,,"Fee schedule rate ($97,015.50). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (30), with a minimum of zero.",,,,0,other,26809.29,97015.50,There are no additional notes associated with this service or procedure.
HC Drain/Inj Joint/Bursa W/US Large|PBB CHARGE|RIGHT SIDE,CASE-20611,APC,20611,CPT,0510,RC,,,PBB|RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],301.68,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,287.31,301.68,OPPS APC
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],96365.69,,"Fee schedule rate ($96,365.69). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,23377.19,96365.69,There are no additional notes associated with this service or procedure.
Ndsc Dcmprn Spinal Cord 1 W/Lamot Ntrspc Lumbar,CASE-62380,APC,62380,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6791.99,7131.59,OPPS APC
"CELLULITIS AND OTHER SKIN INFECTIONS,MODERATE",383,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],6487.32,,"Case rate ($6,487.32). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,6487.32,6811.69,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],86235.79,,"Fee schedule rate ($86,235.79). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,32296.02,88188.38,There are no additional notes associated with this service or procedure.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],105091.76,,"Fee schedule rate ($105,091.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,35719.96,105091.76,There are no additional notes associated with this service or procedure.
Insj Penile Prosthesos Inflatable Self-Contained,CASE-54401,APC,54401,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],20370.16,,"APC Price ($19,400.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,19400.15,20370.16,OPPS APC
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],36875.62,,"Fee schedule rate ($36,875.62). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.7), with a minimum of zero.",,,,0,other,15233.11,38610.21,There are no additional notes associated with this service or procedure.
Excision Olecranon Bursa|RIGHT SIDE,CASE-24105,APC,24105,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
Laparoscopy Surg Partial Nephrectomy|LEFT SIDE,CASE-50543,APC,50543,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],10447.27,,"APC Price ($9,949.78). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,9949.78,10447.27,OPPS APC
"POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT PROCEDURE,MODERATE",561,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],4279.03,,"Case rate ($4,075.27). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4075.27,4279.03,There are no additional notes associated with this service or procedure.
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],13545.65,,,,,,0,other,5919.29,13545.65,There are no additional notes associated with this service or procedure.
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],15802.03,,"Fee schedule rate ($15,802.03). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7566.45,16333.88,There are no additional notes associated with this service or procedure.
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITH MCC,429,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],64217.75,,"Case rate ($62,958.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $58,704.65, add-ons for qualifying new technology services are included. If operating cost exceeds $93,575.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $6,222.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.6. The base transfer operating payment is the transfer adjustment factor * $56,551.19 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $56,759.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,462.45. The transfer capital threshold is the transfer adjustment factor * $4,462.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,62958.58,177294.98,Inpatient DRG
Colpocleisis Le Fort Type,CASE-57120,APC,57120,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],4846.30,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,4682.41,4916.53,OPPS APC
SPINAL PROCEDURES WITH MCC,028,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],42633.57,,"Case rate ($42,633.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $39,796.72, add-ons for qualifying new technology services are included. If operating cost exceeds $74,667.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,735.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.5. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 9.5)) / 2. The base transfer operating payment is the transfer adjustment factor * $37,712.72 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $37,851.77 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,975.91. The transfer capital threshold is the transfer adjustment factor * $2,975.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,42633.57,120982.83,Inpatient DRG
Gastroenterology Procedure,CASE-91299,APC,91299,CPT,0750,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],126.46,,"APC Price ($120.44). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,120.44,126.46,OPPS APC
HC Anterior Epitaxis Simple|RIGHT SIDE,CASE-30901,APC,30901,CPT,0450,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],128.90,,"APC Price ($124.54). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,124.54,130.76,OPPS APC
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],40737.46,,"Fee schedule rate ($40,737.46). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,7665.00,40737.46,There are no additional notes associated with this service or procedure.
"Neuroplasty Sciatic Nerve,Open",CASE-64712,APC,64712,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],15240.59,,"Case rate ($14,725.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,834.15, add-ons for qualifying new technology services are included. If operating cost exceeds $48,705.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,694.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,845.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,889.20 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $934.73. The transfer capital threshold is the transfer adjustment factor * $934.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,7389.00,37134.43,Inpatient DRG
Parathyroidectomy/Exploration Parathyroids,CASE-60500,APC,60500,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5541.10,,"APC Price ($5,541.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5541.10,5818.16,OPPS APC
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],11137.18,,,,,,0,other,5065.00,12558.65,There are no additional notes associated with this service or procedure.
"ALCOHOLIC LIVER DISEASE,EXTREME",280,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],25609.71,,"Case rate ($24,390.20). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,24390.20,25609.71,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITH STERILIZATION WITHOUT CC/MCC,785,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],19006.00,,,,,,0,other,8431.24,20142.33,There are no additional notes associated with this service or procedure.
NEONATE WITH OTHER SIGNIFICANT PROBLEMS,794,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],12536.83,,"Case rate ($11,939.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,242.99, add-ons for qualifying new technology services are included. If operating cost exceeds $46,114.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,490.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $9,263.89 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,298.04 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $731.01. The transfer capital threshold is the transfer adjustment factor * $731.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,1798.85,12536.83,Inpatient DRG
"Amputation Toe Interphalangeal Joint|LEFT FOOT, SECOND DIGIT",CASE-28825,APC,28825,CPT,0360,RC,,,T1,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC,520,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],39786.42,,"Fee schedule rate ($39,786.42). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12061.74,39786.42,There are no additional notes associated with this service or procedure.
Chromotubation Oviduct W/Materials,CASE-58350,APC,58350,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],4682.41,,"APC Price ($4,682.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,4682.41,4916.53,OPPS APC
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],6965.00,,,,,,0,other,6965.00,34422.94,There are no additional notes associated with this service or procedure.
HC Joint Injection/Aspir Large WO US|BILATERAL PROCEDURE|PBB CHARGE,CASE-20610,APC,20610,CPT,0510,RC,,,50|PBB,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],297.37,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,287.31,301.68,OPPS APC
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],86235.79,,"Fee schedule rate ($86,235.79). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,32296.02,88188.38,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],28983.97,,"Fee schedule rate ($28,983.97). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8956.76,28983.97,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],30398.48,,"Case rate ($30,398.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $28,414.67, add-ons for qualifying new technology services are included. If operating cost exceeds $63,285.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,841.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.2. The base transfer operating payment is the transfer adjustment factor * $26,372.48 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $26,469.72 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,081.05. The transfer capital threshold is the transfer adjustment factor * $2,081.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,30398.48,82674.88,Inpatient DRG
Injection Aa&/Strd Intercostal Nrv Ea Addl Lvl|LEFT SIDE,CASE-64421,APC,64421,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],856.86,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,827.89,869.28,OPPS APC
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,097,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],79915.74,,"Fee schedule rate ($79,915.74). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,26404.32,79915.74,There are no additional notes associated with this service or procedure.
"Tendon Sheath Incision|RIGHT HAND, SECOND DIGIT|UNUSUAL NON-OVERLAPPING SERVICE",CASE-26055,APC,26055,CPT,0360,RC,,,F6|XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1557.80,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1505.12,1580.37,OPPS APC
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],23520.23,,"Fee schedule rate ($23,520.23). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10517.71,24909.11,There are no additional notes associated with this service or procedure.
Optx Dstl Radl I-Artic Fx/Epiphysl Sep 3 Frag|LEFT SIDE,CASE-25609,APC,25609,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],33890.73,,"Fee schedule rate ($33,890.73). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6277.00,36801.89,There are no additional notes associated with this service or procedure.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],16900.84,,"Fee schedule rate ($16,900.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8151.55,18033.97,There are no additional notes associated with this service or procedure.
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],34406.22,,"Fee schedule rate ($34,406.22). Adds an outlier to normal pricing equal to the per diem rate ($49,808.13) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,14343.25,36024.65,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],81524.17,,"Fee schedule rate ($81,524.17). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,8972.00,81524.17,There are no additional notes associated with this service or procedure.
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],17835.23,,,,,,0,other,7884.32,17835.23,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],23899.13,,"Fee schedule rate ($23,899.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9795.13,23899.13,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],34481.40,,"Fee schedule rate ($34,481.40). Adds an outlier to normal pricing equal to the per diem rate ($50,543.29) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,14370.36,38378.80,There are no additional notes associated with this service or procedure.
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],28334.16,,"Fee schedule rate ($28,334.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,7868.00,32126.64,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],25059.09,,"Case rate ($24,567.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $22,990.45, add-ons for qualifying new technology services are included. If operating cost exceeds $57,861.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,414.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.7. The base transfer operating payment is the transfer adjustment factor * $20,968.18 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $21,045.49 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,654.60. The transfer capital threshold is the transfer adjustment factor * $1,654.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,9370.00,65732.99,Inpatient DRG
Nasal/Sinus Ndsc Tot W/Frnt Sins Expl Tiss Rmvl|LEFT SIDE,CASE-31253,APC,31253,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6936.25,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6605.95,6936.25,OPPS APC
OTHER CEREBROVASCULAR DISORDERS WITH MCC,070,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],13681.76,,"Case rate ($13,219.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,433.04, add-ons for qualifying new technology services are included. If operating cost exceeds $47,304.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,584.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $10,449.57 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,488.10 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $824.57. The transfer capital threshold is the transfer adjustment factor * $824.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,13219.09,37774.46,Inpatient DRG
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,418,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],13869.60,,"Case rate ($13,400.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,601.88, add-ons for qualifying new technology services are included. If operating cost exceeds $47,472.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,597.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $10,617.79 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,656.93 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $837.85. The transfer capital threshold is the transfer adjustment factor * $837.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,13400.58,39884.93,Inpatient DRG
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],2070.00,,,,,,0,other,1188.00,12138.74,Estimated amount calculated based on 1 day length of stay.
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],22358.90,,"Fee schedule rate ($22,358.90). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9389.48,22358.90,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],13148.66,,"Case rate ($13,148.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,367.53, add-ons for qualifying new technology services are included. If operating cost exceeds $47,238.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,579.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $10,384.29 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,422.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $819.42. The transfer capital threshold is the transfer adjustment factor * $819.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,13148.66,32553.63,Inpatient DRG
Litholapaxy Comp/Lg > 2.5 Cm,CASE-52318,APC,52318,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3299.47,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3299.47,3464.44,OPPS APC
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],18893.86,,,,,,0,other,1188.00,18893.86,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,093,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],7337.55,,"Case rate ($7,337.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,961.57, add-ons for qualifying new technology services are included. If operating cost exceeds $41,832.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,154.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,998.19 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,016.62 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $394.41. The transfer capital threshold is the transfer adjustment factor * $394.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,19011.32,Inpatient DRG
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],59081.91,,"Fee schedule rate ($59,081.91). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,8480.00,59081.91,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],25026.36,,"Fee schedule rate ($25,026.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9356.31,25026.36,There are no additional notes associated with this service or procedure.
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC,964,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],28802.15,,"Fee schedule rate ($28,802.15). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,12323.82,34154.06,There are no additional notes associated with this service or procedure.
DIABETES WITHOUT CC/MCC,639,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],6459.35,,"Case rate ($6,151.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,858.45, add-ons for qualifying new technology services are included. If operating cost exceeds $40,729.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,067.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $3,899.13 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,913.51 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $307.68. The transfer capital threshold is the transfer adjustment factor * $307.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6151.76,12223.35,Inpatient DRG
BRONCHITIS AND ASTHMA WITH CC/MCC,202,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],19110.30,,,,,,0,other,7606.34,19110.30,There are no additional notes associated with this service or procedure.
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],6965.00,,,,,,0,other,6965.00,34422.94,There are no additional notes associated with this service or procedure.
"SKIN ULCERS,MAJOR",380,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],11331.32,,"Case rate ($10,791.73). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,10791.73,11331.32,There are no additional notes associated with this service or procedure.
"Amputation Toe Interphalangeal Joint|LEFT FOOT, SECOND DIGIT",CASE-28825,APC,28825,CPT,0360,RC,,,T1,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITHOUT CC/MCC,816,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],6349.40,,"Case rate ($6,224.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,926.50, add-ons for qualifying new technology services are included. If operating cost exceeds $40,797.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,073.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $3,966.92 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,981.55 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $313.03. The transfer capital threshold is the transfer adjustment factor * $313.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6224.90,14733.53,Inpatient DRG
"EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME, NEONATE",790,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],3054.00,,,,,,0,other,3054.00,44304.49,Estimated amount calculated based on 17 day length of stay.
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],41580.51,,"Fee schedule rate ($41,580.51). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,13783.20,41580.51,There are no additional notes associated with this service or procedure.
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],11133.98,,"Fee schedule rate ($11,133.98). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5919.29,13545.65,There are no additional notes associated with this service or procedure.
"POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT PROCEDURE,MINOR",561,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],1416.46,,"Case rate for a one day stay ($1,349.01). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,1349.01,1416.46,There are no additional notes associated with this service or procedure.
Laps Surg Cholecystectomy W/Cholangiography,CASE-47563,APC,47563,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5856.81,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5658.76,5941.70,OPPS APC
HEART FAILURE AND SHOCK WITH CC,292,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7963.74,,"Case rate ($7,694.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,293.57, add-ons for qualifying new technology services are included. If operating cost exceeds $42,164.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,180.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,328.98 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,348.63 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $420.51. The transfer capital threshold is the transfer adjustment factor * $420.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,5502.00,16705.77,Inpatient DRG
Sigmoidoscopy Flx W/Biopsy Single/Multiple,CASE-45331,APC,45331,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],870.46,,"APC Price ($870.46). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,870.46,913.99,OPPS APC
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,555,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],11441.08,,"Case rate ($10,896.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,272.18, add-ons for qualifying new technology services are included. If operating cost exceeds $45,143.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,414.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,296.64 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,327.23 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $654.69. The transfer capital threshold is the transfer adjustment factor * $654.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10896.27,42290.95,Inpatient DRG
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],86252.84,,"Fee schedule rate ($86,252.84). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,27944.96,86252.84,There are no additional notes associated with this service or procedure.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC,434,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],7060.44,,"Fee schedule rate ($7,060.44). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6770.05,14019.86,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],24703.21,,"Case rate ($23,526.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $22,022.15, add-ons for qualifying new technology services are included. If operating cost exceeds $56,893.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,338.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.7. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.7)) / 2. The base transfer operating payment is the transfer adjustment factor * $20,003.44 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $20,077.20 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,578.47. The transfer capital threshold is the transfer adjustment factor * $1,578.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,23526.87,94787.57,Inpatient DRG
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],14705.65,,"Case rate ($14,005.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,187.01, add-ons for qualifying new technology services are included. If operating cost exceeds $48,058.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,620.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $11,199.59 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,242.06 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $860.83. The transfer capital threshold is the transfer adjustment factor * $860.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,14370.36,38378.80,Inpatient DRG
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC",514,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],9097.91,,"Case rate ($8,664.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,208.71, add-ons for qualifying new technology services are included. If operating cost exceeds $43,079.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,239.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $6,240.10 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,263.76 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $479.63. The transfer capital threshold is the transfer adjustment factor * $479.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8868.04,22699.91,Inpatient DRG
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],59521.43,,"Fee schedule rate ($59,521.43). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,16689.78,59521.43,There are no additional notes associated with this service or procedure.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITHOUT CC/MCC,816,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],14733.53,,"Fee schedule rate ($14,733.53). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6224.90,14733.53,There are no additional notes associated with this service or procedure.
O.R. PROCEDURES FOR OBESITY WITH CC,620,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],13421.42,,"Case rate ($12,782.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,026.70, add-ons for qualifying new technology services are included. If operating cost exceeds $46,897.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,552.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $10,044.72 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,081.75 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $792.63. The transfer capital threshold is the transfer adjustment factor * $792.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12782.30,43753.50,Inpatient DRG
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,477,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],25885.19,,"Case rate ($24,652.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $23,111.73, add-ons for qualifying new technology services are included. If operating cost exceeds $57,982.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,380.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 8.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $21,086.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $21,166.78 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,620.78. The transfer capital threshold is the transfer adjustment factor * $1,620.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,25339.74,67976.16,Inpatient DRG
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC,964,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],28802.15,,"Fee schedule rate ($28,802.15). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,12323.82,34154.06,There are no additional notes associated with this service or procedure.
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],8086.81,,"Case rate ($7,701.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,311.09, add-ons for qualifying new technology services are included. If operating cost exceeds $42,182.10 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,170.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $5,345.87 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,366.14 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $410.90. The transfer capital threshold is the transfer adjustment factor * $410.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7875.94,17233.12,Inpatient DRG
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC",156,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],12624.95,,"Fee schedule rate ($12,624.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6625.12,13598.77,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],21657.71,,"Fee schedule rate ($21,657.71). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,7665.00,40737.46,There are no additional notes associated with this service or procedure.
"CELLULITIS AND OTHER SKIN INFECTIONS,MODERATE",383,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],6811.69,,"Case rate ($6,487.32). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6487.32,6811.69,There are no additional notes associated with this service or procedure.
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],26301.36,,"Fee schedule rate ($26,301.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11247.07,27028.33,There are no additional notes associated with this service or procedure.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,191,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],16587.71,,,,,,0,other,6965.00,16612.88,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,091,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],40030.81,,"Fee schedule rate ($40,030.81). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,13838.06,40030.81,There are no additional notes associated with this service or procedure.
"COAGULATION AND PLATELET DISORDERS,MODERATE",661,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],10268.75,,"Case rate ($9,779.76). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,9779.76,10268.75,There are no additional notes associated with this service or procedure.
TRAUMATIC INJURY WITH MCC,913,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],42838.46,,"Fee schedule rate ($42,838.46). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13014.58,42838.46,There are no additional notes associated with this service or procedure.
OTHER CEREBROVASCULAR DISORDERS WITH CC,071,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],29215.10,,"Fee schedule rate ($29,215.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5843.00,29215.10,There are no additional notes associated with this service or procedure.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,352,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],21946.47,,"Fee schedule rate ($21,946.47). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,9853.37,26528.70,There are no additional notes associated with this service or procedure.
Cystostomy Cystotomy W/Drainage,CASE-51040,APC,51040,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1956.65,,"APC Price ($1,956.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1956.65,2054.48,OPPS APC
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],11747.40,,"Fee schedule rate ($11,747.40). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,6965.00,21195.68,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF NERVOUS SYSTEM WITH CC,092,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],19225.24,,"Fee schedule rate ($19,225.24). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8872.78,26765.51,There are no additional notes associated with this service or procedure.
Dstr Nrolytc Agnt Parverteb Fct Sngl Lmbr/Sacral|LEFT SIDE,CASE-64635,APC,64635,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1919.19,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1827.80,1919.19,OPPS APC
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],67790.93,,"Fee schedule rate ($67,790.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,21597.50,67790.93,There are no additional notes associated with this service or procedure.
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],7086.00,,"Per diem ($7,086). If length of stay < 7.8, first 1 days paid at a per diem of $14,172 instead. Capped at $55,272.09.",,,,0,other,7086.00,57872.02,Estimated amount calculated based on 5 day length of stay.
Perq Drainage Pleura Insert Cath W/O Imaging|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-32556,APC,32556,CPT,0360,RC,,,LT|XU,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5658.76,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5658.76,5856.81,OPPS APC
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],41944.25,,"Fee schedule rate ($41,944.25). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12795.84,41944.25,There are no additional notes associated with this service or procedure.
Suction Assisted Lipectomy Lower Extremity|BILATERAL PROCEDURE,CASE-15879,APC,15879,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6215.36,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6215.36,6526.12,OPPS APC
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],9188.34,,"Case rate ($8,750.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,288.98, add-ons for qualifying new technology services are included. If operating cost exceeds $43,159.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,245.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $6,320.07 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,344.03 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $485.78. The transfer capital threshold is the transfer adjustment factor * $485.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8956.76,28983.97,Inpatient DRG
"Open Tx Phalangeal Shaft Fracture Prox/Middle Ea|LEFT HAND, THIRD DIGIT",CASE-26735,APC,26735,CPT,0360,RC,,,F2,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,451,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],24297.87,,"Case rate ($23,821.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $22,296.19, add-ons for qualifying new technology services are included. If operating cost exceeds $57,167.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,359.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $20,276.48 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $20,351.24 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,600.01. The transfer capital threshold is the transfer adjustment factor * $1,600.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,23821.44,94077.13,Inpatient DRG
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|LEFT HAND, SECOND DIGIT",CASE-26160,APC,26160,CPT,0360,RC,,,F1,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1580.37,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1505.12,1580.37,OPPS APC
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],52803.53,,"Fee schedule rate ($52,803.53). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,14337.84,52803.53,There are no additional notes associated with this service or procedure.
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],24528.10,,"Fee schedule rate ($24,528.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10989.72,26280.60,There are no additional notes associated with this service or procedure.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,097,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],26932.41,,"Case rate ($26,404.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $24,698.97, add-ons for qualifying new technology services are included. If operating cost exceeds $59,569.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,548.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.7. The base transfer operating payment is the transfer adjustment factor * $22,670.44 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $22,754.03 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,788.92. The transfer capital threshold is the transfer adjustment factor * $1,788.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,26404.32,79915.74,Inpatient DRG
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|LEFT HAND, SECOND DIGIT",CASE-26160,APC,26160,CPT,0360,RC,,,F1,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1505.12,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1505.12,1580.37,OPPS APC
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],7386.59,,"Case rate ($7,034.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,679.97, add-ons for qualifying new technology services are included. If operating cost exceeds $41,550.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,132.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $4,717.62 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,735.02 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $372.27. The transfer capital threshold is the transfer adjustment factor * $372.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,21089.59,Inpatient DRG
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],38517.10,,"Fee schedule rate ($38,517.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,16897.01,43444.85,There are no additional notes associated with this service or procedure.
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],10255.35,,"Case rate ($9,767). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,236.23, add-ons for qualifying new technology services are included. If operating cost exceeds $44,107.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,318.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $7,263.74 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,291.28 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $558.31. The transfer capital threshold is the transfer adjustment factor * $558.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10003.71,23415.63,Inpatient DRG
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],13354.32,,"Case rate ($13,092.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,315.24, add-ons for qualifying new technology services are included. If operating cost exceeds $47,186.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,575.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $10,332.19 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,370.29 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $815.31. The transfer capital threshold is the transfer adjustment factor * $815.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,13092.47,33159.45,Inpatient DRG
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],9095.00,,"Case rate ($8,787.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,310.38, add-ons for qualifying new technology services are included. If operating cost exceeds $43,181.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,260.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,342.05 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,365.43 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $500.45. The transfer capital threshold is the transfer adjustment factor * $500.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6965.00,32293.66,Inpatient DRG
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],96365.69,,"Fee schedule rate ($96,365.69). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,23377.19,96365.69,There are no additional notes associated with this service or procedure.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],9552.48,,"Case rate ($9,097.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,598.92, add-ons for qualifying new technology services are included. If operating cost exceeds $43,469.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,283.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,629.53 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,653.97 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $523.14. The transfer capital threshold is the transfer adjustment factor * $523.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9097.60,21455.22,Inpatient DRG
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],27222.08,,"Fee schedule rate ($27,222.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7389.00,37134.43,There are no additional notes associated with this service or procedure.
HC >= 12 Lead Ekg,CASE-93005,APC,93005,CPT,0730,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],57.15,,"APC Price ($55.22). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,55.22,57.98,OPPS APC
Mastectomy Partial|LEFT SIDE,CASE-19301,APC,19301,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6215.36,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6215.36,6526.12,OPPS APC
Unlisted Laparoscopy Px Abd Pertoneum & Omentum,CASE-49329,APC,49329,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5658.76,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5658.76,5856.81,OPPS APC
"POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT PROCEDURE,MODERATE",561,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],4279.03,,"Case rate ($4,075.27). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4075.27,4279.03,There are no additional notes associated with this service or procedure.
Bronchoscopy W/Transbroncl Ndl Aspir Bx Ea Lobe,CASE-31633,APC,31633,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6605.95,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6605.95,6936.25,OPPS APC
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC,831,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],10088.35,,"Case rate ($10,088.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,520.59, add-ons for qualifying new technology services are included. If operating cost exceeds $44,391.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,355.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $7,547.82 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,575.65 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $595.60. The transfer capital threshold is the transfer adjustment factor * $595.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,4941.30,23661.59,Inpatient DRG
Laps Fulg/Exc Ovary Viscera/Peritoneal Surface|RIGHT SIDE,CASE-58662,APC,58662,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5941.70,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5658.76,5941.70,OPPS APC
Excision Pilonidal Cyst/Sinus Complicated,CASE-11772,APC,11772,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],2718.88,,"APC Price ($2,718.88). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2718.88,2854.83,OPPS APC
Excision Hydrocele Unilateral|RIGHT SIDE,CASE-55040,APC,55040,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3518.91,,"APC Price ($3,351.34). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3351.34,3518.91,OPPS APC
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],33221.97,,"Fee schedule rate ($33,221.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (47), with a minimum of zero.",,,,0,other,15283.90,38757.79,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],21195.68,,"Fee schedule rate ($21,195.68). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,6965.00,21195.68,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS WITH MCC,947,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],23855.83,,"Fee schedule rate ($23,855.83). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10541.41,30414.32,There are no additional notes associated with this service or procedure.
"Excis Intrasp Lesn,Xdural,Lumbar",CASE-63267,APC,63267,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7029.71,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6791.99,7131.59,OPPS APC
Arthrs Kne Surg W/Meniscectomy Med/Lat W/Shvg|LEFT SIDE,CASE-29881,APC,29881,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],6780.05,,"Case rate ($6,457.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,142.59, add-ons for qualifying new technology services are included. If operating cost exceeds $41,013.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,089.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $4,182.21 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,197.63 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $330.02. The transfer capital threshold is the transfer adjustment factor * $330.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5139.72,13110.79,Inpatient DRG
Autograft Spine Surgery Local From Same Incision,CASE-20936,APC,20936,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],16986.50,,"APC Price ($16,412.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,16412.07,17232.68,OPPS APC
CESAREAN SECTION WITHOUT STERILIZATION WITH CC,787,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],23722.94,,"Fee schedule rate ($23,722.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9508.01,23722.94,There are no additional notes associated with this service or procedure.
Cervical Lymphadec Modified Radical Neck Dsj|RIGHT SIDE,CASE-38724,APC,38724,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],209.05,,"APC Price ($199.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,199.10,209.05,OPPS APC
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC",061,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],21071.18,,"Case rate ($20,067.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $18,838.06, add-ons for qualifying new technology services are included. If operating cost exceeds $53,709.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,053.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $16,829.30 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $16,893.11 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,293.54. The transfer capital threshold is the transfer adjustment factor * $1,293.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,20616.23,62315.82,Inpatient DRG
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],30236.06,,"Fee schedule rate ($30,236.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.8), with a minimum of zero.",,,,0,other,1188.00,31658.33,There are no additional notes associated with this service or procedure.
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],15453.88,,"Case rate ($15,453.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,512.02, add-ons for qualifying new technology services are included. If operating cost exceeds $49,383.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,747.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $12,520.90 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,567.07 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $988.02. The transfer capital threshold is the transfer adjustment factor * $988.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,15453.88,39251.68,Inpatient DRG
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],72151.96,,"Fee schedule rate ($72,151.96). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,27944.96,86252.84,There are no additional notes associated with this service or procedure.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],18467.93,,"Case rate ($18,105.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,979.06, add-ons for qualifying new technology services are included. If operating cost exceeds $51,850.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,941.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $14,978.89 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,034.11 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,181.98. The transfer capital threshold is the transfer adjustment factor * $1,181.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,18105.81,52699.33,Inpatient DRG
Dstr Nrolytc Agnt Parverteb Fct Sngl Crvcl/Thora|LEFT SIDE,CASE-64633,APC,64633,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1891.77,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1827.80,1919.19,OPPS APC
Cystourethroscopy Inj Chemodenervation Bladder,CASE-52287,APC,52287,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1956.65,,"APC Price ($1,956.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1956.65,2054.48,OPPS APC
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],7600.62,,"Case rate ($7,238.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,869.60, add-ons for qualifying new technology services are included. If operating cost exceeds $41,740.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,147.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,906.55 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,924.64 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $387.18. The transfer capital threshold is the transfer adjustment factor * $387.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7238.69,16804.22,Inpatient DRG
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],21512.35,,"Fee schedule rate ($21,512.35). Adds an outlier to normal pricing equal to the per diem rate ($37,521.53) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,9696.93,35061.53,There are no additional notes associated with this service or procedure.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],133270.57,,"Fee schedule rate ($133,270.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,33623.33,133270.57,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],5910.42,,"Case rate ($5,628.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,372.11, add-ons for qualifying new technology services are included. If operating cost exceeds $40,243.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,029.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,414.56 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,427.15 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $269.44. The transfer capital threshold is the transfer adjustment factor * $269.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5628.97,12272.58,Inpatient DRG
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],8234.89,,"Case rate ($7,842.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,431.55, add-ons for qualifying new technology services are included. If operating cost exceeds $42,302.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,191.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $5,466.44 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,486.60 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $431.36. The transfer capital threshold is the transfer adjustment factor * $431.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5280.00,17136.70,Inpatient DRG
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 2nd Level|LEFT SIDE,CASE-64494,APC,64494,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],869.28,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,827.89,869.28,OPPS APC
Osteot W/WO Lngth Shrt/Corrj Metar Xcp 1st Ea|LEFT SIDE,CASE-28308,APC,28308,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
Sphincterotomy Anal Division Sphincter Spx,CASE-46080,APC,46080,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],2598.08,,"APC Price ($2,598.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2598.08,2727.99,OPPS APC
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],6965.00,,,,,,0,other,6965.00,21089.59,There are no additional notes associated with this service or procedure.
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],17755.26,,"Fee schedule rate ($17,755.26). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7847.50,17755.26,There are no additional notes associated with this service or procedure.
RESPIRATORY NEOPLASMS WITHOUT CC/MCC,182,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],23037.13,,"Fee schedule rate ($23,037.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6965.00,23037.13,There are no additional notes associated with this service or procedure.
COAGULATION DISORDERS,813,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],28664.96,,"Fee schedule rate ($28,664.96). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.7), with a minimum of zero.",,,,0,other,12274.39,30013.33,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],26966.33,,"Fee schedule rate ($26,966.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,9040.72,26966.33,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],31401.22,,"Fee schedule rate ($31,401.22). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.7), with a minimum of zero.",,,,0,other,13260.40,32878.30,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITH CC,386,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],19879.00,,"Fee schedule rate ($19,879.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8556.53,19879.00,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,448,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],79697.35,,"Fee schedule rate ($79,697.35). Adds an outlier to normal pricing equal to the per diem rate ($108,215.07) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,30663.95,94077.13,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,066,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],20083.61,,"Fee schedule rate ($20,083.61). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6579.76,20083.61,There are no additional notes associated with this service or procedure.
PERITONEAL ADHESIOLYSIS WITH CC,336,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],39628.80,,"Fee schedule rate ($39,628.80). Adds an outlier to normal pricing equal to the per diem rate ($54,966.40) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,16225.22,53705.31,There are no additional notes associated with this service or procedure.
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],16283.24,,"Fee schedule rate ($16,283.24). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7875.94,17233.12,There are no additional notes associated with this service or procedure.
OSTEOMYELITIS WITH CC,540,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],10989.02,,"Case rate ($10,465.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,887.55, add-ons for qualifying new technology services are included. If operating cost exceeds $44,758.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,368.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $7,912.60 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,942.60 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $608.18. The transfer capital threshold is the transfer adjustment factor * $608.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9809.07,25507.30,Inpatient DRG
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],25796.13,,"Case rate ($24,567.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $22,990.45, add-ons for qualifying new technology services are included. If operating cost exceeds $57,861.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,414.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.7. The base transfer operating payment is the transfer adjustment factor * $20,968.18 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $21,045.49 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,654.60. The transfer capital threshold is the transfer adjustment factor * $1,654.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9370.00,65732.99,Inpatient DRG
Ligamentous Reconstruction Knee Extra-Articular,CASE-27427,APC,27427,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6791.99,7131.59,OPPS APC
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],6310.74,,"Case rate ($6,010.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,726.79, add-ons for qualifying new technology services are included. If operating cost exceeds $40,597.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,057.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,767.95 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,781.84 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $297.33. The transfer capital threshold is the transfer adjustment factor * $297.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6010.23,12246.05,Inpatient DRG
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,451,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],25012.51,,"Case rate ($23,821.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $22,296.19, add-ons for qualifying new technology services are included. If operating cost exceeds $57,167.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,359.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $20,276.48 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $20,351.24 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,600.01. The transfer capital threshold is the transfer adjustment factor * $1,600.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,23821.44,94077.13,Inpatient DRG
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITHOUT MCC,430,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],108381.11,,"Fee schedule rate ($108,381.11). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.6), with a minimum of zero.",,,,0,other,41000.16,133156.90,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,167,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],14653.23,,"Case rate ($14,157.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,306.21, add-ons for qualifying new technology services are included. If operating cost exceeds $48,177.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,653.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $11,319.53 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,361.26 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $893.22. The transfer capital threshold is the transfer adjustment factor * $893.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,14157.71,43522.37,Inpatient DRG
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],22955.40,,"Case rate ($21,862.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,473.63, add-ons for qualifying new technology services are included. If operating cost exceeds $55,344.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,216.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. The base transfer operating payment is the transfer adjustment factor * $18,460.61 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,528.68 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,456.72. The transfer capital threshold is the transfer adjustment factor * $1,456.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7086.00,57872.02,Inpatient DRG
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],36855.62,,"Fee schedule rate ($36,855.62). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,15821.59,40320.14,There are no additional notes associated with this service or procedure.
"OTHER PNEUMONIA,MAJOR",139,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],10158.02,,"Case rate ($10,158.02). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,10158.02,10665.92,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC,087,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],22679.07,,"Fee schedule rate ($22,679.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,8139.36,22679.07,There are no additional notes associated with this service or procedure.
HC Joint Injection/Aspir Large WO US|LEFT SIDE,CASE-20610,APC,20610,CPT,0510,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],23239.84,,"Fee schedule rate ($23,239.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8543.64,23239.84,There are no additional notes associated with this service or procedure.
COAGULATION DISORDERS,813,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],12274.39,,"Case rate ($12,274.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,554.21, add-ons for qualifying new technology services are included. If operating cost exceeds $46,425.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,515.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $9,573.96 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,609.26 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $755.48. The transfer capital threshold is the transfer adjustment factor * $755.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12274.39,30013.33,Inpatient DRG
Laryngoscopy Direct Operative W/Biopsy,CASE-31535,APC,31535,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3664.31,,"APC Price ($3,489.82). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3489.82,3664.31,OPPS APC
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC,939,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],97674.79,,"Fee schedule rate ($97,674.79). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,26517.40,97674.79,There are no additional notes associated with this service or procedure.
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC",458,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],30202.09,,"Case rate ($30,202.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $28,231.97, add-ons for qualifying new technology services are included. If operating cost exceeds $63,102.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,826.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $26,190.45 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $26,287.02 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,066.69. The transfer capital threshold is the transfer adjustment factor * $2,066.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,30202.09,132827.25,Inpatient DRG
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,191,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],9207.45,,"Fee schedule rate ($9,207.45). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6965.00,16612.88,There are no additional notes associated with this service or procedure.
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,450,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],38037.38,,"Case rate ($38,037.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $35,520.98, add-ons for qualifying new technology services are included. If operating cost exceeds $70,391.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,399.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $33,452.68 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $33,576.02 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,639.75. The transfer capital threshold is the transfer adjustment factor * $2,639.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,38037.38,146009.19,Inpatient DRG
OTHER CEREBROVASCULAR DISORDERS WITH MCC,070,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],37774.46,,"Fee schedule rate ($37,774.46). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,13219.09,37774.46,There are no additional notes associated with this service or procedure.
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH MCC",722,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],56869.13,,"Fee schedule rate ($56,869.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,14200.37,56869.13,There are no additional notes associated with this service or procedure.
Colonoscopy W/Biopsy Single/Multiple|COLORECTAL CANCER SCREEN,CASE-45380,APC,45380,CPT,0360,RC,,,PT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1159.29,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1120.09,1176.09,OPPS APC
HEART FAILURE AND SHOCK WITH CC,292,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],7694.43,,"Case rate ($7,694.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,293.57, add-ons for qualifying new technology services are included. If operating cost exceeds $42,164.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,180.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,328.98 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,348.63 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $420.51. The transfer capital threshold is the transfer adjustment factor * $420.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,5502.00,16705.77,Inpatient DRG
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,069,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],20333.68,,"Fee schedule rate ($20,333.68). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,20333.68,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],51903.64,,"Fee schedule rate ($51,903.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,16017.99,51903.64,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],31091.14,,"Fee schedule rate ($31,091.14). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13148.66,32553.63,There are no additional notes associated with this service or procedure.
OTHER CEREBROVASCULAR DISORDERS WITH CC,071,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],29215.10,,"Fee schedule rate ($29,215.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5843.00,29215.10,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],24838.71,,"Fee schedule rate ($24,838.71). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,10895.60,35192.25,There are no additional notes associated with this service or procedure.
Exc B9 Lesion Mrgn Xcp Sk Tg T/a/L 3.1-4.0 Cm,CASE-11404,APC,11404,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1545.93,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1545.93,1623.23,OPPS APC
HC External Version,CASE-59412,APC,59412,CPT,0720,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3030.03,,"APC Price ($3,030.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3030.03,3181.53,OPPS APC
HC Biopsy/Exc Lymph Node Needle|LEFT SIDE,CASE-38505,APC,38505,CPT,0361,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1600.04,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1545.93,1600.04,OPPS APC
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],30245.71,,"Fee schedule rate ($30,245.71). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9151.11,30245.71,There are no additional notes associated with this service or procedure.
Colon Ca Scrn Not Hi Rsk Ind|DOCUMENTATION ON FILE,CASE-G0121,APC,G0121,CPT,0360,RC,,,KX,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],870.46,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,870.46,913.99,OPPS APC
Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn,CASE-62323,APC,62323,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],683.85,,"APC Price ($660.72). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,660.72,693.76,OPPS APC
Posterior Non-Segmental Instrumentation,CASE-22840,APC,22840,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],25398.09,,"APC Price ($25,398.09). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,25398.09,26287.03,OPPS APC
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],47169.70,,,,,,0,other,18178.96,54764.34,There are no additional notes associated with this service or procedure.
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH MCC",722,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],34009.69,,"Fee schedule rate ($34,009.69). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,14200.37,56869.13,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6787.66,,"Case rate ($6,787.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,450.02, add-ons for qualifying new technology services are included. If operating cost exceeds $41,321.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,114.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,488.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,505.07 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $354.19. The transfer capital threshold is the transfer adjustment factor * $354.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6164.03,14071.02,Inpatient DRG
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],29582.40,,,,,,0,other,12126.09,29582.40,There are no additional notes associated with this service or procedure.
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,069,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],15717.99,,,,,,0,other,6965.00,20333.68,There are no additional notes associated with this service or procedure.
HC Pbb Carpal Tunnel Inj Pmc|PBB CHARGE,CASE-20526,APC,20526,CPT,0510,RC,,,PBB,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],301.68,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,287.31,301.68,OPPS APC
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,451,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],94077.13,,"Fee schedule rate ($94,077.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,23821.44,94077.13,There are no additional notes associated with this service or procedure.
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],90333.60,,"Fee schedule rate ($90,333.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,26127.34,90333.60,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],23954.07,,"Fee schedule rate ($23,954.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,6167.00,29058.99,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,394,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],20909.61,,"Fee schedule rate ($20,909.61). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8281.56,20909.61,There are no additional notes associated with this service or procedure.
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 2nd Level|RIGHT SIDE,CASE-64494,APC,64494,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],869.28,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,827.89,869.28,OPPS APC
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],128358.13,,"Fee schedule rate ($128,358.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,40542.37,128358.13,There are no additional notes associated with this service or procedure.
Rpr Aa Hernia 1st < 3 Cm Ncrc8/Strangulated,CASE-49592,APC,49592,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5856.81,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5856.81,5941.70,OPPS APC
Dstrj Lesion Anus Extensive,CASE-46924,APC,46924,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],2598.08,,"APC Price ($2,598.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2598.08,2727.99,OPPS APC
HC Joint Injection/Aspir Large WO US|PBB CHARGE|BILATERAL PROCEDURE,CASE-20610,APC,20610,CPT,0510,RC,,,PBB|50,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
CHOLECYSTECTOMY WITH C.D.E. WITH MCC,411,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],24315.13,,"Case rate ($24,315.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $22,755.46, add-ons for qualifying new technology services are included. If operating cost exceeds $57,626.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,396.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $20,734.06 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $20,810.51 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,636.12. The transfer capital threshold is the transfer adjustment factor * $1,636.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,24315.13,88615.28,Inpatient DRG
Dstr Nrolytc Agnt Parverteb Fct Sngl Crvcl/Thora,CASE-64633,APC,64633,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1827.80,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1827.80,1919.19,OPPS APC
CERVICAL SPINAL FUSION WITHOUT CC/MCC,473,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],45879.35,,"Fee schedule rate ($45,879.35). Adds an outlier to normal pricing equal to the per diem rate ($58,401.78) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,18477.61,62077.11,There are no additional notes associated with this service or procedure.
"Tendon Sheath Incision|RIGHT HAND, THUMB",CASE-26055,APC,26055,CPT,0360,RC,,,F5,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1557.80,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1505.12,1580.37,OPPS APC
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],41006.47,,"Fee schedule rate ($41,006.47). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12268.97,41006.47,There are no additional notes associated with this service or procedure.
MAJOR ESOPHAGEAL DISORDERS WITH CC,369,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],9023.52,,"Case rate ($8,718.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,246.12, add-ons for qualifying new technology services are included. If operating cost exceeds $43,117.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,255.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,278.03 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,301.17 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $495.40. The transfer capital threshold is the transfer adjustment factor * $495.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6965.00,19680.94,Inpatient DRG
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],47751.13,,"Fee schedule rate ($47,751.13). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.7), with a minimum of zero.",,,,0,other,19152.11,53152.12,There are no additional notes associated with this service or procedure.
"VAGINAL DELIVERY,MODERATE",560,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],4318.66,,"Case rate ($4,318.66). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,4318.66,4534.59,There are no additional notes associated with this service or procedure.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC,027,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],19454.77,,"Case rate ($18,528.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,403.08, add-ons for qualifying new technology services are included. If operating cost exceeds $52,274.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,943.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $15,399.75 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,458.13 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,183.66. The transfer capital threshold is the transfer adjustment factor * $1,183.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,19030.20,56363.30,Inpatient DRG
Ercp Biliary/Panc Duct Stent Exchange W/Dil&Wire,CASE-43276,APC,43276,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5966.63,,"APC Price ($5,682.51). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5682.51,5966.63,OPPS APC
HC Lyr Clos Sc Tk Ext 2.6-7 Cm|SEPARATE STRUCTURE,CASE-12032,APC,12032,CPT,0450,RC,,,XS,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],2718.88,,"APC Price ($2,718.88). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2718.88,2854.83,OPPS APC
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],85305.59,,"Fee schedule rate ($85,305.59). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,21719.40,85305.59,There are no additional notes associated with this service or procedure.
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC,939,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],97674.79,,"Fee schedule rate ($97,674.79). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,26517.40,97674.79,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],10358.84,,"Case rate ($9,865.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,313.33, add-ons for qualifying new technology services are included. If operating cost exceeds $44,184.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,339.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $7,341.31 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,368.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $579.30. The transfer capital threshold is the transfer adjustment factor * $579.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9865.56,37914.65,Inpatient DRG
TRAUMATIC INJURY WITH MCC,913,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],22774.69,,"Fee schedule rate ($22,774.69). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13014.58,42838.46,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],6524.75,,"Case rate ($6,214.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,916.41, add-ons for qualifying new technology services are included. If operating cost exceeds $40,787.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,072.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $3,956.88 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,971.47 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $312.24. The transfer capital threshold is the transfer adjustment factor * $312.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6214.05,15318.94,Inpatient DRG
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],22762.43,,"Fee schedule rate ($22,762.43). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6230.00,22762.43,There are no additional notes associated with this service or procedure.
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],17755.26,,"Fee schedule rate ($17,755.26). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7847.50,17755.26,There are no additional notes associated with this service or procedure.
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],22732.01,,"Fee schedule rate ($22,732.01). Adds an outlier to normal pricing equal to the per diem rate ($114,196.66) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.5), with a minimum of zero.",,,,0,other,10136.44,24444.75,There are no additional notes associated with this service or procedure.
HC Bx Breast 1st Lesion US Img|BILATERAL PROCEDURE,CASE-19083,APC,19083,CPT,0361,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],2718.88,,"APC Price ($2,718.88). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2718.88,2854.83,OPPS APC
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,477,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],25339.74,,"Case rate ($25,339.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $23,708.63, add-ons for qualifying new technology services are included. If operating cost exceeds $58,579.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,471.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 8.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $21,683.73 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $21,763.68 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,711.06. The transfer capital threshold is the transfer adjustment factor * $1,711.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,25339.74,67976.16,Inpatient DRG
NERVOUS SYSTEM NEOPLASMS WITH MCC,054,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],6965.00,,,,,,0,other,6965.00,30044.81,There are no additional notes associated with this service or procedure.
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],22487.70,,"Fee schedule rate ($22,487.70). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10048.39,23545.50,There are no additional notes associated with this service or procedure.
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],11454.97,,"Case rate ($11,454.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,791.92, add-ons for qualifying new technology services are included. If operating cost exceeds $45,662.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,455.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $8,814.47 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,846.97 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $695.55. The transfer capital threshold is the transfer adjustment factor * $695.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,11454.97,28394.78,Inpatient DRG
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],13118.71,,"Fee schedule rate ($13,118.71). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10834.64,25830.00,There are no additional notes associated with this service or procedure.
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],9700.30,,"Fee schedule rate ($9,700.30). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8106.18,18245.94,There are no additional notes associated with this service or procedure.
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],12804.91,,"Case rate ($12,195.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,480.50, add-ons for qualifying new technology services are included. If operating cost exceeds $46,351.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,509.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,500.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,535.55 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $749.68. The transfer capital threshold is the transfer adjustment factor * $749.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12195.15,39424.57,Inpatient DRG
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITHOUT CC/MCC,816,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],14733.53,,"Fee schedule rate ($14,733.53). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6224.90,14733.53,There are no additional notes associated with this service or procedure.
HC Joint Injection/Aspir Large WO US|LEFT SIDE,CASE-20610,APC,20610,CPT,0510,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC,058,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],40853.02,,"Fee schedule rate ($40,853.02). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,13521.80,40853.02,There are no additional notes associated with this service or procedure.
Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn,CASE-62323,APC,62323,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],693.76,,"APC Price ($660.72). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,660.72,693.76,OPPS APC
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH MCC",510,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],89863.76,,"Fee schedule rate ($89,863.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10710.00,89863.76,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL OBSTRUCTION WITH CC,389,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],16423.43,,"Fee schedule rate ($16,423.43). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5118.00,16423.43,There are no additional notes associated with this service or procedure.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],15309.46,,"Fee schedule rate ($15,309.46). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6965.00,15340.19,There are no additional notes associated with this service or procedure.
"VAGINAL DELIVERY,MAJOR",560,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],6397.25,,"Case rate ($6,092.62). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6092.62,6397.25,There are no additional notes associated with this service or procedure.
"Prq Skel Fixj Phlngl Shft Fx Prox/Middle Px/F/T|RIGHT HAND, FIFTH DIGIT",CASE-26727,APC,26727,CPT,0360,RC,,,F9,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
Dstr Nrolytc Agnt Parverteb Fct Addl Crvcl/Thora|RIGHT SIDE,CASE-64634,APC,64634,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1891.77,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1891.77,1919.19,OPPS APC
Rmvl Spinal Nstim Eltrd Prq Array Incl Fluor,CASE-63661,APC,63661,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3386.97,,"APC Price ($3,272.44). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3272.44,3436.06,OPPS APC
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC,831,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],6965.00,,,,,,0,other,4941.30,23661.59,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC,788,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],20142.33,,"Fee schedule rate ($20,142.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8438.02,20142.33,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],25609.86,,"Fee schedule rate ($25,609.86). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,12775.53,31469.43,There are no additional notes associated with this service or procedure.
"Fasct Prtl Palmr Addl Dgt Prox Iphal Jt W/WO Rpr|RIGHT HAND, FOURTH DIGIT",CASE-26125,APC,26125,CPT,0360,RC,,,F8,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],37665.71,,,,,,0,other,14908.05,49717.39,There are no additional notes associated with this service or procedure.
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],23216.87,,"Fee schedule rate ($23,216.87). Adds an outlier to normal pricing equal to the per diem rate ($51,531) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.7), with a minimum of zero.",,,,0,other,10311.17,24308.97,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],78960.67,,"Fee schedule rate ($78,960.67). Adds an outlier to normal pricing equal to the per diem rate ($149,567.78) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19.1), with a minimum of zero.",,,,0,other,30398.48,82674.88,There are no additional notes associated with this service or procedure.
"Tendon Sheath Incision|RIGHT HAND, THIRD DIGIT|UNUSUAL NON-OVERLAPPING SERVICE",CASE-26055,APC,26055,CPT,0360,RC,,,F7|XU,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1505.12,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1505.12,1580.37,OPPS APC
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,085,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],44704.18,,,,,,0,other,9282.00,57443.16,There are no additional notes associated with this service or procedure.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],27329.90,,"Case rate ($26,028.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $24,349.34, add-ons for qualifying new technology services are included. If operating cost exceeds $59,220.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,521.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $22,322.08 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $22,404.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,761.43. The transfer capital threshold is the transfer adjustment factor * $1,761.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,26028.48,80635.65,Inpatient DRG
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],42021.93,,"Fee schedule rate ($42,021.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,21248.73,56089.29,There are no additional notes associated with this service or procedure.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],59521.43,,"Fee schedule rate ($59,521.43). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,16689.78,59521.43,There are no additional notes associated with this service or procedure.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],17194.49,,"Fee schedule rate ($17,194.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8554.50,19204.75,There are no additional notes associated with this service or procedure.
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],23078.81,,"Fee schedule rate ($23,078.81). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10311.17,24308.97,There are no additional notes associated with this service or procedure.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],20553.44,,"Fee schedule rate ($20,553.44). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8874.81,20553.44,There are no additional notes associated with this service or procedure.
Destruction Neurolytic Agt Genicular Nerve W/Img|RIGHT SIDE,CASE-64624,APC,64624,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1891.77,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1827.80,1891.77,OPPS APC
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],21195.68,,"Fee schedule rate ($21,195.68). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,6965.00,21195.68,There are no additional notes associated with this service or procedure.
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],12606.23,,"Case rate ($12,606.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,862.91, add-ons for qualifying new technology services are included. If operating cost exceeds $46,733.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,539.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $9,881.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,917.95 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $779.75. The transfer capital threshold is the transfer adjustment factor * $779.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12606.23,36868.88,Inpatient DRG
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],12698.38,,"Case rate ($12,268.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,549.17, add-ons for qualifying new technology services are included. If operating cost exceeds $46,420.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,515.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,568.94 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,604.22 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $755.08. The transfer capital threshold is the transfer adjustment factor * $755.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,12268.97,41006.47,Inpatient DRG
Cystourethroscopy W/Dest &/Rmvl Med Bladder Tum,CASE-52235,APC,52235,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3299.47,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3299.47,3464.44,OPPS APC
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],31401.22,,"Fee schedule rate ($31,401.22). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.7), with a minimum of zero.",,,,0,other,13260.40,32878.30,There are no additional notes associated with this service or procedure.
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],18217.52,,"Fee schedule rate ($18,217.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7414.07,18217.52,There are no additional notes associated with this service or procedure.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],13647.09,,"Case rate ($13,647.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,831.20, add-ons for qualifying new technology services are included. If operating cost exceeds $47,702.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,615.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $10,846.26 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,886.25 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $855.88. The transfer capital threshold is the transfer adjustment factor * $855.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7921.00,45706.73,Inpatient DRG
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH CC,427,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],134742.59,,"Fee schedule rate ($134,742.59). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,50829.82,142040.39,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,373,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],13780.60,,"Fee schedule rate ($13,780.60). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6870.94,14313.05,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC,832,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],13561.03,,"Fee schedule rate ($13,561.03). Adds an outlier to normal pricing equal to the per diem rate ($18,253.69) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,4803.31,14198.92,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS WITH MCC,947,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],30414.32,,"Fee schedule rate ($30,414.32). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,10541.41,30414.32,There are no additional notes associated with this service or procedure.
Arthrs Knee W/Meniscectomy Med&Lat W/Shaving|LEFT SIDE,CASE-29880,APC,29880,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,056,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],30935.00,,"Case rate ($17,677.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,580.28, add-ons for qualifying new technology services are included. If operating cost exceeds $51,451.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,910.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $14,581.57 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,635.33 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,150.63. The transfer capital threshold is the transfer adjustment factor * $1,150.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,7659.00,59328.19,All Other Inpatient
HC Joint Injection/Aspir Large WO US|PBB CHARGE|BILATERAL PROCEDURE,CASE-20610,APC,20610,CPT,0510,RC,,,PBB|50,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
MAJOR CHEST PROCEDURES WITH CC,164,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],77058.83,,"Fee schedule rate ($77,058.83). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,19037.66,77058.83,There are no additional notes associated with this service or procedure.
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,069,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],15717.99,,,,,,0,other,6965.00,20333.68,There are no additional notes associated with this service or procedure.
"NEONATE BIRTH WEIGHT > 2499 GRAMS WITH MAJOR ANOMALY,MODERATE",633,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],6957.89,,"Case rate ($6,626.56). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6626.56,6957.89,There are no additional notes associated with this service or procedure.
DIABETES WITH CC,638,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],15195.79,,"Fee schedule rate ($15,195.79). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8014.07,17634.53,There are no additional notes associated with this service or procedure.
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],7587.22,,"Case rate ($7,438.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,055.44, add-ons for qualifying new technology services are included. If operating cost exceeds $41,926.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,161.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,091.72 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,110.49 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $401.79. The transfer capital threshold is the transfer adjustment factor * $401.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,7438.45,15961.98,Inpatient DRG
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,699,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],19570.20,,"Fee schedule rate ($19,570.20). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5961.00,19972.16,There are no additional notes associated with this service or procedure.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,309,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6207.80,,"Case rate ($6,207.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $5,875.02, add-ons for qualifying new technology services are included. If operating cost exceeds $44,519.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $3,081.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,495.17 + an uncompensated DSH payment of $1,359.91. The transfer operating threshold is the transfer adjustment factor * $4,515.10 + an uncompensated DSH payment of $1,359.91. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $352.72. The transfer capital threshold is the transfer adjustment factor * $352.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,5055.77,14547.21,Inpatient DRG
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],10846.16,,"Case rate ($10,846.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,225.56, add-ons for qualifying new technology services are included. If operating cost exceeds $45,096.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,410.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $8,250.19 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,280.61 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $651.02. The transfer capital threshold is the transfer adjustment factor * $651.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10846.16,25863.45,Inpatient DRG
"Inj Dx/Ther Agnt Paravert Facet Joint, Lumbar/Sac, Add Level",CASE-64495,APC,64495,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],827.89,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,827.89,869.28,OPPS APC
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC",514,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],9178.42,,"Case rate ($8,868.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,385.35, add-ons for qualifying new technology services are included. If operating cost exceeds $43,256.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,266.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $6,416.74 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,440.40 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $506.34. The transfer capital threshold is the transfer adjustment factor * $506.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,8868.04,22699.91,Inpatient DRG
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],27256.92,,"Case rate ($27,256.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $25,492.14, add-ons for qualifying new technology services are included. If operating cost exceeds $60,363.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,611.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. The base transfer operating payment is the transfer adjustment factor * $23,460.69 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $23,547.19 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,851.28. The transfer capital threshold is the transfer adjustment factor * $1,851.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,27256.92,81353.66,Inpatient DRG
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC",156,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],12624.95,,"Fee schedule rate ($12,624.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6625.12,13598.77,There are no additional notes associated with this service or procedure.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],43888.01,,"Fee schedule rate ($43,888.01). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11717.72,43888.01,There are no additional notes associated with this service or procedure.
"NEONATE BIRTH WEIGHT 2000-2499 GRAMS NORMAL NEWBORN OR NEONATE WITH OTHER PROBLEM,MINOR",626,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],1580.61,,"Case rate ($1,505.34). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,1505.34,1580.61,There are no additional notes associated with this service or procedure.
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],12573.10,,"Case rate ($11,974.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,275.12, add-ons for qualifying new technology services are included. If operating cost exceeds $46,146.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,493.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $9,295.90 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,330.17 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $733.54. The transfer capital threshold is the transfer adjustment factor * $733.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,11974.38,29141.64,Inpatient DRG
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],12272.58,,"Fee schedule rate ($12,272.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5628.97,12272.58,There are no additional notes associated with this service or procedure.
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],16400.70,,"Fee schedule rate ($16,400.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,16400.70,There are no additional notes associated with this service or procedure.
Replacement Tissue Expander W/Permanent Implant|LEFT SIDE,CASE-11970,APC,11970,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6791.99,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],8480.00,,"Per diem ($8,480). If length of stay < 5.5, first 1 days paid at a per diem of $16,960 instead. Capped at $46,638.59.",,,,0,other,8480.00,59081.91,Estimated amount calculated based on 3 day length of stay.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],20970.53,,"Case rate ($20,559.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $19,261.52, add-ons for qualifying new technology services are included. If operating cost exceeds $54,132.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,121.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $17,252.96 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $17,316.57 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,361.43. The transfer capital threshold is the transfer adjustment factor * $1,361.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,20559.34,54086.17,Inpatient DRG
Correction Hammertoe|LEFT SIDE,CASE-28285,APC,28285,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6791.99,7131.59,OPPS APC
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],51903.64,,"Fee schedule rate ($51,903.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,16017.99,51903.64,There are no additional notes associated with this service or procedure.
MAJOR BLADDER PROCEDURES WITH MCC,653,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],37878.05,,"Case rate ($37,135.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $34,681.82, add-ons for qualifying new technology services are included. If operating cost exceeds $69,552.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,333.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.5. The base transfer operating payment is the transfer adjustment factor * $32,616.61 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $32,736.87 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,573.77. The transfer capital threshold is the transfer adjustment factor * $2,573.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,10280.00,125343.98,Inpatient DRG
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC",758,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],8574.80,,"Case rate ($8,574.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,112.57, add-ons for qualifying new technology services are included. If operating cost exceeds $42,983.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,244.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $6,144.96 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,167.62 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $484.90. The transfer capital threshold is the transfer adjustment factor * $484.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8574.80,19263.78,Inpatient DRG
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],18107.36,,"Case rate ($10,347.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,761.25, add-ons for qualifying new technology services are included. If operating cost exceeds $44,632.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,374.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $7,787.59 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,816.30 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $614.52. The transfer capital threshold is the transfer adjustment factor * $614.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,10347.06,28821.04,All Other Inpatient
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],40916.35,,,,,,0,other,11165.00,61234.06,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],25609.86,,"Fee schedule rate ($25,609.86). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,12775.53,31469.43,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITH STERILIZATION WITHOUT CC/MCC,785,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],11163.60,,"Fee schedule rate ($11,163.60). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8431.24,20142.33,There are no additional notes associated with this service or procedure.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],16669.71,,"Fee schedule rate ($16,669.71). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8767.81,19824.58,There are no additional notes associated with this service or procedure.
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],7956.52,,"Case rate ($7,956.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,537.38, add-ons for qualifying new technology services are included. If operating cost exceeds $42,408.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,199.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,571.89 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,592.43 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $439.68. The transfer capital threshold is the transfer adjustment factor * $439.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,17467.27,Inpatient DRG
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,085,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],9282.00,,"Per diem ($9,282). If length of stay < 4.6, first 1 days paid at a per diem of $18,564 instead. Capped at $42,695.82.",,,,0,other,9282.00,57443.16,Estimated amount calculated based on 2 day length of stay.
Repair Intermediate S/a/T/E 20.1-30.0 Cm,CASE-12036,APC,12036,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1545.93,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1545.93,1623.23,OPPS APC
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],11133.98,,"Fee schedule rate ($11,133.98). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5919.29,13545.65,There are no additional notes associated with this service or procedure.
Largsc Exc Tum&/Strpg Cords/Epigl Mcrscp/Tlscp,CASE-31541,APC,31541,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3489.82,,"APC Price ($3,489.82). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3489.82,3664.31,OPPS APC
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],24675.88,,"Fee schedule rate ($24,675.88). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10834.64,25830.00,There are no additional notes associated with this service or procedure.
RESPIRATORY NEOPLASMS WITHOUT CC/MCC,182,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7296.48,,"Case rate ($7,049.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,693.83, add-ons for qualifying new technology services are included. If operating cost exceeds $41,564.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,133.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,731.43 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,748.88 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $373.36. The transfer capital threshold is the transfer adjustment factor * $373.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6965.00,23037.13,Inpatient DRG
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],12736.22,,"Case rate ($12,305.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,583.18, add-ons for qualifying new technology services are included. If operating cost exceeds $46,454.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,517.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $9,602.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,638.24 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $757.76. The transfer capital threshold is the transfer adjustment factor * $757.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,12305.53,30103.84,Inpatient DRG
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],9169.30,,"Case rate ($8,859.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,377.16, add-ons for qualifying new technology services are included. If operating cost exceeds $43,248.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,265.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $6,408.58 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,432.21 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $505.70. The transfer capital threshold is the transfer adjustment factor * $505.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,8859.23,20090.22,Inpatient DRG
TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC,087,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],8139.36,,"Case rate ($8,139.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,707.48, add-ons for qualifying new technology services are included. If operating cost exceeds $42,578.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,213.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $5,741.36 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,762.53 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $453.05. The transfer capital threshold is the transfer adjustment factor * $453.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8139.36,22679.07,Inpatient DRG
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],22737.58,,"Case rate ($12,992.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,222.63, add-ons for qualifying new technology services are included. If operating cost exceeds $47,093.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,568.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $10,239.92 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,277.68 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $808.03. The transfer capital threshold is the transfer adjustment factor * $808.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,7665.00,40737.46,All Other Inpatient
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,064,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],15921.74,,"Case rate ($15,163.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,266.61, add-ons for qualifying new technology services are included. If operating cost exceeds $49,137.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,703.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $12,275.12 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,321.66 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $943.49. The transfer capital threshold is the transfer adjustment factor * $943.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,15563.58,41838.16,Inpatient DRG
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],2070.00,,,,,,0,other,1188.00,31658.33,Estimated amount calculated based on 16 day length of stay.
Thoracoscopy With Biopsyies of Pleura,CASE-32609,APC,32609,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5941.70,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5658.76,5941.70,OPPS APC
Redo Excis Lumbar Disk|LEFT SIDE,CASE-63042,APC,63042,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH MCC",510,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],10710.00,,"Per diem ($10,710). If length of stay < 5.3, first 1 days paid at a per diem of $21,420 instead. Capped at $56,764.26.",,,,0,other,10710.00,89863.76,Estimated amount calculated based on 6 day length of stay.
"Inj Dx/Ther Agnt Paravert Facet Joint, Cerv/Thorac, 2nd Level|BILATERAL PROCEDURE",CASE-64491,APC,64491,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],827.89,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,827.89,856.86,OPPS APC
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC",281,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],17272.65,,"Fee schedule rate ($17,272.65). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.9), with a minimum of zero.",,,,0,other,8169.15,23859.35,There are no additional notes associated with this service or procedure.
Injection Aa&/Strd Genicular Nrv Branches W/Img|LEFT SIDE,CASE-64454,APC,64454,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],660.72,,"APC Price ($660.72). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,660.72,693.76,OPPS APC
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],13594.35,,"Fee schedule rate ($13,594.35). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10989.72,26280.60,There are no additional notes associated with this service or procedure.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6683.37,,"Case rate ($6,683.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,353, add-ons for qualifying new technology services are included. If operating cost exceeds $41,224.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,106.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,391.86 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,408.05 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $346.56. The transfer capital threshold is the transfer adjustment factor * $346.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6683.37,14699.43,Inpatient DRG
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],34892.92,,"Fee schedule rate ($34,892.92). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,6965.00,41030.48,There are no additional notes associated with this service or procedure.
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],12882.53,,,,,,0,other,4341.01,12882.53,There are no additional notes associated with this service or procedure.
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],14625.55,,"Fee schedule rate ($14,625.55). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7438.45,15961.98,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],9991.03,,"Case rate ($9,795.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,247.81, add-ons for qualifying new technology services are included. If operating cost exceeds $44,118.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,334.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $7,276.03 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,302.86 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $574.15. The transfer capital threshold is the transfer adjustment factor * $574.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,9795.13,23899.13,Inpatient DRG
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,064,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],37792.72,,"Fee schedule rate ($37,792.72). Adds an outlier to normal pricing equal to the per diem rate ($115,085.88) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,15563.58,41838.16,There are no additional notes associated with this service or procedure.
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR,518,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],89342.77,,"Fee schedule rate ($89,342.77). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,13252.00,89342.77,There are no additional notes associated with this service or procedure.
Arthrs Kne Surg W/Meniscectomy Med/Lat W/Shvg|LEFT SIDE|SEPARATE STRUCTURE,CASE-29881,APC,29881,CPT,0360,RC,,,LT|XS,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7029.71,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6791.99,7131.59,OPPS APC
NERVOUS SYSTEM NEOPLASMS WITH MCC,054,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],6965.00,,,,,,0,other,6965.00,30044.81,There are no additional notes associated with this service or procedure.
Exc Tumor Soft Tis Neck/Ant Thorax Subq 3 Cm/>,CASE-21552,APC,21552,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],2718.88,,"APC Price ($2,718.88). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2718.88,2854.83,OPPS APC
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],41402.42,,"Fee schedule rate ($41,402.42). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,15456.59,41402.42,There are no additional notes associated with this service or procedure.
O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC,621,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],36669.96,,"Fee schedule rate ($36,669.96). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,12159.94,36669.96,There are no additional notes associated with this service or procedure.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC",061,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],51814.18,,"Fee schedule rate ($51,814.18). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,20616.23,62315.82,There are no additional notes associated with this service or procedure.
"Hallux Rigidus W/Cheilectomy 1st Mp Jt W/O Implt|RIGHT FOOT, GREAT TOE",CASE-28289,APC,28289,CPT,0360,RC,,,T5,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC,027,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],47412.86,,"Fee schedule rate ($47,412.86). Adds an outlier to normal pricing equal to the per diem rate ($103,062) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,19030.20,56363.30,There are no additional notes associated with this service or procedure.
Rpr Aa Hernia 1st < 3 Cm Ncrc8/Strangulated,CASE-49592,APC,49592,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5941.70,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5856.81,5941.70,OPPS APC
"DIABETES,MAJOR",420,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],9870.76,,"Case rate ($9,870.76). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,9870.76,10364.30,There are no additional notes associated with this service or procedure.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,074,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],19371.82,,"Fee schedule rate ($19,371.82). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,8925.60,20919.08,There are no additional notes associated with this service or procedure.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],7585.67,,"Case rate ($7,224.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,856.36, add-ons for qualifying new technology services are included. If operating cost exceeds $41,727.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,146.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $4,893.37 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,911.41 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $386.14. The transfer capital threshold is the transfer adjustment factor * $386.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,15340.19,Inpatient DRG
HYPERTENSION WITHOUT MCC,305,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],17230.49,,"Fee schedule rate ($17,230.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7058.55,17230.49,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,066,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],6965.00,,,,,,0,other,6579.76,20083.61,There are no additional notes associated with this service or procedure.
"NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY",789,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],14432.56,,"Case rate ($14,149.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,298.65, add-ons for qualifying new technology services are included. If operating cost exceeds $48,169.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,652.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $11,312.00 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,353.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $892.63. The transfer capital threshold is the transfer adjustment factor * $892.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,3054.00,14857.05,Inpatient DRG
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],40737.46,,"Fee schedule rate ($40,737.46). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,7665.00,40737.46,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],14650.15,,"Case rate ($13,952.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,115.33, add-ons for qualifying new technology services are included. If operating cost exceeds $47,986.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,638.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $11,129.34 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,170.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $878.22. The transfer capital threshold is the transfer adjustment factor * $878.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13917.42,34889.29,Inpatient DRG
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],22217.08,,"Fee schedule rate ($22,217.08). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.4), with a minimum of zero.",,,,0,other,7243.75,23262.15,There are no additional notes associated with this service or procedure.
Bronchoscopy W/Plmt Fiducial Markers Single/Mult,CASE-31626,APC,31626,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6936.25,,"APC Price ($6,605.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6605.95,6936.25,OPPS APC
MAJOR CHEST PROCEDURES WITH CC,164,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],47433.53,,"Fee schedule rate ($47,433.53). Adds an outlier to normal pricing equal to the per diem rate ($158,028.38) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,19037.66,77058.83,There are no additional notes associated with this service or procedure.
"POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT PROCEDURE,MODERATE",561,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],4075.27,,"Case rate ($4,075.27). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,4075.27,4279.03,There are no additional notes associated with this service or procedure.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],11593.79,,"Case rate ($11,593.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,921.06, add-ons for qualifying new technology services are included. If operating cost exceeds $45,792.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,465.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $8,943.14 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,976.12 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $705.70. The transfer capital threshold is the transfer adjustment factor * $705.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,11593.79,38248.08,Inpatient DRG
NONTRAUMATIC STUPOR AND COMA WITH MCC,080,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],14202.39,,"Case rate ($14,202.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,347.79, add-ons for qualifying new technology services are included. If operating cost exceeds $48,218.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,656.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $11,360.96 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,402.84 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $896.49. The transfer capital threshold is the transfer adjustment factor * $896.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,14202.39,35615.37,Inpatient DRG
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],25099.93,,"Fee schedule rate ($25,099.93). Adds an outlier to normal pricing equal to the per diem rate ($40,783.87) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10989.72,26280.60,There are no additional notes associated with this service or procedure.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],54503.46,,"Fee schedule rate ($54,503.46). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.9), with a minimum of zero.",,,,0,other,21585.31,73588.10,There are no additional notes associated with this service or procedure.
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],15940.79,,"Case rate ($15,940.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,964.98, add-ons for qualifying new technology services are included. If operating cost exceeds $49,835.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,783.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $12,972.20 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,020.03 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,023.63. The transfer capital threshold is the transfer adjustment factor * $1,023.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,15940.79,53275.26,Inpatient DRG
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],17255.73,,"Fee schedule rate ($17,255.73). Adds an outlier to normal pricing equal to the per diem rate ($43,191.57) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,8163.06,18067.42,There are no additional notes associated with this service or procedure.
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC,520,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],12664.83,,"Case rate ($12,061.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,356.39, add-ons for qualifying new technology services are included. If operating cost exceeds $46,227.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,499.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $9,376.87 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,411.44 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $739.93. The transfer capital threshold is the transfer adjustment factor * $739.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12061.74,39786.42,Inpatient DRG
"HC ED Avulsion Nail Plate Single|RIGHT HAND, THUMB",CASE-11730,APC,11730,CPT,0450,RC,,,F5,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],194.37,,"APC Price ($187.80). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,187.80,197.19,OPPS APC
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],16286.16,,"Case rate ($16,286.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,286.28, add-ons for qualifying new technology services are included. If operating cost exceeds $50,157.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,808.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $13,292.32 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,341.33 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,048.90. The transfer capital threshold is the transfer adjustment factor * $1,048.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,16286.16,58320.32,Inpatient DRG
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],42787.31,,"Fee schedule rate ($42,787.31). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,15476.23,42787.31,There are no additional notes associated with this service or procedure.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC,858,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],18729.90,,"Fee schedule rate ($18,729.90). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11377.76,33794.11,There are no additional notes associated with this service or procedure.
BRONCHITIS AND ASTHMA WITH CC/MCC,202,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],14307.27,,"Fee schedule rate ($14,307.27). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7606.34,19110.30,There are no additional notes associated with this service or procedure.
Colsc Flexible W/Transendoscopic Balloon Dilat|COLORECTAL CANCER SCREEN,CASE-45386,APC,45386,CPT,0360,RC,,,PT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1176.09,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1120.09,1176.09,OPPS APC
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],30245.71,,"Fee schedule rate ($30,245.71). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9151.11,30245.71,There are no additional notes associated with this service or procedure.
OSTEOMYELITIS WITH CC,540,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],9809.07,,"Fee schedule rate ($9,809.07). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,9809.07,25507.30,There are no additional notes associated with this service or procedure.
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],45157.33,,"Fee schedule rate ($45,157.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,10733.06,45157.33,There are no additional notes associated with this service or procedure.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],19604.30,,"Fee schedule rate ($19,604.30). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9446.38,21796.21,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],14679.40,,"Case rate ($13,980.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,163.72, add-ons for qualifying new technology services are included. If operating cost exceeds $48,034.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,619.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $11,176.40 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,218.77 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $859.04. The transfer capital threshold is the transfer adjustment factor * $859.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,14344.60,36028.59,Inpatient DRG
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],2070.00,,,,,,0,other,1188.00,31658.33,Estimated amount calculated based on 16 day length of stay.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC,192,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],12753.78,,"Fee schedule rate ($12,753.78). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6292.63,12753.78,There are no additional notes associated with this service or procedure.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],19422.10,,"Case rate ($18,497.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,343.20, add-ons for qualifying new technology services are included. If operating cost exceeds $52,214.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,970.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $15,341.68 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,398.25 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,210.61. The transfer capital threshold is the transfer adjustment factor * $1,210.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,18497.24,62041.12,Inpatient DRG
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],47123.82,,"Fee schedule rate ($47,123.82). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,12696.97,47123.82,There are no additional notes associated with this service or procedure.
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],6965.00,,,,,,0,other,6965.00,29482.05,There are no additional notes associated with this service or procedure.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],16689.78,,"Case rate ($16,689.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,661.75, add-ons for qualifying new technology services are included. If operating cost exceeds $50,532.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,838.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $13,666.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,716.80 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,078.42. The transfer capital threshold is the transfer adjustment factor * $1,078.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,16689.78,59521.43,Inpatient DRG
"HEART FAILURE,MODERATE",194,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],7591.38,,"The inlier payment is calculated as the lesser of the standard DRG payment $7,591.38 and the transfer payment, which is a per diem of $1,820.47. If cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,7591.38,7970.95,Estimated amount calculated based on 4 day length of stay.
"ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",770,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],18843.74,,"Fee schedule rate ($18,843.74). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,8735.30,19730.13,There are no additional notes associated with this service or procedure.
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],8393.44,,"Case rate ($7,993.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,572.03, add-ons for qualifying new technology services are included. If operating cost exceeds $42,443.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,202.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $5,606.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,627.08 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $442.40. The transfer capital threshold is the transfer adjustment factor * $442.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5415.00,17575.50,Inpatient DRG
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],41580.51,,"Fee schedule rate ($41,580.51). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,13783.20,41580.51,There are no additional notes associated with this service or procedure.
SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS,029,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],61889.56,,"Fee schedule rate ($61,889.56). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13641.00,67130.05,There are no additional notes associated with this service or procedure.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],47123.82,,"Fee schedule rate ($47,123.82). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,12696.97,47123.82,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,373,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6870.94,,"Case rate ($6,870.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,527.50, add-ons for qualifying new technology services are included. If operating cost exceeds $41,398.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,120.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $4,565.72 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,582.56 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $360.28. The transfer capital threshold is the transfer adjustment factor * $360.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6870.94,14313.05,Inpatient DRG
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5980.87,,"Case rate ($5,778.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,511.33, add-ons for qualifying new technology services are included. If operating cost exceeds $40,382.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,040.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $3,553.28 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,566.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $280.39. The transfer capital threshold is the transfer adjustment factor * $280.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,5778.62,11681.49,Inpatient DRG
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],13782.90,,"Case rate ($7,875.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,462.42, add-ons for qualifying new technology services are included. If operating cost exceeds $42,333.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,193.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $5,497.20 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,517.46 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $433.78. The transfer capital threshold is the transfer adjustment factor * $433.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,7875.94,17233.12,All Other Inpatient
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],75579.22,,"Fee schedule rate ($75,579.22). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,25162.32,75579.22,There are no additional notes associated with this service or procedure.
HC Joint Injection/Aspir Large WO US|PBB CHARGE,CASE-20610,APC,20610,CPT,0510,RC,,,PBB,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],301.68,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,287.31,301.68,OPPS APC
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],19877.10,,"Fee schedule rate ($19,877.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8009.34,19877.10,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],9370.00,,"Per diem ($9,370). If length of stay < 6.7, first 1 days paid at a per diem of $18,740 instead. Capped at $62,779.90.",,,,0,other,9370.00,65732.99,Estimated amount calculated based on 3 day length of stay.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],34892.92,,"Fee schedule rate ($34,892.92). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,6965.00,41030.48,There are no additional notes associated with this service or procedure.
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],7566.45,,"Case rate ($7,566.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,174.51, add-ons for qualifying new technology services are included. If operating cost exceeds $42,045.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,171.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,210.35 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,229.56 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $411.15. The transfer capital threshold is the transfer adjustment factor * $411.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7566.45,16333.88,Inpatient DRG
COAGULATION DISORDERS,813,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],29046.49,,"Fee schedule rate ($29,046.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12274.39,30013.33,There are no additional notes associated with this service or procedure.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,477,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],62359.39,,"Fee schedule rate ($62,359.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,25339.74,67976.16,There are no additional notes associated with this service or procedure.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],92045.07,,,,,,0,other,33623.33,133270.57,There are no additional notes associated with this service or procedure.
Cystourethroscopy Inj Chemodenervation Bladder|SEPARATE STRUCTURE,CASE-52287,APC,52287,CPT,0360,RC,,,XS,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3299.47,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3299.47,3464.44,OPPS APC
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC",156,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],12624.95,,"Fee schedule rate ($12,624.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6625.12,13598.77,There are no additional notes associated with this service or procedure.
Cysto W/Urtroscopy&/Pyeloscopy Dx,CASE-52351,APC,52351,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3299.47,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3299.47,3464.44,OPPS APC
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,394,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],20909.61,,"Fee schedule rate ($20,909.61). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8281.56,20909.61,There are no additional notes associated with this service or procedure.
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],18045.04,,"Fee schedule rate ($18,045.04). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,1188.00,18893.86,There are no additional notes associated with this service or procedure.
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],29216.99,,"Fee schedule rate ($29,216.99). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9755.86,29216.99,There are no additional notes associated with this service or procedure.
Cysto W/Insert Ureteral Stent|BILATERAL PROCEDURE,CASE-52332,APC,52332,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3299.47,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3299.47,3464.44,OPPS APC
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],54236.60,,"Fee schedule rate ($54,236.60). Adds an outlier to normal pricing equal to the per diem rate ($122,612.56) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,21489.15,68942.79,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],30372.64,,"Fee schedule rate ($30,372.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,13260.40,32878.30,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],6340.03,,"Case rate ($6,340.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,033.60, add-ons for qualifying new technology services are included. If operating cost exceeds $40,904.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,081.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $4,073.62 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,088.64 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $321.45. The transfer capital threshold is the transfer adjustment factor * $321.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6340.03,15076.44,Inpatient DRG
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],8151.55,,"Case rate ($8,151.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,718.82, add-ons for qualifying new technology services are included. If operating cost exceeds $42,589.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,213.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,752.66 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,773.87 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $453.94. The transfer capital threshold is the transfer adjustment factor * $453.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8151.55,18033.97,Inpatient DRG
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],7412.73,,"Case rate ($7,412.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,031.50, add-ons for qualifying new technology services are included. If operating cost exceeds $41,902.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,159.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $5,067.86 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,086.55 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $399.90. The transfer capital threshold is the transfer adjustment factor * $399.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6148.93,15887.21,Inpatient DRG
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,345,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],33616.03,,"Fee schedule rate ($33,616.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12134.89,33616.03,There are no additional notes associated with this service or procedure.
CERVICAL SPINAL FUSION WITHOUT CC/MCC,473,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],62077.11,,"Fee schedule rate ($62,077.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,18477.61,62077.11,There are no additional notes associated with this service or procedure.
"Surg Implnt Neuroelect,Epidural",CASE-63655,APC,63655,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],28883.55,,"APC Price ($28,883.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,28883.55,30327.72,OPPS APC
"NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY",789,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],3054.00,,,,,,0,other,3054.00,14857.05,Estimated amount calculated based on 1 day length of stay.
Dstr Nrolytc Agnt Parverteb Fct Sngl Lmbr/Sacral|LEFT SIDE,CASE-64635,APC,64635,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1891.77,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1827.80,1919.19,OPPS APC
"MAJOR STOMACH ESOPHAGEAL AND DUODENAL PROCEDURES,MINOR",220,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],15981.03,,"Case rate ($15,220.03). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,15220.03,15981.03,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],12775.53,,"Case rate ($12,775.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,020.41, add-ons for qualifying new technology services are included. If operating cost exceeds $46,891.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,552.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $10,038.44 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,075.45 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $792.13. The transfer capital threshold is the transfer adjustment factor * $792.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12775.53,31469.43,Inpatient DRG
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],53152.12,,"Fee schedule rate ($53,152.12). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,19152.11,53152.12,There are no additional notes associated with this service or procedure.
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],32263.82,,"Fee schedule rate ($32,263.82). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13571.25,33781.47,There are no additional notes associated with this service or procedure.
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 2nd Level,CASE-64494,APC,64494,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],827.89,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,827.89,869.28,OPPS APC
"Inj Dx/Ther Agnt Paravert Facet Joint, Cerv/Thorac, 2nd Level|RIGHT SIDE",CASE-64491,APC,64491,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],827.89,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,827.89,869.28,OPPS APC
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5948.62,,"Case rate ($5,665.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,412.90, add-ons for qualifying new technology services are included. If operating cost exceeds $40,283.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,025.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $3,454.86 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,467.95 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $265.55. The transfer capital threshold is the transfer adjustment factor * $265.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5065.00,12558.65,Inpatient DRG
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],19371.27,,"Fee schedule rate ($19,371.27). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8643.20,19462.52,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],25293.50,,"Fee schedule rate ($25,293.50). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11059.47,28423.20,There are no additional notes associated with this service or procedure.
HC Joint Injection/Aspir Large WO US|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-20610,APC,20610,CPT,0510,RC,,,LT|XU,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
"NEONATE BIRTH WEIGHT 1500-1999 GRAMS WITH RESPIRATORY DISTRESS SYNDROME OR OTHER MAJOR RESPIRATORY CONDITION,MINOR",612,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],11512.05,,"Case rate ($10,963.86). Base payment rate plus any adjustments related to outliers.",,,,0,other,10963.86,11512.05,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],12775.53,,"Case rate ($12,775.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,020.41, add-ons for qualifying new technology services are included. If operating cost exceeds $46,891.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,552.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $10,038.44 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,075.45 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $792.13. The transfer capital threshold is the transfer adjustment factor * $792.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12775.53,31469.43,Inpatient DRG
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],14725.21,,"Case rate ($14,725.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,834.15, add-ons for qualifying new technology services are included. If operating cost exceeds $48,705.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,694.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,845.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,889.20 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $934.73. The transfer capital threshold is the transfer adjustment factor * $934.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7389.00,37134.43,Inpatient DRG
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,394,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],8281.56,,"Case rate ($8,281.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,839.77, add-ons for qualifying new technology services are included. If operating cost exceeds $42,710.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,223.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,873.17 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,894.83 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $463.45. The transfer capital threshold is the transfer adjustment factor * $463.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8281.56,20909.61,Inpatient DRG
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],120927.32,,"Fee schedule rate ($120,927.32). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,45521.20,142438.06,There are no additional notes associated with this service or procedure.
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],31973.49,,"Fee schedule rate ($31,973.49). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,13386.36,33244.29,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,426,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],177294.98,,"Fee schedule rate ($177,294.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,76581.29,216864.15,There are no additional notes associated with this service or procedure.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,329,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],86382.02,,"Fee schedule rate ($86,382.02). Adds an outlier to normal pricing equal to the per diem rate ($147,722.18) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,33072.77,90445.33,There are no additional notes associated with this service or procedure.
Laps Tx Ectopic Preg W/Salping&/Oophorectomy|RIGHT SIDE,CASE-59151,APC,59151,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5856.81,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5658.76,5941.70,OPPS APC
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],21160.18,,"Case rate ($12,091.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,384.11, add-ons for qualifying new technology services are included. If operating cost exceeds $46,255.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,502.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $9,404.49 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,439.16 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $742.11. The transfer capital threshold is the transfer adjustment factor * $742.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,6965.00,29482.05,All Other Inpatient
SEIZURES WITH MCC,100,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],15814.14,,"Case rate ($15,061.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,146.62, add-ons for qualifying new technology services are included. If operating cost exceeds $49,017.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,719.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $12,156.85 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,201.67 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $959.30. The transfer capital threshold is the transfer adjustment factor * $959.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,15061.09,38110.41,Inpatient DRG
"LYMPHOMA MYELOMA AND NON-ACUTE LEUKEMIA,MAJOR",691,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],19072.73,,"Case rate ($19,072.73). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,19072.73,20026.37,There are no additional notes associated with this service or procedure.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],48538.56,,"Fee schedule rate ($48,538.56). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,19435.86,50821.76,There are no additional notes associated with this service or procedure.
Insj Inflatable Urethral/Bladder Neck Sphincter,CASE-53445,APC,53445,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],20370.16,,"APC Price ($19,400.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,19400.15,20370.16,OPPS APC
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],9667.64,,"Fee schedule rate ($9,667.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,5139.72,13110.79,There are no additional notes associated with this service or procedure.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],22747.50,,"Fee schedule rate ($22,747.50). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,15476.23,42787.31,There are no additional notes associated with this service or procedure.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],12268.97,,"Case rate ($12,268.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,549.17, add-ons for qualifying new technology services are included. If operating cost exceeds $46,420.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,515.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,568.94 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,604.22 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $755.08. The transfer capital threshold is the transfer adjustment factor * $755.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12268.97,41006.47,Inpatient DRG
Enteroscopy > 2nd Prtn Abltj Lesion,CASE-44369,APC,44369,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1796.14,,"APC Price ($1,796.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1796.14,1885.95,OPPS APC
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",063,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],12024.16,,"Case rate ($11,451.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,788.77, add-ons for qualifying new technology services are included. If operating cost exceeds $45,659.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,455.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $8,811.33 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,843.82 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $695.30. The transfer capital threshold is the transfer adjustment factor * $695.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,35701.87,Inpatient DRG
"LIMB REATTACHMENT, HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA",956,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],27428.25,,"Case rate ($27,428.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $25,651.53, add-ons for qualifying new technology services are included. If operating cost exceeds $60,522.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,623.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $23,619.49 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $23,706.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,863.81. The transfer capital threshold is the transfer adjustment factor * $1,863.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,27428.25,148259.86,Inpatient DRG
PREMATURITY WITHOUT MAJOR PROBLEMS,792,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],2074.00,,,,,,0,other,1956.00,19457.66,Estimated amount calculated based on 3 day length of stay.
MINOR BLADDER PROCEDURES WITHOUT CC/MCC,664,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],19674.39,,"Fee schedule rate ($19,674.39). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,9034.63,31876.87,There are no additional notes associated with this service or procedure.
PERIPHERAL VASCULAR DISORDERS WITH CC,300,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],20331.78,,"Fee schedule rate ($20,331.78). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,9174.14,21005.20,There are no additional notes associated with this service or procedure.
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],52453.14,,"Fee schedule rate ($52,453.14). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14.9), with a minimum of zero.",,,,0,other,20846.48,81306.30,There are no additional notes associated with this service or procedure.
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],13568.55,,"Fee schedule rate ($13,568.55). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6834.39,21354.82,There are no additional notes associated with this service or procedure.
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],10003.71,,"Case rate ($10,003.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,441.84, add-ons for qualifying new technology services are included. If operating cost exceeds $44,312.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,349.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $7,469.36 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,496.90 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $589.41. The transfer capital threshold is the transfer adjustment factor * $589.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10003.71,23415.63,Inpatient DRG
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH CC",457,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],43174.02,,"Case rate ($42,327.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $39,511.96, add-ons for qualifying new technology services are included. If operating cost exceeds $74,382.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,713.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $37,429.01 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $37,567.02 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,953.52. The transfer capital threshold is the transfer adjustment factor * $2,953.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,42327.47,160549.49,Inpatient DRG
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],20477.28,,"Fee schedule rate ($20,477.28). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,16897.01,43444.85,There are no additional notes associated with this service or procedure.
Dilation Esoph Unguided Sound/Bougie 1/Mult Pass,CASE-43450,APC,43450,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],891.41,,"APC Price ($848.96). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,848.96,891.41,OPPS APC
"Tendon Sheath Incision|LEFT HAND, FIFTH DIGIT",CASE-26055,APC,26055,CPT,0360,RC,,,F4,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1505.12,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1505.12,1580.37,OPPS APC
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],41402.42,,"Fee schedule rate ($41,402.42). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,15456.59,41402.42,There are no additional notes associated with this service or procedure.
HC Joint Injection/Aspir Large WO US|PBB CHARGE|LEFT SIDE,CASE-20610,APC,20610,CPT,0510,RC,,,PBB|LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],297.37,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,287.31,301.68,OPPS APC
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC",156,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6857.00,,"Case rate ($6,625.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,298.82, add-ons for qualifying new technology services are included. If operating cost exceeds $41,169.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,102.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $4,337.88 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,353.87 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $342.30. The transfer capital threshold is the transfer adjustment factor * $342.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6625.12,13598.77,Inpatient DRG
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",063,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],11730.96,,"Case rate ($11,172.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,546.21, add-ons for qualifying new technology services are included. If operating cost exceeds $45,417.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,418.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $8,568.78 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,601.26 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $658.62. The transfer capital threshold is the transfer adjustment factor * $658.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,35701.87,Inpatient DRG
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],8537.49,,"Case rate ($8,130.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,711.19, add-ons for qualifying new technology services are included. If operating cost exceeds $42,582.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,201.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,744.46 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,766.24 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $441.53. The transfer capital threshold is the transfer adjustment factor * $441.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8318.14,19763.43,Inpatient DRG
NON-MALIGNANT BREAST DISORDERS WITH CC/MCC,600,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],15046.13,,"Fee schedule rate ($15,046.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7999.14,20495.56,There are no additional notes associated with this service or procedure.
Rpr Aa Hernia 1st < 3 Cm Reducible,CASE-49591,APC,49591,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3518.91,,"APC Price ($3,351.34). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3518.91,3518.91,OPPS APC
SINGLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL,402,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],66165.66,,"Fee schedule rate ($66,165.66). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,29172.05,124455.45,There are no additional notes associated with this service or procedure.
O.R. PROCEDURES FOR OBESITY WITH CC,620,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],30074.44,,"Fee schedule rate ($30,074.44). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7.8), with a minimum of zero.",,,,0,other,12782.30,43753.50,There are no additional notes associated with this service or procedure.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,988,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],42425.46,,"Fee schedule rate ($42,425.46). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,13075.52,42425.46,There are no additional notes associated with this service or procedure.
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6378.61,,"Case rate ($6,378.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,069.50, add-ons for qualifying new technology services are included. If operating cost exceeds $40,940.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,084.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,109.40 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,124.55 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $324.27. The transfer capital threshold is the transfer adjustment factor * $324.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,4341.01,12882.53,Inpatient DRG
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],10862.00,,"Per diem ($10,862). If length of stay < 7.6, first 1 days paid at a per diem of $21,724 instead. Capped at $82,553.89.",,,,0,other,10862.00,86437.13,Estimated amount calculated based on 6 day length of stay.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],16338.35,,"Case rate ($16,017.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,036.80, add-ons for qualifying new technology services are included. If operating cost exceeds $49,907.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,789.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $13,043.76 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,091.85 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,029.28. The transfer capital threshold is the transfer adjustment factor * $1,029.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,16017.99,51903.64,Inpatient DRG
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],15429.83,,"Case rate ($14,908.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,004.25, add-ons for qualifying new technology services are included. If operating cost exceeds $48,875.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,708.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $12,014.99 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,059.30 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $948.10. The transfer capital threshold is the transfer adjustment factor * $948.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,14908.05,49717.39,Inpatient DRG
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,068,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],7798.73,,"Case rate ($7,798.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,390.60, add-ons for qualifying new technology services are included. If operating cost exceeds $42,261.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,188.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $5,425.64 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,445.65 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $428.14. The transfer capital threshold is the transfer adjustment factor * $428.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,23184.90,Inpatient DRG
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],43888.01,,"Fee schedule rate ($43,888.01). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11717.72,43888.01,There are no additional notes associated with this service or procedure.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,544,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],23207.64,,"Fee schedule rate ($23,207.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,7055.15,23207.64,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],39053.73,,"Fee schedule rate ($39,053.73). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,16017.99,51903.64,There are no additional notes associated with this service or procedure.
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,095,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],20090.87,,"Case rate ($19,411.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $18,193.69, add-ons for qualifying new technology services are included. If operating cost exceeds $53,064.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,037.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.6. The base transfer operating payment is the transfer adjustment factor * $16,189.05 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $16,248.74 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,277.48. The transfer capital threshold is the transfer adjustment factor * $1,277.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,19411.47,50750.92,Inpatient DRG
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],38248.08,,"Fee schedule rate ($38,248.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11593.79,38248.08,There are no additional notes associated with this service or procedure.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],16017.90,,"Case rate ($15,476.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,532.81, add-ons for qualifying new technology services are included. If operating cost exceeds $49,403.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,749.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $12,541.62 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,587.86 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $989.66. The transfer capital threshold is the transfer adjustment factor * $989.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,15476.23,42787.31,Inpatient DRG
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],62454.12,,"Fee schedule rate ($62,454.12). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11348.00,62454.12,There are no additional notes associated with this service or procedure.
Dstr Nrolytc Agnt Parverteb Fct Sngl Crvcl/Thora|RIGHT SIDE,CASE-64633,APC,64633,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1827.80,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1827.80,1919.19,OPPS APC
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],32852.04,,"Fee schedule rate ($32,852.04). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,13783.20,41580.51,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],23239.84,,"Fee schedule rate ($23,239.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8543.64,23239.84,There are no additional notes associated with this service or procedure.
"Tendon Sheath Incision|LEFT HAND, THUMB",CASE-26055,APC,26055,CPT,0360,RC,,,FA,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1557.80,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1505.12,1580.37,OPPS APC
MAJOR CHEST TRAUMA WITHOUT CC/MCC,185,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7525.68,,"Case rate ($7,271.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,899.84, add-ons for qualifying new technology services are included. If operating cost exceeds $41,770.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,149.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,936.68 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,954.88 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $389.55. The transfer capital threshold is the transfer adjustment factor * $389.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,7271.19,21771.61,Inpatient DRG
Arthrd Ant Interbody Decompress Cervical Belw C2,CASE-22551,APC,22551,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12618.18,,"APC Price ($12,017.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,12017.31,12618.18,OPPS APC
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],62273.77,,,,,,0,other,23377.19,96365.69,There are no additional notes associated with this service or procedure.
Exc Tumor Soft Tiss Back/Flank Subfascial 5 Cm/>,CASE-21933,APC,21933,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],2854.83,,"APC Price ($2,718.88). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2718.88,2854.83,OPPS APC
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],24007.50,,"Fee schedule rate ($24,007.50). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,10733.06,45157.33,There are no additional notes associated with this service or procedure.
"NEONATE BIRTH WEIGHT 2000-2499 GRAMS NORMAL NEWBORN OR NEONATE WITH OTHER PROBLEM,MODERATE",626,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],2614.38,,"Case rate ($2,489.89). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,2489.89,2614.38,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],7569.84,,"Case rate ($7,569.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,177.66, add-ons for qualifying new technology services are included. If operating cost exceeds $42,048.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,171.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,213.49 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,232.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $411.40. The transfer capital threshold is the transfer adjustment factor * $411.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7569.84,21892.85,Inpatient DRG
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],8321.46,,"Case rate ($7,925.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,519.41, add-ons for qualifying new technology services are included. If operating cost exceeds $42,390.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,186.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,553.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,574.46 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $426.85. The transfer capital threshold is the transfer adjustment factor * $426.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8106.18,18245.94,Inpatient DRG
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],35528.17,,"Fee schedule rate ($35,528.17). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,14747.55,37899.49,There are no additional notes associated with this service or procedure.
ALLERGIC REACTIONS WITH MCC,915,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],27385.01,,"Fee schedule rate ($27,385.01). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,13332.86,33088.84,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],36028.59,,,,,,0,other,14344.60,36028.59,There are no additional notes associated with this service or procedure.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],38517.10,,"Fee schedule rate ($38,517.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,16897.01,43444.85,There are no additional notes associated with this service or procedure.
"HC Unlisted Procedure, Nervous System",CASE-64999,APC,64999,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7029.71,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,7029.71,7131.59,OPPS APC
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],12840.52,,"Case rate ($12,840.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,080.88, add-ons for qualifying new technology services are included. If operating cost exceeds $46,951.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,556.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $10,098.70 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,135.93 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $796.89. The transfer capital threshold is the transfer adjustment factor * $796.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,1188.00,31658.33,Inpatient DRG
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],16822.43,,"Case rate ($16,021.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,066.20, add-ons for qualifying new technology services are included. If operating cost exceeds $49,937.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,764.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $13,071.69 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,121.25 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,004.72. The transfer capital threshold is the transfer adjustment factor * $1,004.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7453.00,42138.30,Inpatient DRG
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],14657.77,,"Case rate ($14,370.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,504.04, add-ons for qualifying new technology services are included. If operating cost exceeds $48,375.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,668.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $11,516.62 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,559.08 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $908.78. The transfer capital threshold is the transfer adjustment factor * $908.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,14370.36,38378.80,Inpatient DRG
MAJOR BLADDER PROCEDURES WITH MCC,653,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],38435.08,,"Case rate ($37,135.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $34,681.82, add-ons for qualifying new technology services are included. If operating cost exceeds $69,552.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,333.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.5. The base transfer operating payment is the transfer adjustment factor * $32,616.61 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $32,736.87 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,573.77. The transfer capital threshold is the transfer adjustment factor * $2,573.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,10280.00,125343.98,Inpatient DRG
"OTHER SKIN SUBCUTANEOUS TISSUE AND BREAST DISORDERS,MINOR",385,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],4972.05,,"Case rate ($4,735.29). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4735.29,4972.05,There are no additional notes associated with this service or procedure.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],28500.78,,"Case rate ($16,286.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,286.28, add-ons for qualifying new technology services are included. If operating cost exceeds $50,157.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,808.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $13,292.32 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,341.33 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,048.90. The transfer capital threshold is the transfer adjustment factor * $1,048.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 175%.",,,,0,other,16286.16,58320.32,All Other Inpatient
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],11165.00,,"Per diem ($11,165). If length of stay < 3.5, first 1 days paid at a per diem of $22,330 instead. Capped at $39,078.16.",,,,0,other,11165.00,61234.06,Estimated amount calculated based on 3 day length of stay.
Unlisted Laparoscopy Procedure Oviduct Ovary,CASE-58679,APC,58679,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5941.70,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5658.76,5941.70,OPPS APC
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],10550.81,,"Case rate ($10,048.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,483.42, add-ons for qualifying new technology services are included. If operating cost exceeds $44,354.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,352.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,510.78 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,538.48 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $592.68. The transfer capital threshold is the transfer adjustment factor * $592.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10048.39,23545.50,Inpatient DRG
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC,833,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5678.08,,"Case rate ($5,486.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,239.18, add-ons for qualifying new technology services are included. If operating cost exceeds $40,110.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,018.96, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $3,282.12 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,294.23 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $258.99. The transfer capital threshold is the transfer adjustment factor * $258.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,3041.73,10289.10,Inpatient DRG
OTHER DISORDERS OF THE EYE WITHOUT MCC,125,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],17952.29,,"Fee schedule rate ($17,952.29). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (6), with a minimum of zero.",,,,0,other,7144.54,17952.29,There are no additional notes associated with this service or procedure.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],38246.19,,"Fee schedule rate ($38,246.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,19435.86,50821.76,There are no additional notes associated with this service or procedure.
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],18217.52,,"Fee schedule rate ($18,217.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7414.07,18217.52,There are no additional notes associated with this service or procedure.
"Suture Digital Nerve Hand/Foot 1 Nerve|RIGHT HAND, SECOND DIGIT",CASE-64831,APC,64831,CPT,0360,RC,,,F6,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
Prep Site F/S/N/H/F/G/M/D Gt 1st 100 Sq Cm/1pct,CASE-15004,APC,15004,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],380.51,,"APC Price ($380.51). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,380.51,399.53,OPPS APC
"POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS,MAJOR",721,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],1958.12,,"Case rate for a one day stay ($1,864.88). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,1864.88,1958.12,There are no additional notes associated with this service or procedure.
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],34245.00,,"Fee schedule rate ($34,245.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,12725.42,34245.00,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITH CC,164,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],49664.75,,,,,,0,other,19037.66,77058.83,There are no additional notes associated with this service or procedure.
Cystourethroscopy W/Dest &/Rmvl Tumor Large,CASE-52240,APC,52240,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5194.43,,"APC Price ($5,018.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5018.77,5269.71,OPPS APC
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],7386.59,,"Case rate ($7,034.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,679.97, add-ons for qualifying new technology services are included. If operating cost exceeds $41,550.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,132.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $4,717.62 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,735.02 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $372.27. The transfer capital threshold is the transfer adjustment factor * $372.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,21089.59,Inpatient DRG
Litholapaxy Smpl/Sm <2.5 Cm,CASE-52317,APC,52317,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3464.44,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3299.47,3464.44,OPPS APC
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],28067.50,,"Fee schedule rate ($28,067.50). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (37), with a minimum of zero.",,,,0,other,13907.80,52794.06,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],19126.88,,"Fee schedule rate ($19,126.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,19126.88,There are no additional notes associated with this service or procedure.
Esophagogastroduodenoscopy Submucosal Injection|SEPARATE STRUCTURE,CASE-43236,APC,43236,CPT,0360,RC,,,XS,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1796.14,,"APC Price ($1,796.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1796.14,1885.95,OPPS APC
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],8982.23,,"Case rate ($8,554.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,093.67, add-ons for qualifying new technology services are included. If operating cost exceeds $42,964.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,243.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,126.13 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,148.72 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $483.41. The transfer capital threshold is the transfer adjustment factor * $483.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8554.50,19204.75,Inpatient DRG
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,082,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],56223.11,,"Fee schedule rate ($56,223.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,17423.21,56223.11,There are no additional notes associated with this service or procedure.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],41888.70,,"Fee schedule rate ($41,888.70). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,25162.32,75579.22,There are no additional notes associated with this service or procedure.
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],39424.57,,"Fee schedule rate ($39,424.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12195.15,39424.57,There are no additional notes associated with this service or procedure.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],19635.68,,,,,,0,other,5683.00,19635.68,There are no additional notes associated with this service or procedure.
HC Perq Vert Agmntj Cavity Crtj Uni/Bi Cannulj Lmbr,CASE-22514,APC,22514,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,6791.99,OPPS APC
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],34759.42,,,,,,0,other,13907.80,52794.06,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],59021.28,,"Fee schedule rate ($59,021.28). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,23851.92,63653.13,There are no additional notes associated with this service or procedure.
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC,797,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],20928.55,,"Fee schedule rate ($20,928.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8719.72,20928.55,There are no additional notes associated with this service or procedure.
CERVICAL SPINAL FUSION WITHOUT CC/MCC,473,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],62077.11,,"Fee schedule rate ($62,077.11). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,18477.61,62077.11,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],29265.60,,"Fee schedule rate ($29,265.60). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,14337.84,52803.53,There are no additional notes associated with this service or procedure.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,270,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],36456.95,,"Case rate ($34,720.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $32,431.98, add-ons for qualifying new technology services are included. If operating cost exceeds $71,076.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $5,156.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.4. The base transfer operating payment is the transfer adjustment factor * $30,933.64 + an uncompensated DSH payment of $1,359.91. The transfer operating threshold is the transfer adjustment factor * $31,072.08 + an uncompensated DSH payment of $1,359.91. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,427.36. The transfer capital threshold is the transfer adjustment factor * $2,427.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,34720.90,101002.04,Inpatient DRG
"OPEN CRANIOTOMY EXCEPT TRAUMA,MODERATE",021,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],32400.67,,"Case rate ($30,857.78). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,30857.78,32400.67,There are no additional notes associated with this service or procedure.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC,027,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],56363.30,,"Fee schedule rate ($56,363.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,19030.20,56363.30,There are no additional notes associated with this service or procedure.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC",156,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6812.03,,"Case rate ($6,487.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,179.41, add-ons for qualifying new technology services are included. If operating cost exceeds $41,050.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,084.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $4,218.46 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,234.46 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $324.24. The transfer capital threshold is the transfer adjustment factor * $324.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6625.12,13598.77,Inpatient DRG
NERVOUS SYSTEM NEOPLASMS WITH MCC,054,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],6965.00,,,,,,0,other,6965.00,30044.81,There are no additional notes associated with this service or procedure.
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],33159.45,,"Fee schedule rate ($33,159.45). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,13092.47,33159.45,There are no additional notes associated with this service or procedure.
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],15584.93,,"Case rate ($14,842.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,967.60, add-ons for qualifying new technology services are included. If operating cost exceeds $48,838.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,680.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $11,977.24 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,022.65 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $920.60. The transfer capital threshold is the transfer adjustment factor * $920.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,15233.11,38610.21,Inpatient DRG
SINGLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL,402,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],75557.26,,"Fee schedule rate ($75,557.26). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.9), with a minimum of zero.",,,,0,other,29172.05,124455.45,There are no additional notes associated with this service or procedure.
HC >= 12 Lead Ekg|UNUSUAL NON-OVERLAPPING SERVICE,CASE-93005,APC,93005,CPT,0730,RC,,,XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3611.96,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3489.82,3611.96,OPPS APC
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],9608.67,,"Case rate ($9,151.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,648.69, add-ons for qualifying new technology services are included. If operating cost exceeds $43,519.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,287.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,679.11 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,703.74 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $527.05. The transfer capital threshold is the transfer adjustment factor * $527.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9151.11,30245.71,Inpatient DRG
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],17023.58,,"Case rate ($16,689.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,661.75, add-ons for qualifying new technology services are included. If operating cost exceeds $50,532.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,838.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $13,666.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,716.80 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,078.42. The transfer capital threshold is the transfer adjustment factor * $1,078.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,16689.78,59521.43,Inpatient DRG
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],23602.95,,"Fee schedule rate ($23,602.95). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,13341.67,42586.49,There are no additional notes associated with this service or procedure.
Insj/Rplcmt Breast Implant Sep Day Mastectomy|BILATERAL PROCEDURE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-19342,APC,19342,CPT,0360,RC,,,50|XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],8033.01,,"APC Price ($7,650.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,7650.49,8033.01,OPPS APC
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],39153.65,,"Fee schedule rate ($39,153.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,7605.00,39153.65,There are no additional notes associated with this service or procedure.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],93728.21,,"Fee schedule rate ($93,728.21). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,35719.96,105091.76,There are no additional notes associated with this service or procedure.
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],14625.55,,"Fee schedule rate ($14,625.55). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7438.45,15961.98,There are no additional notes associated with this service or procedure.
Excision Pilonidal Cyst/Sinus Simple,CASE-11770,APC,11770,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],2718.88,,"APC Price ($2,718.88). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2718.88,2814.04,OPPS APC
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],52909.62,,"Fee schedule rate ($52,909.62). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,23344.70,62179.32,There are no additional notes associated with this service or procedure.
SINGLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL,402,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],75557.26,,"Fee schedule rate ($75,557.26). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.9), with a minimum of zero.",,,,0,other,29172.05,124455.45,There are no additional notes associated with this service or procedure.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],39153.65,,"Fee schedule rate ($39,153.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,7605.00,39153.65,There are no additional notes associated with this service or procedure.
"Inj Dx/Ther Agnt Paravert Facet Joint, Cerv/Thorac, 2nd Level",CASE-64491,APC,64491,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],827.89,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,827.89,869.28,OPPS APC
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],13947.32,,"Fee schedule rate ($13,947.32). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6153.12,13947.32,There are no additional notes associated with this service or procedure.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,025,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],91631.33,,"Fee schedule rate ($91,631.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,13351.00,91631.33,There are no additional notes associated with this service or procedure.
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],16400.70,,"Fee schedule rate ($16,400.70). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,16400.70,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],36028.59,,,,,,0,other,14344.60,36028.59,There are no additional notes associated with this service or procedure.
SALIVARY GLAND PROCEDURES,139,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],10313.19,,"Case rate ($10,313.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,729.75, add-ons for qualifying new technology services are included. If operating cost exceeds $44,600.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,372.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $7,756.21 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,784.80 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $612.04. The transfer capital threshold is the transfer adjustment factor * $612.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10313.19,30690.92,Inpatient DRG
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],14329.44,,"Case rate ($13,647.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,831.20, add-ons for qualifying new technology services are included. If operating cost exceeds $47,702.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,615.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $10,846.26 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,886.25 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $855.88. The transfer capital threshold is the transfer adjustment factor * $855.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7921.00,45706.73,Inpatient DRG
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],34892.92,,"Fee schedule rate ($34,892.92). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,6965.00,41030.48,There are no additional notes associated with this service or procedure.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITHOUT CC/MCC,816,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],14733.53,,"Fee schedule rate ($14,733.53). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6224.90,14733.53,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],21980.29,,"Fee schedule rate ($21,980.29). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9865.56,37914.65,There are no additional notes associated with this service or procedure.
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],31750.77,,"Fee schedule rate ($31,750.77). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13386.36,33244.29,There are no additional notes associated with this service or procedure.
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],11811.40,,"Fee schedule rate ($11,811.40). Adds an outlier to normal pricing equal to the per diem rate ($53,248.69) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.7), with a minimum of zero.",,,,0,other,5937.41,12366.99,There are no additional notes associated with this service or procedure.
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC",514,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],12581.10,,"Fee schedule rate ($12,581.10). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8868.04,22699.91,There are no additional notes associated with this service or procedure.
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC",758,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],8677.99,,"Fee schedule rate ($8,677.99). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8574.80,19263.78,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],39361.94,,"Fee schedule rate ($39,361.94). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.8), with a minimum of zero.",,,,0,other,16129.04,59610.47,There are no additional notes associated with this service or procedure.
Laps Fulg/Exc Ovary Viscera/Peritoneal Surface|RIGHT SIDE,CASE-58662,APC,58662,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5658.76,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5658.76,5941.70,OPPS APC
VENTRICULAR SHUNT PROCEDURES WITH CC,032,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],46275.08,,"Fee schedule rate ($46,275.08). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,16376.22,46275.08,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,690,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],7798.29,,"Case rate ($7,426.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,044.73, add-ons for qualifying new technology services are included. If operating cost exceeds $41,915.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,160.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,081.05 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,099.78 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $400.94. The transfer capital threshold is the transfer adjustment factor * $400.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7426.94,15928.53,Inpatient DRG
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],12455.21,,"Case rate ($12,455.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,722.41, add-ons for qualifying new technology services are included. If operating cost exceeds $46,593.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,528.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $9,741.55 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,777.47 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $768.70. The transfer capital threshold is the transfer adjustment factor * $768.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12455.21,37149.27,Inpatient DRG
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],16897.01,,"Case rate ($16,897.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,854.53, add-ons for qualifying new technology services are included. If operating cost exceeds $50,725.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,853.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $13,858.48 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,909.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,093.57. The transfer capital threshold is the transfer adjustment factor * $1,093.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,16897.01,43444.85,Inpatient DRG
POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES,769,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],31756.41,,"Fee schedule rate ($31,756.41). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.7), with a minimum of zero.",,,,0,other,13388.39,33250.19,There are no additional notes associated with this service or procedure.
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC,520,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],12061.74,,"Case rate ($12,061.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,356.39, add-ons for qualifying new technology services are included. If operating cost exceeds $46,227.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,499.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $9,376.87 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,411.44 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $739.93. The transfer capital threshold is the transfer adjustment factor * $739.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12061.74,39786.42,Inpatient DRG
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],21354.82,,"Fee schedule rate ($21,354.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6834.39,21354.82,There are no additional notes associated with this service or procedure.
"Application Uniplane External Fixation System|RIGHT HAND, FIFTH DIGIT",CASE-20690,APC,20690,CPT,0360,RC,,,F9,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7029.71,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6791.99,7131.59,OPPS APC
Sigmoidoscopy Flx Control Bleeding,CASE-45334,APC,45334,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1120.09,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1120.09,1176.09,OPPS APC
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],41030.48,,,,,,0,other,6965.00,41030.48,There are no additional notes associated with this service or procedure.
CHOLECYSTECTOMY WITH C.D.E. WITH MCC,411,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],25530.89,,"Case rate ($24,315.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $22,755.46, add-ons for qualifying new technology services are included. If operating cost exceeds $57,626.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,396.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $20,734.06 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $20,810.51 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,636.12. The transfer capital threshold is the transfer adjustment factor * $1,636.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,24315.13,88615.28,Inpatient DRG
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],12651.45,,"Fee schedule rate ($12,651.45). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,6503.90,14492.93,There are no additional notes associated with this service or procedure.
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],14046.24,,"Case rate ($13,571.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,760.65, add-ons for qualifying new technology services are included. If operating cost exceeds $47,631.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,610.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $10,775.96 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,815.69 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $850.33. The transfer capital threshold is the transfer adjustment factor * $850.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,13571.25,33781.47,Inpatient DRG
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],28334.16,,"Fee schedule rate ($28,334.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,7868.00,32126.64,There are no additional notes associated with this service or procedure.
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC,519,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],50780.20,,"Fee schedule rate ($50,780.20). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,15490.44,50780.20,There are no additional notes associated with this service or procedure.
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],37899.49,,"Fee schedule rate ($37,899.49). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,14747.55,37899.49,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],14295.18,,"Case rate ($14,295.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,434.11, add-ons for qualifying new technology services are included. If operating cost exceeds $48,305.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,663.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $11,446.95 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,489.15 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $903.28. The transfer capital threshold is the transfer adjustment factor * $903.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,14295.18,42768.36,Inpatient DRG
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],51656.32,,"Fee schedule rate ($51,656.32). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,20559.34,54086.17,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],9370.00,,"Per diem ($9,370). If length of stay < 6.7, first 1 days paid at a per diem of $18,740 instead. Capped at $62,779.90.",,,,0,other,9370.00,65732.99,Estimated amount calculated based on 3 day length of stay.
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],25796.13,,"Case rate ($24,567.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $22,990.45, add-ons for qualifying new technology services are included. If operating cost exceeds $57,861.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,414.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.7. The base transfer operating payment is the transfer adjustment factor * $20,968.18 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $21,045.49 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,654.60. The transfer capital threshold is the transfer adjustment factor * $1,654.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9370.00,65732.99,Inpatient DRG
HC Incis/Drain Scrotum/Testis Epididym,CASE-54700,APC,54700,CPT,0450,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],2054.48,,"APC Price ($1,956.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1956.65,2054.48,OPPS APC
RESPIRATORY NEOPLASMS WITHOUT CC/MCC,182,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],23037.13,,"Fee schedule rate ($23,037.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6965.00,23037.13,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],32296.02,,"Case rate ($32,296.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $30,179.91, add-ons for qualifying new technology services are included. If operating cost exceeds $65,050.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,979.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $28,131.23 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $28,234.95 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,219.83. The transfer capital threshold is the transfer adjustment factor * $2,219.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,32296.02,88188.38,Inpatient DRG
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],25225.91,,,,,,0,other,10626.74,25225.91,There are no additional notes associated with this service or procedure.
Neuroplasty &/Transpos Median Nrv Carpal Tunne|LEFT SIDE,CASE-64721,APC,64721,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1827.80,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1827.80,1919.19,OPPS APC
SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS,029,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],61889.56,,"Fee schedule rate ($61,889.56). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13641.00,67130.05,There are no additional notes associated with this service or procedure.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],20553.44,,"Fee schedule rate ($20,553.44). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8874.81,20553.44,There are no additional notes associated with this service or procedure.
Largsc Exc Tum&/Strpg Cords/Epigl Mcrscp/Tlscp|LEFT SIDE,CASE-31541,APC,31541,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3489.82,,"APC Price ($3,489.82). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3489.82,3611.96,OPPS APC
"ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",770,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],17800.73,,"Fee schedule rate ($17,800.73). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,8735.30,19730.13,There are no additional notes associated with this service or procedure.
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],15453.88,,"Case rate ($15,453.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,512.02, add-ons for qualifying new technology services are included. If operating cost exceeds $49,383.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,747.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $12,520.90 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,567.07 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $988.02. The transfer capital threshold is the transfer adjustment factor * $988.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,15453.88,39251.68,Inpatient DRG
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],15812.70,,"Case rate ($15,059.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,169.80, add-ons for qualifying new technology services are included. If operating cost exceeds $49,040.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,696.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $12,178.67 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,224.85 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $936.08. The transfer capital threshold is the transfer adjustment factor * $936.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,15456.59,41402.42,Inpatient DRG
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR,518,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],89342.77,,"Fee schedule rate ($89,342.77). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,13252.00,89342.77,There are no additional notes associated with this service or procedure.
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],6378.61,,"Case rate ($6,378.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,069.50, add-ons for qualifying new technology services are included. If operating cost exceeds $40,940.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,084.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,109.40 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,124.55 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $324.27. The transfer capital threshold is the transfer adjustment factor * $324.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,4341.01,12882.53,Inpatient DRG
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],11051.33,,"Case rate ($10,834.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,214.84, add-ons for qualifying new technology services are included. If operating cost exceeds $45,085.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,410.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $8,239.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,269.90 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $650.18. The transfer capital threshold is the transfer adjustment factor * $650.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,10834.64,25830.00,Inpatient DRG
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],18497.24,,"Case rate ($18,497.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,343.20, add-ons for qualifying new technology services are included. If operating cost exceeds $52,214.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,970.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $15,341.68 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,398.25 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,210.61. The transfer capital threshold is the transfer adjustment factor * $1,210.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,18497.24,62041.12,Inpatient DRG
VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC,033,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],13519.22,,"Case rate ($12,875.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,133.75, add-ons for qualifying new technology services are included. If operating cost exceeds $47,004.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,540.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $10,150.32 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,188.80 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $780.18. The transfer capital threshold is the transfer adjustment factor * $780.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13206.23,42156.44,Inpatient DRG
PERITONEAL ADHESIOLYSIS WITH CC,336,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],29765.40,,"Fee schedule rate ($29,765.40). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,16225.22,53705.31,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],23954.07,,"Fee schedule rate ($23,954.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,6167.00,29058.99,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],16628.38,,"Case rate ($16,066.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,081.53, add-ons for qualifying new technology services are included. If operating cost exceeds $49,952.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,792.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $13,088.32 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,136.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,032.80. The transfer capital threshold is the transfer adjustment factor * $1,032.80. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6965.00,41030.48,Inpatient DRG
"EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME, NEONATE",790,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],3354.00,,,,,,0,other,3054.00,44304.49,Estimated amount calculated based on 17 day length of stay.
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],18217.52,,"Fee schedule rate ($18,217.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7414.07,18217.52,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITHOUT STERILIZATION WITH CC,787,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],20988.02,,"Fee schedule rate ($20,988.02). Adds an outlier to normal pricing equal to the per diem rate ($39,437.39) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,9508.01,23722.94,There are no additional notes associated with this service or procedure.
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],14674.80,,"Fee schedule rate ($14,674.80). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6711.00,16865.16,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],35192.25,,"Fee schedule rate ($35,192.25). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,10895.60,35192.25,There are no additional notes associated with this service or procedure.
"Tendon Sheath Incision|LEFT HAND, THIRD DIGIT",CASE-26055,APC,26055,CPT,0360,RC,,,F2,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1919.19,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1827.80,1919.19,OPPS APC
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITHOUT CC/MCC",630,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],42541.02,,"Fee schedule rate ($42,541.02). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11828.78,42541.02,There are no additional notes associated with this service or procedure.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],9084.76,,"Case rate ($8,906.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,421.26, add-ons for qualifying new technology services are included. If operating cost exceeds $43,292.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,269.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $6,452.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,476.31 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $509.17. The transfer capital threshold is the transfer adjustment factor * $509.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,8906.63,28434.57,Inpatient DRG
Colsc Flx With Directed Submucosal Njx Any Sbst,CASE-45381,APC,45381,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1120.09,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1120.09,1176.09,OPPS APC
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC,806,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],13416.00,,,,,,0,other,5354.25,13416.00,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],32093.19,,,,,,0,other,9888.00,43399.23,There are no additional notes associated with this service or procedure.
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],8083.15,,"Case rate ($8,083.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,655.19, add-ons for qualifying new technology services are included. If operating cost exceeds $42,526.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,208.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,689.27 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,710.24 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $448.94. The transfer capital threshold is the transfer adjustment factor * $448.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7884.32,17835.23,Inpatient DRG
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC,805,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],20902.03,,"Fee schedule rate ($20,902.03). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9253.36,21235.42,There are no additional notes associated with this service or procedure.
OTHER CEREBROVASCULAR DISORDERS WITH CC,071,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],9337.76,,"Case rate ($8,893.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,408.66, add-ons for qualifying new technology services are included. If operating cost exceeds $43,279.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,268.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,439.97 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,463.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $508.18. The transfer capital threshold is the transfer adjustment factor * $508.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5843.00,29215.10,Inpatient DRG
Insj/Rplcmt Breast Implant Sep Day Mastectomy|LEFT SIDE,CASE-19342,APC,19342,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],8033.01,,"APC Price ($7,650.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,7650.49,8033.01,OPPS APC
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],15461.47,,"Case rate ($14,725.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,834.15, add-ons for qualifying new technology services are included. If operating cost exceeds $48,705.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,694.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,845.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,889.20 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $934.73. The transfer capital threshold is the transfer adjustment factor * $934.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7389.00,37134.43,Inpatient DRG
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],6524.00,,"Per diem ($6,524). If length of stay < 2.6, first 1 days paid at a per diem of $13,048 instead. Capped at $16,962.56.",,,,0,other,6524.00,17760.46,Estimated amount calculated based on 2 day length of stay.
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],22762.43,,"Fee schedule rate ($22,762.43). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6230.00,22762.43,There are no additional notes associated with this service or procedure.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],46215.75,,"Fee schedule rate ($46,215.75). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.7), with a minimum of zero.",,,,0,other,18598.83,48389.68,There are no additional notes associated with this service or procedure.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],52699.33,,"Fee schedule rate ($52,699.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,18105.81,52699.33,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC,831,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],9294.42,,"Fee schedule rate ($9,294.42). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,4941.30,23661.59,There are no additional notes associated with this service or procedure.
Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq|COLORECTAL CANCER SCREEN,CASE-45385,APC,45385,CPT,0360,RC,,,PT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1120.09,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1120.09,1176.09,OPPS APC
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|RIGHT HAND, FIFTH DIGIT",CASE-26160,APC,26160,CPT,0360,RC,,,F9,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1580.37,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1505.12,1580.37,OPPS APC
O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC,621,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],12767.94,,"Case rate ($12,159.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,447.74, add-ons for qualifying new technology services are included. If operating cost exceeds $46,318.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,507.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $9,467.88 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,502.79 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $747.11. The transfer capital threshold is the transfer adjustment factor * $747.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12159.94,36669.96,Inpatient DRG
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC",011,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],38880.49,,"Case rate ($38,880.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $36,305.31, add-ons for qualifying new technology services are included. If operating cost exceeds $71,176.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,461.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 11.4. The base transfer operating payment is the transfer adjustment factor * $34,234.14 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $34,360.36 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,701.41. The transfer capital threshold is the transfer adjustment factor * $2,701.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,38880.49,150008.48,Inpatient DRG
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],11565.93,,"Fee schedule rate ($11,565.93). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6148.93,15887.21,There are no additional notes associated with this service or procedure.
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",759,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],11643.60,,"Fee schedule rate ($11,643.60). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6190.22,13057.66,There are no additional notes associated with this service or procedure.
"Inj Dx/Ther Agnt Paravert Facet Joint, Cerv/Thorac, 2nd Level|LEFT SIDE",CASE-64491,APC,64491,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],827.89,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,827.89,869.28,OPPS APC
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC,807,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6510.67,,"Case rate ($6,510.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,192.35, add-ons for qualifying new technology services are included. If operating cost exceeds $41,063.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,093.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $4,231.80 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,247.40 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $333.93. The transfer capital threshold is the transfer adjustment factor * $333.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,5354.25,13266.23,Inpatient DRG
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],11133.98,,"Fee schedule rate ($11,133.98). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5919.29,13545.65,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],18550.52,,"Fee schedule rate ($18,550.52). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,6965.00,41030.48,There are no additional notes associated with this service or procedure.
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],27553.62,,"Fee schedule rate ($27,553.62). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12305.53,30103.84,There are no additional notes associated with this service or procedure.
NEONATE WITH OTHER SIGNIFICANT PROBLEMS,794,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12228.57,,"Case rate ($11,646.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,987.98, add-ons for qualifying new technology services are included. If operating cost exceeds $45,858.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,452.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $9,008.87 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,043.03 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $692.44. The transfer capital threshold is the transfer adjustment factor * $692.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,1798.85,12536.83,Inpatient DRG
HEART FAILURE AND SHOCK WITH CC,292,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],5502.00,,"Per diem ($5,502). If length of stay < 2.9, first 1 days paid at a per diem of $11,004 instead. Capped at $15,955.26.",,,,0,other,5502.00,16705.77,Estimated amount calculated based on 2 day length of stay.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],43399.23,,"Fee schedule rate ($43,399.23). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9888.00,43399.23,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],6965.00,,,,,,0,other,1188.00,12138.74,There are no additional notes associated with this service or procedure.
VAGINAL DELIVERY WITH O.R. PROCEDURES EXCEPT STERILIZATION AND/OR D&C,768,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],9201.90,,"Case rate ($9,201.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,695.94, add-ons for qualifying new technology services are included. If operating cost exceeds $43,566.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,290.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $6,726.19 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,750.99 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $530.76. The transfer capital threshold is the transfer adjustment factor * $530.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6426.91,13416.00,Inpatient DRG
"Arthrodesis Great Toe Metatarsophalangeal Joint|LEFT FOOT, GREAT TOE",CASE-28750,APC,28750,CPT,0360,RC,,,TA,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7029.71,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6791.99,7131.59,OPPS APC
O.R. PROCEDURES FOR OBESITY WITH CC,620,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],13421.42,,"Case rate ($12,782.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,026.70, add-ons for qualifying new technology services are included. If operating cost exceeds $46,897.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,552.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $10,044.72 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,081.75 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $792.63. The transfer capital threshold is the transfer adjustment factor * $792.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12782.30,43753.50,Inpatient DRG
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],38246.19,,"Fee schedule rate ($38,246.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,19435.86,50821.76,There are no additional notes associated with this service or procedure.
HC N Block Inj Intercost Sng|LEFT SIDE,CASE-64420,APC,64420,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],683.85,,"APC Price ($660.72). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,660.72,693.76,OPPS APC
"HERNIA PROCEDURES EXCEPT INGUINAL FEMORAL AND UMBILICAL,MODERATE",227,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],3586.41,,"Case rate for a one day stay ($3,586.41). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,3586.41,3765.73,There are no additional notes associated with this service or procedure.
Lamnotmy Incl W/Dcmprsn Nrv Root 1 Intrspc Lumbr,CASE-63030,APC,63030,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6791.99,7131.59,OPPS APC
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITHOUT MCC,430,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],108381.11,,"Fee schedule rate ($108,381.11). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.6), with a minimum of zero.",,,,0,other,41000.16,133156.90,There are no additional notes associated with this service or procedure.
Hrhc Ntrnl & Xtrnl 2/> Column/Group W/Fissu,CASE-46261,APC,46261,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],2727.99,,"APC Price ($2,598.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2598.08,2727.99,OPPS APC
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],34889.29,,,,,,0,other,13917.42,34889.29,There are no additional notes associated with this service or procedure.
Dstrj Lesion Penis Simple Laser,CASE-54057,APC,54057,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],685.32,,"APC Price ($652.69). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,652.69,685.32,OPPS APC
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],18915.50,,,,,,0,other,6230.00,22762.43,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],17141.48,,"Case rate ($9,795.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,247.81, add-ons for qualifying new technology services are included. If operating cost exceeds $44,118.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,334.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $7,276.03 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,302.86 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $574.15. The transfer capital threshold is the transfer adjustment factor * $574.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,9795.13,23899.13,All Other Inpatient
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],36042.47,,"Fee schedule rate ($36,042.47). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,10862.00,86437.13,There are no additional notes associated with this service or procedure.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],11043.60,,"Case rate ($10,517.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,920.01, add-ons for qualifying new technology services are included. If operating cost exceeds $44,791.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,386.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $7,945.76 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,975.06 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $627.00. The transfer capital threshold is the transfer adjustment factor * $627.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10517.71,24909.11,Inpatient DRG
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],15283.90,,"Case rate ($15,283.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,353.89, add-ons for qualifying new technology services are included. If operating cost exceeds $49,224.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,735.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.2. The base transfer operating payment is the transfer adjustment factor * $12,363.36 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,408.94 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $975.59. The transfer capital threshold is the transfer adjustment factor * $975.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,15283.90,38757.79,Inpatient DRG
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],51630.84,,"Fee schedule rate ($51,630.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,20559.34,54086.17,There are no additional notes associated with this service or procedure.
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],5280.00,,"Per diem ($5,280). If length of stay < 3.1, first 1 days paid at a per diem of $10,560 instead. Capped at $16,366.82.",,,,0,other,5280.00,17136.70,Estimated amount calculated based on 3 day length of stay.
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITHOUT CC/MCC",630,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12115.38,,"Case rate ($11,538.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,887.49, add-ons for qualifying new technology services are included. If operating cost exceeds $45,758.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,444.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $8,908.77 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,942.54 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $684.75. The transfer capital threshold is the transfer adjustment factor * $684.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,11828.78,42541.02,Inpatient DRG
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",759,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],11643.60,,"Fee schedule rate ($11,643.60). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6190.22,13057.66,There are no additional notes associated with this service or procedure.
"Corrj Hallux Valgus W/Sesmdc W/Dist Metar Osteot|LEFT FOOT, GREAT TOE",CASE-28296,APC,28296,CPT,0360,RC,,,TA,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
"CARDIAC ARREST, UNEXPLAINED WITH MCC",296,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],36459.67,,"Fee schedule rate ($36,459.67). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12522.25,36459.67,There are no additional notes associated with this service or procedure.
Colon Ca Scrn Not Hi Rsk Ind|DOCUMENTATION ON FILE,CASE-G0121,APC,G0121,CPT,0360,RC,,,KX,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],870.46,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,870.46,913.99,OPPS APC
Rpr Recrt Ingun Hernia Any Age Incarcerated|LEFT SIDE,CASE-49521,APC,49521,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6059.65,,"APC Price ($6,059.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6059.65,6362.63,OPPS APC
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],33188.44,,"Fee schedule rate ($33,188.44). Adds an outlier to normal pricing equal to the per diem rate ($84,167.29) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.5), with a minimum of zero.",,,,0,other,13904.43,34749.58,There are no additional notes associated with this service or procedure.
VENTRICULAR SHUNT PROCEDURES WITH MCC,031,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],34588.05,,"Fee schedule rate ($34,588.05). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,32287.20,88162.80,There are no additional notes associated with this service or procedure.
SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS,029,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],67130.05,,,,,,0,other,13641.00,67130.05,There are no additional notes associated with this service or procedure.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],11681.49,,"Fee schedule rate ($11,681.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5778.62,11681.49,There are no additional notes associated with this service or procedure.
HEADACHES WITHOUT MCC,103,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],6965.00,,,,,,0,other,6965.00,20883.08,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],67794.72,,"Fee schedule rate ($67,794.72). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,10862.00,86437.13,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,373,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],13670.03,,"Fee schedule rate ($13,670.03). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6870.94,14313.05,There are no additional notes associated with this service or procedure.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,056,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],59328.19,,"Fee schedule rate ($59,328.19). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (44), with a minimum of zero.",,,,0,other,7659.00,59328.19,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],41402.42,,"Fee schedule rate ($41,402.42). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,15456.59,41402.42,There are no additional notes associated with this service or procedure.
Exc B9 Lesion Mrgn Xcp Sk Tg T/a/L 3.1-4.0 Cm,CASE-11404,APC,11404,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1600.04,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1545.93,1623.23,OPPS APC
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],8108.13,,"Case rate ($7,833.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,423.35, add-ons for qualifying new technology services are included. If operating cost exceeds $42,294.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,190.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,458.28 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,478.41 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $430.71. The transfer capital threshold is the transfer adjustment factor * $430.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,5883.03,17111.12,Inpatient DRG
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITH MCC OR ANTINEOPLASTIC IMPLANT OR EPILEPSY WITH NEUROSTIMULATOR,023,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],42788.50,,"Case rate ($40,750.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $38,045.35, add-ons for qualifying new technology services are included. If operating cost exceeds $72,916.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,598.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $35,967.78 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $36,100.40 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,838.21. The transfer capital threshold is the transfer adjustment factor * $2,838.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,15168.00,136379.44,Inpatient DRG
Vaginal Hysterectomy Uterus 250 Gm/<,CASE-58260,APC,58260,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],4916.53,,"APC Price ($4,682.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,4682.41,4916.53,OPPS APC
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],67790.93,,"Fee schedule rate ($67,790.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,21597.50,67790.93,There are no additional notes associated with this service or procedure.
HC Drain/Inj Joint/Bursa W/US Large|PBB CHARGE|RIGHT SIDE,CASE-20611,APC,20611,CPT,0510,RC,,,PBB|RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],301.68,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,287.31,301.68,OPPS APC
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],2070.00,,,,,,0,other,1188.00,12138.74,Estimated amount calculated based on 1 day length of stay.
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],11980.64,,"Case rate ($11,575.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,904.06, add-ons for qualifying new technology services are included. If operating cost exceeds $45,775.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,464.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $8,926.20 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,959.11 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $704.37. The transfer capital threshold is the transfer adjustment factor * $704.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,11575.50,48961.48,Inpatient DRG
Myomectomy 5/> Myomas &/>250 Gm Abdomina,CASE-58146,APC,58146,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],206.06,,"APC Price ($199.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,206.06,209.05,OPPS APC
Bx/Exc Lymph Node Open Deep Axillary Node|LEFT SIDE,CASE-38525,APC,38525,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6215.36,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6215.36,6526.12,OPPS APC
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],31533.97,,"Fee schedule rate ($31,533.97). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8563.30,31533.97,There are no additional notes associated with this service or procedure.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],45706.73,,"Fee schedule rate ($45,706.73). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,7921.00,45706.73,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL HEMORRHAGE WITH MCC,377,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],14825.64,,"Case rate ($14,324.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,461.19, add-ons for qualifying new technology services are included. If operating cost exceeds $48,332.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,665.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $11,473.94 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,516.24 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $905.41. The transfer capital threshold is the transfer adjustment factor * $905.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,7634.00,35969.56,Inpatient DRG
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],10210.85,,"Case rate ($9,865.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,313.33, add-ons for qualifying new technology services are included. If operating cost exceeds $44,184.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,339.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $7,341.31 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,368.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $579.30. The transfer capital threshold is the transfer adjustment factor * $579.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,9865.56,37914.65,Inpatient DRG
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],17755.26,,"Fee schedule rate ($17,755.26). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7847.50,17755.26,There are no additional notes associated with this service or procedure.
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],16235.87,,"Fee schedule rate ($16,235.87). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6524.00,17760.46,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],32795.66,,"Fee schedule rate ($32,795.66). Adds an outlier to normal pricing equal to the per diem rate ($69,146.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,1188.00,34338.33,There are no additional notes associated with this service or procedure.
Rpr 1st Ingun Hrna Age 5 Yrs/> Reducible|RIGHT SIDE,CASE-49505,APC,49505,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3468.64,,"APC Price ($3,351.34). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3351.34,3518.91,OPPS APC
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC,964,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],30156.97,,,,,,0,other,12323.82,34154.06,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,082,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],56223.11,,"Fee schedule rate ($56,223.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,17423.21,56223.11,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],30063.84,,"Fee schedule rate ($30,063.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13891.57,34712.20,There are no additional notes associated with this service or procedure.
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],20938.30,,,,,,0,other,9151.11,30245.71,There are no additional notes associated with this service or procedure.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],15476.23,,"Case rate ($15,476.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,532.81, add-ons for qualifying new technology services are included. If operating cost exceeds $49,403.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,749.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $12,541.62 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,587.86 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $989.66. The transfer capital threshold is the transfer adjustment factor * $989.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,15476.23,42787.31,Inpatient DRG
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],41944.25,,"Fee schedule rate ($41,944.25). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12795.84,41944.25,There are no additional notes associated with this service or procedure.
Brnchsc Incl Fluor Gdnce Dx W/Cell Washg Spx,CASE-31622,APC,31622,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1749.33,,"APC Price ($1,666.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1666.03,1749.33,OPPS APC
Rinsj Rptd Biceps/Triceps Tdn Dstl W/WO Tdn Grf|RIGHT SIDE,CASE-24342,APC,24342,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR,518,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],89342.77,,"Fee schedule rate ($89,342.77). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,13252.00,89342.77,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,448,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],30663.95,,"Case rate ($30,663.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $28,661.63, add-ons for qualifying new technology services are included. If operating cost exceeds $63,532.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,860.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $26,618.53 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $26,716.68 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,100.47. The transfer capital threshold is the transfer adjustment factor * $2,100.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,30663.95,94077.13,Inpatient DRG
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],21980.29,,"Fee schedule rate ($21,980.29). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9865.56,37914.65,There are no additional notes associated with this service or procedure.
NONTRAUMATIC STUPOR AND COMA WITH MCC,080,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],34015.33,,"Fee schedule rate ($34,015.33). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.5), with a minimum of zero.",,,,0,other,14202.39,35615.37,There are no additional notes associated with this service or procedure.
"LIMB REATTACHMENT, HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA",956,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],27428.25,,"Case rate ($27,428.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $25,651.53, add-ons for qualifying new technology services are included. If operating cost exceeds $60,522.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,623.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $23,619.49 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $23,706.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,863.81. The transfer capital threshold is the transfer adjustment factor * $1,863.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,27428.25,148259.86,Inpatient DRG
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],142438.06,,"Fee schedule rate ($142,438.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (40), with a minimum of zero.",,,,0,other,45521.20,142438.06,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],9015.78,,"Case rate ($8,586.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,135.80, add-ons for qualifying new technology services are included. If operating cost exceeds $43,006.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,234.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,167.47 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,190.85 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $474.05. The transfer capital threshold is the transfer adjustment factor * $474.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,32293.66,Inpatient DRG
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],36094.03,,"Fee schedule rate ($36,094.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11194.25,36094.03,There are no additional notes associated with this service or procedure.
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC,519,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],50780.20,,"Fee schedule rate ($50,780.20). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,15490.44,50780.20,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],86235.79,,"Fee schedule rate ($86,235.79). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,32296.02,88188.38,There are no additional notes associated with this service or procedure.
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC",641,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],7359.28,,"Case rate ($7,214.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,847.54, add-ons for qualifying new technology services are included. If operating cost exceeds $41,718.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,145.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $4,884.58 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,902.59 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $385.44. The transfer capital threshold is the transfer adjustment factor * $385.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,7214.98,15312.64,Inpatient DRG
"Neuroplasty Other Arm/Leg Nerve,Open|RIGHT SIDE",CASE-64708,APC,64708,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],16250.04,,"Case rate ($15,476.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,532.81, add-ons for qualifying new technology services are included. If operating cost exceeds $49,403.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,749.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $12,541.62 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,587.86 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $989.66. The transfer capital threshold is the transfer adjustment factor * $989.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,15476.23,42787.31,Inpatient DRG
O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC,621,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],36669.96,,"Fee schedule rate ($36,669.96). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,12159.94,36669.96,There are no additional notes associated with this service or procedure.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],7017.54,,"Case rate ($6,683.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,353, add-ons for qualifying new technology services are included. If operating cost exceeds $41,224.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,106.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,391.86 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,408.05 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $346.56. The transfer capital threshold is the transfer adjustment factor * $346.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6683.37,14699.43,Inpatient DRG
Destruction Neurolytic Agt Genicular Nerve W/Img|BILATERAL PROCEDURE,CASE-64624,APC,64624,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1827.80,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1827.80,1919.19,OPPS APC
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],9089.85,,"Fee schedule rate ($9,089.85). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,16400.70,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],8859.23,,"Case rate ($8,859.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,377.16, add-ons for qualifying new technology services are included. If operating cost exceeds $43,248.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,265.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $6,408.58 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,432.21 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $505.70. The transfer capital threshold is the transfer adjustment factor * $505.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8859.23,20090.22,Inpatient DRG
Dstr Nrolytc Agnt Parverteb Fct Sngl Crvcl/Thora|BILATERAL PROCEDURE,CASE-64633,APC,64633,CPT,0360,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1891.77,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1827.80,1891.77,OPPS APC
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITHOUT CC/MCC",630,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],28718.58,,,,,,0,other,11828.78,42541.02,There are no additional notes associated with this service or procedure.
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITHOUT MCC,430,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],133156.90,,"Fee schedule rate ($133,156.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,41000.16,133156.90,There are no additional notes associated with this service or procedure.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],19204.75,,,,,,0,other,8554.50,19204.75,There are no additional notes associated with this service or procedure.
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],21377.04,,"Fee schedule rate ($21,377.04). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,9648.19,31477.13,There are no additional notes associated with this service or procedure.
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],14492.93,,"Fee schedule rate ($14,492.93). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6503.90,14492.93,There are no additional notes associated with this service or procedure.
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],48961.48,,"Fee schedule rate ($48,961.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11575.50,48961.48,There are no additional notes associated with this service or procedure.
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],24528.10,,"Fee schedule rate ($24,528.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10989.72,26280.60,There are no additional notes associated with this service or procedure.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],22677.38,,"Case rate ($21,597.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,227.30, add-ons for qualifying new technology services are included. If operating cost exceeds $55,098.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,197.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $18,215.19 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,282.35 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,437.36. The transfer capital threshold is the transfer adjustment factor * $1,437.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,21597.50,67790.93,Inpatient DRG
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],29216.99,,"Fee schedule rate ($29,216.99). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9755.86,29216.99,There are no additional notes associated with this service or procedure.
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],16283.24,,"Fee schedule rate ($16,283.24). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7875.94,17233.12,There are no additional notes associated with this service or procedure.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],25276.59,,"Fee schedule rate ($25,276.59). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,11053.39,36776.05,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH CC,427,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],52608.86,,"Case rate ($50,829.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $47,421.51, add-ons for qualifying new technology services are included. If operating cost exceeds $82,292.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $5,335.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $45,309.50 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $45,476.56 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,575.37. The transfer capital threshold is the transfer adjustment factor * $3,575.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,50829.82,142040.39,Inpatient DRG
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],22358.90,,"Fee schedule rate ($22,358.90). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9389.48,22358.90,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],88188.38,,,,,,0,other,32296.02,88188.38,There are no additional notes associated with this service or procedure.
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],53275.26,,"Fee schedule rate ($53,275.26). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,15940.79,53275.26,There are no additional notes associated with this service or procedure.
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC",011,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],68040.86,,"Case rate ($38,880.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $36,305.31, add-ons for qualifying new technology services are included. If operating cost exceeds $71,176.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,461.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 11.4. The base transfer operating payment is the transfer adjustment factor * $34,234.14 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $34,360.36 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,701.41. The transfer capital threshold is the transfer adjustment factor * $2,701.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,38880.49,150008.48,All Other Inpatient
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],39053.73,,"Fee schedule rate ($39,053.73). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,16017.99,51903.64,There are no additional notes associated with this service or procedure.
"LYMPHATIC AND OTHER MALIGNANCIES AND NEOPLASMS OF UNCERTAIN BEHAVIOR,MODERATE",694,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],2075.72,,"Case rate for a one day stay ($2,075.72). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,2075.72,2179.51,There are no additional notes associated with this service or procedure.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,329,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],33072.77,,"Case rate ($33,072.77). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $30,902.51, add-ons for qualifying new technology services are included. If operating cost exceeds $65,773.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,036.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.4. The base transfer operating payment is the transfer adjustment factor * $28,851.18 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $28,957.55 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,276.64. The transfer capital threshold is the transfer adjustment factor * $2,276.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,33072.77,90445.33,Inpatient DRG
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],16587.74,,"Case rate ($16,026.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,044.99, add-ons for qualifying new technology services are included. If operating cost exceeds $49,916.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,789.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $13,051.92 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,100.04 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,029.93. The transfer capital threshold is the transfer adjustment factor * $1,029.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,11165.00,61234.06,Inpatient DRG
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,191,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],16612.88,,"Fee schedule rate ($16,612.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6965.00,16612.88,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],6963.00,,"Per diem ($6,963). If length of stay < 2.6, first 1 days paid at a per diem of $13,926 instead. Capped at $18,103.30.",,,,0,other,6963.00,18954.85,Estimated amount calculated based on 3 day length of stay.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],25332.30,,"Fee schedule rate ($25,332.30). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,7921.00,45706.73,There are no additional notes associated with this service or procedure.
VAGINAL DELIVERY WITH O.R. PROCEDURES EXCEPT STERILIZATION AND/OR D&C,768,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],6426.91,,"Fee schedule rate ($6,426.91). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6426.91,13416.00,There are no additional notes associated with this service or procedure.
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC,964,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],18157.71,,"Fee schedule rate ($18,157.71). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12323.82,34154.06,There are no additional notes associated with this service or procedure.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],9052.31,,"Case rate ($8,874.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,391.65, add-ons for qualifying new technology services are included. If operating cost exceeds $43,262.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,266.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $6,423.02 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,446.70 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $506.84. The transfer capital threshold is the transfer adjustment factor * $506.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,8874.81,20553.44,Inpatient DRG
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],11168.08,,"Fee schedule rate ($11,168.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5937.41,12366.99,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],15206.21,,"Case rate ($14,908.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,004.25, add-ons for qualifying new technology services are included. If operating cost exceeds $48,875.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,708.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $12,014.99 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,059.30 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $948.10. The transfer capital threshold is the transfer adjustment factor * $948.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,14908.05,49717.39,Inpatient DRG
CHOLECYSTECTOMY WITH C.D.E. WITH MCC,411,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],24315.13,,"Case rate ($24,315.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $22,755.46, add-ons for qualifying new technology services are included. If operating cost exceeds $57,626.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,396.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $20,734.06 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $20,810.51 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,636.12. The transfer capital threshold is the transfer adjustment factor * $1,636.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,24315.13,88615.28,Inpatient DRG
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],12867.00,,"Case rate ($12,254.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,554.74, add-ons for qualifying new technology services are included. If operating cost exceeds $46,425.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,495.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $9,573.49 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,609.79 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $735.84. The transfer capital threshold is the transfer adjustment factor * $735.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12566.28,30861.41,Inpatient DRG
SINGLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL,402,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],75557.26,,"Fee schedule rate ($75,557.26). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.9), with a minimum of zero.",,,,0,other,29172.05,124455.45,There are no additional notes associated with this service or procedure.
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],25013.10,,"Fee schedule rate ($25,013.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10846.16,25863.45,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],23239.84,,"Fee schedule rate ($23,239.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8543.64,23239.84,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL HEMORRHAGE WITH MCC,377,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],14610.78,,"Case rate ($14,324.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,461.19, add-ons for qualifying new technology services are included. If operating cost exceeds $48,332.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,665.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $11,473.94 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,516.24 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $905.41. The transfer capital threshold is the transfer adjustment factor * $905.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,7634.00,35969.56,Inpatient DRG
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],24528.10,,"Fee schedule rate ($24,528.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10989.72,26280.60,There are no additional notes associated with this service or procedure.
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],54180.83,,"Fee schedule rate ($54,180.83). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,15491.11,54180.83,There are no additional notes associated with this service or procedure.
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],25814.06,,"Fee schedule rate ($25,814.06). Adds an outlier to normal pricing equal to the per diem rate ($46,867.46) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,11247.07,27028.33,There are no additional notes associated with this service or procedure.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],29569.77,,"Case rate ($16,897.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,854.53, add-ons for qualifying new technology services are included. If operating cost exceeds $50,725.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,853.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $13,858.48 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,909.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,093.57. The transfer capital threshold is the transfer adjustment factor * $1,093.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,16897.01,43444.85,All Other Inpatient
NEONATE WITH OTHER SIGNIFICANT PROBLEMS,794,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],3383.58,,"Fee schedule rate ($3,383.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,1798.85,12536.83,There are no additional notes associated with this service or procedure.
"ANTEPARTUM WITHOUT O.R. PROCEDURE,MODERATE",566,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],3931.37,,"Case rate ($3,744.16). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,3744.16,3931.37,There are no additional notes associated with this service or procedure.
Brnchsc Removal Bronchial Valve Initial,CASE-31648,APC,31648,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3611.96,,"APC Price ($3,489.82). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3489.82,3664.31,OPPS APC
"POISONING OF MEDICINAL AGENTS,MODERATE",812,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],6200.39,,"Case rate ($5,905.13). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5905.13,6200.39,There are no additional notes associated with this service or procedure.
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],38757.79,,,,,,0,other,15283.90,38757.79,There are no additional notes associated with this service or procedure.
HYPERTENSION WITHOUT MCC,305,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],7058.55,,"Case rate ($7,058.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,702.02, add-ons for qualifying new technology services are included. If operating cost exceeds $41,573.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,133.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,739.59 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,757.07 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $374.00. The transfer capital threshold is the transfer adjustment factor * $374.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7058.55,17230.49,Inpatient DRG
"Remove Spinal Neurostim Electrode Plate/Paddle, Incl Fluoro",CASE-63662,APC,63662,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3386.97,,"APC Price ($3,272.44). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3272.44,3436.06,OPPS APC
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],81306.30,,"Fee schedule rate ($81,306.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,20846.48,81306.30,There are no additional notes associated with this service or procedure.
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],48961.48,,"Fee schedule rate ($48,961.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11575.50,48961.48,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITH CC,386,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],19879.00,,"Fee schedule rate ($19,879.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8556.53,19879.00,There are no additional notes associated with this service or procedure.
Thyroidectomy Total/Complete,CASE-60240,APC,60240,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5856.81,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5658.76,5941.70,OPPS APC
"NEONATE BIRTH WEIGHT 2000-2499 GRAMS WITH OTHER SIGNIFICANT CONDITION,MODERATE",625,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],14038.13,,"Case rate ($14,038.13). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,14038.13,14740.04,There are no additional notes associated with this service or procedure.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC",061,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],34537.65,,"Fee schedule rate ($34,537.65). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,20616.23,62315.82,There are no additional notes associated with this service or procedure.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC",061,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],21028.55,,"Case rate ($20,616.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $19,314.45, add-ons for qualifying new technology services are included. If operating cost exceeds $54,185.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,125.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $17,305.68 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $17,369.49 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,365.59. The transfer capital threshold is the transfer adjustment factor * $1,365.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,20616.23,62315.82,Inpatient DRG
"FEMALE REPRODUCTIVE SYSTEM INFECTIONS,MODERATE",531,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],7220.36,,"Case rate ($6,876.53). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6876.53,7220.36,There are no additional notes associated with this service or procedure.
Surg Nasopharyngoscopy Dilat Eustachian Tube Bi,CASE-69706,APC,69706,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5735.04,,"APC Price ($5,541.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5541.10,5818.16,OPPS APC
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],10864.41,,"Case rate ($10,347.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,761.25, add-ons for qualifying new technology services are included. If operating cost exceeds $44,632.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,374.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $7,787.59 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,816.30 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $614.52. The transfer capital threshold is the transfer adjustment factor * $614.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10347.06,28821.04,Inpatient DRG
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],10723.61,,"Fee schedule rate ($10,723.61). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10048.39,23545.50,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITHOUT CC/MCC,428,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],118904.57,,"Fee schedule rate ($118,904.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,40017.53,118904.57,There are no additional notes associated with this service or procedure.
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,068,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],7798.73,,"Case rate ($7,798.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,390.60, add-ons for qualifying new technology services are included. If operating cost exceeds $42,261.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,188.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $5,425.64 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,445.65 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $428.14. The transfer capital threshold is the transfer adjustment factor * $428.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,23184.90,Inpatient DRG
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,086,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],10766.92,,"Case rate ($10,766.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,151.85, add-ons for qualifying new technology services are included. If operating cost exceeds $45,022.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,405.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $8,176.75 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,206.90 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $645.23. The transfer capital threshold is the transfer adjustment factor * $645.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8442.00,30728.81,Inpatient DRG
Cysto Bladder W/Ureteral Catheterization|RIGHT SIDE,CASE-52005,APC,52005,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],2025.13,,"APC Price ($1,956.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1956.65,2054.48,OPPS APC
NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,601,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],11904.59,,,,,,0,other,6042.05,12359.72,There are no additional notes associated with this service or procedure.
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],16458.91,,"Fee schedule rate ($16,458.91). Adds an outlier to normal pricing equal to the per diem rate ($62,521.14) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,7875.94,17233.12,There are no additional notes associated with this service or procedure.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,345,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],29607.98,,,,,,0,other,12134.89,33616.03,There are no additional notes associated with this service or procedure.
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITHOUT MCC,430,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],133156.90,,"Fee schedule rate ($133,156.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,41000.16,133156.90,There are no additional notes associated with this service or procedure.
Surgical Arthroscopy Shoulder Repair Slap Lesion,CASE-29807,APC,29807,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6791.99,7131.59,OPPS APC
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],13289.94,,"Case rate ($12,840.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,080.88, add-ons for qualifying new technology services are included. If operating cost exceeds $46,951.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,556.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $10,098.70 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,135.93 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $796.89. The transfer capital threshold is the transfer adjustment factor * $796.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,1188.00,31658.33,Inpatient DRG
HC Inj Trigger Pt 1-2 Musc Grps|PBB CHARGE,CASE-20552,APC,20552,CPT,0510,RC,,,PBB,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],17273.92,,"Case rate ($16,689.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,661.75, add-ons for qualifying new technology services are included. If operating cost exceeds $50,532.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,838.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $13,666.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,716.80 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,078.42. The transfer capital threshold is the transfer adjustment factor * $1,078.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,16689.78,59521.43,Inpatient DRG
OTHER CEREBROVASCULAR DISORDERS WITH MCC,070,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],32758.27,,,,,,0,other,13219.09,37774.46,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],14265.61,,"Case rate ($13,783.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,957.83, add-ons for qualifying new technology services are included. If operating cost exceeds $47,828.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,625.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $10,972.42 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,012.88 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $865.83. The transfer capital threshold is the transfer adjustment factor * $865.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,13783.20,41580.51,Inpatient DRG
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],51903.64,,"Fee schedule rate ($51,903.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,16017.99,51903.64,There are no additional notes associated with this service or procedure.
HC Joint Injection/Aspir Large WO US|BILATERAL PROCEDURE,CASE-20610,APC,20610,CPT,0510,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],297.37,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,287.31,301.68,OPPS APC
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],6965.00,,,,,,0,other,6965.00,20401.88,There are no additional notes associated with this service or procedure.
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],36868.88,,"Fee schedule rate ($36,868.88). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12606.23,36868.88,There are no additional notes associated with this service or procedure.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],18497.24,,"Case rate ($18,497.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,343.20, add-ons for qualifying new technology services are included. If operating cost exceeds $52,214.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,970.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $15,341.68 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,398.25 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,210.61. The transfer capital threshold is the transfer adjustment factor * $1,210.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,18497.24,62041.12,Inpatient DRG
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],48961.48,,"Fee schedule rate ($48,961.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11575.50,48961.48,There are no additional notes associated with this service or procedure.
Sgmdsc Flx Rmvl Tum Polyp/Oth Les Snare Tq|COLORECTAL CANCER SCREEN,CASE-45338,APC,45338,CPT,0360,RC,,,PT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1176.09,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1120.09,1176.09,OPPS APC
Ostc Prtl Exostc/Condylc Metar Head|RIGHT SIDE|SEPARATE STRUCTURE,CASE-28288,APC,28288,CPT,0360,RC,,,RT|XS,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3062.67,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],6277.00,,"Per diem ($6,277). If length of stay < 5.6, first 1 days paid at a per diem of $12,554 instead. Capped at $35,148.55.",,,,0,other,6277.00,36801.89,Estimated amount calculated based on 4 day length of stay.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],41944.25,,"Fee schedule rate ($41,944.25). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12795.84,41944.25,There are no additional notes associated with this service or procedure.
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],34570.85,,"Fee schedule rate ($34,570.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,6965.00,36140.75,There are no additional notes associated with this service or procedure.
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],13146.51,,"Case rate ($12,520.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,802.89, add-ons for qualifying new technology services are included. If operating cost exceeds $46,673.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,514.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $9,820.70 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,857.94 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $754.84. The transfer capital threshold is the transfer adjustment factor * $754.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,1188.00,31658.33,Inpatient DRG
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],17234.95,,"Case rate ($16,897.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,854.53, add-ons for qualifying new technology services are included. If operating cost exceeds $50,725.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,853.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $13,858.48 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,909.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,093.57. The transfer capital threshold is the transfer adjustment factor * $1,093.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,16897.01,43444.85,Inpatient DRG
OTHER DISORDERS OF NERVOUS SYSTEM WITH CC,092,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],26765.51,,"Fee schedule rate ($26,765.51). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8872.78,26765.51,There are no additional notes associated with this service or procedure.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],26028.48,,"Case rate ($26,028.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $24,349.34, add-ons for qualifying new technology services are included. If operating cost exceeds $59,220.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,521.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $22,322.08 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $22,404.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,761.43. The transfer capital threshold is the transfer adjustment factor * $1,761.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,26028.48,80635.65,Inpatient DRG
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],28257.86,,"Fee schedule rate ($28,257.86). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,19152.11,53152.12,There are no additional notes associated with this service or procedure.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],15476.23,,"Case rate ($15,476.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,532.81, add-ons for qualifying new technology services are included. If operating cost exceeds $49,403.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,749.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $12,541.62 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,587.86 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $989.66. The transfer capital threshold is the transfer adjustment factor * $989.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,15476.23,42787.31,Inpatient DRG
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,083,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],6965.00,,,,,,0,other,6965.00,28680.85,There are no additional notes associated with this service or procedure.
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],16458.91,,"Fee schedule rate ($16,458.91). Adds an outlier to normal pricing equal to the per diem rate ($62,521.14) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,7875.94,17233.12,There are no additional notes associated with this service or procedure.
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],22762.43,,"Fee schedule rate ($22,762.43). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6230.00,22762.43,There are no additional notes associated with this service or procedure.
Rpr Coltrl Ligm Mtcarphlngl/Iphal Jt,CASE-26540,APC,26540,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
MAJOR BLADDER PROCEDURES WITH MCC,653,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],64986.85,,"Case rate ($37,135.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $34,681.82, add-ons for qualifying new technology services are included. If operating cost exceeds $69,552.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,333.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.5. The base transfer operating payment is the transfer adjustment factor * $32,616.61 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $32,736.87 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,573.77. The transfer capital threshold is the transfer adjustment factor * $2,573.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,10280.00,125343.98,All Other Inpatient
Rpr 1st Ingun Hrna Age 5 Yrs/> Incarcerated|RIGHT SIDE,CASE-49507,APC,49507,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3518.91,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3351.34,3518.91,OPPS APC
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,167,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],43522.37,,"Fee schedule rate ($43,522.37). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,14157.71,43522.37,There are no additional notes associated with this service or procedure.
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],8165.30,,"Fee schedule rate ($8,165.30). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4341.01,12882.53,There are no additional notes associated with this service or procedure.
HC Inj Anes/Steroid C/D Facet Sg|LEFT SIDE|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-64490,APC,64490,CPT,0361,RC,,,LT|74,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],856.86,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,827.89,869.28,OPPS APC
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH CC,026,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],58431.20,,"Fee schedule rate ($58,431.20). Adds an outlier to normal pricing equal to the per diem rate ($112,420.62) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,23000.66,63202.45,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],9795.13,,"Case rate ($9,795.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,247.81, add-ons for qualifying new technology services are included. If operating cost exceeds $44,118.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,334.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $7,276.03 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,302.86 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $574.15. The transfer capital threshold is the transfer adjustment factor * $574.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9795.13,23899.13,Inpatient DRG
Edg US Exam Surgical Alter Stom Duodenum/Jejunum,CASE-43259,APC,43259,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1885.95,,"APC Price ($1,796.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1796.14,1885.95,OPPS APC
CESAREAN SECTION WITH STERILIZATION WITH CC,784,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],20859.59,,,,,,0,other,9124.01,23722.94,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],8891.90,,"Case rate ($8,468.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,013.65, add-ons for qualifying new technology services are included. If operating cost exceeds $42,884.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,237.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,046.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,068.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $477.12. The transfer capital threshold is the transfer adjustment factor * $477.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6963.00,18954.85,Inpatient DRG
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],133270.57,,"Fee schedule rate ($133,270.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,33623.33,133270.57,There are no additional notes associated with this service or procedure.
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC",758,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],16323.02,,"Fee schedule rate ($16,323.02). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8574.80,19263.78,There are no additional notes associated with this service or procedure.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],8906.63,,"Case rate ($8,906.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,421.26, add-ons for qualifying new technology services are included. If operating cost exceeds $43,292.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,269.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $6,452.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,476.31 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $509.17. The transfer capital threshold is the transfer adjustment factor * $509.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8906.63,28434.57,Inpatient DRG
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],11594.35,,"Fee schedule rate ($11,594.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6164.03,14071.02,There are no additional notes associated with this service or procedure.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],6067.55,,"Case rate ($5,778.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,511.33, add-ons for qualifying new technology services are included. If operating cost exceeds $40,382.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,040.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $3,553.28 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,566.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $280.39. The transfer capital threshold is the transfer adjustment factor * $280.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5778.62,11681.49,Inpatient DRG
Sigmoidoscopy Flx W/Biopsy Single/Multiple|COLORECTAL CANCER SCREEN,CASE-45331,APC,45331,CPT,0360,RC,,,PT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],913.99,,"APC Price ($870.46). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,870.46,913.99,OPPS APC
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,073,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],13449.85,,"Case rate ($12,809.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,051.90, add-ons for qualifying new technology services are included. If operating cost exceeds $46,922.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,554.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $10,069.82 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,106.95 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $794.61. The transfer capital threshold is the transfer adjustment factor * $794.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12809.38,43475.01,Inpatient DRG
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],16900.84,,"Fee schedule rate ($16,900.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8151.55,18033.97,There are no additional notes associated with this service or procedure.
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC,806,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6738.54,,"Case rate ($6,510.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,192.35, add-ons for qualifying new technology services are included. If operating cost exceeds $41,063.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,093.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $4,231.80 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,247.40 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $333.93. The transfer capital threshold is the transfer adjustment factor * $333.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,5354.25,13416.00,Inpatient DRG
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],14182.52,,"Case rate ($13,904.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,070.60, add-ons for qualifying new technology services are included. If operating cost exceeds $47,941.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,634.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,084.78 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,125.65 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $874.70. The transfer capital threshold is the transfer adjustment factor * $874.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,13904.43,34749.58,Inpatient DRG
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],8372.32,,"Case rate ($8,372.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,924.20, add-ons for qualifying new technology services are included. If operating cost exceeds $42,795.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,230.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,957.28 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,979.25 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $470.09. The transfer capital threshold is the transfer adjustment factor * $470.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,23385.72,Inpatient DRG
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],7721.24,,"Case rate ($7,569.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,177.66, add-ons for qualifying new technology services are included. If operating cost exceeds $42,048.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,171.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,213.49 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,232.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $411.40. The transfer capital threshold is the transfer adjustment factor * $411.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,7569.84,21892.85,Inpatient DRG
Egd Transoral Control Bleeding Any Method|UNUSUAL NON-OVERLAPPING SERVICE,CASE-43255,APC,43255,CPT,0360,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1796.14,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1796.14,1885.95,OPPS APC
NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,601,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],12359.72,,"Fee schedule rate ($12,359.72). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6042.05,12359.72,There are no additional notes associated with this service or procedure.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],36988.38,,"Fee schedule rate ($36,988.38). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.7), with a minimum of zero.",,,,0,other,15273.74,39820.52,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,082,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],56223.11,,"Fee schedule rate ($56,223.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,17423.21,56223.11,There are no additional notes associated with this service or procedure.
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC,797,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],8719.72,,"Case rate ($8,719.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,247.38, add-ons for qualifying new technology services are included. If operating cost exceeds $43,118.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,255.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $6,279.28 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,302.43 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $495.50. The transfer capital threshold is the transfer adjustment factor * $495.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8719.72,20928.55,Inpatient DRG
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],24675.88,,"Fee schedule rate ($24,675.88). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10834.64,25830.00,There are no additional notes associated with this service or procedure.
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],31750.77,,"Fee schedule rate ($31,750.77). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13386.36,33244.29,There are no additional notes associated with this service or procedure.
Rinsj Rptd Biceps/Triceps Tdn Dstl W/WO Tdn Grf|LEFT SIDE,CASE-24342,APC,24342,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
SIGNS AND SYMPTOMS WITH MCC,947,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],23855.83,,"Fee schedule rate ($23,855.83). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10541.41,30414.32,There are no additional notes associated with this service or procedure.
SALIVARY GLAND PROCEDURES,139,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],23222.51,,"Fee schedule rate ($23,222.51). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.9), with a minimum of zero.",,,,0,other,10313.19,30690.92,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],18905.23,,"Fee schedule rate ($18,905.23). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6963.00,18954.85,There are no additional notes associated with this service or procedure.
Hysteroscopy Lysis Intrauterine Adhesions,CASE-58559,APC,58559,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],4916.53,,"APC Price ($4,682.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,4682.41,4916.53,OPPS APC
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],28691.47,,"Case rate ($27,325.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $25,603.02, add-ons for qualifying new technology services are included. If operating cost exceeds $60,474.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,571.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $23,568.71 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $23,658.07 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,811.55. The transfer capital threshold is the transfer adjustment factor * $1,811.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,10078.00,81454.07,Inpatient DRG
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,057,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],24348.21,,"Fee schedule rate ($24,348.21). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.9), with a minimum of zero.",,,,0,other,10718.84,39884.93,There are no additional notes associated with this service or procedure.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,345,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],28277.83,,"Fee schedule rate ($28,277.83). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12134.89,33616.03,There are no additional notes associated with this service or procedure.
"Amputation Toe Metatarsophalangeal Joint|LEFT FOOT, GREAT TOE",CASE-28820,APC,28820,CPT,0360,RC,,,TA,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3169.86,OPPS APC
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITH MCC,429,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],65162.13,,"Case rate ($62,958.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $58,704.65, add-ons for qualifying new technology services are included. If operating cost exceeds $93,575.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $6,222.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.6. The base transfer operating payment is the transfer adjustment factor * $56,551.19 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $56,759.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,462.45. The transfer capital threshold is the transfer adjustment factor * $4,462.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,62958.58,177294.98,Inpatient DRG
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],38246.19,,"Fee schedule rate ($38,246.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,19435.86,50821.76,There are no additional notes associated with this service or procedure.
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],42767.23,,"Fee schedule rate ($42,767.23). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,17356.15,44778.95,There are no additional notes associated with this service or procedure.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],19824.58,,"Case rate ($19,435.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $18,216.37, add-ons for qualifying new technology services are included. If operating cost exceeds $53,087.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,039.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.9. The base transfer operating payment is the transfer adjustment factor * $16,211.64 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $16,271.42 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,279.26. The transfer capital threshold is the transfer adjustment factor * $1,279.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,19435.86,50821.76,Inpatient DRG
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC",458,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],78415.67,,"Fee schedule rate ($78,415.67). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.8), with a minimum of zero.",,,,0,other,30202.09,132827.25,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,085,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],57443.16,,"Fee schedule rate ($57,443.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,9282.00,57443.16,There are no additional notes associated with this service or procedure.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC",156,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],12624.95,,"Fee schedule rate ($12,624.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6625.12,13598.77,There are no additional notes associated with this service or procedure.
Unlisted Laparoscopy Procedure Uterus,CASE-58578,APC,58578,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],9949.78,,"APC Price ($9,949.78). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,9949.78,10298.02,OPPS APC
NORMAL NEWBORN,795,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],1956.00,,,,,,0,other,1369.79,5771.52,Estimated amount calculated based on 2 day length of stay.
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],48961.48,,"Fee schedule rate ($48,961.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11575.50,48961.48,There are no additional notes associated with this service or procedure.
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",004,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],100534.98,,"Case rate ($95,747.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $89,207.57, add-ons for qualifying new technology services are included. If operating cost exceeds $124,078.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $8,620.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 22.4. The base transfer operating payment is the transfer adjustment factor * $86,942.06 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $87,262.63 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $6,860.59. The transfer capital threshold is the transfer adjustment factor * $6,860.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10249.47,272554.00,Inpatient DRG
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC",758,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],18398.35,,"Fee schedule rate ($18,398.35). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8574.80,19263.78,There are no additional notes associated with this service or procedure.
Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq|COLORECTAL CANCER SCREEN|UNUSUAL NON-OVERLAPPING SERVICE,CASE-45385,APC,45385,CPT,0360,RC,,,PT|XU,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1159.29,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1120.09,1176.09,OPPS APC
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],33114.42,,,,,,0,other,13341.67,42586.49,There are no additional notes associated with this service or procedure.
Dilation & Curettage Dx&/Ther Nonobstetric,CASE-58120,APC,58120,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3030.03,,"APC Price ($3,030.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3030.03,3181.53,OPPS APC
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],14343.25,,"Case rate ($14,343.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,478.83, add-ons for qualifying new technology services are included. If operating cost exceeds $48,349.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,666.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $11,491.51 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,533.88 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $906.79. The transfer capital threshold is the transfer adjustment factor * $906.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,14343.25,36024.65,Inpatient DRG
HYPERTENSION WITHOUT MCC,305,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],14190.59,,"Fee schedule rate ($14,190.59). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,7058.55,17230.49,There are no additional notes associated with this service or procedure.
"Amputation Toe Interphalangeal Joint|RIGHT FOOT, THIRD DIGIT",CASE-28825,APC,28825,CPT,0360,RC,,,T7,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],30112.02,,"Fee schedule rate ($30,112.02). Adds an outlier to normal pricing equal to the per diem rate ($53,484.01) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.5), with a minimum of zero.",,,,0,other,12795.84,41944.25,There are no additional notes associated with this service or procedure.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],12698.38,,"Case rate ($12,268.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,549.17, add-ons for qualifying new technology services are included. If operating cost exceeds $46,420.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,515.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,568.94 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,604.22 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $755.08. The transfer capital threshold is the transfer adjustment factor * $755.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,12268.97,41006.47,Inpatient DRG
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],11440.38,,"Case rate ($10,895.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,271.55, add-ons for qualifying new technology services are included. If operating cost exceeds $45,142.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,414.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $8,296.01 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,326.60 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $654.64. The transfer capital threshold is the transfer adjustment factor * $654.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10895.60,35192.25,Inpatient DRG
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],23078.81,,"Fee schedule rate ($23,078.81). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10311.17,24308.97,There are no additional notes associated with this service or procedure.
INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC,198,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],23505.07,,"Fee schedule rate ($23,505.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6795.12,23505.07,There are no additional notes associated with this service or procedure.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],24909.11,,,,,,0,other,10517.71,24909.11,There are no additional notes associated with this service or procedure.
Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn,CASE-62323,APC,62323,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],683.85,,"APC Price ($660.72). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,660.72,693.76,OPPS APC
"COAGULATION AND PLATELET DISORDERS,MODERATE",661,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],9779.76,,"Case rate ($9,779.76). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,9779.76,10268.75,There are no additional notes associated with this service or procedure.
FULL TERM NEONATE WITH MAJOR PROBLEMS,793,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],31690.87,,"Case rate ($30,181.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $28,213.07, add-ons for qualifying new technology services are included. If operating cost exceeds $63,084.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,825.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $26,171.62 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $26,268.12 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,065.20. The transfer capital threshold is the transfer adjustment factor * $2,065.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,4302.90,82045.22,Inpatient DRG
COMPLICATIONS OF TREATMENT WITH CC,920,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],9169.22,,"Case rate ($8,732.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,259.35, add-ons for qualifying new technology services are included. If operating cost exceeds $43,130.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,256.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,291.21 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,314.40 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $496.44. The transfer capital threshold is the transfer adjustment factor * $496.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8732.59,20731.52,Inpatient DRG
POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES,769,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],29791.03,,"Fee schedule rate ($29,791.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,13388.39,33250.19,There are no additional notes associated with this service or procedure.
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],25829.63,,"Fee schedule rate ($25,829.63). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6965.00,29482.05,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITH STERILIZATION WITH CC,784,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],23722.94,,"Fee schedule rate ($23,722.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9124.01,23722.94,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],24675.88,,"Fee schedule rate ($24,675.88). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10834.64,25830.00,There are no additional notes associated with this service or procedure.
"KIDNEY AND URINARY TRACT INFECTIONS,MINOR",463,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],1739.43,,"Case rate for a one day stay ($1,739.43). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,1739.43,1826.40,There are no additional notes associated with this service or procedure.
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH CC",457,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],160549.49,,"Fee schedule rate ($160,549.49). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,42327.47,160549.49,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],96365.69,,"Fee schedule rate ($96,365.69). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,23377.19,96365.69,There are no additional notes associated with this service or procedure.
Laparoscopy Surg Partial Nephrectomy|LEFT SIDE,CASE-50543,APC,50543,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],10447.27,,"APC Price ($9,949.78). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,9949.78,10447.27,OPPS APC
Parathyroidectomy/Exploration Parathyroids|RIGHT SIDE,CASE-60500,APC,60500,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5941.70,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5658.76,5941.70,OPPS APC
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],8563.30,,"Case rate ($8,563.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,101.85, add-ons for qualifying new technology services are included. If operating cost exceeds $42,972.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,244.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $6,134.29 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,156.91 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $484.06. The transfer capital threshold is the transfer adjustment factor * $484.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8563.30,31533.97,Inpatient DRG
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],6428.77,,"Case rate ($6,122.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,831.37, add-ons for qualifying new technology services are included. If operating cost exceeds $40,702.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,065.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $3,872.14 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,886.42 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $305.55. The transfer capital threshold is the transfer adjustment factor * $305.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,1188.00,12138.74,Inpatient DRG
"CESAREAN SECTION WITHOUT STERILIZATION,MODERATE",540,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],8229.96,,"Case rate ($7,838.06). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7838.06,8229.96,There are no additional notes associated with this service or procedure.
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],31577.54,,"Fee schedule rate ($31,577.54). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,15453.88,39251.68,There are no additional notes associated with this service or procedure.
HC Joint Injection/Aspir Large WO US|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-20610,APC,20610,CPT,0510,RC,,,RT|XU,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],61290.90,,"Fee schedule rate ($61,290.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,23799.09,63499.65,There are no additional notes associated with this service or procedure.
Litholapaxy Smpl/Sm <2.5 Cm,CASE-52317,APC,52317,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3299.47,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3299.47,3464.44,OPPS APC
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,073,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],13065.57,,"Case rate ($12,809.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,051.90, add-ons for qualifying new technology services are included. If operating cost exceeds $46,922.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,554.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $10,069.82 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,106.95 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $794.61. The transfer capital threshold is the transfer adjustment factor * $794.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,12809.38,43475.01,Inpatient DRG
Colsc Flx With Directed Submucosal Njx Any Sbst|COLORECTAL CANCER SCREEN,CASE-45381,APC,45381,CPT,0360,RC,,,PT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1176.09,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1120.09,1176.09,OPPS APC
Open Tx Distal Fibular Fracture Lat Malleolus|RIGHT SIDE,CASE-27792,APC,27792,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6791.99,7131.59,OPPS APC
Dilation & Curettage Dx&/Ther Nonobstetric,CASE-58120,APC,58120,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3181.53,,"APC Price ($3,030.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3030.03,3181.53,OPPS APC
"Exc Tum/Vasc Mal Sft Tiss Hand/Fngr Subq <1.5cm|RIGHT HAND, SECOND DIGIT",CASE-26115,APC,26115,CPT,0360,RC,,,F6,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1545.93,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1545.93,1623.23,OPPS APC
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],11677.97,,"Fee schedule rate ($11,677.97). Adds an outlier to normal pricing equal to the per diem rate ($67,650.85) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.7), with a minimum of zero.",,,,0,other,6153.12,13947.32,There are no additional notes associated with this service or procedure.
APPENDIX PROCEDURES WITH MCC,397,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],51558.84,,"Fee schedule rate ($51,558.84). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,18163.37,51558.84,There are no additional notes associated with this service or procedure.
MINOR BLADDER PROCEDURES WITHOUT CC/MCC,664,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],19674.39,,"Fee schedule rate ($19,674.39). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,9034.63,31876.87,There are no additional notes associated with this service or procedure.
"OTHER ESOPHAGEAL DISORDERS,EXTREME",243,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],20146.09,,"Case rate ($20,146.09). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,20146.09,21153.39,There are no additional notes associated with this service or procedure.
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],23870.71,,"Fee schedule rate ($23,870.71). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,10626.74,25225.91,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],18585.05,,"Fee schedule rate ($18,585.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8859.23,20090.22,There are no additional notes associated with this service or procedure.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,418,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],39884.93,,"Fee schedule rate ($39,884.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,13400.58,39884.93,There are no additional notes associated with this service or procedure.
"Tendon Sheath Incision|LEFT HAND, THUMB|UNUSUAL NON-OVERLAPPING SERVICE",CASE-26055,APC,26055,CPT,0360,RC,,,FA|XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],5910.42,,"Case rate ($5,628.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,372.11, add-ons for qualifying new technology services are included. If operating cost exceeds $40,243.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,029.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,414.56 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,427.15 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $269.44. The transfer capital threshold is the transfer adjustment factor * $269.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5628.97,12272.58,Inpatient DRG
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],16055.90,,"Fee schedule rate ($16,055.90). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8163.06,18067.42,There are no additional notes associated with this service or procedure.
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH MCC",510,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],10710.00,,"Per diem ($10,710). If length of stay < 5.3, first 1 days paid at a per diem of $21,420 instead. Capped at $56,764.26.",,,,0,other,10710.00,89863.76,Estimated amount calculated based on 6 day length of stay.
Arthrs Knee W/Meniscectomy Med&Lat W/Shaving|RIGHT SIDE,CASE-29880,APC,29880,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
Hrhc Ntrnl & Xtrnl 2/> Column/Group W/Fissu,CASE-46261,APC,46261,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],2598.08,,"APC Price ($2,598.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2598.08,2727.99,OPPS APC
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],29474.94,,"Fee schedule rate ($29,474.94). Adds an outlier to normal pricing equal to the per diem rate ($65,448.99) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.4), with a minimum of zero.",,,,0,other,12566.28,30861.41,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],20659.14,,"Fee schedule rate ($20,659.14). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.9), with a minimum of zero.",,,,0,other,9389.48,22358.90,There are no additional notes associated with this service or procedure.
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],21854.96,,"Fee schedule rate ($21,854.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10638.94,25261.33,There are no additional notes associated with this service or procedure.
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],16438.59,,"Fee schedule rate ($16,438.59). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7402.56,16438.59,There are no additional notes associated with this service or procedure.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,352,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],14703.15,,"Fee schedule rate ($14,703.15). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,9853.37,26528.70,There are no additional notes associated with this service or procedure.
MAJOR THUMB OR JOINT PROCEDURES,506,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],19761.54,,"Fee schedule rate ($19,761.54). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11081.83,26548.21,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC,084,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],10777.20,,"Fee schedule rate ($10,777.20). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,6965.00,19445.16,There are no additional notes associated with this service or procedure.
Fasct Palm W/WO Z-Plasty Tissue Reargmt/Skn Grft|LEFT SIDE,CASE-26121,APC,26121,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC,434,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],13280.45,,"Fee schedule rate ($13,280.45). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6770.05,14019.86,There are no additional notes associated with this service or procedure.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],16669.71,,"Fee schedule rate ($16,669.71). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8767.81,19824.58,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,426,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],177294.98,,"Fee schedule rate ($177,294.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,76581.29,216864.15,There are no additional notes associated with this service or procedure.
"Amputation Toe Metatarsophalangeal Joint|RIGHT FOOT, SECOND DIGIT",CASE-28820,APC,28820,CPT,0360,RC,,,T6,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
"DRUG AND ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE,MINOR",770,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],2868.80,,"Case rate ($2,732.19). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,2732.19,2868.80,There are no additional notes associated with this service or procedure.
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],29216.99,,"Fee schedule rate ($29,216.99). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9755.86,29216.99,There are no additional notes associated with this service or procedure.
Repair Intermediate S/a/T/E >30.0 Cm|SEPARATE STRUCTURE,CASE-12037,APC,12037,CPT,0360,RC,,,XS,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1600.04,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1545.93,1623.23,OPPS APC
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC,497,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],37761.19,,"Fee schedule rate ($37,761.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10127.65,37761.19,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITH STERILIZATION WITH MCC,783,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],18942.47,,"Case rate ($18,571.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,411.86, add-ons for qualifying new technology services are included. If operating cost exceeds $52,282.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,975.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $15,410.10 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,466.92 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,216.01. The transfer capital threshold is the transfer adjustment factor * $1,216.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,12612.10,23722.94,Inpatient DRG
Ndsc Njx Implt Matrl Urt&/Bldr Nck,CASE-51715,APC,51715,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3299.47,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3299.47,3464.44,OPPS APC
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITHOUT CC/MCC,428,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],40844.17,,"Case rate ($38,899.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $36,391.67, add-ons for qualifying new technology services are included. If operating cost exceeds $71,262.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,397.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $34,316.61 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $34,446.72 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,637.65. The transfer capital threshold is the transfer adjustment factor * $2,637.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,40017.53,118904.57,Inpatient DRG
INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,352,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],22978.80,,,,,,0,other,9853.37,26528.70,There are no additional notes associated with this service or procedure.
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level|LEFT SIDE,CASE-64483,APC,64483,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],869.28,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,827.89,869.28,OPPS APC
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",063,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],35701.87,,"Fee schedule rate ($35,701.87). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,35701.87,There are no additional notes associated with this service or procedure.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],19604.30,,"Fee schedule rate ($19,604.30). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9446.38,21796.21,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],45089.10,,"Fee schedule rate ($45,089.10). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,27256.92,81353.66,There are no additional notes associated with this service or procedure.
O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC,621,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],28347.36,,"Fee schedule rate ($28,347.36). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12159.94,36669.96,There are no additional notes associated with this service or procedure.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,345,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],33616.03,,"Fee schedule rate ($33,616.03). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,12134.89,33616.03,There are no additional notes associated with this service or procedure.
Blepharoplasty Upper Eyelid W/Excessive Skin,CASE-15823,APC,15823,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1931.28,,"APC Price ($1,931.28). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1931.28,2027.84,OPPS APC
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,373,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],7214.49,,"Case rate ($6,870.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,527.50, add-ons for qualifying new technology services are included. If operating cost exceeds $41,398.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,120.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $4,565.72 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,582.56 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $360.28. The transfer capital threshold is the transfer adjustment factor * $360.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6870.94,14313.05,Inpatient DRG
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,167,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],43522.37,,"Fee schedule rate ($43,522.37). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,14157.71,43522.37,There are no additional notes associated with this service or procedure.
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],25814.06,,"Fee schedule rate ($25,814.06). Adds an outlier to normal pricing equal to the per diem rate ($46,867.46) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,11247.07,27028.33,There are no additional notes associated with this service or procedure.
"TRANSIENT ISCHEMIA,MODERATE",047,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],3318.37,,"Case rate for a one day stay ($3,318.37). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,3318.37,3484.29,There are no additional notes associated with this service or procedure.
CELLULITIS WITH MCC,602,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],28349.31,,"Fee schedule rate ($28,349.31). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11570.10,28349.31,There are no additional notes associated with this service or procedure.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],16900.84,,"Fee schedule rate ($16,900.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8151.55,18033.97,There are no additional notes associated with this service or procedure.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],10351.97,,"Case rate ($9,859.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,322.01, add-ons for qualifying new technology services are included. If operating cost exceeds $44,193.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,324.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $7,349.20 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,377.06 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $564.88. The transfer capital threshold is the transfer adjustment factor * $564.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10098.51,24259.09,Inpatient DRG
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],59385.88,,"Fee schedule rate ($59,385.88). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,23344.70,62179.32,There are no additional notes associated with this service or procedure.
HC Joint Injection/Aspir Large WO US,CASE-20610,APC,20610,CPT,0510,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],6965.00,,,,,,0,other,6965.00,15340.19,There are no additional notes associated with this service or procedure.
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],29594.00,,"Fee schedule rate ($29,594.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,13571.25,33781.47,There are no additional notes associated with this service or procedure.
"Tx Open Tendon Flexor Toe 1 Tendon Spx|LEFT FOOT, SECOND DIGIT",CASE-28232,APC,28232,CPT,0360,RC,,,T1,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1557.80,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1505.12,1580.37,OPPS APC
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],34245.00,,"Fee schedule rate ($34,245.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,12725.42,34245.00,There are no additional notes associated with this service or procedure.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],12778.21,,"Case rate ($12,527.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,789.82, add-ons for qualifying new technology services are included. If operating cost exceeds $46,660.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,533.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $9,808.71 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,844.88 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $774.00. The transfer capital threshold is the transfer adjustment factor * $774.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,12527.66,29917.96,Inpatient DRG
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC",641,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7467.50,,"Case rate ($7,214.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,847.54, add-ons for qualifying new technology services are included. If operating cost exceeds $41,718.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,145.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $4,884.58 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,902.59 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $385.44. The transfer capital threshold is the transfer adjustment factor * $385.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,7214.98,15312.64,Inpatient DRG
Lam Facetectomy&Foramot 1 Vrt Sgm Ea Addl Sgm,CASE-63048,APC,63048,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7029.71,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,7029.71,7131.59,OPPS APC
SPINAL PROCEDURES WITH MCC,028,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],112913.98,,"Fee schedule rate ($112,913.98). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,42633.57,120982.83,There are no additional notes associated with this service or procedure.
Colonoscopy W/Biopsy Single/Multiple|UNUSUAL NON-OVERLAPPING SERVICE|COLORECTAL CANCER SCREEN,CASE-45380,APC,45380,CPT,0360,RC,,,XU|PT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1120.09,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1120.09,1176.09,OPPS APC
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],33608.45,,"Fee schedule rate ($33,608.45). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,7332.00,35314.31,There are no additional notes associated with this service or procedure.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],38246.19,,"Fee schedule rate ($38,246.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,19435.86,50821.76,There are no additional notes associated with this service or procedure.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],85466.62,,"Fee schedule rate ($85,466.62). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,21382.16,85466.62,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],23239.84,,"Fee schedule rate ($23,239.84). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8543.64,23239.84,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITHOUT CC/MCC,428,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],118904.57,,"Fee schedule rate ($118,904.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,40017.53,118904.57,There are no additional notes associated with this service or procedure.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],39316.61,,,,,,0,other,15476.23,42787.31,There are no additional notes associated with this service or procedure.
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],36868.88,,"Fee schedule rate ($36,868.88). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12606.23,36868.88,There are no additional notes associated with this service or procedure.
"NEONATE BIRTH WEIGHT 1500-1999 GRAMS WITH MAJOR ANOMALY,MINOR",611,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],11512.05,,"Case rate ($10,963.86). Base payment rate plus any adjustments related to outliers.",,,,0,other,10963.86,11512.05,There are no additional notes associated with this service or procedure.
"EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME, NEONATE",790,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],42194.75,,"Case rate ($42,194.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $39,388.49, add-ons for qualifying new technology services are included. If operating cost exceeds $74,259.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,703.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 17.9. The base transfer operating payment is the transfer adjustment factor * $37,305.99 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $37,443.54 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,943.81. The transfer capital threshold is the transfer adjustment factor * $2,943.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,3054.00,44304.49,Inpatient DRG
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],11281.44,,"Fee schedule rate ($11,281.44). Adds an outlier to normal pricing equal to the per diem rate ($62,521.14) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,6010.23,12246.05,There are no additional notes associated with this service or procedure.
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6418.23,,"Case rate ($6,201.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,904.45, add-ons for qualifying new technology services are included. If operating cost exceeds $40,775.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,071.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,944.95 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,959.50 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $311.30. The transfer capital threshold is the transfer adjustment factor * $311.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,5937.41,12366.99,Inpatient DRG
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],101083.00,,"Fee schedule rate ($101,083.00). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,35389.50,101083.00,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],51903.64,,"Fee schedule rate ($51,903.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,16017.99,51903.64,There are no additional notes associated with this service or procedure.
CHOLECYSTECTOMY WITH C.D.E. WITH MCC,411,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],62078.92,,"Fee schedule rate ($62,078.92). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15), with a minimum of zero.",,,,0,other,24315.13,88615.28,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],6460.78,,"Case rate ($6,153.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,859.72, add-ons for qualifying new technology services are included. If operating cost exceeds $40,730.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,067.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,900.39 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,914.77 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $307.78. The transfer capital threshold is the transfer adjustment factor * $307.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6153.12,13947.32,Inpatient DRG
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],41669.98,,,,,,0,other,16286.16,58320.32,There are no additional notes associated with this service or procedure.
NON-MALIGNANT BREAST DISORDERS WITH CC/MCC,600,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],19574.79,,"Fee schedule rate ($19,574.79). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7999.14,20495.56,There are no additional notes associated with this service or procedure.
Bx/Exc Lymph Node Open Deep Axillary Node,CASE-38525,APC,38525,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3664.94,,"APC Price ($3,664.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3664.94,3848.19,OPPS APC
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],13029.20,,"Case rate ($12,408.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,698.73, add-ons for qualifying new technology services are included. If operating cost exceeds $46,569.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,506.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $9,716.93 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,753.78 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $746.87. The transfer capital threshold is the transfer adjustment factor * $746.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12725.42,34245.00,Inpatient DRG
MAJOR BLADDER PROCEDURES WITH MCC,653,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],125343.98,,"Fee schedule rate ($125,343.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,10280.00,125343.98,There are no additional notes associated with this service or procedure.
Nsl/Sinus Ndsc Max Antrost W/Rmvl Tiss Max Sinus|BILATERAL PROCEDURE,CASE-31267,APC,31267,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6605.95,,"APC Price ($6,605.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6605.95,6936.25,OPPS APC
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],20981.60,,"Fee schedule rate ($20,981.60). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,10003.71,23415.63,There are no additional notes associated with this service or procedure.
HEADACHES WITHOUT MCC,103,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],7760.60,,"Case rate ($7,608.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,213.57, add-ons for qualifying new technology services are included. If operating cost exceeds $42,084.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,174.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $5,249.26 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,268.62 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $414.22. The transfer capital threshold is the transfer adjustment factor * $414.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6965.00,20883.08,Inpatient DRG
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,426,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],76581.29,,"Case rate ($76,581.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $71,377.56, add-ons for qualifying new technology services are included. If operating cost exceeds $106,248.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $7,218.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $69,177.55 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $69,432.61 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $5,458.79. The transfer capital threshold is the transfer adjustment factor * $5,458.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,76581.29,216864.15,Inpatient DRG
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC",458,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],132827.25,,"Fee schedule rate ($132,827.25). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,30202.09,132827.25,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],21892.85,,"Fee schedule rate ($21,892.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7569.84,21892.85,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],13077.97,,"Case rate ($12,455.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,722.41, add-ons for qualifying new technology services are included. If operating cost exceeds $46,593.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,528.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $9,741.55 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,777.47 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $768.70. The transfer capital threshold is the transfer adjustment factor * $768.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12455.21,37149.27,Inpatient DRG
MAJOR CHEST TRAUMA WITHOUT CC/MCC,185,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],7271.19,,"Case rate ($7,271.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,899.84, add-ons for qualifying new technology services are included. If operating cost exceeds $41,770.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,149.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,936.68 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,954.88 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $389.55. The transfer capital threshold is the transfer adjustment factor * $389.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7271.19,21771.61,Inpatient DRG
Laps Fulg/Exc Ovary Viscera/Peritoneal Surface|LEFT SIDE,CASE-58662,APC,58662,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5856.81,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5658.76,5941.70,OPPS APC
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,093,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7594.36,,"Case rate ($7,337.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,961.57, add-ons for qualifying new technology services are included. If operating cost exceeds $41,832.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,154.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,998.19 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,016.62 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $394.41. The transfer capital threshold is the transfer adjustment factor * $394.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6965.00,19011.32,Inpatient DRG
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],86235.79,,"Fee schedule rate ($86,235.79). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,32296.02,88188.38,There are no additional notes associated with this service or procedure.
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC",011,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],39685.35,,"Case rate ($37,795.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $35,362.92, add-ons for qualifying new technology services are included. If operating cost exceeds $70,233.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,318.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 11.4. The base transfer operating payment is the transfer adjustment factor * $33,291.75 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $33,417.97 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,558.88. The transfer capital threshold is the transfer adjustment factor * $2,558.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,38880.49,150008.48,Inpatient DRG
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,555,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],42290.95,,"Fee schedule rate ($42,290.95). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10896.27,42290.95,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],19535.15,,"Case rate ($19,152.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,952.40, add-ons for qualifying new technology services are included. If operating cost exceeds $52,823.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,018.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $15,948.65 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $16,007.45 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,258.51. The transfer capital threshold is the transfer adjustment factor * $1,258.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,19152.11,53152.12,Inpatient DRG
Fissurectomy Incl Sphincterotomy When Performed,CASE-46200,APC,46200,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],2727.99,,"APC Price ($2,598.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2598.08,2727.99,OPPS APC
Bronchoscopy W/Transbronchial Lung Bx 1 Lobe,CASE-31628,APC,31628,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6936.25,,"APC Price ($6,605.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6605.95,6936.25,OPPS APC
HC Perq Vert Agmntj Cavity Crtj Uni/Bi Cannulj Lmbr,CASE-22514,APC,22514,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,6791.99,OPPS APC
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC,027,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],56363.30,,"Fee schedule rate ($56,363.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,19030.20,56363.30,There are no additional notes associated with this service or procedure.
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],22732.01,,"Fee schedule rate ($22,732.01). Adds an outlier to normal pricing equal to the per diem rate ($114,196.66) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.5), with a minimum of zero.",,,,0,other,10136.44,24444.75,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,167,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],43522.37,,"Fee schedule rate ($43,522.37). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,14157.71,43522.37,There are no additional notes associated with this service or procedure.
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],30236.06,,"Fee schedule rate ($30,236.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.8), with a minimum of zero.",,,,0,other,1188.00,31658.33,There are no additional notes associated with this service or procedure.
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],42021.93,,"Fee schedule rate ($42,021.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,21248.73,56089.29,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6558.75,,"Case rate ($6,558.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,237.08, add-ons for qualifying new technology services are included. If operating cost exceeds $41,108.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,097.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $4,276.36 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,292.13 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $337.45. The transfer capital threshold is the transfer adjustment factor * $337.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6558.75,14871.83,Inpatient DRG
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],13920.03,,"Case rate ($13,647.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,831.20, add-ons for qualifying new technology services are included. If operating cost exceeds $47,702.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,615.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $10,846.26 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,886.25 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $855.88. The transfer capital threshold is the transfer adjustment factor * $855.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,7921.00,45706.73,Inpatient DRG
SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS,029,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],61889.56,,"Fee schedule rate ($61,889.56). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13641.00,67130.05,There are no additional notes associated with this service or procedure.
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5710.23,,"Case rate ($5,710.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,447.70, add-ons for qualifying new technology services are included. If operating cost exceeds $40,318.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,035.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $3,489.88 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,502.75 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $275.39. The transfer capital threshold is the transfer adjustment factor * $275.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,3079.00,10940.41,Inpatient DRG
Osteoplasty Radius/Ulna Shortening,CASE-25390,APC,25390,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7131.59,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6791.99,7131.59,OPPS APC
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,191,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],16612.88,,"Fee schedule rate ($16,612.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6965.00,16612.88,There are no additional notes associated with this service or procedure.
Colorectal Scrn; Hi Risk Ind,CASE-G0105,APC,G0105,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],913.99,,"APC Price ($870.46). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,870.46,913.99,OPPS APC
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],5415.00,,"Per diem ($5,415). If length of stay < 3.1, first 1 days paid at a per diem of $10,830 instead. Capped at $16,785.91.",,,,0,other,5415.00,17575.50,Estimated amount calculated based on 3 day length of stay.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,025,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],91631.33,,"Fee schedule rate ($91,631.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,13351.00,91631.33,There are no additional notes associated with this service or procedure.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],23835.16,,"Fee schedule rate ($23,835.16). Adds an outlier to normal pricing equal to the per diem rate ($63,133.20) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10533.95,24956.34,There are no additional notes associated with this service or procedure.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC",061,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],21647.04,,"Case rate ($20,616.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $19,314.45, add-ons for qualifying new technology services are included. If operating cost exceeds $54,185.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,125.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $17,305.68 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $17,369.49 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,365.59. The transfer capital threshold is the transfer adjustment factor * $1,365.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,20616.23,62315.82,Inpatient DRG
"Inj Dx/Ther Agnt Paravert Facet Joint, Cerv/Thorac, 2nd Level",CASE-64491,APC,64491,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],869.28,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,827.89,869.28,OPPS APC
PSYCHOSES,885,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],11803.32,,"Case rate ($11,404.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,744.67, add-ons for qualifying new technology services are included. If operating cost exceeds $45,615.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,451.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.5. The base transfer operating payment is the transfer adjustment factor * $8,767.39 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,799.72 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $691.83. The transfer capital threshold is the transfer adjustment factor * $691.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,2070.00,27484.83,Inpatient DRG
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5980.87,,"Case rate ($5,778.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,511.33, add-ons for qualifying new technology services are included. If operating cost exceeds $40,382.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,040.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $3,553.28 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,566.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $280.39. The transfer capital threshold is the transfer adjustment factor * $280.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,5778.62,11681.49,Inpatient DRG
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],20407.65,,"Case rate ($19,435.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $18,216.37, add-ons for qualifying new technology services are included. If operating cost exceeds $53,087.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,039.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.9. The base transfer operating payment is the transfer adjustment factor * $16,211.64 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $16,271.42 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,279.26. The transfer capital threshold is the transfer adjustment factor * $1,279.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,19435.86,50821.76,Inpatient DRG
"HC Injection Small Joint/Bursa|RIGHT HAND, FOURTH DIGIT",CASE-20600,APC,20600,CPT,0361,RC,,,F8,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1505.12,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1505.12,1580.37,OPPS APC
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],23385.72,,"Fee schedule rate ($23,385.72). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,23385.72,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],14451.02,,"Case rate ($13,762.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,938.93, add-ons for qualifying new technology services are included. If operating cost exceeds $47,809.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,624.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $10,953.59 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,993.98 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $864.35. The transfer capital threshold is the transfer adjustment factor * $864.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,1188.00,34338.33,Inpatient DRG
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],11065.78,,"Fee schedule rate ($11,065.78). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5883.03,17111.12,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC,832,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],11955.44,,"Case rate ($6,831.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,490.97, add-ons for qualifying new technology services are included. If operating cost exceeds $41,361.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,117.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $4,529.32 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,546.02 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $357.41. The transfer capital threshold is the transfer adjustment factor * $357.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,4803.31,14198.92,All Other Inpatient
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],21089.59,,"Fee schedule rate ($21,089.59). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,6965.00,21089.59,There are no additional notes associated with this service or procedure.
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],36868.88,,"Fee schedule rate ($36,868.88). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12606.23,36868.88,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC,832,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],9034.88,,"Fee schedule rate ($9,034.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,4803.31,14198.92,There are no additional notes associated with this service or procedure.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],41006.47,,"Fee schedule rate ($41,006.47). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12268.97,41006.47,There are no additional notes associated with this service or procedure.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],18933.95,,"Fee schedule rate ($18,933.95). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.8), with a minimum of zero.",,,,0,other,8767.81,19824.58,There are no additional notes associated with this service or procedure.
"LIMB REATTACHMENT, HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA",956,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],148259.86,,"Fee schedule rate ($148,259.86). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,27428.25,148259.86,There are no additional notes associated with this service or procedure.
Colposcopy Cervix Bx Cervix & Endocrv Curretage,CASE-57454,APC,57454,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],295.22,,"APC Price ($285.23). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,285.23,299.50,OPPS APC
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],40714.72,,"Fee schedule rate ($40,714.72). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,17356.15,44778.95,There are no additional notes associated with this service or procedure.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,345,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],12134.89,,"Case rate ($12,134.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,424.43, add-ons for qualifying new technology services are included. If operating cost exceeds $46,295.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,505.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $9,444.66 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,479.48 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $745.28. The transfer capital threshold is the transfer adjustment factor * $745.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12134.89,33616.03,Inpatient DRG
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],6965.00,,,,,,0,other,6965.00,29482.05,There are no additional notes associated with this service or procedure.
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],22557.82,,"Fee schedule rate ($22,557.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6801.88,22557.82,There are no additional notes associated with this service or procedure.
O.R. PROCEDURES FOR OBESITY WITH CC,620,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],30074.44,,"Fee schedule rate ($30,074.44). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7.8), with a minimum of zero.",,,,0,other,12782.30,43753.50,There are no additional notes associated with this service or procedure.
"OTHER NON-HYPOVOLEMIC ELECTROLYTE DISORDERS,MODERATE",425,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],6423.72,,"Case rate ($6,117.83). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,6117.83,6423.72,There are no additional notes associated with this service or procedure.
Replacement Tissue Expander W/Permanent Implant,CASE-11970,APC,11970,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,708,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],11635.30,,"Case rate ($11,081.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $10,413.93, add-ons for qualifying new technology services are included. If operating cost exceeds $49,058.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $3,436.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.3. The base transfer operating payment is the transfer adjustment factor * $9,014.04 + an uncompensated DSH payment of $1,359.91. The transfer operating threshold is the transfer adjustment factor * $9,054.03 + an uncompensated DSH payment of $1,359.91. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $707.29. The transfer capital threshold is the transfer adjustment factor * $707.29. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10138.21,29171.15,Inpatient DRG
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],34712.20,,,,,,0,other,13891.57,34712.20,There are no additional notes associated with this service or procedure.
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC,058,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],22642.20,,"Fee schedule rate ($22,642.20). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,13521.80,40853.02,There are no additional notes associated with this service or procedure.
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],53275.26,,"Fee schedule rate ($53,275.26). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,15940.79,53275.26,There are no additional notes associated with this service or procedure.
Injection Aa&/Strd Intercostal Nrv Ea Addl Lvl|RIGHT SIDE,CASE-64421,APC,64421,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],869.28,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,827.89,869.28,OPPS APC
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],14747.55,,"Case rate ($14,747.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,854.94, add-ons for qualifying new technology services are included. If operating cost exceeds $48,725.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,696.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $11,866.24 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,909.99 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $936.36. The transfer capital threshold is the transfer adjustment factor * $936.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,14747.55,37899.49,Inpatient DRG
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],29166.74,,"Fee schedule rate ($29,166.74). Adds an outlier to normal pricing equal to the per diem rate ($36,758.78) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,12455.21,37149.27,There are no additional notes associated with this service or procedure.
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],12331.11,,"Case rate ($11,914.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,219.06, add-ons for qualifying new technology services are included. If operating cost exceeds $46,090.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,489.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $9,240.03 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,274.10 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $729.13. The transfer capital threshold is the transfer adjustment factor * $729.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,11914.12,40426.76,Inpatient DRG
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],46523.26,,"Fee schedule rate ($46,523.26). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,17782.11,46523.26,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITH STERILIZATION WITH CC,784,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],23722.94,,"Fee schedule rate ($23,722.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9124.01,23722.94,There are no additional notes associated with this service or procedure.
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6010.23,,"Case rate ($6,010.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,726.79, add-ons for qualifying new technology services are included. If operating cost exceeds $40,597.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,057.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,767.95 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,781.84 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $297.33. The transfer capital threshold is the transfer adjustment factor * $297.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6010.23,12246.05,Inpatient DRG
NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,601,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],12359.72,,"Fee schedule rate ($12,359.72). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6042.05,12359.72,There are no additional notes associated with this service or procedure.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],19604.30,,"Fee schedule rate ($19,604.30). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9446.38,21796.21,There are no additional notes associated with this service or procedure.
"CVA AND PRECEREBRAL OCCLUSION WITH INFARCTION,MAJOR",045,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],13696.05,,"Case rate ($13,696.05). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,13696.05,14380.85,There are no additional notes associated with this service or procedure.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],25276.59,,"Fee schedule rate ($25,276.59). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,11053.39,36776.05,There are no additional notes associated with this service or procedure.
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],21888.80,,"Case rate ($20,846.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $19,528.64, add-ons for qualifying new technology services are included. If operating cost exceeds $54,399.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,142.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $17,519.09 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $17,583.69 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,382.43. The transfer capital threshold is the transfer adjustment factor * $1,382.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,20846.48,81306.30,Inpatient DRG
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],11606.06,,"Case rate ($11,053.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,418.34, add-ons for qualifying new technology services are included. If operating cost exceeds $45,289.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,426.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $8,442.26 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,473.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $666.18. The transfer capital threshold is the transfer adjustment factor * $666.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,11053.39,36776.05,Inpatient DRG
VENTRICULAR SHUNT PROCEDURES WITH CC,032,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],16703.74,,"Case rate ($16,376.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,370.06, add-ons for qualifying new technology services are included. If operating cost exceeds $50,241.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,815.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $13,375.80 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,425.12 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,055.48. The transfer capital threshold is the transfer adjustment factor * $1,055.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,16376.22,46275.08,Inpatient DRG
OSTEOMYELITIS WITH CC,540,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],10723.59,,"Case rate ($10,723.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,111.53, add-ons for qualifying new technology services are included. If operating cost exceeds $44,982.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,402.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $8,136.58 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,166.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $642.06. The transfer capital threshold is the transfer adjustment factor * $642.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9809.07,25507.30,Inpatient DRG
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITHOUT CC/MCC,428,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],41418.14,,"Case rate ($40,017.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $37,363.07, add-ons for qualifying new technology services are included. If operating cost exceeds $72,234.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,544.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $35,288.01 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $35,418.12 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,784.57. The transfer capital threshold is the transfer adjustment factor * $2,784.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,40017.53,118904.57,Inpatient DRG
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],37149.27,,"Fee schedule rate ($37,149.27). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,12455.21,37149.27,There are no additional notes associated with this service or procedure.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],38378.80,,"Fee schedule rate ($38,378.80). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,14370.36,38378.80,There are no additional notes associated with this service or procedure.
Excision Choledochal Cyst,CASE-47715,APC,47715,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],297.37,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,287.31,301.68,OPPS APC
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],62454.12,,"Fee schedule rate ($62,454.12). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11348.00,62454.12,There are no additional notes associated with this service or procedure.
Esophagoscopy Flexible Transoral Ultrasound Exam,CASE-43231,APC,43231,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1796.14,,"APC Price ($1,796.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1796.14,1885.95,OPPS APC
"OTHER DISORDERS OF NERVOUS SYSTEM,MAJOR",058,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],1185.06,,"Case rate for a one day stay ($1,185.06). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,1185.06,1244.31,There are no additional notes associated with this service or procedure.
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC",629,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],44657.18,,"Fee schedule rate ($44,657.18). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,16699.94,44657.18,There are no additional notes associated with this service or procedure.
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],26725.53,,"Fee schedule rate ($26,725.53). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.6), with a minimum of zero.",,,,0,other,11575.50,48961.48,There are no additional notes associated with this service or procedure.
Cysto W/Ureteroscopy W/Rmvl/Manj Stones|RIGHT SIDE,CASE-52352,APC,52352,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3464.44,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3299.47,3464.44,OPPS APC
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,095,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],48575.01,,"Fee schedule rate ($48,575.01). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,19411.47,50750.92,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],10834.64,,"Case rate ($10,834.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,214.84, add-ons for qualifying new technology services are included. If operating cost exceeds $45,085.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,410.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $8,239.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,269.90 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $650.18. The transfer capital threshold is the transfer adjustment factor * $650.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10834.64,25830.00,Inpatient DRG
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],54180.83,,"Fee schedule rate ($54,180.83). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,15491.11,54180.83,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,093,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],10536.75,,"Fee schedule rate ($10,536.75). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,19011.32,There are no additional notes associated with this service or procedure.
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],22762.43,,"Fee schedule rate ($22,762.43). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6230.00,22762.43,There are no additional notes associated with this service or procedure.
"CHRONIC OBSTRUCTIVE PULMONARY DISEASE,MINOR",140,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],6127.86,,"Case rate ($5,836.06). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,5836.06,6127.86,There are no additional notes associated with this service or procedure.
ALLERGIC REACTIONS WITH MCC,915,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],31602.31,,"Fee schedule rate ($31,602.31). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.8), with a minimum of zero.",,,,0,other,13332.86,33088.84,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],6841.83,,"Case rate ($6,841.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,500.42, add-ons for qualifying new technology services are included. If operating cost exceeds $41,371.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,118.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $4,538.73 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,555.47 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $358.15. The transfer capital threshold is the transfer adjustment factor * $358.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6841.83,21167.26,Inpatient DRG
Brnchsc Ebus Guided Sampl 3/> Node Station/Strux,CASE-31653,APC,31653,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6837.16,,"APC Price ($6,605.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6605.95,6936.25,OPPS APC
HEART FAILURE AND SHOCK WITH CC,292,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],16705.77,,,,,,0,other,5502.00,16705.77,There are no additional notes associated with this service or procedure.
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR,518,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],28616.93,,"Case rate ($27,254.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $25,489.62, add-ons for qualifying new technology services are included. If operating cost exceeds $60,360.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,611.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 5.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $23,458.18 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $23,544.67 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,851.08. The transfer capital threshold is the transfer adjustment factor * $1,851.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13252.00,89342.77,Inpatient DRG
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],15011.23,,"Fee schedule rate ($15,011.23). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,14344.60,36028.59,There are no additional notes associated with this service or procedure.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],41944.25,,"Fee schedule rate ($41,944.25). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12795.84,41944.25,There are no additional notes associated with this service or procedure.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,025,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],34372.30,,"Case rate ($32,735.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $30,588.77, add-ons for qualifying new technology services are included. If operating cost exceeds $65,459.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,011.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.4. The base transfer operating payment is the transfer adjustment factor * $28,538.59 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $28,643.82 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,251.98. The transfer capital threshold is the transfer adjustment factor * $2,251.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,13351.00,91631.33,Inpatient DRG
"Amputation Toe Interphalangeal Joint|RIGHT FOOT, FOURTH DIGIT",CASE-28825,APC,28825,CPT,0360,RC,,,T8,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],22382.59,,,,,,0,other,9648.19,31477.13,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],22105.92,,"Fee schedule rate ($22,105.92). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,13783.20,41580.51,There are no additional notes associated with this service or procedure.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],19067.30,,"Case rate ($10,895.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,271.55, add-ons for qualifying new technology services are included. If operating cost exceeds $45,142.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,414.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $8,296.01 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,326.60 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $654.64. The transfer capital threshold is the transfer adjustment factor * $654.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,10895.60,35192.25,All Other Inpatient
OTHER DISORDERS OF THE EYE WITHOUT MCC,125,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],17952.29,,"Fee schedule rate ($17,952.29). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (6), with a minimum of zero.",,,,0,other,7144.54,17952.29,There are no additional notes associated with this service or procedure.
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],14610.75,,"Case rate ($14,610.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,727.68, add-ons for qualifying new technology services are included. If operating cost exceeds $48,598.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,686.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.6. The base transfer operating payment is the transfer adjustment factor * $11,739.44 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,782.73 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $926.36. The transfer capital threshold is the transfer adjustment factor * $926.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6277.00,36801.89,Inpatient DRG
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],18043.23,,"Fee schedule rate ($18,043.23). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7733.72,18043.23,There are no additional notes associated with this service or procedure.
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC,939,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],97674.79,,"Fee schedule rate ($97,674.79). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,26517.40,97674.79,There are no additional notes associated with this service or procedure.
HC Inj Aa&/Strd Greater Occipital Nerve|BILATERAL PROCEDURE,CASE-64405,APC,64405,CPT,0450,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],301.68,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,287.31,301.68,OPPS APC
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6917.29,,"Case rate ($6,683.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,353, add-ons for qualifying new technology services are included. If operating cost exceeds $41,224.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,106.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,391.86 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,408.05 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $346.56. The transfer capital threshold is the transfer adjustment factor * $346.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6683.37,14699.43,Inpatient DRG
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH MCC",722,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],34009.69,,"Fee schedule rate ($34,009.69). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,14200.37,56869.13,There are no additional notes associated with this service or procedure.
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],15381.51,,,,,,0,other,7238.69,16804.22,There are no additional notes associated with this service or procedure.
OTHER MENTAL DISORDER DIAGNOSES,887,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],9197.17,,"Case rate ($9,197.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,691.53, add-ons for qualifying new technology services are included. If operating cost exceeds $43,562.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,290.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,721.79 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,746.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $530.42. The transfer capital threshold is the transfer adjustment factor * $530.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,2070.00,21072.10,Inpatient DRG
VAGINAL DELIVERY WITH O.R. PROCEDURES EXCEPT STERILIZATION AND/OR D&C,768,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],12088.81,,"Fee schedule rate ($12,088.81). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6426.91,13416.00,There are no additional notes associated with this service or procedure.
Tissue Expander Placement Breast Reconstruction|LEFT SIDE,CASE-19357,APC,19357,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],12899.30,,"APC Price ($12,899.30). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12899.30,13350.78,OPPS APC
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],21854.96,,"Fee schedule rate ($21,854.96). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10638.94,25261.33,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,091,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],14322.39,,"Case rate ($13,838.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,008.86, add-ons for qualifying new technology services are included. If operating cost exceeds $47,879.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,629.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $11,023.26 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,063.91 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $869.84. The transfer capital threshold is the transfer adjustment factor * $869.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,13838.06,40030.81,Inpatient DRG
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],6915.64,,"Case rate ($6,915.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,569.08, add-ons for qualifying new technology services are included. If operating cost exceeds $41,440.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,123.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,607.15 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,624.14 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $363.55. The transfer capital threshold is the transfer adjustment factor * $363.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6915.64,14442.92,Inpatient DRG
CERVICAL SPINAL FUSION WITHOUT CC/MCC,473,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],34405.35,,"Fee schedule rate ($34,405.35). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,18477.61,62077.11,There are no additional notes associated with this service or procedure.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],15309.46,,"Fee schedule rate ($15,309.46). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6965.00,15340.19,There are no additional notes associated with this service or procedure.
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],15125.60,,"Case rate ($8,643.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,176.19, add-ons for qualifying new technology services are included. If operating cost exceeds $43,047.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,249.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $6,208.35 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,231.24 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $489.90. The transfer capital threshold is the transfer adjustment factor * $489.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,8643.20,19462.52,All Other Inpatient
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITH MCC,429,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],62958.58,,"Case rate ($62,958.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $58,704.65, add-ons for qualifying new technology services are included. If operating cost exceeds $93,575.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $6,222.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.6. The base transfer operating payment is the transfer adjustment factor * $56,551.19 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $56,759.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,462.45. The transfer capital threshold is the transfer adjustment factor * $4,462.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,62958.58,177294.98,Inpatient DRG
"Inj Dx/Ther Agnt Paravert Facet Joint, Cerv/Thorac, 2nd Level|LEFT SIDE|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA",CASE-64491,APC,64491,CPT,0360,RC,,,LT|74,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],827.89,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,827.89,869.28,OPPS APC
"CARDIAC ARREST, UNEXPLAINED WITH MCC",296,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],29352.79,,"Fee schedule rate ($29,352.79). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.2), with a minimum of zero.",,,,0,other,12522.25,36459.67,There are no additional notes associated with this service or procedure.
Dstr Nrolytc Agnt Parverteb Fct Addl Lmbr/Sacral,CASE-64636,APC,64636,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1827.80,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1827.80,1919.19,OPPS APC
PREMATURITY WITHOUT MAJOR PROBLEMS,792,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],11512.88,,"Fee schedule rate ($11,512.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,1956.00,19457.66,There are no additional notes associated with this service or procedure.
OTHER CEREBROVASCULAR DISORDERS WITH CC,071,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],9337.76,,"Case rate ($8,893.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,408.66, add-ons for qualifying new technology services are included. If operating cost exceeds $43,279.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,268.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,439.97 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,463.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $508.18. The transfer capital threshold is the transfer adjustment factor * $508.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5843.00,29215.10,Inpatient DRG
VAGINAL DELIVERY WITH O.R. PROCEDURES EXCEPT STERILIZATION AND/OR D&C,768,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],12088.81,,"Fee schedule rate ($12,088.81). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6426.91,13416.00,There are no additional notes associated with this service or procedure.
Perq Nl/Pl Lithotrp Simple Up to 2 Cm 1 Location|RIGHT SIDE,CASE-50080,APC,50080,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],9303.88,,"APC Price ($8,860.83). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,8860.83,9303.88,OPPS APC
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],36097.29,,"Case rate ($35,389.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $33,057.71, add-ons for qualifying new technology services are included. If operating cost exceeds $67,928.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,206.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.3. The base transfer operating payment is the transfer adjustment factor * $30,998.46 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $31,112.76 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,446.08. The transfer capital threshold is the transfer adjustment factor * $2,446.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,35389.50,101083.00,Inpatient DRG
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],25162.32,,"Case rate ($25,162.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $23,543.58, add-ons for qualifying new technology services are included. If operating cost exceeds $58,414.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,458.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $21,519.28 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $21,598.63 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,698.08. The transfer capital threshold is the transfer adjustment factor * $1,698.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,25162.32,75579.22,Inpatient DRG
"Tenolysis Extensor Tendon Hand/Finger Each|LEFT HAND, SECOND DIGIT",CASE-26445,APC,26445,CPT,0360,RC,,,F1,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3169.86,OPPS APC
MAJOR CHEST TRAUMA WITHOUT CC/MCC,185,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],7271.19,,"Case rate ($7,271.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,899.84, add-ons for qualifying new technology services are included. If operating cost exceeds $41,770.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,149.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,936.68 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,954.88 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $389.55. The transfer capital threshold is the transfer adjustment factor * $389.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7271.19,21771.61,Inpatient DRG
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],15054.73,,"Case rate ($14,337.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,473.80, add-ons for qualifying new technology services are included. If operating cost exceeds $48,344.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,666.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $11,486.49 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,528.84 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $906.40. The transfer capital threshold is the transfer adjustment factor * $906.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,14337.84,52803.53,Inpatient DRG
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],7930.65,,"Fee schedule rate ($7,930.65). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,17467.27,There are no additional notes associated with this service or procedure.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,057,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],39884.93,,"Fee schedule rate ($39,884.93). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,10718.84,39884.93,There are no additional notes associated with this service or procedure.
Thyroidectomy Total/Complete|BILATERAL PROCEDURE,CASE-60240,APC,60240,CPT,0360,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],10447.27,,"APC Price ($9,949.78). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,9949.78,10447.27,OPPS APC
INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC,198,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],14092.67,,,,,,0,other,6795.12,23505.07,There are no additional notes associated with this service or procedure.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC,434,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],7108.55,,"Case rate ($6,770.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,433.64, add-ons for qualifying new technology services are included. If operating cost exceeds $41,304.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,112.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,472.20 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,488.69 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $352.90. The transfer capital threshold is the transfer adjustment factor * $352.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6770.05,14019.86,Inpatient DRG
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],59891.41,,"Fee schedule rate ($59,891.41). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15), with a minimum of zero.",,,,0,other,23526.87,94787.57,There are no additional notes associated with this service or procedure.
Nasal/Sinus Ndsc Tot W/Sphendt W/Sphen Tiss Rmvl|RIGHT SIDE,CASE-31259,APC,31259,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6837.16,,"APC Price ($6,605.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6605.95,6936.25,OPPS APC
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,091,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],22186.50,,"Fee schedule rate ($22,186.50). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,13838.06,40030.81,There are no additional notes associated with this service or procedure.
Transurethral Resection Bladder Neck,CASE-52500,APC,52500,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3299.47,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3299.47,3464.44,OPPS APC
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,083,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],11967.27,,"Case rate ($11,397.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,738.37, add-ons for qualifying new technology services are included. If operating cost exceeds $45,609.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,451.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $8,761.12 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,793.42 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $691.34. The transfer capital threshold is the transfer adjustment factor * $691.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,28680.85,Inpatient DRG
INFLAMMATORY BOWEL DISEASE WITH CC,386,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],19879.00,,"Fee schedule rate ($19,879.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8556.53,19879.00,There are no additional notes associated with this service or procedure.
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC,805,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],9716.03,,"Case rate ($9,253.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,743.82, add-ons for qualifying new technology services are included. If operating cost exceeds $43,614.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,294.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $6,773.89 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,798.87 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $534.53. The transfer capital threshold is the transfer adjustment factor * $534.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9253.36,21235.42,Inpatient DRG
Surgical Arthroscopy Shoulder W/Rotator Cuff Rpr|LEFT SIDE,CASE-29827,APC,29827,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6791.99,7131.59,OPPS APC
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],28235.64,,"Fee schedule rate ($28,235.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,14344.60,36028.59,There are no additional notes associated with this service or procedure.
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",623,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],32096.64,,"Fee schedule rate ($32,096.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,14093.37,33712.76,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC,084,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],14730.98,,"Case rate ($8,417.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,966.41, add-ons for qualifying new technology services are included. If operating cost exceeds $42,837.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,233.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $5,999.34 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,021.46 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $473.41. The transfer capital threshold is the transfer adjustment factor * $473.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,6965.00,19445.16,All Other Inpatient
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITHOUT CC/MCC",630,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],20700.37,,"Case rate ($11,828.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,139.67, add-ons for qualifying new technology services are included. If operating cost exceeds $46,010.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,482.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $9,160.95 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,194.72 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $722.89. The transfer capital threshold is the transfer adjustment factor * $722.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,11828.78,42541.02,All Other Inpatient
ALLERGIC REACTIONS WITH MCC,915,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],27385.01,,"Fee schedule rate ($27,385.01). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,13332.86,33088.84,There are no additional notes associated with this service or procedure.
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],13625.25,,"Fee schedule rate ($13,625.25). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7243.75,23262.15,There are no additional notes associated with this service or procedure.
SPINAL PROCEDURES WITH MCC,028,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],42633.57,,"Case rate ($42,633.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $39,796.72, add-ons for qualifying new technology services are included. If operating cost exceeds $74,667.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,735.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.5. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 9.5)) / 2. The base transfer operating payment is the transfer adjustment factor * $37,712.72 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $37,851.77 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,975.91. The transfer capital threshold is the transfer adjustment factor * $2,975.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,42633.57,120982.83,Inpatient DRG
ALLERGIC REACTIONS WITH MCC,915,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],13599.52,,"Case rate ($13,332.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,538.89, add-ons for qualifying new technology services are included. If operating cost exceeds $47,409.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,592.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $10,555.02 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,593.94 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $832.90. The transfer capital threshold is the transfer adjustment factor * $832.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,13332.86,33088.84,Inpatient DRG
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],12775.53,,"Case rate ($12,775.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,020.41, add-ons for qualifying new technology services are included. If operating cost exceeds $46,891.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,552.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $10,038.44 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,075.45 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $792.13. The transfer capital threshold is the transfer adjustment factor * $792.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12775.53,31469.43,Inpatient DRG
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],26301.36,,"Fee schedule rate ($26,301.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11247.07,27028.33,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],7366.00,,"Case rate ($7,366). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,988.03, add-ons for qualifying new technology services are included. If operating cost exceeds $41,859.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,156.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,024.55 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,043.08 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $396.49. The transfer capital threshold is the transfer adjustment factor * $396.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,21195.68,Inpatient DRG
APPENDIX PROCEDURES WITH MCC,397,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],18799.09,,"Case rate ($18,163.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,032.61, add-ons for qualifying new technology services are included. If operating cost exceeds $51,903.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,946.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $15,032.24 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,087.66 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,186.19. The transfer capital threshold is the transfer adjustment factor * $1,186.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,18163.37,51558.84,Inpatient DRG
PREMATURITY WITH MAJOR PROBLEMS,791,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],3186.77,,,,,,0,other,3048.21,30904.42,Estimated amount calculated based on 5 day length of stay.
"SEPTICEMIA AND DISSEMINATED INFECTIONS,MODERATE",720,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],1948.81,,"Case rate for a one day stay ($1,948.81). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,1948.81,2046.25,There are no additional notes associated with this service or procedure.
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],13194.59,,"Case rate ($12,566.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,825.74, add-ons for qualifying new technology services are included. If operating cost exceeds $46,696.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,536.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $9,844.49 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,880.79 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $776.83. The transfer capital threshold is the transfer adjustment factor * $776.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12566.28,30861.41,Inpatient DRG
"Corrj Hallux Valgus W/Sesmdc W/Rescj Prox Phal|LEFT FOOT, GREAT TOE",CASE-28292,APC,28292,CPT,0360,RC,,,TA,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3062.67,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,448,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],94077.13,,"Fee schedule rate ($94,077.13). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,30663.95,94077.13,There are no additional notes associated with this service or procedure.
POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES,769,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],31756.41,,"Fee schedule rate ($31,756.41). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.7), with a minimum of zero.",,,,0,other,13388.39,33250.19,There are no additional notes associated with this service or procedure.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],22626.77,,"Fee schedule rate ($22,626.77). Adds an outlier to normal pricing equal to the per diem rate ($36,883.74) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.5), with a minimum of zero.",,,,0,other,10098.51,24259.09,There are no additional notes associated with this service or procedure.
SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS,029,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],13641.00,,"Per diem ($13,641). If length of stay < 4.7, first 1 days paid at a per diem of $27,282 instead. Capped at $64,114.20.",,,,0,other,13641.00,67130.05,Estimated amount calculated based on 5 day length of stay.
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],16184.69,,"Case rate ($15,413.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,500.05, add-ons for qualifying new technology services are included. If operating cost exceeds $49,371.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,721.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $12,507.68 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,555.10 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $961.37. The transfer capital threshold is the transfer adjustment factor * $961.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,15821.59,40320.14,Inpatient DRG
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],31007.30,,"Fee schedule rate ($31,007.30). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,16120.25,41187.90,There are no additional notes associated with this service or procedure.
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],19997.63,,"Fee schedule rate ($19,997.63). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,9151.11,30245.71,There are no additional notes associated with this service or procedure.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],20553.44,,"Fee schedule rate ($20,553.44). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8874.81,20553.44,There are no additional notes associated with this service or procedure.
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],18217.52,,"Fee schedule rate ($18,217.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7414.07,18217.52,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],20659.14,,"Fee schedule rate ($20,659.14). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.9), with a minimum of zero.",,,,0,other,9389.48,22358.90,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,086,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],8442.00,,"Per diem ($8,442). If length of stay < 2.9, first 1 days paid at a per diem of $16,884 instead. Capped at $24,481.64.",,,,0,other,8442.00,30728.81,Estimated amount calculated based on 2 day length of stay.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],19319.20,,"Fee schedule rate ($19,319.20). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8906.63,28434.57,There are no additional notes associated with this service or procedure.
PSYCHOSES,885,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],2070.00,,,,,,0,other,2070.00,27484.83,Estimated amount calculated based on 3 day length of stay.
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,447,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],86819.25,,"Fee schedule rate ($86,819.25). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,47193.21,156646.82,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],21534.51,,,,,,0,other,9356.31,25026.36,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF THE EYE WITHOUT MCC,125,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],14429.27,,"Fee schedule rate ($14,429.27). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.9), with a minimum of zero.",,,,0,other,7144.54,17952.29,There are no additional notes associated with this service or procedure.
"Neuroplasty Other Arm/Leg Nerve,Open|RIGHT SIDE",CASE-64708,APC,64708,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6791.99,7131.59,OPPS APC
Arthrs Knee Abrasion Arthrp/Mlt Drlg/Microfx|RIGHT SIDE,CASE-29879,APC,29879,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
PREMATURITY WITH MAJOR PROBLEMS,791,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],30462.93,,"Case rate ($29,432.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $27,516.30, add-ons for qualifying new technology services are included. If operating cost exceeds $62,387.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,770.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 13.3. The base transfer operating payment is the transfer adjustment factor * $25,477.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $25,571.35 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,010.42. The transfer capital threshold is the transfer adjustment factor * $2,010.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,3048.21,30904.42,Inpatient DRG
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],14337.84,,"Case rate ($14,337.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,473.80, add-ons for qualifying new technology services are included. If operating cost exceeds $48,344.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,666.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $11,486.49 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,528.84 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $906.40. The transfer capital threshold is the transfer adjustment factor * $906.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,14337.84,52803.53,Inpatient DRG
HC Drain/Inj Joint/Bursa W/US Large|PBB CHARGE|LEFT SIDE,CASE-20611,APC,20611,CPT,0510,RC,,,PBB|LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC,964,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],34154.06,,"Fee schedule rate ($34,154.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12323.82,34154.06,There are no additional notes associated with this service or procedure.
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],36868.88,,"Fee schedule rate ($36,868.88). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12606.23,36868.88,There are no additional notes associated with this service or procedure.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],120927.32,,"Fee schedule rate ($120,927.32). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,45521.20,142438.06,There are no additional notes associated with this service or procedure.
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITH MCC,429,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],177294.98,,"Fee schedule rate ($177,294.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,62958.58,177294.98,There are no additional notes associated with this service or procedure.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],11681.49,,"Fee schedule rate ($11,681.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5778.62,11681.49,There are no additional notes associated with this service or procedure.
HC Trigger Point 3 or More,CASE-20553,APC,20553,CPT,0510,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],297.37,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,287.31,301.68,OPPS APC
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],13854.88,,"Case rate ($13,386.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,588.65, add-ons for qualifying new technology services are included. If operating cost exceeds $47,459.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,596.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $10,604.60 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,643.70 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $836.81. The transfer capital threshold is the transfer adjustment factor * $836.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,13386.36,33244.29,Inpatient DRG
BRONCHITIS AND ASTHMA WITH CC/MCC,202,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],8521.98,,"Case rate ($8,521.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,063.43, add-ons for qualifying new technology services are included. If operating cost exceeds $42,934.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,241.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,096.00 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,118.48 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $481.03. The transfer capital threshold is the transfer adjustment factor * $481.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7606.34,19110.30,Inpatient DRG
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6992.18,,"Case rate ($6,659.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,339.33, add-ons for qualifying new technology services are included. If operating cost exceeds $41,210.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,096.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,377.78 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,394.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $336.49. The transfer capital threshold is the transfer adjustment factor * $336.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6801.88,22557.82,Inpatient DRG
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],6965.00,,,,,,0,other,6164.03,14071.02,There are no additional notes associated with this service or procedure.
Ercp Remove Foreign Body/Stent Biliary/Panc Duct,CASE-43275,APC,43275,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3789.26,,"APC Price ($3,608.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3608.81,3789.26,OPPS APC
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],29243.52,,"Fee schedule rate ($29,243.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,14343.25,36024.65,There are no additional notes associated with this service or procedure.
Colonoscopy W/Biopsy Single/Multiple|UNUSUAL NON-OVERLAPPING SERVICE|COLORECTAL CANCER SCREEN,CASE-45380,APC,45380,CPT,0360,RC,,,XU|PT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1120.09,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1120.09,1176.09,OPPS APC
Excision H/P/P/U Simple/Intermediate Repair,CASE-11470,APC,11470,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],2718.88,,"APC Price ($2,718.88). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2718.88,2854.83,OPPS APC
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],19319.20,,"Fee schedule rate ($19,319.20). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8906.63,28434.57,There are no additional notes associated with this service or procedure.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],14699.43,,"Fee schedule rate ($14,699.43). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6683.37,14699.43,There are no additional notes associated with this service or procedure.
MAJOR CHEST TRAUMA WITHOUT CC/MCC,185,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],15475.96,,,,,,0,other,7271.19,21771.61,There are no additional notes associated with this service or procedure.
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,306,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],31007.02,,,,,,0,other,12616.37,31007.02,There are no additional notes associated with this service or procedure.
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],32539.66,,"Case rate ($18,594.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,433.29, add-ons for qualifying new technology services are included. If operating cost exceeds $52,304.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,977.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $15,431.44 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,488.34 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,217.69. The transfer capital threshold is the transfer adjustment factor * $1,217.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,18594.09,59494.91,All Other Inpatient
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],8020.50,,"Case rate ($7,749.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,344.60, add-ons for qualifying new technology services are included. If operating cost exceeds $42,215.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,184.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,379.82 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,399.66 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $424.52. The transfer capital threshold is the transfer adjustment factor * $424.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6711.00,16865.16,Inpatient DRG
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,270,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],36456.95,,"Case rate ($34,720.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $32,431.98, add-ons for qualifying new technology services are included. If operating cost exceeds $71,076.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $5,156.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.4. The base transfer operating payment is the transfer adjustment factor * $30,933.64 + an uncompensated DSH payment of $1,359.91. The transfer operating threshold is the transfer adjustment factor * $31,072.08 + an uncompensated DSH payment of $1,359.91. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,427.36. The transfer capital threshold is the transfer adjustment factor * $2,427.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 105%.",,,,0,other,34720.90,101002.04,Inpatient DRG
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],16926.26,,"Case rate ($16,120.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,131.93, add-ons for qualifying new technology services are included. If operating cost exceeds $50,002.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,796.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $13,138.54 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,186.98 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,036.76. The transfer capital threshold is the transfer adjustment factor * $1,036.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,16120.25,41187.90,Inpatient DRG
CESAREAN SECTION WITHOUT STERILIZATION WITH MCC,786,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],12612.10,,"Fee schedule rate ($12,612.10). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12612.10,23722.94,There are no additional notes associated with this service or procedure.
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH MCC",510,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],49805.70,,"Fee schedule rate ($49,805.70). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10710.00,89863.76,There are no additional notes associated with this service or procedure.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],45706.73,,"Fee schedule rate ($45,706.73). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,7921.00,45706.73,There are no additional notes associated with this service or procedure.
"Arthrodesis Interphalangeal Jt W/WO Int Fixj|LEFT HAND, THUMB",CASE-26860,APC,26860,CPT,0360,RC,,,FA,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
Litholapaxy Smpl/Sm <2.5 Cm,CASE-52317,APC,52317,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3414.95,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3299.47,3464.44,OPPS APC
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],18782.86,,"Case rate ($10,733.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,120.35, add-ons for qualifying new technology services are included. If operating cost exceeds $44,991.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,402.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $8,145.37 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,175.40 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $642.75. The transfer capital threshold is the transfer adjustment factor * $642.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,10733.06,45157.33,All Other Inpatient
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],45549.84,,"Case rate ($26,028.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $24,349.34, add-ons for qualifying new technology services are included. If operating cost exceeds $59,220.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,521.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $22,322.08 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $22,404.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,761.43. The transfer capital threshold is the transfer adjustment factor * $1,761.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 175%.",,,,0,other,26028.48,80635.65,All Other Inpatient
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],42787.31,,"Fee schedule rate ($42,787.31). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,15476.23,42787.31,There are no additional notes associated with this service or procedure.
Biopsy Vaginal Mucosa Simple|UNUSUAL NON-OVERLAPPING SERVICE,CASE-57100,APC,57100,CPT,0360,RC,,,XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5941.70,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5658.76,5941.70,OPPS APC
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],6787.20,,"Fee schedule rate ($6,787.20). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6010.23,12246.05,There are no additional notes associated with this service or procedure.
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level|RIGHT SIDE,CASE-64483,APC,64483,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],856.86,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,827.89,869.28,OPPS APC
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC",494,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],39945.55,,"Fee schedule rate ($39,945.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,15533.10,39945.55,There are no additional notes associated with this service or procedure.
MAJOR CHEST TRAUMA WITHOUT CC/MCC,185,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],21771.61,,"Fee schedule rate ($21,771.61). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7271.19,21771.61,There are no additional notes associated with this service or procedure.
SPINAL PROCEDURES WITH MCC,028,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],120982.83,,"Fee schedule rate ($120,982.83). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,42633.57,120982.83,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,085,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],17330.41,,"Case rate ($17,330.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,257.72, add-ons for qualifying new technology services are included. If operating cost exceeds $51,128.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,885.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $14,260.20 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,312.77 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,125.27. The transfer capital threshold is the transfer adjustment factor * $1,125.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9282.00,57443.16,Inpatient DRG
OTHER MENTAL DISORDER DIAGNOSES,887,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],21072.10,,,,,,0,other,2070.00,21072.10,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],7948.33,,"Case rate ($7,569.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,177.66, add-ons for qualifying new technology services are included. If operating cost exceeds $42,048.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,171.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,213.49 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,232.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $411.40. The transfer capital threshold is the transfer adjustment factor * $411.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7569.84,21892.85,Inpatient DRG
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC,058,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],21719.15,,"Fee schedule rate ($21,719.15). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,13521.80,40853.02,There are no additional notes associated with this service or procedure.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC,027,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],56363.30,,"Fee schedule rate ($56,363.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,19030.20,56363.30,There are no additional notes associated with this service or procedure.
Exc Breast Les Preop Plmt Rad Marker Open 1 Les|LEFT SIDE,CASE-19125,APC,19125,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3793.21,,"APC Price ($3,664.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3664.94,3848.19,OPPS APC
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC",156,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],12987.84,,"Fee schedule rate ($12,987.84). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,6625.12,13598.77,There are no additional notes associated with this service or procedure.
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC",641,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],14928.67,,"Fee schedule rate ($14,928.67). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,7214.98,15312.64,There are no additional notes associated with this service or procedure.
VENTRICULAR SHUNT PROCEDURES WITH CC,032,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],16949.39,,"Case rate ($16,376.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,370.06, add-ons for qualifying new technology services are included. If operating cost exceeds $50,241.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,815.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $13,375.80 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,425.12 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,055.48. The transfer capital threshold is the transfer adjustment factor * $1,055.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,16376.22,46275.08,Inpatient DRG
Insertion Breast Implant Same Day of Mastectomy,CASE-19340,APC,19340,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7918.25,,"APC Price ($7,650.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,7650.49,8033.01,OPPS APC
HEART FAILURE AND SHOCK WITH CC,292,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],5502.00,,"Per diem ($5,502). If length of stay < 2.9, first 1 days paid at a per diem of $11,004 instead. Capped at $15,955.26.",,,,0,other,5502.00,16705.77,Estimated amount calculated based on 2 day length of stay.
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH MCC",722,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],56869.13,,"Fee schedule rate ($56,869.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,14200.37,56869.13,There are no additional notes associated with this service or procedure.
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],15333.48,,"Case rate ($14,603.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,720.75, add-ons for qualifying new technology services are included. If operating cost exceeds $48,591.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,685.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $11,732.54 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,775.80 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $925.81. The transfer capital threshold is the transfer adjustment factor * $925.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,14603.31,45017.13,Inpatient DRG
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],15785.75,,"Case rate ($15,476.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,532.81, add-ons for qualifying new technology services are included. If operating cost exceeds $49,403.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,749.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $12,541.62 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,587.86 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $989.66. The transfer capital threshold is the transfer adjustment factor * $989.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,15476.23,42787.31,Inpatient DRG
Cysto W/Simple Removal Stone & Stent|RIGHT SIDE,CASE-52310,APC,52310,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],2025.13,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1956.65,2054.48,OPPS APC
"PERIPHERAL AND OTHER VASCULAR DISORDERS,MAJOR",197,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],10944.13,,"Case rate ($10,944.13). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,10944.13,11491.34,There are no additional notes associated with this service or procedure.
PERIPHERAL VASCULAR DISORDERS WITH CC,300,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],20331.78,,"Fee schedule rate ($20,331.78). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,9174.14,21005.20,There are no additional notes associated with this service or procedure.
PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,337,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],38926.31,,"Fee schedule rate ($38,926.31). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,12340.08,38926.31,There are no additional notes associated with this service or procedure.
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],2070.00,,,,,,0,other,1188.00,31658.33,Estimated amount calculated based on 16 day length of stay.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],73588.10,,"Fee schedule rate ($73,588.10). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,21585.31,73588.10,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],11847.11,,"Fee schedule rate ($11,847.11). Adds an outlier to normal pricing equal to the per diem rate ($62,538.40) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9), with a minimum of zero.",,,,0,other,6214.05,15318.94,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH CC,427,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],53371.31,,"Case rate ($50,829.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $47,421.51, add-ons for qualifying new technology services are included. If operating cost exceeds $82,292.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $5,335.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $45,309.50 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $45,476.56 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,575.37. The transfer capital threshold is the transfer adjustment factor * $3,575.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,50829.82,142040.39,Inpatient DRG
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],19604.30,,"Fee schedule rate ($19,604.30). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9446.38,21796.21,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],10874.59,,"Case rate ($6,214.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,916.41, add-ons for qualifying new technology services are included. If operating cost exceeds $40,787.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,072.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $3,956.88 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,971.47 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $312.24. The transfer capital threshold is the transfer adjustment factor * $312.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,6214.05,15318.94,All Other Inpatient
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],9533.13,,"Fee schedule rate ($9,533.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5068.21,14525.56,There are no additional notes associated with this service or procedure.
HC Inj Trigger Pt 1-2 Musc Grps|PBB CHARGE|SEPARATE STRUCTURE,CASE-20552,APC,20552,CPT,0510,RC,,,PBB|XS,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],28983.97,,"Fee schedule rate ($28,983.97). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8956.76,28983.97,There are no additional notes associated with this service or procedure.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],45706.73,,"Fee schedule rate ($45,706.73). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,7921.00,45706.73,There are no additional notes associated with this service or procedure.
HC Inj Anesth Celiac Plexus,CASE-64530,APC,64530,CPT,0361,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],869.28,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,827.89,869.28,OPPS APC
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],11539.21,,"Case rate ($10,989.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,359.11, add-ons for qualifying new technology services are included. If operating cost exceeds $45,230.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,421.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $8,383.26 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,414.17 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $661.52. The transfer capital threshold is the transfer adjustment factor * $661.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10989.72,26280.60,Inpatient DRG
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],13960.40,,"Case rate ($13,295.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,504.24, add-ons for qualifying new technology services are included. If operating cost exceeds $47,375.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,590.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $10,520.50 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,559.29 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $830.17. The transfer capital threshold is the transfer adjustment factor * $830.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7000.00,33835.79,Inpatient DRG
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC,831,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],10290.12,,"Case rate ($10,088.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,520.59, add-ons for qualifying new technology services are included. If operating cost exceeds $44,391.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,355.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $7,547.82 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,575.65 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $595.60. The transfer capital threshold is the transfer adjustment factor * $595.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,4941.30,23661.59,Inpatient DRG
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],16373.54,,"Case rate ($9,356.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,839.58, add-ons for qualifying new technology services are included. If operating cost exceeds $43,710.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,302.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $6,869.30 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,894.63 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $542.06. The transfer capital threshold is the transfer adjustment factor * $542.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,9356.31,25026.36,All Other Inpatient
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,074,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],8925.60,,"Case rate ($8,925.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,438.90, add-ons for qualifying new technology services are included. If operating cost exceeds $43,309.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,270.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,470.10 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,493.95 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $510.55. The transfer capital threshold is the transfer adjustment factor * $510.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8925.60,20919.08,Inpatient DRG
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],31626.74,,"Fee schedule rate ($31,626.74). Adds an outlier to normal pricing equal to the per diem rate ($86,383.13) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,13341.67,42586.49,There are no additional notes associated with this service or procedure.
HC >= 12 Lead Ekg,CASE-93005,APC,93005,CPT,0730,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],55.22,,"APC Price ($55.22). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,55.22,57.98,OPPS APC
OTHER CEREBROVASCULAR DISORDERS WITH CC,071,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],16192.05,,"Fee schedule rate ($16,192.05). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5843.00,29215.10,There are no additional notes associated with this service or procedure.
INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC,198,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],23505.07,,"Fee schedule rate ($23,505.07). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6795.12,23505.07,There are no additional notes associated with this service or procedure.
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC",458,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],30840.69,,"Case rate ($29,372.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $27,511.01, add-ons for qualifying new technology services are included. If operating cost exceeds $62,382.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,717.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $25,469.49 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $25,566.06 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,957.64. The transfer capital threshold is the transfer adjustment factor * $1,957.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,30202.09,132827.25,Inpatient DRG
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],16393.83,,"Case rate ($15,613.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,685.70, add-ons for qualifying new technology services are included. If operating cost exceeds $49,556.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,735.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $12,692.63 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,740.75 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $975.59. The transfer capital threshold is the transfer adjustment factor * $975.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,11165.00,61234.06,Inpatient DRG
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],16229.42,,"Case rate ($15,456.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,514.54, add-ons for qualifying new technology services are included. If operating cost exceeds $49,385.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,748.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $12,523.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,569.59 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $988.22. The transfer capital threshold is the transfer adjustment factor * $988.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,15456.59,41402.42,Inpatient DRG
SALIVARY GLAND PROCEDURES,139,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],30690.92,,"Fee schedule rate ($30,690.92). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,10313.19,30690.92,There are no additional notes associated with this service or procedure.
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITH MCC,429,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],177294.98,,"Fee schedule rate ($177,294.98). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,62958.58,177294.98,There are no additional notes associated with this service or procedure.
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],29243.52,,"Fee schedule rate ($29,243.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,14343.25,36024.65,There are no additional notes associated with this service or procedure.
SKIN ULCERS WITH MCC,592,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],38644.05,,"Fee schedule rate ($38,644.05). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15), with a minimum of zero.",,,,0,other,15116.17,38644.05,There are no additional notes associated with this service or procedure.
PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,337,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],38926.31,,"Fee schedule rate ($38,926.31). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,12340.08,38926.31,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],13783.20,,"Case rate ($13,783.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,957.83, add-ons for qualifying new technology services are included. If operating cost exceeds $47,828.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,625.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $10,972.42 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,012.88 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $865.83. The transfer capital threshold is the transfer adjustment factor * $865.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,13783.20,41580.51,Inpatient DRG
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],37591.64,,"Fee schedule rate ($37,591.64). Adds an outlier to normal pricing equal to the per diem rate ($51,531) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.1), with a minimum of zero.",,,,0,other,15491.11,54180.83,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,447,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],156646.82,,"Fee schedule rate ($156,646.82). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,47193.21,156646.82,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],9221.53,,"Case rate ($9,040.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,546, add-ons for qualifying new technology services are included. If operating cost exceeds $43,417.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,278.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,576.80 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,601.05 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $518.97. The transfer capital threshold is the transfer adjustment factor * $518.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,9040.72,26966.33,Inpatient DRG
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,477,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],62359.39,,"Fee schedule rate ($62,359.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,25339.74,67976.16,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],7127.04,,"Case rate ($6,787.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,450.02, add-ons for qualifying new technology services are included. If operating cost exceeds $41,321.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,114.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,488.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,505.07 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $354.19. The transfer capital threshold is the transfer adjustment factor * $354.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6164.03,14071.02,Inpatient DRG
HC Joint Injection/Aspir Large WO US|BILATERAL PROCEDURE,CASE-20610,APC,20610,CPT,0510,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],301.68,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,287.31,301.68,OPPS APC
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],13615.26,,"Fee schedule rate ($13,615.26). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,12775.53,31469.43,There are no additional notes associated with this service or procedure.
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],14908.05,,"Case rate ($14,908.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,004.25, add-ons for qualifying new technology services are included. If operating cost exceeds $48,875.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,708.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $12,014.99 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,059.30 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $948.10. The transfer capital threshold is the transfer adjustment factor * $948.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,14908.05,49717.39,Inpatient DRG
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],22011.24,,"Fee schedule rate ($22,011.24). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,15456.59,41402.42,There are no additional notes associated with this service or procedure.
Rpr/Advmnt Flxr Tdn Zone 2 W/O Fr Grft Ea Tendon,CASE-26356,APC,26356,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
Esophagogastroduodenoscopy Submucosal Injection|SEPARATE STRUCTURE,CASE-43236,APC,43236,CPT,0360,RC,,,XS,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1796.14,,"APC Price ($1,796.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1796.14,1885.95,OPPS APC
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],28423.20,,"Fee schedule rate ($28,423.20). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11059.47,28423.20,There are no additional notes associated with this service or procedure.
Endoscopic Papilla Cannulation Bile/Pancreatic,CASE-43273,APC,43273,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3608.81,,"APC Price ($3,608.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3608.81,3789.26,OPPS APC
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",062,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],14170.07,,"Case rate ($13,495.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,711.54, add-ons for qualifying new technology services are included. If operating cost exceeds $47,582.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,584.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $10,725.92 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,766.59 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $824.42. The transfer capital threshold is the transfer adjustment factor * $824.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13844.84,44304.80,Inpatient DRG
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],21918.93,,"Case rate ($21,489.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $20,126.50, add-ons for qualifying new technology services are included. If operating cost exceeds $54,997.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,189.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.6. The base transfer operating payment is the transfer adjustment factor * $18,114.76 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $18,181.55 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,429.43. The transfer capital threshold is the transfer adjustment factor * $1,429.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,21489.15,68942.79,Inpatient DRG
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC",061,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],54251.46,,,,,,0,other,20616.23,62315.82,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],42768.36,,"Fee schedule rate ($42,768.36). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,14295.18,42768.36,There are no additional notes associated with this service or procedure.
DIABETES WITH CC,638,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],8414.77,,"Case rate ($8,014.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,590.93, add-ons for qualifying new technology services are included. If operating cost exceeds $42,461.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,203.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,625.24 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,645.98 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $443.89. The transfer capital threshold is the transfer adjustment factor * $443.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8014.07,17634.53,Inpatient DRG
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],51903.64,,"Fee schedule rate ($51,903.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,16017.99,51903.64,There are no additional notes associated with this service or procedure.
Tr/Trnspl Tdn Carp/Mtcrpl Hand W/O Fr Grf Ea Tdn,CASE-26480,APC,26480,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
Cysto Bladder W/Ureteral Catheterization|RIGHT SIDE,CASE-52005,APC,52005,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1956.65,,"APC Price ($1,956.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1956.65,2054.48,OPPS APC
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],11065.78,,"Fee schedule rate ($11,065.78). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5883.03,17111.12,There are no additional notes associated with this service or procedure.
Rpr Nonunion Scaphoid Carpal Bne W/WO Rdl Stylec|RIGHT SIDE,CASE-25440,APC,25440,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7029.71,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6791.99,7029.71,OPPS APC
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,097,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],27328.47,,"Case rate ($26,404.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $24,698.97, add-ons for qualifying new technology services are included. If operating cost exceeds $59,569.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,548.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.7. The base transfer operating payment is the transfer adjustment factor * $22,670.44 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $22,754.03 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,788.92. The transfer capital threshold is the transfer adjustment factor * $1,788.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,26404.32,79915.74,Inpatient DRG
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],8372.32,,"Case rate ($8,372.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,924.20, add-ons for qualifying new technology services are included. If operating cost exceeds $42,795.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,230.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,957.28 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,979.25 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $470.09. The transfer capital threshold is the transfer adjustment factor * $470.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,23385.72,Inpatient DRG
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],30977.50,,,,,,0,other,12606.23,36868.88,There are no additional notes associated with this service or procedure.
CERVICAL SPINAL FUSION WITH MCC,471,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],34645.26,,"Case rate ($34,645.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $32,365.35, add-ons for qualifying new technology services are included. If operating cost exceeds $67,236.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,151.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $30,308.64 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $30,420.39 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,391.65. The transfer capital threshold is the transfer adjustment factor * $2,391.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,34645.26,111337.93,Inpatient DRG
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],19661.25,,"Fee schedule rate ($19,661.25). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,16428.39,42083.20,There are no additional notes associated with this service or procedure.
HC Inj Lympho for Sentinal Node,CASE-38792,APC,38792,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6215.36,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6215.36,6526.12,OPPS APC
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],48961.48,,"Fee schedule rate ($48,961.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11575.50,48961.48,There are no additional notes associated with this service or procedure.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,270,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],101002.04,,,,,,0,other,34720.90,101002.04,There are no additional notes associated with this service or procedure.
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],12526.44,,"Fee schedule rate ($12,526.44). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5415.00,17575.50,There are no additional notes associated with this service or procedure.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],18587.22,,"Case rate ($17,702.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,632.90, add-ons for qualifying new technology services are included. If operating cost exceeds $51,503.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,884.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $14,632.47 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,687.95 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,124.69. The transfer capital threshold is the transfer adjustment factor * $1,124.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,18178.96,54764.34,Inpatient DRG
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],7147.93,,"Case rate ($7,147.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,785.17, add-ons for qualifying new technology services are included. If operating cost exceeds $41,656.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,140.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $4,822.44 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,840.22 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $380.54. The transfer capital threshold is the transfer adjustment factor * $380.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,16400.70,Inpatient DRG
Laps Surg Cholecystectomy W/Cholangiography|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-47563,APC,47563,CPT,0360,RC,,,74,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],5658.76,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5658.76,5941.70,OPPS APC
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],12827.65,,"Case rate ($12,216.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,519.81, add-ons for qualifying new technology services are included. If operating cost exceeds $46,390.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,493.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $9,538.70 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,574.86 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $733.17. The transfer capital threshold is the transfer adjustment factor * $733.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12527.66,29917.96,Inpatient DRG
"MAJOR LARGE BOWEL PROCEDURES,EXTREME",231,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],45476.07,,"Case rate ($43,310.54). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,43310.54,45476.07,There are no additional notes associated with this service or procedure.
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|LEFT HAND, THUMB",CASE-26160,APC,26160,CPT,0360,RC,,,FA,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1557.80,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1505.12,1580.37,OPPS APC
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],67460.63,,,,,,0,other,25162.32,75579.22,There are no additional notes associated with this service or procedure.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],58320.32,,"Fee schedule rate ($58,320.32). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,16286.16,58320.32,There are no additional notes associated with this service or procedure.
"KNEE AND LOWER LEG PROCEDURES EXCEPT FOOT,MODERATE",313,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],20171.42,,"Case rate ($19,210.88). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,19210.88,20171.42,There are no additional notes associated with this service or procedure.
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC",758,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],16323.02,,"Fee schedule rate ($16,323.02). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8574.80,19263.78,There are no additional notes associated with this service or procedure.
HC Joint Injection/Aspir Large WO US|PBB CHARGE|BILATERAL PROCEDURE,CASE-20610,APC,20610,CPT,0510,RC,,,PBB|50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],301.68,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,287.31,301.68,OPPS APC
HC Inject Tendon Origin/Insert|RIGHT SIDE,CASE-20551,APC,20551,CPT,0361,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],18918.49,,"Fee schedule rate ($18,918.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9282.47,21320.03,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,690,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],14625.55,,"Fee schedule rate ($14,625.55). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7426.94,15928.53,There are no additional notes associated with this service or procedure.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],13035.75,,"Fee schedule rate ($13,035.75). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10517.71,24909.11,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],21167.26,,"Fee schedule rate ($21,167.26). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,6841.83,21167.26,There are no additional notes associated with this service or procedure.
FRACTURES OF FEMUR WITH MCC,533,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],49490.05,,"Fee schedule rate ($49,490.05). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,6852.00,49490.05,There are no additional notes associated with this service or procedure.
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],16035.06,,"Fee schedule rate ($16,035.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,7396.47,16035.06,There are no additional notes associated with this service or procedure.
Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level|BILATERAL PROCEDURE,CASE-64483,APC,64483,CPT,0360,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],856.86,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,827.89,869.28,OPPS APC
"DIVERTICULITIS AND DIVERTICULOSIS,MAJOR",244,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],11621.42,,"Case rate ($11,068.02). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11068.02,11621.42,There are no additional notes associated with this service or procedure.
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],13289.94,,"Case rate ($12,840.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,080.88, add-ons for qualifying new technology services are included. If operating cost exceeds $46,951.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,556.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $10,098.70 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,135.93 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $796.89. The transfer capital threshold is the transfer adjustment factor * $796.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,1188.00,31658.33,Inpatient DRG
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],24444.75,,"Fee schedule rate ($24,444.75). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10136.44,24444.75,There are no additional notes associated with this service or procedure.
PERIPHERAL VASCULAR DISORDERS WITH CC,300,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],20331.78,,"Fee schedule rate ($20,331.78). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,9174.14,21005.20,There are no additional notes associated with this service or procedure.
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],12526.44,,"Fee schedule rate ($12,526.44). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,5415.00,17575.50,There are no additional notes associated with this service or procedure.
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],9497.85,,"Case rate ($9,311.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,798, add-ons for qualifying new technology services are included. If operating cost exceeds $43,669.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,298.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $6,827.87 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,853.05 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $538.79. The transfer capital threshold is the transfer adjustment factor * $538.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6965.00,21404.64,Inpatient DRG
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],6640.88,,"Case rate ($6,324.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,027.46, add-ons for qualifying new technology services are included. If operating cost exceeds $40,898.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,072.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $4,067.09 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,082.51 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $312.61. The transfer capital threshold is the transfer adjustment factor * $312.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5139.72,13110.79,Inpatient DRG
"OPEN CRANIOTOMY EXCEPT TRAUMA,MODERATE",021,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],30857.78,,"Case rate ($30,857.78). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,30857.78,32400.67,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],31693.30,,"Case rate ($31,693.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $29,619.21, add-ons for qualifying new technology services are included. If operating cost exceeds $64,490.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,935.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. The base transfer operating payment is the transfer adjustment factor * $27,572.60 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $27,674.26 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,175.75. The transfer capital threshold is the transfer adjustment factor * $2,175.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10862.00,86437.13,Inpatient DRG
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],15653.45,,"Case rate ($14,908.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,004.25, add-ons for qualifying new technology services are included. If operating cost exceeds $48,875.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,708.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $12,014.99 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,059.30 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $948.10. The transfer capital threshold is the transfer adjustment factor * $948.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,14908.05,49717.39,Inpatient DRG
"Tendon Sheath Incision|LEFT HAND, FIFTH DIGIT",CASE-26055,APC,26055,CPT,0360,RC,,,F4,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1557.80,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1505.12,1580.37,OPPS APC
O.R. PROCEDURES FOR OBESITY WITH CC,620,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],30074.44,,"Fee schedule rate ($30,074.44). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7.8), with a minimum of zero.",,,,0,other,12782.30,43753.50,There are no additional notes associated with this service or procedure.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],52909.62,,"Fee schedule rate ($52,909.62). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,23344.70,62179.32,There are no additional notes associated with this service or procedure.
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],24444.75,,"Fee schedule rate ($24,444.75). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10136.44,24444.75,There are no additional notes associated with this service or procedure.
Open Tx Carpal Scaphoid Navicular Fracture|RIGHT SIDE,CASE-25628,APC,25628,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,7029.71,7131.59,OPPS APC
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],81306.30,,"Fee schedule rate ($81,306.30). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,20846.48,81306.30,There are no additional notes associated with this service or procedure.
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],38839.49,,"Fee schedule rate ($38,839.49). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.6), with a minimum of zero.",,,,0,other,15940.79,53275.26,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,066,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],20083.61,,"Fee schedule rate ($20,083.61). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6579.76,20083.61,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],31533.97,,"Fee schedule rate ($31,533.97). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8563.30,31533.97,There are no additional notes associated with this service or procedure.
SIGNS AND SYMPTOMS WITH MCC,947,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],11068.48,,"Case rate ($10,541.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,942.06, add-ons for qualifying new technology services are included. If operating cost exceeds $44,813.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,388.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $7,967.73 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,997.11 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $628.73. The transfer capital threshold is the transfer adjustment factor * $628.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10541.41,30414.32,Inpatient DRG
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,097,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],79915.74,,"Fee schedule rate ($79,915.74). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,26404.32,79915.74,There are no additional notes associated with this service or procedure.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC,858,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],11377.76,,"Case rate ($11,377.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,720.10, add-ons for qualifying new technology services are included. If operating cost exceeds $45,591.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,449.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $8,742.91 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,775.15 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $689.90. The transfer capital threshold is the transfer adjustment factor * $689.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,11377.76,33794.11,Inpatient DRG
Rpr Ingun Hernia Sliding Any Age|LEFT SIDE,CASE-49525,APC,49525,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3468.64,,"APC Price ($3,351.34). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3468.64,3468.64,OPPS APC
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],8943.17,,"Case rate ($8,767.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,292.11, add-ons for qualifying new technology services are included. If operating cost exceeds $43,163.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,258.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,323.85 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,347.16 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $499.01. The transfer capital threshold is the transfer adjustment factor * $499.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,8767.81,19824.58,Inpatient DRG
Egd Flexible Foreign Body Removal,CASE-43247,APC,43247,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1796.14,,"APC Price ($1,796.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1796.14,1885.95,OPPS APC
CESAREAN SECTION WITH STERILIZATION WITH CC,784,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],23722.94,,"Fee schedule rate ($23,722.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9124.01,23722.94,There are no additional notes associated with this service or procedure.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],13149.46,,"Fee schedule rate ($13,149.46). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.9), with a minimum of zero.",,,,0,other,6683.37,14699.43,There are no additional notes associated with this service or procedure.
"NEONATE BIRTH WEIGHT > 2499 GRAMS WITH MAJOR ANOMALY,MINOR",633,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],2014.61,,"Case rate ($1,918.68). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,1918.68,2014.61,There are no additional notes associated with this service or procedure.
MINOR BLADDER PROCEDURES WITHOUT CC/MCC,664,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],17667.30,,"Fee schedule rate ($17,667.30). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9034.63,31876.87,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],24328.96,,"Case rate ($23,851.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $22,324.54, add-ons for qualifying new technology services are included. If operating cost exceeds $57,195.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,362.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.8. The base transfer operating payment is the transfer adjustment factor * $20,304.73 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $20,379.59 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,602.24. The transfer capital threshold is the transfer adjustment factor * $1,602.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,23851.92,63653.13,Inpatient DRG
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],6892.39,,"Case rate ($6,564.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,242.12, add-ons for qualifying new technology services are included. If operating cost exceeds $41,113.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,097.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $4,281.39 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,297.17 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $337.84. The transfer capital threshold is the transfer adjustment factor * $337.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6564.18,17651.07,Inpatient DRG
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],47123.82,,"Fee schedule rate ($47,123.82). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,12696.97,47123.82,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,085,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],57443.16,,"Fee schedule rate ($57,443.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,9282.00,57443.16,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],9370.00,,"Per diem ($9,370). If length of stay < 6.7, first 1 days paid at a per diem of $18,740 instead. Capped at $62,779.90.",,,,0,other,9370.00,65732.99,Estimated amount calculated based on 3 day length of stay.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],11593.79,,"Case rate ($11,593.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,921.06, add-ons for qualifying new technology services are included. If operating cost exceeds $45,792.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,465.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $8,943.14 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,976.12 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $705.70. The transfer capital threshold is the transfer adjustment factor * $705.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,11593.79,38248.08,Inpatient DRG
Open Tx Clavicular Fracture Internal Fixation|LEFT SIDE,CASE-23515,APC,23515,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7029.71,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6791.99,7131.59,OPPS APC
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],18671.22,,"Case rate ($17,782.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,677.93, add-ons for qualifying new technology services are included. If operating cost exceeds $51,548.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,918.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $14,678.86 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,732.98 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,158.31. The transfer capital threshold is the transfer adjustment factor * $1,158.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,17782.11,46523.26,Inpatient DRG
"MAJOR LARGE BOWEL PROCEDURES,EXTREME",231,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],43310.54,,"Case rate ($43,310.54). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,43310.54,45476.07,There are no additional notes associated with this service or procedure.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],23520.23,,"Fee schedule rate ($23,520.23). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10517.71,24909.11,There are no additional notes associated with this service or procedure.
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,450,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],104870.54,,,,,,0,other,38037.38,146009.19,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],28253.40,,"Fee schedule rate ($28,253.40). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,12126.09,29582.40,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,066,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],20083.61,,"Fee schedule rate ($20,083.61). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6579.76,20083.61,There are no additional notes associated with this service or procedure.
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",004,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],260309.36,,"Fee schedule rate ($260,309.36). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (35), with a minimum of zero.",,,,0,other,10249.47,272554.00,There are no additional notes associated with this service or procedure.
Bx/Exc Lymph Node Open Deep Axillary Node|BILATERAL PROCEDURE,CASE-38525,APC,38525,CPT,0360,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6432.89,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6215.36,6526.12,OPPS APC
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],19010.30,,"Case rate ($18,105.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,008.50, add-ons for qualifying new technology services are included. If operating cost exceeds $51,879.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,913.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $15,006.65 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,063.55 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,153.45. The transfer capital threshold is the transfer adjustment factor * $1,153.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,18594.09,59494.91,Inpatient DRG
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],38248.08,,"Fee schedule rate ($38,248.08). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11593.79,38248.08,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITH CC,386,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],11017.65,,"Fee schedule rate ($11,017.65). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8556.53,19879.00,There are no additional notes associated with this service or procedure.
SINGLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL,402,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],29172.05,,"Case rate ($29,172.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $27,273.75, add-ons for qualifying new technology services are included. If operating cost exceeds $62,144.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,751.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $25,235.76 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $25,328.80 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,991.35. The transfer capital threshold is the transfer adjustment factor * $1,991.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,29172.05,124455.45,Inpatient DRG
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],23316.48,,"Fee schedule rate ($23,316.48). Adds an outlier to normal pricing equal to the per diem rate ($44,995.76) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7.7), with a minimum of zero.",,,,0,other,10347.06,28821.04,There are no additional notes associated with this service or procedure.
HC Inj Anesth Celiac Plexus,CASE-64530,APC,64530,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],827.89,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,827.89,869.28,OPPS APC
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,064,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],37792.72,,"Fee schedule rate ($37,792.72). Adds an outlier to normal pricing equal to the per diem rate ($115,085.88) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,15563.58,41838.16,There are no additional notes associated with this service or procedure.
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],10626.74,,"Case rate ($10,626.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,021.44, add-ons for qualifying new technology services are included. If operating cost exceeds $44,892.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,394.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $8,046.82 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,076.49 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $634.97. The transfer capital threshold is the transfer adjustment factor * $634.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10626.74,25225.91,Inpatient DRG
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],27589.62,,"Fee schedule rate ($27,589.62). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,12566.28,30861.41,There are no additional notes associated with this service or procedure.
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC,520,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],12302.97,,"Case rate ($12,061.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,356.39, add-ons for qualifying new technology services are included. If operating cost exceeds $46,227.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,499.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $9,376.87 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,411.44 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $739.93. The transfer capital threshold is the transfer adjustment factor * $739.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,12061.74,39786.42,Inpatient DRG
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],19015.13,,"Case rate ($18,109.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,012.79, add-ons for qualifying new technology services are included. If operating cost exceeds $51,883.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,913.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 5.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $15,010.92 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,067.84 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,153.77. The transfer capital threshold is the transfer adjustment factor * $1,153.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,18598.83,48389.68,Inpatient DRG
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],28615.65,,"Fee schedule rate ($28,615.65). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,20559.34,54086.17,There are no additional notes associated with this service or procedure.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],52909.62,,"Fee schedule rate ($52,909.62). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,23344.70,62179.32,There are no additional notes associated with this service or procedure.
Dstr Nrolytc Agnt Parverteb Fct Addl Lmbr/Sacral,CASE-64636,APC,64636,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1919.19,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1827.80,1919.19,OPPS APC
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC,807,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],10071.17,,"Fee schedule rate ($10,071.17). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5354.25,13266.23,There are no additional notes associated with this service or procedure.
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,068,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],6965.00,,,,,,0,other,6965.00,23184.90,There are no additional notes associated with this service or procedure.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,056,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],7659.00,,"Per diem ($7,659). If length of stay < 5.7, first 1 days paid at a per diem of $15,318 instead. Capped at $43,658.02.",,,,0,other,7659.00,59328.19,Estimated amount calculated based on 3 day length of stay.
"Amputation Toe Interphalangeal Joint|RIGHT FOOT, SECOND DIGIT",CASE-28825,APC,28825,CPT,0360,RC,,,T6,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],107110.70,,"Fee schedule rate ($107,110.70). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (21), with a minimum of zero.",,,,0,other,40542.37,128358.13,There are no additional notes associated with this service or procedure.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],19877.10,,"Fee schedule rate ($19,877.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8009.34,19877.10,There are no additional notes associated with this service or procedure.
Bx/Exc Lymph Node Open Deep Axillary Node,CASE-38525,APC,38525,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3793.21,,"APC Price ($3,664.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3664.94,3848.19,OPPS APC
"UTERINE AND ADNEXA PROCEDURES FOR LEIOMYOMA,MODERATE",519,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],4868.92,,"Case rate for a one day stay ($4,637.07). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4637.07,4868.92,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],45183.60,,"Fee schedule rate ($45,183.60). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,8972.00,81524.17,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],19371.27,,"Fee schedule rate ($19,371.27). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7641.61,19371.27,There are no additional notes associated with this service or procedure.
HC Joint Injection/Aspir Large WO US|LEFT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-20610,APC,20610,CPT,0510,RC,,,LT|XU,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
HC Perq Vert Agmntj Cavity Crtj Uni/Bi Cannulation,CASE-22513,APC,22513,CPT,0361,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7029.71,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6791.99,7131.59,OPPS APC
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],19126.88,,"Fee schedule rate ($19,126.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,19126.88,There are no additional notes associated with this service or procedure.
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC,058,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],40853.02,,"Fee schedule rate ($40,853.02). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,13521.80,40853.02,There are no additional notes associated with this service or procedure.
"Inj Dx/Ther Agnt Paravert Facet Joint, Cerv/Thorac, 2nd Level|LEFT SIDE",CASE-64491,APC,64491,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],827.89,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,827.89,869.28,OPPS APC
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],22911.82,,"Case rate ($13,092.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,315.24, add-ons for qualifying new technology services are included. If operating cost exceeds $47,186.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,575.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $10,332.19 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,370.29 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $815.31. The transfer capital threshold is the transfer adjustment factor * $815.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,13092.47,33159.45,All Other Inpatient
HC Inj Anesth Celiac Plexus,CASE-64530,APC,64530,CPT,0361,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],827.89,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,827.89,869.28,OPPS APC
COAGULATION DISORDERS,813,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],28664.96,,"Fee schedule rate ($28,664.96). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.7), with a minimum of zero.",,,,0,other,12274.39,30013.33,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],30372.64,,"Fee schedule rate ($30,372.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,13260.40,32878.30,There are no additional notes associated with this service or procedure.
Laps Gastric Restrictive Px Remove Device & Port,CASE-43774,APC,43774,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3608.81,,"APC Price ($3,608.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3608.81,3789.26,OPPS APC
Laps Fulg/Exc Ovary Viscera/Peritoneal Surface|BILATERAL PROCEDURE,CASE-58662,APC,58662,CPT,0360,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5941.70,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5658.76,5941.70,OPPS APC
Cysto W/Removal of Tumors Small,CASE-52234,APC,52234,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3414.95,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3299.47,3464.44,OPPS APC
Suture Infrapatellar Tendon Primary|BILATERAL PROCEDURE,CASE-27380,APC,27380,CPT,0360,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6791.99,7131.59,OPPS APC
Redo Excis Lumbar Disk|SEPARATE STRUCTURE,CASE-63042,APC,63042,CPT,0360,RC,,,XS,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],26668.00,,"APC Price ($25,398.09). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,25398.09,26668.00,OPPS APC
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],96365.69,,"Fee schedule rate ($96,365.69). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,23377.19,96365.69,There are no additional notes associated with this service or procedure.
"LIMB REATTACHMENT, HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA",956,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],70718.06,,"Fee schedule rate ($70,718.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,27428.25,148259.86,There are no additional notes associated with this service or procedure.
CHOLECYSTECTOMY WITH C.D.E. WITH MCC,411,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],62078.92,,"Fee schedule rate ($62,078.92). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15), with a minimum of zero.",,,,0,other,24315.13,88615.28,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6431.54,,"Case rate ($6,214.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,916.41, add-ons for qualifying new technology services are included. If operating cost exceeds $40,787.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,072.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $3,956.88 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,971.47 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $312.24. The transfer capital threshold is the transfer adjustment factor * $312.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6214.05,15318.94,Inpatient DRG
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],49717.39,,"Fee schedule rate ($49,717.39). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,14908.05,49717.39,There are no additional notes associated with this service or procedure.
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],9533.13,,"Fee schedule rate ($9,533.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5068.21,14525.56,There are no additional notes associated with this service or procedure.
HC Joint Injection/Aspir Large WO US|LEFT SIDE,CASE-20610,APC,20610,CPT,0510,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],301.68,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,287.31,301.68,OPPS APC
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],45157.33,,"Fee schedule rate ($45,157.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,10733.06,45157.33,There are no additional notes associated with this service or procedure.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],27120.18,,"Fee schedule rate ($27,120.18). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,11717.72,43888.01,There are no additional notes associated with this service or procedure.
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6801.88,,"Case rate ($6,801.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,463.25, add-ons for qualifying new technology services are included. If operating cost exceeds $41,334.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,115.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,501.70 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,518.30 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $355.23. The transfer capital threshold is the transfer adjustment factor * $355.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6801.88,22557.82,Inpatient DRG
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],10243.65,,"Case rate ($9,755.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,211.27, add-ons for qualifying new technology services are included. If operating cost exceeds $44,082.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,331.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $7,239.63 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,266.32 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $571.28. The transfer capital threshold is the transfer adjustment factor * $571.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9755.86,29216.99,Inpatient DRG
OTHER DISORDERS OF NERVOUS SYSTEM WITH CC,092,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],26765.51,,"Fee schedule rate ($26,765.51). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8872.78,26765.51,There are no additional notes associated with this service or procedure.
Exc B9 Lesion Mrgn Xcp Sk Tg S/N/H/F/G 3.1-4.0cm,CASE-11424,APC,11424,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1827.80,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1827.80,1919.19,OPPS APC
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],34570.85,,"Fee schedule rate ($34,570.85). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,6965.00,36140.75,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,448,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],79697.35,,"Fee schedule rate ($79,697.35). Adds an outlier to normal pricing equal to the per diem rate ($108,215.07) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,30663.95,94077.13,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],86252.84,,"Fee schedule rate ($86,252.84). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (25), with a minimum of zero.",,,,0,other,27944.96,86252.84,There are no additional notes associated with this service or procedure.
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",759,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6438.90,,"Case rate ($6,438.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,125.57, add-ons for qualifying new technology services are included. If operating cost exceeds $40,996.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,088.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,165.27 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,180.62 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $328.68. The transfer capital threshold is the transfer adjustment factor * $328.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6190.22,13057.66,Inpatient DRG
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],22626.77,,"Fee schedule rate ($22,626.77). Adds an outlier to normal pricing equal to the per diem rate ($36,883.74) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.5), with a minimum of zero.",,,,0,other,10098.51,24259.09,There are no additional notes associated with this service or procedure.
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",623,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],32096.64,,"Fee schedule rate ($32,096.64). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,14093.37,33712.76,There are no additional notes associated with this service or procedure.
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],33835.79,,"Fee schedule rate ($33,835.79). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,7000.00,33835.79,There are no additional notes associated with this service or procedure.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,352,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],26528.70,,"Fee schedule rate ($26,528.70). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,9853.37,26528.70,There are no additional notes associated with this service or procedure.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,057,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],11094.00,,"Case rate ($10,718.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,107.12, add-ons for qualifying new technology services are included. If operating cost exceeds $44,978.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,401.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,132.18 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,162.17 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $641.71. The transfer capital threshold is the transfer adjustment factor * $641.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,10718.84,39884.93,Inpatient DRG
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],22487.70,,"Fee schedule rate ($22,487.70). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,10048.39,23545.50,There are no additional notes associated with this service or procedure.
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],11974.38,,"Case rate ($11,974.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,275.12, add-ons for qualifying new technology services are included. If operating cost exceeds $46,146.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,493.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $9,295.90 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,330.17 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $733.54. The transfer capital threshold is the transfer adjustment factor * $733.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,11974.38,29141.64,Inpatient DRG
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],11855.89,,"Case rate ($11,454.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,791.92, add-ons for qualifying new technology services are included. If operating cost exceeds $45,662.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,455.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $8,814.47 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,846.97 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $695.55. The transfer capital threshold is the transfer adjustment factor * $695.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,11454.97,28394.78,Inpatient DRG
TRAUMATIC INJURY WITH MCC,913,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],13323.90,,"Case rate ($12,689.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,960.36, add-ons for qualifying new technology services are included. If operating cost exceeds $46,831.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,526.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $9,977.58 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,015.41 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $766.90. The transfer capital threshold is the transfer adjustment factor * $766.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13014.58,42838.46,Inpatient DRG
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],27553.62,,"Fee schedule rate ($27,553.62). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12305.53,30103.84,There are no additional notes associated with this service or procedure.
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],18862.20,,"Fee schedule rate ($18,862.20). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,15233.11,38610.21,There are no additional notes associated with this service or procedure.
COAGULATION DISORDERS,813,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],12888.11,,"Case rate ($12,274.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,554.21, add-ons for qualifying new technology services are included. If operating cost exceeds $46,425.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,515.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $9,573.96 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,609.26 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $755.48. The transfer capital threshold is the transfer adjustment factor * $755.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12274.39,30013.33,Inpatient DRG
HC App Skin Sub Other Tot <100 1st 25,CASE-15275,APC,15275,CPT,0361,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1557.80,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1505.12,1557.80,OPPS APC
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],32293.66,,"Fee schedule rate ($32,293.66). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,32293.66,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],31401.22,,"Fee schedule rate ($31,401.22). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.7), with a minimum of zero.",,,,0,other,13260.40,32878.30,There are no additional notes associated with this service or procedure.
Exc Tumor Soft Tis Neck/Ant Thorax Subq 3 Cm/>,CASE-21552,APC,21552,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],2814.04,,"APC Price ($2,718.88). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,2718.88,2854.83,OPPS APC
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],24703.21,,"Case rate ($23,526.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $22,022.15, add-ons for qualifying new technology services are included. If operating cost exceeds $56,893.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,338.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.7. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.7)) / 2. The base transfer operating payment is the transfer adjustment factor * $20,003.44 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $20,077.20 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,578.47. The transfer capital threshold is the transfer adjustment factor * $1,578.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,23526.87,94787.57,Inpatient DRG
CESAREAN SECTION WITHOUT STERILIZATION WITH MCC,786,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],23722.94,,"Fee schedule rate ($23,722.94). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12612.10,23722.94,There are no additional notes associated with this service or procedure.
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],13625.25,,"Fee schedule rate ($13,625.25). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7243.75,23262.15,There are no additional notes associated with this service or procedure.
Rinsj Rptd Biceps/Triceps Tdn Dstl W/WO Tdn Grf|LEFT SIDE,CASE-24342,APC,24342,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6791.99,7131.59,OPPS APC
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,091,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],13838.06,,"Case rate ($13,838.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,008.86, add-ons for qualifying new technology services are included. If operating cost exceeds $47,879.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,629.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $11,023.26 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,063.91 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $869.84. The transfer capital threshold is the transfer adjustment factor * $869.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,13838.06,40030.81,Inpatient DRG
HC Joint Injection/Aspir Large WO US|PBB CHARGE|LEFT SIDE,CASE-20610,APC,20610,CPT,0510,RC,,,PBB|LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],301.68,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,287.31,301.68,OPPS APC
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],17506.49,,"Case rate ($10,003.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,441.84, add-ons for qualifying new technology services are included. If operating cost exceeds $44,312.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,349.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $7,469.36 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,496.90 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $589.41. The transfer capital threshold is the transfer adjustment factor * $589.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,10003.71,23415.63,All Other Inpatient
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITHOUT MCC,430,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],133156.90,,"Fee schedule rate ($133,156.90). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,41000.16,133156.90,There are no additional notes associated with this service or procedure.
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],24092.63,,"Fee schedule rate ($24,092.63). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10626.74,25225.91,There are no additional notes associated with this service or procedure.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],16447.34,,"Case rate ($16,447.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,436.22, add-ons for qualifying new technology services are included. If operating cost exceeds $50,307.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,820.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $13,441.70 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,491.27 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,060.68. The transfer capital threshold is the transfer adjustment factor * $1,060.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7453.00,42138.30,Inpatient DRG
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],11677.97,,"Fee schedule rate ($11,677.97). Adds an outlier to normal pricing equal to the per diem rate ($67,650.85) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.7), with a minimum of zero.",,,,0,other,6153.12,13947.32,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],28038.61,,"Fee schedule rate ($28,038.61). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12126.09,29582.40,There are no additional notes associated with this service or procedure.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],105091.76,,"Fee schedule rate ($105,091.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,35719.96,105091.76,There are no additional notes associated with this service or procedure.
Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq|SEPARATE STRUCTURE|COLORECTAL CANCER SCREEN,CASE-45385,APC,45385,CPT,0360,RC,,,XS|PT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1120.09,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1120.09,1176.09,OPPS APC
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],15547.06,,"Fee schedule rate ($15,547.06). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,14343.25,36024.65,There are no additional notes associated with this service or procedure.
Cysto W/Urtroscopy&/Pyeloscopy Dx|RIGHT SIDE,CASE-52351,APC,52351,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3414.95,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3299.47,3464.44,OPPS APC
HC Joint Injection/Aspir Medium WO US|PBB CHARGE,CASE-20605,APC,20605,CPT,0510,RC,,,PBB,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],287.31,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
Excision Pilonidal Cyst/Sinus Extensive,CASE-11771,APC,11771,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],2854.83,,"APC Price ($2,718.88). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2814.04,2854.83,OPPS APC
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],21675.85,,"Fee schedule rate ($21,675.85). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,9755.86,29216.99,There are no additional notes associated with this service or procedure.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],72246.07,,,,,,0,other,26809.29,97015.50,There are no additional notes associated with this service or procedure.
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],36868.88,,"Fee schedule rate ($36,868.88). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,12606.23,36868.88,There are no additional notes associated with this service or procedure.
SPINAL PROCEDURES WITHOUT CC/MCC,030,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],16810.99,,"Case rate ($16,810.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,774.52, add-ons for qualifying new technology services are included. If operating cost exceeds $50,645.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,847.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $13,778.77 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,829.57 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,087.28. The transfer capital threshold is the transfer adjustment factor * $1,087.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,16810.99,44714.01,Inpatient DRG
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,082,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],56223.11,,"Fee schedule rate ($56,223.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,17423.21,56223.11,There are no additional notes associated with this service or procedure.
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],26301.36,,"Fee schedule rate ($26,301.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,11247.07,27028.33,There are no additional notes associated with this service or procedure.
OSTEOMYELITIS WITH CC,540,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],18450.55,,"Fee schedule rate ($18,450.55). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (19), with a minimum of zero.",,,,0,other,9809.07,25507.30,There are no additional notes associated with this service or procedure.
"NEONATE BIRTH WEIGHT 1500-1999 GRAMS WITH MAJOR ANOMALY,MINOR",611,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],11512.05,,"Case rate ($10,963.86). Base payment rate plus any adjustments related to outliers.",,,,0,other,10963.86,11512.05,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],11878.41,,"Case rate ($6,787.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,450.02, add-ons for qualifying new technology services are included. If operating cost exceeds $41,321.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,114.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,488.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,505.07 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $354.19. The transfer capital threshold is the transfer adjustment factor * $354.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,6164.03,14071.02,All Other Inpatient
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6122.64,,"Case rate ($6,122.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,831.37, add-ons for qualifying new technology services are included. If operating cost exceeds $40,702.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,065.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $3,872.14 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,886.42 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $305.55. The transfer capital threshold is the transfer adjustment factor * $305.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,1188.00,12138.74,Inpatient DRG
INFLAMMATORY BOWEL DISEASE WITH MCC,385,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],12660.40,,"Case rate ($12,660.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,913.31, add-ons for qualifying new technology services are included. If operating cost exceeds $46,784.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,543.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $9,931.73 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,968.35 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $783.71. The transfer capital threshold is the transfer adjustment factor * $783.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,11480.01,31134.92,Inpatient DRG
INFLAMMATORY BOWEL DISEASE WITH MCC,385,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],21593.52,,"Fee schedule rate ($21,593.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11480.01,31134.92,There are no additional notes associated with this service or procedure.
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],31577.54,,"Fee schedule rate ($31,577.54). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,15453.88,39251.68,There are no additional notes associated with this service or procedure.
HC Inj Aa&/Strd Greater Occipital Nerve|BILATERAL PROCEDURE,CASE-64405,APC,64405,CPT,0450,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],20401.88,,"Fee schedule rate ($20,401.88). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,20401.88,There are no additional notes associated with this service or procedure.
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],16226.57,,"Case rate ($15,453.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,512.02, add-ons for qualifying new technology services are included. If operating cost exceeds $49,383.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,747.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $12,520.90 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,567.07 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $988.02. The transfer capital threshold is the transfer adjustment factor * $988.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,15453.88,39251.68,Inpatient DRG
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,,inpatient,,,,,DEVOTED HEALTH PLAN [4501],DEVOTED HEALTH PLANS [4501001],8543.64,,"Case rate ($8,543.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,083.58, add-ons for qualifying new technology services are included. If operating cost exceeds $42,954.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,242.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,116.09 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,138.64 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $482.62. The transfer capital threshold is the transfer adjustment factor * $482.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,8543.64,23239.84,Inpatient DRG
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],10554.00,,"Case rate ($10,347.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,761.25, add-ons for qualifying new technology services are included. If operating cost exceeds $44,632.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,374.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $7,787.59 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,816.30 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $614.52. The transfer capital threshold is the transfer adjustment factor * $614.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,10347.06,28821.04,Inpatient DRG
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],18588.16,,"Fee schedule rate ($18,588.16). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.8), with a minimum of zero.",,,,0,other,8643.20,19462.52,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],33321.87,,"Fee schedule rate ($33,321.87). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.9), with a minimum of zero.",,,,0,other,13917.42,34889.29,There are no additional notes associated with this service or procedure.
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],6971.08,,"Case rate ($6,834.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,493.49, add-ons for qualifying new technology services are included. If operating cost exceeds $41,364.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,117.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $4,531.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,548.54 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $357.61. The transfer capital threshold is the transfer adjustment factor * $357.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6834.39,21354.82,Inpatient DRG
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,309,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],14547.21,,,,,,0,other,5055.77,14547.21,There are no additional notes associated with this service or procedure.
"DISORDERS OF GALLBLADDER AND BILIARY TRACT,MODERATE",284,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],9371.91,,"The inlier payment is calculated as the lesser of the standard DRG payment $9,371.91 and the transfer payment, which is a per diem of $2,617.85. If cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,9371.91,9840.51,Estimated amount calculated based on 1 day length of stay.
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],34032.82,,"Fee schedule rate ($34,032.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,15233.11,38610.21,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],9015.78,,"Case rate ($8,586.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,135.80, add-ons for qualifying new technology services are included. If operating cost exceeds $43,006.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,234.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,167.47 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,190.85 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $474.05. The transfer capital threshold is the transfer adjustment factor * $474.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,32293.66,Inpatient DRG
SPINAL PROCEDURES WITHOUT CC/MCC,030,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],44714.01,,"Fee schedule rate ($44,714.01). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,16810.99,44714.01,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,082,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],56223.11,,"Fee schedule rate ($56,223.11). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,17423.21,56223.11,There are no additional notes associated with this service or procedure.
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR,518,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],47498.31,,"Fee schedule rate ($47,498.31). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,13252.00,89342.77,There are no additional notes associated with this service or procedure.
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],15821.59,,"Case rate ($15,821.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,854.10, add-ons for qualifying new technology services are included. If operating cost exceeds $49,725.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,774.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $12,861.73 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,909.15 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,014.92. The transfer capital threshold is the transfer adjustment factor * $1,014.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,15821.59,40320.14,Inpatient DRG
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],12606.23,,"Case rate ($12,606.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,862.91, add-ons for qualifying new technology services are included. If operating cost exceeds $46,733.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,539.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $9,881.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,917.95 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $779.75. The transfer capital threshold is the transfer adjustment factor * $779.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12606.23,36868.88,Inpatient DRG
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],31973.49,,"Fee schedule rate ($31,973.49). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,13386.36,33244.29,There are no additional notes associated with this service or procedure.
Tympanostomy General Anesthesia|RIGHT SIDE,CASE-69436,APC,69436,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5541.10,,"APC Price ($5,541.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5541.10,5735.04,OPPS APC
COAGULATION DISORDERS,813,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],12888.11,,"Case rate ($12,274.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,554.21, add-ons for qualifying new technology services are included. If operating cost exceeds $46,425.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,515.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $9,573.96 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,609.26 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $755.48. The transfer capital threshold is the transfer adjustment factor * $755.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12274.39,30013.33,Inpatient DRG
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,056,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],59328.19,,"Fee schedule rate ($59,328.19). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (44), with a minimum of zero.",,,,0,other,7659.00,59328.19,There are no additional notes associated with this service or procedure.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],54764.34,,"Fee schedule rate ($54,764.34). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,18178.96,54764.34,There are no additional notes associated with this service or procedure.
RESPIRATORY NEOPLASMS WITHOUT CC/MCC,182,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],23037.13,,"Fee schedule rate ($23,037.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,6965.00,23037.13,There are no additional notes associated with this service or procedure.
Nasal/Sinus Ndsc W/Rmvl Tiss From Frontal Sinus,CASE-31276,APC,31276,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6605.95,,"APC Price ($6,605.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6605.95,6936.25,OPPS APC
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,167,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],43522.37,,"Fee schedule rate ($43,522.37). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,14157.71,43522.37,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,426,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],78112.92,,"Case rate ($76,581.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $71,377.56, add-ons for qualifying new technology services are included. If operating cost exceeds $106,248.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $7,218.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $69,177.55 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $69,432.61 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $5,458.79. The transfer capital threshold is the transfer adjustment factor * $5,458.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,76581.29,216864.15,Inpatient DRG
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC,939,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],27843.27,,"Case rate ($26,517.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $24,804.19, add-ons for qualifying new technology services are included. If operating cost exceeds $59,675.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,557.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $22,775.26 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $22,859.24 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,797.19. The transfer capital threshold is the transfer adjustment factor * $1,797.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,26517.40,97674.79,Inpatient DRG
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],142438.06,,"Fee schedule rate ($142,438.06). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (40), with a minimum of zero.",,,,0,other,45521.20,142438.06,There are no additional notes associated with this service or procedure.
HC Pbb Carpal Tunnel Inj Pmc|PBB CHARGE,CASE-20526,APC,20526,CPT,0510,RC,,,PBB,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 1 Level|RIGHT SIDE,CASE-64493,APC,64493,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],827.89,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,827.89,869.28,OPPS APC
SIGNS AND SYMPTOMS WITH MCC,947,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],30414.32,,"Fee schedule rate ($30,414.32). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,10541.41,30414.32,There are no additional notes associated with this service or procedure.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,098,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],45156.75,,,,,,0,other,6965.00,45156.75,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,064,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],22242.89,,"Fee schedule rate ($22,242.89). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,15563.58,41838.16,There are no additional notes associated with this service or procedure.
"Amputation Toe Interphalangeal Joint|RIGHT FOOT, SECOND DIGIT",CASE-28825,APC,28825,CPT,0360,RC,,,T6,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],31533.97,,"Fee schedule rate ($31,533.97). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8563.30,31533.97,There are no additional notes associated with this service or procedure.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],41006.47,,"Fee schedule rate ($41,006.47). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12268.97,41006.47,There are no additional notes associated with this service or procedure.
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],35528.17,,"Fee schedule rate ($35,528.17). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,14747.55,37899.49,There are no additional notes associated with this service or procedure.
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],6965.00,,,,,,0,other,6965.00,21404.64,There are no additional notes associated with this service or procedure.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],9918.70,,"Case rate ($9,446.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,923.36, add-ons for qualifying new technology services are included. If operating cost exceeds $43,794.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,308.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,952.78 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,978.41 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $548.64. The transfer capital threshold is the transfer adjustment factor * $548.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9446.38,21796.21,Inpatient DRG
"CVA AND PRECEREBRAL OCCLUSION WITH INFARCTION,MODERATE",045,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],10234.76,,"Case rate ($10,234.76). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,10234.76,10746.50,There are no additional notes associated with this service or procedure.
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],14309.17,,"Fee schedule rate ($14,309.17). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,17467.27,There are no additional notes associated with this service or procedure.
Peri-Implant Capsulectomy Breast Complete,CASE-19371,APC,19371,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7918.25,,"APC Price ($7,650.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,7918.25,8033.01,OPPS APC
"RESPIRATORY MALIGNANCY,MAJOR",136,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],13038.55,,"Case rate ($12,417.67). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12417.67,13038.55,There are no additional notes associated with this service or procedure.
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",623,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],14093.37,,"Case rate ($14,093.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,246.37, add-ons for qualifying new technology services are included. If operating cost exceeds $48,117.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,648.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $11,259.90 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,301.42 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $888.52. The transfer capital threshold is the transfer adjustment factor * $888.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,14093.37,33712.76,Inpatient DRG
Laps Supracrv Hysterect 250 Gm/< Rmvl Tube/Ovar,CASE-58542,APC,58542,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],9949.78,,"APC Price ($9,949.78). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,9949.78,10298.02,OPPS APC
"Tendon Sheath Incision|RIGHT HAND, SECOND DIGIT|UNUSUAL NON-OVERLAPPING SERVICE",CASE-26055,APC,26055,CPT,0360,RC,,,F6|XU,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1505.12,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1505.12,1580.37,OPPS APC
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],26725.53,,"Fee schedule rate ($26,725.53). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.6), with a minimum of zero.",,,,0,other,11575.50,48961.48,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],16278.78,,,,,,0,other,6965.00,19126.88,There are no additional notes associated with this service or procedure.
Conization Cervix W/WO D&C Rpr Knife/Laser,CASE-57520,APC,57520,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3181.53,,"APC Price ($3,030.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3030.03,3181.53,OPPS APC
HC Blood Occult Peroxidase Actv Qual Feces 1-3 Spec,CASE-82272,APC,82272,CPT,0301,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],4.23,,,,,,0,other,4.23,4.44,There are no additional notes associated with this service or procedure.
NERVOUS SYSTEM NEOPLASMS WITH MCC,054,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],25589.03,,"Fee schedule rate ($25,589.03). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,6965.00,30044.81,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],81353.66,,"Fee schedule rate ($81,353.66). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,27256.92,81353.66,There are no additional notes associated with this service or procedure.
"NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY",789,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],3054.00,,,,,,0,other,3054.00,14857.05,Estimated amount calculated based on 1 day length of stay.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],8081.80,,"Case rate ($7,923.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,506.51, add-ons for qualifying new technology services are included. If operating cost exceeds $42,377.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,197.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $5,541.13 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,561.56 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $437.25. The transfer capital threshold is the transfer adjustment factor * $437.25. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,1188.00,17370.86,Inpatient DRG
Strtctc Cptr Asstd Px Extradural Cranial,CASE-61782,APC,61782,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],5735.04,,"APC Price ($5,541.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5541.10,5818.16,OPPS APC
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],26127.34,,"Case rate ($26,127.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $24,441.31, add-ons for qualifying new technology services are included. If operating cost exceeds $59,312.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,528.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. The base transfer operating payment is the transfer adjustment factor * $22,413.72 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $22,496.36 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,768.66. The transfer capital threshold is the transfer adjustment factor * $1,768.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,26127.34,90333.60,Inpatient DRG
INFLAMMATORY BOWEL DISEASE WITH MCC,385,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],13293.42,,"Case rate ($12,660.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,913.31, add-ons for qualifying new technology services are included. If operating cost exceeds $46,784.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,543.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $9,931.73 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,968.35 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $783.71. The transfer capital threshold is the transfer adjustment factor * $783.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,11480.01,31134.92,Inpatient DRG
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC,858,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],26176.77,,"Fee schedule rate ($26,176.77). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,11377.76,33794.11,There are no additional notes associated with this service or procedure.
NERVOUS SYSTEM NEOPLASMS WITH MCC,054,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],21499.14,,"Case rate ($12,285.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,564.29, add-ons for qualifying new technology services are included. If operating cost exceeds $46,435.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,516.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $9,584.00 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,619.34 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $756.27. The transfer capital threshold is the transfer adjustment factor * $756.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,6965.00,30044.81,All Other Inpatient
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],85466.62,,"Fee schedule rate ($85,466.62). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,21382.16,85466.62,There are no additional notes associated with this service or procedure.
PREMATURITY WITHOUT MAJOR PROBLEMS,792,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],19179.69,,"Case rate ($18,531.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,374.70, add-ons for qualifying new technology services are included. If operating cost exceeds $52,245.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,973.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. The base transfer operating payment is the transfer adjustment factor * $15,373.07 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,429.75 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,213.09. The transfer capital threshold is the transfer adjustment factor * $1,213.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,1956.00,19457.66,Inpatient DRG
INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,352,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],10102.12,,"Case rate ($9,621.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,100.21, add-ons for qualifying new technology services are included. If operating cost exceeds $43,971.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,307.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $7,128.23 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,155.26 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $547.89. The transfer capital threshold is the transfer adjustment factor * $547.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9853.37,26528.70,Inpatient DRG
Chemodenervation Muscle Neck Unilat for Dystonia|BILATERAL PROCEDURE,CASE-64616,APC,64616,CPT,0360,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],301.68,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,287.31,301.68,OPPS APC
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],33203.19,,"Fee schedule rate ($33,203.19). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,11348.00,62454.12,There are no additional notes associated with this service or procedure.
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],25814.06,,"Fee schedule rate ($25,814.06). Adds an outlier to normal pricing equal to the per diem rate ($46,867.46) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,11247.07,27028.33,There are no additional notes associated with this service or procedure.
Brnchsc Incl Fluor Gdnce Dx W/Cell Washg Spx,CASE-31622,APC,31622,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1666.03,,"APC Price ($1,666.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1666.03,1749.33,OPPS APC
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,418,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],39884.93,,"Fee schedule rate ($39,884.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,13400.58,39884.93,There are no additional notes associated with this service or procedure.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],23618.74,,"Fee schedule rate ($23,618.74). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,10533.95,24956.34,There are no additional notes associated with this service or procedure.
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC",458,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],132827.25,,"Fee schedule rate ($132,827.25). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,30202.09,132827.25,There are no additional notes associated with this service or procedure.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],9120.24,,"Case rate ($8,811.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,333.06, add-ons for qualifying new technology services are included. If operating cost exceeds $43,204.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,262.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,364.65 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,388.11 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $502.23. The transfer capital threshold is the transfer adjustment factor * $502.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6965.00,20401.88,Inpatient DRG
SPINAL PROCEDURES WITHOUT CC/MCC,030,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],41254.39,,"Fee schedule rate ($41,254.39). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,16810.99,44714.01,There are no additional notes associated with this service or procedure.
Exc Rct Procidentia W/Anast Perineal Approach,CASE-45130,APC,45130,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],48.78,,"APC Price ($48.78). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,48.78,51.22,OPPS APC
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],54180.83,,"Fee schedule rate ($54,180.83). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,15491.11,54180.83,There are no additional notes associated with this service or procedure.
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],25013.10,,"Fee schedule rate ($25,013.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10846.16,25863.45,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],6276.18,,"Case rate ($6,153.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,859.72, add-ons for qualifying new technology services are included. If operating cost exceeds $40,730.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,067.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,900.39 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,914.77 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $307.78. The transfer capital threshold is the transfer adjustment factor * $307.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6153.12,13947.32,Inpatient DRG
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC,807,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],10071.17,,"Fee schedule rate ($10,071.17). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5354.25,13266.23,There are no additional notes associated with this service or procedure.
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],28423.20,,"Fee schedule rate ($28,423.20). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11059.47,28423.20,There are no additional notes associated with this service or procedure.
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],16612.67,,"Case rate ($15,821.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,854.10, add-ons for qualifying new technology services are included. If operating cost exceeds $49,725.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,774.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $12,861.73 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,909.15 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,014.92. The transfer capital threshold is the transfer adjustment factor * $1,014.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,15821.59,40320.14,Inpatient DRG
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC,099,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],25603.58,,"Fee schedule rate ($25,603.58). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.7), with a minimum of zero.",,,,0,other,11171.21,26807.94,There are no additional notes associated with this service or procedure.
Anoscopy Dx W/HRA &Chem Agnts Enhancement W/Bx,CASE-46607,APC,46607,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],1120.09,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1120.09,1176.09,OPPS APC
SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS,029,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],34301.40,,"Fee schedule rate ($34,301.40). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13641.00,67130.05,There are no additional notes associated with this service or procedure.
OTHER CEREBROVASCULAR DISORDERS WITH MCC,070,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],13880.04,,"Case rate ($13,219.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,433.04, add-ons for qualifying new technology services are included. If operating cost exceeds $47,304.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,584.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $10,449.57 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,488.10 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $824.57. The transfer capital threshold is the transfer adjustment factor * $824.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13219.09,37774.46,Inpatient DRG
Neuroplasty &/Transposition Ulnar Nerve Elbow|UNUSUAL NON-OVERLAPPING SERVICE|LEFT SIDE,CASE-64718,APC,64718,CPT,0360,RC,,,XU|LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
"Open Tx Phalangeal Shaft Fracture Prox/Middle Ea|RIGHT HAND, FOURTH DIGIT",CASE-26735,APC,26735,CPT,0360,RC,,,F8,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],22557.82,,"Fee schedule rate ($22,557.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6801.88,22557.82,There are no additional notes associated with this service or procedure.
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC,520,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],28074.86,,"Fee schedule rate ($28,074.86). Adds an outlier to normal pricing equal to the per diem rate ($68,872.56) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,12061.74,39786.42,There are no additional notes associated with this service or procedure.
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],12392.10,,"Fee schedule rate ($12,392.10). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9389.48,22358.90,There are no additional notes associated with this service or procedure.
OSTEOMYELITIS WITH CC,540,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],24361.37,,"Fee schedule rate ($24,361.37). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.6), with a minimum of zero.",,,,0,other,9809.07,25507.30,There are no additional notes associated with this service or procedure.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,309,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5055.77,,"Case rate ($4,815.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $4,493.87, add-ons for qualifying new technology services are included. If operating cost exceeds $44,063.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $3,132.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,473.46. The transfer operating threshold is the transfer adjustment factor * $4,493.87 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $341.56. The transfer capital threshold is the transfer adjustment factor * $341.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5055.77,14547.21,Inpatient DRG
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],2070.00,,,,,,0,other,1188.00,12138.74,Estimated amount calculated based on 1 day length of stay.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",063,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],35701.87,,"Fee schedule rate ($35,701.87). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,35701.87,There are no additional notes associated with this service or procedure.
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],29594.00,,"Fee schedule rate ($29,594.00). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,13571.25,33781.47,There are no additional notes associated with this service or procedure.
NEONATE WITH OTHER SIGNIFICANT PROBLEMS,794,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],11939.84,,"Case rate ($11,939.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,242.99, add-ons for qualifying new technology services are included. If operating cost exceeds $46,114.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,490.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $9,263.89 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,298.04 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $731.01. The transfer capital threshold is the transfer adjustment factor * $731.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,1798.85,12536.83,Inpatient DRG
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,373,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],13780.60,,"Fee schedule rate ($13,780.60). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6870.94,14313.05,There are no additional notes associated with this service or procedure.
MAJOR BLADDER PROCEDURES WITH MCC,653,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],37135.34,,"Case rate ($37,135.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $34,681.82, add-ons for qualifying new technology services are included. If operating cost exceeds $69,552.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,333.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.5. The base transfer operating payment is the transfer adjustment factor * $32,616.61 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $32,736.87 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,573.77. The transfer capital threshold is the transfer adjustment factor * $2,573.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10280.00,125343.98,Inpatient DRG
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],6965.00,,,,,,0,other,6965.00,16400.70,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],11677.97,,"Fee schedule rate ($11,677.97). Adds an outlier to normal pricing equal to the per diem rate ($67,650.85) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.7), with a minimum of zero.",,,,0,other,6153.12,13947.32,There are no additional notes associated with this service or procedure.
Colsc Flexible W/Control Bleeding Any Method|UNUSUAL NON-OVERLAPPING SERVICE,CASE-45382,APC,45382,CPT,0360,RC,,,XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1176.09,,"APC Price ($1,120.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1120.09,1176.09,OPPS APC
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],54086.17,,,,,,0,other,20559.34,54086.17,There are no additional notes associated with this service or procedure.
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],12514.73,,"Case rate ($12,091.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,384.11, add-ons for qualifying new technology services are included. If operating cost exceeds $46,255.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,502.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $9,404.49 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,439.16 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $742.11. The transfer capital threshold is the transfer adjustment factor * $742.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6965.00,29482.05,Inpatient DRG
Hysteroscopy Removal Impacted Foreign Body,CASE-58562,APC,58562,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],3030.03,,"APC Price ($3,030.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3030.03,3136.08,OPPS APC
Laparoscopy Radical Nephrectomy|RIGHT SIDE,CASE-50545,APC,50545,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],352.29,,"APC Price ($335.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,347.26,352.29,OPPS APC
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],20567.06,,"Fee schedule rate ($20,567.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,9356.31,25026.36,There are no additional notes associated with this service or procedure.
Vulvectomy Simple Partial|BILATERAL PROCEDURE,CASE-56620,APC,56620,CPT,0360,RC,,,50,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3136.08,,"APC Price ($3,030.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3030.03,3181.53,OPPS APC
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],15579.21,,"Case rate ($15,273.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,344.45, add-ons for qualifying new technology services are included. If operating cost exceeds $49,215.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,734.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $12,353.94 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,399.49 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $974.85. The transfer capital threshold is the transfer adjustment factor * $974.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,15273.74,39820.52,Inpatient DRG
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,690,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],15928.53,,,,,,0,other,7426.94,15928.53,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],26178.21,,"Fee schedule rate ($26,178.21). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,13917.42,34889.29,There are no additional notes associated with this service or procedure.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],60646.89,,"Fee schedule rate ($60,646.89). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15.6), with a minimum of zero.",,,,0,other,23799.09,63499.65,There are no additional notes associated with this service or procedure.
SALIVARY GLAND PROCEDURES,139,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],24314.87,,,,,,0,other,10313.19,30690.92,There are no additional notes associated with this service or procedure.
"HEART FAILURE,MAJOR",194,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],11699.54,,"Case rate ($11,699.54). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,11699.54,12284.52,There are no additional notes associated with this service or procedure.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,373,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],13780.60,,"Fee schedule rate ($13,780.60). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6870.94,14313.05,There are no additional notes associated with this service or procedure.
"NERVOUS SYSTEM MALIGNANCY,MAJOR",041,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],13083.45,,"Case rate ($12,460.43). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,12460.43,13083.45,There are no additional notes associated with this service or procedure.
Thyroidectomy Total/Complete|BILATERAL PROCEDURE,CASE-60240,APC,60240,CPT,0360,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],10447.27,,"APC Price ($9,949.78). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,9949.78,10447.27,OPPS APC
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,057,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],24348.21,,"Fee schedule rate ($24,348.21). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.9), with a minimum of zero.",,,,0,other,10718.84,39884.93,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITHOUT CC/MCC,428,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],118904.57,,"Fee schedule rate ($118,904.57). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,40017.53,118904.57,There are no additional notes associated with this service or procedure.
Neuroplasty &/Transposition Ulnar Nerve Elbow|LEFT SIDE,CASE-64718,APC,64718,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],1827.80,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1827.80,1919.19,OPPS APC
O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC,621,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],36669.96,,"Fee schedule rate ($36,669.96). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,12159.94,36669.96,There are no additional notes associated with this service or procedure.
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],25170.62,,"Case rate ($14,383.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,516, add-ons for qualifying new technology services are included. If operating cost exceeds $48,387.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,669.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,528.54 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,571.05 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $909.72. The transfer capital threshold is the transfer adjustment factor * $909.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,6965.00,36140.75,All Other Inpatient
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],17867.64,,"Fee schedule rate ($17,867.64). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,7332.00,35314.31,There are no additional notes associated with this service or procedure.
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],35419.59,,"Fee schedule rate ($35,419.59). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,7086.00,57872.02,There are no additional notes associated with this service or procedure.
Egd Insert Guide Wire Dilator Passage Esophagus,CASE-43248,APC,43248,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],848.96,,"APC Price ($848.96). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,848.96,891.41,OPPS APC
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],31577.54,,"Fee schedule rate ($31,577.54). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,15453.88,39251.68,There are no additional notes associated with this service or procedure.
Colonoscopy Flx W/Endoscopic Mucosal Resection|UNUSUAL NON-OVERLAPPING SERVICE|COLORECTAL CANCER SCREEN,CASE-45390,APC,45390,CPT,0360,RC,,,XU|PT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],2727.99,,"APC Price ($2,598.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,2598.08,2727.99,OPPS APC
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITH MCC OR ANTINEOPLASTIC IMPLANT OR EPILEPSY WITH NEUROSTIMULATOR,023,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],40750.95,,"Case rate ($40,750.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $38,045.35, add-ons for qualifying new technology services are included. If operating cost exceeds $72,916.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,598.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $35,967.78 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $36,100.40 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,838.21. The transfer capital threshold is the transfer adjustment factor * $2,838.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,15168.00,136379.44,Inpatient DRG
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],16829.13,,"Fee schedule rate ($16,829.13). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.5), with a minimum of zero.",,,,0,other,8009.34,19877.10,There are no additional notes associated with this service or procedure.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH CC,026,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],58431.20,,"Fee schedule rate ($58,431.20). Adds an outlier to normal pricing equal to the per diem rate ($112,420.62) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,23000.66,63202.45,There are no additional notes associated with this service or procedure.
HC Drain/Inj Joint/Bursa W/US Large|BILATERAL PROCEDURE,CASE-20611,APC,20611,CPT,0510,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,699,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],5961.00,,"Per diem ($5,961). If length of stay < 3.2, first 1 days paid at a per diem of $11,922 instead. Capped at $19,074.90.",,,,0,other,5961.00,19972.16,Estimated amount calculated based on 3 day length of stay.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],15808.67,,"Fee schedule rate ($15,808.67). Adds an outlier to normal pricing equal to the per diem rate ($67,650.85) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,7641.61,19371.27,There are no additional notes associated with this service or procedure.
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC",605,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],8555.58,,"Case rate ($8,148.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,715.67, add-ons for qualifying new technology services are included. If operating cost exceeds $42,586.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,213.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,749.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,770.72 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $453.69. The transfer capital threshold is the transfer adjustment factor * $453.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8148.17,18024.13,Inpatient DRG
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],12439.05,,"Case rate ($12,195.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,480.50, add-ons for qualifying new technology services are included. If operating cost exceeds $46,351.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,509.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,500.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,535.55 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $749.68. The transfer capital threshold is the transfer adjustment factor * $749.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,12195.15,39424.57,Inpatient DRG
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],28093.27,,"Case rate ($28,093.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $26,270.18, add-ons for qualifying new technology services are included. If operating cost exceeds $61,141.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,672.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $24,235.87 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $24,325.23 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,912.45. The transfer capital threshold is the transfer adjustment factor * $1,912.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.",,,,0,other,10078.00,81454.07,Inpatient DRG
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC,027,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],49643.10,,,,,,0,other,19030.20,56363.30,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],7994.00,,"Per diem ($7,994). If length of stay < 1.7, first 1 days paid at a per diem of $15,988 instead. Capped at $13,589.22.",,,,0,other,6841.83,21167.26,Estimated amount calculated based on 1 day length of stay.
Exc Breast Les Preop Plmt Rad Marker Open 1 Les|RIGHT SIDE,CASE-19125,APC,19125,CPT,0360,RC,,,RT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3664.94,,"APC Price ($3,664.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3664.94,3848.19,OPPS APC
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],18905.23,,"Fee schedule rate ($18,905.23). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6963.00,18954.85,There are no additional notes associated with this service or procedure.
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC",629,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],17079.87,,"Case rate ($16,266.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,294.74, add-ons for qualifying new technology services are included. If operating cost exceeds $50,165.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,782.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $13,299.36 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,349.79 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,022.22. The transfer capital threshold is the transfer adjustment factor * $1,022.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,16699.94,44657.18,Inpatient DRG
Laparoscopy Supracervical Hysterectomy 250 Gm/<,CASE-58541,APC,58541,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],9949.78,,"APC Price ($9,949.78). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,9949.78,10447.27,OPPS APC
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC,832,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],6831.68,,"Case rate ($6,831.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,490.97, add-ons for qualifying new technology services are included. If operating cost exceeds $41,361.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,117.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $4,529.32 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,546.02 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $357.41. The transfer capital threshold is the transfer adjustment factor * $357.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,4803.31,14198.92,Inpatient DRG
Unlisted Laparoscopy Procedure Uterus,CASE-58578,APC,58578,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],10298.02,,"APC Price ($9,949.78). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,9949.78,10298.02,OPPS APC
PSYCHOSES,885,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],2070.00,,,,,,0,other,2070.00,27484.83,Estimated amount calculated based on 3 day length of stay.
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC,833,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],9600.62,,"Case rate ($5,486.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,239.18, add-ons for qualifying new technology services are included. If operating cost exceeds $40,110.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,018.96, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $3,282.12 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,294.23 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $258.99. The transfer capital threshold is the transfer adjustment factor * $258.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,3041.73,10289.10,All Other Inpatient
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC",641,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],7575.73,,"Case rate ($7,214.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,847.54, add-ons for qualifying new technology services are included. If operating cost exceeds $41,718.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,145.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $4,884.58 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,902.59 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $385.44. The transfer capital threshold is the transfer adjustment factor * $385.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,7214.98,15312.64,Inpatient DRG
HC Injection Small Joint/Bursa,CASE-20600,APC,20600,CPT,0361,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],301.68,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,287.31,301.68,OPPS APC
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],39153.65,,"Fee schedule rate ($39,153.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,7605.00,39153.65,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,093,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],7704.43,,"Case rate ($7,337.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,961.57, add-ons for qualifying new technology services are included. If operating cost exceeds $41,832.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,154.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,998.19 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,016.62 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $394.41. The transfer capital threshold is the transfer adjustment factor * $394.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,19011.32,Inpatient DRG
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],33221.97,,"Fee schedule rate ($33,221.97). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (47), with a minimum of zero.",,,,0,other,15283.90,38757.79,There are no additional notes associated with this service or procedure.
Xpedicul Decompress Throacic Cord|RIGHT SIDE,CASE-63055,APC,63055,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6791.99,7131.59,OPPS APC
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],10249.36,,"Case rate ($10,048.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,483.42, add-ons for qualifying new technology services are included. If operating cost exceeds $44,354.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,352.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,510.78 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,538.48 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $592.68. The transfer capital threshold is the transfer adjustment factor * $592.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,10048.39,23545.50,Inpatient DRG
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],18245.94,,"Fee schedule rate ($18,245.94). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8106.18,18245.94,There are no additional notes associated with this service or procedure.
"Laminec/Facetect/Foramin,Lumbar",CASE-63047,APC,63047,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],7029.71,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6791.99,7131.59,OPPS APC
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],62990.26,,"Fee schedule rate ($62,990.26). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,16787.98,62990.26,There are no additional notes associated with this service or procedure.
Insj Biomchn Dev Intervertebral Dsc Spc W/Arthrd,CASE-22853,APC,22853,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],12017.31,,"APC Price ($12,017.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12017.31,12618.18,OPPS APC
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH CC,026,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],40251.16,,"Case rate ($23,000.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $21,532.64, add-ons for qualifying new technology services are included. If operating cost exceeds $56,403.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,299.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $19,515.74 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $19,587.69 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,539.98. The transfer capital threshold is the transfer adjustment factor * $1,539.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 175%.",,,,0,other,23000.66,63202.45,All Other Inpatient
ALLERGIC REACTIONS WITH MCC,915,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],31602.31,,"Fee schedule rate ($31,602.31). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.8), with a minimum of zero.",,,,0,other,13332.86,33088.84,There are no additional notes associated with this service or procedure.
Colonoscopy Flx W/Endoscopic Mucosal Resection|UNUSUAL NON-OVERLAPPING SERVICE|COLORECTAL CANCER SCREEN,CASE-45390,APC,45390,CPT,0360,RC,,,XU|PT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],2598.08,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2598.08,2727.99,OPPS APC
SKIN ULCERS WITH MCC,592,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],15871.98,,"Case rate ($15,116.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $14,168.54, add-ons for qualifying new technology services are included. If operating cost exceeds $53,556.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $3,795.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.8. The base transfer operating payment is the transfer adjustment factor * $12,752.10 + an uncompensated DSH payment of $1,359.91. The transfer operating threshold is the transfer adjustment factor * $12,808.63 + an uncompensated DSH payment of $1,359.91. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,004.16. The transfer capital threshold is the transfer adjustment factor * $1,004.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,15116.17,38644.05,Inpatient DRG
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],13792.01,,"Case rate ($13,792.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,966.02, add-ons for qualifying new technology services are included. If operating cost exceeds $47,837.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,626.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $10,980.58 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,021.07 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $866.48. The transfer capital threshold is the transfer adjustment factor * $866.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,34422.94,Inpatient DRG
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],7921.00,,"Per diem ($7,921). If length of stay < 4.1, first 1 days paid at a per diem of $15,842 instead. Capped at $32,474.30.",,,,0,other,7921.00,45706.73,Estimated amount calculated based on 2 day length of stay.
Hysteroscopy Removal Impacted Foreign Body,CASE-58562,APC,58562,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3136.08,,"APC Price ($3,030.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3030.03,3136.08,OPPS APC
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,191,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],7806.89,,"Case rate ($7,653.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,255.78, add-ons for qualifying new technology services are included. If operating cost exceeds $42,126.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,177.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,291.32 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,310.83 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $417.54. The transfer capital threshold is the transfer adjustment factor * $417.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6965.00,16612.88,Inpatient DRG
"Tendon Sheath Incision|RIGHT HAND, SECOND DIGIT|UNUSUAL NON-OVERLAPPING SERVICE",CASE-26055,APC,26055,CPT,0360,RC,,,F6|XU,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1505.12,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1505.12,1580.37,OPPS APC
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],90333.60,,"Fee schedule rate ($90,333.60). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (34), with a minimum of zero.",,,,0,other,26127.34,90333.60,There are no additional notes associated with this service or procedure.
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR,518,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],13252.00,,"Per diem ($13,252). If length of stay < 5.3, first 1 days paid at a per diem of $26,504 instead. Capped at $70,235.08.",,,,0,other,13252.00,89342.77,Estimated amount calculated based on 1 day length of stay.
CESAREAN SECTION WITHOUT STERILIZATION WITH MCC,786,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],13771.26,,"Case rate ($13,115.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,336.66, add-ons for qualifying new technology services are included. If operating cost exceeds $47,207.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,576.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $10,353.53 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,391.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $817.00. The transfer capital threshold is the transfer adjustment factor * $817.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12612.10,23722.94,Inpatient DRG
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],12455.21,,"Case rate ($12,455.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,722.41, add-ons for qualifying new technology services are included. If operating cost exceeds $46,593.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,528.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $9,741.55 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,777.47 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $768.70. The transfer capital threshold is the transfer adjustment factor * $768.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,12455.21,37149.27,Inpatient DRG
Nasal/Sinus Ndsc W/Partial Ethmoidectomy|LEFT SIDE,CASE-31254,APC,31254,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6837.16,,"APC Price ($6,605.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6837.16,6936.25,OPPS APC
HYPERTENSION WITHOUT MCC,305,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],14858.10,,,,,,0,other,7058.55,17230.49,There are no additional notes associated with this service or procedure.
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],16804.22,,"Fee schedule rate ($16,804.22). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7238.69,16804.22,There are no additional notes associated with this service or procedure.
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITH MCC OR ANTINEOPLASTIC IMPLANT OR EPILEPSY WITH NEUROSTIMULATOR,023,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],15168.00,,"Per diem ($15,168). If length of stay < 7.1, first 1 days paid at a per diem of $30,336 instead. Capped at $107,689.53.",,,,0,other,15168.00,136379.44,Estimated amount calculated based on 6 day length of stay.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],37768.77,,"Fee schedule rate ($37,768.77). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7453.00,42138.30,There are no additional notes associated with this service or procedure.
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH MCC",722,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],56869.13,,"Fee schedule rate ($56,869.13). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (28), with a minimum of zero.",,,,0,other,14200.37,56869.13,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,448,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],52140.90,,"Fee schedule rate ($52,140.90). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,30663.95,94077.13,There are no additional notes associated with this service or procedure.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],18598.83,,"Case rate ($18,598.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,437.70, add-ons for qualifying new technology services are included. If operating cost exceeds $52,308.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,978.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 5.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $15,435.83 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,492.75 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,218.04. The transfer capital threshold is the transfer adjustment factor * $1,218.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,18598.83,48389.68,Inpatient DRG
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],46215.75,,"Fee schedule rate ($46,215.75). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12.7), with a minimum of zero.",,,,0,other,18598.83,48389.68,There are no additional notes associated with this service or procedure.
Dbrdmt W/Rmvl Fm Fx&/Dislc Skin&Subq Tissus,CASE-11010,APC,11010,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],662.83,,"APC Price ($662.83). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,662.83,662.83,OPPS APC
DIABETES WITH MCC,637,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],27368.25,,"Fee schedule rate ($27,368.25). Adds an outlier to normal pricing equal to the per diem rate ($39,561.63) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,9959.03,28655.62,There are no additional notes associated with this service or procedure.
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],11065.78,,"Fee schedule rate ($11,065.78). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5883.03,17111.12,There are no additional notes associated with this service or procedure.
"PROCEDURES FOR OBESITY,MINOR",403,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],11655.96,,"Case rate ($11,100.91). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11100.91,11655.96,There are no additional notes associated with this service or procedure.
MAJOR BLADDER PROCEDURES WITH MCC,653,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],37135.34,,"Case rate ($37,135.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $34,681.82, add-ons for qualifying new technology services are included. If operating cost exceeds $69,552.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,333.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.5. The base transfer operating payment is the transfer adjustment factor * $32,616.61 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $32,736.87 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,573.77. The transfer capital threshold is the transfer adjustment factor * $2,573.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,10280.00,125343.98,Inpatient DRG
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],22762.43,,"Fee schedule rate ($22,762.43). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6230.00,22762.43,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],7665.00,,"Per diem ($7,665). If length of stay < 4, first 1 days paid at a per diem of $15,330 instead. Capped at $30,658.90.",,,,0,other,7665.00,40737.46,Estimated amount calculated based on 5 day length of stay.
SPINAL PROCEDURES WITHOUT CC/MCC,030,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],29419.23,,"Case rate ($16,810.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,774.52, add-ons for qualifying new technology services are included. If operating cost exceeds $50,645.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,847.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $13,778.77 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,829.57 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,087.28. The transfer capital threshold is the transfer adjustment factor * $1,087.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,16810.99,44714.01,All Other Inpatient
Neuroplasty &/Transpos Median Nrv Carpal Tunne|RIGHT SIDE|SEPARATE STRUCTURE,CASE-64721,APC,64721,CPT,0360,RC,,,RT|XS,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7029.71,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6791.99,7131.59,OPPS APC
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],21796.21,,,,,,0,other,9446.38,21796.21,There are no additional notes associated with this service or procedure.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],52909.62,,"Fee schedule rate ($52,909.62). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,23344.70,62179.32,There are no additional notes associated with this service or procedure.
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],15117.84,,,,,,0,other,6965.00,16400.70,There are no additional notes associated with this service or procedure.
"Exc Lesion Tdn Shth/Jt Capsl Hand/Fngr|RIGHT HAND, THIRD DIGIT",CASE-26160,APC,26160,CPT,0360,RC,,,F7,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1505.12,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1505.12,1580.37,OPPS APC
HC Drain/Inj Joint/Bursa W/US Large,CASE-20611,APC,20611,CPT,0510,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],301.68,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,287.31,301.68,OPPS APC
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],9905.96,,"Case rate ($9,570.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,039.28, add-ons for qualifying new technology services are included. If operating cost exceeds $43,910.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,317.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $7,068.27 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,094.33 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $557.76. The transfer capital threshold is the transfer adjustment factor * $557.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,5569.00,40108.48,Inpatient DRG
"TRANSIENT ISCHEMIA,MODERATE",047,DRG,,,,,,,,inpatient,,,,,MOLINA HEALTHCARE SC MEDICAID [4847],MOLINA HEALTHCARE SC MEDICAID [4847001],3318.37,,"Case rate for a one day stay ($3,318.37). For same day discharges, this is multiplied by 0.5. For same day discharges an outlier is calculated if cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000. The outlier payment is 60% of the excess amount.",,,,0,other,3318.37,3484.29,There are no additional notes associated with this service or procedure.
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],24675.88,,"Fee schedule rate ($24,675.88). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10834.64,25830.00,There are no additional notes associated with this service or procedure.
SINGLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL,402,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],79111.38,,,,,,0,other,29172.05,124455.45,There are no additional notes associated with this service or procedure.
TRAUMATIC INJURY WITH MCC,913,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],42838.46,,"Fee schedule rate ($42,838.46). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,13014.58,42838.46,There are no additional notes associated with this service or procedure.
PLEURAL EFFUSION WITH MCC,186,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],31089.66,,,,,,0,other,10804.96,31089.66,There are no additional notes associated with this service or procedure.
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],53569.45,,"Fee schedule rate ($53,569.45). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14.8), with a minimum of zero.",,,,0,other,21248.73,56089.29,There are no additional notes associated with this service or procedure.
Suture Infrapatellar Tendon Primary|BILATERAL PROCEDURE,CASE-27380,APC,27380,CPT,0360,RC,,,50,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
Lithotripsy Xtrcorp Shock Wave|LEFT SIDE,CASE-50590,APC,50590,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3414.95,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3299.47,3414.95,OPPS APC
"DIVERTICULITIS AND DIVERTICULOSIS,MAJOR",244,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],11068.02,,"Case rate ($11,068.02). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,11068.02,11621.42,There are no additional notes associated with this service or procedure.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],41944.25,,"Fee schedule rate ($41,944.25). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12795.84,41944.25,There are no additional notes associated with this service or procedure.
Exc Cyst/Aberrant Breast Tissue Open 1/> Lesion|RIGHT SIDE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-19120,APC,19120,CPT,0360,RC,,,RT|XU,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6215.36,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6215.36,6526.12,OPPS APC
FRACTURES OF FEMUR WITH MCC,533,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],12862.16,,"Case rate ($12,249.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,550.45, add-ons for qualifying new technology services are included. If operating cost exceeds $46,421.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,495.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $9,569.22 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,605.50 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $735.51. The transfer capital threshold is the transfer adjustment factor * $735.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6852.00,49490.05,Inpatient DRG
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],9543.44,,"Case rate ($9,356.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,839.58, add-ons for qualifying new technology services are included. If operating cost exceeds $43,710.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,302.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $6,869.30 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,894.63 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $542.06. The transfer capital threshold is the transfer adjustment factor * $542.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,9356.31,25026.36,Inpatient DRG
Inj for Sacroiliac Jt Anesth|RIGHT SIDE,CASE-G0260,APC,G0260,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],693.76,,"APC Price ($660.72). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,660.72,693.76,OPPS APC
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC,806,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],10071.17,,"Fee schedule rate ($10,071.17). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,5354.25,13416.00,There are no additional notes associated with this service or procedure.
HC Joint Injection/Aspir Large WO US|SEPARATE STRUCTURE|LEFT SIDE,CASE-20610,APC,20610,CPT,0510,RC,,,XS|LT,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
BRONCHITIS AND ASTHMA WITH CC/MCC,202,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],14307.27,,"Fee schedule rate ($14,307.27). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7606.34,19110.30,There are no additional notes associated with this service or procedure.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],26117.70,,"Fee schedule rate ($26,117.70). Adds an outlier to normal pricing equal to the per diem rate ($7,328.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,12696.97,47123.82,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],9040.72,,"Case rate ($9,040.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,546, add-ons for qualifying new technology services are included. If operating cost exceeds $43,417.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,278.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,576.80 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,601.05 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $518.97. The transfer capital threshold is the transfer adjustment factor * $518.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9040.72,26966.33,Inpatient DRG
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],18217.52,,"Fee schedule rate ($18,217.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,7414.07,18217.52,There are no additional notes associated with this service or procedure.
BRONCHITIS AND ASTHMA WITHOUT CC/MCC,203,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],6046.34,,"Case rate ($5,927.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $5,614.23, add-ons for qualifying new technology services are included. If operating cost exceeds $44,258.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $3,061.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,235.54 + an uncompensated DSH payment of $1,359.91. The transfer operating threshold is the transfer adjustment factor * $4,254.32 + an uncompensated DSH payment of $1,359.91. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $332.34. The transfer capital threshold is the transfer adjustment factor * $332.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,4763.76,13707.00,Inpatient DRG
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC",629,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],17079.87,,"Case rate ($16,266.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,294.74, add-ons for qualifying new technology services are included. If operating cost exceeds $50,165.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,782.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $13,299.36 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,349.79 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,022.22. The transfer capital threshold is the transfer adjustment factor * $1,022.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,16699.94,44657.18,Inpatient DRG
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC",458,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],132827.25,,"Fee schedule rate ($132,827.25). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,30202.09,132827.25,There are no additional notes associated with this service or procedure.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],105091.76,,"Fee schedule rate ($105,091.76). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,35719.96,105091.76,There are no additional notes associated with this service or procedure.
VENTRICULAR SHUNT PROCEDURES WITH CC,032,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],16949.39,,"Case rate ($16,376.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,370.06, add-ons for qualifying new technology services are included. If operating cost exceeds $50,241.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,815.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $13,375.80 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,425.12 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,055.48. The transfer capital threshold is the transfer adjustment factor * $1,055.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,16376.22,46275.08,Inpatient DRG
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],9302.19,,"Case rate ($8,859.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,377.16, add-ons for qualifying new technology services are included. If operating cost exceeds $43,248.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,265.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $6,408.58 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,432.21 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $505.70. The transfer capital threshold is the transfer adjustment factor * $505.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8859.23,20090.22,Inpatient DRG
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],58394.20,,"Fee schedule rate ($58,394.20). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (29), with a minimum of zero.",,,,0,other,9370.00,65732.99,There are no additional notes associated with this service or procedure.
HC Inj Anes/Steroid C/D Facet Sg|BILATERAL PROCEDURE,CASE-64490,APC,64490,CPT,0361,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],869.28,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,827.89,869.28,OPPS APC
"Application Uniplane External Fixation System|RIGHT HAND, FIFTH DIGIT",CASE-20690,APC,20690,CPT,0360,RC,,,F9,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
Exc Rct Procidentia W/Anast Perineal Approach,CASE-45130,APC,45130,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],48.78,,"APC Price ($48.78). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,48.78,51.22,OPPS APC
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],54180.83,,"Fee schedule rate ($54,180.83). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,15491.11,54180.83,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],15288.21,,"Fee schedule rate ($15,288.21). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,13148.66,32553.63,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITHOUT CC/MCC,428,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],105654.25,,"Fee schedule rate ($105,654.25). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,40017.53,118904.57,There are no additional notes associated with this service or procedure.
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],5824.43,,"Case rate ($5,710.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,447.70, add-ons for qualifying new technology services are included. If operating cost exceeds $40,318.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,035.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $3,489.88 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,502.75 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $275.39. The transfer capital threshold is the transfer adjustment factor * $275.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,3079.00,10940.41,Inpatient DRG
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,083,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],11796.31,,"Case rate ($11,397.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,738.37, add-ons for qualifying new technology services are included. If operating cost exceeds $45,609.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,451.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $8,761.12 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,793.42 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $691.34. The transfer capital threshold is the transfer adjustment factor * $691.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,6965.00,28680.85,Inpatient DRG
Exc Tumor Soft Tiss Face&Scalp Subfascial 2 Cm/>,CASE-21014,APC,21014,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],2718.88,,"APC Price ($2,718.88). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2718.88,2854.83,OPPS APC
Inj for Sacroiliac Jt Anesth|RIGHT SIDE,CASE-G0260,APC,G0260,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],693.76,,"APC Price ($660.72). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,660.72,693.76,OPPS APC
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],17755.26,,"Fee schedule rate ($17,755.26). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7847.50,17755.26,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC,832,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],14198.92,,,,,,0,other,4803.31,14198.92,There are no additional notes associated with this service or procedure.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],31918.40,,"Case rate ($30,398.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $28,414.67, add-ons for qualifying new technology services are included. If operating cost exceeds $63,285.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,841.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.2. The base transfer operating payment is the transfer adjustment factor * $26,372.48 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $26,469.72 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,081.05. The transfer capital threshold is the transfer adjustment factor * $2,081.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,30398.48,82674.88,Inpatient DRG
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,094,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],67889.44,,"Fee schedule rate ($67,889.44). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,25778.58,67889.44,There are no additional notes associated with this service or procedure.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],50821.76,,,,,,0,other,19435.86,50821.76,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC",281,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],23859.35,,"Fee schedule rate ($23,859.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8169.15,23859.35,There are no additional notes associated with this service or procedure.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC",281,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],12684.61,,"Fee schedule rate ($12,684.61). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8169.15,23859.35,There are no additional notes associated with this service or procedure.
SPINAL PROCEDURES WITHOUT CC/MCC,030,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],17147.21,,"Case rate ($16,810.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,774.52, add-ons for qualifying new technology services are included. If operating cost exceeds $50,645.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,847.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $13,778.77 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,829.57 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,087.28. The transfer capital threshold is the transfer adjustment factor * $1,087.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,16810.99,44714.01,Inpatient DRG
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,086,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],8442.00,,"Per diem ($8,442). If length of stay < 2.9, first 1 days paid at a per diem of $16,884 instead. Capped at $24,481.64.",,,,0,other,8442.00,30728.81,Estimated amount calculated based on 2 day length of stay.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],35192.25,,"Fee schedule rate ($35,192.25). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,10895.60,35192.25,There are no additional notes associated with this service or procedure.
"Remv Vert Body,Cerv,One Sgmt",CASE-63081,APC,63081,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],12017.31,,"APC Price ($12,017.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,12017.31,12437.92,OPPS APC
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],20297.68,,"Fee schedule rate ($20,297.68). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6965.00,21404.64,There are no additional notes associated with this service or procedure.
CELLULITIS WITH MCC,602,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],27966.92,,,,,,0,other,11570.10,28349.31,There are no additional notes associated with this service or procedure.
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],9950.89,,"Case rate ($9,950.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,392.71, add-ons for qualifying new technology services are included. If operating cost exceeds $44,263.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,345.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $7,420.40 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,447.76 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $585.54. The transfer capital threshold is the transfer adjustment factor * $585.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7243.75,23262.15,Inpatient DRG
Surgical Arthroscopy Shoulder Repair Slap Lesion,CASE-29807,APC,29807,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
Cysto W/Ureteroscopy W/Lithotripsy,CASE-52353,APC,52353,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],5018.77,,"APC Price ($5,018.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,5018.77,5269.71,OPPS APC
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],23332.68,,"Fee schedule rate ($23,332.68). Adds an outlier to normal pricing equal to the per diem rate ($4,950) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,11717.72,43888.01,There are no additional notes associated with this service or procedure.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],7422.85,,"Case rate ($7,069.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,721.66, add-ons for qualifying new technology services are included. If operating cost exceeds $41,592.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,125.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $4,758.67 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,776.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $365.76. The transfer capital threshold is the transfer adjustment factor * $365.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6965.00,15340.19,Inpatient DRG
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],38517.10,,"Fee schedule rate ($38,517.10). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,16897.01,43444.85,There are no additional notes associated with this service or procedure.
Laparoscopy Surg Cholecystectomy,CASE-47562,APC,47562,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],5856.81,,"APC Price ($5,658.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,5658.76,5941.70,OPPS APC
HC Gastroesophag Reflx Test W/Tel Ph Eltrd,CASE-91035,APC,91035,CPT,0750,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],831.93,,"APC Price ($803.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,803.80,843.99,OPPS APC
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],19371.27,,"Fee schedule rate ($19,371.27). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7641.61,19371.27,There are no additional notes associated with this service or procedure.
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],35061.53,,"Fee schedule rate ($35,061.53). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,9696.93,35061.53,There are no additional notes associated with this service or procedure.
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC",758,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],18398.35,,"Fee schedule rate ($18,398.35). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,8574.80,19263.78,There are no additional notes associated with this service or procedure.
OTHER DISORDERS OF NERVOUS SYSTEM WITH CC,092,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],9183.33,,"Case rate ($8,872.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,389.76, add-ons for qualifying new technology services are included. If operating cost exceeds $43,260.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,266.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $6,421.14 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,444.81 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $506.69. The transfer capital threshold is the transfer adjustment factor * $506.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,8872.78,26765.51,Inpatient DRG
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH MCC",722,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],34009.69,,"Fee schedule rate ($34,009.69). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,14200.37,56869.13,There are no additional notes associated with this service or procedure.
DIABETES WITH MCC,637,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],28655.62,,,,,,0,other,9959.03,28655.62,There are no additional notes associated with this service or procedure.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,309,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],6965.00,,,,,,0,other,5055.77,14547.21,There are no additional notes associated with this service or procedure.
"Rpr Coltrl Ligm Mtcarphlngl/Iphal Jt|RIGHT HAND, THUMB",CASE-26540,APC,26540,CPT,0360,RC,,,F5,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
CESAREAN SECTION WITH STERILIZATION WITHOUT CC/MCC,785,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],20142.33,,"Fee schedule rate ($20,142.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8431.24,20142.33,There are no additional notes associated with this service or procedure.
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],17627.38,,"Case rate ($16,787.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,753.10, add-ons for qualifying new technology services are included. If operating cost exceeds $50,624.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,845.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $13,757.43 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,808.15 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,085.60. The transfer capital threshold is the transfer adjustment factor * $1,085.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,16787.98,62990.26,Inpatient DRG
SEIZURES WITH MCC,100,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],32323.98,,"Fee schedule rate ($32,323.98). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,15061.09,38110.41,There are no additional notes associated with this service or procedure.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],62041.12,,"Fee schedule rate ($62,041.12). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,18497.24,62041.12,There are no additional notes associated with this service or procedure.
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],28334.16,,"Fee schedule rate ($28,334.16). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,7868.00,32126.64,There are no additional notes associated with this service or procedure.
INFLAMMATORY BOWEL DISEASE WITH MCC,385,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],21593.52,,"Fee schedule rate ($21,593.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,11480.01,31134.92,There are no additional notes associated with this service or procedure.
O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC,621,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],36669.96,,"Fee schedule rate ($36,669.96). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,12159.94,36669.96,There are no additional notes associated with this service or procedure.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],16611.88,,"Case rate ($16,286.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,286.28, add-ons for qualifying new technology services are included. If operating cost exceeds $50,157.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,808.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $13,292.32 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,341.33 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,048.90. The transfer capital threshold is the transfer adjustment factor * $1,048.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 102%.",,,,0,other,16286.16,58320.32,Inpatient DRG
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC,797,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],20928.55,,"Fee schedule rate ($20,928.55). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8719.72,20928.55,There are no additional notes associated with this service or procedure.
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITHOUT CC/MCC,428,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],40017.53,,"Case rate ($40,017.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $37,363.07, add-ons for qualifying new technology services are included. If operating cost exceeds $72,234.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,544.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $35,288.01 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $35,418.12 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,784.57. The transfer capital threshold is the transfer adjustment factor * $2,784.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,40017.53,118904.57,Inpatient DRG
SEIZURES WITH MCC,100,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],36398.28,,"Fee schedule rate ($36,398.28). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,15061.09,38110.41,There are no additional notes associated with this service or procedure.
VENTRICULAR SHUNT PROCEDURES WITH MCC,031,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],88162.80,,,,,,0,other,32287.20,88162.80,There are no additional notes associated with this service or procedure.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],64429.92,,"Fee schedule rate ($64,429.92). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,25162.32,75579.22,There are no additional notes associated with this service or procedure.
Rpr Aa Hernia Recr 3-10 Cm Reducible,CASE-49615,APC,49615,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],6271.74,,"APC Price ($6,059.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6059.65,6362.63,OPPS APC
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],32168.63,,"Fee schedule rate ($32,168.63). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,13904.43,34749.58,There are no additional notes associated with this service or procedure.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],41944.25,,"Fee schedule rate ($41,944.25). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12795.84,41944.25,There are no additional notes associated with this service or procedure.
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR,518,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],89342.77,,"Fee schedule rate ($89,342.77). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,13252.00,89342.77,There are no additional notes associated with this service or procedure.
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],29166.74,,"Fee schedule rate ($29,166.74). Adds an outlier to normal pricing equal to the per diem rate ($36,758.78) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.9), with a minimum of zero.",,,,0,other,12455.21,37149.27,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],14336.41,,"Fee schedule rate ($14,336.41). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,9040.72,26966.33,There are no additional notes associated with this service or procedure.
HC Inj Anesth Celiac Plexus,CASE-64530,APC,64530,CPT,0361,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],856.86,,"APC Price ($827.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,827.89,869.28,OPPS APC
HC Joint Injection/Aspir Large WO US|UNUSUAL NON-OVERLAPPING SERVICE|RIGHT SIDE,CASE-20610,APC,20610,CPT,0510,RC,,,XU|RT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
"LIMB REATTACHMENT, HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA",956,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],148259.86,,"Fee schedule rate ($148,259.86). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (31), with a minimum of zero.",,,,0,other,27428.25,148259.86,There are no additional notes associated with this service or procedure.
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],27832.43,,"Fee schedule rate ($27,832.43). Adds an outlier to normal pricing equal to the per diem rate ($62,521.14) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.7), with a minimum of zero.",,,,0,other,11974.38,29141.64,There are no additional notes associated with this service or procedure.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],9351.96,,"Case rate ($8,906.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,421.26, add-ons for qualifying new technology services are included. If operating cost exceeds $43,292.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,269.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $6,452.52 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,476.31 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $509.17. The transfer capital threshold is the transfer adjustment factor * $509.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8906.63,28434.57,Inpatient DRG
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,270,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],96464.47,,"Fee schedule rate ($96,464.47). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,34720.90,101002.04,There are no additional notes associated with this service or procedure.
GASTROINTESTINAL OBSTRUCTION WITH CC,389,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],7293.54,,"Case rate ($7,293.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,920.63, add-ons for qualifying new technology services are included. If operating cost exceeds $41,791.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,151.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $4,957.39 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,975.67 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $391.19. The transfer capital threshold is the transfer adjustment factor * $391.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,5118.00,16423.43,Inpatient DRG
RESPIRATORY NEOPLASMS WITH CC,181,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],17609.39,,"Fee schedule rate ($17,609.39). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,9197.84,21074.07,There are no additional notes associated with this service or procedure.
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],33890.73,,"Fee schedule rate ($33,890.73). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,6277.00,36801.89,There are no additional notes associated with this service or procedure.
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],14383.21,,"Case rate ($14,383.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,516, add-ons for qualifying new technology services are included. If operating cost exceeds $48,387.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,669.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,528.54 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,571.05 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $909.72. The transfer capital threshold is the transfer adjustment factor * $909.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6965.00,36140.75,Inpatient DRG
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],28649.93,,"Fee schedule rate ($28,649.93). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,12268.97,41006.47,There are no additional notes associated with this service or procedure.
Exc B9 Lesion Mrgn Xcp Sk Tg S/N/H/F/G 1.1-2.0cm,CASE-11422,APC,11422,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],1600.04,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1600.04,1623.23,OPPS APC
Cysto W/Urtroscopy&/Pyeloscopy Dx|UNUSUAL NON-OVERLAPPING SERVICE|LEFT SIDE,CASE-52351,APC,52351,CPT,0360,RC,,,XU|LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3464.44,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3299.47,3464.44,OPPS APC
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC",281,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],23859.35,,"Fee schedule rate ($23,859.35). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,8169.15,23859.35,There are no additional notes associated with this service or procedure.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,167,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],33891.30,,"Fee schedule rate ($33,891.30). Adds an outlier to normal pricing equal to the per diem rate ($66,990.29) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.6), with a minimum of zero.",,,,0,other,14157.71,43522.37,There are no additional notes associated with this service or procedure.
Bronchoscopy Needle Bx Trachea Main Stem&/Bron,CASE-31629,APC,31629,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],6837.16,,"APC Price ($6,605.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6605.95,6936.25,OPPS APC
"Correction Hammertoe|LEFT FOOT, SECOND DIGIT",CASE-28285,APC,28285,CPT,0360,RC,,,T1,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6791.99,7131.59,OPPS APC
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],57872.02,,,,,,0,other,7086.00,57872.02,There are no additional notes associated with this service or procedure.
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],18918.49,,"Fee schedule rate ($18,918.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9282.47,21320.03,There are no additional notes associated with this service or procedure.
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],14492.93,,"Fee schedule rate ($14,492.93). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6503.90,14492.93,There are no additional notes associated with this service or procedure.
"Amp F/Th 1/2 Jt/Phalanx W/Neurect W/Dir Clsr|LEFT HAND, THIRD DIGIT",CASE-26951,APC,26951,CPT,0360,RC,,,F2,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],27832.43,,"Fee schedule rate ($27,832.43). Adds an outlier to normal pricing equal to the per diem rate ($62,521.14) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11.7), with a minimum of zero.",,,,0,other,11974.38,29141.64,There are no additional notes associated with this service or procedure.
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],48832.41,,,,,,0,other,8480.00,59081.91,There are no additional notes associated with this service or procedure.
HC Inj Lympho for Sentinal Node|UNUSUAL NON-OVERLAPPING SERVICE,CASE-38792,APC,38792,CPT,0361,RC,,,XU,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6215.36,,"APC Price ($6,215.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6215.36,6526.12,OPPS APC
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],97176.83,,,,,,0,other,35389.50,101083.00,There are no additional notes associated with this service or procedure.
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH CC",457,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],160549.49,,"Fee schedule rate ($160,549.49). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,42327.47,160549.49,There are no additional notes associated with this service or procedure.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,,inpatient,,,,,PAI [3082],PAI [3082001],39153.65,,"Fee schedule rate ($39,153.65). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (17), with a minimum of zero.",,,,0,other,7605.00,39153.65,There are no additional notes associated with this service or procedure.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],13080.27,,"Case rate ($12,457.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $11,744.07, add-ons for qualifying new technology services are included. If operating cost exceeds $46,615.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,510.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $9,762.10 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $9,799.12 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $750.34. The transfer capital threshold is the transfer adjustment factor * $750.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,12775.53,31469.43,Inpatient DRG
DIABETES WITHOUT CC/MCC,639,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],6965.00,,,,,,0,other,6151.76,12223.35,There are no additional notes associated with this service or procedure.
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],18918.49,,"Fee schedule rate ($18,918.49). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9282.47,21320.03,There are no additional notes associated with this service or procedure.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],52909.62,,"Fee schedule rate ($52,909.62). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,23344.70,62179.32,There are no additional notes associated with this service or procedure.
Dstr Nrolytc Agnt Parverteb Fct Sngl Lmbr/Sacral|RIGHT SIDE,CASE-64635,APC,64635,CPT,0360,RC,,,RT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],1919.19,,"APC Price ($1,827.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1827.80,1919.19,OPPS APC
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],40192.59,,"Fee schedule rate ($40,192.59). Adds an outlier to normal pricing equal to the per diem rate ($235,324.88) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13.6), with a minimum of zero.",,,,0,other,16428.39,42083.20,There are no additional notes associated with this service or procedure.
Excision Prepatellar Bursa|BILATERAL PROCEDURE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-27340,APC,27340,CPT,0360,RC,,,50|XU,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],7131.59,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,6791.99,7131.59,OPPS APC
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],22762.43,,"Fee schedule rate ($22,762.43). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6230.00,22762.43,There are no additional notes associated with this service or procedure.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,066,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],20083.61,,"Fee schedule rate ($20,083.61). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6579.76,20083.61,There are no additional notes associated with this service or procedure.
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],14309.17,,"Fee schedule rate ($14,309.17). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6965.00,17467.27,There are no additional notes associated with this service or procedure.
Osteot W/WO Lngth Shrt/Corrj Metar Xcp 1st Ea|LEFT SIDE,CASE-28308,APC,28308,CPT,0360,RC,,,LT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
Parathyroidectomy/Exploration Parathyroids,CASE-60500,APC,60500,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],5818.16,,"APC Price ($5,541.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5541.10,5818.16,OPPS APC
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],39251.68,,,,,,0,other,15453.88,39251.68,There are no additional notes associated with this service or procedure.
Arthrd Ant Interbody Min Dsc Crv Below C2|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA,CASE-22554,APC,22554,CPT,0360,RC,,,74,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],12618.18,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,12437.92,12618.18,OPPS APC
"Tendon Sheath Incision|LEFT HAND, FOURTH DIGIT",CASE-26055,APC,26055,CPT,0360,RC,,,F3,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],1557.80,,"APC Price ($1,505.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,1505.12,1580.37,OPPS APC
"INFECTIOUS AND PARASITIC DISEASES INCLUDING HIV WITH O.R. PROCEDURE,MINOR",710,DRG,,,,,,,,inpatient,,,,,BLUE CHOICE MEDICAID SC [4807],BLUE CHOICE HEALTHPLAN MEDICAID SC [4807001],12749.87,,"Case rate ($12,749.87). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount.",,,,0,other,12749.87,13387.36,There are no additional notes associated with this service or procedure.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,085,MS-DRG,,,,,,,,inpatient,,,,,FIRST CHOICE VIP CARE PLUS [4833],DUAL FIRST CHOICE VIP CARE PLUS [4833001],18196.93,,"Case rate ($17,330.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $16,257.72, add-ons for qualifying new technology services are included. If operating cost exceeds $51,128.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,885.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $14,260.20 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $14,312.77 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,125.27. The transfer capital threshold is the transfer adjustment factor * $1,125.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9282.00,57443.16,Inpatient DRG
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,,,,,,,,inpatient,,,,,IL BCBS [5358],IL BCBS [5358001],21354.82,,"Fee schedule rate ($21,354.82). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6834.39,21354.82,There are no additional notes associated with this service or procedure.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS BOEING SC [5312011],67790.93,,"Fee schedule rate ($67,790.93). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,21597.50,67790.93,There are no additional notes associated with this service or procedure.
"OPEN CRANIOTOMY EXCEPT TRAUMA,EXTREME",021,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],66079.19,,"Case rate ($62,932.56). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $56,008, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,62932.56,66079.19,There are no additional notes associated with this service or procedure.
HC Inj Tendon Sheath/Ligament|PBB CHARGE|SEPARATE STRUCTURE,CASE-20550,APC,20550,CPT,0510,RC,,,PBB|XS,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],301.68,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,287.31,301.68,OPPS APC
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH CC,427,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],134742.59,,"Fee schedule rate ($134,742.59). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,50829.82,142040.39,There are no additional notes associated with this service or procedure.
"ANTEPARTUM WITHOUT O.R. PROCEDURE,MODERATE",566,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],3931.37,,"Case rate ($3,744.16). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,3744.16,3931.37,There are no additional notes associated with this service or procedure.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],32293.66,,"Fee schedule rate ($32,293.66). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6965.00,32293.66,There are no additional notes associated with this service or procedure.
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],11565.93,,"Fee schedule rate ($11,565.93). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6148.93,15887.21,There are no additional notes associated with this service or procedure.
"NEONATE BIRTH WEIGHT > 2499 GRAMS NORMAL NEWBORN OR NEONATE WITH OTHER PROBLEM,MAJOR",640,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],3043.78,,"Case rate ($2,898.84). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,2898.84,3043.78,There are no additional notes associated with this service or procedure.
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC,939,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA [3020001],71397.99,,,,,,0,other,26517.40,97674.79,There are no additional notes associated with this service or procedure.
Excision Tumor Soft Tis Back/Flank Subq 3 Cm/>,CASE-21931,APC,21931,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],1545.93,,"APC Price ($1,545.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,1545.93,1600.04,OPPS APC
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC,939,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],71397.99,,,,,,0,other,26517.40,97674.79,There are no additional notes associated with this service or procedure.
Surgical Arthroscopy Shoulder Xtnsv Dbrdmt 3+|LEFT SIDE,CASE-29823,APC,29823,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],6791.99,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,6791.99,7131.59,OPPS APC
MAJOR THUMB OR JOINT PROCEDURES,506,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],11081.83,,"Case rate ($11,081.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,444.79, add-ons for qualifying new technology services are included. If operating cost exceeds $45,315.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,428.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $8,468.62 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,499.84 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $668.26. The transfer capital threshold is the transfer adjustment factor * $668.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,11081.83,26548.21,Inpatient DRG
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,,inpatient,,,,,NC BCBS [5316],ANTHEM BCBS BLUE CROSS OF NC PC [5316001],31577.54,,"Fee schedule rate ($31,577.54). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (18), with a minimum of zero.",,,,0,other,15453.88,39251.68,There are no additional notes associated with this service or procedure.
VENTRICULAR SHUNT PROCEDURES WITH MCC,031,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC AARP MEDICARE ADVANTAGE [1011017],32287.20,,"Case rate ($32,287.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $30,171.71, add-ons for qualifying new technology services are included. If operating cost exceeds $65,042.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,979.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7. The base transfer operating payment is the transfer adjustment factor * $28,123.07 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $28,226.76 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,219.19. The transfer capital threshold is the transfer adjustment factor * $2,219.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,32287.20,88162.80,Inpatient DRG
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],7814.83,,"Fee schedule rate ($7,814.83). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6683.37,14699.43,There are no additional notes associated with this service or procedure.
"Rpr Coltrl Ligm Mtcarphlngl/Iphal Jt|RIGHT HAND, THUMB",CASE-26540,APC,26540,CPT,0360,RC,,,F5,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
OSTEOMYELITIS WITH CC,540,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],18766.28,,"Case rate ($10,723.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,111.53, add-ons for qualifying new technology services are included. If operating cost exceeds $44,982.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,402.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $8,136.58 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,166.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $642.06. The transfer capital threshold is the transfer adjustment factor * $642.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,9809.07,25507.30,All Other Inpatient
"NEONATE TRANSFERRED < 5 DAYS OLD BORN HERE,EXTREME",581,DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4890],SELECT HEALTH OF SC [4890001],5011.20,,"The inlier payment is calculated as the lesser of the standard DRG payment $4,772.57 and the transfer payment, which is a per diem of $3,615.58. If cost, defined as billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,4772.57,5011.20,Estimated amount calculated based on 1 day length of stay.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],6963.00,,"Per diem ($6,963). If length of stay < 2.6, first 1 days paid at a per diem of $13,926 instead. Capped at $18,103.30.",,,,0,other,6963.00,18954.85,Estimated amount calculated based on 3 day length of stay.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],17069.51,,"Case rate ($16,256.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,285.55, add-ons for qualifying new technology services are included. If operating cost exceeds $50,156.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,781.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $13,290.21 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,340.60 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,021.52. The transfer capital threshold is the transfer adjustment factor * $1,021.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,16689.78,59521.43,Inpatient DRG
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],6841.83,,"Case rate ($6,841.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,500.42, add-ons for qualifying new technology services are included. If operating cost exceeds $41,371.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,118.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $4,538.73 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,555.47 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $358.15. The transfer capital threshold is the transfer adjustment factor * $358.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6841.83,21167.26,Inpatient DRG
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],39053.73,,"Fee schedule rate ($39,053.73). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,16017.99,51903.64,There are no additional notes associated with this service or procedure.
Peri-Implant Capsulectomy Breast Complete|LEFT SIDE,CASE-19371,APC,19371,CPT,0360,RC,,,LT,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],3848.19,,"APC Price ($3,664.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3664.94,3848.19,OPPS APC
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,,inpatient,,,,,CA BCBS [5353],CA BCBS [5353001],17755.26,,"Fee schedule rate ($17,755.26). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,7847.50,17755.26,There are no additional notes associated with this service or procedure.
Cysto W/Removal of Tumors Small,CASE-52234,APC,52234,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3299.47,,"APC Price ($3,299.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3299.47,3464.44,OPPS APC
OSTEOMYELITIS WITHOUT CC/MCC,541,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],11429.52,,"Fee schedule rate ($11,429.52). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,5103.00,15493.67,There are no additional notes associated with this service or procedure.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],19371.27,,"Fee schedule rate ($19,371.27). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,7641.61,19371.27,There are no additional notes associated with this service or procedure.
MINOR BLADDER PROCEDURES WITHOUT CC/MCC,664,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],9034.63,,"Case rate ($9,034.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,540.33, add-ons for qualifying new technology services are included. If operating cost exceeds $43,411.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,278.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $6,571.15 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,595.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $518.53. The transfer capital threshold is the transfer adjustment factor * $518.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,9034.63,31876.87,Inpatient DRG
COMPLICATIONS OF TREATMENT WITH CC,920,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],18836.22,,"Fee schedule rate ($18,836.22). Adds an outlier to normal pricing equal to the per diem rate ($49,808.13) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.7), with a minimum of zero.",,,,0,other,8732.59,20731.52,There are no additional notes associated with this service or procedure.
Ercp W/Biopsy Single/Multiple,CASE-43261,APC,43261,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3735.12,,"APC Price ($3,608.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3608.81,3789.26,OPPS APC
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC,497,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],37761.19,,"Fee schedule rate ($37,761.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10127.65,37761.19,There are no additional notes associated with this service or procedure.
"CHOLECYSTECTOMY,MINOR",263,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],12396.17,,"Case rate ($11,805.88). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,11805.88,12396.17,There are no additional notes associated with this service or procedure.
Perq Nl/Pl Lithotrp Simple Up to 2 Cm 1 Location|LEFT SIDE,CASE-50080,APC,50080,CPT,0360,RC,,,LT,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],8860.83,,"If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,8860.83,9303.88,OPPS APC
ALLERGIC REACTIONS WITH MCC,915,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE-ADVANTAGE PPO [103002],13799.51,,"Case rate ($13,332.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,538.89, add-ons for qualifying new technology services are included. If operating cost exceeds $47,409.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,592.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $10,555.02 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,593.94 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $832.90. The transfer capital threshold is the transfer adjustment factor * $832.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,13332.86,33088.84,Inpatient DRG
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],15653.45,,"Case rate ($14,908.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,004.25, add-ons for qualifying new technology services are included. If operating cost exceeds $48,875.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,708.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $12,014.99 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,059.30 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $948.10. The transfer capital threshold is the transfer adjustment factor * $948.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,14908.05,49717.39,Inpatient DRG
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],62041.12,,"Fee schedule rate ($62,041.12). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,18497.24,62041.12,There are no additional notes associated with this service or procedure.
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],11835.60,,"Fee schedule rate ($11,835.60). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,6834.39,21354.82,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],2070.00,,,,,,0,other,1188.00,34338.33,Estimated amount calculated based on 6 day length of stay.
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR,518,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],89342.77,,"Fee schedule rate ($89,342.77). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (24), with a minimum of zero.",,,,0,other,13252.00,89342.77,There are no additional notes associated with this service or procedure.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],41172.02,,"Case rate ($23,526.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $22,022.15, add-ons for qualifying new technology services are included. If operating cost exceeds $56,893.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,338.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.7. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.7)) / 2. The base transfer operating payment is the transfer adjustment factor * $20,003.44 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $20,077.20 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,578.47. The transfer capital threshold is the transfer adjustment factor * $1,578.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,23526.87,94787.57,All Other Inpatient
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],6393.09,,"Case rate ($6,088.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,807.49, add-ons for qualifying new technology services are included. If operating cost exceeds $40,678.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,055.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $3,847.95 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,862.54 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $295.76. The transfer capital threshold is the transfer adjustment factor * $295.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6214.05,15318.94,Inpatient DRG
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],11348.00,,"Per diem ($11,348). If length of stay < 4.2, first 1 days paid at a per diem of $22,696 instead. Capped at $47,660.93.",,,,0,other,11348.00,62454.12,Estimated amount calculated based on 5 day length of stay.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,270,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],96464.47,,"Fee schedule rate ($96,464.47). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,34720.90,101002.04,There are no additional notes associated with this service or procedure.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC,027,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],19696.26,,"Case rate ($19,030.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $17,839, add-ons for qualifying new technology services are included. If operating cost exceeds $52,710.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,009.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $15,835.66 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $15,894.05 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,249.59. The transfer capital threshold is the transfer adjustment factor * $1,249.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103.5%.",,,,0,other,19030.20,56363.30,Inpatient DRG
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],28235.64,,"Fee schedule rate ($28,235.64). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,14344.60,36028.59,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],10042.78,,"Case rate ($9,564.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,047.52, add-ons for qualifying new technology services are included. If operating cost exceeds $43,918.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,303.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $7,075.74 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,102.57 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $543.86. The transfer capital threshold is the transfer adjustment factor * $543.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9795.13,23899.13,Inpatient DRG
PSYCHOSES,885,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],26250.06,,"Fee schedule rate ($26,250.06). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15.8), with a minimum of zero.",,,,0,other,2070.00,27484.83,There are no additional notes associated with this service or procedure.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],8891.90,,"Case rate ($8,468.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,013.65, add-ons for qualifying new technology services are included. If operating cost exceeds $42,884.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,237.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,046.41 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,068.71 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $477.12. The transfer capital threshold is the transfer adjustment factor * $477.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6963.00,18954.85,Inpatient DRG
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],40108.48,,"Fee schedule rate ($40,108.48). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (23), with a minimum of zero.",,,,0,other,5569.00,40108.48,There are no additional notes associated with this service or procedure.
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC,497,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],37761.19,,"Fee schedule rate ($37,761.19). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,10127.65,37761.19,There are no additional notes associated with this service or procedure.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],6965.00,,,,,,0,other,1188.00,12138.74,There are no additional notes associated with this service or procedure.
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],35061.53,,"Fee schedule rate ($35,061.53). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,9696.93,35061.53,There are no additional notes associated with this service or procedure.
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],8616.44,,"Case rate ($8,447.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,994.13, add-ons for qualifying new technology services are included. If operating cost exceeds $42,865.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,235.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,026.96 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,049.18 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $475.59. The transfer capital threshold is the transfer adjustment factor * $475.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,1188.00,18893.86,Inpatient DRG
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],35419.59,,"Fee schedule rate ($35,419.59). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (20), with a minimum of zero.",,,,0,other,7086.00,57872.02,There are no additional notes associated with this service or procedure.
CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC,788,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],20142.33,,"Fee schedule rate ($20,142.33). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,8438.02,20142.33,There are no additional notes associated with this service or procedure.
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],14830.15,,"Fee schedule rate ($14,830.15). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,7884.32,17835.23,There are no additional notes associated with this service or procedure.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,073,MS-DRG,,,,,,,,inpatient,,,,,TN BCBS [5363],TN BCBS [5363001],43475.01,,"Fee schedule rate ($43,475.01). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (22), with a minimum of zero.",,,,0,other,12809.38,43475.01,There are no additional notes associated with this service or procedure.
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,,,,inpatient,,,,,BCBS [3123],BCBS OUT OF STATE [3123021],26966.33,,"Fee schedule rate ($26,966.33). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,9040.72,26966.33,There are no additional notes associated with this service or procedure.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],7921.00,,"Per diem ($7,921). If length of stay < 4.1, first 1 days paid at a per diem of $15,842 instead. Capped at $32,474.30.",,,,0,other,7921.00,45706.73,Estimated amount calculated based on 2 day length of stay.
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA HEALTHSPRING MEDICARE [349702],14055.68,,"Case rate ($13,386.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $12,588.65, add-ons for qualifying new technology services are included. If operating cost exceeds $47,459.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,596.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $10,604.60 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $10,643.70 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $836.81. The transfer capital threshold is the transfer adjustment factor * $836.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,13386.36,33244.29,Inpatient DRG
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC,833,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112015],6965.00,,,,,,0,other,3041.73,10289.10,There are no additional notes associated with this service or procedure.
"Open Tx Phalangeal Shaft Fracture Prox/Middle Ea|RIGHT HAND, SECOND DIGIT",CASE-26735,APC,26735,CPT,0360,RC,,,F6,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],3215.80,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,3062.67,3215.80,OPPS APC
"PULMONARY EMBOLISM,MODERATE",134,DRG,,,,,,,,inpatient,,,,,HUMANA MEDICAID SC [4884],HUMANA MEDICAID SC [4884001],8239.17,,"Case rate ($7,846.83). If cost, defined as Billed amount excluding RC 0990 * a cost-to-charge ratio of 0.3021, exceeds an outlier threshold of the inlier plus a fixed threshold of $44,000, the stay qualifies for an outlier and adds an outlier payment of 60% of the excess amount. Final payment is multiplied by 105%.",,,,0,other,7846.83,8239.17,There are no additional notes associated with this service or procedure.
Ercp Remove Calculi/Debris Biliary/Pancreas Duct,CASE-43264,APC,43264,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],5966.63,,"APC Price ($5,682.51). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,5682.51,5966.63,OPPS APC
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,,inpatient,,,,,AL BCBS [5351],AL BCBS [5351001],54764.34,,"Fee schedule rate ($54,764.34). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,18178.96,54764.34,There are no additional notes associated with this service or procedure.
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS HIX SC [5312003],15532.96,,"Fee schedule rate ($15,532.96). Adds an outlier to normal pricing equal to the per diem rate ($2,475) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,9755.86,29216.99,There are no additional notes associated with this service or procedure.
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,,inpatient,,,,,TX BCBS [5364],TX BCBS [5364001],81454.07,,"Fee schedule rate ($81,454.07). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (26), with a minimum of zero.",,,,0,other,10078.00,81454.07,There are no additional notes associated with this service or procedure.
NEONATE WITH OTHER SIGNIFICANT PROBLEMS,794,MS-DRG,,,,,,,,inpatient,,,,,AR BCBS [5352],AR BCBS [5352001],3383.58,,"Fee schedule rate ($3,383.58). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,1798.85,12536.83,There are no additional notes associated with this service or procedure.
Tympanostomy General Anesthesia|BILATERAL PROCEDURE,CASE-69436,APC,69436,CPT,0360,RC,,,50,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],1524.94,,"APC Price ($1,452.32). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,1452.32,1524.94,OPPS APC
CESAREAN SECTION WITHOUT STERILIZATION WITH CC,787,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],9750.15,,"Case rate ($9,285.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,787.73, add-ons for qualifying new technology services are included. If operating cost exceeds $43,658.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,283.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $6,816.93 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,842.78 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $523.97. The transfer capital threshold is the transfer adjustment factor * $523.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9508.01,23722.94,Inpatient DRG
Sigmoidoscopy Flx Dx W/Collj Spec Br/Wa if Pfrmd,CASE-45330,APC,45330,CPT,0360,RC,,,,outpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],913.99,,"APC Price ($870.46). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 105%.",,,,0,other,870.46,913.99,OPPS APC
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],25098.39,,"Case rate ($23,903.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $22,413.24, add-ons for qualifying new technology services are included. If operating cost exceeds $57,284.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,327.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.7. The base transfer operating payment is the transfer adjustment factor * $20,390.97 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $20,468.29 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,567.30. The transfer capital threshold is the transfer adjustment factor * $1,567.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,9370.00,65732.99,Inpatient DRG
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC CHOICE PLUS [3112089],15808.67,,"Fee schedule rate ($15,808.67). Adds an outlier to normal pricing equal to the per diem rate ($67,650.85) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (9.6), with a minimum of zero.",,,,0,other,7641.61,19371.27,There are no additional notes associated with this service or procedure.
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,,inpatient,,,,,VA BCBS [5313],ANTHEM BCBS VA [5313001],59081.91,,"Fee schedule rate ($59,081.91). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (32), with a minimum of zero.",,,,0,other,8480.00,59081.91,There are no additional notes associated with this service or procedure.
"Neuroplasty Sciatic Nerve,Open",CASE-64712,APC,64712,CPT,0360,RC,,,,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7029.71,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6791.99,7131.59,OPPS APC
ALLERGIC REACTIONS WITH MCC,915,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],27385.01,,"Fee schedule rate ($27,385.01). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,13332.86,33088.84,There are no additional notes associated with this service or procedure.
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,,inpatient,,,,,GA BCBS [5357],GA BCBS [5357001],21089.59,,"Fee schedule rate ($21,089.59). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,6965.00,21089.59,There are no additional notes associated with this service or procedure.
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],46202.59,,"Fee schedule rate ($46,202.59). Adds an outlier to normal pricing equal to the per diem rate ($126,777.34) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (13), with a minimum of zero.",,,,0,other,18594.09,59494.91,There are no additional notes associated with this service or procedure.
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",759,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],6567.68,,"Case rate ($6,438.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,125.57, add-ons for qualifying new technology services are included. If operating cost exceeds $40,996.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,088.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,165.27 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,180.62 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $328.68. The transfer capital threshold is the transfer adjustment factor * $328.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6190.22,13057.66,Inpatient DRG
NERVOUS SYSTEM NEOPLASMS WITH MCC,054,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC LOCAL [5312001],25589.03,,"Fee schedule rate ($25,589.03). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (14), with a minimum of zero.",,,,0,other,6965.00,30044.81,There are no additional notes associated with this service or procedure.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],SUREST UHC CHOICE PLUS [3112030],9888.00,,"Per diem ($9,888). If length of stay < 3.1, first 1 days paid at a per diem of $19,776 instead. Capped at $30,651.38.",,,,0,other,9888.00,43399.23,Estimated amount calculated based on 1 day length of stay.
Arthroscopy Knee W/Meniscus Rpr Medial/Lateral|RIGHT SIDE,CASE-29882,APC,29882,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],7029.71,,"APC Price ($6,791.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,6791.99,7029.71,OPPS APC
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],16897.01,,"Case rate ($16,897.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $15,854.53, add-ons for qualifying new technology services are included. If operating cost exceeds $50,725.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,853.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $13,858.48 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $13,909.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,093.57. The transfer capital threshold is the transfer adjustment factor * $1,093.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,16897.01,43444.85,Inpatient DRG
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITHOUT CC/MCC",630,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],27428.38,,"Fee schedule rate ($27,428.38). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8.6), with a minimum of zero.",,,,0,other,11828.78,42541.02,There are no additional notes associated with this service or procedure.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,MS-DRG,,,,,,,,inpatient,,,,,CIGNA MEDICARE [3497],CIGNA PREFERRED MEDICARE HMO [3497003],15009.94,,"Case rate ($14,295.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $13,434.11, add-ons for qualifying new technology services are included. If operating cost exceeds $48,305.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,663.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $11,446.95 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $11,489.15 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $903.28. The transfer capital threshold is the transfer adjustment factor * $903.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,14295.18,42768.36,Inpatient DRG
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],6410.25,,"Fee schedule rate ($6,410.25). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,6148.93,15887.21,There are no additional notes associated with this service or procedure.
NON-MALIGNANT BREAST DISORDERS WITH CC/MCC,600,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],8998.74,,"Case rate ($8,998.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,506.94, add-ons for qualifying new technology services are included. If operating cost exceeds $43,377.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,275.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $6,537.88 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,561.99 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $515.90. The transfer capital threshold is the transfer adjustment factor * $515.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,7999.14,20495.56,Inpatient DRG
"LIMB REATTACHMENT, HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA",956,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],27976.82,,"Case rate ($27,428.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $25,651.53, add-ons for qualifying new technology services are included. If operating cost exceeds $60,522.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,623.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $23,619.49 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $23,706.58 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,863.81. The transfer capital threshold is the transfer adjustment factor * $1,863.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,27428.25,148259.86,Inpatient DRG
SPINAL PROCEDURES WITH MCC,028,MS-DRG,,,,,,,,inpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],44125.74,,"Case rate ($42,633.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $39,796.72, add-ons for qualifying new technology services are included. If operating cost exceeds $74,667.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,735.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.5. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 9.5)) / 2. The base transfer operating payment is the transfer adjustment factor * $37,712.72 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $37,851.77 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,975.91. The transfer capital threshold is the transfer adjustment factor * $2,975.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103.5%.",,,,0,other,42633.57,120982.83,Inpatient DRG
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],6963.00,,"Per diem ($6,963). If length of stay < 2.6, first 1 days paid at a per diem of $13,926 instead. Capped at $18,103.30.",,,,0,other,6963.00,18954.85,Estimated amount calculated based on 3 day length of stay.
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],ANTHEM BCBS SC BLUE CHOICE [5312007],35061.53,,"Fee schedule rate ($35,061.53). Adds an outlier to normal pricing equal to the per diem rate ($6,727.50) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,9696.93,35061.53,There are no additional notes associated with this service or procedure.
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],21263.41,,"Case rate ($20,846.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $19,528.64, add-ons for qualifying new technology services are included. If operating cost exceeds $54,399.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,142.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $17,519.09 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $17,583.69 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,382.43. The transfer capital threshold is the transfer adjustment factor * $1,382.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,20846.48,81306.30,Inpatient DRG
PREMATURITY WITH MAJOR PROBLEMS,791,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UHC BRONZE SILVER GOLD ACA [3112088],3054.00,,,,,,0,other,3048.21,30904.42,Estimated amount calculated based on 5 day length of stay.
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC",458,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],30806.13,,"Case rate ($30,202.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $28,231.97, add-ons for qualifying new technology services are included. If operating cost exceeds $63,102.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $3,826.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $26,190.45 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $26,287.02 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,066.69. The transfer capital threshold is the transfer adjustment factor * $2,066.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,30202.09,132827.25,Inpatient DRG
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC STATE [5312002],10477.95,,"Fee schedule rate ($10,477.95). Adds an outlier to normal pricing equal to the per diem rate ($4,292.95) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,6963.00,18954.85,There are no additional notes associated with this service or procedure.
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC,497,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA GOLD PLUS HMO [101001],10381.65,,"Case rate ($9,887.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,348.36, add-ons for qualifying new technology services are included. If operating cost exceeds $44,219.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,326.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 1.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $7,375.45 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,403.41 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $566.89. The transfer capital threshold is the transfer adjustment factor * $566.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,10127.65,37761.19,Inpatient DRG
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112042],60793.48,,"Fee schedule rate ($60,793.48). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (15.7), with a minimum of zero.",,,,0,other,23851.92,63653.13,There are no additional notes associated with this service or procedure.
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],15283.90,,"Case rate ($15,283.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $14,353.89, add-ons for qualifying new technology services are included. If operating cost exceeds $49,224.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,735.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.2. The base transfer operating payment is the transfer adjustment factor * $12,363.36 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $12,408.94 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $975.59. The transfer capital threshold is the transfer adjustment factor * $975.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,15283.90,38757.79,Inpatient DRG
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,270,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],96464.47,,"Fee schedule rate ($96,464.47). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (16), with a minimum of zero.",,,,0,other,34720.90,101002.04,There are no additional notes associated with this service or procedure.
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,307,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS MEDICARE [5342],BCBS SC MEDICARE PPO [5342002],7434.68,,"Case rate ($7,434.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.223, exceeds $7,017.68, add-ons for qualifying new technology services are included. If operating cost exceeds $45,662.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.016, exceeds $3,170.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $5,632.79 + an uncompensated DSH payment of $1,359.91. The transfer operating threshold is the transfer adjustment factor * $5,657.77 + an uncompensated DSH payment of $1,359.91. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $441.98. The transfer capital threshold is the transfer adjustment factor * $441.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,6335.27,18228.77,Inpatient DRG
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],20817.01,,"Fee schedule rate ($20,817.01). Adds an outlier to normal pricing equal to the per diem rate ($37,789.38) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (11), with a minimum of zero.",,,,0,other,9446.38,21796.21,There are no additional notes associated with this service or procedure.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],OH WELLCARE MEDICARE [1009002],11274.46,,"Case rate ($11,053.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $10,418.34, add-ons for qualifying new technology services are included. If operating cost exceeds $45,289.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,426.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $8,442.26 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $8,473.38 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $666.18. The transfer capital threshold is the transfer adjustment factor * $666.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,11053.39,36776.05,Inpatient DRG
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,,inpatient,,,,,FL BCBS [5356],FL BCBS [5356001],19604.30,,"Fee schedule rate ($19,604.30). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9446.38,21796.21,There are no additional notes associated with this service or procedure.
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,,inpatient,,,,,WELLCARE MEDICARE [1009],WELLCARE OF SC MEDICARE HMO/PPO [1009009],7175.55,,"Case rate ($7,034.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $6,679.97, add-ons for qualifying new technology services are included. If operating cost exceeds $41,550.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,132.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $4,717.62 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $4,735.02 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $372.27. The transfer capital threshold is the transfer adjustment factor * $372.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 102%.",,,,0,other,6965.00,21089.59,Inpatient DRG
GASTROINTESTINAL OBSTRUCTION WITH CC,389,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA OPEN ACCESS PLUS OAP [30200027],15540.89,,,,,,0,other,5118.00,16423.43,There are no additional notes associated with this service or procedure.
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,,inpatient,,,,,SELECT HEALTH OF SC [4877],FIRST CHOICE NEXT HIX [4877001],17414.06,,"Case rate ($9,950.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $9,392.71, add-ons for qualifying new technology services are included. If operating cost exceeds $44,263.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,345.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $7,420.40 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $7,447.76 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $585.54. The transfer capital threshold is the transfer adjustment factor * $585.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 175%.",,,,0,other,7243.75,23262.15,All Other Inpatient
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE - CHOICE PLUS [3112014],11165.00,,"Per diem ($11,165). If length of stay < 3.5, first 1 days paid at a per diem of $22,330 instead. Capped at $39,078.16.",,,,0,other,11165.00,61234.06,Estimated amount calculated based on 3 day length of stay.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,,inpatient,,,,,UMR [3113],UMR [3113004],8972.00,,"Per diem ($8,972). If length of stay < 6.1, first 1 days paid at a per diem of $17,944 instead. Capped at $54,730.85.",,,,0,other,8972.00,81524.17,Estimated amount calculated based on 4 day length of stay.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],21167.26,,"Fee schedule rate ($21,167.26). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (7), with a minimum of zero.",,,,0,other,6841.83,21167.26,There are no additional notes associated with this service or procedure.
Arthrs Kne Surg W/Meniscectomy Med/Lat W/Shvg|RIGHT SIDE,CASE-29881,APC,29881,CPT,0360,RC,,,RT,outpatient,,,,,AETNA MEDICARE [1003],AETNA MEDICARE ADVANTAGE HMO [103003],3169.86,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103.5%.",,,,0,other,3062.67,3215.80,OPPS APC
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],8511.49,,"Case rate ($8,106.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $7,676.61, add-ons for qualifying new technology services are included. If operating cost exceeds $42,547.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,210.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,710.61 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $5,731.66 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $450.62. The transfer capital threshold is the transfer adjustment factor * $450.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,8106.18,18245.94,Inpatient DRG
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,,inpatient,,,,,PA BCBS [4901],PA BCBS HIGHMARK [4901001],23520.23,,"Fee schedule rate ($23,520.23). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (12), with a minimum of zero.",,,,0,other,10517.71,24909.11,There are no additional notes associated with this service or procedure.
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC FEDERAL [5312004],25026.36,,"Fee schedule rate ($25,026.36). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10), with a minimum of zero.",,,,0,other,9356.31,25026.36,There are no additional notes associated with this service or procedure.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITHOUT CC/MCC,816,MS-DRG,,,,,,,,inpatient,,,,,CLOVER MEDICARE PPO [4057],CLOVER MEDICARE PPO [4057001],6536.15,,"Case rate ($6,224.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $5,926.50, add-ons for qualifying new technology services are included. If operating cost exceeds $40,797.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,073.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $3,966.92 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $3,981.55 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $313.03. The transfer capital threshold is the transfer adjustment factor * $313.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,6224.90,14733.53,Inpatient DRG
Exc Rct Tum Not Incl Muscularis Propria,CASE-45171,APC,45171,CPT,0360,RC,,,,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],2598.08,,"APC Price ($2,598.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,2598.08,2727.99,OPPS APC
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH CC,427,MS-DRG,,,,,,,,inpatient,,,,,UNITED HEALTHCARE [3112],UNITED HEALTHCARE [3112044],135659.15,,"Fee schedule rate ($135,659.15). Adds an outlier to normal pricing equal to the per diem rate ($0.00) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (10.8), with a minimum of zero.",,,,0,other,50829.82,142040.39,There are no additional notes associated with this service or procedure.
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC,833,MS-DRG,,,,,,,,inpatient,,,,,SC BCBS [5312],BCBS SC TEAMMATE [5312012],5721.39,,"Fee schedule rate ($5,721.39). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,3041.73,10289.10,There are no additional notes associated with this service or procedure.
HC Joint Injection/Aspir Large WO US|PBB CHARGE|UNUSUAL NON-OVERLAPPING SERVICE,CASE-20610,APC,20610,CPT,0510,RC,,,PBB|XU,outpatient,,,,,UHC MEDICARE [1011],UNITEDHEALTHCARE DUAL COMPLETE [1011009],287.31,,"APC Price ($287.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,287.31,301.68,OPPS APC
PREMATURITY WITH MAJOR PROBLEMS,791,MS-DRG,,,,,,,,inpatient,,,,,CIGNA [3020],CIGNA PPO [3020024],3354.00,,,,,,0,other,3048.21,30904.42,Estimated amount calculated based on 5 day length of stay.
"CARDIAC ARREST, UNEXPLAINED WITH MCC",296,MS-DRG,,,,,,,,inpatient,,,,,OH BCBS [5311],BCBS - OH PPO [5311002],36459.67,,"Fee schedule rate ($36,459.67). Adds an outlier to normal pricing equal to the per diem rate ($3,363.75) multiplied by the outlier percent (100%) multiplied by the number of days that the length of stay is greater than the length of stay threshold (8), with a minimum of zero.",,,,0,other,12522.25,36459.67,There are no additional notes associated with this service or procedure.
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC",011,MS-DRG,,,,,,,,inpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],38880.49,,"Case rate ($38,880.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $36,305.31, add-ons for qualifying new technology services are included. If operating cost exceeds $71,176.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $4,461.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 11.4. The base transfer operating payment is the transfer adjustment factor * $34,234.14 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $34,360.36 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,701.41. The transfer capital threshold is the transfer adjustment factor * $2,701.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.",,,,0,other,38880.49,150008.48,Inpatient DRG
"Open Tx Phalangeal Shaft Fracture Prox/Middle Ea|RIGHT HAND, FOURTH DIGIT",CASE-26735,APC,26735,CPT,0360,RC,,,F8,outpatient,,,,,UHC MEDICARE [1011],UHC MEDICARE COMPLETE [44],3062.67,,"APC Price ($3,062.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.149). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.",,,,0,other,3062.67,3215.80,OPPS APC
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,,inpatient,,,,,HUMANA MEDICARE [1010],HUMANA CHOICE-PPO MEDICARE [101003],8929.50,,"Case rate ($8,504.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.215, exceeds $8,059.21, add-ons for qualifying new technology services are included. If operating cost exceeds $42,930.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.011, exceeds $2,228.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,091.17 + an uncompensated DSH payment of $1,944.95. The transfer operating threshold is the transfer adjustment factor * $6,114.26 + an uncompensated DSH payment of $1,944.95. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $468.18. The transfer capital threshold is the transfer adjustment factor * $468.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 105%.",,,,0,other,5683.00,19635.68,Inpatient DRG